Begin Main Content Area

2021 Workers' Compensation Part B Fee Schedule

24075-25109

View the PDF


CPT/HCPC Code Modifier Medicare Location Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount Site of Service Amount
24075   4 90 2 X 487.96 X
24075   2 90 2 X 505.57 X
24075   3 90 2 X 506.81 X
24075   1 90 2 X 518.01 X
24076   4 90 2 X 843.54 X
24076   3 90 2 X 907.44 X
24076   2 90 2 X 936.93 X
24076   1 90 2 X 975.22 X
24077   3 90 2 X 1,487.83 X
24077   2 90 2 X 1,573.77 X
24077   4 90 2 X 2,009.85 X
24077   1 90 2 X 2,224.01 X
24079   2 90 2 X 1,867.88 X
24079   3 90 2 X 1,867.88 X
24079   4 90 2 X 1,867.88 X
24079   1 90 2 X 2,090.53 X
24100   4 90 2 X 843.70 X
24100   3 90 2 X 853.82 X
24100   1 90 2 X 929.65 X
24100   2 90 2 X 1,392.87 X
24101   2 90 2 X 1,549.85 X
24101   4 90 2 X 1,617.40 X
24101   3 90 2 X 1,624.32 X
24101   1 90 2 X 1,830.38 X
24102   3 90 2 X 1,861.15 X
24102   4 90 2 X 1,881.62 X
24102   2 90 2 X 1,978.14 X
24102   1 90 2 X 2,052.23 X
24105   3 90 2 X 747.04 X
24105   4 90 2 X 807.47 X
24105   2 90 2 X 874.92 X
24105   1 90 2 X 899.99 X
24110   4 90 2 X 1,403.89 X
24110   3 90 2 X 1,421.09 X
24110   1 90 2 X 1,552.85 X
24110   2 90 2 X 1,622.51 X
24115   4 90 2 X 1,574.43 X
24115   3 90 2 X 1,593.10 X
24115   2 90 2 X 1,707.74 X
24115   1 90 2 X 1,735.49 X
24116   4 90 2 X 1,963.63 X
24116   3 90 2 X 1,987.16 X
24116   2 90 2 X 2,123.40 X
24116   1 90 2 X 2,156.42 X
24120   3 90 2 X 1,403.63 X
24120   1 90 2 X 1,512.36 X
24120   4 90 2 X 1,548.40 X
24120   2 90 2 X 1,590.43 X
24125   4 90 2 X 1,214.32 X
24125   3 90 2 X 1,228.97 X
24125   2 90 2 X 1,300.75 X
24125   1 90 2 X 1,318.09 X
24126   4 90 2 X 1,438.83 X
24126   3 90 2 X 1,456.18 X
24126   2 90 2 X 1,561.90 X
24126   1 90 2 X 1,587.46 X
24130   3 90 2 X 1,262.43 X
24130   4 90 2 X 1,276.10 X
24130   2 90 2 X 1,355.47 X
24130   1 90 2 X 1,387.61 X
24134   4 90 2 X 1,661.51 X
24134   3 90 2 X 1,681.75 X
24134   2 90 2 X 1,798.05 X
24134   1 90 2 X 1,826.20 X
24136   3 90 2 X 1,280.51 X
24136   4 90 2 X 1,492.15 X
24136   2 90 2 X 1,611.07 X
24136   1 90 2 X 1,635.07 X
24138   4 90 2 X 1,302.73 X
24138   3 90 2 X 1,318.24 X
24138   2 90 2 X 1,350.63 X
24138   1 90 2 X 1,434.29 X
24140   4 90 2 X 1,650.76 X
24140   3 90 2 X 1,670.75 X
24140   2 90 2 X 1,795.69 X
24140   1 90 2 X 1,825.87 X
24145   4 90 2 X 1,277.90 X
24145   3 90 2 X 1,293.20 X
24145   2 90 2 X 1,384.80 X
