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2021 Workers' Compensation Part B Fee Schedule

69644-70450

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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
69644   4 90 2 X 3,669.71 X
69644   3 90 2 X 3,716.86 X
69644   2 90 2 X 3,843.20 X
69644   1 90 2 X 4,047.59 X
69645   3 90 2 X 3,472.25 X
69645   4 90 2 X 3,493.37 X
69645   2 90 2 X 3,789.47 X
69645   1 90 2 X 3,849.97 X
69646   4 90 2 X 3,653.23 X
69646   3 90 2 X 3,768.24 X
69646   2 90 2 X 3,951.94 X
69646   1 90 2 X 4,012.65 X
69650   4 90 2 X 1,991.91 X
69650   3 90 2 X 2,017.38 X
69650   2 90 2 X 2,114.27 X
69650   1 90 2 X 2,185.18 X
69660   3 90 2 X 2,573.53 X
69660   4 90 2 X 2,886.18 X
69660   1 90 2 X 2,961.95 X
69660   2 90 2 X 3,120.11 X
69661   4 90 2 X 3,127.14 X
69661   3 90 2 X 3,167.08 X
69661   2 90 2 X 3,376.49 X
69661   1 90 2 X 3,426.95 X
69662   4 90 2 X 3,066.84 X
69662   3 90 2 X 3,105.81 X
69662   2 90 2 X 3,312.93 X
69662   1 90 2 X 3,362.81 X
69666   4 90 2 X 2,621.76 X
69666   3 90 2 X 2,634.15 X
69666   2 90 2 X 2,705.77 X
69666   1 90 2 X 2,722.96 X
69667   4 90 2 X 2,202.50 X
69667   3 90 2 X 2,231.10 X
69667   1 90 2 X 2,433.36 X
69667   2 90 2 X 2,690.22 X
69670   4 90 2 X 1,959.50 X
69670   3 90 2 X 2,165.42 X
69670   2 90 2 X 2,173.66 X
69670   1 90 2 X 2,263.44 X
69676   4 90 2 X 1,635.23 X
69676   3 90 2 X 1,655.41 X
69676   2 90 2 X 1,755.72 X
69676   1 90 2 X 1,779.85 X
69700   4 90 2 X 1,464.00 X
69700   3 90 2 X 1,482.23 X
69700   2 90 2 X 1,575.50 X
69700   1 90 2 X 1,597.96 X
69705   2 0 3 X 3,308.89 193.69
69705   3 0 3 X 3,308.89 193.69
69705   4 0 3 X 3,308.89 193.69
69705   1 0 3 X 3,803.75 210.82
69706   2 0 3 X 3,411.22 269.73
69706   3 0 3 X 3,411.22 269.73
69706   4 0 3 X 3,411.22 269.73
69706   1 0 3 X 3,916.30 293.05
69711     90 2 X * X
69714   2 90 2 X 1,718.76 X
69714   3 90 2 X 1,718.76 X
69714   4 90 2 X 1,718.76 X
69714   1 90 2 X 1,905.34 X
69715   2 90 2 X 2,178.74 X
69715   3 90 2 X 2,178.74 X
69715   4 90 2 X 2,178.74 X
69715   1 90 2 X 2,410.75 X
69717   2 90 2 X 1,772.13 X
69717   3 90 2 X 1,772.13 X
69717   4 90 2 X 1,772.13 X
69717   1 90 2 X 1,960.30 X
69718   2 90 2 X 2,204.93 X
69718   3 90 2 X 2,204.93 X
69718   4 90 2 X 2,204.93 X
69718   1 90 2 X 2,439.61 X
