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2024 Workers' Compensation Part B Fee Schedule

51785-53510

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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
51785		001	XXX	2	X	272.82	X
51785	26	001	XXX	2	X	229.20	X
51785	TC	001	XXX	2	X	48.83	X
51785		003	XXX	2	X	249.00	X
51785	26	003	XXX	2	X	221.20	X
51785	TC	003	XXX	2	X	43.46	X
51785		002	XXX	2	X	267.35	X
51785	26	002	XXX	2	X	227.58	X
51785	TC	002	XXX	2	X	47.80	X
51785		004	XXX	2	X	244.31	X
51785	26	004	XXX	2	X	219.64	X
51785	TC	004	XXX	2	X	42.87	X
51792		003	0	2	X	280.79	X
51792	26	003	0	2	X	183.26	X
51792	TC	003	0	2	X	150.82	X
51792		002	0	2	X	360.72	X
51792	26	002	0	2	X	192.66	X
51792	TC	002	0	2	X	165.69	X
51792		004	0	2	X	329.72	X
51792	26	004	0	2	X	181.22	X
51792	TC	004	0	2	X	148.51	X
51792		001	0	2	X	364.14	X
51792	26	001	0	2	X	194.95	X
51792	TC	001	0	2	X	169.20	X
51797		002	ZZZ	0	X	258.63	X
51797	26	002	ZZZ	0	X	208.48	X
51797	TC	002	ZZZ	0	X	55.72	X
51797		003	ZZZ	0	X	250.05	X
51797	26	003	ZZZ	0	X	190.91	X
51797	TC	003	ZZZ	0	X	50.61	X
51797		004	ZZZ	0	X	275.14	X
51797	26	004	ZZZ	0	X	225.31	X
51797	TC	004	ZZZ	0	X	49.87	X
51797		001	ZZZ	0	X	260.66	X
51797	26	001	ZZZ	0	X	209.82	X
51797	TC	001	ZZZ	0	X	56.98	X
51798		003	XXX	0	X	40.82	X
51798		002	XXX	0	X	40.82	X
51798		004	XXX	0	X	40.82	X
51798		001	XXX	0	X	50.90	X
51800		001	90	2	X	3,344.67	X
51800		004	90	2	X	3,075.91	X
51800		003	90	2	X	3,112.51	X
51800		002	90	2	X	3,299.54	X
51820		001	90	2	X	2,051.59	X
51820		004	90	2	X	1,914.43	X
51820		002	90	2	X	2,022.61	X
51820		003	90	2	X	1,922.11	X
51840		004	90	2	X	1,875.29	X
51840		001	90	2	X	2,126.04	X
51840		003	90	2	X	1,875.29	X
51840		002	90	2	X	1,875.29	X
51841		004	90	2	X	2,709.80	X
51841		003	90	2	X	2,631.68	X
51841		002	90	2	X	2,733.99	X
51841		001	90	2	X	2,775.23	X
51845		003	90	2	X	2,556.14	X
51845		002	90	2	X	2,604.53	X
51845		001	90	2	X	2,629.95	X
51845		004	90	2	X	2,544.62	X
51860		001	90	2	X	2,206.54	X
51860		004	90	2	X	2,034.09	X
51860		003	90	2	X	2,058.15	X
51860		002	90	2	X	2,177.57	X
51865		002	90	2	X	2,901.37	X
51865		003	90	2	X	2,736.90	X
51865		004	90	2	X	2,704.41	X
51865		001	90	2	X	2,941.07	X
51880		001	90	2	X	1,419.27	X
51880		003	90	2	X	1,327.02	X
51880		002	90	2	X	1,401.37	X
51880		004	90	2	X	1,311.46	X
51900		004	90	2	X	2,545.19	X
51900		001	90	2	X	3,243.78	X
51900		003	90	2	X	2,811.47	X
51900		002	90	2	X	3,143.31	X
51920		002	90	2	X	2,073.70	X
51920		003	90	2	X	1,965.12	X
51920		001	90	2	X	2,099.88	X
51920		004	90	2	X	1,941.89	X
