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2024 Workers' Compensation Part B Fee Schedule

21015-21435

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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
21015   003 90 2 X 1,287.84 X
21015   002 90 2 X 1,394.02 X
21015   004 90 2 X 1,272.19 X
21015   001 90 2 X 1,419.76 X
21016   004 90 2 X 1,753.46 X
21016   002 90 2 X 1,753.46 X
21016   003 90 2 X 1,753.46 X
21016   001 90 2 X 1,965.61 X
21025   003 90 2 X 982.35 X
21025   002 90 2 X 1,053.10 X
21025   001 90 2 X 1,066.73 X
21025   004 90 2 X 984.59 X
21026   004 90 2 X 819.96 X
21026   002 90 2 X 940.28 X
21026   003 90 2 X 921.67 X
21026   001 90 2 X 1,060.63 X
21029   001 90 2 X 1,928.59 X
21029   004 90 2 X 1,766.01 X
21029   002 90 2 X 1,901.57 X
21029   003 90 2 X 1,788.85 X
21030   004 90 2 X 1,108.08 940.07
21030   001 90 2 X 1,185.91 1,002.66
21030   003 90 2 X 1,120.71 949.78
21030   002 90 2 X 1,173.26 992.23
21031   004 90 2 X 613.42 X
21031   001 90 2 X 674.98 X
21031   003 90 2 X 621.81 X
21031   002 90 2 X 664.61 X
21032   001 90 2 X 949.31 X
21032   004 90 2 X 874.60 X
21032   003 90 2 X 885.44 X
21032   002 90 2 X 936.89 X
21034   002 90 2 X 2,281.95 X
21034   003 90 2 X 2,315.12 X
21034   004 90 2 X 2,383.64 X
21034   001 90 2 X 2,366.81 X
21040   003 90 2 X 652.57 X
21040   002 90 2 X 720.28 X
21040   001 90 2 X 664.93 X
21040   004 90 2 X 624.89 X
21044   001 90 2 X 2,441.87 X
21044   004 90 2 X 2,240.05 X
21044   003 90 2 X 2,267.28 X
21044   002 90 2 X 2,407.94 X
21045   004 90 2 X 3,143.02 X
21045   003 90 2 X 3,181.57 X
21045   002 90 2 X 3,381.68 X
21045   001 90 2 X 3,429.97 X
21046   002 90 2 X 1,903.11 X
21046   003 90 2 X 1,903.11 X
21046   001 90 2 X 2,130.46 X
21046   004 90 2 X 1,903.11 X
21047   004 90 2 X 2,358.37 X
21047   001 90 2 X 2,621.50 X
21047   003 90 2 X 2,358.37 X
21047   002 90 2 X 2,358.37 X
21048   001 90 2 X 2,190.92 X
21048   004 90 2 X 1,959.38 X
21048   002 90 2 X 1,959.38 X
21048   003 90 2 X 1,959.38 X
21049   001 90 2 X 2,470.37 X
21049   004 90 2 X 2,240.72 X
21049   003 90 2 X 2,240.72 X
21049   002 90 2 X 2,240.72 X
21050   001 90 2 X 2,630.49 X
21050   004 90 2 X 2,409.31 X
21050   003 90 2 X 2,440.33 X
21050   002 90 2 X 2,640.31 X
21060   003 90 2 X 2,306.98 X
21060   002 90 2 X 2,452.60 X
21060   004 90 2 X 2,277.68 X
21060   001 90 2 X 2,487.61 X
21070   001 90 2 X 1,721.02 X
21070   003 90 2 X 1,595.38 X
21070   002 90 2 X 1,696.61 X
21070   004 90 2 X 1,576.17 X
21073   001 90 2 X 683.81 435.44
21073   004 90 2 X 590.57 384.62
