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 27470-27750
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
27470-27750
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
27470
004
90
2
X
3,505.61
X
27470
003
90
2
X
3,548.72
X
27470
002
90
2
X
3,815.23
X
27470
001
90
2
X
3,879.62
X
27472
001
90
2
X
4,762.78
X
27472
003
90
2
X
4,330.41
X
27472
002
90
2
X
4,651.42
X
27472
004
90
2
X
4,377.83
X
27475
001
90
2
X
1,945.89
X
27475
004
90
2
X
1,763.50
X
27475
003
90
2
X
1,784.70
X
27475
002
90
2
X
1,914.47
X
27477
002
90
2
X
2,993.85
X
27477
003
90
2
X
2,755.25
X
27477
001
90
2
X
3,051.42
X
27477
004
90
2
X
2,720.97
X
27479
001
90
2
X
2,920.96
X
27479
004
90
2
X
2,647.74
X
27479
003
90
2
X
2,679.66
X
27479
002
90
2
X
2,873.94
X
27485
004
90
2
X
1,804.28
X
27485
003
90
2
X
1,826.02
X
27485
002
90
2
X
1,958.74
X
27485
001
90
2
X
1,990.86
X
27486
003
90
2
X
5,941.19
X
27486
002
90
2
X
5,972.19
X
27486
001
90
2
X
6,026.80
X
27486
004
90
2
X
5,772.57
X
27487
004
90
2
X
6,950.01
X
27487
001
90
2
X
7,026.17
X
27487
002
90
2
X
6,893.13
X
27487
003
90
2
X
6,954.63
X
27488
001
90
2
X
4,457.18
X
27488
003
90
2
X
4,320.89
X
27488
002
90
2
X
4,370.26
X
27488
004
90
2
X
4,303.36
X
27495
002
90
2
X
3,892.38
X
27495
003
90
2
X
3,610.86
X
27495
001
90
2
X
3,960.40
X
27495
004
90
2
X
3,617.42
X
27496
002
90
2
X
1,120.36
X
27496
003
90
2
X
1,044.48
X
27496
001
90
2
X
1,138.82
X
27496
004
90
2
X
1,032.02
X
27497
004
90
2
X
1,263.23
X
27497
002
90
2
X
1,371.59
X
27497
003
90
2
X
1,278.52
X
27497
001
90
2
X
1,394.09
X
27498
002
90
2
X
1,564.11
X
27498
003
90
2
X
1,457.88
X
27498
004
90
2
X
1,440.62
X
27498
001
90
2
X
1,589.82
X
27499
001
90
2
X
1,829.89
X
27499
004
90
2
X
1,658.59
X
27499
002
90
2
X
1,800.43
X
27499
003
90
2
X
1,678.55
X
27500
001
90
2
X
1,463.17
X
27500
004
90
2
X
1,387.14
X
27500
003
90
2
X
1,389.13
X
27500
002
90
2
X
1,427.17
X
27501
001
90
2
X
1,463.17
X
27501
003
90
2
X
1,389.13
X
27501
002
90
2
X
1,427.17
X
27501
004
90
2
X
1,387.14
X
27502
001
90
2
X
2,499.14
X
27502
003
90
2
X
1,965.51
X
27502
002
90
2
X
2,531.71
X
27502
004
90
2
X
2,093.33
X
27503
003
90
2
X
1,965.51
X
27503
002
90
2
X
2,531.71
X
27503
004
90
2
X
2,093.33
X
27503
001
90
2
X
2,499.14
X
27506
001
90
2
X
3,923.78
X
27506
004
90
2
X
3,553.51
X
27506
002
90
2
X
3,860.05
X
27506
003
90
2
X
3,596.62
X
27507
004
90
2
X
3,229.00
X
27507
001
90
2
X
3,586.30
X
27507
003
