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2021 Workers' Compensation Part B Fee Schedule

25922-26565

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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
25922   4 90 2 X 1,191.74 X
25922   3 90 2 X 1,205.71 X
25922   2 90 2 X 1,292.25 X
25922   1 90 2 X 1,313.20 X
25924   4 90 2 X 1,457.94 X
25924   3 90 2 X 1,475.57 X
25924   2 90 2 X 1,582.43 X
25924   1 90 2 X 1,608.27 X
25927   4 90 2 X 1,390.32 X
25927   2 90 2 X 1,507.93 X
25927   3 90 2 X 1,525.58 X
25927   1 90 2 X 1,592.80 X
25929   2 90 2 X 1,095.63 X
25929   4 90 2 X 1,132.14 X
25929   3 90 2 X 1,144.98 X
25929   1 90 2 X 1,244.74 X
25931   4 90 2 X 1,129.38 X
25931   3 90 2 X 1,142.11 X
25931   1 90 2 X 1,238.14 X
25931   2 90 2 X 1,492.19 X
25999     YYY 2 X # X
26010   4 10 2 X 141.07 124.63
26010   3 10 2 X 151.55 134.33
26010   2 10 2 X 157.53 139.01
26010   1 10 2 X 158.37 139.56
26011   3 10 2 X 286.75 X
26011   4 10 2 X 295.58 X
26011   2 10 2 X 311.74 X
26011   1 10 2 X 344.55 X
26020   3 90 2 X 719.27 X
26020   4 90 2 X 734.87 X
26020   2 90 2 X 777.04 X
26020   1 90 2 X 801.52 X
26025   4 90 2 X 842.64 X
26025   3 90 2 X 862.87 X
26025   2 90 2 X 911.47 X
26025   1 90 2 X 933.12 X
26030   3 90 2 X 1,072.48 X
26030   4 90 2 X 1,086.76 X
26030   2 90 2 X 1,154.72 X
26030   1 90 2 X 1,174.66 X
26034   4 90 2 X 1,032.76 X
26034   3 90 2 X 1,037.35 X
26034   2 90 2 X 1,057.65 X
26034   1 90 2 X 1,070.64 X
26035   3 90 2 X 1,228.85 X
26035   4 90 2 X 1,272.18 X
26035   2 90 2 X 1,334.80 X
26035   1 90 2 X 1,387.53 X
26037   4 90 2 X 1,238.93 X
26037   3 90 2 X 1,253.78 X
26037   2 90 2 X 1,345.16 X
26037   1 90 2 X 1,367.30 X
26040   3 90 2 X 759.23 X
26040   2 90 2 X 764.48 X
26040   4 90 2 X 765.59 X
26040   1 90 2 X 781.65 X
26045   1 90 2 X 1,058.29 X
26045   4 90 2 X 1,283.55 X
26045   2 90 2 X 1,285.07 X
26045   3 90 2 X 1,286.68 X
26055   3 90 2 X 683.21 X
26055   4 90 2 X 719.15 X
26055   2 90 2 X 739.38 X
26055   1 90 2 X 751.89 X
26060   3 90 2 X 336.80 X
26060   2 90 2 X 339.21 X
26060   4 90 2 X 354.88 X
26060   1 90 2 X 382.19 X
26070   3 90 2 X 677.13 X
26070   4 90 2 X 709.33 X
26070   2 90 2 X 721.57 X
26070   1 90 2 X 728.70 X
26075   4 90 2 X 556.32 X
26075   3 90 2 X 561.19 X
26075   1 90 2 X 613.99 X
26075   2 90 2 X 685.23 X
26080   1 90 2 X 718.69 X
26080   4 90 2 X 722.39 X
