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2021 Workers' Compensation Part B Fee Schedule

66155-67880

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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
66155   4 90 2 X 2,044.16 X
66155   3 90 2 X 2,052.72 X
66155   2 90 2 X 2,089.31 X
66155   1 90 2 X 2,098.02 X
66160   4 90 2 X 1,821.55 X
66160   3 90 2 X 1,980.84 X
66160   2 90 2 X 2,022.65 X
66160   1 90 2 X 2,032.65 X
66170   3 90 2 X 2,113.65 X
66170   4 90 2 X 2,123.42 X
66170   2 90 2 X 2,192.41 X
66170   1 90 2 X 2,414.63 X
66172   3 90 2 X 2,184.01 X
66172   4 90 2 X 2,193.13 X
66172   2 90 2 X 2,264.47 X
66172   1 90 2 X 2,487.10 X
66174   2 90 2 X 1,444.74 X
66174   3 90 2 X 1,444.74 X
66174   4 90 2 X 1,444.74 X
66174   1 90 2 X 1,601.85 X
66175   2 90 2 X 1,652.68 X
66175   3 90 2 X 1,652.68 X
66175   4 90 2 X 1,652.68 X
66175   1 90 2 X 1,881.81 X
66179   2 90 2 X 1,189.05 1,417.00
66179   3 90 2 X 1,189.05 1,417.00
66179   4 90 2 X 1,189.05 1,417.00
66179   1 90 2 X 1,296.41 1,563.10
66180   4 90 2 X 2,675.50 X
66180   3 90 2 X 2,710.96 X
66180   2 90 2 X 2,869.15 X
66180   1 90 2 X 2,906.96 X
66183   2 90 2 X 1,441.36 X
66183   3 90 2 X 1,441.36 X
66183   4 90 2 X 1,441.36 X
66183   1 90 2 X 1,607.24 X
66184   2 90 2 X 828.56 1,031.00
66184   3 90 2 X 828.56 1,031.00
66184   4 90 2 X 828.56 1,031.00
66184   1 90 2 X 904.69 1,141.58
66185   4 90 2 X 1,593.41 X
66185   3 90 2 X 1,614.45 X
66185   2 90 2 X 1,707.09 X
66185   1 90 2 X 1,729.24 X
66225   4 90 2 X 2,324.16 X
66225   2 90 2 X 2,492.84 X
66225   3 90 2 X 2,731.88 X
66225   1 90 2 X 2,907.46 X
66250   4 90 2 X 1,154.85 X
66250   3 90 2 X 1,170.02 X
66250   2 90 2 X 1,235.33 X
66250   1 90 2 X 1,250.97 X
66500   4 90 2 X 741.35 X
66500   3 90 2 X 751.09 X
66500   1 90 2 X 804.26 X
66500   2 90 2 X 992.89 X
66505   4 90 2 X 647.55 X
66505   3 90 2 X 655.65 X
66505   2 90 2 X 688.21 X
66505   1 90 2 X 696.03 X
66600   4 90 2 X 1,585.23 X
66600   2 90 2 X 1,899.38 X
66600   1 90 2 X 1,899.96 X
66600   3 90 2 X 1,915.94 X
66605   4 90 2 X 2,183.55 X
66605   3 90 2 X 2,211.28 X
66605   2 90 2 X 2,327.84 X
66605   1 90 2 X 2,626.87 X
66625   2 90 2 X 1,490.70 X
66625   4 90 2 X 1,562.61 X
66625   3 90 2 X 1,566.02 X
66625   1 90 2 X 1,733.47 X
66630   4 90 2 X 1,242.24 X
66630   2 90 2 X 1,507.45 X
66630   3 90 2 X 1,539.34 X
66630   1 90 2 X 1,778.75 X
66635   2 90 2 X 1,503.78 X
66635   4 90 2 X 1,613.78 X
66635   3 90 2 X 1,621.26 X
66635   1 90 2 X 1,813.29 X
