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DLI
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Workers' Compensation
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Health Care Services Review
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Medical Fee Review
>
Fee Schedule
>
Fee Schedule 25922-26565
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
25922-26565
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
25922
002
90
2
X
1,514.30
X
25922
003
90
2
X
1,412.89
X
25922
004
90
2
X
1,396.51
X
25922
001
90
2
X
1,538.85
X
25924
002
90
2
X
1,854.34
X
25924
003
90
2
X
1,729.12
X
25924
001
90
2
X
1,884.63
X
25924
004
90
2
X
1,708.46
X
25927
003
90
2
X
1,787.73
X
25927
002
90
2
X
1,767.03
X
25927
004
90
2
X
1,629.22
X
25927
001
90
2
X
1,866.49
X
25929
004
90
2
X
1,326.68
X
25929
002
90
2
X
1,283.89
X
25929
003
90
2
X
1,341.72
X
25929
001
90
2
X
1,458.62
X
25931
001
90
2
X
1,450.89
X
25931
004
90
2
X
1,323.44
X
25931
003
90
2
X
1,338.37
X
25931
002
90
2
X
1,748.59
X
25999
YYY
2
X
#
X
26010
001
10
2
X
185.58
163.54
26010
004
10
2
X
165.31
146.05
26010
002
10
2
X
184.60
162.90
26010
003
10
2
X
177.59
157.41
26011
003
10
2
X
336.02
X
26011
002
10
2
X
365.30
X
26011
004
10
2
X
346.37
X
26011
001
10
2
X
403.76
X
26020
002
90
2
X
910.55
X
26020
003
90
2
X
842.86
X
26020
004
90
2
X
861.14
X
26020
001
90
2
X
939.24
X
26025
003
90
2
X
1,011.14
X
26025
002
90
2
X
1,068.09
X
26025
001
90
2
X
1,093.47
X
26025
004
90
2
X
987.43
X
26030
001
90
2
X
1,376.50
X
26030
004
90
2
X
1,273.50
X
26030
002
90
2
X
1,353.13
X
26030
003
90
2
X
1,256.77
X
26034
004
90
2
X
1,210.22
X
26034
002
90
2
X
1,239.38
X
26034
003
90
2
X
1,215.60
X
26034
001
90
2
X
1,254.60
X
26035
002
90
2
X
1,564.17
X
26035
003
90
2
X
1,440.00
X
26035
004
90
2
X
1,490.78
X
26035
001
90
2
X
1,625.96
X
26037
003
90
2
X
1,469.22
X
26037
002
90
2
X
1,576.30
X
26037
004
90
2
X
1,451.82
X
26037
001
90
2
X
1,602.24
X
26040
003
90
2
X
889.69
X
26040
002
90
2
X
895.85
X
26040
001
90
2
X
915.96
X
26040
004
90
2
X
897.15
X
26045
001
90
2
X
1,240.14
X
26045
003
90
2
X
1,507.77
X
26045
002
90
2
X
1,505.88
X
26045
004
90
2
X
1,504.10
X
26055
004
90
2
X
842.72
X
26055
001
90
2
X
881.09
X
26055
003
90
2
X
800.60
X
26055
002
90
2
X
866.43
X
26060
003
90
2
X
394.67
X
26060
001
90
2
X
447.86
X
26060
002
90
2
X
397.50
X
26060
004
90
2
X
415.85
X
26070
004
90
2
X
831.22
X
26070
001
90
2
X
853.91
X
26070
003
90
2
X
793.48
X
26070
002
90
2
X
845.55
X
26075
