2018 Workers' Compensation Part B Fee Schedule

55530-57511

View the PDF

CPT/HCPC Code
Modifier
Medicare Location
Global Surgery Indicator
Multiple Surgery Indicator
Prevailing Charge Amount
Fee Schedule Amount
Site of Service Amount
55530   1 90 2 0 979.27 0
55530   2 90 2 0 965.24 0
55530   3 90 2 0 907.18 0
55530   4 90 2 0 896.13 0
55535   1 90 2 0 958.79 0
55535   2 90 2 0 946.67 0
55535   3 90 2 0 973.85 0
55535   4 90 2 0 886.19 0
55540   1 90 2 0 1,115.17 0
55540   2 90 2 0 1,389.91 0
55540   3 90 2 0 1,322.59 0
55540   4 90 2 0 1,346.56 0
55550   1 90 2 0 807.79 0
55550   2 90 2 0 731.14 0
55550   3 90 2 0 731.14 0
55550   4 90 2 0 731.14 0
55559     YYY 2 0 * 0
55600   1 90 2 0 950.28 0
55600   2 90 2 0 937.36 0
55600   3 90 2 0 884.10 0
55600   4 90 2 0 873.76 0
55605   1 90 2 0 1,193.01 0
55605   2 90 2 0 1,177.59 0
55605   3 90 2 0 1,113.74 0
55605   4 90 2 0 1,100.59 0
55650   1 90 2 0 1,662.41 0
55650   2 90 2 0 1,641.87 0
55650   3 90 2 0 1,838.79 0
55650   4 90 2 0 1,538.58 0
55680   1 90 2 0 831.00 0
55680   2 90 2 0 820.24 0
55680   3 90 2 0 775.68 0
55680   4 90 2 0 766.12 0
55700   1 0 2 0 382.45 0
55700   2 0 2 0 374.01 0
55700   3 0 2 0 309.21 0
55700   4 0 2 0 307.85 0
55705   1 10 2 0 915.57 0
55705   2 10 2 0 911.83 0
55705   3 10 2 0 821.94 0
55705   4 10 2 0 832.08 0
55706   1 10 2 0 584.12 0
55706   2 10 2 0 531.06 0
55706   3 10 2 0 531.06 0
55706   4 10 2 0 531.06 0
55720   1 90 2 0 981.99 0
55720   2 90 2 0 971.01 0
55720   3 90 2 0 925.65 0
55720   4 90 2 0 915.30 0
55725   1 90 2 0 1,197.50 0
55725   2 90 2 0 1,182.45 0
55725   3 90 2 0 1,120.21 0
55725   4 90 2 0 1,299.01 0
55801   1 90 2 0 2,641.08 0
55801   2 90 2 0 2,605.57 0
55801   3 90 2 0 2,458.76 0
55801   4 90 2 0 2,429.51 0
55810   1 90 2 0 3,536.76 0
55810   2 90 2 0 3,543.41 0
55810   3 90 2 0 3,462.37 0
55810   4 90 2 0 3,257.32 0
55812   1 90 2 0 3,917.53 0
55812   2 90 2 0 3,867.36 0
55812   3 90 2 0 3,659.92 0
55812   4 90 2 0 3,617.10 0
55815   1 90 2 0 4,854.55 0
55815   2 90 2 0 4,790.40 0
55815   3 90 2 0 4,523.82 0
55815   4 90 2 0 4,468.87 0
55821   1 90 2 0 2,423.25 0
55821   2 90 2 0 2,389.47 0
55821   3 90 2 0 2,248.96 0
55821   4 90 2 0 2,266.16 0
55831   1 90 2 0 2,628.54 0
55831   2 90 2 0 2,592.07 0
55831   3 90 2 0 2,440.67 0
55831   4 90 2 0 2,410.53 0
55840   1 90 2 0 3,407.50 0
55840   2 90 2 0 3,363.82 0
55840   3 90 2 0 3,182.73 0
55840   4 90 2 0 3,144.65 0
