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2024 Workers' Compensation Part B Fee Schedule

26567-27178

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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
26567   003 90 2 X 1,200.80 X
26567   002 90 2 X 1,276.49 X
26567   004 90 2 X 1,187.09 X
26567   001 90 2 X 1,294.85 X
26568   004 90 2 X 1,870.00 X
26568   001 90 2 X 2,048.55 X
26568   002 90 2 X 1,908.74 X
26568   003 90 2 X 1,892.97 X
26580   002 90 2 X 3,939.27 X
26580   003 90 2 X 3,679.23 X
26580   004 90 2 X 3,628.59 X
26580   001 90 2 X 4,062.40 X
26587   003 90 2 X 1,503.11 X
26587   002 90 2 X 1,606.73 X
26587   004 90 2 X 1,485.89 X
26587   001 90 2 X 1,631.87 X
26590   002 90 2 X 1,173.58 X
26590   003 90 2 X 1,099.54 X
26590   004 90 2 X 1,086.45 X
26590   001 90 2 X 1,191.52 X
26591   002 90 2 X 622.73 X
26591   003 90 2 X 582.41 X
26591   004 90 2 X 575.66 X
26591   001 90 2 X 632.46 X
26593   001 90 2 X 1,103.00 X
26593   003 90 2 X 1,013.59 X
26593   002 90 2 X 1,085.53 X
26593   004 90 2 X 1,001.74 X
26596   003 90 2 X 1,900.26 X
26596   002 90 2 X 2,038.23 X
26596   001 90 2 X 2,071.67 X
26596   004 90 2 X 1,877.65 X
26600   004 90 2 X 368.09 290.77
26600   003 90 2 X 378.53 298.68
26600   002 90 2 X 397.18 313.85
26600   001 90 2 X 403.10 318.76
26605   004 90 2 X 548.64 X
26605   002 90 2 X 591.21 X
26605   003 90 2 X 552.02 X
26605   001 90 2 X 559.97 X
26607   001 90 2 X 1,044.67 X
26607   003 90 2 X 966.64 X
26607   002 90 2 X 1,029.43 X
26607   004 90 2 X 955.57 X
26608   002 90 2 X 1,029.43 X
26608   003 90 2 X 966.64 X
26608   004 90 2 X 955.57 X
26608   001 90 2 X 1,044.67 X
26615   001 90 2 X 1,233.12 X
26615   004 90 2 X 1,117.80 X
26615   003 90 2 X 1,131.27 X
26615   002 90 2 X 1,213.22 X
26641   002 90 2 X 430.41 X
26641   003 90 2 X 524.40 X
26641   001 90 2 X 553.20 X
26641   004 90 2 X 408.67 X
26645   001 90 2 X 757.72 X
26645   004 90 2 X 699.91 X
26645   003 90 2 X 707.83 X
26645   002 90 2 X 691.61 X
26650   001 90 2 X 1,178.01 X
26650   004 90 2 X 1,115.09 X
26650   003 90 2 X 1,059.21 X
26650   002 90 2 X 1,182.01 X
26665   001 90 2 X 1,661.90 X
26665   002 90 2 X 1,782.31 X
26665   003 90 2 X 1,736.03 X
26665   004 90 2 X 1,689.00 X
26670   001 90 2 X 508.73 X
26670   004 90 2 X 420.34 X
26670   003 90 2 X 484.07 X
26670   002 90 2 X 477.74 X
26675   001 90 2 X 1,061.53 X
26675   004 90 2 X 966.20 X
26675   003 90 2 X 978.02 X
26675   002 90 2 X 821.04 X
26676   004 90 2 X 1,114.56 X
26676   002 90 2 X 1,204.12 X
26676   003 90 2 X 1,128.04 X
