Begin Main Content Area

2021 Workers' Compensation Part B Fee Schedule

27470-27750

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
27470   4 90 2 X 2,991.57 X
27470   3 90 2 X 3,028.35 X
27470   2 90 2 X 3,255.78 X
27470   1 90 2 X 3,310.72 X
27472   3 90 2 X 3,695.42 X
27472   4 90 2 X 3,735.88 X
27472   2 90 2 X 3,969.35 X
27472   1 90 2 X 4,064.39 X
27475   4 90 2 X 1,504.91 X
27475   3 90 2 X 1,523.00 X
27475   2 90 2 X 1,633.74 X
27475   1 90 2 X 1,660.55 X
27477   4 90 2 X 2,321.98 X
27477   3 90 2 X 2,351.23 X
27477   2 90 2 X 2,554.84 X
27477   1 90 2 X 2,603.98 X
27479   4 90 2 X 2,259.48 X
27479   3 90 2 X 2,286.73 X
27479   2 90 2 X 2,452.51 X
27479   1 90 2 X 2,492.65 X
27485   4 90 2 X 1,539.70 X
27485   3 90 2 X 1,558.26 X
27485   2 90 2 X 1,671.52 X
27485   1 90 2 X 1,698.93 X
27486   4 90 2 X 4,926.11 X
27486   3 90 2 X 5,070.00 X
27486   2 90 2 X 5,096.45 X
27486   1 90 2 X 5,143.06 X
27487   2 90 2 X 5,882.35 X
27487   4 90 2 X 5,930.89 X
27487   3 90 2 X 5,934.83 X
27487   1 90 2 X 5,995.88 X
27488   4 90 2 X 3,672.34 X
27488   3 90 2 X 3,687.29 X
27488   2 90 2 X 3,729.42 X
27488   1 90 2 X 3,803.60 X
27495   3 90 2 X 3,081.38 X
27495   4 90 2 X 3,086.98 X
27495   2 90 2 X 3,321.61 X
27495   1 90 2 X 3,379.66 X
27496   4 90 2 X 880.69 X
27496   3 90 2 X 891.32 X
27496   2 90 2 X 956.08 X
27496   1 90 2 X 971.83 X
27497   4 90 2 X 1,077.99 X
27497   3 90 2 X 1,091.05 X
27497   2 90 2 X 1,170.47 X
27497   1 90 2 X 1,189.66 X
27498   4 90 2 X 1,229.37 X
27498   3 90 2 X 1,244.11 X
27498   2 90 2 X 1,334.76 X
27498   1 90 2 X 1,356.69 X
27499   4 90 2 X 1,415.38 X
27499   3 90 2 X 1,432.41 X
27499   2 90 2 X 1,536.42 X
27499   1 90 2 X 1,561.57 X
27500   4 90 2 X 1,183.73 X
27500   3 90 2 X 1,185.43 X
27500   2 90 2 X 1,217.90 X
27500   1 90 2 X 1,248.61 X
27501   4 90 2 X 1,183.73 X
27501   3 90 2 X 1,185.43 X
27501   2 90 2 X 1,217.90 X
27501   1 90 2 X 1,248.61 X
27502   3 90 2 X 1,677.29 X
27502   4 90 2 X 1,786.38 X
27502   1 90 2 X 2,132.67 X
27502   2 90 2 X 2,160.48 X
27503   3 90 2 X 1,677.29 X
27503   4 90 2 X 1,786.38 X
27503   1 90 2 X 2,132.67 X
27503   2 90 2 X 2,160.48 X
27506   4 90 2 X 3,032.44 X
27506   3 90 2 X 3,069.23 X
27506   2 90 2 X 3,294.03 X
27506   1 90 2 X 3,348.41 X
27507   4 90 2 X 2,755.52 X
27507   3 90 2 X 2,789.73 X
27507   2 90 2 X 3,007.76 X
27507   1 90 2 X 3,060.42 X
