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2021 Workers' Compensation Part B Fee Schedule

28270-29358

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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
28270   4 90 2 X 656.54 544.07
28270   3 90 2 X 664.22 549.80
28270   2 90 2 X 697.36 576.21
28270   1 90 2 X 705.43 582.64
28272   4 90 2 X 519.66 432.56
28272   1 90 2 X 599.94 497.75
28272   3 90 2 X 629.18 524.01
28272   2 90 2 X 636.33 527.71
28280   4 90 2 X 702.84 X
28280   1 90 2 X 708.87 X
28280   3 90 2 X 759.52 X
28280   2 90 2 X 771.14 X
28285   4 90 2 X 790.66 X
28285   3 90 2 X 793.98 X
28285   2 90 2 X 863.18 X
28285   1 90 2 X 874.81 X
28286   3 90 2 X 678.83 X
28286   4 90 2 X 736.11 X
28286   1 90 2 X 799.53 X
28286   2 90 2 X 844.79 X
28288   4 90 2 X 693.76 X
28288   3 90 2 X 702.33 X
28288   2 90 2 X 747.70 X
28288   1 90 2 X 758.60 X
28289   2 90 2 X 741.35 765.26
28289   3 90 2 X 741.35 765.26
28289   4 90 2 X 741.35 765.26
28289   1 90 2 X 811.19 839.14
28291   2 90 2 X 936.38 622.54
28291   3 90 2 X 936.38 622.54
28291   4 90 2 X 936.38 622.54
28291   1 90 2 X 1,039.87 676.22
28292   4 90 2 X 1,230.36 X
28292   3 90 2 X 1,245.94 X
28292   2 90 2 X 1,327.07 X
28292   1 90 2 X 1,346.61 X
28295   2 90 2 X 1,194.23 692.03
28295   3 90 2 X 1,194.23 692.03
28295   4 90 2 X 1,194.23 692.03
28295   1 90 2 X 1,334.81 752.96
28296   4 90 2 X 1,622.58 X
28296   3 90 2 X 1,642.76 X
28296   2 90 2 X 1,748.31 X
28296   1 90 2 X 1,773.74 X
28297   4 90 2 X 1,646.61 X
28297   3 90 2 X 1,667.11 X
28297   1 90 2 X 1,672.97 X
28297   2 90 2 X 1,776.68 X
28298   4 90 2 X 1,506.62 X
28298   3 90 2 X 1,525.99 X
28298   2 90 2 X 1,621.48 X
28298   1 90 2 X 1,644.39 X
28299   1 90 2 X 1,671.52 X
28299   4 90 2 X 1,723.54 X
28299   3 90 2 X 1,745.54 X
28299   2 90 2 X 1,816.63 X
28300   3 90 2 X 1,464.64 X
28300   4 90 2 X 1,541.17 X
28300   2 90 2 X 1,551.43 X
28300   1 90 2 X 1,572.42 X
28302   4 90 2 X 1,680.96 X
28302   3 90 2 X 1,701.58 X
28302   2 90 2 X 1,814.31 X
28302   1 90 2 X 1,841.58 X
28304   4 90 2 X 1,392.70 X
28304   3 90 2 X 1,409.37 X
28304   2 90 2 X 1,491.06 X
28304   1 90 2 X 1,510.81 X
28305   4 90 2 X 1,832.15 X
28305   3 90 2 X 1,854.92 X
28305   2 90 2 X 1,970.72 X
28305   1 90 2 X 1,998.65 X
28306   2 90 2 X 1,058.54 X
28306   4 90 2 X 1,063.20 X
28306   1 90 2 X 1,147.78 X
28306   3 90 2 X 1,156.82 X
28307   4 90 2 X 1,113.78 X
28307   3 90 2 X 1,127.40 X
28307   1 90 2 X 1,221.08 X
28307   2 90 2 X 1,483.66 X
28308   3 90 2 X 1,003.47 X
28308   4 90 2 X 1,009.79 X
28308   2 90 2 X 1,065.27 X
28308   1 90 2 X 1,147.74 X
28309   4 90 2 X 1,471.04 X
28309   3 90 2 X 1,488.50 X
28309   2 90 2 X 1,585.20 X
28309   1 90 2 X 1,608.53 X
28310   3 90 2 X 859.40 X
