Begin Main Content Area

2021 Workers' Compensation Part B Fee Schedule

26567-27178

     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
26567   4 90 2 X 1,013.02 X
26567   3 90 2 X 1,024.73 X
26567   2 90 2 X 1,089.31 X
26567   1 90 2 X 1,104.98 X
26568   4 90 2 X 1,595.80 X
26568   3 90 2 X 1,615.39 X
26568   2 90 2 X 1,628.86 X
26568   1 90 2 X 1,748.16 X
26580   4 90 2 X 3,096.51 X
26580   3 90 2 X 3,139.72 X
26580   2 90 2 X 3,361.63 X
26580   1 90 2 X 3,466.71 X
26587   4 90 2 X 1,268.00 X
26587   3 90 2 X 1,282.70 X
26587   2 90 2 X 1,371.13 X
26587   1 90 2 X 1,392.58 X
26590   4 90 2 X 927.14 X
26590   3 90 2 X 938.31 X
26590   2 90 2 X 1,001.49 X
26590   1 90 2 X 1,016.80 X
26591   4 90 2 X 491.25 X
26591   3 90 2 X 497.01 X
26591   2 90 2 X 531.42 X
26591   1 90 2 X 539.72 X
26593   4 90 2 X 854.85 X
26593   3 90 2 X 864.96 X
26593   2 90 2 X 926.35 X
26593   1 90 2 X 941.27 X
26596   4 90 2 X 1,602.32 X
26596   3 90 2 X 1,621.61 X
26596   2 90 2 X 1,739.35 X
26596   1 90 2 X 1,767.89 X
26600   4 90 2 X 314.11 248.13
26600   3 90 2 X 323.02 254.88
26600   2 90 2 X 338.94 267.83
26600   1 90 2 X 344.00 272.02
26605   4 90 2 X 468.19 X
26605   3 90 2 X 471.08 X
26605   1 90 2 X 477.85 X
26605   2 90 2 X 504.51 X
26607   4 90 2 X 815.45 X
26607   3 90 2 X 824.90 X
26607   2 90 2 X 878.48 X
26607   1 90 2 X 891.48 X
26608   4 90 2 X 815.45 X
26608   3 90 2 X 824.90 X
26608   2 90 2 X 878.48 X
26608   1 90 2 X 891.48 X
26615   4 90 2 X 953.89 X
26615   3 90 2 X 965.38 X
26615   2 90 2 X 1,035.32 X
26615   1 90 2 X 1,052.30 X
26641   4 90 2 X 348.74 X
26641   2 90 2 X 367.30 X
26641   3 90 2 X 447.50 X
26641   1 90 2 X 472.08 X
26645   2 90 2 X 590.20 X
26645   4 90 2 X 597.28 X
26645   3 90 2 X 604.04 X
26645   1 90 2 X 646.61 X
26650   3 90 2 X 903.89 X
26650   4 90 2 X 951.58 X
26650   1 90 2 X 1,005.27 X
26650   2 90 2 X 1,008.69 X
26665   1 90 2 X 1,418.21 X
26665   4 90 2 X 1,441.33 X
26665   3 90 2 X 1,481.46 X
26665   2 90 2 X 1,520.96 X
26670   4 90 2 X 358.70 X
26670   2 90 2 X 407.69 X
26670   3 90 2 X 413.09 X
26670   1 90 2 X 434.13 X
26675   2 90 2 X 700.65 X
26675   4 90 2 X 824.52 X
26675   3 90 2 X 834.61 X
26675   1 90 2 X 905.87 X
26676   4 90 2 X 951.13 X
26676   3 90 2 X 962.63 X
26676   2 90 2 X 1,027.55 X
26676   1 90 2 X 1,043.19 X
26685   4 90 2 X 1,161.46 X
