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Workforce Development
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Individual Services
Uniform Construction Code
Labor Management Relations
Misclassified Workers
Businesses
Businesses
Employer UC Info
Finding Skilled Workers
Disability Services
Workforce Development
Workers' Compensation Services
Labor-Management Relations
Pennsylvania Business One-Stop
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About L&I
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Health Care Services Review
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Medical Fee Review
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Fee Schedule
>
Fee Schedule D5226-E0660
Begin Main Content Area
Page Content
2021 Workers' Compensation Part B Fee Schedule
D5226-E0660
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
D5226
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9
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D5284
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D5926
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D5927
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#
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X
#
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E0100
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13.56
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X
38.26
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X
47.95
X
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RR
X
20.19
X
E0105
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X
84.20
X
E0105
NU
X
111.74
X
E0110
RR
X
36.42
X
E0110
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X
132.40
X
E0110
NU
X
150.08
X
E0111
RR
X
19.17
X
E0111
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X
93.51
X
E0111
NU
X
121.21
X
E0112
RR
X
22.57
X
E0112
UE
X
64.26
X
E0112
NU
X
84.20
X
E0113
RR
X
11.73
X
E0113
UE
X
36.11
X
E0113
NU
X
48.07
X
E0114
RR
X
19.55
X
E0114
UE
X
81.16
X
E0114
NU
X
107.34
X
E0116
RR
X
12.27
X
E0116
UE
X
47.48
X
E0116
NU
X
63.15
X
E0117
RR
X
36.49
X
E0117
UE
X
273.64
X
E0117
NU
X
364.88
X
E0118
X
*
X
E0130
RR
X
38.28
X
E0130
UE
X
122.92
X
E0130
NU
X
159.81
X
E0135
RR
X
39.28
X
E0135
UE
X
135.70
X
E0135
NU
X
181.44
X
E0140
RR
X
66.80
X
E0140
UE
X
501.17
X
E0140
NU
X
668.24
X
E0141
RR
X
43.26
X
E0141
UE
X
196.75
X
E0141
NU
X
262.35
X
E0143
RR
X
49.15
X
E0143
UE
X
195.85
X
E0143
NU
X
273.58
X
E0144
X
*
X
E0147
RR
X
79.79
X
E0147
UE
X
596.53
X
E0147
NU
X
785.05
X
E0148
XXX
X
*
X
E0149
XXX
X
*
X
E0153
RR
X
17.79
X
E0153
UE
X
118.41
X
E0153
NU
X
157.89
X
E0154
RR
X
19.52
X
E0154
UE
X
118.50
X
E0154
NU
X
155.36
X
E0155
RR
X
8.79
X
E0155
UE
