2018 Workers' Compensation Part B Fee Schedule

42235-43261

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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
42235   1 90 2 0 1,167.69 0
42235   2 90 2 0 1,153.29 0
42235   3 90 2 0 1,093.59 0
42235   4 90 2 0 1,080.55 0
42260   1 90 2 0 981.96 0
42260   2 90 2 0 931.04 0
42260   3 90 2 0 691.91 0
42260   4 90 2 0 683.49 0
42280   1 10 2 0 316.26 0
42280   2 10 2 0 311.81 0
42280   3 10 2 0 293.16 0
42280   4 10 2 0 289.42 0
42281   1 10 2 0 293.67 0
42281   2 10 2 0 317.23 0
42281   3 10 2 0 273.71 0
42281   4 10 2 0 270.44 0
42299     YYY 2 0 * 0
42300   1 10 2 0 255.49 0
42300   2 10 2 0 252.44 0
42300   3 10 2 0 239.66 0
42300   4 10 2 0 236.97 0
42305   1 90 2 0 691.41 0
42305   2 90 2 0 595.24 0
42305   3 90 2 0 577.22 0
42305   4 90 2 0 645.17 0
42310   1 10 2 0 228.88 0
42310   2 10 2 0 221.69 0
42310   3 10 2 0 215.07 0
42310   4 10 2 0 212.63 0
42320   1 10 2 0 377.86 0
42320   2 10 2 0 372.74 0
42320   3 10 2 0 351.36 0
42320   4 10 2 0 347.16 0
42330   1 10 2 0 312.15 262.94
42330   2 10 2 0 310.70 261.18
42330   3 10 2 0 301.30 253.66
42330   4 10 2 0 303.57 255.79
42335   1 90 2 0 634.62 0
42335   2 90 2 0 630.47 0
42335   3 90 2 0 614.35 0
42335   4 90 2 0 617.60 0
42340   1 90 2 0 796.86 0
42340   2 90 2 0 785.78 0
42340   3 90 2 0 760.18 0
42340   4 90 2 0 730.71 0
42400   1 0 2 0 145.85 0
42400   2 0 2 0 143.66 0
42400   3 0 2 0 136.40 0
42400   4 0 2 0 135.70 0
42405   1 10 2 0 429.28 0
42405   2 10 2 0 424.26 0
42405   3 10 2 0 403.44 0
42405   4 10 2 0 398.93 0
42408   1 90 2 0 696.31 0
42408   2 90 2 0 985.45 0
42408   3 90 2 0 969.41 0
42408   4 90 2 0 641.19 0
42409   1 90 2 0 505.33 0
42409   2 90 2 0 498.10 0
42409   3 90 2 0 468.34 0
42409   4 90 2 0 462.55 0
42410   1 90 2 0 1,674.69 0
42410   2 90 2 0 1,553.82 0
42410   3 90 2 0 1,345.57 0
42410   4 90 2 0 1,576.30 0
42415   1 90 2 0 2,654.23 0
42415   2 90 2 0 2,616.70 0
42415   3 90 2 0 2,461.50 0
42415   4 90 2 0 2,432.45 0
42420   1 90 2 0 3,071.81 0
42420   2 90 2 0 3,029.00 0
42420   3 90 2 0 2,851.61 0
42420   4 90 2 0 2,817.83 0
42425   1 90 2 0 2,170.36 0
42425   2 90 2 0 2,138.78 0
42425   3 90 2 0 2,046.75 0
42425   4 90 2 0 2,036.64 0
42426   1 90 2 0 4,138.72 0
42426   2 90 2 0 4,072.58 0
42426   3 90 2 0 3,798.32 0
42426   4 90 2 0 3,751.21 0
42440   1 90 2 0 1,387.36 0
42440   2 90 2 0 1,341.00 0
42440   3 90 2 0 1,252.97 0
42440   4 90 2 0 1,237.42 0
42450   1 90 2 0 992.99 0
42450   2 90 2 0 862.38 0
