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2021 Workers' Compensation Part B Fee Schedule

57513-59100

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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
57513   3 10 2 X 401.97 X
57513   4 10 2 X 423.60 X
57513   2 10 2 X 434.00 X
57513   1 10 2 X 452.70 X
57520   4 90 2 X 678.06 X
57520   3 90 2 X 684.51 X
57520   1 90 2 X 898.51 X
57520   2 90 2 X 904.34 X
57522   4 90 2 X 678.06 X
57522   3 90 2 X 684.51 X
57522   1 90 2 X 898.51 X
57522   2 90 2 X 904.34 X
57530   3 90 2 X 785.33 X
57530   1 90 2 X 861.18 X
57530   4 90 2 X 868.68 X
57530   2 90 2 X 958.46 X
57531   2 90 2 X 3,273.12 X
57531   3 90 2 X 3,273.12 X
57531   4 90 2 X 3,273.12 X
57531   1 90 2 X 3,758.55 X
57540   4 90 2 X 1,252.90 X
57540   3 90 2 X 1,267.83 X
57540   2 90 2 X 1,379.06 X
57540   1 90 2 X 1,475.19 X
57545   4 90 2 X 1,079.61 X
57545   1 90 2 X 1,192.83 X
57545   3 90 2 X 1,409.37 X
57545   2 90 2 X 1,687.32 X
57550   4 90 2 X 1,157.84 X
57550   1 90 2 X 1,308.79 X
57550   3 90 2 X 1,327.66 X
57550   2 90 2 X 1,343.47 X
57555   4 90 2 X 1,790.53 X
57555   3 90 2 X 1,812.15 X
57555   2 90 2 X 1,972.71 X
57555   1 90 2 X 2,011.60 X
57556   3 90 2 X 1,595.48 X
57556   4 90 2 X 1,659.97 X
57556   2 90 2 X 1,693.94 X
57556   1 90 2 X 1,860.84 X
57558   2 10 2 X 175.14 158.07
57558   3 10 2 X 175.14 158.07
57558   4 10 2 X 175.14 158.07
57558   1 10 2 X 201.20 180.29
57700   4 90 2 X 531.60 X
57700   3 90 2 X 537.87 X
57700   1 90 2 X 579.77 X
57700   2 90 2 X 730.30 X
57720   4 90 2 X 628.77 X
57720   3 90 2 X 636.01 X
57720   1 90 2 X 690.55 X
57720   2 90 2 X 717.15 X
57800   4 0 2 X 119.66 X
57800   3 0 2 X 125.04 X
57800   2 0 2 X 131.25 X
57800   1 0 2 X 131.31 X
58100   3 0 2 X 158.49 124.26
58100   2 0 2 X 194.14 153.09
58100   4 0 2 X 194.65 153.18
58100   1 0 2 X 221.88 175.21
58110   2 ZZZ 0 X 83.08 69.64
58110   3 ZZZ 0 X 83.08 69.64
58110   4 ZZZ 0 X 83.08 69.64
58110   1 ZZZ 0 X 93.95 77.54
58120   4 10 2 X 525.67 X
58120   3 10 2 X 538.17 X
58120   2 10 2 X 583.71 X
58120   1 10 2 X 599.38 X
58140   4 90 2 X 1,549.94 X
58140   3 90 2 X 1,568.49 X
58140   2 90 2 X 1,699.72 X
58140   1 90 2 X 1,731.52 X
58145   4 90 2 X 1,504.85 X
58145   3 90 2 X 1,523.15 X
58145   2 90 2 X 1,644.66 X
58145   1 90 2 X 1,676.13 X
58146   2 90 2 X 1,979.42 X
58146   3 90 2 X 1,979.42 X
