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2024 Workers' Compensation Part B Fee Schedule

29365-30620

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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
29365   001 0 2 X 311.05 251.04
29365   004 0 2 X 234.48 189.24
29365   002 0 2 X 321.55 259.36
29365   003 0 2 X 244.37 196.88
29405   004 0 2 X 205.65 161.15
29405   001 0 2 X 228.94 179.69
29405   002 0 2 X 232.06 181.58
29405   003 0 2 X 184.60 144.27
29425   001 0 2 X 317.65 247.19
29425   004 0 2 X 272.34 211.64
29425   002 0 2 X 335.69 261.07
29425   003 0 2 X 280.96 218.32
29435   002 0 2 X 446.00 345.40
29435   003 0 2 X 442.56 342.17
29435   004 0 2 X 287.15 222.03
29435   001 0 2 X 444.10 344.40
29440   002 0 2 X 94.04 81.23
29440   003 0 2 X 87.30 75.66
29440   004 0 2 X 91.72 79.52
29440   001 0 2 X 92.58 80.17
29445   001 0 2 X 457.89 X
29445   004 0 2 X 408.93 X
29445   003 0 2 X 414.62 X
29445   002 0 2 X 444.01 X
29450   001 0 2 X 196.33 X
29450   004 0 2 X 150.02 X
29450   002 0 2 X 180.06 X
29450   003 0 2 X 151.64 X
29505   002 0 2 X 151.63 X
29505   003 0 2 X 146.34 X
29505   004 0 2 X 152.53 X
29505   001 0 2 X 161.93 X
29515   001 0 2 X 141.92 115.92
29515   004 0 2 X 130.84 107.11
29515   003 0 2 X 132.35 108.15
29515   002 0 2 X 137.76 112.64
29520   001 0 2 X 103.41 83.92
29520   003 0 2 X 97.17 79.03
29520   002 0 2 X 102.21 83.04
29520   004 0 2 X 96.02 78.19
29530   001 0 2 X 102.33 84.55
29530   004 0 2 X 100.20 83.13
29530   002 0 2 X 104.34 86.14
29530   003 0 2 X 101.41 83.78
29540   003 0 2 X 88.02 72.85
29540   002 0 2 X 92.58 76.54
29540   004 0 2 X 85.95 71.43
29540   001 0 2 X 89.98 74.64
29550   004 0 2 X 70.30 58.43
29550   001 0 2 X 80.14 66.12
29550   002 0 2 X 78.77 64.91
29550   003 0 2 X 81.75 67.65
29580   004 0 2 X 100.61 71.05
29580   001 0 2 X 120.23 85.89
29580   003 0 2 X 103.48 73.07
29580   002 0 2 X 113.67 80.82
29581   001 0 2 X 167.14 61.29
29581   004 0 2 X 145.07 55.81
29581   003 0 2 X 145.07 55.81
29581   002 0 2 X 145.07 55.81
29584   003 0 2 X 109.24 25.42
29584   002 0 2 X 109.24 25.42
29584   001 0 2 X 123.97 26.79
29584   004 0 2 X 109.24 25.42
29700     0 2 X * X
29705     0 2 X * X
29710     0 2 X * X
29720   002 0 2 X 96.70 X
29720   003 0 2 X 99.83 X
29720   004 0 2 X 98.77 X
29720   001 0 2 X 97.59 X
29730   001 0 2 X 116.94 X
29730   003 0 2 X 111.94 X
29730   002 0 2 X 115.69 X
29730   004 0 2 X 109.00 X
29740   004 0 2 X 139.04 X
29740   001 0 2 X 172.95 X
29740   003 0 2 X 163.27 X
29740   002 0 2 X 168.36 X
29750   003 0 2 X 192.09 X
29750   002 0 2 X 201.77 X
29750   004 0 2 X 190.01 X
29750   001 0 2 X 204.16 X
