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2021 Workers' Compensation Part B Fee Schedule

67882-69643

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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
67882   3 90 2 X 1,243.96 X
67882   4 90 2 X 1,252.95 X
67882   2 90 2 X 1,282.56 X
67882   1 90 2 X 1,288.33 X
67900   4 90 2 X 748.42 X
67900   3 90 2 X 757.71 X
67900   2 90 2 X 795.51 X
67900   1 90 2 X 804.56 X
67901   4 90 2 X 1,454.79 X
67901   1 90 2 X 1,727.11 X
67901   3 90 2 X 1,755.74 X
67901   2 90 2 X 1,793.52 X
67902   4 90 2 X 1,516.34 X
67902   2 90 2 X 1,631.99 X
67902   3 90 2 X 1,783.34 X
67902   1 90 2 X 1,909.03 X
67903   4 90 2 X 1,544.85 X
67903   3 90 2 X 1,565.87 X
67903   2 90 2 X 1,665.65 X
67903   1 90 2 X 1,877.83 X
67904   4 90 2 X 1,716.64 X
67904   1 90 2 X 1,755.13 X
67904   3 90 2 X 1,779.31 X
67904   2 90 2 X 1,795.24 X
67906   4 90 2 X 1,094.72 X
67906   3 90 2 X 1,108.24 X
67906   2 90 2 X 1,165.92 X
67906   1 90 2 X 1,179.80 X
67908   4 90 2 X 1,707.60 X
67908   3 90 2 X 1,713.57 X
67908   2 90 2 X 1,751.02 X
67908   1 90 2 X 1,759.61 X
67909   4 90 2 X 1,037.48 X
67909   3 90 2 X 1,046.16 X
67909   2 90 2 X 1,086.08 X
67909   1 90 2 X 1,095.62 X
67911   4 90 2 X 1,345.03 X
67911   3 90 2 X 1,363.26 X
67911   2 90 2 X 1,456.80 X
67911   1 90 2 X 1,479.23 X
67912   2 90 2 X 1,717.03 746.13
67912   3 90 2 X 1,717.03 746.13
67912   4 90 2 X 1,717.03 746.13
67912   1 90 2 X 1,967.66 826.36
67914   4 90 2 X 1,223.09 X
67914   3 90 2 X 1,227.53 X
67914   1 90 2 X 1,320.75 X
67914   2 90 2 X 1,374.07 X
67915   4 90 2 X 379.23 X
67915   3 90 2 X 395.05 X
67915   2 90 2 X 410.87 X
67915   1 90 2 X 413.21 X
67916   4 90 2 X 1,050.41 X
67916   3 90 2 X 1,064.24 X
67916   2 90 2 X 1,124.76 X
67916   1 90 2 X 1,231.45 X
67917   3 90 2 X 1,354.30 X
67917   4 90 2 X 1,363.96 X
67917   1 90 2 X 1,472.76 X
67917   2 90 2 X 1,487.11 X
67921   1 90 2 X 1,082.59 X
67921   3 90 2 X 1,111.66 X
67921   4 90 2 X 1,120.67 X
67921   2 90 2 X 1,252.30 X
67922   3 90 2 X 344.82 X
67922   1 90 2 X 369.50 X
67922   4 90 2 X 375.46 X
67922   2 90 2 X 390.37 X
67923   4 90 2 X 952.83 X
67923   3 90 2 X 1,148.81 X
67923   2 90 2 X 1,212.58 X
67923   1 90 2 X 1,280.25 X
67924   4 90 2 X 1,174.58 X
67924   3 90 2 X 1,190.10 X
67924   2 90 2 X 1,258.26 X
67924   1 90 2 X 1,274.60 X
67930   4 10 2 X 434.96 X
