You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page.
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 100-842
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
0001A-00842
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
0001A
002
XXX
9
X
21.49
X
0001A
003
XXX
9
X
21.49
X
0001A
001
XXX
9
X
23.91
X
0001A
004
XXX
9
X
21.49
X
0001U
X
813.60
X
0002A
002
XXX
9
X
36.03
X
0002A
003
XXX
9
X
36.03
X
0002A
004
XXX
9
X
36.03
X
0002A
001
XXX
9
X
40.05
X
0002U
X
28.25
X
0003A
002
XXX
9
X
50.98
X
0003A
003
XXX
9
X
50.98
X
0003A
001
XXX
9
X
56.52
X
0003A
004
XXX
9
X
50.98
X
0003U
X
1,073.50
X
0004A
003
XXX
9
X
47.42
X
0004A
002
XXX
9
X
47.42
X
0004A
004
XXX
9
X
47.42
X
0004A
001
XXX
9
X
52.59
X
0005U
X
858.80
X
0007U
X
129.31
X
0008U
X
675.64
X
0009U
X
120.91
X
00100
003
XXX
9
73.48
X
X
00100
002
XXX
9
76.34
X
X
00100
004
XXX
9
68.46
X
X
00100
001
XXX
9
76.85
X
X
00102
002
XXX
9
76.34
X
X
00102
003
XXX
9
73.48
X
X
00102
001
XXX
9
76.85
X
X
00102
004
XXX
9
68.46
X
X
00103
002
XXX
9
76.34
X
X
00103
003
XXX
9
73.48
X
X
00103
001
XXX
9
76.85
X
X
00103
004
XXX
9
68.46
X
X
00104
003
XXX
9
73.48
X
X
00104
002
XXX
9
76.34
X
X
00104
004
XXX
9
68.46
X
X
00104
001
XXX
9
76.85
X
X
0010U
X
482.80
X
0011A
003
XXX
9
X
21.49
X
0011A
002
XXX
9
X
21.49
X
0011A
001
XXX
9
X
23.91
X
0011A
004
XXX
9
X
21.49
X
0011U
X
129.31
X
00120
003
XXX
9
73.48
X
X
00120
002
XXX
9
76.34
X
X
00120
001
XXX
9
76.85
X
X
00120
004
XXX
9
68.46
X
X
00124
003
XXX
9
73.48
X
X
00124
002
XXX
9
76.34
X
X
00124
004
XXX
9
68.46
X
X
00124
001
XXX
9
76.85
X
X
00126
001
XXX
9
76.85
X
X
00126
004
XXX
9
68.46
X
X
00126
002
XXX
9
76.34
X
X
00126
003
XXX
9
73.48
X
X
0012A
002
XXX
9
X
36.03
X
0012A
003
XXX
9
X
36.03
X
0012A
001
XXX
9
X
40.05
X
0012A
004
XXX
9
X
36.03
X
0013A
002
XXX
9
X
50.98
X
0013A
003
XXX
9
X
50.98
X
0013A
001
XXX
9
X
56.52
X
0013A
004
XXX
9
X
50.98
X
00140
004
XXX
9
68.46
X
X
00140
002
XXX
9
76.34
X
X
00140
001
XXX
9
76.85
X
X
00140
003
XXX
9
73.48
X
X
00142
002
XXX
9
76.34
X
X
00142
003
XXX
9
73.48
X
X
00142
001
XXX
9
76.85
X
X
00142
004
XXX
9
68.46
X
X
00144
002
XXX
9
76.34
X
X
00144
003
XXX
9
73.48
X
X
00144
001
XXX
9
76.85
X
X
00144
004
XXX
9
68.46
X
X
00145
004
XXX
9
68.46
X
X
00145
002
XXX
9
76.34
X
X
00145
003
XXX
9
73.48
X
X
00145
001
XXX
9
76.85
X
X
00147
001
XXX
9
76.85
X
X
00147
004
XXX
9
68.46
X
X
00147
002
XXX
9
76.34
X
X
00147
003
XXX
9
73.48
X
X
00148
004
XXX
9
68.46
X
X
00148
002
XXX
9
76.34
X
X
00148
003
XXX
9
73.48
