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2018 Workers' Compensation Part B Fee Schedule

90849-92134

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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
90849   1 XXX 0 0 66.39 0
90849   2 XXX 0 0 60.44 0
90849   3 XXX 0 0 60.44 0
90849   4 XXX 0 0 60.44 0
90853   1 XXX 0 0 66.39 0
90853   2 XXX 0 0 60.44 0
90853   3 XXX 0 0 60.44 0
90853   4 XXX 0 0 60.44 0
90863     XXX 9 0 * 0
90865   1 XXX 0 0 250.24 0
90865   2 XXX 0 0 234.15 0
90865   3 XXX 0 0 234.15 0
90865   4 XXX 0 0 234.15 0
90867     0 0 0 * 0
90868     0 0 0 * 0
90869   1 0 0 0 638.34 157.08
90869   2 0 0 0 565.49 150.57
90869   3 0 0 0 565.49 150.57
90869   4 0 0 0 565.49 150.57
90870   1 0 0 0 202.24 0
90870   2 0 0 0 200.10 0
90870   3 0 0 0 191.38 0
90870   4 0 0 0 189.30 0
90875     XXX 9 0 * 0
90876   1 XXX 9 0 165.24 0
90876   2 XXX 9 0 155.67 0
90876   3 XXX 9 0 151.45 0
90876   4 XXX 9 0 151.45 0
90880   1 XXX 0 0 215.51 0
90880   2 XXX 0 0 199.25 0
90880   3 XXX 0 0 199.25 0
90880   4 XXX 0 0 199.25 0
90882     XXX 9 0 * 0
90885     XXX 9 0 * 0
90887   1 XXX 9 0 138.16 0
90887   2 XXX 9 0 129.08 0
90887   3 XXX 9 0 134.34 0
90887   4 XXX 9 0 113.49 0
90899     XXX 0 0 * 0
90901   1 0 0 0 51.84 0
90901   2 0 0 0 47.88 0
90901   3 0 0 0 46.63 0
90901   4 0 0 0 46.63 0
90911   1 0 0 0 182.52 0
90911   2 0 0 0 154.71 0
90911   3 0 0 0 154.71 0
90911   4 0 0 0 154.71 0
90935   1 0 0 0 250.96 0
90935   2 0 0 0 253.33 0
90935   3 0 0 0 247.38 0
90935   4 0 0 0 240.97 0
90937   1 0 0 0 521.99 0
90937   2 0 0 0 511.36 0
90937   3 0 0 0 504.94 0
90937   4 0 0 0 502.66 0
90940     XXX 9 0 * 0
90945   1 0 0 0 188.16 0
90945   2 0 0 0 200.55 0
90945   3 0 0 0 190.09 0
90945   4 0 0 0 187.70 0
90947   1 0 0 0 371.30 0
90947   2 0 0 0 380.56 0
90947   3 0 0 0 349.39 0
90947   4 0 0 0 369.19 0
90951   1 XXX 0 0 1,402.45 0
90951   2 XXX 0 0 1,306.09 0
90951   3 XXX 0 0 1,306.09 0
90951   4 XXX 0 0 1,306.09 0
90952     XXX 0 0 * 0
90953     XXX 0 0 * 0
90954   1 XXX 0 0 1,147.11 0
90954   2 XXX 0 0 1,073.73 0
90954   3 XXX 0 0 1,073.73 0
90954   4 XXX 0 0 1,073.73 0
90955   1 XXX 0 0 651.37 0
90955   2 XXX 0 0 607.77 0
90955   3 XXX 0 0 607.77 0
90955   4 XXX 0 0 607.77 0
90956   1 XXX 0 0 440.82 0
90956   2 XXX 0 0 411.47 0
