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2021 Workers' Compensation Part B Fee Schedule

49424-50551

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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
49424   2 0 2 X 105.89 X
49424   3 0 2 X 105.89 X
49424   4 0 2 X 105.89 X
49424   1 0 2 X 118.98 X
49425   4 90 2 X 2,155.07 X
49425   3 90 2 X 2,163.83 X
49425   2 90 2 X 2,219.93 X
49425   1 90 2 X 2,237.17 X
49426   4 90 2 X 1,675.64 X
49426   3 90 2 X 1,681.98 X
49426   2 90 2 X 1,720.27 X
49426   1 90 2 X 1,729.56 X
49427   4 0 2 X 116.87 X
49427   3 0 2 X 175.64 X
49427   2 0 2 X 177.91 X
49427   1 0 2 X 178.47 X
49428   4 10 2 X 305.17 X
49428   3 10 2 X 309.16 X
49428   2 10 2 X 328.71 X
49428   1 10 2 X 338.42 X
49429   4 10 2 X 977.41 X
49429   3 10 2 X 989.94 X
49429   2 10 2 X 1,052.64 X
49429   1 10 2 X 1,083.82 X
49435   2 ZZZ 0 X 163.34 X
49435   3 ZZZ 0 X 163.34 X
49435   4 ZZZ 0 X 163.34 X
49435   1 ZZZ 0 X 182.80 X
49436   2 10 2 X 241.72 X
49436   3 10 2 X 241.72 X
49436   4 10 2 X 241.72 X
49436   1 10 2 X 273.99 X
49440   2 10 2 X 1,630.36 349.28
49440   3 10 2 X 1,630.36 349.28
49440   4 10 2 X 1,630.36 349.28
49440   1 10 2 X 1,934.28 389.71
49441   2 10 2 X 1,929.75 380.36
49441   3 10 2 X 1,929.75 380.36
49441   4 10 2 X 1,929.75 380.36
49441   1 10 2 X 2,284.99 416.86
49442   2 10 2 X 1,573.52 315.58
49442   3 10 2 X 1,573.52 315.58
49442   4 10 2 X 1,573.52 315.58
49442   1 10 2 X 1,862.14 345.47
49446   2 0 2 X 1,606.07 248.97
49446   3 0 2 X 1,606.07 248.97
49446   4 0 2 X 1,606.07 248.97
49446   1 0 2 X 1,907.09 270.81
49450   2 0 2 X 1,122.14 101.12
49450   3 0 2 X 1,122.14 101.12
49450   4 0 2 X 1,122.14 101.12
49450   1 0 2 X 1,340.94 109.92
49451   2 0 2 X 1,189.91 139.15
49451   3 0 2 X 1,189.91 139.15
49451   4 0 2 X 1,189.91 139.15
49451   1 0 2 X 1,418.52 151.63
49452   2 0 2 X 1,457.51 217.20
49452   3 0 2 X 1,457.51 217.20
49452   4 0 2 X 1,457.51 217.20
49452   1 0 2 X 1,732.37 236.99
49460   2 0 2 X 1,188.58 71.13
49460   3 0 2 X 1,188.58 71.13
49460   4 0 2 X 1,188.58 71.13
49460   1 0 2 X 1,424.44 77.15
49465   2 0 2 X 249.22 46.99
49465   3 0 2 X 249.22 46.99
49465   4 0 2 X 249.22 46.99
49465   1 0 2 X 294.82 50.98
49491   2 90 2 X 1,190.50 X
49491   3 90 2 X 1,190.50 X
49491   4 90 2 X 1,190.50 X
49491   1 90 2 X 1,326.07 X
49492   2 90 2 X 1,462.44 X
49492   3 90 2 X 1,462.44 X
49492   4 90 2 X 1,462.44 X
49492   1 90 2 X 1,632.15 X
49495   4 90 2 X 1,151.56 X
