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2021 Workers' Compensation Part B Fee Schedule

55530-57511

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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
55530   4 90 2 X 988.64 X
55530   3 90 2 X 1,000.83 X
55530   2 90 2 X 1,064.88 X
55530   1 90 2 X 1,080.36 X
55535   4 90 2 X 977.66 X
55535   2 90 2 X 1,044.39 X
55535   1 90 2 X 1,057.77 X
55535   3 90 2 X 1,074.38 X
55540   1 90 2 X 1,230.29 X
55540   3 90 2 X 1,459.12 X
55540   4 90 2 X 1,485.56 X
55540   2 90 2 X 1,533.39 X
55550   2 90 2 X 806.62 X
55550   3 90 2 X 806.62 X
55550   4 90 2 X 806.62 X
55550   1 90 2 X 891.18 X
55559     YYY 2 X # X
55600   4 90 2 X 963.96 X
55600   3 90 2 X 975.36 X
55600   2 90 2 X 1,034.13 X
55600   1 90 2 X 1,048.38 X
55605   4 90 2 X 1,214.20 X
55605   3 90 2 X 1,228.72 X
55605   2 90 2 X 1,299.14 X
55605   1 90 2 X 1,316.16 X
55650   4 90 2 X 1,697.41 X
55650   2 90 2 X 1,811.36 X
55650   1 90 2 X 1,834.03 X
55650   3 90 2 X 2,028.60 X
55680   4 90 2 X 845.21 X
55680   3 90 2 X 855.75 X
55680   2 90 2 X 904.92 X
55680   1 90 2 X 916.78 X
55700   4 0 2 X 339.63 X
55700   3 0 2 X 341.13 X
55700   2 0 2 X 412.62 X
55700   1 0 2 X 421.94 X
55705   3 10 2 X 906.79 X
55705   4 10 2 X 917.98 X
55705   2 10 2 X 1,005.96 X
55705   1 10 2 X 1,010.09 X
55706   2 10 2 X 585.88 X
55706   3 10 2 X 585.88 X
55706   4 10 2 X 585.88 X
55706   1 10 2 X 644.41 X
55720   4 90 2 X 1,009.79 X
55720   3 90 2 X 1,021.21 X
55720   2 90 2 X 1,071.24 X
55720   1 90 2 X 1,083.36 X
55725   3 90 2 X 1,235.85 X
55725   2 90 2 X 1,304.52 X
55725   1 90 2 X 1,321.12 X
55725   4 90 2 X 1,433.11 X
55801   4 90 2 X 2,680.31 X
55801   3 90 2 X 2,712.57 X
55801   2 90 2 X 2,874.54 X
55801   1 90 2 X 2,913.72 X
55810   4 90 2 X 3,593.57 X
55810   3 90 2 X 3,819.78 X
55810   1 90 2 X 3,901.86 X
55810   2 90 2 X 3,909.19 X
55812   4 90 2 X 3,990.49 X
55812   3 90 2 X 4,037.74 X
55812   2 90 2 X 4,266.59 X
55812   1 90 2 X 4,321.94 X
55815   4 90 2 X 4,930.19 X
55815   3 90 2 X 4,990.81 X
55815   2 90 2 X 5,284.92 X
55815   1 90 2 X 5,355.68 X
55821   3 90 2 X 2,481.12 X
55821   4 90 2 X 2,500.10 X
55821   2 90 2 X 2,636.14 X
55821   1 90 2 X 2,673.40 X
55831   4 90 2 X 2,659.37 X
55831   3 90 2 X 2,692.62 X
55831   2 90 2 X 2,859.65 X
55831   1 90 2 X 2,899.89 X
55840   4 90 2 X 3,469.28 X
55840   3 90 2 X 3,511.28 X
55840   2 90 2 X 3,711.07 X
55840   1 90 2 X 3,759.25 X
55842   4 90 2 X 4,150.35 X
