CPT/HCPC Code | Modifier | Medicare Location | Global Surgery Indicator | Multiple Surgery Indicator | Prevailing Charge Amount | Fee Schedule Amount | Site of Service Amount |
---|---|---|---|---|---|---|---|
59120 | 003 | 90 | 2 | X | 1,716.02 | X | |
59120 | 001 | 90 | 2 | X | 1,889.36 | X | |
59120 | 002 | 90 | 2 | X | 1,855.59 | X | |
59120 | 004 | 90 | 2 | X | 1,894.26 | X | |
59121 | 004 | 90 | 2 | X | 1,388.11 | X | |
59121 | 002 | 90 | 2 | X | 1,507.06 | X | |
59121 | 003 | 90 | 2 | X | 1,404.17 | X | |
59121 | 001 | 90 | 2 | X | 1,532.02 | X | |
59130 | 002 | 90 | 2 | X | 1,609.99 | X | |
59130 | 003 | 90 | 2 | X | 1,519.17 | X | |
59130 | 004 | 90 | 2 | X | 1,501.23 | X | |
59130 | 001 | 90 | 2 | X | 1,631.92 | X | |
59136 | 001 | 90 | 2 | X | 1,872.95 | X | |
59136 | 003 | 90 | 2 | X | 1,710.37 | X | |
59136 | 002 | 90 | 2 | X | 1,841.15 | X | |
59136 | 004 | 90 | 2 | X | 1,691.21 | X | |
59140 | 004 | 90 | 2 | X | 1,033.02 | X | |
59140 | 002 | 90 | 2 | X | 1,101.22 | X | |
59140 | 003 | 90 | 2 | X | 1,045.94 | X | |
59140 | 001 | 90 | 2 | X | 1,114.56 | X | |
59150 | 001 | 90 | 2 | X | 1,364.33 | X | |
59150 | 002 | 90 | 2 | X | 1,341.18 | X | |
59150 | 003 | 90 | 2 | X | 1,246.04 | X | |
59150 | 004 | 90 | 2 | X | 1,232.05 | X | |
59151 | 004 | 90 | 2 | X | 1,692.93 | X | |
59151 | 001 | 90 | 2 | X | 1,841.60 | X | |
59151 | 003 | 90 | 2 | X | 1,714.85 | X | |
59151 | 002 | 90 | 2 | X | 1,817.05 | X | |
59160 | 001 | 10 | 2 | X | 626.56 | X | |
59160 | 004 | 10 | 2 | X | 542.36 | X | |
59160 | 003 | 10 | 2 | X | 542.36 | X | |
59160 | 002 | 10 | 2 | X | 542.36 | X | |
59200 | 0 | 2 | X | * | X | ||
59300 | 002 | 0 | 2 | X | 384.50 | X | |
59300 | 003 | 0 | 2 | X | 367.43 | X | |
59300 | 001 | 0 | 2 | X | 447.99 | X | |
59300 | 004 | 0 | 2 | X | 471.03 | X | |
59320 | 003 | 0 | 2 | X | 488.08 | X | |
59320 | 002 | 0 | 2 | X | 525.14 | X | |
59320 | 004 | 0 | 2 | X | 482.58 | X | |
59320 | 001 | 0 | 2 | X | 534.03 | X | |
59325 | 002 | 0 | 2 | X | 799.35 | X | |
59325 | 003 | 0 | 2 | X | 757.37 | X | |
59325 | 001 | 0 | 2 | X | 809.53 | X | |
59325 | 004 | 0 | 2 | X | 748.45 | X | |
59350 | 002 | 0 | 2 | X | 1,047.45 | X | |
59350 | 003 | 0 | 2 | X | 973.04 | X | |
59350 | 001 | 0 | 2 | X | 1,065.54 | X | |
59350 | 004 | 0 | 2 | X | 962.15 | X | |
59400 | 002 | MMM | 2 | X | 3,408.18 | X | |
59400 | 003 | MMM | 2 | X | 3,146.94 | X | |
59400 | 001 | MMM | 2 | X | 3,570.56 | X | |
59400 | 004 | MMM | 2 | X | 3,035.30 | X | |
59409 | 004 | MMM | 2 | X | 1,933.60 | X | |
59409 | 002 | MMM | 2 | X | 2,809.19 | X | |
59409 | 003 | MMM | 2 | X | 2,610.10 | X | |
59409 | 001 | MMM | 2 | X | 2,574.94 | X | |
