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2018 Workers' Compensation Part B Fee Schedule

67882-69643

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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
67882   1 90 2 0 1,167.78 0
67882   2 90 2 0 1,162.55 0
67882   3 90 2 0 1,127.56 0
67882   4 90 2 0 1,135.71 0
67900   1 90 2 0 729.28 0
67900   2 90 2 0 721.08 0
67900   3 90 2 0 686.81 0
67900   4 90 2 0 678.40 0
67901   1 90 2 0 1,565.50 0
67901   2 90 2 0 1,625.70 0
67901   3 90 2 0 1,591.46 0
67901   4 90 2 0 1,318.66 0
67902   1 90 2 0 1,730.40 0
67902   2 90 2 0 1,479.29 0
67902   3 90 2 0 1,616.47 0
67902   4 90 2 0 1,374.46 0
67903   1 90 2 0 1,702.12 0
67903   2 90 2 0 1,509.79 0
67903   3 90 2 0 1,419.35 0
67903   4 90 2 0 1,400.29 0
67904   1 90 2 0 1,590.90 0
67904   2 90 2 0 1,627.25 0
67904   3 90 2 0 1,612.82 0
67904   4 90 2 0 1,556.01 0
67906   1 90 2 0 1,069.41 0
67906   2 90 2 0 1,056.82 0
67906   3 90 2 0 1,004.54 0
67906   4 90 2 0 992.29 0
67908   1 90 2 0 1,594.97 0
67908   2 90 2 0 1,587.18 0
67908   3 90 2 0 1,553.23 0
67908   4 90 2 0 1,547.81 0
67909   1 90 2 0 993.11 0
67909   2 90 2 0 984.46 0
67909   3 90 2 0 948.27 0
67909   4 90 2 0 940.40 0
67911   1 90 2 0 1,340.82 0
67911   2 90 2 0 1,320.48 0
67911   3 90 2 0 1,235.70 0
67911   4 90 2 0 1,219.18 0
67912   1 90 2 0 1,783.55 749.04
67912   2 90 2 0 1,556.36 676.31
67912   3 90 2 0 1,556.36 676.31
67912   4 90 2 0 1,556.36 676.31
67914   1 90 2 0 1,197.17 0
67914   2 90 2 0 1,245.49 0
67914   3 90 2 0 1,112.67 0
67914   4 90 2 0 1,108.64 0
67915   1 90 2 0 374.55 0
67915   2 90 2 0 372.42 0
67915   3 90 2 0 358.08 0
67915   4 90 2 0 343.74 0
67916   1 90 2 0 1,116.22 0
67916   2 90 2 0 1,019.52 0
67916   3 90 2 0 964.66 0
67916   4 90 2 0 952.13 0
67917   1 90 2 0 1,334.95 0
67917   2 90 2 0 1,347.96 0
67917   3 90 2 0 1,227.58 0
67917   4 90 2 0 1,236.33 0
67921   1 90 2 0 981.29 0
67921   2 90 2 0 1,135.12 0
67921   3 90 2 0 1,007.63 0
67921   4 90 2 0 1,015.82 0
67922   1 90 2 0 334.93 0
67922   2 90 2 0 353.84 0
67922   3 90 2 0 312.56 0
67922   4 90 2 0 340.33 0
67923   1 90 2 0 1,160.46 0
67923   2 90 2 0 1,099.11 0
67923   3 90 2 0 1,041.32 0
67923   4 90 2 0 863.68 0
67924   1 90 2 0 1,155.34 0
67924   2 90 2 0 1,140.53 0
67924   3 90 2 0 1,078.74 0
67924   4 90 2 0 1,064.68 0
67930   1 10 2 0 448.60 0
67930   2 10 2 0 414.66 0
