12
CPT/HCPC Code Modifier Medicare Location Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount Site of Service Amount 59120 3 90 2 X 1,464.39 X 59120 2 90 2 X 1,583.49 X 59120 1 90 2 X 1,612.31 X 59120 4 90 2 X 1,616.49 X 59121 4 90 2 X 1,184.56 X 59121 3 90 2 X 1,198.26 X 59121 2 90 2 X 1,286.08 X 59121 1 90 2 X 1,307.37 X 59130 4 90 2 X 1,281.10 X 59130 3 90 2 X 1,296.41 X 59130 2 90 2 X 1,373.91 X 59130 1 90 2 X 1,392.62 X 59135 4 90 2 X 2,112.71 X 59135 3 90 2 X 2,138.00 X 59135 2 90 2 X 2,265.43 X 59135 1 90 2 X 2,296.27 X 59136 4 90 2 X 1,443.22 X 59136 3 90 2 X 1,459.57 X 59136 2 90 2 X 1,571.17 X 59136 1 90 2 X 1,598.30 X 59140 4 90 2 X 881.55 X 59140 3 90 2 X 892.57 X 59140 2 90 2 X 939.75 X 59140 1 90 2 X 951.13 X 59150 4 90 2 X 1,051.39 X 59150 3 90 2 X 1,063.33 X 59150 2 90 2 X 1,144.52 X 59150 1 90 2 X 1,164.28 X 59151 4 90 2 X 1,444.69 X 59151 3 90 2 X 1,463.39 X 59151 2 90 2 X 1,550.60 X 59151 1 90 2 X 1,571.56 X 59160 2 10 2 X 462.83 X 59160 3 10 2 X 462.83 X 59160 4 10 2 X 462.83 X 59160 1 10 2 X 534.68 X 59200 0 2 X * X 59300 3 0 2 X 313.56 X 59300 2 0 2 X 328.11 X 59300 1 0 2 X 382.30 X 2021 Workers' Compensation Part B Fee Schedule 59120-61520

2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

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Page 1: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

