2020 workers' compensation part b fee schedule 59120-61520€¦ · medicare location: global...
TRANSCRIPT
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
59120 3 90 2 X 1,464.39 X
59120 2 90 2 X 1,583.49 X
59120 1 90 2 X 1,612.31 X
59120 4 90 2 X 1,616.49 X
59121 4 90 2 X 1,184.56 X
59121 3 90 2 X 1,198.26 X
59121 2 90 2 X 1,286.08 X
59121 1 90 2 X 1,307.37 X
59130 4 90 2 X 1,281.10 X
59130 3 90 2 X 1,296.41 X
59130 2 90 2 X 1,373.91 X
59130 1 90 2 X 1,392.62 X
59135 4 90 2 X 2,112.71 X
59135 3 90 2 X 2,138.00 X
59135 2 90 2 X 2,265.43 X
59135 1 90 2 X 2,296.27 X
59136 4 90 2 X 1,443.22 X
59136 3 90 2 X 1,459.57 X
59136 2 90 2 X 1,571.17 X
59136 1 90 2 X 1,598.30 X
59140 4 90 2 X 881.55 X
59140 3 90 2 X 892.57 X
59140 2 90 2 X 939.75 X
59140 1 90 2 X 951.13 X
59150 4 90 2 X 1,051.39 X
59150 3 90 2 X 1,063.33 X
59150 2 90 2 X 1,144.52 X
59150 1 90 2 X 1,164.28 X
59151 4 90 2 X 1,444.69 X
59151 3 90 2 X 1,463.39 X
59151 2 90 2 X 1,550.60 X
59151 1 90 2 X 1,571.56 X
59160 2 10 2 X 462.83 X
59160 3 10 2 X 462.83 X
59160 4 10 2 X 462.83 X
59160 1 10 2 X 534.68 X
59200 0 2 X * X
59300 3 0 2 X 313.56 X
59300 2 0 2 X 328.11 X
59300 1 0 2 X 382.30 X
2021 Workers' Compensation Part B Fee Schedule
59120-61520
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
59300 4 0 2 X 401.96 X
59320 4 0 2 X 411.82 X
59320 3 0 2 X 416.51 X
59320 2 0 2 X 448.13 X
59320 1 0 2 X 455.72 X
59325 4 0 2 X 638.70 X
59325 3 0 2 X 646.31 X
59325 2 0 2 X 682.14 X
59325 1 0 2 X 690.82 X
59350 4 0 2 X 821.06 X
59350 3 0 2 X 830.37 X
59350 2 0 2 X 893.86 X
59350 1 0 2 X 909.30 X
59400 4 MMM 2 X 2,590.22 X
59400 3 MMM 2 X 2,685.48 X
59400 2 MMM 2 X 2,908.42 X
59400 1 MMM 2 X 3,046.99 X
59409 4 MMM 2 X 1,650.07 X
59409 1 MMM 2 X 2,197.35 X
59409 3 MMM 2 X 2,227.36 X
59409 2 MMM 2 X 2,397.26 X
59410 4 MMM 2 X 1,713.47 X
59410 1 MMM 2 X 2,267.67 X
59410 3 MMM 2 X 2,421.44 X
59410 2 MMM 2 X 2,606.52 X
59412 MMM 0 X * X
59414 4 MMM 2 X 267.05 X
59414 3 MMM 2 X 270.04 X
59414 2 MMM 2 X 290.63 X
59414 1 MMM 2 X 295.73 X
59425 4 MMM 0 X 668.39 545.36
59425 3 MMM 0 X 675.98 550.77
59425 2 MMM 0 X 727.36 594.83
59425 1 MMM 0 X 739.87 605.60
59426 4 MMM 0 X 1,145.63 934.65
59426 3 MMM 0 X 1,158.62 944.04
59426 2 MMM 0 X 1,246.83 1,019.55