27508   3 90 2 X 1,067.24 X
27508   4 90 2 X 1,071.31 X
27508   2 90 2 X 1,100.45 X
27508   1 90 2 X 1,107.99 X
27509   3 90 2 X 1,137.55 X
27509   4 90 2 X 1,141.02 X
27509   2 90 2 X 1,172.45 X
27509   1 90 2 X 1,180.42 X
27510   4 90 2 X 1,460.43 X
27510   3 90 2 X 1,482.74 X
27510   2 90 2 X 1,532.79 X
27510   1 90 2 X 1,556.66 X
27511   4 90 2 X 2,722.76 X
27511   3 90 2 X 2,756.67 X
27511   2 90 2 X 2,973.83 X
27511   1 90 2 X 3,026.27 X
27513   4 90 2 X 3,108.73 X
27513   3 90 2 X 3,146.24 X
27513   2 90 2 X 3,372.97 X
27513   1 90 2 X 3,427.80 X
27514   3 90 2 X 3,048.63 X
27514   4 90 2 X 3,054.96 X
27514   2 90 2 X 3,271.01 X
27514   1 90 2 X 3,507.36 X
27516   4 90 2 X 917.61 X
27516   3 90 2 X 928.79 X
27516   2 90 2 X 994.26 X
27516   1 90 2 X 1,010.05 X
27517   4 90 2 X 1,520.53 X
27517   3 90 2 X 1,538.90 X
27517   2 90 2 X 1,650.61 X
27517   1 90 2 X 1,677.69 X
27519   4 90 2 X 2,509.94 X
27519   3 90 2 X 2,540.02 X
27519   2 90 2 X 2,721.51 X
27519   1 90 2 X 2,765.36 X
27520   3 90 2 X 548.18 X
27520   4 90 2 X 603.75 X
27520   1 90 2 X 636.19 X
27520   2 90 2 X 655.26 X
27524   4 90 2 X 1,875.93 X
27524   3 90 2 X 1,898.89 X
27524   2 90 2 X 2,041.96 X
27524   1 90 2 X 2,076.56 X
27530   3 90 2 X 635.58 X
27530   4 90 2 X 706.07 X
27530   1 90 2 X 779.25 X
27530   2 90 2 X 788.95 X
27532   4 90 2 X 1,179.54 X
27532   3 90 2 X 1,193.56 X
27532   2 90 2 X 1,275.88 X
27532   1 90 2 X 1,295.85 X
27535   4 90 2 X 2,053.50 X
27535   3 90 2 X 2,126.21 X
27535   2 90 2 X 2,158.87 X
27535   1 90 2 X 2,326.95 X
27536   4 90 2 X 2,233.14 X
27536   2 90 2 X 2,344.60 X
27536   3 90 2 X 2,501.50 X
27536   1 90 2 X 2,713.73 X
27538   1 90 2 X 714.08 X
27538   4 90 2 X 751.26 X
27538   3 90 2 X 768.81 X
27538   2 90 2 X 800.39 X
27540   3 90 2 X 2,231.83 X
27540   2 90 2 X 2,388.32 X
27540   4 90 2 X 2,463.42 X
27540   1 90 2 X 2,570.35 X
27550   1 90 2 X 736.80 X
27550   4 90 2 X 748.38 X
27550   3 90 2 X 756.72 X
27550   2 90 2 X 799.40 X
27552   4 90 2 X 1,004.94 X
27552   3 90 2 X 1,016.15 X
27552   2 90 2 X 1,077.58 X
27552   1 90 2 X 1,085.52 X
27556   4 90 2 X 2,453.03 X
27556   3 90 2 X 2,482.51 X
27556   2 90 2 X 2,658.02 X
27556   1 90 2 X 2,700.53 X
27557   4 90 2 X 2,887.43 X
27557   3 90 2 X 2,922.03 X
27557   1 90 2 X 3,185.14 X
27557   2 90 2 X 3,668.48 X
27558   4 90 2 X 2,972.67 X
