CPT/HCPC Code | Modifier | Medicare Location | Global Surgery Indicator | Multiple Surgery Indicator | Prevailing Charge Amount | Fee Schedule Amount | Site of Service Amount |
---|---|---|---|---|---|---|---|

L1680 | X | 2,409.11 | X | ||||

L1681 | X | 2,854.83 | X | ||||

L1685 | X | 2,458.53 | X | ||||

L1686 | X | 2,270.23 | X | ||||

L1690 | X | 3,619.50 | X | ||||

L1700 | X | 3,019.41 | X | ||||

L1710 | X | 3,534.63 | X | ||||

L1720 | X | 2,605.44 | X | ||||

L1730 | X | 2,237.78 | X | ||||

L1755 | X | 3,551.27 | X | ||||

L1810 | X | 194.74 | X | ||||

L1812 | X | 139.45 | X | ||||

L1820 | X | 301.74 | X | ||||

L1830 | X | 183.54 | X | ||||

L1831 | X | 502.04 | X | ||||

L1832 | X | 1,398.37 | X | ||||

L1833 | X | 1,001.59 | X | ||||

L1834 | X | 1,534.88 | X | ||||

L1836 | X | 232.61 | X | ||||

L1840 | X | 2,044.42 | X | ||||

L1843 | XXX | X | 1,048.76 | X | |||

L1844 | X | 3,209.86 | X | ||||

L1845 | X | 1,921.67 | X | ||||

L1846 | X | 2,180.52 | X | ||||

L1847 | X | 1,076.49 | X | ||||

L1848 | X | 850.27 | X | ||||

L1850 | X | 600.94 | X | ||||

L1851 | X | 1,265.02 | X | ||||

L1852 | X | 1,312.77 | X | ||||

L1860 | X | 2,121.66 | X | ||||

L1900 | X | 533.41 | X | ||||

L1902 | X | 184.33 | X | ||||

L1904 | X | 1,108.47 | X | ||||

L1906 | X | 237.74 | X | ||||

L1907 | X | 959.81 | X | ||||

L1910 | X | 540.12 | X | ||||

L1920 | X | 691.25 | X | ||||

L1930 | X | 467.68 | X | ||||

L1932 | X | 1,466.41 | X | ||||

L1940 | X | 977.82 | X | ||||

L1945 | X | 2,337.85 | X | ||||

L1950 | X | 1,550.07 | X | ||||

L1951 | X | 1,432.55 | X | ||||

L1960 | X | 1,169.11 | X | ||||

L1970 | X | 1,406.95 | X | ||||

L1971 | X | 799.52 | X | ||||

L1980 | X | 725.66 | X | ||||

L1990 | X | 881.39 | X | ||||

L2000 | X | 2,088.00 | X | ||||

L2005 | X | 5,915.33 | X | ||||

L2006 | X | * | X | ||||

L2010 | X | 1,947.78 | X | ||||

L2020 | X | 2,452.60 | X | ||||

L2030 | X | 2,226.38 | X | ||||

L2034 | X | * | X | ||||

L2035 | XXX | X | 339.82 | X | |||

L2036 | X | 3,801.53 | X | ||||

L2037 | X | 3,546.60 | X | ||||

L2038 | X | 3,602.78 | X | ||||

L2040 | X | 436.95 | X | ||||

L2050 | X | 941.87 | X | ||||

L2060 | X | 1,147.92 | X | ||||

L2070 | X | 294.75 | X | ||||

L2080 | X | 711.20 | X | ||||

L2090 | X | 866.96 | X | ||||

L2106 | X | 1,344.35 | X | ||||

L2108 | X | 2,340.71 | X | ||||

L2112 | X | 1,076.63 | X | ||||

L2114 | X | 1,350.41 | X | ||||

L2116 | X | 1,553.79 | X | ||||

L2126 | X | 2,599.11 | X | ||||

L2128 | X | 3,680.52 | X | ||||

L2132 | X | 1,995.44 | X | ||||

L2134 | X | 2,129.33 | X | ||||

L2136 | X | 2,541.42 | X | ||||

L2180 | X | 237.20 | X | ||||

L2182 | X | 196.50 | X | ||||

L2184 | X | 268.61 | X | ||||

