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2021 Workers' Compensation Part B Fee Schedule

51785-53510

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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
51785 TC 4 0 2 X 36.59 X
51785 TC 3 0 2 X 37.09 X
51785 TC 2 0 2 X 40.79 X
51785 TC 1 0 2 X 41.67 X
51785 26 4 0 2 X 187.43 X
51785 26 3 0 2 X 188.76 X
51785 26 2 0 2 X 194.21 X
51785 26 1 0 2 X 195.59 X
51785   4 0 2 X 208.48 X
51785   3 0 2 X 212.49 X
51785   2 0 2 X 228.15 X
51785   1 0 2 X 232.81 X
51792 TC 4 0 2 X 126.74 X
51792 TC 3 0 2 X 128.71 X
51792 TC 2 0 2 X 141.40 X
51792 TC 1 0 2 X 144.39 X
51792 26 4 0 2 X 154.64 X
51792 26 3 0 2 X 156.39 X
51792 26 2 0 2 X 164.41 X
51792 26 1 0 2 X 166.36 X
51792   3 0 2 X 239.62 X
51792   4 0 2 X 281.37 X
51792   2 0 2 X 307.83 X
51792   1 0 2 X 310.74 X
51797 TC 4 0 2 X 42.55 X
51797 TC 3 0 2 X 43.19 X
51797 TC 2 0 2 X 47.55 X
51797 TC 1 0 2 X 48.63 X
51797 26 3 0 2 X 162.92 X
51797 26 2 0 2 X 177.91 X
51797 26 1 0 2 X 179.05 X
51797 26 4 0 2 X 192.27 X
51797   3 0 2 X 213.38 X
51797   2 0 2 X 220.70 X
51797   1 0 2 X 222.43 X
51797   4 0 2 X 234.79 X
51798   2 0 2 X 34.83 X
51798   3 0 2 X 34.83 X
51798   4 0 2 X 34.83 X
51798   1 0 2 X 43.43 X
51800   4 90 2 X 2,624.88 X
51800   3 90 2 X 2,656.11 X
51800   2 90 2 X 2,815.70 X
51800   1 90 2 X 2,854.22 X
51820   4 90 2 X 1,633.71 X
51820   3 90 2 X 1,640.25 X
51820   2 90 2 X 1,726.02 X
51820   1 90 2 X 1,750.75 X
51840   2 90 2 X 1,600.30 X
51840   3 90 2 X 1,600.30 X
51840   4 90 2 X 1,600.30 X
51840   1 90 2 X 1,814.29 X
51841   3 90 2 X 2,245.78 X
51841   4 90 2 X 2,312.45 X
51841   2 90 2 X 2,333.10 X
51841   1 90 2 X 2,368.28 X
51845   4 90 2 X 2,171.49 X
51845   3 90 2 X 2,181.32 X
51845   2 90 2 X 2,222.62 X
51845   1 90 2 X 2,244.31 X
51860   4 90 2 X 1,735.83 X
51860   3 90 2 X 1,756.35 X
51860   2 90 2 X 1,858.26 X
51860   1 90 2 X 1,882.98 X
51865   4 90 2 X 2,307.84 X
51865   3 90 2 X 2,335.57 X
51865   2 90 2 X 2,475.93 X
51865   1 90 2 X 2,509.80 X
51880   4 90 2 X 1,119.16 X
51880   3 90 2 X 1,132.43 X
51880   2 90 2 X 1,195.88 X
51880   1 90 2 X 1,211.15 X
51900   4 90 2 X 2,171.98 X
51900   3 90 2 X 2,399.21 X
51900   2 90 2 X 2,682.38 X
51900   1 90 2 X 2,768.12 X
51920   4 90 2 X 1,657.14 X
51920   3 90 2 X 1,676.96 X
51920   2 90 2 X 1,769.62 X
51920   1 90 2 X 1,791.97 X
