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2020 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 154.28 X
75726 26 4 XXX 0 X 154.95 X
75726 26 2 XXX 0 X 161.29 X
75726 26 1 XXX 0 X 161.83 X
75726 TC 4 XXX 0 X 979.67 X
75726 TC 3 XXX 0 X 995.48 X
75726 TC 2 XXX 0 X 1,078.97 X
75726 TC 1 XXX 0 X 1,098.77 X
75726   4 XXX 0 X 1,116.03 X
75726   3 XXX 0 X 1,133.35 X
75726   2 XXX 0 X 1,224.41 X
75726   1 XXX 0 X 1,245.96 X
75731 26 4 XXX 0 X 150.32 X
75731 26 3 XXX 0 X 154.28 X
75731 26 2 XXX 0 X 161.29 X
75731 26 1 XXX 0 X 161.83 X
75731 TC 4 XXX 0 X 979.67 X
75731 TC 3 XXX 0 X 995.48 X
75731 TC 2 XXX 0 X 1,078.97 X
75731 TC 1 XXX 0 X 1,098.77 X
75731   4 XXX 0 X 1,116.03 X
75731   3 XXX 0 X 1,133.35 X
75731   2 XXX 0 X 1,224.41 X
75731   1 XXX 0 X 1,245.96 X
75733 26 4 XXX 0 X 172.83 X
75733 26 3 XXX 0 X 177.36 X
75733 26 2 XXX 0 X 185.42 X
75733 26 1 XXX 0 X 185.97 X
75733 TC 4 XXX 0 X 979.67 X
75733 TC 3 XXX 0 X 995.48 X
75733 TC 2 XXX 0 X 1,078.97 X
75733 TC 1 XXX 0 X 1,098.77 X
75733   4 XXX 0 X 1,136.40 X
75733   3 XXX 0 X 1,153.94 X
75733   2 XXX 0 X 1,246.02 X
75733   1 XXX 0 X 1,267.91 X
75736 26 4 XXX 0 X 150.32 X
75736 26 3 XXX 0 X 154.28 X
75736 26 2 XXX 0 X 161.29 X
75736 26 1 XXX 0 X 161.83 X
75736 TC 4 XXX 0 X 979.67 X
75736 TC 3 XXX 0 X 995.48 X
75736 TC 2 XXX 0 X 1,078.97 X
75736 TC 1 XXX 0 X 1,098.77 X
75736   4 XXX 0 X 1,116.03 X
75736   3 XXX 0 X 1,133.35 X
75736   2 XXX 0 X 1,224.41 X
75736   1 XXX 0 X 1,245.96 X
75741 26 4 XXX 0 X 172.83 X
75741 26 3 XXX 0 X 177.36 X
75741 26 2 XXX 0 X 185.42 X
75741 26 1 XXX 0 X 185.97 X
75741 TC 4 XXX 0 X 979.67 X
75741 TC 3 XXX 0 X 995.48 X
75741 TC 2 XXX 0 X 1,078.97 X
75741 TC 1 XXX 0 X 1,098.77 X
75741   4 XXX 0 X 1,136.40 X
75741   3 XXX 0 X 1,153.94 X
75741   2 XXX 0 X 1,246.02 X
75741   1 XXX 0 X 1,267.91 X
75743 26 4 XXX 0 X 218.82 X
75743 26 3 XXX 0 X 224.53 X
75743 26 2 XXX 0 X 234.65 X
75743 26 1 XXX 0 X 235.35 X
75743 TC 4 XXX 0 X 979.67 X
75743 TC 3 XXX 0 X 995.48 X
75743 TC 2 XXX 0 X 1,078.97 X
75743 TC 1 XXX 0 X 1,098.77 X