26685   3 90 2 X 1,175.34 X
26685   2 90 2 X 1,257.53 X
26685   1 90 2 X 1,277.36 X
26686   4 90 2 X 1,304.79 X
26686   3 90 2 X 1,320.29 X
26686   2 90 2 X 1,412.73 X
26686   1 90 2 X 1,435.11 X
26700   4 90 2 X 293.27 X
26700   1 90 2 X 307.45 X
26700   3 90 2 X 313.63 X
26700   2 90 2 X 363.54 X
26705   3 90 2 X 533.70 X
26705   4 90 2 X 534.19 X
26705   2 90 2 X 546.30 X
26705   1 90 2 X 554.47 X
26706   4 90 2 X 909.37 X
26706   3 90 2 X 920.34 X
26706   2 90 2 X 986.70 X
26706   1 90 2 X 1,002.82 X
26715   4 90 2 X 905.41 X
26715   3 90 2 X 915.96 X
26715   2 90 2 X 977.10 X
26715   1 90 2 X 991.92 X
26720   4 90 2 X 247.58 200.62
26720   3 90 2 X 250.48 202.75
26720   2 90 2 X 265.80 215.24
26720   1 90 2 X 269.51 218.30
26725   3 90 2 X 403.97 X
26725   4 90 2 X 407.74 X
26725   1 90 2 X 429.84 X
26725   2 90 2 X 430.96 X
26727   3 90 2 X 692.67 X
26727   4 90 2 X 803.44 X
26727   2 90 2 X 910.34 X
26727   1 90 2 X 914.36 X
26735   3 90 2 X 897.75 X
26735   4 90 2 X 925.63 X
26735   2 90 2 X 955.20 X
26735   1 90 2 X 998.31 X
26740   4 90 2 X 220.83 X
26740   2 90 2 X 233.24 X
26740   1 90 2 X 235.17 X
26740   3 90 2 X 278.94 X
26742   3 90 2 X 470.77 X
26742   4 90 2 X 490.55 X
26742   2 90 2 X 514.53 X
26742   1 90 2 X 520.31 X
26746   3 90 2 X 1,011.93 X
26746   4 90 2 X 1,024.98 X
26746   1 90 2 X 1,075.41 X
26746   2 90 2 X 1,088.80 X
26750   4 90 2 X 223.81 X
26750   3 90 2 X 226.38 X
26750   2 90 2 X 238.33 X
26750   1 90 2 X 241.22 X
26755   3 90 2 X 338.09 X
26755   4 90 2 X 340.41 X
26755   2 90 2 X 352.49 X
26755   1 90 2 X 391.32 X
26756   4 90 2 X 568.31 X
26756   3 90 2 X 574.64 X
26756   2 90 2 X 607.29 X
26756   1 90 2 X 615.27 X
26765   3 90 2 X 637.29 X
26765   4 90 2 X 731.53 X
26765   2 90 2 X 812.91 X
26765   1 90 2 X 860.61 X
26770   4 90 2 X 288.48 X
26770   3 90 2 X 299.49 X
26770   1 90 2 X 318.89 X
26770   2 90 2 X 332.64 X
26775   3 90 2 X 353.37 X
26775   1 90 2 X 368.04 X
26775   4 90 2 X 426.78 X
26775   2 90 2 X 439.49 X
26776   4 90 2 X 621.72 X
26776   3 90 2 X 628.58 X
26776   2 90 2 X 642.62 X
26776   1 90 2 X 672.54 X
26785   4 90 2 X 664.23 X
26785   3 90 2 X 671.99 X
26785   2 90 2 X 716.64 X
26785   1 90 2 X 727.36 X
26820   4 90 2 X 1,367.30 X
26820   3 90 2 X 1,383.61 X
26820   2 90 2 X 1,478.99 X
26820   1 90 2 X 1,502.09 X
26841   4 90 2 X 1,269.37 X
