2020 workers' compensation part b fee schedule 90849-92134...90849-92134 cpt/hcpc code modifier...
TRANSCRIPT
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CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
90849 2 XXX 0 X 66.68 X
90849 3 XXX 0 X 66.68 X
90849 4 XXX 0 X 66.68 X
90849 1 XXX 0 X 73.25 X
90853 2 XXX 0 X 66.68 X
90853 3 XXX 0 X 66.68 X
90853 4 XXX 0 X 66.68 X
90853 1 XXX 0 X 73.25 X
90863 XXX 9 X * X
90865 2 XXX 0 X 258.33 X
90865 3 XXX 0 X 258.33 X
90865 4 XXX 0 X 258.33 X
90865 1 XXX 0 X 276.08 X
90867 0 0 X * X
90868 0 0 X * X
90869 2 0 0 X 623.87 166.10
90869 3 0 0 X 623.87 166.10
90869 4 0 0 X 623.87 166.10
90869 1 0 0 X 704.23 173.29
90870 4 0 0 X 208.83 X
90870 3 0 0 X 211.14 X
90870 2 0 0 X 220.76 X
90870 1 0 0 X 223.11 X
90875 XXX 9 X * X
90876 3 XXX 9 X 167.08 X
90876 4 XXX 9 X 167.08 X
90876 2 XXX 9 X 171.74 X
90876 1 XXX 9 X 182.30 X
90880 2 XXX 0 X 219.82 X
90880 3 XXX 0 X 219.82 X
90880 4 XXX 0 X 219.82 X
90880 1 XXX 0 X 237.76 X
90882 XXX 9 X * X
90885 XXX 9 X * X
90887 4 XXX 9 X 125.21 X
90887 2 XXX 9 X 142.40 X
90887 3 XXX 9 X 148.21 X
90887 1 XXX 9 X 152.42 X
90899 XXX 0 X # X
90901 3 0 0 X 51.44 X
2021 Workers' Compensation Part B Fee Schedule
90849-92134
-
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
90901 4 0 0 X 51.44 X
90901 2 0 0 X 52.82 X
90901 1 0 0 X 57.18 X
90912 2 0 0 X 92.93 52.56
90912 3 0 0 X 92.93 52.56
90912 4 0 0 X 92.93 52.56
90912 1 0 0 X 102.74 56.25
90913 2 ZZZ 0 X 38.00 29.20
90913 3 ZZZ 0 X 38.00 29.20
90913 4 ZZZ 0 X 38.00 29.20
90913 1 ZZZ 0 X 41.39 31.28
90935 4 0 0 X 265.84 X
90935 3 0 0 X 272.92 X
90935 1 0 0 X 276.87 X
90935 2 0 0 X 279.48 X
90937 4 0 0 X 554.55 X
90937 3 0 0 X 557.06 X
90937 2 0 0 X 564.15 X
90937 1 0 0 X 575.88 X
90940 XXX 9 X * X
90945 4 0 0 X 207.08 X
90945 1 0 0 X 207.59 X
90945 3 0 0 X 209.71 X
90945 2 0 0 X 221.25 X
90947 3 0 0 X 385.46 X
90947 4 0 0 X 407.30 X
90947 1 0 0 X 409.63 X
90947 2 0 0 X 419.84 X
90951 2 XXX 0 X 1,440.92 X
90951 3 XXX 0 X 1,440.92 X
90951 4 XXX 0 X 1,440.92 X
90951 1 XXX 0 X 1,547.23 X
90952 XXX 0 X * X
90953 XXX 0 X * X
90954 2 XXX 0 X 1,184.57 X
90954 3 XXX 0 X 1,184.57 X
90954 4 XXX 0 X 1,184.57 X
90954 1 XXX 0 X 1,265.52 X
90955 2 XXX 0 X 670.51 X
90955 3 XXX 0 X 670.51 X
90955 4 XXX 0 X 670.51 X
90955 1 XXX 0 X 718.61 X
90956 2 XXX 0 X 453.94 X
