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2018 Workers' Compensation Part B Fee Schedule

59120-61520

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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
59120   1 90 2 0 1,461.45 0
59120   2 90 2 0 1,435.32 0
59120   3 90 2 0 1,327.37 0
59120   4 90 2 0 1,465.23 0
59121   1 90 2 0 1,185.04 0
59121   2 90 2 0 1,165.74 0
59121   3 90 2 0 1,086.14 0
59121   4 90 2 0 1,073.72 0
59130   1 90 2 0 1,262.32 0
59130   2 90 2 0 1,245.36 0
59130   3 90 2 0 1,175.10 0
59130   4 90 2 0 1,161.22 0
59135   1 90 2 0 2,081.41 0
59135   2 90 2 0 2,053.45 0
59135   3 90 2 0 1,937.95 0
59135   4 90 2 0 1,915.02 0
59136   1 90 2 0 1,448.75 0
59136   2 90 2 0 1,424.15 0
59136   3 90 2 0 1,322.99 0
59136   4 90 2 0 1,308.17 0
59140   1 90 2 0 862.13 0
59140   2 90 2 0 851.82 0
59140   3 90 2 0 809.05 0
59140   4 90 2 0 799.06 0
59150   1 90 2 0 1,055.34 0
59150   2 90 2 0 1,037.43 0
59150   3 90 2 0 963.83 0
59150   4 90 2 0 953.01 0
59151   1 90 2 0 1,424.51 0
59151   2 90 2 0 1,405.51 0
59151   3 90 2 0 1,326.45 0
59151   4 90 2 0 1,309.51 0
59160   1 10 2 0 484.65 0
59160   2 10 2 0 419.53 0
59160   3 10 2 0 419.53 0
59160   4 10 2 0 419.53 0
59200     0 2 0 * 0
59300   1 0 2 0 346.53 0
59300   2 0 2 0 297.41 0
59300   3 0 2 0 284.22 0
59300   4 0 2 0 364.35 0
59320   1 0 2 0 413.08 0
59320   2 0 2 0 406.20 0
59320   3 0 2 0 377.54 0
59320   4 0 2 0 373.28 0
59325   1 0 2 0 626.18 0
59325   2 0 2 0 618.31 0
59325   3 0 2 0 585.84 0
59325   4 0 2 0 578.93 0
59350   1 0 2 0 824.21 0
59350   2 0 2 0 810.22 0
59350   3 0 2 0 752.67 0
59350   4 0 2 0 744.23 0
59400   1 MMM 2 0 2,761.88 0
59400   2 MMM 2 0 2,636.29 0
59400   3 MMM 2 0 2,434.19 0
59400   4 MMM 2 0 2,347.85 0
59409   1 MMM 2 0 1,991.75 0
59409   2 MMM 2 0 2,172.95 0
59409   3 MMM 2 0 2,018.94 0
59409   4 MMM 2 0 1,495.67 0
59410   1 MMM 2 0 2,055.47 0
59410   2 MMM 2 0 2,362.62 0
59410   3 MMM 2 0 2,194.86 0
59410   4 MMM 2 0 1,553.15 0
59412     MMM 0 0 * 0
59414   1 MMM 2 0 268.05 0
59414   2 MMM 2 0 263.44 0
59414   3 MMM 2 0 244.77 0
59414   4 MMM 2 0 242.06 0
59425   1 MMM 0 0 670.64 548.93
59425   2 MMM 0 0 659.30 539.17
59425   3 MMM 0 0 612.73 499.24
59425   4 MMM 0 0 605.86 494.33
59426   1 MMM 0 0 1,149.63 940.91
59426   2 MMM 0 0 1,130.17 924.14
