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2021 Workers' Compensation Part B Fee Schedule

38570-42227

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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
38570   2 10 3 X 1,148.70 X
38570   3 10 3 X 1,148.70 X
38570   4 10 3 X 1,148.70 X
38570   1 10 3 X 1,278.22 X
38571   2 10 2 X 1,497.45 X
38571   3 10 2 X 1,497.45 X
38571   4 10 2 X 1,497.45 X
38571   1 10 2 X 1,653.32 X
38572   2 10 2 X 1,739.64 X
38572   3 10 2 X 1,739.64 X
38572   4 10 2 X 1,739.64 X
38572   1 10 2 X 1,926.04 X
38573   2 10 3 X 1,483.55 X
38573   3 10 3 X 1,483.55 X
38573   4 10 3 X 1,483.55 X
38573   1 10 3 X 1,619.86 X
38589     YYY 2 X # X
38700   4 90 2 X 2,490.09 X
38700   3 90 2 X 2,498.70 X
38700   2 90 2 X 2,549.48 X
38700   1 90 2 X 2,561.67 X
38720   4 90 2 X 2,633.73 X
38720   3 90 2 X 2,761.03 X
38720   2 90 2 X 2,926.79 X
38720   1 90 2 X 2,983.10 X
38724   3 90 2 X 2,739.84 X
38724   4 90 2 X 2,792.55 X
38724   2 90 2 X 2,877.79 X
38724   1 90 2 X 2,972.37 X
38740   3 90 2 X 987.99 X
38740   4 90 2 X 996.06 X
38740   2 90 2 X 1,149.73 X
38740   1 90 2 X 1,169.16 X
38745   3 90 2 X 1,644.86 X
38745   4 90 2 X 1,794.03 X
38745   2 90 2 X 1,925.23 X
38745   1 90 2 X 2,090.47 X
38746   4 ZZZ 0 X 638.78 X
38746   3 ZZZ 0 X 645.76 X
38746   2 ZZZ 0 X 689.64 X
38746   1 ZZZ 0 X 700.30 X
38747   4 ZZZ 0 X 711.34 X
38747   3 ZZZ 0 X 719.16 X
38747   2 ZZZ 0 X 767.98 X
38747   1 ZZZ 0 X 779.88 X
38760   3 90 2 X 1,539.82 X
38760   4 90 2 X 1,539.92 X
38760   2 90 2 X 1,593.28 X
38760   1 90 2 X 1,604.40 X
38765   4 90 2 X 2,595.28 X
38765   3 90 2 X 2,679.04 X
38765   2 90 2 X 2,878.70 X
38765   1 90 2 X 2,927.08 X
38770   4 90 2 X 2,559.33 X
38770   3 90 2 X 2,592.04 X
38770   2 90 2 X 2,770.48 X
38770   1 90 2 X 2,813.45 X
38780   4 90 2 X 3,084.62 X
38780   3 90 2 X 3,099.83 X
38780   2 90 2 X 3,301.74 X
38780   1 90 2 X 3,361.56 X
38790   4 0 2 X 291.01 X
38790   3 0 2 X 294.86 X
38790   1 0 2 X 319.72 X
38790   2 0 2 X 352.76 X
38792     0 2 X * X
38792 26   0 2 X * X
38792 TC   0 2 X * X
38794   4 90 2 X 640.77 X
38794   3 90 2 X 648.25 X
38794   2 90 2 X 687.55 X
38794   1 90 2 X 697.10 X
38900   2 ZZZ 0 X 204.91 X
38900   3 ZZZ 0 X 204.91 X
38900   4 ZZZ 0 X 204.91 X
38900   1 ZZZ 0 X 227.16 X
38999     YYY 2 X # X
39000   4 90 2 X 1,067.24 X
39000   3 90 2 X 1,080.31 X
39000   2 90 2 X 1,167.68 X
39000   1 90 2 X 1,188.77 X
39010   4 90 2 X 2,091.51 X
39010   3 90 2 X 2,115.86 X
39010   2 90 2 X 2,266.53 X
39010   1 90 2 X 2,303.03 X
39200   4 90 2 X 2,297.24 X
39200   2 90 2 X 2,500.95 X
39200   1 90 2 X 2,543.70 X
39200   3 90 2 X 2,671.64 X
39220   3 90 2 X 3,192.03 X
39220   4 90 2 X 3,273.52 X
39220   2 90 2 X 3,386.32 X
39220   1 90 2 X 3,410.00 X
