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2024 Workers' Compensation Part B Fee Schedule

15570-19101

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CPT/HCPC Code Modifier Medicare Location Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount Site of Service Amount
15570   004 90 2 X 1,518.93 X
15570   001 90 2 X 3,518.08 X
15570   002 90 2 X 4,215.91 X
15570   003 90 2 X 2,891.21 X
15572   001 90 2 X 3,810.20 X
15572   003 90 2 X 3,607.44 X
15572   002 90 2 X 3,880.07 X
15572   004 90 2 X 4,244.40 X
15574   001 90 2 X 3,260.61 X
15574   003 90 2 X 2,866.61 X
15574   002 90 2 X 3,355.47 X
15574   004 90 2 X 3,368.38 X
15576   001 90 2 X 3,473.29 X
15576   004 90 2 X 3,453.16 X
15576   002 90 2 X 4,054.92 X
15576   003 90 2 X 3,498.79 X
15600   003 90 2 X 693.52 X
15600   002 90 2 X 1,092.25 X
15600   004 90 2 X 1,298.23 X
15600   001 90 2 X 783.41 X
15610   001 90 2 X 1,142.33 X
15610   003 90 2 X 1,144.44 X
15610   002 90 2 X 763.65 X
15610   004 90 2 X 687.77 X
15620   002 90 2 X 1,531.69 X
15620   003 90 2 X 844.79 X
15620   004 90 2 X 834.25 X
15620   001 90 2 X 1,465.89 X
15630   001 90 2 X 1,644.53 X
15630   004 90 2 X 902.54 X
15630   002 90 2 X 1,636.14 X
15630   003 90 2 X 1,601.70 X
15650   004 90 2 X 988.85 X
15650   003 90 2 X 1,224.34 X
15650   002 90 2 X 1,238.27 X
15650   001 90 2 X 1,107.53 X
15730   004 90 2 X 2,232.42 1,355.23
15730   002 90 2 X 2,232.42 1,355.23
15730   003 90 2 X 2,232.42 1,355.23
15730   001 90 2 X 2,491.06 1,484.54
15731   001 90 2 X 1,940.59 1,744.05
15731   004 90 2 X 1,699.58 1,538.91
15731   003 90 2 X 1,699.58 1,538.91
15731   002 90 2 X 1,699.58 1,538.91
15733   003 90 2 X 1,548.80 X
15733   002 90 2 X 1,548.80 X
15733   004 90 2 X 1,548.80 X
15733   001 90 2 X 1,695.50 X
15734   004 90 2 X 5,838.32 X
15734   001 90 2 X 5,900.24 X
15734   003 90 2 X 5,858.95 X
15734   002 90 2 X 5,922.19 X
15736   002 90 2 X 4,877.56 X
15736   003 90 2 X 3,592.77 X
15736   001 90 2 X 4,909.23 X
15736   004 90 2 X 3,549.95 X
15738   001 90 2 X 5,542.56 X
15738   003 90 2 X 5,468.89 X
15738   002 90 2 X 5,585.70 X
15738   004 90 2 X 2,949.12 X
15740   003 90 2 X 3,838.44 X
15740   002 90 2 X 3,763.32 X
15740   004 90 2 X 2,208.41 X
15740   001 90 2 X 3,925.25 X
15750   003 90 2 X 2,560.74 X
15750   002 90 2 X 2,759.69 X
15750   004 90 2 X 2,529.84 X
15750   001 90 2 X 2,807.81 X
15756   001 90 2 X 7,917.98 X
15756   002 90 2 X 7,081.76 X
15756   003 90 2 X 6,891.37 X
15756   004 90 2 X 6,891.37 X
15757   002 90 2 X 7,081.76 X
15757   003 90 2 X 6,891.37 X
