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 97018-99347
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
97018-99347
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
97018
001
XXX
5
X
53.06
X
97018
003
XXX
5
X
47.59
X
97018
002
XXX
5
X
51.62
X
97018
004
XXX
5
X
48.62
X
97022
001
XXX
5
X
42.55
X
97022
002
XXX
5
X
42.01
X
97022
003
XXX
5
X
38.30
X
97022
004
XXX
5
X
39.06
X
97024
001
XXX
5
X
46.08
X
97024
002
XXX
5
X
41.01
X
97024
003
XXX
5
X
40.46
X
97024
004
XXX
5
X
38.00
X
97026
004
XXX
5
X
40.01
X
97026
002
XXX
5
X
42.95
X
97026
003
XXX
5
X
40.52
X
97026
001
XXX
5
X
54.40
X
97028
002
XXX
5
X
37.59
X
97028
004
XXX
5
X
43.20
X
97028
003
XXX
5
X
35.71
X
97028
001
XXX
5
X
35.09
X
97032
002
XXX
5
X
41.13
X
97032
003
XXX
5
X
39.21
X
97032
004
XXX
5
X
38.72
X
97032
001
XXX
5
X
42.01
X
97033
001
XXX
5
X
44.42
X
97033
002
XXX
5
X
43.34
X
97033
004
XXX
5
X
46.31
X
97033
003
XXX
5
X
41.02
X
97034
004
XXX
5
X
35.05
X
97034
003
XXX
5
X
42.50
X
97034
002
XXX
5
X
41.61
X
97034
001
XXX
5
X
38.57
X
97035
002
XXX
5
X
33.98
X
97035
003
XXX
5
X
32.34
X
97035
004
XXX
5
X
31.95
X
97035
001
XXX
5
X
34.74
X
97036
002
XXX
5
X
44.46
X
97036
004
XXX
5
X
58.96
X
97036
003
XXX
5
X
59.66
X
97036
001
XXX
5
X
45.27
X
97037
XXX
9
X
#
X
97039
002
XXX
0
X
57.50
X
97039
003
XXX
0
X
54.13
X
97039
004
XXX
0
X
53.45
X
97039
001
XXX
0
X
58.28
X
97110
003
XXX
5
X
52.18
X
97110
004
XXX
5
X
49.65
X
97110
002
XXX
5
X
53.46
X
97110
001
XXX
5
X
54.26
X
97112
001
XXX
5
X
50.64
X
97112
004
XXX
5
X
46.71
X
97112
003
XXX
5
X
47.30
X
97112
002
XXX
5
X
50.79
X
97113
001
XXX
5
X
69.35
X
97113
002
XXX
5
X
47.12
X
97113
003
XXX
5
X
48.07
X
97113
004
XXX
5
X
63.94
X
97116
004
XXX
5
X
41.05
X
97116
003
XXX
5
X
46.90
X
97116
002
XXX
5
X
44.01
X
97116
001
XXX
5
X
50.32
X
97124
002
XXX
5
X
42.01
X
97124
001
XXX
5
X
42.55
X
97124
004
XXX
5
X
39.14
X
97124
003
XXX
5
X
39.59
X
97129
003
XXX
0
X
33.26
32.80
97129
002
XXX
0
X
33.26
32.80
97129
001
XXX
0
X
35.46
34.92
97129
004
XXX
0
X
33.26
32.80
97130
001
ZZZ
0
X
33.90
X
97130
004
ZZZ
0
X
31.81
X
97130
003
ZZZ
0
X
31.81
X
97130
002
ZZZ
0
X
31.81
X
97139
002
XXX
0
X
67.53
X
97139
003
XXX
0
X
63.77
X
97139
004
XXX
0
X
63.01
X
97139
001
XXX
0
X
68.40
X
97140
001
XXX
5
X
58.43
44.92
97140
003
XXX
5
X
53.56
42.07
97140
004
XXX
5
X
53.56
42.07
97140
002
XXX
5
X
53.56
42.07
97150
003
XXX
5
X
47.75
X
97150
004
XXX
5
X
47.09
X
97150
002
XXX
5
X
50.48
X
97150
001
XXX
5
X
51.79
X
