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DLI
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Workers' Compensation
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Health Care Services Review
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Medical Fee Review
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Fee Schedule
>
Fee Schedule A Part II
Begin Main Content Area
Page Content
2022 Workers' Compensation Fee Schedule
Table A: Prospective Payment System
NPI or Provider #
Provider #
Indirect Medical Education Add-On
Direct Medical Education Add-On
Disproportionate Share Add-On
Paramedical Education Add-On
Aggregate RCC
DRG Rate
Capital Rate
Hold Harmless Rate
Implied Decimal 6
(in percentages)
Implied Decimal 4
(in percentages)
Implied Decimal 6
(in percentages)
Implied Decimal 2 (in dollars)
1750805552
390127
0
0
0
0
633294
1001631
111892
0
1184620486
390130
0
0
0
0
672000
822027
57345
0
1164400131
390133
96119
30636
0
2145
517000
934455
85124
0
1255585303
390137
23063
14230
635
0
455845
823524
80761
0
1821091059
390138
0
0
0
0
791148
820261
59220
0
1508971441
390139
70978
34408
0
4335
408291
1001631
97319
0
1902805245
390142
369904
212140
1506
4035
365688
1001631
237001
0
1689691214
390145
0
0
360
1235
427067
915327
98490
0
1659360220
390146
0
0
0
0
566000
820261
81152
0
1912905548
390147
0
0
0
0
549750
915327
98554
0
1225417421
390150
0
0
0
0
591382
820261
79648
0
1972982882
390150
0
0
0
0
591382
820261
79648
0
1902804552
390151
0
0
0
0
640294
820261
55091
0
1215042114
390153
0
0
0
0
894406
1001631
132391
0
1730173550
390156
159051
111309
1547
0
352862
1001631
112524
0
1861486698
390156
159051
111309
1547
0
352862
1001631
112524
0
1073598439
390157
0
0
0
35511
621777
915327
93673
0
1962401497
390160
0
0
0
0
539000
915327
93673
0
1073047981
390162
75610
51350
0
0
625314
934455
81732
0
1457408973
390163
0
0
374
0
591000
833462
72676
0
1568577724
390163
0
0
374
0
591000
833462
72676
0
1144384082
390164
429609
170349
862
7967
363586
915327
36453
279167
1821007881
390164
429609
170349
862
7967
363586
915327
36453
279167
1447317896
390168
0
0
732
0
515034
915327
18139
100556
1356334510
390173
0
0
0
0
537053
876411
24880
81212
1134297393
390174
52652
34199
731
45941
383273
1001631
15413
200782
1215916002
390174
463742
229874
1399
15681
377172
1001631
24038
278908
1225048838
390178
28914
1845
826
0
674040
842215
79329
0
1952465890
390178
28914
1845
826
0
674040
842215
79329
0
1356333579
390179
0
0
260
41582
430116
1001631
59310
87148
1457715146
390180
112319
70954
923
9057
384000
1001631
107677
0
1437182847
390183
0
0
0
0
569778
820261
82931
0
1144215039
390184
0
0
0
0
815338
915327
58352
0
1548322720
390185
18769
18809
0
15960
461393
823524
72282
0
1518256726
390192
0
0
0
0
635752
823524
69302
0
1356354567
390194
0
0
0
0
565986
919658
94750
0
1245335629
390195
146350
43945
0
21370
404312
1001631
82221
0
1548263973
390198
157011
55037
1444
0
386206
844436
47365
0
1265449870
390199
0
0
840
0
649447
820261
72743
0
1568459436
390201
0
0
0
0
473822
1141857
82931
0
1225091697
390203
0
0
0
2762
460513
1001631
154849
0
1124023015
390204
0
0
0
6730
410795
1001631
132746
0
1184672214
390211
0
0
359
42894
516785
842215
