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Fee Schedule
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Fee Schedule 67882-69643
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2024 Workers' Compensation Part B Fee Schedule
67882-69643
View the PDF
CPT/HCPC Code
Modifier
Medicare Location
Global Surgery Indicator
Multiple Surgery Indicator
Prevailing Charge Amount
Fee Schedule Amount
Site of Service Amount
67882
003
90
2
X
1,457.72
X
67882
002
90
2
X
1,502.95
X
67882
004
90
2
X
1,468.24
X
67882
001
90
2
X
1,509.71
X
67900
001
90
2
X
942.81
X
67900
003
90
2
X
887.91
X
67900
002
90
2
X
932.20
X
67900
004
90
2
X
877.03
X
67901
003
90
2
X
2,057.43
X
67901
001
90
2
X
2,023.88
X
67901
004
90
2
X
1,704.78
X
67901
002
90
2
X
2,101.70
X
67902
002
90
2
X
1,912.41
X
67902
003
90
2
X
2,089.78
X
67902
001
90
2
X
2,237.07
X
67902
004
90
2
X
1,776.90
X
67903
002
90
2
X
1,951.86
X
67903
003
90
2
X
1,834.94
X
67903
001
90
2
X
2,200.50
X
67903
004
90
2
X
1,810.31
X
67904
002
90
2
X
2,103.72
X
67904
003
90
2
X
2,085.04
X
67904
004
90
2
X
2,011.62
X
67904
001
90
2
X
2,056.72
X
67906
001
90
2
X
1,382.53
X
67906
004
90
2
X
1,282.83
X
67906
003
90
2
X
1,298.67
X
67906
002
90
2
X
1,366.26
X
67908
003
90
2
X
2,008.02
X
67908
002
90
2
X
2,051.91
X
67908
001
90
2
X
2,061.97
X
67908
004
90
2
X
2,001.02
X
67909
003
90
2
X
1,225.93
X
67909
002
90
2
X
1,272.70
X
67909
001
90
2
X
1,283.88
X
67909
004
90
2
X
1,215.75
X
67911
004
90
2
X
1,576.15
X
67911
002
90
2
X
1,707.13
X
67911
003
90
2
X
1,597.51
X
67911
001
90
2
X
1,733.41
X
67912
001
90
2
X
2,305.77
968.35
67912
003
90
2
X
2,012.07
874.34
67912
002
90
2
X
2,012.07
874.34
67912
004
90
2
X
2,012.07
874.34
67914
001
90
2
X
1,547.70
X
67914
002
90
2
X
1,610.18
X
67914
003
90
2
X
1,438.47
X
67914
004
90
2
X
1,433.26
X
67915
001
90
2
X
484.21
X
67915
004
90
2
X
444.39
X
67915
002
90
2
X
481.48
X
67915
003
90
2
X
462.92
X
67916
004
90
2
X
1,230.91
X
67916
001
90
2
X
1,443.06
X
67916
003
90
2
X
1,247.12
X
67916
002
90
2
X
1,318.02
X
67917
003
90
2
X
1,587.01
X
67917
002
90
2
X
1,742.64
X
67917
004
90
2
X
1,598.33
X
67917
001
90
2
X
1,725.83
X
67921
004
90
2
X
1,313.23
X
67921
003
90
2
X
1,302.68
X
67921
002
90
2
X
1,467.48
X
67921
001
90
2
X
1,268.61
X
67922
004
90
2
X
439.97
X
67922
001
90
2
X
432.99
X
67922
003
90
2
X
404.07
X
67922
002
90
2
X
457.44
X
67923
001
90
2
X
1,500.24
X
67923
004
90
2
X
1,116.56
X
67923
002
90
2
X
1,420.94
X
67923
003