49495   3 90 2 X 1,155.12 X
49495   2 90 2 X 1,221.75 X
49495   1 90 2 X 1,250.26 X
49496   4 90 2 X 1,280.05 X
49496   3 90 2 X 1,294.40 X
49496   2 90 2 X 1,383.95 X
49496   1 90 2 X 1,405.73 X
49500   4 90 2 X 1,110.90 X
49500   3 90 2 X 1,114.03 X
49500   2 90 2 X 1,179.68 X
49500   1 90 2 X 1,207.96 X
49501   4 90 2 X 1,180.67 X
49501   3 90 2 X 1,194.07 X
49501   2 90 2 X 1,281.15 X
49501   1 90 2 X 1,302.34 X
49505   4 90 2 X 1,033.80 X
49505   3 90 2 X 1,043.23 X
49505   2 90 2 X 1,113.73 X
49505   1 90 2 X 1,131.50 X
49507   4 90 2 X 1,193.04 X
49507   3 90 2 X 1,206.64 X
49507   2 90 2 X 1,293.98 X
49507   1 90 2 X 1,315.26 X
49520   4 90 2 X 1,229.20 X
49520   3 90 2 X 1,235.22 X
49520   2 90 2 X 1,358.40 X
49520   1 90 2 X 1,380.42 X
49521   4 90 2 X 1,375.00 X
49521   3 90 2 X 1,390.24 X
49521   2 90 2 X 1,482.10 X
49521   1 90 2 X 1,504.51 X
49525   4 90 2 X 1,185.07 X
49525   3 90 2 X 1,231.76 X
49525   2 90 2 X 1,336.52 X
49525   1 90 2 X 1,348.58 X
49540   4 90 2 X 1,256.34 X
49540   3 90 2 X 1,270.56 X
49540   2 90 2 X 1,361.55 X
49540   1 90 2 X 1,383.66 X
49550   3 90 2 X 1,096.08 X
49550   4 90 2 X 1,098.16 X
49550   2 90 2 X 1,176.57 X
49550   1 90 2 X 1,196.72 X
49553   3 90 2 X 1,108.79 X
49553   4 90 2 X 1,110.80 X
49553   2 90 2 X 1,189.56 X
49553   1 90 2 X 1,209.81 X
49555   4 90 2 X 1,380.14 X
49555   3 90 2 X 1,381.90 X
49555   2 90 2 X 1,471.44 X
49555   1 90 2 X 1,498.22 X
49557   4 90 2 X 1,422.85 X
49557   3 90 2 X 1,425.01 X
49557   2 90 2 X 1,515.64 X
49557   1 90 2 X 1,542.71 X
49560   2 90 2 X 1,256.32 X
49560   3 90 2 X 1,256.32 X
49560   4 90 2 X 1,256.32 X
49560   1 90 2 X 1,416.47 X
49561   4 90 2 X 1,433.58 X
49561   3 90 2 X 1,629.96 X
49561   2 90 2 X 1,733.83 X
49561   1 90 2 X 1,759.12 X
49565   2 90 2 X 1,324.48 X
49565   3 90 2 X 1,324.48 X
49565   4 90 2 X 1,324.48 X
49565   1 90 2 X 1,502.54 X
49566   4 90 2 X 1,538.18 X
49566   3 90 2 X 1,552.21 X
49566   2 90 2 X 1,826.28 X
49566   1 90 2 X 1,854.19 X
49568   2 ZZZ 0 X 603.52 X
49568   3 ZZZ 0 X 603.52 X
49568   4 ZZZ 0 X 603.52 X
49568   1 ZZZ 0 X 679.62 X
49570   4 90 2 X 1,020.58 X
49570   3 90 2 X 1,044.78 X
49570   2 90 2 X 1,112.38 X
49570   1 90 2 X 1,129.40 X
49572   4 90 2 X 1,249.20 X
49572   3 90 2 X 1,251.94 X
49572   2 90 2 X 1,314.41 X
49572   1 90 2 X 1,352.83 X
49580   1 90 2 X 1,018.40 X
49580   4 90 2 X 1,042.11 X
49580   3 90 2 X 1,050.60 X
49580   2 90 2 X 1,112.46 X
49582   1 90 2 X 1,087.31 X
49582   4 90 2 X 1,107.84 X
