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2021 Workers' Compensation Part B Fee Schedule

21015-21435

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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
21015   4 90 2 X 1,085.64 X
21015   3 90 2 X 1,099.00 X
21015   2 90 2 X 1,189.61 X
21015   1 90 2 X 1,211.57 X
21016   2 90 2 X 1,496.34 X
21016   3 90 2 X 1,496.34 X
21016   4 90 2 X 1,496.34 X
21016   1 90 2 X 1,677.38 X
21025   3 90 2 X 838.30 X
21025   4 90 2 X 840.22 X
21025   2 90 2 X 898.68 X
21025   1 90 2 X 910.31 X
21026   4 90 2 X 699.72 X
21026   3 90 2 X 786.52 X
21026   2 90 2 X 802.40 X
21026   1 90 2 X 905.10 X
21029   4 90 2 X 1,507.05 X
21029   3 90 2 X 1,526.54 X
21029   2 90 2 X 1,622.73 X
21029   1 90 2 X 1,645.79 X
21030   4 90 2 X 945.59 802.22
21030   3 90 2 X 956.38 810.51
21030   2 90 2 X 1,001.21 846.74
21030   1 90 2 X 1,012.02 855.64
21031   4 90 2 X 523.47 X
21031   3 90 2 X 530.63 X
21031   2 90 2 X 567.16 X
21031   1 90 2 X 576.00 X
21032   4 90 2 X 746.35 X
21032   3 90 2 X 755.60 X
21032   2 90 2 X 799.51 X
21032   1 90 2 X 810.11 X
21034   2 90 2 X 1,947.34 X
21034   3 90 2 X 1,975.65 X
21034   1 90 2 X 2,019.76 X
21034   4 90 2 X 2,034.11 X
21040   4 90 2 X 533.26 X
21040   3 90 2 X 556.88 X
21040   1 90 2 X 567.43 X
21040   2 90 2 X 614.66 X
21044   4 90 2 X 1,911.58 X
21044   3 90 2 X 1,934.82 X
21044   2 90 2 X 2,054.85 X
21044   1 90 2 X 2,083.80 X
21045   4 90 2 X 2,682.14 X
21045   3 90 2 X 2,715.04 X
21045   2 90 2 X 2,885.81 X
21045   1 90 2 X 2,927.02 X
21046   2 90 2 X 1,624.04 X
21046   3 90 2 X 1,624.04 X
21046   4 90 2 X 1,624.04 X
21046   1 90 2 X 1,818.06 X
21047   2 90 2 X 2,012.54 X
21047   3 90 2 X 2,012.54 X
21047   4 90 2 X 2,012.54 X
21047   1 90 2 X 2,237.09 X
21048   2 90 2 X 1,672.06 X
21048   3 90 2 X 1,672.06 X
21048   4 90 2 X 1,672.06 X
21048   1 90 2 X 1,869.65 X
21049   2 90 2 X 1,912.15 X
21049   3 90 2 X 1,912.15 X
21049   4 90 2 X 1,912.15 X
21049   1 90 2 X 2,108.13 X
21050   4 90 2 X 2,056.01 X
21050   3 90 2 X 2,082.49 X
21050   1 90 2 X 2,244.77 X
21050   2 90 2 X 2,253.14 X
21060   4 90 2 X 1,943.70 X
21060   3 90 2 X 1,968.70 X
21060   2 90 2 X 2,092.96 X
21060   1 90 2 X 2,122.83 X
21070   4 90 2 X 1,345.05 X
21070   3 90 2 X 1,361.44 X
21070   2 90 2 X 1,447.83 X
21070   1 90 2 X 1,468.66 X
21073   2 90 2 X 503.98 328.23
21073   3 90 2 X 503.98 328.23