42450   3 90 2 0 846.53 0
42450   4 90 2 0 650.13 0
42500   1 90 2 0 817.11 0
42500   2 90 2 0 787.40 0
42500   3 90 2 0 738.57 0
42500   4 90 2 0 729.39 0
42505   1 90 2 0 1,233.44 0
42505   2 90 2 0 1,353.02 0
42505   3 90 2 0 1,135.71 0
42505   4 90 2 0 1,121.49 0
42507   1 90 2 0 1,457.34 0
42507   2 90 2 0 1,451.32 0
42507   3 90 2 0 911.42 0
42507   4 90 2 0 900.76 0
42509   1 90 2 0 1,714.24 0
42509   2 90 2 0 1,689.34 0
42509   3 90 2 0 1,586.50 0
42509   4 90 2 0 1,568.50 0
42510   1 90 2 0 1,409.09 0
42510   2 90 2 0 1,389.07 0
42510   3 90 2 0 1,306.06 0
42510   4 90 2 0 1,290.00 0
42550   1 0 2 0 137.91 0
42550   2 0 2 0 136.56 0
42550   3 0 2 0 130.92 0
42550   4 0 2 0 129.44 0
42600   1 90 2 0 953.36 0
42600   2 90 2 0 765.55 0
42600   3 90 2 0 720.64 0
42600   4 90 2 0 711.99 0
42650   1 0 2 0 104.68 89.67
42650   2 0 2 0 118.54 101.90
42650   3 0 2 0 96.97 81.81
42650   4 0 2 0 95.89 80.98
42660   1 0 2 0 118.39 0
42660   2 0 2 0 143.46 0
42660   3 0 2 0 106.68 0
42660   4 0 2 0 135.70 0
42665   1 90 2 0 410.21 0
42665   2 90 2 0 495.57 0
42665   3 90 2 0 380.71 0
42665   4 90 2 0 376.22 0
42699     YYY 2 0 * 0
42700   1 10 2 0 217.81 0
42700   2 10 2 0 209.38 0
42700   3 10 2 0 204.33 0
42700   4 10 2 0 201.96 0
42720   1 10 2 0 408.89 0
42720   2 10 2 0 403.53 0
42720   3 10 2 0 381.16 0
42720   4 10 2 0 376.68 0
42725   1 90 2 0 1,088.31 0
42725   2 90 2 0 1,074.63 0
42725   3 90 2 0 1,018.42 0
42725   4 90 2 0 1,006.76 0
42800   1 10 2 0 192.94 160.36
42800   2 10 2 0 183.76 152.77
42800   3 10 2 0 182.86 152.38
42800   4 10 2 0 181.06 150.81
42804   1 10 2 0 262.40 0
42804   2 10 2 0 256.16 0
42804   3 10 2 0 246.75 0
42804   4 10 2 0 249.14 0
42806   1 10 2 0 287.63 0
42806   2 10 2 0 280.23 0
42806   3 10 2 0 249.64 0
42806   4 10 2 0 246.58 0
42808   1 10 2 0 367.92 0
42808   2 10 2 0 357.16 0
42808   3 10 2 0 339.54 0
42808   4 10 2 0 348.58 0
42809   1 10 2 0 228.61 0
42809   2 10 2 0 226.13 0
42809   3 10 2 0 215.77 0
42809   4 10 2 0 213.33 0
42810   1 90 2 0 597.82 0
42810   2 90 2 0 588.38 0
42810   3 90 2 0 549.32 0
42810   4 90 2 0 542.69 0
42815   1 90 2 0 1,557.88 0
42815   2 90 2 0 1,531.89 0
42815   3 90 2 0 1,453.64 0
42815   4 90 2 0 1,364.73 0
42820   1 90 2 0 610.78 0
42820   2 90 2 0 602.62 0
42820   3 90 2 0 568.77 0
42820   4 90 2 0 561.89 0
42821   1 90 2 0 739.62 0
42821   2 90 2 0 699.95 0
42821   3 90 2 0 684.75 0
42821   4 90 2 0 676.46 0
42825   1 90 2 0 537.58 0
42825   2 90 2 0 530.06 0
