2018 Workers' Compensation Part B Fee Schedule

11644-15278

View the PDF


CPT/HCPC Code
Modifier
Medicare Location
Global Surgery Indicator
Multiple Surgery Indicator
Prevailing Charge Amount
Fee Schedule Amount
Site of Service Amount
11644   1 10 2 0 719.98 0
11644   2 10 2 0 710.91 0
11644   3 10 2 0 673.11 0
11644   4 10 2 0 688.04 0
11646   1 10 2 0 939.09 0
11646   2 10 2 0 925.84 0
11646   3 10 2 0 871.10 0
11646   4 10 2 0 860.92 0
11719   1 0 2 0 28.59 13.76
11719   2 0 2 0 24.95 12.30
11719   3 0 2 0 24.95 12.30
11719   4 0 2 0 24.95 12.30
11720   1 0 0 0 59.39 44.37
11720   2 0 0 0 53.84 40.76
11720   3 0 0 0 52.41 39.61
11720   4 0 0 0 52.41 39.61
11721   1 0 0 0 100.16 74.78
11721   2 0 0 0 90.78 68.73
11721   3 0 0 0 88.34 66.90
11721   4 0 0 0 88.34 66.90
11730   1 0 2 0 123.67 106.89
11730   2 0 2 0 125.10 108.25
11730   3 0 2 0 107.58 92.89
11730   4 0 2 0 112.97 97.71
11732   1 ZZZ 0 0 55.27 44.84
11732   2 ZZZ 0 0 54.66 44.30
11732   3 ZZZ 0 0 51.96 42.23
11732   4 ZZZ 0 0 51.32 41.76
11740   1 0 2 0 68.78 52.40
11740   2 0 2 0 79.69 60.64
11740   3 0 2 0 78.69 59.78
11740   4 0 2 0 66.69 50.72
11750   1 10 2 0 342.27 253.60
11750   2 10 2 0 353.32 262.00
11750   3 10 2 0 385.75 285.83
11750   4 10 2 0 313.15 231.87
11755   1 0 2 0 209.48 0
11755   2 0 2 0 206.65 0
11755   3 0 2 0 194.91 0
11755   4 0 2 0 192.63 0
11760   1 10 2 0 166.87 137.08
11760   2 10 2 0 167.79 138.26
11760   3 10 2 0 161.63 133.39
11760   4 10 2 0 160.30 131.97
11762   1 10 2 0 366.71 284.46
11762   2 10 2 0 360.65 280.69
11762   3 10 2 0 341.52 265.17
11762   4 10 2 0 344.51 267.72
11765   1 10 2 0 138.57 109.36
11765   2 10 2 0 110.65 87.34
11765   3 10 2 0 133.01 105.03
11765   4 10 2 0 130.92 103.47
11770   1 10 2 0 756.26 0
11770   2 10 2 0 521.62 0
11770   3 10 2 0 668.22 0
11770   4 10 2 0 622.30 0
11771   1 90 2 0 937.38 0
11771   2 90 2 0 945.85 0
11771   3 90 2 0 855.04 0
11771   4 90 2 0 845.17 0
11772   1 90 2 0 1,076.10 0
11772   2 90 2 0 1,058.25 0
11772   3 90 2 0 975.51 0
11772   4 90 2 0 973.62 0
11900   1 0 2 0 67.86 57.37
11900   2 0 2 0 67.11 56.74
11900   3 0 2 0 64.15 54.40
11900   4 0 2 0 63.41 53.86
11901   1 0 2 0 105.93 88.80
11901   2 0 2 0 104.77 87.93
11901   3 0 2 0 100.15 84.18
11901   4 0 2 0 99.03 83.32
11920     0 2 0 * 0
11921     0 2 0 * 0
11922     ZZZ 0 0 * 0
11950     0 2 0 * 0
11951     0 2 0 * 0
11952     0 2 0 * 0