21073   4 90 2 X 503.98 328.23
21073   1 90 2 X 583.54 371.59
21076   4 10 2 X 2,793.83 2,048.27
21076   3 10 2 X 2,838.34 2,077.89
21076   2 10 2 X 3,034.54 2,203.60
21076   1 10 2 X 3,160.58 2,298.17
21077   4 90 2 X 7,026.56 5,151.42
21077   3 90 2 X 7,138.54 5,225.85
21077   2 90 2 X 7,631.94 5,541.94
21077   1 90 2 X 7,948.86 5,779.59
21079     90 2 X * X
21080     90 2 X * X
21081     90 2 X * X
21082     90 2 X * X
21083     90 2 X * X
21084     90 2 X * X
21085     10 2 X * X
21086     90 2 X * X
21087     90 2 X * X
21088     90 0 X * X
21089     90 0 X # X
21100   4 90 2 X 462.50 X
21100   1 90 2 X 490.96 X
21100   3 90 2 X 671.55 X
21100   2 90 2 X 754.94 X
21110   4 90 2 X 966.72 X
21110   3 90 2 X 979.04 X
21110   2 90 2 X 1,038.08 X
21110   1 90 2 X 1,052.26 X
21116   1 0 2 X 129.74 X
21116   2 0 2 X 138.93 X
21116   4 0 2 X 140.79 X
21116   3 0 2 X 142.47 X
21120   4 90 2 X 770.73 X
21120   3 90 2 X 779.97 X
21120   2 90 2 X 826.33 X
21120   1 90 2 X 837.50 X
21121   4 90 2 X 1,212.26 X
21121   3 90 2 X 1,226.82 X
21121   2 90 2 X 1,300.03 X
21121   1 90 2 X 1,317.72 X
21122   4 90 2 X 1,335.93 X
21122   3 90 2 X 1,351.88 X
21122   2 90 2 X 1,432.73 X
21122   1 90 2 X 1,452.28 X
21123   4 90 2 X 1,746.12 X
21123   3 90 2 X 1,767.00 X
21123   2 90 2 X 1,872.32 X
21123   1 90 2 X 1,897.82 X
21125   4 90 2 X 1,011.08 X
21125   3 90 2 X 1,023.14 X
21125   2 90 2 X 1,084.01 X
21125   1 90 2 X 1,098.65 X
21127   4 90 2 X 1,696.46 X
21127   3 90 2 X 1,716.73 X
21127   2 90 2 X 1,818.96 X
21127   1 90 2 X 1,843.72 X
21137   1 90 2 X 3,363.14 X
21137   2 90 2 X 3,363.14 X
21137   3 90 2 X 3,363.14 X
21137   4 90 2 X 3,363.14 X
21138   1 90 2 X 4,203.96 X
21138   2 90 2 X 4,203.96 X
21138   3 90 2 X 4,203.96 X
21138   4 90 2 X 4,203.96 X
21139   1 90 2 X 4,203.96 X
21139   2 90 2 X 4,203.96 X
21139   3 90 2 X 4,203.96 X
21139   4 90 2 X 4,203.96 X
21141   4 90 2 X 3,022.76 X
21141   3 90 2 X 3,067.80 X
21141   2 90 2 X 3,260.11 X
21141   1 90 2 X 3,395.14 X
21142   4 90 2 X 3,135.00 X
21142   3 90 2 X 3,181.68 X
21142   2 90 2 X 3,380.85 X
21142   1 90 2 X 3,520.77 X
21143   4 90 2 X 3,258.99 X
21143   3 90 2 X 3,307.58 X
21143   2 90 2 X 3,514.49 X
21143   1 90 2 X 3,659.95 X
21145   4 90 2 X 3,076.83 X
21145   3 90 2 X 3,113.57 X
21145   2 90 2 X 3,299.59 X
21145   1 90 2 X 3,344.53 X
21146   4 90 2 X 3,183.98 X
21146   3 90 2 X 3,222.01 X
21146   2 90 2 X 3,414.51 X