001
90
2
X
719.49
X
26075
004
90
2
X
651.91
X
26075
002
90
2
X
802.98
X
26075
003
90
2
X
657.62
X
26080
001
90
2
X
842.18
X
26080
004
90
2
X
846.52
X
26080
002
90
2
X
870.33
X
26080
003
90
2
X
866.13
X
26100
001
90
2
X
790.11
X
26100
004
90
2
X
840.25
X
26100
003
90
2
X
792.41
X
26100
002
90
2
X
778.11
X
26105
004
90
2
X
866.28
X
26105
001
90
2
X
960.62
X
26105
003
90
2
X
876.96
X
26105
002
90
2
X
944.29
X
26110
001
90
2
X
776.73
X
26110
003
90
2
X
758.69
X
26110
002
90
2
X
816.59
X
26110
004
90
2
X
768.96
X
26111
001
90
2
X
774.39
X
26111
003
90
2
X
687.70
X
26111
002
90
2
X
687.70
X
26111
004
90
2
X
687.70
X
26113
001
90
2
X
1,018.23
X
26113
004
90
2
X
904.62
X
26113
003
90
2
X
904.62
X
26113
002
90
2
X
904.62
X
26115
001
90
2
X
658.06
X
26115
003
90
2
X
614.63
X
26115
002
90
2
X
650.70
X
26115
004
90
2
X
602.23
X
26116
004
90
2
X
779.07
X
26116
001
90
2
X
839.35
X
26116
002
90
2
X
983.33
X
26116
003
90
2
X
821.87
X
26117
004
90
2
X
1,471.60
X
26117
001
90
2
X
1,288.55
X
26117
002
90
2
X
1,283.78
X
26117
003
90
2
X
1,488.32
X
26118
003
90
2
X
1,781.29
X
26118
002
90
2
X
1,781.29
X
26118
001
90
2
X
2,003.63
X
26118
004
90
2
X
1,781.29
X
26121
001
90
2
X
2,457.84
X
26121
004
90
2
X
2,265.98
X
26121
003
90
2
X
2,017.50
X
26121
002
90
2
X
2,382.67
X
26123
004
90
2
X
2,060.84
X
26123
002
90
2
X
2,160.34
X
26123
003
90
2
X
2,036.62
X
26123
001
90
2
X
2,228.50
X
26125
004
ZZZ
0
X
1,644.12
X
26125
002
ZZZ
0
X
1,710.62
X
26125
003
ZZZ
0
X
1,616.92
X
26125
001
ZZZ
0
X
1,771.76
X
26130
001
90
2
X
1,253.88
X
26130
002
90
2
X
1,233.13
X
26130
003
90
2
X
1,147.41
X
26130
004
90
2
X
1,133.76
X
26135
002
90
2
X
1,376.59
X
26135
003
90
2
X
1,289.75
X
26135
001
90
2
X
1,397.60
X
26135
004
90
2
X
1,274.88
X
26140
003
90
2
X
1,153.15
X
26140
002
90
2
X
1,231.68
X
26140
004
90
2
X
1,139.75
X
26140
001
90
2
X
1,250.79
X
26145
002
90
2
X
1,178.15
X
26145
003
90
2
X
1,119.86
X
26145
001
90
2
X
1,193.80
X
26145
004
90
2
X
1,116.34
X
26160
003
90
2
X
687.22
X
26160
002
90
2
X
715.04
X
26160
004
90
2
X
640.14
X
26160
001
90
2
X
810.70
X
26170
003
90
2
X
825.83
X
26170
002
90
2
X
876.65
X
26170
004
90
2
X
816.54
X
26170
001
90
2
X
888.99
X
26180
004
90
2
X
1,003.41
X
26180
001
90
2
X
1,104.66
X
26180
002
90
2
X
1,111.27
X
26180
003
90
2
X
1,015.19
X
26185
004
90
2
X
975.24
X
26185
001
90
2
X
1,099.07
X
26185
002
90
2
X
1,002.20
X
26185
003
90
2
X
975.24
X
26200
004
90
2
X
1,078.03
X
26200
001
90
2
X
1,185.26
X
26200
002
90
2
X
