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2021 Workers' Compensation Part B Fee Schedule

53515-55520

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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
53515   4 90 2 X 1,992.60 X
53515   3 90 2 X 2,016.40 X
53515   2 90 2 X 2,127.83 X
53515   1 90 2 X 2,154.68 X
53520   1 90 2 X 844.31 X
53520   3 90 2 X 1,159.47 X
53520   4 90 2 X 1,199.84 X
53520   2 90 2 X 1,262.45 X
53600   3 0 2 X 110.38 99.23
53600   4 0 2 X 110.89 99.60
53600   2 0 2 X 124.14 111.75
53600   1 0 2 X 127.20 114.13
53601   3 0 2 X 96.45 86.23
53601   4 0 2 X 98.72 88.01
53601   2 0 2 X 113.74 101.29
53601   1 0 2 X 115.31 102.81
53605   3 0 2 X 122.38 X
53605   2 0 2 X 137.40 X
53605   1 0 2 X 142.75 X
53605   4 0 2 X 158.72 X
53620   4 0 2 X 139.91 125.02
53620   3 0 2 X 149.95 134.22
53620   1 0 2 X 153.44 136.22
53620   2 0 2 X 160.41 143.25
53621   3 0 2 X 119.36 106.91
53621   4 0 2 X 119.81 107.33
53621   2 0 2 X 138.47 124.09
53621   1 0 2 X 140.65 125.94
53660   4 0 2 X 82.92 72.06
53660   3 0 2 X 83.53 72.29
53660   2 0 2 X 95.78 83.20
53660   1 0 2 X 96.97 84.06
53661   3 0 2 X 81.32 71.59
53661   4 0 2 X 81.42 71.65
53661   2 0 2 X 93.67 82.31
53661   1 0 2 X 94.65 83.18
53665   3 0 2 X 89.42 X
53665   4 0 2 X 102.37 X
53665   1 0 2 X 106.79 X
53665   2 0 2 X 107.56 X
53850   2 90 2 X 1,275.48 X
53850   3 90 2 X 1,275.48 X
53850   4 90 2 X 1,275.48 X
53850   1 90 2 X 1,423.39 X
53852   2 90 2 X 1,333.09 X
53852   3 90 2 X 1,333.09 X
53852   4 90 2 X 1,333.09 X
53852   1 90 2 X 1,487.62 X
53854   2 90 2 X 2,094.31 453.22
53854   3 90 2 X 2,094.31 453.22
53854   4 90 2 X 2,094.31 453.22
53854   1 90 2 X 2,377.11 494.05
53855   2 0 2 X 918.00 122.51
53855   3 0 2 X 918.00 122.51
53855   4 0 2 X 918.00 122.51
53855   1 0 2 X 1,076.23 132.85
53860   2 90 2 X 2,095.74 346.78
53860   3 90 2 X 2,095.74 346.78
53860   4 90 2 X 2,095.74 346.78
53860   1 90 2 X 2,360.82 381.83
53899     YYY 2 X # X
54000     10 2 X * X
54001   4 10 2 X 266.04 X
54001   3 10 2 X 271.10 X
54001   2 10 2 X 280.29 X
54001   1 10 2 X 288.78 X
54015   2 10 2 X 432.82 X
54015   1 10 2 X 441.73 X
54015   4 10 2 X 542.42 X
54015   3 10 2 X 547.88 X
54050   2 10 2 X 118.00 X
54050   3 10 2 X 121.32 X
54050   4 10 2 X 122.66 X
54050   1 10 2 X 128.24 X
54055   4 10 2 X 164.36 X
54055   3 10 2 X 167.00 X
54055   2 10 2 X 169.28 X
54055   1 10 2 X 176.50 X
