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2024 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   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