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2021 Workers' Compensation Part B Fee Schedule

45332-47130

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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
45332   3 0 3 X 374.16 X
45332   4 0 3 X 395.56 X
45332   2 0 3 X 399.22 X
45332   1 0 3 X 402.22 X
45333   4 0 3 X 382.63 X
45333   3 0 3 X 387.42 X
45333   2 0 3 X 412.74 X
45333   1 0 3 X 418.85 X
45334   4 0 3 X 487.06 X
45334   3 0 3 X 493.13 X
45334   2 0 3 X 521.27 X
45334   1 0 3 X 528.05 X
45335   2 0 3 X 257.91 139.49
45335   3 0 3 X 257.91 139.49
45335   4 0 3 X 257.91 139.49
45335   1 0 3 X 292.42 153.22
45337   3 0 3 X 511.15 X
45337   4 0 3 X 511.69 X
45337   2 0 3 X 523.13 X
45337   1 0 3 X 531.46 X
45338   4 0 3 X 382.63 X
45338   3 0 3 X 387.42 X
45338   2 0 3 X 412.74 X
45338   1 0 3 X 418.85 X
45340   2 0 3 X 583.32 167.31
45340   3 0 3 X 583.32 167.31
45340   4 0 3 X 583.32 167.31
45340   1 0 3 X 671.97 182.95
45341   2 0 2 X 389.99 X
45341   3 0 2 X 389.99 X
45341   4 0 2 X 389.99 X
45341   1 0 2 X 430.15 X
45342   2 0 2 X 449.86 X
45342   3 0 2 X 449.86 X
45342   4 0 2 X 449.86 X
45342   1 0 2 X 495.70 X
45346     0 3 X * X
45347     0 3 X * X
45349     0 3 X * X
45350     0 3 X * X
45378   4 0 2 X 711.09 X
45378   3 0 2 X 717.61 X
45378   2 0 2 X 762.00 X
45378   1 0 2 X 777.58 X
45379   3 0 3 X 956.38 X
45379   4 0 3 X 961.06 X
45379   2 0 3 X 1,022.97 X
45379   1 0 3 X 1,034.56 X
45380   4 0 3 X 820.90 X
45380   3 0 3 X 825.12 X
45380   2 0 3 X 857.44 X
45380   1 0 3 X 874.22 X
45381   2 0 3 X 698.50 410.59
45381   3 0 3 X 698.50 410.59
45381   4 0 3 X 698.50 410.59
45381   1 0 3 X 787.63 449.16
45382   4 0 3 X 1,024.54 X
45382   3 0 3 X 1,025.35 X
45382   2 0 3 X 1,090.88 X
45382   1 0 3 X 1,102.87 X
45384   4 0 3 X 1,124.54 X
45384   3 0 3 X 1,136.52 X
45384   2 0 3 X 1,210.16 X
45384   1 0 3 X 1,232.98 X
45385   4 0 3 X 1,124.54 X
45385   3 0 3 X 1,136.52 X
45385   2 0 3 X 1,210.16 X
45385   1 0 3 X 1,232.98 X
45386   2 0 3 X 1,316.07 445.82
45386   3 0 3 X 1,316.07 445.82
45386   4 0 3 X 1,316.07 445.82
45386   1 0 3 X 1,509.84 486.89
45388     0 3 X * X
45389     0 3 X * X
45390     0 3 X * X
45391   2 0 3 X 489.19 X
45391   3 0 3 X 489.19 X
45391   4 0 3 X 489.19 X
45391   1 0 3 X 536.83 X
45392   2 0 3 X 618.88 X
45392   3 0 3 X 618.88 X
45392   4 0 3 X 618.88 X
45392   1 0 3 X 674.73 X
45393     0 3 X * X
45395   2 90 2 X 2,840.99 X
45395   3 90 2 X 2,840.99 X
45395   4 90 2 X 2,840.99 X
45395   1 90 2 X 3,173.40 X
45397   2 90 2 X 3,093.19 X
45397   3 90 2 X 3,093.19 X
45397   4 90 2 X 3,093.19 X
45397   1 90 2 X 3,437.93 X
45398     0 3 X * X
45399     XXX 2 X # X
45400   2 90 2 X 1,661.05 X
45400   3 90 2 X 1,661.05 X
45400   4 90 2 X 1,661.05 X
