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2021 Workers' Compensation Part B Fee Schedule

50553-51784

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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
50553   3 0 2 X 702.66 X
50553   1 0 2 X 738.51 X
50553   4 0 2 X 749.34 X
50553   2 0 2 X 764.51 X
50555   4 0 3 X 1,028.81 X
50555   3 0 3 X 1,041.16 X
50555   2 0 3 X 1,098.80 X
50555   1 0 3 X 1,112.67 X
50557   3 0 3 X 964.02 X
50557   2 0 3 X 1,020.30 X
50557   4 0 3 X 1,041.25 X
50557   1 0 3 X 1,044.81 X
50561   4 0 3 X 1,163.72 X
50561   3 0 3 X 1,310.47 X
50561   2 0 3 X 1,337.28 X
50561   1 0 3 X 1,343.83 X
50562   2 0 3 X 1,057.55 X
50562   3 0 3 X 1,057.55 X
50562   4 0 3 X 1,057.55 X
50562   1 0 3 X 1,166.42 X
50570   2 0 2 X 1,037.83 X
50570   4 0 2 X 1,070.71 X
50570   3 0 2 X 1,074.90 X
50570   1 0 2 X 1,092.85 X
50572   3 0 3 X 1,593.72 X
50572   4 0 3 X 1,617.48 X
50572   2 0 3 X 1,728.34 X
50572   1 0 3 X 1,750.49 X
50574   4 0 3 X 1,652.64 X
50574   2 0 3 X 1,664.35 X
50574   3 0 3 X 1,672.22 X
50574   1 0 3 X 1,781.10 X
50575   4 0 3 X 2,192.07 X
50575   3 0 3 X 2,218.27 X
50575   2 0 3 X 2,340.91 X
50575   1 0 3 X 2,370.51 X
50576   4 0 3 X 1,799.51 X
50576   3 0 3 X 1,821.43 X
50576   2 0 3 X 1,922.75 X
50576   1 0 3 X 1,947.10 X
50580   4 0 3 X 1,401.80 X
50580   3 0 3 X 1,416.85 X
50580   2 0 3 X 1,476.02 X
50580   1 0 3 X 1,490.40 X
50590   4 90 2 X 1,815.87 X
50590   3 90 2 X 1,838.74 X
50590   2 90 2 X 1,952.61 X
50590   1 90 2 X 1,980.07 X
50592   2 10 2 X 8,805.15 607.71
50592   3 10 2 X 8,805.15 607.71
50592   4 10 2 X 8,805.15 607.71
50592   1 10 2 X 10,700.63 667.35
50593   2 10 2 X 6,830.63 705.18
50593   3 10 2 X 6,830.63 705.18
50593   4 10 2 X 6,830.63 705.18
50593   1 10 2 X 8,156.80 771.34
50600   3 90 2 X 2,240.03 X
50600   4 90 2 X 2,259.22 X
50600   1 90 2 X 2,375.27 X
50600   2 90 2 X 2,399.10 X
50605   4 90 2 X 1,869.71 X
50605   3 90 2 X 1,890.65 X
50605   2 90 2 X 1,979.17 X
50605   1 90 2 X 2,000.67 X
50606   2 ZZZ 0 X 663.86 209.51
50606   3 ZZZ 0 X 663.86 209.51
50606   4 ZZZ 0 X 663.86 209.51
50606   1 ZZZ 0 X 756.52 224.91
50610   4 90 2 X 2,446.33 X
50610   3 90 2 X 2,475.99 X
50610   2 90 2 X 2,618.22 X
50610   1 90 2 X 2,652.60 X
50620   4 90 2 X 2,359.68 X
50620   3 90 2 X 2,388.31 X
50620   2 90 2 X 2,527.19 X
50620   1 90 2 X 2,560.65 X
50630   4 90 2 X 2,452.25 X
50630   3 90 2 X 2,482.47 X
50630   2 90 2 X 2,630.90 X
50630   1 90 2 X 2,666.65 X
