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2021 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 26 3 XXX 0 X 161.38 X
75726 26 4 XXX 0 X 162.08 X
75726 26 2 XXX 0 X 168.71 X
75726 26 1 XXX 0 X 169.27 X
75726 TC 4 XXX 0 X 1,024.73 X
75726 TC 3 XXX 0 X 1,041.27 X
75726 TC 2 XXX 0 X 1,128.60 X
75726 TC 1 XXX 0 X 1,149.31 X
75726   4 XXX 0 X 1,167.37 X
75726   3 XXX 0 X 1,185.48 X
75726   2 XXX 0 X 1,280.73 X
75726   1 XXX 0 X 1,303.27 X
75731 26 4 XXX 0 X 157.23 X
75731 26 3 XXX 0 X 161.38 X
75731 26 2 XXX 0 X 168.71 X
75731 26 1 XXX 0 X 169.27 X
75731 TC 4 XXX 0 X 1,024.73 X
75731 TC 3 XXX 0 X 1,041.27 X
75731 TC 2 XXX 0 X 1,128.60 X
75731 TC 1 XXX 0 X 1,149.31 X
75731   4 XXX 0 X 1,167.37 X
75731   3 XXX 0 X 1,185.48 X
75731   2 XXX 0 X 1,280.73 X
75731   1 XXX 0 X 1,303.27 X
75733 26 4 XXX 0 X 180.78 X
75733 26 3 XXX 0 X 185.52 X
75733 26 2 XXX 0 X 193.95 X
75733 26 1 XXX 0 X 194.52 X
75733 TC 4 XXX 0 X 1,024.73 X
75733 TC 3 XXX 0 X 1,041.27 X
75733 TC 2 XXX 0 X 1,128.60 X
75733 TC 1 XXX 0 X 1,149.31 X
75733   4 XXX 0 X 1,188.67 X
75733   3 XXX 0 X 1,207.02 X
75733   2 XXX 0 X 1,303.34 X
75733   1 XXX 0 X 1,326.23 X
75736 26 4 XXX 0 X 157.23 X
75736 26 3 XXX 0 X 161.38 X
75736 26 2 XXX 0 X 168.71 X
75736 26 1 XXX 0 X 169.27 X
75736 TC 4 XXX 0 X 1,024.73 X
75736 TC 3 XXX 0 X 1,041.27 X
75736 TC 2 XXX 0 X 1,128.60 X
75736 TC 1 XXX 0 X 1,149.31 X
75736   4 XXX 0 X 1,167.37 X
75736   3 XXX 0 X 1,185.48 X
75736   2 XXX 0 X 1,280.73 X
75736   1 XXX 0 X 1,303.27 X
75741 26 4 XXX 0 X 180.78 X
75741 26 3 XXX 0 X 185.52 X
75741 26 2 XXX 0 X 193.95 X
75741 26 1 XXX 0 X 194.52 X
75741 TC 4 XXX 0 X 1,024.73 X
75741 TC 3 XXX 0 X 1,041.27 X
75741 TC 2 XXX 0 X 1,128.60 X
75741 TC 1 XXX 0 X 1,149.31 X
75741   4 XXX 0 X 1,188.67 X
75741   3 XXX 0 X 1,207.02 X
75741   2 XXX 0 X 1,303.34 X
75741   1 XXX 0 X 1,326.23 X
75743 26 4 XXX 0 X 228.89 X
75743 26 3 XXX 0 X 234.86 X
75743 26 2 XXX 0 X 245.44 X
75743 26 1 XXX 0 X 246.18 X
75743 TC 4 XXX 0 X 1,024.73 X
75743 TC 3 XXX 0 X 1,041.27 X
75743 TC 2 XXX 0 X 1,128.60 X
75743 TC 1 XXX 0 X 1,149.31 X