90956 3 XXX 0 X 453.94 X
-
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
90956 4 XXX 0 X 453.94 X
90956 1 XXX 0 X 486.33 X
90957 2 XXX 0 X 949.79 X
90957 3 XXX 0 X 949.79 X
90957 4 XXX 0 X 949.79 X
90957 1 XXX 0 X 1,016.72 X
90958 2 XXX 0 X 640.86 X
90958 3 XXX 0 X 640.86 X
90958 4 XXX 0 X 640.86 X
90958 1 XXX 0 X 687.10 X
90959 2 XXX 0 X 420.22 X
90959 3 XXX 0 X 420.22 X
90959 4 XXX 0 X 420.22 X
90959 1 XXX 0 X 450.00 X
90960 2 XXX 0 X 420.94 X
90960 3 XXX 0 X 420.94 X
90960 4 XXX 0 X 420.94 X
90960 1 XXX 0 X 453.86 X
90961 2 XXX 0 X 339.91 X
90961 3 XXX 0 X 339.91 X
90961 4 XXX 0 X 339.91 X
90961 1 XXX 0 X 365.83 X
90962 2 XXX 0 X 245.79 X
90962 3 XXX 0 X 245.79 X
90962 4 XXX 0 X 245.79 X
90962 1 XXX 0 X 263.84 X
90963 2 XXX 0 X 814.35 X
90963 3 XXX 0 X 814.35 X
90963 4 XXX 0 X 814.35 X
90963 1 XXX 0 X 873.51 X
90964 2 XXX 0 X 680.29 X
90964 3 XXX 0 X 680.29 X
90964 4 XXX 0 X 680.29 X
90964 1 XXX 0 X 727.28 X
90965 2 XXX 0 X 646.48 X
90965 3 XXX 0 X 646.48 X
90965 4 XXX 0 X 646.48 X
90965 1 XXX 0 X 690.66 X
90966 2 XXX 0 X 336.35 X
90966 3 XXX 0 X 336.35 X
90966 4 XXX 0 X 336.35 X
90966 1 XXX 0 X 361.59 X
90967 2 XXX 0 X 29.08 X
90967 3 XXX 0 X 29.08 X
-
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
90967 4 XXX 0 X 29.08 X
90967 1 XXX 0 X 31.37 X
90968 2 XXX 0 X 22.69 X
90968 3 XXX 0 X 22.69 X
90968 4 XXX 0 X 22.69 X
90968 1 XXX 0 X 24.34 X
90969 2 XXX 0 X 22.21 X
90969 3 XXX 0 X 22.21 X
90969 4 XXX 0 X 22.21 X
90969 1 XXX 0 X 23.78 X
90970 2 XXX 0 X 11.87 X
90970 3 XXX 0 X 11.87 X
90970 4 XXX 0 X 11.87 X
90970 1 XXX 0 X 12.96 X
90989 XXX 9 X 1,294.62 X
90993 XXX 9 X 51.80 X
90997 3 0 0 X 360.97 X
90997 4 0 0 X 523.63 X
90997 1 0 0 X 568.87 X
90997 2 0 0 X 594.10 X
90999 XXX 0 X # X
91010 TC 4 0 0 X 67.58 X
91010 TC 3 0 0 X 68.62 X
91010 TC 2 0 0 X 74.71 X
91010 TC 1 0 0 X 76.14 X
91010 4 0 0 X 212.40 X
91010 26 3 0 0 X 237.69 X
91010 3 0 0 X 274.52 X
91010 2 0 0 X 281.27 X
91010 26 1 0 0 X 290.15 X
91010 26 2 0 0 X 298.18 X
91010 26 4 0 0 X 301.43 X
91010 1 0 0 X 319.80 X
91013 26 2 ZZZ 0 X 14.51 X
91013 26 3 ZZZ 0 X 14.51 X
91013 26 4 ZZZ 0 X 14.51 X
91013 26 1 ZZZ 0 X 15.54 X
91013 TC 2 ZZZ 0 X 18.97 X
91013 TC 3 ZZZ 0 X 18.97 X
91013 TC 4 ZZZ 0 X 18.97 X
91013 TC 1 ZZZ 0 X 21.66 X
91013 2 ZZZ 0 X 33.47 X
91013 3 ZZZ 0 X 33.47 X
91013 4 ZZZ 0 X 33.47 X