49582   3 90 2 X 1,117.01 X
49582   2 90 2 X 1,180.84 X
49585   4 90 2 X 958.79 X
49585   3 90 2 X 967.07 X
49585   2 90 2 X 1,041.53 X
49585   1 90 2 X 1,059.32 X
49587   4 90 2 X 988.12 X
49587   3 90 2 X 996.59 X
49587   2 90 2 X 1,071.80 X
49587   1 90 2 X 1,089.80 X
49590   4 90 2 X 1,338.29 X
49590   3 90 2 X 1,348.60 X
49590   2 90 2 X 1,433.11 X
49590   1 90 2 X 1,452.74 X
49600   4 90 2 X 1,371.13 X
49600   3 90 2 X 1,386.71 X
49600   2 90 2 X 1,467.10 X
49600   1 90 2 X 1,486.54 X
49605   4 90 2 X 2,860.76 X
49605   3 90 2 X 2,891.59 X
49605   2 90 2 X 3,058.21 X
49605   1 90 2 X 3,098.82 X
49606   4 90 2 X 2,406.63 X
49606   3 90 2 X 2,433.77 X
49606   2 90 2 X 2,556.30 X
49606   1 90 2 X 2,585.92 X
49610   4 90 2 X 1,465.64 X
49610   3 90 2 X 1,481.87 X
49610   2 90 2 X 1,584.77 X
49610   1 90 2 X 1,609.78 X
49611   4 90 2 X 1,562.74 X
49611   3 90 2 X 1,582.87 X
49611   2 90 2 X 1,671.88 X
49611   1 90 2 X 1,693.22 X
49650   2 90 2 X 798.43 X
49650   3 90 2 X 798.43 X
49650   4 90 2 X 798.43 X
49650   1 90 2 X 892.11 X
49651   2 90 2 X 1,024.30 X
49651   3 90 2 X 1,024.30 X
49651   4 90 2 X 1,024.30 X
49651   1 90 2 X 1,143.29 X
49652   2 90 2 X 1,079.76 X
49652   3 90 2 X 1,079.76 X
49652   4 90 2 X 1,079.76 X
49652   1 90 2 X 1,190.95 X
49653   2 90 2 X 1,347.71 X
49653   3 90 2 X 1,347.71 X
49653   4 90 2 X 1,347.71 X
49653   1 90 2 X 1,484.27 X
49654   2 90 2 X 1,239.63 X
49654   3 90 2 X 1,239.63 X
49654   4 90 2 X 1,239.63 X
49654   1 90 2 X 1,363.92 X
49655   2 90 2 X 1,492.61 X
49655   3 90 2 X 1,492.61 X
49655   4 90 2 X 1,492.61 X
49655   1 90 2 X 1,642.54 X
49656   2 90 2 X 1,244.69 X
49656   3 90 2 X 1,244.69 X
49656   4 90 2 X 1,244.69 X
49656   1 90 2 X 1,370.00 X
49657   2 90 2 X 1,798.94 X
49657   3 90 2 X 1,798.94 X
49657   4 90 2 X 1,798.94 X
49657   1 90 2 X 1,977.81 X
49659     YYY 2 X # X
49900   3 90 2 X 797.66 X
49900   4 90 2 X 830.10 X
49900   2 90 2 X 933.68 X
49900   1 90 2 X 939.89 X
49904   2 90 2 X 2,514.44 X
49904   3 90 2 X 2,514.44 X
49904   4 90 2 X 2,514.44 X
49904   1 90 2 X 2,828.22 X
49905   4 ZZZ 0 X 952.92 X
49905   3 ZZZ 0 X 963.33 X
49905   2 ZZZ 0 X 1,028.96 X
49905   1 ZZZ 0 X 1,044.90 X
49906     90 2 X * X
49999     YYY 2 X # X
50010   1 90 2 X 1,992.47 X
50010   4 90 2 X 2,163.33 X
50010   3 90 2 X 2,172.74 X
50010   2 90 2 X 2,222.54 X
50020   2 90 2 X 1,688.73 X
50020   3 90 2 X 1,688.73 X
50020   4 90 2 X 1,688.73 X
50020   1 90 2 X 1,860.91 X
50040   1 90 2 X 1,649.88 X
