2018 Workers' Compensation Part B Fee Schedule

24075-25109

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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
24075   1 90 2 0 469.54 0
24075   2 90 2 0 458.27 0
24075   3 90 2 0 459.38 0
24075   4 90 2 0 442.30 0
24076   1 90 2 0 883.97 0
24076   2 90 2 0 849.27 0
24076   3 90 2 0 822.53 0
24076   4 90 2 0 764.60 0
24077   1 90 2 0 2,015.90 0
24077   2 90 2 0 1,426.51 0
24077   3 90 2 0 1,348.61 0
24077   4 90 2 0 1,821.79 0
24079   1 90 2 0 1,894.92 0
24079   2 90 2 0 1,693.11 0
24079   3 90 2 0 1,693.11 0
24079   4 90 2 0 1,693.11 0
24100   1 90 2 0 842.67 0
24100   2 90 2 0 1,262.54 0
24100   3 90 2 0 773.93 0
24100   4 90 2 0 764.76 0
24101   1 90 2 0 1,659.11 0
24101   2 90 2 0 1,404.83 0
24101   3 90 2 0 1,472.34 0
24101   4 90 2 0 1,466.06 0
24102   1 90 2 0 1,860.21 0
24102   2 90 2 0 1,793.05 0
24102   3 90 2 0 1,687.00 0
24102   4 90 2 0 1,705.55 0
24105   1 90 2 0 815.78 0
24105   2 90 2 0 793.05 0
24105   3 90 2 0 677.15 0
24105   4 90 2 0 731.92 0
24110   1 90 2 0 1,407.55 0
24110   2 90 2 0 1,470.69 0
24110   3 90 2 0 1,288.11 0
24110   4 90 2 0 1,272.52 0
24115   1 90 2 0 1,573.10 0
24115   2 90 2 0 1,547.95 0
24115   3 90 2 0 1,444.04 0
24115   4 90 2 0 1,427.11 0
24116   1 90 2 0 1,954.64 0
24116   2 90 2 0 1,924.71 0
24116   3 90 2 0 1,801.22 0
24116   4 90 2 0 1,779.89 0
24120   1 90 2 0 1,370.85 0
24120   2 90 2 0 1,441.61 0
24120   3 90 2 0 1,272.29 0
24120   4 90 2 0 1,403.52 0
24125   1 90 2 0 1,194.75 0
24125   2 90 2 0 1,179.04 0
24125   3 90 2 0 1,113.97 0
24125   4 90 2 0 1,100.69 0
24126   1 90 2 0 1,438.92 0
24126   2 90 2 0 1,415.75 0
24126   3 90 2 0 1,319.92 0
24126   4 90 2 0 1,304.19 0
24130   1 90 2 0 1,257.77 0
24130   2 90 2 0 1,228.64 0
24130   3 90 2 0 1,144.30 0
24130   4 90 2 0 1,156.70 0
24134   1 90 2 0 1,655.32 0
24134   2 90 2 0 1,629.80 0
24134   3 90 2 0 1,524.39 0
24134   4 90 2 0 1,506.04 0
24136   1 90 2 0 1,482.07 0
24136   2 90 2 0 1,460.32 0
24136   3 90 2 0 1,160.69 0
24136   4 90 2 0 1,352.53 0
24138   1 90 2 0 1,300.08 0
24138   2 90 2 0 1,224.25 0
24138   3 90 2 0 1,194.90 0
24138   4 90 2 0 1,180.83 0
24140   1 90 2 0 1,655.01 0
24140   2 90 2 0 1,627.66 0
24140   3 90 2 0 1,514.42 0
24140   4 90 2 0 1,496.30 0
24145   1 90 2 0 1,275.29 0
24145   2 90 2 0 1,255.22 0
24145   3 90 2 0 1,172.20 0
24145   4 90 2 0 1,158.33 0
