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2021 Workers' Compensation Part B Fee Schedule

29365-30620

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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
29365   4 0 2 X 200.09 161.49
29365   3 0 2 X 208.54 168.01
29365   1 0 2 X 265.44 214.22
29365   2 0 2 X 274.40 221.32
29405   3 0 2 X 157.53 123.11
29405   4 0 2 X 175.50 137.51
29405   1 0 2 X 195.37 153.34
29405   2 0 2 X 198.03 154.95
29425   4 0 2 X 232.41 180.61
29425   3 0 2 X 239.76 186.30
29425   1 0 2 X 271.07 210.94
29425   2 0 2 X 286.46 222.79
29435   4 0 2 X 245.05 189.47
29435   3 0 2 X 377.66 292.00
29435   1 0 2 X 378.98 293.89
29435   2 0 2 X 380.60 294.76
29440   3 0 2 X 74.49 64.57
29440   4 0 2 X 78.26 67.86
29440   1 0 2 X 79.01 68.41
29440   2 0 2 X 80.24 69.32
29445   4 0 2 X 348.97 X
29445   3 0 2 X 353.82 X
29445   2 0 2 X 378.90 X
29445   1 0 2 X 390.75 X
29450   4 0 2 X 128.02 X
29450   3 0 2 X 129.41 X
29450   2 0 2 X 153.65 X
29450   1 0 2 X 167.54 X
29505   3 0 2 X 124.88 X
29505   2 0 2 X 129.40 X
29505   4 0 2 X 130.16 X
29505   1 0 2 X 138.18 X
29515   4 0 2 X 111.66 91.41
29515   3 0 2 X 112.95 92.29
29515   2 0 2 X 117.56 96.13
29515   1 0 2 X 121.11 98.92
29520   4 0 2 X 81.94 66.73
29520   3 0 2 X 82.92 67.44
29520   2 0 2 X 87.22 70.86
29520   1 0 2 X 88.25 71.61
29530   4 0 2 X 85.51 70.94
29530   3 0 2 X 86.54 71.50
29530   1 0 2 X 87.32 72.16
29530   2 0 2 X 89.04 73.51
29540   4 0 2 X 73.34 60.96
29540   3 0 2 X 75.11 62.17
29540   1 0 2 X 76.78 63.70
29540   2 0 2 X 79.01 65.32
29550   4 0 2 X 59.99 49.86
29550   2 0 2 X 67.22 55.38
29550   1 0 2 X 68.39 56.43
29550   3 0 2 X 69.77 57.73
29580   4 0 2 X 85.85 60.64
29580   3 0 2 X 88.30 62.35
29580   2 0 2 X 97.01 68.97
29580   1 0 2 X 102.61 73.30
29581   2 0 2 X 123.80 47.63
29581   3 0 2 X 123.80 47.63
29581   4 0 2 X 123.80 47.63
29581   1 0 2 X 142.63 52.30
29584   2 0 2 X 93.23 21.69
29584   3 0 2 X 93.23 21.69
29584   4 0 2 X 93.23 21.69
29584   1 0 2 X 105.79 22.86
29700     0 2 X * X
29705     0 2 X * X
29710     0 2 X * X
29720   2 0 2 X 82.52 X
29720   1 0 2 X 83.28 X
29720   4 0 2 X 84.29 X
29720   3 0 2 X 85.19 X
29730   4 0 2 X 93.02 X
29730   3 0 2 X 95.53 X
29730   2 0 2 X 98.72 X
29730   1 0 2 X 99.79 X
29740   4 0 2 X 118.65 X
29740   3 0 2 X 139.32 X
29740   2 0 2 X 143.67 X
29740   1 0 2 X 147.59 X
29750   4 0 2 X 162.15 X
29750   3 0 2 X 163.92 X
29750   2 0 2 X 172.19 X
