2018 Workers' Compensation Part B Fee Schedule

75726-75902

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CPT/HCPC Code
Modifier
Medicare Location
Global Surgery Indicator
Multiple Surgery Indicator
Prevailing Charge Amount
Fee Schedule Amount
Site of Service Amount
75726   1 XXX 0 0 1,181.33 0
75726 26 1 XXX 0 0 153.43 0
75726 TC 1 XXX 0 0 1,041.77 0
75726   2 XXX 0 0 1,160.89 0
75726 26 2 XXX 0 0 152.92 0
75726 TC 2 XXX 0 0 1,023.00 0
75726   3 XXX 0 0 1,074.56 0
75726 26 3 XXX 0 0 146.28 0
75726 TC 3 XXX 0 0 943.84 0
75726   4 XXX 0 0 1,058.13 0
75726 26 4 XXX 0 0 146.91 0
75726 TC 4 XXX 0 0 928.85 0
75731   1 XXX 0 0 1,181.33 0
75731 26 1 XXX 0 0 153.43 0
75731 TC 1 XXX 0 0 1,041.77 0
75731   2 XXX 0 0 1,160.89 0
75731 26 2 XXX 0 0 152.92 0
75731 TC 2 XXX 0 0 1,023.00 0
75731   3 XXX 0 0 1,074.56 0
75731 26 3 XXX 0 0 146.28 0
75731 TC 3 XXX 0 0 943.84 0
75731   4 XXX 0 0 1,058.13 0
75731 26 4 XXX 0 0 142.52 0
75731 TC 4 XXX 0 0 928.85 0
75733   1 XXX 0 0 1,202.14 0
75733 26 1 XXX 0 0 176.32 0
75733 TC 1 XXX 0 0 1,041.77 0
75733   2 XXX 0 0 1,181.38 0
75733 26 2 XXX 0 0 175.80 0
75733 TC 2 XXX 0 0 1,023.00 0
75733   3 XXX 0 0 1,094.08 0
75733 26 3 XXX 0 0 168.16 0
75733 TC 3 XXX 0 0 943.84 0
75733   4 XXX 0 0 1,077.45 0
75733 26 4 XXX 0 0 163.86 0
75733 TC 4 XXX 0 0 928.85 0
75736   1 XXX 0 0 1,181.33 0
75736 26 1 XXX 0 0 153.43 0
75736 TC 1 XXX 0 0 1,041.77 0
75736   2 XXX 0 0 1,160.89 0
75736 26 2 XXX 0 0 152.92 0
75736 TC 2 XXX 0 0 1,023.00 0
75736   3 XXX 0 0 1,074.56 0
75736 26 3 XXX 0 0 146.28 0
75736 TC 3 XXX 0 0 943.84 0
75736   4 XXX 0 0 1,058.13 0
75736 26 4 XXX 0 0 142.52 0
75736 TC 4 XXX 0 0 928.85 0
75741   1 XXX 0 0 1,202.14 0
75741 26 1 XXX 0 0 176.32 0
75741 TC 1 XXX 0 0 1,041.77 0
75741   2 XXX 0 0 1,181.38 0
75741 26 2 XXX 0 0 175.80 0
75741 TC 2 XXX 0 0 1,023.00 0
75741   3 XXX 0 0 1,094.08 0
75741 26 3 XXX 0 0 168.16 0
75741 TC 3 XXX 0 0 943.84 0
75741   4 XXX 0 0 1,077.45 0
75741 26 4 XXX 0 0 163.86 0
75741 TC 4 XXX 0 0 928.85 0
75743   1 XXX 0 0 1,245.26 0
75743 26 1 XXX 0 0 223.14 0
75743 TC 1 XXX 0 0 1,041.77 0
