2018 Workers' Compensation Part B Fee Schedule

51785-53510

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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
51785   1 0 2 0 211.03 0
51785 26 1 0 2 0 177.29 0
51785 TC 1 0 2 0 37.77 0
51785   2 0 2 0 206.80 0
51785 26 2 0 2 0 176.04 0
51785 TC 2 0 2 0 36.98 0
51785   3 0 2 0 192.61 0
51785 26 3 0 2 0 171.09 0
51785 TC 3 0 2 0 33.62 0
51785   4 0 2 0 188.97 0
51785 26 4 0 2 0 169.89 0
51785 TC 4 0 2 0 33.17 0
51792   1 0 2 0 281.66 0
51792 26 1 0 2 0 150.79 0
51792 TC 1 0 2 0 130.88 0
51792   2 0 2 0 279.02 0
51792 26 2 0 2 0 149.02 0
51792 TC 2 0 2 0 128.17 0
51792   3 0 2 0 217.19 0
51792 26 3 0 2 0 141.75 0
51792 TC 3 0 2 0 116.67 0
51792   4 0 2 0 255.04 0
51792 26 4 0 2 0 140.17 0
51792 TC 4 0 2 0 114.89 0
51797   1 0 2 0 201.62 0
51797 26 1 0 2 0 162.30 0
51797 TC 1 0 2 0 44.08 0
51797   2 0 2 0 200.05 0
51797 26 2 0 2 0 161.27 0
51797 TC 2 0 2 0 43.10 0
51797   3 0 2 0 193.42 0
51797 26 3 0 2 0 147.68 0
51797 TC 3 0 2 0 39.15 0
51797   4 0 2 0 212.82 0
51797 26 4 0 2 0 174.27 0
51797 TC 4 0 2 0 38.57 0
51798   1 0 2 0 39.36 0
51798   2 0 2 0 31.57 0
51798   3 0 2 0 31.57 0
51798   4 0 2 0 31.57 0
51800   1 90 2 0 2,587.15 0
51800   2 90 2 0 2,552.23 0
51800   3 90 2 0 2,407.58 0
51800   4 90 2 0 2,379.28 0
51820   1 90 2 0 1,586.93 0
51820   2 90 2 0 1,564.51 0
51820   3 90 2 0 1,486.77 0
51820   4 90 2 0 1,480.84 0
51840   1 90 2 0 1,644.53 0
51840   2 90 2 0 1,450.56 0
51840   3 90 2 0 1,450.56 0
51840   4 90 2 0 1,450.56 0
51841   1 90 2 0 2,146.68 0
51841   2 90 2 0 2,114.79 0
51841   3 90 2 0 2,035.64 0
51841   4 90 2 0 2,096.08 0
51845   1 90 2 0 2,034.31 0
51845   2 90 2 0 2,014.65 0
51845   3 90 2 0 1,977.21 0
51845   4 90 2 0 1,968.30 0
51860   1 90 2 0 1,706.78 0
51860   2 90 2 0 1,684.38 0
51860   3 90 2 0 1,592.00 0
51860   4 90 2 0 1,573.40 0
51865   1 90 2 0 2,274.96 0
51865   2 90 2 0 2,244.26 0
51865   3 90 2 0 2,117.03 0
51865   4 90 2 0 2,091.90 0
51880   1 90 2 0 1,097.82 0
51880   2 90 2 0 1,083.98 0
51880   3 90 2 0 1,026.47 0
51880   4 90 2 0 1,014.44 0
51900   1 90 2 0 2,509.11 0
51900   2 90 2 0 2,431.39 0
51900   3 90 2 0 2,174.71 0
51900   4 90 2 0 1,968.75 0
51920   1 90 2 0 1,624.29 0
51920   2 90 2 0 1,604.04 0
51920   3 90 2 0 1,520.04 0
51920   4 90 2 0 1,502.07 0
51925   1 90 2 0 2,347.17 0
