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2021 Workers' Compensation Part B Fee Schedule

27752-28264

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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
27752   4 90 2 X 972.45 X
27752   3 90 2 X 984.29 X
27752   2 90 2 X 1,055.78 X
27752   1 90 2 X 1,073.13 X
27756   1 90 2 X 1,664.60 X
27756   4 90 2 X 1,761.36 X
27756   3 90 2 X 1,769.26 X
27756   2 90 2 X 1,930.45 X
27758   4 90 2 X 2,186.69 X
27758   3 90 2 X 2,187.80 X
27758   2 90 2 X 2,389.48 X
27758   1 90 2 X 2,457.93 X
27759   4 90 2 X 2,286.52 X
27759   3 90 2 X 2,288.70 X
27759   2 90 2 X 2,493.11 X
27759   1 90 2 X 2,562.24 X
27760   4 90 2 X 548.48 X
27760   3 90 2 X 571.02 X
27760   2 90 2 X 601.26 X
27760   1 90 2 X 607.13 X
27762   4 90 2 X 763.81 X
27762   3 90 2 X 772.76 X
27762   2 90 2 X 856.30 X
27762   1 90 2 X 925.01 X
27766   3 90 2 X 1,487.62 X
27766   4 90 2 X 1,490.74 X
27766   2 90 2 X 1,597.49 X
27766   1 90 2 X 1,624.10 X
27767   2 90 2 X 349.06 350.68
27767   3 90 2 X 349.06 350.68
27767   4 90 2 X 349.06 350.68
27767   1 90 2 X 402.23 404.24
27768   2 90 2 X 546.88 X
27768   3 90 2 X 546.88 X
27768   4 90 2 X 546.88 X
27768   1 90 2 X 626.19 X
27769   2 90 2 X 948.10 X
27769   3 90 2 X 948.10 X
27769   4 90 2 X 948.10 X
27769   1 90 2 X 1,073.95 X
27780   1 90 2 X 471.85 X
27780   3 90 2 X 478.45 X
27780   4 90 2 X 498.69 X
27780   2 90 2 X 499.54 X
27781   1 90 2 X 770.36 X
27781   2 90 2 X 839.12 X
27781   4 90 2 X 839.57 X
27781   3 90 2 X 843.13 X
27784   4 90 2 X 1,135.50 X
27784   3 90 2 X 1,149.10 X
27784   2 90 2 X 1,228.52 X
27784   1 90 2 X 1,247.70 X
27786   4 90 2 X 488.54 X
27786   3 90 2 X 494.41 X
27786   2 90 2 X 529.00 X
27786   1 90 2 X 537.34 X
27788   3 90 2 X 716.76 X
27788   4 90 2 X 726.28 X
27788   2 90 2 X 763.11 X
27788   1 90 2 X 774.52 X
27792   4 90 2 X 1,413.48 X
27792   3 90 2 X 1,415.44 X
27792   2 90 2 X 1,487.83 X
27792   1 90 2 X 1,512.57 X
27808   2 90 2 X 566.92 X
27808   1 90 2 X 571.41 X
27808   4 90 2 X 572.32 X
27808   3 90 2 X 573.39 X
27810   3 90 2 X 948.58 X
27810   4 90 2 X 1,087.14 X
27810   2 90 2 X 1,223.56 X
27810   1 90 2 X 1,266.71 X
27814   4 90 2 X 1,886.23 X
27814   3 90 2 X 1,909.13 X
27814   2 90 2 X 2,049.43 X
27814   1 90 2 X 2,083.35 X
27816   1 90 2 X 663.40 X
27816   3 90 2 X 708.47 X
27816   4 90 2 X 714.17 X