39401   2 0 2 X 414.66 X
39401   3 0 2 X 414.66 X
39401   4 0 2 X 414.66 X
39401   1 0 2 X 453.85 X
39402   2 0 2 X 542.14 X
39402   3 0 2 X 542.14 X
39402   4 0 2 X 542.14 X
39402   1 0 2 X 592.59 X
39499     YYY 2 X # X
39501   3 90 2 X 2,213.19 X
39501   4 90 2 X 2,230.32 X
39501   2 90 2 X 2,382.46 X
39501   1 90 2 X 2,545.50 X
39503   4 90 2 X 5,401.14 X
39503   3 90 2 X 5,465.76 X
39503   2 90 2 X 5,791.71 X
39503   1 90 2 X 5,870.43 X
39540   4 90 2 X 2,337.71 X
39540   2 90 2 X 2,820.76 X
39540   3 90 2 X 2,860.12 X
39540   1 90 2 X 3,081.38 X
39541   2 90 2 X 2,651.31 X
39541   4 90 2 X 3,040.87 X
39541   3 90 2 X 3,052.97 X
39541   1 90 2 X 3,152.41 X
39545   4 90 2 X 1,914.72 X
39545   3 90 2 X 1,936.61 X
39545   1 90 2 X 2,101.14 X
39545   2 90 2 X 2,777.09 X
39560   2 90 2 X 1,594.20 X
39560   3 90 2 X 1,594.20 X
39560   4 90 2 X 1,594.20 X
39560   1 90 2 X 1,785.83 X
39561   2 90 2 X 2,187.94 X
39561   3 90 2 X 2,187.94 X
39561   4 90 2 X 2,187.94 X
39561   1 90 2 X 2,444.62 X
39599     YYY 2 X # X
40490   3 0 2 X 187.81 154.64
40490   4 0 2 X 188.43 155.35
40490   2 0 2 X 190.38 156.23
40490   1 0 2 X 192.67 158.06
40500   3 90 2 X 1,344.30 X
40500   4 90 2 X 1,346.75 X
40500   2 90 2 X 1,365.17 X
40500   1 90 2 X 1,434.47 X
40510   3 90 2 X 1,295.19 X
40510   4 90 2 X 1,297.05 X
40510   2 90 2 X 1,322.71 X
40510   1 90 2 X 1,373.46 X
40520   4 90 2 X 854.12 X
40520   3 90 2 X 969.39 X
40520   1 90 2 X 1,034.82 X
40520   2 90 2 X 1,045.96 X
40525   1 90 2 X 1,750.11 X
40525   3 90 2 X 2,086.80 X
40525   4 90 2 X 2,193.33 X
40525   2 90 2 X 2,253.71 X
40527   4 90 2 X 1,885.84 X
40527   3 90 2 X 1,909.51 X
40527   2 90 2 X 2,050.61 X
40527   1 90 2 X 2,066.78 X
40530   4 90 2 X 1,062.40 X
40530   3 90 2 X 1,067.28 X
40530   2 90 2 X 1,096.09 X
40530   1 90 2 X 1,103.07 X
40650   4 90 2 X 754.86 X
40650   1 90 2 X 836.37 X
40650   2 90 2 X 1,159.16 X
40650   3 90 2 X 1,346.20 X
40652   4 90 2 X 885.79 X
40652   3 90 2 X 896.86 X
40652   1 90 2 X 982.56 X
40652   2 90 2 X 1,218.54 X
40654   4 90 2 X 1,112.82 X
40654   3 90 2 X 1,494.26 X
40654   2 90 2 X 1,561.26 X
40654   1 90 2 X 1,562.96 X
40700   4 90 2 X 1,919.10 X
40700   3 90 2 X 1,941.47 X
40700   2 90 2 X 2,064.97 X
40700   1 90 2 X 2,094.92 X
40701   4 90 2 X 3,155.90 X
40701   3 90 2 X 3,196.91 X
40701   2 90 2 X 3,397.69 X
40701   1 90 2 X 3,445.91 X
40702   4 90 2 X 2,008.26 X
40702   3 90 2 X 2,032.17 X
40702   2 90 2 X 2,153.68 X
40702   1 90 2 X 2,183.01 X
40720   4 90 2 X 2,141.16 X
40720   3 90 2 X 2,165.90 X
40720   2 90 2 X 2,318.69 X
40720   1 90 2 X 2,500.30 X
40761   4 90 2 X 2,341.68 X
40761   3 90 2 X 2,369.27 X
40761   2 90 2 X 2,528.81 X
40761   1 90 2 X 2,567.46 X
40799     YYY 2 X # X
40800   4 10 2 X 170.02 X
