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2024 Workers' Compensation Part B Fee Schedule

38570-42227

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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
38570   002 10 3 X 1,346.08 X
38570   003 10 3 X 1,346.08 X
38570   004 10 3 X 1,346.08 X
38570   001 10 3 X 1,497.86 X
38571   002 10 3 X 1,754.76 X
38571   003 10 3 X 1,754.76 X
38571   001 10 3 X 1,937.42 X
38571   004 10 3 X 1,754.76 X
38572   001 10 3 X 2,257.00 X
38572   003 10 3 X 2,038.57 X
38572   002 10 3 X 2,038.57 X
38572   004 10 3 X 2,038.57 X
38573   002 10 3 X 1,738.46 X
38573   003 10 3 X 1,738.46 X
38573   001 10 3 X 1,898.21 X
38573   004 10 3 X 1,738.46 X
38589     YYY 2 X # X
38700   004 90 2 X 2,917.97 X
38700   001 90 2 X 3,001.85 X
38700   002 90 2 X 2,987.57 X
38700   003 90 2 X 2,928.06 X
38720   001 90 2 X 3,495.69 X
38720   004 90 2 X 3,086.29 X
38720   003 90 2 X 3,235.47 X
38720   002 90 2 X 3,429.71 X
38724   002 90 2 X 3,372.28 X
38724   003 90 2 X 3,210.64 X
38724   001 90 2 X 3,483.13 X
38724   004 90 2 X 3,272.40 X
38740   001 90 2 X 1,370.05 X
38740   004 90 2 X 1,167.21 X
38740   002 90 2 X 1,347.29 X
38740   003 90 2 X 1,157.76 X
38745   001 90 2 X 2,449.68 X
38745   004 90 2 X 2,102.31 X
38745   003 90 2 X 1,927.49 X
38745   002 90 2 X 2,256.05 X
38746   003 ZZZ 0 X 756.72 X
38746   002 ZZZ 0 X 808.14 X
38746   004 ZZZ 0 X 748.54 X
38746   001 ZZZ 0 X 820.63 X
38747   004 ZZZ 0 X 833.57 X
38747   001 ZZZ 0 X 913.89 X
38747   003 ZZZ 0 X 842.73 X
38747   002 ZZZ 0 X 899.94 X
38760   004 90 2 X 1,804.52 X
38760   001 90 2 X 1,880.09 X
38760   003 90 2 X 1,804.41 X
38760   002 90 2 X 1,867.06 X
38765   004 90 2 X 3,041.23 X
38765   001 90 2 X 3,430.06 X
38765   003 90 2 X 3,139.39 X
38765   002 90 2 X 3,373.35 X
38770   001 90 2 X 3,296.89 X
38770   004 90 2 X 2,999.11 X
38770   002 90 2 X 3,246.54 X
38770   003 90 2 X 3,037.43 X
38780   001 90 2 X 3,939.18 X
38780   004 90 2 X 3,614.66 X
38780   003 90 2 X 3,632.48 X
38780   002 90 2 X 3,869.08 X
38790   004 0 2 X 341.02 X
38790   002 0 2 X 413.37 X
38790   003 0 2 X 345.53 X
38790   001 0 2 X 374.66 X
38792     0 2 X * X
38794   001 90 2 X 816.89 X
38794   002 90 2 X 805.70 X
38794   003 90 2 X 759.64 X
38794   004 90 2 X 750.87 X
38900   003 ZZZ 0 X 240.12 X
38900   002 ZZZ 0 X 240.12 X
38900   004 ZZZ 0 X 240.12 X
38900   001 ZZZ 0 X 266.19 X
38999     YYY 2 X # X
39000   003 90 2 X 1,265.94 X
39000   002 90 2 X 1,368.33 X
39000   004 90 2 X 1,250.63 X
39000   001 90 2 X 1,393.04 X
39010   004 90 2 X 2,450.90 X
39010   002 90 2 X 2,655.99 X
39010   003 90 2 X 2,479.43 X
39010   001 90 2 X 2,698.77 X
39200   004 90 2 X 2,691.99 X
39200   001 90 2 X 2,980.79 X
39200   003 90 2 X 3,130.71 X
39200   002 90 2 X 2,930.69 X
39220   004 90 2 X 3,836.02 X
39220   001 90 2 X 3,995.95 X
39220   002 90 2 X 3,968.20 X
39220   003 90 2 X 3,740.52 X
39401   001 0 2 X 531.84 X
