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 76942-77285
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
76942-77285
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
76942
003
XXX
0
X
256.51
X
76942
26
003
XXX
0
X
112.24
X
76942
TC
003
XXX
0
X
148.51
X
76942
002
XXX
0
X
270.45
X
76942
26
002
XXX
0
X
117.02
X
76942
TC
002
XXX
0
X
161.28
X
76942
004
XXX
0
X
249.93
X
76942
26
004
XXX
0
X
109.00
X
76942
TC
004
XXX
0
X
146.16
X
76942
001
XXX
0
X
272.29
X
76942
26
001
XXX
0
X
117.43
X
76942
TC
001
XXX
0
X
164.29
X
76945
003
XXX
0
X
279.98
X
76945
26
003
XXX
0
X
133.69
X
76945
TC
003
XXX
0
X
146.17
X
76945
002
XXX
0
X
302.73
X
76945
26
002
XXX
0
X
142.97
X
76945
TC
002
XXX
0
X
159.76
X
76945
004
XXX
0
X
275.51
X
76945
26
004
XXX
0
X
131.87
X
76945
TC
004
XXX
0
X
143.62
X
76945
001
XXX
0
X
312.61
X
76945
26
001
XXX
0
X
147.33
X
76945
TC
001
XXX
0
X
165.27
X
76946
001
XXX
0
X
224.67
X
76946
26
001
XXX
0
X
65.04
X
76946
TC
001
XXX
0
X
164.29
X
76946
002
XXX
0
X
220.82
X
76946
26
002
XXX
0
X
64.76
X
76946
TC
002
XXX
0
X
161.28
X
76946
003
XXX
0
X
206.55
X
76946
26
003
XXX
0
X
61.89
X
76946
TC
003
XXX
0
X
148.51
X
76946
004
XXX
0
X
201.91
X
76946
26
004
XXX
0
X
60.30
X
76946
TC
004
XXX
0
X
146.16
X
76948
XXX
0
X
*
X
76965
004
XXX
0
X
817.70
X
76965
26
004
XXX
0
X
324.77
X
76965
TC
004
XXX
0
X
492.94
X
76965
003
XXX
0
X
832.95
X
76965
26
003
XXX
0
X
330.09
X
76965
TC
003
XXX
0
X
502.85
X
76965
002
XXX
0
X
907.89
X
76965
26
002
XXX
0
X
354.16
X
76965
TC
002
XXX
0
X
553.77
X
76965
001
XXX
0
X
952.43
X
76965
26
001
XXX
0
X
369.78
X
76965
TC
001
XXX
0
X
582.66
X
76975
XXX
0
X
*
X
76977
003
XXX
0
X
100.11
X
76977
26
003
XXX
0
X
26.99
X
76977
TC
003
XXX
0
X
73.11
X
76977
001
XXX
0
X
116.93
X
76977
26
001
XXX
0
X
29.81
X
76977
TC
001
XXX
0
X
87.16
X
76977
004
XXX
0
X
100.11
X
76977
26
004
XXX
0
X
26.99
X
76977
TC
004
XXX
0
X
73.11
X
76977
002
XXX
0
X
100.11
X
76977
26
002
XXX
0
X
26.99
X
76977
TC
002
XXX
0
X
73.11
X
76978
001
XXX
4
X
489.61
X
76978
26
001
XXX
4
X
120.62
X
76978
TC
001
XXX
4
X
368.99
X
76978
002
XXX
4
X
434.63
X
76978
26
002
XXX
4
X
113.13
X
76978
TC
002
XXX
4
X
321.52
X
76978
003
XXX
4
X
434.63
X