40800   3 10 2 X 172.06 X
40800   2 10 2 X 181.23 X
40800   1 10 2 X 183.38 X
40801   4 10 2 X 382.60 X
40801   3 10 2 X 388.15 X
40801   2 10 2 X 406.06 X
40801   1 10 2 X 407.49 X
40804   4 10 2 X 127.26 X
40804   3 10 2 X 163.70 X
40804   2 10 2 X 170.02 X
40804   1 10 2 X 177.78 X
40805   4 10 2 X 477.85 X
40805   3 10 2 X 483.79 X
40805   2 10 2 X 514.90 X
40805   1 10 2 X 522.40 X
40806     0 2 X * X
40808   4 10 2 X 185.34 146.36
40808   1 10 2 X 185.38 145.99
40808   2 10 2 X 187.05 147.30
40808   3 10 2 X 189.17 149.24
40810   1 10 2 X 266.90 206.42
40810   3 10 2 X 279.29 215.87
40810   2 10 2 X 280.22 217.09
40810   4 10 2 X 296.96 230.45
40812   1 10 2 X 371.51 301.28
40812   4 10 2 X 375.83 306.37
40812   2 10 2 X 376.61 305.70
40812   3 10 2 X 398.53 324.25
40814   4 90 2 X 599.09 X
40814   3 90 2 X 708.93 X
40814   2 90 2 X 724.51 X
40814   1 90 2 X 799.13 X
40816   1 90 2 X 795.85 X
40816   3 90 2 X 797.85 X
40816   4 90 2 X 965.38 X
40816   2 90 2 X 967.37 X
40818   4 90 2 X 414.05 X
40818   3 90 2 X 419.22 X
40818   2 90 2 X 444.10 X
40818   1 90 2 X 450.11 X
40819     90 2 X * X
40820   3 10 2 X 159.78 X
40820   4 10 2 X 162.74 X
40820   2 10 2 X 164.39 X
40820   1 10 2 X 172.75 X
40830   4 10 2 X 203.91 X
40830   2 10 2 X 205.34 X
40830   3 10 2 X 205.95 X
40830   1 10 2 X 208.71 X
40831   2 10 2 X 352.53 X
40831   1 10 2 X 401.04 X
40831   4 10 2 X 401.15 X
40831   3 10 2 X 405.97 X
40840     90 2 X * X
40842     90 2 X * X
40843     90 2 X * X
40844     90 2 X * X
40845     90 2 X * X
40899     YYY 2 X # X
41000   4 10 2 X 190.57 X
41000   3 10 2 X 190.64 X
41000   2 10 2 X 196.26 X
41000   1 10 2 X 198.73 X
41005   4 10 2 X 167.84 X
41005   3 10 2 X 169.77 X
41005   2 10 2 X 178.49 X
41005   1 10 2 X 208.69 X
41006   3 90 2 X 343.52 X
41006   4 90 2 X 349.40 X
41006   2 90 2 X 353.63 X
41006   1 90 2 X 364.71 X
41007   2 90 2 X 396.12 X
41007   4 90 2 X 533.90 X
41007   3 90 2 X 540.57 X
41007   1 90 2 X 582.38 X
41008   3 90 2 X 283.40 X
41008   2 90 2 X 292.24 X
41008   4 90 2 X 384.41 X
41008   1 90 2 X 409.72 X
41009   2 90 2 X 513.64 X
41009   4 90 2 X 614.68 X
41009   3 90 2 X 622.38 X
41009   1 90 2 X 670.14 X
41010   4 10 2 X 141.43 X
41010   3 10 2 X 142.88 X
41010   2 10 2 X 149.09 X
41010   1 10 2 X 150.54 X
41015   1 90 2 X 325.21 X
41015   2 90 2 X 325.57 X
41015   4 90 2 X 417.14 X
41015   3 90 2 X 421.49 X
41016   4 90 2 X 532.23 X
41016   2 90 2 X 581.06 X
41016   1 90 2 X 587.73 X
41016   3 90 2 X 691.79 X
41017   3 90 2 X 331.15 X
41017   2 90 2 X 342.51 X
41017   4 90 2 X 466.37 X
41017   1 90 2 X 497.96 X
41018   4 90 2 X 795.90 X
41018   3 90 2 X 805.62 X
41018   2 90 2 X 852.02 X
41018   1 90 2 X 863.27 X
41019   2 0 2 X 683.13 X
41019   3 0 2 X 683.13 X
