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 24075-25109
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
24075-25109
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
24075
003
90
2
X
593.89
X
24075
002
90
2
X
592.45
X
24075
004
90
2
X
571.81
X
24075
001
90
2
X
607.03
X
24076
002
90
2
X
1,097.93
X
24076
003
90
2
X
1,063.37
X
24076
001
90
2
X
1,142.79
X
24076
004
90
2
X
988.48
X
24077
001
90
2
X
2,606.17
X
24077
004
90
2
X
2,355.20
X
24077
002
90
2
X
1,844.20
X
24077
003
90
2
X
1,743.49
X
24079
002
90
2
X
2,188.85
X
24079
003
90
2
X
2,188.85
X
24079
001
90
2
X
2,449.74
X
24079
004
90
2
X
2,188.85
X
24100
003
90
2
X
1,000.53
X
24100
002
90
2
X
1,632.21
X
24100
001
90
2
X
1,089.40
X
24100
004
90
2
X
988.67
X
24101
004
90
2
X
1,895.33
X
24101
003
90
2
X
1,903.44
X
24101
002
90
2
X
1,816.16
X
24101
001
90
2
X
2,144.91
X
24102
001
90
2
X
2,404.88
X
24102
003
90
2
X
2,180.96
X
24102
002
90
2
X
2,318.06
X
24102
004
90
2
X
2,204.95
X
24105
001
90
2
X
1,054.64
X
24105
004
90
2
X
946.21
X
24105
003
90
2
X
875.40
X
24105
002
90
2
X
1,025.25
X
24110
001
90
2
X
1,819.68
X
24110
004
90
2
X
1,645.12
X
24110
003
90
2
X
1,665.28
X
24110
002
90
2
X
1,901.32
X
24115
002
90
2
X
2,001.19
X
24115
003
90
2
X
1,866.84
X
24115
004
90
2
X
1,844.97
X
24115
001
90
2
X
2,033.70
X
24116
001
90
2
X
2,526.96
X
24116
004
90
2
X
2,301.04
X
24116
003
90
2
X
2,328.61
X
24116
002
90
2
X
2,488.26
X
24120
002
90
2
X
1,863.72
X
24120
003
90
2
X
1,644.82
X
24120
004
90
2
X
1,814.46
X
24120
001
90
2
X
1,772.23
X
24125
001
90
2
X
1,544.58
X
24125
002
90
2
X
1,524.27
X
24125
003
90
2
X
1,440.14
X
24125
004
90
2
X
1,422.98
X
24126
003
90
2
X
1,706.40
X
24126
002
90
2
X
1,830.29
X
24126
001
90
2
X
1,860.24
X
24126
004
90
2
X
1,686.07
X
24130
003
90
2
X
1,479.36
X
24130
002
90
2
X
1,588.38
X
24130
004
90
2
X
1,495.37
X
24130
001
90
2
X
1,626.04
X
24134
004
90
2
X
1,947.02
X
24134
002
90
2
X
2,107.01
X
24134
003
90
2
X
1,970.74
X
24134
001
90
2
X
2,140.00
X
24136
004
90
2
X
1,748.55
X
24136
002
90
2
X
1,887.90
X
24136
003
90
2
X
1,500.54
X
24136
001
90
2
X
1,916.02
X
24138
001
90
2
X
1,680.74
X
24138
004
90
2
X
1,526.58
X
24138
002
90
2
X
1,582.71
X
24138
003
90
2
X
1,544.75
X
24140
003
90
2
X
1,957.84
X
24140
002
90
2
X
2,104.25
X
24140
004
90
2
X
1,934.41
X
24140
001
90
2
X
2,139.61
X
24145
004
90
2
X
1,497.49
X
24145
002
90
2
X
1,622.75
X
24145
003
90
2
X
1,515.42
X
24145
001
90
2
X
1,648.69
