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2024 Workers' Compensation Part B Fee Schedule

42235-43261

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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
42235   003 90 2 X 1,413.80 X
42235   002 90 2 X 1,490.96 X
42235   004 90 2 X 1,396.93 X
42235   001 90 2 X 1,509.59 X
42260   004 90 2 X 883.63 X
42260   002 90 2 X 1,203.64 X
42260   003 90 2 X 894.49 X
42260   001 90 2 X 1,269.49 X
42280   004 10 2 X 374.16 X
42280   003 10 2 X 379.00 X
42280   002 10 2 X 403.10 X
42280   001 10 2 X 408.86 X
42281   003 10 2 X 353.86 X
42281   002 10 2 X 410.12 X
42281   004 10 2 X 349.63 X
42281   001 10 2 X 379.65 X
42299     YYY 2 X # X
42300   004 10 2 X 306.37 X
42300   001 10 2 X 330.30 X
42300   003 10 2 X 309.84 X
42300   002 10 2 X 326.36 X
42305   003 90 2 X 746.24 X
42305   002 90 2 X 769.53 X
42305   004 90 2 X 834.08 X
42305   001 90 2 X 893.86 X
42310   004 10 2 X 274.88 X
42310   003 10 2 X 278.04 X
42310   002 10 2 X 286.60 X
42310   001 10 2 X 295.89 X
42320   003 10 2 X 454.23 X
42320   002 10 2 X 481.87 X
42320   004 10 2 X 448.80 X
42320   001 10 2 X 488.49 X
42330   002 10 2 X 401.67 337.66
42330   003 10 2 X 389.53 327.92
42330   001 10 2 X 403.54 339.94
42330   004 10 2 X 392.45 330.68
42335   002 90 2 X 815.07 X
42335   003 90 2 X 794.23 X
42335   001 90 2 X 820.45 X
42335   004 90 2 X 798.43 X
42340   002 90 2 X 1,015.84 X
42340   003 90 2 X 982.76 X
42340   001 90 2 X 1,030.18 X
42340   004 90 2 X 944.66 X
42400   004 0 2 X 175.43 X
42400   003 0 2 X 176.34 X
42400   002 0 2 X 185.72 X
42400   001 0 2 X 188.56 X
42405   004 10 2 X 515.74 X
42405   001 10 2 X 554.98 X
42405   003 10 2 X 521.56 X
42405   002 10 2 X 548.48 X
42408   002 90 2 X 1,273.99 X
42408   003 90 2 X 1,253.25 X
42408   004 90 2 X 828.93 X
42408   001 90 2 X 900.19 X
42409   004 90 2 X 597.99 X
42409   001 90 2 X 653.31 X
42409   003 90 2 X 605.46 X
42409   002 90 2 X 643.96 X
42410   001 90 2 X 2,165.04 X
42410   004 90 2 X 2,037.85 X
42410   003 90 2 X 1,739.56 X
42410   002 90 2 X 2,008.79 X
42415   001 90 2 X 3,431.38 X
42415   004 90 2 X 3,144.67 X
42415   002 90 2 X 3,382.86 X
42415   003 90 2 X 3,182.21 X
42420   002 90 2 X 3,915.90 X
42420   003 90 2 X 3,686.56 X
42420   004 90 2 X 3,642.88 X
42420   001 90 2 X 3,971.24 X
42425   002 90 2 X 2,765.02 X
42425   003 90 2 X 2,646.04 X
42425   001 90 2 X 2,805.85 X
42425   004 90 2 X 2,632.96 X
42426   004 90 2 X 4,849.57 X
42426   001 90 2 X 5,350.54 X
42426   002 90 2 X 5,265.03 X
42426   003 90 2 X 4,910.47 X
42440   001 90 2 X 1,793.58 X
42440   003 90 2 X 1,619.84 X
42440   002 90 2 X 1,733.64 X
42440   004 90 2 X 1,599.74 X
42450   001 90 2 X 1,283.73 X
42450   004 90 2 X 840.49 X