76978
26
003
XXX
4
X
113.13
X
76978
TC
003
XXX
4
X
321.52
X
76978
004
XXX
4
X
434.63
X
76978
26
004
XXX
4
X
113.13
X
76978
TC
004
XXX
4
X
321.52
X
76979
002
ZZZ
0
X
294.04
X
76979
26
002
ZZZ
0
X
59.48
X
76979
TC
002
ZZZ
0
X
234.54
X
76979
003
ZZZ
0
X
294.04
X
76979
26
003
ZZZ
0
X
59.48
X
76979
TC
003
ZZZ
0
X
234.54
X
76979
004
ZZZ
0
X
294.04
X
76979
26
004
ZZZ
0
X
59.48
X
76979
TC
004
ZZZ
0
X
234.54
X
76979
001
ZZZ
0
X
332.55
X
76979
26
001
ZZZ
0
X
63.42
X
76979
TC
001
ZZZ
0
X
269.12
X
76981
001
XXX
4
X
162.21
X
76981
26
001
XXX
4
X
44.64
X
76981
TC
001
XXX
4
X
117.56
X
76981
004
XXX
4
X
144.15
X
76981
26
004
XXX
4
X
41.79
X
76981
TC
004
XXX
4
X
102.38
X
76981
003
XXX
4
X
144.15
X
76981
26
003
XXX
4
X
41.79
X
76981
TC
003
XXX
4
X
102.38
X
76981
002
XXX
4
X
144.15
X
76981
26
002
XXX
4
X
41.79
X
76981
TC
002
XXX
4
X
102.38
X
76982
004
XXX
4
X
129.22
X
76982
26
004
XXX
4
X
41.79
X
76982
TC
004
XXX
4
X
87.40
X
76982
001
XXX
4
X
145.04
X
76982
26
001
XXX
4
X
44.64
X
76982
TC
001
XXX
4
X
100.40
X
76982
002
XXX
4
X
129.22
X
76982
26
002
XXX
4
X
41.79
X
76982
TC
002
XXX
4
X
87.40
X
76982
003
XXX
4
X
129.22
X
76982
26
003
XXX
4
X
41.79
X
76982
TC
003
XXX
4
X
87.40
X
76983
004
ZZZ
0
X
79.77
X
76983
26
004
ZZZ
0
X
35.38
X
76983
TC
004
ZZZ
0
X
44.40
X
76983
002
ZZZ
0
X
79.77
X
76983
26
002
ZZZ
0
X
35.38
X
76983
TC
002
ZZZ
0
X
44.40
X
76983
003
ZZZ
0
X
79.77
X
76983
26
003
ZZZ
0
X
35.38
X
76983
TC
003
ZZZ
0
X
44.40
X
76983
001
ZZZ
0
X
88.68
X
76983
26
001
ZZZ
0
X
37.76
X
76983
TC
001
ZZZ
0
X
50.93
X
76984
26
001
XXX
0
X
35.71
X
76984
26
004
XXX
0
X
32.91
X
76984
26
003
XXX
0
X
32.91
X
76984
26
002
XXX
0
X
32.91
X
76987
26
001
XXX
0
X
108.64
X
76987
26
002
XXX
0
X
100.65
X
76987
26
004
XXX
0
X
100.65
X
76987
26
003
XXX
0
X
100.65
X
76988
26
001
XXX
0
X
69.28
X
76988
26
004
XXX
0
X
64.09
X
76988
26
003
XXX
0
X
64.09
X
76988
26
002
XXX
0
X
64.09
X
76989
26
001
XXX
0
X
40.67
X
76989
26
002
XXX
0
X
37.58
X
76989
26
003
XXX
0
X
37.58
X
76989
26
004
XXX
0
X
37.58
X
76998
26
001
XXX
0
X
117.98
X
76998
26
004
XXX
0
X
105.61
X
76998
26
003
XXX
0
X
105.61
X
76998
26
002
XXX
0
X
105.61
X
76999
XXX
0
X
#
X
77001
002
ZZZ
0
X
137.49
X
77001
