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2018 Workers' Compensation Part B Fee Schedule

53515-55520

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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
53515   1 90 2 0 1,953.06 0
53515   2 90 2 0 1,928.72 0
53515   3 90 2 0 1,827.72 0
53515   4 90 2 0 1,806.15 0
53520   1 90 2 0 765.31 0
53520   2 90 2 0 1,144.32 0
53520   3 90 2 0 1,050.98 0
53520   4 90 2 0 1,087.57 0
53600   1 0 2 0 115.30 103.45
53600   2 0 2 0 112.52 101.30
53600   3 0 2 0 100.06 89.95
53600   4 0 2 0 100.51 90.28
53601   1 0 2 0 104.53 93.19
53601   2 0 2 0 103.10 91.82
53601   3 0 2 0 87.43 78.16
53601   4 0 2 0 89.48 79.78
53605   1 0 2 0 129.39 0
53605   2 0 2 0 124.55 0
53605   3 0 2 0 110.93 0
53605   4 0 2 0 143.87 0
53620   1 0 2 0 139.08 123.47
53620   2 0 2 0 145.41 129.84
53620   3 0 2 0 135.92 121.66
53620   4 0 2 0 126.82 113.32
53621   1 0 2 0 127.49 114.15
53621   2 0 2 0 125.51 112.47
53621   3 0 2 0 108.19 96.91
53621   4 0 2 0 108.60 97.28
53660   1 0 2 0 87.90 76.19
53660   2 0 2 0 86.82 75.42
53660   3 0 2 0 75.72 65.52
53660   4 0 2 0 75.16 65.32
53661   1 0 2 0 85.80 75.40
53661   2 0 2 0 84.91 74.60
53661   3 0 2 0 73.70 64.89
53661   4 0 2 0 73.80 64.95
53665   1 0 2 0 96.79 0
53665   2 0 2 0 97.50 0
53665   3 0 2 0 81.06 0
53665   4 0 2 0 92.80 0
53850   1 90 2 0 1,290.20 0
53850   2 90 2 0 1,156.14 0
53850   3 90 2 0 1,156.14 0
53850   4 90 2 0 1,156.14 0
53852   1 90 2 0 1,348.43 0
53852   2 90 2 0 1,208.35 0
53852   3 90 2 0 1,208.35 0
53852   4 90 2 0 1,208.35 0
53855   1 0 2 0 975.52 120.42
53855   2 0 2 0 832.10 111.05
53855   3 0 2 0 832.10 111.05
53855   4 0 2 0 832.10 111.05
53860   1 90 2 0 2,139.92 346.10
53860   2 90 2 0 1,899.65 314.33
53860   3 90 2 0 1,899.65 314.33
53860   4 90 2 0 1,899.65 314.33
53899     YYY 2 0 * 0
54000     10 2 0 * 0
54001   1 10 2 0 261.76 0
54001   2 10 2 0 254.06 0
54001   3 10 2 0 245.74 0
54001   4 10 2 0 241.14 0
54015   1 10 2 0 400.39 0
54015   2 10 2 0 392.33 0
54015   3 10 2 0 496.62 0
54015   4 10 2 0 491.67 0
54050   1 10 2 0 116.24 0
54050   2 10 2 0 106.96 0
54050   3 10 2 0 109.96 0
54050   4 10 2 0 111.18 0
54055   1 10 2 0 159.99 0
54055   2 10 2 0 153.44 0
54055   3 10 2 0 151.38 0
54055   4 10 2 0 148.98 0
54056   1 10 2 0 140.66 0
54056   2 10 2 0 143.70 0
54056   3 10 2 0 128.10 0
54056   4 10 2 0 141.19 0
