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2021 Workers' Compensation Part B Fee Schedule

42235-43261

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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
42235   4 90 2 X 1,192.09 X
42235   3 90 2 X 1,206.48 X
42235   2 90 2 X 1,272.34 X
42235   1 90 2 X 1,288.23 X
42260   4 90 2 X 754.05 X
42260   3 90 2 X 763.33 X
42260   2 90 2 X 1,027.15 X
42260   1 90 2 X 1,083.33 X
42280   4 10 2 X 319.30 X
42280   3 10 2 X 323.42 X
42280   2 10 2 X 344.00 X
42280   1 10 2 X 348.90 X
42281   4 10 2 X 298.36 X
42281   3 10 2 X 301.97 X
42281   1 10 2 X 323.98 X
42281   2 10 2 X 349.98 X
42299     YYY 2 X # X
42300   4 10 2 X 261.44 X
42300   3 10 2 X 264.40 X
42300   2 10 2 X 278.51 X
42300   1 10 2 X 281.87 X
42305   3 90 2 X 636.82 X
42305   2 90 2 X 656.69 X
42305   4 90 2 X 711.77 X
42305   1 90 2 X 762.79 X
42310   4 10 2 X 234.58 X
42310   3 10 2 X 237.27 X
42310   2 10 2 X 244.58 X
42310   1 10 2 X 252.50 X
42320   4 10 2 X 382.99 X
42320   3 10 2 X 387.63 X
42320   2 10 2 X 411.21 X
42320   1 10 2 X 416.86 X
42330   3 10 2 X 332.41 279.84
42330   4 10 2 X 334.91 282.19
42330   2 10 2 X 342.77 288.14
42330   1 10 2 X 344.37 290.09
42335   3 90 2 X 677.77 X
42335   4 90 2 X 681.35 X
42335   2 90 2 X 695.55 X
42335   1 90 2 X 700.14 X
42340   4 90 2 X 806.14 X
42340   3 90 2 X 838.65 X
42340   2 90 2 X 866.89 X
42340   1 90 2 X 879.12 X
42400   4 0 2 X 149.70 X
42400   3 0 2 X 150.49 X
42400   2 0 2 X 158.49 X
42400   1 0 2 X 160.91 X
42405   4 10 2 X 440.11 X
42405   3 10 2 X 445.08 X
42405   2 10 2 X 468.05 X
42405   1 10 2 X 473.59 X
42408   4 90 2 X 707.38 X
42408   1 90 2 X 768.19 X
42408   3 90 2 X 1,069.48 X
42408   2 90 2 X 1,087.18 X
42409   4 90 2 X 510.30 X
42409   3 90 2 X 516.68 X
42409   2 90 2 X 549.53 X
42409   1 90 2 X 557.50 X
42410   3 90 2 X 1,484.47 X
42410   2 90 2 X 1,714.23 X
42410   4 90 2 X 1,739.02 X
42410   1 90 2 X 1,847.57 X
42415   4 90 2 X 2,683.55 X
42415   3 90 2 X 2,715.59 X
42415   2 90 2 X 2,886.81 X
42415   1 90 2 X 2,928.22 X
42420   4 90 2 X 3,108.71 X
42420   3 90 2 X 3,145.98 X
42420   2 90 2 X 3,341.69 X
42420   1 90 2 X 3,388.91 X
42425   4 90 2 X 2,246.88 X
42425   3 90 2 X 2,258.04 X
42425   2 90 2 X 2,359.57 X
42425   1 90 2 X 2,394.41 X
42426   4 90 2 X 4,138.45 X
42426   3 90 2 X 4,190.42 X
42426   2 90 2 X 4,492.99 X
42426   1 90 2 X 4,565.96 X
42440   4 90 2 X 1,365.16 X
42440   3 90 2 X 1,382.32 X
42440   2 90 2 X 1,479.43 X
42440   1 90 2 X 1,530.58 X