59426 1 MMM 0 X 1,268.31 1,038.04
59430 4 MMM 2 X 218.57 X
59430 3 MMM 2 X 220.83 X
59430 2 MMM 2 X 230.05 X
59430 1 MMM 2 X 232.36 X
59510 4 MMM 2 X 3,924.75 X
59510 3 MMM 2 X 3,969.22 X
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
59510 2 MMM 2 X 4,272.33 X
59510 1 MMM 2 X 4,346.05 X
59514 1 MMM 2 X 2,504.85 X
59514 4 MMM 2 X 2,552.25 X
59514 3 MMM 2 X 2,581.19 X
59514 2 MMM 2 X 2,778.42 X
59515 1 MMM 2 X 2,574.54 X
59515 4 MMM 2 X 2,743.29 X
59515 3 MMM 2 X 2,774.39 X
59515 2 MMM 2 X 2,985.92 X
59525 4 MMM 0 X 1,172.33 X
59525 3 MMM 0 X 1,185.08 X
59525 2 MMM 0 X 1,260.34 X
59525 1 MMM 0 X 1,278.68 X
59610 4 MMM 2 X 3,749.60 X
59610 3 MMM 2 X 3,804.45 X
59610 2 MMM 2 X 4,050.34 X
59610 1 MMM 2 X 4,248.58 X
59612 4 MMM 2 X 2,427.47 X
59612 3 MMM 2 X 2,462.68 X
59612 2 MMM 2 X 2,619.62 X
59612 1 MMM 2 X 2,746.37 X
59614 4 MMM 2 X 2,622.50 X
59614 3 MMM 2 X 2,660.67 X
59614 2 MMM 2 X 2,830.93 X
59614 1 MMM 2 X 2,968.29 X
59618 4 MMM 2 X 4,209.32 X
59618 3 MMM 2 X 4,270.94 X
59618 2 MMM 2 X 4,547.99 X
59618 1 MMM 2 X 4,771.27 X
59620 4 MMM 2 X 2,789.63 X
59620 3 MMM 2 X 2,830.24 X
59620 2 MMM 2 X 3,011.63 X
59620 1 MMM 2 X 3,157.99 X
59622 4 MMM 2 X 2,987.85 X
59622 3 MMM 2 X 3,031.39 X
59622 2 MMM 2 X 3,225.96 X
59622 1 MMM 2 X 3,382.80 X
59812 4 90 2 X 656.52 X
59812 3 90 2 X 664.39 X
59812 2 90 2 X 722.05 X
59812 1 90 2 X 736.09 X
59820 4 90 2 X 725.20 X
59820 3 90 2 X 809.57 X
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
59820 2 90 2 X 839.33 X
59820 1 90 2 X 873.59 X
59821 4 90 2 X 671.63 X
59821 3 90 2 X 679.22 X
59821 2 90 2 X 728.71 X
59821 1 90 2 X 851.94 X
59830 4 90 2 X 970.14 X
59830 3 90 2 X 981.77 X
59830 2 90 2 X 1,040.16 X
59830 1 90 2 X 1,054.26 X
59840 4 10 2 X 599.44 X
59840 3 10 2 X 606.64 X
59840 1 10 2 X 671.21 X
59840 2 10 2 X 781.28 X
59841 4 10 2 X 680.79 X
59841 2 10 2 X 747.28 X
59841 3 10 2 X 897.45 X
59841 1 10 2 X 927.96 X
59850 4 90 2 X 908.83 X
59850 3 90 2 X 919.24 X
59850 1 90 2 X 981.61 X
59850 2 90 2 X 987.43 X
59851 4 90 2 X 950.24 X
59851 3 90 2 X 961.20 X
59851 2 90 2 X 1,032.53 X
59851 1 90 2 X 1,049.74 X
59852 4 90 2 X 1,277.36 X
59852 3 90 2 X 1,291.84 X
59852 2 90 2 X 1,390.18 X
59852 1 90 2 X 1,414.09 X
59855 4 90 2 X 830.33 X
