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2021 Workers' Compensation Part B Fee Schedule

90849-92134

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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
90849   2 XXX 0 X 66.68 X
90849   3 XXX 0 X 66.68 X
90849   4 XXX 0 X 66.68 X
90849   1 XXX 0 X 73.25 X
90853   2 XXX 0 X 66.68 X
90853   3 XXX 0 X 66.68 X
90853   4 XXX 0 X 66.68 X
90853   1 XXX 0 X 73.25 X
90863     XXX 9 X * X
90865   2 XXX 0 X 258.33 X
90865   3 XXX 0 X 258.33 X
90865   4 XXX 0 X 258.33 X
90865   1 XXX 0 X 276.08 X
90867     0 0 X * X
90868     0 0 X * X
90869   2 0 0 X 623.87 166.10
90869   3 0 0 X 623.87 166.10
90869   4 0 0 X 623.87 166.10
90869   1 0 0 X 704.23 173.29
90870   4 0 0 X 208.83 X
90870   3 0 0 X 211.14 X
90870   2 0 0 X 220.76 X
90870   1 0 0 X 223.11 X
90875     XXX 9 X * X
90876   3 XXX 9 X 167.08 X
90876   4 XXX 9 X 167.08 X
90876   2 XXX 9 X 171.74 X
90876   1 XXX 9 X 182.30 X
90880   2 XXX 0 X 219.82 X
90880   3 XXX 0 X 219.82 X
90880   4 XXX 0 X 219.82 X
90880   1 XXX 0 X 237.76 X
90882     XXX 9 X * X
90885     XXX 9 X * X
90887   4 XXX 9 X 125.21 X
90887   2 XXX 9 X 142.40 X
90887   3 XXX 9 X 148.21 X
90887   1 XXX 9 X 152.42 X
90899     XXX 0 X # X
90901   3 0 0 X 51.44 X
90901   4 0 0 X 51.44 X
90901   2 0 0 X 52.82 X
90901   1 0 0 X 57.18 X
90912   2 0 0 X 92.93 52.56
90912   3 0 0 X 92.93 52.56
90912   4 0 0 X 92.93 52.56
90912   1 0 0 X 102.74 56.25
90913   2 ZZZ 0 X 38.00 29.20
90913   3 ZZZ 0 X 38.00 29.20
90913   4 ZZZ 0 X 38.00 29.20
90913   1 ZZZ 0 X 41.39 31.28
90935   4 0 0 X 265.84 X
90935   3 0 0 X 272.92 X
90935   1 0 0 X 276.87 X
90935   2 0 0 X 279.48 X
90937   4 0 0 X 554.55 X
90937   3 0 0 X 557.06 X
90937   2 0 0 X 564.15 X
90937   1 0 0 X 575.88 X
90940     XXX 9 X * X
90945   4 0 0 X 207.08 X
90945   1 0 0 X 207.59 X
90945   3 0 0 X 209.71 X
90945   2 0 0 X 221.25 X
90947   3 0 0 X 385.46 X
90947   4 0 0 X 407.30 X
90947   1 0 0 X 409.63 X
90947   2 0 0 X 419.84 X
90951   2 XXX 0 X 1,440.92 X
90951   3 XXX 0 X 1,440.92 X
90951   4 XXX 0 X 1,440.92 X
90951   1 XXX 0 X 1,547.23 X
90952     XXX 0 X * X
90953     XXX 0 X * X
90954   2 XXX 0 X 1,184.57 X
90954   3 XXX 0 X 1,184.57 X
90954   4 XXX 0 X 1,184.57 X
90954   1 XXX 0 X 1,265.52 X
90955   2 XXX 0 X 670.51 X
90955   3 XXX 0 X 670.51 X
