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# 2021 Workers' Compensation Part B Fee Schedule

## L1680-L5999

CPT/HCPC Code | Modifier | Medicare Location | Global Surgery Indicator | Multiple Surgery Indicator | Prevailing Charge Amount | Fee Schedule Amount | Site of Service Amount |
---|---|---|---|---|---|---|---|

L1680 | X | 2,055.84 | X | ||||

L1685 | X | 2,098.02 | X | ||||

L1686 | X | 1,937.33 | X | ||||

L1690 | X | 3,088.75 | X | ||||

L1700 | X | 2,576.66 | X | ||||

L1710 | X | 3,016.32 | X | ||||

L1720 | X | 2,223.39 | X | ||||

L1730 | X | 1,909.64 | X | ||||

L1755 | X | 3,030.53 | X | ||||

L1810 | X | 166.18 | X | ||||

L1812 | X | 119.01 | X | ||||

L1820 | X | 257.49 | X | ||||

L1830 | X | 156.62 | X | ||||

L1831 | X | 428.42 | X | ||||

L1832 | X | 1,193.32 | X | ||||

L1833 | X | 854.73 | X | ||||

L1834 | X | 1,309.81 | X | ||||

L1836 | X | 198.50 | X | ||||

L1840 | X | 1,744.63 | X | ||||

L1843 | XXX | X | 894.97 | X | |||

L1844 | X | 2,739.17 | X | ||||

L1845 | X | 1,639.89 | X | ||||

L1846 | X | 1,860.78 | X | ||||

L1847 | X | 918.64 | X | ||||

L1848 | X | 725.59 | X | ||||

L1850 | X | 512.82 | X | ||||

L1851 | X | 1,079.53 | X | ||||

L1852 | X | 1,120.27 | X | ||||

L1860 | X | 1,810.55 | X | ||||

L1900 | X | 455.19 | X | ||||

L1902 | X | 157.30 | X | ||||

L1904 | X | 945.93 | X | ||||

L1906 | X | 202.88 | X | ||||

L1907 | X | 819.06 | X | ||||

L1910 | X | 460.92 | X | ||||

L1920 | X | 589.89 | X | ||||

L1930 | X | 399.10 | X | ||||

L1932 | X | 1,251.38 | X | ||||

L1940 | X | 834.44 | X | ||||

L1945 | X | 1,995.04 | X | ||||

L1950 | X | 1,322.78 | X | ||||

L1951 | X | 1,222.49 | X | ||||

L1960 | X | 997.67 | X | ||||

L1970 | X | 1,200.65 | X | ||||

L1971 | X | 682.28 | X | ||||

L1980 | X | 619.25 | X | ||||

L1990 | X | 752.15 | X | ||||

L2000 | X | 1,781.82 | X | ||||

L2005 | X | 5,047.94 | X | ||||

L2006 | X | # | X | ||||

L2010 | X | 1,662.17 | X | ||||

L2020 | X | 2,092.96 | X | ||||

L2030 | X | 1,899.92 | X | ||||

L2034 | X | * | X | ||||

L2035 | XXX | X | 289.99 | X | |||

L2036 | X | 3,244.09 | X | ||||

L2037 | X | 3,026.54 | X | ||||

L2038 | X | 3,074.48 | X | ||||

L2040 | X | 372.87 | X | ||||

L2050 | X | 803.75 | X | ||||

L2060 | X | 979.60 | X | ||||

L2070 | X | 251.53 | X | ||||

L2080 | X | 606.91 | X | ||||

L2090 | X | 739.84 | X | ||||

L2106 | X | 1,147.21 | X | ||||

L2108 | X | 1,997.48 | X | ||||

L2112 | X | 918.75 | X | ||||

L2114 | X | 1,152.39 | X | ||||

L2116 | X | 1,325.95 | X | ||||

L2126 | X | 2,217.98 | X | ||||

L2128 | X | 3,140.83 | X | ||||

L2132 | X | 1,702.83 | X | ||||

L2134 | X | 1,817.09 | X | ||||

L2136 | X | 2,168.75 | X | ||||