75743   4 XXX 0 X 1,232.92 X
75743   3 XXX 0 X 1,251.77 X
75743   2 XXX 0 X 1,350.41 X
75743   1 XXX 0 X 1,373.81 X
75746 26 4 XXX 0 X 158.42 X
75746 26 3 XXX 0 X 161.38 X
75746 26 2 XXX 0 X 168.71 X
75746 26 1 XXX 0 X 169.27 X
75746 TC 4 XXX 0 X 1,024.73 X
75746 TC 3 XXX 0 X 1,041.27 X
75746 TC 2 XXX 0 X 1,128.60 X
75746 TC 1 XXX 0 X 1,149.31 X
75746   4 XXX 0 X 1,167.37 X
75746   3 XXX 0 X 1,185.48 X
75746   2 XXX 0 X 1,280.73 X
75746   1 XXX 0 X 1,303.27 X
75756 26 4 XXX 0 X 157.23 X
75756 26 3 XXX 0 X 161.38 X
75756 26 2 XXX 0 X 168.71 X
75756 26 1 XXX 0 X 169.27 X
75756 TC 4 XXX 0 X 1,024.73 X
75756 TC 3 XXX 0 X 1,041.27 X
75756 TC 2 XXX 0 X 1,128.60 X
75756 TC 1 XXX 0 X 1,149.31 X
75756   4 XXX 0 X 1,167.37 X
75756   3 XXX 0 X 1,185.48 X
75756   2 XXX 0 X 1,280.73 X
75756   1 XXX 0 X 1,303.27 X
75774 26 3 ZZZ 0 X 49.37 X
75774 26 4 ZZZ 0 X 49.90 X
75774 26 2 ZZZ 0 X 51.53 X
75774 26 1 ZZZ 0 X 51.62 X
75774 TC 4 ZZZ 0 X 1,024.73 X
75774 TC 3 ZZZ 0 X 1,041.27 X
75774   4 ZZZ 0 X 1,069.02 X
75774   3 ZZZ 0 X 1,086.06 X
75774 TC 2 ZZZ 0 X 1,128.60 X
75774 TC 1 ZZZ 0 X 1,149.31 X
75774   2 ZZZ 0 X 1,175.68 X
75774   1 ZZZ 0 X 1,196.85 X
75801 26 4 XXX 0 X 111.64 X
75801 26 3 XXX 0 X 114.55 X
75801 26 2 XXX 0 X 119.65 X
75801 26 1 XXX 0 X 120.02 X
75801 TC 4 XXX 0 X 440.91 X
75801 TC 3 XXX 0 X 447.98 X
75801 TC 2 XXX 0 X 485.67 X
75801 TC 1 XXX 0 X 494.61 X
75801   4 XXX 0 X 542.51 X
75801   3 XXX 0 X 550.74 X
75801   2 XXX 0 X 593.79 X
75801   1 XXX 0 X 604.07 X
75803 26 4 XXX 0 X 160.61 X
75803 26 3 XXX 0 X 164.84 X
75803 26 2 XXX 0 X 172.29 X
75803 26 1 XXX 0 X 172.81 X
75803 TC 4 XXX 0 X 440.91 X
75803 TC 3 XXX 0 X 447.98 X
75803 TC 2 XXX 0 X 485.67 X
75803 TC 1 XXX 0 X 494.61 X
75803   4 XXX 0 X 586.77 X
75803   3 XXX 0 X 595.54 X
75803   2 XXX 0 X 641.17 X
75803   1 XXX 0 X 652.05 X
75805 26 4 XXX 0 X 111.64 X
75805 26 3 XXX 0 X 114.55 X
75805 26 2 XXX 0 X 119.65 X
75805 26 1 XXX 0 X 120.02 X
75805 TC 4 XXX 0 X 495.69 X
75805 TC 3 XXX 0 X 503.66 X
75805 TC 2 XXX 0 X 546.02 X
75805 TC 1 XXX 0 X 556.07 X
75805   4 XXX 0 X 597.33 X