75743   2 XXX 0 0 1,224.05 0
75743 26 2 XXX 0 0 222.47 0
75743 TC 2 XXX 0 0 1,023.00 0
75743   3 XXX 0 0 1,134.64 0
75743 26 3 XXX 0 0 212.88 0
75743 TC 3 XXX 0 0 943.84 0
75743   4 XXX 0 0 1,117.56 0
75743 26 4 XXX 0 0 207.47 0
75743 TC 4 XXX 0 0 928.85 0
75746   1 XXX 0 0 1,181.33 0
75746 26 1 XXX 0 0 153.43 0
75746 TC 1 XXX 0 0 1,041.77 0
75746   2 XXX 0 0 1,160.89 0
75746 26 2 XXX 0 0 152.92 0
75746 TC 2 XXX 0 0 1,023.00 0
75746   3 XXX 0 0 1,074.56 0
75746 26 3 XXX 0 0 146.28 0
75746 TC 3 XXX 0 0 943.84 0
75746   4 XXX 0 0 1,058.13 0
75746 26 4 XXX 0 0 143.60 0
75746 TC 4 XXX 0 0 928.85 0
75756   1 XXX 0 0 1,181.33 0
75756 26 1 XXX 0 0 153.43 0
75756 TC 1 XXX 0 0 1,041.77 0
75756   2 XXX 0 0 1,160.89 0
75756 26 2 XXX 0 0 152.92 0
75756 TC 2 XXX 0 0 1,023.00 0
75756   3 XXX 0 0 1,074.56 0
75756 26 3 XXX 0 0 146.28 0
75756 TC 3 XXX 0 0 943.84 0
75756   4 XXX 0 0 1,058.13 0
75756 26 4 XXX 0 0 142.52 0
75756 TC 4 XXX 0 0 928.85 0
75774   1 ZZZ 0 0 1,084.87 0
75774 26 1 ZZZ 0 0 46.79 0
75774 TC 1 ZZZ 0 0 1,041.77 0
75774   2 ZZZ 0 0 1,065.67 0
75774 26 2 ZZZ 0 0 46.71 0
75774 TC 2 ZZZ 0 0 1,023.00 0
75774   3 ZZZ 0 0 984.44 0
75774 26 3 ZZZ 0 0 44.75 0
75774 TC 3 ZZZ 0 0 943.84 0
75774   4 ZZZ 0 0 968.99 0
75774 26 4 ZZZ 0 0 45.24 0
75774 TC 4 ZZZ 0 0 928.85 0
75801   1 XXX 0 0 547.55 0
75801 26 1 XXX 0 0 108.79 0
75801 TC 1 XXX 0 0 448.33 0
75801   2 XXX 0 0 538.23 0
75801 26 2 XXX 0 0 108.46 0
75801 TC 2 XXX 0 0 440.22 0
75801   3 XXX 0 0 499.21 0
75801 26 3 XXX 0 0 103.83 0
75801 TC 3 XXX 0 0 406.06 0
75801   4 XXX 0 0 491.75 0
75801 26 4 XXX 0 0 101.19 0
75801 TC 4 XXX 0 0 399.66 0
75803   1 XXX 0 0 591.04 0
75803 26 1 XXX 0 0 156.64 0
75803 TC 1 XXX 0 0 448.33 0
75803   2 XXX 0 0 581.17 0
75803 26 2 XXX 0 0 156.17 0
75803 TC 2 XXX 0 0 440.22 0
75803   3 XXX 0 0 539.81 0
75803 26 3 XXX 0 0 149.41 0
75803 TC 3 XXX 0 0 406.06 0
75803   4 XXX 0 0 531.87 0
75803 26 4 XXX 0 0 145.58 0
75803 TC 4 XXX 0 0 399.66 0
75805   1 XXX 0 0 603.22 0
75805 26 1 XXX 0 0 108.79 0
75805 TC 1 XXX 0 0 504.05 0
75805   2 XXX 0 0 592.93 0
75805 26 2 XXX 0 0 108.46 0
