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DLI
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Health Care Services Review
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Medical Fee Review
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Fee Schedule
>
Fee Schedule 95937-97016
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
95937-97016
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
95937
002
XXX
0
X
164.18
X
95937
26
002
XXX
0
X
176.33
X
95937
TC
002
XXX
0
X
36.28
X
95937
003
XXX
0
X
144.71
X
95937
26
003
XXX
0
X
134.68
X
95937
TC
003
XXX
0
X
33.14
X
95937
004
XXX
0
X
144.15
X
95937
26
004
XXX
0
X
151.26
X
95937
TC
004
XXX
0
X
32.66
X
95937
001
XXX
0
X
150.55
X
95937
26
001
XXX
0
X
176.83
X
95937
TC
001
XXX
0
X
37.03
X
95938
001
XXX
0
X
528.08
X
95938
26
001
XXX
0
X
76.85
X
95938
TC
001
XXX
0
X
451.22
X
95938
004
XXX
0
X
460.36
X
95938
26
004
XXX
0
X
71.83
X
95938
TC
004
XXX
0
X
388.52
X
95938
003
XXX
0
X
460.36
X
95938
26
003
XXX
0
X
71.83
X
95938
TC
003
XXX
0
X
388.52
X
95938
002
XXX
0
X
460.36
X
95938
26
002
XXX
0
X
71.83
X
95938
TC
002
XXX
0
X
388.52
X
95939
004
XXX
0
X
725.49
X
95939
26
004
XXX
0
X
189.10
X
95939
TC
004
XXX
0
X
536.38
X
95939
002
XXX
0
X
725.49
X
95939
26
002
XXX
0
X
189.10
X
95939
TC
002
XXX
0
X
536.38
X
95939
003
XXX
0
X
725.49
X
95939
26
003
XXX
0
X
189.10
X
95939
TC
003
XXX
0
X
536.38
X
95939
001
XXX
0
X
825.44
X
95939
26
001
XXX
0
X
202.51
X
95939
TC
001
XXX
0
X
622.89
X
95940
001
XXX
0
X
54.71
X
95940
003
XXX
0
X
50.91
X
95940
002
XXX
0
X
50.91
X
95940
004
XXX
0
X
50.91
X
95941
XXX
9
X
*
X
95954
001
XXX
0
X
532.43
X
95954
26
001
XXX
0
X
283.47
X
95954
TC
001
XXX
0
X
55.88
X
95954
002
XXX
0
X
524.69
X
95954
26
002
XXX
0
X
470.07
X
95954
TC
002
XXX
0
X
54.59
X
95954
003
XXX
0
X
492.90
X
95954
26
003
XXX
0
X
443.64
X
95954
TC
003
XXX
0
X
49.32
X
95954
004
XXX
0
X
486.90
X
95954
26
004
XXX
0
X
438.37
X
95954
TC
004
XXX
0
X
48.60
X
95955
004
XXX
0
X
400.58
X
95955
26
004
XXX
0
X
206.55
X
95955
TC
004
XXX
0
X
194.03
X
95955
003
XXX
0
X
539.82
X
95955
26
003
XXX
0
X
209.13
X
95955
TC
003
XXX
0
X
197.04
X
95955
002
XXX
0
X
496.20
X
95955
26
002
XXX
0
X
222.42
X
95955
TC
002
XXX
0
X
216.21
X
95955
001
XXX
0
X
446.35
X
95955
26
001
XXX
0
X
225.59
X
95955
TC
001
XXX
0
X
220.77
X
95957
001
XXX
0
X
554.31
X
95957
26
001
XXX
0
X
302.79
X
95957
TC
001
XXX
0
X
186.13
X
95957
002
XXX
0
X
348.47
X