66680   3 90 2 X 1,175.99 X
66680   4 90 2 X 1,189.09 X
66680   2 90 2 X 1,218.51 X
66680   1 90 2 X 1,234.09 X
66682   3 90 2 X 1,974.47 X
66682   4 90 2 X 2,008.47 X
66682   2 90 2 X 2,029.78 X
66682   1 90 2 X 2,049.64 X
66700   3 90 2 X 1,018.06 X
66700   2 90 2 X 1,020.23 X
66700   4 90 2 X 1,024.61 X
66700   1 90 2 X 1,094.81 X
66710   4 90 2 X 1,030.34 X
66710   3 90 2 X 1,044.14 X
66710   2 90 2 X 1,106.44 X
66710   1 90 2 X 1,121.34 X
66711   2 90 3 X 863.60 X
66711   3 90 3 X 863.60 X
66711   4 90 3 X 863.60 X
66711   1 90 3 X 963.92 X
66720   4 90 2 X 994.65 X
66720   3 90 2 X 1,008.04 X
66720   2 90 2 X 1,066.98 X
66720   1 90 2 X 1,081.12 X
66740   4 90 2 X 1,020.93 X
66740   3 90 2 X 1,034.61 X
66740   2 90 2 X 1,095.62 X
66740   1 90 2 X 1,110.15 X
66761   3 90 2 X 1,187.83 793.50
66761   4 90 2 X 1,201.62 803.48
66761   2 90 2 X 1,237.78 828.88
66761   1 90 2 X 1,274.91 854.40
66762   4 90 2 X 1,219.57 X
66762   3 90 2 X 1,236.64 X
66762   2 90 2 X 1,316.39 X
66762   1 90 2 X 1,335.49 X
66770   3 90 2 X 1,157.37 X
66770   4 90 2 X 1,302.83 X
66770   2 90 2 X 1,339.12 X
66770   1 90 2 X 1,346.26 X
66820   4 90 2 X 792.93 X
66820   3 90 2 X 803.47 X
66820   1 90 2 X 860.65 X
66820   2 90 2 X 1,067.36 X
66821   4 90 2 X 782.43 X
66821   3 90 2 X 793.33 X
66821   1 90 2 X 857.20 X
66821   2 90 2 X 1,067.28 X
66825   3 90 2 X 2,058.55 X
66825   4 90 2 X 2,091.77 X
66825   2 90 2 X 2,115.89 X
66825   1 90 2 X 2,136.28 X
66830   4 90 2 X 1,392.47 X
66830   3 90 2 X 1,410.24 X
66830   2 90 2 X 1,483.58 X
66830   1 90 2 X 1,501.15 X
66840   4 90 2 X 1,623.36 X
66840   3 90 2 X 1,856.69 X
66840   2 90 2 X 1,927.75 X
66840   1 90 2 X 1,958.92 X
66850   4 90 2 X 2,017.09 X
66850   3 90 2 X 2,023.88 X
66850   2 90 2 X 2,078.93 X
66850   1 90 2 X 2,190.04 X
66852   4 90 2 X 2,226.99 X
66852   3 90 2 X 2,257.09 X
66852   2 90 2 X 2,393.54 X
66852   1 90 2 X 2,426.13 X
66920   4 90 2 X 1,917.87 X
66920   3 90 2 X 1,951.06 X
66920   2 90 2 X 2,053.65 X
66920   1 90 2 X 2,097.03 X
66930   3 90 2 X 1,959.96 X
66930   4 90 2 X 1,996.27 X
66930   2 90 2 X 2,047.95 X
66930   1 90 2 X 2,162.93 X
66940   4 90 2 X 1,995.62 X
66940   3 90 2 X 2,002.94 X
66940   2 90 2 X 2,064.66 X
66940   1 90 2 X 2,160.45 X
66982   2 90 2 X 1,685.56 X
66982   3 90 2 X 1,685.56 X
66982   4 90 2 X 1,685.56 X
66982   1 90 2 X 1,856.15 X
66983   4 90 2 X 2,750.79 X
66983   3 90 2 X 2,816.40 X
66983   2 90 2 X 2,982.22 X
66983   1 90 2 X 3,047.40 X
66984   4 90 2 X 2,858.98 X