75805 TC 2 XXX 0 0 494.93 0
75805   3 XXX 0 0 549.71 0
75805 26 3 XXX 0 0 103.83 0
75805 TC 3 XXX 0 0 456.53 0
75805   4 XXX 0 0 541.44 0
75805 26 4 XXX 0 0 101.19 0
75805 TC 4 XXX 0 0 449.31 0
75807   1 XXX 0 0 646.73 0
75807 26 1 XXX 0 0 156.64 0
75807 TC 1 XXX 0 0 504.05 0
75807   2 XXX 0 0 635.91 0
75807 26 2 XXX 0 0 156.17 0
75807 TC 2 XXX 0 0 494.93 0
75807   3 XXX 0 0 590.31 0
75807 26 3 XXX 0 0 149.41 0
75807 TC 3 XXX 0 0 456.53 0
75807   4 XXX 0 0 581.55 0
75807 26 4 XXX 0 0 145.58 0
75807 TC 4 XXX 0 0 449.31 0
75809   1 XXX 0 0 121.55 0
75809 26 1 XXX 0 0 56.05 0
75809 TC 1 XXX 0 0 65.50 0
75809   2 XXX 0 0 119.62 0
75809 26 2 XXX 0 0 55.37 0
75809 TC 2 XXX 0 0 64.30 0
75809   3 XXX 0 0 111.91 0
75809 26 3 XXX 0 0 52.57 0
75809 TC 3 XXX 0 0 59.26 0
75809   4 XXX 0 0 110.41 0
75809 26 4 XXX 0 0 52.06 0
75809 TC 4 XXX 0 0 58.32 0
75810   1 XXX 0 0 1,181.33 0
75810 26 1 XXX 0 0 153.43 0
75810 TC 1 XXX 0 0 1,041.77 0
75810   2 XXX 0 0 1,160.89 0
75810 26 2 XXX 0 0 152.92 0
75810 TC 2 XXX 0 0 1,023.00 0
75810   3 XXX 0 0 1,074.56 0
75810 26 3 XXX 0 0 146.28 0
75810 TC 3 XXX 0 0 943.84 0
75810   4 XXX 0 0 1,058.13 0
75810 26 4 XXX 0 0 142.52 0
75810 TC 4 XXX 0 0 928.85 0
75820   1 XXX 0 0 165.10 0
75820 26 1 XXX 0 0 94.65 0
75820 TC 1 XXX 0 0 78.44 0
75820   2 XXX 0 0 162.64 0
75820 26 2 XXX 0 0 94.37 0
75820 TC 2 XXX 0 0 77.03 0
75820   3 XXX 0 0 152.05 0
75820 26 3 XXX 0 0 90.24 0
75820 TC 3 XXX 0 0 70.96 0
75820   4 XXX 0 0 150.10 0
75820 26 4 XXX 0 0 88.30 0
75820 TC 4 XXX 0 0 69.85 0
75822   1 XXX 0 0 252.51 0
75822 26 1 XXX 0 0 141.82 0
75822 TC 1 XXX 0 0 122.78 0
75822   2 XXX 0 0 248.72 0
75822 26 2 XXX 0 0 141.41 0
75822 TC 2 XXX 0 0 120.58 0
75822   3 XXX 0 0 232.91 0
75822 26 3 XXX 0 0 135.32 0
75822 TC 3 XXX 0 0 111.20 0
75822   4 XXX 0 0 229.79 0
75822 26 4 XXX 0 0 131.84 0
75822 TC 4 XXX 0 0 109.45 0
75825   1 XXX 0 0 1,181.33 0
75825 26 1 XXX 0 0 153.43 0
75825 TC 1 XXX 0 0 1,041.77 0
75825   2 XXX 0 0 1,160.89 0
75825 26 2 XXX 0 0 152.92 0
75825 TC 2 XXX 0 0 1,023.00 0
75825   3 XXX 0 0 1,074.56 0
75825 26 3 XXX 0 0 146.28 0