75743   4 XXX 0 X 1,178.70 X
75743   3 XXX 0 X 1,196.72 X
75743   2 XXX 0 X 1,291.02 X
75743   1 XXX 0 X 1,313.39 X
75746 26 4 XXX 0 X 151.45 X
75746 26 3 XXX 0 X 154.28 X
75746 26 2 XXX 0 X 161.29 X
75746 26 1 XXX 0 X 161.83 X
75746 TC 4 XXX 0 X 979.67 X
75746 TC 3 XXX 0 X 995.48 X
75746 TC 2 XXX 0 X 1,078.97 X
75746 TC 1 XXX 0 X 1,098.77 X
75746   4 XXX 0 X 1,116.03 X
75746   3 XXX 0 X 1,133.35 X
75746   2 XXX 0 X 1,224.41 X
75746   1 XXX 0 X 1,245.96 X
75756 26 4 XXX 0 X 150.32 X
75756 26 3 XXX 0 X 154.28 X
75756 26 2 XXX 0 X 161.29 X
75756 26 1 XXX 0 X 161.83 X
75756 TC 4 XXX 0 X 979.67 X
75756 TC 3 XXX 0 X 995.48 X
75756 TC 2 XXX 0 X 1,078.97 X
75756 TC 1 XXX 0 X 1,098.77 X
75756   4 XXX 0 X 1,116.03 X
75756   3 XXX 0 X 1,133.35 X
75756   2 XXX 0 X 1,224.41 X
75756   1 XXX 0 X 1,245.96 X
75774 26 3 ZZZ 0 X 47.20 X
75774 26 4 ZZZ 0 X 47.71 X
75774 26 2 ZZZ 0 X 49.26 X
75774 26 1 ZZZ 0 X 49.35 X
75774 TC 4 ZZZ 0 X 979.67 X
75774 TC 3 ZZZ 0 X 995.48 X
75774   4 ZZZ 0 X 1,022.01 X
75774   3 ZZZ 0 X 1,038.30 X
75774 TC 2 ZZZ 0 X 1,078.97 X
75774 TC 1 ZZZ 0 X 1,098.77 X
75774   2 ZZZ 0 X 1,123.98 X
75774   1 ZZZ 0 X 1,144.22 X
75801 26 4 XXX 0 X 106.73 X
75801 26 3 XXX 0 X 109.51 X
75801 26 2 XXX 0 X 114.39 X
75801 26 1 XXX 0 X 114.74 X
75801 TC 4 XXX 0 X 421.52 X
75801 TC 3 XXX 0 X 428.28 X
75801 TC 2 XXX 0 X 464.31 X
75801 TC 1 XXX 0 X 472.86 X
75801   4 XXX 0 X 518.65 X
75801   3 XXX 0 X 526.52 X
75801   2 XXX 0 X 567.68 X
75801   1 XXX 0 X 577.50 X
75803 26 4 XXX 0 X 153.55 X
75803 26 3 XXX 0 X 157.59 X
75803 26 2 XXX 0 X 164.71 X
75803 26 1 XXX 0 X 165.21 X
75803 TC 4 XXX 0 X 421.52 X
75803 TC 3 XXX 0 X 428.28 X
75803 TC 2 XXX 0 X 464.31 X
75803 TC 1 XXX 0 X 472.86 X
75803   4 XXX 0 X 560.97 X
75803   3 XXX 0 X 569.35 X
75803   2 XXX 0 X 612.97 X
75803   1 XXX 0 X 623.37 X
75805 26 4 XXX 0 X 106.73 X
75805 26 3 XXX 0 X 109.51 X
75805 26 2 XXX 0 X 114.39 X
75805 26 1 XXX 0 X 114.74 X
75805 TC 4 XXX 0 X 473.89 X
75805 TC 3 XXX 0 X 481.51 X
75805 TC 2 XXX 0 X 522.01 X
75805 TC 1 XXX 0 X 531.62 X
75805   4 XXX 0 X 571.06 X