90955   4 XXX 0 X 670.51 X
90955   1 XXX 0 X 718.61 X
90956   2 XXX 0 X 453.94 X
90956   3 XXX 0 X 453.94 X
90956   4 XXX 0 X 453.94 X
90956   1 XXX 0 X 486.33 X
90957   2 XXX 0 X 949.79 X
90957   3 XXX 0 X 949.79 X
90957   4 XXX 0 X 949.79 X
90957   1 XXX 0 X 1,016.72 X
90958   2 XXX 0 X 640.86 X
90958   3 XXX 0 X 640.86 X
90958   4 XXX 0 X 640.86 X
90958   1 XXX 0 X 687.10 X
90959   2 XXX 0 X 420.22 X
90959   3 XXX 0 X 420.22 X
90959   4 XXX 0 X 420.22 X
90959   1 XXX 0 X 450.00 X
90960   2 XXX 0 X 420.94 X
90960   3 XXX 0 X 420.94 X
90960   4 XXX 0 X 420.94 X
90960   1 XXX 0 X 453.86 X
90961   2 XXX 0 X 339.91 X
90961   3 XXX 0 X 339.91 X
90961   4 XXX 0 X 339.91 X
90961   1 XXX 0 X 365.83 X
90962   2 XXX 0 X 245.79 X
90962   3 XXX 0 X 245.79 X
90962   4 XXX 0 X 245.79 X
90962   1 XXX 0 X 263.84 X
90963   2 XXX 0 X 814.35 X
90963   3 XXX 0 X 814.35 X
90963   4 XXX 0 X 814.35 X
90963   1 XXX 0 X 873.51 X
90964   2 XXX 0 X 680.29 X
90964   3 XXX 0 X 680.29 X
90964   4 XXX 0 X 680.29 X
90964   1 XXX 0 X 727.28 X
90965   2 XXX 0 X 646.48 X
90965   3 XXX 0 X 646.48 X
90965   4 XXX 0 X 646.48 X
90965   1 XXX 0 X 690.66 X
90966   2 XXX 0 X 336.35 X
90966   3 XXX 0 X 336.35 X
90966   4 XXX 0 X 336.35 X
90966   1 XXX 0 X 361.59 X
90967   2 XXX 0 X 29.08 X
90967   3 XXX 0 X 29.08 X
90967   4 XXX 0 X 29.08 X
90967   1 XXX 0 X 31.37 X
90968   2 XXX 0 X 22.69 X
90968   3 XXX 0 X 22.69 X
90968   4 XXX 0 X 22.69 X
90968   1 XXX 0 X 24.34 X
90969   2 XXX 0 X 22.21 X
90969   3 XXX 0 X 22.21 X
90969   4 XXX 0 X 22.21 X
90969   1 XXX 0 X 23.78 X
90970   2 XXX 0 X 11.87 X
90970   3 XXX 0 X 11.87 X
90970   4 XXX 0 X 11.87 X
90970   1 XXX 0 X 12.96 X
90989     XXX 9 X 1,294.62 X
90993     XXX 9 X 51.80 X
90997   3 0 0 X 360.97 X
90997   4 0 0 X 523.63 X
90997   1 0 0 X 568.87 X
90997   2 0 0 X 594.10 X
90999     XXX 0 X # X
91010 TC 4 0 0 X 67.58 X
91010 TC 3 0 0 X 68.62 X
91010 TC 2 0 0 X 74.71 X
91010 TC 1 0 0 X 76.14 X
91010   4 0 0 X 212.40 X
91010 26 3 0 0 X 237.69 X
91010   3 0 0 X 274.52 X
91010   2 0 0 X 281.27 X
91010 26 1 0 0 X 290.15 X
91010 26 2 0 0 X 298.18 X
91010 26 4 0 0 X 301.43 X
91010   1 0 0 X 319.80 X
91013 26 2 ZZZ 0 X 14.51 X
91013 26 3 ZZZ 0 X 14.51 X
91013 26 4 ZZZ 0 X 14.51 X
91013 26 1 ZZZ 0 X 15.54 X
91013 TC 2 ZZZ 0 X 18.97 X
91013 TC 3 ZZZ 0 X 18.97 X
91013 TC 4 ZZZ 0 X 18.97 X