50650   4 90 2 X 2,610.20 X
50650   3 90 2 X 2,641.56 X
50650   2 90 2 X 2,790.32 X
50650   1 90 2 X 2,826.21 X
50660   4 90 2 X 2,862.61 X
50660   1 90 2 X 3,106.38 X
50660   3 90 2 X 4,235.70 X
50660   2 90 2 X 4,306.73 X
50684   3 0 2 X 116.48 X
50684   2 0 2 X 161.00 X
50684   4 0 2 X 161.38 X
50684   1 0 2 X 165.22 X
50686   4 0 2 X 170.68 X
50686   3 0 2 X 172.47 X
50686   2 0 2 X 179.40 X
50686   1 0 2 X 181.04 X
50688   4 10 2 X 138.66 X
50688   3 10 2 X 140.15 X
50688   1 10 2 X 147.80 X
50688   2 10 2 X 151.27 X
50690   1 0 2 X 144.59 X
50690   4 0 2 X 145.89 X
50690   3 0 2 X 146.47 X
50690   2 0 2 X 148.76 X
50693   2 0 2 X 1,322.41 289.91
50693   3 0 2 X 1,322.41 289.91
50693   4 0 2 X 1,322.41 289.91
50693   1 0 2 X 1,519.88 311.79
50694   2 0 2 X 1,459.49 374.90
50694   3 0 2 X 1,459.49 374.90
50694   4 0 2 X 1,459.49 374.90
50694   1 0 2 X 1,671.90 402.84
50695   2 0 2 X 1,780.79 475.95
50695   3 0 2 X 1,780.79 475.95
50695   4 0 2 X 1,780.79 475.95
50695   1 0 2 X 2,037.68 510.93
50700   4 90 2 X 2,457.28 X
50700   3 90 2 X 2,487.50 X
50700   2 90 2 X 2,637.13 X
50700   1 90 2 X 2,673.21 X
50705   2 ZZZ 0 X 2,119.58 268.31
50705   3 ZZZ 0 X 2,119.58 268.31
50705   4 ZZZ 0 X 2,119.58 268.31
50705   1 ZZZ 0 X 2,454.37 288.27
50706   2 ZZZ 0 X 957.91 249.45
50706   3 ZZZ 0 X 957.91 249.45
50706   4 ZZZ 0 X 957.91 249.45
50706   1 ZZZ 0 X 1,096.17 267.21
50715   4 90 2 X 2,677.03 X
50715   3 90 2 X 2,708.16 X
50715   2 90 2 X 2,867.41 X
50715   1 90 2 X 2,906.02 X
50722   4 90 2 X 2,416.95 X
50722   3 90 2 X 2,444.67 X
50722   2 90 2 X 2,613.48 X
50722   1 90 2 X 2,654.41 X
50725   4 90 2 X 2,725.34 X
50725   3 90 2 X 2,757.32 X
50725   2 90 2 X 2,930.32 X
50725   1 90 2 X 3,203.28 X
50727   4 90 2 X 1,184.94 X
50727   3 90 2 X 1,199.08 X
50727   2 90 2 X 1,264.97 X
50727   1 90 2 X 1,280.89 X
50728   4 90 2 X 1,744.25 X
50728   3 90 2 X 1,765.13 X
50728   2 90 2 X 1,862.63 X
50728   1 90 2 X 1,886.23 X
50740   4 90 2 X 2,852.69 X
50740   3 90 2 X 2,854.16 X
50740   2 90 2 X 3,012.38 X
50740   1 90 2 X 3,071.56 X
50750   4 90 2 X 2,942.74 X
50750   3 90 2 X 2,978.43 X
50750   2 90 2 X 3,143.41 X
50750   1 90 2 X 3,183.20 X
50760   4 90 2 X 2,822.90 X
50760   3 90 2 X 2,856.90 X
50760   2 90 2 X 3,026.18 X
50760   1 90 2 X 3,067.05 X
50770   4 90 2 X 3,069.34 X
50770   3 90 2 X 3,106.82 X
50770   2 90 2 X 3,289.44 X
50770   1 90 2 X 3,333.49 X
50780   4 90 2 X 2,847.32 X
50780   3 90 2 X 2,881.82 X
50780   2 90 2 X 3,051.78 X
