CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

L6000 X 2,388.47 X

L6010 X 2,657.96 X

L6020 X 2,478.10 X

L6026 X 5,418.28 X

L6050 X 3,414.71 X

L6055 X 5,427.88 X

L6100 X 3,459.73 X

L6110 X 3,669.60 X

L6120 X 4,276.34 X

L6130 X 4,653.46 X

L6200 X 4,903.99 X

L6205 X 8,172.03 X

L6250 X 4,827.15 X

L6300 X 6,697.15 X

L6310 X 5,507.56 X

L6320 X 3,071.96 X

L6350 X 7,041.03 X

L6360 X 5,780.32 X

L6370 X 4,351.69 X

L6380 X 2,350.29 X

L6382 X 2,812.40 X

L6384 X 3,431.99 X

L6386 X 822.98 X

L6388 X 790.29 X

L6400 X 4,179.93 X

L6450 X 5,542.16 X

L6500 X 5,546.65 X

L6550 X 6,854.73 X

L6570 X 8,317.12 X

L6580 X 2,903.19 X

L6582 X 2,474.04 X

L6584 X 4,007.48 X

L6586 X 3,505.73 X

L6588 X 5,787.19 X

L6590 X 5,293.60 X

L6600 X 357.18 X

L6605 X 333.40 X

L6610 X 299.33 X

L6611 X * X

L6615 X 369.01 X

2021 Workers' Compensation Part B Fee Schedule

L6000-V5364

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

L6616 X 155.46 X

L6620 X 579.14 X

L6621 XXX 9 X * X

L6623 X 1,325.71 X

L6624 X * X

L6625 X 964.73 X

L6628 X 985.80 X

L6629 X 262.97 X

L6630 X 387.46 X

L6632 X 129.22 X

L6635 X 358.81 X

L6637 X 744.83 X

L6638 X 3,727.48 X

L6640 X 508.30 X

L6641 X 337.84 X

L6642 X 481.02 X

L6645 X 584.07 X

L6646 X 4,701.21 X

L6647 X 773.92 X

L6648 X 4,848.62 X

L6650 X 608.42 X

L6655 X 135.01 X

L6660 X 164.98 X

L6665 X 94.35 X

L6670 X 89.42 X

L6672 X 303.11 X

L6675 X 215.87 X

L6676 X 218.05 X

L6677 XXX 9 X * X

L6680 X 417.04 X

L6682 X 467.45 X

L6684 X 626.59 X

L6686 X 1,165.23 X

L6687 X 1,036.87 X

L6688 X 1,003.00 X

L6689 X 1,211.16 X

L6690 X 1,311.67 X

L6691 X 784.37 X

L6692 X 1,005.28 X

L6693 X 4,543.53 X

L6694 X * X

L6695 X * X

L6696 X * X

L6697 X * X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

L6698 X * X

L6703 X 485.09 X

L6704 X 803.29 X

L6706 X 478.58 X

L6707 X 2,017.03 X

L6708 X 1,147.32 X

L6709 X 1,856.86 X

L6711 X 909.52 X

L6712 X 1,674.60 X

L6713 X 2,113.58 X

L6714 X 1,790.16 X

L6715 X * X

L6721 X 3,181.85 X

L6722 X 2,743.02 X

L6805 X 647.05 X

L6810 X 352.74 X

L6880 X * X

L6881 X 6,148.00 X

L6882 X 4,663.57 X

L6883 XXX 9 X * X

L6884 XXX 9 X * X

L6885 XXX 9 X * X

L6890 X 305.77 X

L6895 X 1,112.81 X

L6900 X 2,888.11 X

L6905 X 2,835.30 X

L6910 X 2,910.64 X

L6915 X 1,125.35 X

L6920 X 13,856.34 X

L6925 X 15,190.51 X

L6930 X 13,108.37 X

L6935 X 15,511.52 X

L6940 X 17,089.18 X

L6945 X 19,113.91 X

L6950 X 18,110.88 X

L6955 X 22,026.32 X

L6960 X 23,384.29 X

L6965 X 26,786.64 X

L6970 X 28,790.28 X

L6975 X 31,784.88 X

L7007 X 4,974.87 X

