2018 Workers' Compensation Part B Fee Schedule

38570-42227

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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
38570   1 10 3 0 1,158.62 0
38570   2 10 3 0 1,041.21 0
38570   3 10 3 0 1,041.21 0
38570   4 10 3 0 1,041.21 0
38571   1 10 2 0 1,498.61 0
38571   2 10 2 0 1,357.33 0
38571   3 10 2 0 1,357.33 0
38571   4 10 2 0 1,357.33 0
38572   1 10 2 0 1,745.82 0
38572   2 10 2 0 1,576.86 0
38572   3 10 2 0 1,576.86 0
38572   4 10 2 0 1,576.86 0
38573   1 10 3 0 1,468.29 0
38573   2 10 3 0 1,344.73 0
38573   3 10 3 0 1,344.73 0
38573   4 10 3 0 1,344.73 0
38589     YYY 2 0 * 0
38700   1 90 2 0 2,321.97 0
38700   2 90 2 0 2,310.92 0
38700   3 90 2 0 2,264.89 0
38700   4 90 2 0 2,257.09 0
38720   1 90 2 0 2,703.97 0
38720   2 90 2 0 2,652.93 0
38720   3 90 2 0 2,502.68 0
38720   4 90 2 0 2,387.29 0
38724   1 90 2 0 2,694.24 0
38724   2 90 2 0 2,608.51 0
38724   3 90 2 0 2,483.47 0
38724   4 90 2 0 2,531.25 0
38740   1 90 2 0 1,059.76 0
38740   2 90 2 0 1,042.15 0
38740   3 90 2 0 895.54 0
38740   4 90 2 0 902.86 0
38745   1 90 2 0 1,894.87 0
38745   2 90 2 0 1,745.08 0
38745   3 90 2 0 1,490.95 0
38745   4 90 2 0 1,626.16 0
38746   1 ZZZ 0 0 634.77 0
38746   2 ZZZ 0 0 625.11 0
38746   3 ZZZ 0 0 585.34 0
38746   4 ZZZ 0 0 579.01 0
38747   1 ZZZ 0 0 706.90 0
38747   2 ZZZ 0 0 696.12 0
38747   3 ZZZ 0 0 651.87 0
38747   4 ZZZ 0 0 644.78 0
38760   1 90 2 0 1,454.27 0
38760   2 90 2 0 1,444.19 0
38760   3 90 2 0 1,395.74 0
38760   4 90 2 0 1,395.83 0
38765   1 90 2 0 2,653.20 0
38765   2 90 2 0 2,609.34 0
38765   3 90 2 0 2,428.36 0
38765   4 90 2 0 2,352.44 0
38770   1 90 2 0 2,550.20 0
38770   2 90 2 0 2,511.24 0
38770   3 90 2 0 2,349.50 0
38770   4 90 2 0 2,319.85 0
38780   1 90 2 0 3,047.02 0
38780   2 90 2 0 2,992.80 0
38780   3 90 2 0 2,809.78 0
38780   4 90 2 0 2,795.99 0
38790   1 0 2 0 289.80 0
38790   2 0 2 0 319.76 0
38790   3 0 2 0 267.26 0
38790   4 0 2 0 263.77 0
38792     0 2 0 * 0
38792 26   0 2 0 # 0
38792 TC   0 2 0 # 0
38794   1 90 2 0 631.87 0
38794   2 90 2 0 623.22 0
38794   3 90 2 0 587.60 0
38794   4 90 2 0 580.81 0
38900   1 ZZZ 0 0 205.90 0
38900   2 ZZZ 0 0 185.74 0
38900   3 ZZZ 0 0 185.74 0
38900   4 ZZZ 0 0 185.74 0
38999     YYY 2 0 * 0
39000   1 90 2 0 1,077.54 0
39000   2 90 2 0 1,058.42 0
39000   3 90 2 0 979.23 0
39000   4 90 2 0 967.38 0
39010   1 90 2 0 2,087.54 0
39010   2 90 2 0 2,054.45 0
39010   3 90 2 0 1,917.88 0
39010   4 90 2 0 1,895.81 0
39200   1 90 2 0 2,305.69 0
39200   2 90 2 0 2,266.94 0
39200   3 90 2 0 2,421.65 0
39200   4 90 2 0 2,082.28 0
39220   1 90 2 0 3,090.93 0
39220   2 90 2 0 3,069.46 0
39220   3 90 2 0 2,893.34 0
39220   4 90 2 0 2,967.21 0
39401   1 0 2 0 411.38 0
39401   2 0 2 0 375.86 0