24147   1 90 2 0 1,290.90 0
24147   2 90 2 0 1,270.13 0
24147   3 90 2 0 1,176.44 0
24147   4 90 2 0 1,170.34 0
24149   1 90 2 0 2,496.26 0
24149   2 90 2 0 2,233.11 0
24149   3 90 2 0 2,173.12 0
24149   4 90 2 0 2,173.12 0
24150   1 90 2 0 2,768.35 0
24150   2 90 2 0 2,490.28 0
24150   3 90 2 0 2,314.93 0
24150   4 90 2 0 2,286.79 0
24152   1 90 2 0 1,530.44 0
24152   2 90 2 0 1,507.48 0
24152   3 90 2 0 1,412.77 0
24152   4 90 2 0 1,396.57 0
24155   1 90 2 0 2,574.84 0
24155   2 90 2 0 2,543.60 0
24155   3 90 2 0 2,148.21 0
24155   4 90 2 0 1,878.35 0
24160   1 90 2 0 1,141.24 0
24160   2 90 2 0 1,124.78 0
24160   3 90 2 0 1,057.02 0
24160   4 90 2 0 1,044.96 0
24164   1 90 2 0 1,073.74 0
24164   2 90 2 0 1,056.43 0
24164   3 90 2 0 984.93 0
24164   4 90 2 0 973.20 0
24200   1 10 2 0 163.05 0
24200   2 10 2 0 145.58 0
24200   3 10 2 0 157.52 0
24200   4 10 2 0 175.74 0
24201   1 90 2 0 686.55 0
24201   2 90 2 0 674.85 0
24201   3 90 2 0 634.83 0
24201   4 90 2 0 627.49 0
24220   1 0 2 0 129.82 0
24220   2 0 2 0 148.54 0
24220   3 0 2 0 142.08 0
24220   4 0 2 0 95.07 0
24300   1 90 2 0 667.46 0
24300   2 90 2 0 581.92 0
24300   3 90 2 0 581.92 0
24300   4 90 2 0 581.92 0
24301   1 90 2 0 1,654.87 0
24301   2 90 2 0 1,468.71 0
24301   3 90 2 0 1,371.56 0
24301   4 90 2 0 1,509.02 0
24305   1 90 2 0 903.12 0
24305   2 90 2 0 893.55 0
24305   3 90 2 0 853.98 0
24305   4 90 2 0 844.49 0
24310   1 90 2 0 795.71 0
24310   2 90 2 0 785.15 0
24310   3 90 2 0 741.56 0
24310   4 90 2 0 733.31 0
24320   1 90 2 0 2,202.53 0
24320   2 90 2 0 1,764.40 0
24320   3 90 2 0 1,652.65 0
24320   4 90 2 0 2,069.72 0
24330   1 90 2 0 1,701.85 0
24330   2 90 2 0 974.32 0
24330   3 90 2 0 1,560.76 0
24330   4 90 2 0 1,701.54 0
24331   1 90 2 0 1,872.05 0
24331   2 90 2 0 1,841.85 0
24331   3 90 2 0 1,717.13 0
24331   4 90 2 0 1,696.70 0
24332   1 90 2 0 913.75 0
24332   2 90 2 0 812.51 0
24332   3 90 2 0 812.51 0
24332   4 90 2 0 812.51 0
24340   1 90 2 0 1,514.95 0
24340   2 90 2 0 1,357.41 0
24340   3 90 2 0 1,380.70 0
24340   4 90 2 0 1,251.74 0
24341   1 90 2 0 1,380.13 0
24341   2 90 2 0 1,234.81 0
24341   3 90 2 0 1,201.64 0
24341   4 90 2 0 1,201.64 0
24342   1 90 2 0 1,963.28 0
24342   2 90 2 0 1,930.51 0
24342   3 90 2 0 1,795.04 0
24342   4 90 2 0 1,773.59 0
24343   1 90 2 0 1,216.37 0
24343   2 90 2 0 1,067.07 0
24343   3 90 2 0 1,067.07 0
24343   4 90 2 0 1,067.07 0
