Begin Main Content Area

2018 Workers' Compensation Part B Fee Schedule

26567-27178

     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
26567   1 90 2 0 1,001.59 0
26567   2 90 2 0 987.39 0
26567   3 90 2 0 928.85 0
26567   4 90 2 0 918.23 0
26568   1 90 2 0 1,584.58 0
26568   2 90 2 0 1,476.45 0
26568   3 90 2 0 1,464.23 0
26568   4 90 2 0 1,446.48 0
26580   1 90 2 0 3,142.33 0
26580   2 90 2 0 3,047.09 0
26580   3 90 2 0 2,845.93 0
26580   4 90 2 0 2,806.76 0
26587   1 90 2 0 1,262.28 0
26587   2 90 2 0 1,242.83 0
26587   3 90 2 0 1,162.68 0
26587   4 90 2 0 1,149.35 0
26590   1 90 2 0 921.65 0
26590   2 90 2 0 907.78 0
26590   3 90 2 0 850.52 0
26590   4 90 2 0 840.39 0
26591   1 90 2 0 489.22 0
26591   2 90 2 0 481.69 0
26591   3 90 2 0 450.50 0
26591   4 90 2 0 445.29 0
26593   1 90 2 0 853.20 0
26593   2 90 2 0 839.67 0
26593   3 90 2 0 784.03 0
26593   4 90 2 0 774.87 0
26596   1 90 2 0 1,602.46 0
26596   2 90 2 0 1,576.60 0
26596   3 90 2 0 1,469.88 0
26596   4 90 2 0 1,452.39 0
26600   1 90 2 0 311.81 246.57
26600   2 90 2 0 307.22 242.77
26600   3 90 2 0 292.79 231.03
26600   4 90 2 0 284.72 224.92
26605   1 90 2 0 433.14 0
26605   2 90 2 0 457.30 0
26605   3 90 2 0 427.00 0
26605   4 90 2 0 424.38 0
26607   1 90 2 0 808.06 0
26607   2 90 2 0 796.29 0
26607   3 90 2 0 747.71 0
26607   4 90 2 0 739.15 0
26608   1 90 2 0 808.06 0
26608   2 90 2 0 796.29 0
26608   3 90 2 0 747.71 0
26608   4 90 2 0 739.15 0
26615   1 90 2 0 953.83 0
26615   2 90 2 0 938.45 0
26615   3 90 2 0 875.05 0
26615   4 90 2 0 864.63 0
26641   1 90 2 0 427.91 0
26641   2 90 2 0 332.93 0
26641   3 90 2 0 405.63 0
26641   4 90 2 0 316.11 0
26645   1 90 2 0 586.10 0
26645   2 90 2 0 534.97 0
26645   3 90 2 0 547.53 0
26645   4 90 2 0 541.39 0
26650   1 90 2 0 911.20 0
26650   2 90 2 0 914.30 0
26650   3 90 2 0 819.32 0
26650   4 90 2 0 862.54 0
26665   1 90 2 0 1,285.50 0
26665   2 90 2 0 1,378.64 0
26665   3 90 2 0 1,342.83 0
26665   4 90 2 0 1,306.46 0
26670   1 90 2 0 393.51 0
26670   2 90 2 0 369.54 0
26670   3 90 2 0 374.44 0
26670   4 90 2 0 325.14 0
26675   1 90 2 0 821.10 0
26675   2 90 2 0 635.09 0
26675   3 90 2 0 756.52 0
26675   4 90 2 0 747.37 0
26676   1 90 2 0 945.57 0
26676   2 90 2 0 931.40 0
26676   3 90 2 0 872.56 0
26676   4 90 2 0 862.13 0
26685   1 90 2 0 1,157.84 0
26685   2 90 2 0 1,139.86 0