26080   3 90 2 X 739.13 X
26080   2 90 2 X 742.71 X
26100   2 90 2 X 664.01 X
26100   1 90 2 X 674.25 X
26100   3 90 2 X 676.21 X
26100   4 90 2 X 717.04 X
26105   4 90 2 X 739.25 X
26105   3 90 2 X 748.37 X
26105   2 90 2 X 805.83 X
26105   1 90 2 X 819.76 X
26110   3 90 2 X 647.44 X
26110   4 90 2 X 656.20 X
26110   1 90 2 X 662.83 X
26110   2 90 2 X 696.85 X
26111   2 90 2 X 586.86 X
26111   3 90 2 X 586.86 X
26111   4 90 2 X 586.86 X
26111   1 90 2 X 660.84 X
26113   2 90 2 X 771.97 X
26113   3 90 2 X 771.97 X
26113   4 90 2 X 771.97 X
26113   1 90 2 X 868.92 X
26115   4 90 2 X 513.92 X
26115   3 90 2 X 524.50 X
26115   2 90 2 X 555.28 X
26115   1 90 2 X 561.57 X
26116   4 90 2 X 664.83 X
26116   3 90 2 X 701.35 X
26116   1 90 2 X 716.28 X
26116   2 90 2 X 839.14 X
26117   2 90 2 X 1,095.53 X
26117   1 90 2 X 1,099.61 X
26117   4 90 2 X 1,255.81 X
26117   3 90 2 X 1,270.08 X
26118   2 90 2 X 1,520.09 X
26118   3 90 2 X 1,520.09 X
26118   4 90 2 X 1,520.09 X
26118   1 90 2 X 1,709.83 X
26121   3 90 2 X 1,721.66 X
26121   4 90 2 X 1,933.71 X
26121   2 90 2 X 2,033.28 X
26121   1 90 2 X 2,097.44 X
26123   3 90 2 X 1,737.98 X
26123   4 90 2 X 1,758.65 X
26123   2 90 2 X 1,843.56 X
26123   1 90 2 X 1,901.73 X
26125   3 ZZZ 0 X 1,379.82 X
26125   4 ZZZ 0 X 1,403.03 X
26125   2 ZZZ 0 X 1,459.78 X
26125   1 ZZZ 0 X 1,511.96 X
26130   4 90 2 X 967.50 X
26130   3 90 2 X 979.16 X
26130   2 90 2 X 1,052.31 X
26130   1 90 2 X 1,070.01 X
26135   4 90 2 X 1,087.94 X
26135   3 90 2 X 1,100.62 X
26135   2 90 2 X 1,174.73 X
26135   1 90 2 X 1,192.66 X
26140   4 90 2 X 972.62 X
26140   3 90 2 X 984.06 X
26140   2 90 2 X 1,051.07 X
26140   1 90 2 X 1,067.37 X
26145   4 90 2 X 952.65 X
26145   3 90 2 X 955.65 X
26145   2 90 2 X 1,005.39 X
26145   1 90 2 X 1,018.74 X
26160   4 90 2 X 546.28 X
26160   3 90 2 X 586.45 X
26160   2 90 2 X 610.19 X
26160   1 90 2 X 691.82 X
26170   4 90 2 X 696.80 X
26170   3 90 2 X 704.74 X
26170   2 90 2 X 748.10 X
26170   1 90 2 X 758.63 X
26180   4 90 2 X 856.28 X
26180   3 90 2 X 866.32 X
26180   1 90 2 X 942.67 X
26180   2 90 2 X 948.32 X
26185   3 90 2 X 832.23 X
26185   4 90 2 X 832.23 X
26185   2 90 2 X 855.23 X
26185   1 90 2 X 937.91 X
26200   4 90 2 X 919.95 X
26200   3 90 2 X 930.87 X
26200   2 90 2 X 995.76 X
26200   1 90 2 X 1,011.45 X
26205   4 90 2 X 1,290.27 X
26205   3 90 2 X 1,305.64 X
26205   2 90 2 X 1,397.65 X