45400   1 90 2 X 1,850.09 X
45402   2 90 2 X 2,254.58 X
45402   3 90 2 X 2,254.58 X
45402   4 90 2 X 2,254.58 X
45402   1 90 2 X 2,506.07 X
45499     YYY 2 X # X
45500   3 90 2 X 1,223.98 X
45500   1 90 2 X 1,399.50 X
45500   4 90 2 X 1,412.60 X
45500   2 90 2 X 1,432.24 X
45505   1 90 2 X 1,279.22 X
45505   2 90 2 X 1,369.10 X
45505   4 90 2 X 1,385.88 X
45505   3 90 2 X 1,391.70 X
45520   4 0 2 X 104.02 X
45520   3 0 2 X 105.32 X
45520   1 0 2 X 115.18 X
45520   2 0 2 X 135.07 X
45540   3 90 2 X 2,135.33 X
45540   4 90 2 X 2,158.24 X
45540   2 90 2 X 2,300.41 X
45540   1 90 2 X 2,340.46 X
45541   3 90 2 X 2,035.85 X
45541   4 90 2 X 2,083.57 X
45541   2 90 2 X 2,115.30 X
45541   1 90 2 X 2,210.49 X
45550   3 90 2 X 2,753.66 X
45550   4 90 2 X 2,779.01 X
45550   2 90 2 X 2,861.32 X
45550   1 90 2 X 2,959.96 X
45560   3 90 2 X 1,182.44 X
45560   2 90 2 X 1,264.52 X
45560   4 90 2 X 1,268.88 X
45560   1 90 2 X 1,284.52 X
45562   4 90 2 X 1,937.99 X
45562   3 90 2 X 1,964.00 X
45562   2 90 2 X 2,097.35 X
45562   1 90 2 X 2,161.99 X
45563   4 90 2 X 3,057.01 X
45563   3 90 2 X 3,098.06 X
45563   2 90 2 X 3,308.34 X
45563   1 90 2 X 3,410.29 X
45800   3 90 2 X 2,483.87 X
45800   4 90 2 X 2,697.84 X
45800   2 90 2 X 2,784.36 X
45800   1 90 2 X 2,862.19 X
45805   3 90 2 X 2,655.17 X
45805   2 90 2 X 2,852.03 X
45805   4 90 2 X 3,117.68 X
45805   1 90 2 X 3,296.20 X
45820   4 90 2 X 2,073.89 X
45820   2 90 2 X 2,225.07 X
45820   1 90 2 X 2,474.82 X
45820   3 90 2 X 2,657.01 X
45825   4 90 2 X 2,381.22 X
45825   3 90 2 X 2,408.61 X
45825   2 90 2 X 2,562.96 X
45825   1 90 2 X 2,600.45 X
45900   3 10 2 X 212.91 X
45900   1 10 2 X 226.94 X
45900   2 10 2 X 379.38 X
45900   4 10 2 X 453.51 X
45905   4 10 2 X 207.47 X
45905   3 10 2 X 216.35 X
45905   2 10 2 X 221.74 X
45905   1 10 2 X 224.65 X
45910   4 10 2 X 252.95 X
45910   3 10 2 X 255.77 X
45910   2 10 2 X 269.73 X
45910   1 10 2 X 273.12 X
45915   3 10 2 X 227.14 X
45915   4 10 2 X 229.83 X
45915   2 10 2 X 238.97 X
45915   1 10 2 X 240.78 X
45990   2 0 2 X 164.41 X
45990   3 0 2 X 164.41 X
45990   4 0 2 X 164.41 X
45990   1 0 2 X 182.20 X
45999     YYY 2 X # X
46020   2 10 2 X 413.05 365.67
46020   3 10 2 X 413.05 365.67
46020   4 10 2 X 413.05 365.67
46020   1 10 2 X 465.00 409.24
46030   3 10 2 X 149.13 X
46030   2 10 2 X 242.42 X
46030   4 10 2 X 255.88 X
46030   1 10 2 X 268.67 X
46040   3 90 2 X 613.68 X
46040   4 90 2 X 618.17 X
46040   2 90 2 X 654.61 X
46040   1 90 2 X 662.82 X
46045   4 90 2 X 440.03 X
46045   3 90 2 X 458.98 X
46045   1 90 2 X 468.64 X
46045   2 90 2 X 582.64 X
46050   3 10 2 X 196.56 X
46050   2 10 2 X 240.19 X
46050   4 10 2 X 265.16 X
46050   1 10 2 X 279.22 X
46060   4 90 2 X 1,035.13 X
46060   3 90 2 X 1,040.14 X
46060   2 90 2 X 1,108.21 X