L2180 | X | 202.42 | X | ||||

L2182 | X | 167.68 | X | ||||

L2184 | X | 229.22 | X | ||||

L2186 | X | 317.99 | X | ||||

L2188 | X | 609.00 | X | ||||

L2190 | X | 157.39 | X | ||||

L2192 | X | 690.94 | X | ||||

L2200 | X | 80.23 | X | ||||

L2210 | X | 116.11 | X | ||||

L2220 | X | 138.17 | X | ||||

L2230 | X | 129.45 | X | ||||

L2232 | X | * | X | ||||

L2240 | X | 160.23 | X | ||||

L2250 | X | 649.69 | X | ||||

L2260 | X | 338.20 | X | ||||

L2265 | X | 198.65 | X | ||||

L2270 | X | 93.21 | X | ||||

L2275 | XXX | X | * | X | |||

L2280 | X | 768.17 | X | ||||

L2300 | X | 481.65 | X | ||||

L2310 | X | 241.16 | X | ||||

L2320 | X | 347.14 | X | ||||

L2330 | X | 726.75 | X | ||||

L2335 | X | 448.70 | X | ||||

L2340 | X | 971.38 | X | ||||

L2350 | X | 1,677.59 | X | ||||

L2360 | X | 87.30 | X | ||||

L2370 | X | 565.69 | X | ||||

L2375 | X | 238.99 | X | ||||

L2380 | X | 207.70 | X | ||||

L2385 | X | 226.04 | X | ||||

L2387 | X | * | X | ||||

L2390 | X | 189.14 | X | ||||

L2395 | X | 263.98 | X | ||||

L2397 | X | * | X | ||||

L2405 | X | 98.83 | X | ||||

L2415 | X | 313.39 | X | ||||

L2425 | X | 383.38 | X | ||||

L2430 | XXX | X | 162.94 | X | |||

L2492 | X | 229.19 | X | ||||

L2500 | X | 548.34 | X | ||||

L2510 | X | 1,230.34 | X | ||||

L2520 | X | 811.57 | X | ||||

L2525 | X | 2,189.76 | X | ||||

L2526 | X | 1,249.56 | X | ||||

L2530 | X | 396.49 | X | ||||

L2540 | X | 713.32 | X | ||||

L2550 | X | 484.58 | X | ||||

L2570 | X | 803.66 | X | ||||

L2580 | X | 783.07 | X | ||||

L2600 | X | 428.85 | X | ||||

L2610 | X | 454.20 | X | ||||

L2620 | X | 510.74 | X | ||||

L2622 | X | 578.99 | X | ||||

L2624 | X | 558.72 | X | ||||

L2627 | X | 3,048.80 | X | ||||

L2628 | X | 2,998.98 | X | ||||

L2630 | X | 417.84 | X | ||||

L2640 | X | 567.04 | X | ||||

L2650 | X | 241.44 | X | ||||

L2660 | X | 314.48 | X | ||||

L2670 | X | 305.00 | X | ||||

L2680 | X | 282.51 | X | ||||

L2750 | X | 141.03 | X | ||||

L2755 | XXX | X | 216.48 | X | |||

L2760 | X | 102.54 | X | ||||

L2768 | X | 195.59 | X | ||||

L2780 | X | 114.15 | X | ||||

L2785 | X | 53.76 | X | ||||

L2795 | X | 145.59 | X | ||||

L2800 | X | 223.83 | X | ||||

L2810 | X | 175.69 | X | ||||

L2820 | X | 146.57 | X | ||||

L2830 | X | 158.50 | X | ||||

L2840 | X | 93.74 | X | ||||

L2850 | X | 104.50 | X | ||||

L2861 | X | * | X | ||||

L2999 | X | # | X | ||||

L3000 | X | * | X | ||||

L3001 | X | * | X | ||||

L3002 | X | * | X | ||||

L3003 | X | * | X | ||||

L3010 | X | * | X | ||||

L3020 | X | * | X | ||||

L3030 | X | * | X | ||||

L3031 | X | * | X | ||||

L3040 | X | * | X | ||||

L3050 | X | * | X | ||||

L3060 | X | * | X | ||||

L3070 | X | * | X | ||||