69720   4 90 2 X 3,028.63 X
69720   3 90 2 X 3,645.40 X
69720   2 90 2 X 3,793.89 X
69720   1 90 2 X 3,896.41 X
69725   4 90 2 X 3,093.14 X
69725   3 90 2 X 3,130.42 X
69725   2 90 2 X 3,311.09 X
69725   1 90 2 X 3,354.66 X
69740   4 90 2 X 2,546.05 X
69740   2 90 2 X 2,741.86 X
69740   1 90 2 X 2,781.94 X
69740   3 90 2 X 3,274.05 X
69745   4 90 2 X 2,948.26 X
69745   3 90 2 X 2,985.05 X
69745   2 90 2 X 3,166.89 X
69745   1 90 2 X 3,210.73 X
69799     YYY 2 X # X
69801   4 90 2 X 2,140.84 X
69801   2 90 2 X 2,338.56 X
69801   3 90 2 X 2,358.04 X
69801   1 90 2 X 2,379.44 X
69805   4 90 2 X 2,526.77 X
69805   3 90 2 X 2,559.84 X
69805   2 90 2 X 2,751.86 X
69805   1 90 2 X 2,798.05 X
69806   4 90 2 X 3,023.35 X
69806   3 90 2 X 3,063.01 X
69806   2 90 2 X 3,557.92 X
69806   1 90 2 X 3,711.11 X
69905   4 90 2 X 2,556.07 X
69905   3 90 2 X 2,589.16 X
69905   2 90 2 X 2,784.09 X
69905   1 90 2 X 2,831.02 X
69910   4 90 2 X 3,136.87 X
69910   3 90 2 X 3,177.83 X
69910   2 90 2 X 3,410.08 X
69910   1 90 2 X 3,465.95 X
69915   4 90 2 X 3,482.73 X
69915   3 90 2 X 3,525.23 X
69915   2 90 2 X 3,744.87 X
69915   1 90 2 X 3,872.78 X
69930   4 90 2 X 3,927.36 X
69930   3 90 2 X 3,979.73 X
69930   2 90 2 X 4,293.04 X
69930   1 90 2 X 4,778.02 X
69949     YYY 2 X # X
69950   4 90 2 X 3,646.92 X
69950   3 90 2 X 3,690.94 X
69950   2 90 2 X 3,927.11 X
69950   1 90 2 X 4,286.87 X
69955   4 90 2 X 3,923.81 X
69955   3 90 2 X 3,972.05 X
69955   2 90 2 X 4,219.30 X
69955   1 90 2 X 4,278.92 X
69960   4 90 2 X 3,474.08 X
69960   3 90 2 X 3,516.67 X
69960   1 90 2 X 3,785.09 X
69960   2 90 2 X 4,835.19 X
69970   4 90 2 X 3,890.87 X
69970   3 90 2 X 3,938.31 X
69970   2 90 2 X 4,183.75 X
69970   1 90 2 X 4,242.96 X
69979     YYY 2 X # X
69990   2 ZZZ 0 X 422.08 X
69990   3 ZZZ 0 X 422.08 X
69990   4 ZZZ 0 X 422.08 X
69990   1 ZZZ 0 X 484.50 X
70010 26 4 XXX 0 X 163.48 X
70010 26 3 XXX 0 X 167.74 X
70010 26 2 XXX 0 X 175.28 X
70010 26 1 XXX 0 X 175.88 X
70010 TC 4 XXX 0 X 352.70 X
70010 TC 3 XXX 0 X 358.37 X
70010 TC 2 XXX 0 X 388.38 X
70010 TC 1 XXX 0 X 395.49 X
70010   4 XXX 0 X 501.09 X
70010   3 XXX 0 X 508.38 X
70010   2 XXX 0 X 546.51 X
70010   1 XXX 0 X 555.55 X
70015 TC 4 XXX 0 X 110.43 X
70015 TC 3 XXX 0 X 112.18 X
70015 TC 2 XXX 0 X 121.85 X
