VIRGINIA WORKERS’ COMPENSATION 2020 MEDICAL FEE SCHEDULES

ADOPTED BY THE COMMISSION ON

JULY 18, 2019 AND REVISED ON

OCTOBER 17, 2019

Contents

Introduction ............................................................................................ 1

Table A – Type One Teaching Hospitals - Acute Inpatient Hospital Stays ........................................................................................ 2

Table B – Other than Type One Teaching Hospitals – Acute Inpatient Hospital Stays ...................................................................... 22

Table C – Rehabilitation Admissions Billed Using DRG Codes ...... 42

Table D – Rehabilitation Admissions Billed Using CMG Codes ...... 43

Table E – Outpatient Facility – Services Reimbursed as a Percentage of Billed Charges ............................................................. 49

Table F – Type One Teaching Hospitals – Outpatient Facility Services Billed with a CPT Code ........................................................ 51

Table G – Type One Teaching Hospitals – Outpatient Facility Services Billed with a HCPCS Code ................................................. 243

Table H – Other than Type One Teaching Hospitals – Outpatient Facility Services Billed with a CPT Code ......................................... 250

Table I – Other than Type One Teaching Hospitals – Outpatient Facility Services Billed with a HCPCS Code ................................... 443

Table J – Ambulatory Surgical Centers – Services Reimbursed as a Percentage of Billed Charges ................................................... 449

Table K – Ambulatory Surgical Centers – Services Reimbursed on a per Surgery Basis ...................................................................... 450

Table L – Ambulatory Surgical Centers – Stand Alone Flouroscopy Procedures ................................................................... 538

Table M – Professional Services and Other Providers of Medical Services Reimbursed as a Percentage of Billed Charges ............................................................................................... 539

Table N – Anesthesia Conversion Factors, Base Units, and Physical Status Units ......................................................................... 540

Table O – Anesthesia Qualifying Circumstances ........................... 543

Table P – Professional Services Billed by a Surgeon - Surgical Procedures ......................................................................................... 544

Table Q – Professional Services Billed by a Physician Non-Surgeon - Surgical Procedures ........................................................ 677

Table R – Professional Services Billed by a Surgeon – Radiology Procedures ....................................................................... 810

Table S – Professional Services Billed by a Physician Non-Surgeon – Radiology Procedures .................................................... 849

Table T – Professional Services – Lab/Pathology Procedures ...... 888

Table U – Professional Services Billed by a Surgeon – Evaluation and Management Procedures ........................................ 922

Table V – Professional Services Billed by a Physician Non-Surgeon – Evaluation and Management Procedures ..................... 926

Table W – Professional Services Billed by a Surgeon – Other Services Billed with a CPT Code ...................................................... 930

Table X – Professional Services Billed by a Physician Non-Surgeon – Other Professional Services Billed with a CPT Code ... 958

Table Y – Professional Services – Other Professional Services Billed with a HCPCS Code ................................................................. 986

Table Z – Other Providers of Medical Services – Physical Medicine and Rehabilitation Procedures ....................................... 1030

Table AA – Other Providers of Medical Services – Osteopathic and Chiropractic Manipulative Treatment Procedures ................. 1032

Table AB – Other Providers of Medical Services – Acupuncture Proceudres ....................................................................................... 1033

Table AC – Other Providers of Medical Services - Dental Procedures ....................................................................................... 1034

Table AD – Other Providers of Medical Services – Ground Ambulance ........................................................................................ 1039

Table AE – Other Providers of Medical Services – Private Payer Codes ................................................................................................ 1040

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules

CPT only copyright 2018 American Medical Association. All rights reserved. Page 1

Introduction

This document contains the Virginia Workers’ Compensation Medical Fee Schedules (MFS) which outline maximum fees for health care providers, hospitals, and ambulatory surgical centers, rendering health care services to injured employees as provided in the Virginia Workers' Compensation Act, Title 65.2 of the Code of Virginia. The MFS will apply to health care services provided to an injured person for any dates of service on or after January 1, 2020, regardless of the date of injury.

Please refer to the document titled ‘Virginia Workers’ Compensation Medical Fee Schedules – Ground Rules’ for additional provisions that detail the applicability and use of the medical fee schedules that follow.

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

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Table A – Type One Teaching Hospitals - Acute Inpatient Hospital Stays

The maximum fee at Type One Teaching Hospitals for acute inpatient hospital stays, other than for treatment of a traumatic injury at a Level I or Level II Trauma Center or a serious burn at a Burn Center, shall be determined after discharge according to the following table. Admissions for one of the DRGs listed below that utilize ICD-10 diagnoses codes and contain at least one claim line reflecting revenue code 118, 128, 138, 148, or 158 are not considered an acute inpatient hospital stay and shall instead be considered a rehabilitation admission and reimbursed based on Table C.

Maximum Fee Per Admission – Type One Teaching Hospitals

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 001 N/A $746,243 $898,746 N/A N/A N/A 002 N/A $460,877 $555,062 N/A N/A N/A 003 N/A N/A N/A N/A N/A N/A 004 N/A N/A N/A N/A N/A N/A 005 N/A $308,504 $371,551 N/A N/A N/A 006 N/A $139,482 $167,988 N/A N/A N/A 007 N/A $273,276 $329,123 N/A N/A N/A 008 N/A $156,649 $188,662 N/A N/A N/A 010 N/A $120,051 $144,585 N/A N/A N/A 011 N/A N/A N/A N/A N/A N/A 012 N/A N/A N/A N/A N/A N/A 013 N/A N/A N/A N/A N/A N/A 014 N/A $308,819 $387,209 N/A N/A N/A 016 N/A $165,197 $207,131 N/A N/A N/A 017 N/A $116,922 $146,602 N/A N/A N/A 020 N/A $277,499 $334,209 N/A N/A N/A 021 N/A $210,293 $253,268 N/A N/A N/A 022 N/A $132,057 $159,043 N/A N/A N/A 023 N/A $197,155 $203,401 N/A N/A N/A 024 N/A $139,512 $143,932 N/A N/A N/A 025 N/A N/A N/A N/A N/A N/A 026 N/A N/A N/A N/A N/A N/A 027 N/A N/A N/A N/A N/A N/A 028 N/A N/A N/A N/A N/A N/A 029 N/A N/A N/A N/A N/A N/A 030 N/A $60,727 $63,509 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

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DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 031 N/A $96,878 $133,905 N/A N/A N/A 032 N/A $45,673 $65,592 N/A N/A N/A 033 N/A $36,427 $50,350 N/A N/A N/A 034 N/A $108,762 $130,989 N/A N/A N/A 035 N/A $64,976 $78,254 N/A N/A N/A 036 N/A $50,881 $61,280 N/A N/A N/A 037 N/A $92,355 $110,270 N/A N/A N/A 038 N/A $46,590 $55,627 N/A N/A N/A 039 N/A $31,066 $37,092 N/A N/A N/A 040 N/A $97,159 $77,857 N/A N/A N/A 041 N/A $54,432 $43,619 N/A N/A N/A 042 N/A $47,571 $38,120 N/A N/A N/A 052 N/A $48,396 $67,386 N/A N/A N/A 053 N/A $28,444 $39,605 N/A N/A N/A 054 N/A $38,347 $46,184 N/A N/A N/A 055 N/A $29,951 $36,071 N/A N/A N/A 056 N/A $51,769 $62,348 N/A N/A N/A 057 N/A $29,680 $35,745 N/A N/A N/A 058 N/A $48,010 $57,822 N/A N/A N/A 059 N/A $30,241 $36,421 N/A N/A N/A 060 N/A $23,121 $27,846 N/A N/A N/A 061 N/A $81,028 $97,587 N/A N/A N/A 062 N/A $54,531 $65,676 N/A N/A N/A 063 N/A $44,372 $53,439 N/A N/A N/A 064 N/A $51,081 $61,520 N/A N/A N/A 065 N/A $31,278 $37,671 N/A N/A N/A 066 N/A $22,130 $26,652 N/A N/A N/A 067 N/A $42,693 $51,418 N/A N/A N/A 068 N/A $24,672 $29,714 N/A N/A N/A 069 N/A $20,528 $24,723 N/A N/A N/A 070 N/A $51,457 $58,809 N/A N/A N/A 071 N/A $30,515 $34,874 N/A N/A N/A 072 N/A $21,746 $24,853 N/A N/A N/A 073 N/A $24,610 $33,186 N/A N/A N/A 074 N/A $16,383 $22,091 N/A N/A N/A 075 N/A $48,771 $58,738 N/A N/A N/A 076 N/A $25,360 $30,542 N/A N/A N/A 077 N/A $47,743 $57,499 N/A N/A N/A 078 N/A $27,511 $33,133 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

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DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 079 N/A $19,623 $23,633 N/A N/A N/A 080 N/A $37,588 $45,270 N/A N/A N/A 081 N/A $23,070 $27,785 N/A N/A N/A 082 N/A N/A N/A N/A N/A N/A 083 N/A $45,124 $52,000 N/A N/A N/A 084 N/A $29,757 $35,592 N/A N/A N/A 085 N/A N/A N/A N/A N/A N/A 086 N/A $39,766 $43,644 N/A N/A N/A 087 N/A $26,532 $31,275 N/A N/A N/A 088 N/A $56,293 $65,541 N/A N/A N/A 089 N/A $34,361 $40,005 N/A N/A N/A 090 N/A $26,350 $30,679 N/A N/A N/A 091 N/A $46,958 $56,554 N/A N/A N/A 092 N/A $26,417 $31,816 N/A N/A N/A 093 N/A $19,935 $24,009 N/A N/A N/A 094 N/A $98,033 $118,067 N/A N/A N/A 095 N/A $70,075 $84,395 N/A N/A N/A 096 N/A $60,911 $73,359 N/A N/A N/A 097 N/A $92,943 $111,936 N/A N/A N/A 098 N/A $50,517 $60,840 N/A N/A N/A 099 N/A $34,117 $41,090 N/A N/A N/A 100 N/A $47,543 $71,279 N/A N/A N/A 101 N/A $23,507 $35,244 N/A N/A N/A 102 N/A $29,467 $34,822 N/A N/A N/A 103 N/A $20,229 $23,904 N/A N/A N/A 113 N/A $53,159 $56,794 N/A N/A N/A 114 N/A $33,041 $35,302 N/A N/A N/A 115 N/A $41,320 $47,747 N/A N/A N/A 116 N/A $46,613 $51,851 N/A N/A N/A 117 N/A $27,422 $30,504 N/A N/A N/A 121 N/A $31,255 $37,642 N/A N/A N/A 122 N/A $18,668 $22,483 N/A N/A N/A 123 N/A $19,784 $23,828 N/A N/A N/A 124 N/A $33,598 $40,463 N/A N/A N/A 125 N/A $20,138 $24,252 N/A N/A N/A 129 N/A $68,429 $82,413 N/A N/A N/A 130 N/A $37,027 $44,594 N/A N/A N/A 131 N/A $69,660 $83,897 N/A N/A N/A 132 N/A $41,874 $50,430 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

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DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 133 N/A $56,057 $73,841 N/A N/A N/A 134 N/A $30,317 $39,935 N/A N/A N/A 135 N/A $56,280 $67,781 N/A N/A N/A 136 N/A $30,884 $37,197 N/A N/A N/A 137 N/A $40,366 $48,614 N/A N/A N/A 138 N/A $23,182 $27,920 N/A N/A N/A 139 N/A $28,966 $34,886 N/A N/A N/A 146 N/A $58,040 $69,901 N/A N/A N/A 147 N/A $37,821 $45,549 N/A N/A N/A 148 N/A $24,113 $29,041 N/A N/A N/A 149 N/A $17,504 $21,737 N/A N/A N/A 150 N/A $38,038 $45,812 N/A N/A N/A 151 N/A $19,662 $23,679 N/A N/A N/A 152 N/A $29,865 $35,969 N/A N/A N/A 153 N/A $20,231 $24,366 N/A N/A N/A 154 N/A $40,272 $48,502 N/A N/A N/A 155 N/A $26,003 $31,318 N/A N/A N/A 156 N/A $19,150 $23,063 N/A N/A N/A 157 N/A $46,476 $55,973 N/A N/A N/A 158 N/A $25,036 $30,153 N/A N/A N/A 159 N/A $17,443 $21,006 N/A N/A N/A 163 N/A $147,920 $178,150 N/A N/A N/A 164 N/A $76,441 $92,063 N/A N/A N/A 165 N/A $53,546 $64,489 N/A N/A N/A 166 N/A $106,245 $123,557 N/A N/A N/A 167 N/A $57,513 $66,884 N/A N/A N/A 168 N/A $38,571 $44,857 N/A N/A N/A 175 N/A $44,880 $54,052 N/A N/A N/A 176 N/A $28,419 $34,227 N/A N/A N/A 177 N/A $56,596 $62,021 N/A N/A N/A 178 N/A $40,386 $44,256 N/A N/A N/A 179 N/A $28,145 $30,842 N/A N/A N/A 180 N/A $49,577 $59,707 N/A N/A N/A 181 N/A $34,038 $40,994 N/A N/A N/A 182 N/A $23,769 $28,627 N/A N/A N/A 183 N/A $49,117 $70,199 N/A N/A N/A 184 N/A $32,164 $46,093 N/A N/A N/A 185 N/A $21,558 $30,811 N/A N/A N/A 186 N/A $45,412 $54,692 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