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CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
91013 1 ZZZ 0 X 37.21 X
91020 TC 2 0 0 X 60.08 X
91020 TC 3 0 0 X 60.08 X
91020 TC 4 0 0 X 60.08 X
91020 TC 1 0 0 X 72.85 X
91020 26 2 0 0 X 238.69 X
91020 26 3 0 0 X 238.69 X
91020 26 4 0 0 X 238.69 X
91020 26 1 0 0 X 269.73 X
91020 2 0 0 X 298.80 X
91020 3 0 0 X 298.80 X
91020 4 0 0 X 298.80 X
91020 1 0 0 X 342.62 X
91022 26 2 0 0 X 121.41 X
91022 26 3 0 0 X 121.41 X
91022 26 4 0 0 X 121.41 X
91022 26 1 0 0 X 131.76 X
91022 TC 2 0 0 X 221.29 X
91022 TC 3 0 0 X 221.29 X
91022 TC 4 0 0 X 221.29 X
91022 TC 1 0 0 X 272.34 X
91022 2 0 0 X 342.67 X
91022 3 0 0 X 342.67 X
91022 4 0 0 X 342.67 X
91022 1 0 0 X 404.07 X
91030 TC 4 0 0 X 18.34 X
91030 TC 3 0 0 X 18.57 X
91030 TC 2 0 0 X 20.33 X
91030 TC 1 0 0 X 20.77 X
91030 26 3 0 0 X 116.88 X
91030 26 4 0 0 X 117.46 X
91030 26 2 0 0 X 121.22 X
91030 26 1 0 0 X 123.47 X
91030 1 0 0 X 147.96 X
91030 4 0 0 X 149.03 X
91030 3 0 0 X 150.73 X
91030 2 0 0 X 157.83 X
91034 26 2 0 0 X 89.94 X
91034 26 3 0 0 X 89.94 X
91034 26 4 0 0 X 89.94 X
91034 26 1 0 0 X 97.81 X
91034 TC 2 0 0 X 306.83 X
91034 TC 3 0 0 X 306.83 X
91034 TC 4 0 0 X 306.83 X
-
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
91034 TC 1 0 0 X 369.54 X
91034 2 0 0 X 396.79 X
91034 3 0 0 X 396.79 X
91034 4 0 0 X 396.79 X
91034 1 0 0 X 467.29 X
91035 26 2 0 0 X 145.50 X
91035 26 3 0 0 X 145.50 X
91035 26 4 0 0 X 145.50 X
91035 26 1 0 0 X 156.92 X
91035 TC 2 0 0 X 637.68 X
91035 TC 3 0 0 X 637.68 X
91035 TC 4 0 0 X 637.68 X
91035 TC 1 0 0 X 766.06 X
91035 2 0 0 X 783.16 X
91035 3 0 0 X 783.16 X
91035 4 0 0 X 783.16 X
91035 1 0 0 X 922.99 X
91037 26 2 0 0 X 89.94 X
91037 26 3 0 0 X 89.94 X
91037 26 4 0 0 X 89.94 X
91037 26 1 0 0 X 97.81 X
91037 TC 2 0 0 X 163.73 X
91037 TC 3 0 0 X 163.73 X
91037 TC 4 0 0 X 163.73 X
91037 TC 1 0 0 X 197.98 X
91037 2 0 0 X 253.69 X
91037 3 0 0 X 253.69 X
91037 4 0 0 X 253.69 X
91037 1 0 0 X 295.77 X
91038 26 2 0 0 X 101.85 X
91038 26 3 0 0 X 101.85 X
91038 26 4 0 0 X 101.85 X
91038 26 1 0 0 X 110.46 X
91038 TC 2 0 0 X 116.64 X
91038 TC 3 0 0 X 116.64 X
91038 TC 4 0 0 X 116.64 X
91038 TC 1 0 0 X 141.53 X
91038 2 0 0 X 218.46 X
91038 3 0 0 X 218.46 X
91038 4 0 0 X 218.46 X
91038 1 0 0 X 252.00 X
91040 26 2 0 0 X 89.94 X
91040 26 3 0 0 X 89.94 X
91040 26 4 0 0 X 89.94 X
-
