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2024 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   004 90 2 X 1,158.52 X
55530   001 90 2 X 1,265.99 X
55530   003 90 2 X 1,172.80 X
55530   002 90 2 X 1,247.85 X
55535   001 90 2 X 1,239.52 X
55535   004 90 2 X 1,145.65 X
55535   002 90 2 X 1,223.85 X
55535   003 90 2 X 1,258.99 X
55540   001 90 2 X 1,441.69 X
55540   004 90 2 X 1,740.84 X
55540   003 90 2 X 1,709.84 X
55540   002 90 2 X 1,796.87 X
55550   002 90 2 X 945.22 X
55550   003 90 2 X 945.22 X
55550   001 90 2 X 1,044.32 X
55550   004 90 2 X 945.22 X
55559     YYY 2 X # X
55600   002 90 2 X 1,211.83 X
55600   003 90 2 X 1,142.95 X
55600   001 90 2 X 1,228.52 X
55600   004 90 2 X 1,129.60 X
55605   004 90 2 X 1,422.84 X
55605   001 90 2 X 1,542.32 X
55605   002 90 2 X 1,522.37 X
55605   003 90 2 X 1,439.86 X
55650   001 90 2 X 2,149.18 X
55650   003 90 2 X 2,377.18 X
55650   002 90 2 X 2,122.61 X
55650   004 90 2 X 1,989.08 X
55680   004 90 2 X 990.44 X
55680   002 90 2 X 1,060.40 X
55680   003 90 2 X 1,002.80 X
55680   001 90 2 X 1,074.32 X
55700   003 0 2 X 399.74 X
55700   002 0 2 X 483.52 X
55700   004 0 2 X 398.00 X
55700   001 0 2 X 494.45 X
55705   001 10 2 X 1,183.67 X
55705   003 10 2 X 1,062.61 X
55705   002 10 2 X 1,178.81 X
55705   004 10 2 X 1,075.72 X
55706   004 10 2 X 686.56 X
55706   001 10 2 X 755.14 X
55706   002 10 2 X 686.56 X
55706   003 10 2 X 686.56 X
55720   003 90 2 X 1,196.69 X
55720   002 90 2 X 1,255.31 X
55720   004 90 2 X 1,183.31 X
55720   001 90 2 X 1,269.52 X
55725   003 90 2 X 1,448.21 X
55725   002 90 2 X 1,528.69 X
55725   001 90 2 X 1,548.12 X
55725   004 90 2 X 1,679.37 X
55801   002 90 2 X 3,368.48 X
55801   003 90 2 X 3,178.68 X
55801   004 90 2 X 3,140.87 X
55801   001 90 2 X 3,414.39 X
55810   002 90 2 X 4,580.92 X
55810   003 90 2 X 4,476.15 X
55810   004 90 2 X 4,211.06 X
55810   001 90 2 X 4,572.32 X
55812   003 90 2 X 4,731.55 X
55812   002 90 2 X 4,999.73 X
55812   001 90 2 X 5,064.59 X
55812   004 90 2 X 4,676.18 X
55815   004 90 2 X 5,777.36 X
55815   003 90 2 X 5,848.39 X
55815   002 90 2 X 6,193.03 X
55815   001 90 2 X 6,275.95 X
55821   002 90 2 X 3,089.12 X
55821   003 90 2 X 2,907.46 X
55821   004 90 2 X 2,929.70 X
55821   001 90 2 X 3,132.77 X
55831   003 90 2 X 3,155.30 X
55831   002 90 2 X 3,351.04 X
55831   004 90 2 X 3,116.34 X
55831   001 90 2 X 3,398.18 X
55840   001 90 2 X 4,405.21 X
55840   004 90 2 X 4,065.41 X
55840   002 90 2 X 4,348.75 X
55840   003 90 2 X 4,114.62 X
55842   004 90 2 X 4,863.51 X
55842   002 90 2 X 4,998.45 X
55842   003 90 2 X 4,886.62 X
55842   001 90 2 X 5,025.50 X
55845   002 90 2 X 5,996.15 X
