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Health Care Services Review
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Fee Schedule
>
Fee Schedule 75952-76519
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
75956-76519
View the PDF
CPT/HCPC Code
Modifier
Medicare Location
Global Surgery Indicator
Multiple Surgery Indicator
Prevailing Charge Amount
Fee Schedule Amount
Site of Service Amount
75956
26
002
XXX
0
X
727.19
X
75956
26
003
XXX
0
X
727.19
X
75956
26
004
XXX
0
X
727.19
X
75956
26
001
XXX
0
X
804.25
X
75957
26
001
XXX
0
X
688.96
X
75957
26
003
XXX
0
X
623.01
X
75957
26
002
XXX
0
X
623.01
X
75957
26
004
XXX
0
X
623.01
X
75958
26
001
XXX
0
X
459.26
X
75958
26
002
XXX
0
X
415.37
X
75958
26
003
XXX
0
X
415.37
X
75958
26
004
XXX
0
X
415.37
X
75959
26
004
XXX
0
X
363.62
X
75959
26
003
XXX
0
X
363.62
X
75959
26
002
XXX
0
X
363.62
X
75959
26
001
XXX
0
X
402.02
X
75970
002
XXX
0
X
1,343.17
X
75970
26
002
XXX
0
X
143.81
X
75970
TC
002
XXX
0
X
1,211.92
X
75970
003
XXX
0
X
1,242.35
X
75970
26
003
XXX
0
X
137.54
X
75970
TC
003
XXX
0
X
1,118.05
X
75970
004
XXX
0
X
1,223.28
X
75970
26
004
XXX
0
X
134.07
X
75970
TC
004
XXX
0
X
1,100.30
X
75970
001
XXX
0
X
1,367.01
X
75970
26
001
XXX
0
X
144.32
X
75970
TC
001
XXX
0
X
1,234.25
X
75984
002
XXX
0
X
318.77
X
75984
26
002
XXX
0
X
125.72
X
75984
TC
002
XXX
0
X
205.15
X
75984
003
XXX
0
X
304.74
X
75984
26
003
XXX
0
X
120.27
X
75984
TC
003
XXX
0
X
189.21
X
75984
004
XXX
0
X
296.85
X
75984
26
004
XXX
0
X
117.18
X
75984
TC
004
XXX
0
X
186.13
X
75984
001
XXX
0
X
324.02
X
75984
26
001
XXX
0
X
126.05
X
75984
TC
001
XXX
0
X
208.92
X
75989
004
XXX
0
X
443.93
X
75989
26
004
XXX
0
X
158.50
X
75989
TC
004
XXX
0
X
285.47
X
75989
003
XXX
0
X
443.93
X
75989
26
003
XXX
0
X
158.50
X
75989
TC
003
XXX
0
X
285.47
X
75989
002
XXX
0
X
443.93
X
75989
26
002
XXX
0
X
158.50
X
75989
TC
002
XXX
0
X
285.47
X
75989
001
XXX
0
X
518.76
X
75989
26
001
XXX
0
X
174.94
X
75989
TC
001
XXX
0
X
343.75
X
76000
002
XXX
0
X
161.93
X
76000
26
002
XXX
0
X
27.73
X
76000
TC
002
XXX
0
X
136.46
X
76000
004
XXX
0
X
147.84
X
76000
26
004
XXX
0
X
26.04
X
76000
TC
004
XXX
0
X
123.86
X
76000
003
XXX
0
X
150.06
X
76000
26
003
XXX
0
X
26.48
X
76000
TC
003
XXX
0
X
125.78
X
