Listing of a payment amount does not guarantee payment ......A7045 $15.47 E0193 $8,827.71 E0470 $1,375.21 E0747 $5,253.75 A7046 $17.07 E0194 $37,110.77 E0471 $3,420.56 E0748 $5,219.72

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0080

Effective January 1, 2019 Link to temporary medical fee and payment rules

HCPCSMaximum

Payment HCPCSMaximum



PaymentA4216 $0.51 A4380 $49.87 A4595 $13.01 A6022 $28.08A4217 $4.19 A4381 $6.18 A4602 $4.97 A6023 $254.24A4221 $23.40 A4382 $32.88 A4604 $51.09 A6024 $8.27A4222 $44.37 A4383 $37.66 A4605 $21.91 A6154 $19.19A4224 $23.40 A4384 $12.84 A4608 $66.96 A6196 $9.83A4225 $3.13 A4385 $6.81 A4614 $31.76 A6197 $21.96A4233 $0.61 A4387 $3.00 A4615 $0.97 A6199 $7.06A4234 $2.80 A4388 $5.83 A4616 $0.08 A6203 $4.50A4235 $1.19 A4389 $8.31 A4617 $4.14 A6204 $8.32A4236 $1.38 A4390 $12.83 A4618 $10.23 A6207 $9.80A4253 $9.88 A4391 $9.45 A4619 $2.31 A6209 $9.98A4255 $5.50 A4392 $10.92 A4620 $0.80 A6210 $26.61A4256 $4.01 A4393 $12.08 A4623 $7.43 A6211 $39.24A4257 $17.05 A4394 $3.45 A4624 $3.51 A6212 $12.97A4258 $2.52 A4395 $0.06 A4625 $7.86 A6214 $13.75A4259 $1.69 A4396 $54.08 A4626 $3.62 A6216 $0.06A4265 $4.55 A4397 $5.44 A4628 $4.87 A6219 $1.28A4280 $6.93 A4398 $18.47 A4629 $6.18 A6220 $3.45A4310 $8.77 A4399 $16.38 A4630 $8.34 A6222 $2.85A4311 $16.83 A4400 $55.49 A4633 $54.82 A6223 $3.24A4312 $20.49 A4402 $2.14 A4635 $6.84 A6224 $4.82A4313 $21.03 A4404 $1.91 A4636 $3.57 A6229 $4.82A4314 $28.71 A4405 $4.56 A4637 $1.98 A6231 $6.27A4315 $29.96 A4406 $7.64 A4639 $383.76 A6232 $9.16A4316 $32.25 A4407 $11.70 A4640 $67.17 A6233 $25.62A4320 $7.13 A4408 $13.19 A5051 $2.77 A6234 $8.74A4322 $3.67 A4409 $8.31 A5052 $1.98 A6235 $22.47A4326 $13.85 A4410 $12.08 A5053 $2.31 A6236 $36.41A4327 $59.60 A4411 $6.81 A5054 $2.40 A6237 $10.58A4328 $13.20 A4412 $3.61 A5055 $1.92 A6238 $30.46A4330 $9.25 A4413 $7.36 A5056 $6.24 A6240 $16.36A4331 $4.25 A4414 $6.58 A5057 $12.83 A6241 $3.43A4332 $0.15 A4415 $8.00 A5061 $4.71 A6242 $8.10A4333 $2.96 A4416 $3.68 A5062 $2.79 A6243 $16.46A4334 $6.58 A4417 $4.97 A5063 $3.61 A6244 $52.48A4336 $1.92 A4418 $2.42 A5071 $8.02 A6245 $9.71A4338 $16.38 A4419 $2.31 A5072 $4.69 A6246 $13.27A4340 $42.42 A4422 $0.15 A5073 $4.25 A6247 $31.76A4344 $21.39 A4423 $2.48 A5081 $3.76 A6248 $21.71A4346 $26.16 A4424 $6.36 A5082 $13.57 A6251 $2.66A4349 $2.69 A4425 $4.78 A5083 $0.85 A6252 $4.36A4351 $2.42 A4426 $3.64 A5093 $2.22 A6253 $8.46A4352 $8.58 A4427 $3.72 A5102 $30.16 A6254 $1.60A4353 $9.35 A4428 $8.70 A5105 $46.30 A6255 $4.06A4354 $13.40 A4429 $11.02 A5112 $46.25 A6257 $2.05A4355 $11.92 A4430 $11.37 A5113 $5.35 A6258 $5.76A4356 $56.68 A4431 $8.31 A5114 $10.17 A6259 $14.61A4357 $12.97 A4432 $4.80 A5120 $0.27 A6266 $2.56A4358 $7.81 A4433 $4.47 A5121 $9.96 A6402 $0.15A4360 $0.59 A4434 $5.02 A5122 $14.59 A6403 $0.57A4361 $24.54 A4435 $7.70 A5126 $1.50 A6407 $2.50A4362 $3.94 A4450 $0.14 A5131 $17.99 A6410 $0.51A4363 $3.17 A4452 $0.52 A5200 $15.09 A6441 $0.91A4364 $3.93 A4455 $1.91 A5500 $84.94 A6442 $0.21A4366 $1.73 A4456 $0.32 A5501 $254.79 A6443 $0.37A4367 $9.83 A4461 $4.40 A5503 $41.87 A6444 $0.75A4368 $0.33 A4463 $17.78 A5504 $41.87 A6445 $0.43A4369 $2.75 A4481 $0.50 A5505 $41.87 A6446 $0.53A4371 $4.81 A4556 $15.83 A5506 $41.87 A6447 $0.91A4372 $5.60 A4557 $13.02 A5507 $41.87 A6448 $1.54A4373 $8.38 A4558 $6.69 A5512 $34.65 A6449 $2.34A4375 $22.94 A4559 $0.13 A5513 $51.71 A6450 $2.34A4376 $63.58 A4561 $26.65 A5514 $52.89 A6451 $2.34A4377 $5.73 A4562 $66.37 A6010 $41.38 A6452 $7.89A4378 $41.07 A4563 $148.29 A6011 $3.05 A6453 $0.83A4379 $20.06 A4565 $10.28 A6021 $28.08 A6454 $1.04

