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2018 Workers' Compensation Part B Fee Schedule

28270-29358

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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
28270   1 90 2 0 639.42 528.12
28270   2 90 2 0 632.10 522.30
28270   3 90 2 0 602.07 498.36
28270   4 90 2 0 595.11 493.16
28272   1 90 2 0 543.80 451.17
28272   2 90 2 0 576.79 478.33
28272   3 90 2 0 570.30 474.99
28272   4 90 2 0 471.04 392.09
28280   1 90 2 0 642.54 0
28280   2 90 2 0 698.98 0
28280   3 90 2 0 688.46 0
28280   4 90 2 0 637.08 0
28285   1 90 2 0 792.95 0
28285   2 90 2 0 782.41 0
28285   3 90 2 0 719.69 0
28285   4 90 2 0 716.68 0
28286   1 90 2 0 724.72 0
28286   2 90 2 0 765.75 0
28286   3 90 2 0 615.32 0
28286   4 90 2 0 667.23 0
28288   1 90 2 0 687.61 0
28288   2 90 2 0 677.74 0
28288   3 90 2 0 636.61 0
28288   4 90 2 0 628.85 0
28289   1 90 2 0 735.29 760.63
28289   2 90 2 0 671.98 693.66
28289   3 90 2 0 671.98 693.66
28289   4 90 2 0 671.98 693.66
28291   1 90 2 0 942.57 612.94
28291   2 90 2 0 848.76 564.28
28291   3 90 2 0 848.76 564.28
28291   4 90 2 0 848.76 564.28
28292   1 90 2 0 1,220.61 0
28292   2 90 2 0 1,202.89 0
28292   3 90 2 0 1,129.35 0
28292   4 90 2 0 1,115.23 0
28295   1 90 2 0 1,209.91 682.51
28295   2 90 2 0 1,082.48 627.28
28295   3 90 2 0 1,082.48 627.28
28295   4 90 2 0 1,082.48 627.28
28296   1 90 2 0 1,607.77 0
28296   2 90 2 0 1,584.71 0
28296   3 90 2 0 1,489.05 0
28296   4 90 2 0 1,470.75 0
28297   1 90 2 0 1,516.43 0
28297   2 90 2 0 1,610.44 0
28297   3 90 2 0 1,511.12 0
28297   4 90 2 0 1,492.54 0
28298   1 90 2 0 1,490.52 0
28298   2 90 2 0 1,469.76 0
28298   3 90 2 0 1,383.20 0
28298   4 90 2 0 1,365.64 0
28299   1 90 2 0 1,515.11 0
28299   2 90 2 0 1,646.65 0
28299   3 90 2 0 1,582.21 0
28299   4 90 2 0 1,562.27 0
28300   1 90 2 0 1,425.29 0
28300   2 90 2 0 1,406.26 0
28300   3 90 2 0 1,327.60 0
28300   4 90 2 0 1,396.96 0
28302   1 90 2 0 1,669.26 0
28302   2 90 2 0 1,644.55 0
28302   3 90 2 0 1,542.37 0
28302   4 90 2 0 1,523.68 0
28304   1 90 2 0 1,369.44 0
28304   2 90 2 0 1,351.54 0
28304   3 90 2 0 1,277.50 0
28304   4 90 2 0 1,262.39 0
28305   1 90 2 0 1,811.64 0
28305   2 90 2 0 1,786.31 0
28305   3 90 2 0 1,681.36 0
28305   4 90 2 0 1,660.71 0
28306   1 90 2 0 1,040.38 0
28306   2 90 2 0 959.49 0
28306   3 90 2 0 1,048.58 0
28306   4 90 2 0 963.71 0
28307   1 90 2 0 1,106.82 0
28307   2 90 2 0 1,344.83 0
28307   3 90 2 0 1,021.91 0
28307   4 90 2 0 1,009.56 0
28308   1 90 2 0 1,040.35 0
28308   2 90 2 0 965.59 0
28308   3 90 2 0 909.57 0
28308   4 90 2 0 915.30 0
28309   1 90 2 0 1,458.02 0
28309   2 90 2 0 1,436.87 0
28309   3 90 2 0 1,349.22 0
28309   4 90 2 0 1,333.39 0
28310   1 90 2 0 952.85 0