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DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 187 N/A $31,419 $37,840 N/A N/A N/A 188 N/A $22,362 $26,932 N/A N/A N/A 189 N/A $35,666 $42,955 N/A N/A N/A 190 N/A $32,749 $32,019 N/A N/A N/A 191 N/A $26,131 $25,550 N/A N/A N/A 192 N/A $20,051 $19,605 N/A N/A N/A 193 N/A $42,587 $51,291 N/A N/A N/A 194 N/A $28,472 $34,291 N/A N/A N/A 195 N/A $20,702 $24,932 N/A N/A N/A 196 N/A $48,888 $58,879 N/A N/A N/A 197 N/A $31,196 $37,571 N/A N/A N/A 198 N/A $23,670 $28,507 N/A N/A N/A 199 N/A $55,775 $63,132 N/A N/A N/A 200 N/A $30,659 $34,703 N/A N/A N/A 201 N/A $21,574 $24,420 N/A N/A N/A 202 N/A $25,789 $31,059 N/A N/A N/A 203 N/A $19,206 $23,131 N/A N/A N/A 204 N/A $19,841 $22,968 N/A N/A N/A 205 N/A $36,476 $44,876 N/A N/A N/A 206 N/A $20,694 $25,512 N/A N/A N/A 207 N/A $139,744 $176,988 N/A N/A N/A 208 N/A $60,254 $76,093 N/A N/A N/A 215 N/A $453,613 $546,313 N/A N/A N/A 216 N/A $279,894 $337,094 N/A N/A N/A 217 N/A $186,006 $224,018 N/A N/A N/A 218 N/A $163,676 $197,124 N/A N/A N/A 219 N/A $226,492 $272,777 N/A N/A N/A 220 N/A $152,987 $184,252 N/A N/A N/A 221 N/A $136,209 $164,044 N/A N/A N/A 222 N/A $254,420 $306,413 N/A N/A N/A 223 N/A $184,927 $222,718 N/A N/A N/A 224 N/A $225,510 $271,596 N/A N/A N/A 225 N/A $172,249 $207,450 N/A N/A N/A 226 N/A $204,468 $246,252 N/A N/A N/A 227 N/A $160,149 $192,877 N/A N/A N/A 228 N/A $214,871 $258,782 N/A N/A N/A 229 N/A $131,092 $157,882 N/A N/A N/A 231 N/A $227,021 $273,415 N/A N/A N/A 232 N/A $164,507 $198,126 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

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DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 233 N/A $215,988 $260,127 N/A N/A N/A 234 N/A $143,465 $172,783 N/A N/A N/A 235 N/A $167,778 $202,066 N/A N/A N/A 236 N/A $111,537 $134,330 N/A N/A N/A 239 N/A $139,862 $168,444 N/A N/A N/A 240 N/A $81,095 $97,668 N/A N/A N/A 241 N/A $41,471 $49,946 N/A N/A N/A 242 N/A $109,450 $131,817 N/A N/A N/A 243 N/A $78,453 $94,486 N/A N/A N/A 244 N/A $63,348 $76,293 N/A N/A N/A 245 N/A $136,615 $164,533 N/A N/A N/A 246 N/A $110,814 $118,603 N/A N/A N/A 247 N/A $70,478 $75,431 N/A N/A N/A 248 N/A $88,378 $101,953 N/A N/A N/A 249 N/A $54,659 $63,054 N/A N/A N/A 250 N/A $87,829 $105,777 N/A N/A N/A 251 N/A $59,951 $72,202 N/A N/A N/A 252 N/A $91,699 $114,666 N/A N/A N/A 253 N/A $71,717 $89,678 N/A N/A N/A 254 N/A $48,605 $60,778 N/A N/A N/A 255 N/A $76,561 $92,207 N/A N/A N/A 256 N/A $49,920 $60,121 N/A N/A N/A 257 N/A $31,029 $37,370 N/A N/A N/A 258 N/A $81,151 $97,735 N/A N/A N/A 259 N/A $58,554 $70,521 N/A N/A N/A 260 N/A $110,079 $132,575 N/A N/A N/A 261 N/A $54,523 $65,664 N/A N/A N/A 262 N/A $41,080 $49,475 N/A N/A N/A 263 N/A $54,852 $66,061 N/A N/A N/A 264 N/A $83,147 $100,139 N/A N/A N/A 265 N/A $84,173 $101,374 N/A N/A N/A 266 N/A $257,104 $280,359 N/A N/A N/A 267 N/A $193,048 $210,509 N/A N/A N/A 268 N/A $184,583 $222,304 N/A N/A N/A 269 N/A $114,738 $138,185 N/A N/A N/A 270 N/A $139,153 $167,591 N/A N/A N/A 271 N/A $92,358 $111,232 N/A N/A N/A 272 N/A $66,149 $79,666 N/A N/A N/A 273 N/A $104,328 $125,648 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

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DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 274 N/A $71,112 $85,645 N/A N/A N/A 280 N/A $50,811 $61,194 N/A N/A N/A 281 N/A $30,115 $36,269 N/A N/A N/A 282 N/A $22,223 $26,766 N/A N/A N/A 283 N/A $49,236 $59,297 N/A N/A N/A 284 N/A $22,639 $27,265 N/A N/A N/A 285 N/A $14,886 $17,928 N/A N/A N/A 286 N/A $58,635 $74,356 N/A N/A N/A 287 N/A $31,167 $39,523 N/A N/A N/A 288 N/A $79,756 $96,055 N/A N/A N/A 289 N/A $49,935 $60,140 N/A N/A N/A 290 N/A $36,666 $44,159 N/A N/A N/A 291 N/A $44,369 $53,436 N/A N/A N/A 292 N/A $28,872 $34,772 N/A N/A N/A 293 N/A $19,873 $23,934 N/A N/A N/A 294 N/A $30,799 $37,094 N/A N/A N/A 295 N/A $20,355 $24,514 N/A N/A N/A 296 N/A $36,286 $43,702 N/A N/A N/A 297 N/A $19,029 $22,918 N/A N/A N/A 298 N/A $12,423 $14,961 N/A N/A N/A 299 N/A $33,158 $48,708 N/A N/A N/A 300 N/A $22,986 $33,765 N/A N/A N/A 301 N/A $15,942 $23,417 N/A N/A N/A 302 N/A $30,303 $36,495 N/A N/A N/A 303 N/A $17,930 $21,594 N/A N/A N/A 304 N/A $29,436 $35,452 N/A N/A N/A 305 N/A $18,432 $22,200 N/A N/A N/A 306 N/A $40,224 $48,445 N/A N/A N/A 307 N/A $22,623 $27,247 N/A N/A N/A 308 N/A $35,581 $42,852 N/A N/A N/A 309 N/A $23,115 $27,838 N/A N/A N/A 310 N/A $16,144 $19,442 N/A N/A N/A 311 N/A $16,640 $20,040 N/A N/A N/A 312 N/A $20,603 $23,515 N/A N/A N/A 313 N/A $18,039 $21,725 N/A N/A N/A 314 N/A $56,434 $67,968 N/A N/A N/A 315 N/A $28,263 $34,039 N/A N/A N/A 316 N/A $18,258 $21,989 N/A N/A N/A 326 N/A $158,251 $190,591 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

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DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 327 N/A $77,974 $93,910 N/A N/A N/A 328 N/A $43,933 $52,912 N/A N/A N/A 329 N/A $149,225 $179,721 N/A N/A N/A 330 N/A $74,915 $90,225 N/A N/A N/A 331 N/A $48,727 $58,684 N/A N/A N/A 332 N/A $138,269 $166,526 N/A N/A N/A 333 N/A $72,673 $87,524 N/A N/A N/A 334 N/A $47,116 $56,745 N/A N/A N/A 335 N/A $126,022 $151,777 N/A N/A N/A 336 N/A $69,178 $83,316 N/A N/A N/A 337 N/A $45,835 $55,202 N/A N/A N/A 338 N/A $90,227 $108,666 N/A N/A N/A 339 N/A $50,960 $61,375 N/A N/A N/A 340 N/A $35,669 $42,959 N/A N/A N/A 341 N/A $67,189 $80,920 N/A N/A N/A 342 N/A $38,534 $46,410 N/A N/A N/A 343 N/A $27,637 $33,285 N/A N/A N/A 344 N/A $96,316 $106,427 N/A N/A N/A 345 N/A $49,810 $55,039 N/A N/A N/A 346 N/A $34,914 $38,579 N/A N/A N/A 347 N/A $68,812 $91,853 N/A N/A N/A 348 N/A $36,274 $48,421 N/A N/A N/A 349 N/A $23,819 $31,795 N/A N/A N/A 350 N/A $72,488 $87,301 N/A N/A N/A 351 N/A $41,215 $49,638 N/A N/A N/A 352 N/A $27,296 $32,875 N/A N/A N/A 353 N/A $90,776 $108,717 N/A N/A N/A 354 N/A $52,807 $63,244 N/A N/A N/A 355 N/A $39,090 $46,815 N/A N/A N/A 356 N/A $96,817 $133,482 N/A N/A N/A 357 N/A $52,890 $72,920 N/A N/A N/A 358 N/A $34,480 $47,537 N/A N/A N/A 368 N/A $54,784 $65,979 N/A N/A N/A 369 N/A $31,455 $37,883 N/A N/A N/A 370 N/A $21,718 $26,157 N/A N/A N/A 371 N/A $54,760 $65,952 N/A N/A N/A 372 N/A $33,336 $40,148 N/A N/A N/A 373 N/A $23,549 $28,362 N/A N/A N/A 374 N/A $59,313 $71,434 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 10

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 375 N/A $36,528 $43,992 N/A N/A N/A 376 N/A $26,512 $31,930 N/A N/A N/A 377 N/A $50,663 $50,671 N/A N/A N/A 378 N/A $28,562 $28,566 N/A N/A N/A 379 N/A $19,313 $19,316 N/A N/A N/A 380 N/A $56,618 $68,188 N/A N/A N/A 381 N/A $31,960 $38,492 N/A N/A N/A 382 N/A $22,309 $26,868 N/A N/A N/A 383 N/A $38,838 $46,774 N/A N/A N/A 384 N/A $25,010 $30,121 N/A N/A N/A 385 N/A $51,869 $62,468 N/A N/A N/A 386 N/A $29,506 $35,536 N/A N/A N/A 387 N/A $21,892 $26,366 N/A N/A N/A 388 N/A $46,443 $49,982 N/A N/A N/A 389 N/A $25,146 $27,061 N/A N/A N/A 390 N/A $17,406 $18,732 N/A N/A N/A 391 N/A $35,196 $42,388 N/A N/A N/A 392 N/A $21,713 $26,149 N/A N/A N/A 393 N/A $49,647 $59,793 N/A N/A N/A 394 N/A $27,766 $33,441 N/A N/A N/A 395 N/A $19,321 $23,269 N/A N/A N/A 405 N/A $143,283 $192,645 N/A N/A N/A 406 N/A $72,608 $97,622 N/A N/A N/A 407 N/A $50,373 $67,727 N/A N/A N/A 408 N/A $117,580 $161,287 N/A N/A N/A 409 N/A $67,041 $91,962 N/A N/A N/A 410 N/A $48,901 $67,077 N/A N/A N/A 411 N/A $106,567 $128,346 N/A N/A N/A 412 N/A $71,022 $85,535 N/A N/A N/A 413 N/A $52,042 $62,677 N/A N/A N/A 414 N/A $104,463 $125,811 N/A N/A N/A 415 N/A $59,562 $71,735 N/A N/A N/A 416 N/A $39,572 $47,659 N/A N/A N/A 417 N/A $71,571 $86,197 N/A N/A N/A 418 N/A $48,786 $58,755 N/A N/A N/A 419 N/A $36,195 $43,592 N/A N/A N/A 420 N/A $101,748 $122,541 N/A N/A N/A 421 N/A $52,016 $62,646 N/A N/A N/A 422 N/A $36,301 $43,720 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 11

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 423 N/A $123,318 $148,520 N/A N/A N/A 424 N/A $67,574 $81,384 N/A N/A N/A 425 N/A $40,536 $48,820 N/A N/A N/A 432 N/A $49,109 $59,145 N/A N/A N/A 433 N/A $26,958 $32,468 N/A N/A N/A 434 N/A $18,307 $22,048 N/A N/A N/A 435 N/A $51,501 $62,026 N/A N/A N/A 436 N/A $34,209 $41,200 N/A N/A N/A 437 N/A $26,365 $31,752 N/A N/A N/A 438 N/A $50,028 $60,252 N/A N/A N/A 439 N/A $26,659 $32,106 N/A N/A N/A 440 N/A $18,877 $22,734 N/A N/A N/A 441 N/A $55,700 $69,376 N/A N/A N/A 442 N/A $27,402 $34,130 N/A N/A N/A 443 N/A $19,258 $23,986 N/A N/A N/A 444 N/A $47,645 $57,382 N/A N/A N/A 445 N/A $31,311 $37,709 N/A N/A N/A 446 N/A $22,245 $26,790 N/A N/A N/A 453 N/A N/A N/A N/A N/A N/A 454 N/A N/A N/A N/A N/A N/A 455 N/A N/A N/A N/A N/A N/A 456 N/A $288,365 $334,866 N/A N/A N/A 457 N/A $211,810 $245,967 N/A N/A N/A 458 N/A $161,407 $187,436 N/A N/A N/A 459 N/A N/A N/A N/A N/A N/A 460 N/A N/A N/A N/A N/A N/A 461 N/A $147,538 $177,689 N/A N/A N/A 462 N/A $102,582 $123,546 N/A N/A N/A 463 N/A N/A N/A N/A N/A N/A 464 N/A N/A N/A N/A N/A N/A 465 N/A N/A N/A N/A N/A N/A 466 N/A $144,428 $174,197 N/A N/A N/A 467 N/A $97,367 $115,124 N/A N/A N/A 468 N/A $77,529 $93,508 N/A N/A N/A 469 N/A $82,202 $96,085 N/A N/A N/A 470 N/A $51,246 $59,901 N/A N/A N/A 471 N/A $130,763 $145,546 N/A N/A N/A 472 N/A $78,253 $89,461 N/A N/A N/A 473 N/A $57,425 $67,656 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 12