Temporary Appendix E for Adminitrative Order No. 18-064

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

2019 Temporary Appendix E Page 1 of 7

https://wcd.oregon.gov/Rules/div_009/9-18064t-marked.pdf



HCPCSMaximum




Payment



A6455 $1.86 E0100 $27.80 E0261 $778.73 E0605 $35.45A6456 $1.70 E0105 $65.38 E0265 $1,664.51 E0606 $297.88A6457 $1.52 E0110 $104.10 E0266 $1,448.40 E0607 $89.64A6531 $57.80 E0111 $71.44 E0271 $157.25 E0610 $271.24A6532 $81.44 E0112 $49.65 E0272 $178.39 E0615 $546.01A6545 $113.80 E0113 $28.36 E0275 $17.75 E0617 $4,528.88A6550 $31.60 E0114 $63.32 E0276 $15.26 E0618 $3,761.36A7000 $10.62 E0116 $37.23 E0277 $2,448.49 E0620 $1,172.93A7001 $44.19 E0117 $258.43 E0280 $39.87 E0621 $106.39A7002 $5.12 E0130 $57.80 E0290 $725.09 E0627 $333.97A7003 $1.92 E0135 $57.90 E0291 $564.29 E0629 $330.18A7004 $1.60 E0140 $356.29 E0292 $765.26 E0630 $747.74A7005 $15.12 E0141 $60.33 E0293 $714.84 E0635 $1,486.19A7006 $9.20 E0143 $60.33 E0294 $779.21 E0636 $12,563.68A7007 $4.06 E0144 $310.87 E0295 $778.73 E0639 $1,440.41A7008 $14.70 E0147 $503.95 E0296 $1,298.68 E0640 $1,440.41A7009 $56.17 E0148 $105.11 E0297 $1,146.11 E0650 $966.22A7010 $19.60 E0149 $149.00 E0300 $2,893.94 E0651 $1,232.13A7012 $3.58 E0153 $93.10 E0301 $2,046.31 E0652 $7,112.35A7013 $0.71 E0154 $62.23 E0302 $5,983.72 E0655 $144.80A7014 $4.14 E0155 $26.55 E0303 $2,074.56 E0656 $775.28A7015 $1.61 E0156 $19.99 E0304 $6,148.10 E0657 $728.19A7016 $9.69 E0157 $71.26 E0305 $136.96 E0660 $214.32A7017 $148.26 E0158 $27.48 E0310 $142.24 E0665 $183.79A7018 $0.42 E0159 $18.64 E0316 $2,276.24 E0666 $185.27A7020 $18.64 E0160 $36.71 E0325 $11.60 E0667 $434.36A7025 $581.16 E0161 $31.43 E0326 $11.97 E0668 $592.82A7026 $38.40 E0162 $195.48 E0371 $2,445.75 E0669 $245.93A7027 $153.19 E0163 $67.11 E0372 $2,448.49 E0670 $1,686.44A7028 $42.99 E0165 $155.68 E0373 $2,448.49 E0671 $557.24A7029 $19.72 E0167 $13.78 E0424 $908.78 E0672 $432.96A7030 $114.06 E0168 $148.81 E0431 $454.39 E0673 $359.77A7031 $43.37 E0170 $2,075.63 E0433 $499.57 E0675 $5,159.10A7032 $24.25 E0171 $388.00 E0434 $454.39 E0691 $1,205.53A7033 $19.89 E0175 $79.82 E0439 $908.78 E0692 $1,513.83A7034 $71.36 E0181 $197.75 E0441 $69.10 E0693 $1,866.11A7035 $23.60 E0182 $264.74 E0442 $69.10 E0694 $5,939.66A7036 $13.56 E0184 $204.58 E0443 $62.71 E0705 $73.96A7037 $15.25 E0185 $215.49 E0444 $62.71 E0720 $85.06A7038 $2.68 E0186 $237.80 E0447 $110.31 E0730 $85.96A7039 $7.76 E0187 $270.58 E0462 $3,909.52 E0731 $106.55A7040 $52.74 E0188 $31.34 E0465 $12,549.97 E0740 $701.61A7041 $99.11 E0189 $59.27 E0466 $12,549.97 E0744 $1,228.48A7044 $106.37 E0191 $11.40 E0467 $15,140.19 E0745 $1,200.94A7045 $15.47 E0193 $8,827.71 E0470 $1,375.21 E0747 $5,253.75A7046 $17.07 E0194 $37,110.77 E0471 $3,420.56 E0748 $5,219.72A7047 $161.53 E0196 $402.90 E0472 $5,132.63 E0749 $3,815.00A7048 $55.17 E0197 $230.65 E0480 $562.39 E0760 $4,337.50A7501 $140.30 E0198 $297.28 E0482 $5,769.28 E0762 $1,253.86A7502 $66.70 E0199 $36.56 E0483 $14,262.88 E0764 $14,846.84A7503 $15.16 E0200 $106.36 E0484 $49.55 E0765 $112.87A7504 $0.91 E0202 $714.01 E0500 $1,370.68 E0776 $166.84A7505 $6.27 E0205 $221.31 E0550 $571.68 E0779 $216.47A7506 $0.44 E0210 $41.06 E0560 $168.56 E0780 $13.77A7507 $3.32 E0215 $80.79 E0561 $92.37 E0781 $2,809.07A7508 $3.83 E0217 $666.07 E0562 $176.02 E0782 $5,759.99A7509 $1.89 E0225 $521.40 E0565 $537.59 E0783 $10,983.43A7520 $63.43 E0235 $231.37 E0570 $73.67 E0784 $5,065.05A7521 $62.84 E0236 $504.45 E0572 $367.14 E0785 $633.92A7522 $60.34 E0239 $603.49 E0574 $540.10 E0786 $10,327.01A7524 $103.42 E0249 $113.59 E0575 $1,341.36 E0791 $3,337.24A7525 $2.77 E0250 $773.37 E0580 $151.05 E0840 $98.29A7526 $4.52 E0251 $726.76 E0585 $362.13 E0849 $691.48A7527 $4.78 E0255 $778.97 E0600 $535.57 E0850 $140.93A8000 $204.89 E0256 $756.09 E0601 $523.88 E0855 $663.23A8001 $204.89 E0260 $779.57 E0602 $39.60 E0856 $206.45





