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2021 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 3,481.20 X
35013   3 90 2 X 3,495.79 X
35013   2 90 2 X 3,595.48 X
35013   1 90 2 X 3,619.65 X
35021   4 90 2 X 3,409.24 X
35021   3 90 2 X 3,450.53 X
35021   2 90 2 X 3,710.61 X
35021   1 90 2 X 3,773.49 X
35022   4 90 2 X 3,416.07 X
35022   3 90 2 X 3,455.34 X
35022   2 90 2 X 3,695.19 X
35022   1 90 2 X 3,753.49 X
35045   4 90 2 X 2,179.00 X
35045   3 90 2 X 2,253.94 X
35045   2 90 2 X 2,395.66 X
35045   1 90 2 X 2,441.81 X
35081   3 90 2 X 4,402.11 X
35081   4 90 2 X 4,583.28 X
35081   1 90 2 X 4,796.21 X
35081   2 90 2 X 4,801.19 X
35082   4 90 2 X 5,327.06 X
35082   3 90 2 X 5,378.25 X
35082   2 90 2 X 5,707.97 X
35082   1 90 2 X 5,810.96 X
35091   4 90 2 X 4,824.84 X
35091   3 90 2 X 4,834.46 X
35091   2 90 2 X 5,259.26 X
35091   1 90 2 X 5,434.00 X
35092   4 90 2 X 7,560.72 X
35092   3 90 2 X 7,589.84 X
35092   2 90 2 X 7,772.09 X
35092   1 90 2 X 7,816.45 X
35102   2 90 2 X 4,788.82 X
35102   3 90 2 X 4,818.74 X
35102   4 90 2 X 4,834.85 X
35102   1 90 2 X 5,216.63 X
35103   4 90 2 X 5,919.52 X
35103   3 90 2 X 5,967.41 X
35103   2 90 2 X 6,396.10 X
35103   1 90 2 X 6,478.18 X
35111   4 90 2 X 3,198.16 X
35111   3 90 2 X 3,236.61 X
35111   2 90 2 X 3,420.10 X
35111   1 90 2 X 3,582.95 X
35112   4 90 2 X 2,654.46 X
35112   3 90 2 X 2,684.25 X
35112   2 90 2 X 2,869.15 X
35112   1 90 2 X 2,913.98 X
35121   4 90 2 X 4,455.69 X
35121   3 90 2 X 4,564.01 X
35121   1 90 2 X 4,759.33 X
35121   2 90 2 X 4,785.23 X
35122   4 90 2 X 4,770.76 X
35122   3 90 2 X 5,276.42 X
35122   2 90 2 X 5,284.32 X
35122   1 90 2 X 5,404.58 X
35131   4 90 2 X 3,765.92 X
35131   3 90 2 X 3,780.20 X
35131   1 90 2 X 3,879.54 X
35131   2 90 2 X 3,945.82 X
35132   4 90 2 X 4,022.30 X
35132   3 90 2 X 4,055.68 X
35132   2 90 2 X 4,335.28 X
35132   1 90 2 X 4,400.67 X
35141   4 90 2 X 3,158.34 X
35141   3 90 2 X 3,203.85 X
35141   2 90 2 X 3,393.71 X
35141   1 90 2 X 3,453.17 X
35142   4 90 2 X 3,503.03 X
35142   3 90 2 X 3,518.07 X
35142   2 90 2 X 3,623.36 X
35142   1 90 2 X 3,686.57 X
35151   4 90 2 X 3,421.59 X
35151   3 90 2 X 3,435.19 X
35151   2 90 2 X 3,612.66 X
35151   1 90 2 X 3,679.86 X
35152   4 90 2 X 2,356.52 X
35152   3 90 2 X 2,382.99 X
35152   1 90 2 X 2,586.04 X
35152   2 90 2 X 3,718.01 X
35180   4 90 2 X 1,856.40 X
35180   3 90 2 X 1,877.35 X
35180   2 90 2 X 2,802.18 X
35180   1 90 2 X 2,815.16 X
35182   4 90 2 X 2,503.90 X
35182   3 90 2 X 2,532.95 X
35182   1 90 2 X 2,729.11 X
35182   2 90 2 X 3,090.35 X
35184   3 90 2 X 2,001.48 X
35184   4 90 2 X 2,710.14 X
35184   2 90 2 X 2,945.89 X
35184   1 90 2 X 2,961.76 X
35188   4 90 2 X 2,014.08 X
35188   3 90 2 X 2,036.80 X
35188   2 90 2 X 2,873.51 X
35188   1 90 2 X 2,887.49 X
35189   3 90 2 X 2,736.63 X