59120 3 90 2 X 1,464.39 X

59120 2 90 2 X 1,583.49 X

59120 1 90 2 X 1,612.31 X

59120 4 90 2 X 1,616.49 X

59121 4 90 2 X 1,184.56 X

59121 3 90 2 X 1,198.26 X

59121 2 90 2 X 1,286.08 X

59121 1 90 2 X 1,307.37 X

59130 4 90 2 X 1,281.10 X

59130 3 90 2 X 1,296.41 X

59130 2 90 2 X 1,373.91 X

59130 1 90 2 X 1,392.62 X

59135 4 90 2 X 2,112.71 X

59135 3 90 2 X 2,138.00 X

59135 2 90 2 X 2,265.43 X

59135 1 90 2 X 2,296.27 X

59136 4 90 2 X 1,443.22 X

59136 3 90 2 X 1,459.57 X

59136 2 90 2 X 1,571.17 X

59136 1 90 2 X 1,598.30 X

59140 4 90 2 X 881.55 X

59140 3 90 2 X 892.57 X

59140 2 90 2 X 939.75 X

59140 1 90 2 X 951.13 X

59150 4 90 2 X 1,051.39 X

59150 3 90 2 X 1,063.33 X

59150 2 90 2 X 1,144.52 X

59150 1 90 2 X 1,164.28 X

59151 4 90 2 X 1,444.69 X

59151 3 90 2 X 1,463.39 X

59151 2 90 2 X 1,550.60 X

59151 1 90 2 X 1,571.56 X

59160 2 10 2 X 462.83 X

59160 3 10 2 X 462.83 X

59160 4 10 2 X 462.83 X

59160 1 10 2 X 534.68 X

59200 0 2 X * X

59300 3 0 2 X 313.56 X

59300 2 0 2 X 328.11 X

59300 1 0 2 X 382.30 X

2021 Workers' Compensation Part B Fee Schedule

59120-61520

Page 2: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

59300 4 0 2 X 401.96 X

59320 4 0 2 X 411.82 X

59320 3 0 2 X 416.51 X

59320 2 0 2 X 448.13 X

59320 1 0 2 X 455.72 X

59325 4 0 2 X 638.70 X

59325 3 0 2 X 646.31 X

59325 2 0 2 X 682.14 X

59325 1 0 2 X 690.82 X

59350 4 0 2 X 821.06 X

59350 3 0 2 X 830.37 X

59350 2 0 2 X 893.86 X

59350 1 0 2 X 909.30 X

59400 4 MMM 2 X 2,590.22 X

59400 3 MMM 2 X 2,685.48 X

59400 2 MMM 2 X 2,908.42 X

59400 1 MMM 2 X 3,046.99 X

59409 4 MMM 2 X 1,650.07 X

59409 1 MMM 2 X 2,197.35 X

59409 3 MMM 2 X 2,227.36 X

59409 2 MMM 2 X 2,397.26 X

59410 4 MMM 2 X 1,713.47 X

59410 1 MMM 2 X 2,267.67 X

59410 3 MMM 2 X 2,421.44 X

59410 2 MMM 2 X 2,606.52 X

59412 MMM 0 X * X

59414 4 MMM 2 X 267.05 X

59414 3 MMM 2 X 270.04 X

59414 2 MMM 2 X 290.63 X

59414 1 MMM 2 X 295.73 X

59425 4 MMM 0 X 668.39 545.36

59425 3 MMM 0 X 675.98 550.77

59425 2 MMM 0 X 727.36 594.83

59425 1 MMM 0 X 739.87 605.60

59426 4 MMM 0 X 1,145.63 934.65

59426 3 MMM 0 X 1,158.62 944.04

59426 2 MMM 0 X 1,246.83 1,019.55

59426 1 MMM 0 X 1,268.31 1,038.04

59430 4 MMM 2 X 218.57 X

59430 3 MMM 2 X 220.83 X

59430 2 MMM 2 X 230.05 X

59430 1 MMM 2 X 232.36 X

59510 4 MMM 2 X 3,924.75 X

59510 3 MMM 2 X 3,969.22 X

Page 3: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

59510 2 MMM 2 X 4,272.33 X

59510 1 MMM 2 X 4,346.05 X

59514 1 MMM 2 X 2,504.85 X

59514 4 MMM 2 X 2,552.25 X

59514 3 MMM 2 X 2,581.19 X

59514 2 MMM 2 X 2,778.42 X

59515 1 MMM 2 X 2,574.54 X

59515 4 MMM 2 X 2,743.29 X

59515 3 MMM 2 X 2,774.39 X

59515 2 MMM 2 X 2,985.92 X

59525 4 MMM 0 X 1,172.33 X

59525 3 MMM 0 X 1,185.08 X