76000
001
XXX
0
X
164.82
X
76000
26
001
XXX
0
X
27.76
X
76000
TC
001
XXX
0
X
138.94
X
76010
004
XXX
0
X
77.13
X
76010
26
004
XXX
0
X
28.69
X
76010
TC
004
XXX
0
X
50.23
X
76010
001
XXX
0
X
84.08
X
76010
26
001
XXX
0
X
30.84
X
76010
TC
001
XXX
0
X
56.30
X
76010
002
XXX
0
X
82.86
X
76010
26
002
XXX
0
X
30.71
X
76010
TC
002
XXX
0
X
55.23
X
76010
003
XXX
0
X
79.14
X
76010
26
003
XXX
0
X
29.40
X
76010
TC
003
XXX
0
X
51.08
X
76080
001
XXX
0
X
200.26
X
76080
26
001
XXX
0
X
95.91
X
76080
TC
001
XXX
0
X
113.15
X
76080
003
XXX
0
X
191.06
X
76080
26
003
XXX
0
X
91.49
X
76080
TC
003
XXX
0
X
102.21
X
76080
004
XXX
0
X
186.04
X
76080
26
004
XXX
0
X
90.72
X
76080
TC
004
XXX
0
X
100.56
X
76080
002
XXX
0
X
201.28
X
76080
26
002
XXX
0
X
95.70
X
76080
TC
002
XXX
0
X
111.00
X
76098
001
XXX
0
X
69.97
X
76098
26
001
XXX
0
X
26.31
X
76098
TC
001
XXX
0
X
45.15
X
76098
004
XXX
0
X
63.09
X
76098
26
004
XXX
0
X
24.69
X
76098
TC
004
XXX
0
X
40.05
X
76098
003
XXX
0
X
64.86
X
76098
26
003
XXX
0
X
25.20
X
76098
TC
003
XXX
0
X
40.66
X
76098
002
XXX
0
X
68.84
X
76098
26
002
XXX
0
X
26.27
X
76098
TC
002
XXX
0
X
44.31
X
76100
001
XXX
0
X
227.14
X
76100
26
001
XXX
0
X
102.71
X
76100
TC
001
XXX
0
X
133.88
X
76100
004
XXX
0
X
205.62
X
76100
26
004
XXX
0
X
96.04
X
76100
TC
004
XXX
0
X
119.18
X
76100
003
XXX
0
X
208.46
X
76100
26
003
XXX
0
X
98.06
X
76100
TC
003
XXX
0
X
121.10
X
76100
002
XXX
0
X
223.54
X
76100
26
002
XXX
0
X
102.42
X
76100
TC
002
XXX
0
X
131.42
X
76120
001
XXX
0
X
173.40
X
76120
26
001
XXX
0
X
65.63
X
76120
TC
001
XXX
0
X
113.15
X
76120
002
XXX
0
X
170.51
X
76120
26
002
XXX
0
X
65.35
X
76120
TC
002
XXX
0
X
111.00
X
76120
003
XXX
0
X
162.26
X
76120
26
003
XXX
0
X
62.54
X
76120
TC
003
XXX
0
X
102.21
X
76120
004
XXX
0
X
156.29
X
76120
26
004
XXX
0
X
60.95
X
76120
TC
004
XXX
0
X
100.56
X
76125
001
ZZZ
0
X
127.30
X
76125
26
001
ZZZ
0
X
46.08
X
76125
TC
001
ZZZ
0
X
84.69
X
76125
002
ZZZ
0
X
125.18
X
76125
26
002
ZZZ
0
X
45.93
X
76125
TC
002
ZZZ
0
X
83.13
X
76125
003
ZZZ
0
X
118.50
X
76125
26
003
ZZZ
0
X
43.86
X
76125
TC
003
ZZZ
0
X
76.62
X
76125
004
ZZZ
0
X
114.82
X
76125
26
004
ZZZ
0
X
42.81
X
76125
TC
004
ZZZ
0
X
75.40
X
76140
XXX
9
X
*
X
76145
004
XXX
0
X
1,053.44
X
76145
003
XXX
0
X
1,053.44
X
76145
002