75825 TC 3 XXX 0 0 943.84 0
75825   4 XXX 0 0 1,058.13 0
75825 26 4 XXX 0 0 142.52 0
75825 TC 4 XXX 0 0 928.85 0
75827   1 XXX 0 0 1,181.33 0
75827 26 1 XXX 0 0 153.43 0
75827 TC 1 XXX 0 0 1,041.77 0
75827   2 XXX 0 0 1,160.89 0
75827 26 2 XXX 0 0 152.92 0
75827 TC 2 XXX 0 0 1,023.00 0
75827   3 XXX 0 0 1,074.56 0
75827 26 3 XXX 0 0 146.28 0
75827 TC 3 XXX 0 0 943.84 0
75827   4 XXX 0 0 1,058.13 0
75827 26 4 XXX 0 0 149.07 0
75827 TC 4 XXX 0 0 928.85 0
75831   1 XXX 0 0 1,181.33 0
75831 26 1 XXX 0 0 153.43 0
75831 TC 1 XXX 0 0 1,041.77 0
75831   2 XXX 0 0 1,160.89 0
75831 26 2 XXX 0 0 152.92 0
75831 TC 2 XXX 0 0 1,023.00 0
75831   3 XXX 0 0 1,074.56 0
75831 26 3 XXX 0 0 146.28 0
75831 TC 3 XXX 0 0 943.84 0
75831   4 XXX 0 0 1,058.13 0
75831 26 4 XXX 0 0 142.52 0
75831 TC 4 XXX 0 0 928.85 0
75833   1 XXX 0 0 1,224.46 0
75833 26 1 XXX 0 0 200.10 0
75833 TC 1 XXX 0 0 1,041.77 0
75833   2 XXX 0 0 1,203.48 0
75833 26 2 XXX 0 0 199.50 0
75833 TC 2 XXX 0 0 1,023.00 0
75833   3 XXX 0 0 1,115.14 0
75833 26 3 XXX 0 0 190.84 0
75833 TC 3 XXX 0 0 943.84 0
75833   4 XXX 0 0 1,098.23 0
75833 26 4 XXX 0 0 185.98 0
75833 TC 4 XXX 0 0 928.85 0
75840   1 XXX 0 0 1,181.33 0
75840 26 1 XXX 0 0 153.43 0
75840 TC 1 XXX 0 0 1,041.77 0
75840   2 XXX 0 0 1,160.89 0
75840 26 2 XXX 0 0 152.92 0
75840 TC 2 XXX 0 0 1,023.00 0
75840   3 XXX 0 0 1,074.56 0
75840 26 3 XXX 0 0 146.28 0
75840 TC 3 XXX 0 0 943.84 0
75840   4 XXX 0 0 1,058.13 0
75840 26 4 XXX 0 0 142.52 0
75840 TC 4 XXX 0 0 928.85 0
75842   1 XXX 0 0 1,224.46 0
75842 26 1 XXX 0 0 200.10 0
75842 TC 1 XXX 0 0 1,041.77 0
75842   2 XXX 0 0 1,203.48 0
75842 26 2 XXX 0 0 199.50 0
75842 TC 2 XXX 0 0 1,023.00 0
75842   3 XXX 0 0 1,115.14 0
75842 26 3 XXX 0 0 190.84 0
75842 TC 3 XXX 0 0 943.84 0
75842   4 XXX 0 0 1,098.23 0
75842 26 4 XXX 0 0 185.98 0
75842 TC 4 XXX 0 0 928.85 0
75860   1 XXX 0 0 1,181.33 0
75860 26 1 XXX 0 0 153.43 0
75860 TC 1 XXX 0 0 1,041.77 0
75860   2 XXX 0 0 1,160.89 0
75860 26 2 XXX 0 0 152.92 0
75860 TC 2 XXX 0 0 1,023.00 0
75860   3 XXX 0 0 1,074.56 0
75860 26 3 XXX 0 0 146.28 0