55845   003 90 2 X 5,728.20 X
55845   001 90 2 X 6,078.17 X
55845   004 90 2 X 5,694.10 X
55860   002 90 2 X 2,328.47 X
55860   003 90 2 X 2,216.54 X
55860   004 90 2 X 2,191.22 X
55860   001 90 2 X 2,355.56 X
55862   002 90 2 X 3,306.17 X
55862   003 90 2 X 3,132.75 X
55862   001 90 2 X 3,348.17 X
55862   004 90 2 X 3,095.97 X
55865   001 90 2 X 5,428.08 X
55865   004 90 2 X 4,988.10 X
55865   002 90 2 X 5,383.64 X
55865   003 90 2 X 5,051.42 X
55866   001 90 2 X 3,775.15 X
55866   004 90 2 X 3,461.58 X
55866   002 90 2 X 3,461.58 X
55866   003 90 2 X 3,461.58 X
55867   001 90 2 X 1,289.95 X
55867   004 90 2 X 1,197.35 X
55867   003 90 2 X 1,197.35 X
55867   002 90 2 X 1,197.35 X
55870     0 2 X * X
55873   001 90 2 X 2,724.01 X
55873   004 90 2 X 2,471.13 X
55873   002 90 2 X 2,471.13 X
55873   003 90 2 X 2,471.13 X
55874   001 0 2 X 5,955.73 269.65
55874   003 0 2 X 5,204.41 248.96
55874   002 0 2 X 5,204.41 248.96
55874   004 0 2 X 5,204.41 248.96
55875   003 90 2 X 1,268.68 X
55875   002 90 2 X 1,268.68 X
55875   004 90 2 X 1,268.68 X
55875   001 90 2 X 1,412.80 X
55876   001 0 2 X 292.04 214.79
55876   004 0 2 X 249.89 186.74
55876   002 0 2 X 249.89 186.74
55876   003 0 2 X 249.89 186.74
55880   004 90 2 X 1,284.58 X
55880   001 90 2 X 1,390.86 X
55880   003 90 2 X 1,284.58 X
55880   002 90 2 X 1,284.58 X
55899     YYY 2 X # X
55920   004 0 2 X 758.28 X
55920   002 0 2 X 758.28 X
55920   001 0 2 X 830.95 X
55920   003 0 2 X 758.28 X
56405   001 10 2 X 313.25 X
56405   004 10 2 X 315.58 X
56405   003 10 2 X 317.69 X
56405   002 10 2 X 321.55 X
56420   001 10 2 X 303.16 X
56420   004 10 2 X 278.69 X
56420   003 10 2 X 293.75 X
56420   002 10 2 X 296.35 X
56440   002 10 2 X 668.72 X
56440   003 10 2 X 619.89 X
56440   001 10 2 X 680.52 X
56440   004 10 2 X 612.66 X
56441   004 10 2 X 398.84 X
56441   001 10 2 X 440.18 X
56441   002 10 2 X 433.00 X
56441   003 10 2 X 403.57 X
56442   004 0 2 X 78.11 X
56442   001 0 2 X 89.42 X
56442   002 0 2 X 78.11 X
56442   003 0 2 X 78.11 X
56501   004 10 2 X 280.25 246.15
56501   001 10 2 X 325.86 284.71
56501   003 10 2 X 261.85 229.28
56501   002 10 2 X 329.27 288.66
56515   002 10 2 X 1,014.20 X
56515   003 10 2 X 999.23 X
56515   001 10 2 X 1,027.60 X
56515   004 10 2 X 765.24 X
56605   004 0 2 X 247.20 X
56605   001 0 2 X 306.73 X
56605   003 0 2 X 258.03 X
56605   002 0 2 X 314.55 X
56606   003 ZZZ 0 X 88.92 X
56606   002 ZZZ 0 X 95.89 X
56606   004 ZZZ 0 X 87.82 X
56606   001 ZZZ 0 X 97.59 X
56620   004 90 2 X 1,549.34 X
56620   002 90 2 X 1,628.15 X
56620   003 90 2 X 1,541.36 X
56620   001 90 2 X 1,684.40 X
56625   002 90 2 X 2,167.24 X