95957
26
002
XXX
0
X
291.82
X
95957
TC
002
XXX
0
X
182.58
X
95957
004
XXX
0
X
513.46
X
95957
26
004
XXX
0
X
348.50
X
95957
TC
004
XXX
0
X
164.95
X
95957
003
XXX
0
X
519.71
X
95957
26
003
XXX
0
X
352.22
X
95957
TC
003
XXX
0
X
167.54
X
95958
001
XXX
0
X
819.72
X
95958
26
001
XXX
0
X
529.13
X
95958
TC
001
XXX
0
X
191.83
X
95958
002
XXX
0
X
1,002.20
X
95958
26
002
XXX
0
X
814.17
X
95958
TC
002
XXX
0
X
188.05
X
95958
003
XXX
0
X
940.63
X
95958
26
003
XXX
0
X
768.38
X
95958
TC
003
XXX
0
X
172.33
X
95958
004
XXX
0
X
928.93
X
95958
26
004
XXX
0
X
759.30
X
95958
TC
004
XXX
0
X
169.64
X
95961
XXX
0
X
*
X
95962
ZZZ
0
X
*
X
95965
26
002
XXX
0
X
903.54
X
95965
26
003
XXX
0
X
903.54
X
95965
26
004
XXX
0
X
903.54
X
95965
26
001
XXX
0
X
978.93
X
95966
26
002
XXX
0
X
457.23
X
95966
26
003
XXX
0
X
457.23
X
95966
26
004
XXX
0
X
457.23
X
95966
26
001
XXX
0
X
499.19
X
95967
26
004
ZZZ
0
X
400.87
X
95967
26
003
ZZZ
0
X
400.87
X
95967
26
002
ZZZ
0
X
400.87
X
95967
26
001
ZZZ
0
X
438.21
X
95970
004
XXX
0
X
54.31
52.70
95970
002
XXX
0
X
54.31
52.70
95970
001
XXX
0
X
61.94
60.00
95970
003
XXX
0
X
54.31
52.70
95971
002
XXX
0
X
90.62
88.14
95971
001
XXX
0
X
100.52
97.61
95971
004
XXX
0
X
90.62
88.14
95971
003
XXX
0
X
90.62
88.14
95972
002
XXX
0
X
169.26
165.15
95972
003
XXX
0
X
169.26
165.15
95972
004
XXX
0
X
169.26
165.15
95972
001
XXX
0
X
184.07
179.29
95976
001
XXX
0
X
61.36
60.30
95976
002
XXX
0
X
56.87
55.93
95976
003
XXX
0
X
56.87
55.93
95976
004
XXX
0
X
56.87
55.93
95977
001
XXX
0
X
81.42
80.32
95977
003
XXX
0
X
75.47
74.57
95977
004
XXX
0
X
75.47
74.57
95977
002
XXX
0
X
75.47
74.57
95980
004
XXX
0
X
70.20
X
95980
003
XXX
0
X
70.20
X
95980
002
XXX
0
X
70.20
X
95980
001
XXX
0
X
77.08
X
95981
003
XXX
0
X
48.07
27.41
95981
004
XXX
0
X
48.07
27.41
95981
002
XXX
0
X
48.07
27.41
95981
001
XXX
0
X
55.05
30.12
95982
001
XXX
0
X
82.76
60.21
95982
004
XXX
0
X
73.95
55.18
95982
003
XXX
0
X
73.95
55.18
95982
002
XXX
0
X
73.95
55.18
95983
002
XXX
0
X
71.60
70.66
95983
003
XXX
0
X
71.60
70.66
95983
004
XXX
0
X
71.60
70.66
95983
001
XXX
0
X
77.44
76.37
95984
002
ZZZ
0
X
62.30
61.82
95984
003
ZZZ
0
X
62.30
61.82
95984
004
ZZZ
0
X
62.30
61.82
95984
001
ZZZ
0
X
67.24
66.70
95990
003
XXX
0
X
116.14
X
95990
004
XXX
0
X
116.14
X
95990
001
XXX
0
X
138.52
X
95990
002
XXX
0
X
116.14
X
95991
003
XXX
0
X
173.94
80.54
95991
001
XXX
0
X
197.25
87.47
95991
002
XXX
0
X
173.94
80.54
95991
004
XXX
0
X
