2018 Workers' Compensation Part B Fee Schedule

22850-24073

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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
22850   1 90 2 0 1,730.04 0
22850   2 90 2 0 1,587.50 0
22850   3 90 2 0 1,583.83 0
22850   4 90 2 0 1,564.79 0
22852   1 90 2 0 1,611.46 0
22852   2 90 2 0 1,594.54 0
22852   3 90 2 0 1,591.48 0
22852   4 90 2 0 1,572.11 0
22853   1 ZZZ 0 0 348.19 0
22853   2 ZZZ 0 0 314.02 0
22853   3 ZZZ 0 0 314.02 0
22853   4 ZZZ 0 0 314.02 0
22854   1 ZZZ 0 0 450.75 0
22854   2 ZZZ 0 0 406.49 0
22854   3 ZZZ 0 0 406.49 0
22854   4 ZZZ 0 0 406.49 0
22855   1 90 2 0 1,562.02 0
22855   2 90 2 0 1,537.72 0
22855   3 90 2 0 1,437.48 0
22855   4 90 2 0 1,420.68 0
22856   1 90 2 0 2,413.53 0
22856   2 90 2 0 2,126.89 0
22856   3 90 2 0 2,126.89 0
22856   4 90 2 0 2,126.89 0
22857   1 90 2 0 2,096.46 0
22857   2 90 2 0 1,861.56 0
22857   3 90 2 0 1,861.56 0
22857   4 90 2 0 1,861.56 0
22858   1 ZZZ 0 0 918.55 0
22858   2 ZZZ 0 0 803.77 0
22858   3 ZZZ 0 0 803.77 0
22858   4 ZZZ 0 0 803.77 0
22859   1 ZZZ 0 0 450.75 0
22859   2 ZZZ 0 0 406.49 0
22859   3 ZZZ 0 0 406.49 0
22859   4 ZZZ 0 0 406.49 0
22861   1 90 2 0 2,870.57 0
22861   2 90 2 0 2,580.70 0
22861   3 90 2 0 2,580.70 0
22861   4 90 2 0 2,580.70 0
22862   1 90 2 0 2,571.90 0
22862   2 90 2 0 2,261.97 0
22862   3 90 2 0 2,261.97 0
22862   4 90 2 0 2,261.97 0
22864   1 90 2 0 2,722.45 0
22864   2 90 2 0 2,405.63 0
22864   3 90 2 0 2,405.63 0
22864   4 90 2 0 2,405.63 0
22865   1 90 2 0 2,504.02 0
22865   2 90 2 0 2,202.75 0
22865   3 90 2 0 2,202.75 0
22865   4 90 2 0 2,202.75 0
22867   1 90 2 0 1,298.86 0
22867   2 90 2 0 1,164.17 0
22867   3 90 2 0 1,164.17 0
22867   4 90 2 0 1,164.17 0
22868   1 ZZZ 0 0 324.82 0
22868   2 ZZZ 0 0 293.39 0
22868   3 ZZZ 0 0 293.39 0
22868   4 ZZZ 0 0 293.39 0
22869   1 90 2 0 711.33 0
22869   2 90 2 0 637.84 0
22869   3 90 2 0 637.84 0
22869   4 90 2 0 637.84 0
22870   1 ZZZ 0 0 189.02 0
22870   2 ZZZ 0 0 170.90 0
22870   3 ZZZ 0 0 170.90 0
22870   4 ZZZ 0 0 170.90 0
22899     YYY 2 0 * 0
22900   1 90 2 0 885.37 0
22900   2 90 2 0 869.00 0
22900   3 90 2 0 830.50 0
22900   4 90 2 0 716.55 0
22901   1 90 2 0 971.67 0
22901   2 90 2 0 866.61 0
22901   3 90 2 0 866.61 0
22901   4 90 2 0 866.61 0
22902   1 90 2 0 609.49 486.41
22902   2 90 2 0 536.73 432.96
22902   3 90 2 0 536.73 432.96
22902   4 90 2 0 536.73 432.96
22903   1 90 2 0 640.69 0
22903   2 90 2 0 571.27 0
22903   3 90 2 0 571.27 0
22903   4 90 2 0 571.27 0
22904   1 90 2 0 1,522.69 0