58146   4 90 2 X 1,979.42 X
58146   1 90 2 X 2,193.23 X
58150   4 90 2 X 2,173.44 X
58150   3 90 2 X 2,198.29 X
58150   2 90 2 X 2,363.15 X
58150   1 90 2 X 2,403.17 X
58152   2 90 2 X 2,223.85 X
58152   3 90 2 X 2,223.85 X
58152   4 90 2 X 2,223.85 X
58152   1 90 2 X 2,550.95 X
58180   4 90 2 X 2,323.80 X
58180   3 90 2 X 2,333.01 X
58180   2 90 2 X 2,399.46 X
58180   1 90 2 X 2,415.60 X
58200   3 90 2 X 2,984.65 X
58200   4 90 2 X 3,183.57 X
58200   2 90 2 X 3,380.48 X
58200   1 90 2 X 3,550.55 X
58210   4 90 2 X 4,022.14 X
58210   3 90 2 X 4,068.22 X
58210   2 90 2 X 4,374.40 X
58210   1 90 2 X 4,448.78 X
58240   4 90 2 X 5,598.87 X
58240   3 90 2 X 5,873.24 X
58240   2 90 2 X 6,133.78 X
58240   1 90 2 X 6,247.47 X
58260   4 90 2 X 2,012.73 X
58260   3 90 2 X 2,035.94 X
58260   2 90 2 X 2,195.88 X
58260   1 90 2 X 2,234.68 X
58262   4 90 2 X 2,162.69 X
58262   3 90 2 X 2,187.35 X
58262   2 90 2 X 2,350.93 X
58262   1 90 2 X 2,390.67 X
58263   4 90 2 X 2,363.92 X
58263   3 90 2 X 2,390.93 X
58263   2 90 2 X 2,568.21 X
58263   1 90 2 X 2,611.26 X
58267   4 90 2 X 2,461.06 X
58267   3 90 2 X 2,489.63 X
58267   2 90 2 X 2,682.85 X
58267   1 90 2 X 2,729.69 X
58270   4 90 2 X 2,213.93 X
58270   3 90 2 X 2,239.57 X
58270   2 90 2 X 2,413.17 X
58270   1 90 2 X 2,455.28 X
58275   3 90 2 X 2,541.82 X
58275   4 90 2 X 2,557.00 X
58275   2 90 2 X 2,621.65 X
58275   1 90 2 X 2,666.51 X
58280   4 90 2 X 2,395.17 X
58280   3 90 2 X 2,422.54 X
58280   2 90 2 X 2,604.63 X
58280   1 90 2 X 2,648.91 X
58285   4 90 2 X 2,802.74 X
58285   3 90 2 X 2,834.27 X
58285   2 90 2 X 3,045.47 X
58285   1 90 2 X 3,096.83 X
58290   2 90 2 X 1,981.24 X
58290   3 90 2 X 1,981.24 X
58290   4 90 2 X 1,981.24 X
58290   1 90 2 X 2,187.34 X
58291   2 90 2 X 2,177.51 X
58291   3 90 2 X 2,177.51 X
58291   4 90 2 X 2,177.51 X
58291   1 90 2 X 2,407.34 X
58292   2 90 2 X 2,306.40 X
58292   3 90 2 X 2,306.40 X
58292   4 90 2 X 2,306.40 X
58292   1 90 2 X 2,550.81 X
58294   2 90 2 X 2,124.19 X
58294   3 90 2 X 2,124.19 X
58294   4 90 2 X 2,124.19 X
58294   1 90 2 X 2,347.83 X
58301     0 2 X * X
58321     0 2 X * X
58322     0 2 X * X
58323     0 2 X * X
58340   2 0 2 X 115.57 X
58340   3 0 2 X 115.57 X
58340   4 0 2 X 115.57 X
58340   1 0 2 X 129.48 X
58345   4 10 2 X 748.98 X
58345   3 10 2 X 757.90 X
58345   2 10 2 X 803.04 X