35189   1 90 2 X 2,970.80 X
35189   4 90 2 X 3,096.74 X
35189   2 90 2 X 3,188.80 X
35190   4 90 2 X 2,937.20 X
35190   1 90 2 X 2,948.56 X
35190   3 90 2 X 2,950.76 X
35190   2 90 2 X 3,012.20 X
35201   4 90 2 X 1,835.68 X
35201   3 90 2 X 1,857.91 X
35201   2 90 2 X 2,091.32 X
35201   1 90 2 X 2,158.50 X
35206   4 90 2 X 1,813.24 X
35206   3 90 2 X 1,835.25 X
35206   2 90 2 X 1,990.97 X
35206   1 90 2 X 2,028.76 X
35207   4 90 2 X 1,911.58 X
35207   2 90 2 X 2,771.53 X
35207   3 90 2 X 2,832.38 X
35207   1 90 2 X 2,913.84 X
35211   4 90 2 X 3,187.38 X
35211   3 90 2 X 3,223.86 X
35211   2 90 2 X 3,445.63 X
35211   1 90 2 X 4,092.64 X
35216   4 90 2 X 2,638.25 X
35216   3 90 2 X 2,668.22 X
35216   1 90 2 X 2,891.50 X
35216   2 90 2 X 3,715.43 X
35221   4 90 2 X 2,503.53 X
35221   3 90 2 X 2,532.37 X
35221   2 90 2 X 2,714.65 X
35221   1 90 2 X 2,758.95 X
35226   4 90 2 X 1,788.65 X
35226   3 90 2 X 1,810.55 X
35226   1 90 2 X 2,230.69 X
35226   2 90 2 X 2,770.29 X
35231   4 90 2 X 2,487.99 X
35231   3 90 2 X 3,056.78 X
35231   2 90 2 X 3,235.77 X
35231   1 90 2 X 3,343.95 X
35236   4 90 2 X 2,102.33 X
35236   3 90 2 X 2,180.76 X
35236   2 90 2 X 2,317.50 X
35236   1 90 2 X 2,385.38 X
35241   4 90 2 X 3,288.18 X
35241   3 90 2 X 3,325.59 X
35241   2 90 2 X 3,550.52 X
35241   1 90 2 X 3,605.14 X
35246   4 90 2 X 3,272.16 X
35246   3 90 2 X 3,312.10 X
35246   2 90 2 X 3,529.27 X
35246   1 90 2 X 3,581.77 X
35251   4 90 2 X 2,437.64 X
35251   3 90 2 X 2,465.18 X
35251   2 90 2 X 2,628.70 X
35251   1 90 2 X 2,668.49 X
35256   4 90 2 X 2,187.50 X
35256   3 90 2 X 2,232.67 X
35256   2 90 2 X 2,400.51 X
35256   1 90 2 X 2,410.22 X
35261   4 90 2 X 2,299.93 X
35261   2 90 2 X 2,529.94 X
35261   1 90 2 X 2,793.89 X
35261   3 90 2 X 2,866.78 X
35266   4 90 2 X 2,023.20 X
35266   3 90 2 X 2,047.83 X
35266   2 90 2 X 2,228.38 X
35266   1 90 2 X 2,272.22 X
35271   4 90 2 X 3,111.97 X
35271   3 90 2 X 3,147.13 X
35271   2 90 2 X 3,363.32 X
35271   1 90 2 X 3,415.82 X
35276   4 90 2 X 2,669.71 X
35276   3 90 2 X 2,699.86 X
35276   1 90 2 X 2,934.04 X
35276   2 90 2 X 3,199.59 X
35281   4 90 2 X 3,139.76 X
35281   3 90 2 X 3,323.24 X
35281   2 90 2 X 3,441.11 X
35281   1 90 2 X 3,504.91 X
35286   4 90 2 X 2,180.60 X
35286   3 90 2 X 2,213.27 X
35286   2 90 2 X 2,388.51 X
35286   1 90 2 X 2,412.87 X
35301   4 90 2 X 3,062.86 X
35301   3 90 2 X 3,067.12 X
35301   2 90 2 X 3,254.50 X
35301   1 90 2 X 3,322.45 X
35302   2 90 2 X 1,640.11 X
35302   3 90 2 X 1,640.11 X
35302   4 90 2 X 1,640.11 X
35302   1 90 2 X 1,852.70 X
35303   2 90 2 X 1,802.36 X
35303   3 90 2 X 1,802.36 X
35303   4 90 2 X 1,802.36 X
35303   1 90 2 X 2,034.19 X
35304   2 90 2 X 1,875.44 X
35304   3 90 2 X 1,875.44 X
35304   4 90 2 X 1,875.44 X
35304   1 90 2 X 2,116.55 X
35305   2 90 2 X 1,802.36 X
35305   3 90 2 X 1,802.36 X