56625   003 90 2 X 1,986.31 X
56625   004 90 2 X 1,962.69 X
56625   001 90 2 X 2,319.28 X
56630   003 90 2 X 4,420.93 X
56630   002 90 2 X 4,537.97 X
56630   004 90 2 X 2,925.47 X
56630   001 90 2 X 4,553.56 X
56631   003 90 2 X 4,040.17 X
56631   002 90 2 X 4,417.95 X
56631   001 90 2 X 4,509.54 X
56631   004 90 2 X 3,991.95 X
56632   002 90 2 X 4,813.49 X
56632   003 90 2 X 4,420.78 X
56632   004 90 2 X 4,367.79 X
56632   001 90 2 X 4,908.72 X
56633   001 90 2 X 4,704.85 X
56633   004 90 2 X 3,262.33 X
56633   003 90 2 X 4,565.93 X
56633   002 90 2 X 4,688.08 X
56634   004 90 2 X 4,348.57 X
56634   003 90 2 X 4,401.30 X
56634   002 90 2 X 4,793.22 X
56634   001 90 2 X 4,888.12 X
56637   004 90 2 X 4,584.70 X
56637   003 90 2 X 4,639.81 X
56637   002 90 2 X 5,038.20 X
56637   001 90 2 X 5,134.77 X
56640   001 90 2 X 5,108.83 X
56640   004 90 2 X 4,575.17 X
56640   002 90 2 X 5,015.20 X
56640   003 90 2 X 4,629.14 X
56700   003 10 2 X 479.45 X
56700   002 10 2 X 513.69 X
56700   001 10 2 X 521.96 X
56700   004 10 2 X 474.00 X
56740   004 10 2 X 746.05 X
56740   002 10 2 X 810.04 X
56740   003 10 2 X 733.36 X
56740   001 10 2 X 800.18 X
56800   001 10 2 X 822.96 X
56800   003 10 2 X 906.43 X
56800   002 10 2 X 936.64 X
56800   004 10 2 X 745.50 X
56805   001 90 2 X 3,209.13 X
56805   004 90 2 X 2,952.27 X
56805   002 90 2 X 3,166.06 X
56805   003 90 2 X 2,987.74 X
56810   001 10 2 X 911.84 X
56810   002 10 2 X 890.41 X
56810   003 10 2 X 861.68 X
56810   004 10 2 X 872.55 X
56820   003 0 2 X 251.74 176.66
56820   002 0 2 X 251.74 176.66
56820   004 0 2 X 251.74 176.66
56820   001 0 2 X 282.91 194.71
56821   001 0 2 X 366.15 268.12
56821   004 0 2 X 326.81 243.43
56821   003 0 2 X 326.81 243.43
56821   002 0 2 X 326.81 243.43
57000   003 10 2 X 350.45 X
57000   002 10 2 X 645.85 X
57000   004 10 2 X 546.83 X
57000   001 10 2 X 696.59 X
57010   001 90 2 X 954.31 X
57010   004 90 2 X 889.22 X
57010   003 90 2 X 898.99 X
57010   002 90 2 X 956.51 X
57020   001 0 2 X 259.00 X
57020   004 0 2 X 238.20 X
57020   002 0 2 X 255.35 X
57020   003 0 2 X 240.84 X
57022   001 10 2 X 404.57 X
57022   003 10 2 X 366.57 X
57022   002 10 2 X 366.57 X
57022   004 10 2 X 366.57 X
57023   001 10 2 X 404.57 X
57023   003 10 2 X 366.57 X
57023   002 10 2 X 366.57 X
57023   004 10 2 X 366.57 X
57061   002 10 2 X 324.37 X
57061   003 10 2 X 325.75 X
57061   001 10 2 X 334.26 X
57061   004 10 2 X 312.83 X
57065   004 10 2 X 1,051.32 X
57065   001 10 2 X 1,087.55 X
57065   003 10 2 X 1,054.76 X
57065   002 10 2 X 1,081.12 X
57100   003 0 2 X 315.87 260.27
57100   002 0 2 X 317.84 262.43
57100   004 0 2 X 306.75 252.35
