2018 Workers' Compensation Part B Fee Schedule

50553-51784

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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
50553   1 0 2 0 669.40 0
50553   2 0 2 0 692.97 0
50553   3 0 2 0 636.91 0
50553   4 0 2 0 679.23 0
50555   1 0 3 0 1,008.56 0
50555   2 0 3 0 995.98 0
50555   3 0 3 0 943.73 0
50555   4 0 3 0 932.55 0
50557   1 0 3 0 947.05 0
50557   2 0 3 0 924.83 0
50557   3 0 3 0 873.82 0
50557   4 0 3 0 943.82 0
50561   1 0 3 0 1,218.08 0
50561   2 0 3 0 1,212.15 0
50561   3 0 3 0 1,187.85 0
50561   4 0 3 0 1,054.83 0
50562   1 0 3 0 1,057.27 0
50562   2 0 3 0 958.59 0
50562   3 0 3 0 958.59 0
50562   4 0 3 0 958.59 0
50570   1 0 2 0 990.60 0
50570   2 0 2 0 940.72 0
50570   3 0 2 0 974.32 0
50570   4 0 2 0 970.52 0
50572   1 0 3 0 1,586.70 0
50572   2 0 3 0 1,566.62 0
50572   3 0 3 0 1,444.59 0
50572   4 0 3 0 1,466.13 0
50574   1 0 3 0 1,614.44 0
50574   2 0 3 0 1,508.62 0
50574   3 0 3 0 1,515.75 0
50574   4 0 3 0 1,498.00 0
50575   1 0 3 0 2,148.70 0
50575   2 0 3 0 2,121.87 0
50575   3 0 3 0 2,010.70 0
50575   4 0 3 0 1,986.96 0
50576   1 0 3 0 1,764.91 0
50576   2 0 3 0 1,742.83 0
50576   3 0 3 0 1,651.00 0
50576   4 0 3 0 1,631.12 0
50580   1 0 3 0 1,350.95 0
50580   2 0 3 0 1,337.91 0
50580   3 0 3 0 1,284.27 0
50580   4 0 3 0 1,270.63 0
50590   1 90 2 0 1,794.79 0
50590   2 90 2 0 1,769.90 0
50590   3 90 2 0 1,666.69 0
50590   4 90 2 0 1,645.95 0
50592   1 10 2 0 9,699.36 604.91
50592   2 10 2 0 7,981.25 550.84
50592   3 10 2 0 7,981.25 550.84
50592   4 10 2 0 7,981.25 550.84
50593   1 10 2 0 7,393.57 699.17
50593   2 10 2 0 6,191.49 639.20
50593   3 10 2 0 6,191.49 639.20
50593   4 10 2 0 6,191.49 639.20
50600   1 90 2 0 2,153.01 0
50600   2 90 2 0 2,174.61 0
50600   3 90 2 0 2,030.43 0
50600   4 90 2 0 2,047.83 0
50605   1 90 2 0 1,813.47 0
50605   2 90 2 0 1,793.98 0
50605   3 90 2 0 1,713.73 0
50605   4 90 2 0 1,694.76 0
50606   1 ZZZ 0 0 685.73 203.86
50606   2 ZZZ 0 0 601.75 189.91
50606   3 ZZZ 0 0 601.75 189.91
50606   4 ZZZ 0 0 601.75 189.91
50610   1 90 2 0 2,404.40 0
50610   2 90 2 0 2,373.24 0
50610   3 90 2 0 2,244.31 0
50610   4 90 2 0 2,217.43 0
50620   1 90 2 0 2,321.05 0
50620   2 90 2 0 2,290.71 0
50620   3 90 2 0 2,164.84 0
50620   4 90 2 0 2,138.89 0
50630   1 90 2 0 2,417.14 0
50630   2 90 2 0 2,384.72 0
50630   3 90 2 0 2,250.19 0
50630   4 90 2 0 2,222.80 0
50650   1 90 2 0 2,561.76 0
50650   2 90 2 0 2,529.23 0
50650   3 90 2 0 2,394.39 0
