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2024 Workers' Compensation Part B Fee Schedule

95937-97016

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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
95937   002 XXX 0 X 164.18 X
95937 26 002 XXX 0 X 176.33 X
95937 TC 002 XXX 0 X 36.28 X
95937   003 XXX 0 X 144.71 X
95937 26 003 XXX 0 X 134.68 X
95937 TC 003 XXX 0 X 33.14 X
95937   004 XXX 0 X 144.15 X
95937 26 004 XXX 0 X 151.26 X
95937 TC 004 XXX 0 X 32.66 X
95937   001 XXX 0 X 150.55 X
95937 26 001 XXX 0 X 176.83 X
95937 TC 001 XXX 0 X 37.03 X
95938   001 XXX 0 X 528.08 X
95938 26 001 XXX 0 X 76.85 X
95938 TC 001 XXX 0 X 451.22 X
95938   004 XXX 0 X 460.36 X
95938 26 004 XXX 0 X 71.83 X
95938 TC 004 XXX 0 X 388.52 X
95938   003 XXX 0 X 460.36 X
95938 26 003 XXX 0 X 71.83 X
95938 TC 003 XXX 0 X 388.52 X
95938   002 XXX 0 X 460.36 X
95938 26 002 XXX 0 X 71.83 X
95938 TC 002 XXX 0 X 388.52 X
95939   004 XXX 0 X 725.49 X
95939 26 004 XXX 0 X 189.10 X
95939 TC 004 XXX 0 X 536.38 X
95939   002 XXX 0 X 725.49 X
95939 26 002 XXX 0 X 189.10 X
95939 TC 002 XXX 0 X 536.38 X
95939   003 XXX 0 X 725.49 X
95939 26 003 XXX 0 X 189.10 X
95939 TC 003 XXX 0 X 536.38 X
95939   001 XXX 0 X 825.44 X
95939 26 001 XXX 0 X 202.51 X
95939 TC 001 XXX 0 X 622.89 X
95940   001 XXX 0 X 54.71 X
95940   003 XXX 0 X 50.91 X
95940   002 XXX 0 X 50.91 X
95940   004 XXX 0 X 50.91 X
95941     XXX 9 X * X
95954   001 XXX 0 X 532.43 X
95954 26 001 XXX 0 X 283.47 X
95954 TC 001 XXX 0 X 55.88 X
95954   002 XXX 0 X 524.69 X
95954 26 002 XXX 0 X 470.07 X
95954 TC 002 XXX 0 X 54.59 X
95954   003 XXX 0 X 492.90 X
95954 26 003 XXX 0 X 443.64 X
95954 TC 003 XXX 0 X 49.32 X
95954   004 XXX 0 X 486.90 X
95954 26 004 XXX 0 X 438.37 X
95954 TC 004 XXX 0 X 48.60 X
95955   004 XXX 0 X 400.58 X
95955 26 004 XXX 0 X 206.55 X
95955 TC 004 XXX 0 X 194.03 X
95955   003 XXX 0 X 539.82 X
95955 26 003 XXX 0 X 209.13 X
95955 TC 003 XXX 0 X 197.04 X
95955   002 XXX 0 X 496.20 X
95955 26 002 XXX 0 X 222.42 X
95955 TC 002 XXX 0 X 216.21 X
95955   001 XXX 0 X 446.35 X
95955 26 001 XXX 0 X 225.59 X
95955 TC 001 XXX 0 X 220.77 X
95957   001 XXX 0 X 554.31 X
95957 26 001 XXX 0 X 302.79 X
95957 TC 001 XXX 0 X 186.13 X
95957   002 XXX 0 X 348.47 X
95957 26 002 XXX 0 X 291.82 X
95957 TC 002 XXX 0 X 182.58 X
95957   004 XXX 0 X 513.46 X
95957 26 004 XXX 0 X 348.50 X
95957 TC 004 XXX 0 X 164.95 X
95957   003 XXX 0 X 519.71 X
95957 26 003 XXX 0 X 352.22 X
95957 TC 003 XXX 0 X 167.54 X
95958   001 XXX 0 X 819.72 X