HCPCSMaximum




Payment



E0860 $43.94 E1030 $1,347.44 E1805 $1,695.14 E2362 $121.35E0870 $156.04 E1031 $536.04 E1806 $1,421.10 E2363 $211.48E0880 $168.43 E1035 $7,389.92 E1810 $1,671.42 E2364 $128.12E0890 $159.45 E1036 $10,751.84 E1811 $1,799.32 E2365 $127.56E0900 $171.90 E1037 $1,343.38 E1812 $1,153.62 E2366 $304.83E0910 $141.01 E1038 $183.81 E1815 $1,695.14 E2367 $484.58E0911 $535.21 E1039 $412.91 E1816 $1,827.81 E2368 $597.31E0912 $1,038.47 E1050 $1,366.27 E1818 $1,865.96 E2369 $520.55E0920 $583.72 E1060 $1,691.21 E1820 $103.44 E2370 $928.45E0930 $520.90 E1070 $1,249.10 E1821 $141.19 E2371 $174.31E0935 $305.15 E1083 $897.93 E1825 $1,695.14 E2373 $1,399.41E0940 $267.48 E1084 $1,291.06 E1830 $1,695.14 E2374 $617.69E0941 $582.29 E1087 $1,697.53 E1831 $852.52 E2375 $990.19E0942 $26.62 E1088 $1,719.46 E1840 $5,134.42 E2376 $1,552.22E0944 $61.53 E1092 $1,724.11 E1841 $6,077.29 E2377 $561.43E0945 $59.46 E1093 $1,424.56 E2000 $695.29 E2378 $686.59E0946 $793.75 E1100 $1,392.49 E2100 $733.46 E2381 $86.60E0947 $813.62 E1110 $1,363.77 E2101 $252.97 E2382 $23.60E0948 $763.73 E1150 $1,094.38 E2120 $3,803.67 E2383 $172.69E0950 $120.20 E1160 $838.57 E2201 $383.54 E2384 $92.02E0951 $21.96 E1161 $3,174.30 E2202 $558.80 E2385 $56.27E0952 $21.79 E1170 $1,198.32 E2203 $522.69 E2386 $171.11E0953 $113.98 E1171 $1,075.30 E2204 $914.74 E2387 $73.83E0954 $71.33 E1172 $1,314.30 E2205 $43.09 E2388 $58.25E0955 $233.87 E1180 $1,155.52 E2206 $47.42 E2389 $31.65E0956 $113.98 E1190 $1,335.04 E2207 $57.18 E2390 $49.48E0957 $159.50 E1195 $1,446.97 E2208 $135.03 E2391 $23.70E0958 $520.07 E1200 $1,167.33 E2209 $121.86 E2392 $62.29E0959 $55.44 E1221 $637.48 E2210 $7.56 E2394 $88.77E0960 $105.21 E1222 $909.38 E2211 $42.29 E2395 $63.07E0961 $25.64 E1223 $926.18 E2212 $7.75 E2396 $76.90E0966 $88.80 E1224 $925.35 E2213 $36.95 E2397 $555.59E0967 $86.66 E1225 $472.51 E2214 $40.66 E2402 $8,381.67E0968 $204.31 E1226 $474.30 E2215 $12.67 E2500 $524.62E0969 $210.14 E1227 $372.30 E2219 $50.34 E2502 $1,604.25E0971 $37.86 E1228 $375.96 E2220 $32.54 E2504 $2,116.24E0973 $132.94 E1230 $3,034.40 E2221 $33.04 E2506 $3,103.04E0974 $91.93 E1232 $2,869.02 E2222 $27.61 E2508 $4,798.32E0978 $41.97 E1233 $2,972.49 E2224 $117.34 E2510 $9,080.19E0980 $41.36 E1234 $2,587.95 E2225 $23.28 E2601 $70.72E0981 $54.52 E1235 $2,492.11 E2226 $48.82 E2602 $138.06E0982 $59.56 E1236 $2,198.52 E2227 $2,412.97 E2603 $175.27E0983 $3,353.10 E1237 $2,217.72 E2228 $1,182.11 E2604 $217.87E0984 $2,242.99 E1238 $2,198.52 E2231 $172.71 E2605 $311.26E0985 $272.37 E1240 $1,339.81 E2310 $1,352.92 E2606 $485.57E0986 $6,525.96 E1270 $1,014.51 E2311 $2,739.57 E2607 $335.15E0988 $3,861.48 E1280 $1,496.79 E2312 $3,318.17 E2608 $402.49E0990 $116.01 E1295 $1,421.34 E2313 $413.39 E2611 $361.18E0992 $100.18 E1296 $659.59 E2321 $2,993.35 E2612 $488.59E0994 $21.81 E1297 $140.35 E2322 $3,169.65 E2613 $454.49E0995 $35.14 E1298 $551.37 E2323 $79.98 E2614 $628.97E1002 $4,686.59 E1310 $2,448.80 E2324 $50.67 E2615 $523.01E1003 $5,077.80 E1353 $38.00 E2325 $1,557.47 E2616 $703.71E1004 $5,630.05 E1355 $28.63 E2326 $401.58 E2619 $59.33E1005 $6,094.10 E1372 $157.30 E2327 $4,589.20 E2620 $633.30E1006 $7,464.66 E1390 $908.78 E2328 $5,729.82 E2621 $664.61E1007 $10,107.80 E1391 $908.78 E2329 $2,042.13 E2622 $383.28E1008 $10,108.52 E1392 $499.57 E2330 $3,956.84 E2623 $487.71E1010 $1,322.64 E1405 $1,270.08 E2340 $480.77 E2624 $386.43E1012 $1,322.64 E1406 $981.73 E2341 $721.21 E2625 $489.20E1014 $490.03 E1700 $462.73 E2342 $601.02 E2626 $833.30E1015 $149.12 E1701 $14.22 E2343 $961.63 E2627 $1,329.68E1016 $151.86 E1702 $30.28 E2351 $807.84 E2628 $1,001.70E1020 $281.31 E1800 $1,643.53 E2359 $224.62 E2629 $1,267.62E1028 $238.76 E1801 $1,730.78 E2360 $128.12 E2630 $886.44E1029 $427.21 E1802 $4,384.41 E2361 $158.61 E2631 $301.42





