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Health Care Services Review
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Medical Fee Review
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Fee Schedule
>
Fee Schedule 29365-30620
Begin Main Content Area
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2024 Workers' Compensation Part B Fee Schedule
29365-30620
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
29365
001
0
2
X
311.05
251.04
29365
004
0
2
X
234.48
189.24
29365
002
0
2
X
321.55
259.36
29365
003
0
2
X
244.37
196.88
29405
004
0
2
X
205.65
161.15
29405
001
0
2
X
228.94
179.69
29405
002
0
2
X
232.06
181.58
29405
003
0
2
X
184.60
144.27
29425
001
0
2
X
317.65
247.19
29425
004
0
2
X
272.34
211.64
29425
002
0
2
X
335.69
261.07
29425
003
0
2
X
280.96
218.32
29435
002
0
2
X
446.00
345.40
29435
003
0
2
X
442.56
342.17
29435
004
0
2
X
287.15
222.03
29435
001
0
2
X
444.10
344.40
29440
002
0
2
X
94.04
81.23
29440
003
0
2
X
87.30
75.66
29440
004
0
2
X
91.72
79.52
29440
001
0
2
X
92.58
80.17
29445
001
0
2
X
457.89
X
29445
004
0
2
X
408.93
X
29445
003
0
2
X
414.62
X
29445
002
0
2
X
444.01
X
29450
001
0
2
X
196.33
X
29450
004
0
2
X
150.02
X
29450
002
0
2
X
180.06
X
29450
003
0
2
X
151.64
X
29505
002
0
2
X
151.63
X
29505
003
0
2
X
146.34
X
29505
004
0
2
X
152.53
X
29505
001
0
2
X
161.93
X
29515
001
0
2
X
141.92
115.92
29515
004
0
2
X
130.84
107.11
29515
003
0
2
X
132.35
108.15
29515
002
0
2
X
137.76
112.64
29520
001
0
2
X
103.41
83.92
29520
003
0
2
X
97.17
79.03
29520
002
0
2
X
102.21
83.04
29520
004
0
2
X
96.02
78.19
29530
001
0
2
X
102.33
84.55
29530
004
0
2
X
100.20
83.13
29530
002
0
2
X
104.34
86.14
29530
003
0
2
X
101.41
83.78
29540
003
0
2
X
88.02
72.85
29540
002
0
2
X
92.58
76.54
29540
004
0
2
X
85.95
71.43
29540
001
0
2
X
89.98
74.64
29550
004
0
2
X
70.30
58.43
29550
001
0
2
X
80.14
66.12
29550
002
0
2
X
78.77
64.91
29550
003
0
2
X
81.75
67.65
29580
004
0
2
X
100.61
71.05
29580
001
0
2
X
120.23
85.89
29580
003
0
2
X
103.48
73.07
29580
002
0
2
X
113.67
80.82
29581
001
0
2
X
167.14
61.29
29581
004
0
2
X
145.07
55.81
29581
003
0
2
X
145.07
55.81
29581
002
0
2
X
145.07
55.81
29584
003
0
2
X
109.24
25.42
29584
002
0
2
X
109.24
25.42
29584
001
0
2
X
123.97
26.79
29584
004
0
2
X
109.24
25.42
29700
0
2
X
*
X
29705
0
2
X
*
X
29710
0
2
X
*
X
29720
002
0
2
X
96.70
X
29720
003
0
2
X
99.83
X
29720
004
0
2
X
98.77
X
29720
001
0
2
X
97.59
X
29730
001
0
2
X
116.94
X
29730
003
0
2
X
111.94
X
29730
002
0
2
X
115.69
X
29730
004
0
2
X
109.00
X
29740
004
0
2
X
139.04
X
29740
001