51925   4 90 2 X 2,338.49 X
51925   3 90 2 X 2,365.02 X
51925   2 90 2 X 2,545.52 X
51925   1 90 2 X 2,589.47 X
51940   4 90 2 X 4,065.26 X
51940   3 90 2 X 4,113.87 X
51940   2 90 2 X 4,359.36 X
51940   1 90 2 X 4,418.67 X
51960   4 90 2 X 3,935.11 X
51960   3 90 2 X 3,984.13 X
51960   2 90 2 X 4,236.29 X
51960   1 90 2 X 4,297.02 X
51980   4 90 2 X 1,642.25 X
51980   3 90 2 X 1,661.91 X
51980   2 90 2 X 2,435.14 X
51980   1 90 2 X 2,515.55 X
51990   2 90 2 X 1,411.91 X
51990   3 90 2 X 1,411.91 X
51990   4 90 2 X 1,411.91 X
51990   1 90 2 X 1,555.14 X
51992   2 90 2 X 1,540.64 X
51992   3 90 2 X 1,540.64 X
51992   4 90 2 X 1,540.64 X
51992   1 90 2 X 1,690.08 X
51999     YYY 0 X # X
52000   4 0 2 X 306.04 X
52000   3 0 2 X 309.68 X
52000   2 0 2 X 326.73 X
52000   1 0 2 X 330.88 X
52001   2 0 2 X 244.81 X
52001   3 0 2 X 244.81 X
52001   4 0 2 X 244.81 X
52001   1 0 2 X 275.87 X
52005   4 0 2 X 420.50 X
52005   3 0 2 X 425.68 X
52005   2 0 2 X 451.33 X
52005   1 0 2 X 457.52 X
52007   4 0 3 X 509.85 X
52007   3 0 3 X 525.11 X
52007   1 0 3 X 549.08 X
52007   2 0 3 X 551.36 X
52010   2 0 3 X 426.41 X
52010   4 0 3 X 451.04 X
52010   3 0 3 X 456.31 X
52010   1 0 3 X 487.01 X
52204   3 0 3 X 454.41 X
52204   2 0 3 X 499.26 X
52204   4 0 3 X 535.83 X
52204   1 0 3 X 563.47 X
52214   3 0 3 X 625.59 X
52214   4 0 3 X 679.36 X
52214   2 0 3 X 690.12 X
52214   1 0 3 X 697.86 X
52224   3 0 3 X 592.76 X
52224   4 0 3 X 632.59 X
52224   1 0 3 X 678.15 X
52224   2 0 3 X 678.63 X
52234   4 0 2 X 960.92 X
52234   3 0 2 X 962.44 X
52234   2 0 2 X 989.30 X
52234   1 0 2 X 995.16 X
52235   3 0 2 X 1,420.47 X
52235   2 0 2 X 1,461.01 X
52235   4 0 2 X 1,496.04 X
52235   1 0 2 X 1,619.63 X
52240   3 0 2 X 1,867.46 X
52240   4 0 2 X 1,931.03 X
52240   1 0 2 X 2,049.93 X
52240   2 0 2 X 2,066.00 X
52250   3 0 3 X 545.49 X
52250   4 0 3 X 674.28 X
52250   2 0 3 X 718.88 X
52250   1 0 3 X 727.76 X
52260   4 0 3 X 469.56 X
52260   3 0 3 X 472.85 X
52260   2 0 3 X 487.38 X
52260   1 0 3 X 492.07 X
52265   3 0 3 X 346.81 X
52265   4 0 3 X 358.87 X
52265   2 0 3 X 367.99 X
52265   1 0 3 X 380.04 X
52270   4 0 3 X 672.60 X
52270   3 0 3 X 680.95 X
52270   2 0 3 X 721.79 X
52270   1 0 3 X 731.59 X
52275   4 0 3 X 744.75 X
52275   3 0 3 X 753.70 X
52275   1 0 3 X 805.89 X
52275   2 0 3 X 808.38 X
52276   4 0 3 X 825.67 X