90
2
X
3,269.09
X
27507
002
90
2
X
3,524.59
X
27508
004
90
2
X
1,255.40
X
27508
002
90
2
X
1,289.55
X
27508
003
90
2
X
1,250.63
X
27508
001
90
2
X
1,298.38
X
27509
001
90
2
X
1,383.25
X
27509
003
90
2
X
1,333.02
X
27509
002
90
2
X
1,373.91
X
27509
004
90
2
X
1,337.09
X
27510
002
90
2
X
1,796.17
X
27510
003
90
2
X
1,737.52
X
27510
004
90
2
X
1,711.38
X
27510
001
90
2
X
1,824.15
X
27511
001
90
2
X
3,546.28
X
27511
003
90
2
X
3,230.35
X
27511
002
90
2
X
3,484.83
X
27511
004
90
2
X
3,190.62
X
27513
001
90
2
X
4,016.80
X
27513
002
90
2
X
3,952.56
X
27513
003
90
2
X
3,686.86
X
27513
004
90
2
X
3,642.91
X
27514
003
90
2
X
3,572.48
X
27514
002
90
2
X
3,833.08
X
27514
001
90
2
X
4,110.04
X
27514
004
90
2
X
3,579.91
X
27516
004
90
2
X
1,075.29
X
27516
001
90
2
X
1,183.60
X
27516
003
90
2
X
1,088.39
X
27516
002
90
2
X
1,165.10
X
27517
001
90
2
X
1,965.97
X
27517
004
90
2
X
1,781.80
X
27517
002
90
2
X
1,934.23
X
27517
003
90
2
X
1,803.34
X
27519
004
90
2
X
2,941.23
X
27519
001
90
2
X
3,240.54
X
27519
003
90
2
X
2,976.48
X
27519
002
90
2
X
3,189.15
X
27520
002
90
2
X
767.86
X
27520
003
90
2
X
642.38
X
27520
001
90
2
X
745.51
X
27520
004
90
2
X
707.50
X
27524
001
90
2
X
2,433.38
X
27524
003
90
2
X
2,225.18
X
27524
002
90
2
X
2,392.83
X
27524
004
90
2
X
2,198.28
X
27530
004
90
2
X
827.39
X
27530
002
90
2
X
924.52
X
27530
003
90
2
X
744.80
X
27530
001
90
2
X
913.15
X
27532
002
90
2
X
1,495.12
X
27532
003
90
2
X
1,398.64
X
27532
001
90
2
X
1,518.52
X
27532
004
90
2
X
1,382.22
X
27535
004
90
2
X
2,406.35
X
27535
001
90
2
X
2,726.80
X
27535
003
90
2
X
2,491.56
X
27535
002
90
2
X
2,529.84
X
27536
001
90
2
X
3,180.04
X
27536
004
90
2
X
2,616.87
X
27536
002
90
2
X
2,747.47
X
27536
003
90
2
X
2,931.34
X
27538
003
90
2
X
900.91
X
27538
002
90
2
X
937.92
X
27538
004
90
2
X
880.35
X
27538
001
90
2
X
836.78
X
27540
002
90
2
X
2,798.71
X
27540
003
90
2
X
2,615.33
X
27540
004
90
2
X
2,886.72
X
27540
001
90
2
X
3,012.02
X
27550
003
90
2
X
886.75
X
27550
002
90
2
X
936.76
X
27550
004
90
2
X
876.97
X
27550
001
90
2
X
863.41
X
27552
001
90
2
X
1,272.04
X
27552
004
90
2
X
1,177.62
X
27552
002
90
2
X
1,262.75
X
27552
003
90
2
X
1,190.76
X
27556
001
90
2
X
3,164.56
X
27556
003
90
2
X
2,909.09
X
27556
002
90
2
X
3,114.76
X
27556
004
90
2
X
2,874.54
X
27557
004
90
2
X
3,383.59
X
27557
002
90
2
X
4,298.84
X
27557
003
90
2
X
3,424.13
X
27557
001
90
2
X
3,732.46
X
27558
001
90
2