26841   3 90 2 X 1,275.54 X
26841   2 90 2 X 1,331.43 X
26841   1 90 2 X 1,352.87 X
26842   4 90 2 X 1,554.73 X
26842   3 90 2 X 1,573.77 X
26842   2 90 2 X 1,692.60 X
26842   1 90 2 X 1,721.32 X
26843   4 90 2 X 1,291.31 X
26843   3 90 2 X 1,306.69 X
26843   2 90 2 X 1,401.25 X
26843   1 90 2 X 1,424.20 X
26844   4 90 2 X 1,475.44 X
26844   3 90 2 X 1,493.10 X
26844   2 90 2 X 1,598.76 X
26844   1 90 2 X 1,624.32 X
26850   4 90 2 X 1,054.23 X
26850   3 90 2 X 1,117.64 X
26850   2 90 2 X 1,186.27 X
26850   1 90 2 X 1,198.06 X
26852   4 90 2 X 1,294.86 X
26852   3 90 2 X 1,309.93 X
26852   2 90 2 X 1,362.59 X
26852   1 90 2 X 1,420.27 X
26860   2 90 2 X 903.43 X
26860   3 90 2 X 904.72 X
26860   4 90 2 X 907.90 X
26860   1 90 2 X 963.26 X
26861   4 ZZZ 0 X 402.91 X
26861   1 ZZZ 0 X 450.30 X
26861   3 ZZZ 0 X 639.30 X
26861   2 ZZZ 0 X 653.83 X
26862   4 90 2 X 1,152.39 X
26862   2 90 2 X 1,243.63 X
26862   3 90 2 X 1,343.43 X
26862   1 90 2 X 1,648.33 X
26863   4 ZZZ 0 X 690.17 X
26863   3 ZZZ 0 X 698.32 X
26863   2 ZZZ 0 X 748.34 X
26863   1 ZZZ 0 X 760.46 X
26910   3 90 2 X 1,259.13 X
26910   4 90 2 X 1,260.20 X
26910   2 90 2 X 1,299.99 X
26910   1 90 2 X 1,308.32 X
26951   4 90 2 X 685.98 X
26951   3 90 2 X 693.90 X
26951   2 90 2 X 739.05 X
26951   1 90 2 X 764.85 X
26952   4 90 2 X 1,212.77 X
26952   3 90 2 X 1,217.35 X
26952   2 90 2 X 1,243.66 X
26952   1 90 2 X 1,250.10 X
26989     YYY 2 X # X
26990   4 90 2 X 739.77 X
26990   3 90 2 X 778.12 X
26990   2 90 2 X 806.62 X
26990   1 90 2 X 811.07 X
26991   1 90 2 X 470.91 X
26991   3 90 2 X 524.88 X
26991   2 90 2 X 544.79 X
26991   4 90 2 X 723.99 X
26992   4 90 2 X 1,635.95 X
26992   3 90 2 X 1,722.87 X
26992   2 90 2 X 1,805.04 X
26992   1 90 2 X 1,820.06 X
27000   4 90 2 X 652.74 X
27000   3 90 2 X 659.89 X
27000   2 90 2 X 690.97 X
27000   1 90 2 X 698.54 X
27001   4 90 2 X 874.25 X
27001   3 90 2 X 887.07 X
27001   2 90 2 X 912.82 X
27001   1 90 2 X 991.52 X
27003   4 90 2 X 1,262.95 X
27003   3 90 2 X 1,278.32 X
27003   2 90 2 X 1,372.77 X
27003   1 90 2 X 1,396.32 X
27005   4 90 2 X 1,145.47 X
27005   3 90 2 X 1,157.84 X
27005   2 90 2 X 1,217.88 X
27005   1 90 2 X 1,232.48 X
27006   4 90 2 X 1,319.60 X
27006   3 90 2 X 1,334.34 X
27006   2 90 2 X 1,411.46 X
27006   1 90 2 X 1,430.25 X
27025   4 90 2 X 1,527.53 X
27025   2 90 2 X 1,641.45 X