26676   001 90 2 X 1,222.45 X
26685   002 90 2 X 1,473.62 X
26685   003 90 2 X 1,377.30 X
26685   004 90 2 X 1,361.04 X
26685   001 90 2 X 1,496.86 X
26686   001 90 2 X 1,681.71 X
26686   004 90 2 X 1,529.00 X
26686   002 90 2 X 1,655.48 X
26686   003 90 2 X 1,547.16 X
26700   004 90 2 X 343.67 X
26700   001 90 2 X 360.28 X
26700   003 90 2 X 367.53 X
26700   002 90 2 X 426.00 X
26705   001 90 2 X 649.75 X
26705   002 90 2 X 640.17 X
26705   003 90 2 X 625.40 X
26705   004 90 2 X 625.99 X
26706   004 90 2 X 1,065.64 X
26706   002 90 2 X 1,156.24 X
26706   001 90 2 X 1,175.14 X
26706   003 90 2 X 1,078.48 X
26715   001 90 2 X 1,162.37 X
26715   004 90 2 X 1,060.99 X
26715   003 90 2 X 1,073.35 X
26715   002 90 2 X 1,145.00 X
26720   004 90 2 X 290.12 235.09
26720   002 90 2 X 311.47 252.23
26720   003 90 2 X 293.52 237.59
26720   001 90 2 X 315.83 255.81
26725   003 90 2 X 473.39 X
26725   002 90 2 X 505.01 X
26725   004 90 2 X 477.81 X
26725   001 90 2 X 503.70 X
26727   001 90 2 X 1,071.48 X
26727   003 90 2 X 811.70 X
26727   002 90 2 X 1,066.76 X
26727   004 90 2 X 941.50 X
26735   001 90 2 X 1,169.85 X
26735   003 90 2 X 1,052.01 X
26735   002 90 2 X 1,119.33 X
26735   004 90 2 X 1,084.68 X
26740   004 90 2 X 258.77 X
26740   003 90 2 X 326.87 X
26740   002 90 2 X 273.31 X
26740   001 90 2 X 275.58 X
26742   002 90 2 X 602.94 X
26742   003 90 2 X 551.66 X
26742   004 90 2 X 574.85 X
26742   001 90 2 X 609.72 X
26746   004 90 2 X 1,201.11 X
26746   002 90 2 X 1,275.89 X
26746   003 90 2 X 1,185.82 X
26746   001 90 2 X 1,260.20 X
26750   004 90 2 X 262.27 X
26750   001 90 2 X 282.67 X
26750   002 90 2 X 279.28 X
26750   003 90 2 X 265.28 X
26755   001 90 2 X 458.57 X
26755   003 90 2 X 396.18 X
26755   002 90 2 X 413.06 X
26755   004 90 2 X 398.90 X
26756   003 90 2 X 673.39 X
26756   002 90 2 X 711.64 X
26756   004 90 2 X 665.96 X
26756   001 90 2 X 721.00 X
26765   004 90 2 X 857.23 X
26765   002 90 2 X 952.59 X
26765   003 90 2 X 746.79 X
26765   001 90 2 X 1,008.49 X
26770   001 90 2 X 373.69 X
26770   003 90 2 X 350.96 X
26770   002 90 2 X 389.79 X
26770   004 90 2 X 338.05 X
26775   003 90 2 X 414.09 X
26775   002 90 2 X 515.01 X
26775   004 90 2 X 500.12 X
26775   001 90 2 X 431.28 X
26776   002 90 2 X 753.04 X
26776   003 90 2 X 736.59 X
26776   001 90 2 X 788.11 X
26776   004 90 2 X 728.55 X
26785   001 90 2 X 852.35 X
26785   004 90 2 X 778.37 X
26785   003 90 2 X 787.46 X
26785   002 90 2 X 839.78 X
26820   002 90 2 X 1,733.13 X
26820   003 90 2 X 1,621.36 X
