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2024 Workers' Compensation Part B Fee Schedule

57513-59100

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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
57513   001 10 2 X 530.49 X
57513   004 10 2 X 496.39 X
57513   002 10 2 X 508.57 X
57513   003 10 2 X 471.04 X
57520   001 90 2 X 1,052.91 X
57520   004 90 2 X 794.57 X
57520   003 90 2 X 802.13 X
57520   002 90 2 X 1,059.74 X
57522   001 90 2 X 1,052.91 X
57522   003 90 2 X 802.13 X
57522   002 90 2 X 1,059.74 X
57522   004 90 2 X 794.57 X
57530   003 90 2 X 920.28 X
57530   002 90 2 X 1,123.16 X
57530   004 90 2 X 1,017.94 X
57530   001 90 2 X 1,009.16 X
57531   001 90 2 X 4,404.39 X
57531   004 90 2 X 3,835.55 X
57531   002 90 2 X 3,835.55 X
57531   003 90 2 X 3,835.55 X
57540   004 90 2 X 1,468.19 X
57540   001 90 2 X 1,728.68 X
57540   003 90 2 X 1,485.69 X
57540   002 90 2 X 1,616.02 X
57545   004 90 2 X 1,265.12 X
57545   001 90 2 X 1,397.80 X
57545   003 90 2 X 1,651.55 X
57545   002 90 2 X 1,977.25 X
57550   001 90 2 X 1,533.68 X
57550   004 90 2 X 1,356.79 X
57550   003 90 2 X 1,555.80 X
57550   002 90 2 X 1,574.32 X
57555   001 90 2 X 2,357.26 X
57555   004 90 2 X 2,098.20 X
57555   002 90 2 X 2,311.69 X
57555   003 90 2 X 2,123.53 X
57556   003 90 2 X 1,869.63 X
57556   002 90 2 X 1,985.02 X
57556   004 90 2 X 1,945.21 X
57556   001 90 2 X 2,180.60 X
57558   004 10 2 X 205.23 185.22
57558   001 10 2 X 235.78 211.27
57558   002 10 2 X 205.23 185.22
57558   003 10 2 X 205.23 185.22
57700   001 90 2 X 679.39 X
57700   004 90 2 X 622.95 X
57700   002 90 2 X 855.78 X
57700   003 90 2 X 630.29 X
57720   001 90 2 X 809.21 X
57720   002 90 2 X 840.38 X
57720   003 90 2 X 745.31 X
57720   004 90 2 X 736.82 X
57800   001 0 2 X 153.88 X
57800   003 0 2 X 146.53 X
57800   002 0 2 X 153.80 X
57800   004 0 2 X 140.22 X
58100   002 0 2 X 227.50 179.39
58100   003 0 2 X 185.72 145.61
58100   001 0 2 X 260.00 205.32
58100   004 0 2 X 228.10 179.50
58110   002 ZZZ 0 X 97.35 81.61
58110   003 ZZZ 0 X 97.35 81.61
58110   004 ZZZ 0 X 97.35 81.61
58110   001 ZZZ 0 X 110.09 90.86
58120   003 10 2 X 630.65 X
58120   002 10 2 X 684.01 X
58120   004 10 2 X 615.99 X
58120   001 10 2 X 702.37 X
58140   003 90 2 X 1,838.00 X
58140   002 90 2 X 1,991.79 X
58140   004 90 2 X 1,816.28 X
58140   001 90 2 X 2,029.05 X
58145   002 90 2 X 1,927.27 X
58145   003 90 2 X 1,784.88 X
58145   004 90 2 X 1,763.43 X
58145   001 90 2 X 1,964.13 X
58146   003 90 2 X 2,319.54 X
58146   002 90 2 X 2,319.54 X