51925   2 90 2 0 2,307.34 0
51925   3 90 2 0 2,143.72 0
51925   4 90 2 0 2,119.68 0
51940   1 90 2 0 4,005.21 0
51940   2 90 2 0 3,951.46 0
51940   3 90 2 0 3,728.92 0
51940   4 90 2 0 3,684.87 0
51960   1 90 2 0 3,894.95 0
51960   2 90 2 0 3,839.90 0
51960   3 90 2 0 3,611.33 0
51960   4 90 2 0 3,566.90 0
51980   1 90 2 0 2,280.17 0
51980   2 90 2 0 2,207.28 0
51980   3 90 2 0 1,506.40 0
51980   4 90 2 0 1,488.58 0
51990   1 90 2 0 1,409.63 0
51990   2 90 2 0 1,279.79 0
51990   3 90 2 0 1,279.79 0
51990   4 90 2 0 1,279.79 0
51992   1 90 2 0 1,531.95 0
51992   2 90 2 0 1,396.48 0
51992   3 90 2 0 1,396.48 0
51992   4 90 2 0 1,396.48 0
51999     YYY 0 0 * 0
52000   1 0 2 0 299.92 0
52000   2 0 2 0 296.16 0
52000   3 0 2 0 280.70 0
52000   4 0 2 0 277.40 0
52001   1 0 2 0 250.06 0
52001   2 0 2 0 221.90 0
52001   3 0 2 0 221.90 0
52001   4 0 2 0 221.90 0
52005   1 0 2 0 414.71 0
52005   2 0 2 0 409.10 0
52005   3 0 2 0 385.85 0
52005   4 0 2 0 381.15 0
52007   1 0 3 0 497.70 0
52007   2 0 3 0 499.77 0
52007   3 0 3 0 475.98 0
52007   4 0 3 0 462.14 0
52010   1 0 3 0 441.44 0
52010   2 0 3 0 386.51 0
52010   3 0 3 0 413.61 0
52010   4 0 3 0 408.83 0
52204   1 0 3 0 510.74 0
52204   2 0 3 0 452.54 0
52204   3 0 3 0 411.90 0
52204   4 0 3 0 485.70 0
52214   1 0 3 0 632.56 0
52214   2 0 3 0 625.54 0
52214   3 0 3 0 567.06 0
52214   4 0 3 0 615.79 0
52224   1 0 3 0 614.70 0
52224   2 0 3 0 615.13 0
52224   3 0 3 0 537.29 0
52224   4 0 3 0 573.40 0
52234   1 0 2 0 902.04 0
52234   2 0 2 0 896.73 0
52234   3 0 2 0 872.38 0
52234   4 0 2 0 871.01 0
52235   1 0 2 0 1,468.07 0
52235   2 0 2 0 1,324.30 0
52235   3 0 2 0 1,287.56 0
52235   4 0 2 0 1,356.06 0
52240   1 0 2 0 1,858.11 0
52240   2 0 2 0 1,872.68 0
52240   3 0 2 0 1,692.72 0
52240   4 0 2 0 1,750.34 0
52250   1 0 3 0 659.67 0
52250   2 0 3 0 651.62 0
52250   3 0 3 0 494.45 0
52250   4 0 3 0 611.19 0
52260   1 0 3 0 446.03 0
52260   2 0 3 0 441.78 0
52260   3 0 3 0 428.61 0
52260   4 0 3 0 425.62 0
52265   1 0 3 0 344.49 0
52265   2 0 3 0 333.56 0
52265   3 0 3 0 314.36 0
52265   4 0 3 0 325.29 0
52270   1 0 3 0 663.14 0
52270   2 0 3 0 654.25 0
52270   3 0 3 0 617.23 0
52270   4 0 3 0 609.67 0
52275   1 0 3 0 730.48 0
52275   2 0 3 0 732.74 0
52275   3 0 3 0 683.17 0
52275   4 0 3 0 675.06 0
52276   1 0 3 0 777.24 0
52276   2 0 3 0 766.08 0