59410 | 001 | MMM | 2 | X | 2,657.34 | X | |
59410 | 002 | MMM | 2 | X | 3,054.41 | X | |
59410 | 003 | MMM | 2 | X | 2,837.53 | X | |
59410 | 004 | MMM | 2 | X | 2,007.90 | X | |
59412 | MMM | 0 | X | * | X | ||
59414 | 003 | MMM | 2 | X | 316.44 | X | |
59414 | 002 | MMM | 2 | X | 340.57 | X | |
59414 | 004 | MMM | 2 | X | 312.95 | X | |
59414 | 001 | MMM | 2 | X | 346.55 | X | |
59425 | 002 | MMM | 0 | X | 852.35 | 697.04 | |
59425 | 003 | MMM | 0 | X | 792.13 | 645.41 | |
59425 | 004 | MMM | 0 | X | 783.23 | 639.07 | |
59425 | 001 | MMM | 0 | X | 867.01 | 709.66 | |
59426 | 001 | MMM | 0 | X | 1,486.25 | 1,216.40 | |
59426 | 003 | MMM | 0 | X | 1,357.71 | 1,106.26 | |
59426 | 002 | MMM | 0 | X | 1,461.08 | 1,194.74 | |
59426 | 004 | MMM | 0 | X | 1,342.48 | 1,095.26 | |
59430 | 004 | MMM | 2 | X | 256.13 | X | |
59430 | 001 | MMM | 2 | X | 272.29 | X | |
59430 | 002 | MMM | 2 | X | 269.58 | X | |
59430 | 003 | MMM | 2 | X | 258.77 | X | |
59510 | 001 | MMM | 2 | X | 5,092.84 | X | |
59510 | 004 | MMM | 2 | X | 4,599.15 | X | |
59510 | 002 | MMM | 2 | X | 5,006.46 | X | |
59510 | 003 | MMM | 2 | X | 4,651.26 | X | |
59514 | 004 | MMM | 2 | X | 2,990.81 | X | |
59514 | 002 | MMM | 2 | X | 3,255.84 | X | |
59514 | 003 | MMM | 2 | X | 3,024.73 | X | |
59514 | 001 | MMM | 2 | X | 2,935.26 | X | |
59515 | 004 | MMM | 2 | X | 3,214.68 | X | |
59515 | 001 | MMM | 2 | X | 3,016.93 | X | |
59515 | 003 | MMM | 2 | X | 3,251.12 | X | |
59515 | 002 | MMM | 2 | X | 3,499.00 | X | |
59525 | 003 | ZZZ | 0 | X | 1,388.72 | X | |
59525 | 002 | ZZZ | 0 | X | 1,476.90 | X | |
59525 | 004 | ZZZ | 0 | X | 1,373.77 | X | |
59525 | 001 | ZZZ | 0 | X | 1,498.39 | X | |
59610 | 003 | MMM | 2 | X | 4,458.18 | X | |
59610 | 002 | MMM | 2 | X | 4,746.32 | X | |
59610 | 001 | MMM | 2 | X | 4,978.63 | X | |
59610 | 004 | MMM | 2 | X | 4,393.90 | X | |
59612 | 004 | MMM | 2 | X | 2,844.59 | X | |
59612 | 002 | MMM | 2 | X | 3,069.75 | X | |
59612 | 003 | MMM | 2 | X | 2,885.85 | X | |
59612 | 001 | MMM | 2 | X | 3,218.28 | X | |
59614 | 001 | MMM | 2 | X | 3,478.34 | X | |
59614 | 002 | MMM | 2 | X | 3,317.37 | X | |
59614 | 003 | MMM | 2 | X | 3,117.86 | X | |
59614 | 004 | MMM | 2 | X | 3,073.14 | X | |
59618 | 001 | MMM | 2 | X | 5,591.12 | X | |
59618 | 004 | MMM | 2 | X | 4,932.63 | X | |
59618 | 002 | MMM | 2 | X | 5,329.49 | X | |
59618 | 003 | MMM | 2 | X | 5,004.82 | X | |
59620 | 003 | MMM | 2 | X | 3,316.57 | X | |
59620 | 002 | MMM | 2 | X | 3,529.13 | X | |
59620 | 001 | MMM | 2 | X | 3,700.64 | X | |
59620 | 004 | MMM | 2 | X | 3,268.98 | X | |
59622 | 004 | MMM | 2 | X | 3,501.26 | X | |
59622 | 003 | MMM | 2 | X | 3,552.28 | X | |