54056   3 10 2 X 141.33 X
54056   1 10 2 X 155.18 X
54056   4 10 2 X 155.77 X
54056   2 10 2 X 158.54 X
54057   3 10 2 X 243.32 X
54057   2 10 2 X 251.90 X
54057   1 10 2 X 259.21 X
54057   4 10 2 X 280.96 X
54060   4 10 2 X 256.52 X
54060   3 10 2 X 262.48 X
54060   2 10 2 X 271.46 X
54060   1 10 2 X 274.79 X
54065   4 10 2 X 446.88 X
54065   1 10 2 X 487.62 X
54065   3 10 2 X 549.18 X
54065   2 10 2 X 699.31 X
54100   3 0 2 X 200.82 X
54100   2 0 2 X 206.55 X
54100   1 0 2 X 208.28 X
54100   4 0 2 X 232.53 X
54105   3 10 2 X 369.31 X
54105   4 10 2 X 371.51 X
54105   2 10 2 X 383.93 X
54105   1 10 2 X 386.38 X
54110   4 90 2 X 1,438.72 X
54110   3 90 2 X 1,455.58 X
54110   2 90 2 X 1,533.69 X
54110   1 90 2 X 1,552.55 X
54111   4 90 2 X 2,041.76 X
54111   3 90 2 X 2,066.07 X
54111   2 90 2 X 2,182.64 X
54111   1 90 2 X 2,210.79 X
54112   4 90 2 X 2,389.01 X
54112   3 90 2 X 2,417.50 X
54112   2 90 2 X 3,033.19 X
54112   1 90 2 X 3,047.03 X
54115   4 90 2 X 906.68 X
54115   1 90 2 X 982.48 X
54115   3 90 2 X 1,334.50 X
54115   2 90 2 X 1,499.55 X
54120   4 90 2 X 1,438.65 X
54120   3 90 2 X 1,455.85 X
54120   2 90 2 X 1,535.65 X
54120   1 90 2 X 1,554.89 X
54125   3 90 2 X 2,270.67 X
54125   4 90 2 X 2,358.29 X
54125   2 90 2 X 2,407.34 X
54125   1 90 2 X 2,440.28 X
54130   3 90 2 X 3,107.94 X
54130   4 90 2 X 3,130.21 X
54130   2 90 2 X 3,280.27 X
54130   1 90 2 X 3,321.82 X
54135   4 90 2 X 3,920.75 X
54135   3 90 2 X 3,967.57 X
54135   2 90 2 X 4,187.05 X
54135   1 90 2 X 4,240.07 X
54150     10 2 X * X
54160     10 2 X * X
54161   4 10 2 X 493.83 X
54161   3 10 2 X 501.11 X
54161   2 10 2 X 528.87 X
54161   1 10 2 X 535.55 X
54162   2 10 2 X 406.11 X
54162   3 10 2 X 406.11 X
54162   4 10 2 X 406.11 X
54162   1 10 2 X 454.42 X
54163   2 10 2 X 382.11 X
54163   3 10 2 X 382.11 X
54163   4 10 2 X 382.11 X
54163   1 10 2 X 426.21 X
54164   2 10 2 X 334.90 X
54164   3 10 2 X 334.90 X
54164   4 10 2 X 334.90 X
54164   1 10 2 X 374.53 X
54200   2 10 2 X 99.13 X
54200   1 10 2 X 100.11 X
54200   4 10 2 X 120.33 X
54200   3 10 2 X 121.63 X
54205   4 90 2 X 1,129.19 X
54205   3 90 2 X 1,142.67 X
54205   2 90 2 X 1,206.02 X
54205   1 90 2 X 1,221.30 X
54220   4 0 2 X 368.04 X
54220   3 0 2 X 573.34 X
54220   2 0 2 X 645.47 X
54220   1 0 2 X 667.92 X
54230   3 0 2 X 168.79 X
54230   2 0 2 X 178.18 X
54230   1 0 2 X 180.54 X
54230   4 0 2 X 245.72 X