52276   3 0 3 X 829.90 X
52276   2 0 3 X 845.16 X
52276   1 0 3 X 857.48 X
52277   3 0 3 X 904.24 X
52277   2 0 3 X 968.41 X
52277   4 0 3 X 1,008.81 X
52277   1 0 3 X 1,009.01 X
52281   2 0 3 X 404.86 315.31
52281   3 0 3 X 404.86 315.31
52281   4 0 3 X 404.86 315.31
52281   1 0 3 X 454.70 349.47
52282   2 0 3 X 866.76 X
52282   3 0 3 X 866.76 X
52282   4 0 3 X 866.76 X
52282   1 0 3 X 967.51 X
52283   2 0 3 X 407.91 X
52283   4 0 3 X 478.40 X
52283   3 0 3 X 483.63 X
52283   1 0 3 X 511.32 X
52285   4 0 3 X 616.65 X
52285   3 0 3 X 629.97 X
52285   1 0 3 X 653.50 X
52285   2 0 3 X 666.51 X
52287   2 0 3 X 409.69 227.56
52287   3 0 3 X 409.69 227.56
52287   4 0 3 X 409.69 227.56
52287   1 0 3 X 458.09 246.88
52290   4 0 3 X 633.80 X
52290   3 0 3 X 641.09 X
52290   2 0 3 X 673.22 X
52290   1 0 3 X 680.97 X
52300   3 0 3 X 818.87 X
52300   4 0 3 X 895.90 X
52300   2 0 3 X 935.66 X
52300   1 0 3 X 940.17 X
52301   3 0 3 X 805.15 X
52301   4 0 3 X 805.15 X
52301   2 0 3 X 827.38 X
52301   1 0 3 X 897.33 X
52305   4 0 3 X 807.44 X
52305   3 0 3 X 816.99 X
52305   2 0 3 X 861.23 X
52305   1 0 3 X 871.91 X
52310   3 0 3 X 673.11 X
52310   4 0 3 X 680.78 X
52310   2 0 3 X 698.85 X
52310   1 0 3 X 710.06 X
52315   4 0 3 X 852.06 X
52315   3 0 3 X 872.22 X
52315   2 0 3 X 911.47 X
52315   1 0 3 X 923.31 X
52317   4 0 3 X 1,185.92 X
52317   3 0 3 X 1,200.66 X
52317   2 0 3 X 1,272.18 X
52317   1 0 3 X 1,289.45 X
52318   4 0 3 X 1,568.60 X
52318   3 0 3 X 1,587.82 X
52318   2 0 3 X 1,680.97 X
52318   1 0 3 X 1,703.44 X
52320   4 0 3 X 879.90 X
52320   2 0 3 X 946.23 X
52320   3 0 3 X 974.66 X
52320   1 0 3 X 1,005.99 X
52325   4 0 3 X 1,214.50 X
52325   3 0 3 X 1,229.92 X
52325   2 0 3 X 1,308.17 X
52325   1 0 3 X 1,327.06 X
52327   4 0 3 X 864.48 X
52327   3 0 3 X 876.17 X
52327   2 0 3 X 925.49 X
52327   1 0 3 X 948.24 X
52330   4 0 3 X 780.93 X
52330   2 0 3 X 879.25 X
52330   3 0 3 X 920.76 X
52330   1 0 3 X 957.55 X
52332   4 0 3 X 642.62 X
52332   3 0 3 X 652.68 X
52332   2 0 3 X 666.58 X
52332   1 0 3 X 670.77 X
52334   4 0 3 X 930.82 X
52334   2 0 3 X 937.32 X
52334   3 0 3 X 945.68 X
52334   1 0 3 X 993.29 X
52341   2 0 3 X 638.44 X
52341   3 0 3 X 638.44 X
52341   4 0 3 X 638.44 X
52341   1 0 3 X 698.70 X
52342   2 0 3 X 691.19 X
52342   3 0 3 X 691.19 X
52342   4 0 3 X 691.19 X
52342   1 0 3 X 756.08 X