28310   2 90 2 0 861.96 0
28310   3 90 2 0 778.99 0
28310   4 90 2 0 908.23 0
28312   1 90 2 0 807.78 0
28312   2 90 2 0 796.46 0
28312   3 90 2 0 749.26 0
28312   4 90 2 0 716.07 0
28313   1 90 2 0 658.85 0
28313   2 90 2 0 650.81 0
28313   3 90 2 0 617.68 0
28313   4 90 2 0 630.14 0
28315   1 90 2 0 800.53 0
28315   2 90 2 0 789.85 0
28315   3 90 2 0 745.43 0
28315   4 90 2 0 688.04 0
28320   1 90 2 0 1,609.98 0
28320   2 90 2 0 1,526.03 0
28320   3 90 2 0 1,489.44 0
28320   4 90 2 0 1,471.27 0
28322   1 90 2 0 1,142.22 0
28322   2 90 2 0 1,128.23 0
28322   3 90 2 0 1,070.47 0
28322   4 90 2 0 1,058.19 0
28340   1 90 2 0 1,210.57 0
28340   2 90 2 0 1,191.91 0
28340   3 90 2 0 1,178.77 0
28340   4 90 2 0 1,101.22 0
28341   1 90 2 0 1,437.85 0
28341   2 90 2 0 1,416.67 0
28341   3 90 2 0 1,328.77 0
28341   4 90 2 0 1,312.64 0
28344   1 90 2 0 719.89 0
28344   2 90 2 0 708.28 0
28344   3 90 2 0 660.37 0
28344   4 90 2 0 652.52 0
28345   1 90 2 0 1,013.49 0
28345   2 90 2 0 998.10 0
28345   3 90 2 0 934.34 0
28345   4 90 2 0 923.03 0
28360   1 90 2 0 1,013.49 0
28360   2 90 2 0 998.10 0
28360   3 90 2 0 934.34 0
28360   4 90 2 0 923.03 0
28400   1 90 2 0 527.10 0
28400   2 90 2 0 472.85 0
28400   3 90 2 0 567.26 0
28400   4 90 2 0 527.56 0
28405   1 90 2 0 851.81 0
28405   2 90 2 0 964.07 0
28405   3 90 2 0 775.11 0
28405   4 90 2 0 698.38 0
28406   1 90 2 0 1,127.81 0
28406   2 90 2 0 1,132.92 0
28406   3 90 2 0 1,038.31 0
28406   4 90 2 0 1,021.73 0
28415   1 90 2 0 2,067.36 0
28415   2 90 2 0 2,037.87 0
28415   3 90 2 0 1,785.89 0
28415   4 90 2 0 1,776.41 0
28420   1 90 2 0 2,548.99 0
28420   2 90 2 0 2,434.62 0
28420   3 90 2 0 2,405.07 0
28420   4 90 2 0 2,263.92 0
28430   1 90 2 0 502.15 0
28430   2 90 2 0 411.13 0
28430   3 90 2 0 490.37 0
28430   4 90 2 0 483.25 0
28435   1 90 2 0 625.10 0
28435   2 90 2 0 695.22 0
28435   3 90 2 0 681.85 0
28435   4 90 2 0 566.84 0
28436   1 90 2 0 815.44 0
28436   2 90 2 0 802.34 0
28436   3 90 2 0 748.09 0
28436   4 90 2 0 739.17 0
28445   1 90 2 0 1,669.53 0
28445   2 90 2 0 1,642.46 0
28445   3 90 2 0 1,530.57 0
28445   4 90 2 0 1,512.23 0
28446   1 90 2 0 1,679.14 0
28446   2 90 2 0 1,485.05 0
28446   3 90 2 0 1,485.05 0
28446   4 90 2 0 1,485.05 0
28450   1 90 2 0 348.48 0
28450   2 90 2 0 345.75 0
28450   3 90 2 0 327.98 0
28450   4 90 2 0 330.22 0
28455   1 90 2 0 520.36 0
28455   2 90 2 0 499.73 0
28455   3 90 2 0 479.84 0
28455   4 90 2 0 518.12 0
28456   1 90 2 0 443.58 0
28456   2 90 2 0 269.49 0
28456   3 90 2 0 406.75 0
28456   4 90 2 0 401.93 0
28465   1 90 2 0 1,122.71 0
28465   2 90 2 0 1,101.47 0
28465   3 90 2 0 1,040.93 0
28465   4 90 2 0 1,033.28 0
28470   1 90 2 0 330.67 254.59
28470   2 90 2 0 332.55 255.78
28470   3 90 2 0 326.92 251.13
