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Health Care Services Review
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Fee Schedule
>
Fee Schedule 84681-87400
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
84681-87400
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
84681
XXX
9
X
23.52
X
84702
XXX
9
X
17.01
X
84703
XXX
9
X
8.50
X
84704
XXX
9
X
17.28
X
84830
XXX
9
X
14.35
X
84999
XXX
9
X
#
X
85002
XXX
9
X
5.45
X
85004
XXX
9
X
7.31
X
85007
XXX
9
X
4.29
X
85008
XXX
9
X
3.88
X
85009
XXX
9
X
5.73
X
85013
XXX
9
X
7.91
X
85014
XXX
9
X
2.68
X
85018
XXX
9
X
2.68
X
85025
XXX
9
X
8.78
X
85027
XXX
9
X
7.31
X
85032
XXX
9
X
4.87
X
85041
XXX
9
X
3.41
X
85044
XXX
9
X
4.87
X
85045
XXX
9
X
4.51
X
85046
XXX
9
X
6.29
X
85048
XXX
9
X
2.87
X
85049
XXX
9
X
5.06
X
85055
XXX
9
X
40.39
X
85060
002
XXX
0
X
74.01
X
85060
003
XXX
0
X
71.43
X
85060
004
XXX
0
X
68.80
X
85060
001
XXX
0
X
74.19
X
85097
004
XXX
0
X
127.12
X
85097
002
XXX
0
X
133.55
X
85097
003
XXX
0
X
129.18
X
85097
001
XXX
0
X
134.37
X
85130
XXX
9
X
13.44
X
85170
XXX
9
X
18.42
X
85175
XXX
9
X
23.02
X
85210
XXX
9
X
14.67
X
85220
XXX
9
X
19.94
X
85230
XXX
9
X
20.23
X
85240
XXX
9
X
20.23
X
85244
XXX
9
X
23.07
X
85245
XXX
9
X
25.92
X
85246
XXX
9
X
25.92
X
85247
XXX
9
X
25.92
X
85250
XXX
9
X
21.52
X
85260
XXX
9
X
20.23
X
85270
XXX
9
X
20.23
X
85280
XXX
9
X
21.87
X
85290
XXX
9
X
18.46
X
85291
XXX
9
X
10.29
X
85292
XXX
9
X
21.39
X
85293
XXX
9
X
21.39
X
85300
XXX
9
X
13.39
X
85301
XXX
9
X
12.22
X
85302
XXX
9
X
13.57
X
85303
XXX
9
X
15.64
X
85305
XXX
9
X
13.12
X
85306
XXX
9
X
17.31
X
85307
XXX
9
X
17.31
X
85335
XXX
9
X
14.54
X
85337
XXX
9
X
19.52
X
85345
XXX
9
X
5.30
X
85347
XXX
9
X
4.84
X
85348
XXX
9
X
5.07
X
85360
XXX
9
X
9.50
X
85362
XXX
9
X
7.79
X
85366
XXX
9
X
90.92
X
85370
XXX
9
X
14.05
X
85378
XXX
9
X
10.98
X
85379
XXX
9
X
11.50
X
85380
XXX
9
X
11.50
X
85384
XXX
9
X
10.98
X
85385
XXX
9
X
16.34
X
85390
XXX
9
X
17.49
X
85390
26
001
XXX
9
X
59.23
X
85390
26
002
XXX
9
X
58.66
X
85390
26
003
XXX
9
X
56.18
X
85390
26
004
XXX
9
X
55.61
X
85396
004
XXX
0
X
45.32
X
85396
002
XXX
0
X
45.32
X
85396
003
XXX
0
X
45.32