67930   3 10 2 0 398.61 0
67930   4 10 2 0 394.26 0
67935   1 90 2 0 864.95 0
67935   2 90 2 0 1,032.29 0
67935   3 90 2 0 986.92 0
67935   4 90 2 0 807.09 0
67938   1 10 2 0 156.16 0
67938   2 10 2 0 154.66 0
67938   3 10 2 0 148.54 0
67938   4 10 2 0 153.88 0
67950   1 90 2 0 1,584.26 0
67950   2 90 2 0 1,576.40 0
67950   3 90 2 0 1,496.49 0
67950   4 90 2 0 1,549.77 0
67961   1 90 2 0 1,553.81 0
67961   2 90 2 0 1,534.39 0
67961   3 90 2 0 1,478.65 0
67961   4 90 2 0 1,507.64 0
67966   1 90 2 0 1,666.89 0
67966   2 90 2 0 1,660.75 0
67966   3 90 2 0 1,643.01 0
67966   4 90 2 0 1,633.34 0
67971   1 90 2 0 1,957.89 0
67971   2 90 2 0 1,836.95 0
67971   3 90 2 0 1,786.78 0
67971   4 90 2 0 1,658.82 0
67973   1 90 2 0 2,472.74 0
67973   2 90 2 0 2,441.80 0
67973   3 90 2 0 2,408.75 0
67973   4 90 2 0 2,148.45 0
67974   1 90 2 0 2,365.96 0
67974   2 90 2 0 2,336.27 0
67974   3 90 2 0 2,212.43 0
67974   4 90 2 0 2,184.15 0
67975   1 90 2 0 854.82 0
67975   2 90 2 0 845.78 0
67975   3 90 2 0 786.69 0
67975   4 90 2 0 1,065.58 0
67999     YYY 2 0 * 0
68020   1 10 2 0 141.67 121.92
68020   2 10 2 0 140.87 121.52
68020   3 10 2 0 136.37 117.76
68020   4 10 2 0 136.39 117.89
68040     0 2 0 * 0
68100   1 0 2 0 263.50 0
68100   2 0 2 0 257.52 0
68100   3 0 2 0 247.55 0
68100   4 0 2 0 250.76 0
68110   1 10 2 0 322.66 257.07
68110   2 10 2 0 305.30 243.84
68110   3 10 2 0 292.68 234.21
68110   4 10 2 0 291.49 233.73
68115   1 10 2 0 377.98 0
68115   2 10 2 0 368.75 0
68115   3 10 2 0 350.96 0
68115   4 10 2 0 346.72 0
68130   1 90 2 0 630.61 0
68130   2 90 2 0 625.54 0
68130   3 90 2 0 604.35 0
68130   4 90 2 0 599.19 0
68135   1 10 2 0 220.88 0
68135   2 10 2 0 192.98 0
68135   3 10 2 0 188.06 0
68135   4 10 2 0 186.70 0
68200   1 0 2 0 142.63 107.27
68200   2 0 2 0 142.42 107.05
68200   3 0 2 0 140.83 106.01
68200   4 0 2 0 155.25 117.19
68320   1 90 2 0 1,340.97 0
68320   2 90 2 0 1,334.97 0
68320   3 90 2 0 1,265.17 0
68320   4 90 2 0 986.93 0
68325   1 90 2 0 1,589.90 0
68325   2 90 2 0 1,581.69 0
68325   3 90 2 0 1,359.01 0
68325   4 90 2 0 1,341.30 0
68326   1 90 2 0 1,365.11 0
68326   2 90 2 0 1,972.52 0
68326   3 90 2 0 1,512.69 0
68326   4 90 2 0 1,935.13 0
68328   1 90 2 0 1,681.84 0
68328   2 90 2 0 1,658.50 0
68328   3 90 2 0 1,561.19 0
68328   4 90 2 0 1,540.87 0
68330   1 90 2 0 1,501.90 0
68330   2 90 2 0 1,465.66 0
