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2021 Workers' Compensation Part B Fee Schedule

27179-27468

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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
27179   4 90 2 X 2,168.31 X
27179   3 90 2 X 2,194.35 X
27179   2 90 2 X 2,354.11 X
27179   1 90 2 X 2,392.78 X
27181   4 90 2 X 2,557.84 X
27181   3 90 2 X 2,588.58 X
27181   2 90 2 X 2,776.89 X
27181   1 90 2 X 2,822.48 X
27185   4 90 2 X 1,060.48 X
27185   3 90 2 X 1,071.47 X
27185   2 90 2 X 1,140.41 X
27185   1 90 2 X 1,157.20 X
27187   4 90 2 X 2,760.49 X
27187   3 90 2 X 2,794.66 X
27187   2 90 2 X 3,021.04 X
27187   1 90 2 X 3,562.97 X
27197   2 0 2 X 149.52 X
27197   3 0 2 X 149.52 X
27197   4 0 2 X 149.52 X
27197   1 0 2 X 165.05 X
27198   2 0 2 X 384.47 X
27198   3 0 2 X 384.47 X
27198   4 0 2 X 384.47 X
27198   1 0 2 X 420.73 X
27200   3 90 2 X 309.16 X
27200   4 90 2 X 322.06 X
27200   1 90 2 X 327.73 X
27200   2 90 2 X 334.68 X
27202   4 90 2 X 1,191.72 X
27202   3 90 2 X 1,206.16 X
27202   2 90 2 X 1,289.49 X
27202   1 90 2 X 1,309.63 X
27215   4 90 2 X 2,187.40 X
27215   3 90 2 X 2,214.70 X
27215   2 90 2 X 2,401.28 X
27215   1 90 2 X 2,446.38 X
27216   3 90 2 X 1,351.03 X
27216   4 90 2 X 1,418.28 X
27216   1 90 2 X 1,512.42 X
27216   2 90 2 X 1,513.19 X
27217   4 90 2 X 2,639.95 X
27217   3 90 2 X 2,672.26 X
27217   2 90 2 X 2,873.95 X
27217   1 90 2 X 2,922.73 X
27218   4 90 2 X 3,145.83 X
27218   3 90 2 X 3,182.85 X
27218   2 90 2 X 3,397.00 X
27218   1 90 2 X 3,448.85 X
27220   3 90 2 X 905.68 X
27220   4 90 2 X 1,144.25 X
27220   2 90 2 X 1,235.43 X
27220   1 90 2 X 1,250.68 X
27222   3 90 2 X 1,614.57 X
27222   4 90 2 X 1,620.53 X
27222   2 90 2 X 1,701.55 X
27222   1 90 2 X 1,735.45 X
27226   4 90 2 X 2,828.36 X
27226   3 90 2 X 2,863.14 X
27226   2 90 2 X 3,080.68 X
27226   1 90 2 X 3,133.23 X
27227   4 90 2 X 3,356.57 X
27227   3 90 2 X 3,398.31 X
27227   2 90 2 X 3,667.80 X
27227   1 90 2 X 3,952.81 X
27228   4 90 2 X 3,603.15 X
27228   3 90 2 X 3,647.33 X
27228   2 90 2 X 3,923.65 X
27228   1 90 2 X 4,075.09 X
27230   1 90 2 X 678.23 X
27230   4 90 2 X 763.11 X
27230   3 90 2 X 823.31 X
27230   2 90 2 X 877.92 X
27232   4 90 2 X 1,841.61 X
27232   2 90 2 X 1,937.60 X
27232   3 90 2 X 1,988.50 X
27232   1 90 2 X 2,139.49 X
27235   4 90 2 X 2,505.27 X
27235   3 90 2 X 2,536.42 X
27235   2 90 2 X 2,746.66 X
27235   1 90 2 X 2,797.49 X