26685   3 90 2 0 1,065.36 0
26685   4 90 2 0 1,052.78 0
26686   1 90 2 0 1,300.83 0
26686   2 90 2 0 1,280.54 0
26686   3 90 2 0 1,196.75 0
26686   4 90 2 0 1,182.70 0
26700   1 90 2 0 278.68 0
26700   2 90 2 0 329.52 0
26700   3 90 2 0 284.28 0
26700   4 90 2 0 265.83 0
26705   1 90 2 0 502.59 0
26705   2 90 2 0 495.19 0
26705   3 90 2 0 483.76 0
26705   4 90 2 0 484.20 0
26706   1 90 2 0 908.98 0
26706   2 90 2 0 894.38 0
26706   3 90 2 0 834.22 0
26706   4 90 2 0 824.28 0
26715   1 90 2 0 899.11 0
26715   2 90 2 0 885.67 0
26715   3 90 2 0 830.25 0
26715   4 90 2 0 820.68 0
26720   1 90 2 0 244.29 197.87
26720   2 90 2 0 240.93 195.09
26720   3 90 2 0 227.04 183.77
26720   4 90 2 0 224.41 181.85
26725   1 90 2 0 389.62 0
26725   2 90 2 0 390.64 0
26725   3 90 2 0 366.17 0
26725   4 90 2 0 369.59 0
26727   1 90 2 0 828.81 0
26727   2 90 2 0 825.16 0
26727   3 90 2 0 627.86 0
26727   4 90 2 0 728.26 0
26735   1 90 2 0 904.90 0
26735   2 90 2 0 865.82 0
26735   3 90 2 0 813.74 0
26735   4 90 2 0 839.01 0
26740   1 90 2 0 213.17 0
26740   2 90 2 0 211.42 0
26740   3 90 2 0 252.83 0
26740   4 90 2 0 200.17 0
26742   1 90 2 0 471.62 0
26742   2 90 2 0 466.38 0
26742   3 90 2 0 426.73 0
26742   4 90 2 0 444.65 0
26746   1 90 2 0 974.79 0
26746   2 90 2 0 986.92 0
26746   3 90 2 0 917.24 0
26746   4 90 2 0 929.07 0
26750   1 90 2 0 218.65 0
26750   2 90 2 0 216.03 0
26750   3 90 2 0 205.19 0
26750   4 90 2 0 202.87 0
26755   1 90 2 0 354.70 0
26755   2 90 2 0 319.51 0
26755   3 90 2 0 306.45 0
26755   4 90 2 0 308.55 0
26756   1 90 2 0 557.69 0
26756   2 90 2 0 550.46 0
26756   3 90 2 0 520.87 0
26756   4 90 2 0 515.13 0
26765   1 90 2 0 780.08 0
26765   2 90 2 0 736.84 0
26765   3 90 2 0 577.65 0
26765   4 90 2 0 663.08 0
26770   1 90 2 0 289.05 0
26770   2 90 2 0 301.52 0
26770   3 90 2 0 271.47 0
26770   4 90 2 0 261.49 0
26775   1 90 2 0 333.60 0
26775   2 90 2 0 398.37 0
26775   3 90 2 0 320.30 0
26775   4 90 2 0 386.84 0
26776   1 90 2 0 609.61 0
26776   2 90 2 0 582.49 0
26776   3 90 2 0 569.77 0
26776   4 90 2 0 563.55 0
26785   1 90 2 0 659.30 0
26785   2 90 2 0 649.58 0
26785   3 90 2 0 609.11 0
26785   4 90 2 0 602.08 0
26820   1 90 2 0 1,361.53 0
26820   2 90 2 0 1,340.61 0
26820   3 90 2 0 1,254.14 0
26820   4 90 2 0 1,239.36 0
26841   1 90 2 0 1,226.28 0