39401   3 0 2 0 375.86 0
39401   4 0 2 0 375.86 0
39402   1 0 2 0 537.15 0
39402   2 0 2 0 491.42 0
39402   3 0 2 0 491.42 0
39402   4 0 2 0 491.42 0
39499     YYY 2 0 * 0
39501   1 90 2 0 2,307.32 0
39501   2 90 2 0 2,159.53 0
39501   3 90 2 0 2,006.10 0
39501   4 90 2 0 2,021.63 0
39503   1 90 2 0 5,321.13 0
39503   2 90 2 0 5,249.78 0
39503   3 90 2 0 4,954.32 0
39503   4 90 2 0 4,895.75 0
39540   1 90 2 0 2,793.05 0
39540   2 90 2 0 2,556.82 0
39540   3 90 2 0 2,592.49 0
39540   4 90 2 0 2,118.96 0
39541   1 90 2 0 2,857.44 0
39541   2 90 2 0 2,403.23 0
39541   3 90 2 0 2,767.30 0
39541   4 90 2 0 2,756.33 0
39545   1 90 2 0 1,904.54 0
39545   2 90 2 0 2,517.23 0
39545   3 90 2 0 1,755.40 0
39545   4 90 2 0 1,735.56 0
39560   1 90 2 0 1,618.73 0
39560   2 90 2 0 1,445.02 0
39560   3 90 2 0 1,445.02 0
39560   4 90 2 0 1,445.02 0
39561   1 90 2 0 2,215.87 0
39561   2 90 2 0 1,983.22 0
39561   3 90 2 0 1,983.22 0
39561   4 90 2 0 1,983.22 0
39599     YYY 2 0 * 0
40490   1 0 2 0 174.64 143.27
40490   2 0 2 0 172.57 141.61
40490   3 0 2 0 170.23 140.17
40490   4 0 2 0 170.79 140.81
40500   1 90 2 0 1,300.25 0
40500   2 90 2 0 1,237.43 0
40500   3 90 2 0 1,218.51 0
40500   4 90 2 0 1,220.73 0
40510   1 90 2 0 1,244.95 0
40510   2 90 2 0 1,198.94 0
40510   3 90 2 0 1,174.00 0
40510   4 90 2 0 1,175.69 0
40520   1 90 2 0 937.99 0
40520   2 90 2 0 948.08 0
40520   3 90 2 0 878.68 0
40520   4 90 2 0 774.20 0
40525   1 90 2 0 1,586.35 0
40525   2 90 2 0 2,042.83 0
40525   3 90 2 0 1,891.53 0
40525   4 90 2 0 1,988.09 0
40527   1 90 2 0 1,873.39 0
40527   2 90 2 0 1,858.73 0
40527   3 90 2 0 1,730.84 0
40527   4 90 2 0 1,709.38 0
40530   1 90 2 0 999.85 0
40530   2 90 2 0 993.53 0
40530   3 90 2 0 967.41 0
40530   4 90 2 0 962.99 0
40650   1 90 2 0 758.11 0
40650   2 90 2 0 1,050.69 0
40650   3 90 2 0 1,220.23 0
40650   4 90 2 0 684.22 0
40652   1 90 2 0 890.63 0
40652   2 90 2 0 1,104.52 0
40652   3 90 2 0 812.94 0
40652   4 90 2 0 802.91 0
40654   1 90 2 0 1,416.72 0
40654   2 90 2 0 1,415.17 0
40654   3 90 2 0 1,354.45 0
40654   4 90 2 0 1,008.69 0
40700   1 90 2 0 1,898.90 0
40700   2 90 2 0 1,871.75 0
40700   3 90 2 0 1,759.80 0
40700   4 90 2 0 1,739.52 0
40701   1 90 2 0 3,123.48 0
40701   2 90 2 0 3,079.77 0
40701   3 90 2 0 2,897.77 0
40701   4 90 2 0 2,860.60 0
40702   1 90 2 0 1,978.75 0
40702   2 90 2 0 1,952.16 0
40702   3 90 2 0 1,842.01 0
40702   4 90 2 0 1,820.34 0
40720   1 90 2 0 2,266.34 0
40720   2 90 2 0 2,101.73 0
40720   3 90 2 0 1,963.24 0
40720   4 90 2 0 1,940.81 0
40761   1 90 2 0 2,327.22 0
40761   2 90 2 0 2,292.19 0
40761   3 90 2 0 2,147.58 0
40761   4 90 2 0 2,122.57 0
40799     YYY 2 0 * 0
40800   1 10 2 0 166.23 0
40800   2 10 2 0 164.27 0
40800   3 10 2 0 155.95 0
40800   4 10 2 0 154.11 0