24344   1 90 2 0 1,834.21 0
24344   2 90 2 0 1,612.84 0
24344   3 90 2 0 1,612.84 0
24344   4 90 2 0 1,612.84 0
24345   1 90 2 0 1,216.37 0
24345   2 90 2 0 1,067.07 0
24345   3 90 2 0 1,067.07 0
24345   4 90 2 0 1,067.07 0
24346   1 90 2 0 1,834.21 0
24346   2 90 2 0 1,612.84 0
24346   3 90 2 0 1,612.84 0
24346   4 90 2 0 1,612.84 0
24357   1 90 2 0 640.87 0
24357   2 90 2 0 557.54 0
24357   3 90 2 0 557.54 0
24357   4 90 2 0 557.54 0
24358   1 90 2 0 752.04 0
24358   2 90 2 0 655.76 0
24358   3 90 2 0 655.76 0
24358   4 90 2 0 655.76 0
24359   1 90 2 0 921.34 0
24359   2 90 2 0 808.14 0
24359   3 90 2 0 808.14 0
24359   4 90 2 0 808.14 0
24360   1 90 2 0 2,588.49 0
24360   2 90 2 0 3,071.81 0
24360   3 90 2 0 2,851.46 0
24360   4 90 2 0 2,326.72 0
24361   1 90 2 0 2,511.96 0
24361   2 90 2 0 2,472.26 0
24361   3 90 2 0 2,308.22 0
24361   4 90 2 0 2,280.57 0
24362   1 90 2 0 2,727.25 0
24362   2 90 2 0 2,405.86 0
24362   3 90 2 0 2,285.25 0
24362   4 90 2 0 2,256.88 0
24363   1 90 2 0 4,121.71 0
24363   2 90 2 0 4,030.50 0
24363   3 90 2 0 3,739.36 0
24363   4 90 2 0 3,618.30 0
24365   1 90 2 0 2,162.69 0
24365   2 90 2 0 1,437.43 0
24365   3 90 2 0 1,341.44 0
24365   4 90 2 0 1,325.50 0
24366   1 90 2 0 2,927.91 0
24366   2 90 2 0 2,892.44 0
24366   3 90 2 0 1,731.20 0
24366   4 90 2 0 1,709.92 0
24370   1 90 2 0 2,135.55 0
24370   2 90 2 0 1,916.23 0
24370   3 90 2 0 1,916.23 0
24370   4 90 2 0 1,916.23 0
24371   1 90 2 0 2,461.23 0
24371   2 90 2 0 2,209.68 0
24371   3 90 2 0 2,209.68 0
24371   4 90 2 0 2,209.68 0
24400   1 90 2 0 1,783.66 0
24400   2 90 2 0 1,756.36 0
24400   3 90 2 0 1,643.82 0
24400   4 90 2 0 1,624.63 0
24410   1 90 2 0 2,662.73 0
24410   2 90 2 0 2,501.09 0
24410   3 90 2 0 2,448.99 0
24410   4 90 2 0 2,419.55 0
24420   1 90 2 0 2,391.92 0
24420   2 90 2 0 2,353.35 0
24420   3 90 2 0 2,194.02 0
24420   4 90 2 0 2,167.90 0
24430   1 90 2 0 2,581.05 0
24430   2 90 2 0 2,537.08 0
24430   3 90 2 0 2,355.27 0
24430   4 90 2 0 2,326.49 0
24435   1 90 2 0 2,780.63 0
24435   2 90 2 0 2,730.33 0
24435   3 90 2 0 2,522.12 0
24435   4 90 2 0 2,491.12 0
24470   1 90 2 0 1,541.64 0
24470   2 90 2 0 1,516.79 0
24470   3 90 2 0 1,414.01 0
24470   4 90 2 0 1,397.24 0
24495   1 90 2 0 1,270.05 0
24495   2 90 2 0 1,387.76 0
24495   3 90 2 0 1,352.64 0
24495   4 90 2 0 1,347.04 0
24498   1 90 2 0 2,044.09 0