X
85396
001
XXX
0
X
50.25
X
85397
XXX
9
X
34.87
X
85400
XXX
9
X
8.71
X
85410
XXX
9
X
8.71
X
85415
XXX
9
X
19.42
X
85420
XXX
9
X
7.38
X
85421
XXX
9
X
11.50
X
85441
XXX
9
X
4.75
X
85445
XXX
9
X
7.71
X
85460
XXX
9
X
8.73
X
85461
XXX
9
X
10.58
X
85475
XXX
9
X
10.02
X
85520
XXX
9
X
14.79
X
85525
XXX
9
X
13.38
X
85530
XXX
9
X
14.79
X
85536
XXX
9
X
7.77
X
85540
XXX
9
X
9.72
X
85547
XXX
9
X
9.72
X
85549
XXX
9
X
21.19
X
85555
XXX
9
X
8.44
X
85557
XXX
9
X
15.10
X
85576
XXX
9
X
28.15
X
85576
26
004
XXX
9
X
55.61
X
85576
26
002
XXX
9
X
58.66
X
85576
26
003
XXX
9
X
56.18
X
85576
26
001
XXX
9
X
59.23
X
85597
XXX
9
X
20.32
X
85598
XXX
9
X
20.32
X
85610
XXX
9
X
4.85
X
85611
XXX
9
X
4.45
X
85612
XXX
9
X
19.76
X
85613
XXX
9
X
10.83
X
85635
XXX
9
X
11.13
X
85651
XXX
9
X
4.83
X
85652
XXX
9
X
3.05
X
85660
XXX
9
X
6.23
X
85670
XXX
9
X
6.52
X
85675
XXX
9
X
7.74
X
85705
XXX
9
X
10.88
X
85730
XXX
9
X
6.79
X
85732
XXX
9
X
7.31
X
85810
XXX
9
X
13.19
X
85999
XXX
9
X
#
X
86000
XXX
9
X
7.89
X
86001
XXX
9
X
8.84
X
86003
XXX
9
X
5.90
X
86005
XXX
9
X
9.01
X
86008
XXX
9
X
20.26
X
86015
XXX
9
X
13.62
X
86021
XXX
9
X
17.01
X
86022
XXX
9
X
20.76
X
86023
XXX
9
X
14.08
X
86036
XXX
9
X
13.62
X
86037
XXX
9
X
13.62
X
86038
XXX
9
X
13.66
X
86039
XXX
9
X
12.61
X
86041
XXX
9
X
20.79
X
86042
XXX
9
X
20.79
X
86043
XXX
9
X
13.62
X
86051
XXX
9
X
13.03
X
86052
XXX
9
X
13.62
X
86053
XXX
9
X
42.63
X
86060
XXX
9
X
8.25
X
86063
XXX
9
X
6.52
X
86077
001
XXX
0
X
92.64
X
86077
004
XXX
0
X
101.78
X
86077
003
XXX
0
X
102.08
X
86077
002
XXX
0
X
103.56
X
86078
002
XXX
0
X
146.89
X
86078
003
XXX
0
X
148.64
X
86078
004
XXX
0
X
149.27
X
86078
001
XXX
0
X
141.19
X
86079
004
XXX
0
X
68.62
X
86079
003
XXX
0
X
123.27
X
86079
002
XXX
0
X
75.34
X
86079
001
XXX
0
X
76.98
X
86140
XXX
9
X
5.85
X
86141
XXX
9
X
14.63
X
86146
XXX
9
X
28.76
X
86147
XXX
9
X
28.76
X
86148
XXX
9
X
18.16
X
86152
XXX
9
X
283.38
X
86153
26
004
XXX
0
X
53.77
X
86153
26
003
XXX
0
X
53.77
X
86153
26
002
XXX
0
X
53.77
X
86153
26
001
XXX
0
X
57.12
X
86155
XXX
9
X
18.07
X
86156
XXX
9
X
9.12
X
86157
XXX
9
X
9.11
X
86160
XXX
9
X
13.56
X
86161
XXX
9
X
13.56
X
86162
XXX
9
