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2021 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   3 10 2 X 742.60 X
11644   4 10 2 X 759.06 X
11644   2 10 2 X 784.30 X
11644   1 10 2 X 794.30 X
11646   4 10 2 X 949.79 X
11646   3 10 2 X 961.03 X
11646   2 10 2 X 1,021.41 X
11646   1 10 2 X 1,036.03 X
11719   2 0 2 X 27.52 13.57
11719   3 0 2 X 27.52 13.57
11719   4 0 2 X 27.52 13.57
11719   1 0 2 X 31.55 15.19
11720   3 0 0 X 57.82 43.70
11720   4 0 0 X 57.82 43.70
11720   2 0 0 X 59.40 44.97
11720   1 0 0 X 65.52 48.95
11721   3 0 0 X 97.46 73.81
11721   4 0 0 X 97.46 73.81
11721   2 0 0 X 100.15 75.82
11721   1 0 0 X 110.50 82.50
11730   3 0 2 X 118.68 102.49
11730   4 0 2 X 124.63 107.80
11730   1 0 2 X 136.43 117.93
11730   2 0 2 X 138.02 119.42
11732   4 ZZZ 0 X 56.62 46.07
11732   3 ZZZ 0 X 57.33 46.59
11732   2 ZZZ 0 X 60.30 48.87
11732   1 ZZZ 0 X 60.97 49.47
11740   4 0 2 X 73.57 55.96
11740   1 0 2 X 75.88 57.81
11740   3 0 2 X 86.82 65.95
11740   2 0 2 X 87.92 66.89
11750   4 10 2 X 345.47 255.80
11750   1 10 2 X 377.60 279.77
11750   2 10 2 X 389.79 289.05
11750   3 10 2 X 425.57 315.33
11755   4 0 2 X 212.52 X
11755   3 0 2 X 215.03 X
11755   2 0 2 X 227.98 X
11755   1 0 2 X 231.10 X
11760   4 10 2 X 176.85 145.60
11760   3 10 2 X 178.32 147.16
11760   1 10 2 X 184.10 151.23
11760   2 10 2 X 185.11 152.53
11762   3 10 2 X 376.77 292.55
11762   4 10 2 X 380.07 295.36
11762   2 10 2 X 397.88 309.67
11762   1 10 2 X 404.56 313.82
11765   2 10 2 X 122.07 96.36
11765   4 10 2 X 144.43 114.15
11765   3 10 2 X 146.74 115.88
11765   1 10 2 X 152.87 120.66
11770   2 10 2 X 575.47 X
11770   4 10 2 X 686.53 X
11770   3 10 2 X 737.20 X
11770   1 10 2 X 834.32 X
11771   4 90 2 X 932.41 X
11771   3 90 2 X 943.31 X
11771   1 90 2 X 1,034.15 X
11771   2 90 2 X 1,043.49 X
11772   4 90 2 X 1,074.13 X
11772   3 90 2 X 1,076.22 X
11772   2 90 2 X 1,167.49 X
11772   1 90 2 X 1,187.19 X
11900   4 0 2 X 69.96 59.42
11900   3 0 2 X 70.77 60.02
11900   2 0 2 X 74.04 62.60
11900   1 0 2 X 74.86 63.29
11901   4 0 2 X 109.25 91.92
11901   3 0 2 X 110.49 92.87
11901   2 0 2 X 115.58 97.01
11901   1 0 2 X 116.87 97.97
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   4 90 2 X 1,338.32 X
11960   3 90 2 X 1,354.67 X
11960   2 90 2 X 1,469.91 X
11960   1 90 2 X 1,497.84 X
11970   4 90 2 X 1,470.09 X
11970   3 90 2 X 1,488.13 X