52343   2 0 3 X 765.64 X
52343   3 0 3 X 765.64 X
52343   4 0 3 X 765.64 X
52343   1 0 3 X 837.63 X
52344   2 0 3 X 818.42 X
52344   3 0 3 X 818.42 X
52344   4 0 3 X 818.42 X
52344   1 0 3 X 895.01 X
52345   2 0 3 X 872.24 X
52345   3 0 3 X 872.24 X
52345   4 0 3 X 872.24 X
52345   1 0 3 X 954.39 X
52346   2 0 3 X 981.25 X
52346   3 0 3 X 981.25 X
52346   4 0 3 X 981.25 X
52346   1 0 3 X 1,073.36 X
52351   2 0 2 X 650.85 X
52351   3 0 2 X 650.85 X
52351   4 0 2 X 650.85 X
52351   1 0 2 X 713.99 X
52352   2 0 3 X 804.14 X
52352   3 0 3 X 804.14 X
52352   4 0 3 X 804.14 X
52352   1 0 3 X 885.28 X
52353   2 0 3 X 931.59 X
52353   3 0 3 X 931.59 X
52353   4 0 3 X 931.59 X
52353   1 0 3 X 1,025.60 X
52354   2 0 3 X 816.28 X
52354   3 0 3 X 816.28 X
52354   4 0 3 X 816.28 X
52354   1 0 3 X 895.86 X
52355   2 0 3 X 959.10 X
52355   3 0 3 X 959.10 X
52355   4 0 3 X 959.10 X
52355   1 0 3 X 1,051.27 X
52356   2 0 3 X 570.86 X
52356   3 0 3 X 570.86 X
52356   4 0 3 X 570.86 X
52356   1 0 3 X 615.11 X
52400   2 90 2 X 1,138.33 X
52400   3 90 2 X 1,138.33 X
52400   4 90 2 X 1,138.33 X
52400   1 90 2 X 1,253.56 X
52402   2 0 3 X 483.56 X
52402   3 0 3 X 483.56 X
52402   4 0 3 X 483.56 X
52402   1 0 3 X 527.30 X
52441   2 0 3 X 1,587.86 318.60
52441   3 0 3 X 1,587.86 318.60
52441   4 0 3 X 1,587.86 318.60
52441   1 0 3 X 1,829.43 344.30
52442   2 ZZZ 0 X 1,226.20 110.25
52442   3 ZZZ 0 X 1,226.20 110.25
52442   4 ZZZ 0 X 1,226.20 110.25
52442   1 ZZZ 0 X 1,429.91 124.17
52450   4 90 2 X 1,104.82 X
52450   3 90 2 X 1,117.99 X
52450   2 90 2 X 1,180.00 X
52450   1 90 2 X 1,194.97 X
52500   4 90 2 X 1,479.16 X
52500   3 90 2 X 1,493.05 X
52500   1 90 2 X 1,527.51 X
52500   2 90 2 X 1,568.82 X
52601   4 90 2 X 2,258.33 X
52601   3 90 2 X 2,291.10 X
52601   2 90 2 X 2,415.44 X
52601   1 90 2 X 2,448.05 X
52630   4 90 2 X 1,998.50 X
52630   3 90 2 X 2,053.49 X
52630   2 90 2 X 2,108.25 X
52630   1 90 2 X 2,120.05 X
52640   4 90 2 X 1,355.99 X
52640   3 90 2 X 1,362.05 X
52640   2 90 2 X 1,392.48 X
52640   1 90 2 X 1,399.87 X
52647   4 90 2 X 2,258.33 X
52647   3 90 2 X 2,291.10 X
52647   2 90 2 X 2,415.44 X
52647   1 90 2 X 2,448.05 X
52648   4 90 2 X 2,258.33 X
52648   3 90 2 X 2,291.10 X
52648   2 90 2 X 2,415.44 X
52648   1 90 2 X 2,448.05 X
52649   2 90 2 X 1,487.19 X
52649   3 90 2 X 1,487.19 X
52649   4 90 2 X 1,487.19 X