90
2
X
1,346.21
X
67924
004
90
2
X
1,376.41
X
67924
002
90
2
X
1,474.47
X
67924
003
90
2
X
1,394.60
X
67924
001
90
2
X
1,493.62
X
67930
001
10
2
X
579.95
X
67930
002
10
2
X
536.08
X
67930
003
10
2
X
515.32
X
67930
004
10
2
X
509.70
X
67935
002
90
2
X
1,334.54
X
67935
003
90
2
X
1,275.89
X
67935
004
90
2
X
1,043.41
X
67935
001
90
2
X
1,118.20
X
67938
001
10
2
X
201.88
X
67938
003
10
2
X
192.05
X
67938
002
10
2
X
199.94
X
67938
004
10
2
X
198.94
X
67950
004
90
2
X
2,003.54
X
67950
003
90
2
X
1,934.67
X
67950
002
90
2
X
2,037.96
X
67950
001
90
2
X
2,048.12
X
67961
001
90
2
X
2,008.78
X
67961
003
90
2
X
1,911.60
X
67961
002
90
2
X
1,983.65
X
67961
004
90
2
X
1,949.08
X
67966
001
90
2
X
2,154.95
X
67966
004
90
2
X
2,111.58
X
67966
002
90
2
X
2,147.02
X
67966
003
90
2
X
2,124.08
X
67971
004
90
2
X
2,144.52
X
67971
003
90
2
X
2,309.95
X
67971
002
90
2
X
2,374.81
X
67971
001
90
2
X
2,531.16
X
67973
002
90
2
X
3,156.77
X
67973
003
90
2
X
3,114.03
X
67973
004
90
2
X
2,777.52
X
67973
001
90
2
X
3,196.76
X
67974
003
90
2
X
2,860.23
X
67974
002
90
2
X
3,020.33
X
67974
001
90
2
X
3,058.71
X
67974
004
90
2
X
2,823.68
X
67975
004
90
2
X
1,377.58
X
67975
002
90
2
X
1,093.41
X
67975
003
90
2
X
1,017.04
X
67975
001
90
2
X
1,105.10
X
67999
YYY
2
X
#
X
68020
001
10
2
X
183.15
157.62
68020
003
10
2
X
176.30
152.22
68020
002
10
2
X
182.11
157.10
68020
004
10
2
X
176.33
152.40
68040
0
2
X
*
X
68100
003
0
2
X
320.02
X
68100
002
0
2
X
332.91
X
68100
004
0
2
X
324.19
X
68100
001
0
2
X
340.65
X
68110
002
10
2
X
394.69
315.23
68110
004
10
2
X
376.82
302.17
68110
003
10
2
X
378.37
302.79
68110
001
10
2
X
417.12
332.33
68115
004
10
2
X
448.24
X
68115
001
10
2
X
488.65
X
68115
003
10
2
X
453.72
X
68115
002
10
2
X
476.72
X
68130
002
90
2
X
808.70
X
68130
003
90
2
X
781.30
X
68130
001
90
2
X
815.26
X
68130
004
90
2
X
774.63
X
68135
004
10
2
X
241.35
X
68135
003
10
2
X
243.12
X
68135
002
10
2
X
249.49
X
68135
001
10
2
X
285.55
X
68200
002
0
2
X
184.13
138.38
68200
003
0
2
X
182.06
137.05
68200
001
0
2
X
184.39
138.67
68200
004
0
2
X
200.70
151.52
68320
001
90
2
X
1,733.61
X
68320
004
90
2
X
1,275.90
X
68320
003
90
2
X
1,635.61
X
68320
002
90
2
X
1,725.85
X
68325
003
90
2
X
1,756.93
X
68325
002
90
2
X
2,044.82
X
68325
004
90
2
X
1,734.03
X
68325
001
90
2
X
2,055.44
X
68326
004
90
2
X
2,501.74
X
68326
001
90
2
X
1,764.82
X
68326
003
90
2
X
1,955.60
X
68326
002
90
2
X
2,550.08
X
68328
003
90
2
X
2,018.31
X
68328
002
90
2