26820   001 90 2 X 1,760.20 X
26820   004 90 2 X 1,602.24 X
26841   001 90 2 X 1,585.33 X
26841   004 90 2 X 1,487.49 X
26841   002 90 2 X 1,560.21 X
26841   003 90 2 X 1,494.72 X
26842   004 90 2 X 1,821.88 X
26842   002 90 2 X 1,983.45 X
26842   003 90 2 X 1,844.20 X
26842   001 90 2 X 2,017.10 X
26843   001 90 2 X 1,668.93 X
26843   004 90 2 X 1,513.20 X
26843   003 90 2 X 1,531.22 X
26843   002 90 2 X 1,642.02 X
26844   002 90 2 X 1,873.48 X
26844   003 90 2 X 1,749.65 X
26844   001 90 2 X 1,903.44 X
26844   004 90 2 X 1,728.97 X
26850   004 90 2 X 1,235.38 X
26850   002 90 2 X 1,390.11 X
26850   003 90 2 X 1,309.68 X
26850   001 90 2 X 1,403.93 X
26852   003 90 2 X 1,535.02 X
26852   002 90 2 X 1,596.72 X
26852   004 90 2 X 1,517.36 X
26852   001 90 2 X 1,664.32 X
26860   004 90 2 X 1,063.91 X
26860   002 90 2 X 1,058.67 X
26860   003 90 2 X 1,060.18 X
26860   001 90 2 X 1,128.78 X
26861   002 ZZZ 0 X 766.18 X
26861   003 ZZZ 0 X 749.14 X
26861   004 ZZZ 0 X 472.14 X
26861   001 ZZZ 0 X 527.68 X
26862   004 90 2 X 1,350.41 X
26862   001 90 2 X 1,931.57 X
26862   003 90 2 X 1,574.28 X
26862   002 90 2 X 1,457.33 X
26863   001 ZZZ 0 X 891.13 X
26863   003 ZZZ 0 X 818.31 X
26863   002 ZZZ 0 X 876.93 X
26863   004 ZZZ 0 X 808.77 X
26910   004 90 2 X 1,476.74 X
26910   003 90 2 X 1,475.49 X
26910   002 90 2 X 1,523.37 X
26910   001 90 2 X 1,533.14 X
26951   001 90 2 X 896.27 X
26951   004 90 2 X 803.85 X
26951   003 90 2 X 813.13 X
26951   002 90 2 X 866.05 X
26952   001 90 2 X 1,464.91 X
26952   003 90 2 X 1,426.54 X
26952   002 90 2 X 1,457.36 X
26952   004 90 2 X 1,421.16 X
26989     YYY 2 X # X
26990   004 90 2 X 866.88 X
26990   001 90 2 X 950.44 X
26990   002 90 2 X 945.22 X
26990   003 90 2 X 911.83 X
26991   002 90 2 X 638.40 X
26991   003 90 2 X 615.07 X
26991   004 90 2 X 848.39 X
26991   001 90 2 X 551.82 X
26992   001 90 2 X 2,132.80 X
26992   004 90 2 X 1,917.05 X
26992   002 90 2 X 2,115.20 X
26992   003 90 2 X 2,018.92 X
27000   001 90 2 X 818.56 X
27000   004 90 2 X 764.90 X
27000   002 90 2 X 809.69 X
27000   003 90 2 X 773.28 X
27001   004 90 2 X 1,024.47 X
27001   003 90 2 X 1,039.50 X
27001   002 90 2 X 1,069.67 X
27001   001 90 2 X 1,161.90 X
27003   004 90 2 X 1,479.96 X
27003   001 90 2 X 1,636.25 X
27003   003 90 2 X 1,497.97 X
27003   002 90 2 X 1,608.65 X
27005   002 90 2 X 1,427.15 X
27005   003 90 2 X 1,356.79 X
27005   004 90 2 X 1,342.30 X
27005   001 90 2 X 1,444.26 X
27006   002 90 2 X 1,654.00 X
27006   003 90 2 X 1,563.63 X
27006   001 90 2 X 1,676.02 X
27006   004 90 2 X 1,546.34 X