66984   3 90 2 X 2,867.21 X
66984   2 90 2 X 3,047.48 X
66984   1 90 2 X 3,093.41 X
66985   4 90 2 X 2,052.86 X
66985   3 90 2 X 2,073.06 X
66985   2 90 2 X 2,198.41 X
66985   1 90 2 X 2,231.57 X
66986   4 90 2 X 2,246.31 X
66986   3 90 2 X 2,268.65 X
66986   2 90 2 X 2,400.83 X
66986   1 90 2 X 2,435.56 X
66987         X * X
66988         X * X
66990   2 90 2 X 152.51 X
66990   3 90 2 X 152.51 X
66990   4 90 2 X 152.51 X
66990   1 90 2 X 166.73 X
66999     YYY 2 X # X
67005   4 90 2 X 2,199.87 X
67005   3 90 2 X 2,462.65 X
67005   2 90 2 X 2,583.19 X
67005   1 90 2 X 2,644.70 X
67010   4 90 2 X 2,110.72 X
67010   3 90 2 X 2,140.69 X
67010   1 90 2 X 2,318.53 X
67010   2 90 2 X 2,511.90 X
67015   3 90 2 X 1,128.05 X
67015   2 90 2 X 1,170.69 X
67015   4 90 2 X 1,182.84 X
67015   1 90 2 X 1,193.82 X
67025   4 90 2 X 1,187.75 X
67025   1 90 2 X 1,198.31 X
67025   3 90 2 X 1,203.06 X
67025   2 90 2 X 1,273.67 X
67027   2 90 2 X 1,551.55 X
67027   3 90 2 X 1,551.55 X
67027   4 90 2 X 1,551.55 X
67027   1 90 2 X 1,725.63 X
67028   4 0 2 X 518.20 X
67028   3 0 2 X 525.02 X
67028   2 0 2 X 554.63 X
67028   1 0 2 X 561.69 X
67030   2 90 2 X 1,108.98 X
67030   3 90 2 X 1,112.57 X
67030   1 90 2 X 1,141.05 X
67030   4 90 2 X 1,160.62 X
67031   4 90 2 X 1,522.91 X
67031   3 90 2 X 1,535.33 X
67031   2 90 2 X 1,595.52 X
67031   1 90 2 X 1,609.83 X
67036   4 90 2 X 4,063.77 X
67036   3 90 2 X 4,272.82 X
67036   2 90 2 X 4,547.24 X
67036   1 90 2 X 4,673.27 X
67039   4 90 2 X 3,720.71 X
67039   3 90 2 X 3,772.41 X
67039   2 90 2 X 4,014.26 X
67039   1 90 2 X 4,071.95 X
67040   3 90 2 X 5,334.53 X
67040   4 90 2 X 5,575.00 X
67040   2 90 2 X 5,934.48 X
67040   1 90 2 X 5,960.96 X
67041   2 90 2 X 1,628.58 X
67041   3 90 2 X 1,628.58 X
67041   4 90 2 X 1,628.58 X
67041   1 90 2 X 1,790.98 X
67042   2 90 2 X 1,864.60 X
67042   3 90 2 X 1,864.60 X
67042   4 90 2 X 1,864.60 X
67042   1 90 2 X 2,047.01 X
67043   2 90 2 X 1,957.06 X
67043   3 90 2 X 1,957.06 X
67043   4 90 2 X 1,957.06 X
67043   1 90 2 X 2,151.25 X
67101   2 90 2 X 1,775.45 X
67101   4 90 2 X 2,091.69 X
67101   3 90 2 X 2,109.99 X
67101   1 90 2 X 2,182.22 X
67105   4 90 2 X 2,267.27 X
67105   2 90 2 X 2,350.49 X
67105   3 90 2 X 2,619.10 X
67105   1 90 2 X 2,823.72 X
67107   1 90 2 X 3,251.00 X
67107   4 90 2 X 3,459.46 X
67107   3 90 2 X 3,470.09 X
67107   2 90 2 X 3,530.74 X
67108   3 90 2 X 4,964.15 X
67108   4 90 2 X 5,304.98 X
67108   2 90 2 X 5,419.19 X
67108   1 90 2 X 5,474.76 X