42450   003 90 2 X 1,094.40 X
42450   002 90 2 X 1,114.88 X
42500   002 90 2 X 1,017.94 X
42500   003 90 2 X 954.82 X
42500   001 90 2 X 1,056.35 X
42500   004 90 2 X 942.96 X
42505   004 90 2 X 1,449.86 X
42505   001 90 2 X 1,594.59 X
42505   003 90 2 X 1,468.24 X
42505   002 90 2 X 1,749.19 X
42507   001 90 2 X 1,884.05 X
42507   004 90 2 X 1,164.51 X
42507   003 90 2 X 1,178.28 X
42507   002 90 2 X 1,876.27 X
42509   003 90 2 X 2,051.03 X
42509   002 90 2 X 2,183.97 X
42509   004 90 2 X 2,027.76 X
42509   001 90 2 X 2,216.17 X
42510   002 90 2 X 1,795.79 X
42510   003 90 2 X 1,688.48 X
42510   001 90 2 X 1,821.67 X
42510   004 90 2 X 1,667.71 X
42550   004 0 2 X 167.36 X
42550   002 0 2 X 176.54 X
42550   003 0 2 X 169.25 X
42550   001 0 2 X 178.28 X
42600   001 90 2 X 1,232.50 X
42600   004 90 2 X 920.46 X
42600   002 90 2 X 989.71 X
42600   003 90 2 X 931.63 X
42650   003 0 2 X 125.36 105.76
42650   002 0 2 X 153.25 131.73
42650   004 0 2 X 123.97 104.70
42650   001 0 2 X 135.34 115.92
42660   002 0 2 X 185.47 X
42660   003 0 2 X 137.91 X
42660   004 0 2 X 175.43 X
42660   001 0 2 X 153.05 X
42665   002 90 2 X 640.67 X
42665   003 90 2 X 492.18 X
42665   001 90 2 X 530.32 X
42665   004 90 2 X 486.37 X
42699     YYY 2 X # X
42700   001 10 2 X 281.59 X
42700   004 10 2 X 261.10 X
42700   003 10 2 X 264.16 X
42700   002 10 2 X 270.70 X
42720   001 10 2 X 528.61 X
42720   004 10 2 X 486.98 X
42720   002 10 2 X 521.68 X
42720   003 10 2 X 492.76 X
42725   004 90 2 X 1,301.56 X
42725   001 90 2 X 1,406.95 X
42725   002 90 2 X 1,389.29 X
42725   003 90 2 X 1,316.61 X
42800   001 10 2 X 249.43 207.32
42800   004 10 2 X 234.06 194.97
42800   003 10 2 X 236.40 196.98
42800   002 10 2 X 237.58 197.49
42804   003 10 2 X 319.01 X
42804   001 10 2 X 339.24 X
42804   002 10 2 X 331.16 X
42804   004 10 2 X 322.09 X
42806   004 10 2 X 318.77 X
42806   001 10 2 X 371.85 X
42806   003 10 2 X 322.73 X
42806   002 10 2 X 362.30 X
42808   002 10 2 X 461.74 X
42808   003 10 2 X 438.95 X
42808   004 10 2 X 450.64 X
42808   001 10 2 X 475.64 X
42809   002 10 2 X 292.34 X
42809   003 10 2 X 278.94 X
42809   004 10 2 X 275.80 X
42809   001 10 2 X 295.56 X
42810   004 90 2 X 701.58 X
42810   001 90 2 X 772.86 X
42810   003 90 2 X 710.15 X
42810   002 90 2 X 760.66 X
42815   002 90 2 X 1,980.42 X
42815   003 90 2 X 1,879.26 X
42815   001 90 2 X 2,014.02 X
42815   004 90 2 X 1,764.32 X
42820   004 90 2 X 726.41 X
42820   001 90 2 X 789.61 X
42820   003 90 2 X 735.30 X
42820   002 90 2 X 779.07 X
42821   004 90 2 X 874.54 X
42821   003 90 2 X 885.25 X
42821   002 90 2 X 904.90 X
42821   001 90 2 X 956.18 X
42825   004 90 2 X 637.36 X
42825   001 90 2 X 694.98 X
42825   003 90 2 X 645.02 X