41019   4 0 2 X 683.13 X
41019   1 0 2 X 747.48 X
41100   3 10 2 X 226.71 191.26
41100   2 10 2 X 231.10 194.21
41100   1 10 2 X 233.74 196.37
41100   4 10 2 X 240.41 202.54
41105   4 10 2 X 222.13 X
41105   3 10 2 X 224.74 X
41105   2 10 2 X 238.06 X
41105   1 10 2 X 241.27 X
41108   4 10 2 X 176.40 138.91
41108   1 10 2 X 185.34 145.60
41108   2 10 2 X 194.45 152.42
41108   3 10 2 X 208.82 164.08
41110   4 10 2 X 345.03 X
41110   1 10 2 X 426.51 X
41110   3 10 2 X 426.90 X
41110   2 10 2 X 434.72 X
41112   2 90 2 X 640.14 X
41112   3 90 2 X 646.31 X
41112   4 90 2 X 653.74 X
41112   1 90 2 X 711.98 X
41113   3 90 2 X 1,073.90 X
41113   2 90 2 X 1,079.73 X
41113   4 90 2 X 1,087.85 X
41113   1 90 2 X 1,147.74 X
41114   4 90 2 X 1,320.15 X
41114   3 90 2 X 1,336.10 X
41114   2 90 2 X 1,417.00 X
41114   1 90 2 X 1,436.59 X
41115   4 10 2 X 319.30 X
41115   3 10 2 X 331.80 X
41115   2 10 2 X 343.26 X
41115   1 10 2 X 348.03 X
41116   4 90 2 X 503.61 X
41116   3 90 2 X 505.97 X
41116   2 90 2 X 518.21 X
41116   1 90 2 X 521.23 X
41120   4 90 2 X 1,494.97 X
41120   3 90 2 X 1,513.00 X
41120   2 90 2 X 1,606.76 X
41120   1 90 2 X 1,629.48 X
41130   3 90 2 X 2,157.79 X
41130   4 90 2 X 2,177.25 X
41130   2 90 2 X 2,205.69 X
41130   1 90 2 X 2,296.45 X
41135   3 90 2 X 3,228.80 X
41135   4 90 2 X 4,135.89 X
41135   2 90 2 X 4,262.06 X
41135   1 90 2 X 4,442.06 X
41140   4 90 2 X 3,943.28 X
41140   3 90 2 X 3,990.52 X
41140   2 90 2 X 4,242.18 X
41140   1 90 2 X 4,303.01 X
41145   4 90 2 X 4,691.41 X
41145   3 90 2 X 4,747.88 X
41145   2 90 2 X 5,049.46 X
41145   1 90 2 X 5,197.48 X
41150   3 90 2 X 3,100.76 X
41150   2 90 2 X 3,292.53 X
41150   4 90 2 X 3,582.60 X
41150   1 90 2 X 3,609.11 X
41153   4 90 2 X 4,313.81 X
41153   3 90 2 X 6,148.71 X
41153   2 90 2 X 6,275.50 X
41153   1 90 2 X 6,306.07 X
41155   4 90 2 X 5,119.90 X
41155   3 90 2 X 5,231.91 X
41155   1 90 2 X 5,685.08 X
41155   2 90 2 X 5,729.18 X
41250   3 10 2 X 247.56 X
41250   2 10 2 X 259.48 X
41250   4 10 2 X 268.07 X
41250   1 10 2 X 288.73 X
41251   4 10 2 X 304.93 X
41251   2 10 2 X 317.65 X
41251   3 10 2 X 399.29 X
41251   1 10 2 X 429.35 X
41252   4 10 2 X 486.44 X
41252   3 10 2 X 492.35 X
41252   2 10 2 X 521.67 X
41252   1 10 2 X 528.74 X
41510   4 90 2 X 555.15 X
41510   3 90 2 X 561.60 X
41510   2 90 2 X 600.62 X
41510   1 90 2 X 610.02 X
41512   2 90 2 X 829.96 X
41512   3 90 2 X 829.96 X
41512   4 90 2 X 829.96 X
41512   1 90 2 X 929.38 X
41520     90 2 X * X
41530   2 10 2 X 3,986.78 543.71
41530   3 10 2 X 3,986.78 543.71
41530   4 10 2 X 3,986.78 543.71
41530   1 10 2 X 4,692.80 609.53
41599     YYY 2 X # X
41800     10 2 X * X
41805   2 10 2 X 162.55 X
41805   4 10 2 X 185.58 X
41805   3 10 2 X 187.82 X
