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2024 Workers' Compensation Part B Fee Schedule

11644-15278

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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
11644   001 10 2 X 930.78 X
11644   003 10 2 X 870.20 X
11644   002 10 2 X 919.07 X
11644   004 10 2 X 889.49 X
11646   001 10 2 X 1,214.05 X
11646   004 10 2 X 1,113.00 X
11646   002 10 2 X 1,196.92 X
11646   003 10 2 X 1,126.16 X
11719   004 0 2 X 32.25 15.90
11719   001 0 2 X 36.97 17.79
11719   003 0 2 X 32.25 15.90
11719   002 0 2 X 32.25 15.90
11720   001 0 0 X 76.77 57.36
11720   003 0 0 X 67.76 51.21
11720   002 0 0 X 69.61 52.70
11720   004 0 0 X 67.76 51.21
11721   004 0 0 X 114.20 86.49
11721   001 0 0 X 129.48 96.68
11721   003 0 0 X 114.20 86.49
11721   002 0 0 X 117.36 88.85
11730   004 0 2 X 146.05 126.32
11730   001 0 2 X 159.87 138.20
11730   002 0 2 X 161.74 139.94
11730   003 0 2 X 139.07 120.10
11732   001 ZZZ 0 X 71.44 57.98
11732   003 ZZZ 0 X 67.17 54.59
11732   002 ZZZ 0 X 70.66 57.27
11732   004 ZZZ 0 X 66.35 53.99
11740   004 0 2 X 86.22 65.57
11740   002 0 2 X 103.02 78.37
11740   003 0 2 X 101.74 77.28
11740   001 0 2 X 88.92 67.75
11750   001 10 2 X 442.48 327.84
11750   003 10 2 X 498.70 369.51
11750   002 10 2 X 456.77 338.72
11750   004 10 2 X 404.83 299.75
11755   002 0 2 X 267.16 X
11755   003 0 2 X 251.98 X
11755   004 0 2 X 249.04 X
11755   001 0 2 X 270.81 X
11760   002 10 2 X 216.92 178.74
11760   003 10 2 X 208.97 172.44
11760   004 10 2 X 207.24 170.62
11760   001 10 2 X 215.74 177.22
11762   002 10 2 X 466.25 362.89
11762   003 10 2 X 441.51 342.83
11762   004 10 2 X 445.37 346.11
11762   001 10 2 X 474.07 367.74
11765   001 10 2 X 179.14 141.39
11765   003 10 2 X 171.95 135.79
11765   002 10 2 X 143.05 112.92
11765   004 10 2 X 169.25 133.76
11770   001 10 2 X 977.69 X
11770   003 10 2 X 863.88 X
11770   002 10 2 X 674.36 X
11770   004 10 2 X 804.49 X
11771   001 90 2 X 1,211.85 X
11771   004 90 2 X 1,092.63 X
11771   002 90 2 X 1,222.79 X
11771   003 90 2 X 1,105.41 X
11772   004 90 2 X 1,258.70 X
11772   002 90 2 X 1,368.10 X
11772   003 90 2 X 1,261.15 X
11772   001 90 2 X 1,391.19 X
11900   004 0 2 X 81.98 69.63
11900   002 0 2 X 86.77 73.35
11900   003 0 2 X 82.93 70.34
11900   001 0 2 X 87.72 74.17
11901   001 0 2 X 136.95 114.81
11901   004 0 2 X 128.02 107.72
11901   003 0 2 X 129.47 108.83
11901   002 0 2 X 135.44 113.67
11920     0 2 X * X
11921     0 2 X * X
11922     ZZZ 0 X * X
11950     0 2 X * X
11951     0 2 X * X
11952     0 2 X * X