11954     0 2 0 * 0
11960   1 90 2 0 1,357.68 0
11960   2 90 2 0 1,332.38 0
11960   3 90 2 0 1,227.92 0
11960   4 90 2 0 1,213.09 0
11970   1 90 2 0 1,490.59 0
11970   2 90 2 0 1,809.61 0
11970   3 90 2 0 1,348.89 0
11970   4 90 2 0 1,332.53 0
11971   1 90 2 0 564.76 0
11971   2 90 2 0 711.81 0
11971   3 90 2 0 689.46 0
11971   4 90 2 0 493.44 0
11976     XXX 2 0 * 0
11980   1 0 2 0 226.18 157.39
11980   2 0 2 0 201.99 143.24
11980   3 0 2 0 201.99 143.24
11980   4 0 2 0 201.99 143.24
11981   1 XXX 2 0 217.75 149.31
11981   2 XXX 2 0 192.63 134.34
11981   3 XXX 2 0 192.63 134.34
11981   4 XXX 2 0 192.63 134.34
11982   1 XXX 2 0 248.26 179.74
11982   2 XXX 2 0 219.97 161.68
11982   3 XXX 2 0 219.97 161.68
11982   4 XXX 2 0 219.97 161.68
11983   1 XXX 2 0 401.49 332.99
11983   2 XXX 2 0 357.99 299.69
11983   3 XXX 2 0 357.99 299.69
11983   4 XXX 2 0 357.99 299.69
12001   1 10 2 0 168.86 0
12001   2 10 2 0 165.43 0
12001   3 10 2 0 148.72 0
12001   4 10 2 0 150.09 0
12002   1 10 2 0 208.32 0
12002   2 10 2 0 210.89 0
12002   3 10 2 0 202.80 0
12002   4 10 2 0 200.58 0
12004   1 10 2 0 237.36 0
12004   2 10 2 0 295.01 0
12004   3 10 2 0 289.22 0
12004   4 10 2 0 294.49 0
12005   1 10 2 0 380.26 0
12005   2 10 2 0 375.24 0
12005   3 10 2 0 371.38 0
12005   4 10 2 0 361.27 0
12006   1 10 2 0 450.33 0
12006   2 10 2 0 445.20 0
12006   3 10 2 0 423.89 0
12006   4 10 2 0 425.10 0
12007   1 10 2 0 521.36 0
12007   2 10 2 0 515.63 0
12007   3 10 2 0 491.94 0
12007   4 10 2 0 486.43 0
12011   1 10 2 0 184.69 0
12011   2 10 2 0 178.25 0
12011   3 10 2 0 161.92 0
12011   4 10 2 0 161.59 0
12013   1 10 2 0 219.87 0
12013   2 10 2 0 231.49 0
12013   3 10 2 0 233.09 0
12013   4 10 2 0 220.49 0
12014   1 10 2 0 245.45 0
12014   2 10 2 0 259.32 0
12014   3 10 2 0 265.69 0
12014   4 10 2 0 243.56 0
12015   1 10 2 0 307.74 0
12015   2 10 2 0 394.61 0
12015   3 10 2 0 371.24 0
12015   4 10 2 0 400.64 0
12016   1 10 2 0 646.30 0
12016   2 10 2 0 596.31 0
12016   3 10 2 0 529.88 0
12016   4 10 2 0 473.92 0
12017   1 10 2 0 672.28 0
12017   2 10 2 0 777.65 0
12017   3 10 2 0 629.64 0
12017   4 10 2 0 760.10 0
12018   1 10 2 0 962.22 0
12018   2 10 2 0 949.38 0
12018   3 10 2 0 895.94 0
12018   4 10 2 0 884.96 0
12020   1 10 2 0 340.98 0
12020   2 10 2 0 347.07 0
12020   3 10 2 0 337.98 0
12020   4 10 2 0 356.87 0
12021   1 10 2 0 444.09 0
12021   2 10 2 0 444.33 0