58146   004 90 2 X 2,319.54 X
58146   001 90 2 X 2,570.09 X
58150   003 90 2 X 2,576.03 X
58150   002 90 2 X 2,769.22 X
58150   004 90 2 X 2,546.91 X
58150   001 90 2 X 2,816.11 X
58152   002 90 2 X 2,605.98 X
58152   004 90 2 X 2,605.98 X
58152   001 90 2 X 2,989.28 X
58152   003 90 2 X 2,605.98 X
58180   001 90 2 X 2,830.68 X
58180   004 90 2 X 2,723.10 X
58180   003 90 2 X 2,733.90 X
58180   002 90 2 X 2,811.76 X
58200   002 90 2 X 3,961.35 X
58200   003 90 2 X 3,497.51 X
58200   004 90 2 X 3,730.62 X
58200   001 90 2 X 4,160.66 X
58210   001 90 2 X 5,213.23 X
58210   003 90 2 X 4,767.27 X
58210   002 90 2 X 5,126.07 X
58210   004 90 2 X 4,713.27 X
58240   002 90 2 X 7,187.76 X
58240   003 90 2 X 6,882.45 X
58240   001 90 2 X 7,320.99 X
58240   004 90 2 X 6,560.94 X
58260   004 90 2 X 2,358.58 X
58260   002 90 2 X 2,573.21 X
58260   003 90 2 X 2,385.78 X
58260   001 90 2 X 2,618.67 X
58262   003 90 2 X 2,563.22 X
58262   002 90 2 X 2,754.90 X
58262   001 90 2 X 2,801.46 X
58262   004 90 2 X 2,534.31 X
58263   001 90 2 X 3,059.96 X
58263   002 90 2 X 3,009.51 X
58263   003 90 2 X 2,801.77 X
58263   004 90 2 X 2,770.12 X
58267   004 90 2 X 2,883.95 X
58267   001 90 2 X 3,198.74 X
58267   003 90 2 X 2,917.44 X
58267   002 90 2 X 3,143.86 X
58270   001 90 2 X 2,877.18 X
58270   004 90 2 X 2,594.35 X
58270   002 90 2 X 2,827.83 X
58270   003 90 2 X 2,624.40 X
58275   002 90 2 X 3,072.14 X
58275   003 90 2 X 2,978.59 X
58275   004 90 2 X 2,996.38 X
58275   001 90 2 X 3,124.70 X
58280   004 90 2 X 2,806.74 X
58280   001 90 2 X 3,104.08 X
58280   003 90 2 X 2,838.82 X
58280   002 90 2 X 3,052.19 X
58285   002 90 2 X 3,568.78 X
58285   003 90 2 X 3,321.29 X
58285   004 90 2 X 3,284.34 X
58285   001 90 2 X 3,628.97 X
58290   001 90 2 X 2,563.19 X
58290   004 90 2 X 2,321.68 X
58290   003 90 2 X 2,321.68 X
58290   002 90 2 X 2,321.68 X
58291   002 90 2 X 2,551.68 X
58291   003 90 2 X 2,551.68 X
58291   004 90 2 X 2,551.68 X
58291   001 90 2 X 2,820.99 X
58292   001 90 2 X 2,989.12 X
58292   004 90 2 X 2,702.71 X
58292   003 90 2 X 2,702.71 X
58292   002 90 2 X 2,702.71 X
58294   001 90 2 X 2,751.27 X
58294   004 90 2 X 2,489.20 X
58294   002 90 2 X 2,489.20 X
58294   003 90 2 X 2,489.20 X
58301     0 2 X * X
58321     0 2 X * X
58322     0 2 X * X
58323     0 2 X * X
58340   003 0 2 X 135.43 X
58340   001 0 2 X 151.74 X
58340   004 0 2 X 135.43 X
58340   002 0 2 X 135.43 X
58345   004 10 2 X 877.68 X
58345   002 10 2 X 941.02 X
58345   001 10 2 X 953.83 X
58345   003 10 2 X 888.13 X
58346   001 90 2 X 987.89 X
58346   003 90 2 X 882.23 X