95958 26 001 XXX 0 X 529.13 X
95958 TC 001 XXX 0 X 191.83 X
95958   002 XXX 0 X 1,002.20 X
95958 26 002 XXX 0 X 814.17 X
95958 TC 002 XXX 0 X 188.05 X
95958   003 XXX 0 X 940.63 X
95958 26 003 XXX 0 X 768.38 X
95958 TC 003 XXX 0 X 172.33 X
95958   004 XXX 0 X 928.93 X
95958 26 004 XXX 0 X 759.30 X
95958 TC 004 XXX 0 X 169.64 X
95961     XXX 0 X * X
95962     ZZZ 0 X * X
95965 26 002 XXX 0 X 903.54 X
95965 26 003 XXX 0 X 903.54 X
95965 26 004 XXX 0 X 903.54 X
95965 26 001 XXX 0 X 978.93 X
95966 26 002 XXX 0 X 457.23 X
95966 26 003 XXX 0 X 457.23 X
95966 26 004 XXX 0 X 457.23 X
95966 26 001 XXX 0 X 499.19 X
95967 26 004 ZZZ 0 X 400.87 X
95967 26 003 ZZZ 0 X 400.87 X
95967 26 002 ZZZ 0 X 400.87 X
95967 26 001 ZZZ 0 X 438.21 X
95970   004 XXX 0 X 54.31 52.70
95970   002 XXX 0 X 54.31 52.70
95970   001 XXX 0 X 61.94 60.00
95970   003 XXX 0 X 54.31 52.70
95971   002 XXX 0 X 90.62 88.14
95971   001 XXX 0 X 100.52 97.61
95971   004 XXX 0 X 90.62 88.14
95971   003 XXX 0 X 90.62 88.14
95972   002 XXX 0 X 169.26 165.15
95972   003 XXX 0 X 169.26 165.15
95972   004 XXX 0 X 169.26 165.15
95972   001 XXX 0 X 184.07 179.29
95976   001 XXX 0 X 61.36 60.30
95976   002 XXX 0 X 56.87 55.93
95976   003 XXX 0 X 56.87 55.93
95976   004 XXX 0 X 56.87 55.93
95977   001 XXX 0 X 81.42 80.32
95977   003 XXX 0 X 75.47 74.57
95977   004 XXX 0 X 75.47 74.57
95977   002 XXX 0 X 75.47 74.57
95980   004 XXX 0 X 70.20 X
95980   003 XXX 0 X 70.20 X
95980   002 XXX 0 X 70.20 X
95980   001 XXX 0 X 77.08 X
95981   003 XXX 0 X 48.07 27.41
95981   004 XXX 0 X 48.07 27.41
95981   002 XXX 0 X 48.07 27.41
95981   001 XXX 0 X 55.05 30.12
95982   001 XXX 0 X 82.76 60.21
95982   004 XXX 0 X 73.95 55.18
95982   003 XXX 0 X 73.95 55.18
95982   002 XXX 0 X 73.95 55.18
95983   002 XXX 0 X 71.60 70.66
95983   003 XXX 0 X 71.60 70.66
95983   004 XXX 0 X 71.60 70.66
95983   001 XXX 0 X 77.44 76.37
95984   002 ZZZ 0 X 62.30 61.82
95984   003 ZZZ 0 X 62.30 61.82
95984   004 ZZZ 0 X 62.30 61.82
95984   001 ZZZ 0 X 67.24 66.70
95990   003 XXX 0 X 116.14 X
95990   004 XXX 0 X 116.14 X
95990   001 XXX 0 X 138.52 X
95990   002 XXX 0 X 116.14 X
95991   003 XXX 0 X 173.94 80.54
95991   001 XXX 0 X 197.25 87.47
95991   002 XXX 0 X 173.94 80.54
95991   004 XXX 0 X 173.94 80.54
95992     XXX 0 X * X
95999     XXX 0 X # X
96000   002 XXX 0 X 201.90 X
96000   003 XXX 0 X 201.90 X
96000   004 XXX 0 X 201.90 X
96000   001 XXX 0 X 217.55 X
96001   004 XXX 0 X 240.91 X
96001   003 XXX 0 X 240.91 X
96001   002 XXX 0 X 240.91 X