26841   2 90 2 0 1,206.85 0
26841   3 90 2 0 1,156.19 0
26841   4 90 2 0 1,150.60 0
26842   1 90 2 0 1,560.25 0
26842   2 90 2 0 1,534.22 0
26842   3 90 2 0 1,426.51 0
26842   4 90 2 0 1,409.26 0
26843   1 90 2 0 1,290.94 0
26843   2 90 2 0 1,270.14 0
26843   3 90 2 0 1,184.43 0
26843   4 90 2 0 1,170.48 0
26844   1 90 2 0 1,472.34 0
26844   2 90 2 0 1,449.16 0
26844   3 90 2 0 1,353.39 0
26844   4 90 2 0 1,337.38 0
26850   1 90 2 0 1,085.95 0
26850   2 90 2 0 1,075.27 0
26850   3 90 2 0 1,013.06 0
26850   4 90 2 0 955.59 0
26852   1 90 2 0 1,287.37 0
26852   2 90 2 0 1,235.09 0
26852   3 90 2 0 1,187.36 0
26852   4 90 2 0 1,173.70 0
26860   1 90 2 0 873.13 0
26860   2 90 2 0 818.90 0
26860   3 90 2 0 820.06 0
26860   4 90 2 0 822.94 0
26861   1 ZZZ 0 0 408.17 0
26861   2 ZZZ 0 0 592.66 0
26861   3 ZZZ 0 0 579.48 0
26861   4 ZZZ 0 0 365.21 0
26862   1 90 2 0 1,494.10 0
26862   2 90 2 0 1,127.26 0
26862   3 90 2 0 1,217.72 0
26862   4 90 2 0 1,044.56 0
26863   1 ZZZ 0 0 689.31 0
26863   2 ZZZ 0 0 678.32 0
26863   3 ZZZ 0 0 632.98 0
26863   4 ZZZ 0 0 625.59 0
26910   1 90 2 0 1,185.89 0
26910   2 90 2 0 1,178.35 0
26910   3 90 2 0 1,141.32 0
26910   4 90 2 0 1,142.28 0
26951   1 90 2 0 693.27 0
26951   2 90 2 0 669.90 0
26951   3 90 2 0 628.96 0
26951   4 90 2 0 621.79 0
26952   1 90 2 0 1,133.13 0
26952   2 90 2 0 1,127.29 0
26952   3 90 2 0 1,103.44 0
26952   4 90 2 0 1,099.30 0
26989     YYY 2 0 * 0
26990   1 90 2 0 735.18 0
26990   2 90 2 0 731.14 0
26990   3 90 2 0 705.31 0
26990   4 90 2 0 670.55 0
26991   1 90 2 0 426.84 0
26991   2 90 2 0 493.81 0
26991   3 90 2 0 475.77 0
26991   4 90 2 0 656.25 0
26992   1 90 2 0 1,649.76 0
26992   2 90 2 0 1,636.14 0
26992   3 90 2 0 1,561.66 0
26992   4 90 2 0 1,482.87 0
27000   1 90 2 0 633.18 0
27000   2 90 2 0 626.31 0
27000   3 90 2 0 598.14 0
27000   4 90 2 0 591.66 0
27001   1 90 2 0 898.75 0
27001   2 90 2 0 827.41 0
27001   3 90 2 0 804.07 0
27001   4 90 2 0 792.44 0
27003   1 90 2 0 1,265.66 0
27003   2 90 2 0 1,244.32 0
27003   3 90 2 0 1,158.70 0
27003   4 90 2 0 1,144.78 0
27005   1 90 2 0 1,117.16 0
27005   2 90 2 0 1,103.92 0
27005   3 90 2 0 1,049.50 0
27005   4 90 2 0 1,038.29 0
27006   1 90 2 0 1,296.42 0
27006   2 90 2 0 1,279.39 0
27006   3 90 2 0 1,209.48 0
27006   4 90 2 0 1,196.13 0
27025   1 90 2 0 1,509.10 0
27025   2 90 2 0 1,487.86 0