39401   002 0 2 X 485.92 X
39401   003 0 2 X 485.92 X
39401   004 0 2 X 485.92 X
39402   002 0 2 X 635.29 X
39402   003 0 2 X 635.29 X
39402   001 0 2 X 694.42 X
39402   004 0 2 X 635.29 X
39499     YYY 2 X # X
39501   001 90 2 X 2,982.90 X
39501   004 90 2 X 2,613.56 X
39501   003 90 2 X 2,593.49 X
39501   002 90 2 X 2,791.84 X
39503   001 90 2 X 6,879.16 X
39503   002 90 2 X 6,786.92 X
39503   003 90 2 X 6,404.95 X
39503   004 90 2 X 6,329.23 X
39540   002 90 2 X 3,305.46 X
39540   003 90 2 X 3,351.59 X
39540   004 90 2 X 2,739.40 X
39540   001 90 2 X 3,610.86 X
39541   003 90 2 X 3,577.57 X
39541   002 90 2 X 3,106.90 X
39541   001 90 2 X 3,694.10 X
39541   004 90 2 X 3,563.39 X
39545   001 90 2 X 2,462.19 X
39545   004 90 2 X 2,243.73 X
39545   002 90 2 X 3,254.28 X
39545   003 90 2 X 2,269.38 X
39560   001 90 2 X 2,092.69 X
39560   004 90 2 X 1,868.14 X
39560   003 90 2 X 1,868.14 X
39560   002 90 2 X 1,868.14 X
39561   004 90 2 X 2,563.89 X
39561   003 90 2 X 2,563.89 X
39561   002 90 2 X 2,563.89 X
39561   001 90 2 X 2,864.68 X
39599     YYY 2 X # X
40490   004 0 2 X 220.81 182.04
40490   001 0 2 X 225.78 185.21
40490   003 0 2 X 220.08 181.22
40490   002 0 2 X 223.10 183.07
40500   004 90 2 X 1,578.17 X
40500   001 90 2 X 1,680.96 X
40500   002 90 2 X 1,599.75 X
40500   003 90 2 X 1,575.29 X
40510   002 90 2 X 1,550.00 X
40510   003 90 2 X 1,517.74 X
40510   004 90 2 X 1,519.93 X
40510   001 90 2 X 1,609.46 X
40520   001 90 2 X 1,212.64 X
40520   003 90 2 X 1,135.96 X
40520   002 90 2 X 1,225.68 X
40520   004 90 2 X 1,000.89 X
40525   001 90 2 X 2,050.84 X
40525   004 90 2 X 2,570.21 X
40525   003 90 2 X 2,445.38 X
40525   002 90 2 X 2,640.97 X
40527   004 90 2 X 2,209.90 X
40527   002 90 2 X 2,402.97 X
40527   001 90 2 X 2,421.92 X
40527   003 90 2 X 2,237.63 X
40530   004 90 2 X 1,244.95 X
40530   002 90 2 X 1,284.43 X
40530   003 90 2 X 1,250.67 X
40530   001 90 2 X 1,292.61 X
40650   004 90 2 X 884.57 X
40650   001 90 2 X 980.09 X
40650   002 90 2 X 1,358.33 X
40650   003 90 2 X 1,577.52 X
40652   002 90 2 X 1,427.92 X
40652   003 90 2 X 1,050.96 X
40652   004 90 2 X 1,037.99 X
40652   001 90 2 X 1,151.39 X
40654   002 90 2 X 1,829.54 X
40654   003 90 2 X 1,751.02 X
40654   004 90 2 X 1,304.05 X
40654   001 90 2 X 1,831.53 X
40700   001 90 2 X 2,454.89 X
40700   004 90 2 X 2,248.86 X
40700   003 90 2 X 2,275.08 X
40700   002 90 2 X 2,419.80 X
40701   001 90 2 X 4,038.03 X
40701   004 90 2 X 3,698.19 X
40701   002 90 2 X 3,981.53 X
40701   003 90 2 X 3,746.25 X
40702   002 90 2 X 2,523.75 X
40702   003 90 2 X 2,381.36 X
40702   004 90 2 X 2,353.35 X
40702   001 90 2 X 2,558.12 X
40720   004 90 2 X 2,509.08 X
40720   001 90 2 X 2,929.93 X
40720   003 90 2 X 2,538.07 X
40720   002 90 2 X 2,717.11 X
40761   003 90 2 X 2,776.38 X
40761   002 90 2 X 2,963.34 X
40761   004 90 2 X 2,744.06 X
40761   001 90 2 X 3,008.63 X
40799     YYY 2 X # X
40800   002 10 2 X 212.37 X
40800   003 10 2 X 201.62 X