67930   3 10 2 X 439.76 X
67930   2 10 2 X 457.47 X
67930   1 10 2 X 494.91 X
67935   4 90 2 X 890.41 X
67935   1 90 2 X 954.23 X
67935   3 90 2 X 1,088.80 X
67935   2 90 2 X 1,138.85 X
67938   3 10 2 X 163.88 X
67938   4 10 2 X 169.77 X
67938   2 10 2 X 170.62 X
67938   1 10 2 X 172.28 X
67950   3 90 2 X 1,650.98 X
67950   4 90 2 X 1,709.75 X
67950   2 90 2 X 1,739.13 X
67950   1 90 2 X 1,747.80 X
67961   3 90 2 X 1,631.29 X
67961   4 90 2 X 1,663.28 X
67961   2 90 2 X 1,692.78 X
67961   1 90 2 X 1,714.22 X
67966   4 90 2 X 1,801.95 X
67966   3 90 2 X 1,812.61 X
67966   2 90 2 X 1,832.19 X
67966   1 90 2 X 1,838.96 X
67971   4 90 2 X 1,830.06 X
67971   3 90 2 X 1,971.23 X
67971   2 90 2 X 2,026.58 X
67971   1 90 2 X 2,160.00 X
67973   4 90 2 X 2,370.23 X
67973   3 90 2 X 2,657.40 X
67973   2 90 2 X 2,693.87 X
67973   1 90 2 X 2,728.00 X
67974   4 90 2 X 2,409.63 X
67974   3 90 2 X 2,440.82 X
67974   2 90 2 X 2,577.44 X
67974   1 90 2 X 2,610.20 X
67975   3 90 2 X 867.90 X
67975   2 90 2 X 933.08 X
67975   1 90 2 X 943.06 X
67975   4 90 2 X 1,175.58 X
67999     YYY 2 X # X
68020   3 10 2 X 150.45 129.91
68020   4 10 2 X 150.48 130.06
68020   2 10 2 X 155.41 134.06
68020   1 10 2 X 156.29 134.51
68040     0 2 X * X
68100   3 0 2 X 273.10 X
68100   4 0 2 X 276.65 X
68100   2 0 2 X 284.10 X
68100   1 0 2 X 290.70 X
68110   4 10 2 X 321.57 257.86
68110   3 10 2 X 322.89 258.39
68110   2 10 2 X 336.81 269.01
68110   1 10 2 X 355.96 283.60
68115   4 10 2 X 382.51 X
68115   3 10 2 X 387.19 X
68115   2 10 2 X 406.81 X
68115   1 10 2 X 417.00 X
68130   4 90 2 X 661.04 X
68130   3 90 2 X 666.74 X
68130   2 90 2 X 690.12 X
68130   1 90 2 X 695.71 X
68135   4 10 2 X 205.97 X
68135   3 10 2 X 207.47 X
68135   2 10 2 X 212.90 X
68135   1 10 2 X 243.68 X
68200   3 0 2 X 155.37 116.95
68200   2 0 2 X 157.13 118.09
68200   1 0 2 X 157.35 118.34
68200   4 0 2 X 171.27 129.30
68320   4 90 2 X 1,088.81 X
68320   3 90 2 X 1,395.77 X
68320   2 90 2 X 1,472.78 X
68320   1 90 2 X 1,479.40 X
68325   4 90 2 X 1,479.77 X
68325   3 90 2 X 1,499.31 X
68325   2 90 2 X 1,744.97 X
68325   1 90 2 X 1,754.03 X
68326   1 90 2 X 1,506.03 X
68326   3 90 2 X 1,668.84 X
68326   4 90 2 X 2,134.90 X
68326   2 90 2 X 2,176.14 X
68328   4 90 2 X 1,699.94 X
68328   3 90 2 X 1,722.35 X
68328   2 90 2 X 1,829.72 X
68328   1 90 2 X 1,855.46 X