21146   1 90 2 X 3,461.00 X
21147   4 90 2 X 3,303.27 X
21147   3 90 2 X 3,342.74 X
21147   2 90 2 X 3,542.54 X
21147   1 90 2 X 3,590.91 X
21150   1 90 2 X 9,809.25 X
21150   2 90 2 X 9,809.25 X
21150   3 90 2 X 9,809.25 X
21150   4 90 2 X 9,809.25 X
21151   1 90 2 X 9,809.25 X
21151   2 90 2 X 9,809.25 X
21151   3 90 2 X 9,809.25 X
21151   4 90 2 X 9,809.25 X
21154   1 90 2 X 11,210.58 X
21154   2 90 2 X 11,210.58 X
21154   3 90 2 X 11,210.58 X
21154   4 90 2 X 11,210.58 X
21155   1 90 2 X 11,490.83 X
21155   2 90 2 X 11,490.83 X
21155   3 90 2 X 11,490.83 X
21155   4 90 2 X 11,490.83 X
21159   4 90 2 X 7,063.62 X
21159   3 90 2 X 7,159.58 X
21159   2 90 2 X 7,588.37 X
21159   1 90 2 X 7,787.57 X
21160   4 90 2 X 7,736.05 X
21160   3 90 2 X 7,841.08 X
21160   2 90 2 X 8,310.80 X
21160   1 90 2 X 8,528.96 X
21172   1 90 2 X 8,408.00 X
21172   2 90 2 X 8,408.00 X
21172   3 90 2 X 8,408.00 X
21172   4 90 2 X 8,408.00 X
21175   1 90 2 X 11,210.58 X
21175   2 90 2 X 11,210.58 X
21175   3 90 2 X 11,210.58 X
21175   4 90 2 X 11,210.58 X
21179   1 90 2 X 8,408.00 X
21179   2 90 2 X 8,408.00 X
21179   3 90 2 X 8,408.00 X
21179   4 90 2 X 8,408.00 X
21180   1 90 2 X 9,809.25 X
21180   2 90 2 X 9,809.25 X
21180   3 90 2 X 9,809.25 X
21180   4 90 2 X 9,809.25 X
21181   4 90 2 X 945.59 X
21181   3 90 2 X 956.38 X
21181   2 90 2 X 1,001.21 X
21181   1 90 2 X 1,012.02 X
21182   4 90 2 X 5,381.72 X
21182   3 90 2 X 5,454.84 X
21182   2 90 2 X 5,781.68 X
21182   1 90 2 X 5,933.46 X
21183   4 90 2 X 5,887.86 X
21183   3 90 2 X 5,967.87 X
21183   2 90 2 X 6,325.40 X
21183   1 90 2 X 6,491.50 X
21184   4 90 2 X 6,391.34 X
21184   3 90 2 X 6,478.20 X
21184   2 90 2 X 6,865.95 X
21184   1 90 2 X 7,046.08 X
21188   1 90 2 X 9,108.59 X
21188   2 90 2 X 9,108.59 X
21188   3 90 2 X 9,108.59 X
21188   4 90 2 X 9,108.59 X
21193   4 90 2 X 2,640.45 X
21193   3 90 2 X 2,672.13 X
21193   2 90 2 X 2,831.74 X
21193   1 90 2 X 2,870.31 X
21194   4 90 2 X 3,059.38 X
21194   3 90 2 X 3,095.98 X
21194   2 90 2 X 3,280.89 X
21194   1 90 2 X 3,325.61 X
21195   4 90 2 X 2,646.57 X
21195   3 90 2 X 2,678.24 X
21195   2 90 2 X 2,838.10 X
21195   1 90 2 X 2,876.81 X
21196   4 90 2 X 2,917.38 X
21196   3 90 2 X 2,952.26 X
21196   2 90 2 X 3,128.25 X
21196   1 90 2 X 3,170.69 X
21198   4 90 2 X 2,623.99 X
21198   3 90 2 X 2,656.84 X
21198   2 90 2 X 2,835.45 X
21198   1 90 2 X 2,878.57 X
