2018 Workers' Compensation Part B Fee Schedule

15570-19101

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CPT/HCPC Code
Modifier
Medicare Location
Global Surgery Indicator
Multiple Surgery Indicator
Prevailing Charge Amount
Fee Schedule Amount
Site of Service Amount
15570   1 90 2 0 2,721.28 0
15570   2 90 2 0 3,261.07 0
15570   3 90 2 0 2,236.39 0
15570   4 90 2 0 1,174.92 0
15572   1 90 2 0 2,947.23 0
15572   2 90 2 0 3,001.30 0
15572   3 90 2 0 2,790.41 0
15572   4 90 2 0 3,283.10 0
15574   1 90 2 0 2,522.13 0
15574   2 90 2 0 2,595.49 0
15574   3 90 2 0 2,217.37 0
15574   4 90 2 0 2,605.49 0
15576   1 90 2 0 2,686.64 0
15576   2 90 2 0 3,136.54 0
15576   3 90 2 0 2,706.36 0
15576   4 90 2 0 2,671.08 0
15600   1 90 2 0 605.98 0
15600   2 90 2 0 844.87 0
15600   3 90 2 0 536.45 0
15600   4 90 2 0 1,004.19 0
15610   1 90 2 0 883.61 0
15610   2 90 2 0 590.69 0
15610   3 90 2 0 885.24 0
15610   4 90 2 0 532.00 0
15620   1 90 2 0 1,133.89 0
15620   2 90 2 0 1,184.79 0
15620   3 90 2 0 653.47 0
15620   4 90 2 0 645.30 0
15630   1 90 2 0 1,272.07 0
15630   2 90 2 0 1,265.57 0
15630   3 90 2 0 1,238.94 0
15630   4 90 2 0 698.13 0
15650   1 90 2 0 856.69 0
15650   2 90 2 0 957.81 0
15650   3 90 2 0 947.05 0
15650   4 90 2 0 764.90 0
15730   1 90 2 0 1,926.86 1148.31
15730   2 90 2 0 1,726.81 1,048.30
15730   3 90 2 0 1,726.81 1,048.30
15730   4 90 2 0 1,726.81 1,048.30
15731   1 90 2 0 1,501.08 1349.05
15731   2 90 2 0 1,314.65 1190.37
15731   3 90 2 0 1,314.65 1190.37
15731   4 90 2 0 1,314.65 1190.37
15733   1 90 2 0 1,311.50 0
15733   2 90 2 0 1,198.03 0
15733   3 90 2 0 1,198.03 0
15733   4 90 2 0 1,198.03 0
15734   1 90 2 0 4,563.92 0
15734   2 90 2 0 4,580.90 0
15734   3 90 2 0 4,531.98 0
15734   4 90 2 0 4,516.02 0
15736   1 90 2 0 3,797.35 0
15736   2 90 2 0 3,772.86 0
15736   3 90 2 0 2,779.07 0
15736   4 90 2 0 2,745.94 0
15738   1 90 2 0 4,287.25 0
15738   2 90 2 0 4,320.63 0
15738   3 90 2 0 4,230.27 0
15738   4 90 2 0 2,281.18 0
15740   1 90 2 0 3,036.24 0
15740   2 90 2 0 2,910.98 0
15740   3 90 2 0 2,969.09 0
15740   4 90 2 0 1,708.24 0
15750   1 90 2 0 2,171.89 0
15750   2 90 2 0 2,134.65 0
15750   3 90 2 0 1,980.76 0
15750   4 90 2 0 1,956.86 0
15756   1 90 2 0 6,124.67 0
15756   2 90 2 0 5,477.84 0
15756   3 90 2 0 5,330.58 0
15756   4 90 2 0 5,330.58 0
15757   1 90 2 0 6,124.67 0
15757   2 90 2 0 5,477.84 0
15757   3 90 2 0 5,330.58 0
15757   4 90 2 0 5,330.58 0
15758   1 90 2 0 6,124.67 0
15758   2 90 2 0 5,477.84 0
15758   3 90 2 0 5,330.58 0
15758   4 90 2 0 5,330.58 0
15760   1 90 2 0 1,918.43 0
15760   2 90 2 0 1,909.02 0
15760   3 90 2 0 1,870.17 0
15760   4 90 2 0 1,329.48 0
