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2021 Workers' Compensation Part B Fee Schedule

61521-62161

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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
61521   3 90 2 X 6,975.46 X
61521   4 90 2 X 7,469.34 X
61521   2 90 2 X 7,477.32 X
61521   1 90 2 X 7,765.13 X
61522   4 90 2 X 4,523.24 X
61522   3 90 2 X 4,575.47 X
61522   2 90 2 X 4,897.51 X
61522   1 90 2 X 4,975.62 X
61524   4 90 2 X 5,150.59 X
61524   3 90 2 X 5,212.56 X
61524   2 90 2 X 5,626.88 X
61524   1 90 2 X 5,727.23 X
61526   4 90 2 X 6,009.10 X
61526   3 90 2 X 6,083.86 X
61526   2 90 2 X 7,499.62 X
61526   1 90 2 X 7,544.32 X
61530   4 90 2 X 6,009.10 X
61530   3 90 2 X 6,083.86 X
61530   2 90 2 X 6,524.82 X
61530   1 90 2 X 6,631.31 X
61531   4 90 2 X 3,280.08 X
61531   3 90 2 X 3,319.14 X
61531   2 90 2 X 3,514.86 X
61531   1 90 2 X 3,562.08 X
61533   4 90 2 X 3,858.90 X
61533   3 90 2 X 3,903.32 X
61533   2 90 2 X 4,182.05 X
61533   1 90 2 X 4,249.77 X
61534   4 90 2 X 2,444.33 X
61534   3 90 2 X 2,469.52 X
61534   1 90 2 X 2,667.46 X
61534   2 90 2 X 3,531.23 X
61535   4 90 2 X 1,686.24 X
61535   3 90 2 X 1,706.02 X
61535   2 90 2 X 1,820.23 X
61535   1 90 2 X 1,847.87 X
61536   4 90 2 X 4,880.67 X
61536   3 90 2 X 4,937.36 X
61536   2 90 2 X 5,282.16 X
61536   1 90 2 X 5,365.72 X
61537   2 90 2 X 3,009.57 X
61537   3 90 2 X 3,009.57 X
61537   4 90 2 X 3,009.57 X
61537   1 90 2 X 3,486.00 X
61538   4 90 2 X 5,455.09 X
61538   3 90 2 X 5,521.13 X
61538   2 90 2 X 5,940.85 X
61538   1 90 2 X 6,042.97 X
61539   4 90 2 X 5,030.07 X
61539   3 90 2 X 5,088.75 X
61539   2 90 2 X 5,443.75 X
61539   1 90 2 X 5,529.91 X
61540   2 90 2 X 3,631.52 X
61540   3 90 2 X 3,631.52 X
61540   4 90 2 X 3,631.52 X
61540   1 90 2 X 4,212.93 X
61541   4 90 2 X 4,454.66 X
61541   3 90 2 X 4,506.14 X
61541   2 90 2 X 4,825.57 X
61541   1 90 2 X 5,074.01 X
61543   4 90 2 X 3,550.91 X
61543   3 90 2 X 3,593.30 X
61543   2 90 2 X 3,831.90 X
61543   1 90 2 X 3,889.63 X
61544   4 90 2 X 4,729.00 X
61544   3 90 2 X 4,790.16 X
61544   2 90 2 X 5,075.82 X
61544   1 90 2 X 5,144.38 X
61545   4 90 2 X 5,725.84 X
61545   3 90 2 X 5,792.26 X
61545   2 90 2 X 6,201.18 X
61545   1 90 2 X 6,300.37 X
61546   4 90 2 X 5,375.75 X
61546   3 90 2 X 5,993.51 X
61546   2 90 2 X 6,162.93 X
61546   1 90 2 X 6,226.84 X
61548   1 90 2 X 5,131.75 X