HCPCSMaximum




Payment



E2632 $191.65 K0808 $4,409.94 L0468 $579.69 L1210 $267.85E2633 $191.24 K0813 $3,852.95 L0469 $579.69 L1220 $277.44K0001 $339.82 K0814 $3,984.99 L0470 $695.80 L1230 $581.90K0002 $586.42 K0815 $4,397.07 L0472 $494.10 L1240 $84.96K0003 $509.45 K0816 $4,077.36 L0480 $1,703.74 L1250 $77.71K0004 $627.62 K0820 $3,958.08 L0482 $1,736.39 L1260 $82.03K0005 $2,837.75 K0821 $4,084.58 L0484 $1,819.20 L1270 $79.32K0006 $931.51 K0822 $4,392.49 L0486 $1,930.08 L1280 $91.88K0007 $1,308.22 K0823 $4,087.63 L0488 $1,072.63 L1290 $82.19K0009 $1,115.70 K0824 $6,300.03 L0490 $302.29 L1300 $1,729.27K0010 $6,649.97 K0825 $5,837.19 L0491 $820.64 L1310 $1,936.93K0011 $8,878.46 K0826 $10,666.58 L0492 $539.77 L1600 $131.91K0012 $5,072.26 K0827 $9,319.95 L0621 $123.71 L1610 $44.94K0015 $240.23 K0828 $13,219.50 L0622 $328.32 L1620 $144.50K0017 $67.62 K0829 $12,803.26 L0625 $58.85 L1630 $187.36K0018 $37.80 K0835 $4,729.81 L0626 $83.28 L1640 $494.12K0019 $23.16 K0836 $4,905.82 L0627 $439.24 L1650 $237.02K0020 $61.46 K0837 $6,066.46 L0628 $89.65 L1652 $380.89K0037 $64.80 K0838 $5,376.98 L0630 $173.06 L1660 $189.84K0038 $32.10 K0839 $8,058.33 L0631 $1,096.95 L1680 $1,663.01K0039 $71.29 K0840 $12,372.32 L0633 $306.42 L1685 $1,217.64K0040 $98.77 K0841 $5,330.10 L0635 $1,129.13 L1686 $946.89K0041 $70.06 K0842 $5,322.34 L0636 $1,472.21 L1690 $2,066.30K0042 $41.67 K0843 $6,318.34 L0637 $1,201.02 L1700 $1,681.28K0043 $25.84 K0848 $10,665.20 L0638 $1,409.31 L1710 $2,034.18K0044 $22.03 K0849 $10,253.81 L0639 $1,201.02 L1720 $1,419.02K0045 $76.19 K0850 $12,371.07 L0640 $1,118.15 L1730 $1,210.73K0046 $25.84 K0851 $11,894.91 L0641 $83.28 L1755 $1,620.72K0047 $101.14 K0852 $14,294.01 L0642 $439.24 L1810 $116.71K0050 $41.67 K0853 $14,683.61 L0643 $173.06 L1812 $116.71K0051 $69.57 K0854 $19,452.54 L0648 $1,096.95 L1820 $147.67K0052 $122.31 K0855 $18,375.81 L0649 $306.42 L1830 $114.46K0053 $134.98 K0856 $11,447.74 L0650 $1,201.02 L1831 $314.49K0056 $145.94 K0857 $11,677.29 L0651 $1,201.02 L1832 $622.36K0065 $68.25 K0858 $14,203.43 L0700 $2,069.56 L1833 $622.36K0069 $153.32 K0859 $13,545.72 L0710 $2,337.54 L1834 $794.64K0070 $281.28 K0860 $20,291.39 L0810 $2,814.57 L1836 $142.59K0071 $167.66 K0861 $11,466.05 L0820 $2,764.11 L1840 $1,088.80K0072 $94.86 K0862 $14,203.43 L0830 $3,877.05 L1843 $958.78K0073 $51.37 K0863 $20,291.39 L0859 $1,247.07 L1844 $2,153.74K0077 $90.31 K0864 $24,146.84 L0861 $230.30 L1845 $868.94K0098 $34.92 L0112 $1,495.57 L0970 $117.00 L1846 $1,308.78K0105 $152.63 L0113 $316.57 L0972 $105.36 L1847 $614.60K0195 $158.67 L0120 $36.22 L0974 $189.64 L1848 $614.60K0455 $4,134.65 L0130 $201.51 L0976 $200.39 L1850 $329.04K0552 $3.66 L0140 $87.37 L0978 $210.06 L1851 $958.78K0553 $348.29 L0150 $116.35 L0980 $19.01 L1852 $868.94K0554 $336.17 L0160 $160.32 L0982 $17.74 L1860 $1,343.01K0601 $1.66 L0170 $777.69 L0984 $69.99 L1900 $304.47K0602 $9.38 L0172 $140.36 L1000 $2,489.17 L1902 $100.20K0603 $0.85 L0174 $295.51 L1005 $3,420.05 L1904 $481.37K0604 $9.04 L0180 $430.86 L1010 $71.26 L1906 $123.11K0605 $21.61 L0190 $606.18 L1020 $104.46 L1907 $601.26K0606 $39,311.88 L0200 $676.88 L1025 $127.64 L1910 $346.26K0607 $336.62 L0220 $134.85 L1030 $66.91 L1920 $458.70K0608 $210.10 L0450 $234.96 L1040 $98.78 L1930 $282.81K0609 $1,397.10 L0454 $370.59 L1050 $104.90 L1932 $953.53K0672 $115.75 L0455 $370.59 L1060 $115.35 L1940 $543.84K0730 $2,691.20 L0456 $1,062.76 L1070 $104.28 L1945 $1,069.30K0733 $40.64 L0457 $1,062.76 L1080 $64.44 L1950 $1,016.64K0738 $581.29 L0458 $952.97 L1085 $168.23 L1951 $897.40K0800 $1,224.53 L0460 $1,072.63 L1090 $101.75 L1960 $567.41K0801 $2,239.34 L0462 $1,334.19 L1100 $184.90 L1970 $757.22K0802 $2,984.14 L0464 $1,588.33 L1110 $305.97 L1971 $500.85K0806 $1,840.81 L0466 $482.96 L1120 $50.32 L1980 $480.48K0807 $2,852.80 L0467 $482.96 L1200 $2,138.55 L1990 $580.59