50650   4 90 2 0 2,365.96 0
50660   1 90 2 0 2,815.72 0
50660   2 90 2 0 3,903.74 0
50660   3 90 2 0 3,839.36 0
50660   4 90 2 0 2,594.75 0
50684   1 0 2 0 149.76 0
50684   2 0 2 0 145.93 0
50684   3 0 2 0 105.58 0
50684   4 0 2 0 146.28 0
50686   1 0 2 0 164.11 0
50686   2 0 2 0 162.61 0
50686   3 0 2 0 156.33 0
50686   4 0 2 0 154.70 0
50688   1 10 2 0 133.97 0
50688   2 10 2 0 137.12 0
50688   3 10 2 0 127.04 0
50688   4 10 2 0 125.68 0
50690   1 0 2 0 131.06 0
50690   2 0 2 0 134.84 0
50690   3 0 2 0 132.77 0
50690   4 0 2 0 132.24 0
50693   1 0 2 0 1,377.66 282.62
50693   2 0 2 0 1,198.67 262.79
50693   3 0 2 0 1,198.67 262.79
50693   4 0 2 0 1,198.67 262.79
50694   1 0 2 0 1,515.45 365.14
50694   2 0 2 0 1,322.93 339.81
50694   3 0 2 0 1,322.93 339.81
50694   4 0 2 0 1,322.93 339.81
50695   1 0 2 0 1,847.02 463.12
50695   2 0 2 0 1,614.16 431.42
50695   3 0 2 0 1,614.16 431.42
50695   4 0 2 0 1,614.16 431.42
50700   1 90 2 0 2,423.08 0
50700   2 90 2 0 2,390.37 0
50700   3 90 2 0 2,254.75 0
50700   4 90 2 0 2,227.35 0
50705   1 ZZZ 0 0 2,224.71 261.29
50705   2 ZZZ 0 0 1,921.25 243.21
50705   3 ZZZ 0 0 1,921.25 243.21
50705   4 ZZZ 0 0 1,921.25 243.21
50706   1 ZZZ 0 0 993.60 242.21
50706   2 ZZZ 0 0 868.27 226.11
50706   3 ZZZ 0 0 868.27 226.11
50706   4 ZZZ 0 0 868.27 226.11
50715   1 90 2 0 2,634.10 0
50715   2 90 2 0 2,599.10 0
50715   3 90 2 0 2,454.75 0
50715   4 90 2 0 2,426.54 0
50722   1 90 2 0 2,406.04 0
50722   2 90 2 0 2,368.93 0
50722   3 90 2 0 2,215.92 0
50722   4 90 2 0 2,190.79 0
50725   1 90 2 0 2,903.55 0
50725   2 90 2 0 2,656.13 0
50725   3 90 2 0 2,499.32 0
50725   4 90 2 0 2,470.33 0
50727   1 90 2 0 1,161.04 0
50727   2 90 2 0 1,146.61 0
50727   3 90 2 0 1,086.88 0
50727   4 90 2 0 1,074.07 0
50728   1 90 2 0 1,709.74 0
50728   2 90 2 0 1,688.35 0
50728   3 90 2 0 1,599.96 0
50728   4 90 2 0 1,581.04 0
50740   1 90 2 0 2,784.15 0
50740   2 90 2 0 2,730.51 0
50740   3 90 2 0 2,587.10 0
50740   4 90 2 0 2,585.77 0
50750   1 90 2 0 2,885.35 0
50750   2 90 2 0 2,849.28 0
50750   3 90 2 0 2,699.74 0
50750   4 90 2 0 2,667.39 0
50760   1 90 2 0 2,780.07 0
50760   2 90 2 0 2,743.02 0
50760   3 90 2 0 2,589.58 0
50760   4 90 2 0 2,558.76 0
50770   1 90 2 0 3,021.57 0
50770   2 90 2 0 2,981.64 0
50770   3 90 2 0 2,816.11 0
50770   4 90 2 0 2,782.14 0
50780   1 90 2 0 2,803.43 0
50780   2 90 2 0 2,766.22 0
50780   3 90 2 0 2,612.17 0
50780   4 90 2 0 2,580.89 0
50782   1 90 2 0 2,897.15 0