70015 TC 1 XXX 0 X 124.19 X
70015 26 4 XXX 0 X 163.48 X
70015 26 3 XXX 0 X 167.74 X
70015 26 2 XXX 0 X 175.28 X
70015 26 1 XXX 0 X 175.88 X
70015   4 XXX 0 X 258.80 X
70015   3 XXX 0 X 262.19 X
70015   2 XXX 0 X 280.02 X
70015   1 XXX 0 X 284.25 X
70030 26 4 XXX 0 X 23.69 X
70030 26 3 XXX 0 X 24.31 X
70030 26 2 XXX 0 X 25.37 X
70030 26 1 XXX 0 X 25.39 X
70030 TC 4 XXX 0 X 34.17 X
70030 TC 3 XXX 0 X 34.70 X
70030 TC 2 XXX 0 X 37.81 X
70030 TC 1 XXX 0 X 38.53 X
70030   4 XXX 0 X 56.68 X
70030   3 XXX 0 X 58.22 X
70030   2 XXX 0 X 61.39 X
70030   1 XXX 0 X 61.43 X
70100 26 4 XXX 0 X 25.09 X
70100 26 3 XXX 0 X 25.83 X
70100 26 2 XXX 0 X 26.92 X
70100 26 1 XXX 0 X 27.01 X
70100 TC 4 XXX 0 X 42.87 X
70100 TC 3 XXX 0 X 44.29 X
70100 TC 1 XXX 0 X 48.04 X
70100 TC 2 XXX 0 X 52.25 X
70100   4 XXX 0 X 66.59 X
70100   3 XXX 0 X 68.41 X
70100   1 XXX 0 X 74.48 X
70100   2 XXX 0 X 81.83 X
70110 26 4 XXX 0 X 34.51 X
70110 26 3 XXX 0 X 35.33 X
70110 26 2 XXX 0 X 36.97 X
70110 26 1 XXX 0 X 37.06 X
70110 TC 4 XXX 0 X 50.85 X
70110 TC 3 XXX 0 X 51.62 X
70110 TC 2 XXX 0 X 56.09 X
70110 TC 1 XXX 0 X 57.13 X
70110   4 XXX 0 X 83.81 X
70110   3 XXX 0 X 86.05 X
70110   1 XXX 0 X 91.76 X
70110   2 XXX 0 X 93.65 X
70120 26 4 XXX 0 X 25.09 X
70120 26 3 XXX 0 X 25.78 X
70120 26 2 XXX 0 X 26.92 X
70120 26 1 XXX 0 X 27.01 X
70120 TC 4 XXX 0 X 50.85 X
70120 TC 3 XXX 0 X 51.62 X
70120 TC 2 XXX 0 X 56.09 X
70120 TC 1 XXX 0 X 57.13 X
70120   4 XXX 0 X 73.78 X
70120   3 XXX 0 X 76.51 X
70120   2 XXX 0 X 80.44 X
70120   1 XXX 0 X 81.78 X
70130 26 4 XXX 0 X 46.16 X
70130 26 3 XXX 0 X 47.24 X
70130 26 2 XXX 0 X 49.34 X
70130 26 1 XXX 0 X 49.50 X
70130 TC 4 XXX 0 X 64.34 X
70130 TC 3 XXX 0 X 65.38 X
70130 TC 2 XXX 0 X 70.94 X
70130 TC 1 XXX 0 X 72.27 X
70130   4 XXX 0 X 108.16 X
70130   3 XXX 0 X 111.09 X
70130   2 XXX 0 X 117.02 X
70130   1 XXX 0 X 118.11 X
70134 26 4 XXX 0 X 46.04 X
70134 26 3 XXX 0 X 47.34 X
70134 26 2 XXX 0 X 49.34 X
70134 26 1 XXX 0 X 49.50 X
70134 TC 4 XXX 0 X 60.40 X
70134 TC 3 XXX 0 X 61.38 X
70134 TC 2 XXX 0 X 66.70 X
70134 TC 1 XXX 0 X 67.96 X
70134   4 XXX 0 X 104.23 X
70134   3 XXX 0 X 106.98 X
70134   2 XXX 0 X 112.74 X
70134   1 XXX 0 X 113.79 X
70140 26 4 XXX 0 X 25.94 X
70140 26 3 XXX 0 X 26.62 X
70140 26 2 XXX 0 X 27.78 X