L3080 | X | * | X | ||||

L3090 | X | * | X | ||||

L3100 | X | * | X | ||||

L3140 | X | * | X | ||||

L3150 | X | * | X | ||||

L3160 | X | * | X | ||||

L3170 | X | * | X | ||||

L3201 | X | * | X | ||||

L3202 | X | * | X | ||||

L3203 | X | * | X | ||||

L3204 | X | * | X | ||||

L3206 | X | * | X | ||||

L3207 | X | * | X | ||||

L3208 | X | * | X | ||||

L3209 | X | * | X | ||||

L3211 | X | * | X | ||||

L3212 | X | # | X | ||||

L3213 | X | * | X | ||||

L3214 | X | * | X | ||||

L3215 | X | 224.59 | X | ||||

L3216 | X | * | X | ||||

L3217 | X | * | X | ||||

L3219 | X | 230.52 | X | ||||

L3221 | X | * | X | ||||

L3222 | X | * | X | ||||

L3224 | XXX | X | * | X | |||

L3225 | XXX | X | * | X | |||

L3230 | X | * | X | ||||

L3250 | X | * | X | ||||

L3251 | X | * | X | ||||

L3252 | X | * | X | ||||

L3253 | X | * | X | ||||

L3254 | X | * | X | ||||

L3255 | X | * | X | ||||

L3257 | X | * | X | ||||

L3260 | X | * | X | ||||

L3265 | X | * | X | ||||

L3300 | X | * | X | ||||

L3310 | X | * | X | ||||

L3320 | X | * | X | ||||

L3330 | X | 223.73 | X | ||||

L3332 | X | * | X | ||||

L3334 | X | * | X | ||||

L3340 | X | * | X | ||||

L3350 | X | * | X | ||||

L3360 | X | * | X | ||||

L3370 | X | * | X | ||||

L3380 | X | 83.86 | X | ||||

L3390 | X | * | X | ||||

L3400 | X | * | X | ||||

L3410 | X | * | X | ||||

L3420 | X | * | X | ||||

L3430 | X | * | X | ||||

L3440 | X | * | X | ||||

L3450 | X | * | X | ||||

L3455 | X | * | X | ||||

L3460 | X | * | X | ||||

L3465 | X | * | X | ||||

L3470 | X | * | X | ||||

L3480 | X | * | X | ||||

L3485 | X | * | X | ||||

L3500 | X | * | X | ||||

L3510 | X | * | X | ||||

L3520 | X | * | X | ||||

L3530 | X | * | X | ||||

L3540 | X | * | X | ||||

L3550 | X | * | X | ||||

L3560 | X | * | X | ||||

L3570 | X | * | X | ||||

L3580 | X | * | X | ||||

L3590 | X | * | X | ||||

L3595 | X | * | X | ||||

L3600 | X | * | X | ||||

L3610 | X | * | X | ||||

L3620 | X | * | X | ||||

L3630 | X | * | X | ||||

L3640 | X | * | X | ||||

L3649 | X | # | X | ||||

L3650 | X | 112.18 | X | ||||

L3660 | X | 169.72 | X | ||||

L3670 | X | 224.17 | X | ||||

L3671 | XXX | 9 | X | * | X | ||

L3674 | X | 1,414.08 | X | ||||

L3675 | X | 255.12 | X | ||||

L3677 | X | * | X | ||||

L3678 | X | * | X | ||||

L3702 | XXX | 9 | X | * | X | ||

L3710 | X | 258.00 | X | ||||

L3720 | X | 1,151.27 | X | ||||

L3730 | X | 1,488.37 | X | ||||

L3740 | X | 1,764.63 | X | ||||

L3760 | XXX | X | * | X | |||

L3761 | X | 537.48 | X | ||||

L3762 | X | 145.54 | X | ||||

L3763 | XXX | 9 | X | * | X | ||

L3764 | XXX | 9 | X | * | X | ||

L3765 | XXX | 9 | X | * | X | ||

L3766 | XXX | 9 | X | * | X | ||

L3806 | X | * | X | ||||