59622 | 002 | MMM | 2 | X | 3,780.29 | X | |
59622 | 001 | MMM | 2 | X | 3,964.07 | X | |
59812 | 003 | 90 | 2 | X | 778.55 | X | |
59812 | 002 | 90 | 2 | X | 846.12 | X | |
59812 | 001 | 90 | 2 | X | 862.58 | X | |
59812 | 004 | 90 | 2 | X | 769.33 | X | |
59820 | 001 | 90 | 2 | X | 1,023.70 | X | |
59820 | 003 | 90 | 2 | X | 948.68 | X | |
59820 | 002 | 90 | 2 | X | 983.56 | X | |
59820 | 004 | 90 | 2 | X | 849.80 | X | |
59821 | 001 | 90 | 2 | X | 998.34 | X | |
59821 | 004 | 90 | 2 | X | 787.04 | X | |
59821 | 002 | 90 | 2 | X | 853.92 | X | |
59821 | 003 | 90 | 2 | X | 795.93 | X | |
59830 | 002 | 90 | 2 | X | 1,218.89 | X | |
59830 | 003 | 90 | 2 | X | 1,150.47 | X | |
59830 | 001 | 90 | 2 | X | 1,235.42 | X | |
59830 | 004 | 90 | 2 | X | 1,136.84 | X | |
59840 | 001 | 10 | 2 | X | 786.54 | X | |
59840 | 003 | 10 | 2 | X | 710.88 | X | |
59840 | 002 | 10 | 2 | X | 915.52 | X | |
59840 | 004 | 10 | 2 | X | 702.44 | X | |
59841 | 001 | 10 | 2 | X | 1,087.41 | X | |
59841 | 004 | 10 | 2 | X | 797.77 | X | |
59841 | 003 | 10 | 2 | X | 1,051.66 | X | |
59841 | 002 | 10 | 2 | X | 875.69 | X | |
59850 | 004 | 90 | 2 | X | 1,064.99 | X | |
59850 | 003 | 90 | 2 | X | 1,077.19 | X | |
59850 | 002 | 90 | 2 | X | 1,157.10 | X | |
59850 | 001 | 90 | 2 | X | 1,150.28 | X | |
59851 | 004 | 90 | 2 | X | 1,113.53 | X | |
59851 | 001 | 90 | 2 | X | 1,230.11 | X | |
59851 | 002 | 90 | 2 | X | 1,209.96 | X | |
59851 | 003 | 90 | 2 | X | 1,126.36 | X | |
59852 | 002 | 90 | 2 | X | 1,629.06 | X | |
59852 | 003 | 90 | 2 | X | 1,513.81 | X | |
59852 | 001 | 90 | 2 | X | 1,657.07 | X | |
59852 | 004 | 90 | 2 | X | 1,496.86 | X | |
59855 | 002 | 90 | 2 | X | 1,056.19 | X | |
59855 | 003 | 90 | 2 | X | 986.00 | X | |
59855 | 001 | 90 | 2 | X | 1,090.71 | X | |
59855 | 004 | 90 | 2 | X | 973.00 | X | |
59856 | 001 | 90 | 2 | X | 1,646.42 | X | |
59856 | 004 | 90 | 2 | X | 1,468.11 | X | |
59856 | 003 | 90 | 2 | X | 1,487.67 | X | |
59856 | 002 | 90 | 2 | X | 1,593.98 | X | |
59857 | 004 | 90 | 2 | X | 1,785.62 | X | |
59857 | 001 | 90 | 2 | X | 2,002.00 | X | |
59857 | 003 | 90 | 2 | X | 1,809.39 | X | |
59857 | 002 | 90 | 2 | X | 1,938.45 | X | |
59866 | 003 | 0 | 2 | X | 752.65 | X | |
59866 | 002 | 0 | 2 | X | 773.40 | X | |
59866 | 004 | 0 | 2 | X | 752.65 | X | |
59866 | 001 | 0 | 2 | X | 863.14 | X | |
59870 | 002 | 90 | 2 | X | 862.49 | X | |
59870 | 003 | 90 | 2 | X | 801.46 | X | |
59870 | 004 | 90 | 2 | X | 792.42 | X | |
59870 | 001 | 90 | 2 | X | 877.34 | X | |
59871 | 002 | 0 | 2 | X | 378.81 | X | |
59871 | 003 | 0 | 2 | X | 378.81 | X | |
59871 | 004 | 0 | 2 | X | 378.81 | X | |
59871 | 001 | 0 | 2 | X | 436.78 | X | |
