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Health Care Services Review
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Medical Fee Review
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Fee Schedule
>
Fee Schedule 77789-78261
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
77789-78261
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
77789
002
0
0
X
226.03
X
77789
26
002
0
0
X
180.88
X
77789
TC
002
0
0
X
47.30
X
77789
004
0
0
X
210.11
X
77789
26
004
0
0
X
168.57
X
77789
TC
004
0
0
X
42.87
X
77789
003
0
0
X
215.68
X
77789
26
003
0
0
X
173.08
X
77789
TC
003
0
0
X
43.46
X
77789
001
0
0
X
226.94
X
77789
26
001
0
0
X
181.40
X
77789
TC
001
0
0
X
48.17
X
77790
002
XXX
0
X
228.74
X
77790
26
002
XXX
0
X
180.88
X
77790
003
XXX
0
X
218.24
X
77790
26
003
XXX
0
X
173.52
X
77790
004
XXX
0
X
212.58
X
77790
26
004
XXX
0
X
171.32
X
77790
001
XXX
0
X
229.67
X
77790
26
001
XXX
0
X
181.40
X
77790
TC
001
XXX
0
X
54.26
X
77790
TC
004
XXX
0
X
48.40
X
77790
TC
003
XXX
0
X
49.17
X
77790
TC
002
XXX
0
X
53.26
X
77799
XXX
0
X
#
X
78012
001
XXX
0
X
143.62
X
78012
26
001
XXX
0
X
15.72
X
78012
TC
001
XXX
0
X
127.91
X
78012
004
XXX
0
X
124.84
X
78012
26
004
XXX
0
X
14.71
X
78012
TC
004
XXX
0
X
110.10
X
78012
002
XXX
0
X
124.84
X
78012
26
002
XXX
0
X
14.71
X
78012
TC
002
XXX
0
X
110.10
X
78012
003
XXX
0
X
124.84
X
78012
26
003
XXX
0
X
14.71
X
78012
TC
003
XXX
0
X
110.10
X
78013
001
XXX
0
X
289.88
X
78013
26
001
XXX
0
X
29.96
X
78013
TC
001
XXX
0
X
259.93
X
78013
003
XXX
0
X
252.04
X
78013
26
003
XXX
0
X
28.25
X
78013
TC
003
XXX
0
X
223.78
X
78013
002
XXX
0
X
252.04
X
78013
26
002
XXX
0
X
28.25
X
78013
TC
002
XXX
0
X
223.78
X
78013
004
XXX
0
X
252.04
X
78013
26
004
XXX
0
X
28.25
X
78013
TC
004
XXX
0
X
223.78
X
78014
003
XXX
0
X
364.54
X
78014
26
003
XXX
0
X
38.25
X
78014
TC
003
XXX
0
X
326.28
X
78014
001
XXX
0
X
419.86
X
78014
26
001
XXX
0
X
40.83
X
78014
TC
001
XXX
0
X
379.00
X
78014
002
XXX
0
X
364.54
X
78014
26
002
XXX
0
X
38.25
X
78014
TC
002
XXX
0
X
326.28
X
78014
004
XXX
0
X
364.54
X
78014
26
004
XXX
0
X
38.25
X
78014
TC
004
XXX
0
X
326.28
X
78015
002
XXX
0
X
377.47
X
78015
26
002
XXX
0
X
122.84
X
78015
TC
002
XXX
0
X
270.91
X
78015
003
XXX
0
X
350.77
X
78015
26
003
XXX
0
X
119.42
X
78015
TC
003
XXX
0
X
249.76
X
78015
004
XXX
0
X
345.65
X
78015
26
004
XXX
0
X
118.14
X
78015
TC
004
XXX
0
X
245.76
X
78015
001
XXX
0
X
383.82
X
78015
26
001
XXX
0
X
123.40
X
78015
TC
001
XXX
0
X
275.84
X
78016
001
XXX
0
X
504.50
X
78016
26
001
XXX
0
X
133.06
X
78016
TC
001
XXX
0
X
372.68
X
78016
003
XXX
0
X
460.98
X
78016
26
003