96001   001 XXX 0 X 259.42 X
96002   004 XXX 0 X 46.66 X
96002   002 XXX 0 X 46.66 X
96002   003 XXX 0 X 46.66 X
96002   001 XXX 0 X 51.00 X
96003   001 XXX 0 X 47.91 X
96003   004 XXX 0 X 43.32 X
96003   003 XXX 0 X 43.32 X
96003   002 XXX 0 X 43.32 X
96004   001 XXX 0 X 224.53 X
96004   004 XXX 0 X 205.67 X
96004   003 XXX 0 X 205.67 X
96004   002 XXX 0 X 205.67 X
96020 26 001 XXX 0 X 298.17 X
96020 26 002 XXX 0 X 274.35 X
96020 26 003 XXX 0 X 274.35 X
96020 26 004 XXX 0 X 274.35 X
96040     XXX 9 X * X
96105   003 XXX 0 X 166.03 X
96105   002 XXX 0 X 184.02 X
96105   001 XXX 0 X 195.73 X
96105   004 XXX 0 X 162.76 X
96110     XXX 9 X * X
96112   001 XXX 0 X 200.82 189.02
96112   004 XXX 0 X 187.81 177.52
96112   003 XXX 0 X 187.81 177.52
96112   002 XXX 0 X 187.81 177.52
96113   004 ZZZ 0 X 83.94 81.15
96113   002 ZZZ 0 X 83.94 81.15
96113   003 ZZZ 0 X 83.94 81.15
96113   001 ZZZ 0 X 89.72 86.52
96116   003 XXX 0 X 200.23 187.79
96116   002 XXX 0 X 200.23 187.79
96116   001 XXX 0 X 222.19 206.93
96116   004 XXX 0 X 200.23 187.79
96121   003 ZZZ 0 X 114.23 109.10
96121   004 ZZZ 0 X 114.23 109.10
96121   002 ZZZ 0 X 114.23 109.10
96121   001 ZZZ 0 X 121.15 115.27
96125   001 XXX 5 X 183.73 153.33
96125   002 XXX 5 X 165.64 140.45
96125   003 XXX 5 X 165.64 140.45
96125   004 XXX 5 X 165.64 140.45
96127   002 XXX 0 X 7.88 X
96127   003 XXX 0 X 7.88 X
96127   004 XXX 0 X 7.88 X
96127   001 XXX 0 X 9.30 X
96130   002 XXX 0 X 162.83 153.51
96130   001 XXX 0 X 171.80 161.06
96130   004 XXX 0 X 162.83 153.51
96130   003 XXX 0 X 162.83 153.51
96131   003 ZZZ 0 X 123.87 116.86
96131   002 ZZZ 0 X 123.87 116.86
96131   004 ZZZ 0 X 123.87 116.86
96131   001 ZZZ 0 X 130.54 122.50
96132   002 XXX 0 X 181.97 150.64
96132   001 XXX 0 X 193.63 157.71
96132   004 XXX 0 X 181.97 150.64
96132   003 XXX 0 X 181.97 150.64
96133   001 ZZZ 0 X 147.69 120.90
96133   002 ZZZ 0 X 138.83 115.46
96133   003 ZZZ 0 X 138.83 115.46
96133   004 ZZZ 0 X 138.83 115.46
96136   001 XXX 0 X 70.34 36.56
96136   002 XXX 0 X 64.04 34.61
96136   003 XXX 0 X 64.04 34.61
96136   004 XXX 0 X 64.04 34.61
96137   001 ZZZ 0 X 65.05 28.59
96137   003 ZZZ 0 X 59.04 27.26
96137   004 ZZZ 0 X 59.04 27.26
96137   002 ZZZ 0 X 59.04 27.26
96138   002 XXX 0 X 50.52 X
96138   001 XXX 0 X 58.05 X
96138   004 XXX 0 X 50.52 X
96138   003 XXX 0 X 50.52 X
96139   004 ZZZ 0 X 50.52 X
96139   003 ZZZ 0 X 50.52 X
96139   002 ZZZ 0 X 50.52 X
96139   001 ZZZ 0 X 58.05 X
96146   001 XXX 0 X 3.37 X