59897 | YYY | 2 | X | # | X | ||
59898 | YYY | 2 | X | # | X | ||
59899 | YYY | 2 | X | # | X | ||
60000 | 001 | 10 | 2 | X | 270.56 | X | |
60000 | 003 | 10 | 2 | X | 236.37 | X | |
60000 | 002 | 10 | 2 | X | 258.93 | X | |
60000 | 004 | 10 | 2 | X | 233.89 | X | |
60100 | 001 | 0 | 2 | X | 255.31 | 194.82 | |
60100 | 004 | 0 | 2 | X | 233.15 | 177.00 | |
60100 | 003 | 0 | 2 | X | 237.53 | 180.55 | |
60100 | 002 | 0 | 2 | X | 248.27 | 189.34 | |
60200 | 001 | 90 | 2 | X | 1,798.58 | X | |
60200 | 003 | 90 | 2 | X | 1,661.72 | X | |
60200 | 002 | 90 | 2 | X | 1,771.83 | X | |
60200 | 004 | 90 | 2 | X | 1,642.77 | X | |
60210 | 004 | 90 | 2 | X | 2,270.47 | X | |
60210 | 001 | 90 | 2 | X | 2,579.15 | X | |
60210 | 002 | 90 | 2 | X | 2,463.53 | X | |
60210 | 003 | 90 | 2 | X | 2,301.41 | X | |
60212 | 002 | 90 | 2 | X | 2,553.96 | X | |
60212 | 003 | 90 | 2 | X | 2,382.98 | X | |
60212 | 001 | 90 | 2 | X | 2,697.74 | X | |
60212 | 004 | 90 | 2 | X | 2,355.74 | X | |
60220 | 004 | 90 | 2 | X | 2,063.68 | X | |
60220 | 001 | 90 | 2 | X | 2,281.92 | X | |
60220 | 003 | 90 | 2 | X | 2,088.00 | X | |
60220 | 002 | 90 | 2 | X | 2,244.02 | X | |
60225 | 004 | 90 | 2 | X | 2,480.82 | X | |
60225 | 001 | 90 | 2 | X | 2,789.85 | X | |
60225 | 003 | 90 | 2 | X | 2,510.24 | X | |
60225 | 002 | 90 | 2 | X | 2,697.66 | X | |
60240 | 004 | 90 | 2 | X | 2,978.83 | X | |
60240 | 002 | 90 | 2 | X | 3,105.95 | X | |
60240 | 003 | 90 | 2 | X | 2,948.55 | X | |
60240 | 001 | 90 | 2 | X | 3,197.54 | X | |
60252 | 002 | 90 | 2 | X | 3,544.20 | X | |
60252 | 003 | 90 | 2 | X | 3,452.00 | X | |
60252 | 001 | 90 | 2 | X | 3,604.09 | X | |
60252 | 004 | 90 | 2 | X | 3,432.02 | X | |
60254 | 001 | 90 | 2 | X | 4,879.23 | X | |
60254 | 002 | 90 | 2 | X | 4,655.38 | X | |
60254 | 003 | 90 | 2 | X | 4,569.28 | X | |
60254 | 004 | 90 | 2 | X | 4,646.93 | X | |
60260 | 001 | 90 | 2 | X | 2,127.01 | X | |
60260 | 004 | 90 | 2 | X | 1,754.92 | X | |
60260 | 003 | 90 | 2 | X | 2,088.88 | X | |
60260 | 002 | 90 | 2 | X | 1,931.01 | X | |
60270 | 004 | 90 | 2 | X | 3,399.28 | X | |
60270 | 002 | 90 | 2 | X | 3,690.80 | X | |
60270 | 003 | 90 | 2 | X | 3,439.40 | X | |
60270 | 001 | 90 | 2 | X | 3,751.81 | X | |
60271 | 002 | 90 | 2 | X | 3,222.91 | X | |
60271 | 003 | 90 | 2 | X | 2,948.95 | X | |
60271 | 004 | 90 | 2 | X | 2,929.04 | X | |
60271 | 001 | 90 | 2 | X | 3,254.80 | X | |
60280 | 001 | 90 | 2 | X | 1,766.77 | X | |
60280 | 004 | 90 | 2 | X | 1,630.27 | X | |
60280 | 002 | 90 | 2 | X | 1,747.94 | X | |
60280 | 003 | 90 | 2 | X | 1,705.69 | X | |
60281 | 004 | 90 | 2 | X | 1,447.80 | X | |
60281 | 003 | 90 | 2 | X | 1,464.32 | X | |
60281 | 002 | 90 | 2 | X | 1,561.98 | X | |