29750   1 0 2 X 174.22 X
29799     YYY 2 X # X
29800   4 90 2 X 858.67 X
29800   3 90 2 X 868.96 X
29800   2 90 2 X 920.67 X
29800   1 90 2 X 933.20 X
29804   4 90 2 X 2,016.30 X
29804   3 90 2 X 2,042.91 X
29804   2 90 2 X 2,192.03 X
29804   1 90 2 X 2,227.92 X
29805   2 90 2 X 661.87 X
29805   3 90 2 X 661.87 X
29805   4 90 2 X 661.87 X
29805   1 90 2 X 749.74 X
29806   2 90 2 X 1,838.01 X
29806   3 90 2 X 1,838.01 X
29806   4 90 2 X 1,838.01 X
29806   1 90 2 X 2,091.09 X
29807   2 90 2 X 1,788.04 X
29807   3 90 2 X 1,788.04 X
29807   4 90 2 X 1,788.04 X
29807   1 90 2 X 2,036.88 X
29819   4 90 3 X 1,645.24 X
29819   3 90 3 X 2,150.72 X
29819   2 90 3 X 2,286.78 X
29819   1 90 3 X 2,313.58 X
29820   4 90 3 X 1,586.43 X
29820   3 90 3 X 1,606.21 X
29820   2 90 3 X 1,742.83 X
29820   1 90 3 X 1,775.87 X
29821   4 90 3 X 1,871.88 X
29821   3 90 3 X 1,895.47 X
29821   1 90 3 X 2,101.92 X
29821   2 90 3 X 2,667.34 X
29822   4 90 3 X 1,642.85 X
29822   3 90 3 X 1,663.31 X
29822   2 90 3 X 1,802.67 X
29822   1 90 3 X 1,836.38 X
29823   2 90 3 X 2,209.47 X
29823   4 90 3 X 2,230.62 X
29823   3 90 3 X 2,241.47 X
29823   1 90 3 X 2,252.95 X
29824   2 90 2 X 1,118.90 X
29824   3 90 2 X 1,118.90 X
29824   4 90 2 X 1,118.90 X
29824   1 90 2 X 1,275.58 X
29825   4 90 3 X 1,812.68 X
29825   3 90 3 X 1,835.41 X
29825   2 90 3 X 1,995.63 X
29825   1 90 3 X 2,034.33 X
29826   4 ZZZ 0 X 2,087.18 X
29826   3 ZZZ 0 X 2,321.06 X
29826   2 ZZZ 0 X 2,402.33 X
29826   1 ZZZ 0 X 2,423.49 X
29827   2 90 3 X 1,905.53 X
29827   3 90 3 X 1,905.53 X
29827   4 90 3 X 1,905.53 X
29827   1 90 3 X 2,155.79 X
29828   2 90 3 X 1,263.70 X
29828   3 90 3 X 1,263.70 X
29828   4 90 3 X 1,263.70 X
29828   1 90 3 X 1,439.89 X
29830   4 90 2 X 1,035.44 X
29830   3 90 2 X 1,047.94 X
29830   2 90 2 X 1,122.51 X
29830   1 90 2 X 1,140.56 X
29834   3 90 3 X 1,150.85 X
29834   1 90 3 X 1,254.89 X
29834   2 90 3 X 1,468.21 X
29834   4 90 3 X 1,532.86 X
29835   4 90 3 X 1,173.75 X
29835   3 90 3 X 1,187.82 X
29835   2 90 3 X 1,274.28 X
29835   1 90 3 X 1,295.16 X
29836   4 90 3 X 1,366.72 X
29836   3 90 3 X 1,383.15 X
29836   2 90 3 X 1,483.58 X
29836   1 90 3 X 1,507.92 X
29837   4 90 3 X 1,245.89 X
29837   2 90 3 X 1,352.91 X
29837   1 90 3 X 1,375.20 X
29837   3 90 3 X 1,653.46 X
29838   4 90 3 X 1,371.93 X
29838   1 90 3 X 1,512.99 X
29838   3 90 3 X 1,707.09 X
29838   2 90 3 X 1,830.18 X
29840   4 90 2 X 814.68 X
29840   3 90 2 X 824.04 X
29840   2 90 2 X 875.69 X