11954     0 2 X * X
11960   001 90 2 X 1,755.22 X
11960   004 90 2 X 1,568.29 X
11960   003 90 2 X 1,587.45 X
11960   002 90 2 X 1,722.48 X
11970   004 90 2 X 1,722.71 X
11970   002 90 2 X 2,339.47 X
11970   003 90 2 X 1,743.84 X
11970   001 90 2 X 1,927.03 X
11971   001 90 2 X 730.12 X
11971   003 90 2 X 891.33 X
11971   002 90 2 X 920.22 X
11971   004 90 2 X 637.93 X
11976     0 2 X * X
11980   004 0 2 X 261.14 185.17
11980   001 0 2 X 292.40 203.48
11980   002 0 2 X 261.14 185.17
11980   003 0 2 X 261.14 185.17
11981   003 0 2 X 249.04 173.68
11981   002 0 2 X 249.04 173.68
11981   004 0 2 X 249.04 173.68
11981   001 0 2 X 281.52 193.01
11982   004 0 2 X 284.39 209.02
11982   001 0 2 X 320.94 232.37
11982   003 0 2 X 284.39 209.02
11982   002 0 2 X 284.39 209.02
11983   002 0 2 X 462.81 387.43
11983   003 0 2 X 462.81 387.43
11983   001 0 2 X 519.03 430.50
11983   004 0 2 X 462.81 387.43
12001   004 0 2 X 194.03 X
12001   002 0 2 X 213.88 X
12001   003 0 2 X 192.28 X
12001   001 0 2 X 218.29 X
12002   004 0 2 X 259.30 X
12002   001 0 2 X 269.33 X
12002   003 0 2 X 262.17 X
12002   002 0 2 X 272.65 X
12004   003 0 2 X 373.90 X
12004   002 0 2 X 381.40 X
12004   001 0 2 X 306.86 X
12004   004 0 2 X 380.71 X
12005   004 0 2 X 467.06 X
12005   003 0 2 X 480.13 X
12005   002 0 2 X 485.11 X
12005   001 0 2 X 491.61 X
12006   001 0 2 X 582.19 X
12006   004 0 2 X 549.57 X
12006   003 0 2 X 548.01 X
12006   002 0 2 X 575.56 X
12007   002 0 2 X 666.60 X
12007   003 0 2 X 635.98 X
12007   004 0 2 X 628.87 X
12007   001 0 2 X 674.00 X
12011   004 0 2 X 208.90 X
12011   002 0 2 X 230.44 X
12011   003 0 2 X 209.32 X
12011   001 0 2 X 238.77 X
12013   004 0 2 X 285.04 X
12013   001 0 2 X 284.25 X
12013   003 0 2 X 301.33 X
12013   002 0 2 X 299.27 X
12014   002 0 2 X 335.23 X
12014   003 0 2 X 343.49 X
12014   004 0 2 X 314.87 X
12014   001 0 2 X 317.31 X
12015   003 0 2 X 479.94 X
12015   002 0 2 X 510.15 X
12015   004 0 2 X 517.95 X
12015   001 0 2 X 397.85 X
12016   004 0 2 X 612.68 X
12016   001 0 2 X 835.54 X
12016   003 0 2 X 685.03 X
12016   002 0 2 X 770.91 X
12017   001 0 2 X 869.13 X
12017   004 0 2 X 982.64 X
12017   002 0 2 X 1,005.35 X
12017   003 0 2 X 814.01 X
12018   004 0 2 X 1,144.07 X
12018   003 0 2 X 1,158.28 X
12018   002 0 2 X 1,227.37 X
12018   001 0 2 X 1,243.94 X
12020   003 10 2 X 436.95 X
12020   002 10 2 X 448.70 X
12020   004 10 2 X 461.35 X
12020   001 10 2 X 440.81 X
12021   002 10 2 X 574.43 X
12021   003 10 2 X 521.44 X
12021   004 10 2 X 500.42 X
12021   001 10 2 X 574.12 X
12031   002 10 2 X 267.34 X