L3807 | X | * | X | ||||

L3808 | X | * | X | ||||

L3809 | X | 287.09 | X | ||||

L3891 | X | * | X | ||||

L3900 | X | 2,337.26 | X | ||||

L3901 | X | 2,654.18 | X | ||||

L3904 | X | 4,835.19 | X | ||||

L3905 | XXX | 9 | X | * | X | ||

L3906 | X | 705.80 | X | ||||

L3908 | X | 111.06 | X | ||||

L3912 | X | 192.42 | X | ||||

L3913 | XXX | 9 | X | * | X | ||

L3915 | X | * | X | ||||

L3916 | X | 610.27 | X | ||||

L3917 | X | 139.94 | X | ||||

L3918 | X | 121.32 | X | ||||

L3919 | XXX | 9 | X | * | X | ||

L3921 | XXX | 9 | X | * | X | ||

L3923 | XXX | X | * | X | |||

L3924 | X | 110.82 | X | ||||

L3925 | X | 62.74 | X | ||||

L3927 | X | * | X | ||||

L3929 | X | 111.20 | X | ||||

L3930 | X | 105.32 | X | ||||

L3931 | X | 227.71 | X | ||||

L3933 | XXX | 9 | X | * | X | ||

L3935 | XXX | 9 | X | * | X | ||

L3956 | XXX | X | * | X | |||

L3960 | X | 1,214.50 | X | ||||

L3961 | XXX | 9 | X | * | X | ||

L3962 | X | 1,184.66 | X | ||||

L3967 | XXX | 9 | X | * | X | ||

L3971 | XXX | 9 | X | * | X | ||

L3973 | XXX | 9 | X | * | X | ||

L3975 | XXX | 9 | X | * | X | ||

L3976 | XXX | 9 | X | * | X | ||

L3977 | XXX | 9 | X | * | X | ||

L3978 | XXX | 9 | X | * | X | ||

L3980 | X | 528.71 | X | ||||

L3981 | X | 1,149.97 | X | ||||

L3982 | X | 616.38 | X | ||||

L3984 | X | 568.29 | X | ||||

L3995 | X | 58.84 | X | ||||

L3999 | X | # | X | ||||

L4000 | X | 2,322.76 | X | ||||

L4002 | X | * | X | ||||

L4010 | X | 1,132.36 | X | ||||

L4020 | X | 1,583.60 | X | ||||

L4030 | X | 851.93 | X | ||||

L4040 | X | 695.19 | X | ||||

L4045 | X | 553.49 | X | ||||

L4050 | X | 696.57 | X | ||||

L4055 | X | 451.09 | X | ||||

L4060 | X | 536.21 | X | ||||

L4070 | X | 474.86 | X | ||||

L4080 | X | 194.73 | X | ||||

L4090 | X | 153.70 | X | ||||

L4100 | X | 201.77 | X | ||||

L4110 | X | 152.06 | X | ||||

L4130 | X | 852.53 | X | ||||

L4205 | X | * | X | ||||

L4210 | X | * | X | ||||

L4350 | X | 168.87 | X | ||||

L4360 | X | 519.15 | X | ||||

L4361 | X | 371.87 | X | ||||

L4370 | X | 343.38 | X | ||||

L4386 | X | 235.88 | X | ||||

L4387 | X | 200.02 | X | ||||

L4392 | X | 40.02 | X | ||||

L4394 | X | 29.19 | X | ||||

L4396 | X | 285.01 | X | ||||

L4397 | X | 211.67 | X | ||||

L4398 | X | 131.23 | X | ||||

L4631 | X | 2,095.96 | X | ||||

L5000 | X | 1,001.90 | X | ||||

L5010 | X | 2,188.48 | X | ||||

L5020 | X | 3,562.45 | X | ||||

L5050 | X | 4,125.38 | X | ||||

L5060 | X | 4,965.00 | X | ||||

L5100 | X | 4,297.63 | X | ||||

L5105 | X | 6,821.21 | X | ||||

L5150 | X | 6,312.62 | X | ||||

L5160 | X | 6,866.07 | X | ||||

L5200 | X | 5,980.87 | X | ||||

L5210 | X | 4,362.03 | X | ||||

L5220 | X | 4,958.23 | X | ||||