L2186 | X | 372.63 | X | ||||

L2188 | X | 713.64 | X | ||||

L2190 | X | 184.43 | X | ||||

L2192 | X | 809.66 | X | ||||

L2200 | X | 94.03 | X | ||||

L2210 | X | 136.05 | X | ||||

L2220 | X | 161.92 | X | ||||

L2230 | X | 151.69 | X | ||||

L2232 | X | * | X | ||||

L2240 | X | 187.77 | X | ||||

L2250 | X | 761.33 | X | ||||

L2260 | X | 396.31 | X | ||||

L2265 | X | 232.78 | X | ||||

L2270 | X | 109.22 | X | ||||

L2275 | XXX | X | * | X | |||

L2280 | X | 900.17 | X | ||||

L2300 | X | 564.42 | X | ||||

L2310 | X | 282.60 | X | ||||

L2320 | X | 406.79 | X | ||||

L2330 | X | 851.64 | X | ||||

L2335 | X | 525.79 | X | ||||

L2340 | X | 1,138.29 | X | ||||

L2350 | X | 1,965.85 | X | ||||

L2360 | X | 102.29 | X | ||||

L2370 | X | 662.90 | X | ||||

L2375 | X | 280.05 | X | ||||

L2380 | X | 243.39 | X | ||||

L2385 | X | 264.88 | X | ||||

L2387 | X | * | X | ||||

L2390 | X | 221.63 | X | ||||

L2395 | X | 309.34 | X | ||||

L2397 | X | * | X | ||||

L2405 | X | 115.80 | X | ||||

L2415 | X | 367.23 | X | ||||

L2425 | X | 449.25 | X | ||||

L2430 | XXX | X | 190.93 | X | |||

L2492 | X | 268.58 | X | ||||

L2500 | X | 642.56 | X | ||||

L2510 | X | 1,441.75 | X | ||||

L2520 | X | 951.02 | X | ||||

L2525 | X | 2,566.02 | X | ||||

L2526 | X | 1,464.28 | X | ||||

L2530 | X | 464.62 | X | ||||

L2540 | X | 835.89 | X | ||||

L2550 | X | 567.84 | X | ||||

L2570 | X | 941.75 | X | ||||

L2580 | X | 917.62 | X | ||||

L2600 | X | 502.54 | X | ||||

L2610 | X | 532.25 | X | ||||

L2620 | X | 598.50 | X | ||||

L2622 | X | 678.48 | X | ||||

L2624 | X | 654.73 | X | ||||

L2627 | X | 3,572.68 | X | ||||

L2628 | X | 3,514.30 | X | ||||

L2630 | X | 489.64 | X | ||||

L2640 | X | 664.47 | X | ||||

L2650 | X | 282.93 | X | ||||

L2660 | X | 368.52 | X | ||||

L2670 | X | 357.41 | X | ||||

L2680 | X | 331.06 | X | ||||

L2750 | X | 165.27 | X | ||||

L2755 | XXX | X | 253.68 | X | |||

L2760 | X | 120.16 | X | ||||

L2768 | X | 229.20 | X | ||||

L2780 | X | 133.76 | X | ||||

L2785 | X | 63.00 | X | ||||

L2795 | X | 170.61 | X | ||||

L2800 | X | 262.29 | X | ||||

L2810 | X | 205.89 | X | ||||

L2820 | X | 171.76 | X | ||||

L2830 | X | 185.73 | X | ||||

L2840 | X | 109.86 | X | ||||

L2850 | X | 122.46 | X | ||||

L2861 | X | * | X | ||||

L2999 | X | # | X | ||||

L3000 | X | * | X | ||||

L3001 | X | * | X | ||||

L3002 | X | * | X | ||||

L3003 | X | * | X | ||||

L3010 | X | * | X | ||||

L3020 | X | * | X | ||||

L3030 | X | * | X | ||||

L3031 | X | * | X | ||||

L3040 | X | * | X | ||||

L3050 | X | * | X | ||||

L3060 | X | * | X | ||||

L3070 | X | * | X | ||||

L3080 | X | * | X | ||||

L3090 | X | * | X | ||||

L3100 | X | * | X | ||||