97151
XXX
0
X
*
X
97152
XXX
0
X
*
X
97153
XXX
0
X
*
X
97154
XXX
0
X
*
X
97155
XXX
0
X
*
X
97156
XXX
0
X
*
X
97157
XXX
0
X
*
X
97158
XXX
0
X
*
X
97161
001
XXX
5
X
161.44
X
97161
002
XXX
5
X
145.95
X
97161
003
XXX
5
X
145.95
X
97161
004
XXX
5
X
145.95
X
97162
002
XXX
5
X
145.95
X
97162
003
XXX
5
X
145.95
X
97162
004
XXX
5
X
145.95
X
97162
001
XXX
5
X
161.44
X
97163
002
XXX
5
X
145.95
X
97163
004
XXX
5
X
145.95
X
97163
003
XXX
5
X
145.95
X
97163
001
XXX
5
X
161.44
X
97164
004
XXX
5
X
57.66
X
97164
003
XXX
5
X
57.66
X
97164
002
XXX
5
X
57.66
X
97164
001
XXX
5
X
60.73
X
97165
001
XXX
5
X
126.48
X
97165
004
XXX
5
X
116.12
X
97165
003
XXX
5
X
116.12
X
97165
002
XXX
5
X
116.12
X
97166
003
XXX
5
X
116.12
X
97166
004
XXX
5
X
116.12
X
97166
002
XXX
5
X
116.12
X
97166
001
XXX
5
X
126.48
X
97167
003
XXX
5
X
116.12
X
97167
001
XXX
5
X
126.48
X
97167
002
XXX
5
X
116.12
X
97167
004
XXX
5
X
116.12
X
97168
004
XXX
5
X
76.52
X
97168
002
XXX
5
X
76.52
X
97168
003
XXX
5
X
76.52
X
97168
001
XXX
5
X
83.62
X
97169
XXX
9
X
*
X
97170
XXX
9
X
*
X
97171
XXX
9
X
*
X
97172
XXX
9
X
*
X
97530
003
XXX
5
X
69.08
X
97530
004
XXX
5
X
68.72
X
97530
001
XXX
5
X
72.44
X
97530
002
XXX
5
X
70.66
X
97533
001
XXX
5
X
69.35
48.99
97533
002
XXX
5
X
63.38
46.02
97533
003
XXX
5
X
63.38
46.02
97533
004
XXX
5
X
63.38
46.02
97535
001
XXX
5
X
53.08
X
97535
002
XXX
5
X
51.21
X
97535
003
XXX
5
X
48.72
X
97535
004
XXX
5
X
48.04
X
97537
002
XXX
5
X
51.21
X
97537
003
XXX
5
X
48.72
X
97537
004
XXX
5
X
48.04
X
97537
001
XXX
5
X
53.08
X
97542
004
XXX
5
X
40.39
X
97542
003
XXX
5
X
40.98
X
97542
002
XXX
5
X
43.34
X
97542
001
XXX
5
X
44.96
X
97545
001
XXX
0
X
238.10
X
97545
004
XXX
0
X
230.33
X
97545
003
XXX
0
X
240.24
X
97545
002
XXX
0
X
223.51
X
97546
004
ZZZ
0
X
115.17
X
97546
003
ZZZ
0
X
120.16
X
97546
002
ZZZ
0
X
119.18
X
97546
001
ZZZ
0
X
111.73
X
97550
002
XXX
5
X
56.79
X
97550
003
XXX
5
X
56.79
X
97550
004
XXX
5
X
56.79
X
97550
001
XXX
5
X
61.01
X
97551
003
ZZZ
0
X
28.32
26.26
97551
002
ZZZ
0
X
28.32
26.26
97551
001
ZZZ
0
X
30.25
27.91
97551
004
ZZZ
0
X
28.32
26.26
97552
003
XXX
5
X
23.50
X
97552
002
XXX
5
X
23.50
X
97552
001
XXX
5
X
25.90
X
97552
004
XXX
5
X
23.50
X
97597
002
0
0
X
97.07
X
97597
001
0
0
X
109.80
X
97597
004
0
0
X
97.07
X
97597
003
0
0
X
97.07
X
97598
004
ZZZ
0
X
123.96
X
97598
003
ZZZ
0
X
123.96
X
97598
002
ZZZ
0
X
123.96
X
97598
001
ZZZ
0
X
138.88
X
97602
XXX
9
X
*
X
97605
XXX
0
X
*
X
97606
XXX
0
X
*
X
97607
XXX
