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2020 Workers' Compensation Part B Fee Schedule

35013-35601

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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
35013   4 90 2 X 3,328.11 X
35013   3 90 2 X 3,342.06 X
35013   2 90 2 X 3,437.36 X
35013   1 90 2 X 3,460.47 X
35021   4 90 2 X 3,259.31 X
35021   3 90 2 X 3,298.79 X
35021   2 90 2 X 3,547.43 X
35021   1 90 2 X 3,607.54 X
35022   4 90 2 X 3,265.84 X
35022   3 90 2 X 3,303.38 X
35022   2 90 2 X 3,532.69 X
35022   1 90 2 X 3,588.42 X
35045   4 90 2 X 2,083.17 X
35045   3 90 2 X 2,154.82 X
35045   2 90 2 X 2,290.31 X
35045   1 90 2 X 2,334.43 X
35081   3 90 2 X 4,208.52 X
35081   4 90 2 X 4,381.72 X
35081   1 90 2 X 4,585.29 X
35081   2 90 2 X 4,590.05 X
35082   4 90 2 X 5,092.79 X
35082   3 90 2 X 5,141.73 X
35082   2 90 2 X 5,456.95 X
35082   1 90 2 X 5,555.41 X
35091   4 90 2 X 4,612.66 X
35091   3 90 2 X 4,621.85 X
35091   2 90 2 X 5,027.97 X
35091   1 90 2 X 5,195.03 X
35092   4 90 2 X 7,228.22 X
35092   3 90 2 X 7,256.06 X
35092   2 90 2 X 7,430.30 X
35092   1 90 2 X 7,472.71 X
35102   2 90 2 X 4,578.22 X
35102   3 90 2 X 4,606.83 X
35102   4 90 2 X 4,622.23 X
35102   1 90 2 X 4,987.22 X
35103   4 90 2 X 5,659.20 X
35103   3 90 2 X 5,704.98 X
35103   2 90 2 X 6,114.82 X
35103   1 90 2 X 6,193.29 X
35111   4 90 2 X 3,057.51 X
35111   3 90 2 X 3,094.27 X
35111   2 90 2 X 3,269.69 X
35111   1 90 2 X 3,425.38 X
35112   4 90 2 X 2,537.72 X
35112   3 90 2 X 2,566.20 X
35112   2 90 2 X 2,742.97 X
35112   1 90 2 X 2,785.83 X
35121   4 90 2 X 4,259.74 X
35121   3 90 2 X 4,363.30 X
35121   1 90 2 X 4,550.03 X
35121   2 90 2 X 4,574.79 X
35122   4 90 2 X 4,560.96 X
35122   3 90 2 X 5,044.38 X
35122   2 90 2 X 5,051.93 X
35122   1 90 2 X 5,166.90 X
35131   4 90 2 X 3,600.31 X
35131   3 90 2 X 3,613.96 X
35131   1 90 2 X 3,708.93 X
35131   2 90 2 X 3,772.29 X
35132   4 90 2 X 3,845.41 X
35132   3 90 2 X 3,877.32 X
35132   2 90 2 X 4,144.63 X
35132   1 90 2 X 4,207.14 X
35141   4 90 2 X 3,019.45 X
35141   3 90 2 X 3,062.95 X
35141   2 90 2 X 3,244.46 X
35141   1 90 2 X 3,301.31 X
35142   4 90 2 X 3,348.98 X
35142   3 90 2 X 3,363.36 X
35142   2 90 2 X 3,464.02 X
35142   1 90 2 X 3,524.45 X
35151   4 90 2 X 3,271.12 X
35151   3 90 2 X 3,284.12 X
35151   2 90 2 X 3,453.79 X
35151   1 90 2 X 3,518.03 X
35152   4 90 2 X 2,252.89 X
35152   3 90 2 X 2,278.19 X
35152   1 90 2 X 2,472.31 X
35152   2 90 2 X 3,554.50 X
35180   4 90 2 X 1,774.76 X
35180   3 90 2 X 1,794.79 X
35180   2 90 2 X 2,678.95 X
35180   1 90 2 X 2,691.36 X
35182   4 90 2 X 2,393.79 X
35182   3 90 2 X 2,421.56 X
35182   1 90 2 X 2,609.09 X
35182   2 90 2 X 2,954.45 X
35184   3 90 2 X 1,913.46 X
35184   4 90 2 X 2,590.96 X
35184   2 90 2 X 2,816.34 X
35184   1 90 2 X 2,831.51 X
35188   4 90 2 X 1,925.51 X
35188   3 90 2 X 1,947.23 X