26
002
ZZZ
0
X
31.99
X
77001
TC
002
ZZZ
0
X
105.49
X
77001
003
ZZZ
0
X
137.49
X
77001
26
003
ZZZ
0
X
31.99
X
77001
TC
003
ZZZ
0
X
105.49
X
77001
004
ZZZ
0
X
137.49
X
77001
26
004
ZZZ
0
X
31.99
X
77001
TC
004
ZZZ
0
X
105.49
X
77001
001
ZZZ
0
X
166.57
X
77001
26
001
ZZZ
0
X
34.78
X
77001
TC
001
ZZZ
0
X
131.79
X
77002
001
ZZZ
0
X
150.00
X
77002
26
001
ZZZ
0
X
48.52
X
77002
TC
001
ZZZ
0
X
101.41
X
77002
002
ZZZ
0
X
126.06
X
77002
26
002
ZZZ
0
X
44.74
X
77002
TC
002
ZZZ
0
X
81.32
X
77002
003
ZZZ
0
X
126.06
X
77002
26
003
ZZZ
0
X
44.74
X
77002
TC
003
ZZZ
0
X
81.32
X
77002
004
ZZZ
0
X
126.06
X
77002
26
004
ZZZ
0
X
44.74
X
77002
TC
004
ZZZ
0
X
81.32
X
77003
004
ZZZ
0
X
122.53
X
77003
26
004
ZZZ
0
X
48.04
X
77003
TC
004
ZZZ
0
X
74.52
X
77003
003
ZZZ
0
X
122.53
X
77003
26
003
ZZZ
0
X
48.04
X
77003
TC
003
ZZZ
0
X
74.52
X
77003
002
ZZZ
0
X
122.53
X
77003
26
002
ZZZ
0
X
48.04
X
77003
TC
002
ZZZ
0
X
74.52
X
77003
001
ZZZ
0
X
145.24
X
77003
26
001
ZZZ
0
X
52.26
X
77003
TC
001
ZZZ
0
X
93.04
X
77011
003
XXX
0
X
811.92
X
77011
26
003
XXX
0
X
101.88
X
77011
TC
003
XXX
0
X
710.02
X
77011
002
XXX
0
X
811.92
X
77011
26
002
XXX
0
X
101.88
X
77011
TC
002
XXX
0
X
710.02
X
77011
004
XXX
0
X
811.92
X
77011
26
004
XXX
0
X
101.88
X
77011
TC
004
XXX
0
X
710.02
X
77011
001
XXX
0
X
991.20
X
77011
26
001
XXX
0
X
111.11
X
77011
TC
001
XXX
0
X
880.09
X
77012
001
XXX
0
X
654.24
X
77012
26
001
XXX
0
X
106.11
X
77012
TC
001
XXX
0
X
548.20
X
77012
002
XXX
0
X
535.92
X
77012
26
002
XXX
0
X
97.20
X
77012
TC
002
XXX
0
X
438.72
X
77012
003
XXX
0
X
535.92
X
77012
26
003
XXX
0
X
97.20
X
77012
TC
003
XXX
0
X
438.72
X
77012
004
XXX
0
X
535.92
X
77012
26
004
XXX
0
X
97.20
X
77012
TC
004
XXX
0
X
438.72
X
77013
26
002
XXX
0
X
335.51
X
77013
26
003
XXX
0
X
335.51
X
77013
26
004
XXX
0
X
335.51
X
77013
26
001
XXX
0
X
366.29
X
77014
003
XXX
0
X
283.75
X
77014
26
003
XXX
0
X
71.86
X
77014
TC
003
XXX
0
X
211.93
X
77014
004
XXX
0
X
283.75
X
77014
26
004
XXX
0
X
71.86
X
77014
TC
004
XXX
0
X
211.93
X
77014
002
XXX
0
X
283.75
X
77014
26
002
XXX
0
X
71.86
X
77014
TC
002
XXX
0
X
211.93
X
77014
001
XXX
0
X
342.24
X
77014
26
001
XXX
0
X
78.60
X
77014
TC
001
XXX
0
X
263.64
X
77021