28470   4 90 2 0 301.44 231.67
28475   1 90 2 0 468.50 369.32
28475   2 90 2 0 461.76 363.95
28475   3 90 2 0 434.13 341.70
28475   4 90 2 0 428.95 338.17
28476   1 90 2 0 610.28 0
28476   2 90 2 0 600.81 0
28476   3 90 2 0 561.53 0
28476   4 90 2 0 554.66 0
28485   1 90 2 0 923.20 0
28485   2 90 2 0 800.03 0
28485   3 90 2 0 755.02 0
28485   4 90 2 0 757.23 0
28490   1 90 2 0 182.66 142.30
28490   2 90 2 0 178.83 139.65
28490   3 90 2 0 172.06 134.13
28490   4 90 2 0 168.44 131.41
28495   1 90 2 0 236.71 0
28495   2 90 2 0 233.55 0
28495   3 90 2 0 233.08 0
28495   4 90 2 0 220.72 0
28496   1 90 2 0 398.62 0
28496   2 90 2 0 392.46 0
28496   3 90 2 0 366.80 0
28496   4 90 2 0 362.40 0
28505   1 90 2 0 687.54 0
28505   2 90 2 0 599.17 0
28505   3 90 2 0 655.23 0
28505   4 90 2 0 671.47 0
28510   1 90 2 0 181.27 141.35
28510   2 90 2 0 175.14 136.71
28510   3 90 2 0 169.00 132.27
28510   4 90 2 0 167.58 130.84
28515   1 90 2 0 224.10 176.81
28515   2 90 2 0 221.20 174.55
28515   3 90 2 0 228.21 180.38
28515   4 90 2 0 209.69 165.89
28525   1 90 2 0 494.07 0
28525   2 90 2 0 464.87 0
28525   3 90 2 0 480.19 0
28525   4 90 2 0 478.13 0
28530   1 90 2 0 182.66 0
28530   2 90 2 0 180.16 0
28530   3 90 2 0 169.66 0
28530   4 90 2 0 167.58 0
28531   1 90 2 0 372.33 0
28531   2 90 2 0 366.33 0
28531   3 90 2 0 341.36 0
28531   4 90 2 0 337.34 0
28540   1 90 2 0 306.66 0
28540   2 90 2 0 303.74 0
28540   3 90 2 0 295.74 0
28540   4 90 2 0 309.78 0
28545   1 90 2 0 313.28 0
28545   2 90 2 0 309.49 0
28545   3 90 2 0 293.80 0
28545   4 90 2 0 290.38 0
28546   1 90 2 0 533.67 0
28546   2 90 2 0 525.15 0
28546   3 90 2 0 489.66 0
28546   4 90 2 0 483.88 0
28555   1 90 2 0 1,060.32 0
28555   2 90 2 0 1,044.55 0
28555   3 90 2 0 967.52 0
28555   4 90 2 0 967.21 0
28570   1 90 2 0 373.34 0
28570   2 90 2 0 316.51 0
28570   3 90 2 0 267.68 0
28570   4 90 2 0 264.37 0
28575   1 90 2 0 534.09 0
28575   2 90 2 0 525.75 0
28575   3 90 2 0 491.25 0
28575   4 90 2 0 485.35 0
28576   1 90 2 0 605.16 0
28576   2 90 2 0 596.42 0
28576   3 90 2 0 560.23 0
28576   4 90 2 0 553.72 0
28585   1 90 2 0 1,122.59 0
28585   2 90 2 0 1,134.60 0
28585   3 90 2 0 678.44 0
28585   4 90 2 0 1,252.44 0
28600   1 90 2 0 215.24 0
28600   2 90 2 0 214.55 0
28600   3 90 2 0 204.89 0
28600   4 90 2 0 202.61 0
28605   1 90 2 0 440.15 0
28605   2 90 2 0 433.35 0
28605   3 90 2 0 395.18 0
28605   4 90 2 0 400.31 0
28606   1 90 2 0 739.93 0
28606   2 90 2 0 738.56 0
28606   3 90 2 0 688.66 0
28606   4 90 2 0 680.65 0
28615   1 90 2 0 954.65 0
28615   2 90 2 0 939.40 0
28615   3 90 2 0 876.31 0
28615   4 90 2 0 865.82 0
28630   1 10 2 0 229.68 0
28630   2 10 2 0 225.32 0
28630   3 10 2 0 212.71 0
28630   4 10 2 0 223.04 0
