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Workers' Compensation
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Vocational Rehabilitation
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Health Care Services Review
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Medical Fee Review
>
Fee Schedule
>
Fee Schedule 75726-75902
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
75726-75902
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
75726
004
XXX
6
X
1,367.96
X
75726
26
004
XXX
6
X
189.94
X
75726
TC
004
XXX
6
X
1,200.80
X
75726
003
XXX
6
X
1,389.18
X
75726
26
003
XXX
6
X
189.11
X
75726
TC
003
XXX
6
X
1,220.19
X
75726
002
XXX
6
X
1,500.80
X
75726
26
002
XXX
6
X
197.69
X
75726
TC
002
XXX
6
X
1,322.54
X
75726
001
XXX
6
X
1,527.22
X
75726
26
001
XXX
6
X
198.36
X
75726
TC
001
XXX
6
X
1,346.79
X
75731
002
XXX
6
X
1,500.80
X
75731
26
002
XXX
6
X
197.69
X
75731
TC
002
XXX
6
X
1,322.54
X
75731
003
XXX
6
X
1,389.18
X
75731
26
003
XXX
6
X
189.11
X
75731
TC
003
XXX
6
X
1,220.19
X
75731
004
XXX
6
X
1,367.96
X
75731
26
004
XXX
6
X
184.25
X
75731
TC
004
XXX
6
X
1,200.80
X
75731
001
XXX
6
X
1,527.22
X
75731
26
001
XXX
6
X
198.36
X
75731
TC
001
XXX
6
X
1,346.79
X
75733
004
XXX
6
X
1,392.92
X
75733
26
004
XXX
6
X
211.84
X
75733
TC
004
XXX
6
X
1,200.80
X
75733
003
XXX
6
X
1,414.42
X
75733
26
003
XXX
6
X
217.39
X
75733
TC
003
XXX
6
X
1,220.19
X
75733
002
XXX
6
X
1,527.29
X
75733
26
002
XXX
6
X
227.27
X
75733
TC
002
XXX
6
X
1,322.54
X
75733
001
XXX
6
X
1,554.11
X
75733
26
001
XXX
6
X
227.95
X
75733
TC
001
XXX
6
X
1,346.79
X
75736
004
XXX
6
X
1,367.96
X
75736
26
004
XXX
6
X
184.25
X
75736
TC
004
XXX
6
X
1,200.80
X
75736
003
XXX
6
X
1,389.18
X
75736
26
003
XXX
6
X
189.11
X
75736
TC
003
XXX
6
X
1,220.19
X
75736
002
XXX
6
X
1,500.80
X
75736
26
002
XXX
6
X
197.69
X
75736
TC
002
XXX
6
X
1,322.54
X
75736
001
XXX
6
X
1,527.22
X
75736
26
001
XXX
6
X
198.36
X
75736
TC
001
XXX
6
X
1,346.79
X
75741
002
XXX
6
X
1,527.29
X
75741
26
002
XXX
6
X
227.27
X
75741
TC
002
XXX
6
X
1,322.54
X
75741
003
XXX
6
X
1,414.42
X
75741
26
003
XXX
6
X
217.39
X
75741
TC
003
XXX
6
X
1,220.19
X
75741
001
XXX
6
X
1,554.11
X
75741
26
001
XXX
6
X
227.95
X
75741
TC
001
XXX
6
X
1,346.79
X
75741
004
XXX
6
X
1,392.92
X
75741
26
