Palmetto Government Benefits Administrators DMERC MEDICARE ... · Palmetto GBA Announces a New Medical Director Palmetto Government Benefits Administrators (Palmetto GBA) is proud

Palmetto GBA Announces a New Medical Director

Palmetto Government Benefits Administrators (Palmetto GBA) is proud to announce that in January,1995, Dr. Paul Metzger will be the Region C Medical Director. Dr. Metzger brings to Palmetto GBAinvaluable DMERC experience and knowledge. Formerly, he was the Region A Medical Director and ledTravelers DMERC medical policy development. Most recently he was recognized by the Health CareFinancing Administration (HCFA) for his contributions to the DMERC program.

Prior to working at Travelers, Dr. Metzger had a private family practice in Scranton, Pennsylvania. He is agraduate of Temple University Medical School and a member of the American Academy of Family Prac-tice.

Effective in January 1995, Dr. Metzger will be located at our Palmetto GBA offices in Columbia, SouthCarolina. Welcome aboard Dr. Metzger. We look forward to working with you!

ATTENTION PHYSICIANS AND SUPPLIERS

New Interest Rate Payable on Clean Claims .......................... 94-228DMERC Medicare Advisory Update ........................................ 94-228Q & A ...................................................................................... 94-229Disclosure of Patient Social Security Act Information ............. 94-230Anti-Fraud Unit:OIG Notice, Supplier Sanctions, Fraud Alert .................... 94-230-231Beneficiary Eligibility Specifications ........................................ 94-231EDI Added Benefit: Claims Status Inquiry, ERNs ................... 94-232New HCPCS Codes and Category Assignment ...................... 94-232EDI Receives Misdirected Paper Claims ................................ 94-233DMERC Certified Software Vendors, Billing Services& Clearinghouses ............................................................. 94-233-2481995 Modifier and HCPCS Update .................................. 94-249-2541995 DME Fee Schedule ................................................. 94-255-274Region C Directory .................................................................. 94-275Ombudsmen Addresses and Their Territories ........................ 94-276Glossary .................................................................................. 94-277

Palmetto Government Benefits Administrators

Durable Medical Equipment Regional Carrier P.O. Box 100141 Columbia, SC 29202-3141

DECEMBER 1994 ISSUE 9PAGE 94-205

IN THIS ISSUE:Palmetto GBA New Medical Director ...................................... 94-205CMN Deferred Implementation ................................................ 94-206Supplier Satisfaction Survey ................................................... 94-206Professional Relations Staff .................................................... 94-206Medical Policy: New Releases EPO ............................................................................. 94-207-209 Lower Limb Prostheses ................................................ 94-210-216 Therapeutic Shoes ....................................................... 94-217-219 Orthopedic Footwear .................................................... 94-220-222Oral Anticancer Drug Additions ............................................... 94-223Prior Authorization Telephone Number Discontinued ............. 94-223Claim Filing Reminder ............................................................. 94-223Oxygen Billing Tips ................................................................. 94-224Lymphedema Pumps/Pneumatic Compressors ...................... 94-225DMEPOS Supplier Specialty Workshop Notice....................... 94-226Complementary/Supplemental Policies Update ...................... 94-227Helpful Hints ............................................................................ 97-227

Alabama GeorgiaArkansas KentuckyColorado LouisianaFlorida Mississippi

New Mexico South CarolinaNorth Carolina Tennessee

Oklahoma TexasPuerto Rico Virgin Islands

DMERCMEDICARE ADVISORY

Page 94-206 December 1994 DMERC Medicare Advisory

Supplier satisfaction surveys are being conducted with a random group (approxi-mately 10%) of Region C suppliers. If you should receive a supplier satisfactionsurvey, we would appreciate your prompt input and response. Results of the surveyresponses will be published in a future issue of the DMERC Medicare Advisory.

SUPPLIERSATISFACTIONSURVEY

PROFESSIONALRELATIONSSTAFF

Alison SantoroOmbudsman

Vince TemplesOmbudsman

CERTIFICATE OFMEDICAL NECESSITY(CMN) DEFERREDIMPLEMENTATION

The following are changes to the date for the implementation of the requirement thatphysicians complete Durable Medical Equipment (DME) Certificates of MedicalNecessity (CMNs). These changes affect all suppliers in all four DMERC regions.

The Health Care Financing Administration (HCFA) has extended the deferment ofthe requirement that physicians complete the medical portion for most DME CMNs.For dates of services prior to October 1, 1995, physicians still must review and signall CMNs, but do not have to complete the medical portion of the CMN. HCFA isworking with physician and supplier associations to develop a process that meetsthe requirements of the law while keeping burden to a minimum. Effective with thedate of service of October 1, 1995, physicians must complete the medical portionin addition to signing the CMN, unless an alternative process has been selected.

NOTE: This deferment does not apply to the physician completion of CMNs for thefollowing six items: Transcutaneous Electrical Nerve Stimulators (TENS), PowerOperated Vehicles (POVs), air-fluidized beds, alternating pressure pads andmattresses, seat lift mechanisms and oxygen (HCFA-484). CMNs for these itemsmust continue to be completed and signed by the physician.

In addition, effective December 1, 1994, physicians will now be required tocomplete and sign the CMN for lymphedema pumps.

Alison Santoro is the new ombudsman for southern Florida and Puerto Rico.She will be relocating to Miami, Florida in April 1995 after a few months of intensetraining at the Region C offices in Columbia, South Carolina. After obtaining herBachelor of Arts degree, Alison continued her education to complete her Master ofBusiness Administration degree from the University of South Carolina. An avidtraveler, Alison has lived and studied in Ecuador, Chile and Venezuela, and is fluentin Spanish. After her schooling, Alison secured a position as a Sales Representativefor a company in Atlanta, GA. Her responsibilities included servicing a seven stateterritory, providing technological support to her customers. In recent years, she hasheld a number of Marketing Consultant and Public Relation positions. While in theseroles, she successfully coordinated several national projects, as well as planned andimplemented a series of focus group meetings as part of an international networkingventure. Alison is excited about applying her talents in her position with PalmettoGBA. She looks forward to her move to Florida and her challenge to successfullysupport Palmetto GBA suppliers. In the interim, Alison can be reached at (803) 735-1034, Ext. 35715.

Vince Temples is the new ombudsman covering Georgia and Tennessee. Aftercompleting his Palmetto GBA training, he will be relocating to Atlanta, Georgia tofulfill his new responsibilities. Vince is a native of Augusta, Georgia, where heobtained his Bachelor of Arts Degree from Augusta College. He joins Palmetto GBAwith three years of Medicare Claims Analyst experience. In addition, for the last 18months, Vince has been an Ombudsman for the Travelers Insurance Company, theRegion A DMERC. He is a veteran at serving Medicare Durable Medical Equipment,Prosthetic, Orthotic and Supplies (DMEPOS) suppliers, over multiple states, underregional carrier guidelines . He has extensive knowledge of Medicare systems,pricing files and claims processing. Vince is looking forward to settling back into hisnative state in February, and applying his experience to enhance Palmetto GBA andRegion C supplier relations. In the interim, Vince can be reached at (803) 735-1034,Ext. 35728.

December 1994 DMERC Medicare Advisory Page 94-207

Medical Policies for Epoetin Alpha (EPO), Lower Limb Prostheses, TherapeuticShoes for Diabetics and Orthopedic Shoes are listed below. Each medical policywas allotted a 45-day comment and review period. These policies are permanentadditions to DMERC guidelines and therefore, will be issued to suppliers as part of afuture DMEPOS Supplier Manual revision. In the interim, please use the followingpages which have been laid out for ease of copying, to place in your DMEPOSSupplier Manual.

MEDICAL POLICY:NEW RELEASES,

Subject: Epoetin Alpha (EPO)

HCPCS CODES:Q9920 -Injection of EPO, per 1,000 units, at patient Hct of 20 or lessQ9921 -Injection of EPO, per 1,000 units, at patient Hct of 21Q9922 -Injection of EPO, per 1,000 units, at patient Hct of 22Q9923 -Injection of EPO, per 1,000 units, at patient Hct of 23Q9924 -Injection of EPO, per 1,000 units, at patient Hct of 24Q9925 -Injection of EPO, per 1,000 units, at patient Hct of 25Q9926 -Injection of EPO, per 1,000 units, at patient Hct of 26Q9927 -Injection of EPO, per 1,000 units, at patient Hct of 27Q9928 -Injection of EPO, per 1,000 units, at patient Hct of 28Q9929 -Injection of EPO, per 1,000 units, at patient Hct of 29Q9930 -Injection of EPO, per 1,000 units, at patient Hct of 30Q9931 -Injection of EPO, per 1,000 units, at patient Hct of 31Q9932 -Injection of EPO, per 1,000 units, at patient Hct of 32Q9933 -Injection of EPO, per 1,000 units, at patient Hct of 33Q9934 -Injection of EPO, per 1,000 units, at patient Hct of 34Q9935 -Injection of EPO, per 1,000 units, at patient Hct of 35Q9936 -Injection of EPO, per 1,000 units, at patient Hct of 36Q9937 -Injection of EPO, per 1,000 units, at patient Hct of 37Q9938 -Injection of EPO, per 1,000 units, at patient Hct of 38Q9939 -Injection of EPO, per 1,000 units, at patient Hct of 39Q9940 -Injection of EPO, per 1,000 units, at patient Hct of 40 or above

BENEFIT CATEGORY: Epoetin for dialysis patients

COVERAGE AND PAYMENT RULES:Epoetin (EPO) and items related to its administration are covered by the DMERC when all of the following criteria are met:1) The patient is on Method II home dialysis.2) The patient has anemia due to chronic renal failure.3) The EPO is self administered in the home by the patient (or patient caregiver) who is determined competent to use

the drug.4) Prior to initiation of home EPO therapy, the dialysis facility, or the physician responsible for all

dialysis-related services furnished to the patient, has made a comprehensive assessment thatincludes the following:a) Measurement of the patient’s hematocrit (or hemoglobin), serum iron, transferrin

saturation, serum ferritin, and blood pressure,b) Assurance that the patient or a caregiver who assists the patient is:

(i) trained by the facility to inject EPO and is capable of carrying out the procedure,(ii) capable of reading and understanding the drug labeling, and(iii) trained in, and capable of observing, aseptic techniques,

c) Assurance that the EPO can be stored in the patient’s residence under refrigeration and that the patient is awareof the potential hazard of a child’s having access to the drug and syringes.

5) For a patient who is initiating EPO treatment, the most recent hematocrit (Hct.) prior to treatment is no higher than30%, or for a patient who has been receiving EPO from a dialysis facility or a physician, the most recent hematocritprior to initiation of home EPO is between 30-33%.

6) The patient is under the care of a renal dialysis facility which has established a current careplan (a copy of which must be maintained by the designated back-up facility for Method IIpatients) for monitoring home use of EPO which includes the following:a) Review of diet and fluid intake for aberrations as indicated by hyperkalemia and

elevated blood pressure secondary to volume overload;b) Review of medications to ensure adequate provision of supplemental iron;c) Ongoing evaluations of hematocrit and iron stores;

Epoetin Alpha (EPO),Lower Limb Prostheses,Therapeutic Shoes,Orthopedic Shoes


d) Reevaluation of the dialysis prescription taking into account the patient’s increasedappetite and red blood cell volume;

e) A method for the physician and facility (including back-up facility for Method II patients)to follow-up on blood tests and a mechanism (such as a patient log) for keeping thephysician informed of the results;

f) Training of the patient to identify the signs and symptoms of hypotension and hypertension; andg) The decrease or discontinuance of EPO if hypertension is uncontrollable.

7) The patient is under the care of a physician who is responsible for all dialysis-related services and who prescribesthe EPO and follows the drug labelling instructions when monitoring the EPO home therapy.

8) The patient’s physician or dialysis facility develops a protocol that follows the drug label instructions, makes theprotocol available to the patient to ensure safe and effective home use of EPO, and maintains adequate recordsto allow quality assurance for review by the Network and State Survey agencies. (For Method II patients, currentrecords must be provided to and maintained by the designated back-up facility.)

For a patient who is initiating EPO treatment and whose pretreatment hematocrit is higher than 30% (or hemoglobin ishigher than 10 gm %), EPO will be covered if additional medical documentation establishes medical necessity in theindividual case. For example, patients with severe angina, severe pulmonary distress, or severe hypotension mayrequire EPO to prevent adverse symptoms even if they have higher hematocrit or hemoglobin levels.

The patient’s dialysis physician or facility must maintain a flow sheet or log recording the dates and results of hematocrittests, iron studies, and the EPO prescription with dates of change.

In most patients, the EPO dose and administration scheduled is adjusted to maintain the patient’s hematocrit between30-33%. The medical necessity for maintaining the hematocrit higher than 33% must be documented in the patient’smedical record and may be requested by the DMERC.

Supplies (e.g. syringe, needle, alcohol) used for the administration of EPO are included in the allowance for the EPO.These supplies should not be billed separately.

The EPO must be supplied by the Method II supplier of home dialysis equipment and supplies. The amount of EPO thatthe patient has on hand must be limited to a two-month supply by the amount prescribed by the physician and/or theamount dispensed by the facility.

Only EPO self-administered by Method II home dialysis patients (or their caregiver) is billed to the DMERC. EPOprovided in other situations (e.g. in a dialysis facility, in a physician’s office, self-administered at home by a center dialysispatient or Method I home dialysis patient, etc.) is billed to the Medicare intermediary or local carrier.

CODING GUIDELINES:The correct EPO code to use is the one which indicates the patient’s most recent hematocrit or hemoglobin (roundedto the nearest whole percent) prior to the date of service of the EPO. For example, if the patient’s most recent hematocritwas 20.5%, bill Q9921; if it was 28.4%, bill Q9928.

To convert actual hemoglobin (Hgb.) to corresponding Hct. for Q code reporting, multiply the Hgb value by 3 and roundto nearest whole number. For example, if Hgb = 8.4, report as Q9925 (8.4 X 3 = 25.2, rounded down to 25).

One unit of service of EPO is reported for each 1000 units dispensed. For example if 20,000 units are dispensed, bill20 units. If the dose dispensed is not an even multiple of 1,000, rounded down for 1-499 units (e.g. 20,400 unitsdispensed = 20 units billed), round up for 500-999 units (e.g. 20,500 units dispensed = 21 units billed).

DOCUMENTATION:A prescription (order) for the EPO which has been signed and dated by the ordering physician must be kept on file bythe supplier. The prescription must indicate the dose and frequency of administration. A new prescription would beneeded if there were a change in the dose or frequency of administration.The initial claim for EPO must include the date of the patient’s most recent hematocrit and/or hemoglobin prior to theinitiation of EPO (i.e. the test that was used to determine the code). It must also include the prescribed EPO dosagein units/kg and the patient’s weight in kg. If the claim is filed hardcopy, this information would be submitted on a separatesheet attached to the claim. If the claim is filed electronically, it would be transcribed into the HAO record. (See theDMEPOS National Standard Format Matrix for details.)

On the initial claim for EPO, a ZX modifier should be added to the EPO code if all coverage criteria (#1-8) listed in thepolicy are met. (ZX is a new modifier which indicates “The specified coverage criteria in the medical policy have beenmet and documentation is available in the supplier’s records.”) If the hematocrit prior to initiation of EPO therapy is >30%, or if other coverage criteria are not met, the ZX modifier may not be used and the initial claim must be accompanied


by a detailed justification of the medical necessity in that patient.On subsequent claims for EPO, the EJ modifier must be added to the Q code to identify claims which do not requireas much information on initial claims. The ZX modifier should not be used on subsequent claims.

On subsequent claims, if the DMERC requests additional information for patients with hematocrits in excess of 33%,then if the goal is to maintain the hematocrit at greater than 33%, the physician/supplier should send in documentation(diagnosis, patient symptoms, etc.) supporting the medical necessity; if the goal is to maintain the Hct. at < 33%, thephysician/supplier should send a copy of the flow sheet for the past 3 months documenting Hct. dates and dates of EPOprescription change.

EFFECTIVE DATE: Coverage and Payment Rules are effective for claims received by the DMERC on or after 10/1/93. Use of the ZX modifier is required for initial claims received by the DMERC on or after March 1, 1995.


Subject: Lower Limb Prostheses

HCPCS CODES:L5000 - PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLERL5010 - PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGHT, WITH TOE FILLERL5020 - PARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBERCLE HEIGHT, WITH TOE FILLERL5050 - ANKLE, SYMES, MOLDED SOCKET, SACH FOOTL5060 - ANKLE, SYMES, METAL FRAME, MOLDED LEATHER SOCKET, ARTICULATED ANKLE/FOOTL5100 - BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOTL5105 - BELOW KNEE, PLASTIC SOCKET, JOINTS AND THIGH LACER, SACH FOOTL5150 - KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS,

SHIN, SACH FOOTL5160 - KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, BENT KNEE CONFIGURATION,

EXTERNAL KNEE JOINTS, SHIN, SACH FOOTL5200 - ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, EACH FOOTL5210 - ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT (“STUBBIES”), WITH FOOT BLOCKS, NO

ANKLE JOINTS, EACHL5220 - ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT (“STUBBIES”), WITH ARTICULATED ANKLE/

FOOT, DYNAMICALLY ALIGNED, EACHL5230 - ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL DEFICIENCY, CONSTANT FRICTION KNEE, SHIN,

SACH FOOTL5250 - HIP DISARTICULATION, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT

FRICTION KNEE, SHIN, SACH FOOTL5270 - HIP DISARTICULATION, TILT TABLE TYPE; MOLDED SOCKET, LOCKING HIP JOINT, SINGLE AXIS

CONSTANT FRICTION KNEE, SHIN, SACH FOOTL5280 - HEMIPELVECTOMY, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT

FRICTION KNEE, SHIN, SACH FOOTL5300 - BELOW KNEE, MOLDED SOCKET, SACH FOOT, ENDOSKELETAL SYSTEM, INCLUDING SOFT

COVER AND FINISHINGL5310 - KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, SACH FOOT ENDOSKELETAL

SYSTEM, INCLUDING SOFT COVER AND FINISHINGL5320 - ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE AXIS

KNEE, INCLUDING SOFT COVER AND FINISHING\L5330 - HIP DISARTICULATION, CANADIAN TYPE; MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT,

SINGLE AXIS KNEE, SACH FOOT, INCLUDING SOFT COVER AND FINISHINGL5340 - HEMIPELVECTOMY, CANADIAN TYPE; MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT,

SINGLE AXIS KNEE, SACH FOOT, INCLUDING SOFT COVER AND FINISHINGL5400 - IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING,

INCLUDING FITTING, ALIGNMENT, SUSPENSION, AND ONE CAST CHANGE, BELOW KNEEL5410 - IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING,

INCLUDING FITTING, ALIGNMENT AND SUSPENSION, BELOW KNEE, EACH ADDITIONAL CASTCHANGE AND REALIGNMENT

L5420 - IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING,INCLUDING FITTING, ALIGNMENT AND SUSPENSION AND ONE CAST CHANGE “AK” OR KNEEDISARTICULATION

L5430 - IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCL.FITTING, ALIGNMENT AND SUSPENSION, “AK” OR KNEE DISARTICULATION, EACH ADDITIONALCAST CHANGE AND REALIGNMENT

L5450 - IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON WEIGHT BEARING RIGIDDRESSING, BELOW KNEE

L5460 - IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON WEIGHT BEARING RIGIDDRESSING, ABOVE KNEE

L5500 - INITIAL, BELOW KNEE “PTB” TYPE SOCKET, “USMC” OR EQUAL PYLON, NO COVER, SACH FOOT,PLASTER SOCKET, DIRECT FORMED

L5505 - INITIAL, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, ‘USMC’ OR EQUALPYLON, NO COVER, SACH FOOT PLASTER SOCKET, DIRECT FORMED

L5510 - PREPARATORY, BELOW KNEE “PTB” TYPE SOCKET, ‘USMC’ OR EQUAL PYLON, NO COVER, SACHFOOT, PLASTER SOCKET, MOLDED TO MODEL

L5520 - PREPARATORY, BELOW KNEE “PTB” TYPE SOCKET, “USMC” OR EQUAL PYLON, NO COVER, SACHFOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMED

L5530 - PREPARATORY, BELOW KNEE “PTB” TYPE SOCKET, “USMC” OR EQUAL PYLON, NO COVER, SACHFOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL

L5535 - PREPARATORY, BELOW KNEE “PTB” TYPE SOCKET, USMC OR EQUAL PYLON, NO COVER, SACHFOOT, PREFABRICATED, ADJUSTABLE OPEN END SOCKET

L5540 - PREPARATORY, BELOW KNEE “PTB” TYPE SOCKET, “USMC” OR EQUAL PYLON, NO COVER, SACHFOOT, LAMINATED SOCKET, MOLDED TO MODEL

L5560 - PREPARATORY, ABOVE KNEE- KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, “USMC” OREQUAL PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO MODEL

L5570 - PREPARATORY, ABOVE KNEE-KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, “USMC” OREQUAL PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMED

L5580 - PREPARATORY, ABOVE KNEE-KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, “USMC” OREQUAL PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL


L5585 - PREPARATORY, ABOVE KNEE-KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, “USMC” OREQUAL PYLON, NO COVER, SACH FOOT, PREFABRICATED ADJUSTABLE OPEN END SOCKET

L5590 - PREPARATORY, ABOVE KNEE-KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, “USMC” OREQUAL PYLON NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL

L5595 - PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT,THERMOPLASTIC OR EQUAL, MOLDED TO PATIENT MODEL

L5600 - PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT,LAMINATED SOCKET, MOLDED TO PATIENT MODEL

L5610 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE, HYDRACADENCE SYSTEML5611 - ADDITION TO LOWER EXTREMITY ABOVE KNEE-KNEE DISARTICULATION, 4 BAR LINKAGE WITH

FRICTION SWING PHASE CONTROLL5613 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE-KNEE DISARTICULATION, 4-BAR LINKAGE, WITH

HYDRAULIC SWING PHASE CONTROLL5614 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE-KNEE DISARTICULATION, 4 BAR LINKAGE WITH

PNEUMATIC SWING PHASE CONTROLL5616 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE, UNIVERSAL MULTIPLEX SYSTEM, FRICTION

SWING PHASE CONTROLL5618 - ADDITION TO LOWER EXTREMITY, TEST SOCKET, SYMESL5620 - ADDITION TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEEL5622 - ADDITION TO LOWER EXTREMITY, TEST SOCKET, KNEE DISARTICULATIONL5624 - ADDITION TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEEL5626 - ADDITION TO LOWER EXTREMITY, TEST SOCKET, HIP DISARTICULATIONL5628 - ADDITION TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVECTOMYL5629 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, ACRYLIC SOCKETL5630 - ADDITION TO LOWER EXTREMITY, SYMES TYPE, EXPANDABLE WALL SOCKETL5631 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, ACRYLIC SOCKETL5632 - ADDITION TO LOWER EXTREMITY, SYMES TYPE, “PTB” BRIM DESIGN SOCKETL5634 - ADDITION TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPENING (CANADIAN) SOCKETL5636 - ADDITION TO LOWER EXTREMITY, SYMES TYPE, MEDIAL OPENING SOCKETL5637 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, TOTAL CONTACTL5638 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, LEATHER SOCKETL5639 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, WOOD SOCKETL5640 - ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, LEATHER SOCKETL5642 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE, LEATHER SOCKETL5643 - ADDITION TO LOWER EXTREMITY, HIP DISARTICULATION, FLEXIBLE INNER SOCKET, EXTERNAL

FRAMEL5644 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKETL5645 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAMEL5646 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, AIR CUSHION SOCKETL5647 - ADDITION TO LOWER EXTREMITY, BELOW KNEE SUCTION SOCKETL5648 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE, AIR CUSHION SOCKETL5649 - ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M-L SOCKETL5650 - ADDITIONS TO LOWER EXTREMITY, TOTAL CONTACT, ABOVE KNEE OR KNEE DISARTICULATION

SOCKETL5651 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAMEL5652 - ADDITION TO LOWER EXTREMITY, SUCTION SUSPENSION, ABOVE KNEE OR KNEE DISARTICULA-

TION SOCKETL5653 - ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, EXPANDABLE WALL SOCKETL5654 - ADDITION TO LOWER EXTREMITY, SOCKET INSERT, SYMES, (KEMBLO, PELITE, ALIPLAST,

PLASTAZOTE OR EQUAL)L5655 - ADDITION TO LOWER EXTREMITY, SOCKET INSERT, BELOW KNEE (KEMBLO, PELITE, ALIPLAST,

PLASTAZOTE OR EQUAL)L5656 - ADDITION TO LOWER EXTREMITY, SOCKET INSERT, KNEE DISARTICULATION (KEMBLO, PELITE,

ALIPLAST, PLASTAZOTE OR EQUAL)L5658 - ADDITION TO LOWER EXTREMITY, SOCKET INSERT, ABOVE KNEE (KEMBLO, PELITE, ALIPLAST,

PLASTAZOTE OR EQUAL)L5660 - ADDITION TO LOWER EXTREMITY, SOCKET INSERT, SYMES, SILICONE GEL OR EQUALL5661 - ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER SYMESL5662 - ADDITION TO LOWER EXTREMITY, SOCKET INSERT, BELOW KNEE, SILICONE GEL OR EQUALL5663 - ADDITION TO LOWER EXTREMITY, SOCKET INSERT, KNEE DISARTICULATION, SILICONE GEL OR

EQUALL5664 - ADDITION TO LOWER EXTREMITY, SOCKET INSERT, ABOVE KNEE, SILICONE GEL OR EQUALL5665 - ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER, BELOW KNEEL5666 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, CUFF SUSPENSIONL5667 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, SOCKET INSERT, SUCTION SUSPENSION, WITH

LOCKING MECHANISML5668 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED DISTAL CUSHIONL5669 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, SOCKET INSERT, SUCTION SUSPENSION WITH-

OUT LOCKING MECHANISML5670 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED SUPRACONDYLAR SUSPENSION

(“PTS” OR SIMILAR)L5672 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, REMOVABLE MEDIAL BRIM SUSPENSIONL5674 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, LATEX SLEEVE SUSPENSION OR EQUAL, EACH


L5675 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, LATEX SLEEVE SUSPENSION OR EQUAL, HEAVYDUTY, EACH

L5676 - ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, SINGLE AXIS, PAIRL5677 - ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, POLYCENTRIC, PAIRL5678 - ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, JOINT COVERS, PAIRL5680 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, NON-MOLDEDL5682 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, GLUTEAL/ISCHIAL, MOLDEDL5684 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, FORK STRAPL5686 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, BACK CHECK (EXTENSION CONTROL)L5688 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, WEBBINGL5690 - ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, PADDED AND LINEDL5692 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, LIGHTL5694 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, PADDED AND LINEDL5695 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL, SLEEVE SUSPENSION,

NEOPRENE OR EQUAL, EACHL5696 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC JOINTL5697 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC BANDL5698 - ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, SILESIAN BANDAGEL5699 - ALL LOWER EXTREMITY PROSTHESES, SHOULDER HARNESSL5700 - REPLACEMENT, SOCKET, BELOW KNEE, MOLDED TO PATIENT MODELL5701 - REPLACEMENT, SOCKET, ABOVE KNEE/KNEE DISARTICULATION INCLUDING ATTACHMENT

PLATE, MOLDED TO PATIENT MODELL5702 - REPLACEMENT, SOCKET, HIP DISARTICULATION, INCLUDING HIP JOINT, MOLDED TO PATIENT

MODELL5704 - REPLACEMENT, CUSTOM SHAPED PROTECTIVE COVER, BELOW KNEEL5705 - REPLACEMENT, CUSTOM SHAPED PROTECTIVE COVER, ABOVE KNEEL5706 - REPLACEMENT, CUSTOM SHAPED PROTECTIVE COVER KNEE DISARTICULATIONL5707 - REPLACEMENT, CUSTOM SHAPED PROTECTIVE COVER HIP DISARTICULATIONL5710 - ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCKL5711 - ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT

MATERIALL5712 - ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE

PHASE CONTROL (SAFETY KNEE)L5714 - ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, VARIABLE FRICTION SWING PHASE

CONTROLL5716 - ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE

LOCKL5718 - ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING AND STANCE

PHASE CONTROLL5722 - ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION

STANCE PHASE CONTROLL5724 - ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROLL5726 - ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, EXTERNAL JOINTS FLUID SWING

PHASE CONTROLL5728 - ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE

CONTROLL5780 - ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/HYDRA PNEUMATIC

SWING PHASE CONTROL COMPONENT MODIFICATIONL5785 - ADDITION, EXOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON

FIBER OR EQUAL)L5790 - ADDITION, EXOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON

FIBER OR EQUAL)L5795 - ADDITION, EXOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL (TITANIUM,

CARBON FIBER OR EQUAL)L5810 - ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCKL5811 - ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT

MATERIALL5812 - ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE

PHASE CONTROL (SAFETY KNEE)L5816 - ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE

LOCKL5818 - ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING, AND STANCE

PHASE CONTROLL5822 - ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION

STANCE PHASE CONTROLL5824 - ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROLL5828 - ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE

CONTROLL5830 - ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/SWING PHASE CON-

TROLL5840 - ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM MULTIAXIAL, PNEUMATIC SWING PHASE CON-

TROLL5850 - ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, KNEE EXTENSION

ASSIST


L5855 - ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, MECHANICAL HIP EXTENSIONASSIST

L5910 - ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ALIGNABLE SYSTEML5920 - ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, ALIGNABLE SYS-

TEML5925 - ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE DISARTICULATION OR HIP DISARTICU-

LATION, MANUALL5940 - ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON

FIBER OR EQUAL)L5950 - ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON

FIBER OR EQUAL)L5960 - ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL (TITANIUM,

CARBON FIBER OR EQUAL)L5962 - ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE FLEXIBLE PROTECTIVE OUTER SURFACE

COVERING SYSTEML5964 - ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE FLEXIBLE PROTECTIVE OUTER SURFACE

COVERING SYSTEML5966 - ADDITION, ENDOSKELETAL, SYSTEM, HIP DISARTICULATION, FLEXIBLE PROTECTIVE OUTER

SURFACE COVERING SYSTEML5970 - ALL LOWER EXTREMITY PROSTHESES, FOOT, EXTERNAL KEEL, SACH FOOTL5972 - ALL LOWER EXTREMITY PROSTHESES, FLEXIBLE KEEL FOOT (SAFE, STEN, BOCK DYNAMIC OR

EQUAL)L5974 - ALL LOWER EXTREMITY PROSTHESES, FOOT, SINGLE AXIS ANKLE/FOOTL5976 - ALL LOWER EXTREMITY PROSTHESES, ENERGY STORING FOOT (SEATTLE CARBON COPY II OR

EQUAL)L5978 - ALL LOWER EXTREMITY PROSTHESES, FOOT, MULTIAXIALANKLE/FOOTL5979 - ALL LOWER EXTREMITY PROSTHESES, FOOT, MULTIAXIAL, ANKLE/FOOT, DYNAMIC RESPONSEL5980 - ALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEML5981 - ALL LOWER EXTREMITY PROSTHESES, FLEX-WALK SYSTEM OR EQUALL5982 - ALL EXOSKELETAL LOWER EXTREMITY PROSTHESES, AXIAL ROTATION UNITL5984 - ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESES, AXIAL ROTATION UNITL5986 - ALL LOWER EXTREMITY PROSTHESES, MULTI-AXIAL ROTATION UNIT (“MCP” OR EQUAL)L5999 - UNLISTED PROCEDURES FOR LOWER EXTREMITY PROSTHESISL7500 - REPAIR OF PROSTHETIC DEVICE, HOURLY RATEL7510 - REPAIR OF PROSTHETIC DEVICE, REPAIR OR REPLACE MINOR PARTSL8400 - PROSTHETIC SHEATH, BELOW KNEE, EACHL8410 - PROSTHETIC SHEATH, ABOVE KNEE, EACHL8420 - PROSTHETIC SOCK, BELOW KNEE, EACHL8430 - PROSTHETIC SOCK, ABOVE KNEE, EACHL8440 - PROSTHETIC SHRINKER, BELOW KNEEL8460 - PROSTHETIC SHRINKER, ABOVE KNEEL8470 - STUMP SOCK, SINGLE PLY, FITTING, BELOW KNEE, EACHL8480 - STUMP SOCK, SINGLE PLY, FITTING, ABOVE KNEE, EACHL8490 - ADDITION TO PROSTHETIC SHEATH/SOCK, AIR SEAL SUCTION RETENTION SYSTEMK0285 - REPAIR OF PROSTHETIC DEVICE, LABOR COMPONENT, PER 15 MINUTES

LEVEL II MODIFIERSK0 Lower limb extremity prosthesis functional Level 0 - Does not have the ability or potential to ambulate or transfer

safely with or without assistance and a prosthesis does not enhance their quality of life or mobilityK1 Lower extremity prosthesis functional Level 1 - Has the ability or potential to use a prosthesis for transfers or

ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.K2 Lower extremity prosthesis functional Level 2 - Has the ability or potential for ambulation with the ability to

traverse low level environmental barriers such as curbs, stair or uneven surfaces. Typical of the limitedcommunity ambulator.

K3 Lower extremity prosthesis functional Level 3 - Has the ability or potential for ambulation with variable cadence.Typical of the community ambulator who has the ability to traverse most environmental barriers and may havevocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

K4 Lower extremity prosthesis functional Level 4 - Has the ability or potential for prosthetic ambulation thatexceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prostheticdemands of the child, active adult, or athlete.

BENEFITS CATEGORY: Prosthetic Devices

DEFINITIONS:A functional level is a measurement of the capacity and potential of the patient to accomplish his/her expected, post-rehabilitation, daily function. The functional classification is used by the DMERC to establish the medical necessity onlyof prosthetic knees, feet and ankles.

An adjustment is any modification to the prosthesis due to a change in the patient’s condition or to improve the functionof the prosthesis.


A repair is a restoration of the prosthesis to correct problems due to wear or damage.

A replacement is the removal and substitution of a component of a prosthesis that has a HCPCS definition.

COVERAGE AND PAYMENT RULES:A lower limb prosthesis is covered when the patient:

1) Will reach or maintain a defined functional state within a reasonable period of time; and2) Is motivated to ambulate

Functional Levels:A determination of the medical necessity for certain components/additions to the prosthesis is based on the patient’spotential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, andordering physician, considering factors including, but not limited to:

a. the patient’s past history (including prior prosthetic use if applicable)b. the patient’s current condition including the status of the residual limb and the nature of other medical problems:

andc. the patient’s desire to ambulate.

Clinical assessments of patient rehabilitation potential should be based on the following classification levels:Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a

prosthesis does not enhance their quality of life or mobility.Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed

cadence. Typical of the limited and unlimited household ambulator.Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such

as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who

has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exerciseactivity that demands prosthetic utilization beyond simple locomotion.

Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting highimpact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.

The records should document the patient’s current functional capabilities and his/her expected functional potential,including an explanation for the difference, if that is the case. The DMERC recognizes within the functional classificationhierarchy that bilateral amputees often cannot be strictly bound by functional level classifications.

General:Prostheses are covered when furnished incident to physicians’ services or on a physician’s order. Accessories (e.g.stump stockings for the residual limb, harness (including replacements) are also covered when these appliances aidin or are essential to the effective use of the artificial limb.

The following items are included in the reimbursement for a prosthesis and, therefore, are not separately billable toMedicare under the prosthetic benefit:

Evaluation of the residual limb and gaitFitting of the prosthesisCost of base component parts and labor contained in HCPCS base codes

Repairs due to normal wear or tear within 90 days of delivery

Adjustments of the prosthesis or the prosthetic component made when fitting the prosthesis or component and for 90days from the date of delivery when the adjustments are not necessitated by changes in the residual limb or the patient’sfunctional abilities.Any prosthesis or prosthetic component provided in an inpatient hospital setting should not be submitted to the DMERC.

When an initial below knee prosthesis (L5500) or a preparatory below knee prosthesis (L5510-L5530, L5540)prostheses is provided, prosthetic substitutions and/or additions of procedures and components are covered inaccordance with the functional level assessment except for codes L5629, L5638, L5639, L5646, L5647, L5667, L5669,L5785, L5962, and L5980 which will be denied as not medically necessary. When a below knee preparatoryprefabricated prosthesis (L5535) is provided prosthetic substitutions and/or additions of procedures are covered inaccordance with the functional level assessment except for codes L5620, L5629, L5645, L5646, L5667, L5669, L5670,and L5676 which will be denied as not medically necessary.

When an above knee initial prosthesis (L5505) or an above knee preparatory (L5560-L5580, L5590-L5600) prosthesesis provided, prosthetic substitution and/or additions of procedures and components are covered in accordance with thefunctional level assessment except for codes L5610, L5631, L5640, L5642, L5644, L5648, L5980, and L5710-L5780,


L5790-L5795 which will be denied as not medically necessary. When an above knee preparatory prefabricatedprosthesis (L5585) is provided, prosthetic substitution and/or additions of procedures and components are covered inaccordance with the functional level assessment except for codes L5624, L5631, L5648, L5651, L5652, L5964, andL5966 which will be denied as not medically necessary.

In the following sections, the determination of coverage for selected prostheses and components with respect to potentialfunctional levels represents the usual case. Exceptions will be considered in an individual case if additionaldocumentation is included which justifies the medical necessity. Prostheses will be denied as not medically necessaryif the patient’s potential functional level is “0”

Feet:A determination of the type of foot for the prosthesis will be made by the prescribing physician and/or the prosthetistbased upon the functional needs of the patient. Basic lower extremity prostheses include a SACH foot. Prosthetic feetare considered for coverage based upon functional classification.

External keel, SACH foot (L5970) or single axis ankle/foot (L5974) are covered for patients with a functional Level 1or above.

Flexible-keel foot (L5972) and multiaxial ankle/foot (L5978) candidates are expected to demonstrate a functionalLevel 2 or greater functional needs.

Flex foot system (L5980), Energy storing foot (L5976), multiaxial ankle/foot, dynamic response (L5979), or flex-walksystem or equal (L5981) are covered for patients with a functional Level 3 or above.

Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or designfeature of a given type of foot. This information must be retained in the physician’s or prosthetist’s files.

Knees:A determination of the type of knee for the prosthesis will be made by the prescribing physician and/or the prosthetistbased upon the functional needs of the patient. Basic lower extremity prostheses include a single axis, constant frictionknee. Prosthetic knees are considered for coverage based upon functional classification.

Fluid and pneumatic knees (L5610 - L5616, L5722 - L5780, L5822 - L5840) are covered for patients with a functionalLevel 3 or above.

Other knee-shin systems (L5710-L5718, L5810-L5818) are covered for patients with a functional Level 1 or above.

Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic design featureof a given type of knee. This information must be retained in the physician’s or prosthetist’s files.

Ankles:Axial rotation units (L5982 - L5986) are covered for patients with a functional Level 2 or above.

Sockets:Test (diagnostic) sockets for Immediate (L5400 - L5460) prostheses are not medical necessary.

No more than 2 test (diagnostic) sockets for an individual prosthesis are medically necessary without additionaldocumentation.No more than two of the same socket inserts (L5654- L5665) are allowed per individual prosthesis at the same time.

Socket replacements are considered medically necessary if there is adequate documentation of functional and/orphysiological need. The DMERC recognizes that there are situations where the explanation includes but is not limitedto: changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to excessive patientweight or prosthetic demands of very active amputees.

ADJUSTMENT, REPAIRS, AND COMPONENT REPLACEMENT:Routine periodic servicing, such as testing, cleaning, and checking of the prosthesis, is noncovered. Adjustments to aprosthesis required by wear or by change in the patient’s condition are covered under the initial physician’s order for theprosthesis for the life of the prosthesis.

Repairs to a prosthesis are covered when necessary to make the prosthesis functional. If the expense for repairsexceeds the estimated expense of purchasing another entire prosthesis, no payments can be made for the amount ofthe excess. Maintenance which may be necessitated by manufacturer’s recommendations or the construction of theprosthesis and must be performed by the prosthetist is covered as a repair.


Replacement of a prosthesis or prosthetic component is covered in cases of loss or irreparable damage or wear or whenrequired because of a change in the patient’s condition. Expenses for replacement of a prosthesisor prosthetic components required because of loss or irreparable damage may be reimbursed without a physician’sorder when it is determined that the prosthesis as originally ordered still fills the patient’s medical needs. However,claims involving replacement of a prosthesis or major component (foot, ankle, knee, socket) necessitated by wear ora change in the patient’s condition must be supported by a new physician’s order. When the DMERC determines thatmalicious damage, culpable neglect or wrongful disposition of the prosthesis has occurred, investigation will beundertaken to determine whether it is unreasonable to make program payment under the circumstances.

CODING GUIDELINES:Adjustments and repairs are billed as a labor charge using HCPCS code K0285 (one unit of service representing 15minutes of labor time). Documentation should exist in the supplier’s records indicating the precise adjustments and/or repairs performed and actual time involved. The time reported for K0285 should only be for laboratory repair timeand associated prosthetic evaluation. Evaluation not associated with repair or adjustment is noncovered and shouldnot be coded with K0285. The time for patient evaluation, gait instruction, and other general education should not bereported with code K0285. Code L7500 is not valid for billing claims to the DMERC.

The L7510 code is used to bill for any “minor” materials (those without HCPCS definitions) used to achieve theadjustment and/or repair.

Replacement of components (except sockets and covers) are billed using the base code for the component with theaddition of the RP modifier. Socket and cover replacement procedures are identified by the codes L5700 to L5707.Since these codes are defined as a replacement, the modifier RP should not be used. The submitted charge forreplacements reflects both the cost of the component and the labor associated with the removal, replacement, andfinishing of that component. Labor associated with replacement should not be reported using code K0285.The right (RT) and left (LT) modifiers should be used with prosthesis codes. When the same code for prostheses,sockets, or components for bilateral amputees are billed on the same date of service, the items (RT and LT) will beentered on the same line of the claim using the RTLT modifier and billed with 2 units of service.

DOCUMENTATION:An order for the prosthesis including all components which is signed and dated by the ordering physician must be kepton file by the prosthetist. Adjustments and repairs of prostheses and prosthetic components are covered under thisoriginal order. Claims involving replacement of a prosthesis or major component (foot, ankle, knee, socket)necessitated by wear or a change in the patient’s condition must be supported by a new physician’s order. Ifreplacement of a prosthesis or prosthetic component is required because of loss or irreparable damage, reimburse-ment may be made without a new physician’s order if it is determined that the prosthesis as originally ordered,considering the time since it was furnished, still fills the patient’s medical need.

The prosthetist must retain documentation of the prosthesis or prosthetic component replaced, the reason forreplacement, and a description of the labor involved irrespective of the time since the prosthesis was provided to thebeneficiary.

When replacement of the entire prosthesis or socket is billed, the claim must be accompanied by an explanation of themedical necessity of the replacement. The DMERC recognizes that there are situations where the explanation includesbut is not limited to: changes in the residual limb; functional need changes; or irreparable damage or wear/tear due toexcessive patient weight or prosthetic demands of very active amputees.

When submitting a prosthetic claim to the DMERC, the billed code for knees, feet and ankle (HCPCS codes L5610 -L5616, L5710 - 5780, L5810 - L5840, L5970 - L5981) components must be submitted with modifiers K0 - K4, indicatingthe expected patient functional level. This expectation of functional ability information must be clearly documented andretained in the prosthetist's records.

EFFECTIVE DATE: Claims received by the DMERC on or after March 1, 1995.


Subject: Therapeutic Shoes

HCPCS CODES:A5500 -For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlayshoe manufactured to accommodate multi-density insert(s), per shoeA5501 -For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s)of patient’s foot (custom molded shoe), per shoeA5502 -For diabetics only, multiple density insert(s), per shoeA5503 -For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoewith roller or rigid rocker bottom, per shoeA5504 -For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoewith wedge(s), per shoeA5505 -For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoewith metatarsal bar, per shoeA5506 -For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoewith off-set heel(s), per shoeA5507 -For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay orcustom-molded shoe, per shoeL3649 -Unlisted procedures for foot orthopedic shoes, shoe modifications and transfers

BENEFIT CATEGORY: Therapeutic Shoes for Diabetics

DEFINITIONS:A depth shoe (A5500) is one that 1) has a full length, heel-to-toe filler that when removed provides a minimum of 3/16"of additional depth used to accommodate custom-molded or customized inserts,

Therapeutic Shoes2) is made from leather or other suitable material of equal quality, 3) has some form of shoe closure, and 4) is availablein full and half sizes with a minimum of three widths so that the sole is graded to the size and width of the upper portionsof the shoe according to the American standard last sizing schedule or its equivalent. (The American last sizingschedule is the numerical shoe sizing system used for shoes in the United States.) This includes a shoe with or withoutan internally seamless toe.

A custom-molded shoe (A5501) is one that 1) is constructed over a positive model of the patient’s foot, 2) is made fromleather or other suitable material of equal quality, 3) has removable inserts that can be altered or replaced as the patient’scondition warrants, and 4) has some form of shoe closure. This includes a shoe with or without an internally seamlesstoe.

An insert (A5502) is a total contact, multiple density, removable inlay that is directly molded to the patient’s foot or amodel of the patient’s foot and that is made of a suitable material with regard to the patient’s condition.

Rigid rocker bottoms (A5503) are exterior elevations with apex position for 51 percent to 75 percent distance measuredfrom the back end of the heel. The apex is a narrowed or pointed end of an anatomical structure. The apex must bepositioned behind the metatarsal heads and tapering off sharply to the front tip of the sole. Apex height helps to eliminatepressure at the metatarsal heads. Rigidity is ensured by the steel in the shoe. The heel of the shoe tapers off in theback in order to cause the heel to strike in the middle of the heel.

Roller bottoms (sole or bar) (A5503) are the same as rocker bottoms, but the heel is tapered from the apex to the fronttip of the sole.

Wedges (posting) (A5504) are either of hind foot, fore foot, or both and may be in the middle or to the side. The functionis to shift or transfer weight bearing upon standing or during ambulation to the opposite side for added support,stabilization, equalized weight distribution, or balance.

Metatarsal bars (A5505) are exterior bars which are placed behind the metatarsal heads in order to remove pressurefrom the metatarsal heads. The bars are of various shapes, heights, and construction depending on the exact purpose.

Offset heel (A5506) is a heel flanged at its base either in the middle, to the side, or a combination, that is then extendedupward to the shoe in order to stabilize extreme positions of the hind foot.

COVERAGE AND PAYMENT RULES:Diabetic shoes, inserts and/or modifications to the shoes arecovered if the following criteria are met:1) The patient has diabetes mellitus (ICD-9 diagnosis codes 250.00-250.91); and


2) The patient has one or more of the following conditions:a) Previous amputation of the other foot, or part of either foot, orb) History of previous foot ulceration of either foot, orc) History of pre-ulcerative calluses of either foot, ord) Peripheral neuropathy with evidence of callus formation of either foot, ore) Foot deformity of either foot, orf) Poor circulation in either foot; and

3) The physician who is managing the patient’s systemic diabetes condition has certified that indications 1 and 2 aremet and that he/she is treating the patient under a comprehensive plan of care for his/her diabetes and that the patientneeds diabetic shoes.

For patients meeting these criteria, coverage is limited to one of the following within one calendar year:1) One pair of custom molded shoes (A5501) (which includes inserts provided with these shoes) and 2 additional pairs

of inserts (A5502); or2) One pair of depth shoes (A5500) and 3 pairs of inserts (A5502) (not including the non-customized removable inserts

provided with such shoes).

Separate inserts may be covered and dispensed independently of diabetic shoes if the supplier of the shoes verifies inwriting that the patient has appropriate footwear into which the insert can be placed. This footwear must meet thedefinitions found in this policy for depth shoes or custom-molded shoes. In addition, the inserts furnished must fully meetthe definition of an insert set forth in this policy. Inserts which will be used in noncovered shoes are noncovered.

A custom molded shoe (A5501) is covered when the patient has a foot deformity which cannot be accommodated by adepth shoe. The nature and severity of the deformity must be well documented in the supplier’s records and may berequested by the DMERC. If there is insufficient justification for a custom molded shoe but the general coverage criteriaare met, payment will be based on the allowance for the least costly medically appropriate alternative, A5500.

A modification of a custom molded or depth shoe will be covered as a substitute for an insert. Although not intended asa comprehensive list, the following are the most common shoe modifications: rigid rocker bottoms (A5503), roller bottoms(A5503), wedges (A5504), metatarsal bars (A5505), or offset heels (A5506). Other modifications to diabetic shoes(A5507) include, but are not limited to flared heels and inserts for missing toes. Deluxe upgrades to diabetic shoes,including but not limited to style, color, or type of leather, will be denied as not medically necessary.

Shoes, inserts, and/or modifications that are provided to patients who do not meet the coverage criteria will be denied asnoncovered. When codes are billed without a ZX modifier (see Documentation section), they will be denied as noncovered.

The particular type of footwear (shoes, inserts, modifications) which is necessary must be prescribed by a podiatrist orother qualified physician, knowledgeable in the fitting of diabetic shoes and inserts. The footwear must be fitted andfurnished by a podiatrist or other qualified individual such as a pedorthist, orthotist or prosthetist. The certifying physician(i.e. the physician who manages the systemic diabetic condition) may not furnish the footwear unless he/she practicesin a defined rural area or a defined health professional shortage area. The prescribing physician (podiatrist or otherqualified physician) can be the supplier (i.e. the one who furnishes the footwear).

There is no separate payment for the fitting of the shoes, inserts or modifications or for the certification of need orprescription of the footwear. Unrelated evaluation and management services by the physician are processed by the localcarrier.

CODING GUIDELINES:

Code A5507 is only to be used for not otherwise specified therapeutic modifications to the shoe. Code A5507 is not tobe used for deluxe upgrades to diabetic shoes. At this time, deluxe features should be coded using code L3649. A newHCPCS code will be established for deluxe features and will be published separately with its effective date.

A codes for inserts or modifications (A5502-A5506, A5507) may only be used for items related to diabetic shoes (A5500,A5501). They should not be used for items related to footwear coded with codes L3215-L3253. Inserts and modificationsused with L coded footwear should be coded using L codes (L3000-L3649).

When a single shoe, insert or modification is provided, the appropriate modifier, right (RT) or left (LT), should be used.If a pair is provided, report as two (2) units of service on the claim the RT or LT modifiers should not be used.


CODING GUIDELINES:Code A5507 is only to be used for not otherwise specified therapeutic modifications to the shoe. Code A5507 is not tobe used for deluxe upgrades to diabetic shoes. At this time, deluxe features should be coded using code L3649. A newHCPCS code will be established for deluxe features and will be published separately with its effective date.

A codes for inserts or modifications (A5502-A5506, A5507) may only be used for items related to diabetic shoes (A5500,A5501). They should not be used for items related to footwear coded with codes L3215-L3253. Inserts and modificationsused with L coded footwear should be coded using L codes (L3000-L3649).

When a single shoe, insert or modification is provided, the appropriate modifier, right (RT) or left (LT), should be used.If a pair is provided, report as two (2) units of service on the claim the RT or LT modifiers should not be used.