35188   2 90 2 X 2,747.14 X
35188   1 90 2 X 2,760.51 X
35189   3 90 2 X 2,616.28 X
35189   1 90 2 X 2,840.15 X
35189   4 90 2 X 2,960.55 X
35189   2 90 2 X 3,048.57 X
35190   4 90 2 X 2,808.03 X
35190   1 90 2 X 2,818.89 X
35190   3 90 2 X 2,820.99 X
35190   2 90 2 X 2,879.73 X
35201   4 90 2 X 1,754.95 X
35201   3 90 2 X 1,776.20 X
35201   2 90 2 X 1,999.35 X
35201   1 90 2 X 2,063.58 X
35206   4 90 2 X 1,733.50 X
35206   3 90 2 X 1,754.54 X
35206   2 90 2 X 1,903.41 X
35206   1 90 2 X 1,939.54 X
35207   4 90 2 X 1,827.51 X
35207   2 90 2 X 2,649.65 X
35207   3 90 2 X 2,707.82 X
35207   1 90 2 X 2,785.70 X
35211   4 90 2 X 3,047.21 X
35211   3 90 2 X 3,082.08 X
35211   2 90 2 X 3,294.10 X
35211   1 90 2 X 3,912.66 X
35216   4 90 2 X 2,522.23 X
35216   3 90 2 X 2,550.88 X
35216   1 90 2 X 2,764.34 X
35216   2 90 2 X 3,552.04 X
35221   4 90 2 X 2,393.43 X
35221   3 90 2 X 2,421.00 X
35221   2 90 2 X 2,595.27 X
35221   1 90 2 X 2,637.62 X
35226   4 90 2 X 1,709.99 X
35226   3 90 2 X 1,730.93 X
35226   1 90 2 X 2,132.59 X
35226   2 90 2 X 2,648.46 X
35231   4 90 2 X 2,378.58 X
35231   3 90 2 X 2,922.35 X
35231   2 90 2 X 3,093.47 X
35231   1 90 2 X 3,196.89 X
35236   4 90 2 X 2,009.88 X
35236   3 90 2 X 2,084.86 X
35236   2 90 2 X 2,215.58 X
35236   1 90 2 X 2,280.48 X
35241   4 90 2 X 3,143.58 X
35241   3 90 2 X 3,179.34 X
35241   2 90 2 X 3,394.38 X
35241   1 90 2 X 3,446.60 X
35246   4 90 2 X 3,128.26 X
35246   3 90 2 X 3,166.44 X
35246   2 90 2 X 3,374.06 X
35246   1 90 2 X 3,424.25 X
35251   4 90 2 X 2,330.44 X
35251   3 90 2 X 2,356.77 X
35251   2 90 2 X 2,513.10 X
35251   1 90 2 X 2,551.14 X
35256   4 90 2 X 2,091.30 X
35256   3 90 2 X 2,134.48 X
35256   2 90 2 X 2,294.94 X
35256   1 90 2 X 2,304.23 X
35261   4 90 2 X 2,198.79 X
35261   2 90 2 X 2,418.68 X
35261   1 90 2 X 2,671.02 X
35261   3 90 2 X 2,740.71 X
35266   4 90 2 X 1,934.23 X
35266   3 90 2 X 1,957.77 X
35266   2 90 2 X 2,130.38 X
35266   1 90 2 X 2,172.29 X
35271   4 90 2 X 2,975.11 X
35271   3 90 2 X 3,008.73 X
35271   2 90 2 X 3,215.41 X
35271   1 90 2 X 3,265.60 X
35276   4 90 2 X 2,552.30 X
35276   3 90 2 X 2,581.13 X
35276   1 90 2 X 2,805.01 X
35276   2 90 2 X 3,058.88 X
35281   4 90 2 X 3,001.68 X
35281   3 90 2 X 3,177.09 X
35281   2 90 2 X 3,289.78 X
35281   1 90 2 X 3,350.77 X
35286   4 90 2 X 2,084.70 X
35286   3 90 2 X 2,115.94 X
35286   2 90 2 X 2,283.47 X
35286   1 90 2 X 2,306.76 X
35301   4 90 2 X 2,928.16 X
35301   3 90 2 X 2,932.24 X
35301   2 90 2 X 3,111.38 X
35301   1 90 2 X 3,176.34 X
35302   2 90 2 X 1,567.98 X
35302   3 90 2 X 1,567.98 X
35302   4 90 2 X 1,567.98 X
35302   1 90 2 X 1,771.22 X
35303   2 90 2 X 1,723.10 X
35303   3 90 2 X 1,723.10 X
35303   4 90 2 X 1,723.10 X
35303   1 90 2 X 1,944.73 X
35304   2 90 2 X 1,792.96 X
35304   3 90 2 X 1,792.96 X
35304   4 90 2 X 1,792.96 X
35304   1 90 2 X 2,023.47 X