X
22.96
X
86171
XXX
9
X
11.31
X
86200
XXX
9
X
14.63
X
86215
XXX
9
X
14.97
X
86225
XXX
9
X
15.53
X
86226
XXX
9
X
13.68
X
86231
XXX
9
X
13.66
X
86235
XXX
9
X
20.26
X
86255
XXX
9
X
13.62
X
86255
26
004
XXX
9
X
55.61
X
86255
26
002
XXX
9
X
58.66
X
86255
26
003
XXX
9
X
56.18
X
86255
26
001
XXX
9
X
59.23
X
86256
XXX
9
X
13.62
X
86256
26
001
XXX
9
X
59.23
X
86256
26
002
XXX
9
X
58.66
X
86256
26
003
XXX
9
X
56.18
X
86256
26
004
XXX
9
X
55.61
X
86258
XXX
9
X
13.62
X
86277
XXX
9
X
17.79
X
86280
XXX
9
X
9.25
X
86294
XXX
9
X
28.89
X
86300
XXX
9
X
23.52
X
86301
XXX
9
X
23.52
X
86304
XXX
9
X
23.52
X
86305
XXX
9
X
23.52
X
86308
XXX
9
X
5.85
X
86309
XXX
9
X
7.31
X
86310
XXX
9
X
8.33
X
86316
XXX
9
X
23.52
X
86317
XXX
9
X
16.94
X
86318
XXX
9
X
20.44
X
86320
XXX
9
X
33.81
X
86320
26
001
XXX
9
X
59.23
X
86320
26
002
XXX
9
X
58.66
X
86320
26
003
XXX
9
X
56.18
X
86320
26
004
XXX
9
X
55.61
X
86325
XXX
9
X
26.14
X
86325
26
002
XXX
9
X
58.66
X
86325
26
003
XXX
9
X
56.18
X
86325
26
004
XXX
9
X
55.61
X
86325
26
001
XXX
9
X
59.23
X
86327
XXX
9
X
33.81
X
86327
26
003
XXX
9
X
56.18
X
86327
26
002
XXX
9
X
58.66
X
86327
26
001
XXX
9
X
59.23
X
86327
26
004
XXX
9
X
55.61
X
86328
XXX
9
X
51.17
X
86329
XXX
9
X
15.88
X
86331
XXX
9
X
13.54
X
86332
XXX
9
X
27.54
X
86334
XXX
9
X
25.24
X
86334
26
002
XXX
9
X
58.66
X
86334
26
003
XXX
9
X
56.18
X
86334
26
004
XXX
9
X
55.61
X
86334
26
001
XXX
9
X
59.23
X
86335
XXX
9
X
33.17
X
86335
26
004
XXX
9
X
40.09
X
86335
26
002
XXX
9
X
40.09
X
86335
26
003
XXX
9
X
40.09
X
86335
26
001
XXX
9
X
43.18
X
86336
XXX
9
X
17.62
X
86337
XXX
9
X
24.19
X
86340
XXX
9
X
17.04
X
86341
XXX
9
X
26.63
X
86343
XXX
9
X
14.08
X
86344
XXX
9
X
11.74
X
86352
XXX
9
X
153.52
X
86353
XXX
9
X
55.40
X
86355
XXX
9
X
42.63
X
86356
XXX
9
X
30.26
X
86357
XXX
9
X
42.63
X
86359
XXX
9
X
42.63
X
86360
XXX
9
X
53.09
X
86361
XXX
9
X
30.26
X
86362
XXX
9
X
13.62
X
86363
XXX
9
X
42.63
X
86364
XXX
9
X
13.03
X
86366
XXX
9
X
20.79
X
86367
XXX
9
X
87.89
X
86376
XXX
9
X
16.44
X
86381
XXX
9
X
28.76
X
86382
XXX
9
X
19.11
X
86384
XXX
9
X
15.38
X
86386
XXX
9
X
24.61
X
86403
XXX
9
X
13.04
X
86406
XXX
9
X
12.02
X
86408