DOCUMENTATION:An order for the shoes, inserts or modifications which has been signed and dated by the prescribing physician must bekept on file by the supplier. If the prescribing physician is the supplier, a separate order is not required, but the itemprovided must be clearly noted in the patient’s record. A new order is not required for the replacement of an insert ormodification within one year of the order on file. However the supplier’s records should document the reason for thereplacement. A new order is required for the replacement of any shoe. A new order is also required for the replacementof an insert or modification more than one year from the most recent order on file.

The supplier should obtain a signed statement from the certifying physician specifying that the patient has diabetesmellitus, has one of conditions 2a-2f listed in the policy, is being treated under a comprehensive plan of care for his/herdiabetes, and needs diabetic shoes. The Statement of Certifying Physician for Therapeutic Shoes developed by theDMERC is recommended. This statement may be completed by the prescribing physician or supplier but must bereviewed for accuracy of the information and signed by the certifying physician to indicate agreement. A newCertification Statement would be required for a shoe, insert or modification provided more than one year from the mostrecent Certification Statement on file. If the supplier has a current signed statement on file that indicates that thecoverage criteria described above have been met, then a ZX modifier should be added to the code. (ZX is a new modifierwhich indicates “The specified coverage criteria in the medical policy have been met and documentation is available inthe supplier’s records”.) A diagnosis code for diabetes should be entered on the claim.

On hard copy claims, this statement should be on a separate sheet attached to the claim. On electronic claims, it wouldbe put in the HAO record.

If code A5507 or L3649 is submitted, the claim must contain a narrative description of the modification or featureprovided.

The prescribing physician’s name and UPIN number should be listed in Blocks 17 and 17a of the HCFA-1500 (12/90)form or the electronic equivalent.

EFFECTIVE DATE: Coverage and Payment Rules are effective for claims with dates of service on or after 5/1/93received by the DMERC. Use of the ZX modifier is required for claims received by the DMERC on or after 3/1/95.

Statement of Certifying Physician for Therapeutic ShoesPatient name:HIC #:I certify that all of the following statements are true:1) This patient has diabetes mellitus.2) This patient has one or more of the following conditions. (Circle all that apply.):

a) History of partial or complete amputation of the footb) History of previous foot ulcerationc) History of pre-ulcerative callusd) Peripheral neuropathy with evidence of callus formatione) Foot deformityf) Poor circulation

3) I am treating this patient under a comprehensive plan of care for his/her diabetes.4) This patient needs special shoes (depth or custom-molded shoes) because of his/her diabetes.

Physician signature:Date Signed:Physician name (printed):Physician address:Physician UPIN:


Subject: Orthopedic Footwear

HCPCS CODES:L3000 - Foot, insert, removable, molded to patient model, “UCB” type, Berkeley shell, eachL3001 - Foot, insert, removable, molded to patient model, Spenco, eachL3002 - Foot, insert, removable, molded to patient model, plastazote or equal, eachL3003 - Foot, insert, removable, molded to patient model, silicone gel, eachL3010 - Foot, insert, removable, molded to patient model, longitudinal arch support, eachL3020 - Foot, insert, removable, molded to patient model, longitudinal/metatarsal support, eachL3030 - Foot, insert, removable, formed to patient foot, eachL3040 - Foot, arch support, removable, premolded, longitudinal, eachL3050 - Foot, arch support, removable, premolded, metatarsal, eachL3060 - Foot, arch support, removable, premolded longitudinal/metatarsal, eachL3070 - Foot, arch support, non-removable, attached to shoe, longitudinal, eachL3080 - Foot, arch support, non-removable, attached to shoe, metatarsal, eachL3090 - Foot, arch support, non-removable, attached to shoe longitudinal/metatarsal, eachL3100 - Hallus-Valgus night dynamic splintL3140 - Foot, rotation positioning device, including shoe(s)L3150 - Foot, rotation positioning device, without shoe(s)L3160 - Foot, adjustable shoe styled positioning deviceL3170 - Foot, plastic heel stabilizerL3201 - Orthopedic shoe, oxford with supinator or pronator, infantL3202 - Orthopedic shoe, oxford with supinator or pronator, childL3203 - Orthopedic shoe, oxford with supinator or pronator, juniorL3204 - Orthopedic shoe, hightop with supinator or pronator, infantL3206 - Orthopedic shoe, hightop with supinator or pronator, childL3207 - Orthopedic shoe, hightop with supinator or pronator, juniorL3208 - Surgical boot, each, infantL3209 - Surgical boot, each, childL3211 - Surgical boot, each, juniorL3212 - Benesch boot, pair, infantL3213 - Benesch boot, pair, childL3214 - Benesch boot, pair, juniorL3215 - Orthopedic footwear, ladies shoes, oxfordL3216 - Orthopedic footwear, ladies shoes, depth inlayL3217 - Orthopedic footwear, ladies shoes, high top, depth inlayL3218 - Orthopedic footwear, ladies surgical boot, each L3219 - Orthopedic footwear, mens shoes, oxfordL3221 - Orthopedic footwear, mens shoes, depth inlayL3222 - Orthopedic footwear, mens shoes, hightop, depth inlayL3223 - Orthopedic footwear, mens surgical boot, eachL3224 - Orthopedic footwear, woman’s shoe, oxford, used as an integral part of a brace (orthosis)L3225 - Orthopedic footwear, man’s shoe, oxford, used as an integral part of a brace (orthosis)L3230 - Orthopedic footwear, custom shoes, depth inlayL3250 - Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, eachL3251 - Foot, shoe molded to patient model, silicone shoe, eachL3252 - Foot, shoe molded to patient model, plastazote (or similar), custom fabricated, eachL3253 - Foot, molded shoe plastazote (or similar) custom fitted, eachL3254 - Non-standard size or widthL3255 - Non-standard size or lengthL3257 - Orthopedic footwear, additional charge for split sizeL3260 - Ambulatory surgical boot, eachL3265 - Plastazote sandal, eachL3300 - Lift, elevation, heel, tapered to metatarsals, per inchL3310 - Lift, elevation, heel and sole, neoprene, per inchL3320 - Lift, elevation, heel and sole, cork, per inchL3330 - Lift, elevation, metal extension (skate)L3332 - Lift, elevation, inside shoe, tapered, up to one-half inchL3334 - Lift, elevation, heel, per inchL3340 - Heel wedge, SACHL3350 - Heel wedgeL3360 - Sole wedge, outside soleL3370 - Sole wedge, between soleL3380 - Clubfoot wedge


L3390 - Outflare wedgeL3400 - Metatarsal bar wedge, rockerL3410 - Metatarsal bar wedge, between soleL3420 - Full sole and heel wedge, between soleL3430 - Heel, counter, plastic reinforcedL3440 - Heel, counter, leather reinforcedL3450 - Heel, SACH cushion typeL3455 - Heel, new leather, standardL3460 - Heel, new rubber, standardL3465 - Heel, Thomas with wedgeL3470 - Heel, Thomas extended to ballL3480 - Heel, pad and depression for spurL3485 - Heel, pad, removable for spurL3500 - Miscellaneous shoe addition, insole, leatherL3510 - Miscellaneous shoe addition, insole, rubberL3520 - Miscellaneous shoe addition, insole, felt covered with leatherL3530 - Miscellaneous shoe addition, sole, halfL3540 - Miscellaneous shoe addition, sole, fullL3550 - Miscellaneous shoe addition, toe tap, standardL3560 - Miscellaneous shoe addition, toe tap, horseshoeL3570 - Miscellaneous shoe addition, special extension to instep (leather with eyelets)L3580 - Miscellaneous shoe addition, convert instep to velcro closureL3590 - Miscellaneous shoe addition, convert firm shoe counter to soft counterL3595 - Miscellaneous shoe addition, March barL3600 - Transfer of an orthosis from one shoe to another, caliper plate, existingL3610 - Transfer of an orthosis from one shoe to another, caliper plate, newL3620 -Transfer of an orthosis from one shoe to another, solid stirrup, existingL3630 - Transfer of an orthosis from one shoe to another, solid stirrup, newL3640 - Transfer of an orthosis from one shoe to another, Dennis Browne splint (Riveton), both shoesL3649 - Unlisted procedures for foot orthopedic shoes, shoe modifications and transfers

BENEFIT CATEGORY: Braces (Orthotics), Prosthetic Device

REFERENCE: Coverage Issues Manual 70-3

COVERAGE AND PAYMENT RULES:

Shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected patients withdiabetes for the prevention or treatment of diabetic foot ulcers. However, different codes (A5500-A5507) are used forfootwear provided under this benefit. See the medical policy on Therapeutic Shoes for Diabetics for details.

Shoes are also covered if they are an integral part of a covered leg brace described by codes L1900, L1920, L1980-L2030, L2050,L2060, L2080, or L2090. Oxford shoes (L3215, L3219, L3224, L3225 -see Coding Guidelines) arecovered in these situations. Other shoes, e.g. high top, depth inlay or custom for nondiabetics, etc. (L3216, L3217,L3221, L3222, L3230, L3251-L3253, L3649 - see Coding Guidelines), are also covered if they are an integral part of acovered brace and if they are medically necessary for the proper functioning of the brace. Heel replacements (L3455,L3460), sole replacements (L3530, L3540), and shoe transfers (L3600-L3640) involving shoes on a covered brace arealso covered. Inserts and other shoes modifications (L3000-L3170, L3300-L3450, L3465-L3520, L3550-L3595) arecovered if they are on a shoe that is an integral part of a brace and if they are medically necessary for the properfunctioning of the brace. Shoes and related modifications, inserts, heel/sole replacements or shoe transfers billedwithout a ZX modifier will be denied as noncovered. (See Documentation section for definition of ZX modifier.)

According to a national policy determination, a shoe and related modifications, inserts, and heel/sole replacements,are covered only when the shoe is an integral part of a brace. A matching shoe which is not attached to the brace anditems related to that shoe should not be billed with a ZX modifier and will be denied as noncovered.

Shoes which are billed separately (i.e. not as part of a brace) will be denied as noncovered even if they are laterincorporated into a brace. A ZX modifier may not be used in this situation.

Prosthetic shoes (L3250) are covered if they are an integral part of a prosthesis for patients with a partial foot (ICD-9diagnosis codes 895.0-896.3, 755.31, 755.39). Shoes are denied as noncovered when they are put on over a partialfoot or other lower extremity prosthesis (L5010-5600).

With the exception of the situations described above, orthopedic footwear billed using codes L3000-L3649 will bedenied as noncovered.


CODING GUIDELINES:For dates of service prior to 1/1/95. Shoes that are an integral part of a brace are billed using codes L3215-L3217,L3219-L3222, L3230, L3251-L3253 with a ZX modifier (see Documentation section). Shoes that are not an integralpart of a brace are billed using these codes without a ZX modifier. For codes L3215-L3217, L3219-L3222, andL3230 one unit of service is one pair of shoes; for codes L3251-L3253, one unit of service is each shoe.

For dates of service on or after 1/1/95. Oxford shoes that are an integral part of a brace are billed using codesL3224 or L3225 with a ZX modifier. For these codes, one unit of service is each shoe. Oxford shoes that are notpart of a leg brace are billed with codes L3215 or L3219 without a ZX modifier. Other shoes (e.g. high top, depthinlay or custom shoes for nondiabetics, etc.) that are an integral part of a brace are billed using code L3649 with aZX modifier. Other shoes that are not an integral part of a brace are billed using codes L3216, L3217, L3221, L3222,L3230, L3251-L3253 without a ZX modifier.

Depth-inlay or custom molded shoes for diabetics (A5500-A5501) and related inserts and modifications (A5502-A5507) are billed using these A codes whether the shoe is an integral part of a brace or not. (See policy on Thera-peutic Shoes for Diabetics for coverage, documentation, and additional coding guidelines.)

The right (RT) and left (LT) modifiers should be used with footwear codes. When bilateral items are provided on thesame date of service, bill both on the same claim line using the LTRT modifier and 2 units of service.

DOCUMENTATION:An order for the shoe and related modifications and inserts must be signed and dated by the ordering physician andkept on file by the supplier. The physician must see to it that the patient’s medicalrecord contains information which supports the medical necessity of the item ordered. An order is not required for aheel or sole replacement or transfer of a shoe to a brace.

When billing for a shoe that is an integral part of a leg brace or for related modifications, inserts, heel/sole replace-ments or shoe transfer, a ZX modifier should be added to the code. If the shoe or related item is not an integral partof a leg brace, the ZX modifier may not be used. (The ZX modifier indicates that “The specified coverage criteria inthe medical policy are met and documentation is available in the supplier’s records”.)

When billing for prosthetic shoes, a diagnosis code defining the medical condition must be entered on the claim.

When code L3649 with a ZX modifier is billed, the claim must include a narrative description of the item provided aswell as a brief statement of the medical necessity for the item. This could be attached to a hard copy claim orentered in the HAO record of an electronic claim.

EFFECTIVE DATE: Coverage criteria and coding changes are effective for claims with dates of service on or after 1/1/95. The ZX modifier must be used, if appropriate, for all claims received by the DMERC on or after 3/1/95.


Effective January 1, 1995 the following Oral Anticancer Drugs meet the requirementsfor coverage. Use the following National Drug Code (NDC) numbers to bill for thesedrugs. These NDC numbers are additions to the Oral Anticancer Drug codes listedon page 94-60 of the DMERC Medicare Advisory, March 1994 issue.

ORAL ANTICANCERDRUGADDITIONS

Generic How Supplied Package National Drug AllowanceChemical Name Size Code (NDC)

Methotrexate 2.5mg/Oral 36 00405-4643-36* $2.85

Methotrexate 2.5mg/Oral 100 00405-4643-01* $2.85

Methotrexate 2.5mg/Oral 36 00904-1749-73** $2.85

* The manufacturer is Algen** The manufacturer is Major

CLAIM FILINGREMINDER

PRIORAUTHORIZATIONTELEPHONE NUMBERDISCONTINUED

Due to low physician participation and misuse of the telephone lines by nonphysiciancallers, the prior authorization telephone number will be discontinued, effectiveFebruary 1, 1995. Prior authorization may still be obtained for POVs, TENS and seatlift mechanisms through a written request submitted by the ordering physician. Theprior authorization process is conducted by our specially-trained review personnelwho are able to make an authorized decision. This does not guarantee payment byMedicare for the product. The "authorized" determination is a confirmation that thepatient's condition as described meets the criteria defined in the DMERC medicalpolicies.

If the review personnel determines not to "authorize" the item, the justification for thedetermination will be discussed with the physician. A denial of the authorizationrequest means that Palmetto GBA will not cover the item for the conditions described.The physician may choose to appeal this determination. After the request forauthorization is denied, the patient may choose to obtain the item; however, Medicare'scoverage decision remains unchanged.

When a prior authorization has been processed, our review personnel will issue awritten confirmation of the decision to the physician and the patient. On the writtenconfirmation, a prior authorization control number will be indicated. This number mustbe used by the supplier providing the item, and should be indicated on the prescription.The prior authorization number must be recorded in Item 23 of the HCFA-1500 (12/90) form and should be indicated on the prescription for both assigned and non-assigned claims.

Send written prior authorization requests to: Palmetto GBA, Prior AuthorizationDept., Medicare Region C DMERC, P.O. Box 100235, Columbia, SC 29202-3235.

A mandatory claim filing requirement was created by the Omnibus Reconciliation Actof 1989 (OBRA 1989). It specifies that physicians and/or suppliers are required to filebeneficiaries' claims, regardless of their assigned or non-assigned status, whenrendering services covered by the Medicare program to Medicare beneficiaries,effective September 1, 1990.

In order to submit claims to the Durable Medical Equipment Regional Carriers(DMERCs), a physician/supplier must have a supplier number which was assignedto them by the National Supplier Clearinghouse (NSC).

According to the Medicare Carriers Manual Section 3314, Medicare carriers areentitled to monitor physician and supplier compliance with the Medicare claims filingrequirement. Physicians and suppliers who do not submit Medicare claims forMedicare beneficiaries may be subject to a civil monetary penalty of up to $2,000 foreach violation.

If you are a physician or supplier providing services to Medicare beneficiaries,remember to follow the guidelines when filing beneficiaries' claims.


The following chart has been provided as a quick reference to help suppliersdetermine what oxygen items may be billed separately.

OXYGEN BILLINGTIPS

Can Can Can CanIf Stationary Stationary Portable PortableType of System Equipment Contents Equipment ContentsIs: Be Billed? Be Billed? Be Billed? Be Billed?

A. Situation: Beneficiary Uses a Stationary System Only:

1. Rents Stationary System

Concentrator Yes No No NoGaseous Yes No No NoLiquid Yes No No No

2. Owns Stationary System

Concentrator No No No NoGaseous No Yes No NoLiquid No Yes No No

B. Situation: Beneficiary Uses Both a Stationary and a Portable

1. Rents Stationary/Rents Portable:

Concentrator Yes No Yes NoGaseous Yes No Yes NoLiquid Yes No Yes No

2. Rents Stationary/Owns Portable:

Concentrator Yes No No NoGaseous Yes No No NoLiquid Yes No No No

3. Owns Stationary/Owns Portable:

Concentrator No No No YesGaseous No Yes No NoLiquid No Yes No No

4. Owns Stationary/Rents Portable:

Concentrator No No Yes YesGaseous No Yes Yes NoLiquid No Yes Yes No

C. Situation: Beneficiary Uses a Portable System Only

1. Rents Portable System:

Gaseous No No Yes YesLiquid No No Yes Yes

2. Owns Portable System:

Gaseous No No No YesLiquid No No No Yes


LYMPHEDEMAPUMPS/PNEUMATICCOMPRESSORS

It has been brought to our attention that there is some confusion throughout thesupplier community as to which HCPCS code should be used to properly bill for thevarious lymphedema pumps available. The following grid is provided to offerclarification in this area.

Manufacturer/Brand Name Model Name/# HCPCS Code

Bio Compressions Systems/Sequential Circulator 2000 E06513000 E06523001 E06523004 E0652

Huntleigh Flowplus (AC330) E0650Flowpress (AC300) E0651

Flowtron E0650Lymphatron E0651

Lymphatron Trio (AC350) E0652Jobst/Extremity Pump Clinical Model E0650

System 7000 E0650System 7500 (II) E0651

Kendall Home Rx (5550) E0651Lympha Press 103A E0651

103M E0652201A - Mini E0651

201-M E0652Talley/Hemaflow 2 Pump Intermittent E0650

Sequential E0651Talley/Multicom 100 E0650

200 E0650300 E0651

300G E0652500 ('93 & '94 model) E0652*

Talley/Multipulse 1000 E0652Wright Linear Pump II E0652

IV E0652Chattanooga PresSsion E0651

4320 E06504322 E0650

Advantage 2100 E0652Thera-Con Sequential E0652

* Talley/Multicom model '92 or before = E0651


AlabamaArkansasColoradoFlorida

GeorgiaKentuckyLouisianaMississippi

New MexicoNorth CarolinaOklahomaPuerto Rico

South CarolinaTennesseeTexasVirgin Islands

Palmetto GovernmentBenefits Administrators

Please bringyour DMEPOSSupplier Manual!

What you can expect!

DATE CITY/STATE SPECIALTY WORKSHOP LOCATIONS PHONE

Jan. 11 Greenville, SC Hyatt, 220 N. Main St., 29601 (803) 235-1234Jan. 13 Columbia, SC Holiday Inn Coliseum, 630 Assembly St., 29201 (803) 799-7800Jan. 16 Charleston, SC Omni, 130 Market St., 29401 (803) 722-4900Jan. 16 Oklahoma City, OK Century Center Hotel, One North Broadway, 73102 (405) 235-2780Jan. 19 Tampa, FL Holiday Inn Airport, 4500 W. Cypress St., 33607 (813) 879-4800Jan. 19 New Orleans, LA Doubletree Hotel, 300 Canal St., 70130 (504) 581-1300Jan. 23 Tulsa, OK Doubletree at Warren Pl., 6110 S. Yale, 74136 (918) 495-1000Jan. 23 Jackson, MS Holiday Inn Downtown, 200 East Amite St., 39201 (601) 969-5100Jan. 24-25 Ft. Lauderdale, FL Sheraton Design Center, 1825 Griffin Rd., (Dania, FL), 33004 (305) 920-3500Jan. 25 Little Rock, AR Robinson Convention Center, #7 State House Plaza, 72201 (501) 376-4781Jan. 30 Charlotte, NC Adams Mark, 555 S. McDowell St., 28204 (704) 372-4100Jan. 30-31 San Antonio, TX Plaza San Antonio Hotel, 555 S. Alamo St., 78205 (210) 229-1000Feb. 1 Asheville, NC Radisson, One Thomas Wolfe Plaza, 28801 (704) 252-8211Feb. 2-3 Dallas, TX Radisson Hotel Central, 6060 N. Central Expressway, 75206 (214) 750-6060Feb. 3 Raleigh, NC Holiday Inn, I-40 at Research Triangle Park, Exit 282, 27709 (919) 941-6000Feb. 6 Louisville, KY Marriott East, 1903 Embassy Square Blvd., 40299 (502) 499-6220Feb. 8 Lexington, KY Hyatt, 400 W. Vine St., 40507 (606) 253-1234Feb. 8-9 Houston, TX Sheraton Crown Hotel, 15700 J.F.K. Blvd., 77032 (713) 442-5100Feb. 10 Wilmington, NC Hilton, 301 N. Water St., 28401 (910) 763-5900Feb. 13 Memphis, TN Adams Mark, 939 Ridge Lake Blvd., 38120 (901) 684-6664Feb. 13 Mobile, AL Ramada Conference Ctr., 600 S. Beltline Hwy., 36608 (205) 344-8030Feb. 15 Nashville, TN Days Inn, One International Plaza, 37217 (615) 361-7666Feb. 17 Gatlinburg, TN Holiday Inn Resort Complex, 520 Airport Rd., 37738 (615) 436-9201Feb. 20 El Paso, TX Camino Real Paso del Norte, 101 S. El Paso St., 79901 (915) 534-3099Feb. 20-21 Atlanta, GA Westin Peachtree, 210 Peachtree St. NW, 30303 (404) 659-1400Feb. 22 Albuquerque, NM Hyatt, 330 Tijeras N. W., 87102 (505) 842-1234Feb. 23 Savannah, GA Marriott Riverfront, 100 General McIntosh Blvd., 31401 (912) 233-7722Feb. 24 Denver, CO Embassy Suites - Denver Airport, 4444 N. Havana, 80239 (303) 375-0400Feb. 27 Jacksonville, FL Omni, 245 Water St., 32202 (904) 355-6664Mar. 1 Orlando, FL Delta Orlando Resort, 5715 Major Blvd., 32819 (407) 351-3340Mar. 1 Birmingham, AL The Wynfrey Hotel, 1000 Riverchase Galleria, 35244 (205) 987-1600Mar. 3 San Juan, PR Radisson Normandie, Munoz Rivera Ave., 00901 (809) 729-2929Mar. 8 Shreveport, LA Holiday Inn Downtown, 102 Lake St., 71101 (318) 222-7717

Actual invitations havebeen mailed!

Palmetto Government Benefits Administrators (Palmetto GBA), the Medicare Region CDurable Medical Equipment Regional Carrier (DMERC), is sponsoring a series of workshopsthroughout the South and Southwest region from January 11,1995 - March 8, 1995. We will conduct workshop sessionscovering the following medical specialties:

8:30 - 12:00 DME/Oxygen(including Dialysis Equipment & Supplies)

10:00 - 12:00 Vision1:30 - 5:00 PEN/Ostomy, Urologicals & Supplies

(includingSurgical Dressings, TracheostomyCare Supplies & Immunosuppressive Drugs)

2:00 - 4:00 Prosthetics & Orthotics(not including Vision)

We are inviting you and/or your staff to attend these work-shops which will be held in various locations.

Invitations have been sent to suppliers registered with theNational Supplier Clearinghouse (NSC). You need only attend thoseworkshop sessions which pertain to the services you provide. (NOTE: Eachsession will begin with identical introductory information which is a DMERC overview.)There will be a $25.00 fee per attendee for each workshop session. Please return the registrationform and payment in advance (two weeks prior to your selected workshop) per the instructions onthe invitation. Please do not call to verify your registration. Confirmation cards will be sent to you.Cash at the door is unacceptable. On the day of your workshop, registration will begin one halfhour prior to each session.

Each individual attending a workshop can expect to receive workshop materials, as well as freecoffee, tea and assorted sodas. Trained DMERC personnel will conduct the workshops and willbe available, along with your ombudsman, to answer your questions. Lunch will be on your ownand parking will not be validated.

DMEPOS SUPPLIERSPECIALTYWORKSHOPNOTICE


t On electronically filed claims, narrative (support information) submitted to assist the processing of claim line items can be entered in field five of the HA0 record. There are 281 bytes available in this field. This field is defined on page 89 of the NationalStandard Format (NSF) DMERC Matrix.

t To expedite the processing of your motorized wheelchair claims, on the DMERCCertificate of Medical Necessity (CMN) 02.01, please answer question number 12in addition to the required question set numbers 1 through 4. In many cases thisinformation will enable us to continue processing the claim and not suspend it torequest additional information.

t What's in a claim number? The Claim Control Number (CCN) is a unique numberthe DMERCs assign to each claim for tracking purposes. The 14 digits of each CCNcan provide you with processing information you may want to know.

For example, consider the following CCN: 94322-8036-12-000. The first fivedigits identify the year (94) and the julian date (322) the claim was received byPalmetto GBA. In this example the claim was received on November 18, 1994. Thenext two digits document whether the claim was received electronically, or bypaper, (80) means the claim was submitted electronically, (70) means the claimwas submitted electronically and sent to another regional carrier, and (10 through60) means the claim received was a paper claim. The next four digits (3612)represent a sequential number from 0000 - 9999. And the last three digits (000)identify the claim as: an original claim (000), a duplicate claim with some lines thathave been processed separately (010, 020, etc.), a split claim (100, 200, etc.), oran adjustment claim (001, 002, etc.).

COMPLEMENTARY/SUPPLEMENTALPOLICIESUPDATE

Government EmployeeHospital Association

Group Health IncorporatedHumana Health Care PlanKirke-Van Orsdel, Inc.Mutual of OmahaNational Association of Letter CarriersOlympic HealthPrudential (AARP)Union Fidelity ASOUnited American Insurance CompanyUnited States Automobile AssociationUSAble Life Insurance

Non-Medigap Medicare Supplemental policies are Medicare supplement policies thatdo not meet the definition of "Medigap" policies. Often these policies are referred toas "Complementary Coverage" policies.

Do not list these Non-Medigap Medicare Supplemental policies under Item 9 of theHCFA-1500 (12/90) form. If we have an agreement with a Non-Medigap MedicareSupplemental insurer, Palmetto GBA will automatically forward the Medicare claiminformation to that insurer and indicate that we did so on your Medicare remittance.

The most current list of these insurers is shown below.

Aetna Life and Casualty InsuranceAmerican Postal Workers UnionAmerican Republic InsuranceBCBS of AlabamaBCBS of ArkansasBCBS of ColoradoBCBS of FloridaBCBS of MichiganBCBS of North CarolinaBCBS of OklahomaBCBS of South CarolinaBCBS of New MexicoBCBS of Texas

julian date

year electronically received

sequentialnumber

originalclaim

Example: Claim Control Number (CCN)

94322-80-3612-000

HELPFUL HINTS


The Treasury Department has announced that the Prompt Payment interest rate willchange to 7.0 percent effective for scheduled Medicare payment dates of July 1through December 31, 1994. This is a large increase over the 5.5 percent rate paidfor January 1 through June 30, 1994. The new rate has been approved by theSecretary of the Treasury and was published in the Federal Register the week of June28, 1994.

t CMN Instruction Clarification: On page 94-9 of the DMERC Medicare Advisory,January 1994 issue, and on page 94-129 of the DMERC Medicare Advisory, June1994 issue, instruction is given on the completion of CMN 10.01 for EnteralNutrition, omitting question 8 from the needed question set for correct filing of theCMN. Enteral Nutrition suppliers submitting their first claim to Palmetto GBA needto ensure that questions 2,6,8, and 9-13 are completed.

t HCPCS Clarification: On page 94-170 of the DMERC Medicare Advisory, June1994 issue, HCPCS codes A4460 and L3221-L3595 were listed as noncovered.

Code A4460 for elastic bandages may be covered as a secondary dressing usedto secure a primary surgical dressing. Coverage is dependent on the location ofthe wound and whether or not a less costly bandage is an alternative for the patient.Elastic bandages are noncovered for other uses. Please also keep in mind that theDMERCs are using the national policy on surgical dressing for coverage determi-nation at this time.

Codes L3221-L3595 represent integral modifications to correct a foot deformity toassure proper functioning of a covered shoe attached to a brace; therefore, thesecodes are a DMERC covered benefit.

t Address Clarification: On page 94-181 of the DMERC Medicare Advisory,September 1994 issue, P.O. Box 100236 was given for the Hearings Department.The correct address is Medicare Hearings Department, P.O. Box 100249, Colum-bia, SC 29202.

t HCPCS Clarification: On page 94-179 of the DMERC Medicare Advisory,September 1994 issue, Item 25 for the HCFA-1500 (12/90) form was indicated.The correct Item number for the supplier's signature is Item 31.

t Telephone Number Clarification: On page 94-202 of the DMERC MedicareAdvisory, September 1994 issue, the National Supplier Clearinghouse (NSC)telephone number was listed in error. The correct NSC telephone number is (803)754-3951.

t Effective Date Clarification: On page 94-199 of the DMERC Medicare AdvisorySeptember 1994 issue, the effective date pertaining to a K code recategorizationwas missing. Effective July 18, 1994, the following K codes have beenrecategorized from Prosthetics and Orthotics to Inexpensive and RoutinelyPurchased. This change means that Medicare will no longer cover these itemsfor patients in skilled nursing facilities or nursing facilities. A revised feeschedule for codes K0115 and K0116, as Inexpensive and Routinely Pur-chased Items has been developed. This revised fee schedule applies to allclaims submitted with these codes, with dates of service on or after July 18,1994. Items classified as Durable Medical Equipment (DME) are only coveredin the patient's home [Place of Service (POS) 12] or a custodial care facility(POS 33).

K0115 Orthotic seating system, back module, posterior-lateral control, with or without lateral supports, custom fabricated for attachmentto wheelchair base.

K0116 Orthotic seating system, combined back and seat module, custom fabricated for attachment to wheelchair base.

DMERC MEDICAREADVISORY UPDATE

NEW INTEREST RATEPAYABLE ON CLEANCLAIMS


Q A Providing answers to your questions/concernson an on-going basis.&

These questions were submitted to Palmetto GBA by Region C suppliers, and the answers are being published so thatall may benefit.

1. Q Will Medicare pay for a shoe upgrade?A Yes. Medicare will reimburse a shoe upgrade if it is medically necessary for support or to restrict or eliminate

motion so that the leg brace can work effectively. However, Medicare will not pay for shoe upgrades when theseconditions are not met.

2. Q Will Medicare pay separately for the replacement of a heel or sole, or the transfer of an orthoses from one shoeto another, when the shoe wears out?

A Yes. Medicare allows for adjustments or repairs ordered by the physician when required by wear or by changein the patients condition.

3. Q How does Palmetto GBA calculate pricing from milliliters (mls) into units for nebulizer drugs?A One milliliter = 3 times the unit number

One vial = One unit dose One unit dose = 3 mls

Example:

Most nebulizer drugs are prescribed for treatment 4-6 times a day. This means the unit dose (vials) would be120-180 units per month (i.e., One vial four times a day for 30 days = 120 vials (units). One treatment is givenby vial which contains three milliliters (ml) of solution. If the claim for nebulizer drugs is submitted with 120-180units, it would most likely mean units billed are for vials (unit dose). If the claim is submitted for nebulizer drugswith units more than 180, the units billed will more than likely be for mls.

4. Q How does a supplier bill for the one month rental of a wheelchair while the patient-owned chair is being repaired?A The charge for the one month rental should be billed with the claim for the repair charges, itemizing the charge

for the rental, the labor and parts charges. The code billed on the claim should be E1350 and the attachmentor electronic record should indicate the breakdown of charges. A CMN is not needed for the one month rental.

5. Q What is the appropriate use of codes K0048 and K0195?A K0048 is billed for the purchase or rental of elevating leg rests, up to the purchase price of each elevating leg

rest, when attached to a wheelchair that is listed in the purchase category. Code K0048 is allowed with codesK0005, K0008, K0009, K0013, K0014, since none of these wheelchairs are in the capped rental category.

Code K0195, elevating leg rests, should be billed as an attachment to wheelchairs in the capped rental category.Code K0195 is allowed with codes K0001, K0002, K0003, K0004, K0006, K0007, K0010, K0011, K0012.

6. Q How do I bill a humidifier add-on to an existing patient Continuous Positive Airway Pressure (CPAP) device?A Separate reimbursement will be allowed by the DMERCs for the humidifier, as long as the CPAP device is

covered. Suppliers who need to bill for this equipment for existing CPAP patients should submit their claimsusing HCPCS code E0601 for the CPAP (if appropriate) and HCPCS code E1399 for the humidifier, and includeor indicate in the description, "humidifier." The humidifier billed for an existing CPAP patient, after the initial issueof the CPAP, will be reimbursed as a purchase. Code K0193 (CPAP with humidifier) is used only for newlyplaced CPAPs with humidifier.


DISCLOSURE OFPATIENT SOCIALSECURITY ACTINFORMATION

ANTI-FRAUD UNIT

Office of InspectorGeneral Anti-FraudNotice

Suppliers asked to pay fees to physicians for completing Medicare-required Certifica-tion forms should be advised that the Office of Inspector General (OIG) considers thesolicitation of such fees as a potential felony.

When a physician bills for his or her services, including examination, diagnosis, andtreatment, any cost associated with paperwork (such as Medical Necessity Certifi-cates, Prescriptions, etc.), are considered part of the charges made for his or herprofessional services. If a patient needs an item of Durable Medical Equipment,(DME) the completion of a medical certification form is a service to the patient ratherthan the supplier. This view is shared by the Health Care Financing Administration(HCFA), the American Medical Association, (AMA), and the National Association ofMedical Equipment Suppliers (NAMES).

Section 4152 of the Omnibus Reconciliation Act of 1990 requires that physicians mustcomplete Certificates of Medical Necessity for any item of DME they order. Thelanguage in the statute does not authorize physicians to separately charge the patientor supplier for completing the certificates. Allegations of physicians chargingsuppliers for completing CMNs will be investigated under one or more of the followingprinciples:

t As potential kickback situations under Section 1128B (b) of the Social SecurityAct; and/or

t As false representation with respect to the physician's actual charge for professional services furnished on or near the date of his or her DME order for thebeneficiary; and/or

t As a potential assignment violation on assigned claims for professional serviceson or near the date he or she orders DME for the beneficiary; or

t As a potential charge limit violation on unassigned claims for professionalservices on or near the date he or she ordered DME for the beneficiary.

Send information regarding any payment issued to the physician for completing theCMN to the following address, as a review of a potential violation. Include all pertinentinformation in the referral, such as, physician name, beneficiary name and HealthInsurance Claim (HIC) number, and proof of payment made.

Palmetto GBA, Anti-Fraud Unit, Medicare Region C DMERC, P.O. Box 100236,Columbia, SC 29202-3236.

Regulations state that the following beneficiary information is confidential: HealthInsurance Claim (HIC) Number, coinsurance and deductible information, dates ofMedicare entitlement, copies of Medicare claim forms, Medicare report of eligibility,and Explanation of Medicare Benefits (EOMBs).

This information may not be disclosed to any third party without the consent of thebeneficiary or legal representative. The authorization to disclose must: be in writing,be signed and dated, specify the name of the provider being authorized to disclose,specify what information is to be disclosed, specify the name of the third party to whomthe disclosure is made, specify the purpose of the disclosure, and specify theexpiration date of the authorization (not to exceed two years).

The only exception to this requirement, which allows disclosure without consent, isin connection with any claim or other proceeding under the Social Security Act, onlywhen the disclosure is necessary for the proper performance of the duties of: anyofficer or employee of the Department of Health and Human Services, any officer oremployee of a state agency, any officer or employee of an intermediary, and/or aprovider of services or other agency/organization participating in the administrationof the program by contract or agreement. Be advised that this exception pertains onlyto these individuals and must be in connection to a claim or other proceeding underthe Social Security Act.


Jimmy Ronald Mathis, age 46, former owner of a Plano, TX medical supply company,has been sentenced to 33 months in federal prison. Mathis was convicted ofconspiring to commit mail fraud and paying illegal kickbacks for business referrals inhis medical supply business.

U.S. District Judge, Paul Brown, ordered Mathis to pay restitution totalling $386,508to the Department of Health and Human Services for fraudulent acts while doingbusiness as R. M. Medical Supplies and Service.

The following suppliers are being excluded from participation in the Title XVIII(Medicare) program, per Office of Inspector General, Office of Investigations, P.O.Box 2288, Atlanta, GA 30301.

South Carolina

Martin T. Johnson Specialty: Pharmacist2045 Alpine Drive DOB: 07/31/55Aiken, SC 29803 Period of Exclusion: Indefinitely

James H. Campbell Specialty: Business Owner107 Springdale Drive DOB: 08/26/50York, SC 29745 Period of Exclusion: 5 YearsAuthority : 1128 (a) (1)

David M. Pease Specialty: Unknown511 South Dargan St., Suite 300 DOB: 04/10/56Florence, SC 29506 Period of Exclusion: 3 Years

This alert is intended to assist suppliers in obtaining information concerning potentialfraud and abuse. It is for educational purposes only and is provided to inform suppliersof the nature of suspected fraud. This alert is not intended to imply or suggest thatany particular individual or supplier entity is associated with the activity describedbelow. If you have any questions concerning this alert or fraud in general, pleasecontact our Anti-Fraud Hot-Line (803) 788-5414.

Nebulizer Drugs

Some suppliers are reportedly diluting Albuterol 0.5% (HCPCS code J7625) withsaline to create Albuterol 0.083% (HCPCS code J7620). Then they allegedly billMedicare for the six units using HCPCS code J7625.

Medicare has identified some suppliers who are submitting claims for nebulizer drugsin quantities which exceed typical patient medical needs. In some cases, suppliershave been known to bill in excess of 540 units of Albuterol per month.

Supplier Sanctions

Fraud Alert onNebulizer Drugs

Anti-Fraud Hot-Line (803) 788-5414.

Beneficiary eligibility will be available to all participating Medicare providers on May1, 1995. This function will use the communications capabilities currently in place toaccess the Common Working File (CWF) regarding beneficiary eligibility and deduct-ible status. This function will make the following data available: Health InsuranceClaim Number (HICN), Beneficiary surname, first initial and gender, Entitlement date,Termination date, Deductible met (yes/no) for current and prior year, MSP activity(yes/no), HMO data including HMO name, HMO zip code, HMO code entitlementdate, and determination date.

As of May 1, 1995, Palmetto GBA will have this feature ready for use. Specificationsfor beneficiary eligibility have been mailed to all certified DME software vendors andare available to any supplier who wishes to receive them.

Please discuss this feature with your software vendor to determine their plans forimplementation. If you wish to receive specifications yourself, please keep in mindthat this feature is available only to those electronic billers who are participating.

To request specifications, please call the EDI Help Desk at (803) 788- 9751, and askfor Beneficiary Eligibility Specifications.

BENEFICIARYELIGIBILITYSPECIFICATIONS


Claims Status InquiryCSI

Electronic RemittanceNotices (ERNs)

ELECTRONIC DATAINTERCHANGE(EDI) ADDED BENEFITUPDATE

NEW HCPCS CODES AND CATEGORY ASSIGNMENTThe following 1995 new HCPCS codes have been assigned to the categories indicated, and fall under the jurisdiction ofexisting DMERC medical policy.

CODE ITEM FEE SCHED. MEDICAL CMNCATEGORY* POLICY REQUIREMENTS

E0671 Segmental gradient pressure pneumatic appliance, 1 Lymphedema Pump, 04.01full leg

E0672 Segmental gradient pressure pneumatic appliance, 1 Lymphedema Pump, 04.01full arm

E0673 Segmental gradient pressure pneumatic appliance, 1 Lymphedema Pump, 04.01half leg

K0193 CPAP device, with humidifier 4 CPAP 03.01K0194 BIPAP 4 N/A N/AK0267 Replacement battery, any type, for use with medically 1 Blood Glucose Monitors N/A

necessary, glucometer, monitor owned by patient, eachK0277 Skin barrier; solid 4x4 or equivalent, with built in 3 Ostomy N/A

convexity, eachK0278 Skin barrier; with flange (solid, flexible or 3 Ostomy N/A

accordion), with built-in convexity, any size, eachK0280 Extension drainage tubing, any type/length, with 3 Incontinence 05.01

connector/adaptor, used with urinary leg bag orurostomy pouch, each

K0281 Lubricant, individual, sterile packet, for insertion of 3 Incontinence N/Aurinary catheter, each

K0284 External infusion pump, mechanical, reusable, for 4 External Infusion Pump 09.01extended drug infusion.

* FEE SCHEDULE CATEGORY KEY1=Inexpensive or Other Routinely Purchased DME, 2=Items Requiring Frequent and Substantial Servicing, 3=Prosthetic and OrthoticDevices, 4=Capped Rental Items, and 5=Oxygen and Oxygen Equipment

As we stated on page 94-178 of the DMERC Medicare Advisory September 1994 issue, ofthe electronic billers now have an added benefit. As an electronic biller you can have directon-line systems access to the status of your claims filed with Palmetto Government BenefitsAdministrators (Palmetto GBA) through a new Claims Status Inquiry (CSI) system.

CSI continues to be a successful and popular program for electronic submitters. After yourclaims are processed, a history of all claims submitted within the last six months to PalmettoGBA is available for electronic viewing. You will be able to use CSI screens to determine thestatus of your claim(s) as it processes through our system to its final resolution. Through CSIscreens you will also be able to determine the dates and amounts of the last 3 paymentsmailed to you by Palmetto GBA, and the total amount of money pending for your companyon the payment floor.

In addition to this benefit, EDI continues to widen its scope of advantages for electronic billerswith Electronic Remittance Notices (ERNs). As of September 1994, electronic billers beganreceiving their remittance notices electronically, as well as on paper. ERNs are important notonly because of their convenience and automation, but also because they are prerequisitesfor direct deposit of payments, or Electronic Funds Transfer (EFT). In order to be eligible forEFT, suppliers must receive their remittances electronically, as well as submit at least 90percent of their claims electronically.

Enrolling for this benefit is easy. Simply contact our EDI department by calling or writing, andrequest the enrollment forms for the Claims Status Inquiry system and for ElectronicRemittance Notices. After returning your completed enrollment form, you will receive anelectronic notice of your assigned security clearance to our CSI system and specificdocumentation on how to obtain critical claims processing information.

These added features allow you to stay up-to-date on the status of your claims, and receivedocumentation of the final resolution of your claims as quickly as the information becomesavailable.

If you have any questions about these new benefits or if you would like to obtain theenrollment forms, please contact our EDI department at:

Electronic Data Interchange (803)788-9751Palmetto GBA/EDI, Medicare Region C DMERCP.O. Box 100145Columbia, SC 29202-3145


Aim Rite Computer Systems Rob HermanP.O. Box 9 414/255-0222German Town, WI 53022

Aim Systems Ann MacDonald6356 Banburny Rd. 708/971-9290Downers Grove, IL 60516

Alcon Systems Joe Donnelly6201 S. Freeway, S1-4 800/289-1992Ft. Worth, TX 76134

ASAP Software Ed Kutt Certified only for DMERC19253 Hwy. 41 North, Ste. 105 813/949-6251 CMNs 01.01, 02.01, 05.01Tampa, Fl 33629 and 09.01

Bill Ease Systems John Beddow269 Moran 313/337-8670Grosse Pointe, MI 48236

Business Solutions Service Corp. Luis A. Colon Certified only for DMERCCalle Trigo #563 809/876-2091 CMNs 01.01, 02.01 andEl Dorado 8A 03.01Santurce, PR 00907

CDL Healthcare Systems Theresa Fusco Certified only for claims not8181 154th St., Ste. 220, Ste. 350 305/822-5566 requiring CMNsMiami Lakes, FL 233016

Classic Data Service Art Cross8301 S. Western Ave. 213/751-1174Los Angeles, CA 90047-1174

Compu-Meds Dave Floyd15 Locust Ave. 304/366-6895Fairmont, WV 36554

Compu-Services Bob Zektick247 Rutledge St. 908/735-9656Brooklyn, NY 11211

Compulink Systems Jan Motil Certified only for DMERC31348 Vis Colinas, Ste. 103 818/707-0017 CMN 02.01Westlake, CA 91362

Computer Solutions Ken Dickenson Certified only for DMERC2508 S. Atlantic Ave. 904/427-0558 CMNs 04.01 and 10.01New Smyrna Beach, FL 32169

Do not let your paper claims experience processing delays. Please consult Section21 of your Region C DMEPOS Supplier Manual for the correct address for thesubmission of your paper claims.

Hundreds of paper claims are being mailed to the wrong address every day. Thiscauses delays in processing and payment of your claims. The Electronic DataInterchange Department (EDI) does not accept or process paper claims. So avoidunnecessary delays! Remember to use the Dedicated Work Team address grid inSection 21 of your Region C DMEPOS Supplier Manual.

The following is an update including additions, changes and deletions, to the DMERCCertified Software Vendors, Billing Services and Clearinghouses listed on page 94-153-164 of the DMERC Medicare Advisory, June 1994 issue.

These companies have demonstrated their ability and are certified to submit DurableMedical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) claims andCertificates of Medical Necessity (CMNs) electronically to the DMERCs, as ofNovember 15, 1994.

The following companies have systems that are certified as fully capable for electronicsubmission of all types of DMEPOS claims and certifications, unless otherwise noted.

