88
HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040 P2 $40.14 $52.42 10060 P2 $70.40 $91.94 10061 P2 $70.40 $91.94 10080 P2 $70.40 $91.94 10081 P3 $179.98 $235.04 10120 P3 $109.21 $142.62 10121 A2 $629.45 $822.00 10140 P3 $105.81 $138.18 10160 P2 $70.40 $91.94 10180 A2 $740.20 $966.63 11000 P3 $33.00 $43.09 11001 P3 $10.21 $13.33 11010 A2 $188.75 $246.49 11011 A2 $188.75 $246.49 11012 A2 $188.75 $246.49 11042 A2 $117.64 $153.63 11043 A2 $117.64 $153.63 11044 A2 $327.48 $427.66 11045 G2 $117.64 $153.63 11046 G2 $117.64 $153.63 11047 G2 $188.75 $246.49 11055 P3 $35.72 $46.65 11056 P2 $40.14 $52.42 11057 P3 $42.53 $55.54 11100 P2 $60.02 $78.38 11101 P3 $17.01 $22.21 11200 P2 $40.14 $52.42 11201 P3 $7.83 $10.23 11300 P2 $40.14 $52.42 11301 P2 $40.14 $52.42 11302 P2 $40.14 $52.42 11303 P2 $60.02 $78.38 11305 P2 $40.14 $52.42 11306 P2 $40.14 $52.42 11307 P2 $40.14 $52.42 11308 P2 $60.02 $78.38 11310 P2 $40.14 $52.42 11311 P2 $40.14 $52.42 11312 P2 $60.02 $78.38 11313 P2 $60.02 $78.38 11400 P3 $92.20 $120.40 11401 P3 $102.41 $133.74 11402 P3 $112.28 $146.63 11403 P3 $122.48 $159.95 11404 A2 $629.45 $822.00 11406 A2 $629.45 $822.00 11420 P3 $86.76 $113.30 11421 P3 $103.77 $135.51 11422 P3 $113.30 $147.96 11423 P3 $125.20 $163.50 11424 A2 $629.45 $822.00 11426 A2 $932.08 $1,217.20 11440 P3 $97.99 $127.97 11441 P3 $111.94 $146.18 11442 P3 $122.14 $159.50 11443 P3 $135.75 $177.28 11444 A2 $327.48 $427.66 11446 A2 $932.08 $1,217.20 11450 A2 $932.08 $1,217.20 Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version) Updated 3/22/2013 MDWCC Page 1 of 88

Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

  • Upload
    others

  • View
    5

  • Download
    0

Embed Size (px)

