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2021 Workers' Compensation Part B Fee Schedule

25110-25920

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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
25110   4 90 2 X 595.54 X
25110   3 90 2 X 665.05 X
25110   2 90 2 X 670.91 X
25110   1 90 2 X 681.17 X
25111   4 90 2 X 617.08 X
25111   3 90 2 X 664.26 X
25111   1 90 2 X 693.55 X
25111   2 90 2 X 722.27 X
25112   4 90 2 X 780.70 X
25112   2 90 2 X 836.95 X
25112   1 90 2 X 850.66 X
25112   3 90 2 X 868.55 X
25115   4 90 2 X 1,114.35 X
25115   3 90 2 X 1,176.16 X
25115   2 90 2 X 1,186.67 X
25115   1 90 2 X 1,196.07 X
25116   3 90 2 X 1,192.28 X
25116   1 90 2 X 1,349.26 X
25116   4 90 2 X 1,402.03 X
25116   2 90 2 X 1,533.63 X
25118   3 90 2 X 1,230.95 X
25118   4 90 2 X 1,253.96 X
25118   2 90 2 X 1,311.91 X
25118   1 90 2 X 1,325.52 X
25119   4 90 2 X 1,257.03 X
25119   3 90 2 X 1,346.86 X
25119   2 90 2 X 1,378.08 X
25119   1 90 2 X 1,403.63 X
25120   4 90 2 X 1,172.66 X
25120   3 90 2 X 1,187.00 X
25120   2 90 2 X 1,593.17 X
25120   1 90 2 X 1,707.74 X
25125   4 90 2 X 1,313.18 X
25125   3 90 2 X 1,329.11 X
25125   1 90 2 X 1,446.26 X
25125   2 90 2 X 1,578.94 X
25126   4 90 2 X 1,323.26 X
25126   3 90 2 X 1,339.12 X
25126   1 90 2 X 1,460.27 X
25126   2 90 2 X 1,584.48 X
25130   4 90 2 X 877.51 X
25130   3 90 2 X 887.93 X
25130   2 90 2 X 949.00 X
25130   1 90 2 X 963.75 X
25135   4 90 2 X 1,145.06 X
25135   3 90 2 X 1,158.52 X
25135   2 90 2 X 1,241.68 X
25135   1 90 2 X 1,261.83 X
25136   4 90 2 X 991.73 X
25136   3 90 2 X 1,003.44 X
25136   2 90 2 X 1,075.96 X
25136   1 90 2 X 1,093.53 X
25145   4 90 2 X 1,113.45 X
25145   3 90 2 X 1,127.12 X
25145   2 90 2 X 1,202.41 X
25145   1 90 2 X 1,220.62 X
25150   4 90 2 X 1,259.87 X
25150   3 90 2 X 1,275.12 X
25150   2 90 2 X 1,370.70 X
25150   1 90 2 X 1,393.80 X
25151   4 90 2 X 1,199.78 X
25151   3 90 2 X 1,213.99 X
25151   2 90 2 X 1,301.26 X
25151   1 90 2 X 1,322.48 X
25170   3 90 2 X 1,935.80 X
25170   2 90 2 X 2,072.65 X
25170   4 90 2 X 2,579.15 X
25170   1 90 2 X 2,765.16 X
25210   4 90 2 X 987.55 X
25210   3 90 2 X 999.36 X
25210   2 90 2 X 1,055.34 X
25210   1 90 2 X 1,087.42 X
25215   4 90 2 X 1,535.74 X
25215   3 90 2 X 1,554.59 X
25215   2 90 2 X 1,675.29 X
25215   1 90 2 X 1,704.45 X
25230   4 90 2 X 989.12 X
25230   3 90 2 X 1,045.41 X
25230   1 90 2 X 1,094.42 X