27025   3 90 2 0 1,517.35 0
27025   4 90 2 0 1,384.59 0
27027   1 90 2 0 1,222.04 0
27027   2 90 2 0 1,096.10 0
27027   3 90 2 0 1,096.10 0
27027   4 90 2 0 1,096.10 0
27030   1 90 2 0 2,342.52 0
27030   2 90 2 0 2,327.57 0
27030   3 90 2 0 2,045.84 0
27030   4 90 2 0 2,021.46 0
27033   1 90 2 0 2,356.06 0
27033   2 90 2 0 2,340.93 0
27033   3 90 2 0 2,077.11 0
27033   4 90 2 0 2,268.20 0
27035   1 90 2 0 2,618.34 0
27035   2 90 2 0 2,577.00 0
27035   3 90 2 0 2,406.62 0
27035   4 90 2 0 2,378.99 0
27036   1 90 2 0 2,259.49 0
27036   2 90 2 0 2,021.50 0
27036   3 90 2 0 1,967.22 0
27036   4 90 2 0 1,967.22 0
27040   1 10 2 0 242.58 0
27040   2 10 2 0 250.68 0
27040   3 10 2 0 234.30 0
27040   4 10 2 0 229.02 0
27041   1 90 2 0 680.11 0
27041   2 90 2 0 677.23 0
27041   3 90 2 0 637.69 0
27041   4 90 2 0 632.07 0
27043   1 90 2 0 686.48 0
27043   2 90 2 0 611.12 0
27043   3 90 2 0 611.12 0
27043   4 90 2 0 611.12 0
27045   1 90 2 0 1,089.95 0
27045   2 90 2 0 971.57 0
27045   3 90 2 0 971.57 0
27045   4 90 2 0 971.57 0
27047   1 90 2 0 663.90 0
27047   2 90 2 0 639.42 0
27047   3 90 2 0 602.99 0
27047   4 90 2 0 754.96 0
27048   1 90 2 0 718.50 0
27048   2 90 2 0 709.59 0
27048   3 90 2 0 876.76 0
27048   4 90 2 0 668.92 0
27049   1 90 2 0 1,728.18 0
27049   2 90 2 0 1,708.28 0
27049   3 90 2 0 1,981.01 0
27049   4 90 2 0 1,958.04 0
27050   1 90 2 0 873.76 0
27050   2 90 2 0 857.86 0
27050   3 90 2 0 791.84 0
27050   4 90 2 0 782.11 0
27052   1 90 2 0 1,817.51 0
27052   2 90 2 0 1,765.84 0
27052   3 90 2 0 1,284.07 0
27052   4 90 2 0 1,268.07 0
27054   1 90 2 0 2,665.94 0
27054   2 90 2 0 2,507.72 0
27054   3 90 2 0 2,326.20 0
27054   4 90 2 0 1,759.31 0
27057   1 90 2 0 1,328.12 0
27057   2 90 2 0 1,204.18 0
27057   3 90 2 0 1,204.18 0
27057   4 90 2 0 1,204.18 0
27059   1 90 2 0 2,668.06 0
27059   2 90 2 0 2,389.95 0
27059   3 90 2 0 2,389.95 0
27059   4 90 2 0 2,389.95 0
27060   1 90 2 0 820.48 0
27060   2 90 2 0 780.13 0
27060   3 90 2 0 753.82 0
27060   4 90 2 0 745.07 0
27062   1 90 2 0 849.80 0
27062   2 90 2 0 836.27 0
27062   3 90 2 0 780.47 0
27062   4 90 2 0 771.25 0
27065   1 90 2 0 1,011.01 0
27065   2 90 2 0 1,218.88 0
27065   3 90 2 0 1,028.32 0
27065   4 90 2 0 912.63 0
27066   1 90 2 0 1,662.90 0
27066   2 90 2 0 1,642.19 0
27066   3 90 2 0 1,482.28 0
27066   4 90 2 0 1,576.03 0
