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2021 Workers' Compensation Part B Fee Schedule

74415-75716

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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
74415 26 4 XXX 0 X 67.83 X
74415 26 3 XXX 0 X 69.72 X
74415 26 2 XXX 0 X 72.70 X
74415 26 1 XXX 0 X 72.94 X
74415 TC 4 XXX 0 X 172.39 X
74415 TC 3 XXX 0 X 175.16 X
74415 TC 2 XXX 0 X 189.92 X
74415 TC 1 XXX 0 X 193.38 X
74415   4 XXX 0 X 233.86 X
74415   3 XXX 0 X 241.28 X
74415   2 XXX 0 X 255.35 X
74415   1 XXX 0 X 259.61 X
74420 26 4 XXX 0 X 48.25 X
74420 26 3 XXX 0 X 49.44 X
74420 26 2 XXX 0 X 51.53 X
74420 26 1 XXX 0 X 51.62 X
74420 TC 4 XXX 0 X 214.55 X
74420 TC 3 XXX 0 X 218.00 X
74420 TC 2 XXX 0 X 236.62 X
74420 TC 1 XXX 0 X 241.08 X
74420   4 XXX 0 X 258.77 X
74420   3 XXX 0 X 262.73 X
74420   2 XXX 0 X 283.63 X
74420   1 XXX 0 X 288.65 X
74425 26 4 XXX 0 X 49.17 X
74425 26 3 XXX 0 X 49.47 X
74425 26 2 XXX 0 X 51.53 X
74425 26 1 XXX 0 X 51.62 X
74425 TC 4 XXX 0 X 105.70 X
74425 TC 3 XXX 0 X 107.34 X
74425 TC 2 XXX 0 X 116.44 X
74425 TC 1 XXX 0 X 118.57 X
74425   4 XXX 0 X 149.93 X
74425   3 XXX 0 X 154.87 X
74425   2 XXX 0 X 163.42 X
74425   1 XXX 0 X 166.13 X
74430 26 4 XXX 0 X 43.97 X
74430 26 3 XXX 0 X 44.60 X
74430 26 2 XXX 0 X 46.46 X
74430 26 1 XXX 0 X 46.65 X
74430 TC 4 XXX 0 X 85.82 X
74430 TC 3 XXX 0 X 87.22 X
74430 TC 2 XXX 0 X 94.72 X
74430 TC 1 XXX 0 X 96.56 X
74430   4 XXX 0 X 125.97 X
74430   3 XXX 0 X 129.54 X
74430   2 XXX 0 X 137.48 X
74430   1 XXX 0 X 139.77 X
74440 26 4 XXX 0 X 51.45 X
74440 26 3 XXX 0 X 52.81 X
74440 26 2 XXX 0 X 55.26 X
74440 26 1 XXX 0 X 55.51 X
74440 TC 4 XXX 0 X 92.17 X
74440 TC 3 XXX 0 X 93.64 X
74440 TC 2 XXX 0 X 101.56 X
74440 TC 1 XXX 0 X 103.41 X
74440   4 XXX 0 X 140.54 X
74440   3 XXX 0 X 144.24 X
74440   2 XXX 0 X 152.39 X
74440   1 XXX 0 X 154.89 X
74445 TC 4 XXX 0 X 92.17 X
74445 TC 3 XXX 0 X 93.64 X
74445 TC 2 XXX 0 X 101.56 X
74445 TC 1 XXX 0 X 103.41 X
74445 26 4 XXX 0 X 157.23 X
74445 26 3 XXX 0 X 161.38 X
74445 26 2 XXX 0 X 168.71 X
74445 26 1 XXX 0 X 169.27 X
74445   4 XXX 0 X 246.16 X
74445   3 XXX 0 X 252.71 X
74445   2 XXX 0 X 265.54 X
74445   1 XXX 0 X 266.64 X
74450 26 4 XXX 0 X 44.77 X
74450 26 3 XXX 0 X 45.92 X