X
3,836.27
X
27558
004
90
2
X
3,483.48
X
27558
002
90
2
X
4,350.10
X
27558
003
90
2
X
3,524.90
X
27560
001
90
2
X
653.75
X
27560
003
90
2
X
578.69
X
27560
002
90
2
X
643.76
X
27560
004
90
2
X
494.15
X
27562
004
90
2
X
1,057.50
X
27562
003
90
2
X
1,190.77
X
27562
002
90
2
X
1,123.42
X
27562
001
90
2
X
1,293.51
X
27566
002
90
2
X
2,650.67
X
27566
003
90
2
X
2,475.12
X
27566
004
90
2
X
2,445.76
X
27566
001
90
2
X
2,693.09
X
27570
002
10
2
X
516.56
X
27570
003
10
2
X
505.36
X
27570
001
10
2
X
520.05
X
27570
004
10
2
X
499.35
X
27580
003
90
2
X
3,609.17
X
27580
002
90
2
X
3,784.98
X
27580
001
90
2
X
3,886.59
X
27580
004
90
2
X
3,571.45
X
27590
004
90
2
X
2,180.63
X
27590
001
90
2
X
2,417.19
X
27590
002
90
2
X
2,376.02
X
27590
003
90
2
X
2,206.30
X
27591
001
90
2
X
2,852.46
X
27591
002
90
2
X
2,803.35
X
27591
003
90
2
X
2,600.40
X
27591
004
90
2
X
2,569.32
X
27592
001
90
2
X
2,189.00
X
27592
004
90
2
X
1,904.53
X
27592
003
90
2
X
2,062.41
X
27592
002
90
2
X
2,180.63
X
27594
003
90
2
X
1,146.20
X
27594
002
90
2
X
1,184.97
X
27594
001
90
2
X
1,221.50
X
27594
004
90
2
X
1,150.03
X
27596
004
90
2
X
2,035.94
X
27596
002
90
2
X
2,129.99
X
27596
003
90
2
X
2,021.26
X
27596
001
90
2
X
2,187.03
X
27598
003
90
2
X
2,256.28
X
27598
002
90
2
X
2,400.12
X
27598
004
90
2
X
2,292.17
X
27598
001
90
2
X
2,441.93
X
27599
YYY
2
X
#
X
27600
004
90
2
X
1,192.55
X
27600
002
90
2
X
1,231.54
X
27600
003
90
2
X
1,173.97
X
27600
001
90
2
X
1,250.81
X
27601
004
90
2
X
1,184.99
X
27601
002
90
2
X
1,162.10
X
27601
003
90
2
X
1,165.15
X
27601
001
90
2
X
1,250.67
X
27602
004
90
2
X
1,184.28
X
27602
002
90
2
X
1,277.01
X
27602
003
90
2
X
1,197.63
X
27602
001
90
2
X
1,296.33
X
27603
001
90
2
X
714.80
X
27603
004
90
2
X
706.12
X
27603
002
90
2
X
733.61
X
27603
003
90
2
X
710.66
X
27604
004
90
2
X
428.71
X
27604
001
90
2
X
465.95
X
27604
003
90
2
X
567.80
X
27604
002
90
2
X
462.55
X
27605
004
10
2
X
429.10
X
27605
002
10
2
X
455.02
X
27605
003
10
2
X
433.84
X
27605
001
10
2
X
460.23
X
27606
001
10
2
X
712.34
X
27606
004
10
2
X
655.56
X
27606
002
10
2
X
595.08
X
27606
003
10
2
X
533.92
X
27607
004
90
2
X
1,448.27
X
27607
002
90
2
X
1,568.03
X
27607
003
90
2
X
1,465.48
X
27607
001
90
2
X
1,592.85
X
27610
004
90
2
X
1,682.61
X
27610
003
90
2
X
1,648.52
X
27610
002
90
2
X
1,767.44
X
27610
001
90
2
X
1,796.22
X
27612
004
90
2
X
1,607.68
X
27612
001
90
2
X
1,787.50
X
27612
002
90
2
X
