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2018 Workers' Compensation Part B Fee Schedule

25110-25920

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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
25110   1 90 2 0 617.43 0
25110   2 90 2 0 608.13 0
25110   3 90 2 0 602.82 0
25110   4 90 2 0 539.81 0
25111   1 90 2 0 628.65 0
25111   2 90 2 0 654.69 0
25111   3 90 2 0 602.11 0
25111   4 90 2 0 559.34 0
25112   1 90 2 0 771.07 0
25112   2 90 2 0 758.63 0
25112   3 90 2 0 787.27 0
25112   4 90 2 0 707.65 0
25115   1 90 2 0 1,084.15 0
25115   2 90 2 0 1,075.63 0
25115   3 90 2 0 1,066.11 0
25115   4 90 2 0 1,010.08 0
25116   1 90 2 0 1,223.00 0
25116   2 90 2 0 1,390.13 0
25116   3 90 2 0 1,080.72 0
25116   4 90 2 0 1,270.84 0
25118   1 90 2 0 1,201.50 0
25118   2 90 2 0 1,189.16 0
25118   3 90 2 0 1,115.78 0
25118   4 90 2 0 1,136.62 0
25119   1 90 2 0 1,272.29 0
25119   2 90 2 0 1,249.14 0
25119   3 90 2 0 1,220.83 0
25119   4 90 2 0 1,139.41 0
25120   1 90 2 0 1,547.95 0
25120   2 90 2 0 1,444.10 0
25120   3 90 2 0 1,075.93 0
25120   4 90 2 0 1,062.93 0
25125   1 90 2 0 1,310.94 0
25125   2 90 2 0 1,431.19 0
25125   3 90 2 0 1,204.74 0
25125   4 90 2 0 1,190.30 0
25126   1 90 2 0 1,323.63 0
25126   2 90 2 0 1,436.22 0
25126   3 90 2 0 1,213.82 0
25126   4 90 2 0 1,199.44 0
25130   1 90 2 0 873.58 0
25130   2 90 2 0 860.21 0
25130   3 90 2 0 804.85 0
25130   4 90 2 0 795.41 0
25135   1 90 2 0 1,143.76 0
25135   2 90 2 0 1,125.49 0
25135   3 90 2 0 1,050.12 0
25135   4 90 2 0 1,037.91 0
25136   1 90 2 0 991.21 0
25136   2 90 2 0 975.28 0
25136   3 90 2 0 909.55 0
25136   4 90 2 0 898.93 0
25145   1 90 2 0 1,106.40 0
25145   2 90 2 0 1,089.90 0
25145   3 90 2 0 1,021.65 0
25145   4 90 2 0 1,009.26 0
25150   1 90 2 0 1,263.37 0
25150   2 90 2 0 1,242.44 0
25150   3 90 2 0 1,155.81 0
25150   4 90 2 0 1,141.97 0
25151   1 90 2 0 1,198.73 0
25151   2 90 2 0 1,179.49 0
25151   3 90 2 0 1,100.39 0
25151   4 90 2 0 1,087.52 0
25170   1 90 2 0 2,506.42 0
25170   2 90 2 0 1,878.71 0
25170   3 90 2 0 1,754.66 0
25170   4 90 2 0 2,337.82 0
25210   1 90 2 0 985.67 0
25210   2 90 2 0 956.59 0
25210   3 90 2 0 905.85 0
25210   4 90 2 0 895.14 0
25215   1 90 2 0 1,544.96 0
25215   2 90 2 0 1,518.53 0
25215   3 90 2 0 1,409.12 0
25215   4 90 2 0 1,392.03 0
25230   1 90 2 0 992.01 0
25230   2 90 2 0 1,210.25 0
25230   3 90 2 0 947.60 0
