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2018 Workers' Compensation Part B Fee Schedule

69644-70450

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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
69644   1 90 2 0 3,668.86 0
69644   2 90 2 0 3,483.59 0
69644   3 90 2 0 3,369.07 0
69644   4 90 2 0 3,326.33 0
69645   1 90 2 0 3,489.73 0
69645   2 90 2 0 3,434.89 0
69645   3 90 2 0 3,147.35 0
69645   4 90 2 0 3,166.49 0
69646   1 90 2 0 3,637.18 0
69646   2 90 2 0 3,582.16 0
69646   3 90 2 0 3,415.64 0
69646   4 90 2 0 3,311.40 0
69650   1 90 2 0 1,980.71 0
69650   2 90 2 0 1,916.43 0
69650   3 90 2 0 1,828.61 0
69650   4 90 2 0 1,805.52 0
69660   1 90 2 0 2,684.80 0
69660   2 90 2 0 2,828.16 0
69660   3 90 2 0 2,332.72 0
69660   4 90 2 0 2,616.12 0
69661   1 90 2 0 3,106.29 0
69661   2 90 2 0 3,060.55 0
69661   3 90 2 0 2,870.73 0
69661   4 90 2 0 2,834.54 0
69662   1 90 2 0 3,048.14 0
69662   2 90 2 0 3,002.94 0
69662   3 90 2 0 2,815.20 0
69662   4 90 2 0 2,779.87 0
69666   1 90 2 0 2,468.17 0
69666   2 90 2 0 2,452.59 0
69666   3 90 2 0 2,387.67 0
69666   4 90 2 0 2,376.44 0
69667   1 90 2 0 2,205.67 0
69667   2 90 2 0 2,438.49 0
69667   3 90 2 0 2,022.34 0
69667   4 90 2 0 1,996.41 0
69670   1 90 2 0 2,051.65 0
69670   2 90 2 0 1,970.27 0
69670   3 90 2 0 1,962.80 0
69670   4 90 2 0 1,776.15 0
69676   1 90 2 0 1,613.31 0
69676   2 90 2 0 1,591.44 0
69676   3 90 2 0 1,500.51 0
69676   4 90 2 0 1,482.22 0
69700   1 90 2 0 1,448.45 0
69700   2 90 2 0 1,428.07 0
69700   3 90 2 0 1,343.54 0
69700   4 90 2 0 1,327.02 0
69711     90 2 0 * 0
69714   1 90 2 0 1,727.06 0
69714   2 90 2 0 1,557.93 0
69714   3 90 2 0 1,557.93 0
69714   4 90 2 0 1,557.93 0
69715   1 90 2 0 2,185.17 0
69715   2 90 2 0 1,974.88 0
69715   3 90 2 0 1,974.88 0
69715   4 90 2 0 1,974.88 0
69717   1 90 2 0 1,776.87 0
69717   2 90 2 0 1,606.31 0
69717   3 90 2 0 1,606.31 0
69717   4 90 2 0 1,606.31 0
69718   1 90 2 0 2,211.33 0
69718   2 90 2 0 1,998.61 0
69718   3 90 2 0 1,998.61 0
69718   4 90 2 0 1,998.61 0
69720   1 90 2 0 3,531.83 0
69720   2 90 2 0 3,438.90 0
69720   3 90 2 0 3,304.30 0
69720   4 90 2 0 2,745.24 0
69725   1 90 2 0 3,040.76 0
69725   2 90 2 0 3,001.27 0
69725   3 90 2 0 2,837.50 0