27558   3 90 2 X 3,008.03 X
27558   1 90 2 X 3,273.73 X
27558   2 90 2 X 3,712.22 X
27560   4 90 2 X 421.69 X
27560   3 90 2 X 493.83 X
27560   2 90 2 X 549.36 X
27560   1 90 2 X 557.89 X
27562   4 90 2 X 902.44 X
27562   2 90 2 X 958.69 X
27562   3 90 2 X 1,016.16 X
27562   1 90 2 X 1,103.84 X
27566   4 90 2 X 2,087.12 X
27566   3 90 2 X 2,112.18 X
27566   2 90 2 X 2,261.99 X
27566   1 90 2 X 2,298.19 X
27570   4 10 2 X 426.13 X
27570   3 10 2 X 431.26 X
27570   2 10 2 X 440.82 X
27570   1 10 2 X 443.79 X
27580   4 90 2 X 3,047.75 X
27580   3 90 2 X 3,079.94 X
27580   2 90 2 X 3,229.96 X
27580   1 90 2 X 3,316.68 X
27590   4 90 2 X 1,860.87 X
27590   3 90 2 X 1,882.78 X
27590   2 90 2 X 2,027.61 X
27590   1 90 2 X 2,062.74 X
27591   4 90 2 X 2,192.57 X
27591   3 90 2 X 2,219.08 X
27591   2 90 2 X 2,392.28 X
27591   1 90 2 X 2,434.18 X
27592   4 90 2 X 1,625.26 X
27592   3 90 2 X 1,759.99 X
27592   2 90 2 X 1,860.87 X
27592   1 90 2 X 1,868.02 X
27594   3 90 2 X 978.13 X
27594   4 90 2 X 981.40 X
27594   2 90 2 X 1,011.21 X
27594   1 90 2 X 1,042.38 X
27596   3 90 2 X 1,724.87 X
27596   4 90 2 X 1,737.39 X
27596   2 90 2 X 1,817.66 X
27596   1 90 2 X 1,866.33 X
27598   3 90 2 X 1,925.43 X
27598   4 90 2 X 1,956.06 X
27598   2 90 2 X 2,048.18 X
27598   1 90 2 X 2,083.86 X
27599     YYY 2 X # X
27600   3 90 2 X 1,001.83 X
27600   4 90 2 X 1,017.67 X
27600   2 90 2 X 1,050.95 X
27600   1 90 2 X 1,067.39 X
27601   2 90 2 X 991.69 X
27601   3 90 2 X 994.30 X
27601   4 90 2 X 1,011.23 X
27601   1 90 2 X 1,067.28 X
27602   4 90 2 X 1,010.62 X
27602   3 90 2 X 1,022.02 X
27602   2 90 2 X 1,089.75 X
27602   1 90 2 X 1,106.24 X
27603   4 90 2 X 602.58 X
27603   3 90 2 X 606.45 X
27603   1 90 2 X 609.99 X
27603   2 90 2 X 626.03 X
27604   4 90 2 X 365.84 X
27604   2 90 2 X 394.73 X
27604   1 90 2 X 397.63 X
27604   3 90 2 X 484.54 X
27605   4 10 2 X 366.18 X
27605   3 10 2 X 370.22 X
27605   2 10 2 X 388.30 X
27605   1 10 2 X 392.75 X
27606   3 10 2 X 455.63 X
27606   2 10 2 X 507.81 X
27606   4 10 2 X 559.44 X
27606   1 10 2 X 607.88 X
27607   4 90 2 X 1,235.90 X
27607   3 90 2 X 1,250.59 X
27607   2 90 2 X 1,338.10 X
27607   1 90 2 X 1,359.29 X
27610   3 90 2 X 1,406.79 X
27610   4 90 2 X 1,435.87 X
27610   2 90 2 X 1,508.26 X
27610   1 90 2 X 1,532.82 X
27612   4 90 2 X 1,371.94 X
27612   3 90 2 X 1,461.54 X
27612   2 90 2 X 1,498.84 X