21073   002 90 2 X 590.57 384.62
21073   003 90 2 X 590.57 384.62
21076   001 10 2 X 3,703.67 2,693.07
21076   003 10 2 X 3,326.06 2,434.94
21076   002 10 2 X 3,555.97 2,582.26
21076   004 10 2 X 3,273.90 2,400.24
21077   001 90 2 X 9,314.73 6,772.71
21077   003 90 2 X 8,365.17 6,123.82
21077   002 90 2 X 8,943.36 6,494.23
21077   004 90 2 X 8,233.95 6,036.60
21079     90 2 X * X
21080     90 2 X * X
21081     90 2 X * X
21082     90 2 X * X
21083     90 2 X * X
21084     90 2 X * X
21085     10 2 X * X
21086     90 2 X * X
21087     90 2 X * X
21088     90 0 X * X
21089     YYY 0 X # X
21100   003 90 2 X 786.94 X
21100   002 90 2 X 884.67 X
21100   001 90 2 X 575.32 X
21100   004 90 2 X 541.98 X
21110   004 90 2 X 1,132.83 X
21110   001 90 2 X 1,233.08 X
21110   002 90 2 X 1,216.46 X
21110   003 90 2 X 1,147.28 X
21116   004 0 2 X 164.98 X
21116   001 0 2 X 152.03 X
21116   003 0 2 X 166.95 X
21116   002 0 2 X 162.80 X
21120   001 90 2 X 981.42 X
21120   004 90 2 X 903.17 X
21120   002 90 2 X 968.32 X
21120   003 90 2 X 913.99 X
21121   003 90 2 X 1,437.62 X
21121   002 90 2 X 1,523.41 X
21121   004 90 2 X 1,420.57 X
21121   001 90 2 X 1,544.15 X
21122   001 90 2 X 1,701.82 X
21122   004 90 2 X 1,565.48 X
21122   003 90 2 X 1,584.17 X
21122   002 90 2 X 1,678.92 X
21123   004 90 2 X 2,046.16 X
21123   001 90 2 X 2,223.94 X
21123   002 90 2 X 2,194.05 X
21123   003 90 2 X 2,070.63 X
21125   003 90 2 X 1,198.95 X
21125   002 90 2 X 1,270.28 X
21125   004 90 2 X 1,184.82 X
21125   001 90 2 X 1,287.44 X
21127   001 90 2 X 2,160.54 X
21127   004 90 2 X 1,987.97 X
21127   003 90 2 X 2,011.71 X
21127   002 90 2 X 2,131.51 X
21137   001 90 2 X 3,941.04 X
21137   003 90 2 X 3,941.04 X
21137   002 90 2 X 3,941.04 X
21137   004 90 2 X 3,941.04 X
21138   002 90 2 X 4,926.33 X
21138   003 90 2 X 4,926.33 X
21138   004 90 2 X 4,926.33 X
21138   001 90 2 X 4,926.33 X
21139   001 90 2 X 4,926.33 X
21139   004 90 2 X 4,926.33 X
21139   002 90 2 X 4,926.33 X
21139   003 90 2 X 4,926.33 X
21141   004 90 2 X 3,542.17 X
21141   001 90 2 X 3,978.54 X
21141   002 90 2 X 3,820.30 X
21141   003 90 2 X 3,594.95 X
21142   004 90 2 X 3,673.70 X
21142   001 90 2 X 4,125.75 X
21142   002 90 2 X 3,961.80 X
21142   003 90 2 X 3,728.40 X
21143   002 90 2 X 4,118.40 X
21143   003 90 2 X 3,875.93 X
21143   004 90 2 X 3,818.98 X
21143   001 90 2 X 4,288.86 X
21145   003 90 2 X 3,648.59 X
21145   002 90 2 X 3,866.56 X
21145   004 90 2 X 3,605.52 X
21145   001 90 2 X 3,919.23 X
21146   002 90 2 X 4,001.23 X
21146   003 90 2 X 3,775.66 X