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 474 N/A N/A N/A N/A N/A N/A 475 N/A N/A N/A N/A N/A N/A 476 N/A $32,878 $39,596 N/A N/A N/A 477 N/A $92,981 $111,982 N/A N/A N/A 478 N/A $65,952 $79,430 N/A N/A N/A 479 N/A $50,878 $61,276 N/A N/A N/A 480 N/A $98,019 $114,181 N/A N/A N/A 481 N/A $64,502 $75,057 N/A N/A N/A 482 N/A $53,278 $60,844 N/A N/A N/A 483 N/A N/A N/A N/A N/A N/A 485 N/A $90,956 $109,544 N/A N/A N/A 486 N/A $60,706 $73,111 N/A N/A N/A 487 N/A $45,935 $55,323 N/A N/A N/A 488 N/A $47,060 $53,050 N/A N/A N/A 489 N/A $36,025 $40,344 N/A N/A N/A 492 N/A $105,320 $116,105 N/A N/A N/A 493 N/A $64,400 $71,918 N/A N/A N/A 494 N/A $46,146 $51,909 N/A N/A N/A 495 N/A $105,185 $112,933 N/A N/A N/A 496 N/A $59,672 $65,571 N/A N/A N/A 497 N/A $42,710 $49,155 N/A N/A N/A 498 N/A $87,359 $81,159 N/A N/A N/A 499 N/A $43,863 $40,750 N/A N/A N/A 500 N/A N/A N/A N/A N/A N/A 501 N/A $43,030 $48,800 N/A N/A N/A 502 N/A $30,292 $34,353 N/A N/A N/A 503 N/A $92,505 $71,037 N/A N/A N/A 504 N/A $62,194 $47,761 N/A N/A N/A 505 N/A $49,443 $37,969 N/A N/A N/A 506 N/A $37,855 $45,592 N/A N/A N/A 507 N/A N/A N/A N/A N/A N/A 508 N/A $44,665 $53,793 N/A N/A N/A 509 N/A $45,535 $54,840 N/A N/A N/A 510 N/A N/A N/A N/A N/A N/A 511 N/A $51,212 $61,859 N/A N/A N/A 512 N/A $40,212 $46,670 N/A N/A N/A 513 N/A $33,070 $38,837 N/A N/A N/A 514 N/A $20,571 $24,605 N/A N/A N/A 515 N/A N/A N/A N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 13

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 516 N/A N/A N/A N/A N/A N/A 517 N/A $46,546 $52,201 N/A N/A N/A 518 N/A $85,666 $100,705 N/A N/A N/A 519 N/A $46,061 $54,147 N/A N/A N/A 520 N/A $30,844 $37,470 N/A N/A N/A 533 N/A $42,600 $51,305 N/A N/A N/A 534 N/A $22,318 $26,879 N/A N/A N/A 535 N/A $37,365 $46,958 N/A N/A N/A 536 N/A $21,681 $27,248 N/A N/A N/A 537 N/A $26,377 $31,766 N/A N/A N/A 538 N/A $20,328 $24,483 N/A N/A N/A 539 N/A $53,711 $64,688 N/A N/A N/A 540 N/A $38,108 $45,896 N/A N/A N/A 541 N/A $27,090 $32,627 N/A N/A N/A 542 N/A $57,226 $68,921 N/A N/A N/A 543 N/A $32,995 $39,738 N/A N/A N/A 544 N/A $23,323 $28,089 N/A N/A N/A 545 N/A $74,475 $89,695 N/A N/A N/A 546 N/A $34,418 $41,451 N/A N/A N/A 547 N/A $23,467 $28,263 N/A N/A N/A 548 N/A $56,201 $67,685 N/A N/A N/A 549 N/A $33,838 $40,753 N/A N/A N/A 550 N/A $24,657 $29,696 N/A N/A N/A 551 N/A $50,411 $52,341 N/A N/A N/A 552 N/A $28,303 $29,265 N/A N/A N/A 553 N/A $35,816 $43,135 N/A N/A N/A 554 N/A $21,378 $25,746 N/A N/A N/A 555 N/A $38,654 $53,932 N/A N/A N/A 556 N/A $21,973 $30,658 N/A N/A N/A 557 N/A $40,878 $44,096 N/A N/A N/A 558 N/A $24,414 $26,335 N/A N/A N/A 559 N/A $66,343 $60,223 N/A N/A N/A 560 N/A $38,458 $35,973 N/A N/A N/A 561 N/A $23,913 $22,368 N/A N/A N/A 562 N/A $43,355 $54,457 N/A N/A N/A 563 N/A $24,534 $30,816 N/A N/A N/A 564 N/A $44,189 $53,219 N/A N/A N/A 565 N/A $27,620 $33,264 N/A N/A N/A 566 N/A $20,193 $24,319 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 14

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 570 N/A N/A N/A N/A N/A N/A 571 N/A $40,397 $45,626 N/A N/A N/A 572 N/A $27,325 $31,112 N/A N/A N/A 573 N/A $108,956 $131,223 N/A N/A N/A 574 N/A $77,287 $93,082 N/A N/A N/A 575 N/A $43,866 $52,831 N/A N/A N/A 576 N/A $159,051 $243,007 N/A N/A N/A 577 N/A $76,071 $116,227 N/A N/A N/A 578 N/A $47,533 $68,946 N/A N/A N/A 579 N/A $117,091 $105,019 N/A N/A N/A 580 N/A $67,545 $60,581 N/A N/A N/A 581 N/A $48,696 $43,674 N/A N/A N/A 582 N/A $38,215 $46,024 N/A N/A N/A 583 N/A $32,128 $38,694 N/A N/A N/A 584 N/A $51,966 $62,585 N/A N/A N/A 585 N/A $40,415 $48,675 N/A N/A N/A 592 N/A $41,876 $50,434 N/A N/A N/A 593 N/A $29,965 $36,088 N/A N/A N/A 594 N/A $20,936 $25,216 N/A N/A N/A 595 N/A $57,688 $69,477 N/A N/A N/A 596 N/A $27,999 $33,720 N/A N/A N/A 597 N/A $49,250 $59,315 N/A N/A N/A 598 N/A $33,019 $39,766 N/A N/A N/A 599 N/A $21,333 $25,693 N/A N/A N/A 600 N/A $28,810 $34,698 N/A N/A N/A 601 N/A $18,556 $22,348 N/A N/A N/A 602 N/A $37,876 $49,577 N/A N/A N/A 603 N/A $21,957 $28,767 N/A N/A N/A 604 N/A $45,191 $50,241 N/A N/A N/A 605 N/A $27,435 $30,502 N/A N/A N/A 606 N/A $40,157 $48,364 N/A N/A N/A 607 N/A $21,442 $25,824 N/A N/A N/A 614 N/A $72,420 $87,220 N/A N/A N/A 615 N/A $41,859 $50,413 N/A N/A N/A 616 N/A $122,290 $147,282 N/A N/A N/A 617 N/A $58,649 $70,634 N/A N/A N/A 618 N/A $39,710 $47,826 N/A N/A N/A 619 N/A $96,660 $116,413 N/A N/A N/A 620 N/A $54,281 $65,374 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 15

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 621 N/A $45,359 $54,628 N/A N/A N/A 622 N/A $111,816 $134,667 N/A N/A N/A 623 N/A $53,805 $64,801 N/A N/A N/A 624 N/A $33,250 $40,046 N/A N/A N/A 625 N/A $73,166 $88,119 N/A N/A N/A 626 N/A $38,441 $46,296 N/A N/A N/A 627 N/A $25,459 $30,662 N/A N/A N/A 628 N/A $96,792 $116,573 N/A N/A N/A 629 N/A $66,040 $79,535 N/A N/A N/A 630 N/A $42,041 $50,632 N/A N/A N/A 637 N/A $40,980 $49,354 N/A N/A N/A 638 N/A $24,278 $29,240 N/A N/A N/A 639 N/A $17,834 $21,477 N/A N/A N/A 640 N/A $36,429 $61,661 N/A N/A N/A 641 N/A $23,258 $39,367 N/A N/A N/A 642 N/A $33,588 $40,453 N/A N/A N/A 643 N/A $44,215 $57,465 N/A N/A N/A 644 N/A $27,397 $35,607 N/A N/A N/A 645 N/A $19,287 $25,066 N/A N/A N/A 652 N/A $92,581 $111,501 N/A N/A N/A 653 N/A $170,332 $205,142 N/A N/A N/A 654 N/A $91,026 $109,628 N/A N/A N/A 655 N/A $66,389 $79,957 N/A N/A N/A 656 N/A $101,442 $122,173 N/A N/A N/A 657 N/A $59,104 $71,183 N/A N/A N/A 658 N/A $44,962 $54,150 N/A N/A N/A 659 N/A $99,373 $119,681 N/A N/A N/A 660 N/A $55,509 $66,854 N/A N/A N/A 661 N/A $39,657 $47,762 N/A N/A N/A 662 N/A $98,258 $108,091 N/A N/A N/A 663 N/A $49,993 $54,996 N/A N/A N/A 664 N/A $40,577 $44,637 N/A N/A N/A 665 N/A $92,825 $111,795 N/A N/A N/A 666 N/A $51,466 $61,983 N/A N/A N/A 667 N/A $28,478 $34,298 N/A N/A N/A 668 N/A $73,440 $88,448 N/A N/A N/A 669 N/A $37,212 $44,817 N/A N/A N/A 670 N/A $26,324 $31,704 N/A N/A N/A 671 N/A $47,522 $57,234 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 16

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 672 N/A $24,969 $30,071 N/A N/A N/A 673 N/A $102,929 $123,963 N/A N/A N/A 674 N/A $66,419 $79,992 N/A N/A N/A 675 N/A $42,446 $51,120 N/A N/A N/A 682 N/A $55,156 $55,917 N/A N/A N/A 683 N/A $34,530 $35,006 N/A N/A N/A 684 N/A $22,089 $22,394 N/A N/A N/A 686 N/A $51,833 $62,426 N/A N/A N/A 687 N/A $29,548 $35,586 N/A N/A N/A 688 N/A $20,311 $24,462 N/A N/A N/A 689 N/A $32,833 $39,543 N/A N/A N/A 690 N/A $22,906 $27,587 N/A N/A N/A 691 N/A $47,721 $57,474 N/A N/A N/A 692 N/A $33,168 $39,946 N/A N/A N/A 693 N/A $39,478 $47,546 N/A N/A N/A 694 N/A $20,158 $24,278 N/A N/A N/A 695 N/A $36,589 $44,066 N/A N/A N/A 696 N/A $19,452 $23,428 N/A N/A N/A 697 N/A $27,123 $32,666 N/A N/A N/A 698 N/A $45,857 $55,314 N/A N/A N/A 699 N/A $29,847 $36,003 N/A N/A N/A 700 N/A $20,866 $25,170 N/A N/A N/A 707 N/A $53,356 $64,260 N/A N/A N/A 708 N/A $38,976 $46,941 N/A N/A N/A 709 N/A $62,719 $75,536 N/A N/A N/A 710 N/A $38,055 $45,832 N/A N/A N/A 711 N/A $66,263 $79,804 N/A N/A N/A 712 N/A $31,247 $37,632 N/A N/A N/A 713 N/A $43,578 $52,484 N/A N/A N/A 714 N/A $23,315 $28,079 N/A N/A N/A 715 N/A $58,928 $70,970 N/A N/A N/A 716 N/A $34,846 $41,967 N/A N/A N/A 717 N/A $52,068 $62,709 N/A N/A N/A 718 N/A $29,680 $35,745 N/A N/A N/A 722 N/A $51,633 $62,185 N/A N/A N/A 723 N/A $31,255 $37,642 N/A N/A N/A 724 N/A $18,844 $22,695 N/A N/A N/A 725 N/A $34,649 $41,731 N/A N/A N/A 726 N/A $20,657 $24,879 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 17

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 727 N/A $41,718 $50,243 N/A N/A N/A 728 N/A $23,529 $28,337 N/A N/A N/A 729 N/A $30,535 $36,775 N/A N/A N/A 730 N/A $19,573 $23,573 N/A N/A N/A 734 N/A $75,541 $90,979 N/A N/A N/A 735 N/A $36,046 $43,412 N/A N/A N/A 736 N/A $130,314 $156,944 N/A N/A N/A 737 N/A $59,360 $71,491 N/A N/A N/A 738 N/A $37,460 $45,115 N/A N/A N/A 739 N/A $97,374 $117,274 N/A N/A N/A 740 N/A $47,225 $56,876 N/A N/A N/A 741 N/A $34,815 $41,929 N/A N/A N/A 742 N/A $45,364 $54,635 N/A N/A N/A 743 N/A $29,253 $35,232 N/A N/A N/A 744 N/A $51,383 $61,885 N/A N/A N/A 745 N/A $28,075 $33,813 N/A N/A N/A 746 N/A $41,789 $50,328 N/A N/A N/A 747 N/A $26,132 $31,473 N/A N/A N/A 748 N/A $31,872 $38,385 N/A N/A N/A 749 N/A $75,062 $90,402 N/A N/A N/A 750 N/A $34,985 $42,134 N/A N/A N/A 754 N/A $57,678 $69,466 N/A N/A N/A 755 N/A $32,522 $39,168 N/A N/A N/A 756 N/A $19,550 $23,545 N/A N/A N/A 757 N/A $45,250 $54,497 N/A N/A N/A 758 N/A $30,911 $37,228 N/A N/A N/A 759 N/A $20,369 $24,533 N/A N/A N/A 760 N/A $24,684 $29,728 N/A N/A N/A 761 N/A $14,660 $17,655 N/A N/A N/A 768 N/A $32,869 $39,586 N/A N/A N/A 769 N/A $55,633 $67,002 N/A N/A N/A 770 N/A $23,597 $28,419 N/A N/A N/A 776 N/A $23,855 $28,730 N/A N/A N/A 779 N/A $18,776 $22,614 N/A N/A N/A 783 N/A $47,611 $57,341 N/A N/A N/A 784 N/A $30,061 $36,205 N/A N/A N/A 785 N/A $22,446 $27,034 N/A N/A N/A 786 N/A $42,410 $51,076 N/A N/A N/A 787 N/A $29,489 $35,515 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 18