XXX
0
X
137.91
X
78016
TC
003
XXX
0
X
337.66
X
78016
002
XXX
0
X
496.11
X
78016
26
002
XXX
0
X
136.54
X
78016
TC
002
XXX
0
X
366.04
X
78016
004
XXX
0
X
454.25
X
78016
26
004
XXX
0
X
135.06
X
78016
TC
004
XXX
0
X
332.30
X
78018
001
XXX
0
X
730.65
X
78018
26
001
XXX
0
X
150.03
X
78018
TC
001
XXX
0
X
580.66
X
78018
002
XXX
0
X
718.34
X
78018
26
002
XXX
0
X
148.22
X
78018
TC
002
XXX
0
X
570.12
X
78018
003
XXX
0
X
666.75
X
78018
26
003
XXX
0
X
150.04
X
78018
TC
003
XXX
0
X
525.89
X
78018
004
XXX
0
X
656.84
X
78018
26
004
XXX
0
X
147.02
X
78018
TC
004
XXX
0
X
517.57
X
78020
003
ZZZ
0
X
71.03
X
78020
004
ZZZ
0
X
71.03
X
78020
001
ZZZ
0
X
79.33
X
78020
002
ZZZ
0
X
71.03
X
78070
002
XXX
0
X
271.78
X
78070
26
002
XXX
0
X
81.08
X
78070
TC
002
XXX
0
X
190.65
X
78070
003
XXX
0
X
252.67
X
78070
26
003
XXX
0
X
76.71
X
78070
TC
003
XXX
0
X
175.96
X
78070
004
XXX
0
X
249.05
X
78070
26
004
XXX
0
X
75.90
X
78070
TC
004
XXX
0
X
173.14
X
78070
001
XXX
0
X
276.38
X
78070
26
001
XXX
0
X
82.15
X
78070
TC
001
XXX
0
X
194.22
X
78071
001
XXX
0
X
624.83
X
78071
26
001
XXX
0
X
96.50
X
78071
TC
001
XXX
0
X
528.34
X
78071
002
XXX
0
X
545.68
X
78071
26
002
XXX
0
X
90.65
X
78071
TC
002
XXX
0
X
455.03
X
78071
004
XXX
0
X
545.68
X
78071
26
004
XXX
0
X
90.65
X
78071
TC
004
XXX
0
X
455.03
X
78071
003
XXX
0
X
545.68
X
78071
26
003
XXX
0
X
90.65
X
78071
TC
003
XXX
0
X
455.03
X
78072
26
001
XXX
0
X
132.80
X
78072
26
002
XXX
0
X
124.89
X
78072
26
003
XXX
0
X
124.89
X
78072
26
004
XXX
0
X
124.89
X
78075
004
XXX
0
X
627.05
X
78075
26
004
XXX
0
X
168.10
X
78075
TC
004
XXX
0
X
517.57
X
78075
003
XXX
0
X
636.58
X
78075
26
003
XXX
0
X
169.46
X
78075
TC
003
XXX
0
X
525.89
X
78075
002
XXX
0
X
686.78
X
78075
26
002
XXX
0
X
173.14
X
78075
TC
002
XXX
0
X
570.12
X
78075
001
XXX
0
X
698.71
X
78075
26
001
XXX
0
X
173.59
X
78075
TC
001
XXX
0
X
580.66
X
78099
XXX
0
X
#
X
78102
001
XXX
0
X
380.13
X
78102
26
001
XXX
0
X
111.35
X
78102
TC
001
XXX
0
X
218.55
X
78102
004
XXX
0
X
370.13
X
78102
26
004
XXX
0
X
107.16
X
78102
TC
004
XXX
0
X
194.58
X
78102
003
XXX
0
X
360.83
X
78102
26
003
XXX
0
X
108.22
X
78102
TC
003
XXX
0
X
197.69
X
78102
002
XXX
0
X
366.95
X
78102
26
002
XXX
0
X
110.91
X
78102
TC
002
XXX
0
X
214.58
X
78103
001
XXX
0
X
534.53
X
78103
26
001
XXX
0
X
121.92
X
78103
TC
001
XXX
0
X
338.25
X
78103
004
XXX
0
X
518.39
X
78103
26
004
XXX
0
X
123.97
X
78103
TC
004
XXX
0
X
301.60
X
78103
003
XXX
0
X
506.85
X
78103
26
003
XXX
0
X
126.47
X
78103
TC
003
XXX
0
X
306.47
X
78103
002
XXX
0
X
516.74
X
78103
26
002
XXX
0
X
125.21
X
78103
TC
002
XXX
0
X
332.13
X
78104
001
XXX
0