X
2,144.13
X
68328
001
90
2
X
2,174.29
X
68328
004
90
2
X
1,992.05
X
68330
004
90
2
X
1,109.80
X
68330
001
90
2
X
1,941.66
X
68330
002
90
2
X
1,894.81
X
68330
003
90
2
X
1,124.42
X
68335
001
90
2
X
1,984.53
X
68335
002
90
2
X
2,681.26
X
68335
003
90
2
X
1,844.16
X
68335
004
90
2
X
1,819.78
X
68340
004
90
2
X
743.98
X
68340
002
90
2
X
790.43
X
68340
003
90
2
X
753.12
X
68340
001
90
2
X
799.35
X
68360
002
90
2
X
1,149.76
X
68360
003
90
2
X
1,124.44
X
68360
001
90
2
X
1,155.77
X
68360
004
90
2
X
1,016.43
X
68362
002
90
2
X
1,655.59
X
68362
003
90
2
X
1,605.82
X
68362
004
90
2
X
1,591.25
X
68362
001
90
2
X
1,667.58
X
68371
002
10
2
X
757.67
X
68371
003
10
2
X
757.67
X
68371
001
10
2
X
838.20
X
68371
004
10
2
X
757.67
X
68399
YYY
2
X
#
X
68400
002
10
2
X
300.59
X
68400
003
10
2
X
282.37
X
68400
004
10
2
X
293.66
X
68400
001
10
2
X
298.74
X
68420
004
10
2
X
344.50
X
68420
001
10
2
X
366.94
X
68420
003
10
2
X
348.42
X
68420
002
10
2
X
363.31
X
68440
001
10
2
X
164.84
128.48
68440
003
10
2
X
156.72
122.14
68440
004
10
2
X
157.12
122.91
68440
002
10
2
X
163.34
127.16
68500
002
90
2
X
2,076.64
X
68500
003
90
2
X
1,966.88
X
68500
001
90
2
X
2,103.20
X
68500
004
90
2
X
1,943.52
X
68505
002
90
2
X
2,145.58
X
68505
003
90
2
X
2,041.90
X
68505
001
90
2
X
2,170.43
X
68505
004
90
2
X
2,016.83
X
68510
001
0
2
X
953.86
X
68510
004
0
2
X
660.74
X
68510
003
0
2
X
894.60
X
68510
002
0
2
X
694.32
X
68520
004
90
2
X
1,932.10
X
68520
003
90
2
X
1,910.80
X
68520
002
90
2
X
1,950.62
X
68520
001
90
2
X
1,859.01
X
68525
004
0
2
X
858.85
X
68525
001
0
2
X
925.02
X
68525
003
0
2
X
869.46
X
68525
002
0
2
X
908.10
X
68530
002
10
2
X
726.14
X
68530
003
10
2
X
691.34
X
68530
004
10
2
X
682.94
X
68530
001
10
2
X
734.52
X
68540
001
90
2
X
2,097.50
X
68540
004
90
2
X
1,948.08
X
68540
003
90
2
X
2,259.47
X
68540
002
90
2
X
2,073.24
X
68550
004
90
2
X
2,546.92
X
68550
002
90
2
X
2,716.44
X
68550
003
90
2
X
2,578.78
X
68550
001
90
2
X
2,749.53
X
68700
002
90
2
X
1,724.29
X
68700
003
90
2
X
1,451.05
X
68700
001
90
2
X
1,729.37
X
68700
004
90
2
X
937.47
X
68705
002
10
2
X
352.52
X
68705
003
10
2
X
355.91
X
68705
004
10
2
X
354.34
X
68705
001
10
2
X
351.67
X
68720
002
90
2
X
2,554.22
X
68720
003
90
2
X
2,355.70
X
68720
001
90
2
X
2,768.30
X
68720
004
90
2
X
2,209.06
X
68745
003
90
2
X
1,590.12
X
68745
002
90
2
X
1,966.72
X
68745
004
90
2
X
1,570.78
X
68745
001
90
2
X
1,693.33
X
68750
004
90
2
X
2,726.03
X
68750
002
90
2
X