50780   1 90 2 X 3,092.83 X
50782   4 90 2 X 2,946.73 X
50782   3 90 2 X 2,982.10 X
50782   2 90 2 X 3,154.61 X
50782   1 90 2 X 3,196.22 X
50783   4 90 2 X 3,031.08 X
50783   3 90 2 X 3,067.23 X
50783   2 90 2 X 3,241.74 X
50783   1 90 2 X 3,283.95 X
50785   4 90 2 X 3,200.17 X
50785   3 90 2 X 3,238.75 X
50785   2 90 2 X 3,459.24 X
50785   1 90 2 X 3,483.35 X
50800   4 90 2 X 2,567.57 X
50800   3 90 2 X 2,600.06 X
50800   2 90 2 X 2,860.30 X
50800   1 90 2 X 2,948.32 X
50810   4 90 2 X 2,861.59 X
50810   3 90 2 X 2,895.15 X
50810   2 90 2 X 3,073.10 X
50810   1 90 2 X 3,116.26 X
50815   4 90 2 X 3,567.10 X
50815   3 90 2 X 3,611.22 X
50815   2 90 2 X 3,868.05 X
50815   1 90 2 X 4,011.87 X
50820   4 90 2 X 3,657.15 X
50820   3 90 2 X 3,701.86 X
50820   2 90 2 X 3,948.67 X
50820   1 90 2 X 4,008.28 X
50825   4 90 2 X 5,264.36 X
50825   3 90 2 X 5,330.99 X
50825   2 90 2 X 5,685.64 X
50825   1 90 2 X 5,770.99 X
50830   4 90 2 X 4,625.05 X
50830   3 90 2 X 4,680.06 X
50830   2 90 2 X 4,947.74 X
50830   1 90 2 X 5,012.39 X
50840   4 90 2 X 2,890.01 X
50840   1 90 2 X 3,129.89 X
50840   3 90 2 X 3,198.03 X
50840   2 90 2 X 3,564.34 X
50845   4 90 2 X 3,060.74 X
50845   3 90 2 X 3,097.38 X
50845   2 90 2 X 3,268.55 X
50845   1 90 2 X 3,309.91 X
50860   4 90 2 X 2,294.59 X
50860   3 90 2 X 2,322.25 X
50860   2 90 2 X 2,457.82 X
50860   1 90 2 X 2,490.56 X
50900   3 90 2 X 2,111.60 X
50900   1 90 2 X 2,269.42 X
50900   4 90 2 X 2,347.86 X
50900   2 90 2 X 2,451.36 X
50920   4 90 2 X 2,090.88 X
50920   3 90 2 X 2,115.86 X
50920   2 90 2 X 2,433.90 X
50920   1 90 2 X 2,525.22 X
50930   4 90 2 X 2,760.16 X
50930   3 90 2 X 2,793.22 X
50930   2 90 2 X 2,947.38 X
50930   1 90 2 X 2,984.58 X
50940   4 90 2 X 2,141.60 X
50940   3 90 2 X 2,167.32 X
50940   1 90 2 X 2,316.89 X
50940   2 90 2 X 2,471.87 X
50945   2 90 2 X 1,826.41 X
50945   3 90 2 X 1,826.41 X
50945   4 90 2 X 1,826.41 X
50945   1 90 2 X 2,001.33 X
50947   2 90 2 X 2,759.60 X
50947   3 90 2 X 2,759.60 X
50947   4 90 2 X 2,759.60 X
50947   1 90 2 X 3,048.63 X
50948   2 90 2 X 2,523.45 X
50948   3 90 2 X 2,523.45 X
50948   4 90 2 X 2,523.45 X
50948   1 90 2 X 2,787.40 X
50949     YYY 2 X # X
50951   1 0 2 X 724.65 X
50951   4 0 2 X 951.72 X
50951   3 0 2 X 969.38 X
50951   2 0 2 X 981.33 X
50953   4 0 3 X 716.52 X
50953   1 0 3 X 760.18 X
50953   3 0 3 X 957.58 X
50953   2 0 3 X 969.78 X
50955   4 0 3 X 846.87 X
50955   3 0 3 X 856.26 X
50955   2 0 3 X 1,029.09 X
50955   1 0 3 X 1,032.99 X