42825   3 90 2 0 498.92 0
42825   4 90 2 0 493.01 0
42826   1 90 2 0 651.63 0
42826   2 90 2 0 641.89 0
42826   3 90 2 0 601.33 0
42826   4 90 2 0 593.84 0
42830   1 90 2 0 427.37 0
42830   2 90 2 0 419.75 0
42830   3 90 2 0 373.18 0
42830   4 90 2 0 368.81 0
42831   1 90 2 0 452.85 0
42831   2 90 2 0 446.72 0
42831   3 90 2 0 421.05 0
42831   4 90 2 0 415.96 0
42835   1 90 2 0 357.55 0
42835   2 90 2 0 353.48 0
42835   3 90 2 0 336.60 0
42835   4 90 2 0 332.49 0
42836   1 90 2 0 537.53 0
42836   2 90 2 0 530.09 0
42836   3 90 2 0 499.24 0
42836   4 90 2 0 493.18 0
42842   1 90 2 0 1,237.80 0
42842   2 90 2 0 1,195.34 0
42842   3 90 2 0 1,172.51 0
42842   4 90 2 0 1,198.89 0
42844   1 90 2 0 2,158.64 0
42844   2 90 2 0 2,128.71 0
42844   3 90 2 0 2,004.54 0
42844   4 90 2 0 1,980.54 0
42845   1 90 2 0 3,713.19 0
42845   2 90 2 0 3,661.36 0
42845   3 90 2 0 3,446.66 0
42845   4 90 2 0 3,405.38 0
42860   1 90 2 0 367.43 0
42860   2 90 2 0 405.53 0
42860   3 90 2 0 396.77 0
42860   4 90 2 0 337.33 0
42870   1 90 2 0 666.70 0
42870   2 90 2 0 659.89 0
42870   3 90 2 0 628.25 0
42870   4 90 2 0 621.29 0
42890   1 90 2 0 1,881.10 0
42890   2 90 2 0 1,615.19 0
42890   3 90 2 0 1,751.54 0
42890   4 90 2 0 1,730.82 0
42892   1 90 2 0 2,267.43 0
42892   2 90 2 0 2,236.79 0
42892   3 90 2 0 2,663.14 0
42892   4 90 2 0 2,084.83 0
42894   1 90 2 0 3,345.34 0
42894   2 90 2 0 3,300.42 0
42894   3 90 2 0 3,114.72 0
42894   4 90 2 0 3,077.70 0
42900   1 10 2 0 845.10 0
42900   2 10 2 0 833.39 0
42900   3 10 2 0 785.19 0
42900   4 10 2 0 775.74 0
42950   1 90 2 0 1,628.12 0
42950   2 90 2 0 1,603.36 0
42950   3 90 2 0 1,545.26 0
42950   4 90 2 0 1,481.33 0
42953   1 90 2 0 1,351.21 0
42953   2 90 2 0 1,331.50 0
42953   3 90 2 0 1,250.24 0
42953   4 90 2 0 1,235.61 0
42955   1 90 2 0 885.94 0
42955   2 90 2 0 875.09 0
42955   3 90 2 0 830.46 0
42955   4 90 2 0 821.10 0
42960   1 10 2 0 299.88 0
42960   2 10 2 0 302.12 0
42960   3 10 2 0 282.33 0
42960   4 10 2 0 279.14 0
42961   1 90 2 0 610.85 0
42961   2 90 2 0 604.64 0
42961   3 90 2 0 578.99 0
42961   4 90 2 0 572.71 0
42962   1 90 2 0 1,156.04 0
42962   2 90 2 0 1,139.83 0
42962   3 90 2 0 1,072.76 0
42962   4 90 2 0 1,059.76 0
42970   1 90 2 0 357.50 0
42970   2 90 2 0 383.58 0
42970   3 90 2 0 400.45 0
42970   4 90 2 0 445.90 0
42971   1 90 2 0 758.92 0
42971   2 90 2 0 749.88 0
42971   3 90 2 0 712.47 0
42971   4 90 2 0 704.38 0
42972   1 90 2 0 1,033.52 0
42972   2 90 2 0 1,018.51 0
42972   3 90 2 0 956.46 0
42972   4 90 2 0 945.46 0
