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2021 Workers' Compensation Part B Fee Schedule

64771-66150

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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
64771   4 90 2 X 1,242.82 X
64771   3 90 2 X 1,258.05 X
64771   2 90 2 X 1,337.15 X
64771   1 90 2 X 1,356.30 X
64772   4 90 2 X 1,306.69 X
64772   2 90 2 X 1,537.25 X
64772   3 90 2 X 1,607.28 X
64772   1 90 2 X 1,776.38 X
64774   3 90 2 X 754.52 X
64774   2 90 2 X 799.88 X
64774   4 90 2 X 822.31 X
64774   1 90 2 X 884.22 X
64776   4 90 2 X 710.25 X
64776   3 90 2 X 718.38 X
64776   2 90 2 X 760.36 X
64776   1 90 2 X 802.81 X
64778   4 ZZZ 0 X 550.73 X
64778   3 ZZZ 0 X 557.32 X
64778   2 ZZZ 0 X 596.04 X
64778   1 ZZZ 0 X 605.32 X
64782   4 90 2 X 964.86 X
64782   3 90 2 X 976.62 X
64782   2 90 2 X 1,033.13 X
64782   1 90 2 X 1,046.72 X
64783   4 ZZZ 0 X 655.90 X
64783   3 ZZZ 0 X 687.18 X
64783   2 ZZZ 0 X 708.67 X
64783   1 ZZZ 0 X 719.49 X
64784   4 90 2 X 1,418.53 X
64784   3 90 2 X 1,434.69 X
64784   1 90 2 X 1,569.14 X
64784   2 90 2 X 1,575.19 X
64786   3 90 2 X 2,509.62 X
64786   4 90 2 X 2,631.73 X
64786   2 90 2 X 2,850.78 X
64786   1 90 2 X 2,896.29 X
64787   4 ZZZ 0 X 737.70 X
64787   3 ZZZ 0 X 746.35 X
64787   2 ZZZ 0 X 798.93 X
64787   1 ZZZ 0 X 811.80 X
64788   4 90 2 X 636.18 X
64788   2 90 2 X 757.30 X
64788   3 90 2 X 767.81 X
64788   1 90 2 X 812.38 X
64790   4 90 2 X 1,701.06 X
64790   3 90 2 X 1,720.54 X
64790   2 90 2 X 1,781.39 X
64790   1 90 2 X 1,830.57 X
64792   4 90 2 X 2,221.78 X
64792   3 90 2 X 2,237.01 X
64792   2 90 2 X 2,384.64 X
64792   1 90 2 X 2,420.46 X
64795   3 0 2 X 638.50 X
64795   4 0 2 X 665.96 X
64795   2 0 2 X 684.75 X
64795   1 0 2 X 692.92 X
64802   4 90 2 X 1,299.02 X
64802   3 90 2 X 1,313.74 X
64802   1 90 2 X 1,427.95 X
64802   2 90 2 X 1,552.84 X
64804   4 90 2 X 2,538.36 X
64804   3 90 2 X 2,568.53 X
64804   1 90 2 X 2,714.65 X
64804   2 90 2 X 2,766.58 X
64809   4 90 2 X 2,234.93 X
64809   3 90 2 X 2,453.36 X
64809   1 90 2 X 2,469.53 X
64809   2 90 2 X 2,471.35 X
64818   4 90 2 X 1,734.40 X
64818   3 90 2 X 1,754.78 X
64818   2 90 2 X 1,891.74 X
64818   1 90 2 X 1,924.89 X
64820   4 90 2 X 1,585.76 X
64820   3 90 2 X 1,607.00 X
64820   2 90 2 X 1,716.30 X
64820   1 90 2 X 1,769.36 X
64821   2 90 2 X 1,118.97 X
64821   3 90 2 X 1,118.97 X
64821   4 90 2 X 1,118.97 X
64821   1 90 2 X 1,264.78 X
64822   2 90 2 X 1,118.97 X
