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2021 Workers' Compensation Part B Fee Schedule

15570-19101

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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
15570   4 90 2 X 1,296.20 X
15570   3 90 2 X 2,467.25 X
15570   1 90 2 X 3,002.20 X
15570   2 90 2 X 3,597.71 X
15572   3 90 2 X 3,078.46 X
15572   1 90 2 X 3,251.48 X
15572   2 90 2 X 3,311.12 X
15572   4 90 2 X 3,622.02 X
15574   3 90 2 X 2,446.27 X
15574   1 90 2 X 2,782.49 X
15574   2 90 2 X 2,863.43 X
15574   4 90 2 X 2,874.46 X
15576   4 90 2 X 2,946.81 X
15576   1 90 2 X 2,963.98 X
15576   3 90 2 X 2,985.74 X
15576   2 90 2 X 3,460.32 X
15600   3 90 2 X 591.83 X
15600   1 90 2 X 668.54 X
15600   2 90 2 X 932.08 X
15600   4 90 2 X 1,107.86 X
15610   4 90 2 X 586.92 X
15610   2 90 2 X 651.67 X
15610   1 90 2 X 974.82 X
15610   3 90 2 X 976.62 X
15620   4 90 2 X 711.91 X
15620   3 90 2 X 720.92 X
15620   1 90 2 X 1,250.94 X
15620   2 90 2 X 1,307.09 X
15630   4 90 2 X 770.20 X
15630   3 90 2 X 1,366.84 X
15630   2 90 2 X 1,396.22 X
15630   1 90 2 X 1,403.39 X
15650   4 90 2 X 843.86 X
15650   1 90 2 X 945.12 X
15650   3 90 2 X 1,044.81 X
15650   2 90 2 X 1,056.69 X
15730   2 90 2 X 1,905.07 1,156.51
15730   3 90 2 X 1,905.07 1,156.51
15730   4 90 2 X 1,905.07 1,156.51
15730   1 90 2 X 2,125.78 1,266.85
15731   2 90 2 X 1,450.36 1,313.25
15731   3 90 2 X 1,450.36 1,313.25
15731   4 90 2 X 1,450.36 1,313.25
15731   1 90 2 X 1,656.03 1,488.31
15733   2 90 2 X 1,321.69 X
15733   3 90 2 X 1,321.69 X
15733   4 90 2 X 1,321.69 X
15733   1 90 2 X 1,446.88 X
15734   4 90 2 X 4,982.21 X
15734   3 90 2 X 4,999.82 X
15734   1 90 2 X 5,035.06 X
15734   2 90 2 X 5,053.78 X
15736   4 90 2 X 3,029.40 X
15736   3 90 2 X 3,065.95 X
15736   2 90 2 X 4,162.34 X
15736   1 90 2 X 4,189.36 X
15738   4 90 2 X 2,516.67 X
15738   3 90 2 X 4,666.96 X
15738   1 90 2 X 4,729.82 X
15738   2 90 2 X 4,766.64 X
15740   4 90 2 X 1,884.58 X
15740   2 90 2 X 3,211.48 X
15740   3 90 2 X 3,275.59 X
15740   1 90 2 X 3,349.67 X
15750   4 90 2 X 2,158.87 X
15750   3 90 2 X 2,185.24 X
15750   2 90 2 X 2,355.02 X
15750   1 90 2 X 2,396.09 X
15756   3 90 2 X 5,880.85 X
15756   4 90 2 X 5,880.85 X
15756   2 90 2 X 6,043.32 X
15756   1 90 2 X 6,756.92 X
15757   3 90 2 X 5,880.85 X
15757   4 90 2 X 5,880.85 X
15757   2 90 2 X 6,043.32 X
15757   1 90 2 X 6,756.92 X
15758   3 90 2 X 5,880.85 X
15758   4 90 2 X 5,880.85 X
15758   2 90 2 X 6,043.32 X
15758   1 90 2 X 6,756.92 X
15760   4 90 2 X 1,466.72 X
15760   3 90 2 X 2,063.22 X
15760   2 90 2 X 2,106.09 X
15760   1 90 2 X 2,116.47 X
15769   2 90 2 X 571.06 X
15769   3 90 2 X 571.06 X
15769   4 90 2 X 571.06 X
15769   1 90 2 X 631.91 X
15770   4 90 2 X 1,338.96 X
15770   3 90 2 X 1,355.58 X