L5230 | X | 6,838.38 | X | ||||

L5250 | X | 9,326.89 | X | ||||

L5270 | X | 9,245.22 | X | ||||

L5280 | X | 9,152.70 | X | ||||

L5301 | X | 3,517.19 | X | ||||

L5312 | X | 4,378.17 | X | ||||

L5321 | X | 5,034.74 | X | ||||

L5331 | X | 7,124.35 | X | ||||

L5341 | X | 7,741.94 | X | ||||

L5400 | X | 2,163.46 | X | ||||

L5410 | X | 947.92 | X | ||||

L5420 | X | 2,732.39 | X | ||||

L5430 | X | 1,206.07 | X | ||||

L5450 | X | 771.58 | X | ||||

L5460 | X | 1,137.16 | X | ||||

L5500 | X | 2,308.66 | X | ||||

L5505 | X | 3,126.58 | X | ||||

L5510 | X | 2,617.04 | X | ||||

L5520 | X | 2,585.03 | X | ||||

L5530 | X | 3,272.14 | X | ||||

L5535 | X | 3,224.68 | X | ||||

L5540 | X | 3,405.12 | X | ||||

L5560 | X | 3,493.77 | X | ||||

L5570 | X | 3,632.29 | X | ||||

L5580 | X | 4,240.44 | X | ||||

L5585 | X | 4,599.31 | X | ||||

L5590 | X | 4,321.33 | X | ||||

L5595 | X | 7,595.72 | X | ||||

L5600 | X | 8,284.78 | X | ||||

L5610 | X | 3,721.75 | X | ||||

L5611 | X | 2,896.28 | X | ||||

L5613 | X | 4,405.36 | X | ||||

L5614 | XXX | X | * | X | |||

L5616 | X | 2,441.45 | X | ||||

L5617 | X | * | X | ||||

L5618 | X | 568.83 | X | ||||

L5620 | X | 499.79 | X | ||||

L5622 | X | 763.29 | X | ||||

L5624 | X | 728.16 | X | ||||

L5626 | X | 1,023.54 | X | ||||

L5628 | X | 969.51 | X | ||||

L5629 | X | 740.32 | X | ||||

L5630 | X | 806.73 | X | ||||

L5631 | X | 964.76 | X | ||||

L5632 | X | 399.09 | X | ||||

L5634 | X | 546.85 | X | ||||

L5636 | X | 458.04 | X | ||||

L5637 | X | 611.81 | X | ||||

L5638 | X | 874.82 | X | ||||

L5639 | X | 2,052.29 | X | ||||

L5640 | X | 1,249.49 | X | ||||

L5642 | X | 1,118.58 | X | ||||

L5643 | X | 2,797.86 | X | ||||

L5644 | X | 1,061.79 | X | ||||

L5645 | X | 1,434.31 | X | ||||

L5646 | X | 984.94 | X | ||||

L5647 | X | 1,429.88 | X | ||||

L5648 | X | 1,183.53 | X | ||||

L5649 | X | 3,592.89 | X | ||||

L5650 | X | 877.51 | X | ||||

L5651 | X | 2,158.78 | X | ||||

L5652 | X | 783.72 | X | ||||

L5653 | X | 1,046.19 | X | ||||

L5654 | X | 596.18 | X | ||||

L5655 | X | 504.81 | X | ||||

L5656 | X | 711.03 | X | ||||

L5658 | X | 692.51 | X | ||||

L5661 | X | 1,203.33 | X | ||||

L5665 | X | 920.42 | X | ||||

L5666 | X | 136.81 | X | ||||

L5668 | X | 182.61 | X | ||||

L5670 | X | 555.95 | X | ||||

L5671 | X | 761.93 | X | ||||

L5672 | X | 679.29 | X | ||||

L5673 | X | 992.72 | X | ||||

L5676 | X | 651.42 | X | ||||

L5677 | X | 886.33 | X | ||||

L5678 | X | 71.42 | X | ||||

L5679 | X | 827.25 | X | ||||

L5680 | X | 622.58 | X | ||||

L5681 | X | 1,918.46 | X | ||||

L5682 | X | 1,124.22 | X | ||||

L5683 | X | 1,918.46 | X | ||||

L5684 | X | 86.50 | X | ||||

L5685 | X | * | X | ||||