X
X
00148
001
XXX
9
76.85
X
X
00160
004
XXX
9
68.46
X
X
00160
001
XXX
9
76.85
X
X
00160
003
XXX
9
73.48
X
X
00160
002
XXX
9
76.34
X
X
00162
004
XXX
9
68.46
X
X
00162
001
XXX
9
76.85
X
X
00162
003
XXX
9
73.48
X
X
00162
002
XXX
9
76.34
X
X
00164
002
XXX
9
76.34
X
X
00164
003
XXX
9
73.48
X
X
00164
004
XXX
9
68.46
X
X
00164
001
XXX
9
76.85
X
X
0016U
X
185.27
X
00170
003
XXX
9
73.48
X
X
00170
002
XXX
9
76.34
X
X
00170
004
XXX
9
68.46
X
X
00170
001
XXX
9
76.85
X
X
00172
003
XXX
9
73.48
X
X
00172
002
XXX
9
76.34
X
X
00172
004
XXX
9
68.46
X
X
00172
001
XXX
9
76.85
X
X
00174
003
XXX
9
73.48
X
X
00174
002
XXX
9
76.34
X
X
00174
001
XXX
9
76.85
X
X
00174
004
XXX
9
68.46
X
X
00176
004
XXX
9
68.46
X
X
00176
001
XXX
9
76.85
X
X
00176
003
XXX
9
73.48
X
X
00176
002
XXX
9
76.34
X
X
0017U
X
103.58
X
0018U
X
3,392.36
X
00190
002
XXX
9
76.34
X
X
00190
003
XXX
9
73.48
X
X
00190
004
XXX
9
68.46
X
X
00190
001
XXX
9
76.85
X
X
00192
003
XXX
9
73.48
X
X
00192
002
XXX
9
76.34
X
X
00192
004
XXX
9
68.46
X
X
00192
001
XXX
9
76.85
X
X
0019U
X
4,152.75
X
00210
001
XXX
9
76.85
X
X
00210
004
XXX
9
68.46
X
X
00210
002
XXX
9
76.34
X
X
00210
003
XXX
9
73.48
X
X
00211
004
XXX
9
68.46
X
X
00211
001
XXX
9
76.85
X
X
00211
002
XXX
9
76.34
X
X
00211
003
XXX
9
73.48
X
X
00212
004
XXX
9
68.46
X
X
00212
001
XXX
9
76.85
X
X
00212
002
XXX
9
76.34
X
X
00212
003
XXX
9
73.48
X
X
00214
001
XXX
9
76.85
X
X
00214
004
XXX
9
68.46
X
X
00214
002
XXX
9
76.34
X
X
00214
003
XXX
9
73.48
X
X
00215
002
XXX
9
76.34
X
X
00215
003
XXX
9
73.48
X
X
00215
004
XXX
9
68.46
X
X
00215
001
XXX
9
76.85
X
X
00216
001
XXX
9
76.85
X
X
00216
004
XXX
9
68.46
X
X
00216
003
XXX
9
73.48
X
X
00216
002
XXX
9
76.34
X
X
00218
004
XXX
9
68.46
X
X
00218
001
XXX
9
76.85
X
X
00218
003
XXX
9
73.48
X
X
00218
002
XXX
9
76.34
X
X
0021A
X
#
X
0021U
X
858.80
X
00220
003
XXX
9
73.48
X
X
00220
002
XXX
9
76.34
X
X
00220
004
XXX
9
68.46
X
X
00220
001
XXX
9
76.85
X
X
00222
004
XXX
9
68.46
X
X
00222
002
XXX
9
76.34
X
X
00222
003
XXX
9
73.48
X
X
00222
001
XXX
9
76.85
X
X
0022A
X
#
X
0022U
X
2,203.50
X
0023U
X
280.82
X
0024U
X
38.63
X
0025U
X
96.92
X
0026U
X
4,068.00
X
0027U
X
137.76
X
0029U
X
838.77
X
00300
002
XXX
9
76.34
X
X
00300
003
XXX
9
73.48
X
X
00300
001
XXX
9
76.85
X
X
00300
004
XXX
9
68.46
X
X
0030U
X
151.57
X
0031A
003
XXX
9
X
47.42
X
0031A
002
XXX
9
X
47.42
X
0031A
004
XXX
9
X
47.42
X
0031A
001
XXX
9
X
52.59
X
0031U
X
197.54
X
00320
002
XXX
9
76.34
X
X
00320
003
XXX
9
73.48
X
X
00320
001
XXX
