2018 Workers' Compensation Part B Fee Schedule

57513-59100

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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
57513   1 10 2 0 410.34 0
57513   2 10 2 0 393.38 0
57513   3 10 2 0 364.36 0
57513   4 10 2 0 383.96 0
57520   1 90 2 0 814.44 0
57520   2 90 2 0 819.72 0
57520   3 90 2 0 620.46 0
57520   4 90 2 0 614.61 0
57522   1 90 2 0 814.44 0
57522   2 90 2 0 819.72 0
57522   3 90 2 0 620.46 0
57522   4 90 2 0 614.61 0
57530   1 90 2 0 780.60 0
57530   2 90 2 0 868.78 0
57530   3 90 2 0 711.85 0
57530   4 90 2 0 787.40 0
57531   1 90 2 0 3,406.86 0
57531   2 90 2 0 2,966.85 0
57531   3 90 2 0 2,966.85 0
57531   4 90 2 0 2,966.85 0
57540   1 90 2 0 1,337.16 0
57540   2 90 2 0 1,250.02 0
57540   3 90 2 0 1,149.20 0
57540   4 90 2 0 1,135.66 0
57545   1 90 2 0 1,081.21 0
57545   2 90 2 0 1,529.44 0
57545   3 90 2 0 1,277.50 0
57545   4 90 2 0 978.59 0
57550   1 90 2 0 1,186.32 0
57550   2 90 2 0 1,217.76 0
57550   3 90 2 0 1,203.43 0
57550   4 90 2 0 1,049.50 0
57555   1 90 2 0 1,823.38 0
57555   2 90 2 0 1,788.12 0
57555   3 90 2 0 1,642.59 0
57555   4 90 2 0 1,622.99 0
57556   1 90 2 0 1,686.73 0
57556   2 90 2 0 1,535.44 0
57556   3 90 2 0 1,446.20 0
57556   4 90 2 0 1,504.64 0
57558   1 10 2 0 182.38 163.42
57558   2 10 2 0 158.76 143.28
57558   3 10 2 0 158.76 143.28
57558   4 10 2 0 158.76 143.28
57700   1 90 2 0 525.51 0
57700   2 90 2 0 661.96 0
57700   3 90 2 0 487.55 0
57700   4 90 2 0 481.86 0
57720   1 90 2 0 625.93 0
57720   2 90 2 0 650.05 0
57720   3 90 2 0 576.50 0
57720   4 90 2 0 569.94 0
57800   1 0 2 0 119.03 0
57800   2 0 2 0 118.97 0
57800   3 0 2 0 113.34 0
57800   4 0 2 0 108.47 0
58100   1 0 2 0 201.11 158.81
58100   2 0 2 0 175.97 138.77
58100   3 0 2 0 143.66 112.64
58100   4 0 2 0 176.43 138.85
58110   1 ZZZ 0 0 85.16 70.28
58110   2 ZZZ 0 0 75.31 63.13
58110   3 ZZZ 0 0 75.31 63.13
58110   4 ZZZ 0 0 75.31 63.13
58120   1 10 2 0 543.29 0
58120   2 10 2 0 529.09 0
58120   3 10 2 0 487.81 0
58120   4 10 2 0 476.48 0
58140   1 90 2 0 1,569.50 0
58140   2 90 2 0 1,540.67 0
58140   3 90 2 0 1,421.72 0
58140   4 90 2 0 1,404.92 0
58145   1 90 2 0 1,519.30 0
58145   2 90 2 0 1,490.76 0
58145   3 90 2 0 1,380.64 0
58145   4 90 2 0 1,364.04 0
58146   1 90 2 0 1,988.01 0
58146   2 90 2 0 1,794.20 0
58146   3 90 2 0 1,794.20 0
58146   4 90 2 0 1,794.20 0