27236   4 90 2 X 2,961.38 X
27236   3 90 2 X 2,997.98 X
27236   2 90 2 X 3,229.64 X
27236   1 90 2 X 3,621.69 X
27238   4 90 2 X 646.79 X
27238   1 90 2 X 699.65 X
27238   3 90 2 X 948.28 X
27238   2 90 2 X 1,016.19 X
27240   4 90 2 X 1,943.29 X
27240   3 90 2 X 2,068.18 X
27240   2 90 2 X 2,104.69 X
27240   1 90 2 X 2,138.12 X
27244   4 90 2 X 2,919.45 X
27244   3 90 2 X 2,955.35 X
27244   2 90 2 X 3,180.57 X
27244   1 90 2 X 3,592.49 X
27245   4 90 2 X 3,311.75 X
27245   3 90 2 X 3,351.31 X
27245   2 90 2 X 3,586.19 X
27245   1 90 2 X 3,791.68 X
27246   4 90 2 X 781.78 X
27246   3 90 2 X 785.94 X
27246   1 90 2 X 808.28 X
27246   2 90 2 X 817.19 X
27248   4 90 2 X 2,003.94 X
27248   3 90 2 X 2,019.27 X
27248   2 90 2 X 2,119.84 X
27248   1 90 2 X 2,144.09 X
27250   3 90 2 X 916.70 X
27250   1 90 2 X 981.93 X
27250   4 90 2 X 1,065.31 X
27250   2 90 2 X 1,093.23 X
27252   3 90 2 X 1,224.45 X
27252   4 90 2 X 1,283.52 X
27252   2 90 2 X 1,369.58 X
27252   1 90 2 X 1,399.97 X
27253   4 90 2 X 2,511.18 X
27253   3 90 2 X 2,523.41 X
27253   2 90 2 X 2,601.52 X
27253   1 90 2 X 2,645.57 X
27254   4 90 2 X 2,909.82 X
27254   3 90 2 X 2,943.97 X
27254   2 90 2 X 3,146.61 X
27254   1 90 2 X 3,195.73 X
27256   4 10 2 X 522.24 X
27256   3 10 2 X 528.07 X
27256   1 10 2 X 566.29 X
27256   2 10 2 X 823.43 X
27257   4 10 2 X 893.60 X
27257   3 10 2 X 904.38 X
27257   2 10 2 X 969.45 X
27257   1 10 2 X 985.18 X
27258   3 90 2 X 2,702.05 X
27258   4 90 2 X 2,704.79 X
27258   2 90 2 X 2,898.45 X
27258   1 90 2 X 2,945.99 X
27259   4 90 2 X 3,344.54 X
27259   3 90 2 X 3,384.85 X
27259   2 90 2 X 3,631.08 X
27259   1 90 2 X 3,690.71 X
27265   3 90 2 X 855.69 X
27265   1 90 2 X 1,021.95 X
27265   4 90 2 X 1,054.20 X
27265   2 90 2 X 1,080.48 X
27266   3 90 2 X 1,112.39 X
27266   4 90 2 X 1,232.11 X
27266   1 90 2 X 1,239.02 X
27266   2 90 2 X 1,265.15 X
27267   2 90 2 X 578.53 X
27267   3 90 2 X 578.53 X
27267   4 90 2 X 578.53 X
27267   1 90 2 X 662.68 X
27268   2 90 2 X 713.56 X
27268   3 90 2 X 713.56 X
27268   4 90 2 X 713.56 X
27268   1 90 2 X 815.12 X
27269   2 90 2 X 1,705.91 X
27269   3 90 2 X 1,705.91 X
27269   4 90 2 X 1,705.91 X
27269   1 90 2 X 1,931.79 X
27275   4 10 2 X 366.88 X
27275   3 10 2 X 374.03 X
27275   2 10 2 X 389.13 X
27275   1 10 2 X 392.88 X
27279   2 90 2 X 750.34 X
27279   3 90 2 X 750.34 X
27279   4 90 2 X 750.34 X
27279   1 90 2 X 818.96 X
27280   4 90 2 X 2,080.58 X