54057   1 10 2 0 234.96 0
54057   2 10 2 0 228.33 0
54057   3 10 2 0 220.56 0
54057   4 10 2 0 254.66 0
54060   1 10 2 0 249.08 0
54060   2 10 2 0 246.06 0
54060   3 10 2 0 237.92 0
54060   4 10 2 0 232.52 0
54065   1 10 2 0 441.99 0
54065   2 10 2 0 633.88 0
54065   3 10 2 0 497.79 0
54065   4 10 2 0 405.06 0
54100   1 0 2 0 188.79 0
54100   2 0 2 0 187.22 0
54100   3 0 2 0 182.03 0
54100   4 0 2 0 210.77 0
54105   1 10 2 0 350.22 0
54105   2 10 2 0 348.01 0
54105   3 10 2 0 334.75 0
54105   4 10 2 0 336.74 0
54110   1 90 2 0 1,407.27 0
54110   2 90 2 0 1,390.18 0
54110   3 90 2 0 1,319.38 0
54110   4 90 2 0 1,304.10 0
54111   1 90 2 0 2,003.93 0
54111   2 90 2 0 1,978.41 0
54111   3 90 2 0 1,872.75 0
54111   4 90 2 0 1,850.71 0
54112   1 90 2 0 2,761.92 0
54112   2 90 2 0 2,749.37 0
54112   3 90 2 0 2,191.30 0
54112   4 90 2 0 2,165.47 0
54115   1 90 2 0 890.55 0
54115   2 90 2 0 1,359.23 0
54115   3 90 2 0 1,209.63 0
54115   4 90 2 0 821.85 0
54120   1 90 2 0 1,409.39 0
54120   2 90 2 0 1,391.96 0
54120   3 90 2 0 1,319.63 0
54120   4 90 2 0 1,304.04 0
54125   1 90 2 0 2,211.94 0
54125   2 90 2 0 2,182.08 0
54125   3 90 2 0 2,058.20 0
54125   4 90 2 0 2,137.62 0
54130   1 90 2 0 3,011.00 0
54130   2 90 2 0 2,973.33 0
54130   3 90 2 0 2,817.13 0
54130   4 90 2 0 2,837.31 0
54135   1 90 2 0 3,843.32 0
54135   2 90 2 0 3,795.27 0
54135   3 90 2 0 3,596.32 0
54135   4 90 2 0 3,553.89 0
54150     10 2 0 * 0
54160     10 2 0 * 0
54161   1 10 2 0 485.44 0
54161   2 10 2 0 479.38 0
54161   3 10 2 0 454.22 0
54161   4 10 2 0 447.61 0
54162   1 10 2 0 411.91 0
54162   2 10 2 0 368.11 0
54162   3 10 2 0 368.11 0
54162   4 10 2 0 368.11 0
54163   1 10 2 0 386.33 0
54163   2 10 2 0 346.36 0
54163   3 10 2 0 346.36 0
54163   4 10 2 0 346.36 0
54164   1 10 2 0 339.48 0
54164   2 10 2 0 303.56 0
54164   3 10 2 0 303.56 0
54164   4 10 2 0 303.56 0
54200   1 10 2 0 90.74 0
54200   2 10 2 0 89.85 0
54200   3 10 2 0 110.24 0
54200   4 10 2 0 109.07 0
54205   1 90 2 0 1,107.02 0
54205   2 90 2 0 1,093.17 0
54205   3 90 2 0 1,035.75 0
54205   4 90 2 0 1,023.53 0
54220   1 0 2 0 605.43 0
54220   2 0 2 0 585.07 0
54220   3 0 2 0 519.70 0
54220   4 0 2 0 333.60 0
54230   1 0 2 0 163.65 0
54230   2 0 2 0 161.51 0
54230   3 0 2 0 153.00 0
54230   4 0 2 0 222.73 0
54231   1 0 2 0 381.99 0
54231   2 0 2 0 377.18 0
54231   3 0 2 0 357.22 0
54231   4 0 2 0 353.04 0