X
657.77
X
78104
26
001
XXX
0
X
136.16
X
78104
TC
001
XXX
0
X
435.55
X
78104
002
XXX
0
X
635.54
X
78104
26
002
XXX
0
X
139.96
X
78104
TC
002
XXX
0
X
427.70
X
78104
003
XXX
0
X
623.27
X
78104
26
003
XXX
0
X
142.37
X
78104
TC
003
XXX
0
X
394.45
X
78104
004
XXX
0
X
637.72
X
78104
26
004
XXX
0
X
139.32
X
78104
TC
004
XXX
0
X
388.23
X
78110
001
XXX
0
X
142.40
X
78110
26
001
XXX
0
X
36.86
X
78110
TC
001
XXX
0
X
101.41
X
78110
004
XXX
0
X
137.21
X
78110
26
004
XXX
0
X
35.46
X
78110
TC
004
XXX
0
X
90.31
X
78110
002
XXX
0
X
137.91
X
78110
26
002
XXX
0
X
36.71
X
78110
TC
002
XXX
0
X
99.58
X
78110
003
XXX
0
X
134.58
X
78110
26
003
XXX
0
X
35.77
X
78110
TC
003
XXX
0
X
91.74
X
78111
003
XXX
0
X
282.73
X
78111
26
003
XXX
0
X
53.06
X
78111
002
XXX
0
X
306.97
X
78111
26
002
XXX
0
X
54.28
X
78111
004
XXX
0
X
278.48
X
78111
26
004
XXX
0
X
52.73
X
78111
001
XXX
0
X
309.93
X
78111
26
001
XXX
0
X
54.53
X
78111
TC
001
XXX
0
X
275.84
X
78111
TC
003
XXX
0
X
249.76
X
78111
TC
004
XXX
0
X
245.76
X
78111
TC
002
XXX
0
X
270.91
X
78120
002
XXX
0
X
220.93
X
78120
26
002
XXX
0
X
41.36
X
78120
TC
002
XXX
0
X
182.77
X
78120
003
XXX
0
X
203.31
X
78120
26
003
XXX
0
X
40.20
X
78120
TC
003
XXX
0
X
168.47
X
78120
004
XXX
0
X
200.26
X
78120
26
004
XXX
0
X
39.72
X
78120
TC
004
XXX
0
X
165.80
X
78120
001
XXX
0
X
223.60
X
78120
26
001
XXX
0
X
41.61
X
78120
TC
001
XXX
0
X
186.08
X
78121
001
XXX
0
X
360.47
X
78121
26
001
XXX
0
X
57.86
X
78121
TC
001
XXX
0
X
309.78
X
78121
004
XXX
0
X
323.49
X
78121
26
004
XXX
0
X
58.54
X
78121
TC
004
XXX
0
X
276.44
X
78121
003
XXX
0
X
328.46
X
78121
26
003
XXX
0
X
58.42
X
78121
TC
003
XXX
0
X
280.96
X
78121
002
XXX
0
X
354.33
X
78121
26
002
XXX
0
X
58.78
X
78121
TC
002
XXX
0
X
304.28
X
78122
002
XXX
0
X
553.61
X
78122
26
002
XXX
0
X
121.00
X
78122
TC
002
XXX
0
X
483.96
X
78122
003
XXX
0
X
512.53
X
78122
26
003
XXX
0
X
118.77
X
78122
TC
003
XXX
0
X
446.47
X
78122
004
XXX
0
X
504.62
X
78122
26
004
XXX
0
X
117.96
X
78122
TC
004
XXX
0
X
439.41
X
78122
001
XXX
0
X
563.31
X
78122
26
001
XXX
0
X
121.28
X
78122
TC
001
XXX
0
X
492.84
X
78130
004
XXX
0
X
417.61
X
78130
26
004
XXX
0
X
101.18
X
78130
TC
004
XXX
0
X
271.81
X
78130
003
XXX
0
X
409.94
X
78130
26
003
XXX
0
X
101.26
X
78130
TC
003
XXX
0
X
276.20
X
78130
002
XXX
0
X
419.66
X
78130
26
002
XXX
0
X
102.58
X
78130
TC
002
XXX
0
X
299.27
X
78130
001
XXX
0
X
433.21
X
78130
26
001
XXX
0
X
101.22
X
78130
TC
001
XXX
0
X
304.75
X
78140
002
XXX
0
X
494.59
X
78140
26
002
XXX
0
X
120.23
X
78140
TC
002
XXX
0
X
413.31
X
78140
003
XXX
0
X
470.25
X
78140
26
003
XXX
0
X
117.29
X
78140
TC
003