42825   002 90 2 X 685.27 X
42826   001 90 2 X 842.44 X
42826   003 90 2 X 777.39 X
42826   002 90 2 X 829.84 X
42826   004 90 2 X 767.72 X
42830   002 90 2 X 542.64 X
42830   003 90 2 X 482.45 X
42830   004 90 2 X 476.79 X
42830   001 90 2 X 552.50 X
42831   001 90 2 X 585.45 X
42831   004 90 2 X 537.75 X
42831   003 90 2 X 544.33 X
42831   002 90 2 X 577.52 X
42835   001 90 2 X 462.24 X
42835   004 90 2 X 429.84 X
42835   003 90 2 X 435.15 X
42835   002 90 2 X 456.99 X
42836   001 90 2 X 694.92 X
42836   004 90 2 X 637.58 X
42836   002 90 2 X 685.30 X
42836   003 90 2 X 645.41 X
42842   001 90 2 X 1,600.22 X
42842   004 90 2 X 1,549.92 X
42842   002 90 2 X 1,545.34 X
42842   003 90 2 X 1,515.82 X
42844   001 90 2 X 2,790.69 X
42844   004 90 2 X 2,560.44 X
42844   002 90 2 X 2,752.01 X
42844   003 90 2 X 2,591.46 X
42845   004 90 2 X 4,402.48 X
42845   001 90 2 X 4,800.41 X
42845   003 90 2 X 4,455.83 X
42845   002 90 2 X 4,733.41 X
42860   003 90 2 X 512.95 X
42860   002 90 2 X 524.28 X
42860   004 90 2 X 436.10 X
42860   001 90 2 X 475.01 X
42870   002 90 2 X 853.12 X
42870   003 90 2 X 812.19 X
42870   004 90 2 X 803.20 X
42870   001 90 2 X 861.90 X
42890   004 90 2 X 2,237.60 X
42890   001 90 2 X 2,431.90 X
42890   003 90 2 X 2,264.40 X
42890   002 90 2 X 2,088.11 X
42892   003 90 2 X 3,442.91 X
42892   002 90 2 X 2,891.73 X
42892   004 90 2 X 2,695.27 X
42892   001 90 2 X 2,931.34 X
42894   003 90 2 X 4,026.71 X
42894   002 90 2 X 4,266.79 X
42894   004 90 2 X 3,978.85 X
42894   001 90 2 X 4,324.85 X
42900   001 10 2 X 1,092.54 X
42900   004 10 2 X 1,002.87 X
42900   002 10 2 X 1,077.41 X
42900   003 10 2 X 1,015.08 X
42950   001 90 2 X 2,104.84 X
42950   004 90 2 X 1,915.07 X
42950   002 90 2 X 2,072.83 X
42950   003 90 2 X 1,997.69 X
42953   004 90 2 X 1,597.40 X
42953   001 90 2 X 1,746.86 X
42953   002 90 2 X 1,721.37 X
42953   003 90 2 X 1,616.32 X
42955   003 90 2 X 1,073.62 X
42955   002 90 2 X 1,131.32 X
42955   004 90 2 X 1,061.53 X
42955   001 90 2 X 1,145.35 X
42960   004 10 2 X 360.86 X
42960   001 10 2 X 387.69 X
42960   002 10 2 X 390.58 X
42960   003 10 2 X 365.00 X
42961   004 90 2 X 740.40 X
42961   002 90 2 X 781.70 X
42961   003 90 2 X 748.52 X
42961   001 90 2 X 789.71 X
42962   001 90 2 X 1,494.53 X
42962   004 90 2 X 1,370.05 X
42962   003 90 2 X 1,386.86 X
42962   002 90 2 X 1,473.59 X
42970   003 90 2 X 517.70 X
42970   002 90 2 X 495.88 X
42970   004 90 2 X 576.46 X
42970   001 90 2 X 462.17 X
42971   004 90 2 X 910.62 X
42971   003 90 2 X 921.09 X
42971   002 90 2 X 969.45 X
42971   001 90 2 X 981.14 X
42972   004 90 2 X 1,222.29 X
42972   001 90 2 X 1,336.13 X
42972   003 90 2 X 1,236.51 X
42972   002 90 2 X 1,316.74 X
42975   003 0 3 X 134.42 X