69725   4 90 2 0 2,803.71 0
69740   1 90 2 0 2,521.63 0
69740   2 90 2 0 2,485.30 0
69740   3 90 2 0 2,967.70 0
69740   4 90 2 0 2,307.81 0
69745   1 90 2 0 2,910.30 0
69745   2 90 2 0 2,870.57 0
69745   3 90 2 0 2,705.74 0
69745   4 90 2 0 2,672.39 0
69799     YYY 2 0 * 0
69801   1 90 2 0 2,156.79 0
69801   2 90 2 0 2,119.75 0
69801   3 90 2 0 2,137.40 0
69801   4 90 2 0 1,940.52 0
69805   1 90 2 0 2,536.24 0
69805   2 90 2 0 2,494.37 0
69805   3 90 2 0 2,320.32 0
69805   4 90 2 0 2,290.34 0
69806   1 90 2 0 3,363.86 0
69806   2 90 2 0 3,225.00 0
69806   3 90 2 0 2,776.40 0
69806   4 90 2 0 2,740.45 0
69905   1 90 2 0 2,566.12 0
69905   2 90 2 0 2,523.58 0
69905   3 90 2 0 2,346.89 0
69905   4 90 2 0 2,316.89 0
69910   1 90 2 0 3,141.64 0
69910   2 90 2 0 3,091.00 0
69910   3 90 2 0 2,880.48 0
69910   4 90 2 0 2,843.35 0
69915   1 90 2 0 3,510.40 0
69915   2 90 2 0 3,394.46 0
69915   3 90 2 0 3,195.38 0
69915   4 90 2 0 3,156.85 0
69930   1 90 2 0 4,330.94 0
69930   2 90 2 0 3,891.33 0
69930   3 90 2 0 3,607.34 0
69930   4 90 2 0 3,559.88 0
69949     YYY 2 0 * 0
69950   1 90 2 0 3,885.75 0
69950   2 90 2 0 3,559.65 0
69950   3 90 2 0 3,345.57 0
69950   4 90 2 0 3,305.68 0
69955   1 90 2 0 3,878.54 0
69955   2 90 2 0 3,824.50 0
69955   3 90 2 0 3,600.38 0
69955   4 90 2 0 3,556.66 0
69960   1 90 2 0 3,430.92 0
69960   2 90 2 0 4,382.76 0
69960   3 90 2 0 3,187.61 0
69960   4 90 2 0 3,149.01 0
69970   1 90 2 0 3,845.94 0
69970   2 90 2 0 3,792.28 0
69970   3 90 2 0 3,569.79 0
69970   4 90 2 0 3,526.79 0
69979     YYY 2 0 * 0
69990   1 ZZZ 0 0 439.16 0
69990   2 ZZZ 0 0 382.59 0
69990   3 ZZZ 0 0 382.59 0
69990   4 ZZZ 0 0 382.59 0
70010   1 XXX 0 0 503.57 0
70010 26 1 XXX 0 0 159.42 0
70010 TC 1 XXX 0 0 358.48 0
70010   2 XXX 0 0 495.38 0
70010 26 2 XXX 0 0 158.88 0
70010 TC 2 XXX 0 0 352.04 0
70010   3 XXX 0 0 460.81 0
70010 26 3 XXX 0 0 152.04 0
70010 TC 3 XXX 0 0 324.84 0
70010   4 XXX 0 0 454.20 0
70010 26 4 XXX 0 0 148.18 0
70010 TC 4 XXX 0 0 319.70 0
70015   1 XXX 0 0 257.65 0
70015 26 1 XXX 0 0 159.42 0
70015 TC 1 XXX 0 0 112.57 0
70015   2 XXX 0 0 253.82 0
70015 26 2 XXX 0 0 158.88 0
70015 TC 2 XXX 0 0 110.45 0
70015   3 XXX 0 0 237.65 0
70015 26 3 XXX 0 0 152.04 0
70015 TC 3 XXX 0 0 101.69 0