59855 3 90 2 X 841.42 X
59855 2 90 2 X 901.31 X
59855 1 90 2 X 930.77 X
59856 4 90 2 X 1,252.83 X
59856 3 90 2 X 1,269.52 X
59856 2 90 2 X 1,360.24 X
59856 1 90 2 X 1,405.00 X
59857 4 90 2 X 1,523.78 X
59857 3 90 2 X 1,544.07 X
59857 2 90 2 X 1,654.20 X
59857 1 90 2 X 1,708.43 X
59866 3 90 2 X 642.28 X
59866 4 90 2 X 642.28 X
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
59866 2 90 2 X 659.99 X
59866 1 90 2 X 736.57 X
59870 4 90 2 X 676.22 X
59870 3 90 2 X 683.93 X
59870 2 90 2 X 736.02 X
59870 1 90 2 X 748.70 X
59871 2 10 2 X 323.26 X
59871 3 10 2 X 323.26 X
59871 4 10 2 X 323.26 X
59871 1 10 2 X 372.73 X
59897 YYY 2 X # X
59898 YYY 2 X # X
59899 YYY 2 X # X
60000 4 10 2 X 199.59 X
60000 3 10 2 X 201.71 X
60000 2 10 2 X 220.96 X
60000 1 10 2 X 230.88 X
60100 4 0 2 X 198.96 151.04
60100 3 0 2 X 202.69 154.08
60100 2 0 2 X 211.87 161.58
60100 1 0 2 X 217.87 166.26
60200 4 90 2 X 1,401.89 X
60200 3 90 2 X 1,418.06 X
60200 2 90 2 X 1,512.02 X
60200 1 90 2 X 1,534.84 X
60210 4 90 2 X 1,937.53 X
60210 3 90 2 X 1,963.94 X
60210 2 90 2 X 2,102.29 X
60210 1 90 2 X 2,200.96 X
60212 4 90 2 X 2,010.30 X
60212 3 90 2 X 2,033.56 X
60212 2 90 2 X 2,179.46 X
60212 1 90 2 X 2,302.16 X
60220 4 90 2 X 1,761.07 X
60220 3 90 2 X 1,781.82 X
60220 2 90 2 X 1,914.96 X
60220 1 90 2 X 1,947.31 X
60225 4 90 2 X 2,117.04 X
60225 3 90 2 X 2,142.15 X
60225 2 90 2 X 2,302.08 X
60225 1 90 2 X 2,380.76 X
60240 3 90 2 X 2,516.18 X
60240 4 90 2 X 2,542.03 X
60240 2 90 2 X 2,650.51 X
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
60240 1 90 2 X 2,728.67 X
60252 4 90 2 X 2,928.76 X
60252 3 90 2 X 2,945.82 X
60252 2 90 2 X 3,024.49 X
60252 1 90 2 X 3,075.60 X
60254 3 90 2 X 3,899.26 X
60254 4 90 2 X 3,965.53 X
60254 2 90 2 X 3,972.74 X
60254 1 90 2 X 4,163.76 X
60260 4 90 2 X 1,497.58 X
60260 2 90 2 X 1,647.85 X
60260 3 90 2 X 1,782.58 X
60260 1 90 2 X 1,815.11 X
60270 4 90 2 X 2,900.83 X
60270 3 90 2 X 2,935.07 X
60270 2 90 2 X 3,149.60 X
60270 1 90 2 X 3,201.66 X
60271 4 90 2 X 2,499.53 X
60271 3 90 2 X 2,516.53 X
60271 2 90 2 X 2,750.32 X
60271 1 90 2 X 2,777.53 X
60280 4 90 2 X 1,391.22 X
60280 3 90 2 X 1,455.58 X
60280 2 90 2 X 1,491.63 X
60280 1 90 2 X 1,507.70 X
60281 4 90 2 X 1,235.51 X
60281 3 90 2 X 1,249.60 X