21146   004 90 2 X 3,731.08 X
21146   001 90 2 X 4,055.72 X
21147   003 90 2 X 3,917.13 X
21147   002 90 2 X 4,151.26 X
21147   004 90 2 X 3,870.88 X
21147   001 90 2 X 4,207.94 X
21150   001 90 2 X 11,494.80 X
21150   002 90 2 X 11,494.80 X
21150   003 90 2 X 11,494.80 X
21150   004 90 2 X 11,494.80 X
21151   003 90 2 X 11,494.80 X
21151   002 90 2 X 11,494.80 X
21151   001 90 2 X 11,494.80 X
21151   004 90 2 X 11,494.80 X
21154   002 90 2 X 13,136.93 X
21154   003 90 2 X 13,136.93 X
21154   001 90 2 X 13,136.93 X
21154   004 90 2 X 13,136.93 X
21155   001 90 2 X 13,465.33 X
21155   004 90 2 X 13,465.33 X
21155   003 90 2 X 13,465.33 X
21155   002 90 2 X 13,465.33 X
21159   001 90 2 X 9,125.73 X
21159   004 90 2 X 8,277.38 X
21159   003 90 2 X 8,389.83 X
21159   002 90 2 X 8,892.29 X
21160   001 90 2 X 9,994.51 X
21160   004 90 2 X 9,065.36 X
21160   002 90 2 X 9,738.86 X
21160   003 90 2 X 9,188.43 X
21172   002 90 2 X 9,852.77 X
21172   003 90 2 X 9,852.77 X
21172   004 90 2 X 9,852.77 X
21172   001 90 2 X 9,852.77 X
21175   004 90 2 X 13,136.93 X
21175   002 90 2 X 13,136.93 X
21175   003 90 2 X 13,136.93 X
21175   001 90 2 X 13,136.93 X
21179   001 90 2 X 9,852.77 X
21179   004 90 2 X 9,852.77 X
21179   002 90 2 X 9,852.77 X
21179   003 90 2 X 9,852.77 X
21180   001 90 2 X 11,494.80 X
21180   003 90 2 X 11,494.80 X
21180   002 90 2 X 11,494.80 X
21180   004 90 2 X 11,494.80 X
21181   001 90 2 X 1,185.91 X
21181   004 90 2 X 1,108.08 X
21181   003 90 2 X 1,120.71 X
21181   002 90 2 X 1,173.26 X
21182   003 90 2 X 6,392.16 X
21182   002 90 2 X 6,775.16 X
21182   004 90 2 X 6,306.47 X
21182   001 90 2 X 6,953.02 X
21183   001 90 2 X 7,606.96 X
21183   003 90 2 X 6,993.34 X
21183   002 90 2 X 7,412.31 X
21183   004 90 2 X 6,899.59 X
21184   004 90 2 X 7,489.58 X
21184   001 90 2 X 8,256.82 X
21184   003 90 2 X 7,591.37 X
21184   002 90 2 X 8,045.74 X
21188   003 90 2 X 10,673.75 X
21188   002 90 2 X 10,673.75 X
21188   001 90 2 X 10,673.75 X
21188   004 90 2 X 10,673.75 X
21193   004 90 2 X 3,094.17 X
21193   003 90 2 X 3,131.28 X
21193   002 90 2 X 3,318.32 X
21193   001 90 2 X 3,363.53 X
21194   003 90 2 X 3,627.97 X
21194   002 90 2 X 3,844.65 X
21194   004 90 2 X 3,585.08 X
21194   001 90 2 X 3,897.06 X
21195   003 90 2 X 3,138.45 X
21195   001 90 2 X 3,371.14 X
21195   002 90 2 X 3,325.77 X
21195   004 90 2 X 3,101.33 X
21196   001 90 2 X 3,715.52 X
21196   002 90 2 X 3,665.78 X
21196   003 90 2 X 3,459.56 X
21196   004 90 2 X 3,418.69 X
21198   001 90 2 X 3,373.21 X
21198   002 90 2 X 3,322.68 X