27025   1 90 2 X 1,664.89 X
27025   3 90 2 X 1,673.99 X
27027   2 90 2 X 1,209.25 X
27027   3 90 2 X 1,209.25 X
27027   4 90 2 X 1,209.25 X
27027   1 90 2 X 1,348.19 X
27030   4 90 2 X 2,230.13 X
27030   3 90 2 X 2,257.03 X
27030   2 90 2 X 2,567.84 X
27030   1 90 2 X 2,584.34 X
27033   3 90 2 X 2,291.52 X
27033   4 90 2 X 2,502.35 X
27033   2 90 2 X 2,582.58 X
27033   1 90 2 X 2,599.28 X
27035   4 90 2 X 2,624.58 X
27035   3 90 2 X 2,655.05 X
27035   2 90 2 X 2,843.02 X
27035   1 90 2 X 2,888.63 X
27036   3 90 2 X 2,170.30 X
27036   4 90 2 X 2,170.30 X
27036   2 90 2 X 2,230.18 X
27036   1 90 2 X 2,492.74 X
27040   4 10 2 X 252.66 X
27040   3 10 2 X 258.49 X
27040   1 10 2 X 267.62 X
27040   2 10 2 X 276.56 X
27041   4 90 2 X 697.32 X
27041   3 90 2 X 703.52 X
27041   2 90 2 X 747.15 X
27041   1 90 2 X 750.32 X
27043   2 90 2 X 674.21 X
27043   3 90 2 X 674.21 X
27043   4 90 2 X 674.21 X
27043   1 90 2 X 757.35 X
27045   2 90 2 X 1,071.87 X
27045   3 90 2 X 1,071.87 X
27045   4 90 2 X 1,071.87 X
27045   1 90 2 X 1,202.47 X
27047   3 90 2 X 665.24 X
27047   2 90 2 X 705.43 X
27047   1 90 2 X 732.43 X
27047   4 90 2 X 832.89 X
27048   4 90 2 X 737.97 X
27048   2 90 2 X 782.84 X
27048   1 90 2 X 792.68 X
27048   3 90 2 X 967.27 X
27049   2 90 2 X 1,884.62 X
27049   1 90 2 X 1,906.59 X
27049   4 90 2 X 2,160.17 X
27049   3 90 2 X 2,185.50 X
27050   4 90 2 X 862.85 X
27050   3 90 2 X 873.58 X
27050   2 90 2 X 946.42 X
27050   1 90 2 X 963.96 X
27052   4 90 2 X 1,398.97 X
27052   3 90 2 X 1,416.62 X
27052   2 90 2 X 1,948.12 X
27052   1 90 2 X 2,005.13 X
27054   4 90 2 X 1,940.92 X
27054   3 90 2 X 2,566.33 X
27054   2 90 2 X 2,766.60 X
27054   1 90 2 X 2,941.15 X
27057   2 90 2 X 1,328.49 X
27057   3 90 2 X 1,328.49 X
27057   4 90 2 X 1,328.49 X
27057   1 90 2 X 1,465.23 X
27059   2 90 2 X 2,636.66 X
27059   3 90 2 X 2,636.66 X
27059   4 90 2 X 2,636.66 X
27059   1 90 2 X 2,943.49 X
27060   4 90 2 X 821.99 X
27060   3 90 2 X 831.64 X
27060   2 90 2 X 860.66 X
27060   1 90 2 X 905.18 X
27062   4 90 2 X 850.87 X
27062   3 90 2 X 861.04 X
27062   2 90 2 X 922.59 X
27062   1 90 2 X 937.53 X
27065   4 90 2 X 1,006.84 X
27065   1 90 2 X 1,115.37 X
27065   3 90 2 X 1,134.47 X
27065   2 90 2 X 1,344.70 X
27066   3 90 2 X 1,635.30 X
27066   4 90 2 X 1,738.72 X
27066   2 90 2 X 1,811.71 X
27066   1 90 2 X 1,834.57 X