15770   2 90 2 X 1,448.83 X
15770   1 90 2 X 1,471.29 X
15771   2 90 2 X 678.71 567.18
15771   3 90 2 X 678.71 567.18
15771   4 90 2 X 678.71 567.18
15771   1 90 2 X 755.68 627.28
15772   2 ZZZ 0 X 215.04 169.08
15772   3 ZZZ 0 X 215.04 169.08
15772   4 ZZZ 0 X 215.04 169.08
15772   1 ZZZ 0 X 238.04 185.10
15773   2 90 2 X 684.93 573.43
15773   3 90 2 X 684.93 573.43
15773   4 90 2 X 684.93 573.43
15773   1 90 2 X 762.35 633.93
15774   2 ZZZ 0 X 208.39 162.42
15774   3 ZZZ 0 X 208.39 162.42
15774   4 ZZZ 0 X 208.39 162.42
15774   1 ZZZ 0 X 230.61 177.68
15775     0 2 X * X
15776     0 2 X * X
15777   2 ZZZ 0 X 304.65 X
15777   3 ZZZ 0 X 304.65 X
15777   4 ZZZ 0 X 304.65 X
15777   1 ZZZ 0 X 339.43 X
15780   4 90 2 X 746.30 X
15780   2 90 2 X 782.26 X
15780   1 90 2 X 789.19 X
15780   3 90 2 X 1,671.47 X
15781   4 90 2 X 776.16 X
15781   2 90 2 X 831.42 X
15781   3 90 2 X 871.65 X
15781   1 90 2 X 889.16 X
15782   3 90 2 X 494.76 X
15782   2 90 2 X 515.49 X
15782   1 90 2 X 520.50 X
15782   4 90 2 X 804.91 X
15783   4 90 2 X 548.91 X
15783   3 90 2 X 555.07 X
15783   2 90 2 X 581.63 X
15783   1 90 2 X 737.04 X
15786   4 10 2 X 236.14 X
15786   3 10 2 X 238.69 X
15786   2 10 2 X 248.79 X
15786   1 10 2 X 251.21 X
15787   4 ZZZ 0 X 51.42 X
15787   3 ZZZ 0 X 52.04 X
15787   2 ZZZ 0 X 55.21 X
15787   1 ZZZ 0 X 55.92 X
15788     90 2 X * X
15789     90 2 X * X
15792     90 2 X * X
15793     90 2 X * X
15819   4 90 2 X 1,560.19 X
15819   3 90 2 X 1,579.32 X
15819   2 90 2 X 1,676.55 X
15819   1 90 2 X 1,700.06 X
15820   4 90 2 X 1,025.89 X
15820   3 90 2 X 1,039.09 X
15820   2 90 2 X 1,108.90 X
15820   1 90 2 X 1,125.68 X
15821   4 90 2 X 1,176.52 X
15821   3 90 2 X 1,191.86 X
15821   2 90 2 X 1,270.36 X
15821   1 90 2 X 1,289.20 X
15822   1 90 2 X 1,081.16 X
15822   3 90 2 X 1,517.70 X
15822   4 90 2 X 1,605.96 X
15822   2 90 2 X 1,800.65 X
15823   4 90 2 X 1,734.79 X
15823   3 90 2 X 1,779.53 X
15823   2 90 2 X 1,863.11 X
15823   1 90 2 X 1,893.02 X
15824     XXX 2 X * X
15825     XXX 2 X * X
15826     XXX 2 X * X
15828     XXX 2 X * X
15829     XXX 2 X * X
15830   2 90 2 X 1,568.29 X
15830   3 90 2 X 1,568.29 X
15830   4 90 2 X 1,568.29 X
15830   1 90 2 X 1,809.53 X
15832     90 2 X * X
15833     90 2 X * X
15834     90 2 X * X
15835     90 2 X * X
15836     90 2 X * X
15837     90 2 X * X
15838     90 2 X * X
15839     90 2 X * X
15840   4 90 2 X 2,636.56 X
15840   3 90 2 X 2,669.56 X
15840   2 90 2 X 2,872.28 X
15840   1 90 2 X 2,921.17 X
15841   4 90 2 X 3,625.49 X
15841   3 90 2 X 3,668.17 X
15841   2 90 2 X 3,918.05 X
15841   1 90 2 X 3,978.50 X
15842   4 90 2 X 5,951.86 X
15842   3 90 2 X 6,024.38 X
15842   2 90 2 X 6,365.36 X
15842   1 90 2 X 6,447.56 X
15845   4 90 2 X 2,635.13 X
15845   3 90 2 X 2,668.01 X
15845   2 90 2 X 2,881.44 X