DMERC CertifiedSoftware Vendors

Additions

EDI RECEIVESMISDIRECTED PAPERCLAIMS

DMERC CERTIFIEDSOFTWAREVENDORS, BILLINGSERVICES &CLEARINGHOUSES



Additions (Cont'd)

Consolidated Automated Systems Don Wright190 Lester Dr. 904/276-2204Orange Park, FL 33742-0383

Cost Effective Computer Systems Tom Torbet Certified only for DMERC2955-C Cleveland Hwy. 706/259-6091 CMNs 02.01, 05.01, 08.01Dalton, GA 30721 and 09.01

Data House, Inc. Jim Knight1640 Akron Peninsula Rd. 216/923-5258Akron, OH 44313

Elite Software and Services Rick Hartley Certified only for claimsP. O. Box 64 303/466-1895 not requiring CMNsBroomfield, CO 80038-0064

Executive Data Systems Earl Taylor Certified only for DMERCP.O. Box 240123 205/277-6201 CMNs 04.01 and 08.01Montgomery, AL 36124

Finley Systems Rod Smith Certified only for DMERC5500 E. Loop 820 South, Ste. 101 817/572-7540 CMNs 01.01 and 02.01Fort Worth, TX 76119

Four Color Software Corp. Steve Takiff6522 Senator Lane 513/433-3780Dayton, OH 45459

Futura International Marshall Fryman22051 US Hwy. 19 N 813/791-3332Clearwater, FL 34625

Future Tech Corporation Stephen Frye10319 Technology Dr., Ste. 1 615/675-1430Knoxville, TN 37932

Genius Solutions Mark Thuemmel755 W. Big Beaver, Ste. 2000 810/362-6810Troy, MI 48084

Hinkle and Associates Angie Logsdon2127 Tracy Rd. 317/535-7274New Whiteland, IN 46184

Introspect Kurt Teschendort12244 Sylvania-Metam 419/829-3183Berkley, OH 43515

Lifestar Computers Bob Zektick14 Cedar Grove Rd. 908/735-9656Annadale, NJ 08801

Lincare Inc. Jeannine Miele19337 US 19 N., Ste. 500 813/530-7700Clearwater, FL 34624

MG Research Greg610 E. Acacia Ave., #9 818/552-5033Glendale, CA 91205

Maximus Tony Heckman677 W. Imboden 217/421-1857Decatur, IL 62521

Medical Office Software Doug Wolverton Certified for NSF Vers.2280 SW 70 Ave. 305/476-8177 1.03 & 1.04Davie, FL 33317

Medical Solutions Wayne StanfieldP.O. Box 1447 804/572-1144Halifax, VA 24558

Medicare Data Systems William Betts223 Stiger St. 908/852-4500Hackettstown, NJ 07840



Additions (Cont'd)

Medisys Dennis Sullivan15600 B Black Canyon Hwy. #100 602/993-4772Phoenix, AZ 85023

Medix Edwin Ukpaby17050 S. Park Ave. 708/331-1271South Holland, IL 60473

Omni Tech Jay Roy Certified for NSF Vers.2100 45th St., Ste. A1 407/844-0099 1.03 & 1.04West Palm Beach, FL 33407

Paranet Software Carl Jones4740 Cinderella Lane 702/221-0748Las Vegas, NV 89102

Pass Inc. Kim Caldwell5204 Kingston Pike, Ste. 32 615/588-6867Knoxville, TN 37919

Personalized Programming Inc. Larry HorwitzRte. 3, Box 90 904/462-2148Alachua, FL 32615

Pharmacare Inc. Ron Winters2621 Crescent Springs Rd. 606/331-1112Crescent Spring, KY 41017

Physician Micro Systems W.R. Drury301 Cleveland Place 804/671-1802Virginia Beach, VA 23466

Practical Computer Solutions John Brennan302 W. Clay 618/345-7232P.O. Box 777Collinsville, IL 62234

Practiputing Inc. Melody Plett16923 Meridian E., Ste. A 206/848-4443Puyallup, WA 98373

Quadax Hank Termeer4079 Executive Pkwy. 614/882-1200Westerville, OH 43081

Quadramed Corporation Jamie Cross2700 Ygnacio Valley Rd., Ste. 300 510/930-0896Walnut Creek, CA 94598

RNA Inc. Chris Koerner130 W. Wegner Rd. 513/832-0058Englewood, OH 45322

Scientific Data Paul Ballinger23885 Denton 810/468-7600Clinton Twp., MI 48036

Seniors Management Kathleen Toomey1114 Wynwood Ave. 609/663-4044Cherry Hill, NJ 08002

Starting Point Charles Mason30250 John Rd. 313/585-4880Madison Heights, MI 48071

Systems Management Greg Kitcham525 W. Washington 219/234-5807South Bend, IN 46601

Systems Plus/ Reba GibbonsPersonalized Programming 800/222-7701500 Clyde Ave.Mountain View, CA 94043

TeleClaims Inc. Johnnie Farley820 Shades Creek Pkwy., Ste 1000 203/879-3022Birmingham, AL 35209



Additions (Cont'd)

Terry Newman Terry Newman9171 Wilshire Blvd., Ste. 206 800/227-5534Beverly Hills, CA 90210

Unico Inc. Ken Stoltz236 N. Weinback 812/479-3932Evansville, IN 47711

Unicomp Corp. Andy Kaplan3701 NW 126th Ave. 305/755-1710Coral Springs, FL 33065

Unitec Sen Ganesan2300 E. Higgins Rd., Ste 203 708/952-8144Elk Grove Village, IL 60007

Vector Systems George Schnellman4991 Wyffels Rd. 716/394-2270Candigua, NY 14424

Versyss Inc. Jim Madden400 Blue Hill Dr. 617/320-4745Westwood, MS 02090

Weber Automated Javier Elizondo5950 W. Howard 708/965-9600Skokie, IL 60077

151 Claim Services Susan Beason4617 N. Prospect #23 309/682-3314Peoria, IL 61614

2nd Insurance Doctor Barbara Dandone2363 Aberdeen St. 516/794-4160East Meadow, NY 11554

21st Century Billing Barbara Phillips620 Patterson Box 298 308/697-3266Cambridge, NE 69022

A & A Alternative Billing Paula Bushman4020 SW 54th Ave. 305/792-9713Davie, FL 33314

A1A Billing & Collection Isis Gonzalez17000 NW 67th Ave., Ste. 322 305/822-3202Miami, FL 33015

A Perfect Medical Billing Svc . Terri L. Dorfman14539 Diplomat Dr. 813/960-8724Tampa, FL 33613

A Quality Medical Supplies Sandra Lata483 E. 49 St. 305/685-7914Hialeah, FL 33013

AAA Medical Billing Pam Donahue2800 University Ave. #H1B-200 515/222-1906W. Des Moines, IA 50266

A.A.A.A. Inc. Roxana Pio600 Palm Ave., Ste. C 305/889-3339Hialeah, FL 33010

A.D. Services Plus Delia Lopez341 W. 31st St. 305/888-3933Hialeah, FL 33012

A and F Billing Inc. Florence Daudin4471 NW 36 Street 208 305/887-8455Miami, FL 33166

A.K. Billing Service Inc. Ana Maria Doval1111 SW 8th Street, Ste. 202 305/858-8258Miami, FL 33130

DMERC CertifiedElectronic BillingServices

Additions



Additions (Cont'd)

AOS Data Services Stephanie FeolaP.O. Box 607 516/825-7339Valley Stream, NY 11582-0607

ARP Electronic Medical Billing Jerry Miller23657 Emelita St. 818/888-5458Woodland Hills, CA 91367

A & T Enterprises Ray Averyt2500 Cross Drive 807/699-1015Killeen, TX 76543

Access ECS Sherrie RobertsP.O. Box 21887 801/944-5475Salt Lake City, UT 84121

Accounts Receivable Chris Davis8100 Penn Ave. South St. 800/227-1729Bloomington, MN 55431

Additional Reimbursement Services Regena Taylor9458 Hwy. 87 North 915/949-4616San Angelo, TX 76901

Advanced Medical Billing System Marc A. Pine3213 W. Oakellar St. 813/839-5856Tampa, FL 33611

Advanced Medicare Services Inc. Charles Brown13161 56th Court, Ste. 203 813/572-8158Clearwater, FL 34620-4027

All-Med Billing Abner Diaz2189 W. 60th Street, H 203 305/822-0724Hialeah, FL 33016

All State Billing Service Francisco Soto Malave933A SW 87 Avenue 305/267-8118Miami, FL 33174

Allegro Billing Service Ward Cook5025 Homer Ave. 813/837-2773Tampa, FL 33629-7520

AMR Medical Consultants Dina Elwell516 Point’O Wood 818/969-3055Azusa, CA 91702

American Home Therapies Barb Hopkins1842 Lackland Hill Pkwy. 314/994-0100St. Louis, MO 63146

ASAP Billing Ron Hardison28202 Cabot #300 714/365-5626Laguna Niguel, CA 92677

Ask Healthcare Management Al Killinger1398 SW 15th St. 407/393-5345Boca Raton, FL 33486

Associated Medical Products Mary/Jeril6352 Airway Drive 317/856-1320Indianapolis, IN 46241

Astro Billing Systems Carlos Sanchez18524 NW 67th Ave., Ste. 162 305/380-8915Miami, FL 33015

Bemac Medical Billing Marco Betancourt551 West 51st St. Place 305/827-2020Hialeah, FL 33012

Best Billing Service Barbara Schug18359 Meadow Ridge Rd. 408/443-8732Salinas, CA 93907

Better Business Billing Services Mindy S. Breitman2586 NW 89th Drive 305/755-7425Coral Springs, FL 33065



Additions (Cont'd)

Bill Tech Medical Svcs. Susie Garcia8960 SW 89th Court 305/279-1020Miami, FL 33176

Billing Network Inc. Lanny Menendez7331 Coral Way, Ste. 240 305/264-8660Miami, FL 33155-1471

Billing Service of Miami, Inc. Rosa E. Martinez1516 Venera Ave. Ste. 200 305/668-5108Miami, FL 33146

C & C Homecare Inc. Alan CrossP.O. Box 7047 813/951-2099Bradenton, FL 34210-7047

CNH Electronic Medical Billing Colin LauP.O. Box 11133 818/240-0311Glendale, CA 91266

CPT Billing Inc. Mergie Barranco11635 NW 45 St. 305/341-8154Coral Springs, FL 33065

Cash Management Cons Paul McCabeP.O. Box 95 616/669-3344Jenison, MI 49429

Caton & Associates Linda Caton5545 N. Oak, Suite 25A 816/459-9400Kansas City, MO 64118

Cemi Billing Services Hiram H. PuigP.O. Box 192513 809/754-4282San Juan, PR 00919-4282

Central Home Care Inc. Ivonne Tomayo953 SW 1st, Suite 4 305/541-1441Miami, FL 33130

Central Medical Services Becky Boyle3500 N. Rock, Bldg. 100 316/636-2527Wichita, KS 68226

Claimcare Inc. Jaime Zambrano6911 Main St. 305/823-2392Suite 205Miami Lakes, FL 33014

Claims Management Service Brad Leake570 Lawrence St. #110 503/344-9210Eugene, OR 97401

Classic Data Service Art Cross8301 S. Western Ave. 213/751-1174Los Angeles, CA 90047-3038

Clinical Health Systems Anna TroupeP.O. Box 1589 206/693-6443Vancouver, WA 98668

Clinical Resp. Care Consultants Carmen O. Rodriguez9835 Sunset Dr., Ste. 102 305/279-9079Miami, FL 33173

Clinical Support Services Marty Priddy1187 E. Mission Road 619/731-2000Fallbrook, CA 92028

Coleman Billing Service W.L. Coleman, Jr.300 Rockmount Dr. 803/796-4943W. Columbia, SC 29169

Computer Business Systems Phillip Tremper6211 Executive Blvd. 301/770-2292Rockville, MD 20852



Additions (Cont'd)

Computerized Billing Commun. Razen Sanchez11200 W. Flagler St. 305/227-4040Suite 214Miami, FL 33174

Consolidated Automated Systems Don Wright190 Lester Dr. 904/276-2204Orange Park, FL 32073

Cost Control Billing Inc. Kathy ChilverP.O. Box 20383 813/572-5449St. Petersburg, FL 33742-0383

Covenant Home Med. Services Bob Hoffman2222 Edgemont 319/236-4054Waterloo, IA 50702

Creative Environment Inc. Sam Lamey301 N. Broadway 501/374-3312North Little Rock, AR 72114

Cross Shield Med. Equip & Rental Roberto Valdes13780 S W 56 Street 305/382-1638Suite 212Miami, FL 33175

DME Billing Services Larry Jablonew1067 N. Mason Rd. #10 314/878-9966St. Louis, MO 63141

DME EMC Billing Donna Brundidge1040 Travelers Trail 404/423-7597Kennesaw, GA 30144

DNL, Inc. Nicki Neal516 Villa Ave. #25 209/299-8661Colvis, CA 93162

DRJ Technology Richard Mather120 East Ave. 617/933-6293Woodburn, MA 01801

Data House Inc. Jim Knight1640 Akron Peninsula Rd. 216/923-5258Akron, OH 44313

Del Care Tammy Pearson1870 Executive Park Pl. 615/339-8303Cleveland, TN 37312

Dial Medical of Florida, Inc. Trish Fuqua1990 Industrial Drive 904/738-2778Deland, FL 32724-3023

Doctors Electronic Billing Marilyn C. Graese2402 Birkdale Way 502/737-3789Elizabethtown, KY 42701-8626

Dynamic Energy Systems Nancy Matz710 E. Park Blvd., Ste 206 214/423-5171Plano, TX 75074

ECF Systems Inc. Horace A. Willkinson CPA600 W. Campbell Rd., Ste. 1 214/669-8772Richardson, TX 75080

ECP Distributors Inc. Grady GriffinP.O. Box 1038 912/783-4988Hawkinsville, GA 31036

EMC Billing Services Betty TudorP.O. Box 8623 804/740-5643Richmond, VA 23226

Electroclaims of Houston Major C. Davis8618 Heatherview 713/495-0213Houston, TX 77099-1809



Additions (Cont'd)

Electronic Claims of Puerto Rico Enrique Rodriguez1038 J.T. Pinero Ave., Ste. 1038 809/792-1020Puerto Nuevo, PR 00920

Electronic Med. Claims Billing Cen. Roberta Brown2880 Meade Ave., Suite 101 702/367-3625Las Vegas, NV 89102

Elena Coronel Elena Coronel5911 NW 199 St. 305/623-0755Miami, FL 33015

Enterprise Consultants Marilyn ReevesRoute 3 Box 208 B 800/280-2442Summitt, MS 39666

Executive Mgmt. & Consultant Svc. Manuel N. Alvarez755 East 49th St., Ste. 6B 305/769-9888Hialeah, FL 33013

Family Medical Billing Service Dennis Wandle3 Sutton Place 516/585-5716Ronkonkoma, NY 11779

FJB Fast Claim Billing Frank Buck451 Juniper St., Ste. 100 215/672-2440Warmister, PA 18974

Florida Complete Health Care Maribel Pacheco18524 N.W. 67th Ave., Ste. 243 305/362-3264Miami, FL 33015

Florida Underwriting Co. Jennie Grow16956-3 McGregor Blvd. 813/466-5657Ft. Myers, FL 33908

Fry Automated Med Service Doris FrySt. Rt. 2 Box 153-A 417/967-4557Houston, MO 65483

Garver Medical Associates Mishell Garver1815 S. Carson Ave. 918/584-1107Tulsa, OK 74119-5007

Gateway Business Network A. Renee Willis5970 Sam Houston Pkwy. E, Ste. 502 713/441-4142Humble, TX 77396-3258

Gateway Health Service Tina McNuttP.O. Box 690 800/541-1696Maryville, IL 62062

Global Billing Maria Batista957 SW 122 Ave. 305/553-6234Miami, FL 33184

H & H Enterprises Rick Hensley10319 Technology Dr. #3 615/671-4436Knoxville, TN 37932

Healthcare Management Solutions Pat Shannon3417 E. Dutchman Cr., Ste. 201 402/293-0296Omaha, NE 68123-1389

Healthcare Reimbursement Fred Kono330 Brady St. 319/324-1995Davenport, IA 52801

Healthcare Solutions Kendra Ourada1440 Maple Ave., Ste. 2B 708/434-9320Lisle, IL 60532

Hialeah Billing Services Inc . Ailet Rodriguez2586 W. 74th St. 305/558-8400Hialeah, FL 33016



Additions (Cont'd)

Home Medcare Inc . Gerry McCranteP.O. Box 819 912/374-2535Eastman, GA 31023-0819

Hood Home Care Medical Wayne Hood1007 West Scenic Dr. 501/758-8232N. Little Rock, AR 72118

Introspect Kurt Teschendort12244 Sylvania-Metam 419/829-3183Berkley, OH 43515

JAS Medical Equipment Inc. Javier SantosP.O. Box 4952, Ste. 45 809/746-2837Caguas, PR 00725

JMC Billing Service Minerva Mazalra13911 SW 27 Terrace 305/554-0816Miami, FL 33175

JP Processing Services Jo Sears859 Toh-n-hah Trail 316/722-8885Wichita, KS 67212

Juckette Mgmt. Services, Inc. Jill StofferP.O. Box 329 816/665-3774Kicksville, MO 63501

L & D Company Lorna Acton3997 Camas Creek Rd. 509/782-4902Leavenworth, WA 98826-9427

LMS Electronic Medical Billing Lana Mason230 Fig Court 707/586-0746Rohnert Park, CA 94928

Lilia A. Perez Billing Service Lilia A. Perez691 S.E. 3 Place 305/882-5894Hialeah, FL 33010

MDHS Karen Mariott1720 S. Caraway, Ste. 3020 501/972-1030Jonesboro, AR 72401

Med Billing Group Inc. Luis J. Cucet Jr.3191 Coral Way, Ste. 400 305/448-9105Miami, FL 33145

Med Electric Billing Lois Rayome904 De Leon Drive 915/584-4639El Paso, TX 79912

Med Future Jose L. Abreu2742 SW 8th St., Ste. 216 305/642-2198Miami, FL 33135

Med Stat Billing Services Inc. Frank13501 S W 128 St., Ste. 209 305/255-3234Miami, FL 33186-5863

Med Work Technologies Inc. James Brooks1212 Kelly Park Rd. 405/259-7485Edmond, OK 73003

Medi-Bill Systems Todd Larson9705 SW Sunshine Ct. #1000 503/646-8078Beaverton, OR 97005

Medi-Billing Systems Elizabeth Brocca4990 SW 72 Ave., Ste. 109 305/669-4444Miami, FL 33155

Medi-Systems Terry Thomas14000 63rd Way N., Ste. B 818/531-1772Clearwater, FL 34620



Additions (Cont'd)

Medical Accounting Specialists Michael PortaP.O. Box 12568 703/989-1249Roanoke, VA 24026-9983

Medical Advance Billing Corp. Jose L. Abrev820 Salzedo St., Apt. 401 305/422-8282Coral Gables, FL 33134

Medical Billing Associates, Inc. Dale Becker5917 W. Creek Rd. 414/994-2060Random Lake, WI 53075

Medical Billing Associates Inc. Georgiann Rill1107 W. Chapman Ave., Ste. E 714/639-2952Orange, CA 92130

Medical Billing Plus Marlene Ferrer5600 SW 135th St., Ste. 110-B 305/380-9356Miami, FL 33183-5152

Medical Billing Solutions Richard Feingold9539 White Oak Ave. 219/924-2407Munster, IN 46321

Medical Billing Solutions Dawn Maddock949 Spring Valley Rd., Ste. 202 201/712-9200Maywood, NJ 07607

Medical Billing Specialists Kathy Toll8913 Badger Ct. 407/658-4839Orlando, FL 32829

Medical Business Associates Ron MeyerP.O. Box 1479 704/891-5524Etowah, NC 28729

Medical Claim Service June Levey7222 N. Shadeland Ave., Ste. 102 317/577-7661Indianapolis, IN 46250

Medical Claims Service Judy Hodge3213 Cranleigh Dr. 904/893-6692Tallahassee, FL 32308

Medical Claims Services Hardika Patel114 Swamp Fox Trail 803/879-3600Greer, SC 29650

Medical Claims Service Nick Nazikyan11733 Arminta St. 818/982-5690North Hollywood, CA 91605

Medical Data Services Steve Roe12625 High Bluff Dr., Ste. 113 619/259-4650San Diego, CA 92130

Medical Data Systems Greg Kirsch1267 West Bagley Rd. 216/234-5424Berea, OH 44017

Medical Devices Lisa Croom7560 AE Beaty Dr., Ste. #6 901/386-2626Bartlett, kTN 38133

Medical Electronic Processing Systems Debbie Howard3681 SE 25 Ave. 904/629-2181Ocala, FL 34471

Medical Information Systems Nick Edwards115 S. Zarragossa St. 904/433-4345Pensacola, Fl 32501

Medical Insurance Services Poppy PieperP.O. Box 14642 915/550-0732Odessa, TX 79768-4642



Additions (Cont'd)

Medical Solutions Wayne StanfieldP.O. Box 1447 804/572-1144Halifax, VA 24558

Medical Specialist, Inc. Stella PapchekP.O. Box 10158 701/280-2145Fargo, ND 58106

Medicare Billing Consultants Sandy HopperP.O. Box 5822 615/573-9176Knoxville, TN 37928-5822

Medication Plus of Florida Suzanne JohnsonP.O. Box 1390 800/662-6443Quincy, FL 32353-1390

Mediclaims Management Inc. Bonnie RodriguezP.O. Box 5102 305/826-0244Miami, FL 33014-1102

Mediquip Home Health Center Beverly Holbrook11524 Common Wealth Dr. 502/266-6367Louisville, KY 40299-2340

Medisys Management Inc. Violet1419 Yuba St. 916/225-8100Redding, CA 96001

Medline Healthcare Ed HylandOne Medline Pl. 708/949-5500Mundelein, IL 60060

Miami Billing Management Inc. Melva Bustamante4160 W. 16th St., Ste. 305 305/556-8622Hialeah, FL 33012

Mura Medical Services John Mura2308 Methews Ave. #3 310/371-8875Redondo Beach, CA 90278

NCRS Inc. Dennis Bissonnette5025 Arapaha Rd., Ste. 400 214/363-7751Dallas, TX 75248

NM Health & Management Co. Susan Kinsella4115 E. Broadway, Ste. A 310/930-0777Long Beach, CA 40803

N.V. Professional Billing Svc. Nina Vilaomat7221 Coral Way, Ste. 203 A 305/265-7316Miami, FL 33135

National Billing Network Dulce M. Gutierrez5880 West 20th Ave. 305/821-1712Hialeah, FL 33016

New Age Billing Darlene Patterson2677 Kathleen 810/227-8352Brighton, MI 48116

New Mexico Respiratory Svcs. Inc. Debbie Heatherington435 Sudderth Dr. 505/257-4553Ruidoso, NM 88345

Nutri Care Home Services Inc. Scott Vega4612 SW 74th Ave. 305/267-1716Miami, FL 33155

Nutricare Teri Bacio133 N. San Gabriel Blvd. #203 818/440-0120Pasadena, CA 91107

Oba Medical Supply Inc. Edith Goitia1821 Coral Gate Dr. 305/444-0140Miami, FL 33145



Additions (Cont'd)

Online Electronic Claims Processing Carrie E. Boyce11024 Montgomery Blvd. NE, Ste. 219 505/292-5833Albuquerque, NM 87111

Optometric Corp. of Louisiana Jeanne LaFleur130 Third St. 504/343-9293Baton Rouge, LA 70801

Our Billing Service Linda Jones868 Gravenstein Hwy. North 707/823-4695Sebastopol, CA 95473

PM Consulting Group Stacey Finney350 W. Kensington, Ste. 102 708/342-1933Mt. Prospect, IL 60056

Pass Inc. Kim Caldwell5204 Kingston Pike, Ste. 32 615/588-6867Knoxville, TN 37919

Patricia Weaver Medical Billing Svc. Patti Weaver196 Carlisle St. 717/823-9468Wilkes-Barre, PA 18702

Pen Billing Service Myriam Leandro5600 SW 135 Ave. 305/385-2235Miami, FL 33183

Pharmacare Inc. Ron Winters2621 Crescent Springs Rd. 606/331-1112Crescent Spring, KY 41017

Pharmcare Infusion Inc. Sally Down320 South Tamiami Trail 813/484-4842Nokomis, FL 34275-3161

Physician Billing Service Alan Davis2500 S. Willis, #201A 915/692-7111Abilene, TX 79605

Physicians Billing System Inc. Liz Beth Barrial935 West 49th St., Ste. 205 305/826-5887Hialeah, FL 33012

PIK Systems John Raisin3311 Walnut Lane 510/283-7821LaFayette, CA 94549

Power Plus Systems Inc. Harold W. Covert4453 Plumosa St. 904/597-2399Spring Hill, FL 34607

Preferred Medical Equip. Co. Russ Goforth106 West Hill Drive 615/449-8868Lebanon, TN 37087

Primary Medical Services Ivette Rey2801 Ponce De Leon, Ste. 333 305/448-1744Coral Gables, FL 33134

Pro Med Eric Hartung4633 Ventura Canyon Ave. 818/986-1315Sherman Oaks, CA 91423

Professional Billing Service Carolyn Maness410 Prosperity Way 205/383-8389Muscle Shoals, AL 35661

Q-Med John Boldt17129 Main St., Unit B 619/244-6400Hesperia, CA 92345

Quadramed Corporation Jamie Cross2700 Ygnacio Valley, Ste. 300 510/930-0896Walnut Creek, CA 94598


Quality Billing Corp. Ana Castell10240 SW 56th St., Ste. 101 305/270-3334Miami, FL 33165

Quality Billing Service Clayton FarmerP.O. Box 462 918/776-0640Sallisaw, OK 74955

R & E Billing Service Eddie Perez14124 SW 45 Terrace 305/220-4277Miami, FL 33175

R & R Medical Billing Corp. Rebecca Rojas2690 W 76th Street 305/826-1222Suite 103Hialeah, FL 33016

Rancare, Inc. Julie Lopez31742 Enterprise Dr. 313/427-4810Livonia, MI 48150

Rapid-Med Claims Inc. Dahn BoquistP.O. Box 2960 206/698-4828Silverdale, WA 98383

Rapid Reimbursement John WardwelP.O. Box 721097 810/518-4562Burkely, MI 48702

Rapid Reimbursement of the South Vanessa Kckem4470 Chamblee Dunwoody Rd. 404/458-8488Suite 350Atlanta, GA 30338

Respiflow, Inc. Mark Kraemer5100 Sunbeam Rd. 904/268-0537Jacksonville, FL 32257

Revenue Enhancement Professional Andrea Cassity3705 SW 22nd St 816/224-6470Blue Springs, MO 64105

Riverview Homes Inc. David McKenzieP.O. Box 761 606/638-3339Louisa, KY 41230

SAK Billing Services Sheryl Kzemien40575 California Oaks Rd. D2-179 909/698-2063Murrieta, CA 93203

S.T.A.R. Laurie Brown337 Plumtree Dr. 805/854-4148Arvin, CA 94010

Software to Systems Bonnie Michael700 W. Peterose Way 513/621-1200Cincinnati, OH 45203

Source Computing, Inc. Barbara BradfordP.O. Box 579 602/634-6306Cottonwood, AZ 86326

Southern Pharmacy Barbara Fortune120 S. Main St. 803/967-1860Simpsonville, SC 29681

Southwest Medical Clearinghouse Marvin Roe26459 Maricopa Pl. 602/895-7396Sun Lakes, AZ 85248

Specialized Insurance Assistance Kathy Serafin7020 Chippewa St. 314/832-3939St. Louis, MO 63119

Specialty Prosthetics Systems Michele Nielsen1653 Hoyt St. 702/849-2366Reno, NV 89509


Additions (Cont'd)



Additions (Cont'd)

Spoken Word Systems Cindy Bethard3573 E. Sunrise, Ste. 119 602/529-2255Tucson, AZ 85741

Stat Medical Billing Inc. G. David MoralesP.O. Box 522900 305/227-7828Miami, FL 33152-2900

Statewide Claims Consultants Kathy BrodskyP.O. Box 280 501/942-5410Sheridan, AR 72510

Stephens Medical Mgmt. Beverly5337 Verdun Ave. 213/750-6095Los Angeles, CA 90043

Sylvia J. Hill & Associates Sylvia Hill326 East Osage 918/423-7100McAlester, OK 74501

T. Campbell Billing & Consulting Teresa CampbellP.O. Box 777 903/896-7507Edgewood, TX 75117

T.I. Medical Inc. Tonie J. Lanza4727 SW 74th Ave. 305/267-0683Miami, FL 33155

Team Health Services, Inc. Cheri Sweetland1767 Reynolds Ave. 714/250-4774Irvine, CA 92714

Total Health Services Joel Fish3100 Commercial Ave. 708/498-2464Northbrook, IL 60062

Trinity Medical Billing Specialist Kim Eatman1466 N. Marcella Ave. 909/874-6031Rialto, CA 92376

Unified Healthcare Products Paul Rigney14565 Valley View Ave., Ste. U 310/404-8052Santa Fe Springs, CA 90670

Unimed Billing Inc. Lourdes OjitaP.O. Box 172237 305/828-0701Hialeah, FL 33017-2237

Universal Billing Service Maria Crespo85 W. 10th St., Ste. 9 305/888-6493Hialeah, FL 33010

Valu-med Inc. Gina Lindsey3300 Lynchburg Dr. 205/281-3923Montgomery, AL 36116

Wayne Pharmacy Inc. Mindy Barker2302 Wayne Memorial Dr. 919/735-6936Goldsboro, NC 27534-1726

Weber Automated Javier Elizondo5950 W. Howard 708/965-9600Skokie, IL 60077

The Wordsmith Patty Smith8513 Menke Way 916/988-1302Orangevale, CA 95662

Wound Care Management Inc. Pam Forest448. W. Donegan Ave. 407/935-9000Kissimmee, FL 34741


BC/BS Michigan Greg Fullington53200 Grand River 313/486-2061New Hudson, MI 48165

Data Claim Jim GreenlandP.O. Box 4188 310/915-1014Culver City, CA 90231

Electronic Translations & Transmittals Frank HaraksinP.O. Box 93 619/955-1778Victorville, CA 92393

Jugel, Richard D. & Co. Jack Glaeser111 S. 108th Ave. 402/334-9404Omaha, NE 68154

Physicians Practice Mgmt. Cynthia Cole350 E. New York St., Ste. 300 800/428-3515Indianapolis, IN 46204

Power Plus Systems Inc. Harold Covert4453 Plumosa St. 904/597-2399Spring Hill, FL 34607

Quadax Hank Termeer4079 Executive Pkwy. 614/882-1200Westerville, OH 43081

Scinet Inc. Yitzhak6263 N. Scottsdale Rd. 602/991-3445Scottsdale, AZ 85250

Curtis Software Paul Fagan520 South Main Street, Ste. 2521 800/648-2377Akron, OH 44311

DataHouse Jim Collins Certified for NSF Vers.One Perimeter Park South 205/972-9292 1.03 and 1.04Suite 100 SouthBirmingham, AL 35243-2343

Dezine Associates Ray Asmar/Jeff Bloom Certified for NSF Vers.758 State Hwy. 18, Ste. 110 800/447-7370 1.03 and 1.04; MSPEast Brunswick, NJ 08816 limitation

Dynamic Sourcing Jorge Diaz Certified for NSF Vers.6091 Johns Road #7 813/881-1132 1.03 and 1.04; DMERCTampa, FL 33634 CMN 08.01

Healthcare Computer Corp. David E. Pippin4508 Oakfair Blvd., Ste. 109 813/622-8835Tampa, FL 33610

Health Team Management Svcs. Carla Burhanan4141 MacArthur Blvd., Ste. 110 714/252-0668Newport Beach, CA 92660

Info Services Tommy Ladner CMN #10155 McCormack Drive 601/956-1304Ridgeland, MS 39157

MS Group, Inc. Henry Meyer Certified only for claims8151 SW 90th Ave., Ste. 123 305/279-7917 not requiring CMNsMiami, FL 33173

Medical Business Svcs. Gary Foster Certified only for CMN #410201 W. Markham 501/223-2080Suite 206Little Rock, AR 72221

Medical Solutions Dean Reese MSP1 Sugar Creek 800/264-4674Sugarland, TX 77478

Megas Corporation Jan PowellP.O. Box 12292 904/422-1522Tallahassee, FL 32317

DMERC CERTIFIEDELECTRONICCLEARINGHOUSES

Additions

DMERC CertifiedSoftware Vendors,Billing Services &Clearinghouses

Changes


Pacware Byron Maynard8229 Pinefield Drive 916/348-8514Sacramento, CA 95842

Pro Business Systems, Inc. Bonnie Madril Certified for NSF Vers.6266 N. “W” St., #216 904/479-9035 1.03 & 1.04Pensacola, FL 32533

Enturo Med Services A.J. Miceli2132 NE 62nd Ct. 305/491-0854Ft. Lauderdale, FL 33308-1301

Healthcare Computer Corp. David E. Pippen4508 Oak Fair Blvd., Ste. 109 813/622-8835Tampa, FL 33612

Health Team Management Svcs. Carla Burhanan4141 McArthur Blvd., Ste. 110 714/252-0668Newport Beach, CA 92660

Summit Health Services Inc. Nick RossiRD 12 Box 204 800/432-7788Greensburg, PA 15601

DMERC CertifiedSoftware Vendors,Billing Services &ClearinghousesChanges (Cont'd)


Changes


The following are changes, deletions and additions to the HCPCS for 1995. DeletedHCPCS for 1995 will be accepted through March 31, 1995 as a 90-day grace period.Claims received on or after April 1, 1995 must contain the new and correct codes asthey are outlined in the following article.

HCPCS Description ChangesA4212 NON-CORING NEEDLE OR STYLET WITH OR WITHOUT CATHETER

A4402 LUBRICANT, PER OUNCE

A4404 OSTOMY RING, EACH

A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE

A4641 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, NOT OTHERWISE CLASSIFIED

E0160 SITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODE

E0161 SITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODE, WITH FAUCET ATTACHMENT/S

E0185 GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS

E0237 WATER CIRCULATING HEAT/COLD PAD WITH PUMP

E0782 INFUSION PUMP, IMPLANTABLE, NON-PROGRAMMABLE

E0972 TRANSFER BOARD OR DEVICE

J0745 INJECTION, CODEINE PHOSPHATE, PER 30 MG

J1561 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, PER 500 MG

J2175 INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG

J2545 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, PER 300 MG, ADMINISTERED THROUGH A DME

J2810 INJECTION, THEOPHYLLINE, PER 40 MG

L1815 KO, ELASTIC OR OTHER ELASTIC TYPE MATERIAL WITH CONDYLAR PAD(S)

L2275 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION, PADDED/LINED

L3140 FOOT, ABDUCTION ROTATION BAR, INCLUDING SHOES

L3150 FOOT, ABDUCTION ROTATION BAR, WITHOUT SHOES

L5667 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, SOCKET INSERT, SUCTION SUSPENSION WITH LOCKINGMECHANISM

L5669 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, SOCKET INSERT, SUCTION SUSPENSION WITHOUTLOCKING MECHANISM

Modifiers and HCPCS DeletionsKB 16 SQUARE INCHES OR LESS

KC MORE THAN 16, BUT LESS THAN OR EQUAL TO 48 SQUARE INCHES

KD MORE THAN 48 SQUARE INCHES

KE 1 OUNCE

KF 1 LINEAR YARD

KG 1 CUBIC CENTIMETER

E0670 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF ARM

J0700 INJECTION, BETAMETHASONE, UP TO 6 MG

J1360 INJECTION, ERTHROMYCIN-IV, UP TO 500 MG

K0148 HYDROGEL DRESSING, EACH

K0149 HYDROCOLLOID DRESSING, EACH

K0150 ALGINATE DRESSING, EACH

Changes, Deletes andAdditions

1995 MODIFIER ANDHCPCS UPDATE:


MODIFIERS AND HCPCS CODES IN THE SHADED BOX ARE NOT FOR CURRENT USE

Modifiers and HCPCS Deletions (Cont'd)K0151 FOAM DRESSING, EACH

K0153 COMPOSITE DRESSING, EACH

K0282 WATER, DISTILLED, 1000 ML, USED WITH LARGE VOLUME NEBULIZER

Q0117 FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND SUPPLY OF OFF-THE-SHELFDEPTH-INLAY SHOE MANUFACTURED TO ACCOMMODATE MULTI-DENSITY INSERT(S), PER SHOE

Q0118 FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND SUPPLY OFSHOE MOLDED FROMCAST(S) OF PATIENT’S FOOT (CUSTOM MOLDED SHOE), PER SHOE

Q0119 FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT(S), PER SHOE

Q0120 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH ROLLER OR RIGID ROCKER BOTTOM, PER SHOE

Q0121 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDEDSHOE WITH WEDGE(S), PER SHOE

Q0122 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDEDSHOE WITH METATARSAL BAR, PER SHOE

Q0123 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDEDSHOE WITH OFF-SET HEEL(S), PER SHOE

Q0133 FOR DIABETICS ONLY, NOT OTHERWISE SPECIFIED MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAYSHOE OR CUSTOM-MOLDED SHOE, PER SHOE

Modifiers and HCPCS AdditionsKK INHALATION SOLUTION COMPOUNDED FROM AN FDA APPROVED FORMULATION

KL PRODUCT CHARACTERISTICS DEFINED IN MEDICAL POLICY ARE MET

K0 LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 0 - DOES NOT HAVE THE ABILITY OR POTENTIALTO AMBULATE OR TRANSFER SAFELY WITH OR WITHOUT ASSISTANCE AND A PROSTHESIS DOES NOTENHANCE THEIR QUALITY OF LIFE OR MOBILITY

K1 LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 1 - HAS THE ABILITY OR POTENTIAL TO USE APROSTHESIS FOR TRANSFERS OR AMBULATION ON LEVEL SURFACES AT FIXED CADENCE. TYPICAL OFTHE LIMITED AND UNLIMITED HOUSEHOLD AMBULATOR

K2 LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 2 - HAS THE ABILITY OR POTENTIALFORMBULATION WITH THE ABILITY TO TRAVERSE LOW LEVEL ENVIRONMENTAL BARRIERS SUCH AS CURBS, STAIRS OR UNEVEN SURFACES. TYPICAL OF THE LIMITED COMMUNITY AMBULATOR

K3 LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 3 - HAS THE ABILITY OR POTENTIAL FORAMBULATION WITH VARIABLE CADENCE. TYPICAL OF THE COMMUNITY AMBULATOR WHO HAS THEABILITY TO TRANSVERSE MOST ENVIRONMENTAL BARRIERS AND MAY HAVE VOCATIONAL, THERAPEUTIC, OR EXERCISE ACTIVITY THAT DEMANDS PROSTHETIC UTILIZATION BEYOND SIMPLE LOCOMOTION

K4 LOWER PROSTHESIS FUNCTIONAL LEVEL 4 - HAS THE ABILITY OR POTENTIAL FORPROSTHETICAMBULATION THAT EXCEEDS THE BASIC AMBULATION SKILLS, EXHIBITING HIGH IMPACT, STRESS, ORENERGY LEVELS, TYPICAL OF THE PROSTHETIC DEMANDS OF THE CHILD, ACTIVE ADULT, OR ATHLETE

ZX THE SPECIFIED COVERAGE CRITERIA IN THE MEDICAL POLICY HAVE BEEN MET AND DOCUMENTATON ISAVAILABLE IN THE SUPPLIER'S RECORDS.

EJ* SUBSEQUENT CLAIM (FOR EPOETIN, ALPHA-EPO INJECTION ONLY)

*Modifier EJ is an existing HCPCS code modifier. Effective with the publication of the Epoetin Alpha (EPO) medicalpolicy, (see page 94-205 of this issue of the DMERC Medicare Advisory), suppliers may begin using the EJ modifier, asapplicable, when filing EPO claims to the DMERCs. This code was not previously used when filing claims to theDMERCs as prior to the publication of the DMERC EPO medical policy, EPO claim submissions followed national EPOguidelines.

A5500 FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND SUPPLY OR OFF-THE-SHELF DEPTH-INLAY SHOE MANUFACTURED TO ACCOMMODATE MULTI-DENSITY INSERT(S), PER SHOE

A5501 FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND SUPPLY OF SHOEMOLDED FROM CAST(S) OF PATIENT’S FOOT (CUSTOM MOLDED SHOE), PER SHOE

A5502 FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT(S), PER SHOE

A5503 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE ORCUSTOM-MOLDED SHOE WITH ROLLER OR RIGID ROCKER BOTTOM, PER SHOE


Modifiers and HCPCS Additions (Cont'd)A5504 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR

CUSTOM-MOLDED SHOE WITH WEDGE(S), PER SHOE

A5505 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE ORCUSTOM-MOLDED SHOE WITH METATARSAL BAR, PER SHOE

A5506 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE ORCUSTOM-MOLDED SHOE WITH OFF-SET HEEL(S), PER SHOE

A5507 FOR DIABETICS ONLY, NOT OTHERWISE SPECIFIED MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE, PER SHOE

E0350 CONTROL UNIT FOR ELECTRONIC BOWEL IRRIGATION/EVACUATION SYSTEM

E0352 DISPOSABLE PACK (WATER RESERVOIR BAG, SPECULUM, VALVING MECHANISM AND COLLECTION BAG/BOX)FOR USE WITH THE ELECTRONIC BOWEL IRRIGATION/EVACUATION SYSTEM

E0671 SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEG

E0672 SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL ARM

E0673 SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALF LEG

E0740 INCONTINENCE TREATMENT SYSTEM, PELVIC FLOOR STIMULATOR, MONITOR, SENSOR AND/OR TRAINER

J2430 INJECTION, PAMIDRONATE DISODIUM, PER 30 MG

J7645 IPRATROPIUM BROMIDE 0.02%, PER ML, INHALATION SOLUTION, ADMINISTERED THROUGH A DME

J9065 INJECTION, CLADRIBINE, PER 1 MG

J9245 INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG

K0140 ACETYLCYSTEINE, COMPOUNDED, PER MG, INHALATION SOLUTION ADMINISTERED THROUGH DME

K0141 ALBUTEROL SULFATE, COMPOUNDED, PER MG, INHALATION SOLUTION ADMINISTEREDTHROUGH DME

K0142 CROMOLYN SODIUM, COMPOUNDED, PER MG, INHALATION SOLUTION ADMINISTERED THROUGH DME

K0143 ISOETHARINE HYDROCHLORIDE, COMPOUNDED, PER MG, INHALATION SOLUTION ADMINISTEREDTHROUGH DME

K0144 ISOPROTHERENOL HYDROCHLORIDE, COMPOUNDED, PER MG, INHALATION SOLUTION THROUGH DME

K0145 METAPROTERENOL, COMPOUNDED, PER MG, INHALATION SOLUTION ADMINISTEREDTHROUGH DME

K0146 TERBUTALINE, COMPOUNDED, PER MG, INHALATION SOLUTION ADMINISTERED THROUGH DME

K0168 ADMINISTRATION SET, SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, DISPOSABLE

K0169 SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, DISPOSABLE

K0170 ADMINISTRATION SET, SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, NON-DISPOSABLE

K0171 ADMINISTRATION SET, SMALL VOLUME FILTERED PNEUMATIC NEBULIZER

K0172 LARGE VOLUME NEBULIZER, DISPOSABLE, UNFILLED, USED WITH AEROSOL COMPRESSOR

K0173 LARGE VOLUME NEBULIZER, DISPOSABLE, PREFILLED, USED WITH AEROSOL COMPRESSOR

K0174 RESERVOIR BOTTLE, NON-DISPOSABLE, USED WITH LARGE VOLUME ULTRASONIC NEBULIZER

K0175 CORRUGATED TUBING, DISPOSABLE, USED WITH LARGE VOLUME NEBULIZER, 100 FEET

K0176 CORRUGATED TUBING, NON-DISPOSABLE, USED WITH LARGE VOLUME NEBULIZER, 10 FEET

K0177 WATER COLLECTION DEVICE, USED WITH LARGE VOLUME NEBULIZER

K0178 FILTER, DISPOSABLE, USED WITH AEROSOL COMPRESSOR

K0179 FILTER, NON-DISPOSABLE, USED WITH AEROSOL COMPRESSOR OR ULTRASONIC GENERATOR

K0180 AEROSOL MASK, USED WITH DME NEBULIZER




Modifiers and HCPCS Additions (Cont'd)K0181 DOME AND MOUTHPIECE, USED WITH SMALL VOLUME ULTRASONIC NEBULIZER

K0182 WATER, DISTILLED, USED WITH LARGE VOLUME NEBULIZER, 1000 ML

K0183 NASAL APPLICATION DEVICE, USED WITH CPAP DEVICE

K0184 NASAL PILLOWS/SEALS, REPLACEMENT FOR NASAL APPLICATION DEVICE, PAIR

K0185 HEADGEAR, USED WITH CPAP DEVICE

K0186 CHIN STRAP, USED WITH CPAP DEVICE

K0187 TUBING, USED WITH CPAP DEVICE

K0188 FILTER, DISPOSABLE, USED WITH CPAP DEVICE

K0189 FILTER, NON-DISPOSABLE, USED WITH CPAP DEVICE

K0190 CANISTER, DISPOSABLE, USED WITH SUCTION PUMP

K0191 CANISTER, NON-DISPOSABLE, USED WITH SUCTION PUMP

K0192 TUBING, USED WITH SUCTION PUMP

K0193 CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE, WITH HUMIDIFIER

K0194 INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE, WITH HUMIDIFIER

K0195 ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE)

K0196 ALGINATE DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING

K0197 ALGINATE DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 BUT LESS THAN OR EQUAL TO 48 SQ.IN., EACH DRESSING

K0198 ALGINATE DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., EACH DRESSING

K0199 ALGINATE DRESSING, WOUND FILLER, PER 6 INCHES

K0203 COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACHDRESSING

K0204 COMPOSITE DRESSING, PAD SIZE MORE THAN 16 BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANYSIZE ADHESIVE BORDER, EACH DRESSING

K0205 COMPOSITE DRESSING, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACHDRESSING

K0206 CONTACT LAYER, 16 SQ. IN. OR LESS, EACH DRESSING

K0207 CONTACT LAYER, MORE THAN 16 BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING

K0208 CONTACT LAYER, MORE THAN 48 SQ. IN., EACH DRESSING

K0209 FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACHDRESSING

K0210 FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 BUT LESS THAN OR EQUAL TO 48 SQ. IN.,WITHOUT ADHESIVE BORDER, EACH DRESSING

K0211 FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER,EACH DRESSING

K0212 FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER,EACH DRESSING

K0213 FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 BUT LESS THAN OR EQUAL TO 48 SQ. IN.,WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

K0214 FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER,EACH DRESSING

K0215 FOAM DRESSING, WOUND FILLER, PER GRAM

K0216 GAUZE, NON-IMPREGNATED, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACHDRESSING

K0217 GAUZE, NON-IMPREGNATED, PAD SIZE MORE THAN 16 BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

K0218 GAUZE, NON-IMPREGNATED, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACHDRESSING


Modifiers and HCPCS Additions (Cont'd)K0219 GAUZE, NON-IMPREGNATED, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH

DRESSING

K0220 GAUZE, NON-IMPREGNATED, PAD SIZE MORE THAN 16 BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHANY SIZE ADHESIVE BORDER, EACH DRESSING

K0221 GAUZE, NON-IMPREGNATED, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACHDRESSING

K0222 GAUZE, IMPREGNATED, OTHER THAN WATER OR NORMAL SALINE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

K0223 GAUZE, IMPREGNATED, OTHER THAN WATER OR NORMAL SALINE, PAD SIZE MORE THAN16 BUT LESSTHAN OR EQUAL TO 48SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

K0224 GAUZE, IMPREGNATED, OTHER THAN WATER OR NORMAL SALINE, PAD SIZE MORE THAN 48 SQ. IN.,WITHOUT ADHESIVE BORDER, EACH DRESSING

K0228 GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVEBORDER, EACH DRESSING

K0229 GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, PAD SIZE MORE THAN 16 BUT LESS THAN OREQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

K0230 GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUTADHESIVE BORDER, EACH DRESSING

K0234 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER,EACH DRESSING

K0235 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 BUT LESS THAN OR EQUAL T048 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

K0236 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVEBORDER, EACH DRESSING

K0237 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVEBORDER, EACH DRESSING

K0238 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 BUT LESS THAN OR EQUAL TO48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

K0239 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVEBORDER, EACH DRESSING

K0240 HYDROCOLLOID DRESSING, WOUND FILLER, PASTE, PER FLUID OUNCE

K0241 HYDROCOLLOID DRESSING, WOUND FILLER, DRY FORM, PER GRAM

K0242 HYDROGEL DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER,EACH DRESSING

K0243 HYDROGEL DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 BUT LESS THAN OR EQUAL TO 48 SQ.IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

K0244 HYDROGEL DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER,EACH DRESSING

K0245 HYDROGEL DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVEBORDER, EACH DRESSING

K0246 HYDROGEL DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 BUT LESS THAN OR EQUAL TO 48 SQ.IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

K0247 HYDROGEL DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVEBORDER, EACH DRESSING

K0248 HYDROGEL DRESSING, WOUND FILLER, GEL, PER FLUID OUNCE

K0249 HYDROGEL DRESSING, WOUND FILLER, DRY FORM, PER GRAM

K0250 SKIN SEALANTS, PROTECTANTS, MOISTURIZERS, ANY TYPE, ANY SIZE

K0251 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVEBORDER, EACH DRESSING

K0252 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 BUT LESS THAN OREQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

K0253 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER,EACH DRESSING

K0254 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZEADHESIVE BORDER, EACH DRESSING



Modifiers and HCPCS Additions (Cont'd)K0255 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 BUT LESS THAN OR

EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

K0256 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZEADHESIVE BORDER, EACH DRESSING

K0257 TRANSPARENT FILM, 16 SQ. IN. OR LESS, EACH DRESSING

K0258 TRANSPARENT FILM, MORE THAN 16 BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING

K0259 TRANSPARENT FILM, MORE THAN 48 SQ. IN., EACH DRESSING

K0260 WOUND CLEANSERS, ANY TYPE, ANY SIZE

K0261 WOUND FILLER, NOT ELSEWHERE CLASSIFIED, GEL/PASTE, PER FLUID OUNCE

K0262 WOUND FILLER, NOT ELSEWHERE CLASSIFIED, DRY FORM, PER GRAM

K0263 GAUZE, ELASTIC, ALL TYPES, PER LINEAR YARD

K0264 GAUZE, NON-ELASTIC, PER LINEAR YARD

K0265 TAPE, ALL TYPES, PER 18 SQUARE INCHES

K0266 GAUZE, IMPREGNATED, OTHER THAN WATER OR NORMAL SALINE, ANY WIDTH, PER LINEAR YARD

K0267 REPLACEMENT BATTERY, ANY TYPE, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSEMONITOR OWNED BY PATIENT, EACH

K0268 HUMIDIFIER, USED WITH CPAP DEVICE

K0269 AEROSOL COMPRESSOR, ADJUSTABLE PRESSURE, LIGHT DUTY FOR INTERMITTENT USE

K0270 ULTRASONIC GENERATOR WITH SMALL VOLUME ULTRASONIC NEBULIZER

K0271 POUCH, DRAINABLE; WITH FACEPLATE ATTACHED; REUSABLE; RUBBER OR VINYL, EACH

K0272 POUCH, DRAINABLE; WITHOUT FACEPLATE ATTACHED; REUSABLE; RUBBER OR VINYL,, EACH

K0273 POUCH, URINARY; WITH FACEPLATE ATTACHED; REUSABLE; RUBBER OR VINYL, EACH

K0274 POUCH, URINARY; WITHOUT FACEPLATE ATTACHED; REUSABLE; RUBBER OR VINYL, EACH

K0275 OSTOMY FACEPLATE; CONVEX; REUSABLE; RUBBER OR VINYL, EACH

K0276 OSTOMY FACEPLATE; CONVEX; CUSTOM FITTED REUSABLE; RUBBER OR VINYL, EACH

K0277 SKIN BARRIER; SOLID 4 X 4 OR EQUIVALENT, WITH BUILT-IN CONVEXITY, EACH

K0278 SKIN BARRIER; WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITH BUILT-IN CONVEXITY, ANY SIZE, EACH

K0279 SKIN BARRIER; WITH FLANGE (SOLID, FLEXIBLE OR ACCORDIAN), WITH BUILT-IN CONVEXITY, EXTENDEDWEAR, ANY SIZE, EACH

K0280 EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITHURINARY LEG BAG OR UROSTOMY POUCH, EACH

K0281 LUBRICANT, INDIVIDUAL STERILE PACKET, FOR INSERTION OF URINARY CATHETER, EACH

K0283 SALINE SOLUTION, PER 10 ML, METERED DOSE DISPENSER, FOR USE WITH INHALATION DRUGS

K0284 EXTERNAL INFUSION PUMP, MECHANICAL, REUSABLE, FOR EXTENDED DRUG INFUSION

K0285 REPAIR OF PROSTHETIC DEVICE, LABOR COMPONENT, PER 15 MINUTES

L2860 ADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, CONCENTRIC ADJUSTABLE TORSION STYLEMECHANISM, EACH

L3160 FOOT, ADJUSTABLE SHOE-STYLED POSITIONING DEVICE

L3224 ORTHOPEDIC FOOTWEAR, WOMAN’S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE(ORTHOSIS)

L3225 ORTHOPEDIC FOOTWEAR, MAN’S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE(ORTHOSIS)

L3890 ADDITION TO UPPER EXTREMITY JOINT, WRIST OR ELBOW, CONCENTRIC ADJUSTABLE TORSION STYLEMECHANISM, EACH

Q0132 DISPENSING FEE FOR COVERED DRUG ADMINISTERED THROUGH DME NEBULIZER


1995 DME FEESCHEDULE:Payment Changesand Updated Prices

The 1995 Update Factor for Durable Medical Equipment (DME) is a 2.5% increase.For Prosthetics and Orthotics the Update Factor is zero. The following is the 1995 feeschedule matrix. (Pricing for Puerto Rico is published as available.)

NOTE: Fee schedules for HCPCS deleted in 1995 have been included and are validthrough March 31, 1995. Deleted 1995 HCPCS may not be used on or after April 1,1995.

