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2024 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   004 90 2 X 697.88 X
25110   002 90 2 X 786.20 X
25110   003 90 2 X 779.32 X
25110   001 90 2 X 798.22 X
25111   001 90 2 X 812.72 X
25111   004 90 2 X 723.12 X
25111   002 90 2 X 846.38 X
25111   003 90 2 X 778.40 X
25112   004 90 2 X 914.86 X
25112   001 90 2 X 996.83 X
25112   003 90 2 X 1,017.79 X
25112   002 90 2 X 980.76 X
25115   002 90 2 X 1,390.57 X
25115   003 90 2 X 1,378.27 X
25115   004 90 2 X 1,305.83 X
25115   001 90 2 X 1,401.60 X
25116   004 90 2 X 1,642.94 X
25116   001 90 2 X 1,581.10 X
25116   003 90 2 X 1,397.16 X
25116   002 90 2 X 1,797.16 X
25118   001 90 2 X 1,553.28 X
25118   003 90 2 X 1,442.46 X
25118   002 90 2 X 1,537.34 X
25118   004 90 2 X 1,469.43 X
25119   002 90 2 X 1,614.87 X
25119   003 90 2 X 1,578.29 X
25119   004 90 2 X 1,473.02 X
25119   001 90 2 X 1,644.82 X
25120   004 90 2 X 1,374.16 X
25120   002 90 2 X 1,866.92 X
25120   003 90 2 X 1,390.96 X
25120   001 90 2 X 2,001.19 X
25125   004 90 2 X 1,538.83 X
25125   001 90 2 X 1,694.77 X
25125   003 90 2 X 1,557.49 X
25125   002 90 2 X 1,850.25 X
25126   004 90 2 X 1,550.64 X
25126   001 90 2 X 1,711.20 X
25126   003 90 2 X 1,569.22 X
25126   002 90 2 X 1,856.75 X
25130   002 90 2 X 1,112.06 X
25130   003 90 2 X 1,040.50 X
25130   001 90 2 X 1,129.36 X
25130   004 90 2 X 1,028.30 X
25135   001 90 2 X 1,478.65 X
25135   004 90 2 X 1,341.82 X
25135   003 90 2 X 1,357.58 X
25135   002 90 2 X 1,455.04 X
25136   003 90 2 X 1,175.87 X
25136   002 90 2 X 1,260.84 X
25136   004 90 2 X 1,162.14 X
25136   001 90 2 X 1,281.43 X
25145   001 90 2 X 1,430.36 X
25145   004 90 2 X 1,304.78 X
25145   003 90 2 X 1,320.80 X
25145   002 90 2 X 1,409.02 X
25150   004 90 2 X 1,476.35 X
25150   001 90 2 X 1,633.30 X
25150   003 90 2 X 1,494.23 X
25150   002 90 2 X 1,606.24 X
25151   002 90 2 X 1,524.86 X
25151   003 90 2 X 1,422.58 X
25151   001 90 2 X 1,549.72 X
25151   004 90 2 X 1,405.94 X
25170   004 90 2 X 3,022.32 X
25170   001 90 2 X 3,240.31 X
25170   003 90 2 X 2,268.43 X
25170   002 90 2 X 2,428.80 X
25210   001 90 2 X 1,274.27 X
25210   004 90 2 X 1,157.25 X
25210   002 90 2 X 1,236.67 X
25210   003 90 2 X 1,171.08 X
25215   003 90 2 X 1,821.72 X
25215   002 90 2 X 1,963.16 X
25215   001 90 2 X 1,997.33 X
25215   004 90 2 X 1,799.63 X
25230   004 90 2 X 1,159.08 X
25230   003 90 2 X 1,225.05 X
25230   002 90 2 X 1,564.62 X
25230   001 90 2 X 1,282.48 X
25240   003 90 2 X 1,336.73 X
25240   002 90 2 X 1,402.44 X