96146   004 XXX 0 X 2.86 X
96146   002 XXX 0 X 2.86 X
96146   003 XXX 0 X 2.86 X
96156   001 XXX 0 X 144.37 130.33
96156   002 XXX 0 X 135.72 123.56
96156   004 XXX 0 X 135.72 123.56
96156   003 XXX 0 X 135.72 123.56
96158   002 XXX 0 X 92.63 84.21
96158   003 XXX 0 X 92.63 84.21
96158   004 XXX 0 X 92.63 84.21
96158   001 XXX 0 X 98.33 88.63
96159   001 ZZZ 0 X 34.38 30.61
96159   002 ZZZ 0 X 32.34 29.07
96159   003 ZZZ 0 X 32.34 29.07
96159   004 ZZZ 0 X 32.34 29.07
96160   004 ZZZ 9 X 6.56 X
96160   003 ZZZ 9 X 6.56 X
96160   002 ZZZ 9 X 6.56 X
96160   001 ZZZ 9 X 7.60 X
96161   004 ZZZ 9 X 6.56 X
96161   003 ZZZ 9 X 6.56 X
96161   002 ZZZ 9 X 6.56 X
96161   001 ZZZ 9 X 7.60 X
96164   004 XXX 0 X 13.71 12.31
96164   003 XXX 0 X 13.71 12.31
96164   002 XXX 0 X 13.71 12.31
96164   001 XXX 0 X 14.61 12.99
96165   003 ZZZ 0 X 6.38 5.43
96165   004 ZZZ 0 X 6.38 5.43
96165   001 ZZZ 0 X 6.73 5.65
96165   002 ZZZ 0 X 6.38 5.43
96167   001 XXX 0 X 105.71 94.92
96167   004 XXX 0 X 99.49 90.13
96167   003 XXX 0 X 99.49 90.13
96167   002 XXX 0 X 99.49 90.13
96168   004 ZZZ 0 X 35.29 32.00
96168   003 ZZZ 0 X 35.29 32.00
96168   002 ZZZ 0 X 35.29 32.00
96168   001 ZZZ 0 X 37.48 33.70
96170     XXX 9 X * X
96171     ZZZ 9 X * X
96202         X * X
96203         X * X
96360   003 XXX 0 X 95.32 X
96360   004 XXX 0 X 95.32 X
96360   001 XXX 0 X 112.64 X
96360   002 XXX 0 X 95.32 X
96361   004 ZZZ 0 X 28.31 X
96361   003 ZZZ 0 X 28.31 X
96361   002 ZZZ 0 X 28.31 X
96361   001 ZZZ 0 X 33.47 X
96365   001 XXX 0 X 136.55 X
96365   002 XXX 0 X 115.79 X
96365   003 XXX 0 X 115.79 X
96365   004 XXX 0 X 115.79 X
96366   003 ZZZ 0 X 37.67 X
96366   004 ZZZ 0 X 37.67 X
96366   002 ZZZ 0 X 37.67 X
96366   001 ZZZ 0 X 43.62 X
96367   003 ZZZ 0 X 58.67 X
96367   004 ZZZ 0 X 58.67 X
96367   001 ZZZ 0 X 68.34 X
96367   002 ZZZ 0 X 58.67 X
96368   001 ZZZ 0 X 40.83 X
96368   002 ZZZ 0 X 35.26 X
96368   003 ZZZ 0 X 35.26 X
96368   004 ZZZ 0 X 35.26 X
96369   001 XXX 0 X 294.88 X
96369   004 XXX 0 X 249.50 X
96369   003 XXX 0 X 249.50 X
96369   002 XXX 0 X 249.50 X
96370   003 ZZZ 0 X 27.55 X
96370   004 ZZZ 0 X 27.55 X
96370   001 ZZZ 0 X 31.56 X
96370   002 ZZZ 0 X 27.55 X
96371   001 ZZZ 0 X 142.73 X
96371   002 ZZZ 0 X 120.15 X
96371   003 ZZZ 0 X 120.15 X
96371   004 ZZZ 0 X 120.15 X
96372   002 XXX 0 X 35.56 X
96372   004 XXX 0 X 35.56 X
96372   003 XXX 0 X 35.56 X
96372   001 XXX 0 X 40.52 X
96373   001 XXX 0 X 35.20 X
96373   004 XXX 0 X 30.88 X
96373   003 XXX 0 X 30.88 X
96373   002 XXX 0 X 30.88 X