40800   001 10 2 X 214.88 X
40800   004 10 2 X 199.23 X
40801   001 10 2 X 477.51 X
40801   003 10 2 X 454.84 X
40801   002 10 2 X 475.83 X
40801   004 10 2 X 448.34 X
40804   002 10 2 X 199.23 X
40804   003 10 2 X 191.83 X
40804   004 10 2 X 149.13 X
40804   001 10 2 X 208.32 X
40805   001 10 2 X 612.16 X
40805   004 10 2 X 559.97 X
40805   002 10 2 X 603.38 X
40805   003 10 2 X 566.92 X
40806     0 2 X * X
40808   002 10 2 X 219.20 172.61
40808   003 10 2 X 221.68 174.89
40808   004 10 2 X 217.18 171.51
40808   001 10 2 X 217.24 171.08
40810   002 10 2 X 328.37 254.39
40810   003 10 2 X 327.28 252.97
40810   001 10 2 X 312.77 241.88
40810   004 10 2 X 347.98 270.05
40812   004 10 2 X 440.41 359.02
40812   001 10 2 X 435.34 353.05
40812   003 10 2 X 467.01 379.96
40812   002 10 2 X 441.32 358.24
40814   002 90 2 X 849.00 X
40814   003 90 2 X 830.75 X
40814   004 90 2 X 702.03 X
40814   001 90 2 X 936.45 X
40816   002 90 2 X 1,133.60 X
40816   003 90 2 X 934.95 X
40816   004 90 2 X 1,131.27 X
40816   001 90 2 X 932.61 X
40818   004 90 2 X 485.20 X
40818   001 90 2 X 527.46 X
40818   003 90 2 X 491.25 X
40818   002 90 2 X 520.41 X
40819     90 2 X * X
40820   001 10 2 X 202.44 X
40820   004 10 2 X 190.70 X
40820   003 10 2 X 187.24 X
40820   002 10 2 X 192.64 X
40830   001 10 2 X 244.57 X
40830   004 10 2 X 238.95 X
40830   002 10 2 X 240.62 X
40830   003 10 2 X 241.33 X
40831   004 10 2 X 470.08 X
40831   001 10 2 X 469.96 X
40831   003 10 2 X 475.73 X
40831   002 10 2 X 413.11 X
40840     90 2 X * X
40842     90 2 X * X
40843     90 2 X * X
40844     90 2 X * X
40845     90 2 X * X
40899     YYY 2 X # X
41000   001 10 2 X 232.89 X
41000   004 10 2 X 223.32 X
41000   003 10 2 X 223.39 X
41000   002 10 2 X 229.98 X
41005   002 10 2 X 209.16 X
41005   003 10 2 X 198.94 X
41005   001 10 2 X 244.55 X
41005   004 10 2 X 196.68 X
41006   001 90 2 X 427.38 X
41006   004 90 2 X 409.44 X
41006   002 90 2 X 414.40 X
41006   003 90 2 X 402.54 X
41007   002 90 2 X 464.18 X
41007   003 90 2 X 633.46 X
41007   004 90 2 X 625.64 X
41007   001 90 2 X 682.46 X
41008   002 90 2 X 342.46 X
41008   003 90 2 X 332.09 X
41008   001 90 2 X 480.13 X
41008   004 90 2 X 450.47 X
41009   003 90 2 X 729.33 X
41009   002 90 2 X 601.90 X
41009   001 90 2 X 785.29 X
41009   004 90 2 X 720.30 X
41010   001 10 2 X 176.42 X
41010   004 10 2 X 165.72 X
41010   002 10 2 X 174.71 X
41010   003 10 2 X 167.43 X
41015   001 90 2 X 381.09 X
41015   004 90 2 X 488.82 X
41015   003 90 2 X 493.92 X
41015   002 90 2 X 381.51 X
41016   003 90 2 X 810.66 X
41016   002 90 2 X 680.91 X
41016   001 90 2 X 688.72 X
41016   004 90 2 X 623.69 X
41017   001 90 2 X 583.53 X
41017   003 90 2 X 388.06 X
41017   002 90 2 X 401.37 X
41017   004 90 2 X 546.51 X
41018   001 90 2 X 1,011.61 X
41018   002 90 2 X 998.42 X
41018   003 90 2 X 944.05 X
41018   004 90 2 X 932.66 X
41019   001 0 2 X 875.92 X
41019   004 0 2 X 800.52 X
