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Individuals
Individuals
Unemployment Benefits
Disability Services
Find A Job
Workers' Compensation Services
Workforce Development
PennSERVE
Individual Services
Uniform Construction Code
Labor Management Relations
Misclassified Workers
Businesses
Businesses
Employer UC Info
Finding Skilled Workers
Disability Services
Workforce Development
Workers' Compensation Services
Labor-Management Relations
Pennsylvania Business One-Stop
State Workers' Insurance Fund
Employer Services
About L&I
About L&I
Equal Opportunity
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Health Care Services Review
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Medical Fee Review
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Fee Schedule
>
Fee Schedule 77290-77778
Begin Main Content Area
Page Content
2021 Workers' Compensation Part B Fee Schedule
77290-77778
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
77290
26
3
XXX
0
X
222.08
X
77290
26
4
XXX
0
X
223.95
X
77290
26
2
XXX
0
X
231.55
X
77290
26
1
XXX
0
X
232.27
X
77290
TC
4
XXX
0
X
529.02
X
77290
TC
3
XXX
0
X
537.60
X
77290
TC
2
XXX
0
X
582.59
X
77290
TC
1
XXX
0
X
598.06
X
77290
4
XXX
0
X
725.73
X
77290
3
XXX
0
X
736.42
X
77290
2
XXX
0
X
792.33
X
77290
1
XXX
0
X
805.64
X
77293
26
2
ZZZ
0
X
139.55
X
77293
26
3
ZZZ
0
X
139.55
X
77293
26
4
ZZZ
0
X
139.55
X
77293
26
1
ZZZ
0
X
149.20
X
77293
TC
2
ZZZ
0
X
414.74
X
77293
TC
3
ZZZ
0
X
414.74
X
77293
TC
4
ZZZ
0
X
414.74
X
77293
TC
1
ZZZ
0
X
483.30
X
77293
2
ZZZ
0
X
554.29
X
77293
3
ZZZ
0
X
554.29
X
77293
4
ZZZ
0
X
554.29
X
77293
1
ZZZ
0
X
632.50
X
77295
26
2
XXX
0
X
519.79
X
77295
26
3
XXX
0
X
519.79
X
77295
26
4
XXX
0
X
519.79
X
77295
26
1
XXX
0
X
570.95
X
77295
TC
2
XXX
0
X
2,162.55
X
77295
TC
3
XXX
0
X
2,162.55
X
77295
TC
4
XXX
0
X
2,162.55
X
77295
TC
1
XXX
0
X
2,604.55
X
77295
2
XXX
0
X
2,682.33
X
77295
3
XXX
0
X
2,682.33
X
77295
4
XXX
0
X
2,682.33
X
77295
1
XXX
0
X
3,175.52
X
77299
XXX
0
X
#
X
77300
26
4
XXX
0
X
87.24
X
77300
26
3
XXX
0
X
88.61
X
77300
26
2
XXX
0
X
92.17
X
77300
26
1
XXX
0
X
92.44
X
77300
TC
4
XXX
0
X
108.82
X
77300
TC
3
XXX
0
X
110.55
X
77300
TC
2
XXX
0
X
119.80
X
77300
TC
1
XXX
0
X
123.19
X
77300
4
XXX
0