27025   001 90 2 X 1,950.97 X
27025   003 90 2 X 1,961.63 X
27025   002 90 2 X 1,923.51 X
27025   004 90 2 X 1,790.02 X
27027   003 90 2 X 1,417.04 X
27027   002 90 2 X 1,417.04 X
27027   004 90 2 X 1,417.04 X
27027   001 90 2 X 1,579.85 X
27030   004 90 2 X 2,613.34 X
27030   001 90 2 X 3,028.42 X
27030   003 90 2 X 2,644.86 X
27030   002 90 2 X 3,009.08 X
27033   004 90 2 X 2,932.34 X
27033   001 90 2 X 3,045.92 X
27033   002 90 2 X 3,026.35 X
27033   003 90 2 X 2,685.28 X
27035   002 90 2 X 3,331.55 X
27035   003 90 2 X 3,111.27 X
27035   001 90 2 X 3,384.99 X
27035   004 90 2 X 3,075.56 X
27036   001 90 2 X 2,921.07 X
27036   003 90 2 X 2,543.23 X
27036   002 90 2 X 2,613.40 X
27036   004 90 2 X 2,543.23 X
27040   003 10 2 X 302.91 X
27040   002 10 2 X 324.07 X
27040   001 10 2 X 313.60 X
27040   004 10 2 X 296.08 X
27041   004 90 2 X 817.14 X
27041   002 90 2 X 875.53 X
27041   003 90 2 X 824.41 X
27041   001 90 2 X 879.25 X
27043   001 90 2 X 887.49 X
27043   004 90 2 X 790.07 X
27043   003 90 2 X 790.07 X
27043   002 90 2 X 790.07 X
27045   003 90 2 X 1,256.05 X
27045   002 90 2 X 1,256.05 X
27045   004 90 2 X 1,256.05 X
27045   001 90 2 X 1,409.09 X
27047   003 90 2 X 779.55 X
27047   002 90 2 X 826.64 X
27047   001 90 2 X 858.28 X
27047   004 90 2 X 976.01 X
27048   001 90 2 X 928.90 X
27048   003 90 2 X 1,133.48 X
27048   002 90 2 X 917.36 X
27048   004 90 2 X 864.78 X
27049   001 90 2 X 2,234.20 X
27049   003 90 2 X 2,561.04 X
27049   002 90 2 X 2,208.45 X
27049   004 90 2 X 2,531.36 X
27050   001 90 2 X 1,129.60 X
27050   003 90 2 X 1,023.69 X
27050   002 90 2 X 1,109.05 X
27050   004 90 2 X 1,011.12 X
27052   001 90 2 X 2,349.68 X
27052   003 90 2 X 1,660.05 X
27052   002 90 2 X 2,282.87 X
27052   004 90 2 X 1,639.35 X
27054   002 90 2 X 3,241.99 X
27054   003 90 2 X 3,007.32 X
27054   004 90 2 X 2,274.43 X
27054   001 90 2 X 3,446.54 X
27057   004 90 2 X 1,556.77 X
27057   002 90 2 X 1,556.77 X
27057   003 90 2 X 1,556.77 X
27057   001 90 2 X 1,717.01 X
27059   003 90 2 X 3,089.73 X
27059   002 90 2 X 3,089.73 X
27059   004 90 2 X 3,089.73 X
27059   001 90 2 X 3,449.27 X
27060   004 90 2 X 963.24 X
27060   002 90 2 X 1,008.55 X
27060   003 90 2 X 974.54 X
27060   001 90 2 X 1,060.72 X
27062   002 90 2 X 1,081.12 X
27062   003 90 2 X 1,009.00 X
27062   004 90 2 X 997.08 X
27062   001 90 2 X 1,098.64 X
27065   004 90 2 X 1,179.85 X
27065   002 90 2 X 1,575.77 X
27065   003 90 2 X 1,329.41 X
27065   001 90 2 X 1,307.02 X
27066   003 90 2 X 1,916.29 X
27066   002 90 2 X 2,123.01 X
