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Health Care Services Review
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Fee Schedule
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Fee Schedule E0665-E2310
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2024 Workers' Compensation Part B Fee Schedule
E0665-E2310
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
E0665
NU
X
324.17
X
E0665
RR
X
37.52
X
E0665
UE
X
243.12
X
E0666
NU
X
313.06
X
E0666
RR
X
37.96
X
E0666
UE
X
234.77
X
E0667
NU
X
863.39
X
E0667
RR
X
86.36
X
E0667
UE
X
647.55
X
E0668
NU
X
1,001.58
X
E0668
RR
X
98.88
X
E0668
UE
X
751.20
X
E0669
XXX
X
#
X
E0670
NU
X
1,887.85
X
E0670
RR
X
202.10
X
E0670
UE
X
1,415.80
X
E0671
NU
XXX
X
1,094.79
X
E0671
RR
XXX
X
109.50
X
E0671
UE
XXX
X
821.05
X
E0672
NU
XXX
X
850.68
X
E0672
RR
XXX
X
85.07
X
E0672
UE
XXX
X
638.01
X
E0673
NU
XXX
X
706.84
X
E0673
RR
XXX
X
70.67
X
E0673
UE
XXX
X
530.12
X
E0675
RR
X
699.02
X
E0676
X
#
X
E0677
X
#
X
E0691
NU
X
1,993.61
X
E0691
RR
X
199.36
X
E0691
UE
X
1,495.20
X
E0692
NU
X
2,503.43
X
E0692
RR
X
250.32
X
E0692
UE
X
1,877.58
X
E0693
NU
X
3,086.01
X
E0693
RR
X
308.58
X
E0693
UE
X
2,314.51
X
E0694
NU
X
9,822.42
X
E0694
RR
X
982.21
X
E0694
UE
X
7,366.89
X
E0700
X
#
X
E0705
X
#
X
E0710
X
*
X
E0711
X
#
X
E0720
NU
X
876.18
X
E0720
RR
X
87.61
X
E0730
NU
X
839.91
X
E0730
RR
X
83.96
X
E0731
NU
X
951.10
X
E0731
RR
X
95.10
X
E0740
X
#
X
E0744
X
2,441.93
X
E0745
X
2,386.71
X
E0746
X
2,238.69
X
E0747
NU
X
9,066.31
X
E0747
RR
X
906.61
X
E0747
UE
X
6,799.69
X
E0748
NU
X
9,236.60
X
E0748
RR
X
923.62
X
E0748
UE
X
6,927.47
X
E0749
X
6,830.35
X
E0755
X
#
X
E0760
XXX
X
#
X
E0761
X
*
X
E0762
X
#
X
E0764
NU
XXX
9
X
21,659.01
X
E0764
RR
XXX
9
X
2,165.89
X
E0764
UE
XXX
9
X
16,244.29
X
E0765
X
#
X
E0766
X
662.94
X
E0769
X
#
X
E0770
X
#
X
E0776
NU
X
381.69
X
E0776
RR
X
49.77
X
E0776
UE
X
280.90
X
E0779
RR
X
37.65
X
E0780
NU
X
24.22
X
E0781
X
7,138.90
X
E0782
NU
X
10,312.06
X
E0782
RR
X
1,031.25
X
E0782
UE
X
7,734.04
X
E0783
X
18,635.26
X
E0784
XXX
X
#
X
E0785
X
845.22
X
E0786
XXX
X
#
X
E0787
X
#
X
E0791
X
7,167.38
X
E0830
X
#
X
E0840
NU
X
195.44
X
E0840
RR
X
43.46
X
E0840
UE
X
