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2024 Workers' Compensation Part B Fee Schedule

53515-55520

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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
53515		004	90	2	X	2,334.99	X
53515		003	90	2	X	2,362.88	X
53515		002	90	2	X	2,493.46	X
53515		001	90	2	X	2,524.92	X
53520		001	90	2	X	989.38	X
53520		004	90	2	X	1,406.01	X
53520		003	90	2	X	1,358.71	X
53520		002	90	2	X	1,479.38	X
53600		001	0	2	X	149.06	133.73
53600		003	0	2	X	129.36	116.28
53600		002	0	2	X	145.46	130.96
53600		004	0	2	X	129.95	116.71
53601		001	0	2	X	135.13	120.48
53601		002	0	2	X	133.29	118.70
53601		003	0	2	X	113.03	101.05
53601		004	0	2	X	115.69	103.14
53605		004	0	2	X	185.99	X
53605		001	0	2	X	167.27	X
53605		003	0	2	X	143.42	X
53605		002	0	2	X	161.01	X
53620		001	0	2	X	179.81	159.63
53620		003	0	2	X	175.72	157.29
53620		002	0	2	X	187.98	167.86
53620		004	0	2	X	163.95	146.50
53621		003	0	2	X	139.87	125.29
53621		002	0	2	X	162.26	145.41
53621		004	0	2	X	140.40	125.77
53621		001	0	2	X	164.82	147.58
53660		004	0	2	X	97.17	84.45
53660		003	0	2	X	97.88	84.71
53660		002	0	2	X	112.24	97.50
53660		001	0	2	X	113.63	98.51
53661		004	0	2	X	95.41	83.96
53661		002	0	2	X	109.76	96.45
53661		003	0	2	X	95.30	83.89
53661		001	0	2	X	110.92	97.47
53665		004	0	2	X	119.96	X
53665		001	0	2	X	125.14	X
53665		002	0	2	X	126.05	X
53665		003	0	2	X	104.78	X
53850		004	90	2	X	1,494.65	X
53850		001	90	2	X	1,667.97	X
53850		003	90	2	X	1,494.65	X
53850		002	90	2	X	1,494.65	X
53852		001	90	2	X	1,743.24	X
53852		003	90	2	X	1,562.15	X
53852		002	90	2	X	1,562.15	X
53852		004	90	2	X	1,562.15	X
53854		004	90	2	X	2,454.17	531.10
53854		002	90	2	X	2,454.17	531.10
53854		003	90	2	X	2,454.17	531.10
53854		001	90	2	X	2,785.58	578.95
53855		003	0	2	X	1,075.74	143.56
53855		001	0	2	X	1,261.16	155.68
53855		002	0	2	X	1,075.74	143.56
53855		004	0	2	X	1,075.74	143.56
53860		001	90	2	X	2,766.48	447.44
53860		004	90	2	X	2,455.86	406.37
53860		003	90	2	X	2,455.86	406.37
53860		002	90	2	X	2,455.86	406.37
53899			YYY	2	X	#	X
54000			10	2	X	*	X
54001		001	10	2	X	338.41	X
54001		003	10	2	X	317.68	X
54001		002	10	2	X	328.45	X
54001		004	10	2	X	311.76	X
54015		003	10	2	X	642.02	X
54015		002	10	2	X	507.20	X
54015		004	10	2	X	635.63	X
54015		001	10	2	X	517.63	X
54050		004	10	2	X	143.74	X
54050		003	10	2	X	142.17	X
54050		002	10	2	X	138.28	X
54050		001	10	2	X	150.27	X
54055		004	10	2	X	192.61	X
54055		001	10	2	X	206.82	X
54055		003	10	2	X	195.70	X
54055		002	10	2	X	198.37	X