27816   2 90 2 X 737.38 X
27818   3 90 2 X 1,122.55 X
27818   4 90 2 X 1,212.87 X
27818   1 90 2 X 1,322.33 X
27818   2 90 2 X 1,386.60 X
27822   4 90 2 X 1,853.49 X
27822   3 90 2 X 1,876.47 X
27822   2 90 2 X 2,029.57 X
27822   1 90 2 X 2,066.66 X
27823   4 90 2 X 2,257.42 X
27823   3 90 2 X 2,285.24 X
27823   2 90 2 X 2,452.29 X
27823   1 90 2 X 2,503.27 X
27824   1 90 2 X 663.40 X
27824   3 90 2 X 708.47 X
27824   4 90 2 X 714.17 X
27824   2 90 2 X 737.38 X
27825   3 90 2 X 1,122.55 X
27825   4 90 2 X 1,212.87 X
27825   1 90 2 X 1,322.33 X
27825   2 90 2 X 1,386.60 X
27826   4 90 2 X 1,747.08 X
27826   3 90 2 X 1,768.91 X
27826   2 90 2 X 1,918.70 X
27826   1 90 2 X 1,954.92 X
27827   4 90 2 X 2,060.33 X
27827   3 90 2 X 2,085.78 X
27827   2 90 2 X 2,246.56 X
27827   1 90 2 X 2,285.42 X
27828   4 90 2 X 2,386.05 X
27828   3 90 2 X 2,415.14 X
27828   2 90 2 X 2,480.16 X
27828   1 90 2 X 2,637.12 X
27829   4 90 2 X 1,216.91 X
27829   3 90 2 X 1,232.19 X
27829   1 90 2 X 1,365.96 X
27829   2 90 2 X 1,657.92 X
27830   4 90 2 X 634.59 X
27830   3 90 2 X 642.31 X
27830   2 90 2 X 675.10 X
27830   1 90 2 X 696.92 X
27831   4 90 2 X 777.27 X
27831   3 90 2 X 786.68 X
27831   2 90 2 X 841.37 X
27831   1 90 2 X 854.60 X
27832   3 90 2 X 1,116.45 X
27832   4 90 2 X 1,183.24 X
27832   2 90 2 X 1,196.24 X
27832   1 90 2 X 1,215.44 X
27840   4 90 2 X 562.16 X
27840   3 90 2 X 568.44 X
27840   2 90 2 X 596.18 X
27840   1 90 2 X 602.91 X
27842   3 90 2 X 661.20 X
27842   4 90 2 X 704.79 X
27842   2 90 2 X 741.84 X
27842   1 90 2 X 788.38 X
27846   4 90 2 X 1,670.94 X
27846   3 90 2 X 1,691.10 X
27846   1 90 2 X 1,842.28 X
27846   2 90 2 X 1,878.79 X
27848   3 90 2 X 1,701.81 X
27848   4 90 2 X 1,772.24 X
27848   2 90 2 X 1,914.27 X
27848   1 90 2 X 1,964.81 X
27860   4 10 2 X 345.81 X
27860   3 10 2 X 349.75 X
27860   2 10 2 X 461.96 X
27860   1 10 2 X 464.15 X
27870   4 90 2 X 2,512.39 X
27870   3 90 2 X 2,513.33 X
27870   2 90 2 X 2,601.96 X
27870   1 90 2 X 2,620.72 X
27871   4 90 2 X 1,543.67 X
27871   3 90 2 X 1,562.24 X
27871   2 90 2 X 2,531.92 X
27871   1 90 2 X 2,543.04 X
27880   4 90 2 X 1,819.52 X
27880   3 90 2 X 1,840.72 X
27880   2 90 2 X 1,974.30 X
27880   1 90 2 X 2,006.71 X
27881   4 90 2 X 2,072.03 X
27881   3 90 2 X 2,097.06 X
27881   2 90 2 X 2,226.30 X
27881   1 90 2 X 2,293.18 X
27882   4 90 2 X 1,681.16 X