90956   3 XXX 0 0 411.47 0
90956   4 XXX 0 0 411.47 0
90957   1 XXX 0 0 921.58 0
90957   2 XXX 0 0 860.92 0
90957   3 XXX 0 0 860.92 0
90957   4 XXX 0 0 860.92 0
90958   1 XXX 0 0 622.81 0
90958   2 XXX 0 0 580.90 0
90958   3 XXX 0 0 580.90 0
90958   4 XXX 0 0 580.90 0
90959   1 XXX 0 0 407.89 0
90959   2 XXX 0 0 380.90 0
90959   3 XXX 0 0 380.90 0
90959   4 XXX 0 0 380.90 0
90960   1 XXX 0 0 411.39 0
90960   2 XXX 0 0 381.55 0
90960   3 XXX 0 0 381.55 0
90960   4 XXX 0 0 381.55 0
90961   1 XXX 0 0 331.59 0
90961   2 XXX 0 0 308.10 0
90961   3 XXX 0 0 308.10 0
90961   4 XXX 0 0 308.10 0
90962   1 XXX 0 0 239.16 0
90962   2 XXX 0 0 222.79 0
90962   3 XXX 0 0 222.79 0
90962   4 XXX 0 0 222.79 0
90963   1 XXX 0 0 791.78 0
90963   2 XXX 0 0 738.15 0
90963   3 XXX 0 0 738.15 0
90963   4 XXX 0 0 738.15 0
90964   1 XXX 0 0 659.23 0
90964   2 XXX 0 0 616.63 0
90964   3 XXX 0 0 616.63 0
90964   4 XXX 0 0 616.63 0
90965   1 XXX 0 0 626.04 0
90965   2 XXX 0 0 585.99 0
90965   3 XXX 0 0 585.99 0
90965   4 XXX 0 0 585.99 0
90966   1 XXX 0 0 327.76 0
90966   2 XXX 0 0 304.88 0
90966   3 XXX 0 0 304.88 0
90966   4 XXX 0 0 304.88 0
90967   1 XXX 0 0 28.44 0
90967   2 XXX 0 0 26.35 0
90967   3 XXX 0 0 26.35 0
90967   4 XXX 0 0 26.35 0
90968   1 XXX 0 0 22.06 0
90968   2 XXX 0 0 20.57 0
90968   3 XXX 0 0 20.57 0
90968   4 XXX 0 0 20.57 0
90969   1 XXX 0 0 21.55 0
90969   2 XXX 0 0 20.13 0
90969   3 XXX 0 0 20.13 0
90969   4 XXX 0 0 20.13 0
90970   1 XXX 0 0 11.75 0
90970   2 XXX 0 0 10.76 0
90970   3 XXX 0 0 10.76 0
90970   4 XXX 0 0 10.76 0
90989     XXX 9 0 1,173.49 0
90993     XXX 9 0 46.95 0
90997   1 0 0 0 515.64 0
90997   2 0 0 0 538.50 0
90997   3 0 0 0 327.19 0
90997   4 0 0 0 474.63 0
90999     XXX 0 0 * 0
91010   1 0 0 0 289.88 0
91010 26 1 0 0 0 263.00 0
91010 TC 1 0 0 0 69.01 0
91010   2 0 0 0 254.95 0
91010 26 2 0 0 0 270.28 0
91010 TC 2 0 0 0 67.71 0
91010   3 0 0 0 248.84 0
91010 26 3 0 0 0 215.45 0
91010 TC 3 0 0 0 62.20 0
91010   4 0 0 0 192.52 0
91010 26 4 0 0 0 273.23 0
91010 TC 4 0 0 0 61.26 0
91013   1 ZZZ 0 0 33.72 0
91013 26 1 ZZZ 0 0 14.09 0
91013 TC 1 ZZZ 0 0 19.64 0
91013   2 ZZZ 0 0 30.34 0
91013 26 2 ZZZ 0 0 13.15 0
91013 TC 2 ZZZ 0 0 17.19 0
91013   3 ZZZ 0 0 30.34 0
91013 26 3 ZZZ 0 0 13.15 0
91013 TC 3 ZZZ 0 0 17.19 0