58346   002 90 2 X 882.23 X
58346   004 90 2 X 882.23 X
58350   004 10 2 X 187.08 X
58350   003 10 2 X 189.24 X
58350   002 10 2 X 203.65 X
58350   001 10 2 X 207.21 X
58353   001 10 2 X 555.83 X
58353   004 10 2 X 504.09 X
58353   002 10 2 X 504.09 X
58353   003 10 2 X 504.09 X
58356   001 10 2 X 1,199.46 834.84
58356   004 10 2 X 1,053.02 748.86
58356   003 10 2 X 1,053.02 748.86
58356   002 10 2 X 1,053.02 748.86
58400   004 90 2 X 1,282.91 X
58400   002 90 2 X 1,601.88 X
58400   003 90 2 X 1,298.15 X
58400   001 90 2 X 1,429.02 X
58410   004 90 2 X 1,356.87 X
58410   002 90 2 X 1,465.14 X
58410   003 90 2 X 1,372.98 X
58410   001 90 2 X 1,487.49 X
58520   003 90 2 X 1,211.56 X
58520   001 90 2 X 1,324.03 X
58520   002 90 2 X 1,849.69 X
58520   004 90 2 X 1,198.11 X
58540   001 90 2 X 1,847.97 X
58540   003 90 2 X 1,687.61 X
58540   002 90 2 X 1,816.62 X
58540   004 90 2 X 1,668.78 X
58541   004 90 3 X 1,374.53 X
58541   001 90 3 X 1,548.35 X
58541   003 90 3 X 1,374.53 X
58541   002 90 3 X 1,374.53 X
58542   004 90 2 X 1,522.82 X
58542   002 90 2 X 1,522.82 X
58542   003 90 2 X 1,522.82 X
58542   001 90 2 X 1,707.09 X
58543   001 90 2 X 1,735.87 X
58543   004 90 2 X 1,548.58 X
58543   002 90 2 X 1,548.58 X
58543   003 90 2 X 1,548.58 X
58544   002 90 2 X 1,676.82 X
58544   003 90 2 X 1,676.82 X
58544   004 90 2 X 1,676.82 X
58544   001 90 2 X 1,878.66 X
58545   002 90 2 X 1,858.38 X
58545   003 90 2 X 1,858.38 X
58545   004 90 2 X 1,858.38 X
58545   001 90 2 X 2,077.74 X
58546   002 90 2 X 2,349.20 X
58546   003 90 2 X 2,349.20 X
58546   001 90 2 X 2,604.63 X
58546   004 90 2 X 2,349.20 X
58548   004 90 2 X 2,929.90 X
58548   001 90 2 X 3,293.78 X
58548   003 90 2 X 2,929.90 X
58548   002 90 2 X 2,929.90 X
58550   001 90 3 X 2,233.08 X
58550   004 90 3 X 2,014.34 X
58550   003 90 3 X 2,014.34 X
58550   002 90 3 X 2,014.34 X
58552   001 90 2 X 2,024.55 X
58552   003 90 2 X 1,809.53 X
58552   002 90 2 X 1,809.53 X
58552   004 90 2 X 1,809.53 X
58553   002 90 2 X 2,336.81 X
58553   003 90 2 X 2,336.81 X
58553   004 90 2 X 2,336.81 X
58553   001 90 2 X 2,581.02 X
58554   003 90 2 X 2,313.33 X
58554   002 90 2 X 2,313.33 X
58554   001 90 2 X 2,553.42 X
58554   004 90 2 X 2,313.33 X
58555   001 0 2 X 562.53 501.96
58555   004 0 2 X 505.63 453.88
58555   002 0 2 X 505.63 453.88
58555   003 0 2 X 505.63 453.88
58558   003 0 3 X 660.71 608.88
58558   002 0 3 X 660.71 608.88
58558   004 0 3 X 660.71 608.88
58558   001 0 3 X 731.10 670.58
58559   004 0 3 X 846.10 845.27
58559   001 0 3 X 936.08 935.12