22904   2 90 2 0 1,361.21 0
22904   3 90 2 0 1,361.21 0
22904   4 90 2 0 1,361.21 0
22905   1 90 2 0 1,975.14 0
22905   2 90 2 0 1,765.18 0
22905   3 90 2 0 1,765.18 0
22905   4 90 2 0 1,765.18 0
22999     YYY 2 0 * 0
23000   1 90 2 0 684.84 0
23000   2 90 2 0 702.40 0
23000   3 90 2 0 633.44 0
23000   4 90 2 0 679.69 0
23020   1 90 2 0 1,453.67 0
23020   2 90 2 0 1,431.48 0
23020   3 90 2 0 1,339.80 0
23020   4 90 2 0 1,323.90 0
23030   1 10 2 0 495.01 0
23030   2 10 2 0 487.85 0
23030   3 10 2 0 450.95 0
23030   4 10 2 0 453.07 0
23031   1 10 2 0 276.63 0
23031   2 10 2 0 242.58 0
23031   3 10 2 0 231.93 0
23031   4 10 2 0 232.57 0
23035   1 90 2 0 1,320.93 0
23035   2 90 2 0 1,300.58 0
23035   3 90 2 0 1,216.53 0
23035   4 90 2 0 1,202.37 0
23040   1 90 2 0 1,684.37 0
23040   2 90 2 0 1,656.31 0
23040   3 90 2 0 1,540.40 0
23040   4 90 2 0 1,521.76 0
23044   1 90 2 0 1,278.60 0
23044   2 90 2 0 1,427.01 0
23044   3 90 2 0 1,339.02 0
23044   4 90 2 0 1,153.20 0
23065   1 10 2 0 256.68 0
23065   2 10 2 0 213.84 0
23065   3 10 2 0 215.65 0
23065   4 10 2 0 240.51 0
23066   1 90 2 0 328.80 0
23066   2 90 2 0 323.62 0
23066   3 90 2 0 313.42 0
23066   4 90 2 0 299.67 0
23071   1 90 2 0 610.64 0
23071   2 90 2 0 542.68 0
23071   3 90 2 0 542.68 0
23071   4 90 2 0 542.68 0
23073   1 90 2 0 1,010.93 0
23073   2 90 2 0 900.29 0
23073   3 90 2 0 900.29 0
23073   4 90 2 0 900.29 0
23075   1 10 2 0 377.70 0
23075   2 10 2 0 373.69 0
23075   3 10 2 0 348.60 0
23075   4 10 2 0 326.62 0
23076   1 90 2 0 946.76 0
23076   2 90 2 0 892.62 0
23076   3 90 2 0 867.11 0
23076   4 90 2 0 857.52 0
23077   1 90 2 0 1,457.12 0
23077   2 90 2 0 1,448.08 0
23077   3 90 2 0 1,380.17 0
23077   4 90 2 0 1,877.30 0
23078   1 90 2 0 2,055.39 0
23078   2 90 2 0 1,837.27 0
23078   3 90 2 0 1,837.27 0
23078   4 90 2 0 1,837.27 0
23100   1 90 2 0 1,247.81 0
23100   2 90 2 0 1,337.70 0
23100   3 90 2 0 1,243.97 0
23100   4 90 2 0 1,119.84 0
23101   1 90 2 0 1,317.56 0
23101   2 90 2 0 1,306.74 0
23101   3 90 2 0 1,214.60 0
23101   4 90 2 0 1,050.67 0
23105   1 90 2 0 1,848.26 0
23105   2 90 2 0 1,804.48 0
23105   3 90 2 0 1,677.44 0
23105   4 90 2 0 1,540.42 0
23106   1 90 2 0 1,810.20 0
23106   2 90 2 0 960.16 0
23106   3 90 2 0 1,698.80 0
23106   4 90 2 0 886.01 0
23107   1 90 2 0 1,706.87 0
23107   2 90 2 0 1,677.39 0
23107   3 90 2 0 1,555.63 0
23107   4 90 2 0 1,536.71 0
23120   1 90 2 0 1,174.98 0
23120   2 90 2 0 1,168.60 0
23120   3 90 2 0 1,142.18 0
23120   4 90 2 0 1,137.52 0
