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2024 Workers' Compensation Part B Fee Schedule

27752-28264

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CPT/HCPC Code	Medicare Location	Global Surgery Indicator	Multiple Surgery Indicator	Prevailing Charge Amount	Fee Schedule Amount	Site of Service Amount
27752	004	90	2	X	1,139.55	X
27752	002	90	2	X	1,237.19	X
27752	003	90	2	X	1,153.42	X
27752	001	90	2	X	1,257.54	X
27756	004	90	2	X	2,064.02	X
27756	001	90	2	X	1,950.62	X
27756	003	90	2	X	2,073.27	X
27756	002	90	2	X	2,262.17	X
27758	001	90	2	X	2,880.28	X
27758	004	90	2	X	2,562.44	X
27758	002	90	2	X	2,800.08	X
27758	003	90	2	X	2,563.72	X
27759	004	90	2	X	2,679.41	X
27759	003	90	2	X	2,681.97	X
27759	002	90	2	X	2,921.52	X
27759	001	90	2	X	3,002.52	X
27760	001	90	2	X	711.45	X
27760	004	90	2	X	642.73	X
27760	003	90	2	X	669.15	X
27760	002	90	2	X	704.57	X
27762	003	90	2	X	905.54	X
27762	002	90	2	X	1,003.44	X
27762	001	90	2	X	1,083.96	X
27762	004	90	2	X	895.06	X
27766	003	90	2	X	1,743.24	X
27766	002	90	2	X	1,871.99	X
27766	004	90	2	X	1,746.90	X
27766	001	90	2	X	1,903.17	X
27767	004	90	2	X	409.04	410.94
27767	002	90	2	X	409.04	410.94
27767	003	90	2	X	409.04	410.94
27767	001	90	2	X	471.35	473.70
27768	002	90	2	X	640.85	X
27768	003	90	2	X	640.85	X
27768	004	90	2	X	640.85	X
27768	001	90	2	X	733.79	X
27769	001	90	2	X	1,258.49	X
27769	004	90	2	X	1,111.01	X
27769	003	90	2	X	1,111.01	X
27769	002	90	2	X	1,111.01	X
27780	003	90	2	X	560.66	X
27780	002	90	2	X	585.37	X
27780	004	90	2	X	584.38	X
27780	001	90	2	X	552.93	X
27781	004	90	2	X	983.83	X
27781	002	90	2	X	983.31	X
27781	003	90	2	X	988.01	X
27781	001	90	2	X	902.73	X
27784	001	90	2	X	1,462.09	X
27784	004	90	2	X	1,330.62	X
27784	002	90	2	X	1,439.62	X
27784	003	90	2	X	1,346.55	X
27786	004	90	2	X	572.48	X
27786	003	90	2	X	579.36	X
27786	002	90	2	X	619.89	X
27786	001	90	2	X	629.67	X
27788	003	90	2	X	839.92	X
27788	002	90	2	X	894.24	X
27788	004	90	2	X	851.07	X
27788	001	90	2	X	907.61	X
27792	001	90	2	X	1,772.48	X
27792	003	90	2	X	1,658.66	X
27792	002	90	2	X	1,743.49	X
27792	004	90	2	X	1,656.37	X
27808	003	90	2	X	671.91	X
27808	002	90	2	X	664.34	X
27808	004	90	2	X	670.66	X
27808	001	90	2	X	669.59	X
27810	001	90	2	X	1,484.37	X
27810	004	90	2	X	1,273.95	X
27810	003	90	2	X	1,111.58	X
27810	002	90	2	X	1,433.81	X
27814	002	90	2	X	2,401.59	X
27814	003	90	2	X	2,237.18	X
27814	001	90	2	X	2,441.34	X
27814	004	90	2	X	2,210.34	X
