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2024 Workers' Compensation Part B Fee Schedule

67882-69643

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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
67882   003 90 2 X 1,457.72 X
67882   002 90 2 X 1,502.95 X
67882   004 90 2 X 1,468.24 X
67882   001 90 2 X 1,509.71 X
67900   001 90 2 X 942.81 X
67900   003 90 2 X 887.91 X
67900   002 90 2 X 932.20 X
67900   004 90 2 X 877.03 X
67901   003 90 2 X 2,057.43 X
67901   001 90 2 X 2,023.88 X
67901   004 90 2 X 1,704.78 X
67901   002 90 2 X 2,101.70 X
67902   002 90 2 X 1,912.41 X
67902   003 90 2 X 2,089.78 X
67902   001 90 2 X 2,237.07 X
67902   004 90 2 X 1,776.90 X
67903   002 90 2 X 1,951.86 X
67903   003 90 2 X 1,834.94 X
67903   001 90 2 X 2,200.50 X
67903   004 90 2 X 1,810.31 X
67904   002 90 2 X 2,103.72 X
67904   003 90 2 X 2,085.04 X
67904   004 90 2 X 2,011.62 X
67904   001 90 2 X 2,056.72 X
67906   001 90 2 X 1,382.53 X
67906   004 90 2 X 1,282.83 X
67906   003 90 2 X 1,298.67 X
67906   002 90 2 X 1,366.26 X
67908   003 90 2 X 2,008.02 X
67908   002 90 2 X 2,051.91 X
67908   001 90 2 X 2,061.97 X
67908   004 90 2 X 2,001.02 X
67909   003 90 2 X 1,225.93 X
67909   002 90 2 X 1,272.70 X
67909   001 90 2 X 1,283.88 X
67909   004 90 2 X 1,215.75 X
67911   004 90 2 X 1,576.15 X
67911   002 90 2 X 1,707.13 X
67911   003 90 2 X 1,597.51 X
67911   001 90 2 X 1,733.41 X
67912   001 90 2 X 2,305.77 968.35
67912   003 90 2 X 2,012.07 874.34
67912   002 90 2 X 2,012.07 874.34
67912   004 90 2 X 2,012.07 874.34
67914   001 90 2 X 1,547.70 X
67914   002 90 2 X 1,610.18 X
67914   003 90 2 X 1,438.47 X
67914   004 90 2 X 1,433.26 X
67915   001 90 2 X 484.21 X
67915   004 90 2 X 444.39 X
67915   002 90 2 X 481.48 X
67915   003 90 2 X 462.92 X
67916   004 90 2 X 1,230.91 X
67916   001 90 2 X 1,443.06 X
67916   003 90 2 X 1,247.12 X
67916   002 90 2 X 1,318.02 X
67917   003 90 2 X 1,587.01 X
67917   002 90 2 X 1,742.64 X
67917   004 90 2 X 1,598.33 X
67917   001 90 2 X 1,725.83 X
67921   004 90 2 X 1,313.23 X
67921   003 90 2 X 1,302.68 X
67921   002 90 2 X 1,467.48 X
67921   001 90 2 X 1,268.61 X
67922   004 90 2 X 439.97 X
67922   001 90 2 X 432.99 X
67922   003 90 2 X 404.07 X
67922   002 90 2 X 457.44 X
67923   001 90 2 X 1,500.24 X
67923   004 90 2 X 1,116.56 X
67923   002 90 2 X 1,420.94 X
67923   003 90 2 X 1,346.21 X
67924   004 90 2 X 1,376.41 X
67924   002 90 2 X 1,474.47 X
67924   003 90 2 X 1,394.60 X
67924   001 90 2 X 1,493.62 X
67930   001 10 2 X 579.95 X
67930   002 10 2 X 536.08 X