0
X
*
X
97608
XXX
0
X
*
X
97610
XXX
0
X
*
X
97750
002
XXX
5
X
78.27
X
97750
003
XXX
5
X
70.42
X
97750
004
XXX
5
X
75.99
X
97750
001
XXX
5
X
82.07
X
97755
001
XXX
5
X
79.37
X
97755
002
XXX
5
X
73.35
X
97755
003
XXX
5
X
73.35
X
97755
004
XXX
5
X
73.35
X
97760
004
XXX
5
X
56.77
47.61
97760
003
XXX
5
X
56.77
47.61
97760
002
XXX
5
X
56.77
47.61
97760
001
XXX
5
X
63.53
52.32
97761
004
XXX
5
X
52.27
46.33
97761
001
XXX
5
X
57.73
50.53
97761
002
XXX
5
X
52.27
46.33
97761
003
XXX
5
X
52.27
46.33
97763
002
XXX
5
X
69.17
X
97763
003
XXX
5
X
69.17
X
97763
004
XXX
5
X
69.17
X
97763
001
XXX
5
X
76.39
X
97799
XXX
0
X
#
X
97802
XXX
0
X
*
X
97803
XXX
0
X
*
X
97804
XXX
0
X
*
X
97810
XXX
0
X
*
X
97811
ZZZ
0
X
*
X
97813
XXX
0
X
*
X
97814
ZZZ
0
X
*
X
98925
001
0
0
X
64.28
X
98925
002
0
0
X
67.12
X
98925
004
0
0
X
55.96
X
98925
003
0
0
X
63.77
X
98926
001
0
0
X
88.74
X
98926
004
0
0
X
79.10
X
98926
003
0
0
X
78.68
X
98926
002
0
0
X
87.55
X
98927
002
0
0
X
107.54
X
98927
003
0
0
X
102.42
X
98927
004
0
0
X
101.84
X
98927
001
0
0
X
107.92
X
98928
001
0
0
X
135.36
X
98928
004
0
0
X
116.12
X
98928
003
0
0
X
122.84
X
98928
002
0
0
X
132.84
X
98929
004
0
0
X
155.90
X
98929
002
0
0
X
153.25
X
98929
003
0
0
X
137.01
X
98929
001
0
0
X
131.27
X
98940
001
0
0
X
69.26
54.69
98940
002
0
0
X
64.69
52.02
98940
003
0
0
X
67.17
54.00
98940
004
0
0
X
62.96
50.61
98941
001
0
0
X
86.57
72.00
98941
004
0
0
X
79.65
67.31
98941
003
0
0
X
85.02
71.87
98941
002
0
0
X
81.82
69.17
98942
001
0
0
X
105.62
91.03
98942
002
0
0
X
100.71
88.06
98942
003
0
0
X
104.64
91.47
98942
004
0
0
X
98.00
85.76
98943
XXX
9
X
*
X
98960
XXX
9
X
*
X
98961
XXX
9
X
*
X
98962
XXX
9
X
*
X
98966
XXX
0
X
*
X
98967
XXX
0
X
*
X
98968
XXX
0
X
*
X
98970
XXX
0
X
*
X
98971
XXX
0
X
*
X
98972
XXX
0
X
*
X
98975
004
XXX
0
X
21.90
X
98975
002
XXX
0
X
21.90
X
98975
003
XXX
0
X
21.90
X
98975
001
XXX
0
X
25.41
X
98976
002
XXX
0
X
63.08
X
98976
004
XXX
0
X
63.08
X
98976
003
XXX
0
X
63.08
X
98976
001
XXX
0
X
72.82
X
98977
001
XXX
0
X
72.82
X
98977
004
XXX
0
X
63.08
X
98977
003
XXX
0
X
63.08
X
98977
002
XXX
0
X
63.08
X
98978
X
*
X
98980
004
XXX
0
X
58.31
37.16
98980
002
XXX
0
X
58.31
37.16
98980
003
XXX
0
X
58.31
37.16
98980
001
XXX
0
X
64.16
39.75
98981
004
ZZZ
0
X
47.68
37.10
98981
003
ZZZ
0
X
47.68
37.10
98981
002
ZZZ
0
X
47.68
37.10
98981
001
ZZZ
0
X
52.02
39.83
99000
XXX
9
X
*
X
99001
XXX
9
X
*
X
99002
XXX
9
X
*
X
99024
XXX
9
X
*
X
99026
XXX
9
X
*
X
99027
XXX
9
X