24145   1 90 2 X 1,406.93 X
24147   4 90 2 X 1,291.16 X
24147   3 90 2 X 1,297.89 X
24147   2 90 2 X 1,401.24 X
24147   1 90 2 X 1,424.16 X
24149   3 90 2 X 2,397.45 X
24149   4 90 2 X 2,397.45 X
24149   2 90 2 X 2,463.63 X
24149   1 90 2 X 2,753.94 X
24150   4 90 2 X 2,522.86 X
24150   3 90 2 X 2,553.89 X
24150   2 90 2 X 2,747.35 X
24150   1 90 2 X 3,054.12 X
24152   4 90 2 X 1,540.74 X
24152   3 90 2 X 1,558.60 X
24152   2 90 2 X 1,663.10 X
24152   1 90 2 X 1,688.42 X
24155   4 90 2 X 2,072.25 X
24155   3 90 2 X 2,369.97 X
24155   2 90 2 X 2,806.18 X
24155   1 90 2 X 2,840.64 X
24160   4 90 2 X 1,152.83 X
24160   3 90 2 X 1,166.13 X
24160   2 90 2 X 1,240.89 X
24160   1 90 2 X 1,259.05 X
24164   4 90 2 X 1,073.66 X
24164   3 90 2 X 1,086.60 X
24164   2 90 2 X 1,165.48 X
24164   1 90 2 X 1,184.58 X
24200   2 10 2 X 160.61 X
24200   3 10 2 X 173.78 X
24200   1 10 2 X 179.88 X
24200   4 10 2 X 193.88 X
24201   4 90 2 X 692.26 X
24201   3 90 2 X 700.36 X
24201   2 90 2 X 744.51 X
24201   1 90 2 X 757.42 X
24220   4 0 2 X 104.89 X
24220   1 0 2 X 143.23 X
24220   3 0 2 X 156.75 X
24220   2 0 2 X 163.88 X
24300   2 90 2 X 641.98 X
24300   3 90 2 X 641.98 X
24300   4 90 2 X 641.98 X
24300   1 90 2 X 736.36 X
24301   3 90 2 X 1,513.15 X
24301   2 90 2 X 1,620.33 X
24301   4 90 2 X 1,664.80 X
24301   1 90 2 X 1,825.70 X
24305   4 90 2 X 931.66 X
24305   3 90 2 X 942.13 X
24305   2 90 2 X 985.79 X
24305   1 90 2 X 996.35 X
24310   4 90 2 X 809.02 X
24310   3 90 2 X 818.12 X
24310   2 90 2 X 866.20 X
24310   1 90 2 X 877.85 X
24320   3 90 2 X 1,823.25 X
24320   2 90 2 X 1,946.53 X
24320   4 90 2 X 2,283.38 X
24320   1 90 2 X 2,429.90 X
24330   2 90 2 X 1,074.90 X
24330   3 90 2 X 1,721.88 X
24330   4 90 2 X 1,877.19 X
24330   1 90 2 X 1,877.53 X
24331   4 90 2 X 1,871.85 X
24331   3 90 2 X 1,894.39 X
24331   2 90 2 X 2,031.98 X
24331   1 90 2 X 2,065.31 X
24332   2 90 2 X 896.39 X
24332   3 90 2 X 896.39 X
24332   4 90 2 X 896.39 X
24332   1 90 2 X 1,008.08 X
24340   4 90 2 X 1,380.96 X
24340   2 90 2 X 1,497.54 X
24340   3 90 2 X 1,523.24 X
24340   1 90 2 X 1,671.33 X
24341   3 90 2 X 1,325.69 X
24341   4 90 2 X 1,325.69 X
24341   2 90 2 X 1,362.28 X
24341   1 90 2 X 1,522.60 X
24342   4 90 2 X 1,956.68 X
24342   3 90 2 X 1,980.35 X
24342   2 90 2 X 2,129.79 X
24342   1 90 2 X 2,165.95 X
24343   2 90 2 X 1,177.22 X
24343   3 90 2 X 1,177.22 X