75805   3 XXX 0 X 579.78 X
75805   2 XXX 0 X 625.37 X
75805   1 XXX 0 X 636.22 X
75807 26 4 XXX 0 X 153.55 X
75807 26 3 XXX 0 X 157.59 X
75807 26 2 XXX 0 X 164.71 X
75807 26 1 XXX 0 X 165.21 X
75807 TC 4 XXX 0 X 473.89 X
75807 TC 3 XXX 0 X 481.51 X
75807 TC 2 XXX 0 X 522.01 X
75807 TC 1 XXX 0 X 531.62 X
75807   4 XXX 0 X 613.37 X
75807   3 XXX 0 X 622.61 X
75807   2 XXX 0 X 670.71 X
75807   1 XXX 0 X 682.11 X
75809 26 4 XXX 0 X 54.91 X
75809 26 3 XXX 0 X 55.45 X
75809 26 2 XXX 0 X 58.40 X
75809 26 1 XXX 0 X 59.12 X
75809 TC 4 XXX 0 X 61.51 X
75809 TC 3 XXX 0 X 62.50 X
75809 TC 2 XXX 0 X 67.82 X
75809 TC 1 XXX 0 X 69.09 X
75809   4 XXX 0 X 116.45 X
75809   3 XXX 0 X 118.03 X
75809   2 XXX 0 X 126.16 X
75809   1 XXX 0 X 128.20 X
75810 26 4 XXX 0 X 150.32 X
75810 26 3 XXX 0 X 154.28 X
75810 26 2 XXX 0 X 161.29 X
75810 26 1 XXX 0 X 161.83 X
75810 TC 4 XXX 0 X 979.67 X
75810 TC 3 XXX 0 X 995.48 X
75810 TC 2 XXX 0 X 1,078.97 X
75810 TC 1 XXX 0 X 1,098.77 X
75810   4 XXX 0 X 1,116.03 X
75810   3 XXX 0 X 1,133.35 X
75810   2 XXX 0 X 1,224.41 X
75810   1 XXX 0 X 1,245.96 X
75820 TC 4 XXX 0 X 73.68 X
75820 TC 3 XXX 0 X 74.84 X
75820 TC 2 XXX 0 X 81.24 X
75820 TC 1 XXX 0 X 82.73 X
75820 26 4 XXX 0 X 93.13 X
75820 26 3 XXX 0 X 95.18 X
75820 26 2 XXX 0 X 99.53 X
75820 26 1 XXX 0 X 99.83 X
75820   4 XXX 0 X 158.31 X
75820   3 XXX 0 X 160.37 X
75820   2 XXX 0 X 171.54 X
75820   1 XXX 0 X 174.14 X
75822 TC 4 XXX 0 X 115.44 X
75822 TC 3 XXX 0 X 117.29 X
75822 TC 2 XXX 0 X 127.17 X
75822 TC 1 XXX 0 X 129.49 X
75822 26 4 XXX 0 X 139.05 X
75822 26 3 XXX 0 X 142.72 X
75822 26 2 XXX 0 X 149.14 X
75822 26 1 XXX 0 X 149.58 X
75822   4 XXX 0 X 242.37 X
75822   3 XXX 0 X 245.66 X
75822   2 XXX 0 X 262.33 X
75822   1 XXX 0 X 266.33 X
75825 26 4 XXX 0 X 150.32 X
75825 26 3 XXX 0 X 154.28 X
75825 26 2 XXX 0 X 161.29 X
75825 26 1 XXX 0 X 161.83 X
75825 TC 4 XXX 0 X 979.67 X
75825 TC 3 XXX 0 X 995.48 X
75825 TC 2 XXX 0 X 1,078.97 X
75825 TC 1 XXX 0 X 1,098.77 X
75825   4 XXX 0 X 1,116.03 X
75825   3 XXX 0 X 1,133.35 X
75825   2 XXX 0 X 1,224.41 X
