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Department of Labor & Industry
Menu
Individuals
Individuals
Unemployment Benefits
Disability Services
Finding A Job
Workers' Compensation Services
Workforce Development
PennSERVE
Guide to Services
Services and Information for Individuals
Uniform Construction Code
Labor Management Relations
Businesses
Businesses
Employer UC Info
Finding Skilled Workers
Disability Services
Workforce Development
Workers' Compensation Services
Labor-Management Relations
Pennsylvania Business One-Stop Shop
State Workers' Insurance Fund (SWIF)
Services and Information for Employers
Services & Information for Indiv...
Services & Information for Emplo...
Unemployment Compensation
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Disability Services
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Fee Schedule
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Fee Schedule 11644-15278
Begin Main Content Area
Page Content
2018 Workers' Compensation Part B Fee Schedule
11644-15278
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
11644
1
10
2
0
719.98
0
11644
2
10
2
0
710.91
0
11644
3
10
2
0
673.11
0
11644
4
10
2
0
688.04
0
11646
1
10
2
0
939.09
0
11646
2
10
2
0
925.84
0
11646
3
10
2
0
871.10
0
11646
4
10
2
0
860.92
0
11719
1
0
2
0
28.59
13.76
11719
2
0
2
0
24.95
12.30
11719
3
0
2
0
24.95
12.30
11719
4
0
2
0
24.95
12.30
11720
1
0
0
0
59.39
44.37
11720
2
0
0
0
53.84
40.76
11720
3
0
0
0
52.41
39.61
11720
4
0
0
0
52.41
39.61
11721
1
0
0
0
100.16
74.78
11721
2
0
0
0
90.78
68.73
11721
3
0
0
0
88.34
66.90
11721
4
0
0
0
88.34
66.90
11730
1
0
2
0
123.67
106.89
11730
2
0
2
0
125.10
108.25
11730
3
0
2
0
107.58
92.89
11730
4
0
2
0
112.97
97.71
11732
1
ZZZ
0
0
55.27
44.84
11732
2
ZZZ
0
0
54.66
44.30
11732
3
ZZZ
0
0
51.96
42.23
11732
4
ZZZ
0
0
51.32
41.76
11740
1
0
2
0
68.78
52.40
11740
2
0
2
0
79.69
60.64
11740
3
0
2
0
78.69
59.78
11740
4
0
2
0
66.69
50.72
11750
1
10
2
0
342.27
253.60
11750
2
10
2
0
353.32
262.00
11750
3
10
2
0
385.75
285.83
11750
4
10
2
0
313.15
231.87
11755
1
0
2
0
209.48
0
11755
2
0
2
0
206.65
0
11755
3
0
2
0
194.91
0
11755
4
0
2
0
192.63
0
11760
1
10
2
0
166.87
137.08
11760
2
10
2
0
167.79
138.26
11760
3
10
2
0
161.63
133.39
11760
4
10
2
0
160.30
131.97
11762
1
10
2
0
366.71
284.46
11762
2
10
2
0
360.65
280.69
11762
3
10
2
0
341.52
265.17
11762
4
10
2
0
344.51
267.72
11765
1
10
2
0