15770   1 90 2 0 1,333.63 0
15770   2 90 2 0 1,313.26 0
15770   3 90 2 0 1,228.74 0
15770   4 90 2 0 1,213.68 0
15775     0 2 0 * 0
15776     0 2 0 * 0
15777   1 ZZZ 0 0 307.66 0
15777   2 ZZZ 0 0 276.14 0
15777   3 ZZZ 0 0 276.14 0
15777   4 ZZZ 0 0 276.14 0
15780   1 90 2 0 715.34 0
15780   2 90 2 0 709.06 0
15780   3 90 2 0 1,515.06 0
15780   4 90 2 0 676.47 0
15781   1 90 2 0 805.96 0
15781   2 90 2 0 753.63 0
15781   3 90 2 0 790.09 0
15781   4 90 2 0 703.54 0
15782   1 90 2 0 471.80 0
15782   2 90 2 0 467.25 0
15782   3 90 2 0 448.47 0
15782   4 90 2 0 729.59 0
15783   1 90 2 0 668.07 0
15783   2 90 2 0 527.20 0
15783   3 90 2 0 503.13 0
15783   4 90 2 0 497.55 0
15786   1 10 2 0 227.70 0
15786   2 10 2 0 225.51 0
15786   3 10 2 0 216.35 0
15786   4 10 2 0 214.05 0
15787   1 ZZZ 0 0 50.68 0
15787   2 ZZZ 0 0 50.04 0
15787   3 ZZZ 0 0 47.17 0
15787   4 ZZZ 0 0 46.61 0
15788     90 2 0 * 0
15789     90 2 0 * 0
15792     90 2 0 * 0
15793     90 2 0 * 0
15819   1 90 2 0 1,540.99 0
15819   2 90 2 0 1,519.68 0
15819   3 90 2 0 1,431.54 0
15819   4 90 2 0 1,414.20 0
15820   1 90 2 0 1,020.35 0
15820   2 90 2 0 1,005.13 0
15820   3 90 2 0 941.86 0
15820   4 90 2 0 929.89 0
15821   1 90 2 0 1,168.56 0
15821   2 90 2 0 1,151.49 0
15821   3 90 2 0 1,080.34 0
15821   4 90 2 0 1,066.43 0
15822   1 90 2 0 979.99 0
15822   2 90 2 0 1,632.16 0
15822   3 90 2 0 1,375.69 0
15822   4 90 2 0 1,455.69 0
15823   1 90 2 0 1,715.88 0
15823   2 90 2 0 1,688.78 0
15823   3 90 2 0 1,613.02 0
15823   4 90 2 0 1,572.46 0
15824     XXX 2 0 * 0
15825     XXX 2 0 * 0
15826     XXX 2 0 * 0
15828     XXX 2 0 * 0
15829     XXX 2 0 * 0
15830   1 90 2 0 1,640.21 0
15830   2 90 2 0 1,421.54 0
15830   3 90 2 0 1,421.54 0
15830   4 90 2 0 1,421.54 0
15832     90 2 0 * 0
15833     90 2 0 * 0
15834     90 2 0 * 0
15835     90 2 0 * 0
15836     90 2 0 * 0
15837     90 2 0 * 0
15838     90 2 0 * 0
15839     90 2 0 * 0
15840   1 90 2 0 2,647.84 0
15840   2 90 2 0 2,603.52 0
15840   3 90 2 0 2,419.77 0
15840   4 90 2 0 2,389.85 0
15841   1 90 2 0 3,606.24 0
15841   2 90 2 0 3,551.44 0
15841   3 90 2 0 3,324.94 0
15841   4 90 2 0 3,286.25 0
15842   1 90 2 0 5,844.26 0
15842   2 90 2 0 5,769.75 0
15842   3 90 2 0 5,460.68 0
15842   4 90 2 0 5,394.94 0
15845   1 90 2 0 2,658.50 0
15845   2 90 2 0 2,611.82 0
15845   3 90 2 0 2,418.37 0
15845   4 90 2 0 2,388.55 0
15847     YYY 2 0 * 0
15850     XXX 9 0 * 0
15851     0 2 0 * 0
15852   1 0 2 0 102.56 0
15852   2 0 2 0 101.69 0
15852   3 0 2 0 98.29 0
15852   4 0 2 0 97.64 0
15860     0 2 0 * 0
15876     XXX 2 0 * 0
15877     XXX 2 0 * 0
15878     XXX 2 0 * 0
15879     XXX 2 0 * 0
15920   1 90 2 0 954.66 0