004
XXX
0
X
820.32
X
77021
26
004
XXX
0
X
128.18
X
77021
TC
004
XXX
0
X
692.11
X
77021
001
XXX
0
X
1,002.60
X
77021
26
001
XXX
0
X
140.82
X
77021
TC
001
XXX
0
X
861.74
X
77021
003
XXX
0
X
820.32
X
77021
26
003
XXX
0
X
128.18
X
77021
TC
003
XXX
0
X
692.11
X
77021
002
XXX
0
X
820.32
X
77021
26
002
XXX
0
X
128.18
X
77021
TC
002
XXX
0
X
692.11
X
77022
26
004
XXX
0
X
358.28
X
77022
26
003
XXX
0
X
358.28
X
77022
26
002
XXX
0
X
358.28
X
77022
26
001
XXX
0
X
392.79
X
77046
001
XXX
4
X
373.95
X
77046
26
001
XXX
4
X
107.91
X
77046
TC
001
XXX
4
X
266.05
X
77046
002
XXX
4
X
333.06
X
77046
26
002
XXX
4
X
101.25
X
77046
TC
002
XXX
4
X
231.81
X
77046
003
XXX
4
X
333.06
X
77046
26
003
XXX
4
X
101.25
X
77046
TC
003
XXX
4
X
231.81
X
77046
004
XXX
4
X
333.06
X
77046
26
004
XXX
4
X
101.25
X
77046
TC
004
XXX
4
X
231.81
X
77047
004
XXX
4
X
342.46
X
77047
26
004
XXX
4
X
112.08
X
77047
TC
004
XXX
4
X
230.40
X
77047
003
XXX
4
X
342.46
X
77047
26
003
XXX
4
X
112.08
X
77047
TC
003
XXX
4
X
230.40
X
77047
002
XXX
4
X
342.46
X
77047
26
002
XXX
4
X
112.08
X
77047
TC
002
XXX
4
X
230.40
X
77047
001
XXX
4
X
383.91
X
77047
26
001
XXX
4
X
119.44
X
77047
TC
001
XXX
4
X
264.44
X
77048
002
XXX
4
X
528.35
X
77048
26
002
XXX
4
X
146.53
X
77048
TC
002
XXX
4
X
381.84
X
77048
003
XXX
4
X
528.35
X
77048
26
003
XXX
4
X
146.53
X
77048
TC
003
XXX
4
X
381.84
X
77048
004
XXX
4
X
528.35
X
77048
26
004
XXX
4
X
146.53
X
77048
TC
004
XXX
4
X
381.84
X
77048
001
XXX
4
X
594.44
X
77048
26
001
XXX
4
X
156.14
X
77048
TC
001
XXX
4
X
438.32
X
77049
002
XXX
4
X
540.24
X
77049
26
002
XXX
4
X
160.30
X
77049
TC
002
XXX
4
X
379.95
X
77049
001
XXX
4
X
606.94
X
77049
26
001
XXX
4
X
170.79
X
77049
TC
001
XXX
4
X
436.18
X
77049
004
XXX
4
X
540.24
X
77049
26
004
XXX
4
X
160.30
X
77049
TC
004
XXX
4
X
379.95
X
77049
003
XXX
4
X
540.24
X
77049
26
003
XXX
4
X
160.30
X
77049
TC
003
XXX
4
X
379.95
X
77053
004
XXX
0
X
168.85
X
77053
26
004
XXX
0
X
30.56
X
77053
TC
004
XXX
0
X
138.32
X
77053
002
XXX
0
X
168.85
X
77053
26
002
XXX
0
X
30.56
X
77053
TC
002
XXX
0
X
138.32
X
77053
003
XXX
0
X
168.85
X
77053
26
003
XXX
0
X
30.56
X
77053
TC
003
XXX
0
X
138.32
X
77053
001
XXX
0
X
206.59
X
77053
26
