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2024 Workers' Compensation Part B Fee Schedule

28270-29358

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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
28270   004 90 2 X 769.35 637.56
28270   003 90 2 X 778.36 644.28
28270   002 90 2 X 817.19 675.22
28270   001 90 2 X 826.64 682.75
28272   004 90 2 X 608.96 506.89
28272   002 90 2 X 745.67 618.38
28272   003 90 2 X 737.30 614.05
28272   001 90 2 X 703.03 583.27
28280   003 90 2 X 890.03 X
28280   002 90 2 X 903.66 X
28280   004 90 2 X 823.62 X
28280   001 90 2 X 830.68 X
28285   004 90 2 X 926.52 X
28285   001 90 2 X 1,025.14 X
28285   003 90 2 X 930.40 X
28285   002 90 2 X 1,011.50 X
28286   003 90 2 X 795.48 X
28286   002 90 2 X 989.96 X
28286   004 90 2 X 862.60 X
28286   001 90 2 X 936.92 X
28288   001 90 2 X 888.95 X
28288   003 90 2 X 823.00 X
28288   002 90 2 X 876.18 X
28288   004 90 2 X 812.97 X
28289   003 90 2 X 868.74 896.76
28289   002 90 2 X 868.74 896.76
28289   004 90 2 X 868.74 896.76
28289   001 90 2 X 950.58 983.33
28291   002 90 2 X 1,097.28 729.52
28291   003 90 2 X 1,097.28 729.52
28291   004 90 2 X 1,097.28 729.52
28291   001 90 2 X 1,218.55 792.42
28292   004 90 2 X 1,441.77 X
28292   002 90 2 X 1,555.11 X
28292   003 90 2 X 1,460.04 X
28292   001 90 2 X 1,578.00 X
28295   003 90 2 X 1,399.43 810.94
28295   002 90 2 X 1,399.43 810.94
28295   001 90 2 X 1,564.18 882.35
28295   004 90 2 X 1,399.43 810.94
28296   001 90 2 X 2,078.53 X
28296   004 90 2 X 1,901.39 X
28296   003 90 2 X 1,925.04 X
28296   002 90 2 X 2,048.73 X
28297   003 90 2 X 1,953.58 X
28297   002 90 2 X 2,081.97 X
28297   001 90 2 X 1,960.44 X
28297   004 90 2 X 1,929.55 X
28298   002 90 2 X 1,900.10 X
28298   003 90 2 X 1,788.21 X
28298   001 90 2 X 1,926.95 X
28298   004 90 2 X 1,765.51 X
28299   002 90 2 X 2,128.79 X
28299   003 90 2 X 2,045.48 X
28299   004 90 2 X 2,019.70 X
28299   001 90 2 X 1,958.74 X
28300   004 90 2 X 1,805.99 X
28300   001 90 2 X 1,842.61 X
28300   003 90 2 X 1,716.31 X
28300   002 90 2 X 1,818.01 X
28302   002 90 2 X 2,126.06 X
28302   003 90 2 X 1,993.96 X
28302   004 90 2 X 1,969.80 X
28302   001 90 2 X 2,158.02 X
28304   003 90 2 X 1,651.55 X
28304   002 90 2 X 1,747.27 X
28304   001 90 2 X 1,770.41 X
28304   004 90 2 X 1,632.01 X
28305   002 90 2 X 2,309.36 X
28305   003 90 2 X 2,173.65 X
28305   001 90 2 X 2,342.08 X
28305   004 90 2 X 2,146.97 X
28306   001 90 2 X 1,345.00 X
28306   004 90 2 X 1,245.89 X
28306   002 90 2 X 1,240.43 X
28306   003 90 2 X 1,355.60 X
28307   001 90 2 X 1,430.90 X
28307   003 90 2 X 1,321.12 X
28307   002 90 2 X 1,738.60 X
28307   004 90 2 X 1,305.17 X
28308   001 90 2 X 1,344.96 X
28308   004 90 2 X 1,183.31 X
28308   003 90 2 X 1,175.90 X
28308   002 90 2 X 1,248.32 X
28309   002 90 2 X 1,857.59 X
28309   003 90 2 X 1,744.27 X
28309   004 90 2 X 1,723.81 X
28309   001 90 2 X 1,884.93 X
28310   001 90 2 X 1,231.85 X
28310   004 90 2 X 1,174.15 X