138.57
109.36
11765
2
10
2
0
110.65
87.34
11765
3
10
2
0
133.01
105.03
11765
4
10
2
0
130.92
103.47
11770
1
10
2
0
756.26
0
11770
2
10
2
0
521.62
0
11770
3
10
2
0
668.22
0
11770
4
10
2
0
622.30
0
11771
1
90
2
0
937.38
0
11771
2
90
2
0
945.85
0
11771
3
90
2
0
855.04
0
11771
4
90
2
0
845.17
0
11772
1
90
2
0
1,076.10
0
11772
2
90
2
0
1,058.25
0
11772
3
90
2
0
975.51
0
11772
4
90
2
0
973.62
0
11900
1
0
2
0
67.86
57.37
11900
2
0
2
0
67.11
56.74
11900
3
0
2
0
64.15
54.40
11900
4
0
2
0
63.41
53.86
11901
1
0
2
0
105.93
88.80
11901
2
0
2
0
104.77
87.93
11901
3
0
2
0
100.15
84.18
11901
4
0
2
0
99.03
83.32
11920
0
2
0
*
0
11921
0
2
0
*
0
11922
ZZZ
0
0
*
0
11950
0
2
0
*
0
11951
0
2
0
*
0
11952
0
2
0
*
0
11954
0
2
0
*
0
11960
1
90
2
0
1,357.68
0
11960
2
90
2
0
1,332.38
0
11960
3
90
2
0
1,227.92
0
11960
4
90
2
0
1,213.09
0
11970
1
90
2
0
1,490.59
0
11970
2
90
2
0
1,809.61
0
11970
3
90
2
0
1,348.89
0
11970
4
90
2
0
1,332.53
0
11971
1
90
2
0
564.76
0
11971
2
90
2
0
711.81
0
11971
3
90
2
0
689.46
0
11971
4
90
2
0
493.44
0
11976
XXX
2
0
*
0
11980
1
0
2
0
226.18
157.39
11980
2
0
2
0
201.99
143.24
11980
3
0
2
0
201.99
143.24
11980
4
0
2
0
201.99
143.24
11981
1
XXX
2
0
217.75
149.31
11981
2
XXX
2
0
192.63
134.34
11981
3
XXX
2
0
192.63
134.34
11981
4
XXX
2
0
192.63
134.34
11982
1
XXX
2
0
248.26
179.74
11982
2
XXX
2
0
219.97
161.68
11982
3
XXX
2
0
219.97
161.68
11982
4
XXX
2
0
219.97
161.68
11983
1
XXX
2
0
401.49
332.99
11983
2
XXX
2
0
357.99
299.69
11983
3
XXX
2
0
357.99
299.69
11983
4
XXX
2
0
357.99
299.69
12001
1
10
2
0
168.86
0
12001
2
10
2
0
165.43
0
12001
3
10
2
0
148.72
0
12001
4
10
2
0
150.09
0
12002
1
10
2
0
208.32
0
12002
2
10
2
0
210.89
0
12002
3
10
2
0
202.80
0
12002
4
10
2
0
200.58
0
12004
1
10
2
0
237.36
0
12004
2
10
2
0
295.01
0
12004
3
10
2
0
289.22
0
12004
4
10
2
0
294.49
0
12005
1
10
2
0
380.26
0
12005
2
10
2
0
375.24
0
12005
3
10
2
0
371.38
0
12005
4
10
2
0
361.27
0
12006
1
10
2
0
450.33
0
12006
2
10
2
0
445.20
0
12006
3
10
2
0
423.89
0
12006
4
10
2
0
425.10
0
12007
1
10
2
0
521.36
0
12007
2
10
2
0
515.63
0
12007
3
10
2
0
491.94
0
12007
4
10
2
0
486.43
0
12011
1
10
2
0
184.69
0
12011
2
10
2
0
178.25
0
12011
3
10
2
0
161.92
0
12011
4
10
2
0
161.59
0
12013
1
10
2
0
219.87
0
12013
2
10
2
0
231.49
0
12013
3
10
2
0
233.09
0
12013
4
10
2
0
220.49
0
12014
1
10
2
0
245.45
0
12014
2
10
2
0
259.32
0
12014
3
10
2
0
265.69
0
12014
4
10
2
0