70015   4 XXX 0 0 234.58 0
70015 26 4 XXX 0 0 148.18 0
70015 TC 4 XXX 0 0 100.10 0
70030   1 XXX 0 0 55.68 0
70030 26 1 XXX 0 0 23.01 0
70030 TC 1 XXX 0 0 34.93 0
70030   2 XXX 0 0 55.65 0
70030 26 2 XXX 0 0 22.99 0
70030 TC 2 XXX 0 0 34.27 0
70030   3 XXX 0 0 52.78 0
70030 26 3 XXX 0 0 22.03 0
70030 TC 3 XXX 0 0 31.45 0
70030   4 XXX 0 0 51.38 0
70030 26 4 XXX 0 0 21.48 0
70030 TC 4 XXX 0 0 30.98 0
70100   1 XXX 0 0 67.51 0
70100 26 1 XXX 0 0 24.48 0
70100 TC 1 XXX 0 0 43.55 0
70100   2 XXX 0 0 74.17 0
70100 26 2 XXX 0 0 24.41 0
70100 TC 2 XXX 0 0 47.36 0
70100   3 XXX 0 0 62.00 0
70100 26 3 XXX 0 0 23.41 0
70100 TC 3 XXX 0 0 40.15 0
70100   4 XXX 0 0 60.36 0
70100 26 4 XXX 0 0 22.75 0
70100 TC 4 XXX 0 0 38.86 0
70110   1 XXX 0 0 83.17 0
70110 26 1 XXX 0 0 33.59 0
70110 TC 1 XXX 0 0 51.79 0
70110   2 XXX 0 0 84.89 0
70110 26 2 XXX 0 0 33.51 0
70110 TC 2 XXX 0 0 50.84 0
70110   3 XXX 0 0 78.01 0
70110 26 3 XXX 0 0 32.02 0
70110 TC 3 XXX 0 0 46.79 0
70110   4 XXX 0 0 75.96 0
70110 26 4 XXX 0 0 31.28 0
70110 TC 4 XXX 0 0 46.09 0
70120   1 XXX 0 0 74.13 0
70120 26 1 XXX 0 0 24.48 0
70120 TC 1 XXX 0 0 51.79 0
70120   2 XXX 0 0 72.91 0
70120 26 2 XXX 0 0 24.41 0
70120 TC 2 XXX 0 0 50.84 0
70120   3 XXX 0 0 69.35 0
70120 26 3 XXX 0 0 23.37 0
70120 TC 3 XXX 0 0 46.79 0
70120   4 XXX 0 0 66.88 0
70120 26 4 XXX 0 0 22.75 0
70120 TC 4 XXX 0 0 46.09 0
70130   1 XXX 0 0 107.06 0
70130 26 1 XXX 0 0 44.87 0
70130 TC 1 XXX 0 0 65.50 0
70130   2 XXX 0 0 106.07 0
70130 26 2 XXX 0 0 44.72 0
70130 TC 2 XXX 0 0 64.30 0
70130   3 XXX 0 0 100.69 0
70130 26 3 XXX 0 0 42.82 0
70130 TC 3 XXX 0 0 59.26 0
70130   4 XXX 0 0 98.04 0
70130 26 4 XXX 0 0 41.84 0
70130 TC 4 XXX 0 0 58.32 0
70134   1 XXX 0 0 103.15 0
70134 26 1 XXX 0 0 44.87 0
70134 TC 1 XXX 0 0 61.60 0
70134   2 XXX 0 0 102.19 0
70134 26 2 XXX 0 0 44.72 0
70134 TC 2 XXX 0 0 60.46 0
70134   3 XXX 0 0 96.97 0
70134 26 3 XXX 0 0 42.91 0
70134 TC 3 XXX 0 0 55.64 0
70134   4 XXX 0 0 94.48 0
70134 26 4 XXX 0 0 41.74 0
70134 TC 4 XXX 0 0 54.74 0
70140   1 XXX 0 0 102.25 0
70140 26 1 XXX 0 0 25.26 0
70140 TC 1 XXX 0 0 70.25 0
70140   2 XXX 0 0 73.70 0
70140 26 2 XXX 0 0 25.18 0
70140 TC 2 XXX 0 0 54.31 0
70140   3 XXX 0 0 70.12 0
70140 26 3 XXX 0 0 24.13 0
