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2018 Workers' Compensation Part B Fee Schedule

64771-66150

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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
64771   1 90 2 0 1,229.38 0
64771   2 90 2 0 1,212.03 0
64771   3 90 2 0 1,140.33 0
64771   4 90 2 0 1,126.52 0
64772   1 90 2 0 1,610.17 0
64772   2 90 2 0 1,393.41 0
64772   3 90 2 0 1,456.89 0
64772   4 90 2 0 1,184.43 0
64774   1 90 2 0 801.48 0
64774   2 90 2 0 725.03 0
64774   3 90 2 0 683.92 0
64774   4 90 2 0 745.37 0
64776   1 90 2 0 727.68 0
64776   2 90 2 0 689.21 0
64776   3 90 2 0 651.16 0
64776   4 90 2 0 643.79 0
64778   1 ZZZ 0 0 548.68 0
64778   2 ZZZ 0 0 540.27 0
64778   3 ZZZ 0 0 505.17 0
64778   4 ZZZ 0 0 499.20 0
64782   1 90 2 0 948.78 0
64782   2 90 2 0 936.46 0
64782   3 90 2 0 885.24 0
64782   4 90 2 0 874.57 0
64783   1 ZZZ 0 0 652.17 0
64783   2 ZZZ 0 0 642.36 0
64783   3 ZZZ 0 0 622.88 0
64783   4 ZZZ 0 0 594.54 0
64784   1 90 2 0 1,422.31 0
64784   2 90 2 0 1,427.80 0
64784   3 90 2 0 1,300.45 0
64784   4 90 2 0 1,285.80 0
64786   1 90 2 0 2,625.28 0
64786   2 90 2 0 2,584.03 0
64786   3 90 2 0 2,274.79 0
64786   4 90 2 0 2,385.47 0
64787   1 ZZZ 0 0 735.84 0
64787   2 ZZZ 0 0 724.17 0
64787   3 ZZZ 0 0 676.52 0
64787   4 ZZZ 0 0 668.67 0
64788   1 90 2 0 736.36 0
64788   2 90 2 0 686.44 0
64788   3 90 2 0 695.96 0
64788   4 90 2 0 576.65 0
64790   1 90 2 0 1,659.29 0
64790   2 90 2 0 1,614.70 0
64790   3 90 2 0 1,559.55 0
64790   4 90 2 0 1,541.89 0
64792   1 90 2 0 2,193.98 0
64792   2 90 2 0 2,161.51 0
64792   3 90 2 0 2,027.69 0
64792   4 90 2 0 2,013.88 0
64795   1 0 2 0 628.08 0
64795   2 0 2 0 620.68 0
64795   3 0 2 0 578.76 0
64795   4 0 2 0 603.65 0
64802   1 90 2 0 1,294.33 0
64802   2 90 2 0 1,407.54 0
64802   3 90 2 0 1,190.82 0
64802   4 90 2 0 1,177.47 0
64804   1 90 2 0 2,460.65 0
64804   2 90 2 0 2,507.70 0
64804   3 90 2 0 2,328.19 0
64804   4 90 2 0 2,300.84 0
64809   1 90 2 0 2,238.46 0
64809   2 90 2 0 2,240.11 0
64809   3 90 2 0 2,223.80 0
64809   4 90 2 0 2,025.81 0
64818   1 90 2 0 1,744.78 0
64818   2 90 2 0 1,714.73 0
64818   3 90 2 0 1,590.59 0
64818   4 90 2 0 1,572.11 0
64820   1 90 2 0 1,603.80 0
64820   2 90 2 0 1,555.70 0
64820   3 90 2 0 1,456.64 0
64820   4 90 2 0 1,437.38 0
64821   1 90 2 0 1,146.43 0
64821   2 90 2 0 1,014.26 0
64821   3 90 2 0 1,014.26 0
64821   4 90 2 0 1,014.26 0
64822   1 90 2 0 1,146.43 0