85798
0
1144255159
390217
0
0
803
0
613350
915327
72336
0
1821015462
390219
51991
28021
360
3160
445265
915327
74116
0
1760906549
390220
0
0
0
0
469486
1001631
43157
110652
1407856099
390222
0
0
0
0
402183
1001631
73117
0
1245207521
390223
232106
71719
1750
19353
450145
1001631
179345
0
1083615587
390225
0
0
0
0
676859
869575
83808
0
1548423684
390225
0
0
0
0
676859
869575
83808
0
1063489342
390226
0
79589
0
4412
431688
1001631
7912
277371
1073587119
390228
0
0
0
0
490321
915327
96962
0
1811992084
390231
129440
54408
0
21332
366297
1001631
118991
0
1730158981
390233
0
0
0
0
731036
847296
75456
0
1881983039
390237
15748
15537
0
1102
537339
823524
83264
0
1568435477
390256
543218
185283
516
1423
868053
888070
75851
0
1780686931
390258
0
0
0
0
941264
1001631
61276
126819
1578560504
390265
0
0
0
0
506455
915327
93673
0
1023000296
390266
0
0
0
0
889640
842215
85155
0
1679592380
390267
51991
29760
0
0
527563
915327
93673
0
1104991801
390268
0
0
0
4552
868457
905915
87322
0
1730173154
390268
0
0
0
4552
868457
905915
87322
0
1780750620
390268
0
0
0
4552
868457
905915
87322
0
1093001653
390270
0
0
0
0
415541
823524
26414
116967
1104292960
390270
0
0
0
0
415541
823524
26414
116967
1174822068
390270
0
0
0
0
415541
823524
26414
116967
1205197894
390270
0
0
0
0
415541
823524
26414
116967
1235424672
390270
0
0
0
0
415541
823524
26414
116967
1265728810
390270
0
0
0
0
415541
823524
26414
116967
1275620585
390270
0
0
0
0
415541
823524
26414
116967
1447538640
390270
0
0
0
0
415541
823524
26414
116967
1649305129
390270
0
0
0
0
415541
823524
26414
116967
1649568403
390270
0
0
0
0
415541
823524
26414
116967
1669768214
390270
0
0
0
0
415541
823524
26414
116967
1760777106
390270
0
0
0
0
415541
823524
26414
116967
1770953994
390270
0
0
0
0
415541
823524
26414
116967
1861791865
390270
0
0
0
0
415541
823524
26414
116967
1881980803
390270
0
0
0
0
415541
823524
26414
116967
1528026671
390272
0
0
500
0
0
1001631
37561
0
1467510560
390278
0
0
9140
0
0
1001631
141497
0
1083986129
390304
0
0
294
52838
496395
1001631
169702
0
1659392595
390307
0
0
0
0
403000
842215
85155
0
1780919043
390307
0
0
0
0
403000
842215
85155
0
1225678881
390314
0
0
0
0
300000
919658
92767
0
1124193511
390316
0
0
0
0
300000
857392
86668
0
1033759626
390321
0
0
0
0
284000
934455
92795
0
1336378132
390322
0
0
0
0
284000
1001631
102011
0
1528398534
390323
0
0
0
0
278000
915327
93670
0
1265664544
390324
0
0
0
0
271000
1001631
102011
0
1578881652
390325
0
0
0
0
271000
847296
85658
0
1962758375
390325
0
0
0
0
271000
847296
85658
0
1497050470
390326
0
0
0
0
271000
934455
92795
0
1760787576
390327
0
0
0
0
407000
847296
85658
0
1225323983
390328
0
0
0
0
268000
915327
93673
0
1104192590
390329
0
0
0
0
268000
1001631
102011
0
1396194197
390330
0
0
0
0
389000
823524
83264
0
1881899284
390331
0
0
0
0
234000
1001631
102011
0
1265096069
390332
0
0
0
0
344000
820261
84790
0
1215598156
390333
0
0
0
0
326000
915327
93673
0
1285295899
390333
0
0
0
0
326000
915327
93673
0
1578124418
390333
0
0
0
0
326000
915327
93673
0
1699235374
390333
0
0
0
0
326000
915327
93673
0
1164029658
390336
0
0
0
0
326000
888070
75851
0
999993
999993
75972
37367
433
8021
431343
888070
89688
0
1609541853
BWC006
0
0
0
0
326000
820261
84790
0