27280   3 90 2 X 2,105.14 X
27280   2 90 2 X 2,257.04 X
27280   1 90 2 X 2,293.86 X
27282   4 90 2 X 1,872.75 X
27282   2 90 2 X 2,035.22 X
27282   3 90 2 X 2,379.50 X
27282   1 90 2 X 2,468.92 X
27284   4 90 2 X 2,859.38 X
27284   3 90 2 X 2,893.69 X
27284   1 90 2 X 3,536.60 X
27284   2 90 2 X 3,538.22 X
27286   4 90 2 X 2,909.55 X
27286   3 90 2 X 2,944.94 X
27286   1 90 2 X 3,202.59 X
27286   2 90 2 X 3,747.04 X
27290   4 90 2 X 4,543.74 X
27290   3 90 2 X 4,599.13 X
27290   2 90 2 X 4,861.09 X
27290   1 90 2 X 4,928.95 X
27295   3 90 2 X 3,274.40 X
27295   4 90 2 X 3,289.73 X
27295   2 90 2 X 3,521.00 X
27295   1 90 2 X 3,580.77 X
27299     YYY 2 X # X
27301   4 90 2 X 680.38 X
27301   3 90 2 X 687.60 X
27301   2 90 2 X 719.15 X
27301   1 90 2 X 727.83 X
27303   4 90 2 X 1,250.59 X
27303   3 90 2 X 1,294.16 X
27303   2 90 2 X 1,381.46 X
27303   1 90 2 X 1,402.60 X
27305   4 90 2 X 873.05 X
27305   3 90 2 X 883.17 X
27305   2 90 2 X 943.21 X
27305   1 90 2 X 957.81 X
27306   4 90 2 X 582.14 X
27306   3 90 2 X 593.36 X
27306   2 90 2 X 621.55 X
27306   1 90 2 X 629.54 X
27307   4 90 2 X 776.84 X
27307   3 90 2 X 785.62 X
27307   2 90 2 X 833.11 X
27307   1 90 2 X 844.66 X
27310   3 90 2 X 1,720.63 X
27310   4 90 2 X 1,768.94 X
27310   2 90 2 X 1,851.61 X
27310   1 90 2 X 1,996.95 X
27323   2 10 2 X 263.77 X
27323   1 10 2 X 265.54 X
27323   4 10 2 X 272.89 X
27323   3 10 2 X 332.66 X
27324   4 90 2 X 447.75 X
27324   3 90 2 X 450.86 X
27324   2 90 2 X 483.88 X
27324   1 90 2 X 495.93 X
27325   2 90 2 X 695.43 X
27325   3 90 2 X 695.43 X
27325   4 90 2 X 695.43 X
27325   1 90 2 X 801.75 X
27326   2 90 2 X 657.56 X
27326   3 90 2 X 657.56 X
27326   4 90 2 X 657.56 X
27326   1 90 2 X 762.36 X
27327   4 90 2 X 619.97 X
27327   3 90 2 X 655.76 X
27327   2 90 2 X 664.84 X
27327   1 90 2 X 674.05 X
27328   4 90 2 X 699.19 X
27328   3 90 2 X 700.23 X
27328   1 90 2 X 863.28 X
27328   2 90 2 X 868.03 X
27329   4 90 2 X 2,247.07 X
27329   3 90 2 X 2,274.02 X
27329   2 90 2 X 2,449.48 X
27329   1 90 2 X 2,508.76 X
27330   3 90 2 X 1,150.07 X
27330   4 90 2 X 1,345.00 X
27330   2 90 2 X 1,371.50 X
27330   1 90 2 X 1,462.67 X
27331   3 90 2 X 1,513.31 X
27331   4 90 2 X 1,629.46 X
27331   2 90 2 X 1,681.61 X
27331   1 90 2 X 1,824.42 X
27332   4 90 2 X 1,734.58 X
27332   3 90 2 X 1,756.12 X
27332   2 90 2 X 2,009.67 X
27332   1 90 2 X 2,024.18 X
27333   4 90 2 X 1,989.75 X