28310   003 90 2 X 1,007.07 X
28310   002 90 2 X 1,114.35 X
28312   001 90 2 X 1,044.31 X
28312   003 90 2 X 968.65 X
28312   002 90 2 X 1,029.66 X
28312   004 90 2 X 925.74 X
28313   004 90 2 X 814.63 X
28313   003 90 2 X 798.55 X
28313   002 90 2 X 841.38 X
28313   001 90 2 X 851.74 X
28315   004 90 2 X 889.49 X
28315   001 90 2 X 1,034.92 X
28315   002 90 2 X 1,021.12 X
28315   003 90 2 X 963.70 X
28320   001 90 2 X 2,081.38 X
28320   003 90 2 X 1,925.54 X
28320   002 90 2 X 1,972.87 X
28320   004 90 2 X 1,902.07 X
28322   004 90 2 X 1,368.04 X
28322   001 90 2 X 1,476.66 X
28322   003 90 2 X 1,383.91 X
28322   002 90 2 X 1,458.58 X
28340   002 90 2 X 1,540.91 X
28340   003 90 2 X 1,523.91 X
28340   004 90 2 X 1,423.66 X
28340   001 90 2 X 1,565.01 X
28341   004 90 2 X 1,696.99 X
28341   003 90 2 X 1,717.83 X
28341   002 90 2 X 1,831.47 X
28341   001 90 2 X 1,858.85 X
28344   003 90 2 X 853.73 X
28344   002 90 2 X 915.66 X
28344   001 90 2 X 930.69 X
28344   004 90 2 X 843.58 X
28345   004 90 2 X 1,193.29 X
28345   001 90 2 X 1,310.24 X
28345   003 90 2 X 1,207.91 X
28345   002 90 2 X 1,290.34 X
28360   001 90 2 X 1,310.24 X
28360   002 90 2 X 1,290.34 X
28360   003 90 2 X 1,207.91 X
28360   004 90 2 X 1,193.29 X
28400   004 90 2 X 682.02 X
28400   002 90 2 X 611.31 X
28400   003 90 2 X 733.36 X
28400   001 90 2 X 681.43 X
28405   001 90 2 X 1,101.21 X
28405   004 90 2 X 902.87 X
28405   002 90 2 X 1,246.35 X
28405   003 90 2 X 1,002.07 X
28406   004 90 2 X 1,320.89 X
28406   002 90 2 X 1,464.65 X
28406   003 90 2 X 1,342.33 X
28406   001 90 2 X 1,458.04 X
28415   001 90 2 X 2,672.68 X
28415   003 90 2 X 2,308.82 X
28415   002 90 2 X 2,634.56 X
28415   004 90 2 X 2,296.56 X
28420   002 90 2 X 3,147.48 X
28420   003 90 2 X 3,109.28 X
28420   001 90 2 X 3,295.34 X
28420   004 90 2 X 2,926.80 X
28430   004 90 2 X 624.75 X
28430   001 90 2 X 649.17 X
28430   003 90 2 X 633.95 X
28430   002 90 2 X 531.52 X
28435   001 90 2 X 808.13 X
28435   004 90 2 X 732.82 X
28435   003 90 2 X 881.49 X
28435   002 90 2 X 898.78 X
28436   004 90 2 X 955.59 X
28436   002 90 2 X 1,037.25 X
28436   003 90 2 X 967.13 X
28436   001 90 2 X 1,054.20 X
28445   002 90 2 X 2,123.38 X
28445   003 90 2 X 1,978.72 X
28445   004 90 2 X 1,955.01 X
28445   001 90 2 X 2,158.37 X
28446   001 90 2 X 2,170.79 X
28446   003 90 2 X 1,919.88 X
28446   002 90 2 X 1,919.88 X
28446   004 90 2 X 1,919.88 X
28450   004 90 2 X 426.91 X
28450   002 90 2 X 446.97 X
28450   003 90 2 X 424.01 X
28450   001 90 2 X 450.52 X
28455   001 90 2 X 672.72 X
28455   003 90 2 X 620.35 X
28455   002 90 2 X 646.06 X
28455   004 90 2 X 669.83 X
28456   002 90 2 X 348.41 X
28456   003 90 2 X 525.86 X
28456   001 90 2 X 573.47 X
28456   004 90 2 X 519.62 X
28465   004 90 2 X 1,335.84 X
28465   001 90 2 X 1,451.43 X
28465   002 90 2 X 1,423.98 X
28465   003 90 2 X 1,345.71 X
28470   001 90 2 X 427.50 329.14
28470   004 90 2 X 389.70 299.51
28470   003 90 2 X 422.64 324.66
