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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 L1680-L5999
Begin Main Content Area
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Content Editor
2024 Workers' Compensation Part B Fee Schedule
L1680-L5999
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
L1680
X
2,409.11
X
L1681
X
2,854.83
X
L1685
X
2,458.53
X
L1686
X
2,270.23
X
L1690
X
3,619.50
X
L1700
X
3,019.41
X
L1710
X
3,534.63
X
L1720
X
2,605.44
X
L1730
X
2,237.78
X
L1755
X
3,551.27
X
L1810
X
194.74
X
L1812
X
139.45
X
L1820
X
301.74
X
L1830
X
183.54
X
L1831
X
502.04
X
L1832
X
1,398.37
X
L1833
X
1,001.59
X
L1834
X
1,534.88
X
L1836
X
232.61
X
L1840
X
2,044.42
X
L1843
XXX
X
1,048.76
X
L1844
X
3,209.86
X
L1845
X
1,921.67
X
L1846
X
2,180.52
X
L1847
X
1,076.49
X
L1848
X
850.27
X
L1850
X
600.94
X
L1851
X
1,265.02
X
L1852
X
1,312.77
X
L1860
X
2,121.66
X
L1900
X
533.41
X
L1902
X
184.33
X
L1904
X
1,108.47
X
L1906
X
237.74
X
L1907
X
959.81
X
L1910
X
540.12
X
L1920
X
691.25
X
L1930
X
467.68
X
L1932
X
1,466.41
X
L1940
X
977.82
X
L1945
X
2,337.85
X
L1950
X
1,550.07
X
L1951
X
1,432.55
X
L1960
X
1,169.11
X
L1970
X
1,406.95
X
L1971
X
799.52
X
L1980
X
725.66
X
L1990
X
881.39
X
L2000
X
2,088.00
X
L2005
X
5,915.33
X
L2006
X
*
X
L2010
X
1,947.78
X
L2020
X
2,452.60
X
L2030
X
2,226.38
X
L2034
X
*
X
L2035
XXX
X
339.82
X
L2036
X
3,801.53
X
L2037
X
3,546.60
X
L2038
X
3,602.78
X
L2040
X
436.95
X
L2050
X
941.87
X
L2060
X
1,147.92
X
L2070
X
294.75
X
L2080
X
711.20
X
L2090
X
866.96
X
L2106
X
1,344.35
X
L2108
X
2,340.71
X
L2112
X
1,076.63
X
L2114
X
1,350.41
X
L2116
X
1,553.79
X
L2126
X
2,599.11
X
L2128
X
3,680.52
X
L2132
X
1,995.44
X
L2134
X
2,129.33
X
L2136
X
2,541.42
X
L2180
X
237.20
X
L2182
X
196.50
X
L2184
X
268.61
X
L2186
X
372.63
X
L2188
X
713.64
X
L2190
X
184.43
X
L2192
X
809.66
X
L2200
X
94.03
X
L2210
X
136.05
X
L2220
X
161.92
X
L2230
X
151.69
X
L2232
X
*
X
L2240
X
187.77
X
L2250
X
761.33
X
L2260
X
396.31
X
L2265
X
232.78
X
L2270
X
109.22
X
L2275
XXX
X
*
X
L2280
X
900.17
X
L2300
X
564.42
X
L2310
X
282.60
X
L2320
X
406.79
X
L2330
X
851.64
X
L2335
X
525.79
X
L2340
X
1,138.29
X
L2350
X
1,965.85
X
L2360
X
102.29
X
L2370
X
662.90
X
L2375
X
280.05
X
L2380
X
243.39
X
L2385
X
264.88
X
L2387
X
*
X
L2390
X
221.63
X
L2395
X
309.34
X
L2397
X