51925		002	90	2	X	2,982.92	X
51925		003	90	2	X	2,771.40	X
51925		004	90	2	X	2,740.32	X
51925		001	90	2	X	3,034.43	X
51940		001	90	2	X	5,177.94	X
51940		004	90	2	X	4,763.80	X
51940		003	90	2	X	4,820.77	X
51940		002	90	2	X	5,108.44	X
51960		004	90	2	X	4,611.30	X
51960		003	90	2	X	4,668.73	X
51960		002	90	2	X	4,964.23	X
51960		001	90	2	X	5,035.39	X
51980		001	90	2	X	2,947.81	X
51980		004	90	2	X	1,924.45	X
51980		002	90	2	X	2,853.57	X
51980		003	90	2	X	1,947.48	X
51990		002	90	2	X	1,654.53	X
51990		003	90	2	X	1,654.53	X
51990		001	90	2	X	1,822.36	X
51990		004	90	2	X	1,654.53	X
51992		001	90	2	X	1,980.49	X
51992		004	90	2	X	1,805.37	X
51992		003	90	2	X	1,805.37	X
51992		002	90	2	X	1,805.37	X
51999			YYY	0	X	#	X
52000		003	0	2	X	362.90	X
52000		002	0	2	X	382.87	X
52000		004	0	2	X	358.63	X
52000		001	0	2	X	387.74	X
52001		004	0	3	X	286.88	X
52001		001	0	3	X	323.27	X
52001		003	0	3	X	286.88	X
52001		002	0	3	X	286.88	X
52005		004	0	3	X	492.75	X
52005		002	0	3	X	528.88	X
52005		003	0	3	X	498.82	X
52005		001	0	3	X	536.14	X
52007		003	0	3	X	615.35	X
52007		002	0	3	X	646.10	X
52007		001	0	3	X	643.43	X
52007		004	0	3	X	597.46	X
52010		002	0	3	X	499.68	X
52010		003	0	3	X	534.73	X
52010		001	0	3	X	570.69	X
52010		004	0	3	X	528.55	X
52204		001	0	3	X	660.30	X
52204		004	0	3	X	627.90	X
52204		002	0	3	X	585.05	X
52204		003	0	3	X	532.49	X
52214		001	0	3	X	817.77	X
52214		002	0	3	X	808.70	X
52214		003	0	3	X	733.09	X
52214		004	0	3	X	796.10	X
52224		002	0	3	X	795.24	X
52224		003	0	3	X	694.62	X
52224		004	0	3	X	741.29	X
52224		001	0	3	X	794.68	X
52234		004	0	3	X	1,126.04	X
52234		001	0	3	X	1,166.16	X
52234		003	0	3	X	1,127.82	X
52234		002	0	3	X	1,159.29	X
52235		002	0	3	X	1,712.06	X
52235		003	0	3	X	1,664.55	X
52235		004	0	3	X	1,753.11	X
52235		001	0	3	X	1,897.94	X
52240		001	0	3	X	2,402.18	X
52240		004	0	3	X	2,262.84	X
52240		003	0	3	X	2,188.35	X
52240		002	0	3	X	2,421.01	X
52250		004	0	3	X	790.14	X
52250		003	0	3	X	639.22	X
52250		002	0	3	X	842.41	X
52250		001	0	3	X	852.81	X
52260		004	0	3	X	550.24	X
52260		001	0	3	X	576.63	X
52260		002	0	3	X	571.13	X
52260		003	0	3	X	554.10	X
52265		001	0	3	X	445.34	X
52265		003	0	3	X	406.40	X
52265		002	0	3	X	431.23	X
52265		004	0	3	X	420.54	X
52270		004	0	3	X	788.17	X
52270		001	0	3	X	857.29	X
52270		003	0	3	X	797.96	X
52270		002	0	3	X	845.82	X
52275		001	0	3	X	944.37	X
52275		003	0	3	X	883.21	X
52275		002	0	3	X	947.28	X
52275		004	0	3	X	872.72	X
52276		001	0	3	X	1,004.82	X
52276		002	0	3	X	990.38	X
52276		003	0	3	X	972.50	X
52276		004	0	3	X	967.54	X