27067   4 90 2 X 2,303.91 X
27067   3 90 2 X 2,331.50 X
27067   2 90 2 X 2,512.77 X
27067   1 90 2 X 2,540.72 X
27070   4 90 2 X 1,603.02 X
27070   3 90 2 X 1,621.86 X
27070   2 90 2 X 1,673.42 X
27070   1 90 2 X 1,758.26 X
27071   4 90 2 X 1,776.18 X
27071   3 90 2 X 1,786.01 X
27071   1 90 2 X 1,955.10 X
27071   2 90 2 X 1,978.98 X
27075   4 90 2 X 2,791.49 X
27075   3 90 2 X 2,824.56 X
27075   2 90 2 X 3,026.52 X
27075   1 90 2 X 3,075.44 X
27076   4 90 2 X 3,245.80 X
27076   3 90 2 X 3,284.75 X
27076   2 90 2 X 3,517.85 X
27076   1 90 2 X 3,574.28 X
27077   4 90 2 X 3,828.32 X
27077   3 90 2 X 3,873.90 X
27077   2 90 2 X 4,154.34 X
27077   1 90 2 X 4,222.21 X
27078   4 90 2 X 2,002.41 X
27078   3 90 2 X 2,025.79 X
27078   2 90 2 X 2,304.67 X
27078   1 90 2 X 2,806.38 X
27080   4 90 2 X 992.55 X
27080   3 90 2 X 1,004.22 X
27080   2 90 2 X 1,077.58 X
27080   1 90 2 X 1,095.43 X
27086   4 10 2 X 195.88 X
27086   3 10 2 X 202.69 X
27086   2 10 2 X 202.89 X
27086   1 10 2 X 234.22 X
27087   3 90 2 X 969.14 X
27087   2 90 2 X 1,004.59 X
27087   1 90 2 X 1,013.12 X
27087   4 90 2 X 1,083.27 X
27090   4 90 2 X 1,986.72 X
27090   3 90 2 X 2,009.98 X
27090   2 90 2 X 2,144.54 X
27090   1 90 2 X 2,177.12 X
27091   3 90 2 X 4,491.57 X
27091   4 90 2 X 4,755.94 X
27091   2 90 2 X 5,452.54 X
27091   1 90 2 X 5,502.62 X
27093   3 0 2 X 188.91 X
27093   4 0 2 X 196.33 X
27093   1 0 2 X 204.05 X
27093   2 0 2 X 206.73 X
27095   4 0 2 X 211.58 X
27095   3 0 2 X 213.04 X
27095   2 0 2 X 226.66 X
27095   1 0 2 X 229.70 X
27096   2 0 2 X 797.36 113.32
27096   3 0 2 X 797.36 113.32
27096   4 0 2 X 797.36 113.32
27096   1 0 2 X 924.68 124.54
27097   4 90 2 X 1,498.78 X
27097   3 90 2 X 1,516.86 X
27097   2 90 2 X 1,626.94 X
27097   1 90 2 X 1,653.61 X
27098   4 90 2 X 1,498.78 X
27098   3 90 2 X 1,516.86 X
27098   2 90 2 X 1,626.94 X
27098   1 90 2 X 1,653.61 X
27100   4 90 2 X 1,735.22 X
27100   2 90 2 X 1,877.77 X
27100   1 90 2 X 2,058.12 X
27100   3 90 2 X 2,065.72 X
27105   4 90 2 X 1,638.88 X
27105   3 90 2 X 1,656.88 X
27105   2 90 2 X 1,769.21 X
27105   1 90 2 X 1,796.51 X
27110   4 90 2 X 2,197.23 X
27110   3 90 2 X 2,274.57 X
27110   1 90 2 X 2,421.94 X
27110   2 90 2 X 2,677.08 X
27111   4 90 2 X 2,171.37 X
27111   3 90 2 X 2,197.98 X
27111   1 90 2 X 2,389.49 X
27111   2 90 2 X 2,664.01 X