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
91040 26 1 0 0 X 97.81 X
91040 TC 2 0 0 X 671.78 X
91040 TC 3 0 0 X 671.78 X
91040 TC 4 0 0 X 671.78 X
91040 2 0 0 X 761.68 X
91040 3 0 0 X 761.68 X
91040 4 0 0 X 761.68 X
91040 TC 1 0 0 X 806.95 X
91040 1 0 0 X 904.72 X
91065 TC 4 0 0 X 28.58 X
91065 TC 3 0 0 X 29.07 X
91065 TC 2 0 0 X 31.47 X
91065 TC 1 0 0 X 32.06 X
91065 26 4 0 0 X 79.46 X
91065 26 3 0 0 X 80.50 X
91065 26 2 0 0 X 84.98 X
91065 26 1 0 0 X 86.05 X
91065 4 0 0 X 137.20 X
91065 3 0 0 X 137.79 X
91065 2 0 0 X 140.68 X
91065 1 0 0 X 141.40 X
91110 26 2 XXX 0 X 336.41 X
91110 26 3 XXX 0 X 336.41 X
91110 26 4 XXX 0 X 336.41 X
91110 26 1 XXX 0 X 357.66 X
91110 TC 2 XXX 0 X 1,278.04 X
91110 TC 3 XXX 0 X 1,278.04 X
91110 TC 4 XXX 0 X 1,278.04 X
91110 TC 1 XXX 0 X 1,504.57 X
91110 2 XXX 0 X 1,614.44 X
91110 3 XXX 0 X 1,614.44 X
91110 4 XXX 0 X 1,614.44 X
91110 1 XXX 0 X 1,862.24 X
91111 26 2 XXX 0 X 78.64 X
91111 26 3 XXX 0 X 78.64 X
91111 26 4 XXX 0 X 78.64 X
91111 26 1 XXX 0 X 86.37 X
91111 TC 2 XXX 0 X 971.24 X
91111 TC 3 XXX 0 X 971.24 X
91111 TC 4 XXX 0 X 971.24 X
91111 2 XXX 0 X 1,049.86 X
91111 3 XXX 0 X 1,049.86 X
91111 4 XXX 0 X 1,049.86 X
91111 TC 1 XXX 0 X 1,188.73 X
-
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
91111 1 XXX 0 X 1,275.11 X
91112 26 2 XXX 0 X 151.87 X
91112 26 3 XXX 0 X 151.87 X
91112 26 4 XXX 0 X 151.87 X
91112 26 1 XXX 0 X 163.02 X
91112 TC 2 XXX 0 X 1,367.03 X
91112 TC 3 XXX 0 X 1,367.03 X
91112 TC 4 XXX 0 X 1,367.03 X
91112 2 XXX 0 X 1,518.88 X
91112 3 XXX 0 X 1,518.88 X
91112 4 XXX 0 X 1,518.88 X
91112 TC 1 XXX 0 X 1,585.78 X
91112 1 XXX 0 X 1,748.81 X
91117 2 0 0 X 211.00 224.11
91117 3 0 0 X 211.00 224.11
91117 4 0 0 X 211.00 224.11
91117 1 0 0 X 231.50 246.29
91120 26 2 XXX 0 X 90.48 X
91120 26 3 XXX 0 X 90.48 X
91120 26 4 XXX 0 X 90.48 X
91120 26 1 XXX 0 X 98.73 X
91120 TC 2 XXX 0 X 661.39 X
91120 TC 3 XXX 0 X 661.39 X
91120 TC 4 XXX 0 X 661.39 X
91120 2 XXX 0 X 751.85 X
91120 3 XXX 0 X 751.85 X
91120 4 XXX 0 X 751.85 X
91120 TC 1 XXX 0 X 793.91 X
91120 1 XXX 0 X 892.64 X
91122 TC 4 0 0 X 65.59 X
91122 TC 3 0 0 X 66.57 X
91122 TC 2 0 0 X 73.78 X
91122 TC 1 0 0 X 75.48 X
91122 26 4 0 0 X 261.04 X
91122 26 3 0 0 X 264.08 X
91122 26 2 0 0 X 313.13 X
91122 26 1 0 0 X 314.61 X
91122 3 0 0 X 322.46 X
91122 4 0 0 X 326.64 X
91122 2 0 0 X 327.34 X