74450 26 2 XXX 0 X 47.81 X
74450 26 1 XXX 0 X 47.93 X
74450 TC 4 XXX 0 X 119.18 X
74450 TC 3 XXX 0 X 121.10 X
74450 TC 2 XXX 0 X 131.27 X
74450 TC 1 XXX 0 X 133.73 X
74450   4 XXX 0 X 160.12 X
74450   3 XXX 0 X 164.43 X
74450   2 XXX 0 X 174.87 X
74450   1 XXX 0 X 177.80 X
74455 26 4 XXX 0 X 44.60 X
74455 26 3 XXX 0 X 45.79 X
74455 26 2 XXX 0 X 47.81 X
74455 26 1 XXX 0 X 47.93 X
74455 TC 4 XXX 0 X 128.71 X
74455 TC 3 XXX 0 X 130.77 X
74455 TC 2 XXX 0 X 141.90 X
74455 TC 1 XXX 0 X 144.58 X
74455   4 XXX 0 X 169.68 X
74455   3 XXX 0 X 172.21 X
74455   2 XXX 0 X 185.51 X
74455   1 XXX 0 X 188.63 X
74470 26 4 XXX 0 X 76.10 X
74470 26 3 XXX 0 X 78.08 X
74470 26 2 XXX 0 X 81.67 X
74470 26 1 XXX 0 X 81.85 X
74470 TC 4 XXX 0 X 101.71 X
74470 TC 3 XXX 0 X 103.34 X
74470 TC 2 XXX 0 X 112.16 X
74470 TC 1 XXX 0 X 114.25 X
74470   4 XXX 0 X 174.82 X
74470   3 XXX 0 X 179.48 X
74470   1 XXX 0 X 188.63 X
74470   2 XXX 0 X 189.17 X
74485 26 4 XXX 0 X 76.10 X
74485 26 3 XXX 0 X 78.08 X
74485 26 2 XXX 0 X 81.67 X
74485 26 1 XXX 0 X 81.85 X
74485 TC 4 XXX 0 X 255.78 X
74485 TC 3 XXX 0 X 259.90 X
74485 TC 2 XXX 0 X 281.71 X
74485 TC 1 XXX 0 X 286.88 X
74485   4 XXX 0 X 324.58 X
74485   3 XXX 0 X 329.51 X
74485   2 XXX 0 X 355.22 X
74485   1 XXX 0 X 361.34 X
74710 26 4 XXX 0 X 46.47 X
74710 26 3 XXX 0 X 47.75 X
74710 26 2 XXX 0 X 49.83 X
74710 26 1 XXX 0 X 49.98 X
74710 TC 4 XXX 0 X 85.82 X
74710 TC 3 XXX 0 X 87.22 X
74710 TC 2 XXX 0 X 94.72 X
74710 TC 1 XXX 0 X 96.56 X
74710   4 XXX 0 X 129.33 X
74710   3 XXX 0 X 132.76 X
74710   2 XXX 0 X 140.05 X
74710   1 XXX 0 X 142.37 X
74712 26 2 XXX 4 X 196.75 X
74712 26 3 XXX 4 X 196.75 X
74712 26 4 XXX 4 X 196.75 X
74712 26 1 XXX 4 X 210.17 X
74712 TC 2 XXX 4 X 331.05 X
74712 TC 3 XXX 4 X 331.05 X
74712 TC 4 XXX 4 X 331.05 X
74712 TC 1 XXX 4 X 387.45 X
74712   2 XXX 4 X 527.78 X
74712   3 XXX 4 X 527.78 X
74712   4 XXX 4 X 527.78 X
74712   1 XXX 4 X 597.62 X
74713 26 2 ZZZ 0 X 116.94 X
74713 26 3 ZZZ 0 X 116.94 X
74713 26 4 ZZZ 0 X 116.94 X
74713 26 1 ZZZ 0 X 124.93 X
74713 TC 2 ZZZ 0 X 172.47 X
74713 TC 3 ZZZ 0 X 172.47 X
74713 TC 4 ZZZ 0 X 172.47 X
74713 TC 1 ZZZ 0 X 201.85 X
74713   2 ZZZ 0 X 289.41 X
74713   3 ZZZ 0 X 289.41 X
74713   4 ZZZ 0 X 289.41 X
74713   1 ZZZ 0 X 326.78 X