1,166.86
X
26200
003
90
2
X
1,090.82
X
26205
004
90
2
X
1,511.98
X
26205
001
90
2
X
1,663.83
X
26205
003
90
2
X
1,529.99
X
26205
002
90
2
X
1,637.80
X
26210
001
90
2
X
1,077.93
X
26210
004
90
2
X
1,008.51
X
26210
003
90
2
X
993.54
X
26210
002
90
2
X
1,061.43
X
26215
002
90
2
X
1,485.91
X
26215
003
90
2
X
1,388.73
X
26215
001
90
2
X
1,509.36
X
26215
004
90
2
X
1,372.54
X
26230
001
90
2
X
1,274.83
X
26230
002
90
2
X
1,312.49
X
26230
003
90
2
X
1,141.10
X
26230
004
90
2
X
1,127.93
X
26235
004
90
2
X
1,105.56
X
26235
001
90
2
X
1,381.55
X
26235
003
90
2
X
1,340.36
X
26235
002
90
2
X
1,325.72
X
26236
002
90
2
X
1,296.13
X
26236
003
90
2
X
1,298.82
X
26236
004
90
2
X
1,360.92
X
26236
001
90
2
X
1,401.40
X
26250
001
90
2
X
2,007.28
X
26250
004
90
2
X
1,478.61
X
26250
002
90
2
X
1,603.39
X
26250
003
90
2
X
1,495.97
X
26260
001
90
2
X
1,686.39
X
26260
004
90
2
X
1,386.18
X
26260
003
90
2
X
1,491.18
X
26260
002
90
2
X
1,502.16
X
26262
002
90
2
X
1,661.77
X
26262
003
90
2
X
1,139.04
X
26262
004
90
2
X
1,125.64
X
26262
001
90
2
X
1,451.70
X
26320
002
90
2
X
979.61
X
26320
003
90
2
X
818.73
X
26320
004
90
2
X
831.16
X
26320
001
90
2
X
892.13
X
26340
002
90
2
X
567.61
X
26340
003
90
2
X
567.61
X
26340
004
90
2
X
567.61
X
26340
001
90
2
X
651.77
X
26341
002
10
2
X
158.16
120.96
26341
003
10
2
X
158.16
120.96
26341
004
10
2
X
158.16
120.96
26341
001
10
2
X
178.41
135.26
26350
001
90
2
X
1,734.98
X
26350
003
90
2
X
1,505.13
X
26350
002
90
2
X
1,488.01
X
26350
004
90
2
X
1,428.28
X
26352
001
90
2
X
2,101.18
X
26352
004
90
2
X
1,541.22
X
26352
002
90
2
X
2,075.75
X
26352
003
90
2
X
1,559.66
X
26356
004
90
2
X
1,595.53
X
26356
002
90
2
X
1,737.16
X
26356
003
90
2
X
1,614.82
X
26356
001
90
2
X
1,792.74
X
26357
002
90
2
X
1,781.57
X
26357
003
90
2
X
1,714.75
X
26357
004
90
2
X
1,842.61
X
26357
001
90
2
X
1,810.44
X
26358
001
90
2
X
1,971.81
X
26358
004
90
2
X
1,790.16
X
26358
003
90
2
X
1,811.45
X
26358
002
90
2
X
1,940.47
X
26370
001
90
2
X
1,823.11
X
26370
004
90
2
X
1,781.14
X
26370
002
90
2
X
1,703.93
X
26370
003
90
2
X
1,515.09
X
26372
003
90
2
X
1,792.13
X
26372
002
90
2
X
2,115.69
X
26372
001
90
2
X
1,888.02
X
26372
004
90
2
X
1,631.74
X
26373
004
90
2
X
1,611.73
X
26373
001
90
2
X
1,774.45
X
26373
002
90
2
X
1,746.50
X
26373
003
90
2
X
1,630.99
X
26390
002
90
2
X
2,129.61
X
26390
003
90
2
X
1,867.83
X
26390
004
90
2
X
2,019.09
X
26390
001
90
2
X
2,030.12
X
26392
002
90
2
X
2,285.62
X
26392
003
90
2
X
2,048.75
X
26392