58559   003 0 3 X 846.10 845.27
58559   002 0 3 X 846.10 845.27
58560   001 0 3 X 1,034.45 1,033.46
58560   004 0 3 X 936.52 935.72
58560   002 0 3 X 936.52 935.72
58560   003 0 3 X 936.52 935.72
58561   003 0 3 X 1,316.78 1,315.98
58561   002 0 3 X 1,316.78 1,315.98
58561   001 0 3 X 1,453.03 1,452.03
58561   004 0 3 X 1,316.78 1,315.98
58562   004 0 3 X 659.53 X
58562   001 0 3 X 725.95 X
58562   002 0 3 X 659.53 X
58562   003 0 3 X 659.53 X
58563   002 0 3 X 872.82 X
58563   003 0 3 X 872.82 X
58563   001 0 3 X 967.32 X
58563   004 0 3 X 872.82 X
58565   004 90 3 X 4,230.43 915.51
58565   002 90 3 X 4,230.43 915.51
58565   003 90 3 X 4,230.43 915.51
58565   001 90 3 X 5,011.20 1,037.62
58570   004 90 2 X 1,517.54 X
58570   003 90 2 X 1,517.54 X
58570   002 90 2 X 1,517.54 X
58570   001 90 2 X 1,690.25 X
58571   001 90 2 X 1,841.47 X
58571   004 90 2 X 1,660.85 X
58571   002 90 2 X 1,660.85 X
58571   003 90 2 X 1,660.85 X
58572   004 90 2 X 1,885.70 X
58572   001 90 2 X 2,096.91 X
58572   002 90 2 X 1,885.70 X
58572   003 90 2 X 1,885.70 X
58573   003 90 2 X 2,124.58 X
58573   002 90 2 X 2,124.58 X
58573   004 90 2 X 2,124.58 X
58573   001 90 2 X 2,348.50 X
58575   002 90 2 X 2,774.77 X
58575   003 90 2 X 2,774.77 X
58575   001 90 2 X 3,019.94 X
58575   004 90 2 X 2,774.77 X
58578     YYY 2 X # X
58579     YYY 2 X # X
58580   002 10 2 X 3,209.19 426.45
58580   003 10 2 X 3,209.19 426.45
58580   004 10 2 X 3,209.19 426.45
58580   001 10 2 X 3,622.63 461.64
58600   003 90 2 X 1,173.08 X
58600   002 90 2 X 1,287.81 X
58600   001 90 2 X 1,473.48 X
58600   004 90 2 X 1,158.87 X
58605   004 90 2 X 912.43 X
58605   002 90 2 X 1,009.18 X
58605   003 90 2 X 974.90 X
58605   001 90 2 X 1,100.39 X
58611   002 ZZZ 0 X 135.43 X
58611   003 ZZZ 0 X 126.06 X
58611   004 ZZZ 0 X 1,396.68 X
58611   001 ZZZ 0 X 1,407.76 X
58615   004 10 2 X 732.80 X
58615   001 10 2 X 796.82 X
58615   002 10 2 X 786.04 X
58615   003 10 2 X 741.56 X
58660   001 90 3 X 1,705.25 X
58660   004 90 3 X 1,535.96 X
58660   002 90 3 X 1,535.96 X
58660   003 90 3 X 1,535.96 X
58661   004 10 3 X 1,560.98 X
58661   001 10 3 X 1,730.23 X
58661   003 10 3 X 1,560.98 X
58661   002 10 3 X 1,560.98 X
58662   001 90 3 X 1,731.49 X
58662   004 90 3 X 1,567.10 X
58662   002 90 3 X 1,567.10 X
58662   003 90 3 X 1,567.10 X
58670   004 90 3 X 871.18 X
58670   001 90 3 X 970.14 X
58670   003 90 3 X 871.18 X
58670   002 90 3 X 871.18 X
58671   002 90 3 X 896.21 X
58671   003 90 3 X 896.21 X
58671   001 90 3 X 999.44 X
58671   004 90 3 X 896.21 X
58672   003 90 3 X 1,692.11 X
