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2021 Workers' Compensation Part B Fee Schedule

22850-24073

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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
22850   4 90 2 X 1,726.32 X
22850   3 90 2 X 1,747.33 X
22850   2 90 2 X 1,751.37 X
22850   1 90 2 X 1,908.63 X
22852   4 90 2 X 1,734.40 X
22852   3 90 2 X 1,755.76 X
22852   2 90 2 X 1,759.14 X
22852   1 90 2 X 1,777.80 X
22853   2 ZZZ 0 X 346.44 X
22853   3 ZZZ 0 X 346.44 X
22853   4 ZZZ 0 X 346.44 X
22853   1 ZZZ 0 X 384.13 X
22854   2 ZZZ 0 X 448.45 X
22854   3 ZZZ 0 X 448.45 X
22854   4 ZZZ 0 X 448.45 X
22854   1 ZZZ 0 X 497.28 X
22855   4 90 2 X 1,567.34 X
22855   3 90 2 X 1,585.87 X
22855   2 90 2 X 1,696.47 X
22855   1 90 2 X 1,723.27 X
22856   2 90 2 X 2,346.45 X
22856   3 90 2 X 2,346.45 X
22856   4 90 2 X 2,346.45 X
22856   1 90 2 X 2,662.68 X
22857   2 90 2 X 2,053.74 X
22857   3 90 2 X 2,053.74 X
22857   4 90 2 X 2,053.74 X
22857   1 90 2 X 2,312.88 X
22858   2 ZZZ 0 X 886.75 X
22858   3 ZZZ 0 X 886.75 X
22858   4 ZZZ 0 X 886.75 X
22858   1 ZZZ 0 X 1,013.38 X
22859   2 ZZZ 0 X 448.45 X
22859   3 ZZZ 0 X 448.45 X
22859   4 ZZZ 0 X 448.45 X
22859   1 ZZZ 0 X 497.28 X
22861   2 90 2 X 2,847.11 X
22861   3 90 2 X 2,847.11 X
22861   4 90 2 X 2,847.11 X
22861   1 90 2 X 3,166.89 X
22862   2 90 2 X 2,495.47 X
22862   3 90 2 X 2,495.47 X
22862   4 90 2 X 2,495.47 X
22862   1 90 2 X 2,837.39 X
22864   2 90 2 X 2,653.96 X
22864   3 90 2 X 2,653.96 X
22864   4 90 2 X 2,653.96 X
22864   1 90 2 X 3,003.49 X
22865   2 90 2 X 2,430.14 X
22865   3 90 2 X 2,430.14 X
22865   4 90 2 X 2,430.14 X
22865   1 90 2 X 2,762.51 X
22867   2 90 2 X 1,284.35 X
22867   3 90 2 X 1,284.35 X
22867   4 90 2 X 1,284.35 X
22867   1 90 2 X 1,432.94 X
22868   2 ZZZ 0 X 323.67 X
22868   3 ZZZ 0 X 323.67 X
22868   4 ZZZ 0 X 323.67 X
22868   1 ZZZ 0 X 358.35 X
22869   2 90 2 X 703.69 X
22869   3 90 2 X 703.69 X
22869   4 90 2 X 703.69 X
22869   1 90 2 X 784.76 X
22870   2 ZZZ 0 X 188.54 X
22870   3 ZZZ 0 X 188.54 X
22870   4 ZZZ 0 X 188.54 X
22870   1 ZZZ 0 X 208.53 X
22899     YYY 2 X # X
22900   4 90 2 X 790.51 X
22900   3 90 2 X 916.23 X
22900   2 90 2 X 958.71 X
22900   1 90 2 X 976.77 X
22901   2 90 2 X 956.06 X
22901   3 90 2 X 956.06 X
22901   4 90 2 X 956.06 X
22901   1 90 2 X 1,071.97 X
22902   2 90 2 X 592.13 477.66
22902   3 90 2 X 592.13 477.66
22902   4 90 2 X 592.13 477.66
22902   1 90 2 X 672.41 536.63
22903   2 90 2 X 630.25 X
22903   3 90 2 X 630.25 X
22903   4 90 2 X 630.25 X