27067   1 90 2 0 2,302.99 0
27067   2 90 2 0 2,277.65 0
27067   3 90 2 0 2,113.34 0
27067   4 90 2 0 2,088.33 0
27070   1 90 2 0 1,593.74 0
27070   2 90 2 0 1,516.84 0
27070   3 90 2 0 1,470.11 0
27070   4 90 2 0 1,453.02 0
27071   1 90 2 0 1,772.16 0
27071   2 90 2 0 1,793.80 0
27071   3 90 2 0 1,618.90 0
27071   4 90 2 0 1,609.98 0
27075   1 90 2 0 2,787.66 0
27075   2 90 2 0 2,743.32 0
27075   3 90 2 0 2,560.26 0
27075   4 90 2 0 2,530.29 0
27076   1 90 2 0 3,239.83 0
27076   2 90 2 0 3,188.69 0
27076   3 90 2 0 2,977.40 0
27076   4 90 2 0 2,942.09 0
27077   1 90 2 0 3,827.14 0
27077   2 90 2 0 3,765.61 0
27077   3 90 2 0 3,511.42 0
27077   4 90 2 0 3,470.10 0
27078   1 90 2 0 2,543.78 0
27078   2 90 2 0 2,089.02 0
27078   3 90 2 0 1,836.24 0
27078   4 90 2 0 1,815.04 0
27080   1 90 2 0 992.93 0
27080   2 90 2 0 976.74 0
27080   3 90 2 0 910.25 0
27080   4 90 2 0 899.68 0
27086   1 10 2 0 212.31 0
27086   2 10 2 0 183.91 0
27086   3 10 2 0 183.72 0
27086   4 10 2 0 177.56 0
27087   1 90 2 0 918.33 0
27087   2 90 2 0 910.59 0
27087   3 90 2 0 878.46 0
27087   4 90 2 0 981.91 0
27090   1 90 2 0 1,973.41 0
27090   2 90 2 0 1,943.87 0
27090   3 90 2 0 1,821.91 0
27090   4 90 2 0 1,800.82 0
27091   1 90 2 0 4,987.73 0
27091   2 90 2 0 4,942.34 0
27091   3 90 2 0 4,071.29 0
27091   4 90 2 0 4,310.93 0
27093   1 0 2 0 184.96 0
27093   2 0 2 0 187.39 0
27093   3 0 2 0 171.23 0
27093   4 0 2 0 177.97 0
27095   1 0 2 0 208.21 0
27095   2 0 2 0 205.44 0
27095   3 0 2 0 193.11 0
27095   4 0 2 0 191.79 0
27096   1 0 2 0 838.16 112.88
27096   2 0 2 0 722.75 102.72
27096   3 0 2 0 722.75 102.72
27096   4 0 2 0 722.75 102.72
27097   1 90 2 0 1,498.89 0
27097   2 90 2 0 1,474.70 0
27097   3 90 2 0 1,374.93 0
27097   4 90 2 0 1,358.54 0
27098   1 90 2 0 1,498.89 0
27098   2 90 2 0 1,474.70 0
27098   3 90 2 0 1,374.93 0
27098   4 90 2 0 1,358.54 0
27100   1 90 2 0 1,865.54 0
27100   2 90 2 0 1,702.06 0
27100   3 90 2 0 1,872.43 0
27100   4 90 2 0 1,572.85 0
27105   1 90 2 0 1,628.41 0
27105   2 90 2 0 1,603.67 0
27105   3 90 2 0 1,501.85 0
27105   4 90 2 0 1,485.53 0
27110   1 90 2 0 2,195.32 0
27110   2 90 2 0 2,426.59 0
27110   3 90 2 0 2,061.74 0
27110   4 90 2 0 1,991.63 0
27111   1 90 2 0 2,165.90 0
27111   2 90 2 0 2,414.73 0
27111   3 90 2 0 1,992.32 0
27111   4 90 2 0 1,968.19 0