12031   003 10 2 X 249.36 X
12031   001 10 2 X 276.43 X
12031   004 10 2 X 245.04 X
12032   002 10 2 X 336.71 X
12032   003 10 2 X 328.70 X
12032   001 10 2 X 306.78 X
12032   004 10 2 X 320.06 X
12034   004 10 2 X 465.11 X
12034   002 10 2 X 496.11 X
12034   003 10 2 X 470.43 X
12034   001 10 2 X 405.88 X
12035   004 10 2 X 572.17 X
12035   002 10 2 X 610.24 X
12035   001 10 2 X 617.86 X
12035   003 10 2 X 578.78 X
12036   001 10 2 X 746.03 X
12036   002 10 2 X 731.83 X
12036   003 10 2 X 706.45 X
12036   004 10 2 X 692.03 X
12037   002 10 2 X 910.55 X
12037   003 10 2 X 856.34 X
12037   004 10 2 X 846.52 X
12037   001 10 2 X 923.81 X
12041   001 10 2 X 286.45 X
12041   003 10 2 X 254.46 X
12041   002 10 2 X 273.35 X
12041   004 10 2 X 247.89 X
12042   003 10 2 X 361.07 X
12042   002 10 2 X 356.58 X
12042   001 10 2 X 360.01 X
12042   004 10 2 X 337.05 X
12044   001 10 2 X 341.40 X
12044   004 10 2 X 472.53 X
12044   002 10 2 X 502.39 X
12044   003 10 2 X 478.00 X
12045   001 10 2 X 620.79 X
12045   004 10 2 X 575.45 X
12045   002 10 2 X 613.26 X
12045   003 10 2 X 582.11 X
12046   004 10 2 X 763.40 X
12046   001 10 2 X 829.31 X
12046   002 10 2 X 818.15 X
12046   003 10 2 X 774.59 X
12047   002 10 2 X 955.73 X
12047   003 10 2 X 896.03 X
12047   001 10 2 X 970.12 X
12047   004 10 2 X 885.37 X
12051   001 10 2 X 336.13 X
12051   004 10 2 X 287.98 X
12051   003 10 2 X 301.97 X
12051   002 10 2 X 319.24 X
12052   002 10 2 X 423.46 X
12052   003 10 2 X 405.17 X
12052   004 10 2 X 386.28 X
12052   001 10 2 X 415.54 X
12053   001 10 2 X 477.51 X
12053   003 10 2 X 466.65 X
12053   002 10 2 X 443.16 X
12053   004 10 2 X 428.53 X
12054   001 10 2 X 802.07 X
12054   003 10 2 X 653.58 X
12054   002 10 2 X 690.21 X
12054   004 10 2 X 645.79 X
12055   004 10 2 X 824.71 X
12055   003 10 2 X 834.64 X
12055   002 10 2 X 883.44 X
12055   001 10 2 X 895.24 X
12056   003 10 2 X 1,089.74 X
12056   001 10 2 X 1,173.83 X
12056   002 10 2 X 1,157.45 X
12056   004 10 2 X 1,076.48 X
12057   001 10 2 X 1,336.96 X
12057   003 10 2 X 1,246.79 X
12057   002 10 2 X 1,319.49 X
12057   004 10 2 X 1,231.53 X
13100   002 10 2 X 416.83 X
13100   003 10 2 X 399.11 X
13100   004 10 2 X 395.27 X
13100   001 10 2 X 423.79 X
13101   003 10 2 X 562.91 X
13101   002 10 2 X 585.36 X
13101   004 10 2 X 562.30 X
13101   001 10 2 X 589.94 X
13102   002 ZZZ 0 X 173.85 162.21
13102   003 ZZZ 0 X 173.85 162.21
13102   001 ZZZ 0 X 191.90 178.24
13102   004 ZZZ 0 X 173.85 162.21
13120   003 10 2 X 421.22 X
13120   002 10 2 X 448.56 X
13120   004 10 2 X 431.62 X