L3140 | X | * | X | ||||

L3150 | X | * | X | ||||

L3160 | X | * | X | ||||

L3170 | X | * | X | ||||

L3201 | X | * | X | ||||

L3202 | X | * | X | ||||

L3203 | X | * | X | ||||

L3204 | X | * | X | ||||

L3206 | X | * | X | ||||

L3207 | X | * | X | ||||

L3208 | X | * | X | ||||

L3209 | X | * | X | ||||

L3211 | X | * | X | ||||

L3212 | X | # | X | ||||

L3213 | X | * | X | ||||

L3214 | X | * | X | ||||

L3215 | X | 263.18 | X | ||||

L3216 | X | * | X | ||||

L3217 | X | * | X | ||||

L3219 | X | 270.13 | X | ||||

L3221 | X | * | X | ||||

L3222 | X | * | X | ||||

L3224 | XXX | X | * | X | |||

L3225 | XXX | X | * | X | |||

L3230 | X | * | X | ||||

L3250 | X | * | X | ||||

L3251 | X | * | X | ||||

L3252 | X | * | X | ||||

L3253 | X | * | X | ||||

L3254 | X | * | X | ||||

L3255 | X | * | X | ||||

L3257 | X | * | X | ||||

L3260 | X | * | X | ||||

L3265 | X | * | X | ||||

L3300 | X | * | X | ||||

L3310 | X | * | X | ||||

L3320 | X | * | X | ||||

L3330 | X | 262.17 | X | ||||

L3332 | X | * | X | ||||

L3334 | X | * | X | ||||

L3340 | X | * | X | ||||

L3350 | X | * | X | ||||

L3360 | X | * | X | ||||

L3370 | X | * | X | ||||

L3380 | X | 98.27 | X | ||||

L3390 | X | * | X | ||||

L3400 | X | * | X | ||||

L3410 | X | * | X | ||||

L3420 | X | * | X | ||||

L3430 | X | * | X | ||||

L3440 | X | * | X | ||||

L3450 | X | * | X | ||||

L3455 | X | * | X | ||||

L3460 | X | * | X | ||||

L3465 | X | * | X | ||||

L3470 | X | * | X | ||||

L3480 | X | * | X | ||||

L3485 | X | * | X | ||||

L3500 | X | * | X | ||||

L3510 | X | * | X | ||||

L3520 | X | * | X | ||||

L3530 | X | * | X | ||||

L3540 | X | * | X | ||||

L3550 | X | * | X | ||||

L3560 | X | * | X | ||||

L3570 | X | * | X | ||||

L3580 | X | * | X | ||||

L3590 | X | * | X | ||||

L3595 | X | * | X | ||||

L3600 | X | * | X | ||||

L3610 | X | * | X | ||||

L3620 | X | * | X | ||||

L3630 | X | * | X | ||||

L3640 | X | * | X | ||||

L3649 | X | # | X | ||||

L3650 | X | 131.46 | X | ||||

L3660 | X | 198.88 | X | ||||

L3670 | X | 262.69 | X | ||||

L3671 | XXX | 9 | X | * | X | ||

L3674 | X | 1,657.06 | X | ||||

L3675 | X | 298.96 | X | ||||

L3677 | X | * | X | ||||

L3678 | X | * | X | ||||

L3702 | XXX | 9 | X | * | X | ||

L3710 | X | 302.34 | X | ||||

L3720 | X | 1,349.09 | X | ||||

L3730 | X | 1,744.12 | X | ||||

L3740 | X | 2,067.85 | X | ||||

L3760 | XXX | X | * | X | |||

L3761 | X | 629.83 | X | ||||

L3762 | X | 170.55 | X | ||||

L3763 | XXX | 9 | X | * | X | ||

L3764 | XXX | 9 | X | * | X | ||

L3765 | XXX | 9 | X | * | X | ||

L3766 | XXX | 9 | X | * | X | ||

L3806 | X | * | X | ||||

L3807 | X | * | X | ||||

L3808 | X | * | X | ||||

L3809 | X | 336.42 | X | ||||

