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2024 Workers' Compensation Part B Fee Schedule

64771-66150

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CPT/HCPC Code	Medicare Location	Global Surgery Indicator	Multiple Surgery Indicator	Prevailing Charge Amount	Fee Schedule Amount	Site of Service Amount
64771	001	90	2	X	1,589.36	X
64771	004	90	2	X	1,456.38	X
64771	003	90	2	X	1,474.22	X
64771	002	90	2	X	1,566.92	X
64772	002	90	2	X	1,801.40	X
64772	003	90	2	X	1,883.46	X
64772	004	90	2	X	1,531.22	X
64772	001	90	2	X	2,081.62	X
64774	001	90	2	X	1,036.16	X
64774	003	90	2	X	884.18	X
64774	002	90	2	X	937.32	X
64774	004	90	2	X	963.61	X
64776	003	90	2	X	841.82	X
64776	002	90	2	X	891.01	X
64776	004	90	2	X	832.30	X
64776	001	90	2	X	940.76	X
64778	004	ZZZ	0	X	645.36	X
64778	002	ZZZ	0	X	698.46	X
64778	001	ZZZ	0	X	709.33	X
64778	003	ZZZ	0	X	653.08	X
64782	003	90	2	X	1,144.44	X
64782	002	90	2	X	1,210.66	X
64782	004	90	2	X	1,130.66	X
64782	001	90	2	X	1,226.58	X
64783	002	ZZZ	0	X	830.44	X
64783	003	ZZZ	0	X	805.25	X
64783	001	ZZZ	0	X	843.13	X
64783	004	ZZZ	0	X	768.60	X
64784	003	90	2	X	1,681.21	X
64784	002	90	2	X	1,845.85	X
64784	004	90	2	X	1,662.27	X
64784	001	90	2	X	1,838.76	X
64786	001	90	2	X	3,393.97	X
64786	003	90	2	X	2,940.85	X
64786	002	90	2	X	3,340.64	X
64786	004	90	2	X	3,083.94	X
64787	004	ZZZ	0	X	864.46	X
64787	002	ZZZ	0	X	936.21	X
64787	003	ZZZ	0	X	874.60	X
64787	001	ZZZ	0	X	951.30	X
64788	004	90	2	X	745.50	X
64788	002	90	2	X	887.42	X
64788	003	90	2	X	899.75	X
64788	001	90	2	X	951.97	X
64790	004	90	2	X	1,993.36	X
64790	001	90	2	X	2,145.12	X
64790	003	90	2	X	2,016.19	X
64790	002	90	2	X	2,087.49	X
64792	001	90	2	X	2,836.37	X
64792	004	90	2	X	2,603.56	X
64792	003	90	2	X	2,621.40	X
64792	002	90	2	X	2,794.41	X
64795	004	0	2	X	780.38	X
64795	002	0	2	X	802.41	X
64795	003	0	2	X	748.22	X
64795	001	0	2	X	811.98	X
64802	003	90	2	X	1,539.49	X
64802	002	90	2	X	1,819.67	X
64802	004	90	2	X	1,522.24	X
64802	001	90	2	X	1,673.31	X
64804	001	90	2	X	3,181.12	X
64804	004	90	2	X	2,974.54	X
64804	002	90	2	X	3,241.96	X
64804	003	90	2	X	3,009.88	X
64809	001	90	2	X	2,893.87	X
64809	004	90	2	X	2,618.97	X
64809	002	90	2	X	2,896.00	X
64809	003	90	2	X	2,874.92	X
64818	001	90	2	X	2,255.65	X
64818	003	90	2	X	2,056.31	X
64818	002	90	2	X	2,216.80	X
64818	004	90	2	X	2,032.43	X
64820	001	90	2	X	2,073.40	X
64820	004	90	2	X	1,858.24	X
64820	002	90	2	X	2,011.22	X
64820	003	90	2	X	1,883.13	X
64821	003	90	2	X	1,311.24	X
64821	002	90	2	X	1,311.24	X