40801   1 10 2 0 369.36 0
40801   2 10 2 0 368.06 0
40801   3 10 2 0 351.83 0
40801   4 10 2 0 346.79 0
40804   1 10 2 0 161.14 0
40804   2 10 2 0 154.11 0
40804   3 10 2 0 148.38 0
40804   4 10 2 0 115.35 0
40805   1 10 2 0 473.52 0
40805   2 10 2 0 466.73 0
40805   3 10 2 0 438.51 0
40805   4 10 2 0 433.14 0
40806     0 2 0 * 0
40808   1 10 2 0 168.04 132.33
40808   2 10 2 0 169.54 133.52
40808   3 10 2 0 171.47 135.28
40808   4 10 2 0 168.00 132.66
40810   1 10 2 0 241.93 187.11
40810   2 10 2 0 254.00 196.77
40810   3 10 2 0 253.16 195.67
40810   4 10 2 0 269.17 208.90
40812   1 10 2 0 336.74 273.09
40812   2 10 2 0 341.37 277.10
40812   3 10 2 0 361.23 293.91
40812   4 10 2 0 340.66 277.70
40814   1 90 2 0 724.36 0
40814   2 90 2 0 656.72 0
40814   3 90 2 0 642.59 0
40814   4 90 2 0 543.03 0
40816   1 90 2 0 721.38 0
40816   2 90 2 0 876.85 0
40816   3 90 2 0 723.20 0
40816   4 90 2 0 875.05 0
40818   1 90 2 0 408.00 0
40818   2 90 2 0 402.54 0
40818   3 90 2 0 379.99 0
40818   4 90 2 0 375.31 0
40819     90 2 0 * 0
40820   1 10 2 0 156.58 0
40820   2 10 2 0 149.00 0
40820   3 10 2 0 144.83 0
40820   4 10 2 0 147.51 0
40830   1 10 2 0 189.18 0
40830   2 10 2 0 186.13 0
40830   3 10 2 0 186.68 0
40830   4 10 2 0 184.83 0
40831   1 10 2 0 363.51 0
40831   2 10 2 0 319.55 0
40831   3 10 2 0 367.99 0
40831   4 10 2 0 363.62 0
40840     90 2 0 * 0
40842     90 2 0 * 0
40843     90 2 0 * 0
40844     90 2 0 * 0
40845     90 2 0 * 0
40899     YYY 2 0 * 0
41000   1 10 2 0 180.14 0
41000   2 10 2 0 177.90 0
41000   3 10 2 0 172.81 0
41000   4 10 2 0 172.74 0
41005   1 10 2 0 189.16 0
41005   2 10 2 0 161.79 0
41005   3 10 2 0 153.88 0
41005   4 10 2 0 152.14 0
41006   1 90 2 0 330.59 0
41006   2 90 2 0 320.54 0
41006   3 90 2 0 311.38 0
41006   4 90 2 0 316.71 0
41007   1 90 2 0 527.89 0
41007   2 90 2 0 359.05 0
41007   3 90 2 0 489.99 0
41007   4 90 2 0 483.94 0
41008   1 90 2 0 371.38 0
41008   2 90 2 0 264.90 0
41008   3 90 2 0 256.88 0
41008   4 90 2 0 348.44 0
41009   1 90 2 0 607.44 0
41009   2 90 2 0 465.58 0
41009   3 90 2 0 564.14 0
41009   4 90 2 0 557.17 0
41010   1 10 2 0 136.45 0
41010   2 10 2 0 135.13 0
41010   3 10 2 0 129.51 0
41010   4 10 2 0 128.19 0
41015   1 90 2 0 294.78 0
41015   2 90 2 0 295.10 0
41015   3 90 2 0 382.04 0
41015   4 90 2 0 378.11 0
41016   1 90 2 0 532.74 0
41016   2 90 2 0 526.70 0
41016   3 90 2 0 627.06 0
41016   4 90 2 0 482.42 0
41017   1 90 2 0 451.37 0
41017   2 90 2 0 310.46 0
41017   3 90 2 0 300.17 0
41017   4 90 2 0 422.73 0
41018   1 90 2 0 782.49 0
41018   2 90 2 0 772.30 0
41018   3 90 2 0 730.23 0
41018   4 90 2 0 721.43 0
41019   1 0 2 0 677.54 0
41019   2 0 2 0 619.21 0
41019   3 0 2 0 619.21 0
41019   4 0 2 0 619.21 0
41100   1 10 2 0 211.87 178.00