42999     YYY 2 0 * 0
43020   1 90 2 0 1,630.12 0
43020   2 90 2 0 1,284.50 0
43020   3 90 2 0 1,211.25 0
43020   4 90 2 0 1,196.67 0
43030   1 90 2 0 1,535.98 0
43030   2 90 2 0 1,511.16 0
43030   3 90 2 0 1,408.34 0
43030   4 90 2 0 1,478.93 0
43045   1 90 2 0 2,952.61 0
43045   2 90 2 0 2,907.59 0
43045   3 90 2 0 2,722.15 0
43045   4 90 2 0 2,691.42 0
43100   1 90 2 0 1,362.96 0
43100   2 90 2 0 2,159.40 0
43100   3 90 2 0 1,861.89 0
43100   4 90 2 0 1,246.67 0
43101   1 90 2 0 2,324.23 0
43101   2 90 2 0 2,288.81 0
43101   3 90 2 0 2,143.05 0
43101   4 90 2 0 2,119.05 0
43107   1 90 2 0 4,776.93 0
43107   2 90 2 0 4,697.63 0
43107   3 90 2 0 4,370.54 0
43107   4 90 2 0 4,320.15 0
43108   1 90 2 0 5,670.90 0
43108   2 90 2 0 5,620.56 0
43108   3 90 2 0 4,864.98 0
43108   4 90 2 0 4,808.61 0
43112   1 90 2 0 4,805.61 0
43112   2 90 2 0 4,691.86 0
43112   3 90 2 0 4,552.60 0
43112   4 90 2 0 4,568.24 0
43113   1 90 2 0 5,670.90 0
43113   2 90 2 0 5,620.56 0
43113   3 90 2 0 4,864.98 0
43113   4 90 2 0 4,808.61 0
43116   1 90 2 0 5,670.90 0
43116   2 90 2 0 5,620.56 0
43116   3 90 2 0 4,864.98 0
43116   4 90 2 0 4,808.61 0
43117   1 90 2 0 5,670.90 0
43117   2 90 2 0 5,620.56 0
43117   3 90 2 0 4,864.98 0
43117   4 90 2 0 4,808.61 0
43118   1 90 2 0 5,670.90 0
43118   2 90 2 0 5,620.56 0
43118   3 90 2 0 4,864.98 0
43118   4 90 2 0 4,808.61 0
43121   1 90 2 0 5,095.90 0
43121   2 90 2 0 4,479.63 0
43121   3 90 2 0 4,317.38 0
43121   4 90 2 0 4,335.18 0
43122   1 90 2 0 5,095.90 0
43122   2 90 2 0 4,479.63 0
43122   3 90 2 0 4,317.38 0
43122   4 90 2 0 4,335.18 0
43123   1 90 2 0 5,670.90 0
43123   2 90 2 0 5,620.56 0
43123   3 90 2 0 4,864.98 0
43123   4 90 2 0 4,808.61 0
43124   1 90 2 0 4,776.93 0
43124   2 90 2 0 4,697.63 0
43124   3 90 2 0 4,370.54 0
43124   4 90 2 0 4,320.15 0
43130   1 90 2 0 2,000.57 0
43130   2 90 2 0 1,968.80 0
43130   3 90 2 0 1,877.45 0
43130   4 90 2 0 1,899.88 0
43135   1 90 2 0 2,550.42 0
43135   2 90 2 0 2,509.98 0
43135   3 90 2 0 2,342.87 0
43135   4 90 2 0 2,315.89 0
43180   1 90 2 0 710.07 782.60
43180   2 90 2 0 648.57 710.56
43180   3 90 2 0 648.57 710.56
43180   4 90 2 0 648.57 710.56
43191   1 0 2 0 172.40 0
43191   2 0 2 0 157.49 0
43191   3 0 2 0 157.49 0
43191   4 0 2 0 157.49 0
43192   1 0 3 0 205.56 0
43192   2 0 3 0 188.06 0
43192   3 0 3 0 188.06 0
43192   4 0 3 0 188.06 0
43193   1 0 3 0 244.83 0
43193   2 0 3 0 224.38 0
43193   3 0 3 0 224.38 0
43193   4 0 3 0 224.38 0
43194   1 0 3 0 221.91 0