27816	004	90	2	X	836.89	X
27816	001	90	2	X	777.39	X
27816	002	90	2	X	864.08	X
27816	003	90	2	X	830.21	X
27818	004	90	2	X	1,421.28	X
27818	001	90	2	X	1,549.55	X
27818	003	90	2	X	1,315.44	X
27818	002	90	2	X	1,624.86	X
27822	001	90	2	X	2,421.78	X
27822	004	90	2	X	2,171.98	X
27822	003	90	2	X	2,198.91	X
27822	002	90	2	X	2,378.31	X
27823	004	90	2	X	2,645.32	X
27823	002	90	2	X	2,873.68	X
27823	003	90	2	X	2,677.93	X
27823	001	90	2	X	2,933.41	X
27824	004	90	2	X	836.89	X
27824	002	90	2	X	864.08	X
27824	003	90	2	X	830.21	X
27824	001	90	2	X	777.39	X
27825	003	90	2	X	1,315.44	X
27825	002	90	2	X	1,624.86	X
27825	004	90	2	X	1,421.28	X
27825	001	90	2	X	1,549.55	X
27826	001	90	2	X	2,290.83	X
27826	002	90	2	X	2,248.39	X
27826	003	90	2	X	2,072.87	X
27826	004	90	2	X	2,047.29	X
27827	002	90	2	X	2,632.59	X
27827	003	90	2	X	2,444.19	X
27827	004	90	2	X	2,414.36	X
27827	001	90	2	X	2,678.14	X
27828	004	90	2	X	2,796.05	X
27828	001	90	2	X	3,090.27	X
27828	003	90	2	X	2,830.14	X
27828	002	90	2	X	2,906.33	X
27829	001	90	2	X	1,600.67	X
27829	004	90	2	X	1,426.02	X
27829	002	90	2	X	1,942.80	X
27829	003	90	2	X	1,443.92	X
27830	001	90	2	X	816.68	X
27830	004	90	2	X	743.63	X
27830	002	90	2	X	791.11	X
27830	003	90	2	X	752.68	X
27831	003	90	2	X	921.86	X
27831	002	90	2	X	985.94	X
27831	004	90	2	X	910.83	X
27831	001	90	2	X	1,001.45	X
27832	003	90	2	X	1,308.30	X
27832	002	90	2	X	1,401.80	X
27832	004	90	2	X	1,386.56	X
27832	001	90	2	X	1,424.29	X
27840	002	90	2	X	698.63	X
27840	003	90	2	X	666.12	X
27840	001	90	2	X	706.50	X
27840	004	90	2	X	658.76	X
27842	001	90	2	X	923.84	X
27842	003	90	2	X	774.82	X
27842	002	90	2	X	869.32	X
27842	004	90	2	X	825.90	X
27846	001	90	2	X	2,158.84	X
27846	004	90	2	X	1,958.06	X
27846	002	90	2	X	2,201.63	X
27846	003	90	2	X	1,981.68	X
27848	003	90	2	X	1,994.24	X
27848	002	90	2	X	2,243.20	X
27848	004	90	2	X	2,076.77	X
27848	001	90	2	X	2,302.44	X
27860	002	10	2	X	541.34	X
27860	003	10	2	X	409.84	X
27860	001	10	2	X	543.90	X
27860	004	10	2	X	405.23	X
27870	002	90	2	X	3,049.06	X
27870	003	90	2	X	2,945.20	X
27870	001	90	2	X	3,071.05	X
27870	004	90	2	X	2,944.10	X
27871	004	90	2	X	1,808.92	X
27871	001	90	2	X	2,980.02	X
27871	003	90	2	X	1,830.68	X
27871	002	90	2	X	2,966.98	X
27880	001	90	2	X	2,351.52	X
27880	002	90	2	X	2,313.54	X
27880	003	90	2	X	2,157.02	X
27880	004	90	2	X	2,132.18	X
27881	004	90	2	X	2,428.07	X
27881	001	90	2	X	2,687.22	X
27881	002	90	2	X	2,608.85	X
27881	003	90	2	X	2,457.41	X