91013   4 ZZZ 0 0 30.34 0
91013 26 4 ZZZ 0 0 13.15 0
91013 TC 4 ZZZ 0 0 17.19 0
91020   1 0 0 0 310.56 0
91020 26 1 0 0 0 244.50 0
91020 TC 1 0 0 0 66.04 0
91020   2 0 0 0 270.84 0
91020 26 2 0 0 0 216.35 0
91020 TC 2 0 0 0 54.46 0
91020   3 0 0 0 270.84 0
91020 26 3 0 0 0 216.35 0
91020 TC 3 0 0 0 54.46 0
91020   4 0 0 0 270.84 0
91020 26 4 0 0 0 216.35 0
91020 TC 4 0 0 0 54.46 0
91022   1 0 0 0 366.26 0
91022 26 1 0 0 0 119.43 0
91022 TC 1 0 0 0 246.85 0
91022   2 0 0 0 310.61 0
91022 26 2 0 0 0 110.05 0
91022 TC 2 0 0 0 200.59 0
91022   3 0 0 0 310.61 0
91022 26 3 0 0 0 110.05 0
91022 TC 3 0 0 0 200.59 0
91022   4 0 0 0 310.61 0
91022 26 4 0 0 0 110.05 0
91022 TC 4 0 0 0 200.59 0
91030   1 0 0 0 134.12 0
91030 26 1 0 0 0 111.92 0
91030 TC 1 0 0 0 18.83 0
91030   2 0 0 0 143.06 0
91030 26 2 0 0 0 109.88 0
91030 TC 2 0 0 0 18.44 0
91030   3 0 0 0 136.63 0
91030 26 3 0 0 0 105.94 0
91030 TC 3 0 0 0 16.83 0
91030   4 0 0 0 135.09 0
91030 26 4 0 0 0 106.46 0
91030 TC 4 0 0 0 16.62 0
91034   1 0 0 0 423.57 0
91034 26 1 0 0 0 88.66 0
91034 TC 1 0 0 0 334.97 0
91034   2 0 0 0 359.66 0
91034 26 2 0 0 0 81.52 0
91034 TC 2 0 0 0 278.12 0
91034   3 0 0 0 359.66 0
91034 26 3 0 0 0 81.52 0
91034 TC 3 0 0 0 278.12 0
91034   4 0 0 0 359.66 0
91034 26 4 0 0 0 81.52 0
91034 TC 4 0 0 0 278.12 0
91035   1 0 0 0 836.63 0
91035 26 1 0 0 0 142.24 0
91035 TC 1 0 0 0 694.38 0
91035   2 0 0 0 709.88 0
91035 26 2 0 0 0 131.89 0
91035 TC 2 0 0 0 578.02 0
91035   3 0 0 0 709.88 0
91035 26 3 0 0 0 131.89 0
91035 TC 3 0 0 0 578.02 0
91035   4 0 0 0 709.88 0
91035 26 4 0 0 0 131.89 0
91035 TC 4 0 0 0 578.02 0
91037   1 0 0 0 268.09 0
91037 26 1 0 0 0 88.66 0
91037 TC 1 0 0 0 179.45 0
91037   2 0 0 0 229.95 0
91037 26 2 0 0 0 81.52 0
91037 TC 2 0 0 0 148.41 0
91037   3 0 0 0 229.95 0
91037 26 3 0 0 0 81.52 0
91037 TC 3 0 0 0 148.41 0
91037   4 0 0 0 229.95 0
91037 26 4 0 0 0 81.52 0
91037 TC 4 0 0 0 148.41 0
91038   1 0 0 0 228.43 0
91038 26 1 0 0 0 100.12 0
91038 TC 1 0 0 0 128.29 0
91038   2 0 0 0 198.02 0
91038 26 2 0 0 0 92.32 0
91038 TC 2 0 0 0 105.73 0
91038   3 0 0 0 198.02 0
91038 26 3 0 0 0 92.32 0
91038 TC 3 0 0 0 105.73 0
91038   4 0 0 0 198.02 0
91038 26 4 0 0 0 92.32 0
91038 TC 4 0 0 0 105.73 0
91040   1 0 0 0 820.06 0
91040 26 1 0 0 0 88.66 0