24343   4 90 2 X 1,177.22 X
24343   1 90 2 X 1,341.93 X
24344   2 90 2 X 1,779.34 X
24344   3 90 2 X 1,779.34 X
24344   4 90 2 X 1,779.34 X
24344   1 90 2 X 2,023.56 X
24345   2 90 2 X 1,177.22 X
24345   3 90 2 X 1,177.22 X
24345   4 90 2 X 1,177.22 X
24345   1 90 2 X 1,341.93 X
24346   2 90 2 X 1,779.34 X
24346   3 90 2 X 1,779.34 X
24346   4 90 2 X 1,779.34 X
24346   1 90 2 X 2,023.56 X
24357   2 90 2 X 615.09 X
24357   3 90 2 X 615.09 X
24357   4 90 2 X 615.09 X
24357   1 90 2 X 707.02 X
24358   2 90 2 X 723.46 X
24358   3 90 2 X 723.46 X
24358   4 90 2 X 723.46 X
24358   1 90 2 X 829.68 X
24359   2 90 2 X 891.57 X
24359   3 90 2 X 891.57 X
24359   4 90 2 X 891.57 X
24359   1 90 2 X 1,016.45 X
24360   4 90 2 X 2,566.90 X
24360   1 90 2 X 2,855.71 X
24360   3 90 2 X 3,145.81 X
24360   2 90 2 X 3,388.91 X
24361   4 90 2 X 2,515.99 X
24361   3 90 2 X 2,546.50 X
24361   2 90 2 X 2,727.47 X
24361   1 90 2 X 2,771.27 X
24362   4 90 2 X 2,489.86 X
24362   3 90 2 X 2,521.15 X
24362   2 90 2 X 2,654.21 X
24362   1 90 2 X 3,008.79 X
24363   4 90 2 X 3,991.82 X
24363   3 90 2 X 4,125.38 X
24363   2 90 2 X 4,446.57 X
24363   1 90 2 X 4,547.19 X
24365   4 90 2 X 1,462.34 X
24365   3 90 2 X 1,479.91 X
24365   2 90 2 X 1,585.82 X
24365   1 90 2 X 2,385.95 X
24366   4 90 2 X 1,886.44 X
24366   3 90 2 X 1,909.91 X
24366   2 90 2 X 3,191.03 X
24366   1 90 2 X 3,230.15 X
24370   2 90 2 X 2,114.04 X
24370   3 90 2 X 2,114.04 X
24370   4 90 2 X 2,114.04 X
24370   1 90 2 X 2,356.00 X
24371   2 90 2 X 2,437.79 X
24371   3 90 2 X 2,437.79 X
24371   4 90 2 X 2,437.79 X
24371   1 90 2 X 2,715.30 X
24400   4 90 2 X 1,792.34 X
24400   3 90 2 X 1,813.51 X
24400   2 90 2 X 1,937.67 X
24400   1 90 2 X 1,967.79 X
24410   4 90 2 X 2,669.32 X
24410   3 90 2 X 2,701.80 X
24410   2 90 2 X 2,759.29 X
24410   1 90 2 X 2,937.60 X
24420   4 90 2 X 2,391.69 X
24420   3 90 2 X 2,420.51 X
24420   2 90 2 X 2,596.29 X
24420   1 90 2 X 2,638.83 X
24430   4 90 2 X 2,566.65 X
24430   3 90 2 X 2,598.40 X
24430   2 90 2 X 2,798.98 X
24430   1 90 2 X 2,847.48 X
24435   4 90 2 X 2,748.28 X
24435   3 90 2 X 2,782.48 X
24435   2 90 2 X 3,012.19 X
24435   1 90 2 X 3,067.67 X
24470   4 90 2 X 1,541.48 X
24470   3 90 2 X 1,559.97 X
24470   2 90 2 X 1,673.37 X
24470   1 90 2 X 1,700.79 X
24495   1 90 2 X 1,401.16 X
24495   4 90 2 X 1,486.09 X
24495   3 90 2 X 1,492.28 X
24495   2 90 2 X 1,531.02 X
24498   4 90 2 X 2,048.86 X