25230   2 90 2 X 1,335.19 X
25240   3 90 2 X 1,140.72 X
25240   4 90 2 X 1,145.51 X
25240   2 90 2 X 1,196.79 X
25240   1 90 2 X 1,202.38 X
25246   2 0 2 X 141.50 X
25246   4 0 2 X 166.73 X
25246   3 0 2 X 168.52 X
25246   1 0 2 X 177.67 X
25248   4 90 2 X 664.83 X
25248   3 90 2 X 672.18 X
25248   2 90 2 X 709.62 X
25248   1 90 2 X 718.73 X
25250   4 90 2 X 1,040.91 X
25250   3 90 2 X 1,143.62 X
25250   2 90 2 X 1,224.52 X
25250   1 90 2 X 1,244.22 X
25251   4 90 2 X 1,646.68 X
25251   3 90 2 X 1,666.39 X
25251   2 90 2 X 1,787.21 X
25251   1 90 2 X 1,816.47 X
25259   2 90 2 X 634.87 X
25259   3 90 2 X 634.87 X
25259   4 90 2 X 634.87 X
25259   1 90 2 X 727.94 X
25260   1 90 2 X 1,308.12 X
25260   3 90 2 X 1,339.59 X
25260   4 90 2 X 1,349.09 X
25260   2 90 2 X 1,422.33 X
25263   3 90 2 X 1,262.22 X
25263   1 90 2 X 1,372.79 X
25263   4 90 2 X 1,406.01 X
25263   2 90 2 X 1,449.52 X
25265   4 90 2 X 1,663.13 X
25265   3 90 2 X 1,682.74 X
25265   2 90 2 X 1,803.76 X
25265   1 90 2 X 1,833.18 X
25270   2 90 2 X 912.74 X
25270   3 90 2 X 1,051.27 X
25270   4 90 2 X 1,218.41 X
25270   1 90 2 X 1,272.66 X
25272   4 90 2 X 949.87 X
25272   3 90 2 X 960.54 X
25272   1 90 2 X 1,029.46 X
25272   2 90 2 X 1,301.75 X
25274   3 90 2 X 1,441.94 X
25274   2 90 2 X 1,541.74 X
25274   1 90 2 X 1,566.02 X
25274   4 90 2 X 1,709.38 X
25275   2 90 2 X 1,136.75 X
25275   3 90 2 X 1,136.75 X
25275   4 90 2 X 1,136.75 X
25275   1 90 2 X 1,292.31 X
25280   4 90 2 X 1,036.40 X
25280   3 90 2 X 1,048.22 X
25280   2 90 2 X 1,114.03 X
25280   1 90 2 X 1,129.95 X
25290   4 90 2 X 671.25 X
25290   3 90 2 X 707.82 X
25290   2 90 2 X 711.71 X
25290   1 90 2 X 713.32 X
25295   4 90 2 X 869.90 X
25295   3 90 2 X 879.55 X
25295   2 90 2 X 930.98 X
25295   1 90 2 X 943.50 X
25300   4 90 2 X 1,495.80 X
25300   3 90 2 X 1,513.70 X
25300   2 90 2 X 1,619.87 X
25300   1 90 2 X 1,645.60 X
25301   4 90 2 X 1,412.14 X
25301   3 90 2 X 1,418.38 X
25301   2 90 2 X 1,530.80 X
25301   1 90 2 X 1,555.56 X
25310   4 90 2 X 1,406.17 X
25310   3 90 2 X 1,645.99 X
25310   2 90 2 X 1,671.47 X
25310   1 90 2 X 1,699.51 X
25312   4 90 2 X 1,585.31 X
25312   3 90 2 X 1,604.08 X
25312   2 90 2 X 1,650.18 X
25312   1 90 2 X 1,745.58 X
25315   4 90 2 X 1,651.13 X
25315   3 90 2 X 1,670.73 X
25315   2 90 2 X 1,789.07 X
25315   1 90 2 X 1,817.71 X
25316   4 90 2 X 2,063.27 X
25316   3 90 2 X 2,087.96 X