54056		001	10	2	X	181.84	X
54056		003	10	2	X	165.62	X
54056		002	10	2	X	185.78	X
54056		004	10	2	X	182.53	X
54057		001	10	2	X	303.75	X
54057		002	10	2	X	295.19	X
54057		003	10	2	X	285.13	X
54057		004	10	2	X	329.23	X
54060		001	10	2	X	322.02	X
54060		004	10	2	X	300.60	X
54060		003	10	2	X	307.58	X
54060		002	10	2	X	318.10	X
54065		004	10	2	X	523.66	X
54065		002	10	2	X	819.47	X
54065		003	10	2	X	643.55	X
54065		001	10	2	X	571.41	X
54100		002	0	2	X	242.04	X
54100		003	0	2	X	235.32	X
54100		001	0	2	X	244.08	X
54100		004	0	2	X	272.49	X
54105		002	10	2	X	449.90	X
54105		003	10	2	X	432.76	X
54105		004	10	2	X	435.34	X
54105		001	10	2	X	452.77	X
54110		002	90	2	X	1,797.22	X
54110		003	90	2	X	1,705.69	X
54110		004	90	2	X	1,685.94	X
54110		001	90	2	X	1,819.33	X
54111		004	90	2	X	2,392.60	X
54111		002	90	2	X	2,557.68	X
54111		003	90	2	X	2,421.09	X
54111		001	90	2	X	2,590.67	X
54112		004	90	2	X	2,799.51	X
54112		002	90	2	X	3,554.39	X
54112		001	90	2	X	3,570.60	X
54112		003	90	2	X	2,832.91	X
54115		004	90	2	X	1,062.47	X
54115		003	90	2	X	1,563.82	X
54115		002	90	2	X	1,757.23	X
54115		001	90	2	X	1,151.30	X
54120		003	90	2	X	1,706.02	X
54120		002	90	2	X	1,799.52	X
54120		004	90	2	X	1,685.86	X
54120		001	90	2	X	1,822.07	X
54125		001	90	2	X	2,859.60	X
54125		002	90	2	X	2,820.99	X
54125		003	90	2	X	2,660.84	X
54125		004	90	2	X	2,763.52	X
54130		003	90	2	X	3,641.98	X
54130		002	90	2	X	3,843.93	X
54130		001	90	2	X	3,892.62	X
54130		004	90	2	X	3,668.08	X
54135		002	90	2	X	4,906.52	X
54135		003	90	2	X	4,649.33	X
54135		001	90	2	X	4,968.64	X
54135		004	90	2	X	4,594.46	X
54150			0	2	X	*	X
54160			10	2	X	*	X
54161		004	10	2	X	578.69	X
54161		002	10	2	X	619.76	X
54161		003	10	2	X	587.22	X
54161		001	10	2	X	627.58	X
54162		001	10	2	X	532.50	X
54162		004	10	2	X	475.89	X
54162		002	10	2	X	475.89	X
54162		003	10	2	X	475.89	X
54163		001	10	2	X	499.45	X
54163		004	10	2	X	447.77	X
54163		003	10	2	X	447.77	X
54163		002	10	2	X	447.77	X
54164		003	10	2	X	392.44	X
54164		002	10	2	X	392.44	X
54164		004	10	2	X	392.44	X
54164		001	10	2	X	438.89	X
54200		001	10	2	X	117.31	X
54200		004	10	2	X	141.00	X
54200		002	10	2	X	116.16	X
54200		003	10	2	X	142.53	X
54205		001	90	2	X	1,431.16	X
54205		004	90	2	X	1,323.22	X
54205		003	90	2	X	1,339.02	X
54205		002	90	2	X	1,413.26	X
54220		001	0	2	X	782.68	X
54220		004	0	2	X	431.28	X
54220		002	0	2	X	756.38	X
54220		003	0	2	X	671.86	X
54230		002	0	2	X	208.80	X
54230		004	0	2	X	287.94	X
54230		001	0	2	X	211.57	X
54230		003	0	2	X	197.80	X
54231		001	0	2	X	493.83	X
54231		004	0	2	X	456.42	X