41019   002 0 2 X 800.52 X
41019   003 0 2 X 800.52 X
41100   002 10 2 X 270.81 227.58
41100   003 10 2 X 265.67 224.12
41100   001 10 2 X 273.90 230.11
41100   004 10 2 X 281.73 237.35
41105   002 10 2 X 278.96 X
41105   003 10 2 X 263.36 X
41105   004 10 2 X 260.30 X
41105   001 10 2 X 282.72 X
41108   001 10 2 X 217.18 170.62
41108   004 10 2 X 206.71 162.78
41108   003 10 2 X 244.70 192.28
41108   002 10 2 X 227.85 178.61
41110   002 10 2 X 509.41 X
41110   003 10 2 X 500.26 X
41110   001 10 2 X 499.80 X
41110   004 10 2 X 404.31 X
41112   004 90 2 X 766.07 X
41112   002 90 2 X 750.14 X
41112   003 90 2 X 757.37 X
41112   001 90 2 X 834.32 X
41113   004 90 2 X 1,274.78 X
41113   001 90 2 X 1,344.96 X
41113   003 90 2 X 1,258.43 X
41113   002 90 2 X 1,265.26 X
41114   001 90 2 X 1,683.44 X
41114   004 90 2 X 1,546.99 X
41114   003 90 2 X 1,565.68 X
41114   002 90 2 X 1,660.48 X
41115   003 10 2 X 388.81 X
41115   002 10 2 X 402.25 X
41115   004 10 2 X 374.16 X
41115   001 10 2 X 407.84 X
41116   001 90 2 X 610.79 X
41116   004 90 2 X 590.15 X
41116   003 90 2 X 592.90 X
41116   002 90 2 X 607.26 X
41120   002 90 2 X 1,882.86 X
41120   003 90 2 X 1,772.98 X
41120   001 90 2 X 1,909.48 X
41120   004 90 2 X 1,751.86 X
41130   001 90 2 X 2,691.06 X
41130   004 90 2 X 2,551.37 X
41130   002 90 2 X 2,584.70 X
41130   003 90 2 X 2,528.56 X
41135   003 90 2 X 3,783.61 X
41135   002 90 2 X 4,994.42 X
41135   001 90 2 X 5,205.36 X
41135   004 90 2 X 4,846.58 X
41140   004 90 2 X 4,620.87 X
41140   002 90 2 X 4,971.12 X
41140   003 90 2 X 4,676.21 X
41140   001 90 2 X 5,042.41 X
41145   004 90 2 X 5,497.54 X
41145   001 90 2 X 6,090.57 X
41145   003 90 2 X 5,563.72 X
41145   002 90 2 X 5,917.12 X
41150   004 90 2 X 4,198.21 X
41150   001 90 2 X 4,229.27 X
41150   003 90 2 X 3,633.57 X
41150   002 90 2 X 3,858.30 X
41153   001 90 2 X 7,389.66 X
41153   004 90 2 X 5,055.07 X
41153   003 90 2 X 7,205.26 X
41153   002 90 2 X 7,353.83 X
41155   004 90 2 X 5,999.67 X
41155   002 90 2 X 6,713.65 X
41155   003 90 2 X 6,130.92 X
41155   001 90 2 X 6,661.97 X
41250   004 10 2 X 314.13 X
41250   001 10 2 X 338.34 X
41250   003 10 2 X 290.10 X
41250   002 10 2 X 304.08 X
41251   004 10 2 X 357.33 X
41251   001 10 2 X 503.13 X
41251   003 10 2 X 467.90 X
41251   002 10 2 X 372.23 X
41252   001 10 2 X 619.60 X
41252   003 10 2 X 576.96 X
41252   002 10 2 X 611.31 X
41252   004 10 2 X 570.03 X
41510   002 90 2 X 703.82 X
41510   003 90 2 X 658.10 X
41510   004 90 2 X 650.54 X
41510   001 90 2 X 714.84 X
41512   001 90 2 X 1,089.08 X
41512   004 90 2 X 972.58 X
41512   003 90 2 X 972.58 X
41512   002 90 2 X 972.58 X
41520     90 2 X * X
41530   002 0 2 X 4,671.84 637.14
41530   003 0 2 X 4,671.84 637.14
41530   004 0 2 X 4,671.84 637.14
41530   001 0 2 X 5,499.17 714.27
41599     YYY 2 X # X
41800     10 2 X * X
41805   004 10 2 X 217.47 X
41805   002 10 2 X 190.49 X
41805   003 10 2 X 220.10 X