41805   1 10 2 X 200.54 X
41806   4 10 2 X 390.80 X
41806   3 10 2 X 395.41 X
41806   2 10 2 X 415.96 X
41806   1 10 2 X 420.88 X
41820     XXX 2 X * X
41821     XXX 2 X * X
41822     10 2 X * X
41823     90 2 X * X
41825   4 10 2 X 336.95 X
41825   3 10 2 X 338.23 X
41825   2 10 2 X 358.64 X
41825   1 10 2 X 371.62 X
41826   3 10 2 X 458.41 X
41826   4 10 2 X 465.30 X
41826   2 10 2 X 505.47 X
41826   1 10 2 X 506.25 X
41827   4 90 2 X 650.95 X
41827   3 90 2 X 659.26 X
41827   2 90 2 X 701.64 X
41827   1 90 2 X 711.83 X
41828     10 2 X * X
41830     10 2 X * X
41850     XXX 2 X * X
41870     XXX 2 X * X
41872     90 2 X * X
41874     90 2 X * X
41899     YYY 2 X # X
42000   4 10 2 X 179.47 X
42000   3 10 2 X 180.25 X
42000   2 10 2 X 182.90 X
42000   1 10 2 X 184.61 X
42100   4 10 2 X 256.19 210.42
42100   2 10 2 X 259.66 212.69
42100   3 10 2 X 261.36 214.19
42100   1 10 2 X 273.10 223.74
42104   4 10 2 X 439.58 X
42104   3 10 2 X 441.15 X
42104   2 10 2 X 449.10 X
42104   1 10 2 X 451.01 X
42106   4 10 2 X 444.35 X
42106   1 10 2 X 481.97 X
42106   3 10 2 X 923.93 X
42106   2 10 2 X 962.34 X
42107   3 90 2 X 853.21 X
42107   4 90 2 X 1,437.39 X
42107   2 90 2 X 1,465.36 X
42107   1 90 2 X 1,529.12 X
42120   4 90 2 X 1,234.11 X
42120   3 90 2 X 2,166.52 X
42120   2 90 2 X 2,206.20 X
42120   1 90 2 X 2,215.76 X
42140   3 90 2 X 255.84 X
42140   4 90 2 X 257.60 X
42140   2 90 2 X 266.88 X
42140   1 90 2 X 290.70 X
42145   4 90 2 X 2,109.90 X
42145   3 90 2 X 2,120.02 X
42145   2 90 2 X 2,178.69 X
42145   1 90 2 X 2,192.75 X
42160   4 10 2 X 302.57 X
42160   2 10 2 X 439.00 X
42160   1 10 2 X 446.07 X
42160   3 10 2 X 500.50 X
42180   3 10 2 X 328.39 X
42180   4 10 2 X 341.51 X
42180   2 10 2 X 467.57 X
42180   1 10 2 X 474.28 X
42182   3 10 2 X 575.05 X
42182   4 10 2 X 601.43 X
42182   2 10 2 X 720.19 X
42182   1 10 2 X 730.31 X
42200   4 90 2 X 1,543.20 X
42200   3 90 2 X 1,561.71 X
42200   2 90 2 X 1,655.21 X
42200   1 90 2 X 1,677.83 X
42205   4 90 2 X 1,801.14 X
42205   3 90 2 X 1,824.50 X
42205   2 90 2 X 1,933.11 X
42205   1 90 2 X 1,959.21 X
42210   4 90 2 X 2,055.12 X
42210   3 90 2 X 2,081.83 X
42210   2 90 2 X 2,208.12 X
42210   1 90 2 X 2,238.45 X
42215   4 90 2 X 1,490.57 X
42215   3 90 2 X 1,508.82 X
42215   1 90 2 X 1,625.74 X
42215   2 90 2 X 1,817.80 X
42220   4 90 2 X 1,131.79 X
42220   3 90 2 X 1,145.27 X
42220   2 90 2 X 1,221.68 X
42220   1 90 2 X 1,240.14 X
42225   4 90 2 X 1,502.98 X
42225   3 90 2 X 1,520.67 X
42225   2 90 2 X 1,907.13 X
42225   1 90 2 X 2,122.04 X
42226   4 90 2 X 1,597.96 X
42226   3 90 2 X 1,617.40 X
42226   2 90 2 X 1,714.80 X
42226   1 90 2 X 1,938.90 X
42227   4 90 2 X 1,465.52 X
42227   3 90 2 X 1,483.75 X
42227   2 90 2 X 1,557.32 X
42227   1 90 2 X 1,574.93 X