XXX
9
X
47.61
X
86409
XXX
9
X
#
X
86413
XXX
9
X
#
X
86430
XXX
9
X
6.94
X
86431
XXX
9
X
6.41
X
86480
XXX
9
X
70.04
X
86481
XXX
9
X
113.00
X
86485
XXX
0
X
12.10
X
86486
004
XXX
0
X
9.70
X
86486
003
XXX
0
X
9.70
X
86486
002
XXX
0
X
9.70
X
86486
001
XXX
0
X
12.23
X
86490
001
XXX
0
X
31.43
X
86490
002
XXX
0
X
30.88
X
86490
004
XXX
0
X
27.93
X
86490
003
XXX
0
X
28.40
X
86510
004
XXX
0
X
29.83
X
86510
002
XXX
0
X
32.85
X
86510
003
XXX
0
X
30.30
X
86510
001
XXX
0
X
33.42
X
86580
004
XXX
0
X
24.23
X
86580
001
XXX
0
X
27.40
X
86580
003
XXX
0
X
24.61
X
86580
002
XXX
0
X
26.92
X
86590
XXX
9
X
14.31
X
86592
XXX
9
X
4.83
X
86593
XXX
9
X
4.97
X
86596
XXX
9
X
13.62
X
86602
XXX
9
X
11.50
X
86603
XXX
9
X
14.54
X
86606
XXX
9
X
17.01
X
86609
XXX
9
X
14.55
X
86611
XXX
9
X
11.50
X
86612
XXX
9
X
14.58
X
86615
XXX
9
X
14.90
X
86617
XXX
9
X
17.50
X
86618
XXX
9
X
19.24
X
86619
XXX
9
X
15.12
X
86622
XXX
9
X
10.09
X
86625
XXX
9
X
14.83
X
86628
XXX
9
X
13.57
X
86631
XXX
9
X
13.36
X
86632
XXX
9
X
14.33
X
86635
XXX
9
X
12.96
X
86638
XXX
9
X
13.70
X
86641
XXX
9
X
16.28
X
86644
XXX
9
X
16.26
X
86645
XXX
9
X
19.04
X
86648
XXX
9
X
17.19
X
86651
XXX
9
X
14.90
X
86652
XXX
9
X
14.90
X
86653
XXX
9
X
14.90
X
86654
XXX
9
X
14.90
X
86658
XXX
9
X
14.72
X
86663
XXX
9
X
14.83
X
86664
XXX
9
X
17.28
X
86665
XXX
9
X
20.50
X
86666
XXX
9
X
11.50
X
86668
XXX
9
X
16.00
X
86671
XXX
9
X
13.84
X
86674
XXX
9
X
16.63
X
86677
XXX
9
X
19.04
X
86682
XXX
9
X
14.70
X
86684
XXX
9
X
17.90
X
86687
XXX
9
X
10.27
X
86688
XXX
9
X
15.82
X
86689
XXX
9
X
21.87
X
86692
XXX
9
X
19.39
X
86694
XXX
9
X
16.26
X
86695
XXX
9
X
14.90
X
86696
XXX
9
X
21.87
X
86698
XXX
9
X
15.58
X
86701
XXX
9
X
10.05
X
86702
XXX
9
X
15.28
X
86703
XXX
9
X
15.49
X
86704
XXX
9
X
13.62
X
86705
XXX
9
X
13.30
X
86706
XXX
9
X
12.14
X
86707
XXX
9
X
13.07
X
86708
XXX
9
X
14.00
X
86709
XXX
9
X
12.72
X
86710
XXX
9
X
15.31
X
86711
XXX
9
X
19.09
X
86713
XXX
9
X
17.29
X
86717
XXX
9
X
13.84
X
86720
XXX
9
X
18.31
X
86723
XXX
9
X
14.90
X
86727
XXX
9
X
14.54
X
86732
XXX
9
X
16.95
X
86735
XXX
9
X
14.75
X
86738
XXX
9
X
14.96
X
86741
XXX
9
X
14.90
X
86744
XXX
9
X
18.07
X
86747
XXX