13120   001 10 2 X 452.37 X
13121   003 10 2 X 651.15 X
13121   002 10 2 X 690.38 X
13121   001 10 2 X 696.29 X
13121   004 10 2 X 659.78 X
13122   003 ZZZ 0 X 202.18 188.01
13122   002 ZZZ 0 X 202.18 188.01
13122   004 ZZZ 0 X 202.18 188.01
13122   001 ZZZ 0 X 223.05 206.47
13131   003 10 2 X 548.55 X
13131   002 10 2 X 572.48 X
13131   001 10 2 X 571.83 X
13131   004 10 2 X 512.42 X
13132   001 10 2 X 918.08 X
13132   004 10 2 X 864.75 X
13132   003 10 2 X 871.54 X
13132   002 10 2 X 908.94 X
13133   002 ZZZ 0 X 299.67 285.44
13133   003 ZZZ 0 X 299.67 285.44
13133   001 ZZZ 0 X 329.37 312.77
13133   004 ZZZ 0 X 299.67 285.44
13151   001 10 2 X 787.99 X
13151   004 10 2 X 752.42 X
13151   002 10 2 X 780.55 X
13151   003 10 2 X 757.21 X
13152   004 10 2 X 1,247.40 X
13152   002 10 2 X 1,343.01 X
13152   003 10 2 X 1,262.28 X
13152   001 10 2 X 1,362.54 X
13153   004 ZZZ 0 X 329.06 310.72
13153   001 ZZZ 0 X 362.73 341.27
13153   002 ZZZ 0 X 329.06 310.72
13153   003 ZZZ 0 X 329.06 310.72
13160   001 90 2 X 1,456.25 X
13160   004 90 2 X 1,396.20 X
13160   003 90 2 X 1,398.95 X
13160   002 90 2 X 1,450.80 X
14000   001 90 2 X 1,029.91 X
14000   004 90 2 X 952.92 X
14000   002 90 2 X 1,017.15 X
14000   003 90 2 X 964.06 X
14001   004 90 2 X 1,375.19 X
14001   002 90 2 X 1,477.10 X
14001   003 90 2 X 1,391.01 X
14001   001 90 2 X 1,446.86 X
14020   001 90 2 X 1,283.52 X
14020   002 90 2 X 1,266.68 X
14020   003 90 2 X 1,197.16 X
14020   004 90 2 X 1,182.80 X
14021   001 90 2 X 1,861.02 X
14021   004 90 2 X 1,707.25 X
14021   003 90 2 X 1,871.99 X
14021   002 90 2 X 1,902.11 X
14040   002 90 2 X 1,844.67 X
14040   003 90 2 X 1,799.73 X
14040   001 90 2 X 1,780.43 X
14040   004 90 2 X 1,836.36 X
14041   004 90 2 X 2,027.80 X
14041   001 90 2 X 2,232.76 X
14041   003 90 2 X 2,051.76 X
14041   002 90 2 X 2,177.12 X
14060   001 90 2 X 1,999.58 X
14060   004 90 2 X 1,978.26 X
14060   003 90 2 X 2,038.29 X
14060   002 90 2 X 2,113.91 X
14061   004 90 2 X 2,387.39 X
14061   003 90 2 X 2,416.65 X
14061   002 90 2 X 2,571.58 X
14061   001 90 2 X 2,608.95 X
14301   003 90 2 X 1,754.59 1,495.73
14301   002 90 2 X 1,754.59 1,495.73
14301   004 90 2 X 1,754.59 1,495.73
14301   001 90 2 X 1,982.55 1,675.50
14302   001 ZZZ 0 X 434.45 X
14302   004 ZZZ 0 X 390.69 X
14302   002 ZZZ 0 X 390.69 X
14302   003 ZZZ 0 X 390.69 X
14350   001 90 2 X 1,822.08 X
14350   003 90 2 X 1,690.97 X
14350   002 90 2 X 1,759.67 X
14350   004 90 2 X 1,671.70 X
15002   002 0 0 X 509.39 355.02
15002   003 0 0 X 509.39 355.02
15002   001 0 0 X 591.74 402.85