60281 | 001 | 90 | 2 | X | 1,585.74 | X | |
60300 | 002 | 0 | 2 | X | 172.53 | 85.33 | |
60300 | 003 | 0 | 2 | X | 172.53 | 85.33 | |
60300 | 004 | 0 | 2 | X | 172.53 | 85.33 | |
60300 | 001 | 0 | 2 | X | 198.40 | 93.29 | |
60500 | 004 | 90 | 2 | X | 3,316.30 | X | |
60500 | 001 | 90 | 2 | X | 3,515.50 | X | |
60500 | 003 | 90 | 2 | X | 3,404.72 | X | |
60500 | 002 | 90 | 2 | X | 3,487.80 | X | |
60502 | 001 | 90 | 2 | X | 3,741.86 | X | |
60502 | 004 | 90 | 2 | X | 3,413.95 | X | |
60502 | 003 | 90 | 2 | X | 3,578.98 | X | |
60502 | 002 | 90 | 2 | X | 3,685.17 | X | |
60505 | 001 | 90 | 2 | X | 2,789.45 | X | |
60505 | 002 | 90 | 2 | X | 2,761.98 | X | |
60505 | 003 | 90 | 2 | X | 2,592.94 | X | |
60505 | 004 | 90 | 2 | X | 2,602.25 | X | |
60512 | 001 | ZZZ | 0 | X | 889.34 | X | |
60512 | 004 | ZZZ | 0 | X | 802.02 | X | |
60512 | 003 | ZZZ | 0 | X | 812.33 | X | |
60512 | 002 | ZZZ | 0 | X | 863.77 | X | |
60520 | 003 | 90 | 2 | X | 3,457.99 | X | |
60520 | 002 | 90 | 2 | X | 3,704.65 | X | |
60520 | 001 | 90 | 2 | X | 3,764.49 | X | |
60520 | 004 | 90 | 2 | X | 3,418.03 | X | |
60521 | 002 | 90 | 2 | X | 3,704.65 | X | |
60521 | 003 | 90 | 2 | X | 3,457.99 | X | |
60521 | 004 | 90 | 2 | X | 3,418.03 | X | |
60521 | 001 | 90 | 2 | X | 3,764.49 | X | |
60522 | 002 | 90 | 2 | X | 3,704.65 | X | |
60522 | 003 | 90 | 2 | X | 3,457.99 | X | |
60522 | 004 | 90 | 2 | X | 3,418.03 | X | |
60522 | 001 | 90 | 2 | X | 3,764.49 | X | |
60540 | 004 | 90 | 2 | X | 3,080.68 | X | |
60540 | 002 | 90 | 2 | X | 3,331.91 | X | |
60540 | 003 | 90 | 2 | X | 3,116.72 | X | |
60540 | 001 | 90 | 2 | X | 3,384.06 | X | |
60545 | 002 | 90 | 2 | X | 4,233.26 | X | |
60545 | 004 | 90 | 2 | X | 4,110.95 | X | |
60545 | 001 | 90 | 2 | X | 4,258.53 | X | |
60545 | 003 | 90 | 2 | X | 4,128.74 | X | |
60600 | 004 | 90 | 2 | X | 3,044.85 | X | |
60600 | 001 | 90 | 2 | X | 3,332.51 | X | |
60600 | 003 | 90 | 2 | X | 3,080.32 | X | |
60600 | 002 | 90 | 2 | X | 3,287.04 | X | |
60605 | 004 | 90 | 2 | X | 3,221.65 | X | |
60605 | 003 | 90 | 2 | X | 3,656.21 | X | |
60605 | 002 | 90 | 2 | X | 3,847.69 | X | |
60605 | 001 | 90 | 2 | X | 3,906.28 | X | |
60650 | 90 | 2 | X | * | X | ||
60659 | YYY | 2 | X | # | X | ||
60699 | YYY | 2 | X | # | X | ||
61000 | 004 | 0 | 2 | X | 291.28 | X | |
61000 | 001 | 0 | 2 | X | 318.06 | X | |
61000 | 003 | 0 | 2 | X | 294.72 | X | |
61000 | 002 | 0 | 2 | X | 313.52 | X | |
61001 | 003 | 0 | 2 | X | 266.12 | X | |
61001 | 002 | 0 | 2 | X | 283.51 | X | |
61001 | 004 | 0 | 2 | X | 263.18 | X | |
61001 | 001 | 0 | 2 | X | 287.77 | X | |
61020 | 001 | 0 | 2 | X | 550.63 | X | |
61020 | 004 | 0 | 2 | X | 306.03 | X | |