58345   1 10 2 X 813.96 X
58346   2 90 2 X 752.86 X
58346   3 90 2 X 752.86 X
58346   4 90 2 X 752.86 X
58346   1 90 2 X 843.03 X
58350   4 10 2 X 159.64 X
58350   3 10 2 X 161.49 X
58350   2 10 2 X 173.79 X
58350   1 10 2 X 176.83 X
58353   2 10 2 X 430.17 X
58353   3 10 2 X 430.17 X
58353   4 10 2 X 430.17 X
58353   1 10 2 X 474.32 X
58356   2 10 2 X 898.61 639.05
58356   3 10 2 X 898.61 639.05
58356   4 10 2 X 898.61 639.05
58356   1 10 2 X 1,023.58 712.42
58400   4 90 2 X 1,094.79 X
58400   3 90 2 X 1,107.80 X
58400   1 90 2 X 1,219.47 X
58400   2 90 2 X 1,366.99 X
58410   4 90 2 X 1,157.90 X
58410   3 90 2 X 1,171.65 X
58410   2 90 2 X 1,250.30 X
58410   1 90 2 X 1,269.37 X
58520   4 90 2 X 1,022.43 X
58520   3 90 2 X 1,033.90 X
58520   1 90 2 X 1,129.89 X
58520   2 90 2 X 1,578.46 X
58540   4 90 2 X 1,424.08 X
58540   3 90 2 X 1,440.14 X
58540   2 90 2 X 1,550.23 X
58540   1 90 2 X 1,576.99 X
58541   2 90 3 X 1,172.97 X
58541   3 90 3 X 1,172.97 X
58541   4 90 3 X 1,172.97 X
58541   1 90 3 X 1,321.30 X
58542   2 90 2 X 1,299.52 X
58542   3 90 2 X 1,299.52 X
58542   4 90 2 X 1,299.52 X
58542   1 90 2 X 1,456.76 X
58543   2 90 2 X 1,321.50 X
58543   3 90 2 X 1,321.50 X
58543   4 90 2 X 1,321.50 X
58543   1 90 2 X 1,481.33 X
58544   2 90 2 X 1,430.94 X
58544   3 90 2 X 1,430.94 X
58544   4 90 2 X 1,430.94 X
58544   1 90 2 X 1,603.18 X
58545   2 90 2 X 1,585.87 X
58545   3 90 2 X 1,585.87 X
58545   4 90 2 X 1,585.87 X
58545   1 90 2 X 1,773.07 X
58546   2 90 2 X 2,004.73 X
58546   3 90 2 X 2,004.73 X
58546   4 90 2 X 2,004.73 X
58546   1 90 2 X 2,222.69 X
58548   2 90 2 X 2,500.27 X
58548   3 90 2 X 2,500.27 X
58548   4 90 2 X 2,500.27 X
58548   1 90 2 X 2,810.80 X
58550   2 10 3 X 1,718.97 X
58550   3 10 3 X 1,718.97 X
58550   4 10 3 X 1,718.97 X
58550   1 10 3 X 1,905.63 X
58552   2 10 3 X 1,544.18 X
58552   3 10 3 X 1,544.18 X
58552   4 10 3 X 1,544.18 X
58552   1 10 3 X 1,727.67 X
58553   2 90 2 X 1,994.15 X
58553   3 90 2 X 1,994.15 X
58553   4 90 2 X 1,994.15 X
58553   1 90 2 X 2,202.55 X
58554   2 90 2 X 1,974.12 X
58554   3 90 2 X 1,974.12 X
58554   4 90 2 X 1,974.12 X
58554   1 90 2 X 2,179.00 X
58555   2 0 2 X 431.48 387.33
58555   3 0 2 X 431.48 387.33
58555   4 0 2 X 431.48 387.33
58555   1 0 2 X 480.04 428.35
58558   2 0 3 X 563.83 519.60
58558   3 0 3 X 563.83 519.60
58558   4 0 3 X 563.83 519.60