29840   1 90 2 X 888.19 X
29843   4 90 3 X 1,087.55 X
29843   3 90 3 X 1,100.65 X
29843   2 90 3 X 1,180.55 X
29843   1 90 3 X 1,199.84 X
29844   4 90 3 X 1,122.26 X
29844   3 90 3 X 1,135.68 X
29844   2 90 3 X 1,217.89 X
29844   1 90 3 X 1,237.83 X
29845   4 90 3 X 1,361.48 X
29845   3 90 3 X 1,377.87 X
29845   2 90 3 X 1,478.10 X
29845   1 90 3 X 1,735.22 X
29846   4 90 3 X 1,719.89 X
29846   3 90 3 X 1,741.35 X
29846   2 90 3 X 1,903.67 X
29846   1 90 3 X 1,942.91 X
29847   4 90 3 X 1,290.34 X
29847   3 90 3 X 1,306.08 X
29847   2 90 3 X 1,396.84 X
29847   1 90 3 X 1,699.99 X
29848   4 90 2 X 747.68 X
29848   3 90 2 X 756.70 X
29848   2 90 2 X 811.49 X
29848   1 90 2 X 824.72 X
29850   3 90 2 X 1,766.07 X
29850   2 90 2 X 1,908.91 X
29850   4 90 2 X 2,245.16 X
29850   1 90 2 X 2,342.26 X
29851   3 90 2 X 2,231.83 X
29851   2 90 2 X 2,388.32 X
29851   4 90 2 X 2,463.42 X
29851   1 90 2 X 2,570.35 X
29855   4 90 2 X 2,027.44 X
29855   3 90 2 X 2,046.47 X
29855   2 90 2 X 2,131.89 X
29855   1 90 2 X 2,244.75 X
29856   4 90 2 X 2,196.85 X
29856   2 90 2 X 2,307.05 X
29856   3 90 2 X 2,390.42 X
29856   1 90 2 X 2,599.26 X
29860   2 90 2 X 1,029.93 X
29860   3 90 2 X 1,029.93 X
29860   4 90 2 X 1,029.93 X
29860   1 90 2 X 1,153.57 X
29861   2 90 3 X 1,521.28 X
29861   3 90 3 X 1,521.28 X
29861   4 90 3 X 1,521.28 X
29861   1 90 3 X 1,755.90 X
29862   2 90 3 X 1,665.61 X
29862   3 90 3 X 1,665.61 X
29862   4 90 3 X 1,665.61 X
29862   1 90 3 X 1,939.85 X
29863   2 90 3 X 1,527.00 X
29863   3 90 3 X 1,527.00 X
29863   4 90 3 X 1,527.00 X
29863   1 90 3 X 1,754.62 X
29866   2 90 2 X 1,771.67 X
29866   3 90 2 X 1,771.67 X
29866   4 90 2 X 1,771.67 X
29866   1 90 2 X 2,023.56 X
29867   2 90 2 X 2,119.27 X
29867   3 90 2 X 2,119.27 X
29867   4 90 2 X 2,119.27 X
29867   1 90 2 X 2,413.27 X
29868   2 90 2 X 2,871.74 X
29868   3 90 2 X 2,871.74 X
29868   4 90 2 X 2,871.74 X
29868   1 90 2 X 3,280.26 X
29870   4 90 2 X 844.58 X
29870   3 90 2 X 848.53 X
29870   1 90 2 X 873.66 X
29870   2 90 2 X 922.95 X
29871   3 90 3 X 1,261.65 X
29871   4 90 3 X 1,291.53 X
29871   2 90 3 X 1,334.97 X
29871   1 90 3 X 1,454.82 X
29873   2 90 3 X 877.08 X
29873   3 90 3 X 877.08 X
29873   4 90 3 X 877.08 X
29873   1 90 3 X 998.22 X
29874   4 90 3 X 1,633.11 X
29874   3 90 3 X 1,660.94 X
29874   2 90 3 X 1,733.39 X
29874   1 90 3 X 1,768.55 X
29875   4 90 3 X 1,694.69 X
29875   3 90 3 X 1,758.47 X
29875   2 90 3 X 1,894.98 X