24498   3 90 2 X 2,073.52 X
24498   2 90 2 X 2,219.76 X
24498   1 90 2 X 2,255.09 X
24500   3 90 2 X 586.08 X
24500   4 90 2 X 586.25 X
24500   1 90 2 X 613.68 X
24500   2 90 2 X 626.21 X
24505   3 90 2 X 914.87 X
24505   4 90 2 X 927.61 X
24505   2 90 2 X 991.33 X
24505   1 90 2 X 992.25 X
24515   4 90 2 X 1,945.35 X
24515   3 90 2 X 1,968.60 X
24515   2 90 2 X 2,106.92 X
24515   1 90 2 X 2,140.44 X
24516   4 90 2 X 1,945.35 X
24516   3 90 2 X 1,968.60 X
24516   2 90 2 X 2,106.92 X
24516   1 90 2 X 2,140.44 X
24530   4 90 2 X 592.78 X
24530   3 90 2 X 593.99 X
24530   2 90 2 X 613.03 X
24530   1 90 2 X 622.39 X
24535   3 90 2 X 981.90 X
24535   4 90 2 X 1,054.20 X
24535   1 90 2 X 1,110.56 X
24535   2 90 2 X 1,118.28 X
24538   3 90 2 X 1,290.04 X
24538   4 90 2 X 1,346.61 X
24538   2 90 2 X 1,442.22 X
24538   1 90 2 X 1,750.52 X
24545   4 90 2 X 1,992.20 X
24545   3 90 2 X 2,005.34 X
24545   2 90 2 X 2,085.78 X
24545   1 90 2 X 2,105.25 X
24546   4 90 2 X 2,215.44 X
24546   3 90 2 X 2,230.69 X
24546   2 90 2 X 2,316.59 X
24546   1 90 2 X 2,337.44 X
24560   3 90 2 X 495.05 X
24560   4 90 2 X 499.31 X
24560   2 90 2 X 510.62 X
24560   1 90 2 X 521.03 X
24565   3 90 2 X 715.84 X
24565   2 90 2 X 755.10 X
24565   1 90 2 X 759.98 X
24565   4 90 2 X 813.19 X
24566   4 90 2 X 1,249.00 X
24566   3 90 2 X 1,271.14 X
24566   2 90 2 X 1,354.36 X
24566   1 90 2 X 1,372.69 X
24575   4 90 2 X 1,667.97 X
24575   3 90 2 X 1,687.71 X
24575   2 90 2 X 1,801.37 X
24575   1 90 2 X 1,828.94 X
24576   4 90 2 X 482.01 X
24576   3 90 2 X 486.79 X
24576   2 90 2 X 519.73 X
24576   1 90 2 X 521.02 X
24577   4 90 2 X 886.39 X
24577   3 90 2 X 896.78 X
24577   2 90 2 X 922.01 X
24577   1 90 2 X 933.94 X
24579   4 90 2 X 1,811.25 X
24579   3 90 2 X 1,832.58 X
24579   2 90 2 X 1,955.81 X
24579   1 90 2 X 1,991.49 X
24582   4 90 2 X 1,364.76 X
24582   3 90 2 X 1,381.03 X
24582   2 90 2 X 1,513.82 X
24582   1 90 2 X 1,542.31 X
24586   3 90 2 X 2,641.96 X
24586   4 90 2 X 2,762.62 X
24586   2 90 2 X 3,019.51 X
24586   1 90 2 X 3,052.43 X
24587   4 90 2 X 2,649.47 X
24587   3 90 2 X 2,681.48 X
24587   2 90 2 X 2,874.21 X
24587   1 90 2 X 2,920.82 X
24600   4 90 2 X 556.50 X
24600   3 90 2 X 562.75 X
24600   2 90 2 X 592.59 X
24600   1 90 2 X 621.74 X
24605   4 90 2 X 685.63 X
24605   3 90 2 X 699.68 X
24605   2 90 2 X 731.57 X
24605   1 90 2 X 740.92 X
24615   3 90 2 X 1,736.08 X