11970   1 90 2 X 1,644.46 X
11970   2 90 2 X 1,996.42 X
11971   4 90 2 X 544.38 X
11971   1 90 2 X 623.06 X
11971   3 90 2 X 760.63 X
11971   2 90 2 X 785.28 X
11976     XXX 2 X * X
11980   2 0 2 X 222.85 158.02
11980   3 0 2 X 222.85 158.02
11980   4 0 2 X 222.85 158.02
11980   1 0 2 X 249.52 173.64
11981   2 XXX 2 X 212.52 148.21
11981   3 XXX 2 X 212.52 148.21
11981   4 XXX 2 X 212.52 148.21
11981   1 XXX 2 X 240.23 164.71
11982   2 XXX 2 X 242.68 178.37
11982   3 XXX 2 X 242.68 178.37
11982   4 XXX 2 X 242.68 178.37
11982   1 XXX 2 X 273.88 198.29
11983   2 XXX 2 X 394.94 330.62
11983   3 XXX 2 X 394.94 330.62
11983   4 XXX 2 X 394.94 330.62
11983   1 XXX 2 X 442.93 367.37
12001   3 10 2 X 164.08 X
12001   4 10 2 X 165.58 X
12001   2 10 2 X 182.51 X
12001   1 10 2 X 186.28 X
12002   4 10 2 X 221.28 X
12002   3 10 2 X 223.73 X
12002   1 10 2 X 229.83 X
12002   2 10 2 X 232.66 X
12004   1 10 2 X 261.87 X
12004   3 10 2 X 319.07 X
12004   4 10 2 X 324.89 X
12004   2 10 2 X 325.47 X
12005   4 10 2 X 398.57 X
12005   3 10 2 X 409.72 X
12005   2 10 2 X 413.98 X
12005   1 10 2 X 419.52 X
12006   3 10 2 X 467.65 X
12006   4 10 2 X 468.98 X
12006   2 10 2 X 491.16 X
12006   1 10 2 X 496.82 X
12007   4 10 2 X 536.65 X
12007   3 10 2 X 542.72 X
12007   2 10 2 X 568.86 X
12007   1 10 2 X 575.17 X
12011   4 10 2 X 178.27 X
12011   3 10 2 X 178.63 X
12011   2 10 2 X 196.65 X
12011   1 10 2 X 203.76 X
12013   1 10 2 X 242.57 X
12013   4 10 2 X 243.25 X
12013   2 10 2 X 255.38 X
12013   3 10 2 X 257.15 X
12014   4 10 2 X 268.70 X
12014   1 10 2 X 270.79 X
12014   2 10 2 X 286.08 X
12014   3 10 2 X 293.12 X
12015   1 10 2 X 339.51 X
12015   3 10 2 X 409.56 X
12015   2 10 2 X 435.35 X
12015   4 10 2 X 442.00 X
12016   4 10 2 X 522.84 X
12016   3 10 2 X 584.58 X
12016   2 10 2 X 657.87 X
12016   1 10 2 X 713.02 X
12017   3 10 2 X 694.64 X
12017   1 10 2 X 741.68 X
12017   4 10 2 X 838.56 X
12017   2 10 2 X 857.93 X
12018   4 10 2 X 976.31 X
12018   3 10 2 X 988.43 X
12018   2 10 2 X 1,047.39 X
12018   1 10 2 X 1,061.54 X
12020   3 10 2 X 372.87 X
12020   1 10 2 X 376.17 X
12020   2 10 2 X 382.90 X
12020   4 10 2 X 393.71 X
12021   4 10 2 X 427.04 X
12021   3 10 2 X 444.97 X
12021   1 10 2 X 489.93 X
12021   2 10 2 X 490.20 X
12031   4 10 2 X 209.11 X
12031   3 10 2 X 212.80 X
12031   2 10 2 X 228.14 X
12031   1 10 2 X 235.90 X