54235   1 0 2 0 126.22 110.13
54235   2 0 2 0 127.63 111.57
54235   3 0 2 0 117.92 103.47
54235   4 0 2 0 120.91 106.07
54240   1 0 2 0 204.74 0
54240 26 1 0 2 0 149.37 0
54240 TC 1 0 2 0 48.72 0
54240   2 0 2 0 204.96 0
54240 26 2 0 2 0 148.28 0
54240 TC 2 0 2 0 57.94 0
54240   3 0 2 0 194.82 0
54240 26 3 0 2 0 139.98 0
54240 TC 3 0 2 0 43.08 0
54240   4 0 2 0 185.74 0
54240 26 4 0 2 0 124.01 0
54240 TC 4 0 2 0 42.41 0
54250   1 0 2 0 196.82 0
54250 26 1 0 2 0 236.51 0
54250 TC 1 0 2 0 28.94 0
54250   2 0 2 0 194.37 0
54250 26 2 0 2 0 179.10 0
54250 TC 2 0 2 0 28.36 0
54250   3 0 2 0 188.39 0
54250 26 3 0 2 0 174.06 0
54250 TC 3 0 2 0 25.82 0
54250   4 0 2 0 187.32 0
54250 26 4 0 2 0 223.36 0
54250 TC 4 0 2 0 25.43 0
54300   1 90 2 0 955.61 0
54300   2 90 2 0 944.93 0
54300   3 90 2 0 1,439.26 0
54300   4 90 2 0 1,422.53 0
54304   1 90 2 0 1,875.25 0
54304   2 90 2 0 1,962.03 0
54304   3 90 2 0 1,752.59 0
54304   4 90 2 0 1,731.95 0
54308   1 90 2 0 1,570.32 0
54308   2 90 2 0 1,551.28 0
54308   3 90 2 0 1,472.68 0
54308   4 90 2 0 1,456.19 0
54312   1 90 2 0 2,023.86 0
54312   2 90 2 0 1,998.60 0
54312   3 90 2 0 1,894.01 0
54312   4 90 2 0 1,871.67 0
54316   1 90 2 0 2,455.72 0
54316   2 90 2 0 2,424.98 0
54316   3 90 2 0 2,297.66 0
54316   4 90 2 0 2,270.49 0
54318   1 90 2 0 1,666.26 0
54318   2 90 2 0 1,642.47 0
54318   3 90 2 0 1,544.37 0
54318   4 90 2 0 1,526.52 0
54322   1 90 2 0 1,783.68 0
54322   2 90 2 0 1,762.36 0
54322   3 90 2 0 1,674.00 0
54322   4 90 2 0 1,654.54 0
54324   1 90 2 0 2,376.10 0
54324   2 90 2 0 2,406.90 0
54324   3 90 2 0 2,355.24 0
54324   4 90 2 0 2,197.05 0
54326   1 90 2 0 2,275.16 0
54326   2 90 2 0 2,246.73 0
54326   3 90 2 0 2,129.01 0
54326   4 90 2 0 2,103.85 0
54328   1 90 2 0 2,318.83 0
54328   2 90 2 0 2,288.16 0
54328   3 90 2 0 2,161.63 0
54328   4 90 2 0 2,136.25 0
54332   1 90 2 0 2,573.26 0
54332   2 90 2 0 2,541.11 0
54332   3 90 2 0 2,407.47 0
54332   4 90 2 0 2,378.64 0
54336   1 90 2 0 3,374.74 0
54336   2 90 2 0 3,331.80 0
54336   3 90 2 0 3,152.87 0
54336   4 90 2 0 3,113.55 0
54340   1 90 2 0 1,314.35 0
54340   2 90 2 0 1,297.91 0
54340   3 90 2 0 1,229.96 0
54340   4 90 2 0 1,215.44 0
54344   1 90 2 0 2,834.68 0
54344   2 90 2 0 2,798.80 0
54344   3 90 2 0 2,649.20 0
54344   4 90 2 0 2,615.55 0
54348   1 90 2 0 2,515.18 0
54348   2 90 2 0 2,483.72 0