L7008 X 8,404.42 X

L7009 X 5,087.40 X

L7040 X 5,229.26 X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

L7045 X 2,905.53 X

L7170 X 10,540.19 X

L7180 X 62,764.30 X

L7181 X * X

L7185 X 10,791.38 X

L7186 X 16,479.42 X

L7190 X 14,050.05 X

L7191 X 17,749.73 X

L7259 X 5,342.45 X

L7360 X 537.14 X

L7362 X 483.88 X

L7364 X 894.49 X

L7366 X 1,204.98 X

L7367 X 580.31 X

L7368 X 752.26 X

L7400 XXX 9 X * X

L7401 XXX 9 X * X

L7402 XXX 9 X * X

L7403 XXX 9 X * X

L7404 XXX 9 X * X

L7405 XXX 9 X * X

L7499 X # X

L7510 X * X

L7520 X * X

L7600 X * X

L7700 X 173.69 X

L7900 X 894.13 X

L7902 X # X

L8000 X 65.64 X

L8001 X 188.63 X

L8002 X 248.08 X

L8010 X 109.05 X

L8015 X * X

L8020 X 449.74 X

L8030 X 582.12 X

L8031 X * X

L8032 X * X

L8033 X # X

L8035 XXX X 5,694.15 X

L8039 X # X

L8040 XXX X * X

L8041 XXX X * X

L8042 XXX X * X

L8043 XXX X * X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

L8044 XXX X * X

L8045 XXX X * X

L8046 XXX X * X

L8047 XXX X * X

L8048 X # X

L8049 XXX X # X

L8300 X 151.61 X

L8310 X 239.39 X

L8320 X 107.33 X

L8330 X 88.75 X

L8400 X 31.20 X

L8410 X 41.76 X

L8415 X 40.99 X

L8417 XXX X 124.74 X

L8420 X 36.85 X

L8430 X 39.82 X

L8435 X 37.81 X

L8440 X 75.16 X

L8460 X 119.78 X

L8465 X 106.11 X

L8470 X 12.03 X

L8480 X 16.50 X

L8485 XXX X * X

L8499 X # X

L8500 X 1,581.74 X

L8501 X 217.13 X

L8505 X # X

L8507 X 63.00 X

L8509 X 164.24 X

L8510 X 380.00 X

L8511 X * X

L8512 X * X

L8513 X * X

L8514 X * X

L8515 X 88.67 X

L8600 X * X

L8603 X 762.76 X

L8604 X # X

L8605 X 933.03 X

L8606 XXX X * X

L8607 X 52.22 X

L8608 X # X

L8609 XXX 9 X 8,798.35 X

L8610 X * X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

L8612 X * X

L8613 X * X

L8614 X * X

L8615 X 633.70 X

L8616 X 147.59 X

L8617 X 128.92 X

L8618 X 36.83 X

L8619 X 11,028.16 X

L8622 X 0.44 X

L8623 X * X

L8624 X * X

L8625 X 223.46 X

L8627 X 9,748.29 X

L8628 X 1,662.23 X

L8629 X * X

L8630 X * X

L8631 X 3,224.62 X

L8641 X * X

L8642 X * X

L8658 X * X

L8659 X 2,814.39 X

L8670 X * X

L8679 X 10,590.66 X

L8680 X 620.28 X

L8681 XXX 9 X 1,978.58 X

L8682 XXX 9 X 8,050.53 X

L8683 XXX 9 X 7,086.29 X

L8684 XXX 9 X 936.67 X

L8685 XXX 9 X 17,658.70 X

L8686 XXX 9 X 11,267.61 X

L8687 XXX 9 X 22,980.99 X

L8688 XXX 9 X 14,663.72 X

L8689 XXX 9 X 56.16 X

L8690 XXX 9 X * X

L8691 X 3,445.14 X

L8692 X * X

L8693 X 1,997.04 X

L8694 X 1,117.42 X

L8695 X 22.43 X

L8696 X 272.64 X

L8698 X # X

L8699 X # X

L8701 X # X

L8702 X # X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

L9900 X # X