9
76.85
X
X
00320
004
XXX
9
68.46
X
X
00322
002
XXX
9
76.34
X
X
00322
003
XXX
9
73.48
X
X
00322
001
XXX
9
76.85
X
X
00322
004
XXX
9
68.46
X
X
00326
003
XXX
9
73.48
X
X
00326
002
XXX
9
76.34
X
X
00326
001
XXX
9
76.85
X
X
00326
004
XXX
9
68.46
X
X
0032U
X
197.54
X
0033U
X
395.07
X
0034A
004
XXX
9
X
47.42
X
0034A
001
XXX
9
X
52.59
X
0034A
003
XXX
9
X
47.42
X
0034A
002
XXX
9
X
47.42
X
0034U
X
526.77
X
00350
003
XXX
9
73.48
X
X
00350
002
XXX
9
76.34
X
X
00350
004
XXX
9
68.46
X
X
00350
001
XXX
9
76.85
X
X
00352
004
XXX
9
68.46
X
X
00352
003
XXX
9
73.48
X
X
00352
002
XXX
9
76.34
X
X
00352
001
XXX
9
76.85
X
X
0035U
X
611.32
X
0036U
X
5,401.40
X
0037U
X
3,955.00
X
0038U
X
33.45
X
0039U
X
15.53
X
00400
002
XXX
9
76.34
X
X
00400
003
XXX
9
73.48
X
X
00400
001
XXX
9
76.85
X
X
00400
004
XXX
9
68.46
X
X
00402
004
XXX
9
68.46
X
X
00402
002
XXX
9
76.34
X
X
00402
003
XXX
9
73.48
X
X
00402
001
XXX
9
76.85
X
X
00404
004
XXX
9
68.46
X
X
00404
001
XXX
9
76.85
X
X
00404
003
XXX
9
73.48
X
X
00404
002
XXX
9
76.34
X
X
00406
002
XXX
9
76.34
X
X
00406
003
XXX
9
73.48
X
X
00406
001
XXX
9
76.85
X
X
00406
004
XXX
9
68.46
X
X
0040U
X
463.19
X
00410
001
XXX
9
76.85
X
X
00410
004
XXX
9
68.46
X
X
00410
002
XXX
9
76.34
X
X
00410
003
XXX
9
73.48
X
X
0041A
002
X
47.42
X
0041A
003
X
47.42
X
0041A
004
X
47.42
X
0041A
001
X
52.59
X
0041U
X
19.45
X
0042A
001
X
52.59
X
0042A
004
X
47.42
X
0042A
002
X
47.42
X
0042A
003
X
47.42
X
0042U
X
19.45
X
0043U
X
16.79
X
0044A
X
#
X
0044U
X
16.79
X
00450
004
XXX
9
68.46
X
X
00450
001
XXX
9
76.85
X
X
00450
003
XXX
9
73.48
X
X
00450
002
XXX
9
76.34
X
X
00454
002
XXX
9
76.34
X
X
00454
003
XXX
9
73.48
X
X
00454
004
XXX
9
68.46
X
X
00454
001
XXX
9
76.85
X
X
0045U
X
4,376.49
X
0046U
X
460.40
X
00470
003
XXX
9
73.48
X
X
00470
002
XXX
9
76.34
X
X
00470
004
XXX
9
68.46
X
X
00470
001
XXX
9
76.85
X
X
00472
004
XXX
9
68.46
X
X
00472
002
XXX
9
76.34
X
X
00472
003
XXX
9
73.48
X
X
00472
001
XXX
9
76.85
X
X
00474
001
XXX
9
76.85
X
X
00474
004
XXX
9
68.46
X
X
00474
003
XXX
9
73.48
X
X
00474
002
XXX
9
76.34
X
X
0047U
X
4,376.49
X
0048U
X
3,299.15
X
0049U
X
460.40
X
00500
001
XXX
9
76.85
X
X
00500
004
XXX
9
68.46
X
X
00500
003
XXX
9
73.48
X
X
00500
002
XXX
9
76.34
X
X
0050U
X
3,295.76
X
0051A
003
XXX
9
X
47.42
X
0051A
002
XXX
9
X
47.42
X
0051A
001
XXX
9
X
52.59
X
0051A
004
XXX
9
X
47.42
X
0051U
X
218.89
X
00520
001
XXX
9
76.85
X
X
00520
003
XXX
9
73.48
X
X
00520
002
XXX
9
76.34
X
X
00520
004
XXX
9
68.46
X
X
00522
002
XXX
9