64822   2 90 2 0 1,014.26 0
64822   3 90 2 0 1,014.26 0
64822   4 90 2 0 1,014.26 0
64823   1 90 2 0 1,322.88 0
64823   2 90 2 0 1,171.69 0
64823   3 90 2 0 1,171.69 0
64823   4 90 2 0 1,171.69 0
64831   1 90 2 0 1,180.05 0
64831   2 90 2 0 1,154.01 0
64831   3 90 2 0 1,121.83 0
64831   4 90 2 0 1,113.85 0
64832   1 ZZZ 0 0 807.37 0
64832   2 ZZZ 0 0 621.62 0
64832   3 ZZZ 0 0 594.69 0
64832   4 ZZZ 0 0 588.59 0
64834   1 90 2 0 1,195.87 0
64834   2 90 2 0 1,181.93 0
64834   3 90 2 0 1,149.20 0
64834   4 90 2 0 1,112.66 0
64835   1 90 2 0 1,523.80 0
64835   2 90 2 0 1,502.47 0
64835   3 90 2 0 1,414.73 0
64835   4 90 2 0 1,398.84 0
64836   1 90 2 0 1,610.05 0
64836   2 90 2 0 1,586.15 0
64836   3 90 2 0 1,487.84 0
64836   4 90 2 0 1,630.65 0
64837   1 ZZZ 0 0 1,016.27 0
64837   2 ZZZ 0 0 1,000.41 0
64837   3 ZZZ 0 0 934.87 0
64837   4 ZZZ 0 0 924.19 0
64840   1 90 2 0 1,996.93 0
64840   2 90 2 0 1,974.48 0
64840   3 90 2 0 1,880.97 0
64840   4 90 2 0 1,857.85 0
64856   1 90 2 0 1,951.02 0
64856   2 90 2 0 1,921.85 0
64856   3 90 2 0 1,839.82 0
64856   4 90 2 0 1,798.54 0
64857   1 90 2 0 2,142.63 0
64857   2 90 2 0 1,982.50 0
64857   3 90 2 0 1,981.30 0
64857   4 90 2 0 1,958.47 0
64858   1 90 2 0 2,506.78 0
64858   2 90 2 0 2,467.51 0
64858   3 90 2 0 2,305.51 0
64858   4 90 2 0 2,279.28 0
64859   1 ZZZ 0 0 732.42 0
64859   2 ZZZ 0 0 721.02 0
64859   3 ZZZ 0 0 673.95 0
64859   4 ZZZ 0 0 666.11 0
64861   1 90 2 0 2,832.50 0
64861   2 90 2 0 2,796.02 0
64861   3 90 2 0 2,645.00 0
64861   4 90 2 0 2,613.54 0
64862   1 90 2 0 3,567.30 0
64862   2 90 2 0 3,519.78 0
64862   3 90 2 0 3,321.71 0
64862   4 90 2 0 3,279.27 0
64864   1 90 2 0 1,819.09 0
64864   2 90 2 0 1,863.67 0
64864   3 90 2 0 1,689.46 0
64864   4 90 2 0 1,670.06 0
64865   1 90 2 0 2,482.27 0
64865   2 90 2 0 2,447.47 0
64865   3 90 2 0 2,303.37 0
64865   4 90 2 0 2,275.88 0
64866   1 90 2 0 2,448.81 0
64866   2 90 2 0 2,412.00 0
64866   3 90 2 0 2,260.13 0
64866   4 90 2 0 2,233.98 0
64868   1 90 2 0 3,058.50 0
64868   2 90 2 0 2,234.96 0
64868   3 90 2 0 2,100.10 0
64868   4 90 2 0 2,075.18 0
64872   1 ZZZ 0 0 350.75 0
64872   2 ZZZ 0 0 340.13 0
64872   3 ZZZ 0 0 318.34 0
64872   4 ZZZ 0 0 314.12 0
64874   1 ZZZ 0 0 525.92 0
64874   2 ZZZ 0 0 510.13 0
64874   3 ZZZ 0 0 477.56 0
64874   4 ZZZ 0 0 471.17 0
64876   1 ZZZ 0 0 522.54 0
64876   2 ZZZ 0 0 506.90 0
64876   3 ZZZ 0 0 474.65 0
64876   4 ZZZ 0 0 468.39 0
64885   1 90 2 0 2,681.36 0