15757   001 90 2 X 7,917.98 X
15757   004 90 2 X 6,891.37 X
15758   004 90 2 X 6,891.37 X
15758   002 90 2 X 7,081.76 X
15758   001 90 2 X 7,917.98 X
15758   003 90 2 X 6,891.37 X
15760   001 90 2 X 2,480.15 X
15760   004 90 2 X 1,718.75 X
15760   003 90 2 X 2,417.75 X
15760   002 90 2 X 2,467.98 X
15769   003 90 2 X 669.19 X
15769   002 90 2 X 669.19 X
15769   004 90 2 X 669.19 X
15769   001 90 2 X 740.50 X
15770   004 90 2 X 1,569.04 X
15770   001 90 2 X 1,724.11 X
15770   003 90 2 X 1,588.52 X
15770   002 90 2 X 1,697.78 X
15771   002 90 2 X 795.33 664.63
15771   003 90 2 X 795.33 664.63
15771   001 90 2 X 885.53 735.06
15771   004 90 2 X 795.33 664.63
15772   001 ZZZ 0 X 278.94 216.91
15772   004 ZZZ 0 X 251.99 198.13
15772   002 ZZZ 0 X 251.99 198.13
15772   003 ZZZ 0 X 251.99 198.13
15773   001 90 2 X 893.35 742.86
15773   004 90 2 X 802.63 671.96
15773   003 90 2 X 802.63 671.96
15773   002 90 2 X 802.63 671.96
15774   004 ZZZ 0 X 244.19 190.33
15774   002 ZZZ 0 X 244.19 190.33
15774   003 ZZZ 0 X 244.19 190.33
15774   001 ZZZ 0 X 270.23 208.22
15775     0 2 X * X
15776     0 2 X * X
15777   001 ZZZ 0 X 397.75 X
15777   004 ZZZ 0 X 357.00 X
15777   002 ZZZ 0 X 357.00 X
15777   003 ZZZ 0 X 357.00 X
15778   001 0 2 X 481.38 X
15778   002 0 2 X 442.20 X
15778   003 0 2 X 442.20 X
15778   004 0 2 X 442.20 X
15780   004 90 2 X 874.55 X
15780   001 90 2 X 924.80 X
15780   003 90 2 X 1,958.68 X
15780   002 90 2 X 916.68 X
15781   004 90 2 X 909.53 X
15781   003 90 2 X 1,021.43 X
15781   002 90 2 X 974.28 X
15781   001 90 2 X 1,041.94 X
15782   001 90 2 X 609.94 X
15782   004 90 2 X 943.22 X
15782   003 90 2 X 579.77 X
15782   002 90 2 X 604.06 X
15783   001 90 2 X 863.68 X
15783   004 90 2 X 643.23 X
15783   002 90 2 X 681.57 X
15783   003 90 2 X 650.45 X
15786   004 10 2 X 276.72 X
15786   001 10 2 X 294.37 X
15786   003 10 2 X 279.70 X
15786   002 10 2 X 291.54 X
15787   003 ZZZ 0 X 60.98 X
15787   002 ZZZ 0 X 64.69 X
15787   001 ZZZ 0 X 65.53 X
15787   004 ZZZ 0 X 60.25 X
15788     90 2 X * X
15789     90 2 X * X
15792     90 2 X * X
15793     90 2 X * X
15819   003 90 2 X 1,850.70 X
15819   002 90 2 X 1,964.63 X
15819   001 90 2 X 1,992.18 X
15819   004 90 2 X 1,828.28 X
15820   004 90 2 X 1,202.18 X
15820   002 90 2 X 1,299.45 X
15820   003 90 2 X 1,217.64 X
15820   001 90 2 X 1,319.10 X
15821   002 90 2 X 1,488.65 X
15821   003 90 2 X 1,396.66 X
15821   004 90 2 X 1,378.69 X
15821   001 90 2 X 1,510.72 X
15822   002 90 2 X 2,110.06 X
15822   003 90 2 X 1,778.49 X