27333   3 90 2 X 2,068.17 X
27333   2 90 2 X 2,204.92 X
27333   1 90 2 X 2,250.76 X
27334   4 90 2 X 2,142.80 X
27334   3 90 2 X 2,176.12 X
27334   2 90 2 X 2,246.30 X
27334   1 90 2 X 2,264.90 X
27335   4 90 2 X 2,234.36 X
27335   3 90 2 X 2,299.94 X
27335   2 90 2 X 2,370.49 X
27335   1 90 2 X 2,387.46 X
27337   2 90 2 X 599.63 X
27337   3 90 2 X 599.63 X
27337   4 90 2 X 599.63 X
27337   1 90 2 X 674.57 X
27339   2 90 2 X 1,082.45 X
27339   3 90 2 X 1,082.45 X
27339   4 90 2 X 1,082.45 X
27339   1 90 2 X 1,215.03 X
27340   3 90 2 X 758.05 X
27340   4 90 2 X 856.34 X
27340   2 90 2 X 932.38 X
27340   1 90 2 X 970.01 X
27345   3 90 2 X 1,085.39 X
27345   4 90 2 X 1,093.20 X
27345   2 90 2 X 1,195.07 X
27345   1 90 2 X 1,251.71 X
27347   2 90 2 X 638.78 666.19
27347   3 90 2 X 638.78 666.19
27347   4 90 2 X 638.78 666.19
27347   1 90 2 X 714.97 747.05
27350   4 90 2 X 1,617.54 X
27350   3 90 2 X 1,637.75 X
27350   2 90 2 X 1,767.51 X
27350   1 90 2 X 1,798.91 X
27355   4 90 2 X 1,392.87 X
27355   3 90 2 X 1,534.15 X
27355   2 90 2 X 1,691.64 X
27355   1 90 2 X 1,807.38 X
27356   4 90 2 X 1,594.46 X
27356   3 90 2 X 1,613.69 X
27356   2 90 2 X 1,730.70 X
27356   1 90 2 X 1,759.10 X
27357   4 90 2 X 1,747.35 X
27357   3 90 2 X 1,768.26 X
27357   2 90 2 X 1,894.87 X
27357   1 90 2 X 1,925.47 X
27358   4 ZZZ 0 X 1,617.89 X
27358   3 ZZZ 0 X 1,668.83 X
27358   2 ZZZ 0 X 1,695.76 X
27358   1 ZZZ 0 X 1,715.52 X
27360   4 90 2 X 1,687.91 X
27360   3 90 2 X 1,708.24 X
27360   2 90 2 X 1,831.43 X
27360   1 90 2 X 1,861.25 X
27364   2 90 2 X 2,267.02 X
27364   3 90 2 X 2,267.02 X
27364   4 90 2 X 2,267.02 X
27364   1 90 2 X 2,536.99 X
27365   3 90 2 X 2,481.38 X
27365   2 90 2 X 2,645.89 X
27365   4 90 2 X 2,654.12 X
27365   1 90 2 X 2,939.61 X
27369   2 0 0 X 164.35 49.12
27369   3 0 0 X 164.35 49.12
27369   4 0 0 X 164.35 49.12
27369   1 0 0 X 185.20 52.99
27372   3 90 2 X 728.74 X
27372   4 90 2 X 732.14 X
27372   2 90 2 X 775.50 X
27372   1 90 2 X 795.55 X
27380   3 90 2 X 1,434.20 X
27380   4 90 2 X 1,448.89 X
27380   2 90 2 X 1,540.77 X
27380   1 90 2 X 1,577.40 X
27381   4 90 2 X 1,996.45 X
27381   3 90 2 X 2,021.05 X
27381   2 90 2 X 2,176.58 X
27381   1 90 2 X 2,214.11 X
27385   3 90 2 X 1,547.80 X
27385   4 90 2 X 1,565.04 X
27385   2 90 2 X 1,668.76 X
27385   1 90 2 X 1,697.91 X
27386   3 90 2 X 2,145.91 X
27386   4 90 2 X 2,184.05 X
27386   2 90 2 X 2,315.82 X