59426   3 MMM 0 0 1,050.21 855.70
59426   4 MMM 0 0 1,038.44 847.19
59430   1 MMM 2 0 210.62 0
59430   2 MMM 2 0 208.52 0
59430   3 MMM 2 0 200.17 0
59430   4 MMM 2 0 198.12 0
59510   1 MMM 2 0 3,939.38 0
59510   2 MMM 2 0 3,872.57 0
59510   3 MMM 2 0 3,597.82 0
59510   4 MMM 2 0 3,557.51 0
59514   1 MMM 2 0 2,270.47 0
59514   2 MMM 2 0 2,518.44 0
59514   3 MMM 2 0 2,339.67 0
59514   4 MMM 2 0 2,313.43 0
59515   1 MMM 2 0 2,333.64 0
59515   2 MMM 2 0 2,706.53 0
59515   3 MMM 2 0 2,514.79 0
59515   4 MMM 2 0 2,486.60 0
59525   1 MMM 0 0 1,159.03 0
59525   2 MMM 0 0 1,142.40 0
59525   3 MMM 0 0 1,074.18 0
59525   4 MMM 0 0 1,062.63 0
59610   1 MMM 2 0 3,851.04 0
59610   2 MMM 2 0 3,671.35 0
59610   3 MMM 2 0 3,448.47 0
59610   4 MMM 2 0 3,398.75 0
59612   1 MMM 2 0 2,489.38 0
59612   2 MMM 2 0 2,374.51 0
59612   3 MMM 2 0 2,232.25 0
59612   4 MMM 2 0 2,200.33 0
59614   1 MMM 2 0 2,690.54 0
59614   2 MMM 2 0 2,566.03 0
59614   3 MMM 2 0 2,411.71 0
59614   4 MMM 2 0 2,377.11 0
59618   1 MMM 2 0 4,324.82 0
59618   2 MMM 2 0 4,122.43 0
59618   3 MMM 2 0 3,871.31 0
59618   4 MMM 2 0 3,815.45 0
59620   1 MMM 2 0 2,862.49 0
59620   2 MMM 2 0 2,729.83 0
59620   3 MMM 2 0 2,565.41 0
59620   4 MMM 2 0 2,528.60 0
59622   1 MMM 2 0 3,066.27 0
59622   2 MMM 2 0 2,924.11 0
59622   3 MMM 2 0 2,747.74 0
59622   4 MMM 2 0 2,708.27 0
59812   1 90 2 0 667.21 0
59812   2 90 2 0 654.49 0
59812   3 90 2 0 602.22 0
59812   4 90 2 0 595.09 0
59820   1 90 2 0 791.85 0
59820   2 90 2 0 760.79 0
59820   3 90 2 0 733.82 0
59820   4 90 2 0 657.34 0
59821   1 90 2 0 772.22 0
59821   2 90 2 0 660.52 0
59821   3 90 2 0 615.67 0
59821   4 90 2 0 608.78 0
59830   1 90 2 0 955.61 0
59830   2 90 2 0 942.83 0
59830   3 90 2 0 889.90 0
59830   4 90 2 0 879.36 0
59840   1 10 2 0 608.41 0
59840   2 10 2 0 708.17 0
59840   3 10 2 0 549.87 0
59840   4 10 2 0 543.35 0
59841   1 10 2 0 841.13 0
59841   2 10 2 0 677.36 0
59841   3 10 2 0 813.47 0
59841   4 10 2 0 617.09 0
59850   1 90 2 0 889.76 0
59850   2 90 2 0 895.04 0
59850   3 90 2 0 833.23 0
59850   4 90 2 0 823.79 0
59851   1 90 2 0 951.52 0
59851   2 90 2 0 935.91 0
59851   3 90 2 0 871.26 0
59851   4 90 2 0 861.32 0
59852   1 90 2 0 1,281.77 0
59852   2 90 2 0 1,260.10 0
59852   3 90 2 0 1,170.97 0
59852   4 90 2 0 1,157.84 0
59855   1 90 2 0 843.68 0
59855   2 90 2 0 816.97 0
