2018 Workers' Compensation Part B Fee Schedule

27752-28264

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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
27752   1 90 2 0 972.72 0
27752   2 90 2 0 956.99 0
27752   3 90 2 0 892.19 0
27752   4 90 2 0 881.46 0
27756   1 90 2 0 1,508.85 0
27756   2 90 2 0 1,749.81 0
27756   3 90 2 0 1,603.70 0
27756   4 90 2 0 1,596.55 0
27758   1 90 2 0 2,227.95 0
27758   2 90 2 0 2,165.89 0
27758   3 90 2 0 1,983.09 0
27758   4 90 2 0 1,982.08 0
27759   1 90 2 0 2,322.49 0
27759   2 90 2 0 2,259.82 0
27759   3 90 2 0 2,074.55 0
27759   4 90 2 0 2,072.57 0
27760   1 90 2 0 550.32 0
27760   2 90 2 0 545.00 0
27760   3 90 2 0 517.60 0
27760   4 90 2 0 497.16 0
27762   1 90 2 0 838.46 0
27762   2 90 2 0 776.18 0
27762   3 90 2 0 700.46 0
27762   4 90 2 0 692.34 0
27766   1 90 2 0 1,472.13 0
27766   2 90 2 0 1,448.02 0
27766   3 90 2 0 1,348.43 0
27766   4 90 2 0 1,351.25 0
27767   1 90 2 0 364.59 366.41
27767   2 90 2 0 316.40 317.87
27767   3 90 2 0 316.40 317.87
27767   4 90 2 0 316.40 317.87
27768   1 90 2 0 567.60 0
27768   2 90 2 0 495.71 0
27768   3 90 2 0 495.71 0
27768   4 90 2 0 495.71 0
27769   1 90 2 0 973.46 0
27769   2 90 2 0 859.39 0
27769   3 90 2 0 859.39 0
27769   4 90 2 0 859.39 0
27780   1 90 2 0 427.70 0
27780   2 90 2 0 452.80 0
27780   3 90 2 0 433.69 0
27780   4 90 2 0 452.02 0
27781   1 90 2 0 698.28 0
27781   2 90 2 0 760.61 0
27781   3 90 2 0 764.23 0
27781   4 90 2 0 761.02 0
27784   1 90 2 0 1,130.95 0
27784   2 90 2 0 1,113.57 0
27784   3 90 2 0 1,041.58 0
27784   4 90 2 0 1,029.25 0
27786   1 90 2 0 487.06 0
27786   2 90 2 0 479.50 0
27786   3 90 2 0 448.15 0
27786   4 90 2 0 442.83 0
27788   1 90 2 0 702.05 0
27788   2 90 2 0 691.70 0
27788   3 90 2 0 649.70 0
27788   4 90 2 0 658.32 0
27792   1 90 2 0 1,371.04 0
27792   2 90 2 0 1,348.61 0
27792   3 90 2 0 1,282.99 0
27792   4 90 2 0 1,281.22 0
27808   1 90 2 0 517.94 0
27808   2 90 2 0 513.87 0
27808   3 90 2 0 519.74 0
27808   4 90 2 0 518.77 0
27810   1 90 2 0 1,148.18 0
27810   2 90 2 0 1,109.07 0
27810   3 90 2 0 859.81 0
27810   4 90 2 0 985.42 0
27814   1 90 2 0 1,888.41 0
27814   2 90 2 0 1,857.66 0
27814   3 90 2 0 1,730.49 0
27814   4 90 2 0 1,709.74 0
27816   1 90 2 0 601.33 0
27816   2 90 2 0 668.38 0
27816   3 90 2 0 642.17 0
27816   4 90 2 0 647.34 0
27818   1 90 2 0 1,198.60 0
27818   2 90 2 0 1,256.85 0
27818   3 90 2 0 1,017.51 0
27818   4 90 2 0 1,099.38 0
27822   1 90 2 0 1,873.27 0
27822   2 90 2 0 1,839.67 0
27822   3 90 2 0 1,700.89 0
27822   4 90 2 0 1,680.06 0
27823   1 90 2 0 2,269.03 0
27823   2 90 2 0 2,222.83 0
27823   3 90 2 0 2,071.41 0
27823   4 90 2 0 2,046.20 0
27824   1 90 2 0 601.33 0
27824   2 90 2 0 668.38 0
27824   3 90 2 0 642.17 0
27824   4 90 2 0 647.34 0
27825   1 90 2 0 1,198.60 0