25230   4 90 2 0 896.57 0
25240   1 90 2 0 1,089.87 0
25240   2 90 2 0 1,084.81 0
25240   3 90 2 0 1,033.98 0
25240   4 90 2 0 1,038.32 0
25246   1 0 2 0 161.05 0
25246   2 0 2 0 128.26 0
25246   3 0 2 0 152.76 0
25246   4 0 2 0 151.13 0
25248   1 90 2 0 651.48 0
25248   2 90 2 0 643.22 0
25248   3 90 2 0 609.29 0
25248   4 90 2 0 602.62 0
25250   1 90 2 0 1,127.79 0
25250   2 90 2 0 1,109.94 0
25250   3 90 2 0 1,036.62 0
25250   4 90 2 0 943.51 0
25251   1 90 2 0 1,646.50 0
25251   2 90 2 0 1,619.98 0
25251   3 90 2 0 1,510.47 0
25251   4 90 2 0 1,492.60 0
25259   1 90 2 0 659.82 0
25259   2 90 2 0 575.46 0
25259   3 90 2 0 575.46 0
25259   4 90 2 0 575.46 0
25260   1 90 2 0 1,185.72 0
25260   2 90 2 0 1,289.24 0
25260   3 90 2 0 1,214.24 0
25260   4 90 2 0 1,222.85 0
25263   1 90 2 0 1,244.34 0
25263   2 90 2 0 1,313.88 0
25263   3 90 2 0 1,144.12 0
25263   4 90 2 0 1,274.45 0
25265   1 90 2 0 1,661.64 0
25265   2 90 2 0 1,634.99 0
25265   3 90 2 0 1,525.29 0
25265   4 90 2 0 1,507.51 0
25270   1 90 2 0 1,153.58 0
25270   2 90 2 0 827.33 0
25270   3 90 2 0 952.90 0
25270   4 90 2 0 1,104.41 0
25272   1 90 2 0 933.14 0
25272   2 90 2 0 1,179.94 0
25272   3 90 2 0 870.66 0
25272   4 90 2 0 861.00 0
25274   1 90 2 0 1,419.48 0
25274   2 90 2 0 1,397.48 0
25274   3 90 2 0 1,307.02 0
25274   4 90 2 0 1,549.43 0
25275   1 90 2 0 1,171.39 0
25275   2 90 2 0 1,030.38 0
25275   3 90 2 0 1,030.38 0
25275   4 90 2 0 1,030.38 0
25280   1 90 2 0 1,024.22 0
25280   2 90 2 0 1,009.79 0
25280   3 90 2 0 950.14 0
25280   4 90 2 0 939.42 0
25290   1 90 2 0 646.58 0
25290   2 90 2 0 645.11 0
25290   3 90 2 0 641.58 0
25290   4 90 2 0 608.44 0
25295   1 90 2 0 855.22 0
25295   2 90 2 0 843.87 0
25295   3 90 2 0 797.25 0
25295   4 90 2 0 788.49 0
25300   1 90 2 0 1,491.62 0
25300   2 90 2 0 1,468.30 0
25300   3 90 2 0 1,372.06 0
25300   4 90 2 0 1,355.84 0
25301   1 90 2 0 1,410.00 0
25301   2 90 2 0 1,387.57 0
25301   3 90 2 0 1,285.66 0
25301   4 90 2 0 1,280.01 0
25310   1 90 2 0 1,540.49 0
25310   2 90 2 0 1,515.06 0
25310   3 90 2 0 1,491.97 0
25310   4 90 2 0 1,274.59 0
25312   1 90 2 0 1,582.24 0
25312   2 90 2 0 1,495.77 0
25312   3 90 2 0 1,453.99 0
25312   4 90 2 0 1,436.97 0
25315   1 90 2 0 1,647.62 0
25315   2 90 2 0 1,621.66 0
25315   3 90 2 0 1,514.40 0
25315   4 90 2 0 1,496.64 0
25316   1 90 2 0 2,063.25 0
25316   2 90 2 0 2,030.01 0