23125   1 90 2 0 1,634.85 0
23125   2 90 2 0 1,832.06 0
23125   3 90 2 0 1,503.96 0
23125   4 90 2 0 1,485.97 0
23130   1 90 2 0 1,344.58 0
23130   2 90 2 0 1,322.80 0
23130   3 90 2 0 1,232.52 0
23130   4 90 2 0 1,233.50 0
23140   1 90 2 0 990.86 0
23140   2 90 2 0 976.30 0
23140   3 90 2 0 916.24 0
23140   4 90 2 0 905.90 0
23145   1 90 2 0 1,581.47 0
23145   2 90 2 0 1,556.01 0
23145   3 90 2 0 1,450.68 0
23145   4 90 2 0 1,433.50 0
23146   1 90 2 0 1,194.10 0
23146   2 90 2 0 1,175.33 0
23146   3 90 2 0 1,097.99 0
23146   4 90 2 0 1,085.47 0
23150   1 90 2 0 1,352.25 0
23150   2 90 2 0 1,610.83 0
23150   3 90 2 0 1,575.21 0
23150   4 90 2 0 1,569.03 0
23155   1 90 2 0 1,733.46 0
23155   2 90 2 0 1,706.27 0
23155   3 90 2 0 1,593.87 0
23155   4 90 2 0 1,574.89 0
23156   1 90 2 0 1,484.20 0
23156   2 90 2 0 1,460.26 0
23156   3 90 2 0 1,361.40 0
23156   4 90 2 0 1,345.19 0
23170   1 90 2 0 1,038.31 0
23170   2 90 2 0 1,022.64 0
23170   3 90 2 0 958.00 0
23170   4 90 2 0 946.93 0
23172   1 90 2 0 1,059.51 0
23172   2 90 2 0 940.80 0
23172   3 90 2 0 979.61 0
23172   4 90 2 0 967.99 0
23174   1 90 2 0 1,617.11 0
23174   2 90 2 0 1,592.26 0
23174   3 90 2 0 1,489.13 0
23174   4 90 2 0 1,471.12 0
23180   1 90 2 0 1,112.92 0
23180   2 90 2 0 1,098.05 0
23180   3 90 2 0 927.00 0
23180   4 90 2 0 1,025.16 0
23182   1 90 2 0 1,330.75 0
23182   2 90 2 0 1,309.40 0
23182   3 90 2 0 1,221.13 0
23182   4 90 2 0 1,206.77 0
23184   1 90 2 0 1,668.04 0
23184   2 90 2 0 1,640.31 0
23184   3 90 2 0 1,525.59 0
23184   4 90 2 0 1,138.08 0
23190   1 90 2 0 1,214.52 0
23190   2 90 2 0 1,180.69 0
23190   3 90 2 0 1,116.30 0
23190   4 90 2 0 1,103.13 0
23195   1 90 2 0 1,703.52 0
23195   2 90 2 0 1,675.82 0
23195   3 90 2 0 1,561.06 0
23195   4 90 2 0 1,542.37 0
23200   1 90 2 0 1,872.90 0
23200   2 90 2 0 1,844.94 0
23200   3 90 2 0 1,733.17 0
23200   4 90 2 0 1,712.60 0
23210   1 90 2 0 3,099.15 0
23210   2 90 2 0 1,880.58 0
23210   3 90 2 0 1,762.09 0
23210   4 90 2 0 1,741.57 0
23220   1 90 2 0 2,407.86 0
23220   2 90 2 0 2,416.48 0
23220   3 90 2 0 2,349.40 0
23220   4 90 2 0 2,183.38 0
23330   1 10 2 0 208.15 0
23330   2 10 2 0 205.97 0
23330   3 10 2 0 197.17 0
23330   4 10 2 0 195.06 0
23333   1 90 2 0 625.09 0
23333   2 90 2 0 561.05 0
23333   3 90 2 0 561.05 0
23333   4 90 2 0 561.05 0
23334   1 90 2 0 1,476.47 0
23334   2 90 2 0 1,330.56 0
23334   3 90 2 0 1,330.56 0
23334   4 90 2 0 1,330.56 0
23335   1 90 2 0 1,760.86 0
23335   2 90 2 0 1,589.01 0
23335   3 90 2 0 1,589.01 0
23335   4 90 2 0 1,589.01 0