25316   2 90 2 X 2,239.57 X
25316   1 90 2 X 2,276.23 X
25320   4 90 2 X 1,688.68 X
25320   3 90 2 X 1,708.99 X
25320   2 90 2 X 1,829.72 X
25320   1 90 2 X 1,864.62 X
25332   2 90 2 X 1,889.02 X
25332   4 90 2 X 1,971.52 X
25332   3 90 2 X 1,995.18 X
25332   1 90 2 X 2,172.53 X
25335   4 90 2 X 2,204.14 X
25335   3 90 2 X 2,231.00 X
25335   2 90 2 X 2,381.92 X
25335   1 90 2 X 2,418.27 X
25337   4 90 2 X 1,777.53 X
25337   3 90 2 X 1,802.21 X
25337   2 90 2 X 1,930.29 X
25337   1 90 2 X 1,991.18 X
25350   3 90 2 X 1,520.85 X
25350   4 90 2 X 1,551.63 X
25350   2 90 2 X 1,630.70 X
25350   1 90 2 X 1,657.27 X
25355   4 90 2 X 1,772.71 X
25355   3 90 2 X 1,794.04 X
25355   2 90 2 X 1,924.54 X
25355   1 90 2 X 1,956.14 X
25360   4 90 2 X 1,345.16 X
25360   3 90 2 X 1,361.15 X
25360   2 90 2 X 1,545.02 X
25360   1 90 2 X 1,563.83 X
25365   4 90 2 X 2,067.77 X
25365   3 90 2 X 2,092.58 X
25365   2 90 2 X 2,237.09 X
25365   1 90 2 X 2,272.00 X
25370   4 90 2 X 2,287.36 X
25370   3 90 2 X 2,314.93 X
25370   2 90 2 X 2,483.01 X
25370   1 90 2 X 2,523.64 X
25375   4 90 2 X 2,324.71 X
25375   3 90 2 X 2,354.63 X
25375   2 90 2 X 2,487.07 X
25375   1 90 2 X 2,518.79 X
25390   4 90 2 X 1,774.87 X
25390   3 90 2 X 1,779.64 X
25390   2 90 2 X 1,926.02 X
25390   1 90 2 X 1,957.55 X
25391   4 90 2 X 2,281.58 X
25391   3 90 2 X 2,308.64 X
25391   2 90 2 X 2,475.44 X
25391   1 90 2 X 2,515.82 X
25392   4 90 2 X 2,420.41 X
25392   3 90 2 X 2,449.52 X
25392   2 90 2 X 2,627.67 X
25392   1 90 2 X 2,670.80 X
25393   4 90 2 X 2,763.79 X
25393   3 90 2 X 2,797.09 X
25393   2 90 2 X 3,030.60 X
25393   1 90 2 X 3,049.57 X
25394   2 90 2 X 1,328.70 X
25394   3 90 2 X 1,328.70 X
25394   4 90 2 X 1,328.70 X
25394   1 90 2 X 1,500.84 X
25400   4 90 2 X 2,004.70 X
25400   3 90 2 X 2,029.06 X
25400   2 90 2 X 2,180.53 X
25400   1 90 2 X 2,217.20 X
25405   3 90 2 X 2,484.56 X
25405   4 90 2 X 2,541.94 X
25405   2 90 2 X 2,662.62 X
25405   1 90 2 X 2,705.83 X
25415   4 90 2 X 2,285.22 X
25415   3 90 2 X 2,312.54 X
25415   2 90 2 X 2,479.54 X
25415   1 90 2 X 2,519.96 X
25420   4 90 2 X 2,840.74 X
25420   3 90 2 X 2,875.11 X
25420   2 90 2 X 3,080.21 X
25420   1 90 2 X 3,129.81 X
25425   4 90 2 X 2,313.78 X
25425   3 90 2 X 2,341.73 X
25425   1 90 2 X 2,549.82 X
25425   2 90 2 X 2,620.96 X
25426   4 90 2 X 2,534.50 X
25426   3 90 2 X 2,564.16 X
25426   2 90 2 X 2,746.37 X
25426   1 90 2 X 2,790.55 X