52276   3 0 3 0 752.24 0
52276   4 0 3 0 748.42 0
52277   1 0 3 0 914.60 0
52277   2 0 3 0 877.79 0
52277   3 0 3 0 819.63 0
52277   4 0 3 0 914.42 0
52281   1 0 3 0 412.15 316.76
52281   2 0 3 0 366.98 285.81
52281   3 0 3 0 366.98 285.81
52281   4 0 3 0 366.98 285.81
52282   1 0 3 0 876.98 0
52282   2 0 3 0 785.65 0
52282   3 0 3 0 785.65 0
52282   4 0 3 0 785.65 0
52283   1 0 3 0 463.47 0
52283   2 0 3 0 369.74 0
52283   3 0 3 0 438.38 0
52283   4 0 3 0 433.64 0
52285   1 0 3 0 592.35 0
52285   2 0 3 0 604.14 0
52285   3 0 3 0 571.03 0
52285   4 0 3 0 558.94 0
52287   1 0 3 0 415.22 223.77
52287   2 0 3 0 371.35 206.27
52287   3 0 3 0 371.35 206.27
52287   4 0 3 0 371.35 206.27
52290   1 0 3 0 617.25 0
52290   2 0 3 0 610.22 0
52290   3 0 3 0 581.10 0
52290   4 0 3 0 574.50 0
52300   1 0 3 0 852.19 0
52300   2 0 3 0 848.10 0
52300   3 0 3 0 742.25 0
52300   4 0 3 0 812.07 0
52301   1 0 3 0 813.37 0
52301   2 0 3 0 749.96 0
52301   3 0 3 0 729.81 0
52301   4 0 3 0 729.81 0
52305   1 0 3 0 790.33 0
52305   2 0 3 0 780.65 0
52305   3 0 3 0 740.55 0
52305   4 0 3 0 731.89 0
52310   1 0 3 0 643.62 0
52310   2 0 3 0 633.46 0
52310   3 0 3 0 610.13 0
52310   4 0 3 0 617.08 0
52315   1 0 3 0 836.92 0
52315   2 0 3 0 826.19 0
52315   3 0 3 0 790.61 0
52315   4 0 3 0 772.34 0
52317   1 0 3 0 1,168.79 0
52317   2 0 3 0 1,153.14 0
52317   3 0 3 0 1,088.32 0
52317   4 0 3 0 1,074.96 0
52318   1 0 3 0 1,544.05 0
52318   2 0 3 0 1,523.69 0
52318   3 0 3 0 1,439.25 0
52318   4 0 3 0 1,421.83 0
52320   1 0 3 0 911.86 0
52320   2 0 3 0 857.69 0
52320   3 0 3 0 883.46 0
52320   4 0 3 0 797.57 0
52325   1 0 3 0 1,202.88 0
52325   2 0 3 0 1,185.77 0
52325   3 0 3 0 1,114.84 0
52325   4 0 3 0 1,100.86 0
52327   1 0 3 0 859.51 0
52327   2 0 3 0 838.90 0
52327   3 0 3 0 794.18 0
52327   4 0 3 0 783.59 0
52330   1 0 3 0 867.95 0
52330   2 0 3 0 796.98 0
52330   3 0 3 0 834.60 0
52330   4 0 3 0 707.86 0
52332   1 0 3 0 608.01 0
52332   2 0 3 0 604.21 0
52332   3 0 3 0 591.61 0
52332   4 0 3 0 582.49 0
52334   1 0 3 0 900.35 0
52334   2 0 3 0 849.62 0
52334   3 0 3 0 857.19 0
52334   4 0 3 0 843.72 0
52341   1 0 3 0 633.32 0
52341   2 0 3 0 578.70 0
52341   3 0 3 0 578.70 0
52341   4 0 3 0 578.70 0
52342   1 0 3 0 685.34 0
52342   2 0 3 0 626.51 0
52342   3 0 3 0 626.51 0
52342   4 0 3 0 626.51 0
52343   1 0 3 0 759.25 0