12032   1 10 2 X 261.79 X
12032   4 10 2 X 273.12 X
12032   3 10 2 X 280.51 X
12032   2 10 2 X 287.34 X
12034   1 10 2 X 346.36 X
12034   4 10 2 X 396.90 X
12034   3 10 2 X 401.45 X
12034   2 10 2 X 423.37 X
12035   4 10 2 X 488.26 X
12035   3 10 2 X 493.91 X
12035   2 10 2 X 520.76 X
12035   1 10 2 X 527.26 X
12036   4 10 2 X 590.55 X
12036   3 10 2 X 602.86 X
12036   2 10 2 X 624.51 X
12036   1 10 2 X 636.64 X
12037   4 10 2 X 722.39 X
12037   3 10 2 X 730.77 X
12037   2 10 2 X 777.04 X
12037   1 10 2 X 788.35 X
12041   4 10 2 X 211.55 X
12041   3 10 2 X 217.15 X
12041   2 10 2 X 233.27 X
12041   1 10 2 X 244.45 X
12042   4 10 2 X 287.63 X
12042   2 10 2 X 304.30 X
12042   1 10 2 X 307.21 X
12042   3 10 2 X 308.12 X
12044   1 10 2 X 291.34 X
12044   4 10 2 X 403.25 X
12044   3 10 2 X 407.91 X
12044   2 10 2 X 428.72 X
12045   4 10 2 X 491.07 X
12045   3 10 2 X 496.75 X
12045   2 10 2 X 523.33 X
12045   1 10 2 X 529.76 X
12046   4 10 2 X 651.46 X
12046   3 10 2 X 661.01 X
12046   2 10 2 X 698.18 X
12046   1 10 2 X 707.70 X
12047   4 10 2 X 755.54 X
12047   3 10 2 X 764.64 X
12047   2 10 2 X 815.58 X
12047   1 10 2 X 827.87 X
12051   4 10 2 X 245.75 X
12051   3 10 2 X 257.69 X
12051   2 10 2 X 272.43 X
12051   1 10 2 X 286.84 X
12052   4 10 2 X 329.63 X
12052   3 10 2 X 345.76 X
12052   1 10 2 X 354.61 X
12052   2 10 2 X 361.36 X
12053   4 10 2 X 365.69 X
12053   2 10 2 X 378.18 X
12053   3 10 2 X 398.22 X
12053   1 10 2 X 407.49 X
12054   4 10 2 X 551.09 X
12054   3 10 2 X 557.74 X
12054   2 10 2 X 589.00 X
12054   1 10 2 X 684.46 X
12055   4 10 2 X 703.78 X
12055   3 10 2 X 712.25 X
12055   2 10 2 X 753.89 X
12055   1 10 2 X 763.97 X
12056   4 10 2 X 918.63 X
12056   3 10 2 X 929.94 X
12056   2 10 2 X 987.72 X
12056   1 10 2 X 1,001.70 X
12057   4 10 2 X 1,050.94 X
12057   3 10 2 X 1,063.97 X
12057   2 10 2 X 1,126.00 X
12057   1 10 2 X 1,140.92 X
13100   4 10 2 X 337.31 X
13100   3 10 2 X 340.59 X
13100   2 10 2 X 355.71 X
13100   1 10 2 X 361.65 X
13101   4 10 2 X 479.84 X
13101   3 10 2 X 480.37 X
13101   2 10 2 X 499.53 X
13101   1 10 2 X 503.43 X
13102   2 ZZZ 0 X 148.36 138.42
13102   3 ZZZ 0 X 148.36 138.42
13102   4 ZZZ 0 X 148.36 138.42
13102   1 ZZZ 0 X 163.76 152.10
13120   3 10 2 X 359.46 X
13120   4 10 2 X 368.33 X
13120   2 10 2 X 382.79 X
13120   1 10 2 X 386.03 X
13121   3 10 2 X 555.68 X
13121   4 10 2 X 563.03 X