25430   2 90 2 X 1,177.66 X
25430   3 90 2 X 1,177.66 X
25430   4 90 2 X 1,177.66 X
25430   1 90 2 X 1,313.80 X
25431   2 90 2 X 1,169.02 X
25431   3 90 2 X 1,169.02 X
25431   4 90 2 X 1,169.02 X
25431   1 90 2 X 1,292.01 X
25440   4 90 2 X 1,803.12 X
25440   3 90 2 X 1,824.72 X
25440   1 90 2 X 1,988.00 X
25440   2 90 2 X 2,680.69 X
25441   4 90 2 X 2,243.77 X
25441   3 90 2 X 2,270.65 X
25441   1 90 2 X 2,475.13 X
25441   2 90 2 X 2,881.60 X
25442   4 90 2 X 1,641.78 X
25442   3 90 2 X 1,660.76 X
25442   2 90 2 X 1,770.78 X
25442   1 90 2 X 1,797.49 X
25443   4 90 2 X 1,826.68 X
25443   3 90 2 X 1,848.61 X
25443   2 90 2 X 1,982.49 X
25443   1 90 2 X 2,014.83 X
25444   4 90 2 X 1,972.71 X
25444   3 90 2 X 1,996.42 X
25444   2 90 2 X 2,141.61 X
25444   1 90 2 X 2,176.76 X
25445   4 90 2 X 1,874.14 X
25445   3 90 2 X 1,897.07 X
25445   2 90 2 X 2,042.86 X
25445   1 90 2 X 2,078.14 X
25446   4 90 2 X 3,407.68 X
25446   3 90 2 X 3,449.78 X
25446   2 90 2 X 3,732.32 X
25446   1 90 2 X 3,800.66 X
25447   4 90 2 X 1,883.04 X
25447   3 90 2 X 1,896.47 X
25447   2 90 2 X 1,955.28 X
25447   1 90 2 X 1,995.19 X
25449   3 90 2 X 1,502.62 X
25449   1 90 2 X 1,610.65 X
25449   2 90 2 X 1,678.81 X
25449   4 90 2 X 2,012.11 X
25450   4 90 2 X 1,421.42 X
25450   3 90 2 X 1,438.62 X
25450   2 90 2 X 1,542.81 X
25450   1 90 2 X 1,568.06 X
25455   4 90 2 X 1,695.34 X
25455   3 90 2 X 1,715.77 X
25455   2 90 2 X 1,840.38 X
25455   1 90 2 X 1,870.54 X
25490   4 90 2 X 1,691.03 X
25490   3 90 2 X 1,711.34 X
25490   2 90 2 X 1,835.82 X
25490   1 90 2 X 1,865.93 X
25491   4 90 2 X 1,770.08 X
25491   3 90 2 X 1,791.44 X
25491   2 90 2 X 1,921.82 X
25491   1 90 2 X 1,953.35 X
25492   4 90 2 X 2,178.77 X
25492   3 90 2 X 2,204.94 X
25492   2 90 2 X 2,365.49 X
25492   1 90 2 X 2,404.43 X
25500   3 90 2 X 480.55 369.78
25500   4 90 2 X 494.98 381.25
25500   2 90 2 X 534.23 411.75
25500   1 90 2 X 548.34 421.95
25505   4 90 2 X 797.59 X
25505   3 90 2 X 806.92 X
25505   2 90 2 X 869.75 X
25505   1 90 2 X 870.13 X
25515   4 90 2 X 1,537.30 X
25515   3 90 2 X 1,555.72 X
25515   2 90 2 X 1,664.89 X
25515   1 90 2 X 1,703.93 X
25520   4 90 2 X 1,115.43 X
25520   3 90 2 X 1,128.82 X
25520   2 90 2 X 1,210.96 X
25520   1 90 2 X 1,230.85 X
25525   4 90 2 X 2,168.31 X
25525   3 90 2 X 2,194.35 X
25525   2 90 2 X 2,354.11 X
25525   1 90 2 X 2,392.78 X
25526   4 90 2 X 2,304.78 X