21199   2 90 2 X 1,999.13 X
21199   3 90 2 X 1,999.13 X
21199   4 90 2 X 1,999.13 X
21199   1 90 2 X 2,214.35 X
21206   4 90 2 X 2,173.67 X
21206   3 90 2 X 2,199.66 X
21206   2 90 2 X 2,331.11 X
21206   1 90 2 X 2,362.84 X
21208   4 90 2 X 1,918.50 X
21208   3 90 2 X 2,213.78 X
21208   2 90 2 X 2,406.89 X
21208   1 90 2 X 2,507.08 X
21209   4 90 2 X 1,025.14 X
21209   3 90 2 X 1,037.08 X
21209   2 90 2 X 1,106.45 X
21209   1 90 2 X 3,086.23 X
21210   4 90 2 X 2,021.98 X
21210   3 90 2 X 2,260.11 X
21210   2 90 2 X 2,397.55 X
21210   1 90 2 X 2,789.85 X
21215   4 90 2 X 2,234.57 X
21215   3 90 2 X 2,263.61 X
21215   2 90 2 X 4,273.86 X
21215   1 90 2 X 4,398.63 X
21230   4 90 2 X 1,944.22 X
21230   1 90 2 X 2,149.67 X
21230   3 90 2 X 2,175.56 X
21230   2 90 2 X 2,265.05 X
21235   4 90 2 X 1,349.90 X
21235   3 90 2 X 1,366.98 X
21235   2 90 2 X 1,806.86 X
21235   1 90 2 X 1,888.96 X
21240   3 90 2 X 3,200.11 X
21240   4 90 2 X 4,142.18 X
21240   2 90 2 X 4,255.40 X
21240   1 90 2 X 4,278.28 X
21242   4 90 2 X 3,211.64 X
21242   3 90 2 X 3,254.74 X
21242   1 90 2 X 3,548.31 X
21242   2 90 2 X 4,676.10 X
21243   4 90 2 X 3,087.20 X
21243   3 90 2 X 3,124.14 X
21243   2 90 2 X 3,310.54 X
21243   1 90 2 X 3,355.62 X
21244     90 2 X * X
21245     90 2 X * X
21246     90 2 X * X
21247   4 90 2 X 4,420.55 X
21247   3 90 2 X 4,477.97 X
21247   2 90 2 X 4,759.29 X
21247   1 90 2 X 4,826.88 X
21248     90 2 X * X
21249     90 2 X * X
21255   4 90 2 X 3,264.98 X
21255   3 90 2 X 3,307.41 X
21255   2 90 2 X 3,515.29 X
21255   1 90 2 X 3,565.10 X
21256   4 90 2 X 3,162.01 X
21256   3 90 2 X 3,203.08 X
21256   2 90 2 X 3,404.50 X
21256   1 90 2 X 3,452.85 X
21260   4 90 2 X 3,226.07 X
21260   3 90 2 X 3,267.91 X
21260   2 90 2 X 3,473.34 X
21260   1 90 2 X 3,522.61 X
21261   4 90 2 X 4,311.94 X
21261   3 90 2 X 4,362.52 X
21261   2 90 2 X 4,588.22 X
21261   1 90 2 X 4,642.83 X
21263   4 90 2 X 5,551.00 X
21263   3 90 2 X 5,623.13 X
21263   2 90 2 X 5,976.48 X
21263   1 90 2 X 6,061.34 X
21267   4 90 2 X 3,027.31 X
21267   3 90 2 X 3,063.46 X
21267   2 90 2 X 3,266.66 X
21267   1 90 2 X 3,315.85 X
21268   4 90 2 X 3,649.19 X
21268   3 90 2 X 3,690.73 X
21268   2 90 2 X 3,951.02 X
21268   1 90 2 X 4,014.24 X
21270   4 90 2 X 2,035.05 X
21270   3 90 2 X 2,059.25 X
21270   2 90 2 X 2,194.55 X
21270   1 90 2 X 2,227.28 X
21275   4 90 2 X 1,821.95 X
21275   3 90 2 X 1,843.87 X