75860 TC 3 XXX 0 0 943.84 0
75860   4 XXX 0 0 1,058.13 0
75860 26 4 XXX 0 0 142.52 0
75860 TC 4 XXX 0 0 928.85 0
75870   1 XXX 0 0 1,181.33 0
75870 26 1 XXX 0 0 153.43 0
75870 TC 1 XXX 0 0 1,041.77 0
75870   2 XXX 0 0 1,160.89 0
75870 26 2 XXX 0 0 152.92 0
75870 TC 2 XXX 0 0 1,023.00 0
75870   3 XXX 0 0 1,074.56 0
75870 26 3 XXX 0 0 146.28 0
75870 TC 3 XXX 0 0 943.84 0
75870   4 XXX 0 0 1,058.13 0
75870 26 4 XXX 0 0 142.52 0
75870 TC 4 XXX 0 0 928.85 0
75872   1 XXX 0 0 1,181.33 0
75872 26 1 XXX 0 0 153.43 0
75872 TC 1 XXX 0 0 1,041.77 0
75872   2 XXX 0 0 1,160.89 0
75872 26 2 XXX 0 0 152.92 0
75872 TC 2 XXX 0 0 1,023.00 0
75872   3 XXX 0 0 1,074.56 0
75872 26 3 XXX 0 0 146.28 0
75872 TC 3 XXX 0 0 943.84 0
75872   4 XXX 0 0 1,058.13 0
75872 26 4 XXX 0 0 142.52 0
75872 TC 4 XXX 0 0 928.85 0
75880   1 XXX 0 0 165.10 0
75880 26 1 XXX 0 0 94.65 0
75880 TC 1 XXX 0 0 78.44 0
75880   2 XXX 0 0 162.64 0
75880 26 2 XXX 0 0 94.37 0
75880 TC 2 XXX 0 0 77.03 0
75880   3 XXX 0 0 152.05 0
75880 26 3 XXX 0 0 90.24 0
75880 TC 3 XXX 0 0 70.96 0
75880   4 XXX 0 0 150.10 0
75880 26 4 XXX 0 0 87.94 0
75880 TC 4 XXX 0 0 69.85 0
75885   1 XXX 0 0 1,218.98 0
75885 26 1 XXX 0 0 194.07 0
75885 TC 1 XXX 0 0 1,041.77 0
75885   2 XXX 0 0 1,198.02 0
75885 26 2 XXX 0 0 193.50 0
75885 TC 2 XXX 0 0 1,023.00 0
75885   3 XXX 0 0 1,109.87 0
75885 26 3 XXX 0 0 185.12 0
75885 TC 3 XXX 0 0 943.84 0
75885   4 XXX 0 0 1,093.03 0
75885 26 4 XXX 0 0 180.36 0
75885 TC 4 XXX 0 0 928.85 0
75887   1 XXX 0 0 1,218.98 0
75887 26 1 XXX 0 0 194.07 0
75887 TC 1 XXX 0 0 1,041.77 0
75887   2 XXX 0 0 1,198.02 0
75887 26 2 XXX 0 0 193.50 0
75887 TC 2 XXX 0 0 1,023.00 0
75887   3 XXX 0 0 1,109.87 0
75887 26 3 XXX 0 0 185.12 0
75887 TC 3 XXX 0 0 943.84 0
75887   4 XXX 0 0 1,093.03 0
75887 26 4 XXX 0 0 180.36 0
75887 TC 4 XXX 0 0 928.85 0
75889   1 XXX 0 0 1,181.33 0
75889 26 1 XXX 0 0 153.43 0
75889 TC 1 XXX 0 0 1,041.77 0
75889   2 XXX 0 0 1,160.89 0
75889 26 2 XXX 0 0 152.92 0
75889 TC 2 XXX 0 0 1,023.00 0
75889   3 XXX 0 0 1,074.56 0
75889 26 3 XXX 0 0 146.28 0
75889 TC 3 XXX 0 0 943.84 0
75889   4 XXX 0 0 1,058.13 0