9
X
16.98
X
86750
XXX
9
X
14.90
X
86753
XXX
9
X
14.00
X
86756
XXX
9
X
17.96
X
86757
XXX
9
X
21.87
X
86759
XXX
9
X
20.60
X
86762
XXX
9
X
16.26
X
86765
XXX
9
X
14.55
X
86768
XXX
9
X
14.90
X
86769
XXX
9
X
47.61
X
86771
XXX
9
X
27.66
X
86774
XXX
9
X
16.72
X
86777
XXX
9
X
16.26
X
86778
XXX
9
X
16.28
X
86780
XXX
9
X
14.96
X
86784
XXX
9
X
14.19
X
86787
XXX
9
X
14.55
X
86788
XXX
9
X
19.04
X
86789
XXX
9
X
16.26
X
86790
XXX
9
X
14.55
X
86793
XXX
9
X
14.90
X
86794
XXX
9
X
19.04
X
86800
XXX
9
X
17.98
X
86803
XXX
9
X
16.13
X
86804
XXX
9
X
17.50
X
86805
XXX
9
X
214.15
X
86806
XXX
9
X
53.78
X
86807
XXX
9
X
88.87
X
86808
XXX
9
X
33.54
X
86812
XXX
9
X
29.17
X
86813
XXX
9
X
65.54
X
86816
XXX
9
X
34.09
X
86817
XXX
9
X
119.94
X
86821
XXX
9
X
41.31
X
86825
XXX
9
X
123.72
X
86826
XXX
9
X
41.28
X
86828
XXX
9
X
72.53
X
86829
XXX
9
X
72.53
X
86830
XXX
9
X
107.94
X
86831
XXX
9
X
92.52
X
86832
XXX
9
X
365.84
X
86833
XXX
9
X
368.15
X
86834
XXX
9
X
404.04
X
86835
XXX
9
X
364.94
X
86849
XXX
9
X
#
X
86850
XXX
9
X
11.04
X
86860
XXX
9
X
45.52
X
86870
XXX
9
X
45.52
X
86880
XXX
9
X
6.09
X
86885
XXX
9
X
6.46
X
86886
XXX
9
X
5.85
X
86890
XXX
9
X
*
X
86891
XXX
9
X
*
X
86900
XXX
9
X
3.38
X
86901
XXX
9
X
3.38
X
86902
XXX
9
X
7.18
X
86904
XXX
9
X
18.46
X
86905
XXX
9
X
4.33
X
86906
XXX
9
X
8.76
X
86910
XXX
9
X
*
X
86911
XXX
9
X
*
X
86920
XXX
9
X
109.23
X
86921
XXX
9
X
109.23
X
86922
XXX
9
X
109.23
X
86923
XXX
9
X
*
X
86927
XXX
9
X
*
X
86940
XXX
9
X
9.91
X
86941
XXX
9
X
13.68
X
86945
XXX
9
X
*
X
86950
XXX
9
X
236.27
X
86960
XXX
9
X
*
X
86965
XXX
9
X
*
X
86970
XXX
9
X
*
X
86971
XXX
9
X
*
X
86972
XXX
9
X
*
X
86975
XXX
9
X
*
X
86976
XXX
9
X
*
X
86977
XXX
9
X
*
X
86978
XXX
9
X
*
X
86985
XXX
9
X
*
X
86999
XXX
9
X
#
X
87003
XXX
9
X
19.03
X
87015
XXX
9
X
7.55
X
87040
XXX
9
X
11.66
X
87045
XXX
9
X
10.67
X
87046
XXX
9
X
10.67
X
87070
XXX
9
X
9.74
X
87071
XXX
9
X
11.18
X
87073
XXX
9
X
10.92
X
87075
XXX
9
X
10.70
X
87076
XXX
9
X
9.13
X
87077
XXX
9
X
9.13
X
87081
XXX
9
X
7.49
X
87084
XXX
9
X
30.59
X
87086
XXX
9
X
9.12
X
87088
XXX
9
X
9.14
X
87101
XXX
9
X
8.71
X
87102
XXX
9
X
9.50
X
87103
XXX
9
X
23.12
X
87106
XXX
9
X