75805   3 XXX 0 X 606.45 X
75805   2 XXX 0 X 654.14 X
75805   1 XXX 0 X 665.49 X
75807 26 4 XXX 0 X 160.61 X
75807 26 3 XXX 0 X 164.84 X
75807 26 2 XXX 0 X 172.29 X
75807 26 1 XXX 0 X 172.81 X
75807 TC 4 XXX 0 X 495.69 X
75807 TC 3 XXX 0 X 503.66 X
75807 TC 2 XXX 0 X 546.02 X
75807 TC 1 XXX 0 X 556.07 X
75807   4 XXX 0 X 641.59 X
75807   3 XXX 0 X 651.25 X
75807   2 XXX 0 X 701.56 X
75807   1 XXX 0 X 713.49 X
75809 26 4 XXX 0 X 57.44 X
75809 26 3 XXX 0 X 58.00 X
75809 26 2 XXX 0 X 61.09 X
75809 26 1 XXX 0 X 61.84 X
75809 TC 4 XXX 0 X 64.34 X
75809 TC 3 XXX 0 X 65.38 X
75809 TC 2 XXX 0 X 70.94 X
75809 TC 1 XXX 0 X 72.27 X
75809   4 XXX 0 X 121.81 X
75809   3 XXX 0 X 123.46 X
75809   2 XXX 0 X 131.96 X
75809   1 XXX 0 X 134.10 X
75810 26 4 XXX 0 X 157.23 X
75810 26 3 XXX 0 X 161.38 X
75810 26 2 XXX 0 X 168.71 X
75810 26 1 XXX 0 X 169.27 X
75810 TC 4 XXX 0 X 1,024.73 X
75810 TC 3 XXX 0 X 1,041.27 X
75810 TC 2 XXX 0 X 1,128.60 X
75810 TC 1 XXX 0 X 1,149.31 X
75810   4 XXX 0 X 1,167.37 X
75810   3 XXX 0 X 1,185.48 X
75810   2 XXX 0 X 1,280.73 X
75810   1 XXX 0 X 1,303.27 X
75820 TC 4 XXX 0 X 77.07 X
75820 TC 3 XXX 0 X 78.28 X
75820 TC 2 XXX 0 X 84.98 X
75820 TC 1 XXX 0 X 86.54 X
75820 26 4 XXX 0 X 97.41 X
75820 26 3 XXX 0 X 99.56 X
75820 26 2 XXX 0 X 104.11 X
75820 26 1 XXX 0 X 104.42 X
75820   4 XXX 0 X 165.59 X
75820   3 XXX 0 X 167.75 X
75820   2 XXX 0 X 179.43 X
75820   1 XXX 0 X 182.15 X
75822 TC 4 XXX 0 X 120.75 X
75822 TC 3 XXX 0 X 122.69 X
75822 TC 2 XXX 0 X 133.02 X
75822 TC 1 XXX 0 X 135.45 X
75822 26 4 XXX 0 X 145.45 X
75822 26 3 XXX 0 X 149.29 X
75822 26 2 XXX 0 X 156.00 X
75822 26 1 XXX 0 X 156.46 X
75822   4 XXX 0 X 253.52 X
75822   3 XXX 0 X 256.96 X
75822   2 XXX 0 X 274.40 X
75822   1 XXX 0 X 278.58 X
75825 26 4 XXX 0 X 157.23 X
75825 26 3 XXX 0 X 161.38 X
75825 26 2 XXX 0 X 168.71 X
75825 26 1 XXX 0 X 169.27 X
75825 TC 4 XXX 0 X 1,024.73 X
75825 TC 3 XXX 0 X 1,041.27 X
75825 TC 2 XXX 0 X 1,128.60 X
75825 TC 1 XXX 0 X 1,149.31 X
75825   4 XXX 0 X 1,167.37 X
75825   3 XXX 0 X 1,185.48 X
75825   2 XXX 0 X 1,280.73 X