1995 DME FEE SCHEDULES - FREQUENTLY SERVICED ITEMS

HCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM COE0450 859.84 859.84 859.84 859.84 730.86 730.86 859.84 730.86 859.84 839.36 754.08 859.84 859.84 828.89 730.86E0453 578.49 491.72 578.49 578.49 578.49 491.72 578.49 521.25 578.49 491.72 491.72 491.72 491.72 491.72 505.84E0457 52.59 52.59 52.59 56.71 55.00 61.87 52.59 61.87 52.59 52.59 52.59 52.59 61.87 52.59 53.70E0460 561.70 660.82 660.82 660.82 642.15 625.33 660.82 660.82 660.82 660.82 660.82 660.82 660.82 660.82 660.82E0500 98.89 98.89 84.06 92.20 98.89 98.89 95.78 84.06 84.07 98.89 84.06 98.89 98.89 98.89 84.06

E0575 92.58 91.16 90.78 78.69 92.58 92.58 92.58 78.69 92.58 92.58 78.69 92.58 92.58 88.41 82.16 E0935 17.41 20.48 17.41 18.91 17.41 17.41 20.48 17.41 17.41 19.21 19.74 17.41 20.48 17.41 20.48

1995 DME FEE SCHEDULES - CAPPED RENTAL ITEMS

HCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM CO PR E0145 18.69 18.69 18.69 18.69 18.69 18.69 18.69 15.89 15.89 16.14 15.89 18.69 18.69 18.69 15.89 40.28 E0146 14.59 17.16 17.16 14.59 17.16 17.12 14.73 14.67 14.59 17.16 17.16 17.16 17.16 14.59 14.59 40.86 E0165 16.74 16.74 16.74 14.23 16.74 14.23 16.74 14.23 14.23 14.23 14.23 16.74 16.74 14.23 16.74 21.03 E0166 28.04 23.83 23.83 28.04 24.92 23.83 26.31 26.13 28.04 23.83 23.83 27.27 28.04 28.04 23.86 39.78 E0180 33.31 33.31 33.31 28.31 33.31 28.64 28.31 33.31 33.31 28.31 28.31 33.31 33.31 28.96 33.31 39.47 E0181 32.84 32.84 32.84 27.91 32.84 27.91 29.71 32.61 27.91 32.84 27.91 32.84 32.84 31.02 27.91 38.77 E0182 20.21 20.05 20.05 20.05 20.05 20.95 20.05 20.05 20.05 20.05 20.05 23.59 20.05 22.61 23.59 29.79 E0186 18.28 18.28 15.54 15.54 15.54 15.54 15.54 15.54 15.54 15.54 15.72 15.54 18.28 15.54 18.28 43.61 E0187 20.92 18.28 17.78 17.78 17.78 20.92 20.66 17.78 17.78 17.78 17.78 18.60 20.92 17.78 20.92 43.61 E0193 775.83 659.46 659.46 659.46 659.46 775.83 775.83 680.40 659.46 775.83 775.83 775.83 659.47 75.83 678.94 2350.88 E0194 2491.85 2585.89 2491.85 2562.86 2491.85 2931.59 2491.85 2931.59 2592.57 2931.59 2931.59 2658.30 2671.58 2491.85 2931.59 2437.86E0196 29.26 29.26 24.87 29.26 24.87 29.26 24.87 24.87 24.87 24.87 24.87 29.26 29.26 26.50 29.26 43.61E0202 56.41 47.95 47.95 56.41 56.41 56.41 47.95 56.41 56.41 56.41 56.41 56.41 56.41 56.41 49.35 202.65E0235 15.54 15.54 15.54 14.84 14.71 13.65 15.54 15.54 13.21 15.54 15.54 14.72 15.54 13.21 15.54 17.50E0236 34.68 33.88 35.50 39.86 39.86 33.88 33.88 39.86 39.86 39.86 39.86 39.86 39.86 37.24 33.88 31.83E0250 74.86 88.07 76.67 82.24 76.83 74.86 74.86 74.86 74.86 88.07 75.65 88.07 88.07 77.38 86.59 118.71E0251 60.87 66.74 57.48 66.74 56.73 56.73 56.73 66.24 57.73 66.74 62.27 56.73 66.74 56.73 64.61 90.09E0255 105.83 101.15 90.70 94.93 89.96 89.96 90.65 89.96 98.51 105.83 98.97 105.83 105.83 96.27 105.83 151.05E0256 75.08 71.05 63.82 71.67 63.82 63.82 63.82 63.82 63.82 75.08 75.08 75.08 75.08 75.08 75.08 112.60E0260 151.27 128.58 130.14 128.58 128.58 128.58 131.12 128.58 128.58 151.27 144.87 151.27 151.27 130.02 151.27 222.77E0261 123.36 104.86 104.86 104.86 104.86 104.86 104.86 104.86 104.86 123.36 123.36 123.36 123.36 112.67 123.36 175.13E0265 180.07 153.06 153.06 180.07 153.06 153.06 159.99 167.59 161.99 180.07 180.07 166.17 180.07 167.26 180.07 257.24E0266 159.98 135.98 135.98 158.33 135.98 138.62 152.59 135.98 141.74 159.98 144.87 137.58 159.98 159.98 149.10 228.48E0277 747.88 795.94 808.70 823.81 700.24 725.57 700.24 700.24 700.24 700.24 700.24 823.81 700.24 797.43 823.81 880.42E0290 66.34 67.33 57.23 59.28 58.71 57.23 57.23 57.23 57.23 65.31 67.33 67.33 67.33 57.23 67.33 89.89E0291 48.90 48.90 41.57 43.91 41.57 41.57 41.57 47.15 41.57 48.90 48.90 41.57 48.90 41.57 48.90 64.95E0292 75.71 71.21 64.35 64.35 64.35 64.35 64.35 64.35 64.35 75.71 75.71 75.71 75.71 75.71 75.71 118.10E0293 64.43 60.63 54.77 54.77 54.77 54.77 54.77 58.96 54.77 64.43 64.43 64.43 64.43 64.10 64.43 99.03E0294 117.72 100.06 100.06 100.06 100.06 100.06 100.06 100.06 100.06 117.72 117.72 117.72 117.72 115.23 117.72 180.61E0295 114.71 97.50 97.50 97.50 97.50 97.50 97.50 97.50 97.50 114.71 114.71 114.71 114.71 97.89 114.71 85.45E0296 147.91 125.72 125.72 147.91 125.72 125.72 125.72 125.72 125.72 147.91 147.91 135.28 147.91 147.82 147.91 197.07E0297 126.75 107.74 107.74 126.75 107.74 107.74 111.64 107.74 107.74 126.75 126.75 120.95 126.75 126.75 126.75 172.02E0305 13.60 13.60 13.60 13.60 13.60 13.60 16.00 16.00 13.60 13.60 13.60 16.00 16.00 16.00 15.35 9.03E0452 231.14 209.84 231.14 231.14 231.14 212.64 231.14 209.10 231.14 231.14 231.14 231.14 231.14 222.22 231.14 98.97E0459 45.84 42.32 43.12 38.96 38.96 38.96 38.96 38.96 38.96 40.21 38.96 38.96 38.96 38.96 45.54 48.94E0462 223.13 262.50 262.50 249.25 235.88 235.38 262.50 262.50 262.50 230.34 223.13 262.50 262.50 262.50 232.94 175.91E0480 33.64 33.64 38.92 35.37 33.64 39.58 39.58 33.64 33.64 33.94 33.64 39.58 39.58 39.58 36.04 39.70E0550 45.16 45.16 45.16 45.16 40.48 38.39 38.39 45.16 45.16 38.39 38.39 38.39 45.16 38.39 45.16 74.62E0565 54.96 46.72 54.96 54.96 46.72 46.72 46.72 46.72 54.96 46.72 46.72 54.96 54.96 54.96 46.72 27.01E0570 17.78 17.78 17.78 17.32 17.78 15.55 16.95 16.48 17.65 15.11 15.11 17.78 17.78 15.25 15.86 40.27E0585 31.59 30.49 26.85 26.85 31.59 26.85 31.59 26.85 28.80 31.59 31.59 31.59 31.59 27.34 31.59 43.79E0600 41.24 41.24 36.67 41.24 36.67 35.05 35.05 35.05 35.05 35.05 35.05 35.71 41.24 39.35 41.24 38.84E0601 100.63 85.54 100.63 100.63 100.63 100.63 100.36 90.43 100.63 85.54 85.54 100.63 92.58 100.63 88.22 105.73E0606 18.87 17.56 20.66 20.66 18.67 18.62 20.11 20.66 20.66 17.56 17.56 20.66 18.13 20.59 19.74 19.97E0608 252.53 214.65 252.53 252.53 252.53 214.65 214.65 252.53 252.53 252.53 214.65 252.53 214.65 252.53 246.63 312.60E0630 91.77 78.00 82.73 91.77 80.60 84.79 83.07 78.00 91.77 91.77 91.77 91.77 91.77 83.78 91.77 88.65E0635 103.33 93.69 110.22 110.22 110.22 93.69 110.22 110.22 110.22 110.22 110.22 110.22 110.22 110.22 93.69 186.98E0744 82.49 82.49 82.49 70.37 78.81 80.60 82.49 70.12 70.12 81.57 76.75 82.49 70.12 81.36 82.49 120.79E0745 79.97 80.63 80.63 70.37 73.89 80.60 80.63 68.54 68.54 68.54 68.54 80.63 80.63 74.34 79.91 82.25E0749 205.99 196.13 196.13 196.13 198.54 198.11 225.00 230.74 196.13 230.74 230.74 230.74 230.74 207.33 230.74 396.20E0781 241.16 283.72 283.72 283.72 271.73 283.72 283.72 241.16 283.72 247.78 241.16 283.72 283.72 283.72 241.16 158.31E0791 242.12 242.12 242.12 284.85 271.73 242.12 284.85 242.12 284.85 247.78 242.12 284.85 284.85 284.85 284.85 178.29E0910 18.02 18.02 16.94 15.32 18.02 15.32 18.02 15.92 15.80 18.02 16.91 17.43 18.02 15.32 17.84 17.18E0920 41.57 41.57 36.93 41.57 35.33 35.33 41.57 35.33 41.57 35.33 35.52 35.33 41.57 35.33 39.25 57.45E0930 36.44 41.16 34.99 41.16 34.99 34.99 34.99 34.99 41.16 37.45 34.99 41.16 41.16 36.20 37.49 42.52E0940 31.32 27.75 26.62 26.62 26.62 26.62 27.83 26.62 26.62 31.32 26.62 31.32 31.32 26.70 31.32 33.69E0941 39.13 39.13 39.13 39.13 39.13 33.56 39.13 33.26 39.13 35.67 35.52 39.13 39.13 39.13 36.03 41.49E0946 48.22 46.16 45.30 48.47 45.30 45.30 45.30 45.30 45.30 45.30 45.30 45.30 45.30 45.30 47.56 56.27E0958 39.05 34.87 38.65 39.31 39.31 34.54 39.31 35.52 35.25 39.31 39.31 39.31 35.94 35.60 39.31 48.47E0968 16.14 16.16 15.52 16.16 15.99 13.99 13.74 16.16 14.71 13.74 13.74 16.16 16.16 15.94 16.16 19.82E1031 38.68 38.68 38.68 38.68 38.68 38.68 38.68 38.68 38.68 45.50 38.68 45.50 45.50 38.68 45.50 30.94E1050 91.47 77.98 77.98 85.86 77.98 84.44 83.14 77.98 77.98 91.74 91.74 91.74 90.11 91.74 81.35 104.07E1060 99.35 96.53 96.53 100.23 96.53 96.53 113.56 96.53 96.53 113.56 98.66 113.56 113.56 113.56 113.56 121.09E1070 93.66 83.86 83.86 90.96 98.66 83.86 98.66 83.86 83.86 98.66 98.66 96.54 96.53 98.66 96.52 222.84

Page 94-256 December 1994 DMERC Medicare AdvisoryHCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM CO PR

E1083 70.94 60.30 60.30 62.72 70.94 70.94 70.94 60.30 60.30 70.94 70.94 70.13 60.30 70.94 70.94 73.99E1084 83.03 75.11 88.37 81.67 88.37 88.37 88.37 75.11 75.11 75.66 82.64 88.37 88.37 88.37 88.37 93.78E1085 57.28 52.99 62.34 52.99 62.34 61.31 62.34 52.99 52.99 62.34 62.34 52.99 62.34 62.34 62.34 61.96E1086 75.71 64.72 64.35 68.82 75.71 75.71 75.71 64.35 64.35 75.66 75.71 73.90 75.71 75.71 75.71 81.76E1087 113.96 96.87 96.87 112.78 106.73 96.87 96.87 96.87 113.96 101.39 98.07 113.96 113.96 113.96 99.04 155.91E1088 135.82 115.45 124.01 119.60 129.51 115.45 115.45 115.45 135.82 115.45 115.45 135.82 135.82 135.82 128.32 187.58E1089 108.04 92.04 95.42 95.64 97.61 92.04 92.04 92.04 108.28 92.04 92.04 108.28 108.28 108.28 92.04 136.20E1090 122.66 104.26 104.26 114.13 122.66 104.26 120.79 104.26 122.66 104.26 104.26 122.66 122.66 122.66 104.26 167.86E1091 75.10 75.10 74.77 75.10 75.10 73.39 75.10 63.84 72.63 63.84 63.84 63.84 63.84 63.84 72.12 113.51E1092 115.77 98.40 115.77 115.77 115.77 98.40 104.16 113.31 115.77 98.40 104.20 115.77 115.77 115.77 98.40 153.71E1093 99.56 84.63 84.63 99.56 99.56 99.56 84.76 97.14 87.47 99.56 84.63 84.63 99.56 99.56 84.63 141.05E1100 87.83 79.48 79.48 79.48 79.48 79.48 79.48 79.48 79.48 93.51 84.42 93.51 93.51 93.51 85.46 115.54E1110 86.98 77.83 77.83 91.57 91.57 82.02 77.83 77.83 87.58 91.57 77.83 91.57 91.57 91.57 77.83 96.18E1130 39.89 35.76 35.76 35.76 40.26 35.76 41.53 35.76 35.76 42.07 42.07 42.07 42.07 38.47 42.07 59.17E1140 63.10 55.00 60.51 56.40 61.20 55.86 55.00 55.00 55.00 64.70 60.89 61.73 64.70 55.36 64.70 82.30E1150 73.50 62.53 67.42 65.41 67.09 64.01 63.74 62.48 62.48 73.50 66.75 63.79 73.50 66.61 73.50 92.29E1160 56.30 48.26 47.86 47.86 52.36 47.86 51.25 47.86 47.86 56.30 55.69 54.12 56.30 52.05 56.30 71.18E1170 74.42 68.39 68.39 68.39 68.39 80.46 80.46 68.39 68.39 80.46 68.39 80.46 80.46 80.46 80.46 133.22E1171 69.09 61.37 63.86 61.37 61.37 63.09 61.37 61.37 61.37 72.20 72.20 72.20 72.20 72.20 72.20 106.34E1172 88.23 75.00 88.23 75.96 75.59 75.00 75.00 75.00 88.23 88.23 88.23 88.23 88.23 88.23 85.02 99.86E1180 91.29 77.60 77.60 79.46 77.60 77.60 91.29 77.60 91.29 91.29 77.60 91.29 91.29 91.29 82.26 109.85E1190 105.47 89.65 89.65 89.65 89.65 89.65 105.47 89.65 105.47 105.47 91.50 105.47 105.47 105.47 89.65 137.46E1195 113.17 96.19 96.19 96.19 96.19 98.66 113.17 96.19 113.17 96.19 104.20 113.17 113.17 113.17 113.17 200.13E1200 78.39 66.63 66.63 67.46 66.63 66.63 75.46 66.63 78.39 78.39 75.29 78.39 78.39 78.39 66.63 113.51E1210 314.60 314.60 343.11 314.60 314.60 370.12 314.60 315.99 314.60 314.60 314.60 370.12 314.60 370.12 314.60 396.06E1211 362.63 320.45 327.01 326.87 323.75 320.45 324.30 320.45 320.45 320.45 320.45 377.00 320.45 377.00 377.00 396.06E1212 310.58 310.58 310.58 310.58 310.58 310.58 310.58 310.58 310.58 310.58 310.58 365.39 310.58 310.58 365.39 376.36E1213 334.02 334.02 334.02 334.02 334.02 334.02 334.02 334.02 334.02 334.02 334.02 392.96 334.02 392.96 392.96 383.52E1221 42.81 36.39 42.81 36.39 42.81 42.81 36.39 42.81 37.72 38.94 36.39 36.39 42.81 36.39 42.81 55.46E1222 61.07 51.91 60.54 51.91 59.53 61.07 51.91 61.07 51.91 61.00 55.69 54.12 58.38 51.91 61.07 66.77E1223 65.33 56.68 66.68 56.68 66.68 66.68 56.68 66.68 57.63 66.68 60.89 57.30 66.68 56.68 66.68 77.48E1224 62.14 62.14 73.11 62.14 73.11 73.11 62.14 73.11 62.14 73.11 73.11 63.79 73.11 66.60 70.09 87.87E1225 40.72 34.61 36.58 34.61 35.97 34.61 40.72 36.52 34.61 38.98 36.65 39.11 34.61 38.55 39.64 44.62E1228 21.45 21.45 21.45 21.45 21.45 25.24 25.24 21.45 21.45 24.70 23.24 24.79 25.24 21.45 21.45 26.21E1240 85.03 78.89 92.81 81.23 92.81 92.81 78.89 78.89 78.89 92.81 78.89 92.81 92.81 92.81 83.46 99.52E1250 58.20 58.20 68.47 58.20 58.20 68.47 58.20 58.20 66.54 59.17 68.47 64.37 68.47 67.08 68.47 67.19E1260 77.98 71.37 83.70 71.94 83.96 83.96 71.37 71.37 83.96 83.96 83.96 83.96 83.96 83.96 83.96 87.46E1270 63.38 60.44 71.11 64.60 67.63 60.44 68.03 60.44 60.44 71.11 69.54 71.11 71.11 71.11 68.07 78.45E1280 118.24 100.50 102.98 112.93 102.55 118.24 118.24 100.50 100.50 100.50 100.50 103.85 118.24 118.24 118.24 186.98E1285 102.33 92.35 108.65 103.59 92.35 92.67 92.35 92.35 108.65 92.35 92.35 102.85 108.65 102.85 108.65 113.80E1290 112.73 95.82 112.73 106.36 96.91 100.16 107.36 95.82 112.73 95.82 95.82 112.73 109.12 112.73 112.73 174.44E1295 109.41 93.00 109.41 99.48 93.00 93.00 93.00 93.00 109.41 93.00 93.00 99.21 109.41 109.41 109.41 155.31K0001 46.45 41.82 42.37 41.82 46.19 41.82 44.90 41.82 41.82 49.20 48.34 49.20 49.20 43.27 49.20 66.03K0002 73.33 62.65 62.65 65.73 73.71 73.71 73.71 62.65 62.65 73.71 73.71 69.89 73.71 73.71 73.71 79.10K0003 72.27 68.60 79.69 68.60 80.71 80.71 68.60 68.60 80.71 80.71 80.71 78.43 80.71 80.71 80.71 81.81K0004 120.39 102.33 102.33 112.12 120.39 102.33 117.52 102.33 120.39 102.33 102.33 120.39 120.39 120.39 102.33 164.67K0006 112.97 96.02 112.97 105.67 96.02 98.30 100.96 96.02 112.97 96.02 96.02 112.97 112.97 112.97 112.97 159.34K0007 158.07 149.21 158.11 160.13 156.98 159.62 160.13 146.07 152.81 160.13 160.13 160.13 160.13 144.08 160.13 191.16K0010 326.19 326.19 326.19 326.19 326.19 326.19 326.19 326.19 326.19 326.19 326.19 383.75 326.19 383.75 383.75 382.37K0011 517.16 488.18 517.30 523.90 513.57 522.23 523.90 477.91 499.97 523.90 523.90 523.90 523.90 471.45 523.90 625.43K0012 248.10 234.19 248.16 251.34 246.38 250.52 251.34 229.26 239.85 251.34 251.34 251.34 251.34 226.17 251.34 300.06K0101 39.05 34.87 38.64 39.31 39.31 34.54 39.31 35.51 35.24 39.31 39.31 39.31 35.94 35.61 39.31 48.47K0156 678.41 640.40 678.59 687.25 673.70 685.06 687.25 626.91 655.86 687.25 687.25 687.25 687.25 618.42 687.25 820.46K0157 32.44 27.57 27.65 32.44 32.44 27.57 32.44 28.65 27.57 29.29 27.57 27.57 28.01 27.57 32.44 39.47K0158 755.17 795.94 808.70 823.81 700.24 725.57 700.24 700.24 700.24 700.24 700.24 823.81 700.24 797.43 823.81 880.42K0159 753.79 711.56 754.00 763.61 748.56 761.17 763.61 696.57 728.72 763.61 763.61 763.61 763.61 687.15 763.61 911.62K0160 798.79 678.97 798.79 678.97 678.97 678.97 678.97 798.79 798.79 798.79 798.79 798.79 798.79 798.79 798.79 2350.88K0161 1356.82 1280.79 1357.19 1374.51 1347.41 1370.10 1374.51 1253.83 1311.71 1374.51 1374.51 1374.51 1374.51 1236.88 1374.51 1640.93K0195 10.69 9.58 10.69 9.41 9.09 10.69 9.09 9.09 9.09 10.69 9.09 9.09 10.69 10.69 9.57 12.54

1995 DME FEE SCHEDULES - INEXPENSIVE OR ROUTINELY PURCHASED ITEMSNEW - INCLUDING TENS

HCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM CO A4611 150.42 170.20 150.42 150.42 164.09 176.97 164.09 170.20 150.42 176.97 176.97 150.42 176.97 150.42 176.97 A4612 64.21 72.00 68.89 72.00 72.00 72.00 61.20 72.00 61.20 72.00 72.00 72.00 72.00 72.00 72.00 A4613 129.84 117.76 110.42 110.42 117.76 129.90 129.90 129.90 114.49 129.90 129.90 125.27 110.42 125.27 110.42A4618 8.01 6.81 7.37 6.81 8.01 6.81 8.01 6.81 6.81 8.01 8.01 7.93 6.81 7.95 8.01A4631 91.07 91.07 81.67 91.07 79.23 81.37 91.07 77.41 91.07 91.07 77.41 91.07 82.96 91.07 90.14A4635 4.61 3.92 3.92 3.92 3.92 3.92 4.61 4.61 3.92 3.92 3.92 4.61 3.92 3.92 4.61A4636 3.79 3.22 3.22 3.27 3.22 3.38 3.79 3.79 3.22 3.22 3.79 3.79 3.22 3.22 3.79A4637 1.62 1.62 1.62 1.91 1.91 1.62 1.91 1.91 1.62 1.91 1.91 1.62 1.69 1.62 1.91A4640 50.11 48.48 57.04 51.42 48.48 57.04 57.04 48.48 52.28 48.48 48.48 57.04 48.48 57.04 57.04E0100 18.98 18.98 18.98 16.13 17.88 18.98 16.13 16.13 18.98 18.98 18.98 18.98 17.66 18.98 18.98E0105 44.24 44.24 44.24 42.85 44.24 44.24 43.31 44.24 43.45 44.24 44.24 44.24 43.00 44.24 42.83E0110 69.89 65.48 59.41 67.42 69.89 59.41 67.40 66.25 62.85 69.89 69.89 69.89 64.29 69.89 59.41E0111 45.63 40.78 44.30 40.78 44.28 42.85 40.78 40.78 40.78 47.98 40.78 47.98 40.78 47.98 46.37E0112 33.33 28.33 28.33 30.28 28.33 28.33 33.33 33.33 28.33 33.33 33.33 33.33 33.33 28.33 33.03E0113 19.03 16.18 16.18 16.18 16.18 16.18 16.73 19.03 16.18 18.60 17.72 19.03 16.49 19.03 16.51E0114 39.62 37.52 36.13 36.13 42.50 36.13 39.77 42.50 41.68 42.50 42.50 42.50 37.08 36.13 42.50E0116 21.24 21.24 21.24 21.24 24.99 21.24 21.42 23.72 21.24 24.99 24.99 24.99 21.24 24.99 21.24E0130 61.72 63.27 63.27 59.53 59.71 63.27 53.78 53.96 58.30 63.27 63.27 63.27 58.80 63.27 63.27E0135 75.52 75.52 68.08 75.52 67.92 74.84 64.19 64.19 75.52 75.52 74.68 74.35 75.52 75.52 69.23E0141 103.85 103.45 100.37 103.85 94.78 103.85 92.80 103.83 88.27 103.85 103.85 103.85 95.62 101.31 103.85E0142 131.68 131.68 154.92 151.65 131.68 154.92 154.75 154.92 131.68 154.92 154.92 141.38 140.41 131.68 154.92E0143 108.31 101.81 100.37 95.57 95.15 108.31 93.94 98.66 107.92 108.31 108.31 104.40 104.31 108.28 108.31E0147 326.46 310.77 310.77 365.61 310.77 331.25 310.77 365.61 365.61 365.61 365.61 365.61 365.61 365.61 310.77E0153 62.50 53.13 54.38 62.50 57.04 62.50 62.50 62.50 62.50 62.50 62.50 55.62 62.50 55.62 53.88E0154 56.95 53.98 63.51 63.51 63.51 61.65 63.51 63.51 62.34 63.51 63.51 63.51 63.51 63.51 60.89E0155 24.17 26.17 27.57 24.17 26.27 27.98 28.44 24.17 24.35 24.17 24.17 28.44 28.44 28.44 27.95E0156 23.81 20.24 23.81 21.31 23.63 23.81 23.63 23.81 21.31 23.81 23.81 23.81 20.24 23.81 20.24E0157 64.51 62.73 65.18 73.80 73.80 67.69 62.73 62.73 73.80 73.80 73.80 73.63 62.73 73.80 73.80E0158 24.63 24.63 28.98 27.39 28.98 28.98 24.63 24.63 24.63 26.30 26.30 28.98 27.93 28.98 26.30E0160 29.78 25.31 25.31 25.31 25.31 25.31 25.31 29.78 25.31 25.31 29.78 25.31 25.31 25.31 29.78E0161 23.62 23.62 23.62 23.62 22.87 23.62 20.08 23.62 23.62 23.62 23.62 20.08 20.08 20.08 20.08E0162 131.24 131.24 111.55 111.55 126.93 114.12 111.55 131.24 131.24 131.24 131.24 111.55 111.55 111.55 131.24E0163 99.35 96.57 99.35 84.83 99.35 99.35 96.61 89.67 96.62 99.35 90.96 99.35 99.35 99.35 95.44E0164 163.42 138.91 138.91 163.42 138.91 138.91 138.91 138.91 163.42 138.91 138.91 160.02 163.42 163.42 163.42E0167 10.82 9.20 9.20 10.41 10.29 9.20 9.20 10.82 10.68 10.82 9.20 9.36 10.76 10.82 9.20E0175 50.71 59.66 59.66 59.66 50.71 59.66 59.66 59.66 59.66 50.71 50.71 59.66 59.66 59.66 59.66


HCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM CO

E0176 96.49 96.49 96.49 82.02 89.39 82.02 96.49 96.49 96.49 96.49 96.49 95.61 96.49 96.49 95.13E0177 95.61 81.27 95.61 85.91 89.39 81.27 95.61 95.61 92.57 95.61 95.61 95.61 95.61 95.61 83.54E0178 109.31 96.49 109.31 92.91 92.91 101.82 109.31 109.31 92.91 109.31 109.31 95.61 109.31 109.31 109.31E0179 10.43 10.78 10.78 10.78 9.39 9.16 9.16 9.16 10.78 9.64 9.64 9.42 9.16 9.42 10.78E0184 175.39 175.39 175.39 175.39 175.39 149.08 149.08 175.39 175.39 175.39 175.39 149.08 149.08 149.08 149.08E0185 288.14 267.85 261.50 288.14 244.92 244.92 244.92 244.92 288.14 244.92 244.92 288.14 288.14 288.14 288.14E0191 7.65 8.33 7.65 7.65 7.65 9.00 9.00 8.66 7.65 8.45 8.68 9.00 8.44 9.00 9.00E0192 337.48 348.63 348.63 348.63 309.50 332.13 348.63 315.45 348.63 328.06 337.36 348.63 297.62 348.63 348.63E0197 169.66 169.66 169.66 169.66 169.66 181.73 169.66 169.66 169.66 169.66 169.66 169.66 169.66 169.66 199.60E0198 169.66 199.60 169.66 196.86 169.66 169.66 199.60 169.66 199.60 169.66 169.66 169.66 169.66 169.66 199.60E0199 28.87 27.72 28.87 24.54 25.15 26.34 28.87 24.54 28.87 24.54 24.54 27.13 28.12 27.13 28.87E0200 71.42 60.71 71.42 71.42 71.42 71.42 71.42 60.71 71.42 71.42 71.42 68.02 71.42 68.02 71.42E0205 174.82 148.60 174.82 174.82 174.82 148.60 148.60 148.60 174.82 174.82 174.82 174.82 174.82 174.82 174.82E0210 24.99 24.99 26.23 24.99 24.99 24.99 24.99 25.20 24.99 24.99 28.41 24.99 24.99 24.99 29.40E0215 54.25 54.25 54.25 63.82 54.25 54.25 54.25 54.25 63.82 63.82 63.82 54.25 63.82 54.25 63.82E0220 6.49 6.49 7.63 7.63 7.63 6.49 6.49 7.63 7.63 6.49 6.49 7.63 7.63 7.63 6.49E0225 350.10 297.59 350.10 350.10 343.74 297.59 350.10 350.10 350.10 335.65 345.14 350.10 350.10 350.10 350.10E0230 6.49 7.64 6.61 7.13 7.64 7.64 6.49 7.64 7.34 7.15 7.37 7.64 7.64 7.64 7.15E0237 380.15 380.15 444.79 447.23 444.79 444.79 447.23 444.79 447.23 447.23 447.23 447.23 447.23 447.23 447.23E0238 20.71 20.71 24.36 23.85 24.36 24.36 24.36 24.36 24.36 24.36 24.36 20.71 20.71 20.71 20.71E0239 344.43 405.21 405.21 344.43 405.21 405.21 358.48 405.21 344.43 344.43 344.43 345.27 405.21 345.27 405.21E0249 76.26 76.26 89.72 89.72 82.96 76.26 76.26 76.26 89.72 79.49 81.73 76.26 89.72 76.26 89.72E0271 170.01 70.01 182.90 200.01 200.01 200.01 183.76 170.01 200.01 200.01 173.35 200.01 185.45 200.01 200.01E0272 154.96 172.03 182.30 182.30 182.30 154.96 182.30 154.96 182.30 182.30 182.30 182.30 166.67 182.30 177.37E0275 12.59 11.72 13.79 13.18 13.79 13.79 13.79 13.79 12.86 11.72 11.72 13.79 13.79 13.79 13.79E0276 11.98 10.65 11.98 10.18 10.18 10.82 11.98 11.98 10.18 11.98 11.98 11.98 11.98 11.98 11.98

E0280 34.41 33.33 34.41 29.25 34.41 34.41 29.25 29.25 34.41 34.41 34.41 29.25 34.41 29.25 34.41E0310 148.66 165.66 174.89 160.22 174.89 160.40 149.87 157.73 174.89 174.89 174.89 174.89 164.33 174.89 148.66E0325 7.74 8.04 7.74 7.74 7.74 7.74 9.11 9.11 7.74 9.11 9.11 9.11 9.11 9.11 7.74E0326 8.61 9.47 8.30 8.05 8.45 8.16 9.47 9.47 8.05 9.47 9.47 8.05 9.47 8.05 8.05E0560 154.50 136.91 131.33 147.17 131.33 132.84 138.89 153.03 143.00 154.50 154.50 154.50 154.50 154.50 131.33E0605 23.81 23.39 20.24 20.24 23.39 20.24 23.81 23.81 23.81 20.81 21.41 20.24 23.81 20.24 23.81E0607 190.43 190.43 179.47 180.87 190.43 174.83 190.43 190.43 190.43 188.66 190.43 190.43 190.43 190.43 179.23E0609 495.91 492.49 492.49 571.40 571.40 492.49 579.40 579.40 579.40 579.40 579.40 579.40 492.49 579.40 543.73E0610 214.27 214.27 189.52 189.52 189.52 189.52 189.52 214.27 214.27 182.13 182.13 182.86 214.27 188.36 214.27E0615 393.79 431.33 431.33 431.33 431.33 431.33 431.33 431.33 431.33 366.63 366.63 366.63 431.33 366.63 431.33E0621 73.51 76.43 73.51 75.79 73.51 73.51 73.51 86.48 75.79 86.48 86.48 86.48 86.48 86.48 86.48E0627 296.38 303.87 303.87 303.87 303.87 303.87 303.87 297.91 303.87 297.48 297.48 297.91 297.92 297.91 303.87E0628 296.38 303.87 303.87 303.87 303.87 303.87 303.87 297.91 303.87 297.48 297.48 297.91 297.92 297.91 303.87E0629 253.22 297.91 297.91 297.91 297.91 297.91 297.91 297.91 297.91 297.48 297.48 297.91 297.91 297.91 297.91E0650 586.65 599.72 551.47 571.85 551.47 648.79 583.42 551.47 551.47 645.18 648.79 648.79 629.62 648.79 629.57E0651 703.24 827.34 827.34 827.34 827.34 827.34 827.34 827.34 827.34 827.34 827.34 757.71 827.34 827.34 827.34E0652 4531.00 4775.67 4775.67 4775.67 4775.67 4775.67 4308.86 4059.32 4775.67 4775.67 4775.67 4775.67 4775.67 4775.67 4347.99E0655 87.99 93.00 85.04 87.02 96.23 97.22 87.79 82.64 83.03 97.22 97.22 97.22 94.17 97.22 97.22E0660 143.26 122.88 143.90 143.90 143.90 143.90 143.90 143.90 131.97 143.90 143.90 142.51 143.90 142.51 143.90E0665 123.41 113.54 120.76 118.45 119.77 121.81 123.41 104.90 123.41 123.41 123.41 123.41 123.41 123.41 110.17E0666 119.31 124.39 124.39 116.73 124.39 124.39 124.39 105.73 121.94 124.39 124.39 124.39 124.39 124.39 119.03E0667 291.66 291.66 291.66 291.66 291.66 291.66 291.66 247.91 291.66 291.66 291.66 278.77 291.66 291.66 247.91E0668 338.35 398.06 398.06 398.06 398.06 398.06 398.06 338.35 398.06 395.49 398.06 398.06 398.06 398.06 338.35E0669 164.65 156.81 163.07 161.51 164.65 165.14 164.65 165.14 165.14 165.14 165.14 165.04 156.81 165.14 165.14E0690 1227.62 1227.62 1227.62 1227.62 1227.62 1227.62 1227.62 1227.62 1227.62 1043.48 1043.48 1224.72 1043.48 1227.62 1043.48E0720 305.40 331.13 331.13 331.13 331.13 331.13 290.12 331.13 325.22 331.13 295.20 281.46 315.06 331.13 328.48E0730 306.52 333.81 333.81 333.81 333.81 333.81 302.65 333.81 325.22 327.79 295.20 313.23 322.28 333.81 331.13E0747 3157.56 3177.39 3177.39 3177.39 3177.39 3035.55 2700.78 3177.39 3177.39 3177.39 3177.39 3177.39 3177.39 3177.39 3177.39E0776 109.62 128.96 109.62 128.96 109.62 109.62 109.62 128.96 120.29 109.62 109.62 112.89 109.62 126.30 128.96E0782 3483.54 3483.54 3483.54 3483.54 3483.54 3483.54 3483.54 3483.54 3483.54 3022.11 3107.65 3483.54 3107.65 3483.54 2961.01E0840 66.01 66.01 64.00 56.11 66.01 60.46 56.11 66.01 56.11 56.77 58.38 56.45 56.11 61.39 56.11E0850 94.64 94.64 80.44 84.50 80.44 80.44 94.64 94.64 86.70 94.64 80.44 80.44 94.64 80.44 80.44E0860 29.50 33.63 32.60 30.60 34.71 29.50 33.44 34.71 30.73 34.71 34.71 34.71 29.50 34.71 34.71E0870 104.78 89.06 89.06 89.06 89.06 89.06 104.78 89.06 89.06 89.06 89.06 104.78 104.78 104.78 89.06E0880 96.13 113.09 96.13 96.13 96.13 100.60 113.09 96.13 96.13 96.13 96.13 96.13 100.23 96.13 96.13E0890 108.47 92.20 92.20 92.20 96.63 108.47 107.70 92.20 92.20 108.47 108.47 108.47 108.47 108.47 92.20E0900 113.65 98.11 98.11 98.11 98.11 98.11 115.42 98.11 98.11 115.42 115.42 115.42 106.25 115.42 98.11E0942 15.19 17.87 15.49 15.19 17.87 15.19 17.87 15.19 15.19 15.19 15.19 17.87 17.87 15.19 17.87E0943 22.63 24.92 24.92 24.92 21.18 21.18 24.92 21.18 24.92 21.18 21.18 21.46 24.92 24.24 24.92E0944 35.13 35.13 40.37 37.52 41.33 35.34 37.82 35.34 39.07 35.13 35.13 41.33 35.13 35.13 41.33E0945 33.94 33.94 33.94 38.60 39.93 33.94 39.93 33.94 33.94 33.94 33.94 33.94 33.94 33.94 39.93E0947 546.31 464.36 483.96 475.87 514.97 464.36 546.31 464.36 475.87 464.36 464.36 546.31 464.36 546.31 546.31E0948 528.42 449.16 483.96 475.87 514.97 461.29 528.42 461.29 475.87 449.16 449.16 491.76 449.16 492.94 528.42E0950 79.59 79.59 79.59 93.64 79.59 93.64 93.64 93.64 93.64 79.59 79.59 93.64 93.64 93.64 93.64E0951 16.97 16.97 16.97 15.87 16.97 14.42 14.87 14.42 15.33 14.42 14.42 16.97 14.42 16.97 14.72E0952 16.97 16.97 14.42 16.97 16.97 14.42 14.42 16.97 14.42 16.97 16.97 16.97 15.18 16.97 14.42E0953 33.57 36.85 32.97 36.85 34.57 31.35 36.85 31.32 31.32 31.55 32.43 36.85 31.32 36.85 36.85E0954 37.69 32.04 37.69 37.69 37.69 32.04 32.04 32.04 32.04 37.69 37.69 32.04 32.04 32.04 32.63E0959 77.40 67.70 69.30 76.98 73.12 67.70 79.65 78.23 76.98 79.65 79.65 79.65 77.90 79.65 79.65E0961 22.78 22.78 22.78 22.78 26.80 22.78 22.78 22.78 22.78 26.80 26.80 26.80 25.40 22.78 26.80E0962 53.58 48.21 53.58 53.58 53.12 53.58 45.54 53.58 52.77 53.58 53.58 53.58 45.54 53.58 53.58E0963 64.01 62.29 62.55 64.01 63.76 59.23 54.91 64.01 63.88 64.01 64.01 64.01 54.41 64.01 59.47E0964 60.71 69.43 62.83 71.42 69.37 60.71 62.23 71.42 71.42 71.42 71.42 71.42 60.71 71.42 64.25E0965 67.96 75.79 64.90 76.35 72.50 64.90 67.11 76.35 76.35 76.35 76.35 76.35 64.90 76.35 64.90E0966 64.29 58.92 59.07 63.09 59.38 56.77 58.53 54.65 63.49 60.68 62.53 64.29 64.29 64.29 64.29E0967 119.03 104.76 101.18 101.18 101.18 101.18 111.29 119.03 108.78 119.03 119.03 109.16 119.03 117.22 101.18E0969 132.64 141.10 141.10 141.10 141.10 141.10 139.69 141.10 140.95 119.94 119.94 138.45 128.39 141.10 130.94E0970 36.88 43.39 43.39 36.88 36.88 36.88 36.88 36.88 41.30 36.88 36.88 43.39 43.39 37.68 43.39E0971 59.22 54.21 59.22 50.34 50.34 50.34 59.22 59.22 50.34 59.22 59.22 59.22 50.34 59.22 58.67E0972 47.40 48.09 49.65 49.65 49.65 49.65 49.65 49.65 49.65 49.65 49.65 49.65 42.20 49.65 49.65E0973 92.06 88.03 103.56 103.56 103.56 88.03 88.03 88.03 97.66 88.03 88.03 88.03 88.03 88.03 103.56E0974 65.35 60.49 71.17 60.49 60.49 60.49 65.50 71.17 70.63 60.49 60.49 71.17 71.17 71.17 60.49E0975 43.73 44.82 44.82 38.10 44.82 38.10 44.82 38.10 38.10 44.82 38.93 38.10 38.10 38.10 44.49E0976 38.45 45.24 45.24 38.45 45.24 38.45 45.24 38.45 38.45 39.18 38.93 38.45 45.24 38.45 44.49E0977 58.92 50.08 58.92 52.39 58.92 50.08 58.92 58.92 52.39 58.92 58.92 58.92 50.08 58.92 50.08E0978 40.11 34.26 40.31 39.29 40.00 34.26 40.31 40.31 36.01 34.55 35.53 35.09 39.52 34.26 35.66E0979 30.43 25.87 30.43 30.16 30.43 25.87 30.43 30.43 27.83 25.87 25.87 29.13 29.17 27.70 30.43E0980 25.31 25.31 25.31 25.31 25.31 25.31 29.78 29.35 25.31 25.31 25.31 29.61 27.88 29.20 29.78E0990 105.79 105.79 105.79 99.25 102.09 105.79 105.79 89.92 99.25 89.92 105.79 105.79 101.12 104.89 105.79E0991 35.13 41.33 35.13 41.33 35.13 35.67 41.33 35.13 41.33 41.33 41.33 39.66 35.13 37.35 40.76E0992 72.85 82.00 72.85 85.71 74.37 72.85 74.55 84.54 85.00 85.71 85.71 85.71 72.85 82.05 82.91E0993 35.60 41.88 37.71 41.88 40.45 35.60 41.88 35.60 41.88 41.88 41.88 37.60 39.27 41.88 41.88



E0994 13.50 15.88 13.50 15.09 15.88 13.50 15.88 13.50 15.61 15.88 14.93 15.88 13.50 15.88 15.88E0995 23.28 23.28 27.39 25.98 27.39 23.28 25.01 23.28 27.39 27.39 27.39 27.39 23.28 27.39 27.39E0996 22.24 25.69 25.69 25.69 25.69 21.84 21.84 25.69 25.69 25.69 25.69 25.69 21.84 25.69 25.69E0997 51.73 50.92 59.91 59.91 57.63 59.91 50.92 59.91 59.91 59.91 59.91 59.91 50.92 50.92 50.92E0998 31.06 34.49 29.32 29.32 34.49 29.32 29.32 34.49 29.32 29.32 29.32 34.49 29.32 29.32 34.49E0999 103.56 103.56 103.56 88.03 103.56 103.56 103.56 103.56 103.56 88.03 88.03 88.03 88.03 88.03 88.03E1000 27.57 27.57 27.57 27.57 27.57 27.57 27.57 27.57 27.57 32.43 32.43 32.43 27.57 32.43 32.43E1001 77.38 88.33 75.08 86.09 75.08 75.08 75.08 80.07 83.47 88.33 76.76 88.33 75.08 88.33 88.33E1065 2604.47 2532.62 2226.08 2542.13 2226.08 2618.92 2618.92 2226.08 2542.13 2226.08 2226.08 2607.03 2226.08 2607.62 2226.08E1066 232.65 237.48 201.86 201.86 201.86 237.48 237.48 237.48 201.86 237.48 237.48 201.86 237.48 201.86 237.48E1069 101.20 101.20 86.02 101.20 86.02 86.02 101.20 86.02 101.20 86.02 101.20 101.20 97.26 101.20 101.20

E1226 491.52 417.79 491.52 417.79 417.79 491.52 491.52 491.52 491.52 491.52 491.52 491.52 417.79 491.52 417.79E1227 249.98 249.98 249.98 249.98 249.98 249.98 230.50 249.98 249.98 212.48 212.48 249.98 212.48 249.98 212.48E1230 2037.48 1731.86 2037.48 1731.86 1731.86 1919.97 2037.48 1731.86 1815.39 2037.48 1809.13 2037.48 1880.93 2003.97 1731.86E1296 376.47 442.91 442.91 413.67 376.47 442.91 376.47 442.91 390.46 442.91 442.91 442.91 376.47 442.91 442.91E1297 80.10 94.23 94.23 84.55 80.10 94.23 90.34 94.23 81.74 94.23 94.23 80.10 80.10 80.10 94.23E1298 333.84 338.68 381.63 381.63 374.99 381.63 381.63 381.63 381.63 381.63 381.63 381.63 324.39 381.63 324.39E1310 1934.43 1644.27 1934.43 1934.43 1934.43 1644.27 1934.43 1934.43 1934.43 1934.43 1934.43 1654.60 1934.43 1644.27 1934.43E1372 146.86 124.83 124.83 130.53 124.83 124.83 132.76 124.83 144.95 146.86 146.86 133.51 146.86 133.51 146.86E1375 174.67 180.10 204.52 204.52 205.49 205.49 205.49 205.49 205.49 178.49 178.49 175.52 174.67 177.28 174.67E1700 310.64 310.64 310.64 310.64 292.63 310.64 310.64 310.64 310.64 264.04 264.04 310.64 264.04 310.64 292.63K0005 1665.40 1665.40 1665.40 1665.40 1665.40 1665.40 1665.40 1665.40 1665.40 1665.40 1665.40 1665.40 1665.40 1665.40 1665.40K0015 163.68 163.68 163.68 163.68 163.68 163.68 163.68 163.68 163.68 163.68 163.68 163.68 163.68 163.68 163.68K0016 92.06 88.03 103.56 103.56 103.56 88.03 88.03 88.03 97.66 88.03 88.03 88.03 88.03 88.03 103.56K0017 46.04 46.04 46.04 46.04 46.04 46.04 46.04 46.04 46.04 46.04 46.04 46.04 46.04 46.04 46.04K0018 25.72 25.72 25.72 25.72 25.72 25.72 25.72 25.72 25.72 25.72 25.72 25.72 25.72 25.72 25.72

K0019 14.73 14.73 15.31 15.17 15.47 15.52 15.47 15.52 15.52 15.52 15.52 15.50 14.73 15.52 15.52K0020 41.84 41.84 41.84 41.84 41.84 41.84 41.84 41.84 41.84 41.84 41.84 41.84 41.84 41.84 41.84K0021 59.22 54.21 59.22 50.34 50.34 50.34 59.22 59.22 50.34 59.22 59.22 59.22 50.34 59.22 58.67K0022 38.45 45.24 45.24 38.45 45.24 38.45 45.24 38.45 38.45 39.18 38.93 38.45 45.24 38.45 44.49K0023 74.96 80.73 83.96 83.16 84.77 84.77 84.77 84.77 84.77 84.77 84.77 84.77 80.73 84.77 84.77K0024 89.14 95.56 99.38 98.43 100.35 100.35 100.35 100.35 100.35 100.35 100.35 100.35 95.56 100.35 100.35K0025 64.29 58.92 59.07 63.09 59.38 56.77 58.53 54.65 63.49 60.68 62.53 64.29 64.29 64.29 64.29K0026 35.60 41.88 37.71 41.88 40.45 35.60 41.88 35.60 41.88 41.88 41.88 37.60 39.27 41.88 41.88K0027 35.60 41.88 37.71 41.88 40.45 35.60 41.88 35.60 41.88 41.88 41.88 37.60 39.27 41.88 41.88K0028 491.52 417.79 491.52 417.79 417.79 491.52 491.52 491.52 491.52 491.52 491.52 491.52 417.79 491.52 417.79K0029 43.73 44.82 44.82 38.10 44.82 38.10 44.82 38.10 38.10 44.82 38.93 38.10 38.10 38.10 44.49K0030 72.85 82.00 72.85 85.71 74.37 72.85 74.55 84.54 85.00 85.71 85.71 85.71 72.85 82.05 82.91K0031 38.47 32.70 38.47 37.35 38.03 32.70 38.47 38.47 34.28 32.70 32.70 33.83 37.33 32.70 35.17K0032 35.13 41.33 35.13 41.33 35.13 35.67 41.33 35.13 41.33 41.33 41.33 39.66 35.13 37.35 40.76K0033 35.13 41.33 35.13 41.33 35.13 35.67 41.33 35.13 41.33 41.33 41.33 39.66 35.13 37.35 40.76K0034 16.97 16.97 16.97 15.87 16.97 14.42 14.87 14.42 15.33 14.42 14.42 16.97 14.42 16.97 14.72K0035 23.34 22.46 23.34 23.13 23.34 23.34 23.34 23.34 23.34 23.34 23.34 23.34 22.46 23.34 23.34K0036 16.97 16.97 14.42 16.97 16.97 14.42 14.42 16.97 14.42 16.97 16.97 16.97 15.18 16.97 14.42K0037 36.88 43.39 43.39 36.88 36.88 36.88 36.88 36.88 41.30 36.88 36.88 43.39 43.39 37.68 43.39K0038 21.85 21.85 21.85 21.85 21.85 21.85 21.85 21.85 21.85 21.85 21.85 21.85 21.85 21.85 21.85K0039 48.53 48.53 48.53 48.53 48.53 48.53 48.53 48.53 48.53 48.53 48.53 48.53 48.53 48.53 48.53K0040 67.26 67.26 67.26 67.26 67.26 67.26 67.26 67.26 67.26 67.26 67.26 67.26 67.26 67.26 67.26K0041 47.67 47.67 47.67 47.67 47.67 47.67 47.67 47.67 47.67 47.67 47.67 47.67 47.67 47.67 47.67K0042 32.81 32.81 32.81 27.89 32.81 27.89 30.25 27.89 32.81 30.01 30.87 32.81 32.81 32.81 32.81K0043 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59K0044 14.99 14.99 14.99 14.99 14.99 14.99 14.99 14.99 14.99 14.99 14.99 14.99 14.99 14.99 14.99K0045 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00K0046 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59 17.59K0047 68.89 68.89 68.89 68.89 68.89 68.89 68.89 68.89 68.89 68.89 68.89 68.89 68.89 68.89 68.89K0048 105.79 105.79 105.79 99.25 102.09 105.79 105.79 89.92 99.25 89.92 105.79 105.79 101.12 104.89 105.79K0049 23.28 23.28 27.39 25.98 27.39 23.28 25.01 23.28 27.39 27.39 27.39 27.39 23.28 27.39 27.39K0050 29.28 29.28 29.28 29.28 29.28 29.28 29.28 29.28 29.28 29.28 29.28 29.28 29.28 29.28 29.28K0051 47.39 47.39 47.39 47.39 47.39 47.39 47.39 47.39 47.39 47.39 47.39 47.39 47.39 47.39 47.39K0052 83.27 83.27 83.27 83.27 83.27 83.27 83.27 83.27 83.27 83.27 83.27 83.27 83.27 83.27 83.27K0053 91.89 91.89 91.89 91.89 91.89 91.89 91.89 91.89 91.89 91.89 91.89 91.89 91.89 91.89 91.89K0054 94.26 94.26 94.26 94.26 94.26 94.26 94.26 94.26 94.26 94.26 94.26 94.26 94.26 94.26 94.26K0055 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67K0056 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67 85.67K0057 111.88 111.88 111.88 111.88 111.88 111.88 111.88 111.88 111.88 111.88 111.88 111.88 111.88 111.88 111.88K0058 54.38 54.38 54.38 54.38 54.38 54.38 54.38 54.38 54.38 54.38 54.38 54.38 54.38 54.38 54.38K0059 28.57 28.57 28.57 28.57 28.57 28.57 28.57 28.57 28.57 28.57 28.57 28.57 28.57 28.57 28.57K0060 25.00 25.00 25.00 25.00 25.00 25.00 25.00 25.00 25.00 25.00 25.00 25.00 25.00 25.00 25.00K0061 35.45 35.47 35.47 35.47 35.47 35.47 35.47 35.47 35.47 35.47 35.47 35.47 35.47 35.47 35.47K0062 54.94 54.94 54.96 54.96 54.96 54.96 54.96 54.96 54.96 54.96 54.96 54.96 54.94 54.96 54.96K0063 73.38 73.38 73.38 73.38 73.38 73.38 73.38 73.38 73.38 73.38 73.38 73.38 73.38 73.38 73.38K0064 27.39 27.39 27.40 27.40 27.40 27.40 27.40 27.40 27.40 27.40 27.40 27.40 27.39 27.40 27.40K0065 40.05 40.05 40.05 40.05 40.05 40.05 40.05 40.05 40.05 40.05 40.05 40.05 40.05 40.05 40.05K0066 22.24 25.69 25.69 25.69 25.69 21.84 21.84 25.69 25.69 25.69 25.69 25.69 21.84 25.69 25.69K0067 33.57 36.85 32.97 36.85 34.57 31.35 36.85 31.32 31.32 31.55 32.43 36.85 31.32 36.85 36.85K0068 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30K0069 90.00 90.00 90.00 90.00 90.00 90.00 90.00 90.00 90.00 90.00 90.00 90.00 90.00 90.00 90.00K0070 165.00 165.00 165.00 165.00 165.00 165.00 165.00 165.00 165.00 165.00 165.00 165.00 165.00 165.00 165.00K0071 98.41 98.41 98.41 98.41 98.41 98.41 98.41 98.41 98.41 98.41 98.41 98.41 98.41 98.41 98.41K0072 59.23 59.23 59.23 59.23 59.23 59.23 59.23 59.23 59.23 59.23 59.23 59.23 59.23 59.23 59.23K0073 31.35 30.16 31.35 31.05 31.35 31.35 31.35 31.35 31.35 31.35 31.35 31.35 30.16 31.35 31.35K0074 27.57 27.57 27.57 27.57 27.57 27.57 27.57 27.57 27.57 32.43 32.43 32.43 27.57 32.43 32.43K0075 37.69 32.04 37.69 37.69 37.69 32.04 32.04 32.04 32.04 37.69 37.69 32.04 32.04 32.04 32.63K0076 23.02 23.02 23.02 23.02 23.02 23.02 23.02 23.02 23.02 23.02 23.02 23.02 23.02 23.02 23.02K0077 53.01 53.01 53.01 53.01 53.01 53.01 53.01 53.01 53.01 53.01 53.01 53.01 53.01 53.01 53.01K0078 8.65 8.65 8.65 8.65 8.65 8.65 8.65 8.65 8.65 8.65 8.65 8.65 8.65 8.65 8.65K0079 45.57 45.57 45.57 45.57 53.61 45.57 45.57 45.57 45.57 53.61 53.61 53.61 50.83 45.57 53.61K0080 130.69 120.07 141.26 120.07 120.07 120.07 130.97 141.26 141.26 120.07 120.07 141.26 141.26 141.26 120.07K0081 36.64 36.64 36.64 36.64 36.64 36.64 36.64 36.64 36.64 36.64 36.64 36.64 36.64 36.64 36.64K0082 101.20 101.20 86.02 101.20 86.02 86.02 101.20 86.02 101.20 86.02 101.20 101.20 97.26 101.20 101.20K0083 125.64 125.64 125.64 125.64 125.64 125.64 125.64 125.64 125.64 125.64 125.64 125.64 125.64 125.64 125.64K0084 82.85 82.85 82.85 82.85 82.85 82.85 82.85 82.85 82.85 82.85 82.85 82.85 82.85 82.85 82.85K0085 167.56 167.56 167.56 167.56 167.56 167.56 167.56 167.56 167.56 167.56 167.56 167.56 167.56 167.56 167.56K0086 101.20 101.20 86.02 101.20 86.02 86.02 101.20 86.02 101.20 86.02 101.20 101.20 97.26 101.20 101.20K0087 101.05 101.05 101.05 101.05 101.05 101.05 101.05 101.05 101.05 101.05 101.05 101.05 101.05 101.05 101.05K0088 232.65 237.48 201.86 201.86 201.86 237.48 237.48 237.48 201.86 237.48 237.48 201.86 237.48 201.86 237.48K0089 68.01 68.01 68.01 68.01 68.01 68.01 68.01 68.01 68.01 68.01 68.01 68.01 68.01 68.01 68.01K0090 68.62 68.62 68.62 68.62 68.62 68.62 68.62 68.62 68.62 68.62 68.62 68.62 68.62 68.62 68.62