42450   4 90 2 X 717.24 X
42450   3 90 2 X 933.92 X
42450   2 90 2 X 951.40 X
42450   1 90 2 X 1,095.50 X
42500   4 90 2 X 804.69 X
42500   3 90 2 X 814.81 X
42500   2 90 2 X 868.68 X
42500   1 90 2 X 901.45 X
42505   4 90 2 X 1,237.26 X
42505   3 90 2 X 1,252.95 X
42505   1 90 2 X 1,360.77 X
42505   2 90 2 X 1,492.69 X
42507   4 90 2 X 993.75 X
42507   3 90 2 X 1,005.50 X
42507   2 90 2 X 1,601.14 X
42507   1 90 2 X 1,607.79 X
42509   4 90 2 X 1,730.42 X
42509   3 90 2 X 1,750.27 X
42509   2 90 2 X 1,863.72 X
42509   1 90 2 X 1,891.20 X
42510   4 90 2 X 1,423.17 X
42510   3 90 2 X 1,440.89 X
42510   2 90 2 X 1,532.46 X
42510   1 90 2 X 1,554.55 X
42550   4 0 2 X 142.81 X
42550   3 0 2 X 144.43 X
42550   2 0 2 X 150.66 X
42550   1 0 2 X 152.14 X
42600   4 90 2 X 785.49 X
42600   3 90 2 X 795.02 X
42600   2 90 2 X 844.58 X
42600   1 90 2 X 1,051.77 X
42650   4 0 2 X 105.79 89.34
42650   3 0 2 X 106.98 90.25
42650   1 0 2 X 115.49 98.92
42650   2 0 2 X 130.78 112.41
42660   3 0 2 X 117.69 X
42660   1 0 2 X 130.60 X
42660   4 0 2 X 149.70 X
42660   2 0 2 X 158.27 X
42665   4 90 2 X 415.05 X
42665   3 90 2 X 420.01 X
42665   1 90 2 X 452.55 X
42665   2 90 2 X 546.73 X
42699     YYY 2 X # X
42700   4 10 2 X 222.81 X
42700   3 10 2 X 225.42 X
42700   2 10 2 X 231.00 X
42700   1 10 2 X 240.30 X
42720   4 10 2 X 415.57 X
42720   3 10 2 X 420.51 X
42720   2 10 2 X 445.19 X
42720   1 10 2 X 451.10 X
42725   4 90 2 X 1,110.70 X
42725   3 90 2 X 1,123.55 X
42725   2 90 2 X 1,185.57 X
42725   1 90 2 X 1,200.65 X
42800   4 10 2 X 199.74 166.38
42800   3 10 2 X 201.74 168.10
42800   2 10 2 X 202.74 168.53
42800   1 10 2 X 212.86 176.92
42804   3 10 2 X 272.23 X
42804   4 10 2 X 274.86 X
42804   2 10 2 X 282.60 X
42804   1 10 2 X 289.49 X
42806   4 10 2 X 272.03 X
42806   3 10 2 X 275.41 X
42806   2 10 2 X 309.17 X
42806   1 10 2 X 317.33 X
42808   3 10 2 X 374.59 X
42808   4 10 2 X 384.56 X
42808   2 10 2 X 394.03 X
42808   1 10 2 X 405.90 X
42809   4 10 2 X 235.36 X
42809   3 10 2 X 238.04 X
42809   2 10 2 X 249.47 X
42809   1 10 2 X 252.21 X
42810   4 90 2 X 598.71 X
42810   3 90 2 X 606.02 X
42810   2 90 2 X 649.12 X
42810   1 90 2 X 659.53 X
42815   4 90 2 X 1,505.61 X
42815   3 90 2 X 1,603.70 X
42815   2 90 2 X 1,690.02 X
42815   1 90 2 X 1,718.70 X
42820   4 90 2 X 619.89 X
42820   3 90 2 X 627.48 X
42820   2 90 2 X 664.83 X
42820   1 90 2 X 673.83 X
42821   4 90 2 X 746.29 X
42821   3 90 2 X 755.44 X
42821   2 90 2 X 772.21 X
42821   1 90 2 X 815.97 X
42825   4 90 2 X 543.90 X