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 788 N/A $23,912 $28,799 N/A N/A N/A 789 N/A $45,691 $55,028 N/A N/A N/A 790 N/A $150,672 $181,463 N/A N/A N/A 791 N/A $102,906 $123,936 N/A N/A N/A 792 N/A $62,090 $74,779 N/A N/A N/A 793 N/A $105,706 $127,308 N/A N/A N/A 794 N/A $37,415 $45,061 N/A N/A N/A 795 N/A $5,067 $6,102 N/A N/A N/A 796 N/A $39,451 $47,512 N/A N/A N/A 797 N/A $22,756 $27,406 N/A N/A N/A 798 N/A $22,756 $27,406 N/A N/A N/A 799 N/A $147,329 $177,438 N/A N/A N/A 800 N/A $77,596 $93,453 N/A N/A N/A 801 N/A $45,485 $54,781 N/A N/A N/A 802 N/A $98,749 $118,931 N/A N/A N/A 803 N/A $54,193 $65,269 N/A N/A N/A 804 N/A $36,046 $43,412 N/A N/A N/A 805 N/A $25,957 $31,261 N/A N/A N/A 806 N/A $17,946 $21,613 N/A N/A N/A 807 N/A $15,777 $19,001 N/A N/A N/A 808 N/A $59,071 $77,651 N/A N/A N/A 809 N/A $31,942 $41,990 N/A N/A N/A 810 N/A $22,315 $29,334 N/A N/A N/A 811 N/A $37,703 $45,408 N/A N/A N/A 812 N/A $23,987 $28,889 N/A N/A N/A 813 N/A $48,592 $58,522 N/A N/A N/A 814 N/A $50,102 $60,341 N/A N/A N/A 815 N/A $29,236 $35,210 N/A N/A N/A 816 N/A $20,226 $24,359 N/A N/A N/A 817 N/A $65,171 $78,489 N/A N/A N/A 818 N/A $34,971 $42,117 N/A N/A N/A 819 N/A $16,359 $19,701 N/A N/A N/A 820 N/A $162,304 $195,472 N/A N/A N/A 821 N/A $67,783 $81,634 N/A N/A N/A 822 N/A $37,632 $45,323 N/A N/A N/A 823 N/A $131,139 $157,939 N/A N/A N/A 824 N/A $67,451 $81,235 N/A N/A N/A 825 N/A $40,565 $48,856 N/A N/A N/A 826 N/A $149,590 $180,159 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 19

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 827 N/A $68,223 $82,165 N/A N/A N/A 828 N/A $45,026 $54,228 N/A N/A N/A 829 N/A $100,602 $121,161 N/A N/A N/A 830 N/A $36,804 $44,325 N/A N/A N/A 831 N/A $26,465 $31,874 N/A N/A N/A 832 N/A $18,503 $22,285 N/A N/A N/A 833 N/A $9,365 $11,278 N/A N/A N/A 834 N/A $156,685 $192,336 N/A N/A N/A 835 N/A $62,520 $76,745 N/A N/A N/A 836 N/A $34,742 $42,647 N/A N/A N/A 837 N/A $189,944 $228,761 N/A N/A N/A 838 N/A $82,063 $98,833 N/A N/A N/A 839 N/A $36,810 $44,332 N/A N/A N/A 840 N/A $91,276 $109,930 N/A N/A N/A 841 N/A $47,687 $57,432 N/A N/A N/A 842 N/A $31,672 $38,145 N/A N/A N/A 843 N/A $52,613 $63,363 N/A N/A N/A 844 N/A $35,437 $42,679 N/A N/A N/A 845 N/A $25,130 $30,266 N/A N/A N/A 846 N/A $68,370 $82,343 N/A N/A N/A 847 N/A $34,000 $40,948 N/A N/A N/A 848 N/A $24,845 $29,923 N/A N/A N/A 849 N/A $43,076 $51,879 N/A N/A N/A 853 N/A $130,985 $168,463 N/A N/A N/A 854 N/A $60,066 $77,253 N/A N/A N/A 855 N/A $42,909 $55,187 N/A N/A N/A 856 N/A N/A N/A N/A N/A N/A 857 N/A N/A N/A N/A N/A N/A 858 N/A $39,352 $47,393 N/A N/A N/A 862 N/A N/A N/A N/A N/A N/A 863 N/A $26,551 $29,492 N/A N/A N/A 864 N/A $24,743 $29,799 N/A N/A N/A 865 N/A $44,468 $53,555 N/A N/A N/A 866 N/A $21,821 $26,280 N/A N/A N/A 867 N/A $80,070 $96,433 N/A N/A N/A 868 N/A $32,025 $38,570 N/A N/A N/A 869 N/A $20,211 $24,341 N/A N/A N/A 870 N/A $172,507 $207,760 N/A N/A N/A 871 N/A $44,649 $59,266 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 20

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 872 N/A $25,420 $34,525 N/A N/A N/A 876 N/A $98,549 $118,690 N/A N/A N/A 880 N/A $19,702 $23,729 N/A N/A N/A 881 N/A $18,997 $22,879 N/A N/A N/A 882 N/A $20,381 $24,547 N/A N/A N/A 883 N/A $38,388 $46,233 N/A N/A N/A 884 N/A $31,690 $38,166 N/A N/A N/A 885 N/A $24,476 $32,590 N/A N/A N/A 886 N/A $24,358 $29,336 N/A N/A N/A 887 N/A $27,417 $33,020 N/A N/A N/A 894 N/A $13,078 $15,751 N/A N/A N/A 895 N/A $35,714 $43,012 N/A N/A N/A 896 N/A $44,800 $53,956 N/A N/A N/A 897 N/A $20,293 $24,440 N/A N/A N/A 901 N/A N/A N/A N/A N/A N/A 902 N/A $50,492 $57,834 N/A N/A N/A 903 N/A $32,671 $37,421 N/A N/A N/A 904 N/A N/A N/A N/A N/A N/A 905 N/A $38,331 $43,511 N/A N/A N/A 906 N/A $48,081 $57,782 N/A N/A N/A 907 N/A N/A N/A N/A N/A N/A 908 N/A N/A N/A N/A N/A N/A 909 N/A $36,900 $44,442 N/A N/A N/A 913 N/A $33,837 $42,066 N/A N/A N/A 914 N/A $20,786 $25,841 N/A N/A N/A 915 N/A $45,203 $54,441 N/A N/A N/A 916 N/A $15,097 $18,183 N/A N/A N/A 917 N/A $40,029 $40,631 N/A N/A N/A 918 N/A $18,267 $18,542 N/A N/A N/A 919 N/A $56,814 $60,778 N/A N/A N/A 920 N/A $33,410 $35,741 N/A N/A N/A 921 N/A $22,393 $23,956 N/A N/A N/A 922 N/A $45,338 $39,160 N/A N/A N/A 923 N/A $22,279 $19,243 N/A N/A N/A 927 N/A $456,995 $550,387 N/A N/A N/A 928 N/A $106,759 $163,111 N/A N/A N/A 929 N/A $46,305 $70,748 N/A N/A N/A 933 N/A $80,987 $97,537 N/A N/A N/A 934 N/A $36,337 $49,327 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table A

CPT only copyright 2018 American Medical Association. All rights reserved. Page 21

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 935 N/A $29,407 $42,024 N/A N/A N/A 939 N/A $81,252 $97,856 N/A N/A N/A 940 N/A $53,706 $64,681 N/A N/A N/A 941 N/A $39,766 $47,893 N/A N/A N/A 947 N/A $37,349 $49,173 N/A N/A N/A 948 N/A $23,428 $30,401 N/A N/A N/A 951 N/A $27,002 $32,521 N/A N/A N/A 955 N/A N/A N/A N/A N/A N/A 956 N/A N/A N/A N/A N/A N/A 957 N/A N/A N/A N/A N/A N/A 958 N/A N/A N/A N/A N/A N/A 959 N/A N/A N/A N/A N/A N/A 963 N/A N/A N/A N/A N/A N/A 964 N/A $42,187 $62,019 N/A N/A N/A 965 N/A $26,903 $38,277 N/A N/A N/A 969 N/A $178,728 $215,254 N/A N/A N/A 970 N/A $64,905 $78,169 N/A N/A N/A 974 N/A $78,906 $95,031 N/A N/A N/A 975 N/A $38,344 $46,179 N/A N/A N/A 976 N/A $25,786 $31,056 N/A N/A N/A 977 N/A $31,114 $38,690 N/A N/A N/A 981 N/A $136,628 $170,695 N/A N/A N/A 982 N/A $79,493 $96,916 N/A N/A N/A 983 N/A $49,324 $61,623 N/A N/A N/A 987 N/A $97,007 $116,832 N/A N/A N/A 988 N/A $51,851 $62,447 N/A N/A N/A 989 N/A $30,723 $37,002 N/A N/A N/A

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 22

Table B – Other than Type One Teaching Hospitals – Acute Inpatient Hospital Stays

The maximum fee at other than Type One Teaching Hospitals for acute inpatient hospital stays, other than for treatment of a traumatic injury at a Level I or Level II Trauma Center or a serious burn at a Burn Center, shall be determined after discharge according to the following table. Admissions for one of the DRGs listed below that utilize ICD-10 diagnoses codes and contain at least one claim line reflecting revenue code 118, 128, 138, 148, or 158 are not considered an acute inpatient hospital stay and shall instead be considered a rehabilitation admission and reimbursed based on Table C.

Maximum Fee Per Admission – Other than Type One Teaching Hospitals

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 001 $391,190 $460,515 $899,844 $502,411 $607,270 $238,094 002 $241,597 $284,412 $555,740 $310,288 $375,048 $147,046 003 $271,761 $319,921 $625,124 $349,027 $421,873 $165,404 004 $167,207 $196,838 $384,620 $214,746 $259,566 $101,768 005 $161,722 $190,382 $372,005 $207,701 $251,051 $98,431 006 $73,119 $86,076 $168,193 $93,907 $113,506 $44,503 007 $218,714 $215,539 $421,162 $235,148 $284,226 $111,437 008 $82,118 $96,670 $188,893 $105,465 $127,476 $49,980 010 $62,932 $74,085 $144,761 $80,824 $97,694 $38,303 011 $72,994 $85,929 $167,905 $93,747 $113,314 $44,427 012 $51,291 $60,381 $117,984 $65,875 $79,623 $31,218 013 $32,902 $38,733 $75,686 $42,257 $51,077 $20,026 014 $169,287 $199,286 $389,405 $217,417 $262,795 $103,035 016 $90,557 $106,604 $208,305 $116,304 $140,578 $55,117 017 $64,094 $75,452 $147,433 $82,317 $99,497 $39,009 020 $145,469 $171,248 $334,617 $186,827 $225,820 $88,537 021 $110,238 $129,774 $253,577 $141,580 $171,130 $67,096 022 $69,226 $81,493 $159,237 $88,907 $107,463 $42,134 023 $79,314 $93,369 $182,443 $91,582 $123,125 $48,273 024 $56,124 $66,070 $129,102 $64,807 $87,126 $34,160 025 $71,274 $83,090 $163,951 $99,532 $131,075 $43,380 026 $49,316 $57,491 $113,439 $68,867 $90,692 $30,016 027 $37,505 $43,723 $86,273 $52,375 $68,973 $22,827 028 $76,389 $105,923 $221,372 $113,858 $133,204 $49,417 029 $45,366 $61,969 $122,367 $63,819 $77,929 $28,911

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 23

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 030 $25,819 $35,005 $73,157 $37,627 $45,029 $16,331 031 $63,925 $75,252 $147,043 $82,099 $99,234 $38,907 032 $31,313 $36,862 $72,027 $40,215 $48,609 $19,059 033 $24,036 $28,296 $55,290 $30,870 $37,313 $14,629 034 $57,015 $67,119 $131,149 $73,225 $88,508 $34,702 035 $34,061 $40,098 $78,350 $43,745 $52,875 $20,731 036 $26,672 $31,399 $61,354 $34,256 $41,406 $16,234 037 $48,302 $56,861 $111,108 $62,838 $71,564 $29,398 038 $24,367 $28,685 $56,050 $31,699 $36,102 $14,830 039 $16,247 $19,127 $37,373 $21,136 $24,072 $9,889 040 $57,948 $66,722 $164,912 $84,336 $91,557 $35,660 041 $31,954 $37,380 $92,391 $47,249 $51,295 $19,978 042 $28,373 $32,832 $80,744 $41,293 $45,526 $17,460 052 $27,516 $32,629 $61,626 $36,424 $41,589 $20,519 053 $16,172 $19,177 $36,220 $21,408 $24,443 $12,060 054 $20,102 $23,664 $46,239 $25,817 $31,205 $12,235 055 $15,700 $18,482 $36,115 $20,164 $24,372 $9,556 056 $26,468 $31,159 $60,885 $33,994 $41,089 $14,402 057 $15,175 $17,864 $34,907 $19,489 $23,557 $8,257 058 $21,975 $29,174 $57,006 $31,828 $38,472 $15,084 059 $13,842 $18,377 $35,909 $20,048 $24,233 $9,501 060 $10,582 $14,050 $27,453 $15,328 $18,527 $7,264 061 $42,476 $50,003 $97,706 $54,552 $65,938 $25,852 062 $28,585 $33,651 $65,756 $36,714 $44,376 $17,398 063 $23,260 $27,382 $53,505 $29,873 $36,108 $14,157 064 $28,793 $30,780 $58,807 $32,691 $35,773 $15,801 065 $17,338 $18,848 $35,877 $20,018 $21,905 $9,675 066 $12,423 $13,335 $25,384 $14,112 $15,498 $6,845 067 $22,381 $26,346 $51,481 $28,744 $34,742 $13,621 068 $12,933 $15,225 $29,751 $16,610 $20,078 $7,871 069 $11,189 $12,574 $24,570 $13,718 $16,581 $6,135 070 $26,963 $29,966 $57,506 $32,692 $39,515 $15,493 071 $15,989 $17,771 $34,102 $19,387 $23,433 $9,188 072 $11,395 $12,664 $24,303 $13,816 $16,700 $6,548 073 $19,399 $22,836 $39,747 $22,012 $24,147 $11,806 074 $12,913 $15,202 $26,459 $14,654 $16,075 $7,859 075 $25,567 $30,097 $58,809 $32,835 $39,689 $15,561 076 $13,293 $15,649 $30,580 $17,073 $20,637 $8,092 077 $25,474 $29,989 $58,599 $32,718 $39,546 $17,728