X
186.69
X
77300
3
XXX
0
X
189.32
X
77300
2
XXX
0
X
202.74
X
77300
1
XXX
0
X
205.93
X
77301
26
2
XXX
0
X
769.98
X
77301
26
3
XXX
0
X
769.98
X
77301
26
4
XXX
0
X
769.98
X
77301
26
1
XXX
0
X
833.38
X
77301
TC
2
XXX
0
X
1,789.47
X
77301
TC
3
XXX
0
X
1,789.47
X
77301
TC
4
XXX
0
X
1,789.47
X
77301
TC
1
XXX
0
X
2,146.73
X
77301
2
XXX
0
X
2,559.46
X
77301
3
XXX
0
X
2,559.46
X
77301
4
XXX
0
X
2,559.46
X
77301
1
XXX
0
X
2,980.12
X
77306
TC
2
XXX
0
X
91.65
X
77306
TC
3
XXX
0
X
91.65
X
77306
TC
4
XXX
0
X
91.65
X
77306
26
2
XXX
0
X
93.32
X
77306
26
3
XXX
0
X
93.32
X
77306
26
4
XXX
0
X
93.32
X
77306
26
1
XXX
0
X
99.25
X
77306
TC
1
XXX
0
X
107.29
X
77306
2
XXX
0
X
184.99
X
77306
3
XXX
0
X
184.99
X
77306
4
XXX
0
X
184.99
X
77306
1
XXX
0
X
206.55
X
77307
TC
2
XXX
0
X
167.63
X
77307
TC
3
XXX
0
X
167.63
X
77307
TC
4
XXX
0
X
167.63
X
77307
26
2
XXX
0
X
193.72
X
77307
26
3
XXX
0
X
193.72
X
77307
26
4
XXX
0
X
193.72
X
77307
TC
1
XXX
0
X
196.19
X
77307
26
1
XXX
0
X
206.15
X
77307
2
XXX
0
X
361.36
X
77307
3
XXX
0
X
361.36
X
77307
4
XXX
0
X
361.36
X
77307
1
XXX
0
X
402.33
X
77316
26
2
XXX
0
X
93.83
X
77316
26
3
XXX
0
X
93.83
X
77316
26
4
XXX
0
X
93.83
X
77316
26
1
XXX
0
X
99.87
X
77316
TC
2
XXX
0
X
142.15
X
77316
TC
3
XXX
0
X
142.15
X
77316
TC
4
XXX
0
X
142.15
X
77316
TC
1
XXX
0
X
166.39
X
77316
2
XXX
0
X
235.95
X
77316
3
XXX
0
X
235.95
X
77316
4
XXX
0
X
235.95
X
77316
1
XXX
0
X
266.25
X
77317
26
2
XXX
0
X
123.49
X
77317
26
3
XXX
0
X
123.49
X
77317
26
4
XXX
0
X
123.49
X
77317
26
1
XXX
0
X
131.61
X
77317
TC
2
XXX
0
X
185.51
X
77317
TC
3
XXX
0
X
185.51
X
77317
TC
4
XXX
0
X
185.51
X
77317
TC
1
XXX
0
X
217.09
X
77317
2
XXX
0
X
308.99
X
77317
3
XXX
0
X
308.99
X
77317
4
XXX
0
X
308.99
X
77317
1
XXX
0
X
348.73
X
77318
26
2
XXX
0
X
194.68
X
77318
26
3
XXX
0
X
194.68
X
77318
26
4
XXX
0
X
194.68
X
77318
26
1
XXX
0
X
207.35
X
77318
TC
2
XXX
0
X
251.65
X
77318
TC
3
XXX
0
X
251.65
X
77318
TC
4
XXX
0
X
251.65
X
77318
TC
1
XXX
0
X
294.49
X
77318
2
XXX
0
X
446.32
X
77318
3
XXX
0
X
446.32
X
77318
4
XXX
0
X
446.32
X
77318
1
XXX
0
X
501.85
X
77321
26
4
XXX
0
X
130.77
X
77321
26
3
XXX
0
X
134.22
X
77321
26
2
XXX
0
X
140.20
X
77321
26
1
XXX
0
X
140.65
X
77321
TC
4
XXX
0
X
328.05
X
77321
TC
3
XXX
0
X
333.38
X