001
XXX
0
X
33.55
X
77053
TC
001
XXX
0
X
173.06
X
77054
003
XXX
0
X
242.12
X
77054
26
003
XXX
0
X
37.88
X
77054
TC
003
XXX
0
X
204.19
X
77054
002
XXX
0
X
242.12
X
77054
26
002
XXX
0
X
37.88
X
77054
TC
002
XXX
0
X
204.19
X
77054
004
XXX
0
X
242.12
X
77054
26
004
XXX
0
X
37.88
X
77054
TC
004
XXX
0
X
204.19
X
77054
001
XXX
0
X
296.46
X
77054
26
001
XXX
0
X
41.49
X
77054
TC
001
XXX
0
X
255.01
X
77061
XXX
0
X
*
X
77062
XXX
0
X
*
X
77063
001
ZZZ
0
X
95.09
X
77063
26
001
ZZZ
0
X
50.89
X
77063
TC
001
ZZZ
0
X
44.22
X
77063
002
ZZZ
0
X
85.30
X
77063
26
002
ZZZ
0
X
47.59
X
77063
TC
002
ZZZ
0
X
37.76
X
77063
004
ZZZ
0
X
85.30
X
77063
26
004
ZZZ
0
X
47.59
X
77063
TC
004
ZZZ
0
X
37.76
X
77063
003
ZZZ
0
X
85.30
X
77063
26
003
ZZZ
0
X
47.59
X
77063
TC
003
ZZZ
0
X
37.76
X
77065
XXX
0
X
*
X
77066
XXX
0
X
*
X
77067
XXX
0
X
*
X
77071
001
XXX
0
X
56.88
X
77071
002
XXX
0
X
49.32
X
77071
003
XXX
0
X
49.32
X
77071
004
XXX
0
X
49.32
X
77072
002
XXX
0
X
37.66
X
77072
26
002
XXX
0
X
15.37
X
77072
TC
002
XXX
0
X
22.34
X
77072
003
XXX
0
X
37.66
X
77072
26
003
XXX
0
X
15.37
X
77072
TC
003
XXX
0
X
22.34
X
77072
004
XXX
0
X
37.66
X
77072
26
004
XXX
0
X
15.37
X
77072
TC
004
XXX
0
X
22.34
X
77072
001
XXX
0
X
44.60
X
77072
26
001
XXX
0
X
16.74
X
77072
TC
001
XXX
0
X
27.89
X
77073
004
XXX
0
X
70.38
X
77073
26
004
XXX
0
X
22.64
X
77073
TC
004
XXX
0
X
47.76
X
77073
003
XXX
0
X
70.38
X
77073
26
003
XXX
0
X
22.64
X
77073
TC
003
XXX
0
X
47.76
X
77073
002
XXX
0
X
70.38
X
77073
26
002
XXX
0
X
22.64
X
77073
TC
002
XXX
0
X
47.76
X
77073
001
XXX
0
X
84.47
X
77073
26
001
XXX
0
X
24.70
X
77073
TC
001
XXX
0
X
59.78
X
77074
004
XXX
0
X
106.82
X
77074
26
004
XXX
0
X
37.88
X
77074
TC
004
XXX
0
X
68.90
X
77074
001
XXX
0
X
127.42
X
77074
26
001
XXX
0
X
41.49
X
77074
TC
001
XXX
0
X
85.96
X
77074
002
XXX
0
X
106.82
X
77074
26
002
XXX
0
X
37.88
X
77074
TC
002
XXX
0
X
68.90
X
77074
003
XXX
0
X
106.82
X
77074
26
003
XXX
0
X
37.88
X
77074
TC
003
XXX
0
X
68.90
X
77075
002
XXX
0
X
149.13
X
77075
26
002
XXX
0
X
45.99
X
77075
TC
002
XXX
0
X
103.14
X
77075
003
XXX
0
X
149.13
X
77075
26
003
XXX
0
X
45.99
X
77075
TC
003
XXX
0
X
103.14
X
77075
004
XXX
0
X
149.13
X
77075
26
004
XXX