2,439.65
X
68750
001
90
2
X
2,473.39
X
68750
003
90
2
X
1,570.59
X
68760
003
10
2
X
276.43
229.52
68760
002
10
2
X
288.28
238.53
68760
004
10
2
X
273.23
227.12
68760
001
10
2
X
291.13
240.84
68761
002
10
2
X
247.43
197.71
68761
004
10
2
X
233.64
187.56
68761
003
10
2
X
236.51
189.60
68761
001
10
2
X
250.01
199.73
68770
002
90
2
X
1,079.46
X
68770
003
90
2
X
1,158.90
X
68770
004
90
2
X
1,145.16
X
68770
001
90
2
X
1,086.92
X
68801
004
10
2
X
134.84
113.24
68801
003
10
2
X
134.84
113.24
68801
002
10
2
X
138.51
116.28
68801
001
10
2
X
147.22
121.63
68810
001
10
2
X
204.21
170.85
68810
003
10
2
X
187.44
159.12
68810
002
10
2
X
192.61
163.52
68810
004
10
2
X
187.44
159.12
68811
001
10
2
X
429.96
X
68811
002
10
2
X
398.84
X
68811
003
10
2
X
388.18
X
68811
004
10
2
X
388.18
X
68815
001
10
2
X
563.42
446.16
68815
004
10
2
X
510.00
410.74
68815
002
10
2
X
524.14
422.17
68815
003
10
2
X
510.00
410.74
68816
001
10
2
X
1,198.92
401.76
68816
004
10
2
X
1,020.33
359.15
68816
003
10
2
X
1,020.33
359.15
68816
002
10
2
X
1,020.33
359.15
68840
004
10
2
X
155.15
134.01
68840
001
10
2
X
167.54
144.42
68840
003
10
2
X
158.75
137.01
68840
002
10
2
X
166.83
143.15
68841
001
0
2
X
49.12
41.44
68841
004
0
2
X
44.66
38.00
68841
003
0
2
X
44.66
38.00
68841
002
0
2
X
44.66
38.00
68850
003
0
2
X
141.69
X
68850
002
0
2
X
148.76
X
68850
004
0
2
X
146.78
X
68850
001
0
2
X
150.50
X
68899
YYY
2
X
#
X
69000
004
10
2
X
172.61
156.22
69000
002
10
2
X
175.87
158.88
69000
003
10
2
X
169.98
154.32
69000
001
10
2
X
174.08
157.49
69005
002
10
2
X
373.89
X
69005
003
10
2
X
361.82
X
69005
001
10
2
X
383.48
X
69005
004
10
2
X
369.12
X
69020
001
10
2
X
209.10
185.14
69020
004
10
2
X
190.42
169.44
69020
002
10
2
X
179.35
158.57
69020
003
10
2
X
188.93
167.36
69100
001
0
2
X
229.98
180.11
69100
003
0
2
X
217.50
170.26
69100
002
0
2
X
223.85
175.06
69100
004
0
2
X
220.22
172.67
69105
001
0
2
X
207.48
X
69105
004
0
2
X
200.46
X
69105
002
0
2
X
265.73
X
69105
003
0
2
X
195.47
X
69110
004
90
2
X
831.33
X
69110
001
90
2
X
863.41
X
69110
003
90
2
X
817.75
X
69110
002
90
2
X
909.56
X
69120
002
90
2
X
442.38
X
69120
003
90
2
X
686.97
X
69120
001
90
2
X
344.45
X
69120
004
90
2
X
328.40
X
69140
001
90
2
X
1,862.96
X
69140
002
90
2
X
1,836.11
X
69140
003
90
2
X
1,724.78
X
69140
004
90
2
X
1,703.52
X
69145
002
90
2
X
821.29
X
69145
003
90
2
X
806.48
X
69145
004
90
2
X
803.67
X
69145
001
90
2
X
824.93
X
69150
001
90
2
X
2,775.50
X
69150
004
90
2