91040 TC 1 0 0 0 731.44 0
91040   2 0 0 0 690.41 0
91040 26 2 0 0 0 81.52 0
91040 TC 2 0 0 0 608.92 0
91040   3 0 0 0 690.41 0
91040 26 3 0 0 0 81.52 0
91040 TC 3 0 0 0 608.92 0
91040   4 0 0 0 690.41 0
91040 26 4 0 0 0 81.52 0
91040 TC 4 0 0 0 608.92 0
91065   1 0 0 0 128.17 0
91065 26 1 0 0 0 78.01 0
91065 TC 1 0 0 0 29.06 0
91065   2 0 0 0 127.52 0
91065 26 2 0 0 0 77.03 0
91065 TC 2 0 0 0 28.53 0
91065   3 0 0 0 124.90 0
91065 26 3 0 0 0 72.97 0
91065 TC 3 0 0 0 26.34 0
91065   4 0 0 0 124.37 0
91065 26 4 0 0 0 72.03 0
91065 TC 4 0 0 0 25.90 0
91110   1 XXX 0 0 1,687.99 0
91110 26 1 XXX 0 0 324.19 0
91110 TC 1 XXX 0 0 1,363.78 0
91110   2 XXX 0 0 1,463.37 0
91110 26 2 XXX 0 0 304.94 0
91110 TC 2 XXX 0 0 1,158.46 0
91110   3 XXX 0 0 1,463.37 0
91110 26 3 XXX 0 0 304.94 0
91110 TC 3 XXX 0 0 1,158.46 0
91110   4 XXX 0 0 1,463.37 0
91110 26 4 XXX 0 0 304.94 0
91110 TC 4 XXX 0 0 1,158.46 0
91111   1 XXX 0 0 1,155.80 0
91111 26 1 XXX 0 0 78.29 0
91111 TC 1 XXX 0 0 1,077.50 0
91111   2 XXX 0 0 951.62 0
91111 26 2 XXX 0 0 71.28 0
91111 TC 2 XXX 0 0 880.36 0
91111   3 XXX 0 0 951.62 0
91111 26 3 XXX 0 0 71.28 0
91111 TC 3 XXX 0 0 880.36 0
91111   4 XXX 0 0 951.62 0
91111 26 4 XXX 0 0 71.28 0
91111 TC 4 XXX 0 0 880.36 0
91112   1 XXX 0 0 1,585.17 0
91112 26 1 XXX 0 0 147.76 0
91112 TC 1 XXX 0 0 1,437.40 0
91112   2 XXX 0 0 1,376.75 0
91112 26 2 XXX 0 0 137.65 0
91112 TC 2 XXX 0 0 1,239.11 0
91112   3 XXX 0 0 1,376.75 0
91112 26 3 XXX 0 0 137.65 0
91112 TC 3 XXX 0 0 1,239.11 0
91112   4 XXX 0 0 1,376.75 0
91112 26 4 XXX 0 0 137.65 0
91112 TC 4 XXX 0 0 1,239.11 0
91117   1 0 0 0 209.84 223.25
91117   2 0 0 0 191.25 203.14
91117   3 0 0 0 191.25 203.14
91117   4 0 0 0 191.25 203.14
91120   1 XXX 0 0 809.11 0
91120 26 1 XXX 0 0 89.49 0
91120 TC 1 XXX 0 0 719.63 0
91120   2 XXX 0 0 681.51 0
91120 26 2 XXX 0 0 82.01 0
91120 TC 2 XXX 0 0 599.50 0
91120   3 XXX 0 0 681.51 0
91120 26 3 XXX 0 0 82.01 0
91120 TC 3 XXX 0 0 599.50 0
91120   4 XXX 0 0 681.51 0
91120 26 4 XXX 0 0 82.01 0
91120 TC 4 XXX 0 0 599.50 0
91122   1 0 0 0 308.26 0
91122 26 1 0 0 0 285.17 0
91122 TC 1 0 0 0 68.42 0
91122   2 0 0 0 296.71 0
91122 26 2 0 0 0 283.83 0
91122 TC 2 0 0 0 66.88 0
91122   3 0 0 0 292.29 0
91122 26 3 0 0 0 239.37 0
91122 TC 3 0 0 0 60.34 0
91122   4 0 0 0 296.08 0