27882   3 90 2 X 1,718.30 X
27882   2 90 2 X 1,750.17 X
27882   1 90 2 X 1,765.06 X
27884   3 90 2 X 954.34 X
27884   4 90 2 X 956.41 X
27884   2 90 2 X 993.92 X
27884   1 90 2 X 1,005.17 X
27886   2 90 2 X 1,679.57 X
27886   3 90 2 X 1,684.83 X
27886   4 90 2 X 1,706.36 X
27886   1 90 2 X 1,781.47 X
27888   4 90 2 X 1,742.88 X
27888   3 90 2 X 1,844.97 X
27888   2 90 2 X 1,901.27 X
27888   1 90 2 X 1,934.45 X
27889   4 90 2 X 1,653.21 X
27889   3 90 2 X 1,672.93 X
27889   2 90 2 X 1,800.71 X
27889   1 90 2 X 1,831.68 X
27892   3 90 2 X 1,047.14 X
27892   4 90 2 X 1,062.61 X
27892   2 90 2 X 1,097.44 X
27892   1 90 2 X 1,114.15 X
27893   2 90 2 X 1,038.13 X
27893   3 90 2 X 1,039.66 X
27893   4 90 2 X 1,056.18 X
27893   1 90 2 X 1,114.03 X
27894   4 90 2 X 1,101.13 X
27894   3 90 2 X 1,113.43 X
27894   2 90 2 X 1,183.36 X
27894   1 90 2 X 1,200.38 X
27899     YYY 2 X # X
28001   2 10 2 X 218.37 200.99
28001   3 10 2 X 245.72 226.38
28001   4 10 2 X 251.59 232.41
28001   1 10 2 X 274.01 252.08
28002   4 10 2 X 411.86 X
28002   3 10 2 X 425.27 X
28002   2 10 2 X 447.19 X
28002   1 10 2 X 453.83 X
28003   4 90 2 X 860.99 X
28003   3 90 2 X 861.20 X
28003   2 90 2 X 862.13 X
28003   1 90 2 X 909.89 X
28005   4 90 2 X 1,091.91 X
28005   3 90 2 X 1,104.28 X
28005   2 90 2 X 1,167.87 X
28005   1 90 2 X 1,183.30 X
28008   2 90 2 X 712.25 X
28008   4 90 2 X 728.84 X
28008   3 90 2 X 732.32 X
28008   1 90 2 X 775.83 X
28010   3 90 2 X 490.17 365.07
28010   2 90 2 X 502.64 373.70
28010   1 90 2 X 519.61 386.81
28010   4 90 2 X 605.42 450.66
28011   4 90 2 X 526.16 X
28011   3 90 2 X 532.03 X
28011   2 90 2 X 557.85 X
28011   1 90 2 X 564.07 X
28020   4 90 2 X 853.50 X
28020   3 90 2 X 864.00 X
28020   2 90 2 X 920.70 X
28020   1 90 2 X 934.41 X
28022   3 90 2 X 665.64 X
28022   1 90 2 X 672.42 X
28022   4 90 2 X 677.52 X
28022   2 90 2 X 702.32 X
28024   4 90 2 X 592.40 X
28024   3 90 2 X 603.25 X
28024   2 90 2 X 634.59 X
28024   1 90 2 X 642.23 X
28035   1 90 2 X 1,163.34 X
28035   3 90 2 X 1,200.24 X
28035   4 90 2 X 1,221.06 X
28035   2 90 2 X 1,234.01 X
28039   2 90 2 X 671.09 486.97
28039   3 90 2 X 671.09 486.97
28039   4 90 2 X 671.09 486.97
28039   1 90 2 X 755.22 536.85
28041   2 90 2 X 640.79 X
28041   3 90 2 X 640.79 X
28041   4 90 2 X 640.79 X
28041   1 90 2 X 706.77 X
28043   2 90 2 X 455.57 X
28043   4 90 2 X 464.89 X