12021   3 10 2 0 403.33 0
12021   4 10 2 0 387.08 0
12031   1 10 2 0 213.83 0
12031   2 10 2 0 206.79 0
12031   3 10 2 0 192.88 0
12031   4 10 2 0 189.54 0
12032   1 10 2 0 237.29 0
12032   2 10 2 0 260.45 0
12032   3 10 2 0 254.26 0
12032   4 10 2 0 247.57 0
12034   1 10 2 0 313.95 0
12034   2 10 2 0 383.75 0
12034   3 10 2 0 363.89 0
12034   4 10 2 0 359.77 0
12035   1 10 2 0 477.92 0
12035   2 10 2 0 472.03 0
12035   3 10 2 0 447.69 0
12035   4 10 2 0 442.57 0
12036   1 10 2 0 577.07 0
12036   2 10 2 0 566.08 0
12036   3 10 2 0 546.45 0
12036   4 10 2 0 535.29 0
12037   1 10 2 0 714.58 0
12037   2 10 2 0 704.33 0
12037   3 10 2 0 662.39 0
12037   4 10 2 0 654.79 0
12041   1 10 2 0 221.57 0
12041   2 10 2 0 211.44 0
12041   3 10 2 0 196.83 0
12041   4 10 2 0 191.76 0
12042   1 10 2 0 278.47 0
12042   2 10 2 0 275.83 0
12042   3 10 2 0 279.29 0
12042   4 10 2 0 260.71 0
12044   1 10 2 0 264.09 0
12044   2 10 2 0 388.61 0
12044   3 10 2 0 369.74 0
12044   4 10 2 0 365.52 0
12045   1 10 2 0 480.19 0
12045   2 10 2 0 474.37 0
12045   3 10 2 0 450.26 0
12045   4 10 2 0 445.11 0
12046   1 10 2 0 641.49 0
12046   2 10 2 0 632.85 0
12046   3 10 2 0 599.16 0
12046   4 10 2 0 590.50 0
12047   1 10 2 0 750.40 0
12047   2 10 2 0 739.27 0
12047   3 10 2 0 693.09 0
12047   4 10 2 0 684.84 0
12051   1 10 2 0 260.00 0
12051   2 10 2 0 246.94 0
12051   3 10 2 0 233.58 0
12051   4 10 2 0 222.76 0
12052   1 10 2 0 321.44 0
12052   2 10 2 0 327.55 0
12052   3 10 2 0 313.40 0
12052   4 10 2 0 298.78 0
12053   1 10 2 0 369.36 0
12053   2 10 2 0 342.80 0
12053   3 10 2 0 360.96 0
12053   4 10 2 0 331.48 0
12054   1 10 2 0 620.41 0
12054   2 10 2 0 533.89 0
12054   3 10 2 0 505.55 0
12054   4 10 2 0 499.52 0
12055   1 10 2 0 692.48 0
12055   2 10 2 0 683.35 0
12055   3 10 2 0 645.61 0
12055   4 10 2 0 637.93 0
12056   1 10 2 0 907.98 0
12056   2 10 2 0 895.30 0
12056   3 10 2 0 842.92 0
12056   4 10 2 0 832.67 0
12057   1 10 2 0 1,034.16 0
12057   2 10 2 0 1,020.64 0
12057   3 10 2 0 964.42 0
12057   4 10 2 0 952.60 0
13100   1 10 2 0 327.81 0
13100   2 10 2 0 322.42 0
13100   3 10 2 0 308.72 0
13100   4 10 2 0 305.75 0
13101   1 10 2 0 456.32 0
13101   2 10 2 0 452.79 0
13101   3 10 2 0 435.42 0
13101   4 10 2 0 434.95 0
13102   1 ZZZ 0 0 148.44 137.87
13102   2 ZZZ 0 0 134.49 125.46
13102   3 ZZZ 0 0 134.49 125.46
13102   4 ZZZ 0 0 134.49 125.46
13120   1 10 2 0 349.90 0