77321
TC
2
XXX
0
X
361.19
X
77321
TC
1
XXX
0
X
370.84
X
77321
4
XXX
0
X
446.88
X
77321
3
XXX
0
X
453.55
X
77321
2
XXX
0
X
487.70
X
77321
1
XXX
0
X
495.80
X
77331
TC
4
XXX
0
X
41.30
X
77331
TC
3
XXX
0
X
41.96
X
77331
TC
2
XXX
0
X
45.45
X
77331
TC
1
XXX
0
X
46.30
X
77331
26
4
XXX
0
X
120.60
X
77331
26
3
XXX
0
X
123.56
X
77331
26
2
XXX
0
X
129.15
X
77331
26
1
XXX
0
X
129.54
X
77331
4
XXX
0
X
157.95
X
77331
3
XXX
0
X
162.11
X
77331
2
XXX
0
X
170.04
X
77331
1
XXX
0
X
170.76
X
77332
26
3
XXX
0
X
78.50
X
77332
26
4
XXX
0
X
79.10
X
77332
26
2
XXX
0
X
81.45
X
77332
26
1
XXX
0
X
81.74
X
77332
TC
4
XXX
0
X
108.82
X
77332
TC
3
XXX
0
X
110.55
X
77332
TC
2
XXX
0
X
119.80
X
77332
TC
1
XXX
0
X
123.19
X
77332
4
XXX
0
X
177.66
X
77332
3
XXX
0
X
180.20
X
77332
2
XXX
0
X
193.29
X
77332
1
XXX
0
X
196.42
X
77333
26
4
XXX
0
X
115.70
X
77333
26
3
XXX
0
X
118.79
X
77333
26
2
XXX
0
X
123.92
X
77333
26
1
XXX
0
X
124.26
X
77333
TC
4
XXX
0
X
154.89
X
77333
TC
3
XXX
0
X
157.44
X
77333
TC
2
XXX
0
X
170.80
X
77333
TC
1
XXX
0
X
174.82
X
77333
4
XXX
0
X
260.64
X
77333
3
XXX
0
X
264.31
X
77333
2
XXX
0
X
283.56
X
77333
1
XXX
0
X
288.14
X
77334
26
4
XXX
0
X
171.94
X
77334
26
3
XXX
0
X
175.03
X
77334
26
2
XXX
0
X
182.64
X
77334
26
1
XXX
0
X
183.25
X
77334
TC
4
XXX
0
X
263.69
X
77334
TC
3
XXX
0
X
267.97
X
77334
TC
2
XXX
0
X
290.27
X
77334
TC
1
XXX
0
X
298.30
X
77334
4
XXX
0
X
417.84
X
77334
3
XXX
0
X
423.76
X
77334
2
XXX
0
X
454.36
X
77334
1
XXX
0
X
461.64
X
77336
4
XXX
0
X
242.28
X
77336
3
XXX
0
X
246.18
X
77336
2
XXX
0
X
266.87
X
77336
1
XXX
0
X
274.14
X
77338
26
2
XXX
0
X
333.03
X
77338
26
3
XXX
0
X
333.03
X
77338
26
4
XXX
0
X
333.03
X
77338
TC
2
XXX
0
X
352.68
X
77338
TC
3
XXX
0
X
352.68
X
77338
TC
4
XXX
0
X
352.68
X
77338
26
1
XXX
0
X
360.05
X
77338
TC
1
XXX
0
X
418.44
X
77338
2
XXX
0
X
685.72
X
77338
3
XXX
0
X
685.72
X
77338
4
XXX
0
X
685.72
X
77338
1
XXX
0
X
778.50
X
77370
4
XXX
0
X
284.34
X
77370
3
XXX
0
X
289.01
X
77370
2
XXX
0
X
313.18
X
77370
1
XXX
0
X
321.48
X
77371
2
XXX
0
X
1,619.73
X
77371
3
XXX
0
X
1,619.73
X
77371
4
XXX
0
X
1,619.73
X
77371
1
XXX
0
X
1,984.69
X
77372
2
XXX
0
X
1,229.22
X
77372
3
XXX
0
X
1,229.22
X
77372
4
XXX
0
X
1,229.22
X
77372
1
XXX
0
X
1,506.93
X
77373
2
XXX
0
X
2,292.89