68330   4 90 2 X 947.06 X
68330   3 90 2 X 959.54 X
68330   2 90 2 X 1,616.96 X
68330   1 90 2 X 1,656.94 X
68335   4 90 2 X 1,552.94 X
68335   3 90 2 X 1,573.74 X
68335   1 90 2 X 1,693.53 X
68335   2 90 2 X 2,288.09 X
68340   4 90 2 X 634.89 X
68340   3 90 2 X 642.68 X
68340   2 90 2 X 674.52 X
68340   1 90 2 X 682.14 X
68360   4 90 2 X 867.39 X
68360   3 90 2 X 959.56 X
68360   2 90 2 X 981.16 X
68360   1 90 2 X 986.29 X
68362   4 90 2 X 1,357.92 X
68362   3 90 2 X 1,370.35 X
68362   2 90 2 X 1,412.81 X
68362   1 90 2 X 1,423.05 X
68371   2 10 2 X 646.57 X
68371   3 10 2 X 646.57 X
68371   4 10 2 X 646.57 X
68371   1 10 2 X 715.29 X
68399     YYY 2 X # X
68400   3 10 2 X 240.97 X
68400   4 10 2 X 250.60 X
68400   1 10 2 X 254.93 X
68400   2 10 2 X 256.51 X
68420   4 10 2 X 293.99 X
68420   3 10 2 X 297.33 X
68420   2 10 2 X 310.04 X
68420   1 10 2 X 313.13 X
68440   3 10 2 X 133.73 104.23
68440   4 10 2 X 134.08 104.89
68440   2 10 2 X 139.39 108.52
68440   1 10 2 X 140.67 109.64
68500   4 90 2 X 1,658.53 X
68500   3 90 2 X 1,678.46 X
68500   2 90 2 X 1,772.13 X
68500   1 90 2 X 1,794.79 X
68505   4 90 2 X 1,721.09 X
68505   3 90 2 X 1,742.49 X
68505   2 90 2 X 1,830.97 X
68505   1 90 2 X 1,852.17 X
68510   4 0 2 X 563.86 X
68510   2 0 2 X 592.51 X
68510   3 0 2 X 763.41 X
68510   1 0 2 X 813.99 X
68520   1 90 2 X 1,586.42 X
68520   3 90 2 X 1,630.61 X
68520   4 90 2 X 1,648.79 X
68520   2 90 2 X 1,664.60 X
68525   4 0 2 X 732.92 X
68525   3 0 2 X 741.97 X
68525   2 0 2 X 774.93 X
68525   1 0 2 X 789.38 X
68530   4 10 2 X 582.80 X
68530   3 10 2 X 589.96 X
68530   2 10 2 X 619.66 X
68530   1 10 2 X 626.81 X
68540   4 90 2 X 1,662.42 X
68540   2 90 2 X 1,769.23 X
68540   1 90 2 X 1,789.93 X
68540   3 90 2 X 1,928.15 X
68550   4 90 2 X 2,173.45 X
68550   3 90 2 X 2,200.64 X
68550   2 90 2 X 2,318.11 X
68550   1 90 2 X 2,346.35 X
68700   4 90 2 X 800.00 X
68700   3 90 2 X 1,238.27 X
68700   2 90 2 X 1,471.44 X
68700   1 90 2 X 1,475.79 X
68705   1 10 2 X 300.10 X
68705   2 10 2 X 300.83 X
68705   4 10 2 X 302.38 X
68705   3 10 2 X 303.72 X
68720   4 90 2 X 1,885.14 X
68720   3 90 2 X 2,010.27 X
68720   2 90 2 X 2,179.68 X
68720   1 90 2 X 2,362.37 X
68745   4 90 2 X 1,340.45 X
68745   3 90 2 X 1,356.95 X
68745   1 90 2 X 1,445.03 X
68745   2 90 2 X 1,678.33 X
68750   3 90 2 X 1,340.28 X
68750   2 90 2 X 2,081.91 X