X
2,548.76
X
69150
002
90
2
X
2,737.34
X
69150
003
90
2
X
2,579.45
X
69155
001
90
2
X
4,817.10
X
69155
004
90
2
X
3,558.06
X
69155
003
90
2
X
3,602.03
X
69155
002
90
2
X
3,821.27
X
69200
003
0
2
X
120.18
100.40
69200
002
0
2
X
125.66
104.73
69200
004
0
2
X
118.81
99.35
69200
001
0
2
X
127.67
106.39
69205
001
10
2
X
232.78
X
69205
002
10
2
X
288.58
X
69205
003
10
2
X
242.22
X
69205
004
10
2
X
277.14
X
69209
002
0
2
X
18.36
X
69209
003
0
2
X
18.36
X
69209
001
0
2
X
21.54
X
69209
004
0
2
X
18.36
X
69210
003
0
2
X
77.99
67.94
69210
002
0
2
X
87.33
75.86
69210
004
0
2
X
83.28
72.89
69210
001
0
2
X
85.18
74.19
69220
004
0
2
X
126.55
104.47
69220
002
0
2
X
131.53
107.67
69220
003
0
2
X
114.20
94.00
69220
001
0
2
X
129.54
106.37
69222
002
10
2
X
273.42
227.62
69222
003
10
2
X
272.29
227.51
69222
001
10
2
X
326.36
271.81
69222
004
10
2
X
271.17
226.14
69300
001
YYY
2
X
1,428.54
X
69300
002
YYY
2
X
1,397.30
X
69300
003
YYY
2
X
1,326.07
X
69300
004
YYY
2
X
1,307.96
X
69310
004
90
2
X
2,739.47
X
69310
001
90
2
X
2,823.60
X
69310
003
90
2
X
3,099.52
X
69310
002
90
2
X
2,534.25
X
69320
002
90
2
X
3,643.91
X
69320
003
90
2
X
4,388.64
X
69320
004
90
2
X
3,389.65
X
69320
001
90
2
X
5,393.42
X
69399
YYY
2
X
#
X
69420
004
10
2
X
211.98
177.22
69420
003
10
2
X
214.41
179.09
69420
002
10
2
X
225.77
188.36
69420
001
10
2
X
232.45
194.04
69421
003
10
2
X
265.22
X
69421
002
10
2
X
294.61
X
69421
004
10
2
X
298.56
X
69421
001
10
2
X
328.62
X
69424
002
0
2
X
208.80
X
69424
003
0
2
X
202.54
X
69424
004
0
2
X
206.74
X
69424
001
0
2
X
219.30
X
69433
004
10
2
X
363.64
283.55
69433
001
10
2
X
381.23
298.22
69433
003
10
2
X
354.70
276.72
69433
002
10
2
X
326.37
254.85
69436
004
10
2
X
437.99
X
69436
003
10
2
X
443.52
X
69436
002
10
2
X
447.93
X
69436
001
10
2
X
479.42
X
69440
001
90
2
X
2,438.47
X
69440
003
90
2
X
1,854.14
X
69440
002
90
2
X
1,941.74
X
69440
004
90
2
X
1,887.62
X
69450
002
90
2
X
2,253.79
X
69450
003
90
2
X
2,242.50
X
69450
001
90
2
X
1,815.69
X
69450
004
90
2
X
2,347.25
X
69501
004
90
2
X
2,396.32
X
69501
003
90
2
X
2,300.36
X
69501
002
90
2
X
2,316.09
X
69501
001
90
2
X
2,550.91
X
69502
001
90
2
X
3,328.97
X
69502
003
90
2
X
3,233.78
X
69502
002
90
2
X
3,013.14
X
69502
004
90
2
X
3,219.13
X
69505
004
90
2
X
3,125.48
X
69505
003
90
2
X
3,164.70
X
69505
002
90
2
X
3,542.27
X
69505
001
90
2
X
3,564.30
X
69511
004
90
2
X
3,200.58
X
69511
001
90
2
X
3,575.74
X
69511
003
90
2
X
3,296.21
X
69511
002
90