54231		003	0	2	X	461.82	X
54231		002	0	2	X	487.61	X
54235		001	0	2	X	163.17	142.37
54235		003	0	2	X	152.44	133.76
54235		002	0	2	X	165.01	144.24
54235		004	0	2	X	156.30	137.12
54240		001	0	0	X	264.68	X
54240	26	001	0	0	X	193.12	X
54240	TC	001	0	0	X	62.99	X
54240		004	0	0	X	240.12	X
54240	26	004	0	0	X	160.32	X
54240	TC	004	0	0	X	54.84	X
54240		003	0	0	X	251.87	X
54240	26	003	0	0	X	180.96	X
54240	TC	003	0	0	X	55.70	X
54240		002	0	0	X	264.96	X
54240	26	002	0	0	X	191.69	X
54240	TC	002	0	0	X	74.90	X
54250		004	0	0	X	242.17	X
54250	26	004	0	0	X	288.76	X
54250	TC	004	0	0	X	32.86	X
54250		002	0	0	X	251.27	X
54250	26	002	0	0	X	231.55	X
54250	TC	002	0	0	X	36.67	X
54250		003	0	0	X	243.55	X
54250	26	003	0	0	X	225.01	X
54250	TC	003	0	0	X	33.37	X
54250		001	0	0	X	254.45	X
54250	26	001	0	0	X	305.75	X
54250	TC	001	0	0	X	37.42	X
54300		002	90	2	X	1,221.59	X
54300		003	90	2	X	1,860.67	X
54300		001	90	2	X	1,235.42	X
54300		004	90	2	X	1,839.05	X
54304		003	90	2	X	2,265.74	X
54304		002	90	2	X	2,536.51	X
54304		004	90	2	X	2,239.07	X
54304		001	90	2	X	2,424.32	X
54308		002	90	2	X	2,005.49	X
54308		003	90	2	X	1,903.88	X
54308		004	90	2	X	1,882.56	X
54308		001	90	2	X	2,030.12	X
54312		001	90	2	X	2,616.44	X
54312		004	90	2	X	2,419.71	X
54312		003	90	2	X	2,448.57	X
54312		002	90	2	X	2,583.80	X
54316		004	90	2	X	2,935.29	X
54316		003	90	2	X	2,970.43	X
54316		002	90	2	X	3,135.01	X
54316		001	90	2	X	3,174.76	X
54318		001	90	2	X	2,154.14	X
54318		002	90	2	X	2,123.39	X
54318		003	90	2	X	1,996.57	X
54318		004	90	2	X	1,973.48	X
54322		001	90	2	X	2,305.95	X
54322		004	90	2	X	2,138.98	X
54322		003	90	2	X	2,164.16	X
54322		002	90	2	X	2,278.37	X
54324		004	90	2	X	2,840.33	X
54324		001	90	2	X	3,071.82	X
54324		002	90	2	X	3,111.65	X
54324		003	90	2	X	3,044.85	X
54326		004	90	2	X	2,719.86	X
54326		001	90	2	X	2,941.32	X
54326		003	90	2	X	2,752.39	X
54326		002	90	2	X	2,904.56	X
54328		002	90	2	X	2,958.13	X
54328		003	90	2	X	2,794.56	X
54328		004	90	2	X	2,761.74	X
54328		001	90	2	X	2,997.78	X
54332		004	90	2	X	3,075.10	X
54332		001	90	2	X	3,326.72	X
54332		002	90	2	X	3,285.16	X
54332		003	90	2	X	3,112.38	X
54336		001	90	2	X	4,362.86	X
54336		002	90	2	X	4,307.36	X
54336		003	90	2	X	4,076.04	X
54336		004	90	2	X	4,025.21	X
54340		001	90	2	X	1,699.19	X
54340		004	90	2	X	1,571.34	X
54340		003	90	2	X	1,590.10	X
54340		002	90	2	X	1,677.93	X
54344		002	90	2	X	3,618.30	X
54344		003	90	2	X	3,424.89	X
54344		001	90	2	X	3,664.68	X
54344		004	90	2	X	3,381.39	X
54348		001	90	2	X	3,251.62	X
54348		003	90	2	X	3,042.71	X