15822   001 90 2 X 1,266.94 X
15822   004 90 2 X 1,881.91 X
15823   004 90 2 X 2,032.89 X
15823   002 90 2 X 2,183.26 X
15823   003 90 2 X 2,085.31 X
15823   001 90 2 X 2,218.30 X
15824     0 2 X * X
15825     0 2 X * X
15826     0 2 X * X
15828     0 2 X * X
15829     0 2 X * X
15830   001 90 2 X 2,120.47 X
15830   003 90 2 X 1,837.77 X
15830   002 90 2 X 1,837.77 X
15830   004 90 2 X 1,837.77 X
15832     90 2 X * X
15833     90 2 X * X
15834     90 2 X * X
15835     90 2 X * X
15836     90 2 X * X
15837     90 2 X * X
15838     90 2 X * X
15839     90 2 X * X
15840   002 90 2 X 3,365.84 X
15840   003 90 2 X 3,128.28 X
15840   001 90 2 X 3,423.13 X
15840   004 90 2 X 3,089.60 X
15841   001 90 2 X 4,662.13 X
15841   004 90 2 X 4,248.46 X
15841   003 90 2 X 4,298.49 X
15841   002 90 2 X 4,591.30 X
15842   004 90 2 X 6,974.58 X
15842   002 90 2 X 7,459.13 X
15842   003 90 2 X 7,059.56 X
15842   001 90 2 X 7,555.46 X
15845   002 90 2 X 3,376.57 X
15845   003 90 2 X 3,126.46 X
15845   004 90 2 X 3,087.94 X
15845   001 90 2 X 3,436.91 X
15847     YYY 0 X * X
15851     0 2 X * X
15852   004 0 2 X 126.25 X
15852   002 0 2 X 131.46 X
15852   003 0 2 X 127.08 X
15852   001 0 2 X 132.60 X
15853   001 ZZZ 2 X 14.52 X
15853   003 ZZZ 2 X 12.63 X
15853   002 ZZZ 2 X 12.63 X
15853   004 ZZZ 2 X 12.63 X
15854   004 ZZZ 2 X 17.82 X
15854   001 ZZZ 2 X 20.51 X
15854   002 ZZZ 2 X 17.82 X
15854   003 ZZZ 2 X 17.82 X
15860     0 2 X * X
15876     0 2 X * X
15877     0 2 X * X
15878     0 2 X # X
15879     0 2 X * X
15920   004 90 2 X 1,137.53 X
15920   002 90 2 X 1,217.64 X
15920   003 90 2 X 1,149.76 X
15920   001 90 2 X 1,234.20 X
15922   001 90 2 X 1,855.81 X
15922   003 90 2 X 1,709.22 X
15922   002 90 2 X 1,827.14 X
15922   004 90 2 X 1,689.95 X
15931   001 90 2 X 1,085.41 X
15931   004 90 2 X 1,167.25 X
15931   002 90 2 X 1,296.60 X
15931   003 90 2 X 1,198.29 X
15933   004 90 2 X 1,860.36 X
15933   002 90 2 X 2,011.27 X
15933   003 90 2 X 1,881.62 X
15933   001 90 2 X 2,030.36 X
15934   001 90 2 X 2,314.45 X
15934   003 90 2 X 2,130.30 X
15934   002 90 2 X 2,278.45 X
15934   004 90 2 X 2,159.35 X
15935   004 90 2 X 2,740.69 X
15935   003 90 2 X 2,772.74 X
15935   002 90 2 X 2,985.80 X
15935   001 90 2 X 3,037.43 X
15936   001 90 2 X 2,703.00 X
15936   004 90 2 X 2,436.23 X
15936   002 90 2 X 3,506.13 X
15936   003 90 2 X 3,425.77 X
15937   003 90 2 X 3,983.53 X
15937   002 90 2 X 4,086.65 X
15937   004 90 2 X 2,998.35 X
15937   001 90 2 X 4,111.58 X
15940   004 90 2 X 1,294.81 X
15940   001 90 2 X 1,406.50 X