43194   2 0 3 0 204.69 0
43194   3 0 3 0 204.69 0
43194   4 0 3 0 204.69 0
43195   1 0 3 0 245.30 0
43195   2 0 3 0 224.79 0
43195   3 0 3 0 224.79 0
43195   4 0 3 0 224.79 0
43196   1 0 3 0 270.10 0
43196   2 0 3 0 246.92 0
43196   3 0 3 0 246.92 0
43196   4 0 3 0 246.92 0
43197   1 0 2 0 249.07 109.17
43197   2 0 2 0 220.87 100.79
43197   3 0 2 0 220.87 100.79
43197   4 0 2 0 220.87 100.79
43198   1 0 3 0 277.99 129.94
43198   2 0 3 0 247.13 120.05
43198   3 0 3 0 247.13 120.05
43198   4 0 3 0 247.13 120.05
43200   1 0 2 0 543.88 0
43200   2 0 2 0 427.75 0
43200   3 0 2 0 436.01 0
43200   4 0 2 0 427.69 0
43201   1 0 2 0 451.73 233.2
43201   2 0 2 0 396.74 210.82
43201   3 0 2 0 396.74 210.82
43201   4 0 2 0 396.74 210.82
43202   1 0 3 0 543.79 0
43202   2 0 3 0 491.44 0
43202   3 0 3 0 481.84 0
43202   4 0 3 0 480.71 0
43204   1 0 3 0 872.78 0
43204   2 0 3 0 891.53 0
43204   3 0 3 0 879.78 0
43204   4 0 3 0 820.57 0
43205   1 0 3 0 532.20 0
43205   2 0 3 0 526.11 0
43205   3 0 3 0 501.01 0
43205   4 0 3 0 495.04 0
43206     YYY 2 0 * 0
43210   1 YYY 3 0 556.99 0
43210   2 YYY 3 0 513.97 0
43210   3 YYY 3 0 513.97 0
43210   4 YYY 3 0 513.97 0
43211   1 0 3 0 336.25 0
43211   2 0 3 0 307.60 0
43211   3 0 3 0 307.60 0
43211   4 0 3 0 307.60 0
43212   1 0 3 0 266.80 0
43212   2 0 3 0 243.48 0
43212   3 0 3 0 243.48 0
43212   4 0 3 0 243.48 0
43213   1 0 3 0 1,669.45 374.35
43213   2 0 3 0 1,454.03 342.40
43213   3 0 3 0 1,454.03 342.40
43213   4 0 3 0 1,454.03 342.40
43214   1 0 3 0 270.91 0
43214   2 0 3 0 247.57 0
43214   3 0 3 0 247.57 0
43214   4 0 3 0 247.57 0
43215   1 0 3 0 746.56 0
43215   2 0 3 0 632.58 0
43215   3 0 3 0 618.60 0
43215   4 0 3 0 604.67 0
43216   1 0 3 0 847.23 0
43216   2 0 3 0 876.23 0
43216   3 0 3 0 765.95 0
43216   4 0 3 0 799.44 0
43217   1 0 3 0 847.23 0
43217   2 0 3 0 876.23 0
43217   3 0 3 0 765.95 0
43217   4 0 3 0 799.44 0
43220   1 0 3 0 524.43 0
43220   2 0 3 0 480.36 0
43220   3 0 3 0 432.56 0
43220   4 0 3 0 450.01 0
43226   1 0 3 0 489.26 0
43226   2 0 3 0 482.45 0
43226   3 0 3 0 453.87 0
43226   4 0 3 0 447.93 0
43227   1 0 3 0 876.23 0
43227   2 0 3 0 847.05 0
43227   3 0 3 0 695.70 0
43227   4 0 3 0 852.37 0
43229   1 0 3 0 984.94 286.78
43229   2 0 3 0 860.86 261.61
43229   3 0 3 0 860.86 261.61
43229   4 0 3 0 860.86 261.61
43231   1 0 3 0 447.77 0
43231   2 0 3 0 407.91 0
43231   3 0 3 0 407.91 0
43231   4 0 3 0 407.91 0
43232   1 0 3 0 520.56 0
43232   2 0 3 0 473.85 0
43232   3 0 3 0 473.85 0