61020 | 002 | 0 | 2 | X | 548.48 | X | |
61020 | 003 | 0 | 2 | X | 539.58 | X | |
61026 | 004 | 0 | 2 | X | 530.44 | X | |
61026 | 003 | 0 | 2 | X | 383.08 | X | |
61026 | 002 | 0 | 2 | X | 509.57 | X | |
61026 | 001 | 0 | 2 | X | 532.23 | X | |
61050 | 003 | 0 | 2 | X | 463.44 | X | |
61050 | 002 | 0 | 2 | X | 430.80 | X | |
61050 | 004 | 0 | 2 | X | 278.69 | X | |
61050 | 001 | 0 | 2 | X | 434.13 | X | |
61055 | 001 | 0 | 0 | X | 436.43 | X | |
61055 | 004 | 0 | 0 | X | 507.85 | X | |
61055 | 002 | 0 | 0 | X | 517.36 | X | |
61055 | 003 | 0 | 0 | X | 497.45 | X | |
61070 | 001 | 0 | 2 | X | 209.13 | X | |
61070 | 002 | 0 | 2 | X | 208.48 | X | |
61070 | 003 | 0 | 2 | X | 205.82 | X | |
61070 | 004 | 0 | 2 | X | 136.95 | X | |
61105 | 002 | 90 | 2 | X | 2,068.83 | X | |
61105 | 003 | 90 | 2 | X | 1,703.28 | X | |
61105 | 001 | 90 | 2 | X | 2,081.42 | X | |
61105 | 004 | 90 | 2 | X | 1,683.46 | X | |
61107 | 001 | 0 | 0 | X | 1,886.39 | X | |
61107 | 004 | 0 | 0 | X | 1,227.45 | X | |
61107 | 002 | 0 | 0 | X | 1,826.59 | X | |
61107 | 003 | 0 | 0 | X | 1,782.73 | X | |
61108 | 002 | 90 | 2 | X | 4,060.08 | X | |
61108 | 003 | 90 | 2 | X | 3,918.87 | X | |
61108 | 004 | 90 | 2 | X | 3,959.17 | X | |
61108 | 001 | 90 | 2 | X | 3,572.42 | X | |
61120 | 004 | 90 | 2 | X | 1,690.03 | X | |
61120 | 002 | 90 | 2 | X | 1,822.15 | X | |
61120 | 003 | 90 | 2 | X | 1,709.28 | X | |
61120 | 001 | 90 | 2 | X | 1,906.14 | X | |
61140 | 002 | 90 | 2 | X | 3,050.39 | X | |
61140 | 003 | 90 | 2 | X | 2,920.22 | X | |
61140 | 004 | 90 | 2 | X | 2,898.00 | X | |
61140 | 001 | 90 | 2 | X | 3,006.50 | X | |
61150 | 004 | 90 | 2 | X | 3,468.87 | X | |
61150 | 002 | 90 | 2 | X | 3,769.70 | X | |
61150 | 003 | 90 | 2 | X | 3,569.10 | X | |
61150 | 001 | 90 | 2 | X | 3,832.63 | X | |
61151 | 003 | 90 | 2 | X | 1,225.96 | X | |
61151 | 002 | 90 | 2 | X | 1,249.19 | X | |
61151 | 004 | 90 | 2 | X | 1,451.25 | X | |
61151 | 001 | 90 | 2 | X | 1,279.05 | X | |
61154 | 004 | 90 | 2 | X | 4,377.10 | X | |
61154 | 002 | 90 | 2 | X | 4,459.81 | X | |
61154 | 003 | 90 | 2 | X | 4,356.76 | X | |
61154 | 001 | 90 | 2 | X | 4,035.05 | X | |
61156 | 001 | 90 | 2 | X | 3,946.52 | X | |
61156 | 004 | 90 | 2 | X | 3,548.01 | X | |
61156 | 003 | 90 | 2 | X | 3,590.77 | X | |
61156 | 002 | 90 | 2 | X | 3,877.15 | X | |
61210 | 001 | 0 | 2 | X | 2,497.11 | X | |
61210 | 004 | 0 | 2 | X | 1,406.38 | X | |
61210 | 003 | 0 | 2 | X | 2,874.99 | X | |
61210 | 002 | 0 | 2 | X | 2,920.21 | X | |
61215 | 90 | 2 | X | * | X | ||
61250 | 001 | 90 | 2 | X | 2,326.16 | X | |
61250 | 002 | 90 | 2 | X | 2,599.86 | X | |
61250 | 003 | 90 | 2 | X | 2,537.87 | X | |