42825   3 90 2 X 550.43 X
42825   2 90 2 X 584.78 X
42825   1 90 2 X 593.07 X
42826   4 90 2 X 655.14 X
42826   3 90 2 X 663.40 X
42826   2 90 2 X 708.15 X
42826   1 90 2 X 718.91 X
42830   4 90 2 X 406.88 X
42830   3 90 2 X 411.70 X
42830   2 90 2 X 463.07 X
42830   1 90 2 X 471.48 X
42831   4 90 2 X 458.90 X
42831   3 90 2 X 464.51 X
42831   2 90 2 X 492.83 X
42831   1 90 2 X 499.60 X
42835   4 90 2 X 366.81 X
42835   3 90 2 X 371.34 X
42835   2 90 2 X 389.97 X
42835   1 90 2 X 394.46 X
42836   4 90 2 X 544.09 X
42836   3 90 2 X 550.77 X
42836   2 90 2 X 584.81 X
42836   1 90 2 X 593.02 X
42842   3 90 2 X 1,293.55 X
42842   2 90 2 X 1,318.73 X
42842   4 90 2 X 1,322.65 X
42842   1 90 2 X 1,365.57 X
42844   4 90 2 X 2,184.99 X
42844   3 90 2 X 2,211.46 X
42844   2 90 2 X 2,348.46 X
42844   1 90 2 X 2,381.48 X
42845   4 90 2 X 3,756.91 X
42845   3 90 2 X 3,802.45 X
42845   2 90 2 X 4,039.32 X
42845   1 90 2 X 4,096.50 X
42860   4 90 2 X 372.16 X
42860   1 90 2 X 405.36 X
42860   3 90 2 X 437.73 X
42860   2 90 2 X 447.40 X
42870   4 90 2 X 685.42 X
42870   3 90 2 X 693.10 X
42870   2 90 2 X 728.02 X
42870   1 90 2 X 735.52 X
42890   2 90 2 X 1,781.92 X
42890   4 90 2 X 1,909.49 X
42890   3 90 2 X 1,932.36 X
42890   1 90 2 X 2,075.30 X
42892   4 90 2 X 2,300.05 X
42892   2 90 2 X 2,467.70 X
42892   1 90 2 X 2,501.50 X
42892   3 90 2 X 2,938.06 X
42894   4 90 2 X 3,395.41 X
42894   3 90 2 X 3,436.26 X
42894   2 90 2 X 3,641.13 X
42894   1 90 2 X 3,690.68 X
42900   4 10 2 X 855.82 X
42900   3 10 2 X 866.24 X
42900   2 10 2 X 919.42 X
42900   1 10 2 X 932.34 X
42950   4 90 2 X 1,634.25 X
42950   3 90 2 X 1,704.77 X
42950   2 90 2 X 1,768.88 X
42950   1 90 2 X 1,796.19 X
42953   4 90 2 X 1,363.16 X
42953   3 90 2 X 1,379.31 X
42953   2 90 2 X 1,468.95 X
42953   1 90 2 X 1,490.70 X
42955   4 90 2 X 905.87 X
42955   3 90 2 X 916.19 X
42955   2 90 2 X 965.43 X
42955   1 90 2 X 977.40 X
42960   4 10 2 X 307.95 X
42960   3 10 2 X 311.47 X
42960   1 10 2 X 330.84 X
42960   2 10 2 X 333.31 X
42961   4 90 2 X 631.83 X
42961   3 90 2 X 638.76 X
42961   2 90 2 X 667.07 X
42961   1 90 2 X 673.91 X
42962   4 90 2 X 1,169.16 X
42962   3 90 2 X 1,183.50 X
42962   2 90 2 X 1,257.50 X
42962   1 90 2 X 1,275.38 X
42970   1 90 2 X 394.40 X
42970   2 90 2 X 423.17 X
42970   3 90 2 X 441.79 X
42970   4 90 2 X 491.93 X
42971   4 90 2 X 777.09 X
42971   3 90 2 X 786.02 X
42971   2 90 2 X 827.29 X
42971   1 90 2 X 837.27 X
42972   4 90 2 X 1,043.06 X
42972   3 90 2 X 1,055.19 X
42972   2 90 2 X 1,123.66 X