27386   1 90 2 X 2,356.83 X
27390   4 90 2 X 876.01 X
27390   3 90 2 X 886.49 X
27390   1 90 2 X 1,039.54 X
27390   2 90 2 X 1,043.23 X
27391   4 90 2 X 1,143.33 X
27391   3 90 2 X 1,156.89 X
27391   2 90 2 X 1,237.14 X
27391   1 90 2 X 1,256.58 X
27392   4 90 2 X 1,536.25 X
27392   3 90 2 X 1,554.63 X
27392   2 90 2 X 1,666.33 X
27392   1 90 2 X 1,693.36 X
27393   4 90 2 X 1,103.29 X
27393   3 90 2 X 1,116.57 X
27393   2 90 2 X 1,197.75 X
27393   1 90 2 X 1,217.42 X
27394   4 90 2 X 1,290.34 X
27394   3 90 2 X 1,305.37 X
27394   2 90 2 X 1,391.77 X
27394   1 90 2 X 1,412.71 X
27395   4 90 2 X 2,029.78 X
27395   3 90 2 X 2,054.30 X
27395   2 90 2 X 2,201.53 X
27395   1 90 2 X 2,237.21 X
27396   4 90 2 X 1,362.09 X
27396   3 90 2 X 1,378.53 X
27396   1 90 2 X 1,501.36 X
27396   2 90 2 X 2,108.78 X
27397   4 90 2 X 1,728.42 X
27397   3 90 2 X 1,749.19 X
27397   2 90 2 X 1,876.34 X
27397   1 90 2 X 1,907.10 X
27400   4 90 2 X 1,546.78 X
27400   3 90 2 X 1,565.52 X
27400   2 90 2 X 1,676.52 X
27400   1 90 2 X 2,218.90 X
27403   4 90 2 X 1,583.24 X
27403   3 90 2 X 1,728.11 X
27403   1 90 2 X 1,755.22 X
27403   2 90 2 X 1,930.61 X
27405   4 90 2 X 2,301.94 X
27405   3 90 2 X 2,311.01 X
27405   2 90 2 X 2,369.67 X
27405   1 90 2 X 2,383.83 X
27407   4 90 2 X 1,735.49 X
27407   3 90 2 X 1,756.39 X
27407   2 90 2 X 1,882.47 X
27407   1 90 2 X 1,913.05 X
27409   4 90 2 X 2,575.63 X
27409   3 90 2 X 2,607.60 X
27409   2 90 2 X 2,815.30 X
27409   1 90 2 X 2,865.43 X
27412   2 90 2 X 2,724.13 X
27412   3 90 2 X 2,724.13 X
27412   4 90 2 X 2,724.13 X
27412   1 90 2 X 3,107.60 X
27415   2 90 2 X 2,264.14 X
27415   3 90 2 X 2,264.14 X
27415   4 90 2 X 2,264.14 X
27415   1 90 2 X 2,613.50 X
27416   2 90 2 X 1,336.78 X
27416   3 90 2 X 1,336.78 X
27416   4 90 2 X 1,336.78 X
27416   1 90 2 X 1,521.25 X
27418   4 90 2 X 2,095.33 X
27418   3 90 2 X 2,121.53 X
27418   1 90 2 X 2,322.73 X
27418   2 90 2 X 2,373.55 X
27420   4 90 2 X 1,918.58 X
27420   3 90 2 X 1,942.35 X
27420   1 90 2 X 1,973.06 X
27420   2 90 2 X 2,144.23 X
27422   3 90 2 X 1,986.39 X
27422   4 90 2 X 2,131.30 X
27422   2 90 2 X 2,235.05 X
27422   1 90 2 X 2,311.64 X
27424   4 90 2 X 1,989.45 X
27424   3 90 2 X 2,014.23 X
27424   2 90 2 X 2,173.51 X
27424   1 90 2 X 2,212.04 X
27425   2 90 2 X 1,551.16 X
27425   4 90 2 X 1,689.51 X
27425   3 90 2 X 1,693.66 X
27425   1 90 2 X 1,742.13 X
27427   4 90 2 X 2,073.14 X
27427   3 90 2 X 2,099.13 X