67930   003 10 2 X 515.32 X
67930   004 10 2 X 509.70 X
67935   002 90 2 X 1,334.54 X
67935   003 90 2 X 1,275.89 X
67935   004 90 2 X 1,043.41 X
67935   001 90 2 X 1,118.20 X
67938   001 10 2 X 201.88 X
67938   003 10 2 X 192.05 X
67938   002 10 2 X 199.94 X
67938   004 10 2 X 198.94 X
67950   004 90 2 X 2,003.54 X
67950   003 90 2 X 1,934.67 X
67950   002 90 2 X 2,037.96 X
67950   001 90 2 X 2,048.12 X
67961   001 90 2 X 2,008.78 X
67961   003 90 2 X 1,911.60 X
67961   002 90 2 X 1,983.65 X
67961   004 90 2 X 1,949.08 X
67966   001 90 2 X 2,154.95 X
67966   004 90 2 X 2,111.58 X
67966   002 90 2 X 2,147.02 X
67966   003 90 2 X 2,124.08 X
67971   004 90 2 X 2,144.52 X
67971   003 90 2 X 2,309.95 X
67971   002 90 2 X 2,374.81 X
67971   001 90 2 X 2,531.16 X
67973   002 90 2 X 3,156.77 X
67973   003 90 2 X 3,114.03 X
67973   004 90 2 X 2,777.52 X
67973   001 90 2 X 3,196.76 X
67974   003 90 2 X 2,860.23 X
67974   002 90 2 X 3,020.33 X
67974   001 90 2 X 3,058.71 X
67974   004 90 2 X 2,823.68 X
67975   004 90 2 X 1,377.58 X
67975   002 90 2 X 1,093.41 X
67975   003 90 2 X 1,017.04 X
67975   001 90 2 X 1,105.10 X
67999     YYY 2 X # X
68020   001 10 2 X 183.15 157.62
68020   003 10 2 X 176.30 152.22
68020   002 10 2 X 182.11 157.10
68020   004 10 2 X 176.33 152.40
68040     0 2 X * X
68100   003 0 2 X 320.02 X
68100   002 0 2 X 332.91 X
68100   004 0 2 X 324.19 X
68100   001 0 2 X 340.65 X
68110   002 10 2 X 394.69 315.23
68110   004 10 2 X 376.82 302.17
68110   003 10 2 X 378.37 302.79
68110   001 10 2 X 417.12 332.33
68115   004 10 2 X 448.24 X
68115   001 10 2 X 488.65 X
68115   003 10 2 X 453.72 X
68115   002 10 2 X 476.72 X
68130   002 90 2 X 808.70 X
68130   003 90 2 X 781.30 X
68130   001 90 2 X 815.26 X
68130   004 90 2 X 774.63 X
68135   004 10 2 X 241.35 X
68135   003 10 2 X 243.12 X
68135   002 10 2 X 249.49 X
68135   001 10 2 X 285.55 X
68200   002 0 2 X 184.13 138.38
68200   003 0 2 X 182.06 137.05
68200   001 0 2 X 184.39 138.67
68200   004 0 2 X 200.70 151.52
68320   001 90 2 X 1,733.61 X
68320   004 90 2 X 1,275.90 X
68320   003 90 2 X 1,635.61 X
68320   002 90 2 X 1,725.85 X
68325   003 90 2 X 1,756.93 X
68325   002 90 2 X 2,044.82 X
68325   004 90 2 X 1,734.03 X
68325   001 90 2 X 2,055.44 X
68326   004 90 2 X 2,501.74 X
68326   001 90 2 X 1,764.82 X
68326   003 90 2 X 1,955.60 X
68326   002 90 2 X 2,550.08 X
68328   003 90 2 X 2,018.31 X
68328   002 90 2 X 2,144.13 X
68328   001 90 2 X 2,174.29 X
68328   004 90 2 X 1,992.05 X
68330   004 90 2 X 1,109.80 X
68330   001 90 2 X 1,941.66 X
