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2018 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   1 XXX 0 0 235.32 0
74415 26 1 XXX 0 0 66.11 0
74415 TC 1 XXX 0 0 175.29 0
74415   2 XXX 0 0 231.46 0
74415 26 2 XXX 0 0 65.89 0
74415 TC 2 XXX 0 0 172.15 0
74415   3 XXX 0 0 218.70 0
74415 26 3 XXX 0 0 63.20 0
74415 TC 3 XXX 0 0 158.77 0
74415   4 XXX 0 0 211.98 0
74415 26 4 XXX 0 0 61.49 0
74415 TC 4 XXX 0 0 156.26 0
74420   1 XXX 0 0 261.64 0
74420 26 1 XXX 0 0 46.79 0
74420 TC 1 XXX 0 0 218.52 0
74420   2 XXX 0 0 257.10 0
74420 26 2 XXX 0 0 46.71 0
74420 TC 2 XXX 0 0 214.48 0
74420   3 XXX 0 0 238.15 0
74420 26 3 XXX 0 0 44.82 0
74420 TC 3 XXX 0 0 197.60 0
74420   4 XXX 0 0 234.56 0
74420 26 4 XXX 0 0 43.73 0
74420 TC 4 XXX 0 0 194.47 0
74425   1 XXX 0 0 150.58 0
74425 26 1 XXX 0 0 46.79 0
74425 TC 1 XXX 0 0 107.48 0
74425   2 XXX 0 0 148.12 0
74425 26 2 XXX 0 0 46.71 0
74425 TC 2 XXX 0 0 105.54 0
74425   3 XXX 0 0 140.38 0
74425 26 3 XXX 0 0 44.84 0
74425 TC 3 XXX 0 0 97.29 0
74425   4 XXX 0 0 135.90 0
74425 26 4 XXX 0 0 44.57 0
74425 TC 4 XXX 0 0 95.81 0
74430   1 XXX 0 0 126.69 0
74430 26 1 XXX 0 0 42.29 0
74430 TC 1 XXX 0 0 87.52 0
74430   2 XXX 0 0 124.61 0
74430 26 2 XXX 0 0 42.11 0
74430 TC 2 XXX 0 0 85.86 0
74430   3 XXX 0 0 117.42 0
74430 26 3 XXX 0 0 40.43 0
74430 TC 3 XXX 0 0 79.05 0
74430   4 XXX 0 0 114.18 0
74430 26 4 XXX 0 0 39.86 0
74430 TC 4 XXX 0 0 77.79 0
74440   1 XXX 0 0 140.40 0
74440 26 1 XXX 0 0 50.31 0
74440 TC 1 XXX 0 0 93.73 0
74440   2 XXX 0 0 138.13 0
74440 26 2 XXX 0 0 50.09 0
74440 TC 2 XXX 0 0 92.05 0
74440   3 XXX 0 0 130.74 0
74440 26 3 XXX 0 0 47.87 0
74440 TC 3 XXX 0 0 84.88 0
74440   4 XXX 0 0 127.39 0
74440 26 4 XXX 0 0 46.64 0
74440 TC 4 XXX 0 0 83.55 0
74445   1 XXX 0 0 241.69 0
74445 26 1 XXX 0 0 153.43 0
74445 TC 1 XXX 0 0 93.73 0
74445   2 XXX 0 0 240.69 0
74445 26 2 XXX 0 0 152.92 0
74445 TC 2 XXX 0 0 92.05 0
74445   3 XXX 0 0 229.07 0
74445 26 3 XXX 0 0 146.28 0
74445 TC 3 XXX 0 0 84.88 0
74445   4 XXX 0 0 223.12 0
74445 26 4 XXX 0 0 142.52 0
74445 TC 4 XXX 0 0 83.55 0
74450   1 XXX 0 0 161.16 0
74450 26 1 XXX 0 0 43.44 0
74450 TC 1 XXX 0 0 121.22 0
74450   2 XXX 0 0 158.50 0
74450 26 2 XXX 0 0 43.34 0
