2018 Workers' Compensation Part B Fee Schedule

25922-26565

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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
25922   1 90 2 0 1,190.32 0
25922   2 90 2 0 1,171.33 0
25922   3 90 2 0 1,092.89 0
25922   4 90 2 0 1,080.22 0
25924   1 90 2 0 1,457.78 0
25924   2 90 2 0 1,434.36 0
25924   3 90 2 0 1,337.50 0
25924   4 90 2 0 1,321.52 0
25927   1 90 2 0 1,443.75 0
25927   2 90 2 0 1,366.83 0
25927   3 90 2 0 1,382.83 0
25927   4 90 2 0 1,260.22 0
25929   1 90 2 0 1,128.27 0
25929   2 90 2 0 993.12 0
25929   3 90 2 0 1,037.85 0
25929   4 90 2 0 1,026.21 0
25931   1 90 2 0 1,122.29 0
25931   2 90 2 0 1,352.57 0
25931   3 90 2 0 1,035.24 0
25931   4 90 2 0 1,023.70 0
25999     YYY 2 0 * 0
26010   1 10 2 0 143.56 126.50
26010   2 10 2 0 142.79 126.00
26010   3 10 2 0 137.37 121.76
26010   4 10 2 0 127.87 112.97
26011   1 10 2 0 312.32 0
26011   2 10 2 0 282.57 0
26011   3 10 2 0 259.92 0
26011   4 10 2 0 267.92 0
26020   1 90 2 0 726.52 0
26020   2 90 2 0 704.33 0
26020   3 90 2 0 651.96 0
26020   4 90 2 0 666.11 0
26025   1 90 2 0 845.81 0
26025   2 90 2 0 826.19 0
26025   3 90 2 0 782.13 0
26025   4 90 2 0 763.79 0
26030   1 90 2 0 1,064.74 0
26030   2 90 2 0 1,046.68 0
26030   3 90 2 0 972.13 0
26030   4 90 2 0 985.07 0
26034   1 90 2 0 970.46 0
26034   2 90 2 0 958.69 0
26034   3 90 2 0 940.28 0
26034   4 90 2 0 936.12 0
26035   1 90 2 0 1,257.69 0
26035   2 90 2 0 1,209.90 0
26035   3 90 2 0 1,113.87 0
26035   4 90 2 0 1,153.14 0
26037   1 90 2 0 1,239.36 0
26037   2 90 2 0 1,219.29 0
26037   3 90 2 0 1,136.46 0
26037   4 90 2 0 1,123.01 0
26040   1 90 2 0 708.51 0
26040   2 90 2 0 692.94 0
26040   3 90 2 0 688.19 0
26040   4 90 2 0 693.95 0
26045   1 90 2 0 959.27 0
26045   2 90 2 0 1,164.83 0
26045   3 90 2 0 1,166.29 0
26045   4 90 2 0 1,163.44 0
26055   1 90 2 0 681.53 0
26055   2 90 2 0 670.20 0
26055   3 90 2 0 619.28 0
26055   4 90 2 0 651.86 0
26060   1 90 2 0 346.42 0
26060   2 90 2 0 307.47 0
26060   3 90 2 0 305.29 0
26060   4 90 2 0 321.67 0
26070   1 90 2 0 660.51 0
26070   2 90 2 0 654.06 0
26070   3 90 2 0 613.77 0
26070   4 90 2 0 642.96 0
26075   1 90 2 0 556.54 0
26075   2 90 2 0 621.11 0
26075   3 90 2 0 508.68 0
26075   4 90 2 0 504.26 0
26080   1 90 2 0 651.44 0
26080   2 90 2 0 673.22 0
26080   3 90 2 0 669.97 0
26080   4 90 2 0 654.79 0