60281 2 90 2 X 1,332.94 X
60281 1 90 2 X 1,353.22 X
60300 2 0 2 X 147.22 72.82
60300 3 0 2 X 147.22 72.82
60300 4 0 2 X 147.22 72.82
60300 1 0 2 X 169.31 79.61
60500 4 90 2 X 2,830.01 X
60500 3 90 2 X 2,905.47 X
60500 2 90 2 X 2,976.36 X
60500 1 90 2 X 3,000.00 X
60502 4 90 2 X 2,913.34 X
60502 3 90 2 X 3,054.17 X
60502 2 90 2 X 3,144.79 X
60502 1 90 2 X 3,193.17 X
60505 3 90 2 X 2,212.72 X
60505 4 90 2 X 2,220.67 X
60505 2 90 2 X 2,356.98 X
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
60505 1 90 2 X 2,380.41 X
60512 4 ZZZ 0 X 684.41 X
60512 3 ZZZ 0 X 693.22 X
60512 2 ZZZ 0 X 737.11 X
60512 1 ZZZ 0 X 758.93 X
60520 4 90 2 X 2,916.83 X
60520 3 90 2 X 2,950.93 X
60520 2 90 2 X 3,161.42 X
60520 1 90 2 X 3,212.48 X
60521 4 90 2 X 2,916.83 X
60521 3 90 2 X 2,950.93 X
60521 2 90 2 X 3,161.42 X
60521 1 90 2 X 3,212.48 X
60522 4 90 2 X 2,916.83 X
60522 3 90 2 X 2,950.93 X
60522 2 90 2 X 3,161.42 X
60522 1 90 2 X 3,212.48 X
60540 4 90 2 X 2,628.94 X
60540 3 90 2 X 2,659.70 X
60540 2 90 2 X 2,843.33 X
60540 1 90 2 X 2,887.83 X
60545 4 90 2 X 3,508.14 X
60545 3 90 2 X 3,523.32 X
60545 2 90 2 X 3,612.51 X
60545 1 90 2 X 3,634.08 X
60600 4 90 2 X 2,598.37 X
60600 3 90 2 X 2,628.64 X
60600 2 90 2 X 2,805.05 X
60600 1 90 2 X 2,843.85 X
60605 4 90 2 X 2,749.24 X
60605 3 90 2 X 3,120.08 X
60605 2 90 2 X 3,283.48 X
60605 1 90 2 X 3,333.48 X
60650 YYY 2 X * X
60659 YYY 2 X # X
60699 YYY 2 X # X
61000 4 0 2 X 248.57 X
61000 3 0 2 X 251.50 X
61000 2 0 2 X 267.54 X
61000 1 0 2 X 271.43 X
61001 4 0 2 X 224.59 X
61001 3 0 2 X 227.09 X
61001 2 0 2 X 241.94 X
61001 1 0 2 X 245.57 X
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
61020 4 0 2 X 261.15 X
61020 3 0 2 X 460.46 X
61020 2 0 2 X 468.05 X
61020 1 0 2 X 469.89 X
61026 3 0 2 X 326.91 X
61026 2 0 2 X 434.85 X
61026 4 0 2 X 452.66 X
61026 1 0 2 X 454.18 X
61050 4 0 2 X 237.82 X
61050 2 0 2 X 367.63 X
61050 1 0 2 X 370.47 X
61050 3 0 2 X 395.49 X
61055 1 0 0 X 372.43 X
61055 3 0 0 X 424.51 X
61055 4 0 0 X 433.39 X
61055 2 0 0 X 441.49 X
61070 4 0 2 X 116.87 X
61070 3 0 2 X 175.64 X
61070 2 0 2 X 177.91 X
61070 1 0 2 X 178.47 X
61105 4 90 2 X 1,436.60 X
61105 3 90 2 X 1,453.52 X
61105 2 90 2 X 1,765.47 X
61105 1 90 2 X 1,776.21 X
61107 4 0 0 X 1,047.46 X