55842   1 90 2 0 3,887.29 0
55842   2 90 2 0 3,866.38 0
55842   3 90 2 0 3,779.87 0
55842   4 90 2 0 3,762.00 0
55845   1 90 2 0 4,701.55 0
55845   2 90 2 0 4,638.10 0
55845   3 90 2 0 4,430.84 0
55845   4 90 2 0 4,404.48 0
55860   1 90 2 0 1,822.06 0
55860   2 90 2 0 1,801.10 0
55860   3 90 2 0 1,714.54 0
55860   4 90 2 0 1,694.95 0
55862   1 90 2 0 2,589.85 0
55862   2 90 2 0 2,557.37 0
55862   3 90 2 0 2,423.23 0
55862   4 90 2 0 2,394.77 0
55865   1 90 2 0 4,198.70 0
55865   2 90 2 0 4,164.33 0
55865   3 90 2 0 3,907.34 0
55865   4 90 2 0 3,858.37 0
55866   1 90 2 0 2,920.13 0
55866   2 90 2 0 2,677.59 0
55866   3 90 2 0 2,677.59 0
55866   4 90 2 0 2,677.59 0
55870     0 2 0 * 0
55873   1 90 2 0 2,107.06 0
55873   2 90 2 0 1,911.46 0
55873   3 90 2 0 1,911.46 0
55873   4 90 2 0 1,911.46 0
55874   1 0 2 0 4,606.83 208.58
55874   2 0 2 0 4,025.69 192.57
55874   3 0 2 0 4,025.69 192.57
55874   4 0 2 0 4,025.69 192.57
55875   1 90 2 0 1,092.82 0
55875   2 90 2 0 981.35 0
55875   3 90 2 0 981.35 0
55875   4 90 2 0 981.35 0
55876   1 0 2 0 225.90 166.14
55876   2 0 2 0 193.29 144.45
55876   3 0 2 0 193.29 144.45
55876   4 0 2 0 193.29 144.45
55899     YYY 2 0 * 0
55920   1 0 2 0 642.76 0
55920   2 0 2 0 586.54 0
55920   3 0 2 0 586.54 0
55920   4 0 2 0 586.54 0
56405   1 10 2 0 242.31 0
56405   2 10 2 0 248.72 0
56405   3 10 2 0 245.75 0
56405   4 10 2 0 244.12 0
56420   1 10 2 0 234.50 0
56420   2 10 2 0 229.23 0
56420   3 10 2 0 227.22 0
56420   4 10 2 0 215.56 0
56440   1 10 2 0 526.39 0
56440   2 10 2 0 517.27 0
56440   3 10 2 0 479.50 0
56440   4 10 2 0 473.90 0
56441   1 10 2 0 340.49 0
56441   2 10 2 0 334.94 0
56441   3 10 2 0 312.16 0
56441   4 10 2 0 308.51 0
56442   1 0 2 0 69.16 0
56442   2 0 2 0 60.42 0
56442   3 0 2 0 60.42 0
56442   4 0 2 0 60.42 0
56501   1 10 2 0 252.06 220.23
56501   2 10 2 0 254.69 223.28
56501   3 10 2 0 202.54 177.36
56501   4 10 2 0 216.78 190.40
56515   1 10 2 0 794.87 0
56515   2 10 2 0 784.50 0
56515   3 10 2 0 772.92 0
56515   4 10 2 0 591.93 0
56605   1 0 2 0 237.26 0
56605   2 0 2 0 243.30 0
56605   3 0 2 0 199.60 0
56605   4 0 2 0 191.21 0
56606   1 0 0 0 75.49 0
56606   2 0 0 0 74.17 0
56606   3 0 0 0 68.78 0
56606   4 0 0 0 67.93 0
56620   1 90 2 0 1,302.91 0
56620   2 90 2 0 1,259.40 0
56620   3 90 2 0 1,192.27 0
56620   4 90 2 0 1,198.44 0
56625   1 90 2 0 1,794.00 0
56625   2 90 2 0 1,676.39 0
56625   3 90 2 0 1,536.44 0
56625   4 90 2 0 1,518.16 0