K0091 18.71 18.71 18.71 18.71 18.71 18.71 18.71 18.71 18.71 18.71 18.71 18.71 18.71 18.71 18.71K0092 219.01 219.01 219.01 219.01 219.01 219.01 219.01 219.01 219.01 219.01 219.01 219.01 219.01 219.01 219.01K0093 136.82 136.82 136.82 136.82 136.82 136.82 136.82 136.82 136.82 136.82 136.82 136.82 136.82 136.82 136.82K0094 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58K0095 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58 44.58K0096 247.09 247.09 247.09 247.09 247.09 247.09 247.09 247.09 247.09 247.09 247.09 247.09 247.09 247.09 247.09K0097 56.83 54.64 56.83 56.27 56.83 56.83 56.83 56.83 56.83 56.83 56.83 56.83 54.64 56.83 56.83K0098 24.36 23.79 24.36 24.36 24.36 24.36 24.36 24.36 24.36 24.36 24.36 24.36 23.79 24.36 24.36K0099 72.88 72.88 72.88 72.88 72.88 72.88 72.88 72.88 72.88 72.88 72.88 72.88 72.88 72.88 72.88K0100 77.40 67.70 69.30 76.98 73.12 67.70 79.65 78.23 76.98 79.65 79.65 79.65 77.90 79.65 79.65K0102 39.05 39.05 39.05 39.05 39.05 39.05 39.05 39.05 39.05 39.05 39.05 39.05 39.05 39.05 39.05K0103 47.40 48.09 49.65 49.65 49.65 49.65 49.65 49.65 49.65 49.65 49.65 49.65 42.20 49.65 49.65K0104 107.00 107.00 107.00 107.00 107.00 107.00 107.00 107.00 107.00 107.00 107.00 107.00 107.00 107.00 107.00K0105 89.57 89.57 89.57 89.57 89.57 89.57 89.57 89.57 89.57 89.57 89.57 89.57 89.57 89.57 89.57K0106 96.53 96.53 96.53 96.53 96.53 96.53 96.53 96.53 96.53 96.53 96.53 96.53 96.53 96.53 96.53K0107 79.59 79.59 79.59 93.64 79.59 93.64 93.64 93.64 93.64 79.59 79.59 93.64 93.64 93.64 93.64K0115 783.16 783.16 783.16 783.16 783.16 783.16 783.16 783.16 783.16 783.16 783.16 783.16 783.16 783.16 783.16K0116 1634.64 1634.64 1634.64 1634.64 1634.64 1634.64 1634.64 1634.64 1634.64 1634.64 1634.64 1634.64 1634.64 1634.64 1634.64K0164 3.30 3.30 3.37 3.37 3.37 3.37 3.37 3.37 3.37 3.37 3.37 3.37 3.30 3.37 3.37K0168 2.46 2.34 2.43 2.41 2.45 2.47 2.45 2.47 2.47 2.47 2.47 2.46 2.34 2.46 2.47K0169 1.38 1.38 1.38 1.38 1.38 1.38 1.38 1.38 1.38 1.38 1.38 1.38 1.38 1.38 1.38K0170 25.04 23.60 23.60 23.60 23.60 23.60 23.60 23.60 23.60 23.60 23.60 23.60 23.60 23.60 23.60K0171 7.33 8.54 8.59 8.59 8.59 8.59 8.59 8.59 8.59 8.59 8.59 8.59 8.54 8.59 8.59K0172 3.58 3.74 3.88 3.84 3.92 3.99 3.92 3.96 4.02 3.96 4.08 3.93 3.74 3.93 3.98K0173 9.90 8.42 8.42 8.42 8.42 8.42 8.42 8.42 8.42 8.42 8.42 8.42 8.42 8.42 8.42K0174 34.15 35.17 36.58 36.23 36.93 37.64 36.93 37.29 37.87 37.29 37.87 37.01 35.17 37.12 37.46K0175 21.00 18.06 18.06 18.06 18.06 18.06 18.06 18.06 18.06 18.06 18.06 18.06 18.06 18.06 18.06

K0177 3.22 3.24 3.38 3.36 3.41 3.41 3.41 3.41 3.41 3.41 3.41 3.41 3.24 3.41 3.41K0178 0.67 0.64 0.64 0.64 0.64 0.64 0.64 0.64 0.64 0.64 0.64 0.64 0.64 0.64 0.64K0179 3.64 3.90 4.04 4.01 4.04 4.04 4.04 4.04 4.04 4.04 4.04 4.04 3.90 4.04 4.04K0180 1.49 1.69 1.69 1.69 1.69 1.69 1.69 1.69 1.69 1.69 1.69 1.69 1.69 1.69 1.69K0181 5.87 5.87 6.09 6.04 6.15 6.28 6.15 6.22 6.32 6.22 6.39 6.17 5.87 6.19 6.24K0182 0.35 0.30 0.30 0.30 0.30 0.30 0.30 0.30 0.30 0.30 0.30 0.30 0.30 0.30 0.30K0183 65.32 68.95 71.72 71.03 72.40 72.40 72.40 72.40 72.40 72.40 72.40 72.40 68.95 72.40 72.40K0184 20.04 20.93 21.76 21.55 21.97 22.18 21.97 22.18 22.18 22.18 22.18 22.03 20.93 22.08 22.18K0185 31.90 31.25 32.51 32.21 32.81 33.45 32.81 33.13 33.67 33.13 34.07 32.89 31.25 32.97 33.28K0186 16.40 13.94 13.94 13.94 14.04 14.32 14.04 14.17 14.41 14.17 14.58 14.08 13.94 14.10 14.26K0187 35.32 34.52 35.92 35.56 36.25 36.94 36.25 36.60 36.94 36.60 36.94 36.35 34.52 36.43 36.79K0188 4.12 4.62 4.81 4.77 4.85 4.85 4.85 4.85 4.85 4.85 4.85 4.85 4.62 4.85 4.85K0189 13.81 11.74 11.74 11.74 11.74 11.74 11.74 11.74 11.74 11.74 11.82 11.74 11.74 11.74 11.74K0190 7.50 8.19 8.52 8.45 8.59 8.59 8.59 8.59 8.59 8.59 8.59 8.59 8.19 8.59 8.59K0191 26.87 25.33 26.07 25.84 26.33 26.83 26.33 26.59 27.03 26.59 27.34 26.39 25.33 26.46 26.71K0192 3.12 2.93 2.93 2.93 2.93 2.93 2.93 2.93 2.93 2.93 2.93 2.93 2.93 2.93 2.93

1995 DME FEE SCHEDULES - INEXPENSIVE OR ROUTINELY PURCHASED ITEMSPURCHASE USED

HCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM COA4611 112.82 127.64 112.82 112.82 123.06 132.73 123.06 127.64 112.82 132.73 132.73 112.82 132.73 112.82 132.70A4612 48.15 54.91 51.66 53.99 54.00 54.91 46.67 54.91 46.67 54.91 54.91 54.91 54.91 54.91 54.91A4613 93.95 88.33 79.86 79.86 88.33 93.95 93.95 93.95 85.87 93.95 93.95 93.95 79.86 93.95 79.86A4618 6.01 5.11 5.55 5.11 6.01 5.11 6.01 5.11 5.11 6.01 6.01 5.95 5.11 5.97 6.01A4631 67.62 67.62 61.25 67.62 59.43 57.48 67.62 57.48 67.62 67.62 57.48 67.62 62.23 67.62 67.62A4635 3.04 2.59 2.59 2.59 2.59 2.59 3.05 3.05 2.59 2.59 2.59 3.05 2.59 2.59 3.05A4636 2.77 2.35 2.35 2.46 2.35 2.69 2.77 2.77 2.35 2.35 2.77 2.77 2.35 2.35 2.77A4637 1.27 1.23 1.23 1.45 1.45 1.23 1.45 1.45 1.23 1.45 1.45 1.45 1.27 1.23 1.45A4640 36.38 34.43 40.41 35.85 34.35 40.41 40.41 34.35 39.22 36.31 36.31 40.41 34.35 40.41 40.41E0100 15.14 15.14 15.06 12.87 13.40 15.14 12.87 14.41 15.14 15.14 15.14 15.14 13.25 15.14 15.14E0105 34.11 34.11 34.11 32.14 34.11 34.11 32.48 34.11 33.94 34.11 34.11 33.17 34.04 34.11 34.11E0110 52.42 49.11 44.56 50.57 52.42 51.83 50.56 49.69 47.12 52.42 52.42 52.42 48.21 52.42 44.56E0111 34.21 31.47 33.23 31.47 33.21 32.14 31.47 31.47 31.47 36.99 31.47 35.98 31.47 36.30 37.02E0112 25.43 21.62 21.62 22.71 21.62 21.62 25.05 25.43 21.62 25.43 25.43 25.43 25.43 21.62 24.77E0113 14.29 12.15 12.15 12.15 12.15 12.15 12.55 14.29 12.15 13.96 13.30 14.29 12.37 14.29 12.38E0114 30.04 28.13 27.31 27.31 32.13 27.31 29.84 32.13 31.25 32.13 32.13 32.13 27.81 27.31 32.13E0116 15.99 15.99 15.99 15.99 18.81 15.99 16.08 18.81 15.99 18.81 18.81 18.81 15.99 18.81 15.99E0130 49.30 49.30 49.30 44.65 47.70 49.30 41.91 44.12 49.30 49.30 49.30 49.30 46.80 49.30 49.30E0135 57.94 54.51 53.48 57.94 50.94 57.94 49.25 49.25 57.94 57.94 57.94 55.76 57.94 57.94 57.94E0141 77.89 77.06 75.28 77.89 71.08 77.89 69.61 77.87 67.10 77.89 77.89 77.89 71.73 75.97 77.89E0142 100.29 100.29 117.99 113.74 100.29 117.99 116.07 117.99 100.29 117.99 116.19 106.04 105.31 100.29 117.99E0143 81.05 78.42 75.28 68.89 71.37 78.57 70.45 74.01 80.94 81.05 81.05 78.29 73.30 81.05 81.05E0147 247.08 236.14 236.14 277.81 236.14 248.14 236.14 277.81 277.81 277.81 277.81 274.21 277.81 274.21 236.14E0153 46.86 39.83 40.77 46.86 42.79 46.86 46.86 46.86 46.86 46.86 46.86 41.73 46.86 41.73 40.42E0154 44.11 41.02 47.63 48.26 48.26 48.26 48.26 48.26 47.02 48.26 48.26 47.64 48.26 48.26 48.26E0155 18.42 19.62 20.65 18.42 19.70 20.96 21.67 18.42 18.42 18.42 18.42 21.67 21.67 21.67 21.67E0156 17.87 15.19 17.87 15.98 17.71 17.87 17.71 17.87 15.98 17.87 17.87 17.87 15.19 17.87 15.19E0157 48.40 47.05 48.88 55.35 55.35 50.82 47.05 47.05 55.35 55.35 55.35 55.23 47.05 55.35 55.35E0158 18.60 18.60 21.88 20.52 21.88 21.88 18.60 18.60 18.60 19.73 19.73 21.88 20.96 21.88 19.72E0160 22.32 18.97 18.97 18.97 18.97 18.97 18.97 22.32 18.97 18.97 22.32 18.97 18.97 18.97 22.32E0161 17.70 17.70 17.70 17.70 17.15 17.70 15.05 17.70 17.70 17.70 17.70 15.05 15.05 15.05 15.05E0162 101.79 101.79 86.52 86.52 95.20 86.52 86.52 101.79 101.79 101.79 101.79 86.52 86.52 86.52 101.79E0163 76.61 76.61 72.32 65.12 76.61 76.61 71.09 72.40 74.10 76.61 71.51 76.61 76.61 74.89 76.61E0164 122.56 104.18 104.18 122.56 104.18 104.18 104.18 104.18 122.56 104.90 104.18 120.01 122.56 122.56 122.56E0167 8.15 6.93 7.60 7.81 7.71 7.44 6.93 8.13 8.02 8.15 6.93 7.01 8.15 8.15 6.93E0175 37.32 43.90 43.90 43.90 37.32 43.90 43.90 43.90 43.90 37.32 37.32 43.90 43.90 43.90 43.90E0176 71.72 71.37 71.72 70.50 62.96 60.96 71.72 71.72 71.72 71.72 71.72 71.72 71.72 71.72 71.35E0177 71.72 60.96 71.72 64.42 62.96 60.96 71.72 71.72 69.42 71.72 71.72 71.72 71.72 71.72 62.65E0178 81.98 71.37 81.98 69.68 69.68 76.35 81.98 81.98 69.68 81.98 81.98 71.72 81.98 81.98 81.98E0179 7.83 8.49 8.49 8.49 7.22 7.22 7.22 7.22 8.49 7.25 7.25 7.22 7.22 7.22 8.49E0184 134.51 134.51 134.51 134.51 134.51 114.33 114.33 134.51 134.51 131.55 134.51 114.33 114.33 114.33 114.33E0185 221.14 200.88 196.12 221.14 187.97 187.97 187.97 187.97 221.14 187.97 187.97 221.14 221.14 221.14 216.09E0191 5.72 6.25 5.72 5.72 5.72 6.73 6.73 6.50 5.72 6.33 6.52 6.73 6.32 6.73 6.73E0192 250.19 261.48 261.48 261.48 232.14 222.26 261.48 236.60 261.48 246.06 253.02 261.48 223.21 261.48 261.48E0197 149.03 149.03 149.03 149.03 149.03 149.03 149.03 149.03 149.03 149.03 149.03 149.03 149.03 149.03 175.33E0198 128.75 151.47 128.75 147.66 128.75 128.75 151.47 128.75 151.47 128.75 128.75 128.75 128.75 128.75 151.47E0199 21.66 20.78 21.66 18.41 18.88 19.75 21.66 18.41 21.66 18.41 18.41 20.35 21.09 20.35 21.66E0200 53.58 45.54 53.58 53.58 53.58 53.58 53.58 45.54 53.58 53.58 53.58 51.00 53.58 51.00 53.58E0205 131.11 111.44 131.11 131.11 131.11 111.44 111.44 111.44 131.11 131.11 131.11 131.11 131.11 131.11 131.11E0210 18.74 18.74 19.66 18.74 18.74 18.74 18.74 18.90 18.74 18.74 21.31 18.74 18.74 18.74 22.05E0215 40.68 40.68 40.68 47.86 40.68 40.68 40.68 40.68 47.86 47.86 47.86 40.68 47.86 40.68 47.86



E0220 4.85 4.85 5.71 5.71 5.71 4.85 4.85 5.71 5.71 4.85 4.85 5.71 5.71 5.71 4.85E0225 262.57 223.18 262.57 262.57 257.81 223.18 262.57 262.57 262.57 251.73 258.86 262.57 262.57 262.57 262.57E0230 4.86 5.72 4.95 5.36 5.72 5.72 4.86 5.72 5.50 5.37 5.55 5.72 5.72 5.72 5.37E0237 285.09 285.09 333.58 335.40 333.58 333.58 335.40 333.58 335.40 335.40 335.40 335.40 335.40 335.40 335.40

E0238 15.22 15.22 17.90 17.90 17.90 17.90 17.90 17.90 15.86 17.90 17.90 15.22 15.22 15.22 15.22E0239 258.33 303.92 303.92 258.33 303.92 303.92 268.87 303.92 258.33 258.33 258.33 258.97 303.92 258.98 303.92E0249 57.20 57.20 67.29 67.29 62.23 57.20 57.20 57.20 67.29 59.60 61.31 57.20 67.29 57.20 67.29E0271 132.80 132.80 137.19 156.24 156.24 156.24 137.84 144.83 156.24 156.24 132.80 156.24 139.09 156.24 156.24E0272 115.67 129.02 136.08 136.08 136.08 115.67 136.08 115.67 136.08 136.08 136.08 136.08 125.00 136.08 133.03E0275 9.45 8.79 10.34 9.88 10.34 10.34 10.34 10.34 9.64 8.79 8.79 10.34 10.34 10.34 10.34E0276 9.49 8.07 9.49 8.07 8.07 8.07 9.49 9.49 8.07 9.49 9.49 9.49 9.49 9.49 9.49E0280 25.82 25.00 25.82 21.95 25.82 25.82 21.95 21.95 25.82 25.82 25.82 21.95 25.82 21.95 25.82E0310 112.49 124.24 131.20 122.23 132.34 132.34 112.49 118.31 130.94 132.34 132.34 132.34 132.34 131.42 132.34E0325 5.13 6.03 5.13 5.13 5.13 5.36 6.03 6.03 5.13 6.03 6.03 6.03 6.03 6.03 5.13E0326 6.45 7.09 6.23 6.03 6.33 6.25 7.09 7.09 6.03 7.09 7.09 6.03 7.09 6.03 6.03E0560 115.88 102.68 98.50 110.39 98.50 99.67 104.16 114.77 107.26 115.88 115.88 115.88 115.88 115.88 98.50E0605 19.60 17.53 16.66 16.66 17.53 16.66 19.60 19.60 19.60 16.66 16.66 16.66 19.60 16.66 19.60E0607 148.14 149.34 134.61 135.65 149.34 149.34 149.34 149.34 143.17 149.34 149.34 149.34 149.34 149.34 149.34E0609 405.67 369.38 369.38 428.56 428.56 369.38 434.56 434.56 434.56 434.56 434.56 434.56 369.38 434.56 369.38E0610 160.72 160.72 142.14 142.14 142.14 142.14 142.14 160.72 160.72 136.61 136.61 137.17 160.72 141.29 160.72E0615 292.11 323.49 323.49 323.49 323.49 323.49 323.49 323.49 323.49 274.97 274.97 274.97 323.49 274.97 323.49E0621 55.40 57.32 55.40 56.85 55.40 55.40 55.40 65.18 56.85 65.18 65.18 65.18 65.18 65.18 65.18E0627 222.29 227.91 227.91 227.91 227.91 227.91 227.91 223.42 227.91 223.11 223.11 223.42 223.42 223.42 227.91E0628 222.29 227.91 227.91 227.91 227.91 227.91 227.91 223.42 227.91 223.11 223.11 223.42 223.42 223.42 227.91E0629 189.91 223.42 223.42 223.42 223.42 223.42 223.42 223.42 223.42 223.11 223.11 223.42 223.42 223.42 223.42E0650 442.84 461.36 413.60 428.89 413.60 486.59 437.55 413.60 413.60 483.89 486.59 486.59 472.23 486.59 472.74E0651 527.43 620.50 620.50 620.50 620.50 620.50 620.50 620.50 620.50 620.50 620.50 568.28 620.50 620.50 620.50E0652 3223.90 3578.54 3578.54 3578.54 3578.54 3578.54 3231.65 3041.76 3578.54 3578.54 3578.54 3578.54 3578.54 3578.54 3260.98E0655 65.97 69.75 73.01 65.26 72.19 73.01 65.85 62.06 62.28 73.01 73.01 73.01 70.61 73.01 73.01E0660 107.92 92.16 107.92 107.92 107.92 107.92 107.92 107.92 98.97 107.92 107.92 106.88 107.92 106.88 107.92E0665 92.68 85.16 92.68 88.84 89.82 92.68 92.68 78.78 92.68 92.68 92.68 92.68 92.68 92.68 82.63E0666 92.40 93.31 93.31 87.55 93.31 93.31 93.31 79.31 91.46 93.31 93.31 93.31 93.31 93.31 89.29E0667 218.75 218.75 218.75 218.75 218.75 218.75 218.75 185.94 218.75 218.75 218.75 209.07 218.75 218.75 185.94E0668 253.76 298.54 298.54 298.54 298.54 298.54 298.54 253.76 298.54 296.62 298.54 298.54 298.54 298.54 253.76

E0669 123.49 117.61 122.31 121.13 123.49 123.87 123.49 123.87 123.87 123.87 123.87 123.78 117.61 123.87 123.87E0690 918.54 918.54 918.54 918.54 918.54 918.54 918.54 918.54 918.54 780.76 780.76 918.54 780.76 918.54 780.76E0747 2360.75 2360.75 2360.75 2360.75 2360.75 2232.02 2006.64 2360.75 2360.75 2360.75 2360.75 2321.31 2360.75 2321.31 2360.75E0776 80.64 94.87 80.64 94.87 80.64 80.64 80.64 94.87 90.22 80.64 80.64 84.68 80.64 94.73 94.87E0782 2612.66 2612.66 2612.66 2612.66 2612.66 2612.66 2612.66 2612.66 2612.66 2266.58 2330.73 2612.66 2330.73 2612.66 2220.76E0840 49.48 49.48 48.00 42.06 42.06 45.36 42.06 49.48 42.06 42.59 43.79 42.34 42.06 46.05 42.06E0850 70.98 70.98 60.33 63.37 60.33 60.33 70.98 70.98 65.04 70.98 60.33 60.33 70.98 60.33 60.33E0860 22.70 26.58 24.44 22.95 26.58 25.26 25.06 26.58 24.07 26.58 26.58 26.58 22.59 26.14 26.58E0870 78.93 67.09 67.09 67.09 67.09 67.09 78.93 67.09 67.09 67.09 67.09 78.93 78.93 78.93 67.09E0880 72.76 85.60 72.76 72.76 72.76 72.76 85.60 72.76 72.76 72.76 72.76 72.76 75.17 72.76 72.76E0890 87.37 74.26 74.26 74.26 74.26 87.37 80.78 74.26 74.26 87.37 87.37 87.37 87.37 87.37 74.26E0900 85.13 73.59 73.59 73.59 73.59 82.01 86.58 73.59 73.59 86.58 86.58 86.58 79.68 86.58 73.59E0942 11.39 13.40 11.61 11.39 13.40 11.39 13.40 11.39 11.39 11.39 11.39 13.40 13.40 11.39 13.40E0943 16.97 18.68 18.68 18.68 15.88 15.88 18.68 15.88 18.68 15.88 15.88 16.11 18.68 18.18 18.68E0944 26.35 26.35 30.28 28.13 31.00 29.02 28.37 29.02 29.30 26.35 26.35 31.00 26.35 26.35 31.00E0945 26.27 26.27 26.27 28.95 30.91 26.27 30.91 26.27 26.27 26.27 26.27 26.27 26.27 26.27 30.91E0947 409.73 348.27 362.97 356.89 386.22 348.27 409.73 348.27 356.89 348.27 348.27 409.73 348.27 409.73 409.73E0948 372.67 316.77 362.97 356.89 372.67 345.97 372.67 345.97 356.89 316.77 316.77 368.83 316.77 369.72 372.67E0950 59.70 9.70 59.70 70.23 59.70 70.23 70.23 70.23 70.23 59.70 59.70 70.23 70.23 70.23 70.23E0951 12.73 12.73 12.73 11.91 12.73 10.82 11.16 10.82 11.50 10.82 10.82 12.73 10.82 12.73 11.03E0952 12.73 12.73 10.82 12.73 12.73 10.82 10.82 12.73 10.82 12.73 12.73 12.73 11.38 12.73 10.82E0953 25.19 26.40 23.18 26.40 25.94 22.44 26.40 22.44 22.48 23.66 24.32 26.40 22.44 26.40 26.40E0954 28.27 24.03 28.27 28.27 28.27 24.03 24.03 24.03 24.03 28.27 28.27 24.03 24.03 24.03 24.47E0959 60.28 51.24 51.98 57.74 54.84 51.24 60.28 58.67 57.74 60.28 60.28 60.28 58.44 60.28 60.28E0961 17.09 17.09 17.09 17.09 20.11 17.09 17.09 17.09 17.09 20.11 20.11 20.11 19.04 17.09 20.11E0962 40.18 36.17 40.18 40.18 39.84 38.39 34.15 40.18 39.58 40.18 40.18 40.18 34.15 40.18 40.18E0963 47.07 46.72 46.90 48.12 47.82 48.12 41.17 48.12 47.90 48.12 48.12 48.12 40.90 48.12 44.61E0964 45.75 52.08 48.12 53.58 52.03 45.54 46.68 53.58 53.58 53.58 53.58 53.58 45.54 53.58 48.18E0965 52.30 56.85 48.69 57.28 54.39 50.16 50.33 57.28 57.28 57.28 57.28 57.28 48.69 57.28 48.69E0966 48.21 44.20 44.30 47.32 44.54 42.60 43.90 40.98 47.62 45.51 46.89 48.21 48.21 48.21 48.21E0967 89.29 78.57 75.90 75.90 75.90 75.90 83.48 89.29 81.58 89.29 89.29 81.88 89.29 87.91 75.90E0969 103.89 105.83 105.83 105.83 105.83 105.83 104.76 105.83 105.71 89.96 89.96 103.83 96.29 105.83 98.21E0970 27.66 32.54 32.54 27.66 27.66 27.66 27.66 27.66 30.98 27.66 27.66 32.54 32.54 28.25 32.54E0971 44.42 40.69 44.42 37.76 37.76 37.76 44.42 44.42 37.76 44.42 44.42 44.42 37.76 44.42 43.99E0972 36.36 36.06 36.36 36.36 36.36 36.36 36.36 36.36 36.36 36.36 36.36 36.36 30.94 36.36 36.36E0973 77.68 66.03 77.68 77.68 77.68 66.03 66.03 66.03 73.25 66.03 66.03 66.03 66.03 66.03 77.68E0974 50.86 45.37 53.38 45.37 45.37 45.37 49.12 53.38 52.97 45.37 45.37 53.38 53.38 53.38 45.37E0975 32.80 33.62 33.62 28.58 33.62 28.58 33.62 28.58 28.58 33.62 29.19 28.58 28.58 28.58 33.35E0976 28.83 33.92 33.92 28.83 33.92 28.83 33.92 28.83 28.83 29.38 29.19 28.83 33.92 28.83 33.35E0977 44.20 37.57 44.20 39.29 44.20 37.57 44.20 44.20 39.29 44.20 44.20 44.20 37.57 44.20 37.57E0978 30.10 25.70 30.24 29.47 29.99 25.70 30.24 30.24 26.99 25.93 26.66 26.31 29.63 25.70 27.63E0979 22.83 19.41 22.83 22.60 22.83 19.41 22.83 22.83 20.44 19.41 19.41 21.85 21.87 20.77 22.83E0980 18.88 18.88 18.88 18.88 18.88 21.43 22.21 22.02 18.88 18.88 18.88 22.21 20.92 21.89 22.21E0990 82.65 82.65 82.65 74.44 76.57 82.65 82.65 70.25 74.44 70.25 82.65 82.65 75.85 78.67 82.65E0991 26.49 31.16 28.10 31.16 26.49 31.16 31.16 26.49 31.16 31.00 31.16 29.75 26.49 28.03 30.58E0992 54.65 61.50 54.65 64.29 55.79 54.65 55.91 63.41 63.76 64.29 64.29 64.29 54.65 61.55 62.19E0993 26.82 31.55 28.11 31.55 30.32 26.82 31.55 26.82 31.55 31.55 31.55 28.19 29.46 31.55 31.55E0994 10.13 11.92 10.13 11.32 11.92 10.13 11.92 10.13 11.71 11.92 11.20 11.92 10.13 11.92 11.92E0995 17.44 17.44 20.52 19.50 20.52 17.44 18.75 17.44 20.52 20.52 20.52 20.52 17.44 20.52 20.52E0996 16.70 19.64 19.64 19.64 19.64 17.40 16.69 19.64 19.64 19.64 19.64 19.64 16.69 19.64 19.64E0997 38.79 38.20 44.94 44.94 43.22 44.94 38.20 44.94 44.94 44.94 44.94 44.94 38.20 38.20 38.20E0998 23.29 25.88 22.00 22.00 25.88 22.00 22.00 25.88 22.00 22.00 22.00 25.88 22.00 22.00 25.88E0999 77.68 77.68 77.68 66.03 77.68 66.03 77.68 77.68 77.68 66.03 66.03 66.03 66.03 66.03 66.03E1000 20.67 20.67 20.67 20.68 20.67 22.03 20.67 20.67 20.68 24.32 24.32 24.32 20.67 24.32 24.32E1001 58.03 66.25 56.31 64.56 56.31 56.31 56.31 60.07 62.60 66.25 57.56 66.25 56.31 66.25 66.25E1065 1953.35 1899.45 1669.56 1669.56 1669.56 1964.19 1964.19 1669.56 1906.60 1669.56 1669.56 1955.27 1669.56 1955.71 1669.56E1066 178.11 178.11 151.39 151.39 151.39 156.24 178.11 178.11 151.39 178.11 178.11 151.39 178.11 151.39 178.11E1069 75.90 75.90 64.52 75.90 64.52 64.52 75.90 64.52 75.90 64.52 75.90 75.90 72.96 75.90 75.90E1226 368.62 313.33 368.62 313.33 313.33 368.62 368.62 368.62 368.62 368.62 368.62 368.62 313.33 368.62 313.33E1227 187.50 187.50 187.50 187.50 187.50 187.50 172.87 187.50 187.50 159.38 159.38 187.50 159.38 187.50 159.38E1230 1611.41 1369.70 1542.92 1369.70 1369.70 1611.41 1611.41 1369.70 1369.70 1611.41 1611.41 1611.41 1410.69 1502.99 1611.41E1296 282.35 332.18 332.18 310.27 282.35 332.18 282.35 332.18 292.85 332.18 332.18 332.18 282.35 332.18 332.18E1297 60.07 70.67 70.67 63.42 60.07 70.67 67.76 70.67 61.32 70.67 70.67 60.07 60.07 60.07 70.67E1298 250.38 254.01 286.22 286.22 281.24 286.22 286.22 286.22 286.22 286.22 286.22 286.22 243.29 286.22 243.29E1310 1450.83 1233.21 1450.83 1450.83 1450.83 1233.21 1450.83 1450.83 1450.83 1450.83 1450.83 1240.95 1450.83 1233.21 1450.83



E1372 108.71 92.40 92.40 97.89 92.40 92.40 99.58 92.40 108.71 108.71 108.71 100.14 108.71 100.14 108.71E1375 132.80 135.08 153.40 153.40 156.23 156.23 156.23 156.23 156.23 133.88 133.88 132.80 132.80 132.97 132.80E1700 232.98 232.98 232.98 232.98 219.47 232.98 232.98 232.98 232.98 198.03 198.03 232.98 198.03 232.98 232.98K0005 1249.04 1249.04 1249.04 1249.04 1249.04 1249.04 1249.04 1249.04 1249.04 1249.04 1249.04 1249.04 1249.04 1249.04 1249.04K0015 122.76 122.76 122.76 122.76 122.76 122.76 122.76 122.76 122.76 122.76 122.76 122.76 122.76 122.76 122.76K0016 77.68 66.03 77.68 77.68 77.68 66.03 66.03 66.03 73.25 66.03 66.03 66.03 66.03 66.03 77.68K0017 34.52 34.52 34.52 34.52 34.52 34.52 34.52 34.52 34.52 34.52 34.52 34.52 34.52 34.52 34.52K0018 19.30 19.30 19.30 19.30 19.30 19.30 19.30 19.30 19.30 19.30 19.30 19.30 19.30 19.30 19.30K0019 11.04 11.04 11.49 11.37 11.60 11.64 11.60 11.64 11.64 11.64 11.64 11.62 11.04 11.64 11.64K0020 31.38 31.38 31.38 31.38 31.38 31.38 31.38 31.38 31.38 31.38 31.38 31.38 31.38 31.38 31.38K0021 44.42 40.69 44.42 37.76 37.76 37.76 44.42 44.42 37.76 44.42 44.42 44.42 37.76 44.42 43.99K0022 28.83 33.92 33.92 28.83 33.92 28.83 33.92 28.83 28.83 29.38 29.19 28.83 33.92 28.83 33.35K0023 56.22 60.54 62.97 62.36 63.58 63.58 63.58 63.58 63.58 63.58 63.58 63.58 60.54 63.58 63.58K0024 66.85 71.68 74.54 73.82 75.27 75.27 75.27 75.27 75.27 75.27 75.27 75.27 71.68 75.27 75.27K0025 48.21 44.21 44.30 47.32 44.54 42.60 43.90 40.98 47.62 45.51 46.89 48.21 48.21 48.21 48.21K0026 26.82 31.55 28.11 31.55 30.32 26.82 31.55 26.82 31.55 31.55 31.55 28.19 29.46 31.55 31.55K0027 26.82 31.55 28.11 31.55 30.32 26.82 31.55 26.82 31.55 31.55 31.55 28.19 29.46 31.55 31.55K0028 368.62 313.33 368.62 313.33 313.33 368.62 368.62 368.62 368.62 368.62 368.62 368.62 313.33 368.62 313.33K0029 32.81 33.62 33.62 28.58 33.62 28.58 33.62 28.58 28.58 33.62 29.19 28.58 28.58 28.58 33.35K0030 54.65 61.50 54.65 64.29 55.79 54.65 55.91 63.41 63.76 64.29 64.29 64.29 54.65 61.55 62.19K0031 28.52 24.24 28.52 28.03 28.52 24.24 28.52 28.52 25.61 24.24 24.24 25.37 28.02 24.24 27.09K0032 26.49 31.16 28.10 31.16 26.49 31.16 31.16 26.49 31.16 31.00 31.16 29.75 26.49 28.03 30.58K0033 26.49 31.16 28.10 31.16 26.49 31.16 31.16 26.49 31.16 31.00 31.16 29.75 26.49 28.03 30.58K0034 12.73 12.73 12.73 11.91 12.73 10.82 11.16 10.82 11.50 10.82 10.82 12.73 10.82 12.73 11.03K0035 17.51 16.84 17.51 17.34 17.51 17.51 17.51 17.51 17.51 17.51 17.51 17.51 16.84 17.51 17.51

K0036 12.73 12.73 10.82 12.73 12.73 10.82 10.82 12.73 10.82 12.73 12.73 12.73 11.38 12.73 10.82K0037 27.66 2.54 32.54 27.66 27.66 27.66 27.66 27.66 30.98 27.66 27.66 32.54 32.54 28.25 32.54K0038 16.40 16.40 16.40 16.40 16.40 16.40 16.40 16.40 16.40 16.40 16.40 16.40 16.40 16.40 16.40K0039 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40K0040 50.44 50.44 50.44 50.44 50.44 50.44 50.44 50.44 50.44 50.44 50.44 50.44 50.44 50.44 50.44K0041 35.76 35.76 35.76 35.76 35.76 35.76 35.76 35.76 35.76 35.76 35.76 35.76 35.76 35.76 35.76K0042 24.61 24.61 24.61 20.92 24.61 20.92 22.68 20.92 24.61 22.52 23.15 24.61 24.61 24.61 24.61K0043 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20K0044 11.24 11.24 11.24 11.24 11.24 11.24 11.24 11.24 11.24 11.24 11.24 11.24 11.24 11.24 11.24K0045 38.26 38.26 38.26 38.26 38.26 38.26 38.26 38.26 38.26 38.26 38.26 38.26 38.26 38.26 38.26K0046 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20 13.20K0047 51.66 51.66 51.66 51.66 51.66 51.66 51.66 51.66 51.66 51.66 51.66 51.66 51.66 51.66 51.66K0048 82.65 82.65 82.65 74.44 76.57 82.65 82.65 70.25 74.44 70.25 82.65 82.65 75.85 78.67 82.65K0049 17.44 17.44 20.52 19.50 20.52 17.44 18.75 17.44 20.52 20.52 20.52 20.52 17.44 20.52 20.52K0050 21.97 21.97 21.97 21.97 21.97 21.97 21.97 21.97 21.97 21.97 21.97 21.97 21.97 21.97 21.97K0051 35.53 35.53 35.53 35.53 35.53 35.53 35.53 35.53 35.53 35.53 35.53 35.53 35.53 35.53 35.53K0052 62.45 62.45 62.45 62.45 62.45 62.45 62.45 62.45 62.45 62.45 62.45 62.45 62.45 62.45 62.45K0053 68.92 68.92 68.92 68.92 68.92 68.92 68.92 68.92 68.92 68.92 68.92 68.92 68.92 68.92 68.92K0054 70.69 70.69 70.69 70.69 70.69 70.69 70.69 70.69 70.69 70.69 70.69 70.69 70.69 70.69 70.69K0055 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26K0056 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26 64.26K0057 83.90 83.90 83.90 83.90 83.90 83.90 83.90 83.90 83.90 83.90 83.90 83.90 83.90 83.90 83.90K0058 40.78 40.78 40.78 40.78 40.78 40.78 40.78 40.78 40.78 40.78 40.78 40.78 40.78 40.78 40.78K0059 21.43 21.43 21.43 21.43 21.43 21.43 21.43 21.43 21.43 21.43 21.43 21.43 21.43 21.43 21.43K0060 18.74 18.74 18.74 18.74 18.74 18.74 18.74 18.74 18.74 18.74 18.74 18.74 18.74 18.74 18.74K0061 26.60 26.61 26.61 26.61 26.61 26.61 26.61 26.61 26.61 26.61 26.61 26.61 26.61 26.61 26.61K0062 41.21 41.21 41.21 41.21 41.21 41.21 41.21 41.21 41.21 41.21 41.21 41.21 41.21 41.21 41.21K0063 55.02 55.02 55.02 55.02 55.02 55.02 55.02 55.02 55.02 55.02 55.02 55.02 55.02 55.02 55.02K0064 20.52 20.52 20.53 20.53 20.53 20.53 20.53 20.53 20.53 20.53 20.53 20.53 20.52 20.53 20.53K0065 30.03 30.03 30.03 30.03 30.03 30.03 30.03 30.03 30.03 30.03 30.03 30.03 30.03 30.03 30.03K0066 16.70 19.64 19.64 19.64 19.64 17.40 16.69 19.64 19.64 19.64 19.64 19.64 16.69 19.64 19.64K0067 25.20 26.40 23.18 26.40 25.94 22.44 26.40 22.44 22.48 23.66 24.32 26.40 22.44 26.40 26.40K0068 3.98 3.98 4.14 4.10 4.14 4.14 4.14 4.14 4.14 4.14 4.14 4.14 3.98 4.14 4.14K0069 67.50 67.50 70.19 69.53 70.19 70.19 70.19 70.19 70.19 70.19 70.19 70.19 67.50 70.19 70.19K0070 123.75 123.75 128.70 127.46 128.70 128.70 128.70 128.70 128.70 128.70 128.70 128.70 123.75 128.70 128.70K0071 73.80 73.80 76.76 76.00 76.76 76.76 76.76 76.76 76.76 76.76 76.76 76.76 73.80 76.76 76.76K0072 44.43 44.43 46.20 45.76 46.20 46.20 46.20 46.20 46.20 46.20 46.20 46.20 44.43 46.20 46.20K0073 23.51 22.60 23.51 23.29 23.51 23.51 23.51 23.51 23.51 23.51 23.51 23.51 22.60 23.51 23.51K0074 33.58 33.58 33.58 33.58 33.58 33.58 33.58 33.58 33.58 34.07 35.04 39.51 33.58 39.51 39.51K0075 41.74 41.74 41.74 41.74 41.74 41.74 41.74 41.74 41.74 49.11 49.11 41.74 41.74 41.74 41.74K0076 17.27 17.27 17.97 17.79 17.98 17.98 17.98 17.98 17.98 17.98 17.98 17.98 17.27 17.98 17.98K0077 39.75 39.75 41.36 40.94 41.36 41.36 41.36 41.36 41.36 41.36 41.36 41.36 39.75 41.36 41.36K0078 6.47 6.47 6.74 6.69 6.74 6.74 6.74 6.74 6.74 6.74 6.74 6.74 6.47 6.74 6.74K0079 15.49 18.22 18.22 18.22 18.22 18.22 18.22 18.22 18.22 18.22 18.22 18.22 18.22 18.22 18.22K0080 101.72 90.73 106.74 90.73 90.73 90.73 98.24 106.74 105.93 90.73 90.73 106.74 106.74 106.74 90.73K0081 27.48 27.48 28.58 28.32 28.58 28.58 28.58 28.58 28.58 28.58 28.58 28.58 27.48 28.58 28.58K0082 61.59 61.59 52.35 61.59 55.31 52.35 61.59 53.17 61.59 54.66 61.59 61.59 61.59 61.59 61.59K0083 94.24 94.24 98.00 97.06 98.00 98.00 98.00 98.00 98.00 98.00 98.00 98.00 94.24 98.00 98.00K0084 62.15 62.15 64.63 64.00 64.63 64.63 64.63 64.63 64.63 64.63 64.63 64.63 62.15 64.63 64.63K0085 125.67 125.67 128.50 128.50 128.50 128.50 128.50 128.50 128.50 128.50 128.50 128.50 125.67 128.50 128.50K0086 61.59 61.59 52.35 61.59 55.31 52.35 61.59 53.17 61.59 54.66 61.59 61.59 61.59 61.59 61.59K0087 75.80 75.80 78.83 78.07 78.83 78.83 78.83 78.83 78.83 78.83 78.83 78.83 75.80 78.83 78.83K0088 178.11 178.11 151.39 151.39 151.39 156.24 178.11 178.11 151.39 178.11 178.11 151.39 178.11 151.39 178.11K0089 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00 51.00K0090 51.48 51.48 51.48 51.48 51.48 51.48 51.48 51.48 51.48 51.48 51.48 51.48 51.48 51.48 51.48K0091 14.03 14.03 14.03 14.03 14.03 14.03 14.03 14.03 14.03 14.03 14.03 14.03 14.03 14.03 14.03K0092 164.26 164.26 164.26 164.26 164.26 164.26 164.26 164.26 164.26 164.26 164.26 164.26 164.26 164.26 164.26K0093 102.61 102.61 102.61 102.61 102.61 102.61 102.61 102.61 102.61 102.61 102.61 102.61 102.61 102.61 102.61K0094 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44K0095 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44 33.44K0096 185.32 185.32 185.32 185.32 185.32 185.32 185.32 185.32 185.32 185.32 185.32 185.32 185.32 185.32 185.32K0097 42.62 40.98 42.62 42.20 42.62 42.62 42.62 42.62 42.62 42.62 42.62 42.62 40.98 42.62 42.62K0098 18.29 17.84 18.29 18.29 18.29 18.29 18.29 18.29 18.29 18.29 18.29 18.29 17.84 18.29 18.29K0099 54.66 54.66 54.66 54.66 54.66 54.66 54.66 54.66 54.66 54.66 54.66 54.66 54.66 54.66 54.66K0100 60.28 51.24 51.98 57.74 54.84 51.24 60.28 58.67 57.74 60.28 60.28 60.28 58.44 60.28 60.28K0102 29.29 29.29 29.29 29.29 29.29 29.29 29.29 29.29 29.29 29.29 29.29 29.29 29.29 29.29 29.29K0103 36.36 36.06 36.36 36.36 36.36 36.36 36.36 36.36 36.36 36.36 36.36 36.36 30.94 36.36 36.36K0104 80.26 80.26 80.26 80.26 80.26 80.26 80.26 80.26 80.26 80.26 80.26 80.26 80.26 80.26 80.26K0105 67.17 67.17 67.17 67.17 67.17 67.17 67.17 67.17 67.17 67.17 67.17 67.17 67.17 67.17 67.17K0106 72.41 72.41 72.41 72.41 72.41 72.41 72.41 72.41 72.41 72.41 72.41 72.41 72.41 72.41 72.41

K0107 59.70 59.70 59.70 70.23 59.70 70.23 70.23 70.23 70.23 59.70 59.70 70.23 70.23 70.23 70.23K0115 587.38 587.38 587.38 587.38 587.38 587.38 587.38 587.38 587.38 587.38 587.38 587.38 587.38 587.38 587.38K0116 1225.99 1225.99 1225.99 1225.99 1225.99 1225.99 1225.99 1225.99 1225.99 1225.99 1225.99 1225.99 1225.99 1225.99 1225.99


1995 DME FEE SCHEDULES - INEXPENSIVE OR ROUTINELY PURCHASED ITEMSRENTAL

HCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM COA4611 15.60 17.02 15.60 15.60 16.42 18.35 16.42 17.02 15.60 18.35 18.35 15.60 18.35 15.60 18.35A4612 6.42 7.33 6.90 7.21 7.21 7.33 6.23 7.33 6.23 7.33 7.33 7.33 7.33 7.33 7.33A4613 12.99 11.78 11.05 11.05 11.78 13.00 13.00 13.00 11.46 13.00 13.00 12.54 11.05 12.54 11.05A4618 0.91 0.77 0.77 0.77 0.80 0.77 0.80 0.77 0.77 0.91 0.91 0.80 0.77 0.80 0.91A4631 9.29 9.29 8.47 9.29 7.93 8.61 9.29 7.90 9.29 9.29 7.90 9.29 9.06 9.29 9.02A4635 0.56 0.53 0.53 0.53 0.53 0.55 0.62 0.62 0.54 0.57 0.58 0.62 0.57 0.58 0.62A4636 0.38 0.33 0.33 0.33 0.33 0.33 0.39 0.39 0.33 0.33 0.39 0.39 0.33 0.33 0.39A4637 0.23 0.23 0.23 0.27 0.23 0.23 0.27 0.26 0.23 0.27 0.27 0.27 0.24 0.23 0.23A4640 5.24 4.94 5.81 5.26 4.94 5.81 5.81 4.94 5.24 5.26 5.26 5.81 4.94 5.81 5.81E0100 5.36 4.56 4.56 4.56 4.56 4.56 4.56 4.56 4.56 4.56 4.56 4.56 4.56 4.56 5.36E0105 7.98 6.78 6.78 6.78 6.78 6.78 6.78 6.78 6.78 6.78 6.78 6.78 6.78 6.78 7.98E0110 12.25 12.95 12.25 12.25 12.25 12.25 12.25 12.25 12.25 12.25 12.25 14.41 12.25 12.25 12.25E0111 6.45 6.46 6.45 6.45 6.45 6.45 7.59 6.45 6.45 7.59 6.45 7.59 6.45 6.45 6.45E0112 7.60 7.60 7.60 7.60 7.60 7.60 7.85 7.60 7.60 8.94 7.60 7.60 7.60 7.60 8.94E0113 4.64 3.94 3.94 3.94 3.94 3.94 3.94 3.94 3.94 3.94 3.94 3.94 3.94 3.94 4.64E0114 6.96 6.57 6.57 6.57 6.57 6.57 6.57 6.57 6.57 6.57 7.51 6.57 6.57 6.57 7.73E0116 4.86 4.13 4.13 4.13 4.13 4.13 4.13 4.13 4.13 4.86 4.13 4.13 4.13 4.13 4.86E0130 12.89 15.16 15.16 13.23 12.89 12.89 14.63 14.13 14.36 12.89 12.89 12.89 12.89 12.89 15.16E0135 15.09 15.54 15.54 13.23 13.21 13.36 15.54 13.98 14.36 13.21 13.21 13.21 13.21 13.21 15.54E0141 17.13 20.15 17.13 17.87 17.13 17.13 20.15 20.15 17.13 17.13 17.13 17.13 17.13 17.13 20.15E0142 20.24 23.81 20.24 20.24 20.24 23.81 23.81 20.24 20.24 20.24 20.24 20.24 23.81 20.24 20.24E0143 19.46 19.46 16.54 19.46 16.54 16.54 19.46 16.54 16.54 16.54 16.54 16.54 16.54 16.54 19.46E0147 33.13 36.02 31.57 37.14 31.57 33.13 31.57 37.14 37.14 37.14 37.14 36.56 37.14 36.56 31.57E0153 6.52 6.00 6.00 7.06 6.00 6.67 7.06 6.59 7.06 6.50 6.48 6.00 7.06 6.00 7.06E0154 6.56 6.67 6.56 6.56 6.56 7.05 7.64 7.72 6.56 7.57 7.72 6.56 7.72 7.72 7.02E0155 2.95 2.95 2.95 2.95 2.95 2.95 2.95 2.95 2.95 2.95 2.95 3.05 3.47 3.08 3.47E0156 3.04 2.58 3.04 2.58 2.58 3.04 2.58 3.04 2.58 3.04 3.04 3.04 2.58 2.68 2.58E0157 6.87 6.87 6.87 7.97 8.06 8.08 6.87 6.87 7.97 8.08 8.08 7.36 6.87 8.08 8.08E0158 2.71 2.71 3.19 2.75 2.96 2.96 2.71 3.19 2.71 2.71 2.71 3.19 3.19 3.16 2.71E0160 3.90 3.32 3.32 3.32 3.32 3.32 3.32 3.32 3.32 3.32 3.90 3.32 3.32 3.32 3.90