22903   1 90 2 X 706.83 X
22904   2 90 2 X 1,501.73 X
22904   3 90 2 X 1,501.73 X
22904   4 90 2 X 1,501.73 X
22904   1 90 2 X 1,679.88 X
22905   2 90 2 X 1,947.40 X
22905   3 90 2 X 1,947.40 X
22905   4 90 2 X 1,947.40 X
22905   1 90 2 X 2,179.04 X
22999     YYY 2 X # X
23000   3 90 2 X 698.83 X
23000   4 90 2 X 749.85 X
23000   1 90 2 X 755.54 X
23000   2 90 2 X 774.92 X
23020   4 90 2 X 1,460.56 X
23020   3 90 2 X 1,478.11 X
23020   2 90 2 X 1,579.25 X
23020   1 90 2 X 1,603.73 X
23030   3 10 2 X 497.50 X
23030   4 10 2 X 499.84 X
23030   2 10 2 X 538.21 X
23030   1 10 2 X 546.12 X
23031   3 10 2 X 255.87 X
23031   4 10 2 X 256.58 X
23031   2 10 2 X 267.62 X
23031   1 10 2 X 305.18 X
23035   4 90 2 X 1,326.48 X
23035   3 90 2 X 1,342.11 X
23035   2 90 2 X 1,434.84 X
23035   1 90 2 X 1,457.29 X
23040   4 90 2 X 1,678.85 X
23040   3 90 2 X 1,699.42 X
23040   2 90 2 X 1,827.30 X
23040   1 90 2 X 1,858.25 X
23044   4 90 2 X 1,272.24 X
23044   1 90 2 X 1,410.59 X
23044   3 90 2 X 1,477.24 X
23044   2 90 2 X 1,574.31 X
23065   2 10 2 X 235.91 X
23065   3 10 2 X 237.91 X
23065   4 10 2 X 265.34 X
23065   1 10 2 X 283.17 X
23066   4 90 2 X 330.60 X
23066   3 90 2 X 345.78 X
23066   2 90 2 X 357.02 X
23066   1 90 2 X 362.74 X
23071   2 90 2 X 598.70 X
23071   3 90 2 X 598.70 X
23071   4 90 2 X 598.70 X
23071   1 90 2 X 673.68 X
23073   2 90 2 X 993.23 X
23073   3 90 2 X 993.23 X
23073   4 90 2 X 993.23 X
23073   1 90 2 X 1,115.29 X
23075   4 10 2 X 360.34 X
23075   3 10 2 X 384.59 X
23075   2 10 2 X 412.26 X
23075   1 10 2 X 416.70 X
23076   4 90 2 X 946.03 X
23076   3 90 2 X 956.62 X
23076   2 90 2 X 984.77 X
23076   1 90 2 X 1,044.49 X
23077   3 90 2 X 1,522.64 X
23077   2 90 2 X 1,597.57 X
23077   1 90 2 X 1,607.53 X
23077   4 90 2 X 2,071.09 X
23078   2 90 2 X 2,026.94 X
23078   3 90 2 X 2,026.94 X
23078   4 90 2 X 2,026.94 X
23078   1 90 2 X 2,267.56 X
23100   4 90 2 X 1,235.44 X
23100   3 90 2 X 1,372.38 X
23100   1 90 2 X 1,376.62 X
23100   2 90 2 X 1,475.79 X
23101   4 90 2 X 1,159.14 X
23101   3 90 2 X 1,339.99 X
23101   2 90 2 X 1,441.64 X
23101   1 90 2 X 1,453.56 X
23105   4 90 2 X 1,699.44 X
23105   3 90 2 X 1,850.60 X
23105   2 90 2 X 1,990.76 X
23105   1 90 2 X 2,039.05 X
23106   4 90 2 X 977.48 X
23106   2 90 2 X 1,059.27 X
23106   3 90 2 X 1,874.16 X
23106   1 90 2 X 1,997.07 X
23107   4 90 2 X 1,695.34 X
23107   3 90 2 X 1,716.21 X
23107   2 90 2 X 1,850.55 X
23107   1 90 2 X 1,883.07 X
23120   4 90 2 X 1,254.94 X
23120   3 90 2 X 1,260.08 X
23120   2 90 2 X 1,289.24 X