58672   002 90 3 X 1,692.11 X
58672   001 90 3 X 1,871.42 X
58672   004 90 3 X 1,692.11 X
58673   001 90 3 X 1,990.68 X
58673   003 90 3 X 1,802.15 X
58673   002 90 3 X 1,802.15 X
58673   004 90 3 X 1,802.15 X
58674   002 90 2 X 1,228.16 X
58674   003 90 2 X 1,228.16 X
58674   001 90 2 X 1,332.55 X
58674   004 90 2 X 1,228.16 X
58679     YYY 2 X # X
58700   001 90 2 X 1,714.49 X
58700   004 90 2 X 1,557.95 X
58700   003 90 2 X 1,412.83 X
58700   002 90 2 X 1,698.48 X
58720   003 90 2 X 1,634.30 X
58720   002 90 2 X 1,768.50 X
58720   004 90 2 X 1,576.86 X
58720   001 90 2 X 2,122.75 X
58740   001 90 2 X 2,980.56 X
58740   002 90 2 X 2,844.70 X
58740   003 90 2 X 2,723.36 X
58740   004 90 2 X 2,845.95 X
58750     90 2 X * X
58752     90 2 X * X
58760     90 2 X * X
58770     90 2 X * X
58800   003 90 2 X 766.54 X
58800   002 90 2 X 782.05 X
58800   004 90 2 X 721.68 X
58800   001 90 2 X 794.65 X
58805   004 90 2 X 1,356.47 X
58805   001 90 2 X 1,521.08 X
58805   002 90 2 X 1,496.97 X
58805   003 90 2 X 1,372.75 X
58820   004 90 2 X 659.08 X
58820   001 90 2 X 743.70 X
58820   003 90 2 X 659.08 X
58820   002 90 2 X 659.08 X
58822   003 90 2 X 1,104.22 X
58822   002 90 2 X 1,181.40 X
58822   004 90 2 X 1,092.11 X
58822   001 90 2 X 1,200.17 X
58825   004 90 2 X 1,094.06 X
58825   003 90 2 X 1,106.47 X
58825   002 90 2 X 1,190.85 X
58825   001 90 2 X 1,211.41 X
58900   004 90 2 X 1,211.10 X
58900   003 90 2 X 1,559.70 X
58900   002 90 2 X 1,522.01 X
58900   001 90 2 X 1,650.04 X
58920   004 90 2 X 1,490.75 X
58920   002 90 2 X 1,635.03 X
58920   001 90 2 X 1,665.66 X
58920   003 90 2 X 1,508.53 X
58925   002 90 2 X 1,618.79 X
58925   003 90 2 X 1,494.80 X
58925   001 90 2 X 1,648.84 X
58925   004 90 2 X 1,531.63 X
58940   001 90 2 X 1,931.34 X
58940   004 90 2 X 1,586.23 X
58940   003 90 2 X 1,525.68 X
58940   002 90 2 X 1,745.91 X
58943   003 90 2 X 4,036.46 X
58943   002 90 2 X 3,616.77 X
58943   004 90 2 X 4,020.58 X
58943   001 90 2 X 3,946.76 X
58950   004 90 2 X 3,592.95 X
58950   001 90 2 X 3,722.17 X
58950   002 90 2 X 3,653.96 X
58950   003 90 2 X 3,606.82 X
58951   004 90 2 X 5,474.30 X
58951   001 90 2 X 5,681.38 X
58951   003 90 2 X 5,495.93 X
58951   002 90 2 X 5,645.17 X
58952   002 90 2 X 5,716.63 X
58952   003 90 2 X 5,567.05 X
58952   004 90 2 X 5,545.16 X
58952   001 90 2 X 5,752.92 X
58953   001 90 2 X 4,446.68 X
58953   003 90 2 X 3,981.86 X
58953   002 90 2 X 3,981.86 X
58953   004 90 2 X 3,981.86 X
58954   002 90 2 X 4,329.17 X
58954   003 90 2 X 4,329.17 X
58954   004 90 2 X 4,329.17 X