2
X
3,521.56
X
69530
001
90
2
X
4,089.21
X
69530
004
90
2
X
3,754.96
X
69530
003
90
2
X
3,801.37
X
69530
002
90
2
X
4,057.31
X
69535
002
90
2
X
5,742.14
X
69535
003
90
2
X
5,582.08
X
69535
004
90
2
X
6,462.91
X
69535
001
90
2
X
6,154.42
X
69540
001
10
2
X
346.41
X
69540
004
10
2
X
327.05
X
69540
002
10
2
X
337.06
X
69540
003
10
2
X
320.85
X
69550
001
90
2
X
3,449.59
X
69550
003
90
2
X
3,321.68
X
69550
004
90
2
X
2,981.96
X
69550
002
90
2
X
3,424.76
X
69552
004
90
2
X
3,855.97
X
69552
001
90
2
X
4,202.15
X
69552
002
90
2
X
4,144.05
X
69552
003
90
2
X
3,903.15
X
69554
002
90
2
X
5,680.77
X
69554
003
90
2
X
5,347.09
X
69554
004
90
2
X
5,282.58
X
69554
001
90
2
X
5,761.32
X
69601
002
90
2
X
3,148.65
X
69601
003
90
2
X
2,951.92
X
69601
004
90
2
X
2,915.21
X
69601
001
90
2
X
3,192.43
X
69602
001
90
2
X
3,439.56
X
69602
004
90
2
X
3,200.83
X
69602
002
90
2
X
3,328.96
X
69602
003
90
2
X
3,248.46
X
69603
001
90
2
X
3,698.16
X
69603
002
90
2
X
3,642.36
X
69603
003
90
2
X
3,410.39
X
69603
004
90
2
X
3,367.27
X
69604
001
90
2
X
4,387.26
X
69604
004
90
2
X
3,997.68
X
69604
002
90
2
X
3,923.72
X
69604
003
90
2
X
4,050.16
X
69610
001
10
2
X
502.17
460.27
69610
002
10
2
X
514.95
470.30
69610
003
10
2
X
508.42
467.34
69610
004
10
2
X
474.43
436.19
69620
003
90
2
X
2,292.47
X
69620
002
90
2
X
2,130.55
X
69620
004
90
2
X
1,691.55
X
69620
001
90
2
X
2,536.60
X
69631
001
90
2
X
3,047.63
X
69631
004
90
2
X
2,901.52
X
69631
003
90
2
X
2,926.84
X
69631
002
90
2
X
3,028.65
X
69632
004
90
2
X
3,080.99
X
69632
002
90
2
X
3,333.27
X
69632
003
90
2
X
3,120.45
X
69632
001
90
2
X
3,384.48
X
69633
001
90
2
X
3,280.26
X
69633
004
90
2
X
2,979.95
X
69633
002
90
2
X
3,229.44
X
69633
003
90
2
X
3,018.19
X
69635
001
90
2
X
3,928.16
X
69635
004
90
2
X
3,645.29
X
69635
002
90
2
X
3,879.79
X
69635
003
90
2
X
3,672.08
X
69636
004
90
2
X
3,981.76
X
69636
001
90
2
X
4,265.75
X
69636
003
90
2
X
4,009.80
X
69636
002
90
2
X
4,217.17
X
69637
002
90
2
X
4,120.25
X
69637
004
90
2
X
3,717.96
X
69637
003
90
2
X
3,765.58
X
69637
001
90
2
X
4,091.97
X
69641
003
90
2
X
3,165.92
X
69641
002
90
2
X
3,387.76
X
69641
004
90
2
X
3,125.84
X
69641
001
90
2
X
3,680.70
X
69642
003
90
2
X
4,285.81
X
69642
002
90
2
X
4,417.56
X
69642
004
90
2
X
4,022.24
X
69642
001
90
2
X
4,548.02
X
69643
003
90
2
X
3,921.27
X
69643
002
90
2
X
4,232.16
X
69643
004
90
2
X
3,871.65
X
69643
001
90
2
X
4,378.18
X
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