75825   1 XXX 0 X 1,303.27 X
75827 26 3 XXX 0 X 161.38 X
75827 26 4 XXX 0 X 164.46 X
75827 26 2 XXX 0 X 168.71 X
75827 26 1 XXX 0 X 169.27 X
75827 TC 4 XXX 0 X 1,024.73 X
75827 TC 3 XXX 0 X 1,041.27 X
75827 TC 2 XXX 0 X 1,128.60 X
75827 TC 1 XXX 0 X 1,149.31 X
75827   4 XXX 0 X 1,167.37 X
75827   3 XXX 0 X 1,185.48 X
75827   2 XXX 0 X 1,280.73 X
75827   1 XXX 0 X 1,303.27 X
75831 26 4 XXX 0 X 157.23 X
75831 26 3 XXX 0 X 161.38 X
75831 26 2 XXX 0 X 168.71 X
75831 26 1 XXX 0 X 169.27 X
75831 TC 4 XXX 0 X 1,024.73 X
75831 TC 3 XXX 0 X 1,041.27 X
75831 TC 2 XXX 0 X 1,128.60 X
75831 TC 1 XXX 0 X 1,149.31 X
75831   4 XXX 0 X 1,167.37 X
75831   3 XXX 0 X 1,185.48 X
75831   2 XXX 0 X 1,280.73 X
75831   1 XXX 0 X 1,303.27 X
75833 26 4 XXX 0 X 205.18 X
75833 26 3 XXX 0 X 210.54 X
75833 26 2 XXX 0 X 220.10 X
75833 26 1 XXX 0 X 220.76 X
75833 TC 4 XXX 0 X 1,024.73 X
75833 TC 3 XXX 0 X 1,041.27 X
75833 TC 2 XXX 0 X 1,128.60 X
75833 TC 1 XXX 0 X 1,149.31 X
75833   4 XXX 0 X 1,211.60 X
75833   3 XXX 0 X 1,230.25 X
75833   2 XXX 0 X 1,327.72 X
75833   1 XXX 0 X 1,350.86 X
75840 26 4 XXX 0 X 157.23 X
75840 26 3 XXX 0 X 161.38 X
75840 26 2 XXX 0 X 168.71 X
75840 26 1 XXX 0 X 169.27 X
75840 TC 4 XXX 0 X 1,024.73 X
75840 TC 3 XXX 0 X 1,041.27 X
75840 TC 2 XXX 0 X 1,128.60 X
75840 TC 1 XXX 0 X 1,149.31 X
75840   4 XXX 0 X 1,167.37 X
75840   3 XXX 0 X 1,185.48 X
75840   2 XXX 0 X 1,280.73 X
75840   1 XXX 0 X 1,303.27 X
75842 26 4 XXX 0 X 205.18 X
75842 26 3 XXX 0 X 210.54 X
75842 26 2 XXX 0 X 220.10 X
75842 26 1 XXX 0 X 220.76 X
75842 TC 4 XXX 0 X 1,024.73 X
75842 TC 3 XXX 0 X 1,041.27 X
75842 TC 2 XXX 0 X 1,128.60 X
75842 TC 1 XXX 0 X 1,149.31 X
75842   4 XXX 0 X 1,211.60 X
75842   3 XXX 0 X 1,230.25 X
75842   2 XXX 0 X 1,327.72 X
75842   1 XXX 0 X 1,350.86 X
75860 26 4 XXX 0 X 157.23 X
75860 26 3 XXX 0 X 161.38 X
75860 26 2 XXX 0 X 168.71 X
75860 26 1 XXX 0 X 169.27 X
75860 TC 4 XXX 0 X 1,024.73 X
75860 TC 3 XXX 0 X 1,041.27 X
75860 TC 2 XXX 0 X 1,128.60 X
75860 TC 1 XXX 0 X 1,149.31 X
75860   4 XXX 0 X 1,167.37 X
75860   3 XXX 0 X 1,185.48 X