68330   3 90 2 0 869.76 0
68330   4 90 2 0 858.45 0
68335   1 90 2 0 1,535.06 0
68335   2 90 2 0 2,074.00 0
68335   3 90 2 0 1,426.48 0
68335   4 90 2 0 1,407.63 0
68340   1 90 2 0 618.31 0
68340   2 90 2 0 611.41 0
68340   3 90 2 0 582.55 0
68340   4 90 2 0 575.48 0
68360   1 90 2 0 894.01 0
68360   2 90 2 0 889.35 0
68360   3 90 2 0 869.78 0
68360   4 90 2 0 786.23 0
68362   1 90 2 0 1,289.89 0
68362   2 90 2 0 1,280.62 0
68362   3 90 2 0 1,242.13 0
68362   4 90 2 0 1,230.86 0
68371   1 10 2 0 648.36 0
68371   2 10 2 0 586.07 0
68371   3 10 2 0 586.07 0
68371   4 10 2 0 586.07 0
68399     YYY 2 0 * 0
68400   1 10 2 0 231.08 0
68400   2 10 2 0 232.51 0
68400   3 10 2 0 218.42 0
68400   4 10 2 0 227.16 0
68420   1 10 2 0 283.83 0
68420   2 10 2 0 281.04 0
68420   3 10 2 0 269.50 0
68420   4 10 2 0 266.48 0
68440   1 10 2 0 127.51 99.38
68440   2 10 2 0 126.34 98.37
68440   3 10 2 0 121.22 94.48
68440   4 10 2 0 121.53 95.07
68500   1 90 2 0 1,626.85 0
68500   2 90 2 0 1,606.31 0
68500   3 90 2 0 1,521.41 0
68500   4 90 2 0 1,503.33 0
68505   1 90 2 0 1,678.87 0
68505   2 90 2 0 1,659.65 0
68505   3 90 2 0 1,579.44 0
68505   4 90 2 0 1,560.05 0
68510   1 0 2 0 737.82 0
68510   2 0 2 0 537.07 0
68510   3 0 2 0 691.98 0
68510   4 0 2 0 511.09 0
68520   1 90 2 0 1,437.98 0
68520   2 90 2 0 1,508.85 0
68520   3 90 2 0 1,478.04 0
68520   4 90 2 0 1,494.51 0
68525   1 0 2 0 715.52 0
68525   2 0 2 0 702.41 0
68525   3 0 2 0 672.54 0
68525   4 0 2 0 664.34 0
68530   1 10 2 0 568.15 0
68530   2 10 2 0 561.68 0
68530   3 10 2 0 534.76 0
68530   4 10 2 0 528.27 0
68540   1 90 2 0 1,622.44 0
68540   2 90 2 0 1,603.68 0
68540   3 90 2 0 1,747.73 0
68540   4 90 2 0 1,506.86 0
68550   1 90 2 0 2,126.79 0
68550   2 90 2 0 2,101.20 0
68550   3 90 2 0 1,994.72 0
68550   4 90 2 0 1,970.08 0
68700   1 90 2 0 1,337.70 0
68700   2 90 2 0 1,333.75 0
68700   3 90 2 0 1,122.40 0
68700   4 90 2 0 725.14 0
68705   1 10 2 0 272.01 0
68705   2 10 2 0 272.68 0
68705   3 10 2 0 275.30 0
68705   4 10 2 0 274.09 0
68720   1 90 2 0 2,141.32 0
68720   2 90 2 0 1,975.72 0
68720   3 90 2 0 1,822.16 0
68720   4 90 2 0 1,708.75 0
68745   1 90 2 0 1,309.81 0
68745   2 90 2 0 1,521.29 0
68745   3 90 2 0 1,229.98 0
68745   4 90 2 0 1,215.02 0
68750   1 90 2 0 1,913.21 0
68750   2 90 2 0 1,887.10 0
68750   3 90 2 0 1,214.87 0
68750   4 90 2 0 2,108.62 0
68760   1 10 2 0 225.18 186.30