X
24147
002
90
2
X
1,642.01
X
24147
003
90
2
X
1,520.91
X
24147
001
90
2
X
1,668.87
X
24147
004
90
2
X
1,513.02
X
24149
003
90
2
X
2,809.40
X
24149
002
90
2
X
2,886.97
X
24149
001
90
2
X
3,227.15
X
24149
004
90
2
X
2,809.40
X
24150
002
90
2
X
3,219.43
X
24150
003
90
2
X
2,992.74
X
24150
004
90
2
X
2,956.37
X
24150
001
90
2
X
3,578.91
X
24152
002
90
2
X
1,948.87
X
24152
003
90
2
X
1,826.42
X
24152
004
90
2
X
1,805.49
X
24152
001
90
2
X
1,978.55
X
24155
001
90
2
X
3,328.75
X
24155
004
90
2
X
2,428.33
X
24155
003
90
2
X
2,777.21
X
24155
002
90
2
X
3,288.38
X
24160
002
90
2
X
1,454.12
X
24160
003
90
2
X
1,366.51
X
24160
004
90
2
X
1,350.93
X
24160
001
90
2
X
1,475.40
X
24164
004
90
2
X
1,258.15
X
24164
003
90
2
X
1,273.31
X
24164
002
90
2
X
1,365.75
X
24164
001
90
2
X
1,388.13
X
24200
004
10
2
X
227.20
X
24200
002
10
2
X
188.21
X
24200
003
10
2
X
203.64
X
24200
001
10
2
X
210.79
X
24201
001
90
2
X
887.57
X
24201
003
90
2
X
820.71
X
24201
002
90
2
X
872.45
X
24201
004
90
2
X
811.21
X
24220
001
0
2
X
167.84
X
24220
004
0
2
X
122.91
X
24220
003
0
2
X
183.68
X
24220
002
0
2
X
192.05
X
24300
001
90
2
X
862.89
X
24300
004
90
2
X
752.29
X
24300
002
90
2
X
752.29
X
24300
003
90
2
X
752.29
X
24301
004
90
2
X
1,950.87
X
24301
001
90
2
X
2,139.42
X
24301
003
90
2
X
1,773.16
X
24301
002
90
2
X
1,898.75
X
24305
001
90
2
X
1,167.56
X
24305
003
90
2
X
1,104.02
X
24305
002
90
2
X
1,155.18
X
24305
004
90
2
X
1,091.75
X
24310
001
90
2
X
1,028.70
X
24310
002
90
2
X
1,015.04
X
24310
003
90
2
X
958.70
X
24310
004
90
2
X
948.04
X
24320
004
90
2
X
2,675.73
X
24320
003
90
2
X
2,136.53
X
24320
002
90
2
X
2,281.01
X
24320
001
90
2
X
2,847.44
X
24330
001
90
2
X
2,200.15
X
24330
004
90
2
X
2,199.75
X
24330
002
90
2
X
1,259.60
X
24330
003
90
2
X
2,017.75
X
24331
004
90
2
X
2,193.50
X
24331
001
90
2
X
2,420.19
X
24331
003
90
2
X
2,219.91
X
24331
002
90
2
X
2,381.14
X
24332
001
90
2
X
1,181.29
X
24332
004
90
2
X
1,050.42
X
24332
003
90
2
X
1,050.42
X
24332
002
90
2
X
1,050.42
X
24340
002
90
2
X
1,754.86
X
24340
003
90
2
X
1,784.97
X
24340
004
90
2
X
1,618.25
X
24340
001
90
2
X
1,958.52
X
24341
003
90
2
X
1,553.49
X
24341
002
90
2
X
1,596.36
X
24341
004
90
2
X
1,553.49
X
24341
001
90
2
X
1,784.23
X
24342
004
90
2
X
2,292.90
X
24342
002
90
2
X
2,495.76
X
24342
003
90
2
X
2,320.64
X
24342
001
90
2
X
2,538.13
X
24343
001
90
2
X
1,572.52
X
24343
004
90
2
X
1,379.51
X
24343
003
90
2
X
1,379.51
X
24343
002