27120   1 90 2 0 3,360.71 0
27120   2 90 2 0 3,341.39 0
27120   3 90 2 0 3,018.12 0
27120   4 90 2 0 3,094.49 0
27122   1 90 2 0 3,266.11 0
27122   2 90 2 0 3,162.58 0
27122   3 90 2 0 2,901.27 0
27122   4 90 2 0 2,908.47 0
27125   1 90 2 0 3,157.94 0
27125   2 90 2 0 3,107.67 0
27125   3 90 2 0 2,900.02 0
27125   4 90 2 0 2,857.20 0
27130   1 90 2 0 4,798.40 0
27130   2 90 2 0 4,712.16 0
27130   3 90 2 0 4,428.47 0
27130   4 90 2 0 4,329.47 0
27132   1 90 2 0 4,932.67 0
27132   2 90 2 0 5,232.87 0
27132   3 90 2 0 4,890.09 0
27132   4 90 2 0 4,416.21 0
27134   1 90 2 0 6,076.25 0
27134   2 90 2 0 6,111.98 0
27134   3 90 2 0 5,758.97 0
27134   4 90 2 0 5,628.16 0
27137   1 90 2 0 4,882.86 0
27137   2 90 2 0 4,839.52 0
27137   3 90 2 0 4,546.86 0
27137   4 90 2 0 4,516.50 0
27138   1 90 2 0 4,306.97 0
27138   2 90 2 0 4,254.53 0
27138   3 90 2 0 3,955.64 0
27138   4 90 2 0 3,924.76 0
27140   1 90 2 0 2,123.43 0
27140   2 90 2 0 1,961.26 0
27140   3 90 2 0 1,729.07 0
27140   4 90 2 0 1,927.08 0
27146   1 90 2 0 2,255.11 0
27146   2 90 2 0 2,223.83 0
27146   3 90 2 0 2,094.57 0
27146   4 90 2 0 2,069.76 0
27147   1 90 2 0 3,280.80 0
27147   2 90 2 0 3,193.79 0
27147   3 90 2 0 3,008.76 0
27147   4 90 2 0 2,972.89 0
27151   1 90 2 0 3,445.97 0
27151   2 90 2 0 3,390.32 0
27151   3 90 2 0 3,160.68 0
27151   4 90 2 0 3,122.99 0
27156   1 90 2 0 3,653.08 0
27156   2 90 2 0 3,594.44 0
27156   3 90 2 0 3,351.96 0
27156   4 90 2 0 3,312.39 0
27158   1 90 2 0 3,093.06 0
27158   2 90 2 0 3,043.69 0
27158   3 90 2 0 2,840.05 0
27158   4 90 2 0 2,807.22 0
27161   1 90 2 0 2,796.37 0
27161   2 90 2 0 2,751.61 0
27161   3 90 2 0 2,566.70 0
27161   4 90 2 0 2,536.17 0
27165   1 90 2 0 3,129.42 0
27165   2 90 2 0 3,078.54 0
27165   3 90 2 0 2,868.13 0
27165   4 90 2 0 2,833.58 0
27170   1 90 2 0 3,315.58 0
27170   2 90 2 0 3,237.61 0
27170   3 90 2 0 3,016.32 0
27170   4 90 2 0 3,051.63 0
27175   1 90 2 0 735.13 0
27175   2 90 2 0 728.54 0
27175   3 90 2 0 701.80 0
27175   4 90 2 0 694.80 0
27176   1 90 2 0 2,020.86 0
27176   2 90 2 0 1,988.27 0
27176   3 90 2 0 1,853.47 0
27176   4 90 2 0 1,831.41 0
27177   1 90 2 0 2,477.35 0
27177   2 90 2 0 2,879.34 0
27177   3 90 2 0 2,274.89 0
27177   4 90 2 0 2,248.04 0
27178   1 90 2 0 1,996.63 0
27178   2 90 2 0 1,965.42 0
27178   3 90 2 0 1,836.15 0
27178   4 90 2 0 1,814.10 0