75825   1 XXX 0 X 1,245.96 X
75827 26 3 XXX 0 X 154.28 X
75827 26 4 XXX 0 X 157.23 X
75827 26 2 XXX 0 X 161.29 X
75827 26 1 XXX 0 X 161.83 X
75827 TC 4 XXX 0 X 979.67 X
75827 TC 3 XXX 0 X 995.48 X
75827 TC 2 XXX 0 X 1,078.97 X
75827 TC 1 XXX 0 X 1,098.77 X
75827   4 XXX 0 X 1,116.03 X
75827   3 XXX 0 X 1,133.35 X
75827   2 XXX 0 X 1,224.41 X
75827   1 XXX 0 X 1,245.96 X
75831 26 4 XXX 0 X 150.32 X
75831 26 3 XXX 0 X 154.28 X
75831 26 2 XXX 0 X 161.29 X
75831 26 1 XXX 0 X 161.83 X
75831 TC 4 XXX 0 X 979.67 X
75831 TC 3 XXX 0 X 995.48 X
75831 TC 2 XXX 0 X 1,078.97 X
75831 TC 1 XXX 0 X 1,098.77 X
75831   4 XXX 0 X 1,116.03 X
75831   3 XXX 0 X 1,133.35 X
75831   2 XXX 0 X 1,224.41 X
75831   1 XXX 0 X 1,245.96 X
75833 26 4 XXX 0 X 196.16 X
75833 26 3 XXX 0 X 201.28 X
75833 26 2 XXX 0 X 210.42 X
75833 26 1 XXX 0 X 211.05 X
75833 TC 4 XXX 0 X 979.67 X
75833 TC 3 XXX 0 X 995.48 X
75833 TC 2 XXX 0 X 1,078.97 X
75833 TC 1 XXX 0 X 1,098.77 X
75833   4 XXX 0 X 1,158.32 X
75833   3 XXX 0 X 1,176.15 X
75833   2 XXX 0 X 1,269.33 X
75833   1 XXX 0 X 1,291.45 X
75840 26 4 XXX 0 X 150.32 X
75840 26 3 XXX 0 X 154.28 X
75840 26 2 XXX 0 X 161.29 X
75840 26 1 XXX 0 X 161.83 X
75840 TC 4 XXX 0 X 979.67 X
75840 TC 3 XXX 0 X 995.48 X
75840 TC 2 XXX 0 X 1,078.97 X
75840 TC 1 XXX 0 X 1,098.77 X
75840   4 XXX 0 X 1,116.03 X
75840   3 XXX 0 X 1,133.35 X
75840   2 XXX 0 X 1,224.41 X
75840   1 XXX 0 X 1,245.96 X
75842 26 4 XXX 0 X 196.16 X
75842 26 3 XXX 0 X 201.28 X
75842 26 2 XXX 0 X 210.42 X
75842 26 1 XXX 0 X 211.05 X
75842 TC 4 XXX 0 X 979.67 X
75842 TC 3 XXX 0 X 995.48 X
75842 TC 2 XXX 0 X 1,078.97 X
75842 TC 1 XXX 0 X 1,098.77 X
75842   4 XXX 0 X 1,158.32 X
75842   3 XXX 0 X 1,176.15 X
75842   2 XXX 0 X 1,269.33 X
75842   1 XXX 0 X 1,291.45 X
75860 26 4 XXX 0 X 150.32 X
75860 26 3 XXX 0 X 154.28 X
75860 26 2 XXX 0 X 161.29 X
75860 26 1 XXX 0 X 161.83 X
75860 TC 4 XXX 0 X 979.67 X
75860 TC 3 XXX 0 X 995.48 X
75860 TC 2 XXX 0 X 1,078.97 X
75860 TC 1 XXX 0 X 1,098.77 X
75860   4 XXX 0 X 1,116.03 X
75860   3 XXX 0 X 1,133.35 X
75860   2 XXX 0 X 1,224.41 X