Citation preview

Page 1: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

10021 P2 $68.80 $89.85

10022 G2 $193.88 $253.19

10040 P2 $40.14 $52.42

10060 P2 $70.40 $91.94

10061 P2 $70.40 $91.94

10080 P2 $70.40 $91.94

10081 P3 $179.98 $235.04

10120 P3 $109.21 $142.62

10121 A2 $629.45 $822.00

10140 P3 $105.81 $138.18

10160 P2 $70.40 $91.94

10180 A2 $740.20 $966.63

11000 P3 $33.00 $43.09

11001 P3 $10.21 $13.33

11010 A2 $188.75 $246.49

11011 A2 $188.75 $246.49

11012 A2 $188.75 $246.49

11042 A2 $117.64 $153.63

11043 A2 $117.64 $153.63

11044 A2 $327.48 $427.66

11045 G2 $117.64 $153.63

11046 G2 $117.64 $153.63

11047 G2 $188.75 $246.49

11055 P3 $35.72 $46.65

11056 P2 $40.14 $52.42

11057 P3 $42.53 $55.54

11100 P2 $60.02 $78.38

11101 P3 $17.01 $22.21

11200 P2 $40.14 $52.42

11201 P3 $7.83 $10.23

11300 P2 $40.14 $52.42

11301 P2 $40.14 $52.42

11302 P2 $40.14 $52.42

11303 P2 $60.02 $78.38

11305 P2 $40.14 $52.42

11306 P2 $40.14 $52.42

11307 P2 $40.14 $52.42

11308 P2 $60.02 $78.38

11310 P2 $40.14 $52.42

11311 P2 $40.14 $52.42

11312 P2 $60.02 $78.38

11313 P2 $60.02 $78.38

11400 P3 $92.20 $120.40

11401 P3 $102.41 $133.74

11402 P3 $112.28 $146.63

11403 P3 $122.48 $159.95

11404 A2 $629.45 $822.00

11406 A2 $629.45 $822.00

11420 P3 $86.76 $113.30

11421 P3 $103.77 $135.51

11422 P3 $113.30 $147.96

11423 P3 $125.20 $163.50

11424 A2 $629.45 $822.00

11426 A2 $932.08 $1,217.20

11440 P3 $97.99 $127.97

11441 P3 $111.94 $146.18

11442 P3 $122.14 $159.50

11443 P3 $135.75 $177.28

11444 A2 $327.48 $427.66

11446 A2 $932.08 $1,217.20

11450 A2 $932.08 $1,217.20

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

Updated 3/22/2013 MDWCC

Page 1 of 88

Page 2: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

11451 A2 $932.08 $1,217.20

11462 A2 $932.08 $1,217.20

11463 A2 $932.08 $1,217.20

11470 A2 $932.08 $1,217.20

11471 A2 $932.08 $1,217.20

11600 P3 $133.03 $173.72

11601 P3 $152.76 $199.49

11602 P3 $165.01 $215.49

11603 P3 $177.94 $232.37

11604 A2 $327.48 $427.66

11606 A2 $629.45 $822.00

11620 P3 $135.41 $176.83

11621 P3 $154.12 $201.27

11622 P3 $167.73 $219.04

11623 P3 $184.06 $240.36

11624 A2 $629.45 $822.00

11626 A2 $932.08 $1,217.20

11640 P3 $140.51 $183.49

11641 P3 $158.55 $207.05

11642 P3 $174.88 $228.38

11643 P3 $191.55 $250.15

11644 A2 $629.45 $822.00

11646 A2 $932.08 $1,217.20

11719 P3 $5.44 $7.10

11720 P3 $20.75 $27.10

11721 P3 $25.18 $32.88

11730 P2 $40.14 $52.42

11732 P3 $19.73 $25.77

11740 P2 $15.94 $20.82

11750 P3 $134.05 $175.06

11752 P3 $189.85 $247.93

11755 P3 $88.80 $115.96

11760 G2 $48.11 $62.83

11762 P3 $179.64 $234.59

11765 P2 $40.14 $52.42

11770 A2 $932.08 $1,217.20

11771 A2 $932.08 $1,217.20

11772 A2 $932.08 $1,217.20

11900 P3 $36.74 $47.98

11901 P3 $39.81 $51.99

11920 P3 $111.26 $145.29

11921 P3 $125.54 $163.94

11922 P3 $43.89 $57.32

11950 P3 $41.17 $53.76

11951 P3 $59.20 $77.31

11952 P3 $75.53 $98.63

11954 P2 $48.11 $62.83

11960 A2 $847.34 $1,106.54

11970 A2 $1,928.93 $2,518.99

11971 A2 $932.08 $1,217.20

11976 P3 $76.21 $99.52

11980 P2 $27.85 $36.37

11981 P2 $27.85 $36.37

11982 P2 $27.85 $36.37

11983 P2 $27.85 $36.37

12001 P2 $48.11 $62.83

12002 P2 $48.11 $62.83

12004 P2 $48.11 $62.83

12005 A2 $48.11 $62.83

12006 A2 $48.11 $62.83

12007 A2 $48.11 $62.83

Updated 3/22/2013 MDWCC

Page 2 of 88

Page 3: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

12011 P2 $48.11 $62.83

12013 P2 $48.11 $62.83

12014 P2 $48.11 $62.83

12015 G2 $48.11 $62.83

12016 A2 $48.11 $62.83

12017 A2 $48.11 $62.83

12018 A2 $141.11 $184.28

12020 A2 $220.74 $288.26

12021 A2 $141.11 $184.28

12031 P2 $141.11 $184.28

12032 P2 $141.11 $184.28

12034 A2 $141.11 $184.28

12035 A2 $141.11 $184.28

12036 A2 $141.11 $184.28

12037 A2 $141.11 $184.28

12041 P2 $48.11 $62.83

12042 P2 $141.11 $184.28

12044 A2 $141.11 $184.28

12045 A2 $141.11 $184.28

12046 A2 $141.11 $184.28

12047 A2 $141.11 $184.28

12051 P2 $141.11 $184.28

12052 P2 $141.11 $184.28

12053 P2 $141.11 $184.28

12054 A2 $48.11 $62.83

12055 A2 $141.11 $184.28

12056 A2 $141.11 $184.28

12057 A2 $141.11 $184.28

13100 A2 $220.74 $288.26

13101 A2 $220.74 $288.26

13102 A2 $141.11 $184.28

13120 A2 $141.11 $184.28

13121 A2 $141.11 $184.28

13122 A2 $48.11 $62.83

13131 A2 $141.11 $184.28

13132 A2 $220.74 $288.26

13133 A2 $141.11 $184.28

13150 A2 $220.74 $288.26

13151 A2 $220.74 $288.26

13152 A2 $220.74 $288.26

13153 A2 $141.11 $184.28

13160 A2 $847.34 $1,106.54

14000 A2 $623.76 $814.57

14001 A2 $623.76 $814.57

14020 A2 $623.76 $814.57

14021 A2 $623.76 $814.57

14040 A2 $623.76 $814.57

14041 A2 $623.76 $814.57

14060 A2 $623.76 $814.57

14061 A2 $623.76 $814.57

14301 G2 $847.34 $1,106.54

14302 G2 $847.34 $1,106.54

14350 A2 $847.34 $1,106.54

15002 A2 $220.74 $288.26

15003 A2 $220.74 $288.26

15004 A2 $141.11 $184.28

15005 A2 $220.74 $288.26

15040 A2 $141.11 $184.28

15050 A2 $141.11 $184.28

15100 A2 $847.34 $1,106.54

15101 A2 $847.34 $1,106.54

Updated 3/22/2013 MDWCC

Page 3 of 88

Page 4: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

15110 A2 $220.74 $288.26

15111 A2 $220.74 $288.26

15115 A2 $623.76 $814.57

15116 A2 $141.11 $184.28

15120 A2 $847.34 $1,106.54

15121 A2 $847.34 $1,106.54

15130 A2 $623.76 $814.57

15131 A2 $623.76 $814.57

15135 A2 $623.76 $814.57

15136 A2 $623.76 $814.57

15150 A2 $141.11 $184.28

15151 A2 $141.11 $184.28

15152 A2 $141.11 $184.28

15155 A2 $141.11 $184.28

15156 A2 $141.11 $184.28

15157 A2 $141.11 $184.28

15200 A2 $623.76 $814.57

15201 A2 $623.76 $814.57

15220 A2 $623.76 $814.57

15221 A2 $220.74 $288.26

15240 A2 $623.76 $814.57

15241 A2 $141.11 $184.28

15260 A2 $623.76 $814.57

15261 A2 $623.76 $814.57

15271 G2 $141.11 $184.28

15272 G2 $48.11 $62.83

15273 G2 $220.74 $288.26

15274 G2 $141.11 $184.28

15275 G2 $141.11 $184.28

15276 G2 $48.11 $62.83

15277 G2 $220.74 $288.26

15278 G2 $141.11 $184.28

15570 A2 $847.34 $1,106.54

15572 A2 $847.34 $1,106.54

15574 A2 $847.34 $1,106.54

15576 A2 $847.34 $1,106.54

15600 A2 $847.34 $1,106.54

15610 A2 $847.34 $1,106.54

15620 A2 $847.34 $1,106.54

15630 A2 $847.34 $1,106.54

15650 A2 $847.34 $1,106.54

15731 A2 $847.34 $1,106.54

15732 A2 $847.34 $1,106.54

15734 A2 $847.34 $1,106.54

15736 A2 $847.34 $1,106.54

15738 A2 $847.34 $1,106.54

15740 A2 $623.76 $814.57

15750 A2 $847.34 $1,106.54

15760 A2 $847.34 $1,106.54

15770 A2 $847.34 $1,106.54

15775 A2 $48.11 $62.83

15776 A2 $48.11 $62.83

15777 G2 $623.76 $814.57

15780 P3 $600.17 $783.76

15781 P2 $188.75 $246.49

15782 P2 $188.75 $246.49

15783 P2 $117.64 $153.63

15786 P2 $40.14 $52.42

15787 P3 $38.79 $50.66

15788 P2 $40.14 $52.42

15789 P2 $60.02 $78.38

Updated 3/22/2013 MDWCC

Page 4 of 88

Page 5: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

15792 P2 $60.02 $78.38

15793 P2 $40.14 $52.42

15819 G2 $141.11 $184.28

15820 A2 $847.34 $1,106.54

15821 A2 $847.34 $1,106.54

15822 A2 $847.34 $1,106.54

15823 A2 $847.34 $1,106.54

15824 A2 $847.34 $1,106.54

15825 A2 $847.34 $1,106.54

15826 A2 $847.34 $1,106.54

15828 A2 $847.34 $1,106.54

15829 A2 $847.34 $1,106.54

15830 A2 $932.08 $1,217.20

15832 A2 $932.08 $1,217.20

15833 A2 $932.08 $1,217.20

15834 A2 $932.08 $1,217.20

15835 A2 $932.08 $1,217.20

15836 A2 $629.45 $822.00

15837 G2 $629.45 $822.00

15838 G2 $629.45 $822.00

15839 A2 $629.45 $822.00

15840 A2 $847.34 $1,106.54

15841 A2 $847.34 $1,106.54

15842 G2 $847.34 $1,106.54

15845 A2 $847.34 $1,106.54

15847 A2 $932.08 $1,217.20

15850 G2 $117.64 $153.63

15851 P3 $68.73 $89.75

15852 R2 $27.85 $36.37

15860 G2 $27.85 $36.37

15876 A2 $847.34 $1,106.54

15877 A2 $847.34 $1,106.54

15878 A2 $847.34 $1,106.54

15879 A2 $847.34 $1,106.54

15920 A2 $188.75 $246.49

15922 A2 $847.34 $1,106.54

15931 A2 $932.08 $1,217.20

15933 A2 $932.08 $1,217.20

15934 A2 $847.34 $1,106.54

15935 A2 $847.34 $1,106.54

15936 A2 $623.76 $814.57

15937 A2 $847.34 $1,106.54

15940 A2 $932.08 $1,217.20

15941 A2 $932.08 $1,217.20

15944 A2 $847.34 $1,106.54

15945 A2 $847.34 $1,106.54

15946 A2 $847.34 $1,106.54

15950 A2 $932.08 $1,217.20

15951 A2 $932.08 $1,217.20

15952 A2 $623.76 $814.57

15953 A2 $623.76 $814.57

15956 A2 $623.76 $814.57

15958 A2 $623.76 $814.57

16000 P3 $35.38 $46.20

16020 P3 $55.80 $72.87

16025 A2 $60.02 $78.38

16030 A2 $60.02 $78.38

16035 G2 $60.02 $78.38

17000 P2 $40.14 $52.42

17003 P3 $4.08 $5.33

17004 P3 $100.71 $131.52

Updated 3/22/2013 MDWCC

Page 5 of 88

Page 6: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

17106 P2 $117.64 $153.63

17107 P2 $117.64 $153.63

17108 P2 $117.64 $153.63

17110 P2 $40.14 $52.42

17111 P2 $60.02 $78.38

17250 P2 $60.02 $78.38

17260 P3 $59.20 $77.31

17261 P2 $60.02 $78.38

17262 P2 $60.02 $78.38

17263 P2 $60.02 $78.38

17264 P2 $60.02 $78.38

17266 P2 $117.64 $153.63

17270 P2 $60.02 $78.38

17271 P2 $60.02 $78.38

17272 P2 $60.02 $78.38

17273 P2 $117.64 $153.63

17274 P2 $117.64 $153.63

17276 P2 $117.64 $153.63

17280 P2 $60.02 $78.38

17281 P3 $112.62 $147.07

17282 P2 $117.64 $153.63

17283 P2 $117.64 $153.63

17284 P2 $117.64 $153.63

17286 P2 $117.64 $153.63

17311 P2 $206.42 $269.56

17312 P2 $206.42 $269.56

17313 P2 $206.42 $269.56

17314 P2 $206.42 $269.56

17315 P3 $45.59 $59.54

17340 P3 $22.11 $28.87

17360 P2 $60.02 $78.38

17380 R2 $60.02 $78.38

19000 P3 $81.66 $106.64

19001 P3 $10.55 $13.78

19020 A2 $740.20 $966.63

19030 N1 $0.00 $0.00

19100 A2 $193.88 $253.19

19101 A2 $1,045.25 $1,364.99

19102 A2 $350.84 $458.16

19103 A2 $627.64 $819.64

19105 P2 $1,379.81 $1,801.89

19110 A2 $1,045.25 $1,364.99

19112 A2 $1,045.25 $1,364.99

19120 A2 $1,045.25 $1,364.99

19125 A2 $1,045.25 $1,364.99

19126 A2 $1,045.25 $1,364.99

19290 N1 $0.00 $0.00

19291 N1 $0.00 $0.00

19295 N1 $0.00 $0.00

19296 J8 $3,565.14 $4,655.72

19297 J8 $3,565.14 $4,655.72

19298 J8 $3,565.14 $4,655.72

19300 A2 $1,045.25 $1,364.99

19301 A2 $1,045.25 $1,364.99

19302 A2 $1,815.79 $2,371.24

19303 A2 $1,379.81 $1,801.89

19304 A2 $1,379.81 $1,801.89

19316 A2 $1,379.81 $1,801.89

19318 A2 $1,815.79 $2,371.24

19324 A2 $1,815.79 $2,371.24

19325 J8 $3,565.14 $4,655.72

Updated 3/22/2013 MDWCC

Page 6 of 88

Page 7: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

19328 A2 $1,379.81 $1,801.89

19330 A2 $1,379.81 $1,801.89

19340 A2 $1,815.79 $2,371.24

19342 J8 $3,565.14 $4,655.72

19350 A2 $1,045.25 $1,364.99

19355 A2 $1,379.81 $1,801.89

19357 J8 $3,565.14 $4,655.72

19366 A2 $1,379.81 $1,801.89

19370 A2 $1,379.81 $1,801.89

19371 A2 $1,379.81 $1,801.89

19380 A2 $1,815.79 $2,371.24

19396 G2 $1,379.81 $1,801.89

20005 G2 $327.48 $427.66

20103 G2 $407.14 $531.68

20150 G2 $1,928.93 $2,518.99

20200 A2 $629.45 $822.00

20205 A2 $629.45 $822.00

20206 A2 $350.84 $458.16

20220 A2 $327.48 $427.66

20225 A2 $629.45 $822.00

20240 A2 $932.08 $1,217.20

20245 A2 $932.08 $1,217.20

20250 A2 $1,294.39 $1,690.34

20251 A2 $1,294.39 $1,690.34

20500 P3 $59.54 $77.75

20501 N1 $0.00 $0.00

20520 P3 $133.37 $174.17

20525 A2 $932.08 $1,217.20

20526 P3 $39.81 $51.99

20527 P3 $37.43 $48.88

20550 P3 $30.28 $39.54

20551 P3 $32.32 $42.21

20552 P3 $30.96 $40.43

20553 P3 $37.09 $48.44

20555 R2 $1,294.39 $1,690.34

20600 P3 $22.46 $29.33

20605 P3 $28.24 $36.88

20610 P3 $29.60 $38.65

20612 P3 $34.36 $44.87

20615 P3 $158.21 $206.61

20650 A2 $1,294.39 $1,690.34

20662 R2 $872.73 $1,139.70

20663 R2 $1,294.39 $1,690.34

20665 G2 $27.85 $36.37

20670 A2 $629.45 $822.00

20680 A2 $932.08 $1,217.20

20690 A2 $1,294.39 $1,690.34

20692 A2 $1,294.39 $1,690.34

20693 A2 $1,294.39 $1,690.34

20694 A2 $872.73 $1,139.70

20696 G2 $1,294.39 $1,690.34

20697 P2 $468.77 $612.17

20822 G2 $1,159.36 $1,514.01

20900 A2 $1,294.39 $1,690.34

20902 A2 $1,294.39 $1,690.34

20910 A2 $847.34 $1,106.54

20912 A2 $847.34 $1,106.54

20920 A2 $623.76 $814.57

20922 A2 $623.76 $814.57

20924 A2 $1,294.39 $1,690.34

20926 A2 $623.76 $814.57

Updated 3/22/2013 MDWCC

Page 7 of 88

Page 8: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

20930 N1 $0.00 $0.00

20931 N1 $0.00 $0.00

20950 G2 $70.40 $91.94

20972 G2 $2,428.46 $3,171.33

20973 R2 $2,428.46 $3,171.33

20975 N1 $0.00 $0.00

20979 P2 $27.85 $36.37

20982 G2 $1,928.93 $2,518.99

20985 N1 $0.00 $0.00

21010 A2 $1,839.88 $2,402.70

21011 P3 $240.88 $314.57

21012 R2 $327.48 $427.66

21013 P3 $318.80 $416.32

21014 R2 $327.48 $427.66

21015 G2 $629.45 $822.00

21016 G2 $932.08 $1,217.20

21025 A2 $1,839.88 $2,402.70

21026 A2 $1,009.91 $1,318.84

21029 A2 $1,009.91 $1,318.84

21030 P3 $341.25 $445.64

21031 P3 $276.61 $361.22

21032 P3 $283.41 $370.11

21034 A2 $1,839.88 $2,402.70

21040 A2 $1,009.91 $1,318.84

21044 A2 $1,009.91 $1,318.84

21046 A2 $1,839.88 $2,402.70

21047 A2 $1,839.88 $2,402.70

21048 R2 $1,839.88 $2,402.70

21050 A2 $1,839.88 $2,402.70

21060 A2 $1,839.88 $2,402.70

21070 A2 $1,839.88 $2,402.70

21073 P3 $261.30 $341.23

21076 P3 $489.25 $638.91

21077 P3 $1,222.11 $1,595.95

21079 P3 $842.75 $1,100.55

21080 P3 $945.50 $1,234.73

21081 P3 $882.22 $1,152.09

21082 P3 $872.01 $1,138.76

21083 P3 $856.70 $1,118.76

21084 P3 $956.39 $1,248.95

21085 P2 $279.76 $365.34

21086 P3 $919.64 $1,200.96

21087 P3 $901.27 $1,176.97

21088 R2 $1,839.88 $2,402.70

21100 A2 $1,839.88 $2,402.70

21110 P2 $279.76 $365.34

21116 N1 $0.00 $0.00

21120 A2 $1,839.88 $2,402.70

21121 A2 $1,009.91 $1,318.84

21122 A2 $1,009.91 $1,318.84

21123 A2 $1,009.91 $1,318.84

21125 A2 $1,009.91 $1,318.84

21127 A2 $1,839.88 $2,402.70

21137 G2 $1,009.91 $1,318.84

21138 G2 $1,839.88 $2,402.70

21139 G2 $1,839.88 $2,402.70

21150 G2 $1,839.88 $2,402.70

21181 A2 $1,839.88 $2,402.70

21198 G2 $1,009.91 $1,318.84

21199 G2 $1,839.88 $2,402.70

21206 A2 $1,839.88 $2,402.70

Updated 3/22/2013 MDWCC

Page 8 of 88

Page 9: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

21208 A2 $1,839.88 $2,402.70

21209 A2 $1,839.88 $2,402.70

21210 A2 $1,839.88 $2,402.70

21215 A2 $1,839.88 $2,402.70

21230 A2 $1,009.91 $1,318.84

21235 A2 $643.83 $840.78

21240 A2 $1,839.88 $2,402.70

21242 A2 $1,839.88 $2,402.70

21243 A2 $1,839.88 $2,402.70

21244 A2 $1,839.88 $2,402.70

21245 A2 $1,839.88 $2,402.70

21246 A2 $1,839.88 $2,402.70

21248 A2 $1,839.88 $2,402.70

21249 A2 $1,839.88 $2,402.70

21260 G2 $1,839.88 $2,402.70

21267 A2 $1,839.88 $2,402.70

21270 A2 $1,839.88 $2,402.70

21275 A2 $1,839.88 $2,402.70

21280 A2 $1,839.88 $2,402.70

21282 A2 $643.83 $840.78

21295 A2 $279.76 $365.34

21296 A2 $1,009.91 $1,318.84

21310 A2 $43.82 $57.22

21315 A2 $643.83 $840.78

21320 A2 $643.83 $840.78

21325 A2 $1,009.91 $1,318.84

21330 A2 $1,009.91 $1,318.84

21335 A2 $1,009.91 $1,318.84

21336 A2 $1,071.11 $1,398.76

21337 A2 $643.83 $840.78

21338 A2 $1,839.88 $2,402.70

21339 A2 $1,009.91 $1,318.84

21340 A2 $1,839.88 $2,402.70

21345 A2 $1,009.91 $1,318.84

21355 A2 $1,839.88 $2,402.70

21356 A2 $1,009.91 $1,318.84

21360 G2 $1,839.88 $2,402.70

21390 G2 $1,839.88 $2,402.70

21400 A2 $279.76 $365.34

21401 A2 $279.76 $365.34

21406 G2 $1,839.88 $2,402.70

21407 G2 $1,839.88 $2,402.70

21421 A2 $1,839.88 $2,402.70

21440 P3 $468.50 $611.81

21445 A2 $1,009.91 $1,318.84

21450 A2 $128.95 $168.40

21451 A2 $643.83 $840.78

21452 A2 $643.83 $840.78

21453 A2 $1,839.88 $2,402.70

21454 A2 $1,839.88 $2,402.70

21461 A2 $1,839.88 $2,402.70

21462 A2 $1,839.88 $2,402.70

21465 A2 $1,839.88 $2,402.70

21480 A2 $43.82 $57.22

21485 A2 $1,009.91 $1,318.84

21490 A2 $1,839.88 $2,402.70

21495 G2 $643.83 $840.78

21497 A2 $279.76 $365.34

21501 A2 $740.20 $966.63

21502 A2 $872.73 $1,139.70

21550 G2 $629.45 $822.00

Updated 3/22/2013 MDWCC

Page 9 of 88

Page 10: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

21552 G2 $932.08 $1,217.20

21554 G2 $932.08 $1,217.20

21555 G2 $629.45 $822.00

21556 G2 $932.08 $1,217.20

21557 G2 $629.45 $822.00

21558 G2 $932.08 $1,217.20

21600 A2 $1,294.39 $1,690.34

21610 A2 $1,294.39 $1,690.34

21685 G2 $1,009.91 $1,318.84

21700 A2 $872.73 $1,139.70

21720 A2 $872.73 $1,139.70

21725 A2 $70.40 $91.94

21800 A2 $74.99 $97.93

21805 A2 $1,071.11 $1,398.76

21820 A2 $74.99 $97.93

21920 P3 $186.11 $243.04

21925 A2 $932.08 $1,217.20

21930 G2 $629.45 $822.00

21931 G2 $932.08 $1,217.20

21932 G2 $629.45 $822.00

21933 G2 $932.08 $1,217.20

21935 G2 $629.45 $822.00

21936 G2 $932.08 $1,217.20

22102 G2 $2,109.06 $2,754.22

22103 G2 $2,109.06 $2,754.22

22305 A2 $74.99 $97.93

22310 A2 $223.81 $292.27

22315 A2 $468.77 $612.17

22505 A2 $583.05 $761.40

22520 A2 $1,294.39 $1,690.34

22521 A2 $1,294.39 $1,690.34

22522 A2 $1,294.39 $1,690.34

22523 G2 $3,289.61 $4,295.90

22524 G2 $3,289.61 $4,295.90

22525 G2 $3,289.61 $4,295.90

22900 G2 $932.08 $1,217.20

22901 G2 $932.08 $1,217.20

22902 G2 $629.45 $822.00

22903 G2 $932.08 $1,217.20

22904 G2 $629.45 $822.00

22905 G2 $932.08 $1,217.20

23000 A2 $629.45 $822.00

23020 A2 $1,294.39 $1,690.34

23030 A2 $740.20 $966.63

23031 A2 $740.20 $966.63

23035 A2 $872.73 $1,139.70

23040 A2 $1,294.39 $1,690.34

23044 A2 $1,294.39 $1,690.34

23065 P3 $133.03 $173.72

23066 A2 $932.08 $1,217.20

23071 G2 $932.08 $1,217.20

23073 G2 $932.08 $1,217.20

23075 G2 $629.45 $822.00

23076 G2 $629.45 $822.00

23077 G2 $629.45 $822.00

23078 G2 $932.08 $1,217.20

23100 A2 $872.73 $1,139.70

23101 A2 $1,294.39 $1,690.34

23105 A2 $1,294.39 $1,690.34

23106 A2 $1,294.39 $1,690.34

23107 A2 $1,294.39 $1,690.34

Updated 3/22/2013 MDWCC

Page 10 of 88

Page 11: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

23120 A2 $1,294.39 $1,690.34

23125 A2 $1,294.39 $1,690.34

23130 A2 $1,928.93 $2,518.99

23140 A2 $872.73 $1,139.70

23145 A2 $1,294.39 $1,690.34

23146 A2 $1,294.39 $1,690.34

23150 A2 $1,294.39 $1,690.34

23155 A2 $1,294.39 $1,690.34

23156 A2 $1,294.39 $1,690.34

23170 A2 $1,294.39 $1,690.34

23172 A2 $1,294.39 $1,690.34

23174 A2 $1,294.39 $1,690.34

23180 A2 $1,294.39 $1,690.34

23182 A2 $1,294.39 $1,690.34

23184 A2 $1,294.39 $1,690.34

23190 A2 $1,294.39 $1,690.34

23195 A2 $1,294.39 $1,690.34

23330 A2 $327.48 $427.66

23331 A2 $932.08 $1,217.20

23350 N1 $0.00 $0.00

23395 A2 $1,928.93 $2,518.99

23397 A2 $3,289.61 $4,295.90

23400 A2 $1,294.39 $1,690.34

23405 A2 $1,294.39 $1,690.34

23406 A2 $1,294.39 $1,690.34

23410 A2 $1,928.93 $2,518.99

23412 A2 $1,928.93 $2,518.99

23415 A2 $1,928.93 $2,518.99

23420 A2 $1,928.93 $2,518.99

23430 A2 $1,928.93 $2,518.99

23440 A2 $1,294.39 $1,690.34

23450 A2 $3,289.61 $4,295.90

23455 A2 $3,289.61 $4,295.90

23460 A2 $3,289.61 $4,295.90

23462 A2 $1,928.93 $2,518.99

23465 A2 $3,289.61 $4,295.90

23466 A2 $1,928.93 $2,518.99

23480 A2 $1,928.93 $2,518.99

23485 A2 $3,289.61 $4,295.90

23490 A2 $3,289.61 $4,295.90

23491 A2 $3,289.61 $4,295.90

23500 A2 $74.99 $97.93

23505 A2 $468.77 $612.17

23515 A2 $2,828.26 $3,693.42

23520 A2 $223.81 $292.27

23525 A2 $223.81 $292.27

23530 A2 $2,112.06 $2,758.14

23532 A2 $1,071.11 $1,398.76

23540 A2 $74.99 $97.93

23545 A2 $223.81 $292.27

23550 A2 $2,112.06 $2,758.14

23552 A2 $2,112.06 $2,758.14

23570 A2 $74.99 $97.93

23575 A2 $223.81 $292.27

23585 A2 $2,828.26 $3,693.42

23600 P2 $74.99 $97.93

23605 A2 $468.77 $612.17

23615 A2 $2,828.26 $3,693.42

23616 A2 $2,828.26 $3,693.42

23620 P2 $74.99 $97.93

23625 A2 $468.77 $612.17

Updated 3/22/2013 MDWCC

Page 11 of 88

Page 12: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

23630 A2 $2,828.26 $3,693.42

23650 A2 $74.99 $97.93

23655 A2 $583.05 $761.40

23660 A2 $2,112.06 $2,758.14

23665 A2 $223.81 $292.27

23670 A2 $2,828.26 $3,693.42

23675 A2 $74.99 $97.93

23680 A2 $2,112.06 $2,758.14

23700 A2 $583.05 $761.40

23800 A2 $3,289.61 $4,295.90

23802 A2 $3,289.61 $4,295.90

23921 A2 $623.76 $814.57

23930 A2 $740.20 $966.63

23931 A2 $407.14 $531.68

23935 A2 $872.73 $1,139.70

24000 A2 $1,294.39 $1,690.34

24006 A2 $1,294.39 $1,690.34

24065 P3 $182.36 $238.14

24066 A2 $629.45 $822.00

24071 G2 $932.08 $1,217.20

24073 G2 $932.08 $1,217.20

24075 G2 $629.45 $822.00

24076 G2 $629.45 $822.00

24077 G2 $629.45 $822.00

24079 G2 $932.08 $1,217.20

24100 A2 $872.73 $1,139.70

24101 A2 $1,294.39 $1,690.34

24102 A2 $1,294.39 $1,690.34

24105 A2 $872.73 $1,139.70

24110 A2 $872.73 $1,139.70

24115 A2 $1,294.39 $1,690.34

24116 A2 $1,294.39 $1,690.34

24120 A2 $872.73 $1,139.70

24125 A2 $1,294.39 $1,690.34

24126 A2 $1,294.39 $1,690.34

24130 A2 $1,294.39 $1,690.34

24134 A2 $1,294.39 $1,690.34

24136 A2 $1,294.39 $1,690.34

24138 A2 $1,294.39 $1,690.34

24140 A2 $1,294.39 $1,690.34

24145 A2 $1,294.39 $1,690.34

24147 A2 $1,294.39 $1,690.34

24149 G2 $1,294.39 $1,690.34

24152 G2 $1,928.93 $2,518.99

24155 A2 $1,294.39 $1,690.34

24160 A2 $1,294.39 $1,690.34

24164 A2 $1,294.39 $1,690.34

24200 P3 $138.47 $180.83

24201 A2 $629.45 $822.00

24220 N1 $0.00 $0.00

24300 G2 $583.05 $761.40

24301 A2 $1,294.39 $1,690.34

24305 A2 $1,294.39 $1,690.34

24310 A2 $872.73 $1,139.70

24320 A2 $1,294.39 $1,690.34

24330 A2 $3,289.61 $4,295.90

24331 A2 $1,928.93 $2,518.99

24332 G2 $1,294.39 $1,690.34

24340 A2 $1,928.93 $2,518.99

24341 A2 $1,928.93 $2,518.99

24342 A2 $1,928.93 $2,518.99

Updated 3/22/2013 MDWCC

Page 12 of 88

Page 13: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

24343 G2 $1,294.39 $1,690.34

24344 G2 $3,289.61 $4,295.90

24345 A2 $1,294.39 $1,690.34

24346 G2 $3,289.61 $4,295.90

24357 G2 $1,294.39 $1,690.34

24358 G2 $1,294.39 $1,690.34

24359 G2 $1,294.39 $1,690.34

24360 A2 $1,609.32 $2,101.61

24361 J8 $7,888.90 $10,302.11

24362 A2 $2,497.09 $3,260.95

24363 J8 $7,888.90 $10,302.11

24365 A2 $1,609.32 $2,101.61

24366 J8 $7,888.90 $10,302.11

24370 J8 $7,888.90 $10,302.11

24371 J8 $7,888.90 $10,302.11

24400 A2 $3,289.61 $4,295.90

24410 A2 $1,928.93 $2,518.99

24420 A2 $1,928.93 $2,518.99

