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 21015-21435
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
21015-21435
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
21015
003
90
2
X
1,287.84
X
21015
002
90
2
X
1,394.02
X
21015
004
90
2
X
1,272.19
X
21015
001
90
2
X
1,419.76
X
21016
004
90
2
X
1,753.46
X
21016
002
90
2
X
1,753.46
X
21016
003
90
2
X
1,753.46
X
21016
001
90
2
X
1,965.61
X
21025
003
90
2
X
982.35
X
21025
002
90
2
X
1,053.10
X
21025
001
90
2
X
1,066.73
X
21025
004
90
2
X
984.59
X
21026
004
90
2
X
819.96
X
21026
002
90
2
X
940.28
X
21026
003
90
2
X
921.67
X
21026
001
90
2
X
1,060.63
X
21029
001
90
2
X
1,928.59
X
21029
004
90
2
X
1,766.01
X
21029
002
90
2
X
1,901.57
X
21029
003
90
2
X
1,788.85
X
21030
004
90
2
X
1,108.08
940.07
21030
001
90
2
X
1,185.91
1,002.66
21030
003
90
2
X
1,120.71
949.78
21030
002
90
2
X
1,173.26
992.23
21031
004
90
2
X
613.42
X
21031
001
90
2
X
674.98
X
21031
003
90
2
X
621.81
X
21031
002
90
2
X
664.61
X
21032
001
90
2
X
949.31
X
21032
004
90
2
X
874.60
X
21032
003
90
2
X
885.44
X
21032
002
90
2
X
936.89
X
21034
002
90
2
X
2,281.95
X
21034
003
90
2
X
2,315.12
X
21034
004
90
2
X
2,383.64
X
21034
001
90
2
X
2,366.81
X
21040
003
90
2
X
652.57
X
21040
002
90
2
X
720.28
X
21040
001
90
2
X
664.93
X
21040
004
90
2
X
624.89
X
21044
001
90
2
X
2,441.87
X
21044
004
90
2
X
2,240.05
X
21044
003
90
2
X
2,267.28
X
21044
002
90
2
X
2,407.94
X
21045
004
90
2
X
3,143.02
X
21045
003
90
2
X
3,181.57
X
21045
002
90
2
X
3,381.68
X
21045
001
90
2
X
3,429.97
X
21046
002
90
2
X
1,903.11
X
21046
003
90
2
X
1,903.11
X
21046
001
90
2
X
2,130.46
X
21046
004
90
2
X
1,903.11
X
21047
004
90
2
X
2,358.37
X
21047
001
90
2
X
2,621.50
X
21047
003
90
2
X
2,358.37
X
21047
002
90
2
X
2,358.37
X
21048
001
90
2
X
2,190.92
X
21048
004
90
2
X
1,959.38
X
21048
002
90
2
X
1,959.38
X
21048
003
90
2
X
1,959.38
X
21049
001
90
2
X
2,470.37
X
21049
004
90
2
X
2,240.72
X
21049
003
90
2
X
2,240.72
X
21049
002
90
2
X
2,240.72
X
21050
001
90
2
X
2,630.49
X
21050
004
90
2
X
2,409.31
X
21050
003
90
2
X
2,440.33
X
21050
002
90
2
X
2,640.31
X
21060
003
90
2
X
2,306.98
X
21060
002
90
2
X
2,452.60
X
21060
004
90
2
X
2,277.68
X
21060
001
90
2
X
2,487.61
X
21070
001
90
2
X
1,721.02
X
21070
003
90
2
X
1,595.38
X
21070
002
90
2
X
1,696.61
X
21070
004
90
2
X
1,576.17
X
21073
001
90
2
X
683.81
435.44
21073
004
90
2
X
590.57
384.62
21073
002