70140 26 1 XXX 0 X 27.87 X
70140 TC 4 XXX 0 X 50.85 X
70140 TC 3 XXX 0 X 57.82 X
70140 TC 2 XXX 0 X 59.91 X
70140   4 XXX 0 X 74.61 X
70140   3 XXX 0 X 77.35 X
70140 TC 1 XXX 0 X 77.51 X
70140   2 XXX 0 X 81.32 X
70140   1 XXX 0 X 112.80 X
70150 26 4 XXX 0 X 35.88 X
70150 26 3 XXX 0 X 36.77 X
70150 26 2 XXX 0 X 38.48 X
70150 26 1 XXX 0 X 38.57 X
70150 TC 4 XXX 0 X 64.34 X
70150 TC 3 XXX 0 X 65.38 X
70150 TC 2 XXX 0 X 79.08 X
70150 TC 1 XXX 0 X 80.40 X
70150   4 XXX 0 X 97.98 X
70150   3 XXX 0 X 102.00 X
70150   1 XXX 0 X 108.55 X
70150   2 XXX 0 X 116.96 X
70160 26 4 XXX 0 X 23.41 X
70160 26 3 XXX 0 X 24.06 X
70160 26 2 XXX 0 X 25.06 X
70160 26 1 XXX 0 X 25.09 X
70160 TC 4 XXX 0 X 42.87 X
70160 TC 3 XXX 0 X 45.92 X
70160 TC 2 XXX 0 X 53.14 X
70160 TC 1 XXX 0 X 57.06 X
70160   4 XXX 0 X 64.84 X
70160   3 XXX 0 X 66.59 X
70160   2 XXX 0 X 77.42 X
70160   1 XXX 0 X 78.96 X
70170 26 4 XXX 0 X 40.63 X
70170 26 3 XXX 0 X 41.69 X
70170 26 2 XXX 0 X 43.59 X
70170 26 1 XXX 0 X 43.70 X
70170 TC 4 XXX 0 X 77.07 X
70170 TC 3 XXX 0 X 78.28 X
70170 TC 2 XXX 0 X 84.98 X
70170 TC 1 XXX 0 X 86.54 X
70170   4 XXX 0 X 114.76 X
70170   3 XXX 0 X 118.11 X
70170   2 XXX 0 X 125.09 X
70170   1 XXX 0 X 127.26 X
70190 26 3 XXX 0 X 29.87 X
70190 26 4 XXX 0 X 30.14 X
70190 26 2 XXX 0 X 31.10 X
70190 26 1 XXX 0 X 31.20 X
70190 TC 4 XXX 0 X 50.85 X
70190 TC 3 XXX 0 X 51.62 X
70190 TC 2 XXX 0 X 56.09 X
70190 TC 1 XXX 0 X 57.13 X
70190   4 XXX 0 X 78.47 X
70190   3 XXX 0 X 80.62 X
70190   2 XXX 0 X 84.89 X
70190   1 XXX 0 X 85.24 X
70200 26 4 XXX 0 X 38.33 X
70200 26 3 XXX 0 X 39.39 X
70200 26 2 XXX 0 X 41.19 X
70200 26 1 XXX 0 X 41.30 X
70200 TC 4 XXX 0 X 64.34 X
70200 TC 3 XXX 0 X 65.38 X
70200 TC 2 XXX 0 X 72.85 X
70200 TC 1 XXX 0 X 74.07 X
70200   4 XXX 0 X 100.40 X
70200   3 XXX 0 X 103.08 X
70200   2 XXX 0 X 110.67 X
70200   1 XXX 0 X 115.19 X
70210 26 4 XXX 0 X 22.91 X
70210 26 3 XXX 0 X 23.44 X
70210 26 2 XXX 0 X 25.06 X
70210 26 1 XXX 0 X 25.09 X
70210 TC 4 XXX 0 X 50.85 X
70210 TC 3 XXX 0 X 51.62 X
70210 TC 2 XXX 0 X 56.09 X
70210 TC 1 XXX 0 X 57.13 X
70210   4 XXX 0 X 72.15 X
70210   3 XXX 0 X 74.71 X
70210   2 XXX 0 X 78.71 X
70210   1 XXX 0 X 80.06 X
70220 26 4 XXX 0 X 34.47 X
70220 26 3 XXX 0 X 35.33 X
70220 26 2 XXX 0 X 36.97 X
70220 26 1 XXX 0 X 37.06 X