68330   002 90 2 X 1,894.81 X
68330   003 90 2 X 1,124.42 X
68335   001 90 2 X 1,984.53 X
68335   002 90 2 X 2,681.26 X
68335   003 90 2 X 1,844.16 X
68335   004 90 2 X 1,819.78 X
68340   004 90 2 X 743.98 X
68340   002 90 2 X 790.43 X
68340   003 90 2 X 753.12 X
68340   001 90 2 X 799.35 X
68360   002 90 2 X 1,149.76 X
68360   003 90 2 X 1,124.44 X
68360   001 90 2 X 1,155.77 X
68360   004 90 2 X 1,016.43 X
68362   002 90 2 X 1,655.59 X
68362   003 90 2 X 1,605.82 X
68362   004 90 2 X 1,591.25 X
68362   001 90 2 X 1,667.58 X
68371   002 10 2 X 757.67 X
68371   003 10 2 X 757.67 X
68371   001 10 2 X 838.20 X
68371   004 10 2 X 757.67 X
68399     YYY 2 X # X
68400   002 10 2 X 300.59 X
68400   003 10 2 X 282.37 X
68400   004 10 2 X 293.66 X
68400   001 10 2 X 298.74 X
68420   004 10 2 X 344.50 X
68420   001 10 2 X 366.94 X
68420   003 10 2 X 348.42 X
68420   002 10 2 X 363.31 X
68440   001 10 2 X 164.84 128.48
68440   003 10 2 X 156.72 122.14
68440   004 10 2 X 157.12 122.91
68440   002 10 2 X 163.34 127.16
68500   002 90 2 X 2,076.64 X
68500   003 90 2 X 1,966.88 X
68500   001 90 2 X 2,103.20 X
68500   004 90 2 X 1,943.52 X
68505   002 90 2 X 2,145.58 X
68505   003 90 2 X 2,041.90 X
68505   001 90 2 X 2,170.43 X
68505   004 90 2 X 2,016.83 X
68510   001 0 2 X 953.86 X
68510   004 0 2 X 660.74 X
68510   003 0 2 X 894.60 X
68510   002 0 2 X 694.32 X
68520   004 90 2 X 1,932.10 X
68520   003 90 2 X 1,910.80 X
68520   002 90 2 X 1,950.62 X
68520   001 90 2 X 1,859.01 X
68525   004 0 2 X 858.85 X
68525   001 0 2 X 925.02 X
68525   003 0 2 X 869.46 X
68525   002 0 2 X 908.10 X
68530   002 10 2 X 726.14 X
68530   003 10 2 X 691.34 X
68530   004 10 2 X 682.94 X
68530   001 10 2 X 734.52 X
68540   001 90 2 X 2,097.50 X
68540   004 90 2 X 1,948.08 X
68540   003 90 2 X 2,259.47 X
68540   002 90 2 X 2,073.24 X
68550   004 90 2 X 2,546.92 X
68550   002 90 2 X 2,716.44 X
68550   003 90 2 X 2,578.78 X
68550   001 90 2 X 2,749.53 X
68700   002 90 2 X 1,724.29 X
68700   003 90 2 X 1,451.05 X
68700   001 90 2 X 1,729.37 X
68700   004 90 2 X 937.47 X
68705   002 10 2 X 352.52 X
68705   003 10 2 X 355.91 X
68705   004 10 2 X 354.34 X
68705   001 10 2 X 351.67 X
68720   002 90 2 X 2,554.22 X
68720   003 90 2 X 2,355.70 X
68720   001 90 2 X 2,768.30 X
68720   004 90 2 X 2,209.06 X
68745   003 90 2 X 1,590.12 X
68745   002 90 2 X 1,966.72 X
68745   004 90 2 X 1,570.78 X
68745   001 90 2 X 1,693.33 X
68750   004 90 2 X 2,726.03 X
68750   002 90 2 X 2,439.65 X
68750   001 90 2 X 2,473.39 X
68750   003 90 2 X 1,570.59 X