54231   4 0 2 X 389.49 X
54231   3 0 2 X 394.10 X
54231   2 0 2 X 416.12 X
54231   1 0 2 X 421.42 X
54235   3 0 2 X 130.09 114.15
54235   4 0 2 X 133.39 117.02
54235   1 0 2 X 139.24 121.49
54235   2 0 2 X 140.81 123.09
54240 TC 4 0 2 X 46.80 X
54240 TC 3 0 2 X 47.53 X
54240 TC 1 0 2 X 53.75 X
54240 TC 2 0 2 X 63.92 X
54240 26 4 0 2 X 136.81 X
54240 26 3 0 2 X 154.43 X
54240 26 2 0 2 X 163.58 X
54240 26 1 0 2 X 164.80 X
54240   4 0 2 X 204.91 X
54240   3 0 2 X 214.93 X
54240   1 0 2 X 225.87 X
54240   2 0 2 X 226.11 X
54250 TC 4 0 2 X 28.05 X
54250 TC 3 0 2 X 28.48 X
54250 TC 2 0 2 X 31.29 X
54250 TC 1 0 2 X 31.93 X
54250 26 3 0 2 X 192.02 X
54250 26 2 0 2 X 197.59 X
54250   4 0 2 X 206.66 X
54250   3 0 2 X 207.83 X
54250   2 0 2 X 214.43 X
54250   1 0 2 X 217.14 X
54250 26 4 0 2 X 246.42 X
54250 26 1 0 2 X 260.92 X
54300   2 90 2 X 1,042.47 X
54300   1 90 2 X 1,054.26 X
54300   4 90 2 X 1,569.38 X
54300   3 90 2 X 1,587.83 X
54304   4 90 2 X 1,910.74 X
54304   3 90 2 X 1,933.51 X
54304   1 90 2 X 2,068.83 X
54304   2 90 2 X 2,164.57 X
54308   4 90 2 X 1,606.51 X
54308   3 90 2 X 1,624.70 X
54308   2 90 2 X 1,711.42 X
54308   1 90 2 X 1,732.43 X
54312   4 90 2 X 2,064.89 X
54312   3 90 2 X 2,089.52 X
54312   2 90 2 X 2,204.92 X
54312   1 90 2 X 2,232.78 X
54316   4 90 2 X 2,504.87 X
54316   3 90 2 X 2,534.86 X
54316   2 90 2 X 2,675.30 X
54316   1 90 2 X 2,709.22 X
54318   4 90 2 X 1,684.10 X
54318   3 90 2 X 1,703.80 X
54318   2 90 2 X 1,812.03 X
54318   1 90 2 X 1,838.26 X
54322   4 90 2 X 1,825.33 X
54322   3 90 2 X 1,846.81 X
54322   2 90 2 X 1,944.28 X
54322   1 90 2 X 1,967.81 X
54324   4 90 2 X 2,423.84 X
54324   3 90 2 X 2,598.37 X
54324   1 90 2 X 2,621.38 X
54324   2 90 2 X 2,655.37 X
54326   4 90 2 X 2,321.03 X
54326   3 90 2 X 2,348.79 X
54326   2 90 2 X 2,478.65 X
54326   1 90 2 X 2,510.02 X
54328   4 90 2 X 2,356.77 X
54328   3 90 2 X 2,384.78 X
54328   2 90 2 X 2,524.36 X
54328   1 90 2 X 2,558.20 X
54332   4 90 2 X 2,624.18 X
54332   3 90 2 X 2,655.99 X
54332   2 90 2 X 2,803.44 X
54332   1 90 2 X 2,838.90 X
54336   4 90 2 X 3,434.96 X
54336   3 90 2 X 3,478.35 X
54336   2 90 2 X 3,675.74 X
54336   1 90 2 X 3,723.11 X
54340   4 90 2 X 1,340.92 X
54340   3 90 2 X 1,356.93 X
54340   2 90 2 X 1,431.89 X
54340   1 90 2 X 1,450.03 X
54344   4 90 2 X 2,885.56 X
54344   3 90 2 X 2,922.67 X
54344   2 90 2 X 3,087.72 X
54344   1 90 2 X 3,127.31 X