75860   1 XXX 0 X 1,245.96 X
75870 26 4 XXX 0 X 150.32 X
75870 26 3 XXX 0 X 154.28 X
75870 26 2 XXX 0 X 161.29 X
75870 26 1 XXX 0 X 161.83 X
75870 TC 4 XXX 0 X 979.67 X
75870 TC 3 XXX 0 X 995.48 X
75870 TC 2 XXX 0 X 1,078.97 X
75870 TC 1 XXX 0 X 1,098.77 X
75870   4 XXX 0 X 1,116.03 X
75870   3 XXX 0 X 1,133.35 X
75870   2 XXX 0 X 1,224.41 X
75870   1 XXX 0 X 1,245.96 X
75872 26 4 XXX 0 X 150.32 X
75872 26 3 XXX 0 X 154.28 X
75872 26 2 XXX 0 X 161.29 X
75872 26 1 XXX 0 X 161.83 X
75872 TC 4 XXX 0 X 979.67 X
75872 TC 3 XXX 0 X 995.48 X
75872 TC 2 XXX 0 X 1,078.97 X
75872 TC 1 XXX 0 X 1,098.77 X
75872   4 XXX 0 X 1,116.03 X
75872   3 XXX 0 X 1,133.35 X
75872   2 XXX 0 X 1,224.41 X
75872   1 XXX 0 X 1,245.96 X
75880 TC 4 XXX 0 X 73.68 X
75880 TC 3 XXX 0 X 74.84 X
75880 TC 2 XXX 0 X 81.24 X
75880 TC 1 XXX 0 X 82.73 X
75880 26 4 XXX 0 X 92.75 X
75880 26 3 XXX 0 X 95.18 X
75880 26 2 XXX 0 X 99.53 X
75880 26 1 XXX 0 X 99.83 X
75880   4 XXX 0 X 158.31 X
75880   3 XXX 0 X 160.37 X
75880   2 XXX 0 X 171.54 X
75880   1 XXX 0 X 174.14 X
75885 26 4 XXX 0 X 190.23 X
75885 26 3 XXX 0 X 195.25 X
75885 26 2 XXX 0 X 204.09 X
75885 26 1 XXX 0 X 204.68 X
75885 TC 4 XXX 0 X 979.67 X
75885 TC 3 XXX 0 X 995.48 X
75885 TC 2 XXX 0 X 1,078.97 X
75885 TC 1 XXX 0 X 1,098.77 X
75885   4 XXX 0 X 1,152.83 X
75885   3 XXX 0 X 1,170.60 X
75885   2 XXX 0 X 1,263.56 X
75885   1 XXX 0 X 1,285.68 X
75887 26 4 XXX 0 X 190.23 X
75887 26 3 XXX 0 X 195.25 X
75887 26 2 XXX 0 X 204.09 X
75887 26 1 XXX 0 X 204.68 X
75887 TC 4 XXX 0 X 979.67 X
75887 TC 3 XXX 0 X 995.48 X
75887 TC 2 XXX 0 X 1,078.97 X
75887 TC 1 XXX 0 X 1,098.77 X
75887   4 XXX 0 X 1,152.83 X
75887   3 XXX 0 X 1,170.60 X
75887   2 XXX 0 X 1,263.56 X
75887   1 XXX 0 X 1,285.68 X
75889 26 4 XXX 0 X 150.32 X
75889 26 3 XXX 0 X 154.28 X
75889 26 2 XXX 0 X 161.29 X
75889 26 1 XXX 0 X 161.83 X
75889 TC 4 XXX 0 X 979.67 X
75889 TC 3 XXX 0 X 995.48 X
75889 TC 2 XXX 0 X 1,078.97 X
75889 TC 1 XXX 0 X 1,098.77 X
75889   4 XXX 0 X 1,116.03 X
75889   3 XXX 0 X 1,133.35 X
75889   2 XXX 0 X 1,224.41 X