004
XXX
6
X
211.84
X
75741
TC
004
XXX
6
X
1,200.80
X
75743
001
XXX
6
X
1,609.88
X
75743
26
001
XXX
6
X
288.49
X
75743
TC
001
XXX
6
X
1,346.79
X
75743
004
XXX
6
X
1,444.77
X
75743
26
004
XXX
6
X
268.23
X
75743
TC
004
XXX
6
X
1,200.80
X
75743
003
XXX
6
X
1,466.87
X
75743
26
003
XXX
6
X
275.22
X
75743
TC
003
XXX
6
X
1,220.19
X
75743
002
XXX
6
X
1,582.45
X
75743
26
002
XXX
6
X
287.61
X
75743
TC
002
XXX
6
X
1,322.54
X
75746
002
XXX
6
X
1,500.80
X
75746
26
002
XXX
6
X
197.69
X
75746
TC
002
XXX
6
X
1,322.54
X
75746
003
XXX
6
X
1,389.18
X
75746
26
003
XXX
6
X
189.11
X
75746
TC
003
XXX
6
X
1,220.19
X
75746
001
XXX
6
X
1,527.22
X
75746
26
001
XXX
6
X
198.36
X
75746
TC
001
XXX
6
X
1,346.79
X
75746
004
XXX
6
X
1,367.96
X
75746
26
004
XXX
6
X
185.65
X
75746
TC
004
XXX
6
X
1,200.80
X
75756
004
XXX
6
X
1,367.96
X
75756
26
004
XXX
6
X
184.25
X
75756
TC
004
XXX
6
X
1,200.80
X
75756
001
XXX
6
X
1,527.22
X
75756
26
001
XXX
6
X
198.36
X
75756
TC
001
XXX
6
X
1,346.79
X
75756
003
XXX
6
X
1,389.18
X
75756
26
003
XXX
6
X
189.11
X
75756
TC
003
XXX
6
X
1,220.19
X
75756
002
XXX
6
X
1,500.80
X
75756
26
002
XXX
6
X
197.69
X
75756
TC
002
XXX
6
X
1,322.54
X
75774
002
ZZZ
0
X
1,377.70
X
75774
26
002
ZZZ
0
X
60.38
X
75774
TC
002
ZZZ
0
X
1,322.54
X
75774
003
ZZZ
0
X
1,272.68
X
75774
26
003
ZZZ
0
X
57.86
X
75774
TC
003
ZZZ
0
X
1,220.19
X
75774
004
ZZZ
0
X
1,252.72
X
75774
26
004
ZZZ
0
X
58.47
X
75774
TC
004
ZZZ
0
X
1,200.80
X
75774
001
ZZZ
0
X
1,402.50
X
75774
26
001
ZZZ
0
X
60.50
X
75774
TC
001
ZZZ
0
X
1,346.79
X
75801
002
XXX
0
X
695.82
X
75801
26
002
XXX
0
X
140.21
X
75801
TC
002
XXX
0
X
569.12
X
75801
003
XXX
0
X
645.37
X
75801
26
003
XXX
0
X
134.23
X
75801
TC
003
XXX
0
X
524.96
X
75801
004
XXX
0
X
635.73
X
75801
26
004
XXX
0
X
130.82
X
75801
TC
004
XXX
0
X
516.67
X
75801
001
XXX
0
X
707.87
X
75801
26
001
XXX
0
X
140.64
X
75801
TC
001
XXX
0
X
579.59
X
75803
001
XXX
0
X
764.10
X
75803
26
001
XXX
0
X
202.51
X
75803
TC
001
XXX
0
X
579.59
X
75803
002
XXX
0
X
751.35
X
75803
26
002
XXX
0
X
201.90
X
75803
TC
002
XXX
0
X
569.12
X
75803
003
XXX
0
X
697.88
X
75803
26
003
XXX
0
X
193.17
X
75803
TC
003
XXX
0
X
524.96
X
75803
004
XXX
0
X
687.60
X
75803
26
004
XXX
0
X
188.21
X
75803
TC
004
XXX
0
X
516.67
X
75805
001
XXX
0
X
779.84
X
75805
26
