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DLI
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Workers' Compensation
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Health Care Services Review
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Medical Fee Review
>
Fee Schedule
>
Fee Schedule A Part I
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Fee Schedule
Table A: Prospective Payment System
NPI or Provider #
Provider #
Indirect Medical Education Add-On
Direct Medical Education Add-On
Disproportionate Share Add-On
Paramedical Education Add-On
Aggregate RCC
DRG Rate
Capital Rate
Hold Harmless Rate
Implied Decimal 6 (in percentages)
Implied Decimal 4 (in percentages)
Implied Decimal 6 (in percentages)
Implied Decimal 2 (in dollars)
1124405592
390001
36081
15591
646
36277
485198
905284
23235
175471
1255540647
390001
36081
15591
646
36277
485198
905284
23235
175471
1285032128
390001
36081
15591
646
36277
485198
905284
23235
175471
1326446253
390001
36081
15591
646
36277
485198
905284
23235
175471
1336526276
390001
36081
15591
646
36277
485198
905284
23235
175471
1366444507
390001
36081
15591
646
36277
485198
905284
23235
175471
1417334350
390001
36081
15591
646
36277
485198
905284
23235
175471
1467850149
390001
36081
15591
646
36277
485198
905284
23235
175471
1497132336
390001
36081
15591
646
36277
485198
905284
23235
175471
1548648272
390001
36081
15591
646
36277
485198
905284
23235
175471
1770960130
390001
36081
15591
646
36277
485198
905284
23235
175471
1972652063
390001
36081
15591
646
36277
485198
905284
23235
175471
1194734798
390002
135468
52932
414
0
551833
1006201
95112
0
1942364898
390002
135468
52932
414
0
551833
1006201
95112
0
1821198755
390003
0
0
297
0
579483
905284
88431
0
1841408739
390003
0
0
297
0
579483
905284
88431
0
1891852703
390003
0
0
297
0
579483
905284
88431
0
1881690212
390004
0
0
0
1397
498517
976238
77803
0
1013384809
390006
263657
107593
444
15014
508391
905284
78510
0
1033491741
390006
263657
107593
444
15014
508391
905284
78510
0
1063540011
390006
263657
107593
444
15014
508391
905284
78510
0
1063708501
390006
263657
107593
444
15014
508391
905284
78510
0
1154617694
390006
263657
107593
444
15014
508391
905284
78510
0
1235215427
390006
263657
107593
444
15014
508391
905284
78510
0
1245632231
390006
263657
107593
444
15014
508391
905284
78510
0
1275832164
390006
263657
107593
444
15014
508391
905284
78510
0
1275850620
390006
263657
107593
444
15014
508391
905284
78510
0
1417231937
390006
263657
107593
444
15014
508391
905284
78510
0
1427344969
390006
263657
107593
444
15014
508391
905284
78510
0
1457650343
390006
263657
107593
444
15014
508391
905284
78510
0
1467748475
390006
263657
107593
444
15014
508391
905284
78510
0
1528197720
390006
263657
107593
444
15014
508391
905284
78510
0
1659762862
390006
263657
107593
444
15014
508391
905284
78510
0
1669768289
390006
263657
107593
444
15014
508391
905284
78510
0
1770879215
390006
263657
107593
444
15014
508391
905284
78510
0
1851508162
390006
263657
107593
444
15014
508391
905284
78510
0
1982037966
390006
263657
107593
444
15014
508391
905284
78510
0
1982988408
390006
263657
107593
444
15014
508391
905284
78510
0
1861435042
390009
35262
16381
283
16884
388855
928272
98652
0
1386896306
390012
0
0
0
0
681384
1101073
98017
0
1124076039
390013
0
0
0
0
770580
901697
61147
0
1477538312
390016
0
0
383
46405
645555
1006201
102972
0
1437865953
390026
102863
44440
0
0
700974
1101073
78268
0
1962579029
390027
369197
164426
3735
1000
346350
1101073
52243
236563
1568526135
390028
212670
105091
638
19969
407418
1006201
109207
0
1881695146
390028
212670
105091
638
19969
407418
1006201
109207
0
1235138405
390030
0
0
0
36715
651378
901697
91164
0
1689679581
390032
0
0
0
6702
511963
1006201
102972
0
1669405072
390035
0
0
0