13121   2 10 2 X 589.15 X
13121   1 10 2 X 594.19 X
13122   2 ZZZ 0 X 172.53 160.44
13122   3 ZZZ 0 X 172.53 160.44
13122   4 ZZZ 0 X 172.53 160.44
13122   1 ZZZ 0 X 190.34 176.19
13131   4 10 2 X 437.28 X
13131   3 10 2 X 468.11 X
13131   1 10 2 X 487.98 X
13131   2 10 2 X 488.54 X
13132   4 10 2 X 737.95 X
13132   3 10 2 X 743.74 X
13132   2 10 2 X 775.66 X
13132   1 10 2 X 783.46 X
13133   2 ZZZ 0 X 255.72 243.58
13133   3 ZZZ 0 X 255.72 243.58
13133   4 ZZZ 0 X 255.72 243.58
13133   1 ZZZ 0 X 281.07 266.90
13151   4 10 2 X 642.09 X
13151   3 10 2 X 646.18 X
13151   2 10 2 X 666.10 X
13151   1 10 2 X 672.44 X
13152   4 10 2 X 1,064.48 X
13152   3 10 2 X 1,077.19 X
13152   2 10 2 X 1,146.08 X
13152   1 10 2 X 1,162.74 X
13153   2 ZZZ 0 X 280.81 265.16
13153   3 ZZZ 0 X 280.81 265.16
13153   4 ZZZ 0 X 280.81 265.16
13153   1 ZZZ 0 X 309.54 291.22
13160   4 90 2 X 1,191.46 X
13160   3 90 2 X 1,193.81 X
13160   2 90 2 X 1,238.06 X
13160   1 90 2 X 1,242.71 X
14000   4 90 2 X 813.19 X
14000   3 90 2 X 822.69 X
14000   2 90 2 X 868.00 X
14000   1 90 2 X 878.89 X
14001   4 90 2 X 1,173.54 X
14001   3 90 2 X 1,187.04 X
14001   1 90 2 X 1,234.70 X
14001   2 90 2 X 1,260.51 X
14020   4 90 2 X 1,009.36 X
14020   3 90 2 X 1,021.61 X
14020   2 90 2 X 1,080.94 X
14020   1 90 2 X 1,095.31 X
14021   4 90 2 X 1,456.91 X
14021   1 90 2 X 1,588.12 X
14021   3 90 2 X 1,597.49 X
14021   2 90 2 X 1,623.19 X
14040   1 90 2 X 1,519.35 X
14040   3 90 2 X 1,535.83 X
14040   4 90 2 X 1,567.08 X
14040   2 90 2 X 1,574.17 X
14041   4 90 2 X 1,730.45 X
14041   3 90 2 X 1,750.90 X
14041   2 90 2 X 1,857.87 X
14041   1 90 2 X 1,905.36 X
14060   4 90 2 X 1,688.17 X
14060   1 90 2 X 1,706.37 X
14060   3 90 2 X 1,739.40 X
14060   2 90 2 X 1,803.94 X
14061   4 90 2 X 2,037.32 X
14061   3 90 2 X 2,062.28 X
14061   2 90 2 X 2,194.49 X
14061   1 90 2 X 2,226.39 X
14301   2 90 2 X 1,497.31 1,276.40
14301   3 90 2 X 1,497.31 1,276.40
14301   4 90 2 X 1,497.31 1,276.40
14301   1 90 2 X 1,691.84 1,429.81
14302   2 ZZZ 0 X 333.40 X
14302   3 ZZZ 0 X 333.40 X
14302   4 ZZZ 0 X 333.40 X
14302   1 ZZZ 0 X 370.74 X
14350   4 90 2 X 1,426.57 X
14350   3 90 2 X 1,443.01 X
14350   2 90 2 X 1,501.64 X
14350   1 90 2 X 1,554.90 X
15002   2 0 0 X 434.70 302.96
15002   3 0 0 X 434.70 302.96
15002   4 0 0 X 434.70 302.96
15002   1 0 0 X 504.97 343.78
15003   2 ZZZ 0 X 96.37 62.24