52343   2 0 3 0 694.00 0
52343   3 0 3 0 694.00 0
52343   4 0 3 0 694.00 0
52344   1 0 3 0 811.26 0
52344   2 0 3 0 741.84 0
52344   3 0 3 0 741.84 0
52344   4 0 3 0 741.84 0
52345   1 0 3 0 865.09 0
52345   2 0 3 0 790.63 0
52345   3 0 3 0 790.63 0
52345   4 0 3 0 790.63 0
52346   1 0 3 0 972.93 0
52346   2 0 3 0 889.43 0
52346   3 0 3 0 889.43 0
52346   4 0 3 0 889.43 0
52351   1 0 2 0 647.18 0
52351   2 0 2 0 589.95 0
52351   3 0 2 0 589.95 0
52351   4 0 2 0 589.95 0
52352   1 0 3 0 802.44 0
52352   2 0 3 0 728.90 0
52352   3 0 3 0 728.90 0
52352   4 0 3 0 728.90 0
52353   1 0 3 0 929.64 0
52353   2 0 3 0 844.42 0
52353   3 0 3 0 844.42 0
52353   4 0 3 0 844.42 0
52354   1 0 3 0 812.03 0
52354   2 0 3 0 739.90 0
52354   3 0 3 0 739.90 0
52354   4 0 3 0 739.90 0
52355   1 0 3 0 952.90 0
52355   2 0 3 0 869.35 0
52355   3 0 3 0 869.35 0
52355   4 0 3 0 869.35 0
52356   1 0 3 0 557.56 0
52356   2 0 3 0 517.45 0
52356   3 0 3 0 517.45 0
52356   4 0 3 0 517.45 0
52400   1 90 2 0 1,136.27 0
52400   2 90 2 0 1,031.82 0
52400   3 90 2 0 1,031.82 0
52400   4 90 2 0 1,031.82 0
52402   1 0 3 0 477.96 0
52402   2 0 3 0 438.31 0
52402   3 0 3 0 438.31 0
52402   4 0 3 0 438.31 0
52441   1 0 3 0 1,658.25 312.08
52441   2 0 3 0 1,439.29 288.79
52441   3 0 3 0 1,439.29 288.79
52441   4 0 3 0 1,439.29 288.79
52442   1 ZZZ 0 0 1,296.12 112.55
52442   2 ZZZ 0 0 1,111.47 99.93
52442   3 ZZZ 0 0 1,111.47 99.93
52442   4 ZZZ 0 0 1,111.47 99.93
52450   1 90 2 0 1,083.16 0
52450   2 90 2 0 1,069.59 0
52450   3 90 2 0 1,013.37 0
52450   4 90 2 0 1,001.44 0
52500   1 90 2 0 1,384.57 0
52500   2 90 2 0 1,422.02 0
52500   3 90 2 0 1,353.34 0
52500   4 90 2 0 1,340.75 0
52601   1 90 2 0 2,218.98 0
52601   2 90 2 0 2,189.43 0
52601   3 90 2 0 2,076.72 0
52601   4 90 2 0 2,047.02 0
52630   1 90 2 0 1,921.68 0
52630   2 90 2 0 1,910.99 0
52630   3 90 2 0 1,861.34 0
52630   4 90 2 0 1,811.50 0
52640   1 90 2 0 1,268.89 0
52640   2 90 2 0 1,262.18 0
52640   3 90 2 0 1,234.60 0
52640   4 90 2 0 1,229.11 0
52647   1 90 2 0 2,218.98 0
52647   2 90 2 0 2,189.43 0
52647   3 90 2 0 2,076.72 0
52647   4 90 2 0 2,047.02 0
52648   1 90 2 0 2,218.98 0
52648   2 90 2 0 2,189.43 0
52648   3 90 2 0 2,076.72 0
52648   4 90 2 0 2,047.02 0
52649   1 90 2 0 1,490.59 0
52649   2 90 2 0 1,348.04 0
52649   3 90 2 0 1,348.04 0
52649   4 90 2 0 1,348.04 0