24498   2 90 2 0 2,012.05 0
24498   3 90 2 0 1,879.50 0
24498   4 90 2 0 1,857.15 0
24500   1 90 2 0 556.26 0
24500   2 90 2 0 567.61 0
24500   3 90 2 0 531.24 0
24500   4 90 2 0 531.40 0
24505   1 90 2 0 899.40 0
24505   2 90 2 0 898.56 0
24505   3 90 2 0 829.27 0
24505   4 90 2 0 840.82 0
24515   1 90 2 0 1,940.16 0
24515   2 90 2 0 1,909.78 0
24515   3 90 2 0 1,784.40 0
24515   4 90 2 0 1,763.32 0
24516   1 90 2 0 1,940.16 0
24516   2 90 2 0 1,909.78 0
24516   3 90 2 0 1,784.40 0
24516   4 90 2 0 1,763.32 0
24530   1 90 2 0 564.15 0
24530   2 90 2 0 555.67 0
24530   3 90 2 0 538.42 0
24530   4 90 2 0 537.31 0
24535   1 90 2 0 1,006.65 0
24535   2 90 2 0 1,013.64 0
24535   3 90 2 0 890.02 0
24535   4 90 2 0 955.56 0
24538   1 90 2 0 1,586.73 0
24538   2 90 2 0 1,307.27 0
24538   3 90 2 0 1,169.34 0
24538   4 90 2 0 1,220.61 0
24545   1 90 2 0 1,908.26 0
24545   2 90 2 0 1,890.61 0
24545   3 90 2 0 1,817.70 0
24545   4 90 2 0 1,805.79 0
24546   1 90 2 0 2,118.73 0
24546   2 90 2 0 2,099.82 0
24546   3 90 2 0 2,021.96 0
24546   4 90 2 0 2,008.14 0
24560   1 90 2 0 472.28 0
24560   2 90 2 0 462.83 0
24560   3 90 2 0 448.73 0
24560   4 90 2 0 452.59 0
24565   1 90 2 0 688.87 0
24565   2 90 2 0 684.44 0
24565   3 90 2 0 648.86 0
24565   4 90 2 0 737.10 0
24566   1 90 2 0 1,244.24 0
24566   2 90 2 0 1,227.63 0
24566   3 90 2 0 1,152.20 0
24566   4 90 2 0 1,132.13 0
24575   1 90 2 0 1,657.81 0
24575   2 90 2 0 1,632.82 0
24575   3 90 2 0 1,529.79 0
24575   4 90 2 0 1,511.90 0
24576   1 90 2 0 472.27 0
24576   2 90 2 0 471.09 0
24576   3 90 2 0 441.24 0
24576   4 90 2 0 436.90 0
24577   1 90 2 0 846.55 0
24577   2 90 2 0 835.74 0
24577   3 90 2 0 812.86 0
24577   4 90 2 0 803.45 0
24579   1 90 2 0 1,805.14 0
24579   2 90 2 0 1,772.81 0
24579   3 90 2 0 1,661.10 0
24579   4 90 2 0 1,641.77 0
24582   1 90 2 0 1,398.00 0
24582   2 90 2 0 1,372.17 0
24582   3 90 2 0 1,251.81 0
24582   4 90 2 0 1,237.06 0
24586   1 90 2 0 2,766.81 0
24586   2 90 2 0 2,736.97 0
24586   3 90 2 0 2,394.75 0
24586   4 90 2 0 2,504.13 0
24587   1 90 2 0 2,647.52 0
24587   2 90 2 0 2,605.27 0
24587   3 90 2 0 2,430.58 0
24587   4 90 2 0 2,401.55 0
24600   1 90 2 0 563.57 0
24600   2 90 2 0 537.15 0
24600   3 90 2 0 510.09 0
24600   4 90 2 0 504.43 0
24605   1 90 2 0 671.59 0
24605   2 90 2 0 663.12 0
24605   3 90 2 0 634.21 0
24605   4 90 2 0 621.48 0
24615   1 90 2 0 1,719.09 0