243.56
0
12015
1
10
2
0
307.74
0
12015
2
10
2
0
394.61
0
12015
3
10
2
0
371.24
0
12015
4
10
2
0
400.64
0
12016
1
10
2
0
646.30
0
12016
2
10
2
0
596.31
0
12016
3
10
2
0
529.88
0
12016
4
10
2
0
473.92
0
12017
1
10
2
0
672.28
0
12017
2
10
2
0
777.65
0
12017
3
10
2
0
629.64
0
12017
4
10
2
0
760.10
0
12018
1
10
2
0
962.22
0
12018
2
10
2
0
949.38
0
12018
3
10
2
0
895.94
0
12018
4
10
2
0
884.96
0
12020
1
10
2
0
340.98
0
12020
2
10
2
0
347.07
0
12020
3
10
2
0
337.98
0
12020
4
10
2
0
356.87
0
12021
1
10
2
0
444.09
0
12021
2
10
2
0
444.33
0
12021
3
10
2
0
403.33
0
12021
4
10
2
0
387.08
0
12031
1
10
2
0
213.83
0
12031
2
10
2
0
206.79
0
12031
3
10
2
0
192.88
0
12031
4
10
2
0
189.54
0
12032
1
10
2
0
237.29
0
12032
2
10
2
0
260.45
0
12032
3
10
2
0
254.26
0
12032
4
10
2
0
247.57
0
12034
1
10
2
0
313.95
0
12034
2
10
2
0
383.75
0
12034
3
10
2
0
363.89
0
12034
4
10
2
0
359.77
0
12035
1
10
2
0
477.92
0
12035
2
10
2
0
472.03
0
12035
3
10
2
0
447.69
0
12035
4
10
2
0
442.57
0
12036
1
10
2
0
577.07
0
12036
2
10
2
0
566.08
0
12036
3
10
2
0
546.45
0
12036
4
10
2
0
535.29
0
12037
1
10
2
0
714.58
0
12037
2
10
2
0
704.33
0
12037
3
10
2
0
662.39
0
12037
4
10
2
0
654.79
0
12041
1
10
2
0
221.57
0
12041
2
10
2
0
211.44
0
12041
3
10
2
0
196.83
0
12041
4
10
2
0
191.76
0
12042
1
10
2
0
278.47
0
12042
2
10
2
0
275.83
0
12042
3
10
2
0
279.29
0
12042
4
10
2
0
260.71
0
12044
1
10
2
0
264.09
0
12044
2
10
2
0
388.61
0
12044
3
10
2
0
369.74
0
12044
4
10
2
0
365.52
0
12045
1
10
2
0
480.19
0
12045
2
10
2
0
474.37
0
12045
3
10
2
0
450.26
0
12045
4
10
2
0
445.11
0
12046
1
10
2
0
641.49
0
12046
2
10
2
0
632.85
0
12046
3
10
2
0
599.16
0
12046
4
10
2
0
590.50
0
12047
1
10
2
0
750.40
0
12047
2
10
2
0
739.27
0
12047
3
10
2
0
693.09
0
12047
4
10
2
0
684.84
0
12051
1
10
2
0
260.00
0
12051
2
10
2
0
246.94
0
12051
3
10
2
0
233.58
0
12051
4
10
2
0
222.76
0
12052
1
10
2
0
321.44
0
12052
2
10
2
0
327.55
0
12052
3
10
2
0
313.40
0
12052
4
10
2
0
298.78
0
12053
1
10
2
0
369.36
0
12053
2
10
2
0
342.80
0
12053
3
10
2
0
360.96
0
12053
4
10
2
0
331.48
0
12054
1
10
2
0
620.41
0
12054
2
10
2
0
533.89
0
12054
3
10
2
0
505.55
0
12054
4
10
2
0
499.52
0
12055
1
10
2
0
692.48
0
12055
2
10
2
0
683.35
0
12055
3
10
2
0
645.61
0
12055
4
10
2
0
637.93
0
12056
1
10
2
0
907.98
0
12056
2
10
2
0
895.30
0
12056
3
10
2
0
842.92
0
12056
4
10
2
0
832.67
0
12057
1
10
2
0
1,034.16
0
12057
2
10
2
0
1,020.64
0
12057