67110   4 90 2 X 2,146.19 X
67110   3 90 2 X 2,175.81 X
67110   2 90 2 X 2,314.41 X
67110   1 90 2 X 2,347.39 X
67113   2 90 2 X 2,148.97 X
67113   3 90 2 X 2,148.97 X
67113   4 90 2 X 2,148.97 X
67113   1 90 2 X 2,363.80 X
67115   4 90 2 X 1,073.16 X
67115   3 90 2 X 1,087.58 X
67115   2 90 2 X 1,153.29 X
67115   1 90 2 X 1,168.96 X
67120   4 90 2 X 1,150.64 X
67120   3 90 2 X 1,165.78 X
67120   2 90 2 X 1,230.72 X
67120   1 90 2 X 1,246.33 X
67121   2 90 2 X 1,707.10 X
67121   4 90 2 X 1,762.43 X
67121   3 90 2 X 1,784.73 X
67121   1 90 2 X 1,898.37 X
67141   4 90 2 X 1,183.59 X
67141   3 90 2 X 1,199.69 X
67141   2 90 2 X 1,273.00 X
67141   1 90 2 X 1,455.79 X
67145   4 90 2 X 1,211.47 855.83
67145   3 90 2 X 1,227.90 866.20
67145   2 90 2 X 1,302.62 919.42
67145   1 90 2 X 1,465.03 1,019.48
67208   2 90 2 X 2,016.01 X
67208   4 90 2 X 2,067.67 X
67208   3 90 2 X 2,075.69 X
67208   1 90 2 X 2,119.71 X
67210   4 90 2 X 1,714.15 1,277.36
67210   1 90 2 X 1,806.24 1,343.56
67210   3 90 2 X 1,886.94 1,402.12
67210   2 90 2 X 1,919.11 1,421.39
67218   4 90 2 X 2,344.38 X
67218   3 90 2 X 2,374.55 X
67218   2 90 2 X 2,500.58 X
67218   1 90 2 X 2,662.39 X
67220   2 90 2 X 1,462.96 1,458.05
67220   3 90 2 X 1,462.96 1,458.05
67220   4 90 2 X 1,462.96 1,458.05
67220   1 90 2 X 1,592.48 1,586.70
67221   2 0 2 X 638.81 469.23
67221   3 0 2 X 638.81 469.23
67221   4 0 2 X 638.81 469.23
67221   1 0 2 X 725.57 526.90
67225   2 ZZZ 0 X 75.16 71.89
67225   3 ZZZ 0 X 75.16 71.89
67225   4 ZZZ 0 X 75.16 71.89
67225   1 ZZZ 0 X 101.33 97.49
67227   2 90 2 X 1,622.72 X
67227   3 90 2 X 1,627.22 X
67227   4 90 2 X 1,745.36 X
67227   1 90 2 X 2,103.61 X
67228   4 90 2 X 1,823.25 1,384.81
67228   3 90 2 X 2,317.03 1,739.30
67228   2 90 2 X 2,376.41 1,783.51
67228   1 90 2 X 2,412.25 1,810.36
67229   2 90 2 X 1,414.10 X
67229   3 90 2 X 1,414.10 X
67229   4 90 2 X 1,414.10 X
67229   1 90 2 X 1,559.32 X
67250   4 90 2 X 1,383.87 X
67250   3 90 2 X 1,401.10 X
67250   2 90 2 X 1,472.12 X
67250   1 90 2 X 1,489.17 X
67255   4 90 2 X 2,090.08 X
67255   3 90 2 X 2,118.69 X
67255   1 90 2 X 2,280.69 X
67255   2 90 2 X 2,692.82 X
67299     YYY 2 X # X
67311   4 90 2 X 1,321.38 X
67311   3 90 2 X 1,530.14 X
67311   2 90 2 X 1,653.22 X
67311   1 90 2 X 1,663.28 X
67312   4 90 2 X 1,551.96 X
67312   3 90 2 X 1,572.42 X
67312   2 90 2 X 1,740.59 X
67312   1 90 2 X 1,766.59 X
67314   4 90 2 X 1,387.98 X
67314   3 90 2 X 1,681.61 X
67314   2 90 2 X 1,814.98 X
67314   1 90 2 X 1,827.44 X