28635   1 10 2 0 303.33 0
28635   2 10 2 0 273.80 0
28635   3 10 2 0 281.94 0
28635   4 10 2 0 278.56 0
28636   1 10 2 0 496.46 0
28636   2 10 2 0 488.42 0
28636   3 10 2 0 455.39 0
28636   4 10 2 0 449.96 0
28645   1 90 2 0 657.80 0
28645   2 90 2 0 648.79 0
28645   3 90 2 0 611.45 0
28645   4 90 2 0 604.19 0
28660   1 10 2 0 169.96 0
28660   2 10 2 0 158.95 0
28660   3 10 2 0 162.31 0
28660   4 10 2 0 174.42 0
28665   1 10 2 0 255.04 0
28665   2 10 2 0 252.03 0
28665   3 10 2 0 239.59 0
28665   4 10 2 0 236.88 0
28666   1 10 2 0 474.60 0
28666   2 10 2 0 466.94 0
28666   3 10 2 0 435.47 0
28666   4 10 2 0 430.27 0
28675   1 90 2 0 541.64 0
28675   2 90 2 0 524.40 0
28675   3 90 2 0 489.64 0
28675   4 90 2 0 506.25 0
28705   1 90 2 0 2,787.32 0
28705   2 90 2 0 2,214.15 0
28705   3 90 2 0 2,553.55 0
28705   4 90 2 0 2,522.69 0
28715   1 90 2 0 2,318.84 0
28715   2 90 2 0 2,281.71 0
28715   3 90 2 0 2,183.73 0
28715   4 90 2 0 2,127.35 0
28725   1 90 2 0 1,788.56 0
28725   2 90 2 0 1,874.74 0
28725   3 90 2 0 1,754.27 0
28725   4 90 2 0 1,733.49 0
28730   1 90 2 0 1,686.78 0
28730   2 90 2 0 1,744.29 0
28730   3 90 2 0 1,525.00 0
28730   4 90 2 0 1,612.74 0
28735   1 90 2 0 1,855.62 0
28735   2 90 2 0 1,740.25 0
28735   3 90 2 0 1,709.32 0
28735   4 90 2 0 1,688.73 0
28737   1 90 2 0 1,657.23 0
28737   2 90 2 0 1,544.72 0
28737   3 90 2 0 1,522.12 0
28737   4 90 2 0 1,503.64 0
28740   1 90 2 0 1,053.24 0
28740   2 90 2 0 1,037.77 0
28740   3 90 2 0 1,004.51 0
28740   4 90 2 0 991.53 0
28750   1 90 2 0 1,123.10 0
28750   2 90 2 0 1,123.23 0
28750   3 90 2 0 1,113.15 0
28750   4 90 2 0 1,059.25 0
28755   1 90 2 0 750.04 0
28755   2 90 2 0 739.50 0
28755   3 90 2 0 735.03 0
28755   4 90 2 0 687.79 0
28760   1 90 2 0 1,004.11 0
28760   2 90 2 0 1,048.90 0
28760   3 90 2 0 972.22 0
28760   4 90 2 0 1,132.70 0
28800   1 90 2 0 1,450.68 0
28800   2 90 2 0 1,438.18 0
28800   3 90 2 0 1,382.47 0
28800   4 90 2 0 1,399.83 0
28805   1 90 2 0 1,424.75 0
28805   2 90 2 0 1,307.42 0
28805   3 90 2 0 1,217.05 0
28805   4 90 2 0 1,285.13 0
28810   1 90 2 0 895.54 0
28810   2 90 2 0 912.09 0
28810   3 90 2 0 836.20 0
28810   4 90 2 0 814.40 0
28820   1 90 2 0 650.30 0
28820   2 90 2 0 570.86 0
28820   3 90 2 0 534.09 0
28820   4 90 2 0 527.94 0
28825   1 90 2 0 601.98 0
28825   2 90 2 0 523.42 0
28825   3 90 2 0 479.42 0
28825   4 90 2 0 473.87 0
28890   1 90 2 0 576.33 350.31
28890   2 90 2 0 494.88 310.22
28890   3 90 2 0 494.88 310.22
28890   4 90 2 0 494.88 310.22
28899     YYY 2 0 * 0
29000   1 0 2 0 373.30 0
29000   2 0 2 0 376.86 0
29000   3 0 2 0 424.15 0
29000   4 0 2 0 228.59 0
29010   1 0 2 0 533.67 0
29010   2 0 2 0 408.36 0
29010   3 0 2 0 380.56 0
29010   4 0 2 0 375.90 0
29015   1 0 2 0 443.88 0
