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2018 Workers' Compensation Part B Fee Schedule

21015-21435

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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
21015   1 90 2 0 1,098.20 0
21015   2 90 2 0 1,078.29 0
21015   3 90 2 0 996.17 0
21015   4 90 2 0 984.06 0
21016   1 90 2 0 1,520.42 0
21016   2 90 2 0 1,356.33 0
21016   3 90 2 0 1,356.33 0
21016   4 90 2 0 1,356.33 0
21025   1 90 2 0 825.13 0
21025   2 90 2 0 814.59 0
21025   3 90 2 0 759.85 0
21025   4 90 2 0 761.60 0
21026   1 90 2 0 820.41 0
21026   2 90 2 0 727.31 0
21026   3 90 2 0 712.92 0
21026   4 90 2 0 634.25 0
21029   1 90 2 0 1,491.79 0
21029   2 90 2 0 1,470.89 0
21029   3 90 2 0 1,383.70 0
21029   4 90 2 0 1,366.03 0
21030   1 90 2 0 917.32 775.57
21030   2 90 2 0 907.53 767.51
21030   3 90 2 0 866.89 734.67
21030   4 90 2 0 857.12 727.16
21031   1 90 2 0 522.10 0
21031   2 90 2 0 514.10 0
21031   3 90 2 0 480.98 0
21031   4 90 2 0 474.49 0
21032   1 90 2 0 734.30 0
21032   2 90 2 0 724.70 0
21032   3 90 2 0 684.90 0
21032   4 90 2 0 676.52 0
21034   1 90 2 0 1,830.77 0
21034   2 90 2 0 1,765.12 0
21034   3 90 2 0 1,790.79 0
21034   4 90 2 0 1,843.78 0
21040   1 90 2 0 514.34 0
21040   2 90 2 0 557.15 0
21040   3 90 2 0 504.77 0
21040   4 90 2 0 483.36 0
21044   1 90 2 0 1,888.82 0
21044   2 90 2 0 1,862.57 0
21044   3 90 2 0 1,753.77 0
21044   4 90 2 0 1,732.71 0
21045   1 90 2 0 2,653.14 0
21045   2 90 2 0 2,615.79 0
21045   3 90 2 0 2,460.99 0
21045   4 90 2 0 2,431.17 0
21046   1 90 2 0 1,647.95 0
21046   2 90 2 0 1,472.08 0
21046   3 90 2 0 1,472.08 0
21046   4 90 2 0 1,472.08 0
21047   1 90 2 0 2,027.76 0
21047   2 90 2 0 1,824.22 0
21047   3 90 2 0 1,824.22 0
21047   4 90 2 0 1,824.22 0
21048   1 90 2 0 1,694.71 0
21048   2 90 2 0 1,515.61 0
21048   3 90 2 0 1,515.61 0
21048   4 90 2 0 1,515.61 0
21049   1 90 2 0 1,910.87 0
21049   2 90 2 0 1,733.23 0
21049   3 90 2 0 1,733.23 0
21049   4 90 2 0 1,733.23 0
21050   1 90 2 0 2,034.72 0
21050   2 90 2 0 2,042.31 0
21050   3 90 2 0 1,887.63 0
21050   4 90 2 0 1,863.63 0
21060   1 90 2 0 1,924.19 0
21060   2 90 2 0 1,897.13 0
21060   3 90 2 0 1,784.49 0
21060   4 90 2 0 1,761.83 0
21070   1 90 2 0 1,331.23 0
21070   2 90 2 0 1,312.36 0
21070   3 90 2 0 1,234.05 0
21070   4 90 2 0 1,219.20 0
21073   1 90 2 0 528.94 336.82
21073   2 90 2 0 456.82 297.52