X
77373
3
XXX
0
X
2,292.89
X
77373
4
XXX
0
X
2,292.89
X
77373
1
XXX
0
X
2,808.29
X
77385
XXX
0
X
*
X
77386
XXX
0
X
*
X
77387
XXX
0
X
*
X
77399
XXX
0
X
#
X
77401
4
XXX
0
X
144.61
X
77401
3
XXX
0
X
146.93
X
77401
2
XXX
0
X
159.33
X
77401
1
XXX
0
X
163.04
X
77402
4
XXX
0
X
144.61
X
77402
3
XXX
0
X
146.93
X
77402
2
XXX
0
X
159.33
X
77402
1
XXX
0
X
163.04
X
77407
4
XXX
0
X
170.02
X
77407
3
XXX
0
X
172.72
X
77407
2
XXX
0
X
187.41
X
77407
1
XXX
0
X
192.50
X
77412
4
XXX
0
X
189.85
X
77412
3
XXX
0
X
192.97
X
77412
2
XXX
0
X
209.44
X
77412
1
XXX
0
X
214.19
X
77417
4
XXX
0
X
48.45
X
77417
3
XXX
0
X
49.25
X
77417
2
XXX
0
X
53.51
X
77417
1
XXX
0
X
55.12
X
77423
2
XXX
0
X
132.99
X
77423
3
XXX
0
X
132.99
X
77423
4
XXX
0
X
132.99
X
77423
1
XXX
0
X
166.00
X
77424
XXX
9
X
#
X
77425
XXX
9
X
#
X
77427
2
XXX
9
X
332.91
X
77427
3
XXX
9
X
332.91
X
77427
4
XXX
9
X
332.91
X
77427
1
XXX
9
X
359.58
X
77431
4
XXX
0
X
227.00
X
77431
3
XXX
0
X
229.54
X
77431
2
XXX
0
X
241.86
X
77431
1
XXX
0
X
244.82
X
77432
4
XXX
0
X
1,094.81
X
77432
3
XXX
0
X
1,107.80
X
77432
2
XXX
0
X
1,163.43
X
77432
1
XXX
0
X
1,176.91
X
77435
2
XXX
0
X
962.59
X
77435
3
XXX
0
X
962.59
X
77435
4
XXX
0
X
962.59
X
77435
1
XXX
0
X
1,056.92
X
77469
2
XXX
0
X
420.03
X
77469
3
XXX
0
X
420.03
X
77469
4
XXX
0
X
420.03
X
77469
1
XXX
0
X
453.54
X
77470
26
4
XXX
0
X
287.43
X
77470
26
3
XXX
0
X
295.00
X
77470
26
2
XXX
0
X
308.31
X
77470
26
1
XXX
0
X
309.30
X
77470
TC
4
XXX
0
X
906.42
X
77470
TC
3
XXX
0
X
921.04
X
77470
TC
2
XXX
0
X
998.18
X
77470
TC
1
XXX
0
X
1,024.82
X
77470
4
XXX
0
X
1,167.82
X
77470
3
XXX
0
X
1,185.29
X
77470
2
XXX
0
X
1,276.71
X
77470
1
XXX
0
X
1,298.48
X
77499
XXX
0
X
#
X
77520
XXX
9
X
*
X
77522
XXX
9
X
*
X
77523
XXX
9
X
*
X
77525
XXX
9
X
*
X
77600
26
4
XXX
0
X
215.80
X
77600
26
3
XXX
0
X
221.47
X
77600
26
2
XXX
0
X
231.55
X
77600
26
1
XXX
0
X
232.27
X
77600
TC
4
XXX
0
X
247.01
X
77600
TC
3
XXX
0
X
251.06
X
77600
TC
2
XXX
0
X
271.98
X
77600
TC
1
XXX
0
X
276.92
X
77600
4
XXX
0
X
455.34
X
77600
3
XXX
0
X
467.56
X
77600
1
XXX
0
X
489.35
X
77600
2
XXX
0
X
492.16
X
77605
26
4
XXX
0
X
287.43
X
77605
26
3
XXX
0
X
295.00
X
77605
26
2
XXX
0
X
308.31
X
77605
26
1
XXX
0
X
309.30
X
77605
TC
4
XXX
0
X
330.49
X
77605
TC
3
XXX
0
X