50782   2 90 2 0 2,859.43 0
50782   3 90 2 0 2,703.07 0
50782   4 90 2 0 2,671.00 0
50783   1 90 2 0 2,976.67 0
50783   2 90 2 0 2,938.41 0
50783   3 90 2 0 2,780.22 0
50783   4 90 2 0 2,747.46 0
50785   1 90 2 0 3,157.41 0
50785   2 90 2 0 3,135.55 0
50785   3 90 2 0 2,935.70 0
50785   4 90 2 0 2,900.73 0
50800   1 90 2 0 2,672.44 0
50800   2 90 2 0 2,592.66 0
50800   3 90 2 0 2,356.77 0
50800   4 90 2 0 2,327.32 0
50810   1 90 2 0 2,824.67 0
50810   2 90 2 0 2,785.54 0
50810   3 90 2 0 2,624.25 0
50810   4 90 2 0 2,593.83 0
50815   1 90 2 0 3,636.48 0
50815   2 90 2 0 3,506.11 0
50815   3 90 2 0 3,273.31 0
50815   4 90 2 0 3,233.32 0
50820   1 90 2 0 3,633.23 0
50820   2 90 2 0 3,579.19 0
50820   3 90 2 0 3,355.47 0
50820   4 90 2 0 3,314.95 0
50825   1 90 2 0 5,231.00 0
50825   2 90 2 0 5,153.63 0
50825   3 90 2 0 4,832.17 0
50825   4 90 2 0 4,771.77 0
50830   1 90 2 0 4,543.38 0
50830   2 90 2 0 4,484.77 0
50830   3 90 2 0 4,242.14 0
50830   4 90 2 0 4,192.28 0
50840   1 90 2 0 2,837.03 0
50840   2 90 2 0 3,230.82 0
50840   3 90 2 0 2,898.79 0
50840   4 90 2 0 2,619.59 0
50845   1 90 2 0 3,000.20 0
50845   2 90 2 0 2,962.71 0
50845   3 90 2 0 2,807.56 0
50845   4 90 2 0 2,774.35 0
50860   1 90 2 0 2,257.52 0
50860   2 90 2 0 2,227.84 0
50860   3 90 2 0 2,104.96 0
50860   4 90 2 0 2,079.88 0
50900   1 90 2 0 2,057.07 0
50900   2 90 2 0 2,221.98 0
50900   3 90 2 0 1,914.02 0
50900   4 90 2 0 2,128.17 0
50920   1 90 2 0 2,288.93 0
50920   2 90 2 0 2,206.16 0
50920   3 90 2 0 1,917.88 0
50920   4 90 2 0 1,895.24 0
50930   1 90 2 0 2,705.32 0
50930   2 90 2 0 2,671.59 0
50930   3 90 2 0 2,531.86 0
50930   4 90 2 0 2,501.90 0
50940   1 90 2 0 2,100.10 0
50940   2 90 2 0 2,240.57 0
50940   3 90 2 0 1,964.53 0
50940   4 90 2 0 1,941.21 0
50945   1 90 2 0 1,814.07 0
50945   2 90 2 0 1,655.51 0
50945   3 90 2 0 1,655.51 0
50945   4 90 2 0 1,655.51 0
50947   1 90 2 0 2,763.37 0
50947   2 90 2 0 2,501.38 0
50947   3 90 2 0 2,501.38 0
50947   4 90 2 0 2,501.38 0
50948   1 90 2 0 2,526.58 0
50948   2 90 2 0 2,287.33 0
50948   3 90 2 0 2,287.33 0
50948   4 90 2 0 2,287.33 0
50949     YYY 2 0 * 0
50951   1 0 2 0 656.84 0
50951   2 0 2 0 889.50 0
50951   3 0 2 0 878.67 0
50951   4 0 2 0 862.67 0
50953   1 0 3 0 689.05 0
50953   2 0 3 0 879.03 0
50953   3 0 3 0 867.98 0
50953   4 0 3 0 649.47 0
50955   1 0 3 0 936.33 0
50955   2 0 3 0 932.80 0
50955   3 0 3 0 776.14 0
50955   4 0 3 0 767.63 0
50957   1 0 3 0 818.53 0