25316   3 90 2 0 1,892.59 0
25316   4 90 2 0 1,870.21 0
25320   1 90 2 0 1,690.15 0
25320   2 90 2 0 1,658.50 0
25320   3 90 2 0 1,549.07 0
25320   4 90 2 0 1,530.67 0
25332   1 90 2 0 1,969.25 0
25332   2 90 2 0 1,712.27 0
25332   3 90 2 0 1,808.49 0
25332   4 90 2 0 1,787.05 0
25335   1 90 2 0 2,191.99 0
25335   2 90 2 0 2,159.04 0
25335   3 90 2 0 2,022.25 0
25335   4 90 2 0 1,997.90 0
25337   1 90 2 0 1,804.86 0
25337   2 90 2 0 1,749.67 0
25337   3 90 2 0 1,633.57 0
25337   4 90 2 0 1,611.20 0
25350   1 90 2 0 1,502.20 0
25350   2 90 2 0 1,478.11 0
25350   3 90 2 0 1,378.54 0
25350   4 90 2 0 1,406.44 0
25355   1 90 2 0 1,773.10 0
25355   2 90 2 0 1,744.46 0
25355   3 90 2 0 1,626.17 0
25355   4 90 2 0 1,606.83 0
25360   1 90 2 0 1,417.51 0
25360   2 90 2 0 1,400.45 0
25360   3 90 2 0 1,233.78 0
25360   4 90 2 0 1,219.29 0
25365   1 90 2 0 2,059.40 0
25365   2 90 2 0 2,027.76 0
25365   3 90 2 0 1,896.77 0
25365   4 90 2 0 1,874.29 0
25370   1 90 2 0 2,287.51 0
25370   2 90 2 0 2,250.66 0
25370   3 90 2 0 2,098.33 0
25370   4 90 2 0 2,073.33 0
25375   1 90 2 0 2,283.11 0
25375   2 90 2 0 2,254.36 0
25375   3 90 2 0 2,134.30 0
25375   4 90 2 0 2,107.18 0
25390   1 90 2 0 1,774.38 0
25390   2 90 2 0 1,745.81 0
25390   3 90 2 0 1,613.12 0
25390   4 90 2 0 1,608.80 0
25391   1 90 2 0 2,280.41 0
25391   2 90 2 0 2,243.81 0
25391   3 90 2 0 2,092.62 0
25391   4 90 2 0 2,068.08 0
25392   1 90 2 0 2,420.90 0
25392   2 90 2 0 2,381.80 0
25392   3 90 2 0 2,220.32 0
25392   4 90 2 0 2,193.93 0
25393   1 90 2 0 2,764.22 0
25393   2 90 2 0 2,747.02 0
25393   3 90 2 0 2,535.37 0
25393   4 90 2 0 2,505.18 0
25394   1 90 2 0 1,360.41 0
25394   2 90 2 0 1,204.38 0
25394   3 90 2 0 1,204.38 0
25394   4 90 2 0 1,204.38 0
25400   1 90 2 0 2,009.74 0
25400   2 90 2 0 1,976.50 0
25400   3 90 2 0 1,839.20 0
25400   4 90 2 0 1,817.12 0
25405   1 90 2 0 2,452.65 0
25405   2 90 2 0 2,413.48 0
25405   3 90 2 0 2,252.08 0
25405   4 90 2 0 2,304.09 0
25415   1 90 2 0 2,284.16 0
25415   2 90 2 0 2,247.53 0
25415   3 90 2 0 2,096.15 0
25415   4 90 2 0 2,071.39 0
25420   1 90 2 0 2,836.95 0
25420   2 90 2 0 2,791.99 0
25420   3 90 2 0 2,606.08 0
25420   4 90 2 0 2,574.93 0
25425   1 90 2 0 2,311.23 0
25425   2 90 2 0 2,375.72 0
25425   3 90 2 0 2,122.62 0
25425   4 90 2 0 2,097.28 0
25426   1 90 2 0 2,529.43 0
25426   2 90 2 0 2,489.38 0
25426   3 90 2 0 2,324.23 0
25426   4 90 2 0 2,297.34 0