25240   001 90 2 X 1,408.99 X
25240   004 90 2 X 1,342.34 X
25246   001 0 2 X 208.21 X
25246   003 0 2 X 197.48 X
25246   002 0 2 X 165.82 X
25246   004 0 2 X 195.37 X
25248   001 90 2 X 842.23 X
25248   004 90 2 X 779.07 X
25248   002 90 2 X 831.55 X
25248   003 90 2 X 787.68 X
25250   002 90 2 X 1,434.93 X
25250   003 90 2 X 1,340.13 X
25250   001 90 2 X 1,458.02 X
25250   004 90 2 X 1,219.77 X
25251   002 90 2 X 2,094.31 X
25251   003 90 2 X 1,952.72 X
25251   001 90 2 X 2,128.60 X
25251   004 90 2 X 1,929.64 X
25259   004 90 2 X 743.96 X
25259   002 90 2 X 743.96 X
25259   003 90 2 X 743.96 X
25259   001 90 2 X 853.02 X
25260   001 90 2 X 1,532.90 X
25260   003 90 2 X 1,569.78 X
25260   002 90 2 X 1,666.72 X
25260   004 90 2 X 1,580.90 X
25263   003 90 2 X 1,479.12 X
25263   002 90 2 X 1,698.60 X
25263   004 90 2 X 1,647.61 X
25263   001 90 2 X 1,608.67 X
25265   004 90 2 X 1,948.92 X
25265   001 90 2 X 2,148.18 X
25265   003 90 2 X 1,971.89 X
25265   002 90 2 X 2,113.71 X
25270   003 90 2 X 1,231.91 X
25270   002 90 2 X 1,069.58 X
25270   004 90 2 X 1,427.77 X
25270   001 90 2 X 1,491.35 X
25272   001 90 2 X 1,206.35 X
25272   004 90 2 X 1,113.09 X
25272   002 90 2 X 1,525.44 X
25272   003 90 2 X 1,125.59 X
25274   003 90 2 X 1,689.72 X
25274   002 90 2 X 1,806.66 X
25274   004 90 2 X 2,003.11 X
25274   001 90 2 X 1,835.11 X
25275   003 90 2 X 1,332.08 X
25275   002 90 2 X 1,332.08 X
25275   004 90 2 X 1,332.08 X
25275   001 90 2 X 1,514.36 X
25280   001 90 2 X 1,324.12 X
25280   002 90 2 X 1,305.46 X
25280   003 90 2 X 1,228.33 X
25280   004 90 2 X 1,214.48 X
25290   002 90 2 X 834.00 X
25290   003 90 2 X 829.45 X
25290   001 90 2 X 835.89 X
25290   004 90 2 X 786.59 X
25295   004 90 2 X 1,019.38 X
25295   003 90 2 X 1,030.68 X
25295   002 90 2 X 1,090.95 X
25295   001 90 2 X 1,105.62 X
25300   003 90 2 X 1,773.80 X
25300   002 90 2 X 1,898.22 X
25300   004 90 2 X 1,752.83 X
25300   001 90 2 X 1,928.37 X
25301   002 90 2 X 1,793.83 X
25301   003 90 2 X 1,662.10 X
25301   001 90 2 X 1,822.86 X
25301   004 90 2 X 1,654.79 X
25310   004 90 2 X 1,647.80 X
25310   001 90 2 X 1,991.55 X
25310   002 90 2 X 1,958.68 X
25310   003 90 2 X 1,928.83 X
25312   002 90 2 X 1,933.73 X
25312   003 90 2 X 1,879.72 X
25312   001 90 2 X 2,045.53 X
25312   004 90 2 X 1,857.72 X
25315   002 90 2 X 2,096.49 X
25315   003 90 2 X 1,957.82 X
25315   004 90 2 X 1,934.85 X
25315   001 90 2 X 2,130.06 X
25316   002 90 2 X 2,624.40 X
25316   003 90 2 X 2,446.75 X
25316   001 90 2 X 2,667.36 X
25316   004 90 2 X 2,417.81 X
25320   004 90 2 X 1,978.85 X