41100   2 10 2 0 209.48 176.04
41100   3 10 2 0 205.49 173.36
41100   4 10 2 0 217.92 183.59
41105   1 10 2 0 218.69 0
41105   2 10 2 0 215.79 0
41105   3 10 2 0 203.71 0
41105   4 10 2 0 201.34 0
41108   1 10 2 0 168.00 131.97
41108   2 10 2 0 176.26 138.16
41108   3 10 2 0 189.29 148.72
41108   4 10 2 0 159.89 125.91
41110   1 10 2 0 386.60 0
41110   2 10 2 0 394.04 0
41110   3 10 2 0 386.96 0
41110   4 10 2 0 312.75 0
41112   1 90 2 0 645.36 0
41112   2 90 2 0 580.24 0
41112   3 90 2 0 585.84 0
41112   4 90 2 0 592.57 0
41113   1 90 2 0 1,040.35 0
41113   2 90 2 0 978.70 0
41113   3 90 2 0 973.41 0
41113   4 90 2 0 986.06 0
41114   1 90 2 0 1,302.16 0
41114   2 90 2 0 1,284.41 0
41114   3 90 2 0 1,211.08 0
41114   4 90 2 0 1,196.62 0
41115   1 10 2 0 315.46 0
41115   2 10 2 0 311.13 0
41115   3 10 2 0 300.75 0
41115   4 10 2 0 289.42 0
41116   1 90 2 0 472.46 0
41116   2 90 2 0 469.72 0
41116   3 90 2 0 458.63 0
41116   4 90 2 0 456.48 0
41120   1 90 2 0 1,477.01 0
41120   2 90 2 0 1,456.41 0
41120   3 90 2 0 1,371.43 0
41120   4 90 2 0 1,355.09 0
41130   1 90 2 0 2,081.57 0
41130   2 90 2 0 1,999.31 0
41130   3 90 2 0 1,955.88 0
41130   4 90 2 0 1,973.52 0
41135   1 90 2 0 4,026.41 0
41135   2 90 2 0 3,863.26 0
41135   3 90 2 0 2,926.69 0
41135   4 90 2 0 3,748.90 0
41140   1 90 2 0 3,900.38 0
41140   2 90 2 0 3,845.24 0
41140   3 90 2 0 3,617.13 0
41140   4 90 2 0 3,574.31 0
41145   1 90 2 0 4,711.15 0
41145   2 90 2 0 4,576.98 0
41145   3 90 2 0 4,303.62 0
41145   4 90 2 0 4,252.43 0
41150   1 90 2 0 3,271.40 0
41150   2 90 2 0 2,984.44 0
41150   3 90 2 0 2,810.63 0
41150   4 90 2 0 3,247.38 0
41153   1 90 2 0 5,716.01 0
41153   2 90 2 0 5,688.30 0
41153   3 90 2 0 5,573.37 0
41153   4 90 2 0 3,910.17 0
41155   1 90 2 0 5,153.13 0
41155   2 90 2 0 5,193.10 0
41155   3 90 2 0 4,742.37 0
41155   4 90 2 0 4,640.83 0
41250   1 10 2 0 261.71 0
41250   2 10 2 0 235.20 0
41250   3 10 2 0 224.39 0
41250   4 10 2 0 242.98 0
41251   1 10 2 0 389.18 0
41251   2 10 2 0 287.93 0
41251   3 10 2 0 361.93 0
41251   4 10 2 0 276.39 0
41252   1 10 2 0 479.27 0
41252   2 10 2 0 472.85 0
41252   3 10 2 0 446.29 0
41252   4 10 2 0 440.93 0
41500   1 90 2 0 608.09 0
41500   2 90 2 0 600.40 0
41500   3 90 2 0 637.19 0
41500   4 90 2 0 561.23 0
41510   1 90 2 0 552.93 0
41510   2 90 2 0 544.42 0
41510   3 90 2 0 509.05 0
41510   4 90 2 0 503.21 0
41512   1 90 2 0 842.41 0
41512   2 90 2 0 752.30 0
41512   3 90 2 0 752.30 0
41512   4 90 2 0 752.30 0
41520     90 2 0 * 0
41530   1 10 2 0 4,253.69 552.49
41530   2 10 2 0 3,613.73 492.83
41530   3 10 2 0 3,613.73 492.83
41530   4 10 2 0 3,613.73 492.83
41599     YYY 2 0 * 0
41800     10 2 0 * 0
41805   1 10 2 0 181.78 0
41805   2 10 2 0 147.34 0
41805   3 10 2 0 170.24 0