E0161 2.96 2.97 2.73 2.73 2.73 3.21 2.73 3.21 2.73 3.21 3.21 2.73 2.73 2.73 2.73E0162 13.77 13.77 11.70 11.70 12.69 11.70 11.70 13.75 13.77 13.77 13.37 11.70 11.70 11.70 13.77E0163 18.71 22.01 20.95 18.71 18.71 18.71 19.72 18.71 19.40 18.71 18.71 18.71 22.01 18.71 22.01E0164 23.81 22.37 20.24 21.31 20.24 23.29 20.24 23.81 23.81 20.24 20.24 20.24 23.81 20.98 23.81E0167 1.13 0.97 0.97 1.04 0.97 0.97 0.97 1.09 1.06 1.14 0.97 0.97 1.08 1.14 1.14E0175 5.07 5.97 5.97 5.97 5.07 5.97 5.97 5.97 5.97 5.07 5.07 5.97 5.97 5.97 5.97E0176 12.75 12.75 12.75 10.84 10.84 10.84 12.75 12.75 12.75 12.75 12.75 10.84 10.84 10.94 10.84E0177 10.94 9.30 10.94 9.30 9.30 9.30 10.94 10.94 9.30 10.94 10.94 9.55 10.82 10.94 9.30E0178 13.52 13.52 13.52 11.49 11.49 11.49 13.52 13.42 11.49 12.75 13.52 11.49 13.52 11.49 11.56E0179 1.04 1.13 1.13 1.13 0.96 0.96 0.96 0.96 1.13 0.97 0.97 0.96 0.96 0.96 1.13E0184 22.13 22.13 20.35 22.13 22.13 22.13 18.81 22.13 22.13 18.81 18.81 18.81 22.13 18.81 18.81E0185 40.48 34.41 34.41 37.89 34.41 34.41 34.41 34.41 40.48 34.41 34.41 40.48 40.48 38.71 34.41E0191 0.77 0.83 0.77 0.77 0.77 0.91 0.91 0.86 0.77 0.84 0.86 0.91 0.84 0.91 0.91E0192 35.12 34.94 35.12 35.12 29.85 35.12 35.12 31.55 35.12 32.80 33.73 35.12 29.88 35.12 34.91E0197 23.41 23.41 23.41 23.41 23.41 23.41 23.41 23.41 23.41 23.41 23.41 23.41 23.41 23.41 27.54E0198 17.57 20.67 17.57 19.69 17.57 17.57 20.67 17.57 20.20 17.57 17.57 17.57 17.57 17.57 20.67E0199 2.88 2.78 2.88 2.45 2.51 2.64 2.88 2.45 2.88 2.45 2.45 2.73 2.81 2.73 2.88E0200 9.69 8.24 9.69 9.69 9.69 9.69 8.75 8.24 9.69 9.69 9.69 8.24 9.69 8.24 9.69E0205 19.23 16.35 19.23 19.23 19.23 16.35 18.73 16.35 19.22 19.23 19.23 19.23 19.23 19.23 19.23E0210 2.35 2.38 2.61 2.35 2.35 2.35 2.43 2.51 2.35 2.35 2.77 2.40 2.35 2.35 2.77E0215 5.68 5.68 5.68 6.38 5.68 5.68 5.68 5.68 6.68 6.68 6.68 5.68 6.68 5.68 6.68E0220 0.69 0.69 0.81 0.81 0.81 0.69 0.69 0.81 0.81 0.69 0.69 0.81 0.81 0.81 0.69E0225 34.50 29.33 34.50 34.50 29.33 29.33 34.50 34.50 34.50 33.56 34.50 34.50 34.50 34.50 34.50E0230 0.73 0.80 0.73 0.73 0.81 0.86 0.73 0.86 0.73 0.73 0.73 0.86 0.86 0.86 0.73E0237 42.33 42.33 44.47 49.80 42.33 43.41 46.64 43.42 49.80 49.80 49.80 44.72 49.80 44.72 49.80E0238 2.08 2.08 2.45 2.40 2.45 2.39 2.45 2.45 2.12 2.45 2.45 2.08 2.08 2.08 2.08E0239 34.44 40.52 40.52 34.44 40.52 40.52 35.85 40.52 34.44 34.44 34.44 40.52 40.52 34.52 40.52E0249 8.38 8.38 9.86 9.86 8.38 8.38 8.38 8.38 9.86 8.38 8.38 9.86 9.86 8.38 9.86E0271 17.66 17.66 18.30 20.78 17.66 20.78 18.37 17.66 20.78 20.78 17.66 20.78 18.55 20.78 19.50E0272 16.18 17.20 19.03 19.03 16.18 16.18 18.28 16.18 19.03 19.03 19.03 19.03 16.67 19.03 17.72E0275 1.27 1.22 1.44 1.32 1.22 1.44 1.40 1.44 1.29 1.22 1.22 1.44 1.44 1.44 1.44E0276 1.41 1.20 1.41 1.20 1.20 1.20 1.40 1.41 1.20 1.41 1.41 1.41 1.41 1.41 1.41E0280 3.70 3.32 3.70 3.15 3.70 3.70 3.15 3.15 3.70 3.70 3.70 3.15 3.70 3.15 3.70E0310 17.43 17.43 19.58 17.43 17.44 19.66 20.50 18.36 17.58 19.84 19.95 20.50 20.19 17.52 20.50E0325 1.16 1.16 1.16 1.16 1.16 1.16 1.36 1.16 1.16 1.36 1.36 1.36 1.36 1.16 1.16E0326 0.92 1.08 0.92 0.92 0.92 1.08 1.08 0.95 0.92 1.00 1.04 0.92 1.08 0.92 0.92E0560 18.11 17.87 16.58 15.39 15.39 16.58 15.39 15.39 15.39 18.11 15.88 16.80 16.71 16.80 15.39E0605 2.77 2.75 2.35 2.35 2.35 2.35 2.77 2.75 2.75 2.35 2.35 2.35 2.77 2.35 2.77E0607 22.23 21.22 20.93 20.93 24.34 24.62 24.62 24.62 24.62 23.62 20.93 24.62 24.62 20.93 20.93E0609 57.94 49.25 49.25 57.14 57.14 49.25 57.94 57.94 57.94 57.94 57.94 57.94 49.25 57.94 49.25E0610 22.60 22.60 19.21 19.21 19.21 21.61 22.60 22.60 22.60 19.21 19.21 19.21 22.60 19.21 21.43E0615 44.80 52.39 52.70 52.70 52.70 52.70 52.70 52.70 52.70 44.80 44.80 44.80 52.70 44.80 52.70E0621 7.12 7.65 7.08 7.60 7.12 7.08 7.08 8.33 7.60 8.33 8.33 8.33 8.33 8.33 7.08E0627 29.63 30.39 30.39 30.39 30.39 30.39 30.39 29.80 30.39 29.75 29.75 29.80 29.75 29.80 30.39E0628 29.63 30.39 30.39 30.39 30.39 30.39 30.39 29.80 30.39 29.75 29.75 29.80 29.75 29.80 30.39E0629 25.33 29.80 29.80 29.80 29.80 29.80 29.80 29.80 29.80 29.75 29.75 29.80 29.75 29.80 29.80E0650 70.50 73.90 71.93 68.04 68.04 68.04 68.04 68.04 80.05 80.05 80.05 80.05 72.47 80.05 68.04E0651 79.02 84.51 84.51 84.51 84.51 84.51 84.51 84.51 84.51 84.51 84.51 75.77 82.74 83.03 84.51E0652 453.08 471.99 471.99 471.99 471.99 471.99 430.95 401.19 471.99 471.99 471.99 471.99 471.99 471.99 434.78E0655 11.42 9.71 9.71 9.71 9.71 10.12 9.71 9.71 9.71 11.42 11.42 11.42 9.71 11.42 11.42E0660 14.42 12.73 14.68 14.58 14.98 14.29 14.98 14.51 13.20 14.98 14.98 14.98 14.65 14.27 14.98E0665 12.45 11.35 12.07 11.85 11.97 12.67 12.67 10.77 12.67 12.67 12.67 12.67 12.43 12.67 11.01E0666 11.67 12.60 12.83 11.66 12.83 12.78 12.83 10.91 12.21 12.83 12.83 12.83 12.76 12.83 11.91E0667 32.93 32.93 32.93 32.93 32.93 32.93 32.93 27.99 32.93 32.93 32.93 27.99 32.93 30.56 27.99E0668 33.40 39.29 39.29 39.29 39.29 39.29 39.29 33.40 39.29 39.29 39.29 39.29 39.29 39.29 33.40E0669 16.47 15.69 16.30 16.15 16.47 16.51 16.47 16.51 16.51 16.51 16.51 16.50 15.69 16.51 16.51

E0690 126.78 126.78 126.78 126.78 126.78 126.78 126.78 126.78 126.78 107.76 107.76 122.47 107.76 122.76 107.76E0747 315.75 315.75 315.75 315.75 315.75 303.56 268.39 315.75 315.75 315.75 315.75 309.50 315.75 309.50 315.75E0776 14.29 15.48 14.29 14.29 14.29 14.29 14.29 14.51 14.29 14.29 16.81 14.29 14.29 14.29 16.11E0782 348.36 348.36 348.36 348.36 348.36 348.36 348.36 348.36 348.36 302.21 310.76 348.36 310.76 348.36 296.11E0840 14.70 14.70 14.70 12.50 12.50 12.50 14.70 14.70 12.50 12.50 12.50 12.50 13.81 12.50 14.70E0850 13.00 13.00 11.05 11.05 11.05 12.41 11.05 13.00 11.05 13.00 11.05 11.05 11.05 11.05 11.05E0860 4.98 4.98 4.98 4.98 5.84 4.98 5.86 5.60 4.98 4.98 5.86 4.98 4.98 4.98 4.98E0870 12.07 12.07 10.26 10.26 10.26 10.26 10.77 12.07 10.26 10.26 10.26 12.07 12.07 12.07 10.26E0880 15.10 17.76 15.10 15.10 15.10 15.10 17.76 15.10 15.10 15.10 15.10 15.10 15.10 15.10 17.76E0890 29.57 27.93 29.41 25.13 29.57 25.13 25.13 25.13 25.13 25.13 29.57 25.13 25.13 25.13 25.13E0900 21.15 24.88 21.15 21.15 21.15 21.15 24.88 21.15 21.15 21.15 24.88 21.15 21.15 21.15 21.15



E0942 1.79 1.92 1.79 1.79 2.11 1.79 2.11 1.79 1.79 1.79 1.79 2.11 2.11 1.79 2.11E0943 2.48 2.92 2.92 2.92 2.48 2.48 2.68 2.48 2.92 2.48 2.48 2.48 2.92 2.48 2.92E0944 3.53 3.53 4.04 3.75 4.15 3.57 3.78 3.57 3.91 3.53 3.53 4.14 3.53 3.53 4.15E0945 3.39 3.39 3.39 3.86 3.99 3.39 3.99 3.39 3.39 3.39 3.39 3.39 3.39 3.39 3.99E0947 56.66 48.16 49.00 48.16 51.51 48.16 56.66 48.16 48.16 48.16 48.16 56.66 48.16 56.66 56.66E0948 52.83 44.91 48.41 46.42 51.51 46.42 52.83 46.42 46.42 44.91 44.91 49.17 44.91 49.29 52.83E0950 7.97 7.97 7.97 9.38 7.97 9.38 9.38 9.38 9.38 7.97 7.97 9.38 9.38 9.38 9.38E0951 1.76 1.76 1.76 1.60 1.76 1.50 1.50 1.50 1.53 1.50 1.50 1.76 1.50 1.76 1.50E0952 1.77 1.77 1.50 1.77 1.77 1.50 1.50 1.77 1.50 1.77 1.77 1.77 1.52 1.77 1.50E0953 3.37 3.62 3.28 3.62 3.46 3.62 3.62 3.08 3.08 3.08 3.24 3.62 3.08 3.62 3.62E0954 4.25 3.61 4.25 4.25 4.25 4.25 3.61 3.61 3.61 4.25 4.25 3.61 3.61 3.61 3.61E0959 7.69 6.80 6.94 7.70 7.32 6.80 8.00 7.82 7.70 8.00 8.00 8.00 7.80 8.00 8.00E0961 2.38 2.38 2.38 2.38 2.80 2.80 2.38 2.38 2.38 2.80 2.80 2.80 2.80 2.38 2.77E0962 5.36 4.83 5.36 5.36 5.31 5.36 4.56 5.36 5.28 5.36 5.36 5.36 4.56 5.36 5.36E0963 6.50 6.23 6.25 6.50 6.38 5.71 5.53 6.50 6.39 6.50 6.50 6.50 5.53 6.50 5.95E0964 6.90 6.95 6.28 7.19 6.95 6.11 6.23 7.19 7.19 7.19 7.19 7.19 6.11 7.19 6.42E0965 7.65 7.59 6.50 7.65 7.26 6.50 6.70 7.65 7.65 7.65 7.65 7.65 6.50 7.65 6.50E0966 6.34 5.89 5.90 6.31 5.93 6.34 5.86 5.39 6.34 6.34 6.25 6.34 6.34 6.34 6.11E0967 12.21 10.48 10.38 10.38 10.38 12.21 11.13 12.21 10.88 12.21 12.21 10.93 12.21 11.71 10.38E0969 13.97 13.97 13.97 13.97 13.97 13.57 13.97 13.97 13.97 11.87 11.87 13.84 12.85 13.97 13.09E0970 3.39 3.87 3.87 3.29 3.29 3.29 3.29 3.29 3.87 3.29 3.29 3.87 3.87 3.77 3.87E0971 5.72 5.72 5.98 5.72 5.72 6.73 6.73 6.73 5.72 6.73 6.73 6.73 5.72 6.73 5.87E0972 4.85 4.82 5.05 5.05 5.05 5.05 5.05 5.05 4.99 5.05 5.05 5.05 4.29 5.05 5.05E0973 8.86 8.38 9.86 9.86 9.86 8.38 8.38 8.38 9.77 8.38 8.38 8.38 8.38 8.38 9.86E0974 6.77 6.37 7.49 6.37 6.37 6.37 6.56 7.49 7.05 6.37 6.37 7.49 7.49 7.49 6.37E0975 4.37 4.46 4.46 3.79 4.46 3.79 4.46 3.79 3.79 4.46 3.90 3.79 3.79 3.79 4.46E0976 3.79 4.46 4.46 3.79 4.46 3.79 4.46 3.79 3.79 3.92 3.90 3.79 4.46 3.79 4.46E0977 5.68 4.83 5.68 5.25 5.68 4.83 5.68 5.68 5.25 5.68 5.68 5.68 4.83 5.68 4.91E0978 4.01 3.41 4.01 3.93 4.00 3.41 4.01 4.01 3.60 3.45 3.56 3.52 3.96 3.41 3.57E0979 3.05 2.59 3.05 3.03 3.05 2.59 3.05 3.05 2.79 2.59 2.59 2.91 2.91 2.78 3.05E0980 2.52 2.52 2.52 2.52 2.52 2.52 2.96 2.93 2.52 2.52 2.52 2.95 2.79 2.92 2.96E0990 11.01 11.70 10.58 10.12 10.20 11.91 11.91 10.12 10.12 10.12 11.82 11.91 10.12 10.49 11.91E0991 3.43 3.96 3.37 3.96 3.37 3.57 3.96 3.37 3.96 3.96 3.96 3.96 3.37 3.74 3.37E0992 7.27 8.19 7.21 8.33 7.42 7.08 7.45 8.33 8.33 8.33 8.33 8.33 7.08 8.20 8.29E0993 3.54 4.17 3.77 4.17 4.06 3.54 4.17 3.54 4.17 4.17 4.17 3.76 3.92 4.17 4.17

E0994 1.36 1.60 1.36 1.51 1.60 1.36 1.60 1.36 1.56 1.60 1.50 1.60 1.36 1.60 1.60E0995 2.34 2.34 2.75 2.59 2.75 2.34 2.50 2.34 2.75 2.75 2.75 2.75 2.34 2.75 2.75E0996 2.21 2.48 2.48 2.48 2.48 2.39 2.11 2.48 2.48 2.48 2.48 2.48 2.11 2.48 2.48E0997 5.46 5.46 6.36 6.42 5.75 6.42 5.46 6.42 6.42 6.00 6.17 6.42 5.46 5.46 5.46E0998 3.11 3.57 3.03 3.03 3.45 3.03 3.03 3.57 3.03 3.03 3.03 3.57 3.03 3.03 3.57E0999 10.13 10.36 10.36 8.81 10.36 10.36 10.36 10.36 10.36 8.81 8.81 8.81 8.81 8.81 8.81E1000 3.28 3.28 3.28 3.28 3.28 3.57 3.28 3.28 3.28 3.86 3.86 3.86 3.28 3.86 3.86E1001 7.88 9.27 7.88 8.61 7.88 7.88 7.88 8.01 8.34 9.27 7.88 8.84 7.88 8.84 9.27E1065 238.09 238.09 209.93 202.38 202.38 238.09 238.09 202.38 238.09 202.38 202.38 238.09 202.38 238.09 202.38E1066 23.27 23.81 20.24 20.24 20.24 23.81 23.81 23.81 20.24 23.81 23.81 20.24 23.81 20.24 20.24E1069 10.20 10.17 8.67 10.20 8.67 8.67 10.20 8.67 10.20 8.67 10.20 10.20 9.74 10.20 10.20E1226 49.15 41.78 49.15 41.78 41.78 49.15 49.15 49.15 49.15 49.15 49.15 49.15 41.78 49.15 41.78E1227 25.00 25.00 25.00 25.00 25.00 25.00 23.06 25.00 25.00 21.25 21.25 25.00 21.25 25.00 21.25

E1230 200.39 172.39 200.39 170.33 170.33 190.60 198.07 170.33 181.54 200.39 180.91 200.39 200.39 200.39 170.33E1296 38.24 44.99 44.99 41.38 38.24 44.99 38.24 44.29 39.04 44.99 44.99 44.99 38.24 44.99 44.99E1297 8.90 10.47 10.47 8.90 8.90 10.47 9.05 9.43 8.90 10.47 10.47 8.90 8.90 8.90 10.47E1298 33.38 33.86 39.05 39.05 37.52 39.05 39.05 39.05 39.05 39.05 39.05 39.05 33.19 39.05 33.19E1310 157.74 140.64 165.46 165.46 165.46 140.64 165.46 165.46 165.46 165.46 165.46 165.46 152.82 163.16 165.46E1372 18.13 18.13 18.13 18.13 18.13 18.13 18.13 18.13 18.13 21.33 21.33 18.13 21.33 18.13 21.33E1375 31.95 31.95 31.95 31.95 37.59 37.59 31.95 37.59 31.95 31.95 31.95 31.95 31.95 31.95 31.95E1700 30.47 30.47 30.47 30.47 29.26 30.47 30.47 30.47 30.47 25.90 25.90 30.47 25.90 30.47 29.26K0005 166.53 166.53 166.53 166.53 166.53 166.53 166.53 166.53 166.53 166.53 166.53 166.53 166.53 166.53 166.53K0015 16.38 16.38 16.38 16.38 16.38 16.38 16.38 16.38 16.38 16.38 16.38 16.38 16.38 16.38 16.38K0016 8.86 8.38 9.86 9.86 9.86 8.38 8.38 8.38 9.77 8.38 8.38 8.38 8.38 8.38 9.86K0017 4.60 4.60 4.60 4.60 4.60 4.60 4.60 4.60 4.60 4.60 4.60 4.60 4.60 4.60 4.60K0018 2.56 2.56 2.56 2.56 2.56 2.56 2.56 2.56 2.56 2.56 2.56 2.56 2.56 2.56 2.56K0019 1.48 1.48 1.53 1.52 1.54 1.55 1.54 1.55 1.55 1.55 1.55 1.54 1.48 1.55 1.55K0020 4.19 4.19 4.19 4.19 4.19 4.19 4.19 4.19 4.19 4.19 4.19 4.19 4.19 4.19 4.19K0021 5.81 5.81 5.98 5.81 5.81 6.84 6.84 6.84 5.81 6.84 6.84 6.84 5.81 6.84 5.87K0022 3.83 4.50 4.50 3.83 4.50 3.83 4.50 3.83 3.83 3.92 3.90 3.83 4.50 3.83 4.46K0023 7.49 8.08 8.41 8.31 8.48 8.48 8.48 8.48 8.48 8.48 8.48 8.48 8.08 8.48 8.48K0024 8.91 9.54 9.93 9.84 10.05 10.05 10.05 10.05 10.05 10.05 10.05 10.05 9.54 10.05 10.05K0025 6.34 5.89 5.90 6.31 5.93 6.34 5.86 5.39 6.34 6.34 6.25 6.34 6.34 6.34 6.11K0026 3.54 4.17 3.77 4.17 4.06 3.54 4.17 3.54 4.17 4.17 4.17 3.76 3.92 4.17 4.17K0027 3.54 4.17 3.77 4.17 4.06 3.54 4.17 3.54 4.17 4.17 4.17 3.76 3.92 4.17 4.17K0028 50.59 43.00 50.59 43.00 43.00 50.59 50.59 50.59 50.59 50.59 50.59 50.59 43.00 50.59 43.00K0029 4.37 4.46 4.46 3.79 4.46 3.79 4.46 3.79 3.79 4.46 3.90 3.79 3.79 3.79 4.46K0030 7.27 8.20 7.21 8.33 7.42 7.08 7.45 8.33 8.33 8.33 8.33 8.33 7.08 8.20 8.29K0031 3.85 3.27 3.85 3.73 3.79 3.27 3.85 3.85 3.42 3.27 3.27 3.38 3.73 3.27 3.52K0032 3.44 3.96 3.37 3.96 3.37 3.57 3.96 3.37 3.96 3.96 3.96 3.96 3.37 3.74 3.37K0033 3.44 3.96 3.37 3.96 3.37 3.57 3.96 3.37 3.96 3.96 3.96 3.96 3.37 3.74 3.37K0034 1.76 1.76 1.76 1.60 1.76 1.50 1.50 1.50 1.53 1.50 1.50 1.76 1.50 1.76 1.50K0035 2.34 2.23 2.34 2.33 2.34 2.34 2.34 2.34 2.34 2.34 2.34 2.34 2.23 2.34 2.34K0036 1.77 1.77 1.50 1.77 1.77 1.50 1.50 1.77 1.50 1.77 1.77 1.77 1.52 1.77 1.50K0037 3.39 3.87 3.87 3.29 3.29 3.29 3.29 3.29 3.87 3.29 3.29 3.87 3.87 3.77 3.87K0038 2.18 2.18 2.18 2.18 2.18 2.18 2.18 2.18 2.18 2.18 2.18 2.18 2.18 2.18 2.18K0039 4.86 4.86 4.86 4.86 4.86 4.86 4.86 4.86 4.86 4.86 4.86 4.86 4.86 4.86 4.86K0040 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72K0041 4.78 4.78 4.78 4.78 4.78 4.78 4.78 4.78 4.78 4.78 4.78 4.78 4.78 4.78 4.78

K0042 3.27 3.27 3.27 2.78 3.27 2.78 3.04 2.78 3.27 3.02 3.10 3.27 3.27 3.27 3.27K0043 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76K0044 1.50 1.50 1.50 1.50 1.50 1.50 1.50 1.50 1.50 1.50 1.50 1.50 1.50 1.50 1.50K0045 5.11 5.11 5.26 5.26 5.26 5.26 5.26 5.26 5.26 5.26 5.26 5.26 5.11 5.26 5.26K0046 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76 1.76K0047 6.91 6.91 6.91 6.91 6.91 6.91 6.91 6.91 6.91 6.91 6.91 6.91 6.91 6.91 6.91K0048 11.01 11.70 10.58 10.12 10.20 11.91 11.91 10.12 10.12 10.12 11.82 11.91 10.12 10.49 11.91K0049 2.34 2.34 2.75 2.59 2.75 2.34 2.50 2.34 2.75 2.75 2.75 2.75 2.34 2.75 2.75K0050 2.92 2.92 2.92 2.92 2.92 2.92 2.92 2.92 2.92 2.92 2.92 2.92 2.92 2.92 2.92K0051 4.76 4.76 4.76 4.76 4.76 4.76 4.76 4.76 4.76 4.76 4.76 4.76 4.76 4.76 4.76K0052 8.32 8.32 8.32 8.32 8.32 8.32 8.32 8.32 8.32 8.32 8.32 8.32 8.32 8.32 8.32K0053 9.18 9.18 9.18 9.18 9.18 9.18 9.18 9.18 9.18 9.18 9.18 9.18 9.18 9.18 9.18K0054 9.43 9.43 9.43 9.43 9.43 9.43 9.43 9.43 9.43 9.43 9.43 9.43 9.43 9.43 9.43K0055 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56



K0056 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56 8.56K0057 11.19 11.19 11.19 11.19 11.19 11.19 11.19 11.19 11.19 11.19 11.19 11.19 11.19 11.19 11.19K0058 5.44 5.44 5.44 5.44 5.44 5.44 5.44 5.44 5.44 5.44 5.44 5.44 5.44 5.44 5.44K0059 2.85 2.85 2.85 2.85 2.85 2.85 2.85 2.85 2.85 2.85 2.85 2.85 2.85 2.85 2.85K0060 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50K0061 3.55 3.55 3.55 3.55 3.55 3.55 3.55 3.55 3.55 3.55 3.55 3.55 3.55 3.55 3.55K0062 5.49 5.49 5.50 5.50 5.50 5.50 5.50 5.50 5.50 5.50 5.50 5.50 5.49 5.50 5.50K0063 7.34 7.34 7.34 7.34 7.34 7.34 7.34 7.34 7.34 7.34 7.34 7.34 7.34 7.34 7.34K0064 2.75 2.75 2.75 2.75 2.75 2.75 2.75 2.75 2.75 2.75 2.75 2.75 2.75 2.75 2.75K0065 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00K0066 2.21 2.48 2.48 2.48 2.48 2.39 2.11 2.48 2.48 2.48 2.48 2.48 2.11 2.48 2.48K0067 3.37 3.62 3.28 3.62 3.46 3.62 3.62 3.08 3.08 3.08 3.24 3.62 3.08 3.62 3.62K0068 0.54 0.54 0.54 0.54 0.54 0.54 0.54 0.54 0.54 0.54 0.54 0.54 0.54 0.54 0.54K0069 9.00 9.00 9.38 9.26 9.38 9.38 9.38 9.38 9.38 9.38 9.38 9.38 9.00 9.38 9.38K0070 16.50 16.50 16.50 16.50 16.50 16.50 16.50 16.50 16.50 16.50 16.50 16.50 16.50 16.50 16.50K0071 9.84 9.84 9.84 9.84 9.84 9.84 9.84 9.84 9.84 9.84 9.84 9.84 9.84 9.84 9.84K0072 5.92 5.92 5.92 5.92 5.92 5.92 5.92 5.92 5.92 5.92 5.92 5.92 5.92 5.92 5.92K0073 3.14 3.03 3.14 3.11 3.14 3.14 3.14 3.14 3.14 3.14 3.14 3.14 3.03 3.14 3.14K0074 3.03 3.03 3.03 3.03 3.03 3.57 3.03 3.03 3.03 3.57 3.57 3.57 3.03 3.57 3.57K0075 4.25 3.61 4.25 4.25 4.25 4.25 3.61 3.61 3.61 4.25 4.25 3.61 3.61 3.61 3.61K0076 2.32 2.32 2.32 2.32 2.32 2.32 2.32 2.32 2.32 2.32 2.32 2.32 2.32 2.32 2.32K0077 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30 5.30K0078 0.86 0.86 0.86 0.86 0.86 0.86 0.86 0.86 0.86 0.86 0.86 0.86 0.86 0.86 0.86K0079 4.76 4.76 4.76 4.76 5.60 5.60 4.76 4.76 4.76 5.60 5.60 5.60 5.60 4.76 5.52K0080 13.56 12.74 14.99 12.74 12.74 12.74 13.10 14.99 14.11 12.74 12.74 14.99 14.99 14.99 12.74K0081 3.66 3.66 3.66 3.66 3.66 3.66 3.66 3.66 3.66 3.66 3.66 3.66 3.66 3.66 3.66K0082 10.17 10.17 8.64 10.17 8.64 8.64 10.17 8.64 10.17 8.64 10.17 10.17 9.74 10.17 10.17K0083 12.57 12.57 12.57 12.57 12.57 12.57 12.57 12.57 12.57 12.57 12.57 12.57 12.57 12.57 12.57K0084 8.29 8.29 8.29 8.29 8.29 8.29 8.29 8.29 8.29 8.29 8.29 8.29 8.29 8.29 8.29K0085 16.77 16.77 16.77 16.77 16.77 16.77 16.77 16.77 16.77 16.77 16.77 16.77 16.77 16.77 16.77K0086 10.17 10.17 8.64 10.17 8.64 8.64 10.17 8.64 10.17 8.64 10.17 10.17 9.74 10.17 10.17K0087 10.11 10.11 10.11 10.11 10.11 10.11 10.11 10.11 10.11 10.11 10.11 10.11 10.11 10.11 10.11K0088 23.26 23.81 20.24 20.24 20.24 23.81 23.81 23.81 20.24 23.81 23.81 20.24 23.81 20.24 20.24

K0089 6.79 6.79 6.79 6.79 6.79 6.79 6.79 6.79 6.79 6.79 6.79 6.79 6.79 6.79 6.79K0090 6.87 6.87 6.87 6.87 6.87 6.87 6.87 6.87 6.87 6.87 6.87 6.87 6.87 6.87 6.87K0091 1.87 1.87 1.87 1.87 1.87 1.87 1.87 1.87 1.87 1.87 1.87 1.87 1.87 1.87 1.87K0092 21.89 21.89 21.89 21.89 21.89 21.89 21.89 21.89 21.89 21.89 21.89 21.89 21.89 21.89 21.89K0093 13.68 13.68 13.68 13.68 13.68 13.68 13.68 13.68 13.68 13.68 13.68 13.68 13.68 13.68 13.68K0094 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47K0095 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47 4.47K0096 24.70 24.70 24.70 24.70 24.70 24.70 24.70 24.70 24.70 24.70 24.70 24.70 24.70 24.70 24.70K0097 5.69 5.47 5.69 5.63 5.69 5.69 5.69 5.69 5.69 5.69 5.69 5.69 5.47 5.69 5.69K0098 2.44 2.39 2.44 2.44 2.44 2.44 2.44 2.44 2.44 2.44 2.44 2.44 2.39 2.44 2.44K0099 7.30 7.30 7.30 7.30 7.30 7.30 7.30 7.30 7.30 7.30 7.30 7.30 7.30 7.30 7.30K0100 7.69 6.80 6.94 7.70 7.32 6.80 8.00 7.82 7.70 8.00 8.00 8.00 7.80 8.00 8.00K0102 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91K0103 4.85 4.82 5.05 5.05 5.05 5.05 5.05 5.05 4.99 5.05 5.05 5.05 4.29 5.05 5.05K0104 10.69 10.69 10.69 10.69 10.69 10.69 10.69 10.69 10.69 10.69 10.69 10.69 10.69 10.69 10.69K0105 8.94 8.94 8.94 8.94 8.94 8.94 8.94 8.94 8.94 8.94 8.94 8.94 8.94 8.94 8.94K0106 9.67 9.67 9.67 9.67 9.67 9.67 9.67 9.67 9.67 9.67 9.67 9.67 9.67 9.67 9.67K0107 7.97 7.97 7.97 9.38 7.97 9.38 9.38 9.38 9.38 7.97 7.97 9.38 9.38 9.38 9.38K0115 78.33 78.33 78.33 78.33 78.33 78.33 78.33 78.33 78.33 78.33 78.33 78.33 78.33 78.33 78.33K0116 163.48 163.48 163.48 163.48 163.48 163.48 163.48 163.48 163.48 163.48 163.48 163.48 163.48 163.48 163.48

1995 DME FEE SCHEDULES - OXYGEN AND OXYGEN EQUIPMENT

HCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM CO E0424 308.71 287.53 308.71 281.79 303.06 308.71 308.71 263.56 308.71 308.71 283.41 267.75 308.71 277.06 267.16E0431 48.50 48.51 48.51 41.23 46.66 48.32 41.23 41.23 41.23 48.51 48.51 42.38 48.51 47.59 41.23E0434 48.50 48.51 48.51 41.23 46.66 48.32 41.23 41.23 41.23 48.51 48.51 42.38 48.51 47.59 41.23E0439 308.71 287.53 308.71 281.79 303.06 308.71 308.71 263.56 308.71 308.71 283.41 267.75 308.71 277.06 267.16E0441 219.89 186.91 219.89 199.43 194.90 219.89 186.91 186.91 206.41 219.89 213.12 219.24 214.89 190.18 186.91E0442 219.89 186.91 219.89 199.43 194.90 219.89 186.91 186.91 206.41 219.89 213.12 219.24 214.89 190.18 186.91E0443 28.89 24.56 28.54 24.56 24.56 24.56 24.56 24.56 24.56 24.56 24.56 24.56 24.56 28.89 24.56E0444 28.89 24.56 28.54 24.56 24.56 24.56 24.56 24.56 24.56 24.56 24.56 24.56 24.56 28.89 24.56E1400 308.71 287.53 308.71 281.79 303.06 308.71 308.71 263.56 308.71 308.71 283.41 267.75 308.71 277.06 267.16E1401 308.71 287.53 308.71 281.79 303.06 308.71 308.71 263.56 308.71 308.71 283.41 267.75 308.71 277.06 267.16E1402 308.71 287.53 308.71 281.79 303.06 308.71 308.71 263.56 308.71 308.71 283.41 267.75 308.71 277.06 267.16E1403 308.71 287.53 308.71 281.79 303.06 308.71 308.71 263.56 308.71 308.71 283.41 267.75 308.71 277.06 267.16E1404 308.71 287.53 308.71 281.79 303.06 308.71 308.71 263.56 308.71 308.71 283.41 267.75 308.71 277.06 267.16E1405 340.30 318.02 335.56 308.64 334.65 335.56 340.30 290.41 337.51 340.30 315.00 299.34 340.30 304.40 298.75E1406 326.49 305.31 326.49 299.11 320.84 324.26 325.66 280.04 326.36 323.82 298.52 285.53 326.49 292.31 283.02

1995 DME FEE SCHEDULES - SUPPLIES

HCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM COA4253 38.35 38.35 35.54 33.26 35.18 38.35 37.41 38.35 38.35 38.35 38.35 32.60 34.56 33.16 32.65A4256 8.76 9.51 8.76 10.31 10.31 10.31 9.90 10.31 10.31 8.76 8.76 9.73 10.31 10.31 10.31A4259 11.48 11.48 11.48 11.48 10.97 9.76 11.48 9.76 11.48 11.48 11.48 9.86 11.48 11.48 11.48A4556 10.93 9.76 10.93 9.29 9.29 10.93 9.36 9.29 9.29 10.93 10.93 10.93 10.93 10.93 10.93A4557 17.17 19.01 19.01 19.01 19.01 17.95 19.01 16.16 16.41 19.01 19.01 16.16 19.01 18.90 19.01A4558 4.17 4.66 4.91 4.91 4.17 4.91 4.91 4.45 4.17 4.91 4.17 4.91 4.17 4.17 4.91A4624 2.01 2.37 2.37 2.01 2.37 2.37 2.01 2.01 2.01 2.37 2.37 2.01 2.37 2.01 2.37E0731 273.11 321.31 321.31 321.31 321.31 321.31 321.31 321.31 321.31 321.31 321.31 321.31 273.11 321.31 321.31E1701 9.55 9.07 9.07 9.55 9.55 9.55 9.55 8.12 9.55 9.55 9.55 9.55 9.11 9.55 9.55E1702 20.32 18.22 18.22 20.32 20.31 20.07 19.70 17.27 20.32 17.27 17.27 19.58 17.27 19.28 20.32K0110 20.39 20.39 20.39 20.39 20.39 20.39 20.39 20.39 20.39 20.39 20.39 20.39 20.39 20.39 20.39K0111 42.10 40.48 42.10 41.71 42.10 42.10 42.10 42.10 42.10 42.10 42.10 42.10 40.48 42.10 42.10K0118 25.95 25.95 25.95 25.95 25.95 25.95 25.95 25.95 25.95 25.95 25.95 25.95 25.95 25.95 25.95K0131 16.25 16.25 16.25 16.25 16.25 16.25 16.25 16.25 16.25 16.25 16.25 16.25 16.25 16.25 16.25


1995 - OSTOMY, TRACHEOSTOMY AND UROLOGICAL SUPPLIES

HCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM COA4214 1.33 1.57 1.57 1.57 1.57 1.54 1.57 1.57 1.53 1.57 1.57 1.57 1.57 1.57 1.57A4310 6.96 5.92 6.25 5.92 5.92 6.27 6.12 5.92 6.62 6.12 6.89 6.96 5.92 6.96 6.96A4311 12.18 11.36 13.37 13.37 13.37 13.37 13.37 13.37 12.85 13.37 13.37 13.37 11.61 13.37 11.83A4312 13.80 16.24 13.80 16.24 16.24 14.01 15.94 16.24 16.24 16.24 16.24 16.24 16.24 16.24 13.80A4313 16.69 14.19 14.19 16.69 16.69 14.19 16.69 16.69 16.69 16.67 16.69 16.69 16.69 16.69 14.19A4314 21.98 19.36 21.02 22.78 22.78 19.62 22.78 19.36 21.89 22.78 22.78 22.07 22.78 21.17 22.78A4315 23.77 20.20 20.20 23.77 23.77 20.20 23.77 23.77 23.77 22.80 22.78 22.07 23.15 21.17 23.77A4316 25.58 21.74 25.58 25.58 24.69 21.74 25.58 25.58 25.58 22.80 22.78 22.07 25.58 21.74 25.58A4320 4.41 4.80 4.24 4.08 4.80 4.80 4.80 4.08 4.11 4.80 4.80 4.80 4.08 4.80 4.76A4322 2.75 2.93 2.93 2.93 2.76 2.80 2.49 2.49 2.51 2.78 2.85 2.93 2.49 2.93 2.76A4323 6.72 7.25 7.42 7.72 6.72 6.72 6.72 7.62 6.72 7.90 7.90 7.90 7.90 7.90 7.02A4326 8.77 9.72 9.94 9.79 10.26 10.32 10.32 10.32 9.79 10.32 10.32 10.32 9.79 10.32 8.78A4327 36.32 36.32 42.73 42.03 41.84 42.73 41.97 36.32 40.00 42.73 42.73 40.30 42.73 40.18 42.73A4328 9.42 8.01 8.01 9.23 8.01 9.42 9.32 9.42 8.86 9.12 9.12 9.42 8.01 9.42 9.42A4329 31.41 36.95 31.41 31.41 31.41 36.95 31.41 36.95 31.41 36.95 36.95 31.41 31.41 31.41 36.95A4330 5.47 6.44 6.44 6.42 6.43 6.44 6.44 5.47 5.47 5.88 5.88 5.47 6.39 5.47 6.44A4338 9.77 9.77 9.77 9.80 11.49 11.49 9.77 9.77 9.77 11.49 11.49 9.77 11.49 9.77 11.49A4340 18.68 18.68 21.98 21.98 21.98 21.98 21.98 21.98 18.68 18.68 18.68 21.98 18.68 21.98 20.96A4344 14.43 14.43 12.27 12.92 12.83 14.26 14.43 13.18 13.20 14.43 14.43 14.43 12.27 14.43 14.29A4346 16.00 17.65 15.00 15.00 15.00 17.65 17.65 15.64 17.65 15.00 17.65 17.65 15.00 17.65 17.65A4347 15.58 15.58 17.27 15.58 17.26 15.58 18.33 15.58 15.58 18.33 17.43 18.33 16.43 18.33 17.84A4351 1.39 1.63 1.62 1.39 1.63 1.63 1.39 1.52 1.39 1.54 1.54 1.63 1.63 1.63 1.39A4352 5.78 4.91 5.69 5.36 5.78 5.78 4.91 5.78 4.91 4.91 4.91 4.94 5.76 4.94 5.63A4354 9.03 9.03 9.03 10.62 10.62 10.62 10.62 10.62 10.62 10.62 10.62 10.20 10.62 9.77 10.62A4355 8.03 6.83 7.32 8.03 7.50 7.48 8.03 8.03 8.03 8.03 8.03 6.83 8.03 6.83 8.03A4356 34.94 41.10 41.10 40.86 37.94 41.10 41.10 37.48 41.10 41.10 41.10 34.94 34.94 41.10 34.94A4357 8.74 8.74 7.43 8.74 8.74 8.74 7.43 7.43 7.43 8.74 8.74 7.43 7.43 7.43 8.74A4358 5.66 5.98 5.84 5.98 5.08 5.61 5.09 5.35 5.08 5.98 5.98 5.98 5.08 5.98 5.98A4359 27.44 26.14 23.45 25.20 27.59 23.45 27.25 26.50 25.19 27.59 27.59 26.21 27.59 26.21 27.59A4361 14.06 16.54 14.52 16.54 16.54 16.54 16.54 16.54 16.54 16.13 14.06 14.06 16.54 14.06 16.07A4362 3.12 3.05 2.65 3.12 3.12 2.65 2.86 2.65 2.82 3.12 3.12 2.65 2.90 2.65 3.12A4363 3.39 3.54 3.54 3.06 3.01 3.01 3.01 3.01 3.01 3.54 3.54 3.22 3.54 3.22 3.54A4364 2.64 2.36 2.24 2.24 2.31 2.56 2.64 2.64 2.34 2.64 2.64 2.64 2.43 2.64 2.64

A4367 6.17 6.62 6.07 5.63 6.19 6.00 6.62 5.63 5.63 6.28 5.98 6.62 6.15 6.54 6.62A4397 3.82 3.72 3.97 3.67 3.98 4.32 3.67 3.93 3.67 4.32 4.32 3.67 4.32 3.67 4.32A4398 10.38 10.38 11.40 12.21 10.38 11.70 11.31 10.38 12.21 12.21 12.21 12.21 10.82 12.21 12.21A4399 10.69 10.69 9.58 10.69 9.09 10.69 9.84 9.72 10.51 10.69 10.69 10.69 9.09 10.69 10.69A4400 37.43 37.43 37.43 37.43 37.43 37.43 42.13 37.43 37.43 44.03 44.03 44.03 44.03 44.03 37.43A4402 1.44 1.27 1.22 1.22 1.44 1.44 1.22 1.22 1.22 1.44 1.44 1.24 1.44 1.24 1.44A4404 1.52 1.52 1.52 1.29 1.52 1.29 1.34 1.31 1.29 1.52 1.52 1.52 1.52 1.52 1.52A4454 2.00 2.35 2.00 2.00 2.00 2.00 2.35 2.00 2.00 2.16 2.22 2.00 2.35 2.00 2.00A4455 1.09 1.09 1.28 1.09 1.26 1.28 1.09 1.28 1.09 1.28 1.28 1.09 1.09 1.09 1.28A4622 43.85 51.59 51.59 45.99 51.59 51.59 43.85 51.59 47.85 51.59 51.59 43.85 50.44 43.85 50.59A4623 5.90 5.90 5.65 5.02 5.02 5.02 5.02 5.02 5.02 5.90 5.90 5.02 5.03 5.02 5.90A4625 6.24 6.24 6.24 5.30 5.30 6.24 6.24 5.30 5.30 6.24 6.24 6.24 6.24 6.24 6.24A4626 2.88 2.45 2.88 2.45 2.45 2.64 2.45 2.87 2.45 2.88 2.88 2.88 2.45 2.88 2.88A4630 4.79 5.63 4.79 5.63 5.63 5.63 5.63 5.63 5.63 5.63 5.63 4.79 5.63 4.79 5.63A5051 2.03 1.96 2.10 2.02 2.10 2.10 2.10 1.79 2.09 2.10 2.10 2.10 1.98 2.10 2.10A5052 1.50 1.50 1.28 1.50 1.29 1.29 1.28 1.33 1.31 1.28 1.31 1.46 1.48 1.46 1.28A5053 1.49 1.51 1.34 1.33 1.33 1.33 1.33 1.33 1.33 1.56 1.56 1.33 1.48 1.33 1.56A5054 1.45 1.51 1.52 1.52 1.29 1.29 1.34 1.33 1.31 1.52 1.52 1.29 1.48 1.29 1.52A5055 1.27 1.47 1.38 1.25 1.25 1.47 1.47 1.25 1.25 1.33 1.36 1.29 1.25 1.29 1.26A5061 3.13 2.88 3.13 2.81 2.94 3.13 3.13 2.66 2.96 3.13 3.13 2.88 2.75 2.88 3.13A5062 2.34 2.34 2.34 2.34 1.99 1.99 1.99 1.99 1.99 1.99 1.99 2.34 2.34 2.34 2.34A5063 2.01 2.36 2.16 2.34 2.21 2.01 2.36 2.01 2.01 2.36 2.36 2.36 2.01 2.36 2.36A5064 3.90 3.32 3.32 3.32 3.90 3.76 3.32 3.79 3.38 3.32 3.32 3.32 3.32 3.32 3.32A5065 2.86 2.47 2.45 2.43 2.43 2.86 2.43 2.73 2.74 2.52 2.86 2.86 2.43 2.86 2.49A5071 4.20 3.67 4.16 4.32 4.08 3.94 4.32 3.67 3.73 3.67 3.75 4.32 4.32 4.32 3.67A5072 3.27 2.85 3.35 3.06 2.85 2.85 2.85 2.85 2.85 2.85 2.85 3.35 3.35 3.35 2.85A5073 2.75 2.47 2.90 2.90 2.47 2.47 2.90 2.47 2.71 2.87 2.90 2.85 2.90 2.85 2.73A5074 5.09 4.33 4.46 4.46 4.33 4.33 4.33 5.09 4.78 5.09 5.09 5.09 5.09 5.09 5.09A5075 3.70 3.70 3.71 3.70 3.70 3.70 3.94 3.84 3.75 3.70 3.75 4.35 4.35 4.35 3.75A5081 2.96 2.96 2.52 2.61 2.52 2.96 2.81 2.52 2.88 2.52 2.52 2.52 2.52 2.52 2.96A5082 9.10 9.10 10.71 10.12 9.10 9.10 9.10 9.10 9.10 10.71 10.71 10.71 10.71 10.71 10.71A5093 1.60 1.76 1.76 1.50 1.67 1.76 1.76 1.69 1.50 1.63 1.63 1.65 1.76 1.65 1.76A5102 24.92 22.53 22.53 22.53 22.53 22.53 26.50 26.50 22.53 26.50 26.50 25.95 26.50 25.95 26.50A5105 36.72 31.21 36.72 36.72 31.21 31.21 32.00 36.72 36.72 34.44 35.38 34.45 36.72 34.45 32.50A5112 27.63 24.12 24.12 24.12 28.38 24.12 24.12 28.38 28.38 24.12 24.12 28.38 26.19 28.38 26.95A5113 4.23 4.23 4.23 3.60 4.23 3.60 3.60 4.23 3.60 4.23 4.23 3.60 3.60 3.60 4.23A5114 8.05 7.26 6.84 6.84 6.84 6.84 6.84 6.84 6.84 8.05 8.05 8.05 8.05 8.05 8.05A5119 9.71 9.78 9.78 9.14 9.55 9.78 8.87 9.15 9.14 8.68 8.68 9.26 9.78 9.26 9.08A5121 5.72 5.72 5.72 6.73 6.73 6.07 6.73 6.73 6.73 6.73 6.73 6.73 6.42 6.73 6.73A5122 10.26 11.58 11.58 11.29 11.58 11.49 11.58 11.58 9.84 11.58 11.58 11.58 9.84 11.58 11.58A5123 4.34 4.34 4.34 4.34 5.11 5.11 5.11 5.11 4.34 5.11 5.11 5.11 5.11 5.11 5.11A5126 1.01 1.01 1.19 1.01 1.01 1.18 1.01 1.19 1.01 1.19 1.19 1.01 1.19 1.01 1.19A5131 14.29 12.15 14.29 13.03 12.15 14.29 14.27 14.29 13.04 12.15 12.15 14.29 14.29 14.29 14.29K0132 1.27 1.27 1.27 1.27 1.27 1.27 1.27 1.27 1.27 1.27 1.27 1.27 1.27 1.27 1.27K0133 1.57 1.57 1.57 1.57 1.57 1.57 1.57 1.57 1.57 1.57 1.57 1.57 1.57 1.57 1.57K0134 3.19 3.19 3.19 3.19 3.19 3.19 3.19 3.19 3.19 3.19 3.19 3.19 3.19 3.19 3.19K0135 1.51 1.51 1.51 1.51 1.51 1.51 1.51 1.51 1.51 1.51 1.51 1.51 1.51 1.51 1.51K0136 8.92 8.92 8.92 8.92 8.92 8.92 8.92 8.92 8.92 8.92 8.92 8.92 8.92 8.92 8.92K0137 2.17 2.17 2.17 2.17 2.17 2.17 2.17 2.17 2.17 2.17 2.17 2.17 2.17 2.17 2.17K0138 3.09 3.09 3.09 3.09 3.09 3.09 3.09 3.09 3.09 3.09 3.09 3.09 3.09 3.09 3.09K0139 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29K0165 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17

HCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM COA4560 16.94 16.94 16.94 16.94 16.94 16.94 16.94 16.94 16.94 22.58 22.58 22.58 22.58 22.58 21.88E0750 6712.61 6152.90 6152.90 6152.90 6152.90 6152.90 6152.90 6152.90 6152.90 8078.27 8078.27 8078.27 8078.27 8078.27 8203.87K0112 202.40 208.50 208.50 208.50 208.50 208.50 208.50 208.50 208.50 208.48 208.48 208.48 208.48 208.48 205.87K0113 123.46 127.17 127.17 127.17 127.17 127.17 127.17 127.17 127.17 127.16 127.16 127.16 127.16 127.16 125.58K0114 629.86 648.83 648.83 648.83 648.83 648.83 648.83 648.83 648.83 648.77 648.77 648.77 648.77 648.77 640.66K0126 108.13 111.39 111.39 111.39 111.39 111.39 111.39 111.39 111.39 111.38 111.38 111.38 111.38 111.38 109.99K0127 16.01 16.49 16.49 16.49 16.49 16.49 16.49 16.49 16.49 16.49 16.49 16.49 16.49 16.49 16.28K0128 11.68 12.03 12.03 12.03 12.03 12.03 12.03 12.03 12.03 12.03 12.03 12.03 12.03 12.03 11.88