25526   3 90 2 X 2,332.55 X
25526   2 90 2 X 2,502.09 X
25526   1 90 2 X 2,543.07 X
25530   3 90 2 X 482.51 X
25530   4 90 2 X 507.60 X
25530   2 90 2 X 557.89 X
25530   1 90 2 X 602.17 X
25535   4 90 2 X 794.93 X
25535   3 90 2 X 804.23 X
25535   2 90 2 X 856.26 X
25535   1 90 2 X 868.79 X
25545   3 90 2 X 1,523.63 X
25545   4 90 2 X 1,557.95 X
25545   2 90 2 X 1,631.14 X
25545   1 90 2 X 1,686.86 X
25560   3 90 2 X 502.54 X
25560   4 90 2 X 529.50 X
25560   2 90 2 X 561.26 X
25560   1 90 2 X 609.91 X
25565   3 90 2 X 1,000.45 X
25565   4 90 2 X 1,036.43 X
25565   2 90 2 X 1,076.00 X
25565   1 90 2 X 1,085.51 X
25574   3 90 2 X 1,969.65 X
25574   4 90 2 X 1,972.91 X
25574   2 90 2 X 2,035.59 X
25574   1 90 2 X 2,037.98 X
25575   3 90 2 X 2,158.19 X
25575   4 90 2 X 2,159.44 X
25575   2 90 2 X 2,229.85 X
25575   1 90 2 X 2,233.62 X
25600   3 90 2 X 536.91 406.54
25600   4 90 2 X 571.25 433.60
25600   1 90 2 X 573.73 437.38
25600   2 90 2 X 587.75 446.90
25605   3 90 2 X 938.01 X
25605   4 90 2 X 948.48 X
25605   2 90 2 X 973.82 X
25605   1 90 2 X 990.96 X
25606   2 90 2 X 934.32 X
25606   3 90 2 X 934.32 X
25606   4 90 2 X 934.32 X
25606   1 90 2 X 1,087.35 X
25607   2 90 2 X 943.17 X
25607   3 90 2 X 943.17 X
25607   4 90 2 X 943.17 X
25607   1 90 2 X 1,087.47 X
25608   2 90 2 X 1,078.31 X
25608   3 90 2 X 1,078.31 X
25608   4 90 2 X 1,078.31 X
25608   1 90 2 X 1,248.09 X
25609   2 90 2 X 1,375.91 X
25609   3 90 2 X 1,375.91 X
25609   4 90 2 X 1,375.91 X
25609   1 90 2 X 1,590.57 X
25622   3 90 2 X 539.93 X
25622   1 90 2 X 539.98 X
25622   4 90 2 X 542.94 X
25622   2 90 2 X 564.00 X
25624   4 90 2 X 750.15 X
25624   3 90 2 X 823.62 X
25624   1 90 2 X 824.08 X
25624   2 90 2 X 845.21 X
25628   4 90 2 X 1,415.95 X
25628   3 90 2 X 1,432.89 X
25628   2 90 2 X 1,535.32 X
25628   1 90 2 X 1,560.14 X
25630   3 90 2 X 521.45 X
25630   1 90 2 X 542.37 X
25630   4 90 2 X 544.46 X
25630   2 90 2 X 549.70 X
25635   4 90 2 X 749.25 X
25635   3 90 2 X 752.71 X
25635   2 90 2 X 763.05 X
25635   1 90 2 X 774.52 X
25645   4 90 2 X 1,272.15 X
25645   3 90 2 X 1,287.62 X
25645   2 90 2 X 1,376.85 X
25645   1 90 2 X 1,398.40 X
25650   4 90 2 X 610.46 X
25650   3 90 2 X 611.83 X
25650   1 90 2 X 630.64 X
25650   2 90 2 X 641.82 X
25651   2 90 2 X 695.19 X
25651   3 90 2 X 695.19 X
25651   4 90 2 X 695.19 X
25651   1 90 2 X 790.51 X
25652   2 90 2 X 1,026.02 X