70220 TC 4 XXX 0 X 64.34 X
70220 TC 3 XXX 0 X 65.38 X
70220 TC 2 XXX 0 X 70.94 X
70220 TC 1 XXX 0 X 72.27 X
70220   4 XXX 0 X 96.28 X
70220   3 XXX 0 X 99.21 X
70220   2 XXX 0 X 105.14 X
70220   1 XXX 0 X 106.86 X
70240 26 4 XXX 0 X 26.39 X
70240 26 3 XXX 0 X 27.12 X
70240 26 2 XXX 0 X 28.26 X
70240 26 1 XXX 0 X 28.32 X
70240 TC 4 XXX 0 X 34.17 X
70240 TC 3 XXX 0 X 34.70 X
70240 TC 1 XXX 0 X 38.53 X
70240 TC 2 XXX 0 X 39.18 X
70240   4 XXX 0 X 59.44 X
70240   3 XXX 0 X 60.98 X
70240   1 XXX 0 X 63.99 X
70240   2 XXX 0 X 71.64 X
70250 26 4 XXX 0 X 33.23 X
70250 26 3 XXX 0 X 34.15 X
70250 26 2 XXX 0 X 35.76 X
70250 26 1 XXX 0 X 35.88 X
70250 TC 4 XXX 0 X 50.85 X
70250 TC 3 XXX 0 X 55.63 X
70250 TC 2 XXX 0 X 69.94 X
70250 TC 1 XXX 0 X 70.86 X
70250   4 XXX 0 X 82.82 X
70250   3 XXX 0 X 85.36 X
70250   2 XXX 0 X 108.75 X
70250   1 XXX 0 X 108.91 X
70260 26 4 XXX 0 X 46.19 X
70260 26 3 XXX 0 X 47.17 X
70260 26 2 XXX 0 X 49.34 X
70260 26 1 XXX 0 X 49.50 X
70260 TC 4 XXX 0 X 73.09 X
70260 TC 3 XXX 0 X 74.27 X
70260 TC 1 XXX 0 X 82.24 X
70260 TC 2 XXX 0 X 86.21 X
70260   4 XXX 0 X 116.51 X
70260   3 XXX 0 X 120.66 X
70260   1 XXX 0 X 128.05 X
70260   2 XXX 0 X 130.72 X
70300     XXX 0 X * X
70310     XXX 0 X * X
70320     XXX 0 X * X
70328 26 4 XXX 0 X 25.09 X
70328 26 3 XXX 0 X 25.78 X
70328 26 2 XXX 0 X 26.92 X
70328 26 1 XXX 0 X 27.01 X
70328 TC 4 XXX 0 X 40.54 X
70328 TC 3 XXX 0 X 41.19 X
70328 TC 2 XXX 0 X 44.61 X
70328 TC 1 XXX 0 X 51.94 X
70328   4 XXX 0 X 64.34 X
70328   3 XXX 0 X 66.04 X
70328   2 XXX 0 X 68.97 X
70328   1 XXX 0 X 70.10 X
70330 26 4 XXX 0 X 33.23 X
70330 26 3 XXX 0 X 34.17 X
70330 26 2 XXX 0 X 35.73 X
70330 26 1 XXX 0 X 35.87 X
70330 TC 4 XXX 0 X 68.34 X
70330 TC 3 XXX 0 X 69.38 X
70330 TC 2 XXX 0 X 75.22 X
70330 TC 1 XXX 0 X 76.59 X
70330   4 XXX 0 X 99.43 X
70330   3 XXX 0 X 102.00 X
70330   2 XXX 0 X 107.71 X
70330   1 XXX 0 X 109.54 X
70332 26 4 XXX 0 X 76.10 X
70332 26 3 XXX 0 X 78.08 X
70332 26 2 XXX 0 X 81.67 X
70332 26 1 XXX 0 X 81.85 X
70332 TC 4 XXX 0 X 170.84 X
70332 TC 3 XXX 0 X 173.55 X
70332 TC 2 XXX 0 X 188.21 X
70332 TC 1 XXX 0 X 191.73 X
70332   4 XXX 0 X 239.68 X
70332   3 XXX 0 X 247.81 X
70332   2 XXX 0 X 261.72 X
70332   1 XXX 0 X 266.05 X
70336 26 4 XXX 0 X 174.09 X
70336 26 3 XXX 0 X 179.84 X
70336 26 2 XXX 0 X 186.88 X