50957   4 0 3 X 846.14 X
50957   2 0 3 X 893.70 X
50957   1 0 3 X 903.03 X
50957   3 0 3 X 1,012.68 X
50961   1 0 3 X 846.31 X
50961   4 0 3 X 1,107.14 X
50961   3 0 3 X 1,151.56 X
50961   2 0 3 X 1,167.40 X
50970   4 0 2 X 1,130.68 X
50970   3 0 2 X 1,144.25 X
50970   2 0 2 X 1,208.57 X
50970   1 0 2 X 1,224.12 X
50972   4 0 2 X 764.89 X
50972   3 0 2 X 772.92 X
50972   2 0 2 X 802.69 X
50972   1 0 2 X 810.06 X
50974   4 0 3 X 1,481.65 X
50974   3 0 3 X 1,499.56 X
50974   2 0 3 X 1,583.26 X
50974   1 0 3 X 1,603.41 X
50976   4 0 3 X 1,415.86 X
50976   3 0 3 X 1,432.76 X
50976   2 0 3 X 1,511.77 X
50976   1 0 3 X 1,530.88 X
50980   3 0 2 X 744.70 X
50980   4 0 2 X 909.29 X
50980   1 0 2 X 973.78 X
50980   2 0 2 X 1,414.38 X
51020   4 90 2 X 1,415.89 X
51020   3 90 2 X 1,422.18 X
51020   1 90 2 X 1,424.93 X
51020   2 90 2 X 1,444.24 X
51030   4 90 2 X 968.21 X
51030   1 90 2 X 1,396.46 X
51030   3 90 2 X 1,397.77 X
51030   2 90 2 X 1,552.19 X
51040   4 90 2 X 1,341.36 X
51040   1 90 2 X 1,364.32 X
51040   3 90 2 X 1,371.68 X
51040   2 90 2 X 1,376.53 X
51045   2 90 2 X 1,220.59 X
51045   4 90 2 X 1,368.85 X
51045   3 90 2 X 1,373.98 X
51045   1 90 2 X 1,394.76 X
51050   4 90 2 X 1,414.70 X
51050   3 90 2 X 1,421.18 X
51050   2 90 2 X 1,452.33 X
51050   1 90 2 X 1,462.52 X
51060   4 90 2 X 1,783.29 X
51060   3 90 2 X 1,806.40 X
51060   2 90 2 X 1,931.24 X
51060   1 90 2 X 1,961.28 X
51065   4 90 2 X 1,392.63 X
51065   1 90 2 X 1,514.02 X
51065   3 90 2 X 1,578.10 X
51065   2 90 2 X 1,761.95 X
51080   3 90 2 X 992.86 X
51080   1 90 2 X 1,070.58 X
51080   4 90 2 X 1,085.06 X
51080   2 90 2 X 1,128.10 X
51100   2 0 2 X 95.10 59.33
51100   3 0 2 X 95.10 59.33
51100   4 0 2 X 95.10 59.33
51100   1 0 2 X 107.89 64.71
51101   2 0 2 X 192.72 78.66
51101   3 0 2 X 192.72 78.66
51101   4 0 2 X 192.72 78.66
51101   1 0 2 X 224.22 86.71
51102   2 10 2 X 504.22 373.08
51102   3 10 2 X 504.22 373.08
51102   4 10 2 X 504.22 373.08
51102   1 10 2 X 571.07 412.91
51500   4 90 2 X 1,552.95 X
51500   3 90 2 X 1,570.96 X
51500   2 90 2 X 1,677.83 X
51500   1 90 2 X 1,703.77 X
51520   4 90 2 X 1,588.17 X
51520   3 90 2 X 1,730.45 X
51520   1 90 2 X 1,731.43 X
51520   2 90 2 X 1,772.13 X
51525   4 90 2 X 2,155.30 X
51525   3 90 2 X 2,181.60 X
51525   2 90 2 X 2,309.10 X
51525   1 90 2 X 2,339.79 X
51530   1 90 2 X 2,065.53 X
51530   2 90 2 X 2,261.03 X
51530   4 90 2 X 2,275.00 X
51530   3 90 2 X 2,289.00 X
51535   4 90 2 X 1,793.48 X
51535   3 90 2 X 1,814.32 X