25320   001 90 2 X 2,185.02 X
25320   003 90 2 X 2,002.64 X
25320   002 90 2 X 2,144.13 X
25332   001 90 2 X 2,545.85 X
25332   004 90 2 X 2,310.29 X
25332   002 90 2 X 2,213.62 X
25332   003 90 2 X 2,338.01 X
25335   003 90 2 X 2,614.36 X
25335   002 90 2 X 2,791.21 X
25335   004 90 2 X 2,582.88 X
25335   001 90 2 X 2,833.81 X
25337   001 90 2 X 2,333.33 X
25337   004 90 2 X 2,082.97 X
25337   002 90 2 X 2,261.98 X
25337   003 90 2 X 2,111.90 X
25350   001 90 2 X 1,942.04 X
25350   004 90 2 X 1,818.25 X
25350   003 90 2 X 1,782.19 X
25350   002 90 2 X 1,910.91 X
25355   004 90 2 X 2,077.32 X
25355   001 90 2 X 2,292.27 X
25355   003 90 2 X 2,102.32 X
25355   002 90 2 X 2,255.24 X
25360   003 90 2 X 1,595.05 X
25360   002 90 2 X 1,810.50 X
25360   004 90 2 X 1,576.30 X
25360   001 90 2 X 1,832.54 X
25365   004 90 2 X 2,423.08 X
25365   001 90 2 X 2,662.40 X
25365   003 90 2 X 2,452.15 X
25365   002 90 2 X 2,621.50 X
25370   001 90 2 X 2,957.28 X
25370   004 90 2 X 2,680.40 X
25370   003 90 2 X 2,712.72 X
25370   002 90 2 X 2,909.67 X
25375   002 90 2 X 2,914.43 X
25375   003 90 2 X 2,759.23 X
25375   004 90 2 X 2,724.17 X
25375   001 90 2 X 2,951.60 X
25390   003 90 2 X 2,085.44 X
25390   002 90 2 X 2,256.98 X
25390   004 90 2 X 2,079.84 X
25390   001 90 2 X 2,293.92 X
25391   004 90 2 X 2,673.62 X
25391   002 90 2 X 2,900.80 X
25391   003 90 2 X 2,705.34 X
25391   001 90 2 X 2,948.12 X
25392   001 90 2 X 3,129.72 X
25392   004 90 2 X 2,836.32 X
25392   003 90 2 X 2,870.43 X
25392   002 90 2 X 3,079.19 X
25393   001 90 2 X 3,573.59 X
25393   004 90 2 X 3,238.70 X
25393   003 90 2 X 3,277.73 X
25393   002 90 2 X 3,551.36 X
25394   001 90 2 X 1,758.73 X
25394   004 90 2 X 1,557.00 X
25394   003 90 2 X 1,557.00 X
25394   002 90 2 X 1,557.00 X
25400   002 90 2 X 2,555.21 X
25400   003 90 2 X 2,377.72 X
25400   004 90 2 X 2,349.17 X
25400   001 90 2 X 2,598.19 X
25405   001 90 2 X 3,170.77 X
25405   003 90 2 X 2,911.49 X
25405   002 90 2 X 3,120.15 X
25405   004 90 2 X 2,978.73 X
25415   004 90 2 X 2,677.89 X
25415   001 90 2 X 2,952.98 X
25415   003 90 2 X 2,709.91 X
25415   002 90 2 X 2,905.60 X
25420   002 90 2 X 3,609.49 X
25420   003 90 2 X 3,369.15 X
25420   001 90 2 X 3,667.61 X
25420   004 90 2 X 3,328.87 X
25425   001 90 2 X 2,987.96 X
25425   004 90 2 X 2,711.36 X
25425   002 90 2 X 3,071.32 X
25425   003 90 2 X 2,744.11 X
25426   001 90 2 X 3,270.06 X
25426   004 90 2 X 2,970.01 X
25426   002 90 2 X 3,218.28 X
25426   003 90 2 X 3,004.76 X
25430   001 90 2 X 1,539.55 X
25430   004 90 2 X 1,380.03 X