27612   1 90 2 X 1,525.38 X
27613   2 10 2 X 218.39 X
27613   1 10 2 X 231.06 X
27613   4 10 2 X 231.19 X
27613   3 10 2 X 259.16 X
27614   4 90 2 X 464.70 X
27614   3 90 2 X 467.85 X
27614   2 90 2 X 502.01 X
27614   1 90 2 X 510.30 X
27615   4 90 2 X 1,624.73 X
27615   2 90 2 X 1,702.77 X
27615   3 90 2 X 1,912.78 X
27615   1 90 2 X 2,071.82 X
27616   2 90 2 X 1,847.65 X
27616   3 90 2 X 1,847.65 X
27616   4 90 2 X 1,847.65 X
27616   1 90 2 X 2,068.80 X
27618   4 90 2 X 533.79 X
27618   3 90 2 X 554.48 X
27618   2 90 2 X 582.78 X
27618   1 90 2 X 634.41 X
27619   3 90 2 X 841.80 X
27619   2 90 2 X 886.00 X
27619   1 90 2 X 894.21 X
27619   4 90 2 X 1,130.80 X
27620   3 90 2 X 1,300.59 X
27620   4 90 2 X 1,316.95 X
27620   1 90 2 X 1,326.20 X
27620   2 90 2 X 1,390.44 X
27625   3 90 2 X 1,586.70 X
27625   4 90 2 X 1,619.47 X
27625   2 90 2 X 1,701.97 X
27625   1 90 2 X 1,729.78 X
27626   4 90 2 X 1,803.20 X
27626   3 90 2 X 1,826.24 X
27626   2 90 2 X 1,953.09 X
27626   1 90 2 X 1,983.58 X
27630   4 90 2 X 724.03 X
27630   3 90 2 X 732.45 X
27630   2 90 2 X 778.13 X
27630   1 90 2 X 789.21 X
27632   2 90 2 X 591.44 X
27632   3 90 2 X 591.44 X
27632   4 90 2 X 591.44 X
27632   1 90 2 X 663.60 X
27634   2 90 2 X 966.32 X
27634   3 90 2 X 966.32 X
27634   4 90 2 X 966.32 X
27634   1 90 2 X 1,079.71 X
27635   3 90 2 X 1,599.10 X
27635   1 90 2 X 1,611.62 X
27635   4 90 2 X 1,666.96 X
27635   2 90 2 X 1,691.48 X
27637   4 90 2 X 1,671.50 X
27637   3 90 2 X 1,691.52 X
27637   2 90 2 X 1,814.09 X
27637   1 90 2 X 1,843.72 X
27638   4 90 2 X 1,808.12 X
27638   3 90 2 X 1,835.98 X
27638   2 90 2 X 1,962.43 X
27638   1 90 2 X 1,994.51 X
27640   4 90 2 X 1,886.05 X
27640   3 90 2 X 1,920.56 X
27640   2 90 2 X 2,059.41 X
27640   1 90 2 X 2,106.88 X
27641   3 90 2 X 1,513.08 X
27641   4 90 2 X 1,519.87 X
27641   2 90 2 X 1,618.49 X
27641   1 90 2 X 1,668.34 X
27645   4 90 2 X 2,354.53 X
27645   3 90 2 X 2,382.55 X
27645   2 90 2 X 2,554.26 X
27645   1 90 2 X 2,595.87 X
27646   4 90 2 X 2,123.69 X
27646   3 90 2 X 2,149.22 X
27646   2 90 2 X 2,301.97 X
27646   1 90 2 X 2,338.91 X
27647   4 90 2 X 1,978.46 X
27647   3 90 2 X 2,002.41 X
27647   2 90 2 X 2,134.65 X
27647   1 90 2 X 2,166.66 X
27648   4 0 2 X 126.71 X
27648   3 0 2 X 128.16 X
27648   2 0 2 X 134.67 X
27648   1 0 2 X 136.21 X
27650   3 90 2 X 1,676.13 X