L3891 | X | * | X | ||||

L3900 | X | 2,738.88 | X | ||||

L3901 | X | 3,110.26 | X | ||||

L3904 | X | 5,666.03 | X | ||||

L3905 | XXX | 9 | X | * | X | ||

L3906 | X | 827.08 | X | ||||

L3908 | X | 130.15 | X | ||||

L3912 | X | 225.48 | X | ||||

L3913 | XXX | 9 | X | * | X | ||

L3915 | X | * | X | ||||

L3916 | X | 715.14 | X | ||||

L3917 | X | 163.99 | X | ||||

L3918 | X | 142.17 | X | ||||

L3919 | XXX | 9 | X | * | X | ||

L3921 | XXX | 9 | X | * | X | ||

L3923 | XXX | X | * | X | |||

L3924 | X | 129.85 | X | ||||

L3925 | X | 73.52 | X | ||||

L3927 | X | * | X | ||||

L3929 | X | 130.31 | X | ||||

L3930 | X | 123.42 | X | ||||

L3931 | X | 266.84 | X | ||||

L3933 | XXX | 9 | X | * | X | ||

L3935 | XXX | 9 | X | * | X | ||

L3956 | XXX | X | * | X | |||

L3960 | X | 1,423.20 | X | ||||

L3961 | XXX | 9 | X | * | X | ||

L3962 | X | 1,388.22 | X | ||||

L3967 | XXX | 9 | X | * | X | ||

L3971 | XXX | 9 | X | * | X | ||

L3973 | XXX | 9 | X | * | X | ||

L3975 | XXX | 9 | X | * | X | ||

L3976 | XXX | 9 | X | * | X | ||

L3977 | XXX | 9 | X | * | X | ||

L3978 | XXX | 9 | X | * | X | ||

L3980 | X | 619.56 | X | ||||

L3981 | X | 1,347.57 | X | ||||

L3982 | X | 722.29 | X | ||||

L3984 | X | 665.94 | X | ||||

L3995 | X | 68.95 | X | ||||

L3999 | X | # | X | ||||

L4000 | X | 2,721.89 | X | ||||

L4002 | X | * | X | ||||

L4010 | X | 1,326.94 | X | ||||

L4020 | X | 1,855.71 | X | ||||

L4030 | X | 998.33 | X | ||||

L4040 | X | 814.64 | X | ||||

L4045 | X | 648.60 | X | ||||

L4050 | X | 816.25 | X | ||||

L4055 | X | 528.60 | X | ||||

L4060 | X | 628.35 | X | ||||

L4070 | X | 556.45 | X | ||||

L4080 | X | 228.19 | X | ||||

L4090 | X | 180.11 | X | ||||

L4100 | X | 236.44 | X | ||||

L4110 | X | 178.19 | X | ||||

L4130 | X | 999.02 | X | ||||

L4205 | X | * | X | ||||

L4210 | X | * | X | ||||

L4350 | X | 197.89 | X | ||||

L4360 | X | 608.35 | X | ||||

L4361 | X | 435.77 | X | ||||

L4370 | X | 402.38 | X | ||||

L4386 | X | 276.41 | X | ||||

L4387 | X | 234.38 | X | ||||

L4392 | X | 46.89 | X | ||||

L4394 | X | 34.21 | X | ||||

L4396 | X | 333.99 | X | ||||

L4397 | X | 248.04 | X | ||||

L4398 | X | 153.77 | X | ||||

L4631 | X | 2,456.11 | X | ||||

L5000 | X | 1,174.07 | X | ||||

L5010 | X | 2,564.54 | X | ||||

L5020 | X | 4,174.59 | X | ||||

L5050 | X | 4,834.26 | X | ||||

L5060 | X | 5,818.14 | X | ||||

L5100 | X | 5,036.10 | X | ||||

L5105 | X | 7,993.32 | X | ||||

L5150 | X | 7,397.33 | X | ||||

L5160 | X | 8,045.89 | X | ||||

L5200 | X | 7,008.58 | X | ||||

L5210 | X | 5,111.57 | X | ||||

L5220 | X | 5,810.21 | X | ||||

L5230 | X | 8,013.43 | X | ||||

L5250 | X | 10,929.55 | X | ||||

L5270 | X | 10,833.85 | X | ||||