27825   2 90 2 0 1,256.85 0
27825   3 90 2 0 1,017.51 0
27825   4 90 2 0 1,099.38 0
27826   1 90 2 0 1,771.99 0
27826   2 90 2 0 1,739.17 0
27826   3 90 2 0 1,603.39 0
27826   4 90 2 0 1,583.61 0
27827   1 90 2 0 2,071.56 0
27827   2 90 2 0 2,036.34 0
27827   3 90 2 0 1,890.61 0
27827   4 90 2 0 1,867.54 0
27828   1 90 2 0 2,390.36 0
27828   2 90 2 0 2,248.09 0
27828   3 90 2 0 2,189.16 0
27828   4 90 2 0 2,162.79 0
27829   1 90 2 0 1,238.14 0
27829   2 90 2 0 1,502.79 0
27829   3 90 2 0 1,116.89 0
27829   4 90 2 0 1,103.04 0
27830   1 90 2 0 631.71 0
27830   2 90 2 0 611.93 0
27830   3 90 2 0 582.21 0
27830   4 90 2 0 575.21 0
27831   1 90 2 0 774.63 0
27831   2 90 2 0 762.64 0
27831   3 90 2 0 713.07 0
27831   4 90 2 0 704.55 0
27832   1 90 2 0 1,101.71 0
27832   2 90 2 0 1,084.30 0
27832   3 90 2 0 1,011.98 0
27832   4 90 2 0 1,072.52 0
27840   1 90 2 0 546.50 0
27840   2 90 2 0 540.39 0
27840   3 90 2 0 515.25 0
27840   4 90 2 0 509.56 0
27842   1 90 2 0 714.61 0
27842   2 90 2 0 672.43 0
27842   3 90 2 0 599.33 0
27842   4 90 2 0 638.85 0
27846   1 90 2 0 1,669.89 0
27846   2 90 2 0 1,702.99 0
27846   3 90 2 0 1,532.86 0
27846   4 90 2 0 1,514.59 0
27848   1 90 2 0 1,780.96 0
27848   2 90 2 0 1,735.15 0
27848   3 90 2 0 1,542.57 0
27848   4 90 2 0 1,606.41 0
27860   1 10 2 0 420.72 0
27860   2 10 2 0 418.73 0
27860   3 10 2 0 317.03 0
27860   4 10 2 0 313.45 0
27870   1 90 2 0 2,375.50 0
27870   2 90 2 0 2,358.49 0
27870   3 90 2 0 2,278.15 0
27870   4 90 2 0 2,277.30 0
27871   1 90 2 0 2,305.08 0
27871   2 90 2 0 2,295.00 0
27871   3 90 2 0 1,416.06 0
27871   4 90 2 0 1,399.23 0
27880   1 90 2 0 1,818.94 0
27880   2 90 2 0 1,789.57 0
27880   3 90 2 0 1,668.48 0
27880   4 90 2 0 1,649.27 0
27881   1 90 2 0 2,078.60 0
27881   2 90 2 0 2,017.98 0
27881   3 90 2 0 1,900.84 0
27881   4 90 2 0 1,878.15 0
27882   1 90 2 0 1,599.90 0
27882   2 90 2 0 1,586.40 0
27882   3 90 2 0 1,557.52 0
27882   4 90 2 0 1,523.85 0
27884   1 90 2 0 911.12 0
27884   2 90 2 0 900.92 0
27884   3 90 2 0 865.04 0
27884   4 90 2 0 866.92 0
27886   1 90 2 0 1,614.78 0
27886   2 90 2 0 1,522.41 0
27886   3 90 2 0 1,527.18 0
27886   4 90 2 0 1,546.70 0
27888   1 90 2 0 1,753.44 0
27888   2 90 2 0 1,723.37 0
27888   3 90 2 0 1,672.34 0
27888   4 90 2 0 1,579.79 0
27889   1 90 2 0 1,660.29 0
27889   2 90 2 0 1,632.22 0
27889   3 90 2 0 1,516.39 0
27889   4 90 2 0 1,498.52 0
27892   1 90 2 0 1,009.89 0
27892   2 90 2 0 994.75 0
27892   3 90 2 0 949.16 0
27892   4 90 2 0 963.18 0
27893   1 90 2 0 1,009.79 0
27893   2 90 2 0 941.00 0
27893   3 90 2 0 942.38 0
27893   4 90 2 0 957.35 0
27894   1 90 2 0 1,088.05 0
27894   2 90 2 0 1,072.63 0
27894   3 90 2 0 1,009.24 0
27894   4 90 2 0 998.10 0
27899     YYY 2 0 * 0
28001   1 10 2 0 248.37 228.48
28001   2 10 2 0 197.94 182.18
28001   3 10 2 0 222.73 205.19