55842   3 90 2 X 4,170.07 X
55842   2 90 2 X 4,265.50 X
55842   1 90 2 X 4,288.58 X
55845   4 90 2 X 4,859.15 X
55845   3 90 2 X 4,888.24 X
55845   2 90 2 X 5,116.90 X
55845   1 90 2 X 5,186.89 X
55860   4 90 2 X 1,869.91 X
55860   3 90 2 X 1,891.52 X
55860   2 90 2 X 1,987.03 X
55860   1 90 2 X 2,010.15 X
55862   4 90 2 X 2,641.99 X
55862   3 90 2 X 2,673.38 X
55862   2 90 2 X 2,821.37 X
55862   1 90 2 X 2,857.20 X
55865   4 90 2 X 4,256.67 X
55865   3 90 2 X 4,310.69 X
55865   2 90 2 X 4,594.21 X
55865   1 90 2 X 4,632.13 X
55866   2 90 2 X 2,953.99 X
55866   3 90 2 X 2,953.99 X
55866   4 90 2 X 2,953.99 X
55866   1 90 2 X 3,221.58 X
55870     0 2 X * X
55873   2 90 2 X 2,108.78 X
55873   3 90 2 X 2,108.78 X
55873   4 90 2 X 2,108.78 X
55873   1 90 2 X 2,324.57 X
55874   2 0 2 X 4,441.26 212.45
55874   3 0 2 X 4,441.26 212.45
55874   4 0 2 X 4,441.26 212.45
55874   1 0 2 X 5,082.40 230.11
55875   2 90 2 X 1,082.65 X
55875   3 90 2 X 1,082.65 X
55875   4 90 2 X 1,082.65 X
55875   1 90 2 X 1,205.63 X
55876   2 0 2 X 213.25 159.36
55876   3 0 2 X 213.25 159.36
55876   4 0 2 X 213.25 159.36
55876   1 0 2 X 249.22 183.29
55880   2 90 2 X 1,096.21 X
55880   3 90 2 X 1,096.21 X
55880   4 90 2 X 1,096.21 X
55880   1 90 2 X 1,186.91 X
55899     YYY 2 X # X
55920   2 0 2 X 647.09 X
55920   3 0 2 X 647.09 X
55920   4 0 2 X 647.09 X
55920   1 0 2 X 709.10 X
56405   1 10 2 X 267.32 X
56405   4 10 2 X 269.31 X
56405   3 10 2 X 271.11 X
56405   2 10 2 X 274.40 X
56420   4 10 2 X 237.82 X
56420   3 10 2 X 250.68 X
56420   2 10 2 X 252.89 X
56420   1 10 2 X 258.71 X
56440   4 10 2 X 522.82 X
56440   3 10 2 X 529.00 X
56440   2 10 2 X 570.67 X
56440   1 10 2 X 580.73 X
56441   4 10 2 X 340.36 X
56441   3 10 2 X 344.39 X
56441   2 10 2 X 369.51 X
56441   1 10 2 X 375.64 X
56442   2 0 2 X 66.66 X
56442   3 0 2 X 66.66 X
56442   4 0 2 X 66.66 X
56442   1 0 2 X 76.30 X
56501   3 10 2 X 223.45 195.66
56501   4 10 2 X 239.16 210.06
56501   1 10 2 X 278.08 242.96
56501   2 10 2 X 280.99 246.33
56515   4 10 2 X 653.03 X
56515   3 10 2 X 852.71 X
56515   2 10 2 X 865.48 X
56515   1 10 2 X 876.92 X
56605   4 0 2 X 210.95 X
56605   3 0 2 X 220.20 X
56605   1 0 2 X 261.75 X
56605   2 0 2 X 268.42 X
56606   4 0 0 X 74.94 X
56606   3 0 0 X 75.88 X
56606   2 0 0 X 81.83 X
56606   1 0 0 X 83.28 X
56620   3 90 2 X 1,315.35 X
56620   4 90 2 X 1,322.15 X
56620   2 90 2 X 1,389.41 X
56620   1 90 2 X 1,437.41 X
56625   4 90 2 X 1,674.89 X