58150   1 90 2 0 2,178.31 0
58150   2 90 2 0 2,142.03 0
58150   3 90 2 0 1,992.60 0
58150   4 90 2 0 1,970.07 0
58152   1 90 2 0 2,312.26 0
58152   2 90 2 0 2,015.76 0
58152   3 90 2 0 2,015.76 0
58152   4 90 2 0 2,015.76 0
58180   1 90 2 0 2,189.57 0
58180   2 90 2 0 2,174.95 0
58180   3 90 2 0 2,114.71 0
58180   4 90 2 0 2,106.36 0
58200   1 90 2 0 3,218.33 0
58200   2 90 2 0 3,064.17 0
58200   3 90 2 0 2,705.37 0
58200   4 90 2 0 2,885.69 0
58210   1 90 2 0 4,032.51 0
58210   2 90 2 0 3,965.09 0
58210   3 90 2 0 3,687.56 0
58210   4 90 2 0 3,645.79 0
58240   1 90 2 0 5,662.88 0
58240   2 90 2 0 5,559.83 0
58240   3 90 2 0 5,323.68 0
58240   4 90 2 0 5,074.99 0
58260   1 90 2 0 2,025.58 0
58260   2 90 2 0 1,990.41 0
58260   3 90 2 0 1,845.44 0
58260   4 90 2 0 1,824.40 0
58262   1 90 2 0 2,166.98 0
58262   2 90 2 0 2,130.95 0
58262   3 90 2 0 1,982.68 0
58262   4 90 2 0 1,960.32 0
58263   1 90 2 0 2,366.92 0
58263   2 90 2 0 2,327.91 0
58263   3 90 2 0 2,167.20 0
58263   4 90 2 0 2,142.73 0
58267   1 90 2 0 2,474.27 0
58267   2 90 2 0 2,431.82 0
58267   3 90 2 0 2,256.67 0
58267   4 90 2 0 2,230.78 0
58270   1 90 2 0 2,225.53 0
58270   2 90 2 0 2,187.37 0
58270   3 90 2 0 2,030.01 0
58270   4 90 2 0 2,006.77 0
58275   1 90 2 0 2,417.00 0
58275   2 90 2 0 2,376.34 0
58275   3 90 2 0 2,303.98 0
58275   4 90 2 0 2,317.74 0
58280   1 90 2 0 2,401.06 0
58280   2 90 2 0 2,360.92 0
58280   3 90 2 0 2,195.86 0
58280   4 90 2 0 2,171.06 0
58285   1 90 2 0 2,807.06 0
58285   2 90 2 0 2,760.51 0
58285   3 90 2 0 2,569.07 0
58285   4 90 2 0 2,540.48 0
58290   1 90 2 0 1,982.67 0
58290   2 90 2 0 1,795.86 0
58290   3 90 2 0 1,795.86 0
58290   4 90 2 0 1,795.86 0
58291   1 90 2 0 2,182.08 0
58291   2 90 2 0 1,973.76 0
58291   3 90 2 0 1,973.76 0
58291   4 90 2 0 1,973.76 0
58292   1 90 2 0 2,312.13 0
58292   2 90 2 0 2,090.59 0
58292   3 90 2 0 2,090.59 0
58292   4 90 2 0 2,090.59 0
58293   1 90 2 0 2,399.44 0
58293   2 90 2 0 2,173.26 0
58293   3 90 2 0 2,173.26 0
58293   4 90 2 0 2,173.26 0
58294   1 90 2 0 2,128.14 0
58294   2 90 2 0 1,925.43 0
58294   3 90 2 0 1,925.43 0
58294   4 90 2 0 1,925.43 0
58301     0 2 0 * 0
58321     0 2 0 * 0
58322     0 2 0 * 0
58323     0 2 0 * 0
58340   1 0 2 0 117.37 0
58340   2 0 2 0 104.76 0
58340   3 0 2 0 104.76 0
58340   4 0 2 0 104.76 0
58345   1 10 2 0 737.79 0