13120   2 10 2 0 346.98 0
13120   3 10 2 0 325.83 0
13120   4 10 2 0 333.86 0
13121   1 10 2 0 538.59 0
13121   2 10 2 0 534.02 0
13121   3 10 2 0 503.69 0
13121   4 10 2 0 510.35 0
13122   1 ZZZ 0 0 172.53 159.71
13122   2 ZZZ 0 0 156.38 145.43
13122   3 ZZZ 0 0 156.38 145.43
13122   4 ZZZ 0 0 156.38 145.43
13131   1 10 2 0 442.32 0
13131   2 10 2 0 442.83 0
13131   3 10 2 0 424.30 0
13131   4 10 2 0 396.36 0
13132   1 10 2 0 710.16 0
13132   2 10 2 0 703.08 0
13132   3 10 2 0 674.14 0
13132   4 10 2 0 668.91 0
13133   1 ZZZ 0 0 254.77 241.93
13133   2 ZZZ 0 0 231.79 220.79
13133   3 ZZZ 0 0 231.79 220.79
13133   4 ZZZ 0 0 231.79 220.79
13151   1 10 2 0 609.52 0
13151   2 10 2 0 603.77 0
13151   3 10 2 0 585.72 0
13151   4 10 2 0 582.00 0
13152   1 10 2 0 1,053.95 0
13152   2 10 2 0 1,038.85 0
13152   3 10 2 0 976.40 0
13152   4 10 2 0 964.88 0
13153   1 ZZZ 0 0 280.58 263.97
13153   2 ZZZ 0 0 254.54 240.35
13153   3 ZZZ 0 0 254.54 240.35
13153   4 ZZZ 0 0 254.54 240.35
13160   1 90 2 0 1,126.43 0
13160   2 90 2 0 1,122.21 0
13160   3 90 2 0 1,082.10 0
13160   4 90 2 0 1,079.97 0
14000   1 90 2 0 796.66 0
14000   2 90 2 0 786.78 0
14000   3 90 2 0 745.71 0
14000   4 90 2 0 737.10 0
14001   1 90 2 0 1,119.17 0
14001   2 90 2 0 1,142.57 0
14001   3 90 2 0 1,075.97 0
14001   4 90 2 0 1,063.73 0
14020   1 90 2 0 992.82 0
14020   2 90 2 0 979.79 0
14020   3 90 2 0 926.01 0
14020   4 90 2 0 914.92 0
14021   1 90 2 0 1,439.52 0
14021   2 90 2 0 1,471.31 0
14021   3 90 2 0 1,448.02 0
14021   4 90 2 0 1,320.59 0
14040   1 90 2 0 1,377.18 0
14040   2 90 2 0 1,426.87 0
14040   3 90 2 0 1,392.12 0
14040   4 90 2 0 1,420.44 0
14041   1 90 2 0 1,727.08 0
14041   2 90 2 0 1,684.03 0
14041   3 90 2 0 1,587.07 0
14041   4 90 2 0 1,568.53 0
14060   1 90 2 0 1,546.71 0
14060   2 90 2 0 1,635.14 0
14060   3 90 2 0 1,576.65 0
14060   4 90 2 0 1,530.21 0
14061   1 90 2 0 2,018.06 0
14061   2 90 2 0 1,989.15 0
14061   3 90 2 0 1,869.32 0
14061   4 90 2 0 1,846.69 0
14301   1 90 2 0 1,533.54 1296.02
14301   2 90 2 0 1,357.20 1156.97
14301   3 90 2 0 1,357.20 1156.97
14301   4 90 2 0 1,357.20 1156.97
14302   1 ZZZ 0 0 336.05 0
14302   2 ZZZ 0 0 302.21 0
14302   3 ZZZ 0 0 302.21 0
14302   4 ZZZ 0 0 302.21 0
14350   1 90 2 0 1,409.40 0
14350   2 90 2 0 1,361.12 0
14350   3 90 2 0 1,307.99 0
14350   4 90 2 0 1,293.08 0
15002   1 0 0 0 457.71 311.61
15002   2 0 0 0 394.02 274.61