3
10
2
0
964.42
0
12057
4
10
2
0
952.60
0
13100
1
10
2
0
327.81
0
13100
2
10
2
0
322.42
0
13100
3
10
2
0
308.72
0
13100
4
10
2
0
305.75
0
13101
1
10
2
0
456.32
0
13101
2
10
2
0
452.79
0
13101
3
10
2
0
435.42
0
13101
4
10
2
0
434.95
0
13102
1
ZZZ
0
0
148.44
137.87
13102
2
ZZZ
0
0
134.49
125.46
13102
3
ZZZ
0
0
134.49
125.46
13102
4
ZZZ
0
0
134.49
125.46
13120
1
10
2
0
349.90
0
13120
2
10
2
0
346.98
0
13120
3
10
2
0
325.83
0
13120
4
10
2
0
333.86
0
13121
1
10
2
0
538.59
0
13121
2
10
2
0
534.02
0
13121
3
10
2
0
503.69
0
13121
4
10
2
0
510.35
0
13122
1
ZZZ
0
0
172.53
159.71
13122
2
ZZZ
0
0
156.38
145.43
13122
3
ZZZ
0
0
156.38
145.43
13122
4
ZZZ
0
0
156.38
145.43
13131
1
10
2
0
442.32
0
13131
2
10
2
0
442.83
0
13131
3
10
2
0
424.30
0
13131
4
10
2
0
396.36
0
13132
1
10
2
0
710.16
0
13132
2
10
2
0
703.08
0
13132
3
10
2
0
674.14
0
13132
4
10
2
0
668.91
0
13133
1
ZZZ
0
0
254.77
241.93
13133
2
ZZZ
0
0
231.79
220.79
13133
3
ZZZ
0
0
231.79
220.79
13133
4
ZZZ
0
0
231.79
220.79
13151
1
10
2
0
609.52
0
13151
2
10
2
0
603.77
0
13151
3
10
2
0
585.72
0
13151
4
10
2
0
582.00
0
13152
1
10
2
0
1,053.95
0
13152
2
10
2
0
1,038.85
0
13152
3
10
2
0
976.40
0
13152
4
10
2
0
964.88
0
13153
1
ZZZ
0
0
280.58
263.97
13153
2
ZZZ
0
0
254.54
240.35
13153
3
ZZZ
0
0
254.54
240.35
13153
4
ZZZ
0
0
254.54
240.35
13160
1
90
2
0
1,126.43
0
13160
2
90
2
0
1,122.21
0
13160
3
90
2
0
1,082.10
0
13160
4
90
2
0
1,079.97
0
14000
1
90
2
0
796.66
0
14000
2
90
2
0
786.78
0
14000
3
90
2
0
745.71
0
14000
4
90
2
0
737.10
0
14001
1
90
2
0
1,119.17
0
14001
2
90
2
0
1,142.57
0
14001
3
90
2
0
1,075.97
0
14001
4
90
2
0
1,063.73
0
14020
1
90
2
0
992.82
0
14020
2
90
2
0
979.79
0
14020
3
90
2
0
926.01
0
14020
4
90
2
0
914.92
0
14021
1
90
2
0
1,439.52
0
14021
2
90
2
0
1,471.31
0
14021
3
90
2
0
1,448.02
0
14021
4
90
2
0
1,320.59
0
14040
1
90
2
0
1,377.18
0
14040
2
90
2
0
1,426.87
0
14040
3
90
2
0
1,392.12
0
14040
4
90
2
0
1,420.44
0
14041
1
90
2
0
1,727.08
0
14041
2
90
2
0
1,684.03
0
14041
3
90
2
0
1,587.07
0
14041
4
90
2
0
1,568.53
0
14060
1
90
2
0
1,546.71
0
14060
2
90
2
0
1,635.14
0
14060
3
90
2
0
1,576.65
0
14060
4
90
2
0
1,530.21
0
14061
1
90
2
0
2,018.06
0
14061
2
90
2
0
1,989.15
0
14061
3
90
2
0
1,869.32
0
14061
4
90
2
0
1,846.69
0
14301
1
90
2
0
1,533.54
1296.02
14301
2
90
2
0
1,357.20
1156.97
14301
3
90
2
0
1,357.20
1156.97
14301
4
90
2
0
1,357.20
1156.97
14302
1
ZZZ
0
0
336.05
0