64821	004	90	2	X	1,311.24	X
64821	001	90	2	X	1,482.11	X
64822	004	90	2	X	1,311.24	X
64822	002	90	2	X	1,311.24	X
64822	003	90	2	X	1,311.24	X
64822	001	90	2	X	1,482.11	X
64823	001	90	2	X	1,710.22	X
64823	004	90	2	X	1,514.76	X
64823	003	90	2	X	1,514.76	X
64823	002	90	2	X	1,514.76	X
64831	001	90	2	X	1,525.56	X
64831	003	90	2	X	1,450.30	X
64831	002	90	2	X	1,491.91	X
64831	004	90	2	X	1,439.98	X
64832	004	ZZZ	0	X	760.95	X
64832	003	ZZZ	0	X	768.81	X
64832	002	ZZZ	0	X	803.63	X
64832	001	ZZZ	0	X	1,043.76	X
64834	001	90	2	X	1,546.02	X
64834	003	90	2	X	1,485.69	X
64834	002	90	2	X	1,527.99	X
64834	004	90	2	X	1,438.46	X
64835	004	90	2	X	1,808.41	X
64835	001	90	2	X	1,969.97	X
64835	003	90	2	X	1,828.98	X
64835	002	90	2	X	1,942.41	X
64836	001	90	2	X	2,081.47	X
64836	003	90	2	X	1,923.48	X
64836	002	90	2	X	2,050.57	X
64836	004	90	2	X	2,108.09	X
64837	001	ZZZ	0	X	1,313.84	X
64837	004	ZZZ	0	X	1,194.79	X
64837	003	ZZZ	0	X	1,208.60	X
64837	002	ZZZ	0	X	1,293.33	X
64840	001	90	2	X	2,581.62	X
64840	002	90	2	X	2,552.62	X
64840	003	90	2	X	2,431.72	X
64840	004	90	2	X	2,401.84	X
64856	004	90	2	X	2,325.16	X
64856	002	90	2	X	2,484.57	X
64856	003	90	2	X	2,378.52	X
64856	001	90	2	X	2,522.28	X
64857	001	90	2	X	2,769.99	X
64857	004	90	2	X	2,531.90	X
64857	003	90	2	X	2,561.43	X
64857	002	90	2	X	2,562.98	X
64858	004	90	2	X	2,946.64	X
64858	003	90	2	X	2,980.57	X
64858	002	90	2	X	3,190.00	X
64858	001	90	2	X	3,240.78	X
64859	001	ZZZ	0	X	946.89	X
64859	004	ZZZ	0	X	861.14	X
64859	003	ZZZ	0	X	871.28	X
64859	002	ZZZ	0	X	932.13	X
64861	004	90	2	X	3,378.78	X
64861	002	90	2	X	3,614.70	X
64861	003	90	2	X	3,419.46	X
64861	001	90	2	X	3,661.85	X
64862	002	90	2	X	4,550.37	X
64862	003	90	2	X	4,294.31	X
64862	001	90	2	X	4,611.81	X
64862	004	90	2	X	4,239.44	X
64864	002	90	2	X	2,409.35	X
64864	003	90	2	X	2,184.15	X
64864	001	90	2	X	2,351.72	X
64864	004	90	2	X	2,159.05	X
64865	002	90	2	X	3,164.09	X
64865	003	90	2	X	2,977.81	X
64865	001	90	2	X	3,209.08	X
64865	004	90	2	X	2,942.26	X
64866	004	90	2	X	2,888.09	X
64866	001	90	2	X	3,165.82	X
64866	002	90	2	X	3,118.24	X
64866	003	90	2	X	2,921.90	X
64868	003	90	2	X	2,715.00	X
64868	002	90	2	X	2,889.35	X
64868	001	90	2	X	3,954.04	X
64868	004	90	2	X	2,682.79	X
64872	001	ZZZ	0	X	453.45	X
64872	002	ZZZ	0	X	439.72	X
64872	003	ZZZ	0	X	411.55	X
64872	004	ZZZ	0	X	406.09	X
64874	004	ZZZ	0	X	609.13	X
64874	001	ZZZ	0	X	679.92	X
64874	003	ZZZ	0	X	617.38	X
64874	002	ZZZ	0	X	659.50	X
64876	003	ZZZ	0	X	613.63	X
64876	002	ZZZ	0	X	655.32	X
64876	004	ZZZ	0	X	605.52	X