24615   2 90 2 0 1,722.95 0
24615   3 90 2 0 1,573.64 0
24615   4 90 2 0 1,653.69 0
24620   1 90 2 0 953.65 0
24620   2 90 2 0 940.91 0
24620   3 90 2 0 888.29 0
24620   4 90 2 0 878.26 0
24635   1 90 2 0 2,216.86 0
24635   2 90 2 0 2,182.03 0
24635   3 90 2 0 2,038.08 0
24635   4 90 2 0 2,013.93 0
24640   1 10 2 0 180.34 0
24640   2 10 2 0 167.12 0
24640   3 10 2 0 158.77 0
24640   4 10 2 0 166.60 0
24650   1 90 2 0 402.91 307.50
24650   2 90 2 0 448.47 341.77
24650   3 90 2 0 418.88 318.84
24650   4 90 2 0 424.17 322.55
24655   1 90 2 0 666.36 0
24655   2 90 2 0 656.76 0
24655   3 90 2 0 617.16 0
24655   4 90 2 0 610.05 0
24665   1 90 2 0 1,488.21 0
24665   2 90 2 0 1,379.31 0
24665   3 90 2 0 1,360.54 0
24665   4 90 2 0 1,354.13 0
24666   1 90 2 0 1,826.51 0
24666   2 90 2 0 1,795.96 0
24666   3 90 2 0 1,669.56 0
24666   4 90 2 0 1,649.18 0
24670   1 90 2 0 396.35 0
24670   2 90 2 0 396.06 0
24670   3 90 2 0 372.05 0
24670   4 90 2 0 367.65 0
24675   1 90 2 0 749.80 0
24675   2 90 2 0 738.74 0
24675   3 90 2 0 692.61 0
24675   4 90 2 0 684.59 0
24685   1 90 2 0 1,588.58 0
24685   2 90 2 0 1,562.87 0
24685   3 90 2 0 1,456.34 0
24685   4 90 2 0 1,438.87 0
24800   1 90 2 0 2,177.71 0
24800   2 90 2 0 1,975.27 0
24800   3 90 2 0 1,845.46 0
24800   4 90 2 0 1,823.29 0
24802   1 90 2 0 2,370.09 0
24802   2 90 2 0 2,331.92 0
24802   3 90 2 0 2,174.11 0
24802   4 90 2 0 2,148.21 0
24900   1 90 2 0 1,572.05 0
24900   2 90 2 0 1,546.27 0
24900   3 90 2 0 1,439.98 0
24900   4 90 2 0 1,423.14 0
24920   1 90 2 0 1,463.16 0
24920   2 90 2 0 1,440.36 0
24920   3 90 2 0 1,346.26 0
24920   4 90 2 0 1,330.71 0
24925   1 90 2 0 1,186.76 0
24925   2 90 2 0 1,169.61 0
24925   3 90 2 0 834.52 0
24925   4 90 2 0 1,085.23 0
24930   1 90 2 0 1,636.31 0
24930   2 90 2 0 1,611.85 0
24930   3 90 2 0 1,510.66 0
24930   4 90 2 0 1,492.72 0
24931   1 90 2 0 2,173.55 0
24931   2 90 2 0 2,138.37 0
24931   3 90 2 0 1,993.08 0
24931   4 90 2 0 1,969.35 0
24935   1 90 2 0 2,664.01 0
24935   2 90 2 0 2,621.09 0
24935   3 90 2 0 2,443.66 0
24935   4 90 2 0 2,414.57 0
24940   1 90 2 0 2,664.01 0
24940   2 90 2 0 2,621.09 0
24940   3 90 2 0 2,443.66 0
24940   4 90 2 0 2,414.57 0
24999     YYY 2 0 * 0
25000   1 90 2 0 918.83 0
25000   2 90 2 0 863.92 0
25000   3 90 2 0 790.53 0
25000   4 90 2 0 842.24 0
25001   1 90 2 0 556.92 0
25001   2 90 2 0 487.00 0
25001   3 90 2 0 487.00 0