0
X
45.99
X
77075
TC
004
XXX
0
X
103.14
X
77075
001
XXX
0
X
178.45
X
77075
26
001
XXX
0
X
50.11
X
77075
TC
001
XXX
0
X
128.39
X
77076
001
XXX
0
X
143.56
X
77076
26
001
XXX
0
X
63.90
X
77076
TC
001
XXX
0
X
79.66
X
77076
004
XXX
0
X
122.63
X
77076
26
004
XXX
0
X
58.61
X
77076
TC
004
XXX
0
X
63.99
X
77076
003
XXX
0
X
122.63
X
77076
26
003
XXX
0
X
58.61
X
77076
TC
003
XXX
0
X
63.99
X
77076
002
XXX
0
X
122.63
X
77076
26
002
XXX
0
X
58.61
X
77076
TC
002
XXX
0
X
63.99
X
77077
002
XXX
0
X
90.49
X
77077
26
002
XXX
0
X
26.53
X
77077
TC
002
XXX
0
X
63.92
X
77077
003
XXX
0
X
90.49
X
77077
26
003
XXX
0
X
26.53
X
77077
TC
003
XXX
0
X
63.92
X
77077
004
XXX
0
X
90.49
X
77077
26
004
XXX
0
X
26.53
X
77077
TC
004
XXX
0
X
63.92
X
77077
001
XXX
0
X
109.03
X
77077
26
001
XXX
0
X
29.23
X
77077
TC
001
XXX
0
X
79.83
X
77078
001
XXX
0
X
292.29
X
77078
26
001
XXX
0
X
22.54
X
77078
TC
001
XXX
0
X
269.76
X
77078
002
XXX
0
X
237.57
X
77078
26
002
XXX
0
X
20.66
X
77078
TC
002
XXX
0
X
216.93
X
77078
003
XXX
0
X
237.57
X
77078
26
003
XXX
0
X
20.66
X
77078
TC
003
XXX
0
X
216.93
X
77078
004
XXX
0
X
237.57
X
77078
26
004
XXX
0
X
20.66
X
77078
TC
004
XXX
0
X
216.93
X
77080
001
XXX
0
X
227.72
X
77080
26
001
XXX
0
X
20.46
X
77080
TC
001
XXX
0
X
207.24
X
77080
003
XXX
0
X
184.13
X
77080
26
003
XXX
0
X
18.53
X
77080
TC
003
XXX
0
X
165.60
X
77080
002
XXX
0
X
184.13
X
77080
26
002
XXX
0
X
18.53
X
77080
TC
002
XXX
0
X
165.60
X
77080
004
XXX
0
X
184.13
X
77080
26
004
XXX
0
X
18.53
X
77080
TC
004
XXX
0
X
165.60
X
77081
004
XXX
0
X
66.99
X
77081
26
004
XXX
0
X
19.24
X
77081
TC
004
XXX
0
X
47.76
X
77081
003
XXX
0
X
66.99
X
77081
26
003
XXX
0
X
19.24
X
77081
TC
003
XXX
0
X
47.76
X
77081
002
XXX
0
X
66.99
X
77081
26
002
XXX
0
X
19.24
X
77081
TC
002
XXX
0
X
47.76
X
77081
001
XXX
0
X
80.88
X
77081
26
001
XXX
0
X
21.14
X
77081
TC
001
XXX
0
X
59.78
X
77084
001
XXX
0
X
1,099.45
X
77084
26
001
XXX
0
X
146.79
X
77084
TC
001
XXX
0
X
952.72
X
77084
002
XXX
0
X
900.06
X
77084
26
002
XXX
0
X
134.50
X
77084
TC
002
XXX
0
X
765.60
X
77084
003
XXX
0
X
900.06
X
77084
26
003
XXX
0
X
134.50
X
77084
TC
003
XXX
0
X
765.60
X
77084
004
XXX
0
X
900.06
X
77084
26
004
XXX
0
X
134.50
X