24615   4 90 2 X 1,824.39 X
24615   1 90 2 X 1,896.55 X
24615   2 90 2 X 1,900.81 X
24620   4 90 2 X 968.92 X
24620   3 90 2 X 979.99 X
24620   2 90 2 X 1,038.04 X
24620   1 90 2 X 1,052.09 X
24635   4 90 2 X 2,221.83 X
24635   3 90 2 X 2,248.47 X
24635   2 90 2 X 2,407.29 X
24635   1 90 2 X 2,445.70 X
24640   3 10 2 X 175.16 X
24640   4 10 2 X 183.79 X
24640   2 10 2 X 184.37 X
24640   1 10 2 X 198.96 X
24650   1 90 2 X 444.51 339.24
24650   3 90 2 X 462.11 351.75
24650   4 90 2 X 467.96 355.85
24650   2 90 2 X 494.76 377.05
24655   4 90 2 X 673.03 X
24655   3 90 2 X 680.86 X
24655   2 90 2 X 724.56 X
24655   1 90 2 X 735.15 X
24665   4 90 2 X 1,493.91 X
24665   3 90 2 X 1,500.99 X
24665   2 90 2 X 1,521.69 X
24665   1 90 2 X 1,641.84 X
24666   4 90 2 X 1,819.42 X
24666   3 90 2 X 1,841.91 X
24666   2 90 2 X 1,981.36 X
24666   1 90 2 X 2,015.06 X
24670   4 90 2 X 405.61 X
24670   3 90 2 X 410.46 X
24670   2 90 2 X 436.95 X
24670   1 90 2 X 437.27 X
24675   4 90 2 X 755.26 X
24675   3 90 2 X 764.10 X
24675   2 90 2 X 815.00 X
24675   1 90 2 X 827.21 X
24685   4 90 2 X 1,587.40 X
24685   3 90 2 X 1,606.69 X
24685   2 90 2 X 1,724.21 X
24685   1 90 2 X 1,752.57 X
24800   4 90 2 X 2,011.51 X
24800   3 90 2 X 2,035.98 X
24800   2 90 2 X 2,179.17 X
24800   1 90 2 X 2,402.52 X
24802   4 90 2 X 2,369.97 X
24802   3 90 2 X 2,398.54 X
24802   2 90 2 X 2,572.64 X
24802   1 90 2 X 2,614.75 X
24900   4 90 2 X 1,570.05 X
24900   3 90 2 X 1,588.63 X
24900   2 90 2 X 1,705.89 X
24900   1 90 2 X 1,734.33 X
24920   4 90 2 X 1,468.08 X
24920   3 90 2 X 1,485.23 X
24920   2 90 2 X 1,589.05 X
24920   1 90 2 X 1,614.20 X
24925   3 90 2 X 920.67 X
24925   4 90 2 X 1,197.26 X
24925   2 90 2 X 1,290.35 X
24925   1 90 2 X 1,309.28 X
24930   4 90 2 X 1,646.81 X
24930   3 90 2 X 1,666.61 X
24930   2 90 2 X 1,778.24 X
24930   1 90 2 X 1,805.23 X
24931   4 90 2 X 2,172.65 X
24931   3 90 2 X 2,198.83 X
24931   2 90 2 X 2,359.11 X
24931   1 90 2 X 2,397.92 X
24935   4 90 2 X 2,663.83 X
24935   3 90 2 X 2,695.92 X
24935   2 90 2 X 2,891.67 X
24935   1 90 2 X 2,939.01 X
24940   4 90 2 X 2,663.83 X
24940   3 90 2 X 2,695.92 X
24940   2 90 2 X 2,891.67 X
24940   1 90 2 X 2,939.01 X
24999     YYY 2 X # X
25000   3 90 2 X 872.13 X
25000   4 90 2 X 929.18 X
25000   2 90 2 X 953.10 X
25000   1 90 2 X 1,013.68 X
25001   2 90 2 X 537.27 X
25001   3 90 2 X 537.27 X
25001   4 90 2 X 537.27 X