25430   1 90 2 0 1,190.86 0
25430   2 90 2 0 1,067.47 0
25430   3 90 2 0 1,067.47 0
25430   4 90 2 0 1,067.47 0
25431   1 90 2 0 1,171.11 0
25431   2 90 2 0 1,059.64 0
25431   3 90 2 0 1,059.64 0
25431   4 90 2 0 1,059.64 0
25440   1 90 2 0 1,801.97 0
25440   2 90 2 0 2,429.85 0
25440   3 90 2 0 1,653.98 0
25440   4 90 2 0 1,634.40 0
25441   1 90 2 0 2,243.53 0
25441   2 90 2 0 2,611.97 0
25441   3 90 2 0 2,058.18 0
25441   4 90 2 0 2,033.82 0
25442   1 90 2 0 1,629.30 0
25442   2 90 2 0 1,605.09 0
25442   3 90 2 0 1,505.36 0
25442   4 90 2 0 1,488.16 0
25443   1 90 2 0 1,826.30 0
25443   2 90 2 0 1,796.99 0
25443   3 90 2 0 1,675.63 0
25443   4 90 2 0 1,655.76 0
25444   1 90 2 0 1,973.08 0
25444   2 90 2 0 1,941.22 0
25444   3 90 2 0 1,809.61 0
25444   4 90 2 0 1,788.12 0
25445   1 90 2 0 1,883.69 0
25445   2 90 2 0 1,851.71 0
25445   3 90 2 0 1,719.56 0
25445   4 90 2 0 1,698.78 0
25446   1 90 2 0 3,445.03 0
25446   2 90 2 0 3,383.08 0
25446   3 90 2 0 3,126.98 0
25446   4 90 2 0 3,088.82 0
25447   1 90 2 0 1,808.50 0
25447   2 90 2 0 1,772.32 0
25447   3 90 2 0 1,719.01 0
25447   4 90 2 0 1,706.84 0
25449   1 90 2 0 1,459.94 0
25449   2 90 2 0 1,521.72 0
25449   3 90 2 0 1,362.02 0
25449   4 90 2 0 1,823.83 0
25450   1 90 2 0 1,421.34 0
25450   2 90 2 0 1,398.45 0
25450   3 90 2 0 1,304.01 0
25450   4 90 2 0 1,288.42 0
25455   1 90 2 0 1,695.51 0
25455   2 90 2 0 1,668.18 0
25455   3 90 2 0 1,555.23 0
25455   4 90 2 0 1,536.71 0
25490   1 90 2 0 1,691.33 0
25490   2 90 2 0 1,664.05 0
25490   3 90 2 0 1,551.21 0
25490   4 90 2 0 1,532.80 0
25491   1 90 2 0 1,770.58 0
25491   2 90 2 0 1,741.99 0
25491   3 90 2 0 1,623.81 0
25491   4 90 2 0 1,604.46 0
25492   1 90 2 0 2,179.44 0
25492   2 90 2 0 2,144.14 0
25492   3 90 2 0 1,998.62 0
25492   4 90 2 0 1,974.90 0
25500   1 90 2 0 497.04 382.46
25500   2 90 2 0 484.24 373.22
25500   3 90 2 0 435.59 335.18
25500   4 90 2 0 448.66 345.57
25505   1 90 2 0 788.71 0
25505   2 90 2 0 788.37 0
25505   3 90 2 0 731.41 0
25505   4 90 2 0 722.95 0
25515   1 90 2 0 1,544.50 0
25515   2 90 2 0 1,509.10 0
25515   3 90 2 0 1,410.15 0
25515   4 90 2 0 1,393.45 0
25520   1 90 2 0 1,115.68 0
25520   2 90 2 0 1,097.65 0
25520   3 90 2 0 1,023.20 0
25520   4 90 2 0 1,011.07 0
25525   1 90 2 0 2,168.89 0
25525   2 90 2 0 2,133.83 0
25525   3 90 2 0 1,989.02 0
25525   4 90 2 0 1,965.42 0
25526   1 90 2 0 2,305.11 0