28043   3 90 2 X 477.58 X
28043   1 90 2 X 498.99 X
28045   4 90 2 X 632.34 X
28045   3 90 2 X 637.34 X
28045   2 90 2 X 671.17 X
28045   1 90 2 X 681.95 X
28046   2 90 2 X 1,367.58 X
28046   4 90 2 X 1,373.44 X
28046   3 90 2 X 1,389.12 X
28046   1 90 2 X 1,490.23 X
28047   2 90 2 X 1,357.03 X
28047   3 90 2 X 1,357.03 X
28047   4 90 2 X 1,357.03 X
28047   1 90 2 X 1,472.89 X
28050   4 90 2 X 734.29 X
28050   3 90 2 X 743.28 X
28050   2 90 2 X 794.20 X
28050   1 90 2 X 806.48 X
28052   4 90 2 X 696.97 X
28052   3 90 2 X 705.73 X
28052   2 90 2 X 760.60 X
28052   1 90 2 X 761.73 X
28054   4 90 2 X 504.74 X
28054   3 90 2 X 510.74 X
28054   2 90 2 X 540.91 X
28054   1 90 2 X 548.19 X
28055   2 90 2 X 554.37 X
28055   3 90 2 X 554.37 X
28055   4 90 2 X 554.37 X
28055   1 90 2 X 630.32 X
28060   4 90 2 X 863.17 X
28060   3 90 2 X 873.54 X
28060   2 90 2 X 928.81 X
28060   1 90 2 X 942.15 X
28062   1 90 2 X 1,177.08 X
28062   4 90 2 X 1,241.11 X
28062   3 90 2 X 1,256.70 X
28062   2 90 2 X 1,279.30 X
28070   4 90 2 X 851.35 X
28070   3 90 2 X 861.91 X
28070   1 90 2 X 928.63 X
28070   2 90 2 X 973.30 X
28072   4 90 2 X 759.10 X
28072   3 90 2 X 768.75 X
28072   2 90 2 X 780.81 X
28072   1 90 2 X 905.06 X
28080   4 90 2 X 675.52 X
28080   3 90 2 X 684.09 X
28080   1 90 2 X 770.14 X
28080   2 90 2 X 804.21 X
28086   4 90 2 X 714.20 X
28086   3 90 2 X 722.56 X
28086   1 90 2 X 779.10 X
28086   2 90 2 X 901.52 X
28088   4 90 2 X 670.30 X
28088   3 90 2 X 678.64 X
28088   1 90 2 X 732.22 X
28088   2 90 2 X 815.46 X
28090   4 90 2 X 666.53 X
28090   3 90 2 X 674.46 X
28090   2 90 2 X 711.44 X
28090   1 90 2 X 720.38 X
28092   4 90 2 X 509.18 X
28092   3 90 2 X 515.06 X
28092   2 90 2 X 543.51 X
28092   1 90 2 X 550.39 X
28100   4 90 2 X 924.68 X
28100   3 90 2 X 935.88 X
28100   2 90 2 X 994.90 X
28100   1 90 2 X 1,009.14 X
28102   4 90 2 X 1,318.36 X
28102   3 90 2 X 1,334.50 X
28102   2 90 2 X 1,421.42 X
28102   1 90 2 X 1,442.44 X
28103   4 90 2 X 1,089.97 X
28103   2 90 2 X 1,095.50 X
28103   3 90 2 X 1,103.29 X
28103   1 90 2 X 1,191.86 X
28104   4 90 2 X 851.10 X
28104   3 90 2 X 861.45 X
28104   2 90 2 X 915.26 X
28104   1 90 2 X 928.17 X
28106   4 90 2 X 1,226.00 X
28106   3 90 2 X 1,241.04 X
28106   2 90 2 X 1,322.09 X
28106   1 90 2 X 1,341.66 X
28107   4 90 2 X 922.54 X
28107   3 90 2 X 933.97 X
28107   2 90 2 X 990.65 X