11.66
X
87107
XXX
9
X
11.66
X
87109
XXX
9
X
17.39
X
87110
XXX
9
X
22.15
X
87116
XXX
9
X
12.20
X
87118
XXX
9
X
16.51
X
87140
XXX
9
X
6.29
X
87143
XXX
9
X
14.15
X
87147
XXX
9
X
5.85
X
87149
XXX
9
X
22.66
X
87150
XXX
9
X
39.65
X
87152
XXX
9
X
8.75
X
87153
XXX
9
X
130.36
X
87154
XXX
9
X
246.41
X
87158
XXX
9
X
8.75
X
87164
XXX
9
X
12.14
X
87164
26
003
XXX
9
X
56.18
X
87164
26
001
XXX
9
X
59.23
X
87164
26
004
XXX
9
X
55.61
X
87164
26
002
XXX
9
X
58.66
X
87166
XXX
9
X
12.77
X
87168
XXX
9
X
4.83
X
87169
XXX
9
X
4.87
X
87172
XXX
9
X
4.83
X
87176
XXX
9
X
6.64
X
87177
XXX
9
X
10.06
X
87181
XXX
9
X
5.37
X
87184
XXX
9
X
8.45
X
87185
XXX
9
X
5.37
X
87186
XXX
9
X
9.77
X
87187
XXX
9
X
45.39
X
87188
XXX
9
X
7.50
X
87190
XXX
9
X
8.26
X
87197
XXX
9
X
16.97
X
87205
XXX
9
X
4.83
X
87206
XXX
9
X
6.09
X
87207
XXX
9
X
6.77
X
87207
26
003
XXX
9
X
56.18
X
87207
26
004
XXX
9
X
55.61
X
87207
26
002
XXX
9
X
58.66
X
87207
26
001
XXX
9
X
59.23
X
87209
XXX
9
X
20.32
X
87210
XXX
9
X
6.58
X
87220
XXX
9
X
4.83
X
87230
XXX
9
X
22.31
X
87250
XXX
9
X
22.10
X
87252
XXX
9
X
29.46
X
87253
XXX
9
X
22.83
X
87254
XXX
9
X
22.10
X
87255
XXX
9
X
38.26
X
87260
XXX
9
X
16.31
X
87265
XXX
9
X
13.54
X
87267
XXX
9
X
15.16
X
87269
XXX
9
X
15.38
X
87270
XXX
9
X
13.54
X
87271
XXX
9
X
15.16
X
87272
XXX
9
X
13.54
X
87273
XXX
9
X
13.54
X
87274
XXX
9
X
13.54
X
87275
XXX
9
X
13.84
X
87276
XXX
9
X
18.16
X
87278
XXX
9
X
17.63
X
87279
XXX
9
X
18.57
X
87280
XXX
9
X
15.16
X
87281
XXX
9
X
13.54
X
87283
XXX
9
X
68.70
X
87285
XXX
9
X
13.76
X
87290
XXX
9
X
15.16
X
87299
XXX
9
X
18.19
X
87300
XXX
9
X
13.54
X
87301
XXX
9
X
13.54
X
87305
XXX
9
X
13.54
X
87320
XXX
9
X
16.95
X
87324
XXX
9
X
13.54
X
87327
XXX
9
X
15.16
X
87328
XXX
9
X
15.62
X
87329
XXX
9
X
13.54
X
87332
XXX
9
X
13.54
X
87335
XXX
9
X
14.31
X
87336
XXX
9
X
18.08
X
87337
XXX
9
X
13.54
X
87338
XXX
9
X
16.25
X
87339
XXX
9
X
18.08
X
87340
XXX
9
X
11.67
X
87341
XXX
9
X
11.67
X
87350
XXX
9
X
13.03
X
87380
XXX
9
X
20.75
X
87385
XXX
9
X
14.97
X
87389
XXX
9
X
27.21
X
87390
XXX
9
X
27.19
X
87391
XXX
9
X
24.75
X
87400
XXX
9
X
15.97
X
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