74450 TC 2 XXX 0 0 118.99 0
74450   3 XXX 0 0 149.04 0
74450 26 3 XXX 0 0 41.62 0
74450 TC 3 XXX 0 0 109.77 0
74450   4 XXX 0 0 145.14 0
74450 26 4 XXX 0 0 40.58 0
74450 TC 4 XXX 0 0 108.03 0
74455   1 XXX 0 0 170.98 0
74455 26 1 XXX 0 0 43.44 0
74455 TC 1 XXX 0 0 131.05 0
74455   2 XXX 0 0 168.15 0
74455 26 2 XXX 0 0 43.34 0
74455 TC 2 XXX 0 0 128.62 0
74455   3 XXX 0 0 156.10 0
74455 26 3 XXX 0 0 41.51 0
74455 TC 3 XXX 0 0 118.53 0
74455   4 XXX 0 0 153.80 0
74455 26 4 XXX 0 0 40.43 0
74455 TC 4 XXX 0 0 116.67 0
74470   1 XXX 0 0 170.98 0
74470 26 1 XXX 0 0 74.19 0
74470 TC 1 XXX 0 0 103.57 0
74470   2 XXX 0 0 171.47 0
74470 26 2 XXX 0 0 74.03 0
74470 TC 2 XXX 0 0 101.67 0
74470   3 XXX 0 0 162.69 0
74470 26 3 XXX 0 0 70.78 0
74470 TC 3 XXX 0 0 93.68 0
74470   4 XXX 0 0 158.46 0
74470 26 4 XXX 0 0 68.97 0
74470 TC 4 XXX 0 0 92.20 0
74485   1 XXX 0 0 327.53 0
74485 26 1 XXX 0 0 74.19 0
74485 TC 1 XXX 0 0 260.03 0
74485   2 XXX 0 0 321.98 0
74485 26 2 XXX 0 0 74.03 0
74485 TC 2 XXX 0 0 255.35 0
74485   3 XXX 0 0 298.68 0
74485 26 3 XXX 0 0 70.78 0
74485 TC 3 XXX 0 0 235.58 0
74485   4 XXX 0 0 294.21 0
74485 26 4 XXX 0 0 68.97 0
74485 TC 4 XXX 0 0 231.85 0
74710   1 XXX 0 0 129.05 0
74710 26 1 XXX 0 0 45.30 0
74710 TC 1 XXX 0 0 87.52 0
74710   2 XXX 0 0 126.94 0
74710 26 2 XXX 0 0 45.17 0
74710 TC 2 XXX 0 0 85.86 0
74710   3 XXX 0 0 120.33 0
74710 26 3 XXX 0 0 43.28 0
74710 TC 3 XXX 0 0 79.05 0
74710   4 XXX 0 0 117.22 0
74710 26 4 XXX 0 0 42.12 0
74710 TC 4 XXX 0 0 77.79 0
74712   1 XXX 4 0 541.70 0
74712 26 1 XXX 4 0 190.51 0
74712 TC 1 XXX 4 0 351.19 0
74712   2 XXX 4 0 478.40 0
74712 26 2 XXX 4 0 178.34 0
74712 TC 2 XXX 4 0 300.07 0
74712   3 XXX 4 0 478.40 0
74712 26 3 XXX 4 0 178.34 0
74712 TC 3 XXX 4 0 300.07 0
74712   4 XXX 4 0 478.40 0
74712 26 4 XXX 4 0 178.34 0
74712 TC 4 XXX 4 0 300.07 0
74713   1 ZZZ 0 0 296.21 0
74713 26 1 ZZZ 0 0 113.25 0
74713 TC 1 ZZZ 0 0 182.96 0
74713   2 ZZZ 0 0 262.33 0
74713 26 2 ZZZ 0 0 106.00 0
74713 TC 2 ZZZ 0 0 156.33 0
74713   3 ZZZ 0 0 262.33 0
74713 26 3 ZZZ 0 0 106.00 0
74713 TC 3 ZZZ 0 0 156.33 0
74713   4 ZZZ 0 0 262.33 0
74713 26 4 ZZZ 0 0 106.00 0
74713 TC 4 ZZZ 0 0 156.33 0
74740   1 XXX 0 0 154.15 0
74740 26 1 XXX 0 0 50.31 0