51535   2 90 2 X 1,926.89 X
51535   1 90 2 X 1,954.20 X
51550   4 90 2 X 2,308.79 X
51550   3 90 2 X 2,336.50 X
51550   2 90 2 X 2,472.14 X
51550   1 90 2 X 2,504.87 X
51555   4 90 2 X 2,886.97 X
51555   3 90 2 X 2,906.66 X
51555   1 90 2 X 3,021.59 X
51555   2 90 2 X 3,149.91 X
51565   4 90 2 X 3,302.11 X
51565   3 90 2 X 3,341.99 X
51565   2 90 2 X 3,537.70 X
51565   1 90 2 X 3,584.97 X
51570   4 90 2 X 3,475.05 X
51570   3 90 2 X 3,516.48 X
51570   2 90 2 X 3,713.90 X
51570   1 90 2 X 3,761.58 X
51575   4 90 2 X 4,665.54 X
51575   3 90 2 X 4,722.42 X
51575   2 90 2 X 4,995.78 X
51575   1 90 2 X 5,061.71 X
51580   4 90 2 X 4,421.21 X
51580   3 90 2 X 4,473.97 X
51580   2 90 2 X 4,724.20 X
51580   1 90 2 X 4,784.66 X
51585   4 90 2 X 5,259.81 X
51585   3 90 2 X 5,323.41 X
51585   2 90 2 X 5,625.41 X
51585   1 90 2 X 5,698.20 X
51590   2 90 2 X 5,401.83 X
51590   4 90 2 X 5,433.18 X
51590   3 90 2 X 5,517.94 X
51590   1 90 2 X 5,695.18 X
51595   4 90 2 X 6,436.58 X
51595   3 90 2 X 6,437.75 X
51595   2 90 2 X 6,735.49 X
51595   1 90 2 X 6,829.30 X
51596   3 90 2 X 6,209.86 X
51596   2 90 2 X 6,327.37 X
51596   1 90 2 X 6,361.26 X
51596   4 90 2 X 6,551.69 X
51597   4 90 2 X 6,175.65 X
51597   3 90 2 X 6,249.95 X
51597   2 90 2 X 6,665.95 X
51597   1 90 2 X 6,766.59 X
51600   4 0 2 X 90.30 X
51600   3 0 2 X 90.77 X
51600   2 0 2 X 93.08 X
51600   1 0 2 X 94.60 X
51605   4 0 2 X 129.29 X
51605   3 0 2 X 130.65 X
51605   2 0 2 X 135.85 X
51605   1 0 2 X 137.19 X
51610   4 0 2 X 138.78 X
51610   3 0 2 X 139.44 X
51610   1 0 2 X 146.61 X
51610   2 0 2 X 148.52 X
51700   4 0 2 X 88.25 80.07
51700   3 0 2 X 94.55 85.57
51700   2 0 2 X 100.84 91.11
51700   1 0 2 X 104.27 94.37
51701   2 0 2 X 104.64 49.01
51701   3 0 2 X 104.64 49.01
51701   4 0 2 X 104.64 49.01
51701   1 0 2 X 119.22 53.79
51702   2 0 2 X 163.53 53.54
51702   3 0 2 X 163.53 53.54
51702   4 0 2 X 163.53 53.54
51702   1 0 2 X 188.38 59.11
51703   2 0 2 X 229.67 144.27
51703   3 0 2 X 229.67 144.27
51703   4 0 2 X 229.67 144.27
51703   1 0 2 X 258.84 158.44
51705   3 10 2 X 117.36 102.00
51705   4 10 2 X 118.53 103.27
51705   2 10 2 X 121.48 105.34
51705   1 10 2 X 123.34 106.98
51710   4 10 2 X 153.92 X
51710   3 10 2 X 155.11 X
51710   2 10 2 X 160.06 X
51710   1 10 2 X 161.30 X
51715   4 0 2 X 586.39 X
51715   3 0 2 X 593.37 X
51715   2 0 2 X 626.51 X
51715   1 0 2 X 634.45 X
51720   4 0 2 X 172.50 157.08
51720   3 0 2 X 174.56 158.58
51720   2 0 2 X 179.89 163.47