41805   001 10 2 X 235.01 X
41806   001 10 2 X 493.20 X
41806   004 10 2 X 457.95 X
41806   002 10 2 X 487.43 X
41806   003 10 2 X 463.36 X
41820     0 2 X * X
41821     0 2 X * X
41822     10 2 X * X
41823     90 2 X * X
41825   001 10 2 X 435.48 X
41825   004 10 2 X 394.85 X
41825   003 10 2 X 396.34 X
41825   002 10 2 X 420.26 X
41826   004 10 2 X 545.25 X
41826   003 10 2 X 537.18 X
41826   002 10 2 X 592.32 X
41826   001 10 2 X 593.24 X
41827   003 90 2 X 772.54 X
41827   002 90 2 X 822.20 X
41827   004 90 2 X 762.80 X
41827   001 90 2 X 834.14 X
41828     10 2 X * X
41830     10 2 X * X
41850     0 2 X * X
41870     0 2 X * X
41872     90 2 X * X
41874     90 2 X * X
41899     YYY 2 X # X
42000   001 10 2 X 216.33 X
42000   004 10 2 X 210.32 X
42000   002 10 2 X 214.32 X
42000   003 10 2 X 211.22 X
42100   001 10 2 X 320.02 262.19
42100   004 10 2 X 300.22 246.58
42100   003 10 2 X 306.27 250.99
42100   002 10 2 X 304.28 249.24
42104   004 10 2 X 515.11 X
42104   001 10 2 X 528.51 X
42104   002 10 2 X 526.27 X
42104   003 10 2 X 516.96 X
42106   002 10 2 X 1,127.69 X
42106   003 10 2 X 1,082.69 X
42106   004 10 2 X 520.71 X
42106   001 10 2 X 564.79 X
42107   001 90 2 X 1,791.87 X
42107   002 90 2 X 1,717.15 X
42107   003 90 2 X 999.81 X
42107   004 90 2 X 1,684.38 X
42120   001 90 2 X 2,596.50 X
42120   004 90 2 X 1,446.17 X
42120   002 90 2 X 2,585.29 X
42120   003 90 2 X 2,538.80 X
42140   002 90 2 X 312.74 X
42140   003 90 2 X 299.81 X
42140   004 90 2 X 301.86 X
42140   001 90 2 X 340.65 X
42145   003 90 2 X 2,484.31 X
42145   002 90 2 X 2,553.05 X
42145   004 90 2 X 2,472.44 X
42145   001 90 2 X 2,569.54 X
42160   002 10 2 X 514.43 X
42160   003 10 2 X 586.50 X
42160   004 10 2 X 354.56 X
42160   001 10 2 X 522.71 X
42180   001 10 2 X 555.78 X
42180   004 10 2 X 400.19 X
42180   003 10 2 X 384.81 X
42180   002 10 2 X 547.91 X
42182   002 10 2 X 843.94 X
42182   003 10 2 X 673.86 X
42182   001 10 2 X 855.81 X
42182   004 10 2 X 704.77 X
42200   001 90 2 X 1,966.14 X
42200   003 90 2 X 1,830.06 X
42200   002 90 2 X 1,939.62 X
42200   004 90 2 X 1,808.37 X
42205   003 90 2 X 2,138.01 X
42205   002 90 2 X 2,265.29 X
42205   004 90 2 X 2,110.64 X
42205   001 90 2 X 2,295.87 X
42210   001 90 2 X 2,623.09 X
42210   002 90 2 X 2,587.55 X
42210   003 90 2 X 2,439.56 X
42210   004 90 2 X 2,408.26 X
42215   002 90 2 X 2,130.15 X
42215   003 90 2 X 1,768.08 X
42215   004 90 2 X 1,746.70 X
42215   001 90 2 X 1,905.09 X
42220   002 90 2 X 1,431.60 X
42220   003 90 2 X 1,342.07 X
42220   001 90 2 X 1,453.23 X
42220   004 90 2 X 1,326.27 X
42225   003 90 2 X 1,781.97 X
42225   002 90 2 X 2,234.84 X
42225   004 90 2 X 1,761.24 X
42225   001 90 2 X 2,486.67 X
42226   004 90 2 X 1,872.55 X
42226   001 90 2 X 2,272.07 X
42226   003 90 2 X 1,895.33 X
42226   002 90 2 X 2,009.46 X
42227   003 90 2 X 1,738.71 X
42227   002 90 2 X 1,824.92 X
42227   001 90 2 X 1,845.56 X
42227   004 90 2 X 1,717.34 X