96374   004 XXX 0 X 91.46 X
96374   003 XXX 0 X 91.46 X
96374   002 XXX 0 X 91.46 X
96374   001 XXX 0 X 107.38 X
96375   001 ZZZ 0 X 47.59 X
96375   004 ZZZ 0 X 40.32 X
96375   003 ZZZ 0 X 40.32 X
96375   002 ZZZ 0 X 40.32 X
96376     ZZZ 9 X * X
96377     XXX 0 X * X
96379     XXX 0 X # X
96401   004 XXX 0 X 116.24 X
96401   002 XXX 0 X 116.24 X
96401   003 XXX 0 X 116.24 X
96401   001 XXX 0 X 139.35 X
96402   001 XXX 0 X 74.50 X
96402   004 XXX 0 X 62.93 X
96402   003 XXX 0 X 62.93 X
96402   002 XXX 0 X 62.93 X
96405   001 0 2 X 103.41 82.87
96405   003 0 2 X 97.09 77.97
96405   004 0 2 X 95.91 77.13
96405   002 0 2 X 102.21 81.88
96406   001 0 2 X 155.89 125.08
96406   003 0 2 X 146.72 117.96
96406   002 0 2 X 154.12 123.65
96406   004 0 2 X 144.97 116.71
96409   002 XXX 0 X 213.13 X
96409   001 XXX 0 X 258.98 X
96409   004 XXX 0 X 213.13 X
96409   003 XXX 0 X 213.13 X
96411   002 ZZZ 0 X 123.65 X
96411   003 ZZZ 0 X 123.65 X
96411   004 ZZZ 0 X 123.65 X
96411   001 ZZZ 0 X 150.05 X
96413   004 XXX 0 X 300.53 X
96413   001 XXX 0 X 365.91 X
96413   002 XXX 0 X 300.53 X
96413   003 XXX 0 X 300.53 X
96415   003 ZZZ 0 X 68.43 X
96415   004 ZZZ 0 X 68.43 X
96415   002 ZZZ 0 X 68.43 X
96415   001 ZZZ 0 X 82.92 X
96416   004 XXX 0 X 322.35 X
96416   002 XXX 0 X 322.35 X
96416   003 XXX 0 X 322.35 X
96416   001 XXX 0 X 393.63 X
96417   001 ZZZ 0 X 179.09 X
96417   002 ZZZ 0 X 147.30 X
96417   003 ZZZ 0 X 147.30 X
96417   004 ZZZ 0 X 147.30 X
96420   002 XXX 0 X 132.87 X
96420   001 XXX 0 X 135.42 X
96420   004 XXX 0 X 120.17 X
96420   003 XXX 0 X 122.05 X
96422   002 XXX 0 X 145.77 X
96422   003 XXX 0 X 120.18 X
96422   004 XXX 0 X 143.12 X
96422   001 XXX 0 X 133.41 X
96423   002 ZZZ 0 X 106.30 X
96423   003 ZZZ 0 X 47.32 X
96423   004 ZZZ 0 X 46.58 X
96423   001 ZZZ 0 X 106.66 X
96425   001 XXX 0 X 153.64 X
96425   002 XXX 0 X 124.92 X
96425   003 XXX 0 X 118.20 X
96425   004 XXX 0 X 136.86 X
96440   001 0 0 X 369.40 314.68
96440   002 0 0 X 314.56 268.83
96440   003 0 0 X 346.56 296.30
96440   004 0 0 X 315.58 277.57
96446   003 XXX 0 X 297.37 37.28
96446   002 XXX 0 X 297.37 37.28
96446   001 XXX 0 X 335.50 41.20
96446   004 XXX 0 X 297.37 37.28
96450   003 0 0 X 232.44 X
96450   004 0 0 X 185.61 X
96450   001 0 0 X 195.95 X
96450   002 0 0 X 206.52 X
96521   002 XXX 0 X 266.08 X
96521   004 XXX 0 X 266.08 X
96521   003 XXX 0 X 266.08 X
96521   001 XXX 0 X 324.19 X
96522   001 XXX 0 X 234.31 X
96522   004 XXX 0 X 192.61 X
96522   003 XXX 0 X 192.61 X