90
2
X
590.57
384.62
21073
003
90
2
X
590.57
384.62
21076
001
10
2
X
3,703.67
2,693.07
21076
003
10
2
X
3,326.06
2,434.94
21076
002
10
2
X
3,555.97
2,582.26
21076
004
10
2
X
3,273.90
2,400.24
21077
001
90
2
X
9,314.73
6,772.71
21077
003
90
2
X
8,365.17
6,123.82
21077
002
90
2
X
8,943.36
6,494.23
21077
004
90
2
X
8,233.95
6,036.60
21079
90
2
X
*
X
21080
90
2
X
*
X
21081
90
2
X
*
X
21082
90
2
X
*
X
21083
90
2
X
*
X
21084
90
2
X
*
X
21085
10
2
X
*
X
21086
90
2
X
*
X
21087
90
2
X
*
X
21088
90
0
X
*
X
21089
YYY
0
X
#
X
21100
003
90
2
X
786.94
X
21100
002
90
2
X
884.67
X
21100
001
90
2
X
575.32
X
21100
004
90
2
X
541.98
X
21110
004
90
2
X
1,132.83
X
21110
001
90
2
X
1,233.08
X
21110
002
90
2
X
1,216.46
X
21110
003
90
2
X
1,147.28
X
21116
004
0
2
X
164.98
X
21116
001
0
2
X
152.03
X
21116
003
0
2
X
166.95
X
21116
002
0
2
X
162.80
X
21120
001
90
2
X
981.42
X
21120
004
90
2
X
903.17
X
21120
002
90
2
X
968.32
X
21120
003
90
2
X
913.99
X
21121
003
90
2
X
1,437.62
X
21121
002
90
2
X
1,523.41
X
21121
004
90
2
X
1,420.57
X
21121
001
90
2
X
1,544.15
X
21122
001
90
2
X
1,701.82
X
21122
004
90
2
X
1,565.48
X
21122
003
90
2
X
1,584.17
X
21122
002
90
2
X
1,678.92
X
21123
004
90
2
X
2,046.16
X
21123
001
90
2
X
2,223.94
X
21123
002
90
2
X
2,194.05
X
21123
003
90
2
X
2,070.63
X
21125
003
90
2
X
1,198.95
X
21125
002
90
2
X
1,270.28
X
21125
004
90
2
X
1,184.82
X
21125
001
90
2
X
1,287.44
X
21127
001
90
2
X
2,160.54
X
21127
004
90
2
X
1,987.97
X
21127
003
90
2
X
2,011.71
X
21127
002
90
2
X
2,131.51
X
21137
001
90
2
X
3,941.04
X
21137
003
90
2
X
3,941.04
X
21137
002
90
2
X
3,941.04
X
21137
004
90
2
X
3,941.04
X
21138
002
90
2
X
4,926.33
X
21138
003
90
2
X
4,926.33
X
21138
004
90
2
X
4,926.33
X
21138
001
90
2
X
4,926.33
X
21139
001
90
2
X
4,926.33
X
21139
004
90
2
X
4,926.33
X
21139
002
90
2
X
4,926.33
X
21139
003
90
2
X
4,926.33
X
21141
004
90
2
X
3,542.17
X
21141
001
90
2
X
3,978.54
X
21141
002
90
2
X
3,820.30
X
21141
003
90
2
X
3,594.95
X
21142
004
90
2
X
3,673.70
X
21142
001
90
2
X
4,125.75
X
21142
002
90
2
X
3,961.80
X
21142
003
90
2
X
3,728.40
X
21143
002
90
2
X
4,118.40
X
21143
003
90
2
X
3,875.93
X
21143
004
90
2
X
3,818.98
X
21143
001
90
2
X
4,288.86
X
21145
003
90
2
X
3,648.59
X
21145
002
90
2
X
3,866.56
X
21145
004
90
2
X
3,605.52
X
21145
001
90
2
X
3,919.23
X
21146
002
90
2
X
4,001.23
X
21146
003
90
2
X
3,775.66
X
21146
004
90
2
X
3,731.08
X
21146
001