21073   3 90 2 0 456.82 297.52
21073   4 90 2 0 456.82 297.52
21076   1 10 2 0 2,864.85 2083.13
21076   2 10 2 0 2,750.60 1997.41
21076   3 10 2 0 2,572.76 1883.46
21076   4 10 2 0 2,532.41 1856.61
21077   1 90 2 0 7,205.08 5238.79
21077   2 90 2 0 6,917.82 5023.37
21077   3 90 2 0 6,470.59 4736.86
21077   4 90 2 0 6,369.08 4,669.40
21079     90 2 0 * 0
21080     90 2 0 * 0
21081     90 2 0 * 0
21082     90 2 0 * 0
21083     90 2 0 * 0
21084     90 2 0 * 0
21085     10 2 0 * 0
21086     90 2 0 * 0
21087     90 2 0 * 0
21088     90 0 0 * 0
21089     90 0 0 * 0
21100   1 90 2 0 445.02 0
21100   2 90 2 0 684.30 0
21100   3 90 2 0 608.72 0
21100   4 90 2 0 419.23 0
21110   1 90 2 0 953.79 0
21110   2 90 2 0 940.95 0
21110   3 90 2 0 887.43 0
21110   4 90 2 0 876.27 0
21116   1 0 2 0 117.60 0
21116   2 0 2 0 125.93 0
21116   3 0 2 0 129.13 0
21116   4 0 2 0 127.61 0
21120   1 90 2 0 759.14 0
21120   2 90 2 0 749.01 0
21120   3 90 2 0 706.99 0
21120   4 90 2 0 698.61 0
21121   1 90 2 0 1,194.42 0
21121   2 90 2 0 1,178.39 0
21121   3 90 2 0 1,112.02 0
21121   4 90 2 0 1,098.83 0
21122   1 90 2 0 1,316.38 0
21122   2 90 2 0 1,298.67 0
21122   3 90 2 0 1,225.39 0
21122   4 90 2 0 1,210.93 0
21123   1 90 2 0 1,720.24 0
21123   2 90 2 0 1,697.13 0
21123   3 90 2 0 1,601.66 0
21123   4 90 2 0 1,582.74 0
21125   1 90 2 0 995.85 0
21125   2 90 2 0 982.58 0
21125   3 90 2 0 927.41 0
21125   4 90 2 0 916.48 0
21127   1 90 2 0 1,671.20 0
21127   2 90 2 0 1,648.76 0
21127   3 90 2 0 1,556.09 0
21127   4 90 2 0 1,537.71 0
21137   1 90 2 0 3,048.45 0
21137   2 90 2 0 3,048.45 0
21137   3 90 2 0 3,048.45 0
21137   4 90 2 0 3,048.45 0
21138   1 90 2 0 3,810.59 0
21138   2 90 2 0 3,810.59 0
21138   3 90 2 0 3,810.59 0
21138   4 90 2 0 3,810.59 0
21139   1 90 2 0 3,810.59 0
21139   2 90 2 0 3,810.59 0
21139   3 90 2 0 3,810.59 0
21139   4 90 2 0 3,810.59 0
21141   1 90 2 0 3,077.45 0
21141   2 90 2 0 2,955.06 0
21141   3 90 2 0 2,780.74 0
21141   4 90 2 0 2,739.92 0
21142   1 90 2 0 3,191.33 0
21142   2 90 2 0 3,064.51 0
21142   3 90 2 0 2,883.97 0
21142   4 90 2 0 2,841.65 0
21143   1 90 2 0 3,317.49 0
21143   2 90 2 0 3,185.63 0
21143   3 90 2 0 2,998.08 0
21143   4 90 2 0 2,954.05 0
21145   1 90 2 0 3,031.58 0
21145   2 90 2 0 2,990.84 0
21145   3 90 2 0 2,822.23 0
21145   4 90 2 0 2,788.92 0
21146   1 90 2 0 3,137.16 0
21146   2 90 2 0 3,095.01 0
21146   3 90 2 0 2,920.53 0
