2021 Workers' Compensation Part B Fee Schedule …

2023 Workers' Compensation Part B Fee Schedule 67882-69643

CPT/HCPC Code

67882 67882 67882 67882 67900 67900 67900 67900 67901 67901 67901 67901 67902 67902 67902 67902 67903 67903 67903 67903 67904 67904 67904 67904 67906 67906 67906 67906 67908 67908 67908 67908 67909 67909 67909 67909 67911 67911 67911 67911

Modifier

Medicare Location

001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004

Global Surgery Indicator

90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Multiple Surgery Indicator

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Prevailing Charge Amount

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

Fee Schedule Amount

1,451.64 1,445.14 1,401.65 1,411.77 906.55 896.35 853.76 843.30 1,946.04 2,020.87 1,978.30 1,639.21 2,151.03 1,838.86 2,009.40 1,708.56 2,115.87 1,876.79 1,764.37 1,740.68 1,977.62 2,022.81 2,004.85 1,934.25 1,329.36 1,313.71 1,248.72 1,233.49 1,982.66 1,972.99 1,930.79 1,924.06 1,234.50 1,223.75 1,178.78 1,168.99 1,666.74 1,641.47 1,536.07 1,515.53

Site of Service Amount

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

CPT/HCPC Code

67912 67912 67912 67912 67914 67914 67914 67914 67915 67915 67915 67915 67916 67916 67916 67916 67917 67917 67917 67917 67921 67921 67921 67921 67922 67922 67922 67922 67923 67923 67923 67923 67924 67924 67924 67924 67930 67930 67930 67930 67935 67935 67935 67935

Modifier

Medicare Location

001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004

Global Surgery Indicator

90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 10 10 10 90 90 90 90

Multiple Surgery Indicator

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Prevailing Charge Amount

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

Fee Schedule Amount

2,217.09 1,934.68 1,934.68 1,934.68 1,488.17 1,548.25 1,383.14 1,378.13 465.59 462.96 445.12 427.30 1,387.56 1,267.33 1,199.15 1,183.57 1,659.45 1,675.62 1,525.97 1,536.86 1,219.82 1,411.04 1,252.58 1,262.72 416.34 439.85 388.53 423.05 1,442.54 1,366.29 1,294.43 1,073.62 1,436.17 1,417.76 1,340.96 1,323.47 557.64 515.46 495.50 490.10 1,075.19 1,283.21 1,226.82 1,003.28

Site of Service Amount

931.11 840.71 840.71 840.71

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

CPT/HCPC Code

67938 67938 67938 67938 67950 67950 67950 67950 67961 67961 67961 67961 67966 67966 67966 67966 67971 67971 67971 67971 67973 67973 67973 67973 67974 67974 67974 67974 67975 67975 67975 67975 67999 68020 68020 68020 68020 68040 68100 68100 68100 68100 68110 68110

Modifier

Medicare Location

001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004

001 002 003 004

001 002 003 004 001 002

Global Surgery Indicator

10 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 10 10 0 0 0 0 0 10 10

Multiple Surgery Indicator

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Prevailing Charge Amount

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

Fee Schedule Amount

194.12 192.25 184.66 191.29 1,969.35 1,959.58 1,860.26 1,926.48 1,931.52 1,907.36 1,838.08 1,874.12 2,072.07 2,064.44 2,042.38 2,030.37 2,433.81 2,283.47 2,221.11 2,062.04 3,073.81 3,035.36 2,994.26 2,670.69 2,941.07 2,904.16 2,750.22 2,715.08 1,062.60 1,051.36 977.92 1,324.60

# 176.11 175.11 169.52 169.55

* 327.55 320.11 307.71 311.72 401.08 379.51

Site of Service Amount

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 151.56 151.06 146.37 146.54 X X X X X 319.55 303.11

CPT/HCPC Code

68110 68110 68115 68115 68115 68115 68130 68130 68130 68130 68135 68135 68135 68135 68200 68200 68200 68200 68320 68320 68320 68320 68325 68325 68325 68325 68326 68326 68326 68326 68328 68328 68328 68328 68330 68330 68330 68330 68335 68335 68335 68335 68340 68340

Modifier

Medicare Location

003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002

Global Surgery Indicator

10 10 10 10 10 10 90 90 90 90 10 10 10 10 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Multiple Surgery Indicator

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Prevailing Charge Amount

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

Fee Schedule Amount

363.82 362.33 469.86 458.38 436.27 431.00 783.90 777.60 751.25 744.84 274.57 239.89 233.77 232.07 177.30 177.05 175.06 192.98 1,666.93 1,659.47 1,572.70 1,226.83 1,976.38 1,966.17 1,689.36 1,667.34 1,696.94 2,452.00 1,880.38 2,405.52 2,090.66 2,061.66 1,940.68 1,915.43 1,866.98 1,821.93 1,081.17 1,067.12 1,908.20 2,578.13 1,773.23 1,749.79 768.61 760.03

Site of Service Amount

291.14 290.55

X X X X X X X X X X X X 133.34 133.06 131.78 145.69 X X X X X X X X X X X X X X X X X X X X X X X X X X

CPT/HCPC Code

68340 68340 68360 68360 68360 68360 68362 68362 68362 68362 68371 68371 68371 68371 68399 68400 68400 68400 68400 68420 68420 68420 68420 68440 68440 68440 68440 68500 68500 68500 68500 68505 68505 68505 68505 68510 68510 68510 68510 68520 68520 68520 68520 68525

Modifier

Medicare Location

003 004 001 002 003 004 001 002 003 004 001 002 003 004

001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001 002 003 004 001

Global Surgery Indicator

90 90 90 90 90 90 90 90 90 90 10 10 10 10 YYY 10 10 10 10 10 10 10 10 10 10 10 10 90 90 90 90 90 90 90 90 0 0 0 0 90 90 90 90 0

Multiple Surgery Indicator

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Prevailing Charge Amount

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

Fee Schedule Amount

724.15 715.37 1,111.32 1,105.54 1,081.19 977.34 1,603.44 1,591.91 1,544.06 1,530.05 805.96 728.53 728.53 728.53

# 287.25 289.03 271.51 282.37 352.83 349.34 335.02 331.25 158.50 157.06 150.69 151.08 2,022.31 1,996.77 1,891.23 1,868.77 2,086.95 2,063.06 1,963.37 1,939.26 917.17 667.62 860.19 635.33 1,787.51 1,875.60 1,837.31 1,857.79 889.44

Site of Service Amount

X X X X X X X X X X X X X X X X X X X X X X X 123.54 122.27 117.44 118.18 X X X X X X X X X X X X X X X X X

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