42975   002 0 3 X 134.42 X
42975   001 0 3 X 146.44 X
42975   004 0 3 X 134.42 X
42999     YYY 2 X # X
43020   001 90 2 X 2,107.41 X
43020   004 90 2 X 1,547.05 X
43020   002 90 2 X 1,660.61 X
43020   003 90 2 X 1,565.92 X
43030   001 90 2 X 1,985.71 X
43030   004 90 2 X 1,911.97 X
43030   003 90 2 X 1,820.71 X
43030   002 90 2 X 1,953.63 X
43045   002 90 2 X 3,758.93 X
43045   003 90 2 X 3,519.20 X
43045   001 90 2 X 3,817.14 X
43045   004 90 2 X 3,479.47 X
43100   002 90 2 X 2,791.67 X
43100   003 90 2 X 2,407.05 X
43100   004 90 2 X 1,611.69 X
43100   001 90 2 X 1,762.04 X
43101   003 90 2 X 2,770.53 X
43101   002 90 2 X 2,958.98 X
43101   001 90 2 X 3,004.76 X
43101   004 90 2 X 2,739.51 X
43107   004 90 2 X 5,585.08 X
43107   003 90 2 X 5,650.23 X
43107   002 90 2 X 6,073.10 X
43107   001 90 2 X 6,175.61 X
43108   004 90 2 X 6,216.58 X
43108   001 90 2 X 7,331.34 X
43108   003 90 2 X 6,289.43 X
43108   002 90 2 X 7,266.25 X
43112   004 90 2 X 5,905.83 X
43112   002 90 2 X 6,065.63 X
43112   003 90 2 X 5,885.61 X
43112   001 90 2 X 6,212.69 X
43113   004 90 2 X 6,216.58 X
43113   001 90 2 X 7,331.34 X
43113   003 90 2 X 6,289.43 X
43113   002 90 2 X 7,266.25 X
43116   003 90 2 X 6,289.43 X
43116   002 90 2 X 7,266.25 X
43116   004 90 2 X 6,216.58 X
43116   001 90 2 X 7,331.34 X
43117   001 90 2 X 7,331.34 X
43117   004 90 2 X 6,216.58 X
43117   002 90 2 X 7,266.25 X
43117   003 90 2 X 6,289.43 X
43118   004 90 2 X 6,216.58 X
43118   003 90 2 X 6,289.43 X
43118   002 90 2 X 7,266.25 X
43118   001 90 2 X 7,331.34 X
43121   002 90 2 X 5,791.27 X
43121   003 90 2 X 5,581.51 X
43121   004 90 2 X 5,604.53 X
43121   001 90 2 X 6,587.99 X
43122   002 90 2 X 5,791.27 X
43122   003 90 2 X 5,581.51 X
43122   001 90 2 X 6,587.99 X
43122   004 90 2 X 5,604.53 X
43123   001 90 2 X 7,331.34 X
43123   002 90 2 X 7,266.25 X
43123   003 90 2 X 6,289.43 X
43123   004 90 2 X 6,216.58 X
43124   004 90 2 X 5,585.08 X
43124   002 90 2 X 6,073.10 X
43124   003 90 2 X 5,650.23 X
43124   001 90 2 X 6,175.61 X
43130   004 90 2 X 2,456.18 X
43130   003 90 2 X 2,427.16 X
43130   002 90 2 X 2,545.26 X
43130   001 90 2 X 2,586.33 X
43135   002 90 2 X 3,244.91 X
43135   003 90 2 X 3,028.86 X
43135   001 90 2 X 3,297.18 X
43135   004 90 2 X 2,993.98 X
43180   001 90 2 X 917.98 1,011.74
43180   004 90 2 X 838.48 918.60
43180   003 90 2 X 838.48 918.60
43180   002 90 2 X 838.48 918.60
43191   004 0 2 X 203.60 X
43191   002 0 2 X 203.60 X
43191   003 0 2 X 203.60 X
43191   001 0 2 X 222.88 X
43192   001 0 3 X 265.75 X
43192   002 0 3 X 243.12 X
43192   003 0 3 X 243.12 X
43192   004 0 3 X 243.12 X
43193   004 0 3 X 290.09 X
43193   001 0 3 X 316.51 X
43193   003 0 3 X 290.09 X
43193   002 0 3 X 290.09 X
43194   002 0 3 X 264.62 X