42972   1 90 2 X 1,140.21 X
42999     YYY 2 X # X
43020   4 90 2 X 1,320.20 X
43020   3 90 2 X 1,336.29 X
43020   2 90 2 X 1,417.10 X
43020   1 90 2 X 1,798.40 X
43030   3 90 2 X 1,553.72 X
43030   4 90 2 X 1,631.60 X
43030   2 90 2 X 1,667.16 X
43030   1 90 2 X 1,694.54 X
43045   4 90 2 X 2,969.25 X
43045   3 90 2 X 3,003.16 X
43045   2 90 2 X 3,207.74 X
43045   1 90 2 X 3,257.41 X
43100   4 90 2 X 1,375.36 X
43100   1 90 2 X 1,503.66 X
43100   3 90 2 X 2,054.09 X
43100   2 90 2 X 2,382.32 X
43101   4 90 2 X 2,337.80 X
43101   3 90 2 X 2,364.27 X
43101   2 90 2 X 2,525.08 X
43101   1 90 2 X 2,564.16 X
43107   4 90 2 X 4,766.11 X
43107   3 90 2 X 4,821.70 X
43107   2 90 2 X 5,182.57 X
43107   1 90 2 X 5,270.05 X
43108   4 90 2 X 5,305.01 X
43108   3 90 2 X 5,367.18 X
43108   2 90 2 X 6,200.76 X
43108   1 90 2 X 6,256.30 X
43112   3 90 2 X 5,022.57 X
43112   4 90 2 X 5,039.82 X
43112   2 90 2 X 5,176.19 X
43112   1 90 2 X 5,301.69 X
43113   4 90 2 X 5,305.01 X
43113   3 90 2 X 5,367.18 X
43113   2 90 2 X 6,200.76 X
43113   1 90 2 X 6,256.30 X
43116   4 90 2 X 5,305.01 X
43116   3 90 2 X 5,367.18 X
43116   2 90 2 X 6,200.76 X
43116   1 90 2 X 6,256.30 X
43117   4 90 2 X 5,305.01 X
43117   3 90 2 X 5,367.18 X
43117   2 90 2 X 6,200.76 X
43117   1 90 2 X 6,256.30 X
43118   4 90 2 X 5,305.01 X
43118   3 90 2 X 5,367.18 X
43118   2 90 2 X 6,200.76 X
43118   1 90 2 X 6,256.30 X
43121   3 90 2 X 4,763.07 X
43121   4 90 2 X 4,782.70 X
43121   2 90 2 X 4,942.06 X
43121   1 90 2 X 5,621.96 X
43122   3 90 2 X 4,763.07 X
43122   4 90 2 X 4,782.70 X
43122   2 90 2 X 4,942.06 X
43122   1 90 2 X 5,621.96 X
43123   4 90 2 X 5,305.01 X
43123   3 90 2 X 5,367.18 X
43123   2 90 2 X 6,200.76 X
43123   1 90 2 X 6,256.30 X
43124   4 90 2 X 4,766.11 X
43124   3 90 2 X 4,821.70 X
43124   2 90 2 X 5,182.57 X
43124   1 90 2 X 5,270.05 X
43130   3 90 2 X 2,071.26 X
43130   4 90 2 X 2,096.01 X
43130   2 90 2 X 2,172.04 X
43130   1 90 2 X 2,207.08 X
43135   4 90 2 X 2,554.96 X
43135   3 90 2 X 2,584.73 X
43135   2 90 2 X 2,769.09 X
43135   1 90 2 X 2,813.70 X
43180   2 90 2 X 715.53 783.90
43180   3 90 2 X 715.53 783.90
43180   4 90 2 X 715.53 783.90
43180   1 90 2 X 783.37 863.39
43191   2 0 2 X 173.74 X
43191   3 0 2 X 173.74 X
43191   4 0 2 X 173.74 X
43191   1 0 2 X 190.20 X
43192   2 0 3 X 207.47 X
43192   3 0 3 X 207.47 X
43192   4 0 3 X 207.47 X
43192   1 0 3 X 226.78 X
43193   2 0 3 X 247.55 X
43193   3 0 3 X 247.55 X
43193   4 0 3 X 247.55 X
43193   1 0 3 X 270.10 X
43194   2 0 3 X 225.82 X