61250 | 004 | 90 | 2 | X | 2,118.00 | X | |
61253 | 004 | 90 | 2 | X | 2,510.87 | X | |
61253 | 001 | 90 | 2 | X | 2,757.02 | X | |
61253 | 003 | 90 | 2 | X | 2,540.05 | X | |
61253 | 002 | 90 | 2 | X | 2,714.64 | X | |
61304 | 001 | 90 | 2 | X | 5,903.18 | X | |
61304 | 004 | 90 | 2 | X | 5,538.44 | X | |
61304 | 002 | 90 | 2 | X | 5,795.58 | X | |
61304 | 003 | 90 | 2 | X | 5,525.75 | X | |
61305 | 004 | 90 | 2 | X | 6,059.55 | X | |
61305 | 001 | 90 | 2 | X | 6,739.12 | X | |
61305 | 003 | 90 | 2 | X | 6,133.84 | X | |
61305 | 002 | 90 | 2 | X | 6,683.23 | X | |
61312 | 004 | 90 | 2 | X | 5,052.81 | X | |
61312 | 003 | 90 | 2 | X | 5,088.45 | X | |
61312 | 002 | 90 | 2 | X | 5,531.73 | X | |
61312 | 001 | 90 | 2 | X | 5,632.75 | X | |
61313 | 002 | 90 | 2 | X | 5,509.90 | X | |
61313 | 003 | 90 | 2 | X | 5,096.87 | X | |
61313 | 004 | 90 | 2 | X | 5,035.44 | X | |
61313 | 001 | 90 | 2 | X | 5,609.78 | X | |
61314 | 004 | 90 | 2 | X | 5,460.69 | X | |
61314 | 001 | 90 | 2 | X | 6,076.98 | X | |
61314 | 003 | 90 | 2 | X | 5,263.77 | X | |
61314 | 002 | 90 | 2 | X | 5,969.78 | X | |
61315 | 001 | 90 | 2 | X | 6,252.08 | X | |
61315 | 004 | 90 | 2 | X | 5,646.39 | X | |
61315 | 002 | 90 | 2 | X | 6,147.11 | X | |
61315 | 003 | 90 | 2 | X | 5,627.38 | X | |
61316 | 001 | ZZZ | 0 | X | 216.46 | X | |
61316 | 004 | ZZZ | 0 | X | 182.58 | X | |
61316 | 002 | ZZZ | 0 | X | 182.58 | X | |
61316 | 003 | ZZZ | 0 | X | 182.58 | X | |
61320 | 004 | 90 | 2 | X | 4,750.90 | X | |
61320 | 002 | 90 | 2 | X | 5,130.86 | X | |
61320 | 003 | 90 | 2 | X | 4,806.30 | X | |
61320 | 001 | 90 | 2 | X | 5,278.82 | X | |
61321 | 003 | 90 | 2 | X | 5,227.79 | X | |
61321 | 002 | 90 | 2 | X | 5,589.99 | X | |
61321 | 001 | 90 | 2 | X | 5,677.81 | X | |
61321 | 004 | 90 | 2 | X | 5,167.73 | X | |
61322 | 002 | 90 | 2 | X | 3,748.65 | X | |
61322 | 003 | 90 | 2 | X | 3,748.65 | X | |
61322 | 004 | 90 | 2 | X | 3,748.65 | X | |
61322 | 001 | 90 | 2 | X | 4,275.38 | X | |
61323 | 002 | 90 | 2 | X | 3,884.83 | X | |
61323 | 003 | 90 | 2 | X | 3,884.83 | X | |
61323 | 004 | 90 | 2 | X | 3,884.83 | X | |
61323 | 001 | 90 | 2 | X | 4,418.45 | X | |
61330 | 001 | 90 | 2 | X | 3,333.01 | X | |
61330 | 002 | 90 | 2 | X | 3,290.02 | X | |
61330 | 003 | 90 | 2 | X | 3,111.65 | X | |
61330 | 004 | 90 | 2 | X | 3,074.08 | X | |
61333 | 003 | 90 | 2 | X | 5,272.28 | X | |
61333 | 002 | 90 | 2 | X | 5,624.96 | X | |
61333 | 004 | 90 | 2 | X | 5,210.99 | X | |
61333 | 001 | 90 | 2 | X | 5,710.43 | X | |
61340 | 004 | 90 | 2 | X | 2,968.79 | X | |
61340 | 001 | 90 | 2 | X | 3,351.23 | X | |
61340 | 003 | 90 | 2 | X | 3,005.58 | X | |
61340 | 002 | 90 | 2 | X | 3,236.63 | X | |