64876	001	ZZZ	0	X	675.54	X
64885	001	90	2	X	3,466.46	X
64885	004	90	2	X	3,189.09	X
64885	003	90	2	X	3,227.26	X
64885	002	90	2	X	3,419.85	X
64886	001	90	2	X	4,133.18	X
64886	003	90	2	X	3,847.89	X
64886	002	90	2	X	4,077.68	X
64886	004	90	2	X	3,802.46	X
64890	001	90	2	X	3,265.17	X
64890	004	90	2	X	2,963.15	X
64890	002	90	2	X	3,213.12	X
64890	003	90	2	X	2,998.28	X
64891	001	90	2	X	3,093.50	X
64891	004	90	2	X	2,828.34	X
64891	003	90	2	X	2,861.05	X
64891	002	90	2	X	3,048.13	X
64892	001	90	2	X	3,004.71	X
64892	004	90	2	X	2,741.97	X
64892	002	90	2	X	2,959.83	X
64892	003	90	2	X	2,774.44	X
64893	004	90	2	X	3,173.51	X
64893	001	90	2	X	3,501.54	X
64893	002	90	2	X	3,445.09	X
64893	003	90	2	X	3,211.74	X
64895	004	90	2	X	3,523.96	X
64895	003	90	2	X	3,564.54	X
64895	002	90	2	X	3,816.61	X
64895	001	90	2	X	3,877.74	X
64896	004	90	2	X	3,997.68	X
64896	001	90	2	X	4,355.87	X
64896	003	90	2	X	4,046.73	X
64896	002	90	2	X	4,295.84	X
64897	004	90	2	X	3,355.94	X
64897	001	90	2	X	3,695.78	X
64897	003	90	2	X	3,394.61	X
64897	002	90	2	X	3,637.00	X
64898	001	90	2	X	3,979.92	X
64898	004	90	2	X	3,626.83	X
64898	002	90	2	X	3,919.35	X
64898	003	90	2	X	3,669.56	X
64901	001	ZZZ	0	X	2,373.96	X
64901	004	ZZZ	0	X	2,184.76	X
64901	002	ZZZ	0	X	2,342.58	X
64901	003	ZZZ	0	X	2,212.23	X
64902	001	ZZZ	0	X	3,420.18	X
64902	003	ZZZ	0	X	2,575.35	X
64902	002	ZZZ	0	X	2,726.45	X
64902	004	ZZZ	0	X	2,543.34	X
64905		90	2	X	*	X
64907		90	2	X	*	X
64910	002	90	2	X	1,112.50	X
64910	003	90	2	X	1,112.50	X
64910	004	90	2	X	1,112.50	X
64910	001	90	2	X	1,270.71	X
64911	002	90	2	X	1,354.56	X
64911	003	90	2	X	1,354.56	X
64911	001	90	2	X	1,534.55	X
64911	004	90	2	X	1,354.56	X
64912	003	90	2	X	1,151.52	X
64912	002	90	2	X	1,151.52	X
64912	001	90	2	X	1,260.06	X
64912	004	90	2	X	1,151.52	X
64913	001	ZZZ	0	X	255.61	X
64913	003	ZZZ	0	X	235.92	X
64913	002	ZZZ	0	X	235.92	X
64913	004	ZZZ	0	X	235.92	X
64999		YYY	2	X	#	X
65091	002	90	2	X	1,794.46	X
65091	003	90	2	X	1,657.40	X
65091	004	90	2	X	1,733.28	X
65091	001	90	2	X	1,618.69	X
65093	004	90	2	X	1,801.88	X
65093	001	90	2	X	1,905.53	X
65093	002	90	2	X	1,769.20	X
65093	003	90	2	X	1,783.18	X
65101	002	90	2	X	1,770.54	X
65101	003	90	2	X	1,669.20	X
65101	001	90	2	X	1,903.29	X
65101	004	90	2	X	1,572.33	X
65103	003	90	2	X	1,863.01	X
65103	002	90	2	X	1,983.68	X
65103	001	90	2	X	2,040.37	X
65103	004	90	2	X	1,932.25	X
65105	003	90	2	X	1,909.45	X
65105	002	90	2	X	2,073.22	X
65105	004	90	2	X	2,005.83	X
65105	001	90	2	X	2,119.25	X
65110	001	90	2	X	3,381.46	X