46060   1 90 2 X 1,128.89 X
46070   4 90 2 X 383.26 X
46070   3 90 2 X 387.48 X
46070   2 90 2 X 414.04 X
46070   1 90 2 X 420.48 X
46080   4 10 2 X 600.53 X
46080   3 10 2 X 632.53 X
46080   1 10 2 X 657.92 X
46080   2 10 2 X 673.49 X
46083   4 10 2 X 170.39 145.04
46083   3 10 2 X 172.29 146.56
46083   2 10 2 X 181.22 153.91
46083   1 10 2 X 183.36 155.72
46200   4 90 2 X 638.41 X
46200   3 90 2 X 644.41 X
46200   2 90 2 X 754.18 X
46200   1 90 2 X 831.54 X
46220   4 10 2 X 224.06 X
46220   3 10 2 X 225.02 X
46220   2 10 2 X 229.88 X
46220   1 10 2 X 231.06 X
46221   3 10 2 X 178.13 151.58
46221   1 10 2 X 181.33 154.99
46221   2 10 2 X 183.11 156.39
46221   4 10 2 X 185.47 158.50
46230   4 10 2 X 308.17 272.65
46230   1 10 2 X 309.47 272.86
46230   3 10 2 X 311.47 275.29
46230   2 10 2 X 326.28 288.02
46250   1 90 2 X 674.76 X
46250   4 90 2 X 675.50 X
46250   3 90 2 X 683.26 X
46250   2 90 2 X 729.21 X
46255   4 90 2 X 924.35 X
46255   3 90 2 X 935.45 X
46255   1 90 2 X 1,023.38 X
46255   2 90 2 X 1,077.00 X
46257   4 90 2 X 1,093.60 X
46257   3 90 2 X 1,113.44 X
46257   2 90 2 X 1,226.57 X
46257   1 90 2 X 1,283.90 X
46258   4 90 2 X 1,174.61 X
46258   3 90 2 X 1,188.45 X
46258   2 90 2 X 1,283.34 X
46258   1 90 2 X 1,306.38 X
46260   3 90 2 X 1,295.75 X
46260   4 90 2 X 1,315.69 X
46260   1 90 2 X 1,369.73 X
46260   2 90 2 X 1,477.69 X
46261   4 90 2 X 1,273.66 X
46261   3 90 2 X 1,288.84 X
46261   2 90 2 X 1,393.14 X
46261   1 90 2 X 1,418.47 X
46262   4 90 2 X 1,308.81 X
46262   3 90 2 X 1,324.30 X
46262   2 90 2 X 1,432.17 X
46262   1 90 2 X 1,458.31 X
46270   3 90 2 X 652.42 X
46270   4 90 2 X 674.23 X
46270   1 90 2 X 717.91 X
46270   2 90 2 X 730.81 X
46275   3 90 2 X 1,044.05 X
46275   4 90 2 X 1,047.19 X
46275   2 90 2 X 1,059.86 X
46275   1 90 2 X 1,128.17 X
46280   3 90 2 X 1,321.87 X
46280   4 90 2 X 1,363.42 X
46280   2 90 2 X 1,381.04 X
46280   1 90 2 X 1,381.36 X
46285   3 90 2 X 588.51 X
46285   2 90 2 X 626.59 X
46285   4 90 2 X 677.71 X
46285   1 90 2 X 682.40 X
46288   4 90 2 X 994.01 X
46288   3 90 2 X 1,004.91 X
46288   2 90 2 X 1,073.18 X
46288   1 90 2 X 1,089.80 X
46320   4 10 2 X 211.93 181.88
46320   3 10 2 X 214.30 183.72
46320   2 10 2 X 225.96 193.64
46320   1 10 2 X 252.35 216.35
46500   3 10 2 X 134.08 123.86
46500   2 10 2 X 134.97 123.97
46500   4 10 2 X 145.50 133.91
46500   1 10 2 X 148.99 137.11
46505   2 10 2 X 355.16 294.73
46505   3 10 2 X 355.16 294.73
46505   4 10 2 X 355.16 294.73
46505   1 10 2 X 401.29 327.28
46600   4 0 2 X 66.69 55.69
46600   3 0 2 X 67.14 55.96
46600   2 0 2 X 67.98 56.68
46600   1 0 2 X 68.41 57.06
46601     0 3 X * X
46604   2 0 3 X 154.90 138.93
46604   3 0 3 X 156.30 139.99
46604   4 0 3 X 161.15 144.59
46604   1 0 3 X 179.59 160.99