0
361107
1101073
112139
0
1063422053
390036
39427
27555
0
969
537674
1006201
47376
85653
1588770416
390037
0
0
0
43300
635158
1006201
105831
0
1073598439
390037
0
0
0
43300
635158
1006201
105831
0
1912900168
390039
0
0
825
2588
541040
918172
97986
0
1871594127
390041
0
0
841
23769
496716
1006201
102972
0
1609984889
390042
43209
30912
256
42196
0
1006201
102972
0
1669530069
390044
84971
23313
0
21042
468000
942514
81898
0
1609801976
390045
44467
21869
287
5640
402000
890026
18255
144847
1326060492
390046
144496
64117
259
5922
604415
931416
73309
0
1609263946
390048
8240
34578
0
0
770000
901697
89126
0
1639560550
390048
8240
34578
0
0
770000
901697
89126
0
1689061921
390048
8240
34578
0
0
770000
901697
89126
0
1750778981
390048
8240
34578
0
0
770000
901697
89126
0
1861545683
390048
8240
34578
0
0
770000
901697
89126
0
1013933175
390049
68656
32236
0
133798
607630
1027228
102007
0
1548293954
390049
68656
32236
0
133798
607630
1027228
102007
0
1952399933
390049
68656
32236
0
133798
607630
1027228
102007
0
1285667493
390050
248542
77734
534
3112
387091
1006201
51803
129032
1700878840
390056
0
0
0
0
597279
901697
13056
205948
1568459287
390057
0
0
0
0
450593
1101073
121073
0
1689107328
390058
0
0
0
3047
554630
976238
81400
0
1497708473
390062
0
0
0
0
734000
945733
93586
0
1487647590
390063
52946
32583
539
6973
397020
928272
93846
0
1265466957
390065
0
0
0
0
736431
1098668
111913
0
1407928500
390066
39353
17255
0
0
492272
976238
75974
0
1407813603
390067
130828
52674
433
2232
445000
976238
86910
0
1285167916
390068
58594
33076
854
0
193955
955907
97705
0
1528319621
390070
9153
2964
0
0
431480
1101073
64480
0
1841712882
390071
0
0
0
0
686000
901697
89744
0
1316919699
390072
0
0
710
0
519617
905284
83780
0
1649278730
390073
37941
30974
410
25331
446000
945733
95593
0
1083614382
390079
112108
37346
0
20184
634945
901697
30383
183243
1134734528
390079
112108
37346
0
20184
634945
901697
30383
183243
1548624851
390081
29962
0
0
0
351953
1101073
79465
0
1144249657
390086
0
0
400
0
677485
901697
89133
0
1316537228
390086
0
0
400
0
677485
901697
89133
0
1194744805
390090
174532
60762
649
37073
356554
1006201
102972
0
1619069440
390091
0
0
0
3356
597181
901697
95748
0
1265422901
390093
30411
20351
0
0
620784
901697
6790
132162
1699734665
390096
26367
33298
859
3219
528137
942514
32219
89240
1750371522
390097
0
0
0
570
357027
1101073
99349
0
1104875103
390100
56910
18259
0
19607
724335
955907
70268
0
1245571942
390100
56910
18259
0
19607
724335
955907
70268
0
1063945707
390101
92128
52381
390
0
497259
931416
66643
0
1750445607
390102
110841
116437
0
14691
462514
1006201
109855
0
1790795359
390102
110841
116437
0
14691
462514
1006201
109855
0
1861478307
390104
0
0
0
0
0
993413
91164
0
1225047699
390107
0
0
0
0
560569
1006201
81432
0
1639218936
390107
0
0
0
0
560569
1006201
81432
0
1801897038
390110
126380
68584
690
37359
416925
903638
30795
123321
1851370910
390111
539305
313211
1585
7937
321731
1101073
29122
376876
1275620536
390112
0
0
0
0
607604
903638
9439
108767
1942276423
390113
0
0
1000
0
802026
921870
81818
0
1659435501
390114
147995
110633
1702
0
479453
1006201
42687
173018
1952311508
390114
147995
110633
1702
0
479453
1006201
42687
173018
1114095791
390115
60642
41217
671
31461
288789
1101073
61641
107806
1205904885
390115
60642
41217
671
31461
288789
1101073
61641
107806
1215952106
390115
60642
41217
671
31461
288789
1101073
61641
107806
1801963343
390115
60642
41217
671
31461
288789
1101073
61641
107806
1124495239
390116
219851
95443
268
894
449520
1101073
117834
174181
1295724193
390117
0
0
0
0
726684
901697
73287
0
1578569885
390118
0
0
0
0
414013
901697
78196
0
1922376136
390119
24716
27385
0
0
428010
905284
7988
162588
1649794421
390123
0
0
0
0
475055
1101073
97792
0
1124026182
390125
0
0
0
0
562680
901697
91164
0