004
90
2
X
2,167.95
X
26392
001
90
2
X
2,348.87
X
26410
004
90
2
X
1,036.86
X
26410
001
90
2
X
1,094.82
X
26410
002
90
2
X
1,089.04
X
26410
003
90
2
X
972.60
X
26412
004
90
2
X
1,327.62
X
26412
003
90
2
X
1,343.75
X
26412
002
90
2
X
1,584.50
X
26412
001
90
2
X
1,466.80
X
26415
003
90
2
X
1,879.26
X
26415
002
90
2
X
1,983.23
X
26415
001
90
2
X
1,769.92
X
26415
004
90
2
X
1,950.56
X
26416
001
90
2
X
2,173.03
X
26416
004
90
2
X
1,969.28
X
26416
003
90
2
X
1,993.02
X
26416
002
90
2
X
2,137.92
X
26418
002
90
2
X
1,088.95
X
26418
003
90
2
X
949.40
X
26418
001
90
2
X
1,097.14
X
26418
004
90
2
X
1,061.10
X
26420
003
90
2
X
1,356.72
X
26420
002
90
2
X
1,454.52
X
26420
004
90
2
X
1,340.66
X
26420
001
90
2
X
1,478.15
X
26426
003
90
2
X
1,566.99
X
26426
002
90
2
X
1,683.32
X
26426
004
90
2
X
1,362.67
X
26426
001
90
2
X
1,721.61
X
26428
003
90
2
X
1,399.48
X
26428
002
90
2
X
1,499.40
X
26428
004
90
2
X
1,383.22
X
26428
001
90
2
X
1,523.68
X
26432
003
90
2
X
1,092.63
X
26432
002
90
2
X
1,092.84
X
26432
001
90
2
X
931.53
X
26432
004
90
2
X
1,058.20
X
26433
001
90
2
X
1,218.46
X
26433
003
90
2
X
1,154.57
X
26433
002
90
2
X
1,215.26
X
26433
004
90
2
X
1,126.02
X
26434
002
90
2
X
1,527.94
X
26434
003
90
2
X
1,209.57
X
26434
001
90
2
X
1,316.57
X
26434
004
90
2
X
1,195.48
X
26437
004
90
2
X
1,060.31
X
26437
001
90
2
X
1,482.15
X
26437
002
90
2
X
1,310.68
X
26437
003
90
2
X
1,072.69
X
26440
002
90
2
X
1,037.02
X
26440
003
90
2
X
988.66
X
26440
004
90
2
X
1,006.17
X
26440
001
90
2
X
1,037.18
X
26442
004
90
2
X
1,042.80
X
26442
001
90
2
X
1,135.61
X
26442
003
90
2
X
1,202.92
X
26442
002
90
2
X
1,188.47
X
26445
003
90
2
X
831.43
X
26445
002
90
2
X
842.73
X
26445
004
90
2
X
821.76
X
26445
001
90
2
X
902.32
X
26449
004
90
2
X
1,331.82
X
26449
002
90
2
X
1,444.81
X
26449
003
90
2
X
1,347.70
X
26449
001
90
2
X
1,468.29
X
26450
001
90
2
X
696.73
X
26450
004
90
2
X
639.15
X
26450
002
90
2
X
727.23
X
26450
003
90
2
X
646.52
X
26455
004
90
2
X
593.23
X
26455
001
90
2
X
645.29
X
26455
003
90
2
X
599.91
X
26455
002
90
2
X
544.29
X
26460
001
90
2
X
1,024.13
X
26460
003
90
2
X
834.35
X
26460
002
90
2
X
920.83
X
26460
004
90
2
X
554.53
X
26471
004
90
2
X
1,071.24
X
26471
002
90
2
X
1,249.02
X
26471
003
90
2
X
1,083.83
X
26471
001
90
2
X
1,173.69
X
26474
001
90
2
X
1,192.40
X
26474
004
90
2
X
1,082.57
X
26474
003
90
2
X
1,095.61
X
26474
002
90
2
X
1,173.53
X
26476
004
90
2
X
844.10
X
26476
002
90
2
X
897.41
X
26476
001
90
2
X
907.86
X
26476