96522   002 XXX 0 X 192.61 X
96523   002 XXX 0 X 48.76 X
96523   003 XXX 0 X 48.76 X
96523   004 XXX 0 X 48.76 X
96523   001 XXX 0 X 59.40 X
96542   001 XXX 0 X 277.28 X
96542   002 XXX 0 X 273.55 X
96542   004 XXX 0 X 255.01 X
96542   003 XXX 0 X 258.03 X
96547     ZZZ 9 X # X
96548     ZZZ 9 X # X
96549     XXX 0 X # X
96567   004 XXX 0 X 125.99 X
96567   003 XXX 0 X 125.99 X
96567   002 XXX 0 X 125.99 X
96567   001 XXX 0 X 149.27 X
96570   004 ZZZ 0 X 172.86 149.47
96570   003 ZZZ 0 X 172.86 149.47
96570   002 ZZZ 0 X 172.86 149.47
96570   001 ZZZ 0 X 200.66 173.33
96571   004 ZZZ 0 X 90.67 82.31
96571   003 ZZZ 0 X 90.67 82.31
96571   002 ZZZ 0 X 90.67 82.31
96571   001 ZZZ 0 X 111.11 101.34
96573   001 0 0 X 302.47 X
96573   002 0 0 X 266.12 X
96573   003 0 0 X 266.12 X
96573   004 0 0 X 266.12 X
96574   001 0 0 X 388.89 X
96574   004 0 0 X 344.30 X
96574   003 0 0 X 344.30 X
96574   002 0 0 X 344.30 X
96900   004 XXX 0 X 46.33 X
96900   003 XXX 0 X 38.81 X
96900   002 XXX 0 X 42.30 X
96900   001 XXX 0 X 47.38 X
96902     XXX 9 X * X
96904   002 XXX 0 X 115.59 X
96904   001 XXX 0 X 141.66 X
96904   004 XXX 0 X 115.59 X
96904   003 XXX 0 X 115.59 X
96910   004 XXX 0 X 55.92 X
96910   002 XXX 0 X 61.82 X
96910   003 XXX 0 X 56.75 X
96910   001 XXX 0 X 62.93 X
96912   001 XXX 0 X 70.79 X
96912   004 XXX 0 X 64.28 X
96912   003 XXX 0 X 65.30 X
96912   002 XXX 0 X 68.45 X
96913   003 XXX 0 X 96.19 X
96913   004 XXX 0 X 95.00 X
96913   002 XXX 0 X 101.07 X
96913   001 XXX 0 X 102.27 X
96920   002 0 2 X 316.86 132.63
96920   001 0 2 X 363.04 146.49
96920   004 0 2 X 316.86 132.63
96920   003 0 2 X 316.86 132.63
96921   001 0 2 X 371.89 149.06
96921   003 0 2 X 324.54 134.99
96921   004 0 2 X 324.54 134.99
96921   002 0 2 X 324.54 134.99
96922   004 0 2 X 449.54 241.78
96922   002 0 2 X 449.54 241.78
96922   001 0 2 X 511.09 266.84
96922   003 0 2 X 449.54 241.78
96931     XXX 0 X * X
96932     XXX 0 X * X
96933     XXX 0 X * X
96934     ZZZ 0 X * X
96935     ZZZ 0 X * X
96936     ZZZ 0 X * X
96999     XXX 0 X # X
97010   003 XXX 9 X 43.38 X
97010   002 XXX 9 X 46.03 X
97010   001 XXX 9 X 46.66 X
97010   004 XXX 9 X 43.46 X
97012   004 XXX 5 X 49.90 X
97012   003 XXX 5 X 45.12 X
97012   002 XXX 5 X 48.24 X
97012   001 XXX 5 X 48.04 X
97014   001 XXX 9 X 44.86 X
97014   004 XXX 9 X 46.58 X
97014   003 XXX 9 X 43.60 X
97014   002 XXX 9 X 42.95 X
97016   001 XXX 5 X 50.64 X
97016   004 XXX 5 X 46.31 X
97016   003 XXX 5 X 53.70 X
97016   002 XXX 5 X 50.06 X