173.94
80.54
95992
XXX
0
X
*
X
95999
XXX
0
X
#
X
96000
002
XXX
0
X
201.90
X
96000
003
XXX
0
X
201.90
X
96000
004
XXX
0
X
201.90
X
96000
001
XXX
0
X
217.55
X
96001
004
XXX
0
X
240.91
X
96001
003
XXX
0
X
240.91
X
96001
002
XXX
0
X
240.91
X
96001
001
XXX
0
X
259.42
X
96002
004
XXX
0
X
46.66
X
96002
002
XXX
0
X
46.66
X
96002
003
XXX
0
X
46.66
X
96002
001
XXX
0
X
51.00
X
96003
001
XXX
0
X
47.91
X
96003
004
XXX
0
X
43.32
X
96003
003
XXX
0
X
43.32
X
96003
002
XXX
0
X
43.32
X
96004
001
XXX
0
X
224.53
X
96004
004
XXX
0
X
205.67
X
96004
003
XXX
0
X
205.67
X
96004
002
XXX
0
X
205.67
X
96020
26
001
XXX
0
X
298.17
X
96020
26
002
XXX
0
X
274.35
X
96020
26
003
XXX
0
X
274.35
X
96020
26
004
XXX
0
X
274.35
X
96040
XXX
9
X
*
X
96105
003
XXX
0
X
166.03
X
96105
002
XXX
0
X
184.02
X
96105
001
XXX
0
X
195.73
X
96105
004
XXX
0
X
162.76
X
96110
XXX
9
X
*
X
96112
001
XXX
0
X
200.82
189.02
96112
004
XXX
0
X
187.81
177.52
96112
003
XXX
0
X
187.81
177.52
96112
002
XXX
0
X
187.81
177.52
96113
004
ZZZ
0
X
83.94
81.15
96113
002
ZZZ
0
X
83.94
81.15
96113
003
ZZZ
0
X
83.94
81.15
96113
001
ZZZ
0
X
89.72
86.52
96116
003
XXX
0
X
200.23
187.79
96116
002
XXX
0
X
200.23
187.79
96116
001
XXX
0
X
222.19
206.93
96116
004
XXX
0
X
200.23
187.79
96121
003
ZZZ
0
X
114.23
109.10
96121
004
ZZZ
0
X
114.23
109.10
96121
002
ZZZ
0
X
114.23
109.10
96121
001
ZZZ
0
X
121.15
115.27
96125
001
XXX
5
X
183.73
153.33
96125
002
XXX
5
X
165.64
140.45
96125
003
XXX
5
X
165.64
140.45
96125
004
XXX
5
X
165.64
140.45
96127
002
XXX
0
X
7.88
X
96127
003
XXX
0
X
7.88
X
96127
004
XXX
0
X
7.88
X
96127
001
XXX
0
X
9.30
X
96130
002
XXX
0
X
162.83
153.51
96130
001
XXX
0
X
171.80
161.06
96130
004
XXX
0
X
162.83
153.51
96130
003
XXX
0
X
162.83
153.51
96131
003
ZZZ
0
X
123.87
116.86
96131
002
ZZZ
0
X
123.87
116.86
96131
004
ZZZ
0
X
123.87
116.86
96131
001
ZZZ
0
X
130.54
122.50
96132
002
XXX
0
X
181.97
150.64
96132
001
XXX
0
X
193.63
157.71
96132
004
XXX
0
X
181.97
150.64
96132
003
XXX
0
X
181.97
150.64
96133
001
ZZZ
0
X
147.69
120.90
96133
002
ZZZ
0
X
138.83
115.46
96133
003
ZZZ
0
X
138.83
115.46
96133
004
ZZZ
0
X
138.83
115.46
96136
001
XXX
0
X
70.34
36.56
96136
002
XXX
0
X
64.04
34.61
96136
003
XXX
0
X
64.04
34.61
96136
004
XXX
0
X
64.04
34.61
96137
001
ZZZ
0
X
65.05
28.59
96137
003
ZZZ
0
X
59.04
27.26
96137
004
ZZZ
0
X
59.04
27.26
96137
002
ZZZ
0
X
59.04
27.26
96138
002
XXX
0
X
50.52
X
96138
001
XXX
0
X
58.05
X
96138
004