21198   003 90 2 X 3,113.36 X
21198   004 90 2 X 3,074.87 X
21199   002 90 2 X 2,342.64 X
21199   003 90 2 X 2,342.64 X
21199   004 90 2 X 2,342.64 X
21199   001 90 2 X 2,594.85 X
21206   002 90 2 X 2,731.66 X
21206   003 90 2 X 2,577.64 X
21206   001 90 2 X 2,768.85 X
21206   004 90 2 X 2,547.18 X
21208   003 90 2 X 2,594.18 X
21208   002 90 2 X 2,820.47 X
21208   004 90 2 X 2,248.16 X
21208   001 90 2 X 2,937.89 X
21209   002 90 2 X 1,296.58 X
21209   003 90 2 X 1,215.29 X
21209   001 90 2 X 3,616.55 X
21209   004 90 2 X 1,201.29 X
21210   003 90 2 X 2,648.47 X
21210   002 90 2 X 2,809.53 X
21210   004 90 2 X 2,369.42 X
21210   001 90 2 X 3,269.24 X
21215   002 90 2 X 5,008.24 X
21215   003 90 2 X 2,652.57 X
21215   001 90 2 X 5,154.46 X
21215   004 90 2 X 2,618.54 X
21230   004 90 2 X 2,278.30 X
21230   003 90 2 X 2,549.39 X
21230   002 90 2 X 2,654.26 X
21230   001 90 2 X 2,519.06 X
21235   003 90 2 X 1,601.87 X
21235   002 90 2 X 2,117.34 X
21235   001 90 2 X 2,213.55 X
21235   004 90 2 X 1,581.85 X
21240   001 90 2 X 5,013.43 X
21240   004 90 2 X 4,853.94 X
21240   003 90 2 X 3,750.00 X
21240   002 90 2 X 4,986.62 X
21242   004 90 2 X 3,763.51 X
21242   002 90 2 X 5,479.60 X
21242   003 90 2 X 3,814.00 X
21242   001 90 2 X 4,158.02 X
21243   004 90 2 X 3,617.68 X
21243   001 90 2 X 3,932.22 X
21243   002 90 2 X 3,879.41 X
21243   003 90 2 X 3,660.97 X
21244     90 2 X * X
21245     90 2 X * X
21246     90 2 X * X
21247   001 90 2 X 5,656.29 X
21247   004 90 2 X 5,180.15 X
21247   002 90 2 X 5,577.08 X
21247   003 90 2 X 5,247.43 X
21248     90 2 X * X
21249     90 2 X * X
21255   004 90 2 X 3,826.01 X
21255   001 90 2 X 4,177.70 X
21255   003 90 2 X 3,875.73 X
21255   002 90 2 X 4,119.34 X
21256   002 90 2 X 3,989.50 X
21256   003 90 2 X 3,753.47 X
21256   004 90 2 X 3,705.34 X
21256   001 90 2 X 4,046.16 X
21260   001 90 2 X 4,127.91 X
21260   004 90 2 X 3,780.41 X
21260   002 90 2 X 4,070.18 X
21260   003 90 2 X 3,829.44 X
21261   003 90 2 X 5,112.15 X
21261   002 90 2 X 5,376.62 X
21261   004 90 2 X 5,052.87 X
21261   001 90 2 X 5,440.62 X
21263   001 90 2 X 7,102.88 X
21263   004 90 2 X 6,504.85 X
21263   002 90 2 X 7,003.43 X
21263   003 90 2 X 6,589.37 X
21267   003 90 2 X 3,589.86 X
21267   002 90 2 X 3,827.98 X
21267   001 90 2 X 3,885.63 X
21267   004 90 2 X 3,547.50 X
21268   001 90 2 X 4,704.01 X
21268   004 90 2 X 4,276.24 X
21268   002 90 2 X 4,629.93 X
21268   003 90 2 X 4,324.92 X
21270   004 90 2 X 2,384.73 X
21270   002 90 2 X 2,571.65 X
21270   003 90 2 X 2,413.09 X
21270   001 90 2 X 2,609.99 X