003
90
2
X
853.95
X
26477
004
90
2
X
1,000.40
X
26477
002
90
2
X
1,221.36
X
26477
003
90
2
X
1,012.10
X
26477
001
90
2
X
1,102.54
X
26478
001
90
2
X
1,205.79
X
26478
004
90
2
X
1,098.64
X
26478
003
90
2
X
1,111.57
X
26478
002
90
2
X
1,187.43
X
26479
001
90
2
X
1,330.63
X
26479
004
90
2
X
1,206.33
X
26479
003
90
2
X
1,220.76
X
26479
002
90
2
X
1,309.30
X
26480
003
90
2
X
1,521.86
X
26480
002
90
2
X
1,636.85
X
26480
004
90
2
X
1,454.13
X
26480
001
90
2
X
1,707.60
X
26483
004
90
2
X
1,828.55
X
26483
002
90
2
X
1,991.37
X
26483
003
90
2
X
1,850.86
X
26483
001
90
2
X
2,025.33
X
26485
003
90
2
X
1,592.91
X
26485
002
90
2
X
1,827.88
X
26485
001
90
2
X
1,945.21
X
26485
004
90
2
X
1,531.33
X
26489
003
90
2
X
1,238.94
X
26489
002
90
2
X
1,278.69
X
26489
001
90
2
X
1,442.58
X
26489
004
90
2
X
1,342.08
X
26490
004
90
2
X
1,758.05
X
26490
003
90
2
X
1,779.23
X
26490
002
90
2
X
1,909.54
X
26490
001
90
2
X
1,941.08
X
26492
004
90
2
X
1,969.55
X
26492
002
90
2
X
2,129.31
X
26492
003
90
2
X
1,993.53
X
26492
001
90
2
X
2,162.02
X
26494
001
90
2
X
1,881.99
X
26494
004
90
2
X
1,706.47
X
26494
002
90
2
X
1,851.72
X
26494
003
90
2
X
1,726.88
X
26496
001
90
2
X
2,214.51
X
26496
004
90
2
X
2,002.27
X
26496
002
90
2
X
2,177.81
X
26496
003
90
2
X
2,026.23
X
26497
001
90
2
X
2,109.63
X
26497
004
90
2
X
1,913.10
X
26497
002
90
2
X
1,969.71
X
26497
003
90
2
X
1,935.82
X
26498
004
90
2
X
2,622.00
X
26498
001
90
2
X
3,111.30
X
26498
002
90
2
X
3,061.38
X
26498
003
90
2
X
2,855.44
X
26499
001
90
2
X
1,993.45
X
26499
004
90
2
X
1,810.20
X
26499
002
90
2
X
1,961.93
X
26499
003
90
2
X
1,831.95
X
26500
001
90
2
X
961.47
X
26500
004
90
2
X
892.35
X
26500
002
90
2
X
1,086.77
X
26500
003
90
2
X
1,021.50
X
26502
004
90
2
X
1,337.54
X
26502
002
90
2
X
1,448.94
X
26502
003
90
2
X
1,353.11
X
26502
001
90
2
X
1,472.13
X
26508
001
90
2
X
1,188.50
X
26508
004
90
2
X
1,082.72
X
26508
003
90
2
X
1,095.34
X
26508
002
90
2
X
1,170.36
X
26510
001
90
2
X
1,119.15
X
26510
004
90
2
X
1,018.23
X
26510
002
90
2
X
1,101.82
X
26510
003
90
2
X
1,030.28
X
26516
001
90
2
X
1,306.74
X
26516
002
90
2
X
1,850.85
X
26516
003
90
2
X
1,557.11
X
26516
004
90
2
X
1,199.17
X
26517
004
90
2
X
1,715.83
X
26517
001
90
2
X
2,782.01
X
26517
003
90
2
X
2,717.16
X
26517
002
90
2
X
1,860.49
X
26518
002
90
2
X
1,818.47
X
26518
003
90
2
X
1,697.58
X
26518
001
90
2
X
3,427.56
X
26518
004
90
2
X
1,678.02
X
26520
003
90
2
X
1,064.62
X
26520
002
90
2
X
1,139.50
X
26520
001
90
2
X