50957   2 0 3 0 810.08 0
50957   3 0 3 0 917.93 0
50957   4 0 3 0 766.97 0
50961   1 0 3 0 767.12 0
50961   2 0 3 0 1,058.16 0
50961   3 0 3 0 1,043.81 0
50961   4 0 3 0 1,003.54 0
50970   1 0 2 0 1,109.58 0
50970   2 0 2 0 1,095.48 0
50970   3 0 2 0 1,037.18 0
50970   4 0 2 0 1,024.89 0
50972   1 0 2 0 734.26 0
50972   2 0 2 0 727.59 0
50972   3 0 2 0 700.60 0
50972   4 0 2 0 693.31 0
50974   1 0 3 0 1,453.38 0
50974   2 0 3 0 1,435.11 0
50974   3 0 3 0 1,359.24 0
50974   4 0 3 0 1,343.01 0
50976   1 0 3 0 1,387.63 0
50976   2 0 3 0 1,370.31 0
50976   3 0 3 0 1,298.69 0
50976   4 0 3 0 1,283.37 0
50980   1 0 2 0 882.67 0
50980   2 0 2 0 1,282.03 0
50980   3 0 2 0 675.01 0
50980   4 0 2 0 824.20 0
51020   1 90 2 0 1,291.60 0
51020   2 90 2 0 1,309.10 0
51020   3 90 2 0 1,289.11 0
51020   4 90 2 0 1,283.40 0
51030   1 90 2 0 1,265.80 0
51030   2 90 2 0 1,406.95 0
51030   3 90 2 0 1,266.98 0
51030   4 90 2 0 877.61 0
51040   1 90 2 0 1,236.66 0
51040   2 90 2 0 1,247.72 0
51040   3 90 2 0 1,243.33 0
51040   4 90 2 0 1,215.85 0
51045   1 90 2 0 1,264.25 0
51045   2 90 2 0 1,106.37 0
51045   3 90 2 0 1,245.42 0
51045   4 90 2 0 1,240.76 0
51050   1 90 2 0 1,325.67 0
51050   2 90 2 0 1,316.43 0
51050   3 90 2 0 1,288.20 0
51050   4 90 2 0 1,282.33 0
51060   1 90 2 0 1,777.76 0
51060   2 90 2 0 1,750.54 0
51060   3 90 2 0 1,637.37 0
51060   4 90 2 0 1,616.43 0
51065   1 90 2 0 1,372.36 0
51065   2 90 2 0 1,597.08 0
51065   3 90 2 0 1,430.44 0
51065   4 90 2 0 1,262.33 0
51080   1 90 2 0 970.41 0
51080   2 90 2 0 1,022.54 0
51080   3 90 2 0 899.96 0
51080   4 90 2 0 983.53 0
51100   1 0 2 0 97.80 58.65
51100   2 0 2 0 86.21 53.77
51100   3 0 2 0 86.21 53.77
51100   4 0 2 0 86.21 53.77
51101   1 0 2 0 203.24 78.60
51101   2 0 2 0 174.68 71.30
51101   3 0 2 0 174.68 71.30
51101   4 0 2 0 174.68 71.30
51102   1 10 2 0 517.63 374.27
51102   2 10 2 0 457.05 338.17
51102   3 10 2 0 457.05 338.17
51102   4 10 2 0 457.05 338.17
51500   1 90 2 0 1,544.34 0
51500   2 90 2 0 1,520.83 0
51500   3 90 2 0 1,423.96 0
51500   4 90 2 0 1,407.64 0
51520   1 90 2 0 1,569.42 0
51520   2 90 2 0 1,606.31 0
51520   3 90 2 0 1,568.53 0
51520   4 90 2 0 1,439.57 0
51525   1 90 2 0 2,120.85 0
51525   2 90 2 0 2,093.03 0
51525   3 90 2 0 1,977.47 0
51525   4 90 2 0 1,953.63 0
51530   1 90 2 0 1,872.26 0
51530   2 90 2 0 2,049.47 0
51530   3 90 2 0 2,074.82 0
51530   4 90 2 0 2,062.12 0
51535   1 90 2 0 1,771.35 0
51535   2 90 2 0 1,746.59 0