68750   1 90 2 X 2,110.70 X
68750   4 90 2 X 2,326.29 X
68760   4 10 2 X 233.16 193.81
68760   3 10 2 X 235.90 195.86
68760   2 10 2 X 246.00 203.56
68760   1 10 2 X 248.43 205.53
68761   4 10 2 X 199.38 160.06
68761   3 10 2 X 201.83 161.80
68761   2 10 2 X 211.14 168.72
68761   1 10 2 X 213.35 170.44
68770   2 90 2 X 921.17 X
68770   1 90 2 X 927.54 X
68770   4 90 2 X 977.24 X
68770   3 90 2 X 988.97 X
68801   3 10 2 X 115.07 96.63
68801   4 10 2 X 115.07 96.63
68801   2 10 2 X 118.20 99.23
68801   1 10 2 X 125.64 103.79
68810   3 10 2 X 159.95 135.79
68810   4 10 2 X 159.95 135.79
68810   2 10 2 X 164.36 139.54
68810   1 10 2 X 174.27 145.80
68811   3 10 2 X 331.26 X
68811   4 10 2 X 331.26 X
68811   2 10 2 X 340.36 X
68811   1 10 2 X 366.91 X
68815   3 10 2 X 435.22 350.51
68815   4 10 2 X 435.22 350.51
68815   2 10 2 X 447.28 360.26
68815   1 10 2 X 480.81 380.74
68816   2 10 2 X 870.71 306.49
68816   3 10 2 X 870.71 306.49
68816   4 10 2 X 870.71 306.49
68816   1 10 2 X 1,023.11 342.85
68840   4 10 2 X 132.40 114.36
68840   3 10 2 X 135.47 116.92
68840   2 10 2 X 142.36 122.16
68840   1 10 2 X 142.97 123.25
68850   3 0 2 X 120.91 X
68850   4 0 2 X 125.25 X
68850   2 0 2 X 126.95 X
68850   1 0 2 X 128.43 X
68899     YYY 2 X # X
69000   3 10 2 X 145.06 131.69
69000   4 10 2 X 147.30 133.31
69000   1 10 2 X 148.55 134.39
69000   2 10 2 X 150.08 135.58
69005   3 10 2 X 308.76 X
69005   4 10 2 X 314.99 X
69005   2 10 2 X 319.06 X
69005   1 10 2 X 327.25 X
69020   2 10 2 X 153.05 135.32
69020   3 10 2 X 161.22 142.81
69020   4 10 2 X 162.50 144.59
69020   1 10 2 X 178.44 157.99
69100   3 0 2 X 185.60 145.29
69100   4 0 2 X 187.93 147.35
69100   2 0 2 X 191.02 149.39
69100   1 0 2 X 196.26 153.70
69105   3 0 2 X 166.80 X
69105   4 0 2 X 171.07 X
69105   1 0 2 X 177.05 X
69105   2 0 2 X 226.76 X
69110   3 90 2 X 697.84 X
69110   4 90 2 X 709.43 X
69110   1 90 2 X 736.80 X
69110   2 90 2 X 776.19 X
69120   4 90 2 X 280.24 X
69120   1 90 2 X 293.94 X
69120   2 90 2 X 377.51 X
69120   3 90 2 X 586.24 X
69140   4 90 2 X 1,453.72 X
69140   3 90 2 X 1,471.87 X
69140   2 90 2 X 1,566.87 X
69140   1 90 2 X 1,589.78 X
69145   4 90 2 X 685.83 X
69145   3 90 2 X 688.22 X
69145   2 90 2 X 700.85 X
69145   1 90 2 X 703.97 X
69150   4 90 2 X 2,175.02 X
69150   3 90 2 X 2,201.21 X
69150   2 90 2 X 2,335.95 X
69150   1 90 2 X 2,368.51 X