28310   2 90 2 X 950.95 X
28310   4 90 2 X 1,001.98 X
28310   1 90 2 X 1,051.22 X
28312   4 90 2 X 789.99 X
28312   3 90 2 X 826.60 X
28312   2 90 2 X 878.68 X
28312   1 90 2 X 891.17 X
28313   3 90 2 X 681.45 X
28313   4 90 2 X 695.18 X
28313   2 90 2 X 718.00 X
28313   1 90 2 X 726.85 X
28315   4 90 2 X 759.06 X
28315   3 90 2 X 822.38 X
28315   2 90 2 X 871.39 X
28315   1 90 2 X 883.17 X
28320   4 90 2 X 1,623.15 X
28320   3 90 2 X 1,643.19 X
28320   2 90 2 X 1,683.57 X
28320   1 90 2 X 1,776.18 X
28322   4 90 2 X 1,167.43 X
28322   3 90 2 X 1,180.98 X
28322   2 90 2 X 1,244.70 X
28322   1 90 2 X 1,260.13 X
28340   4 90 2 X 1,214.90 X
28340   3 90 2 X 1,300.45 X
28340   2 90 2 X 1,314.95 X
28340   1 90 2 X 1,335.53 X
28341   4 90 2 X 1,448.15 X
28341   3 90 2 X 1,465.94 X
28341   2 90 2 X 1,562.91 X
28341   1 90 2 X 1,586.28 X
28344   4 90 2 X 719.88 X
28344   3 90 2 X 728.54 X
28344   2 90 2 X 781.39 X
28344   1 90 2 X 794.21 X
28345   4 90 2 X 1,018.31 X
28345   3 90 2 X 1,030.79 X
28345   2 90 2 X 1,101.13 X
28345   1 90 2 X 1,118.11 X
28360   4 90 2 X 1,018.31 X
28360   3 90 2 X 1,030.79 X
28360   2 90 2 X 1,101.13 X
28360   1 90 2 X 1,118.11 X
28400   2 90 2 X 521.67 X
28400   1 90 2 X 581.51 X
28400   4 90 2 X 582.02 X
28400   3 90 2 X 625.82 X
28405   4 90 2 X 770.47 X
28405   3 90 2 X 855.13 X
28405   1 90 2 X 939.74 X
28405   2 90 2 X 1,063.58 X
28406   4 90 2 X 1,127.20 X
28406   3 90 2 X 1,145.50 X
28406   1 90 2 X 1,244.24 X
28406   2 90 2 X 1,249.88 X
28415   4 90 2 X 1,959.80 X
28415   3 90 2 X 1,970.26 X
28415   2 90 2 X 2,248.24 X
28415   1 90 2 X 2,280.77 X
28420   4 90 2 X 2,497.63 X
28420   3 90 2 X 2,653.35 X
28420   2 90 2 X 2,685.95 X
28420   1 90 2 X 2,812.13 X
28430   2 90 2 X 453.58 X
28430   4 90 2 X 533.14 X
28430   3 90 2 X 540.99 X
28430   1 90 2 X 553.98 X
28435   4 90 2 X 625.36 X
28435   1 90 2 X 689.63 X
28435   3 90 2 X 752.23 X
28435   2 90 2 X 766.99 X
28436   4 90 2 X 815.47 X
28436   3 90 2 X 825.31 X
28436   2 90 2 X 885.16 X
28436   1 90 2 X 899.62 X
28445   4 90 2 X 1,668.34 X
28445   3 90 2 X 1,688.57 X
28445   2 90 2 X 1,812.02 X
28445   1 90 2 X 1,841.88 X
28446   2 90 2 X 1,638.36 X
28446   3 90 2 X 1,638.36 X
28446   4 90 2 X 1,638.36 X
28446   1 90 2 X 1,852.48 X
28450   3 90 2 X 361.83 X
28450   4 90 2 X 364.31 X
28450   2 90 2 X 381.43 X
28450   1 90 2 X 384.46 X
28455   3 90 2 X 529.38 X
28455   2 90 2 X 551.32 X
28455   4 90 2 X 571.61 X
28455   1 90 2 X 574.08 X
28456   2 90 2 X 297.32 X
28456   4 90 2 X 443.42 X
28456   3 90 2 X 448.74 X
28456   1 90 2 X 489.37 X
28465   4 90 2 X 1,139.95 X
28465   3 90 2 X 1,148.38 X
28465   2 90 2 X 1,215.17 X
28465   1 90 2 X 1,238.60 X
28470   4 90 2 X 332.55 255.59
28470   3 90 2 X 360.67 277.05