001
XXX
0
X
140.64
X
75805
TC
001
XXX
0
X
651.62
X
75805
004
XXX
0
X
699.96
X
75805
26
004
XXX
0
X
130.82
X
75805
TC
004
XXX
0
X
580.87
X
75805
002
XXX
0
X
766.54
X
75805
26
002
XXX
0
X
140.21
X
75805
TC
002
XXX
0
X
639.85
X
75805
003
XXX
0
X
710.66
X
75805
26
003
XXX
0
X
134.23
X
75805
TC
003
XXX
0
X
590.20
X
75807
004
XXX
0
X
751.83
X
75807
26
004
XXX
0
X
188.21
X
75807
TC
004
XXX
0
X
580.87
X
75807
003
XXX
0
X
763.15
X
75807
26
003
XXX
0
X
193.17
X
75807
TC
003
XXX
0
X
590.20
X
75807
002
XXX
0
X
822.11
X
75807
26
002
XXX
0
X
201.90
X
75807
TC
002
XXX
0
X
639.85
X
75807
001
XXX
0
X
836.09
X
75807
26
001
XXX
0
X
202.51
X
75807
TC
001
XXX
0
X
651.62
X
75809
001
XXX
6
X
157.14
X
75809
26
001
XXX
6
X
72.47
X
75809
TC
001
XXX
6
X
84.69
X
75809
002
XXX
6
X
154.64
X
75809
26
002
XXX
6
X
71.58
X
75809
TC
002
XXX
6
X
83.13
X
75809
003
XXX
6
X
144.67
X
75809
26
003
XXX
6
X
67.96
X
75809
TC
003
XXX
6
X
76.62
X
75809
004
XXX
6
X
142.74
X
75809
26
004
XXX
6
X
67.31
X
75809
TC
004
XXX
6
X
75.40
X
75810
002
XXX
0
X
1,500.80
X
75810
26
002
XXX
0
X
197.69
X
75810
TC
002
XXX
0
X
1,322.54
X
75810
003
XXX
0
X
1,389.18
X
75810
26
003
XXX
0
X
189.11
X
75810
TC
003
XXX
0
X
1,220.19
X
75810
004
XXX
0
X
1,367.96
X
75810
26
004
XXX
0
X
184.25
X
75810
TC
004
XXX
0
X
1,200.80
X
75810
001
XXX
0
X
1,527.22
X
75810
26
001
XXX
0
X
198.36
X
75810
TC
001
XXX
0
X
1,346.79
X
75820
002
XXX
6
X
210.26
X
75820
26
002
XXX
6
X
122.00
X
75820
TC
002
XXX
6
X
99.58
X
75820
003
XXX
6
X
196.57
X
75820
26
003
XXX
6
X
116.67
X
75820
TC
003
XXX
6
X
91.74
X
75820
004
XXX
6
X
194.04
X
75820
26
004
XXX
6
X
114.15
X
75820
TC
004
XXX
6
X
90.31
X
75820
001
XXX
6
X
213.45
X
75820
26
001
XXX
6
X
122.36
X
75820
TC
001
XXX
6
X
101.41
X
75822
001
XXX
6
X
326.46
X
75822
26
001
XXX
6
X
183.35
X
75822
TC
001
XXX
6
X
158.72
X
75822
002
XXX
6
X
321.55
X
75822
26
002
XXX
6
X
182.81
X
75822
TC
002
XXX
6
X
155.88
X
75822
003
XXX
6
X
301.11
X
75822
26
003
XXX
6
X
174.94
X
75822
TC
003
XXX
6
X
143.78
X
75822
004
XXX
6
X
297.08
X
75822
26
004
XXX
6
X
170.45
X
75822
TC
004
XXX
6
X
141.50
X
75825
003
XXX
6
X
1,389.18
X
75825
26
003
XXX
6
X
189.11
X
75825
TC
003
XXX
6
X
1,220.19
X
75825
002
XXX
6
X
1,500.80
X
75825
26
002
XXX
6
X
197.69
X
75825
TC
002
XXX
6
X
1,322.54