K0129 114.15 117.59 117.59 117.59 117.59 117.59 117.59 117.59 117.59 117.58 117.58 117.58 117.58 117.58 116.11K0130 52.55 54.13 54.13 54.13 54.13 54.13 54.13 54.13 54.13 54.13 54.13 54.13 54.13 54.13 53.46K0163 358.10 379.96 379.96 379.96 379.96 379.96 379.96 379.96 379.96 379.93 379.93 379.93 379.93 379.93 378.89L0100 440.04 396.46 396.46 396.46 396.46 396.46 396.46 396.46 396.46 405.63 405.63 405.63 405.63 405.63 412.63L0110 93.62 116.97 116.97 116.97 116.97 116.97 116.97 116.97 116.97 124.82 124.82 124.82 124.82 124.82 93.62L0120 17.29 19.60 19.60 19.60 19.60 19.60 19.60 19.60 19.60 17.29 17.29 17.29 17.29 17.29 17.29L0130 141.74 141.74 141.74 141.74 141.74 141.74 141.74 141.74 141.74 106.31 106.31 106.31 106.31 106.31 106.31L0140 41.72 48.92 48.92 48.92 48.92 48.92 48.92 48.92 48.92 42.56 42.56 42.56 42.56 42.56 47.11L0150 80.59 81.58 81.58 81.58 81.58 81.58 81.58 81.58 81.58 70.43 70.43 70.43 70.43 70.43 70.43L0160 109.19 116.14 116.14 116.14 116.14 116.14 116.14 116.14 116.14 136.08 136.08 136.08 136.08 136.08 102.06L0170 420.26 491.45 491.45 491.45 491.45 491.45 491.45 491.45 491.45 445.74 445.74 445.74 445.74 445.74 420.26L0172 95.36 99.64 99.64 99.64 99.64 99.64 99.64 99.64 99.64 91.84 91.84 91.84 91.84 91.84 85.94L0174 179.01 179.01 179.01 179.01 179.01 179.01 179.01 179.01 179.01 179.01 179.01 179.01 179.01 179.01 209.38L0180 264.28 243.47 243.47 243.47 243.47 243.47 243.47 243.47 243.47 268.22 268.22 268.22 268.22 268.22 241.45L0190 353.98 366.48 366.48 366.48 366.48 366.48 366.48 366.48 366.48 347.34 347.34 347.34 347.34 347.34 335.18L0200 340.86 336.51 336.51 336.51 336.51 336.51 336.51 336.51 336.51 388.10 388.10 388.10 388.10 388.10 364.00L0210 36.66 34.92 34.92 34.92 34.92 34.92 34.92 34.92 34.92 38.47 38.47 38.47 38.47 38.47 28.85L0220 100.58 79.80 79.80 79.80 79.80 79.80 79.80 79.80 79.80 106.40 106.40 106.40 106.40 106.40 79.80L0300 132.65 131.75 131.75 131.75 131.75 131.75 131.75 131.75 131.75 113.26 113.26 113.26 113.26 113.26 113.26L0310 286.40 246.20 246.20 246.20 246.20 246.20 246.20 246.20 246.20 228.37 228.37 228.37 228.37 228.37 214.80L0315 219.44 171.36 171.36 171.36 171.36 171.36 171.36 171.36 171.36 171.36 171.36 171.36 171.36 171.36 171.36L0317 270.66 232.47 232.47 232.47 232.47 232.47 232.47 232.47 232.47 295.73 295.73 295.73 295.73 295.73 282.55L0320 243.46 267.83 267.83 267.83 267.83 267.83 267.83 267.83 267.83 278.95 278.95 278.95 278.95 278.95 254.37L0330 298.70 335.78 335.78 335.78 335.78 335.78 335.78 335.78 335.78 322.96 322.96 322.96 322.96 322.96 298.70L0340 425.41 535.00 535.00 535.00 535.00 535.00 535.00 535.00 535.00 425.41 425.41 425.41 425.41 425.41 425.41L0350 663.10 745.09 745.09 745.09 745.09 745.09 745.09 745.09 745.09 693.24 693.24 693.24 693.24 693.24 623.75

L0360 983.42 1099.41 1099.41 1099.41 1099.41 1099.41 1099.41 1099.41 1099.41 939.78 939.78 939.78 939.78 939.78 1085.45

1995 PROSTHETICS AND ORTHOTICS FEE SCHEDULE

HCPCS VI FL GA NC SC AL KY MS TN AR LA OK TX NM COL0370 315.54 300.08 300.08 300.08 300.08 300.08 300.08 300.08 300.08 290.01 290.01 290.01 290.01 290.01 263.49L0380 540.67 421.13 421.13 421.13 421.13 421.13 421.13 421.13 421.13 405.61 405.61 405.61 405.61 405.61 405.50L0390 1120.33 927.90 927.90 927.90 927.90 927.90 927.90 927.90 927.90 999.23 999.23 999.23 999.23 999.23 1153.06L0400 1248.50 1063.70 1063.70 1063.70 1063.70 1063.70 1063.70 1063.70 1063.70 1010.51 1010.51 1010.51 1010.51 1010.51 1289.30L0410 1240.37 1240.26 1240.26 1240.26 1240.26 1240.26 1240.26 1240.26 1240.26 1158.06 1158.06 1158.06 1158.06 1158.06 1391.52L0420 1318.78 1228.63 1228.63 1228.63 1228.63 1228.63 1228.63 1228.63 1228.63 1249.61 1249.61 1249.61 1249.61 1249.61 1409.91L0430 968.61 974.64 974.64 974.64 974.64 974.64 974.64 974.64 974.64 1063.69 1063.69 1063.69 1063.69 1063.69 987.62L0440 732.85 794.86 794.86 794.86 794.86 794.86 794.86 794.86 794.86 805.28 805.28 805.28 805.28 805.28 730.04L0500 92.15 98.21 98.21 98.21 98.21 98.21 98.21 98.21 98.21 99.72 99.72 99.72 99.72 99.72 88.37L0510 212.53 199.91 199.91 199.91 199.91 199.91 199.91 199.91 199.91 179.60 179.60 179.60 179.60 179.60 179.60L0515 143.86 119.26 119.26 119.26 119.26 119.26 119.26 119.26 119.26 119.26 119.26 119.26 119.26 119.26 130.01L0520 297.33 293.30 293.30 293.30 293.30 293.30 293.30 293.30 293.30 274.80 274.80 274.80 274.80 274.80 271.43L0530 269.96 269.96 269.96 269.96 269.96 269.96 269.96 269.96 269.96 269.96 269.96 269.96 269.96 269.96 346.41L0540 356.50 291.34 291.34 291.34 291.34 291.34 291.34 291.34 291.34 290.76 290.76 290.76 290.76 290.76 347.37L0550 957.54 874.26 874.26 874.26 874.26 874.26 874.26 874.26 874.26 891.97 891.97 891.97 891.97 891.97 1009.99L0560 961.10 956.59 956.59 956.59 956.59 956.59 956.59 956.59 956.59 941.66 941.66 941.66 941.66 941.66 1130.65L0565 730.74 953.91 953.91 953.91 953.91 953.91 953.91 953.91 953.91 851.20 851.20 851.20 851.20 851.20 730.74L0600 63.05 62.48 62.48 62.48 62.48 62.48 62.48 62.48 62.48 65.08 65.08 65.08 65.08 65.08 74.35L0610 168.35 169.41 169.41 169.41 169.41 169.41 169.41 169.41 169.41 168.35 168.35 168.35 168.35 168.35 168.35L0620 367.86 282.48 282.48 282.48 282.48 282.48 282.48 282.48 282.48 278.99 278.99 278.99 278.99 278.99 275.90L0700 1317.42 1508.61 1508.61 1508.61 1508.61 1508.61 1508.61 1508.61 1508.61 1337.25 1337.25 1337.25 1337.25 1337.25 1332.74L0710 1367.57 1646.74 1646.74 1646.74 1646.74 1646.74 1646.74 1646.74 1646.74 1440.53 1440.53 1440.53 1440.53 1440.53 1555.21L0810 1706.94 1749.42 1749.42 1749.42 1749.42 1749.42 1749.42 1749.42 1749.42 1784.65 1784.65 1784.65 1784.65 1784.65 1756.03L0820 1407.59 1415.21 1415.21 1415.21 1415.21 1415.21 1415.21 1415.21 1415.21 1505.47 1505.47 1505.47 1505.47 1505.47 1519.19L0830 2043.41 2043.41 2043.41 2043.41 2043.41 2043.41 2043.41 2043.41 2043.41 2412.10 2412.10 2412.10 2412.10 2412.10 2043.41L0860 793.85 793.85 793.85 793.85 793.85 793.85 793.85 793.85 793.85 1058.46 1058.46 1058.46 1058.46 1058.46 1058.46L0900 104.34 130.04 130.04 130.04 130.04 130.04 130.04 130.04 130.04 116.29 116.29 116.29 116.29 116.29 104.34L0910 232.80 259.75 259.75 259.75 259.75 259.75 259.75 259.75 259.75 226.57 226.57 226.57 226.57 226.57 226.57L0920 110.60 147.47 147.47 147.47 147.47 147.47 147.47 147.47 147.47 110.60 110.60 110.60 110.60 110.60 110.60L0930 263.87 301.95 301.95 301.95 301.95 301.95 301.95 301.95 301.95 246.54 246.54 246.54 246.54 246.54 246.54L0940 103.04 104.18 104.18 104.18 104.18 104.18 104.18 104.18 104.18 128.72 128.72 128.72 128.72 128.72 103.04L0950 252.46 267.34 267.34 267.34 267.34 267.34 267.34 267.34 267.34 226.03 226.03 226.03 226.03 226.03 224.33L0960 45.01 60.01 60.01 60.01 60.01 60.01 60.01 60.01 60.01 60.01 60.01 60.01 60.01 60.01 45.01L0970 77.09 74.48 74.48 74.48 74.48 74.48 74.48 74.48 74.48 94.76 94.76 94.76 94.76 94.76 99.30L0972 74.31 76.13 76.13 76.13 76.13 76.13 76.13 76.13 76.13 86.62 86.62 86.62 86.62 86.62 72.14L0974 116.67 155.56 155.56 155.56 155.56 155.56 155.56 155.56 155.56 130.96 130.96 130.96 130.96 130.96 116.67L0976 104.19 138.92 138.92 138.92 138.92 138.92 138.92 138.92 138.92 122.64 122.64 122.64 122.64 122.64 132.19L0978 125.43 125.43 125.43 125.43 125.43 125.43 125.43 125.43 125.43 128.49 128.49 128.49 128.49 128.49 125.43L0980 11.38 11.38 11.38 11.38 11.38 11.38 11.38 11.38 11.38 15.17 15.17 15.17 15.17 15.17 11.38L0982 10.61 12.40 12.40 12.40 12.40 12.40 12.40 12.40 12.40 14.15 14.15 14.15 14.15 14.15 10.61L0984 42.66 39.55 39.55 39.55 39.55 39.55 39.55 39.55 39.55 39.55 39.55 39.55 39.55 39.55 43.43L1000 1322.98 1322.98 1322.98 1322.98 1322.98 1322.98 1322.98 1322.98 1322.98 1438.33 1438.33 1438.33 1438.33 1438.33 1541.67L1010 43.73 53.27 53.27 53.27 53.27 53.27 53.27 53.27 53.27 51.52 51.52 51.52 51.52 51.52 43.73L1020 56.33 72.79 72.79 72.79 72.79 72.79 72.79 72.79 72.79 71.41 71.41 71.41 71.41 71.41 56.33L1025 108.35 82.73 82.73 82.73 82.73 82.73 82.73 82.73 82.73 81.26 81.26 81.26 81.26 81.26 81.26L1030 41.45 55.27 55.27 55.27 55.27 55.27 55.27 55.27 55.27 55.27 55.27 55.27 55.27 55.27 41.45L1040 50.84 66.53 66.53 66.53 66.53 66.53 66.53 66.53 66.53 57.80 57.80 57.80 57.80 57.80 50.84L1050 54.25 57.61 57.61 57.61 57.61 57.61 57.61 57.61 57.61 69.93 69.93 69.93 69.93 69.93 54.25L1060 62.32 64.98 64.98 64.98 64.98 64.98 64.98 64.98 64.98 67.87 67.87 67.87 67.87 67.87 62.32L1070 58.64 66.43 66.43 66.43 66.43 66.43 66.43 66.43 66.43 66.39 66.39 66.39 66.39 66.39 58.64L1080 36.06 46.02 46.02 46.02 46.02 46.02 46.02 46.02 46.02 37.33 37.33 37.33 37.33 37.33 46.35L1085 100.31 127.87 127.87 127.87 127.87 127.87 127.87 127.87 127.87 112.80 112.80 112.80 112.80 112.80 100.31L1090 65.55 59.73 59.73 59.73 59.73 59.73 59.73 59.73 59.73 66.80 66.80 66.80 66.80 66.80 64.50L1100 106.39 105.44 105.44 105.44 105.44 105.44 105.44 105.44 105.44 115.13 115.13 115.13 115.13 115.13 103.63L1110 166.43 178.60 178.60 178.60 178.60 178.60 178.60 178.60 178.60 167.90 167.90 167.90 167.90 167.90 166.43L1120 25.88 28.46 28.46 28.46 28.46 28.46 28.46 28.46 28.46 30.44 30.44 30.44 30.44 30.44 27.97L1200 1021.01 1132.49 1132.49 1132.49 1132.49 1132.49 1132.49 1132.49 1132.49 1174.25 1174.25 1174.25 1174.25 1174.25 1224.41L1210 227.34 170.51 170.51 170.51 170.51 170.51 170.51 170.51 170.51 170.51 170.51 170.51 170.51 170.51 227.34L1220 192.48 144.36 144.36 144.36 144.36 144.36 144.36 144.36 144.36 165.01 165.01 165.01 165.01 165.01 150.52L1230 493.91 370.43 370.43 370.43 370.43 370.43 370.43 370.43 370.43 370.43 370.43 370.43 370.43 370.43 492.37L1240 51.07 63.75 63.75 63.75 63.75 63.75 63.75 63.75 63.75 54.63 54.63 54.63 54.63 54.63 50.60L1250 47.08 62.77 62.77 62.77 62.77 62.77 62.77 62.77 62.77 53.01 53.01 53.01 53.01 53.01 47.08L1260 49.30 64.50 64.50 64.50 64.50 64.50 64.50 64.50 64.50 53.34 53.34 53.34 53.34 53.34 49.30L1270 50.49 64.41 64.41 64.41 64.41 64.41 64.41 64.41 64.41 51.28 51.28 51.28 51.28 51.28 50.49L1280 60.39 57.43 57.43 57.43 57.43 57.43 57.43 57.43 57.43 56.21 56.21 56.21 56.21 56.21 56.21L1290 51.22 65.11 65.11 65.11 65.11 65.11 65.11 65.11 65.11 51.22 51.22 51.22 51.22 51.22 51.22



L1300 1451.36 1088.52 1088.52 1088.52 1088.52 1088.52 1088.52 1088.52 1088.52 1254.70 1254.70 1254.70 1254.70 1254.70 1352.76L1310 1445.54 1120.10 1120.10 1120.10 1120.10 1120.10 1120.10 1120.10 1120.10 1208.67 1208.67 1208.67 1208.67 1208.67 1432.47L1500 1237.77 1237.77 1237.77 1237.77 1237.77 1237.77 1237.77 1237.77 1237.77 1356.07 1356.07 1356.07 1356.07 1356.07 1356.21L1510 1044.08 783.06 783.06 783.06 783.06 783.06 783.06 783.06 783.06 783.06 783.06 783.06 783.06 783.06 1005.65L1520 1937.01 1859.92 1859.92 1859.92 1859.92 1859.92 1859.92 1859.92 1859.92 1776.92 1776.92 1776.92 1776.92 1776.92 1516.96L1600 83.97 83.97 83.97 83.97 83.97 83.97 83.97 83.97 83.97 111.96 111.96 111.96 111.96 111.96 85.87L1610 31.27 28.60 28.60 28.60 28.60 28.60 28.60 28.60 28.60 29.66 29.66 29.66 29.66 29.66 28.60L1620 96.63 94.20 94.20 94.20 94.20 94.20 94.20 94.20 94.20 87.31 87.31 87.31 87.31 87.31 87.31L1630 110.42 112.43 112.43 112.43 112.43 112.43 112.43 112.43 112.43 110.42 110.42 110.42 110.42 110.42 110.42L1640 351.34 300.69 300.69 300.69 300.69 300.69 300.69 300.69 300.69 346.24 346.24 346.24 346.24 346.24 368.92L1650 150.87 159.45 159.45 159.45 159.45 159.45 159.45 159.45 159.45 159.01 159.01 159.01 159.01 159.01 170.00L1660 111.52 111.52 111.52 111.52 111.52 111.52 111.52 111.52 111.52 148.69 148.69 148.69 148.69 148.69 111.52L1680 793.97 916.85 916.85 916.85 916.85 916.85 916.85 916.85 916.85 938.59 938.59 938.59 938.59 938.59 793.97L1685 775.12 967.44 967.44 967.44 967.44 967.44 967.44 967.44 967.44 775.12 775.12 775.12 775.12 775.12 775.12L1686 792.56 649.02 649.02 649.02 649.02 649.02 649.02 649.02 649.02 594.42 594.42 594.42 594.42 594.42 669.97L1700 995.12 1127.23 1127.23 1127.23 1127.23 1127.23 1127.23 1127.23 1127.23 1117.78 1117.78 1117.78 1117.78 1117.78 995.12L1710 1164.91 1325.02 1325.02 1325.02 1325.02 1325.02 1325.02 1325.02 1325.02 1437.36 1437.36 1437.36 1437.36 1437.36 1164.91L1720 858.68 978.79 978.79 978.79 978.79 978.79 978.79 978.79 978.79 1066.30 1066.30 1066.30 1066.30 1066.30 858.68L1730 757.26 738.48 738.48 738.48 738.48 738.48 738.48 738.48 738.48 844.06 844.06 844.06 844.06 844.06 738.75L1750 170.94 128.21 128.21 128.21 128.21 128.21 128.21 128.21 128.21 128.21 128.21 128.21 128.21 128.21 128.21L1755 1061.92 1074.85 1074.85 1074.85 1074.85 1074.85 1074.85 1074.85 1074.85 1031.71 1031.71 1031.71 1031.71 1031.71 1031.71L1800 43.34 57.79 57.79 57.79 57.79 57.79 57.79 57.79 57.79 57.79 57.79 57.79 57.79 57.79 43.34L1810 69.99 84.83 84.83 84.83 84.83 84.83 84.83 84.83 84.83 69.70 69.70 69.70 69.70 69.70 65.79L1815 63.13 77.75 77.75 77.75 77.75 77.75 77.75 77.75 77.75 65.39 65.39 65.39 65.39 65.39 63.13L1820 95.89 84.49 84.49 84.49 84.49 84.49 84.49 84.49 84.49 93.77 93.77 93.77 93.77 93.77 92.40L1825 35.83 37.66 37.66 37.66 37.66 37.66 37.66 37.66 37.66 47.77 47.77 47.77 47.77 47.77 35.83L1830 67.57 70.68 70.68 70.68 70.68 70.68 70.68 70.68 70.68 57.01 57.01 57.01 57.01 57.01 60.19

L1832 528.24 528.24 528.24 528.24 528.24 528.24 528.24 528.24 528.24 396.18 396.18 396.18 396.18 396.18 396.18L1834 572.70 621.46 621.46 621.46 621.46 621.46 621.46 621.46 621.46 505.85 505.85 505.85 505.85 505.85 534.34L1840 674.32 653.24 653.24 653.24 653.24 653.24 653.24 653.24 653.24 736.23 736.23 736.23 736.23 736.23 599.17L1844 1065.46 1089.40 1089.40 1089.40 1089.40 1089.40 1089.40 1089.40 1089.40 1087.49 1087.49 1087.49 1087.49 1087.49 1169.69L1845 669.44 656.31 656.31 656.31 656.31 656.31 656.31 656.31 656.31 610.36 610.36 610.36 610.36 610.36 550.11L1846 889.18 822.58 822.58 822.58 822.58 822.58 822.58 822.58 822.58 753.77 753.77 753.77 753.77 753.77 691.85L1850 205.98 187.57 187.57 187.57 187.57 187.57 187.57 187.57 187.57 216.89 216.89 216.89 216.89 216.89 213.61L1855 954.77 802.62 802.62 802.62 802.62 802.62 802.62 802.62 802.62 716.08 716.08 716.08 716.08 716.08 716.08L1858 854.73 882.10 882.10 882.10 882.10 882.10 882.10 882.10 882.10 829.03 829.03 829.03 829.03 829.03 862.56L1860 851.68 727.50 727.50 727.50 727.50 727.50 727.50 727.50 727.50 712.66 712.66 712.66 712.66 712.66 699.25L1870 840.45 747.65 747.65 747.65 747.65 747.65 747.65 747.65 747.65 729.33 729.33 729.33 729.33 729.33 681.96L1880 544.07 461.23 461.23 461.23 461.23 461.23 461.23 461.23 461.23 499.98 499.98 499.98 499.98 499.98 466.15L1900 175.80 197.08 197.08 197.08 197.08 197.08 197.08 197.08 197.08 225.77 225.77 225.77 225.77 225.77 191.70L1902 68.08 53.52 53.52 53.52 53.52 53.52 53.52 53.52 53.52 69.36 69.36 69.36 69.36 69.36 52.02L1904 316.89 306.43 306.43 306.43 306.43 306.43 306.43 306.43 306.43 306.43 306.43 306.43 306.43 306.43 306.43L1906 79.15 89.54 89.54 89.54 89.54 89.54 89.54 89.54 89.54 78.37 78.37 78.37 78.37 78.37 104.50L1910 216.80 174.27 174.27 174.27 174.27 174.27 174.27 174.27 174.27 196.33 196.33 196.33 196.33 196.33 176.19L1920 243.70 227.81 227.81 227.81 227.81 227.81 227.81 227.81 227.81 235.88 235.88 235.88 235.88 235.88 286.53L1930 154.15 154.15 154.15 154.15 154.15 154.15 154.15 154.15 154.15 205.54 205.54 205.54 205.54 205.54 168.26L1940 409.07 348.37 348.37 348.37 348.37 348.37 348.37 348.37 348.37 329.97 329.97 329.97 329.97 329.97 322.26L1945 603.22 639.76 639.76 639.76 639.76 639.76 639.76 639.76 639.76 603.22 603.22 603.22 603.22 603.22 620.69L1950 647.16 485.37 485.37 485.37 485.37 485.37 485.37 485.37 485.37 487.03 487.03 487.03 487.03 487.03 525.14L1960 481.60 361.20 361.20 361.20 361.20 361.20 361.20 361.20 361.20 361.20 361.20 361.20 361.20 361.20 361.20L1970 614.99 534.23 534.23 534.23 534.23 534.23 534.23 534.23 534.23 463.68 463.68 463.68 463.68 463.68 487.14L1980 268.45 239.16 239.16 239.16 239.16 239.16 239.16 239.16 239.16 249.99 249.99 249.99 249.99 249.99 257.86L1990 346.41 307.28 307.28 307.28 307.28 307.28 307.28 307.28 307.28 290.48 290.48 290.48 290.48 290.48 290.48L2000 745.31 660.95 660.95 660.95 660.95 660.95 660.95 660.95 660.95 660.95 660.95 660.95 660.95 660.95 684.80L2010 803.35 602.51 602.51 602.51 602.51 602.51 602.51 602.51 602.51 645.46 645.46 645.46 645.46 645.46 704.97L2020 826.65 760.89 760.89 760.89 760.89 760.89 760.89 760.89 760.89 760.89 760.89 760.89 760.89 760.89 760.89L2030 847.60 660.14 660.14 660.14 660.14 660.14 660.14 660.14 660.14 667.41 667.41 667.41 667.41 667.41 660.14L2036 1612.01 1209.01 1209.01 1209.01 1209.01 1209.01 1209.01 1209.01 1209.01 1270.40 1270.40 1270.40 1270.40 1270.40 1327.15L2037 1426.36 1114.18 1114.18 1114.18 1114.18 1114.18 1114.18 1114.18 1114.18 1085.37 1085.37 1085.37 1085.37 1085.37 1085.37L2038 1223.93 931.67 931.67 931.67 931.67 931.67 931.67 931.67 931.67 931.67 931.67 931.67 931.67 931.67 931.67L2040 115.70 119.00 119.00 119.00 119.00 119.00 119.00 119.00 119.00 115.70 115.70 115.70 115.70 115.70 150.34L2050 318.23 316.93 316.93 316.93 316.93 316.93 316.93 316.93 316.93 368.21 368.21 368.21 368.21 368.21 343.46L2060 400.56 406.77 406.77 406.77 406.77 406.77 406.77 406.77 406.77 426.02 426.02 426.02 426.02 426.02 385.68L2070 88.20 116.84 116.84 116.84 116.84 116.84 116.84 116.84 116.84 88.29 88.29 88.29 88.29 88.29 87.63L2080 248.69 249.17 249.17 249.17 249.17 249.17 249.17 249.17 249.17 250.44 250.44 250.44 250.44 250.44 234.38L2090 285.74 307.16 307.16 307.16 307.16 307.16 307.16 307.16 307.16 303.51 303.51 303.51 303.51 303.51 317.67L2102 380.81 303.15 303.15 303.15 303.15 303.15 303.15 303.15 303.15 379.27 379.27 379.27 379.27 379.27 307.60L2104 387.68 321.63 321.63 321.63 321.63 321.63 321.63 321.63 321.63 427.58 427.58 427.58 427.58 427.58 321.63L2106 568.47 443.06 443.06 443.06 443.06 443.06 443.06 443.06 443.06 545.29 545.29 545.29 545.29 545.29 443.06L2108 844.99 696.25 696.25 696.25 696.25 696.25 696.25 696.25 696.25 757.57 757.57 757.57 757.57 757.57 792.85L2112 386.16 330.59 330.59 330.59 330.59 330.59 330.59 330.59 330.59 369.10 369.10 369.10 369.10 369.10 304.03L2114 503.91 378.23 378.23 378.23 378.23 378.23 378.23 378.23 378.23 427.29 427.29 427.29 427.29 427.29 381.34L2116 554.39 498.34 498.34 498.34 498.34 498.34 498.34 498.34 498.34 511.91 511.91 511.91 511.91 511.91 463.91L2122 642.82 534.45 534.45 534.45 534.45 534.45 534.45 534.45 534.45 690.84 690.84 690.84 690.84 690.84 534.45L2124 717.69 663.48 663.48 663.48 663.48 663.48 663.48 663.48 663.48 742.52 742.52 742.52 742.52 742.52 638.35L2126 1040.42 886.66 886.66 886.66 886.66 886.66 886.66 886.66 886.66 780.32 780.32 780.32 780.32 780.32 876.26L2128 1346.18 1117.39 1117.39 1117.39 1117.39 1117.39 1117.39 1117.39 1117.39 1117.39 1117.39 1117.39 1117.39 1117.39 1117.39L2132 700.88 525.66 525.66 525.66 525.66 525.66 525.66 525.66 525.66 593.01 593.01 593.01 593.01 593.01 679.69L2134 840.34 630.25 630.25 630.25 630.25 630.25 630.25 630.25 630.25 741.70 741.70 741.70 741.70 741.70 630.25L2136 1027.50 770.63 770.63 770.63 770.63 770.63 770.63 770.63 770.63 839.72 839.72 839.72 839.72 839.72 866.18L2180 76.31 76.31 76.31 76.31 76.31 76.31 76.31 76.31 76.31 101.75 101.75 101.75 101.75 101.75 99.38L2182 59.72 59.72 59.72 59.72 59.72 59.72 59.72 59.72 59.72 74.75 74.75 74.75 74.75 74.75 63.59L2184 80.72 107.63 107.63 107.63 107.63 107.63 107.63 107.63 107.63 97.13 97.13 97.13 97.13 97.13 88.43L2186 107.87 119.26 119.26 119.26 119.26 119.26 119.26 119.26 119.26 98.10 98.10 98.10 98.10 98.10 117.47L2188 260.22 260.22 260.22 260.22 260.22 260.22 260.22 260.22 260.22 228.28 228.28 228.28 228.28 228.28 195.17L2190 61.28 67.58 67.58 67.58 67.58 67.58 67.58 67.58 67.58 65.25 65.25 65.25 65.25 65.25 58.92L2192 296.52 232.35 232.35 232.35 232.35 232.35 232.35 232.35 232.35 257.01 257.01 257.01 257.01 257.01 232.35L2200 32.10 30.98 30.98 30.98 30.98 30.98 30.98 30.98 30.98 41.30 41.30 41.30 41.30 41.30 41.30L2210 47.86 50.28 50.28 50.28 50.28 50.28 50.28 50.28 50.28 43.80 43.80 43.80 43.80 43.80 58.40L2220 60.53 57.73 57.73 57.73 57.73 57.73 57.73 57.73 57.73 56.93 56.93 56.93 56.93 56.93 69.15L2230 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 52.61 52.61 52.61 52.61 52.61 54.54L2240 54.50 54.50 54.50 54.50 54.50 54.50 54.50 54.50 54.50 54.50 54.50 54.50 54.50 54.50 54.50L2250 231.55 231.55 231.55 231.55 231.55 231.55 231.55 231.55 231.55 231.55 231.55 231.55 231.55 231.55 274.12L2260 174.17 130.63 130.63 130.63 130.63 130.63 130.63 130.63 130.63 134.80 134.80 134.80 134.80 134.80 149.38



L2265 76.73 76.73 76.73 76.73 76.73 76.73 76.73 76.73 76.73 102.31 102.31 102.31 102.31 102.31 76.73 L2270 35.79 35.00 35.00 35.00 35.00 35.00 35.00 35.00 35.00 35.00 35.00 35.00 35.00 35.00 38.43 L2275 82.14 85.15 85.15 85.15 85.15 85.15 85.15 85.15 85.15 85.14 85.14 85.14 85.14 85.14 97.07 L2280 340.21 316.34 316.34 316.34 316.34 316.34 316.34 316.34 316.34 295.07 295.07 295.07 295.07 295.07 295.07L2300 233.93 178.56 178.56 178.56 178.56 178.56 178.56 178.56 178.56 233.93 233.93 233.93 233.93 233.93 175.45L2310 80.16 80.16 80.16 80.16 80.16 80.16 80.16 80.16 80.16 106.88 106.88 106.88 106.88 106.88 87.01L2320 160.46 134.07 134.07 134.07 134.07 134.07 134.07 134.07 134.07 146.27 146.27 146.27 146.27 146.27 171.10L2330 341.16 255.87 255.87 255.87 255.87 255.87 255.87 255.87 255.87 271.18 271.18 271.18 271.18 271.18 282.03L2335 148.03 150.52 150.52 150.52 150.52 150.52 150.52 150.52 150.52 148.03 148.03 148.03 148.03 148.03 155.34L2340 316.54 355.20 355.20 355.20 355.20 355.20 355.20 355.20 355.20 361.15 361.15 361.15 361.15 361.15 291.24L2350 771.70 580.64 580.64 580.64 580.64 580.64 580.64 580.64 580.64 618.74 618.74 618.74 618.74 618.74 678.19L2360 44.96 33.72 33.72 33.72 33.72 33.72 33.72 33.72 33.72 44.96 44.96 44.96 44.96 44.96 37.48L2370 223.04 167.28 167.28 167.28 167.28 167.28 167.28 167.28 167.28 191.23 191.23 191.23 191.23 191.23 167.28L2375 73.63 73.63 73.63 73.63 73.63 73.63 73.63 73.63 73.63 98.17 98.17 98.17 98.17 98.17 73.63L2380 80.23 80.23 80.23 80.23 80.23 80.23 80.23 80.23 80.23 106.97 106.97 106.97 106.97 106.97 106.97L2385 87.28 87.28 87.28 87.28 87.28 87.28 87.28 87.28 87.28 112.68 112.68 112.68 112.68 112.68 116.38L2390 76.04 71.33 71.33 71.33 71.33 71.33 71.33 71.33 71.33 71.33 71.33 71.33 71.33 71.33 95.11L2395 101.95 108.91 108.91 108.91 108.91 108.91 108.91 108.91 108.91 135.94 135.94 135.94 135.94 135.94 121.15L2397 76.92 76.38 76.38 76.38 76.38 76.38 76.38 76.38 76.38 76.38 76.38 76.38 76.38 76.38 83.92L2405 36.77 34.78 34.78 34.78 34.78 34.78 34.78 34.78 34.78 38.36 38.36 38.36 38.36 38.36 44.22L2415 119.67 159.56 159.56 159.56 159.56 159.56 159.56 159.56 159.56 122.77 122.77 122.77 122.77 122.77 123.88L2425 142.43 118.65 118.65 118.65 118.65 118.65 118.65 118.65 118.65 119.46 119.46 119.46 119.46 119.46 141.79L2435 107.85 118.46 118.46 118.46 118.46 118.46 118.46 118.46 118.46 107.85 107.85 107.85 107.85 107.85 107.85L2492 75.71 66.45 66.45 66.45 66.45 66.45 66.45 66.45 66.45 74.18 74.18 74.18 74.18 74.18 83.20L2500 205.58 205.58 205.58 205.58 205.58 205.58 205.58 205.58 205.58 239.72 239.72 239.72 239.72 239.72 205.58L2510 550.95 550.40 550.40 550.40 550.40 550.40 550.40 550.40 550.40 543.71 543.71 543.71 543.71 543.71 473.34L2520 369.87 300.20 300.20 300.20 300.20 300.20 300.20 300.20 300.20 343.24 343.24 343.24 343.24 343.24 321.28L2525 914.26 1029.93 1029.93 1029.93 1029.93 1029.93 1029.93 1029.93 1029.93 794.35 794.35 794.35 794.35 794.35 893.13L2526 446.34 555.12 555.12 555.12 555.12 555.12 555.12 555.12 555.12 446.34 446.34 446.34 446.34 446.34 578.15L2530 199.52 153.11 153.11 153.11 153.11 153.11 153.11 153.11 153.11 154.37 154.37 154.37 154.37 154.37 204.14L2540 281.45 275.50 275.50 275.50 275.50 275.50 275.50 275.50 275.50 293.05 293.05 293.05 293.05 293.05 312.71L2550 227.44 187.15 187.15 187.15 187.15 187.15 187.15 187.15 187.15 187.15 187.15 187.15 187.15 187.15 249.53L2570 310.38 413.84 413.84 413.84 413.84 413.84 413.84 413.84 413.84 413.84 413.84 413.84 413.84 413.84 310.38L2580 346.99 392.30 392.30 392.30 392.30 392.30 392.30 392.30 392.30 302.43 302.43 302.43 302.43 302.43 395.56L2600 133.83 133.83 133.83 133.83 133.83 133.83 133.83 133.83 133.83 178.44 178.44 178.44 178.44 178.44 145.32L2610 184.67 158.25 158.25 158.25 158.25 158.25 158.25 158.25 158.25 211.00 211.00 211.00 211.00 211.00 165.67L2620 232.31 174.23 174.23 174.23 174.23 174.23 174.23 174.23 174.23 203.87 203.87 203.87 203.87 203.87 174.23

L2622 199.83 199.83 199.83 199.83 199.83 199.83 199.83 199.83 199.83 266.44 266.44 266.44 266.44 266.44 199.83L2624 231.06 271.67 271.67 271.67 271.67 271.67 271.67 271.67 271.67 231.71 231.71 231.71 231.71 231.71 215.78L2627 1359.10 1119.23 1119.23 1119.23 1119.23 1119.23 1119.23 1119.23 1119.23 1117.10 1117.10 1117.10 1117.10 1117.10 1489.46L2628 1403.29 1314.77 1314.77 1314.77 1314.77 1314.77 1314.77 1314.77 1314.77 1091.75 1091.75 1091.75 1091.75 1091.75 1455.67L2630 196.53 161.36 161.36 161.36 161.36 161.36 161.36 161.36 161.36 190.81 190.81 190.81 190.81 190.81 215.15L2640 291.98 218.99 218.99 218.99 218.99 218.99 218.99 218.99 218.99 250.84 250.84 250.84 250.84 250.84 218.99L2650 80.28 78.20 78.20 78.20 78.20 78.20 78.20 78.20 78.20 94.20 94.20 94.20 94.20 94.20 78.20L2660 121.46 121.46 121.46 121.46 121.46 121.46 121.46 121.46 121.46 146.70 146.70 146.70 146.70 146.70 161.94L2670 137.29 111.16 111.16 111.16 111.16 111.16 111.16 111.16 111.16 148.21 148.21 148.21 148.21 148.21 148.21L2680 127.62 101.97 101.97 101.97 101.97 101.97 101.97 101.97 101.97 135.96 135.96 135.96 135.96 135.96 135.96L2750 64.10 54.47 54.47 54.47 54.47 54.47 54.47 54.47 54.47 71.61 71.61 71.61 71.61 71.61 54.47L2760 48.70 39.59 39.59 39.59 39.59 39.59 39.59 39.59 39.59 52.79 52.79 52.79 52.79 52.79 52.79L2770 47.42 40.23 40.23 40.23 40.23 40.23 40.23 40.23 40.23 53.64 53.64 53.64 53.64 53.64 53.64L2780 53.10 46.83 46.83 46.83 46.83 46.83 46.83 46.83 46.83 44.10 44.10 44.10 44.10 44.10 44.10L2785 24.31 27.54 27.54 27.54 27.54 27.54 27.54 27.54 27.54 20.66 20.66 20.66 20.66 20.66 20.66L2795 62.22 55.37 55.37 55.37 55.37 55.37 55.37 55.37 55.37 63.81 63.81 63.81 63.81 63.81 55.37

L2800 69.51 69.51 69.51 69.51 69.51 69.51 69.51 69.51 69.51 69.51 69.51 69.51 69.51 69.51 76.22L2810 50.90 50.90 50.90 50.90 50.90 50.90 50.90 50.90 50.90 56.66 56.66 56.66 56.66 56.66 50.90L2820 65.00 56.59 56.59 56.59 56.59 56.59 56.59 56.59 56.59 56.59 56.59 56.59 56.59 56.59 75.46L2830 75.40 63.63 63.63 63.63 63.63 63.63 63.63 63.63 63.63 61.22 61.22 61.22 61.22 61.22 81.62L2840 33.69 35.51 35.51 35.51 35.51 35.51 35.51 35.51 35.51 37.97 37.97 37.97 37.97 37.97 28.48L2850 43.32 40.35 40.35 40.35 40.35 40.35 40.35 40.35 40.35 43.42 43.42 43.42 43.42 43.42 51.82L3215 84.37 76.64 76.64 76.64 76.64 76.64 76.64 76.64 76.64 76.64 76.64 76.64 76.64 76.64 79.68L3219 94.77 88.16 88.16 88.16 88.16 88.16 88.16 88.16 88.16 89.83 89.83 89.83 89.83 89.83 106.34L3650 43.45 38.17 38.17 38.17 38.17 38.17 38.17 38.17 38.17 41.44 41.44 41.44 41.44 41.44 37.82L3660 67.09 65.54 65.54 65.54 65.54 65.54 65.54 65.54 65.54 65.54 65.54 65.54 65.54 65.54 85.53L3670 85.49 91.35 91.35 91.35 91.35 91.35 91.35 91.35 91.35 74.86 74.86 74.86 74.86 74.86 72.11L3700 51.51 44.51 44.51 44.51 44.51 44.51 44.51 44.51 44.51 59.35 59.35 59.35 59.35 59.35 44.51L3710 82.28 92.45 92.45 92.45 92.45 92.45 92.45 92.45 92.45 94.74 94.74 94.74 94.74 94.74 78.83L3720 556.10 461.27 461.27 461.27 461.27 461.27 461.27 461.27 461.27 483.82 483.82 483.82 483.82 483.82 417.08L3730 749.66 607.21 607.21 607.21 607.21 607.21 607.21 607.21 607.21 707.67 707.67 707.67 707.67 707.67 574.83L3740 840.74 682.39 682.39 682.39 682.39 682.39 682.39 682.39 682.39 908.66 908.66 908.66 908.66 908.66 681.50L3800 127.50 127.50 127.50 127.50 127.50 127.50 127.50 127.50 127.50 127.50 127.50 127.50 127.50 127.50 170.00L3805 270.73 204.01 204.01 204.01 204.01 204.01 204.01 204.01 204.01 235.78 235.78 235.78 235.78 235.78 240.99L3810 41.32 41.32 41.32 41.32 41.32 41.32 41.32 41.32 41.32 41.32 41.32 41.32 41.32 41.32 55.09L3815 39.62 38.37 38.37 38.37 38.37 38.37 38.37 38.37 38.37 45.47 45.47 45.47 45.47 45.47 51.16L3820 65.90 65.90 65.90 65.90 65.90 65.90 65.90 65.90 65.90 71.10 71.10 71.10 71.10 71.10 87.86L3825 42.76 46.78 46.78 46.78 46.78 46.78 46.78 46.78 46.78 52.12 52.12 52.12 52.12 52.12 55.11L3830 53.98 53.98 53.98 53.98 53.98 53.98 53.98 53.98 53.98 57.74 57.74 57.74 57.74 57.74 66.07L3835 58.52 58.52 58.52 58.52 58.52 58.52 58.52 58.52 58.52 73.01 73.01 73.01 73.01 73.01 65.56L3840 40.09 40.09 40.09 40.09 40.09 40.09 40.09 40.09 40.09 53.45 53.45 53.45 53.45 53.45 49.45L3845 51.77 51.77 51.77 51.77 51.77 51.77 51.77 51.77 51.77 55.58 55.58 55.58 55.58 55.58 68.43L3850 98.59 73.94 73.94 73.94 73.94 73.94 73.94 73.94 73.94 79.39 79.39 79.39 79.39 79.39 85.25L3855 74.54 79.92 79.92 79.92 79.92 79.92 79.92 79.92 79.92 89.61 89.61 89.61 89.61 89.61 93.89L3860 102.02 108.66 108.66 108.66 108.66 108.66 108.66 108.66 108.66 136.03 136.03 136.03 136.03 136.03 120.49L3900 825.10 996.18 996.18 996.18 996.18 996.18 996.18 996.18 996.18 833.51 833.51 833.51 833.51 833.51 825.10L3901 1133.71 1116.98 1116.98 1116.98 1116.98 1116.98 1116.98 1116.98 1116.98 1024.74 1024.74 1024.74 1024.74 1024.74 1312.95L3902 1553.27 1718.92 1718.92 1718.92 1718.92 1718.92 1718.92 1718.92 1718.92 1714.19 1714.19 1714.19 1714.19 1714.19 2041.61L3904 1867.37 2273.87 2273.87 2273.87 2273.87 2273.87 2273.87 2273.87 2273.87 1867.37 1867.37 1867.37 1867.37 1867.37 2489.82L3906 260.37 269.01 269.01 269.01 269.01 269.01 269.01 269.01 269.01 251.96 251.96 251.96 251.96 251.96 260.78L3907 380.24 362.04 362.04 362.04 362.04 362.04 362.04 362.04 362.04 323.92 323.92 323.92 323.92 323.92 323.92L3908 50.94 38.21 38.21 38.21 38.21 38.21 38.21 38.21 38.21 38.21 38.21 38.21 38.21 38.21 38.21L3910 260.17 282.25 282.25 282.25 282.25 282.25 282.25 282.25 282.25 255.58 255.58 255.58 255.58 255.58 282.48L3912 60.47 61.30 61.30 61.30 61.30 61.30 61.30 61.30 61.30 79.49 79.49 79.49 79.49 79.49 60.47L3914 72.65 61.73 61.73 61.73 61.73 61.73 61.73 61.73 61.73 54.66 54.66 54.66 54.66 54.66 54.66L3916 80.98 80.98 80.98 80.98 80.98 80.98 80.98 80.98 80.98 107.98 107.98 107.98 107.98 107.98 80.98L3918 49.98 54.76 54.76 54.76 54.76 54.76 54.76 54.76 54.76 57.85 57.85 57.85 57.85 57.85 49.98L3920 72.15 65.29 65.29 65.29 65.29 65.29 65.29 65.29 65.29 69.94 69.94 69.94 69.94 69.94 62.45



L3922 62.35 74.90 74.90 74.90 74.90 74.90 74.90 74.90 74.90 76.29 76.29 76.29 76.29 76.29 62.35L3924 68.00 80.05 80.05 80.05 80.05 80.05 80.05 80.05 80.05 78.01 78.01 78.01 78.01 78.01 68.00L3926 66.28 65.83 65.83 65.83 65.83 65.83 65.83 65.83 65.83 64.13 64.13 64.13 64.13 64.13 59.20L3928 44.48 38.87 38.87 38.87 38.87 38.87 38.87 38.87 38.87 43.70 43.70 43.70 43.70 43.70 37.12L3930 40.99 40.15 40.15 40.15 40.15 40.15 40.15 40.15 40.15 48.41 48.41 48.41 48.41 48.41 39.23L3932 29.97 34.82 34.82 34.82 34.82 34.82 34.82 34.82 34.82 37.14 37.14 37.14 37.14 37.14 29.97L3934 30.73 30.73 30.73 30.73 30.73 30.73 30.73 30.73 30.73 33.72 33.72 33.72 33.72 33.72 30.73L3936 57.58 56.80 56.80 56.80 56.80 56.80 56.80 56.80 56.80 59.23 59.23 59.23 59.23 59.23 56.80L3938 59.47 59.75 59.75 59.75 59.75 59.75 59.75 59.75 59.75 62.97 62.97 62.97 62.97 62.97 59.47L3940 68.55 68.55 68.55 68.55 68.55 68.55 68.55 68.55 68.55 72.70 72.70 72.70 72.70 72.70 68.55L3942 47.41 47.41 47.41 47.41 47.41 47.41 47.41 47.41 47.41 54.96 54.96 54.96 54.96 54.96 50.83L3944 62.62 78.08 78.08 78.08 78.08 78.08 78.08 78.08 78.08 68.56 68.56 68.56 68.56 68.56 62.62L3946 56.51 64.07 64.07 64.07 64.07 64.07 64.07 64.07 64.07 67.47 67.47 67.47 67.47 67.47 56.51L3948 41.09 42.90 42.90 42.90 42.90 42.90 42.90 42.90 42.90 35.14 35.14 35.14 35.14 35.14 35.14L3950 95.63 101.02 101.02 101.02 101.02 101.02 101.02 101.02 101.02 116.77 116.77 116.77 116.77 116.77 95.63L3952 106.13 111.94 111.94 111.94 111.94 111.94 111.94 111.94 111.94 126.72 126.72 126.72 126.72 126.72 106.13L3954 70.42 70.42 70.42 70.42 70.42 70.42 70.42 70.42 70.42 70.42 70.42 70.42 70.42 70.42 70.42L3960 480.70 525.62 525.62 525.62 525.62 525.62 525.62 525.62 525.62 571.40 571.40 571.40 571.40 571.40 468.63L3962 457.52 547.31 547.31 547.31 547.31 547.31 547.31 547.31 547.31 457.52 457.52 457.52 457.52 457.52 457.52L3963 1161.17 1384.54 1384.54 1384.54 1384.54 1384.54 1384.54 1384.54 1384.54 1063.83 1063.83 1063.83 1063.83 1063.83 1063.83L3964 585.99 603.36 603.36 603.36 603.36 603.36 603.36 603.36 603.36 483.94 483.94 483.94 483.94 483.94 483.94L3965 772.40 1029.86 1029.86 1029.86 1029.86 1029.86 1029.86 1029.86 1029.86 778.61 778.61 778.61 778.61 778.61 772.40L3966 719.39 624.21 624.21 624.21 624.21 624.21 624.21 624.21 624.21 613.07 613.07 613.07 613.07 613.07 613.07L3968 858.29 794.56 794.56 794.56 794.56 794.56 794.56 794.56 794.56 770.23 770.23 770.23 770.23 770.23 678.87L3969 508.56 660.89 660.89 660.89 660.89 660.89 660.89 660.89 660.89 514.90 514.90 514.90 514.90 514.90 495.67L3970 255.25 255.25 255.25 255.25 255.25 255.25 255.25 255.25 255.25 201.49 201.49 201.49 201.49 201.49 191.44L3972 185.46 178.22 178.22 178.22 178.22 178.22 178.22 178.22 178.22 180.55 180.55 180.55 180.55 180.55 178.22L3974 146.64 109.98 109.98 109.98 109.98 109.98 109.98 109.98 109.98 146.64 146.64 146.64 146.64 146.64 109.98