91122 26 4 0 0 0 236.62 0
91122 TC 4 0 0 0 59.45 0
91132     XXX 0 0 * 0
91133     XXX 0 0 * 0
91200   1 XXX 0 0 47.71 0
91200 26 1 XXX 0 0 19.20 0
91200 TC 1 XXX 0 0 28.51 0
91200   2 XXX 0 0 42.33 0
91200 26 2 XXX 0 0 17.98 0
91200 TC 2 XXX 0 0 24.33 0
91200   3 XXX 0 0 42.33 0
91200 26 3 XXX 0 0 17.98 0
91200 TC 3 XXX 0 0 24.33 0
91200   4 XXX 0 0 42.33 0
91200 26 4 XXX 0 0 17.98 0
91200 TC 4 XXX 0 0 24.33 0
91299     XXX 0 0 * 0
92002   1 XXX 0 0 112.64 94.73
92002   2 XXX 0 0 112.82 94.42
92002   3 XXX 0 0 106.19 89.50
92002   4 XXX 0 0 105.18 88.48
92004   1 XXX 0 0 163.19 142.39
92004   2 XXX 0 0 158.82 138.12
92004   3 XXX 0 0 147.70 128.97
92004   4 XXX 0 0 147.53 129.08
92012   1 XXX 0 0 95.44 79.41
92012   2 XXX 0 0 95.79 79.49
92012   3 XXX 0 0 88.70 74.02
92012   4 XXX 0 0 89.83 74.93
92014   1 XXX 0 0 130.35 108.28
92014   2 XXX 0 0 125.30 104.70
92014   3 XXX 0 0 112.14 93.98
92014   4 XXX 0 0 117.82 98.72
92015     XXX 9 0 * 0
92018   1 XXX 0 0 191.87 169.27
92018   2 XXX 0 0 159.54 140.98
92018   3 XXX 0 0 146.42 129.84
92018   4 XXX 0 0 150.10 133.42
92019   1 XXX 0 0 144.57 0
92019   2 XXX 0 0 115.68 0
92019   3 XXX 0 0 112.49 0
92019   4 XXX 0 0 136.12 0
92020   1 XXX 0 0 48.48 38.06
92020   2 XXX 0 0 52.33 41.14
92020   3 XXX 0 0 50.05 39.49
92020   4 XXX 0 0 39.44 31.02
92025   1 XXX 0 0 44.35 0
92025 26 1 XXX 0 0 24.68 0
92025 TC 1 XXX 0 0 19.67 0
92025   2 XXX 0 0 38.57 0
92025 26 2 XXX 0 0 22.66 0
92025 TC 2 XXX 0 0 15.92 0
92025   3 XXX 0 0 38.57 0
92025 26 3 XXX 0 0 22.66 0
92025 TC 3 XXX 0 0 15.92 0
92025   4 XXX 0 0 38.57 0
92025 26 4 XXX 0 0 22.66 0
92025 TC 4 XXX 0 0 15.92 0
92060   1 XXX 0 0 72.86 0
92060 26 1 XXX 0 0 57.57 0
92060 TC 1 XXX 0 0 15.31 0
92060   2 XXX 0 0 72.05 0
92060 26 2 XXX 0 0 57.07 0
92060 TC 2 XXX 0 0 14.97 0
92060   3 XXX 0 0 68.79 0
92060 26 3 XXX 0 0 54.85 0
92060 TC 3 XXX 0 0 13.85 0
92060   4 XXX 0 0 67.92 0
92060 26 4 XXX 0 0 54.22 0
92060 TC 4 XXX 0 0 13.69 0
92065   1 XXX 0 0 58.36 0
92065 26 1 XXX 0 0 45.82 0
92065 TC 1 XXX 0 0 12.51 0
92065   2 XXX 0 0 64.46 0
92065 26 2 XXX 0 0 49.81 0
92065 TC 2 XXX 0 0 12.38 0
92065   3 XXX 0 0 54.14 0
92065 26 3 XXX 0 0 41.98 0
92065 TC 3 XXX 0 0 11.69 0
92065   4 XXX 0 0 54.46 0
92065 26 4 XXX 0 0 43.02 0
92065 TC 4 XXX 0 0 11.47 0
