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2021 Workers' Compensation Part B Fee Schedule

59120-61520

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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
59120   3 90 2 X 1,464.39 X
59120   2 90 2 X 1,583.49 X
59120   1 90 2 X 1,612.31 X
59120   4 90 2 X 1,616.49 X
59121   4 90 2 X 1,184.56 X
59121   3 90 2 X 1,198.26 X
59121   2 90 2 X 1,286.08 X
59121   1 90 2 X 1,307.37 X
59130   4 90 2 X 1,281.10 X
59130   3 90 2 X 1,296.41 X
59130   2 90 2 X 1,373.91 X
59130   1 90 2 X 1,392.62 X
59135   4 90 2 X 2,112.71 X
59135   3 90 2 X 2,138.00 X
59135   2 90 2 X 2,265.43 X
59135   1 90 2 X 2,296.27 X
59136   4 90 2 X 1,443.22 X
59136   3 90 2 X 1,459.57 X
59136   2 90 2 X 1,571.17 X
59136   1 90 2 X 1,598.30 X
59140   4 90 2 X 881.55 X
59140   3 90 2 X 892.57 X
59140   2 90 2 X 939.75 X
59140   1 90 2 X 951.13 X
59150   4 90 2 X 1,051.39 X
59150   3 90 2 X 1,063.33 X
59150   2 90 2 X 1,144.52 X
59150   1 90 2 X 1,164.28 X
59151   4 90 2 X 1,444.69 X
59151   3 90 2 X 1,463.39 X
59151   2 90 2 X 1,550.60 X
59151   1 90 2 X 1,571.56 X
59160   2 10 2 X 462.83 X
59160   3 10 2 X 462.83 X
59160   4 10 2 X 462.83 X
59160   1 10 2 X 534.68 X
59200     0 2 X * X
59300   3 0 2 X 313.56 X
59300   2 0 2 X 328.11 X
59300   1 0 2 X 382.30 X
59300   4 0 2 X 401.96 X
59320   4 0 2 X 411.82 X
59320   3 0 2 X 416.51 X
59320   2 0 2 X 448.13 X
59320   1 0 2 X 455.72 X
59325   4 0 2 X 638.70 X
59325   3 0 2 X 646.31 X
59325   2 0 2 X 682.14 X
59325   1 0 2 X 690.82 X
59350   4 0 2 X 821.06 X
59350   3 0 2 X 830.37 X
59350   2 0 2 X 893.86 X
59350   1 0 2 X 909.30 X
59400   4 MMM 2 X 2,590.22 X
59400   3 MMM 2 X 2,685.48 X
59400   2 MMM 2 X 2,908.42 X
59400   1 MMM 2 X 3,046.99 X
59409   4 MMM 2 X 1,650.07 X
59409   1 MMM 2 X 2,197.35 X
59409   3 MMM 2 X 2,227.36 X
59409   2 MMM 2 X 2,397.26 X
59410   4 MMM 2 X 1,713.47 X
59410   1 MMM 2 X 2,267.67 X
59410   3 MMM 2 X 2,421.44 X
59410   2 MMM 2 X 2,606.52 X
59412     MMM 0 X * X
59414   4 MMM 2 X 267.05 X
59414   3 MMM 2 X 270.04 X
59414   2 MMM 2 X 290.63 X
59414   1 MMM 2 X 295.73 X
59425   4 MMM 0 X 668.39 545.36
59425   3 MMM 0 X 675.98 550.77
59425   2 MMM 0 X 727.36 594.83
59425   1 MMM 0 X 739.87 605.60
59426   4 MMM 0 X 1,145.63 934.65
59426   3 MMM 0 X 1,158.62 944.04
59426   2 MMM 0 X 1,246.83 1,019.55
59426   1 MMM 0 X 1,268.31 1,038.04
59430   4 MMM 2 X 218.57 X
59430   3 MMM 2 X 220.83 X
59430   2 MMM 2 X 230.05 X
59430   1 MMM 2 X 232.36 X
59510   4 MMM 2 X 3,924.75 X
59510   3 MMM 2 X 3,969.22 X
59510   2 MMM 2 X 4,272.33 X
59510   1 MMM 2 X 4,346.05 X
59514   1 MMM 2 X 2,504.85 X
59514   4 MMM 2 X 2,552.25 X
59514   3 MMM 2 X 2,581.19 X
59514   2 MMM 2 X 2,778.42 X
59515   1 MMM 2 X 2,574.54 X