28470   1 90 2 X 364.81 280.87
28470   2 90 2 X 366.88 282.18
28475   4 90 2 X 473.23 373.08
28475   3 90 2 X 478.94 376.98
28475   2 90 2 X 509.42 401.52
28475   1 90 2 X 516.87 407.44
28476   4 90 2 X 611.92 X
28476   3 90 2 X 619.50 X
28476   2 90 2 X 662.83 X
28476   1 90 2 X 673.28 X
28485   3 90 2 X 832.96 X
28485   4 90 2 X 835.40 X
28485   2 90 2 X 882.61 X
28485   1 90 2 X 1,018.50 X
28490   4 90 2 X 185.82 144.98
28490   3 90 2 X 189.83 147.97
28490   2 90 2 X 197.29 154.07
28490   1 90 2 X 201.51 156.98
28495   4 90 2 X 243.51 X
28495   3 90 2 X 257.14 X
28495   2 90 2 X 257.66 X
28495   1 90 2 X 261.14 X
28496   4 90 2 X 399.81 X
28496   3 90 2 X 404.67 X
28496   2 90 2 X 432.98 X
28496   1 90 2 X 439.77 X
28505   2 90 2 X 661.02 X
28505   3 90 2 X 722.87 X
28505   4 90 2 X 740.78 X
28505   1 90 2 X 758.51 X
28510   4 90 2 X 184.87 144.35
28510   3 90 2 X 186.45 145.92
28510   2 90 2 X 193.22 150.82
28510   1 90 2 X 199.98 155.94
28515   4 90 2 X 231.33 183.02
28515   2 90 2 X 244.03 192.57
28515   1 90 2 X 247.23 195.07
28515   3 90 2 X 251.77 199.00
28525   2 90 2 X 512.85 X
28525   4 90 2 X 527.49 X
28525   3 90 2 X 529.76 X
28525   1 90 2 X 545.07 X
28530   4 90 2 X 184.87 X
28530   3 90 2 X 187.17 X
28530   2 90 2 X 198.75 X
28530   1 90 2 X 201.51 X
28531   4 90 2 X 372.17 X
28531   3 90 2 X 376.60 X
28531   2 90 2 X 404.15 X
28531   1 90 2 X 410.76 X
28540   3 90 2 X 326.27 X
28540   2 90 2 X 335.10 X
28540   1 90 2 X 338.32 X
28540   4 90 2 X 341.75 X
28545   4 90 2 X 320.36 X
28545   3 90 2 X 324.13 X
28545   2 90 2 X 341.44 X
28545   1 90 2 X 345.63 X
28546   4 90 2 X 533.84 X
28546   3 90 2 X 540.21 X
28546   2 90 2 X 579.36 X
28546   1 90 2 X 588.75 X
28555   4 90 2 X 1,067.06 X
28555   3 90 2 X 1,067.39 X
28555   2 90 2 X 1,152.38 X
28555   1 90 2 X 1,169.78 X
28570   4 90 2 X 291.66 X
28570   3 90 2 X 295.32 X
28570   2 90 2 X 349.19 X
28570   1 90 2 X 411.88 X
28575   4 90 2 X 535.45 X
28575   3 90 2 X 541.96 X
28575   2 90 2 X 580.02 X
28575   1 90 2 X 589.22 X
28576   4 90 2 X 610.88 X
28576   3 90 2 X 618.07 X
28576   2 90 2 X 657.99 X
28576   1 90 2 X 667.63 X
28585   3 90 2 X 748.48 X
28585   1 90 2 X 1,238.47 X
28585   2 90 2 X 1,251.73 X
28585   4 90 2 X 1,381.73 X
28600   4 90 2 X 223.53 X
28600   3 90 2 X 226.04 X
28600   2 90 2 X 236.69 X
28600   1 90 2 X 237.46 X
28605   3 90 2 X 435.97 X
28605   4 90 2 X 441.64 X
28605   2 90 2 X 478.08 X
28605   1 90 2 X 485.58 X
28606   4 90 2 X 750.91 X
28606   3 90 2 X 759.75 X
28606   2 90 2 X 814.80 X
28606   1 90 2 X 816.32 X
28615   4 90 2 X 955.20 X
28615   3 90 2 X 966.78 X
28615   2 90 2 X 1,036.38 X
28615   1 90 2 X 1,053.20 X
28630   3 10 2 X 234.67 X
28630   4 10 2 X 246.06 X
28630   2 10 2 X 248.58 X
28630   1 10 2 X 253.38 X