67316   4 90 2 X 1,764.40 X
67316   3 90 2 X 1,788.04 X
67316   2 90 2 X 1,887.80 X
67316   1 90 2 X 1,916.26 X
67318   4 90 2 X 1,229.07 X
67318   3 90 2 X 1,484.97 X
67318   2 90 2 X 1,601.59 X
67318   1 90 2 X 1,610.11 X
67320   4 90 2 X 1,782.45 X
67320   3 90 2 X 1,806.12 X
67320   2 90 2 X 1,912.32 X
67320   1 90 2 X 1,937.67 X
67331   4 90 2 X 1,588.26 X
67331   3 90 2 X 1,609.24 X
67331   2 90 2 X 1,771.13 X
67331   1 90 2 X 1,780.21 X
67332   4 90 2 X 1,764.71 X
67332   3 90 2 X 1,788.04 X
67332   2 90 2 X 2,101.08 X
67332   1 90 2 X 2,111.14 X
67334   4 90 2 X 1,246.48 X
67334   3 90 2 X 1,261.97 X
67334   2 90 2 X 1,324.75 X
67334   1 90 2 X 1,339.89 X
67335   4 ZZZ 0 X 833.13 X
67335   3 ZZZ 0 X 845.05 X
67335   2 ZZZ 0 X 902.68 X
67335   1 ZZZ 0 X 916.46 X
67340   4 90 2 X 1,559.40 X
67340   3 90 2 X 1,578.86 X
67340   2 90 2 X 1,657.26 X
67340   1 90 2 X 1,676.11 X
67343   4 90 2 X 1,154.37 X
67343   3 90 2 X 1,168.74 X
67343   2 90 2 X 1,227.05 X
67343   1 90 2 X 1,241.04 X
67345   4 10 2 X 473.73 X
67345   3 10 2 X 479.43 X
67345   2 10 2 X 507.97 X
67345   1 10 2 X 514.96 X
67346   2 0 2 X 255.67 X
67346   3 0 2 X 255.67 X
67346   4 0 2 X 255.67 X
67346   1 0 2 X 286.21 X
67399     YYY 2 X # X
67400   3 90 2 X 2,046.39 X
67400   4 90 2 X 2,057.33 X
67400   2 90 2 X 2,143.12 X
67400   1 90 2 X 2,153.35 X
67405   4 90 2 X 1,538.60 X
67405   3 90 2 X 1,638.61 X
67405   2 90 2 X 1,652.15 X
67405   1 90 2 X 1,674.58 X
67412   3 90 2 X 1,906.39 X
67412   4 90 2 X 2,189.76 X
67412   2 90 2 X 2,245.84 X
67412   1 90 2 X 2,256.79 X
67413   3 90 2 X 1,639.00 X
67413   1 90 2 X 1,747.17 X
67413   4 90 2 X 1,904.10 X
67413   2 90 2 X 1,973.40 X
67414   4 90 2 X 1,660.21 X
67414   3 90 2 X 1,680.90 X
67414   2 90 2 X 1,764.57 X
67414   1 90 2 X 1,784.63 X
67415   4 0 2 X 422.89 X
67415   3 0 2 X 424.76 X
67415   2 0 2 X 432.83 X
67415   1 0 2 X 434.80 X
67420   4 90 2 X 2,734.83 X
67420   3 90 2 X 2,770.60 X
67420   2 90 2 X 3,591.79 X
67420   1 90 2 X 3,680.16 X
67430   4 90 2 X 2,107.84 X
67430   3 90 2 X 2,134.10 X
67430   2 90 2 X 2,240.01 X
67430   1 90 2 X 2,265.43 X
67440   4 90 2 X 2,564.37 X
67440   3 90 2 X 2,598.13 X
67440   2 90 2 X 3,364.50 X
67440   1 90 2 X 3,379.62 X
67445   4 90 2 X 2,202.64 X
67445   3 90 2 X 2,229.99 X
67445   2 90 2 X 2,340.91 X
67445   1 90 2 X 2,367.53 X
67450   4 90 2 X 2,189.62 X
67450   3 90 2 X 2,397.88 X
67450   2 90 2 X 2,422.79 X
67450   1 90 2 X 2,745.88 X
67500   3 0 2 X 225.71 X