58558   1 0 3 X 623.89 572.25
58559   2 0 3 X 722.04 721.32
58559   3 0 3 X 722.04 721.32
58559   4 0 3 X 722.04 721.32
58559   1 0 3 X 798.82 797.99
58560   2 0 3 X 799.19 798.51
58560   3 0 3 X 799.19 798.51
58560   4 0 3 X 799.19 798.51
58560   1 0 3 X 882.76 881.91
58561   2 0 3 X 1,123.69 1,123.01
58561   3 0 3 X 1,123.69 1,123.01
58561   4 0 3 X 1,123.69 1,123.01
58561   1 0 3 X 1,239.96 1,239.11
58562   2 0 3 X 562.81 X
58562   3 0 3 X 562.81 X
58562   4 0 3 X 562.81 X
58562   1 0 3 X 619.50 X
58563   2 0 3 X 744.83 X
58563   3 0 3 X 744.83 X
58563   4 0 3 X 744.83 X
58563   1 0 3 X 825.48 X
58565   2 90 3 X 3,610.09 781.27
58565   3 90 3 X 3,610.09 781.27
58565   4 90 3 X 3,610.09 781.27
58565   1 90 3 X 4,276.38 885.47
58570   2 90 2 X 1,295.01 X
58570   3 90 2 X 1,295.01 X
58570   4 90 2 X 1,295.01 X
58570   1 90 2 X 1,442.40 X
58571   2 90 2 X 1,417.31 X
58571   3 90 2 X 1,417.31 X
58571   4 90 2 X 1,417.31 X
58571   1 90 2 X 1,571.44 X
58572   2 90 2 X 1,609.18 X
58572   3 90 2 X 1,609.18 X
58572   4 90 2 X 1,609.18 X
58572   1 90 2 X 1,789.43 X
58573   2 90 2 X 1,813.05 X
58573   3 90 2 X 1,813.05 X
58573   4 90 2 X 1,813.05 X
58573   1 90 2 X 2,004.13 X
58575   2 90 2 X 2,367.89 X
58575   3 90 2 X 2,367.89 X
58575   4 90 2 X 2,367.89 X
58575   1 90 2 X 2,577.11 X
58578     YYY 2 X # X
58579     YYY 2 X # X
58600   4 90 2 X 988.94 X
58600   3 90 2 X 1,001.06 X
58600   2 90 2 X 1,098.97 X
58600   1 90 2 X 1,257.42 X
58605   4 90 2 X 778.64 X
58605   3 90 2 X 831.94 X
58605   2 90 2 X 861.20 X
58605   1 90 2 X 939.03 X
58611   3 ZZZ 0 X 107.57 X
58611   2 ZZZ 0 X 115.57 X
58611   4 ZZZ 0 X 1,191.88 X
58611   1 ZZZ 0 X 1,201.33 X
58615   4 10 2 X 625.35 X
58615   3 10 2 X 632.82 X
58615   2 10 2 X 670.78 X
58615   1 10 2 X 679.97 X
58660   2 90 3 X 1,310.73 X
58660   3 90 3 X 1,310.73 X
58660   4 90 3 X 1,310.73 X
58660   1 90 3 X 1,455.20 X
58661   2 10 3 X 1,332.08 X
58661   3 10 3 X 1,332.08 X
58661   4 10 3 X 1,332.08 X
58661   1 10 3 X 1,476.51 X
58662   2 90 3 X 1,337.31 X
58662   3 90 3 X 1,337.31 X
58662   4 90 3 X 1,337.31 X
58662   1 90 3 X 1,477.59 X
58670   2 90 3 X 743.43 X
58670   3 90 3 X 743.43 X
58670   4 90 3 X 743.43 X
58670   1 90 3 X 827.89 X
58671   2 90 3 X 764.79 X
58671   3 90 3 X 764.79 X
58671   4 90 3 X 764.79 X
58671   1 90 3 X 852.89 X
58672   2 90 3 X 1,443.99 X
58672   3 90 3 X 1,443.99 X