15845   1 90 2 X 2,932.94 X
15847     YYY 2 X * X
15850     XXX 9 X * X
15851     0 2 X * X
15852   4 0 2 X 107.73 X
15852   3 0 2 X 108.44 X
15852   2 0 2 X 112.18 X
15852   1 0 2 X 113.15 X
15860     0 2 X * X
15876     XXX 2 X * X
15877     XXX 2 X * X
15878     XXX 2 X # X
15879     XXX 2 X * X
15920   4 90 2 X 970.73 X
15920   3 90 2 X 981.16 X
15920   2 90 2 X 1,039.09 X
15920   1 90 2 X 1,053.22 X
15922   4 90 2 X 1,442.14 X
15922   3 90 2 X 1,458.58 X
15922   2 90 2 X 1,559.22 X
15922   1 90 2 X 1,583.68 X
15931   1 90 2 X 926.25 X
15931   4 90 2 X 996.10 X
15931   3 90 2 X 1,022.58 X
15931   2 90 2 X 1,106.47 X
15933   4 90 2 X 1,587.57 X
15933   3 90 2 X 1,605.70 X
15933   2 90 2 X 1,716.34 X
15933   1 90 2 X 1,732.64 X
15934   3 90 2 X 1,817.93 X
15934   4 90 2 X 1,842.71 X
15934   2 90 2 X 1,944.35 X
15934   1 90 2 X 1,975.07 X
15935   4 90 2 X 2,338.81 X
15935   3 90 2 X 2,366.16 X
15935   2 90 2 X 2,547.97 X
15935   1 90 2 X 2,592.04 X
15936   4 90 2 X 2,079.00 X
15936   1 90 2 X 2,306.64 X
15936   3 90 2 X 2,923.43 X
15936   2 90 2 X 2,992.01 X
15937   4 90 2 X 2,558.69 X
15937   3 90 2 X 3,399.41 X
15937   2 90 2 X 3,487.40 X
15937   1 90 2 X 3,508.68 X
15940   4 90 2 X 1,104.94 X
15940   3 90 2 X 1,116.97 X
15940   2 90 2 X 1,183.92 X
15940   1 90 2 X 1,200.25 X
15941   4 90 2 X 1,640.25 X
15941   3 90 2 X 1,659.01 X
15941   1 90 2 X 1,690.79 X
15941   2 90 2 X 1,747.12 X
15944   1 90 2 X 2,073.86 X
15944   4 90 2 X 2,145.26 X
15944   3 90 2 X 2,154.49 X
15944   2 90 2 X 2,215.86 X
15945   4 90 2 X 2,157.95 X
15945   3 90 2 X 2,532.79 X
15945   2 90 2 X 2,603.98 X
15945   1 90 2 X 2,621.24 X
15946   4 90 2 X 3,492.20 X
15946   3 90 2 X 3,533.06 X
15946   2 90 2 X 3,797.95 X
15946   1 90 2 X 3,862.22 X
15950   3 90 2 X 994.13 X
15950   1 90 2 X 998.14 X
15950   4 90 2 X 1,015.25 X
15950   2 90 2 X 1,042.47 X
15951   4 90 2 X 1,657.41 X
15951   3 90 2 X 1,676.55 X
15951   2 90 2 X 1,803.31 X
15951   1 90 2 X 1,834.05 X
15952   4 90 2 X 1,647.85 X
15952   2 90 2 X 1,783.47 X
15952   3 90 2 X 1,787.76 X
15952   1 90 2 X 1,848.61 X
15953   4 90 2 X 1,968.54 X
15953   2 90 2 X 2,141.36 X
15953   1 90 2 X 2,177.85 X
15953   3 90 2 X 2,196.09 X
15956   4 90 2 X 3,025.77 X
15956   3 90 2 X 3,171.13 X
15956   2 90 2 X 3,323.59 X
15956   1 90 2 X 3,386.77 X
15958   4 90 2 X 3,107.01 X
15958   3 90 2 X 3,318.39 X
15958   2 90 2 X 3,424.02 X
15958   1 90 2 X 3,491.64 X
15999     YYY 2 X # X
16000   4 0 2 X 104.98 91.14
16000   3 0 2 X 105.37 91.65
16000   2 0 2 X 110.98 95.94
16000   1 0 2 X 111.94 96.80
16020   4 0 2 X 96.70 83.26
16020   3 0 2 X 97.81 84.10
16020   2 0 2 X 102.25 87.75
16020   1 0 2 X 103.33 88.63
16025   4 0 2 X 208.54 189.48
16025   3 0 2 X 210.72 191.39
16025   2 0 2 X 219.15 198.62