146.48
X
E0849
NU
X
1,077.70
X
E0849
RR
X
107.75
X
E0849
UE
X
808.24
X
E0850
NU
X
280.14
X
E0850
RR
X
38.42
X
E0850
UE
X
210.14
X
E0855
NU
XXX
X
1,280.00
X
E0855
RR
XXX
X
127.99
X
E0855
UE
XXX
X
960.03
X
E0856
X
#
X
E0860
NU
X
102.71
X
E0860
RR
X
17.35
X
E0860
UE
X
78.70
X
E0870
NU
X
280.14
X
E0870
RR
X
35.26
X
E0870
UE
X
210.14
X
E0880
NU
X
334.71
X
E0880
RR
X
52.57
X
E0880
UE
X
253.46
X
E0890
NU
X
321.11
X
E0890
RR
X
87.53
X
E0890
UE
X
258.65
X
E0900
NU
X
341.68
X
E0900
RR
X
67.96
X
E0900
UE
X
256.34
X
E0910
X
533.41
X
E0911
RR
XXX
9
X
100.21
X
E0912
RR
XXX
9
X
230.08
X
E0920
X
1,230.70
X
E0930
X
1,218.52
X
E0935
X
60.62
X
E0936
X
*
X
E0940
X
788.22
X
E0941
X
1,158.15
X
E0942
NU
X
52.90
X
E0942
RR
X
6.24
X
E0942
UE
X
39.70
X
E0944
NU
X
122.35
X
E0944
RR
X
12.31
X
E0944
UE
X
91.75
X
E0945
NU
X
118.20
X
E0945
RR
X
11.82
X
E0945
UE
X
91.49
X
E0946
X
1,577.53
X
E0947
NU
X
1,617.21
X
E0947
RR
X
167.75
X
E0947
UE
X
1,212.90
X
E0948
NU
X
1,564.20
X
E0948
RR
X
156.36
X
E0948
UE
X
1,103.15
X
E0950
NU
X
277.20
X
E0950
RR
X
27.77
X
E0950
UE
X
207.91
X
E0951
NU
X
50.23
X
E0951
RR
X
5.01
X
E0951
UE
X
37.66
X
E0952
NU
X
50.23
X
E0952
RR
X
5.01
X
E0952
UE
X
37.66
X
E0953
NU
X
102.10
X
E0953
RR
X
10.20
X
E0953
UE
X
76.56
X
E0954
NU
X
72.66
X
E0954
RR
X
7.27
X
E0954
UE
X
54.52
X
E0955
NU
X
438.90
X
E0955
RR
X
43.91
X
E0955
UE
X
329.16
X
E0956
NU
X
213.99
X
E0956
RR
X
21.36
X
E0956
UE
X
160.49
X
E0957
NU
X
299.44
X
E0957
RR
X
29.90
X
E0957
UE
X
224.59
X
E0958
X
1,157.24
X
E0959
NU
X
233.04
X
E0959
RR
X
23.67
X
E0959
UE
X
178.42
X
E0960
NU
X
197.50
X
E0960
RR
X
19.73
X
E0960
UE
X
148.14
X
E0961
NU
X
68.39
X
E0961
RR
X
8.27
X
E0961
UE
X
51.25
X
E0966
NU
X
172.61
X
E0966
RR
X
17.27
X
E0966
UE
X
129.44
X
E0967
NU
X
352.33
X
E0967
RR
X
35.26
X
E0967
UE
X
264.26
X
E0968
X
478.50
X
E0969
NU
X
355.08
X
E0969
RR
X
38.99
X
E0969
UE
X
292.38
X
E0970
NU
X
128.42
X
E0970
RR
X
11.44
X
E0970
UE
X
96.36
X
E0971
NU
X
175.30
X
E0971
RR
X
19.93
X
E0971
UE
X
131.49
X
E0973
NU
X
260.56
X
E0973
RR
X
29.23
X
E0973
UE
X
195.50
X
E0974
NU
X
210.68
X
E0974
RR
X
22.16
X
E0974
UE
X
158.03
X
E0978
NU
X
119.35
X
E0978
RR
X
11.85
X
E0978
UE
X
89.49
X