29799     YYY 2 X # X
29800   004 90 2 X 1,006.21 X
29800   001 90 2 X 1,093.55 X
29800   002 90 2 X 1,078.86 X
29800   003 90 2 X 1,018.27 X
29804   003 90 2 X 2,393.94 X
29804   002 90 2 X 2,568.69 X
29804   001 90 2 X 2,610.74 X
29804   004 90 2 X 2,362.77 X
29805   004 90 2 X 775.60 X
29805   002 90 2 X 775.60 X
29805   003 90 2 X 775.60 X
29805   001 90 2 X 878.57 X
29806   004 90 3 X 2,153.84 X
29806   001 90 3 X 2,450.41 X
29806   003 90 3 X 2,153.84 X
29806   002 90 3 X 2,153.84 X
29807   001 90 3 X 2,386.87 X
29807   004 90 3 X 2,095.28 X
29807   002 90 3 X 2,095.28 X
29807   003 90 3 X 2,095.28 X
29819   002 90 3 X 2,679.73 X
29819   003 90 3 X 2,520.28 X
29819   004 90 3 X 1,927.95 X
29819   001 90 3 X 2,711.13 X
29820   002 90 3 X 2,042.31 X
29820   003 90 3 X 1,882.21 X
29820   001 90 3 X 2,081.03 X
29820   004 90 3 X 1,859.02 X
29821   001 90 3 X 2,463.10 X
29821   004 90 3 X 2,193.53 X
29821   003 90 3 X 2,221.17 X
29821   002 90 3 X 3,125.67 X
29822   003 90 3 X 1,949.13 X
29822   002 90 3 X 2,112.43 X
29822   001 90 3 X 2,151.93 X
29822   004 90 3 X 1,925.14 X
29823   004 90 3 X 2,613.92 X
29823   002 90 3 X 2,589.13 X
29823   003 90 3 X 2,626.63 X
29823   001 90 3 X 2,640.07 X
29824   002 90 3 X 1,311.17 X
29824   003 90 3 X 1,311.17 X
29824   001 90 3 X 1,494.77 X
29824   004 90 3 X 1,311.17 X
29825   003 90 3 X 2,150.79 X
29825   002 90 3 X 2,338.54 X
29825   004 90 3 X 2,124.16 X
29825   001 90 3 X 2,383.90 X
29826   004 ZZZ 0 X 2,445.82 X
29826   002 ZZZ 0 X 2,815.12 X
29826   003 ZZZ 0 X 2,719.89 X
29826   001 ZZZ 0 X 2,839.93 X
29827   001 90 3 X 2,526.22 X
29827   002 90 3 X 2,232.95 X
29827   003 90 3 X 2,232.95 X
29827   004 90 3 X 2,232.95 X
29828   004 90 3 X 1,480.84 X
29828   001 90 3 X 1,687.31 X
29828   003 90 3 X 1,480.84 X
29828   002 90 3 X 1,480.84 X
29830   001 90 2 X 1,336.55 X
29830   004 90 2 X 1,213.37 X
29830   002 90 2 X 1,315.40 X
29830   003 90 2 X 1,228.00 X
29834   001 90 3 X 1,470.52 X
29834   004 90 3 X 1,796.26 X
29834   003 90 3 X 1,348.61 X
29834   002 90 3 X 1,720.49 X
29835   003 90 3 X 1,391.93 X
29835   002 90 3 X 1,493.24 X
29835   004 90 3 X 1,375.44 X
29835   001 90 3 X 1,517.71 X
29836   001 90 3 X 1,767.02 X
29836   004 90 3 X 1,601.56 X
29836   003 90 3 X 1,620.82 X
29836   002 90 3 X 1,738.52 X
29837   002 90 3 X 1,585.39 X
29837   003 90 3 X 1,937.58 X
29837   001 90 3 X 1,611.50 X
29837   004 90 3 X 1,459.97 X
29838   002 90 3 X 2,144.67 X
29838   003 90 3 X 2,000.43 X
29838   001 90 3 X 1,772.97 X
29838   004 90 3 X 1,607.67 X
29840   004 90 2 X 954.67 X
29840   003 90 2 X 965.64 X
29840   002 90 2 X 1,026.17 X
29840   001 90 2 X 1,040.81 X
29843   004 90 3 X 1,274.43 X