15002   3 0 0 0 394.02 274.61
15002   4 0 0 0 394.02 274.61
15003   1 ZZZ 0 0 101.57 63.71
15003   2 ZZZ 0 0 87.35 56.41
15003   3 ZZZ 0 0 87.35 56.41
15003   4 ZZZ 0 0 87.35 56.41
15004   1 0 0 0 551.31 385.67
15004   2 0 0 0 475.52 340.15
15004   3 0 0 0 475.52 340.15
15004   4 0 0 0 475.52 340.15
15005   1 ZZZ 0 0 170.01 127.41
15005   2 ZZZ 0 0 147.64 112.84
15005   3 ZZZ 0 0 147.64 112.84
15005   4 ZZZ 0 0 147.64 112.84
15040   1 0 0 0 416.77 203.17
15040   2 0 0 0 355.24 180.71
15040   3 0 0 0 355.24 180.71
15040   4 0 0 0 355.24 180.71
15050   1 90 2 0 877.02 0
15050   2 90 2 0 859.42 0
15050   3 90 2 0 840.82 0
15050   4 90 2 0 837.14 0
15100   1 90 2 0 1,439.61 0
15100   2 90 2 0 1,432.37 0
15100   3 90 2 0 1,402.58 0
15100   4 90 2 0 1,397.44 0
15101   1 ZZZ 0 0 1,074.32 0
15101   2 ZZZ 0 0 1,075.65 0
15101   3 ZZZ 0 0 1,057.99 0
15101   4 ZZZ 0 0 1,065.97 0
15110   1 90 2 0 1,309.43 1,080.90
15110   2 90 2 0 1,136.58 949.88
15110   3 90 2 0 1,136.58 949.88
15110   4 90 2 0 1,136.58 949.88
15111   1 ZZZ 0 0 206.07 175.05
15111   2 ZZZ 0 0 181.28 155.93
15111   3 ZZZ 0 0 181.28 155.93
15111   4 ZZZ 0 0 181.28 155.93
15115   1 90 2 0 1,224.62 1107.88
15115   2 90 2 0 1,073.18 977.81
15115   3 90 2 0 1,073.18 977.81
15115   4 90 2 0 1,073.18 977.81
15116   1 ZZZ 0 0 266.71 238.14
15116   2 ZZZ 0 0 235.74 212.38
15116   3 ZZZ 0 0 235.74 212.38
15116   4 ZZZ 0 0 235.74 212.38
15120   1 90 2 0 2,134.06 0
15120   2 90 2 0 2,125.73 0
15120   3 90 2 0 2,091.24 0
15120   4 90 2 0 2,084.97 0
15121   1 ZZZ 0 0 1,677.57 0
15121   2 ZZZ 0 0 1,673.55 0
15121   3 ZZZ 0 0 492.40 0
15121   4 ZZZ 0 0 1,654.63 0
15130   1 90 2 0 1,089.76 870.56
15130   2 90 2 0 939.45 760.36
15130   3 90 2 0 939.45 760.36
15130   4 90 2 0 939.45 760.36
15131   1 ZZZ 0 0 168.52 141.82
15131   2 ZZZ 0 0 148.17 126.34
15131   3 ZZZ 0 0 148.17 126.34
15131   4 ZZZ 0 0 148.17 126.34
15135   1 90 2 0 1,310.63 1202.02
15135   2 90 2 0 1,148.59 1059.81
15135   3 90 2 0 1,148.59 1059.81
15135   4 90 2 0 1,148.59 1059.81
15136   1 ZZZ 0 0 156.58 142.92
15136   2 ZZZ 0 0 138.57 127.41
15136   3 ZZZ 0 0 138.57 127.41
15136   4 ZZZ 0 0 138.57 127.41
15150   1 90 2 0 1,086.89 961.45
15150   2 90 2 0 945.93 843.45
15150   3 90 2 0 945.93 843.45
15150   4 90 2 0 945.93 843.45
15151   1 ZZZ 0 0 217.45 188.92
15151   2 ZZZ 0 0 191.67 168.30
15151   3 ZZZ 0 0 191.67 168.30