51535   3 90 2 0 1,644.56 0
51535   4 90 2 0 1,625.67 0
51550   1 90 2 0 2,270.49 0
51550   2 90 2 0 2,240.82 0
51550   3 90 2 0 2,117.88 0
51550   4 90 2 0 2,092.76 0
51555   1 90 2 0 2,738.86 0
51555   2 90 2 0 2,855.17 0
51555   3 90 2 0 2,634.68 0
51555   4 90 2 0 2,616.83 0
51565   1 90 2 0 3,249.52 0
51565   2 90 2 0 3,206.68 0
51565   3 90 2 0 3,029.28 0
51565   4 90 2 0 2,993.13 0
51570   1 90 2 0 3,409.61 0
51570   2 90 2 0 3,366.38 0
51570   3 90 2 0 3,187.45 0
51570   4 90 2 0 3,149.89 0
51575   1 90 2 0 4,588.08 0
51575   2 90 2 0 4,528.32 0
51575   3 90 2 0 4,280.54 0
51575   4 90 2 0 4,228.98 0
51580   1 90 2 0 4,336.95 0
51580   2 90 2 0 4,282.15 0
51580   3 90 2 0 4,055.34 0
51580   4 90 2 0 4,007.52 0
51585   1 90 2 0 5,165.01 0
51585   2 90 2 0 5,099.03 0
51585   3 90 2 0 4,825.30 0
51585   4 90 2 0 4,767.64 0
51590   1 90 2 0 5,162.28 0
51590   2 90 2 0 4,896.37 0
51590   3 90 2 0 5,001.62 0
51590   4 90 2 0 4,924.79 0
51595   1 90 2 0 6,190.28 0
51595   2 90 2 0 6,105.24 0
51595   3 90 2 0 5,835.37 0
51595   4 90 2 0 5,834.31 0
51596   1 90 2 0 5,766.03 0
51596   2 90 2 0 5,735.32 0
51596   3 90 2 0 5,628.80 0
51596   4 90 2 0 5,938.65 0
51597   1 90 2 0 6,133.44 0
51597   2 90 2 0 6,042.21 0
51597   3 90 2 0 5,665.14 0
51597   4 90 2 0 5,597.79 0
51600   1 0 2 0 85.75 0
51600   2 0 2 0 84.37 0
51600   3 0 2 0 82.28 0
51600   4 0 2 0 81.85 0
51605   1 0 2 0 124.36 0
51605   2 0 2 0 123.14 0
51605   3 0 2 0 118.42 0
51605   4 0 2 0 117.18 0
51610   1 0 2 0 132.89 0
51610   2 0 2 0 134.62 0
51610   3 0 2 0 126.39 0
51610   4 0 2 0 125.80 0
51700   1 0 2 0 94.51 85.54
51700   2 0 2 0 91.41 82.58
51700   3 0 2 0 85.70 77.57
51700   4 0 2 0 79.99 72.58
51701   1 0 2 0 108.06 48.75
51701   2 0 2 0 94.85 44.42
51701   3 0 2 0 94.85 44.42
51701   4 0 2 0 94.85 44.42
51702   1 0 2 0 170.75 53.58
51702   2 0 2 0 148.23 48.53
51702   3 0 2 0 148.23 48.53
51702   4 0 2 0 148.23 48.53
51703   1 0 2 0 234.62 143.62
51703   2 0 2 0 208.18 130.77
51703   3 0 2 0 208.18 130.77
51703   4 0 2 0 208.18 130.77
51705   1 10 2 0 111.80 96.97
51705   2 10 2 0 110.12 95.48
51705   3 10 2 0 106.38 92.45
51705   4 10 2 0 107.44 93.61
51710   1 10 2 0 146.21 0
51710   2 10 2 0 145.08 0
51710   3 10 2 0 140.60 0
51710   4 10 2 0 139.52 0
51715   1 0 2 0 575.08 0
51715   2 0 2 0 567.89 0
51715   3 0 2 0 537.85 0
51715   4 0 2 0 531.52 0
51720   1 0 2 0 164.92 149.47
51720   2 0 2 0 163.06 148.17
51720   3 0 2 0 158.22 143.74