65110	003	90	2	X	3,235.86	X
65110	002	90	2	X	3,336.74	X
65110	004	90	2	X	3,109.95	X
65112	002	90	2	X	3,161.00	X
65112	003	90	2	X	2,994.26	X
65112	004	90	2	X	2,958.34	X
65112	001	90	2	X	3,201.17	X
65114	002	90	2	X	3,471.56	X
65114	003	90	2	X	3,268.71	X
65114	001	90	2	X	3,520.55	X
65114	004	90	2	X	3,230.03	X
65125	003	90	2	X	1,725.50	X
65125	002	90	2	X	1,823.19	X
65125	004	90	2	X	1,703.09	X
65125	001	90	2	X	1,846.54	X
65130	004	90	2	X	1,630.20	X
65130	001	90	2	X	1,737.99	X
65130	003	90	2	X	1,651.67	X
65130	002	90	2	X	1,746.11	X
65135	001	90	2	X	1,847.06	X
65135	004	90	2	X	1,308.96	X
65135	003	90	2	X	1,325.07	X
65135	002	90	2	X	1,392.73	X
65140	004	90	2	X	1,442.26	X
65140	002	90	2	X	1,899.11	X
65140	003	90	2	X	1,460.24	X
65140	001	90	2	X	1,550.65	X
65150	003	90	2	X	1,678.89	X
65150	001	90	2	X	1,804.52	X
65150	002	90	2	X	1,984.60	X
65150	004	90	2	X	1,656.41	X
65155	002	90	2	X	2,388.36	X
65155	004	90	2	X	2,217.63	X
65155	003	90	2	X	2,247.23	X
65155	001	90	2	X	2,422.24	X
65175	001	90	2	X	1,518.94	X
65175	004	90	2	X	1,416.32	X
65175	002	90	2	X	1,514.97	X
65175	003	90	2	X	1,434.97	X
65205	001	0	2	X	128.56	109.95
65205	002	0	2	X	137.01	117.70
65205	003	0	2	X	119.53	103.14
65205	004	0	2	X	126.93	109.71
65210	001	0	2	X	147.79	122.35
65210	004	0	2	X	138.16	114.84
65210	003	0	2	X	139.84	116.11
65210	002	0	2	X	146.16	121.10
65220	004	0	2	X	131.28	106.82
65220	001	0	2	X	128.00	103.90
65220	003	0	2	X	124.75	99.70
65220	002	0	2	X	131.16	104.73
65222	004	0	2	X	150.94	125.49
65222	001	0	2	X	176.02	145.68
65222	003	0	2	X	159.63	132.27
65222	002	0	2	X	167.63	136.69
65235	001	90	2	X	1,998.67	X
65235	003	90	2	X	1,780.22	X
65235	002	90	2	X	1,667.04	X
65235	004	90	2	X	1,342.34	X
65260	001	90	2	X	2,151.44	X
65260	004	90	2	X	2,001.49	X
65260	002	90	2	X	2,127.17	X
65260	003	90	2	X	2,026.41	X
65265	001	90	2	X	2,500.46	X
65265	004	90	2	X	2,326.37	X
65265	003	90	2	X	2,355.36	X
65265	002	90	2	X	2,472.42	X
65270	001	10	2	X	272.62	X
65270	004	10	2	X	318.80	X
65270	003	10	2	X	261.75	X
65270	002	10	2	X	337.75	X
65272	002	90	2	X	434.72	X
65272	003	90	2	X	440.80	X
65272	004	90	2	X	550.53	X
65272	001	90	2	X	586.61	X
65273	003	90	2	X	763.26	X
65273	002	90	2	X	802.96	X
65273	004	90	2	X	753.91	X
65273	001	90	2	X	812.47	X
65275	002	90	2	X	1,059.48	X
65275	003	90	2	X	1,051.47	X
65275	004	90	2	X	1,048.92	X
65275	001	90	2	X	1,061.42	X
65280	004	90	2	X	1,710.13	X
65280	002	90	2	X	2,276.87	X
65280	003	90	2	X	2,235.83	X
65280	001	90	2	X	2,034.38	X
65285	001	90	2	X	2,767.49	X