14302
2
ZZZ
0
0
302.21
0
14302
3
ZZZ
0
0
302.21
0
14302
4
ZZZ
0
0
302.21
0
14350
1
90
2
0
1,409.40
0
14350
2
90
2
0
1,361.12
0
14350
3
90
2
0
1,307.99
0
14350
4
90
2
0
1,293.08
0
15002
1
0
0
0
457.71
311.61
15002
2
0
0
0
394.02
274.61
15002
3
0
0
0
394.02
274.61
15002
4
0
0
0
394.02
274.61
15003
1
ZZZ
0
0
101.57
63.71
15003
2
ZZZ
0
0
87.35
56.41
15003
3
ZZZ
0
0
87.35
56.41
15003
4
ZZZ
0
0
87.35
56.41
15004
1
0
0
0
551.31
385.67
15004
2
0
0
0
475.52
340.15
15004
3
0
0
0
475.52
340.15
15004
4
0
0
0
475.52
340.15
15005
1
ZZZ
0
0
170.01
127.41
15005
2
ZZZ
0
0
147.64
112.84
15005
3
ZZZ
0
0
147.64
112.84
15005
4
ZZZ
0
0
147.64
112.84
15040
1
0
0
0
416.77
203.17
15040
2
0
0
0
355.24
180.71
15040
3
0
0
0
355.24
180.71
15040
4
0
0
0
355.24
180.71
15050
1
90
2
0
877.02
0
15050
2
90
2
0
859.42
0
15050
3
90
2
0
840.82
0
15050
4
90
2
0
837.14
0
15100
1
90
2
0
1,439.61
0
15100
2
90
2
0
1,432.37
0
15100
3
90
2
0
1,402.58
0
15100
4
90
2
0
1,397.44
0
15101
1
ZZZ
0
0
1,074.32
0
15101
2
ZZZ
0
0
1,075.65
0
15101
3
ZZZ
0
0
1,057.99
0
15101
4
ZZZ
0
0
1,065.97
0
15110
1
90
2
0
1,309.43
1,080.90
15110
2
90
2
0
1,136.58
949.88
15110
3
90
2
0
1,136.58
949.88
15110
4
90
2
0
1,136.58
949.88
15111
1
ZZZ
0
0
206.07
175.05
15111
2
ZZZ
0
0
181.28
155.93
15111
3
ZZZ
0
0
181.28
155.93
15111
4
ZZZ
0
0
181.28
155.93
15115
1
90
2
0
1,224.62
1107.88
15115
2
90
2
0
1,073.18
977.81
15115
3
90
2
0
1,073.18
977.81
15115
4
90
2
0
1,073.18
977.81
15116
1
ZZZ
0
0
266.71
238.14
15116
2
ZZZ
0
0
235.74
212.38
15116
3
ZZZ
0
0
235.74
212.38
15116
4
ZZZ
0
0
235.74
212.38
15120
1
90
2
0
2,134.06
0
15120
2
90
2
0
2,125.73
0
15120
3
90
2
0
2,091.24
0
15120
4
90
2
0
2,084.97
0
15121
1
ZZZ
0
0
1,677.57
0
15121
2
ZZZ
0
0
1,673.55
0
15121
3
ZZZ
0
0
492.40
0
15121
4
ZZZ
0
0
1,654.63
0
15130
1
90
2
0
1,089.76
870.56
15130
2
90
2
0
939.45
760.36
15130
3
90
2
0
939.45
760.36
15130
4
90
2
0
939.45
760.36
15131
1
ZZZ
0
0
168.52
141.82
15131
2
ZZZ
0
0
148.17
126.34
15131
3
ZZZ
0
0
148.17
126.34
15131
4
ZZZ
0
0
148.17
126.34
15135
1
90
2
0
1,310.63
1202.02
15135
2
90
2
0
1,148.59
1059.81
15135
3
90
2
0
1,148.59
1059.81
15135
4
90
2
0
1,148.59
1059.81
15136
1
ZZZ
0
0
156.58
142.92
15136
2
ZZZ
0
0
138.57
127.41
15136
3
ZZZ
0
0
138.57
127.41
15136
4
ZZZ
0
0
138.57
127.41
15150
1
90
2
0
1,086.89
961.45
15150
2
90
2
0
945.93
843.45
15150
3
90
2
0
945.93
843.45
15150
4
90
2
0
945.93
843.45
15151
1
ZZZ