X
54.74
X
E0155
NU
X
69.54
X
E0156
RR
X
7.69
X
E0156
UE
X
45.15
X
E0156
NU
X
60.13
X
E0157
RR
X
20.42
X
E0157
UE
X
118.84
X
E0157
NU
X
158.44
X
E0158
RR
X
8.06
X
E0158
UE
X
55.29
X
E0158
NU
X
73.25
X
E0159
RR
X
3.90
X
E0159
UE
X
29.09
X
E0159
NU
X
38.71
X
E0160
RR
X
9.79
X
E0160
UE
X
56.41
X
E0160
NU
X
67.26
X
E0161
RR
X
8.12
X
E0161
UE
X
44.73
X
E0161
NU
X
59.63
X
E0162
RR
X
34.75
X
E0162
UE
X
257.14
X
E0162
NU
X
331.52
X
E0163
RR
X
55.61
X
E0163
UE
X
176.67
X
E0163
NU
X
242.32
X
E0165
X
359.44
X
E0167
RR
X
2.88
X
E0167
UE
X
20.11
X
E0167
NU
X
23.24
X
E0168
RR
X
29.15
X
E0168
UE
X
217.49
X
E0168
NU
X
290.01
X
E0170
RR
XXX
9
X
275.66
X
E0171
RR
XXX
9
X
49.60
X
E0172
X
#
X
E0175
RR
X
12.81
X
E0175
UE
X
94.28
X
E0175
NU
X
128.06
X
E0181
X
726.56
X
E0182
X
595.79
X
E0184
RR
X
55.90
X
E0184
UE
X
339.80
X
E0184
NU
X
443.04
X
E0185
RR
X
102.27
X
E0185
UE
X
558.66
X
E0185
NU
X
621.61
X
E0186
X
461.68
X
E0187
X
528.45
X
E0188
X
*
X
E0189
X
*
X
E0190
X
*
X
E0191
RR
X
2.32
X
E0191
UE
X
17.01
X
E0191
NU
X
22.69
X
E0193
X
17,252.94
X
E0194
X
73,204.67
X
E0196
X
739.25
X
E0197
RR
X
69.58
X
E0197
UE
X
442.90
X
E0197
NU
X
504.21
X
E0198
RR
X
52.25
X
E0198
UE
X
382.64
X
E0198
NU
X
504.21
X
E0199
RR
X
7.29
X
E0199
UE
X
54.71
X
E0199
NU
X
72.94
X
E0200
RR
X
24.48
X
E0200
UE
X
135.32
X
E0200
NU
X
180.44
X
E0202
X
1,424.89
X
E0203
X
*
X
E0205
RR
X
47.80
X
E0205
UE
X
281.53
X
E0205
NU
X
375.41
X
E0210
RR
X
7.00
X
E0210
UE
X
55.69
X
E0210
NU
X
74.23
X
E0215
RR
X
16.88
X
E0215
UE
X
120.88
X
E0215
NU
X
161.20
X
E0217
RR
X
105.69
X
E0217
UE
X
711.81
X
E0217
NU
X
949.20
X
E0218
X
*
X
E0221
RR
X
406.08
X
E0221
UE
X
3,045.89
X
E0221
NU
X
4,061.18
X
E0225
RR
X
74.07
X
E0225
UE
X
563.83
X
E0225
NU
X
751.77
X
E0231
X
#
X
E0232
X
#
X
E0235
X
392.52
X
E0236
RR
X
89.04
X
E0236
NU
X
890.27
X
E0239
RR
X
102.34
X
E0239
UE
X
767.78
X
E0239
NU
X
1,023.61
X
E0240
X
*
X
E0241
X
*
X
E0242
X
*
X
E0243
X
*
X
E0244
X
*
X
E0245
X
*
X
E0246
X
*
X
E0247
X
*
X
E0248
X
*
X
E0249
RR
X
24.94
X
E0249
UE
X
170.01
X
E0249
NU
X
226.61
X
E0250
X
2,224.72
X
E0251
X
1,685.86
X
E0255
X
2,602.76
X
E0256
X
1,776.77
X
E0260
X
3,821.27
X
E0261
X
2,927.47
X
E0265
X
4,548.86
X
E0266
X
4,041.36
X
E0270
X
#
X
E0271
RR
X
52.49
X
E0271
UE
X
394.70
X
E0271
NU
X
484.21
X
E0272
RR
X
48.07
X
E0272
UE
X
332.64
X
E0272
NU
X
443.52
X
E0273
X
*
X
E0274
X
*
X
E0275
RR
X
3.63
X
E0275
UE
X
26.12
X
E0275
NU
X
34.80
X
E0276
RR
X
3.55
X
E0276
UE
X
23.97
X
E0276
NU
X
30.29
X
E0277
X
17,689.03
X
E0280
RR
X
9.34
X
E0280
UE
X
63.16
X
E0280
NU
X
84.20
X
E0290
X
1,700.92
X
E0291
X
1,235.34
X
E0292
X
1,844.87
X
E0293
X
1,627.64
X
E0294
X
2,973.83
X
E0295
X
2,897.70
X
E0296
X
3,736.37
X
E0297
X
3,201.70
X
E0300
RR
X
525.87
X