16025   1 0 2 X 221.28 200.44
16030   4 0 2 X 238.40 X
16030   3 0 2 X 240.85 X
16030   2 0 2 X 251.50 X
16030   1 0 2 X 254.12 X
16035   4 90 2 X 597.71 X
16035   3 90 2 X 604.21 X
16035   2 90 2 X 638.01 X
16035   1 90 2 X 646.18 X
16036   2 ZZZ 0 X 167.53 X
16036   3 ZZZ 0 X 167.53 X
16036   4 ZZZ 0 X 167.53 X
16036   1 ZZZ 0 X 187.43 X
17000   2 10 2 X 79.85 63.53
17000   3 10 2 X 79.85 63.53
17000   4 10 2 X 79.85 63.53
17000   1 10 2 X 88.56 69.39
17003   2 ZZZ 0 X 22.04 16.98
17003   3 ZZZ 0 X 22.04 16.98
17003   4 ZZZ 0 X 22.04 16.98
17003   1 ZZZ 0 X 24.66 18.77
17004   2 10 2 X 397.73 310.49
17004   3 10 2 X 397.73 310.49
17004   4 10 2 X 397.73 310.49
17004   1 10 2 X 445.27 342.78
17106   4 90 2 X 588.51 X
17106   3 90 2 X 595.06 X
17106   2 90 2 X 622.43 X
17106   1 90 2 X 629.13 X
17107   4 90 2 X 1,164.38 X
17107   3 90 2 X 1,177.31 X
17107   2 90 2 X 1,232.46 X
17107   1 90 2 X 1,245.89 X
17108   4 90 2 X 2,035.56 X
17108   3 90 2 X 2,060.10 X
17108   2 90 2 X 2,165.98 X
17108   1 90 2 X 2,191.59 X
17110   2 10 2 X 82.08 66.56
17110   3 10 2 X 82.08 66.56
17110   4 10 2 X 82.08 66.56
17110   1 10 2 X 90.70 72.45
17111   2 10 2 X 119.25 95.97
17111   3 10 2 X 119.25 95.97
17111   4 10 2 X 119.25 95.97
17111   1 10 2 X 132.26 104.89
17250   4 0 2 X 77.58 63.24
17250   3 0 2 X 78.57 63.92
17250   2 0 2 X 83.02 67.50
17250   1 0 2 X 84.10 68.44
17260   3 10 2 X 255.84 X
17260   4 10 2 X 256.35 X
17260   2 10 2 X 261.63 X
17260   1 10 2 X 263.26 X
17261   4 10 2 X 301.37 X
17261   3 10 2 X 302.49 X
17261   1 10 2 X 312.51 X
17261   2 10 2 X 313.22 X
17262   4 10 2 X 345.76 X
17262   3 10 2 X 379.69 X
17262   2 10 2 X 384.02 X
17262   1 10 2 X 391.14 X
17263   4 10 2 X 420.01 X
17263   1 10 2 X 454.25 X
17263   3 10 2 X 464.53 X
17263   2 10 2 X 467.20 X
17264   3 10 2 X 567.43 X
17264   1 10 2 X 579.66 X
17264   4 10 2 X 579.79 X
17264   2 10 2 X 596.32 X
17266   3 10 2 X 729.95 X
17266   4 10 2 X 829.59 X
17266   2 10 2 X 829.61 X
17266   1 10 2 X 836.58 X
17270   3 10 2 X 306.91 X
17270   4 10 2 X 309.06 X
17270   2 10 2 X 319.79 X
17270   1 10 2 X 326.45 X
17271   4 10 2 X 339.90 X
17271   3 10 2 X 392.63 X
17271   2 10 2 X 400.21 X
17271   1 10 2 X 408.98 X
17272   4 10 2 X 389.47 X
17272   3 10 2 X 426.34 X
17272   2 10 2 X 432.98 X
17272   1 10 2 X 439.75 X
17273   4 10 2 X 457.49 X
17273   1 10 2 X 459.92 X
17273   3 10 2 X 485.26 X
17273   2 10 2 X 492.33 X
17274   4 10 2 X 595.63 X
17274   3 10 2 X 615.58 X
17274   2 10 2 X 624.97 X
17274   1 10 2 X 635.99 X
17276   3 10 2 X 688.90 X
17276   4 10 2 X 728.74 X
17276   2 10 2 X 748.43 X
17276   1 10 2 X 758.04 X
17280   3 10 2 X 331.14 X
17280   4 10 2 X 336.68 X
17280   2 10 2 X 357.74 X
17280   1 10 2 X 364.09 X
17281   4 10 2 X 389.69 X
17281   3 10 2 X 420.39 X