25526   2 90 2 0 2,267.98 0
25526   3 90 2 0 2,114.29 0
25526   4 90 2 0 2,089.12 0
25530   1 90 2 0 545.83 0
25530   2 90 2 0 505.69 0
25530   3 90 2 0 437.36 0
25530   4 90 2 0 460.11 0
25535   1 90 2 0 787.50 0
25535   2 90 2 0 776.14 0
25535   3 90 2 0 728.97 0
25535   4 90 2 0 720.55 0
25545   1 90 2 0 1,529.02 0
25545   2 90 2 0 1,478.51 0
25545   3 90 2 0 1,381.07 0
25545   4 90 2 0 1,412.18 0
25560   1 90 2 0 552.84 0
25560   2 90 2 0 508.75 0
25560   3 90 2 0 455.51 0
25560   4 90 2 0 479.95 0
25565   1 90 2 0 983.94 0
25565   2 90 2 0 975.32 0
25565   3 90 2 0 906.83 0
25565   4 90 2 0 939.45 0
25574   1 90 2 0 1,847.29 0
25574   2 90 2 0 1,845.12 0
25574   3 90 2 0 1,785.35 0
25574   4 90 2 0 1,788.31 0
25575   1 90 2 0 2,024.61 0
25575   2 90 2 0 2,021.20 0
25575   3 90 2 0 1,956.25 0
25575   4 90 2 0 1,957.38 0
25600   1 90 2 0 520.05 396.46
25600   2 90 2 0 532.75 405.08
25600   3 90 2 0 486.68 368.49
25600   4 90 2 0 517.80 393.03
25605   1 90 2 0 898.23 0
25605   2 90 2 0 882.70 0
25605   3 90 2 0 850.24 0
25605   4 90 2 0 859.74 0
25606   1 90 2 0 985.60 0
25606   2 90 2 0 846.89 0
25606   3 90 2 0 846.89 0
25606   4 90 2 0 846.89 0
25607   1 90 2 0 985.72 0
25607   2 90 2 0 854.92 0
25607   3 90 2 0 854.92 0
25607   4 90 2 0 854.92 0
25608   1 90 2 0 1,131.30 0
25608   2 90 2 0 977.41 0
25608   3 90 2 0 977.41 0
25608   4 90 2 0 977.41 0
25609   1 90 2 0 1,441.74 0
25609   2 90 2 0 1,247.17 0
25609   3 90 2 0 1,247.17 0
25609   4 90 2 0 1,247.17 0
25622   1 90 2 0 489.45 0
25622   2 90 2 0 511.23 0
25622   3 90 2 0 489.41 0
25622   4 90 2 0 492.13 0
25624   1 90 2 0 746.97 0
25624   2 90 2 0 766.12 0
25624   3 90 2 0 746.55 0
25624   4 90 2 0 679.96 0
25628   1 90 2 0 1,414.15 0
25628   2 90 2 0 1,391.66 0
25628   3 90 2 0 1,298.82 0
25628   4 90 2 0 1,283.46 0
25630   1 90 2 0 491.62 0
25630   2 90 2 0 498.27 0
25630   3 90 2 0 472.66 0
25630   4 90 2 0 493.52 0
25635   1 90 2 0 702.05 0
25635   2 90 2 0 691.65 0
25635   3 90 2 0 682.28 0
25635   4 90 2 0 679.14 0
25645   1 90 2 0 1,267.55 0
25645   2 90 2 0 1,248.02 0
25645   3 90 2 0 1,167.14 0
25645   4 90 2 0 1,153.11 0
25650   1 90 2 0 571.63 0
25650   2 90 2 0 581.76 0
25650   3 90 2 0 554.57 0
25650   4 90 2 0 553.33 0
25651   1 90 2 0 716.55 0
25651   2 90 2 0 630.15 0
25651   3 90 2 0 630.15 0
25651   4 90 2 0 630.15 0
25652   1 90 2 0 1,056.97 0