15940   002 90 2 X 1,387.36 X
15940   003 90 2 X 1,308.90 X
15941   002 90 2 X 2,047.33 X
15941   003 90 2 X 1,944.07 X
15941   004 90 2 X 1,922.11 X
15941   001 90 2 X 1,981.32 X
15944   004 90 2 X 2,513.89 X
15944   001 90 2 X 2,430.21 X
15944   003 90 2 X 2,524.70 X
15944   002 90 2 X 2,596.62 X
15945   001 90 2 X 3,071.65 X
15945   004 90 2 X 2,528.75 X
15945   002 90 2 X 3,051.42 X
15945   003 90 2 X 2,968.00 X
15946   004 90 2 X 4,092.28 X
15946   001 90 2 X 4,525.88 X
15946   003 90 2 X 4,140.16 X
15946   002 90 2 X 4,450.56 X
15950   003 90 2 X 1,164.96 X
15950   002 90 2 X 1,221.59 X
15950   004 90 2 X 1,189.71 X
15950   001 90 2 X 1,169.66 X
15951   001 90 2 X 2,149.20 X
15951   003 90 2 X 1,964.63 X
15951   002 90 2 X 2,113.18 X
15951   004 90 2 X 1,942.21 X
15952   003 90 2 X 2,094.96 X
15952   002 90 2 X 2,089.93 X
15952   001 90 2 X 2,166.27 X
15952   004 90 2 X 1,931.01 X
15953   003 90 2 X 2,573.45 X
15953   002 90 2 X 2,509.31 X
15953   004 90 2 X 2,306.79 X
15953   001 90 2 X 2,552.08 X
15956   004 90 2 X 3,545.69 X
15956   001 90 2 X 3,968.73 X
15956   003 90 2 X 3,716.02 X
15956   002 90 2 X 3,894.70 X
15958   001 90 2 X 4,091.62 X
15958   004 90 2 X 3,640.89 X
15958   003 90 2 X 3,888.59 X
15958   002 90 2 X 4,012.38 X
15999     YYY 2 X # X
16000   003 0 2 X 123.47 107.40
16000   002 0 2 X 130.04 112.42
16000   004 0 2 X 123.02 106.81
16000   001 0 2 X 131.18 113.43
16020   004 0 2 X 113.32 97.57
16020   003 0 2 X 114.62 98.55
16020   002 0 2 X 119.82 102.82
16020   001 0 2 X 121.09 103.86
16025   002 0 2 X 256.81 232.75
16025   003 0 2 X 246.93 224.28
16025   004 0 2 X 244.37 222.04
16025   001 0 2 X 259.30 234.88
16030   001 0 2 X 297.78 X
16030   004 0 2 X 279.36 X
16030   003 0 2 X 282.24 X
16030   002 0 2 X 294.72 X
16035   004 0 2 X 700.42 X
16035   001 0 2 X 757.21 X
16035   003 0 2 X 708.03 X
16035   002 0 2 X 747.65 X
16036   002 ZZZ 0 X 196.32 X
16036   003 ZZZ 0 X 196.32 X
16036   004 ZZZ 0 X 196.32 X
16036   001 ZZZ 0 X 219.64 X
17000   001 10 2 X 103.77 81.32
17000   004 10 2 X 93.57 74.44
17000   003 10 2 X 93.57 74.44
17000   002 10 2 X 93.57 74.44
17003   001 ZZZ 0 X 28.90 22.00
17003   004 ZZZ 0 X 25.82 19.90
17003   003 ZZZ 0 X 25.82 19.90
17003   002 ZZZ 0 X 25.82 19.90
17004   002 10 0 X 466.08 363.84
17004   003 10 0 X 466.08 363.84
17004   004 10 0 X 466.08 363.84
17004   001 10 0 X 521.79 401.68
17106   002 90 2 X 729.38 X
17106   003 90 2 X 697.31 X
17106   004 90 2 X 689.63 X
17106   001 90 2 X 737.24 X
17107   004 90 2 X 1,364.46 X