91122 1 0 0 X 340.09 X
91132 XXX 0 X * X
91133 XXX 0 X * X
91200 26 2 XXX 0 X 19.83 X
-
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
91200 26 3 XXX 0 X 19.83 X
91200 26 4 XXX 0 X 19.83 X
91200 26 1 XXX 0 X 21.18 X
91200 TC 2 XXX 0 X 26.84 X
91200 TC 3 XXX 0 X 26.84 X
91200 TC 4 XXX 0 X 26.84 X
91200 TC 1 XXX 0 X 31.45 X
91200 2 XXX 0 X 46.69 X
91200 3 XXX 0 X 46.69 X
91200 4 XXX 0 X 46.69 X
91200 1 XXX 0 X 52.63 X
91299 XXX 0 X # X
91300 XXX 9 X 0.01 X
91301 XXX 9 X 0.01 X
91302 XXX 9 X # X
91303 XXX 9 X # X
92002 4 XXX 0 X 116.04 97.62
92002 3 XXX 0 X 117.15 98.74
92002 1 XXX 0 X 124.26 104.51
92002 2 XXX 0 X 124.46 104.16
92004 4 XXX 0 X 162.76 142.40
92004 3 XXX 0 X 162.95 142.29
92004 2 XXX 0 X 175.22 152.38
92004 1 XXX 0 X 180.04 157.09
92012 3 XXX 0 X 97.85 81.66
92012 4 XXX 0 X 99.11 82.67
92012 1 XXX 0 X 105.30 87.61
92012 2 XXX 0 X 105.68 87.70
92014 3 XXX 0 X 123.72 103.68
92014 4 XXX 0 X 129.99 108.91
92014 2 XXX 0 X 138.23 115.51
92014 1 XXX 0 X 143.80 119.45
92015 XXX 9 X * X
92018 3 XXX 0 X 161.53 143.25
92018 4 XXX 0 X 165.59 147.19
92018 2 XXX 0 X 176.01 155.53
92018 1 XXX 0 X 211.67 186.74
92019 3 XXX 0 X 124.11 X
92019 2 XXX 0 X 127.62 X
92019 4 XXX 0 X 150.17 X
92019 1 XXX 0 X 159.49 X
92020 4 XXX 0 X 43.51 34.21
92020 1 XXX 0 X 53.49 42.00
92020 3 XXX 0 X 55.22 43.57
-
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
92020 2 XXX 0 X 57.73 45.39
92025 TC 2 XXX 0 X 17.56 X
92025 TC 3 XXX 0 X 17.56 X
92025 TC 4 XXX 0 X 17.56 X
92025 TC 1 XXX 0 X 21.69 X
92025 26 2 XXX 0 X 25.00 X
92025 26 3 XXX 0 X 25.00 X
92025 26 4 XXX 0 X 25.00 X
92025 26 1 XXX 0 X 27.23 X
92025 2 XXX 0 X 42.55 X
92025 3 XXX 0 X 42.55 X
92025 4 XXX 0 X 42.55 X
92025 1 XXX 0 X 48.93 X
92060 TC 4 XXX 0 X 15.09 X
92060 TC 3 XXX 0 X 15.28 X
92060 TC 2 XXX 0 X 16.51 X
92060 TC 1 XXX 0 X 16.89 X
92060 26 4 XXX 0 X 59.82 X
92060 26 3 XXX 0 X 60.51 X
92060 26 2 XXX 0 X 62.96 X
92060 26 1 XXX 0 X 63.51 X
92060 4 XXX 0 X 74.92 X
92060 3 XXX 0 X 75.89 X
92060 2 XXX 0 X 79.50 X
92060 1 XXX 0 X 80.39 X
92065 TC 4 XXX 0 X 12.65 X
92065 TC 3 XXX 0 X 12.90 X
92065 TC 2 XXX 0 X 13.65 X
92065 TC 1 XXX 0 X 13.81 X
92065 26 3 XXX 0 X 46.32 X
92065 26 4 XXX 0 X 47.46 X
92065 26 1 XXX 0 X 50.54 X
92065 26 2 XXX 0 X 54.96 X
92065 3 XXX 0 X 59.74 X
92065 4 XXX 0 X 60.08 X
92065 1 XXX 0 X 64.38 X
92065 2 XXX 0 X 71.11 X