35305   4 90 2 X 1,802.36 X
35305   1 90 2 X 2,034.19 X
35306   2 ZZZ 0 X 676.70 X
35306   3 ZZZ 0 X 676.70 X
35306   4 ZZZ 0 X 676.70 X
35306   1 ZZZ 0 X 761.97 X
35311   3 90 2 X 4,170.58 X
35311   2 90 2 X 4,293.71 X
35311   4 90 2 X 4,334.10 X
35311   1 90 2 X 4,827.93 X
35321   4 90 2 X 2,346.10 X
35321   3 90 2 X 2,374.41 X
35321   2 90 2 X 2,578.06 X
35321   1 90 2 X 2,627.41 X
35331   4 90 2 X 3,370.52 X
35331   1 90 2 X 3,693.02 X
35331   3 90 2 X 3,898.02 X
35331   2 90 2 X 4,050.71 X
35341   4 90 2 X 3,929.54 X
35341   3 90 2 X 3,974.65 X
35341   2 90 2 X 4,264.00 X
35341   1 90 2 X 4,334.27 X
35351   3 90 2 X 3,537.44 X
35351   4 90 2 X 3,575.56 X
35351   2 90 2 X 3,763.86 X
35351   1 90 2 X 3,828.61 X
35355   4 90 2 X 3,585.44 X
35355   3 90 2 X 3,600.23 X
35355   2 90 2 X 3,699.97 X
35355   1 90 2 X 3,724.18 X
35361   4 90 2 X 3,996.78 X
35361   2 90 2 X 4,354.44 X
35361   1 90 2 X 4,429.90 X
35361   3 90 2 X 4,482.33 X
35363   4 90 2 X 4,424.94 X
35363   3 90 2 X 4,477.64 X
35363   2 90 2 X 4,830.15 X
35363   1 90 2 X 4,915.51 X
35371   4 90 2 X 2,718.71 X
35371   3 90 2 X 2,766.66 X
35371   2 90 2 X 2,969.63 X
35371   1 90 2 X 3,010.24 X
35372   4 90 2 X 2,761.91 X
35372   3 90 2 X 2,787.43 X
35372   2 90 2 X 2,983.56 X
35372   1 90 2 X 3,027.74 X
35390   4 ZZZ 0 X 464.60 X
35390   3 ZZZ 0 X 469.75 X
35390   2 ZZZ 0 X 501.55 X
35390   1 ZZZ 0 X 509.26 X
35400   2 ZZZ 0 X 419.26 X
35400   3 ZZZ 0 X 419.26 X
35400   4 ZZZ 0 X 419.26 X
35400   1 ZZZ 0 X 470.96 X
35500     ZZZ 0 X * X
35501   4 90 2 X 3,607.72 X
35501   3 90 2 X 3,651.28 X
35501   2 90 2 X 3,937.23 X
35501   1 90 2 X 4,006.48 X
35506   4 90 2 X 3,605.12 X
35506   3 90 2 X 3,648.47 X
35506   2 90 2 X 4,164.16 X
35506   1 90 2 X 4,210.36 X
35508   4 90 2 X 3,404.31 X
35508   3 90 2 X 3,445.29 X
35508   2 90 2 X 3,720.07 X
35508   1 90 2 X 3,786.59 X
35509   4 90 2 X 3,470.75 X
35509   3 90 2 X 3,512.44 X
35509   2 90 2 X 3,810.38 X
35509   1 90 2 X 3,882.63 X
35510   2 90 2 X 2,357.00 X
35510   3 90 2 X 2,357.00 X
35510   4 90 2 X 2,357.00 X
35510   1 90 2 X 2,596.84 X
35511   4 90 2 X 2,444.89 X
35511   1 90 2 X 2,681.48 X
35511   3 90 2 X 2,849.56 X
35511   2 90 2 X 2,862.62 X
35512   2 90 2 X 2,311.51 X
35512   3 90 2 X 2,311.51 X
35512   4 90 2 X 2,311.51 X
35512   1 90 2 X 2,548.62 X
35515   4 90 2 X 2,689.06 X
35515   3 90 2 X 2,719.86 X
35515   2 90 2 X 2,899.84 X
35515   1 90 2 X 2,943.48 X
35516   4 90 2 X 3,142.17 X
35516   3 90 2 X 3,180.12 X
35516   2 90 2 X 3,450.51 X
35516   1 90 2 X 3,515.97 X
35518   3 90 2 X 3,099.12 X
35518   4 90 2 X 3,199.80 X
35518   2 90 2 X 3,361.55 X
35518   1 90 2 X 3,425.10 X
35521   3 90 2 X 4,175.55 X
35521   4 90 2 X 4,269.07 X
35521   2 90 2 X 4,364.08 X
35521   1 90 2 X 4,385.70 X
35522   2 90 2 X 2,243.61 X
35522   3 90 2 X 2,243.61 X
35522   4 90 2 X 2,243.61 X