23120   1 90 2 X 1,296.27 X
23125   4 90 2 X 1,639.36 X
23125   3 90 2 X 1,659.22 X
23125   1 90 2 X 1,803.62 X
23125   2 90 2 X 2,021.19 X
23130   3 90 2 X 1,359.76 X
23130   4 90 2 X 1,360.84 X
23130   2 90 2 X 1,459.35 X
23130   1 90 2 X 1,483.38 X
23140   4 90 2 X 999.42 X
23140   3 90 2 X 1,010.82 X
23140   2 90 2 X 1,077.08 X
23140   1 90 2 X 1,093.14 X
23145   4 90 2 X 1,581.48 X
23145   3 90 2 X 1,600.44 X
23145   2 90 2 X 1,716.64 X
23145   1 90 2 X 1,744.72 X
23146   4 90 2 X 1,197.52 X
23146   3 90 2 X 1,211.33 X
23146   2 90 2 X 1,296.65 X
23146   1 90 2 X 1,317.36 X
23150   1 90 2 X 1,491.84 X
23150   4 90 2 X 1,731.00 X
23150   3 90 2 X 1,737.81 X
23150   2 90 2 X 1,777.11 X
23155   4 90 2 X 1,737.46 X
23155   3 90 2 X 1,758.41 X
23155   2 90 2 X 1,882.40 X
23155   1 90 2 X 1,912.40 X
23156   4 90 2 X 1,484.05 X
23156   3 90 2 X 1,501.93 X
23156   2 90 2 X 1,611.01 X
23156   1 90 2 X 1,637.42 X
23170   4 90 2 X 1,044.68 X
23170   3 90 2 X 1,056.89 X
23170   2 90 2 X 1,128.21 X
23170   1 90 2 X 1,145.50 X
23172   2 90 2 X 1,037.92 X
23172   4 90 2 X 1,067.91 X
23172   3 90 2 X 1,080.74 X
23172   1 90 2 X 1,168.88 X
23174   4 90 2 X 1,622.98 X
23174   3 90 2 X 1,642.85 X
23174   2 90 2 X 1,756.63 X
23174   1 90 2 X 1,784.04 X
23180   3 90 2 X 1,022.70 X
23180   4 90 2 X 1,130.99 X
23180   2 90 2 X 1,211.40 X
23180   1 90 2 X 1,227.81 X
23182   4 90 2 X 1,331.35 X
23182   3 90 2 X 1,347.20 X
23182   2 90 2 X 1,444.58 X
23182   1 90 2 X 1,468.12 X
23184   4 90 2 X 1,255.57 X
23184   3 90 2 X 1,683.08 X
23184   2 90 2 X 1,809.64 X
23184   1 90 2 X 1,840.23 X
23190   4 90 2 X 1,217.00 X
23190   3 90 2 X 1,231.53 X
23190   2 90 2 X 1,302.57 X
23190   1 90 2 X 1,339.89 X
23195   4 90 2 X 1,701.58 X
23195   3 90 2 X 1,722.21 X
23195   2 90 2 X 1,848.82 X
23195   1 90 2 X 1,879.37 X
23200   4 90 2 X 1,889.39 X
23200   3 90 2 X 1,912.08 X
23200   2 90 2 X 2,035.39 X
23200   1 90 2 X 2,066.25 X
23210   4 90 2 X 1,921.36 X
23210   3 90 2 X 1,943.99 X
23210   2 90 2 X 2,074.71 X
23210   1 90 2 X 3,419.07 X
23220   4 90 2 X 2,408.77 X
23220   3 90 2 X 2,591.94 X
23220   1 90 2 X 2,656.42 X
23220   2 90 2 X 2,665.93 X
23330   4 10 2 X 215.20 X
23330   3 10 2 X 217.52 X
23330   2 10 2 X 227.23 X
23330   1 10 2 X 229.64 X
23333   2 90 2 X 618.96 X
23333   3 90 2 X 618.96 X
23333   4 90 2 X 618.96 X
23333   1 90 2 X 689.62 X
23334   2 90 2 X 1,467.91 X
23334   3 90 2 X 1,467.91 X
23334   4 90 2 X 1,467.91 X
23334   1 90 2 X 1,628.88 X
23335   2 90 2 X 1,753.04 X
23335   3 90 2 X 1,753.04 X