29875   1 90 3 X 1,930.04 X
29876   4 90 3 X 1,968.33 X
29876   3 90 3 X 1,984.61 X
29876   2 90 3 X 2,129.58 X
29876   1 90 3 X 2,163.30 X
29877   4 90 3 X 1,834.30 X
29877   3 90 3 X 1,838.22 X
29877   2 90 3 X 1,993.05 X
29877   1 90 3 X 2,032.37 X
29879   4 90 3 X 2,129.58 X
29879   3 90 3 X 2,138.67 X
29879   2 90 3 X 2,288.96 X
29879   1 90 3 X 2,326.96 X
29880   4 90 3 X 1,985.07 X
29880   3 90 3 X 2,009.98 X
29880   2 90 3 X 2,184.25 X
29880   1 90 3 X 2,226.31 X
29881   4 90 3 X 1,816.95 X
29881   3 90 3 X 1,850.55 X
29881   2 90 3 X 1,992.38 X
29881   1 90 3 X 2,026.71 X
29882   4 90 3 X 1,842.00 X
29882   3 90 3 X 1,966.38 X
29882   2 90 3 X 2,112.41 X
29882   1 90 3 X 2,146.19 X
29883   4 90 3 X 2,353.98 X
29883   3 90 3 X 2,383.67 X
29883   2 90 3 X 2,598.38 X
29883   1 90 3 X 2,650.29 X
29884   4 90 3 X 1,529.38 X
29884   3 90 3 X 1,985.83 X
29884   1 90 3 X 2,135.33 X
29884   2 90 3 X 2,144.77 X
29885   4 90 3 X 1,600.57 X
29885   3 90 3 X 1,619.86 X
29885   2 90 3 X 1,737.57 X
29885   1 90 3 X 1,834.81 X
29886   4 90 3 X 1,323.26 X
29886   3 90 3 X 1,339.12 X
29886   1 90 3 X 1,460.27 X
29886   2 90 3 X 1,685.43 X
29887   4 90 3 X 1,825.56 X
29887   3 90 3 X 1,848.17 X
29887   2 90 3 X 1,992.80 X
29887   1 90 3 X 2,027.87 X
29888   4 90 2 X 3,048.11 X
29888   3 90 2 X 3,086.18 X
29888   2 90 2 X 3,343.05 X
29888   1 90 2 X 3,405.12 X
29889   4 90 2 X 1,995.25 X
29889   3 90 2 X 2,019.29 X
29889   2 90 2 X 2,166.19 X
29889   1 90 2 X 2,201.81 X
29891   2 90 2 X 1,426.32 X
29891   3 90 2 X 1,426.32 X
29891   4 90 2 X 1,426.32 X
29891   1 90 2 X 1,653.77 X
29892   2 90 2 X 1,471.87 X
29892   3 90 2 X 1,471.87 X
29892   4 90 2 X 1,471.87 X
29892   1 90 2 X 1,700.92 X
29893   2 90 2 X 825.88 X
29893   3 90 2 X 825.88 X
29893   4 90 2 X 825.88 X
29893   1 90 2 X 932.40 X
29894   3 90 2 X 1,578.25 X
29894   4 90 2 X 1,619.33 X
29894   1 90 2 X 1,766.81 X
29894   2 90 2 X 1,851.58 X
29895   4 90 2 X 1,510.43 X
29895   3 90 2 X 1,560.57 X
29895   2 90 2 X 1,653.79 X
29895   1 90 2 X 1,806.66 X
29897   3 90 2 X 1,647.97 X
29897   4 90 2 X 1,734.33 X
29897   2 90 2 X 1,788.24 X
29897   1 90 2 X 1,822.13 X
29898   4 90 2 X 1,867.34 X
29898   3 90 2 X 1,975.89 X
29898   2 90 2 X 2,046.98 X
29898   1 90 2 X 2,084.71 X
29899   2 90 2 X 1,747.76 X
29899   3 90 2 X 1,747.76 X
29899   4 90 2 X 1,747.76 X
29899   1 90 2 X 1,987.57 X
29900   2 90 2 X 793.88 X
29900   3 90 2 X 793.88 X
29900   4 90 2 X 793.88 X