74740 TC 1 XXX 0 0 107.48 0
74740   2 XXX 0 0 151.64 0
74740 26 2 XXX 0 0 50.09 0
74740 TC 2 XXX 0 0 105.54 0
74740   3 XXX 0 0 143.66 0
74740 26 3 XXX 0 0 47.87 0
74740 TC 3 XXX 0 0 97.29 0
74740   4 XXX 0 0 138.89 0
74740 26 4 XXX 0 0 46.64 0
74740 TC 4 XXX 0 0 95.81 0
74742   1 XXX 0 0 332.94 0
74742 26 1 XXX 0 0 72.91 0
74742 TC 1 XXX 0 0 260.03 0
74742   2 XXX 0 0 327.40 0
74742 26 2 XXX 0 0 72.03 0
74742 TC 2 XXX 0 0 255.35 0
74742   3 XXX 0 0 303.99 0
74742 26 3 XXX 0 0 68.42 0
74742 TC 3 XXX 0 0 235.58 0
74742   4 XXX 0 0 299.53 0
74742 26 4 XXX 0 0 67.65 0
74742 TC 4 XXX 0 0 231.85 0
74775   1 XXX 0 0 198.01 0
74775 26 1 XXX 0 0 84.26 0
74775 TC 1 XXX 0 0 121.22 0
74775   2 XXX 0 0 197.99 0
74775 26 2 XXX 0 0 84.01 0
74775 TC 2 XXX 0 0 118.99 0
74775   3 XXX 0 0 188.02 0
74775 26 3 XXX 0 0 80.45 0
74775 TC 3 XXX 0 0 109.77 0
74775   4 XXX 0 0 183.06 0
74775 26 4 XXX 0 0 78.38 0
74775 TC 4 XXX 0 0 108.03 0
75557   1 XXX 0 0 737.76 0
75557 26 1 XXX 0 0 179.67 0
75557 TC 1 XXX 0 0 558.07 0
75557   2 XXX 0 0 616.60 0
75557 26 2 XXX 0 0 165.17 0
75557 TC 2 XXX 0 0 451.43 0
75557   3 XXX 0 0 616.60 0
75557 26 3 XXX 0 0 165.17 0
75557 TC 3 XXX 0 0 451.43 0
75557   4 XXX 0 0 616.60 0
75557 26 4 XXX 0 0 165.17 0
75557 TC 4 XXX 0 0 451.43 0
75559   1 XXX 0 0 782.15 0
75559 26 1 XXX 0 0 228.99 0
75559 TC 1 XXX 0 0 553.17 0
75559   2 XXX 0 0 661.73 0
75559 26 2 XXX 0 0 210.64 0
75559 TC 2 XXX 0 0 451.12 0
75559   3 XXX 0 0 661.73 0
75559 26 3 XXX 0 0 210.64 0
75559 TC 3 XXX 0 0 451.12 0
75559   4 XXX 0 0 661.73 0
75559 26 4 XXX 0 0 210.64 0
75559 TC 4 XXX 0 0 451.12 0
75561   1 XXX 0 0 1,046.81 0
75561 26 1 XXX 0 0 198.75 0
75561 TC 1 XXX 0 0 848.08 0
75561   2 XXX 0 0 872.52 0
75561 26 2 XXX 0 0 182.72 0
75561 TC 2 XXX 0 0 689.84 0
75561   3 XXX 0 0 872.52 0
75561 26 3 XXX 0 0 182.72 0
75561 TC 3 XXX 0 0 689.84 0
75561   4 XXX 0 0 872.52 0
75561 26 4 XXX 0 0 182.72 0
75561 TC 4 XXX 0 0 689.84 0
75563   1 XXX 0 0 1,084.12 0
75563 26 1 XXX 0 0 238.62 0
75563 TC 1 XXX 0 0 845.49 0
75563   2 XXX 0 0 908.93 0
75563 26 2 XXX 0 0 218.81 0
75563 TC 2 XXX 0 0 690.11 0
75563   3 XXX 0 0 908.93 0
75563 26 3 XXX 0 0 218.81 0
75563 TC 3 XXX 0 0 690.11 0
75563   4 XXX 0 0 908.93 0