61548   4 90 2 X 6,143.19 X
61548   3 90 2 X 6,368.25 X
61548   2 90 2 X 6,458.74 X
61550   4 90 2 X 2,388.47 X
61550   3 90 2 X 2,417.56 X
61550   2 90 2 X 2,556.20 X
61550   1 90 2 X 2,589.64 X
61552   4 90 2 X 3,134.15 X
61552   3 90 2 X 3,170.27 X
61552   1 90 2 X 3,451.31 X
61552   2 90 2 X 4,134.17 X
61556   1 90 2 X 5,325.03 X
61556   2 90 2 X 5,325.03 X
61556   3 90 2 X 5,325.03 X
61556   4 90 2 X 5,325.03 X
61557   1 90 2 X 7,987.58 X
61557   2 90 2 X 7,987.58 X
61557   3 90 2 X 7,987.58 X
61557   4 90 2 X 7,987.58 X
61558   4 90 2 X 4,250.49 X
61558   3 90 2 X 4,307.58 X
61558   2 90 2 X 4,600.14 X
61558   1 90 2 X 4,742.05 X
61559   4 90 2 X 5,512.04 X
61559   3 90 2 X 5,586.08 X
61559   2 90 2 X 5,965.41 X
61559   1 90 2 X 6,149.50 X
61563   1 90 2 X 7,707.29 X
61563   2 90 2 X 7,707.29 X
61563   3 90 2 X 7,707.29 X
61563   4 90 2 X 7,707.29 X
61564   1 90 2 X 9,809.25 X
61564   2 90 2 X 9,809.25 X
61564   3 90 2 X 9,809.25 X
61564   4 90 2 X 9,809.25 X
61566   2 90 2 X 3,614.69 X
61566   3 90 2 X 3,614.69 X
61566   4 90 2 X 3,614.69 X
61566   1 90 2 X 4,134.21 X
61567   2 90 2 X 4,138.66 X
61567   3 90 2 X 4,138.66 X
61567   4 90 2 X 4,138.66 X
61567   1 90 2 X 4,702.61 X
61570   4 90 2 X 3,741.03 X
61570   3 90 2 X 4,039.55 X
61570   2 90 2 X 4,047.52 X
61570   1 90 2 X 4,314.87 X
61571   4 90 2 X 4,060.95 X
61571   3 90 2 X 4,108.25 X
61571   2 90 2 X 4,391.24 X
61571   1 90 2 X 4,459.80 X
61575   4 90 2 X 6,181.47 X
61575   3 90 2 X 6,548.06 X
61575   2 90 2 X 6,709.51 X
61575   1 90 2 X 6,818.95 X
61576   4 90 2 X 5,803.79 X
61576   3 90 2 X 5,873.33 X
61576   2 90 2 X 6,256.77 X
61576   1 90 2 X 6,349.52 X
61580   4 90 2 X 4,762.32 X
61580   3 90 2 X 4,817.18 X
61580   2 90 2 X 5,160.86 X
61580   1 90 2 X 5,244.28 X
61581   4 90 2 X 5,404.95 X
61581   3 90 2 X 5,467.31 X
61581   2 90 2 X 5,857.32 X
61581   1 90 2 X 5,951.96 X
61582   4 90 2 X 4,906.18 X
61582   3 90 2 X 4,962.72 X
61582   2 90 2 X 5,316.58 X
61582   1 90 2 X 5,402.42 X
61583   4 90 2 X 5,598.62 X
61583   3 90 2 X 5,663.14 X
61583   2 90 2 X 6,067.16 X
61583   1 90 2 X 6,165.23 X
61584   4 90 2 X 5,421.60 X
61584   3 90 2 X 5,484.12 X
61584   2 90 2 X 5,875.50 X
61584   1 90 2 X 5,970.53 X
61585   4 90 2 X 6,065.22 X
61585   3 90 2 X 6,135.06 X
61585   2 90 2 X 6,572.90 X
61585   1 90 2 X 6,679.21 X
61586   3 90 2 X 4,075.16 X
61586   4 90 2 X 4,075.16 X