56630   1 90 2 0 3,522.24 0
56630   2 90 2 0 3,510.19 0
56630   3 90 2 0 3,419.65 0
56630   4 90 2 0 2,262.89 0
56631   1 90 2 0 3,488.19 0
56631   2 90 2 0 3,417.35 0
56631   3 90 2 0 3,125.13 0
56631   4 90 2 0 3,087.84 0
56632   1 90 2 0 3,796.96 0
56632   2 90 2 0 3,723.30 0
56632   3 90 2 0 3,419.54 0
56632   4 90 2 0 3,378.55 0
56633   1 90 2 0 3,639.26 0
56633   2 90 2 0 3,626.30 0
56633   3 90 2 0 3,531.83 0
56633   4 90 2 0 2,523.46 0
56634   1 90 2 0 3,781.04 0
56634   2 90 2 0 3,707.63 0
56634   3 90 2 0 3,404.47 0
56634   4 90 2 0 3,363.69 0
56637   1 90 2 0 3,971.82 0
56637   2 90 2 0 3,897.12 0
56637   3 90 2 0 3,588.96 0
56637   4 90 2 0 3,546.33 0
56640   1 90 2 0 3,951.76 0
56640   2 90 2 0 3,879.33 0
56640   3 90 2 0 3,580.71 0
56640   4 90 2 0 3,538.96 0
56700   1 10 2 0 403.74 0
56700   2 10 2 0 397.34 0
56700   3 10 2 0 370.87 0
56700   4 10 2 0 366.64 0
56740   1 10 2 0 618.94 0
56740   2 10 2 0 626.58 0
56740   3 10 2 0 567.26 0
56740   4 10 2 0 577.09 0
56800   1 10 2 0 636.58 0
56800   2 10 2 0 724.51 0
56800   3 10 2 0 701.13 0
56800   4 10 2 0 576.65 0
56805   1 90 2 0 2,482.32 0
56805   2 90 2 0 2,448.99 0
56805   3 90 2 0 2,311.06 0
56805   4 90 2 0 2,283.63 0
56810   1 10 2 0 705.32 0
56810   2 10 2 0 688.74 0
56810   3 10 2 0 666.52 0
56810   4 10 2 0 674.94 0
56820   1 10 2 0 218.84 150.60
56820   2 10 2 0 194.72 136.66
56820   3 10 2 0 194.72 136.66
56820   4 10 2 0 194.72 136.66
56821   1 0 2 0 283.23 207.40
56821   2 0 2 0 252.79 188.30
56821   3 0 2 0 252.79 188.30
56821   4 0 2 0 252.79 188.30
57000   1 10 2 0 538.83 0
57000   2 10 2 0 499.57 0
57000   3 10 2 0 271.08 0
57000   4 10 2 0 422.99 0
57010   1 90 2 0 738.18 0
57010   2 90 2 0 739.87 0
57010   3 90 2 0 695.39 0
57010   4 90 2 0 687.83 0
57020   1 0 2 0 200.34 0
57020   2 0 2 0 197.53 0
57020   3 0 2 0 186.30 0
57020   4 0 2 0 184.25 0
57022   1 10 2 0 312.94 0
57022   2 10 2 0 283.54 0
57022   3 10 2 0 283.54 0
57022   4 10 2 0 283.54 0
57023   1 10 2 0 312.94 0
57023   2 10 2 0 283.54 0
57023   3 10 2 0 283.54 0
57023   4 10 2 0 283.54 0
57061   1 10 2 0 258.55 0
57061   2 10 2 0 250.90 0
57061   3 10 2 0 251.97 0
57061   4 10 2 0 241.98 0
57065   1 10 2 0 841.24 0
57065   2 10 2 0 836.27 0
57065   3 10 2 0 815.87 0
57065   4 10 2 0 813.22 0
57100   1 0 2 0 246.28 203.04
57100   2 0 2 0 245.86 202.99
57100   3 0 2 0 244.33 201.32
57100   4 0 2 0 237.27 195.20
57105   1 10 2 0 321.88 0
57105   2 10 2 0 316.67 0