51720   4 0 2 0 156.35 142.38
51725   1 0 2 0 222.81 0
51725 26 1 0 2 0 190.52 0
51725 TC 1 0 2 0 36.90 0
51725   2 0 2 0 224.59 0
51725 26 2 0 2 0 188.44 0
51725 TC 2 0 2 0 36.14 0
51725   3 0 2 0 187.00 0
51725 26 3 0 2 0 160.04 0
51725 TC 3 0 2 0 32.87 0
51725   4 0 2 0 182.86 0
51725 26 4 0 2 0 156.90 0
51725 TC 4 0 2 0 32.39 0
51726   1 0 2 0 246.94 0
51726 26 1 0 2 0 220.67 0
51726 TC 1 0 2 0 47.43 0
51726   2 0 2 0 260.13 0
51726 26 2 0 2 0 206.32 0
51726 TC 2 0 2 0 46.45 0
51726   3 0 2 0 210.07 0
51726 26 3 0 2 0 177.86 0
51726 TC 3 0 2 0 42.29 0
51726   4 0 2 0 211.86 0
51726 26 4 0 2 0 174.40 0
51726 TC 4 0 2 0 41.62 0
51727   1 0 2 0 433.78 0
51727 26 1 0 2 0 158.62 0
51727 TC 1 0 2 0 275.15 0
51727   2 0 2 0 377.73 0
51727 26 2 0 2 0 145.85 0
51727 TC 2 0 2 0 231.88 0
51727   3 0 2 0 377.73 0
51727 26 3 0 2 0 145.85 0
51727 TC 3 0 2 0 231.88 0
51727   4 0 2 0 377.73 0
51727 26 4 0 2 0 145.85 0
51727 TC 4 0 2 0 231.88 0
51728   1 0 2 0 432.72 0
51728 26 1 0 2 0 155.94 0
51728 TC 1 0 2 0 276.80 0
51728   2 0 2 0 377.14 0
51728 26 2 0 2 0 143.90 0
51728 TC 2 0 2 0 233.27 0
51728   3 0 2 0 377.14 0
51728 26 3 0 2 0 143.90 0
51728 TC 3 0 2 0 233.27 0
51728   4 0 2 0 377.14 0
51728 26 4 0 2 0 143.90 0
51728 TC 4 0 2 0 233.27 0
51729   1 0 2 0 464.20 0
51729 26 1 0 2 0 184.16 0
51729 TC 1 0 2 0 280.05 0
51729   2 0 2 0 406.37 0
51729 26 2 0 2 0 170.36 0
51729 TC 2 0 2 0 236.00 0
51729   3 0 2 0 406.37 0
51729 26 3 0 2 0 170.36 0
51729 TC 3 0 2 0 236.00 0
51729   4 0 2 0 406.37 0
51729 26 4 0 2 0 170.36 0
51729 TC 4 0 2 0 236.00 0
51736   1 0 2 0 101.16 0
51736 26 1 0 2 0 85.80 0
51736 TC 1 0 2 0 13.81 0
51736   2 0 2 0 97.44 0
51736 26 2 0 2 0 85.27 0
51736 TC 2 0 2 0 13.64 0
51736   3 0 2 0 95.32 0
51736 26 3 0 2 0 91.69 0
51736 TC 3 0 2 0 12.50 0
51736   4 0 2 0 92.76 0
51736 26 4 0 2 0 74.80 0
51736 TC 4 0 2 0 12.32 0
51741   1 0 2 0 142.87 0
51741 26 1 0 2 0 126.44 0
51741 TC 1 0 2 0 20.14 0
51741   2 0 2 0 149.12 0
51741 26 2 0 2 0 125.60 0
51741 TC 2 0 2 0 96.92 0
51741   3 0 2 0 136.74 0
51741 26 3 0 2 0 121.80 0
51741 TC 3 0 2 0 17.98 0
51741   4 0 2 0 136.08 0
51741 26 4 0 2 0 121.10 0
51741 TC 4 0 2 0 17.74 0
51784   1 0 2 0 249.46 0
51784 26 1 0 2 0 208.53 0
51784 TC 1 0 2 0 40.91 0
51784   2 0 2 0 243.41 0
51784 26 2 0 2 0 204.12 0
51784 TC 2 0 2 0 39.32 0
51784   3 0 2 0 230.42 0
51784 26 3 0 2 0 194.74 0
51784 TC 3 0 2 0 35.68 0
51784   4 0 2 0 227.37 0
51784 26 4 0 2 0 192.31 0
51784 TC 4 0 2 0 35.03 0