E0300
UE
X
3,943.92
X
E0300
NU
X
5,258.57
X
E0301
RR
X
874.49
X
E0302
RR
X
712.39
X
E0303
RR
X
540.79
X
E0304
RR
X
1,427.67
X
E0305
X
364.28
X
E0310
RR
X
51.80
X
E0310
UE
X
284.17
X
E0310
NU
X
375.51
X
E0315
X
#
X
E0316
RR
X
405.94
X
E0325
RR
X
3.44
X
E0325
UE
X
15.22
X
E0325
NU
X
23.03
X
E0326
RR
X
2.72
X
E0326
UE
X
16.89
X
E0326
NU
X
22.51
X
E0328
X
*
X
E0329
X
*
X
E0350
X
#
X
E0352
X
*
X
E0370
X
#
X
E0371
X
925.69
X
E0372
X
1,123.28
X
E0373
X
1,286.75
X
E0424
X
779.85
X
E0425
X
*
X
E0430
X
*
X
E0431
X
122.54
X
E0433
RR
X
78.02
X
E0434
X
122.54
X
E0435
X
#
X
E0439
X
779.85
X
E0440
X
*
X
E0441
X
551.36
X
E0442
X
551.36
X
E0443
X
72.81
X
E0444
X
72.81
X
E0445
X
*
X
E0446
X
*
X
E0447
X
73.23
X
E0455
X
5,109.15
X
E0457
X
1,140.60
X
E0459
X
1,157.90
X
E0462
RR
X
6,631.21
X
E0465
RR
X
1,378.00
X
E0466
RR
X
1,378.00
X
E0467
RR
X
1,511.90
X
E0470
RR
X
404.02
X
E0471
RR
X
1,011.18
X
E0472
RR
X
1,011.18
X
E0480
X
999.72
X
E0481
X
#
X
E0482
X
791.92
X
E0483
RR
X
2,012.81
X
E0484
RR
X
6.99
X
E0484
UE
X
52.47
X
E0484
NU
X
69.90
X
E0485
XXX
9
X
*
X
E0486
XXX
9
X
*
X
E0487
X
#
X
E0500
X
1,152.74
X
E0550
X
1,140.63
X
E0555
X
300.67
X
E0560
RR
X
45.76
X
E0560
UE
X
248.80
X
E0560
NU
X
331.76
X
E0561
RR
X
19.81
X
E0561
UE
X
148.65
X
E0561
NU
X
198.21
X
E0562
RR
X
55.76
X
E0562
UE
X
418.49
X
E0562
NU
X
557.99
X
E0565
X
1,388.40
X
E0570
X
449.19
X
E0572
XXX
X
*
X
E0574
XXX
X
*
X
E0575
X
215.38
X
E0580
X
345.84
X
E0585
X
798.02
X
E0600
X
1,041.92
X
E0601
X
2,326.23
X
E0602
X
*
X
E0603
X
*
X
E0604
X
*
X
E0605
RR
X
6.04
X
E0605
UE
X
45.15
X
E0605
NU
X
60.13
X
E0606
X
443.52
X
E0607
RR
X
62.18
X
E0607
UE
X
320.69
X
E0607
NU
X
433.06
X
E0610
RR
X
57.10
X
E0610
UE
X
405.95
X
E0610
NU
X
541.27
X
E0615
RR
X
133.10
X
E0615
UE
X
719.46
X
E0615
NU
X
959.27
X
E0616
X
#
X
E0617
X
*
X
E0618
RR
X
474.21
X
E0619
X
*
X
E0620
RR
X
168.02
X
E0620
UE
X
1,260.14
X
E0620
NU
X
1,680.22
X
E0621
RR
X
21.08
X
E0621
UE
X
164.64
X
E0621
NU
X
211.16
X
E0625
X
#
X
E0627
RR
X
75.26
X
E0627
UE
X
564.39
X
E0627
NU
X
752.54
X
E0629
RR
X
75.26
X
E0629
UE
X
564.39
X
E0629
NU
X
752.54
X
E0630
X
2,318.19
X
E0635
X
2,366.61
X
E0636
X
*
X
E0637
RR
X
389.94
X
E0637
UE
X
2,924.57
X
E0637
NU
X
3,899.50
X
E0638
RR
X
158.12
X
E0638
UE
X
1,185.92
X
E0638
NU
X
1,581.24
X
E0639
X
#
X
E0640
X
*
X
E0641
X
*
X
E0642
X
*
X
E0650
RR
X
202.20
X
E0650
UE
X
1,044.77
X
E0650
NU
X
1,608.37
X
E0651
RR
X
209.05
X
E0651
UE
X
1,567.49
X
E0651
NU
X
2,089.95
X
E0652
RR
X
1,192.30
X
E0652
UE
X
7,683.90
X
E0652
NU
X
11,923.37
X
E0655
RR
X
28.84
X
E0655
UE
X
156.78
X
E0655
NU
X
208.75
X
E0656
X
*
X
E0657
X
*
X
E0660
RR
X
37.82
X
E0660
UE
X
248.08
X
E0660
NU
X
330.78
X
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