57105   3 10 2 0 303.04 0
57105   4 10 2 0 306.12 0
57106   1 90 2 0 699.38 0
57106   2 90 2 0 624.12 0
57106   3 90 2 0 624.12 0
57106   4 90 2 0 624.12 0
57107   1 90 2 0 2,332.18 2318.78
57107   2 90 2 0 2,149.35 2137.87
57107   3 90 2 0 2,149.35 2137.87
57107   4 90 2 0 2,149.35 2137.87
57109   1 90 2 0 2,873.04 2840.24
57109   2 90 2 0 2,584.16 2556.13
57109   3 90 2 0 2,584.16 2556.13
57109   4 90 2 0 2,584.16 2556.13
57110   1 90 2 0 1,813.53 0
57110   2 90 2 0 1,800.22 0
57110   3 90 2 0 1,745.38 0
57110   4 90 2 0 1,736.67 0
57111   1 90 2 0 2,845.46 2896.89
57111   2 90 2 0 2,560.57 2604.55
57111   3 90 2 0 2,560.57 2604.55
57111   4 90 2 0 2,560.57 2604.55
57112   1 90 2 0 3,028.11 3025.12
57112   2 90 2 0 2,732.28 2729.74
57112   3 90 2 0 2,732.28 2729.74
57112   4 90 2 0 2,732.28 2729.74
57120   1 90 2 0 1,356.41 0
57120   2 90 2 0 1,331.37 0
57120   3 90 2 0 1,423.58 0
57120   4 90 2 0 1,213.49 0
57130   1 10 2 0 496.78 0
57130   2 10 2 0 504.39 0
57130   3 10 2 0 449.52 0
57130   4 10 2 0 444.20 0
57135   1 10 2 0 443.83 0
57135   2 10 2 0 428.28 0
57135   3 10 2 0 399.79 0
57135   4 10 2 0 395.19 0
57150   1 0 2 0 100.52 92.59
57150   2 0 2 0 99.41 91.64
57150   3 0 2 0 95.16 87.76
57150   4 0 2 0 94.29 86.96
57155   1 90 2 0 716.77 0
57155   2 90 2 0 639.83 0
57155   3 90 2 0 639.83 0
57155   4 90 2 0 639.83 0
57156   1 0 2 0 217.20 148.10
57156   2 0 2 0 198.37 137.32
57156   3 0 2 0 198.37 137.32
57156   4 0 2 0 198.37 137.32
57160   1 0 2 0 95.09 85.61
57160   2 0 2 0 94.31 84.62
57160   3 0 2 0 87.80 78.93
57160   4 0 2 0 89.18 80.38
57170     0 2 0 * 0
57180   1 10 2 0 182.20 0
57180   2 10 2 0 180.89 0
57180   3 10 2 0 175.25 0
57180   4 10 2 0 174.12 0
57200   1 90 2 0 618.64 0
57200   2 90 2 0 608.19 0
57200   3 90 2 0 573.57 0
57200   4 90 2 0 577.10 0
57210   1 90 2 0 817.26 0
57210   2 90 2 0 785.99 0
57210   3 90 2 0 750.17 0
57210   4 90 2 0 758.08 0
57220   1 90 2 0 823.22 0
57220   2 90 2 0 792.34 0
57220   3 90 2 0 825.79 0
57220   4 90 2 0 724.65 0
57230   1 90 2 0 837.14 0
57230   2 90 2 0 824.39 0
57230   3 90 2 0 826.83 0
57230   4 90 2 0 763.03 0
57240   1 90 2 0 1,262.55 0
57240   2 90 2 0 1,237.19 0
57240   3 90 2 0 1,132.65 0
57240   4 90 2 0 1,119.14 0
57250   1 90 2 0 1,324.52 0
57250   2 90 2 0 1,214.63 0
57250   3 90 2 0 1,107.37 0
57250   4 90 2 0 1,094.23 0
57260   1 90 2 0 1,617.22 0
57260   2 90 2 0 1,616.41 0
57260   3 90 2 0 1,459.70 0