68760   003 10 2 X 276.43 229.52
68760   002 10 2 X 288.28 238.53
68760   004 10 2 X 273.23 227.12
68760   001 10 2 X 291.13 240.84
68761   002 10 2 X 247.43 197.71
68761   004 10 2 X 233.64 187.56
68761   003 10 2 X 236.51 189.60
68761   001 10 2 X 250.01 199.73
68770   002 90 2 X 1,079.46 X
68770   003 90 2 X 1,158.90 X
68770   004 90 2 X 1,145.16 X
68770   001 90 2 X 1,086.92 X
68801   004 10 2 X 134.84 113.24
68801   003 10 2 X 134.84 113.24
68801   002 10 2 X 138.51 116.28
68801   001 10 2 X 147.22 121.63
68810   001 10 2 X 204.21 170.85
68810   003 10 2 X 187.44 159.12
68810   002 10 2 X 192.61 163.52
68810   004 10 2 X 187.44 159.12
68811   001 10 2 X 429.96 X
68811   002 10 2 X 398.84 X
68811   003 10 2 X 388.18 X
68811   004 10 2 X 388.18 X
68815   001 10 2 X 563.42 446.16
68815   004 10 2 X 510.00 410.74
68815   002 10 2 X 524.14 422.17
68815   003 10 2 X 510.00 410.74
68816   001 10 2 X 1,198.92 401.76
68816   004 10 2 X 1,020.33 359.15
68816   003 10 2 X 1,020.33 359.15
68816   002 10 2 X 1,020.33 359.15
68840   004 10 2 X 155.15 134.01
68840   001 10 2 X 167.54 144.42
68840   003 10 2 X 158.75 137.01
68840   002 10 2 X 166.83 143.15
68841   001 0 2 X 49.12 41.44
68841   004 0 2 X 44.66 38.00
68841   003 0 2 X 44.66 38.00
68841   002 0 2 X 44.66 38.00
68850   003 0 2 X 141.69 X
68850   002 0 2 X 148.76 X
68850   004 0 2 X 146.78 X
68850   001 0 2 X 150.50 X
68899     YYY 2 X # X
69000   004 10 2 X 172.61 156.22
69000   002 10 2 X 175.87 158.88
69000   003 10 2 X 169.98 154.32
69000   001 10 2 X 174.08 157.49
69005   002 10 2 X 373.89 X
69005   003 10 2 X 361.82 X
69005   001 10 2 X 383.48 X
69005   004 10 2 X 369.12 X
69020   001 10 2 X 209.10 185.14
69020   004 10 2 X 190.42 169.44
69020   002 10 2 X 179.35 158.57
69020   003 10 2 X 188.93 167.36
69100   001 0 2 X 229.98 180.11
69100   003 0 2 X 217.50 170.26
69100   002 0 2 X 223.85 175.06
69100   004 0 2 X 220.22 172.67
69105   001 0 2 X 207.48 X
69105   004 0 2 X 200.46 X
69105   002 0 2 X 265.73 X
69105   003 0 2 X 195.47 X
69110   004 90 2 X 831.33 X
69110   001 90 2 X 863.41 X
69110   003 90 2 X 817.75 X
69110   002 90 2 X 909.56 X
69120   002 90 2 X 442.38 X
69120   003 90 2 X 686.97 X
69120   001 90 2 X 344.45 X
69120   004 90 2 X 328.40 X
69140   001 90 2 X 1,862.96 X
69140   002 90 2 X 1,836.11 X
69140   003 90 2 X 1,724.78 X
69140   004 90 2 X 1,703.52 X
69145   002 90 2 X 821.29 X
69145   003 90 2 X 806.48 X
69145   004 90 2 X 803.67 X
69145   001 90 2 X 824.93 X
69150   001 90 2 X 2,775.50 X
69150   004 90 2 X 2,548.76 X
69150   002 90 2 X 2,737.34 X