51720   1 0 2 X 181.94 164.90
51725 TC 4 0 2 X 35.73 X
51725 TC 3 0 2 X 36.26 X
51725 TC 2 0 2 X 39.87 X
51725 TC 1 0 2 X 40.71 X
51725 26 4 0 2 X 173.10 X
51725 26 3 0 2 X 176.56 X
51725   4 0 2 X 201.74 X
51725   3 0 2 X 206.30 X
51725 26 2 0 2 X 207.89 X
51725 26 1 0 2 X 210.18 X
51725   1 0 2 X 245.81 X
51725   2 0 2 X 247.78 X
51726 TC 4 0 2 X 45.92 X
51726 TC 3 0 2 X 46.65 X
51726 TC 2 0 2 X 51.24 X
51726 TC 1 0 2 X 52.32 X
51726 26 4 0 2 X 192.40 X
51726 26 3 0 2 X 196.22 X
51726 26 2 0 2 X 227.62 X
51726   3 0 2 X 231.75 X
51726   4 0 2 X 233.73 X
51726 26 1 0 2 X 243.46 X
51726   1 0 2 X 272.43 X
51726   2 0 2 X 286.98 X
51727 26 2 0 2 X 160.91 X
51727 26 3 0 2 X 160.91 X
51727 26 4 0 2 X 160.91 X
51727 26 1 0 2 X 175.00 X
51727 TC 2 0 2 X 255.81 X
51727 TC 3 0 2 X 255.81 X
51727 TC 4 0 2 X 255.81 X
51727 TC 1 0 2 X 303.56 X
51727   2 0 2 X 416.73 X
51727   3 0 2 X 416.73 X
51727   4 0 2 X 416.73 X
51727   1 0 2 X 478.57 X
51728 26 2 0 2 X 158.75 X
51728 26 3 0 2 X 158.75 X
51728 26 4 0 2 X 158.75 X
51728 26 1 0 2 X 172.05 X
51728 TC 2 0 2 X 257.36 X
51728 TC 3 0 2 X 257.36 X
51728 TC 4 0 2 X 257.36 X
51728 TC 1 0 2 X 305.38 X
51728   2 0 2 X 416.07 X
51728   3 0 2 X 416.07 X
51728   4 0 2 X 416.07 X
51728   1 0 2 X 477.38 X
51729 26 2 0 2 X 187.95 X
51729 26 3 0 2 X 187.95 X
51729 26 4 0 2 X 187.95 X
51729 26 1 0 2 X 203.18 X
51729 TC 2 0 2 X 260.36 X
51729 TC 3 0 2 X 260.36 X
51729 TC 4 0 2 X 260.36 X
51729 TC 1 0 2 X 308.96 X
51729   2 0 2 X 448.33 X
51729   3 0 2 X 448.33 X
51729   4 0 2 X 448.33 X
51729   1 0 2 X 512.12 X
51736 TC 4 0 2 X 13.59 X
51736 TC 3 0 2 X 13.80 X
51736 TC 2 0 2 X 15.04 X
51736 TC 1 0 2 X 15.24 X
51736 26 4 0 2 X 82.52 X
51736 26 2 0 2 X 94.07 X
51736 26 1 0 2 X 94.65 X
51736 26 3 0 2 X 101.16 X
51736   4 0 2 X 102.33 X
51736   3 0 2 X 105.15 X
51736   2 0 2 X 107.50 X
51736   1 0 2 X 111.61 X
51741 TC 4 0 2 X 19.57 X
51741 TC 3 0 2 X 19.83 X
51741 TC 1 0 2 X 22.22 X
51741 TC 2 0 2 X 106.92 X
51741 26 4 0 2 X 133.61 X
51741 26 3 0 2 X 134.37 X
51741 26 2 0 2 X 138.56 X
51741 26 1 0 2 X 139.49 X
51741   4 0 2 X 150.13 X
51741   3 0 2 X 150.86 X
51741   1 0 2 X 157.62 X
51741   2 0 2 X 164.51 X
51784 TC 4 0 2 X 38.65 X
51784 TC 3 0 2 X 39.36 X
51784 TC 2 0 2 X 43.38 X
51784 TC 1 0 2 X 45.13 X
51784 26 4 0 2 X 212.16 X
51784 26 3 0 2 X 214.85 X
51784 26 2 0 2 X 225.18 X
51784 26 1 0 2 X 230.06 X
51784   4 0 2 X 250.84 X
51784   3 0 2 X 254.21 X
51784   2 0 2 X 268.54 X
51784   1 0 2 X 275.21 X