15920   2 90 2 0 941.86 0
15920   3 90 2 0 889.35 0
15920   4 90 2 0 879.90 0
15922   1 90 2 0 1,435.49 0
15922   2 90 2 0 1,413.32 0
15922   3 90 2 0 1,322.10 0
15922   4 90 2 0 1,307.19 0
15931   1 90 2 0 839.58 0
15931   2 90 2 0 1,002.93 0
15931   3 90 2 0 926.90 0
15931   4 90 2 0 902.89 0
15933   1 90 2 0 1,570.51 0
15933   2 90 2 0 1,555.74 0
15933   3 90 2 0 1,455.45 0
15933   4 90 2 0 1,439.01 0
15934   1 90 2 0 1,790.26 0
15934   2 90 2 0 1,762.41 0
15934   3 90 2 0 1,647.82 0
15934   4 90 2 0 1,670.28 0
15935   1 90 2 0 2,349.50 0
15935   2 90 2 0 2,309.56 0
15935   3 90 2 0 2,144.75 0
15935   4 90 2 0 2,119.97 0
15936   1 90 2 0 2,090.80 0
15936   2 90 2 0 2,712.04 0
15936   3 90 2 0 2,649.88 0
15936   4 90 2 0 1,884.47 0
15937   1 90 2 0 3,180.37 0
15937   2 90 2 0 3,161.08 0
15937   3 90 2 0 3,081.32 0
15937   4 90 2 0 2,319.28 0
15940   1 90 2 0 1,087.95 0
15940   2 90 2 0 1,073.14 0
15940   3 90 2 0 1,012.45 0
15940   4 90 2 0 1,001.55 0
15941   1 90 2 0 1,532.58 0
15941   2 90 2 0 1,583.65 0
15941   3 90 2 0 1,503.77 0
15941   4 90 2 0 1,486.77 0
15944   1 90 2 0 1,879.81 0
15944   2 90 2 0 2,008.51 0
15944   3 90 2 0 1,952.89 0
15944   4 90 2 0 1,944.53 0
15945   1 90 2 0 2,375.97 0
15945   2 90 2 0 2,360.32 0
15945   3 90 2 0 2,295.80 0
15945   4 90 2 0 1,956.03 0
15946   1 90 2 0 3,500.83 0
15946   2 90 2 0 3,442.58 0
15946   3 90 2 0 3,202.47 0
15946   4 90 2 0 3,165.43 0
15950   1 90 2 0 904.74 0
15950   2 90 2 0 944.93 0
15950   3 90 2 0 901.10 0
15950   4 90 2 0 920.25 0
15951   1 90 2 0 1,662.43 0
15951   2 90 2 0 1,634.57 0
15951   3 90 2 0 1,519.68 0
15951   4 90 2 0 1,502.33 0
15952   1 90 2 0 1,675.63 0
15952   2 90 2 0 1,616.59 0
15952   3 90 2 0 1,620.48 0
15952   4 90 2 0 1,493.66 0
15953   1 90 2 0 1,974.07 0
15953   2 90 2 0 1,941.00 0
15953   3 90 2 0 1,990.60 0
15953   4 90 2 0 1,784.34 0
15956   1 90 2 0 3,069.87 0
15956   2 90 2 0 3,012.60 0
15956   3 90 2 0 2,874.40 0
15956   4 90 2 0 2,742.65 0
15958   1 90 2 0 3,164.93 0
15958   2 90 2 0 3,103.63 0
15958   3 90 2 0 3,007.89 0
15958   4 90 2 0 2,816.29 0
15999     YYY 2 0 * 0
16000   1 0 2 0 101.47 87.74
16000   2 0 2 0 100.60 86.96
16000   3 0 2 0 95.51 83.08
16000   4 0 2 0 95.15 82.61
16020   1 0 2 0 93.67 80.33
16020   2 0 2 0 92.68 79.54
16020   3 0 2 0 88.66 76.23
16020   4 0 2 0 87.65 75.47
16025   1 0 2 0 200.58 181.69
16025   2 0 2 0 198.64 180.04
16025   3 0 2 0 191.00 173.48
16025   4 0 2 0 189.03 171.75
16030   1 0 2 0 230.34 0
16030   2 0 2 0 227.97 0
16030   3 0 2 0 218.32 0
16030   4 0 2 0 216.10 0
16035   1 90 2 0 585.72 0
16035   2 90 2 0 578.31 0
16035   3 90 2 0 547.67 0
16035   4 90 2 0 541.78 0