E0980
NU
X
88.14
X
E0980
RR
X
8.81
X
E0980
UE
X
65.77
X
E0981
NU
X
102.34
X
E0981
RR
X
10.45
X
E0981
UE
X
77.49
X
E0982
NU
X
111.85
X
E0982
RR
X
11.18
X
E0982
UE
X
83.89
X
E0983
RR
X
521.04
X
E0984
NU
X
3,525.42
X
E0984
RR
X
327.69
X
E0984
UE
X
2,720.36
X
E0985
NU
X
440.35
X
E0985
RR
X
44.04
X
E0985
UE
X
330.24
X
E0986
NU
X
10,559.43
X
E0986
RR
X
1,055.96
X
E0986
UE
X
7,919.63
X
E0988
X
521.14
X
E0990
NU
X
313.18
X
E0990
RR
X
35.26
X
E0990
UE
X
244.63
X
E0992
NU
X
215.68
X
E0992
RR
X
20.94
X
E0992
UE
X
161.80
X
E0994
NU
X
40.01
X
E0994
RR
X
4.04
X
E0994
UE
X
30.02
X
E0995
NU
X
70.46
X
E0995
RR
X
7.08
X
E0995
UE
X
52.90
X
E1002
NU
X
8,928.66
X
E1002
RR
X
892.90
X
E1002
UE
X
6,696.51
X
E1003
NU
X
9,532.78
X
E1003
RR
X
953.28
X
E1003
UE
X
7,149.57
X
E1004
NU
X
10,569.88
X
E1004
RR
X
1,056.99
X
E1004
UE
X
7,927.38
X
E1005
NU
X
11,441.03
X
E1005
RR
X
1,144.10
X
E1005
UE
X
8,580.81
X
E1006
NU
X
14,014.27
X
E1006
RR
X
1,401.38
X
E1006
UE
X
10,510.65
X
E1007
NU
X
18,975.85
X
E1007
RR
X
1,897.58
X
E1007
UE
X
14,231.84
X
E1008
NU
X
18,977.50
X
E1008
RR
X
1,897.75
X
E1008
UE
X
14,233.17
X
E1009
X
#
X
E1010
NU
X
2,499.40
X
E1010
RR
X
249.94
X
E1010
UE
X
1,874.53
X
E1011
X
#
X
E1012
RR
X
145.37
X
E1014
X
#
X
E1015
NU
X
254.47
X
E1015
RR
X
25.42
X
E1015
UE
X
190.87
X
E1016
NU
X
291.29
X
E1016
RR
X
29.18
X
E1016
UE
X
218.48
X
E1017
X
#
X
E1018
X
#
X
E1020
NU
X
540.04
X
E1020
RR
X
53.94
X
E1020
UE
X
404.98
X
E1028
NU
X
448.36
X
E1028
RR
X
44.81
X
E1028
UE
X
336.26
X
E1029
NU
X
802.20
X
E1029
RR
X
80.24
X
E1029
UE
X
601.68
X
E1030
NU
X
2,529.58
X
E1030
RR
X
252.98
X
E1030
UE
X
1,897.20
X
E1031
X
1,346.86
X
E1035
X
#
X
E1036
X
#
X
E1037
X
#
X
E1038
RR
X
88.76
X
E1039
RR
X
47.36
X
E1050
X
2,526.57
X
E1060
X
3,361.60
X
E1070
X
2,920.48
X
E1083
X
2,099.97
X
E1084
X
2,615.82
X
E1085
X
1,845.39
X
E1086
X
2,241.05
X
E1087
X
2,908.93
X
E1088
X
3,937.51
X
E1089
X
3,205.35
X
E1090
X
3,355.85
X
E1092
X
3,426.86
X
E1093
X
2,947.11
X
E1100
X
2,768.19
X
E1110
X
2,675.55
X
E1130
X
1,245.22
X
E1140
X
1,915.20
X
E1150
X
2,175.80
X
E1160
X
1,666.67
X
E1161
RR
X
523.38
X
E1170
X
2,024.76
X
E1171
X
1,870.33
X
E1172
X
2,372.44
X
E1180
X
2,296.90