XXX
0
X
1,053.44
X
76145
001
XXX
0
X
1,219.36
X
76376
004
XXX
0
X
249.96
X
76376
26
004
XXX
0
X
20.27
X
76376
TC
004
XXX
0
X
229.64
X
76376
002
XXX
0
X
249.96
X
76376
26
002
XXX
0
X
20.27
X
76376
TC
002
XXX
0
X
229.64
X
76376
003
XXX
0
X
249.96
X
76376
26
003
XXX
0
X
20.27
X
76376
TC
003
XXX
0
X
229.64
X
76376
001
XXX
0
X
305.81
X
76376
26
001
XXX
0
X
22.42
X
76376
TC
001
XXX
0
X
283.42
X
76377
003
XXX
0
X
322.96
X
76377
26
003
XXX
0
X
79.82
X
76377
TC
003
XXX
0
X
243.16
X
76377
002
XXX
0
X
322.96
X
76377
26
002
XXX
0
X
79.82
X
76377
TC
002
XXX
0
X
243.16
X
76377
001
XXX
0
X
394.69
X
76377
26
001
XXX
0
X
88.12
X
76377
TC
001
XXX
0
X
306.59
X
76377
004
XXX
0
X
322.96
X
76377
26
004
XXX
0
X
79.82
X
76377
TC
004
XXX
0
X
243.16
X
76380
004
XXX
0
X
478.28
X
76380
26
004
XXX
0
X
144.09
X
76380
TC
004
XXX
0
X
334.17
X
76380
003
XXX
0
X
485.22
X
76380
26
003
XXX
0
X
145.61
X
76380
TC
003
XXX
0
X
339.60
X
76380
002
XXX
0
X
521.70
X
76380
26
002
XXX
0
X
153.65
X
76380
TC
002
XXX
0
X
368.04
X
76380
001
XXX
0
X
530.36
X
76380
26
001
XXX
0
X
155.57
X
76380
TC
001
XXX
0
X
374.70
X
76390
004
XXX
9
X
1,207.04
X
76390
002
XXX
9
X
1,207.04
X
76390
003
XXX
9
X
1,207.04
X
76390
001
XXX
9
X
1,434.76
X
76391
004
XXX
4
X
315.02
X
76391
26
004
XXX
4
X
77.62
X
76391
TC
004
XXX
4
X
237.40
X
76391
003
XXX
4
X
315.02
X
76391
26
003
XXX
4
X
77.62
X
76391
TC
003
XXX
4
X
237.40
X
76391
002
XXX
4
X
315.02
X
76391
26
002
XXX
4
X
77.62
X
76391
TC
002
XXX
4
X
237.40
X
76391
001
XXX
4
X
355.25
X
76391
26
001
XXX
4
X
82.76
X
76391
TC
001
XXX
4
X
272.51
X
76496
XXX
0
X
#
X
76497
XXX
0
X
#
X
76498
XXX
0
X
#
X
76499
XXX
0
X
#
X
76506
001
XXX
0
X
251.98
X
76506
26
001
XXX
0
X
110.44
X
76506
TC
001
XXX
0
X
151.63
X
76506
003
XXX
0
X
239.56
X
76506
26
003
XXX
0
X
106.35
X
76506
TC
003
XXX
0
X
137.14
X
76506
002
XXX
0
X
252.35
X
76506
26
002
XXX
0
X
110.14
X
76506
TC
002
XXX
0
X
148.81
X
76506
004
XXX
0
X
233.23
X
76506
26
004
XXX
0
X
105.13
X
76506
TC
004
XXX
0
X
134.98
X
76510
004
XXX
7
X
336.86
X
76510
26
004
XXX
7
X
174.13
X
76510
TC
004
XXX
7
X
162.76
X
76510
003
XXX
7
X
336.86
X
76510
26
003
XXX
7
X
174.13
X
76510
TC
003
XXX
7
X
162.76
X
76510
002
XXX
7
X
336.86
X
76510
26
002
XXX
7
X
174.13
X
76510
TC
002
XXX
7