1,756.38
X
27612
003
90
2
X
1,712.68
X
27613
003
10
2
X
303.69
X
27613
002
10
2
X
255.91
X
27613
004
10
2
X
270.92
X
27613
001
10
2
X
270.76
X
27614
001
90
2
X
597.99
X
27614
003
90
2
X
548.25
X
27614
002
90
2
X
588.27
X
27614
004
90
2
X
544.55
X
27615
002
90
2
X
1,995.35
X
27615
003
90
2
X
2,241.45
X
27615
001
90
2
X
2,427.83
X
27615
004
90
2
X
1,903.91
X
27616
002
90
2
X
2,165.13
X
27616
003
90
2
X
2,165.13
X
27616
004
90
2
X
2,165.13
X
27616
001
90
2
X
2,424.28
X
27618
004
90
2
X
625.51
X
27618
002
90
2
X
682.92
X
27618
003
90
2
X
649.76
X
27618
001
90
2
X
743.42
X
27619
001
90
2
X
1,047.86
X
27619
003
90
2
X
986.45
X
27619
002
90
2
X
1,038.25
X
27619
004
90
2
X
1,325.11
X
27620
001
90
2
X
1,554.08
X
27620
003
90
2
X
1,524.08
X
27620
002
90
2
X
1,629.37
X
27620
004
90
2
X
1,543.25
X
27625
003
90
2
X
1,859.34
X
27625
002
90
2
X
1,994.43
X
27625
004
90
2
X
1,897.75
X
27625
001
90
2
X
2,027.02
X
27626
001
90
2
X
2,324.43
X
27626
003
90
2
X
2,140.05
X
27626
002
90
2
X
2,288.69
X
27626
004
90
2
X
2,113.05
X
27630
001
90
2
X
924.82
X
27630
004
90
2
X
848.44
X
27630
003
90
2
X
858.31
X
27630
002
90
2
X
911.84
X
27632
001
90
2
X
777.63
X
27632
004
90
2
X
693.08
X
27632
003
90
2
X
693.08
X
27632
002
90
2
X
693.08
X
27634
003
90
2
X
1,132.37
X
27634
002
90
2
X
1,132.37
X
27634
001
90
2
X
1,265.24
X
27634
004
90
2
X
1,132.37
X
27635
003
90
2
X
1,873.87
X
27635
002
90
2
X
1,982.14
X
27635
001
90
2
X
1,888.56
X
27635
004
90
2
X
1,953.40
X
27637
002
90
2
X
2,125.81
X
27637
003
90
2
X
1,982.18
X
27637
001
90
2
X
2,160.54
X
27637
004
90
2
X
1,958.72
X
27638
001
90
2
X
2,337.23
X
27638
003
90
2
X
2,151.46
X
27638
002
90
2
X
2,299.64
X
27638
004
90
2
X
2,118.82
X
27640
003
90
2
X
2,250.58
X
27640
002
90
2
X
2,413.28
X
27640
004
90
2
X
2,210.14
X
27640
001
90
2
X
2,468.91
X
27641
001
90
2
X
1,955.01
X
27641
004
90
2
X
1,781.03
X
27641
002
90
2
X
1,896.60
X
27641
003
90
2
X
1,773.08
X
27645
003
90
2
X
2,791.95
X
27645
002
90
2
X
2,993.16
X
27645
004
90
2
X
2,759.12
X
27645
001
90
2
X
3,041.93
X
27646
001
90
2
X
2,740.82
X
27646
004
90
2
X
2,488.61
X
27646
002
90
2
X
2,697.52
X
27646
003
90
2
X
2,518.53
X
27647
001
90
2
X
2,538.96
X
27647
004
90
2
X
2,318.43
X
27647
003
90
2
X
2,346.49
X
27647
002
90
2
X
2,501.46
X
27648
003
0
2
X
150.19
X
27648
002
0
2
X
157.81
X
27648
004
0
2
X
148.48
X
27648
001
0
2
X
159.62
X
27650
004
90
2
X
1,982.93
X
27650
001
90
2