56625   3 90 2 X 1,695.05 X
56625   2 90 2 X 1,849.44 X
56625   1 90 2 X 1,979.19 X
56630   4 90 2 X 2,496.49 X
56630   3 90 2 X 3,772.66 X
56630   2 90 2 X 3,872.54 X
56630   1 90 2 X 3,885.84 X
56631   4 90 2 X 3,406.59 X
56631   3 90 2 X 3,447.74 X
56631   2 90 2 X 3,770.12 X
56631   1 90 2 X 3,848.28 X
56632   4 90 2 X 3,727.32 X
56632   3 90 2 X 3,772.53 X
56632   2 90 2 X 4,107.66 X
56632   1 90 2 X 4,188.92 X
56633   4 90 2 X 2,783.96 X
56633   3 90 2 X 3,896.41 X
56633   2 90 2 X 4,000.64 X
56633   1 90 2 X 4,014.94 X
56634   4 90 2 X 3,710.92 X
56634   3 90 2 X 3,755.91 X
56634   2 90 2 X 4,090.37 X
56634   1 90 2 X 4,171.35 X
56637   4 90 2 X 3,912.42 X
56637   3 90 2 X 3,959.46 X
56637   2 90 2 X 4,299.42 X
56637   1 90 2 X 4,381.83 X
56640   4 90 2 X 3,904.29 X
56640   3 90 2 X 3,950.35 X
56640   2 90 2 X 4,279.79 X
56640   1 90 2 X 4,359.70 X
56700   4 10 2 X 404.49 X
56700   3 10 2 X 409.15 X
56700   2 10 2 X 438.36 X
56700   1 10 2 X 445.42 X
56740   3 10 2 X 625.82 X
56740   4 10 2 X 636.66 X
56740   1 10 2 X 682.84 X
56740   2 10 2 X 691.26 X
56800   4 10 2 X 636.18 X
56800   1 10 2 X 702.29 X
56800   3 10 2 X 773.52 X
56800   2 10 2 X 799.30 X
56805   4 90 2 X 2,519.36 X
56805   3 90 2 X 2,549.63 X
56805   2 90 2 X 2,701.80 X
56805   1 90 2 X 2,738.56 X
56810   3 10 2 X 735.33 X
56810   4 10 2 X 744.61 X
56810   2 10 2 X 759.84 X
56810   1 10 2 X 778.13 X
56820   2 10 2 X 214.83 150.76
56820   3 10 2 X 214.83 150.76
56820   4 10 2 X 214.83 150.76
56820   1 10 2 X 241.43 166.15
56821   2 0 2 X 278.88 207.74
56821   3 0 2 X 278.88 207.74
56821   4 0 2 X 278.88 207.74
56821   1 0 2 X 312.46 228.81
57000   3 10 2 X 299.06 X
57000   4 10 2 X 466.65 X
57000   2 10 2 X 551.14 X
57000   1 10 2 X 594.45 X
57010   4 90 2 X 758.83 X
57010   3 90 2 X 767.17 X
57010   1 90 2 X 814.38 X
57010   2 90 2 X 816.25 X
57020   4 0 2 X 203.27 X
57020   3 0 2 X 205.53 X
57020   2 0 2 X 217.91 X
57020   1 0 2 X 221.02 X
57022   2 10 2 X 312.81 X
57022   3 10 2 X 312.81 X
57022   4 10 2 X 312.81 X
57022   1 10 2 X 345.24 X
57023   2 10 2 X 312.81 X
57023   3 10 2 X 312.81 X
57023   4 10 2 X 312.81 X
57023   1 10 2 X 345.24 X
57061   4 10 2 X 266.96 X
57061   2 10 2 X 276.80 X
57061   3 10 2 X 277.98 X
57061   1 10 2 X 285.24 X
57065   4 10 2 X 897.16 X
57065   3 10 2 X 900.09 X
57065   2 10 2 X 922.59 X
57065   1 10 2 X 928.08 X
57100   4 0 2 X 261.76 215.35
57100   3 0 2 X 269.55 222.10
57100   2 0 2 X 271.24 223.95