M0075 XXX 9 X # X

M0076 XXX 9 X # X

M0100 XXX 9 X # X

M0239 2 X 330.49 X

M0239 3 X 330.49 X

M0239 4 X 330.49 X

M0239 1 X 379.70 X

M0243 2 X 330.49 X

M0243 3 X 330.49 X

M0243 4 X 330.49 X

M0243 1 X 379.70 X

M0300 XXX 9 X # X

M0301 XXX 9 X # X

M1003 X # X

M1004 X # X

M1005 X # X

M1006 X # X

M1007 X # X

M1008 X # X

M1009 X # X

M1010 X # X

M1011 X # X

M1012 X # X

M1013 X # X

M1014 X # X

M1016 X # X

M1017 X # X

M1018 X # X

M1019 X # X

M1020 X # X

M1021 X # X

M1022 X # X

M1025 X # X

M1026 X # X

M1027 X # X

M1028 X # X

M1029 X # X

M1031 X # X

M1032 X # X

M1034 X # X

M1035 X # X

M1036 X # X

M1037 X # X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

M1038 X # X

M1039 X # X

M1040 X # X

M1041 X # X

M1043 X # X

M1045 X # X

M1046 X # X

M1049 X # X

M1051 X # X

M1052 X # X

M1054 X # X

M1055 X # X

M1056 X # X

M1057 X # X

M1058 X # X

M1059 X # X

M1060 X # X

M1067 X # X

M1068 X # X

M1069 X # X

M1070 X # X

M1071 X # X

M1106 X # X

M1107 X # X

M1108 X # X

M1109 X # X

M1110 X # X

M1111 X # X

M1112 X # X

M1113 X # X

M1114 X # X

M1115 X # X

M1116 X # X

M1117 X # X

M1118 X # X

M1119 X # X

M1120 X # X

M1121 X # X

M1122 X # X

M1123 X # X

M1124 X # X

M1125 X # X

M1126 X # X

M1127 X # X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

M1128 X # X

M1129 X # X

M1130 X # X

M1131 X # X

M1132 X # X

M1133 X # X

M1134 X # X

M1135 X # X

M1141 X # X

M1142 X # X

M1143 X # X

M1145 X # X

M1146 X # X

M1147 X # X

M1148 X # X

M1149 X # X

P2028 XXX 9 X 23.01 X

P2029 XXX 9 X * X

P2031 XXX 9 X * X

P2033 XXX 9 X 26.15 X

P2038 XXX 9 X 19.33 19.94

P3000 XXX 9 X 19.57 20.21

P3001 XXX 0 X 19.57 X

P3001 26 4 XXX 0 X 63.57 X

P3001 26 3 XXX 0 X 64.34 X

P3001 26 2 XXX 0 X 68.31 X

P3001 26 1 XXX 0 X 69.20 X

P7001 XXX 9 X 46.43 X

P9010 XXX 9 X 286.05 X

P9011 XXX 9 X 67.75 X

P9012 XXX 9 X 62.71 X

P9016 XXX 9 X 184.69 X

P9017 XXX 9 X 142.84 X

P9019 XXX 9 X 157.69 X

P9020 XXX 9 X 1,165.41 X

P9021 XXX 9 X 184.69 X

P9022 XXX 9 X 534.68 X

P9023 XXX 9 X * X

P9031 XXX 9 X * X

P9032 XXX 9 X * X

P9033 XXX 9 X * X

P9034 XXX 9 X * X

P9035 XXX 9 X * X

P9036 XXX 9 X * X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

P9037 XXX 9 X * X

P9038 XXX 9 X * X

P9039 XXX 9 X * X

P9040 XXX 9 X * X

P9041 XXX 9 X * X

P9043 XXX 9 X * X

P9044 XXX 9 X * X

P9045 XXX 9 X * X

P9046 XXX 9 X * X

P9047 XXX 9 X * X

P9048 XXX 9 X * X

P9050 XXX 9 X # X

P9051 XXX 9 X * X

P9052 XXX 9 X * X

P9053 XXX 9 X * X

P9054 XXX 9 X * X

P9055 XXX 9 X * X

P9056 XXX 9 X * X

P9057 XXX 9 X * X