75889   1 XXX 0 X 1,245.96 X
75891 26 4 XXX 0 X 150.32 X
75891 26 3 XXX 0 X 154.28 X
75891 26 2 XXX 0 X 161.29 X
75891 26 1 XXX 0 X 161.83 X
75891 TC 4 XXX 0 X 979.67 X
75891 TC 3 XXX 0 X 995.48 X
75891 TC 2 XXX 0 X 1,078.97 X
75891 TC 1 XXX 0 X 1,098.77 X
75891   4 XXX 0 X 1,116.03 X
75891   3 XXX 0 X 1,133.35 X
75891   2 XXX 0 X 1,224.41 X
75891   1 XXX 0 X 1,245.96 X
75893 26 4 XXX 0 X 72.75 X
75893 26 3 XXX 0 X 74.80 X
75893 26 2 XXX 0 X 78.08 X
75893 26 1 XXX 0 X 78.25 X
75893 TC 4 XXX 0 X 979.67 X
75893 TC 3 XXX 0 X 995.48 X
75893   4 XXX 0 X 1,045.51 X
75893   3 XXX 0 X 1,062.05 X
75893 TC 2 XXX 0 X 1,078.97 X
75893 TC 1 XXX 0 X 1,098.77 X
75893   2 XXX 0 X 1,149.19 X
75893   1 XXX 0 X 1,169.90 X
75894 26 4 XXX 0 X 172.83 X
75894 26 3 XXX 0 X 177.36 X
75894 26 2 XXX 0 X 185.42 X
75894 26 1 XXX 0 X 185.97 X
75894 TC 4 XXX 0 X 1,877.36 X
75894 TC 3 XXX 0 X 1,907.64 X
75894   4 XXX 0 X 2,034.05 X
75894   3 XXX 0 X 2,066.08 X
75894 TC 2 XXX 0 X 2,067.78 X
75894 TC 1 XXX 0 X 2,105.70 X
75894   2 XXX 0 X 2,234.82 X
75894   1 XXX 0 X 2,274.86 X
75898 TC 4 XXX 0 X 82.05 X
75898 TC 3 XXX 0 X 83.38 X
75898 TC 2 XXX 0 X 90.55 X
75898 TC 1 XXX 0 X 92.31 X
75898 26 4 XXX 0 X 217.99 X
75898 26 3 XXX 0 X 223.93 X
75898 26 2 XXX 0 X 233.85 X
75898 26 1 XXX 0 X 234.50 X
75898   4 XXX 0 X 297.21 X
75898   3 XXX 0 X 305.11 X
75898   2 XXX 0 X 320.15 X
75898   1 XXX 0 X 321.43 X
75901 26 2 XXX 0 X 43.84 X
75901 26 3 XXX 0 X 43.84 X
75901 26 4 XXX 0 X 43.84 X
75901 26 1 XXX 0 X 47.61 X
75901 TC 2 XXX 0 X 115.96 X
75901 TC 3 XXX 0 X 115.96 X
75901 TC 4 XXX 0 X 115.96 X
75901 TC 1 XXX 0 X 159.45 X
75901   2 XXX 0 X 159.79 X
75901   3 XXX 0 X 159.79 X
75901   4 XXX 0 X 159.79 X
75901   1 XXX 0 X 207.02 X
75902 26 2 XXX 0 X 34.76 X
75902 26 3 XXX 0 X 34.76 X
75902 26 4 XXX 0 X 34.76 X
75902 26 1 XXX 0 X 37.89 X
75902 TC 2 XXX 0 X 115.96 X
75902 TC 3 XXX 0 X 115.96 X
75902 TC 4 XXX 0 X 115.96 X
75902   2 XXX 0 X 150.72 X
75902   3 XXX 0 X 150.72 X
75902   4 XXX 0 X 150.72 X
75902 TC 1 XXX 0 X 159.45 X
75902   1 XXX 0 X 197.29 X