25001   1 90 2 X 614.41 X
25020   4 90 2 X 940.08 X
25020   3 90 2 X 951.04 X
25020   2 90 2 X 1,021.73 X
25020   1 90 2 X 1,034.18 X
25023   4 90 2 X 1,568.82 X
25023   3 90 2 X 1,579.69 X
25023   1 90 2 X 1,650.02 X
25023   2 90 2 X 1,666.18 X
25024   2 90 2 X 1,252.31 X
25024   3 90 2 X 1,252.31 X
25024   4 90 2 X 1,252.31 X
25024   1 90 2 X 1,421.60 X
25025   2 90 2 X 2,029.42 X
25025   3 90 2 X 2,029.42 X
25025   4 90 2 X 2,029.42 X
25025   1 90 2 X 2,291.36 X
25028   4 90 2 X 588.13 X
25028   3 90 2 X 603.04 X
25028   2 90 2 X 639.48 X
25028   1 90 2 X 645.29 X
25031   4 90 2 X 350.69 X
25031   3 90 2 X 418.66 X
25031   2 90 2 X 434.39 X
25031   1 90 2 X 438.26 X
25035   3 90 2 X 1,154.48 X
25035   4 90 2 X 1,243.63 X
25035   2 90 2 X 1,313.93 X
25035   1 90 2 X 1,331.95 X
25040   4 90 2 X 1,160.88 X
25040   3 90 2 X 1,174.73 X
25040   1 90 2 X 1,275.97 X
25040   2 90 2 X 1,332.94 X
25065   4 10 2 X 226.34 X
25065   2 10 2 X 243.32 X
25065   3 10 2 X 290.23 X
25065   1 10 2 X 306.30 X
25066   2 90 2 X 391.25 X
25066   1 90 2 X 395.85 X
25066   4 90 2 X 498.73 X
25066   3 90 2 X 504.19 X
25071   2 90 2 X 607.46 X
25071   3 90 2 X 607.46 X
25071   4 90 2 X 607.46 X
25071   1 90 2 X 683.27 X
25073   2 90 2 X 755.39 X
25073   3 90 2 X 755.39 X
25073   4 90 2 X 755.39 X
25073   1 90 2 X 850.54 X
25075   4 90 2 X 578.28 X
25075   1 90 2 X 602.81 X
25075   3 90 2 X 603.25 X
25075   2 90 2 X 651.56 X
25076   4 90 2 X 799.09 X
25076   3 90 2 X 820.56 X
25076   2 90 2 X 869.56 X
25076   1 90 2 X 892.69 X
25077   2 90 2 X 1,591.19 X
25077   1 90 2 X 1,609.90 X
25077   4 90 2 X 1,706.37 X
25077   3 90 2 X 1,726.52 X
25078   2 90 2 X 1,628.79 X
25078   3 90 2 X 1,628.79 X
25078   4 90 2 X 1,628.79 X
25078   1 90 2 X 1,824.49 X
25085   4 90 2 X 920.25 X
25085   3 90 2 X 931.32 X
25085   1 90 2 X 1,011.93 X
25085   2 90 2 X 1,113.40 X
25100   3 90 2 X 811.03 X
25100   1 90 2 X 892.12 X
25100   4 90 2 X 1,008.05 X
25100   2 90 2 X 1,068.25 X
25101   3 90 2 X 991.29 X
25101   4 90 2 X 1,001.81 X
25101   2 90 2 X 1,057.58 X
25101   1 90 2 X 1,090.02 X
25105   4 90 2 X 1,214.60 X
25105   2 90 2 X 1,590.57 X
25105   3 90 2 X 1,621.24 X
25105   1 90 2 X 1,672.62 X
25107   4 90 2 X 1,061.43 X
25107   3 90 2 X 1,074.05 X
25107   2 90 2 X 1,151.50 X
25107   1 90 2 X 1,170.30 X
25109   2 90 2 X 686.97 X
25109   3 90 2 X 686.97 X
25109   4 90 2 X 686.97 X
25109   1 90 2 X 791.36 X