61107 3 0 0 X 1,521.31 X
61107 2 0 0 X 1,558.75 X
61107 1 0 0 X 1,609.78 X
61108 1 90 2 X 3,048.57 X
61108 3 90 2 X 3,344.22 X
61108 4 90 2 X 3,378.61 X
61108 2 90 2 X 3,464.73 X
61120 4 90 2 X 1,442.21 X
61120 3 90 2 X 1,458.64 X
61120 2 90 2 X 1,554.96 X
61120 1 90 2 X 1,626.63 X
61140 4 90 2 X 2,473.05 X
61140 3 90 2 X 2,492.01 X
61140 1 90 2 X 2,565.65 X
61140 2 90 2 X 2,603.10 X
61150 4 90 2 X 2,960.21 X
61150 3 90 2 X 3,045.74 X
61150 2 90 2 X 3,216.92 X
61150 1 90 2 X 3,270.63 X
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
61151 3 90 2 X 1,046.19 X
61151 2 90 2 X 1,066.01 X
61151 1 90 2 X 1,091.50 X
61151 4 90 2 X 1,238.44 X
61154 1 90 2 X 3,443.37 X
61154 3 90 2 X 3,717.90 X
61154 4 90 2 X 3,735.26 X
61154 2 90 2 X 3,805.84 X
61156 4 90 2 X 3,027.75 X
61156 3 90 2 X 3,064.23 X
61156 2 90 2 X 3,308.62 X
61156 1 90 2 X 3,367.81 X
61210 4 0 0 X 1,200.16 X
61210 1 0 0 X 2,130.95 X
61210 3 0 0 X 2,453.41 X
61210 2 0 0 X 2,492.00 X
61215 90 2 X * X
61250 4 90 2 X 1,807.43 X
61250 1 90 2 X 1,985.06 X
61250 3 90 2 X 2,165.73 X
61250 2 90 2 X 2,218.63 X
61253 4 90 2 X 2,142.69 X
61253 3 90 2 X 2,167.59 X
61253 2 90 2 X 2,316.58 X
61253 1 90 2 X 2,352.74 X
61304 3 90 2 X 4,715.48 X
61304 4 90 2 X 4,726.30 X
61304 2 90 2 X 4,945.74 X
61304 1 90 2 X 5,037.56 X
61305 4 90 2 X 5,171.00 X
61305 3 90 2 X 5,234.40 X
61305 2 90 2 X 5,703.23 X
61305 1 90 2 X 5,750.92 X
61312 4 90 2 X 4,311.89 X
61312 3 90 2 X 4,342.30 X
61312 2 90 2 X 4,720.58 X
61312 1 90 2 X 4,806.79 X
61313 4 90 2 X 4,297.06 X
61313 3 90 2 X 4,349.49 X
61313 2 90 2 X 4,701.95 X
61313 1 90 2 X 4,787.19 X
61314 3 90 2 X 4,491.91 X
61314 4 90 2 X 4,659.95 X
61314 2 90 2 X 5,094.39 X
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
61314 1 90 2 X 5,185.88 X
61315 3 90 2 X 4,802.20 X
61315 4 90 2 X 4,818.42 X
61315 2 90 2 X 5,245.72 X
61315 1 90 2 X 5,335.31 X
61316 2 90 2 X 155.81 X
61316 3 90 2 X 155.81 X
61316 4 90 2 X 155.81 X
61316 1 90 2 X 184.72 X
61320 4 90 2 X 4,054.25 X
61320 3 90 2 X 4,101.52 X
61320 2 90 2 X 4,378.49 X
61320 1 90 2 X 4,504.76 X
61321 4 90 2 X 4,409.95 X
61321 3 90 2 X 4,461.21 X
61321 2 90 2 X 4,770.30 X
61321 1 90 2 X 4,845.23 X
61322 2 90 2 X 3,198.96 X
61322 3 90 2 X 3,198.96 X