58672   4 90 3 X 1,443.99 X
58672   1 90 3 X 1,597.00 X
58673   2 90 3 X 1,537.89 X
58673   3 90 3 X 1,537.89 X
58673   4 90 3 X 1,537.89 X
58673   1 90 3 X 1,698.78 X
58674   2 90 2 X 1,048.07 X
58674   3 90 2 X 1,048.07 X
58674   4 90 2 X 1,048.07 X
58674   1 90 2 X 1,137.15 X
58679     YYY 2 X # X
58700   3 90 2 X 1,205.66 X
58700   4 90 2 X 1,329.50 X
58700   2 90 2 X 1,449.42 X
58700   1 90 2 X 1,463.09 X
58720   4 90 2 X 1,345.64 X
58720   3 90 2 X 1,394.65 X
58720   2 90 2 X 1,509.17 X
58720   1 90 2 X 1,811.48 X
58740   3 90 2 X 2,324.02 X
58740   2 90 2 X 2,427.57 X
58740   4 90 2 X 2,428.63 X
58740   1 90 2 X 2,543.50 X
58750     90 2 X * X
58752     90 2 X * X
58760     90 2 X * X
58770     90 2 X * X
58800   4 90 2 X 615.85 X
58800   3 90 2 X 654.14 X
58800   2 90 2 X 667.37 X
58800   1 90 2 X 678.13 X
58805   4 90 2 X 1,157.56 X
58805   3 90 2 X 1,171.45 X
58805   2 90 2 X 1,277.46 X
58805   1 90 2 X 1,298.04 X
58820   2 90 2 X 562.44 X
58820   3 90 2 X 562.44 X
58820   4 90 2 X 562.44 X
58820   1 90 2 X 634.65 X
58822   4 90 2 X 931.97 X
58822   3 90 2 X 942.30 X
58822   2 90 2 X 1,008.16 X
58822   1 90 2 X 1,024.18 X
58825   4 90 2 X 933.63 X
58825   3 90 2 X 944.22 X
58825   2 90 2 X 1,016.23 X
58825   1 90 2 X 1,033.78 X
58900   4 90 2 X 1,033.51 X
58900   2 90 2 X 1,298.83 X
58900   3 90 2 X 1,330.99 X
58900   1 90 2 X 1,408.09 X
58920   4 90 2 X 1,272.15 X
58920   3 90 2 X 1,287.33 X
58920   2 90 2 X 1,395.27 X
58920   1 90 2 X 1,421.42 X
58925   3 90 2 X 1,275.61 X
58925   4 90 2 X 1,307.04 X
58925   2 90 2 X 1,381.42 X
58925   1 90 2 X 1,407.05 X
58940   3 90 2 X 1,301.96 X
58940   4 90 2 X 1,353.63 X
58940   2 90 2 X 1,489.90 X
58940   1 90 2 X 1,648.14 X
58943   2 90 2 X 3,086.42 X
58943   1 90 2 X 3,368.02 X
58943   4 90 2 X 3,431.01 X
58943   3 90 2 X 3,444.57 X
58950   4 90 2 X 3,066.10 X
58950   3 90 2 X 3,077.94 X
58950   2 90 2 X 3,118.15 X
58950   1 90 2 X 3,176.37 X
58951   4 90 2 X 4,671.58 X
58951   3 90 2 X 4,690.03 X
58951   2 90 2 X 4,817.39 X
58951   1 90 2 X 4,848.29 X
58952   4 90 2 X 4,732.04 X
58952   3 90 2 X 4,750.72 X
58952   2 90 2 X 4,878.37 X
58952   1 90 2 X 4,909.33 X
58953   2 90 2 X 3,397.97 X
58953   3 90 2 X 3,397.97 X
58953   4 90 2 X 3,397.97 X
58953   1 90 2 X 3,794.63 X
58954   2 90 2 X 3,694.35 X
58954   3 90 2 X 3,694.35 X
58954   4 90 2 X 3,694.35 X