75860   2 XXX 0 X 1,280.73 X
75860   1 XXX 0 X 1,303.27 X
75870 26 4 XXX 0 X 157.23 X
75870 26 3 XXX 0 X 161.38 X
75870 26 2 XXX 0 X 168.71 X
75870 26 1 XXX 0 X 169.27 X
75870 TC 4 XXX 0 X 1,024.73 X
75870 TC 3 XXX 0 X 1,041.27 X
75870 TC 2 XXX 0 X 1,128.60 X
75870 TC 1 XXX 0 X 1,149.31 X
75870   4 XXX 0 X 1,167.37 X
75870   3 XXX 0 X 1,185.48 X
75870   2 XXX 0 X 1,280.73 X
75870   1 XXX 0 X 1,303.27 X
75872 26 4 XXX 0 X 157.23 X
75872 26 3 XXX 0 X 161.38 X
75872 26 2 XXX 0 X 168.71 X
75872 26 1 XXX 0 X 169.27 X
75872 TC 4 XXX 0 X 1,024.73 X
75872 TC 3 XXX 0 X 1,041.27 X
75872 TC 2 XXX 0 X 1,128.60 X
75872 TC 1 XXX 0 X 1,149.31 X
75872   4 XXX 0 X 1,167.37 X
75872   3 XXX 0 X 1,185.48 X
75872   2 XXX 0 X 1,280.73 X
75872   1 XXX 0 X 1,303.27 X
75880 TC 4 XXX 0 X 77.07 X
75880 TC 3 XXX 0 X 78.28 X
75880 TC 2 XXX 0 X 84.98 X
75880 TC 1 XXX 0 X 86.54 X
75880 26 4 XXX 0 X 97.02 X
75880 26 3 XXX 0 X 99.56 X
75880 26 2 XXX 0 X 104.11 X
75880 26 1 XXX 0 X 104.42 X
75880   4 XXX 0 X 165.59 X
75880   3 XXX 0 X 167.75 X
75880   2 XXX 0 X 179.43 X
75880   1 XXX 0 X 182.15 X
75885 26 4 XXX 0 X 198.98 X
75885 26 3 XXX 0 X 204.23 X
75885 26 2 XXX 0 X 213.48 X
75885 26 1 XXX 0 X 214.10 X
75885 TC 4 XXX 0 X 1,024.73 X
75885 TC 3 XXX 0 X 1,041.27 X
75885 TC 2 XXX 0 X 1,128.60 X
75885 TC 1 XXX 0 X 1,149.31 X
75885   4 XXX 0 X 1,205.86 X
75885   3 XXX 0 X 1,224.45 X
75885   2 XXX 0 X 1,321.68 X
75885   1 XXX 0 X 1,344.82 X
75887 26 4 XXX 0 X 198.98 X
75887 26 3 XXX 0 X 204.23 X
75887 26 2 XXX 0 X 213.48 X
75887 26 1 XXX 0 X 214.10 X
75887 TC 4 XXX 0 X 1,024.73 X
75887 TC 3 XXX 0 X 1,041.27 X
75887 TC 2 XXX 0 X 1,128.60 X
75887 TC 1 XXX 0 X 1,149.31 X
75887   4 XXX 0 X 1,205.86 X
75887   3 XXX 0 X 1,224.45 X
75887   2 XXX 0 X 1,321.68 X
75887   1 XXX 0 X 1,344.82 X
75889 26 4 XXX 0 X 157.23 X
75889 26 3 XXX 0 X 161.38 X
75889 26 2 XXX 0 X 168.71 X
75889 26 1 XXX 0 X 169.27 X
75889 TC 4 XXX 0 X 1,024.73 X
75889 TC 3 XXX 0 X 1,041.27 X
75889 TC 2 XXX 0 X 1,128.60 X
75889 TC 1 XXX 0 X 1,149.31 X
75889   4 XXX 0 X 1,167.37 X
75889   3 XXX 0 X 1,185.48 X