52700   1 90 2 0 896.71 0
52700   2 90 2 0 870.90 0
52700   3 90 2 0 806.14 0
52700   4 90 2 0 836.56 0
53000   1 10 2 0 358.38 0
53000   2 10 2 0 343.80 0
53000   3 10 2 0 325.14 0
53000   4 10 2 0 313.57 0
53010   1 90 2 0 600.48 0
53010   2 90 2 0 692.54 0
53010   3 90 2 0 658.80 0
53010   4 90 2 0 548.36 0
53020   1 0 2 0 233.50 0
53020   2 0 2 0 228.10 0
53020   3 0 2 0 233.06 0
53020   4 0 2 0 214.99 0
53025   1 0 2 0 173.41 0
53025   2 0 2 0 171.27 0
53025   3 0 2 0 162.21 0
53025   4 0 2 0 160.35 0
53040   1 90 2 0 649.31 0
53040   2 90 2 0 608.06 0
53040   3 90 2 0 629.53 0
53040   4 90 2 0 647.96 0
53060   1 10 2 0 270.84 0
53060   2 10 2 0 243.97 0
53060   3 10 2 0 258.18 0
53060   4 10 2 0 255.52 0
53080   1 90 2 0 891.00 0
53080   2 90 2 0 879.62 0
53080   3 90 2 0 832.40 0
53080   4 90 2 0 822.69 0
53085   1 90 2 0 1,480.74 0
53085   2 90 2 0 1,461.96 0
53085   3 90 2 0 1,384.48 0
53085   4 90 2 0 1,368.17 0
53200   1 0 2 0 327.45 0
53200   2 0 2 0 323.85 0
53200   3 0 2 0 309.04 0
53200   4 0 2 0 305.67 0
53210   1 90 2 0 1,524.25 0
53210   2 90 2 0 1,539.84 0
53210   3 90 2 0 1,447.42 0
53210   4 90 2 0 1,522.25 0
53215   1 90 2 0 2,204.27 0
53215   2 90 2 0 2,177.12 0
53215   3 90 2 0 2,064.90 0
53215   4 90 2 0 2,040.62 0
53220   1 90 2 0 1,023.73 0
53220   2 90 2 0 1,010.65 0
53220   3 90 2 0 956.49 0
53220   4 90 2 0 945.17 0
53230   1 90 2 0 1,538.24 0
53230   2 90 2 0 1,517.72 0
53230   3 90 2 0 1,432.60 0
53230   4 90 2 0 1,415.21 0
53235   1 90 2 0 1,218.13 0
53235   2 90 2 0 1,102.76 0
53235   3 90 2 0 1,068.76 0
53235   4 90 2 0 1,133.66 0
53240   1 90 2 0 804.16 0
53240   2 90 2 0 786.68 0
53240   3 90 2 0 873.47 0
53240   4 90 2 0 863.13 0
53250   1 90 2 0 874.53 0
53250   2 90 2 0 863.68 0
53250   3 90 2 0 541.31 0
53250   4 90 2 0 808.67 0
53260   1 10 2 0 404.38 0
53260   2 10 2 0 378.82 0
53260   3 10 2 0 391.75 0
53260   4 10 2 0 393.78 0
53265   1 10 2 0 491.49 0
53265   2 10 2 0 566.71 0
53265   3 10 2 0 530.89 0
53265   4 10 2 0 510.93 0
53270   1 10 2 0 341.83 0
53270   2 10 2 0 337.78 0
53270   3 10 2 0 260.30 0
53270   4 10 2 0 317.94 0
53275   1 10 2 0 586.14 0
53275   2 10 2 0 591.71 0
53275   3 10 2 0 566.38 0
53275   4 10 2 0 559.94 0
53400   1 90 2 0 1,727.73 0
53400   2 90 2 0 1,706.58 0
53400   3 90 2 0 1,619.26 0
53400   4 90 2 0 1,600.42 0