X
E1190
X
2,718.90
X
E1195
X
2,847.66
X
E1200
X
2,320.53
X
E1220
X
#
X
E1221
X
1,077.17
X
E1222
X
1,807.78
X
E1223
X
1,935.84
X
E1224
X
2,164.29
X
E1225
X
1,205.54
X
E1226
NU
X
1,236.76
X
E1226
RR
X
74.02
X
E1226
UE
X
927.56
X
E1227
NU
X
739.96
X
E1227
RR
X
74.02
X
E1227
UE
X
555.02
X
E1228
X
635.09
X
E1229
X
#
X
E1230
NU
X
5,426.77
X
E1230
RR
X
542.64
X
E1230
UE
X
4,054.59
X
E1231
X
#
X
E1232
X
#
X
E1233
X
#
X
E1234
X
#
X
E1235
X
#
X
E1236
X
#
X
E1237
X
#
X
E1238
X
#
X
E1239
X
#
X
E1240
X
2,466.50
X
E1250
X
2,026.85
X
E1260
X
2,485.31
X
E1270
X
2,105.16
X
E1280
X
3,500.27
X
E1285
X
2,733.82
X
E1290
X
3,337.32
X
E1295
X
3,156.47
X
E1296
NU
X
1,114.44
X
E1296
RR
X
113.21
X
E1296
UE
X
835.86
X
E1297
NU
X
237.17
X
E1297
RR
X
26.35
X
E1297
UE
X
177.83
X
E1298
NU
X
960.22
X
E1298
RR
X
98.27
X
E1298
UE
X
720.21
X
E1300
X
#
X
E1310
NU
X
5,726.34
X
E1310
RR
X
416.36
X
E1310
UE
X
4,294.75
X
E1352
X
#
X
E1353
X
#
X
E1354
X
*
X
E1355
X
158.60
X
E1356
X
*
X
E1357
X
#
X
E1358
X
#
X
E1372
NU
X
434.70
X
E1372
RR
X
63.11
X
E1372
UE
X
321.86
X
E1390
RR
X
560.45
X
E1391
RR
X
496.65
X
E1392
RR
XXX
9
X
64.46
X
E1399
X
#
X
E1405
X
1,007.35
X
E1406
X
966.45
X
E1500
X
#
X
E1510
X
24,165.97
X
E1520
X
2,738.75
X
E1530
X
1,450.01
X
E1540
X
#
X
E1550
X
322.19
X
E1560
X
1,582.03
X
E1570
X
1,862.36
X
E1575
X
#
X
E1580
X
#
X
E1590
X
11,599.69
X
E1592
X
#
X
E1594
X
16,110.61
X
E1600
X
#
X
E1610
X
5,919.02
X
E1615
X
#
X
E1620
X
#
X
E1625
X
#
X
E1629
X
#
X
E1630
X
13,155.91
X
E1632
X
#
X
E1634
X
#
X
E1635
X
#
X
E1636
X
#
X
E1637
X
*
X
E1639
X
#
X
E1699
X
#
X
E1700
NU
X
781.62
X
E1700
RR
X
76.68
X
E1700
UE
X
586.25
X
E1701
X
27.71
X
E1702
X
55.47
X
E1800
RR
X
261.10
X
E1801
RR
X
278.38
X
E1802
RR
X
725.02
X
E1805
RR
X
282.08
X
E1806
RR
X
228.56
X
E1810
RR
X
282.08
X
E1811
RR
X
289.44
X
E1812
RR
XXX
9
X
*
X
E1815
RR
X
282.08
X
E1816
RR
X
293.98
X
E1818
RR
X
300.11
X
E1820
NU
X
215.42
X
E1820
RR
X
21.56
X
E1820
UE
X
161.57
X
E1821
NU
X
237.03
X
E1821
RR
X
23.67
X
E1821
UE
X
177.77
X
E1825
RR
X
282.08
X
E1830
RR
X
282.08
X
E1831
X
116.28
X
E1840
RR
X
854.96
X
E1841
RR
X
947.40
X
E1902
X
#
X
E1905
X
#
X
E2000
RR
X
111.80
X
E2100
NU
X
1,231.06