76.34
X
X
00522
003
XXX
9
73.48
X
X
00522
004
XXX
9
68.46
X
X
00522
001
XXX
9
76.85
X
X
00524
001
XXX
9
76.85
X
X
00524
004
XXX
9
68.46
X
X
00524
003
XXX
9
73.48
X
X
00524
002
XXX
9
76.34
X
X
00528
002
XXX
9
76.34
X
X
00528
003
XXX
9
73.48
X
X
00528
004
XXX
9
68.46
X
X
00528
001
XXX
9
76.85
X
X
00529
002
XXX
9
76.34
X
X
00529
003
XXX
9
73.48
X
X
00529
004
XXX
9
68.46
X
X
00529
001
XXX
9
76.85
X
X
0052A
004
XXX
9
X
47.42
X
0052A
001
XXX
9
X
52.59
X
0052A
003
XXX
9
X
47.42
X
0052A
002
XXX
9
X
47.42
X
0052U
X
38.26
X
00530
004
XXX
9
68.46
X
X
00530
002
XXX
9
76.34
X
X
00530
003
XXX
9
73.48
X
X
00530
001
XXX
9
76.85
X
X
00532
002
XXX
9
76.34
X
X
00532
003
XXX
9
73.48
X
X
00532
004
XXX
9
68.46
X
X
00532
001
XXX
9
76.85
X
X
00534
004
XXX
9
68.46
X
X
00534
001
XXX
9
76.85
X
X
00534
003
XXX
9
73.48
X
X
00534
002
XXX
9
76.34
X
X
00537
004
XXX
9
68.46
X
X
00537
001
XXX
9
76.85
X
X
00537
002
XXX
9
76.34
X
X
00537
003
XXX
9
73.48
X
X
00539
003
XXX
9
73.48
X
X
00539
001
XXX
9
76.85
X
X
00539
002
XXX
9
76.34
X
X
00539
004
XXX
9
68.46
X
X
0053A
002
XXX
9
X
47.42
X
0053A
003
XXX
9
X
47.42
X
0053A
004
XXX
9
X
47.42
X
0053A
001
XXX
9
X
52.59
X
00540
004
XXX
9
68.46
X
X
00540
001
XXX
9
76.85
X
X
00540
003
XXX
9
73.48
X
X
00540
002
XXX
9
76.34
X
X
00541
002
XXX
9
76.34
X
X
00541
003
XXX
9
73.48
X
X
00541
001
XXX
9
76.85
X
X
00541
004
XXX
9
68.46
X
X
00542
004
XXX
9
68.46
X
X
00542
003
XXX
9
73.48
X
X
00542
002
XXX
9
76.34
X
X
00542
001
XXX
9
76.85
X
X
00546
004
XXX
9
68.46
X
X
00546
001
XXX
9
76.85
X
X
00546
002
XXX
9
76.34
X
X
00546
003
XXX
9
73.48
X
X
00548
001
XXX
9
76.85
X
X
00548
004
XXX
9
68.46
X
X
00548
003
XXX
9
73.48
X
X
00548
002
XXX
9
76.34
X
X
0054A
004
XXX
9
X
47.42
X
0054A
001
XXX
9
X
52.59
X
0054A
003
XXX
9
X
47.42
X
0054A
002
XXX
9
X
47.42
X
0054U
X
168.32
X
00550
002
XXX
9
76.34
X
X
00550
003
XXX
9
73.48
X
X
00550
004
XXX
9
68.46
X
X
00550
001
XXX
9
76.85
X
X
0055U
X
3,661.20
X
00560
001
XXX
9
76.85
X
X
00560
004
XXX
9
68.46
X
X
00560
002
XXX
9
76.34
X
X
00560
003
XXX
9
73.48
X
X
00561
001
XXX
9
76.85
X
X
00561
004
XXX
9
68.46
X
X
00561
003
XXX
9
73.48
X
X
00561
002
XXX
9
76.34
X
X
00562
003
XXX
9
73.48
X
X
00562
002
XXX
9
76.34
X
X
00562
004
XXX
9
68.46
X
X
00562
001
XXX
9
76.85
X
X
00563
002
XXX
9
76.34
X
X
00563
003
XXX
9
73.48
X
X
00563
001
XXX
9
76.85
X
X
00563
004
XXX
9
68.46
X
X
00566
002
XXX
9
76.34
X
X
00566
003
XXX
9
73.48
X
X
00566
001
XXX
9
76.85
X
X
00566
004
XXX
9
68.46
X
X
00567
001
XXX
9