26205   1 90 2 X 1,419.86 X
26210   3 90 2 X 847.85 X
26210   4 90 2 X 860.63 X
26210   2 90 2 X 905.79 X
26210   1 90 2 X 919.87 X
26215   4 90 2 X 1,171.28 X
26215   3 90 2 X 1,185.09 X
26215   2 90 2 X 1,268.02 X
26215   1 90 2 X 1,288.04 X
26230   4 90 2 X 962.53 X
26230   3 90 2 X 973.77 X
26230   1 90 2 X 1,087.90 X
26230   2 90 2 X 1,120.03 X
26235   4 90 2 X 943.44 X
26235   2 90 2 X 1,131.32 X
26235   3 90 2 X 1,143.82 X
26235   1 90 2 X 1,178.96 X
26236   2 90 2 X 1,106.07 X
26236   3 90 2 X 1,108.37 X
26236   4 90 2 X 1,161.36 X
26236   1 90 2 X 1,195.90 X
26250   4 90 2 X 1,261.79 X
26250   3 90 2 X 1,276.60 X
26250   2 90 2 X 1,368.27 X
26250   1 90 2 X 1,712.95 X
26260   4 90 2 X 1,182.92 X
26260   3 90 2 X 1,272.52 X
26260   2 90 2 X 1,281.89 X
26260   1 90 2 X 1,439.11 X
26262   4 90 2 X 960.58 X
26262   3 90 2 X 972.02 X
26262   1 90 2 X 1,238.84 X
26262   2 90 2 X 1,418.10 X
26320   3 90 2 X 698.68 X
26320   4 90 2 X 709.28 X
26320   1 90 2 X 761.31 X
26320   2 90 2 X 835.97 X
26340   2 90 2 X 484.38 X
26340   3 90 2 X 484.38 X
26340   4 90 2 X 484.38 X
26340   1 90 2 X 556.19 X
26341   2 10 2 X 134.97 103.23
26341   3 10 2 X 134.97 103.23
26341   4 10 2 X 134.97 103.23
26341   1 10 2 X 152.25 115.43
26350   4 90 2 X 1,218.85 X
26350   2 90 2 X 1,269.81 X
26350   3 90 2 X 1,284.43 X
26350   1 90 2 X 1,480.57 X
26352   4 90 2 X 1,315.22 X
26352   3 90 2 X 1,330.96 X
26352   2 90 2 X 1,771.37 X
26352   1 90 2 X 1,793.08 X
26356   4 90 2 X 1,361.57 X
26356   3 90 2 X 1,378.03 X
26356   2 90 2 X 1,482.43 X
26356   1 90 2 X 1,529.86 X
26357   3 90 2 X 1,463.31 X
26357   2 90 2 X 1,520.33 X
26357   1 90 2 X 1,544.96 X
26357   4 90 2 X 1,572.42 X
26358   4 90 2 X 1,527.66 X
26358   3 90 2 X 1,545.83 X
26358   2 90 2 X 1,655.93 X
26358   1 90 2 X 1,682.67 X
26370   3 90 2 X 1,292.93 X
26370   2 90 2 X 1,454.07 X
26370   4 90 2 X 1,519.95 X
26370   1 90 2 X 1,555.78 X
26372   4 90 2 X 1,392.47 X
26372   3 90 2 X 1,529.33 X
26372   1 90 2 X 1,611.16 X
26372   2 90 2 X 1,805.46 X
26373   4 90 2 X 1,375.39 X
26373   3 90 2 X 1,391.83 X
26373   2 90 2 X 1,490.40 X
26373   1 90 2 X 1,514.25 X
26390   3 90 2 X 1,593.94 X
26390   4 90 2 X 1,723.02 X
26390   1 90 2 X 1,732.43 X
26390   2 90 2 X 1,817.34 X
26392   3 90 2 X 1,748.33 X
26392   4 90 2 X 1,850.06 X
26392   2 90 2 X 1,950.47 X
26392   1 90 2 X 2,004.45 X