P9058 XXX 9 X * X

P9059 XXX 9 X * X

P9060 XXX 9 X * X

P9073 X * X

P9099 X # X

P9100 X * X

P9603 XXX 9 X # X

P9604 XXX 9 X 4.17 X

P9612 XXX 9 X * X

P9615 XXX 9 X 7.73 8.03

R0070 2 XXX 0 X 241.54 X

R0070 3 XXX 0 X 251.77 X

R0070 4 XXX 0 X 252.50 X

R0070 1 XXX 0 X 263.56 X

R0075 XXX 0 X # X

R0076 XXX 9 X * X

T5999 XXX X # X

U0001 XXX X 40.59 X

U0002 XXX X 57.98 X

U0003 XXX 9 X 118.20 X

U0004 XXX 9 X 118.20 X

U0005 XXX 9 X 28.25 X

U224U XXX 9 X 47.61 X

V2020 XXX 9 X 112.71 X

V2025 XXX 9 X * X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

V2100 XXX 9 X 86.47 X

V2101 XXX 9 X 90.65 X

V2102 XXX 9 X 133.50 X

V2103 XXX 9 X 81.53 X

V2104 XXX 9 X 88.35 X

V2105 XXX 9 X 98.31 X

V2106 XXX 9 X 109.12 X

V2107 XXX 9 X 101.12 X

V2108 XXX 9 X 107.35 X

V2109 XXX 9 X 118.84 X

V2110 XXX 9 X 117.29 X

V2111 XXX 9 X 120.29 X

V2112 XXX 9 X 133.34 X

V2113 XXX 9 X 138.97 X

V2114 XXX 9 X 162.97 X

V2115 XXX 9 X 144.20 X

V2118 XXX 9 X 175.71 X

V2121 XXX 9 X * X

V2199 XXX 9 X # X

V2200 XXX 9 X 119.08 X

V2201 XXX 9 X 130.47 X

V2202 XXX 9 X 157.56 X

V2203 XXX 9 X 122.96 X

V2204 XXX 9 X 129.56 X

V2205 XXX 9 X 140.14 X

V2206 XXX 9 X 150.50 X

V2207 XXX 9 X 133.04 X

V2208 XXX 9 X 142.71 X

V2209 XXX 9 X 152.60 X

V2210 XXX 9 X 170.68 X

V2211 XXX 9 X 157.91 X

V2212 XXX 9 X 164.54 X

V2213 XXX 9 X 155.54 X

V2214 XXX 9 X 200.70 X

V2215 XXX 9 X 170.84 X

V2218 XXX 9 X 242.42 X

V2219 XXX 9 X 106.74 X

V2220 XXX 9 X 86.54 X

V2221 XXX 9 X 143.65 X

V2299 XXX 9 X # X

V2300 XXX 9 X 142.40 X

V2301 XXX 9 X 166.89 X

V2302 XXX 9 X 196.55 X

V2303 XXX 9 X 130.47 X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

V2304 XXX 9 X 152.43 X

V2305 XXX 9 X 176.61 X

V2306 XXX 9 X 187.49 X

V2307 XXX 9 X 173.08 X

V2308 XXX 9 X 179.88 X

V2309 XXX 9 X 188.00 X

V2310 XXX 9 X 199.39 X

V2311 XXX 9 X 180.15 X

V2312 XXX 9 X 181.19 X

V2313 XXX 9 X 187.93 X

V2314 XXX 9 X 241.47 X

V2315 XXX 9 X 214.53 X

V2318 XXX 9 X 335.58 X

V2319 XXX 9 X 118.97 X

V2320 XXX 9 X 125.59 X

V2321 XXX 9 X 211.30 X

V2399 XXX 9 X # X

V2410 XXX 9 X 187.12 X

V2430 XXX 9 X 209.14 X

V2499 XXX 9 X # X

V2500 XXX 9 X 194.82 X

V2501 XXX 9 X 264.78 X

V2502 XXX 9 X 348.57 X

V2503 XXX 9 X 336.05 X

V2510 XXX 9 X 263.37 X

V2511 XXX 9 X 341.51 X

V2512 XXX 9 X 420.19 X

V2513 XXX 9 X 342.46 X

V2520 XXX 9 X 244.00 X

V2521 XXX 9 X 385.07 X

V2522 XXX 9 X 343.54 X

V2523 XXX 9 X 339.53 X

V2524 X # X

V2530 XXX 9 X 458.69 X

V2531 XXX X 921.44 X

V2599 XXX 9 X # X

V2600 XXX 9 X * X

V2610 XXX 9 X * X

V2615 XXX 9 X # X

V2623 XXX 9 X 1,613.60 X

V2624 XXX 9 X 145.92 X