23335   4 90 2 X 1,753.04 X
23335   1 90 2 X 1,942.63 X
23350   4 0 2 X 130.06 X
23350   3 0 2 X 131.54 X
23350   2 0 2 X 138.11 X
23350   1 0 2 X 139.63 X
23395   4 90 2 X 2,233.15 X
23395   3 90 2 X 2,259.83 X
23395   2 90 2 X 2,421.55 X
23395   1 90 2 X 2,460.67 X
23397   4 90 2 X 2,774.55 X
23397   3 90 2 X 2,807.79 X
23397   2 90 2 X 3,011.44 X
23397   1 90 2 X 3,060.71 X
23400   4 90 2 X 2,156.80 X
23400   3 90 2 X 2,182.03 X
23400   2 90 2 X 2,331.64 X
23400   1 90 2 X 2,367.90 X
23405   4 90 2 X 1,445.34 X
23405   3 90 2 X 1,462.96 X
23405   2 90 2 X 1,560.51 X
23405   1 90 2 X 1,584.08 X
23406   4 90 2 X 1,874.54 X
23406   3 90 2 X 1,896.94 X
23406   2 90 2 X 2,034.34 X
23406   1 90 2 X 2,067.63 X
23410   4 90 2 X 2,161.98 X
23410   3 90 2 X 2,188.02 X
23410   2 90 2 X 2,343.81 X
23410   1 90 2 X 2,381.48 X
23412   4 90 2 X 2,477.86 X
23412   3 90 2 X 2,535.81 X
23412   2 90 2 X 2,681.34 X
23412   1 90 2 X 2,815.79 X
23415   3 90 2 X 1,874.80 X
23415   1 90 2 X 1,879.59 X
23415   4 90 2 X 1,883.45 X
23415   2 90 2 X 1,898.44 X
23420   4 90 2 X 2,602.08 X
23420   3 90 2 X 2,607.60 X
23420   2 90 2 X 2,763.51 X
23420   1 90 2 X 2,780.64 X
23430   4 90 2 X 1,593.53 X
23430   3 90 2 X 1,612.24 X
23430   2 90 2 X 1,720.84 X
23430   1 90 2 X 1,747.08 X
23440   4 90 2 X 1,623.52 X
23440   3 90 2 X 1,642.43 X
23440   2 90 2 X 1,750.42 X
23440   1 90 2 X 1,776.59 X
23450   4 90 2 X 2,427.96 X
23450   3 90 2 X 2,457.42 X
23450   1 90 2 X 2,552.74 X
23450   2 90 2 X 2,647.58 X
23455   4 90 2 X 2,797.38 X
23455   3 90 2 X 2,831.71 X
23455   2 90 2 X 3,046.99 X
23455   1 90 2 X 3,099.05 X
23460   4 90 2 X 2,721.71 X
23460   3 90 2 X 2,754.60 X
23460   2 90 2 X 2,952.91 X
23460   1 90 2 X 3,000.87 X
23462   4 90 2 X 2,831.06 X
23462   3 90 2 X 2,865.51 X
23462   2 90 2 X 3,079.50 X
23462   1 90 2 X 3,131.28 X
23465   3 90 2 X 2,581.58 X
23465   4 90 2 X 2,775.59 X
23465   2 90 2 X 2,939.51 X
23465   1 90 2 X 2,979.93 X
23466   4 90 2 X 2,880.44 X
23466   3 90 2 X 2,916.04 X
23466   2 90 2 X 3,142.93 X
23466   1 90 2 X 3,197.84 X
23470   4 90 2 X 3,120.79 X
23470   3 90 2 X 3,158.77 X
23470   2 90 2 X 3,391.58 X
23470   1 90 2 X 3,481.44 X
23472   4 90 2 X 4,192.92 X
23472   1 90 2 X 4,716.15 X
23472   3 90 2 X 5,203.39 X
23472   2 90 2 X 5,350.01 X
23473   2 90 2 X 2,239.63 X
23473   3 90 2 X 2,239.63 X
23473   4 90 2 X 2,239.63 X
23473   1 90 2 X 2,499.23 X
23474   2 90 2 X 2,421.34 X
23474   3 90 2 X 2,421.34 X
23474   4 90 2 X 2,421.34 X
23474   1 90 2 X 2,702.05 X
23480   4 90 2 X 1,603.63 X