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 24

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 078 $14,680 $17,281 $33,767 $18,853 $22,788 $10,216 079 $10,471 $12,326 $24,085 $13,448 $16,254 $7,287 080 $19,704 $23,196 $45,326 $25,307 $30,588 $11,993 081 $12,094 $14,237 $27,819 $15,533 $18,773 $7,361 082 $28,988 $31,944 $66,765 $37,277 $46,097 $17,665 083 $18,780 $20,695 $43,253 $24,150 $29,863 $11,444 084 $13,011 $14,310 $29,968 $16,732 $20,691 $7,929 085 $31,945 $34,028 $68,662 $43,952 $43,816 $16,446 086 $18,067 $19,010 $39,086 $24,857 $24,780 $9,300 087 $12,228 $12,840 $25,909 $16,625 $16,633 $6,206 088 $27,567 $28,361 $57,244 $30,941 $42,139 $13,785 089 $16,827 $17,311 $34,941 $18,886 $25,721 $9,000 090 $12,902 $13,276 $26,669 $14,484 $19,616 $6,902 091 $23,441 $28,093 $59,349 $30,047 $32,412 $15,087 092 $13,188 $15,805 $32,915 $17,020 $18,234 $8,487 093 $9,951 $11,926 $24,837 $12,756 $13,759 $6,405 094 $51,390 $60,497 $118,211 $66,000 $79,776 $31,278 095 $36,734 $43,244 $84,499 $47,178 $57,025 $22,357 096 $31,931 $37,590 $73,449 $41,009 $49,568 $19,434 097 $48,722 $57,356 $112,073 $62,574 $75,634 $29,654 098 $26,481 $31,175 $60,914 $34,011 $41,109 $16,117 099 $17,885 $21,054 $41,140 $22,969 $27,764 $10,886 100 $23,417 $27,482 $41,327 $23,962 $29,890 $12,730 101 $11,578 $13,589 $20,434 $11,848 $15,054 $6,294 102 $14,417 $16,973 $33,164 $17,812 $20,568 $8,775 103 $9,897 $11,651 $22,766 $12,228 $14,120 $6,024 113 $27,201 $32,021 $62,570 $33,191 $42,226 $16,556 114 $16,907 $19,903 $38,891 $20,863 $26,246 $10,290 115 $19,689 $23,179 $45,290 $25,287 $30,565 $11,983 116 $19,122 $24,912 $48,678 $27,179 $31,753 $12,880 117 $11,249 $14,656 $28,637 $15,989 $18,680 $7,577 121 $15,547 $18,961 $37,051 $20,687 $25,005 $9,804 122 $9,286 $11,325 $22,129 $12,356 $14,935 $5,856 123 $10,371 $12,209 $23,857 $13,320 $16,100 $6,312 124 $17,432 $20,521 $40,098 $20,680 $26,928 $10,610 125 $10,448 $12,300 $24,033 $12,394 $16,140 $6,359 129 $35,871 $42,228 $82,514 $46,070 $55,686 $21,833 130 $19,410 $22,850 $44,649 $24,928 $30,131 $11,814 131 $33,744 $43,786 $112,786 $42,264 $58,334 $22,639

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 25

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 132 $20,284 $26,320 $67,796 $27,487 $35,065 $13,608 133 $35,649 $35,324 $69,022 $38,538 $46,580 $18,263 134 $19,280 $19,103 $37,329 $20,842 $25,191 $9,877 135 $29,503 $34,731 $67,864 $37,891 $45,799 $17,956 136 $16,190 $19,060 $37,242 $20,793 $25,133 $9,854 137 $21,161 $24,910 $48,674 $27,177 $32,848 $12,879 138 $12,153 $14,305 $27,953 $15,608 $18,865 $7,396 139 $15,184 $17,875 $34,928 $19,501 $23,571 $9,242 146 $33,478 $39,410 $77,007 $42,995 $75,033 $20,375 147 $21,814 $25,681 $50,180 $28,017 $48,894 $13,277 148 $13,909 $16,373 $31,994 $17,863 $31,174 $8,465 149 $9,770 $11,502 $22,475 $12,548 $15,167 $5,947 150 $19,940 $23,474 $45,868 $25,609 $30,954 $12,136 151 $10,306 $12,133 $23,708 $13,237 $15,999 $6,273 152 $16,435 $19,347 $37,805 $24,801 $25,513 $10,003 153 $11,134 $13,107 $25,609 $16,800 $17,283 $6,776 154 $20,562 $24,205 $47,297 $22,725 $31,919 $12,515 155 $13,276 $15,629 $30,539 $14,673 $20,610 $8,080 156 $9,777 $11,510 $22,490 $10,806 $15,178 $5,951 157 $24,398 $28,721 $57,751 $31,334 $37,385 $14,849 158 $13,143 $15,473 $31,111 $16,879 $20,140 $7,999 159 $9,156 $10,779 $21,674 $11,760 $14,030 $5,573 163 $88,633 $94,790 $185,219 $103,414 $124,997 $51,358 164 $45,803 $48,985 $95,716 $53,441 $64,595 $26,540 165 $32,085 $34,314 $67,049 $37,435 $45,249 $18,592 166 $58,549 $68,156 $133,176 $72,384 $97,411 $35,238 167 $31,694 $36,894 $72,092 $39,183 $52,731 $19,075 168 $21,256 $24,744 $48,349 $26,278 $35,365 $12,793 175 $20,996 $23,949 $43,159 $25,833 $27,540 $12,597 176 $13,050 $14,919 $27,329 $15,818 $17,440 $7,806 177 $25,899 $30,488 $48,112 $27,970 $40,204 $12,859 178 $18,480 $21,756 $34,331 $19,959 $28,689 $9,409 179 $12,878 $15,161 $23,926 $13,909 $19,992 $6,557 180 $25,988 $30,594 $59,780 $33,377 $40,343 $15,818 181 $17,844 $21,005 $41,045 $22,917 $27,699 $10,861 182 $12,460 $14,669 $28,663 $16,004 $19,343 $7,584 183 $25,782 $31,090 $61,020 $34,742 $36,600 $15,373 184 $16,079 $20,360 $39,959 $22,321 $23,967 $10,068 185 $11,138 $13,647 $26,782 $15,249 $16,064 $6,748

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 26

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 186 $23,360 $27,499 $43,778 $30,001 $37,733 $14,218 187 $16,163 $19,027 $30,290 $20,758 $26,107 $9,837 188 $11,503 $13,542 $21,558 $14,773 $18,581 $7,001 189 $16,844 $19,828 $39,832 $22,628 $24,246 $9,181 190 $14,139 $13,463 $37,192 $15,268 $17,740 $10,221 191 $10,895 $10,742 $29,676 $12,182 $14,155 $6,572 192 $8,657 $8,243 $22,772 $9,348 $10,862 $6,313 193 $24,356 $26,008 $48,859 $28,514 $37,810 $15,082 194 $16,284 $17,340 $32,665 $19,001 $25,278 $10,074 195 $11,839 $12,608 $23,750 $13,815 $18,379 $8,011 196 $24,981 $29,408 $57,463 $32,083 $38,780 $13,119 197 $15,941 $18,765 $36,668 $20,473 $24,746 $8,372 198 $12,095 $14,238 $27,821 $15,534 $18,775 $6,352 199 $23,626 $28,236 $54,038 $30,338 $34,056 $25,579 200 $12,987 $15,521 $29,704 $16,759 $18,557 $14,061 201 $9,139 $10,922 $20,902 $11,735 $13,174 $9,894 202 $14,512 $15,981 $28,213 $18,957 $20,335 $8,238 203 $10,808 $11,902 $21,012 $14,118 $15,144 $6,135 204 $10,847 $12,770 $24,952 $13,932 $16,839 $6,603 205 $21,467 $24,827 $48,339 $27,133 $29,901 $12,790 206 $12,179 $14,119 $27,424 $15,602 $16,964 $7,256 207 $78,793 $92,757 $181,247 $101,196 $122,317 $44,309 208 $33,876 $39,879 $77,924 $43,507 $52,587 $19,050 215 $237,789 $279,929 $546,980 $305,396 $369,136 $144,728 216 $146,724 $172,726 $337,506 $188,440 $227,769 $89,302 217 $97,507 $114,786 $224,292 $125,229 $151,366 $59,346 218 $85,801 $101,006 $197,366 $110,196 $133,194 $52,222 219 $123,586 $145,488 $284,283 $192,320 $191,851 $75,220 220 $83,479 $98,272 $192,023 $129,906 $129,589 $50,808 221 $74,323 $87,494 $170,964 $115,658 $115,377 $45,237 222 $133,370 $157,005 $306,788 $171,289 $207,040 $81,175 223 $96,941 $114,121 $222,990 $124,503 $150,488 $59,002 224 $118,215 $139,165 $271,928 $151,826 $183,513 $71,950 225 $90,295 $106,296 $207,702 $115,967 $140,170 $54,957 226 $109,186 $128,535 $251,156 $148,749 $169,495 $66,454 227 $85,519 $100,674 $196,717 $116,508 $132,757 $52,050 228 $117,737 $138,601 $270,826 $151,211 $228,121 $71,659 229 $71,831 $84,560 $165,230 $92,253 $139,176 $43,719 231 $119,007 $140,096 $273,749 $152,843 $184,742 $72,432

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 27

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 232 $86,237 $101,519 $198,369 $110,755 $133,871 $52,487 233 $106,461 $142,800 $339,700 $134,038 $251,477 $73,830 234 $70,715 $94,852 $225,639 $89,032 $167,038 $49,040 235 $86,358 $103,237 $201,724 $110,029 $137,872 $53,375 236 $57,409 $68,630 $134,104 $73,146 $91,656 $35,483 239 $80,923 $82,430 $157,716 $84,366 $97,355 $42,618 240 $46,921 $47,795 $91,828 $48,918 $56,449 $24,711 241 $23,995 $24,441 $46,764 $25,016 $28,867 $12,637 242 $59,466 $66,242 $118,161 $72,268 $87,352 $34,248 243 $42,625 $47,482 $84,698 $51,802 $62,613 $24,549 244 $34,418 $38,340 $68,390 $41,827 $50,557 $19,822 245 $71,615 $84,306 $164,735 $91,976 $111,173 $43,588 246 $67,449 $66,837 $131,041 $74,457 $88,760 $44,030 247 $42,897 $42,508 $83,342 $47,947 $56,451 $28,003 248 $49,531 $58,309 $128,511 $63,613 $70,732 $30,147 249 $30,633 $36,062 $79,479 $39,342 $43,745 $18,645 250 $44,585 $52,486 $106,389 $57,260 $66,974 $27,136 251 $30,433 $35,825 $72,619 $39,085 $46,484 $18,523 252 $58,921 $63,847 $117,386 $69,404 $73,753 $30,617 253 $46,081 $49,934 $91,806 $54,280 $58,288 $23,946 254 $31,231 $33,842 $62,221 $36,788 $39,683 $16,229 255 $39,062 $45,985 $89,853 $50,168 $56,237 $23,774 256 $25,469 $29,983 $58,587 $32,711 $36,603 $15,502 257 $15,831 $18,636 $36,416 $20,332 $22,792 $9,635 258 $42,541 $50,079 $97,855 $54,635 $66,039 $25,892 259 $30,695 $36,135 $70,606 $39,422 $47,650 $18,682 260 $57,705 $67,931 $132,737 $74,111 $89,579 $35,121 261 $28,581 $33,646 $65,745 $36,707 $44,369 $17,396 262 $21,534 $25,351 $49,535 $27,657 $33,430 $13,107 263 $28,754 $33,849 $66,141 $36,929 $44,637 $17,501 264 $42,241 $49,727 $94,407 $54,251 $65,573 $25,710 265 $44,124 $51,944 $101,498 $56,669 $68,497 $26,856 266 $138,531 $163,081 $318,659 $177,917 $215,051 $84,315 267 $104,017 $122,451 $239,267 $133,590 $161,472 $63,309 268 $96,761 $113,908 $222,576 $124,272 $150,208 $58,892 269 $60,147 $70,805 $138,354 $77,248 $93,370 $36,608 270 $72,946 $85,873 $167,796 $93,686 $113,239 $44,398 271 $48,416 $56,995 $111,368 $62,180 $75,158 $29,467 272 $34,676 $40,821 $79,764 $44,535 $53,830 $21,105