90
2
X
4,055.72
X
21147
003
90
2
X
3,917.13
X
21147
002
90
2
X
4,151.26
X
21147
004
90
2
X
3,870.88
X
21147
001
90
2
X
4,207.94
X
21150
001
90
2
X
11,494.80
X
21150
002
90
2
X
11,494.80
X
21150
003
90
2
X
11,494.80
X
21150
004
90
2
X
11,494.80
X
21151
003
90
2
X
11,494.80
X
21151
002
90
2
X
11,494.80
X
21151
001
90
2
X
11,494.80
X
21151
004
90
2
X
11,494.80
X
21154
002
90
2
X
13,136.93
X
21154
003
90
2
X
13,136.93
X
21154
001
90
2
X
13,136.93
X
21154
004
90
2
X
13,136.93
X
21155
001
90
2
X
13,465.33
X
21155
004
90
2
X
13,465.33
X
21155
003
90
2
X
13,465.33
X
21155
002
90
2
X
13,465.33
X
21159
001
90
2
X
9,125.73
X
21159
004
90
2
X
8,277.38
X
21159
003
90
2
X
8,389.83
X
21159
002
90
2
X
8,892.29
X
21160
001
90
2
X
9,994.51
X
21160
004
90
2
X
9,065.36
X
21160
002
90
2
X
9,738.86
X
21160
003
90
2
X
9,188.43
X
21172
002
90
2
X
9,852.77
X
21172
003
90
2
X
9,852.77
X
21172
004
90
2
X
9,852.77
X
21172
001
90
2
X
9,852.77
X
21175
004
90
2
X
13,136.93
X
21175
002
90
2
X
13,136.93
X
21175
003
90
2
X
13,136.93
X
21175
001
90
2
X
13,136.93
X
21179
001
90
2
X
9,852.77
X
21179
004
90
2
X
9,852.77
X
21179
002
90
2
X
9,852.77
X
21179
003
90
2
X
9,852.77
X
21180
001
90
2
X
11,494.80
X
21180
003
90
2
X
11,494.80
X
21180
002
90
2
X
11,494.80
X
21180
004
90
2
X
11,494.80
X
21181
001
90
2
X
1,185.91
X
21181
004
90
2
X
1,108.08
X
21181
003
90
2
X
1,120.71
X
21181
002
90
2
X
1,173.26
X
21182
003
90
2
X
6,392.16
X
21182
002
90
2
X
6,775.16
X
21182
004
90
2
X
6,306.47
X
21182
001
90
2
X
6,953.02
X
21183
001
90
2
X
7,606.96
X
21183
003
90
2
X
6,993.34
X
21183
002
90
2
X
7,412.31
X
21183
004
90
2
X
6,899.59
X
21184
004
90
2
X
7,489.58
X
21184
001
90
2
X
8,256.82
X
21184
003
90
2
X
7,591.37
X
21184
002
90
2
X
8,045.74
X
21188
003
90
2
X
10,673.75
X
21188
002
90
2
X
10,673.75
X
21188
001
90
2
X
10,673.75
X
21188
004
90
2
X
10,673.75
X
21193
004
90
2
X
3,094.17
X
21193
003
90
2
X
3,131.28
X
21193
002
90
2
X
3,318.32
X
21193
001
90
2
X
3,363.53
X
21194
003
90
2
X
3,627.97
X
21194
002
90
2
X
3,844.65
X
21194
004
90
2
X
3,585.08
X
21194
001
90
2
X
3,897.06
X
21195
003
90
2
X
3,138.45
X
21195
001
90
2
X
3,371.14
X
21195
002
90
2
X
3,325.77
X
21195
004
90
2
X
3,101.33
X
21196
001
90
2
X
3,715.52
X
21196
002
90
2
X
3,665.78
X
21196
003
90
2
X
3,459.56
X
21196
004
90
2
X
3,418.69
X
21198
001
90
2
X
3,373.21
X
21198
002
90
2
X
3,322.68
X
21198
003
90
2
X
3,113.36
X
21198