52649   1 90 2 X 1,644.46 X
52700   3 90 2 X 889.36 X
52700   4 90 2 X 922.92 X
52700   2 90 2 X 960.80 X
52700   1 90 2 X 989.28 X
53000   4 10 2 X 345.93 X
53000   3 10 2 X 358.70 X
53000   2 10 2 X 379.29 X
53000   1 10 2 X 395.38 X
53010   4 90 2 X 604.96 X
53010   1 90 2 X 662.46 X
53010   3 90 2 X 726.80 X
53010   2 90 2 X 764.03 X
53020   4 0 2 X 237.18 X
53020   2 0 2 X 251.65 X
53020   3 0 2 X 257.12 X
53020   1 0 2 X 257.60 X
53025   4 0 2 X 176.91 X
53025   3 0 2 X 178.95 X
53025   2 0 2 X 188.95 X
53025   1 0 2 X 191.31 X
53040   2 90 2 X 670.83 X
53040   3 90 2 X 694.51 X
53040   4 90 2 X 714.85 X
53040   1 90 2 X 716.33 X
53060   2 10 2 X 269.16 X
53060   4 10 2 X 281.90 X
53060   3 10 2 X 284.84 X
53060   1 10 2 X 298.80 X
53080   4 90 2 X 907.61 X
53080   3 90 2 X 918.34 X
53080   2 90 2 X 970.43 X
53080   1 90 2 X 982.98 X
53085   4 90 2 X 1,509.41 X
53085   3 90 2 X 1,527.40 X
53085   2 90 2 X 1,612.88 X
53085   1 90 2 X 1,633.60 X
53200   4 0 2 X 337.22 X
53200   3 0 2 X 340.94 X
53200   2 0 2 X 357.28 X
53200   1 0 2 X 361.25 X
53210   3 90 2 X 1,596.83 X
53210   4 90 2 X 1,679.39 X
53210   1 90 2 X 1,681.60 X
53210   2 90 2 X 1,698.80 X
53215   4 90 2 X 2,251.26 X
53215   3 90 2 X 2,278.05 X
53215   2 90 2 X 2,401.86 X
53215   1 90 2 X 2,431.81 X
53220   4 90 2 X 1,042.74 X
53220   3 90 2 X 1,055.23 X
53220   2 90 2 X 1,114.97 X
53220   1 90 2 X 1,129.42 X
53230   4 90 2 X 1,561.30 X
53230   3 90 2 X 1,580.49 X
53230   2 90 2 X 1,674.39 X
53230   1 90 2 X 1,697.03 X
53235   3 90 2 X 1,179.08 X
53235   2 90 2 X 1,216.59 X
53235   4 90 2 X 1,250.68 X
53235   1 90 2 X 1,343.88 X
53240   2 90 2 X 867.89 X
53240   1 90 2 X 887.18 X
53240   4 90 2 X 952.23 X
53240   3 90 2 X 963.64 X
53250   3 90 2 X 597.19 X
53250   4 90 2 X 892.15 X
53250   2 90 2 X 952.83 X
53250   1 90 2 X 964.80 X
53260   2 10 2 X 417.92 X
53260   3 10 2 X 432.19 X
53260   4 10 2 X 434.44 X
53260   1 10 2 X 446.12 X
53265   1 10 2 X 542.23 X
53265   4 10 2 X 563.67 X
53265   3 10 2 X 585.70 X
53265   2 10 2 X 625.20 X
53270   3 10 2 X 287.17 X
53270   4 10 2 X 350.76 X
53270   2 10 2 X 372.65 X
53270   1 10 2 X 377.11 X
53275   4 10 2 X 617.75 X
53275   3 10 2 X 624.85 X
53275   1 10 2 X 646.65 X
53275   2 10 2 X 652.79 X
53400   4 90 2 X 1,765.63 X
53400   3 90 2 X 1,786.41 X
53400   2 90 2 X 1,882.75 X
53400   1 90 2 X 1,906.08 X