XXX
0
X
50.52
X
96138
003
XXX
0
X
50.52
X
96139
004
ZZZ
0
X
50.52
X
96139
003
ZZZ
0
X
50.52
X
96139
002
ZZZ
0
X
50.52
X
96139
001
ZZZ
0
X
58.05
X
96146
001
XXX
0
X
3.37
X
96146
004
XXX
0
X
2.86
X
96146
002
XXX
0
X
2.86
X
96146
003
XXX
0
X
2.86
X
96156
001
XXX
0
X
144.37
130.33
96156
002
XXX
0
X
135.72
123.56
96156
004
XXX
0
X
135.72
123.56
96156
003
XXX
0
X
135.72
123.56
96158
002
XXX
0
X
92.63
84.21
96158
003
XXX
0
X
92.63
84.21
96158
004
XXX
0
X
92.63
84.21
96158
001
XXX
0
X
98.33
88.63
96159
001
ZZZ
0
X
34.38
30.61
96159
002
ZZZ
0
X
32.34
29.07
96159
003
ZZZ
0
X
32.34
29.07
96159
004
ZZZ
0
X
32.34
29.07
96160
004
ZZZ
9
X
6.56
X
96160
003
ZZZ
9
X
6.56
X
96160
002
ZZZ
9
X
6.56
X
96160
001
ZZZ
9
X
7.60
X
96161
004
ZZZ
9
X
6.56
X
96161
003
ZZZ
9
X
6.56
X
96161
002
ZZZ
9
X
6.56
X
96161
001
ZZZ
9
X
7.60
X
96164
004
XXX
0
X
13.71
12.31
96164
003
XXX
0
X
13.71
12.31
96164
002
XXX
0
X
13.71
12.31
96164
001
XXX
0
X
14.61
12.99
96165
003
ZZZ
0
X
6.38
5.43
96165
004
ZZZ
0
X
6.38
5.43
96165
001
ZZZ
0
X
6.73
5.65
96165
002
ZZZ
0
X
6.38
5.43
96167
001
XXX
0
X
105.71
94.92
96167
004
XXX
0
X
99.49
90.13
96167
003
XXX
0
X
99.49
90.13
96167
002
XXX
0
X
99.49
90.13
96168
004
ZZZ
0
X
35.29
32.00
96168
003
ZZZ
0
X
35.29
32.00
96168
002
ZZZ
0
X
35.29
32.00
96168
001
ZZZ
0
X
37.48
33.70
96170
XXX
9
X
*
X
96171
ZZZ
9
X
*
X
96202
X
*
X
96203
X
*
X
96360
003
XXX
0
X
95.32
X
96360
004
XXX
0
X
95.32
X
96360
001
XXX
0
X
112.64
X
96360
002
XXX
0
X
95.32
X
96361
004
ZZZ
0
X
28.31
X
96361
003
ZZZ
0
X
28.31
X
96361
002
ZZZ
0
X
28.31
X
96361
001
ZZZ
0
X
33.47
X
96365
001
XXX
0
X
136.55
X
96365
002
XXX
0
X
115.79
X
96365
003
XXX
0
X
115.79
X
96365
004
XXX
0
X
115.79
X
96366
003
ZZZ
0
X
37.67
X
96366
004
ZZZ
0
X
37.67
X
96366
002
ZZZ
0
X
37.67
X
96366
001
ZZZ
0
X
43.62
X
96367
003
ZZZ
0
X
58.67
X
96367
004
ZZZ
0
X
58.67
X
96367
001
ZZZ
0
X
68.34
X
96367
002
ZZZ
0
X
58.67
X
96368
001
ZZZ
0
X
40.83
X
96368
002
ZZZ
0
X
35.26
X
96368
003
ZZZ
0
X
35.26
X
96368
004
ZZZ
0
X
35.26
X
96369
001
XXX
0
X
294.88
X
96369
004
XXX
0
X
249.50
X
96369
003
XXX
0
X
249.50
X
96369
002
XXX
0
X
249.50
X
96370
003
ZZZ
0
X
27.55
X
96370
004
ZZZ
0
X
27.55
X
96370
001
ZZZ
0
X
31.56
X
96370
002
ZZZ
0
X
27.55
X
96371
001
ZZZ
0
X
142.73
X
96371
002
ZZZ
0
X
120.15
X
96371
003
ZZZ
0
X
120.15
X
96371
004
ZZZ
0
X
120.15
X
96372
002
XXX
0
X
35.56
X
96372
004
XXX
0
X
35.56
X
96372
003
XXX
0
X
35.56
X
96372
001
XXX
0