0
2
X
172.95
X
29740
003
0
2
X
163.27
X
29740
002
0
2
X
168.36
X
29750
003
0
2
X
192.09
X
29750
002
0
2
X
201.77
X
29750
004
0
2
X
190.01
X
29750
001
0
2
X
204.16
X
29799
YYY
2
X
#
X
29800
004
90
2
X
1,006.21
X
29800
001
90
2
X
1,093.55
X
29800
002
90
2
X
1,078.86
X
29800
003
90
2
X
1,018.27
X
29804
003
90
2
X
2,393.94
X
29804
002
90
2
X
2,568.69
X
29804
001
90
2
X
2,610.74
X
29804
004
90
2
X
2,362.77
X
29805
004
90
2
X
775.60
X
29805
002
90
2
X
775.60
X
29805
003
90
2
X
775.60
X
29805
001
90
2
X
878.57
X
29806
004
90
3
X
2,153.84
X
29806
001
90
3
X
2,450.41
X
29806
003
90
3
X
2,153.84
X
29806
002
90
3
X
2,153.84
X
29807
001
90
3
X
2,386.87
X
29807
004
90
3
X
2,095.28
X
29807
002
90
3
X
2,095.28
X
29807
003
90
3
X
2,095.28
X
29819
002
90
3
X
2,679.73
X
29819
003
90
3
X
2,520.28
X
29819
004
90
3
X
1,927.95
X
29819
001
90
3
X
2,711.13
X
29820
002
90
3
X
2,042.31
X
29820
003
90
3
X
1,882.21
X
29820
001
90
3
X
2,081.03
X
29820
004
90
3
X
1,859.02
X
29821
001
90
3
X
2,463.10
X
29821
004
90
3
X
2,193.53
X
29821
003
90
3
X
2,221.17
X
29821
002
90
3
X
3,125.67
X
29822
003
90
3
X
1,949.13
X
29822
002
90
3
X
2,112.43
X
29822
001
90
3
X
2,151.93
X
29822
004
90
3
X
1,925.14
X
29823
004
90
3
X
2,613.92
X
29823
002
90
3
X
2,589.13
X
29823
003
90
3
X
2,626.63
X
29823
001
90
3
X
2,640.07
X
29824
002
90
3
X
1,311.17
X
29824
003
90
3
X
1,311.17
X
29824
001
90
3
X
1,494.77
X
29824
004
90
3
X
1,311.17
X
29825
003
90
3
X
2,150.79
X
29825
002
90
3
X
2,338.54
X
29825
004
90
3
X
2,124.16
X
29825
001
90
3
X
2,383.90
X
29826
004
ZZZ
0
X
2,445.82
X
29826
002
ZZZ
0
X
2,815.12
X
29826
003
ZZZ
0
X
2,719.89
X
29826
001
ZZZ
0
X
2,839.93
X
29827
001
90
3
X
2,526.22
X
29827
002
90
3
X
2,232.95
X
29827
003
90
3
X
2,232.95
X
29827
004
90
3
X
2,232.95
X
29828
004
90
3
X
1,480.84
X
29828
001
90
3
X
1,687.31
X
29828
003
90
3
X
1,480.84
X
29828
002
90
3
X
1,480.84
X
29830
001
90
2
X
1,336.55
X
29830
004
90
2
X
1,213.37
X
29830
002
90
2
X
1,315.40
X
29830
003
90
2
X
1,228.00
X
29834
001
90
3
X
1,470.52
X
29834
004
90
3
X
1,796.26
X
29834
003
90
3
X
1,348.61
X
29834
002
90
3
X
1,720.49
X
29835
003
90
3
X
1,391.93
X
29835
002
90
3
X
1,493.24
X
29835
004
90
3
X
1,375.44
X
29835
001
90
3
X
1,517.71
X
29836
001
90
3
X
1,767.02
X
29836
004
90
3
X
1,601.56
X
29836
003
90
3
X
1,620.82
X
29836
002
90
3
X
1,738.52
X
29837
002
90
3
X
1,585.39
X
29837
003
90
3
X
1,937.58
X
29837
001
90
3
X
1,611.50
X
29837
004
90
3
X
1,459.97
X
29838
002
90
3
X
2,144.67
X
29838
003
90
3
X
2,000.43
X
29838
001
90
3
X
1,772.97
X
29838
004
90
3
X
1,607.67