61586   2 90 2 X 4,187.73 X
61586   1 90 2 X 4,616.77 X
61590   4 90 2 X 6,595.38 X
61590   3 90 2 X 6,671.35 X
61590   2 90 2 X 7,146.99 X
61590   1 90 2 X 7,262.43 X
61591   4 90 2 X 6,918.00 X
61591   3 90 2 X 6,997.71 X
61591   2 90 2 X 7,497.05 X
61591   1 90 2 X 7,618.19 X
61592   4 90 2 X 6,274.45 X
61592   3 90 2 X 6,346.76 X
61592   2 90 2 X 6,799.59 X
61592   1 90 2 X 6,909.52 X
61595   4 90 2 X 4,634.10 X
61595   3 90 2 X 4,687.52 X
61595   2 90 2 X 5,022.00 X
61595   1 90 2 X 5,103.17 X
61596   4 90 2 X 5,631.75 X
61596   3 90 2 X 5,696.64 X
61596   2 90 2 X 6,103.11 X
61596   1 90 2 X 6,201.73 X
61597   4 90 2 X 5,952.65 X
61597   3 90 2 X 6,021.30 X
61597   2 90 2 X 6,450.94 X
61597   1 90 2 X 6,555.14 X
61598   4 90 2 X 5,244.59 X
61598   3 90 2 X 5,305.01 X
61598   2 90 2 X 5,683.42 X
61598   1 90 2 X 5,775.29 X
61600   4 90 2 X 4,021.92 X
61600   3 90 2 X 4,068.24 X
61600   2 90 2 X 4,358.24 X
61600   1 90 2 X 4,428.67 X
61601   4 90 2 X 4,312.34 X
61601   3 90 2 X 4,362.02 X
61601   2 90 2 X 4,673.27 X
61601   1 90 2 X 4,748.82 X
61605   4 90 2 X 4,553.00 X
61605   3 90 2 X 4,605.49 X
61605   2 90 2 X 4,934.11 X
61605   1 90 2 X 5,013.88 X
61606   4 90 2 X 6,097.40 X
61606   3 90 2 X 6,167.67 X
61606   2 90 2 X 6,607.54 X
61606   1 90 2 X 6,714.27 X
61607   4 90 2 X 5,695.40 X
61607   3 90 2 X 5,761.02 X
61607   2 90 2 X 6,171.87 X
61607   1 90 2 X 6,271.62 X
61608   4 90 2 X 6,627.63 X
61608   3 90 2 X 6,704.00 X
61608   2 90 2 X 7,182.05 X
61608   1 90 2 X 7,298.09 X
61611   4 ZZZ 0 X 964.51 X
61611   3 ZZZ 0 X 975.60 X
61611   2 ZZZ 0 X 1,045.18 X
61611   1 ZZZ 0 X 1,062.06 X
61613   4 90 2 X 6,499.46 X
61613   3 90 2 X 6,574.36 X
61613   2 90 2 X 7,043.60 X
61613   1 90 2 X 7,157.46 X
61615   4 90 2 X 5,003.84 X
61615   3 90 2 X 5,061.54 X
61615   2 90 2 X 5,422.60 X
61615   1 90 2 X 5,510.22 X
61616   4 90 2 X 6,805.53 X
61616   3 90 2 X 6,883.98 X
61616   2 90 2 X 7,375.00 X
61616   1 90 2 X 7,494.18 X
61618   4 90 2 X 2,573.41 X
61618   3 90 2 X 2,603.10 X
61618   2 90 2 X 2,788.70 X
61618   1 90 2 X 2,833.76 X
61619   4 90 2 X 3,217.05 X
61619   3 90 2 X 3,254.09 X
61619   2 90 2 X 3,486.12 X
61619   1 90 2 X 3,542.39 X
61623   2 90 2 X 986.68 X
61623   3 90 2 X 986.68 X
61623   4 90 2 X 986.68 X
61623   1 90 2 X 1,080.55 X
61624   4 0 2 X 3,067.07 X
61624   3 0 2 X 3,103.79 X
61624   2 0 2 X 3,289.11 X