X
75825
004
XXX
6
X
1,367.96
X
75825
26
004
XXX
6
X
184.25
X
75825
TC
004
XXX
6
X
1,200.80
X
75825
001
XXX
6
X
1,527.22
X
75825
26
001
XXX
6
X
198.36
X
75825
TC
001
XXX
6
X
1,346.79
X
75827
001
XXX
6
X
1,527.22
X
75827
26
001
XXX
6
X
198.36
X
75827
TC
001
XXX
6
X
1,346.79
X
75827
004
XXX
6
X
1,367.96
X
75827
26
004
XXX
6
X
192.71
X
75827
TC
004
XXX
6
X
1,200.80
X
75827
003
XXX
6
X
1,389.18
X
75827
26
003
XXX
6
X
189.11
X
75827
TC
003
XXX
6
X
1,220.19
X
75827
002
XXX
6
X
1,500.80
X
75827
26
002
XXX
6
X
197.69
X
75827
TC
002
XXX
6
X
1,322.54
X
75831
001
XXX
6
X
1,527.22
X
75831
26
001
XXX
6
X
198.36
X
75831
TC
001
XXX
6
X
1,346.79
X
75831
004
XXX
6
X
1,367.96
X
75831
26
004
XXX
6
X
184.25
X
75831
TC
004
XXX
6
X
1,200.80
X
75831
003
XXX
6
X
1,389.18
X
75831
26
003
XXX
6
X
189.11
X
75831
TC
003
XXX
6
X
1,220.19
X
75831
002
XXX
6
X
1,500.80
X
75831
26
002
XXX
6
X
197.69
X
75831
TC
002
XXX
6
X
1,322.54
X
75833
001
XXX
6
X
1,582.98
X
75833
26
001
XXX
6
X
258.69
X
75833
TC
001
XXX
6
X
1,346.79
X
75833
002
XXX
6
X
1,555.86
X
75833
26
002
XXX
6
X
257.92
X
75833
TC
002
XXX
6
X
1,322.54
X
75833
003
XXX
6
X
1,441.65
X
75833
26
003
XXX
6
X
246.72
X
75833
TC
003
XXX
6
X
1,220.19
X
75833
004
XXX
6
X
1,419.80
X
75833
26
004
XXX
6
X
240.44
X
75833
TC
004
XXX
6
X
1,200.80
X
75840
003
XXX
6
X
1,389.18
X
75840
26
003
XXX
6
X
189.11
X
75840
TC
003
XXX
6
X
1,220.19
X
75840
002
XXX
6
X
1,500.80
X
75840
26
002
XXX
6
X
197.69
X
75840
TC
002
XXX
6
X
1,322.54
X
75840
004
XXX
6
X
1,367.96
X
75840
26
004
XXX
6
X
184.25
X
75840
TC
004
XXX
6
X
1,200.80
X
75840
001
XXX
6
X
1,527.22
X
75840
26
001
XXX
6
X
198.36
X
75840
TC
001
XXX
6
X
1,346.79
X
75842
003
XXX
6
X
1,441.65
X
75842
26
003
XXX
6
X
246.72
X
75842
TC
003
XXX
6
X
1,220.19
X
75842
002
XXX
6
X
1,555.86
X
75842
26
002
XXX
6
X
257.92
X
75842
TC
002
XXX
6
X
1,322.54
X
75842
001
XXX
6
X
1,582.98
X
75842
26
001
XXX
6
X
258.69
X
75842
TC
001
XXX
6
X
1,346.79
X
75842
004
XXX
6
X
1,419.80
X
75842
26
004
XXX
6
X
240.44
X
75842
TC
004
XXX
6
X
1,200.80
X
75860
001
XXX
6
X
1,527.22
X
75860
26
001
XXX
6
X
198.36
X
75860
TC
001
XXX
6
X
1,346.79
X
75860
004
XXX
6
X
1,367.96
X
75860
26
004
XXX
6
X
184.25
X
75860
TC
004
XXX
6
X
1,200.80
X
75860
003
XXX
6
X
1,389.18
X
75860
26
003
XXX
6
X