X
29840
004
90
2
X
954.67
X
29840
003
90
2
X
965.64
X
29840
002
90
2
X
1,026.17
X
29840
001
90
2
X
1,040.81
X
29843
004
90
3
X
1,274.43
X
29843
002
90
3
X
1,383.41
X
29843
003
90
3
X
1,289.78
X
29843
001
90
3
X
1,406.01
X
29844
003
90
3
X
1,330.83
X
29844
002
90
3
X
1,427.16
X
29844
004
90
3
X
1,315.10
X
29844
001
90
3
X
1,450.53
X
29845
002
90
3
X
1,732.08
X
29845
003
90
3
X
1,614.63
X
29845
004
90
3
X
1,595.43
X
29845
001
90
3
X
2,033.39
X
29846
004
90
3
X
2,015.42
X
29846
001
90
3
X
2,276.76
X
29846
003
90
3
X
2,040.57
X
29846
002
90
3
X
2,230.78
X
29847
004
90
3
X
1,512.06
X
29847
002
90
3
X
1,636.86
X
29847
003
90
3
X
1,530.51
X
29847
001
90
3
X
1,992.10
X
29848
002
90
2
X
950.93
X
29848
003
90
2
X
886.72
X
29848
004
90
2
X
876.16
X
29848
001
90
2
X
966.43
X
29850
001
90
2
X
2,744.74
X
29850
004
90
2
X
2,630.95
X
29850
003
90
2
X
2,069.54
X
29850
002
90
2
X
2,236.93
X
29851
001
90
2
X
3,012.02
X
29851
003
90
2
X
2,615.33
X
29851
002
90
2
X
2,798.71
X
29851
004
90
2
X
2,886.72
X
29855
002
90
2
X
2,498.22
X
29855
003
90
2
X
2,398.13
X
29855
004
90
2
X
2,375.82
X
29855
001
90
2
X
2,630.47
X
29856
002
90
2
X
2,703.48
X
29856
003
90
2
X
2,801.18
X
29856
001
90
2
X
3,045.90
X
29856
004
90
2
X
2,574.33
X
29860
003
90
2
X
1,206.91
X
29860
002
90
2
X
1,206.91
X
29860
004
90
2
X
1,206.91
X
29860
001
90
2
X
1,351.79
X
29861
001
90
3
X
2,057.62
X
29861
003
90
3
X
1,782.68
X
29861
002
90
3
X
1,782.68
X
29861
004
90
3
X
1,782.68
X
29862
003
90
3
X
1,951.82
X
29862
002
90
3
X
1,951.82
X
29862
004
90
3
X
1,951.82
X
29862
001
90
3
X
2,273.18
X
29863
002
90
3
X
1,789.38
X
29863
003
90
3
X
1,789.38
X
29863
004
90
3
X
1,789.38
X
29863
001
90
3
X
2,056.11
X
29866
001
90
2
X
2,371.27
X
29866
003
90
2
X
2,076.10
X
29866
002
90
2
X
2,076.10
X
29866
004
90
2
X
2,076.10
X
29867
003
90
2
X
2,483.43
X
29867
002
90
2
X
2,483.43
X
29867
004
90
2
X
2,483.43
X
29867
001
90
2
X
2,827.96
X
29868
004
90
2
X
3,365.19
X
29868
003
90
2
X
3,365.19
X
29868
002
90
2
X
3,365.19
X
29868
001
90
2
X
3,843.92
X
29870
004
90
2
X
989.71
X
29870
001
90
2
X
1,023.79
X
29870
003
90
2
X
994.33
X
29870
002
90
2
X
1,081.54
X
29871
001
90
3
X
1,704.81
X
29871
004
90
3
X
1,513.46
X
29871
002
90
3
X
1,564.37
X
29871
003
90
3
X
1,478.44
X
29873
001
90
3
X
1,169.74
X
29873
004
90
3
X
1,027.79
X
29873
002
90
3
X
1,027.79
X
29873
003
90
3
X
1,027.79
X
29874
004
90
3
X
1,913.74
X
29874
002
90
3
X
2,031.23
X
29874
003
90
3
X
1,946.34
X
29874
001
90
3
X
2,072.44
X
29875
001
90
3
X
2,261.68
X
29875
002
90
3
X
2,220.60
X
29875
003
90
3
X