74740 26 4 XXX 0 X 51.45 X
74740 26 3 XXX 0 X 52.81 X
74740 26 2 XXX 0 X 55.26 X
74740 26 1 XXX 0 X 55.51 X
74740 TC 4 XXX 0 X 105.70 X
74740 TC 3 XXX 0 X 107.34 X
74740 TC 2 XXX 0 X 116.44 X
74740 TC 1 XXX 0 X 118.57 X
74740   4 XXX 0 X 153.22 X
74740   3 XXX 0 X 158.49 X
74740   2 XXX 0 X 167.30 X
74740   1 XXX 0 X 170.07 X
74742 26 4 XXX 0 X 74.64 X
74742 26 3 XXX 0 X 75.48 X
74742 26 2 XXX 0 X 79.46 X
74742 26 1 XXX 0 X 80.44 X
74742 TC 4 XXX 0 X 255.78 X
74742 TC 3 XXX 0 X 259.90 X
74742 TC 2 XXX 0 X 281.71 X
74742 TC 1 XXX 0 X 286.88 X
74742   4 XXX 0 X 330.45 X
74742   3 XXX 0 X 335.37 X
74742   2 XXX 0 X 361.19 X
74742   1 XXX 0 X 367.31 X
74775 26 4 XXX 0 X 86.47 X
74775 26 3 XXX 0 X 88.75 X
74775 26 2 XXX 0 X 92.68 X
74775 26 1 XXX 0 X 92.96 X
74775 TC 4 XXX 0 X 119.18 X
74775 TC 3 XXX 0 X 121.10 X
74775 TC 2 XXX 0 X 131.27 X
74775 TC 1 XXX 0 X 133.73 X
74775   4 XXX 0 X 201.96 X
74775   3 XXX 0 X 207.42 X
74775   2 XXX 0 X 218.43 X
74775   1 XXX 0 X 218.45 X
75557 26 2 XXX 0 X 182.22 X
75557 26 3 XXX 0 X 182.22 X
75557 26 4 XXX 0 X 182.22 X
75557 26 1 XXX 0 X 198.22 X
75557 TC 2 XXX 0 X 498.03 X
75557 TC 3 XXX 0 X 498.03 X
75557 TC 4 XXX 0 X 498.03 X
75557 TC 1 XXX 0 X 615.69 X
75557   2 XXX 0 X 680.25 X
75557   3 XXX 0 X 680.25 X
75557   4 XXX 0 X 680.25 X
75557   1 XXX 0 X 813.92 X
75559 26 2 XXX 0 X 232.38 X
75559 26 3 XXX 0 X 232.38 X
75559 26 4 XXX 0 X 232.38 X
75559 26 1 XXX 0 X 252.63 X
75559 TC 2 XXX 0 X 497.70 X
75559 TC 3 XXX 0 X 497.70 X
75559 TC 4 XXX 0 X 497.70 X
75559 TC 1 XXX 0 X 610.27 X
75559   2 XXX 0 X 730.05 X
75559   3 XXX 0 X 730.05 X
75559   4 XXX 0 X 730.05 X
75559   1 XXX 0 X 862.89 X
75561 26 2 XXX 0 X 201.57 X
75561 26 3 XXX 0 X 201.57 X
75561 26 4 XXX 0 X 201.57 X
75561 26 1 XXX 0 X 219.26 X
75561 TC 2 XXX 0 X 761.06 X
75561 TC 3 XXX 0 X 761.06 X
75561 TC 4 XXX 0 X 761.06 X
75561 TC 1 XXX 0 X 935.64 X
75561   2 XXX 0 X 962.59 X
75561   3 XXX 0 X 962.59 X
75561   4 XXX 0 X 962.59 X
75561   1 XXX 0 X 1,154.88 X
75563 26 2 XXX 0 X 241.40 X
75563 26 3 XXX 0 X 241.40 X
75563 26 4 XXX 0 X 241.40 X
75563 26 1 XXX 0 X 263.26 X
75563 TC 2 XXX 0 X 761.35 X
75563 TC 3 XXX 0 X 761.35 X
75563 TC 4 XXX 0 X 761.35 X
75563 TC 1 XXX 0 X 932.77 X
75563   2 XXX 0 X 1,002.77 X