L5686 | X | 116.73 | X | ||||

L5688 | X | 109.71 | X | ||||

L5690 | X | 212.65 | X | ||||

L5692 | X | 246.80 | X | ||||

L5694 | X | 326.09 | X | ||||

L5695 | X | 342.12 | X | ||||

L5696 | X | 373.87 | X | ||||

L5697 | X | 151.83 | X | ||||

L5698 | X | 188.88 | X | ||||

L5699 | X | 335.15 | X | ||||

L5700 | XXX | X | * | X | |||

L5701 | XXX | X | * | X | |||

L5702 | XXX | X | * | X | |||

L5703 | XXX | 9 | X | * | X | ||

L5704 | XXX | X | * | X | |||

L5705 | XXX | X | * | X | |||

L5706 | XXX | X | * | X | |||

L5707 | XXX | X | * | X | |||

L5710 | X | 646.52 | X | ||||

L5711 | X | 980.76 | X | ||||

L5712 | X | 774.59 | X | ||||

L5714 | X | 798.79 | X | ||||

L5716 | X | 1,310.14 | X | ||||

L5718 | X | 1,637.53 | X | ||||

L5722 | X | 1,708.87 | X | ||||

L5724 | X | 2,713.30 | X | ||||

L5726 | X | 3,562.93 | X | ||||

L5728 | X | 4,438.88 | X | ||||

L5780 | X | 2,140.19 | X | ||||

L5781 | X | 5,963.93 | X | ||||

L5782 | X | * | X | ||||

L5785 | X | 933.94 | X | ||||

L5790 | X | 1,292.50 | X | ||||

L5795 | X | 1,930.04 | X | ||||

L5810 | X | 897.90 | X | ||||

L5811 | X | 1,311.03 | X | ||||

L5812 | X | 1,016.16 | X | ||||

L5814 | X | 6,167.26 | X | ||||

L5816 | X | 1,528.72 | X | ||||

L5818 | X | 1,726.26 | X | ||||

L5822 | X | 3,349.15 | X | ||||

L5824 | X | 2,756.72 | X | ||||

L5826 | XXX | X | 5,237.79 | X | |||

L5828 | X | 5,254.91 | X | ||||

L5830 | X | 3,733.83 | X | ||||

L5840 | XXX | X | * | X | |||

L5845 | X | * | X | ||||

L5848 | X | 1,602.84 | X | ||||

L5850 | X | 238.69 | X | ||||

L5855 | XXX | X | * | X | |||

L5856 | X | 33,729.96 | X | ||||

L5857 | X | 11,968.66 | X | ||||

L5858 | XXX | 9 | X | 25,097.12 | X | ||

L5859 | X | * | X | ||||

L5910 | X | 655.69 | X | ||||

L5920 | X | 953.77 | X | ||||

L5925 | XXX | X | * | X | |||

L5930 | X | * | X | ||||

L5940 | X | 901.65 | X | ||||

L5950 | X | 1,523.28 | X | ||||

L5960 | X | 1,824.68 | X | ||||

L5961 | X | 6,103.49 | X | ||||

L5962 | XXX | X | * | X | |||

L5964 | XXX | X | * | X | |||

L5966 | XXX | X | * | X | |||

L5968 | X | 5,815.77 | X | ||||

L5969 | X | 18,339.66 | X | ||||

L5970 | X | 394.61 | X | ||||

L5971 | XXX | 9 | X | * | X | ||

L5972 | X | 633.56 | X | ||||

L5973 | X | 23,427.02 | X | ||||

L5974 | X | 534.53 | X | ||||

L5975 | X | 741.96 | X | ||||

L5976 | X | 1,006.69 | X | ||||

L5978 | X | 524.61 | X | ||||

L5979 | XXX | X | * | X | |||

L5980 | X | 6,664.98 | X | ||||

L5981 | XXX | X | * | X | |||

L5982 | X | 1,039.22 | X | ||||

L5984 | X | 1,029.95 | X | ||||

L5985 | X | * | X | ||||

L5986 | X | 1,145.13 | X | ||||

L5987 | X | 11,945.98 | X | ||||

L5988 | X | 3,197.14 | X | ||||

L5990 | X | 2,728.23 | X | ||||

L5999 | X | # | X |