21275   001 90 2 X 2,337.98 X
21275   004 90 2 X 2,135.03 X
21275   003 90 2 X 2,160.71 X
21275   002 90 2 X 2,303.51 X
21280   001 90 2 X 1,505.61 X
21280   004 90 2 X 1,378.51 X
21280   002 90 2 X 1,484.49 X
21280   003 90 2 X 1,578.09 X
21282   004 90 2 X 1,135.96 X
21282   002 90 2 X 1,241.26 X
21282   003 90 2 X 1,727.72 X
21282   001 90 2 X 1,262.89 X
21295   004 90 2 X 260.59 X
21295   001 90 2 X 283.37 X
21295   003 90 2 X 263.68 X
21295   002 90 2 X 279.50 X
21296   001 90 2 X 866.13 X
21296   004 90 2 X 802.92 X
21296   003 90 2 X 813.07 X
21296   002 90 2 X 855.82 X
21299     YYY 2 X # X
21315   003 0 2 X 450.05 X
21315   002 0 2 X 454.43 X
21315   004 0 2 X 479.17 X
21315   001 0 2 X 510.00 X
21320   002 0 2 X 592.14 X
21320   003 0 2 X 569.56 X
21320   004 0 2 X 556.45 X
21320   001 0 2 X 610.64 X
21325   004 90 2 X 836.38 X
21325   001 90 2 X 920.64 X
21325   002 90 2 X 906.29 X
21325   003 90 2 X 846.80 X
21330   002 90 2 X 1,374.64 X
21330   003 90 2 X 1,306.43 X
21330   001 90 2 X 1,437.50 X
21330   004 90 2 X 1,267.05 X
21335   003 90 2 X 2,000.29 X
21335   002 90 2 X 2,120.01 X
21335   004 90 2 X 2,188.16 X
21335   001 90 2 X 2,166.63 X
21336   004 90 2 X 1,028.74 X
21336   003 90 2 X 1,040.99 X
21336   002 90 2 X 1,105.22 X
21336   001 90 2 X 1,120.80 X
21337   004 90 2 X 587.64 X
21337   002 90 2 X 636.93 X
21337   003 90 2 X 594.99 X
21337   001 90 2 X 647.00 X
21338   001 90 2 X 1,320.31 X
21338   003 90 2 X 1,222.92 X
21338   002 90 2 X 1,301.31 X
21338   004 90 2 X 1,208.44 X
21339   004 90 2 X 1,579.88 X
21339   002 90 2 X 2,627.00 X
21339   001 90 2 X 1,719.54 X
21339   003 90 2 X 1,599.44 X
21340   002 90 2 X 2,218.06 X
21340   003 90 2 X 2,087.35 X
21340   004 90 2 X 2,062.22 X
21340   001 90 2 X 2,249.68 X
21343   002 90 2 X 2,472.44 X
21343   003 90 2 X 2,332.94 X
21343   004 90 2 X 2,305.35 X
21343   001 90 2 X 2,506.14 X
21344   004 90 2 X 2,971.08 X
21344   003 90 2 X 3,004.76 X
21344   002 90 2 X 3,160.65 X
21344   001 90 2 X 3,198.44 X
21345   003 90 2 X 1,701.06 X
21345   002 90 2 X 1,808.20 X
21345   001 90 2 X 1,834.04 X
21345   004 90 2 X 1,842.72 X
21346   002 90 2 X 2,275.43 X
21346   003 90 2 X 2,120.99 X
21346   001 90 2 X 2,286.42 X
21346   004 90 2 X 2,095.11 X
21347   001 90 2 X 2,659.11 X
21347   004 90 2 X 2,430.79 X
21347   002 90 2 X 2,620.35 X
21347   003 90 2 X 2,460.21 X
21348   003 90 2 X 3,047.28 X
21348   002 90 2 X 2,492.52 X
21348   004 90 2 X 3,012.55 X
21348   001 90 2 X 3,317.46 X
21355   004 10 2 X 544.76 X
21355   001 10 2 X 584.16 X