75563   3 XXX 0 X 1,002.77 X
75563   4 XXX 0 X 1,002.77 X
75563   1 XXX 0 X 1,196.03 X
75565 26 2 ZZZ 0 X 18.67 X
75565 26 3 ZZZ 0 X 18.67 X
75565 26 4 ZZZ 0 X 18.67 X
75565 26 1 ZZZ 0 X 20.11 X
75565 TC 2 ZZZ 0 X 110.57 X
75565 TC 3 ZZZ 0 X 110.57 X
75565 TC 4 ZZZ 0 X 110.57 X
75565   2 ZZZ 0 X 129.21 X
75565   3 ZZZ 0 X 129.21 X
75565   4 ZZZ 0 X 129.21 X
75565 TC 1 ZZZ 0 X 131.27 X
75565   1 ZZZ 0 X 151.41 X
75571 26 2 XXX 0 X 41.67 X
75571 26 3 XXX 0 X 41.67 X
75571 26 4 XXX 0 X 41.67 X
75571 26 1 XXX 0 X 44.67 X
75571 TC 2 XXX 0 X 63.16 X
75571 TC 3 XXX 0 X 63.16 X
75571 TC 4 XXX 0 X 63.16 X
75571 TC 1 XXX 0 X 75.05 X
75571   2 XXX 0 X 104.82 X
75571   3 XXX 0 X 104.82 X
75571   4 XXX 0 X 104.82 X
75571   1 XXX 0 X 119.70 X
75572 26 2 XXX 0 X 126.47 X
75572 26 3 XXX 0 X 126.47 X
75572 26 4 XXX 0 X 126.47 X
75572 26 1 XXX 0 X 135.45 X
75572 TC 2 XXX 0 X 248.77 X
75572 TC 3 XXX 0 X 248.77 X
75572 TC 4 XXX 0 X 248.77 X
75572 TC 1 XXX 0 X 295.18 X
75572   2 XXX 0 X 375.23 X
75572   3 XXX 0 X 375.23 X
75572   4 XXX 0 X 375.23 X
75572   1 XXX 0 X 430.66 X
75573 26 2 XXX 0 X 181.02 X
75573 26 3 XXX 0 X 181.02 X
75573 26 4 XXX 0 X 181.02 X
75573 26 1 XXX 0 X 193.51 X
75573 TC 2 XXX 0 X 352.18 X
75573 TC 3 XXX 0 X 352.18 X
75573 TC 4 XXX 0 X 352.18 X
75573 TC 1 XXX 0 X 417.82 X
75573   2 XXX 0 X 533.20 X
75573   3 XXX 0 X 533.20 X
75573   4 XXX 0 X 533.20 X
75573   1 XXX 0 X 611.35 X
75574 26 2 XXX 0 X 172.34 X
75574 26 3 XXX 0 X 172.34 X
75574 26 4 XXX 0 X 172.34 X
75574 26 1 XXX 0 X 184.34 X
75574 TC 2 XXX 0 X 376.40 X
75574 TC 3 XXX 0 X 376.40 X
75574 TC 4 XXX 0 X 376.40 X
75574 TC 1 XXX 0 X 446.55 X
75574   2 XXX 0 X 548.70 X
75574   3 XXX 0 X 548.70 X
75574   4 XXX 0 X 548.70 X
75574   1 XXX 0 X 630.85 X
75600 26 4 XXX 0 X 67.83 X
75600 26 3 XXX 0 X 69.65 X
75600 26 2 XXX 0 X 72.70 X
75600 26 1 XXX 0 X 72.94 X
75600 TC 4 XXX 0 X 648.70 X
75600 TC 3 XXX 0 X 660.40 X
75600 TC 2 XXX 0 X 713.00 X
75600 TC 1 XXX 0 X 724.65 X
75600   4 XXX 0 X 1,086.22 X
75600   3 XXX 0 X 1,103.44 X
75600   2 XXX 0 X 1,193.98 X
75600   1 XXX 0 X 1,215.46 X
75605 26 4 XXX 0 X 157.23 X
75605 26 3 XXX 0 X 161.38 X
75605 26 2 XXX 0 X 168.71 X
75605 26 1 XXX 0 X 169.27 X
75605 TC 4 XXX 0 X 727.91 X
75605 TC 3 XXX 0 X 742.51 X