21146   4 90 2 0 2,886.05 0
21147   1 90 2 0 3,254.91 0
21147   2 90 2 0 3,211.07 0
21147   3 90 2 0 3,029.96 0
21147   4 90 2 0 2,994.18 0
21150   1 90 2 0 8,891.40 0
21150   2 90 2 0 8,891.40 0
21150   3 90 2 0 8,891.40 0
21150   4 90 2 0 8,891.40 0
21151   1 90 2 0 8,891.40 0
21151   2 90 2 0 8,891.40 0
21151   3 90 2 0 8,891.40 0
21151   4 90 2 0 8,891.40 0
21154   1 90 2 0 10,161.60 0
21154   2 90 2 0 10,161.60 0
21154   3 90 2 0 10,161.60 0
21154   4 90 2 0 10,161.60 0
21155   1 90 2 0 10,415.63 0
21155   2 90 2 0 10,415.63 0
21155   3 90 2 0 10,415.63 0
21155   4 90 2 0 10,415.63 0
21159   1 90 2 0 7,058.89 0
21159   2 90 2 0 6,878.33 0
21159   3 90 2 0 6,489.65 0
21159   4 90 2 0 6,402.67 0
21160   1 90 2 0 7,730.90 0
21160   2 90 2 0 7,533.16 0
21160   3 90 2 0 7,107.38 0
21160   4 90 2 0 7,012.18 0
21172   1 90 2 0 7,621.26 0
21172   2 90 2 0 7,621.26 0
21172   3 90 2 0 7,621.26 0
21172   4 90 2 0 7,621.26 0
21175   1 90 2 0 10,161.60 0
21175   2 90 2 0 10,161.60 0
21175   3 90 2 0 10,161.60 0
21175   4 90 2 0 10,161.60 0
21179   1 90 2 0 7,621.26 0
21179   2 90 2 0 7,621.26 0
21179   3 90 2 0 7,621.26 0
21179   4 90 2 0 7,621.26 0
21180   1 90 2 0 8,891.40 0
21180   2 90 2 0 8,891.40 0
21180   3 90 2 0 8,891.40 0
21180   4 90 2 0 8,891.40 0
21181   1 90 2 0 917.32 0
21181   2 90 2 0 907.53 0
21181   3 90 2 0 866.89 0
21181   4 90 2 0 857.12 0
21182   1 90 2 0 5,378.26 0
21182   2 90 2 0 5,240.68 0
21182   3 90 2 0 4,944.43 0
21182   4 90 2 0 4,878.15 0
21183   1 90 2 0 5,884.09 0
21183   2 90 2 0 5,733.53 0
21183   3 90 2 0 5,409.45 0
21183   4 90 2 0 5,336.93 0
21184   1 90 2 0 6,386.77 0
21184   2 90 2 0 6,223.50 0
21184   3 90 2 0 5,872.03 0
21184   4 90 2 0 5,793.30 0
21188   1 90 2 0 8,256.30 0
21188   2 90 2 0 8,256.30 0
21188   3 90 2 0 8,256.30 0
21188   4 90 2 0 8,256.30 0
21193   1 90 2 0 2,601.73 0
21193   2 90 2 0 2,566.77 0
21193   3 90 2 0 2,422.10 0
21193   4 90 2 0 2,393.38 0
21194   1 90 2 0 3,014.43 0
21194   2 90 2 0 2,973.90 0
21194   3 90 2 0 2,806.29 0
21194   4 90 2 0 2,773.12 0
21195   1 90 2 0 2,607.62 0
21195   2 90 2 0 2,572.54 0
21195   3 90 2 0 2,427.63 0
21195   4 90 2 0 2,398.92 0
21196   1 90 2 0 2,874.01 0
21196   2 90 2 0 2,835.54 0
21196   3 90 2 0 2,676.02 0
21196   4 90 2 0 2,644.40 0
21198   1 90 2 0 2,609.22 0
21198   2 90 2 0 2,570.14 0
21198   3 90 2 0 2,408.24 0
21198   4 90 2 0 2,378.46 0