0
0
217.45
188.92
15151
2
ZZZ
0
0
191.67
168.30
15151
3
ZZZ
0
0
191.67
168.30
15151
4
ZZZ
0
0
191.67
168.30
15152
1
ZZZ
0
0
267.02
235.97
15152
2
ZZZ
0
0
235.63
210.24
15152
3
ZZZ
0
0
235.63
210.24
15152
4
ZZZ
0
0
235.63
210.24
15155
1
90
2
0
1,083.00
1029.58
15155
2
90
2
0
951.54
907.93
15155
3
90
2
0
951.54
907.93
15155
4
90
2
0
951.54
907.93
15156
1
ZZZ
0
0
282.09
262.20
15156
2
ZZZ
0
0
250.15
233.89
15156
3
ZZZ
0
0
250.15
233.89
15156
4
ZZZ
0
0
250.15
233.89
15157
1
ZZZ
0
0
312.35
285.67
15157
2
ZZZ
0
0
276.70
254.91
15157
3
ZZZ
0
0
276.70
254.91
15157
4
ZZZ
0
0
276.70
254.91
15200
1
90
2
0
1,070.28
0
15200
2
90
2
0
1,372.69
0
15200
3
90
2
0
1,289.62
0
15200
4
90
2
0
1,350.95
0
15201
1
ZZZ
0
0
382.44
0
15201
2
ZZZ
0
0
374.39
0
15201
3
ZZZ
0
0
341.30
0
15201
4
ZZZ
0
0
337.08
0
15220
1
90
2
0
1,457.01
0
15220
2
90
2
0
1,465.42
0
15220
3
90
2
0
1,400.78
0
15220
4
90
2
0
1,393.44
0
15221
1
ZZZ
0
0
1,046.05
0
15221
2
ZZZ
0
0
1,042.67
0
15221
3
ZZZ
0
0
326.85
0
15221
4
ZZZ
0
0
322.76
0
15240
1
90
2
0
1,454.36
0
15240
2
90
2
0
1,442.77
0
15240
3
90
2
0
1,379.90
0
15240
4
90
2
0
1,404.50
0
15241
1
ZZZ
0
0
1,159.13
0
15241
2
ZZZ
0
0
1,155.06
0
15241
3
ZZZ
0
0
1,138.08
0
15241
4
ZZZ
0
0
1,135.71
0
15260
1
90
2
0
1,606.83
0
15260
2
90
2
0
1,597.74
0
15260
3
90
2
0
1,555.91
0
15260
4
90
2
0
1,553.85
0
15261
1
ZZZ
0
0
850.69
0
15261
2
ZZZ
0
0
919.32
0
15261
3
ZZZ
0
0
813.37
0
15261
4
ZZZ
0
0
533.47
0
15271
1
0
2
0
202.54
124.54
15271
2
0
2
0
179.93
112.66
15271
3
0
2
0
179.93
112.66
15271
4
0
2
0
179.93
112.66
15272
1
ZZZ
0
0
37.95
24.31
15272
2
ZZZ
0
0
34.06
22.31
15272
3
ZZZ
0
0
34.06
22.31
15272
4
ZZZ
0
0
34.06
22.31
15273
1
0
2
0
417.92
297.60
15273
2
0
2
0
372.22
268.50
15273
3
0
2
0
372.22
268.50
15273
4
0
2
0
372.22
268.50
15274
1
ZZZ
0
0
97.26
62.02
15274
2
ZZZ
0
0
87.08
56.69
15274
3
ZZZ
0
0
87.08
56.69
15274
4
ZZZ
0
0
87.08
56.69
15275
1
0
2
0
217.97
144.65
15275
2
0
2
0
194.31
131.12
15275
3
0
2
0
194.31
131.12
15275
4
0
2
0
194.31
131.12
15276
1
ZZZ
0
0
47.04
34.82
15276
2
ZZZ
0
0
42.62
32.07
15276
3
ZZZ
0
0
42.62
32.07
15276
4
ZZZ
0
0
42.62
32.07
15277
1
0
2
0
418.52
305.24
15277
2
0
2
0
375.90
278.26
15277
3
0
2
0
375.90
278.26
15277
4
0
2
0
375.90
278.26
15278
1
ZZZ
0
0
114.54
76.93
15278
2
ZZZ
0
0
102.72
70.31
15278
3
ZZZ
0
0
102.72
70.31
15278
4
ZZZ
0
0
102.72
70.31
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