75889   2 XXX 0 X 1,280.73 X
75889   1 XXX 0 X 1,303.27 X
75891 26 4 XXX 0 X 157.23 X
75891 26 3 XXX 0 X 161.38 X
75891 26 2 XXX 0 X 168.71 X
75891 26 1 XXX 0 X 169.27 X
75891 TC 4 XXX 0 X 1,024.73 X
75891 TC 3 XXX 0 X 1,041.27 X
75891 TC 2 XXX 0 X 1,128.60 X
75891 TC 1 XXX 0 X 1,149.31 X
75891   4 XXX 0 X 1,167.37 X
75891   3 XXX 0 X 1,185.48 X
75891   2 XXX 0 X 1,280.73 X
75891   1 XXX 0 X 1,303.27 X
75893 26 4 XXX 0 X 76.10 X
75893 26 3 XXX 0 X 78.24 X
75893 26 2 XXX 0 X 81.67 X
75893 26 1 XXX 0 X 81.85 X
75893 TC 4 XXX 0 X 1,024.73 X
75893 TC 3 XXX 0 X 1,041.27 X
75893   4 XXX 0 X 1,093.60 X
75893   3 XXX 0 X 1,110.90 X
75893 TC 2 XXX 0 X 1,128.60 X
75893 TC 1 XXX 0 X 1,149.31 X
75893   2 XXX 0 X 1,202.05 X
75893   1 XXX 0 X 1,223.72 X
75894 26 4 XXX 0 X 180.78 X
75894 26 3 XXX 0 X 185.52 X
75894 26 2 XXX 0 X 193.95 X
75894 26 1 XXX 0 X 194.52 X
75894 TC 4 XXX 0 X 1,963.72 X
75894 TC 3 XXX 0 X 1,995.39 X
75894   4 XXX 0 X 2,127.62 X
75894   3 XXX 0 X 2,161.12 X
75894 TC 2 XXX 0 X 2,162.90 X
75894 TC 1 XXX 0 X 2,202.56 X
75894   2 XXX 0 X 2,337.62 X
75894   1 XXX 0 X 2,379.50 X
75898 TC 4 XXX 0 X 85.82 X
75898 TC 3 XXX 0 X 87.22 X
75898 TC 2 XXX 0 X 94.72 X
75898 TC 1 XXX 0 X 96.56 X
75898 26 4 XXX 0 X 228.02 X
75898 26 3 XXX 0 X 234.23 X
75898 26 2 XXX 0 X 244.61 X
75898 26 1 XXX 0 X 245.29 X
75898   4 XXX 0 X 310.88 X
75898   3 XXX 0 X 319.15 X
75898   2 XXX 0 X 334.88 X
75898   1 XXX 0 X 336.22 X
75901 26 2 XXX 0 X 45.86 X
75901 26 3 XXX 0 X 45.86 X
75901 26 4 XXX 0 X 45.86 X
75901 26 1 XXX 0 X 49.80 X
75901 TC 2 XXX 0 X 121.29 X
75901 TC 3 XXX 0 X 121.29 X
75901 TC 4 XXX 0 X 121.29 X
75901 TC 1 XXX 0 X 166.78 X
75901   2 XXX 0 X 167.14 X
75901   3 XXX 0 X 167.14 X
75901   4 XXX 0 X 167.14 X
75901   1 XXX 0 X 216.54 X
75902 26 2 XXX 0 X 36.36 X
75902 26 3 XXX 0 X 36.36 X
75902 26 4 XXX 0 X 36.36 X
75902 26 1 XXX 0 X 39.63 X
75902 TC 2 XXX 0 X 121.29 X
75902 TC 3 XXX 0 X 121.29 X
75902 TC 4 XXX 0 X 121.29 X
75902   2 XXX 0 X 157.65 X
75902   3 XXX 0 X 157.65 X
75902   4 XXX 0 X 157.65 X
75902 TC 1 XXX 0 X 166.78 X
75902   1 XXX 0 X 206.37 X