50040   2 90 2 X 1,725.11 X
50040   3 90 2 X 1,806.99 X
50040   4 90 2 X 1,957.71 X
50045   4 90 2 X 2,219.14 X
50045   3 90 2 X 2,245.59 X
50045   2 90 2 X 2,365.35 X
50045   1 90 2 X 2,394.33 X
50060   4 90 2 X 2,772.76 X
50060   3 90 2 X 2,817.76 X
50060   2 90 2 X 2,959.02 X
50060   1 90 2 X 2,996.10 X
50065   4 90 2 X 3,074.70 X
50065   3 90 2 X 3,111.44 X
50065   2 90 2 X 3,283.20 X
50065   1 90 2 X 3,324.67 X
50070   4 90 2 X 2,941.60 X
50070   3 90 2 X 2,976.42 X
50070   2 90 2 X 3,141.64 X
50070   1 90 2 X 3,181.62 X
50075   3 90 2 X 3,384.82 X
50075   1 90 2 X 3,683.76 X
50075   4 90 2 X 3,748.62 X
50075   2 90 2 X 3,805.80 X
50080   4 90 2 X 2,402.72 X
50080   3 90 2 X 2,432.34 X
50080   2 90 2 X 2,574.10 X
50080   1 90 2 X 2,608.17 X
50081   1 90 2 X 2,922.50 X
50081   3 90 2 X 3,099.63 X
50081   4 90 2 X 3,227.91 X
50081   2 90 2 X 3,506.27 X
50100   4 90 2 X 2,362.89 X
50100   3 90 2 X 2,390.65 X
50100   2 90 2 X 2,533.61 X
50100   1 90 2 X 2,577.61 X
50120   4 90 2 X 2,391.48 X
50120   3 90 2 X 2,420.00 X
50120   2 90 2 X 2,561.03 X
50120   1 90 2 X 2,595.08 X
50125   4 90 2 X 2,432.87 X
50125   3 90 2 X 2,461.88 X
50125   2 90 2 X 2,597.05 X
50125   1 90 2 X 2,629.60 X
50130   4 90 2 X 2,655.08 X
50130   3 90 2 X 2,687.30 X
50130   2 90 2 X 2,838.27 X
50130   1 90 2 X 2,878.57 X
50135   4 90 2 X 3,233.96 X
50135   3 90 2 X 3,274.05 X
50135   2 90 2 X 3,470.23 X
50135   1 90 2 X 3,517.45 X
50200   3 0 2 X 521.03 X
50200   4 0 2 X 522.06 X
50200   2 0 2 X 527.42 X
50200   1 0 2 X 555.62 X
50205   4 90 2 X 1,573.56 X
50205   3 90 2 X 1,581.07 X
50205   2 90 2 X 1,602.42 X
50205   1 90 2 X 1,690.82 X
50220   4 90 2 X 2,702.83 X
50220   3 90 2 X 2,735.68 X
50220   2 90 2 X 2,899.50 X
50220   1 90 2 X 2,939.04 X
50225   4 90 2 X 3,265.57 X
50225   3 90 2 X 3,305.53 X
50225   2 90 2 X 3,519.97 X
50225   1 90 2 X 3,547.45 X
50230   4 90 2 X 3,792.58 X
50230   3 90 2 X 3,811.11 X
50230   1 90 2 X 3,898.82 X
50230   2 90 2 X 3,902.21 X
50234   4 90 2 X 3,468.21 X
50234   3 90 2 X 3,510.21 X
50234   2 90 2 X 3,711.67 X
50234   1 90 2 X 3,760.31 X
50236   4 90 2 X 3,777.79 X
50236   3 90 2 X 3,826.78 X
50236   2 90 2 X 3,971.47 X
50236   1 90 2 X 3,999.83 X
50240   4 90 2 X 3,339.61 X
50240   3 90 2 X 3,379.98 X
50240   2 90 2 X 3,586.19 X
50240   1 90 2 X 3,626.16 X
50250   2 90 2 X 1,822.47 X
50250   3 90 2 X 1,822.47 X
50250   4 90 2 X 1,822.47 X
50250   1 90 2 X 2,007.43 X
50280   3 90 2 X 2,374.48 X