17107   002 90 2 X 1,444.24 X
17107   003 90 2 X 1,379.61 X
17107   001 90 2 X 1,459.97 X
17108   001 90 2 X 2,568.18 X
17108   004 90 2 X 2,385.33 X
17108   002 90 2 X 2,538.16 X
17108   003 90 2 X 2,414.10 X
17110   004 10 2 X 96.19 77.99
17110   002 10 2 X 96.19 77.99
17110   003 10 2 X 96.19 77.99
17110   001 10 2 X 106.29 84.90
17111   003 10 2 X 139.74 112.46
17111   001 10 2 X 154.99 122.91
17111   002 10 2 X 139.74 112.46
17111   004 10 2 X 139.74 112.46
17250   002 0 2 X 97.28 79.10
17250   003 0 2 X 92.07 74.90
17250   001 0 2 X 98.55 80.20
17250   004 0 2 X 90.91 74.10
17260   004 10 2 X 300.40 X
17260   002 10 2 X 306.59 X
17260   003 10 2 X 299.81 X
17260   001 10 2 X 308.51 X
17261   004 10 2 X 353.15 X
17261   001 10 2 X 366.22 X
17261   003 10 2 X 354.46 X
17261   002 10 2 X 367.04 X
17262   004 10 2 X 405.17 X
17262   001 10 2 X 458.36 X
17262   002 10 2 X 450.01 X
17262   003 10 2 X 444.93 X
17263   002 10 2 X 547.49 X
17263   003 10 2 X 544.36 X
17263   001 10 2 X 532.30 X
17263   004 10 2 X 492.18 X
17264   001 10 2 X 679.27 X
17264   003 10 2 X 664.93 X
17264   002 10 2 X 698.79 X
17264   004 10 2 X 679.42 X
17266   004 10 2 X 972.14 X
17266   001 10 2 X 980.32 X
17266   002 10 2 X 972.16 X
17266   003 10 2 X 855.38 X
17270   004 10 2 X 362.17 X
17270   003 10 2 X 359.65 X
17270   002 10 2 X 374.74 X
17270   001 10 2 X 382.55 X
17271   003 10 2 X 460.10 X
17271   002 10 2 X 468.98 X
17271   004 10 2 X 398.30 X
17271   001 10 2 X 479.25 X
17272   001 10 2 X 515.31 X
17272   004 10 2 X 456.40 X
17272   003 10 2 X 499.61 X
17272   002 10 2 X 507.38 X
17273   002 10 2 X 576.92 X
17273   003 10 2 X 568.65 X
17273   004 10 2 X 536.10 X
17273   001 10 2 X 538.95 X
17274   001 10 2 X 745.27 X
17274   004 10 2 X 697.98 X
17274   003 10 2 X 721.35 X
17274   002 10 2 X 732.36 X
17276   001 10 2 X 888.30 X
17276   004 10 2 X 853.96 X
17276   003 10 2 X 807.28 X
17276   002 10 2 X 877.04 X
17280   004 10 2 X 394.53 X
17280   002 10 2 X 419.21 X
17280   003 10 2 X 388.04 X
17280   001 10 2 X 426.65 X
17281   001 10 2 X 507.54 X
17281   002 10 2 X 508.57 X
17281   003 10 2 X 492.63 X
17281   004 10 2 X 456.65 X
17282   004 10 2 X 507.47 X
17282   001 10 2 X 607.26 X
17282   002 10 2 X 598.04 X
17282   003 10 2 X 601.36 X
17283   001 10 2 X 654.21 X
17283   003 10 2 X 698.07 X
17283   002 10 2 X 707.15 X
17283   004 10 2 X 630.49 X
17284   001 10 2 X 850.92 X
17284   004 10 2 X 838.55 X
17284   003 10 2 X 737.29 X
17284   002 10 2 X 817.88 X
17286   001 10 2 X 1,054.03 X
17286   003 10 2 X 970.69 X