43232   4 0 3 0 473.85 0
43233   1 0 3 0 321.38 0
43233   2 0 3 0 293.91 0
43233   3 0 3 0 293.91 0
43233   4 0 3 0 293.91 0
43235   1 0 2 0 586.97 0
43235   2 0 2 0 562.00 0
43235   3 0 2 0 544.65 0
43235   4 0 2 0 555.15 0
43236   1 0 2 0 525.06 287.92
43236   2 0 2 0 464.80 263.05
43236   3 0 2 0 464.80 263.05
43236   4 0 2 0 464.80 263.05
43237   1 0 3 0 389.20 0
43237   2 0 3 0 356.66 0
43237   3 0 3 0 356.66 0
43237   4 0 3 0 356.66 0
43238   1 0 3 0 480.54 0
43238   2 0 3 0 442.84 0
43238   3 0 3 0 442.84 0
43238   4 0 3 0 442.84 0
43239   1 0 3 0 709.45 0
43239   2 0 3 0 669.74 0
43239   3 0 3 0 608.07 0
43239   4 0 3 0 645.85 0
43240   1 0 3 0 789.91 0
43240   2 0 3 0 720.26 0
43240   3 0 3 0 720.26 0
43240   4 0 3 0 720.26 0
43241   1 0 3 0 853.04 0
43241   2 0 3 0 745.60 0
43241   3 0 3 0 785.06 0
43241   4 0 3 0 798.93 0
43242   1 0 3 0 567.30 0
43242   2 0 3 0 518.43 0
43242   3 0 3 0 518.43 0
43242   4 0 3 0 518.43 0
43243   1 0 3 0 916.73 0
43243   2 0 3 0 925.66 0
43243   3 0 3 0 928.51 0
43243   4 0 3 0 888.20 0
43244   1 0 3 0 644.59 0
43244   2 0 3 0 637.33 0
43244   3 0 3 0 607.20 0
43244   4 0 3 0 599.91 0
43245   1 0 3 0 912.15 0
43245   2 0 3 0 900.18 0
43245   3 0 3 0 890.55 0
43245   4 0 3 0 868.52 0
43246   1 0 3 0 931.47 0
43246   2 0 3 0 921.07 0
43246   3 0 3 0 900.10 0
43246   4 0 3 0 902.32 0
43247   1 0 3 0 831.90 0
43247   2 0 3 0 758.62 0
43247   3 0 3 0 721.62 0
43247   4 0 3 0 746.01 0
43248   1 0 2 0 615.97 0
43248   2 0 2 0 607.31 0
43248   3 0 2 0 571.16 0
43248   4 0 2 0 563.85 0
43249   1 0 3 0 582.73 0
43249   2 0 3 0 589.34 0
43249   3 0 3 0 536.78 0
43249   4 0 3 0 549.77 0
43250   1 0 3 0 997.05 0
43250   2 0 3 0 1,003.20 0
43250   3 0 3 0 973.97 0
43250   4 0 3 0 948.20 0
43251   1 0 3 0 997.05 0
43251   2 0 3 0 1,003.20 0
43251   3 0 3 0 973.97 0
43251   4 0 3 0 948.20 0
43252     YYY 2 0 * 0
43253   1 0 3 0 372.87 0
43253   2 0 3 0 340.92 0
43253   3 0 3 0 340.92 0
43253   4 0 3 0 340.92 0
43254   1 0 3 0 387.55 0
43254   2 0 3 0 354.23 0
43254   3 0 3 0 354.23 0
43254   4 0 3 0 354.23 0
43255   1 0 3 0 1,010.77 0
43255   2 0 3 0 1,008.53 0
43255   3 0 3 0 968.87 0
43255   4 0 3 0 930.17 0
43257   1 0 3 0 522.62 0
43257   2 0 3 0 478.52 0
43257   3 0 3 0 478.52 0
43257   4 0 3 0 478.52 0
43259     0 3 0 * 0
43260   1 0 2 0 1,014.35 0
43260   2 0 2 0 980.47 0
43260   3 0 2 0 943.12 0
43260   4 0 2 0 917.84 0
43261   1 0 3 0 1,022.37 0
43261   2 0 3 0 1,004.63 0
43261   3 0 3 0 950.93 0
43261   4 0 3 0 941.17 0