XXX
0
X
381.20
X
78140
004
XXX
0
X
463.04
X
78140
26
004
XXX
0
X
116.14
X
78140
TC
004
XXX
0
X
375.14
X
78140
001
XXX
0
X
499.45
X
78140
26
001
XXX
0
X
120.71
X
78140
TC
001
XXX
0
X
420.85
X
78185
26
002
XXX
0
X
92.53
X
78185
TC
002
XXX
0
X
248.42
X
78185
26
003
XXX
0
X
91.33
X
78185
TC
003
XXX
0
X
228.94
X
78185
26
004
XXX
0
X
90.62
X
78185
TC
004
XXX
0
X
225.33
X
78185
004
XXX
0
X
326.11
X
78185
001
XXX
0
X
338.83
X
78185
26
001
XXX
0
X
90.41
X
78185
TC
001
XXX
0
X
253.07
X
78185
003
XXX
0
X
319.99
X
78185
002
XXX
0
X
328.17
X
78191
004
XXX
0
X
655.35
X
78191
26
004
XXX
0
X
90.27
X
78191
TC
004
XXX
0
X
699.09
X
78191
003
XXX
0
X
667.64
X
78191
26
003
XXX
0
X
91.27
X
78191
TC
003
XXX
0
X
710.37
X
78191
002
XXX
0
X
710.22
X
78191
26
002
XXX
0
X
96.18
X
78191
TC
002
XXX
0
X
769.83
X
78191
001
XXX
0
X
718.47
X
78191
26
001
XXX
0
X
97.31
X
78191
TC
001
XXX
0
X
783.94
X
78195
004
XXX
0
X
495.40
X
78195
26
004
XXX
0
X
131.04
X
78195
TC
004
XXX
0
X
388.23
X
78195
003
XXX
0
X
503.01
X
78195
26
003
XXX
0
X
132.40
X
78195
TC
003
XXX
0
X
394.45
X
78195
002
XXX
0
X
528.88
X
78195
26
002
XXX
0
X
135.97
X
78195
TC
002
XXX
0
X
427.70
X
78195
001
XXX
0
X
533.92
X
78195
26
001
XXX
0
X
136.51
X
78195
TC
001
XXX
0
X
435.55
X
78199
XXX
0
X
#
X
78201
004
XXX
0
X
316.98
X
78201
26
004
XXX
0
X
96.92
X
78201
TC
004
XXX
0
X
225.33
X
78201
002
XXX
0
X
333.27
X
78201
26
002
XXX
0
X
96.20
X
78201
TC
002
XXX
0
X
248.42
X
78201
001
XXX
0
X
335.55
X
78201
26
001
XXX
0
X
94.04
X
78201
TC
001
XXX
0
X
253.07
X
78201
003
XXX
0
X
320.83
X
78201
26
003
XXX
0
X
96.38
X
78201
TC
003
XXX
0
X
228.94
X
78202
001
XXX
0
X
530.82
X
78202
26
001
XXX
0
X
121.34
X
78202
TC
001
XXX
0
X
307.84
X
78202
004
XXX
0
X
519.73
X
78202
26
004
XXX
0
X
124.98
X
78202
TC
004
XXX
0
X
274.56
X
78202
003
XXX
0
X
504.58
X
78202
26
003
XXX
0
X
124.68
X
78202
TC
003
XXX
0
X
279.05
X
78202
002
XXX
0
X
510.95
X
78202
26
002
XXX
0
X
124.12
X
78202
TC
002
XXX
0
X
302.26
X
78215
004
XXX
0
X
379.19
X
78215
26
004
XXX
0
X
102.66
X
78215
TC
004
XXX
0
X
279.24
X
78215
003
XXX
0
X
383.94
X
78215
26
003
XXX
0
X
102.24
X
78215
TC
003
XXX
0
X
283.73
X
78215
002
XXX
0
X
398.82
X
78215
26
002
XXX
0
X
102.27
X
78215
TC
002
XXX
0
X
307.24
X
78215
001
XXX
0
X
390.40
X
78215
26
001
XXX
0
X
100.16
X
78215
TC
001
XXX
0
X
312.85
X
78216
001
XXX
0
X
463.94
X
78216
26
001
XXX
0
X
127.44
X
78216
TC
001
XXX
0
X
372.68
X
78216
004
XXX
0
X
436.78
X
78216
26
004
XXX
0
X
131.36
X
78216
TC
004
XXX
0
X
332.30
X
78216
002
XXX
0
X
456.14
X
78216
26
002
XXX
0
X
130.15
X
78216
TC
002
XXX
0
X
366.04
X
78216
003