59515   4 MMM 2 X 2,743.29 X
59515   3 MMM 2 X 2,774.39 X
59515   2 MMM 2 X 2,985.92 X
59525   4 MMM 0 X 1,172.33 X
59525   3 MMM 0 X 1,185.08 X
59525   2 MMM 0 X 1,260.34 X
59525   1 MMM 0 X 1,278.68 X
59610   4 MMM 2 X 3,749.60 X
59610   3 MMM 2 X 3,804.45 X
59610   2 MMM 2 X 4,050.34 X
59610   1 MMM 2 X 4,248.58 X
59612   4 MMM 2 X 2,427.47 X
59612   3 MMM 2 X 2,462.68 X
59612   2 MMM 2 X 2,619.62 X
59612   1 MMM 2 X 2,746.37 X
59614   4 MMM 2 X 2,622.50 X
59614   3 MMM 2 X 2,660.67 X
59614   2 MMM 2 X 2,830.93 X
59614   1 MMM 2 X 2,968.29 X
59618   4 MMM 2 X 4,209.32 X
59618   3 MMM 2 X 4,270.94 X
59618   2 MMM 2 X 4,547.99 X
59618   1 MMM 2 X 4,771.27 X
59620   4 MMM 2 X 2,789.63 X
59620   3 MMM 2 X 2,830.24 X
59620   2 MMM 2 X 3,011.63 X
59620   1 MMM 2 X 3,157.99 X
59622   4 MMM 2 X 2,987.85 X
59622   3 MMM 2 X 3,031.39 X
59622   2 MMM 2 X 3,225.96 X
59622   1 MMM 2 X 3,382.80 X
59812   4 90 2 X 656.52 X
59812   3 90 2 X 664.39 X
59812   2 90 2 X 722.05 X
59812   1 90 2 X 736.09 X
59820   4 90 2 X 725.20 X
59820   3 90 2 X 809.57 X
59820   2 90 2 X 839.33 X
59820   1 90 2 X 873.59 X
59821   4 90 2 X 671.63 X
59821   3 90 2 X 679.22 X
59821   2 90 2 X 728.71 X
59821   1 90 2 X 851.94 X
59830   4 90 2 X 970.14 X
59830   3 90 2 X 981.77 X
59830   2 90 2 X 1,040.16 X
59830   1 90 2 X 1,054.26 X
59840   4 10 2 X 599.44 X
59840   3 10 2 X 606.64 X
59840   1 10 2 X 671.21 X
59840   2 10 2 X 781.28 X
59841   4 10 2 X 680.79 X
59841   2 10 2 X 747.28 X
59841   3 10 2 X 897.45 X
59841   1 10 2 X 927.96 X
59850   4 90 2 X 908.83 X
59850   3 90 2 X 919.24 X
59850   1 90 2 X 981.61 X
59850   2 90 2 X 987.43 X
59851   4 90 2 X 950.24 X
59851   3 90 2 X 961.20 X
59851   2 90 2 X 1,032.53 X
59851   1 90 2 X 1,049.74 X
59852   4 90 2 X 1,277.36 X
59852   3 90 2 X 1,291.84 X
59852   2 90 2 X 1,390.18 X
59852   1 90 2 X 1,414.09 X
59855   4 90 2 X 830.33 X
59855   3 90 2 X 841.42 X
59855   2 90 2 X 901.31 X
59855   1 90 2 X 930.77 X
59856   4 90 2 X 1,252.83 X
59856   3 90 2 X 1,269.52 X
59856   2 90 2 X 1,360.24 X
59856   1 90 2 X 1,405.00 X
59857   4 90 2 X 1,523.78 X
59857   3 90 2 X 1,544.07 X
59857   2 90 2 X 1,654.20 X
59857   1 90 2 X 1,708.43 X
59866   3 90 2 X 642.28 X
59866   4 90 2 X 642.28 X
59866   2 90 2 X 659.99 X
59866   1 90 2 X 736.57 X
59870   4 90 2 X 676.22 X
59870   3 90 2 X 683.93 X
59870   2 90 2 X 736.02 X
59870   1 90 2 X 748.70 X
59871   2 10 2 X 323.26 X
59871   3 10 2 X 323.26 X
59871   4 10 2 X 323.26 X
59871   1 10 2 X 372.73 X
59897     YYY 2 X # X
59898     YYY 2 X # X
59899     YYY 2 X # X
60000   4 10 2 X 199.59 X
60000   3 10 2 X 201.71 X
60000   2 10 2 X 220.96 X
60000   1 10 2 X 230.88 X
60100   4 0 2 X 198.96 151.04
60100   3 0 2 X 202.69 154.08