15151   4 ZZZ 0 0 191.67 168.30
15152   1 ZZZ 0 0 267.02 235.97
15152   2 ZZZ 0 0 235.63 210.24
15152   3 ZZZ 0 0 235.63 210.24
15152   4 ZZZ 0 0 235.63 210.24
15155   1 90 2 0 1,083.00 1029.58
15155   2 90 2 0 951.54 907.93
15155   3 90 2 0 951.54 907.93
15155   4 90 2 0 951.54 907.93
15156   1 ZZZ 0 0 282.09 262.20
15156   2 ZZZ 0 0 250.15 233.89
15156   3 ZZZ 0 0 250.15 233.89
15156   4 ZZZ 0 0 250.15 233.89
15157   1 ZZZ 0 0 312.35 285.67
15157   2 ZZZ 0 0 276.70 254.91
15157   3 ZZZ 0 0 276.70 254.91
15157   4 ZZZ 0 0 276.70 254.91
15200   1 90 2 0 1,070.28 0
15200   2 90 2 0 1,372.69 0
15200   3 90 2 0 1,289.62 0
15200   4 90 2 0 1,350.95 0
15201   1 ZZZ 0 0 382.44 0
15201   2 ZZZ 0 0 374.39 0
15201   3 ZZZ 0 0 341.30 0
15201   4 ZZZ 0 0 337.08 0
15220   1 90 2 0 1,457.01 0
15220   2 90 2 0 1,465.42 0
15220   3 90 2 0 1,400.78 0
15220   4 90 2 0 1,393.44 0
15221   1 ZZZ 0 0 1,046.05 0
15221   2 ZZZ 0 0 1,042.67 0
15221   3 ZZZ 0 0 326.85 0
15221   4 ZZZ 0 0 322.76 0
15240   1 90 2 0 1,454.36 0
15240   2 90 2 0 1,442.77 0
15240   3 90 2 0 1,379.90 0
15240   4 90 2 0 1,404.50 0
15241   1 ZZZ 0 0 1,159.13 0
15241   2 ZZZ 0 0 1,155.06 0
15241   3 ZZZ 0 0 1,138.08 0
15241   4 ZZZ 0 0 1,135.71 0
15260   1 90 2 0 1,606.83 0
15260   2 90 2 0 1,597.74 0
15260   3 90 2 0 1,555.91 0
15260   4 90 2 0 1,553.85 0
15261   1 ZZZ 0 0 850.69 0
15261   2 ZZZ 0 0 919.32 0
15261   3 ZZZ 0 0 813.37 0
15261   4 ZZZ 0 0 533.47 0
15271   1 0 2 0 202.54 124.54
15271   2 0 2 0 179.93 112.66
15271   3 0 2 0 179.93 112.66
15271   4 0 2 0 179.93 112.66
15272   1 ZZZ 0 0 37.95 24.31
15272   2 ZZZ 0 0 34.06 22.31
15272   3 ZZZ 0 0 34.06 22.31
15272   4 ZZZ 0 0 34.06 22.31
15273   1 0 2 0 417.92 297.60
15273   2 0 2 0 372.22 268.50
15273   3 0 2 0 372.22 268.50
15273   4 0 2 0 372.22 268.50
15274   1 ZZZ 0 0 97.26 62.02
15274   2 ZZZ 0 0 87.08 56.69
15274   3 ZZZ 0 0 87.08 56.69
15274   4 ZZZ 0 0 87.08 56.69
15275   1 0 2 0 217.97 144.65
15275   2 0 2 0 194.31 131.12
15275   3 0 2 0 194.31 131.12
15275   4 0 2 0 194.31 131.12
15276   1 ZZZ 0 0 47.04 34.82
15276   2 ZZZ 0 0 42.62 32.07
15276   3 ZZZ 0 0 42.62 32.07
15276   4 ZZZ 0 0 42.62 32.07
15277   1 0 2 0 418.52 305.24
15277   2 0 2 0 375.90 278.26
15277   3 0 2 0 375.90 278.26
15277   4 0 2 0 375.90 278.26
15278   1 ZZZ 0 0 114.54 76.93
15278   2 ZZZ 0 0 102.72 70.31
15278   3 ZZZ 0 0 102.72 70.31
15278   4 ZZZ 0 0 102.72 70.31