27066   004 90 2 X 2,037.50 X
27066   001 90 2 X 2,149.80 X
27067   001 90 2 X 2,977.30 X
27067   002 90 2 X 2,944.54 X
27067   003 90 2 X 2,732.13 X
27067   004 90 2 X 2,699.80 X
27070   004 90 2 X 1,878.47 X
27070   001 90 2 X 2,060.40 X
27070   002 90 2 X 1,960.97 X
27070   003 90 2 X 1,900.55 X
27071   002 90 2 X 2,319.03 X
27071   003 90 2 X 2,092.91 X
27071   004 90 2 X 2,081.38 X
27071   001 90 2 X 2,291.06 X
27075   001 90 2 X 3,603.90 X
27075   002 90 2 X 3,546.58 X
27075   003 90 2 X 3,309.91 X
27075   004 90 2 X 3,271.16 X
27076   004 90 2 X 3,803.53 X
27076   001 90 2 X 4,188.45 X
27076   003 90 2 X 3,849.18 X
27076   002 90 2 X 4,122.33 X
27077   001 90 2 X 4,947.73 X
27077   003 90 2 X 4,539.57 X
27077   002 90 2 X 4,868.20 X
27077   004 90 2 X 4,486.15 X
27078   002 90 2 X 2,700.69 X
27078   003 90 2 X 2,373.88 X
27078   001 90 2 X 3,288.60 X
27078   004 90 2 X 2,346.49 X
27080   004 90 2 X 1,163.10 X
27080   002 90 2 X 1,262.75 X
27080   003 90 2 X 1,176.78 X
27080   001 90 2 X 1,283.66 X
27086   003 10 2 X 237.53 X
27086   002 10 2 X 237.75 X
27086   001 10 2 X 274.47 X
27086   004 10 2 X 229.54 X
27087   001 90 2 X 1,187.21 X
27087   003 90 2 X 1,135.67 X
27087   002 90 2 X 1,177.21 X
27087   004 90 2 X 1,269.41 X
27090   001 90 2 X 2,551.22 X
27090   003 90 2 X 2,355.36 X
27090   002 90 2 X 2,513.05 X
27090   004 90 2 X 2,328.10 X
27091   003 90 2 X 5,263.37 X
27091   002 90 2 X 6,389.47 X
27091   004 90 2 X 5,573.16 X
27091   001 90 2 X 6,448.15 X
27093   004 0 2 X 230.07 X
27093   002 0 2 X 242.25 X
27093   003 0 2 X 221.37 X
27093   001 0 2 X 239.12 X
27095   001 0 2 X 269.17 X
27095   004 0 2 X 247.94 X
27095   002 0 2 X 265.61 X
27095   003 0 2 X 249.64 X
27096   001 0 2 X 1,083.58 145.94
27096   004 0 2 X 934.38 132.80
27096   002 0 2 X 934.38 132.80
27096   003 0 2 X 934.38 132.80
27097   001 90 2 X 1,937.76 X
27097   004 90 2 X 1,756.32 X
27097   003 90 2 X 1,777.51 X
27097   002 90 2 X 1,906.51 X
27098   001 90 2 X 1,937.76 X
27098   003 90 2 X 1,777.51 X
27098   002 90 2 X 1,906.51 X
27098   004 90 2 X 1,756.32 X
27100   001 90 2 X 2,411.78 X
27100   004 90 2 X 2,033.39 X
27100   003 90 2 X 2,420.68 X
27100   002 90 2 X 2,200.43 X
27105   001 90 2 X 2,105.21 X
27105   003 90 2 X 1,941.59 X
27105   002 90 2 X 2,073.22 X
27105   004 90 2 X 1,920.50 X
27110   001 90 2 X 2,838.11 X
27110   004 90 2 X 2,574.79 X
27110   003 90 2 X 2,665.42 X
27110   002 90 2 X 3,137.09 X
27111   003 90 2 X 2,575.66 X
27111   002 90 2 X 3,121.77 X
27111   004 90 2 X 2,544.48 X