X
2,153.80
X
27650
002
90
2
X
2,100.96
X
27650
003
90
2
X
1,964.13
X
27652
002
90
2
X
2,342.18
X
27652
003
90
2
X
2,249.05
X
27652
004
90
2
X
2,319.93
X
27652
001
90
2
X
2,453.10
X
27654
003
90
2
X
2,595.62
X
27654
002
90
2
X
2,667.45
X
27654
004
90
2
X
2,252.63
X
27654
001
90
2
X
2,412.88
X
27656
002
90
2
X
897.16
X
27656
003
90
2
X
871.58
X
27656
004
90
2
X
830.44
X
27656
001
90
2
X
911.01
X
27658
004
90
2
X
951.19
X
27658
001
90
2
X
1,044.25
X
27658
003
90
2
X
962.54
X
27658
002
90
2
X
1,028.30
X
27659
004
90
2
X
1,340.63
X
27659
001
90
2
X
1,473.43
X
27659
002
90
2
X
1,450.78
X
27659
003
90
2
X
1,356.80
X
27664
001
90
2
X
934.70
X
27664
003
90
2
X
843.82
X
27664
002
90
2
X
920.81
X
27664
004
90
2
X
853.21
X
27665
003
90
2
X
1,127.71
X
27665
002
90
2
X
1,208.17
X
27665
001
90
2
X
1,227.58
X
27665
004
90
2
X
1,114.28
X
27675
001
90
2
X
1,599.20
X
27675
004
90
2
X
1,454.61
X
27675
003
90
2
X
1,472.23
X
27675
002
90
2
X
1,574.42
X
27676
002
90
2
X
1,848.37
X
27676
003
90
2
X
1,726.76
X
27676
004
90
2
X
1,706.03
X
27676
001
90
2
X
1,877.84
X
27680
002
90
2
X
1,124.41
X
27680
003
90
2
X
1,055.58
X
27680
001
90
2
X
1,141.10
X
27680
004
90
2
X
1,043.27
X
27681
001
90
2
X
1,492.95
X
27681
003
90
2
X
1,375.41
X
27681
002
90
2
X
1,470.00
X
27681
004
90
2
X
1,358.90
X
27685
002
90
2
X
1,159.15
X
27685
003
90
2
X
1,078.83
X
27685
004
90
2
X
1,066.31
X
27685
001
90
2
X
1,190.34
X
27686
003
90
2
X
1,499.95
X
27686
002
90
2
X
1,601.61
X
27686
004
90
2
X
1,481.85
X
27686
001
90
2
X
1,490.94
X
27687
003
90
2
X
1,255.75
X
27687
002
90
2
X
1,341.09
X
27687
004
90
2
X
1,240.75
X
27687
001
90
2
X
1,338.26
X
27690
001
90
2
X
1,769.88
X
27690
002
90
2
X
1,744.59
X
27690
003
90
2
X
1,639.73
X
27690
004
90
2
X
1,620.32
X
27691
004
90
2
X
1,893.74
X
27691
002
90
2
X
2,048.07
X
27691
001
90
2
X
2,079.90
X
27691
003
90
2
X
1,916.34
X
27692
003
ZZZ
0
X
435.52
X
27692
002
ZZZ
0
X
466.70
X
27692
001
ZZZ
0
X
474.20
X
27692
004
ZZZ
0
X
430.25
X
27695
002
90
2
X
2,022.19
X
27695
003
90
2
X
1,851.19
X
27695
004
90
2
X
1,920.14
X
27695
001
90
2
X
2,071.98
X
27696
001
90
2
X
1,810.88
X
27696
004
90
2
X
1,642.94
X
27696
003
90
2
X
1,662.68
X
27696
002
90
2
X
1,782.02
X
27698
002
90
2
X
2,490.92
X
27698
003
90
2
X
2,307.69
X
27698
004
90
2
X
2,491.40
X
27698
001
90
2
X
2,579.03
X
27700
004
90
2
X
2,198.91
X
27700
003
90
2
X
2,226.75
X
27700
002
90
2
X
2,391.16
X
27700
001
90