57100   001 0 2 X 318.39 262.49
57105   004 10 2 X 395.75 X
57105   002 10 2 X 409.39 X
57105   003 10 2 X 391.77 X
57105   001 10 2 X 416.14 X
57106   002 90 2 X 806.85 X
57106   003 90 2 X 806.85 X
57106   004 90 2 X 806.85 X
57106   001 90 2 X 904.16 X
57107   001 90 2 X 3,015.04 2,997.73
57107   003 90 2 X 2,778.68 2,763.83
57107   002 90 2 X 2,778.68 2,763.83
57107   004 90 2 X 2,778.68 2,763.83
57109   001 90 2 X 3,714.26 3,671.87
57109   004 90 2 X 3,340.81 3,304.57
57109   003 90 2 X 3,340.81 3,304.57
57109   002 90 2 X 3,340.81 3,304.57
57110   002 90 2 X 2,327.33 X
57110   003 90 2 X 2,256.43 X
57110   004 90 2 X 2,245.16 X
57110   001 90 2 X 2,344.53 X
57111   001 90 2 X 3,678.62 3,745.10
57111   004 90 2 X 3,310.30 3,367.16
57111   003 90 2 X 3,310.30 3,367.16
57111   002 90 2 X 3,310.30 3,367.16
57120   003 90 2 X 1,840.42 X
57120   001 90 2 X 1,753.59 X
57120   002 90 2 X 1,721.19 X
57120   004 90 2 X 1,568.80 X
57130   001 10 2 X 642.23 X
57130   004 10 2 X 574.27 X
57130   002 10 2 X 652.08 X
57130   003 10 2 X 581.14 X
57135   004 10 2 X 510.89 X
57135   001 10 2 X 573.79 X
57135   003 10 2 X 516.86 X
57135   002 10 2 X 553.68 X
57150   004 0 2 X 121.90 112.42
57150   002 0 2 X 128.51 118.48
57150   003 0 2 X 123.03 113.45
57150   001 0 2 X 129.96 119.70
57155   004 0 2 X 827.17 X
57155   001 0 2 X 926.65 X
57155   002 0 2 X 827.17 X
57155   003 0 2 X 827.17 X
57156   001 0 2 X 280.81 191.47
57156   004 0 2 X 256.44 177.52
57156   002 0 2 X 256.44 177.52
57156   003 0 2 X 256.44 177.52
57160   002 0 2 X 121.93 109.40
57160   003 0 2 X 113.51 102.04
57160   004 0 2 X 115.29 103.92
57160   001 0 2 X 122.93 110.67
57170     0 2 X * X
57180   001 10 2 X 235.55 X
57180   004 10 2 X 225.10 X
57180   002 10 2 X 233.86 X
57180   003 10 2 X 226.56 X
57200   001 90 2 X 799.78 X
57200   002 90 2 X 786.27 X
57200   003 90 2 X 741.51 X
57200   004 90 2 X 746.08 X
57210   001 90 2 X 1,056.56 X
57210   004 90 2 X 980.05 X
57210   003 90 2 X 969.82 X
57210   002 90 2 X 1,016.13 X
57220   002 90 2 X 1,024.33 X
57220   003 90 2 X 1,067.58 X
57220   001 90 2 X 1,064.25 X
57220   004 90 2 X 936.83 X
57230   002 90 2 X 1,065.77 X
57230   003 90 2 X 1,068.93 X
57230   001 90 2 X 1,082.26 X
57230   004 90 2 X 986.45 X
57240   003 90 2 X 1,464.29 X
57240   002 90 2 X 1,599.44 X
57240   004 90 2 X 1,446.83 X
57240   001 90 2 X 1,632.22 X
57250   004 90 2 X 1,414.62 X
57250   001 90 2 X 1,712.33 X
57250   003 90 2 X 1,431.61 X
57250   002 90 2 X 1,570.28 X
57260   004 90 2 X 1,971.92 X
57260   002 90 2 X 2,089.70 X
57260   001 90 2 X 2,090.75 X
57260   003 90 2 X 1,887.10 X
57265   004 90 2 X 1,941.32 X