29843   002 90 3 X 1,383.41 X
29843   003 90 3 X 1,289.78 X
29843   001 90 3 X 1,406.01 X
29844   003 90 3 X 1,330.83 X
29844   002 90 3 X 1,427.16 X
29844   004 90 3 X 1,315.10 X
29844   001 90 3 X 1,450.53 X
29845   002 90 3 X 1,732.08 X
29845   003 90 3 X 1,614.63 X
29845   004 90 3 X 1,595.43 X
29845   001 90 3 X 2,033.39 X
29846   004 90 3 X 2,015.42 X
29846   001 90 3 X 2,276.76 X
29846   003 90 3 X 2,040.57 X
29846   002 90 3 X 2,230.78 X
29847   004 90 3 X 1,512.06 X
29847   002 90 3 X 1,636.86 X
29847   003 90 3 X 1,530.51 X
29847   001 90 3 X 1,992.10 X
29848   002 90 2 X 950.93 X
29848   003 90 2 X 886.72 X
29848   004 90 2 X 876.16 X
29848   001 90 2 X 966.43 X
29850   001 90 2 X 2,744.74 X
29850   004 90 2 X 2,630.95 X
29850   003 90 2 X 2,069.54 X
29850   002 90 2 X 2,236.93 X
29851   001 90 2 X 3,012.02 X
29851   003 90 2 X 2,615.33 X
29851   002 90 2 X 2,798.71 X
29851   004 90 2 X 2,886.72 X
29855   002 90 2 X 2,498.22 X
29855   003 90 2 X 2,398.13 X
29855   004 90 2 X 2,375.82 X
29855   001 90 2 X 2,630.47 X
29856   002 90 2 X 2,703.48 X
29856   003 90 2 X 2,801.18 X
29856   001 90 2 X 3,045.90 X
29856   004 90 2 X 2,574.33 X
29860   003 90 2 X 1,206.91 X
29860   002 90 2 X 1,206.91 X
29860   004 90 2 X 1,206.91 X
29860   001 90 2 X 1,351.79 X
29861   001 90 3 X 2,057.62 X
29861   003 90 3 X 1,782.68 X
29861   002 90 3 X 1,782.68 X
29861   004 90 3 X 1,782.68 X
29862   003 90 3 X 1,951.82 X
29862   002 90 3 X 1,951.82 X
29862   004 90 3 X 1,951.82 X
29862   001 90 3 X 2,273.18 X
29863   002 90 3 X 1,789.38 X
29863   003 90 3 X 1,789.38 X
29863   004 90 3 X 1,789.38 X
29863   001 90 3 X 2,056.11 X
29866   001 90 2 X 2,371.27 X
29866   003 90 2 X 2,076.10 X
29866   002 90 2 X 2,076.10 X
29866   004 90 2 X 2,076.10 X
29867   003 90 2 X 2,483.43 X
29867   002 90 2 X 2,483.43 X
29867   004 90 2 X 2,483.43 X
29867   001 90 2 X 2,827.96 X
29868   004 90 2 X 3,365.19 X
29868   003 90 2 X 3,365.19 X
29868   002 90 2 X 3,365.19 X
29868   001 90 2 X 3,843.92 X
29870   004 90 2 X 989.71 X
29870   001 90 2 X 1,023.79 X
29870   003 90 2 X 994.33 X
29870   002 90 2 X 1,081.54 X
29871   001 90 3 X 1,704.81 X
29871   004 90 3 X 1,513.46 X
29871   002 90 3 X 1,564.37 X
29871   003 90 3 X 1,478.44 X
29873   001 90 3 X 1,169.74 X
29873   004 90 3 X 1,027.79 X
29873   002 90 3 X 1,027.79 X
29873   003 90 3 X 1,027.79 X
29874   004 90 3 X 1,913.74 X
29874   002 90 3 X 2,031.23 X
29874   003 90 3 X 1,946.34 X
29874   001 90 3 X 2,072.44 X
29875   001 90 3 X 2,261.68 X
29875   002 90 3 X 2,220.60 X
29875   003 90 3 X 2,060.64 X
29875   004 90 3 X 1,985.89 X
29876   002 90 3 X 2,495.51 X
29876   003 90 3 X 2,325.63 X