53405   1 90 2 0 2,193.65 0
53405   2 90 2 0 2,164.25 0
53405   3 90 2 0 2,042.57 0
53405   4 90 2 0 2,018.45 0
53410   1 90 2 0 2,152.11 0
53410   2 90 2 0 2,127.14 0
53410   3 90 2 0 2,024.09 0
53410   4 90 2 0 2,000.92 0
53415   1 90 2 0 2,718.09 0
53415   2 90 2 0 2,479.05 0
53415   3 90 2 0 2,401.40 0
53415   4 90 2 0 2,519.57 0
53420   1 90 2 0 1,264.49 0
53420   2 90 2 0 1,245.06 0
53420   3 90 2 0 2,034.40 0
53420   4 90 2 0 1,144.33 0
53425   1 90 2 0 2,180.63 0
53425   2 90 2 0 2,154.77 0
53425   3 90 2 0 2,047.87 0
53425   4 90 2 0 2,024.10 0
53430   1 90 2 0 2,018.88 0
53430   2 90 2 0 1,996.22 0
53430   3 90 2 0 1,902.78 0
53430   4 90 2 0 1,881.57 0
53431   1 90 2 0 1,950.63 0
53431   2 90 2 0 1,775.15 0
53431   3 90 2 0 1,775.15 0
53431   4 90 2 0 1,775.15 0
53440   1 90 2 0 2,378.04 0
53440   2 90 2 0 2,306.89 0
53440   3 90 2 0 2,094.55 0
53440   4 90 2 0 2,202.40 0
53442   1 90 2 0 1,230.04 0
53442   2 90 2 0 1,213.63 0
53442   3 90 2 0 1,145.45 0
53442   4 90 2 0 1,131.90 0
53444   1 90 2 0 1,400.17 0
53444   2 90 2 0 1,270.51 0
53444   3 90 2 0 1,270.51 0
53444   4 90 2 0 1,270.51 0
53445   1 90 2 0 2,953.40 0
53445   2 90 2 0 2,907.64 0
53445   3 90 2 0 2,717.38 0
53445   4 90 2 0 2,682.61 0
53446   1 90 2 0 1,303.16 0
53446   2 90 2 0 1,168.99 0
53446   3 90 2 0 1,168.99 0
53446   4 90 2 0 1,168.99 0
53447   1 90 2 0 1,936.80 0
53447   2 90 2 0 1,912.31 0
53447   3 90 2 0 1,811.08 0
53447   4 90 2 0 1,789.53 0
53448   1 90 2 0 2,339.24 0
53448   2 90 2 0 2,114.67 0
53448   3 90 2 0 2,114.67 0
53448   4 90 2 0 2,114.67 0
53449   1 90 2 0 1,592.32 0
53449   2 90 2 0 1,494.56 0
53449   3 90 2 0 1,482.22 0
53449   4 90 2 0 1,464.09 0
53450   1 90 2 0 749.95 0
53450   2 90 2 0 741.66 0
53450   3 90 2 0 707.32 0
53450   4 90 2 0 722.80 0
53460   1 90 2 0 805.17 0
53460   2 90 2 0 796.84 0
53460   3 90 2 0 757.82 0
53460   4 90 2 0 754.32 0
53500   1 90 2 0 1,283.76 0
53500   2 90 2 0 1,168.85 0
53500   3 90 2 0 1,168.85 0
53500   4 90 2 0 1,168.85 0
53502   1 90 2 0 1,207.44 0
53502   2 90 2 0 1,089.55 0
53502   3 90 2 0 1,030.53 0
53502   4 90 2 0 1,018.45 0
53505   1 90 2 0 1,115.01 0
53505   2 90 2 0 1,100.96 0
53505   3 90 2 0 1,042.84 0
53505   4 90 2 0 1,127.99 0
53510   1 90 2 0 1,486.41 0
53510   2 90 2 0 1,467.93 0
53510   3 90 2 0 1,391.00 0
53510   4 90 2 0 1,374.49 0