61624   1 0 2 X 3,333.99 X
61626   4 0 2 X 2,529.14 X
61626   3 0 2 X 2,559.38 X
61626   2 0 2 X 2,712.18 X
61626   1 0 2 X 2,749.06 X
61630     90 9 X * X
61635     90 9 X * X
61640     0 9 X * X
61641     ZZZ 9 X * X
61642     ZZZ 9 X * X
61645   2 0 0 X 1,039.27 X
61645   3 0 0 X 1,039.27 X
61645   4 0 0 X 1,039.27 X
61645   1 0 0 X 1,126.99 X
61650   2 ZZZ 2 X 692.69 X
61650   3 ZZZ 2 X 692.69 X
61650   4 ZZZ 2 X 692.69 X
61650   1 ZZZ 2 X 750.03 X
61651   2 ZZZ 2 X 294.20 X
61651   3 ZZZ 2 X 294.20 X
61651   4 ZZZ 2 X 294.20 X
61651   1 ZZZ 2 X 318.54 X
61680   4 90 2 X 6,453.10 X
61680   3 90 2 X 6,529.03 X
61680   2 90 2 X 7,011.46 X
61680   1 90 2 X 7,128.46 X
61682   4 90 2 X 7,384.54 X
61682   3 90 2 X 7,471.55 X
61682   2 90 2 X 8,012.52 X
61682   1 90 2 X 8,143.61 X
61684   4 90 2 X 6,382.65 X
61684   3 90 2 X 6,458.95 X
61684   2 90 2 X 6,844.16 X
61684   1 90 2 X 6,937.23 X
61686   4 90 2 X 7,716.79 X
61686   3 90 2 X 7,809.11 X
61686   2 90 2 X 8,275.07 X
61686   1 90 2 X 8,387.69 X
61690   4 90 2 X 5,755.67 X
61690   3 90 2 X 5,824.17 X
61690   2 90 2 X 6,211.51 X
61690   1 90 2 X 6,305.27 X
61692   4 90 2 X 6,173.62 X
61692   3 90 2 X 6,247.44 X
61692   2 90 2 X 6,620.22 X
61692   1 90 2 X 6,710.26 X
61697   2 90 2 X 6,267.98 X
61697   3 90 2 X 6,267.98 X
61697   4 90 2 X 6,267.98 X
61697   1 90 2 X 7,175.51 X
61698   2 90 2 X 6,031.13 X
61698   3 90 2 X 6,031.13 X
61698   4 90 2 X 6,031.13 X
61698   1 90 2 X 6,909.07 X
61700   4 90 2 X 6,347.40 X
61700   3 90 2 X 6,425.58 X
61700   2 90 2 X 6,902.70 X
61700   1 90 2 X 7,042.10 X
61702   4 90 2 X 7,222.57 X
61702   3 90 2 X 7,308.57 X
61702   2 90 2 X 7,858.37 X
61702   1 90 2 X 7,991.59 X
61703   4 90 2 X 2,707.42 X
61703   3 90 2 X 2,738.83 X
61703   2 90 2 X 2,931.14 X
61703   1 90 2 X 2,977.78 X
61705   4 90 2 X 6,172.22 X
61705   3 90 2 X 6,354.63 X
61705   2 90 2 X 6,697.94 X
61705   1 90 2 X 6,807.49 X
61708   4 90 2 X 5,380.02 X
61708   3 90 2 X 5,444.97 X
61708   2 90 2 X 5,728.29 X
61708   1 90 2 X 5,818.87 X
61710   4 90 2 X 4,106.53 X
61710   3 90 2 X 4,154.37 X
61710   2 90 2 X 4,375.41 X
61710   1 90 2 X 4,771.32 X
61711   2 90 2 X 6,493.44 X
61711   4 90 2 X 6,495.71 X
61711   3 90 2 X 6,573.05 X
61711   1 90 2 X 6,708.57 X
61720   4 90 2 X 3,724.07 X
61720   3 90 2 X 3,770.52 X
61720   1 90 2 X 5,336.69 X
61720   2 90 2 X 5,431.89 X