64822   3 90 2 X 1,118.97 X
64822   4 90 2 X 1,118.97 X
64822   1 90 2 X 1,264.78 X
64823   2 90 2 X 1,292.65 X
64823   3 90 2 X 1,292.65 X
64823   4 90 2 X 1,292.65 X
64823   1 90 2 X 1,459.44 X
64831   4 90 2 X 1,228.83 X
64831   3 90 2 X 1,237.64 X
64831   2 90 2 X 1,273.14 X
64831   1 90 2 X 1,301.86 X
64832   4 ZZZ 0 X 649.36 X
64832   3 ZZZ 0 X 656.08 X
64832   2 ZZZ 0 X 685.79 X
64832   1 ZZZ 0 X 890.71 X
64834   4 90 2 X 1,227.52 X
64834   3 90 2 X 1,267.83 X
64834   2 90 2 X 1,303.93 X
64834   1 90 2 X 1,319.32 X
64835   4 90 2 X 1,543.24 X
64835   3 90 2 X 1,560.78 X
64835   2 90 2 X 1,657.58 X
64835   1 90 2 X 1,681.10 X
64836   3 90 2 X 1,641.43 X
64836   2 90 2 X 1,749.88 X
64836   1 90 2 X 1,776.25 X
64836   4 90 2 X 1,798.97 X
64837   4 ZZZ 0 X 1,019.60 X
64837   3 ZZZ 0 X 1,031.38 X
64837   2 ZZZ 0 X 1,103.69 X
64837   1 ZZZ 0 X 1,121.18 X
64840   4 90 2 X 2,049.64 X
64840   3 90 2 X 2,075.14 X
64840   2 90 2 X 2,178.31 X
64840   1 90 2 X 2,203.07 X
64856   4 90 2 X 1,984.21 X
64856   3 90 2 X 2,029.75 X
64856   2 90 2 X 2,120.24 X
64856   1 90 2 X 2,152.42 X
64857   4 90 2 X 2,160.64 X
64857   3 90 2 X 2,185.83 X
64857   2 90 2 X 2,187.15 X
64857   1 90 2 X 2,363.81 X
64858   4 90 2 X 2,514.56 X
64858   3 90 2 X 2,543.51 X
64858   2 90 2 X 2,722.23 X
64858   1 90 2 X 2,765.56 X
64859   4 ZZZ 0 X 734.87 X
64859   3 ZZZ 0 X 743.52 X
64859   2 ZZZ 0 X 795.45 X
64859   1 ZZZ 0 X 808.04 X
64861   4 90 2 X 2,883.33 X
64861   3 90 2 X 2,918.04 X
64861   2 90 2 X 3,084.65 X
64861   1 90 2 X 3,124.90 X
64862   4 90 2 X 3,617.79 X
64862   3 90 2 X 3,664.61 X
64862   2 90 2 X 3,883.12 X
64862   1 90 2 X 3,935.55 X
64864   4 90 2 X 1,842.46 X
64864   3 90 2 X 1,863.87 X
64864   1 90 2 X 2,006.88 X
64864   2 90 2 X 2,056.05 X
64865   4 90 2 X 2,510.83 X
64865   3 90 2 X 2,541.15 X
64865   2 90 2 X 2,700.12 X
64865   1 90 2 X 2,738.51 X
64866   4 90 2 X 2,464.60 X
64866   3 90 2 X 2,493.44 X
64866   2 90 2 X 2,660.99 X
64866   1 90 2 X 2,701.60 X
64868   4 90 2 X 2,289.40 X
64868   3 90 2 X 2,316.89 X
64868   2 90 2 X 2,465.67 X
64868   1 90 2 X 3,374.23 X
64872   4 ZZZ 0 X 346.54 X
64872   3 ZZZ 0 X 351.20 X
64872   2 ZZZ 0 X 375.24 X
64872   1 ZZZ 0 X 386.96 X
64874   4 ZZZ 0 X 519.81 X
64874   3 ZZZ 0 X 526.85 X
64874   2 ZZZ 0 X 562.79 X
64874   1 ZZZ 0 X 580.22 X
64876   4 ZZZ 0 X 516.73 X
64876   3 ZZZ 0 X 523.65 X
64876   2 ZZZ 0 X 559.23 X
64876   1 ZZZ 0 X 576.48 X
64885   4 90 2 X 2,721.45 X