27650   4 90 2 X 1,692.16 X
27650   2 90 2 X 1,792.88 X
27650   1 90 2 X 1,837.97 X
27652   3 90 2 X 1,919.26 X
27652   4 90 2 X 1,979.75 X
27652   2 90 2 X 1,998.73 X
27652   1 90 2 X 2,093.39 X
27654   4 90 2 X 1,922.32 X
27654   1 90 2 X 2,059.07 X
27654   3 90 2 X 2,215.01 X
27654   2 90 2 X 2,276.31 X
27656   4 90 2 X 708.67 X
27656   3 90 2 X 743.78 X
27656   2 90 2 X 765.60 X
27656   1 90 2 X 777.42 X
27658   4 90 2 X 811.72 X
27658   3 90 2 X 821.40 X
27658   2 90 2 X 877.51 X
27658   1 90 2 X 891.13 X
27659   4 90 2 X 1,144.05 X
27659   3 90 2 X 1,157.85 X
27659   2 90 2 X 1,238.04 X
27659   1 90 2 X 1,257.37 X
27664   3 90 2 X 720.09 X
27664   4 90 2 X 728.10 X
27664   2 90 2 X 785.78 X
27664   1 90 2 X 797.64 X
27665   4 90 2 X 950.88 X
27665   3 90 2 X 962.35 X
27665   2 90 2 X 1,031.00 X
27665   1 90 2 X 1,047.58 X
27675   4 90 2 X 1,241.31 X
27675   3 90 2 X 1,256.35 X
27675   2 90 2 X 1,343.56 X
27675   1 90 2 X 1,364.70 X
27676   4 90 2 X 1,455.86 X
27676   3 90 2 X 1,473.56 X
27676   2 90 2 X 1,577.34 X
27676   1 90 2 X 1,602.49 X
27680   4 90 2 X 890.28 X
27680   3 90 2 X 900.80 X
27680   2 90 2 X 959.53 X
27680   1 90 2 X 973.77 X
27681   4 90 2 X 1,159.63 X
27681   3 90 2 X 1,173.72 X
27681   2 90 2 X 1,254.45 X
27681   1 90 2 X 1,274.03 X
27685   4 90 2 X 909.95 X
27685   3 90 2 X 920.64 X
27685   2 90 2 X 989.18 X
27685   1 90 2 X 1,015.80 X
27686   4 90 2 X 1,264.56 X
27686   1 90 2 X 1,272.32 X
27686   3 90 2 X 1,280.00 X
27686   2 90 2 X 1,366.75 X
27687   4 90 2 X 1,058.81 X
27687   3 90 2 X 1,071.61 X
27687   1 90 2 X 1,142.03 X
27687   2 90 2 X 1,144.44 X
27690   4 90 2 X 1,382.72 X
27690   3 90 2 X 1,399.29 X
27690   2 90 2 X 1,488.77 X
27690   1 90 2 X 1,510.36 X
27691   4 90 2 X 1,616.05 X
27691   3 90 2 X 1,635.33 X
27691   2 90 2 X 1,747.75 X
27691   1 90 2 X 1,774.91 X
27692   4 ZZZ 0 X 367.16 X
27692   3 ZZZ 0 X 371.66 X
27692   2 ZZZ 0 X 398.26 X
27692   1 ZZZ 0 X 404.66 X
27695   3 90 2 X 1,579.74 X
27695   4 90 2 X 1,638.58 X
27695   2 90 2 X 1,725.67 X
27695   1 90 2 X 1,768.15 X
27696   4 90 2 X 1,402.03 X
27696   3 90 2 X 1,418.87 X
27696   2 90 2 X 1,520.71 X
27696   1 90 2 X 1,545.34 X
27698   3 90 2 X 1,969.30 X
27698   2 90 2 X 2,125.67 X
27698   4 90 2 X 2,126.08 X
27698   1 90 2 X 2,200.85 X
27700   4 90 2 X 1,876.47 X
27700   3 90 2 X 1,900.23 X
27700   2 90 2 X 2,040.53 X