90
2
X
1,379.51
X
24344
004
90
2
X
2,085.10
X
24344
002
90
2
X
2,085.10
X
24344
003
90
2
X
2,085.10
X
24344
001
90
2
X
2,371.27
X
24345
002
90
2
X
1,379.51
X
24345
003
90
2
X
1,379.51
X
24345
001
90
2
X
1,572.52
X
24345
004
90
2
X
1,379.51
X
24346
002
90
2
X
2,085.10
X
24346
003
90
2
X
2,085.10
X
24346
001
90
2
X
2,371.27
X
24346
004
90
2
X
2,085.10
X
24357
004
90
2
X
720.78
X
24357
001
90
2
X
828.51
X
24357
002
90
2
X
720.78
X
24357
003
90
2
X
720.78
X
24358
004
90
2
X
847.78
X
24358
002
90
2
X
847.78
X
24358
003
90
2
X
847.78
X
24358
001
90
2
X
972.24
X
24359
001
90
2
X
1,191.11
X
24359
002
90
2
X
1,044.76
X
24359
003
90
2
X
1,044.76
X
24359
004
90
2
X
1,044.76
X
24360
003
90
2
X
3,686.36
X
24360
002
90
2
X
3,971.24
X
24360
001
90
2
X
3,346.42
X
24360
004
90
2
X
3,007.98
X
24361
001
90
2
X
3,247.46
X
24361
004
90
2
X
2,948.33
X
24361
003
90
2
X
2,984.07
X
24361
002
90
2
X
3,196.14
X
24362
003
90
2
X
2,954.37
X
24362
002
90
2
X
3,110.30
X
24362
004
90
2
X
2,917.70
X
24362
001
90
2
X
3,525.80
X
24363
001
90
2
X
5,328.54
X
24363
003
90
2
X
4,834.26
X
24363
002
90
2
X
5,210.63
X
24363
004
90
2
X
4,677.74
X
24365
001
90
2
X
2,795.93
X
24365
002
90
2
X
1,858.31
X
24365
003
90
2
X
1,734.20
X
24365
004
90
2
X
1,713.61
X
24366
004
90
2
X
2,210.59
X
24366
001
90
2
X
3,785.19
X
24366
003
90
2
X
2,238.09
X
24366
002
90
2
X
3,739.35
X
24370
004
90
2
X
2,477.30
X
24370
003
90
2
X
2,477.30
X
24370
002
90
2
X
2,477.30
X
24370
001
90
2
X
2,760.85
X
24371
002
90
2
X
2,856.67
X
24371
003
90
2
X
2,856.67
X
24371
004
90
2
X
2,856.67
X
24371
001
90
2
X
3,181.88
X
24400
001
90
2
X
2,305.92
X
24400
004
90
2
X
2,100.32
X
24400
002
90
2
X
2,270.63
X
24400
003
90
2
X
2,125.13
X
24410
004
90
2
X
3,128.00
X
24410
001
90
2
X
3,442.37
X
24410
002
90
2
X
3,233.42
X
24410
003
90
2
X
3,166.06
X
24420
002
90
2
X
3,042.43
X
24420
003
90
2
X
2,836.42
X
24420
004
90
2
X
2,802.65
X
24420
001
90
2
X
3,092.26
X
24430
001
90
2
X
3,336.77
X
24430
004
90
2
X
3,007.68
X
24430
002
90
2
X
3,279.93
X
24430
003
90
2
X
3,044.88
X
24435
001
90
2
X
3,594.80
X
24435
004
90
2
X
3,220.53
X
24435
003
90
2
X
3,260.60
X
24435
002
90
2
X
3,529.78
X
24470
003
90
2
X
1,828.03
X
24470
002
90
2
X
1,960.91
X
24470
001
90
2
X
1,993.04
X
24470
004
90
2
X
1,806.36
X
24495
004
90
2
X
1,741.45
X
24495
002
90
2
X
1,794.10
X
24495
003
90
2
X
1,748.70
X
24495
001
90
2
X
1,641.93
X
24498
001
90
2
X
2,642.59
X
24498
003
90
2
X
2,429.81