27882	002	90	2	X	2,050.90	X
27882	003	90	2	X	2,013.56	X
27882	004	90	2	X	1,970.04	X
27882	001	90	2	X	2,068.35	X
27884	001	90	2	X	1,177.89	X
27884	004	90	2	X	1,120.75	X
27884	002	90	2	X	1,164.71	X
27884	003	90	2	X	1,118.33	X
27886	004	90	2	X	1,999.57	X
27886	003	90	2	X	1,974.34	X
27886	002	90	2	X	1,968.17	X
27886	001	90	2	X	2,087.59	X
27888	004	90	2	X	2,042.36	X
27888	001	90	2	X	2,266.85	X
27888	003	90	2	X	2,161.99	X
27888	002	90	2	X	2,227.96	X
27889	001	90	2	X	2,146.42	X
27889	004	90	2	X	1,937.28	X
27889	003	90	2	X	1,960.39	X
27889	002	90	2	X	2,110.13	X
27892	004	90	2	X	1,245.20	X
27892	002	90	2	X	1,286.01	X
27892	003	90	2	X	1,227.08	X
27892	001	90	2	X	1,305.60	X
27893	004	90	2	X	1,237.67	X
27893	001	90	2	X	1,305.46	X
27893	003	90	2	X	1,218.31	X
27893	002	90	2	X	1,216.52	X
27894	001	90	2	X	1,406.65	X
27894	002	90	2	X	1,386.69	X
27894	003	90	2	X	1,304.75	X
27894	004	90	2	X	1,290.34	X
27899		YYY	2	X	#	X
28001	001	0	2	X	321.09	295.40
28001	004	0	2	X	294.82	272.34
28001	003	0	2	X	287.94	265.28
28001	002	0	2	X	255.89	235.53
28002	001	0	2	X	531.81	X
28002	003	0	2	X	498.35	X
28002	002	0	2	X	524.02	X
28002	004	0	2	X	482.63	X
28003	001	0	2	X	1,066.24	X
28003	004	0	2	X	1,008.95	X
28003	002	0	2	X	1,010.27	X
28003	003	0	2	X	1,009.18	X
28005	001	90	2	X	1,386.63	X
28005	004	90	2	X	1,279.54	X
28005	003	90	2	X	1,294.03	X
28005	002	90	2	X	1,368.55	X
28008	004	90	2	X	854.08	X
28008	002	90	2	X	834.64	X
28008	003	90	2	X	858.16	X
28008	001	90	2	X	909.14	X
28010	001	90	2	X	608.89	453.27
28010	004	90	2	X	709.46	528.09
28010	002	90	2	X	589.00	437.91
28010	003	90	2	X	574.39	427.79
28011	003	90	2	X	623.45	X
28011	002	90	2	X	653.71	X
28011	001	90	2	X	660.99	X
28011	004	90	2	X	616.57	X
28020	001	90	2	X	1,094.97	X
28020	004	90	2	X	1,000.16	X
28020	003	90	2	X	1,012.46	X
28020	002	90	2	X	1,078.91	X
28022	004	90	2	X	793.95	X
28022	003	90	2	X	780.02	X
28022	002	90	2	X	822.99	X
28022	001	90	2	X	787.97	X
28024	004	90	2	X	694.20	X
28024	001	90	2	X	752.59	X
28024	003	90	2	X	706.90	X
28024	002	90	2	X	743.63	X
28035	003	90	2	X	1,406.49	X
28035	002	90	2	X	1,446.05	X
28035	004	90	2	X	1,430.87	X
28035	001	90	2	X	1,363.24	X
28039	003	90	2	X	786.41	570.65
28039	002	90	2	X	786.41	570.65
28039	004	90	2	X	786.41	570.65
28039	001	90	2	X	884.99	629.10
28041	002	90	2	X	750.90	X
28041	003	90	2	X	750.90	X
28041	004	90	2	X	750.90	X
28041	001	90	2	X	828.21	X
28043	002	90	2	X	533.85	X
28043	003	90	2	X	559.64	X