27700   1 90 2 X 2,074.33 X
27702   4 90 2 X 3,338.84 X
27702   3 90 2 X 3,381.11 X
27702   2 90 2 X 3,686.61 X
27702   1 90 2 X 3,760.50 X
27703   4 90 2 X 2,686.44 X
27703   3 90 2 X 2,718.79 X
27703   2 90 2 X 2,916.25 X
27703   1 90 2 X 2,963.98 X
27704   3 90 2 X 1,211.73 X
27704   4 90 2 X 1,234.79 X
27704   2 90 2 X 1,282.92 X
27704   1 90 2 X 1,302.97 X
27705   4 90 2 X 1,942.73 X
27705   3 90 2 X 1,966.54 X
27705   1 90 2 X 2,153.06 X
27705   2 90 2 X 2,245.70 X
27707   4 90 2 X 810.61 X
27707   3 90 2 X 866.66 X
27707   2 90 2 X 1,024.83 X
27707   1 90 2 X 1,038.08 X
27709   4 90 2 X 2,053.41 X
27709   3 90 2 X 2,078.86 X
27709   2 90 2 X 2,250.99 X
27709   1 90 2 X 2,292.57 X
27712   4 90 2 X 2,147.48 X
27712   3 90 2 X 2,173.44 X
27712   1 90 2 X 2,360.84 X
27712   2 90 2 X 2,652.43 X
27715   4 90 2 X 2,412.45 X
27715   3 90 2 X 2,441.79 X
27715   2 90 2 X 2,613.95 X
27715   1 90 2 X 2,655.57 X
27720   4 90 2 X 2,382.19 X
27720   3 90 2 X 2,455.13 X
27720   2 90 2 X 2,638.83 X
27720   1 90 2 X 2,698.66 X
27722   4 90 2 X 2,027.06 X
27722   1 90 2 X 2,233.90 X
27722   3 90 2 X 2,350.89 X
27722   2 90 2 X 2,785.01 X
27724   4 90 2 X 2,737.92 X
27724   3 90 2 X 2,771.90 X
27724   2 90 2 X 3,002.34 X
27724   1 90 2 X 3,058.05 X
27725   3 90 2 X 2,046.43 X
27725   2 90 2 X 2,188.61 X
27725   1 90 2 X 2,222.98 X
27725   4 90 2 X 2,822.84 X
27726   2 90 2 X 1,257.61 X
27726   3 90 2 X 1,257.61 X
27726   4 90 2 X 1,257.61 X
27726   1 90 2 X 1,404.45 X
27727   4 90 2 X 2,125.20 X
27727   3 90 2 X 2,149.69 X
27727   2 90 2 X 2,303.32 X
27727   1 90 2 X 2,340.68 X
27730   4 90 2 X 1,001.05 X
27730   3 90 2 X 1,012.01 X
27730   2 90 2 X 1,080.86 X
27730   1 90 2 X 1,097.64 X
27732   4 90 2 X 939.76 X
27732   3 90 2 X 951.08 X
27732   2 90 2 X 1,020.29 X
27732   1 90 2 X 1,037.06 X
27734   4 90 2 X 1,464.00 X
27734   3 90 2 X 1,481.67 X
27734   2 90 2 X 1,589.18 X
27734   1 90 2 X 1,615.18 X
27740   4 90 2 X 1,624.03 X
27740   3 90 2 X 1,643.57 X
27740   2 90 2 X 1,762.99 X
27740   1 90 2 X 1,791.93 X
27742   4 90 2 X 1,804.87 X
27742   3 90 2 X 1,826.61 X
27742   2 90 2 X 1,959.57 X
27742   1 90 2 X 1,991.76 X
27745   4 90 2 X 1,735.93 X
27745   3 90 2 X 1,756.90 X
27745   2 90 2 X 1,882.19 X
27745   1 90 2 X 1,912.44 X
27750   3 90 2 X 652.30 X
27750   4 90 2 X 692.73 X
27750   1 90 2 X 765.01 X
27750   2 90 2 X 803.01 X