70140 TC 3 XXX 0 0 52.41 0
70140   4 XXX 0 0 67.63 0
70140 26 4 XXX 0 0 23.51 0
70140 TC 4 XXX 0 0 46.09 0
70150   1 XXX 0 0 98.40 0
70150 26 1 XXX 0 0 34.96 0
70150 TC 1 XXX 0 0 72.87 0
70150   2 XXX 0 0 106.02 0
70150 26 2 XXX 0 0 34.88 0
70150 TC 2 XXX 0 0 71.68 0
70150   3 XXX 0 0 92.45 0
70150 26 3 XXX 0 0 33.32 0
70150 TC 3 XXX 0 0 59.26 0
70150   4 XXX 0 0 88.81 0
70150 26 4 XXX 0 0 32.52 0
70150 TC 4 XXX 0 0 58.32 0
70160   1 XXX 0 0 71.57 0
70160 26 1 XXX 0 0 22.75 0
70160 TC 1 XXX 0 0 51.72 0
70160   2 XXX 0 0 70.18 0
70160 26 2 XXX 0 0 22.72 0
70160 TC 2 XXX 0 0 48.16 0
70160   3 XXX 0 0 60.36 0
70160 26 3 XXX 0 0 21.81 0
70160 TC 3 XXX 0 0 41.62 0
70160   4 XXX 0 0 58.78 0
70160 26 4 XXX 0 0 21.22 0
70160 TC 4 XXX 0 0 38.86 0
70170   1 XXX 0 0 115.35 0
70170 26 1 XXX 0 0 39.61 0
70170 TC 1 XXX 0 0 78.44 0
70170   2 XXX 0 0 113.38 0
70170 26 2 XXX 0 0 39.51 0
70170 TC 2 XXX 0 0 77.03 0
70170   3 XXX 0 0 107.06 0
70170 26 3 XXX 0 0 37.79 0
70170 TC 3 XXX 0 0 70.96 0
70170   4 XXX 0 0 104.02 0
70170 26 4 XXX 0 0 36.82 0
70170 TC 4 XXX 0 0 69.85 0
70190   1 XXX 0 0 77.26 0
70190 26 1 XXX 0 0 28.28 0
70190 TC 1 XXX 0 0 51.79 0
70190   2 XXX 0 0 76.95 0
70190 26 2 XXX 0 0 28.19 0
70190 TC 2 XXX 0 0 50.84 0
70190   3 XXX 0 0 73.07 0
70190 26 3 XXX 0 0 27.08 0
70190 TC 3 XXX 0 0 46.79 0
70190   4 XXX 0 0 71.12 0
70190 26 4 XXX 0 0 27.31 0
70190 TC 4 XXX 0 0 46.09 0
70200   1 XXX 0 0 104.41 0
70200 26 1 XXX 0 0 37.43 0
70200 TC 1 XXX 0 0 67.14 0
70200   2 XXX 0 0 100.31 0
70200 26 2 XXX 0 0 37.34 0
70200 TC 2 XXX 0 0 66.04 0
70200   3 XXX 0 0 93.44 0
70200 26 3 XXX 0 0 35.71 0
70200 TC 3 XXX 0 0 59.26 0
70200   4 XXX 0 0 91.00 0
70200 26 4 XXX 0 0 34.74 0
70200 TC 4 XXX 0 0 58.32 0
70210   1 XXX 0 0 72.57 0
70210 26 1 XXX 0 0 22.75 0
70210 TC 1 XXX 0 0 51.79 0
70210   2 XXX 0 0 71.35 0
70210 26 2 XXX 0 0 22.72 0
70210 TC 2 XXX 0 0 50.84 0
70210   3 XXX 0 0 67.71 0
70210 26 3 XXX 0 0 21.25 0
70210 TC 3 XXX 0 0 46.79 0
70210   4 XXX 0 0 65.41 0
70210 26 4 XXX 0 0 20.76 0
70210 TC 4 XXX 0 0 46.09 0
70220   1 XXX 0 0 96.86 0
70220 26 1 XXX 0 0 33.59 0
70220 TC 1 XXX 0 0 65.50 0
70220   2 XXX 0 0 95.31 0
70220 26 2 XXX 0 0 33.51 0
70220 TC 2 XXX 0 0 64.30 0
70220   3 XXX 0 0 89.93 0