21199   1 90 2 0 2,007.16 0
21199   2 90 2 0 1,812.06 0
21199   3 90 2 0 1,812.06 0
21199   4 90 2 0 1,812.06 0
21206   1 90 2 0 2,141.75 0
21206   2 90 2 0 2,112.98 0
21206   3 90 2 0 1,993.84 0
21206   4 90 2 0 1,970.28 0
21208   1 90 2 0 2,272.49 0
21208   2 90 2 0 2,181.67 0
21208   3 90 2 0 2,006.63 0
21208   4 90 2 0 1,738.98 0
21209   1 90 2 0 2,797.45 0
21209   2 90 2 0 1,002.91 0
21209   3 90 2 0 940.04 0
21209   4 90 2 0 929.22 0
21210   1 90 2 0 2,528.80 0
21210   2 90 2 0 2,173.21 0
21210   3 90 2 0 2,048.63 0
21210   4 90 2 0 1,832.79 0
21215   1 90 2 0 3,987.05 0
21215   2 90 2 0 3,873.96 0
21215   3 90 2 0 2,051.80 0
21215   4 90 2 0 2,025.48 0
21230   1 90 2 0 1,948.52 0
21230   2 90 2 0 2,053.11 0
21230   3 90 2 0 1,971.99 0
21230   4 90 2 0 1,762.30 0
21235   1 90 2 0 1,712.21 0
21235   2 90 2 0 1,637.79 0
21235   3 90 2 0 1,239.07 0
21235   4 90 2 0 1,223.60 0
21240   1 90 2 0 3,877.96 0
21240   2 90 2 0 3,857.22 0
21240   3 90 2 0 2,900.67 0
21240   4 90 2 0 3,754.59 0
21242   1 90 2 0 3,216.30 0
21242   2 90 2 0 4,238.55 0
21242   3 90 2 0 2,950.20 0
21242   4 90 2 0 2,911.12 0
21243   1 90 2 0 3,041.63 0
21243   2 90 2 0 3,000.77 0
21243   3 90 2 0 2,831.81 0
21243   4 90 2 0 2,798.33 0
21244     90 2 0 * 0
21245     90 2 0 * 0
21246     90 2 0 * 0
21247   1 90 2 0 4,375.23 0
21247   2 90 2 0 4,313.96 0
21247   3 90 2 0 4,058.96 0
21247   4 90 2 0 4,006.92 0
21248     90 2 0 * 0
21249     90 2 0 * 0
21255   1 90 2 0 3,231.52 0
21255   2 90 2 0 3,186.36 0
21255   3 90 2 0 2,997.94 0
21255   4 90 2 0 2,959.48 0
21256   1 90 2 0 3,129.77 0
21256   2 90 2 0 3,085.94 0
21256   3 90 2 0 2,903.37 0
21256   4 90 2 0 2,866.14 0
21260   1 90 2 0 3,193.00 0
21260   2 90 2 0 3,148.34 0
21260   3 90 2 0 2,962.13 0
21260   4 90 2 0 2,924.20 0
21261   1 90 2 0 4,208.40 0
21261   2 90 2 0 4,158.90 0
21261   3 90 2 0 3,954.32 0
21261   4 90 2 0 3,908.47 0
21263   1 90 2 0 5,494.17 0
21263   2 90 2 0 5,417.25 0
21263   3 90 2 0 5,096.97 0
21263   4 90 2 0 5,031.58 0
21267   1 90 2 0 3,005.58 0
21267   2 90 2 0 2,961.00 0
21267   3 90 2 0 2,776.81 0
21267   4 90 2 0 2,744.05 0
21268   1 90 2 0 3,638.63 0
21268   2 90 2 0 3,581.33 0
21268   3 90 2 0 3,345.39 0
21268   4 90 2 0 3,307.73 0
21270   1 90 2 0 2,018.88 0
21270   2 90 2 0 1,989.21 0
21270   3 90 2 0 1,866.57 0
21270   4 90 2 0 1,844.62 0
21275   1 90 2 0 1,808.47 0
21275   2 90 2 0 1,781.79 0