HCPCSMaximum




Payment



L2000 $1,384.41 L2500 $346.74 L3390 $52.96 L3925 $62.16L2005 $4,378.63 L2510 $845.84 L3400 $43.50 L3927 $34.00L2010 $1,249.72 L2520 $498.33 L3410 $99.20 L3929 $94.89L2020 $1,593.72 L2525 $1,328.33 L3420 $58.45 L3930 $94.89L2030 $1,372.54 L2526 $934.88 L3430 $171.23 L3931 $187.36L2034 $2,166.87 L2530 $251.13 L3440 $81.55 L3933 $207.47L2035 $192.27 L2540 $545.90 L3450 $112.81 L3935 $214.83L2036 $2,450.13 L2550 $320.78 L3455 $43.50 L3960 $827.79L2037 $2,021.33 L2570 $502.28 L3460 $36.66 L3961 $1,633.87L2038 $1,702.77 L2580 $561.48 L3465 $62.51 L3962 $894.55L2040 $233.89 L2600 $243.52 L3470 $66.59 L3967 $1,929.05L2050 $494.56 L2610 $293.48 L3480 $66.59 L3971 $1,831.13L2060 $700.21 L2620 $321.95 L3500 $31.25 L3973 $1,929.05L2070 $137.67 L2622 $313.92 L3510 $31.25 L3975 $1,633.87L2080 $424.46 L2624 $338.99 L3520 $33.94 L3976 $1,633.87L2090 $598.49 L2627 $1,754.87 L3530 $33.94 L3977 $1,831.13L2106 $717.42 L2628 $2,286.74 L3540 $54.38 L3978 $1,929.05L2108 $1,226.72 L2630 $267.75 L3550 $9.49 L3980 $309.67L2112 $495.18 L2640 $417.31 L3560 $24.49 L3981 $978.87L2114 $607.63 L2650 $163.79 L3570 $91.09 L3982 $373.95L2116 $728.74 L2660 $190.79 L3580 $69.30 L3984 $359.85L2126 $1,225.81 L2670 $180.53 L3590 $57.08 L3995 $36.36L2128 $2,340.43 L2680 $160.19 L3595 $44.83 L4000 $1,482.82L2132 $825.79 L2750 $100.53 L3600 $81.55 L4010 $819.31L2134 $1,035.37 L2755 $139.64 L3610 $107.35 L4020 $980.92L2136 $1,210.59 L2760 $63.52 L3620 $81.55 L4030 $676.38L2180 $119.88 L2768 $139.21 L3630 $107.35 L4040 $557.14L2182 $110.31 L2780 $92.37 L3640 $46.20 L4045 $338.74L2184 $126.81 L2785 $35.81 L3650 $63.33 L4050 $509.18L2186 $177.42 L2795 $107.83 L3660 $102.95 L4055 $277.61L2188 $332.18 L2800 $125.17 L3670 $117.74 L4060 $413.63L2190 $89.39 L2810 $79.95 L3671 $876.29 L4070 $341.01L2192 $365.00 L2820 $88.90 L3674 $1,149.51 L4080 $122.62L2200 $64.89 L2830 $96.17 L3675 $170.67 L4090 $123.14L2210 $72.14 L2840 $44.73 L3702 $280.80 L4100 $142.36L2220 $99.06 L2850 $63.38 L3710 $123.83 L4110 $115.74L2230 $96.43 L3000 $335.67 L3720 $782.60 L4130 $677.17L2232 $106.35 L3001 $141.34 L3730 $1,052.90 L4350 $100.78L2240 $86.42 L3002 $172.57 L3740 $1,074.81 L4360 $377.93L2250 $484.98 L3003 $186.22 L3760 $486.31 L4361 $377.93L2260 $205.21 L3010 $186.22 L3761 $486.31 L4370 $257.68L2265 $120.56 L3020 $212.00 L3762 $104.57 L4386 $169.41L2270 $73.30 L3030 $81.55 L3763 $718.96 L4387 $169.41L2275 $160.11 L3031 $136.00 L3764 $807.26 L4392 $24.73L2280 $464.24 L3040 $50.27 L3765 $1,246.95 L4394 $18.01L2300 $343.63 L3050 $50.27 L3766 $1,320.43 L4396 $176.31L2310 $167.91 L3060 $78.80 L3806 $441.75 L4397 $176.31L2320 $269.07 L3070 $33.94 L3807 $243.17 L4398 $81.17L2330 $475.55 L3080 $33.94 L3808 $350.42 L4631 $1,634.63L2335 $254.60 L3090 $43.50 L3809 $243.17 L5000 $574.96L2340 $564.95 L3100 $46.20 L3900 $1,458.81 L5010 $1,385.41L2350 $1,029.07 L3140 $95.15 L3901 $1,803.54 L5020 $2,569.27L2360 $70.61 L3150 $86.98 L3904 $2,933.47 L5050 $3,067.54L2370 $280.80 L3170 $54.38 L3905 $964.42 L5060 $4,070.54L2375 $115.67 L3224 $60.20 L3906 $415.13 L5100 $3,179.51L2380 $128.30 L3225 $69.25 L3908 $80.02 L5105 $4,487.38L2385 $137.11 L3300 $55.71 L3912 $126.66 L5150 $4,639.91L2387 $207.89 L3310 $86.98 L3913 $263.39 L5160 $5,660.84L2390 $112.06 L3330 $604.74 L3915 $516.93 L5200 $4,635.47L2395 $160.16 L3332 $78.80 L3916 $516.93 L5210 $3,681.83L2397 $135.28 L3334 $40.79 L3917 $102.76 L5220 $4,185.08L2405 $93.15 L3340 $91.09 L3918 $102.76 L5230 $5,597.28L2415 $129.78 L3350 $24.49 L3919 $263.39 L5250 $7,283.74L2425 $153.17 L3360 $38.05 L3921 $312.37 L5270 $7,803.59L2430 $153.17 L3370 $52.96 L3923 $95.77 L5280 $7,725.56L2492 $108.23 L3380 $52.96 L3924 $95.77 L5301 $3,188.10