70220 26 3 XXX 0 0 32.02 0
70220 TC 3 XXX 0 0 59.26 0
70220   4 XXX 0 0 87.27 0
70220 26 4 XXX 0 0 31.24 0
70220 TC 4 XXX 0 0 58.32 0
70240   1 XXX 0 0 58.01 0
70240 26 1 XXX 0 0 25.67 0
70240 TC 1 XXX 0 0 34.93 0
70240   2 XXX 0 0 64.94 0
70240 26 2 XXX 0 0 25.62 0
70240 TC 2 XXX 0 0 35.51 0
70240   3 XXX 0 0 55.28 0
70240 26 3 XXX 0 0 24.58 0
70240 TC 3 XXX 0 0 31.45 0
70240   4 XXX 0 0 53.88 0
70240 26 4 XXX 0 0 23.92 0
70240 TC 4 XXX 0 0 30.98 0
70250   1 XXX 0 0 98.72 0
70250 26 1 XXX 0 0 32.52 0
70250 TC 1 XXX 0 0 64.22 0
70250   2 XXX 0 0 98.57 0
70250 26 2 XXX 0 0 32.41 0
70250 TC 2 XXX 0 0 63.39 0
70250   3 XXX 0 0 77.38 0
70250 26 3 XXX 0 0 30.96 0
70250 TC 3 XXX 0 0 50.42 0
70250   4 XXX 0 0 75.07 0
70250 26 4 XXX 0 0 30.12 0
70250 TC 4 XXX 0 0 46.09 0
70260   1 XXX 0 0 116.07 0
70260 26 1 XXX 0 0 44.87 0
70260 TC 1 XXX 0 0 74.55 0
70260   2 XXX 0 0 118.48 0
70260 26 2 XXX 0 0 44.72 0
70260 TC 2 XXX 0 0 78.14 0
70260   3 XXX 0 0 109.36 0
70260 26 3 XXX 0 0 42.76 0
70260 TC 3 XXX 0 0 67.32 0
70260   4 XXX 0 0 105.61 0
70260 26 4 XXX 0 0 41.87 0
70260 TC 4 XXX 0 0 66.26 0
70300     XXX 0 0 * 0
70310     XXX 0 0 * 0
70320     XXX 0 0 * 0
70328   1 XXX 0 0 63.54 0
70328 26 1 XXX 0 0 24.48 0
70328 TC 1 XXX 0 0 47.09 0
70328   2 XXX 0 0 62.52 0
70328 26 2 XXX 0 0 24.41 0
70328 TC 2 XXX 0 0 40.44 0
70328   3 XXX 0 0 59.86 0
70328 26 3 XXX 0 0 23.37 0
70328 TC 3 XXX 0 0 37.34 0
70328   4 XXX 0 0 58.32 0
70328 26 4 XXX 0 0 22.75 0
70328 TC 4 XXX 0 0 36.74 0
70330   1 XXX 0 0 99.29 0
70330 26 1 XXX 0 0 32.51 0
70330 TC 1 XXX 0 0 69.42 0
70330   2 XXX 0 0 97.62 0
70330 26 2 XXX 0 0 32.39 0
70330 TC 2 XXX 0 0 68.18 0
70330   3 XXX 0 0 92.45 0
70330 26 3 XXX 0 0 30.98 0
70330 TC 3 XXX 0 0 62.89 0
70330   4 XXX 0 0 90.13 0
70330 26 4 XXX 0 0 30.12 0
70330 TC 4 XXX 0 0 61.95 0
70332   1 XXX 0 0 241.15 0
70332 26 1 XXX 0 0 74.19 0
70332 TC 1 XXX 0 0 173.79 0
70332   2 XXX 0 0 237.23 0
70332 26 2 XXX 0 0 74.03 0
70332 TC 2 XXX 0 0 170.60 0
70332   3 XXX 0 0 224.62 0
70332 26 3 XXX 0 0 70.78 0
70332 TC 3 XXX 0 0 157.31 0
70332   4 XXX 0 0 217.25 0
70332 26 4 XXX 0 0 68.97 0
70332 TC 4 XXX 0 0 154.86 0
70336   1 XXX 0 0 1,043.26 0
70336 26 1 XXX 0 0 169.63 0
70336 TC 1 XXX 0 0 927.25 0
70336   2 XXX 0 0 1,040.44 0