57265   001 90 2 X 2,187.18 X
57265   002 90 2 X 2,143.78 X
57265   003 90 2 X 1,964.66 X
57267   001 ZZZ 0 X 636.23 X
57267   003 ZZZ 0 X 570.68 X
57267   002 ZZZ 0 X 570.68 X
57267   004 ZZZ 0 X 570.68 X
57268   004 90 2 X 1,534.60 X
57268   002 90 2 X 1,659.38 X
57268   003 90 2 X 1,527.41 X
57268   001 90 2 X 1,691.39 X
57270   004 90 2 X 1,690.97 X
57270   003 90 2 X 1,669.87 X
57270   002 90 2 X 1,762.18 X
57270   001 90 2 X 1,794.03 X
57280   001 90 2 X 2,154.97 X
57280   003 90 2 X 1,951.59 X
57280   002 90 2 X 2,115.29 X
57280   004 90 2 X 1,928.75 X
57282   004 90 2 X 1,922.63 X
57282   001 90 2 X 2,151.90 X
57282   003 90 2 X 1,945.56 X
57282   002 90 2 X 2,111.58 X
57283   004 90 2 X 1,353.39 X
57283   001 90 2 X 1,502.65 X
57283   003 90 2 X 1,353.39 X
57283   002 90 2 X 1,353.39 X
57284   004 90 2 X 2,329.49 X
57284   002 90 2 X 2,499.42 X
57284   003 90 2 X 2,363.09 X
57284   001 90 2 X 2,593.73 X
57285   004 90 2 X 1,091.23 X
57285   003 90 2 X 1,091.23 X
57285   002 90 2 X 1,091.23 X
57285   001 90 2 X 1,195.92 X
57287   003 90 2 X 1,563.93 X
57287   002 90 2 X 1,563.93 X
57287   001 90 2 X 1,730.77 X
57287   004 90 2 X 1,563.93 X
57288   003 90 2 X 2,488.39 X
57288   001 90 2 X 2,637.65 X
57288   002 90 2 X 2,581.83 X
57288   004 90 2 X 2,494.76 X
57289   003 90 2 X 1,652.94 X
57289   002 90 2 X 1,775.30 X
57289   001 90 2 X 1,804.80 X
57289   004 90 2 X 1,632.26 X
57291   004 90 2 X 1,446.64 X
57291   001 90 2 X 1,599.50 X
57291   002 90 2 X 1,572.79 X
57291   003 90 2 X 1,463.08 X
57292   003 90 2 X 2,124.68 X
57292   002 90 2 X 2,263.94 X
57292   004 90 2 X 2,101.40 X
57292   001 90 2 X 2,297.83 X
57295   001 90 2 X 998.50 X
57295   004 90 2 X 886.28 X
57295   002 90 2 X 886.28 X
57295   003 90 2 X 886.28 X
57296   001 90 2 X 1,714.39 X
57296   004 90 2 X 1,529.25 X
57296   003 90 2 X 1,529.25 X
57296   002 90 2 X 1,529.25 X
57300   003 90 2 X 1,811.05 X
57300   002 90 2 X 1,898.38 X
57300   004 90 2 X 1,848.08 X
57300   001 90 2 X 1,972.18 X
57305   004 90 2 X 2,548.25 X
57305   001 90 2 X 2,037.74 X
57305   002 90 2 X 2,667.78 X
57305   003 90 2 X 1,858.05 X
57307   003 90 2 X 1,825.15 X
57307   002 90 2 X 1,950.62 X
57307   001 90 2 X 1,981.10 X
57307   004 90 2 X 2,906.27 X
57308   003 90 2 X 1,636.01 X
57308   002 90 2 X 1,636.01 X
57308   004 90 2 X 1,636.01 X
57308   001 90 2 X 1,861.20 X
57310   004 90 2 X 1,126.36 X
57310   001 90 2 X 2,126.82 X
57310   002 90 2 X 1,205.36 X
57310   003 90 2 X 1,139.72 X
57311   001 90 2 X 1,468.73 X
57311   004 90 2 X 1,362.38 X
57311   002 90 2 X 1,451.27 X
57311   003 90 2 X 1,379.03 X
57320   003 90 2 X 1,877.60 X
57320   002 90 2 X 2,400.52 X