*
X
99050
XXX
9
X
*
X
99051
XXX
9
X
*
X
99053
XXX
9
X
*
X
99056
XXX
9
X
*
X
99058
XXX
9
X
*
X
99060
XXX
9
X
*
X
99070
XXX
9
X
#
X
99071
XXX
9
X
#
X
99072
XXX
9
X
*
X
99075
XXX
9
X
#
X
99078
XXX
9
X
#
X
99080
XXX
9
X
#
X
99082
XXX
0
X
#
X
99091
XXX
0
X
*
X
99100
ZZZ
9
X
*
X
99116
ZZZ
9
X
*
X
99135
ZZZ
9
X
*
X
99140
ZZZ
9
X
*
X
99151
002
XXX
9
X
111.85
35.77
99151
001
XXX
9
X
126.32
38.18
99151
004
XXX
9
X
111.85
35.77
99151
003
XXX
9
X
111.85
35.77
99152
004
XXX
9
X
74.06
18.64
99152
003
XXX
9
X
74.06
18.64
99152
002
XXX
9
X
74.06
18.64
99152
001
XXX
9
X
84.13
19.90
99153
003
ZZZ
9
X
15.65
X
99153
002
ZZZ
9
X
15.65
X
99153
004
ZZZ
9
X
15.65
X
99153
001
ZZZ
9
X
18.21
X
99155
004
XXX
9
X
140.09
X
99155
003
XXX
9
X
140.09
X
99155
002
XXX
9
X
140.09
X
99155
001
XXX
9
X
149.68
X
99156
002
XXX
9
X
114.91
X
99156
003
XXX
9
X
114.91
X
99156
004
XXX
9
X
114.91
X
99156
001
XXX
9
X
122.20
X
99157
001
ZZZ
9
X
92.61
X
99157
002
ZZZ
9
X
87.12
X
99157
003
ZZZ
9
X
87.12
X
99157
004
ZZZ
9
X
87.12
X
99170
004
0
2
X
313.48
218.32
99170
003
0
2
X
313.48
218.32
99170
002
0
2
X
313.48
218.32
99170
001
0
2
X
350.41
239.03
99172
XXX
9
X
*
X
99173
XXX
9
X
*
X
99174
XXX
9
X
*
X
99175
004
XXX
0
X
134.10
X
99175
002
XXX
0
X
148.31
X
99175
001
XXX
0
X
151.17
X
99175
003
XXX
0
X
136.24
X
99177
XXX
9
X
*
X
99183
002
XXX
0
X
423.24
X
99183
003
XXX
0
X
403.10
X
99183
004
XXX
0
X
398.35
X
99183
001
XXX
0
X
428.10
X
99184
001
XXX
0
X
391.48
X
99184
003
XXX
0
X
364.89
X
99184
002
XXX
0
X
364.89
X
99184
004
XXX
0
X
364.89
X
99188
XXX
0
X
*
X
99190
XXX
9
X
*
X
99191
XXX
9
X
*
X
99192
XXX
9
X
*
X
99195
003
XXX
0
X
42.55
X
99195
004
XXX
0
X
41.90
X
99195
002
XXX
0
X
42.31
X
99195
001
XXX
0
X
36.63
X
99199
XXX
0
X
#
X
99202
002
XXX
0
X
125.82
103.43
99202
003
XXX
0
X
115.15
94.53
99202
004
XXX
0
X
115.15
94.59
99202
001
XXX
0
X
132.29
108.68
99203
002
XXX
0
X
159.26
135.03
99203
001
XXX
0
X
161.28
136.54
99203
003
XXX
0
X
149.13
126.55
99203
004
XXX
0
X
144.81
123.21
99204
003
XXX
0
X
224.98
191.56
99204
002
XXX
0
X
250.73
212.92
99204
004
XXX
0
X
221.53
188.56
99204
001
XXX
0
X
269.07
227.72
99205
001
XXX
0
X
321.15
278.62
99205
004
XXX
0
X
269.87
234.44
99205
003
XXX
0
X
275.56
239.56
99205
002
XXX
0
X
302.35
261.47
99211
003
XXX
0
X
41.63
31.94
99211
002
XXX
0
X
47.16
36.17
99211
001
XXX
0
X
50.02
38.41
99211
004
XXX
0
X
37.03
27.96
99212
001
XXX
0
X
71.62
57.15
99212
002
XXX
0
X
70.79
56.48
99212
003
XXX
0
X
67.33