57100   1 0 2 X 271.70 224.00
57105   3 10 2 X 334.32 X
57105   4 10 2 X 337.72 X
57105   2 10 2 X 349.35 X
57105   1 10 2 X 355.11 X
57106   2 90 2 X 688.54 X
57106   3 90 2 X 688.54 X
57106   4 90 2 X 688.54 X
57106   1 90 2 X 771.58 X
57107   2 90 2 X 2,371.23 2,358.56
57107   3 90 2 X 2,371.23 2,358.56
57107   4 90 2 X 2,371.23 2,358.56
57107   1 90 2 X 2,572.93 2,558.15
57109   2 90 2 X 2,850.93 2,820.00
57109   3 90 2 X 2,850.93 2,820.00
57109   4 90 2 X 2,850.93 2,820.00
57109   1 90 2 X 3,169.62 3,133.44
57110   4 90 2 X 1,915.94 X
57110   3 90 2 X 1,925.55 X
57110   2 90 2 X 1,986.06 X
57110   1 90 2 X 2,000.74 X
57111   2 90 2 X 2,824.89 2,873.41
57111   3 90 2 X 2,824.89 2,873.41
57111   4 90 2 X 2,824.89 2,873.41
57111   1 90 2 X 3,139.20 3,195.94
57120   4 90 2 X 1,338.75 X
57120   2 90 2 X 1,468.80 X
57120   1 90 2 X 1,496.44 X
57120   3 90 2 X 1,570.54 X
57130   4 10 2 X 490.06 X
57130   3 10 2 X 495.93 X
57130   1 10 2 X 548.06 X
57130   2 10 2 X 556.46 X
57135   4 10 2 X 435.98 X
57135   3 10 2 X 441.07 X
57135   2 10 2 X 472.49 X
57135   1 10 2 X 489.65 X
57150   4 0 2 X 104.02 95.94
57150   3 0 2 X 104.99 96.82
57150   2 0 2 X 109.67 101.11
57150   1 0 2 X 110.90 102.15
57155   2 90 2 X 705.88 X
57155   3 90 2 X 705.88 X
57155   4 90 2 X 705.88 X
57155   1 90 2 X 790.77 X
57156   2 0 2 X 218.84 151.49
57156   3 0 2 X 218.84 151.49
57156   4 0 2 X 218.84 151.49
57156   1 0 2 X 239.63 163.40
57160   3 0 2 X 96.86 87.08
57160   4 0 2 X 98.39 88.68
57160   2 0 2 X 104.05 93.36
57160   1 0 2 X 104.91 94.44
57170     0 2 X * X
57180   4 10 2 X 192.09 X
57180   3 10 2 X 193.34 X
57180   2 10 2 X 199.57 X
57180   1 10 2 X 201.01 X
57200   3 90 2 X 632.78 X
57200   4 90 2 X 636.67 X
57200   2 90 2 X 670.98 X
57200   1 90 2 X 682.50 X
57210   3 90 2 X 827.61 X
57210   4 90 2 X 836.34 X
57210   2 90 2 X 867.13 X
57210   1 90 2 X 901.63 X
57220   4 90 2 X 799.46 X
57220   2 90 2 X 874.13 X
57220   1 90 2 X 908.20 X
57220   3 90 2 X 911.03 X
57230   4 90 2 X 841.80 X
57230   2 90 2 X 909.49 X
57230   3 90 2 X 912.19 X
57230   1 90 2 X 923.56 X
57240   4 90 2 X 1,234.67 X
57240   3 90 2 X 1,249.57 X
57240   2 90 2 X 1,364.91 X
57240   1 90 2 X 1,392.88 X
57250   4 90 2 X 1,207.19 X
57250   3 90 2 X 1,221.69 X
57250   2 90 2 X 1,340.02 X
57250   1 90 2 X 1,461.24 X
57260   3 90 2 X 1,610.38 X
57260   4 90 2 X 1,682.77 X
57260   2 90 2 X 1,783.27 X
57260   1 90 2 X 1,784.17 X
57265   4 90 2 X 1,656.65 X
57265   3 90 2 X 1,676.58 X