15003   3 ZZZ 0 X 96.37 62.24
15003   4 ZZZ 0 X 96.37 62.24
15003   1 ZZZ 0 X 112.06 70.29
15004   2 0 0 X 524.61 375.26
15004   3 0 0 X 524.61 375.26
15004   4 0 0 X 524.61 375.26
15004   1 0 0 X 608.22 425.48
15005   2 ZZZ 0 X 162.88 124.49
15005   3 ZZZ 0 X 162.88 124.49
15005   4 ZZZ 0 X 162.88 124.49
15005   1 ZZZ 0 X 187.56 140.56
15040   2 0 0 X 391.92 199.37
15040   3 0 0 X 391.92 199.37
15040   4 0 0 X 391.92 199.37
15040   1 0 0 X 459.80 224.14
15050   4 90 2 X 923.56 X
15050   3 90 2 X 927.61 X
15050   2 90 2 X 948.14 X
15050   1 90 2 X 967.55 X
15100   4 90 2 X 1,541.70 X
15100   3 90 2 X 1,547.37 X
15100   2 90 2 X 1,580.22 X
15100   1 90 2 X 1,588.22 X
15101   3 ZZZ 0 X 1,167.20 X
15101   4 ZZZ 0 X 1,176.02 X
15101   1 ZZZ 0 X 1,185.22 X
15101   2 ZZZ 0 X 1,186.69 X
15110   2 90 2 X 1,253.90 1,047.94
15110   3 90 2 X 1,253.90 1,047.94
15110   4 90 2 X 1,253.90 1,047.94
15110   1 90 2 X 1,444.61 1,192.48
15111   2 ZZZ 0 X 200.00 172.04
15111   3 ZZZ 0 X 200.00 172.04
15111   4 ZZZ 0 X 200.00 172.04
15111   1 ZZZ 0 X 227.35 193.12
15115   2 90 2 X 1,183.96 1,078.75
15115   3 90 2 X 1,183.96 1,078.75
15115   4 90 2 X 1,183.96 1,078.75
15115   1 90 2 X 1,351.04 1,222.24
15116   2 ZZZ 0 X 260.08 234.30
15116   3 ZZZ 0 X 260.08 234.30
15116   4 ZZZ 0 X 260.08 234.30
15116   1 ZZZ 0 X 294.24 262.72
15120   4 90 2 X 2,300.20 X
15120   3 90 2 X 2,307.12 X
15120   2 90 2 X 2,345.16 X
15120   1 90 2 X 2,354.36 X
15121   3 ZZZ 0 X 543.24 X
15121   4 ZZZ 0 X 1,825.44 X
15121   2 ZZZ 0 X 1,846.31 X
15121   1 ZZZ 0 X 1,850.74 X
15130   2 90 2 X 1,036.43 838.85
15130   3 90 2 X 1,036.43 838.85
15130   4 90 2 X 1,036.43 838.85
15130   1 90 2 X 1,202.25 960.43
15131   2 ZZZ 0 X 163.47 139.39
15131   3 ZZZ 0 X 163.47 139.39
15131   4 ZZZ 0 X 163.47 139.39
15131   1 ZZZ 0 X 185.92 156.46
15135   2 90 2 X 1,267.17 1,169.22
15135   3 90 2 X 1,267.17 1,169.22
15135   4 90 2 X 1,267.17 1,169.22
15135   1 90 2 X 1,445.92 1,326.11
15136   2 ZZZ 0 X 152.87 140.56
15136   3 ZZZ 0 X 152.87 140.56
15136   4 ZZZ 0 X 152.87 140.56
15136   1 ZZZ 0 X 172.75 157.67
15150   2 90 2 X 1,043.58 930.52
15150   3 90 2 X 1,043.58 930.52
15150   4 90 2 X 1,043.58 930.52
15150   1 90 2 X 1,199.09 1,060.70
15151   2 ZZZ 0 X 211.46 185.68
15151   3 ZZZ 0 X 211.46 185.68
15151   4 ZZZ 0 X 211.46 185.68
15151   1 ZZZ 0 X 239.90 208.43
15152   2 ZZZ 0 X 259.95 231.95