*
X
L2405
X
115.80
X
L2415
X
367.23
X
L2425
X
449.25
X
L2430
XXX
X
190.93
X
L2492
X
268.58
X
L2500
X
642.56
X
L2510
X
1,441.75
X
L2520
X
951.02
X
L2525
X
2,566.02
X
L2526
X
1,464.28
X
L2530
X
464.62
X
L2540
X
835.89
X
L2550
X
567.84
X
L2570
X
941.75
X
L2580
X
917.62
X
L2600
X
502.54
X
L2610
X
532.25
X
L2620
X
598.50
X
L2622
X
678.48
X
L2624
X
654.73
X
L2627
X
3,572.68
X
L2628
X
3,514.30
X
L2630
X
489.64
X
L2640
X
664.47
X
L2650
X
282.93
X
L2660
X
368.52
X
L2670
X
357.41
X
L2680
X
331.06
X
L2750
X
165.27
X
L2755
XXX
X
253.68
X
L2760
X
120.16
X
L2768
X
229.20
X
L2780
X
133.76
X
L2785
X
63.00
X
L2795
X
170.61
X
L2800
X
262.29
X
L2810
X
205.89
X
L2820
X
171.76
X
L2830
X
185.73
X
L2840
X
109.86
X
L2850
X
122.46
X
L2861
X
*
X
L2999
X
#
X
L3000
X
*
X
L3001
X
*
X
L3002
X
*
X
L3003
X
*
X
L3010
X
*
X
L3020
X
*
X
L3030
X
*
X
L3031
X
*
X
L3040
X
*
X
L3050
X
*
X
L3060
X
*
X
L3070
X
*
X
L3080
X
*
X
L3090
X
*
X
L3100
X
*
X
L3140
X
*
X
L3150
X
*
X
L3160
X
*
X
L3170
X
*
X
L3201
X
*
X
L3202
X
*
X
L3203
X
*
X
L3204
X
*
X
L3206
X
*
X
L3207
X
*
X
L3208
X
*
X
L3209
X
*
X
L3211
X
*
X
L3212
X
#
X
L3213
X
*
X
L3214
X
*
X
L3215
X
263.18
X
L3216
X
*
X
L3217
X
*
X
L3219
X
270.13
X
L3221
X
*
X
L3222
X
*
X
L3224
XXX
X
*
X
L3225
XXX
X
*
X
L3230
X
*
X
L3250
X
*
X
L3251
X
*
X
L3252
X
*
X
L3253
X
*
X
L3254
X
*
X
L3255
X
*
X
L3257
X
*
X
L3260
X
*
X
L3265
X
*
X
L3300
X
*
X
L3310
X
*
X
L3320
X
*
X
L3330
X
262.17
X
L3332
X
*
X
L3334
X
*
X
L3340
X
*
X
L3350
X
*
X
L3360
X
*
X
L3370
X
*
X
L3380
X
98.27
X
L3390
X
*
X
L3400
X
*
X
L3410
X
*
X
L3420
X
*
X
L3430
X
*
X
L3440
X
*
X
L3450
X
*
X
L3455
X
*
X
L3460
X
*
X
L3465
X
*
X
L3470
X
*
X
L3480
X
*
X
L3485
X
*
X
L3500
X
*
X
L3510
X
*
X
L3520
X
*
X
L3530
X
*
X
L3540
X
*
X
L3550
X
*
X
L3560
X
*
X
L3570
X
*
X
L3580
X
*
X
L3590
X
*
X
L3595
X
*
X
L3600
X
*
X
L3610
X
*
X
L3620
X
*
X
L3630
X
*
X
L3640
X
*
X
L3649
X
#
X
L3650
X
131.46
X
L3660
X
198.88
X
L3670
X
262.69
X
L3671
XXX
9
X
*
X
L3674
X
1,657.06
X
L3675
X
298.96
X
L3677
X
*
X
L3678
X
*
X
L3702
XXX
9
X
*
X
L3710
X
302.34
X
L3720
X
1,349.09
X
L3730
X
1,744.12
X
L3740
X
2,067.85
X
L3760
XXX
X
*
X
L3761
X
629.83
X
L3762
X
170.55
X
L3763
XXX
9
X
*
X
L3764
XXX
9
X
*
X
L3765
XXX
9
X
*
X
L3766
XXX
9
X
*
X
L3806
X
*
X
L3807
X
*
X
L3808
X
*
X
L3809
X
336.42
X
L3891
X
*
X
L3900
X
2,738.88