57265   2 90 2 X 1,829.43 X
57265   1 90 2 X 1,866.46 X
57267   2 ZZZ 0 X 487.00 X
57267   3 ZZZ 0 X 487.00 X
57267   4 ZZZ 0 X 487.00 X
57267   1 ZZZ 0 X 542.94 X
57268   3 90 2 X 1,303.43 X
57268   4 90 2 X 1,309.58 X
57268   2 90 2 X 1,416.06 X
57268   1 90 2 X 1,443.38 X
57270   3 90 2 X 1,425.00 X
57270   4 90 2 X 1,443.01 X
57270   2 90 2 X 1,503.78 X
57270   1 90 2 X 1,530.97 X
57280   4 90 2 X 1,645.93 X
57280   3 90 2 X 1,665.42 X
57280   2 90 2 X 1,805.11 X
57280   1 90 2 X 1,838.98 X
57282   4 90 2 X 1,640.70 X
57282   3 90 2 X 1,660.27 X
57282   2 90 2 X 1,801.95 X
57282   1 90 2 X 1,836.35 X
57283   2 90 2 X 1,154.93 X
57283   3 90 2 X 1,154.93 X
57283   4 90 2 X 1,154.93 X
57283   1 90 2 X 1,282.31 X
57284   4 90 2 X 1,987.90 X
57284   3 90 2 X 2,016.58 X
57284   2 90 2 X 2,132.92 X
57284   1 90 2 X 2,213.40 X
57285   2 90 2 X 931.22 X
57285   3 90 2 X 931.22 X
57285   4 90 2 X 931.22 X
57285   1 90 2 X 1,020.55 X
57287   2 90 2 X 1,334.61 X
57287   3 90 2 X 1,334.61 X
57287   4 90 2 X 1,334.61 X
57287   1 90 2 X 1,476.98 X
57288   3 90 2 X 2,123.50 X
57288   4 90 2 X 2,128.94 X
57288   2 90 2 X 2,203.25 X
57288   1 90 2 X 2,250.87 X
57289   4 90 2 X 1,392.91 X
57289   3 90 2 X 1,410.56 X
57289   2 90 2 X 1,514.98 X
57289   1 90 2 X 1,540.15 X
57291   4 90 2 X 1,234.51 X
57291   3 90 2 X 1,248.55 X
57291   2 90 2 X 1,342.17 X
57291   1 90 2 X 1,364.95 X
57292   4 90 2 X 1,793.26 X
57292   3 90 2 X 1,813.12 X
57292   2 90 2 X 1,931.97 X
57292   1 90 2 X 1,960.88 X
57295   2 90 2 X 756.31 X
57295   3 90 2 X 756.31 X
57295   4 90 2 X 756.31 X
57295   1 90 2 X 852.09 X
57296   2 90 2 X 1,305.01 X
57296   3 90 2 X 1,305.01 X
57296   4 90 2 X 1,305.01 X
57296   1 90 2 X 1,463.00 X
57300   3 90 2 X 1,545.48 X
57300   4 90 2 X 1,577.08 X
57300   2 90 2 X 1,620.01 X
57300   1 90 2 X 1,682.99 X
57305   3 90 2 X 1,585.60 X
57305   1 90 2 X 1,738.94 X
57305   4 90 2 X 2,174.59 X
57305   2 90 2 X 2,276.59 X
57307   3 90 2 X 1,557.51 X
57307   2 90 2 X 1,664.60 X
57307   1 90 2 X 1,690.60 X
57307   4 90 2 X 2,480.10 X
57308   2 90 2 X 1,396.12 X
57308   3 90 2 X 1,396.12 X
57308   4 90 2 X 1,396.12 X
57308   1 90 2 X 1,588.28 X
57310   4 90 2 X 961.20 X
57310   3 90 2 X 972.59 X
57310   2 90 2 X 1,028.61 X
57310   1 90 2 X 1,814.95 X
57311   4 90 2 X 1,162.61 X
57311   3 90 2 X 1,176.81 X
57311   2 90 2 X 1,238.46 X
57311   1 90 2 X 1,253.36 X
57320   3 90 2 X 1,602.27 X
57320   4 90 2 X 1,954.37 X