1,257.29
X
26520
004
90
2
X
1,079.98
X
26525
003
90
2
X
1,136.61
X
26525
002
90
2
X
1,156.74
X
26525
004
90
2
X
1,139.72
X
26525
001
90
2
X
1,134.54
X
26530
002
90
2
X
1,448.94
X
26530
003
90
2
X
1,411.45
X
26530
004
90
2
X
1,349.49
X
26530
001
90
2
X
1,458.03
X
26531
001
90
2
X
1,739.84
X
26531
003
90
2
X
1,653.83
X
26531
002
90
2
X
1,712.25
X
26531
004
90
2
X
1,645.96
X
26535
002
90
2
X
1,305.56
X
26535
003
90
2
X
1,228.95
X
26535
004
90
2
X
1,066.72
X
26535
001
90
2
X
1,333.17
X
26536
001
90
2
X
1,775.19
X
26536
004
90
2
X
1,707.00
X
26536
003
90
2
X
1,695.91
X
26536
002
90
2
X
1,763.41
X
26540
001
90
2
X
1,838.66
X
26540
004
90
2
X
1,722.05
X
26540
002
90
2
X
1,705.30
X
26540
003
90
2
X
1,700.11
X
26541
001
90
2
X
2,121.34
X
26541
004
90
2
X
1,914.87
X
26541
002
90
2
X
2,082.74
X
26541
003
90
2
X
1,938.27
X
26542
002
90
2
X
1,455.99
X
26542
003
90
2
X
1,357.74
X
26542
004
90
2
X
1,341.82
X
26542
001
90
2
X
1,479.73
X
26545
004
90
2
X
1,311.46
X
26545
001
90
2
X
1,444.52
X
26545
002
90
2
X
1,421.58
X
26545
003
90
2
X
1,326.89
X
26546
004
90
2
X
1,802.56
X
26546
001
90
2
X
2,070.72
X
26546
003
90
2
X
1,802.56
X
26546
002
90
2
X
1,852.29
X
26548
003
90
2
X
1,503.11
X
26548
001
90
2
X
1,631.87
X
26548
002
90
2
X
1,606.73
X
26548
004
90
2
X
1,485.89
X
26550
001
90
2
X
1,631.87
X
26550
004
90
2
X
1,485.89
X
26550
002
90
2
X
1,606.73
X
26550
003
90
2
X
1,503.11
X
26551
002
90
2
X
9,652.18
X
26551
003
90
2
X
9,392.73
X
26551
001
90
2
X
10,789.19
X
26551
004
90
2
X
9,392.73
X
26553
002
90
2
X
9,585.10
X
26553
003
90
2
X
9,327.44
X
26553
001
90
2
X
10,714.16
X
26553
004
90
2
X
9,327.44
X
26554
003
90
2
X
11,128.96
X
26554
002
90
2
X
11,436.34
X
26554
001
90
2
X
12,783.64
X
26554
004
90
2
X
11,128.96
X
26555
002
90
2
X
4,025.36
X
26555
003
90
2
X
3,759.82
X
26555
004
90
2
X
3,708.04
X
26555
001
90
2
X
4,151.09
X
26556
004
90
2
X
9,486.17
X
26556
002
90
2
X
9,748.13
X
26556
003
90
2
X
9,486.17
X
26556
001
90
2
X
10,896.61
X
26560
003
90
2
X
1,099.54
X
26560
002
90
2
X
1,173.58
X
26560
004
90
2
X
1,086.45
X
26560
001
90
2
X
1,823.47
X
26561
001
90
2
X
2,382.79
X
26561
004
90
2
X
2,161.70
X
26561
003
90
2
X
2,187.20
X
26561
002
90
2
X
2,344.68
X
26562
001
90
2
X
2,346.26
X
26562
003
90
2
X
2,184.64
X
26562
002
90
2
X
2,314.99
X
26562
004
90
2
X
2,156.76
X
26565
001
90
2
X
1,483.73
X
26565
004
90
2
X
1,351.30
X
26565
002
90
2
X
1,488.72
X
26565
003
90
2
X
1,367.56
X
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