25430   002 90 2 X 1,380.03 X
25430   003 90 2 X 1,380.03 X
25431   004 90 2 X 1,369.90 X
25431   003 90 2 X 1,369.90 X
25431   002 90 2 X 1,369.90 X
25431   001 90 2 X 1,514.01 X
25440   002 90 2 X 3,141.32 X
25440   003 90 2 X 2,138.26 X
25440   004 90 2 X 2,112.96 X
25440   001 90 2 X 2,329.60 X
25441   001 90 2 X 2,900.44 X
25441   004 90 2 X 2,629.33 X
25441   002 90 2 X 3,376.76 X
25441   003 90 2 X 2,660.82 X
25442   003 90 2 X 1,946.13 X
25442   002 90 2 X 2,075.06 X
25442   001 90 2 X 2,106.35 X
25442   004 90 2 X 1,923.90 X
25443   004 90 2 X 2,140.56 X
25443   002 90 2 X 2,323.14 X
25443   003 90 2 X 2,166.27 X
25443   001 90 2 X 2,361.05 X
25444   001 90 2 X 2,550.80 X
25444   004 90 2 X 2,311.69 X
25444   002 90 2 X 2,509.61 X
25444   003 90 2 X 2,339.47 X
25445   001 90 2 X 2,435.23 X
25445   003 90 2 X 2,223.05 X
25445   002 90 2 X 2,393.89 X
25445   004 90 2 X 2,196.18 X
25446   004 90 2 X 3,993.24 X
25446   001 90 2 X 4,453.74 X
25446   002 90 2 X 4,373.65 X
25446   003 90 2 X 4,042.57 X
25447   004 90 2 X 2,206.61 X
25447   002 90 2 X 2,291.27 X
25447   001 90 2 X 2,338.02 X
25447   003 90 2 X 2,222.34 X
25449   001 90 2 X 1,887.41 X
25449   004 90 2 X 2,357.86 X
25449   002 90 2 X 1,967.28 X
25449   003 90 2 X 1,760.81 X
25450   003 90 2 X 1,685.82 X
25450   002 90 2 X 1,807.92 X
25450   001 90 2 X 1,837.50 X
25450   004 90 2 X 1,665.66 X
25455   004 90 2 X 1,986.65 X
25455   002 90 2 X 2,156.63 X
25455   003 90 2 X 2,010.59 X
25455   001 90 2 X 2,191.97 X
25490   002 90 2 X 2,151.27 X
25490   003 90 2 X 2,005.40 X
25490   004 90 2 X 1,981.61 X
25490   001 90 2 X 2,186.56 X
25491   001 90 2 X 2,289.00 X
25491   004 90 2 X 2,074.24 X
25491   002 90 2 X 2,252.05 X
25491   003 90 2 X 2,099.27 X
25492   002 90 2 X 2,771.95 X
25492   003 90 2 X 2,583.83 X
25492   001 90 2 X 2,817.59 X
25492   004 90 2 X 2,553.16 X
25500   001 90 2 X 642.56 494.46
25500   003 90 2 X 563.13 433.33
25500   002 90 2 X 626.03 482.51
25500   004 90 2 X 580.04 446.76
25505   001 90 2 X 1,019.65 X
25505   003 90 2 X 945.58 X
25505   002 90 2 X 1,019.20 X
25505   004 90 2 X 934.64 X
25515   003 90 2 X 1,823.05 X
25515   002 90 2 X 1,950.97 X
25515   004 90 2 X 1,801.46 X
25515   001 90 2 X 1,996.72 X
25520   003 90 2 X 1,322.79 X
25520   002 90 2 X 1,419.04 X
25520   004 90 2 X 1,307.10 X
25520   001 90 2 X 1,442.36 X
25525   001 90 2 X 2,803.93 X
25525   004 90 2 X 2,540.90 X
25525   003 90 2 X 2,571.41 X
25525   002 90 2 X 2,758.62 X
25526   002 90 2 X 2,932.03 X
25526   003 90 2 X 2,733.36 X
25526   004 90 2 X 2,700.82 X