54348   4 90 2 X 2,565.85 X
54348   3 90 2 X 2,596.54 X
54348   2 90 2 X 2,740.12 X
54348   1 90 2 X 2,774.82 X
54352   4 90 2 X 3,659.09 X
54352   3 90 2 X 3,702.67 X
54352   2 90 2 X 3,901.18 X
54352   1 90 2 X 3,949.08 X
54360   4 90 2 X 1,689.37 X
54360   3 90 2 X 1,709.17 X
54360   2 90 2 X 1,801.11 X
54360   1 90 2 X 1,823.33 X
54380   4 90 2 X 2,003.25 X
54380   3 90 2 X 2,027.50 X
54380   2 90 2 X 2,135.27 X
54380   1 90 2 X 2,161.28 X
54385   4 90 2 X 2,298.93 X
54385   3 90 2 X 2,326.59 X
54385   2 90 2 X 2,450.24 X
54385   1 90 2 X 2,480.10 X
54390   4 90 2 X 3,185.61 X
54390   3 90 2 X 3,222.99 X
54390   2 90 2 X 3,405.34 X
54390   1 90 2 X 3,449.48 X
54400   4 90 2 X 2,487.27 X
54400   3 90 2 X 2,497.72 X
54400   2 90 2 X 2,554.28 X
54400   1 90 2 X 2,567.90 X
54401   4 90 2 X 2,690.71 X
54401   3 90 2 X 2,704.07 X
54401   2 90 2 X 2,778.50 X
54401   1 90 2 X 2,796.42 X
54405   4 90 2 X 3,364.10 X
54405   3 90 2 X 3,380.71 X
54405   2 90 2 X 3,472.12 X
54405   1 90 2 X 3,494.03 X
54406   2 90 2 X 1,275.35 X
54406   3 90 2 X 1,275.35 X
54406   4 90 2 X 1,275.35 X
54406   1 90 2 X 1,409.24 X
54408   2 90 2 X 1,344.31 X
54408   3 90 2 X 1,344.31 X
54408   4 90 2 X 1,344.31 X
54408   1 90 2 X 1,483.97 X
54410   2 90 2 X 1,592.88 X
54410   3 90 2 X 1,592.88 X
54410   4 90 2 X 1,592.88 X
54410   1 90 2 X 1,749.30 X
54411   2 90 2 X 1,732.65 X
54411   3 90 2 X 1,732.65 X
54411   4 90 2 X 1,732.65 X
54411   1 90 2 X 1,908.72 X
54415   2 90 2 X 944.11 X
54415   3 90 2 X 944.11 X
54415   4 90 2 X 944.11 X
54415   1 90 2 X 1,049.16 X
54416   2 90 2 X 1,231.95 X
54416   3 90 2 X 1,231.95 X
54416   4 90 2 X 1,231.95 X
54416   1 90 2 X 1,361.45 X
54417   2 90 2 X 1,523.23 X
54417   3 90 2 X 1,523.23 X
54417   4 90 2 X 1,523.23 X
54417   1 90 2 X 1,671.41 X
54420   4 90 2 X 1,705.98 X
54420   3 90 2 X 1,726.29 X
54420   2 90 2 X 1,826.31 X
54420   1 90 2 X 1,850.52 X
54430   4 90 2 X 1,518.12 X
54430   3 90 2 X 1,536.38 X
54430   2 90 2 X 1,622.50 X
54430   1 90 2 X 1,643.23 X
54435   2 90 2 X 802.90 X
54435   4 90 2 X 895.22 X
54435   3 90 2 X 906.05 X
54435   1 90 2 X 968.06 X
54437   2 90 2 X 892.54 X
54437   3 90 2 X 892.54 X
54437   4 90 2 X 892.54 X
54437   1 90 2 X 971.48 X
54438   2 90 2 X 1,804.85 X
54438   3 90 2 X 1,804.85 X
54438   4 90 2 X 1,804.85 X
54438   1 90 2 X 1,958.13 X
54440   4 90 2 X 1,689.37 X
54440   3 90 2 X 1,709.17 X
54440   2 90 2 X 1,801.11 X