X
24498
002
90
2
X
2,601.19
X
24498
004
90
2
X
2,400.91
X
24500
003
90
2
X
686.78
X
24500
002
90
2
X
733.81
X
24500
001
90
2
X
719.13
X
24500
004
90
2
X
686.98
X
24505
001
90
2
X
1,162.75
X
24505
004
90
2
X
1,087.00
X
24505
002
90
2
X
1,161.68
X
24505
003
90
2
X
1,072.07
X
24515
001
90
2
X
2,508.24
X
24515
003
90
2
X
2,306.88
X
24515
002
90
2
X
2,468.96
X
24515
004
90
2
X
2,279.62
X
24516
001
90
2
X
2,508.24
X
24516
004
90
2
X
2,279.62
X
24516
002
90
2
X
2,468.96
X
24516
003
90
2
X
2,306.88
X
24530
001
90
2
X
729.34
X
24530
004
90
2
X
694.64
X
24530
003
90
2
X
696.05
X
24530
002
90
2
X
718.37
X
24535
001
90
2
X
1,301.39
X
24535
004
90
2
X
1,235.35
X
24535
002
90
2
X
1,310.44
X
24535
003
90
2
X
1,150.62
X
24538
002
90
2
X
1,690.04
X
24538
003
90
2
X
1,511.71
X
24538
001
90
2
X
2,051.31
X
24538
004
90
2
X
1,578.00
X
24545
001
90
2
X
2,467.00
X
24545
004
90
2
X
2,334.53
X
24545
002
90
2
X
2,444.19
X
24545
003
90
2
X
2,349.92
X
24546
003
90
2
X
2,614.00
X
24546
002
90
2
X
2,714.65
X
24546
004
90
2
X
2,596.12
X
24546
001
90
2
X
2,739.09
X
24560
004
90
2
X
585.10
X
24560
001
90
2
X
610.56
X
24560
003
90
2
X
580.11
X
24560
002
90
2
X
598.36
X
24565
001
90
2
X
890.57
X
24565
003
90
2
X
838.85
X
24565
002
90
2
X
884.85
X
24565
004
90
2
X
952.92
X
24566
001
90
2
X
1,608.57
X
24566
003
90
2
X
1,489.57
X
24566
002
90
2
X
1,587.08
X
24566
004
90
2
X
1,463.61
X
24575
003
90
2
X
1,977.72
X
24575
002
90
2
X
2,110.90
X
24575
004
90
2
X
1,954.59
X
24575
001
90
2
X
2,143.21
X
24576
001
90
2
X
610.55
X
24576
004
90
2
X
564.83
X
24576
002
90
2
X
609.03
X
24576
003
90
2
X
570.44
X
24577
002
90
2
X
1,080.44
X
24577
003
90
2
X
1,050.88
X
24577
001
90
2
X
1,094.42
X
24577
004
90
2
X
1,038.70
X
24579
004
90
2
X
2,122.48
X
24579
003
90
2
X
2,147.48
X
24579
002
90
2
X
2,291.88
X
24579
001
90
2
X
2,333.70
X
24582
002
90
2
X
1,773.94
X
24582
003
90
2
X
1,618.33
X
24582
001
90
2
X
1,807.32
X
24582
004
90
2
X
1,599.27
X
24586
001
90
2
X
3,576.93
X
24586
004
90
2
X
3,237.32
X
24586
002
90
2
X
3,538.36
X
24586
003
90
2
X
3,095.93
X
24587
003
90
2
X
3,142.25
X
24587
002
90
2
X
3,368.09
X
24587
004
90
2
X
3,104.74
X
24587
001
90
2
X
3,422.70
X
24600
003
90
2
X
659.44
X
24600
002
90
2
X
694.42
X
24600
004
90
2
X
652.12
X
24600
001
90
2
X
728.57
X
24605
001
90
2
X
868.23
X
24605
004
90
2
X
803.44
X
24605
002
90
2
X
857.27
X
24605
003
90
2
X
819.90
X
24615
003
90
2
X
2,034.40
X
24615
002
90
2
X
2,227.43