75889 26 4 XXX 0 0 142.52 0
75889 TC 4 XXX 0 0 928.85 0
75891   1 XXX 0 0 1,181.33 0
75891 26 1 XXX 0 0 153.43 0
75891 TC 1 XXX 0 0 1,041.77 0
75891   2 XXX 0 0 1,160.89 0
75891 26 2 XXX 0 0 152.92 0
75891 TC 2 XXX 0 0 1,023.00 0
75891   3 XXX 0 0 1,074.56 0
75891 26 3 XXX 0 0 146.28 0
75891 TC 3 XXX 0 0 943.84 0
75891   4 XXX 0 0 1,058.13 0
75891 26 4 XXX 0 0 142.52 0
75891 TC 4 XXX 0 0 928.85 0
75893   1 XXX 0 0 1,109.21 0
75893 26 1 XXX 0 0 74.19 0
75893 TC 1 XXX 0 0 1,041.77 0
75893   2 XXX 0 0 1,089.58 0
75893 26 2 XXX 0 0 74.03 0
75893 TC 2 XXX 0 0 1,023.00 0
75893   3 XXX 0 0 1,006.96 0
75893 26 3 XXX 0 0 70.92 0
75893 TC 3 XXX 0 0 943.84 0
75893   4 XXX 0 0 991.27 0
75893 26 4 XXX 0 0 68.97 0
75893 TC 4 XXX 0 0 928.85 0
75894   1 XXX 0 0 2,156.85 0
75894 26 1 XXX 0 0 176.32 0
75894 TC 1 XXX 0 0 1,996.47 0
75894   2 XXX 0 0 2,118.89 0
75894 26 2 XXX 0 0 175.80 0
75894 TC 2 XXX 0 0 1,960.52 0
75894   3 XXX 0 0 1,958.91 0
75894 26 3 XXX 0 0 168.16 0
75894 TC 3 XXX 0 0 1,808.68 0
75894   4 XXX 0 0 1,928.53 0
75894 26 4 XXX 0 0 163.86 0
75894 TC 4 XXX 0 0 1,779.97 0
75898   1 XXX 0 0 304.76 0
75898 26 1 XXX 0 0 222.34 0
75898 TC 1 XXX 0 0 87.52 0
75898   2 XXX 0 0 303.54 0
75898 26 2 XXX 0 0 221.72 0
75898 TC 2 XXX 0 0 85.86 0
75898   3 XXX 0 0 289.29 0
75898 26 3 XXX 0 0 212.32 0
75898 TC 3 XXX 0 0 79.05 0
75898   4 XXX 0 0 281.79 0
75898 26 4 XXX 0 0 206.69 0
75898 TC 4 XXX 0 0 77.79 0
75901   1 XXX 0 0 196.29 0
75901 26 1 XXX 0 0 45.14 0
75901 TC 1 XXX 0 0 151.18 0
75901   2 XXX 0 0 151.51 0
75901 26 2 XXX 0 0 41.56 0
75901 TC 2 XXX 0 0 109.94 0
75901   3 XXX 0 0 151.51 0
75901 26 3 XXX 0 0 41.56 0
75901 TC 3 XXX 0 0 109.94 0
75901   4 XXX 0 0 151.51 0
75901 26 4 XXX 0 0 41.56 0
75901 TC 4 XXX 0 0 109.94 0
75902   1 XXX 0 0 187.06 0
75902 26 1 XXX 0 0 35.92 0
75902 TC 1 XXX 0 0 151.18 0
75902   2 XXX 0 0 142.90 0
75902 26 2 XXX 0 0 32.95 0
75902 TC 2 XXX 0 0 109.94 0
75902   3 XXX 0 0 142.90 0
75902 26 3 XXX 0 0 32.95 0
75902 TC 3 XXX 0 0 109.94 0
75902   4 XXX 0 0 142.90 0
75902 26 4 XXX 0 0 32.95 0
75902 TC 4 XXX 0 0 109.94 0