69150   003 90 2 X 2,579.45 X
69155   001 90 2 X 4,817.10 X
69155   004 90 2 X 3,558.06 X
69155   003 90 2 X 3,602.03 X
69155   002 90 2 X 3,821.27 X
69200   003 0 2 X 120.18 100.40
69200   002 0 2 X 125.66 104.73
69200   004 0 2 X 118.81 99.35
69200   001 0 2 X 127.67 106.39
69205   001 10 2 X 232.78 X
69205   002 10 2 X 288.58 X
69205   003 10 2 X 242.22 X
69205   004 10 2 X 277.14 X
69209   002 0 2 X 18.36 X
69209   003 0 2 X 18.36 X
69209   001 0 2 X 21.54 X
69209   004 0 2 X 18.36 X
69210   003 0 2 X 77.99 67.94
69210   002 0 2 X 87.33 75.86
69210   004 0 2 X 83.28 72.89
69210   001 0 2 X 85.18 74.19
69220   004 0 2 X 126.55 104.47
69220   002 0 2 X 131.53 107.67
69220   003 0 2 X 114.20 94.00
69220   001 0 2 X 129.54 106.37
69222   002 10 2 X 273.42 227.62
69222   003 10 2 X 272.29 227.51
69222   001 10 2 X 326.36 271.81
69222   004 10 2 X 271.17 226.14
69300   001 YYY 2 X 1,428.54 X
69300   002 YYY 2 X 1,397.30 X
69300   003 YYY 2 X 1,326.07 X
69300   004 YYY 2 X 1,307.96 X
69310   004 90 2 X 2,739.47 X
69310   001 90 2 X 2,823.60 X
69310   003 90 2 X 3,099.52 X
69310   002 90 2 X 2,534.25 X
69320   002 90 2 X 3,643.91 X
69320   003 90 2 X 4,388.64 X
69320   004 90 2 X 3,389.65 X
69320   001 90 2 X 5,393.42 X
69399     YYY 2 X # X
69420   004 10 2 X 211.98 177.22
69420   003 10 2 X 214.41 179.09
69420   002 10 2 X 225.77 188.36
69420   001 10 2 X 232.45 194.04
69421   003 10 2 X 265.22 X
69421   002 10 2 X 294.61 X
69421   004 10 2 X 298.56 X
69421   001 10 2 X 328.62 X
69424   002 0 2 X 208.80 X
69424   003 0 2 X 202.54 X
69424   004 0 2 X 206.74 X
69424   001 0 2 X 219.30 X
69433   004 10 2 X 363.64 283.55
69433   001 10 2 X 381.23 298.22
69433   003 10 2 X 354.70 276.72
69433   002 10 2 X 326.37 254.85
69436   004 10 2 X 437.99 X
69436   003 10 2 X 443.52 X
69436   002 10 2 X 447.93 X
69436   001 10 2 X 479.42 X
69440   001 90 2 X 2,438.47 X
69440   003 90 2 X 1,854.14 X
69440   002 90 2 X 1,941.74 X
69440   004 90 2 X 1,887.62 X
69450   002 90 2 X 2,253.79 X
69450   003 90 2 X 2,242.50 X
69450   001 90 2 X 1,815.69 X
69450   004 90 2 X 2,347.25 X
69501   004 90 2 X 2,396.32 X
69501   003 90 2 X 2,300.36 X
69501   002 90 2 X 2,316.09 X
69501   001 90 2 X 2,550.91 X
69502   001 90 2 X 3,328.97 X
69502   003 90 2 X 3,233.78 X
69502   002 90 2 X 3,013.14 X
69502   004 90 2 X 3,219.13 X
69505   004 90 2 X 3,125.48 X
69505   003 90 2 X 3,164.70 X
69505   002 90 2 X 3,542.27 X
69505   001 90 2 X 3,564.30 X
69511   004 90 2 X 3,200.58 X
69511   001 90 2 X 3,575.74 X
69511   003 90 2 X 3,296.21 X