24430 A2 $3,289.61 $4,295.90

24435 A2 $3,289.61 $4,295.90

24470 A2 $1,928.93 $2,518.99

24495 A2 $1,294.39 $1,690.34

24498 A2 $3,289.61 $4,295.90

24500 A2 $74.99 $97.93

24505 A2 $74.99 $97.93

24515 A2 $2,828.26 $3,693.42

24516 A2 $2,828.26 $3,693.42

24530 A2 $74.99 $97.93

24535 A2 $223.81 $292.27

24538 A2 $1,071.11 $1,398.76

24545 A2 $2,828.26 $3,693.42

24546 A2 $2,828.26 $3,693.42

24560 A2 $74.99 $97.93

24565 A2 $74.99 $97.93

24566 A2 $1,071.11 $1,398.76

24575 A2 $2,828.26 $3,693.42

24576 A2 $74.99 $97.93

24577 A2 $74.99 $97.93

24579 A2 $2,828.26 $3,693.42

24582 A2 $1,071.11 $1,398.76

24586 A2 $2,828.26 $3,693.42

24587 A2 $2,828.26 $3,693.42

24600 A2 $74.99 $97.93

24605 A2 $583.05 $761.40

24615 A2 $2,828.26 $3,693.42

24620 A2 $468.77 $612.17

24635 A2 $2,828.26 $3,693.42

24640 P2 $74.99 $97.93

24650 P2 $74.99 $97.93

24655 A2 $223.81 $292.27

24665 A2 $2,112.06 $2,758.14

24666 A2 $2,828.26 $3,693.42

24670 A2 $74.99 $97.93

24675 A2 $74.99 $97.93

24685 A2 $2,112.06 $2,758.14

24800 A2 $1,928.93 $2,518.99

24802 A2 $3,289.61 $4,295.90

24925 A2 $872.73 $1,139.70

25000 A2 $872.73 $1,139.70

25001 G2 $872.73 $1,139.70

25020 A2 $1,294.39 $1,690.34

Updated 3/22/2013 MDWCC

Page 13 of 88

Page 14: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

25023 A2 $1,294.39 $1,690.34

25024 A2 $1,294.39 $1,690.34

25025 A2 $1,294.39 $1,690.34

25028 A2 $872.73 $1,139.70

25031 A2 $872.73 $1,139.70

25035 A2 $872.73 $1,139.70

25040 A2 $1,294.39 $1,690.34

25065 P3 $183.72 $239.92

25066 A2 $932.08 $1,217.20

25071 G2 $932.08 $1,217.20

25073 G2 $932.08 $1,217.20

25075 G2 $629.45 $822.00

25076 G2 $629.45 $822.00

25077 G2 $629.45 $822.00

25078 G2 $932.08 $1,217.20

25085 A2 $872.73 $1,139.70

25100 A2 $872.73 $1,139.70

25101 A2 $1,294.39 $1,690.34

25105 A2 $1,294.39 $1,690.34

25107 A2 $1,294.39 $1,690.34

25109 G2 $872.73 $1,139.70

25110 A2 $872.73 $1,139.70

25111 A2 $872.73 $1,139.70

25112 A2 $872.73 $1,139.70

25115 A2 $872.73 $1,139.70

25116 A2 $872.73 $1,139.70

25118 A2 $1,294.39 $1,690.34

25119 A2 $1,294.39 $1,690.34

25120 A2 $1,294.39 $1,690.34

25125 A2 $1,294.39 $1,690.34

25126 A2 $1,294.39 $1,690.34

25130 A2 $1,294.39 $1,690.34

25135 A2 $1,294.39 $1,690.34

25136 A2 $1,294.39 $1,690.34

25145 A2 $1,294.39 $1,690.34

25150 A2 $1,294.39 $1,690.34

25151 A2 $1,294.39 $1,690.34

25210 A2 $1,294.39 $1,690.34

25215 A2 $1,294.39 $1,690.34

25230 A2 $1,294.39 $1,690.34

25240 A2 $1,294.39 $1,690.34

25246 N1 $0.00 $0.00

25248 A2 $872.73 $1,139.70

25250 A2 $1,294.39 $1,690.34

25251 A2 $1,294.39 $1,690.34

25259 G2 $468.77 $612.17

25260 A2 $1,294.39 $1,690.34

25263 A2 $1,294.39 $1,690.34

25265 A2 $1,294.39 $1,690.34

25270 A2 $1,294.39 $1,690.34

25272 A2 $1,294.39 $1,690.34

25274 A2 $1,294.39 $1,690.34

25275 A2 $1,294.39 $1,690.34

25280 A2 $1,294.39 $1,690.34

25290 A2 $1,294.39 $1,690.34

25295 A2 $872.73 $1,139.70

25300 A2 $1,294.39 $1,690.34

25301 A2 $1,294.39 $1,690.34

25310 A2 $1,294.39 $1,690.34

25312 A2 $1,928.93 $2,518.99

25315 A2 $1,294.39 $1,690.34

Updated 3/22/2013 MDWCC

Page 14 of 88

Page 15: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

25316 A2 $3,289.61 $4,295.90

25320 A2 $1,928.93 $2,518.99

25332 A2 $1,609.32 $2,101.61

25335 A2 $1,928.93 $2,518.99

25337 A2 $1,928.93 $2,518.99

25350 A2 $1,928.93 $2,518.99

25355 A2 $1,928.93 $2,518.99

25360 A2 $1,928.93 $2,518.99

25365 A2 $3,289.61 $4,295.90

25370 A2 $1,928.93 $2,518.99

25375 A2 $1,928.93 $2,518.99

25390 A2 $1,928.93 $2,518.99

25391 A2 $3,289.61 $4,295.90

25392 A2 $1,294.39 $1,690.34

25393 A2 $1,928.93 $2,518.99

25394 G2 $1,928.93 $2,518.99

25400 A2 $3,289.61 $4,295.90

25405 A2 $3,289.61 $4,295.90

25415 A2 $3,289.61 $4,295.90

25420 A2 $3,289.61 $4,295.90

25425 A2 $3,289.61 $4,295.90

25426 A2 $1,928.93 $2,518.99

25430 G2 $1,928.93 $2,518.99

25431 G2 $1,928.93 $2,518.99

25440 A2 $3,289.61 $4,295.90

25441 J8 $7,888.90 $10,302.11

25442 J8 $7,888.90 $10,302.11

25443 A2 $2,497.09 $3,260.95

25444 A2 $2,497.09 $3,260.95

25445 A2 $2,497.09 $3,260.95

25446 J8 $7,888.90 $10,302.11

25447 A2 $1,609.32 $2,101.61

25449 A2 $1,609.32 $2,101.61

25450 A2 $1,928.93 $2,518.99

25455 A2 $1,928.93 $2,518.99

25490 A2 $1,928.93 $2,518.99

25491 A2 $1,928.93 $2,518.99

25492 A2 $1,928.93 $2,518.99

25500 P2 $74.99 $97.93

25505 A2 $223.81 $292.27

25515 A2 $2,112.06 $2,758.14

25520 A2 $223.81 $292.27

25525 A2 $2,112.06 $2,758.14

25526 A2 $2,112.06 $2,758.14

25530 P2 $74.99 $97.93

25535 A2 $74.99 $97.93

25545 A2 $2,112.06 $2,758.14

25560 P2 $74.99 $97.93

25565 A2 $223.81 $292.27

25574 A2 $2,828.26 $3,693.42

25575 A2 $2,828.26 $3,693.42

25600 P2 $74.99 $97.93

25605 A2 $223.81 $292.27

25606 A2 $1,071.11 $1,398.76

25607 A2 $2,828.26 $3,693.42

25608 A2 $2,828.26 $3,693.42

25609 A2 $2,828.26 $3,693.42

25622 P2 $74.99 $97.93

25624 A2 $223.81 $292.27

25628 A2 $2,112.06 $2,758.14

25630 P2 $74.99 $97.93

Updated 3/22/2013 MDWCC

Page 15 of 88

Page 16: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

25635 A2 $74.99 $97.93

25645 A2 $2,112.06 $2,758.14

25650 P2 $74.99 $97.93

25651 G2 $1,071.11 $1,398.76

25652 G2 $2,112.06 $2,758.14

25660 A2 $74.99 $97.93

25670 A2 $1,071.11 $1,398.76

25671 A2 $1,071.11 $1,398.76

25675 A2 $74.99 $97.93

25676 A2 $1,071.11 $1,398.76

25680 A2 $74.99 $97.93

25685 A2 $1,071.11 $1,398.76

25690 A2 $468.77 $612.17

25695 A2 $1,071.11 $1,398.76

25800 A2 $3,289.61 $4,295.90

25805 A2 $3,289.61 $4,295.90

25810 A2 $3,289.61 $4,295.90

25820 A2 $1,928.93 $2,518.99

25825 A2 $3,289.61 $4,295.90

25830 A2 $3,289.61 $4,295.90

25907 A2 $872.73 $1,139.70

25922 A2 $872.73 $1,139.70

25929 A2 $623.76 $814.57

25931 G2 $872.73 $1,139.70

26010 P2 $70.40 $91.94

26011 A2 $407.14 $531.68

26020 A2 $665.18 $868.66

26025 A2 $665.18 $868.66

26030 A2 $665.18 $868.66

26034 A2 $665.18 $868.66

26035 G2 $665.18 $868.66

26037 G2 $665.18 $868.66

26040 A2 $665.18 $868.66

26045 A2 $1,159.36 $1,514.01

26055 A2 $665.18 $868.66

26060 A2 $665.18 $868.66

26070 A2 $665.18 $868.66

26075 A2 $665.18 $868.66

26080 A2 $665.18 $868.66

26100 A2 $665.18 $868.66

26105 A2 $665.18 $868.66

26110 A2 $665.18 $868.66

26111 G2 $932.08 $1,217.20

26113 G2 $932.08 $1,217.20

26115 G2 $629.45 $822.00

26116 G2 $629.45 $822.00

26117 G2 $629.45 $822.00

26118 G2 $932.08 $1,217.20

26121 A2 $1,159.36 $1,514.01

26123 A2 $1,159.36 $1,514.01

26125 A2 $665.18 $868.66

26130 A2 $665.18 $868.66

26135 A2 $1,159.36 $1,514.01

26140 A2 $665.18 $868.66

26145 A2 $665.18 $868.66

26160 A2 $665.18 $868.66

26170 A2 $665.18 $868.66

26180 A2 $665.18 $868.66

26185 A2 $665.18 $868.66

26200 A2 $665.18 $868.66

26205 A2 $1,159.36 $1,514.01

Updated 3/22/2013 MDWCC

Page 16 of 88

Page 17: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

26210 A2 $665.18 $868.66

26215 A2 $665.18 $868.66

26230 A2 $665.18 $868.66

26235 A2 $665.18 $868.66

26236 A2 $665.18 $868.66

26250 A2 $665.18 $868.66

26260 A2 $665.18 $868.66

26262 A2 $665.18 $868.66

26320 A2 $629.45 $822.00

26340 G2 $223.81 $292.27

26341 G2 $223.81 $292.27

26350 A2 $1,159.36 $1,514.01

26352 A2 $1,159.36 $1,514.01

26356 A2 $1,159.36 $1,514.01

26357 A2 $1,159.36 $1,514.01

26358 A2 $1,159.36 $1,514.01

26370 A2 $1,159.36 $1,514.01

26372 A2 $1,159.36 $1,514.01

26373 A2 $1,159.36 $1,514.01

26390 A2 $1,159.36 $1,514.01

26392 A2 $1,159.36 $1,514.01

26410 A2 $665.18 $868.66

26412 A2 $1,159.36 $1,514.01

26415 A2 $1,159.36 $1,514.01

26416 A2 $1,159.36 $1,514.01

26418 A2 $665.18 $868.66

26420 A2 $1,159.36 $1,514.01

26426 A2 $1,159.36 $1,514.01

26428 A2 $1,159.36 $1,514.01

26432 A2 $665.18 $868.66

26433 A2 $665.18 $868.66

26434 A2 $1,159.36 $1,514.01

26437 A2 $665.18 $868.66

26440 A2 $665.18 $868.66

26442 A2 $1,159.36 $1,514.01

26445 A2 $665.18 $868.66

26449 A2 $1,159.36 $1,514.01

26450 A2 $665.18 $868.66

26455 A2 $665.18 $868.66

26460 A2 $665.18 $868.66

26471 A2 $665.18 $868.66

26474 A2 $665.18 $868.66

26476 A2 $665.18 $868.66

26477 A2 $665.18 $868.66

26478 A2 $665.18 $868.66

26479 A2 $665.18 $868.66

26480 A2 $1,159.36 $1,514.01

26483 A2 $1,159.36 $1,514.01

26485 A2 $1,159.36 $1,514.01

26489 A2 $1,159.36 $1,514.01

26490 A2 $1,159.36 $1,514.01

26492 A2 $1,159.36 $1,514.01

26494 A2 $1,159.36 $1,514.01

26496 A2 $1,159.36 $1,514.01

26497 A2 $1,159.36 $1,514.01

26498 A2 $1,159.36 $1,514.01

26499 A2 $1,159.36 $1,514.01

26500 A2 $665.18 $868.66

26502 A2 $1,159.36 $1,514.01

26508 A2 $665.18 $868.66

26510 A2 $1,159.36 $1,514.01

Updated 3/22/2013 MDWCC

Page 17 of 88

Page 18: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

26516 A2 $1,159.36 $1,514.01

26517 A2 $1,159.36 $1,514.01

26518 A2 $1,159.36 $1,514.01

26520 A2 $665.18 $868.66

26525 A2 $665.18 $868.66

26530 A2 $1,609.32 $2,101.61

26531 A2 $2,497.09 $3,260.95

26535 A2 $1,609.32 $2,101.61

26536 A2 $2,497.09 $3,260.95

26540 A2 $665.18 $868.66

26541 A2 $1,159.36 $1,514.01

26542 A2 $665.18 $868.66

26545 A2 $1,159.36 $1,514.01

26546 A2 $1,159.36 $1,514.01

26548 A2 $1,159.36 $1,514.01

26550 A2 $1,159.36 $1,514.01

26555 A2 $1,159.36 $1,514.01

26560 A2 $665.18 $868.66

26561 A2 $1,159.36 $1,514.01

26562 A2 $1,159.36 $1,514.01

26565 A2 $1,159.36 $1,514.01

26567 A2 $1,159.36 $1,514.01

26568 A2 $1,159.36 $1,514.01

26580 A2 $665.18 $868.66

26587 A2 $665.18 $868.66

26590 A2 $665.18 $868.66

26591 A2 $1,159.36 $1,514.01

26593 A2 $665.18 $868.66

26596 A2 $665.18 $868.66

26600 P2 $74.99 $97.93

26605 A2 $74.99 $97.93

26607 A2 $468.77 $612.17

26608 A2 $1,071.11 $1,398.76

26615 A2 $2,112.06 $2,758.14

26641 P2 $74.99 $97.93

26645 A2 $223.81 $292.27

26650 A2 $1,071.11 $1,398.76

26665 A2 $2,112.06 $2,758.14

26670 P2 $74.99 $97.93

26675 A2 $74.99 $97.93

26676 A2 $1,071.11 $1,398.76

26685 A2 $1,071.11 $1,398.76

26686 A2 $2,828.26 $3,693.42

26700 P2 $74.99 $97.93

26705 A2 $74.99 $97.93

26706 A2 $468.77 $612.17

26715 A2 $1,071.11 $1,398.76

26720 P2 $74.99 $97.93

26725 P2 $74.99 $97.93

26727 A2 $1,071.11 $1,398.76

26735 A2 $1,071.11 $1,398.76

26740 P2 $74.99 $97.93

26742 A2 $74.99 $97.93

26746 A2 $1,071.11 $1,398.76

26750 P2 $74.99 $97.93

26755 G2 $74.99 $97.93

26756 A2 $1,071.11 $1,398.76

26765 A2 $1,071.11 $1,398.76

26770 G2 $74.99 $97.93

26775 P3 $237.14 $309.68

26776 A2 $1,071.11 $1,398.76

Updated 3/22/2013 MDWCC

Page 18 of 88

Page 19: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

26785 A2 $1,071.11 $1,398.76

26820 A2 $1,159.36 $1,514.01

26841 A2 $1,159.36 $1,514.01

26842 A2 $1,159.36 $1,514.01

26843 A2 $1,159.36 $1,514.01

26844 A2 $1,159.36 $1,514.01

26850 A2 $1,159.36 $1,514.01

26852 A2 $1,159.36 $1,514.01

26860 A2 $1,159.36 $1,514.01

26861 A2 $1,159.36 $1,514.01

26862 A2 $1,159.36 $1,514.01

26863 A2 $1,159.36 $1,514.01

26910 A2 $1,159.36 $1,514.01

26951 A2 $665.18 $868.66

26952 A2 $665.18 $868.66

26990 A2 $872.73 $1,139.70

26991 A2 $872.73 $1,139.70

27000 A2 $872.73 $1,139.70

27001 A2 $1,294.39 $1,690.34

27003 A2 $1,294.39 $1,690.34

27033 A2 $1,928.93 $2,518.99

27035 A2 $1,294.39 $1,690.34

27040 A2 $327.48 $427.66

27041 A2 $327.48 $427.66

27043 G2 $932.08 $1,217.20

27045 G2 $932.08 $1,217.20

27047 G2 $629.45 $822.00

27048 G2 $629.45 $822.00

27049 G2 $629.45 $822.00

27050 A2 $872.73 $1,139.70

27052 A2 $872.73 $1,139.70

27059 G2 $932.08 $1,217.20

27060 A2 $872.73 $1,139.70

27062 A2 $872.73 $1,139.70

27065 A2 $872.73 $1,139.70

27066 A2 $1,294.39 $1,690.34

27067 A2 $1,294.39 $1,690.34

27080 A2 $1,294.39 $1,690.34

27086 A2 $327.48 $427.66

27087 A2 $872.73 $1,139.70

27093 N1 $0.00 $0.00

27095 N1 $0.00 $0.00

27097 A2 $1,294.39 $1,690.34

27098 A2 $1,294.39 $1,690.34

27100 A2 $1,928.93 $2,518.99

27105 A2 $1,928.93 $2,518.99

27110 A2 $1,928.93 $2,518.99

27111 A2 $1,928.93 $2,518.99

27193 A2 $74.99 $97.93

27194 A2 $583.05 $761.40

27200 P2 $74.99 $97.93

27202 A2 $2,112.06 $2,758.14

27220 G2 $74.99 $97.93

27230 A2 $74.99 $97.93

27238 A2 $223.81 $292.27

27246 A2 $223.81 $292.27

27250 A2 $74.99 $97.93

27252 A2 $583.05 $761.40

27256 G2 $74.99 $97.93

27257 A2 $583.05 $761.40

27265 A2 $74.99 $97.93

Updated 3/22/2013 MDWCC

Page 19 of 88

Page 20: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

27266 A2 $583.05 $761.40

27267 G2 $74.99 $97.93

27275 A2 $583.05 $761.40

27301 A2 $740.20 $966.63

27305 A2 $872.73 $1,139.70

27306 A2 $872.73 $1,139.70

27307 A2 $1,294.39 $1,690.34

27310 A2 $1,294.39 $1,690.34

27323 A2 $327.48 $427.66

27324 A2 $932.08 $1,217.20

27325 A2 $754.56 $985.38

27326 A2 $754.56 $985.38

27327 G2 $932.08 $1,217.20

27328 G2 $629.45 $822.00

27329 G2 $629.45 $822.00

27330 A2 $1,294.39 $1,690.34

27331 A2 $1,294.39 $1,690.34

27332 A2 $1,294.39 $1,690.34

27333 A2 $1,294.39 $1,690.34

27334 A2 $1,294.39 $1,690.34

27335 A2 $1,294.39 $1,690.34

27337 G2 $932.08 $1,217.20

27339 G2 $932.08 $1,217.20

27340 A2 $872.73 $1,139.70

27345 A2 $872.73 $1,139.70

27347 A2 $872.73 $1,139.70

27350 A2 $1,294.39 $1,690.34

27355 A2 $1,294.39 $1,690.34

27356 A2 $1,294.39 $1,690.34

27357 A2 $1,294.39 $1,690.34

27358 A2 $1,294.39 $1,690.34

27360 A2 $1,294.39 $1,690.34

27364 G2 $932.08 $1,217.20

27370 N1 $0.00 $0.00

27372 A2 $932.08 $1,217.20

27380 A2 $1,294.39 $1,690.34

27381 A2 $1,294.39 $1,690.34

27385 A2 $1,294.39 $1,690.34

27386 A2 $1,294.39 $1,690.34

27390 A2 $872.73 $1,139.70

27391 A2 $872.73 $1,139.70

27392 A2 $1,294.39 $1,690.34

27393 A2 $1,294.39 $1,690.34

27394 A2 $1,294.39 $1,690.34

27395 A2 $1,928.93 $2,518.99

27396 A2 $1,294.39 $1,690.34

27397 A2 $1,928.93 $2,518.99

27400 A2 $1,928.93 $2,518.99

27403 A2 $1,294.39 $1,690.34

27405 A2 $1,928.93 $2,518.99

27407 A2 $3,289.61 $4,295.90

27409 A2 $3,289.61 $4,295.90

27416 G2 $1,928.93 $2,518.99

27418 A2 $1,928.93 $2,518.99

27420 A2 $1,928.93 $2,518.99

27422 A2 $1,928.93 $2,518.99

27424 A2 $1,928.93 $2,518.99

27425 A2 $1,294.39 $1,690.34

27427 A2 $3,289.61 $4,295.90

27428 A2 $3,289.61 $4,295.90

27429 A2 $3,289.61 $4,295.90

Updated 3/22/2013 MDWCC

Page 20 of 88

Page 21: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

27430 A2 $1,928.93 $2,518.99

27435 A2 $1,294.39 $1,690.34

27437 A2 $1,609.32 $2,101.61

27438 A2 $2,497.09 $3,260.95

27440 G2 $1,609.32 $2,101.61

27441 A2 $1,609.32 $2,101.61

27442 A2 $1,609.32 $2,101.61

27443 A2 $1,609.32 $2,101.61

27446 J8 $7,888.90 $10,302.11

27475 G2 $1,294.39 $1,690.34

27479 G2 $1,294.39 $1,690.34

27496 A2 $1,294.39 $1,690.34

27497 A2 $872.73 $1,139.70

27498 A2 $1,294.39 $1,690.34

27499 A2 $1,294.39 $1,690.34

27500 A2 $223.81 $292.27

27501 A2 $74.99 $97.93

27502 A2 $468.77 $612.17

27503 A2 $74.99 $97.93

27508 A2 $74.99 $97.93

27509 A2 $1,071.11 $1,398.76

27510 A2 $223.81 $292.27

27516 A2 $74.99 $97.93

27517 A2 $74.99 $97.93

27520 A2 $74.99 $97.93

27530 A2 $74.99 $97.93

27532 A2 $468.77 $612.17

27538 A2 $74.99 $97.93

27550 A2 $74.99 $97.93

27552 A2 $583.05 $761.40

27560 A2 $74.99 $97.93

27562 A2 $583.05 $761.40

27566 A2 $2,112.06 $2,758.14

27570 A2 $583.05 $761.40

27594 A2 $872.73 $1,139.70

27600 A2 $872.73 $1,139.70

27601 A2 $872.73 $1,139.70

27602 A2 $1,294.39 $1,690.34

27603 A2 $740.20 $966.63

27604 A2 $1,294.39 $1,690.34

27605 A2 $888.79 $1,160.67

27606 A2 $872.73 $1,139.70

27607 A2 $872.73 $1,139.70

27610 A2 $1,294.39 $1,690.34

27612 A2 $1,294.39 $1,690.34

27613 P3 $177.60 $231.93

27614 A2 $932.08 $1,217.20

27615 G2 $629.45 $822.00

27616 G2 $932.08 $1,217.20

27618 G2 $629.45 $822.00

27619 G2 $629.45 $822.00

27620 A2 $1,294.39 $1,690.34

27625 A2 $1,294.39 $1,690.34

27626 A2 $1,294.39 $1,690.34

27630 A2 $872.73 $1,139.70

27632 G2 $932.08 $1,217.20

27634 G2 $932.08 $1,217.20

27635 A2 $1,294.39 $1,690.34

27637 A2 $1,294.39 $1,690.34

27638 A2 $1,294.39 $1,690.34

27640 A2 $1,294.39 $1,690.34

Updated 3/22/2013 MDWCC

Page 21 of 88

Page 22: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

27641 A2 $1,294.39 $1,690.34

27647 A2 $1,294.39 $1,690.34

27648 N1 $0.00 $0.00

27650 A2 $1,928.93 $2,518.99

27652 A2 $3,289.61 $4,295.90

27654 A2 $1,928.93 $2,518.99

27656 A2 $872.73 $1,139.70

27658 A2 $872.73 $1,139.70

27659 A2 $872.73 $1,139.70

27664 A2 $1,294.39 $1,690.34

27665 A2 $1,294.39 $1,690.34

27675 A2 $872.73 $1,139.70

27676 A2 $1,294.39 $1,690.34

27680 A2 $1,294.39 $1,690.34

27681 A2 $1,294.39 $1,690.34

27685 A2 $1,294.39 $1,690.34

27686 A2 $1,294.39 $1,690.34

27687 A2 $1,294.39 $1,690.34

27690 A2 $1,928.93 $2,518.99

27691 A2 $1,928.93 $2,518.99

27692 A2 $1,928.93 $2,518.99

27695 A2 $1,294.39 $1,690.34

27696 A2 $1,294.39 $1,690.34

27698 A2 $1,294.39 $1,690.34

27700 A2 $1,609.32 $2,101.61

27704 A2 $872.73 $1,139.70

27705 A2 $1,928.93 $2,518.99

27707 A2 $1,294.39 $1,690.34

27709 A2 $1,294.39 $1,690.34

27720 G2 $2,112.06 $2,758.14

27726 G2 $2,112.06 $2,758.14

27730 A2 $1,294.39 $1,690.34

27732 A2 $1,294.39 $1,690.34

27734 A2 $1,294.39 $1,690.34

27740 A2 $1,294.39 $1,690.34

27742 A2 $1,928.93 $2,518.99

27745 A2 $3,289.61 $4,295.90

27750 A2 $74.99 $97.93

27752 A2 $468.77 $612.17

27756 A2 $1,071.11 $1,398.76

27758 A2 $2,112.06 $2,758.14

27759 A2 $2,828.26 $3,693.42

27760 A2 $74.99 $97.93

27762 A2 $468.77 $612.17

27766 A2 $2,112.06 $2,758.14

27767 P2 $74.99 $97.93

27768 G2 $74.99 $97.93

27769 G2 $2,112.06 $2,758.14

27780 A2 $74.99 $97.93

27781 A2 $468.77 $612.17

27784 A2 $2,112.06 $2,758.14

27786 A2 $74.99 $97.93

27788 A2 $74.99 $97.93

27792 A2 $2,112.06 $2,758.14

27808 A2 $74.99 $97.93

27810 A2 $74.99 $97.93

27814 A2 $2,112.06 $2,758.14

27816 A2 $74.99 $97.93

27818 A2 $223.81 $292.27

27822 A2 $2,112.06 $2,758.14

27823 A2 $2,828.26 $3,693.42

Updated 3/22/2013 MDWCC

Page 22 of 88

Page 23: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

27824 A2 $74.99 $97.93

27825 A2 $468.77 $612.17

27826 A2 $2,112.06 $2,758.14

27827 A2 $2,828.26 $3,693.42

27828 A2 $2,828.26 $3,693.42

27829 A2 $2,112.06 $2,758.14

27830 A2 $74.99 $97.93

27831 A2 $468.77 $612.17

27832 A2 $2,112.06 $2,758.14

27840 A2 $74.99 $97.93

27842 A2 $583.05 $761.40

27846 A2 $2,112.06 $2,758.14

27848 A2 $2,112.06 $2,758.14

27860 A2 $583.05 $761.40

27870 A2 $3,289.61 $4,295.90

27871 A2 $3,289.61 $4,295.90

27884 A2 $872.73 $1,139.70

27889 A2 $1,294.39 $1,690.34

27892 A2 $1,294.39 $1,690.34

27893 A2 $1,294.39 $1,690.34

27894 A2 $1,294.39 $1,690.34

28001 P3 $180.32 $235.48

28002 A2 $872.73 $1,139.70

28003 A2 $872.73 $1,139.70

28005 A2 $888.79 $1,160.67

28008 A2 $888.79 $1,160.67

28010 P3 $127.25 $166.18

28011 A2 $888.79 $1,160.67

28020 A2 $888.79 $1,160.67

28022 A2 $888.79 $1,160.67

28024 A2 $888.79 $1,160.67

28035 A2 $754.56 $985.38

28039 G2 $932.08 $1,217.20

28041 G2 $932.08 $1,217.20

28043 G2 $629.45 $822.00

28045 G2 $629.45 $822.00

28046 G2 $629.45 $822.00

28047 G2 $932.08 $1,217.20

28050 A2 $888.79 $1,160.67

28052 A2 $888.79 $1,160.67

28054 A2 $888.79 $1,160.67

28055 A2 $754.56 $985.38

28060 A2 $888.79 $1,160.67

28062 A2 $888.79 $1,160.67

28070 A2 $888.79 $1,160.67

28072 A2 $888.79 $1,160.67

28080 A2 $888.79 $1,160.67

28086 A2 $888.79 $1,160.67

28088 A2 $888.79 $1,160.67

28090 A2 $888.79 $1,160.67

28092 A2 $888.79 $1,160.67

28100 A2 $888.79 $1,160.67

28102 A2 $2,428.46 $3,171.33

28103 A2 $2,428.46 $3,171.33

28104 A2 $888.79 $1,160.67

28106 A2 $2,428.46 $3,171.33

28107 A2 $2,428.46 $3,171.33

28108 A2 $888.79 $1,160.67

28110 A2 $888.79 $1,160.67

28111 A2 $888.79 $1,160.67

28112 A2 $888.79 $1,160.67

Updated 3/22/2013 MDWCC

Page 23 of 88

Page 24: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

28113 A2 $888.79 $1,160.67

28114 A2 $888.79 $1,160.67

28116 A2 $888.79 $1,160.67

28118 A2 $888.79 $1,160.67

28119 A2 $888.79 $1,160.67

28120 A2 $888.79 $1,160.67

28122 A2 $888.79 $1,160.67

28124 P3 $307.57 $401.66

28126 A2 $888.79 $1,160.67

28130 A2 $888.79 $1,160.67

28140 A2 $888.79 $1,160.67

28150 A2 $888.79 $1,160.67

28153 A2 $888.79 $1,160.67

28160 A2 $888.79 $1,160.67

28171 A2 $888.79 $1,160.67

28173 A2 $888.79 $1,160.67

28175 A2 $888.79 $1,160.67

28190 P3 $192.57 $251.48

28192 A2 $629.45 $822.00

28193 A2 $327.48 $427.66

28200 A2 $888.79 $1,160.67

28202 A2 $888.79 $1,160.67

28208 A2 $888.79 $1,160.67

28210 A2 $2,428.46 $3,171.33

28220 P3 $290.22 $379.00

28222 A2 $888.79 $1,160.67

28225 A2 $888.79 $1,160.67

28226 A2 $888.79 $1,160.67

28230 P3 $284.43 $371.44

28232 P3 $274.91 $359.00

28234 A2 $888.79 $1,160.67

28238 A2 $2,428.46 $3,171.33

28240 A2 $888.79 $1,160.67

28250 A2 $888.79 $1,160.67

28260 A2 $888.79 $1,160.67

28261 A2 $888.79 $1,160.67

28262 A2 $888.79 $1,160.67

28264 A2 $2,428.46 $3,171.33

28270 A2 $888.79 $1,160.67

28272 P3 $263.00 $343.45

28280 A2 $888.79 $1,160.67

28285 A2 $888.79 $1,160.67

28286 A2 $888.79 $1,160.67

28288 A2 $888.79 $1,160.67

28289 A2 $888.79 $1,160.67

28290 A2 $1,377.81 $1,799.28

28292 A2 $1,377.81 $1,799.28

28293 A2 $1,377.81 $1,799.28

28294 A2 $1,377.81 $1,799.28

28296 A2 $1,377.81 $1,799.28

28297 A2 $1,377.81 $1,799.28

28298 A2 $1,377.81 $1,799.28

28299 A2 $1,377.81 $1,799.28

28300 A2 $2,428.46 $3,171.33

28302 A2 $888.79 $1,160.67

28304 A2 $2,428.46 $3,171.33

28305 A2 $2,428.46 $3,171.33

28306 A2 $888.79 $1,160.67

28307 A2 $888.79 $1,160.67

28308 A2 $888.79 $1,160.67

28309 A2 $2,428.46 $3,171.33

Updated 3/22/2013 MDWCC

Page 24 of 88

Page 25: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

28310 A2 $888.79 $1,160.67

28312 A2 $888.79 $1,160.67

28313 A2 $888.79 $1,160.67

28315 A2 $888.79 $1,160.67

28320 A2 $2,428.46 $3,171.33

28322 A2 $2,428.46 $3,171.33

28340 A2 $888.79 $1,160.67

28341 A2 $888.79 $1,160.67

28344 A2 $888.79 $1,160.67

28345 A2 $888.79 $1,160.67

28400 A2 $74.99 $97.93

28405 A2 $468.77 $612.17

28406 A2 $1,071.11 $1,398.76

28415 A2 $2,828.26 $3,693.42

28420 A2 $2,112.06 $2,758.14