58345   2 10 2 0 727.90 0
58345   3 10 2 0 686.98 0
58345   4 10 2 0 678.90 0
58346   1 90 2 0 764.15 0
58346   2 90 2 0 682.41 0
58346   3 90 2 0 682.41 0
58346   4 90 2 0 682.41 0
58350   1 10 2 0 160.28 0
58350   2 10 2 0 157.53 0
58350   3 10 2 0 146.38 0
58350   4 10 2 0 144.70 0
58353   1 10 2 0 429.94 0
58353   2 10 2 0 389.91 0
58353   3 10 2 0 389.91 0
58353   4 10 2 0 389.91 0
58356   1 10 2 0 927.81 645.76
58356   2 10 2 0 814.53 579.26
58356   3 10 2 0 814.53 579.26
58356   4 10 2 0 814.53 579.26
58400   1 90 2 0 1,105.37 0
58400   2 90 2 0 1,239.08 0
58400   3 90 2 0 1,004.14 0
58400   4 90 2 0 992.35 0
58410   1 90 2 0 1,150.60 0
58410   2 90 2 0 1,133.31 0
58410   3 90 2 0 1,062.01 0
58410   4 90 2 0 1,049.56 0
58520   1 90 2 0 1,024.16 0
58520   2 90 2 0 1,430.76 0
58520   3 90 2 0 937.16 0
58520   4 90 2 0 926.76 0
58540   1 90 2 0 1,429.43 0
58540   2 90 2 0 1,405.18 0
58540   3 90 2 0 1,305.39 0
58540   4 90 2 0 1,290.82 0
58541   1 90 3 0 1,197.66 0
58541   2 90 3 0 1,063.22 0
58541   3 90 3 0 1,063.22 0
58541   4 90 3 0 1,063.22 0
58542   1 90 2 0 1,320.45 0
58542   2 90 2 0 1,177.92 0
58542   3 90 2 0 1,177.92 0
58542   4 90 2 0 1,177.92 0
58543   1 90 2 0 1,342.73 0
58543   2 90 2 0 1,197.84 0
58543   3 90 2 0 1,197.84 0
58543   4 90 2 0 1,197.84 0
58544   1 90 2 0 1,453.18 0
58544   2 90 2 0 1,297.05 0
58544   3 90 2 0 1,297.05 0
58544   4 90 2 0 1,297.05 0
58545   1 90 2 0 1,607.17 0
58545   2 90 2 0 1,437.48 0
58545   3 90 2 0 1,437.48 0
58545   4 90 2 0 1,437.48 0
58546   1 90 2 0 2,014.71 0
58546   2 90 2 0 1,817.15 0
58546   3 90 2 0 1,817.15 0
58546   4 90 2 0 1,817.15 0
58548   1 90 2 0 2,547.79 0
58548   2 90 2 0 2,266.32 0
58548   3 90 2 0 2,266.32 0
58548   4 90 2 0 2,266.32 0
58550   1 10 3 0 1,727.32 0
58550   2 10 3 0 1,558.12 0
58550   3 10 3 0 1,558.12 0
58550   4 10 3 0 1,558.12 0
58552   1 10 3 0 1,566.01 0
58552   2 10 3 0 1,399.69 0
58552   3 10 3 0 1,399.69 0
58552   4 10 3 0 1,399.69 0
58553   1 90 2 0 1,996.46 0
58553   2 90 2 0 1,807.56 0
58553   3 90 2 0 1,807.56 0
58553   4 90 2 0 1,807.56 0
58554   1 90 2 0 1,975.10 0
58554   2 90 2 0 1,789.39 0
58554   3 90 2 0 1,789.39 0
58554   4 90 2 0 1,789.39 0
58555   1 0 2 0 435.12 388.27
58555   2 0 2 0 391.10 351.09
58555   3 0 2 0 391.10 351.09
58555   4 0 2 0 391.10 351.09
58558   1 0 3 0 565.51 518.70
58558   2 0 3 0 511.07 470.98