21275   3 90 2 0 1,671.34 0
21275   4 90 2 0 1,651.48 0
21280   1 90 2 0 1,164.61 0
21280   2 90 2 0 1,148.27 0
21280   3 90 2 0 1,220.67 0
21280   4 90 2 0 1,066.30 0
21282   1 90 2 0 976.87 0
21282   2 90 2 0 960.14 0
21282   3 90 2 0 1,336.41 0
21282   4 90 2 0 878.68 0
21295   1 90 2 0 219.20 0
21295   2 90 2 0 216.20 0
21295   3 90 2 0 203.96 0
21295   4 90 2 0 201.57 0
21296   1 90 2 0 669.97 0
21296   2 90 2 0 661.98 0
21296   3 90 2 0 628.92 0
21296   4 90 2 0 621.08 0
21299     YYY 2 0 * 0
21310   1 0 2 0 180.91 0
21310   2 0 2 0 182.62 0
21310   3 0 2 0 168.20 0
21310   4 0 2 0 162.46 0
21315   1 10 2 0 394.50 0
21315   2 10 2 0 351.52 0
21315   3 10 2 0 348.11 0
21315   4 10 2 0 370.65 0
21320   1 10 2 0 472.34 0
21320   2 10 2 0 458.04 0
21320   3 10 2 0 440.57 0
21320   4 10 2 0 430.43 0
21325   1 90 2 0 712.13 0
21325   2 90 2 0 701.04 0
21325   3 90 2 0 655.01 0
21325   4 90 2 0 646.94 0
21330   1 90 2 0 1,111.93 0
21330   2 90 2 0 1,063.30 0
21330   3 90 2 0 1,010.54 0
21330   4 90 2 0 980.09 0
21335   1 90 2 0 1,675.92 0
21335   2 90 2 0 1,639.86 0
21335   3 90 2 0 1,547.25 0
21335   4 90 2 0 1,692.57 0
21336   1 90 2 0 866.95 0
21336   2 90 2 0 854.90 0
21336   3 90 2 0 805.21 0
21336   4 90 2 0 795.74 0
21337   1 90 2 0 500.47 0
21337   2 90 2 0 492.68 0
21337   3 90 2 0 460.23 0
21337   4 90 2 0 454.55 0
21338   1 90 2 0 1,021.28 0
21338   2 90 2 0 1,006.58 0
21338   3 90 2 0 945.94 0
21338   4 90 2 0 934.75 0
21339   1 90 2 0 1,330.09 0
21339   2 90 2 0 2,032.01 0
21339   3 90 2 0 1,237.19 0
21339   4 90 2 0 1,222.06 0
21340   1 90 2 0 1,740.15 0
21340   2 90 2 0 1,715.70 0
21340   3 90 2 0 1,614.60 0
21340   4 90 2 0 1,595.15 0
21343   1 90 2 0 1,938.53 0
21343   2 90 2 0 1,912.47 0
21343   3 90 2 0 1,804.56 0
21343   4 90 2 0 1,783.22 0
21344   1 90 2 0 2,474.04 0
21344   2 90 2 0 2,444.82 0
21344   3 90 2 0 2,324.23 0
21344   4 90 2 0 2,298.17 0
21345   1 90 2 0 1,418.65 0
21345   2 90 2 0 1,398.66 0
21345   3 90 2 0 1,315.79 0
21345   4 90 2 0 1,425.38 0
21346   1 90 2 0 1,768.56 0
21346   2 90 2 0 1,760.07 0
21346   3 90 2 0 1,640.61 0
21346   4 90 2 0 1,620.60 0
21347   1 90 2 0 2,056.86 0
21347   2 90 2 0 2,026.88 0
21347   3 90 2 0 1,903.01 0
21347   4 90 2 0 1,880.25 0
21348   1 90 2 0 2,566.10 0
21348   2 90 2 0 1,928.01 0
21348   3 90 2 0 2,357.12 0
21348   4 90 2 0 2,330.24 0
21355   1 10 2 0 451.86 0
21355   2 10 2 0 446.82 0