35305   2 90 2 X 1,723.10 X
35305   3 90 2 X 1,723.10 X
35305   4 90 2 X 1,723.10 X
35305   1 90 2 X 1,944.73 X
35306   2 ZZZ 0 X 646.94 X
35306   3 ZZZ 0 X 646.94 X
35306   4 ZZZ 0 X 646.94 X
35306   1 ZZZ 0 X 728.46 X
35311   3 90 2 X 3,987.17 X
35311   2 90 2 X 4,104.89 X
35311   4 90 2 X 4,143.50 X
35311   1 90 2 X 4,615.61 X
35321   4 90 2 X 2,242.93 X
35321   3 90 2 X 2,269.99 X
35321   2 90 2 X 2,464.68 X
35321   1 90 2 X 2,511.86 X
35331   4 90 2 X 3,222.29 X
35331   1 90 2 X 3,530.61 X
35331   3 90 2 X 3,726.60 X
35331   2 90 2 X 3,872.57 X
35341   4 90 2 X 3,756.73 X
35341   3 90 2 X 3,799.86 X
35341   2 90 2 X 4,076.48 X
35341   1 90 2 X 4,143.66 X
35351   3 90 2 X 3,381.87 X
35351   4 90 2 X 3,418.32 X
35351   2 90 2 X 3,598.34 X
35351   1 90 2 X 3,660.24 X
35355   4 90 2 X 3,427.76 X
35355   3 90 2 X 3,441.90 X
35355   2 90 2 X 3,537.26 X
35355   1 90 2 X 3,560.40 X
35361   4 90 2 X 3,821.01 X
35361   2 90 2 X 4,162.94 X
35361   1 90 2 X 4,235.09 X
35361   3 90 2 X 4,285.21 X
35363   4 90 2 X 4,230.34 X
35363   3 90 2 X 4,280.73 X
35363   2 90 2 X 4,617.73 X
35363   1 90 2 X 4,699.34 X
35371   4 90 2 X 2,599.15 X
35371   3 90 2 X 2,644.99 X
35371   2 90 2 X 2,839.03 X
35371   1 90 2 X 2,877.86 X
35372   4 90 2 X 2,640.45 X
35372   3 90 2 X 2,664.85 X
35372   2 90 2 X 2,852.35 X
35372   1 90 2 X 2,894.59 X
35390   4 ZZZ 0 X 444.17 X
35390   3 ZZZ 0 X 449.09 X
35390   2 ZZZ 0 X 479.49 X
35390   1 ZZZ 0 X 486.86 X
35400   2 ZZZ 0 X 400.82 X
35400   3 ZZZ 0 X 400.82 X
35400   4 ZZZ 0 X 400.82 X
35400   1 ZZZ 0 X 450.25 X
35500     ZZZ 0 X * X
35501   4 90 2 X 3,449.06 X
35501   3 90 2 X 3,490.71 X
35501   2 90 2 X 3,764.08 X
35501   1 90 2 X 3,830.29 X
35506   4 90 2 X 3,446.58 X
35506   3 90 2 X 3,488.02 X
35506   2 90 2 X 3,981.03 X
35506   1 90 2 X 4,025.20 X
35508   4 90 2 X 3,254.60 X
35508   3 90 2 X 3,293.78 X
35508   2 90 2 X 3,556.47 X
35508   1 90 2 X 3,620.07 X
35509   4 90 2 X 3,318.12 X
35509   3 90 2 X 3,357.97 X
35509   2 90 2 X 3,642.81 X
35509   1 90 2 X 3,711.88 X
35510   2 90 2 X 2,253.35 X
35510   3 90 2 X 2,253.35 X
35510   4 90 2 X 2,253.35 X
35510   1 90 2 X 2,482.64 X
35511   4 90 2 X 2,337.37 X
35511   1 90 2 X 2,563.56 X
35511   3 90 2 X 2,724.24 X
35511   2 90 2 X 2,736.73 X
35512   2 90 2 X 2,209.86 X
35512   3 90 2 X 2,209.86 X
35512   4 90 2 X 2,209.86 X
35512   1 90 2 X 2,436.54 X
35515   4 90 2 X 2,570.80 X
35515   3 90 2 X 2,600.25 X
35515   2 90 2 X 2,772.31 X
35515   1 90 2 X 2,814.03 X
35516   4 90 2 X 3,003.99 X
35516   3 90 2 X 3,040.27 X
35516   2 90 2 X 3,298.77 X
35516   1 90 2 X 3,361.35 X
35518   3 90 2 X 2,962.83 X
35518   4 90 2 X 3,059.08 X
35518   2 90 2 X 3,213.72 X
35518   1 90 2 X 3,274.47 X
35521   3 90 2 X 3,991.92 X
35521   4 90 2 X 4,081.33 X
35521   2 90 2 X 4,172.16 X
35521   1 90 2 X 4,192.83 X
35522   2 90 2 X 2,144.94 X
35522   3 90 2 X 2,144.94 X