76.85
X
X
00567
003
XXX
9
73.48
X
X
00567
002
XXX
9
76.34
X
X
00567
004
XXX
9
68.46
X
X
00580
001
XXX
9
76.85
X
X
00580
004
XXX
9
68.46
X
X
00580
003
XXX
9
73.48
X
X
00580
002
XXX
9
76.34
X
X
0058U
X
364.94
X
0059U
X
364.94
X
00600
002
XXX
9
76.34
X
X
00600
003
XXX
9
73.48
X
X
00600
004
XXX
9
68.46
X
X
00600
001
XXX
9
76.85
X
X
00604
004
XXX
9
68.46
X
X
00604
001
XXX
9
76.85
X
X
00604
003
XXX
9
73.48
X
X
00604
002
XXX
9
76.34
X
X
0060U
X
857.73
X
0061U
X
28.36
X
00620
004
XXX
9
68.46
X
X
00620
001
XXX
9
76.85
X
X
00620
003
XXX
9
73.48
X
X
00620
002
XXX
9
76.34
X
X
00625
002
XXX
9
76.34
X
X
00625
003
XXX
9
73.48
X
X
00625
004
XXX
9
68.46
X
X
00625
001
XXX
9
76.85
X
X
00626
004
XXX
9
68.46
X
X
00626
001
XXX
9
76.85
X
X
00626
003
XXX
9
73.48
X
X
00626
002
XXX
9
76.34
X
X
0062U
X
430.21
X
00630
001
XXX
9
76.85
X
X
00630
004
XXX
9
68.46
X
X
00630
003
XXX
9
73.48
X
X
00630
002
XXX
9
76.34
X
X
00632
002
XXX
9
76.34
X
X
00632
003
XXX
9
73.48
X
X
00632
004
XXX
9
68.46
X
X
00632
001
XXX
9
76.85
X
X
00635
003
XXX
9
73.48
X
X
00635
002
XXX
9
76.34
X
X
00635
001
XXX
9
76.85
X
X
00635
004
XXX
9
68.46
X
X
0063U
X
847.50
X
00640
001
XXX
9
76.85
X
X
00640
004
XXX
9
68.46
X
X
00640
002
XXX
9
76.34
X
X
00640
003
XXX
9
73.48
X
X
0064A
002
XXX
9
X
47.42
X
0064A
003
XXX
9
X
47.42
X
0064A
004
XXX
9
X
47.42
X
0064A
001
XXX
9
X
52.59
X
0064U
X
35.40
X
0065U
X
20.44
X
00670
003
XXX
9
73.48
X
X
00670
002
XXX
9
76.34
X
X
00670
004
XXX
9
68.46
X
X
00670
001
XXX
9
76.85
X
X
0067U
X
2,143.61
X
0068U
X
161.17
X
0069U
X
429.40
X
00700
002
XXX
9
76.34
X
X
00700
003
XXX
9
73.48
X
X
00700
004
XXX
9
68.46
X
X
00700
001
XXX
9
76.85
X
X
00702
004
XXX
9
68.46
X
X
00702
003
XXX
9
73.48
X
X
00702
002
XXX
9
76.34
X
X
00702
001
XXX
9
76.85
X
X
0070U
X
764.30
X
0071A
001
XXX
9
X
52.59
X
0071A
004
XXX
9
X
47.42
X
0071A
002
XXX
9
X
47.42
X
0071A
003
XXX
9
X
47.42
X
0071U
X
678.00
X
0072A
003
XXX
9
X
47.42
X
0072A
002
XXX
9
X
47.42
X
0072A
001
XXX
9
X
52.59
X
0072A
004
XXX
9
X
47.42
X
0072U
X
509.53
X
00730
001
XXX
9
76.85
X
X
00730
004
XXX
9
68.46
X
X
00730
003
XXX
9
73.48
X
X
00730
002
XXX
9
76.34
X
X
00731
001
XXX
9
76.85
X
X
00731
004
XXX
9
68.46
X
X
00731
002
XXX
9
76.34
X
X
00731
003
XXX
9
73.48
X
X
00732
004
XXX
9
68.46
X
X
00732
002
XXX
9
76.34
X
X
00732
003
XXX
9
73.48
X
X
00732
001
XXX
9
76.85
X
X
0073A
003
XXX
9
X
47.42
X
0073A
002
XXX
9
X
47.42
X
0073A
004
XXX
9
X
47.42
X
0073A
001
XXX
9
X
52.59
X
0073U
X
509.53
X
0074A
X
#
X
0074U
X
509.53