59525 2 MMM 0 X 1,260.34 X

59525 1 MMM 0 X 1,278.68 X

59610 4 MMM 2 X 3,749.60 X

59610 3 MMM 2 X 3,804.45 X

59610 2 MMM 2 X 4,050.34 X

59610 1 MMM 2 X 4,248.58 X

59612 4 MMM 2 X 2,427.47 X

59612 3 MMM 2 X 2,462.68 X

59612 2 MMM 2 X 2,619.62 X

59612 1 MMM 2 X 2,746.37 X

59614 4 MMM 2 X 2,622.50 X

59614 3 MMM 2 X 2,660.67 X

59614 2 MMM 2 X 2,830.93 X

59614 1 MMM 2 X 2,968.29 X

59618 4 MMM 2 X 4,209.32 X

59618 3 MMM 2 X 4,270.94 X

59618 2 MMM 2 X 4,547.99 X

59618 1 MMM 2 X 4,771.27 X

59620 4 MMM 2 X 2,789.63 X

59620 3 MMM 2 X 2,830.24 X

59620 2 MMM 2 X 3,011.63 X

59620 1 MMM 2 X 3,157.99 X

59622 4 MMM 2 X 2,987.85 X

59622 3 MMM 2 X 3,031.39 X

59622 2 MMM 2 X 3,225.96 X

59622 1 MMM 2 X 3,382.80 X

59812 4 90 2 X 656.52 X

59812 3 90 2 X 664.39 X

59812 2 90 2 X 722.05 X

59812 1 90 2 X 736.09 X

59820 4 90 2 X 725.20 X

59820 3 90 2 X 809.57 X

Page 4: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

59820 2 90 2 X 839.33 X

59820 1 90 2 X 873.59 X

59821 4 90 2 X 671.63 X

59821 3 90 2 X 679.22 X

59821 2 90 2 X 728.71 X

59821 1 90 2 X 851.94 X

59830 4 90 2 X 970.14 X

59830 3 90 2 X 981.77 X

59830 2 90 2 X 1,040.16 X

59830 1 90 2 X 1,054.26 X

59840 4 10 2 X 599.44 X

59840 3 10 2 X 606.64 X

59840 1 10 2 X 671.21 X

59840 2 10 2 X 781.28 X

59841 4 10 2 X 680.79 X

59841 2 10 2 X 747.28 X

59841 3 10 2 X 897.45 X

59841 1 10 2 X 927.96 X

59850 4 90 2 X 908.83 X

59850 3 90 2 X 919.24 X

59850 1 90 2 X 981.61 X

59850 2 90 2 X 987.43 X

59851 4 90 2 X 950.24 X

59851 3 90 2 X 961.20 X

59851 2 90 2 X 1,032.53 X

59851 1 90 2 X 1,049.74 X

59852 4 90 2 X 1,277.36 X

59852 3 90 2 X 1,291.84 X

59852 2 90 2 X 1,390.18 X

59852 1 90 2 X 1,414.09 X

59855 4 90 2 X 830.33 X

59855 3 90 2 X 841.42 X

59855 2 90 2 X 901.31 X

59855 1 90 2 X 930.77 X

59856 4 90 2 X 1,252.83 X

59856 3 90 2 X 1,269.52 X

59856 2 90 2 X 1,360.24 X

59856 1 90 2 X 1,405.00 X

59857 4 90 2 X 1,523.78 X

59857 3 90 2 X 1,544.07 X

59857 2 90 2 X 1,654.20 X

59857 1 90 2 X 1,708.43 X

59866 3 90 2 X 642.28 X

59866 4 90 2 X 642.28 X

Page 5: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

59866 2 90 2 X 659.99 X

59866 1 90 2 X 736.57 X

59870 4 90 2 X 676.22 X

59870 3 90 2 X 683.93 X

59870 2 90 2 X 736.02 X

59870 1 90 2 X 748.70 X

59871 2 10 2 X 323.26 X

59871 3 10 2 X 323.26 X

59871 4 10 2 X 323.26 X

59871 1 10 2 X 372.73 X

59897 YYY 2 X # X

59898 YYY 2 X # X

59899 YYY 2 X # X

60000 4 10 2 X 199.59 X

60000 3 10 2 X 201.71 X

60000 2 10 2 X 220.96 X

60000 1 10 2 X 230.88 X

60100 4 0 2 X 198.96 151.04

60100 3 0 2 X 202.69 154.08

60100 2 0 2 X 211.87 161.58

60100 1 0 2 X 217.87 166.26

60200 4 90 2 X 1,401.89 X

60200 3 90 2 X 1,418.06 X

60200 2 90 2 X 1,512.02 X

60200 1 90 2 X 1,534.84 X