54348		002	90	2	X	3,210.97	X
54348		004	90	2	X	3,006.75	X
54352		001	90	2	X	4,627.66	X
54352		004	90	2	X	4,287.84	X
54352		002	90	2	X	4,571.53	X
54352		003	90	2	X	4,338.91	X
54360		001	90	2	X	2,136.64	X
54360		002	90	2	X	2,110.60	X
54360		003	90	2	X	2,002.86	X
54360		004	90	2	X	1,979.66	X
54380		003	90	2	X	2,375.90	X
54380		002	90	2	X	2,502.18	X
54380		004	90	2	X	2,347.47	X
54380		001	90	2	X	2,532.65	X
54385		002	90	2	X	2,871.27	X
54385		003	90	2	X	2,726.37	X
54385		004	90	2	X	2,693.96	X
54385		001	90	2	X	2,906.27	X
54390		002	90	2	X	3,990.49	X
54390		003	90	2	X	3,776.81	X
54390		004	90	2	X	3,733.00	X
54390		001	90	2	X	4,042.22	X
54400		004	90	2	X	2,914.66	X
54400		001	90	2	X	3,009.15	X
54400		002	90	2	X	2,993.18	X
54400		003	90	2	X	2,926.91	X
54401		002	90	2	X	3,255.94	X
54401		003	90	2	X	3,168.71	X
54401		004	90	2	X	3,153.06	X
54401		001	90	2	X	3,276.94	X
54405		003	90	2	X	3,961.63	X
54405		002	90	2	X	4,068.74	X
54405		004	90	2	X	3,942.16	X
54405		001	90	2	X	4,094.42	X
54406		001	90	2	X	1,651.40	X
54406		002	90	2	X	1,494.49	X
54406		003	90	2	X	1,494.49	X
54406		004	90	2	X	1,494.49	X
54408		004	90	2	X	1,575.30	X
54408		002	90	2	X	1,575.30	X
54408		003	90	2	X	1,575.30	X
54408		001	90	2	X	1,738.96	X
54410		004	90	2	X	1,866.59	X
54410		001	90	2	X	2,049.88	X
54410		003	90	2	X	1,866.59	X
54410		002	90	2	X	1,866.59	X
54411		001	90	2	X	2,236.71	X
54411		004	90	2	X	2,030.37	X
54411		002	90	2	X	2,030.37	X
54411		003	90	2	X	2,030.37	X
54415		003	90	2	X	1,106.34	X
54415		002	90	2	X	1,106.34	X
54415		001	90	2	X	1,229.44	X
54415		004	90	2	X	1,106.34	X
54416		004	90	2	X	1,443.64	X
54416		003	90	2	X	1,443.64	X
54416		002	90	2	X	1,443.64	X
54416		001	90	2	X	1,595.39	X
54417		004	90	2	X	1,784.96	X
54417		001	90	2	X	1,958.61	X
54417		003	90	2	X	1,784.96	X
54417		002	90	2	X	1,784.96	X
54420		003	90	2	X	2,022.92	X
54420		001	90	2	X	2,168.49	X
54420		002	90	2	X	2,140.13	X
54420		004	90	2	X	1,999.12	X
54430		001	90	2	X	1,925.59	X
54430		004	90	2	X	1,778.98	X
54430		003	90	2	X	1,800.38	X
54430		002	90	2	X	1,901.31	X
54435		001	90	2	X	1,134.40	X
54435		003	90	2	X	1,061.74	X
54435		002	90	2	X	940.87	X
54435		004	90	2	X	1,049.05	X
54437		001	90	2	X	1,138.42	X
54437		002	90	2	X	1,045.91	X
54437		003	90	2	X	1,045.91	X
54437		004	90	2	X	1,045.91	X
54438		003	90	2	X	2,114.99	X
54438		001	90	2	X	2,294.60	X
54438		004	90	2	X	2,114.99	X
54438		002	90	2	X	2,114.99	X
54440		001	90	2	X	2,136.64	X
54440		003	90	2	X	2,002.86	X
54440		002	90	2	X	2,110.60	X
54440		004	90	2	X	1,979.66	X
54450		002	0	2	X	205.91	X