16036   1 ZZZ 0 0 169.89 0
16036   2 ZZZ 0 0 151.85 0
16036   3 ZZZ 0 0 151.85 0
16036   4 ZZZ 0 0 151.85 0
17000   1 10 2 0 80.27 62.9
17000   2 10 2 0 72.38 57.59
17000   3 10 2 0 72.38 57.59
17000   4 10 2 0 72.38 57.59
17003   1 ZZZ 0 0 22.36 17.01
17003   2 ZZZ 0 0 19.98 15.39
17003   3 ZZZ 0 0 19.98 15.39
17003   4 ZZZ 0 0 19.98 15.39
17004   1 10 2 0 403.61 310.71
17004   2 10 2 0 360.52 281.44
17004   3 10 2 0 360.52 281.44
17004   4 10 2 0 360.52 281.44
17106   1 90 2 0 570.26 0
17106   2 90 2 0 564.19 0
17106   3 90 2 0 539.37 0
17106   4 90 2 0 533.44 0
17107   1 90 2 0 1,129.32 0
17107   2 90 2 0 1,117.14 0
17107   3 90 2 0 1,067.16 0
17107   4 90 2 0 1,055.43 0
17108   1 90 2 0 1,986.52 0
17108   2 90 2 0 1,963.31 0
17108   3 90 2 0 1,867.33 0
17108   4 90 2 0 1,845.09 0
17110   1 10 2 0 82.21 65.67
17110   2 10 2 0 74.40 60.33
17110   3 10 2 0 74.40 60.33
17110   4 10 2 0 74.40 60.33
17111   1 10 2 0 119.88 95.07
17111   2 10 2 0 108.09 86.99
17111   3 10 2 0 108.09 86.99
17111   4 10 2 0 108.09 86.99
17250   1 0 2 0 76.23 62.03
17250   2 0 2 0 75.25 61.18
17250   3 0 2 0 71.21 57.94
17250   4 0 2 0 70.32 57.32
17260   1 10 2 0 238.62 0
17260   2 10 2 0 237.15 0
17260   3 10 2 0 231.91 0
17260   4 10 2 0 232.37 0
17261   1 10 2 0 283.27 0
17261   2 10 2 0 283.92 0
17261   3 10 2 0 274.18 0
17261   4 10 2 0 273.18 0
17262   1 10 2 0 354.55 0
17262   2 10 2 0 348.08 0
17262   3 10 2 0 344.16 0
17262   4 10 2 0 313.40 0
17263   1 10 2 0 411.74 0
17263   2 10 2 0 423.48 0
17263   3 10 2 0 421.07 0
17263   4 10 2 0 380.71 0
17264   1 10 2 0 525.43 0
17264   2 10 2 0 540.53 0
17264   3 10 2 0 514.34 0
17264   4 10 2 0 525.53 0
17266   1 10 2 0 758.30 0
17266   2 10 2 0 751.98 0
17266   3 10 2 0 661.65 0
17266   4 10 2 0 751.96 0
17270   1 10 2 0 295.90 0
17270   2 10 2 0 289.87 0
17270   3 10 2 0 278.19 0
17270   4 10 2 0 280.15 0
17271   1 10 2 0 370.70 0
17271   2 10 2 0 362.77 0
17271   3 10 2 0 355.88 0
17271   4 10 2 0 308.09 0
17272   1 10 2 0 398.60 0
17272   2 10 2 0 392.46 0
17272   3 10 2 0 386.44 0
17272   4 10 2 0 353.02 0
17273   1 10 2 0 416.88 0
17273   2 10 2 0 446.27 0
17273   3 10 2 0 439.85 0
17273   4 10 2 0 414.68 0
17274   1 10 2 0 576.48 0
17274   2 10 2 0 566.49 0
17274   3 10 2 0 557.98 0
17274   4 10 2 0 539.90 0
17276   1 10 2 0 687.11 0
17276   2 10 2 0 678.41 0
17276   3 10 2 0 624.44 0
17276   4 10 2 0 660.55 0
17280   1 10 2 0 330.02 0
17280   2 10 2 0 324.27 0
17280   3 10 2 0 300.16 0
17280   4 10 2 0 305.17 0
17281   1 10 2 0 392.58 0
17281   2 10 2 0 393.38 0
17281   3 10 2 0 381.06 0
17281   4 10 2 0 353.23 0
17282   1 10 2 0 469.72 0
17282   2 10 2 0 462.60 0