28001   4 10 2 0 228.05 210.66
28002   1 10 2 0 411.36 0
28002   2 10 2 0 405.35 0
28002   3 10 2 0 385.48 0
28002   4 10 2 0 373.32 0
28003   1 90 2 0 824.75 0
28003   2 90 2 0 781.47 0
28003   3 90 2 0 780.62 0
28003   4 90 2 0 780.43 0
28005   1 90 2 0 1,072.58 0
28005   2 90 2 0 1,058.59 0
28005   3 90 2 0 1,000.96 0
28005   4 90 2 0 989.74 0
28008   1 90 2 0 703.24 0
28008   2 90 2 0 645.61 0
28008   3 90 2 0 663.79 0
28008   4 90 2 0 660.65 0
28010   1 90 2 0 470.99 350.62
28010   2 90 2 0 455.61 338.74
28010   3 90 2 0 444.30 330.92
28010   4 90 2 0 548.78 408.49
28011   1 90 2 0 511.29 0
28011   2 90 2 0 505.65 0
28011   3 90 2 0 482.25 0
28011   4 90 2 0 476.93 0
28020   1 90 2 0 846.98 0
28020   2 90 2 0 834.55 0
28020   3 90 2 0 783.15 0
28020   4 90 2 0 773.65 0
28022   1 90 2 0 609.50 0
28022   2 90 2 0 636.60 0
28022   3 90 2 0 603.36 0
28022   4 90 2 0 614.12 0
28024   1 90 2 0 582.14 0
28024   2 90 2 0 575.21 0
28024   3 90 2 0 546.80 0
28024   4 90 2 0 536.97 0
28035   1 90 2 0 1,054.49 0
28035   2 90 2 0 1,118.54 0
28035   3 90 2 0 1,087.94 0
28035   4 90 2 0 1,106.80 0
28039   1 90 2 0 684.56 486.62
28039   2 90 2 0 608.30 441.40
28039   3 90 2 0 608.30 441.40
28039   4 90 2 0 608.30 441.40
28041   1 90 2 0 640.64 0
28041   2 90 2 0 580.83 0
28041   3 90 2 0 580.83 0
28041   4 90 2 0 580.83 0
28043   1 90 2 0 452.31 0
28043   2 90 2 0 412.94 0
28043   3 90 2 0 432.89 0
28043   4 90 2 0 421.40 0
28045   1 90 2 0 618.14 0
28045   2 90 2 0 608.37 0
28045   3 90 2 0 577.70 0
28045   4 90 2 0 573.17 0
28046   1 90 2 0 1,350.78 0
28046   2 90 2 0 1,239.62 0
28046   3 90 2 0 1,259.14 0
28046   4 90 2 0 1,244.93 0
28047   1 90 2 0 1,335.07 0
28047   2 90 2 0 1,230.05 0
28047   3 90 2 0 1,230.05 0
28047   4 90 2 0 1,230.05 0
28050   1 90 2 0 731.02 0
28050   2 90 2 0 719.88 0
28050   3 90 2 0 673.72 0
28050   4 90 2 0 665.58 0
28052   1 90 2 0 690.45 0
28052   2 90 2 0 689.43 0
28052   3 90 2 0 639.69 0
28052   4 90 2 0 631.76 0
28054   1 90 2 0 496.89 0
28054   2 90 2 0 490.29 0
28054   3 90 2 0 462.95 0
28054   4 90 2 0 457.51 0
28055   1 90 2 0 571.34 0
28055   2 90 2 0 502.49 0
28055   3 90 2 0 502.49 0
28055   4 90 2 0 502.49 0
28060   1 90 2 0 854.00 0
28060   2 90 2 0 841.90 0
28060   3 90 2 0 791.80 0
28060   4 90 2 0 782.40 0
28062   1 90 2 0 1,066.94 0
28062   2 90 2 0 1,159.60 0
28062   3 90 2 0 1,139.11 0
28062   4 90 2 0 1,124.98 0
28070   1 90 2 0 841.74 0
28070   2 90 2 0 882.23 0
28070   3 90 2 0 781.26 0
28070   4 90 2 0 771.69 0
28072   1 90 2 0 820.37 0
28072   2 90 2 0 707.75 0
28072   3 90 2 0 696.81 0
28072   4 90 2 0 688.07 0
28080   1 90 2 0 698.07 0
28080   2 90 2 0 728.95 0
28080   3 90 2 0 620.09 0
28080   4 90 2 0 612.31 0
28086   1 90 2 0 706.20 0
28086   2 90 2 0 817.17 0
28086   3 90 2 0 654.95 0
28086   4 90 2 0 647.37 0