23350   1 0 2 0 126.57 0
23350   2 0 2 0 125.19 0
23350   3 0 2 0 119.24 0
23350   4 0 2 0 117.89 0
23395   1 90 2 0 2,230.43 0
23395   2 90 2 0 2,194.97 0
23395   3 90 2 0 2,048.38 0
23395   4 90 2 0 2,024.19 0
23397   1 90 2 0 2,774.32 0
23397   2 90 2 0 2,729.66 0
23397   3 90 2 0 2,545.06 0
23397   4 90 2 0 2,514.93 0
23400   1 90 2 0 2,146.33 0
23400   2 90 2 0 2,113.47 0
23400   3 90 2 0 1,977.86 0
23400   4 90 2 0 1,954.99 0
23405   1 90 2 0 1,435.86 0
23405   2 90 2 0 1,414.49 0
23405   3 90 2 0 1,326.07 0
23405   4 90 2 0 1,310.10 0
23406   1 90 2 0 1,874.15 0
23406   2 90 2 0 1,843.99 0
23406   3 90 2 0 1,719.44 0
23406   4 90 2 0 1,699.14 0
23410   1 90 2 0 2,158.64 0
23410   2 90 2 0 2,124.51 0
23410   3 90 2 0 1,983.28 0
23410   4 90 2 0 1,959.68 0
23412   1 90 2 0 2,552.32 0
23412   2 90 2 0 2,430.44 0
23412   3 90 2 0 2,298.53 0
23412   4 90 2 0 2,246.00 0
23415   1 90 2 0 1,703.71 0
23415   2 90 2 0 1,720.80 0
23415   3 90 2 0 1,699.37 0
23415   4 90 2 0 1,707.21 0
23420   1 90 2 0 2,520.46 0
23420   2 90 2 0 2,504.93 0
23420   3 90 2 0 2,363.61 0
23420   4 90 2 0 2,358.60 0
23430   1 90 2 0 1,583.61 0
23430   2 90 2 0 1,559.81 0
23430   3 90 2 0 1,461.39 0
23430   4 90 2 0 1,444.42 0
23440   1 90 2 0 1,610.35 0
23440   2 90 2 0 1,586.63 0
23440   3 90 2 0 1,488.75 0
23440   4 90 2 0 1,471.60 0
23450   1 90 2 0 2,313.88 0
23450   2 90 2 0 2,399.84 0
23450   3 90 2 0 2,227.48 0
23450   4 90 2 0 2,200.78 0
23455   1 90 2 0 2,809.07 0
23455   2 90 2 0 2,761.88 0
23455   3 90 2 0 2,566.74 0
23455   4 90 2 0 2,535.63 0
23460   1 90 2 0 2,720.08 0
23460   2 90 2 0 2,676.61 0
23460   3 90 2 0 2,496.85 0
23460   4 90 2 0 2,467.04 0
23462   1 90 2 0 2,838.29 0
23462   2 90 2 0 2,791.35 0
23462   3 90 2 0 2,597.38 0
23462   4 90 2 0 2,566.16 0
23465   1 90 2 0 2,701.09 0
23465   2 90 2 0 2,664.46 0
23465   3 90 2 0 2,340.02 0
23465   4 90 2 0 2,515.87 0
23466   1 90 2 0 2,898.62 0
23466   2 90 2 0 2,848.84 0
23466   3 90 2 0 2,643.19 0
23466   4 90 2 0 2,610.92 0
23470   1 90 2 0 3,155.68 0
23470   2 90 2 0 3,074.23 0
23470   3 90 2 0 2,863.21 0
23470   4 90 2 0 2,828.78 0
23472   1 90 2 0 4,274.86 0
23472   2 90 2 0 4,849.40 0
23472   3 90 2 0 4,716.51 0
23472   4 90 2 0 3,800.59 0
23473   1 90 2 0 2,265.38 0
23473   2 90 2 0 2,030.07 0
23473   3 90 2 0 2,030.07 0
23473   4 90 2 0 2,030.07 0
23474   1 90 2 0 2,449.22 0
23474   2 90 2 0 2,194.78 0
23474   3 90 2 0 2,194.78 0
23474   4 90 2 0 2,194.78 0
23480   1 90 2 0 1,582.83 0
23480   2 90 2 0 1,560.77 0