58954   001 90 2 X 4,832.93 X
58956   001 90 2 X 3,014.30 X
58956   004 90 2 X 2,649.70 X
58956   003 90 2 X 2,649.70 X
58956   002 90 2 X 2,649.70 X
58957   002 90 2 X 2,371.55 X
58957   003 90 2 X 2,371.55 X
58957   004 90 2 X 2,371.55 X
58957   001 90 2 X 2,661.44 X
58958   003 90 2 X 2,626.05 X
58958   002 90 2 X 2,626.05 X
58958   004 90 2 X 2,626.05 X
58958   001 90 2 X 2,945.14 X
58960   004 90 2 X 3,997.18 X
58960   002 90 2 X 4,115.39 X
58960   003 90 2 X 4,010.71 X
58960   001 90 2 X 4,140.80 X
58970     0 2 X * X
58974     0 2 X * X
58976     0 2 X * X
58999     YYY 2 X # X
59000   001 0 2 X 265.38 X
59000   002 0 2 X 262.92 X
59000   003 0 2 X 252.62 X
59000   004 0 2 X 252.31 X
59001   004 0 2 X 361.88 X
59001   002 0 2 X 361.88 X
59001   003 0 2 X 361.88 X
59001   001 0 2 X 400.60 X
59012   004 0 2 X 658.18 X
59012   003 0 2 X 666.12 X
59012   002 0 2 X 705.84 X
59012   001 0 2 X 715.53 X
59015   001 0 2 X 387.61 X
59015   004 0 2 X 361.31 X
59015   002 0 2 X 383.32 X
59015   003 0 2 X 365.58 X
59020   001 0 0 X 269.81 X
59020 26 001 0 0 X 304.06 X
59020 TC 001 0 0 X 71.73 X
59020   004 0 0 X 236.89 X
59020 26 004 0 0 X 175.92 X
59020 TC 004 0 0 X 61.06 X
59020   003 0 0 X 239.98 X
59020 26 003 0 0 X 178.01 X
59020 TC 003 0 0 X 61.90 X
59020   002 0 0 X 263.96 X
59020 26 002 0 0 X 194.13 X
59020 TC 002 0 0 X 69.80 X
59025   002 0 0 X 120.92 X
59025 26 002 0 0 X 101.22 X
59025 TC 002 0 0 X 29.66 X
59025   003 0 0 X 114.19 X
59025 26 003 0 0 X 104.36 X
59025 TC 003 0 0 X 26.38 X
59025   001 0 0 X 121.74 X
59025 26 001 0 0 X 102.24 X
59025 TC 001 0 0 X 30.42 X
59025   004 0 0 X 113.17 X
59025 26 004 0 0 X 103.22 X
59025 TC 004 0 0 X 26.00 X
59030     0 2 X * X
59050   004 XXX 0 X 162.84 X
59050   001 XXX 0 X 186.96 X
59050   002 XXX 0 X 162.84 X
59050   003 XXX 0 X 162.84 X
59051   004 XXX 0 X 259.33 X
59051   001 XXX 0 X 282.24 X
59051   003 XXX 0 X 262.19 X
59051   002 XXX 0 X 278.36 X
59070   001 0 2 X 919.41 679.55
59070   004 0 2 X 828.16 624.09
59070   002 0 2 X 828.16 624.09
59070   003 0 2 X 828.16 624.09
59072   004 0 2 X 1,007.95 X
59072   001 0 2 X 1,099.61 X
59072   002 0 2 X 1,007.95 X
59072   003 0 2 X 1,007.95 X
59074   004 0 2 X 789.74 624.09
59074   001 0 2 X 874.31 679.55
59074   003 0 2 X 789.74 624.09
59074   002 0 2 X 789.74 624.09
59076   001 0 2 X 1,099.61 X
59076   004 0 2 X 1,007.95 X
59076   003 0 2 X 1,007.95 X
59076   002 0 2 X 1,007.95 X
59100   001 90 2 X 1,266.08 X
59100   003 90 2 X 1,157.41 X
59100   002 90 2 X 1,244.90 X
59100   004 90 2 X 1,144.44 X