X
00750
002
XXX
9
76.34
X
X
00750
003
XXX
9
73.48
X
X
00750
001
XXX
9
76.85
X
X
00750
004
XXX
9
68.46
X
X
00752
002
XXX
9
76.34
X
X
00752
003
XXX
9
73.48
X
X
00752
001
XXX
9
76.85
X
X
00752
004
XXX
9
68.46
X
X
00754
002
XXX
9
76.34
X
X
00754
003
XXX
9
73.48
X
X
00754
001
XXX
9
76.85
X
X
00754
004
XXX
9
68.46
X
X
00756
001
XXX
9
76.85
X
X
00756
004
XXX
9
68.46
X
X
00756
003
XXX
9
73.48
X
X
00756
002
XXX
9
76.34
X
X
0075U
X
509.53
X
0076U
X
509.53
X
00770
004
XXX
9
68.46
X
X
00770
003
XXX
9
73.48
X
X
00770
002
XXX
9
76.34
X
X
00770
001
XXX
9
76.85
X
X
0077U
X
49.08
X
0078U
X
509.53
X
00790
004
XXX
9
68.46
X
X
00790
001
XXX
9
76.85
X
X
00790
003
XXX
9
73.48
X
X
00790
002
XXX
9
76.34
X
X
00792
004
XXX
9
68.46
X
X
00792
002
XXX
9
76.34
X
X
00792
003
XXX
9
73.48
X
X
00792
001
XXX
9
76.85
X
X
00794
004
XXX
9
68.46
X
X
00794
001
XXX
9
76.85
X
X
00794
003
XXX
9
73.48
X
X
00794
002
XXX
9
76.34
X
X
00796
001
XXX
9
76.85
X
X
00796
004
XXX
9
68.46
X
X
00796
002
XXX
9
76.34
X
X
00796
003
XXX
9
73.48
X
X
00797
003
XXX
9
73.48
X
X
00797
002
XXX
9
76.34
X
X
00797
004
XXX
9
68.46
X
X
00797
001
XXX
9
76.85
X
X
0079U
X
#
X
00800
004
XXX
9
68.46
X
X
00800
001
XXX
9
76.85
X
X
00800
002
XXX
9
76.34
X
X
00800
003
XXX
9
73.48
X
X
00802
004
XXX
9
68.46
X
X
00802
002
XXX
9
76.34
X
X
00802
003
XXX
9
73.48
X
X
00802
001
XXX
9
76.85
X
X
0080U
X
3,977.60
X
00811
004
XXX
9
68.46
X
X
00811
001
XXX
9
76.85
X
X
00811
003
XXX
9
73.48
X
X
00811
002
XXX
9
76.34
X
X
00812
003
XXX
9
73.48
X
X
00812
002
XXX
9
76.34
X
X
00812
004
XXX
9
68.46
X
X
00812
001
XXX
9
76.85
X
X
00813
004
XXX
9
68.46
X
X
00813
001
XXX
9
76.85
X
X
00813
003
XXX
9
73.48
X
X
00813
002
XXX
9
76.34
X
X
00820
002
XXX
9
76.34
X
X
00820
003
XXX
9
73.48
X
X
00820
001
XXX
9
76.85
X
X
00820
004
XXX
9
68.46
X
X
0082U
X
279.02
X
00830
002
XXX
9
76.34
X
X
00830
003
XXX
9
73.48
X
X
00830
004
XXX
9
68.46
X
X
00830
001
XXX
9
76.85
X
X
00832
002
XXX
9
76.34
X
X
00832
003
XXX
9
73.48
X
X
00832
004
XXX
9
68.46
X
X
00832
001
XXX
9
76.85
X
X
00834
001
XXX
9
76.85
X
X
00834
004
XXX
9
68.46
X
X
00834
002
XXX
9
76.34
X
X
00834
003
XXX
9
73.48
X
X
00836
004
XXX
9
68.46
X
X
00836
002
XXX
9
76.34
X
X
00836
003
XXX
9
73.48
X
X
00836
001
XXX
9
76.85
X
X
0083U
X
189.11
X
00840
004
XXX
9
68.46
X
X
00840
001
XXX
9
76.85
X
X
00840
002
XXX
9
76.34
X
X
00840
003
XXX
9
73.48
X
X
00842
003
XXX
9
73.48
X
X
00842
002
XXX
9
76.34
X
X
00842
004
XXX
9
68.46
X
X
00842
001
XXX
9
76.85
X
X
Return to CPT/HCPC List