46606   4 0 3 X 92.28 X
46606   3 0 3 X 92.96 X
46606   2 0 3 X 96.46 X
46606   1 0 3 X 97.31 X
46607     0 3 X * X
46608   1 0 3 X 241.34 X
46608   4 0 3 X 307.45 X
46608   2 0 3 X 317.14 X
46608   3 0 3 X 318.07 X
46610   4 0 3 X 233.01 X
46610   3 0 3 X 234.07 X
46610   2 0 3 X 238.43 X
46610   1 0 3 X 241.86 X
46611   4 0 3 X 233.01 X
46611   3 0 3 X 234.07 X
46611   2 0 3 X 238.43 X
46611   1 0 3 X 241.86 X
46612   4 0 3 X 281.87 X
46612   3 0 3 X 285.24 X
46612   1 0 3 X 308.84 X
46612   2 0 3 X 325.63 X
46614   4 0 3 X 395.87 317.03
46614   2 0 3 X 419.87 336.40
46614   3 0 3 X 422.01 338.58
46614   1 0 3 X 433.87 347.78
46615   4 0 3 X 415.82 336.94
46615   2 0 3 X 440.49 356.94
46615   3 0 3 X 442.09 358.69
46615   1 0 3 X 454.59 368.48
46700   3 90 2 X 1,364.27 X
46700   2 90 2 X 1,393.02 X
46700   4 90 2 X 1,403.33 X
46700   1 90 2 X 1,412.05 X
46705   4 90 2 X 950.34 X
46705   3 90 2 X 960.98 X
46705   2 90 2 X 1,025.86 X
46705   1 90 2 X 1,041.62 X
46706   2 90 2 X 254.05 X
46706   3 90 2 X 254.05 X
46706   4 90 2 X 254.05 X
46706   1 90 2 X 281.32 X
46707   2 90 2 X 649.56 X
46707   3 90 2 X 649.56 X
46707   4 90 2 X 649.56 X
46707   1 90 2 X 725.73 X
46710   2 90 2 X 1,496.74 X
46710   3 90 2 X 1,496.74 X
46710   4 90 2 X 1,496.74 X
46710   1 90 2 X 1,659.70 X
46712   2 90 2 X 3,136.85 X
46712   3 90 2 X 3,136.85 X
46712   4 90 2 X 3,136.85 X
46712   1 90 2 X 3,491.32 X
46715   4 90 2 X 978.31 X
46715   3 90 2 X 989.05 X
46715   2 90 2 X 1,056.28 X
46715   1 90 2 X 1,072.69 X
46716   4 90 2 X 1,684.38 X
46716   3 90 2 X 1,702.91 X
46716   2 90 2 X 1,818.40 X
46716   1 90 2 X 2,807.93 X
46730   4 90 2 X 2,989.04 X
46730   3 90 2 X 3,021.90 X
46730   2 90 2 X 3,227.23 X
46730   1 90 2 X 3,277.19 X
46735   4 90 2 X 3,394.46 X
46735   3 90 2 X 3,665.88 X
46735   2 90 2 X 3,914.98 X
46735   1 90 2 X 3,975.61 X
46740   4 90 2 X 3,213.06 X
46740   3 90 2 X 3,248.31 X
46740   2 90 2 X 3,468.69 X
46740   1 90 2 X 3,522.29 X
46742   4 90 2 X 4,360.69 X
46742   3 90 2 X 4,412.81 X
46742   2 90 2 X 4,656.68 X
46742   1 90 2 X 4,715.56 X
46744   4 90 2 X 4,895.64 X
46744   3 90 2 X 4,954.17 X
46744   2 90 2 X 5,227.96 X
46744   1 90 2 X 5,294.10 X
46746   4 90 2 X 5,356.57 X
46746   3 90 2 X 5,420.59 X
46746   2 90 2 X 5,720.34 X
46746   1 90 2 X 5,792.65 X
46748   4 90 2 X 5,967.25 X
46748   3 90 2 X 6,038.64 X
46748   2 90 2 X 6,372.42 X
46748   1 90 2 X 6,453.00 X
46750   4 90 2 X 1,363.50 X
46750   3 90 2 X 1,369.74 X
46750   2 90 2 X 1,396.18 X
46750   1 90 2 X 1,419.91 X
46751   4 90 2 X 1,133.09 X
46751   3 90 2 X 1,145.58 X
46751   2 90 2 X 1,223.51 X
46751   1 90 2 X 1,242.43 X
46753   4 90 2 X 1,244.37 X
46753   3 90 2 X 1,249.53 X
46753   2 90 2 X 1,275.23 X
46753   1 90 2 X 1,291.79 X