15152   3 ZZZ 0 X 259.95 231.95
15152   4 ZZZ 0 X 259.95 231.95
15152   1 ZZZ 0 X 294.58 260.33
15155   2 90 2 X 1,049.78 1,001.65
15155   3 90 2 X 1,049.78 1,001.65
15155   4 90 2 X 1,049.78 1,001.65
15155   1 90 2 X 1,194.80 1,135.86
15156   2 ZZZ 0 X 275.97 258.04
15156   3 ZZZ 0 X 275.97 258.04
15156   4 ZZZ 0 X 275.97 258.04
15156   1 ZZZ 0 X 311.22 289.27
15157   2 ZZZ 0 X 305.25 281.22
15157   3 ZZZ 0 X 305.25 281.22
15157   4 ZZZ 0 X 305.25 281.22
15157   1 ZZZ 0 X 344.59 315.16
15200   1 90 2 X 1,180.77 X
15200   3 90 2 X 1,422.75 X
15200   4 90 2 X 1,490.40 X
15200   2 90 2 X 1,514.39 X
15201   4 ZZZ 0 X 371.87 X
15201   3 ZZZ 0 X 376.53 X
15201   2 ZZZ 0 X 413.03 X
15201   1 ZZZ 0 X 421.93 X
15220   4 90 2 X 1,537.29 X
15220   3 90 2 X 1,545.38 X
15220   1 90 2 X 1,607.42 X
15220   2 90 2 X 1,616.69 X
15221   4 ZZZ 0 X 356.08 X
15221   3 ZZZ 0 X 360.60 X
15221   2 ZZZ 0 X 1,150.31 X
15221   1 ZZZ 0 X 1,154.03 X
15240   3 90 2 X 1,522.35 X
15240   4 90 2 X 1,549.48 X
15240   2 90 2 X 1,591.70 X
15240   1 90 2 X 1,604.49 X
15241   4 ZZZ 0 X 1,252.95 X
15241   3 ZZZ 0 X 1,255.57 X
15241   2 ZZZ 0 X 1,274.30 X
15241   1 ZZZ 0 X 1,278.79 X
15260   4 90 2 X 1,714.26 X
15260   3 90 2 X 1,716.53 X
15260   2 90 2 X 1,762.68 X
15260   1 90 2 X 1,772.71 X
15261   4 ZZZ 0 X 588.54 X
15261   3 ZZZ 0 X 897.33 X
15261   1 ZZZ 0 X 938.51 X
15261   2 ZZZ 0 X 1,014.21 X
15271   2 0 2 X 198.51 124.29
15271   3 0 2 X 198.51 124.29
15271   4 0 2 X 198.51 124.29
15271   1 0 2 X 223.45 137.39
15272   2 ZZZ 0 X 37.57 24.61
15272   3 ZZZ 0 X 37.57 24.61
15272   4 ZZZ 0 X 37.57 24.61
15272   1 ZZZ 0 X 41.86 26.82
15273   2 0 2 X 410.64 296.23
15273   3 0 2 X 410.64 296.23
15273   4 0 2 X 410.64 296.23
15273   1 0 2 X 461.06 328.32
15274   2 ZZZ 0 X 96.06 62.54
15274   3 ZZZ 0 X 96.06 62.54
15274   4 ZZZ 0 X 96.06 62.54
15274   1 ZZZ 0 X 107.30 68.43
15275   2 0 2 X 214.37 144.66
15275   3 0 2 X 214.37 144.66
15275   4 0 2 X 214.37 144.66
15275   1 0 2 X 240.46 159.59
15276   2 ZZZ 0 X 47.02 35.39
15276   3 ZZZ 0 X 47.02 35.39
15276   4 ZZZ 0 X 47.02 35.39
15276   1 ZZZ 0 X 51.89 38.41
15277   2 0 2 X 414.71 306.98
15277   3 0 2 X 414.71 306.98
15277   4 0 2 X 414.71 306.98
15277   1 0 2 X 461.73 336.75
15278   2 ZZZ 0 X 113.32 77.57
15278   3 ZZZ 0 X 113.32 77.57
15278   4 ZZZ 0 X 113.32 77.57
15278   1 ZZZ 0 X 126.36 84.87