59855   3 90 2 0 762.69 0
59855   4 90 2 0 752.63 0
59856   1 90 2 0 1,273.53 0
59856   2 90 2 0 1,232.96 0
59856   3 90 2 0 1,150.73 0
59856   4 90 2 0 1,135.60 0
59857   1 90 2 0 1,548.57 0
59857   2 90 2 0 1,499.41 0
59857   3 90 2 0 1,399.59 0
59857   4 90 2 0 1,381.20 0
59866   1 90 2 0 667.65 0
59866   2 90 2 0 598.24 0
59866   3 90 2 0 582.18 0
59866   4 90 2 0 582.18 0
59870   1 90 2 0 678.64 0
59870   2 90 2 0 667.15 0
59870   3 90 2 0 619.93 0
59870   4 90 2 0 612.94 0
59871   1 10 2 0 337.86 0
59871   2 10 2 0 293.01 0
59871   3 10 2 0 293.01 0
59871   4 10 2 0 293.01 0
59897     YYY 2 0 * 0
59898     YYY 2 0 * 0
59899     YYY 2 0 * 0
60000   1 10 2 0 209.28 0
60000   2 10 2 0 200.28 0
60000   3 10 2 0 182.83 0
60000   4 10 2 0 180.91 0
60100   1 0 2 0 197.49 150.70
60100   2 0 2 0 192.04 146.46
60100   3 0 2 0 183.72 139.66
60100   4 0 2 0 180.34 136.91
60200   1 90 2 0 1,391.22 0
60200   2 90 2 0 1,370.55 0
60200   3 90 2 0 1,285.38 0
60200   4 90 2 0 1,270.71 0
60210   1 90 2 0 1,995.01 0
60210   2 90 2 0 1,905.58 0
60210   3 90 2 0 1,780.18 0
60210   4 90 2 0 1,756.23 0
60212   1 90 2 0 2,086.74 0
60212   2 90 2 0 1,975.52 0
60212   3 90 2 0 1,843.27 0
60212   4 90 2 0 1,822.19 0
60220   1 90 2 0 1,765.09 0
60220   2 90 2 0 1,735.78 0
60220   3 90 2 0 1,615.09 0
60220   4 90 2 0 1,596.29 0
60225   1 90 2 0 2,157.99 0
60225   2 90 2 0 2,086.68 0
60225   3 90 2 0 1,941.70 0
60225   4 90 2 0 1,918.94 0
60240   1 90 2 0 2,473.34 0
60240   2 90 2 0 2,402.50 0
60240   3 90 2 0 2,280.74 0
60240   4 90 2 0 2,304.17 0
60252   1 90 2 0 2,787.81 0
60252   2 90 2 0 2,741.49 0
60252   3 90 2 0 2,670.18 0
60252   4 90 2 0 2,654.71 0
60254   1 90 2 0 3,774.15 0
60254   2 90 2 0 3,601.01 0
60254   3 90 2 0 3,534.40 0
60254   4 90 2 0 3,594.48 0
60260   1 90 2 0 1,645.27 0
60260   2 90 2 0 1,493.66 0
60260   3 90 2 0 1,615.79 0
60260   4 90 2 0 1,357.45 0
60270   1 90 2 0 2,902.08 0
60270   2 90 2 0 2,854.89 0
60270   3 90 2 0 2,660.43 0
60270   4 90 2 0 2,629.39 0
60271   1 90 2 0 2,517.63 0
60271   2 90 2 0 2,492.97 0
60271   3 90 2 0 2,281.06 0
60271   4 90 2 0 2,265.65 0
60280   1 90 2 0 1,366.63 0
60280   2 90 2 0 1,352.05 0
60280   3 90 2 0 1,319.38 0
60280   4 90 2 0 1,261.05 0
60281   1 90 2 0 1,226.60 0
60281   2 90 2 0 1,208.21 0
60281   3 90 2 0 1,132.68 0