64885   2 90 2 0 2,645.31 0
64885   3 90 2 0 2,496.32 0
64885   4 90 2 0 2,466.80 0
64886   1 90 2 0 3,197.08 0
64886   2 90 2 0 3,154.14 0
64886   3 90 2 0 2,976.39 0
64886   4 90 2 0 2,941.25 0
64890   1 90 2 0 2,525.65 0
64890   2 90 2 0 2,485.40 0
64890   3 90 2 0 2,319.21 0
64890   4 90 2 0 2,292.03 0
64891   1 90 2 0 2,392.87 0
64891   2 90 2 0 2,357.77 0
64891   3 90 2 0 2,213.07 0
64891   4 90 2 0 2,187.76 0
64892   1 90 2 0 2,324.18 0
64892   2 90 2 0 2,289.47 0
64892   3 90 2 0 2,146.07 0
64892   4 90 2 0 2,120.96 0
64893   1 90 2 0 2,708.50 0
64893   2 90 2 0 2,664.83 0
64893   3 90 2 0 2,484.32 0
64893   4 90 2 0 2,454.75 0
64895   1 90 2 0 2,999.49 0
64895   2 90 2 0 2,952.21 0
64895   3 90 2 0 2,757.22 0
64895   4 90 2 0 2,725.84 0
64896   1 90 2 0 3,369.34 0
64896   2 90 2 0 3,322.89 0
64896   3 90 2 0 3,130.21 0
64896   4 90 2 0 3,092.26 0
64897   1 90 2 0 2,858.74 0
64897   2 90 2 0 2,813.27 0
64897   3 90 2 0 2,625.79 0
64897   4 90 2 0 2,595.88 0
64898   1 90 2 0 3,078.52 0
64898   2 90 2 0 3,031.67 0
64898   3 90 2 0 2,838.46 0
64898   4 90 2 0 2,805.41 0
64901   1 ZZZ 0 0 1,836.30 0
64901   2 ZZZ 0 0 1,812.02 0
64901   3 ZZZ 0 0 1,711.18 0
64901   4 ZZZ 0 0 1,689.95 0
64902   1 ZZZ 0 0 2,645.56 0
64902   2 ZZZ 0 0 2,108.95 0
64902   3 ZZZ 0 0 1,992.07 0
64902   4 ZZZ 0 0 1,967.30 0
64905     90 2 0 * 0
64907     90 2 0 * 0
64910   1 90 2 0 982.91 0
64910   2 90 2 0 860.53 0
64910   3 90 2 0 860.53 0
64910   4 90 2 0 860.53 0
64911   1 90 2 0 1,187.00 0
64911   2 90 2 0 1,047.77 0
64911   3 90 2 0 1,047.77 0
64911   4 90 2 0 1,047.77 0
64912   1 90 2 0 974.67 0
64912   2 90 2 0 890.71 0
64912   3 90 2 0 890.71 0
64912   4 90 2 0 890.71 0
64913   1 ZZZ 0 0 197.72 0
64913   2 ZZZ 0 0 182.49 0
64913   3 ZZZ 0 0 182.49 0
64913   4 ZZZ 0 0 182.49 0
64999     YYY 2 0 * 0
65091   1 90 2 0 1,252.07 0
65091   2 90 2 0 1,388.04 0
65091   3 90 2 0 1,282.01 0
65091   4 90 2 0 1,340.72 0
65093   1 90 2 0 1,473.96 0
65093   2 90 2 0 1,368.49 0
65093   3 90 2 0 1,379.33 0
65093   4 90 2 0 1,393.78 0
65101   1 90 2 0 1,472.22 0
65101   2 90 2 0 1,369.53 0
65101   3 90 2 0 1,291.15 0
65101   4 90 2 0 1,216.22 0
65103   1 90 2 0 1,578.25 0
65103   2 90 2 0 1,534.41 0
65103   3 90 2 0 1,441.07 0
65103   4 90 2 0 1,494.62 0
65105   1 90 2 0 1,639.27 0
65105   2 90 2 0 1,603.67 0
65105   3 90 2 0 1,476.99 0
65105   4 90 2 0 1,551.53 0
65110   1 90 2 0 2,615.60 0