15002   004 0 0 X 509.39 355.02
15003   003 ZZZ 0 X 112.93 72.94
15003   002 ZZZ 0 X 112.93 72.94
15003   004 ZZZ 0 X 112.93 72.94
15003   001 ZZZ 0 X 131.32 82.37
15004   002 0 0 X 614.75 439.74
15004   003 0 0 X 614.75 439.74
15004   004 0 0 X 614.75 439.74
15004   001 0 0 X 712.73 498.59
15005   003 ZZZ 0 X 190.87 145.88
15005   002 ZZZ 0 X 190.87 145.88
15005   004 ZZZ 0 X 190.87 145.88
15005   001 ZZZ 0 X 219.79 164.72
15040   001 0 0 X 538.81 262.65
15040   004 0 0 X 459.26 233.63
15040   002 0 0 X 459.26 233.63
15040   003 0 0 X 459.26 233.63
15050   003 90 2 X 1,087.00 X
15050   002 90 2 X 1,111.06 X
15050   004 90 2 X 1,082.26 X
15050   001 90 2 X 1,133.81 X
15100   003 90 2 X 1,813.26 X
15100   002 90 2 X 1,851.75 X
15100   004 90 2 X 1,806.62 X
15100   001 90 2 X 1,861.12 X
15101   002 ZZZ 0 X 1,390.60 X
15101   003 ZZZ 0 X 1,367.77 X
15101   004 ZZZ 0 X 1,378.10 X
15101   001 ZZZ 0 X 1,388.88 X
15110   003 90 2 X 1,469.36 1,228.00
15110   002 90 2 X 1,469.36 1,228.00
15110   004 90 2 X 1,469.36 1,228.00
15110   001 90 2 X 1,692.84 1,397.39
15111   001 ZZZ 0 X 266.42 226.30
15111   004 ZZZ 0 X 234.36 201.59
15111   002 ZZZ 0 X 234.36 201.59
15111   003 ZZZ 0 X 234.36 201.59
15115   003 90 2 X 1,387.40 1,264.12
15115   002 90 2 X 1,387.40 1,264.12
15115   001 90 2 X 1,583.19 1,432.27
15115   004 90 2 X 1,387.40 1,264.12
15116   004 ZZZ 0 X 304.77 274.56
15116   002 ZZZ 0 X 304.77 274.56
15116   003 ZZZ 0 X 304.77 274.56
15116   001 ZZZ 0 X 344.80 307.86
15120   002 90 2 X 2,748.14 X
15120   003 90 2 X 2,703.56 X
15120   004 90 2 X 2,695.44 X
15120   001 90 2 X 2,758.92 X
15121   004 ZZZ 0 X 2,139.11 X
15121   001 ZZZ 0 X 2,168.75 X
15121   003 ZZZ 0 X 636.58 X
15121   002 ZZZ 0 X 2,163.57 X
15130   001 90 2 X 1,408.84 1,125.47
15130   004 90 2 X 1,214.52 982.99
15130   003 90 2 X 1,214.52 982.99
15130   002 90 2 X 1,214.52 982.99
15131   004 ZZZ 0 X 191.56 163.34
15131   001 ZZZ 0 X 217.87 183.35
15131   002 ZZZ 0 X 191.56 163.34
15131   003 ZZZ 0 X 191.56 163.34
15135   001 90 2 X 1,694.38 1,553.98
15135   004 90 2 X 1,484.91 1,370.13
15135   002 90 2 X 1,484.91 1,370.13
15135   003 90 2 X 1,484.91 1,370.13
15136   002 ZZZ 0 X 179.14 164.72
15136   003 ZZZ 0 X 179.14 164.72
15136   004 ZZZ 0 X 179.14 164.72
15136   001 ZZZ 0 X 202.44 184.77
15150   001 90 2 X 1,405.13 1,242.97
15150   004 90 2 X 1,222.90 1,090.41
15150   002 90 2 X 1,222.90 1,090.41
15150   003 90 2 X 1,222.90 1,090.41
15151   002 ZZZ 0 X 247.80 217.58
15151   003 ZZZ 0 X 247.80 217.58
15151   004 ZZZ 0 X 247.80 217.58
15151   001 ZZZ 0 X 281.12 244.24