61735   4 90 2 X 2,778.10 X
61735   3 90 2 X 2,811.30 X
61735   1 90 2 X 3,019.58 X
61735   2 90 2 X 3,747.23 X
61750   4 90 2 X 4,614.35 X
61750   3 90 2 X 4,631.00 X
61750   2 90 2 X 4,761.94 X
61750   1 90 2 X 4,793.62 X
61751   4 90 2 X 5,012.35 X
61751   3 90 2 X 5,032.37 X
61751   2 90 2 X 5,175.62 X
61751   1 90 2 X 5,194.85 X
61760   4 90 2 X 3,668.82 X
61760   3 90 2 X 3,711.48 X
61760   2 90 2 X 3,916.75 X
61760   1 90 2 X 3,966.43 X
61770   4 90 2 X 3,328.02 X
61770   3 90 2 X 3,369.03 X
61770   2 90 2 X 4,122.80 X
61770   1 90 2 X 4,305.21 X
61781   2 ZZZ 0 X 362.53 X
61781   3 ZZZ 0 X 362.53 X
61781   4 ZZZ 0 X 362.53 X
61781   1 ZZZ 0 X 411.73 X
61782   2 ZZZ 0 X 296.54 X
61782   3 ZZZ 0 X 296.54 X
61782   4 ZZZ 0 X 296.54 X
61782   1 ZZZ 0 X 333.25 X
61783   2 ZZZ 0 X 362.53 X
61783   3 ZZZ 0 X 362.53 X
61783   4 ZZZ 0 X 362.53 X
61783   1 ZZZ 0 X 411.73 X
61790   2 90 2 X 3,678.16 X
61790   4 90 2 X 3,793.21 X
61790   3 90 2 X 3,806.58 X
61790   1 90 2 X 3,927.02 X
61791   3 90 2 X 2,230.98 X
61791   4 90 2 X 3,558.58 X
61791   2 90 2 X 3,665.92 X
61791   1 90 2 X 3,688.97 X
61796   2 90 0 X 1,100.97 X
61796   3 90 0 X 1,100.97 X
61796   4 90 0 X 1,100.97 X
61796   1 90 0 X 1,253.38 X
61797   2 ZZZ 0 X 302.96 X
61797   3 ZZZ 0 X 302.96 X
61797   4 ZZZ 0 X 302.96 X
61797   1 ZZZ 0 X 339.98 X
61798   2 90 0 X 1,100.97 X
61798   3 90 0 X 1,100.97 X
61798   4 90 0 X 1,100.97 X
61798   1 90 0 X 1,253.38 X
61799   2 ZZZ 0 X 418.91 X
61799   3 ZZZ 0 X 418.91 X
61799   4 ZZZ 0 X 418.91 X
61799   1 ZZZ 0 X 470.21 X
61800   2 ZZZ 0 X 214.52 X
61800   3 ZZZ 0 X 214.52 X
61800   4 ZZZ 0 X 214.52 X
61800   1 ZZZ 0 X 243.86 X
61850   2 90 2 X 2,549.28 X
61850   4 90 2 X 2,634.45 X
61850   3 90 2 X 2,664.82 X
61850   1 90 2 X 2,900.82 X
61860   4 90 2 X 1,845.33 X
61860   3 90 2 X 1,866.58 X
61860   2 90 2 X 1,999.75 X
61860   1 90 2 X 2,032.09 X
61863   2 90 2 X 2,165.67 X
61863   3 90 2 X 2,165.67 X
61863   4 90 2 X 2,165.67 X
61863   1 90 2 X 2,501.76 X
61864   2 ZZZ 0 X 519.46 X
61864   3 ZZZ 0 X 519.46 X
61864   4 ZZZ 0 X 519.46 X
61864   1 ZZZ 0 X 600.10 X
61867   2 90 2 X 3,313.40 X
61867   3 90 2 X 3,313.40 X
61867   4 90 2 X 3,313.40 X
61867   1 90 2 X 3,720.96 X
61868   2 ZZZ 0 X 872.21 X
61868   3 ZZZ 0 X 872.21 X
61868   4 ZZZ 0 X 872.21 X
61868   1 ZZZ 0 X 981.26 X
61880   4 90 2 X 982.48 X
61880   3 90 2 X 994.30 X