23480   3 90 2 0 1,470.31 0
23480   4 90 2 0 1,453.58 0
23485   1 90 2 0 2,275.27 0
23485   2 90 2 0 2,196.21 0
23485   3 90 2 0 2,089.90 0
23485   4 90 2 0 2,065.20 0
23490   1 90 2 0 1,905.20 0
23490   2 90 2 0 1,881.22 0
23490   3 90 2 0 1,618.71 0
23490   4 90 2 0 1,759.73 0
23491   1 90 2 0 2,500.12 0
23491   2 90 2 0 2,459.83 0
23491   3 90 2 0 2,191.94 0
23491   4 90 2 0 2,266.22 0
23500   1 90 2 0 331.47 0
23500   2 90 2 0 371.18 0
23500   3 90 2 0 316.53 0
23500   4 90 2 0 320.69 0
23505   1 90 2 0 530.09 0
23505   2 90 2 0 557.69 0
23505   3 90 2 0 514.81 0
23505   4 90 2 0 518.22 0
23515   1 90 2 0 1,324.48 0
23515   2 90 2 0 1,303.00 0
23515   3 90 2 0 1,214.28 0
23515   4 90 2 0 1,199.70 0
23520   1 90 2 0 312.96 0
23520   2 90 2 0 308.74 0
23520   3 90 2 0 287.90 0
23520   4 90 2 0 287.70 0
23525   1 90 2 0 489.73 0
23525   2 90 2 0 483.43 0
23525   3 90 2 0 457.22 0
23525   4 90 2 0 452.04 0
23530   1 90 2 0 1,268.28 0
23530   2 90 2 0 1,249.14 0
23530   3 90 2 0 1,169.92 0
23530   4 90 2 0 1,155.81 0
23532   1 90 2 0 1,407.09 0
23532   2 90 2 0 1,384.31 0
23532   3 90 2 0 1,290.43 0
23532   4 90 2 0 1,275.09 0
23540   1 90 2 0 333.10 0
23540   2 90 2 0 328.60 0
23540   3 90 2 0 310.00 0
23540   4 90 2 0 306.39 0
23545   1 90 2 0 511.49 0
23545   2 90 2 0 508.84 0
23545   3 90 2 0 450.27 0
23545   4 90 2 0 439.84 0
23550   1 90 2 0 1,471.43 0
23550   2 90 2 0 1,511.10 0
23550   3 90 2 0 1,336.67 0
23550   4 90 2 0 1,320.32 0
23552   1 90 2 0 1,430.47 0
23552   2 90 2 0 1,407.70 0
23552   3 90 2 0 1,313.77 0
23552   4 90 2 0 1,298.16 0
23570   1 90 2 0 353.29 0
23570   2 90 2 0 348.07 0
23570   3 90 2 0 326.58 0
23570   4 90 2 0 322.75 0
23575   1 90 2 0 615.68 0
23575   2 90 2 0 606.81 0
23575   3 90 2 0 576.94 0
23575   4 90 2 0 563.46 0
23585   1 90 2 0 1,529.49 0
23585   2 90 2 0 1,504.92 0
23585   3 90 2 0 1,403.42 0
23585   4 90 2 0 1,386.76 0
23600   1 90 2 0 555.56 0
23600   2 90 2 0 574.87 0
23600   3 90 2 0 579.42 0
23600   4 90 2 0 564.62 0
23605   1 90 2 0 945.94 0
23605   2 90 2 0 959.49 0
23605   3 90 2 0 874.03 0
23605   4 90 2 0 802.26 0
23615   1 90 2 0 2,039.81 0
23615   2 90 2 0 1,813.73 0
23615   3 90 2 0 1,679.43 0
23615   4 90 2 0 1,746.50 0
23616   1 90 2 0 3,120.13 0
23616   2 90 2 0 3,961.47 0
23616   3 90 2 0 3,683.31 0
23616   4 90 2 0 2,726.32 0
23620   1 90 2 0 567.12 0
23620   2 90 2 0 594.15 0
23620   3 90 2 0 578.40 0
23620   4 90 2 0 573.57 0
23625   1 90 2 0 709.00 0
23625   2 90 2 0 697.38 0
23625   3 90 2 0 649.43 0