27427   1 90 2 X 2,321.03 X
27427   2 90 2 X 2,645.20 X
27428   4 90 2 X 2,491.72 X
27428   3 90 2 X 2,522.74 X
27428   2 90 2 X 2,737.11 X
27428   1 90 2 X 2,789.02 X
27429   4 90 2 X 2,194.33 X
27429   3 90 2 X 2,220.83 X
27429   1 90 2 X 2,420.46 X
27429   2 90 2 X 3,352.81 X
27430   3 90 2 X 1,787.25 X
27430   4 90 2 X 1,854.18 X
27430   2 90 2 X 1,917.87 X
27430   1 90 2 X 1,962.79 X
27435   4 90 2 X 1,488.23 X
27435   3 90 2 X 2,184.10 X
27435   2 90 2 X 2,227.22 X
27435   1 90 2 X 2,237.68 X
27437   4 90 2 X 1,683.27 X
27437   3 90 2 X 1,839.24 X
27437   1 90 2 X 1,978.79 X
27437   2 90 2 X 1,983.94 X
27438   4 90 2 X 2,240.07 X
27438   1 90 2 X 4,584.37 X
27438   3 90 2 X 4,603.63 X
27438   2 90 2 X 4,743.26 X
27440   4 90 2 X 2,053.88 X
27440   3 90 2 X 2,079.17 X
27440   1 90 2 X 2,289.74 X
27440   2 90 2 X 2,353.58 X
27441   4 90 2 X 1,799.28 X
27441   3 90 2 X 1,820.86 X
27441   2 90 2 X 1,952.84 X
27441   1 90 2 X 1,984.81 X
27442   4 90 2 X 2,721.20 X
27442   3 90 2 X 2,755.30 X
27442   2 90 2 X 2,994.32 X
27442   1 90 2 X 3,052.13 X
27443   4 90 2 X 2,740.70 X
27443   3 90 2 X 2,775.33 X
27443   2 90 2 X 3,029.39 X
27443   1 90 2 X 3,090.81 X
27445   4 90 2 X 5,398.33 X
27445   3 90 2 X 5,456.20 X
27445   2 90 2 X 5,607.80 X
27445   1 90 2 X 5,665.85 X
27446   1 90 2 X 4,024.16 X
27446   4 90 2 X 4,197.58 X
27446   3 90 2 X 4,282.81 X
27446   2 90 2 X 4,413.66 X
27447   4 90 2 X 5,592.66 X
27447   3 90 2 X 5,594.24 X
27447   2 90 2 X 5,811.52 X
27447   1 90 2 X 5,858.36 X
27448   4 90 2 X 2,209.18 X
27448   3 90 2 X 2,354.34 X
27448   1 90 2 X 2,455.37 X
27448   2 90 2 X 2,782.37 X
27450   4 90 2 X 2,657.37 X
27450   3 90 2 X 2,690.04 X
27450   1 90 2 X 2,943.59 X
27450   2 90 2 X 2,984.36 X
27454   4 90 2 X 2,735.76 X
27454   3 90 2 X 2,769.67 X
27454   2 90 2 X 3,181.82 X
27454   1 90 2 X 3,225.32 X
27455   4 90 2 X 2,281.00 X
27455   3 90 2 X 2,308.63 X
27455   2 90 2 X 2,478.50 X
27455   1 90 2 X 2,519.63 X
27457   4 90 2 X 2,462.11 X
27457   3 90 2 X 2,492.18 X
27457   1 90 2 X 2,649.59 X
27457   2 90 2 X 2,677.84 X
27465   4 90 2 X 2,380.41 X
27465   3 90 2 X 2,409.03 X
27465   2 90 2 X 2,946.81 X
27465   1 90 2 X 2,983.63 X
27466   4 90 2 X 2,708.47 X
27466   3 90 2 X 2,740.78 X
27466   2 90 2 X 2,938.41 X
27466   1 90 2 X 2,986.24 X
27468   4 90 2 X 3,274.07 X
27468   3 90 2 X 3,313.54 X
27468   2 90 2 X 3,554.31 X
27468   1 90 2 X 3,612.53 X