60281   4 90 2 0 1,119.90 0
60300   1 0 2 0 153.46 72.16
60300   2 0 2 0 133.45 66.01
60300   3 0 2 0 133.45 66.01
60300   4 0 2 0 133.45 66.01
60500   1 90 2 0 2,719.29 0
60500   2 90 2 0 2,697.86 0
60500   3 90 2 0 2,633.61 0
60500   4 90 2 0 2,565.20 0
60502   1 90 2 0 2,894.38 0
60502   2 90 2 0 2,850.53 0
60502   3 90 2 0 2,768.40 0
60502   4 90 2 0 2,640.73 0
60505   1 90 2 0 2,157.67 0
60505   2 90 2 0 2,136.44 0
60505   3 90 2 0 2,005.67 0
60505   4 90 2 0 2,012.88 0
60512   1 ZZZ 0 0 687.91 0
60512   2 ZZZ 0 0 668.13 0
60512   3 ZZZ 0 0 628.35 0
60512   4 ZZZ 0 0 620.37 0
60520   1 90 2 0 2,911.89 0
60520   2 90 2 0 2,865.60 0
60520   3 90 2 0 2,674.81 0
60520   4 90 2 0 2,643.90 0
60521   1 90 2 0 2,911.89 0
60521   2 90 2 0 2,865.60 0
60521   3 90 2 0 2,674.81 0
60521   4 90 2 0 2,643.90 0
60522   1 90 2 0 2,911.89 0
60522   2 90 2 0 2,865.60 0
60522   3 90 2 0 2,674.81 0
60522   4 90 2 0 2,643.90 0
60540   1 90 2 0 2,617.61 0
60540   2 90 2 0 2,577.28 0
60540   3 90 2 0 2,410.83 0
60540   4 90 2 0 2,382.95 0
60545   1 90 2 0 3,294.04 0
60545   2 90 2 0 3,274.49 0
60545   3 90 2 0 3,193.64 0
60545   4 90 2 0 3,179.88 0
60600   1 90 2 0 2,577.75 0
60600   2 90 2 0 2,542.58 0
60600   3 90 2 0 2,382.68 0
60600   4 90 2 0 2,355.24 0
60605   1 90 2 0 3,021.56 0
60605   2 90 2 0 2,976.24 0
60605   3 90 2 0 2,828.13 0
60605   4 90 2 0 2,491.99 0
60650     YYY 2 0 * 0
60659     YYY 2 0 * 0
60699     YYY 2 0 * 0
61000   1 0 2 0 246.03 0
61000   2 0 2 0 242.50 0
61000   3 0 2 0 227.97 0
61000   4 0 2 0 225.31 0
61001   1 0 2 0 222.59 0
61001   2 0 2 0 219.31 0
61001   3 0 2 0 205.84 0
61001   4 0 2 0 203.57 0
61020   1 0 2 0 425.92 0
61020   2 0 2 0 424.26 0
61020   3 0 2 0 417.37 0
61020   4 0 2 0 236.72 0
61026   1 0 2 0 411.68 0
61026   2 0 2 0 394.16 0
61026   3 0 2 0 296.31 0
61026   4 0 2 0 410.30 0
61050   1 0 2 0 335.81 0
61050   2 0 2 0 333.23 0
61050   3 0 2 0 358.48 0
61050   4 0 2 0 215.56 0
61055   1 0 0 0 337.58 0
61055   2 0 0 0 400.18 0
61055   3 0 0 0 384.79 0
61055   4 0 0 0 392.83 0
61070   1 0 2 0 161.77 0
61070   2 0 2 0 161.27 0
61070   3 0 2 0 159.21 0
61070   4 0 2 0 105.93 0
61105   1 90 2 0 1,610.01 0
61105   2 90 2 0 1,600.27 0
61105   3 90 2 0 1,317.52 0
61105   4 90 2 0 1,302.17 0
61107   1 0 0 0 1,459.16 0
61107   2 0 0 0 1,412.89 0