004
90
2
X
3,074.87
X
21199
002
90
2
X
2,342.64
X
21199
003
90
2
X
2,342.64
X
21199
004
90
2
X
2,342.64
X
21199
001
90
2
X
2,594.85
X
21206
002
90
2
X
2,731.66
X
21206
003
90
2
X
2,577.64
X
21206
001
90
2
X
2,768.85
X
21206
004
90
2
X
2,547.18
X
21208
003
90
2
X
2,594.18
X
21208
002
90
2
X
2,820.47
X
21208
004
90
2
X
2,248.16
X
21208
001
90
2
X
2,937.89
X
21209
002
90
2
X
1,296.58
X
21209
003
90
2
X
1,215.29
X
21209
001
90
2
X
3,616.55
X
21209
004
90
2
X
1,201.29
X
21210
003
90
2
X
2,648.47
X
21210
002
90
2
X
2,809.53
X
21210
004
90
2
X
2,369.42
X
21210
001
90
2
X
3,269.24
X
21215
002
90
2
X
5,008.24
X
21215
003
90
2
X
2,652.57
X
21215
001
90
2
X
5,154.46
X
21215
004
90
2
X
2,618.54
X
21230
004
90
2
X
2,278.30
X
21230
003
90
2
X
2,549.39
X
21230
002
90
2
X
2,654.26
X
21230
001
90
2
X
2,519.06
X
21235
003
90
2
X
1,601.87
X
21235
002
90
2
X
2,117.34
X
21235
001
90
2
X
2,213.55
X
21235
004
90
2
X
1,581.85
X
21240
001
90
2
X
5,013.43
X
21240
004
90
2
X
4,853.94
X
21240
003
90
2
X
3,750.00
X
21240
002
90
2
X
4,986.62
X
21242
004
90
2
X
3,763.51
X
21242
002
90
2
X
5,479.60
X
21242
003
90
2
X
3,814.00
X
21242
001
90
2
X
4,158.02
X
21243
004
90
2
X
3,617.68
X
21243
001
90
2
X
3,932.22
X
21243
002
90
2
X
3,879.41
X
21243
003
90
2
X
3,660.97
X
21244
90
2
X
*
X
21245
90
2
X
*
X
21246
90
2
X
*
X
21247
001
90
2
X
5,656.29
X
21247
004
90
2
X
5,180.15
X
21247
002
90
2
X
5,577.08
X
21247
003
90
2
X
5,247.43
X
21248
90
2
X
*
X
21249
90
2
X
*
X
21255
004
90
2
X
3,826.01
X
21255
001
90
2
X
4,177.70
X
21255
003
90
2
X
3,875.73
X
21255
002
90
2
X
4,119.34
X
21256
002
90
2
X
3,989.50
X
21256
003
90
2
X
3,753.47
X
21256
004
90
2
X
3,705.34
X
21256
001
90
2
X
4,046.16
X
21260
001
90
2
X
4,127.91
X
21260
004
90
2
X
3,780.41
X
21260
002
90
2
X
4,070.18
X
21260
003
90
2
X
3,829.44
X
21261
003
90
2
X
5,112.15
X
21261
002
90
2
X
5,376.62
X
21261
004
90
2
X
5,052.87
X
21261
001
90
2
X
5,440.62
X
21263
001
90
2
X
7,102.88
X
21263
004
90
2
X
6,504.85
X
21263
002
90
2
X
7,003.43
X
21263
003
90
2
X
6,589.37
X
21267
003
90
2
X
3,589.86
X
21267
002
90
2
X
3,827.98
X
21267
001
90
2
X
3,885.63
X
21267
004
90
2
X
3,547.50
X
21268
001
90
2
X
4,704.01
X
21268
004
90
2
X
4,276.24
X
21268
002
90
2
X
4,629.93
X
21268
003
90
2
X
4,324.92
X
21270
004
90
2
X
2,384.73
X
21270
002
90
2
X
2,571.65
X
21270
003
90
2
X
2,413.09
X
21270
001
90
2
X
2,609.99
X
21275
001
90
2
X
2,337.98