28470   002 90 2 X 429.92 330.67
28475   001 90 2 X 605.69 477.45
28475   003 90 2 X 561.24 441.76
28475   002 90 2 X 596.95 470.52
28475   004 90 2 X 554.54 437.18
28476   004 90 2 X 717.07 X
28476   002 90 2 X 776.73 X
28476   003 90 2 X 725.95 X
28476   001 90 2 X 788.98 X
28485   001 90 2 X 1,193.51 X
28485   004 90 2 X 978.95 X
28485   002 90 2 X 1,034.27 X
28485   003 90 2 X 976.09 X
28490   002 90 2 X 231.19 180.54
28490   003 90 2 X 222.45 173.40
28490   001 90 2 X 236.13 183.96
28490   004 90 2 X 217.74 169.89
28495   002 90 2 X 301.94 X
28495   003 90 2 X 301.32 X
28495   001 90 2 X 306.02 X
28495   004 90 2 X 285.36 X
28496   002 90 2 X 507.38 X
28496   003 90 2 X 474.21 X
28496   004 90 2 X 468.51 X
28496   001 90 2 X 515.33 X
28505   004 90 2 X 868.07 X
28505   002 90 2 X 774.61 X
28505   003 90 2 X 847.08 X
28505   001 90 2 X 888.85 X
28510   001 90 2 X 234.34 182.74
28510   004 90 2 X 216.63 169.16
28510   003 90 2 X 218.49 171.00
28510   002 90 2 X 226.42 176.73
28515   003 90 2 X 295.04 233.19
28515   002 90 2 X 285.97 225.66
28515   001 90 2 X 289.71 228.58
28515   004 90 2 X 271.09 214.47
28525   001 90 2 X 638.73 X
28525   004 90 2 X 618.12 X
28525   003 90 2 X 620.79 X
28525   002 90 2 X 600.97 X
28530   004 90 2 X 216.63 X
28530   001 90 2 X 236.13 X
28530   002 90 2 X 232.91 X
28530   003 90 2 X 219.33 X
28531   003 90 2 X 441.31 X
28531   002 90 2 X 473.60 X
28531   004 90 2 X 436.11 X
28531   001 90 2 X 481.34 X
28540   003 90 2 X 382.32 X
28540   002 90 2 X 392.68 X
28540   001 90 2 X 396.46 X
28540   004 90 2 X 400.48 X
28545   001 90 2 X 405.02 X
28545   002 90 2 X 400.12 X
28545   003 90 2 X 379.82 X
28545   004 90 2 X 375.41 X
28546   002 90 2 X 678.91 X
28546   003 90 2 X 633.03 X
28546   001 90 2 X 689.92 X
28546   004 90 2 X 625.57 X
28555   004 90 2 X 1,250.42 X
28555   003 90 2 X 1,250.81 X
28555   002 90 2 X 1,350.40 X
28555   001 90 2 X 1,370.79 X
28570   003 90 2 X 346.06 X
28570   002 90 2 X 409.20 X
28570   004 90 2 X 341.78 X
28570   001 90 2 X 482.65 X
28575   001 90 2 X 690.47 X
28575   004 90 2 X 627.46 X
28575   003 90 2 X 635.09 X
28575   002 90 2 X 679.68 X
28576   004 90 2 X 715.85 X
28576   001 90 2 X 782.35 X
28576   003 90 2 X 724.28 X
28576   002 90 2 X 771.06 X
28585   001 90 2 X 1,451.28 X
28585   004 90 2 X 1,619.16 X
28585   002 90 2 X 1,466.82 X
28585   003 90 2 X 877.09 X
28600   004 90 2 X 261.93 X
28600   001 90 2 X 278.26 X
28600   002 90 2 X 277.36 X
28600   003 90 2 X 264.88 X
28605   002 90 2 X 560.23 X
28605   003 90 2 X 510.88 X
28605   001 90 2 X 569.02 X
28605   004 90 2 X 517.54 X
28606   001 90 2 X 956.59 X
28606   004 90 2 X 879.94 X
28606   003 90 2 X 890.29 X
28606   002 90 2 X 954.81 X
28615   002 90 2 X 1,214.46 X
28615   003 90 2 X 1,132.90 X
28615   004 90 2 X 1,119.33 X
28615   001 90 2 X 1,234.17 X
28630   003 10 2 X 275.00 X
28630   002 10 2 X 291.29 X
28630   001 10 2 X 296.92 X
28630   004 10 2 X 288.34 X