77084
TC
004
XXX
0
X
765.60
X
77085
004
XXX
0
X
84.00
X
77085
26
004
XXX
0
X
23.73
X
77085
TC
004
XXX
0
X
60.26
X
77085
001
XXX
0
X
95.91
X
77085
26
001
XXX
0
X
25.33
X
77085
TC
001
XXX
0
X
70.60
X
77085
003
XXX
0
X
84.00
X
77085
26
003
XXX
0
X
23.73
X
77085
TC
003
XXX
0
X
60.26
X
77085
002
XXX
0
X
84.00
X
77085
26
002
XXX
0
X
23.73
X
77085
TC
002
XXX
0
X
60.26
X
77086
004
XXX
0
X
53.11
X
77086
26
004
XXX
0
X
13.82
X
77086
TC
004
XXX
0
X
39.32
X
77086
002
XXX
0
X
53.11
X
77086
26
002
XXX
0
X
13.82
X
77086
TC
002
XXX
0
X
39.32
X
77086
003
XXX
0
X
53.11
X
77086
26
003
XXX
0
X
13.82
X
77086
TC
003
XXX
0
X
39.32
X
77086
001
XXX
0
X
60.83
X
77086
26
001
XXX
0
X
14.78
X
77086
TC
001
XXX
0
X
46.06
X
77089
001
XXX
0
X
22.24
X
77089
002
XXX
0
X
20.04
X
77089
004
XXX
0
X
20.04
X
77089
003
XXX
0
X
20.04
X
77090
001
XXX
0
X
3.22
X
77090
003
XXX
0
X
2.71
X
77090
002
XXX
0
X
2.71
X
77090
004
XXX
0
X
2.71
X
77091
004
XXX
0
X
5.06
X
77091
003
XXX
0
X
5.06
X
77091
002
XXX
0
X
5.06
X
77091
001
XXX
0
X
5.93
X
77092
002
XXX
0
X
12.24
X
77092
003
XXX
0
X
12.24
X
77092
004
XXX
0
X
12.24
X
77092
001
XXX
0
X
13.10
X
77261
004
XXX
0
X
225.45
X
77261
003
XXX
0
X
231.39
X
77261
002
XXX
0
X
241.72
X
77261
001
XXX
0
X
242.47
X
77262
002
XXX
0
X
364.70
X
77262
003
XXX
0
X
348.99
X
77262
004
XXX
0
X
340.03
X
77262
001
XXX
0
X
365.78
X
77263
001
XXX
0
X
544.55
X
77263
004
XXX
0
X
506.45
X
77263
003
XXX
0
X
519.73
X
77263
002
XXX
0
X
542.93
X
77280
001
XXX
0
X
483.75
X
77280
26
001
XXX
0
X
122.00
X
77280
TC
001
XXX
0
X
374.66
X
77280
002
XXX
0
X
475.63
X
77280
26
002
XXX
0
X
121.56
X
77280
TC
002
XXX
0
X
365.00
X
77280
003
XXX
0
X
441.60
X
77280
26
003
XXX
0
X
116.81
X
77280
TC
003
XXX
0
X
336.74
X
77280
004
XXX
0
X
435.12
X
77280
26
004
XXX
0
X
114.59
X
77280
TC
004
XXX
0
X
331.41
X
77285
001
XXX
0
X
762.04
X
77285
26
001
XXX
0
X
181.40
X
77285
TC
001
XXX
0
X
600.82
X
77285
002
XXX
0
X
749.25
X
77285
26
002
XXX
0
X
180.88
X
77285
TC
002
XXX
0
X
585.56
X
77285
003
XXX
0
X
695.51
X
77285
26
003
XXX
0
X
173.40
X
77285
TC
003
XXX
0
X
540.12
X
77285
004
XXX
0
X
685.22
X
77285
26
004
XXX
0
X
168.65
X
77285
TC
004
XXX
0
X
531.56
X
Return to CPT/HCPC List