92071 2 XXX 0 X 52.10 46.71
92071 3 XXX 0 X 52.10 46.71
92071 4 XXX 0 X 52.10 46.71
92071 1 XXX 0 X 56.52 50.31
92072 2 XXX 0 X 166.42 135.13
92072 3 XXX 0 X 166.42 135.13
92072 4 XXX 0 X 166.42 135.13
-
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
92072 1 XXX 0 X 180.71 144.39
92081 TC 4 XXX 0 X 11.96 X
92081 TC 3 XXX 0 X 12.09 X
92081 TC 2 XXX 0 X 12.80 X
92081 TC 1 XXX 0 X 12.95 X
92081 26 4 XXX 0 X 44.21 X
92081 26 3 XXX 0 X 44.70 X
92081 26 2 XXX 0 X 46.65 X
92081 26 1 XXX 0 X 47.76 X
92081 4 XXX 0 X 56.09 X
92081 3 XXX 0 X 56.78 X
92081 2 XXX 0 X 59.44 X
92081 1 XXX 0 X 61.38 X
92082 TC 4 XXX 0 X 15.90 X
92082 TC 3 XXX 0 X 16.13 X
92082 TC 2 XXX 0 X 17.41 X
92082 TC 1 XXX 0 X 17.73 X
92082 26 3 XXX 0 X 58.08 X
92082 26 4 XXX 0 X 58.91 X
92082 26 2 XXX 0 X 64.62 X
92082 26 1 XXX 0 X 65.25 X
92082 3 XXX 0 X 75.32 X
92082 4 XXX 0 X 76.13 X
92082 2 XXX 0 X 82.07 X
92082 1 XXX 0 X 83.01 X
92083 TC 4 XXX 0 X 23.01 X
92083 TC 3 XXX 0 X 23.39 X
92083 TC 2 XXX 0 X 25.09 X
92083 TC 1 XXX 0 X 25.51 X
92083 26 4 XXX 0 X 87.99 X
92083 26 3 XXX 0 X 92.38 X
92083 26 1 XXX 0 X 96.46 X
92083 26 2 XXX 0 X 96.60 X
92083 4 XXX 0 X 117.85 X
92083 3 XXX 0 X 123.97 X
92083 1 XXX 0 X 129.54 X
92083 2 XXX 0 X 129.99 X
92100 2 XXX 0 X 72.56 63.39
92100 3 XXX 0 X 74.19 64.85
92100 4 XXX 0 X 75.37 65.88
92100 1 XXX 0 X 79.71 69.18
92132 TC 2 XXX 0 X 21.88 X
92132 TC 3 XXX 0 X 21.88 X
92132 TC 4 XXX 0 X 21.88 X
-
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
92132 TC 1 XXX 0 X 24.96 X
92132 26 2 XXX 0 X 31.01 X
92132 26 3 XXX 0 X 31.01 X
92132 26 4 XXX 0 X 31.01 X
92132 26 1 XXX 0 X 33.59 X
92132 2 XXX 0 X 52.89 X
92132 3 XXX 0 X 52.89 X
92132 4 XXX 0 X 52.89 X
92132 1 XXX 0 X 58.56 X
92133 TC 2 XXX 0 X 21.88 X
92133 TC 3 XXX 0 X 21.88 X
92133 TC 4 XXX 0 X 21.88 X
92133 TC 1 XXX 0 X 24.96 X
92133 26 2 XXX 0 X 42.95 X
92133 26 3 XXX 0 X 42.95 X
92133 26 4 XXX 0 X 42.95 X
92133 26 1 XXX 0 X 46.23 X
92133 2 XXX 0 X 64.82 X
92133 3 XXX 0 X 64.82 X
92133 4 XXX 0 X 64.82 X
92133 1 XXX 0 X 71.16 X
92134 TC 2 XXX 0 X 21.88 X
92134 TC 3 XXX 0 X 21.88 X
92134 TC 4 XXX 0 X 21.88 X
92134 TC 1 XXX 0 X 24.96 X
92134 26 2 XXX 0 X 42.95 X
92134 26 3 XXX 0 X 42.95 X
92134 26 4 XXX 0 X 42.95 X
92134 26 1 XXX 0 X 46.23 X
92134 2 XXX 0 X 64.82 X
92134 3 XXX 0 X 64.82 X
92134 4 XXX 0 X 64.82 X
92134 1 XXX 0 X 71.16 X