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 28

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 273 $54,690 $64,381 $125,802 $70,239 $84,899 $33,287 274 $37,278 $43,885 $85,749 $47,877 $57,869 $22,689 280 $23,270 $28,659 $53,701 $30,739 $36,715 $13,438 281 $13,792 $16,986 $31,827 $18,219 $21,761 $7,962 282 $10,177 $12,535 $23,488 $13,445 $16,058 $5,878 283 $25,809 $30,384 $59,369 $33,148 $40,066 $15,709 284 $11,867 $13,970 $27,298 $15,241 $18,422 $7,223 285 $7,803 $9,186 $17,949 $10,022 $12,113 $4,749 286 $32,227 $37,939 $72,490 $39,838 $55,549 $19,615 287 $17,130 $20,166 $38,531 $21,045 $29,526 $10,426 288 $41,809 $49,218 $96,172 $53,696 $64,903 $25,446 289 $26,177 $30,815 $60,213 $33,619 $40,636 $15,932 290 $19,221 $22,626 $44,212 $24,685 $29,837 $11,699 291 $22,503 $26,490 $58,347 $27,671 $33,771 $13,183 292 $14,643 $17,238 $37,968 $17,881 $21,976 $8,499 293 $10,079 $11,865 $26,134 $12,394 $15,106 $5,969 294 $16,146 $19,007 $37,139 $20,735 $25,063 $9,827 295 $10,671 $12,562 $24,545 $13,704 $16,564 $6,494 296 $19,022 $22,393 $43,756 $24,430 $29,528 $11,577 297 $9,975 $11,744 $22,946 $12,811 $15,486 $6,072 298 $6,512 $7,666 $14,979 $8,364 $10,109 $3,964 299 $16,975 $21,648 $44,781 $23,291 $30,114 $10,169 300 $11,947 $15,312 $32,265 $16,146 $20,876 $7,148 301 $8,285 $10,620 $22,150 $11,198 $14,478 $4,957 302 $16,136 $18,758 $36,653 $20,464 $24,736 $9,698 303 $9,548 $11,099 $21,688 $12,109 $14,636 $5,739 304 $14,965 $17,617 $34,424 $19,220 $21,730 $9,109 305 $9,371 $11,032 $21,556 $12,036 $13,607 $5,703 306 $21,087 $24,823 $48,504 $27,081 $32,734 $12,834 307 $11,859 $13,961 $27,280 $15,231 $18,410 $7,219 308 $15,273 $19,200 $35,874 $19,485 $22,325 $9,358 309 $9,922 $12,472 $23,308 $12,658 $14,502 $6,080 310 $6,720 $8,711 $15,950 $8,698 $10,129 $4,099 311 $8,544 $10,058 $19,653 $11,293 $13,263 $4,919 312 $10,021 $12,474 $20,792 $14,377 $16,462 $6,449 313 $11,699 $13,551 $25,085 $16,931 $17,708 $6,943 314 $26,411 $26,166 $60,493 $31,502 $34,556 $15,125 315 $13,227 $13,104 $30,296 $16,173 $17,306 $7,617 316 $8,544 $8,465 $19,571 $10,192 $11,179 $4,893

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 29

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 326 $81,857 $96,362 $188,292 $96,935 $127,071 $49,821 327 $40,333 $47,481 $92,777 $47,763 $62,611 $24,548 328 $22,725 $26,752 $52,274 $26,911 $35,277 $13,831 329 $65,587 $87,999 $171,950 $94,900 $96,573 $37,422 330 $32,927 $44,178 $86,324 $47,611 $48,482 $18,788 331 $21,417 $28,735 $56,148 $33,536 $31,534 $12,220 332 $72,482 $85,327 $166,729 $93,090 $112,519 $44,116 333 $38,096 $44,847 $87,631 $48,927 $59,139 $23,187 334 $24,699 $29,076 $56,815 $31,721 $38,342 $15,033 335 $64,379 $75,788 $148,091 $77,288 $92,557 $39,184 336 $35,340 $41,603 $81,292 $42,427 $50,808 $21,510 337 $23,415 $27,564 $53,861 $28,140 $33,663 $14,252 338 $46,268 $54,468 $106,429 $54,304 $71,825 $26,809 339 $26,132 $30,764 $60,111 $30,670 $40,567 $15,142 340 $18,291 $21,532 $42,075 $21,467 $28,395 $10,599 341 $35,163 $41,394 $80,882 $44,565 $54,585 $21,401 342 $20,167 $23,740 $46,389 $25,559 $31,306 $12,274 343 $14,464 $17,027 $33,270 $18,331 $22,453 $8,803 344 $51,417 $60,529 $118,273 $66,035 $85,897 $31,294 345 $26,591 $31,303 $61,165 $34,151 $44,422 $16,184 346 $18,638 $21,941 $42,874 $23,938 $31,137 $11,344 347 $40,404 $47,564 $92,939 $51,891 $62,722 $24,591 348 $21,299 $25,074 $48,993 $27,354 $33,064 $12,964 349 $13,986 $16,464 $32,170 $17,961 $21,711 $8,512 350 $29,725 $42,433 $82,915 $41,430 $55,956 $21,939 351 $16,901 $24,127 $47,144 $23,556 $31,815 $12,474 352 $11,193 $15,979 $31,223 $15,356 $21,071 $8,261 353 $38,960 $52,175 $101,950 $62,880 $59,358 $26,976 354 $22,664 $30,352 $59,307 $37,900 $34,530 $15,692 355 $16,777 $22,467 $43,901 $27,077 $25,561 $11,616 356 $60,013 $70,648 $138,046 $77,075 $95,543 $36,526 357 $32,785 $38,594 $75,413 $42,105 $52,194 $19,954 358 $21,373 $25,160 $49,163 $27,449 $34,026 $13,008 368 $28,718 $33,808 $66,060 $36,883 $44,582 $17,479 369 $16,489 $19,411 $37,930 $21,177 $25,597 $10,036 370 $11,385 $13,403 $26,189 $14,622 $17,674 $6,929 371 $28,338 $32,647 $65,184 $36,395 $41,576 $17,248 372 $17,251 $19,875 $39,681 $22,155 $25,310 $10,499 373 $12,186 $14,040 $28,032 $15,651 $17,879 $7,418

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 30

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 374 $30,344 $35,722 $69,801 $38,972 $40,907 $18,469 375 $18,687 $21,999 $42,986 $24,001 $25,192 $11,374 376 $13,563 $15,967 $31,200 $17,419 $18,284 $8,255 377 $25,576 $30,109 $62,339 $30,876 $39,704 $14,020 378 $14,419 $16,975 $35,145 $17,334 $22,384 $7,843 379 $9,750 $11,478 $23,764 $11,770 $15,136 $5,345 380 $29,680 $34,939 $68,272 $38,118 $46,074 $18,064 381 $16,754 $19,723 $38,539 $21,517 $26,008 $10,197 382 $11,695 $13,767 $26,902 $15,020 $18,154 $7,118 383 $20,359 $23,967 $46,831 $26,147 $31,605 $12,391 384 $13,111 $15,434 $30,158 $16,838 $20,353 $7,980 385 $27,190 $32,009 $62,544 $34,921 $42,209 $16,549 386 $15,468 $18,209 $35,580 $19,866 $24,012 $9,414 387 $11,476 $13,510 $26,398 $14,739 $17,815 $6,984 388 $23,080 $27,994 $54,699 $30,540 $30,705 $13,581 389 $12,497 $15,156 $29,616 $16,535 $16,625 $6,928 390 $8,856 $10,491 $20,500 $11,446 $11,508 $5,090 391 $16,565 $19,741 $40,298 $18,461 $25,090 $10,207 392 $10,750 $12,178 $24,859 $11,388 $16,209 $6,296 393 $21,924 $28,617 $55,918 $31,220 $32,758 $14,796 394 $12,524 $16,006 $31,274 $17,461 $18,321 $8,275 395 $8,714 $11,137 $21,761 $12,150 $12,748 $5,758 405 $85,330 $100,452 $196,281 $109,590 $132,463 $51,935 406 $43,240 $50,903 $99,464 $55,534 $67,125 $26,318 407 $29,998 $35,315 $69,005 $38,527 $46,569 $18,259 408 $60,033 $70,671 $138,092 $77,100 $93,193 $36,538 409 $34,229 $40,296 $78,737 $43,961 $53,136 $20,833 410 $24,967 $29,391 $57,431 $32,066 $38,758 $15,196 411 $55,864 $65,764 $128,502 $71,746 $86,722 $34,000 412 $37,230 $43,828 $85,640 $47,816 $57,795 $22,660 413 $27,281 $32,116 $62,753 $35,038 $42,350 $16,604 414 $54,761 $64,465 $125,965 $70,330 $85,009 $33,330 415 $31,223 $36,756 $71,822 $40,101 $48,470 $19,004 416 $20,745 $24,421 $47,717 $26,642 $32,203 $12,626 417 $37,392 $44,018 $86,010 $47,199 $58,045 $22,758 418 $25,488 $30,004 $58,628 $32,172 $39,566 $15,512 419 $18,909 $22,261 $43,498 $23,870 $29,355 $11,509 420 $53,337 $62,789 $122,690 $68,501 $82,799 $32,463 421 $27,267 $32,099 $62,722 $35,020 $42,329 $16,596

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 31

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 422 $19,029 $22,402 $43,773 $24,440 $29,541 $11,582 423 $61,352 $72,223 $141,125 $78,794 $95,239 $32,392 424 $33,618 $39,576 $77,331 $43,176 $52,187 $17,749 425 $20,167 $23,741 $46,390 $25,901 $31,307 $10,647 432 $24,592 $28,951 $56,569 $31,585 $38,176 $14,024 433 $13,501 $15,893 $31,054 $17,338 $20,957 $7,699 434 $9,167 $10,791 $21,088 $11,774 $14,231 $5,227 435 $26,998 $31,782 $62,102 $34,673 $41,910 $16,432 436 $17,933 $21,111 $41,250 $23,031 $27,838 $10,914 437 $13,821 $16,270 $31,792 $17,750 $21,455 $8,412 438 $25,184 $30,330 $59,266 $33,597 $39,996 $14,474 439 $13,420 $16,162 $31,581 $17,903 $21,313 $7,707 440 $9,502 $11,444 $22,361 $12,676 $15,091 $5,462 441 $28,322 $32,266 $65,147 $36,489 $42,753 $17,238 442 $13,933 $15,874 $32,050 $17,951 $21,033 $8,480 443 $9,792 $11,156 $22,524 $12,615 $14,781 $5,960 444 $24,976 $29,403 $57,452 $32,077 $38,772 $15,202 445 $16,414 $19,323 $37,756 $21,081 $25,480 $9,990 446 $11,661 $13,727 $26,823 $14,976 $18,102 $7,097 453 $147,550 $173,608 $404,534 $260,311 $233,112 $104,507 454 $105,978 $124,695 $296,604 $189,632 $167,434 $75,063 455 $77,718 $97,198 $223,997 $147,817 $130,514 $58,512 456 $142,916 $168,242 $321,471 $183,549 $196,370 $86,984 457 $104,975 $123,578 $232,009 $134,821 $144,239 $63,892 458 $79,995 $94,172 $177,296 $102,738 $109,915 $48,689 459 $102,464 $119,726 $233,523 $139,551 $185,862 $59,805 460 $62,892 $73,931 $153,003 $90,554 $111,479 $35,870 461 $73,355 $93,662 $175,228 $100,968 $131,341 $47,298 462 $51,003 $65,122 $121,835 $70,202 $91,320 $32,886 463 $83,341 $112,976 $240,716 $106,815 $130,465 $51,152 464 $48,271 $63,716 $139,121 $61,167 $73,578 $28,848 465 $30,790 $41,219 $87,826 $38,972 $47,600 $18,663 466 $89,067 $115,119 $202,271 $111,059 $118,274 $54,164 467 $59,186 $76,498 $134,411 $73,801 $78,594 $35,993 468 $47,980 $64,503 $108,703 $62,537 $63,489 $29,076 469 $55,238 $59,099 $102,478 $64,261 $80,304 $48,318 470 $35,262 $36,413 $62,866 $40,816 $50,726 $30,122 471 $71,800 $75,293 $141,647 $76,960 $92,041 $39,110 472 $42,968 $45,058 $85,626 $44,877 $55,081 $23,405