35522   1 90 2 X 2,476.62 X
35523   2 90 2 X 1,902.84 X
35523   3 90 2 X 1,902.84 X
35523   4 90 2 X 1,902.84 X
35523   1 90 2 X 2,099.18 X
35525   2 90 2 X 2,140.42 X
35525   3 90 2 X 2,140.42 X
35525   4 90 2 X 2,140.42 X
35525   1 90 2 X 2,367.20 X
35526   4 90 2 X 3,000.92 X
35526   3 90 2 X 3,035.46 X
35526   2 90 2 X 3,245.38 X
35526   1 90 2 X 3,296.39 X
35531   4 90 2 X 4,254.94 X
35531   3 90 2 X 4,630.25 X
35531   2 90 2 X 4,743.52 X
35531   1 90 2 X 4,798.43 X
35533   4 90 2 X 3,919.29 X
35533   3 90 2 X 5,031.74 X
35533   2 90 2 X 5,172.64 X
35533   1 90 2 X 5,206.80 X
35535   2 90 2 X 3,097.62 X
35535   3 90 2 X 3,097.62 X
35535   4 90 2 X 3,097.62 X
35535   1 90 2 X 3,414.31 X
35536   4 90 2 X 4,149.31 X
35536   3 90 2 X 4,198.66 X
35536   2 90 2 X 4,472.05 X
35536   1 90 2 X 4,611.65 X
35537   2 90 2 X 3,170.87 X
35537   3 90 2 X 3,170.87 X
35537   4 90 2 X 3,170.87 X
35537   1 90 2 X 3,574.36 X
35538   2 90 2 X 3,542.76 X
35538   3 90 2 X 3,542.76 X
35538   4 90 2 X 3,542.76 X
35538   1 90 2 X 3,991.76 X
35539   2 90 2 X 3,329.76 X
35539   3 90 2 X 3,329.76 X
35539   4 90 2 X 3,329.76 X
35539   1 90 2 X 3,752.29 X
35540   2 90 2 X 3,712.01 X
35540   3 90 2 X 3,712.01 X
35540   4 90 2 X 3,712.01 X
35540   1 90 2 X 4,182.43 X
35556   2 90 2 X 3,797.04 X
35556   4 90 2 X 3,801.22 X
35556   3 90 2 X 3,816.35 X
35556   1 90 2 X 3,975.99 X
35558   3 90 2 X 3,173.52 X
35558   4 90 2 X 3,266.83 X
35558   1 90 2 X 3,431.14 X
35558   2 90 2 X 3,432.47 X
35560   4 90 2 X 5,644.17 X
35560   3 90 2 X 5,664.55 X
35560   2 90 2 X 5,795.05 X
35560   1 90 2 X 5,830.52 X
35563   4 90 2 X 2,106.50 X
35563   3 90 2 X 2,130.20 X
35563   1 90 2 X 2,309.82 X
35563   2 90 2 X 3,423.10 X
35565   3 90 2 X 3,452.80 X
35565   4 90 2 X 3,478.45 X
35565   2 90 2 X 3,618.06 X
35565   1 90 2 X 3,681.64 X
35566   3 90 2 X 4,502.61 X
35566   2 90 2 X 4,585.62 X
35566   4 90 2 X 4,801.73 X
35566   1 90 2 X 5,114.92 X
35570   2 90 2 X 2,389.01 X
35570   3 90 2 X 2,389.01 X
35570   4 90 2 X 2,389.01 X
35570   1 90 2 X 2,633.86 X
35571   4 90 2 X 5,285.06 X
35571   3 90 2 X 5,299.05 X
35571   2 90 2 X 5,435.34 X
35571   1 90 2 X 5,465.70 X
35572   2 90 2 X 669.99 X
35572   3 90 2 X 669.99 X
35572   4 90 2 X 669.99 X
35572   1 90 2 X 743.37 X
35583   4 90 2 X 3,862.60 X
35583   3 90 2 X 3,908.91 X
35583   2 90 2 X 3,913.49 X
35583   1 90 2 X 3,989.38 X
35585   2 90 2 X 4,495.89 X
35585   3 90 2 X 4,560.44 X
35585   4 90 2 X 4,809.19 X
35585   1 90 2 X 5,180.45 X
35587   4 90 2 X 5,393.77 X
35587   3 90 2 X 5,401.71 X
35587   2 90 2 X 5,496.40 X
35587   1 90 2 X 5,580.93 X
35600   2 ZZZ 0 X 540.57 X
35600   3 ZZZ 0 X 540.57 X
35600   4 ZZZ 0 X 540.57 X
35600   1 ZZZ 0 X 602.27 X
35601   4 90 2 X 3,365.70 X
35601   3 90 2 X 3,406.83 X
35601   2 90 2 X 3,678.94 X
35601   1 90 2 X 3,744.84 X