52277		002	0	3	X	1,134.82	X
52277		003	0	3	X	1,059.61	X
52277		004	0	3	X	1,182.16	X
52277		001	0	3	X	1,182.39	X
52281		004	0	3	X	474.43	369.49
52281		002	0	3	X	474.43	369.49
52281		003	0	3	X	474.43	369.49
52281		001	0	3	X	532.83	409.52
52282		001	0	3	X	1,133.77	X
52282		003	0	3	X	1,015.71	X
52282		002	0	3	X	1,015.71	X
52282		004	0	3	X	1,015.71	X
52283		004	0	3	X	560.60	X
52283		002	0	3	X	478.00	X
52283		003	0	3	X	566.74	X
52283		001	0	3	X	599.19	X
52284		004	0	3	X	2,760.57	173.67
52284		003	0	3	X	2,760.57	173.67
52284		002	0	3	X	2,760.57	173.67
52284		001	0	3	X	3,126.28	187.77
52285		004	0	3	X	722.61	X
52285		003	0	3	X	738.22	X
52285		002	0	3	X	781.04	X
52285		001	0	3	X	765.79	X
52287		001	0	3	X	536.80	289.30
52287		004	0	3	X	480.08	266.67
52287		002	0	3	X	480.08	266.67
52287		003	0	3	X	480.08	266.67
52290		002	0	3	X	788.90	X
52290		003	0	3	X	751.24	X
52290		001	0	3	X	797.98	X
52290		004	0	3	X	742.71	X
52300		001	0	3	X	1,101.72	X
52300		004	0	3	X	1,049.85	X
52300		003	0	3	X	959.59	X
52300		002	0	3	X	1,096.43	X
52301		004	0	3	X	943.50	X
52301		002	0	3	X	969.55	X
52301		003	0	3	X	943.50	X
52301		001	0	3	X	1,051.51	X
52305		001	0	3	X	1,021.74	X
52305		002	0	3	X	1,009.22	X
52305		003	0	3	X	957.37	X
52305		004	0	3	X	946.18	X
52310		001	0	3	X	832.06	X
52310		003	0	3	X	788.78	X
52310		002	0	3	X	818.93	X
52310		004	0	3	X	797.76	X
52315		001	0	3	X	1,081.96	X
52315		003	0	3	X	1,022.10	X
52315		002	0	3	X	1,068.09	X
52315		004	0	3	X	998.47	X
52317		004	0	3	X	1,389.70	X
52317		001	0	3	X	1,511.02	X
52317		003	0	3	X	1,406.96	X
52317		002	0	3	X	1,490.78	X
52318		004	0	3	X	1,838.14	X
52318		001	0	3	X	1,996.14	X
52318		002	0	3	X	1,969.81	X
52318		003	0	3	X	1,860.66	X
52320		004	0	3	X	1,031.09	X
52320		001	0	3	X	1,178.86	X
52320		003	0	3	X	1,142.14	X
52320		002	0	3	X	1,108.82	X
52325		001	0	3	X	1,555.10	X
52325		004	0	3	X	1,423.20	X
52325		002	0	3	X	1,532.96	X
52325		003	0	3	X	1,441.25	X
52327		001	0	3	X	1,111.18	X
52327		003	0	3	X	1,026.73	X
52327		002	0	3	X	1,084.51	X
52327		004	0	3	X	1,013.03	X
52330		001	0	3	X	1,122.09	X
52330		003	0	3	X	1,078.98	X
52330		002	0	3	X	1,030.33	X
52330		004	0	3	X	915.12	X
52332		002	0	3	X	781.11	X
52332		003	0	3	X	764.84	X
52332		004	0	3	X	753.04	X
52332		001	0	3	X	786.03	X
52334		003	0	3	X	1,108.17	X
52334		002	0	3	X	1,098.38	X
52334		001	0	3	X	1,163.97	X
52334		004	0	3	X	1,090.76	X
52341		004	0	3	X	748.14	X
52341		002	0	3	X	748.14	X
52341		003	0	3	X	748.14	X
52341		001	0	3	X	818.75	X
52342		004	0	3	X	809.96	X
52342		001	0	3	X	886.00	X
52342		002	0	3	X	809.96	X