23480   3 90 2 X 1,622.09 X
23480   2 90 2 X 1,721.89 X
23480   1 90 2 X 1,746.23 X
23485   4 90 2 X 2,278.39 X
23485   3 90 2 X 2,305.65 X
23485   2 90 2 X 2,422.92 X
23485   1 90 2 X 2,510.15 X
23490   3 90 2 X 1,785.80 X
23490   4 90 2 X 1,941.39 X
23490   2 90 2 X 2,075.42 X
23490   1 90 2 X 2,101.87 X
23491   3 90 2 X 2,418.21 X
23491   4 90 2 X 2,500.16 X
23491   2 90 2 X 2,713.76 X
23491   1 90 2 X 2,758.21 X
23500   3 90 2 X 349.21 X
23500   4 90 2 X 353.80 X
23500   1 90 2 X 365.68 X
23500   2 90 2 X 409.50 X
23505   3 90 2 X 567.96 X
23505   4 90 2 X 571.71 X
23505   1 90 2 X 584.81 X
23505   2 90 2 X 615.27 X
23515   4 90 2 X 1,323.55 X
23515   3 90 2 X 1,339.63 X
23515   2 90 2 X 1,437.51 X
23515   1 90 2 X 1,461.20 X
23520   4 90 2 X 317.40 X
23520   3 90 2 X 317.62 X
23520   2 90 2 X 340.61 X
23520   1 90 2 X 345.26 X
23525   4 90 2 X 498.71 X
23525   3 90 2 X 504.42 X
23525   2 90 2 X 533.33 X
23525   1 90 2 X 540.28 X
23530   4 90 2 X 1,275.12 X
23530   3 90 2 X 1,290.69 X
23530   2 90 2 X 1,378.08 X
23530   1 90 2 X 1,399.20 X
23532   4 90 2 X 1,406.72 X
23532   3 90 2 X 1,423.64 X
23532   2 90 2 X 1,527.21 X
23532   1 90 2 X 1,552.34 X
23540   4 90 2 X 338.03 X
23540   3 90 2 X 342.00 X
23540   2 90 2 X 362.52 X
23540   1 90 2 X 367.48 X
23545   4 90 2 X 485.25 X
23545   3 90 2 X 496.76 X
23545   2 90 2 X 561.37 X
23545   1 90 2 X 564.29 X
23550   4 90 2 X 1,456.62 X
23550   3 90 2 X 1,474.65 X
23550   1 90 2 X 1,623.32 X
23550   2 90 2 X 1,667.09 X
23552   4 90 2 X 1,432.17 X
23552   3 90 2 X 1,449.39 X
23552   2 90 2 X 1,553.02 X
23552   1 90 2 X 1,578.13 X
23570   4 90 2 X 356.07 X
23570   3 90 2 X 360.29 X
23570   2 90 2 X 384.01 X
23570   1 90 2 X 389.76 X
23575   4 90 2 X 621.63 X
23575   3 90 2 X 636.50 X
23575   2 90 2 X 669.45 X
23575   1 90 2 X 679.24 X
23585   4 90 2 X 1,529.92 X
23585   3 90 2 X 1,548.30 X
23585   2 90 2 X 1,660.27 X
23585   1 90 2 X 1,687.38 X
23600   1 90 2 X 612.91 X
23600   4 90 2 X 622.91 X
23600   2 90 2 X 634.21 X
23600   3 90 2 X 639.24 X
23605   4 90 2 X 885.07 X
23605   3 90 2 X 964.26 X
23605   1 90 2 X 1,043.59 X
23605   2 90 2 X 1,058.54 X
23615   3 90 2 X 1,852.80 X
23615   4 90 2 X 1,926.79 X
23615   2 90 2 X 2,000.97 X
23615   1 90 2 X 2,250.39 X
23616   4 90 2 X 3,007.76 X
23616   1 90 2 X 3,442.22 X
23616   3 90 2 X 4,063.54 X
23616   2 90 2 X 4,370.41 X
23620   1 90 2 X 625.65 X
23620   4 90 2 X 632.78 X
23620   3 90 2 X 638.10 X
23620   2 90 2 X 655.49 X
23625   3 90 2 X 716.48 X
23625   4 90 2 X 730.55 X
23625   2 90 2 X 769.37 X