25001   4 90 2 0 487.00 0
25020   1 90 2 0 937.41 0
25020   2 90 2 0 926.13 0
25020   3 90 2 0 862.05 0
25020   4 90 2 0 852.12 0
25023   1 90 2 0 1,495.63 0
25023   2 90 2 0 1,510.27 0
25023   3 90 2 0 1,431.88 0
25023   4 90 2 0 1,422.02 0
25024   1 90 2 0 1,288.58 0
25024   2 90 2 0 1,135.13 0
25024   3 90 2 0 1,135.13 0
25024   4 90 2 0 1,135.13 0
25025   1 90 2 0 2,076.95 0
25025   2 90 2 0 1,839.52 0
25025   3 90 2 0 1,839.52 0
25025   4 90 2 0 1,839.52 0
25028   1 90 2 0 584.91 0
25028   2 90 2 0 579.65 0
25028   3 90 2 0 546.62 0
25028   4 90 2 0 533.10 0
25031   1 90 2 0 397.25 0
25031   2 90 2 0 393.74 0
25031   3 90 2 0 379.49 0
25031   4 90 2 0 317.88 0
25035   1 90 2 0 1,207.31 0
25035   2 90 2 0 1,190.99 0
25035   3 90 2 0 1,046.45 0
25035   4 90 2 0 1,127.26 0
25040   1 90 2 0 1,156.58 0
25040   2 90 2 0 1,208.21 0
25040   3 90 2 0 1,064.81 0
25040   4 90 2 0 1,052.26 0
25065   1 10 2 0 277.64 0
25065   2 10 2 0 220.56 0
25065   3 10 2 0 263.08 0
25065   4 10 2 0 205.16 0
25066   1 90 2 0 358.81 0
25066   2 90 2 0 354.63 0
25066   3 90 2 0 457.02 0
25066   4 90 2 0 452.06 0
25071   1 90 2 0 619.34 0
25071   2 90 2 0 550.63 0
25071   3 90 2 0 550.63 0
25071   4 90 2 0 550.63 0
25073   1 90 2 0 770.96 0
25073   2 90 2 0 684.71 0
25073   3 90 2 0 684.71 0
25073   4 90 2 0 684.71 0
25075   1 90 2 0 546.40 0
25075   2 90 2 0 590.60 0
25075   3 90 2 0 546.80 0
25075   4 90 2 0 524.17 0
25076   1 90 2 0 809.16 0
25076   2 90 2 0 788.19 0
25076   3 90 2 0 743.77 0
25076   4 90 2 0 724.32 0
25077   1 90 2 0 1,459.26 0
25077   2 90 2 0 1,442.30 0
25077   3 90 2 0 1,564.97 0
25077   4 90 2 0 1,546.71 0
25078   1 90 2 0 1,653.76 0
25078   2 90 2 0 1,476.38 0
25078   3 90 2 0 1,476.38 0
25078   4 90 2 0 1,476.38 0
25085   1 90 2 0 917.24 0
25085   2 90 2 0 1,009.22 0
25085   3 90 2 0 844.17 0
25085   4 90 2 0 834.14 0
25100   1 90 2 0 808.65 0
25100   2 90 2 0 968.29 0
25100   3 90 2 0 735.14 0
25100   4 90 2 0 913.72 0
25101   1 90 2 0 988.03 0
25101   2 90 2 0 958.62 0
25101   3 90 2 0 898.53 0
25101   4 90 2 0 908.06 0
25105   1 90 2 0 1,516.11 0
25105   2 90 2 0 1,441.74 0
25105   3 90 2 0 1,469.54 0
25105   4 90 2 0 1,100.96 0
25107   1 90 2 0 1,060.79 0
25107   2 90 2 0 1,043.75 0
25107   3 90 2 0 973.56 0
25107   4 90 2 0 962.11 0
25109   1 90 2 0 717.31 0
25109   2 90 2 0 622.69 0
25109   3 90 2 0 622.69 0
25109   4 90 2 0 622.69 0