60210 4 90 2 X 1,937.53 X

60210 3 90 2 X 1,963.94 X

60210 2 90 2 X 2,102.29 X

60210 1 90 2 X 2,200.96 X

60212 4 90 2 X 2,010.30 X

60212 3 90 2 X 2,033.56 X

60212 2 90 2 X 2,179.46 X

60212 1 90 2 X 2,302.16 X

60220 4 90 2 X 1,761.07 X

60220 3 90 2 X 1,781.82 X

60220 2 90 2 X 1,914.96 X

60220 1 90 2 X 1,947.31 X

60225 4 90 2 X 2,117.04 X

60225 3 90 2 X 2,142.15 X

60225 2 90 2 X 2,302.08 X

60225 1 90 2 X 2,380.76 X

60240 3 90 2 X 2,516.18 X

60240 4 90 2 X 2,542.03 X

60240 2 90 2 X 2,650.51 X

Page 6: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

60240 1 90 2 X 2,728.67 X

60252 4 90 2 X 2,928.76 X

60252 3 90 2 X 2,945.82 X

60252 2 90 2 X 3,024.49 X

60252 1 90 2 X 3,075.60 X

60254 3 90 2 X 3,899.26 X

60254 4 90 2 X 3,965.53 X

60254 2 90 2 X 3,972.74 X

60254 1 90 2 X 4,163.76 X

60260 4 90 2 X 1,497.58 X

60260 2 90 2 X 1,647.85 X

60260 3 90 2 X 1,782.58 X

60260 1 90 2 X 1,815.11 X

60270 4 90 2 X 2,900.83 X

60270 3 90 2 X 2,935.07 X

60270 2 90 2 X 3,149.60 X

60270 1 90 2 X 3,201.66 X

60271 4 90 2 X 2,499.53 X

60271 3 90 2 X 2,516.53 X

60271 2 90 2 X 2,750.32 X

60271 1 90 2 X 2,777.53 X

60280 4 90 2 X 1,391.22 X

60280 3 90 2 X 1,455.58 X

60280 2 90 2 X 1,491.63 X

60280 1 90 2 X 1,507.70 X

60281 4 90 2 X 1,235.51 X

60281 3 90 2 X 1,249.60 X

60281 2 90 2 X 1,332.94 X

60281 1 90 2 X 1,353.22 X

60300 2 0 2 X 147.22 72.82

60300 3 0 2 X 147.22 72.82

60300 4 0 2 X 147.22 72.82

60300 1 0 2 X 169.31 79.61

60500 4 90 2 X 2,830.01 X

60500 3 90 2 X 2,905.47 X

60500 2 90 2 X 2,976.36 X

60500 1 90 2 X 3,000.00 X

60502 4 90 2 X 2,913.34 X

60502 3 90 2 X 3,054.17 X

60502 2 90 2 X 3,144.79 X

60502 1 90 2 X 3,193.17 X

60505 3 90 2 X 2,212.72 X

60505 4 90 2 X 2,220.67 X

60505 2 90 2 X 2,356.98 X

Page 7: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

60505 1 90 2 X 2,380.41 X

60512 4 ZZZ 0 X 684.41 X

60512 3 ZZZ 0 X 693.22 X

60512 2 ZZZ 0 X 737.11 X

60512 1 ZZZ 0 X 758.93 X

60520 4 90 2 X 2,916.83 X

60520 3 90 2 X 2,950.93 X

60520 2 90 2 X 3,161.42 X

60520 1 90 2 X 3,212.48 X

60521 4 90 2 X 2,916.83 X

60521 3 90 2 X 2,950.93 X

60521 2 90 2 X 3,161.42 X

60521 1 90 2 X 3,212.48 X

60522 4 90 2 X 2,916.83 X

60522 3 90 2 X 2,950.93 X

60522 2 90 2 X 3,161.42 X

60522 1 90 2 X 3,212.48 X

60540 4 90 2 X 2,628.94 X

60540 3 90 2 X 2,659.70 X

60540 2 90 2 X 2,843.33 X

60540 1 90 2 X 2,887.83 X

60545 4 90 2 X 3,508.14 X

60545 3 90 2 X 3,523.32 X

60545 2 90 2 X 3,612.51 X

60545 1 90 2 X 3,634.08 X

60600 4 90 2 X 2,598.37 X

60600 3 90 2 X 2,628.64 X

60600 2 90 2 X 2,805.05 X

60600 1 90 2 X 2,843.85 X

60605 4 90 2 X 2,749.24 X

60605 3 90 2 X 3,120.08 X

60605 2 90 2 X 3,283.48 X

60605 1 90 2 X 3,333.48 X

60650 YYY 2 X * X

60659 YYY 2 X # X