65285	004	90	2	X	2,670.68	X
65285	003	90	2	X	2,597.98	X
65285	002	90	2	X	2,734.74	X
65286	001	90	2	X	1,551.32	X
65286	004	90	2	X	1,624.01	X
65286	002	90	2	X	1,378.92	X
65286	003	90	2	X	1,062.21	X
65290	002	90	2	X	1,276.94	X
65290	003	90	2	X	1,208.44	X
65290	001	90	2	X	1,293.35	X
65290	004	90	2	X	1,192.80	X
65400	003	90	2	X	892.60	X
65400	002	90	2	X	922.06	X
65400	001	90	2	X	943.38	X
65400	004	90	2	X	884.55	X
65410	002	0	2	X	383.16	X
65410	003	0	2	X	330.29	X
65410	001	0	2	X	353.51	X
65410	004	0	2	X	371.96	X
65420	002	90	2	X	928.93	X
65420	003	90	2	X	881.61	X
65420	004	90	2	X	870.37	X
65420	001	90	2	X	940.20	X
65426	004	90	2	X	1,205.94	X
65426	001	90	2	X	1,341.53	X
65426	003	90	2	X	1,252.79	X
65426	002	90	2	X	1,324.38	X
65430	002	0	2	X	159.63	129.79
65430	003	0	2	X	150.98	123.26
65430	004	0	2	X	149.21	121.95
65430	001	0	2	X	160.59	130.36
65435	001	0	2	X	244.30	190.21
65435	003	0	2	X	239.56	187.69
65435	002	0	2	X	225.69	176.01
65435	004	0	2	X	229.85	179.90
65436	001	90	2	X	596.76	X
65436	003	90	2	X	573.37	X
65436	002	90	2	X	594.31	X
65436	004	90	2	X	581.44	X
65450	001	90	2	X	569.75	X
65450	004	90	2	X	669.39	X
65450	003	90	2	X	677.96	X
65450	002	90	2	X	576.20	X
65600	003	90	2	X	615.63	X
65600	002	90	2	X	949.04	X
65600	004	90	2	X	608.08	X
65600	001	90	2	X	992.66	X
65710	004	90	2	X	3,918.09	X
65710	001	90	2	X	4,036.66	X
65710	003	90	2	X	4,036.93	X
65710	002	90	2	X	4,444.13	X
65730	004	90	2	X	4,372.05	X
65730	003	90	2	X	4,766.37	X
65730	002	90	2	X	5,163.23	X
65730	001	90	2	X	5,185.91	X
65750	004	90	2	X	5,443.21	X
65750	002	90	2	X	5,827.01	X
65750	003	90	2	X	5,518.02	X
65750	001	90	2	X	5,867.27	X
65755	004	90	2	X	5,630.90	X
65755	002	90	2	X	6,032.93	X
65755	003	90	2	X	5,708.56	X
65755	001	90	2	X	6,076.69	X
65756	002	90	2	X	1,729.19	X
65756	003	90	2	X	1,729.19	X
65756	004	90	2	X	1,729.19	X
65756	001	90	2	X	1,884.57	X
65757		ZZZ	0	X	*	X
65770	004	90	2	X	3,200.32	X
65770	001	90	2	X	3,440.09	X
65770	003	90	2	X	3,240.29	X
65770	002	90	2	X	3,401.35	X
65772	001	90	2	X	1,248.57	X
65772	003	90	2	X	1,218.13	X
65772	002	90	2	X	894.54	X
65772	004	90	2	X	999.08	X
65775	003	90	2	X	1,518.10	X
65775	002	90	2	X	1,609.46	X
65775	004	90	2	X	1,369.31	X
65775	001	90	2	X	1,631.29	X
65778	002	0	2	X	2,101.68	130.01
65778	003	0	2	X	2,101.68	130.01
65778	004	0	2	X	2,101.68	130.01
65778	001	0	2	X	2,373.85	142.83
65779	002	0	2	X	1,911.81	500.08
65779	003	0	2	X	1,911.81	500.08
65779	001	0	2	X	2,148.57	551.15
65779	004	0	2	X	1,911.81	500.08
65780	001	90	2	X	1,767.73	X