28088   1 90 2 0 663.70 0
28088   2 90 2 0 739.16 0
28088   3 90 2 0 615.14 0
28088   4 90 2 0 607.58 0
28090   1 90 2 0 652.97 0
28090   2 90 2 0 644.87 0
28090   3 90 2 0 611.35 0
28090   4 90 2 0 604.16 0
28092   1 90 2 0 498.90 0
28092   2 90 2 0 492.66 0
28092   3 90 2 0 466.86 0
28092   4 90 2 0 461.53 0
28100   1 90 2 0 914.71 0
28100   2 90 2 0 901.81 0
28100   3 90 2 0 848.31 0
28100   4 90 2 0 838.16 0
28102   1 90 2 0 1,307.48 0
28102   2 90 2 0 1,288.42 0
28102   3 90 2 0 1,209.63 0
28102   4 90 2 0 1,195.00 0
28103   1 90 2 0 1,080.34 0
28103   2 90 2 0 992.99 0
28103   3 90 2 0 1,000.06 0
28103   4 90 2 0 987.99 0
28104   1 90 2 0 841.32 0
28104   2 90 2 0 829.62 0
28104   3 90 2 0 780.85 0
28104   4 90 2 0 771.46 0
28106   1 90 2 0 1,216.12 0
28106   2 90 2 0 1,198.39 0
28106   3 90 2 0 1,124.92 0
28106   4 90 2 0 1,111.28 0
28107   1 90 2 0 910.31 0
28107   2 90 2 0 897.95 0
28107   3 90 2 0 846.58 0
28107   4 90 2 0 836.22 0
28108   1 90 2 0 685.21 522.30
28108   2 90 2 0 704.01 535.27
28108   3 90 2 0 691.14 525.50
28108   4 90 2 0 689.40 525.73
28110   1 90 2 0 684.74 0
28110   2 90 2 0 658.15 0
28110   3 90 2 0 638.63 0
28110   4 90 2 0 643.22 0
28111   1 90 2 0 1,012.96 0
28111   2 90 2 0 986.39 0
28111   3 90 2 0 940.34 0
28111   4 90 2 0 905.91 0
28112   1 90 2 0 928.79 0
28112   2 90 2 0 890.29 0
28112   3 90 2 0 864.10 0
28112   4 90 2 0 843.60 0
28113   1 90 2 0 902.06 0
28113   2 90 2 0 902.77 0
28113   3 90 2 0 890.61 0
28113   4 90 2 0 756.40 0
28114   1 90 2 0 1,698.26 0
28114   2 90 2 0 1,690.10 0
28114   3 90 2 0 1,559.15 0
28114   4 90 2 0 1,615.40 0
28116   1 90 2 0 1,059.90 0
28116   2 90 2 0 1,045.57 0
28116   3 90 2 0 985.82 0
28116   4 90 2 0 973.85 0
28118   1 90 2 0 1,038.80 0
28118   2 90 2 0 1,023.63 0
28118   3 90 2 0 960.77 0
28118   4 90 2 0 1,013.49 0
28119   1 90 2 0 966.24 0
28119   2 90 2 0 952.36 0
28119   3 90 2 0 929.74 0
28119   4 90 2 0 883.97 0
28120   1 90 2 0 920.40 0
28120   2 90 2 0 906.30 0
28120   3 90 2 0 847.62 0
28120   4 90 2 0 837.29 0
28122   1 90 2 0 1,009.25 0
28122   2 90 2 0 995.98 0
28122   3 90 2 0 974.20 0
28122   4 90 2 0 930.24 0
28124   1 90 2 0 766.95 592.93
28124   2 90 2 0 756.83 585.05
28124   3 90 2 0 715.00 552.81
28124   4 90 2 0 706.24 546.74
28126   1 90 2 0 744.73 558.98
28126   2 90 2 0 690.73 517.89
28126   3 90 2 0 677.23 506.15
28126   4 90 2 0 660.12 493.39
28130   1 90 2 0 1,328.85 0
28130   2 90 2 0 1,309.39 0
28130   3 90 2 0 1,228.51 0
28130   4 90 2 0 1,213.65 0
28140   1 90 2 0 1,042.93 0
28140   2 90 2 0 1,025.30 0
28140   3 90 2 0 969.01 0
28140   4 90 2 0 957.55 0
28150   1 90 2 0 677.23 0
28150   2 90 2 0 642.12 0
28150   3 90 2 0 612.23 0
28150   4 90 2 0 597.58 0
28153   1 90 2 0 739.17 552.49
28153   2 90 2 0 676.30 506.41
28153   3 90 2 0 622.85 465.76