61107   3 0 0 0 1,378.96 0
61107   4 0 0 0 949.45 0
61108   1 90 2 0 2,763.31 0
61108   2 90 2 0 3,140.53 0
61108   3 90 2 0 3,031.30 0
61108   4 90 2 0 3,062.47 0
61120   1 90 2 0 1,474.43 0
61120   2 90 2 0 1,409.46 0
61120   3 90 2 0 1,322.15 0
61120   4 90 2 0 1,307.26 0
61140   1 90 2 0 2,325.58 0
61140   2 90 2 0 2,359.52 0
61140   3 90 2 0 2,258.84 0
61140   4 90 2 0 2,241.64 0
61150   1 90 2 0 2,964.59 0
61150   2 90 2 0 2,915.91 0
61150   3 90 2 0 2,760.75 0
61150   4 90 2 0 2,683.23 0
61151   1 90 2 0 989.36 0
61151   2 90 2 0 966.27 0
61151   3 90 2 0 948.30 0
61151   4 90 2 0 1,122.56 0
61154   1 90 2 0 3,121.17 0
61154   2 90 2 0 3,449.73 0
61154   3 90 2 0 3,370.02 0
61154   4 90 2 0 3,385.75 0
61156   1 90 2 0 3,052.68 0
61156   2 90 2 0 2,999.03 0
61156   3 90 2 0 2,777.51 0
61156   4 90 2 0 2,744.45 0
61210   1 0 0 0 1,931.55 0
61210   2 0 0 0 2,258.83 0
61210   3 0 0 0 2,223.85 0
61210   4 0 0 0 1,087.86 0
61215     90 2 0 * 0
61250   1 90 2 0 1,799.32 0
61250   2 90 2 0 2,011.03 0
61250   3 90 2 0 1,963.08 0
61250   4 90 2 0 1,638.30 0
61253   1 90 2 0 2,132.59 0
61253   2 90 2 0 2,099.81 0
61253   3 90 2 0 1,964.77 0
61253   4 90 2 0 1,942.20 0
61304   1 90 2 0 4,566.19 0
61304   2 90 2 0 4,482.96 0
61304   3 90 2 0 4,274.25 0
61304   4 90 2 0 4,284.06 0
61305   1 90 2 0 5,212.81 0
61305   2 90 2 0 5,169.58 0
61305   3 90 2 0 4,744.61 0
61305   4 90 2 0 4,687.15 0
61312   1 90 2 0 4,357.02 0
61312   2 90 2 0 4,278.87 0
61312   3 90 2 0 3,935.99 0
61312   4 90 2 0 3,908.43 0
61313   1 90 2 0 4,339.25 0
61313   2 90 2 0 4,261.98 0
61313   3 90 2 0 3,942.50 0
61313   4 90 2 0 3,894.99 0
61314   1 90 2 0 4,700.64 0
61314   2 90 2 0 4,617.70 0
61314   3 90 2 0 4,071.60 0
61314   4 90 2 0 4,223.92 0
61315   1 90 2 0 4,836.08 0
61315   2 90 2 0 4,754.88 0
61315   3 90 2 0 4,352.85 0
61315   4 90 2 0 4,367.56 0
61316   1 90 2 0 167.44 0
61316   2 90 2 0 141.23 0
61316   3 90 2 0 141.23 0
61316   4 90 2 0 141.23 0
61320   1 90 2 0 4,083.25 0
61320   2 90 2 0 3,968.80 0
61320   3 90 2 0 3,717.74 0
61320   4 90 2 0 3,674.90 0
61321   1 90 2 0 4,391.86 0
61321   2 90 2 0 4,323.94 0
61321   3 90 2 0 4,043.77 0
61321   4 90 2 0 3,997.30 0
61322   1 90 2 0 3,307.06 0
61322   2 90 2 0 2,899.63 0
61322   3 90 2 0 2,899.63 0
61322   4 90 2 0 2,899.63 0
61323   1 90 2 0 3,417.72 0