58558   3 0 3 0 511.07 470.98
58558   4 0 3 0 511.07 470.98
58559   1 0 3 0 724.08 723.32
58559   2 0 3 0 654.48 653.83
58559   3 0 3 0 654.48 653.83
58559   4 0 3 0 654.48 653.83
58560   1 0 3 0 800.16 799.39
58560   2 0 3 0 724.41 723.79
58560   3 0 3 0 724.41 723.79
58560   4 0 3 0 724.41 723.79
58561   1 0 3 0 1,123.94 1123.17
58561   2 0 3 0 1,018.54 1017.93
58561   3 0 3 0 1,018.54 1017.93
58561   4 0 3 0 1,018.54 1017.93
58562   1 0 3 0 561.53 0
58562   2 0 3 0 510.15 0
58562   3 0 3 0 510.15 0
58562   4 0 3 0 510.15 0
58563   1 0 3 0 748.24 0
58563   2 0 3 0 675.13 0
58563   3 0 3 0 675.13 0
58563   4 0 3 0 675.13 0
58565   1 90 3 0 3,876.24 802.62
58565   2 90 3 0 3,272.30 708.16
58565   3 90 3 0 3,272.30 708.16
58565   4 90 3 0 3,272.30 708.16
58570   1 90 2 0 1,307.44 0
58570   2 90 2 0 1,173.83 0
58570   3 90 2 0 1,173.83 0
58570   4 90 2 0 1,173.83 0
58571   1 90 2 0 1,424.40 0
58571   2 90 2 0 1,284.69 0
58571   3 90 2 0 1,284.69 0
58571   4 90 2 0 1,284.69 0
58572   1 90 2 0 1,621.99 0
58572   2 90 2 0 1,458.60 0
58572   3 90 2 0 1,458.60 0
58572   4 90 2 0 1,458.60 0
58573   1 90 2 0 1,816.60 0
58573   2 90 2 0 1,643.40 0
58573   3 90 2 0 1,643.40 0
58573   4 90 2 0 1,643.40 0
58575   1 90 2 0 2,335.97 0
58575   2 90 2 0 2,146.32 0
58575   3 90 2 0 2,146.32 0
58575   4 90 2 0 2,146.32 0
58578     YYY 2 0 * 0
58579     YYY 2 0 * 0
58600   1 90 2 0 1,139.76 0
58600   2 90 2 0 996.14 0
58600   3 90 2 0 907.39 0
58600   4 90 2 0 896.40 0
58605   1 90 2 0 851.16 0
58605   2 90 2 0 780.62 0
58605   3 90 2 0 754.10 0
58605   4 90 2 0 705.79 0
58611   1 ZZZ 0 0 1,088.92 0
58611   2 ZZZ 0 0 104.76 0
58611   3 ZZZ 0 0 97.51 0
58611   4 ZZZ 0 0 1,080.35 0
58615   1 10 2 0 616.34 0
58615   2 10 2 0 608.02 0
58615   3 10 2 0 573.61 0
58615   4 10 2 0 566.83 0
58660   1 90 3 0 1,319.03 0
58660   2 90 3 0 1,188.08 0
58660   3 90 3 0 1,188.08 0
58660   4 90 3 0 1,188.08 0
58661   1 10 3 0 1,338.36 0
58661   2 10 3 0 1,207.44 0
58661   3 10 3 0 1,207.44 0
58661   4 10 3 0 1,207.44 0
58662   1 90 3 0 1,339.34 0
58662   2 90 3 0 1,212.18 0
58662   3 90 3 0 1,212.18 0
58662   4 90 3 0 1,212.18 0
58670   1 90 3 0 750.42 0
58670   2 90 3 0 673.87 0
58670   3 90 3 0 673.87 0
58670   4 90 3 0 673.87 0
58671   1 90 3 0 773.08 0
58671   2 90 3 0 693.24 0
58671   3 90 3 0 693.24 0
58671   4 90 3 0 693.24 0
58672   1 90 3 0 1,447.57 0