29876   004 90 3 X 2,306.55 X
29876   001 90 3 X 2,535.03 X
29877   001 90 3 X 2,381.60 X
29877   004 90 3 X 2,149.49 X
29877   002 90 3 X 2,335.52 X
29877   003 90 3 X 2,154.08 X
29879   004 90 3 X 2,495.51 X
29879   003 90 3 X 2,506.16 X
29879   002 90 3 X 2,682.27 X
29879   001 90 3 X 2,726.81 X
29880   002 90 3 X 2,559.58 X
29880   003 90 3 X 2,355.36 X
29880   001 90 3 X 2,608.87 X
29880   004 90 3 X 2,326.17 X
29881   004 90 3 X 2,129.16 X
29881   002 90 3 X 2,334.74 X
29881   003 90 3 X 2,168.54 X
29881   001 90 3 X 2,374.96 X
29882   002 90 3 X 2,475.39 X
29882   003 90 3 X 2,304.27 X
29882   001 90 3 X 2,514.98 X
29882   004 90 3 X 2,158.51 X
29883   002 90 3 X 3,044.86 X
29883   003 90 3 X 2,793.26 X
29883   004 90 3 X 2,758.46 X
29883   001 90 3 X 3,105.70 X
29884   001 90 3 X 2,502.25 X
29884   004 90 3 X 1,792.18 X
29884   002 90 3 X 2,513.31 X
29884   003 90 3 X 2,327.05 X
29885   001 90 3 X 2,150.10 X
29885   003 90 3 X 1,898.21 X
29885   002 90 3 X 2,036.14 X
29885   004 90 3 X 1,875.60 X
29886   004 90 3 X 1,550.64 X
29886   001 90 3 X 1,711.20 X
29886   002 90 3 X 1,975.04 X
29886   003 90 3 X 1,569.22 X
29887   001 90 3 X 2,376.33 X
29887   002 90 3 X 2,335.23 X
29887   003 90 3 X 2,165.75 X
29887   004 90 3 X 2,139.25 X
29888   004 90 2 X 3,571.88 X
29888   001 90 2 X 3,990.23 X
29888   003 90 2 X 3,616.49 X
29888   002 90 2 X 3,917.49 X
29889   001 90 2 X 2,580.16 X
29889   003 90 2 X 2,366.27 X
29889   002 90 2 X 2,538.41 X
29889   004 90 2 X 2,338.11 X
29891   002 90 2 X 1,671.42 X
29891   003 90 2 X 1,671.42 X
29891   001 90 2 X 1,937.95 X
29891   004 90 2 X 1,671.42 X
29892   004 90 2 X 1,724.78 X
29892   001 90 2 X 1,993.19 X
29892   002 90 2 X 1,724.78 X
29892   003 90 2 X 1,724.78 X
29893   001 90 2 X 1,092.61 X
29893   004 90 2 X 967.79 X
29893   002 90 2 X 967.79 X
29893   003 90 2 X 967.79 X
29894   001 90 2 X 2,070.40 X
29894   004 90 2 X 1,897.58 X
29894   003 90 2 X 1,849.44 X
29894   002 90 2 X 2,169.74 X
29895   002 90 2 X 1,937.97 X
29895   003 90 2 X 1,828.73 X
29895   004 90 2 X 1,769.98 X
29895   001 90 2 X 2,117.11 X
29897   004 90 2 X 2,032.35 X
29897   001 90 2 X 2,135.23 X
29897   003 90 2 X 1,931.14 X
29897   002 90 2 X 2,095.52 X
29898   004 90 2 X 2,188.20 X
29898   001 90 2 X 2,442.93 X
29898   003 90 2 X 2,315.41 X
29898   002 90 2 X 2,398.72 X
29899   001 90 2 X 2,329.10 X
29899   004 90 2 X 2,048.08 X
29899   002 90 2 X 2,048.08 X
29899   003 90 2 X 2,048.08 X
29900   002 90 2 X 930.30 X
29900   003 90 2 X 930.30 X
29900   001 90 2 X 1,060.09 X
29900   004 90 2 X 930.30 X
29901   001 90 2 X 1,169.23 X
29901   004 90 2 X 1,025.94 X
29901   003 90 2 X 1,025.94 X