26100   1 90 2 0 611.16 0
26100   2 90 2 0 601.88 0
26100   3 90 2 0 612.93 0
26100   4 90 2 0 649.95 0
26105   1 90 2 0 743.06 0
26105   2 90 2 0 730.43 0
26105   3 90 2 0 678.35 0
26105   4 90 2 0 670.08 0
26110   1 90 2 0 600.81 0
26110   2 90 2 0 631.64 0
26110   3 90 2 0 586.86 0
26110   4 90 2 0 594.80 0
26111   1 90 2 0 599.00 0
26111   2 90 2 0 531.95 0
26111   3 90 2 0 531.95 0
26111   4 90 2 0 531.95 0
26113   1 90 2 0 787.61 0
26113   2 90 2 0 699.74 0
26113   3 90 2 0 699.74 0
26113   4 90 2 0 699.74 0
26115   1 90 2 0 509.02 0
26115   2 90 2 0 503.32 0
26115   3 90 2 0 475.42 0
26115   4 90 2 0 465.84 0
26116   1 90 2 0 649.26 0
26116   2 90 2 0 760.63 0
26116   3 90 2 0 635.73 0
26116   4 90 2 0 602.62 0
26117   1 90 2 0 996.72 0
26117   2 90 2 0 993.02 0
26117   3 90 2 0 1,151.24 0
26117   4 90 2 0 1,138.30 0
26118   1 90 2 0 1,549.84 0
26118   2 90 2 0 1,377.85 0
26118   3 90 2 0 1,377.85 0
26118   4 90 2 0 1,377.85 0
26121   1 90 2 0 1,901.18 0
26121   2 90 2 0 1,843.02 0
26121   3 90 2 0 1,560.57 0
26121   4 90 2 0 1,752.77 0
26123   1 90 2 0 1,723.78 0
26123   2 90 2 0 1,671.07 0
26123   3 90 2 0 1,575.36 0
26123   4 90 2 0 1,594.10 0
26125   1 ZZZ 0 0 1,370.49 0
26125   2 ZZZ 0 0 1,323.19 0
26125   3 ZZZ 0 0 1,250.71 0
26125   4 ZZZ 0 0 1,271.75 0
26130   1 90 2 0 969.88 0
26130   2 90 2 0 953.84 0
26130   3 90 2 0 887.54 0
26130   4 90 2 0 876.97 0
26135   1 90 2 0 1,081.07 0
26135   2 90 2 0 1,064.81 0
26135   3 90 2 0 997.63 0
26135   4 90 2 0 986.15 0
26140   1 90 2 0 967.50 0
26140   2 90 2 0 952.73 0
26140   3 90 2 0 891.97 0
26140   4 90 2 0 881.61 0
26145   1 90 2 0 923.42 0
26145   2 90 2 0 911.32 0
26145   3 90 2 0 866.23 0
26145   4 90 2 0 863.52 0
26160   1 90 2 0 627.09 0
26160   2 90 2 0 553.10 0
26160   3 90 2 0 531.57 0
26160   4 90 2 0 495.17 0
26170   1 90 2 0 687.64 0
26170   2 90 2 0 678.10 0
26170   3 90 2 0 638.80 0
26170   4 90 2 0 631.60 0
26180   1 90 2 0 854.46 0
26180   2 90 2 0 859.59 0
26180   3 90 2 0 785.26 0
26180   4 90 2 0 776.16 0
26185   1 90 2 0 850.15 0
26185   2 90 2 0 775.21 0
26185   3 90 2 0 754.36 0
26185   4 90 2 0 754.36 0
26200   1 90 2 0 916.81 0
26200   2 90 2 0 902.59 0
26200   3 90 2 0 843.76 0
26200   4 90 2 0 833.87 0
26205   1 90 2 0 1,287.01 0
26205   2 90 2 0 1,266.87 0
26205   3 90 2 0 1,183.47 0
26205   4 90 2 0 1,169.54 0