L5280 | X | 10,725.44 | X | ||||

L5301 | X | 4,121.55 | X | ||||

L5312 | X | 5,130.49 | X | ||||

L5321 | X | 5,899.87 | X | ||||

L5331 | X | 8,348.55 | X | ||||

L5341 | X | 9,072.26 | X | ||||

L5400 | X | 2,535.22 | X | ||||

L5410 | X | 1,110.80 | X | ||||

L5420 | X | 3,201.91 | X | ||||

L5430 | X | 1,413.31 | X | ||||

L5450 | X | 904.16 | X | ||||

L5460 | X | 1,332.56 | X | ||||

L5500 | X | 2,705.36 | X | ||||

L5505 | X | 3,663.83 | X | ||||

L5510 | X | 3,066.73 | X | ||||

L5520 | X | 3,029.22 | X | ||||

L5530 | X | 3,834.40 | X | ||||

L5535 | X | 3,778.79 | X | ||||

L5540 | X | 3,990.23 | X | ||||

L5560 | X | 4,094.12 | X | ||||

L5570 | X | 4,256.44 | X | ||||

L5580 | X | 4,969.09 | X | ||||

L5585 | X | 5,389.61 | X | ||||

L5590 | X | 5,063.87 | X | ||||

L5595 | X | 8,900.91 | X | ||||

L5600 | X | 9,708.38 | X | ||||

L5610 | X | 4,361.27 | X | ||||

L5611 | X | 3,393.95 | X | ||||

L5613 | X | 5,162.34 | X | ||||

L5614 | XXX | X | * | X | |||

L5616 | X | 2,860.98 | X | ||||

L5617 | X | * | X | ||||

L5618 | X | 666.57 | X | ||||

L5620 | X | 585.68 | X | ||||

L5622 | X | 894.45 | X | ||||

L5624 | X | 853.28 | X | ||||

L5626 | X | 1,199.41 | X | ||||

L5628 | X | 1,136.11 | X | ||||

L5629 | X | 867.53 | X | ||||

L5630 | X | 945.35 | X | ||||

L5631 | X | 1,130.53 | X | ||||

L5632 | X | 467.67 | X | ||||

L5634 | X | 640.82 | X | ||||

L5636 | X | 536.74 | X | ||||

L5637 | X | 716.93 | X | ||||

L5638 | X | 1,025.15 | X | ||||

L5639 | X | 2,404.94 | X | ||||

L5640 | X | 1,464.20 | X | ||||

L5642 | X | 1,310.80 | X | ||||

L5643 | X | 3,278.62 | X | ||||

L5644 | X | 1,244.25 | X | ||||

L5645 | X | 1,680.76 | X | ||||

L5646 | X | 1,154.19 | X | ||||

L5647 | X | 1,675.58 | X | ||||

L5648 | X | 1,386.89 | X | ||||

L5649 | X | 4,210.26 | X | ||||

L5650 | X | 1,028.30 | X | ||||

L5651 | X | 2,529.73 | X | ||||

L5652 | X | 918.39 | X | ||||

L5653 | X | 1,225.96 | X | ||||

L5654 | X | 698.63 | X | ||||

L5655 | X | 591.55 | X | ||||

L5656 | X | 833.21 | X | ||||

L5658 | X | 811.51 | X | ||||

L5661 | X | 1,410.10 | X | ||||

L5665 | X | 1,078.58 | X | ||||

L5666 | X | 160.32 | X | ||||

L5668 | X | 213.99 | X | ||||

L5670 | X | 651.48 | X | ||||

L5671 | X | 892.86 | X | ||||

L5672 | X | 796.01 | X | ||||

L5673 | X | 1,163.30 | X | ||||

L5676 | X | 763.35 | X | ||||

L5677 | X | 1,038.64 | X | ||||

L5678 | X | 83.69 | X | ||||

L5679 | X | 969.40 | X | ||||

L5680 | X | 729.56 | X | ||||

L5681 | X | 2,248.12 | X | ||||

L5682 | X | 1,317.40 | X | ||||

L5683 | X | 2,248.12 | X | ||||

L5684 | X | 101.37 | X | ||||

L5685 | X | * | X | ||||

L5686 | X | 136.78 | X | ||||

L5688 | X | 128.56 | X | ||||