28430 P2 $74.99 $97.93

28435 A2 $74.99 $97.93

28436 A2 $1,071.11 $1,398.76

28445 A2 $2,112.06 $2,758.14

28446 G2 $2,428.46 $3,171.33

28450 P2 $74.99 $97.93

28455 P2 $74.99 $97.93

28456 A2 $1,071.11 $1,398.76

28465 A2 $2,112.06 $2,758.14

28470 P2 $74.99 $97.93

28475 P2 $74.99 $97.93

28476 A2 $1,071.11 $1,398.76

28485 A2 $2,112.06 $2,758.14

28490 P2 $74.99 $97.93

28495 P2 $74.99 $97.93

28496 A2 $1,071.11 $1,398.76

28505 A2 $1,071.11 $1,398.76

28510 P2 $74.99 $97.93

28515 P2 $74.99 $97.93

28525 A2 $1,071.11 $1,398.76

28530 P2 $74.99 $97.93

28531 A2 $1,071.11 $1,398.76

28540 P2 $74.99 $97.93

28545 A2 $1,071.11 $1,398.76

28546 A2 $1,071.11 $1,398.76

28555 A2 $2,112.06 $2,758.14

28570 P2 $74.99 $97.93

28575 A2 $468.77 $612.17

28576 A2 $1,071.11 $1,398.76

28585 A2 $1,071.11 $1,398.76

28600 P2 $74.99 $97.93

28605 A2 $74.99 $97.93

28606 A2 $1,071.11 $1,398.76

28615 A2 $2,112.06 $2,758.14

28630 P2 $74.99 $97.93

28635 A2 $583.05 $761.40

28636 A2 $1,071.11 $1,398.76

28645 A2 $1,071.11 $1,398.76

28660 P3 $70.09 $91.53

28665 A2 $583.05 $761.40

28666 A2 $1,071.11 $1,398.76

28675 A2 $1,071.11 $1,398.76

28705 A2 $2,428.46 $3,171.33

28715 A2 $3,289.61 $4,295.90

28725 A2 $2,428.46 $3,171.33

28730 A2 $2,428.46 $3,171.33

Updated 3/22/2013 MDWCC

Page 25 of 88

Page 26: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

28735 A2 $2,428.46 $3,171.33

28737 A2 $2,428.46 $3,171.33

28740 A2 $2,428.46 $3,171.33

28750 A2 $2,428.46 $3,171.33

28755 A2 $888.79 $1,160.67

28760 A2 $2,428.46 $3,171.33

28810 A2 $888.79 $1,160.67

28820 A2 $888.79 $1,160.67

28825 A2 $888.79 $1,160.67

28890 P3 $207.54 $271.03

29000 G2 $53.05 $69.28

29010 P2 $106.13 $138.60

29015 P2 $106.13 $138.60

29020 G2 $53.05 $69.28

29025 P2 $53.05 $69.28

29035 P2 $106.13 $138.60

29040 G2 $53.05 $69.28

29044 P2 $106.13 $138.60

29046 G2 $106.13 $138.60

29049 P2 $53.05 $69.28

29055 P2 $106.13 $138.60

29058 P2 $53.05 $69.28

29065 P3 $64.30 $83.97

29075 P3 $58.52 $76.42

29085 P2 $53.05 $69.28

29086 P2 $53.05 $69.28

29105 P2 $53.05 $69.28

29125 P3 $47.63 $62.20

29126 P2 $53.05 $69.28

29130 P3 $22.46 $29.33

29131 P2 $30.27 $39.53

29200 P2 $30.27 $39.53

29240 P2 $30.27 $39.53

29260 P2 $30.27 $39.53

29280 P2 $30.27 $39.53

29305 P2 $106.13 $138.60

29325 P2 $106.13 $138.60

29345 P3 $83.70 $109.30

29355 P3 $84.04 $109.75

29358 P2 $106.13 $138.60

29365 P3 $79.27 $103.52

29405 P3 $53.08 $69.32

29425 P3 $50.01 $65.31

29435 P3 $75.53 $98.63

29440 P3 $23.48 $30.66

29445 P3 $70.77 $92.42

29450 P2 $53.05 $69.28

29505 P2 $53.05 $69.28

29515 P3 $45.93 $59.98

29520 P3 $29.94 $39.10

29530 P2 $30.27 $39.53

29540 P3 $23.48 $30.66

29550 P3 $23.48 $30.66

29580 P3 $33.00 $43.09

29581 P2 $53.05 $69.28

29582 P2 $30.27 $39.53

29583 P2 $30.27 $39.53

29584 P2 $30.27 $39.53

29700 P3 $45.25 $59.09

29705 P3 $38.11 $49.77

29710 P3 $71.79 $93.75

Updated 3/22/2013 MDWCC

Page 26 of 88

Page 27: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

29715 P3 $46.27 $60.42

29720 P2 $53.05 $69.28

29730 P3 $37.43 $48.88

29740 P3 $51.37 $67.08

29750 P2 $53.05 $69.28

29800 A2 $1,184.89 $1,547.35

29804 A2 $1,184.89 $1,547.35

29805 A2 $1,184.89 $1,547.35

29806 A2 $2,177.30 $2,843.34

29807 A2 $2,177.30 $2,843.34

29819 A2 $2,177.30 $2,843.34

29820 A2 $2,177.30 $2,843.34

29821 A2 $2,177.30 $2,843.34

29822 A2 $1,184.89 $1,547.35

29823 A2 $2,177.30 $2,843.34

29824 A2 $1,184.89 $1,547.35

29825 A2 $2,177.30 $2,843.34

29826 A2 $1,184.89 $1,547.35

29827 A2 $2,177.30 $2,843.34

29828 G2 $2,177.30 $2,843.34

29830 A2 $1,184.89 $1,547.35

29834 A2 $1,184.89 $1,547.35

29835 A2 $1,184.89 $1,547.35

29836 A2 $1,184.89 $1,547.35

29837 A2 $1,184.89 $1,547.35

29838 A2 $1,184.89 $1,547.35

29840 A2 $1,184.89 $1,547.35

29843 A2 $1,184.89 $1,547.35

29844 A2 $1,184.89 $1,547.35

29845 A2 $1,184.89 $1,547.35

29846 A2 $1,184.89 $1,547.35

29847 A2 $2,177.30 $2,843.34

29848 A2 $1,184.89 $1,547.35

29850 A2 $1,184.89 $1,547.35

29851 A2 $2,177.30 $2,843.34

29855 A2 $2,177.30 $2,843.34

29856 A2 $2,177.30 $2,843.34

29860 A2 $2,177.30 $2,843.34

29861 A2 $2,177.30 $2,843.34

29862 A2 $2,177.30 $2,843.34

29863 A2 $2,177.30 $2,843.34

29866 G2 $2,177.30 $2,843.34

29870 A2 $1,184.89 $1,547.35

29871 A2 $1,184.89 $1,547.35

29873 A2 $1,184.89 $1,547.35

29874 A2 $1,184.89 $1,547.35

29875 A2 $1,184.89 $1,547.35

29876 A2 $1,184.89 $1,547.35

29877 A2 $1,184.89 $1,547.35

29879 A2 $1,184.89 $1,547.35

29880 A2 $1,184.89 $1,547.35

29881 A2 $1,184.89 $1,547.35

29882 A2 $1,184.89 $1,547.35

29883 A2 $1,184.89 $1,547.35

29884 A2 $1,184.89 $1,547.35

29885 A2 $2,177.30 $2,843.34

29886 A2 $1,184.89 $1,547.35

29887 A2 $1,184.89 $1,547.35

29888 A2 $3,289.61 $4,295.90

29889 A2 $3,289.61 $4,295.90

29891 A2 $2,177.30 $2,843.34

Updated 3/22/2013 MDWCC

Page 27 of 88

Page 28: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

29892 A2 $3,289.61 $4,295.90

29893 A2 $888.79 $1,160.67

29894 A2 $1,184.89 $1,547.35

29895 A2 $1,184.89 $1,547.35

29897 A2 $1,184.89 $1,547.35

29898 A2 $1,184.89 $1,547.35

29899 A2 $2,177.30 $2,843.34

29900 A2 $1,184.89 $1,547.35

29901 A2 $1,184.89 $1,547.35

29902 A2 $1,184.89 $1,547.35

29904 G2 $1,184.89 $1,547.35

29905 G2 $1,184.89 $1,547.35

29906 G2 $1,184.89 $1,547.35

29907 G2 $2,177.30 $2,843.34

29914 G2 $2,177.30 $2,843.34

29915 G2 $2,177.30 $2,843.34

29916 G2 $2,177.30 $2,843.34

30000 P2 $128.95 $168.40

30020 P2 $128.95 $168.40

30100 P3 $113.64 $148.40

30110 P3 $177.60 $231.93

30115 A2 $1,009.91 $1,318.84

30117 A2 $643.83 $840.78

30118 A2 $1,009.91 $1,318.84

30120 A2 $1,009.91 $1,318.84

30124 R2 $1,009.91 $1,318.84

30125 A2 $1,839.88 $2,402.70

30130 A2 $1,009.91 $1,318.84

30140 A2 $1,009.91 $1,318.84

30150 A2 $1,839.88 $2,402.70

30160 A2 $1,839.88 $2,402.70

30200 P3 $90.50 $118.18

30210 P3 $114.32 $149.29

30220 A2 $643.83 $840.78

30300 P2 $27.85 $36.37

30310 A2 $643.83 $840.78

30320 A2 $1,009.91 $1,318.84

30400 A2 $1,009.91 $1,318.84

30410 A2 $1,839.88 $2,402.70

30420 A2 $1,839.88 $2,402.70

30430 A2 $1,009.91 $1,318.84

30435 A2 $1,839.88 $2,402.70

30450 A2 $1,839.88 $2,402.70

30460 A2 $1,839.88 $2,402.70

30462 A2 $1,839.88 $2,402.70

30465 A2 $1,839.88 $2,402.70

30520 A2 $1,009.91 $1,318.84

30540 A2 $1,839.88 $2,402.70

30545 A2 $1,839.88 $2,402.70

30560 A2 $128.95 $168.40

30580 A2 $1,839.88 $2,402.70

30600 A2 $1,839.88 $2,402.70

30620 A2 $1,839.88 $2,402.70

30630 A2 $1,009.91 $1,318.84

30801 A2 $643.83 $840.78

30802 A2 $643.83 $840.78

30901 P2 $43.82 $57.22

30903 A2 $43.82 $57.22

30905 A2 $43.82 $57.22

30906 A2 $43.82 $57.22

30915 A2 $1,099.07 $1,435.28

Updated 3/22/2013 MDWCC

Page 28 of 88

Page 29: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

30920 A2 $1,099.07 $1,435.28

30930 A2 $1,009.91 $1,318.84

31000 P2 $128.95 $168.40

31002 R2 $279.76 $365.34

31020 A2 $1,009.91 $1,318.84

31030 A2 $1,839.88 $2,402.70

31032 A2 $1,839.88 $2,402.70

31040 R2 $1,009.91 $1,318.84

31050 A2 $1,839.88 $2,402.70

31051 A2 $1,839.88 $2,402.70

31070 A2 $1,839.88 $2,402.70

31075 A2 $1,839.88 $2,402.70

31080 A2 $1,839.88 $2,402.70

31081 A2 $1,839.88 $2,402.70

31084 A2 $1,839.88 $2,402.70

31085 A2 $1,839.88 $2,402.70

31086 A2 $1,839.88 $2,402.70

31087 A2 $1,839.88 $2,402.70

31090 A2 $1,839.88 $2,402.70

31200 A2 $1,009.91 $1,318.84

31201 A2 $1,009.91 $1,318.84

31205 A2 $1,009.91 $1,318.84

31231 P2 $80.18 $104.71

31233 A2 $80.18 $104.71

31235 A2 $758.67 $990.75

31237 A2 $758.67 $990.75

31238 A2 $758.67 $990.75

31239 A2 $1,137.31 $1,485.21

31240 A2 $1,137.31 $1,485.21

31254 A2 $1,137.31 $1,485.21

31255 A2 $1,137.31 $1,485.21

31256 A2 $1,137.31 $1,485.21

31267 A2 $1,137.31 $1,485.21

31276 A2 $1,137.31 $1,485.21

31287 A2 $1,137.31 $1,485.21

31288 A2 $1,137.31 $1,485.21

31295 P2 $1,137.31 $1,485.21

31296 P2 $1,137.31 $1,485.21

31297 P2 $1,137.31 $1,485.21

31300 A2 $1,009.91 $1,318.84

31320 A2 $1,839.88 $2,402.70

31400 A2 $1,839.88 $2,402.70

31420 A2 $1,839.88 $2,402.70

31500 G2 $90.24 $117.84

31502 G2 $56.64 $73.97

31505 P2 $43.37 $56.64

31510 A2 $758.67 $990.75

31511 A2 $80.18 $104.71

31512 A2 $758.67 $990.75

31513 A2 $80.18 $104.71

31515 A2 $758.67 $990.75

31520 G2 $80.18 $104.71

31525 A2 $758.67 $990.75

31526 A2 $758.67 $990.75

31527 A2 $1,137.31 $1,485.21

31528 A2 $1,137.31 $1,485.21

31529 A2 $1,137.31 $1,485.21

31530 A2 $758.67 $990.75

31531 A2 $758.67 $990.75

31535 A2 $758.67 $990.75

31536 A2 $758.67 $990.75

Updated 3/22/2013 MDWCC

Page 29 of 88

Page 30: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

31540 A2 $758.67 $990.75

31541 A2 $1,137.31 $1,485.21

31545 A2 $1,137.31 $1,485.21

31546 A2 $1,137.31 $1,485.21

31560 A2 $1,137.31 $1,485.21

31561 A2 $1,137.31 $1,485.21

31570 A2 $758.67 $990.75

31571 A2 $1,137.31 $1,485.21

31575 P3 $76.55 $99.97

31576 A2 $758.67 $990.75

31577 A2 $189.24 $247.13

31578 A2 $758.67 $990.75

31579 P3 $130.99 $171.06

31580 A2 $1,839.88 $2,402.70

31582 A2 $1,839.88 $2,402.70

31588 A2 $1,839.88 $2,402.70

31590 A2 $1,839.88 $2,402.70

31595 A2 $1,839.88 $2,402.70

31603 A2 $279.76 $365.34

31605 G2 $279.76 $365.34

31611 A2 $1,009.91 $1,318.84

31612 A2 $1,839.88 $2,402.70

31613 A2 $1,009.91 $1,318.84

31614 A2 $1,839.88 $2,402.70

31615 A2 $279.76 $365.34

31620 N1 $0.00 $0.00

31622 A2 $428.64 $559.76

31623 A2 $428.64 $559.76

31624 A2 $428.64 $559.76

31625 A2 $428.64 $559.76

31626 G2 $882.21 $1,152.08

31627 N1 $0.00 $0.00

31628 A2 $428.64 $559.76

31629 A2 $882.21 $1,152.08

31630 A2 $882.21 $1,152.08

31631 A2 $882.21 $1,152.08

31632 G2 $428.64 $559.76

31633 G2 $428.64 $559.76

31634 G2 $882.21 $1,152.08

31635 A2 $428.64 $559.76

31636 A2 $882.21 $1,152.08

31637 A2 $428.64 $559.76

31638 A2 $882.21 $1,152.08

31640 A2 $882.21 $1,152.08

31641 A2 $882.21 $1,152.08

31643 A2 $428.64 $559.76

31645 A2 $428.64 $559.76

31646 A2 $428.64 $559.76

31647 G2 $882.21 $1,152.08

31648 G2 $882.21 $1,152.08

31649 G2 $428.64 $559.76

31651 G2 $882.21 $1,152.08

31717 A2 $189.24 $247.13

31720 A2 $19.69 $25.71

31730 A2 $189.24 $247.13

31750 A2 $1,839.88 $2,402.70

31755 A2 $1,839.88 $2,402.70

31820 A2 $1,009.91 $1,318.84

31825 A2 $1,009.91 $1,318.84

31830 A2 $1,009.91 $1,318.84

32400 A2 $400.40 $522.88

Updated 3/22/2013 MDWCC

Page 30 of 88

Page 31: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

32405 A2 $400.40 $522.88

32550 G2 $1,267.64 $1,655.41

32552 G2 $231.40 $302.19

32553 G2 $552.43 $721.42

32554 G2 $231.40 $302.19

32555 G2 $231.40 $302.19

32556 G2 $231.40 $302.19

32557 G2 $231.40 $302.19

32960 G2 $231.40 $302.19

32998 G2 $2,270.67 $2,965.27

33010 A2 $231.40 $302.19

33011 A2 $231.40 $302.19

33206 J8 $7,127.41 $9,307.68

33207 J8 $7,127.41 $9,307.68

33208 J8 $8,988.91 $11,738.62

33210 G2 $2,113.24 $2,759.68

33211 G2 $2,113.24 $2,759.68

33212 J8 $5,772.53 $7,538.35

33213 J8 $6,833.73 $8,924.17

33214 J8 $8,988.91 $11,738.62

33215 G2 $944.45 $1,233.36

33216 G2 $2,113.24 $2,759.68

33217 G2 $2,113.24 $2,759.68

33218 G2 $944.45 $1,233.36

33220 G2 $944.45 $1,233.36

33221 J8 $6,833.73 $8,924.17

33222 A2 $623.76 $814.57

33223 A2 $623.76 $814.57

33224 J8 $8,988.91 $11,738.62

33225 J8 $8,988.91 $11,738.62

33226 G2 $944.45 $1,233.36

33227 J8 $5,772.53 $7,538.35

33228 J8 $6,833.73 $8,924.17

33229 J8 $6,833.73 $8,924.17

33230 J8 $20,941.14 $27,347.03

33231 J8 $20,941.14 $27,347.03

33233 A2 $944.45 $1,233.36

33234 G2 $944.45 $1,233.36

33235 G2 $944.45 $1,233.36

33240 J8 $20,941.14 $27,347.03

33241 G2 $944.45 $1,233.36

33249 J8 $28,513.56 $37,235.86

33262 J8 $20,941.14 $27,347.03

33263 J8 $20,941.14 $27,347.03

33264 J8 $20,941.14 $27,347.03

33282 J8 $5,221.31 $6,818.51

33284 G2 $327.48 $427.66

33508 N1 $0.00 $0.00

34490 G2 $1,739.63 $2,271.78

35188 A2 $1,739.63 $2,271.78

35207 A2 $1,739.63 $2,271.78

35460 G2 $2,257.45 $2,948.00

35475 P3 $1,410.93 $1,842.53

35476 P3 $1,328.94 $1,735.46

35572 N1 $0.00 $0.00

35761 G2 $1,206.01 $1,574.93

35875 A2 $1,739.63 $2,271.78

35876 A2 $1,739.63 $2,271.78

36000 N1 $0.00 $0.00

36002 G2 $86.83 $113.39

36005 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 31 of 88

Page 32: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

36010 N1 $0.00 $0.00

36011 N1 $0.00 $0.00

36012 N1 $0.00 $0.00

36013 N1 $0.00 $0.00

36014 N1 $0.00 $0.00

36015 N1 $0.00 $0.00

36100 N1 $0.00 $0.00

36120 N1 $0.00 $0.00

36140 N1 $0.00 $0.00

36147 P2 $401.78 $524.68

36148 N1 $0.00 $0.00

36160 N1 $0.00 $0.00

36200 N1 $0.00 $0.00

36215 N1 $0.00 $0.00

36216 N1 $0.00 $0.00

36217 N1 $0.00 $0.00

36218 N1 $0.00 $0.00

36221 N1 $0.00 $0.00

36222 N1 $0.00 $0.00

36223 N1 $0.00 $0.00

36224 N1 $0.00 $0.00

36225 N1 $0.00 $0.00

36226 N1 $0.00 $0.00

36227 N1 $0.00 $0.00

36228 N1 $0.00 $0.00

36245 N1 $0.00 $0.00

36246 N1 $0.00 $0.00

36247 N1 $0.00 $0.00

36248 N1 $0.00 $0.00

36251 N1 $0.00 $0.00

36252 N1 $0.00 $0.00

36253 N1 $0.00 $0.00

36254 N1 $0.00 $0.00

36260 A2 $1,250.19 $1,632.62

36261 A2 $944.45 $1,233.36

36262 A2 $944.45 $1,233.36

36400 N1 $0.00 $0.00

36405 N1 $0.00 $0.00

36406 N1 $0.00 $0.00

36410 N1 $0.00 $0.00

36416 N1 $0.00 $0.00

36420 R2 $13.15 $17.17

36425 R2 $13.15 $17.17

36430 P3 $34.36 $44.87

36440 R2 $146.14 $190.84

36450 R2 $146.14 $190.84

36455 G2 $146.14 $190.84

36468 R2 $40.14 $52.42

36469 R2 $60.02 $78.38

36470 P2 $60.02 $78.38

36471 P2 $60.02 $78.38

36475 A2 $1,697.22 $2,216.40

36476 A2 $1,099.07 $1,435.28

36478 A2 $1,099.07 $1,435.28

36479 A2 $1,099.07 $1,435.28

36481 N1 $0.00 $0.00

36500 N1 $0.00 $0.00

36510 N1 $0.00 $0.00

36511 G2 $533.44 $696.62

36512 G2 $533.44 $696.62

36513 G2 $533.44 $696.62

Updated 3/22/2013 MDWCC

Page 32 of 88

Page 33: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

36514 G2 $533.44 $696.62

36515 P2 $1,620.94 $2,116.79

36516 P2 $1,620.94 $2,116.79

36522 G2 $1,620.94 $2,116.79

36555 A2 $441.09 $576.02

36556 A2 $441.09 $576.02

36557 A2 $984.28 $1,285.37

36558 A2 $984.28 $1,285.37

36560 A2 $1,250.19 $1,632.62

36561 A2 $1,250.19 $1,632.62

36563 A2 $1,250.19 $1,632.62

36565 A2 $1,250.19 $1,632.62

36566 A2 $1,250.19 $1,632.62

36568 A2 $441.09 $576.02

36569 A2 $441.09 $576.02

36570 A2 $984.28 $1,285.37

36571 A2 $984.28 $1,285.37

36575 A2 $246.69 $322.15

36576 A2 $441.09 $576.02

36578 A2 $984.28 $1,285.37

36580 A2 $441.09 $576.02

36581 A2 $984.28 $1,285.37

36582 A2 $1,250.19 $1,632.62

36583 A2 $1,250.19 $1,632.62

36584 A2 $441.09 $576.02

36585 A2 $984.28 $1,285.37

36589 A2 $246.69 $322.15

36590 A2 $441.09 $576.02

36591 N1 $0.00 $0.00

36592 N1 $0.00 $0.00

36593 P3 $31.30 $40.87

36595 G2 $984.28 $1,285.37

36596 G2 $441.09 $576.02

36597 G2 $441.09 $576.02

36598 P3 $85.06 $111.08

36600 N1 $0.00 $0.00

36620 N1 $0.00 $0.00

36625 N1 $0.00 $0.00

36640 A2 $1,250.19 $1,632.62

36680 G2 $68.80 $89.85

36800 A2 $1,503.67 $1,963.64

36810 A2 $1,503.67 $1,963.64

36815 A2 $1,503.67 $1,963.64

36818 A2 $1,739.63 $2,271.78

36819 A2 $1,739.63 $2,271.78

36820 A2 $1,739.63 $2,271.78

36821 A2 $1,739.63 $2,271.78

36825 A2 $1,739.63 $2,271.78

36830 A2 $1,739.63 $2,271.78

36831 A2 $1,739.63 $2,271.78

36832 A2 $1,739.63 $2,271.78

36833 A2 $1,739.63 $2,271.78

36835 A2 $1,503.67 $1,963.64

36860 A2 $96.89 $126.53

36861 A2 $1,503.67 $1,963.64

36870 A2 $1,498.95 $1,957.48

37184 G2 $1,739.63 $2,271.78

37185 G2 $1,739.63 $2,271.78

37186 G2 $1,739.63 $2,271.78

37187 G2 $1,739.63 $2,271.78

37188 G2 $1,739.63 $2,271.78

Updated 3/22/2013 MDWCC

Page 33 of 88

Page 34: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

37197 G2 $1,250.19 $1,632.62

37200 G2 $1,250.19 $1,632.62

37202 G2 $648.95 $847.46

37204 G2 $4,304.52 $5,621.27

37205 G2 $4,857.59 $6,343.53

37206 G2 $4,857.59 $6,343.53

37207 G2 $4,857.59 $6,343.53

37208 G2 $4,857.59 $6,343.53

37210 G2 $4,857.59 $6,343.53

37211 G2 $441.09 $576.02

37212 G2 $441.09 $576.02

37220 G2 $2,257.45 $2,948.00

37221 G2 $4,857.59 $6,343.53

37222 G2 $2,257.45 $2,948.00

37223 G2 $2,257.45 $2,948.00

37224 G2 $2,257.45 $2,948.00

37225 G2 $4,857.59 $6,343.53

37226 G2 $4,857.59 $6,343.53

37227 J8 $11,601.50 $15,150.40

37228 G2 $2,257.45 $2,948.00

37229 G2 $4,857.59 $6,343.53

37230 G2 $4,857.59 $6,343.53

37231 J8 $11,601.50 $15,150.40

37232 G2 $2,257.45 $2,948.00

37233 G2 $4,857.59 $6,343.53

37234 G2 $2,257.45 $2,948.00

37235 G2 $2,257.45 $2,948.00

37250 N1 $0.00 $0.00

37251 N1 $0.00 $0.00

37500 A2 $1,697.22 $2,216.40

37607 A2 $1,099.07 $1,435.28

37609 A2 $629.45 $822.00

37650 A2 $1,099.07 $1,435.28

37700 A2 $1,099.07 $1,435.28

37718 A2 $1,099.07 $1,435.28

37722 A2 $1,697.22 $2,216.40

37735 A2 $1,697.22 $2,216.40

37760 A2 $1,099.07 $1,435.28

37761 G2 $1,099.07 $1,435.28

37765 P3 $372.21 $486.07

37766 P3 $420.86 $549.60

37780 A2 $1,099.07 $1,435.28

37785 A2 $1,099.07 $1,435.28

37790 A2 $1,557.41 $2,033.82

38200 N1 $0.00 $0.00

38204 N1 $0.00 $0.00

38206 G2 $533.44 $696.62

38220 P3 $124.52 $162.61

38221 P3 $118.40 $154.62

38230 G2 $1,620.94 $2,116.79

38232 G2 $1,620.94 $2,116.79

38241 G2 $1,620.94 $2,116.79

38242 R2 $533.44 $696.62

38243 R2 $533.44 $696.62

38300 A2 $407.14 $531.68

38305 A2 $740.20 $966.63

38308 A2 $1,021.26 $1,333.66

38500 A2 $1,021.26 $1,333.66

38505 A2 $350.84 $458.16

38510 A2 $1,021.26 $1,333.66

38520 A2 $1,021.26 $1,333.66

Updated 3/22/2013 MDWCC

Page 34 of 88

Page 35: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

38525 A2 $1,021.26 $1,333.66

38530 A2 $1,021.26 $1,333.66

38542 A2 $2,059.99 $2,690.14

38550 A2 $1,021.26 $1,333.66

38555 A2 $1,021.26 $1,333.66

38570 A2 $1,956.74 $2,555.31

38571 A2 $2,873.76 $3,752.84

38572 A2 $1,956.74 $2,555.31

38700 G2 $1,021.26 $1,333.66

38740 A2 $2,059.99 $2,690.14

38745 A2 $2,059.99 $2,690.14

38760 A2 $1,021.26 $1,333.66

38790 N1 $0.00 $0.00

38792 N1 $0.00 $0.00

38794 N1 $0.00 $0.00

38900 N1 $0.00 $0.00

40490 P3 $85.74 $111.97

40500 A2 $643.83 $840.78

40510 A2 $1,009.91 $1,318.84

40520 A2 $643.83 $840.78

40525 A2 $1,009.91 $1,318.84

40527 A2 $1,839.88 $2,402.70

40530 A2 $1,009.91 $1,318.84

40650 A2 $279.76 $365.34

40652 A2 $279.76 $365.34

40654 A2 $279.76 $365.34

40700 A2 $1,839.88 $2,402.70

40701 A2 $1,839.88 $2,402.70

40702 R2 $1,839.88 $2,402.70

40720 A2 $1,839.88 $2,402.70

40761 A2 $1,839.88 $2,402.70

40800 P2 $70.40 $91.94

40801 A2 $279.76 $365.34

40804 P2 $27.85 $36.37

40805 P3 $309.27 $403.88

40806 P3 $109.89 $143.51

40808 P2 $128.95 $168.40

40810 P3 $167.05 $218.15

40812 P3 $210.94 $275.47

40814 A2 $1,009.91 $1,318.84

40816 A2 $1,009.91 $1,318.84

40818 A2 $128.95 $168.40

40819 A2 $643.83 $840.78

40820 P3 $233.40 $304.80

40830 G2 $128.95 $168.40

40831 A2 $279.76 $365.34

40840 A2 $1,009.91 $1,318.84

40842 A2 $1,839.88 $2,402.70

40843 A2 $1,009.91 $1,318.84

40844 A2 $1,839.88 $2,402.70

40845 A2 $1,839.88 $2,402.70

41000 P3 $118.06 $154.17

41005 A2 $128.95 $168.40

41006 A2 $1,009.91 $1,318.84

41007 A2 $1,009.91 $1,318.84

41008 A2 $643.83 $840.78

41009 A2 $128.95 $168.40

41010 A2 $279.76 $365.34

41015 A2 $128.95 $168.40

41016 A2 $1,009.91 $1,318.84

41017 A2 $643.83 $840.78

Updated 3/22/2013 MDWCC

Page 35 of 88

Page 36: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

41018 A2 $279.76 $365.34

41019 G2 $1,009.91 $1,318.84

41100 P3 $122.48 $159.95

41105 P3 $123.16 $160.83

41108 P3 $114.66 $149.73

41110 P3 $166.03 $216.82

41112 A2 $643.83 $840.78

41113 A2 $643.83 $840.78

41114 A2 $1,009.91 $1,318.84

41115 P3 $196.31 $256.36

41116 A2 $1,009.91 $1,318.84

41120 A2 $1,009.91 $1,318.84

41250 A2 $43.82 $57.22

41251 A2 $128.95 $168.40

41252 A2 $279.76 $365.34

41500 A2 $643.83 $840.78

41510 A2 $643.83 $840.78

41512 G2 $1,009.91 $1,318.84

41520 A2 $1,009.91 $1,318.84

41530 P2 $1,009.91 $1,318.84

41800 A2 $70.40 $91.94

41805 P3 $209.92 $274.13

41806 P3 $262.66 $343.01

41820 R2 $1,009.91 $1,318.84

41821 G2 $279.76 $365.34

41822 P3 $210.94 $275.47

41823 P3 $300.76 $392.76

41825 P3 $169.77 $221.70

41826 P3 $237.14 $309.68

41827 A2 $1,009.91 $1,318.84

41828 P3 $196.31 $256.36

41830 P3 $276.27 $360.78

41850 R2 $1,009.91 $1,318.84

41870 G2 $1,839.88 $2,402.70

41872 P3 $277.63 $362.56

41874 P3 $266.74 $348.34

42000 A2 $128.95 $168.40

42100 P3 $105.47 $137.73

42104 P3 $163.31 $213.27

42106 P3 $204.48 $267.03

42107 A2 $1,839.88 $2,402.70

42120 A2 $1,009.91 $1,318.84

42140 A2 $643.83 $840.78

42145 A2 $1,839.88 $2,402.70

42160 P3 $174.54 $227.93

42180 A2 $128.95 $168.40

42182 A2 $1,009.91 $1,318.84

42200 A2 $1,839.88 $2,402.70

42205 A2 $1,839.88 $2,402.70

42210 A2 $1,839.88 $2,402.70

42215 A2 $1,839.88 $2,402.70

42220 A2 $1,839.88 $2,402.70

42225 G2 $1,009.91 $1,318.84

42226 A2 $1,839.88 $2,402.70

42227 G2 $1,839.88 $2,402.70

42235 A2 $1,009.91 $1,318.84

42260 A2 $1,009.91 $1,318.84

42280 P3 $108.53 $141.73

42281 G2 $643.83 $840.78

42300 A2 $279.76 $365.34

42305 A2 $1,009.91 $1,318.84

Updated 3/22/2013 MDWCC

Page 36 of 88

Page 37: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

42310 A2 $128.95 $168.40

42320 A2 $128.95 $168.40

42330 P3 $157.53 $205.72

42335 P3 $265.04 $346.12

42340 A2 $643.83 $840.78

42400 P3 $82.68 $107.97

42405 A2 $1,009.91 $1,318.84

42408 A2 $1,009.91 $1,318.84

42409 A2 $1,009.91 $1,318.84

42410 A2 $1,839.88 $2,402.70

42415 A2 $1,839.88 $2,402.70

42420 A2 $1,839.88 $2,402.70

42425 A2 $1,839.88 $2,402.70

42440 A2 $1,839.88 $2,402.70

42450 A2 $1,839.88 $2,402.70

42500 A2 $1,009.91 $1,318.84

42505 A2 $1,839.88 $2,402.70

42507 A2 $1,839.88 $2,402.70

42508 A2 $1,009.91 $1,318.84

42509 A2 $1,839.88 $2,402.70

42510 A2 $1,839.88 $2,402.70

42550 N1 $0.00 $0.00

42600 A2 $643.83 $840.78

42650 P3 $58.52 $76.42

42660 P3 $84.72 $110.64

42665 A2 $1,839.88 $2,402.70

42700 A2 $128.95 $168.40