23625   4 90 2 0 662.19 0
23630   1 90 2 0 1,711.68 0
23630   2 90 2 0 1,700.69 0
23630   3 90 2 0 1,655.28 0
23630   4 90 2 0 1,648.14 0
23650   1 90 2 0 517.27 0
23650   2 90 2 0 493.01 0
23650   3 90 2 0 457.11 0
23650   4 90 2 0 473.59 0
23655   1 90 2 0 664.67 0
23655   2 90 2 0 655.27 0
23655   3 90 2 0 616.55 0
23655   4 90 2 0 609.48 0
23660   1 90 2 0 1,885.86 0
23660   2 90 2 0 1,822.97 0
23660   3 90 2 0 1,728.73 0
23660   4 90 2 0 1,752.27 0
23665   1 90 2 0 702.50 0
23665   2 90 2 0 691.93 0
23665   3 90 2 0 663.81 0
23665   4 90 2 0 661.10 0
23670   1 90 2 0 1,743.91 0
23670   2 90 2 0 1,711.68 0
23670   3 90 2 0 1,646.69 0
23670   4 90 2 0 1,559.00 0
23675   1 90 2 0 885.14 0
23675   2 90 2 0 872.38 0
23675   3 90 2 0 819.58 0
23675   4 90 2 0 810.17 0
23680   1 90 2 0 2,110.26 0
23680   2 90 2 0 2,072.39 0
23680   3 90 2 0 1,915.76 0
23680   4 90 2 0 1,892.23 0
23700   1 10 2 0 560.38 0
23700   2 10 2 0 556.13 0
23700   3 10 2 0 546.06 0
23700   4 10 2 0 544.11 0
23800   1 90 2 0 2,850.81 0
23800   2 90 2 0 2,801.80 0
23800   3 90 2 0 2,599.10 0
23800   4 90 2 0 2,567.28 0
23802   1 90 2 0 2,720.92 0
23802   2 90 2 0 2,677.45 0
23802   3 90 2 0 2,497.65 0
23802   4 90 2 0 2,467.83 0
23900   1 90 2 0 2,930.97 0
23900   2 90 2 0 2,885.67 0
23900   3 90 2 0 2,699.06 0
23900   4 90 2 0 2,668.43 0
23920   1 90 2 0 2,650.99 0
23920   2 90 2 0 2,605.46 0
23920   3 90 2 0 2,417.23 0
23920   4 90 2 0 2,388.55 0
23921   1 90 2 0 883.39 0
23921   2 90 2 0 869.30 0
23921   3 90 2 0 811.17 0
23921   4 90 2 0 801.68 0
23929     YYY 2 0 * 0
23930   1 10 2 0 402.25 0
23930   2 10 2 0 396.84 0
23930   3 10 2 0 374.79 0
23930   4 10 2 0 376.20 0
23931   1 10 2 0 215.73 0
23931   2 10 2 0 215.27 0
23931   3 10 2 0 202.20 0
23931   4 10 2 0 199.39 0
23935   1 90 2 0 967.97 0
23935   2 90 2 0 952.85 0
23935   3 90 2 0 890.22 0
23935   4 90 2 0 879.78 0
24000   1 90 2 0 1,313.23 0
24000   2 90 2 0 1,408.62 0
24000   3 90 2 0 1,460.72 0
24000   4 90 2 0 1,171.01 0
24006   1 90 2 0 1,491.55 0
24006   2 90 2 0 1,468.51 0
24006   3 90 2 0 1,373.51 0
24006   4 90 2 0 1,357.45 0
24065   1 10 2 0 251.28 0
24065   2 10 2 0 248.49 0
24065   3 10 2 0 212.17 0
24065   4 10 2 0 234.42 0
24066   1 90 2 0 466.21 0
24066   2 90 2 0 453.95 0
24066   3 90 2 0 440.53 0
24066   4 90 2 0 646.46 0
24071   1 90 2 0 591.72 0
24071   2 90 2 0 526.06 0
24071   3 90 2 0 526.06 0
24071   4 90 2 0 526.06 0
24073   1 90 2 0 1,015.85 0
24073   2 90 2 0 904.69 0
24073   3 90 2 0 904.69 0
24073   4 90 2 0 904.69 0