21355   3 10 2 0 426.07 0
21355   4 10 2 0 421.39 0
21356   1 10 2 0 1,272.02 0
21356   2 10 2 0 1,328.10 0
21356   3 10 2 0 1,363.33 0
21356   4 10 2 0 1,218.12 0
21360   1 90 2 0 1,386.80 0
21360   2 90 2 0 1,442.14 0
21360   3 90 2 0 1,473.87 0
21360   4 90 2 0 1,327.41 0
21365   1 90 2 0 2,418.80 0
21365   2 90 2 0 2,374.12 0
21365   3 90 2 0 2,305.47 0
21365   4 90 2 0 2,228.51 0
21366   1 90 2 0 2,432.62 0
21366   2 90 2 0 2,387.82 0
21366   3 90 2 0 2,319.23 0
21366   4 90 2 0 2,481.28 0
21385   1 90 2 0 1,682.22 0
21385   2 90 2 0 1,656.97 0
21385   3 90 2 0 1,552.27 0
21385   4 90 2 0 1,533.03 0
21386   1 90 2 0 1,653.24 0
21386   2 90 2 0 1,627.43 0
21386   3 90 2 0 1,520.72 0
21386   4 90 2 0 1,502.15 0
21387   1 90 2 0 1,521.52 0
21387   2 90 2 0 2,170.03 0
21387   3 90 2 0 1,410.66 0
21387   4 90 2 0 1,393.91 0
21390   1 90 2 0 1,985.35 0
21390   2 90 2 0 2,227.33 0
21390   3 90 2 0 2,103.85 0
21390   4 90 2 0 1,805.23 0
21395   1 90 2 0 1,995.36 0
21395   2 90 2 0 1,994.44 0
21395   3 90 2 0 1,845.28 0
21395   4 90 2 0 1,823.56 0
21400   1 90 2 0 622.91 0
21400   2 90 2 0 257.72 0
21400   3 90 2 0 614.14 0
21400   4 90 2 0 659.30 0
21401   1 90 2 0 517.08 0
21401   2 90 2 0 509.76 0
21401   3 90 2 0 479.67 0
21401   4 90 2 0 473.90 0
21406   1 90 2 0 1,223.70 0
21406   2 90 2 0 1,173.69 0
21406   3 90 2 0 1,160.61 0
21406   4 90 2 0 997.59 0
21407   1 90 2 0 1,382.19 0
21407   2 90 2 0 1,363.21 0
21407   3 90 2 0 1,284.28 0
21407   4 90 2 0 1,268.81 0
21408   1 90 2 0 1,824.94 0
21408   2 90 2 0 1,800.66 0
21408   3 90 2 0 1,700.40 0
21408   4 90 2 0 1,680.39 0
21421   1 90 2 0 1,551.03 0
21421   2 90 2 0 1,544.69 0
21421   3 90 2 0 1,518.56 0
21421   4 90 2 0 917.53 0
21422   1 90 2 0 1,641.35 0
21422   2 90 2 0 1,615.73 0
21422   3 90 2 0 1,509.44 0
21422   4 90 2 0 1,490.47 0
21423   1 90 2 0 1,805.34 0
21423   2 90 2 0 1,778.80 0
21423   3 90 2 0 1,668.57 0
21423   4 90 2 0 1,648.14 0
21431   1 90 2 0 1,159.03 0
21431   2 90 2 0 1,142.51 0
21431   3 90 2 0 1,074.21 0
21431   4 90 2 0 1,061.22 0
21432   1 90 2 0 1,362.28 0
21432   2 90 2 0 2,933.74 0
21432   3 90 2 0 1,263.43 0
21432   4 90 2 0 1,248.40 0
21433   1 90 2 0 3,794.91 0
21433   2 90 2 0 3,612.59 0
21433   3 90 2 0 3,533.24 0
21433   4 90 2 0 3,491.41 0
21435   1 90 2 0 2,728.39 0
21435   2 90 2 0 2,688.36 0
21435   3 90 2 0 2,523.00 0
21435   4 90 2 0 2,493.20 0