64885   3 90 2 X 2,754.02 X
64885   2 90 2 X 2,918.38 X
64885   1 90 2 X 2,958.15 X
64886   4 90 2 X 3,244.88 X
64886   3 90 2 X 3,283.65 X
64886   2 90 2 X 3,479.75 X
64886   1 90 2 X 3,527.11 X
64890   4 90 2 X 2,528.64 X
64890   3 90 2 X 2,558.62 X
64890   2 90 2 X 2,741.96 X
64890   1 90 2 X 2,786.38 X
64891   4 90 2 X 2,413.60 X
64891   3 90 2 X 2,441.52 X
64891   2 90 2 X 2,601.16 X
64891   1 90 2 X 2,639.89 X
64892   4 90 2 X 2,339.90 X
64892   3 90 2 X 2,367.61 X
64892   2 90 2 X 2,525.82 X
64892   1 90 2 X 2,564.11 X
64893   4 90 2 X 2,708.16 X
64893   3 90 2 X 2,740.78 X
64893   2 90 2 X 2,939.92 X
64893   1 90 2 X 2,988.10 X
64895   4 90 2 X 3,007.22 X
64895   3 90 2 X 3,041.85 X
64895   2 90 2 X 3,256.96 X
64895   1 90 2 X 3,309.13 X
64896   4 90 2 X 3,411.47 X
64896   3 90 2 X 3,453.34 X
64896   2 90 2 X 3,665.92 X
64896   1 90 2 X 3,717.15 X
64897   4 90 2 X 2,863.85 X
64897   3 90 2 X 2,896.84 X
64897   2 90 2 X 3,103.69 X
64897   1 90 2 X 3,153.85 X
64898   4 90 2 X 3,095.01 X
64898   3 90 2 X 3,131.47 X
64898   2 90 2 X 3,344.63 X
64898   1 90 2 X 3,396.32 X
64901   4 ZZZ 0 X 1,864.40 X
64901   3 ZZZ 0 X 1,887.83 X
64901   2 ZZZ 0 X 1,999.07 X
64901   1 ZZZ 0 X 2,025.85 X
64902   4 ZZZ 0 X 2,170.39 X
64902   3 ZZZ 0 X 2,197.71 X
64902   2 ZZZ 0 X 2,326.66 X
64902   1 ZZZ 0 X 2,918.66 X
64905     90 2 X * X
64907     90 2 X * X
64910   2 90 2 X 949.36 X
64910   3 90 2 X 949.36 X
64910   4 90 2 X 949.36 X
64910   1 90 2 X 1,084.38 X
64911   2 90 2 X 1,155.93 X
64911   3 90 2 X 1,155.93 X
64911   4 90 2 X 1,155.93 X
64911   1 90 2 X 1,309.53 X
64912   2 90 2 X 982.66 X
64912   3 90 2 X 982.66 X
64912   4 90 2 X 982.66 X
64912   1 90 2 X 1,075.29 X
64913   2 ZZZ 0 X 201.33 X
64913   3 ZZZ 0 X 201.33 X
64913   4 ZZZ 0 X 201.33 X
64913   1 ZZZ 0 X 218.13 X
64999     YYY 2 X # X
65091   1 90 2 X 1,381.33 X
65091   3 90 2 X 1,414.36 X
65091   4 90 2 X 1,479.13 X
65091   2 90 2 X 1,531.32 X
65093   2 90 2 X 1,509.77 X
65093   3 90 2 X 1,521.71 X
65093   4 90 2 X 1,537.66 X
65093   1 90 2 X 1,626.11 X
65101   4 90 2 X 1,341.77 X
65101   3 90 2 X 1,424.44 X
65101   2 90 2 X 1,510.91 X
65101   1 90 2 X 1,624.20 X
65103   3 90 2 X 1,589.83 X
65103   4 90 2 X 1,648.91 X
65103   2 90 2 X 1,692.80 X
65103   1 90 2 X 1,741.17 X
65105   3 90 2 X 1,629.46 X
65105   4 90 2 X 1,711.70 X
65105   2 90 2 X 1,769.21 X
65105   1 90 2 X 1,808.49 X
65110   4 90 2 X 2,653.92 X
65110   3 90 2 X 2,761.36 X