68760   2 10 2 0 222.98 184.52
68760   3 10 2 0 213.83 177.54
68760   4 10 2 0 211.35 175.68
68761   1 10 2 0 193.39 154.49
68761   2 10 2 0 191.38 152.93
68761   3 10 2 0 182.94 146.66
68761   4 10 2 0 180.72 145.08
68770   1 90 2 0 840.75 0
68770   2 90 2 0 834.98 0
68770   3 90 2 0 896.43 0
68770   4 90 2 0 885.80 0
68801   1 10 2 0 113.88 94.09
68801   2 10 2 0 107.14 89.95
68801   3 10 2 0 104.30 87.59
68801   4 10 2 0 104.30 87.59
68810   1 10 2 0 157.97 132.16
68810   2 10 2 0 148.98 126.48
68810   3 10 2 0 144.99 123.09
68810   4 10 2 0 144.99 123.09
68811   1 10 2 0 332.57 0
68811   2 10 2 0 308.51 0
68811   3 10 2 0 300.26 0
68811   4 10 2 0 300.26 0
68815   1 10 2 0 435.83 345.12
68815   2 10 2 0 405.43 326.55
68815   3 10 2 0 394.50 317.71
68815   4 10 2 0 394.50 317.71
68816   1 10 2 0 927.38 310.76
68816   2 10 2 0 789.24 277.81
68816   3 10 2 0 789.24 277.81
68816   4 10 2 0 789.24 277.81
68840   1 10 2 0 129.59 111.72
68840   2 10 2 0 129.04 110.73
68840   3 10 2 0 122.80 105.98
68840   4 10 2 0 120.01 103.66
68850   1 0 2 0 116.41 0
68850   2 0 2 0 115.07 0
68850   3 0 2 0 109.59 0
68850   4 0 2 0 113.53 0
68899     YYY 2 0 * 0
69000   1 10 2 0 134.65 121.82
69000   2 10 2 0 136.04 122.89
69000   3 10 2 0 131.49 119.36
69000   4 10 2 0 133.52 120.84
69005   1 10 2 0 296.63 0
69005   2 10 2 0 289.21 0
69005   3 10 2 0 279.86 0
69005   4 10 2 0 285.52 0
69020   1 10 2 0 161.74 143.21
69020   2 10 2 0 138.73 122.66
69020   3 10 2 0 146.14 129.44
69020   4 10 2 0 147.29 131.06
69100   1 0 2 0 177.90 139.32
69100   2 0 2 0 173.15 135.42
69100   3 0 2 0 168.23 131.69
69100   4 0 2 0 170.35 133.56
69105   1 0 2 0 160.48 0
69105   2 0 2 0 205.54 0
69105   3 0 2 0 151.19 0
69105   4 0 2 0 155.06 0
69110   1 90 2 0 667.86 0
69110   2 90 2 0 703.57 0
69110   3 90 2 0 632.54 0
69110   4 90 2 0 643.05 0
69120   1 90 2 0 266.43 0
69120   2 90 2 0 342.19 0
69120   3 90 2 0 531.39 0
69120   4 90 2 0 254.02 0
69140   1 90 2 0 1,441.03 0
69140   2 90 2 0 1,420.25 0
69140   3 90 2 0 1,334.14 0
69140   4 90 2 0 1,317.69 0
69145   1 90 2 0 638.09 0
69145   2 90 2 0 635.27 0
69145   3 90 2 0 623.82 0
69145   4 90 2 0 621.66 0
69150   1 90 2 0 2,146.89 0
69150   2 90 2 0 2,117.37 0
69150   3 90 2 0 1,995.24 0
69150   4 90 2 0 1,971.51 0
69155   1 90 2 0 3,726.09 0
69155   2 90 2 0 2,955.81 0
69155   3 90 2 0 2,786.23 0