29900   1 90 2 X 904.64 X
29901   2 90 2 X 875.50 X
29901   3 90 2 X 875.50 X
29901   4 90 2 X 875.50 X
29901   1 90 2 X 997.78 X
29902   2 90 2 X 939.99 X
29902   3 90 2 X 939.99 X
29902   4 90 2 X 939.99 X
29902   1 90 2 X 1,070.86 X
29904   2 90 2 X 846.76 X
29904   3 90 2 X 846.76 X
29904   4 90 2 X 846.76 X
29904   1 90 2 X 962.50 X
29905   2 90 2 X 911.98 X
29905   3 90 2 X 911.98 X
29905   4 90 2 X 911.98 X
29905   1 90 2 X 1,037.58 X
29906   2 90 2 X 960.47 X
29906   3 90 2 X 960.47 X
29906   4 90 2 X 960.47 X
29906   1 90 2 X 1,092.89 X
29914   2 90 3 X 1,521.57 X
29914   3 90 3 X 1,521.57 X
29914   4 90 3 X 1,521.57 X
29914   1 90 3 X 1,690.15 X
29915   2 90 3 X 1,550.17 X
29915   3 90 3 X 1,550.17 X
29915   4 90 3 X 1,550.17 X
29915   1 90 3 X 1,721.34 X
29916   2 90 3 X 1,550.17 X
29916   3 90 3 X 1,550.17 X
29916   4 90 3 X 1,550.17 X
29916   1 90 3 X 1,721.34 X
29999     YYY 2 X # X
30000   4 10 2 X 178.63 X
30000   1 10 2 X 190.76 X
30000   3 10 2 X 215.69 X
30000   2 10 2 X 225.59 X
30020   3 10 2 X 223.47 X
30020   2 10 2 X 226.24 X
30020   4 10 2 X 227.78 X
30020   1 10 2 X 237.38 X
30100   4 0 2 X 168.80 135.48
30100   3 0 2 X 169.58 136.26
30100   2 0 2 X 173.31 138.89
30100   1 0 2 X 174.22 140.06
30110   4 10 2 X 264.51 209.55
30110   3 10 2 X 276.22 218.73
30110   2 10 2 X 283.62 224.44
30110   1 10 2 X 287.43 227.49
30115   4 90 2 X 534.13 X
30115   1 90 2 X 629.05 X
30115   3 90 2 X 656.46 X
30115   2 90 2 X 690.17 X
30117   4 90 2 X 468.11 X
30117   3 90 2 X 483.80 X
30117   2 90 2 X 499.29 X
30117   1 90 2 X 508.76 X
30118   3 90 2 X 1,616.03 X
30118   4 90 2 X 1,679.59 X
30118   2 90 2 X 1,716.17 X
30118   1 90 2 X 1,740.33 X
30120   4 90 2 X 1,575.33 X
30120   3 90 2 X 1,581.24 X
30120   2 90 2 X 1,617.92 X
30120   1 90 2 X 1,626.79 X
30124   1 90 2 X 426.91 X
30124   2 90 2 X 477.06 X
30124   3 90 2 X 480.66 X
30124   4 90 2 X 500.75 X
30125   4 90 2 X 1,150.67 X
30125   1 90 2 X 1,256.53 X
30125   2 90 2 X 1,316.87 X
30125   3 90 2 X 1,365.41 X
30130   4 90 2 X 443.11 X
30130   3 90 2 X 448.19 X
30130   2 90 2 X 470.84 X
30130   1 90 2 X 476.30 X
30140   4 90 2 X 697.86 X
30140   3 90 2 X 709.77 X
30140   2 90 2 X 717.63 X
30140   1 90 2 X 723.03 X
30150   4 90 2 X 1,535.04 X
30150   3 90 2 X 2,352.46 X
30150   2 90 2 X 2,396.25 X
30150   1 90 2 X 2,406.81 X
30160   4 90 2 X 1,946.28 X
30160   3 90 2 X 1,970.72 X
30160   2 90 2 X 2,095.70 X
30160   1 90 2 X 2,149.93 X