21275   2 90 2 X 1,965.73 X
21275   1 90 2 X 1,995.15 X
21280   4 90 2 X 1,176.37 X
21280   2 90 2 X 1,266.81 X
21280   1 90 2 X 1,284.83 X
21280   3 90 2 X 1,346.68 X
21282   4 90 2 X 969.39 X
21282   2 90 2 X 1,059.25 X
21282   1 90 2 X 1,077.71 X
21282   3 90 2 X 1,474.37 X
21295   4 90 2 X 222.38 X
21295   3 90 2 X 225.02 X
21295   2 90 2 X 238.52 X
21295   1 90 2 X 241.82 X
21296   4 90 2 X 685.19 X
21296   3 90 2 X 693.85 X
21296   2 90 2 X 730.32 X
21296   1 90 2 X 739.13 X
21299     YYY 2 X # X
21310   4 0 2 X 179.23 X
21310   3 0 2 X 185.56 X
21310   1 0 2 X 199.59 X
21310   2 0 2 X 201.47 X
21315   3 10 2 X 384.05 X
21315   2 10 2 X 387.80 X
21315   4 10 2 X 408.90 X
21315   1 10 2 X 435.22 X
21320   4 10 2 X 474.86 X
21320   3 10 2 X 486.04 X
21320   2 10 2 X 505.32 X
21320   1 10 2 X 521.10 X
21325   4 90 2 X 713.73 X
21325   3 90 2 X 722.63 X
21325   2 90 2 X 773.40 X
21325   1 90 2 X 785.64 X
21330   4 90 2 X 1,081.26 X
21330   3 90 2 X 1,114.86 X
21330   2 90 2 X 1,173.07 X
21330   1 90 2 X 1,226.71 X
21335   3 90 2 X 1,706.98 X
21335   2 90 2 X 1,809.14 X
21335   1 90 2 X 1,848.93 X
21335   4 90 2 X 1,867.30 X
21336   4 90 2 X 877.89 X
21336   3 90 2 X 888.34 X
21336   2 90 2 X 943.15 X
21336   1 90 2 X 956.44 X
21337   4 90 2 X 501.47 X
21337   3 90 2 X 507.75 X
21337   2 90 2 X 543.53 X
21337   1 90 2 X 552.13 X
21338   4 90 2 X 1,031.24 X
21338   3 90 2 X 1,043.59 X
21338   2 90 2 X 1,110.49 X
21338   1 90 2 X 1,126.71 X
21339   4 90 2 X 1,348.22 X
21339   3 90 2 X 1,364.91 X
21339   1 90 2 X 1,467.39 X
21339   2 90 2 X 2,241.78 X
21340   4 90 2 X 1,759.82 X
21340   3 90 2 X 1,781.28 X
21340   2 90 2 X 1,892.81 X
21340   1 90 2 X 1,919.79 X
21343   4 90 2 X 1,967.30 X
21343   3 90 2 X 1,990.84 X
21343   2 90 2 X 2,109.90 X
21343   1 90 2 X 2,138.65 X
21344   4 90 2 X 2,535.41 X
21344   3 90 2 X 2,564.16 X
21344   2 90 2 X 2,697.19 X
21344   1 90 2 X 2,729.43 X
21345   3 90 2 X 1,451.62 X
21345   2 90 2 X 1,543.05 X
21345   1 90 2 X 1,565.10 X
21345   4 90 2 X 1,572.51 X
21346   4 90 2 X 1,787.89 X
21346   3 90 2 X 1,809.97 X
21346   2 90 2 X 1,941.76 X
21346   1 90 2 X 1,951.14 X
21347   4 90 2 X 2,074.35 X
21347   3 90 2 X 2,099.46 X
21347   2 90 2 X 2,236.12 X
21347   1 90 2 X 2,269.19 X
21348   2 90 2 X 2,127.03 X
21348   4 90 2 X 2,570.80 X
21348   3 90 2 X 2,600.44 X
21348   1 90 2 X 2,831.00 X
21355   4 10 2 X 464.88 X
21355   3 10 2 X 470.05 X