28635   001 10 2 X 392.15 X
28635   003 10 2 X 364.49 X
28635   002 10 2 X 353.96 X
28635   004 10 2 X 360.11 X
28636   001 10 2 X 641.83 X
28636   004 10 2 X 581.70 X
28636   002 10 2 X 631.43 X
28636   003 10 2 X 588.72 X
28645   004 90 2 X 781.09 X
28645   001 90 2 X 850.41 X
28645   003 90 2 X 790.48 X
28645   002 90 2 X 838.76 X
28660   003 10 2 X 209.83 X
28660   002 10 2 X 205.49 X
28660   004 10 2 X 225.48 X
28660   001 10 2 X 219.73 X
28665   002 10 2 X 325.82 X
28665   003 10 2 X 309.74 X
28665   001 10 2 X 329.72 X
28665   004 10 2 X 306.24 X
28666   001 10 2 X 613.58 X
28666   004 10 2 X 556.26 X
28666   003 10 2 X 562.98 X
28666   002 10 2 X 603.66 X
28675   004 90 2 X 654.47 X
28675   002 90 2 X 677.93 X
28675   003 90 2 X 633.01 X
28675   001 90 2 X 700.24 X
28705   001 90 2 X 3,603.44 X
28705   004 90 2 X 3,261.33 X
28705   002 90 2 X 2,862.45 X
28705   003 90 2 X 3,301.23 X
28715   002 90 2 X 2,949.79 X
28715   003 90 2 X 2,823.13 X
28715   001 90 2 X 2,997.79 X
28715   004 90 2 X 2,750.24 X
28725   003 90 2 X 2,267.92 X
28725   002 90 2 X 2,423.67 X
28725   004 90 2 X 2,241.04 X
28725   001 90 2 X 2,312.26 X
28730   002 90 2 X 2,255.03 X
28730   003 90 2 X 1,971.52 X
28730   001 90 2 X 2,180.67 X
28730   004 90 2 X 2,084.94 X
28735   002 90 2 X 2,249.80 X
28735   003 90 2 X 2,209.80 X
28735   004 90 2 X 2,183.18 X
28735   001 90 2 X 2,398.95 X
28737   002 90 2 X 1,997.03 X
28737   003 90 2 X 1,967.79 X
28737   004 90 2 X 1,943.88 X
28737   001 90 2 X 2,142.47 X
28740   002 90 2 X 1,341.63 X
28740   003 90 2 X 1,298.64 X
28740   004 90 2 X 1,281.86 X
28740   001 90 2 X 1,361.62 X
28750   001 90 2 X 1,451.95 X
28750   004 90 2 X 1,369.40 X
28750   003 90 2 X 1,439.08 X
28750   002 90 2 X 1,452.12 X
28755   001 90 2 X 969.65 X
28755   003 90 2 X 950.25 X
28755   002 90 2 X 956.03 X
28755   004 90 2 X 889.18 X
28760   004 90 2 X 1,464.34 X
28760   001 90 2 X 1,298.11 X
28760   003 90 2 X 1,256.88 X
28760   002 90 2 X 1,356.00 X
28800   004 90 2 X 1,809.71 X
28800   001 90 2 X 1,875.45 X
28800   002 90 2 X 1,859.29 X
28800   003 90 2 X 1,787.25 X
28805   004 90 2 X 1,661.42 X
28805   002 90 2 X 1,690.23 X
28805   003 90 2 X 1,573.41 X
28805   001 90 2 X 1,841.91 X
28810   004 90 2 X 1,052.85 X
28810   001 90 2 X 1,157.76 X
28810   002 90 2 X 1,179.15 X
28810   003 90 2 X 1,081.04 X
28820   004 0 2 X 682.51 X
28820   001 0 2 X 840.70 X
28820   003 0 2 X 690.47 X
28820   002 0 2 X 738.02 X
28825   004 0 2 X 612.62 X
28825   001 0 2 X 778.24 X
28825   002 0 2 X 676.68 X
28825   003 0 2 X 619.80 X
28890   003 90 2 X 639.77 401.07
28890   001 90 2 X 745.08 452.89
28890   002 90 2 X 639.77 401.07
28890   004 90 2 X 639.77 401.07
28899     YYY 2 X # X
29000   003 0 2 X 548.34 X
29000   002 0 2 X 487.20 X
29000   001 0 2 X 482.60 X
29000   004 0 2 X 295.52 X
29010   003 0 2 X 491.98 X
29010   002 0 2 X 527.91 X
29010   004 0 2 X 485.97 X
29010   001 0 2 X 689.92 X
29015   003 0 2 X 528.74 X
29015   002 0 2 X 697.16 X