HCPCSMaximum




Payment



L5312 $5,004.79 L5670 $337.05 L5858 $20,762.35 L6590 $3,690.44L5321 $4,925.10 L5671 $754.72 L5859 $17,176.83 L6600 $231.28L5331 $6,988.13 L5672 $367.21 L5910 $412.15 L6605 $218.20L5341 $7,293.69 L5673 $815.14 L5920 $603.80 L6610 $199.00L5400 $1,521.80 L5676 $480.39 L5925 $496.32 L6611 $459.97L5410 $584.98 L5677 $611.52 L5930 $3,760.22 L6615 $243.20L5420 $1,838.11 L5678 $53.85 L5940 $709.71 L6616 $88.63L5430 $573.74 L5679 $679.28 L5950 $1,020.12 L6620 $380.92L5450 $502.08 L5680 $403.49 L5960 $1,165.95 L6621 $2,555.26L5460 $664.78 L5681 $1,469.47 L5961 $5,520.82 L6623 $819.46L5500 $1,461.53 L5682 $719.50 L5962 $891.85 L6624 $4,207.29L5505 $1,979.29 L5683 $1,469.47 L5964 $1,283.90 L6625 $700.82L5510 $1,795.22 L5684 $73.02 L5966 $1,664.50 L6628 $658.13L5520 $1,636.47 L5685 $143.09 L5968 $4,059.63 L6629 $166.79L5530 $2,283.71 L5686 $72.54 L5970 $279.14 L6630 $245.25L5535 $2,358.88 L5688 $79.41 L5971 $279.14 L6632 $73.94L5540 $2,517.80 L5690 $120.80 L5972 $446.11 L6635 $215.03L5560 $2,459.79 L5692 $177.47 L5973 $19,638.74 L6637 $494.45L5570 $2,587.21 L5694 $274.18 L5974 $353.58 L6638 $2,793.69L5580 $2,963.82 L5695 $185.58 L5975 $517.89 L6640 $392.04L5585 $3,284.92 L5696 $280.73 L5976 $712.41 L6641 $195.43L5590 $2,875.79 L5697 $121.81 L5978 $402.63 L6642 $264.28L5595 $5,137.04 L5698 $142.29 L5979 $3,430.13 L6645 $451.14L5600 $6,474.88 L5699 $279.73 L5980 $4,613.35 L6646 $3,523.47L5610 $3,022.63 L5700 $4,155.17 L5981 $3,727.58 L6647 $580.05L5611 $2,007.69 L5701 $5,049.42 L5982 $869.60 L6648 $3,633.95L5613 $2,788.82 L5702 $6,046.24 L5984 $822.09 L6650 $389.08L5614 $1,885.13 L5703 $2,788.38 L5985 $315.48 L6655 $113.98L5616 $1,545.54 L5704 $693.92 L5986 $870.10 L6660 $120.65L5617 $625.05 L5705 $1,139.24 L5987 $8,036.45 L6665 $56.11L5618 $355.50 L5706 $1,129.14 L5988 $2,231.73 L6670 $58.03L5620 $337.55 L5707 $1,605.12 L5990 $2,026.76 L6672 $220.30L5622 $476.07 L5710 $517.77 L6000 $2,016.01 L6675 $136.66L5624 $428.60 L5711 $700.95 L6010 $2,243.49 L6676 $168.00L5626 $622.28 L5712 $629.27 L6020 $2,091.71 L6677 $331.40L5628 $688.02 L5714 $475.98 L6026 $4,969.60 L6680 $270.71L5629 $361.65 L5716 $829.40 L6050 $2,470.63 L6682 $344.43L5630 $576.33 L5718 $1,036.65 L6055 $3,689.05 L6684 $527.73L5631 $500.00 L5722 $1,207.04 L6100 $2,661.20 L6686 $756.59L5632 $336.90 L5724 $1,827.72 L6110 $2,714.24 L6687 $656.39L5634 $401.35 L5726 $2,211.96 L6120 $3,413.08 L6688 $803.77L5636 $357.71 L5728 $2,943.79 L6130 $3,927.85 L6689 $983.76L5637 $338.80 L5780 $1,302.88 L6200 $4,031.02 L6690 $1,043.32L5638 $627.79 L5781 $4,469.87 L6205 $5,050.30 L6691 $451.37L5639 $1,438.01 L5782 $4,712.26 L6250 $3,759.21 L6692 $636.39L5640 $952.38 L5785 $706.29 L6300 $5,287.81 L6693 $3,171.58L5642 $940.06 L5790 $850.42 L6310 $4,389.32 L6694 $815.14L5643 $2,033.29 L5795 $1,221.82 L6320 $1,944.71 L6695 $679.28L5644 $750.44 L5810 $632.68 L6350 $5,943.13 L6696 $1,469.47L5645 $907.98 L5811 $829.94 L6360 $4,832.86 L6697 $1,469.47L5646 $667.44 L5812 $718.26 L6370 $2,311.31 L6698 $754.72L5647 $905.21 L5814 $4,148.94 L6380 $1,556.14 L6703 $375.70L5648 $749.21 L5816 $967.79 L6382 $1,831.92 L6704 $713.13L5649 $2,290.22 L5818 $1,092.82 L6384 $2,319.23 L6706 $453.62L5650 $653.08 L5822 $1,937.85 L6386 $525.31 L6707 $1,600.34L5651 $1,366.61 L5824 $1,745.15 L6388 $577.37 L6708 $1,116.70L5652 $496.13 L5826 $3,624.10 L6400 $2,946.17 L6709 $1,601.36L5653 $813.98 L5828 $3,213.55 L6450 $3,999.39 L6711 $751.07L5654 $440.88 L5830 $2,801.98 L6500 $4,045.09 L6712 $1,382.86L5655 $395.05 L5840 $4,593.05 L6550 $5,411.19 L6713 $1,745.34L5656 $562.84 L5845 $2,002.34 L6570 $6,031.92 L6714 $1,478.30L5658 $551.68 L5848 $1,201.29 L6580 $2,049.87 L6715 $3,526.96L5661 $692.51 L5850 $145.57 L6582 $1,628.98 L6721 $2,627.48L5665 $582.67 L5855 $468.59 L6584 $2,767.74 L6722 $2,265.09L5666 $80.84 L5856 $26,818.00 L6586 $2,365.44 L6805 $481.31L5668 $127.68 L5857 $9,516.07 L6588 $4,005.18 L6810 $227.76