41805   4 10 2 0 168.22 0
41806   1 10 2 0 381.50 0
41806   2 10 2 0 377.04 0
41806   3 10 2 0 358.41 0
41806   4 10 2 0 354.23 0
41820     XXX 2 0 * 0
41821     XXX 2 0 * 0
41822     10 2 0 * 0
41823     90 2 0 * 0
41825   1 10 2 0 336.85 0
41825   2 10 2 0 325.08 0
41825   3 10 2 0 306.59 0
41825   4 10 2 0 305.42 0
41826   1 10 2 0 458.89 0
41826   2 10 2 0 458.17 0
41826   3 10 2 0 415.51 0
41826   4 10 2 0 421.76 0
41827   1 90 2 0 645.23 0
41827   2 90 2 0 635.98 0
41827   3 90 2 0 597.58 0
41827   4 90 2 0 590.04 0
41828     10 2 0 * 0
41830     10 2 0 * 0
41850     XXX 2 0 * 0
41870     XXX 2 0 * 0
41872     90 2 0 * 0
41874     90 2 0 * 0
41899     YYY 2 0 * 0
42000   1 10 2 0 167.33 0
42000   2 10 2 0 165.79 0
42000   3 10 2 0 163.38 0
42000   4 10 2 0 162.68 0
42100   1 10 2 0 247.55 202.81
42100   2 10 2 0 235.37 192.80
42100   3 10 2 0 236.91 194.14
42100   4 10 2 0 232.22 190.73
42104   1 10 2 0 408.82 0
42104   2 10 2 0 407.08 0
42104   3 10 2 0 399.87 0
42104   4 10 2 0 398.45 0
42106   1 10 2 0 436.87 0
42106   2 10 2 0 872.30 0
42106   3 10 2 0 837.48 0
42106   4 10 2 0 402.78 0
42107   1 90 2 0 1,386.03 0
42107   2 90 2 0 1,328.25 0
42107   3 90 2 0 773.37 0
42107   4 90 2 0 1,302.89 0
42120   1 90 2 0 2,008.44 0
42120   2 90 2 0 1,999.77 0
42120   3 90 2 0 1,963.79 0
42120   4 90 2 0 1,118.63 0
42140   1 90 2 0 263.50 0
42140   2 90 2 0 241.91 0
42140   3 90 2 0 231.91 0
42140   4 90 2 0 233.50 0
42145   1 90 2 0 1,987.58 0
42145   2 90 2 0 1,974.83 0
42145   3 90 2 0 1,921.65 0
42145   4 90 2 0 1,912.47 0
42160   1 10 2 0 404.33 0
42160   2 10 2 0 397.92 0
42160   3 10 2 0 453.67 0
42160   4 10 2 0 274.25 0
42180   1 10 2 0 429.90 0
42180   2 10 2 0 423.82 0
42180   3 10 2 0 297.66 0
42180   4 10 2 0 309.55 0
42182   1 10 2 0 661.97 0
42182   2 10 2 0 652.81 0
42182   3 10 2 0 521.24 0
42182   4 10 2 0 545.15 0
42200   1 90 2 0 1,520.83 0
42200   2 90 2 0 1,500.33 0
42200   3 90 2 0 1,415.58 0
42200   4 90 2 0 1,398.80 0
42205   1 90 2 0 1,775.88 0
42205   2 90 2 0 1,752.23 0
42205   3 90 2 0 1,653.77 0
42205   4 90 2 0 1,632.61 0
42210   1 90 2 0 2,028.99 0
42210   2 90 2 0 2,001.51 0
42210   3 90 2 0 1,887.04 0
42210   4 90 2 0 1,862.82 0
42215   1 90 2 0 1,473.62 0
42215   2 90 2 0 1,647.71 0
42215   3 90 2 0 1,367.64 0
42215   4 90 2 0 1,351.09 0
42220   1 90 2 0 1,124.10 0
42220   2 90 2 0 1,107.36 0
42220   3 90 2 0 1,038.10 0
42220   4 90 2 0 1,025.89 0
42225   1 90 2 0 1,923.48 0
42225   2 90 2 0 1,728.68 0
42225   3 90 2 0 1,378.39 0
42225   4 90 2 0 1,362.35 0
42226   1 90 2 0 1,757.48 0
42226   2 90 2 0 1,554.35 0
42226   3 90 2 0 1,466.06 0
42226   4 90 2 0 1,448.45 0
42227   1 90 2 0 1,427.57 0
42227   2 90 2 0 1,411.59 0
42227   3 90 2 0 1,344.92 0
42227   4 90 2 0 1,328.39 0