30200   3 0 2 X 83.86 71.59
30200   4 0 2 X 97.35 82.76
30200   2 0 2 X 101.14 86.15
30200   1 0 2 X 103.25 87.57
30210   4 10 2 X 116.95 106.01
30210   3 10 2 X 118.19 107.08
30210   2 10 2 X 123.08 111.19
30210   1 10 2 X 124.23 112.24
30220   4 10 2 X 277.81 X
30220   3 10 2 X 281.25 X
30220   2 10 2 X 298.97 X
30220   1 10 2 X 303.22 X
30300   4 10 2 X 131.89 X
30300   3 10 2 X 135.85 X
30300   2 10 2 X 141.97 X
30300   1 10 2 X 142.74 X
30310   4 10 2 X 326.10 X
30310   3 10 2 X 330.13 X
30310   2 10 2 X 345.87 X
30310   1 10 2 X 354.96 X
30320   4 90 2 X 799.73 X
30320   3 90 2 X 809.70 X
30320   2 90 2 X 859.35 X
30320   1 90 2 X 871.20 X
30400   4 90 2 X 1,907.30 X
30400   3 90 2 X 1,934.46 X
30400   2 90 2 X 2,069.54 X
30400   1 90 2 X 2,132.23 X
30410     90 2 X * X
30420   4 90 2 X 3,280.15 X
30420   3 90 2 X 3,327.27 X
30420   2 90 2 X 3,559.11 X
30420   1 90 2 X 3,665.52 X
30430   4 90 2 X 881.74 X
30430   3 90 2 X 892.15 X
30430   2 90 2 X 939.49 X
30430   1 90 2 X 950.90 X
30435   4 90 2 X 1,211.59 X
30435   3 90 2 X 1,226.47 X
30435   2 90 2 X 1,303.42 X
30435   1 90 2 X 1,322.04 X
30450   4 90 2 X 1,946.28 X
30450   3 90 2 X 1,970.72 X
30450   2 90 2 X 2,122.44 X
30450   1 90 2 X 2,159.00 X
30460   4 90 2 X 1,669.64 X
30460   3 90 2 X 1,690.15 X
30460   2 90 2 X 1,794.16 X
30460   1 90 2 X 1,819.30 X
30462   4 90 2 X 3,340.30 X
30462   3 90 2 X 3,381.21 X
30462   2 90 2 X 3,589.74 X
30462   1 90 2 X 3,639.99 X
30465   2 90 2 X 1,562.40 X
30465   3 90 2 X 1,562.40 X
30465   4 90 2 X 1,562.40 X
30465   1 90 2 X 1,740.97 X
30468   2 0 2 X 3,112.29 186.28
30468   3 0 2 X 3,112.29 186.28
30468   4 0 2 X 3,112.29 186.28
30468   1 0 2 X 3,577.68 202.96
30520   4 90 2 X 1,262.43 X
30520   3 90 2 X 1,278.68 X
30520   2 90 2 X 1,371.87 X
30520   1 90 2 X 1,394.27 X
30540   4 90 2 X 1,299.58 X
30540   3 90 2 X 1,315.54 X
30540   2 90 2 X 1,395.46 X
30540   1 90 2 X 1,414.80 X
30545   4 90 2 X 1,987.64 X
30545   3 90 2 X 2,012.63 X
30545   2 90 2 X 2,131.34 X
30545   1 90 2 X 2,159.91 X
30560   4 10 2 X 141.61 X
30560   3 10 2 X 142.65 X
30560   2 10 2 X 147.22 X
30560   1 10 2 X 172.75 X
30580   4 90 2 X 1,167.91 X
30580   3 90 2 X 1,182.51 X
30580   2 90 2 X 1,252.95 X
30580   1 90 2 X 1,269.99 X
30600   4 90 2 X 881.74 X
30600   3 90 2 X 892.15 X
30600   1 90 2 X 950.90 X
30600   2 90 2 X 1,064.47 X
30620   4 90 2 X 1,335.87 X
30620   3 90 2 X 1,353.22 X
30620   2 90 2 X 1,455.85 X
30620   1 90 2 X 1,480.57 X