65110   2 90 2 0 2,581.02 0
65110   3 90 2 0 2,502.97 0
65110   4 90 2 0 2,405.59 0
65112   1 90 2 0 2,476.15 0
65112   2 90 2 0 2,445.08 0
65112   3 90 2 0 2,316.11 0
65112   4 90 2 0 2,288.32 0
65114   1 90 2 0 2,723.20 0
65114   2 90 2 0 2,685.30 0
65114   3 90 2 0 2,528.40 0
65114   4 90 2 0 2,498.48 0
65125   1 90 2 0 1,428.32 0
65125   2 90 2 0 1,410.26 0
65125   3 90 2 0 1,334.69 0
65125   4 90 2 0 1,317.37 0
65130   1 90 2 0 1,344.36 0
65130   2 90 2 0 1,350.65 0
65130   3 90 2 0 1,277.59 0
65130   4 90 2 0 1,260.98 0
65135   1 90 2 0 1,428.73 0
65135   2 90 2 0 1,077.29 0
65135   3 90 2 0 1,024.97 0
65135   4 90 2 0 1,012.51 0
65140   1 90 2 0 1,199.45 0
65140   2 90 2 0 1,468.99 0
65140   3 90 2 0 1,129.52 0
65140   4 90 2 0 1,115.61 0
65150   1 90 2 0 1,395.83 0
65150   2 90 2 0 1,535.11 0
65150   3 90 2 0 1,298.65 0
65150   4 90 2 0 1,281.26 0
65155   1 90 2 0 1,873.64 0
65155   2 90 2 0 1,847.43 0
65155   3 90 2 0 1,738.26 0
65155   4 90 2 0 1,715.38 0
65175   1 90 2 0 1,174.93 0
65175   2 90 2 0 1,171.86 0
65175   3 90 2 0 1,109.97 0
65175   4 90 2 0 1,095.55 0
65205   1 0 2 0 99.45 85.04
65205   2 0 2 0 105.98 91.04
65205   3 0 2 0 92.45 79.78
65205   4 0 2 0 98.19 84.86
65210   1 0 2 0 114.32 94.64
65210   2 0 2 0 113.05 93.68
65210   3 0 2 0 108.16 89.80
65210   4 0 2 0 106.87 88.83
65220   1 0 2 0 99.01 80.36
65220   2 0 2 0 101.46 81.01
65220   3 0 2 0 96.49 77.12
65220   4 0 2 0 101.54 82.62
65222   1 0 2 0 136.15 112.69
65222   2 0 2 0 129.67 105.73
65222   3 0 2 0 123.47 102.32
65222   4 0 2 0 116.75 97.06
65235   1 90 2 0 1,545.99 0
65235   2 90 2 0 1,289.48 0
65235   3 90 2 0 1,377.02 0
65235   4 90 2 0 1,038.32 0
65260   1 90 2 0 1,664.16 0
65260   2 90 2 0 1,645.40 0
65260   3 90 2 0 1,567.46 0
65260   4 90 2 0 1,548.18 0
65265   1 90 2 0 1,934.14 0
65265   2 90 2 0 1,912.45 0
65265   3 90 2 0 1,821.91 0
65265   4 90 2 0 1,799.47 0
65270   1 10 2 0 210.87 0
65270   2 10 2 0 261.25 0
65270   3 10 2 0 202.47 0
65270   4 10 2 0 246.60 0
65272   1 90 2 0 453.75 0
65272   2 90 2 0 336.28 0
65272   3 90 2 0 340.97 0
65272   4 90 2 0 425.85 0
65273   1 90 2 0 628.46 0
65273   2 90 2 0 621.10 0
65273   3 90 2 0 590.39 0
65273   4 90 2 0 583.17 0
65275   1 90 2 0 821.03 0
65275   2 90 2 0 819.52 0
65275   3 90 2 0 813.33 0
65275   4 90 2 0 811.36 0
65280   1 90 2 0 1,573.62 0
65280   2 90 2 0 1,761.19 0
65280   3 90 2 0 1,729.44 0
65280   4 90 2 0 1,322.82 0
65285   1 90 2 0 2,140.69 0