42720 A2 $643.83 $840.78

42725 A2 $1,839.88 $2,402.70

42800 P3 $112.62 $147.07

42802 A2 $643.83 $840.78

42804 A2 $643.83 $840.78

42806 A2 $1,009.91 $1,318.84

42808 A2 $1,009.91 $1,318.84

42809 G2 $27.85 $36.37

42810 A2 $1,009.91 $1,318.84

42815 A2 $1,839.88 $2,402.70

42820 A2 $1,009.91 $1,318.84

42821 A2 $1,009.91 $1,318.84

42825 A2 $1,839.88 $2,402.70

42826 A2 $1,009.91 $1,318.84

42830 A2 $1,839.88 $2,402.70

42831 A2 $1,009.91 $1,318.84

42835 A2 $1,009.91 $1,318.84

42836 A2 $1,009.91 $1,318.84

42860 A2 $1,839.88 $2,402.70

42870 A2 $1,009.91 $1,318.84

42890 A2 $1,839.88 $2,402.70

42892 A2 $1,839.88 $2,402.70

42900 A2 $1,009.91 $1,318.84

42950 A2 $1,839.88 $2,402.70

42955 A2 $1,009.91 $1,318.84

42960 A2 $43.82 $57.22

42962 A2 $1,009.91 $1,318.84

42970 R2 $43.82 $57.22

42972 A2 $643.83 $840.78

43030 G2 $1,009.91 $1,318.84

43130 G2 $1,839.88 $2,402.70

43200 A2 $349.83 $456.84

43201 A2 $520.05 $679.13

43202 A2 $349.83 $456.84

Updated 3/22/2013 MDWCC

Page 37 of 88

Page 38: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

43204 A2 $349.83 $456.84

43205 A2 $520.05 $679.13

43206 G2 $520.05 $679.13

43215 A2 $520.05 $679.13

43216 A2 $1,047.82 $1,368.35

43217 A2 $520.05 $679.13

43219 A2 $1,187.92 $1,551.30

43220 A2 $520.05 $679.13

43226 A2 $520.05 $679.13

43227 A2 $520.05 $679.13

43228 A2 $1,047.82 $1,368.35

43231 A2 $520.05 $679.13

43232 A2 $520.05 $679.13

43235 A2 $349.83 $456.84

43236 A2 $349.83 $456.84

43237 A2 $520.05 $679.13

43238 A2 $520.05 $679.13

43239 A2 $349.83 $456.84

43240 A2 $520.05 $679.13

43241 A2 $349.83 $456.84

43242 A2 $520.05 $679.13

43243 A2 $349.83 $456.84

43244 A2 $520.05 $679.13

43245 A2 $520.05 $679.13

43246 A2 $520.05 $679.13

43247 A2 $349.83 $456.84

43248 A2 $349.83 $456.84

43249 A2 $520.05 $679.13

43250 A2 $520.05 $679.13

43251 A2 $520.05 $679.13

43252 G2 $520.05 $679.13

43255 A2 $520.05 $679.13

43256 A2 $1,187.92 $1,551.30

43257 A2 $1,047.82 $1,368.35

43258 A2 $520.05 $679.13

43259 A2 $520.05 $679.13

43260 A2 $969.24 $1,265.73

43261 A2 $969.24 $1,265.73

43262 A2 $969.24 $1,265.73

43263 A2 $969.24 $1,265.73

43264 A2 $969.24 $1,265.73

43265 A2 $969.24 $1,265.73

43267 A2 $969.24 $1,265.73

43268 A2 $1,187.92 $1,551.30

43269 A2 $1,187.92 $1,551.30

43271 A2 $969.24 $1,265.73

43272 A2 $969.24 $1,265.73

43273 G2 $969.24 $1,265.73

43450 A2 $271.06 $353.98

43453 A2 $271.06 $353.98

43456 A2 $271.06 $353.98

43458 A2 $520.05 $679.13

43653 A2 $1,956.74 $2,555.31

43752 G2 $64.12 $83.73

43753 G2 $27.85 $36.37

43754 G2 $27.85 $36.37

43755 G2 $37.32 $48.74

43756 G2 $64.12 $83.73

43757 G2 $64.12 $83.73

43760 A2 $96.89 $126.53

43761 A2 $349.83 $456.84

Updated 3/22/2013 MDWCC

Page 38 of 88

Page 39: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

43870 A2 $1,047.82 $1,368.35

43886 G2 $847.34 $1,106.54

43887 G2 $623.76 $814.57

43888 G2 $847.34 $1,106.54

44100 A2 $520.05 $679.13

44312 A2 $847.34 $1,106.54

44340 A2 $847.34 $1,106.54

44360 A2 $421.23 $550.08

44361 A2 $421.23 $550.08

44363 A2 $421.23 $550.08

44364 A2 $621.79 $812.00

44365 A2 $621.79 $812.00

44366 A2 $621.79 $812.00

44369 A2 $621.79 $812.00

44370 A2 $1,187.92 $1,551.30

44372 A2 $621.79 $812.00

44373 A2 $621.79 $812.00

44376 A2 $421.23 $550.08

44377 A2 $421.23 $550.08

44378 A2 $621.79 $812.00

44379 A2 $1,187.92 $1,551.30

44380 A2 $421.23 $550.08

44382 A2 $421.23 $550.08

44383 A2 $1,187.92 $1,551.30

44385 A2 $387.92 $506.58

44386 A2 $387.92 $506.58

44388 A2 $387.92 $506.58

44389 A2 $387.92 $506.58

44390 A2 $387.92 $506.58

44391 A2 $387.92 $506.58

44392 A2 $387.92 $506.58

44393 A2 $387.92 $506.58

44394 A2 $387.92 $506.58

44397 A2 $1,187.92 $1,551.30

44500 G2 $246.69 $322.15

44701 N1 $0.00 $0.00

45000 A2 $1,026.54 $1,340.56

45005 A2 $717.60 $937.11

45020 A2 $717.60 $937.11

45100 A2 $717.60 $937.11

45108 A2 $1,026.54 $1,340.56

45150 A2 $1,026.54 $1,340.56

45160 A2 $1,026.54 $1,340.56

45171 G2 $1,026.54 $1,340.56

45172 G2 $1,327.61 $1,733.73

45190 A2 $1,026.54 $1,340.56

45300 P3 $98.33 $128.41

45303 P2 $401.52 $524.34

45305 A2 $401.52 $524.34

45307 A2 $859.19 $1,122.02

45308 A2 $401.52 $524.34

45309 A2 $401.52 $524.34

45315 A2 $401.52 $524.34

45317 A2 $401.52 $524.34

45320 A2 $859.19 $1,122.02

45321 A2 $859.19 $1,122.02

45327 A2 $1,187.92 $1,551.30

45330 P3 $107.85 $140.84

45331 A2 $235.85 $308.00

45332 A2 $235.85 $308.00

45333 A2 $235.85 $308.00

Updated 3/22/2013 MDWCC

Page 39 of 88

Page 40: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

45334 A2 $401.52 $524.34

45335 A2 $235.85 $308.00

45337 A2 $401.52 $524.34

45338 A2 $401.52 $524.34

45339 A2 $401.52 $524.34

45340 A2 $401.52 $524.34

45341 A2 $401.52 $524.34

45342 A2 $401.52 $524.34

45345 A2 $1,187.92 $1,551.30

45355 A2 $387.92 $506.58

45378 A2 $387.92 $506.58

45379 A2 $387.92 $506.58

45380 A2 $387.92 $506.58

45381 A2 $387.92 $506.58

45382 A2 $387.92 $506.58

45383 A2 $387.92 $506.58

45384 A2 $387.92 $506.58

45385 A2 $387.92 $506.58

45386 A2 $387.92 $506.58

45387 A2 $1,187.92 $1,551.30

45391 A2 $387.92 $506.58

45392 A2 $387.92 $506.58

45500 A2 $1,026.54 $1,340.56

45505 A2 $1,327.61 $1,733.73

45520 P2 $60.02 $78.38

45541 G2 $1,327.61 $1,733.73

45560 A2 $1,327.61 $1,733.73

45900 A2 $246.53 $321.94

45905 A2 $717.60 $937.11

45910 A2 $717.60 $937.11

45915 A2 $717.60 $937.11

45990 A2 $717.60 $937.11

46020 A2 $1,026.54 $1,340.56

46030 A2 $246.53 $321.94

46040 A2 $717.60 $937.11

46045 A2 $1,026.54 $1,340.56

46050 A2 $246.53 $321.94

46060 A2 $717.60 $937.11

46070 G2 $717.60 $937.11

46080 A2 $717.60 $937.11

46083 P2 $85.71 $111.93

46200 A2 $1,026.54 $1,340.56

46220 A2 $717.60 $937.11

46221 P3 $186.79 $243.93

46230 A2 $717.60 $937.11

46250 A2 $1,026.54 $1,340.56

46255 A2 $1,026.54 $1,340.56

46257 A2 $1,026.54 $1,340.56

46258 A2 $1,026.54 $1,340.56

46260 A2 $1,026.54 $1,340.56

46261 A2 $1,026.54 $1,340.56

46262 A2 $1,026.54 $1,340.56

46270 A2 $1,026.54 $1,340.56

46275 A2 $1,026.54 $1,340.56

46280 A2 $1,026.54 $1,340.56

46285 A2 $1,026.54 $1,340.56

46288 A2 $1,327.61 $1,733.73

46320 P3 $124.86 $163.05

46500 P3 $182.02 $237.70

46505 G2 $717.60 $937.11

46600 P2 $27.85 $36.37

Updated 3/22/2013 MDWCC

Page 40 of 88

Page 41: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

46604 P2 $401.52 $524.34

46606 P3 $190.53 $248.81

46608 A2 $401.52 $524.34

46610 A2 $859.19 $1,122.02

46611 A2 $401.52 $524.34

46612 A2 $859.19 $1,122.02

46614 P3 $94.58 $123.51

46615 A2 $859.19 $1,122.02

46700 A2 $1,026.54 $1,340.56

46706 A2 $1,026.54 $1,340.56

46707 G2 $1,327.61 $1,733.73

46750 A2 $1,327.61 $1,733.73

46753 A2 $1,026.54 $1,340.56

46754 A2 $717.60 $937.11

46760 A2 $1,327.61 $1,733.73

46761 A2 $1,327.61 $1,733.73

46762 A2 $1,327.61 $1,733.73

46900 P2 $117.64 $153.63

46910 P3 $189.51 $247.48

46916 P2 $60.02 $78.38

46917 A2 $795.57 $1,038.93

46922 A2 $795.57 $1,038.93

46924 A2 $795.57 $1,038.93

46930 P3 $149.70 $195.49

46940 P3 $145.28 $189.72

46942 P3 $143.58 $187.50

46945 P3 $233.40 $304.80

46946 A2 $1,026.54 $1,340.56

46947 A2 $1,327.61 $1,733.73

47000 A2 $400.40 $522.88

47001 N1 $0.00 $0.00

47382 G2 $2,270.67 $2,965.27

47500 N1 $0.00 $0.00

47505 N1 $0.00 $0.00

47510 A2 $1,137.84 $1,485.91

47511 A2 $1,137.84 $1,485.91

47525 A2 $674.26 $880.52

47530 A2 $674.26 $880.52

47552 A2 $1,137.84 $1,485.91

47553 A2 $1,137.84 $1,485.91

47554 A2 $1,137.84 $1,485.91

47555 A2 $1,137.84 $1,485.91

47556 A2 $2,270.67 $2,965.27

47560 A2 $1,531.92 $2,000.53

47561 A2 $1,531.92 $2,000.53

47562 G2 $1,956.74 $2,555.31

47563 G2 $1,956.74 $2,555.31

47564 G2 $1,956.74 $2,555.31

47630 A2 $1,137.84 $1,485.91

48102 A2 $400.40 $522.88

49082 G2 $231.40 $302.19

49083 G2 $231.40 $302.19

49084 G2 $231.40 $302.19

49180 A2 $400.40 $522.88

49250 A2 $1,039.54 $1,357.54

49320 A2 $1,531.92 $2,000.53

49321 A2 $1,531.92 $2,000.53

49322 A2 $1,531.92 $2,000.53

49324 G2 $1,531.92 $2,000.53

49325 G2 $1,531.92 $2,000.53

49326 G2 $1,531.92 $2,000.53

Updated 3/22/2013 MDWCC

Page 41 of 88

Page 42: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

49327 G2 $1,531.92 $2,000.53

49400 N1 $0.00 $0.00

49402 A2 $1,039.54 $1,357.54

49411 P3 $410.66 $536.28

49418 G2 $1,267.64 $1,655.41

49419 A2 $1,503.67 $1,963.64

49421 G2 $1,267.64 $1,655.41

49422 A2 $944.45 $1,233.36

49423 G2 $674.26 $880.52

49424 N1 $0.00 $0.00

49426 A2 $1,039.54 $1,357.54

49427 N1 $0.00 $0.00

49429 G2 $944.45 $1,233.36

49435 G2 $674.26 $880.52

49436 G2 $674.26 $880.52

49440 G2 $520.05 $679.13

49441 G2 $520.05 $679.13

49442 G2 $717.60 $937.11

49446 G2 $520.05 $679.13

49450 G2 $246.69 $322.15

49451 G2 $246.69 $322.15

49452 G2 $246.69 $322.15

49460 G2 $246.69 $322.15

49465 N1 $0.00 $0.00

49495 A2 $1,363.05 $1,780.01

49496 A2 $1,363.05 $1,780.01

49500 A2 $1,363.05 $1,780.01

49501 A2 $1,363.05 $1,780.01

49505 A2 $1,363.05 $1,780.01

49507 A2 $1,363.05 $1,780.01

49520 A2 $1,363.05 $1,780.01

49521 A2 $1,363.05 $1,780.01

49525 A2 $1,363.05 $1,780.01

49540 A2 $1,363.05 $1,780.01

49550 A2 $1,363.05 $1,780.01

49553 A2 $1,363.05 $1,780.01

49555 A2 $1,363.05 $1,780.01

49557 A2 $1,363.05 $1,780.01

49560 A2 $1,363.05 $1,780.01

49561 A2 $1,363.05 $1,780.01

49565 A2 $1,363.05 $1,780.01

49566 A2 $1,363.05 $1,780.01

49568 A2 $1,363.05 $1,780.01

49570 A2 $1,363.05 $1,780.01

49572 A2 $1,363.05 $1,780.01

49580 A2 $1,363.05 $1,780.01

49582 A2 $1,363.05 $1,780.01

49585 A2 $1,363.05 $1,780.01

49587 A2 $1,363.05 $1,780.01

49590 A2 $1,363.05 $1,780.01

49600 A2 $1,363.05 $1,780.01

49650 A2 $1,956.74 $2,555.31

49651 A2 $1,956.74 $2,555.31

49652 G2 $2,873.76 $3,752.84

49653 G2 $2,873.76 $3,752.84

49654 G2 $2,873.76 $3,752.84

49655 G2 $2,873.76 $3,752.84

49656 G2 $2,873.76 $3,752.84

49657 G2 $2,873.76 $3,752.84

50080 G2 $1,829.87 $2,389.63

50081 G2 $1,829.87 $2,389.63

Updated 3/22/2013 MDWCC

Page 42 of 88

Page 43: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

50200 A2 $400.40 $522.88

50382 G2 $1,071.11 $1,398.76

50384 G2 $634.79 $828.97

50385 G2 $1,071.11 $1,398.76

50386 P2 $286.04 $373.54

50387 G2 $674.26 $880.52

50389 G2 $286.04 $373.54

50390 A2 $400.40 $522.88

50391 P2 $46.01 $60.08

50392 A2 $634.79 $828.97

50393 A2 $1,071.11 $1,398.76

50394 N1 $0.00 $0.00

50395 A2 $1,071.11 $1,398.76

50396 A2 $85.71 $111.93

50398 A2 $674.26 $880.52

50551 A2 $286.04 $373.54

50553 A2 $1,071.11 $1,398.76

50555 A2 $286.04 $373.54

50557 A2 $1,071.11 $1,398.76

50561 A2 $1,071.11 $1,398.76

50562 G2 $286.04 $373.54

50570 G2 $286.04 $373.54

50572 G2 $286.04 $373.54

50574 G2 $286.04 $373.54

50575 G2 $1,535.86 $2,005.68

50576 G2 $634.79 $828.97

50580 G2 $634.79 $828.97

50590 G2 $1,592.65 $2,079.84

50592 G2 $2,270.67 $2,965.27

50593 G2 $2,270.67 $2,965.27

50684 N1 $0.00 $0.00

50686 P2 $46.01 $60.08

50688 A2 $674.26 $880.52

50690 N1 $0.00 $0.00

50727 G2 $790.93 $1,032.88

50947 A2 $1,956.74 $2,555.31

50948 A2 $1,956.74 $2,555.31

50951 A2 $286.04 $373.54

50953 A2 $286.04 $373.54

50955 A2 $1,071.11 $1,398.76

50957 A2 $1,071.11 $1,398.76

50961 A2 $1,071.11 $1,398.76

50970 A2 $286.04 $373.54

50972 A2 $286.04 $373.54

50974 A2 $634.79 $828.97

50976 A2 $634.79 $828.97

50980 A2 $1,071.11 $1,398.76

51020 A2 $1,071.11 $1,398.76

51030 A2 $1,071.11 $1,398.76

51040 A2 $1,071.11 $1,398.76

51045 A2 $286.04 $373.54

51050 A2 $1,071.11 $1,398.76

51065 A2 $1,071.11 $1,398.76

51080 A2 $740.20 $966.63

51100 P3 $32.66 $42.65

51101 P2 $46.01 $60.08

51102 A2 $790.93 $1,032.88

51500 A2 $1,363.05 $1,780.01

51520 A2 $1,071.11 $1,398.76

51535 G2 $1,071.11 $1,398.76

51600 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 43 of 88

Page 44: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

51605 N1 $0.00 $0.00

51610 N1 $0.00 $0.00

51700 P3 $50.35 $65.75

51701 P2 $27.85 $36.37

51702 P2 $27.85 $36.37

51703 P2 $46.01 $60.08

51705 P3 $57.50 $75.09

51710 A2 $246.69 $322.15

51715 A2 $1,331.68 $1,739.04

51720 P3 $51.71 $67.53

51725 P3 $114.66 $149.73

51726 A2 $130.36 $170.24

51727 P2 $130.36 $170.24

51728 P2 $130.36 $170.24

51729 P2 $130.36 $170.24

51736 P3 $6.80 $8.88

51741 P3 $7.14 $9.32

51784 P2 $46.01 $60.08

51785 A2 $85.71 $111.93

51792 P2 $46.01 $60.08

51797 P3 $74.17 $96.86

51798 P3 $19.39 $25.32

51880 A2 $1,071.11 $1,398.76

51992 A2 $1,956.74 $2,555.31

52000 A2 $286.04 $373.54

52001 A2 $634.79 $828.97

52005 A2 $1,071.11 $1,398.76

52007 A2 $1,071.11 $1,398.76

52010 A2 $286.04 $373.54

52204 A2 $1,071.11 $1,398.76

52214 A2 $1,071.11 $1,398.76

52224 A2 $1,071.11 $1,398.76

52234 A2 $1,071.11 $1,398.76

52235 A2 $1,071.11 $1,398.76

52240 A2 $1,071.11 $1,398.76

52250 A2 $1,071.11 $1,398.76

52260 A2 $634.79 $828.97

52265 P3 $257.55 $336.33

52270 A2 $634.79 $828.97

52275 A2 $1,071.11 $1,398.76

52276 A2 $1,071.11 $1,398.76

52277 A2 $1,071.11 $1,398.76

52281 A2 $634.79 $828.97

52282 A2 $1,535.86 $2,005.68

52283 A2 $1,071.11 $1,398.76

52285 A2 $634.79 $828.97

52287 G2 $634.79 $828.97

52290 A2 $1,071.11 $1,398.76

52300 A2 $1,071.11 $1,398.76

52301 A2 $1,071.11 $1,398.76

52305 A2 $1,071.11 $1,398.76

52310 A2 $634.79 $828.97

52315 A2 $1,071.11 $1,398.76

52317 A2 $1,071.11 $1,398.76

52318 A2 $1,071.11 $1,398.76

52320 A2 $1,071.11 $1,398.76

52325 A2 $1,071.11 $1,398.76

52327 A2 $1,535.86 $2,005.68

52330 A2 $1,071.11 $1,398.76

52332 A2 $1,071.11 $1,398.76

52334 A2 $1,071.11 $1,398.76

Updated 3/22/2013 MDWCC

Page 44 of 88

Page 45: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

52341 A2 $1,071.11 $1,398.76

52342 A2 $1,071.11 $1,398.76

52343 A2 $1,071.11 $1,398.76

52344 A2 $1,071.11 $1,398.76

52345 A2 $1,071.11 $1,398.76

52346 A2 $1,071.11 $1,398.76

52351 A2 $1,071.11 $1,398.76

52352 A2 $1,071.11 $1,398.76

52353 A2 $1,535.86 $2,005.68

52354 A2 $1,071.11 $1,398.76

52355 A2 $1,071.11 $1,398.76

52400 A2 $1,071.11 $1,398.76

52402 A2 $1,071.11 $1,398.76

52450 A2 $1,071.11 $1,398.76

52500 A2 $1,071.11 $1,398.76

52601 A2 $1,535.86 $2,005.68

52630 A2 $1,535.86 $2,005.68

52640 A2 $1,071.11 $1,398.76

52647 A2 $1,829.87 $2,389.63

52648 A2 $1,829.87 $2,389.63

52649 G2 $1,829.87 $2,389.63

52700 A2 $1,071.11 $1,398.76

53000 A2 $864.21 $1,128.57

53010 A2 $864.21 $1,128.57

53020 A2 $864.21 $1,128.57

53025 R2 $864.21 $1,128.57

53040 A2 $864.21 $1,128.57

53060 P3 $78.59 $102.63

53080 A2 $864.21 $1,128.57

53085 G2 $864.21 $1,128.57

53200 A2 $864.21 $1,128.57

53210 A2 $1,331.68 $1,739.04

53215 A2 $864.21 $1,128.57

53220 A2 $1,331.68 $1,739.04

53230 A2 $1,331.68 $1,739.04

53235 A2 $864.21 $1,128.57

53240 A2 $1,331.68 $1,739.04

53250 A2 $864.21 $1,128.57

53260 A2 $864.21 $1,128.57

53265 A2 $864.21 $1,128.57

53270 A2 $864.21 $1,128.57

53275 A2 $864.21 $1,128.57

53400 A2 $1,331.68 $1,739.04

53405 A2 $1,331.68 $1,739.04

53410 A2 $1,331.68 $1,739.04

53420 A2 $1,331.68 $1,739.04

53425 A2 $1,331.68 $1,739.04

53430 A2 $1,331.68 $1,739.04

53431 A2 $1,331.68 $1,739.04

53440 J8 $6,371.69 $8,320.79

53442 A2 $1,331.68 $1,739.04

53444 J8 $6,371.69 $8,320.79

53445 J8 $10,864.48 $14,187.92

53446 A2 $1,331.68 $1,739.04

53447 J8 $10,864.48 $14,187.92

53449 A2 $1,331.68 $1,739.04

53450 A2 $1,331.68 $1,739.04

53460 A2 $864.21 $1,128.57

53502 A2 $864.21 $1,128.57

53505 A2 $1,331.68 $1,739.04

53510 A2 $864.21 $1,128.57

Updated 3/22/2013 MDWCC

Page 45 of 88

Page 46: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

53515 A2 $1,331.68 $1,739.04

53520 A2 $1,331.68 $1,739.04

53600 P3 $37.09 $48.44

53601 P3 $43.89 $57.32

53605 A2 $634.79 $828.97

53620 P3 $54.10 $70.65

53621 P3 $58.18 $75.98

53660 P3 $43.89 $57.32

53661 P3 $42.19 $55.10

53665 A2 $864.21 $1,128.57

53850 P3 $1,724.97 $2,252.64

53852 P3 $1,527.97 $1,995.38

53855 P2 $85.71 $111.93

53860 P2 $790.93 $1,032.88

54000 A2 $864.21 $1,128.57

54001 A2 $864.21 $1,128.57

54015 A2 $740.20 $966.63

54050 P2 $60.02 $78.38

54055 P3 $72.81 $95.08

54056 P2 $40.14 $52.42

54057 A2 $795.57 $1,038.93

54060 A2 $795.57 $1,038.93

54065 A2 $795.57 $1,038.93

54100 A2 $629.45 $822.00

54105 A2 $932.08 $1,217.20

54110 A2 $1,557.41 $2,033.82

54111 A2 $1,557.41 $2,033.82

54112 A2 $1,557.41 $2,033.82

54115 A2 $740.20 $966.63

54120 A2 $1,557.41 $2,033.82

54150 A2 $952.14 $1,243.40

54160 A2 $952.14 $1,243.40

54161 A2 $952.14 $1,243.40

54162 A2 $952.14 $1,243.40

54163 A2 $952.14 $1,243.40

54164 A2 $952.14 $1,243.40

54200 P3 $66.00 $86.19

54205 A2 $1,557.41 $2,033.82

54220 A2 $85.71 $111.93

54230 N1 $0.00 $0.00

54231 P3 $62.26 $81.31

54235 P3 $45.25 $59.09

54240 P3 $35.72 $46.65

54250 P3 $10.89 $14.22

54300 A2 $1,557.41 $2,033.82

54304 A2 $1,557.41 $2,033.82

54308 A2 $1,557.41 $2,033.82

54312 A2 $1,557.41 $2,033.82

54316 A2 $1,557.41 $2,033.82

54318 A2 $1,557.41 $2,033.82

54322 A2 $1,557.41 $2,033.82

54324 A2 $1,557.41 $2,033.82

54326 A2 $1,557.41 $2,033.82

54328 A2 $1,557.41 $2,033.82

54340 A2 $1,557.41 $2,033.82

54344 A2 $1,557.41 $2,033.82

54348 A2 $1,557.41 $2,033.82

54352 A2 $1,557.41 $2,033.82

54360 A2 $1,557.41 $2,033.82

54380 A2 $1,557.41 $2,033.82

54385 A2 $1,557.41 $2,033.82

Updated 3/22/2013 MDWCC

Page 46 of 88

Page 47: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

54400 J8 $6,371.69 $8,320.79

54401 J8 $10,864.48 $14,187.92

54405 J8 $10,864.48 $14,187.92

54406 A2 $1,557.41 $2,033.82

54408 A2 $1,557.41 $2,033.82

54410 J8 $10,864.48 $14,187.92

54415 A2 $1,557.41 $2,033.82

54416 J8 $10,864.48 $14,187.92

54420 A2 $1,557.41 $2,033.82

54435 A2 $1,557.41 $2,033.82

54440 A2 $1,557.41 $2,033.82

54450 A2 $130.36 $170.24

54500 A2 $627.64 $819.64

54505 A2 $952.14 $1,243.40

54512 A2 $952.14 $1,243.40

54520 A2 $952.14 $1,243.40

54522 A2 $952.14 $1,243.40

54530 A2 $1,363.05 $1,780.01

54550 A2 $1,363.05 $1,780.01

54560 G2 $952.14 $1,243.40

54600 A2 $952.14 $1,243.40

54620 A2 $952.14 $1,243.40

54640 A2 $1,363.05 $1,780.01

54660 A2 $952.14 $1,243.40

54670 A2 $952.14 $1,243.40

54680 A2 $952.14 $1,243.40

54690 A2 $1,956.74 $2,555.31

54692 G2 $2,873.76 $3,752.84

54700 A2 $952.14 $1,243.40

54800 A2 $193.88 $253.19

54830 A2 $952.14 $1,243.40

54840 A2 $952.14 $1,243.40

54860 A2 $952.14 $1,243.40

54861 A2 $952.14 $1,243.40

54865 A2 $952.14 $1,243.40

54900 A2 $952.14 $1,243.40

54901 A2 $952.14 $1,243.40

55000 P3 $63.28 $82.64

55040 A2 $1,363.05 $1,780.01

55041 A2 $1,363.05 $1,780.01

55060 A2 $952.14 $1,243.40

55100 A2 $407.14 $531.68

55110 A2 $952.14 $1,243.40

55120 A2 $952.14 $1,243.40

55150 A2 $952.14 $1,243.40

55175 A2 $952.14 $1,243.40

55180 A2 $952.14 $1,243.40

55200 A2 $952.14 $1,243.40

55250 A2 $952.14 $1,243.40

55300 N1 $0.00 $0.00

55400 A2 $952.14 $1,243.40

55450 P3 $191.21 $249.70

55500 A2 $952.14 $1,243.40

55520 A2 $952.14 $1,243.40

55530 A2 $952.14 $1,243.40

55535 A2 $1,363.05 $1,780.01

55540 A2 $1,363.05 $1,780.01

55550 A2 $1,956.74 $2,555.31

55600 R2 $952.14 $1,243.40

55680 A2 $952.14 $1,243.40

55700 A2 $542.73 $708.75

Updated 3/22/2013 MDWCC

Page 47 of 88

Page 48: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

55705 A2 $542.73 $708.75

55706 G2 $542.73 $708.75

55720 A2 $1,071.11 $1,398.76

55725 A2 $1,071.11 $1,398.76

55860 G2 $790.93 $1,032.88

55870 P3 $77.23 $100.85

55873 J8 $6,264.93 $8,181.37

55875 A2 $1,535.86 $2,005.68

55876 P3 $70.09 $91.53

55920 G2 $1,039.54 $1,357.54

56405 P3 $52.74 $68.87

56420 P2 $66.53 $86.88

56440 A2 $816.19 $1,065.86

56441 A2 $816.19 $1,065.86

56442 A2 $816.19 $1,065.86

56501 P3 $71.11 $92.86

56515 A2 $795.57 $1,038.93

56605 P3 $40.49 $52.88

56606 P3 $16.33 $21.33

56620 A2 $816.19 $1,065.86

56625 A2 $816.19 $1,065.86

56700 A2 $816.19 $1,065.86

56740 A2 $816.19 $1,065.86

56800 A2 $816.19 $1,065.86

56805 G2 $816.19 $1,065.86

56810 A2 $816.19 $1,065.86

56820 P3 $53.42 $69.76

56821 P2 $66.53 $86.88

57000 A2 $816.19 $1,065.86

57010 A2 $816.19 $1,065.86

57020 A2 $279.51 $365.01

57022 R2 $407.14 $531.68

57023 A2 $740.20 $966.63

57061 P3 $64.98 $84.86

57065 A2 $816.19 $1,065.86

57100 P3 $42.19 $55.10

57105 A2 $816.19 $1,065.86

57130 A2 $816.19 $1,065.86

57135 A2 $816.19 $1,065.86

57150 P3 $24.84 $32.44

57155 A2 $279.51 $365.01

57156 G2 $131.36 $171.54

57160 P3 $43.21 $56.43

57170 P2 $4.63 $6.05

57180 A2 $66.53 $86.88

57200 A2 $816.19 $1,065.86

57210 A2 $816.19 $1,065.86

57220 A2 $1,910.94 $2,495.50

57230 A2 $1,481.07 $1,934.13

57240 A2 $1,481.07 $1,934.13

57250 A2 $1,481.07 $1,934.13

57260 A2 $1,481.07 $1,934.13

57265 A2 $1,910.94 $2,495.50

57267 A2 $1,481.07 $1,934.13

57268 A2 $1,481.07 $1,934.13

57287 G2 $1,481.07 $1,934.13

57288 A2 $1,910.94 $2,495.50

57289 A2 $1,481.07 $1,934.13

57291 A2 $1,481.07 $1,934.13

57295 G2 $816.19 $1,065.86

57300 A2 $1,481.07 $1,934.13

Updated 3/22/2013 MDWCC

Page 48 of 88

Page 49: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

57320 G2 $1,481.07 $1,934.13

57400 A2 $816.19 $1,065.86

57410 A2 $816.19 $1,065.86

57415 A2 $816.19 $1,065.86

57420 P3 $55.12 $71.98

57421 P3 $71.79 $93.75

57426 G2 $816.19 $1,065.86

57452 P3 $51.71 $67.53

57454 P3 $63.96 $83.53

57455 P3 $67.03 $87.53

57456 P3 $64.30 $83.97

57460 P3 $179.64 $234.59

57461 P3 $192.91 $251.92

57500 P3 $84.38 $110.19

57505 P3 $57.50 $75.09

57510 P3 $58.86 $76.87

57511 P2 $66.53 $86.88

57513 A2 $816.19 $1,065.86

57520 A2 $816.19 $1,065.86

57522 A2 $816.19 $1,065.86

57530 A2 $1,481.07 $1,934.13

57550 A2 $1,481.07 $1,934.13

57556 A2 $1,910.94 $2,495.50

57558 A2 $816.19 $1,065.86

57700 A2 $816.19 $1,065.86

57720 A2 $816.19 $1,065.86

57800 P3 $31.30 $40.87

58100 P3 $50.69 $66.20

58110 N1 $0.00 $0.00

58120 A2 $816.19 $1,065.86

58145 A2 $1,481.07 $1,934.13

58301 P3 $46.95 $61.31

58321 P3 $42.53 $55.54

58322 P3 $44.23 $57.76

58323 P3 $6.80 $8.88

58340 N1 $0.00 $0.00