17282   3 10 2 0 465.16 0
17282   4 10 2 0 392.54 0
17283   1 10 2 0 506.04 0
17283   2 10 2 0 546.98 0
17283   3 10 2 0 539.96 0
17283   4 10 2 0 487.69 0
17284   1 10 2 0 658.20 0
17284   2 10 2 0 632.65 0
17284   3 10 2 0 570.29 0
17284   4 10 2 0 648.63 0
17286   1 10 2 0 815.30 0
17286   2 10 2 0 802.73 0
17286   3 10 2 0 750.85 0
17286   4 10 2 0 741.86 0
17311   1 0 2 0 959.04 507.66
17311   2 0 2 0 827.98 459.04
17311   3 0 2 0 827.98 459.04
17311   4 0 2 0 827.98 459.04
17312   1 ZZZ 0 0 580.24 270.27
17312   2 ZZZ 0 0 497.70 244.33
17312   3 ZZZ 0 0 497.70 244.33
17312   4 ZZZ 0 0 497.70 244.33
17313   1 0 2 0 876.35 455.19
17313   2 0 2 0 755.71 411.45
17313   3 0 2 0 755.71 411.45
17313   4 0 2 0 755.71 411.45
17314   1 ZZZ 0 0 537.39 249.90
17314   2 ZZZ 0 0 460.93 225.95
17314   3 ZZZ 0 0 460.93 225.95
17314   4 ZZZ 0 0 460.93 225.95
17315   1 ZZZ 0 0 112.60 70.60
17315   2 ZZZ 0 0 98.26 63.92
17315   3 ZZZ 0 0 98.26 63.92
17315   4 ZZZ 0 0 98.26 63.92
17340   1 10 2 0 87.94 76.19
17340   2 10 2 0 87.04 75.47
17340   3 10 2 0 76.86 67.06
17340   4 10 2 0 82.62 71.90
17360   1 10 2 0 129.47 119.21
17360   2 10 2 0 142.79 131.69
17360   3 10 2 0 137.98 127.48
17360   4 10 2 0 136.57 126.22
17380     XXX 2 0 * 0
17999     YYY 2 0 * 0
19000   1 0 2 0 116.00 99.42
19000   2 0 2 0 111.94 96.21
19000   3 0 2 0 110.80 95.12
19000   4 0 2 0 108.17 92.81
19001   1 ZZZ 0 0 61.62 0
19001   2 ZZZ 0 0 60.68 0
19001   3 ZZZ 0 0 56.86 0
19001   4 ZZZ 0 0 56.29 0
19020   1 90 2 0 439.99 0
19020   2 90 2 0 448.93 0
19020   3 90 2 0 441.02 0
19020   4 90 2 0 374.98 0
19030   1 0 2 0 165.37 0
19030   2 0 2 0 163.78 0
19030   3 0 2 0 157.31 0
19030   4 0 2 0 155.64 0
19081   1 0 2 0 913.24 253.76
19081   2 0 2 0 796.37 230.31
19081   3 0 2 0 796.37 230.31
19081   4 0 2 0 796.37 230.31
19082   1 ZZZ 0 0 734.38 118.83
19082   2 ZZZ 0 0 637.65 109.29
19082   3 ZZZ 0 0 637.65 109.29
19082   4 ZZZ 0 0 637.65 109.29
19083   1 0 2 0 906.34 237.30
19083   2 0 2 0 789.94 215.68
19083   3 0 2 0 789.94 215.68
19083   4 0 2 0 789.94 215.68
19084   1 ZZZ 0 0 724.28 111.58
19084   2 ZZZ 0 0 628.56 102.68
19084   3 ZZZ 0 0 628.56 102.68
19084   4 ZZZ 0 0 628.56 102.68
19085   1 0 2 0 1,370.21 276.63
19085   2 0 2 0 1,190.39 251.73
19085   3 0 2 0 1,190.39 251.73
19085   4 0 2 0 1,190.39 251.73
19086   1 ZZZ 0 0 1,085.81 118.31
19086   2 ZZZ 0 0 941.72 111.27
19086   3 ZZZ 0 0 941.72 111.27
19086   4 ZZZ 0 0 941.72 111.27
19100   1 0 2 0 209.39 0
19100   2 0 2 0 229.93 0
19100   3 0 2 0 238.14 0
19100   4 0 2 0 210.00 0
19101   1 10 2 0 534.96 0
19101   2 10 2 0 547.17 0
19101   3 10 2 0 477.95 0
19101   4 10 2 0 472.51 0