70336 26 2 XXX 0 0 169.39 0
70336 TC 2 XXX 0 0 910.51 0
70336   3 XXX 0 0 984.32 0
70336 26 3 XXX 0 0 163.01 0
70336 TC 3 XXX 0 0 839.99 0
70336   4 XXX 0 0 957.96 0
70336 26 4 XXX 0 0 157.80 0
70336 TC 4 XXX 0 0 826.67 0
70350     XXX 0 0 * 0
70355     XXX 0 0 * 0
70360   1 XXX 0 0 55.68 0
70360 26 1 XXX 0 0 22.62 0
70360 TC 1 XXX 0 0 34.93 0
70360   2 XXX 0 0 56.52 0
70360 26 2 XXX 0 0 22.57 0
70360 TC 2 XXX 0 0 34.27 0
70360   3 XXX 0 0 52.39 0
70360 26 3 XXX 0 0 21.61 0
70360 TC 3 XXX 0 0 31.45 0
70360   4 XXX 0 0 51.06 0
70360 26 4 XXX 0 0 21.05 0
70360 TC 4 XXX 0 0 30.98 0
70370   1 XXX 0 0 146.66 0
70370 26 1 XXX 0 0 42.68 0
70370 TC 1 XXX 0 0 107.48 0
70370   2 XXX 0 0 144.27 0
70370 26 2 XXX 0 0 42.59 0
70370 TC 2 XXX 0 0 105.54 0
70370   3 XXX 0 0 136.37 0
70370 26 3 XXX 0 0 40.72 0
70370 TC 3 XXX 0 0 97.29 0
70370   4 XXX 0 0 132.18 0
70370 26 4 XXX 0 0 39.64 0
70370 TC 4 XXX 0 0 95.81 0
70371   1 XXX 0 0 277.27 0
70371 26 1 XXX 0 0 113.21 0
70371 TC 1 XXX 0 0 173.79 0
70371   2 XXX 0 0 275.94 0
70371 26 2 XXX 0 0 112.85 0
70371 TC 2 XXX 0 0 170.60 0
70371   3 XXX 0 0 261.75 0
70371 26 3 XXX 0 0 107.92 0
70371 TC 3 XXX 0 0 157.31 0
70371   4 XXX 0 0 254.95 0
70371 26 4 XXX 0 0 105.17 0
70371 TC 4 XXX 0 0 154.86 0
70380   1 XXX 0 0 76.50 0
70380 26 1 XXX 0 0 22.75 0
70380 TC 1 XXX 0 0 55.68 0
70380   2 XXX 0 0 75.24 0
70380 26 2 XXX 0 0 22.72 0
70380 TC 2 XXX 0 0 54.68 0
70380   3 XXX 0 0 71.53 0
70380 26 3 XXX 0 0 21.79 0
70380 TC 3 XXX 0 0 50.49 0
70380   4 XXX 0 0 68.97 0
70380 26 4 XXX 0 0 21.43 0
70380 TC 4 XXX 0 0 49.70 0
70390   1 XXX 0 0 194.54 0
70390 26 1 XXX 0 0 50.31 0
70390 TC 1 XXX 0 0 147.87 0
70390   2 XXX 0 0 191.25 0
70390 26 2 XXX 0 0 50.09 0
70390 TC 2 XXX 0 0 145.19 0
70390   3 XXX 0 0 177.47 0
70390 26 3 XXX 0 0 47.87 0
70390 TC 3 XXX 0 0 133.90 0
70390   4 XXX 0 0 174.87 0
70390 26 4 XXX 0 0 48.76 0
70390 TC 4 XXX 0 0 131.81 0
70450   1 XXX 0 0 505.65 0
70450 26 1 XXX 0 0 114.65 0
70450 TC 1 XXX 0 0 391.05 0
70450   2 XXX 0 0 502.79 0
70450 26 2 XXX 0 0 114.33 0
70450 TC 2 XXX 0 0 388.55 0
70450   3 XXX 0 0 476.36 0
70450 26 3 XXX 0 0 109.41 0
70450 TC 3 XXX 0 0 366.97 0
70450   4 XXX 0 0 463.62 0
70450 26 4 XXX 0 0 106.88 0
70450 TC 4 XXX 0 0 357.06 0