23625   1 90 2 X 782.19 X
23630   4 90 2 X 1,818.28 X
23630   3 90 2 X 1,826.15 X
23630   2 90 2 X 1,876.25 X
23630   1 90 2 X 1,888.38 X
23650   3 90 2 X 504.30 X
23650   4 90 2 X 522.48 X
23650   2 90 2 X 543.90 X
23650   1 90 2 X 570.67 X
23655   4 90 2 X 672.40 X
23655   3 90 2 X 680.19 X
23655   2 90 2 X 722.91 X
23655   1 90 2 X 733.29 X
23660   3 90 2 X 1,907.18 X
23660   4 90 2 X 1,933.15 X
23660   2 90 2 X 2,011.15 X
23660   1 90 2 X 2,080.54 X
23665   4 90 2 X 729.35 X
23665   3 90 2 X 732.34 X
23665   2 90 2 X 763.35 X
23665   1 90 2 X 775.02 X
23670   4 90 2 X 1,719.94 X
23670   3 90 2 X 1,816.67 X
23670   2 90 2 X 1,888.38 X
23670   1 90 2 X 1,923.93 X
23675   4 90 2 X 893.80 X
23675   3 90 2 X 904.18 X
23675   2 90 2 X 962.44 X
23675   1 90 2 X 976.51 X
23680   4 90 2 X 2,087.56 X
23680   3 90 2 X 2,113.52 X
23680   2 90 2 X 2,286.32 X
23680   1 90 2 X 2,328.10 X
23700   4 10 2 X 600.28 X
23700   3 10 2 X 602.43 X
23700   2 10 2 X 613.54 X
23700   1 10 2 X 618.23 X
23800   4 90 2 X 2,832.31 X
23800   3 90 2 X 2,867.41 X
23800   2 90 2 X 3,091.02 X
23800   1 90 2 X 3,145.10 X
23802   4 90 2 X 2,722.58 X
23802   3 90 2 X 2,755.49 X
23802   2 90 2 X 2,953.84 X
23802   1 90 2 X 3,001.80 X
23900   4 90 2 X 2,943.88 X
23900   3 90 2 X 2,977.69 X
23900   2 90 2 X 3,183.55 X
23900   1 90 2 X 3,233.53 X
23920   4 90 2 X 2,635.13 X
23920   3 90 2 X 2,666.77 X
23920   2 90 2 X 2,874.43 X
23920   1 90 2 X 2,924.65 X
23921   4 90 2 X 884.43 X
23921   3 90 2 X 894.91 X
23921   2 90 2 X 959.04 X
23921   1 90 2 X 974.59 X
23929     YYY 2 X # X
23930   3 10 2 X 413.48 X
23930   4 10 2 X 415.03 X
23930   2 10 2 X 437.81 X
23930   1 10 2 X 443.78 X
23931   4 10 2 X 219.97 X
23931   3 10 2 X 223.07 X
23931   2 10 2 X 237.49 X
23931   1 10 2 X 238.00 X
23935   4 90 2 X 970.59 X
23935   3 90 2 X 982.12 X
23935   2 90 2 X 1,051.22 X
23935   1 90 2 X 1,067.89 X
24000   4 90 2 X 1,291.89 X
24000   1 90 2 X 1,448.79 X
24000   2 90 2 X 1,554.03 X
24000   3 90 2 X 1,611.51 X
24006   4 90 2 X 1,497.58 X
24006   3 90 2 X 1,515.30 X
24006   2 90 2 X 1,620.11 X
24006   1 90 2 X 1,645.53 X
24065   3 10 2 X 234.07 X
24065   4 10 2 X 258.61 X
24065   2 10 2 X 274.15 X
24065   1 10 2 X 277.22 X
24066   3 90 2 X 486.00 X
24066   2 90 2 X 500.81 X
24066   1 90 2 X 514.33 X
24066   4 90 2 X 713.19 X
24071   2 90 2 X 580.36 X
24071   3 90 2 X 580.36 X
24071   4 90 2 X 580.36 X
24071   1 90 2 X 652.81 X
24073   2 90 2 X 998.08 X
24073   3 90 2 X 998.08 X
24073   4 90 2 X 998.08 X
24073   1 90 2 X 1,120.72 X