58345 R2 $816.19 $1,065.86

58346 A2 $816.19 $1,065.86

58350 A2 $1,481.07 $1,934.13

58353 A2 $1,481.07 $1,934.13

58356 P3 $1,711.02 $2,234.42

58541 G2 $2,873.76 $3,752.84

58542 G2 $2,873.76 $3,752.84

58545 A2 $1,531.92 $2,000.53

58546 A2 $1,956.74 $2,555.31

58550 A2 $2,873.76 $3,752.84

58552 G2 $1,956.74 $2,555.31

58555 A2 $943.85 $1,232.57

58558 A2 $943.85 $1,232.57

58559 A2 $943.85 $1,232.57

58560 A2 $1,501.63 $1,960.98

58561 A2 $1,501.63 $1,960.98

58562 A2 $943.85 $1,232.57

58563 A2 $1,501.63 $1,960.98

58565 A2 $1,910.94 $2,495.50

58570 G2 $1,956.74 $2,555.31

58571 G2 $1,956.74 $2,555.31

58600 G2 $1,481.07 $1,934.13

58615 G2 $816.19 $1,065.86

58660 A2 $1,956.74 $2,555.31

58661 A2 $1,956.74 $2,555.31

Updated 3/22/2013 MDWCC

Page 49 of 88

Page 50: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

58662 A2 $1,956.74 $2,555.31

58670 A2 $1,956.74 $2,555.31

58671 A2 $1,956.74 $2,555.31

58672 A2 $1,956.74 $2,555.31

58673 A2 $1,956.74 $2,555.31

58800 A2 $816.19 $1,065.86

58805 G2 $1,481.07 $1,934.13

58820 A2 $1,481.07 $1,934.13

58900 A2 $816.19 $1,065.86

58970 A2 $131.36 $171.54

58974 A2 $131.36 $171.54

58976 A2 $131.36 $171.54

59000 P3 $73.15 $95.53

59001 R2 $279.51 $365.01

59012 G2 $131.36 $171.54

59015 P3 $63.96 $83.53

59020 P3 $35.38 $46.20

59025 P3 $19.05 $24.88

59070 G2 $66.53 $86.88

59072 G2 $131.36 $171.54

59074 G2 $131.36 $171.54

59076 G2 $131.36 $171.54

59100 R2 $1,481.07 $1,934.13

59150 G2 $1,956.74 $2,555.31

59151 G2 $1,956.74 $2,555.31

59160 A2 $816.19 $1,065.86

59200 P3 $39.81 $51.99

59300 P3 $93.90 $122.62

59320 A2 $816.19 $1,065.86

59412 G2 $816.19 $1,065.86

59414 G2 $816.19 $1,065.86

59812 A2 $816.19 $1,065.86

59820 A2 $816.19 $1,065.86

59821 A2 $816.19 $1,065.86

59840 A2 $816.19 $1,065.86

59841 A2 $816.19 $1,065.86

59866 G2 $131.36 $171.54

59870 A2 $816.19 $1,065.86

59871 A2 $816.19 $1,065.86

60000 A2 $279.76 $365.34

60100 P3 $53.76 $70.21

60200 A2 $2,059.99 $2,690.14

60210 G2 $2,059.99 $2,690.14

60212 G2 $2,059.99 $2,690.14

60220 G2 $2,059.99 $2,690.14

60225 G2 $2,059.99 $2,690.14

60280 A2 $2,059.99 $2,690.14

60281 A2 $2,059.99 $2,690.14

60300 P3 $83.70 $109.30

61000 R2 $317.46 $414.57

61001 R2 $317.46 $414.57

61020 A2 $317.46 $414.57

61026 A2 $317.46 $414.57

61050 A2 $317.46 $414.57

61055 A2 $317.46 $414.57

61070 A2 $246.69 $322.15

61215 A2 $1,824.28 $2,382.33

61330 G2 $1,839.88 $2,402.70

61334 G2 $1,839.88 $2,402.70

61770 G2 $1,392.48 $1,818.44

61781 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 50 of 88

Page 51: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

61782 N1 $0.00 $0.00

61783 N1 $0.00 $0.00

61790 A2 $754.56 $985.38

61791 A2 $480.71 $627.76

61880 G2 $847.91 $1,107.29

61885 J8 $15,431.30 $20,151.73

61886 J8 $19,560.64 $25,544.24

61888 A2 $1,457.96 $1,903.95

62160 N1 $0.00 $0.00

62194 A2 $317.46 $414.57

62225 A2 $674.26 $880.52

62230 A2 $1,824.28 $2,382.33

62252 P3 $42.19 $55.10

62263 A2 $480.71 $627.76

62264 A2 $480.71 $627.76

62267 G2 $193.88 $253.19

62268 A2 $317.46 $414.57

62269 A2 $400.40 $522.88

62270 A2 $163.70 $213.78

62272 A2 $163.70 $213.78

62273 A2 $317.46 $414.57

62280 A2 $317.46 $414.57

62281 A2 $480.71 $627.76

62282 A2 $480.71 $627.76

62284 N1 $0.00 $0.00

62287 A2 $1,392.48 $1,818.44

62290 N1 $0.00 $0.00

62291 N1 $0.00 $0.00

62292 R2 $317.46 $414.57

62294 A2 $317.46 $414.57

62310 A2 $317.46 $414.57

62311 A2 $317.46 $414.57

62318 A2 $317.46 $414.57

62319 A2 $480.71 $627.76

62350 A2 $1,824.28 $2,382.33

62355 A2 $480.71 $627.76

62360 A2 $1,824.28 $2,382.33

62361 J8 $12,969.25 $16,936.54

62362 J8 $12,969.25 $16,936.54

62365 A2 $1,392.48 $1,818.44

62367 P3 $24.84 $32.44

62368 P3 $33.34 $43.54

62369 P3 $104.79 $136.85

62370 P3 $101.73 $132.85

63001 G2 $2,109.06 $2,754.22

63003 G2 $2,109.06 $2,754.22

63005 G2 $2,109.06 $2,754.22

63600 A2 $754.56 $985.38

63610 A2 $754.56 $985.38

63615 R2 $754.56 $985.38

63650 J8 $3,550.55 $4,636.66

63655 J8 $5,860.83 $7,653.66

63661 G2 $847.91 $1,107.29

63662 G2 $847.91 $1,107.29

63663 J8 $3,550.55 $4,636.66

63664 J8 $3,550.55 $4,636.66

63685 J8 $15,431.30 $20,151.73

63688 A2 $1,457.96 $1,903.95

63744 A2 $1,824.28 $2,382.33

63746 A2 $480.71 $627.76

64400 P3 $82.34 $107.53

Updated 3/22/2013 MDWCC

Page 51 of 88

Page 52: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

64402 P3 $76.21 $99.52

64405 P3 $65.32 $85.30

64408 P3 $47.97 $62.64

64410 A2 $102.47 $133.82

64412 P3 $96.29 $125.75

64413 P3 $74.17 $96.86

64415 A2 $163.70 $213.78

64416 G2 $317.46 $414.57

64417 A2 $163.70 $213.78

64418 P3 $96.29 $125.75

64420 A2 $163.70 $213.78

64421 A2 $317.46 $414.57

64425 P3 $72.13 $94.19

64430 A2 $317.46 $414.57

64435 P3 $81.66 $106.64

64445 P3 $83.36 $108.86

64446 G2 $317.46 $414.57

64447 P3 $66.69 $87.09

64448 G2 $317.46 $414.57

64449 G2 $317.46 $414.57

64450 P3 $53.76 $70.21

64455 P3 $20.07 $26.21

64479 A2 $317.46 $414.57

64480 A2 $163.70 $213.78

64483 A2 $317.46 $414.57

64484 A2 $163.70 $213.78

64490 G2 $317.46 $414.57

64491 G2 $102.47 $133.82

64492 G2 $102.47 $133.82

64493 G2 $317.46 $414.57

64494 G2 $102.47 $133.82

64495 G2 $102.47 $133.82

64505 P3 $55.46 $72.43

64508 P3 $19.39 $25.32

64510 A2 $317.46 $414.57

64517 A2 $317.46 $414.57

64520 A2 $317.46 $414.57

64530 A2 $317.46 $414.57

64553 J8 $3,550.55 $4,636.66

64555 J8 $3,550.55 $4,636.66

64561 J8 $3,550.55 $4,636.66

64565 J8 $3,550.55 $4,636.66

64566 P3 $101.73 $132.85

64568 J8 $24,363.34 $31,816.09

64569 J8 $3,550.55 $4,636.66

64570 G2 $1,392.48 $1,818.44

64575 J8 $5,860.83 $7,653.66

64580 J8 $5,860.83 $7,653.66

64581 J8 $5,860.83 $7,653.66

64585 A2 $847.91 $1,107.29

64590 J8 $15,431.30 $20,151.73

64595 A2 $1,457.96 $1,903.95

64600 A2 $480.71 $627.76

64605 A2 $754.56 $985.38

64610 A2 $754.56 $985.38

64611 P3 $69.75 $91.09

64612 P3 $76.21 $99.52

64613 P3 $86.76 $113.30

64614 P3 $99.01 $129.30

64615 P3 $60.56 $79.09

64620 A2 $480.71 $627.76

Updated 3/22/2013 MDWCC

Page 52 of 88

Page 53: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

64630 A2 $317.46 $414.57

64632 P3 $40.83 $53.32

64633 G2 $317.46 $414.57

64634 G2 $102.47 $133.82

64635 G2 $480.71 $627.76

64636 G2 $317.46 $414.57

64640 P3 $92.88 $121.29

64650 P3 $100.03 $130.63

64653 P2 $102.47 $133.82

64680 A2 $480.71 $627.76

64681 A2 $480.71 $627.76

64702 A2 $754.56 $985.38

64704 A2 $754.56 $985.38

64708 G2 $754.56 $985.38

64712 G2 $754.56 $985.38

64713 G2 $754.56 $985.38

64714 G2 $754.56 $985.38

64716 A2 $754.56 $985.38

64718 A2 $754.56 $985.38

64719 A2 $754.56 $985.38

64721 A2 $754.56 $985.38

64722 A2 $754.56 $985.38

64726 A2 $754.56 $985.38

64727 A2 $754.56 $985.38

64732 A2 $754.56 $985.38

64734 A2 $754.56 $985.38

64736 A2 $754.56 $985.38

64738 A2 $754.56 $985.38

64740 A2 $754.56 $985.38

64742 A2 $754.56 $985.38

64744 A2 $754.56 $985.38

64746 A2 $754.56 $985.38

64761 G2 $754.56 $985.38

64763 G2 $754.56 $985.38

64766 G2 $1,392.48 $1,818.44

64771 A2 $754.56 $985.38

64772 A2 $754.56 $985.38

64774 A2 $754.56 $985.38

64776 A2 $754.56 $985.38

64778 A2 $754.56 $985.38

64782 A2 $754.56 $985.38

64783 A2 $754.56 $985.38

64784 A2 $754.56 $985.38

64786 A2 $1,392.48 $1,818.44

64787 A2 $754.56 $985.38

64788 A2 $754.56 $985.38

64790 A2 $754.56 $985.38

64792 A2 $1,392.48 $1,818.44

64795 A2 $754.56 $985.38

64802 A2 $754.56 $985.38

64820 G2 $754.56 $985.38

64821 A2 $1,159.36 $1,514.01

64822 G2 $1,159.36 $1,514.01

64823 G2 $1,159.36 $1,514.01

64831 A2 $1,392.48 $1,818.44

64832 A2 $1,392.48 $1,818.44

64834 A2 $1,392.48 $1,818.44

64835 A2 $1,392.48 $1,818.44

64836 A2 $1,392.48 $1,818.44

64837 A2 $1,392.48 $1,818.44

64840 A2 $1,392.48 $1,818.44

Updated 3/22/2013 MDWCC

Page 53 of 88

Page 54: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

64856 A2 $1,392.48 $1,818.44

64857 A2 $1,392.48 $1,818.44

64858 A2 $1,392.48 $1,818.44

64859 A2 $1,392.48 $1,818.44

64861 A2 $1,392.48 $1,818.44

64862 A2 $1,392.48 $1,818.44

64864 A2 $1,392.48 $1,818.44

64865 A2 $1,392.48 $1,818.44

64870 A2 $1,392.48 $1,818.44

64872 A2 $1,392.48 $1,818.44

64874 A2 $1,392.48 $1,818.44

64876 A2 $1,392.48 $1,818.44

64885 A2 $1,392.48 $1,818.44

64886 A2 $1,392.48 $1,818.44

64890 A2 $1,392.48 $1,818.44

64891 A2 $1,392.48 $1,818.44

64892 A2 $1,392.48 $1,818.44

64893 A2 $1,392.48 $1,818.44

64895 A2 $1,392.48 $1,818.44

64896 A2 $1,392.48 $1,818.44

64897 A2 $1,392.48 $1,818.44

64898 A2 $1,392.48 $1,818.44

64901 A2 $1,392.48 $1,818.44

64902 A2 $1,392.48 $1,818.44

64905 A2 $1,392.48 $1,818.44

64907 A2 $1,392.48 $1,818.44

64910 G2 $1,392.48 $1,818.44

65091 A2 $1,589.52 $2,075.75

65093 A2 $1,589.52 $2,075.75

65101 A2 $1,589.52 $2,075.75

65103 A2 $1,589.52 $2,075.75

65105 A2 $1,589.52 $2,075.75

65110 A2 $1,589.52 $2,075.75

65112 A2 $1,589.52 $2,075.75

65114 A2 $1,589.52 $2,075.75

65125 G2 $1,068.42 $1,395.25

65130 A2 $1,068.42 $1,395.25

65135 A2 $1,068.42 $1,395.25

65140 A2 $1,589.52 $2,075.75

65150 A2 $1,068.42 $1,395.25

65155 A2 $1,589.52 $2,075.75

65175 A2 $767.58 $1,002.38

65205 P3 $30.28 $39.54

65210 P3 $38.79 $50.66

65220 G2 $41.56 $54.27

65222 P3 $37.09 $48.44

65235 A2 $633.77 $827.64

65260 A2 $233.65 $305.12

65265 A2 $809.22 $1,056.76

65270 A2 $767.58 $1,002.38

65272 A2 $940.80 $1,228.59

65275 A2 $940.80 $1,228.59

65280 A2 $809.22 $1,056.76

65285 A2 $1,635.00 $2,135.15

65286 P2 $371.94 $485.72

65290 A2 $1,008.73 $1,317.30

65400 A2 $633.77 $827.64

65410 A2 $633.77 $827.64

65420 A2 $633.77 $827.64

65426 A2 $940.80 $1,228.59

65430 P2 $41.56 $54.27

Updated 3/22/2013 MDWCC

Page 54 of 88

Page 55: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

65435 P3 $47.29 $61.76

65436 P3 $214.69 $280.36

65450 G2 $81.30 $106.17

65600 P3 $247.35 $323.01

65710 A2 $1,665.08 $2,174.43

65730 A2 $1,665.08 $2,174.43

65750 A2 $1,665.08 $2,174.43

65755 A2 $1,665.08 $2,174.43

65756 G2 $1,665.08 $2,174.43

65757 N1 $0.00 $0.00

65770 J8 $7,378.12 $9,635.09

65772 A2 $633.77 $827.64

65775 A2 $633.77 $827.64

65778 N1 $0.00 $0.00

65779 N1 $0.00 $0.00

65780 A2 $1,665.08 $2,174.43

65781 A2 $1,665.08 $2,174.43

65782 A2 $1,665.08 $2,174.43

65800 A2 $371.94 $485.72

65810 A2 $940.80 $1,228.59

65815 A2 $940.80 $1,228.59

65820 A2 $940.80 $1,228.59

65850 A2 $940.80 $1,228.59

65855 P3 $195.97 $255.92

65860 P3 $181.00 $236.37

65865 A2 $633.77 $827.64

65870 A2 $940.80 $1,228.59

65875 A2 $940.80 $1,228.59

65880 A2 $633.77 $827.64

65900 A2 $81.25 $106.10

65920 A2 $940.80 $1,228.59

65930 A2 $1,671.00 $2,182.16

66020 A2 $633.77 $827.64

66030 A2 $633.77 $827.64

66130 A2 $940.80 $1,228.59

66150 A2 $940.80 $1,228.59

66155 A2 $1,671.00 $2,182.16

66160 A2 $940.80 $1,228.59

66165 A2 $940.80 $1,228.59

66170 A2 $940.80 $1,228.59

66172 A2 $940.80 $1,228.59

66174 A2 $1,671.00 $2,182.16

66175 A2 $1,671.00 $2,182.16

66180 A2 $1,671.00 $2,182.16

66185 A2 $1,671.00 $2,182.16

66220 A2 $1,635.00 $2,135.15

66225 A2 $1,671.00 $2,182.16

66250 A2 $633.77 $827.64

66500 A2 $81.25 $106.10

66505 A2 $371.94 $485.72

66600 A2 $940.80 $1,228.59

66605 A2 $1,671.00 $2,182.16

66625 A2 $371.94 $485.72

66630 A2 $940.80 $1,228.59

66635 A2 $940.80 $1,228.59

66680 A2 $940.80 $1,228.59

66682 A2 $940.80 $1,228.59

66700 A2 $633.77 $827.64

66710 A2 $633.77 $827.64

66711 A2 $940.80 $1,228.59

66720 A2 $633.77 $827.64

Updated 3/22/2013 MDWCC

Page 55 of 88

Page 56: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

66740 A2 $940.80 $1,228.59

66761 P3 $191.89 $250.59

66762 P2 $230.51 $301.02

66770 P2 $230.51 $301.02

66820 G2 $371.94 $485.72

66821 A2 $230.51 $301.02

66825 A2 $940.80 $1,228.59

66830 A2 $371.94 $485.72

66840 A2 $633.77 $827.64

66850 A2 $1,175.82 $1,535.50

66852 A2 $1,175.82 $1,535.50

66920 A2 $1,175.82 $1,535.50

66930 A2 $1,175.82 $1,535.50

66940 A2 $371.94 $485.72

66982 A2 $971.02 $1,268.06

66983 A2 $971.02 $1,268.06

66984 A2 $971.02 $1,268.06

66985 A2 $971.02 $1,268.06

66986 A2 $971.02 $1,268.06

66990 N1 $0.00 $0.00

67005 A2 $809.22 $1,056.76

67010 A2 $1,635.00 $2,135.15

67015 A2 $1,635.00 $2,135.15

67025 A2 $1,635.00 $2,135.15

67027 A2 $1,635.00 $2,135.15

67028 P3 $49.33 $64.42

67030 A2 $809.22 $1,056.76

67031 A2 $230.51 $301.02

67036 A2 $1,635.00 $2,135.15

67039 A2 $1,635.00 $2,135.15

67040 A2 $1,635.00 $2,135.15

67041 G2 $1,635.00 $2,135.15

67042 G2 $1,635.00 $2,135.15

67043 G2 $1,635.00 $2,135.15

67101 P3 $472.24 $616.70

67105 P2 $230.51 $301.02

67107 A2 $1,635.00 $2,135.15

67108 A2 $1,635.00 $2,135.15

67110 P3 $503.88 $658.02

67112 A2 $1,635.00 $2,135.15

67113 G2 $1,635.00 $2,135.15

67115 A2 $809.22 $1,056.76

67120 A2 $809.22 $1,056.76

67121 A2 $1,635.00 $2,135.15

67141 A2 $233.65 $305.12

67145 P2 $230.51 $301.02

67208 P2 $233.65 $305.12

67210 P2 $230.51 $301.02

67218 A2 $809.22 $1,056.76

67220 P2 $233.65 $305.12

67221 P3 $163.65 $213.71

67225 P3 $12.59 $16.44

67227 A2 $809.22 $1,056.76

67228 P2 $230.51 $301.02

67229 R2 $230.51 $301.02

67250 A2 $767.58 $1,002.38

67255 A2 $809.22 $1,056.76

67311 A2 $1,008.73 $1,317.30

67312 A2 $1,008.73 $1,317.30

67314 A2 $1,008.73 $1,317.30

67316 A2 $1,008.73 $1,317.30

Updated 3/22/2013 MDWCC

Page 56 of 88

Page 57: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

67318 A2 $1,008.73 $1,317.30

67320 A2 $1,008.73 $1,317.30

67331 A2 $1,008.73 $1,317.30

67332 A2 $1,008.73 $1,317.30

67334 A2 $1,008.73 $1,317.30

67335 A2 $1,008.73 $1,317.30

67340 A2 $1,008.73 $1,317.30

67343 A2 $1,008.73 $1,317.30

67345 P3 $127.93 $167.06

67346 A2 $634.98 $829.22

67400 A2 $767.58 $1,002.38

67405 A2 $1,068.42 $1,395.25

67412 A2 $767.58 $1,002.38

67413 A2 $1,068.42 $1,395.25

67414 G2 $1,589.52 $2,075.75

67415 A2 $767.58 $1,002.38

67420 A2 $1,589.52 $2,075.75

67430 A2 $1,589.52 $2,075.75

67440 A2 $1,589.52 $2,075.75

67445 A2 $1,589.52 $2,075.75

67450 A2 $1,589.52 $2,075.75

67500 G2 $81.30 $106.17

67505 P3 $42.87 $55.98

67515 P3 $45.93 $59.98

67550 A2 $1,589.52 $2,075.75

67560 A2 $1,068.42 $1,395.25

67570 A2 $1,589.52 $2,075.75

67700 P2 $130.05 $169.83

67710 P3 $192.91 $251.92

67715 A2 $767.58 $1,002.38

67800 P3 $76.89 $100.41

67801 P3 $93.90 $122.62

67805 P3 $121.12 $158.17

67808 A2 $767.58 $1,002.38

67810 P2 $130.05 $169.83

67820 P3 $24.50 $31.99

67825 P3 $77.91 $101.74

67830 A2 $345.48 $451.16

67835 A2 $767.58 $1,002.38

67840 P3 $205.84 $268.81

67850 P3 $154.80 $202.15

67875 G2 $345.48 $451.16

67880 A2 $633.77 $827.64

67882 A2 $767.58 $1,002.38

67900 A2 $1,068.42 $1,395.25

67901 A2 $767.58 $1,002.38

67902 A2 $1,068.42 $1,395.25

67903 A2 $767.58 $1,002.38

67904 A2 $767.58 $1,002.38

67906 A2 $767.58 $1,002.38

67908 A2 $767.58 $1,002.38

67909 A2 $767.58 $1,002.38

67911 A2 $767.58 $1,002.38

67912 A2 $767.58 $1,002.38

67914 A2 $767.58 $1,002.38

67915 P3 $239.18 $312.35

67916 A2 $767.58 $1,002.38

67917 A2 $767.58 $1,002.38

67921 A2 $767.58 $1,002.38

67922 P3 $235.10 $307.02

67923 A2 $767.58 $1,002.38

Updated 3/22/2013 MDWCC

Page 57 of 88

Page 58: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

67924 A2 $767.58 $1,002.38

67930 P3 $236.80 $309.24

67935 A2 $767.58 $1,002.38

67938 P2 $81.30 $106.17

67950 A2 $767.58 $1,002.38

67961 A2 $767.58 $1,002.38

67966 A2 $767.58 $1,002.38

67971 A2 $767.58 $1,002.38

67973 A2 $1,068.42 $1,395.25

67974 A2 $767.58 $1,002.38

67975 A2 $767.58 $1,002.38

68020 P3 $69.07 $90.20

68040 P3 $33.68 $43.98

68100 P3 $124.52 $162.61

68110 P3 $164.33 $214.60

68115 A2 $767.58 $1,002.38

68130 A2 $633.77 $827.64

68135 P3 $88.80 $115.96

68200 P3 $23.48 $30.66

68320 A2 $1,068.42 $1,395.25

68325 A2 $1,068.42 $1,395.25

68326 A2 $767.58 $1,002.38

68328 A2 $1,068.42 $1,395.25

68330 A2 $940.80 $1,228.59

68335 A2 $1,068.42 $1,395.25

68340 A2 $767.58 $1,002.38

68360 A2 $940.80 $1,228.59

68362 A2 $940.80 $1,228.59

68371 A2 $940.80 $1,228.59

68400 P2 $130.05 $169.83

68420 P3 $243.60 $318.12

68440 P3 $68.05 $88.87

68500 A2 $1,068.42 $1,395.25

68505 A2 $1,068.42 $1,395.25

68510 A2 $767.58 $1,002.38

68520 A2 $1,068.42 $1,395.25

68525 A2 $767.58 $1,002.38

68530 P2 $130.05 $169.83

68540 A2 $767.58 $1,002.38

68550 A2 $1,068.42 $1,395.25

68700 A2 $767.58 $1,002.38

68705 P2 $130.05 $169.83

68720 A2 $1,068.42 $1,395.25

68745 A2 $1,068.42 $1,395.25

68750 A2 $1,068.42 $1,395.25

68760 P2 $130.05 $169.83

68761 P3 $99.35 $129.74

68770 A2 $1,068.42 $1,395.25

68801 P2 $41.56 $54.27

68810 A2 $130.05 $169.83

68811 A2 $767.58 $1,002.38

68815 A2 $767.58 $1,002.38

68816 G2 $767.58 $1,002.38

68840 P2 $81.30 $106.17

68850 N1 $0.00 $0.00

69000 P2 $70.40 $91.94

69005 P3 $140.51 $183.49

69020 P2 $70.40 $91.94

69100 P3 $72.47 $94.64

69105 P3 $116.36 $151.95

69110 A2 $629.45 $822.00

Updated 3/22/2013 MDWCC

Page 58 of 88

Page 59: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

69120 A2 $1,009.91 $1,318.84

69140 A2 $1,839.88 $2,402.70

69145 A2 $629.45 $822.00

69150 A2 $1,009.91 $1,318.84

69200 P2 $27.85 $36.37

69205 A2 $932.08 $1,217.20

69210 P2 $27.85 $36.37

69220 P2 $40.14 $52.42

69222 P3 $177.26 $231.48

69300 A2 $1,009.91 $1,318.84

69310 A2 $1,839.88 $2,402.70

69320 A2 $1,839.88 $2,402.70

69400 P3 $126.23 $164.84

69401 P3 $69.41 $90.64

69405 P3 $169.43 $221.26

69420 P2 $128.95 $168.40

69421 A2 $643.83 $840.78

69424 P3 $103.09 $134.63

69433 P3 $153.10 $199.93

69436 A2 $643.83 $840.78

69440 A2 $1,839.88 $2,402.70

69450 A2 $1,839.88 $2,402.70

69501 A2 $1,839.88 $2,402.70

69502 A2 $1,839.88 $2,402.70

69505 A2 $1,839.88 $2,402.70

69511 A2 $1,839.88 $2,402.70

69530 A2 $1,839.88 $2,402.70

69540 P3 $173.86 $227.04

69550 A2 $1,839.88 $2,402.70

69552 A2 $1,839.88 $2,402.70

69601 A2 $1,839.88 $2,402.70

69602 A2 $1,839.88 $2,402.70

69603 A2 $1,839.88 $2,402.70

69604 A2 $1,839.88 $2,402.70

69605 A2 $1,839.88 $2,402.70

69610 P3 $225.57 $294.57

69620 A2 $1,009.91 $1,318.84

69631 A2 $1,839.88 $2,402.70

69632 A2 $1,839.88 $2,402.70

69633 A2 $1,839.88 $2,402.70

69635 A2 $1,839.88 $2,402.70

69636 A2 $1,839.88 $2,402.70

69637 A2 $1,839.88 $2,402.70

69641 A2 $1,839.88 $2,402.70

69642 A2 $1,839.88 $2,402.70

69643 A2 $1,839.88 $2,402.70

69644 A2 $1,839.88 $2,402.70

69645 A2 $1,839.88 $2,402.70

69646 A2 $1,839.88 $2,402.70

69650 A2 $1,839.88 $2,402.70

69660 A2 $1,839.88 $2,402.70

69661 A2 $1,839.88 $2,402.70

69662 A2 $1,839.88 $2,402.70

69666 A2 $1,009.91 $1,318.84

69667 A2 $1,009.91 $1,318.84

69670 A2 $1,839.88 $2,402.70

69676 A2 $1,009.91 $1,318.84

69700 A2 $1,009.91 $1,318.84

69711 A2 $1,839.88 $2,402.70

69714 J8 $7,888.90 $10,302.11

69715 J8 $7,888.90 $10,302.11

Updated 3/22/2013 MDWCC

Page 59 of 88

Page 60: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

69717 J8 $7,888.90 $10,302.11

69718 J8 $7,888.90 $10,302.11

69720 A2 $1,839.88 $2,402.70

69740 A2 $1,839.88 $2,402.70

69745 A2 $1,839.88 $2,402.70

69801 P3 $124.52 $162.61

69805 A2 $1,839.88 $2,402.70

69806 A2 $1,839.88 $2,402.70

69820 A2 $1,839.88 $2,402.70

69840 A2 $1,839.88 $2,402.70

69905 A2 $1,839.88 $2,402.70

69910 A2 $1,839.88 $2,402.70

69915 A2 $1,839.88 $2,402.70

69930 J8 $28,186.69 $36,809.00

69990 N1 $0.00 $0.00

0099T R2 $940.80 $1,228.59

0100T G2 $1,635.00 $2,135.15

0101T G2 $1,294.39 $1,690.34

0102T G2 $1,294.39 $1,690.34

0123T G2 $940.80 $1,228.59

0124T R2 $81.25 $106.10

0186T G2 $809.22 $1,056.76

0190T G2 $809.22 $1,056.76

0191T G2 $1,671.00 $2,182.16

0192T G2 $1,671.00 $2,182.16

0200T G2 $1,294.39 $1,690.34

0201T G2 $1,294.39 $1,690.34

0213T R2 $317.46 $414.57

0214T R2 $102.47 $133.82

0215T R2 $102.47 $133.82

0216T R2 $317.46 $414.57

0217T R2 $102.47 $133.82

0218T R2 $102.47 $133.82

0226T R2 $27.85 $36.37

0227T R2 $235.85 $308.00

0228T G2 $317.46 $414.57

0229T G2 $163.70 $213.78

0230T G2 $317.46 $414.57

0231T G2 $163.70 $213.78

0232T G2 $27.85 $36.37

0238T G2 $4,304.52 $5,621.27

0249T G2 $1,327.61 $1,733.73

0253T G2 $1,671.00 $2,182.16

0260T N1 $0.00 $0.00

0261T N1 $0.00 $0.00

0263T G2 $1,620.94 $2,116.79

0264T G2 $1,620.94 $2,116.79

0265T G2 $1,620.94 $2,116.79

0269T G2 $1,392.48 $1,818.44

0270T G2 $847.91 $1,107.29

0271T G2 $1,457.96 $1,903.95

0274T G2 $2,109.06 $2,754.22

0275T G2 $2,109.06 $2,754.22

0282T J8 $3,550.55 $4,636.66

0283T J8 $24,363.34 $31,816.09

0284T G2 $847.91 $1,107.29

0288T G2 $1,327.61 $1,733.73

0289T N1 $0.00 $0.00

0290T N1 $0.00 $0.00

0299T R2 $48.11 $62.83

0300T R2 $48.11 $62.83

Updated 3/22/2013 MDWCC

Page 60 of 88

Page 61: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

0301T G2 $548.93 $716.85

0302T J8 $7,127.41 $9,307.68

0303T G2 $2,113.24 $2,759.68

0304T J8 $5,772.53 $7,538.35

0307T G2 $944.45 $1,233.36

0308T G2 $940.80 $1,228.59

0313T G2 $847.91 $1,107.29

0314T G2 $1,457.96 $1,903.95

0315T G2 $1,457.96 $1,903.95

0316T J8 $15,431.30 $20,151.73

0319T J8 $20,941.14 $27,347.03

0320T G2 $2,113.24 $2,759.68

0321T J8 $20,941.14 $27,347.03

0322T G2 $944.45 $1,233.36

0323T J8 $20,941.14 $27,347.03

0325T G2 $944.45 $1,233.36

0326T N1 $0.00 $0.00

C9724 G2 $1,047.82 $1,368.35

C9725 G2 $246.53 $321.94

C9726 G2 $1,045.25 $1,364.99

C9727 G2 $279.76 $365.34

C9728 R2 $552.43 $721.42

C9800 R2 $220.74 $288.26

G0104 P3 $107.85 $140.84

G0105 A2 $343.28 $448.29

G0121 A2 $343.28 $448.29

G0127 P2 $15.94 $20.82

G0186 R2 $233.65 $305.12

G0247 P2 $40.14 $52.42

G0259 N1 $0.00 $0.00

G0260 A2 $317.46 $414.57

G0268 N1 $0.00 $0.00

G0269 N1 $0.00 $0.00

G0289 N1 $0.00 $0.00

G0364 P3 $6.46 $8.44

G0365 P2 $86.83 $113.39

G0448 J8 $28,513.56 $37,235.86

G0458 G2 $1,826.29 $2,384.95

70010 N1 $0.00 $0.00

70015 N1 $0.00 $0.00

70030 Z3 $21.43 $27.99

70100 Z2 $25.78 $33.67

70110 Z3 $28.24 $36.88

70120 Z3 $27.90 $36.43

70130 Z2 $25.78 $33.67

70134 Z3 $30.96 $40.43