65285   2 90 2 0 2,115.37 0
65285   3 90 2 0 2,009.58 0
65285   4 90 2 0 2,065.81 0
65286   1 90 2 0 1,199.97 0
65286   2 90 2 0 1,066.61 0
65286   3 90 2 0 821.63 0
65286   4 90 2 0 1,256.19 0
65290   1 90 2 0 1,000.43 0
65290   2 90 2 0 987.74 0
65290   3 90 2 0 934.75 0
65290   4 90 2 0 922.65 0
65400   1 90 2 0 729.73 0
65400   2 90 2 0 713.24 0
65400   3 90 2 0 690.44 0
65400   4 90 2 0 684.20 0
65410   1 0 2 0 273.44 0
65410   2 0 2 0 296.37 0
65410   3 0 2 0 255.48 0
65410   4 0 2 0 287.71 0
65420   1 90 2 0 727.27 0
65420   2 90 2 0 718.53 0
65420   3 90 2 0 681.94 0
65420   4 90 2 0 673.25 0
65426   1 90 2 0 1,037.68 0
65426   2 90 2 0 1,024.43 0
65426   3 90 2 0 969.05 0
65426   4 90 2 0 932.82 0
65430   1 0 2 0 124.21 100.84
65430   2 0 2 0 123.47 100.40
65430   3 0 2 0 116.78 95.35
65430   4 0 2 0 115.42 94.33
65435   1 0 2 0 188.96 147.13
65435   2 0 2 0 174.57 136.14
65435   3 0 2 0 185.31 145.19
65435   4 0 2 0 177.78 139.16
65436   1 90 2 0 461.60 0
65436   2 90 2 0 459.71 0
65436   3 90 2 0 443.51 0
65436   4 90 2 0 449.76 0
65450   1 90 2 0 440.71 0
65450   2 90 2 0 445.71 0
65450   3 90 2 0 524.42 0
65450   4 90 2 0 517.78 0
65600   1 90 2 0 767.84 0
65600   2 90 2 0 734.10 0
65600   3 90 2 0 476.21 0
65600   4 90 2 0 470.35 0
65710   1 90 2 0 3,122.41 0
65710   2 90 2 0 3,437.60 0
65710   3 90 2 0 3,122.62 0
65710   4 90 2 0 3,030.70 0
65730   1 90 2 0 4,011.38 0
65730   2 90 2 0 3,993.83 0
65730   3 90 2 0 3,686.86 0
65730   4 90 2 0 3,381.84 0
65750   1 90 2 0 4,538.42 0
65750   2 90 2 0 4,507.27 0
65750   3 90 2 0 4,268.27 0
65750   4 90 2 0 4,210.41 0
65755   1 90 2 0 4,700.41 0
65755   2 90 2 0 4,666.55 0
65755   3 90 2 0 4,415.66 0
65755   4 90 2 0 4,355.59 0
65756   1 90 2 0 1,457.74 0
65756   2 90 2 0 1,337.56 0
65756   3 90 2 0 1,337.56 0
65756   4 90 2 0 1,337.56 0
65757     ZZZ 0 0 * 0
65770   1 90 2 0 2,660.96 0
65770   2 90 2 0 2,630.99 0
65770   3 90 2 0 2,506.40 0
65770   4 90 2 0 2,475.49 0
65772   1 90 2 0 965.79 0
65772   2 90 2 0 691.95 0
65772   3 90 2 0 942.25 0
65772   4 90 2 0 772.81 0
65775   1 90 2 0 1,261.82 0
65775   2 90 2 0 1,244.95 0
65775   3 90 2 0 1,174.27 0
65775   4 90 2 0 1,059.18 0
65778   1 10 2 0 1,836.21 110.49
65778   2 10 2 0 1,625.68 100.57
65778   3 10 2 0 1,625.68 100.57
65778   4 10 2 0 1,625.68 100.57
65779   1 10 2 0 1,661.95 426.32
65779   2 10 2 0 1,478.81 386.81
65779   3 10 2 0 1,478.81 386.81
65779   4 10 2 0 1,478.81 386.81