58672   2 90 3 0 1,308.88 0
58672   3 90 3 0 1,308.88 0
58672   4 90 3 0 1,308.88 0
58673   1 90 3 0 1,539.82 0
58673   2 90 3 0 1,393.99 0
58673   3 90 3 0 1,393.99 0
58673   4 90 3 0 1,393.99 0
58674   1 90 2 0 1,030.74 0
58674   2 90 2 0 950.00 0
58674   3 90 2 0 950.00 0
58674   4 90 2 0 950.00 0
58679     YYY 2 0 * 0
58700   1 90 2 0 1,326.19 0
58700   2 90 2 0 1,313.80 0
58700   3 90 2 0 1,092.84 0
58700   4 90 2 0 1,205.09 0
58720   1 90 2 0 1,641.98 0
58720   2 90 2 0 1,367.96 0
58720   3 90 2 0 1,264.15 0
58720   4 90 2 0 1,219.73 0
58740   1 90 2 0 2,305.50 0
58740   2 90 2 0 2,200.42 0
58740   3 90 2 0 2,106.56 0
58740   4 90 2 0 2,201.39 0
58750     90 2 0 * 0
58752     90 2 0 * 0
58760     90 2 0 * 0
58770     90 2 0 * 0
58800   1 90 2 0 614.68 0
58800   2 90 2 0 604.93 0
58800   3 90 2 0 592.93 0
58800   4 90 2 0 558.23 0
58805   1 90 2 0 1,176.59 0
58805   2 90 2 0 1,157.93 0
58805   3 90 2 0 1,061.84 0
58805   4 90 2 0 1,049.25 0
58820   1 90 2 0 575.27 0
58820   2 90 2 0 509.81 0
58820   3 90 2 0 509.81 0
58820   4 90 2 0 509.81 0
58822   1 90 2 0 928.35 0
58822   2 90 2 0 913.82 0
58822   3 90 2 0 854.13 0
58822   4 90 2 0 844.76 0
58825   1 90 2 0 937.05 0
58825   2 90 2 0 921.14 0
58825   3 90 2 0 855.87 0
58825   4 90 2 0 846.27 0
58900   1 90 2 0 1,276.33 0
58900   2 90 2 0 1,177.29 0
58900   3 90 2 0 1,206.45 0
58900   4 90 2 0 936.80 0
58920   1 90 2 0 1,288.42 0
58920   2 90 2 0 1,264.71 0
58920   3 90 2 0 1,166.87 0
58920   4 90 2 0 1,153.11 0
58925   1 90 2 0 1,275.39 0
58925   2 90 2 0 1,252.16 0
58925   3 90 2 0 1,156.25 0
58925   4 90 2 0 1,184.74 0
58940   1 90 2 0 1,493.92 0
58940   2 90 2 0 1,350.49 0
58940   3 90 2 0 1,180.13 0
58940   4 90 2 0 1,226.97 0
58943   1 90 2 0 3,052.86 0
58943   2 90 2 0 2,797.62 0
58943   3 90 2 0 3,122.26 0
58943   4 90 2 0 3,109.96 0
58950   1 90 2 0 2,879.15 0
58950   2 90 2 0 2,826.38 0
58950   3 90 2 0 2,789.93 0
58950   4 90 2 0 2,779.20 0
58951   1 90 2 0 4,394.63 0
58951   2 90 2 0 4,366.63 0
58951   3 90 2 0 4,251.18 0
58951   4 90 2 0 4,234.46 0
58952   1 90 2 0 4,449.96 0
58952   2 90 2 0 4,421.90 0
58952   3 90 2 0 4,306.20 0
58952   4 90 2 0 4,289.26 0
58953   1 90 2 0 3,439.56 0
58953   2 90 2 0 3,080.02 0
58953   3 90 2 0 3,080.02 0
58953   4 90 2 0 3,080.02 0
58954   1 90 2 0 3,738.35 0
58954   2 90 2 0 3,348.66 0