X
L3901
X
3,110.26
X
L3904
X
5,666.03
X
L3905
XXX
9
X
*
X
L3906
X
827.08
X
L3908
X
130.15
X
L3912
X
225.48
X
L3913
XXX
9
X
*
X
L3915
X
*
X
L3916
X
715.14
X
L3917
X
163.99
X
L3918
X
142.17
X
L3919
XXX
9
X
*
X
L3921
XXX
9
X
*
X
L3923
XXX
X
*
X
L3924
X
129.85
X
L3925
X
73.52
X
L3927
X
*
X
L3929
X
130.31
X
L3930
X
123.42
X
L3931
X
266.84
X
L3933
XXX
9
X
*
X
L3935
XXX
9
X
*
X
L3956
XXX
X
*
X
L3960
X
1,423.20
X
L3961
XXX
9
X
*
X
L3962
X
1,388.22
X
L3967
XXX
9
X
*
X
L3971
XXX
9
X
*
X
L3973
XXX
9
X
*
X
L3975
XXX
9
X
*
X
L3976
XXX
9
X
*
X
L3977
XXX
9
X
*
X
L3978
XXX
9
X
*
X
L3980
X
619.56
X
L3981
X
1,347.57
X
L3982
X
722.29
X
L3984
X
665.94
X
L3995
X
68.95
X
L3999
X
#
X
L4000
X
2,721.89
X
L4002
X
*
X
L4010
X
1,326.94
X
L4020
X
1,855.71
X
L4030
X
998.33
X
L4040
X
814.64
X
L4045
X
648.60
X
L4050
X
816.25
X
L4055
X
528.60
X
L4060
X
628.35
X
L4070
X
556.45
X
L4080
X
228.19
X
L4090
X
180.11
X
L4100
X
236.44
X
L4110
X
178.19
X
L4130
X
999.02
X
L4205
X
*
X
L4210
X
*
X
L4350
X
197.89
X
L4360
X
608.35
X
L4361
X
435.77
X
L4370
X
402.38
X
L4386
X
276.41
X
L4387
X
234.38
X
L4392
X
46.89
X
L4394
X
34.21
X
L4396
X
333.99
X
L4397
X
248.04
X
L4398
X
153.77
X
L4631
X
2,456.11
X
L5000
X
1,174.07
X
L5010
X
2,564.54
X
L5020
X
4,174.59
X
L5050
X
4,834.26
X
L5060
X
5,818.14
X
L5100
X
5,036.10
X
L5105
X
7,993.32
X
L5150
X
7,397.33
X
L5160
X
8,045.89
X
L5200
X
7,008.58
X
L5210
X
5,111.57
X
L5220
X
5,810.21
X
L5230
X
8,013.43
X
L5250
X
10,929.55
X
L5270
X
10,833.85
X
L5280
X
10,725.44
X
L5301
X
4,121.55
X
L5312
X
5,130.49
X
L5321
X
5,899.87
X
L5331
X
8,348.55
X
L5341
X
9,072.26
X
L5400
X
2,535.22
X
L5410
X
1,110.80
X
L5420
X
3,201.91
X
L5430
X
1,413.31
X
L5450
X
904.16
X
L5460
X
1,332.56
X
L5500
X
2,705.36
X
L5505
X
3,663.83
X
L5510
X
3,066.73
X
L5520
X
3,029.22
X
L5530
X
3,834.40
X
L5535
X
3,778.79
X
L5540
X
3,990.23
X
L5560
X
4,094.12
X
L5570
X
4,256.44
X
L5580
X
4,969.09
X
L5585
X
5,389.61
X
L5590
X
5,063.87
X
L5595
X
8,900.91
X
L5600
X
9,708.38
X
L5610
X
4,361.27
X
L5611
X
3,393.95
X
L5613
X
5,162.34
X
L5614
XXX
X
*
X
L5616
X
2,860.98
X
L5617
X
*
X
L5618
X
666.57
X
L5620
X
585.68
X
L5622
X
894.45
X
L5624
X
853.28
X
L5626
X
1,199.41
X
L5628
X
1,136.11
X
L5629
X
867.53
X
L5630
X
945.35
X
L5631
X
1,130.53
X
L5632
X
467.67
X
L5634
X
640.82
X
L5636
X
536.74
X
L5637