50280   4 90 2 X 2,382.99 X
50280   2 90 2 X 2,511.11 X
50280   1 90 2 X 2,544.11 X
50290   4 90 2 X 2,094.72 X
50290   3 90 2 X 2,119.09 X
50290   1 90 2 X 2,275.10 X
50290   2 90 2 X 2,291.19 X
50320     90 2 X * X
50323     XXX 2 X * X
50325     XXX 2 X * X
50327   2 XXX 2 X 369.98 X
50327   3 XXX 2 X 369.98 X
50327   4 XXX 2 X 369.98 X
50327   1 XXX 2 X 403.39 X
50328   2 XXX 2 X 324.02 X
50328   3 XXX 2 X 324.02 X
50328   4 XXX 2 X 324.02 X
50328   1 XXX 2 X 353.45 X
50329   2 XXX 2 X 309.53 X
50329   3 XXX 2 X 309.53 X
50329   4 XXX 2 X 309.53 X
50329   1 XXX 2 X 337.78 X
50340   4 90 2 X 2,234.00 X
50340   3 90 2 X 2,421.20 X
50340   2 90 2 X 2,560.50 X
50340   1 90 2 X 2,642.34 X
50360   4 90 2 X 4,903.21 X
50360   3 90 2 X 4,961.66 X
50360   2 90 2 X 5,324.65 X
50360   1 90 2 X 5,412.64 X
50365   4 90 2 X 5,898.80 X
50365   3 90 2 X 6,360.64 X
50365   2 90 2 X 6,363.61 X
50365   1 90 2 X 6,723.95 X
50370   4 90 2 X 2,397.10 X
50370   3 90 2 X 2,407.77 X
50370   2 90 2 X 2,475.66 X
50370   1 90 2 X 2,492.13 X
50380   4 90 2 X 2,500.06 X
50380   3 90 2 X 2,528.59 X
50380   2 90 2 X 2,688.66 X
50380   1 90 2 X 3,542.74 X
50382   2 0 2 X 2,385.55 462.96
50382   3 0 2 X 2,385.55 462.96
50382   4 0 2 X 2,385.55 462.96
50382   1 0 2 X 2,857.24 504.10
50384   2 0 2 X 2,302.62 421.49
50384   3 0 2 X 2,302.62 421.49
50384   4 0 2 X 2,302.62 421.49
50384   1 0 2 X 2,761.48 459.02
50385   2 0 2 X 1,939.24 363.91
50385   3 0 2 X 1,939.24 363.91
50385   4 0 2 X 1,939.24 363.91
50385   1 0 2 X 2,299.26 399.95
50386   2 0 2 X 1,254.59 275.44
50386   3 0 2 X 1,254.59 275.44
50386   4 0 2 X 1,254.59 275.44
50386   1 0 2 X 1,483.69 303.18
50387   2 0 2 X 1,152.15 167.61
50387   3 0 2 X 1,152.15 167.61
50387   4 0 2 X 1,152.15 167.61
50387   1 0 2 X 1,387.32 182.32
50389   2 0 2 X 787.06 92.48
50389   3 0 2 X 787.06 92.48
50389   4 0 2 X 787.06 92.48
50389   1 0 2 X 950.89 100.73
50390   2 0 2 X 445.97 X
50390   4 0 2 X 449.11 X
50390   1 0 2 X 450.97 X
50390   3 0 2 X 464.48 X
50391   2 0 2 X 238.07 179.26
50391   3 0 2 X 238.07 179.26
50391   4 0 2 X 238.07 179.26
50391   1 0 2 X 265.67 195.11
50396   4 0 2 X 219.85 X
50396   3 0 2 X 222.16 X
50396   2 0 2 X 230.84 X
50396   1 0 2 X 232.97 X
50400   3 90 2 X 2,948.48 X
50400   4 90 2 X 3,023.16 X
50400   1 90 2 X 3,156.25 X
50400   2 90 2 X 3,209.95 X
50405   4 90 2 X 3,651.07 X
50405   3 90 2 X 3,946.88 X
50405   2 90 2 X 4,044.52 X
50405   1 90 2 X 4,065.03 X
50430   2 0 2 X 654.93 221.47