67500   2 0 2 X 232.26 X
67500   4 0 2 X 253.55 X
67500   1 0 2 X 266.56 X
67505   3 0 2 X 261.28 191.81
67505   4 0 2 X 293.71 216.11
67505   2 0 2 X 294.52 215.97
67505   1 0 2 X 299.93 220.03
67515   1 0 2 X 119.71 91.87
67515   2 0 2 X 147.72 113.76
67515   3 0 2 X 148.70 114.47
67515   4 0 2 X 157.12 121.24
67550   4 90 2 X 1,756.44 X
67550   3 90 2 X 1,778.64 X
67550   2 90 2 X 1,878.97 X
67550   1 90 2 X 1,903.10 X
67560   3 90 2 X 1,680.36 X
67560   1 90 2 X 1,786.16 X
67560   4 90 2 X 2,265.49 X
67560   2 90 2 X 2,309.91 X
67570   4 90 2 X 1,804.77 X
67570   3 90 2 X 1,826.30 X
67570   2 90 2 X 1,909.04 X
67570   1 90 2 X 1,929.00 X
67599     YYY 2 X # X
67700   4 10 2 X 161.25 140.11
67700   3 10 2 X 163.07 141.57
67700   2 10 2 X 169.72 146.93
67700   1 10 2 X 175.22 151.75
67710   4 10 2 X 178.63 X
67710   3 10 2 X 180.91 X
67710   2 10 2 X 190.76 X
67710   1 10 2 X 193.10 X
67715   4 10 2 X 240.53 X
67715   2 10 2 X 314.17 X
67715   1 10 2 X 322.41 X
67715   3 10 2 X 329.78 X
67800   4 10 2 X 180.72 146.09
67800   3 10 2 X 193.38 155.41
67800   2 10 2 X 218.83 175.52
67800   1 10 2 X 221.28 177.41
67801   4 10 2 X 292.42 232.75
67801   3 10 2 X 295.97 235.32
67801   2 10 2 X 310.55 246.28
67801   1 10 2 X 314.09 248.98
67805   4 10 2 X 319.96 X
67805   3 10 2 X 323.78 X
67805   2 10 2 X 338.99 X
67805   1 10 2 X 342.70 X
67808   3 90 2 X 505.00 X
67808   4 90 2 X 512.08 X
67808   2 90 2 X 521.23 X
67808   1 90 2 X 524.58 X
67810   4 0 2 X 206.94 172.30
67810   3 0 2 X 209.36 174.10
67810   2 0 2 X 218.89 181.59
67810   1 0 2 X 221.28 183.36
67820   3 0 2 X 98.15 84.09
67820   4 0 2 X 100.25 86.24
67820   2 0 2 X 106.45 90.99
67820   1 0 2 X 107.33 91.77
67825   3 10 2 X 202.80 163.71
67825   2 10 2 X 212.48 170.93
67825   4 10 2 X 226.18 182.36
67825   1 10 2 X 270.88 217.71
67830   4 10 2 X 396.92 X
67830   3 10 2 X 904.67 X
67830   2 10 2 X 932.97 X
67830   1 10 2 X 966.25 X
67835   3 90 2 X 1,203.16 X
67835   2 90 2 X 1,273.94 X
67835   4 90 2 X 1,369.90 X
67835   1 90 2 X 1,465.54 X
67840   4 10 2 X 288.70 236.67
67840   3 10 2 X 330.84 270.93
67840   2 10 2 X 413.85 338.09
67840   1 10 2 X 436.20 355.85
67850   3 10 2 X 174.01 146.27
67850   4 10 2 X 174.66 146.68
67850   2 10 2 X 185.01 155.37
67850   1 10 2 X 194.03 163.02
67875   4 0 2 X 289.72 X
67875   3 0 2 X 293.53 X
67875   2 0 2 X 311.30 X
67875   1 0 2 X 315.59 X
67880   4 90 2 X 726.55 X
67880   3 90 2 X 734.55 X
67880   2 90 2 X 771.02 X
67880   1 90 2 X 976.15 X