29901   002 90 2 X 1,025.94 X
29902   001 90 2 X 1,254.87 X
29902   002 90 2 X 1,101.52 X
29902   003 90 2 X 1,101.52 X
29902   004 90 2 X 1,101.52 X
29904   002 90 2 X 992.26 X
29904   003 90 2 X 992.26 X
29904   004 90 2 X 992.26 X
29904   001 90 2 X 1,127.89 X
29905   001 90 2 X 1,215.87 X
29905   003 90 2 X 1,068.68 X
29905   002 90 2 X 1,068.68 X
29905   004 90 2 X 1,068.68 X
29906   002 90 2 X 1,125.51 X
29906   003 90 2 X 1,125.51 X
29906   004 90 2 X 1,125.51 X
29906   001 90 2 X 1,280.69 X
29914   001 90 3 X 1,980.58 X
29914   004 90 3 X 1,783.02 X
29914   003 90 3 X 1,783.02 X
29914   002 90 3 X 1,783.02 X
29915   001 90 3 X 2,017.12 X
29915   003 90 3 X 1,816.54 X
29915   002 90 3 X 1,816.54 X
29915   004 90 3 X 1,816.54 X
29916   002 90 3 X 1,816.54 X
29916   003 90 3 X 1,816.54 X
29916   001 90 3 X 2,017.12 X
29916   004 90 3 X 1,816.54 X
29999     YYY 2 X # X
30000   003 10 2 X 252.76 X
30000   002 10 2 X 264.36 X
30000   004 10 2 X 209.32 X
30000   001 10 2 X 223.54 X
30020   004 10 2 X 266.92 X
30020   001 10 2 X 278.17 X
30020   003 10 2 X 261.87 X
30020   002 10 2 X 265.12 X
30100   001 0 2 X 204.16 164.12
30100   004 0 2 X 197.81 158.76
30100   002 0 2 X 203.09 162.76
30100   003 0 2 X 198.71 159.67
30110   004 10 2 X 309.96 245.55
30110   001 10 2 X 336.81 266.57
30110   002 10 2 X 332.35 263.01
30110   003 10 2 X 323.68 256.32
30115   001 90 2 X 737.14 X
30115   003 90 2 X 769.27 X
30115   002 90 2 X 808.77 X
30115   004 90 2 X 625.90 X
30117   003 90 2 X 566.94 X
30117   002 90 2 X 585.08 X
30117   004 90 2 X 548.55 X
30117   001 90 2 X 596.18 X
30118   003 90 2 X 1,893.72 X
30118   002 90 2 X 2,011.07 X
30118   001 90 2 X 2,039.38 X
30118   004 90 2 X 1,968.20 X
30120   004 90 2 X 1,846.02 X
30120   002 90 2 X 1,895.93 X
30120   003 90 2 X 1,852.95 X
30120   001 90 2 X 1,906.33 X
30124   004 90 2 X 586.80 X
30124   003 90 2 X 563.25 X
30124   002 90 2 X 559.04 X
30124   001 90 2 X 500.27 X
30125   004 90 2 X 1,348.39 X
30125   001 90 2 X 1,472.44 X
30125   003 90 2 X 1,600.04 X
30125   002 90 2 X 1,543.15 X
30130   004 90 2 X 519.25 X
30130   002 90 2 X 551.75 X
30130   003 90 2 X 525.20 X
30130   001 90 2 X 558.15 X
30140   002 0 2 X 840.93 X
30140   003 0 2 X 831.73 X
30140   004 0 2 X 817.77 X
30140   001 0 2 X 847.27 X
30150   001 90 2 X 2,820.38 X
30150   004 90 2 X 1,798.80 X
30150   003 90 2 X 2,756.69 X
30150   002 90 2 X 2,808.00 X
30160   004 90 2 X 2,280.71 X
30160   003 90 2 X 2,309.36 X
30160   002 90 2 X 2,455.81 X
30160   001 90 2 X 2,519.36 X
30200   004 0 2 X 114.09 96.98
30200   002 0 2 X 118.53 100.95
30200   003 0 2 X 98.27 83.89
30200   001 0 2 X 120.98 102.62