54348   3 90 2 0 2,353.58 0
54348   4 90 2 0 2,325.76 0
54352   1 90 2 0 3,579.56 0
54352   2 90 2 0 3,536.15 0
54352   3 90 2 0 3,356.21 0
54352   4 90 2 0 3,316.71 0
54360   1 90 2 0 1,652.73 0
54360   2 90 2 0 1,632.58 0
54360   3 90 2 0 1,549.25 0
54360   4 90 2 0 1,531.30 0
54380   1 90 2 0 1,959.04 0
54380   2 90 2 0 1,935.47 0
54380   3 90 2 0 1,837.79 0
54380   4 90 2 0 1,815.81 0
54385   1 90 2 0 2,248.04 0
54385   2 90 2 0 2,220.98 0
54385   3 90 2 0 2,108.89 0
54385   4 90 2 0 2,083.82 0
54390   1 90 2 0 3,126.71 0
54390   2 90 2 0 3,086.70 0
54390   3 90 2 0 2,921.41 0
54390   4 90 2 0 2,887.54 0
54400   1 90 2 0 2,327.61 0
54400   2 90 2 0 2,315.28 0
54400   3 90 2 0 2,264.01 0
54400   4 90 2 0 2,254.54 0
54401   1 90 2 0 2,534.76 0
54401   2 90 2 0 2,518.51 0
54401   3 90 2 0 2,451.05 0
54401   4 90 2 0 2,438.93 0
54405   1 90 2 0 3,167.09 0
54405   2 90 2 0 3,147.23 0
54405   3 90 2 0 3,064.38 0
54405   4 90 2 0 3,049.33 0
54406   1 90 2 0 1,277.38 0
54406   2 90 2 0 1,156.01 0
54406   3 90 2 0 1,156.01 0
54406   4 90 2 0 1,156.01 0
54408   1 90 2 0 1,345.11 0
54408   2 90 2 0 1,218.52 0
54408   3 90 2 0 1,218.52 0
54408   4 90 2 0 1,218.52 0
54410   1 90 2 0 1,585.62 0
54410   2 90 2 0 1,443.83 0
54410   3 90 2 0 1,443.83 0
54410   4 90 2 0 1,443.83 0
54411   1 90 2 0 1,730.12 0
54411   2 90 2 0 1,570.52 0
54411   3 90 2 0 1,570.52 0
54411   4 90 2 0 1,570.52 0
54415   1 90 2 0 950.99 0
54415   2 90 2 0 855.77 0
54415   3 90 2 0 855.77 0
54415   4 90 2 0 855.77 0
54416   1 90 2 0 1,234.06 0
54416   2 90 2 0 1,116.68 0
54416   3 90 2 0 1,116.68 0
54416   4 90 2 0 1,116.68 0
54417   1 90 2 0 1,515.01 0
54417   2 90 2 0 1,380.69 0
54417   3 90 2 0 1,380.69 0
54417   4 90 2 0 1,380.69 0
54420   1 90 2 0 1,677.37 0
54420   2 90 2 0 1,655.42 0
54420   3 90 2 0 1,564.76 0
54420   4 90 2 0 1,546.35 0
54430   1 90 2 0 1,489.47 0
54430   2 90 2 0 1,470.68 0
54430   3 90 2 0 1,392.62 0
54430   4 90 2 0 1,376.07 0
54435   1 90 2 0 877.48 0
54435   2 90 2 0 727.77 0
54435   3 90 2 0 821.27 0
54435   4 90 2 0 811.46 0
54437   1 90 2 0 880.58 0
54437   2 90 2 0 809.02 0
54437   3 90 2 0 809.02 0
54437   4 90 2 0 809.02 0
54438   1 90 2 0 1,774.91 0
54438   2 90 2 0 1,635.97 0
54438   3 90 2 0 1,635.97 0
54438   4 90 2 0 1,635.97 0
54440   1 90 2 0 1,652.73 0
54440   2 90 2 0 1,632.58 0
54440   3 90 2 0 1,549.25 0
54440   4 90 2 0 1,531.30 0