92071   1 XXX 0 0 51.23 45.60
92071   2 XXX 0 0 47.22 42.35
92071   3 XXX 0 0 47.22 42.35
92071   4 XXX 0 0 47.22 42.35
92072   1 XXX 0 0 163.80 130.88
92072   2 XXX 0 0 150.85 122.49
92072   3 XXX 0 0 150.85 122.49
92072   4 XXX 0 0 150.85 122.49
92081   1 XXX 0 0 55.64 0
92081 26 1 XXX 0 0 43.29 0
92081 TC 1 XXX 0 0 11.74 0
92081   2 XXX 0 0 53.88 0
92081 26 2 XXX 0 0 42.29 0
92081 TC 2 XXX 0 0 11.60 0
92081   3 XXX 0 0 51.47 0
92081 26 3 XXX 0 0 40.52 0
92081 TC 3 XXX 0 0 10.96 0
92081   4 XXX 0 0 50.84 0
92081 26 4 XXX 0 0 40.08 0
92081 TC 4 XXX 0 0 10.84 0
92082   1 XXX 0 0 75.24 0
92082 26 1 XXX 0 0 59.14 0
92082 TC 1 XXX 0 0 16.07 0
92082   2 XXX 0 0 74.39 0
92082 26 2 XXX 0 0 58.57 0
92082 TC 2 XXX 0 0 15.78 0
92082   3 XXX 0 0 68.27 0
92082 26 3 XXX 0 0 52.65 0
92082 TC 3 XXX 0 0 14.62 0
92082   4 XXX 0 0 69.00 0
92082 26 4 XXX 0 0 53.40 0
92082 TC 4 XXX 0 0 14.41 0
92083   1 XXX 0 0 117.42 0
92083 26 1 XXX 0 0 87.44 0
92083 TC 1 XXX 0 0 23.13 0
92083   2 XXX 0 0 117.82 0
92083 26 2 XXX 0 0 87.56 0
92083 TC 2 XXX 0 0 22.75 0
92083   3 XXX 0 0 112.38 0
92083 26 3 XXX 0 0 83.73 0
92083 TC 3 XXX 0 0 21.20 0
92083   4 XXX 0 0 106.82 0
92083 26 4 XXX 0 0 79.76 0
92083 TC 4 XXX 0 0 20.86 0
92100   1 XXX 0 0 72.25 62.71
92100   2 XXX 0 0 65.77 57.46
92100   3 XXX 0 0 67.25 58.79
92100   4 XXX 0 0 68.32 59.72
92132   1 XXX 0 0 53.08 0
92132 26 1 XXX 0 0 30.44 0
92132 TC 1 XXX 0 0 22.62 0
92132   2 XXX 0 0 47.94 0
92132 26 2 XXX 0 0 28.11 0
92132 TC 2 XXX 0 0 19.83 0
92132   3 XXX 0 0 47.94 0
92132 26 3 XXX 0 0 28.11 0
92132 TC 3 XXX 0 0 19.83 0
92132   4 XXX 0 0 47.94 0
92132 26 4 XXX 0 0 28.11 0
92132 TC 4 XXX 0 0 19.83 0
92133   1 XXX 0 0 64.50 0
92133 26 1 XXX 0 0 41.91 0
92133 TC 1 XXX 0 0 22.62 0
92133   2 XXX 0 0 58.76 0
92133 26 2 XXX 0 0 38.93 0
92133 TC 2 XXX 0 0 19.83 0
92133   3 XXX 0 0 58.76 0
92133 26 3 XXX 0 0 38.93 0
92133 TC 3 XXX 0 0 19.83 0
92133   4 XXX 0 0 58.76 0
92133 26 4 XXX 0 0 38.93 0
92133 TC 4 XXX 0 0 19.83 0
92134   1 XXX 0 0 64.50 0
92134 26 1 XXX 0 0 41.91 0
92134 TC 1 XXX 0 0 22.62 0
92134   2 XXX 0 0 58.76 0
92134 26 2 XXX 0 0 38.93 0
92134 TC 2 XXX 0 0 19.83 0
92134   3 XXX 0 0 58.76 0
92134 26 3 XXX 0 0 38.93 0
92134 TC 3 XXX 0 0 19.83 0
92134   4 XXX 0 0 58.76 0
92134 26 4 XXX 0 0 38.93 0
92134 TC 4 XXX 0 0 19.83 0