60100   2 0 2 X 211.87 161.58
60100   1 0 2 X 217.87 166.26
60200   4 90 2 X 1,401.89 X
60200   3 90 2 X 1,418.06 X
60200   2 90 2 X 1,512.02 X
60200   1 90 2 X 1,534.84 X
60210   4 90 2 X 1,937.53 X
60210   3 90 2 X 1,963.94 X
60210   2 90 2 X 2,102.29 X
60210   1 90 2 X 2,200.96 X
60212   4 90 2 X 2,010.30 X
60212   3 90 2 X 2,033.56 X
60212   2 90 2 X 2,179.46 X
60212   1 90 2 X 2,302.16 X
60220   4 90 2 X 1,761.07 X
60220   3 90 2 X 1,781.82 X
60220   2 90 2 X 1,914.96 X
60220   1 90 2 X 1,947.31 X
60225   4 90 2 X 2,117.04 X
60225   3 90 2 X 2,142.15 X
60225   2 90 2 X 2,302.08 X
60225   1 90 2 X 2,380.76 X
60240   3 90 2 X 2,516.18 X
60240   4 90 2 X 2,542.03 X
60240   2 90 2 X 2,650.51 X
60240   1 90 2 X 2,728.67 X
60252   4 90 2 X 2,928.76 X
60252   3 90 2 X 2,945.82 X
60252   2 90 2 X 3,024.49 X
60252   1 90 2 X 3,075.60 X
60254   3 90 2 X 3,899.26 X
60254   4 90 2 X 3,965.53 X
60254   2 90 2 X 3,972.74 X
60254   1 90 2 X 4,163.76 X
60260   4 90 2 X 1,497.58 X
60260   2 90 2 X 1,647.85 X
60260   3 90 2 X 1,782.58 X
60260   1 90 2 X 1,815.11 X
60270   4 90 2 X 2,900.83 X
60270   3 90 2 X 2,935.07 X
60270   2 90 2 X 3,149.60 X
60270   1 90 2 X 3,201.66 X
60271   4 90 2 X 2,499.53 X
60271   3 90 2 X 2,516.53 X
60271   2 90 2 X 2,750.32 X
60271   1 90 2 X 2,777.53 X
60280   4 90 2 X 1,391.22 X
60280   3 90 2 X 1,455.58 X
60280   2 90 2 X 1,491.63 X
60280   1 90 2 X 1,507.70 X
60281   4 90 2 X 1,235.51 X
60281   3 90 2 X 1,249.60 X
60281   2 90 2 X 1,332.94 X
60281   1 90 2 X 1,353.22 X
60300   2 0 2 X 147.22 72.82
60300   3 0 2 X 147.22 72.82
60300   4 0 2 X 147.22 72.82
60300   1 0 2 X 169.31 79.61
60500   4 90 2 X 2,830.01 X
60500   3 90 2 X 2,905.47 X
60500   2 90 2 X 2,976.36 X
60500   1 90 2 X 3,000.00 X
60502   4 90 2 X 2,913.34 X
60502   3 90 2 X 3,054.17 X
60502   2 90 2 X 3,144.79 X
60502   1 90 2 X 3,193.17 X
60505   3 90 2 X 2,212.72 X
60505   4 90 2 X 2,220.67 X
60505   2 90 2 X 2,356.98 X
60505   1 90 2 X 2,380.41 X
60512   4 ZZZ 0 X 684.41 X
60512   3 ZZZ 0 X 693.22 X
60512   2 ZZZ 0 X 737.11 X
60512   1 ZZZ 0 X 758.93 X
60520   4 90 2 X 2,916.83 X
60520   3 90 2 X 2,950.93 X
60520   2 90 2 X 3,161.42 X
60520   1 90 2 X 3,212.48 X
60521   4 90 2 X 2,916.83 X
60521   3 90 2 X 2,950.93 X
60521   2 90 2 X 3,161.42 X
60521   1 90 2 X 3,212.48 X
60522   4 90 2 X 2,916.83 X
60522   3 90 2 X 2,950.93 X
60522   2 90 2 X 3,161.42 X
60522   1 90 2 X 3,212.48 X
60540   4 90 2 X 2,628.94 X
60540   3 90 2 X 2,659.70 X
60540   2 90 2 X 2,843.33 X
60540   1 90 2 X 2,887.83 X
60545   4 90 2 X 3,508.14 X
60545   3 90 2 X 3,523.32 X
60545   2 90 2 X 3,612.51 X
60545   1 90 2 X 3,634.08 X
60600   4 90 2 X 2,598.37 X
60600   3 90 2 X 2,628.64 X
60600   2 90 2 X 2,805.05 X
60600   1 90 2 X 2,843.85 X