43194   003 0 3 X 264.62 X
43194   004 0 3 X 264.62 X
43194   001 0 3 X 286.89 X
43195   001 0 3 X 317.12 X
43195   004 0 3 X 290.62 X
43195   003 0 3 X 290.62 X
43195   002 0 3 X 290.62 X
43196   003 0 3 X 319.22 X
43196   002 0 3 X 319.22 X
43196   004 0 3 X 319.22 X
43196   001 0 3 X 349.19 X
43197   002 0 2 X 285.54 130.31
43197   003 0 2 X 285.54 130.31
43197   001 0 2 X 322.00 141.14
43197   004 0 2 X 285.54 130.31
43198   004 0 3 X 319.49 155.20
43198   001 0 3 X 359.39 167.98
43198   002 0 3 X 319.49 155.20
43198   003 0 3 X 319.49 155.20
43200   002 0 2 X 553.00 X
43200   003 0 2 X 563.68 X
43200   001 0 2 X 703.13 X
43200   004 0 2 X 552.92 X
43201   001 0 3 X 584.00 301.48
43201   003 0 3 X 512.92 272.55
43201   002 0 3 X 512.92 272.55
43201   004 0 3 X 512.92 272.55
43202   001 0 3 X 703.02 X
43202   004 0 3 X 621.45 X
43202   002 0 3 X 635.32 X
43202   003 0 3 X 622.92 X
43204   001 0 3 X 1,128.33 X
43204   004 0 3 X 1,060.83 X
43204   002 0 3 X 1,152.56 X
43204   003 0 3 X 1,137.38 X
43205   004 0 3 X 640.01 X
43205   001 0 3 X 688.03 X
43205   002 0 3 X 680.15 X
43205   003 0 3 X 647.70 X
43206     0 3 X * X
43210   004 0 3 X 664.46 X
43210   001 0 3 X 720.08 X
43210   002 0 3 X 664.46 X
43210   003 0 3 X 664.46 X
43211   001 0 3 X 434.69 X
43211   003 0 3 X 397.65 X
43211   002 0 3 X 397.65 X
43211   004 0 3 X 397.65 X
43212   001 0 3 X 344.92 X
43212   003 0 3 X 314.77 X
43212   002 0 3 X 314.77 X
43212   004 0 3 X 314.77 X
43213   002 0 3 X 1,879.76 442.66
43213   003 0 3 X 1,879.76 442.66
43213   001 0 3 X 2,158.27 483.95
43213   004 0 3 X 1,879.76 442.66
43214   001 0 3 X 350.23 X
43214   004 0 3 X 320.06 X
43214   003 0 3 X 320.06 X
43214   002 0 3 X 320.06 X
43215   003 0 3 X 799.73 X
43215   002 0 3 X 817.79 X
43215   004 0 3 X 781.73 X
43215   001 0 3 X 965.16 X
43216   004 0 3 X 1,033.52 X
43216   001 0 3 X 1,095.31 X
43216   003 0 3 X 990.23 X
43216   002 0 3 X 1,132.79 X
43217   001 0 3 X 1,095.31 X
43217   004 0 3 X 1,033.52 X
43217   002 0 3 X 1,132.79 X
43217   003 0 3 X 990.23 X
43220   002 0 3 X 621.02 X
43220   003 0 3 X 559.23 X
43220   004 0 3 X 581.78 X
43220   001 0 3 X 677.97 X
43226   003 0 3 X 586.76 X
43226   002 0 3 X 623.72 X
43226   001 0 3 X 632.52 X
43226   004 0 3 X 579.09 X
43227   003 0 3 X 899.40 X
43227   002 0 3 X 1,095.07 X
43227   001 0 3 X 1,132.79 X
43227   004 0 3 X 1,101.93 X
43229   001 0 3 X 1,273.34 370.74
43229   002 0 3 X 1,112.92 338.22
43229   003 0 3 X 1,112.92 338.22
43229   004 0 3 X 1,112.92 338.22
43231   002 0 3 X 527.34 X
43231   003 0 3 X 527.34 X
43231   004 0 3 X 527.34 X
43231   001 0 3 X 578.87 X
43232   001 0 3 X 672.98 X
43232   004 0 3 X 612.59 X
43232   003 0 3 X 612.59 X
43232   002 0 3 X 612.59 X