54440   1 90 2 X 1,823.33 X
54450   4 0 2 X 164.94 X
54450   3 0 2 X 166.88 X
54450   2 0 2 X 175.71 X
54450   1 0 2 X 177.85 X
54500   2 0 2 X 137.25 X
54500   4 0 2 X 158.82 X
54500   3 0 2 X 160.59 X
54500   1 0 2 X 169.51 X
54505   4 10 2 X 484.95 X
54505   3 10 2 X 490.54 X
54505   2 10 2 X 516.74 X
54505   1 10 2 X 523.13 X
54512   2 90 2 X 1,015.07 X
54512   3 90 2 X 1,015.07 X
54512   4 90 2 X 1,015.07 X
54512   1 90 2 X 1,119.70 X
54520   4 90 2 X 943.76 X
54520   3 90 2 X 955.65 X
54520   2 90 2 X 1,015.80 X
54520   1 90 2 X 1,030.32 X
54522   2 90 2 X 1,153.08 X
54522   3 90 2 X 1,153.08 X
54522   4 90 2 X 1,153.08 X
54522   1 90 2 X 1,274.15 X
54530   4 90 2 X 1,417.45 X
54530   3 90 2 X 1,438.72 X
54530   2 90 2 X 1,502.46 X
54530   1 90 2 X 1,504.38 X
54535   4 90 2 X 1,848.31 X
54535   3 90 2 X 1,870.39 X
54535   2 90 2 X 1,982.22 X
54535   1 90 2 X 2,009.21 X
54550   4 90 2 X 1,165.10 X
54550   3 90 2 X 1,178.93 X
54550   2 90 2 X 1,247.89 X
54550   1 90 2 X 1,264.51 X
54560   4 90 2 X 1,630.91 X
54560   3 90 2 X 1,650.24 X
54560   2 90 2 X 1,744.49 X
54560   1 90 2 X 1,767.28 X
54600   4 90 2 X 1,030.12 X
54600   3 90 2 X 1,042.32 X
54600   2 90 2 X 1,100.89 X
54600   1 90 2 X 1,115.07 X
54620   4 10 2 X 734.55 X
54620   3 10 2 X 743.33 X
54620   2 10 2 X 784.37 X
54620   1 10 2 X 794.30 X
54640   4 90 2 X 1,464.07 X
54640   1 90 2 X 1,471.25 X
54640   3 90 2 X 1,471.25 X
54640   2 90 2 X 1,479.46 X
54650   4 90 2 X 1,593.83 X
54650   3 90 2 X 1,602.17 X
54650   2 90 2 X 1,613.66 X
54650   1 90 2 X 1,880.19 X
54660   4 90 2 X 751.89 X
54660   3 90 2 X 760.89 X
54660   2 90 2 X 803.11 X
54660   1 90 2 X 813.25 X
54670   4 90 2 X 256.18 X
54670   3 90 2 X 258.97 X
54670   2 90 2 X 270.24 X
54670   1 90 2 X 272.92 X
54680   4 90 2 X 1,807.93 X
54680   3 90 2 X 1,829.47 X
54680   2 90 2 X 1,930.64 X
54680   1 90 2 X 1,955.08 X
54690   2 90 2 X 1,369.93 X
54690   3 90 2 X 1,369.93 X
54690   4 90 2 X 1,369.93 X
54690   1 90 2 X 1,515.33 X
54692   2 90 2 X 1,413.56 X
54692   3 90 2 X 1,413.56 X
54692   4 90 2 X 1,413.56 X
54692   1 90 2 X 1,553.27 X
54699     YYY 2 X # X
54700   3 10 2 X 337.14 X
54700   4 10 2 X 337.32 X
54700   2 10 2 X 345.81 X
54700   1 10 2 X 349.13 X
54800   4 0 2 X 394.78 X
54800   3 0 2 X 399.66 X
54800   2 0 2 X 422.78 X
54800   1 0 2 X 428.36 X
54830   3 90 2 X 799.93 X
54830   4 90 2 X 809.01 X
54830   2 90 2 X 845.37 X