X
716.93
X
L5638
X
1,025.15
X
L5639
X
2,404.94
X
L5640
X
1,464.20
X
L5642
X
1,310.80
X
L5643
X
3,278.62
X
L5644
X
1,244.25
X
L5645
X
1,680.76
X
L5646
X
1,154.19
X
L5647
X
1,675.58
X
L5648
X
1,386.89
X
L5649
X
4,210.26
X
L5650
X
1,028.30
X
L5651
X
2,529.73
X
L5652
X
918.39
X
L5653
X
1,225.96
X
L5654
X
698.63
X
L5655
X
591.55
X
L5656
X
833.21
X
L5658
X
811.51
X
L5661
X
1,410.10
X
L5665
X
1,078.58
X
L5666
X
160.32
X
L5668
X
213.99
X
L5670
X
651.48
X
L5671
X
892.86
X
L5672
X
796.01
X
L5673
X
1,163.30
X
L5676
X
763.35
X
L5677
X
1,038.64
X
L5678
X
83.69
X
L5679
X
969.40
X
L5680
X
729.56
X
L5681
X
2,248.12
X
L5682
X
1,317.40
X
L5683
X
2,248.12
X
L5684
X
101.37
X
L5685
X
*
X
L5686
X
136.78
X
L5688
X
128.56
X
L5690
X
249.18
X
L5692
X
289.21
X
L5694
X
382.12
X
L5695
X
400.91
X
L5696
X
438.12
X
L5697
X
177.92
X
L5698
X
221.34
X
L5699
X
392.74
X
L5700
XXX
X
*
X
L5701
XXX
X
*
X
L5702
XXX
X
*
X
L5703
XXX
9
X
*
X
L5704
XXX
X
*
X
L5705
XXX
X
*
X
L5706
XXX
X
*
X
L5707
XXX
X
*
X
L5710
X
757.61
X
L5711
X
1,149.28
X
L5712
X
907.69
X
L5714
X
936.05
X
L5716
X
1,535.27
X
L5718
X
1,918.91
X
L5722
X
2,002.51
X
L5724
X
3,179.54
X
L5726
X
4,175.15
X
L5728
X
5,201.63
X
L5780
X
2,507.94
X
L5781
X
6,988.73
X
L5782
X
*
X
L5785
X
1,094.42
X
L5790
X
1,514.60
X
L5795
X
2,261.68
X
L5810
X
1,052.19
X
L5811
X
1,536.31
X
L5812
X
1,190.77
X
L5814
X
7,227.00
X
L5816
X
1,791.41
X
L5818
X
2,022.88
X
L5822
X
3,924.64
X
L5824
X
3,230.41
X
L5826
XXX
X
6,137.81
X
L5828
X
6,157.87
X
L5830
X
4,375.42
X
L5840
XXX
X
*
X
L5845
X
*
X
L5848
X
1,878.26
X
L5850
X
279.70
X
L5855
XXX
X
*
X
L5856
X
39,525.87
X
L5857
X
14,025.26
X
L5858
XXX
9
X
29,409.62
X
L5859
X
*
X
L5910
X
768.36
X
L5920
X
1,117.66
X
L5925
XXX
X
*
X
L5930
X
*
X
L5940
X
1,056.59
X
L5950
X
1,785.04
X
L5960
X
2,138.22
X
L5961
X
7,152.27
X
L5962
XXX
X
*
X
L5964
XXX
X
*
X
L5966
XXX
X
*
X
L5968
X
6,815.11
X
L5969
X
21,491.01
X
L5970
X
462.42
X
L5971
XXX
9
X
*
X
L5972
X
742.42
X
L5973
X
27,452.54
X
L5974
X
626.38
X
L5975
X
869.45
X
L5976
X
1,179.67
X
L5978
X
614.75
X
L5979
XXX
X
*
X
L5980
X
7,810.24
X
L5981
XXX
X
*
X
L5982
X
1,217.80
X
L5984
X
1,206.93
X
L5985
X
*
X
L5986
X
1,341.90
X
L5987
X
13,998.68
X
L5988
X
3,746.51
X
L5990
X
3,197.02
X
L5991
X
12,717.52
X
L5999
X
#
X
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