26410   3 90 2 X 829.98 X
26410   4 90 2 X 884.82 X
26410   2 90 2 X 929.34 X
26410   1 90 2 X 934.28 X
26412   4 90 2 X 1,132.95 X
26412   3 90 2 X 1,146.71 X
26412   1 90 2 X 1,251.71 X
26412   2 90 2 X 1,352.16 X
26415   1 90 2 X 1,510.39 X
26415   3 90 2 X 1,603.70 X
26415   4 90 2 X 1,664.54 X
26415   2 90 2 X 1,692.42 X
26416   4 90 2 X 1,680.52 X
26416   3 90 2 X 1,700.78 X
26416   2 90 2 X 1,824.42 X
26416   1 90 2 X 1,854.38 X
26418   3 90 2 X 810.18 X
26418   4 90 2 X 905.51 X
26418   2 90 2 X 929.28 X
26418   1 90 2 X 936.26 X
26420   4 90 2 X 1,144.07 X
26420   3 90 2 X 1,157.78 X
26420   2 90 2 X 1,241.24 X
26420   1 90 2 X 1,261.40 X
26426   4 90 2 X 1,162.85 X
26426   3 90 2 X 1,337.21 X
26426   2 90 2 X 1,436.49 X
26426   1 90 2 X 1,469.16 X
26428   4 90 2 X 1,180.39 X
26428   3 90 2 X 1,194.26 X
26428   2 90 2 X 1,279.53 X
26428   1 90 2 X 1,300.25 X
26432   1 90 2 X 794.93 X
26432   4 90 2 X 903.03 X
26432   3 90 2 X 932.41 X
26432   2 90 2 X 932.59 X
26433   4 90 2 X 960.90 X
26433   3 90 2 X 985.26 X
26433   2 90 2 X 1,037.06 X
26433   1 90 2 X 1,039.79 X
26434   4 90 2 X 1,020.18 X
26434   3 90 2 X 1,032.20 X
26434   1 90 2 X 1,123.51 X
26434   2 90 2 X 1,303.88 X
26437   4 90 2 X 904.83 X
26437   3 90 2 X 915.39 X
26437   2 90 2 X 1,118.49 X
26437   1 90 2 X 1,264.81 X
26440   3 90 2 X 843.69 X
26440   4 90 2 X 858.63 X
26440   2 90 2 X 884.95 X
26440   1 90 2 X 885.09 X
26442   4 90 2 X 889.89 X
26442   1 90 2 X 969.09 X
26442   2 90 2 X 1,014.20 X
26442   3 90 2 X 1,026.53 X
26445   4 90 2 X 701.26 X
26445   3 90 2 X 709.51 X
26445   2 90 2 X 719.16 X
26445   1 90 2 X 770.01 X
26449   4 90 2 X 1,136.53 X
26449   3 90 2 X 1,150.08 X
26449   2 90 2 X 1,232.95 X
26449   1 90 2 X 1,252.99 X
26450   4 90 2 X 545.43 X
26450   3 90 2 X 551.72 X
26450   1 90 2 X 594.56 X
26450   2 90 2 X 620.59 X
26455   2 90 2 X 464.48 X
26455   4 90 2 X 506.24 X
26455   3 90 2 X 511.94 X
26455   1 90 2 X 550.67 X
26460   4 90 2 X 473.22 X
26460   3 90 2 X 712.01 X
26460   2 90 2 X 785.80 X
26460   1 90 2 X 873.96 X
26471   4 90 2 X 914.16 X
26471   3 90 2 X 924.90 X
26471   1 90 2 X 1,001.59 X
26471   2 90 2 X 1,065.87 X
26474   4 90 2 X 923.83 X
26474   3 90 2 X 934.95 X
26474   2 90 2 X 1,001.44 X
26474   1 90 2 X 1,017.55 X
26476   4 90 2 X 720.32 X
26476   3 90 2 X 728.73 X
26476   2 90 2 X 765.82 X
26476   1 90 2 X 774.74 X
26477   4 90 2 X 853.71 X