25526   001 90 2 X 2,980.05 X
25530   004 90 2 X 594.82 X
25530   003 90 2 X 565.43 X
25530   002 90 2 X 653.75 X
25530   001 90 2 X 705.64 X
25535   004 90 2 X 931.53 X
25535   002 90 2 X 1,003.39 X
25535   003 90 2 X 942.43 X
25535   001 90 2 X 1,018.08 X
25545   004 90 2 X 1,825.65 X
25545   002 90 2 X 1,911.43 X
25545   003 90 2 X 1,785.44 X
25545   001 90 2 X 1,976.72 X
25560   001 90 2 X 714.71 X
25560   003 90 2 X 588.90 X
25560   002 90 2 X 657.70 X
25560   004 90 2 X 620.48 X
25565   001 90 2 X 1,272.03 X
25565   003 90 2 X 1,172.36 X
25565   002 90 2 X 1,260.90 X
25565   004 90 2 X 1,214.52 X
25574   004 90 2 X 2,311.92 X
25574   001 90 2 X 2,388.17 X
25574   003 90 2 X 2,308.10 X
25574   002 90 2 X 2,385.38 X
25575   001 90 2 X 2,617.43 X
25575   004 90 2 X 2,530.50 X
25575   002 90 2 X 2,613.01 X
25575   003 90 2 X 2,529.04 X
25600   004 90 2 X 669.41 508.11
25600   002 90 2 X 688.74 523.69
25600   003 90 2 X 629.17 476.39
25600   001 90 2 X 672.32 512.54
25605   001 90 2 X 1,161.23 X
25605   004 90 2 X 1,111.46 X
25605   003 90 2 X 1,099.20 X
25605   002 90 2 X 1,141.15 X
25606   003 90 2 X 1,094.87 X
25606   002 90 2 X 1,094.87 X
25606   004 90 2 X 1,094.87 X
25606   001 90 2 X 1,274.20 X
25607   004 90 2 X 1,105.24 X
25607   002 90 2 X 1,105.24 X
25607   003 90 2 X 1,105.24 X
25607   001 90 2 X 1,274.33 X
25608   003 90 2 X 1,263.60 X
25608   002 90 2 X 1,263.60 X
25608   001 90 2 X 1,462.55 X
25608   004 90 2 X 1,263.60 X
25609   004 90 2 X 1,612.33 X
25609   001 90 2 X 1,863.89 X
25609   002 90 2 X 1,612.33 X
25609   003 90 2 X 1,612.33 X
25622   001 90 2 X 632.77 X
25622   003 90 2 X 632.72 X
25622   002 90 2 X 660.91 X
25622   004 90 2 X 636.23 X
25624   003 90 2 X 965.14 X
25624   002 90 2 X 990.44 X
25624   004 90 2 X 879.05 X
25624   001 90 2 X 965.68 X
25628   003 90 2 X 1,679.11 X
25628   002 90 2 X 1,799.14 X
25628   001 90 2 X 1,828.23 X
25628   004 90 2 X 1,659.26 X
25630   001 90 2 X 635.58 X
25630   002 90 2 X 644.16 X
25630   003 90 2 X 611.05 X
25630   004 90 2 X 638.01 X
25635   002 90 2 X 894.16 X
25635   003 90 2 X 882.06 X
25635   004 90 2 X 878.00 X
25635   001 90 2 X 907.61 X
25645   002 90 2 X 1,613.44 X
25645   003 90 2 X 1,508.87 X
25645   004 90 2 X 1,490.75 X
25645   001 90 2 X 1,638.69 X
25650   004 90 2 X 715.35 X
25650   001 90 2 X 739.00 X
25650   002 90 2 X 752.11 X
25650   003 90 2 X 716.97 X
25651   001 90 2 X 926.34 X
25651   004 90 2 X 814.64 X
25651   003 90 2 X 814.64 X
25651   002 90 2 X 814.64 X
25652   001 90 2 X 1,366.45 X
25652   004 90 2 X 1,202.32 X