28635   2 10 2 X 302.06 X
28635   4 10 2 X 307.31 X
28635   3 10 2 X 311.04 X
28635   1 10 2 X 334.65 X
28636   4 10 2 X 496.41 X
28636   3 10 2 X 502.39 X
28636   2 10 2 X 538.84 X
28636   1 10 2 X 547.71 X
28645   4 90 2 X 666.56 X
28645   3 90 2 X 674.57 X
28645   2 90 2 X 715.77 X
28645   1 90 2 X 725.70 X
28660   2 10 2 X 175.36 X
28660   3 10 2 X 179.06 X
28660   1 10 2 X 187.51 X
28660   4 10 2 X 192.42 X
28665   4 10 2 X 261.33 X
28665   3 10 2 X 264.32 X
28665   2 10 2 X 278.05 X
28665   1 10 2 X 281.37 X
28666   4 10 2 X 474.70 X
28666   3 10 2 X 480.43 X
28666   2 10 2 X 515.14 X
28666   1 10 2 X 523.60 X
28675   3 90 2 X 540.19 X
28675   4 90 2 X 558.50 X
28675   2 90 2 X 578.53 X
28675   1 90 2 X 597.56 X
28705   2 90 2 X 2,442.72 X
28705   4 90 2 X 2,783.10 X
28705   3 90 2 X 2,817.15 X
28705   1 90 2 X 3,075.05 X
28715   4 90 2 X 2,346.95 X
28715   3 90 2 X 2,409.16 X
28715   2 90 2 X 2,517.25 X
28715   1 90 2 X 2,558.21 X
28725   4 90 2 X 1,912.43 X
28725   3 90 2 X 1,935.36 X
28725   1 90 2 X 1,973.20 X
28725   2 90 2 X 2,068.27 X
28730   3 90 2 X 1,682.42 X
28730   4 90 2 X 1,779.21 X
28730   1 90 2 X 1,860.91 X
28730   2 90 2 X 1,924.36 X
28735   4 90 2 X 1,863.05 X
28735   3 90 2 X 1,885.77 X
28735   2 90 2 X 1,919.90 X
28735   1 90 2 X 2,047.18 X
28737   4 90 2 X 1,658.85 X
28737   3 90 2 X 1,679.25 X
28737   2 90 2 X 1,704.19 X
28737   1 90 2 X 1,828.31 X
28740   4 90 2 X 1,093.89 X
28740   3 90 2 X 1,108.21 X
28740   2 90 2 X 1,144.90 X
28740   1 90 2 X 1,161.96 X
28750   4 90 2 X 1,168.59 X
28750   3 90 2 X 1,228.06 X
28750   1 90 2 X 1,239.04 X
28750   2 90 2 X 1,239.18 X
28755   4 90 2 X 758.79 X
28755   3 90 2 X 810.91 X
28755   2 90 2 X 815.84 X
28755   1 90 2 X 827.47 X
28760   3 90 2 X 1,072.58 X
28760   1 90 2 X 1,107.76 X
28760   2 90 2 X 1,157.17 X
28760   4 90 2 X 1,249.62 X
28800   3 90 2 X 1,525.18 X
28800   4 90 2 X 1,544.34 X
28800   2 90 2 X 1,586.65 X
28800   1 90 2 X 1,600.44 X
28805   3 90 2 X 1,342.69 X
28805   4 90 2 X 1,417.80 X
28805   2 90 2 X 1,442.38 X
28805   1 90 2 X 1,571.82 X
28810   4 90 2 X 898.47 X
28810   3 90 2 X 922.52 X
28810   1 90 2 X 987.99 X
28810   2 90 2 X 1,006.25 X
28820   4 90 2 X 582.43 X
28820   3 90 2 X 589.22 X
28820   2 90 2 X 629.79 X
28820   1 90 2 X 717.43 X
28825   4 90 2 X 522.79 X
28825   3 90 2 X 528.91 X
28825   2 90 2 X 577.45 X
28825   1 90 2 X 664.13 X
28890   2 90 2 X 545.96 342.25
28890   3 90 2 X 545.96 342.25
28890   4 90 2 X 545.96 342.25
28890   1 90 2 X 635.83 386.48
28899     YYY 2 X # X
29000   4 0 2 X 252.19 X
29000   1 0 2 X 411.84 X
29000   2 0 2 X 415.76 X
29000   3 0 2 X 467.94 X
29010   4 0 2 X 414.71 X
29010   3 0 2 X 419.84 X
29010   2 0 2 X 450.51 X
29010   1 0 2 X 588.75 X
29015   4 0 2 X 445.79 X