17286   002 10 2 X 1,037.77 X
17286   004 10 2 X 959.08 X
17311   001 0 2 X 1,239.85 656.30
17311   004 0 2 X 1,070.41 593.44
17311   002 0 2 X 1,070.41 593.44
17311   003 0 2 X 1,070.41 593.44
17312   004 ZZZ 0 X 643.43 315.87
17312   001 ZZZ 0 X 750.14 349.41
17312   003 ZZZ 0 X 643.43 315.87
17312   002 ZZZ 0 X 643.43 315.87
17313   004 0 2 X 976.99 531.92
17313   001 0 2 X 1,132.96 588.46
17313   003 0 2 X 976.99 531.92
17313   002 0 2 X 976.99 531.92
17314   004 ZZZ 0 X 595.89 292.12
17314   002 ZZZ 0 X 595.89 292.12
17314   003 ZZZ 0 X 595.89 292.12
17314   001 ZZZ 0 X 694.73 323.08
17315   002 ZZZ 0 X 127.05 82.63
17315   003 ZZZ 0 X 127.05 82.63
17315   004 ZZZ 0 X 127.05 82.63
17315   001 ZZZ 0 X 145.57 91.27
17340   001 10 2 X 113.68 98.51
17340   004 10 2 X 106.82 92.96
17340   003 10 2 X 99.37 86.69
17340   002 10 2 X 112.52 97.57
17360   004 10 2 X 176.55 163.17
17360   001 10 2 X 167.39 154.11
17360   002 10 2 X 184.60 170.26
17360   003 10 2 X 178.38 164.79
17380     0 2 X * X
17999     YYY 2 X # X
19000   001 0 2 X 149.98 128.52
19000   004 0 2 X 139.85 119.97
19000   003 0 2 X 143.25 122.99
19000   002 0 2 X 144.71 124.38
19001   002 ZZZ 0 X 78.45 X
19001   003 ZZZ 0 X 73.51 X
19001   004 ZZZ 0 X 72.76 X
19001   001 ZZZ 0 X 79.66 X
19020   002 90 2 X 580.38 X
19020   003 90 2 X 570.15 X
19020   004 90 2 X 484.76 X
19020   001 90 2 X 568.82 X
19030   001 0 2 X 213.77 X
19030   003 0 2 X 203.37 X
19030   002 0 2 X 211.74 X
19030   004 0 2 X 201.21 X
19081   001 0 2 X 1,180.64 328.07
19081   004 0 2 X 1,029.57 297.74
19081   002 0 2 X 1,029.57 297.74
19081   003 0 2 X 1,029.57 297.74
19082   004 ZZZ 0 X 824.36 141.29
19082   003 ZZZ 0 X 824.36 141.29
19082   002 ZZZ 0 X 824.36 141.29
19082   001 ZZZ 0 X 949.41 153.63
19083   003 0 2 X 1,021.24 278.82
19083   002 0 2 X 1,021.24 278.82
19083   004 0 2 X 1,021.24 278.82
19083   001 0 2 X 1,171.72 306.79
19084   001 ZZZ 0 X 936.35 144.25
19084   004 ZZZ 0 X 812.61 132.75
19084   003 ZZZ 0 X 812.61 132.75
19084   002 ZZZ 0 X 812.61 132.75
19085   003 0 2 X 1,538.94 325.43
19085   002 0 2 X 1,538.94 325.43
19085   001 0 2 X 1,771.40 357.61
19085   004 0 2 X 1,538.94 325.43
19086   001 ZZZ 0 X 1,403.73 152.94
19086   004 ZZZ 0 X 1,217.46 143.85
19086   002 ZZZ 0 X 1,217.46 143.85
19086   003 ZZZ 0 X 1,217.46 143.85
19100   003 0 2 X 307.86 X
19100   002 0 2 X 297.25 X
19100   001 0 2 X 270.71 X
19100   004 0 2 X 271.49 X
19101   001 10 2 X 691.59 X
19101   002 10 2 X 707.38 X
19101   003 10 2 X 617.90 X
19101   004 10 2 X 610.84 X