27111   001 90 2 X 2,800.09 X
27120   003 90 2 X 3,901.83 X
27120   002 90 2 X 4,319.75 X
27120   004 90 2 X 4,000.56 X
27120   001 90 2 X 4,344.72 X
27122   001 90 2 X 4,222.43 X
27122   004 90 2 X 3,760.07 X
27122   002 90 2 X 4,088.58 X
27122   003 90 2 X 3,750.77 X
27125   003 90 2 X 3,749.15 X
27125   002 90 2 X 4,017.59 X
27125   004 90 2 X 3,693.79 X
27125   001 90 2 X 4,082.58 X
27130   001 90 2 X 6,203.37 X
27130   004 90 2 X 5,597.13 X
27130   003 90 2 X 5,725.12 X
27130   002 90 2 X 6,091.89 X
27132   002 90 2 X 6,765.05 X
27132   003 90 2 X 6,321.90 X
27132   004 90 2 X 5,709.28 X
27132   001 90 2 X 6,376.96 X
27134   003 90 2 X 7,445.20 X
27134   002 90 2 X 7,901.57 X
27134   004 90 2 X 7,276.09 X
27134   001 90 2 X 7,855.38 X
27137   003 90 2 X 5,878.18 X
27137   002 90 2 X 6,256.54 X
27137   001 90 2 X 6,312.57 X
27137   004 90 2 X 5,838.93 X
27138   001 90 2 X 5,568.06 X
27138   004 90 2 X 5,073.93 X
27138   003 90 2 X 5,113.86 X
27138   002 90 2 X 5,500.26 X
27140   001 90 2 X 2,745.16 X
27140   004 90 2 X 2,491.33 X
27140   003 90 2 X 2,235.34 X
27140   002 90 2 X 2,535.52 X
27146   002 90 2 X 2,874.96 X
27146   003 90 2 X 2,707.87 X
27146   004 90 2 X 2,675.80 X
27146   001 90 2 X 2,915.41 X
27147   004 90 2 X 3,843.37 X
27147   002 90 2 X 4,128.92 X
27147   003 90 2 X 3,889.74 X
27147   001 90 2 X 4,241.42 X
27151   001 90 2 X 4,454.95 X
27151   004 90 2 X 4,037.42 X
27151   002 90 2 X 4,383.02 X
27151   003 90 2 X 4,086.13 X
27156   001 90 2 X 4,722.70 X
27156   004 90 2 X 4,282.26 X
27156   002 90 2 X 4,646.89 X
27156   003 90 2 X 4,333.43 X
27158   004 90 2 X 3,629.18 X
27158   001 90 2 X 3,998.72 X
27158   003 90 2 X 3,671.62 X
27158   002 90 2 X 3,934.87 X
27161   001 90 2 X 3,615.14 X
27161   004 90 2 X 3,278.77 X
27161   002 90 2 X 3,557.28 X
27161   003 90 2 X 3,318.23 X
27165   002 90 2 X 3,979.94 X
27165   003 90 2 X 3,707.92 X
27165   004 90 2 X 3,663.25 X
27165   001 90 2 X 4,045.71 X
27170   003 90 2 X 3,899.51 X
27170   002 90 2 X 4,185.58 X
27170   004 90 2 X 3,945.17 X
27170   001 90 2 X 4,286.39 X
27175   002 90 2 X 941.87 X
27175   003 90 2 X 907.29 X
27175   004 90 2 X 898.24 X
27175   001 90 2 X 950.38 X
27176   002 90 2 X 2,570.42 X
27176   003 90 2 X 2,396.17 X
27176   001 90 2 X 2,612.58 X
27176   004 90 2 X 2,367.64 X
27177   003 90 2 X 2,940.97 X
27177   002 90 2 X 3,722.40 X
27177   004 90 2 X 2,906.27 X
27177   001 90 2 X 3,202.71 X
27178   003 90 2 X 2,373.78 X
27178   002 90 2 X 2,540.90 X
27178   001 90 2 X 2,581.24 X
27178   004 90 2 X 2,345.26 X