54830   1 90 2 X 856.33 X
54840   4 90 2 X 923.76 X
54840   2 90 2 X 975.07 X
54840   3 90 2 X 984.09 X
54840   1 90 2 X 1,018.23 X
54860   4 90 2 X 1,064.64 X
54860   2 90 2 X 1,101.35 X
54860   3 90 2 X 1,104.20 X
54860   1 90 2 X 1,153.61 X
54861   4 90 2 X 1,455.62 X
54861   3 90 2 X 1,473.46 X
54861   2 90 2 X 1,560.14 X
54861   1 90 2 X 1,581.02 X
54865   2 90 2 X 492.73 X
54865   3 90 2 X 492.73 X
54865   4 90 2 X 492.73 X
54865   1 90 2 X 552.66 X
54900   4 90 2 X 1,976.02 X
54900   3 90 2 X 1,999.67 X
54900   2 90 2 X 2,110.04 X
54900   1 90 2 X 2,136.70 X
54901   4 90 2 X 2,712.19 X
54901   3 90 2 X 2,744.62 X
54901   2 90 2 X 2,896.20 X
54901   1 90 2 X 2,932.86 X
55000   4 0 2 X 158.27 141.84
55000   3 0 2 X 163.02 146.29
55000   1 0 2 X 175.71 157.42
55000   2 0 2 X 176.19 157.56
55040   4 90 2 X 929.60 X
55040   3 90 2 X 987.49 X
55040   2 90 2 X 1,000.71 X
55040   1 90 2 X 1,029.19 X
55041   3 90 2 X 1,429.45 X
55041   4 90 2 X 1,439.86 X
55041   1 90 2 X 1,501.43 X
55041   2 90 2 X 1,501.67 X
55060   4 90 2 X 933.08 X
55060   3 90 2 X 941.66 X
55060   2 90 2 X 960.45 X
55060   1 90 2 X 969.80 X
55100   4 10 2 X 188.21 X
55100   3 10 2 X 189.78 X
55100   2 10 2 X 195.37 X
55100   1 10 2 X 197.29 X
55110   3 90 2 X 739.72 X
55110   2 90 2 X 765.45 X
55110   1 90 2 X 771.66 X
55110   4 90 2 X 804.91 X
55120   4 90 2 X 534.67 X
55120   3 90 2 X 543.46 X
55120   2 90 2 X 635.66 X
55120   1 90 2 X 642.62 X
55150   4 90 2 X 1,111.85 X
55150   3 90 2 X 1,125.36 X
55150   2 90 2 X 1,192.05 X
55150   1 90 2 X 1,208.10 X
55175   4 90 2 X 869.94 X
55175   3 90 2 X 880.62 X
55175   2 90 2 X 929.27 X
55175   1 90 2 X 947.99 X
55180   2 90 2 X 1,483.30 X
55180   1 90 2 X 1,496.03 X
55180   4 90 2 X 1,562.47 X
55180   3 90 2 X 1,580.84 X
55200   4 90 2 X 558.14 X
55200   3 90 2 X 564.49 X
55200   2 90 2 X 592.05 X
55200   1 90 2 X 598.70 X
55250   3 90 2 X 648.22 X
55250   4 90 2 X 650.38 X
55250   1 90 2 X 681.53 X
55250   2 90 2 X 691.05 X
55300   4 0 2 X 571.02 X
55300   3 0 2 X 577.93 X
55300   2 0 2 X 610.83 X
55300   1 0 2 X 618.75 X
55400   4 90 2 X 1,357.53 X
55400   3 90 2 X 1,373.98 X
55400   2 90 2 X 1,452.02 X
55400   1 90 2 X 1,470.86 X
55500   4 90 2 X 878.32 X
55500   3 90 2 X 881.68 X
55500   2 90 2 X 930.58 X
55500   1 90 2 X 938.29 X
55520   4 90 2 X 826.14 X
55520   3 90 2 X 835.40 X
55520   2 90 2 X 885.57 X
55520   1 90 2 X 897.78 X