53405   4 90 2 X 2,226.81 X
53405   3 90 2 X 2,253.43 X
53405   2 90 2 X 2,387.66 X
53405   1 90 2 X 2,420.10 X
53410   4 90 2 X 2,207.48 X
53410   3 90 2 X 2,233.03 X
53410   2 90 2 X 2,346.72 X
53410   1 90 2 X 2,374.27 X
53415   3 90 2 X 2,649.30 X
53415   2 90 2 X 2,734.97 X
53415   4 90 2 X 2,779.66 X
53415   1 90 2 X 2,998.68 X
53420   4 90 2 X 1,262.46 X
53420   2 90 2 X 1,373.59 X
53420   1 90 2 X 1,395.02 X
53420   3 90 2 X 2,244.41 X
53425   4 90 2 X 2,233.04 X
53425   3 90 2 X 2,259.27 X
53425   2 90 2 X 2,377.20 X
53425   1 90 2 X 2,405.73 X
53430   4 90 2 X 2,075.81 X
53430   3 90 2 X 2,099.20 X
53430   2 90 2 X 2,202.29 X
53430   1 90 2 X 2,227.28 X
53431   2 90 2 X 1,958.40 X
53431   3 90 2 X 1,958.40 X
53431   4 90 2 X 1,958.40 X
53431   1 90 2 X 2,151.99 X
53440   3 90 2 X 2,310.76 X
53440   4 90 2 X 2,429.75 X
53440   2 90 2 X 2,545.03 X
53440   1 90 2 X 2,623.51 X
53442   4 90 2 X 1,248.75 X
53442   3 90 2 X 1,263.70 X
53442   2 90 2 X 1,338.91 X
53442   1 90 2 X 1,357.02 X
53444   2 90 2 X 1,401.66 X
53444   3 90 2 X 1,401.66 X
53444   4 90 2 X 1,401.66 X
53444   1 90 2 X 1,544.70 X
53445   4 90 2 X 2,959.53 X
53445   3 90 2 X 2,997.90 X
53445   2 90 2 X 3,207.80 X
53445   1 90 2 X 3,258.28 X
53446   2 90 2 X 1,289.67 X
53446   3 90 2 X 1,289.67 X
53446   4 90 2 X 1,289.67 X
53446   1 90 2 X 1,437.69 X
53447   4 90 2 X 1,974.26 X
53447   3 90 2 X 1,998.03 X
53447   2 90 2 X 2,109.71 X
53447   1 90 2 X 2,136.74 X
53448   2 90 2 X 2,332.97 X
53448   3 90 2 X 2,332.97 X
53448   4 90 2 X 2,332.97 X
53448   1 90 2 X 2,580.71 X
53449   4 90 2 X 1,615.22 X
53449   3 90 2 X 1,635.23 X
53449   2 90 2 X 1,648.84 X
53449   1 90 2 X 1,756.69 X
53450   3 90 2 X 780.34 X
53450   4 90 2 X 797.41 X
53450   2 90 2 X 818.22 X
53450   1 90 2 X 827.37 X
53460   4 90 2 X 832.19 X
53460   3 90 2 X 836.05 X
53460   2 90 2 X 879.10 X
53460   1 90 2 X 888.28 X
53500   2 90 2 X 1,289.51 X
53500   3 90 2 X 1,289.51 X
53500   4 90 2 X 1,289.51 X
53500   1 90 2 X 1,416.28 X
53502   4 90 2 X 1,123.58 X
53502   3 90 2 X 1,136.91 X
53502   2 90 2 X 1,202.02 X
53502   1 90 2 X 1,332.08 X
53505   3 90 2 X 1,150.50 X
53505   2 90 2 X 1,214.60 X
53505   1 90 2 X 1,230.12 X
53505   4 90 2 X 1,244.43 X
53510   4 90 2 X 1,516.38 X
53510   3 90 2 X 1,534.59 X
53510   2 90 2 X 1,619.46 X
53510   1 90 2 X 1,639.86 X