52342		003	0	3	X	809.96	X
52343		002	0	3	X	897.20	X
52343		003	0	3	X	897.20	X
52343		001	0	3	X	981.56	X
52343		004	0	3	X	897.20	X
52344		001	0	3	X	1,048.80	X
52344		003	0	3	X	959.06	X
52344		002	0	3	X	959.06	X
52344		004	0	3	X	959.06	X
52345		001	0	3	X	1,118.38	X
52345		004	0	3	X	1,022.12	X
52345		002	0	3	X	1,022.12	X
52345		003	0	3	X	1,022.12	X
52346		002	0	3	X	1,149.86	X
52346		003	0	3	X	1,149.86	X
52346		001	0	3	X	1,257.80	X
52346		004	0	3	X	1,149.86	X
52351		001	0	2	X	836.67	X
52351		002	0	2	X	762.69	X
52351		003	0	2	X	762.69	X
52351		004	0	2	X	762.69	X
52352		003	0	3	X	942.31	X
52352		002	0	3	X	942.31	X
52352		004	0	3	X	942.31	X
52352		001	0	3	X	1,037.40	X
52353		002	0	3	X	1,091.66	X
52353		003	0	3	X	1,091.66	X
52353		001	0	3	X	1,201.83	X
52353		004	0	3	X	1,091.66	X
52354		001	0	3	X	1,049.80	X
52354		002	0	3	X	956.54	X
52354		003	0	3	X	956.54	X
52354		004	0	3	X	956.54	X
52355		001	0	3	X	1,231.91	X
52355		004	0	3	X	1,123.91	X
52355		002	0	3	X	1,123.91	X
52355		003	0	3	X	1,123.91	X
52356		004	0	3	X	668.96	X
52356		001	0	3	X	720.81	X
52356		003	0	3	X	668.96	X
52356		002	0	3	X	668.96	X
52400		003	90	3	X	1,333.94	X
52400		002	90	3	X	1,333.94	X
52400		004	90	3	X	1,333.94	X
52400		001	90	3	X	1,468.96	X
52402		002	0	3	X	566.64	X
52402		003	0	3	X	566.64	X
52402		001	0	3	X	617.91	X
52402		004	0	3	X	566.64	X
52441		003	0	3	X	1,860.71	373.35
52441		002	0	3	X	1,860.71	373.35
52441		001	0	3	X	2,143.78	403.46
52441		004	0	3	X	1,860.71	373.35
52442		003	ZZZ	0	X	1,436.91	129.20
52442		002	ZZZ	0	X	1,436.91	129.20
52442		001	ZZZ	0	X	1,675.61	145.52
52442		004	ZZZ	0	X	1,436.91	129.20
52450		002	90	2	X	1,382.76	X
52450		003	90	2	X	1,310.10	X
52450		004	90	2	X	1,294.66	X
52450		001	90	2	X	1,400.31	X
52500		004	90	2	X	1,733.33	X
52500		002	90	2	X	1,838.39	X
52500		003	90	2	X	1,749.60	X
52500		001	90	2	X	1,789.99	X
52601		004	90	2	X	2,646.38	X
52601		002	90	2	X	2,830.50	X
52601		003	90	2	X	2,684.78	X
52601		001	90	2	X	2,868.70	X
52630		004	90	2	X	2,341.90	X
52630		002	90	2	X	2,470.51	X
52630		003	90	2	X	2,406.34	X
52630		001	90	2	X	2,484.34	X
52640		001	90	2	X	1,640.41	X
52640		003	90	2	X	1,596.10	X
52640		002	90	2	X	1,631.75	X
52640		004	90	2	X	1,589.00	X
52647		001	90	2	X	2,868.70	X
52647		002	90	2	X	2,830.50	X
52647		003	90	2	X	2,684.78	X
52647		004	90	2	X	2,646.38	X
52648		003	90	2	X	2,684.78	X
52648		002	90	2	X	2,830.50	X
52648		004	90	2	X	2,646.38	X
52648		001	90	2	X	2,868.70	X
52649		001	90	2	X	1,927.03	X
52649		004	90	2	X	1,742.73	X
52649		003	90	2	X	1,742.73	X