X
21275
004
90
2
X
2,135.03
X
21275
003
90
2
X
2,160.71
X
21275
002
90
2
X
2,303.51
X
21280
001
90
2
X
1,505.61
X
21280
004
90
2
X
1,378.51
X
21280
002
90
2
X
1,484.49
X
21280
003
90
2
X
1,578.09
X
21282
004
90
2
X
1,135.96
X
21282
002
90
2
X
1,241.26
X
21282
003
90
2
X
1,727.72
X
21282
001
90
2
X
1,262.89
X
21295
004
90
2
X
260.59
X
21295
001
90
2
X
283.37
X
21295
003
90
2
X
263.68
X
21295
002
90
2
X
279.50
X
21296
001
90
2
X
866.13
X
21296
004
90
2
X
802.92
X
21296
003
90
2
X
813.07
X
21296
002
90
2
X
855.82
X
21299
YYY
2
X
#
X
21315
003
0
2
X
450.05
X
21315
002
0
2
X
454.43
X
21315
004
0
2
X
479.17
X
21315
001
0
2
X
510.00
X
21320
002
0
2
X
592.14
X
21320
003
0
2
X
569.56
X
21320
004
0
2
X
556.45
X
21320
001
0
2
X
610.64
X
21325
004
90
2
X
836.38
X
21325
001
90
2
X
920.64
X
21325
002
90
2
X
906.29
X
21325
003
90
2
X
846.80
X
21330
002
90
2
X
1,374.64
X
21330
003
90
2
X
1,306.43
X
21330
001
90
2
X
1,437.50
X
21330
004
90
2
X
1,267.05
X
21335
003
90
2
X
2,000.29
X
21335
002
90
2
X
2,120.01
X
21335
004
90
2
X
2,188.16
X
21335
001
90
2
X
2,166.63
X
21336
004
90
2
X
1,028.74
X
21336
003
90
2
X
1,040.99
X
21336
002
90
2
X
1,105.22
X
21336
001
90
2
X
1,120.80
X
21337
004
90
2
X
587.64
X
21337
002
90
2
X
636.93
X
21337
003
90
2
X
594.99
X
21337
001
90
2
X
647.00
X
21338
001
90
2
X
1,320.31
X
21338
003
90
2
X
1,222.92
X
21338
002
90
2
X
1,301.31
X
21338
004
90
2
X
1,208.44
X
21339
004
90
2
X
1,579.88
X
21339
002
90
2
X
2,627.00
X
21339
001
90
2
X
1,719.54
X
21339
003
90
2
X
1,599.44
X
21340
002
90
2
X
2,218.06
X
21340
003
90
2
X
2,087.35
X
21340
004
90
2
X
2,062.22
X
21340
001
90
2
X
2,249.68
X
21343
002
90
2
X
2,472.44
X
21343
003
90
2
X
2,332.94
X
21343
004
90
2
X
2,305.35
X
21343
001
90
2
X
2,506.14
X
21344
004
90
2
X
2,971.08
X
21344
003
90
2
X
3,004.76
X
21344
002
90
2
X
3,160.65
X
21344
001
90
2
X
3,198.44
X
21345
003
90
2
X
1,701.06
X
21345
002
90
2
X
1,808.20
X
21345
001
90
2
X
1,834.04
X
21345
004
90
2
X
1,842.72
X
21346
002
90
2
X
2,275.43
X
21346
003
90
2
X
2,120.99
X
21346
001
90
2
X
2,286.42
X
21346
004
90
2
X
2,095.11
X
21347
001
90
2
X
2,659.11
X
21347
004
90
2
X
2,430.79
X
21347
002
90
2
X
2,620.35
X
21347
003
90
2
X
2,460.21
X
21348
003
90
2
X
3,047.28
X
21348
002
90
2
X
2,492.52
X
21348
004
90
2
X
3,012.55
X
21348
001
90
2
X
3,317.46
X
21355
004
10
2
X
544.76
X
21355
001
10
2
X
584.16
X
21355
003
10
2
X
550.82
X
21355
002