X
162.76
X
76510
001
XXX
7
X
385.18
X
76510
26
001
XXX
7
X
187.80
X
76510
TC
001
XXX
7
X
197.43
X
76511
002
XXX
7
X
241.69
X
76511
26
002
XXX
7
X
115.65
X
76511
TC
002
XXX
7
X
131.42
X
76511
003
XXX
7
X
229.87
X
76511
26
003
XXX
7
X
110.91
X
76511
TC
003
XXX
7
X
121.10
X
76511
004
XXX
7
X
224.12
X
76511
26
004
XXX
7
X
108.41
X
76511
TC
004
XXX
7
X
119.18
X
76511
001
XXX
7
X
261.55
X
76511
26
001
XXX
7
X
116.01
X
76511
TC
001
XXX
7
X
133.88
X
76512
001
XXX
7
X
270.32
X
76512
26
001
XXX
7
X
115.99
X
76512
TC
001
XXX
7
X
164.29
X
76512
004
XXX
7
X
248.55
X
76512
26
004
XXX
7
X
108.05
X
76512
TC
004
XXX
7
X
146.16
X
76512
003
XXX
7
X
255.15
X
76512
26
003
XXX
7
X
111.61
X
76512
TC
003
XXX
7
X
148.51
X
76512
002
XXX
7
X
269.10
X
76512
26
002
XXX
7
X
115.52
X
76512
TC
002
XXX
7
X
161.28
X
76513
002
XXX
7
X
269.10
X
76513
003
XXX
7
X
255.15
X
76513
004
XXX
7
X
248.55
X
76513
001
XXX
7
X
270.32
X
76513
26
003
XXX
7
X
110.49
X
76513
TC
003
XXX
7
X
148.51
X
76513
26
004
XXX
7
X
107.67
X
76513
TC
004
XXX
7
X
146.16
X
76513
26
001
XXX
7
X
115.99
X
76513
TC
001
XXX
7
X
164.29
X
76513
26
002
XXX
7
X
115.29
X
76513
TC
002
XXX
7
X
161.28
X
76514
001
XXX
7
X
28.77
X
76514
26
001
XXX
7
X
22.32
X
76514
TC
001
XXX
7
X
6.44
X
76514
002
XXX
7
X
25.59
X
76514
26
002
XXX
7
X
20.45
X
76514
TC
002
XXX
7
X
5.16
X
76514
003
XXX
7
X
25.59
X
76514
26
003
XXX
7
X
20.45
X
76514
TC
003
XXX
7
X
5.16
X
76514
004
XXX
7
X
25.59
X
76514
26
004
XXX
7
X
20.45
X
76514
TC
004
XXX
7
X
5.16
X
76516
004
XXX
7
X
204.40
X
76516
26
004
XXX
7
X
89.47
X
76516
TC
004
XXX
7
X
119.18
X
76516
003
XXX
7
X
209.82
X
76516
26
003
XXX
7
X
92.64
X
76516
TC
003
XXX
7
X
121.10
X
76516
002
XXX
7
X
221.21
X
76516
26
002
XXX
7
X
95.04
X
76516
TC
002
XXX
7
X
131.42
X
76516
001
XXX
7
X
221.04
X
76516
26
001
XXX
7
X
95.42
X
76516
TC
001
XXX
7
X
133.88
X
76519
001
XXX
7
X
221.04
X
76519
26
001
XXX
7
X
95.42
X
76519
TC
001
XXX
7
X
133.88
X
76519
002
XXX
7
X
221.21
X
76519
26
002
XXX
7
X
95.11
X
76519
003
XXX
7
X
209.82
X
76519
26
003
XXX
7
X
90.91
X
76519
004
XXX
7
X
204.40
X
76519
26
004
XXX
7
X
88.94
X
76519
TC
002
XXX
7
X
131.42
X
76519
TC
003
XXX
7
X
121.10
X
76519
TC
004
XXX
7
X
119.18
X
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