25652   003 90 2 X 1,202.32 X
25652   002 90 2 X 1,202.32 X
25660   002 90 2 X 728.93 X
25660   003 90 2 X 674.23 X
25660   004 90 2 X 686.06 X
25660   001 90 2 X 663.99 X
25670   001 90 2 X 1,783.68 X
25670   004 90 2 X 1,618.90 X
25670   002 90 2 X 1,755.37 X
25670   003 90 2 X 1,638.43 X
25671   003 90 2 X 991.80 X
25671   002 90 2 X 991.80 X
25671   004 90 2 X 991.80 X
25671   001 90 2 X 1,128.15 X
25675   004 90 2 X 731.71 X
25675   001 90 2 X 791.86 X
25675   003 90 2 X 739.93 X
25675   002 90 2 X 781.74 X
25676   003 90 2 X 1,664.72 X
25676   002 90 2 X 1,782.73 X
25676   004 90 2 X 1,644.70 X
25676   001 90 2 X 1,811.25 X
25680   003 90 2 X 884.18 X
25680   002 90 2 X 930.86 X
25680   001 90 2 X 942.31 X
25680   004 90 2 X 874.47 X
25685   004 90 2 X 2,004.95 X
25685   001 90 2 X 2,252.09 X
25685   002 90 2 X 2,223.63 X
25685   003 90 2 X 2,029.15 X
25690   001 90 2 X 1,221.50 X
25690   004 90 2 X 1,110.36 X
25690   002 90 2 X 1,202.47 X
25690   003 90 2 X 1,072.07 X
25695   002 90 2 X 1,830.09 X
25695   003 90 2 X 1,684.80 X
25695   004 90 2 X 1,664.94 X
25695   001 90 2 X 1,834.12 X
25800   004 90 2 X 2,255.84 X
25800   001 90 2 X 2,504.81 X
25800   002 90 2 X 2,461.70 X
25800   003 90 2 X 2,283.69 X
25805   004 90 2 X 2,621.13 X
25805   001 90 2 X 2,910.81 X
25805   002 90 2 X 2,957.66 X
25805   003 90 2 X 3,481.20 X
25810   002 90 2 X 3,120.26 X
25810   003 90 2 X 2,957.00 X
25810   001 90 2 X 3,234.98 X
25810   004 90 2 X 2,986.78 X
25820   002 90 2 X 2,054.74 X
25820   003 90 2 X 1,823.99 X
25820   001 90 2 X 2,003.91 X
25820   004 90 2 X 1,801.68 X
25825   001 90 2 X 2,501.53 X
25825   002 90 2 X 3,103.87 X
25825   003 90 2 X 2,859.86 X
25825   004 90 2 X 2,241.12 X
25830   001 90 2 X 2,333.33 X
25830   004 90 2 X 2,082.97 X
25830   002 90 2 X 2,261.98 X
25830   003 90 2 X 2,111.90 X
25900   002 90 2 X 1,853.38 X
25900   003 90 2 X 1,725.61 X
25900   004 90 2 X 1,767.53 X
25900   001 90 2 X 1,884.44 X
25905   003 90 2 X 1,738.09 X
25905   002 90 2 X 1,858.91 X
25905   004 90 2 X 1,717.58 X
25905   001 90 2 X 1,888.14 X
25907   004 90 2 X 1,445.54 X
25907   001 90 2 X 1,589.60 X
25907   003 90 2 X 1,462.48 X
25907   002 90 2 X 1,178.59 X
25909   004 90 2 X 1,548.42 X
25909   002 90 2 X 1,673.18 X
25909   003 90 2 X 1,566.14 X
25909   001 90 2 X 1,699.14 X
25915   002 90 2 X 1,673.18 X
25915   003 90 2 X 1,566.14 X
25915   001 90 2 X 1,699.14 X
25915   004 90 2 X 1,548.42 X
25920   001 90 2 X 1,851.06 X
25920   003 90 2 X 1,699.67 X
25920   002 90 2 X 1,802.60 X
25920   004 90 2 X 1,679.77 X