60605   4 90 2 X 2,749.24 X
60605   3 90 2 X 3,120.08 X
60605   2 90 2 X 3,283.48 X
60605   1 90 2 X 3,333.48 X
60650     YYY 2 X * X
60659     YYY 2 X # X
60699     YYY 2 X # X
61000   4 0 2 X 248.57 X
61000   3 0 2 X 251.50 X
61000   2 0 2 X 267.54 X
61000   1 0 2 X 271.43 X
61001   4 0 2 X 224.59 X
61001   3 0 2 X 227.09 X
61001   2 0 2 X 241.94 X
61001   1 0 2 X 245.57 X
61020   4 0 2 X 261.15 X
61020   3 0 2 X 460.46 X
61020   2 0 2 X 468.05 X
61020   1 0 2 X 469.89 X
61026   3 0 2 X 326.91 X
61026   2 0 2 X 434.85 X
61026   4 0 2 X 452.66 X
61026   1 0 2 X 454.18 X
61050   4 0 2 X 237.82 X
61050   2 0 2 X 367.63 X
61050   1 0 2 X 370.47 X
61050   3 0 2 X 395.49 X
61055   1 0 0 X 372.43 X
61055   3 0 0 X 424.51 X
61055   4 0 0 X 433.39 X
61055   2 0 0 X 441.49 X
61070   4 0 2 X 116.87 X
61070   3 0 2 X 175.64 X
61070   2 0 2 X 177.91 X
61070   1 0 2 X 178.47 X
61105   4 90 2 X 1,436.60 X
61105   3 90 2 X 1,453.52 X
61105   2 90 2 X 1,765.47 X
61105   1 90 2 X 1,776.21 X
61107   4 0 0 X 1,047.46 X
61107   3 0 0 X 1,521.31 X
61107   2 0 0 X 1,558.75 X
61107   1 0 0 X 1,609.78 X
61108   1 90 2 X 3,048.57 X
61108   3 90 2 X 3,344.22 X
61108   4 90 2 X 3,378.61 X
61108   2 90 2 X 3,464.73 X
61120   4 90 2 X 1,442.21 X
61120   3 90 2 X 1,458.64 X
61120   2 90 2 X 1,554.96 X
61120   1 90 2 X 1,626.63 X
61140   4 90 2 X 2,473.05 X
61140   3 90 2 X 2,492.01 X
61140   1 90 2 X 2,565.65 X
61140   2 90 2 X 2,603.10 X
61150   4 90 2 X 2,960.21 X
61150   3 90 2 X 3,045.74 X
61150   2 90 2 X 3,216.92 X
61150   1 90 2 X 3,270.63 X
61151   3 90 2 X 1,046.19 X
61151   2 90 2 X 1,066.01 X
61151   1 90 2 X 1,091.50 X
61151   4 90 2 X 1,238.44 X
61154   1 90 2 X 3,443.37 X
61154   3 90 2 X 3,717.90 X
61154   4 90 2 X 3,735.26 X
61154   2 90 2 X 3,805.84 X
61156   4 90 2 X 3,027.75 X
61156   3 90 2 X 3,064.23 X
61156   2 90 2 X 3,308.62 X
61156   1 90 2 X 3,367.81 X
61210   4 0 0 X 1,200.16 X
61210   1 0 0 X 2,130.95 X
61210   3 0 0 X 2,453.41 X
61210   2 0 0 X 2,492.00 X
61215     90 2 X * X
61250   4 90 2 X 1,807.43 X
61250   1 90 2 X 1,985.06 X
61250   3 90 2 X 2,165.73 X
61250   2 90 2 X 2,218.63 X
61253   4 90 2 X 2,142.69 X
61253   3 90 2 X 2,167.59 X
61253   2 90 2 X 2,316.58 X
61253   1 90 2 X 2,352.74 X
61304   3 90 2 X 4,715.48 X
61304   4 90 2 X 4,726.30 X
61304   2 90 2 X 4,945.74 X
61304   1 90 2 X 5,037.56 X
61305   4 90 2 X 5,171.00 X
61305   3 90 2 X 5,234.40 X
61305   2 90 2 X 5,703.23 X
61305   1 90 2 X 5,750.92 X
61312   4 90 2 X 4,311.89 X
61312   3 90 2 X 4,342.30 X
61312   2 90 2 X 4,720.58 X
61312   1 90 2 X 4,806.79 X
61313   4 90 2 X 4,297.06 X
61313   3 90 2 X 4,349.49 X
61313   2 90 2 X 4,701.95 X
61313   1 90 2 X 4,787.19 X
61314   3 90 2 X 4,491.91 X
61314   4 90 2 X 4,659.95 X