75563 26 4 XXX 0 0 218.81 0
75563 TC 4 XXX 0 0 690.11 0
75565   1 ZZZ 0 0 137.24 0
75565 26 1 ZZZ 0 0 18.23 0
75565 TC 1 ZZZ 0 0 118.99 0
75565   2 ZZZ 0 0 117.13 0
75565 26 2 ZZZ 0 0 16.92 0
75565 TC 2 ZZZ 0 0 100.22 0
75565   3 ZZZ 0 0 117.13 0
75565 26 3 ZZZ 0 0 16.92 0
75565 TC 3 ZZZ 0 0 100.22 0
75565   4 ZZZ 0 0 117.13 0
75565 26 4 ZZZ 0 0 16.92 0
75565 TC 4 ZZZ 0 0 100.22 0
75571   1 XXX 0 0 108.50 0
75571 26 1 XXX 0 0 40.50 0
75571 TC 1 XXX 0 0 68.03 0
75571   2 XXX 0 0 95.01 0
75571 26 2 XXX 0 0 37.77 0
75571 TC 2 XXX 0 0 57.24 0
75571   3 XXX 0 0 95.01 0
75571 26 3 XXX 0 0 37.77 0
75571 TC 3 XXX 0 0 57.24 0
75571   4 XXX 0 0 95.01 0
75571 26 4 XXX 0 0 37.77 0
75571 TC 4 XXX 0 0 57.24 0
75572   1 XXX 0 0 390.36 0
75572 26 1 XXX 0 0 122.78 0
75572 TC 1 XXX 0 0 267.56 0
75572   2 XXX 0 0 340.12 0
75572 26 2 XXX 0 0 114.63 0
75572 TC 2 XXX 0 0 225.49 0
75572   3 XXX 0 0 340.12 0
75572 26 3 XXX 0 0 114.63 0
75572 TC 3 XXX 0 0 225.49 0
75572   4 XXX 0 0 340.12 0
75572 26 4 XXX 0 0 114.63 0
75572 TC 4 XXX 0 0 225.49 0
75573   1 XXX 0 0 554.14 0
75573 26 1 XXX 0 0 175.41 0
75573 TC 1 XXX 0 0 378.73 0
75573   2 XXX 0 0 483.30 0
75573 26 2 XXX 0 0 164.09 0
75573 TC 2 XXX 0 0 319.23 0
75573   3 XXX 0 0 483.30 0
75573 26 3 XXX 0 0 164.09 0
75573 TC 3 XXX 0 0 319.23 0
75573   4 XXX 0 0 483.30 0
75573 26 4 XXX 0 0 164.09 0
75573 TC 4 XXX 0 0 319.23 0
75574   1 XXX 0 0 571.83 0
75574 26 1 XXX 0 0 167.09 0
75574 TC 1 XXX 0 0 404.76 0
75574   2 XXX 0 0 497.36 0
75574 26 2 XXX 0 0 156.22 0
75574 TC 2 XXX 0 0 341.18 0
75574   3 XXX 0 0 497.36 0
75574 26 3 XXX 0 0 156.22 0
75574 TC 3 XXX 0 0 341.18 0
75574   4 XXX 0 0 497.36 0
75574 26 4 XXX 0 0 156.22 0
75574 TC 4 XXX 0 0 341.18 0
75600   1 XXX 0 0 1,101.73 0
75600 26 1 XXX 0 0 66.11 0
75600 TC 1 XXX 0 0 656.84 0
75600   2 XXX 0 0 1,082.26 0
75600 26 2 XXX 0 0 65.89 0
75600 TC 2 XXX 0 0 646.28 0
75600   3 XXX 0 0 1,000.19 0
75600 26 3 XXX 0 0 63.14 0
75600 TC 3 XXX 0 0 598.61 0
75600   4 XXX 0 0 984.58 0
75600 26 4 XXX 0 0 61.49 0
75600 TC 4 XXX 0 0 588.00 0
75605   1 XXX 0 0 1,181.33 0
75605 26 1 XXX 0 0 153.43 0
75605 TC 1 XXX 0 0 733.96 0
75605   2 XXX 0 0 1,160.89 0
75605 26 2 XXX 0 0 152.92 0
75605 TC 2 XXX 0 0 723.59 0