2,060.64
X
29875
004
90
3
X
1,985.89
X
29876
002
90
3
X
2,495.51
X
29876
003
90
3
X
2,325.63
X
29876
004
90
3
X
2,306.55
X
29876
001
90
3
X
2,535.03
X
29877
001
90
3
X
2,381.60
X
29877
004
90
3
X
2,149.49
X
29877
002
90
3
X
2,335.52
X
29877
003
90
3
X
2,154.08
X
29879
004
90
3
X
2,495.51
X
29879
003
90
3
X
2,506.16
X
29879
002
90
3
X
2,682.27
X
29879
001
90
3
X
2,726.81
X
29880
002
90
3
X
2,559.58
X
29880
003
90
3
X
2,355.36
X
29880
001
90
3
X
2,608.87
X
29880
004
90
3
X
2,326.17
X
29881
004
90
3
X
2,129.16
X
29881
002
90
3
X
2,334.74
X
29881
003
90
3
X
2,168.54
X
29881
001
90
3
X
2,374.96
X
29882
002
90
3
X
2,475.39
X
29882
003
90
3
X
2,304.27
X
29882
001
90
3
X
2,514.98
X
29882
004
90
3
X
2,158.51
X
29883
002
90
3
X
3,044.86
X
29883
003
90
3
X
2,793.26
X
29883
004
90
3
X
2,758.46
X
29883
001
90
3
X
3,105.70
X
29884
001
90
3
X
2,502.25
X
29884
004
90
3
X
1,792.18
X
29884
002
90
3
X
2,513.31
X
29884
003
90
3
X
2,327.05
X
29885
001
90
3
X
2,150.10
X
29885
003
90
3
X
1,898.21
X
29885
002
90
3
X
2,036.14
X
29885
004
90
3
X
1,875.60
X
29886
004
90
3
X
1,550.64
X
29886
001
90
3
X
1,711.20
X
29886
002
90
3
X
1,975.04
X
29886
003
90
3
X
1,569.22
X
29887
001
90
3
X
2,376.33
X
29887
002
90
3
X
2,335.23
X
29887
003
90
3
X
2,165.75
X
29887
004
90
3
X
2,139.25
X
29888
004
90
2
X
3,571.88
X
29888
001
90
2
X
3,990.23
X
29888
003
90
2
X
3,616.49
X
29888
002
90
2
X
3,917.49
X
29889
001
90
2
X
2,580.16
X
29889
003
90
2
X
2,366.27
X
29889
002
90
2
X
2,538.41
X
29889
004
90
2
X
2,338.11
X
29891
002
90
2
X
1,671.42
X
29891
003
90
2
X
1,671.42
X
29891
001
90
2
X
1,937.95
X
29891
004
90
2
X
1,671.42
X
29892
004
90
2
X
1,724.78
X
29892
001
90
2
X
1,993.19
X
29892
002
90
2
X
1,724.78
X
29892
003
90
2
X
1,724.78
X
29893
001
90
2
X
1,092.61
X
29893
004
90
2
X
967.79
X
29893
002
90
2
X
967.79
X
29893
003
90
2
X
967.79
X
29894
001
90
2
X
2,070.40
X
29894
004
90
2
X
1,897.58
X
29894
003
90
2
X
1,849.44
X
29894
002
90
2
X
2,169.74
X
29895
002
90
2
X
1,937.97
X
29895
003
90
2
X
1,828.73
X
29895
004
90
2
X
1,769.98
X
29895
001
90
2
X
2,117.11
X
29897
004
90
2
X
2,032.35
X
29897
001
90
2
X
2,135.23
X
29897
003
90
2
X
1,931.14
X
29897
002
90
2
X
2,095.52
X
29898
004
90
2
X
2,188.20
X
29898
001
90
2
X
2,442.93
X
29898
003
90
2
X
2,315.41
X
29898
002
90
2
X
2,398.72
X
29899
001
90
2
X
2,329.10
X
29899
004
90
2
X
2,048.08
X
29899
002
90
2
X
2,048.08
X
29899
003
90
2
X
2,048.08
X
29900
002
90
2
X
930.30
X
29900
003
90
2
X
930.30
X
29900
001
90
2
X
1,060.09
X
29900
004
90
2
X
930.30
X
29901
001
90
2
X
1,169.23
X
29901
004