25652   2 90 2 0 930.02 0
25652   3 90 2 0 930.02 0
25652   4 90 2 0 930.02 0
25660   1 90 2 0 513.60 0
25660   2 90 2 0 563.83 0
25660   3 90 2 0 521.53 0
25660   4 90 2 0 530.67 0
25670   1 90 2 0 1,379.71 0
25670   2 90 2 0 1,357.80 0
25670   3 90 2 0 1,267.34 0
25670   4 90 2 0 1,252.25 0
25671   1 90 2 0 872.64 0
25671   2 90 2 0 767.17 0
25671   3 90 2 0 767.17 0
25671   4 90 2 0 767.17 0
25675   1 90 2 0 612.51 0
25675   2 90 2 0 604.68 0
25675   3 90 2 0 572.35 0
25675   4 90 2 0 565.99 0
25676   1 90 2 0 1,401.04 0
25676   2 90 2 0 1,378.96 0
25676   3 90 2 0 1,287.68 0
25676   4 90 2 0 1,272.20 0
25680   1 90 2 0 728.90 0
25680   2 90 2 0 720.04 0
25680   3 90 2 0 683.92 0
25680   4 90 2 0 676.42 0
25685   1 90 2 0 1,742.02 0
25685   2 90 2 0 1,720.01 0
25685   3 90 2 0 1,569.57 0
25685   4 90 2 0 1,550.87 0
25690   1 90 2 0 944.85 0
25690   2 90 2 0 930.12 0
25690   3 90 2 0 829.27 0
25690   4 90 2 0 858.88 0
25695   1 90 2 0 1,418.73 0
25695   2 90 2 0 1,415.61 0
25695   3 90 2 0 1,303.22 0
25695   4 90 2 0 1,287.86 0
25800   1 90 2 0 1,937.51 0
25800   2 90 2 0 1,904.16 0
25800   3 90 2 0 1,766.48 0
25800   4 90 2 0 1,744.93 0
25805   1 90 2 0 2,251.56 0
25805   2 90 2 0 2,287.79 0
25805   3 90 2 0 2,692.76 0
25805   4 90 2 0 2,027.48 0
25810   1 90 2 0 2,502.31 0
25810   2 90 2 0 2,413.57 0
25810   3 90 2 0 2,287.28 0
25810   4 90 2 0 2,310.31 0
25820   1 90 2 0 1,550.06 0
25820   2 90 2 0 1,589.37 0
25820   3 90 2 0 1,410.89 0
25820   4 90 2 0 1,393.63 0
25825   1 90 2 0 1,934.98 0
25825   2 90 2 0 2,400.89 0
25825   3 90 2 0 2,212.15 0
25825   4 90 2 0 1,733.53 0
25830   1 90 2 0 1,804.86 0
25830   2 90 2 0 1,749.67 0
25830   3 90 2 0 1,633.57 0
25830   4 90 2 0 1,611.20 0
25900   1 90 2 0 1,457.63 0
25900   2 90 2 0 1,433.63 0
25900   3 90 2 0 1,334.78 0
25900   4 90 2 0 1,367.21 0
25905   1 90 2 0 1,460.51 0
25905   2 90 2 0 1,437.89 0
25905   3 90 2 0 1,344.44 0
25905   4 90 2 0 1,328.57 0
25907   1 90 2 0 1,229.58 0
25907   2 90 2 0 911.66 0
25907   3 90 2 0 1,131.25 0
25907   4 90 2 0 1,118.14 0
25909   1 90 2 0 1,314.31 0
25909   2 90 2 0 1,294.23 0
25909   3 90 2 0 1,211.43 0
25909   4 90 2 0 1,197.73 0
25915   1 90 2 0 1,314.31 0
25915   2 90 2 0 1,294.23 0
25915   3 90 2 0 1,211.43 0
25915   4 90 2 0 1,197.73 0
25920   1 90 2 0 1,431.82 0
25920   2 90 2 0 1,394.33 0
25920   3 90 2 0 1,314.72 0
25920   4 90 2 0 1,299.32 0