28043	004	90	2	X	544.77	X
28043	001	90	2	X	584.73	X
28045	003	90	2	X	746.86	X
28045	002	90	2	X	786.50	X
28045	004	90	2	X	740.99	X
28045	001	90	2	X	799.14	X
28046	001	90	2	X	1,746.31	X
28046	003	90	2	X	1,627.82	X
28046	002	90	2	X	1,602.58	X
28046	004	90	2	X	1,609.44	X
28047	004	90	2	X	1,590.21	X
28047	003	90	2	X	1,590.21	X
28047	002	90	2	X	1,590.21	X
28047	001	90	2	X	1,725.98	X
28050	004	90	2	X	860.46	X
28050	002	90	2	X	930.68	X
28050	003	90	2	X	871.00	X
28050	001	90	2	X	945.06	X
28052	004	90	2	X	816.73	X
28052	001	90	2	X	892.61	X
28052	002	90	2	X	891.30	X
28052	003	90	2	X	827.00	X
28054	002	90	2	X	633.86	X
28054	003	90	2	X	598.50	X
28054	001	90	2	X	642.39	X
28054	004	90	2	X	591.47	X
28055	003	90	2	X	649.63	X
28055	002	90	2	X	649.63	X
28055	004	90	2	X	649.63	X
28055	001	90	2	X	738.63	X
28060	002	90	2	X	1,088.41	X
28060	003	90	2	X	1,023.64	X
28060	004	90	2	X	1,011.49	X
28060	001	90	2	X	1,104.04	X
28062	001	90	2	X	1,379.34	X
28062	004	90	2	X	1,454.37	X
28062	003	90	2	X	1,472.64	X
28062	002	90	2	X	1,499.12	X
28070	004	90	2	X	997.64	X
28070	001	90	2	X	1,088.20	X
28070	002	90	2	X	1,140.55	X
28070	003	90	2	X	1,010.02	X
28072	004	90	2	X	889.53	X
28072	001	90	2	X	1,060.57	X
28072	003	90	2	X	900.85	X
28072	002	90	2	X	914.97	X
28080	001	90	2	X	902.48	X
28080	004	90	2	X	791.60	X
28080	002	90	2	X	942.41	X
28080	003	90	2	X	801.64	X
28086	001	90	2	X	912.97	X
28086	004	90	2	X	836.93	X
28086	002	90	2	X	1,056.43	X
28086	003	90	2	X	846.72	X
28088	001	90	2	X	858.04	X
28088	004	90	2	X	785.48	X
28088	003	90	2	X	795.26	X
28088	002	90	2	X	955.58	X
28090	004	90	2	X	781.06	X
28090	002	90	2	X	833.70	X
28090	003	90	2	X	790.35	X
28090	001	90	2	X	844.17	X
28092	002	90	2	X	636.90	X
28092	003	90	2	X	603.56	X
28092	001	90	2	X	644.97	X
28092	004	90	2	X	596.68	X
28100	002	90	2	X	1,165.85	X
28100	003	90	2	X	1,096.70	X
28100	004	90	2	X	1,083.58	X
28100	001	90	2	X	1,182.54	X
28102	002	90	2	X	1,665.66	X
28102	003	90	2	X	1,563.82	X
28102	001	90	2	X	1,690.30	X
28102	004	90	2	X	1,544.90	X
28103	004	90	2	X	1,277.27	X
28103	002	90	2	X	1,283.73	X
28103	003	90	2	X	1,292.88	X
28103	001	90	2	X	1,396.66	X
28104	002	90	2	X	1,072.53	X
28104	003	90	2	X	1,009.48	X
28104	004	90	2	X	997.34	X
28104	001	90	2	X	1,087.66	X
28106	001	90	2	X	1,572.20	X
28106	004	90	2	X	1,436.67	X
28106	002	90	2	X	1,549.27	X
28106	003	90	2	X	1,454.29	X
28107	002	90	2	X	1,160.87	X
28107	003	90	2	X	1,094.45	X
28107	001	90	2	X	1,176.85	X