335.79
X
77605
TC
2
XXX
0
X
364.11
X
77605
TC
1
XXX
0
X
370.88
X
77605
4
XXX
0
X
607.19
X
77605
3
XXX
0
X
623.45
X
77605
1
XXX
0
X
652.84
X
77605
2
XXX
0
X
656.44
X
77610
26
4
XXX
0
X
215.80
X
77610
26
3
XXX
0
X
221.47
X
77610
26
2
XXX
0
X
231.55
X
77610
26
1
XXX
0
X
232.27
X
77610
TC
4
XXX
0
X
247.01
X
77610
TC
3
XXX
0
X
251.06
X
77610
TC
2
XXX
0
X
271.98
X
77610
TC
1
XXX
0
X
276.92
X
77610
4
XXX
0
X
455.34
X
77610
3
XXX
0
X
467.56
X
77610
1
XXX
0
X
489.35
X
77610
2
XXX
0
X
492.16
X
77615
26
4
XXX
0
X
287.43
X
77615
26
3
XXX
0
X
295.00
X
77615
26
2
XXX
0
X
308.31
X
77615
26
1
XXX
0
X
309.30
X
77615
TC
4
XXX
0
X
330.49
X
77615
TC
3
XXX
0
X
335.79
X
77615
TC
2
XXX
0
X
364.11
X
77615
TC
1
XXX
0
X
370.88
X
77615
4
XXX
0
X
607.19
X
77615
3
XXX
0
X
623.45
X
77615
1
XXX
0
X
652.84
X
77615
2
XXX
0
X
656.44
X
77620
26
4
XXX
0
X
215.80
X
77620
26
3
XXX
0
X
221.47
X
77620
26
2
XXX
0
X
231.55
X
77620
26
1
XXX
0
X
232.27
X
77620
TC
4
XXX
0
X
247.01
X
77620
TC
3
XXX
0
X
251.06
X
77620
TC
2
XXX
0
X
271.98
X
77620
TC
1
XXX
0
X
276.92
X
77620
4
XXX
0
X
455.34
X
77620
3
XXX
0
X
467.56
X
77620
1
XXX
0
X
489.35
X
77620
2
XXX
0
X
492.16
X
77750
TC
4
90
0
X
107.99
X
77750
TC
3
90
0
X
109.71
X
77750
TC
2
90
0
X
118.96
X
77750
TC
1
90
0
X
121.15
X
77750
26
4
90
0
X
632.06
X
77750
26
3
90
0
X
653.77
X
77750
26
2
90
0
X
677.78
X
77750
26
1
90
0
X
679.81
X
77750
4
90
0
X
737.05
X
77750
3
90
0
X
756.57
X
77750
2
90
0
X
792.04
X
77750
1
90
0
X
794.84
X
77761
TC
4
90
0
X
205.00
X
77761
TC
3
90
0
X
208.28
X
77761
TC
2
90
0
X
226.05
X
77761
TC
1
90
0
X
230.27
X
77761
26
4
90
0
X
497.80
X
77761
26
3
90
0
X
505.17
X
77761
26
2
90
0
X
526.36
X
77761
26
1
90
0
X
527.98
X
77761
4
90
0
X
675.75
X
77761
3
90
0
X
693.59
X
77761
2
90
0
X
727.84
X
77761
1
90
0
X
730.96
X
77762
TC
4
90
0
X
293.94
X
77762
TC
3
90
0
X
298.70
X
77762
TC
2
90
0
X
323.78
X
77762
TC
1
90
0
X
329.78
X
77762
26
4
90
0
X
737.89
X
77762
26
3
90
0
X
757.83
X
77762
26
2
90
0
X
791.24
X
77762
26
1
90
0
X
793.62
X
77762
4
90
0
X
1,003.81
X
77762
3
90
0
X
1,030.33
X
77762
2
90
0
X
1,080.92
X
77762
1
90
0
X
1,085.51
X
77763
TC
4
90
0
X
365.42
X
77763
TC
3
90
0
X
371.31
X
77763
TC
2
90
0
X
402.36
X
77763
TC
1
90
0
X
409.79
X
77763
26
4
90
0