75605 TC 2 XXX 0 X 798.29 X
75605 TC 1 XXX 0 X 809.73 X
75605   4 XXX 0 X 1,167.37 X
75605   3 XXX 0 X 1,185.48 X
75605   2 XXX 0 X 1,280.73 X
75605   1 XXX 0 X 1,303.27 X
75625 26 4 XXX 0 X 157.23 X
75625 26 3 XXX 0 X 161.38 X
75625 26 2 XXX 0 X 168.71 X
75625 26 1 XXX 0 X 169.27 X
75625 TC 4 XXX 0 X 727.91 X
75625 TC 3 XXX 0 X 742.51 X
75625 TC 2 XXX 0 X 798.29 X
75625 TC 1 XXX 0 X 809.73 X
75625   4 XXX 0 X 1,167.37 X
75625   3 XXX 0 X 1,185.48 X
75625   2 XXX 0 X 1,280.73 X
75625   1 XXX 0 X 1,303.27 X
75630 26 4 XXX 0 X 180.78 X
75630 26 3 XXX 0 X 185.52 X
75630 26 2 XXX 0 X 193.95 X
75630 26 1 XXX 0 X 194.52 X
75630 TC 4 XXX 0 X 774.02 X
75630 TC 3 XXX 0 X 789.87 X
75630 TC 2 XXX 0 X 848.85 X
75630 TC 1 XXX 0 X 860.62 X
75630   4 XXX 0 X 1,232.38 X
75630   3 XXX 0 X 1,251.47 X
75630   2 XXX 0 X 1,351.72 X
75630   1 XXX 0 X 1,375.55 X
75635 26 2 XXX 0 X 198.32 X
75635 26 3 XXX 0 X 198.32 X
75635 26 4 XXX 0 X 198.32 X
75635 26 1 XXX 0 X 214.75 X
75635 TC 2 XXX 0 X 612.55 X
75635 TC 3 XXX 0 X 612.55 X
75635 TC 4 XXX 0 X 612.55 X
75635 TC 1 XXX 0 X 729.67 X
75635   2 XXX 0 X 810.91 X
75635   3 XXX 0 X 810.91 X
75635   4 XXX 0 X 810.91 X
75635   1 XXX 0 X 944.42 X
75705 26 4 XXX 0 X 300.61 X
75705 26 3 XXX 0 X 308.47 X
75705 26 2 XXX 0 X 322.41 X
75705 26 1 XXX 0 X 323.50 X
75705 TC 4 XXX 0 X 1,024.73 X
75705 TC 3 XXX 0 X 1,041.27 X
75705 TC 2 XXX 0 X 1,128.60 X
75705 TC 1 XXX 0 X 1,149.31 X
75705   4 XXX 0 X 1,298.45 X
75705   3 XXX 0 X 1,318.06 X
75705   2 XXX 0 X 1,420.35 X
75705   1 XXX 0 X 1,444.74 X
75710 26 4 XXX 0 X 157.23 X
75710 26 3 XXX 0 X 161.38 X
75710 26 2 XXX 0 X 168.71 X
75710 26 1 XXX 0 X 169.27 X
75710 TC 4 XXX 0 X 1,024.73 X
75710 TC 3 XXX 0 X 1,041.27 X
75710 TC 2 XXX 0 X 1,128.60 X
75710 TC 1 XXX 0 X 1,149.31 X
75710   4 XXX 0 X 1,167.37 X
75710   3 XXX 0 X 1,185.48 X
75710   2 XXX 0 X 1,280.73 X
75710   1 XXX 0 X 1,303.27 X
75716 26 4 XXX 0 X 180.78 X
75716 26 3 XXX 0 X 185.52 X
75716 26 2 XXX 0 X 193.95 X
75716 26 1 XXX 0 X 194.52 X
75716 TC 4 XXX 0 X 1,024.73 X
75716 TC 3 XXX 0 X 1,041.27 X
75716 TC 2 XXX 0 X 1,128.60 X
75716 TC 1 XXX 0 X 1,149.31 X
75716   4 XXX 0 X 1,188.67 X
75716   3 XXX 0 X 1,207.02 X
75716   2 XXX 0 X 1,303.34 X
75716   1 XXX 0 X 1,326.23 X