10
2
X
577.65
X
21356
004
10
2
X
1,574.80
X
21356
001
10
2
X
1,644.47
X
21356
002
10
2
X
1,716.98
X
21356
003
10
2
X
1,762.52
X
21360
001
90
2
X
1,792.86
X
21360
004
90
2
X
1,716.07
X
21360
002
90
2
X
1,864.40
X
21360
003
90
2
X
1,905.43
X
21365
001
90
2
X
3,127.02
X
21365
004
90
2
X
2,881.02
X
21365
002
90
2
X
3,069.26
X
21365
003
90
2
X
2,980.52
X
21366
001
90
2
X
3,144.90
X
21366
004
90
2
X
3,207.80
X
21366
002
90
2
X
3,086.97
X
21366
003
90
2
X
2,998.30
X
21385
003
90
2
X
2,006.78
X
21385
002
90
2
X
2,142.13
X
21385
004
90
2
X
1,981.92
X
21385
001
90
2
X
2,174.79
X
21386
001
90
2
X
2,137.30
X
21386
002
90
2
X
2,103.94
X
21386
003
90
2
X
1,966.00
X
21386
004
90
2
X
1,941.99
X
21387
001
90
2
X
1,967.01
X
21387
003
90
2
X
1,823.71
X
21387
002
90
2
X
2,805.42
X
21387
004
90
2
X
1,802.06
X
21390
004
90
2
X
2,333.79
X
21390
002
90
2
X
2,879.50
X
21390
003
90
2
X
2,719.86
X
21390
001
90
2
X
2,566.66
X
21395
004
90
2
X
2,357.49
X
21395
002
90
2
X
2,578.41
X
21395
003
90
2
X
2,385.58
X
21395
001
90
2
X
2,579.61
X
21400
003
90
2
X
793.98
X
21400
002
90
2
X
333.18
X
21400
004
90
2
X
852.35
X
21400
001
90
2
X
805.30
X
21401
001
90
2
X
668.48
X
21401
003
90
2
X
620.11
X
21401
002
90
2
X
659.02
X
21401
004
90
2
X
612.66
X
21406
002
90
2
X
1,517.34
X
21406
003
90
2
X
1,500.44
X
21406
004
90
2
X
1,289.68
X
21406
001
90
2
X
1,582.01
X
21407
002
90
2
X
1,762.35
X
21407
003
90
2
X
1,660.32
X
21407
004
90
2
X
1,640.32
X
21407
001
90
2
X
1,786.89
X
21408
001
90
2
X
2,359.27
X
21408
004
90
2
X
2,172.40
X
21408
002
90
2
X
2,327.89
X
21408
003
90
2
X
2,198.28
X
21421
004
90
2
X
1,186.19
X
21421
001
90
2
X
2,005.17
X
21421
003
90
2
X
1,963.21
X
21421
002
90
2
X
1,996.98
X
21422
002
90
2
X
2,088.82
X
21422
003
90
2
X
1,951.40
X
21422
004
90
2
X
1,926.88
X
21422
001
90
2
X
2,121.93
X
21423
001
90
2
X
2,333.94
X
21423
003
90
2
X
2,157.13
X
21423
002
90
2
X
2,299.63
X
21423
004
90
2
X
2,130.72
X
21431
002
90
2
X
1,477.04
X
21431
003
90
2
X
1,388.75
X
21431
001
90
2
X
1,498.39
X
21431
004
90
2
X
1,371.95
X
21432
001
90
2
X
1,761.15
X
21432
003
90
2
X
1,633.36
X
21432
002
90
2
X
3,792.76
X
21432
004
90
2
X
1,613.93
X
21433
004
90
2
X
4,513.68
X
21433
001
90
2
X
4,906.06
X
21433
002
90
2
X
4,670.36
X
21433
003
90
2
X
4,567.77
X
21435
004
90
2
X
3,223.21
X
21435
001
90
2
X
3,527.26
X
21435
002
90
2
X
3,475.51
X
21435
003
90
2
X
3,261.74
X
Return to CPT/HCPC List