50430   3 0 2 X 654.93 221.47
50430   4 0 2 X 654.93 221.47
50430   1 0 2 X 745.80 238.58
50431   2 0 2 X 204.16 87.32
50431   3 0 2 X 204.16 87.32
50431   4 0 2 X 204.16 87.32
50431   1 0 2 X 231.73 95.02
50432   2 0 2 X 1,058.90 293.11
50432   3 0 2 X 1,058.90 293.11
50432   4 0 2 X 1,058.90 293.11
50432   1 0 2 X 1,211.25 315.22
50433   2 0 2 X 1,423.60 361.59
50433   3 0 2 X 1,423.60 361.59
50433   4 0 2 X 1,423.60 361.59
50433   1 0 2 X 1,631.17 388.55
50434   2 0 2 X 1,125.79 277.04
50434   3 0 2 X 1,125.79 277.04
50434   4 0 2 X 1,125.79 277.04
50434   1 0 2 X 1,291.21 298.13
50435   2 0 2 X 589.84 134.18
50435   3 0 2 X 589.84 134.18
50435   4 0 2 X 589.84 134.18
50435   1 0 2 X 678.28 145.14
50436   2 0 2 X 182.93 X
50436   3 0 2 X 182.93 X
50436   4 0 2 X 182.93 X
50436   1 0 2 X 197.28 X
50437   2 0 2 X 305.75 X
50437   3 0 2 X 305.75 X
50437   4 0 2 X 305.75 X
50437   1 0 2 X 328.61 X
50500   4 90 2 X 2,853.99 X
50500   3 90 2 X 2,887.45 X
50500   2 90 2 X 3,060.64 X
50500   1 90 2 X 3,102.59 X
50520   4 90 2 X 2,450.92 X
50520   3 90 2 X 2,479.35 X
50520   2 90 2 X 2,630.74 X
50520   1 90 2 X 2,667.43 X
50525   4 90 2 X 3,106.68 X
50525   3 90 2 X 3,142.27 X
50525   2 90 2 X 3,335.81 X
50525   1 90 2 X 3,382.77 X
50526   4 90 2 X 2,830.87 X
50526   3 90 2 X 2,860.11 X
50526   2 90 2 X 3,044.26 X
50526   1 90 2 X 3,089.26 X
50540   4 90 2 X 3,005.18 X
50540   3 90 2 X 3,040.82 X
50540   2 90 2 X 3,216.71 X
50540   1 90 2 X 3,259.27 X
50541   2 90 2 X 1,726.71 X
50541   3 90 2 X 1,726.71 X
50541   4 90 2 X 1,726.71 X
50541   1 90 2 X 1,893.41 X
50542   2 90 2 X 1,990.50 X
50542   3 90 2 X 1,990.50 X
50542   4 90 2 X 1,990.50 X
50542   1 90 2 X 2,193.04 X
50543   2 90 2 X 2,507.80 X
50543   3 90 2 X 2,507.80 X
50543   4 90 2 X 2,507.80 X
50543   1 90 2 X 2,747.66 X
50544   2 90 2 X 2,381.83 X
50544   3 90 2 X 2,381.83 X
50544   4 90 2 X 2,381.83 X
50544   1 90 2 X 2,606.38 X
50545   2 90 2 X 2,564.31 X
50545   3 90 2 X 2,564.31 X
50545   4 90 2 X 2,564.31 X
50545   1 90 2 X 2,823.82 X
50546   2 90 2 X 2,205.44 X
50546   3 90 2 X 2,205.44 X
50546   4 90 2 X 2,205.44 X
50546   1 90 2 X 2,421.36 X
50547   2 90 2 X 2,825.59 X
50547   3 90 2 X 2,825.59 X
50547   4 90 2 X 2,825.59 X
50547   1 90 2 X 3,115.85 X
50548   2 90 2 X 2,592.33 X
50548   3 90 2 X 2,592.33 X
50548   4 90 2 X 2,592.33 X
50548   1 90 2 X 2,837.92 X
50549     YYY 2 X # X
50551   1 0 2 X 756.13 X
50551   3 0 2 X 766.59 X
50551   4 0 2 X 786.52 X
50551   2 0 2 X 803.40 X