91013 TC 1 ZZZ 0 X 21.66 X
91013   2 ZZZ 0 X 33.47 X
91013   3 ZZZ 0 X 33.47 X
91013   4 ZZZ 0 X 33.47 X
91013   1 ZZZ 0 X 37.21 X
91020 TC 2 0 0 X 60.08 X
91020 TC 3 0 0 X 60.08 X
91020 TC 4 0 0 X 60.08 X
91020 TC 1 0 0 X 72.85 X
91020 26 2 0 0 X 238.69 X
91020 26 3 0 0 X 238.69 X
91020 26 4 0 0 X 238.69 X
91020 26 1 0 0 X 269.73 X
91020   2 0 0 X 298.80 X
91020   3 0 0 X 298.80 X
91020   4 0 0 X 298.80 X
91020   1 0 0 X 342.62 X
91022 26 2 0 0 X 121.41 X
91022 26 3 0 0 X 121.41 X
91022 26 4 0 0 X 121.41 X
91022 26 1 0 0 X 131.76 X
91022 TC 2 0 0 X 221.29 X
91022 TC 3 0 0 X 221.29 X
91022 TC 4 0 0 X 221.29 X
91022 TC 1 0 0 X 272.34 X
91022   2 0 0 X 342.67 X
91022   3 0 0 X 342.67 X
91022   4 0 0 X 342.67 X
91022   1 0 0 X 404.07 X
91030 TC 4 0 0 X 18.34 X
91030 TC 3 0 0 X 18.57 X
91030 TC 2 0 0 X 20.33 X
91030 TC 1 0 0 X 20.77 X
91030 26 3 0 0 X 116.88 X
91030 26 4 0 0 X 117.46 X
91030 26 2 0 0 X 121.22 X
91030 26 1 0 0 X 123.47 X
91030   1 0 0 X 147.96 X
91030   4 0 0 X 149.03 X
91030   3 0 0 X 150.73 X
91030   2 0 0 X 157.83 X
91034 26 2 0 0 X 89.94 X
91034 26 3 0 0 X 89.94 X
91034 26 4 0 0 X 89.94 X
91034 26 1 0 0 X 97.81 X
91034 TC 2 0 0 X 306.83 X
91034 TC 3 0 0 X 306.83 X
91034 TC 4 0 0 X 306.83 X
91034 TC 1 0 0 X 369.54 X
91034   2 0 0 X 396.79 X
91034   3 0 0 X 396.79 X
91034   4 0 0 X 396.79 X
91034   1 0 0 X 467.29 X
91035 26 2 0 0 X 145.50 X
91035 26 3 0 0 X 145.50 X
91035 26 4 0 0 X 145.50 X
91035 26 1 0 0 X 156.92 X
91035 TC 2 0 0 X 637.68 X
91035 TC 3 0 0 X 637.68 X
91035 TC 4 0 0 X 637.68 X
91035 TC 1 0 0 X 766.06 X
91035   2 0 0 X 783.16 X
91035   3 0 0 X 783.16 X
91035   4 0 0 X 783.16 X
91035   1 0 0 X 922.99 X
91037 26 2 0 0 X 89.94 X
91037 26 3 0 0 X 89.94 X
91037 26 4 0 0 X 89.94 X
91037 26 1 0 0 X 97.81 X
91037 TC 2 0 0 X 163.73 X
91037 TC 3 0 0 X 163.73 X
91037 TC 4 0 0 X 163.73 X
91037 TC 1 0 0 X 197.98 X
91037   2 0 0 X 253.69 X
91037   3 0 0 X 253.69 X
91037   4 0 0 X 253.69 X
91037   1 0 0 X 295.77 X
91038 26 2 0 0 X 101.85 X
91038 26 3 0 0 X 101.85 X
91038 26 4 0 0 X 101.85 X
91038 26 1 0 0 X 110.46 X
91038 TC 2 0 0 X 116.64 X
91038 TC 3 0 0 X 116.64 X
91038 TC 4 0 0 X 116.64 X
91038 TC 1 0 0 X 141.53 X
91038   2 0 0 X 218.46 X
91038   3 0 0 X 218.46 X
91038   4 0 0 X 218.46 X
91038   1 0 0 X 252.00 X
91040 26 2 0 0 X 89.94 X
91040 26 3 0 0 X 89.94 X