53.77
99212
004
XXX
0
X
66.54
53.24
99213
002
XXX
0
X
101.07
81.65
99213
001
XXX
0
X
102.27
82.53
99213
004
XXX
0
X
93.82
76.29
99213
003
XXX
0
X
96.63
78.24
99214
002
XXX
0
X
154.99
127.99
99214
003
XXX
0
X
139.52
115.69
99214
004
XXX
0
X
139.79
116.23
99214
001
XXX
0
X
157.82
131.37
99215
004
XXX
0
X
214.58
180.18
99215
002
XXX
0
X
241.61
201.62
99215
003
XXX
0
X
216.18
181.11
99215
001
XXX
0
X
249.71
209.80
99221
004
XXX
0
X
173.14
X
99221
003
XXX
0
X
175.24
X
99221
002
XXX
0
X
184.25
X
99221
001
XXX
0
X
186.47
X
99222
003
XXX
0
X
290.65
X
99222
002
XXX
0
X
305.08
X
99222
004
XXX
0
X
287.29
X
99222
001
XXX
0
X
308.55
X
99223
001
XXX
0
X
391.01
X
99223
002
XXX
0
X
377.10
X
99223
003
XXX
0
X
343.70
X
99223
004
XXX
0
X
343.87
X
99231
001
XXX
0
X
101.76
X
99231
002
XXX
0
X
94.59
X
99231
003
XXX
0
X
89.95
X
99231
004
XXX
0
X
88.84
X
99232
004
XXX
0
X
130.84
X
99232
003
XXX
0
X
131.28
X
99232
002
XXX
0
X
141.00
X
99232
001
XXX
0
X
141.87
X
99233
003
XXX
0
X
186.24
X
99233
004
XXX
0
X
187.90
X
99233
002
XXX
0
X
194.96
X
99233
001
XXX
0
X
197.07
X
99234
002
XXX
0
X
293.49
X
99234
003
XXX
0
X
293.49
X
99234
004
XXX
0
X
293.49
X
99234
001
XXX
0
X
315.67
X
99235
004
XXX
0
X
405.64
X
99235
003
XXX
0
X
405.64
X
99235
002
XXX
0
X
405.64
X
99235
001
XXX
0
X
438.10
X
99236
004
XXX
0
X
489.38
X
99236
003
XXX
0
X
489.38
X
99236
002
XXX
0
X
489.38
X
99236
001
XXX
0
X
525.94
X
99238
001
XXX
0
X
167.16
X
99238
002
XXX
0
X
165.40
X
99238
004
XXX
0
X
156.30
X
99238
003
XXX
0
X
161.86
X
99239
004
XXX
0
X
215.39
X
99239
002
XXX
0
X
227.12
X
99239
003
XXX
0
X
218.09
X
99239
001
XXX
0
X
233.79
X
99242
001
XXX
9
X
206.29
166.84
99242
002
XXX
9
X
197.45
159.63
99242
003
XXX
9
X
189.50
153.24
99242
004
XXX
9
X
189.06
153.12
99243
002
XXX
9
X
242.20
196.97
99243
003
XXX
9
X
229.37
186.71
99243
004
XXX
9
X
227.73
185.65
99243
001
XXX
9
X
256.38
208.46
99244
001
XXX
9
X
370.31
307.61
99244
004
XXX
9
X
336.96
280.79
99244
002
XXX
9
X
366.15
304.21
99244
003
XXX
9
X
345.68
287.75
99245
004
XXX
9
X
398.70
330.74
99245
002
XXX
9
X
439.22
363.40
99245
003
XXX
9
X
415.54
344.40
99245
001
XXX
9
X
441.03
364.76
99252
003
XXX
9
X
191.30
X
99252
002
XXX
9
X
199.36
X
99252
004
XXX
9
X
190.94
X
99252
001
XXX
9
X
207.07
X
99253
002
XXX
9
X
247.38
X
99253
003
XXX
9
X
234.32
X
99253
004
XXX
9
X
232.67
X
99253
001
XXX
9
X
261.57
X
99254
003
XXX
9
X
347.70
X
99254
002
XXX
9
X
368.22
X
99254
004
XXX
9
X
339.00
X
99254
001