65110   2 90 2 X 2,847.45 X
65110   1 90 2 X 2,885.61 X
65112   4 90 2 X 2,524.54 X
65112   3 90 2 X 2,555.20 X
65112   2 90 2 X 2,697.49 X
65112   1 90 2 X 2,731.76 X
65114   4 90 2 X 2,756.40 X
65114   3 90 2 X 2,789.40 X
65114   2 90 2 X 2,962.50 X
65114   1 90 2 X 3,004.31 X
65125   4 90 2 X 1,453.36 X
65125   3 90 2 X 1,472.48 X
65125   2 90 2 X 1,555.84 X
65125   1 90 2 X 1,575.77 X
65130   4 90 2 X 1,391.15 X
65130   3 90 2 X 1,409.47 X
65130   1 90 2 X 1,483.13 X
65130   2 90 2 X 1,490.07 X
65135   4 90 2 X 1,117.03 X
65135   3 90 2 X 1,130.77 X
65135   2 90 2 X 1,188.50 X
65135   1 90 2 X 1,576.22 X
65140   4 90 2 X 1,230.78 X
65140   3 90 2 X 1,246.12 X
65140   1 90 2 X 1,323.27 X
65140   2 90 2 X 1,620.64 X
65150   4 90 2 X 1,413.52 X
65150   3 90 2 X 1,432.71 X
65150   1 90 2 X 1,539.92 X
65150   2 90 2 X 1,693.58 X
65155   4 90 2 X 1,892.45 X
65155   3 90 2 X 1,917.71 X
65155   2 90 2 X 2,038.14 X
65155   1 90 2 X 2,067.05 X
65175   4 90 2 X 1,208.64 X
65175   3 90 2 X 1,224.55 X
65175   2 90 2 X 1,292.82 X
65175   1 90 2 X 1,296.21 X
65205   3 0 2 X 102.00 88.01
65205   4 0 2 X 108.32 93.62
65205   1 0 2 X 109.71 93.83
65205   2 0 2 X 116.92 100.44
65210   4 0 2 X 117.91 98.00
65210   3 0 2 X 119.33 99.08
65210   2 0 2 X 124.73 103.34
65210   1 0 2 X 126.13 104.41
65220   3 0 2 X 106.45 85.08
65220   1 0 2 X 109.23 88.66
65220   2 0 2 X 111.93 89.37
65220   4 0 2 X 112.03 91.15
65222   4 0 2 X 128.80 107.08
65222   3 0 2 X 136.22 112.87
65222   2 0 2 X 143.05 116.64
65222   1 0 2 X 150.21 124.32
65235   4 90 2 X 1,145.51 X
65235   2 90 2 X 1,422.59 X
65235   3 90 2 X 1,519.17 X
65235   1 90 2 X 1,705.59 X
65260   4 90 2 X 1,708.00 X
65260   3 90 2 X 1,729.27 X
65260   2 90 2 X 1,815.25 X
65260   1 90 2 X 1,835.96 X
65265   4 90 2 X 1,985.23 X
65265   3 90 2 X 2,009.98 X
65265   2 90 2 X 2,109.88 X
65265   1 90 2 X 2,133.81 X
65270   3 10 2 X 223.37 X
65270   1 10 2 X 232.64 X
65270   4 10 2 X 272.05 X
65270   2 10 2 X 288.23 X
65272   2 90 2 X 370.98 X
65272   3 90 2 X 376.16 X
65272   4 90 2 X 469.80 X
65272   1 90 2 X 500.59 X
65273   4 90 2 X 643.36 X
65273   3 90 2 X 651.33 X
65273   2 90 2 X 685.22 X
65273   1 90 2 X 693.33 X
65275   4 90 2 X 895.11 X
65275   3 90 2 X 897.29 X
65275   2 90 2 X 904.12 X
65275   1 90 2 X 905.78 X
65280   4 90 2 X 1,459.37 X
65280   1 90 2 X 1,736.06 X
65280   3 90 2 X 1,907.98 X
65280   2 90 2 X 1,943.00 X
65285   3 90 2 X 2,217.03 X