29015   2 0 2 0 539.27 0
29015   3 0 2 0 408.98 0
29015   4 0 2 0 404.09 0
29035   1 0 2 0 355.59 0
29035   2 0 2 0 551.36 0
29035   3 0 2 0 478.13 0
29035   4 0 2 0 321.05 0
29040   1 0 2 0 396.53 0
29040   2 0 2 0 390.51 0
29040   3 0 2 0 365.37 0
29040   4 0 2 0 361.00 0
29044   1 0 2 0 399.18 0
29044   2 0 2 0 392.66 0
29044   3 0 2 0 365.91 0
29044   4 0 2 0 361.61 0
29046   1 0 2 0 438.52 0
29046   2 0 2 0 431.56 0
29046   3 0 2 0 402.87 0
29046   4 0 2 0 398.06 0
29049   1 0 2 0 118.12 0
29049   2 0 2 0 116.67 0
29049   3 0 2 0 110.71 0
29049   4 0 2 0 100.98 0
29055   1 0 2 0 273.65 0
29055   2 0 2 0 350.67 0
29055   3 0 2 0 254.31 0
29055   4 0 2 0 362.77 0
29058   1 0 2 0 177.19 0
29058   2 0 2 0 175.02 0
29058   3 0 2 0 165.97 0
29058   4 0 2 0 246.65 0
29065   1 0 2 0 245.36 192.81
29065   2 0 2 0 246.57 193.40
29065   3 0 2 0 238.36 186.56
29065   4 0 2 0 225.21 176.51
29075   1 0 2 0 179.81 143.87
29075   2 0 2 0 192.58 153.67
29075   3 0 2 0 173.30 138.31
29075   4 0 2 0 144.24 115.03
29085   1 0 2 0 96.41 79.86
29085   2 0 2 0 95.31 79.29
29085   3 0 2 0 91.35 75.81
29085   4 0 2 0 90.59 75.56
29086   1 0 2 0 102.50 81.05
29086   2 0 2 0 89.97 71.71
29086   3 0 2 0 89.97 71.71
29086   4 0 2 0 89.97 71.71
29105   1 0 2 0 126.27 104.97
29105   2 0 2 0 124.83 103.73
29105   3 0 2 0 116.05 96.16
29105   4 0 2 0 116.41 96.85
29125   1 0 2 0 87.57 72.05
29125   2 0 2 0 86.40 71.15
29125   3 0 2 0 85.79 70.82
29125   4 0 2 0 80.69 66.51
29126   1 0 2 0 106.39 89.67
29126   2 0 2 0 92.41 77.65
29126   3 0 2 0 102.61 86.43
29126   4 0 2 0 79.65 67.23
29130   1 0 2 0 59.45 52.33
29130   2 0 2 0 58.82 51.83
29130   3 0 2 0 72.37 63.79
29130   4 0 2 0 72.75 64.22
29131   1 0 2 0 147.20 0
29131   2 0 2 0 138.67 0
29131   3 0 2 0 144.98 0
29131   4 0 2 0 79.83 0
29200   1 0 2 0 65.47 56.43
29200   2 0 2 0 65.93 56.85
29200   3 0 2 0 63.17 54.40
29200   4 0 2 0 62.87 54.47
29240   1 0 2 0 79.22 0
29240   2 0 2 0 80.88 0
29240   3 0 2 0 78.72 0
29240   4 0 2 0 75.72 0
29260   1 0 2 0 62.71 54.06
29260   2 0 2 0 62.57 54.10
29260   3 0 2 0 60.17 51.90
29260   4 0 2 0 60.14 51.93
29280   1 0 2 0 63.66 0
29280   2 0 2 0 62.98 0
29280   3 0 2 0 60.23 0
29280   4 0 2 0 59.56 0
29305   1 0 2 0 469.56 0
29305   2 0 2 0 469.63 0
29305   3 0 2 0 388.61 0
29305   4 0 2 0 335.79 0
29325   1 0 2 0 396.49 0
29325   2 0 2 0 390.65 0
29325   3 0 2 0 374.28 0
29325   4 0 2 0 362.14 0
29345   1 0 2 0 292.82 236.46
29345   2 0 2 0 297.61 240.31
29345   3 0 2 0 235.04 190.09
29345   4 0 2 0 223.33 180.38
29355   1 0 2 0 244.33 197.94
29355   2 0 2 0 254.22 205.45
29355   3 0 2 0 226.26 182.97
29355   4 0 2 0 207.11 167.79
29358   1 0 2 0 342.31 0
29358   2 0 2 0 339.90 0
29358   3 0 2 0 294.29 0
29358   4 0 2 0 290.69 0