52649		002	90	2	X	1,742.73	X
52700		002	90	2	X	1,125.89	X
52700		003	90	2	X	1,042.18	X
52700		004	90	2	X	1,081.51	X
52700		001	90	2	X	1,159.27	X
53000		001	10	2	X	463.32	X
53000		003	10	2	X	420.34	X
53000		002	10	2	X	444.46	X
53000		004	10	2	X	405.37	X
53010		002	90	2	X	895.32	X
53010		003	90	2	X	851.69	X
53010		001	90	2	X	776.29	X
53010		004	90	2	X	708.92	X
53020		002	0	2	X	294.89	X
53020		003	0	2	X	301.30	X
53020		004	0	2	X	277.93	X
53020		001	0	2	X	301.86	X
53025		003	0	2	X	209.70	X
53025		002	0	2	X	221.42	X
53025		001	0	2	X	224.18	X
53025		004	0	2	X	207.31	X
53040		001	90	2	X	839.43	X
53040		004	90	2	X	837.69	X
53040		003	90	2	X	813.85	X
53040		002	90	2	X	786.09	X
53060		004	10	2	X	330.35	X
53060		002	10	2	X	315.40	X
53060		003	10	2	X	333.79	X
53060		001	10	2	X	350.15	X
53080		001	90	2	X	1,151.89	X
53080		004	90	2	X	1,063.57	X
53080		002	90	2	X	1,137.19	X
53080		003	90	2	X	1,076.14	X
53085		004	90	2	X	1,768.77	X
53085		002	90	2	X	1,890.02	X
53085		003	90	2	X	1,789.86	X
53085		001	90	2	X	1,914.31	X
53200		003	0	2	X	399.53	X
53200		002	0	2	X	418.67	X
53200		004	0	2	X	395.17	X
53200		001	0	2	X	423.32	X
53210		003	90	2	X	1,871.22	X
53210		002	90	2	X	1,990.71	X
53210		001	90	2	X	1,970.56	X
53210		004	90	2	X	1,967.96	X
53215		001	90	2	X	2,849.67	X
53215		003	90	2	X	2,669.49	X
53215		002	90	2	X	2,814.57	X
53215		004	90	2	X	2,638.10	X
53220		002	90	2	X	1,306.56	X
53220		003	90	2	X	1,236.56	X
53220		004	90	2	X	1,221.92	X
53220		001	90	2	X	1,323.49	X
53230		001	90	2	X	1,988.63	X
53230		003	90	2	X	1,852.06	X
53230		002	90	2	X	1,962.11	X
53230		004	90	2	X	1,829.59	X
53235		001	90	2	X	1,574.81	X
53235		004	90	2	X	1,465.58	X
53235		002	90	2	X	1,425.63	X
53235		003	90	2	X	1,381.68	X
53240		001	90	2	X	1,039.63	X
53240		004	90	2	X	1,115.86	X
53240		003	90	2	X	1,129.22	X
53240		002	90	2	X	1,017.02	X
53250		004	90	2	X	1,045.45	X
53250		002	90	2	X	1,116.56	X
53250		003	90	2	X	699.81	X
53250		001	90	2	X	1,130.58	X
53260		001	10	2	X	522.78	X
53260		004	10	2	X	509.09	X
53260		003	10	2	X	506.45	X
53260		002	10	2	X	489.73	X
53265		003	10	2	X	686.35	X
53265		002	10	2	X	732.63	X
53265		004	10	2	X	660.52	X
53265		001	10	2	X	635.41	X
53270		002	10	2	X	436.68	X
53270		003	10	2	X	336.51	X
53270		001	10	2	X	441.91	X
53270		004	10	2	X	411.03	X
53275		001	10	2	X	757.76	X
53275		004	10	2	X	723.90	X
53275		002	10	2	X	764.95	X
53275		003	10	2	X	732.22	X
53400		004	90	2	X	2,069.02	X
53400		002	90	2	X	2,206.27	X
53400		003	90	2	X	2,093.37	X
53400		001	90	2	X	2,233.61	X
53405		001	90	2	X	2,835.96	X