28107   1 90 2 X 1,004.29 X
28108   1 90 2 X 755.94 576.21
28108   4 90 2 X 760.57 580.00
28108   3 90 2 X 762.49 579.76
28108   2 90 2 X 776.69 590.52
28110   3 90 2 X 704.55 X
28110   4 90 2 X 709.62 X
28110   2 90 2 X 726.09 X
28110   1 90 2 X 755.43 X
28111   4 90 2 X 999.43 X
28111   3 90 2 X 1,037.41 X
28111   2 90 2 X 1,088.22 X
28111   1 90 2 X 1,117.53 X
28112   4 90 2 X 930.68 X
28112   3 90 2 X 953.29 X
28112   2 90 2 X 982.19 X
28112   1 90 2 X 1,024.66 X
28113   4 90 2 X 834.49 X
28113   3 90 2 X 982.54 X
28113   1 90 2 X 995.19 X
28113   2 90 2 X 995.96 X
28114   3 90 2 X 1,720.11 X
28114   4 90 2 X 1,782.15 X
28114   2 90 2 X 1,864.57 X
28114   1 90 2 X 1,873.57 X
28116   4 90 2 X 1,074.38 X
28116   3 90 2 X 1,087.58 X
28116   2 90 2 X 1,153.51 X
28116   1 90 2 X 1,169.31 X
28118   3 90 2 X 1,059.95 X
28118   4 90 2 X 1,118.11 X
28118   2 90 2 X 1,129.29 X
28118   1 90 2 X 1,146.03 X
28119   4 90 2 X 975.22 X
28119   3 90 2 X 1,025.71 X
28119   2 90 2 X 1,050.67 X
28119   1 90 2 X 1,065.98 X
28120   4 90 2 X 923.72 X
28120   3 90 2 X 935.12 X
28120   2 90 2 X 999.85 X
28120   1 90 2 X 1,015.41 X
28122   4 90 2 X 1,026.27 X
28122   3 90 2 X 1,074.77 X
28122   2 90 2 X 1,098.80 X
28122   1 90 2 X 1,113.44 X
28124   4 90 2 X 779.14 603.19
28124   3 90 2 X 788.81 609.87
28124   2 90 2 X 834.96 645.44
28124   1 90 2 X 846.12 654.14
28126   4 90 2 X 728.26 544.33
28126   3 90 2 X 747.15 558.40
28126   2 90 2 X 762.04 571.35
28126   1 90 2 X 821.61 616.69
28130   4 90 2 X 1,338.93 X
28130   3 90 2 X 1,355.33 X
28130   2 90 2 X 1,444.56 X
28130   1 90 2 X 1,466.02 X
28140   4 90 2 X 1,056.40 X
28140   3 90 2 X 1,069.04 X
28140   2 90 2 X 1,131.14 X
28140   1 90 2 X 1,150.59 X
28150   4 90 2 X 659.26 X
28150   3 90 2 X 675.43 X
28150   2 90 2 X 708.40 X
28150   1 90 2 X 747.15 X
28153   3 90 2 X 687.15 513.84
28153   2 90 2 X 746.11 558.69
28153   4 90 2 X 746.81 558.75
28153   1 90 2 X 815.47 609.53
28160   4 90 2 X 710.30 533.54
28160   3 90 2 X 717.98 538.57
28160   2 90 2 X 762.94 572.88
28160   1 90 2 X 773.78 581.22
28171   4 90 2 X 1,569.14 X
28171   3 90 2 X 1,588.36 X
28171   2 90 2 X 1,686.16 X
28171   1 90 2 X 1,709.76 X
28173   4 90 2 X 1,291.84 X
28173   3 90 2 X 1,307.06 X
28173   2 90 2 X 1,385.69 X
28173   1 90 2 X 1,404.77 X
28175   4 90 2 X 1,014.52 X
28175   3 90 2 X 1,027.13 X
28175   2 90 2 X 1,091.54 X