69155   4 90 2 0 2,752.21 0
69200   1 0 2 0 98.76 82.30
69200   2 0 2 0 97.19 81.01
69200   3 0 2 0 92.96 77.66
69200   4 0 2 0 91.91 76.84
69205   1 10 2 0 180.06 0
69205   2 10 2 0 223.23 0
69205   3 10 2 0 187.36 0
69205   4 10 2 0 214.37 0
69209   1 0 2 0 16.66 0
69209   2 0 2 0 14.20 0
69209   3 0 2 0 14.20 0
69209   4 0 2 0 14.20 0
69210   1 0 2 0 65.87 57.39
69210   2 0 2 0 67.55 58.68
69210   3 0 2 0 60.33 52.55
69210   4 0 2 0 64.42 56.37
69220   1 0 2 0 100.20 82.28
69220   2 0 2 0 101.73 83.29
69220   3 0 2 0 88.34 72.71
69220   4 0 2 0 97.89 80.81
69222   1 10 2 0 252.44 210.25
69222   2 10 2 0 211.49 176.08
69222   3 10 2 0 210.62 175.98
69222   4 10 2 0 209.76 174.91
69300   1 YYY 0 0 1,105.00 0
69300   2 YYY 0 0 1,080.83 0
69300   3 YYY 0 0 1,025.73 0
69300   4 YYY 0 0 1,011.72 0
69310   1 90 2 0 2,184.10 0
69310   2 90 2 0 1,960.27 0
69310   3 90 2 0 2,397.53 0
69310   4 90 2 0 2,119.02 0
69320   1 90 2 0 4,171.89 0
69320   2 90 2 0 2,818.62 0
69320   3 90 2 0 3,394.67 0
69320   4 90 2 0 2,621.95 0
69399     YYY 2 0 * 0
69420   1 10 2 0 179.81 150.10
69420   2 10 2 0 174.63 145.70
69420   3 10 2 0 165.84 138.52
69420   4 10 2 0 163.97 137.08
69421   1 10 2 0 254.19 0
69421   2 10 2 0 227.88 0
69421   3 10 2 0 205.15 0
69421   4 10 2 0 230.95 0
69424   1 0 2 0 169.64 0
69424   2 0 2 0 161.51 0
69424   3 0 2 0 156.67 0
69424   4 0 2 0 159.92 0
69433   1 10 2 0 294.89 230.67
69433   2 10 2 0 252.45 197.15
69433   3 10 2 0 274.37 214.05
69433   4 10 2 0 281.27 219.33
69436   1 10 2 0 370.84 0
69436   2 10 2 0 346.47 0
69436   3 10 2 0 343.07 0
69436   4 10 2 0 338.79 0
69440   1 90 2 0 1,886.19 0
69440   2 90 2 0 1,501.97 0
69440   3 90 2 0 1,434.21 0
69440   4 90 2 0 1,460.11 0
69450   1 90 2 0 1,404.47 0
69450   2 90 2 0 1,743.34 0
69450   3 90 2 0 1,734.60 0
69450   4 90 2 0 1,815.63 0
69501   1 90 2 0 1,973.17 0
69501   2 90 2 0 1,791.53 0
69501   3 90 2 0 1,779.35 0
69501   4 90 2 0 1,853.59 0
69502   1 90 2 0 2,575.01 0
69502   2 90 2 0 2,330.70 0
69502   3 90 2 0 2,501.37 0
69502   4 90 2 0 2,490.04 0
69505   1 90 2 0 2,757.04 0
69505   2 90 2 0 2,740.00 0
69505   3 90 2 0 2,447.94 0
69505   4 90 2 0 2,417.61 0
69511   1 90 2 0 2,765.89 0
69511   2 90 2 0 2,723.98 0
69511   3 90 2 0 2,549.66 0
69511   4 90 2 0 2,475.70 0
69530   1 90 2 0 3,163.07 0
69530   2 90 2 0 3,138.39 0
69530   3 90 2 0 2,940.41 0