58954   1 90 2 X 4,124.25 X
58956   2 90 2 X 2,261.16 X
58956   3 90 2 X 2,261.16 X
58956   4 90 2 X 2,261.16 X
58956   1 90 2 X 2,572.30 X
58957   2 90 2 X 2,023.80 X
58957   3 90 2 X 2,023.80 X
58957   4 90 2 X 2,023.80 X
58957   1 90 2 X 2,271.18 X
58958   2 90 2 X 2,240.98 X
58958   3 90 2 X 2,240.98 X
58958   4 90 2 X 2,240.98 X
58958   1 90 2 X 2,513.28 X
58960   4 90 2 X 3,411.05 X
58960   3 90 2 X 3,422.60 X
58960   2 90 2 X 3,511.93 X
58960   1 90 2 X 3,533.61 X
58970     0 2 X * X
58974     0 2 X * X
58976     0 2 X * X
58999     YYY 2 X # X
59000   4 0 2 X 215.32 X
59000   3 0 2 X 215.57 X
59000   2 0 2 X 224.37 X
59000   1 0 2 X 226.46 X
59001   2 0 2 X 308.82 X
59001   3 0 2 X 308.82 X
59001   4 0 2 X 308.82 X
59001   1 0 2 X 341.86 X
59012   4 0 2 X 561.67 X
59012   3 0 2 X 568.44 X
59012   2 0 2 X 602.34 X
59012   1 0 2 X 610.61 X
59015   4 0 2 X 308.33 X
59015   3 0 2 X 311.97 X
59015   2 0 2 X 327.11 X
59015   1 0 2 X 330.77 X
59020 TC 4 0 2 X 52.10 X
59020 TC 3 0 2 X 52.82 X
59020 TC 2 0 2 X 59.57 X
59020 TC 1 0 2 X 61.21 X
59020 26 4 0 2 X 150.12 X
59020 26 3 0 2 X 151.90 X
59020 26 2 0 2 X 165.66 X
59020   4 0 2 X 202.16 X
59020   3 0 2 X 204.79 X
59020   2 0 2 X 225.25 X
59020   1 0 2 X 230.24 X
59020 26 1 0 2 X 259.47 X
59025 TC 4 0 2 X 22.19 X
59025 TC 3 0 2 X 22.51 X
59025 TC 2 0 2 X 25.31 X
59025 TC 1 0 2 X 25.96 X
59025 26 2 0 2 X 86.38 X
59025 26 1 0 2 X 87.25 X
59025 26 4 0 2 X 88.09 X
59025 26 3 0 2 X 89.06 X
59025   4 0 2 X 96.58 X
59025   3 0 2 X 97.45 X
59025   2 0 2 X 103.19 X
59025   1 0 2 X 103.89 X
59030     0 2 X * X
59050   2 XXX 0 X 138.97 X
59050   3 XXX 0 X 138.97 X
59050   4 XXX 0 X 138.97 X
59050   1 XXX 0 X 159.55 X
59051   4 XXX 0 X 221.30 X
59051   3 XXX 0 X 223.74 X
59051   2 XXX 0 X 237.54 X
59051   1 XXX 0 X 240.85 X
59070   2 0 2 X 706.73 532.58
59070   3 0 2 X 706.73 532.58
59070   4 0 2 X 706.73 532.58
59070   1 0 2 X 784.60 579.90
59072   2 0 2 X 860.15 X
59072   3 0 2 X 860.15 X
59072   4 0 2 X 860.15 X
59072   1 0 2 X 938.37 X
59074   2 0 2 X 673.94 532.58
59074   3 0 2 X 673.94 532.58
59074   4 0 2 X 673.94 532.58
59074   1 0 2 X 746.11 579.90
59076   2 0 2 X 860.15 X
59076   3 0 2 X 860.15 X
59076   4 0 2 X 860.15 X
59076   1 0 2 X 938.37 X
59100   4 90 2 X 976.62 X
59100   3 90 2 X 987.69 X
59100   2 90 2 X 1,062.35 X
59100   1 90 2 X 1,080.42 X