X
40.52
X
96373
001
XXX
0
X
35.20
X
96373
004
XXX
0
X
30.88
X
96373
003
XXX
0
X
30.88
X
96373
002
XXX
0
X
30.88
X
96374
004
XXX
0
X
91.46
X
96374
003
XXX
0
X
91.46
X
96374
002
XXX
0
X
91.46
X
96374
001
XXX
0
X
107.38
X
96375
001
ZZZ
0
X
47.59
X
96375
004
ZZZ
0
X
40.32
X
96375
003
ZZZ
0
X
40.32
X
96375
002
ZZZ
0
X
40.32
X
96376
ZZZ
9
X
*
X
96377
XXX
0
X
*
X
96379
XXX
0
X
#
X
96401
004
XXX
0
X
116.24
X
96401
002
XXX
0
X
116.24
X
96401
003
XXX
0
X
116.24
X
96401
001
XXX
0
X
139.35
X
96402
001
XXX
0
X
74.50
X
96402
004
XXX
0
X
62.93
X
96402
003
XXX
0
X
62.93
X
96402
002
XXX
0
X
62.93
X
96405
001
0
2
X
103.41
82.87
96405
003
0
2
X
97.09
77.97
96405
004
0
2
X
95.91
77.13
96405
002
0
2
X
102.21
81.88
96406
001
0
2
X
155.89
125.08
96406
003
0
2
X
146.72
117.96
96406
002
0
2
X
154.12
123.65
96406
004
0
2
X
144.97
116.71
96409
002
XXX
0
X
213.13
X
96409
001
XXX
0
X
258.98
X
96409
004
XXX
0
X
213.13
X
96409
003
XXX
0
X
213.13
X
96411
002
ZZZ
0
X
123.65
X
96411
003
ZZZ
0
X
123.65
X
96411
004
ZZZ
0
X
123.65
X
96411
001
ZZZ
0
X
150.05
X
96413
004
XXX
0
X
300.53
X
96413
001
XXX
0
X
365.91
X
96413
002
XXX
0
X
300.53
X
96413
003
XXX
0
X
300.53
X
96415
003
ZZZ
0
X
68.43
X
96415
004
ZZZ
0
X
68.43
X
96415
002
ZZZ
0
X
68.43
X
96415
001
ZZZ
0
X
82.92
X
96416
004
XXX
0
X
322.35
X
96416
002
XXX
0
X
322.35
X
96416
003
XXX
0
X
322.35
X
96416
001
XXX
0
X
393.63
X
96417
001
ZZZ
0
X
179.09
X
96417
002
ZZZ
0
X
147.30
X
96417
003
ZZZ
0
X
147.30
X
96417
004
ZZZ
0
X
147.30
X
96420
002
XXX
0
X
132.87
X
96420
001
XXX
0
X
135.42
X
96420
004
XXX
0
X
120.17
X
96420
003
XXX
0
X
122.05
X
96422
002
XXX
0
X
145.77
X
96422
003
XXX
0
X
120.18
X
96422
004
XXX
0
X
143.12
X
96422
001
XXX
0
X
133.41
X
96423
002
ZZZ
0
X
106.30
X
96423
003
ZZZ
0
X
47.32
X
96423
004
ZZZ
0
X
46.58
X
96423
001
ZZZ
0
X
106.66
X
96425
001
XXX
0
X
153.64
X
96425
002
XXX
0
X
124.92
X
96425
003
XXX
0
X
118.20
X
96425
004
XXX
0
X
136.86
X
96440
001
0
0
X
369.40
314.68
96440
002
0
0
X
314.56
268.83
96440
003
0
0
X
346.56
296.30
96440
004
0
0
X
315.58
277.57
96446
003
XXX
0
X
297.37
37.28
96446
002
XXX
0
X
297.37
37.28
96446
001
XXX
0
X
335.50
41.20
96446
004
XXX
0
X
297.37
37.28
96450
003
0
0
X
232.44
X
96450
004
0
0
X
185.61
X
96450
001
0
0
X
195.95
X
96450
002
0
0
X
206.52
X
96521
002
XXX
0
X
266.08
X
96521
004
XXX
0
X
266.08
X
96521
003
XXX
0
X
266.08
X
96521
001
XXX
0
X
324.19
X
96522
001
XXX
0
X
234.31
X
96522
004
XXX