25652   3 90 2 X 1,026.02 X
25652   4 90 2 X 1,026.02 X
25652   1 90 2 X 1,166.08 X
25660   1 90 2 X 566.62 X
25660   3 90 2 X 575.37 X
25660   4 90 2 X 585.46 X
25660   2 90 2 X 622.04 X
25670   4 90 2 X 1,381.51 X
25670   3 90 2 X 1,398.17 X
25670   2 90 2 X 1,497.97 X
25670   1 90 2 X 1,522.13 X
25671   2 90 2 X 846.36 X
25671   3 90 2 X 846.36 X
25671   4 90 2 X 846.36 X
25671   1 90 2 X 962.72 X
25675   4 90 2 X 624.42 X
25675   3 90 2 X 631.43 X
25675   2 90 2 X 667.11 X
25675   1 90 2 X 675.74 X
25676   4 90 2 X 1,403.53 X
25676   3 90 2 X 1,420.61 X
25676   2 90 2 X 1,521.31 X
25676   1 90 2 X 1,545.66 X
25680   4 90 2 X 746.25 X
25680   3 90 2 X 754.52 X
25680   2 90 2 X 794.36 X
25680   1 90 2 X 804.14 X
25685   4 90 2 X 1,710.96 X
25685   3 90 2 X 1,731.60 X
25685   2 90 2 X 1,897.57 X
25685   1 90 2 X 1,921.85 X
25690   3 90 2 X 914.87 X
25690   4 90 2 X 947.54 X
25690   2 90 2 X 1,026.14 X
25690   1 90 2 X 1,042.38 X
25695   4 90 2 X 1,420.80 X
25695   3 90 2 X 1,437.75 X
25695   2 90 2 X 1,561.74 X
25695   1 90 2 X 1,565.18 X
25800   4 90 2 X 1,925.06 X
25800   3 90 2 X 1,948.83 X
25800   2 90 2 X 2,100.73 X
25800   1 90 2 X 2,137.51 X
25805   4 90 2 X 2,236.78 X
25805   1 90 2 X 2,483.99 X
25805   2 90 2 X 2,523.96 X
25805   3 90 2 X 2,970.73 X
25810   3 90 2 X 2,523.40 X
25810   4 90 2 X 2,548.81 X
25810   2 90 2 X 2,662.72 X
25810   1 90 2 X 2,760.62 X
25820   4 90 2 X 1,537.49 X
25820   3 90 2 X 1,556.53 X
25820   1 90 2 X 1,710.07 X
25820   2 90 2 X 1,753.44 X
25825   4 90 2 X 1,912.49 X
25825   1 90 2 X 2,134.72 X
25825   3 90 2 X 2,440.51 X
25825   2 90 2 X 2,648.73 X
25830   4 90 2 X 1,777.53 X
25830   3 90 2 X 1,802.21 X
25830   2 90 2 X 1,930.29 X
25830   1 90 2 X 1,991.18 X
25900   3 90 2 X 1,472.57 X
25900   4 90 2 X 1,508.35 X
25900   2 90 2 X 1,581.61 X
25900   1 90 2 X 1,608.11 X
25905   4 90 2 X 1,465.72 X
25905   3 90 2 X 1,483.23 X
25905   2 90 2 X 1,586.32 X
25905   1 90 2 X 1,611.28 X
25907   2 90 2 X 1,005.77 X
25907   4 90 2 X 1,233.57 X
25907   3 90 2 X 1,248.03 X
25907   1 90 2 X 1,356.51 X
25909   4 90 2 X 1,321.37 X
25909   3 90 2 X 1,336.48 X
25909   2 90 2 X 1,427.83 X
25909   1 90 2 X 1,449.99 X
25915   4 90 2 X 1,321.37 X
25915   3 90 2 X 1,336.48 X
25915   2 90 2 X 1,427.83 X
25915   1 90 2 X 1,449.99 X
25920   4 90 2 X 1,433.45 X
25920   3 90 2 X 1,450.44 X
25920   2 90 2 X 1,538.27 X
25920   1 90 2 X 1,579.63 X