HCPCSMaximum




Payment



L6880 $26,691.38 L8047 $1,550.94 L8693 $1,693.96 Q4035 $14.62L6881 $4,567.16 L8300 $119.27 L8694 $1,054.99 Q4036 $36.37L6882 $3,464.41 L8310 $167.05 L8695 $18.60 Q4037 $17.82L6883 $2,331.97 L8320 $63.61 L8696 $242.14 Q4038 $44.67L6884 $3,186.63 L8330 $56.18 Q0477 $107.14 Q4039 $8.94L6885 $4,832.86 L8400 $21.12 Q0478 $188.02 Q4040 $22.34L6890 $211.31 L8410 $30.11 Q0479 $12,250.54 Q4041 $21.69L6895 $705.51 L8415 $30.91 Q0480 $92,152.19 Q4042 $37.02L6900 $2,209.63 L8417 $84.01 Q0481 $14,867.67 Q4043 $10.86L6905 $2,227.71 L8420 $22.82 Q0482 $4,656.84 Q4044 $18.52L6910 $1,828.36 L8430 $26.07 Q0483 $19,184.09 Q4045 $12.59L6915 $826.30 L8435 $31.91 Q0484 $3,725.50 Q4046 $20.24L6920 $8,854.95 L8440 $47.59 Q0485 $359.67 Q4047 $6.27L6925 $9,684.14 L8460 $99.32 Q0486 $299.37 Q4048 $10.12L6930 $9,607.50 L8465 $55.51 Q0487 $349.27 Q4049 $2.29L6935 $10,153.78 L8470 $7.59 Q0489 $16,631.56L6940 $11,502.93 L8480 $13.96 Q0490 $719.41L6945 $12,745.16 L8485 $16.37 Q0491 $1,130.98L6950 $12,014.44 L8500 $888.41 Q0492 $91.10L6955 $13,591.38 L8501 $137.46 Q0493 $259.45L6960 $14,802.56 L8507 $46.79 Q0494 $219.56L6965 $16,716.26 L8509 $122.01 Q0495 $4,273.88L6970 $16,597.22 L8510 $282.28 Q0496 $1,533.96L6975 $18,185.29 L8511 $81.25 Q0497 $479.00L7007 $3,970.19 L8512 $2.41 Q0498 $525.57L7008 $6,876.26 L8513 $5.80 Q0499 $170.76L7009 $4,293.77 L8514 $105.34 Q0500 $31.25L7040 $3,427.60 L8515 $70.50 Q0501 $522.52L7045 $1,839.33 L8600 $829.90 Q0502 $665.24L7170 $6,948.55 L8603 $501.27 Q0503 $1,330.52L7180 $41,692.61 L8605 $800.14 Q0504 $702.09L7181 $44,761.85 L8606 $254.18 Q0506 $873.93L7185 $7,298.59 L8607 $47.90 Q4001 $53.10L7186 $10,065.99 L8609 $7,278.70 Q4002 $200.62L7190 $9,067.10 L8610 $754.92 Q4003 $38.12L7191 $10,518.35 L8612 $824.16 Q4004 $131.98L7259 $4,735.61 L8613 $342.53 Q4005 $14.06L7360 $302.02 L8614 $21,377.75 Q4006 $31.67L7362 $313.06 L8615 $503.85 Q4007 $7.03L7364 $592.98 L8616 $117.36 Q4008 $15.83L7366 $766.47 L8617 $102.50 Q4009 $9.39L7367 $434.94 L8618 $29.30 Q4010 $21.12L7368 $563.81 L8619 $9,177.32 Q4011 $4.68L7400 $342.40 L8621 $0.69 Q4012 $10.58L7401 $383.31 L8622 $0.35 Q4013 $17.09L7402 $413.95 L8623 $72.26 Q4014 $28.80L7403 $411.39 L8624 $180.16 Q4015 $8.56L7404 $620.94 L8625 $210.98 Q4016 $14.40L7405 $812.09 L8627 $7,741.65 Q4017 $9.87L7700 $146.89 L8628 $1,435.65 Q4018 $15.74L8000 $46.96 L8629 $200.03 Q4019 $4.95L8001 $140.13 L8630 $383.38 Q4020 $7.89L8002 $184.29 L8631 $2,425.22 Q4021 $7.31L8015 $69.55 L8641 $531.12 Q4022 $13.18L8020 $274.16 L8642 $349.52 Q4023 $3.68L8030 $359.01 L8658 $463.09 Q4024 $6.61L8031 $359.01 L8659 $2,155.73 Q4025 $40.97L8032 $45.44 L8670 $633.46 Q4026 $127.97L8035 $4,092.82 L8679 $9,683.30 Q4027 $20.50L8040 $2,793.04 L8681 $1,227.63 Q4028 $64.02L8041 $3,366.75 L8682 $6,918.56 Q4029 $31.35L8042 $3,782.83 L8683 $6,089.90 Q4030 $82.51L8043 $4,236.78 L8684 $901.35 Q4031 $15.66L8044 $4,690.71 L8689 $1,927.01 Q4032 $41.26L8045 $2,944.55 L8690 $5,314.47 Q4033 $29.25L8046 $3,026.24 L8691 $1,923.88 Q4034 $72.70



Documents

Listing of a payment amount does not guarantee payment ......A7045 $15.47 E0193 $8,827.71 E0470 $1,375.21 E0747 $5,253.75 A7046 $17.07 E0194 $37,110.77 E0471 $3,420.56 E0748 $5,219.72