35522   4 90 2 X 2,144.94 X
35522   1 90 2 X 2,367.71 X
35523   2 90 2 X 1,819.16 X
35523   3 90 2 X 1,819.16 X
35523   4 90 2 X 1,819.16 X
35523   1 90 2 X 2,006.86 X
35525   2 90 2 X 2,046.29 X
35525   3 90 2 X 2,046.29 X
35525   4 90 2 X 2,046.29 X
35525   1 90 2 X 2,263.10 X
35526   4 90 2 X 2,868.95 X
35526   3 90 2 X 2,901.97 X
35526   2 90 2 X 3,102.66 X
35526   1 90 2 X 3,151.42 X
35531   4 90 2 X 4,067.82 X
35531   3 90 2 X 4,426.63 X
35531   2 90 2 X 4,534.91 X
35531   1 90 2 X 4,587.41 X
35533   4 90 2 X 3,746.93 X
35533   3 90 2 X 4,810.46 X
35533   2 90 2 X 4,945.16 X
35533   1 90 2 X 4,977.82 X
35535   2 90 2 X 2,961.40 X
35535   3 90 2 X 2,961.40 X
35535   4 90 2 X 2,961.40 X
35535   1 90 2 X 3,264.16 X
35536   4 90 2 X 3,966.84 X
35536   3 90 2 X 4,014.02 X
35536   2 90 2 X 4,275.38 X
35536   1 90 2 X 4,408.84 X
35537   2 90 2 X 3,031.42 X
35537   3 90 2 X 3,031.42 X
35537   4 90 2 X 3,031.42 X
35537   1 90 2 X 3,417.17 X
35538   2 90 2 X 3,386.96 X
35538   3 90 2 X 3,386.96 X
35538   4 90 2 X 3,386.96 X
35538   1 90 2 X 3,816.21 X
35539   2 90 2 X 3,183.33 X
35539   3 90 2 X 3,183.33 X
35539   4 90 2 X 3,183.33 X
35539   1 90 2 X 3,587.28 X
35540   2 90 2 X 3,548.77 X
35540   3 90 2 X 3,548.77 X
35540   4 90 2 X 3,548.77 X
35540   1 90 2 X 3,998.50 X
35556   2 90 2 X 3,630.06 X
35556   4 90 2 X 3,634.05 X
35556   3 90 2 X 3,648.52 X
35556   1 90 2 X 3,801.14 X
35558   3 90 2 X 3,033.96 X
35558   4 90 2 X 3,123.16 X
35558   1 90 2 X 3,280.25 X
35558   2 90 2 X 3,281.52 X
35560   4 90 2 X 5,395.96 X
35560   3 90 2 X 5,415.44 X
35560   2 90 2 X 5,540.20 X
35560   1 90 2 X 5,574.11 X
35563   4 90 2 X 2,013.86 X
35563   3 90 2 X 2,036.52 X
35563   1 90 2 X 2,208.24 X
35563   2 90 2 X 3,272.56 X
35565   3 90 2 X 3,300.96 X
35565   4 90 2 X 3,325.48 X
35565   2 90 2 X 3,458.95 X
35565   1 90 2 X 3,519.73 X
35566   3 90 2 X 4,304.60 X
35566   2 90 2 X 4,383.96 X
35566   4 90 2 X 4,590.56 X
35566   1 90 2 X 4,889.98 X
35570   2 90 2 X 2,283.95 X
35570   3 90 2 X 2,283.95 X
35570   4 90 2 X 2,283.95 X
35570   1 90 2 X 2,518.03 X
35571   4 90 2 X 5,052.64 X
35571   3 90 2 X 5,066.01 X
35571   2 90 2 X 5,196.31 X
35571   1 90 2 X 5,225.33 X
35572   2 90 2 X 640.53 X
35572   3 90 2 X 640.53 X
35572   4 90 2 X 640.53 X
35572   1 90 2 X 710.68 X
35583   4 90 2 X 3,692.73 X
35583   3 90 2 X 3,737.01 X
35583   2 90 2 X 3,741.39 X
35583   1 90 2 X 3,813.94 X
35585   2 90 2 X 4,298.17 X
35585   3 90 2 X 4,359.89 X
35585   4 90 2 X 4,597.70 X
35585   1 90 2 X 4,952.63 X
35587   4 90 2 X 5,156.57 X
35587   3 90 2 X 5,164.16 X
35587   2 90 2 X 5,254.68 X
35587   1 90 2 X 5,335.50 X
35600   2 ZZZ 0 X 516.80 X
35600   3 ZZZ 0 X 516.80 X
35600   4 ZZZ 0 X 516.80 X
35600   1 ZZZ 0 X 575.78 X
35601   4 90 2 X 3,217.69 X
35601   3 90 2 X 3,257.01 X
35601   2 90 2 X 3,517.15 X
35601   1 90 2 X 3,580.15 X