54450		003	0	2	X	195.55	X
54450		001	0	2	X	208.42	X
54450		004	0	2	X	193.28	X
54500		004	0	2	X	186.11	X
54500		002	0	2	X	160.84	X
54500		003	0	2	X	188.19	X
54500		001	0	2	X	198.64	X
54505		002	10	2	X	605.53	X
54505		003	10	2	X	574.84	X
54505		004	10	2	X	568.29	X
54505		001	10	2	X	613.03	X
54512		002	90	2	X	1,189.49	X
54512		003	90	2	X	1,189.49	X
54512		004	90	2	X	1,189.49	X
54512		001	90	2	X	1,312.11	X
54520		001	90	2	X	1,207.36	X
54520		004	90	2	X	1,105.93	X
54520		002	90	2	X	1,190.34	X
54520		003	90	2	X	1,119.86	X
54522		004	90	2	X	1,351.21	X
54522		002	90	2	X	1,351.21	X
54522		003	90	2	X	1,351.21	X
54522		001	90	2	X	1,493.09	X
54530		002	90	2	X	1,760.63	X
54530		003	90	2	X	1,685.94	X
54530		004	90	2	X	1,661.02	X
54530		001	90	2	X	1,762.88	X
54535		004	90	2	X	2,165.91	X
54535		002	90	2	X	2,322.83	X
54535		003	90	2	X	2,191.79	X
54535		001	90	2	X	2,354.46	X
54550		001	90	2	X	1,481.79	X
54550		004	90	2	X	1,365.30	X
54550		002	90	2	X	1,462.31	X
54550		003	90	2	X	1,381.50	X
54560		001	90	2	X	2,070.95	X
54560		004	90	2	X	1,911.16	X
54560		002	90	2	X	2,044.26	X
54560		003	90	2	X	1,933.81	X
54600		003	90	2	X	1,221.42	X
54600		002	90	2	X	1,290.06	X
54600		004	90	2	X	1,207.13	X
54600		001	90	2	X	1,306.67	X
54620		002	10	2	X	919.15	X
54620		003	10	2	X	871.06	X
54620		001	10	2	X	930.78	X
54620		004	10	2	X	860.77	X
54640		002	90	2	X	1,733.67	X
54640		003	90	2	X	1,724.06	X
54640		004	90	2	X	1,715.65	X
54640		001	90	2	X	1,724.06	X
54650		002	90	2	X	1,890.94	X
54650		003	90	2	X	1,877.47	X
54650		004	90	2	X	1,867.69	X
54650		001	90	2	X	2,203.26	X
54660		001	90	2	X	952.98	X
54660		003	90	2	X	891.63	X
54660		002	90	2	X	941.12	X
54660		004	90	2	X	881.09	X
54670		004	90	2	X	300.21	X
54670		002	90	2	X	316.68	X
54670		003	90	2	X	303.47	X
54670		001	90	2	X	319.81	X
54680		001	90	2	X	2,291.03	X
54680		004	90	2	X	2,118.58	X
54680		003	90	2	X	2,143.84	X
54680		002	90	2	X	2,262.38	X
54690		001	90	2	X	1,775.71	X
54690		003	90	2	X	1,605.33	X
54690		002	90	2	X	1,605.33	X
54690		004	90	2	X	1,605.33	X
54692		002	90	2	X	1,656.45	X
54692		003	90	2	X	1,656.45	X
54692		004	90	2	X	1,656.45	X
54692		001	90	2	X	1,820.18	X
54699			YYY	2	X	#	X
54700		001	10	2	X	409.12	X
54700		004	10	2	X	395.28	X
54700		003	10	2	X	395.08	X
54700		002	10	2	X	405.23	X
54800		004	0	2	X	462.62	X
54800		002	0	2	X	495.42	X
54800		003	0	2	X	468.33	X
54800		001	0	2	X	501.97	X
54830		001	90	2	X	1,003.48	X
54830		004	90	2	X	948.02	X
54830		003	90	2	X	937.39	X
54830		002	90	2	X	990.63	X
54840		001	90	2	X	1,193.19	X