L5690 | X | 249.18 | X | ||||

L5692 | X | 289.21 | X | ||||

L5694 | X | 382.12 | X | ||||

L5695 | X | 400.91 | X | ||||

L5696 | X | 438.12 | X | ||||

L5697 | X | 177.92 | X | ||||

L5698 | X | 221.34 | X | ||||

L5699 | X | 392.74 | X | ||||

L5700 | XXX | X | * | X | |||

L5701 | XXX | X | * | X | |||

L5702 | XXX | X | * | X | |||

L5703 | XXX | 9 | X | * | X | ||

L5704 | XXX | X | * | X | |||

L5705 | XXX | X | * | X | |||

L5706 | XXX | X | * | X | |||

L5707 | XXX | X | * | X | |||

L5710 | X | 757.61 | X | ||||

L5711 | X | 1,149.28 | X | ||||

L5712 | X | 907.69 | X | ||||

L5714 | X | 936.05 | X | ||||

L5716 | X | 1,535.27 | X | ||||

L5718 | X | 1,918.91 | X | ||||

L5722 | X | 2,002.51 | X | ||||

L5724 | X | 3,179.54 | X | ||||

L5726 | X | 4,175.15 | X | ||||

L5728 | X | 5,201.63 | X | ||||

L5780 | X | 2,507.94 | X | ||||

L5781 | X | 6,988.73 | X | ||||

L5782 | X | * | X | ||||

L5785 | X | 1,094.42 | X | ||||

L5790 | X | 1,514.60 | X | ||||

L5795 | X | 2,261.68 | X | ||||

L5810 | X | 1,052.19 | X | ||||

L5811 | X | 1,536.31 | X | ||||

L5812 | X | 1,190.77 | X | ||||

L5814 | X | 7,227.00 | X | ||||

L5816 | X | 1,791.41 | X | ||||

L5818 | X | 2,022.88 | X | ||||

L5822 | X | 3,924.64 | X | ||||

L5824 | X | 3,230.41 | X | ||||

L5826 | XXX | X | 6,137.81 | X | |||

L5828 | X | 6,157.87 | X | ||||

L5830 | X | 4,375.42 | X | ||||

L5840 | XXX | X | * | X | |||

L5845 | X | * | X | ||||

L5848 | X | 1,878.26 | X | ||||

L5850 | X | 279.70 | X | ||||

L5855 | XXX | X | * | X | |||

L5856 | X | 39,525.87 | X | ||||

L5857 | X | 14,025.26 | X | ||||

L5858 | XXX | 9 | X | 29,409.62 | X | ||

L5859 | X | * | X | ||||

L5910 | X | 768.36 | X | ||||

L5920 | X | 1,117.66 | X | ||||

L5925 | XXX | X | * | X | |||

L5930 | X | * | X | ||||

L5940 | X | 1,056.59 | X | ||||

L5950 | X | 1,785.04 | X | ||||

L5960 | X | 2,138.22 | X | ||||

L5961 | X | 7,152.27 | X | ||||

L5962 | XXX | X | * | X | |||

L5964 | XXX | X | * | X | |||

L5966 | XXX | X | * | X | |||

L5968 | X | 6,815.11 | X | ||||

L5969 | X | 21,491.01 | X | ||||

L5970 | X | 462.42 | X | ||||

L5971 | XXX | 9 | X | * | X | ||

L5972 | X | 742.42 | X | ||||

L5973 | X | 27,452.54 | X | ||||

L5974 | X | 626.38 | X | ||||

L5975 | X | 869.45 | X | ||||

L5976 | X | 1,179.67 | X | ||||

L5978 | X | 614.75 | X | ||||

L5979 | XXX | X | * | X | |||

L5980 | X | 7,810.24 | X | ||||

L5981 | XXX | X | * | X | |||

L5982 | X | 1,217.80 | X | ||||

L5984 | X | 1,206.93 | X | ||||

L5985 | X | * | X | ||||

L5986 | X | 1,341.90 | X | ||||

L5987 | X | 13,998.68 | X | ||||

L5988 | X | 3,746.51 | X | ||||

L5990 | X | 3,197.02 | X | ||||

L5991 | X | 12,717.52 | X | ||||

L5999 | X | # | X |

PART B FEE SCHEDULES