65285   4 90 2 X 2,279.06 X
65285   2 90 2 X 2,333.73 X
65285   1 90 2 X 2,361.68 X
65286   3 90 2 X 906.45 X
65286   2 90 2 X 1,176.72 X
65286   1 90 2 X 1,323.84 X
65286   4 90 2 X 1,385.87 X
65290   4 90 2 X 1,017.89 X
65290   3 90 2 X 1,031.24 X
65290   2 90 2 X 1,089.70 X
65290   1 90 2 X 1,103.71 X
65400   4 90 2 X 754.84 X
65400   3 90 2 X 761.72 X
65400   2 90 2 X 786.86 X
65400   1 90 2 X 805.05 X
65410   3 0 2 X 281.86 X
65410   1 0 2 X 301.67 X
65410   4 0 2 X 317.41 X
65410   2 0 2 X 326.97 X
65420   4 90 2 X 742.74 X
65420   3 90 2 X 752.34 X
65420   2 90 2 X 792.71 X
65420   1 90 2 X 802.34 X
65426   4 90 2 X 1,029.11 X
65426   3 90 2 X 1,069.09 X
65426   2 90 2 X 1,130.18 X
65426   1 90 2 X 1,144.81 X
65430   4 0 2 X 127.33 104.07
65430   3 0 2 X 128.84 105.19
65430   2 0 2 X 136.22 110.76
65430   1 0 2 X 137.04 111.25
65435   2 0 2 X 192.60 150.20
65435   4 0 2 X 196.14 153.52
65435   3 0 2 X 204.44 160.17
65435   1 0 2 X 208.47 162.32
65436   3 90 2 X 489.30 X
65436   4 90 2 X 496.18 X
65436   2 90 2 X 507.16 X
65436   1 90 2 X 509.26 X
65450   1 90 2 X 486.21 X
65450   2 90 2 X 491.71 X
65450   4 90 2 X 571.23 X
65450   3 90 2 X 578.55 X
65600   4 90 2 X 518.91 X
65600   3 90 2 X 525.36 X
65600   2 90 2 X 809.88 X
65600   1 90 2 X 847.10 X
65710   4 90 2 X 3,343.56 X
65710   1 90 2 X 3,444.74 X
65710   3 90 2 X 3,444.97 X
65710   2 90 2 X 3,792.46 X
65730   4 90 2 X 3,730.95 X
65730   3 90 2 X 4,067.45 X
65730   2 90 2 X 4,406.12 X
65730   1 90 2 X 4,425.47 X
65750   4 90 2 X 4,645.05 X
65750   3 90 2 X 4,708.88 X
65750   2 90 2 X 4,972.56 X
65750   1 90 2 X 5,006.92 X
65755   4 90 2 X 4,805.22 X
65755   3 90 2 X 4,871.48 X
65755   2 90 2 X 5,148.28 X
65755   1 90 2 X 5,185.63 X
65756   2 90 2 X 1,475.63 X
65756   3 90 2 X 1,475.63 X
65756   4 90 2 X 1,475.63 X
65756   1 90 2 X 1,608.23 X
65757     ZZZ 0 X * X
65770   4 90 2 X 2,731.04 X
65770   3 90 2 X 2,765.14 X
65770   2 90 2 X 2,902.59 X
65770   1 90 2 X 2,935.65 X
65772   2 90 2 X 763.37 X
65772   4 90 2 X 852.58 X
65772   3 90 2 X 1,039.51 X
65772   1 90 2 X 1,065.49 X
65775   4 90 2 X 1,168.52 X
65775   3 90 2 X 1,295.49 X
65775   2 90 2 X 1,373.46 X
65775   1 90 2 X 1,392.08 X
65778   2 10 2 X 1,793.50 110.95
65778   3 10 2 X 1,793.50 110.95
65778   4 10 2 X 1,793.50 110.95
65778   1 10 2 X 2,025.76 121.89
65779   2 10 2 X 1,631.47 426.75
65779   3 10 2 X 1,631.47 426.75
65779   4 10 2 X 1,631.47 426.75
65779   1 10 2 X 1,833.51 470.33