91040 26 4 0 0 X 89.94 X
91040 26 1 0 0 X 97.81 X
91040 TC 2 0 0 X 671.78 X
91040 TC 3 0 0 X 671.78 X
91040 TC 4 0 0 X 671.78 X
91040   2 0 0 X 761.68 X
91040   3 0 0 X 761.68 X
91040   4 0 0 X 761.68 X
91040 TC 1 0 0 X 806.95 X
91040   1 0 0 X 904.72 X
91065 TC 4 0 0 X 28.58 X
91065 TC 3 0 0 X 29.07 X
91065 TC 2 0 0 X 31.47 X
91065 TC 1 0 0 X 32.06 X
91065 26 4 0 0 X 79.46 X
91065 26 3 0 0 X 80.50 X
91065 26 2 0 0 X 84.98 X
91065 26 1 0 0 X 86.05 X
91065   4 0 0 X 137.20 X
91065   3 0 0 X 137.79 X
91065   2 0 0 X 140.68 X
91065   1 0 0 X 141.40 X
91110 26 2 XXX 0 X 336.41 X
91110 26 3 XXX 0 X 336.41 X
91110 26 4 XXX 0 X 336.41 X
91110 26 1 XXX 0 X 357.66 X
91110 TC 2 XXX 0 X 1,278.04 X
91110 TC 3 XXX 0 X 1,278.04 X
91110 TC 4 XXX 0 X 1,278.04 X
91110 TC 1 XXX 0 X 1,504.57 X
91110   2 XXX 0 X 1,614.44 X
91110   3 XXX 0 X 1,614.44 X
91110   4 XXX 0 X 1,614.44 X
91110   1 XXX 0 X 1,862.24 X
91111 26 2 XXX 0 X 78.64 X
91111 26 3 XXX 0 X 78.64 X
91111 26 4 XXX 0 X 78.64 X
91111 26 1 XXX 0 X 86.37 X
91111 TC 2 XXX 0 X 971.24 X
91111 TC 3 XXX 0 X 971.24 X
91111 TC 4 XXX 0 X 971.24 X
91111   2 XXX 0 X 1,049.86 X
91111   3 XXX 0 X 1,049.86 X
91111   4 XXX 0 X 1,049.86 X
91111 TC 1 XXX 0 X 1,188.73 X
91111   1 XXX 0 X 1,275.11 X
91112 26 2 XXX 0 X 151.87 X
91112 26 3 XXX 0 X 151.87 X
91112 26 4 XXX 0 X 151.87 X
91112 26 1 XXX 0 X 163.02 X
91112 TC 2 XXX 0 X 1,367.03 X
91112 TC 3 XXX 0 X 1,367.03 X
91112 TC 4 XXX 0 X 1,367.03 X
91112   2 XXX 0 X 1,518.88 X
91112   3 XXX 0 X 1,518.88 X
91112   4 XXX 0 X 1,518.88 X
91112 TC 1 XXX 0 X 1,585.78 X
91112   1 XXX 0 X 1,748.81 X
91117   2 0 0 X 211.00 224.11
91117   3 0 0 X 211.00 224.11
91117   4 0 0 X 211.00 224.11
91117   1 0 0 X 231.50 246.29
91120 26 2 XXX 0 X 90.48 X
91120 26 3 XXX 0 X 90.48 X
91120 26 4 XXX 0 X 90.48 X
91120 26 1 XXX 0 X 98.73 X
91120 TC 2 XXX 0 X 661.39 X
91120 TC 3 XXX 0 X 661.39 X
91120 TC 4 XXX 0 X 661.39 X
91120   2 XXX 0 X 751.85 X
91120   3 XXX 0 X 751.85 X
91120   4 XXX 0 X 751.85 X
91120 TC 1 XXX 0 X 793.91 X
91120   1 XXX 0 X 892.64 X
91122 TC 4 0 0 X 65.59 X
91122 TC 3 0 0 X 66.57 X
91122 TC 2 0 0 X 73.78 X
91122 TC 1 0 0 X 75.48 X
91122 26 4 0 0 X 261.04 X
91122 26 3 0 0 X 264.08 X
91122 26 2 0 0 X 313.13 X
91122 26 1 0 0 X 314.61 X
91122   3 0 0 X 322.46 X
91122   4 0 0 X 326.64 X
91122   2 0 0 X 327.34 X
91122   1 0 0 X 340.09 X