29015   3 0 2 X 451.20 X
29015   1 0 2 X 489.71 X
29015   2 0 2 X 594.93 X
29035   4 0 2 X 354.19 X
29035   1 0 2 X 392.30 X
29035   3 0 2 X 527.49 X
29035   2 0 2 X 608.28 X
29040   4 0 2 X 398.26 X
29040   3 0 2 X 403.09 X
29040   2 0 2 X 430.82 X
29040   1 0 2 X 437.47 X
29044   4 0 2 X 398.94 X
29044   3 0 2 X 403.68 X
29044   2 0 2 X 433.19 X
29044   1 0 2 X 440.39 X
29046   4 0 2 X 439.15 X
29046   3 0 2 X 444.47 X
29046   2 0 2 X 476.12 X
29046   1 0 2 X 483.80 X
29049   4 0 2 X 111.40 X
29049   3 0 2 X 122.14 X
29049   2 0 2 X 128.71 X
29049   1 0 2 X 130.32 X
29055   3 0 2 X 280.56 X
29055   1 0 2 X 301.90 X
29055   2 0 2 X 386.87 X
29055   4 0 2 X 400.21 X
29058   3 0 2 X 183.10 X
29058   2 0 2 X 193.09 X
29058   1 0 2 X 195.49 X
29058   4 0 2 X 272.11 X
29065   4 0 2 X 248.46 194.73
29065   3 0 2 X 262.96 205.82
29065   1 0 2 X 270.68 212.70
29065   2 0 2 X 272.02 213.36
29075   4 0 2 X 159.13 126.91
29075   3 0 2 X 191.20 152.59
29075   1 0 2 X 198.37 158.72
29075   2 0 2 X 212.46 169.53
29085   4 0 2 X 99.93 83.37
29085   3 0 2 X 100.78 83.63
29085   2 0 2 X 105.14 87.47
29085   1 0 2 X 106.37 88.10
29086   2 0 2 X 99.25 79.11
29086   3 0 2 X 99.25 79.11
29086   4 0 2 X 99.25 79.11
29086   1 0 2 X 113.08 89.41
29105   3 0 2 X 128.03 106.09
29105   4 0 2 X 128.43 106.85
29105   2 0 2 X 137.72 114.44
29105   1 0 2 X 139.30 115.80
29125   4 0 2 X 89.03 73.38
29125   3 0 2 X 94.64 78.14
29125   2 0 2 X 95.32 78.50
29125   1 0 2 X 96.61 79.50
29126   4 0 2 X 87.87 74.17
29126   2 0 2 X 101.95 85.67
29126   3 0 2 X 113.20 95.35
29126   1 0 2 X 117.37 98.92
29130   2 0 2 X 64.89 57.17
29130   1 0 2 X 65.59 57.73
29130   3 0 2 X 79.83 70.37
29130   4 0 2 X 80.26 70.86
29131   4 0 2 X 88.07 X
29131   2 0 2 X 152.99 X
29131   3 0 2 X 159.94 X
29131   1 0 2 X 162.40 X
29200   4 0 2 X 69.36 60.09
29200   3 0 2 X 69.68 60.02
29200   1 0 2 X 72.24 62.26
29200   2 0 2 X 72.74 62.72
29240   4 0 2 X 83.53 X
29240   3 0 2 X 86.85 X
29240   1 0 2 X 87.39 X
29240   2 0 2 X 89.22 X
29260   4 0 2 X 66.35 57.29
29260   3 0 2 X 66.38 57.26
29260   2 0 2 X 69.03 59.68
29260   1 0 2 X 69.18 59.63
29280   4 0 2 X 65.71 X
29280   3 0 2 X 66.45 X
29280   2 0 2 X 69.49 X
29280   1 0 2 X 70.23 X
29305   4 0 2 X 370.45 X
29305   3 0 2 X 428.72 X
29305   1 0 2 X 518.03 X
29305   2 0 2 X 518.10 X
29325   4 0 2 X 399.52 X
29325   3 0 2 X 412.92 X
29325   2 0 2 X 430.97 X
29325   1 0 2 X 437.42 X
29345   4 0 2 X 246.39 199.00
29345   3 0 2 X 259.30 209.71
29345   1 0 2 X 323.05 260.87
29345   2 0 2 X 328.34 265.12
29355   4 0 2 X 228.49 185.11
29355   3 0 2 X 249.62 201.86
29355   1 0 2 X 269.55 218.37
29355   2 0 2 X 280.46 226.67
29358   4 0 2 X 320.70 X
29358   3 0 2 X 324.67 X
29358   2 0 2 X 374.99 X
29358   1 0 2 X 377.65 X