61314   2 90 2 X 5,094.39 X
61314   1 90 2 X 5,185.88 X
61315   3 90 2 X 4,802.20 X
61315   4 90 2 X 4,818.42 X
61315   2 90 2 X 5,245.72 X
61315   1 90 2 X 5,335.31 X
61316   2 90 2 X 155.81 X
61316   3 90 2 X 155.81 X
61316   4 90 2 X 155.81 X
61316   1 90 2 X 184.72 X
61320   4 90 2 X 4,054.25 X
61320   3 90 2 X 4,101.52 X
61320   2 90 2 X 4,378.49 X
61320   1 90 2 X 4,504.76 X
61321   4 90 2 X 4,409.95 X
61321   3 90 2 X 4,461.21 X
61321   2 90 2 X 4,770.30 X
61321   1 90 2 X 4,845.23 X
61322   2 90 2 X 3,198.96 X
61322   3 90 2 X 3,198.96 X
61322   4 90 2 X 3,198.96 X
61322   1 90 2 X 3,648.45 X
61323   2 90 2 X 3,315.17 X
61323   3 90 2 X 3,315.17 X
61323   4 90 2 X 3,315.17 X
61323   1 90 2 X 3,770.54 X
61330   4 90 2 X 2,623.31 X
61330   3 90 2 X 2,655.37 X
61330   2 90 2 X 2,807.59 X
61330   1 90 2 X 2,844.28 X
61333   4 90 2 X 4,446.88 X
61333   3 90 2 X 4,499.17 X
61333   2 90 2 X 4,800.14 X
61333   1 90 2 X 4,873.08 X
61340   4 90 2 X 2,533.46 X
61340   3 90 2 X 2,564.85 X
61340   2 90 2 X 2,762.02 X
61340   1 90 2 X 2,859.82 X
61343   4 90 2 X 5,549.77 X
61343   3 90 2 X 5,617.10 X
61343   1 90 2 X 5,786.95 X
61343   2 90 2 X 6,054.28 X
61345   4 90 2 X 4,228.89 X
61345   3 90 2 X 4,278.11 X
61345   2 90 2 X 4,577.19 X
61345   1 90 2 X 4,649.72 X
61450   4 90 2 X 4,238.60 X
61450   3 90 2 X 4,288.82 X
61450   2 90 2 X 4,591.23 X
61450   1 90 2 X 4,664.48 X
61458   4 90 2 X 5,104.88 X
61458   3 90 2 X 5,828.50 X
61458   2 90 2 X 6,019.43 X
61458   1 90 2 X 6,138.88 X
61460   4 90 2 X 4,903.94 X
61460   3 90 2 X 4,963.01 X
61460   2 90 2 X 5,914.26 X
61460   1 90 2 X 6,029.03 X
61500   4 90 2 X 3,560.45 X
61500   3 90 2 X 3,721.87 X
61500   2 90 2 X 3,894.46 X
61500   1 90 2 X 3,964.77 X
61501   4 90 2 X 3,032.46 X
61501   3 90 2 X 3,069.81 X
61501   2 90 2 X 3,330.10 X
61501   1 90 2 X 3,393.14 X
61510   4 90 2 X 5,054.14 X
61510   3 90 2 X 5,078.97 X
61510   2 90 2 X 5,310.44 X
61510   1 90 2 X 5,406.18 X
61512   4 90 2 X 5,137.87 X
61512   3 90 2 X 5,200.68 X
61512   2 90 2 X 5,624.53 X
61512   1 90 2 X 5,727.12 X
61514   4 90 2 X 4,719.88 X
61514   3 90 2 X 4,776.95 X
61514   2 90 2 X 5,158.32 X
61514   1 90 2 X 5,502.40 X
61516   4 90 2 X 4,728.08 X
61516   3 90 2 X 4,786.05 X
61516   2 90 2 X 5,163.83 X
61516   1 90 2 X 5,255.25 X
61517   2 90 2 X 135.58 X
61517   3 90 2 X 135.58 X
61517   4 90 2 X 135.58 X
61517   1 90 2 X 148.79 X
61518   4 90 2 X 5,958.41 X
61518   3 90 2 X 6,029.31 X
61518   1 90 2 X 6,407.99 X
61518   2 90 2 X 6,483.47 X
61519   4 90 2 X 6,230.50 X
61519   3 90 2 X 6,304.51 X
61519   1 90 2 X 6,613.02 X
61519   2 90 2 X 6,781.18 X
61520   4 90 2 X 6,871.84 X
61520   3 90 2 X 6,953.53 X
61520   2 90 2 X 7,891.86 X
61520   1 90 2 X 7,943.28 X