43233   002 0 3 X 379.96 X
43233   003 0 3 X 379.96 X
43233   004 0 3 X 379.96 X
43233   001 0 3 X 415.47 X
43235   001 0 2 X 758.84 X
43235   004 0 2 X 717.69 X
43235   002 0 2 X 726.55 X
43235   003 0 2 X 704.12 X
43236   002 0 3 X 600.89 340.06
43236   003 0 3 X 600.89 340.06
43236   004 0 3 X 600.89 340.06
43236   001 0 3 X 678.80 372.22
43237   003 0 3 X 461.08 X
43237   002 0 3 X 461.08 X
43237   004 0 3 X 461.08 X
43237   001 0 3 X 503.15 X
43238   003 0 3 X 572.51 X
43238   002 0 3 X 572.51 X
43238   004 0 3 X 572.51 X
43238   001 0 3 X 621.23 X
43239   003 0 3 X 786.12 X
43239   002 0 3 X 865.84 X
43239   004 0 3 X 834.94 X
43239   001 0 3 X 917.19 X
43240   003 0 3 X 931.14 X
43240   002 0 3 X 931.14 X
43240   004 0 3 X 931.14 X
43240   001 0 3 X 1,021.20 X
43241   001 0 3 X 1,102.81 X
43241   002 0 3 X 963.91 X
43241   003 0 3 X 1,014.94 X
43241   004 0 3 X 1,032.87 X
43242   001 0 3 X 733.41 X
43242   004 0 3 X 670.22 X
43242   002 0 3 X 670.22 X
43242   003 0 3 X 670.22 X
43243   002 0 3 X 1,196.70 X
43243   003 0 3 X 1,200.39 X
43243   001 0 3 X 1,185.14 X
43243   004 0 3 X 1,148.26 X
43244   002 0 3 X 823.94 X
43244   003 0 3 X 784.99 X
43244   001 0 3 X 833.32 X
43244   004 0 3 X 775.58 X
43245   004 0 3 X 1,122.83 X
43245   002 0 3 X 1,163.74 X
43245   003 0 3 X 1,151.30 X
43245   001 0 3 X 1,179.24 X
43246   004 0 3 X 1,166.53 X
43246   001 0 3 X 1,204.20 X
43246   003 0 3 X 1,163.65 X
43246   002 0 3 X 1,190.76 X
43247   004 0 3 X 964.44 X
43247   001 0 3 X 1,075.47 X
43247   003 0 3 X 932.90 X
43247   002 0 3 X 980.75 X
43248   001 0 3 X 796.32 X
43248   004 0 3 X 728.96 X
43248   003 0 3 X 738.40 X
43248   002 0 3 X 785.13 X
43249   003 0 3 X 693.94 X
43249   002 0 3 X 761.89 X
43249   004 0 3 X 710.73 X
43249   001 0 3 X 753.34 X
43250   004 0 3 X 1,225.83 X
43250   001 0 3 X 1,288.99 X
43250   003 0 3 X 1,259.15 X
43250   002 0 3 X 1,296.93 X
43251   004 0 3 X 1,225.83 X
43251   002 0 3 X 1,296.93 X
43251   001 0 3 X 1,288.99 X
43251   003 0 3 X 1,259.15 X
43252     0 3 X * X
43253   004 0 3 X 440.73 X
43253   003 0 3 X 440.73 X
43253   002 0 3 X 440.73 X
43253   001 0 3 X 482.05 X
43254   004 0 3 X 457.95 X
43254   002 0 3 X 457.95 X
43254   003 0 3 X 457.95 X
43254   001 0 3 X 501.02 X
43255   003 0 3 X 1,252.57 X
43255   002 0 3 X 1,303.83 X
43255   004 0 3 X 1,202.52 X
43255   001 0 3 X 1,306.73 X
43257   004 0 3 X 618.64 X
43257   003 0 3 X 618.64 X
43257   002 0 3 X 618.64 X
43257   001 0 3 X 675.64 X
43259     0 3 X * X
43260   003 0 2 X 1,219.26 X
43260   002 0 2 X 1,267.54 X
43260   004 0 2 X 1,186.59 X
43260   001 0 2 X 1,311.36 X
43261   001 0 3 X 1,321.70 X
43261   002 0 3 X 1,298.78 X
43261   003 0 3 X 1,229.37 X
43261   004 0 3 X 1,216.75 X