60699 YYY 2 X # X

61000 4 0 2 X 248.57 X

61000 3 0 2 X 251.50 X

61000 2 0 2 X 267.54 X

61000 1 0 2 X 271.43 X

61001 4 0 2 X 224.59 X

61001 3 0 2 X 227.09 X

61001 2 0 2 X 241.94 X

61001 1 0 2 X 245.57 X

Page 8: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

61020 4 0 2 X 261.15 X

61020 3 0 2 X 460.46 X

61020 2 0 2 X 468.05 X

61020 1 0 2 X 469.89 X

61026 3 0 2 X 326.91 X

61026 2 0 2 X 434.85 X

61026 4 0 2 X 452.66 X

61026 1 0 2 X 454.18 X

61050 4 0 2 X 237.82 X

61050 2 0 2 X 367.63 X

61050 1 0 2 X 370.47 X

61050 3 0 2 X 395.49 X

61055 1 0 0 X 372.43 X

61055 3 0 0 X 424.51 X

61055 4 0 0 X 433.39 X

61055 2 0 0 X 441.49 X

61070 4 0 2 X 116.87 X

61070 3 0 2 X 175.64 X

61070 2 0 2 X 177.91 X

61070 1 0 2 X 178.47 X

61105 4 90 2 X 1,436.60 X

61105 3 90 2 X 1,453.52 X

61105 2 90 2 X 1,765.47 X

61105 1 90 2 X 1,776.21 X

61107 4 0 0 X 1,047.46 X

61107 3 0 0 X 1,521.31 X

61107 2 0 0 X 1,558.75 X

61107 1 0 0 X 1,609.78 X

61108 1 90 2 X 3,048.57 X

61108 3 90 2 X 3,344.22 X

61108 4 90 2 X 3,378.61 X

61108 2 90 2 X 3,464.73 X

61120 4 90 2 X 1,442.21 X

61120 3 90 2 X 1,458.64 X

61120 2 90 2 X 1,554.96 X

61120 1 90 2 X 1,626.63 X

61140 4 90 2 X 2,473.05 X

61140 3 90 2 X 2,492.01 X

61140 1 90 2 X 2,565.65 X

61140 2 90 2 X 2,603.10 X

61150 4 90 2 X 2,960.21 X

61150 3 90 2 X 3,045.74 X

61150 2 90 2 X 3,216.92 X

61150 1 90 2 X 3,270.63 X

Page 9: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

61151 3 90 2 X 1,046.19 X

61151 2 90 2 X 1,066.01 X

61151 1 90 2 X 1,091.50 X

61151 4 90 2 X 1,238.44 X

61154 1 90 2 X 3,443.37 X

61154 3 90 2 X 3,717.90 X

61154 4 90 2 X 3,735.26 X

61154 2 90 2 X 3,805.84 X

61156 4 90 2 X 3,027.75 X

61156 3 90 2 X 3,064.23 X

61156 2 90 2 X 3,308.62 X

61156 1 90 2 X 3,367.81 X

61210 4 0 0 X 1,200.16 X

61210 1 0 0 X 2,130.95 X

61210 3 0 0 X 2,453.41 X

61210 2 0 0 X 2,492.00 X

61215 90 2 X * X

61250 4 90 2 X 1,807.43 X

61250 1 90 2 X 1,985.06 X

61250 3 90 2 X 2,165.73 X

61250 2 90 2 X 2,218.63 X

61253 4 90 2 X 2,142.69 X

61253 3 90 2 X 2,167.59 X

61253 2 90 2 X 2,316.58 X

61253 1 90 2 X 2,352.74 X

61304 3 90 2 X 4,715.48 X

61304 4 90 2 X 4,726.30 X

61304 2 90 2 X 4,945.74 X

61304 1 90 2 X 5,037.56 X

61305 4 90 2 X 5,171.00 X

61305 3 90 2 X 5,234.40 X

61305 2 90 2 X 5,703.23 X

61305 1 90 2 X 5,750.92 X

61312 4 90 2 X 4,311.89 X

61312 3 90 2 X 4,342.30 X

61312 2 90 2 X 4,720.58 X

61312 1 90 2 X 4,806.79 X

61313 4 90 2 X 4,297.06 X

61313 3 90 2 X 4,349.49 X

61313 2 90 2 X 4,701.95 X

61313 1 90 2 X 4,787.19 X

61314 3 90 2 X 4,491.91 X

61314 4 90 2 X 4,659.95 X

61314 2 90 2 X 5,094.39 X

Page 10: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

61314 1 90 2 X 5,185.88 X

61315 3 90 2 X 4,802.20 X