28153   4 90 2 0 676.93 506.47
28160   1 90 2 0 701.38 526.83
28160   2 90 2 0 691.55 519.28
28160   3 90 2 0 650.80 488.18
28160   4 90 2 0 643.83 483.62
28171   1 90 2 0 1,549.78 0
28171   2 90 2 0 1,528.39 0
28171   3 90 2 0 1,439.74 0
28171   4 90 2 0 1,422.31 0
28173   1 90 2 0 1,273.32 0
28173   2 90 2 0 1,256.03 0
28173   3 90 2 0 1,184.76 0
28173   4 90 2 0 1,170.97 0
28175   1 90 2 0 1,003.48 0
28175   2 90 2 0 989.40 0
28175   3 90 2 0 931.02 0
28175   4 90 2 0 919.59 0
28190   1 10 2 0 175.46 157.51
28190   2 10 2 0 179.59 160.92
28190   3 10 2 0 169.56 152.23
28190   4 10 2 0 167.30 150.74
28192   1 90 2 0 545.11 0
28192   2 90 2 0 528.42 0
28192   3 90 2 0 522.47 0
28192   4 90 2 0 522.32 0
28193   1 90 2 0 700.24 0
28193   2 90 2 0 692.19 0
28193   3 90 2 0 658.92 0
28193   4 90 2 0 651.63 0
28200   1 90 2 0 870.25 0
28200   2 90 2 0 877.34 0
28200   3 90 2 0 806.14 0
28200   4 90 2 0 836.06 0
28202   1 90 2 0 1,131.55 0
28202   2 90 2 0 1,114.84 0
28202   3 90 2 0 1,045.67 0
28202   4 90 2 0 1,033.15 0
28208   1 90 2 0 695.10 0
28208   2 90 2 0 780.27 0
28208   3 90 2 0 693.35 0
28208   4 90 2 0 760.97 0
28210   1 90 2 0 1,055.44 0
28210   2 90 2 0 1,040.70 0
28210   3 90 2 0 979.78 0
28210   4 90 2 0 967.86 0
28220   1 90 2 0 743.68 0
28220   2 90 2 0 703.19 0
28220   3 90 2 0 690.66 0
28220   4 90 2 0 682.24 0
28222   1 90 2 0 1,076.81 0
28222   2 90 2 0 1,061.25 0
28222   3 90 2 0 813.76 0
28222   4 90 2 0 984.09 0
28225   1 90 2 0 522.32 0
28225   2 90 2 0 515.75 0
28225   3 90 2 0 459.99 0
28225   4 90 2 0 482.69 0
28226   1 90 2 0 698.82 0
28226   2 90 2 0 630.91 0
28226   3 90 2 0 602.07 0
28226   4 90 2 0 642.26 0
28230   1 90 2 0 523.71 428.82
28230   2 90 2 0 524.55 431.10
28230   3 90 2 0 513.76 422.08
28230   4 90 2 0 419.06 345.61
28232   1 90 2 0 430.87 363.11
28232   2 90 2 0 426.10 359.20
28232   3 90 2 0 406.47 343.32
28232   4 90 2 0 401.91 339.78
28234   1 90 2 0 393.22 332.96
28234   2 90 2 0 398.14 336.73
28234   3 90 2 0 375.64 318.66
28234   4 90 2 0 365.67 310.38
28238   1 90 2 0 1,360.15 0
28238   2 90 2 0 1,317.34 0
28238   3 90 2 0 1,236.79 0
28238   4 90 2 0 1,221.67 0
28240   1 90 2 0 558.27 0
28240   2 90 2 0 513.87 0
28240   3 90 2 0 501.08 0
28240   4 90 2 0 518.99 0
28250   1 90 2 0 921.28 0
28250   2 90 2 0 908.89 0
28250   3 90 2 0 869.67 0
28250   4 90 2 0 847.45 0
28260   1 90 2 0 1,071.81 0
28260   2 90 2 0 1,004.32 0
28260   3 90 2 0 965.56 0
28260   4 90 2 0 993.14 0
28261   1 90 2 0 1,330.66 0
28261   2 90 2 0 1,314.33 0
28261   3 90 2 0 1,246.70 0
28261   4 90 2 0 1,232.13 0
28262   1 90 2 0 2,226.04 0
28262   2 90 2 0 2,193.57 0
28262   3 90 2 0 1,955.50 0
28262   4 90 2 0 2,033.72 0
28264   1 90 2 0 1,789.39 0
28264   2 90 2 0 1,763.18 0
28264   3 90 2 0 1,654.70 0
28264   4 90 2 0 1,634.57 0