70140 Z3 $20.75 $27.10

70150 Z3 $30.96 $40.43

70160 Z2 $25.78 $33.67

70170 N1 $0.00 $0.00

70190 Z2 $25.78 $33.67

70200 Z3 $30.96 $40.43

70210 Z3 $23.14 $30.22

70220 Z3 $27.56 $35.99

70240 Z3 $21.09 $27.54

70250 Z2 $25.78 $33.67

70260 Z3 $31.30 $40.87

70300 Z3 $9.19 $12.00

70310 Z2 $20.13 $26.29

70320 Z2 $20.13 $26.29

70328 Z3 $23.48 $30.66

Updated 3/22/2013 MDWCC

Page 61 of 88

Page 62: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

70330 Z2 $25.78 $33.67

70332 N1 $0.00 $0.00

70336 Z2 $189.94 $248.04

70350 Z3 $11.91 $15.55

70355 Z3 $10.21 $13.33

70360 Z3 $20.07 $26.21

70370 Z2 $64.12 $83.73

70371 Z3 $52.40 $68.43

70373 N1 $0.00 $0.00

70380 Z2 $25.78 $33.67

70390 N1 $0.00 $0.00

70450 Z2 $97.40 $127.19

70460 Z3 $165.01 $215.49

70470 Z3 $160.25 $209.27

70480 Z2 $97.40 $127.19

70481 Z2 $166.74 $217.75

70482 Z2 $184.80 $241.33

70486 Z2 $97.40 $127.19

70487 Z2 $166.74 $217.75

70488 Z2 $184.80 $241.33

70490 Z2 $97.40 $127.19

70491 Z2 $166.74 $217.75

70492 Z2 $184.80 $241.33

70496 Z2 $190.35 $248.58

70498 Z2 $190.35 $248.58

70540 Z2 $189.94 $248.04

70542 Z2 $255.06 $333.08

70543 Z2 $308.32 $402.64

70544 Z2 $189.94 $248.04

70545 Z2 $255.06 $333.08

70546 Z2 $308.32 $402.64

70547 Z2 $189.94 $248.04

70548 Z2 $255.06 $333.08

70549 Z2 $308.32 $402.64

70551 Z2 $189.94 $248.04

70552 Z2 $255.06 $333.08

70553 Z2 $308.32 $402.64

70554 Z2 $189.94 $248.04

70555 Z2 $189.94 $248.04

70557 Z2 $189.94 $248.04

70558 Z2 $255.06 $333.08

70559 Z2 $308.32 $402.64

71010 Z3 $14.63 $19.11

71015 Z3 $20.75 $27.10

71020 Z3 $20.07 $26.21

71021 Z3 $24.84 $32.44

71022 Z2 $25.78 $33.67

71023 Z3 $48.99 $63.98

71030 Z3 $31.98 $41.76

71034 Z2 $64.12 $83.73

71035 Z2 $25.78 $33.67

71100 Z3 $22.11 $28.87

71101 Z3 $27.22 $35.55

71110 Z3 $28.24 $36.88

71111 Z3 $38.79 $50.66

71120 Z3 $22.46 $29.33

71130 Z2 $25.78 $33.67

71250 Z2 $97.40 $127.19

71260 Z2 $166.74 $217.75

71270 Z2 $184.80 $241.33

71275 Z2 $190.35 $248.58

Updated 3/22/2013 MDWCC

Page 62 of 88

Page 63: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

71550 Z2 $189.94 $248.04

71551 Z2 $255.06 $333.08

71552 Z2 $308.32 $402.64

72010 Z2 $39.75 $51.91

72020 Z3 $16.33 $21.33

72040 Z3 $24.84 $32.44

72050 Z3 $33.68 $43.98

72052 Z2 $39.75 $51.91

72069 Z2 $25.78 $33.67

72070 Z3 $23.48 $30.66

72072 Z3 $27.22 $35.55

72074 Z2 $25.78 $33.67

72080 Z2 $25.78 $33.67

72090 Z3 $38.45 $50.21

72100 Z3 $25.18 $32.88

72110 Z3 $34.36 $44.87

72114 Z2 $39.75 $51.91

72120 Z3 $31.64 $41.32

72125 Z2 $97.40 $127.19

72126 Z2 $166.74 $217.75

72127 Z2 $184.80 $241.33

72128 Z2 $97.40 $127.19

72129 Z2 $166.74 $217.75

72130 Z2 $184.80 $241.33

72131 Z2 $97.40 $127.19

72132 Z2 $166.74 $217.75

72133 Z2 $184.80 $241.33

72141 Z2 $189.94 $248.04

72142 Z2 $255.06 $333.08

72146 Z2 $189.94 $248.04

72147 Z2 $255.06 $333.08

72148 Z2 $189.94 $248.04

72149 Z2 $255.06 $333.08

72156 Z2 $308.32 $402.64

72157 Z2 $308.32 $402.64

72158 Z2 $308.32 $402.64

72170 Z3 $20.41 $26.65

72190 Z2 $25.78 $33.67

72191 Z2 $190.35 $248.58

72192 Z2 $97.40 $127.19

72193 Z2 $166.74 $217.75

72194 Z2 $184.80 $241.33

72195 Z2 $189.94 $248.04

72196 Z2 $255.06 $333.08

72197 Z2 $308.32 $402.64

72200 Z3 $21.77 $28.43

72202 Z2 $25.78 $33.67

72220 Z3 $21.09 $27.54

72240 N1 $0.00 $0.00

72255 N1 $0.00 $0.00

72265 N1 $0.00 $0.00

72270 N1 $0.00 $0.00

72275 N1 $0.00 $0.00

72285 N1 $0.00 $0.00

72291 N1 $0.00 $0.00

72292 N1 $0.00 $0.00

72295 N1 $0.00 $0.00

73000 Z3 $21.43 $27.99

73010 Z3 $23.48 $30.66

73020 Z3 $16.67 $21.77

73030 Z3 $21.77 $28.43

Updated 3/22/2013 MDWCC

Page 63 of 88

Page 64: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

73040 N1 $0.00 $0.00

73050 Z2 $25.78 $33.67

73060 Z3 $21.09 $27.54

73070 Z3 $21.43 $27.99

73080 Z2 $25.78 $33.67

73085 N1 $0.00 $0.00

73090 Z3 $20.41 $26.65

73092 Z3 $25.18 $32.88

73100 Z3 $23.82 $31.11

73110 Z2 $25.78 $33.67

73115 N1 $0.00 $0.00

73120 Z3 $20.07 $26.21

73130 Z3 $24.84 $32.44

73140 Z2 $25.78 $33.67

73200 Z2 $97.40 $127.19

73201 Z2 $166.74 $217.75

73202 Z2 $184.80 $241.33

73206 Z2 $190.35 $248.58

73218 Z2 $189.94 $248.04

73219 Z2 $255.06 $333.08

73220 Z2 $308.32 $402.64

73221 Z2 $189.94 $248.04

73222 Z2 $255.06 $333.08

73223 Z2 $308.32 $402.64

73500 Z3 $18.71 $24.43

73510 Z2 $25.78 $33.67

73520 Z3 $28.58 $37.32

73525 N1 $0.00 $0.00

73530 N1 $0.00 $0.00

73540 Z2 $25.78 $33.67

73550 Z3 $20.07 $26.21

73560 Z3 $22.46 $29.33

73562 Z2 $25.78 $33.67

73564 Z3 $33.34 $43.54

73565 Z2 $25.78 $33.67

73580 N1 $0.00 $0.00

73590 Z3 $19.73 $25.77

73592 Z3 $20.75 $27.10

73600 Z3 $21.43 $27.99

73610 Z2 $25.78 $33.67

73615 N1 $0.00 $0.00

73620 Z3 $20.75 $27.10

73630 Z3 $24.16 $31.55

73650 Z3 $21.43 $27.99

73660 Z3 $24.84 $32.44

73700 Z2 $97.40 $127.19

73701 Z2 $166.74 $217.75

73702 Z2 $184.80 $241.33

73706 Z2 $190.35 $248.58

73718 Z2 $189.94 $248.04

73719 Z2 $255.06 $333.08

73720 Z2 $308.32 $402.64

73721 Z2 $189.94 $248.04

73722 Z2 $255.06 $333.08

73723 Z2 $308.32 $402.64

74000 Z3 $15.65 $20.44

74010 Z2 $25.78 $33.67

74020 Z2 $25.78 $33.67

74022 Z3 $34.36 $44.87

74150 Z2 $97.40 $127.19

74160 Z2 $166.74 $217.75

Updated 3/22/2013 MDWCC

Page 64 of 88

Page 65: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

74170 Z2 $184.80 $241.33

74174 Z2 $270.79 $353.62

74175 Z2 $190.35 $248.58

74176 Z3 $148.00 $193.27

74177 Z2 $270.79 $353.62

74178 Z2 $270.79 $353.62

74181 Z2 $189.94 $248.04

74182 Z2 $255.06 $333.08

74183 Z2 $308.32 $402.64

74190 N1 $0.00 $0.00

74210 Z2 $46.42 $60.62

74220 Z2 $46.42 $60.62

74230 Z2 $46.42 $60.62

74235 N1 $0.00 $0.00

74240 Z2 $68.92 $90.00

74241 Z2 $68.92 $90.00

74245 Z2 $68.92 $90.00

74246 Z2 $68.92 $90.00

74247 Z2 $68.92 $90.00

74249 Z2 $68.92 $90.00

74250 Z2 $46.42 $60.62

74251 Z2 $68.92 $90.00

74260 Z2 $46.42 $60.62

74261 Z2 $97.40 $127.19

74262 Z2 $166.74 $217.75

74270 Z2 $68.92 $90.00

74280 Z2 $68.92 $90.00

74283 Z2 $68.92 $90.00

74290 Z2 $46.42 $60.62

74291 Z2 $46.42 $60.62

74300 N1 $0.00 $0.00

74301 N1 $0.00 $0.00

74305 N1 $0.00 $0.00

74320 N1 $0.00 $0.00

74327 N1 $0.00 $0.00

74328 N1 $0.00 $0.00

74329 N1 $0.00 $0.00

74330 N1 $0.00 $0.00

74340 N1 $0.00 $0.00

74355 N1 $0.00 $0.00

74360 N1 $0.00 $0.00

74363 N1 $0.00 $0.00

74400 Z2 $117.59 $153.56

74410 Z2 $117.59 $153.56

74415 Z2 $117.59 $153.56

74420 Z2 $117.59 $153.56

74425 N1 $0.00 $0.00

74430 N1 $0.00 $0.00

74440 N1 $0.00 $0.00

74445 N1 $0.00 $0.00

74450 N1 $0.00 $0.00

74455 N1 $0.00 $0.00

74470 N1 $0.00 $0.00

74475 N1 $0.00 $0.00

74480 N1 $0.00 $0.00

74485 N1 $0.00 $0.00

74710 Z3 $18.37 $23.99

74740 N1 $0.00 $0.00

74742 N1 $0.00 $0.00

74775 Z2 $117.59 $153.56

75557 Z2 $189.94 $248.04

Updated 3/22/2013 MDWCC

Page 65 of 88

Page 66: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

75559 Z2 $189.94 $248.04

75561 Z2 $308.32 $402.64

75563 Z2 $308.32 $402.64

75565 N1 $0.00 $0.00

75571 Z2 $27.85 $36.37

75572 Z2 $149.93 $195.79

75573 Z2 $149.93 $195.79

75574 Z2 $149.93 $195.79

75600 N1 $0.00 $0.00

75605 N1 $0.00 $0.00

75625 N1 $0.00 $0.00

75630 N1 $0.00 $0.00

75635 N1 $0.00 $0.00

75658 N1 $0.00 $0.00

75705 N1 $0.00 $0.00

75710 N1 $0.00 $0.00

75716 N1 $0.00 $0.00

75726 N1 $0.00 $0.00

75731 N1 $0.00 $0.00

75733 N1 $0.00 $0.00

75736 N1 $0.00 $0.00

75741 N1 $0.00 $0.00

75743 N1 $0.00 $0.00

75746 N1 $0.00 $0.00

75756 N1 $0.00 $0.00

75774 N1 $0.00 $0.00

75791 N1 $0.00 $0.00

75801 N1 $0.00 $0.00

75803 N1 $0.00 $0.00

75805 N1 $0.00 $0.00

75807 N1 $0.00 $0.00

75809 N1 $0.00 $0.00

75810 N1 $0.00 $0.00

75820 N1 $0.00 $0.00

75822 N1 $0.00 $0.00

75825 N1 $0.00 $0.00

75827 N1 $0.00 $0.00

75831 N1 $0.00 $0.00

75833 N1 $0.00 $0.00

75840 N1 $0.00 $0.00

75842 N1 $0.00 $0.00

75860 N1 $0.00 $0.00

75870 N1 $0.00 $0.00

75872 N1 $0.00 $0.00

75880 N1 $0.00 $0.00

75885 N1 $0.00 $0.00

75887 N1 $0.00 $0.00

75889 N1 $0.00 $0.00

75891 N1 $0.00 $0.00

75893 N1 $0.00 $0.00

75894 N1 $0.00 $0.00

75896 N1 $0.00 $0.00

75898 N1 $0.00 $0.00

75901 N1 $0.00 $0.00

75902 N1 $0.00 $0.00

75945 N1 $0.00 $0.00

75946 N1 $0.00 $0.00

75960 N1 $0.00 $0.00

75962 N1 $0.00 $0.00

75964 N1 $0.00 $0.00

75966 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 66 of 88

Page 67: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

75968 N1 $0.00 $0.00

75970 N1 $0.00 $0.00

75978 N1 $0.00 $0.00

75980 N1 $0.00 $0.00

75982 N1 $0.00 $0.00

75984 N1 $0.00 $0.00

75989 N1 $0.00 $0.00

76000 N1 $0.00 $0.00

76001 N1 $0.00 $0.00

76010 Z3 $18.37 $23.99

76080 N1 $0.00 $0.00

76098 N1 $0.00 $0.00

76100 Z2 $39.75 $51.91

76101 Z3 $121.12 $158.17

76102 Z2 $143.35 $187.20

76120 Z3 $58.18 $75.98

76125 N1 $0.00 $0.00

76376 N1 $0.00 $0.00

76377 N1 $0.00 $0.00

76380 Z2 $55.48 $72.45

76496 Z2 $64.12 $83.73

76497 Z2 $55.48 $72.45

76498 Z2 $189.94 $248.04

76499 Z2 $25.78 $33.67

76506 Z2 $36.23 $47.31

76510 Z2 $81.25 $106.10

76511 Z3 $50.69 $66.20

76512 Z3 $41.85 $54.65

76513 Z2 $55.73 $72.78

76514 Z3 $5.44 $7.10

76516 Z2 $36.23 $47.31

76519 Z2 $55.73 $72.78

76529 Z2 $36.23 $47.31

76536 Z2 $55.73 $72.78

76604 Z2 $36.23 $47.31

76645 Z2 $36.23 $47.31

76700 Z2 $55.73 $72.78

76705 Z2 $55.73 $72.78

76770 Z2 $55.73 $72.78

76775 Z2 $55.73 $72.78

76776 Z2 $55.73 $72.78

76800 Z2 $55.73 $72.78

76801 Z2 $55.73 $72.78

76802 Z3 $26.20 $34.21

76805 Z2 $55.73 $72.78

76810 Z3 $50.35 $65.75

76811 Z2 $86.83 $113.39

76812 Z2 $36.23 $47.31

76813 Z2 $36.23 $47.31

76814 Z3 $31.30 $40.87

76815 Z2 $36.23 $47.31

76816 Z2 $36.23 $47.31

76817 Z2 $36.23 $47.31

76818 Z2 $55.73 $72.78

76819 Z3 $53.42 $69.76

76820 Z3 $15.99 $20.88

76821 Z2 $36.23 $47.31

76825 Z2 $119.33 $155.83

76826 Z3 $92.88 $121.29

76827 Z3 $32.32 $42.21

76828 Z3 $17.35 $22.66

Updated 3/22/2013 MDWCC

Page 67 of 88

Page 68: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

76830 Z3 $42.19 $55.10

76831 Z2 $86.83 $113.39

76856 Z2 $55.73 $72.78

76857 Z2 $36.23 $47.31

76870 Z2 $55.73 $72.78

76872 Z3 $40.15 $52.43

76873 Z2 $86.83 $113.39

76881 Z2 $55.73 $72.78

76882 Z3 $11.23 $14.67

76885 Z2 $36.23 $47.31

76886 Z2 $36.23 $47.31

76930 N1 $0.00 $0.00

76932 N1 $0.00 $0.00

76936 Z2 $60.94 $79.58

76937 N1 $0.00 $0.00

76940 N1 $0.00 $0.00

76941 N1 $0.00 $0.00

76942 N1 $0.00 $0.00

76945 N1 $0.00 $0.00

76946 N1 $0.00 $0.00

76948 N1 $0.00 $0.00

76950 N1 $0.00 $0.00

76965 N1 $0.00 $0.00

76970 Z2 $36.23 $47.31

76975 N1 $0.00 $0.00

76977 Z3 $4.08 $5.33

76998 N1 $0.00 $0.00

76999 Z2 $36.23 $47.31

77001 N1 $0.00 $0.00

77002 N1 $0.00 $0.00

77003 N1 $0.00 $0.00

77011 N1 $0.00 $0.00

77012 N1 $0.00 $0.00

77013 N1 $0.00 $0.00

77014 N1 $0.00 $0.00

77021 N1 $0.00 $0.00

77022 N1 $0.00 $0.00

77031 N1 $0.00 $0.00

77032 N1 $0.00 $0.00

77053 N1 $0.00 $0.00

77054 N1 $0.00 $0.00

77071 Z2 $25.78 $33.67

77072 Z3 $14.29 $18.66

77073 Z3 $24.50 $31.99

77074 Z2 $39.75 $51.91

77075 Z2 $39.75 $51.91

77076 Z2 $39.75 $51.91

77077 Z3 $24.50 $31.99

77078 Z2 $41.45 $54.13

77080 Z3 $40.15 $52.43

77081 Z3 $17.35 $22.66

77082 Z3 $19.73 $25.77

77084 Z2 $189.94 $248.04

77280 Z2 $61.57 $80.40

77285 Z2 $163.28 $213.23

77290 Z2 $163.28 $213.23

77295 Z3 $217.75 $284.36

77299 Z2 $61.57 $80.40

77300 Z3 $35.72 $46.65

77301 Z2 $552.43 $721.42

77305 Z3 $23.82 $31.11

Updated 3/22/2013 MDWCC

Page 68 of 88

Page 69: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

77310 Z3 $32.32 $42.21

77315 Z3 $56.48 $73.76

77321 Z3 $43.55 $56.87

77326 Z2 $61.57 $80.40

77327 Z3 $134.05 $175.06

77328 Z2 $163.28 $213.23

77331 Z3 $18.71 $24.43

77332 Z3 $53.08 $69.32

77333 Z3 $9.19 $12.00

77334 Z3 $88.80 $115.96

77336 Z3 $43.55 $56.87

77338 Z2 $163.28 $213.23

77370 Z2 $61.57 $80.40

77371 Z2 $4,438.82 $5,796.66

77399 Z2 $61.57 $80.40

77401 Z3 $20.41 $26.65

77402 Z2 $53.59 $69.98

77403 Z2 $53.59 $69.98

77404 Z2 $53.59 $69.98

77406 Z2 $53.59 $69.98

77407 Z2 $53.59 $69.98

77408 Z2 $100.73 $131.54

77409 Z2 $100.73 $131.54

77411 Z2 $100.73 $131.54

77412 Z2 $100.73 $131.54

77413 Z2 $100.73 $131.54

77414 Z2 $100.73 $131.54

77416 Z2 $100.73 $131.54

77417 N1 $0.00 $0.00

77418 Z2 $271.42 $354.45

77421 N1 $0.00 $0.00

77422 Z2 $100.73 $131.54

77423 Z2 $100.73 $131.54

77424 Z2 $548.93 $716.85

77425 Z2 $548.93 $716.85

77435 N1 $0.00 $0.00

77470 Z3 $47.63 $62.20

77520 Z2 $637.79 $832.89

77522 Z2 $637.79 $832.89

77523 Z2 $382.89 $500.02

77525 Z2 $382.89 $500.02

77600 Z2 $220.19 $287.55

77605 Z2 $220.19 $287.55

77610 Z2 $220.19 $287.55

77615 Z2 $220.19 $287.55

77620 Z2 $220.19 $287.55

77750 Z2 $100.73 $131.54

77761 Z3 $192.23 $251.03

77762 Z3 $220.81 $288.36

77763 Z2 $230.53 $301.05

77776 Z3 $192.57 $251.48

77777 Z3 $206.18 $269.25

77778 Z3 $290.56 $379.44

77785 Z3 $179.30 $234.15

77786 Z2 $385.88 $503.92

77787 Z2 $385.88 $503.92

77789 Z2 $53.59 $69.98

77790 N1 $0.00 $0.00

77799 Z2 $230.53 $301.05

78012 Z2 $63.98 $83.55

78013 Z2 $84.19 $109.94

Updated 3/22/2013 MDWCC

Page 69 of 88

Page 70: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

78014 Z2 $130.71 $170.69

78015 Z2 $168.38 $219.89

78016 Z2 $168.38 $219.89

78018 Z2 $168.38 $219.89

78020 N1 $0.00 $0.00

78070 Z2 $130.71 $170.69

78071 Z2 $180.71 $235.99

78072 Z2 $180.71 $235.99

78075 Z2 $536.22 $700.25

78099 Z2 $84.19 $109.94

78102 Z2 $157.09 $205.14

78103 Z2 $157.09 $205.14

78104 Z2 $157.09 $205.14

78110 Z2 $244.53 $319.33

78111 Z2 $244.53 $319.33

78120 Z2 $244.53 $319.33

78121 Z2 $244.53 $319.33

78122 Z2 $244.53 $319.33

78130 Z2 $244.53 $319.33

78135 Z2 $244.53 $319.33

78140 Z2 $244.53 $319.33

78185 Z2 $157.09 $205.14

78190 Z2 $110.31 $144.05

78191 Z2 $110.31 $144.05

78195 Z2 $157.09 $205.14

78199 Z2 $157.09 $205.14

78201 Z2 $176.41 $230.37

78202 Z2 $176.41 $230.37

78205 Z2 $176.41 $230.37

78206 Z2 $176.41 $230.37

78215 Z2 $176.41 $230.37

78216 Z2 $176.41 $230.37

78226 Z2 $176.41 $230.37

78227 Z2 $176.41 $230.37

78230 Z2 $144.07 $188.14

78231 Z2 $144.07 $188.14

78232 Z2 $144.07 $188.14

78258 Z2 $144.07 $188.14

78261 Z2 $144.07 $188.14

78262 Z2 $144.07 $188.14

78264 Z2 $144.07 $188.14

78270 Z2 $110.31 $144.05

78271 Z2 $110.31 $144.05

78272 Z2 $110.31 $144.05

78278 Z2 $144.07 $188.14

78282 Z2 $144.07 $188.14

78290 Z2 $144.07 $188.14

78291 Z2 $144.07 $188.14

78299 Z2 $144.07 $188.14

78300 Z2 $146.83 $191.75

78305 Z2 $146.83 $191.75

78306 Z2 $146.83 $191.75

78315 Z2 $146.83 $191.75

78320 Z2 $146.83 $191.75

78399 Z2 $146.83 $191.75

78414 Z2 $173.38 $226.42

78428 Z2 $173.38 $226.42

78445 Z2 $185.72 $242.53

78451 Z2 $381.39 $498.06

78452 Z2 $381.39 $498.06

78453 Z2 $381.39 $498.06

Updated 3/22/2013 MDWCC

Page 70 of 88

Page 71: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

78454 Z2 $381.39 $498.06

78456 Z2 $185.72 $242.53

78457 Z2 $185.72 $242.53

78458 Z2 $185.72 $242.53

78459 Z2 $592.62 $773.90

78466 Z2 $173.38 $226.42

78468 Z2 $173.38 $226.42

78469 Z2 $173.38 $226.42

78472 Z2 $173.38 $226.42

78473 Z2 $173.38 $226.42

78481 Z2 $173.38 $226.42

78483 Z2 $173.38 $226.42

78491 Z2 $592.62 $773.90

78492 Z2 $592.62 $773.90

78494 Z2 $173.38 $226.42

78496 N1 $0.00 $0.00

78499 Z2 $173.38 $226.42

78579 Z2 $123.98 $161.91

78580 Z2 $123.98 $161.91

78582 Z2 $188.77 $246.51

78597 Z2 $123.98 $161.91

78598 Z2 $188.77 $246.51

78599 Z2 $123.98 $161.91

78600 Z2 $148.19 $193.52

78601 Z2 $257.19 $335.86

78605 Z2 $148.19 $193.52

78606 Z2 $257.19 $335.86

78607 Z2 $257.19 $335.86

78608 Z2 $592.62 $773.90

78610 Z2 $148.19 $193.52

78630 Z2 $257.19 $335.86

78635 Z2 $257.19 $335.86

78645 Z2 $148.19 $193.52

78647 Z2 $257.19 $335.86

78650 Z2 $257.19 $335.86

78660 Z2 $148.19 $193.52

78699 Z2 $148.19 $193.52

78700 Z2 $186.80 $243.94

78701 Z2 $186.80 $243.94

78707 Z2 $186.80 $243.94

78708 Z2 $186.80 $243.94

78709 Z2 $186.80 $243.94

78710 Z2 $186.80 $243.94

78725 Z2 $110.31 $144.05

78730 Z2 $63.98 $83.55

78740 Z2 $186.80 $243.94

78761 Z2 $186.80 $243.94

78799 Z2 $186.80 $243.94

78800 Z2 $168.38 $219.89

78801 Z2 $281.99 $368.25

78802 Z2 $281.99 $368.25

78803 Z2 $281.99 $368.25

78804 Z2 $536.22 $700.25

78805 Z2 $281.99 $368.25

78806 Z2 $281.99 $368.25

78807 Z2 $281.99 $368.25

78808 N1 $0.00 $0.00

78811 Z2 $592.62 $773.90

78812 Z2 $592.62 $773.90

78813 Z2 $592.62 $773.90

78814 Z2 $592.62 $773.90

Updated 3/22/2013 MDWCC

Page 71 of 88

Page 72: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

78815 Z2 $592.62 $773.90

78816 Z2 $592.62 $773.90

78999 Z2 $63.98 $83.55

79005 Z3 $49.33 $64.42

79101 Z3 $51.03 $66.64

79200 Z3 $56.48 $73.76

79300 Z2 $132.82 $173.45

79403 Z3 $80.97 $105.74

79440 Z3 $47.97 $62.64

79445 Z2 $132.82 $173.45

79999 Z2 $132.82 $173.45

90371 K2 $104.73 $136.77

90375 K2 $206.47 $269.63

90376 K2 $197.46 $257.86

90378 K2 $1,313.55 $1,715.36

90385 N1 $0.00 $0.00

90396 K2 $79.88 $104.32

90476 N1 $0.00 $0.00

90477 N1 $0.00 $0.00

90581 K2 $112.86 $147.38

90585 K2 $120.87 $157.84

90632 N1 $0.00 $0.00

90633 N1 $0.00 $0.00

90634 N1 $0.00 $0.00

90636 N1 $0.00 $0.00

90644 N1 $0.00 $0.00

90645 N1 $0.00 $0.00

90646 N1 $0.00 $0.00

90647 N1 $0.00 $0.00

90648 N1 $0.00 $0.00

90654 L1 $0.00 $0.00

90655 L1 $0.00 $0.00

90656 L1 $0.00 $0.00

90657 L1 $0.00 $0.00

90660 L1 $0.00 $0.00

90662 L1 $0.00 $0.00

90669 L1 $0.00 $0.00

90670 L1 $0.00 $0.00

90672 L1 $0.00 $0.00

90675 K2 $190.40 $248.64

90676 K2 $155.64 $203.25

90680 N1 $0.00 $0.00

90681 K2 $102.50 $133.85

90690 N1 $0.00 $0.00

90691 N1 $0.00 $0.00

90692 N1 $0.00 $0.00

90696 N1 $0.00 $0.00

90698 N1 $0.00 $0.00

90700 N1 $0.00 $0.00

90702 N1 $0.00 $0.00

90703 N1 $0.00 $0.00

90704 N1 $0.00 $0.00

90705 N1 $0.00 $0.00

90707 N1 $0.00 $0.00

90708 N1 $0.00 $0.00

90710 N1 $0.00 $0.00

90712 N1 $0.00 $0.00

90713 N1 $0.00 $0.00

90714 N1 $0.00 $0.00

90715 N1 $0.00 $0.00

90717 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 72 of 88

Page 73: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

90719 N1 $0.00 $0.00

90720 N1 $0.00 $0.00

90721 N1 $0.00 $0.00

90732 L1 $0.00 $0.00

90733 K2 $106.49 $139.07

90734 K2 $98.98 $129.26

90735 K2 $102.08 $133.31

90740 F4 $0.00 $0.00

90743 F4 $0.00 $0.00

90744 F4 $0.00 $0.00

90746 F4 $0.00 $0.00

90747 F4 $0.00 $0.00

90749 N1 $0.00 $0.00

92071 N1 $0.00 $0.00

92072 N1 $0.00 $0.00

95940 N1 $0.00 $0.00

95941 N1 $0.00 $0.00

0042T N1 $0.00 $0.00

0073T Z2 $271.42 $354.45

0174T N1 $0.00 $0.00

0175T N1 $0.00 $0.00

0182T Z2 $385.88 $503.92

0185T N1 $0.00 $0.00

0286T N1 $0.00 $0.00

0287T N1 $0.00 $0.00

0291T N1 $0.00 $0.00

0292T N1 $0.00 $0.00

A4218 N1 $0.00 $0.00

A4220 N1 $0.00 $0.00

A4248 N1 $0.00 $0.00

A4262 N1 $0.00 $0.00

A4263 N1 $0.00 $0.00

A4270 N1 $0.00 $0.00

A4300 N1 $0.00 $0.00

A4301 N1 $0.00 $0.00

A4305 N1 $0.00 $0.00

A4306 N1 $0.00 $0.00

A4641 N1 $0.00 $0.00

A4642 N1 $0.00 $0.00

A4648 N1 $0.00 $0.00

A4650 N1 $0.00 $0.00

A9500 N1 $0.00 $0.00

A9501 N1 $0.00 $0.00

A9502 N1 $0.00 $0.00

A9503 N1 $0.00 $0.00

A9504 N1 $0.00 $0.00

A9505 N1 $0.00 $0.00

A9507 N1 $0.00 $0.00

A9508 N1 $0.00 $0.00

A9509 N1 $0.00 $0.00

A9510 N1 $0.00 $0.00

A9512 N1 $0.00 $0.00

A9516 N1 $0.00 $0.00

A9521 N1 $0.00 $0.00

A9524 N1 $0.00 $0.00

A9526 N1 $0.00 $0.00

A9527 H2 $21.03 $27.46

A9528 N1 $0.00 $0.00

A9529 N1 $0.00 $0.00

A9531 N1 $0.00 $0.00

A9532 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 73 of 88

Page 74: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

A9536 N1 $0.00 $0.00

A9537 N1 $0.00 $0.00

A9538 N1 $0.00 $0.00

A9539 N1 $0.00 $0.00

A9540 N1 $0.00 $0.00

A9541 N1 $0.00 $0.00

A9542 N1 $0.00 $0.00

A9544 N1 $0.00 $0.00

A9546 N1 $0.00 $0.00

A9547 N1 $0.00 $0.00

A9548 N1 $0.00 $0.00

A9550 N1 $0.00 $0.00

A9551 N1 $0.00 $0.00

A9552 N1 $0.00 $0.00

A9553 N1 $0.00 $0.00

A9554 N1 $0.00 $0.00

A9555 N1 $0.00 $0.00

A9556 N1 $0.00 $0.00

A9557 N1 $0.00 $0.00

A9558 N1 $0.00 $0.00

A9559 N1 $0.00 $0.00

A9560 N1 $0.00 $0.00

A9561 N1 $0.00 $0.00

A9562 N1 $0.00 $0.00

A9566 N1 $0.00 $0.00

A9567 N1 $0.00 $0.00

A9568 N1 $0.00 $0.00

A9569 N1 $0.00 $0.00

A9570 N1 $0.00 $0.00

A9571 N1 $0.00 $0.00

A9572 N1 $0.00 $0.00

A9576 N1 $0.00 $0.00

A9577 N1 $0.00 $0.00

A9578 N1 $0.00 $0.00

A9579 N1 $0.00 $0.00

A9580 N1 $0.00 $0.00

A9581 N1 $0.00 $0.00

A9582 N1 $0.00 $0.00

A9583 N1 $0.00 $0.00

A9584 K2 $2,010.05 $2,624.92

A9585 N1 $0.00 $0.00

A9698 N1 $0.00 $0.00

C1713 N1 $0.00 $0.00

C1714 N1 $0.00 $0.00

C1715 N1 $0.00 $0.00

C1716 H2 $109.39 $142.85

C1717 H2 $249.07 $325.26

C1719 H2 $37.12 $48.48

C1721 N1 $0.00 $0.00

C1722 N1 $0.00 $0.00

C1724 N1 $0.00 $0.00

C1725 N1 $0.00 $0.00

C1726 N1 $0.00 $0.00

C1727 N1 $0.00 $0.00

C1728 N1 $0.00 $0.00

C1729 N1 $0.00 $0.00

C1730 N1 $0.00 $0.00

C1731 N1 $0.00 $0.00

C1732 N1 $0.00 $0.00

C1733 N1 $0.00 $0.00

C1749 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 74 of 88

Page 75: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

C1750 N1 $0.00 $0.00

C1751 N1 $0.00 $0.00

C1752 N1 $0.00 $0.00

C1753 N1 $0.00 $0.00

C1754 N1 $0.00 $0.00

C1755 N1 $0.00 $0.00

C1756 N1 $0.00 $0.00

C1757 N1 $0.00 $0.00

C1758 N1 $0.00 $0.00

C1759 N1 $0.00 $0.00

C1760 N1 $0.00 $0.00

C1762 N1 $0.00 $0.00

C1763 N1 $0.00 $0.00

C1764 N1 $0.00 $0.00

C1765 N1 $0.00 $0.00

C1766 N1 $0.00 $0.00

C1767 N1 $0.00 $0.00

C1768 N1 $0.00 $0.00

C1769 N1 $0.00 $0.00

C1770 N1 $0.00 $0.00

C1771 N1 $0.00 $0.00

C1772 N1 $0.00 $0.00

C1773 N1 $0.00 $0.00

C1776 N1 $0.00 $0.00

C1777 N1 $0.00 $0.00

C1778 N1 $0.00 $0.00

C1779 N1 $0.00 $0.00

C1780 N1 $0.00 $0.00

C1781 N1 $0.00 $0.00

C1782 N1 $0.00 $0.00

C1783 N1 $0.00 $0.00

C1784 N1 $0.00 $0.00

C1785 N1 $0.00 $0.00

C1786 N1 $0.00 $0.00

C1787 N1 $0.00 $0.00

C1788 N1 $0.00 $0.00

C1789 N1 $0.00 $0.00

C1813 N1 $0.00 $0.00

C1814 N1 $0.00 $0.00

C1815 N1 $0.00 $0.00

C1816 N1 $0.00 $0.00

C1817 N1 $0.00 $0.00