X
24615
004
90
2
X
2,137.88
X
24615
001
90
2
X
2,222.44
X
24620
004
90
2
X
1,135.41
X
24620
001
90
2
X
1,232.88
X
24620
002
90
2
X
1,216.40
X
24620
003
90
2
X
1,148.39
X
24635
003
90
2
X
2,634.83
X
24635
002
90
2
X
2,820.94
X
24635
004
90
2
X
2,603.61
X
24635
001
90
2
X
2,865.96
X
24640
001
10
2
X
233.15
X
24640
002
10
2
X
216.05
X
24640
003
10
2
X
205.25
X
24640
004
10
2
X
215.37
X
24650
001
90
2
X
520.89
397.53
24650
004
90
2
X
548.37
417.00
24650
003
90
2
X
541.52
412.19
24650
002
90
2
X
579.77
441.84
24655
001
90
2
X
861.47
X
24655
004
90
2
X
788.67
X
24655
002
90
2
X
849.07
X
24655
003
90
2
X
797.86
X
24665
004
90
2
X
1,750.61
X
24665
001
90
2
X
1,923.96
X
24665
003
90
2
X
1,758.91
X
24665
002
90
2
X
1,783.16
X
24666
001
90
2
X
2,361.31
X
24666
002
90
2
X
2,321.82
X
24666
003
90
2
X
2,158.42
X
24666
004
90
2
X
2,132.05
X
24670
004
90
2
X
475.31
X
24670
002
90
2
X
512.03
X
24670
001
90
2
X
512.41
X
24670
003
90
2
X
480.99
X
24675
001
90
2
X
969.35
X
24675
004
90
2
X
885.04
X
24675
003
90
2
X
895.40
X
24675
002
90
2
X
955.04
X
24685
003
90
2
X
1,882.77
X
24685
002
90
2
X
2,020.49
X
24685
004
90
2
X
1,860.16
X
24685
001
90
2
X
2,053.72
X
24800
004
90
2
X
2,357.15
X
24800
003
90
2
X
2,385.82
X
24800
002
90
2
X
2,553.63
X
24800
001
90
2
X
2,815.35
X
24802
004
90
2
X
2,777.21
X
24802
002
90
2
X
3,014.70
X
24802
003
90
2
X
2,810.68
X
24802
001
90
2
X
3,064.05
X
24900
001
90
2
X
2,032.35
X
24900
004
90
2
X
1,839.83
X
24900
002
90
2
X
1,999.02
X
24900
003
90
2
X
1,861.61
X
24920
003
90
2
X
1,740.45
X
24920
002
90
2
X
1,862.10
X
24920
004
90
2
X
1,720.34
X
24920
001
90
2
X
1,891.57
X
24925
002
90
2
X
1,512.07
X
24925
003
90
2
X
1,078.86
X
24925
001
90
2
X
1,534.25
X
24925
004
90
2
X
1,402.99
X
24930
001
90
2
X
2,115.43
X
24930
002
90
2
X
2,083.80
X
24930
003
90
2
X
1,953.00
X
24930
004
90
2
X
1,929.78
X
24931
002
90
2
X
2,764.48
X
24931
003
90
2
X
2,576.66
X
24931
001
90
2
X
2,809.96
X
24931
004
90
2
X
2,545.97
X
24935
001
90
2
X
3,444.02
X
24935
004
90
2
X
3,121.56
X
24935
003
90
2
X
3,159.17
X
24935
002
90
2
X
3,388.55
X
24940
004
90
2
X
3,121.56
X
24940
001
90
2
X
3,444.02
X
24940
003
90
2
X
3,159.17
X
24940
002
90
2
X
3,388.55
X
24999
YYY
2
X
#
X
25000
001
90
2
X
1,187.86
X
25000
004
90
2
X
1,088.85
X
25000
002
90
2
X
1,116.87
X
25000
003
90
2
X
1,021.99
X
25001
002
90
2
X
629.60
X
25001
003
90
2
X
629.60
X
25001
004
90
2
X
629.60
X
25001
001
90
2
X
719.98
X
25020
004