189.11
X
75860
TC
003
XXX
6
X
1,220.19
X
75860
002
XXX
6
X
1,500.80
X
75860
26
002
XXX
6
X
197.69
X
75860
TC
002
XXX
6
X
1,322.54
X
75870
002
XXX
6
X
1,500.80
X
75870
26
002
XXX
6
X
197.69
X
75870
TC
002
XXX
6
X
1,322.54
X
75870
003
XXX
6
X
1,389.18
X
75870
26
003
XXX
6
X
189.11
X
75870
TC
003
XXX
6
X
1,220.19
X
75870
004
XXX
6
X
1,367.96
X
75870
26
004
XXX
6
X
184.25
X
75870
TC
004
XXX
6
X
1,200.80
X
75870
001
XXX
6
X
1,527.22
X
75870
26
001
XXX
6
X
198.36
X
75870
TC
001
XXX
6
X
1,346.79
X
75872
004
XXX
6
X
1,367.96
X
75872
26
004
XXX
6
X
184.25
X
75872
TC
004
XXX
6
X
1,200.80
X
75872
003
XXX
6
X
1,389.18
X
75872
26
003
XXX
6
X
189.11
X
75872
TC
003
XXX
6
X
1,220.19
X
75872
002
XXX
6
X
1,500.80
X
75872
26
002
XXX
6
X
197.69
X
75872
TC
002
XXX
6
X
1,322.54
X
75872
001
XXX
6
X
1,527.22
X
75872
26
001
XXX
6
X
198.36
X
75872
TC
001
XXX
6
X
1,346.79
X
75880
002
XXX
6
X
210.26
X
75880
26
002
XXX
6
X
122.00
X
75880
TC
002
XXX
6
X
99.58
X
75880
003
XXX
6
X
196.57
X
75880
26
003
XXX
6
X
116.67
X
75880
TC
003
XXX
6
X
91.74
X
75880
004
XXX
6
X
194.04
X
75880
26
004
XXX
6
X
113.68
X
75880
TC
004
XXX
6
X
90.31
X
75880
001
XXX
6
X
213.45
X
75880
26
001
XXX
6
X
122.36
X
75880
TC
001
XXX
6
X
101.41
X
75885
001
XXX
6
X
1,575.90
X
75885
26
001
XXX
6
X
250.89
X
75885
TC
001
XXX
6
X
1,346.79
X
75885
002
XXX
6
X
1,548.79
X
75885
26
002
XXX
6
X
250.16
X
75885
TC
002
XXX
6
X
1,322.54
X
75885
003
XXX
6
X
1,434.85
X
75885
26
003
XXX
6
X
239.32
X
75885
TC
003
XXX
6
X
1,220.19
X
75885
004
XXX
6
X
1,413.07
X
75885
26
004
XXX
6
X
233.17
X
75885
TC
004
XXX
6
X
1,200.80
X
75887
004
XXX
6
X
1,413.07
X
75887
26
004
XXX
6
X
233.17
X
75887
TC
004
XXX
6
X
1,200.80
X
75887
003
XXX
6
X
1,434.85
X
75887
26
003
XXX
6
X
239.32
X
75887
TC
003
XXX
6
X
1,220.19
X
75887
002
XXX
6
X
1,548.79
X
75887
26
002
XXX
6
X
250.16
X
75887
TC
002
XXX
6
X
1,322.54
X
75887
001
XXX
6
X
1,575.90
X
75887
26
001
XXX
6
X
250.89
X
75887
TC
001
XXX
6
X
1,346.79
X
75889
004
XXX
6
X
1,367.96
X
75889
26
004
XXX
6
X
184.25
X
75889
TC
004
XXX
6
X
1,200.80
X
75889
003
XXX
6
X
1,389.18
X
75889
26
003
XXX
6
X
189.11
X
75889
TC
003
XXX
6
X
1,220.19
X
75889
002
XXX
6
X
1,500.80
X
75889
26
002
XXX
6
X
197.69
X
75889
TC
002
XXX
6
X
1,322.54
X
75889
001
XXX
6
X
1,527.22
X