69155   4 90 2 X 3,036.32 X
69155   3 90 2 X 3,073.85 X
69155   2 90 2 X 3,260.94 X
69155   1 90 2 X 4,110.74 X
69200   4 0 2 X 101.39 84.78
69200   3 0 2 X 102.56 85.68
69200   2 0 2 X 107.23 89.37
69200   1 0 2 X 108.95 90.79
69205   1 10 2 X 198.65 X
69205   3 10 2 X 206.70 X
69205   4 10 2 X 236.50 X
69205   2 10 2 X 246.27 X
69209   2 0 2 X 15.67 X
69209   3 0 2 X 15.67 X
69209   4 0 2 X 15.67 X
69209   1 0 2 X 18.38 X
69210   3 0 2 X 66.56 57.98
69210   4 0 2 X 71.07 62.20
69210   1 0 2 X 72.68 63.31
69210   2 0 2 X 74.52 64.74
69220   3 0 2 X 97.46 80.22
69220   4 0 2 X 107.99 89.15
69220   1 0 2 X 110.54 90.77
69220   2 0 2 X 112.24 91.89
69222   4 10 2 X 231.41 192.97
69222   3 10 2 X 232.36 194.15
69222   2 10 2 X 233.32 194.25
69222   1 10 2 X 278.51 231.96
69300   4 YYY 0 X 1,116.16 X
69300   3 YYY 0 X 1,131.62 X
69300   2 YYY 0 X 1,192.41 X
69300   1 YYY 0 X 1,219.07 X
69310   2 90 2 X 2,162.64 X
69310   4 90 2 X 2,337.77 X
69310   1 90 2 X 2,409.56 X
69310   3 90 2 X 2,645.02 X
69320   4 90 2 X 2,892.61 X
69320   2 90 2 X 3,109.59 X
69320   3 90 2 X 3,745.11 X
69320   1 90 2 X 4,602.55 X
69399     YYY 2 X # X
69420   4 10 2 X 180.90 151.23
69420   3 10 2 X 182.96 152.82
69420   2 10 2 X 192.66 160.74
69420   1 10 2 X 198.37 165.59
69421   3 10 2 X 226.33 X
69421   2 10 2 X 251.41 X
69421   4 10 2 X 254.78 X
69421   1 10 2 X 280.43 X
69424   3 0 2 X 172.84 X
69424   4 0 2 X 176.43 X
69424   2 0 2 X 178.18 X
69424   1 0 2 X 187.15 X
69433   2 10 2 X 278.52 217.49
69433   3 10 2 X 302.69 236.14
69433   4 10 2 X 310.31 241.97
69433   1 10 2 X 325.33 254.49
69436   4 10 2 X 373.76 X
69436   3 10 2 X 378.48 X
69436   2 10 2 X 382.24 X
69436   1 10 2 X 409.12 X
69440   3 90 2 X 1,582.26 X
69440   4 90 2 X 1,610.83 X
69440   2 90 2 X 1,657.02 X
69440   1 90 2 X 2,080.90 X
69450   1 90 2 X 1,549.45 X
69450   3 90 2 X 1,913.67 X
69450   2 90 2 X 1,923.31 X
69450   4 90 2 X 2,003.06 X
69501   3 90 2 X 1,963.04 X
69501   2 90 2 X 1,976.47 X
69501   4 90 2 X 2,044.93 X
69501   1 90 2 X 2,176.86 X
69502   2 90 2 X 2,571.30 X
69502   4 90 2 X 2,747.09 X
69502   3 90 2 X 2,759.59 X
69502   1 90 2 X 2,840.83 X
69505   4 90 2 X 2,667.18 X
69505   3 90 2 X 2,700.64 X
69505   2 90 2 X 3,022.85 X
69505   1 90 2 X 3,041.64 X
69511   4 90 2 X 2,731.26 X
69511   3 90 2 X 2,812.86 X
69511   2 90 2 X 3,005.18 X
69511   1 90 2 X 3,051.41 X