43194   3 0 3 X 225.82 X
43194   4 0 3 X 225.82 X
43194   1 0 3 X 244.82 X
43195   2 0 3 X 248.00 X
43195   3 0 3 X 248.00 X
43195   4 0 3 X 248.00 X
43195   1 0 3 X 270.62 X
43196   2 0 3 X 272.41 X
43196   3 0 3 X 272.41 X
43196   4 0 3 X 272.41 X
43196   1 0 3 X 297.98 X
43197   2 0 2 X 243.67 111.20
43197   3 0 2 X 243.67 111.20
43197   4 0 2 X 243.67 111.20
43197   1 0 2 X 274.78 120.44
43198   2 0 3 X 272.64 132.44
43198   3 0 3 X 272.64 132.44
43198   4 0 3 X 272.64 132.44
43198   1 0 3 X 306.69 143.35
43200   4 0 2 X 471.84 X
43200   2 0 2 X 471.91 X
43200   3 0 2 X 481.02 X
43200   1 0 2 X 600.03 X
43201   2 0 2 X 437.70 232.59
43201   3 0 2 X 437.70 232.59
43201   4 0 2 X 437.70 232.59
43201   1 0 2 X 498.37 257.27
43202   4 0 3 X 530.33 X
43202   3 0 3 X 531.58 X
43202   2 0 3 X 542.16 X
43202   1 0 3 X 599.93 X
43204   4 0 3 X 905.27 X
43204   1 0 3 X 962.87 X
43204   3 0 3 X 970.59 X
43204   2 0 3 X 983.56 X
43205   4 0 3 X 546.15 X
43205   3 0 3 X 552.73 X
43205   2 0 3 X 580.41 X
43205   1 0 3 X 587.14 X
43206     YYY 2 X * X
43210   2 YYY 3 X 567.03 X
43210   3 YYY 3 X 567.03 X
43210   4 YYY 3 X 567.03 X
43210   1 YYY 3 X 614.48 X
43211   2 0 3 X 339.34 X
43211   3 0 3 X 339.34 X
43211   4 0 3 X 339.34 X
43211   1 0 3 X 370.95 X
43212   2 0 3 X 268.61 X
43212   3 0 3 X 268.61 X
43212   4 0 3 X 268.61 X
43212   1 0 3 X 294.34 X
43213   2 0 3 X 1,604.12 377.75
43213   3 0 3 X 1,604.12 377.75
43213   4 0 3 X 1,604.12 377.75
43213   1 0 3 X 1,841.79 412.99
43214   2 0 3 X 273.12 X
43214   3 0 3 X 273.12 X
43214   4 0 3 X 273.12 X
43214   1 0 3 X 298.87 X
43215   4 0 3 X 667.10 X
43215   3 0 3 X 682.46 X
43215   2 0 3 X 697.88 X
43215   1 0 3 X 823.63 X
43216   3 0 3 X 845.02 X
43216   4 0 3 X 881.97 X
43216   1 0 3 X 934.70 X
43216   2 0 3 X 966.68 X
43217   3 0 3 X 845.02 X
43217   4 0 3 X 881.97 X
43217   1 0 3 X 934.70 X
43217   2 0 3 X 966.68 X
43220   3 0 3 X 477.22 X
43220   4 0 3 X 496.46 X
43220   2 0 3 X 529.95 X
43220   1 0 3 X 578.56 X
43226   4 0 3 X 494.17 X
43226   3 0 3 X 500.72 X
43226   2 0 3 X 532.26 X
43226   1 0 3 X 539.77 X
43227   3 0 3 X 767.51 X
43227   2 0 3 X 934.49 X
43227   4 0 3 X 940.35 X
43227   1 0 3 X 966.68 X
43229   2 0 3 X 949.73 288.62
43229   3 0 3 X 949.73 288.62
43229   4 0 3 X 949.73 288.62
43229   1 0 3 X 1,086.62 316.38
43231   2 0 3 X 450.02 X
43231   3 0 3 X 450.02 X
43231   4 0 3 X 450.02 X
43231   1 0 3 X 493.99 X
43232   2 0 3 X 522.77 X
43232   3 0 3 X 522.77 X
43232   4 0 3 X 522.77 X
43232   1 0 3 X 574.30 X