90
2
X
1,025.94
X
29901
003
90
2
X
1,025.94
X
29901
002
90
2
X
1,025.94
X
29902
001
90
2
X
1,254.87
X
29902
002
90
2
X
1,101.52
X
29902
003
90
2
X
1,101.52
X
29902
004
90
2
X
1,101.52
X
29904
002
90
2
X
992.26
X
29904
003
90
2
X
992.26
X
29904
004
90
2
X
992.26
X
29904
001
90
2
X
1,127.89
X
29905
001
90
2
X
1,215.87
X
29905
003
90
2
X
1,068.68
X
29905
002
90
2
X
1,068.68
X
29905
004
90
2
X
1,068.68
X
29906
002
90
2
X
1,125.51
X
29906
003
90
2
X
1,125.51
X
29906
004
90
2
X
1,125.51
X
29906
001
90
2
X
1,280.69
X
29914
001
90
3
X
1,980.58
X
29914
004
90
3
X
1,783.02
X
29914
003
90
3
X
1,783.02
X
29914
002
90
3
X
1,783.02
X
29915
001
90
3
X
2,017.12
X
29915
003
90
3
X
1,816.54
X
29915
002
90
3
X
1,816.54
X
29915
004
90
3
X
1,816.54
X
29916
002
90
3
X
1,816.54
X
29916
003
90
3
X
1,816.54
X
29916
001
90
3
X
2,017.12
X
29916
004
90
3
X
1,816.54
X
29999
YYY
2
X
#
X
30000
003
10
2
X
252.76
X
30000
002
10
2
X
264.36
X
30000
004
10
2
X
209.32
X
30000
001
10
2
X
223.54
X
30020
004
10
2
X
266.92
X
30020
001
10
2
X
278.17
X
30020
003
10
2
X
261.87
X
30020
002
10
2
X
265.12
X
30100
001
0
2
X
204.16
164.12
30100
004
0
2
X
197.81
158.76
30100
002
0
2
X
203.09
162.76
30100
003
0
2
X
198.71
159.67
30110
004
10
2
X
309.96
245.55
30110
001
10
2
X
336.81
266.57
30110
002
10
2
X
332.35
263.01
30110
003
10
2
X
323.68
256.32
30115
001
90
2
X
737.14
X
30115
003
90
2
X
769.27
X
30115
002
90
2
X
808.77
X
30115
004
90
2
X
625.90
X
30117
003
90
2
X
566.94
X
30117
002
90
2
X
585.08
X
30117
004
90
2
X
548.55
X
30117
001
90
2
X
596.18
X
30118
003
90
2
X
1,893.72
X
30118
002
90
2
X
2,011.07
X
30118
001
90
2
X
2,039.38
X
30118
004
90
2
X
1,968.20
X
30120
004
90
2
X
1,846.02
X
30120
002
90
2
X
1,895.93
X
30120
003
90
2
X
1,852.95
X
30120
001
90
2
X
1,906.33
X
30124
004
90
2
X
586.80
X
30124
003
90
2
X
563.25
X
30124
002
90
2
X
559.04
X
30124
001
90
2
X
500.27
X
30125
004
90
2
X
1,348.39
X
30125
001
90
2
X
1,472.44
X
30125
003
90
2
X
1,600.04
X
30125
002
90
2
X
1,543.15
X
30130
004
90
2
X
519.25
X
30130
002
90
2
X
551.75
X
30130
003
90
2
X
525.20
X
30130
001
90
2
X
558.15
X
30140
002
0
2
X
840.93
X
30140
003
0
2
X
831.73
X
30140
004
0
2
X
817.77
X
30140
001
0
2
X
847.27
X
30150
001
90
2
X
2,820.38
X
30150
004
90
2
X
1,798.80
X
30150
003
90
2
X
2,756.69
X
30150
002
90
2
X
2,808.00
X
30160
004
90
2
X
2,280.71
X
30160
003
90
2
X
2,309.36
X
30160
002
90
2
X
2,455.81
X
30160
001
90
2
X
2,519.36
X
30200
004
0
2
X
114.09
96.98
30200
002
0
2
X
118.53
100.95
30200
003
0
2
X
98.27
83.89
30200
001
0
2
X
120.98
102.62
30210
002
10
2