54840		004	90	2	X	1,082.49	X
54840		002	90	2	X	1,142.62	X
54840		003	90	2	X	1,153.19	X
54860		004	90	2	X	1,247.58	X
54860		001	90	2	X	1,351.84	X
54860		003	90	2	X	1,293.94	X
54860		002	90	2	X	1,290.60	X
54861		001	90	2	X	1,852.70	X
54861		004	90	2	X	1,705.75	X
54861		003	90	2	X	1,726.65	X
54861		002	90	2	X	1,828.23	X
54865		003	90	2	X	577.40	X
54865		002	90	2	X	577.40	X
54865		001	90	2	X	647.63	X
54865		004	90	2	X	577.40	X
54900		003	90	2	X	2,343.28	X
54900		002	90	2	X	2,472.61	X
54900		001	90	2	X	2,503.85	X
54900		004	90	2	X	2,315.57	X
54901		001	90	2	X	3,436.83	X
54901		004	90	2	X	3,178.23	X
54901		002	90	2	X	3,393.86	X
54901		003	90	2	X	3,216.23	X
55000		004	0	2	X	185.47	166.21
55000		001	0	2	X	205.91	184.48
55000		003	0	2	X	191.04	171.43
55000		002	0	2	X	206.47	184.63
55040		001	90	2	X	1,206.05	X
55040		004	90	2	X	1,089.33	X
55040		003	90	2	X	1,157.17	X
55040		002	90	2	X	1,172.67	X
55041		003	90	2	X	1,675.08	X
55041		002	90	2	X	1,759.70	X
55041		004	90	2	X	1,687.28	X
55041		001	90	2	X	1,759.42	X
55060		004	90	2	X	1,093.41	X
55060		001	90	2	X	1,136.45	X
55060		003	90	2	X	1,103.47	X
55060		002	90	2	X	1,125.49	X
55100		003	10	2	X	222.39	X
55100		002	10	2	X	228.94	X
55100		004	10	2	X	220.55	X
55100		001	10	2	X	231.19	X
55110		001	90	2	X	904.26	X
55110		004	90	2	X	943.22	X
55110		003	90	2	X	866.83	X
55110		002	90	2	X	896.98	X
55120		004	90	2	X	626.55	X
55120		001	90	2	X	753.04	X
55120		003	90	2	X	636.84	X
55120		002	90	2	X	744.88	X
55150		002	90	2	X	1,396.89	X
55150		003	90	2	X	1,318.73	X
55150		001	90	2	X	1,415.69	X
55150		004	90	2	X	1,302.90	X
55175		004	90	2	X	1,019.43	X
55175		001	90	2	X	1,110.89	X
55175		003	90	2	X	1,031.94	X
55175		002	90	2	X	1,088.94	X
55180		002	90	2	X	1,738.18	X
55180		003	90	2	X	1,852.49	X
55180		001	90	2	X	1,753.10	X
55180		004	90	2	X	1,830.95	X
55200		002	90	2	X	693.78	X
55200		003	90	2	X	661.49	X
55200		001	90	2	X	701.57	X
55200		004	90	2	X	654.05	X
55250		002	90	2	X	809.80	X
55250		003	90	2	X	759.61	X
55250		001	90	2	X	798.64	X
55250		004	90	2	X	762.14	X
55300		002	0	2	X	715.78	X
55300		003	0	2	X	677.24	X
55300		004	0	2	X	669.15	X
55300		001	0	2	X	725.08	X
55400		001	90	2	X	1,723.60	X
55400		004	90	2	X	1,590.80	X
55400		003	90	2	X	1,610.08	X
55400		002	90	2	X	1,701.52	X
55500		004	90	2	X	1,029.25	X
55500		001	90	2	X	1,099.52	X
55500		003	90	2	X	1,033.18	X
55500		002	90	2	X	1,090.48	X
55520		004	90	2	X	968.10	X
55520		001	90	2	X	1,052.04	X
55520		003	90	2	X	978.95	X
55520		002	90	2	X	1,037.74	X

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