27120   3 90 2 X 3,329.68 X
27120   4 90 2 X 3,413.93 X
27120   2 90 2 X 3,686.32 X
27120   1 90 2 X 3,707.64 X
27122   3 90 2 X 3,200.77 X
27122   4 90 2 X 3,208.71 X
27122   2 90 2 X 3,489.05 X
27122   1 90 2 X 3,603.27 X
27125   4 90 2 X 3,152.15 X
27125   3 90 2 X 3,199.39 X
27125   2 90 2 X 3,428.47 X
27125   1 90 2 X 3,483.93 X
27130   4 90 2 X 4,776.40 X
27130   3 90 2 X 4,885.61 X
27130   2 90 2 X 5,198.60 X
27130   1 90 2 X 5,293.73 X
27132   4 90 2 X 4,872.09 X
27132   3 90 2 X 5,394.89 X
27132   1 90 2 X 5,441.87 X
27132   2 90 2 X 5,773.06 X
27134   4 90 2 X 6,209.16 X
27134   3 90 2 X 6,353.47 X
27134   1 90 2 X 6,703.50 X
27134   2 90 2 X 6,742.92 X
27137   4 90 2 X 4,982.74 X
27137   3 90 2 X 5,016.23 X
27137   2 90 2 X 5,339.11 X
27137   1 90 2 X 5,386.92 X
27138   4 90 2 X 4,329.92 X
27138   3 90 2 X 4,363.99 X
27138   2 90 2 X 4,693.72 X
27138   1 90 2 X 4,751.58 X
27140   3 90 2 X 1,907.56 X
27140   4 90 2 X 2,126.01 X
27140   2 90 2 X 2,163.72 X
27140   1 90 2 X 2,342.63 X
27146   4 90 2 X 2,283.42 X
27146   3 90 2 X 2,310.80 X
27146   2 90 2 X 2,453.39 X
27146   1 90 2 X 2,487.91 X
27147   4 90 2 X 3,279.79 X
27147   3 90 2 X 3,319.36 X
27147   2 90 2 X 3,523.48 X
27147   1 90 2 X 3,619.47 X
27151   4 90 2 X 3,445.38 X
27151   3 90 2 X 3,486.96 X
27151   2 90 2 X 3,740.31 X
27151   1 90 2 X 3,801.70 X
27156   4 90 2 X 3,654.33 X
27156   3 90 2 X 3,697.99 X
27156   2 90 2 X 3,965.49 X
27156   1 90 2 X 4,030.19 X
27158   4 90 2 X 3,097.02 X
27158   3 90 2 X 3,133.23 X
27158   2 90 2 X 3,357.88 X
27158   1 90 2 X 3,412.36 X
27161   4 90 2 X 2,797.98 X
27161   3 90 2 X 2,831.66 X
27161   2 90 2 X 3,035.66 X
27161   1 90 2 X 3,085.04 X
27165   4 90 2 X 3,126.09 X
27165   3 90 2 X 3,164.21 X
27165   2 90 2 X 3,396.34 X
27165   1 90 2 X 3,452.47 X
27170   3 90 2 X 3,327.70 X
27170   4 90 2 X 3,366.66 X
27170   2 90 2 X 3,571.83 X
27170   1 90 2 X 3,657.85 X
27175   4 90 2 X 766.52 X
27175   3 90 2 X 774.25 X
27175   2 90 2 X 803.75 X
27175   1 90 2 X 811.02 X
27176   4 90 2 X 2,020.46 X
27176   3 90 2 X 2,044.80 X
27176   2 90 2 X 2,193.51 X
27176   1 90 2 X 2,229.48 X
27177   4 90 2 X 2,480.10 X
27177   3 90 2 X 2,509.72 X
27177   1 90 2 X 2,733.08 X
27177   2 90 2 X 3,176.57 X
27178   4 90 2 X 2,001.36 X
27178   3 90 2 X 2,025.69 X
27178   2 90 2 X 2,168.31 X
27178   1 90 2 X 2,202.74 X