69530   4 90 2 X 3,204.35 X
69530   3 90 2 X 3,243.95 X
69530   2 90 2 X 3,462.36 X
69530   1 90 2 X 3,489.59 X
69535   3 90 2 X 4,763.55 X
69535   2 90 2 X 4,900.14 X
69535   1 90 2 X 5,251.96 X
69535   4 90 2 X 5,515.22 X
69540   3 10 2 X 273.80 X
69540   4 10 2 X 279.09 X
69540   2 10 2 X 287.64 X
69540   1 10 2 X 295.62 X
69550   4 90 2 X 2,544.70 X
69550   3 90 2 X 2,834.60 X
69550   2 90 2 X 2,922.57 X
69550   1 90 2 X 2,943.75 X
69552   4 90 2 X 3,290.54 X
69552   3 90 2 X 3,330.81 X
69552   2 90 2 X 3,536.38 X
69552   1 90 2 X 3,585.97 X
69554   4 90 2 X 4,507.96 X
69554   3 90 2 X 4,563.01 X
69554   2 90 2 X 4,847.77 X
69554   1 90 2 X 4,916.50 X
69601   4 90 2 X 2,487.74 X
69601   3 90 2 X 2,519.06 X
69601   2 90 2 X 2,686.95 X
69601   1 90 2 X 2,724.31 X
69602   4 90 2 X 2,731.47 X
69602   3 90 2 X 2,772.12 X
69602   2 90 2 X 2,840.82 X
69602   1 90 2 X 2,935.20 X
69603   4 90 2 X 2,873.51 X
69603   3 90 2 X 2,910.30 X
69603   2 90 2 X 3,108.26 X
69603   1 90 2 X 3,155.87 X
69604   2 90 2 X 3,348.37 X
69604   4 90 2 X 3,411.47 X
69604   3 90 2 X 3,456.26 X
69604   1 90 2 X 3,743.93 X
69610   4 10 2 X 404.86 372.22
69610   1 10 2 X 428.54 392.78
69610   3 10 2 X 433.87 398.82
69610   2 10 2 X 439.44 401.33
69620   4 90 2 X 1,443.51 X
69620   2 90 2 X 1,818.14 X
69620   3 90 2 X 1,956.31 X
69620   1 90 2 X 2,164.64 X
69631   4 90 2 X 2,476.05 X
69631   3 90 2 X 2,497.66 X
69631   2 90 2 X 2,584.54 X
69631   1 90 2 X 2,600.73 X
69632   4 90 2 X 2,629.20 X
69632   3 90 2 X 2,662.88 X
69632   2 90 2 X 2,844.49 X
69632   1 90 2 X 2,888.20 X
69633   4 90 2 X 2,542.98 X
69633   3 90 2 X 2,575.62 X
69633   2 90 2 X 2,755.89 X
69633   1 90 2 X 2,799.26 X
69635   4 90 2 X 3,110.76 X
69635   3 90 2 X 3,133.62 X
69635   2 90 2 X 3,310.87 X
69635   1 90 2 X 3,352.16 X
69636   4 90 2 X 3,397.90 X
69636   3 90 2 X 3,421.82 X
69636   2 90 2 X 3,598.78 X
69636   1 90 2 X 3,640.23 X
69637   4 90 2 X 3,172.78 X
69637   3 90 2 X 3,213.41 X
69637   1 90 2 X 3,491.94 X
69637   2 90 2 X 3,516.08 X
69641   4 90 2 X 2,667.49 X
69641   3 90 2 X 2,701.68 X
69641   2 90 2 X 2,890.99 X
69641   1 90 2 X 3,140.98 X
69642   4 90 2 X 3,432.44 X
69642   3 90 2 X 3,657.35 X
69642   2 90 2 X 3,769.78 X
69642   1 90 2 X 3,881.13 X
69643   4 90 2 X 3,303.93 X
69643   3 90 2 X 3,346.27 X
69643   2 90 2 X 3,611.57 X
69643   1 90 2 X 3,736.18 X