28107	004	90	2	X	1,081.07	X
28108	004	90	2	X	891.26	679.66
28108	001	90	2	X	885.83	675.22
28108	003	90	2	X	893.51	679.38
28108	002	90	2	X	910.15	691.98
28110	004	90	2	X	831.55	X
28110	001	90	2	X	885.24	X
28110	003	90	2	X	825.61	X
28110	002	90	2	X	850.86	X
28111	002	90	2	X	1,275.21	X
28111	003	90	2	X	1,215.68	X
28111	001	90	2	X	1,309.56	X
28111	004	90	2	X	1,171.16	X
28112	003	90	2	X	1,117.10	X
28112	002	90	2	X	1,150.96	X
28112	001	90	2	X	1,200.73	X
28112	004	90	2	X	1,090.60	X
28113	004	90	2	X	977.89	X
28113	001	90	2	X	1,166.19	X
28113	002	90	2	X	1,167.10	X
28113	003	90	2	X	1,151.37	X
28114	001	90	2	X	2,195.51	X
28114	004	90	2	X	2,088.38	X
28114	003	90	2	X	2,015.69	X
28114	002	90	2	X	2,184.96	X
28116	001	90	2	X	1,370.23	X
28116	002	90	2	X	1,351.72	X
28116	003	90	2	X	1,274.46	X
28116	004	90	2	X	1,258.99	X
28118	003	90	2	X	1,242.08	X
28118	002	90	2	X	1,323.34	X
28118	001	90	2	X	1,342.96	X
28118	004	90	2	X	1,310.24	X
28119	002	90	2	X	1,231.20	X
28119	003	90	2	X	1,201.96	X
28119	001	90	2	X	1,249.14	X
28119	004	90	2	X	1,142.79	X
28120	003	90	2	X	1,095.81	X
28120	002	90	2	X	1,171.65	X
28120	001	90	2	X	1,189.90	X
28120	004	90	2	X	1,082.45	X
28122	001	90	2	X	1,304.77	X
28122	002	90	2	X	1,287.61	X
28122	003	90	2	X	1,259.44	X
28122	004	90	2	X	1,202.61	X
28124	001	90	2	X	991.50	766.54
28124	003	90	2	X	924.35	714.67
28124	002	90	2	X	978.43	756.35
28124	004	90	2	X	913.02	706.84
28126	004	90	2	X	853.40	637.86
28126	001	90	2	X	962.79	722.65
28126	003	90	2	X	875.53	654.35
28126	002	90	2	X	892.98	669.53
28130	001	90	2	X	1,717.93	X
28130	004	90	2	X	1,569.01	X
28130	003	90	2	X	1,588.22	X
28130	002	90	2	X	1,692.78	X
28140	003	90	2	X	1,252.74	X
28140	002	90	2	X	1,325.51	X
28140	004	90	2	X	1,237.92	X
28140	001	90	2	X	1,348.30	X
28150	001	90	2	X	875.53	X
28150	003	90	2	X	791.49	X
28150	002	90	2	X	830.12	X
28150	004	90	2	X	772.54	X
28153	004	90	2	X	875.14	654.76
28153	001	90	2	X	955.59	714.27
28153	003	90	2	X	805.22	602.13
28153	002	90	2	X	874.31	654.69
28160	002	90	2	X	894.04	671.32
28160	003	90	2	X	841.36	631.11
28160	004	90	2	X	832.35	625.22
28160	001	90	2	X	906.74	681.10
28171	001	90	2	X	2,003.55	X
28171	004	90	2	X	1,838.76	X
28171	003	90	2	X	1,861.29	X
28171	002	90	2	X	1,975.90	X
28173	004	90	2	X	1,513.81	X
28173	003	90	2	X	1,531.66	X
28173	002	90	2	X	1,623.80	X
28173	001	90	2	X	1,646.15	X
28175	004	90	2	X	1,188.84	X
28175	002	90	2	X	1,279.10	X
28175	003	90	2	X	1,203.62	X
28175	001	90	2	X	1,297.31	X