69530   4 90 2 0 2,904.52 0
69535   1 90 2 0 4,760.53 0
69535   2 90 2 0 4,441.63 0
69535   3 90 2 0 4,317.82 0
69535   4 90 2 0 4,999.16 0
69540   1 10 2 0 267.96 0
69540   2 10 2 0 260.72 0
69540   3 10 2 0 248.18 0
69540   4 10 2 0 252.98 0
69550   1 90 2 0 2,668.30 0
69550   2 90 2 0 2,649.10 0
69550   3 90 2 0 2,569.36 0
69550   4 90 2 0 2,306.59 0
69552   1 90 2 0 3,250.43 0
69552   2 90 2 0 3,205.47 0
69552   3 90 2 0 3,019.14 0
69552   4 90 2 0 2,982.64 0
69554   1 90 2 0 4,456.46 0
69554   2 90 2 0 4,394.16 0
69554   3 90 2 0 4,136.04 0
69554   4 90 2 0 4,086.15 0
69601   1 90 2 0 2,469.39 0
69601   2 90 2 0 2,435.53 0
69601   3 90 2 0 2,283.35 0
69601   4 90 2 0 2,254.97 0
69602   1 90 2 0 2,660.56 0
69602   2 90 2 0 2,575.00 0
69602   3 90 2 0 2,512.73 0
69602   4 90 2 0 2,475.88 0
69603   1 90 2 0 2,860.57 0
69603   2 90 2 0 2,817.42 0
69603   3 90 2 0 2,637.98 0
69603   4 90 2 0 2,604.63 0
69604   1 90 2 0 3,393.61 0
69604   2 90 2 0 3,035.06 0
69604   3 90 2 0 3,132.85 0
69604   4 90 2 0 3,092.26 0
69605   1 90 2 0 3,032.02 0
69605   2 90 2 0 2,989.43 0
69605   3 90 2 0 2,812.99 0
69605   4 90 2 0 2,779.49 0
69610   1 10 2 0 388.44 356.03
69610   2 10 2 0 398.32 363.77
69610   3 10 2 0 393.27 361.51
69610   4 10 2 0 366.98 337.39
69620   1 90 2 0 1,962.10 0
69620   2 90 2 0 1,648.02 0
69620   3 90 2 0 1,773.26 0
69620   4 90 2 0 1,308.45 0
69631   1 90 2 0 2,357.38 0
69631   2 90 2 0 2,342.71 0
69631   3 90 2 0 2,263.95 0
69631   4 90 2 0 2,244.36 0
69632   1 90 2 0 2,617.96 0
69632   2 90 2 0 2,578.33 0
69632   3 90 2 0 2,413.70 0
69632   4 90 2 0 2,383.19 0
69633   1 90 2 0 2,537.33 0
69633   2 90 2 0 2,498.02 0
69633   3 90 2 0 2,334.61 0
69633   4 90 2 0 2,305.03 0
69635   1 90 2 0 3,038.49 0
69635   2 90 2 0 3,001.08 0
69635   3 90 2 0 2,840.40 0
69635   4 90 2 0 2,819.69 0
69636   1 90 2 0 3,299.61 0
69636   2 90 2 0 3,262.04 0
69636   3 90 2 0 3,101.64 0
69636   4 90 2 0 3,079.96 0
69637   1 90 2 0 3,165.19 0
69637   2 90 2 0 3,187.08 0
69637   3 90 2 0 2,912.73 0
69637   4 90 2 0 2,875.90 0
69641   1 90 2 0 2,847.08 0
69641   2 90 2 0 2,620.48 0
69641   3 90 2 0 2,448.89 0
69641   4 90 2 0 2,417.89 0
69642   1 90 2 0 3,517.97 0
69642   2 90 2 0 3,417.05 0
69642   3 90 2 0 3,315.13 0
69642   4 90 2 0 3,111.26 0
69643   1 90 2 0 3,386.58 0
69643   2 90 2 0 3,273.63 0
69643   3 90 2 0 3,033.16 0
69643   4 90 2 0 2,994.78 0