65780	004	90	2	X	1,600.06	X
65780	002	90	2	X	1,600.06	X
65780	003	90	2	X	1,600.06	X
65781	002	90	2	X	2,454.41	X
65781	003	90	2	X	2,454.41	X
65781	004	90	2	X	2,454.41	X
65781	001	90	2	X	2,680.48	X
65782	002	90	2	X	2,114.58	X
65782	003	90	2	X	2,114.58	X
65782	001	90	2	X	2,313.85	X
65782	004	90	2	X	2,114.58	X
65785	001	90	2	X	3,553.38	644.58
65785	004	90	2	X	3,070.71	584.73
65785	003	90	2	X	3,070.71	584.73
65785	002	90	2	X	3,070.71	584.73
65800	002	0	2	X	429.74	X
65800	003	0	2	X	388.54	X
65800	004	0	2	X	426.18	X
65800	001	0	2	X	431.86	X
65810	002	90	2	X	1,050.88	X
65810	003	90	2	X	1,071.98	X
65810	004	90	2	X	1,013.18	X
65810	001	90	2	X	1,078.84	X
65815	002	90	2	X	1,023.93	X
65815	003	90	2	X	986.81	X
65815	001	90	2	X	1,051.22	X
65815	004	90	2	X	974.43	X
65820	004	90	2	X	1,809.92	X
65820	001	90	2	X	1,888.14	X
65820	002	90	2	X	1,872.52	X
65820	003	90	2	X	1,833.64	X
65850	002	90	2	X	2,651.31	X
65850	003	90	2	X	2,481.44	X
65850	001	90	2	X	2,726.03	X
65850	004	90	2	X	2,556.03	X
65855	004	10	2	X	1,785.05	X
65855	001	10	2	X	1,977.37	X
65855	003	10	2	X	1,823.45	X
65855	002	10	2	X	1,940.00	X
65860	002	90	2	X	1,287.87	X
65860	003	90	2	X	1,007.74	X
65860	004	90	2	X	994.20	X
65860	001	90	2	X	1,085.64	X
65865	003	90	2	X	1,330.09	X
65865	002	90	2	X	1,222.85	X
65865	004	90	2	X	1,172.50	X
65865	001	90	2	X	1,424.31	X
65870	004	90	2	X	1,243.29	X
65870	001	90	2	X	1,461.91	X
65870	003	90	2	X	1,259.17	X
65870	002	90	2	X	1,404.71	X
65875	002	90	2	X	1,873.56	X
65875	003	90	2	X	1,851.63	X
65875	001	90	2	X	1,888.17	X
65875	004	90	2	X	1,310.92	X
65880	001	90	2	X	1,542.10	X
65880	004	90	2	X	1,428.85	X
65880	003	90	2	X	1,447.18	X
65880	002	90	2	X	1,523.74	X
65900	002	90	2	X	2,131.51	X
65900	003	90	2	X	2,806.65	X
65900	004	90	2	X	1,987.97	X
65900	001	90	2	X	2,813.11	X
65920	004	90	2	X	2,213.18	X
65920	003	90	2	X	2,210.27	X
65920	002	90	2	X	2,231.11	X
65920	001	90	2	X	2,256.21	X
65930	001	90	2	X	1,610.70	X
65930	004	90	2	X	1,552.66	X
65930	002	90	2	X	1,607.17	X
65930	003	90	2	X	1,572.73	X
66020	004	10	2	X	450.32	X
66020	002	10	2	X	462.98	X
66020	003	10	2	X	447.24	X
66020	001	10	2	X	465.49	X
66030	003	10	2	X	185.60	X
66030	002	10	2	X	256.43	X
66030	004	10	2	X	261.49	X
66030	001	10	2	X	270.13	X
66130	001	90	2	X	1,790.59	X
66130	002	90	2	X	1,783.83	X
66130	003	90	2	X	1,367.61	X
66130	004	90	2	X	1,748.57	X
66150	001	90	2	X	2,226.44	X
66150	003	90	2	X	2,073.70	X
66150	004	90	2	X	2,211.70	X
66150	002	90	2	X	2,017.85	X

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