28190	001	10	2	X	226.83	203.63
28190	004	10	2	X	216.30	194.88
28190	002	10	2	X	232.18	208.04
28190	003	10	2	X	219.22	196.80
28192	002	90	2	X	683.14	X
28192	003	90	2	X	675.45	X
28192	004	90	2	X	675.24	X
28192	001	90	2	X	704.72	X
28193	002	90	2	X	894.86	X
28193	003	90	2	X	851.86	X
28193	001	90	2	X	905.28	X
28193	004	90	2	X	842.44	X
28200	001	90	2	X	1,125.07	X
28200	003	90	2	X	1,042.18	X
28200	002	90	2	X	1,134.22	X
28200	004	90	2	X	1,080.85	X
28202	001	90	2	X	1,462.86	X
28202	004	90	2	X	1,335.65	X
28202	002	90	2	X	1,441.25	X
28202	003	90	2	X	1,351.84	X
28208	002	90	2	X	1,008.73	X
28208	003	90	2	X	896.38	X
28208	001	90	2	X	898.62	X
28208	004	90	2	X	983.78	X
28210	002	90	2	X	1,345.42	X
28210	003	90	2	X	1,266.66	X
28210	004	90	2	X	1,251.24	X
28210	001	90	2	X	1,364.48	X
28220	001	90	2	X	961.42	X
28220	004	90	2	X	882.00	X
28220	003	90	2	X	892.89	X
28220	002	90	2	X	909.08	X
28222	002	90	2	X	1,371.99	X
28222	003	90	2	X	1,052.03	X
28222	001	90	2	X	1,392.10	X
28222	004	90	2	X	1,272.22	X
28225	001	90	2	X	675.24	X
28225	003	90	2	X	594.68	X
28225	002	90	2	X	666.75	X
28225	004	90	2	X	624.03	X
28226	004	90	2	X	830.30	X
28226	001	90	2	X	903.42	X
28226	003	90	2	X	778.36	X
28226	002	90	2	X	815.64	X
28230	003	90	2	X	664.20	545.67
28230	002	90	2	X	678.12	557.34
28230	004	90	2	X	541.76	446.82
28230	001	90	2	X	677.06	554.37
28232	001	90	2	X	557.01	469.44
28232	004	90	2	X	519.58	439.28
28232	002	90	2	X	550.86	464.37
28232	003	90	2	X	525.49	443.85
28234	004	90	2	X	472.74	401.26
28234	002	90	2	X	514.73	435.32
28234	003	90	2	X	485.62	411.96
28234	001	90	2	X	508.35	430.45
28238	001	90	2	X	1,758.40	X
28238	004	90	2	X	1,579.36	X
28238	003	90	2	X	1,598.94	X
28238	002	90	2	X	1,703.06	X
28240	004	90	2	X	670.96	X
28240	002	90	2	X	664.34	X
28240	003	90	2	X	647.78	X
28240	001	90	2	X	721.73	X
28250	004	90	2	X	1,095.60	X
28250	001	90	2	X	1,191.04	X
28250	002	90	2	X	1,175.01	X
28250	003	90	2	X	1,124.30	X
28260	003	90	2	X	1,248.29	X
28260	002	90	2	X	1,298.39	X
28260	004	90	2	X	1,283.92	X
28260	001	90	2	X	1,385.63	X
28261	002	90	2	X	1,699.17	X
28261	003	90	2	X	1,611.74	X
28261	004	90	2	X	1,592.91	X
28261	001	90	2	X	1,720.28	X
28262	003	90	2	X	2,528.07	X
28262	002	90	2	X	2,835.83	X
28262	004	90	2	X	2,629.20	X
28262	001	90	2	X	2,877.82	X
28264	004	90	2	X	2,113.18	X
28264	001	90	2	X	2,313.33	X
28264	002	90	2	X	2,279.43	X
28264	003	90	2	X	2,139.20	X

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