91132     XXX 0 X * X
91133     XXX 0 X * X
91200 26 2 XXX 0 X 19.83 X
91200 26 3 XXX 0 X 19.83 X
91200 26 4 XXX 0 X 19.83 X
91200 26 1 XXX 0 X 21.18 X
91200 TC 2 XXX 0 X 26.84 X
91200 TC 3 XXX 0 X 26.84 X
91200 TC 4 XXX 0 X 26.84 X
91200 TC 1 XXX 0 X 31.45 X
91200   2 XXX 0 X 46.69 X
91200   3 XXX 0 X 46.69 X
91200   4 XXX 0 X 46.69 X
91200   1 XXX 0 X 52.63 X
91299     XXX 0 X # X
91300     XXX 9 X 0.01 X
91301     XXX 9 X 0.01 X
91302     XXX 9 X # X
91303     XXX 9 X # X
91304     XXX   X   X
92002   4 XXX 0 X 116.04 97.62
92002   3 XXX 0 X 117.15 98.74
92002   1 XXX 0 X 124.26 104.51
92002   2 XXX 0 X 124.46 104.16
92004   4 XXX 0 X 162.76 142.40
92004   3 XXX 0 X 162.95 142.29
92004   2 XXX 0 X 175.22 152.38
92004   1 XXX 0 X 180.04 157.09
92012   3 XXX 0 X 97.85 81.66
92012   4 XXX 0 X 99.11 82.67
92012   1 XXX 0 X 105.30 87.61
92012   2 XXX 0 X 105.68 87.70
92014   3 XXX 0 X 123.72 103.68
92014   4 XXX 0 X 129.99 108.91
92014   2 XXX 0 X 138.23 115.51
92014   1 XXX 0 X 143.80 119.45
92015     XXX 9 X * X
92018   3 XXX 0 X 161.53 143.25
92018   4 XXX 0 X 165.59 147.19
92018   2 XXX 0 X 176.01 155.53
92018   1 XXX 0 X 211.67 186.74
92019   3 XXX 0 X 124.11 X
92019   2 XXX 0 X 127.62 X
92019   4 XXX 0 X 150.17 X
92019   1 XXX 0 X 159.49 X
92020   4 XXX 0 X 43.51 34.21
92020   1 XXX 0 X 53.49 42.00
92020   3 XXX 0 X 55.22 43.57
92020   2 XXX 0 X 57.73 45.39
92025 TC 2 XXX 0 X 17.56 X
92025 TC 3 XXX 0 X 17.56 X
92025 TC 4 XXX 0 X 17.56 X
92025 TC 1 XXX 0 X 21.69 X
92025 26 2 XXX 0 X 25.00 X
92025 26 3 XXX 0 X 25.00 X
92025 26 4 XXX 0 X 25.00 X
92025 26 1 XXX 0 X 27.23 X
92025   2 XXX 0 X 42.55 X
92025   3 XXX 0 X 42.55 X
92025   4 XXX 0 X 42.55 X
92025   1 XXX 0 X 48.93 X
92060 TC 4 XXX 0 X 15.09 X
92060 TC 3 XXX 0 X 15.28 X
92060 TC 2 XXX 0 X 16.51 X
92060 TC 1 XXX 0 X 16.89 X
92060 26 4 XXX 0 X 59.82 X
92060 26 3 XXX 0 X 60.51 X
92060 26 2 XXX 0 X 62.96 X
92060 26 1 XXX 0 X 63.51 X
92060   4 XXX 0 X 74.92 X
92060   3 XXX 0 X 75.89 X
92060   2 XXX 0 X 79.50 X
92060   1 XXX 0 X 80.39 X
92065 TC 4 XXX 0 X 12.65 X
92065 TC 3 XXX 0 X 12.90 X
92065 TC 2 XXX 0 X 13.65 X
92065 TC 1 XXX 0 X 13.81 X
92065 26 3 XXX 0 X 46.32 X
92065 26 4 XXX 0 X 47.46 X
92065 26 1 XXX 0 X 50.54 X
92065 26 2 XXX 0 X 54.96 X
92065   3 XXX 0 X 59.74 X
92065   4 XXX 0 X 60.08 X
92065   1 XXX 0 X 64.38 X