C1818 N1 $0.00 $0.00

C1819 N1 $0.00 $0.00

C1820 N1 $0.00 $0.00

C1821 N1 $0.00 $0.00

C1830 J7 $0.00 $0.00

C1840 J7 $0.00 $0.00

C1874 N1 $0.00 $0.00

C1875 N1 $0.00 $0.00

C1876 N1 $0.00 $0.00

C1877 N1 $0.00 $0.00

C1878 N1 $0.00 $0.00

C1879 N1 $0.00 $0.00

C1880 N1 $0.00 $0.00

C1881 N1 $0.00 $0.00

C1882 N1 $0.00 $0.00

C1883 N1 $0.00 $0.00

C1884 N1 $0.00 $0.00

C1885 N1 $0.00 $0.00

C1886 J7 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 75 of 88

Page 76: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

C1887 N1 $0.00 $0.00

C1888 N1 $0.00 $0.00

C1891 N1 $0.00 $0.00

C1892 N1 $0.00 $0.00

C1893 N1 $0.00 $0.00

C1894 N1 $0.00 $0.00

C1895 N1 $0.00 $0.00

C1896 N1 $0.00 $0.00

C1897 N1 $0.00 $0.00

C1898 N1 $0.00 $0.00

C1899 N1 $0.00 $0.00

C1900 N1 $0.00 $0.00

C2614 N1 $0.00 $0.00

C2615 N1 $0.00 $0.00

C2616 H2 $15,669.18 $20,462.38

C2617 N1 $0.00 $0.00

C2618 N1 $0.00 $0.00

C2619 N1 $0.00 $0.00

C2620 N1 $0.00 $0.00

C2621 N1 $0.00 $0.00

C2622 N1 $0.00 $0.00

C2625 N1 $0.00 $0.00

C2626 N1 $0.00 $0.00

C2627 N1 $0.00 $0.00

C2628 N1 $0.00 $0.00

C2629 N1 $0.00 $0.00

C2630 N1 $0.00 $0.00

C2631 N1 $0.00 $0.00

C2634 H2 $65.81 $85.94

C2635 H2 $30.56 $39.91

C2636 H2 $35.61 $46.50

C2638 H2 $46.70 $60.99

C2639 H2 $35.69 $46.61

C2640 H2 $75.43 $98.50

C2641 H2 $60.48 $78.98

C2642 H2 $110.26 $143.99

C2643 H2 $66.03 $86.23

C2698 H2 $46.70 $60.99

C2699 H2 $30.56 $39.91

C8900 Z2 $255.06 $333.08

C8901 Z2 $189.94 $248.04

C8902 Z2 $308.32 $402.64

C8903 Z2 $255.06 $333.08

C8904 Z2 $189.94 $248.04

C8905 Z2 $308.32 $402.64

C8906 Z2 $255.06 $333.08

C8907 Z2 $189.94 $248.04

C8908 Z2 $308.32 $402.64

C8909 Z2 $255.06 $333.08

C8910 Z2 $189.94 $248.04

C8911 Z2 $308.32 $402.64

C8912 Z2 $255.06 $333.08

C8913 Z2 $189.94 $248.04

C8914 Z2 $308.32 $402.64

C8918 Z2 $255.06 $333.08

C8919 Z2 $189.94 $248.04

C8920 Z2 $308.32 $402.64

C8931 Z2 $255.06 $333.08

C8932 Z2 $189.94 $248.04

C8933 Z2 $308.32 $402.64

C8934 Z2 $255.06 $333.08

Updated 3/22/2013 MDWCC

Page 76 of 88

Page 77: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

C8935 Z2 $189.94 $248.04

C8936 Z2 $308.32 $402.64

C9113 N1 $0.00 $0.00

C9121 K2 $17.85 $23.31

C9248 K2 $2.96 $3.87

C9250 K2 $39.08 $51.03

C9254 N1 $0.00 $0.00

C9257 K2 $1.59 $2.08

C9275 N1 $0.00 $0.00

C9285 K2 $13.31 $17.38

C9290 K2 $1.09 $1.42

C9292 K2 $102.33 $133.63

C9293 K2 $233.73 $305.23

C9294 K2 $30.90 $40.35

C9295 K2 $29.29 $38.25

C9296 K2 $16.96 $22.15

C9352 N1 $0.00 $0.00

C9353 N1 $0.00 $0.00

C9354 N1 $0.00 $0.00

C9355 N1 $0.00 $0.00

C9356 N1 $0.00 $0.00

C9358 K2 $11.78 $15.38

C9359 N1 $0.00 $0.00

C9360 K2 $11.88 $15.51

C9361 N1 $0.00 $0.00

C9362 N1 $0.00 $0.00

C9363 K2 $24.61 $32.14

C9364 N1 $0.00 $0.00

C9367 K2 $4.35 $5.68

C9399 K7 $0.00 $0.00

C9733 N1 $0.00 $0.00

E0616 N1 $0.00 $0.00

E0749 N1 $0.00 $0.00

E0782 N1 $0.00 $0.00

E0783 N1 $0.00 $0.00

E0785 N1 $0.00 $0.00

E0786 N1 $0.00 $0.00

G0130 Z3 $23.48 $30.66

G0173 Z2 $1,852.08 $2,418.63

G0251 Z2 $548.93 $716.85

G0288 N1 $0.00 $0.00

G0339 Z2 $1,852.08 $2,418.63

G0340 Z2 $1,321.34 $1,725.54

G0453 N1 $0.00 $0.00

J0120 N1 $0.00 $0.00

J0129 K2 $22.40 $29.25

J0130 K2 $577.27 $753.86

J0131 K2 $0.12 $0.16

J0132 K2 $3.04 $3.97

J0133 N1 $0.00 $0.00

J0135 K2 $484.72 $633.00

J0150 N1 $0.00 $0.00

J0152 K2 $109.01 $142.36

J0171 N1 $0.00 $0.00

J0178 K2 $980.50 $1,280.43

J0180 K2 $140.68 $183.71

J0200 N1 $0.00 $0.00

J0205 K2 $42.03 $54.89

J0207 K2 $306.16 $399.81

J0210 K2 $42.40 $55.37

J0215 K2 $41.64 $54.38

Updated 3/22/2013 MDWCC

Page 77 of 88

Page 78: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

J0220 K2 $206.03 $269.05

J0221 K2 $153.62 $200.61

J0256 K2 $3.95 $5.16

J0257 K2 $3.92 $5.12

J0278 N1 $0.00 $0.00

J0280 N1 $0.00 $0.00

J0282 N1 $0.00 $0.00

J0285 N1 $0.00 $0.00

J0287 K2 $11.91 $15.55

J0288 K2 $14.00 $18.28

J0289 K2 $14.46 $18.88

J0290 N1 $0.00 $0.00

J0295 N1 $0.00 $0.00

J0300 K2 $152.43 $199.06

J0330 N1 $0.00 $0.00

J0348 K2 $1.16 $1.51

J0350 N1 $0.00 $0.00

J0360 N1 $0.00 $0.00

J0364 N1 $0.00 $0.00

J0365 K2 $2.65 $3.46

J0380 N1 $0.00 $0.00

J0390 N1 $0.00 $0.00

J0395 K2 $86.37 $112.79

J0400 N1 $0.00 $0.00

J0456 N1 $0.00 $0.00

J0461 N1 $0.00 $0.00

J0470 N1 $0.00 $0.00

J0475 K2 $175.88 $229.68

J0476 K2 $76.51 $99.91

J0480 K2 $2,516.73 $3,286.60

J0485 K2 $3.81 $4.98

J0490 K2 $38.27 $49.98

J0500 N1 $0.00 $0.00

J0515 N1 $0.00 $0.00

J0520 N1 $0.00 $0.00

J0558 N1 $0.00 $0.00

J0561 N1 $0.00 $0.00

J0583 K2 $2.99 $3.90

J0585 K2 $5.47 $7.14

J0586 K2 $6.90 $9.01

J0587 K2 $10.89 $14.22

J0588 K2 $4.46 $5.82

J0592 N1 $0.00 $0.00

J0594 K2 $21.92 $28.63

J0595 N1 $0.00 $0.00

J0597 K2 $31.06 $40.56

J0598 K2 $47.19 $61.63

J0600 K2 $201.40 $263.01

J0610 N1 $0.00 $0.00

J0620 N1 $0.00 $0.00

J0630 K2 $62.75 $81.95

J0636 N1 $0.00 $0.00

J0637 K2 $12.83 $16.75

J0638 K2 $89.54 $116.93

J0640 N1 $0.00 $0.00

J0641 K2 $1.85 $2.42

J0670 N1 $0.00 $0.00

J0690 N1 $0.00 $0.00

J0692 N1 $0.00 $0.00

J0694 N1 $0.00 $0.00

J0696 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 78 of 88

Page 79: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

J0697 N1 $0.00 $0.00

J0698 N1 $0.00 $0.00

J0702 N1 $0.00 $0.00

J0706 N1 $0.00 $0.00

J0710 N1 $0.00 $0.00

J0712 K2 $0.78 $1.02

J0713 N1 $0.00 $0.00

J0715 N1 $0.00 $0.00

J0716 K2 $3,635.80 $4,747.99

J0718 K2 $4.89 $6.39

J0720 N1 $0.00 $0.00

J0725 N1 $0.00 $0.00

J0735 N1 $0.00 $0.00

J0740 K2 $756.64 $988.10

J0743 N1 $0.00 $0.00

J0744 N1 $0.00 $0.00

J0745 N1 $0.00 $0.00

J0760 N1 $0.00 $0.00

J0770 N1 $0.00 $0.00

J0775 K2 $37.51 $48.98

J0780 N1 $0.00 $0.00

J0795 K2 $5.82 $7.60

J0800 K2 $3,014.33 $3,936.41

J0833 K2 $101.68 $132.78

J0834 N1 $0.00 $0.00

J0840 K2 $2,216.80 $2,894.92

J0850 K2 $1,013.87 $1,324.01

J0878 K2 $0.57 $0.74

J0881 K2 $3.45 $4.51

J0885 K2 $10.26 $13.40

J0894 K2 $34.05 $44.47

J0895 N1 $0.00 $0.00

J0897 K2 $14.27 $18.64

J0900 K2 $33.36 $43.56

J0945 N1 $0.00 $0.00

J1000 N1 $0.00 $0.00

J1020 N1 $0.00 $0.00

J1030 N1 $0.00 $0.00

J1040 N1 $0.00 $0.00

J1050 N1 $0.00 $0.00

J1060 N1 $0.00 $0.00

J1070 N1 $0.00 $0.00

J1080 N1 $0.00 $0.00

J1094 N1 $0.00 $0.00

J1100 N1 $0.00 $0.00

J1110 N1 $0.00 $0.00

J1120 N1 $0.00 $0.00

J1160 N1 $0.00 $0.00

J1162 K2 $899.60 $1,174.79

J1165 N1 $0.00 $0.00

J1170 N1 $0.00 $0.00

J1180 N1 $0.00 $0.00

J1190 K2 $165.93 $216.69

J1200 N1 $0.00 $0.00

J1205 K2 $227.14 $296.62

J1212 K2 $86.09 $112.42

J1230 N1 $0.00 $0.00

J1240 N1 $0.00 $0.00

J1245 N1 $0.00 $0.00

J1250 N1 $0.00 $0.00

J1260 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 79 of 88

Page 80: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

J1265 N1 $0.00 $0.00

J1267 N1 $0.00 $0.00

J1270 N1 $0.00 $0.00

J1290 K2 $319.61 $417.38

J1300 K2 $199.36 $260.34

J1320 N1 $0.00 $0.00

J1324 K2 $0.53 $0.69

J1325 N1 $0.00 $0.00

J1327 K2 $25.06 $32.73

J1330 N1 $0.00 $0.00

J1335 N1 $0.00 $0.00

J1364 N1 $0.00 $0.00

J1380 N1 $0.00 $0.00

J1410 K2 $139.45 $182.11

J1430 K2 $299.94 $391.69

J1435 K2 $1.54 $2.01

J1436 N1 $0.00 $0.00

J1438 K2 $241.34 $315.17

J1440 K2 $275.69 $360.02

J1441 K2 $435.92 $569.27

J1450 N1 $0.00 $0.00

J1451 K2 $6.25 $8.16

J1452 K2 $85.00 $111.00

J1453 K2 $1.73 $2.26

J1455 N1 $0.00 $0.00

J1457 N1 $0.00 $0.00

J1458 K2 $355.52 $464.27

J1459 K2 $35.57 $46.45

J1460 K2 $23.76 $31.03

J1557 K2 $36.59 $47.78

J1559 K2 $7.29 $9.52

J1560 K2 $237.62 $310.31

J1561 K2 $38.23 $49.92

J1562 K2 $12.72 $16.61

J1566 K2 $34.74 $45.37

J1568 K2 $31.60 $41.27

J1569 K2 $37.64 $49.15

J1570 K2 $72.47 $94.64

J1571 K2 $52.01 $67.92

J1572 K2 $34.95 $45.64

J1573 K2 $52.01 $67.92

J1580 N1 $0.00 $0.00

J1590 K2 $86.33 $112.74

J1595 K2 $130.44 $170.34

J1599 N1 $0.00 $0.00

J1600 N1 $0.00 $0.00

J1610 K2 $118.18 $154.33

J1620 K2 $6.06 $7.91

J1626 N1 $0.00 $0.00

J1630 N1 $0.00 $0.00

J1631 N1 $0.00 $0.00

J1640 K2 $13.32 $17.39

J1642 N1 $0.00 $0.00

J1644 N1 $0.00 $0.00

J1645 N1 $0.00 $0.00

J1650 N1 $0.00 $0.00

J1652 N1 $0.00 $0.00

J1655 N1 $0.00 $0.00

J1670 K2 $278.27 $363.39

J1700 N1 $0.00 $0.00

J1710 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 80 of 88

Page 81: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

J1720 N1 $0.00 $0.00

J1725 K2 $2.65 $3.46

J1730 K2 $88.27 $115.27

J1740 K2 $151.51 $197.86

J1741 N1 $0.00 $0.00

J1742 K2 $114.39 $149.38

J1743 K2 $455.03 $594.22

J1744 K2 $234.87 $306.72

J1745 K2 $66.41 $86.72

J1750 K2 $11.97 $15.63

J1756 N1 $0.00 $0.00

J1786 K2 $41.86 $54.66

J1790 N1 $0.00 $0.00

J1800 N1 $0.00 $0.00

J1815 N1 $0.00 $0.00

J1817 N1 $0.00 $0.00

J1830 K2 $251.48 $328.41

J1835 K2 $0.28 $0.37

J1840 N1 $0.00 $0.00

J1850 N1 $0.00 $0.00

J1885 N1 $0.00 $0.00

J1890 N1 $0.00 $0.00

J1930 K2 $34.97 $45.67

J1931 K2 $28.20 $36.83

J1940 N1 $0.00 $0.00

J1945 K2 $570.54 $745.07

J1950 K2 $672.89 $878.73

J1953 N1 $0.00 $0.00

J1956 N1 $0.00 $0.00

J1960 N1 $0.00 $0.00

J1980 N1 $0.00 $0.00

J1990 N1 $0.00 $0.00

J2001 N1 $0.00 $0.00

J2010 N1 $0.00 $0.00

J2020 K2 $38.95 $50.86

J2060 N1 $0.00 $0.00

J2150 N1 $0.00 $0.00

J2170 N1 $0.00 $0.00

J2175 N1 $0.00 $0.00

J2180 N1 $0.00 $0.00

J2185 N1 $0.00 $0.00

J2210 N1 $0.00 $0.00

J2212 K2 $0.38 $0.50

J2248 K2 $0.94 $1.23

J2250 N1 $0.00 $0.00

J2260 N1 $0.00 $0.00

J2265 K2 $0.58 $0.76

J2270 N1 $0.00 $0.00

J2271 N1 $0.00 $0.00

J2275 N1 $0.00 $0.00

J2278 K2 $6.62 $8.65

J2280 N1 $0.00 $0.00

J2300 N1 $0.00 $0.00

J2310 N1 $0.00 $0.00

J2315 K2 $2.84 $3.71

J2320 N1 $0.00 $0.00

J2323 K2 $12.30 $16.06

J2325 K2 $54.32 $70.94

J2353 K2 $129.66 $169.32

J2354 N1 $0.00 $0.00

J2355 K2 $262.88 $343.29

Updated 3/22/2013 MDWCC

Page 81 of 88

Page 82: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

J2357 K2 $23.54 $30.74

J2358 K2 $2.75 $3.59

J2360 N1 $0.00 $0.00

J2370 N1 $0.00 $0.00

J2400 N1 $0.00 $0.00

J2405 N1 $0.00 $0.00

J2410 N1 $0.00 $0.00

J2425 K2 $12.97 $16.94

J2426 K2 $7.24 $9.45

J2430 N1 $0.00 $0.00

J2440 N1 $0.00 $0.00

J2460 N1 $0.00 $0.00

J2469 K2 $18.98 $24.79

J2501 N1 $0.00 $0.00

J2503 K2 $1,029.33 $1,344.20

J2504 K2 $267.83 $349.76

J2505 K2 $2,921.12 $3,814.69

J2507 K2 $356.54 $465.61

J2510 N1 $0.00 $0.00

J2513 N1 $0.00 $0.00

J2515 N1 $0.00 $0.00

J2540 N1 $0.00 $0.00

J2543 N1 $0.00 $0.00

J2550 N1 $0.00 $0.00

J2560 N1 $0.00 $0.00

J2562 K2 $291.39 $380.53

J2590 N1 $0.00 $0.00

J2597 K2 $5.63 $7.35

J2650 N1 $0.00 $0.00

J2675 N1 $0.00 $0.00

J2680 N1 $0.00 $0.00

J2690 N1 $0.00 $0.00

J2700 K2 $2.26 $2.95

J2710 N1 $0.00 $0.00

J2720 N1 $0.00 $0.00

J2724 K2 $13.50 $17.63

J2725 K2 $29.74 $38.84

J2730 K2 $89.99 $117.52

J2760 N1 $0.00 $0.00

J2765 N1 $0.00 $0.00

J2770 K2 $187.32 $244.62

J2778 K2 $398.01 $519.76

J2780 N1 $0.00 $0.00

J2783 K2 $208.19 $271.88

J2785 K2 $53.64 $70.05

J2788 K2 $24.54 $32.05

J2790 K2 $84.45 $110.28

J2791 K2 $5.07 $6.62

J2792 K2 $18.33 $23.94

J2793 K2 $24.09 $31.46

J2794 K2 $5.64 $7.37

J2795 N1 $0.00 $0.00

J2796 K2 $49.32 $64.41

J2800 N1 $0.00 $0.00

J2805 N1 $0.00 $0.00

J2810 N1 $0.00 $0.00

J2820 K2 $29.69 $38.77

J2850 K2 $27.49 $35.90

J2910 N1 $0.00 $0.00

J2916 N1 $0.00 $0.00

J2920 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 82 of 88

Page 83: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

J2930 N1 $0.00 $0.00

J2941 K2 $65.03 $84.92

J2950 N1 $0.00 $0.00

J2993 K2 $2,301.90 $3,006.05

J2995 N1 $0.00 $0.00

J2997 K2 $51.91 $67.79

J3000 N1 $0.00 $0.00

J3010 N1 $0.00 $0.00

J3030 N1 $0.00 $0.00

J3070 N1 $0.00 $0.00

J3095 K2 $2.65 $3.46

J3101 K2 $70.77 $92.42

J3105 N1 $0.00 $0.00

J3120 N1 $0.00 $0.00

J3130 N1 $0.00 $0.00

J3140 N1 $0.00 $0.00

J3150 N1 $0.00 $0.00

J3230 N1 $0.00 $0.00

J3240 K2 $1,051.90 $1,373.68

J3243 K2 $1.68 $2.19

J3246 K2 $7.90 $10.32

J3250 N1 $0.00 $0.00

J3260 N1 $0.00 $0.00

J3262 K2 $3.56 $4.65

J3265 N1 $0.00 $0.00

J3280 N1 $0.00 $0.00

J3285 K2 $61.24 $79.97

J3300 K2 $3.78 $4.94

J3301 N1 $0.00 $0.00

J3302 N1 $0.00 $0.00

J3303 N1 $0.00 $0.00

J3310 N1 $0.00 $0.00

J3315 K2 $175.79 $229.56

J3350 N1 $0.00 $0.00

J3355 K2 $66.48 $86.82

J3357 K2 $134.00 $174.99

J3360 N1 $0.00 $0.00

J3364 N1 $0.00 $0.00

J3365 K2 $457.73 $597.75

J3370 N1 $0.00 $0.00

J3385 K2 $348.86 $455.58

J3396 K2 $10.28 $13.42

J3400 N1 $0.00 $0.00

J3410 N1 $0.00 $0.00

J3411 N1 $0.00 $0.00

J3415 N1 $0.00 $0.00

J3420 N1 $0.00 $0.00

J3430 N1 $0.00 $0.00

J3465 K2 $4.92 $6.43

J3470 N1 $0.00 $0.00

J3471 N1 $0.00 $0.00

J3472 N1 $0.00 $0.00

J3473 N1 $0.00 $0.00

J3475 N1 $0.00 $0.00

J3480 N1 $0.00 $0.00

J3485 N1 $0.00 $0.00

J3486 N1 $0.00 $0.00

J3487 K2 $222.60 $290.69

J3488 K2 $224.70 $293.44

J3490 N1 $0.00 $0.00

J3530 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 83 of 88

Page 84: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

J3590 N1 $0.00 $0.00

J7030 N1 $0.00 $0.00

J7040 N1 $0.00 $0.00

J7042 N1 $0.00 $0.00

J7050 N1 $0.00 $0.00

J7060 N1 $0.00 $0.00

J7070 N1 $0.00 $0.00

J7100 N1 $0.00 $0.00

J7110 N1 $0.00 $0.00

J7120 N1 $0.00 $0.00

J7131 N1 $0.00 $0.00

J7178 K2 $0.92 $1.20

J7180 K2 $6.42 $8.38

J7183 K2 $0.93 $1.21

J7185 K2 $1.10 $1.44

J7186 K2 $0.94 $1.23

J7187 K2 $0.90 $1.18

J7189 K2 $1.61 $2.10

J7190 K2 $0.92 $1.20

J7191 N1 $0.00 $0.00

J7192 K2 $1.13 $1.48

J7193 K2 $0.96 $1.25

J7194 K2 $1.06 $1.38

J7195 K2 $1.25 $1.63

J7196 K2 $103.35 $134.96

J7197 K2 $3.04 $3.97

J7198 K2 $1.63 $2.13

J7308 K2 $160.72 $209.88

J7309 K2 $83.69 $109.29

J7310 K2 $16,960.00 $22,148.06

J7311 K2 $19,345.00 $25,262.64

J7312 K2 $195.86 $255.77

J7315 N1 $0.00 $0.00

J7321 K2 $89.98 $117.50

J7323 K2 $151.34 $197.63

J7324 K2 $167.46 $218.69

J7325 K2 $12.06 $15.75

J7326 K2 $606.63 $792.20

J7335 K2 $25.55 $33.37

J7500 N1 $0.00 $0.00

J7501 K2 $161.37 $210.73

J7502 N1 $0.00 $0.00

J7504 K2 $671.43 $876.82

J7505 K2 $1,156.08 $1,509.72

J7506 N1 $0.00 $0.00

J7507 N1 $0.00 $0.00

J7509 N1 $0.00 $0.00

J7510 N1 $0.00 $0.00

J7511 K2 $538.68 $703.46

J7513 K2 $526.34 $687.35

J7515 N1 $0.00 $0.00

J7516 N1 $0.00 $0.00

J7517 N1 $0.00 $0.00

J7518 N1 $0.00 $0.00

J7520 N1 $0.00 $0.00

J7525 K2 $138.89 $181.38

J7527 K2 $6.18 $8.07

J7599 N1 $0.00 $0.00

J7665 N1 $0.00 $0.00

J7674 N1 $0.00 $0.00

J7799 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 84 of 88

Page 85: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

J8501 K2 $6.48 $8.46

J8510 K2 $5.56 $7.26

J8520 K2 $8.87 $11.58

J8521 K2 $29.51 $38.54

J8530 N1 $0.00 $0.00

J8540 N1 $0.00 $0.00

J8560 K2 $52.36 $68.38

J8562 K2 $81.77 $106.78

J8597 N1 $0.00 $0.00

J8600 N1 $0.00 $0.00

J8610 N1 $0.00 $0.00

J8650 K2 $25.78 $33.67

J8700 K2 $10.67 $13.93

J8705 K2 $84.22 $109.98

J9000 N1 $0.00 $0.00

J9002 K2 $539.08 $703.98

J9010 K2 $611.45 $798.49

J9015 K2 $1,246.98 $1,628.43

J9017 K2 $45.13 $58.94

J9019 K2 $334.32 $436.59

J9020 K2 $63.20 $82.53

J9025 K2 $5.53 $7.22

J9027 K2 $126.25 $164.87

J9031 K2 $120.87 $157.84

J9033 K2 $20.62 $26.93

J9035 K2 $63.45 $82.86

J9040 N1 $0.00 $0.00

J9041 K2 $44.31 $57.86

J9042 K2 $98.99 $129.27

J9043 K2 $137.82 $179.98

J9045 N1 $0.00 $0.00

J9050 K2 $175.75 $229.51

J9055 K2 $51.80 $67.65

J9060 N1 $0.00 $0.00

J9065 K2 $29.17 $38.09

J9070 K2 $23.37 $30.52

J9098 K2 $528.75 $690.49

J9100 N1 $0.00 $0.00

J9120 K2 $577.60 $754.29

J9130 N1 $0.00 $0.00

J9150 K2 $22.05 $28.80

J9151 K2 $243.80 $318.38

J9155 K2 $2.86 $3.73

J9160 K2 $1,646.18 $2,149.75

J9171 K2 $6.37 $8.32

J9175 N1 $0.00 $0.00

J9178 K2 $1.58 $2.06

J9179 K2 $95.54 $124.77

J9181 N1 $0.00 $0.00

J9185 K2 $86.66 $113.17

J9190 N1 $0.00 $0.00

J9200 K2 $65.32 $85.30

J9201 K2 $10.86 $14.18

J9202 K2 $178.39 $232.96

J9206 N1 $0.00 $0.00

J9207 K2 $66.43 $86.75

J9208 K2 $29.16 $38.08

J9209 N1 $0.00 $0.00

J9211 K2 $97.96 $127.93

J9212 K2 $17.06 $22.28

J9213 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 85 of 88

Page 86: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

J9214 K2 $19.29 $25.19

J9215 N1 $0.00 $0.00

J9216 K2 $2,517.90 $3,288.13

J9217 K2 $215.13 $280.94

J9218 K2 $7.46 $9.74

J9219 K2 $4,819.82 $6,294.20

J9225 K2 $2,981.05 $3,892.95

J9226 K2 $16,177.64 $21,126.38

J9228 K2 $125.17 $163.46

J9230 K2 $157.86 $206.15

J9245 K2 $1,314.21 $1,716.23

J9250 N1 $0.00 $0.00

J9260 N1 $0.00 $0.00

J9261 K2 $123.40 $161.15

J9263 K2 $4.08 $5.33

J9264 K2 $9.52 $12.43

J9265 N1 $0.00 $0.00

J9266 K2 $5,890.00 $7,691.75

J9268 K2 $1,290.39 $1,685.12

J9270 N1 $0.00 $0.00

J9280 K2 $24.04 $31.39

J9293 K2 $36.88 $48.16

J9300 K2 $2,742.59 $3,581.55

J9302 K2 $45.42 $59.31

J9303 K2 $89.20 $116.49

J9305 K2 $58.06 $75.82

J9307 K2 $182.65 $238.52

J9310 K2 $660.78 $862.91

J9315 K2 $242.28 $316.39

J9320 K2 $271.16 $354.11

J9328 K2 $4.83 $6.31

J9330 K2 $56.14 $73.31

J9340 K2 $175.48 $229.16

J9351 K2 $3.17 $4.14

J9355 K2 $76.54 $99.95

J9357 K2 $1,038.99 $1,356.82

J9360 N1 $0.00 $0.00

J9370 N1 $0.00 $0.00

J9390 N1 $0.00 $0.00

J9395 K2 $88.34 $115.36

J9600 K2 $19,325.78 $25,237.54

J9999 N1 $0.00 $0.00

L8600 N1 $0.00 $0.00

L8603 N1 $0.00 $0.00

L8604 N1 $0.00 $0.00

L8606 N1 $0.00 $0.00

L8609 N1 $0.00 $0.00

L8610 N1 $0.00 $0.00

L8612 N1 $0.00 $0.00

L8613 N1 $0.00 $0.00

L8614 N1 $0.00 $0.00

L8630 N1 $0.00 $0.00

L8631 N1 $0.00 $0.00

L8641 N1 $0.00 $0.00

L8642 N1 $0.00 $0.00

L8658 N1 $0.00 $0.00

L8659 N1 $0.00 $0.00

L8690 N1 $0.00 $0.00

L8699 N1 $0.00 $0.00

L9900 N1 $0.00 $0.00

P9041 K2 $22.63 $29.55

Updated 3/22/2013 MDWCC

Page 86 of 88

Page 87: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

P9045 K2 $60.67 $79.23

P9046 K2 $30.24 $39.49

P9047 K2 $69.20 $90.37

Q0138 K2 $0.64 $0.84

Q0162 N1 $0.00 $0.00

Q0163 N1 $0.00 $0.00

Q0164 N1 $0.00 $0.00

Q0165 N1 $0.00 $0.00

Q0166 N1 $0.00 $0.00

Q0167 N1 $0.00 $0.00

Q0168 N1 $0.00 $0.00

Q0169 N1 $0.00 $0.00

Q0170 N1 $0.00 $0.00

Q0171 N1 $0.00 $0.00

Q0172 N1 $0.00 $0.00

Q0173 N1 $0.00 $0.00

Q0174 N1 $0.00 $0.00

Q0175 N1 $0.00 $0.00

Q0176 N1 $0.00 $0.00

Q0177 N1 $0.00 $0.00

Q0178 N1 $0.00 $0.00

Q0180 N1 $0.00 $0.00

Q0515 K2 $1.80 $2.35

Q2004 N1 $0.00 $0.00

Q2009 N1 $0.00 $0.00

Q2017 K2 $321.94 $420.42

Q2035 L1 $0.00 $0.00

Q2036 L1 $0.00 $0.00

Q2037 L1 $0.00 $0.00

Q2038 L1 $0.00 $0.00

Q2039 L1 $0.00 $0.00

Q2043 K2 $32,560.45 $42,520.69

Q2049 K2 $498.26 $650.68

Q3025 K2 $291.64 $380.85

Q3031 N1 $0.00 $0.00

Q4100 N1 $0.00 $0.00

Q4101 K2 $39.47 $51.54

Q4102 K2 $8.08 $10.55

Q4103 K2 $8.08 $10.55

Q4104 K2 $18.71 $24.43

Q4105 K2 $13.76 $17.97

Q4106 K2 $40.91 $53.42

Q4107 K2 $99.17 $129.51

Q4108 K2 $25.22 $32.93

Q4110 K2 $34.21 $44.67

Q4111 K2 $7.02 $9.17

Q4112 K2 $394.62 $515.33

Q4113 K2 $394.62 $515.33

Q4114 K2 $1,198.51 $1,565.13

Q4115 K2 $8.13 $10.62

Q4116 K2 $32.37 $42.27

Q4118 K2 $2.85 $3.72

Q4119 K2 $4.58 $5.98

Q4121 K2 $22.12 $28.89

Q4122 K2 $86.57 $113.05

Q4123 K2 $14.04 $18.33

Q4124 K2 $11.13 $14.53

Q4125 K2 $114.05 $148.94

Q4128 K2 $31.93 $41.70

Q4129 K2 $31.26 $40.82

Q4130 N1 $0.00 $0.00

Updated 3/22/2013 MDWCC

Page 87 of 88

Page 88: Calendar Year 2013 Maryland Workers' Compensation ... · HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates 10021 P2 $68.80 $89.85 10022 G2 $193.88 $253.19 10040

HCPCS Code CMS Payment Indicator CMS 2013 Payment WCC 2013 Payment Rates

Calendar Year 2013 Maryland Workers' Compensation Commission Medical Fee Guide

ASC Covered Surgical Procedures (including surgical procedures for which payment is packaged

and ancillary services approved by CMS ) Effective February 8, 2013 (corrected version)

Q4131 K2 $153.25 $200.13

Q4132 K2 $129.26 $168.80

Q4133 K2 $123.95 $161.87

Q9951 N1 $0.00 $0.00

Q9953 N1 $0.00 $0.00

Q9954 N1 $0.00 $0.00

Q9955 N1 $0.00 $0.00

Q9956 N1 $0.00 $0.00

Q9957 N1 $0.00 $0.00

Q9958 N1 $0.00 $0.00

Q9959 N1 $0.00 $0.00

Q9960 N1 $0.00 $0.00

Q9961 N1 $0.00 $0.00

Q9962 N1 $0.00 $0.00

Q9963 N1 $0.00 $0.00

Q9964 N1 $0.00 $0.00

Q9965 N1 $0.00 $0.00

Q9966 N1 $0.00 $0.00

Q9967 N1 $0.00 $0.00

Q9968 K2 $1.20 $1.57

V2630 N1 $0.00 $0.00

V2631 N1 $0.00 $0.00

V2632 N1 $0.00 $0.00

V2785 F4 $0.00 $0.00

V2790 N1 $0.00 $0.00

Indicator

A2

D5

F4

G2

H7

H8

J7

J8

K2

K7

L1

L6

N1

P2

P3

R2

Z2

Z3

Corneal tissue acquisition, hepatitis B vaccine; paid at reasonable cost.

Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on MPFS

non-facility PE RVUs.

Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weightr-

Brachytherapy source paid separately when provided integral to a surgical procedure on ASC list; payment contractor-

Device-intensive procedure on ASC list in CY 2007; paid at adjusted rate.

OPPS pass-through device paid separately when provided integral to a surgical procedure on ASC list; payment

contractor

Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate

Unclassified drugs and biologicals; payment contractor-priced..

Influenza vaccine; pneumococcal vaccine. Packaged item/service; no separate payment made.

New Technology Intraocular Lens (NTIOL); special payment.

Packaged service/item; no separate payment made.Packaged service/item; no separate payment made.

Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on

OPPS

Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS non-facility PE RVUs; payment based

on MPFS non-facility PE RVUs.

Office-based surgical procedure added to ASC list in CY 2008 or later without MPFS non-facility PE RVUs; payment

based on OPPS relative payment weight.

Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS

relative payment weight

Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS non-facility PE RVUs; payment based

on OPPS relative payment weight

CPT codes are a registered trademark of the American Medical Association. Applicable FARS/DFARS apply

Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight

Deleted/discontinued code; no payment made.

Updated 3/22/2013 MDWCC

Page 88 of 88