28175   1 90 2 X 1,107.07 X
28190   4 10 2 X 184.58 166.30
28190   3 10 2 X 187.07 167.95
28190   1 10 2 X 193.57 173.77
28190   2 10 2 X 198.13 177.53
28192   4 90 2 X 576.23 X
28192   3 90 2 X 576.41 X
28192   2 90 2 X 582.97 X
28192   1 90 2 X 601.39 X
28193   4 90 2 X 718.91 X
28193   3 90 2 X 726.95 X
28193   2 90 2 X 763.64 X
28193   1 90 2 X 772.53 X
28200   3 90 2 X 889.36 X
28200   4 90 2 X 922.36 X
28200   1 90 2 X 960.09 X
28200   2 90 2 X 967.91 X
28202   4 90 2 X 1,139.79 X
28202   3 90 2 X 1,153.61 X
28202   2 90 2 X 1,229.92 X
28202   1 90 2 X 1,248.36 X
28208   3 90 2 X 764.93 X
28208   1 90 2 X 766.85 X
28208   4 90 2 X 839.52 X
28208   2 90 2 X 860.82 X
28210   4 90 2 X 1,067.77 X
28210   3 90 2 X 1,080.92 X
28210   2 90 2 X 1,148.13 X
28210   1 90 2 X 1,164.40 X
28220   4 90 2 X 752.67 X
28220   3 90 2 X 761.96 X
28220   2 90 2 X 775.78 X
28220   1 90 2 X 820.44 X
28222   3 90 2 X 897.77 X
28222   4 90 2 X 1,085.67 X
28222   2 90 2 X 1,170.81 X
28222   1 90 2 X 1,187.97 X
28225   3 90 2 X 507.48 X
28225   4 90 2 X 532.52 X
28225   2 90 2 X 568.99 X
28225   1 90 2 X 576.23 X
28226   3 90 2 X 664.22 X
28226   2 90 2 X 696.04 X
28226   4 90 2 X 708.56 X
28226   1 90 2 X 770.95 X
28230   4 90 2 X 462.32 381.29
28230   3 90 2 X 566.80 465.66
28230   1 90 2 X 577.78 473.08
28230   2 90 2 X 578.69 475.61
28232   4 90 2 X 443.40 374.86
28232   3 90 2 X 448.43 378.77
28232   2 90 2 X 470.08 396.28
28232   1 90 2 X 475.34 400.60
28234   4 90 2 X 403.42 342.42
28234   3 90 2 X 414.41 351.56
28234   1 90 2 X 433.81 367.33
28234   2 90 2 X 439.25 371.49
28238   4 90 2 X 1,347.78 X
28238   3 90 2 X 1,364.47 X
28238   2 90 2 X 1,453.33 X
28238   1 90 2 X 1,500.55 X
28240   3 90 2 X 552.80 X
28240   2 90 2 X 566.92 X
28240   4 90 2 X 572.57 X
28240   1 90 2 X 615.90 X
28250   4 90 2 X 934.94 X
28250   3 90 2 X 959.44 X
28250   2 90 2 X 1,002.71 X
28250   1 90 2 X 1,016.39 X
28260   3 90 2 X 1,065.24 X
28260   4 90 2 X 1,095.66 X
28260   2 90 2 X 1,108.00 X
28260   1 90 2 X 1,182.45 X
28261   4 90 2 X 1,359.32 X
28261   3 90 2 X 1,375.40 X
28261   2 90 2 X 1,450.01 X
28261   1 90 2 X 1,468.03 X
28262   3 90 2 X 2,157.36 X
28262   4 90 2 X 2,243.67 X
28262   2 90 2 X 2,420.00 X
28262   1 90 2 X 2,455.83 X
28264   4 90 2 X 1,803.31 X
28264   3 90 2 X 1,825.52 X
28264   2 90 2 X 1,945.19 X
28264   1 90 2 X 1,974.12 X