65780   1 90 2 0 1,367.37 0
65780   2 90 2 0 1,237.66 0
65780   3 90 2 0 1,237.66 0
65780   4 90 2 0 1,237.66 0
65781   1 90 2 0 2,073.39 0
65781   2 90 2 0 1,898.51 0
65781   3 90 2 0 1,898.51 0
65781   4 90 2 0 1,898.51 0
65782   1 90 2 0 1,789.79 0
65782   2 90 2 0 1,635.65 0
65782   3 90 2 0 1,635.65 0
65782   4 90 2 0 1,635.65 0
65785   1 90 2 0 2,748.59 498.60
65785   2 90 2 0 2,375.24 452.31
65785   3 90 2 0 2,375.24 452.31
65785   4 90 2 0 2,375.24 452.31
65800   1 0 2 0 334.06 0
65800   2 0 2 0 332.41 0
65800   3 0 2 0 300.55 0
65800   4 0 2 0 329.67 0
65810   1 90 2 0 834.51 0
65810   2 90 2 0 812.86 0
65810   3 90 2 0 829.19 0
65810   4 90 2 0 783.71 0
65815   1 90 2 0 813.13 0
65815   2 90 2 0 792.02 0
65815   3 90 2 0 763.31 0
65815   4 90 2 0 753.73 0
65820   1 90 2 0 1,460.51 0
65820   2 90 2 0 1,448.44 0
65820   3 90 2 0 1,418.36 0
65820   4 90 2 0 1,400.00 0
65850   1 90 2 0 2,108.62 0
65850   2 90 2 0 2,050.82 0
65850   3 90 2 0 1,919.43 0
65850   4 90 2 0 1,977.13 0
65855   1 90 2 0 1,529.52 0
65855   2 90 2 0 1,500.62 0
65855   3 90 2 0 1,410.47 0
65855   4 90 2 0 1,380.75 0
65860   1 90 2 0 839.76 0
65860   2 90 2 0 996.19 0
65860   3 90 2 0 779.50 0
65860   4 90 2 0 769.02 0
65865   1 90 2 0 1,101.73 0
65865   2 90 2 0 945.89 0
65865   3 90 2 0 1,028.84 0
65865   4 90 2 0 906.94 0
65870   1 90 2 0 1,130.81 0
65870   2 90 2 0 1,086.55 0
65870   3 90 2 0 973.99 0
65870   4 90 2 0 961.70 0
65875   1 90 2 0 1,460.52 0
65875   2 90 2 0 1,449.23 0
65875   3 90 2 0 1,432.26 0
65875   4 90 2 0 1,014.02 0
65880   1 90 2 0 1,192.84 0
65880   2 90 2 0 1,178.63 0
65880   3 90 2 0 1,119.41 0
65880   4 90 2 0 1,105.23 0
65900   1 90 2 0 2,175.97 0
65900   2 90 2 0 1,648.76 0
65900   3 90 2 0 2,170.98 0
65900   4 90 2 0 1,537.71 0
65920   1 90 2 0 1,745.21 0
65920   2 90 2 0 1,725.80 0
65920   3 90 2 0 1,709.67 0
65920   4 90 2 0 1,711.93 0
65930   1 90 2 0 1,245.89 0
65930   2 90 2 0 1,243.18 0
65930   3 90 2 0 1,216.53 0
65930   4 90 2 0 1,201.00 0
66020   1 10 2 0 360.06 0
66020   2 10 2 0 358.11 0
66020   3 10 2 0 345.95 0
66020   4 10 2 0 348.33 0
66030   1 10 2 0 208.94 0
66030   2 10 2 0 198.36 0
66030   3 10 2 0 143.57 0
66030   4 10 2 0 202.27 0
66130   1 90 2 0 1,385.04 0
66130   2 90 2 0 1,379.81 0
66130   3 90 2 0 1,057.87 0
66130   4 90 2 0 1,352.55 0
66150   1 90 2 0 1,722.18 0
66150   2 90 2 0 1,560.83 0
66150   3 90 2 0 1,604.04 0
66150   4 90 2 0 1,710.78 0