57320   2 90 2 X 2,048.52 X
57320   1 90 2 X 2,116.20 X
57330   4 90 2 X 1,829.62 X
57330   3 90 2 X 1,851.55 X
57330   2 90 2 X 1,953.94 X
57330   1 90 2 X 1,978.63 X
57335   4 90 2 X 1,482.23 X
57335   3 90 2 X 1,499.95 X
57335   2 90 2 X 1,589.59 X
57335   1 90 2 X 1,611.27 X
57400   1 0 2 X 123.25 X
57400   4 0 2 X 133.34 X
57400   3 0 2 X 133.85 X
57400   2 0 2 X 136.40 X
57410   4 0 2 X 83.81 X
57410   2 0 2 X 85.85 X
57410   1 0 2 X 95.67 X
57410   3 0 2 X 109.59 X
57415   4 10 2 X 97.85 X
57415   2 10 2 X 100.42 X
57415   3 10 2 X 123.84 X
57415   1 10 2 X 125.22 X
57420   2 10 2 X 224.29 160.25
57420   3 10 2 X 224.29 160.25
57420   4 10 2 X 224.29 160.25
57420   1 10 2 X 251.59 176.31
57421   2 0 2 X 293.12 221.94
57421   3 0 2 X 293.12 221.94
57421   4 0 2 X 293.12 221.94
57421   1 0 2 X 327.72 244.06
57423   2 90 2 X 1,301.92 X
57423   3 90 2 X 1,301.92 X
57423   4 90 2 X 1,301.92 X
57423   1 90 2 X 1,444.56 X
57425   2 90 2 X 1,612.96 X
57425   3 90 2 X 1,612.96 X
57425   4 90 2 X 1,612.96 X
57425   1 90 2 X 1,786.84 X
57426   2 90 2 X 1,258.99 X
57426   3 90 2 X 1,258.99 X
57426   4 90 2 X 1,258.99 X
57426   1 90 2 X 1,398.27 X
57452   3 0 2 X 123.16 100.92
57452   4 0 2 X 157.13 129.24
57452   2 0 2 X 170.25 140.16
57452   1 0 2 X 173.06 142.53
57454   4 0 3 X 240.15 188.53
57454   3 0 3 X 242.90 190.43
57454   2 0 3 X 262.72 207.09
57454   1 0 3 X 267.51 211.22
57455   2 0 3 X 269.60 201.66
57455   3 0 3 X 269.60 201.66
57455   4 0 3 X 269.60 201.66
57455   1 0 3 X 302.11 222.25
57456   2 0 3 X 254.77 188.77
57456   3 0 3 X 254.77 188.77
57456   4 0 3 X 254.77 188.77
57456   1 0 3 X 286.07 208.53
57460   4 0 3 X 468.55 X
57460   3 0 3 X 473.87 X
57460   2 0 3 X 509.97 X
57460   1 0 3 X 518.69 X
57461   2 0 3 X 596.24 349.08
57461   3 0 3 X 596.24 349.08
57461   4 0 3 X 596.24 349.08
57461   1 0 3 X 677.25 386.72
57465   2 ZZZ 0 X 63.14 48.70
57465   3 ZZZ 0 X 63.14 48.70
57465   4 ZZZ 0 X 63.14 48.70
57465   1 ZZZ 0 X 69.53 52.87
57500   3 0 2 X 168.94 140.70
57500   4 0 2 X 196.64 163.79
57500   2 0 2 X 197.20 163.92
57500   1 0 2 X 234.23 194.71
57505   3 10 2 X 140.54 117.02
57505   2 10 2 X 146.84 122.69
57505   1 10 2 X 148.35 123.86
57505   4 10 2 X 163.42 136.40
57510   3 10 2 X 181.44 162.65
57510   4 10 2 X 190.42 171.22
57510   2 10 2 X 192.57 172.30
57510   1 10 2 X 193.39 173.10
57511   3 10 2 X 256.76 219.75
57511   4 10 2 X 269.73 230.71
57511   2 10 2 X 272.23 233.05
57511   1 10 2 X 276.01 236.33