61323   2 90 2 0 3,004.97 0
61323   3 90 2 0 3,004.97 0
61323   4 90 2 0 3,004.97 0
61330   1 90 2 0 2,578.14 0
61330   2 90 2 0 2,544.88 0
61330   3 90 2 0 2,406.90 0
61330   4 90 2 0 2,377.84 0
61332   1 90 2 0 4,316.62 0
61332   2 90 2 0 4,255.31 0
61332   3 90 2 0 4,001.74 0
61332   4 90 2 0 4,079.26 0
61333   1 90 2 0 4,417.11 0
61333   2 90 2 0 4,350.99 0
61333   3 90 2 0 4,078.18 0
61333   4 90 2 0 4,030.78 0
61340   1 90 2 0 2,592.22 0
61340   2 90 2 0 2,503.57 0
61340   3 90 2 0 2,324.86 0
61340   4 90 2 0 2,296.40 0
61343   1 90 2 0 5,245.46 0
61343   2 90 2 0 5,487.78 0
61343   3 90 2 0 5,091.51 0
61343   4 90 2 0 5,030.48 0
61345   1 90 2 0 4,214.64 0
61345   2 90 2 0 4,148.91 0
61345   3 90 2 0 3,877.80 0
61345   4 90 2 0 3,833.20 0
61450   1 90 2 0 4,228.03 0
61450   2 90 2 0 4,161.62 0
61450   3 90 2 0 3,887.52 0
61450   4 90 2 0 3,841.99 0
61458   1 90 2 0 5,564.46 0
61458   2 90 2 0 5,456.19 0
61458   3 90 2 0 5,283.13 0
61458   4 90 2 0 4,627.21 0
61460   1 90 2 0 5,464.89 0
61460   2 90 2 0 5,360.86 0
61460   3 90 2 0 4,498.62 0
61460   4 90 2 0 4,445.07 0
61480   1 90 2 0 2,924.70 0
61480   2 90 2 0 2,883.36 0
61480   3 90 2 0 2,711.91 0
61480   4 90 2 0 2,679.19 0
61500   1 90 2 0 3,593.78 0
61500   2 90 2 0 3,530.05 0
61500   3 90 2 0 3,373.61 0
61500   4 90 2 0 3,227.29 0
61501   1 90 2 0 3,075.64 0
61501   2 90 2 0 3,018.49 0
61501   3 90 2 0 2,782.57 0
61501   4 90 2 0 2,748.71 0
61510   1 90 2 0 4,900.32 0
61510   2 90 2 0 4,813.54 0
61510   3 90 2 0 4,603.72 0
61510   4 90 2 0 4,581.22 0
61512   1 90 2 0 5,191.23 0
61512   2 90 2 0 5,098.24 0
61512   3 90 2 0 4,714.05 0
61512   4 90 2 0 4,657.12 0
61514   1 90 2 0 4,987.54 0
61514   2 90 2 0 4,675.65 0
61514   3 90 2 0 4,329.96 0
61514   4 90 2 0 4,278.23 0
61516   1 90 2 0 4,763.51 0
61516   2 90 2 0 4,680.65 0
61516   3 90 2 0 4,338.21 0
61516   4 90 2 0 4,285.67 0
61517   1 90 2 0 134.87 0
61517   2 90 2 0 122.89 0
61517   3 90 2 0 122.89 0
61517   4 90 2 0 122.89 0
61518   1 90 2 0 5,808.40 0
61518   2 90 2 0 5,876.81 0
61518   3 90 2 0 5,465.14 0
61518   4 90 2 0 5,400.88 0
61519   1 90 2 0 5,994.23 0
61519   2 90 2 0 6,146.66 0
61519   3 90 2 0 5,714.59 0
61519   4 90 2 0 5,647.51 0
61520   1 90 2 0 7,200.03 0
61520   2 90 2 0 7,153.41 0
61520   3 90 2 0 6,302.88 0
61520   4 90 2 0 6,228.84 0