65780   2 90 2 X 1,365.43 X
65780   3 90 2 X 1,365.43 X
65780   4 90 2 X 1,365.43 X
65780   1 90 2 X 1,508.52 X
65781   2 90 2 X 2,094.50 X
65781   3 90 2 X 2,094.50 X
65781   4 90 2 X 2,094.50 X
65781   1 90 2 X 2,287.42 X
65782   2 90 2 X 1,804.50 X
65782   3 90 2 X 1,804.50 X
65782   4 90 2 X 1,804.50 X
65782   1 90 2 X 1,974.56 X
65785   2 90 2 X 2,620.44 498.99
65785   3 90 2 X 2,620.44 498.99
65785   4 90 2 X 2,620.44 498.99
65785   1 90 2 X 3,032.33 550.07
65800   3 0 2 X 331.57 X
65800   4 0 2 X 363.69 X
65800   2 0 2 X 366.73 X
65800   1 0 2 X 368.54 X
65810   4 90 2 X 864.61 X
65810   2 90 2 X 896.78 X
65810   3 90 2 X 914.79 X
65810   1 90 2 X 920.65 X
65815   4 90 2 X 831.54 X
65815   3 90 2 X 842.11 X
65815   2 90 2 X 873.79 X
65815   1 90 2 X 897.07 X
65820   4 90 2 X 1,544.52 X
65820   3 90 2 X 1,564.77 X
65820   2 90 2 X 1,597.95 X
65820   1 90 2 X 1,611.28 X
65850   3 90 2 X 2,117.57 X
65850   4 90 2 X 2,181.22 X
65850   2 90 2 X 2,262.53 X
65850   1 90 2 X 2,326.29 X
65855   4 90 2 X 1,523.29 X
65855   3 90 2 X 1,556.07 X
65855   2 90 2 X 1,655.53 X
65855   1 90 2 X 1,687.42 X
65860   4 90 2 X 848.41 X
65860   3 90 2 X 859.97 X
65860   1 90 2 X 926.44 X
65860   2 90 2 X 1,099.02 X
65865   4 90 2 X 1,000.56 X
65865   2 90 2 X 1,043.54 X
65865   3 90 2 X 1,135.05 X
65865   1 90 2 X 1,215.46 X
65870   4 90 2 X 1,060.98 X
65870   3 90 2 X 1,074.53 X
65870   2 90 2 X 1,198.72 X
65870   1 90 2 X 1,247.54 X
65875   4 90 2 X 1,118.70 X
65875   3 90 2 X 1,580.11 X
65875   2 90 2 X 1,598.83 X
65875   1 90 2 X 1,611.29 X
65880   4 90 2 X 1,219.32 X
65880   3 90 2 X 1,234.97 X
65880   2 90 2 X 1,300.30 X
65880   1 90 2 X 1,315.98 X
65900   4 90 2 X 1,696.46 X
65900   2 90 2 X 1,818.96 X
65900   3 90 2 X 2,395.09 X
65900   1 90 2 X 2,400.60 X
65920   3 90 2 X 1,886.16 X
65920   4 90 2 X 1,888.65 X
65920   2 90 2 X 1,903.95 X
65920   1 90 2 X 1,925.37 X
65930   4 90 2 X 1,324.98 X
65930   3 90 2 X 1,342.11 X
65930   2 90 2 X 1,371.50 X
65930   1 90 2 X 1,374.51 X
66020   3 10 2 X 381.66 X
66020   4 10 2 X 384.29 X
66020   2 10 2 X 395.08 X
66020   1 10 2 X 397.23 X
66030   3 10 2 X 158.39 X
66030   2 10 2 X 218.83 X
66030   4 10 2 X 223.14 X
66030   1 10 2 X 230.52 X
66130   3 90 2 X 1,167.07 X
66130   4 90 2 X 1,492.17 X
66130   2 90 2 X 1,522.25 X
66130   1 90 2 X 1,528.02 X
66150   2 90 2 X 1,721.96 X
66150   3 90 2 X 1,769.62 X
66150   4 90 2 X 1,887.38 X
66150   1 90 2 X 1,899.96 X