92065   2 XXX 0 X 71.11 X
92071   2 XXX 0 X 52.10 46.71
92071   3 XXX 0 X 52.10 46.71
92071   4 XXX 0 X 52.10 46.71
92071   1 XXX 0 X 56.52 50.31
92072   2 XXX 0 X 166.42 135.13
92072   3 XXX 0 X 166.42 135.13
92072   4 XXX 0 X 166.42 135.13
92072   1 XXX 0 X 180.71 144.39
92081 TC 4 XXX 0 X 11.96 X
92081 TC 3 XXX 0 X 12.09 X
92081 TC 2 XXX 0 X 12.80 X
92081 TC 1 XXX 0 X 12.95 X
92081 26 4 XXX 0 X 44.21 X
92081 26 3 XXX 0 X 44.70 X
92081 26 2 XXX 0 X 46.65 X
92081 26 1 XXX 0 X 47.76 X
92081   4 XXX 0 X 56.09 X
92081   3 XXX 0 X 56.78 X
92081   2 XXX 0 X 59.44 X
92081   1 XXX 0 X 61.38 X
92082 TC 4 XXX 0 X 15.90 X
92082 TC 3 XXX 0 X 16.13 X
92082 TC 2 XXX 0 X 17.41 X
92082 TC 1 XXX 0 X 17.73 X
92082 26 3 XXX 0 X 58.08 X
92082 26 4 XXX 0 X 58.91 X
92082 26 2 XXX 0 X 64.62 X
92082 26 1 XXX 0 X 65.25 X
92082   3 XXX 0 X 75.32 X
92082   4 XXX 0 X 76.13 X
92082   2 XXX 0 X 82.07 X
92082   1 XXX 0 X 83.01 X
92083 TC 4 XXX 0 X 23.01 X
92083 TC 3 XXX 0 X 23.39 X
92083 TC 2 XXX 0 X 25.09 X
92083 TC 1 XXX 0 X 25.51 X
92083 26 4 XXX 0 X 87.99 X
92083 26 3 XXX 0 X 92.38 X
92083 26 1 XXX 0 X 96.46 X
92083 26 2 XXX 0 X 96.60 X
92083   4 XXX 0 X 117.85 X
92083   3 XXX 0 X 123.97 X
92083   1 XXX 0 X 129.54 X
92083   2 XXX 0 X 129.99 X
92100   2 XXX 0 X 72.56 63.39
92100   3 XXX 0 X 74.19 64.85
92100   4 XXX 0 X 75.37 65.88
92100   1 XXX 0 X 79.71 69.18
92132 TC 2 XXX 0 X 21.88 X
92132 TC 3 XXX 0 X 21.88 X
92132 TC 4 XXX 0 X 21.88 X
92132 TC 1 XXX 0 X 24.96 X
92132 26 2 XXX 0 X 31.01 X
92132 26 3 XXX 0 X 31.01 X
92132 26 4 XXX 0 X 31.01 X
92132 26 1 XXX 0 X 33.59 X
92132   2 XXX 0 X 52.89 X
92132   3 XXX 0 X 52.89 X
92132   4 XXX 0 X 52.89 X
92132   1 XXX 0 X 58.56 X
92133 TC 2 XXX 0 X 21.88 X
92133 TC 3 XXX 0 X 21.88 X
92133 TC 4 XXX 0 X 21.88 X
92133 TC 1 XXX 0 X 24.96 X
92133 26 2 XXX 0 X 42.95 X
92133 26 3 XXX 0 X 42.95 X
92133 26 4 XXX 0 X 42.95 X
92133 26 1 XXX 0 X 46.23 X
92133   2 XXX 0 X 64.82 X
92133   3 XXX 0 X 64.82 X
92133   4 XXX 0 X 64.82 X
92133   1 XXX 0 X 71.16 X
92134 TC 2 XXX 0 X 21.88 X
92134 TC 3 XXX 0 X 21.88 X
92134 TC 4 XXX 0 X 21.88 X
92134 TC 1 XXX 0 X 24.96 X
92134 26 2 XXX 0 X 42.95 X
92134 26 3 XXX 0 X 42.95 X
92134 26 4 XXX 0 X 42.95 X
92134 26 1 XXX 0 X 46.23 X
92134   2 XXX 0 X 64.82 X
92134   3 XXX 0 X 64.82 X
92134   4 XXX 0 X 64.82 X
92134   1 XXX 0 X 71.16 X