75889
26
001
XXX
6
X
198.36
X
75889
TC
001
XXX
6
X
1,346.79
X
75891
004
XXX
6
X
1,367.96
X
75891
26
004
XXX
6
X
184.25
X
75891
TC
004
XXX
6
X
1,200.80
X
75891
003
XXX
6
X
1,389.18
X
75891
26
003
XXX
6
X
189.11
X
75891
TC
003
XXX
6
X
1,220.19
X
75891
002
XXX
6
X
1,500.80
X
75891
26
002
XXX
6
X
197.69
X
75891
TC
002
XXX
6
X
1,322.54
X
75891
001
XXX
6
X
1,527.22
X
75891
26
001
XXX
6
X
198.36
X
75891
TC
001
XXX
6
X
1,346.79
X
75893
003
XXX
6
X
1,301.79
X
75893
26
003
XXX
6
X
91.68
X
75893
TC
003
XXX
6
X
1,220.19
X
75893
002
XXX
6
X
1,408.61
X
75893
26
002
XXX
6
X
95.70
X
75893
TC
002
XXX
6
X
1,322.54
X
75893
001
XXX
6
X
1,434.00
X
75893
26
001
XXX
6
X
95.91
X
75893
TC
001
XXX
6
X
1,346.79
X
75893
004
XXX
6
X
1,281.52
X
75893
26
004
XXX
6
X
89.17
X
75893
TC
004
XXX
6
X
1,200.80
X
75894
001
XXX
0
X
2,788.38
X
75894
26
001
XXX
0
X
227.95
X
75894
TC
001
XXX
0
X
2,581.03
X
75894
004
XXX
0
X
2,493.21
X
75894
26
004
XXX
0
X
211.84
X
75894
TC
004
XXX
0
X
2,301.16
X
75894
003
XXX
0
X
2,532.46
X
75894
26
003
XXX
0
X
217.39
X
75894
TC
003
XXX
0
X
2,338.26
X
75894
002
XXX
0
X
2,739.30
X
75894
26
002
XXX
0
X
227.27
X
75894
TC
002
XXX
0
X
2,534.55
X
75898
001
XXX
0
X
393.99
X
75898
004
XXX
0
X
364.30
X
75898
003
XXX
0
X
373.98
X
75898
002
XXX
0
X
392.42
X
75898
26
001
XXX
0
X
287.44
X
75898
TC
001
XXX
0
X
113.15
X
75898
26
002
XXX
0
X
286.63
X
75898
TC
002
XXX
0
X
111.00
X
75898
26
003
XXX
0
X
274.48
X
75898
TC
003
XXX
0
X
102.21
X
75898
26
004
XXX
0
X
267.20
X
75898
TC
004
XXX
0
X
100.56
X
75901
001
XXX
0
X
253.75
X
75901
26
001
XXX
0
X
58.36
X
75901
TC
001
XXX
0
X
195.44
X
75901
002
XXX
0
X
195.86
X
75901
26
002
XXX
0
X
53.75
X
75901
TC
002
XXX
0
X
142.14
X
75901
003
XXX
0
X
195.86
X
75901
26
003
XXX
0
X
53.75
X
75901
TC
003
XXX
0
X
142.14
X
75901
004
XXX
0
X
195.86
X
75901
26
004
XXX
0
X
53.75
X
75901
TC
004
XXX
0
X
142.14
X
75902
001
XXX
0
X
241.83
X
75902
26
001
XXX
0
X
46.45
X
75902
TC
001
XXX
0
X
195.44
X
75902
004
XXX
0
X
184.74
X
75902
26
004
XXX
0
X
42.61
X
75902
TC
004
XXX
0
X
142.14
X
75902
003
XXX
0
X
184.74
X
75902
26
003
XXX
0
X
42.61
X
75902
TC
003
XXX
0
X
142.14
X
75902
002
XXX
0
X
184.74
X
75902
26
002
XXX
0
X
42.61
X
75902
TC
002
XXX
0
X
142.14
X
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