XXX
9
X
372.40
X
99255
001
XXX
9
X
444.39
X
99255
004
XXX
9
X
402.63
X
99255
003
XXX
9
X
419.44
X
99255
002
XXX
9
X
442.81
X
99281
001
XXX
0
X
59.64
X
99281
003
XXX
0
X
58.61
X
99281
002
XXX
0
X
59.00
X
99281
004
XXX
0
X
55.61
X
99282
004
XXX
0
X
85.10
X
99282
002
XXX
0
X
91.25
X
99282
003
XXX
0
X
83.69
X
99282
001
XXX
0
X
96.17
X
99283
004
XXX
0
X
130.75
X
99283
003
XXX
0
X
129.48
X
99283
002
XXX
0
X
137.32
X
99283
001
XXX
0
X
142.65
X
99284
002
XXX
0
X
198.89
X
99284
003
XXX
0
X
186.08
X
99284
004
XXX
0
X
192.08
X
99284
001
XXX
0
X
206.82
X
99285
001
XXX
0
X
331.83
X
99285
004
XXX
0
X
295.19
X
99285
003
XXX
0
X
303.86
X
99285
002
XXX
0
X
331.59
X
99288
XXX
9
X
#
X
99291
002
XXX
0
X
443.60
X
99291
003
XXX
0
X
406.85
X
99291
004
XXX
0
X
392.86
X
99291
001
XXX
0
X
460.09
X
99292
004
ZZZ
0
X
193.01
X
99292
003
ZZZ
0
X
196.80
X
99292
002
ZZZ
0
X
219.59
X
99292
001
ZZZ
0
X
225.77
X
99304
004
XXX
0
X
122.34
X
99304
002
XXX
0
X
122.34
X
99304
003
XXX
0
X
122.34
X
99304
001
XXX
0
X
133.02
X
99305
001
XXX
0
X
176.59
X
99305
002
XXX
0
X
162.49
X
99305
003
XXX
0
X
162.49
X
99305
004
XXX
0
X
162.49
X
99306
004
XXX
0
X
200.63
X
99306
002
XXX
0
X
200.63
X
99306
003
XXX
0
X
200.63
X
99306
001
XXX
0
X
217.76
X
99307
001
XXX
0
X
69.00
X
99307
004
XXX
0
X
63.09
X
99307
003
XXX
0
X
63.09
X
99307
002
XXX
0
X
63.09
X
99308
001
XXX
0
X
113.99
X
99308
002
XXX
0
X
104.55
X
99308
003
XXX
0
X
104.55
X
99308
004
XXX
0
X
104.55
X
99309
001
XXX
0
X
160.70
X
99309
004
XXX
0
X
147.40
X
99309
003
XXX
0
X
147.40
X
99309
002
XXX
0
X
147.40
X
99310
004
XXX
0
X
184.57
X
99310
003
XXX
0
X
184.57
X
99310
002
XXX
0
X
184.57
X
99310
001
XXX
0
X
201.45
X
99315
002
XXX
0
X
149.54
X
99315
003
XXX
0
X
149.54
X
99315
004
XXX
0
X
149.54
X
99315
001
XXX
0
X
163.39
X
99316
004
XXX
0
X
182.47
X
99316
002
XXX
0
X
182.47
X
99316
003
XXX
0
X
182.47
X
99316
001
XXX
0
X
197.49
X
99341
004
XXX
0
X
141.33
X
99341
003
XXX
0
X
141.33
X
99341
002
XXX
0
X
141.33
X
99341
001
XXX
0
X
155.78
X
99342
001
XXX
0
X
210.20
X
99342
002
XXX
0
X
193.07
X
99342
003
XXX
0
X
193.07
X
99342
004
XXX
0
X
193.07
X
99344
004
XXX
0
X
352.76
X
99344
003
XXX
0
X
352.76
X
99344
002
XXX
0
X
352.76
X
99344
001
XXX
0
X
380.83
X
99345
001
XXX
0
X
450.79
X
99345
004
XXX
0
X
420.37
X
99345
003
XXX
0
X
420.37
X
99345
002
XXX
0
X
420.37
X
99347
004
XXX
0
X
111.16
X
99347
003
XXX
0
X
111.16
X
99347
002
XXX
0
X
111.16
X
99347
001
XXX
0
X
122.94
X
Return to CPT/HCPC List