54450   1 0 2 0 161.21 0
54450   2 0 2 0 159.27 0
54450   3 0 2 0 151.26 0
54450   4 0 2 0 149.51 0
54500   1 0 2 0 153.66 0
54500   2 0 2 0 124.40 0
54500   3 0 2 0 145.56 0
54500   4 0 2 0 143.96 0
54505   1 10 2 0 474.17 0
54505   2 10 2 0 468.40 0
54505   3 10 2 0 444.64 0
54505   4 10 2 0 439.57 0
54512   1 90 2 0 1,014.93 0
54512   2 90 2 0 920.09 0
54512   3 90 2 0 920.09 0
54512   4 90 2 0 920.09 0
54520   1 90 2 0 933.91 0
54520   2 90 2 0 920.75 0
54520   3 90 2 0 866.23 0
54520   4 90 2 0 855.45 0
54522   1 90 2 0 1,154.93 0
54522   2 90 2 0 1,045.18 0
54522   3 90 2 0 1,045.18 0
54522   4 90 2 0 1,045.18 0
54530   1 90 2 0 1,363.62 0
54530   2 90 2 0 1,361.88 0
54530   3 90 2 0 1,304.10 0
54530   4 90 2 0 1,284.81 0
54535   1 90 2 0 1,821.20 0
54535   2 90 2 0 1,796.74 0
54535   3 90 2 0 1,695.38 0
54535   4 90 2 0 1,675.37 0
54550   1 90 2 0 1,146.19 0
54550   2 90 2 0 1,131.12 0
54550   3 90 2 0 1,068.61 0
54550   4 90 2 0 1,056.08 0
54560   1 90 2 0 1,601.92 0
54560   2 90 2 0 1,581.25 0
54560   3 90 2 0 1,495.83 0
54560   4 90 2 0 1,478.31 0
54600   1 90 2 0 1,010.73 0
54600   2 90 2 0 997.88 0
54600   3 90 2 0 944.79 0
54600   4 90 2 0 933.73 0
54620   1 10 2 0 719.98 0
54620   2 10 2 0 710.98 0
54620   3 10 2 0 673.77 0
54620   4 10 2 0 665.82 0
54640   1 90 2 0 1,333.59 0
54640   2 90 2 0 1,341.03 0
54640   3 90 2 0 1,333.59 0
54640   4 90 2 0 1,327.07 0
54650   1 90 2 0 1,704.25 0
54650   2 90 2 0 1,462.67 0
54650   3 90 2 0 1,452.25 0
54650   4 90 2 0 1,444.69 0
54660   1 90 2 0 737.16 0
54660   2 90 2 0 727.96 0
54660   3 90 2 0 689.70 0
54660   4 90 2 0 681.53 0
54670   1 90 2 0 247.38 0
54670   2 90 2 0 244.96 0
54670   3 90 2 0 234.74 0
54670   4 90 2 0 232.21 0
54680   1 90 2 0 1,772.14 0
54680   2 90 2 0 1,749.99 0
54680   3 90 2 0 1,658.29 0
54680   4 90 2 0 1,638.76 0
54690   1 90 2 0 1,373.54 0
54690   2 90 2 0 1,241.74 0
54690   3 90 2 0 1,241.74 0
54690   4 90 2 0 1,241.74 0
54692   1 90 2 0 1,407.93 0
54692   2 90 2 0 1,281.30 0
54692   3 90 2 0 1,281.30 0
54692   4 90 2 0 1,281.30 0
54699     YYY 2 0 * 0
54700   1 10 2 0 316.46 0
54700   2 10 2 0 313.45 0
54700   3 10 2 0 305.59 0
54700   4 10 2 0 305.76 0
54800   1 0 2 0 388.28 0
54800   2 0 2 0 383.23 0
54800   3 0 2 0 362.26 0
54800   4 0 2 0 357.84 0
54830   1 90 2 0 776.20 0
54830   2 90 2 0 766.27 0
54830   3 90 2 0 725.08 0
54830   4 90 2 0 733.30 0