X
E2100
RR
X
123.08
X
E2100
UE
X
923.32
X
E2101
NU
X
424.59
X
E2101
RR
X
42.45
X
E2101
UE
X
318.45
X
E2102
NU
X
207.73
X
E2102
RR
X
20.78
X
E2102
UE
X
155.82
X
E2103
NU
X
297.44
X
E2103
RR
X
29.74
X
E2103
UE
X
223.08
X
E2120
RR
X
615.49
X
E2201
NU
X
809.95
X
E2201
RR
X
81.00
X
E2201
UE
X
607.47
X
E2202
NU
X
1,028.92
X
E2202
RR
X
102.88
X
E2202
UE
X
771.77
X
E2203
NU
X
1,039.92
X
E2203
RR
X
103.98
X
E2203
UE
X
779.95
X
E2204
NU
X
1,765.75
X
E2204
RR
X
176.62
X
E2204
UE
X
1,324.34
X
E2205
NU
X
68.34
X
E2205
RR
X
6.81
X
E2205
UE
X
51.25
X
E2206
NU
X
85.07
X
E2206
RR
X
8.51
X
E2206
UE
X
63.80
X
E2207
NU
XXX
9
X
87.12
X
E2207
RR
XXX
9
X
8.72
X
E2207
UE
XXX
9
X
65.33
X
E2208
NU
XXX
9
X
238.76
X
E2208
RR
XXX
9
X
23.89
X
E2208
UE
XXX
9
X
179.05
X
E2209
NU
XXX
9
X
215.36
X
E2209
RR
XXX
9
X
21.60
X
E2209
UE
XXX
9
X
161.54
X
E2210
NU
XXX
9
X
13.17
X
E2210
RR
XXX
9
X
1.10
X
E2210
UE
XXX
9
X
9.89
X
E2211
NU
XXX
9
X
82.22
X
E2211
RR
XXX
9
X
8.06
X
E2211
UE
XXX
9
X
58.88
X
E2212
NU
XXX
9
X
11.82
X
E2212
RR
XXX
9
X
1.25
X
E2212
UE
XXX
9
X
8.86
X
E2213
NU
XXX
9
X
61.09
X
E2213
RR
XXX
9
X
6.16
X
E2213
UE
XXX
9
X
45.76
X
E2214
NU
XXX
9
X
72.37
X
E2214
RR
XXX
9
X
7.98
X
E2214
UE
XXX
9
X
54.26
X
E2215
NU
XXX
9
X
19.27
X
E2215
RR
XXX
9
X
1.89
X
E2215
UE
XXX
9
X
14.44
X
E2216
XXX
9
X
#
X
E2217
XXX
9
X
#
X
E2218
XXX
9
X
#
X
E2219
NU
XXX
9
X
84.14
X
E2219
RR
XXX
9
X
9.51
X
E2219
UE
XXX
9
X
63.09
X
E2220
NU
XXX
9
X
57.34
X
E2220
RR
XXX
9
X
5.54
X
E2220
UE
XXX
9
X
43.64
X
E2221
NU
XXX
9
X
51.36
X
E2221
RR
XXX
9
X
5.20
X
E2221
UE
XXX
9
X
38.56
X
E2222
NU
XXX
9
X
42.34
X
E2222
RR
XXX
9
X
4.20
X
E2222
UE
XXX
9
X
31.78
X
E2224
NU
XXX
9
X
197.09
X
E2224
RR
XXX
9
X
20.70
X
E2224
UE
XXX
9
X
147.85
X
E2225
NU
XXX
9
X
34.95
X
E2225
RR
XXX
9
X
3.49
X
E2225
UE
XXX
9
X
26.23
X
E2226
NU
XXX
9
X
76.24
X
E2226
RR
XXX
9
X
7.63
X
E2226
UE
XXX
9
X
57.22
X
E2227
X
#
X
E2228
X
#
X
E2230
X
#
X
E2231
NU
X
288.91
X
E2231
RR
X
28.90
X
E2231
UE
X
216.62
X
E2291
X
*
X
E2292
X
*
X
E2293
X
*
X
E2294
X
*
X
E2295
X
#
X
E2300
X
*
X
E2301
X
*
X
E2310
NU
X
2,540.43
X
E2310
RR
X
254.01
X
E2310
UE
X
1,905.31
X
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