26210   1 90 2 0 833.80 0
26210   2 90 2 0 821.04 0
26210   3 90 2 0 768.51 0
26210   4 90 2 0 780.10 0
26215   1 90 2 0 1,167.52 0
26215   2 90 2 0 1,149.37 0
26215   3 90 2 0 1,074.19 0
26215   4 90 2 0 1,061.68 0
26230   1 90 2 0 986.11 0
26230   2 90 2 0 1,015.22 0
26230   3 90 2 0 882.66 0
26230   4 90 2 0 872.46 0
26235   1 90 2 0 1,068.64 0
26235   2 90 2 0 1,025.46 0
26235   3 90 2 0 1,036.79 0
26235   4 90 2 0 855.16 0
26236   1 90 2 0 1,084.00 0
26236   2 90 2 0 1,002.58 0
26236   3 90 2 0 1,004.66 0
26236   4 90 2 0 1,052.70 0
26250   1 90 2 0 1,552.67 0
26250   2 90 2 0 1,240.24 0
26250   3 90 2 0 1,157.15 0
26250   4 90 2 0 1,143.72 0
26260   1 90 2 0 1,304.45 0
26260   2 90 2 0 1,161.95 0
26260   3 90 2 0 1,153.45 0
26260   4 90 2 0 1,072.24 0
26262   1 90 2 0 1,122.92 0
26262   2 90 2 0 1,285.42 0
26262   3 90 2 0 881.07 0
26262   4 90 2 0 870.70 0
26320   1 90 2 0 690.08 0
26320   2 90 2 0 757.75 0
26320   3 90 2 0 633.30 0
26320   4 90 2 0 642.91 0
26340   1 90 2 0 504.14 0
26340   2 90 2 0 439.06 0
26340   3 90 2 0 439.06 0
26340   4 90 2 0 439.06 0
26341   1 10 2 0 138.00 104.62
26341   2 10 2 0 122.34 93.57
26341   3 10 2 0 122.34 93.57
26341   4 10 2 0 122.34 93.57
26350   1 90 2 0 1,342.03 0
26350   2 90 2 0 1,151.00 0
26350   3 90 2 0 1,164.24 0
26350   4 90 2 0 1,104.80 0
26352   1 90 2 0 1,625.31 0
26352   2 90 2 0 1,605.62 0
26352   3 90 2 0 1,206.42 0
26352   4 90 2 0 1,192.15 0
26356   1 90 2 0 1,386.71 0
26356   2 90 2 0 1,343.72 0
26356   3 90 2 0 1,249.09 0
26356   4 90 2 0 1,234.16 0
26357   1 90 2 0 1,400.40 0
26357   2 90 2 0 1,378.07 0
26357   3 90 2 0 1,326.39 0
26357   4 90 2 0 1,425.29 0
26358   1 90 2 0 1,525.22 0
26358   2 90 2 0 1,500.99 0
26358   3 90 2 0 1,401.18 0
26358   4 90 2 0 1,384.72 0
26370   1 90 2 0 1,410.21 0
26370   2 90 2 0 1,318.01 0
26370   3 90 2 0 1,171.95 0
26370   4 90 2 0 1,377.73 0
26372   1 90 2 0 1,460.41 0
26372   2 90 2 0 1,636.52 0
26372   3 90 2 0 1,386.23 0
26372   4 90 2 0 1,262.17 0
26373   1 90 2 0 1,372.56 0
26373   2 90 2 0 1,350.95 0
26373   3 90 2 0 1,261.59 0
26373   4 90 2 0 1,246.69 0
26390   1 90 2 0 1,570.32 0
26390   2 90 2 0 1,647.29 0
26390   3 90 2 0 1,444.79 0
26390   4 90 2 0 1,561.80 0
26392   1 90 2 0 1,816.89 0
26392   2 90 2 0 1,767.96 0
26392   3 90 2 0 1,584.73 0
26392   4 90 2 0 1,676.95 0
26410   1 90 2 0 846.85 0