29015   001 0 2 X 573.86 X
29015   004 0 2 X 522.39 X
29035   003 0 2 X 618.12 X
29035   002 0 2 X 712.81 X
29035   004 0 2 X 415.05 X
29035   001 0 2 X 459.71 X
29040   001 0 2 X 512.64 X
29040   003 0 2 X 472.35 X
29040   002 0 2 X 504.85 X
29040   004 0 2 X 466.70 X
29044   001 0 2 X 516.07 X
29044   004 0 2 X 467.49 X
29044   003 0 2 X 473.04 X
29044   002 0 2 X 507.62 X
29046   001 0 2 X 566.94 X
29046   003 0 2 X 520.85 X
29046   002 0 2 X 557.93 X
29046   004 0 2 X 514.60 X
29049   001 0 2 X 152.71 X
29049   004 0 2 X 130.54 X
29049   002 0 2 X 150.82 X
29049   003 0 2 X 143.12 X
29055   004 0 2 X 468.98 X
29055   002 0 2 X 453.35 X
29055   003 0 2 X 328.78 X
29055   001 0 2 X 353.78 X
29058   001 0 2 X 229.08 X
29058   004 0 2 X 318.86 X
29058   003 0 2 X 214.56 X
29058   002 0 2 X 226.26 X
29065   003 0 2 X 308.15 241.19
29065   002 0 2 X 318.76 250.02
29065   004 0 2 X 291.16 228.19
29065   001 0 2 X 317.19 249.25
29075   004 0 2 X 186.47 148.72
29075   001 0 2 X 232.45 185.99
29075   003 0 2 X 224.06 178.81
29075   002 0 2 X 248.97 198.66
29085   004 0 2 X 117.10 97.70
29085   001 0 2 X 124.64 103.23
29085   003 0 2 X 118.09 98.00
29085   002 0 2 X 123.21 102.49
29086   004 0 2 X 116.30 92.71
29086   001 0 2 X 132.51 104.77
29086   003 0 2 X 116.30 92.71
29086   002 0 2 X 116.30 92.71
29105   001 0 2 X 163.23 135.70
29105   004 0 2 X 150.50 125.21
29105   002 0 2 X 161.39 134.10
29105   003 0 2 X 150.03 124.32
29125   001 0 2 X 113.21 93.16
29125   003 0 2 X 110.91 91.57
29125   002 0 2 X 111.70 91.99
29125   004 0 2 X 104.33 85.99
29126   004 0 2 X 102.97 86.92
29126   002 0 2 X 119.46 100.39
29126   003 0 2 X 132.65 111.73
29126   001 0 2 X 137.54 115.92
29130   001 0 2 X 76.87 67.65
29130   002 0 2 X 76.03 66.99
29130   003 0 2 X 93.55 82.46
29130   004 0 2 X 94.06 83.04
29131   001 0 2 X 190.31 X
29131   004 0 2 X 103.20 X
29131   003 0 2 X 187.43 X
29131   002 0 2 X 179.29 X
29200   004 0 2 X 81.28 70.42
29200   001 0 2 X 84.66 72.96
29200   002 0 2 X 85.24 73.50
29200   003 0 2 X 81.65 70.34
29240   002 0 2 X 104.55 X
29240   003 0 2 X 101.77 X
29240   004 0 2 X 97.88 X
29240   001 0 2 X 102.41 X
29260   001 0 2 X 81.07 69.88
29260   004 0 2 X 77.75 67.13
29260   002 0 2 X 80.89 69.94
29260   003 0 2 X 77.78 67.10
29280   004 0 2 X 77.00 X
29280   001 0 2 X 82.31 X
29280   002 0 2 X 81.43 X
29280   003 0 2 X 77.88 X
29305   001 0 2 X 607.05 X
29305   003 0 2 X 502.39 X
29305   002 0 2 X 607.12 X
29305   004 0 2 X 434.11 X
29325   001 0 2 X 512.58 X
29325   004 0 2 X 468.18 X
29325   002 0 2 X 505.02 X
29325   003 0 2 X 483.87 X
29345   002 0 2 X 384.76 310.68
29345   003 0 2 X 303.86 245.74
29345   001 0 2 X 378.56 305.70
29345   004 0 2 X 288.72 233.19
29355   003 0 2 X 292.51 236.55
29355   002 0 2 X 328.65 265.62
29355   001 0 2 X 315.87 255.89
29355   004 0 2 X 267.75 216.92
29358   003 0 2 X 380.46 X
29358   002 0 2 X 439.43 X
29358   004 0 2 X 375.81 X
29358   001 0 2 X 442.54 X