57260   4 90 2 0 1,525.32 0
57265   1 90 2 0 1,691.82 0
57265   2 90 2 0 1,658.25 0
57265   3 90 2 0 1,519.71 0
57265   4 90 2 0 1,501.64 0
57267   1 ZZZ 0 0 492.13 0
57267   2 ZZZ 0 0 441.43 0
57267   3 ZZZ 0 0 441.43 0
57267   4 ZZZ 0 0 441.43 0
57268   1 90 2 0 1,308.32 0
57268   2 90 2 0 1,283.56 0
57268   3 90 2 0 1,181.47 0
57268   4 90 2 0 1,187.05 0
57270   1 90 2 0 1,387.71 0
57270   2 90 2 0 1,363.07 0
57270   3 90 2 0 1,291.66 0
57270   4 90 2 0 1,307.99 0
57280   1 90 2 0 1,666.91 0
57280   2 90 2 0 1,636.21 0
57280   3 90 2 0 1,509.59 0
57280   4 90 2 0 1,491.93 0
57282   1 90 2 0 1,664.52 0
57282   2 90 2 0 1,633.34 0
57282   3 90 2 0 1,504.92 0
57282   4 90 2 0 1,487.18 0
57283   1 90 2 0 1,162.33 0
57283   2 90 2 0 1,046.86 0
57283   3 90 2 0 1,046.86 0
57283   4 90 2 0 1,046.86 0
57284   1 90 2 0 2,006.29 0
57284   2 90 2 0 1,933.34 0
57284   3 90 2 0 1,827.89 0
57284   4 90 2 0 1,801.90 0
57285   1 90 2 0 925.05 0
57285   2 90 2 0 844.09 0
57285   3 90 2 0 844.09 0
57285   4 90 2 0 844.09 0
57287   1 90 2 0 1,338.78 0
57287   2 90 2 0 1,209.74 0
57287   3 90 2 0 1,209.74 0
57287   4 90 2 0 1,209.74 0
57288   1 90 2 0 2,040.25 0
57288   2 90 2 0 1,997.10 0
57288   3 90 2 0 1,924.80 0
57288   4 90 2 0 1,929.74 0
57289   1 90 2 0 1,396.04 0
57289   2 90 2 0 1,373.23 0
57289   3 90 2 0 1,278.57 0
57289   4 90 2 0 1,262.57 0
57291   1 90 2 0 1,237.22 0
57291   2 90 2 0 1,216.59 0
57291   3 90 2 0 1,131.72 0
57291   4 90 2 0 1,118.99 0
57292   1 90 2 0 1,777.40 0
57292   2 90 2 0 1,751.19 0
57292   3 90 2 0 1,643.46 0
57292   4 90 2 0 1,625.46 0
57295   1 90 2 0 772.37 0
57295   2 90 2 0 685.54 0
57295   3 90 2 0 685.54 0
57295   4 90 2 0 685.54 0
57296   1 90 2 0 1,326.11 0
57296   2 90 2 0 1,182.90 0
57296   3 90 2 0 1,182.90 0
57296   4 90 2 0 1,182.90 0
57300   1 90 2 0 1,525.51 0
57300   2 90 2 0 1,468.43 0
57300   3 90 2 0 1,400.86 0
57300   4 90 2 0 1,429.51 0
57305   1 90 2 0 1,576.23 0
57305   2 90 2 0 2,063.57 0
57305   3 90 2 0 1,437.23 0
57305   4 90 2 0 1,971.11 0
57307   1 90 2 0 1,532.40 0
57307   2 90 2 0 1,508.85 0
57307   3 90 2 0 1,411.78 0
57307   4 90 2 0 2,248.04 0
57308   1 90 2 0 1,439.66 0
57308   2 90 2 0 1,265.48 0
57308   3 90 2 0 1,265.48 0
57308   4 90 2 0 1,265.48 0
57310   1 90 2 0 1,645.12 0
57310   2 90 2 0 932.36 0
57310   3 90 2 0 881.58 0
57310   4 90 2 0 871.26 0
57311   1 90 2 0 1,136.08 0
57311   2 90 2 0 1,122.58 0
57311   3 90 2 0 1,066.70 0