61343 | 003 | 90 | 2 | X | 6,582.31 | X | |
61343 | 002 | 90 | 2 | X | 7,094.60 | X | |
61343 | 004 | 90 | 2 | X | 6,503.39 | X | |
61343 | 001 | 90 | 2 | X | 6,781.34 | X | |
61345 | 001 | 90 | 2 | X | 5,448.70 | X | |
61345 | 004 | 90 | 2 | X | 4,955.56 | X | |
61345 | 003 | 90 | 2 | X | 5,013.24 | X | |
61345 | 002 | 90 | 2 | X | 5,363.70 | X | |
61450 | 002 | 90 | 2 | X | 5,380.15 | X | |
61450 | 003 | 90 | 2 | X | 5,025.78 | X | |
61450 | 001 | 90 | 2 | X | 5,465.99 | X | |
61450 | 004 | 90 | 2 | X | 4,966.94 | X | |
61458 | 001 | 90 | 2 | X | 7,193.74 | X | |
61458 | 003 | 90 | 2 | X | 6,830.02 | X | |
61458 | 002 | 90 | 2 | X | 7,053.76 | X | |
61458 | 004 | 90 | 2 | X | 5,982.06 | X | |
61460 | 004 | 90 | 2 | X | 5,746.59 | X | |
61460 | 001 | 90 | 2 | X | 7,065.02 | X | |
61460 | 003 | 90 | 2 | X | 5,815.82 | X | |
61460 | 002 | 90 | 2 | X | 6,930.52 | X | |
61500 | 003 | 90 | 2 | X | 4,361.41 | X | |
61500 | 002 | 90 | 2 | X | 4,563.64 | X | |
61500 | 001 | 90 | 2 | X | 4,646.04 | X | |
61500 | 004 | 90 | 2 | X | 4,172.25 | X | |
61501 | 004 | 90 | 2 | X | 3,553.53 | X | |
61501 | 003 | 90 | 2 | X | 3,597.31 | X | |
61501 | 002 | 90 | 2 | X | 3,902.32 | X | |
61501 | 001 | 90 | 2 | X | 3,976.19 | X | |
61510 | 001 | 90 | 2 | X | 6,335.14 | X | |
61510 | 004 | 90 | 2 | X | 5,922.60 | X | |
61510 | 003 | 90 | 2 | X | 5,951.70 | X | |
61510 | 002 | 90 | 2 | X | 6,222.94 | X | |
61512 | 001 | 90 | 2 | X | 6,711.22 | X | |
61512 | 004 | 90 | 2 | X | 6,020.73 | X | |
61512 | 003 | 90 | 2 | X | 6,094.32 | X | |
61512 | 002 | 90 | 2 | X | 6,591.01 | X | |
61514 | 002 | 90 | 2 | X | 6,044.69 | X | |
61514 | 003 | 90 | 2 | X | 5,597.79 | X | |
61514 | 004 | 90 | 2 | X | 5,530.91 | X | |
61514 | 001 | 90 | 2 | X | 6,447.90 | X | |
61516 | 001 | 90 | 2 | X | 6,158.28 | X | |
61516 | 003 | 90 | 2 | X | 5,608.45 | X | |
61516 | 002 | 90 | 2 | X | 6,051.14 | X | |
61516 | 004 | 90 | 2 | X | 5,540.52 | X | |
61517 | 004 | ZZZ | 0 | X | 158.88 | X | |
61517 | 002 | ZZZ | 0 | X | 158.88 | X | |
61517 | 001 | ZZZ | 0 | X | 174.36 | X | |
61517 | 003 | ZZZ | 0 | X | 158.88 | X | |
61518 | 002 | 90 | 2 | X | 7,597.54 | X | |
61518 | 003 | 90 | 2 | X | 7,065.33 | X | |
61518 | 004 | 90 | 2 | X | 6,982.27 | X | |
61518 | 001 | 90 | 2 | X | 7,509.09 | X | |
61519 | 002 | 90 | 2 | X | 7,946.41 | X | |
61519 | 003 | 90 | 2 | X | 7,387.83 | X | |
61519 | 001 | 90 | 2 | X | 7,749.35 | X | |
61519 | 004 | 90 | 2 | X | 7,301.10 | X | |
61520 | 001 | 90 | 2 | X | 9,308.20 | X | |
61520 | 004 | 90 | 2 | X | 8,052.65 | X | |
61520 | 003 | 90 | 2 | X | 8,148.37 | X | |
61520 | 002 | 90 | 2 | X | 9,247.94 | X |
Part B Fee Schedules