X
1,132.81
X
77763
26
3
90
0
X
1,133.29
X
77763
26
2
90
0
X
1,183.59
X
77763
26
1
90
0
X
1,187.09
X
77763
4
90
0
X
1,434.59
X
77763
3
90
0
X
1,472.46
X
77763
2
90
0
X
1,543.78
X
77763
1
90
0
X
1,550.00
X
77767
26
2
XXX
0
X
70.52
X
77767
26
3
XXX
0
X
70.52
X
77767
26
4
XXX
0
X
70.52
X
77767
26
1
XXX
0
X
75.44
X
77767
TC
2
XXX
0
X
209.01
X
77767
TC
3
XXX
0
X
209.01
X
77767
TC
4
XXX
0
X
209.01
X
77767
TC
1
XXX
0
X
244.70
X
77767
2
XXX
0
X
279.53
X
77767
3
XXX
0
X
279.53
X
77767
4
XXX
0
X
279.53
X
77767
1
XXX
0
X
320.14
X
77768
26
2
XXX
0
X
93.43
X
77768
26
3
XXX
0
X
93.43
X
77768
26
4
XXX
0
X
93.43
X
77768
26
1
XXX
0
X
99.86
X
77768
TC
2
XXX
0
X
343.73
X
77768
TC
3
XXX
0
X
343.73
X
77768
TC
4
XXX
0
X
343.73
X
77768
TC
1
XXX
0
X
402.43
X
77768
2
XXX
0
X
437.14
X
77768
3
XXX
0
X
437.14
X
77768
4
XXX
0
X
437.14
X
77768
1
XXX
0
X
502.29
X
77770
26
2
XXX
0
X
130.48
X
77770
26
3
XXX
0
X
130.48
X
77770
26
4
XXX
0
X
130.48
X
77770
26
1
XXX
0
X
139.49
X
77770
TC
2
XXX
0
X
269.85
X
77770
TC
3
XXX
0
X
269.85
X
77770
TC
4
XXX
0
X
269.85
X
77770
TC
1
XXX
0
X
315.94
X
77770
2
XXX
0
X
400.34
X
77770
3
XXX
0
X
400.34
X
77770
4
XXX
0
X
400.34
X
77770
1
XXX
0
X
455.43
X
77771
26
2
XXX
0
X
254.14
X
77771
26
3
XXX
0
X
254.14
X
77771
26
4
XXX
0
X
254.14
X
77771
26
1
XXX
0
X
271.68
X
77771
TC
2
XXX
0
X
491.45
X
77771
TC
3
XXX
0
X
491.45
X
77771
TC
4
XXX
0
X
491.45
X
77771
TC
1
XXX
0
X
575.39
X
77771
2
XXX
0
X
745.57
X
77771
3
XXX
0
X
745.57
X
77771
4
XXX
0
X
745.57
X
77771
1
XXX
0
X
847.07
X
77772
26
2
XXX
0
X
360.83
X
77772
26
3
XXX
0
X
360.83
X
77772
26
4
XXX
0
X
360.83
X
77772
26
1
XXX
0
X
385.72
X
77772
TC
2
XXX
0
X
776.97
X
77772
TC
3
XXX
0
X
776.97
X
77772
TC
4
XXX
0
X
776.97
X
77772
TC
1
XXX
0
X
909.73
X
77772
2
XXX
0
X
1,137.81
X
77772
3
XXX
0
X
1,137.81
X
77772
4
XXX
0
X
1,137.81
X
77772
1
XXX
0
X
1,295.46
X
77778
TC
4
90
0
X
417.04
X
77778
TC
3
90
0
X
423.77
X
77778
TC
2
90
0
X
459.34
X
77778
TC
1
90
0
X
467.81
X
77778
26
4
90
0
X
1,476.27
X
77778
26
3
90
0
X
1,483.95
X
77778
26
2
90
0
X
1,547.62
X
77778
26
1
90
0
X
1,552.21
X
77778
4
90
0
X
1,846.55
X
77778
3
90
0
X
1,895.59
X
77778
2
90
0
X
1,986.62
X
77778
1
90
0
X
1,994.37
X
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