61315 4 90 2 X 4,818.42 X

61315 2 90 2 X 5,245.72 X

61315 1 90 2 X 5,335.31 X

61316 2 90 2 X 155.81 X

61316 3 90 2 X 155.81 X

61316 4 90 2 X 155.81 X

61316 1 90 2 X 184.72 X

61320 4 90 2 X 4,054.25 X

61320 3 90 2 X 4,101.52 X

61320 2 90 2 X 4,378.49 X

61320 1 90 2 X 4,504.76 X

61321 4 90 2 X 4,409.95 X

61321 3 90 2 X 4,461.21 X

61321 2 90 2 X 4,770.30 X

61321 1 90 2 X 4,845.23 X

61322 2 90 2 X 3,198.96 X

61322 3 90 2 X 3,198.96 X

61322 4 90 2 X 3,198.96 X

61322 1 90 2 X 3,648.45 X

61323 2 90 2 X 3,315.17 X

61323 3 90 2 X 3,315.17 X

61323 4 90 2 X 3,315.17 X

61323 1 90 2 X 3,770.54 X

61330 4 90 2 X 2,623.31 X

61330 3 90 2 X 2,655.37 X

61330 2 90 2 X 2,807.59 X

61330 1 90 2 X 2,844.28 X

61333 4 90 2 X 4,446.88 X

61333 3 90 2 X 4,499.17 X

61333 2 90 2 X 4,800.14 X

61333 1 90 2 X 4,873.08 X

61340 4 90 2 X 2,533.46 X

61340 3 90 2 X 2,564.85 X

61340 2 90 2 X 2,762.02 X

61340 1 90 2 X 2,859.82 X

61343 4 90 2 X 5,549.77 X

61343 3 90 2 X 5,617.10 X

61343 1 90 2 X 5,786.95 X

61343 2 90 2 X 6,054.28 X

61345 4 90 2 X 4,228.89 X

61345 3 90 2 X 4,278.11 X

61345 2 90 2 X 4,577.19 X

Page 11: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

61345 1 90 2 X 4,649.72 X

61450 4 90 2 X 4,238.60 X

61450 3 90 2 X 4,288.82 X

61450 2 90 2 X 4,591.23 X

61450 1 90 2 X 4,664.48 X

61458 4 90 2 X 5,104.88 X

61458 3 90 2 X 5,828.50 X

61458 2 90 2 X 6,019.43 X

61458 1 90 2 X 6,138.88 X

61460 4 90 2 X 4,903.94 X

61460 3 90 2 X 4,963.01 X

61460 2 90 2 X 5,914.26 X

61460 1 90 2 X 6,029.03 X

61500 4 90 2 X 3,560.45 X

61500 3 90 2 X 3,721.87 X

61500 2 90 2 X 3,894.46 X

61500 1 90 2 X 3,964.77 X

61501 4 90 2 X 3,032.46 X

61501 3 90 2 X 3,069.81 X

61501 2 90 2 X 3,330.10 X

61501 1 90 2 X 3,393.14 X

61510 4 90 2 X 5,054.14 X

61510 3 90 2 X 5,078.97 X

61510 2 90 2 X 5,310.44 X

61510 1 90 2 X 5,406.18 X

61512 4 90 2 X 5,137.87 X

61512 3 90 2 X 5,200.68 X

61512 2 90 2 X 5,624.53 X

61512 1 90 2 X 5,727.12 X

61514 4 90 2 X 4,719.88 X

61514 3 90 2 X 4,776.95 X

61514 2 90 2 X 5,158.32 X

61514 1 90 2 X 5,502.40 X

61516 4 90 2 X 4,728.08 X

61516 3 90 2 X 4,786.05 X

61516 2 90 2 X 5,163.83 X

61516 1 90 2 X 5,255.25 X

61517 2 90 2 X 135.58 X

61517 3 90 2 X 135.58 X

61517 4 90 2 X 135.58 X

61517 1 90 2 X 148.79 X

61518 4 90 2 X 5,958.41 X

61518 3 90 2 X 6,029.31 X

61518 1 90 2 X 6,407.99 X

Page 12: 2020 Workers' Compensation Part B Fee Schedule 59120-61520€¦ · Medicare Location: Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

61518 2 90 2 X 6,483.47 X

61519 4 90 2 X 6,230.50 X

61519 3 90 2 X 6,304.51 X

61519 1 90 2 X 6,613.02 X

61519 2 90 2 X 6,781.18 X

61520 4 90 2 X 6,871.84 X

61520 3 90 2 X 6,953.53 X

61520 2 90 2 X 7,891.86 X

61520 1 90 2 X 7,943.28 X