69511   002 90 2 X 3,521.56 X
69530   001 90 2 X 4,089.21 X
69530   004 90 2 X 3,754.96 X
69530   003 90 2 X 3,801.37 X
69530   002 90 2 X 4,057.31 X
69535   002 90 2 X 5,742.14 X
69535   003 90 2 X 5,582.08 X
69535   004 90 2 X 6,462.91 X
69535   001 90 2 X 6,154.42 X
69540   001 10 2 X 346.41 X
69540   004 10 2 X 327.05 X
69540   002 10 2 X 337.06 X
69540   003 10 2 X 320.85 X
69550   001 90 2 X 3,449.59 X
69550   003 90 2 X 3,321.68 X
69550   004 90 2 X 2,981.96 X
69550   002 90 2 X 3,424.76 X
69552   004 90 2 X 3,855.97 X
69552   001 90 2 X 4,202.15 X
69552   002 90 2 X 4,144.05 X
69552   003 90 2 X 3,903.15 X
69554   002 90 2 X 5,680.77 X
69554   003 90 2 X 5,347.09 X
69554   004 90 2 X 5,282.58 X
69554   001 90 2 X 5,761.32 X
69601   002 90 2 X 3,148.65 X
69601   003 90 2 X 2,951.92 X
69601   004 90 2 X 2,915.21 X
69601   001 90 2 X 3,192.43 X
69602   001 90 2 X 3,439.56 X
69602   004 90 2 X 3,200.83 X
69602   002 90 2 X 3,328.96 X
69602   003 90 2 X 3,248.46 X
69603   001 90 2 X 3,698.16 X
69603   002 90 2 X 3,642.36 X
69603   003 90 2 X 3,410.39 X
69603   004 90 2 X 3,367.27 X
69604   001 90 2 X 4,387.26 X
69604   004 90 2 X 3,997.68 X
69604   002 90 2 X 3,923.72 X
69604   003 90 2 X 4,050.16 X
69610   001 10 2 X 502.17 460.27
69610   002 10 2 X 514.95 470.30
69610   003 10 2 X 508.42 467.34
69610   004 10 2 X 474.43 436.19
69620   003 90 2 X 2,292.47 X
69620   002 90 2 X 2,130.55 X
69620   004 90 2 X 1,691.55 X
69620   001 90 2 X 2,536.60 X
69631   001 90 2 X 3,047.63 X
69631   004 90 2 X 2,901.52 X
69631   003 90 2 X 2,926.84 X
69631   002 90 2 X 3,028.65 X
69632   004 90 2 X 3,080.99 X
69632   002 90 2 X 3,333.27 X
69632   003 90 2 X 3,120.45 X
69632   001 90 2 X 3,384.48 X
69633   001 90 2 X 3,280.26 X
69633   004 90 2 X 2,979.95 X
69633   002 90 2 X 3,229.44 X
69633   003 90 2 X 3,018.19 X
69635   001 90 2 X 3,928.16 X
69635   004 90 2 X 3,645.29 X
69635   002 90 2 X 3,879.79 X
69635   003 90 2 X 3,672.08 X
69636   004 90 2 X 3,981.76 X
69636   001 90 2 X 4,265.75 X
69636   003 90 2 X 4,009.80 X
69636   002 90 2 X 4,217.17 X
69637   002 90 2 X 4,120.25 X
69637   004 90 2 X 3,717.96 X
69637   003 90 2 X 3,765.58 X
69637   001 90 2 X 4,091.97 X
69641   003 90 2 X 3,165.92 X
69641   002 90 2 X 3,387.76 X
69641   004 90 2 X 3,125.84 X
69641   001 90 2 X 3,680.70 X
69642   003 90 2 X 4,285.81 X
69642   002 90 2 X 4,417.56 X
69642   004 90 2 X 4,022.24 X
69642   001 90 2 X 4,548.02 X
69643   003 90 2 X 3,921.27 X
69643   002 90 2 X 4,232.16 X
69643   004 90 2 X 3,871.65 X
69643   001 90 2 X 4,378.18 X