26410   2 90 2 0 842.39 0
26410   3 90 2 0 752.32 0
26410   4 90 2 0 802.03 0
26412   1 90 2 0 1,134.58 0
26412   2 90 2 0 1,225.64 0
26412   3 90 2 0 1,039.41 0
26412   4 90 2 0 1,026.94 0
26415   1 90 2 0 1,369.06 0
26415   2 90 2 0 1,534.06 0
26415   3 90 2 0 1,453.64 0
26415   4 90 2 0 1,508.79 0
26416   1 90 2 0 1,680.86 0
26416   2 90 2 0 1,653.71 0
26416   3 90 2 0 1,541.63 0
26416   4 90 2 0 1,523.27 0
26418   1 90 2 0 848.66 0
26418   2 90 2 0 842.33 0
26418   3 90 2 0 734.37 0
26418   4 90 2 0 820.78 0
26420   1 90 2 0 1,143.37 0
26420   2 90 2 0 1,125.09 0
26420   3 90 2 0 1,049.44 0
26420   4 90 2 0 1,037.02 0
26426   1 90 2 0 1,331.69 0
26426   2 90 2 0 1,302.08 0
26426   3 90 2 0 1,212.08 0
26426   4 90 2 0 1,054.04 0
26428   1 90 2 0 1,178.58 0
26428   2 90 2 0 1,159.80 0
26428   3 90 2 0 1,082.51 0
26428   4 90 2 0 1,069.94 0
26432   1 90 2 0 720.55 0
26432   2 90 2 0 845.33 0
26432   3 90 2 0 845.17 0
26432   4 90 2 0 818.53 0
26433   1 90 2 0 942.49 0
26433   2 90 2 0 940.02 0
26433   3 90 2 0 893.07 0
26433   4 90 2 0 870.99 0
26434   1 90 2 0 1,018.38 0
26434   2 90 2 0 1,181.88 0
26434   3 90 2 0 935.62 0
26434   4 90 2 0 924.72 0
26437   1 90 2 0 1,146.46 0
26437   2 90 2 0 1,013.83 0
26437   3 90 2 0 829.74 0
26437   4 90 2 0 820.17 0
26440   1 90 2 0 802.28 0
26440   2 90 2 0 802.14 0
26440   3 90 2 0 764.75 0
26440   4 90 2 0 778.29 0
26442   1 90 2 0 878.41 0
26442   2 90 2 0 919.31 0
26442   3 90 2 0 930.48 0
26442   4 90 2 0 806.63 0
26445   1 90 2 0 697.97 0
26445   2 90 2 0 651.87 0
26445   3 90 2 0 643.12 0
26445   4 90 2 0 635.64 0
26449   1 90 2 0 1,135.75 0
26449   2 90 2 0 1,117.59 0
26449   3 90 2 0 1,042.46 0
26449   4 90 2 0 1,030.19 0
26450   1 90 2 0 538.92 0
26450   2 90 2 0 562.52 0
26450   3 90 2 0 500.10 0
26450   4 90 2 0 494.39 0
26455   1 90 2 0 499.14 0
26455   2 90 2 0 421.02 0
26455   3 90 2 0 464.04 0
26455   4 90 2 0 458.88 0
26460   1 90 2 0 792.19 0
26460   2 90 2 0 712.27 0
26460   3 90 2 0 645.39 0
26460   4 90 2 0 428.94 0
26471   1 90 2 0 907.87 0
26471   2 90 2 0 966.14 0
26471   3 90 2 0 838.36 0
26471   4 90 2 0 828.62 0
26474   1 90 2 0 922.34 0
26474   2 90 2 0 907.73 0
26474   3 90 2 0 847.46 0
26474   4 90 2 0 837.38 0
26476   1 90 2 0 702.25 0
26476   2 90 2 0 694.16 0
26476   3 90 2 0 660.54 0
26476   4 90 2 0 652.91 0
26477   1 90 2 0 852.82 0