70336 26 1 XXX 0 X 187.14 X
70336 TC 4 XXX 0 X 912.01 X
70336 TC 3 XXX 0 X 926.70 X
70336 TC 2 XXX 0 X 1,004.49 X
70336 TC 1 XXX 0 X 1,022.98 X
70336   4 XXX 0 X 1,056.85 X
70336   3 XXX 0 X 1,085.94 X
70336   2 XXX 0 X 1,147.85 X
70336   1 XXX 0 X 1,150.95 X
70350     XXX 0 X * X
70355     XXX 0 X * X
70360 26 4 XXX 0 X 23.22 X
70360 26 3 XXX 0 X 23.85 X
70360 26 2 XXX 0 X 24.91 X
70360 26 1 XXX 0 X 24.96 X
70360 TC 4 XXX 0 X 34.17 X
70360 TC 3 XXX 0 X 34.70 X
70360 TC 2 XXX 0 X 37.81 X
70360 TC 1 XXX 0 X 38.53 X
70360   4 XXX 0 X 56.33 X
70360   3 XXX 0 X 57.79 X
70360   1 XXX 0 X 61.43 X
70360   2 XXX 0 X 62.35 X
70370 26 4 XXX 0 X 43.73 X
70370 26 3 XXX 0 X 44.93 X
70370 26 2 XXX 0 X 46.99 X
70370 26 1 XXX 0 X 47.08 X
70370 TC 4 XXX 0 X 105.70 X
70370 TC 3 XXX 0 X 107.34 X
70370 TC 2 XXX 0 X 116.44 X
70370 TC 1 XXX 0 X 118.57 X
70370   4 XXX 0 X 145.82 X
70370   3 XXX 0 X 150.45 X
70370   2 XXX 0 X 159.17 X
70370   1 XXX 0 X 161.80 X
70371 26 4 XXX 0 X 116.03 X
70371 26 3 XXX 0 X 119.06 X
70371 26 2 XXX 0 X 124.51 X
70371 26 1 XXX 0 X 124.89 X
70371 TC 4 XXX 0 X 170.84 X
70371 TC 3 XXX 0 X 173.55 X
70371 TC 2 XXX 0 X 188.21 X
70371 TC 1 XXX 0 X 191.73 X
70371   4 XXX 0 X 281.27 X
70371   3 XXX 0 X 288.77 X
70371   2 XXX 0 X 304.43 X
70371   1 XXX 0 X 305.89 X
70380 26 4 XXX 0 X 23.64 X
70380 26 3 XXX 0 X 24.04 X
70380 26 2 XXX 0 X 25.06 X
70380 26 1 XXX 0 X 25.09 X
70380 TC 4 XXX 0 X 54.83 X
70380 TC 3 XXX 0 X 55.70 X
70380 TC 2 XXX 0 X 60.32 X
70380 TC 1 XXX 0 X 61.43 X
70380   4 XXX 0 X 76.10 X
70380   3 XXX 0 X 78.92 X
70380   2 XXX 0 X 83.01 X
70380   1 XXX 0 X 84.40 X
70390 26 3 XXX 0 X 52.81 X
70390 26 4 XXX 0 X 53.80 X
70390 26 2 XXX 0 X 55.26 X
70390 26 1 XXX 0 X 55.51 X
70390 TC 4 XXX 0 X 145.41 X
70390 TC 3 XXX 0 X 147.73 X
70390 TC 2 XXX 0 X 160.17 X
70390 TC 1 XXX 0 X 163.13 X
70390   4 XXX 0 X 192.92 X
70390   3 XXX 0 X 195.79 X
70390   2 XXX 0 X 211.00 X
70390   1 XXX 0 X 214.62 X
70450 26 4 XXX 0 X 117.92 X
70450 26 3 XXX 0 X 120.71 X
70450 26 2 XXX 0 X 126.14 X
70450 26 1 XXX 0 X 126.49 X
70450 TC 4 XXX 0 X 393.91 X
70450 TC 3 XXX 0 X 404.85 X
70450 TC 2 XXX 0 X 428.66 X
70450 TC 1 XXX 0 X 431.41 X
70450   4 XXX 0 X 511.47 X
70450   3 XXX 0 X 525.54 X
70450   2 XXX 0 X 554.68 X
70450   1 XXX 0 X 557.85 X