61322 4 90 2 X 3,198.96 X
61322 1 90 2 X 3,648.45 X
61323 2 90 2 X 3,315.17 X
61323 3 90 2 X 3,315.17 X
61323 4 90 2 X 3,315.17 X
61323 1 90 2 X 3,770.54 X
61330 4 90 2 X 2,623.31 X
61330 3 90 2 X 2,655.37 X
61330 2 90 2 X 2,807.59 X
61330 1 90 2 X 2,844.28 X
61333 4 90 2 X 4,446.88 X
61333 3 90 2 X 4,499.17 X
61333 2 90 2 X 4,800.14 X
61333 1 90 2 X 4,873.08 X
61340 4 90 2 X 2,533.46 X
61340 3 90 2 X 2,564.85 X
61340 2 90 2 X 2,762.02 X
61340 1 90 2 X 2,859.82 X
61343 4 90 2 X 5,549.77 X
61343 3 90 2 X 5,617.10 X
61343 1 90 2 X 5,786.95 X
61343 2 90 2 X 6,054.28 X
61345 4 90 2 X 4,228.89 X
61345 3 90 2 X 4,278.11 X
61345 2 90 2 X 4,577.19 X
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
61345 1 90 2 X 4,649.72 X
61450 4 90 2 X 4,238.60 X
61450 3 90 2 X 4,288.82 X
61450 2 90 2 X 4,591.23 X
61450 1 90 2 X 4,664.48 X
61458 4 90 2 X 5,104.88 X
61458 3 90 2 X 5,828.50 X
61458 2 90 2 X 6,019.43 X
61458 1 90 2 X 6,138.88 X
61460 4 90 2 X 4,903.94 X
61460 3 90 2 X 4,963.01 X
61460 2 90 2 X 5,914.26 X
61460 1 90 2 X 6,029.03 X
61500 4 90 2 X 3,560.45 X
61500 3 90 2 X 3,721.87 X
61500 2 90 2 X 3,894.46 X
61500 1 90 2 X 3,964.77 X
61501 4 90 2 X 3,032.46 X
61501 3 90 2 X 3,069.81 X
61501 2 90 2 X 3,330.10 X
61501 1 90 2 X 3,393.14 X
61510 4 90 2 X 5,054.14 X
61510 3 90 2 X 5,078.97 X
61510 2 90 2 X 5,310.44 X
61510 1 90 2 X 5,406.18 X
61512 4 90 2 X 5,137.87 X
61512 3 90 2 X 5,200.68 X
61512 2 90 2 X 5,624.53 X
61512 1 90 2 X 5,727.12 X
61514 4 90 2 X 4,719.88 X
61514 3 90 2 X 4,776.95 X
61514 2 90 2 X 5,158.32 X
61514 1 90 2 X 5,502.40 X
61516 4 90 2 X 4,728.08 X
61516 3 90 2 X 4,786.05 X
61516 2 90 2 X 5,163.83 X
61516 1 90 2 X 5,255.25 X
61517 2 90 2 X 135.58 X
61517 3 90 2 X 135.58 X
61517 4 90 2 X 135.58 X
61517 1 90 2 X 148.79 X
61518 4 90 2 X 5,958.41 X
61518 3 90 2 X 6,029.31 X
61518 1 90 2 X 6,407.99 X
CPT/HCPC
CodeModifier
Medicare
Location
Global
Surgery
Indicator
Multiple Surgery
Indicator
Prevailing
Charge
Amount
Fee
Schedule
Amount
Site of
Service
Amount
61518 2 90 2 X 6,483.47 X
61519 4 90 2 X 6,230.50 X
61519 3 90 2 X 6,304.51 X
61519 1 90 2 X 6,613.02 X
61519 2 90 2 X 6,781.18 X
61520 4 90 2 X 6,871.84 X
61520 3 90 2 X 6,953.53 X
61520 2 90 2 X 7,891.86 X
61520 1 90 2 X 7,943.28 X