21355   2 10 2 X 492.95 X
21355   1 10 2 X 498.50 X
21356   4 10 2 X 1,343.87 X
21356   1 10 2 X 1,403.33 X
21356   2 10 2 X 1,465.21 X
21356   3 10 2 X 1,504.07 X
21360   4 90 2 X 1,464.44 X
21360   1 90 2 X 1,529.96 X
21360   2 90 2 X 1,591.01 X
21360   3 90 2 X 1,626.02 X
21365   4 90 2 X 2,458.56 X
21365   3 90 2 X 2,543.46 X
21365   2 90 2 X 2,619.19 X
21365   1 90 2 X 2,668.49 X
21366   3 90 2 X 2,558.64 X
21366   2 90 2 X 2,634.31 X
21366   1 90 2 X 2,683.74 X
21366   4 90 2 X 2,737.42 X
21385   4 90 2 X 1,691.29 X
21385   3 90 2 X 1,712.51 X
21385   2 90 2 X 1,828.02 X
21385   1 90 2 X 1,855.88 X
21386   4 90 2 X 1,657.22 X
21386   3 90 2 X 1,677.71 X
21386   2 90 2 X 1,795.43 X
21386   1 90 2 X 1,823.90 X
21387   4 90 2 X 1,537.81 X
21387   3 90 2 X 1,556.29 X
21387   1 90 2 X 1,678.58 X
21387   2 90 2 X 2,394.04 X
21390   4 90 2 X 1,991.58 X
21390   1 90 2 X 2,190.29 X
21390   3 90 2 X 2,321.03 X
21390   2 90 2 X 2,457.26 X
21395   4 90 2 X 2,011.80 X
21395   3 90 2 X 2,035.77 X
21395   2 90 2 X 2,200.32 X
21395   1 90 2 X 2,201.34 X
21400   2 90 2 X 284.32 X
21400   3 90 2 X 677.55 X
21400   1 90 2 X 687.21 X
21400   4 90 2 X 727.36 X
21401   4 90 2 X 522.82 X
21401   3 90 2 X 529.18 X
21401   2 90 2 X 562.38 X
21401   1 90 2 X 570.46 X
21406   4 90 2 X 1,100.57 X
21406   3 90 2 X 1,280.42 X
21406   2 90 2 X 1,294.84 X
21406   1 90 2 X 1,350.03 X
21407   4 90 2 X 1,399.79 X
21407   3 90 2 X 1,416.86 X
21407   2 90 2 X 1,503.93 X
21407   1 90 2 X 1,524.87 X
21408   4 90 2 X 1,853.86 X
21408   3 90 2 X 1,875.93 X
21408   2 90 2 X 1,986.54 X
21408   1 90 2 X 2,013.32 X
21421   4 90 2 X 1,012.25 X
21421   3 90 2 X 1,675.33 X
21421   2 90 2 X 1,704.15 X
21421   1 90 2 X 1,711.14 X
21422   4 90 2 X 1,644.33 X
21422   3 90 2 X 1,665.26 X
21422   2 90 2 X 1,782.52 X
21422   1 90 2 X 1,810.78 X
21423   4 90 2 X 1,818.28 X
21423   3 90 2 X 1,840.82 X
21423   2 90 2 X 1,962.42 X
21423   1 90 2 X 1,991.70 X
21431   4 90 2 X 1,170.77 X
21431   3 90 2 X 1,185.11 X
21431   2 90 2 X 1,260.45 X
21431   1 90 2 X 1,278.68 X
21432   4 90 2 X 1,377.27 X
21432   3 90 2 X 1,393.86 X
21432   1 90 2 X 1,502.90 X
21432   2 90 2 X 3,236.60 X
21433   4 90 2 X 3,851.82 X
21433   3 90 2 X 3,897.97 X
21433   2 90 2 X 3,985.52 X
21433   1 90 2 X 4,186.66 X
21435   4 90 2 X 2,750.57 X
21435   3 90 2 X 2,783.45 X
21435   2 90 2 X 2,965.88 X
21435   1 90 2 X 3,010.04 X