53405		004	90	2	X	2,609.45	X
53405		003	90	2	X	2,640.64	X
53405		002	90	2	X	2,797.94	X
53410		004	90	2	X	2,586.79	X
53410		001	90	2	X	2,782.25	X
53410		003	90	2	X	2,616.73	X
53410		002	90	2	X	2,749.96	X
53415		003	90	2	X	3,104.54	X
53415		002	90	2	X	3,204.93	X
53415		004	90	2	X	3,257.30	X
53415		001	90	2	X	3,513.95	X
53420		004	90	2	X	1,479.39	X
53420		001	90	2	X	1,634.72	X
53420		002	90	2	X	1,609.62	X
53420		003	90	2	X	2,630.07	X
53425		002	90	2	X	2,785.68	X
53425		003	90	2	X	2,647.49	X
53425		004	90	2	X	2,616.74	X
53425		001	90	2	X	2,819.12	X
53430		001	90	2	X	2,609.99	X
53430		003	90	2	X	2,459.91	X
53430		002	90	2	X	2,580.72	X
53430		004	90	2	X	2,432.50	X
53431		004	90	2	X	2,294.92	X
53431		001	90	2	X	2,521.77	X
53431		003	90	2	X	2,294.92	X
53431		002	90	2	X	2,294.92	X
53440		004	90	2	X	2,847.26	X
53440		003	90	2	X	2,707.83	X
53440		002	90	2	X	2,982.35	X
53440		001	90	2	X	3,074.31	X
53442		001	90	2	X	1,590.20	X
53442		004	90	2	X	1,463.33	X
53442		003	90	2	X	1,480.84	X
53442		002	90	2	X	1,568.98	X
53444		003	90	2	X	1,642.51	X
53444		002	90	2	X	1,642.51	X
53444		004	90	2	X	1,642.51	X
53444		001	90	2	X	1,810.13	X
53445		004	90	2	X	3,468.08	X
53445		002	90	2	X	3,759.00	X
53445		003	90	2	X	3,513.04	X
53445		001	90	2	X	3,818.16	X
53446		004	90	2	X	1,511.28	X
53446		001	90	2	X	1,684.74	X
53446		003	90	2	X	1,511.28	X
53446		002	90	2	X	1,511.28	X
53447		004	90	2	X	2,313.50	X
53447		001	90	2	X	2,503.89	X
53447		003	90	2	X	2,341.35	X
53447		002	90	2	X	2,472.23	X
53448		002	90	2	X	2,733.86	X
53448		003	90	2	X	2,733.86	X
53448		004	90	2	X	2,733.86	X
53448		001	90	2	X	3,024.16	X
53449		001	90	2	X	2,058.54	X
53449		004	90	2	X	1,892.76	X
53449		002	90	2	X	1,932.16	X
53449		003	90	2	X	1,916.22	X
53450		001	90	2	X	969.54	X
53450		004	90	2	X	934.43	X
53450		002	90	2	X	958.82	X
53450		003	90	2	X	914.42	X
53451			10	0	X	#	X
53452			10	0	X	#	X
53453			0	0	X	#	X
53454			0	0	X	*	X
53460		002	90	2	X	1,030.16	X
53460		003	90	2	X	979.71	X
53460		001	90	2	X	1,040.92	X
53460		004	90	2	X	975.19	X
53500		004	90	2	X	1,511.09	X
53500		002	90	2	X	1,511.09	X
53500		003	90	2	X	1,511.09	X
53500		001	90	2	X	1,659.64	X
53502		004	90	2	X	1,316.65	X
53502		003	90	2	X	1,332.27	X
53502		002	90	2	X	1,408.57	X
53502		001	90	2	X	1,560.98	X
53505		004	90	2	X	1,458.26	X
53505		001	90	2	X	1,441.49	X
53505		003	90	2	X	1,348.19	X
53505		002	90	2	X	1,423.30	X
53510		002	90	2	X	1,897.73	X
53510		003	90	2	X	1,798.27	X
53510		001	90	2	X	1,921.64	X
53510		004	90	2	X	1,776.94	X

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