58954   3 90 2 0 3,348.66 0
58954   4 90 2 0 3,348.66 0
58956   1 90 2 0 2,331.61 0
58956   2 90 2 0 2,049.58 0
58956   3 90 2 0 2,049.58 0
58956   4 90 2 0 2,049.58 0
58957   1 90 2 0 2,058.66 0
58957   2 90 2 0 1,834.43 0
58957   3 90 2 0 1,834.43 0
58957   4 90 2 0 1,834.43 0
58958   1 90 2 0 2,278.10 0
58958   2 90 2 0 2,031.29 0
58958   3 90 2 0 2,031.29 0
58958   4 90 2 0 2,031.29 0
58960   1 90 2 0 3,202.96 0
58960   2 90 2 0 3,183.32 0
58960   3 90 2 0 3,102.35 0
58960   4 90 2 0 3,091.88 0
58970     0 2 0 * 0
58974     0 2 0 * 0
58976     0 2 0 * 0
58999     YYY 2 0 * 0
59000   1 0 2 0 205.27 0
59000   2 0 2 0 203.37 0
59000   3 0 2 0 195.40 0
59000   4 0 2 0 195.17 0
59001   1 0 2 0 309.87 0
59001   2 0 2 0 279.92 0
59001   3 0 2 0 279.92 0
59001   4 0 2 0 279.92 0
59012   1 0 2 0 553.48 0
59012   2 0 2 0 545.98 0
59012   3 0 2 0 515.25 0
59012   4 0 2 0 509.11 0
59015   1 0 2 0 299.81 0
59015   2 0 2 0 296.50 0
59015   3 0 2 0 282.78 0
59015   4 0 2 0 279.48 0
59020   1 0 2 0 208.69 0
59020 26 1 0 2 0 235.19 0
59020 TC 1 0 2 0 55.48 0
59020   2 0 2 0 204.17 0
59020 26 2 0 2 0 150.16 0
59020 TC 2 0 2 0 54.00 0
59020   3 0 2 0 185.62 0
59020 26 3 0 2 0 137.68 0
59020 TC 3 0 2 0 47.88 0
59020   4 0 2 0 183.25 0
59020 26 4 0 2 0 136.07 0
59020 TC 4 0 2 0 47.22 0
59025   1 0 2 0 94.16 0
59025 26 1 0 2 0 79.08 0
59025 TC 1 0 2 0 23.53 0
59025   2 0 2 0 93.53 0
59025 26 2 0 2 0 78.30 0
59025 TC 2 0 2 0 22.94 0
59025   3 0 2 0 88.33 0
59025 26 3 0 2 0 80.72 0
59025 TC 3 0 2 0 20.40 0
59025   4 0 2 0 87.54 0
59025 26 4 0 2 0 79.85 0
59025 TC 4 0 2 0 20.11 0
59030     0 2 0 * 0
59050   1 XXX 0 0 144.61 0
59050   2 XXX 0 0 125.97 0
59050   3 XXX 0 0 125.97 0
59050   4 XXX 0 0 125.97 0
59051   1 XXX 0 0 218.32 0
59051   2 XXX 0 0 215.31 0
59051   3 XXX 0 0 202.81 0
59051   4 XXX 0 0 200.60 0
59070   1 0 2 0 711.19 525.64
59070   2 0 2 0 640.60 482.75
59070   3 0 2 0 640.60 482.75
59070   4 0 2 0 640.60 482.75
59072   1 0 2 0 850.57 0
59072   2 0 2 0 779.66 0
59072   3 0 2 0 779.66 0
59072   4 0 2 0 779.66 0
59074   1 0 2 0 676.30 525.64
59074   2 0 2 0 610.88 482.75
59074   3 0 2 0 610.88 482.75
59074   4 0 2 0 610.88 482.75
59076   1 0 2 0 850.57 0
59076   2 0 2 0 779.66 0
59076   3 0 2 0 779.66 0
59076   4 0 2 0 779.66 0
59100   1 90 2 0 979.33 0
59100   2 90 2 0 962.94 0
59100   3 90 2 0 895.27 0
59100   4 90 2 0 885.24 0