75605   3 XXX 0 0 1,074.56 0
75605 26 3 XXX 0 0 146.28 0
75605 TC 3 XXX 0 0 673.04 0
75605   4 XXX 0 0 1,058.13 0
75605 26 4 XXX 0 0 142.52 0
75605 TC 4 XXX 0 0 659.80 0
75625   1 XXX 0 0 1,181.33 0
75625 26 1 XXX 0 0 153.43 0
75625 TC 1 XXX 0 0 733.96 0
75625   2 XXX 0 0 1,160.89 0
75625 26 2 XXX 0 0 152.92 0
75625 TC 2 XXX 0 0 723.59 0
75625   3 XXX 0 0 1,074.56 0
75625 26 3 XXX 0 0 146.28 0
75625 TC 3 XXX 0 0 673.04 0
75625   4 XXX 0 0 1,058.13 0
75625 26 4 XXX 0 0 142.52 0
75625 TC 4 XXX 0 0 659.80 0
75630   1 XXX 0 0 1,246.84 0
75630 26 1 XXX 0 0 176.32 0
75630 TC 1 XXX 0 0 780.09 0
75630   2 XXX 0 0 1,225.24 0
75630 26 2 XXX 0 0 175.80 0
75630 TC 2 XXX 0 0 769.42 0
75630   3 XXX 0 0 1,134.37 0
75630 26 3 XXX 0 0 168.16 0
75630 TC 3 XXX 0 0 715.95 0
75630   4 XXX 0 0 1,117.06 0
75630 26 4 XXX 0 0 163.86 0
75630 TC 4 XXX 0 0 701.59 0
75635   1 XXX 0 0 856.05 0
75635 26 1 XXX 0 0 194.66 0
75635 TC 1 XXX 0 0 661.40 0
75635   2 XXX 0 0 735.03 0
75635 26 2 XXX 0 0 179.77 0
75635 TC 2 XXX 0 0 555.23 0
75635   3 XXX 0 0 735.03 0
75635 26 3 XXX 0 0 179.77 0
75635 TC 3 XXX 0 0 555.23 0
75635   4 XXX 0 0 735.03 0
75635 26 4 XXX 0 0 179.77 0
75635 TC 4 XXX 0 0 555.23 0
75705   1 XXX 0 0 1,309.55 0
75705 26 1 XXX 0 0 293.23 0
75705 TC 1 XXX 0 0 1,041.77 0
75705   2 XXX 0 0 1,287.45 0
75705 26 2 XXX 0 0 292.24 0
75705 TC 2 XXX 0 0 1,023.00 0
75705   3 XXX 0 0 1,194.73 0
75705 26 3 XXX 0 0 279.60 0
75705 TC 3 XXX 0 0 943.84 0
75705   4 XXX 0 0 1,176.96 0
75705 26 4 XXX 0 0 272.48 0
75705 TC 4 XXX 0 0 928.85 0
75710   1 XXX 0 0 1,181.33 0
75710 26 1 XXX 0 0 153.43 0
75710 TC 1 XXX 0 0 1,041.77 0
75710   2 XXX 0 0 1,160.89 0
75710 26 2 XXX 0 0 152.92 0
75710 TC 2 XXX 0 0 1,023.00 0
75710   3 XXX 0 0 1,074.56 0
75710 26 3 XXX 0 0 146.28 0
75710 TC 3 XXX 0 0 943.84 0
75710   4 XXX 0 0 1,058.13 0
75710 26 4 XXX 0 0 142.52 0
75710 TC 4 XXX 0 0 928.85 0
75716   1 XXX 0 0 1,202.14 0
75716 26 1 XXX 0 0 176.32 0
75716 TC 1 XXX 0 0 1,041.77 0
75716   2 XXX 0 0 1,181.38 0
75716 26 2 XXX 0 0 175.80 0
75716 TC 2 XXX 0 0 1,023.00 0
75716   3 XXX 0 0 1,094.08 0
75716 26 3 XXX 0 0 168.16 0
75716 TC 3 XXX 0 0 943.84 0
75716   4 XXX 0 0 1,077.45 0
75716 26 4 XXX 0 0 163.86 0
75716 TC 4 XXX 0 0 928.85 0