57311   4 90 2 0 1,053.82 0
57320   1 90 2 0 1,918.19 0
57320   2 90 2 0 1,856.83 0
57320   3 90 2 0 1,452.35 0
57320   4 90 2 0 1,771.50 0
57330   1 90 2 0 1,793.49 0
57330   2 90 2 0 1,771.10 0
57330   3 90 2 0 1,678.30 0
57330   4 90 2 0 1,658.43 0
57335   1 90 2 0 1,460.50 0
57335   2 90 2 0 1,440.85 0
57335   3 90 2 0 1,359.60 0
57335   4 90 2 0 1,343.54 0
57400   1 0 2 0 111.72 0
57400   2 0 2 0 123.64 0
57400   3 0 2 0 121.32 0
57400   4 0 2 0 120.87 0
57410   1 0 2 0 86.72 0
57410   2 0 2 0 77.81 0
57410   3 0 2 0 99.34 0
57410   4 0 2 0 75.96 0
57415   1 10 2 0 113.50 0
57415   2 10 2 0 91.02 0
57415   3 10 2 0 112.25 0
57415   4 10 2 0 88.70 0
57420   1 10 2 0 228.05 159.81
57420   2 10 2 0 203.30 145.25
57420   3 10 2 0 203.30 145.25
57420   4 10 2 0 203.30 145.25
57421   1 0 2 0 297.06 221.22
57421   2 0 2 0 265.69 201.17
57421   3 0 2 0 265.69 201.17
57421   4 0 2 0 265.69 201.17
57423   1 90 2 0 1,309.39 0
57423   2 90 2 0 1,180.11 0
57423   3 90 2 0 1,180.11 0
57423   4 90 2 0 1,180.11 0
57425   1 90 2 0 1,619.65 0
57425   2 90 2 0 1,462.03 0
57425   3 90 2 0 1,462.03 0
57425   4 90 2 0 1,462.03 0
57426   1 90 2 0 1,267.44 0
57426   2 90 2 0 1,141.18 0
57426   3 90 2 0 1,141.18 0
57426   4 90 2 0 1,141.18 0
57452   1 0 2 0 156.87 129.19
57452   2 0 2 0 154.32 127.05
57452   3 0 2 0 111.63 91.48
57452   4 0 2 0 142.42 117.15
57454   1 0 3 0 242.48 191.46
57454   2 0 3 0 238.14 187.71
57454   3 0 3 0 220.18 172.62
57454   4 0 3 0 217.68 170.89
57455   1 0 3 0 273.84 201.46
57455   2 0 3 0 244.37 182.79
57455   3 0 3 0 244.37 182.79
57455   4 0 3 0 244.37 182.79
57456   1 0 3 0 259.31 189.02
57456   2 0 3 0 230.94 171.10
57456   3 0 3 0 230.94 171.10
57456   4 0 3 0 230.94 171.10
57460   1 0 3 0 470.16 0
57460   2 0 3 0 462.25 0
57460   3 0 3 0 429.53 0
57460   4 0 3 0 424.70 0
57461   1 0 3 0 613.88 350.53
57461   2 0 3 0 540.45 316.42
57461   3 0 3 0 540.45 316.42
57461   4 0 3 0 540.45 316.42
57500   1 0 2 0 212.32 176.49
57500   2 0 2 0 178.75 148.58
57500   3 0 2 0 153.13 127.54
57500   4 0 2 0 178.24 148.47
57505   1 10 2 0 134.48 112.27
57505   2 10 2 0 133.10 111.20
57505   3 10 2 0 127.39 106.07
57505   4 10 2 0 148.12 123.64
57510   1 10 2 0 175.30 156.90
57510   2 10 2 0 174.55 156.18
57510   3 10 2 0 164.46 147.43
57510   4 10 2 0 172.61 155.20
57511   1 10 2 0 250.19 214.22
57511   2 10 2 0 246.75 211.24
57511   3 10 2 0 232.74 199.19
57511   4 10 2 0 244.50 209.12