26477   3 90 2 X 863.69 X
26477   1 90 2 X 940.86 X
26477   2 90 2 X 1,042.26 X
26478   4 90 2 X 937.53 X
26478   3 90 2 X 948.57 X
26478   2 90 2 X 1,013.31 X
26478   1 90 2 X 1,028.98 X
26479   4 90 2 X 1,029.44 X
26479   3 90 2 X 1,041.75 X
26479   2 90 2 X 1,117.31 X
26479   1 90 2 X 1,135.51 X
26480   4 90 2 X 1,240.90 X
26480   3 90 2 X 1,298.71 X
26480   2 90 2 X 1,396.83 X
26480   1 90 2 X 1,457.20 X
26483   4 90 2 X 1,560.42 X
26483   3 90 2 X 1,579.46 X
26483   2 90 2 X 1,699.36 X
26483   1 90 2 X 1,728.34 X
26485   4 90 2 X 1,306.78 X
26485   3 90 2 X 1,359.32 X
26485   2 90 2 X 1,559.85 X
26485   1 90 2 X 1,659.97 X
26489   3 90 2 X 1,057.27 X
26489   2 90 2 X 1,091.19 X
26489   4 90 2 X 1,145.28 X
26489   1 90 2 X 1,231.05 X
26490   4 90 2 X 1,500.25 X
26490   3 90 2 X 1,518.33 X
26490   2 90 2 X 1,629.54 X
26490   1 90 2 X 1,656.44 X
26492   4 90 2 X 1,680.74 X
26492   3 90 2 X 1,701.21 X
26492   2 90 2 X 1,817.07 X
26492   1 90 2 X 1,844.99 X
26494   4 90 2 X 1,456.25 X
26494   3 90 2 X 1,473.66 X
26494   2 90 2 X 1,580.19 X
26494   1 90 2 X 1,606.02 X
26496   4 90 2 X 1,708.67 X
26496   3 90 2 X 1,729.12 X
26496   2 90 2 X 1,858.47 X
26496   1 90 2 X 1,889.78 X
26497   4 90 2 X 1,632.57 X
26497   3 90 2 X 1,651.96 X
26497   2 90 2 X 1,680.88 X
26497   1 90 2 X 1,800.28 X
26498   4 90 2 X 2,237.51 X
26498   3 90 2 X 2,436.74 X
26498   2 90 2 X 2,612.47 X
26498   1 90 2 X 2,655.07 X
26499   4 90 2 X 1,544.77 X
26499   3 90 2 X 1,563.32 X
26499   2 90 2 X 1,674.24 X
26499   1 90 2 X 1,701.14 X
26500   4 90 2 X 761.50 X
26500   1 90 2 X 820.49 X
26500   3 90 2 X 871.71 X
26500   2 90 2 X 927.41 X
26502   4 90 2 X 1,141.42 X
26502   3 90 2 X 1,154.70 X
26502   2 90 2 X 1,236.47 X
26502   1 90 2 X 1,256.27 X
26508   4 90 2 X 923.96 X
26508   3 90 2 X 934.72 X
26508   2 90 2 X 998.74 X
26508   1 90 2 X 1,014.22 X
26510   4 90 2 X 868.92 X
26510   3 90 2 X 879.20 X
26510   2 90 2 X 940.25 X
26510   1 90 2 X 955.05 X
26516   4 90 2 X 1,023.33 X
26516   1 90 2 X 1,115.12 X
26516   3 90 2 X 1,328.78 X
26516   2 90 2 X 1,579.45 X
26517   4 90 2 X 1,464.23 X
26517   2 90 2 X 1,587.67 X
26517   3 90 2 X 2,318.72 X
26517   1 90 2 X 2,374.07 X
26518   4 90 2 X 1,431.96 X
26518   3 90 2 X 1,448.66 X
26518   2 90 2 X 1,551.82 X
26518   1 90 2 X 2,924.95 X
26520   3 90 2 X 908.51 X
26520   4 90 2 X 921.61 X
26520   2 90 2 X 972.40 X