46754   2 10 2 X 227.63 X
46754   4 10 2 X 289.60 X
46754   3 10 2 X 293.01 X
46754   1 10 2 X 322.08 X
46760   4 90 2 X 1,662.60 X
46760   3 90 2 X 1,681.38 X
46760   2 90 2 X 1,798.97 X
46760   1 90 2 X 1,827.63 X
46761   4 90 2 X 1,618.90 X
46761   3 90 2 X 1,637.41 X
46761   2 90 2 X 1,725.20 X
46761   1 90 2 X 1,779.40 X
46900   4 10 2 X 179.46 164.46
46900   3 10 2 X 179.51 165.06
46900   2 10 2 X 184.10 168.67
46900   1 10 2 X 186.69 171.26
46910   4 10 2 X 224.60 X
46910   2 10 2 X 309.97 X
46910   3 10 2 X 330.89 X
46910   1 10 2 X 340.12 X
46916   4 10 2 X 225.32 X
46916   2 10 2 X 310.91 X
46916   3 10 2 X 340.31 X
46916   1 10 2 X 362.28 X
46917   4 10 2 X 355.99 X
46917   3 10 2 X 500.78 X
46917   2 10 2 X 512.02 X
46917   1 10 2 X 514.71 X
46922   4 10 2 X 445.84 X
46922   1 10 2 X 450.14 X
46922   3 10 2 X 465.53 X
46922   2 10 2 X 471.17 X
46924   3 10 2 X 635.48 X
46924   4 10 2 X 641.82 X
46924   2 10 2 X 658.74 X
46924   1 10 2 X 687.13 X
46930   2 90 2 X 275.90 202.02
46930   3 90 2 X 275.90 202.02
46930   4 90 2 X 275.90 202.02
46930   1 90 2 X 315.58 227.92
46940   2 10 2 X 217.35 X
46940   3 10 2 X 219.64 X
46940   1 10 2 X 233.24 X
46940   4 10 2 X 257.97 X
46942   2 10 2 X 196.41 X
46942   4 10 2 X 227.10 X
46942   3 10 2 X 229.45 X
46942   1 10 2 X 242.09 X
46945   4 90 2 X 262.58 241.87
46945   1 90 2 X 267.67 244.99
46945   2 90 2 X 270.91 249.35
46945   3 90 2 X 272.09 250.63
46946   3 90 2 X 365.65 X
46946   4 90 2 X 457.73 X
46946   2 90 2 X 483.23 X
46946   1 90 2 X 488.33 X
46947   2 90 2 X 560.51 X
46947   3 90 2 X 560.51 X
46947   4 90 2 X 560.51 X
46947   1 90 2 X 630.29 X
46948   2 90 2 X 522.38 X
46948   3 90 2 X 522.38 X
46948   4 90 2 X 522.38 X
46948   1 90 2 X 581.23 X
46999     YYY 2 X # X
47000   4 0 2 X 282.81 X
47000   3 0 2 X 286.23 X
47000   2 0 2 X 301.93 X
47000   1 0 2 X 305.77 X
47001   4 ZZZ 0 X 304.97 X
47001   3 ZZZ 0 X 305.82 X
47001   1 ZZZ 0 X 326.70 X
47001   2 ZZZ 0 X 351.57 X
47010   2 90 2 X 1,368.53 X
47010   3 90 2 X 1,368.53 X
47010   4 90 2 X 1,368.53 X
47010   1 90 2 X 1,541.72 X
47015   4 90 2 X 1,742.04 X
47015   3 90 2 X 1,749.26 X
47015   2 90 2 X 1,791.75 X
47015   1 90 2 X 1,796.46 X
47100   3 90 2 X 1,019.66 X
47100   1 90 2 X 1,033.93 X
47100   2 90 2 X 1,083.19 X
47100   4 90 2 X 1,113.78 X
47120   2 90 2 X 3,288.95 X
47120   1 90 2 X 3,339.93 X
47120   4 90 2 X 3,348.70 X
47120   3 90 2 X 3,362.85 X
47122   4 90 2 X 4,749.65 X
47122   3 90 2 X 4,802.50 X
47122   2 90 2 X 5,115.02 X
47122   1 90 2 X 5,191.03 X
47125   3 90 2 X 4,667.43 X
47125   4 90 2 X 4,969.67 X
47125   2 90 2 X 5,119.66 X
47125   1 90 2 X 5,151.01 X
47130   4 90 2 X 4,825.74 X
47130   3 90 2 X 5,075.77 X
47130   2 90 2 X 5,103.17 X
47130   1 90 2 X 5,337.86 X