XXX
0
X
442.44
X
78216
26
003
XXX
0
X
130.45
X
78216
TC
003
XXX
0
X
337.66
X
78226
001
XXX
0
X
586.73
X
78226
26
001
XXX
0
X
61.97
X
78226
TC
001
XXX
0
X
524.73
X
78226
004
XXX
0
X
510.05
X
78226
003
XXX
0
X
510.05
X
78226
002
XXX
0
X
510.05
X
78226
26
002
XXX
0
X
58.13
X
78226
TC
002
XXX
0
X
451.91
X
78226
26
003
XXX
0
X
58.13
X
78226
TC
003
XXX
0
X
451.91
X
78226
26
004
XXX
0
X
58.13
X
78226
TC
004
XXX
0
X
451.91
X
78227
001
XXX
0
X
599.07
X
78227
26
001
XXX
0
X
74.31
X
78227
TC
001
XXX
0
X
524.73
X
78227
002
XXX
0
X
521.84
X
78227
26
002
XXX
0
X
69.94
X
78227
TC
002
XXX
0
X
451.91
X
78227
003
XXX
0
X
521.84
X
78227
26
003
XXX
0
X
69.94
X
78227
TC
003
XXX
0
X
451.91
X
78227
004
XXX
0
X
521.84
X
78227
26
004
XXX
0
X
69.94
X
78227
TC
004
XXX
0
X
451.91
X
78230
002
XXX
0
X
365.44
X
78230
26
002
XXX
0
X
100.66
X
78230
TC
002
XXX
0
X
228.99
X
78230
003
XXX
0
X
359.27
X
78230
26
003
XXX
0
X
98.43
X
78230
TC
003
XXX
0
X
210.98
X
78230
004
XXX
0
X
368.58
X
78230
26
004
XXX
0
X
97.57
X
78230
TC
004
XXX
0
X
207.62
X
78230
001
XXX
0
X
378.71
X
78230
26
001
XXX
0
X
101.03
X
78230
TC
001
XXX
0
X
233.23
X
78231
001
XXX
0
X
422.29
X
78231
26
001
XXX
0
X
118.97
X
78231
TC
001
XXX
0
X
338.25
X
78231
002
XXX
0
X
415.22
X
78231
26
002
XXX
0
X
118.50
X
78231
TC
002
XXX
0
X
332.13
X
78231
003
XXX
0
X
385.14
X
78231
26
003
XXX
0
X
115.85
X
78231
TC
003
XXX
0
X
306.47
X
78231
004
XXX
0
X
379.40
X
78231
26
004
XXX
0
X
114.84
X
78231
TC
004
XXX
0
X
301.60
X
78232
004
XXX
0
X
451.02
X
78232
26
004
XXX
0
X
110.01
X
78232
TC
004
XXX
0
X
336.96
X
78232
001
XXX
0
X
469.77
X
78232
26
001
XXX
0
X
105.24
X
78232
TC
001
XXX
0
X
377.79
X
78232
003
XXX
0
X
443.56
X
78232
26
003
XXX
0
X
105.42
X
78232
TC
003
XXX
0
X
342.45
X
78232
002
XXX
0
X
455.42
X
78232
26
002
XXX
0
X
106.81
X
78232
TC
002
XXX
0
X
371.03
X
78258
004
XXX
0
X
419.44
X
78258
26
004
XXX
0
X
124.40
X
78258
TC
004
XXX
0
X
274.56
X
78258
003
XXX
0
X
424.73
X
78258
26
003
XXX
0
X
125.93
X
78258
TC
003
XXX
0
X
279.05
X
78258
002
XXX
0
X
440.69
X
78258
26
002
XXX
0
X
129.48
X
78258
TC
002
XXX
0
X
302.26
X
78258
001
XXX
0
X
443.54
X
78258
26
001
XXX
0
X
130.06
X
78258
TC
001
XXX
0
X
307.84
X
78261
001
XXX
0
X
549.66
X
78261
26
001
XXX
0
X
122.36
X
78261
TC
001
XXX
0
X
438.64
X
78261
004
XXX
0
X
493.71
X
78261
26
004
XXX
0
X
124.42
X
78261
TC
004
XXX
0
X
390.98
X
78261
003
XXX
0
X
501.16
X
78261
26
003
XXX
0
X
120.81
X
78261
TC
003
XXX
0
X
397.28
X
78261
002
XXX
0
X
540.31
X
78261
26
002
XXX
0
X
123.46
X
78261
TC
002
XXX
0
X
430.67
X
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