26477   2 90 2 0 944.73 0
26477   3 90 2 0 782.87 0
26477   4 90 2 0 773.83 0
26478   1 90 2 0 932.70 0
26478   2 90 2 0 918.49 0
26478   3 90 2 0 859.80 0
26478   4 90 2 0 849.80 0
26479   1 90 2 0 1,029.26 0
26479   2 90 2 0 1,012.76 0
26479   3 90 2 0 944.27 0
26479   4 90 2 0 933.12 0
26480   1 90 2 0 1,320.85 0
26480   2 90 2 0 1,266.13 0
26480   3 90 2 0 1,177.19 0
26480   4 90 2 0 1,124.79 0
26483   1 90 2 0 1,566.62 0
26483   2 90 2 0 1,540.35 0
26483   3 90 2 0 1,431.67 0
26483   4 90 2 0 1,414.41 0
26485   1 90 2 0 1,504.64 0
26485   2 90 2 0 1,413.89 0
26485   3 90 2 0 1,232.13 0
26485   4 90 2 0 1,184.51 0
26489   1 90 2 0 1,115.86 0
26489   2 90 2 0 989.08 0
26489   3 90 2 0 958.34 0
26489   4 90 2 0 1,038.11 0
26490   1 90 2 0 1,501.44 0
26490   2 90 2 0 1,477.07 0
26490   3 90 2 0 1,376.26 0
26490   4 90 2 0 1,359.86 0
26492   1 90 2 0 1,672.35 0
26492   2 90 2 0 1,647.05 0
26492   3 90 2 0 1,542.03 0
26492   4 90 2 0 1,523.48 0
26494   1 90 2 0 1,455.74 0
26494   2 90 2 0 1,432.34 0
26494   3 90 2 0 1,335.77 0
26494   4 90 2 0 1,319.99 0
26496   1 90 2 0 1,712.95 0
26496   2 90 2 0 1,684.57 0
26496   3 90 2 0 1,567.33 0
26496   4 90 2 0 1,548.79 0
26497   1 90 2 0 1,631.83 0
26497   2 90 2 0 1,523.60 0
26497   3 90 2 0 1,497.38 0
26497   4 90 2 0 1,479.80 0
26498   1 90 2 0 2,406.64 0
26498   2 90 2 0 2,368.02 0
26498   3 90 2 0 2,208.73 0
26498   4 90 2 0 2,028.14 0
26499   1 90 2 0 1,541.96 0
26499   2 90 2 0 1,517.58 0
26499   3 90 2 0 1,417.04 0
26499   4 90 2 0 1,400.22 0
26500   1 90 2 0 743.71 0
26500   2 90 2 0 840.64 0
26500   3 90 2 0 790.14 0
26500   4 90 2 0 690.24 0
26502   1 90 2 0 1,138.72 0
26502   2 90 2 0 1,120.77 0
26502   3 90 2 0 1,046.66 0
26502   4 90 2 0 1,034.61 0
26508   1 90 2 0 919.33 0
26508   2 90 2 0 905.29 0
26508   3 90 2 0 847.25 0
26508   4 90 2 0 837.51 0
26510   1 90 2 0 865.69 0
26510   2 90 2 0 852.27 0
26510   3 90 2 0 796.94 0
26510   4 90 2 0 787.61 0
26516   1 90 2 0 1,010.78 0
26516   2 90 2 0 1,431.66 0
26516   3 90 2 0 1,204.44 0
26516   4 90 2 0 927.58 0
26517   1 90 2 0 2,151.94 0
26517   2 90 2 0 1,439.11 0
26517   3 90 2 0 2,101.76 0
26517   4 90 2 0 1,327.22 0
26518   1 90 2 0 2,651.26 0
26518   2 90 2 0 1,406.62 0
26518   3 90 2 0 1,313.11 0
26518   4 90 2 0 1,297.98 0
26520   1 90 2 0 972.54 0
26520   2 90 2 0 881.42 0
26520   3 90 2 0 823.50 0