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 32

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 473 $34,025 $34,712 $67,511 $38,572 $45,294 $18,180 474 $52,266 $64,207 $125,460 $70,048 $84,668 $33,196 475 $29,592 $36,627 $71,570 $39,960 $48,300 $18,937 476 $16,267 $19,984 $39,048 $21,802 $26,352 $10,332 477 $49,898 $61,848 $103,246 $65,057 $93,569 $30,370 478 $35,393 $43,869 $73,232 $45,837 $66,369 $21,541 479 $27,305 $33,842 $56,495 $35,598 $51,200 $16,619 480 $44,736 $55,058 $97,886 $56,052 $72,733 $27,524 481 $30,204 $35,955 $64,415 $37,077 $48,702 $18,113 482 $24,808 $29,758 $51,927 $31,585 $40,046 $14,877 483 $38,934 $47,601 $89,625 $49,911 $69,901 $28,599 485 $44,975 $65,680 $168,864 $55,232 $71,035 $33,958 486 $30,017 $43,836 $104,536 $37,196 $47,410 $22,664 487 $22,714 $33,170 $85,280 $27,894 $35,874 $17,149 488 $28,401 $30,694 $63,496 $34,578 $44,945 $16,938 489 $22,372 $23,929 $50,792 $27,134 $36,148 $12,967 492 $53,506 $62,546 $127,562 $67,082 $86,200 $40,790 493 $35,026 $41,730 $87,814 $42,701 $54,603 $26,048 494 $26,547 $30,987 $66,480 $34,633 $42,126 $19,704 495 $47,059 $56,977 $101,745 $63,653 $72,714 $23,596 496 $26,697 $32,324 $57,720 $36,111 $41,251 $13,386 497 $18,737 $22,488 $40,256 $23,179 $28,539 $9,469 498 $41,326 $48,650 $76,332 $71,992 $64,153 $25,153 499 $20,750 $24,427 $38,326 $36,147 $32,211 $12,630 500 $51,180 $54,897 $95,873 $59,269 $72,685 $35,800 501 $26,007 $27,895 $50,113 $30,117 $37,380 $18,192 502 $18,586 $19,704 $35,418 $21,747 $26,800 $12,806 503 $31,279 $38,972 $75,366 $45,676 $52,997 $24,341 504 $21,030 $24,468 $49,629 $30,710 $35,632 $16,365 505 $17,701 $20,830 $40,303 $26,156 $29,426 $13,009 506 $19,265 $22,719 $44,315 $24,743 $28,779 $11,725 507 $28,941 $34,069 $66,571 $36,598 $44,926 $17,614 508 $22,963 $27,032 $52,822 $28,899 $35,648 $13,977 509 $23,870 $28,100 $54,907 $30,657 $37,056 $14,529 510 $39,807 $46,638 $90,194 $46,536 $60,072 $17,525 511 $28,752 $33,686 $65,145 $33,612 $43,388 $12,658 512 $22,576 $26,675 $51,511 $28,371 $35,358 $9,939 513 $20,980 $26,251 $48,418 $26,020 $34,174 $13,148 514 $13,117 $16,253 $30,146 $16,247 $21,503 $8,179

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 33

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 515 $55,514 $67,662 $132,901 $71,061 $86,479 $31,365 516 $35,191 $42,892 $84,247 $45,046 $54,819 $19,883 517 $29,940 $36,210 $71,123 $38,029 $46,280 $16,785 518 $58,083 $61,673 $131,873 $66,642 $81,747 $31,886 519 $32,356 $33,161 $70,905 $35,832 $45,160 $17,144 520 $22,130 $22,947 $49,383 $25,256 $31,935 $11,864 533 $22,331 $26,289 $51,367 $28,680 $34,666 $13,592 534 $11,699 $13,773 $26,912 $15,026 $18,161 $7,120 535 $19,245 $21,106 $40,774 $24,735 $28,905 $10,706 536 $11,167 $12,247 $23,660 $14,353 $16,773 $6,212 537 $13,647 $15,047 $31,390 $17,526 $21,184 $8,244 538 $10,517 $11,597 $24,193 $13,508 $16,326 $6,354 539 $27,461 $28,425 $63,166 $35,268 $40,992 $16,714 540 $19,484 $20,168 $44,817 $25,023 $28,182 $11,858 541 $13,851 $14,337 $31,860 $17,789 $20,676 $8,430 542 $29,687 $34,947 $68,287 $38,126 $42,104 $18,068 543 $17,116 $20,150 $39,372 $21,983 $24,276 $10,418 544 $12,099 $14,243 $27,831 $15,539 $17,160 $7,364 545 $38,764 $45,633 $89,168 $49,785 $56,027 $23,594 546 $17,915 $21,089 $41,208 $23,008 $25,893 $10,903 547 $12,215 $14,380 $28,097 $15,688 $17,654 $7,434 548 $29,461 $34,682 $67,769 $37,837 $45,734 $17,931 549 $17,738 $20,882 $40,803 $22,782 $27,537 $10,797 550 $12,926 $15,216 $29,732 $16,600 $20,066 $7,867 551 $23,513 $25,792 $49,328 $30,232 $32,154 $14,060 552 $13,253 $14,421 $27,914 $16,995 $17,888 $7,861 553 $18,386 $22,132 $44,589 $24,146 $29,185 $11,443 554 $10,974 $13,210 $26,613 $14,412 $17,419 $6,830 555 $18,990 $22,355 $40,364 $21,843 $27,542 $11,558 556 $10,795 $12,708 $22,945 $12,416 $15,656 $6,570 557 $19,439 $21,294 $52,736 $24,338 $30,286 $12,953 558 $11,610 $12,718 $31,496 $14,536 $18,088 $7,736 559 $31,418 $27,581 $59,366 $31,014 $43,326 $15,645 560 $18,213 $16,531 $34,914 $17,979 $25,115 $9,069 561 $12,828 $10,279 $24,087 $11,179 $15,617 $5,639 562 $18,306 $25,190 $41,877 $25,546 $26,595 $12,375 563 $10,205 $13,891 $23,287 $14,456 $15,049 $7,002 564 $24,038 $27,792 $66,810 $30,320 $36,649 $14,495 565 $14,883 $17,371 $41,759 $18,951 $22,907 $9,060

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 34

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 566 $10,984 $12,700 $30,530 $13,856 $16,748 $6,624 570 $32,914 $38,579 $71,984 $50,968 $52,492 $22,269 571 $20,151 $23,619 $44,070 $31,204 $32,137 $13,633 572 $13,630 $16,141 $29,810 $20,225 $21,738 $9,222 573 $58,900 $68,315 $125,636 $70,147 $77,786 $28,556 574 $41,780 $48,458 $89,118 $49,757 $55,176 $20,256 575 $23,713 $27,503 $50,580 $28,241 $31,317 $11,497 576 $61,744 $72,686 $142,029 $67,679 $95,851 $36,826 577 $29,531 $34,765 $67,931 $32,370 $45,843 $17,613 578 $19,619 $23,096 $45,129 $21,505 $30,456 $11,701 579 $37,602 $50,262 $85,367 $50,045 $62,797 $24,690 580 $21,083 $28,861 $48,488 $29,022 $35,595 $14,242 581 $15,637 $20,805 $35,502 $20,932 $26,061 $10,268 582 $20,032 $23,583 $46,080 $25,728 $31,098 $12,192 583 $16,842 $19,827 $38,741 $21,631 $26,144 $10,250 584 $27,241 $32,069 $62,662 $34,986 $42,288 $16,580 585 $21,186 $24,941 $48,734 $27,210 $32,889 $12,895 592 $21,562 $25,383 $49,598 $27,692 $33,472 $11,969 593 $15,429 $18,162 $35,490 $19,815 $23,951 $8,565 594 $10,780 $12,691 $24,797 $13,845 $16,734 $5,984 595 $30,489 $35,891 $72,876 $39,157 $47,329 $18,556 596 $14,798 $17,420 $35,371 $19,005 $22,971 $9,006 597 $25,818 $30,393 $59,388 $33,158 $40,078 $15,713 598 $17,309 $20,376 $39,814 $22,230 $26,869 $10,535 599 $11,183 $13,166 $25,724 $14,363 $17,361 $6,807 600 $15,102 $17,779 $34,740 $19,397 $23,444 $9,192 601 $9,728 $11,451 $22,376 $12,493 $15,100 $5,920 602 $18,634 $21,415 $40,823 $21,867 $25,429 $10,987 603 $10,410 $12,427 $23,688 $12,689 $14,755 $6,375 604 $19,415 $24,688 $45,016 $26,068 $36,457 $11,862 605 $11,978 $14,987 $27,330 $15,826 $22,133 $7,201 606 $18,976 $24,279 $47,441 $25,716 $28,337 $12,553 607 $10,133 $12,964 $25,331 $13,731 $15,131 $6,703 614 $40,771 $47,996 $93,784 $59,536 $63,291 $24,815 615 $23,565 $27,741 $54,207 $34,412 $36,582 $14,343 616 $63,033 $65,195 $144,992 $76,822 $97,849 $38,364 617 $30,230 $31,267 $69,536 $36,842 $46,928 $18,399 618 $20,468 $21,171 $47,082 $24,946 $31,774 $12,458 619 $50,671 $59,650 $116,555 $65,077 $78,659 $30,840

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 35

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 620 $28,455 $33,498 $65,454 $36,545 $44,173 $17,319 621 $23,777 $27,992 $54,695 $30,538 $36,911 $14,472 622 $56,646 $61,202 $130,303 $72,752 $87,937 $34,478 623 $27,258 $29,450 $62,701 $35,007 $42,314 $16,590 624 $16,845 $18,200 $38,748 $21,634 $26,149 $10,253 625 $38,355 $45,152 $88,227 $49,260 $59,541 $23,344 626 $20,151 $23,723 $46,353 $25,880 $31,282 $12,264 627 $13,346 $15,711 $30,700 $17,140 $20,718 $8,123 628 $49,577 $60,010 $117,259 $65,470 $79,133 $33,024 629 $33,826 $40,944 $80,004 $44,669 $53,992 $22,532 630 $21,533 $26,064 $50,931 $28,436 $34,371 $14,344 637 $20,821 $24,486 $46,452 $26,740 $32,321 $11,245 638 $12,335 $14,506 $27,458 $15,842 $19,148 $6,662 639 $9,060 $10,655 $20,215 $11,636 $14,065 $4,893 640 $14,057 $19,560 $30,655 $18,831 $23,417 $8,761 641 $9,077 $12,489 $19,571 $12,023 $14,951 $5,594 642 $17,607 $20,728 $40,503 $22,613 $27,333 $10,716 643 $21,986 $28,832 $56,338 $31,455 $38,020 $14,906 644 $13,623 $17,865 $34,908 $19,490 $23,558 $9,237 645 $9,591 $12,577 $24,575 $13,721 $16,585 $6,502 652 $48,532 $57,132 $111,637 $62,330 $75,339 $29,539 653 $89,291 $105,113 $205,392 $114,677 $138,611 $54,345 654 $47,717 $56,173 $109,762 $61,284 $74,075 $29,042 655 $34,802 $40,969 $80,055 $44,697 $54,025 $21,182 656 $53,177 $62,601 $122,322 $68,296 $82,550 $32,365 657 $30,983 $36,474 $71,269 $39,792 $48,097 $18,858 658 $23,569 $27,747 $54,217 $30,271 $36,589 $14,345 659 $53,275 $62,716 $122,547 $72,541 $82,702 $32,425 660 $29,760 $35,034 $68,456 $40,521 $46,198 $18,113 661 $21,261 $25,029 $48,906 $28,950 $33,005 $12,940 662 $46,283 $54,485 $106,463 $59,441 $71,848 $28,169 663 $23,548 $27,722 $54,168 $30,243 $36,555 $14,333 664 $19,112 $22,500 $43,965 $24,547 $29,669 $11,633 665 $48,660 $57,284 $111,931 $62,495 $75,538 $29,617 666 $26,979 $31,760 $62,059 $34,650 $41,881 $16,421 667 $14,929 $17,574 $34,339 $19,172 $23,174 $9,086 668 $39,306 $45,589 $89,080 $49,736 $60,116 $23,570 669 $19,916 $23,100 $45,137 $25,201 $30,461 $11,944 670 $14,089 $16,340 $31,930 $17,827 $21,548 $8,449

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 36

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 671 $25,684 $30,235 $59,079 $37,447 $39,870 $15,632 672 $13,494 $15,886 $31,041 $19,676 $20,949 $8,213 673 $52,661 $55,633 $121,136 $67,634 $80,930 $32,052 674 $33,982 $35,900 $78,168 $43,644 $52,224 $20,683 675 $21,717 $22,942 $49,954 $27,891 $33,374 $13,217 682 $20,305 $24,411 $38,828 $21,910 $27,126 $11,409 683 $12,402 $15,009 $24,307 $13,585 $16,982 $6,918 684 $8,132 $9,776 $15,550 $8,775 $10,685 $4,569 686 $27,172 $31,987 $62,503 $34,897 $42,180 $16,537 687 $15,489 $18,234 $35,630 $19,893 $24,045 $9,427 688 $10,647 $12,534 $24,491 $13,674 $16,528 $6,480 689 $15,568 $19,250 $35,534 $21,334 $25,385 $10,692 690 $10,896 $13,430 $24,790 $14,884 $17,710 $7,459 691 $25,017 $29,449 $57,544 $32,129 $38,835 $15,226 692 $17,387 $20,468 $39,995 $22,331 $26,992 $10,582 693 $20,695 $24,362 $47,604 $26,579 $32,126 $12,596 694 $10,567 $12,440 $24,307 $13,572 $16,403 $6,431 695 $19,180 $22,580 $44,120 $24,634 $29,775 $11,674 696 $10,198 $12,004 $23,457 $13,097 $15,830 $6,207 697 $14,218 $16,738 $32,705 $18,261 $22,072 $8,654 698 $17,902 $25,155 $39,169 $27,444 $33,171 $13,043 699 $12,047 $16,373 $25,494 $17,863 $21,591 $8,489 700 $8,422 $11,446 $17,823 $12,488 $15,094 $5,935 707 $27,969 $32,927 $64,338 $35,922 $43,420 $17,024 708 $20,432 $24,052 $46,998 $26,241 $31,717 $12,436 709 $33,821 $39,814 $77,797 $43,436 $52,502 $22,889 710 $20,521 $24,158 $47,205 $26,355 $31,857 $13,888 711 $34,736 $40,891 $79,902 $44,612 $53,923 $21,141 712 $16,380 $19,282 $37,678 $21,037 $25,428 $9,969 713 $26,158 $38,233 $60,168 $33,594 $40,605 $15,920 714 $13,994 $20,454 $32,191 $17,973 $21,724 $8,517 715 $30,891 $36,365 $71,057 $39,673 $47,954 $18,801 716 $18,267 $21,504 $42,019 $23,461 $28,357 $11,118 717 $27,295 $32,132 $62,786 $35,055 $42,371 $16,613 718 $15,559 $18,316 $35,789 $19,982 $24,153 $9,470 722 $27,067 $31,864 $62,261 $34,763 $42,018 $16,474 723 $16,384 $19,288 $37,688 $21,043 $25,435 $9,972 724 $9,878 $11,629 $22,723 $12,686 $15,335 $6,013 725 $18,163 $21,383 $41,781 $23,328 $28,197 $11,055