54840   1 90 2 0 922.95 0
54840   2 90 2 0 883.83 0
54840   3 90 2 0 892.00 0
54840   4 90 2 0 837.33 0
54860   1 90 2 0 1,045.67 0
54860   2 90 2 0 998.30 0
54860   3 90 2 0 1,000.88 0
54860   4 90 2 0 965.02 0
54861   1 90 2 0 1,433.08 0
54861   2 90 2 0 1,414.15 0
54861   3 90 2 0 1,335.58 0
54861   4 90 2 0 1,319.42 0
54865   1 90 2 0 500.95 0
54865   2 90 2 0 446.63 0
54865   3 90 2 0 446.63 0
54865   4 90 2 0 446.63 0
54900   1 90 2 0 1,936.76 0
54900   2 90 2 0 1,912.61 0
54900   3 90 2 0 1,812.56 0
54900   4 90 2 0 1,791.12 0
54901   1 90 2 0 2,658.43 0
54901   2 90 2 0 2,625.20 0
54901   3 90 2 0 2,487.80 0
54901   4 90 2 0 2,458.42 0
55000   1 0 2 0 159.27 142.69
55000   2 0 2 0 159.71 142.82
55000   3 0 2 0 147.76 132.60
55000   4 0 2 0 143.46 128.56
55040   1 90 2 0 932.89 0
55040   2 90 2 0 907.07 0
55040   3 90 2 0 895.08 0
55040   4 90 2 0 842.62 0
55041   1 90 2 0 1,360.94 0
55041   2 90 2 0 1,361.15 0
55041   3 90 2 0 1,295.70 0
55041   4 90 2 0 1,305.13 0
55060   1 90 2 0 879.05 0
55060   2 90 2 0 870.58 0
55060   3 90 2 0 853.55 0
55060   4 90 2 0 845.78 0
55100   1 10 2 0 178.83 0
55100   2 10 2 0 177.09 0
55100   3 10 2 0 172.01 0
55100   4 10 2 0 170.60 0
55110   1 90 2 0 699.45 0
55110   2 90 2 0 693.83 0
55110   3 90 2 0 670.51 0
55110   4 90 2 0 729.59 0
55120   1 90 2 0 582.49 0
55120   2 90 2 0 576.19 0
55120   3 90 2 0 492.61 0
55120   4 90 2 0 484.64 0
55150   1 90 2 0 1,095.05 0
55150   2 90 2 0 1,080.51 0
55150   3 90 2 0 1,020.06 0
55150   4 90 2 0 1,007.81 0
55175   1 90 2 0 859.29 0
55175   2 90 2 0 842.32 0
55175   3 90 2 0 798.22 0
55175   4 90 2 0 788.53 0
55180   1 90 2 0 1,356.05 0
55180   2 90 2 0 1,344.51 0
55180   3 90 2 0 1,432.92 0
55180   4 90 2 0 1,416.28 0
55200   1 90 2 0 542.68 0
55200   2 90 2 0 536.65 0
55200   3 90 2 0 511.67 0
55200   4 90 2 0 505.91 0
55250   1 90 2 0 617.76 0
55250   2 90 2 0 626.39 0
55250   3 90 2 0 587.57 0
55250   4 90 2 0 589.52 0
55300   1 0 2 0 560.85 0
55300   2 0 2 0 553.68 0
55300   3 0 2 0 523.85 0
55300   4 0 2 0 517.60 0
55400   1 90 2 0 1,333.24 0
55400   2 90 2 0 1,316.15 0
55400   3 90 2 0 1,245.42 0
55400   4 90 2 0 1,230.51 0
55500   1 90 2 0 850.50 0
55500   2 90 2 0 843.51 0
55500   3 90 2 0 799.19 0
55500   4 90 2 0 796.13 0
55520   1 90 2 0 813.77 0
55520   2 90 2 0 802.71 0
55520   3 90 2 0 757.23 0
55520   4 90 2 0 748.84 0