43233   2 0 3 X 324.25 X
43233   3 0 3 X 324.25 X
43233   4 0 3 X 324.25 X
43233   1 0 3 X 354.55 X
43235   3 0 2 X 600.87 X
43235   4 0 2 X 612.46 X
43235   2 0 2 X 620.02 X
43235   1 0 2 X 647.56 X
43236   2 0 2 X 512.78 290.20
43236   3 0 2 X 512.78 290.20
43236   4 0 2 X 512.78 290.20
43236   1 0 2 X 579.26 317.64
43237   2 0 3 X 393.47 X
43237   3 0 3 X 393.47 X
43237   4 0 3 X 393.47 X
43237   1 0 3 X 429.37 X
43238   2 0 3 X 488.56 X
43238   3 0 3 X 488.56 X
43238   4 0 3 X 488.56 X
43238   1 0 3 X 530.14 X
43239   3 0 3 X 670.84 X
43239   4 0 3 X 712.51 X
43239   2 0 3 X 738.87 X
43239   1 0 3 X 782.69 X
43240   2 0 3 X 794.61 X
43240   3 0 3 X 794.61 X
43240   4 0 3 X 794.61 X
43240   1 0 3 X 871.45 X
43241   2 0 3 X 822.57 X
43241   3 0 3 X 866.11 X
43241   4 0 3 X 881.41 X
43241   1 0 3 X 941.10 X
43242   2 0 3 X 571.94 X
43242   3 0 3 X 571.94 X
43242   4 0 3 X 571.94 X
43242   1 0 3 X 625.86 X
43243   4 0 3 X 979.89 X
43243   1 0 3 X 1,011.36 X
43243   2 0 3 X 1,021.22 X
43243   3 0 3 X 1,024.37 X
43244   4 0 3 X 661.85 X
43244   3 0 3 X 669.89 X
43244   2 0 3 X 703.12 X
43244   1 0 3 X 711.13 X
43245   4 0 3 X 958.18 X
43245   3 0 3 X 982.48 X
43245   2 0 3 X 993.10 X
43245   1 0 3 X 1,006.31 X
43246   3 0 3 X 993.01 X
43246   4 0 3 X 995.47 X
43246   2 0 3 X 1,016.15 X
43246   1 0 3 X 1,027.62 X
43247   3 0 3 X 796.11 X
43247   4 0 3 X 823.02 X
43247   2 0 3 X 836.94 X
43247   1 0 3 X 917.77 X
43248   4 0 2 X 622.06 X
43248   3 0 2 X 630.12 X
43248   2 0 2 X 670.00 X
43248   1 0 2 X 679.55 X
43249   3 0 3 X 592.19 X
43249   4 0 3 X 606.51 X
43249   1 0 3 X 642.88 X
43249   2 0 3 X 650.17 X
43250   4 0 3 X 1,046.08 X
43250   3 0 3 X 1,074.51 X
43250   1 0 3 X 1,099.97 X
43250   2 0 3 X 1,106.75 X
43251   4 0 3 X 1,046.08 X
43251   3 0 3 X 1,074.51 X
43251   1 0 3 X 1,099.97 X
43251   2 0 3 X 1,106.75 X
43252     YYY 2 X * X
43253   2 0 3 X 376.11 X
43253   3 0 3 X 376.11 X
43253   4 0 3 X 376.11 X
43253   1 0 3 X 411.36 X
43254   2 0 3 X 390.80 X
43254   3 0 3 X 390.80 X
43254   4 0 3 X 390.80 X
43254   1 0 3 X 427.55 X
43255   4 0 3 X 1,026.19 X
43255   3 0 3 X 1,068.89 X
43255   2 0 3 X 1,112.64 X
43255   1 0 3 X 1,115.11 X
43257   2 0 3 X 527.93 X
43257   3 0 3 X 527.93 X
43257   4 0 3 X 527.93 X
43257   1 0 3 X 576.57 X
43259     0 3 X * X
43260   4 0 2 X 1,012.59 X
43260   3 0 2 X 1,040.48 X
43260   2 0 2 X 1,081.68 X
43260   1 0 2 X 1,119.06 X
43261   4 0 3 X 1,038.33 X
43261   3 0 3 X 1,049.10 X
43261   2 0 3 X 1,108.34 X
43261   1 0 3 X 1,127.90 X