61880   1 90 2 X 1,075.00 X
61880   2 90 2 X 1,354.57 X
61885   4 90 2 X 404.71 X
61885   3 90 2 X 409.55 X
61885   2 90 2 X 436.84 X
61885   1 90 2 X 1,150.24 X
61886   2 90 2 X 1,101.38 X
61886   3 90 2 X 1,101.38 X
61886   4 90 2 X 1,101.38 X
61886   1 90 2 X 1,257.55 X
61888   4 10 2 X 509.29 X
61888   3 10 2 X 515.12 X
61888   2 10 2 X 551.78 X
61888   1 10 2 X 560.66 X
62000   3 90 2 X 1,604.54 X
62000   1 90 2 X 1,721.50 X
62000   4 90 2 X 1,990.22 X
62000   2 90 2 X 2,246.53 X
62005   4 90 2 X 2,457.20 X
62005   2 90 2 X 2,657.94 X
62005   1 90 2 X 2,699.64 X
62005   3 90 2 X 3,233.30 X
62010   3 90 2 X 3,646.49 X
62010   4 90 2 X 3,810.20 X
62010   2 90 2 X 3,927.94 X
62010   1 90 2 X 3,996.04 X
62100   4 90 2 X 4,051.02 X
62100   3 90 2 X 4,498.32 X
62100   2 90 2 X 4,634.93 X
62100   1 90 2 X 4,821.22 X
62115   1 90 2 X 8,408.00 X
62115   2 90 2 X 8,408.00 X
62115   3 90 2 X 8,408.00 X
62115   4 90 2 X 8,408.00 X
62117   1 90 2 X 9,809.25 X
62117   2 90 2 X 9,809.25 X
62117   3 90 2 X 9,809.25 X
62117   4 90 2 X 9,809.25 X
62120   4 90 2 X 3,624.40 X
62120   3 90 2 X 3,666.91 X
62120   2 90 2 X 3,944.47 X
62120   1 90 2 X 4,011.86 X
62121   4 90 2 X 3,624.40 X
62121   3 90 2 X 3,666.91 X
62121   2 90 2 X 3,944.47 X
62121   1 90 2 X 4,011.86 X
62140   3 90 2 X 2,765.54 X
62140   4 90 2 X 2,779.57 X
62140   2 90 2 X 2,836.38 X
62140   1 90 2 X 2,928.39 X
62141   4 90 2 X 3,056.89 X
62141   3 90 2 X 3,099.06 X
62141   2 90 2 X 3,227.40 X
62141   1 90 2 X 3,421.11 X
62142   4 90 2 X 2,241.97 X
62142   3 90 2 X 3,519.73 X
62142   2 90 2 X 3,603.83 X
62142   1 90 2 X 3,624.19 X
62143   4 90 2 X 2,020.28 X
62143   3 90 2 X 2,043.81 X
62143   2 90 2 X 2,186.81 X
62143   1 90 2 X 2,221.52 X
62145   4 90 2 X 2,920.85 X
62145   3 90 2 X 2,954.95 X
62145   1 90 2 X 3,206.88 X
62145   2 90 2 X 4,653.16 X
62146   4 90 2 X 2,490.58 X
62146   3 90 2 X 2,519.31 X
62146   2 90 2 X 2,699.00 X
62146   1 90 2 X 2,742.64 X
62147   4 90 2 X 2,987.71 X
62147   3 90 2 X 3,022.13 X
62147   2 90 2 X 3,237.52 X
62147   1 90 2 X 3,289.84 X
62148   2 90 2 X 214.00 X
62148   3 90 2 X 214.00 X
62148   4 90 2 X 214.00 X
62148   1 90 2 X 247.19 X
62160   2 ZZZ 0 X 309.73 X
62160   3 ZZZ 0 X 309.73 X
62160   4 ZZZ 0 X 309.73 X
62160   1 ZZZ 0 X 353.12 X
62161   2 ZZZ 0 X 2,205.27 X
62161   3 ZZZ 0 X 2,205.27 X
62161   4 ZZZ 0 X 2,205.27 X
62161   1 ZZZ 0 X 2,527.52 X