17281   1 10 2 X 433.11 X
17281   2 10 2 X 434.00 X
17282   4 10 2 X 433.06 X
17282   2 10 2 X 510.35 X
17282   3 10 2 X 513.18 X
17282   1 10 2 X 518.21 X
17283   4 10 2 X 538.04 X
17283   1 10 2 X 558.28 X
17283   3 10 2 X 595.70 X
17283   2 10 2 X 603.45 X
17284   3 10 2 X 629.17 X
17284   2 10 2 X 697.95 X
17284   4 10 2 X 715.59 X
17284   1 10 2 X 726.14 X
17286   4 10 2 X 818.44 X
17286   3 10 2 X 828.36 X
17286   2 10 2 X 885.60 X
17286   1 10 2 X 899.47 X
17311   2 0 2 X 913.45 506.43
17311   3 0 2 X 913.45 506.43
17311   4 0 2 X 913.45 506.43
17311   1 0 2 X 1,058.04 560.07
17312   2 ZZZ 0 X 549.08 269.55
17312   3 ZZZ 0 X 549.08 269.55
17312   4 ZZZ 0 X 549.08 269.55
17312   1 ZZZ 0 X 640.14 298.17
17313   2 0 2 X 833.72 453.92
17313   3 0 2 X 833.72 453.92
17313   4 0 2 X 833.72 453.92
17313   1 0 2 X 966.82 502.18
17314   2 ZZZ 0 X 508.51 249.28
17314   3 ZZZ 0 X 508.51 249.28
17314   4 ZZZ 0 X 508.51 249.28
17314   1 ZZZ 0 X 592.86 275.70
17315   2 ZZZ 0 X 108.41 70.52
17315   3 ZZZ 0 X 108.41 70.52
17315   4 ZZZ 0 X 108.41 70.52
17315   1 ZZZ 0 X 124.22 77.89
17340   3 10 2 X 84.80 73.98
17340   4 10 2 X 91.15 79.32
17340   2 10 2 X 96.02 83.26
17340   1 10 2 X 97.02 84.06
17360   1 10 2 X 142.84 131.51
17360   4 10 2 X 150.67 139.24
17360   3 10 2 X 152.22 140.63
17360   2 10 2 X 157.53 145.29
17380     XXX 2 X * X
17999     YYY 2 X # X
19000   4 0 2 X 119.34 102.38
19000   3 0 2 X 122.24 104.95
19000   2 0 2 X 123.49 106.14
19000   1 0 2 X 127.98 109.68
19001   4 ZZZ 0 X 62.09 X
19001   3 ZZZ 0 X 62.73 X
19001   2 ZZZ 0 X 66.94 X
19001   1 ZZZ 0 X 67.98 X
19020   4 90 2 X 413.68 X
19020   1 90 2 X 485.41 X
19020   3 90 2 X 486.55 X
19020   2 90 2 X 495.28 X
19030   4 0 2 X 171.71 X
19030   3 0 2 X 173.55 X
19030   2 0 2 X 180.69 X
19030   1 0 2 X 182.43 X
19081   2 0 2 X 878.59 254.08
19081   3 0 2 X 878.59 254.08
19081   4 0 2 X 878.59 254.08
19081   1 0 2 X 1,007.51 279.96
19082   2 ZZZ 0 X 703.48 120.57
19082   3 ZZZ 0 X 703.48 120.57
19082   4 ZZZ 0 X 703.48 120.57
19082   1 ZZZ 0 X 810.19 131.10
19083   2 0 2 X 871.49 237.94
19083   3 0 2 X 871.49 237.94
19083   4 0 2 X 871.49 237.94
19083   1 0 2 X 999.90 261.80
19084   2 ZZZ 0 X 693.45 113.28
19084   3 ZZZ 0 X 693.45 113.28
19084   4 ZZZ 0 X 693.45 113.28
19084   1 ZZZ 0 X 799.05 123.10
19085   2 0 2 X 1,313.27 277.71
19085   3 0 2 X 1,313.27 277.71
19085   4 0 2 X 1,313.27 277.71
19085   1 0 2 X 1,511.65 305.18
19086   2 ZZZ 0 X 1,038.93 122.76
19086   3 ZZZ 0 X 1,038.93 122.76
19086   4 ZZZ 0 X 1,038.93 122.76
19086   1 ZZZ 0 X 1,197.89 130.52
19100   1 0 2 X 231.01 X
19100   4 0 2 X 231.68 X
19100   2 0 2 X 253.67 X
19100   3 0 2 X 262.72 X
19101   4 10 2 X 521.28 X
19101   3 10 2 X 527.29 X
19101   1 10 2 X 590.18 X
19101   2 10 2 X 603.65 X