15152   001 ZZZ 0 X 345.20 305.06
15152   004 ZZZ 0 X 304.63 271.80
15152   003 ZZZ 0 X 304.63 271.80
15152   002 ZZZ 0 X 304.63 271.80
15155   004 90 2 X 1,230.17 1,173.76
15155   002 90 2 X 1,230.17 1,173.76
15155   003 90 2 X 1,230.17 1,173.76
15155   001 90 2 X 1,400.11 1,331.04
15156   001 ZZZ 0 X 364.70 338.98
15156   003 ZZZ 0 X 323.39 302.38
15156   002 ZZZ 0 X 323.39 302.38
15156   004 ZZZ 0 X 323.39 302.38
15157   003 ZZZ 0 X 357.71 329.54
15157   002 ZZZ 0 X 357.71 329.54
15157   004 ZZZ 0 X 357.71 329.54
15157   001 ZZZ 0 X 403.80 369.31
15200   001 90 2 X 1,383.67 X
15200   004 90 2 X 1,746.50 X
15200   002 90 2 X 1,774.61 X
15200   003 90 2 X 1,667.22 X
15201   004 ZZZ 0 X 435.77 X
15201   002 ZZZ 0 X 484.01 X
15201   003 ZZZ 0 X 441.23 X
15201   001 ZZZ 0 X 494.44 X
15220   004 90 2 X 1,801.45 X
15220   003 90 2 X 1,810.93 X
15220   002 90 2 X 1,894.48 X
15220   001 90 2 X 1,883.63 X
15221   003 ZZZ 0 X 422.56 X
15221   002 ZZZ 0 X 1,347.98 X
15221   004 ZZZ 0 X 417.27 X
15221   001 ZZZ 0 X 1,352.33 X
15240   004 90 2 X 1,815.74 X
15240   001 90 2 X 1,880.20 X
15240   003 90 2 X 1,783.94 X
15240   002 90 2 X 1,865.20 X
15241   003 ZZZ 0 X 1,471.32 X
15241   002 ZZZ 0 X 1,493.26 X
15241   004 ZZZ 0 X 1,468.24 X
15241   001 ZZZ 0 X 1,498.53 X
15260   001 90 2 X 2,077.32 X
15260   004 90 2 X 2,008.82 X
15260   002 90 2 X 2,065.56 X
15260   003 90 2 X 2,011.48 X
15261   001 ZZZ 0 X 1,099.78 X
15261   002 ZZZ 0 X 1,188.49 X
15261   003 ZZZ 0 X 1,051.51 X
15261   004 ZZZ 0 X 689.67 X
15271   001 0 2 X 261.85 161.00
15271   004 0 2 X 232.62 145.64
15271   002 0 2 X 232.62 145.64
15271   003 0 2 X 232.62 145.64
15272   002 ZZZ 0 X 44.02 28.84
15272   003 ZZZ 0 X 44.02 28.84
15272   001 ZZZ 0 X 49.05 31.43
15272   004 ZZZ 0 X 44.02 28.84
15273   002 0 2 X 481.20 347.13
15273   003 0 2 X 481.20 347.13
15273   004 0 2 X 481.20 347.13
15273   001 0 2 X 540.28 384.74
15274   002 ZZZ 0 X 112.57 73.29
15274   003 ZZZ 0 X 112.57 73.29
15274   004 ZZZ 0 X 112.57 73.29
15274   001 ZZZ 0 X 125.74 80.19
15275   001 0 2 X 281.78 187.01
15275   004 0 2 X 251.21 169.52
15275   002 0 2 X 251.21 169.52
15275   003 0 2 X 251.21 169.52
15276   004 ZZZ 0 X 55.10 41.48
15276   001 ZZZ 0 X 60.80 45.01
15276   003 ZZZ 0 X 55.10 41.48
15276   002 ZZZ 0 X 55.10 41.48
15277   004 0 2 X 485.97 359.73
15277   001 0 2 X 541.07 394.62
15277   003 0 2 X 485.97 359.73
15277   002 0 2 X 485.97 359.73
15278   001 ZZZ 0 X 148.08 99.46
15278   004 ZZZ 0 X 132.80 90.90
15278   003 ZZZ 0 X 132.80 90.90
15278   002 ZZZ 0 X 132.80 90.90