X
144.23
130.30
30210
003
10
2
X
138.50
125.49
30210
004
10
2
X
137.05
124.23
30210
001
10
2
X
145.58
131.53
30220
001
10
2
X
355.32
X
30220
004
10
2
X
325.55
X
30220
003
10
2
X
329.58
X
30220
002
10
2
X
350.34
X
30300
004
10
2
X
154.54
X
30300
002
10
2
X
166.37
X
30300
001
10
2
X
167.26
X
30300
003
10
2
X
159.19
X
30310
002
10
2
X
405.31
X
30310
003
10
2
X
386.86
X
30310
004
10
2
X
382.13
X
30310
001
10
2
X
415.96
X
30320
001
90
2
X
1,020.91
X
30320
004
90
2
X
937.14
X
30320
003
90
2
X
948.83
X
30320
002
90
2
X
1,007.02
X
30400
001
90
2
X
2,498.62
X
30400
003
90
2
X
2,266.86
X
30400
002
90
2
X
2,425.16
X
30400
004
90
2
X
2,235.03
X
30410
90
2
X
*
X
30420
003
90
2
X
3,899.00
X
30420
002
90
2
X
4,170.68
X
30420
001
90
2
X
4,295.37
X
30420
004
90
2
X
3,843.79
X
30430
001
90
2
X
1,114.30
X
30430
004
90
2
X
1,033.25
X
30430
003
90
2
X
1,045.45
X
30430
002
90
2
X
1,100.93
X
30435
004
90
2
X
1,419.78
X
30435
002
90
2
X
1,527.40
X
30435
003
90
2
X
1,437.22
X
30435
001
90
2
X
1,549.20
X
30450
003
90
2
X
2,309.36
X
30450
002
90
2
X
2,487.14
X
30450
004
90
2
X
2,280.71
X
30450
001
90
2
X
2,529.98
X
30460
001
90
2
X
2,131.91
X
30460
004
90
2
X
1,956.54
X
30460
003
90
2
X
1,980.58
X
30460
002
90
2
X
2,102.45
X
30462
001
90
2
X
4,265.46
X
30462
002
90
2
X
4,206.57
X
30462
003
90
2
X
3,962.21
X
30462
004
90
2
X
3,914.27
X
30465
003
90
2
X
1,830.87
X
30465
002
90
2
X
1,830.87
X
30465
004
90
2
X
1,830.87
X
30465
001
90
2
X
2,040.12
X
30468
001
0
2
X
4,192.45
237.84
30468
004
0
2
X
3,647.08
218.29
30468
003
0
2
X
3,647.08
218.29
30468
002
0
2
X
3,647.08
218.29
30469
004
0
2
X
2,812.90
172.59
30469
003
0
2
X
2,812.90
172.59
30469
002
0
2
X
2,812.90
172.59
30469
001
0
2
X
3,210.19
187.84
30520
002
90
2
X
1,607.60
X
30520
003
90
2
X
1,498.39
X
30520
004
90
2
X
1,479.36
X
30520
001
90
2
X
1,633.85
X
30540
001
90
2
X
1,657.92
X
30540
004
90
2
X
1,522.88
X
30540
003
90
2
X
1,541.60
X
30540
002
90
2
X
1,635.24
X
30545
001
90
2
X
2,531.05
X
30545
004
90
2
X
2,329.17
X
30545
002
90
2
X
2,497.57
X
30545
003
90
2
X
2,358.46
X
30560
004
10
2
X
165.94
X
30560
002
10
2
X
172.53
X
30560
003
10
2
X
167.16
X
30560
001
10
2
X
202.44
X
30580
004
90
2
X
1,368.59
X
30580
001
90
2
X
1,488.22
X
30580
003
90
2
X
1,385.71
X
30580
002
90
2
X
1,468.24
X
30600
003
90
2
X
1,045.45
X
30600
002
90
2
X
1,247.39
X
30600
001
90
2
X
1,114.30
X
30600
004
90
2
X
1,033.25
X
30620
001
90
2
X
1,734.98
X
30620
002
90
2
X
1,706.02
X
30620
003
90
2
X
1,585.74
X
30620
004
90
2
X
1,565.42
X
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