90
2
X
1,101.62
X
25020
001
90
2
X
1,211.89
X
25020
002
90
2
X
1,197.29
X
25020
003
90
2
X
1,114.46
X
25023
004
90
2
X
1,838.39
X
25023
003
90
2
X
1,851.14
X
25023
002
90
2
X
1,952.49
X
25023
001
90
2
X
1,933.55
X
25024
004
90
2
X
1,467.49
X
25024
001
90
2
X
1,665.88
X
25024
003
90
2
X
1,467.49
X
25024
002
90
2
X
1,467.49
X
25025
003
90
2
X
2,378.14
X
25025
002
90
2
X
2,378.14
X
25025
004
90
2
X
2,378.14
X
25025
001
90
2
X
2,685.09
X
25028
001
90
2
X
756.17
X
25028
004
90
2
X
689.20
X
25028
003
90
2
X
706.66
X
25028
002
90
2
X
749.37
X
25031
002
90
2
X
509.03
X
25031
003
90
2
X
490.60
X
25031
004
90
2
X
410.96
X
25031
001
90
2
X
513.57
X
25035
003
90
2
X
1,352.86
X
25035
001
90
2
X
1,560.82
X
25035
002
90
2
X
1,539.71
X
25035
004
90
2
X
1,457.33
X
25040
004
90
2
X
1,360.36
X
25040
001
90
2
X
1,495.22
X
25040
003
90
2
X
1,376.59
X
25040
002
90
2
X
1,561.98
X
25065
003
10
2
X
340.11
X
25065
002
10
2
X
285.13
X
25065
004
10
2
X
265.23
X
25065
001
10
2
X
358.94
X
25066
002
90
2
X
458.47
X
25066
003
90
2
X
590.83
X
25066
004
90
2
X
584.43
X
25066
001
90
2
X
463.87
X
25071
001
90
2
X
800.69
X
25071
003
90
2
X
711.84
X
25071
002
90
2
X
711.84
X
25071
004
90
2
X
711.84
X
25073
004
90
2
X
885.20
X
25073
002
90
2
X
885.20
X
25073
003
90
2
X
885.20
X
25073
001
90
2
X
996.69
X
25075
001
90
2
X
706.40
X
25075
004
90
2
X
677.65
X
25075
003
90
2
X
706.90
X
25075
002
90
2
X
763.52
X
25076
003
90
2
X
961.56
X
25076
002
90
2
X
1,018.98
X
25076
004
90
2
X
936.40
X
25076
001
90
2
X
1,046.08
X
25077
002
90
2
X
1,864.61
X
25077
003
90
2
X
2,023.20
X
25077
001
90
2
X
1,886.53
X
25077
004
90
2
X
1,999.58
X
25078
001
90
2
X
2,138.00
X
25078
004
90
2
X
1,908.67
X
25078
003
90
2
X
1,908.67
X
25078
002
90
2
X
1,908.67
X
25085
002
90
2
X
1,304.71
X
25085
003
90
2
X
1,091.36
X
25085
004
90
2
X
1,078.39
X
25085
001
90
2
X
1,185.82
X
25100
004
90
2
X
1,181.26
X
25100
001
90
2
X
1,045.42
X
25100
003
90
2
X
950.39
X
25100
002
90
2
X
1,251.81
X
25101
001
90
2
X
1,277.32
X
25101
003
90
2
X
1,161.63
X
25101
002
90
2
X
1,239.31
X
25101
004
90
2
X
1,173.95
X
25105
001
90
2
X
1,960.03
X
25105
004
90
2
X
1,423.30
X
25105
003
90
2
X
1,899.82
X
25105
002
90
2
X
1,863.89
X
25107
004
90
2
X
1,243.81
X
25107
001
90
2
X
1,371.40
X
25107
002
90
2
X
1,349.37
X
25107
003
90
2
X
1,258.61
X
25109
002
90
2
X
805.01
X
25109
003
90
2
X
805.01
X
25109
001
90
2
X
927.34
X
25109
004
90
2
X
805.01
X
Return to CPT/HCPC List