30210   002 10 2 X 144.23 130.30
30210   003 10 2 X 138.50 125.49
30210   004 10 2 X 137.05 124.23
30210   001 10 2 X 145.58 131.53
30220   001 10 2 X 355.32 X
30220   004 10 2 X 325.55 X
30220   003 10 2 X 329.58 X
30220   002 10 2 X 350.34 X
30300   004 10 2 X 154.54 X
30300   002 10 2 X 166.37 X
30300   001 10 2 X 167.26 X
30300   003 10 2 X 159.19 X
30310   002 10 2 X 405.31 X
30310   003 10 2 X 386.86 X
30310   004 10 2 X 382.13 X
30310   001 10 2 X 415.96 X
30320   001 90 2 X 1,020.91 X
30320   004 90 2 X 937.14 X
30320   003 90 2 X 948.83 X
30320   002 90 2 X 1,007.02 X
30400   001 90 2 X 2,498.62 X
30400   003 90 2 X 2,266.86 X
30400   002 90 2 X 2,425.16 X
30400   004 90 2 X 2,235.03 X
30410     90 2 X * X
30420   003 90 2 X 3,899.00 X
30420   002 90 2 X 4,170.68 X
30420   001 90 2 X 4,295.37 X
30420   004 90 2 X 3,843.79 X
30430   001 90 2 X 1,114.30 X
30430   004 90 2 X 1,033.25 X
30430   003 90 2 X 1,045.45 X
30430   002 90 2 X 1,100.93 X
30435   004 90 2 X 1,419.78 X
30435   002 90 2 X 1,527.40 X
30435   003 90 2 X 1,437.22 X
30435   001 90 2 X 1,549.20 X
30450   003 90 2 X 2,309.36 X
30450   002 90 2 X 2,487.14 X
30450   004 90 2 X 2,280.71 X
30450   001 90 2 X 2,529.98 X
30460   001 90 2 X 2,131.91 X
30460   004 90 2 X 1,956.54 X
30460   003 90 2 X 1,980.58 X
30460   002 90 2 X 2,102.45 X
30462   001 90 2 X 4,265.46 X
30462   002 90 2 X 4,206.57 X
30462   003 90 2 X 3,962.21 X
30462   004 90 2 X 3,914.27 X
30465   003 90 2 X 1,830.87 X
30465   002 90 2 X 1,830.87 X
30465   004 90 2 X 1,830.87 X
30465   001 90 2 X 2,040.12 X
30468   001 0 2 X 4,192.45 237.84
30468   004 0 2 X 3,647.08 218.29
30468   003 0 2 X 3,647.08 218.29
30468   002 0 2 X 3,647.08 218.29
30469   004 0 2 X 2,812.90 172.59
30469   003 0 2 X 2,812.90 172.59
30469   002 0 2 X 2,812.90 172.59
30469   001 0 2 X 3,210.19 187.84
30520   002 90 2 X 1,607.60 X
30520   003 90 2 X 1,498.39 X
30520   004 90 2 X 1,479.36 X
30520   001 90 2 X 1,633.85 X
30540   001 90 2 X 1,657.92 X
30540   004 90 2 X 1,522.88 X
30540   003 90 2 X 1,541.60 X
30540   002 90 2 X 1,635.24 X
30545   001 90 2 X 2,531.05 X
30545   004 90 2 X 2,329.17 X
30545   002 90 2 X 2,497.57 X
30545   003 90 2 X 2,358.46 X
30560   004 10 2 X 165.94 X
30560   002 10 2 X 172.53 X
30560   003 10 2 X 167.16 X
30560   001 10 2 X 202.44 X
30580   004 90 2 X 1,368.59 X
30580   001 90 2 X 1,488.22 X
30580   003 90 2 X 1,385.71 X
30580   002 90 2 X 1,468.24 X
30600   003 90 2 X 1,045.45 X
30600   002 90 2 X 1,247.39 X
30600   001 90 2 X 1,114.30 X
30600   004 90 2 X 1,033.25 X
30620   001 90 2 X 1,734.98 X
30620   002 90 2 X 1,706.02 X
30620   003 90 2 X 1,585.74 X
30620   004 90 2 X 1,565.42 X