0
X
192.61
X
96522
003
XXX
0
X
192.61
X
96522
002
XXX
0
X
192.61
X
96523
002
XXX
0
X
48.76
X
96523
003
XXX
0
X
48.76
X
96523
004
XXX
0
X
48.76
X
96523
001
XXX
0
X
59.40
X
96542
001
XXX
0
X
277.28
X
96542
002
XXX
0
X
273.55
X
96542
004
XXX
0
X
255.01
X
96542
003
XXX
0
X
258.03
X
96547
ZZZ
9
X
#
X
96548
ZZZ
9
X
#
X
96549
XXX
0
X
#
X
96567
004
XXX
0
X
125.99
X
96567
003
XXX
0
X
125.99
X
96567
002
XXX
0
X
125.99
X
96567
001
XXX
0
X
149.27
X
96570
004
ZZZ
0
X
172.86
149.47
96570
003
ZZZ
0
X
172.86
149.47
96570
002
ZZZ
0
X
172.86
149.47
96570
001
ZZZ
0
X
200.66
173.33
96571
004
ZZZ
0
X
90.67
82.31
96571
003
ZZZ
0
X
90.67
82.31
96571
002
ZZZ
0
X
90.67
82.31
96571
001
ZZZ
0
X
111.11
101.34
96573
001
0
0
X
302.47
X
96573
002
0
0
X
266.12
X
96573
003
0
0
X
266.12
X
96573
004
0
0
X
266.12
X
96574
001
0
0
X
388.89
X
96574
004
0
0
X
344.30
X
96574
003
0
0
X
344.30
X
96574
002
0
0
X
344.30
X
96900
004
XXX
0
X
46.33
X
96900
003
XXX
0
X
38.81
X
96900
002
XXX
0
X
42.30
X
96900
001
XXX
0
X
47.38
X
96902
XXX
9
X
*
X
96904
002
XXX
0
X
115.59
X
96904
001
XXX
0
X
141.66
X
96904
004
XXX
0
X
115.59
X
96904
003
XXX
0
X
115.59
X
96910
004
XXX
0
X
55.92
X
96910
002
XXX
0
X
61.82
X
96910
003
XXX
0
X
56.75
X
96910
001
XXX
0
X
62.93
X
96912
001
XXX
0
X
70.79
X
96912
004
XXX
0
X
64.28
X
96912
003
XXX
0
X
65.30
X
96912
002
XXX
0
X
68.45
X
96913
003
XXX
0
X
96.19
X
96913
004
XXX
0
X
95.00
X
96913
002
XXX
0
X
101.07
X
96913
001
XXX
0
X
102.27
X
96920
002
0
2
X
316.86
132.63
96920
001
0
2
X
363.04
146.49
96920
004
0
2
X
316.86
132.63
96920
003
0
2
X
316.86
132.63
96921
001
0
2
X
371.89
149.06
96921
003
0
2
X
324.54
134.99
96921
004
0
2
X
324.54
134.99
96921
002
0
2
X
324.54
134.99
96922
004
0
2
X
449.54
241.78
96922
002
0
2
X
449.54
241.78
96922
001
0
2
X
511.09
266.84
96922
003
0
2
X
449.54
241.78
96931
XXX
0
X
*
X
96932
XXX
0
X
*
X
96933
XXX
0
X
*
X
96934
ZZZ
0
X
*
X
96935
ZZZ
0
X
*
X
96936
ZZZ
0
X
*
X
96999
XXX
0
X
#
X
97010
003
XXX
9
X
43.38
X
97010
002
XXX
9
X
46.03
X
97010
001
XXX
9
X
46.66
X
97010
004
XXX
9
X
43.46
X
97012
004
XXX
5
X
49.90
X
97012
003
XXX
5
X
45.12
X
97012
002
XXX
5
X
48.24
X
97012
001
XXX
5
X
48.04
X
97014
001
XXX
9
X
44.86
X
97014
004
XXX
9
X
46.58
X
97014
003
XXX
9
X
43.60
X
97014
002
XXX
9
X
42.95
X
97016
001
XXX
5
X
50.64
X
97016
004
XXX
5
X
46.31
X
97016
003
XXX
5
X
53.70
X
97016
002
XXX
5
X
50.06
X
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