21355   003 10 2 X 550.82 X
21355   002 10 2 X 577.65 X
21356   004 10 2 X 1,574.80 X
21356   001 10 2 X 1,644.47 X
21356   002 10 2 X 1,716.98 X
21356   003 10 2 X 1,762.52 X
21360   001 90 2 X 1,792.86 X
21360   004 90 2 X 1,716.07 X
21360   002 90 2 X 1,864.40 X
21360   003 90 2 X 1,905.43 X
21365   001 90 2 X 3,127.02 X
21365   004 90 2 X 2,881.02 X
21365   002 90 2 X 3,069.26 X
21365   003 90 2 X 2,980.52 X
21366   001 90 2 X 3,144.90 X
21366   004 90 2 X 3,207.80 X
21366   002 90 2 X 3,086.97 X
21366   003 90 2 X 2,998.30 X
21385   003 90 2 X 2,006.78 X
21385   002 90 2 X 2,142.13 X
21385   004 90 2 X 1,981.92 X
21385   001 90 2 X 2,174.79 X
21386   001 90 2 X 2,137.30 X
21386   002 90 2 X 2,103.94 X
21386   003 90 2 X 1,966.00 X
21386   004 90 2 X 1,941.99 X
21387   001 90 2 X 1,967.01 X
21387   003 90 2 X 1,823.71 X
21387   002 90 2 X 2,805.42 X
21387   004 90 2 X 1,802.06 X
21390   004 90 2 X 2,333.79 X
21390   002 90 2 X 2,879.50 X
21390   003 90 2 X 2,719.86 X
21390   001 90 2 X 2,566.66 X
21395   004 90 2 X 2,357.49 X
21395   002 90 2 X 2,578.41 X
21395   003 90 2 X 2,385.58 X
21395   001 90 2 X 2,579.61 X
21400   003 90 2 X 793.98 X
21400   002 90 2 X 333.18 X
21400   004 90 2 X 852.35 X
21400   001 90 2 X 805.30 X
21401   001 90 2 X 668.48 X
21401   003 90 2 X 620.11 X
21401   002 90 2 X 659.02 X
21401   004 90 2 X 612.66 X
21406   002 90 2 X 1,517.34 X
21406   003 90 2 X 1,500.44 X
21406   004 90 2 X 1,289.68 X
21406   001 90 2 X 1,582.01 X
21407   002 90 2 X 1,762.35 X
21407   003 90 2 X 1,660.32 X
21407   004 90 2 X 1,640.32 X
21407   001 90 2 X 1,786.89 X
21408   001 90 2 X 2,359.27 X
21408   004 90 2 X 2,172.40 X
21408   002 90 2 X 2,327.89 X
21408   003 90 2 X 2,198.28 X
21421   004 90 2 X 1,186.19 X
21421   001 90 2 X 2,005.17 X
21421   003 90 2 X 1,963.21 X
21421   002 90 2 X 1,996.98 X
21422   002 90 2 X 2,088.82 X
21422   003 90 2 X 1,951.40 X
21422   004 90 2 X 1,926.88 X
21422   001 90 2 X 2,121.93 X
21423   001 90 2 X 2,333.94 X
21423   003 90 2 X 2,157.13 X
21423   002 90 2 X 2,299.63 X
21423   004 90 2 X 2,130.72 X
21431   002 90 2 X 1,477.04 X
21431   003 90 2 X 1,388.75 X
21431   001 90 2 X 1,498.39 X
21431   004 90 2 X 1,371.95 X
21432   001 90 2 X 1,761.15 X
21432   003 90 2 X 1,633.36 X
21432   002 90 2 X 3,792.76 X
21432   004 90 2 X 1,613.93 X
21433   004 90 2 X 4,513.68 X
21433   001 90 2 X 4,906.06 X
21433   002 90 2 X 4,670.36 X
21433   003 90 2 X 4,567.77 X
21435   004 90 2 X 3,223.21 X
21435   001 90 2 X 3,527.26 X
21435   002 90 2 X 3,475.51 X
21435   003 90 2 X 3,261.74 X