57320   004 90 2 X 2,290.19 X
57320   001 90 2 X 2,479.83 X
57330   004 90 2 X 2,144.00 X
57330   001 90 2 X 2,318.63 X
57330   003 90 2 X 2,169.70 X
57330   002 90 2 X 2,289.70 X
57335   002 90 2 X 1,862.73 X
57335   003 90 2 X 1,757.69 X
57335   001 90 2 X 1,888.13 X
57335   004 90 2 X 1,736.92 X
57400   004 0 2 X 156.25 X
57400   001 0 2 X 144.42 X
57400   002 0 2 X 159.84 X
57400   003 0 2 X 156.84 X
57410   002 0 2 X 100.61 X
57410   003 0 2 X 128.42 X
57410   001 0 2 X 112.10 X
57410   004 0 2 X 98.21 X
57415   002 10 2 X 117.68 X
57415   003 10 2 X 145.11 X
57415   004 10 2 X 114.67 X
57415   001 10 2 X 146.73 X
57420   003 0 2 X 262.83 187.79
57420   002 0 2 X 262.83 187.79
57420   004 0 2 X 262.83 187.79
57420   001 0 2 X 294.82 206.61
57421   001 0 2 X 384.03 286.00
57421   003 0 2 X 343.49 260.08
57421   002 0 2 X 343.49 260.08
57421   004 0 2 X 343.49 260.08
57423   001 90 2 X 1,692.78 X
57423   003 90 2 X 1,525.64 X
57423   002 90 2 X 1,525.64 X
57423   004 90 2 X 1,525.64 X
57425   003 90 2 X 1,890.13 X
57425   002 90 2 X 1,890.13 X
57425   001 90 2 X 2,093.87 X
57425   004 90 2 X 1,890.13 X
57426   002 90 2 X 1,475.32 X
57426   003 90 2 X 1,475.32 X
57426   001 90 2 X 1,638.54 X
57426   004 90 2 X 1,475.32 X
57452   003 0 2 X 144.32 118.26
57452   002 0 2 X 199.50 164.25
57452   001 0 2 X 202.80 167.02
57452   004 0 2 X 184.13 151.44
57454   001 0 3 X 313.48 247.51
57454   004 0 3 X 281.41 220.93
57454   002 0 3 X 307.86 242.67
57454   003 0 3 X 284.64 223.15
57455   004 0 3 X 315.92 236.31
57455   001 0 3 X 354.03 260.44
57455   002 0 3 X 315.92 236.31
57455   003 0 3 X 315.92 236.31
57456   003 0 3 X 298.54 221.21
57456   002 0 3 X 298.54 221.21
57456   004 0 3 X 298.54 221.21
57456   001 0 3 X 335.22 244.36
57460   004 0 3 X 549.06 X
57460   002 0 3 X 597.60 X
57460   003 0 3 X 555.30 X
57460   001 0 3 X 607.82 X
57461   002 0 3 X 698.69 409.06
57461   003 0 3 X 698.69 409.06
57461   001 0 3 X 793.62 453.17
57461   004 0 3 X 698.69 409.06
57465   001 ZZZ 0 X 81.47 61.95
57465   004 ZZZ 0 X 74.00 57.06
57465   003 ZZZ 0 X 74.00 57.06
57465   002 ZZZ 0 X 74.00 57.06
57500   003 0 2 X 197.97 164.88
57500   002 0 2 X 231.09 192.09
57500   004 0 2 X 230.43 191.93
57500   001 0 2 X 274.48 228.17
57505   002 10 2 X 172.07 143.78
57505   003 10 2 X 164.69 137.12
57505   004 10 2 X 191.51 159.84
57505   001 10 2 X 173.84 145.14
57510   001 10 2 X 226.62 202.84
57510   003 10 2 X 212.62 190.59
57510   002 10 2 X 225.66 201.91
57510   004 10 2 X 223.14 200.64
57511   003 10 2 X 300.88 257.50
57511   002 10 2 X 319.01 273.09
57511   004 10 2 X 316.08 270.36
57511   001 10 2 X 323.44 276.94