26520   4 90 2 0 835.38 0
26525   1 90 2 0 877.58 0
26525   2 90 2 0 894.75 0
26525   3 90 2 0 879.18 0
26525   4 90 2 0 881.58 0
26530   1 90 2 0 1,127.80 0
26530   2 90 2 0 1,120.77 0
26530   3 90 2 0 1,091.77 0
26530   4 90 2 0 1,043.86 0
26531   1 90 2 0 1,345.80 0
26531   2 90 2 0 1,324.45 0
26531   3 90 2 0 1,279.26 0
26531   4 90 2 0 1,273.17 0
26535   1 90 2 0 1,031.22 0
26535   2 90 2 0 1,009.86 0
26535   3 90 2 0 950.61 0
26535   4 90 2 0 825.12 0
26536   1 90 2 0 1,373.13 0
26536   2 90 2 0 1,364.02 0
26536   3 90 2 0 1,311.81 0
26536   4 90 2 0 1,320.40 0
26540   1 90 2 0 1,422.23 0
26540   2 90 2 0 1,319.07 0
26540   3 90 2 0 1,315.07 0
26540   4 90 2 0 1,332.03 0
26541   1 90 2 0 1,640.88 0
26541   2 90 2 0 1,611.04 0
26541   3 90 2 0 1,499.28 0
26541   4 90 2 0 1,481.18 0
26542   1 90 2 0 1,144.59 0
26542   2 90 2 0 1,126.23 0
26542   3 90 2 0 1,050.23 0
26542   4 90 2 0 1,037.91 0
26545   1 90 2 0 1,117.36 0
26545   2 90 2 0 1,099.61 0
26545   3 90 2 0 1,026.37 0
26545   4 90 2 0 1,014.44 0
26546   1 90 2 0 1,601.73 0
26546   2 90 2 0 1,432.78 0
26546   3 90 2 0 1,394.30 0
26546   4 90 2 0 1,394.30 0
26548   1 90 2 0 1,262.28 0
26548   2 90 2 0 1,242.83 0
26548   3 90 2 0 1,162.68 0
26548   4 90 2 0 1,149.35 0
26550   1 90 2 0 1,262.28 0
26550   2 90 2 0 1,242.83 0
26550   3 90 2 0 1,162.68 0
26550   4 90 2 0 1,149.35 0
26551   1 90 2 0 8,345.60 0
26551   2 90 2 0 7,466.10 0
26551   3 90 2 0 7,265.42 0
26551   4 90 2 0 7,265.42 0
26553   1 90 2 0 8,287.57 0
26553   2 90 2 0 7,414.21 0
26553   3 90 2 0 7,214.91 0
26553   4 90 2 0 7,214.91 0
26554   1 90 2 0 9,888.33 0
26554   2 90 2 0 8,846.17 0
26554   3 90 2 0 8,608.41 0
26554   4 90 2 0 8,608.41 0
26555   1 90 2 0 3,210.93 0
26555   2 90 2 0 3,113.68 0
26555   3 90 2 0 2,908.28 0
26555   4 90 2 0 2,868.22 0
26556   1 90 2 0 8,428.69 0
26556   2 90 2 0 7,540.32 0
26556   3 90 2 0 7,337.69 0
26556   4 90 2 0 7,337.69 0
26560   1 90 2 0 1,410.49 0
26560   2 90 2 0 907.78 0
26560   3 90 2 0 850.52 0
26560   4 90 2 0 840.39 0
26561   1 90 2 0 1,843.13 0
26561   2 90 2 0 1,813.64 0
26561   3 90 2 0 1,691.84 0
26561   4 90 2 0 1,672.10 0
26562   1 90 2 0 1,814.87 0
26562   2 90 2 0 1,790.67 0
26562   3 90 2 0 1,689.85 0
26562   4 90 2 0 1,668.29 0
26565   1 90 2 0 1,147.68 0
26565   2 90 2 0 1,151.54 0
26565   3 90 2 0 1,057.83 0
26565   4 90 2 0 1,045.25 0