2
X
2,430.77
X
27702
004
90
2
X
3,912.55
X
27702
001
90
2
X
4,406.68
X
27702
003
90
2
X
3,962.09
X
27702
002
90
2
X
4,320.10
X
27703
001
90
2
X
3,473.29
X
27703
002
90
2
X
3,417.36
X
27703
003
90
2
X
3,185.97
X
27703
004
90
2
X
3,148.06
X
27704
001
90
2
X
1,526.87
X
27704
004
90
2
X
1,446.97
X
27704
003
90
2
X
1,419.94
X
27704
002
90
2
X
1,503.36
X
27705
003
90
2
X
2,304.45
X
27705
002
90
2
X
2,631.58
X
27705
004
90
2
X
2,276.55
X
27705
001
90
2
X
2,523.02
X
27707
001
90
2
X
1,216.46
X
27707
004
90
2
X
949.89
X
27707
002
90
2
X
1,200.93
X
27707
003
90
2
X
1,015.58
X
27709
003
90
2
X
2,436.08
X
27709
002
90
2
X
2,637.78
X
27709
001
90
2
X
2,686.51
X
27709
004
90
2
X
2,406.26
X
27712
002
90
2
X
3,108.21
X
27712
003
90
2
X
2,546.91
X
27712
001
90
2
X
2,766.51
X
27712
004
90
2
X
2,516.48
X
27715
002
90
2
X
3,063.11
X
27715
003
90
2
X
2,861.37
X
27715
001
90
2
X
3,111.89
X
27715
004
90
2
X
2,826.99
X
27720
001
90
2
X
3,162.38
X
27720
004
90
2
X
2,791.53
X
27720
002
90
2
X
3,092.26
X
27720
003
90
2
X
2,877.00
X
27722
004
90
2
X
2,375.38
X
27722
001
90
2
X
2,617.76
X
27722
002
90
2
X
3,263.56
X
27722
003
90
2
X
2,754.85
X
27724
001
90
2
X
3,583.52
X
27724
002
90
2
X
3,518.24
X
27724
003
90
2
X
3,248.21
X
27724
004
90
2
X
3,208.38
X
27725
002
90
2
X
2,564.68
X
27725
003
90
2
X
2,398.06
X
27725
004
90
2
X
3,307.90
X
27725
001
90
2
X
2,604.96
X
27726
001
90
2
X
1,645.78
X
27726
002
90
2
X
1,473.70
X
27726
003
90
2
X
1,473.70
X
27726
004
90
2
X
1,473.70
X
27727
004
90
2
X
2,490.37
X
27727
001
90
2
X
2,742.88
X
27727
003
90
2
X
2,519.08
X
27727
002
90
2
X
2,699.10
X
27730
004
90
2
X
1,173.07
X
27730
001
90
2
X
1,286.24
X
27730
002
90
2
X
1,266.60
X
27730
003
90
2
X
1,185.90
X
27732
004
90
2
X
1,101.24
X
27732
002
90
2
X
1,195.60
X
27732
003
90
2
X
1,114.51
X
27732
001
90
2
X
1,215.26
X
27734
004
90
2
X
1,715.56
X
27734
001
90
2
X
1,892.72
X
27734
003
90
2
X
1,736.27
X
27734
002
90
2
X
1,862.26
X
27740
001
90
2
X
2,099.84
X
27740
003
90
2
X
1,926.00
X
27740
002
90
2
X
2,065.93
X
27740
004
90
2
X
1,903.10
X
27742
004
90
2
X
2,115.01
X
27742
001
90
2
X
2,334.01
X
27742
003
90
2
X
2,140.49
X
27742
002
90
2
X
2,296.29
X
27745
004
90
2
X
2,034.22
X
27745
003
90
2
X
2,058.79
X
27745
002
90
2
X
2,205.61
X
27745
001
90
2
X
2,241.05
X
27750
001
90
2
X
896.46
X
27750
004
90
2
X
811.76
X
27750
002
90
2
X
940.99
X
27750
003
90
2
X
764.38
X
Return to CPT/HCPC List