26520   1 90 2 X 1,072.93 X
26525   1 90 2 X 968.17 X
26525   3 90 2 X 969.93 X
26525   4 90 2 X 972.59 X
26525   2 90 2 X 987.12 X
26530   4 90 2 X 1,151.61 X
26530   3 90 2 X 1,204.47 X
26530   2 90 2 X 1,236.47 X
26530   1 90 2 X 1,244.23 X
26531   4 90 2 X 1,404.60 X
26531   3 90 2 X 1,411.32 X
26531   2 90 2 X 1,461.17 X
26531   1 90 2 X 1,484.72 X
26535   4 90 2 X 910.30 X
26535   3 90 2 X 1,048.74 X
26535   2 90 2 X 1,114.12 X
26535   1 90 2 X 1,137.67 X
26536   3 90 2 X 1,447.22 X
26536   4 90 2 X 1,456.70 X
26536   2 90 2 X 1,504.83 X
26536   1 90 2 X 1,514.88 X
26540   3 90 2 X 1,450.82 X
26540   2 90 2 X 1,455.24 X
26540   4 90 2 X 1,469.54 X
26540   1 90 2 X 1,569.04 X
26541   4 90 2 X 1,634.08 X
26541   3 90 2 X 1,654.05 X
26541   2 90 2 X 1,777.34 X
26541   1 90 2 X 1,810.27 X
26542   4 90 2 X 1,145.06 X
26542   3 90 2 X 1,158.65 X
26542   2 90 2 X 1,242.49 X
26542   1 90 2 X 1,262.75 X
26545   4 90 2 X 1,119.16 X
26545   3 90 2 X 1,132.33 X
26545   2 90 2 X 1,213.12 X
26545   1 90 2 X 1,232.70 X
26546   3 90 2 X 1,538.24 X
26546   4 90 2 X 1,538.24 X
26546   2 90 2 X 1,580.68 X
26546   1 90 2 X 1,767.08 X
26548   4 90 2 X 1,268.00 X
26548   3 90 2 X 1,282.70 X
26548   2 90 2 X 1,371.13 X
26548   1 90 2 X 1,392.58 X
26550   4 90 2 X 1,268.00 X
26550   3 90 2 X 1,282.70 X
26550   2 90 2 X 1,371.13 X
26550   1 90 2 X 1,392.58 X
26551   3 90 2 X 8,015.42 X
26551   4 90 2 X 8,015.42 X
26551   2 90 2 X 8,236.82 X
26551   1 90 2 X 9,207.11 X
26553   3 90 2 X 7,959.70 X
26553   4 90 2 X 7,959.70 X
26553   2 90 2 X 8,179.58 X
26553   1 90 2 X 9,143.09 X
26554   3 90 2 X 9,497.05 X
26554   4 90 2 X 9,497.05 X
26554   2 90 2 X 9,759.36 X
26554   1 90 2 X 10,909.10 X
26555   4 90 2 X 3,164.31 X
26555   3 90 2 X 3,208.50 X
26555   2 90 2 X 3,435.10 X
26555   1 90 2 X 3,542.39 X
26556   3 90 2 X 8,095.16 X
26556   4 90 2 X 8,095.16 X
26556   2 90 2 X 8,318.71 X
26556   1 90 2 X 9,298.78 X
26560   4 90 2 X 927.14 X
26560   3 90 2 X 938.31 X
26560   2 90 2 X 1,001.49 X
26560   1 90 2 X 1,556.09 X
26561   4 90 2 X 1,844.72 X
26561   3 90 2 X 1,866.48 X
26561   2 90 2 X 2,000.86 X
26561   1 90 2 X 2,033.39 X
26562   4 90 2 X 1,840.51 X
26562   3 90 2 X 1,864.30 X
26562   2 90 2 X 1,975.53 X
26562   1 90 2 X 2,002.21 X
26565   4 90 2 X 1,153.15 X
26565   3 90 2 X 1,167.03 X
26565   1 90 2 X 1,266.16 X
26565   2 90 2 X 1,270.42 X