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 37

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 726 $10,829 $12,748 $24,909 $13,908 $16,810 $6,590 727 $18,363 $23,804 $46,512 $24,420 $31,390 $12,307 728 $10,357 $13,425 $26,234 $13,774 $17,704 $6,942 729 $16,113 $18,968 $37,064 $21,219 $25,013 $9,807 730 $10,329 $12,159 $23,758 $13,601 $16,033 $6,286 734 $39,600 $46,617 $91,090 $50,859 $61,473 $24,102 735 $18,895 $22,244 $43,464 $24,268 $29,332 $11,501 736 $68,312 $80,417 $157,136 $87,734 $106,045 $41,577 737 $31,117 $36,631 $71,578 $39,965 $48,305 $18,939 738 $19,636 $23,117 $45,170 $25,220 $30,483 $11,952 739 $51,045 $60,091 $117,417 $65,558 $79,240 $31,068 740 $24,756 $29,143 $56,946 $31,795 $38,430 $15,068 741 $18,250 $21,485 $41,980 $23,438 $28,331 $11,108 742 $23,780 $27,995 $54,702 $30,542 $36,917 $14,474 743 $15,336 $18,053 $35,275 $19,695 $23,806 $9,334 744 $26,936 $31,710 $61,960 $34,594 $41,814 $16,394 745 $14,718 $17,325 $33,854 $18,901 $22,847 $8,957 746 $21,906 $25,788 $50,390 $28,134 $34,006 $13,333 747 $13,699 $16,126 $31,512 $17,594 $21,266 $8,338 748 $16,708 $19,669 $38,433 $21,458 $25,936 $10,169 749 $39,349 $46,322 $90,513 $50,536 $61,084 $23,949 750 $18,339 $21,589 $42,185 $23,553 $28,470 $11,162 754 $30,236 $35,594 $69,551 $38,833 $46,938 $18,403 755 $17,048 $20,070 $39,216 $21,896 $26,465 $10,376 756 $10,248 $12,064 $23,573 $13,162 $15,909 $6,237 757 $23,721 $27,925 $54,564 $30,465 $36,823 $14,437 758 $16,204 $19,076 $37,274 $20,812 $25,155 $9,863 759 $10,678 $12,570 $24,562 $13,714 $16,576 $6,499 760 $12,939 $15,232 $29,765 $16,619 $20,087 $7,875 761 $7,685 $9,047 $17,676 $9,870 $11,929 $4,677 768 $17,231 $20,284 $39,634 $22,129 $26,747 $10,487 769 $29,164 $34,331 $67,084 $37,456 $45,273 $17,750 770 $12,370 $14,561 $28,453 $15,887 $19,202 $7,528 776 $12,505 $14,722 $28,765 $16,060 $19,413 $7,611 779 $9,842 $11,587 $22,642 $12,642 $15,280 $5,991 783 $24,959 $29,381 $57,410 $32,054 $38,745 $15,191 784 $15,759 $18,551 $36,249 $20,239 $24,464 $9,592 785 $11,767 $13,852 $27,067 $15,112 $18,267 $7,162 786 $22,232 $26,171 $51,138 $28,552 $34,512 $13,531

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 38

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 787 $15,458 $18,198 $35,558 $19,853 $23,997 $9,409 788 $12,535 $14,757 $28,834 $16,099 $19,459 $7,630 789 $23,952 $28,197 $55,095 $30,762 $37,181 $14,578 790 $78,984 $92,981 $181,684 $101,440 $122,612 $48,072 791 $53,944 $63,503 $124,087 $69,282 $83,742 $32,832 792 $32,548 $38,316 $74,870 $41,803 $50,527 $19,810 793 $55,413 $65,232 $127,464 $71,167 $86,020 $33,726 794 $19,614 $23,089 $45,117 $25,190 $30,447 $11,937 795 $2,656 $3,126 $6,109 $3,411 $4,123 $1,617 796 $20,680 $24,345 $47,572 $26,560 $32,104 $12,586 797 $11,929 $14,043 $27,441 $15,321 $18,519 $7,260 798 $11,929 $14,043 $27,441 $15,321 $18,519 $7,260 799 $77,232 $90,919 $177,654 $99,190 $119,893 $47,007 800 $40,676 $47,885 $93,567 $52,241 $63,145 $24,757 801 $23,844 $28,070 $54,848 $30,624 $37,015 $14,512 802 $51,766 $60,940 $119,076 $66,484 $80,360 $31,507 803 $28,409 $33,443 $65,348 $36,486 $44,101 $17,291 804 $18,895 $22,244 $43,464 $24,268 $29,332 $11,501 805 $13,607 $16,018 $31,300 $17,475 $21,124 $8,282 806 $9,407 $11,075 $21,640 $12,082 $14,604 $5,726 807 $8,271 $9,736 $19,025 $10,622 $12,839 $5,034 808 $33,086 $39,267 $76,728 $42,839 $44,972 $20,302 809 $17,891 $21,234 $41,490 $23,165 $24,318 $10,978 810 $12,499 $14,833 $28,985 $16,183 $16,989 $7,669 811 $18,858 $22,199 $43,377 $24,363 $29,274 $10,149 812 $11,997 $14,124 $27,597 $15,500 $18,624 $6,456 813 $24,126 $28,402 $55,496 $29,443 $37,452 $14,684 814 $25,951 $30,548 $59,692 $31,133 $40,284 $15,794 815 $15,143 $17,826 $34,833 $18,167 $23,507 $9,216 816 $10,476 $12,332 $24,097 $12,568 $16,262 $6,376 817 $28,873 $37,294 $62,630 $40,685 $49,177 $19,281 818 $15,493 $20,012 $33,607 $21,832 $26,388 $10,346 819 $7,247 $9,361 $15,721 $10,212 $12,344 $4,839 820 $85,081 $100,159 $195,710 $109,271 $132,078 $51,784 821 $35,532 $41,829 $81,735 $45,634 $55,159 $21,627 822 $19,728 $23,223 $45,379 $25,336 $30,625 $12,006 823 $68,745 $80,927 $158,132 $88,290 $106,717 $41,840 824 $35,359 $41,624 $81,334 $45,411 $54,889 $21,520 825 $21,265 $25,033 $48,915 $27,311 $33,011 $12,942

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 39

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 826 $78,417 $92,313 $180,380 $100,711 $121,732 $47,727 827 $35,764 $42,101 $82,266 $45,932 $55,518 $21,767 828 $23,604 $27,787 $54,294 $30,314 $36,642 $14,366 829 $52,736 $62,082 $121,308 $67,730 $81,866 $32,097 830 $19,293 $22,712 $44,379 $24,778 $29,950 $11,743 831 $11,725 $15,145 $25,433 $16,522 $19,970 $7,830 832 $8,198 $10,588 $17,782 $11,551 $13,962 $5,474 833 $4,149 $5,359 $9,000 $5,846 $7,067 $2,770 834 $81,244 $95,641 $186,883 $104,343 $126,120 $49,448 835 $32,417 $38,162 $74,569 $41,634 $50,324 $19,731 836 $18,014 $21,206 $41,437 $23,136 $27,964 $10,964 837 $99,570 $117,216 $229,040 $127,880 $154,570 $60,603 838 $43,019 $50,641 $98,953 $55,249 $66,780 $26,183 839 $19,296 $22,716 $44,386 $24,782 $29,955 $11,745 840 $47,848 $56,327 $110,064 $61,452 $74,278 $29,122 841 $24,997 $29,428 $57,502 $32,105 $38,805 $15,215 842 $16,603 $19,546 $38,191 $21,323 $25,774 $10,105 843 $27,969 $36,382 $64,337 $35,922 $43,419 $17,024 844 $18,839 $24,505 $43,334 $24,196 $29,245 $11,466 845 $13,359 $17,378 $30,731 $17,159 $20,739 $8,131 846 $35,142 $41,370 $80,837 $45,134 $47,960 $21,389 847 $17,476 $20,573 $40,199 $22,445 $23,850 $10,636 848 $12,771 $15,033 $29,375 $16,401 $17,429 $7,773 849 $22,581 $26,582 $51,942 $29,001 $35,053 $13,743 853 $80,070 $120,019 $201,369 $97,298 $128,092 $51,867 854 $36,718 $53,656 $92,343 $44,618 $57,775 $23,784 855 $26,231 $39,317 $65,967 $31,874 $41,962 $16,991 856 $54,539 $82,051 $117,036 $77,419 $98,302 $41,406 857 $24,183 $34,914 $52,608 $31,851 $41,829 $17,618 858 $16,050 $22,805 $34,362 $21,517 $27,322 $11,508 862 $21,850 $24,228 $52,267 $25,124 $39,591 $13,212 863 $11,243 $12,877 $27,781 $13,353 $21,043 $7,022 864 $11,846 $13,945 $24,940 $15,214 $18,389 $7,210 865 $23,310 $27,442 $53,621 $29,938 $36,187 $14,188 866 $11,439 $13,466 $26,313 $14,691 $17,757 $6,962 867 $35,390 $47,923 $97,577 $50,563 $61,116 $23,962 868 $14,313 $19,167 $39,028 $20,223 $24,444 $9,584 869 $9,032 $12,097 $24,630 $12,763 $15,427 $6,048 870 $92,208 $103,815 $207,668 $115,948 $140,147 $54,948

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 40

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 871 $25,054 $29,003 $62,593 $35,272 $40,663 $13,547 872 $14,618 $17,003 $36,464 $20,341 $23,705 $7,909 876 $51,661 $60,816 $118,834 $66,350 $80,197 $31,443 880 $9,643 $11,731 $22,924 $12,799 $15,470 $6,066 881 $8,471 $10,776 $21,056 $11,757 $14,210 $5,571 882 $9,280 $11,508 $21,986 $12,556 $14,756 $5,950 883 $20,123 $23,689 $46,289 $25,845 $31,239 $12,248 884 $14,340 $18,143 $35,451 $19,794 $23,925 $9,380 885 $13,005 $16,305 $28,933 $17,789 $20,261 $8,617 886 $12,769 $15,031 $29,371 $16,398 $19,822 $7,772 887 $14,372 $16,919 $33,061 $18,459 $22,311 $8,747 894 $6,855 $8,070 $15,770 $8,805 $10,642 $4,173 895 $18,722 $22,039 $43,064 $24,044 $29,062 $11,394 896 $16,483 $25,801 $43,023 $28,148 $24,731 $13,339 897 $7,466 $11,687 $19,488 $12,750 $11,203 $6,042 901 $60,674 $72,126 $129,688 $70,324 $94,950 $37,227 902 $27,206 $31,490 $58,501 $30,704 $41,455 $16,253 903 $17,140 $20,376 $36,637 $19,867 $26,823 $10,516 904 $50,472 $59,416 $116,099 $63,295 $78,350 $30,719 905 $20,840 $24,534 $47,938 $26,235 $32,351 $12,684 906 $16,752 $20,335 $41,752 $25,110 $29,257 $10,878 907 $50,593 $58,423 $115,003 $61,886 $82,610 $33,318 908 $25,005 $29,284 $57,732 $29,918 $42,296 $17,222 909 $16,773 $19,369 $38,126 $20,517 $27,388 $11,046 913 $16,816 $20,272 $37,072 $21,801 $28,320 $10,852 914 $10,333 $12,452 $22,773 $13,392 $17,005 $6,667 915 $27,767 $28,273 $53,906 $30,845 $39,556 $14,617 916 $9,274 $9,443 $18,003 $10,301 $13,211 $4,882 917 $37,610 $34,345 $52,256 $40,276 $35,914 $23,479 918 $17,163 $15,673 $25,112 $18,380 $16,965 $10,714 919 $26,805 $26,743 $65,047 $33,306 $38,759 $15,487 920 $15,763 $15,726 $38,251 $19,585 $22,793 $9,108 921 $10,565 $10,541 $25,638 $13,127 $15,277 $6,104 922 $19,253 $25,282 $49,400 $26,596 $36,045 $13,071 923 $9,461 $12,424 $24,276 $13,069 $17,713 $6,423 927 $230,191 $270,984 $529,501 $284,906 $357,340 $140,102 928 $82,915 $97,610 $190,728 $106,490 $128,715 $50,466 929 $35,963 $42,337 $82,727 $46,189 $55,829 $21,889 933 $42,454 $49,978 $97,657 $54,525 $65,905 $25,840

Virginia Workers’ Compensation Commission Workers’ Compensation Medical Fee Schedules Table B

CPT only copyright 2018 American Medical Association. All rights reserved. Page 41

DRG Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 934 $21,421 $25,217 $49,274 $26,319 $29,759 $13,038 935 $20,044 $23,597 $46,107 $23,204 $30,636 $12,199 939 $59,209 $55,206 $107,911 $51,880 $69,331 $28,543 940 $39,135 $36,489 $71,326 $34,291 $45,826 $18,866 941 $28,978 $27,019 $52,813 $25,391 $33,931 $13,969 947 $15,290 $18,152 $34,536 $19,378 $25,023 $9,811 948 $9,456 $11,387 $21,664 $12,156 $15,697 $6,154 951 $14,155 $16,663 $32,560 $18,180 $21,974 $8,615 955 $85,854 $101,068 $197,486 $110,262 $133,276 $52,253 956 $54,284 $61,549 $124,868 $69,717 $84,268 $33,039 957 $115,294 $159,225 $422,681 $14