V2625 XXX 9 X 665.29 X

V2626 XXX 9 X 358.69 X

V2627 XXX 9 X 2,229.34 X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

V2628 XXX 9 X 546.92 X

V2629 XXX 9 X # X

V2630 XXX 9 X * X

V2631 XXX 9 X * X

V2632 XXX 9 X * X

V2700 XXX 9 X 96.76 X

V2702 XXX 9 X * X

V2710 XXX 9 X 135.16 X

V2715 XXX 9 X 22.12 X

V2718 XXX 9 X 53.19 X

V2730 XXX 9 X 37.91 X

V2744 XXX 9 X 29.48 X

V2745 XXX 9 X 19.80 X

V2750 XXX 9 X 39.07 X

V2755 XXX 9 X 29.87 X

V2756 XXX 9 X * X

V2760 XXX 9 X 36.98 X

V2761 XXX 9 X * X

V2762 XXX 9 X 86.90 X

V2770 XXX 9 X 35.10 X

V2780 XXX 9 X 22.49 X

V2781 XXX 9 X # X

V2782 XXX 9 X 93.89 X

V2783 XXX 9 X 105.84 X

V2784 XXX 9 X 68.86 X

V2785 XXX 9 X # X

V2786 XXX 9 X * X

V2787 XXX 9 X * X

V2788 XXX 9 X * X

V2790 XXX 9 X * X

V2797 XXX 9 X * X

V2799 XXX 9 X # X

V5008 XXX 9 X * X

V5010 XXX 9 X * X

V5011 XXX 9 X * X

V5014 XXX 9 X * X

V5020 XXX 9 X * X

V5030 XXX 9 X * X

V5040 XXX 9 X * X

V5050 XXX 9 X * X

V5060 XXX 9 X * X

V5070 XXX 9 X # X

V5080 XXX 9 X * X

V5090 XXX 9 X * X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

V5095 XXX 9 X # X

V5100 XXX 9 X * X

V5110 XXX 9 X * X

V5120 XXX 9 X * X

V5130 XXX 9 X * X

V5140 XXX 9 X * X

V5150 XXX 9 X * X

V5160 XXX 9 X * X

V5171 X # X

V5172 X # X

V5181 X * X

V5190 XXX 9 X * X

V5200 XXX 9 X * X

V5211 X # X

V5212 X # X

V5213 X # X

V5214 X # X

V5215 X * X

V5221 X * X

V5230 XXX 9 X # X

V5240 XXX 9 X * X

V5241 XXX 9 X * X

V5242 XXX 9 X # X

V5243 XXX 9 X # X

V5244 XXX 9 X * X

V5245 XXX 9 X * X

V5246 XXX 9 X * X

V5247 XXX 9 X * X

V5248 XXX 9 X * X

V5249 XXX 9 X # X

V5250 XXX 9 X * X

V5251 XXX 9 X * X

V5252 XXX 9 X * X

V5253 XXX 9 X * X

V5254 XXX 9 X * X

V5255 XXX 9 X * X

V5256 XXX 9 X * X

V5257 XXX 9 X * X

V5258 XXX 9 X * X

V5259 XXX 9 X * X

V5260 XXX 9 X * X

V5261 XXX 9 X * X

V5262 XXX 9 X * X

V5263 XXX 9 X * X

CPT/HCPC

CodeModifier

Medicare

Location

Global

Surgery

Indicator

Multiple Surgery

Indicator

Prevailing

Charge

Amount

Fee

Schedule

Amount

Site of

Service

Amount

V5264 XXX 9 X * X

V5265 XXX 9 X * X

V5266 XXX 9 X * X

V5267 XXX 9 X * X

V5268 XXX 9 X * X

V5269 XXX 9 X * X

V5270 XXX 9 X * X

V5271 XXX 9 X # X

V5272 XXX 9 X # X

V5273 XXX 9 X # X

V5274 XXX 9 X # X

V5275 XXX 9 X * X

V5281 XXX 9 X # X

V5282 XXX 9 X * X

V5283 XXX 9 X # X

V5284 XXX 9 X * X

V5285 XXX 9 X * X

V5286 XXX 9 X * X

V5287 XXX 9 X # X

V5288 XXX 9 X # X

V5289 XXX 9 X # X

V5290 XXX 9 X * X

V5298 XXX 9 X # X

V5299 XXX 9 X # X

V5336 XXX 9 X # X

V5362 XXX 9 X # X

V5363 XXX 9 X # X

V5364 XXX 9 X # X