L3980 225.40 197.13 197.13 197.13 197.13 197.13 197.13 197.13 197.13 234.73 234.73 234.73 234.73 234.73 197.13L3982 317.40 243.56 243.56 243.56 243.56 243.56 243.56 243.56 243.56 264.89 264.89 264.89 264.89 264.89 243.74L3984 234.77 259.98 259.98 259.98 259.98 259.98 259.98 259.98 259.98 230.45 230.45 230.45 230.45 230.45 252.20L3985 496.93 385.82 385.82 385.82 385.82 385.82 385.82 385.82 385.82 372.70 372.70 372.70 372.70 372.70 372.70L3986 415.90 446.22 446.22 446.22 446.22 446.22 446.22 446.22 446.22 374.80 374.80 374.80 374.80 374.80 357.42L3995 27.80 21.83 21.83 21.83 21.83 21.83 21.83 21.83 21.83 27.20 27.20 27.20 27.20 27.20 20.85L4000 830.87 850.10 850.10 850.10 850.10 850.10 850.10 850.10 850.10 878.07 878.07 878.07 878.07 878.07 942.29L4010 515.70 478.37 478.37 478.37 478.37 478.37 478.37 478.37 478.37 448.75 448.75 448.75 448.75 448.75 474.07L4020 715.82 597.54 597.54 597.54 597.54 597.54 597.54 597.54 597.54 656.21 656.21 656.21 656.21 656.21 561.28L4030 438.67 329.00 329.00 329.00 329.00 329.00 329.00 329.00 329.00 429.16 429.16 429.16 429.16 429.16 329.00L4040 314.52 266.00 266.00 266.00 266.00 266.00 266.00 266.00 266.00 279.69 279.69 279.69 279.69 279.69 277.67L4045 213.76 213.76 213.76 213.76 213.76 213.76 213.76 213.76 213.76 213.76 213.76 213.76 213.76 213.76 257.29L4050 358.70 269.03 269.03 269.03 269.03 269.03 269.03 269.03 269.03 269.03 269.03 269.03 269.03 269.03 269.03L4055 174.20 174.20 174.20 174.20 174.20 174.20 174.20 174.20 174.20 177.45 177.45 177.45 177.45 177.45 174.20L4060 207.09 207.09 207.09 207.09 207.09 207.09 207.09 207.09 207.09 207.09 207.09 207.09 207.09 207.09 276.12L4070 183.39 197.59 197.59 197.59 197.59 197.59 197.59 197.59 197.59 230.86 230.86 230.86 230.86 230.86 183.39L4080 67.36 69.65 69.65 69.65 69.65 69.65 69.65 69.65 69.65 65.91 65.91 65.91 65.91 65.91 65.91L4090 70.04 61.65 61.65 61.65 61.65 61.65 61.65 61.65 61.65 74.45 74.45 74.45 74.45 74.45 58.84L4100 84.45 69.53 69.53 69.53 69.53 69.53 69.53 69.53 69.53 76.45 76.45 76.45 76.45 76.45 67.97L4110 72.84 55.26 55.26 55.26 55.26 55.26 55.26 55.26 55.26 61.16 61.16 61.16 61.16 61.16 56.00L4130 323.31 380.33 380.33 380.33 380.33 380.33 380.33 380.33 380.33 376.79 376.79 376.79 376.79 376.79 371.55L4310 316.77 265.95 265.95 265.95 265.95 265.95 265.95 265.95 265.95 274.43 274.43 274.43 274.43 274.43 354.60L4320 95.58 107.15 107.15 107.15 107.15 107.15 107.15 107.15 107.15 80.69 80.69 80.69 80.69 80.69 107.59L4350 58.25 68.51 68.51 68.51 68.51 68.51 68.51 68.51 68.51 59.89 59.89 59.89 59.89 59.89 58.25L4360 187.18 191.70 191.70 191.70 191.70 191.70 191.70 191.70 191.70 180.43 180.43 180.43 180.43 180.43 194.71L4370 123.02 123.02 123.02 123.02 123.02 123.02 123.02 123.02 123.02 123.02 123.02 123.02 123.02 123.02 134.94L4380 86.54 75.43 75.43 75.43 75.43 75.43 75.43 75.43 75.43 69.99 69.99 69.99 69.99 69.99 69.99L5000 350.77 367.40 367.40 367.40 367.40 367.40 367.40 367.40 367.40 467.69 467.69 467.69 467.69 467.69 350.77L5010 1072.92 887.36 887.36 887.36 887.36 887.36 887.36 887.36 887.36 1061.96 1061.96 1061.96 1061.96 1061.96 927.21L5020 1375.82 1506.96 1506.96 1506.96 1506.96 1506.96 1506.96 1506.96 1506.96 1595.35 1595.35 1595.35 1595.35 1595.35 1626.84L5050 1698.29 1666.97 1666.97 1666.97 1666.97 1666.97 1666.97 1666.97 1666.97 2008.30 2008.30 2008.30 2008.30 2008.30 1728.41L5060 2556.67 1917.50 1917.50 1917.50 1917.50 1917.50 1917.50 1917.50 1917.50 2269.26 2269.26 2269.26 2269.26 2269.26 2342.70L5100 1759.50 1670.65 1670.65 1670.65 1670.65 1670.65 1670.65 1670.65 1670.65 1973.47 1973.47 1973.47 1973.47 1973.47 1613.53L5105 2939.26 2411.77 2411.77 2411.77 2411.77 2411.77 2411.77 2411.77 2411.77 2411.77 2411.77 2411.77 2411.77 2411.77 2645.72L5150 2707.86 2437.97 2437.97 2437.97 2437.97 2437.97 2437.97 2437.97 2437.97 2874.78 2874.78 2874.78 2874.78 2874.78 2700.33L5160 2651.72 2651.72 2651.72 2651.72 2651.72 2651.72 2651.72 2651.72 2651.72 3024.59 3024.59 3024.59 3024.59 3024.59 2973.80L5200 2294.43 2539.39 2539.39 2539.39 2539.39 2539.39 2539.39 2539.39 2539.39 2628.62 2628.62 2628.62 2628.62 2628.62 2293.42L5210 2246.18 1684.64 1684.64 1684.64 1684.64 1684.64 1684.64 1684.64 1684.64 1942.96 1942.96 1942.96 1942.96 1942.96 1815.83L5220 2050.20 1914.89 1914.89 1914.89 1914.89 1914.89 1914.89 1914.89 1914.89 2440.95 2440.95 2440.95 2440.95 2440.95 2092.27L5230 2641.02 2641.02 2641.02 2641.02 2641.02 2641.02 2641.02 2641.02 2641.02 2893.23 2893.23 2893.23 2893.23 2893.23 3521.36L5250 3847.54 3602.12 3602.12 3602.12 3602.12 3602.12 3602.12 3602.12 3602.12 3916.87 3916.87 3916.87 3916.87 3916.87 4524.64L5270 3570.56 3586.15 3586.15 3586.15 3586.15 3586.15 3586.15 3586.15 3586.15 3721.83 3721.83 3721.83 3721.83 3721.83 4127.33L5280 3534.85 3558.66 3558.66 3558.66 3558.66 3558.66 3558.66 3558.66 3558.66 4051.42 4051.42 4051.42 4051.42 4051.42 4688.28L5300 1959.56 2281.79 2281.79 2281.79 2281.79 2281.79 2281.79 2281.79 2281.79 2286.75 2286.75 2286.75 2286.75 2286.75 2018.25L5310 3035.74 3385.35 3385.35 3385.35 3385.35 3385.35 3385.35 3385.35 3385.35 3207.26 3207.26 3207.26 3207.26 3207.26 3220.69L5320 2926.67 3433.01 3433.01 3433.01 3433.01 3433.01 3433.01 3433.01 3433.01 3336.06 3336.06 3336.06 3336.06 3336.06 2943.60L5330 4087.60 4386.43 4386.43 4386.43 4386.43 4386.43 4386.43 4386.43 4386.43 4880.66 4880.66 4880.66 4880.66 4880.66 4839.65L5340 4483.63 4531.06 4531.06 4531.06 4531.06 4531.06 4531.06 4531.06 4531.06 5055.83 5055.83 5055.83 5055.83 5055.83 5161.64L5400 835.55 945.45 945.45 945.45 945.45 945.45 945.45 945.45 945.45 990.12 990.12 990.12 990.12 990.12 852.02L5410 290.07 290.07 290.07 290.07 290.07 290.07 290.07 290.07 290.07 386.76 386.76 386.76 386.76 386.76 290.07L5420 1055.26 1158.62 1158.62 1158.62 1158.62 1158.62 1158.62 1158.62 1158.62 1267.95 1267.95 1267.95 1267.95 1267.95 1186.80L5430 465.80 349.35 349.35 349.35 349.35 349.35 349.35 349.35 349.35 465.80 465.80 465.80 465.80 465.80 349.35L5450 314.64 284.20 284.20 284.20 284.20 284.20 284.20 284.20 284.20 377.11 377.11 377.11 377.11 377.11 340.14L5460 378.55 378.65 378.65 378.65 378.65 378.65 378.65 378.65 378.65 504.73 504.73 504.73 504.73 504.73 398.38L5500 891.64 891.64 891.64 891.64 891.64 891.64 891.64 891.64 891.64 996.27 996.27 996.27 996.27 996.27 1174.58L5505 1207.51 1233.16 1233.16 1233.16 1233.16 1233.16 1233.16 1233.16 1233.16 1610.02 1610.02 1610.02 1610.02 1610.02 1367.24L5510 1010.73 1010.73 1010.73 1010.73 1010.73 1010.73 1010.73 1010.73 1010.73 1184.42 1184.42 1184.42 1184.42 1184.42 1170.30L5520 1219.73 998.35 998.35 998.35 998.35 998.35 998.35 998.35 998.35 1331.14 1331.14 1331.14 1331.14 1331.14 998.35L5530 1199.12 1199.12 1199.12 1199.12 1199.12 1199.12 1199.12 1199.12 1199.12 1375.68 1375.68 1375.68 1375.68 1375.68 1313.87L5535 1316.84 1177.30 1177.30 1177.30 1177.30 1177.30 1177.30 1177.30 1177.30 1378.36 1378.36 1378.36 1378.36 1378.36 1177.30L5540 1256.55 1256.55 1256.55 1256.55 1256.55 1256.55 1256.55 1256.55 1256.55 1477.87 1477.87 1477.87 1477.87 1477.87 1410.25L5560 1576.67 1349.32 1349.32 1349.32 1349.32 1349.32 1349.32 1349.32 1349.32 1777.37 1777.37 1777.37 1777.37 1777.37 1648.68L5570 1588.09 1402.81 1402.81 1402.81 1402.81 1402.81 1402.81 1402.81 1402.81 1754.85 1754.85 1754.85 1754.85 1754.85 1784.18L5580 1800.03 1637.69 1637.69 1637.69 1637.69 1637.69 1637.69 1637.69 1637.69 1959.43 1959.43 1959.43 1959.43 1959.43 2004.04L5585 1776.27 2015.45 2015.45 2015.45 2015.45 2015.45 2015.45 2015.45 2015.45 1965.87 1965.87 1965.87 1965.87 1965.87 2009.31



L5590 1852.05 1668.92 1668.92 1668.92 1668.92 1668.92 1668.92 1668.92 1668.92 1923.46 1923.46 1923.46 1923.46 1923.46 2131.42L5595 3085.92 2948.37 2948.37 2948.37 2948.37 2948.37 2948.37 2948.37 2948.37 2795.37 2795.37 2795.37 2795.37 2795.37 2795.37L5600 3413.87 3169.37 3169.37 3169.37 3169.37 3169.37 3169.37 3169.37 3169.37 3086.92 3086.92 3086.92 3086.92 3086.92 3086.92L5610 1437.35 1437.35 1437.35 1437.35 1437.35 1437.35 1437.35 1437.35 1437.35 1665.86 1665.86 1665.86 1665.86 1665.86 1861.39L5611 1118.55 1118.55 1118.55 1118.55 1118.55 1118.55 1118.55 1118.55 1118.55 1118.55 1118.55 1118.55 1118.55 1118.55 1491.40L5613 1701.38 1748.80 1748.80 1748.80 1748.80 1748.80 1748.80 1748.80 1748.80 1722.90 1722.90 1722.90 1722.90 1722.90 2132.94L5614 2883.95 2760.95 2760.95 2760.95 2760.95 2760.95 2760.95 2760.95 2760.95 2760.68 2760.68 2760.68 2760.68 2760.68 3028.67L5616 942.89 945.04 945.04 945.04 945.04 945.04 945.04 945.04 945.04 1257.18 1257.18 1257.18 1257.18 1257.18 1238.08L5618 205.77 207.82 207.82 207.82 207.82 207.82 207.82 207.82 207.82 209.72 209.72 209.72 209.72 209.72 195.25L5620 228.35 193.01 193.01 193.01 193.01 193.01 193.01 193.01 193.01 257.35 257.35 257.35 257.35 257.35 193.01L5622 335.58 251.69 251.69 251.69 251.69 251.69 251.69 251.69 251.69 335.58 335.58 335.58 335.58 335.58 251.69L5624 291.60 252.40 252.40 252.40 252.40 252.40 252.40 252.40 252.40 336.53 336.53 336.53 336.53 336.53 253.18L5626 331.00 331.00 331.00 331.00 331.00 331.00 331.00 331.00 331.00 369.57 369.57 369.57 369.57 369.57 331.00L5628 346.10 353.92 353.92 353.92 353.92 353.92 353.92 353.92 353.92 398.84 398.84 398.84 398.84 398.84 335.20L5629 294.18 220.64 220.64 220.64 220.64 220.64 220.64 220.64 220.64 294.18 294.18 294.18 294.18 294.18 220.64L5630 314.74 311.57 311.57 311.57 311.57 311.57 311.57 311.57 311.57 359.11 359.11 359.11 359.11 359.11 340.25L5631 406.72 305.04 305.04 305.04 305.04 305.04 305.04 305.04 305.04 406.72 406.72 406.72 406.72 406.72 305.04L5632 167.91 170.24 170.24 170.24 170.24 170.24 170.24 170.24 170.24 154.14 154.14 154.14 154.14 154.14 189.50L5634 247.57 211.18 211.18 211.18 211.18 211.18 211.18 211.18 211.18 211.18 211.18 211.18 211.18 211.18 281.57L5636 235.86 176.90 176.90 176.90 176.90 176.90 176.90 176.90 176.90 176.90 176.90 176.90 176.90 176.90 235.86L5637 255.88 200.56 200.56 200.56 200.56 200.56 200.56 200.56 200.56 267.41 267.41 267.41 267.41 267.41 200.56L5638 406.49 349.37 349.37 349.37 349.37 349.37 349.37 349.37 349.37 350.43 350.43 350.43 350.43 350.43 450.48L5639 991.60 778.37 778.37 778.37 778.37 778.37 778.37 778.37 778.37 778.37 778.37 778.37 778.37 778.37 1037.83L5640 591.89 443.92 443.92 443.92 443.92 443.92 443.92 443.92 443.92 443.92 443.92 443.92 443.92 443.92 591.89L5642 513.30 430.13 430.13 430.13 430.13 430.13 430.13 430.13 430.13 443.61 443.61 443.61 443.61 443.61 573.50L5643 1080.55 1080.55 1080.55 1080.55 1080.55 1080.55 1080.55 1080.55 1080.55 1162.15 1162.15 1162.15 1162.15 1162.15 1440.73L5644 410.05 410.05 410.05 410.05 410.05 410.05 410.05 410.05 410.05 489.17 489.17 489.17 489.17 489.17 546.73L5645 553.93 553.93 553.93 553.93 553.93 553.93 553.93 553.93 553.93 555.04 555.04 555.04 555.04 555.04 738.58

L5646 402.78 380.39 380.39 380.39 380.39 380.39 380.39 380.39 380.39 493.76 493.76 493.76 493.76 493.76 492.69L5647 578.06 552.24 552.24 552.24 552.24 552.24 552.24 552.24 552.24 552.24 552.24 552.24 552.24 552.24 674.27L5648 507.98 457.07 457.07 457.07 457.07 457.07 457.07 457.07 457.07 538.59 538.59 538.59 538.59 538.59 609.43L5649 1321.79 1656.21 1656.21 1656.21 1656.21 1656.21 1656.21 1656.21 1656.21 1686.81 1686.81 1686.81 1686.81 1686.81 1471.78L5650 451.88 338.91 338.91 338.91 338.91 338.91 338.91 338.91 338.91 397.70 397.70 397.70 397.70 397.70 451.88L5651 833.72 833.72 833.72 833.72 833.72 833.72 833.72 833.72 833.72 1111.63 1111.63 1111.63 1111.63 1111.63 1111.63L5652 302.68 302.68 302.68 302.68 302.68 302.68 302.68 302.68 302.68 353.13 353.13 353.13 353.13 353.13 403.57L5653 404.05 404.05 404.05 404.05 404.05 404.05 404.05 404.05 404.05 413.60 413.60 413.60 413.60 413.60 538.73L5654 243.84 230.24 230.24 230.24 230.24 230.24 230.24 230.24 230.24 273.67 273.67 273.67 273.67 273.67 231.47L5655 236.90 195.10 195.10 195.10 195.10 195.10 195.10 195.10 195.10 212.91 212.91 212.91 212.91 212.91 184.14L5656 336.56 261.75 261.75 261.75 261.75 261.75 261.75 261.75 261.75 263.88 263.88 263.88 263.88 263.88 265.76L5658 271.74 252.42 252.42 252.42 252.42 252.42 252.42 252.42 252.42 252.42 252.42 252.42 252.42 252.42 289.35L5660 400.24 422.50 422.50 422.50 422.50 422.50 422.50 422.50 422.50 450.75 450.75 450.75 450.75 450.75 406.66L5661 423.71 422.47 422.47 422.47 422.47 422.47 422.47 422.47 422.47 422.47 422.47 422.47 422.47 422.47 422.47L5662 367.01 392.73 392.73 392.73 392.73 392.73 392.73 392.73 392.73 399.08 399.08 399.08 399.08 399.08 412.29L5663 489.13 478.40 478.40 478.40 478.40 478.40 478.40 478.40 478.40 549.67 549.67 549.67 549.67 549.67 544.99L5664 489.13 460.91 460.91 460.91 460.91 460.91 460.91 460.91 460.91 476.20 476.20 476.20 476.20 476.20 487.29L5665 355.47 355.47 355.47 355.47 355.47 355.47 355.47 355.47 355.47 379.91 379.91 379.91 379.91 379.91 355.47L5666 54.59 48.60 48.60 48.60 48.60 48.60 48.60 48.60 48.60 64.80 64.80 64.80 64.80 64.80 48.60L5667 1136.29 1162.34 1162.34 1162.34 1162.34 1162.34 1162.34 1162.34 1162.34 1162.23 1162.23 1162.23 1162.23 1162.23 1309.05L5668 73.06 78.38 78.38 78.38 78.38 78.38 78.38 78.38 78.38 93.48 93.48 93.48 93.48 93.48 70.11L5669 871.32 775.08 775.08 775.08 775.08 775.08 775.08 775.08 775.08 775.08 775.08 775.08 775.08 775.08 846.79L5670 194.90 188.38 188.38 188.38 188.38 188.38 188.38 188.38 188.38 251.17 251.17 251.17 251.17 251.17 251.17L5672 207.02 207.02 207.02 207.02 207.02 207.02 207.02 207.02 207.02 207.02 207.02 207.02 207.02 207.02 276.02L5674 44.37 45.84 45.84 45.84 45.84 45.84 45.84 45.84 45.84 59.16 59.16 59.16 59.16 59.16 47.19L5675 60.15 66.50 66.50 66.50 66.50 66.50 66.50 66.50 66.50 80.20 80.20 80.20 80.20 80.20 60.54L5676 251.58 251.58 251.58 251.58 251.58 251.58 251.58 251.58 251.58 327.64 327.64 327.64 327.64 327.64 311.14L5677 342.30 342.30 342.30 342.30 342.30 342.30 342.30 342.30 342.30 456.40 456.40 456.40 456.40 456.40 342.30L5678 27.57 27.57 27.57 27.57 27.57 27.57 27.57 27.57 27.57 36.76 36.76 36.76 36.76 36.76 35.88L5680 270.61 230.09 230.09 230.09 230.09 230.09 230.09 230.09 230.09 226.60 226.60 226.60 226.60 226.60 257.98L5682 452.61 434.18 434.18 434.18 434.18 434.18 434.18 434.18 434.18 442.98 442.98 442.98 442.98 442.98 434.18L5684 34.31 33.41 33.41 33.41 33.41 33.41 33.41 33.41 33.41 37.36 37.36 37.36 37.36 37.36 34.07L5686 47.29 35.47 35.47 35.47 35.47 35.47 35.47 35.47 35.47 37.51 37.51 37.51 37.51 37.51 41.90L5688 56.53 42.40 42.40 42.40 42.40 42.40 42.40 42.40 42.40 53.32 53.32 53.32 53.32 53.32 42.40L5690 71.87 67.93 67.93 67.93 67.93 67.93 67.93 67.93 67.93 74.91 74.91 74.91 74.91 74.91 67.93L5692 92.25 92.25 92.25 92.25 92.25 92.25 92.25 92.25 92.25 123.00 123.00 123.00 123.00 123.00 95.47L5694 125.95 125.95 125.95 125.95 125.95 125.95 125.95 125.95 125.95 167.93 167.93 167.93 167.93 167.93 140.41L5695 131.68 116.27 116.27 116.27 116.27 116.27 116.27 116.27 116.27 150.96 150.96 150.96 150.96 150.96 137.63L5696 139.53 128.46 128.46 128.46 128.46 128.46 128.46 128.46 128.46 154.12 154.12 154.12 154.12 154.12 128.46L5697 55.74 55.74 55.74 55.74 55.74 55.74 55.74 55.74 55.74 55.74 55.74 55.74 55.74 55.74 60.72L5698 90.92 91.14 91.14 91.14 91.14 91.14 91.14 91.14 91.14 83.09 83.09 83.09 83.09 83.09 72.42L5699 132.05 164.17 164.17 164.17 164.17 164.17 164.17 164.17 164.17 129.45 129.45 129.45 129.45 129.45 129.45L5700 1936.63 1989.14 1989.14 1989.14 1989.14 1989.14 1989.14 1989.14 1989.14 1988.95 1988.95 1988.95 1988.95 1988.95 1970.00L5701 2402.56 2388.82 2388.82 2388.82 2388.82 2388.82 2388.82 2388.82 2388.82 2388.59 2388.59 2388.59 2388.59 2388.59 2629.37L5702 3028.06 3022.20 3022.20 3022.20 3022.20 3022.20 3022.20 3022.20 3022.20 3021.91 3021.91 3021.91 3021.91 3021.91 3624.05L5704 394.87 372.12 372.12 372.12 372.12 372.12 372.12 372.12 372.12 372.09 372.09 372.09 372.09 372.09 411.10L5705 723.93 664.90 664.90 664.90 664.90 664.90 664.90 664.90 664.90 664.84 664.84 664.84 664.84 664.84 698.03L5706 706.11 651.80 651.80 651.80 651.80 651.80 651.80 651.80 651.80 651.74 651.74 651.74 651.74 651.74 688.74L5707 948.66 859.30 859.30 859.30 859.30 859.30 859.30 859.30 859.30 859.23 859.23 859.23 859.23 859.23 950.26L5710 262.76 259.63 259.63 259.63 259.63 259.63 259.63 259.63 259.63 297.15 297.15 297.15 297.15 297.15 294.64L5711 394.52 362.86 362.86 362.86 362.86 362.86 362.86 362.86 362.86 376.38 376.38 376.38 376.38 376.38 362.50L5712 341.91 304.07 304.07 304.07 304.07 304.07 304.07 304.07 304.07 394.44 394.44 394.44 394.44 394.44 299.15L5714 301.21 312.31 312.31 312.31 312.31 312.31 312.31 312.31 312.31 333.25 333.25 333.25 333.25 333.25 352.36L5716 505.99 505.99 505.99 505.99 505.99 505.99 505.99 505.99 505.99 589.05 589.05 589.05 589.05 589.05 674.65L5718 632.43 632.43 632.43 632.43 632.43 632.43 632.43 632.43 632.43 649.86 649.86 649.86 649.86 649.86 843.24L5722 626.81 668.14 668.14 668.14 668.14 668.14 668.14 668.14 668.14 631.75 631.75 631.75 631.75 631.75 697.32L5724 1305.12 1047.90 1047.90 1047.90 1047.90 1047.90 1047.90 1047.90 1047.90 1397.20 1397.20 1397.20 1397.20 1397.20 1095.25L5726 1207.68 1207.68 1207.68 1207.68 1207.68 1207.68 1207.68 1207.68 1207.68 1610.24 1610.24 1610.24 1610.24 1610.24 1207.68L5728 1838.05 1651.95 1651.95 1651.95 1651.95 1651.95 1651.95 1651.95 1651.95 1720.35 1720.35 1720.35 1720.35 1720.35 1988.50L5780 794.84 794.84 794.84 794.84 794.84 794.84 794.84 794.84 794.84 915.80 915.80 915.80 915.80 915.80 797.90L5785 360.69 446.80 446.80 446.80 446.80 446.80 446.80 446.80 446.80 402.16 402.16 402.16 402.16 402.16 360.69L5790 499.18 499.18 499.18 499.18 499.18 499.18 499.18 499.18 499.18 665.57 665.57 665.57 665.57 665.57 499.18L5795 745.40 993.86 993.86 993.86 993.86 993.86 993.86 993.86 993.86 993.86 993.86 993.86 993.86 993.86 745.40L5810 349.24 338.00 338.00 338.00 338.00 338.00 338.00 338.00 338.00 373.19 373.19 373.19 373.19 373.19 375.26L5811 506.32 506.32 506.32 506.32 506.32 506.32 506.32 506.32 506.32 552.82 552.82 552.82 552.82 552.82 655.84L5812 392.45 392.45 392.45 392.45 392.45 392.45 392.45 392.45 392.45 418.32 418.32 418.32 418.32 418.32 482.78L5816 590.41 593.96 593.96 593.96 593.96 593.96 593.96 593.96 593.96 672.87 672.87 672.87 672.87 672.87 787.21



L5818 714.51 666.70 666.70 666.70 666.70 666.70 666.70 666.70 666.70 674.68 674.68 674.68 674.68 674.68 888.94L5822 1465.87 1182.22 1182.22 1182.22 1182.22 1182.22 1182.22 1182.22 1182.22 1182.22 1182.22 1182.22 1182.22 1182.22 1307.58L5824 1318.17 1064.66 1064.66 1064.66 1064.66 1064.66 1064.66 1064.66 1064.66 1268.27 1268.27 1268.27 1268.27 1268.27 1419.55L5828 2395.67 1960.50 1960.50 1960.50 1960.50 1960.50 1960.50 1960.50 1960.50 1960.50 1960.50 1960.50 1960.50 1960.50 2204.58

L5830 1413.73 1317.35 1317.35 1317.35 1317.35 1317.35 1317.35 1317.35 1317.35 1445.83 1445.83 1445.83 1445.83 1445.83 1317.35L5840 1577.60 1677.08 1677.08 1677.08 1677.08 1677.08 1677.08 1677.08 1677.08 1676.92 1676.92 1676.92 1676.92 1676.92 1964.19L5850 93.05 88.81 88.81 88.81 88.81 88.81 88.81 88.81 88.81 118.42 118.42 118.42 118.42 118.42 118.42L5855 214.41 238.65 238.65 238.65 238.65 238.65 238.65 238.65 238.65 238.62 238.62 238.62 238.62 238.62 284.23L5910 275.07 251.44 251.44 251.44 251.44 251.44 251.44 251.44 251.44 335.26 335.26 335.26 335.26 335.26 335.26L5920 368.35 368.35 368.35 368.35 368.35 368.35 368.35 368.35 368.35 491.14 491.14 491.14 491.14 491.14 487.77L5925 233.27 311.03 311.03 311.03 311.03 311.03 311.03 311.03 311.03 311.03 311.03 311.03 311.03 311.03 311.03L5940 378.30 348.23 348.23 348.23 348.23 348.23 348.23 348.23 348.23 464.30 464.30 464.30 464.30 464.30 464.30L5950 613.31 544.50 544.50 544.50 544.50 544.50 544.50 544.50 544.50 720.17 720.17 720.17 720.17 720.17 561.20L5960 888.46 669.28 669.28 669.28 669.28 669.28 669.28 669.28 669.28 892.37 892.37 892.37 892.37 892.37 669.28L5962 408.07 440.46 440.46 440.46 440.46 440.46 440.46 440.46 440.46 440.42 440.42 440.42 440.42 440.42 519.87L5964 707.76 650.18 650.18 650.18 650.18 650.18 650.18 650.18 650.18 650.18 650.18 650.18 650.18 650.18 734.66L5966 911.71 828.49 828.49 828.49 828.49 828.49 828.49 828.49 828.49 828.49 828.49 828.49 828.49 828.49 934.23L5970 140.99 140.99 140.99 140.99 140.99 140.99 140.99 140.99 140.99 158.01 158.01 158.01 158.01 158.01 157.63L5972 244.67 263.36 263.36 263.36 263.36 263.36 263.36 263.36 263.36 297.45 297.45 297.45 297.45 297.45 305.65L5974 161.78 161.78 161.78 161.78 161.78 161.78 161.78 161.78 161.78 184.01 184.01 184.01 184.01 184.01 164.04L5976 490.59 388.80 388.80 388.80 388.80 388.80 388.80 388.80 388.80 421.42 421.42 421.42 421.42 421.42 419.79L5978 202.60 202.60 202.60 202.60 202.60 202.60 202.60 202.60 202.60 236.27 236.27 236.27 236.27 236.27 202.60L5979 1584.09 1584.09 1584.09 1584.09 1584.09 1584.09 1584.09 1584.09 1584.09 1584.09 1584.09 1584.09 1584.09 1584.09 1917.52L5980 3380.15 2574.05 2574.05 2574.05 2574.05 2574.05 2574.05 2574.05 2574.05 2722.65 2722.65 2722.65 2722.65 2722.65 3432.06L5981 2154.36 2079.48 2079.48 2079.48 2079.48 2079.48 2079.48 2079.48 2079.48 2079.28 2079.28 2079.28 2079.28 2079.28 2242.78L5982 401.35 401.35 401.35 401.35 401.35 401.35 401.35 401.35 401.35 434.53 434.53 434.53 434.53 434.53 535.13L5984 395.50 395.50 395.50 395.50 395.50 395.50 395.50 395.50 395.50 466.76 466.76 466.76 466.76 466.76 418.77L5986 439.93 439.93 439.93 439.93 439.93 439.93 439.93 439.93 439.93 464.40 464.40 464.40 464.40 464.40 586.57L6000 943.43 922.43 922.43 922.43 922.43 922.43 922.43 922.43 922.43 1039.12 1039.12 1039.12 1039.12 1039.12 922.43L6010 1077.83 1026.52 1026.52 1026.52 1026.52 1026.52 1026.52 1026.52 1026.52 1045.46 1045.46 1045.46 1045.46 1045.46 1092.89

L6020 957.07 957.07 957.07 957.07 957.07 957.07 957.07 957.07 957.07 1039.92 1039.92 1039.92 1039.92 1039.92 972.93L6050 1538.57 1318.80 1318.80 1318.80 1318.80 1318.80 1318.80 1318.80 1318.80 1597.56 1597.56 1597.56 1597.56 1597.56 1419.20L6055 2005.00 1838.06 1838.06 1838.06 1838.06 1838.06 1838.06 1838.06 1838.06 1970.70 1970.70 1970.70 1970.70 1970.70 1964.87L6100 1781.53 1336.15 1336.15 1336.15 1336.15 1336.15 1336.15 1336.15 1336.15 1639.05 1639.05 1639.05 1639.05 1639.05 1404.76L6110 1889.62 1417.21 1417.21 1417.21 1417.21 1417.21 1417.21 1417.21 1417.21 1739.88 1739.88 1739.88 1739.88 1739.88 1449.77L6120 2052.79 1651.55 1651.55 1651.55 1651.55 1651.55 1651.55 1651.55 1651.55 1961.71 1961.71 1961.71 1961.71 1961.71 1820.22L6130 2221.61 1797.20 1797.20 1797.20 1797.20 1797.20 1797.20 1797.20 1797.20 1817.79 1817.79 1817.79 1817.79 1817.79 1963.82L6200 1893.95 1893.95 1893.95 1893.95 1893.95 1893.95 1893.95 1893.95 1893.95 2211.65 2211.65 2211.65 2211.65 2211.65 2116.91L6205 2842.34 2528.14 2528.14 2528.14 2528.14 2528.14 2528.14 2528.14 2528.14 2528.14 2528.14 2528.14 2528.14 2528.14 2592.74L6250 1964.69 1984.44 1984.44 1984.44 1984.44 1984.44 1984.44 1984.44 1984.44 2293.50 2293.50 2293.50 2293.50 2293.50 1884.80L6300 3139.34 2586.48 2586.48 2586.48 2586.48 2586.48 2586.48 2586.48 2586.48 2761.85 2761.85 2761.85 2761.85 2761.85 2763.70

L6310 2241.60 2233.31 2233.31 2233.31 2233.31 2233.31 2233.31 2233.31 2233.31 2217.52 2217.52 2217.52 2217.52 2217.52 2106.75L6320 1186.42 1220.01 1220.01 1220.01 1220.01 1220.01 1220.01 1220.01 1220.01 1334.09 1334.09 1334.09 1334.09 1334.09 1264.83L6350 3625.73 2719.30 2719.30 2719.30 2719.30 2719.30 2719.30 2719.30 2719.30 2719.30 2719.30 2719.30 2719.30 2719.30 3175.52L6360 2211.29 2445.58 2445.58 2445.58 2445.58 2445.58 2445.58 2445.58 2445.58 2211.29 2211.29 2211.29 2211.29 2211.29 2211.29L6370 1880.09 1463.37 1463.37 1463.37 1463.37 1463.37 1463.37 1463.37 1463.37 1541.67 1541.67 1541.67 1541.67 1541.67 1410.07L6380 961.24 847.97 847.97 847.97 847.97 847.97 847.97 847.97 847.97 911.33 911.33 911.33 911.33 911.33 808.41L6382 1370.59 1275.77 1275.77 1275.77 1275.77 1275.77 1275.77 1275.77 1275.77 1081.17 1081.17 1081.17 1081.17 1081.17 1098.78L6384 1764.86 1764.86 1764.86 1764.86 1764.86 1764.86 1764.86 1764.86 1764.86 1340.29 1340.29 1340.29 1340.29 1340.29 1523.68L6386 371.72 278.79 278.79 278.79 278.79 278.79 278.79 278.79 278.79 310.35 310.35 310.35 310.35 310.35 278.79L6388 305.21 305.21 305.21 305.21 305.21 305.21 305.21 305.21 305.21 346.85 346.85 346.85 346.85 346.85 351.00L6400 1874.95 1610.92 1610.92 1610.92 1610.92 1610.92 1610.92 1610.92 1610.92 1741.30 1741.30 1741.30 1741.30 1741.30 2147.89L6450 2154.01 2152.14 2152.14 2152.14 2152.14 2152.14 2152.14 2152.14 2152.14 2140.41 2140.41 2140.41 2140.41 2140.41 2853.88L6500 2219.65 2251.59 2251.59 2251.59 2251.59 2251.59 2251.59 2251.59 2251.59 2159.70 2159.70 2159.70 2159.70 2159.70 2806.47L6550 2647.32 2706.46 2706.46 2706.46 2706.46 2706.46 2706.46 2706.46 2706.46 2647.32 2647.32 2647.32 2647.32 2647.32 3510.32L6570 3235.78 3038.62 3038.62 3038.62 3038.62 3038.62 3038.62 3038.62 3038.62 3038.62 3038.62 3038.62 3038.62 3038.62 3652.44L6580 1087.89 1160.08 1160.08 1160.08 1160.08 1160.08 1160.08 1160.08 1160.08 1140.81 1140.81 1140.81 1140.81 1140.81 1305.94L6582 961.24 1050.71 1050.71 1050.71 1050.71 1050.71 1050.71 1050.71 1050.71 1057.99 1057.99 1057.99 1057.99 1057.99 1273.99L6584 1458.93 1647.80 1647.80 1647.80 1647.80 1647.80 1647.80 1647.80 1647.80 1545.58 1545.58 1545.58 1545.58 1545.58 1420.98L6586 1307.56 1542.07 1542.07 1542.07 1542.07 1542.07 1542.07 1542.07 1542.07 1520.68 1520.68 1520.68 1520.68 1520.68 1478.46L6588 2003.06 2026.24 2026.24 2026.24 2026.24 2026.24 2026.24 2026.24 2026.24 2093.61 2093.61 2093.61 2093.61 2093.61 1962.30L6590 1865.69 1924.63 1924.63 1924.63 1924.63 1924.63 1924.63 1924.63 1924.63 2053.24 2053.24 2053.24 2053.24 2053.24 1968.06L6600 173.63 130.22 130.22 130.22 130.22 130.22 130.22 130.22 130.22 173.63 173.63 173.63 173.63 173.63 130.22L6605 171.44 128.58 128.58 128.58 128.58 128.58 128.58 128.58 128.58 171.44 171.44 171.44 171.44 171.44 128.58L6610 115.59 123.49 123.49 123.49 123.49 123.49 123.49 123.49 123.49 140.41 140.41 140.41 140.41 140.41 117.67L6615 127.60 133.05 133.05 133.05 133.05 133.05 133.05 133.05 133.05 134.79 134.79 134.79 134.79 134.79 135.54L6616 52.50 49.30 49.30 49.30 49.30 49.30 49.30 49.30 49.30 57.29 57.29 57.29 57.29 57.29 45.03L6620 210.49 212.87 212.87 212.87 212.87 212.87 212.87 212.87 212.87 232.88 232.88 232.88 232.88 232.88 236.19L6623 445.33 593.77 593.77 593.77 593.77 593.77 593.77 593.77 593.77 467.63 467.63 467.63 467.63 467.63 445.33L6625 369.23 421.89 421.89 421.89 421.89 421.89 421.89 421.89 421.89 492.31 492.31 492.31 492.31 492.31 369.23L6628 332.58 332.58 332.58 332.58 332.58 332.58 332.58 332.58 332.58 358.38 358.38 358.38 358.38 358.38 443.44L6629 121.66 101.57 101.57 101.57 101.57 101.57 101.57 101.57 101.57 123.23 123.23 123.23 123.23 123.23 127.26L6630 149.63 149.63 149.63 149.63 149.63 149.63 149.63 149.63 149.63 199.50 199.50 199.50 199.50 199.50 149.63L6632 45.11 51.96 51.96 51.96 51.96 51.96 51.96 51.96 51.96 45.11 45.11 45.11 45.11 45.11 60.14L6635 140.28 122.27 122.27 122.27 122.27 122.27 122.27 122.27 122.27 153.59 153.59 153.59 153.59 153.59 143.82L6637 254.92 260.82 260.82 260.82 260.82 260.82 260.82 260.82 260.82 299.29 299.29 299.29 299.29 299.29 254.92L6640 259.30 231.71 231.71 231.71 231.71 231.71 231.71 231.71 231.71 250.43 250.43 250.43 250.43 250.43 203.63L6641 148.50 111.38 111.38 111.38 111.38 111.38 111.38 111.38 111.38 135.41 135.41 135.41 135.41 135.41 112.08L6642 201.28 150.96 150.96 150.96 150.96 150.96 150.96 150.96 150.96 161.23 161.23 161.23 161.23 161.23 150.96L6645 224.05 278.65 278.65 278.65 278.65 278.65 278.65 278.65 278.65 279.62 279.62 279.62 279.62 279.62 221.62L6650 269.14 289.32 289.32 289.32 289.32 289.32 289.32 289.32 289.32 293.60 293.60 293.60 293.60 293.60 234.99L6655 55.49 56.87 56.87 56.87 56.87 56.87 56.87 56.87 56.87 64.29 64.29 64.29 64.29 64.29 52.15L6660 63.72 63.72 63.72 63.72 63.72 63.72 63.72 63.72 63.72 71.66 71.66 71.66 71.66 71.66 65.27L6665 37.03 31.98 31.98 31.98 31.98 31.98 31.98 31.98 31.98 42.64 42.64 42.64 42.64 42.64 31.98L6670 41.04 35.35 35.35 35.35 35.35 35.35 35.35 35.35 35.35 44.39 44.39 44.39 44.39 44.39 33.29L6672 142.30 140.28 140.28 140.28 140.28 140.28 140.28 140.28 140.28 123.52 123.52 123.52 123.52 123.52 140.39L6675 94.36 83.37 83.37 83.37 83.37 83.37 83.37 83.37 83.37 86.60 86.60 86.60 86.60 86.60 83.37L6676 101.29 96.38 96.38 96.38 96.38 96.38 96.38 96.38 96.38 91.07 91.07 91.07 91.07 91.07 98.29L6680 203.00 161.07 161.07 161.07 161.07 161.07 161.07 161.07 161.07 214.76 214.76 214.76 214.76 214.76 170.60L6682 217.69 178.08 178.08 178.08 178.08 178.08 178.08 178.08 178.08 210.29 210.29 210.29 210.29 210.29 185.95L6684 309.03 241.99 241.99 241.99 241.99 241.99 241.99 241.99 241.99 241.99 241.99 241.99 241.99 241.99 264.34L6686 415.85 546.47 546.47 546.47 546.47 546.47 546.47 546.47 546.47 449.92 449.92 449.92 449.92 449.92 409.85L6687 407.54 400.45 400.45 400.45 400.45 400.45 400.45 400.45 400.45 400.45 400.45 400.45 400.45 400.45 533.93



L6688 378.43 398.04 398.04 398.04 398.04 398.04 398.04 398.04 398.04 473.30 473.30 473.30 473.30 473.30 367.77L6689 623.71 476.89 476.89 476.89 476.89 476.89 476.89 476.89 476.89 495.27 495.27 495.27 495.27 495.27 623.71L6690 536.48 519.67 519.67 519.67 519.67 519.67 519.67 519.67 519.67 537.38 537.38 537.38 537.38 537.38 477.37L6691 255.86 240.53 240.53 240.53 240.53 240.53 240.53 240.53 240.53 239.64 239.64 239.64 239.64 239.64 239.64L6692 393.79 388.24 388.24 388.24 388.24 388.24 388.24 388.24 388.24 493.96 493.96 493.96 493.96 493.96 485.76L6700 360.13 360.13 360.13 360.13 360.13 360.13 360.13 360.13 360.13 480.17 480.17 480.17 480.17 480.17 480.17L6705 211.43 211.43 211.43 211.43 211.43 211.43 211.43 211.43 211.43 271.20 271.20 271.20 271.20 271.20 252.28L6710 239.61 239.61 239.61 239.61 239.61 239.61 239.61 239.61 239.61 262.69 262.69 262.69 262.69 262.69 303.43L6715 238.01 238.01 238.01 238.01 238.01 238.01 238.01 238.01 238.01 278.44 278.44 278.44 278.44 278.44 317.34L6720 592.26 592.26 592.26 592.26 592.26 592.26 592.26 592.26 592.26 789.68 789.68 789.68 789.68 789.68 789.68L6725 286.74 286.74 286.74 286.74 286.74 286.74 286.74 286.74 286.74 353.68 353.68 353.68 353.68 353.68 370.03L6730 512.88 472.38 472.38 472.38 472.38 472.38 472.38 472.38 472.38 578.70 578.70 578.70 578.70 578.70 497.18L6735 206.87 206.87 206.87 206.87 206.87 206.87 206.87 206.87 206.87 233.55 233.55 233.55 233.55 233.55 269.55L6740 269.70 293.95 293.95 293.95 293.95 293.95 293.95 293.95 293.95 294.92 294.92 294.92 294.92 294.92 359.60L6745 246.77 258.06 258.06 258.06 258.06 258.06 258.06 258.06 258.06 277.33 277.33 277.33 277.33 277.33 329.03L6750 243.92 258.83 258.83 258.83 258.83 258.83 258.83 258.83 258.83 272.52 272.52 272.52 272.52 272.52 317.10L6755 243.23 259.49 259.49 259.49 259.49 259.49 259.49 259.49 259.49 279.15 279.15 279.15 279.15 279.15 306.46L6765 254.12 274.17 274.17 274.17 274.17 274.17 274.17 274.17 274.17 335.46 335.46 335.46 335.46 335.46 298.78L6770 244.97 260.11 260.11 260.11 260.11 260.11 260.11 260.11 260.11 286.77 286.77 286.77 286.77 286.77 309.83L6775 290.26 290.71 290.71 290.71 290.71 290.71 290.71 290.71 290.71 370.93 370.93 370.93 370.93 370.93 348.06L6780 310.27 325.27 325.27 325.27 325.27 325.27 325.27 325.27 325.27 347.69 347.69 347.69 347.69 347.69 361.79L6790 321.91 313.70 313.70 313.70 313.70 313.70 313.70 313.70 313.70 418.27 418.27 418.27 418.27 418.27 324.54L6795 859.20 875.71 875.71 875.71 875.71 875.71 875.71 875.71 875.71 994.79 994.79 994.79 994.79 994.79 882.69L6800 703.41 703.41 703.41 703.41 703.41 703.41 703.41 703.41 703.41 768.08 768.08 768.08 768.08 768.08 867.00L6805 277.26 236.21 236.21 236.21 236.21 236.21 236.21 236.21 236.21 295.43 295.43 295.43 295.43 295.43 247.21L6806 1061.13 914.84 914.84 914.84 914.84 914.84 914.84 914.84 914.84 1026.87 1026.87 1026.87 1026.87 1026.87 914.84L6807 805.80 781.17 781.17 781.17 781.17 781.17 781.17 781.17 781.17 781.17 781.17 781.17 781.17 781.17 871.95L6808 679.14 645.08 645.08 645.08 645.08 645.08 645.08 645.08 645.08 682.14 682.14 682.14 682.14 682.14 752.62L6809 343.46 274.18 274.18 274.18 274.18 274.18 274.18 274.18 274.18 297.33 297.33 297.33 297.33 297.33 338.02

L6810 129.49 133.89 133.89 133.89 133.89 133.89 133.89 133.89 133.89 172.66 172.66 172.66 172.66 172.66 152.84L6825 764.17 788.73 788.73 788.73 788.73 788.73 788.73 788.73 788.73 812.89 812.89 812.89 812.89 812.89 808.15L6830 940.13 940.13 940.13 940.13 940.13 940.13 940.13 940.13 940.13 1080.81 1080.81 1080.81 1080.81 1080.81 1253.51L6835 818.95 818.95 818.95 818.95 818.95 818.95 818.95 818.95 818.95 895.10 895.10 895.10 895.10 895.10 1080.04L6840 568.94 597.51 597.51 597.51 597.51 597.51 597.51 597.51 597.51 630.80 630.80 630.80 630.80 630.80 713.32

L6845 657.77 567.91 567.91 567.91 567.91 567.91 567.91 567.91 567.91 590.42 590.42 590.42 590.42 590.42 594.45L6850 478.33 515.21 515.21 515.21 515.21 515.21 515.21 515.21 515.21 488.17 488.17 488.17 488.17 488.17 541.07L6855 608.47 608.39 608.39 608.39 608.39 608.39 608.39 608.39 608.39 629.51 629.51 629.51 629.51 629.51 724.88L6860 477.25 463.08 463.08 463.08 463.08 463.08 463.08 463.08 463.08 511.29 511.29 511.29 511.29 511.29 615.22L6865 301.42 252.98 252.98 252.98 252.98 252.98 252.98 252.98 252.98 229.99 229.99 229.99 229.99 229.99 257.12L6867 744.00 676.35 676.35 676.35 676.35 676.35 676.35 676.35 676.35 766.06 766.06 766.06 766.06 766.06 666.97L6868 176.45 166.45 166.45 166.45 166.45 166.45 166.45 166.45 166.45 221.93 221.93 221.93 221.93 221.93 166.45L6870 184.98 165.02 165.02 165.02 165.02 165.02 165.02 165.02 165.02 165.93 165.93 165.93 165.93 165.93 200.76L6872 790.75 653.85 653.85 653.85 653.85 653.85 653.85 653.85 653.85 755.68 755.68 755.68 755.68 755.68 810.08L6873 343.55 324.77 324.77 324.77 324.77 324.77 324.77 324.77 324.77 433.02 433.02 433.02 433.02 433.02 324.77L6875 688.19 539.60 539.60 539.60 539.60 539.60 539.60 539.60 539.60 673.60 673.60 673.60 673.60 673.60 539.60L6880 466.76 350.07 350.07 350.07 350.07 350.07 350.07 350.07 350.07 463.31 463.31 463.31 463.31 463.31 407.19L6890 157.44 118.08 118.08 118.08 118.08 118.08 118.08 118.08 118.08 127.97 127.97 127.97 127.97 127.97 126.16L6895 387.66 434.39 434.39 434.39 434.39 434.39 434.39 434.39 434.39 387.66 387.66 387.66 387.66 387.66 396.22L6900 1232.25 1239.63 1239.63 1239.63 1239.63 1239.63 1239.63 1239.63 1239.63 1073.41 1073.41 1073.41 1073.41 1073.41 1048.63L6905 1217.57 1232.60 1232.60 1232.60 1232.60 1232.60 1232.60 1232.60 1232.60 1019.30 1019.30 1019.30 1019.30 1019.30 1019.30L6910 1265.98 1054.01 1054.01 1054.01 1054.01 1054.01 1054.01 1054.01 1054.01 1004.44 1004.44 1004.44 1004.44 1004.44 993.01L6915 434.61 531.40 531.40 531.40 531.40 531.40 531.40 531.40 531.40 434.61 434.61 434.61 434.61 434.61 434.61L6920 4633.19 4633.19 4633.19 4633.19 4633.19 4633.19 4633.19 4633.19 4633.19 5087.48 5087.48 5087.48 5087.48 5087.48 5632.00L6925 5348.95 6237.07 6237.07 6237.07 6237.07 6237.07 6237.07 6237.07 6237.07 5371.94 5371.94 5371.94 5371.94 5371.94 6074.31L6930 4661.92 4661.92 4661.92 4661.92 4661.92 4661.92 4661.92 4661.92 4661.92 5462.01 5462.01 5462.01 5462.01 5462.01 5917.51L6935 5449.09 6333.85 6333.85 6333.85 6333.85 6333.85 6333.85 6333.85 6333.85 6008.15 6008.15 6008.15 6008.15 6008.15 6353.17L6940 6457.48 6091.10 6091.10 6091.10 6091.10 6091.10 6091.10 6091.10 6091.10 6826.31 6826.31 6826.31 6826.31 6826.31 8121.47L6945 7239.90 7442.61 7442.61 7442.61 7442.61 7442.61 7442.61 7442.61 7442.61 7722.15 7722.15 7722.15 7722.15 7722.15 9448.39L6950 6923.39 6923.39 6923.39 6923.39 6923.39 6923.39 6923.39 6923.39 6923.39 7257.68 7257.68 7257.68 7257.68 7257.68 9231.19L6955 8291.71 8291.71 8291.71 8291.71 8291.71 8291.71 8291.71 8291.71 8291.71 9107.39 9107.39 9107.39 9107.39 9107.39 11055.61L6960 8362.81 9392.43 9392.43 9392.43 9392.43 9392.43 9392.43 9392.43 9392.43 8980.35 8980.35 8980.35 8980.35 8980.35 11150.41L6965 9839.24 10017.37 10017.37 10017.3710017.37 10017.3710017.37 10017.3710017.37 13118.9913118.9913118.99 13118.99 13118.9912080.86L6970 10125.49 10438.28 10438.28 10438.2810438.28 10438.2810438.28 10438.2810438.28 13334.5613334.5613334.56 13334.56 13334.5612230.01L6975 11094.32 11416.12 11416.12 11416.1211416.12 11416.1211416.12 11416.1211416.12 13406.1413406.1413406.14 13406.14 13406.1413103.22L7010 2535.62 2535.62 2535.62 2535.62 2535.62 2535.62 2535.62 2535.62 2535.62 3380.83 3380.83 3380.83 3380.83 3380.83 2535.62L7015 4101.78 4029.29 4029.29 4029.29 4029.29 4029.29 4029.29 4029.29 4029.29 5372.39 5372.39 5372.39 5372.39 5372.39 4078.00L7020 2616.06 2362.44 2362.44 2362.44 2362.44 2362.44 2362.44 2362.44 2362.44 3149.92 3149.92 3149.92 3149.92 3149.92 2424.28L7025 2734.11 2384.06 2384.06 2384.06 2384.06 2384.06 2384.06 2384.06 2384.06 3178.74 3178.74 3178.74 3178.74 3178.74 2384.06L7030 4336.22 3645.59 3645.59 3645.59 3645.59 3645.59 3645.59 3645.59 3645.59 4587.87 4587.87 4587.87 4587.87 4587.87 3995.59L7035 2580.32 2441.56 2441.56 2441.56 2441.56 2441.56 2441.56 2441.56 2441.56 3255.41 3255.41 3255.41 3255.41 3255.41 2505.70L7040 2118.20 1957.19 1957.19 1957.19 1957.19 1957.19 1957.19 1957.19 1957.19 2609.59 2609.59 2609.59 2609.59 2609.59 1957.19L7045 1122.13 1122.13 1122.13 1122.13 1122.13 1122.13 1122.13 1122.13 1122.13 1496.17 1496.17 1496.17 1496.17 1496.17 1122.13L7160 11290.02 10680.42 10680.42 10680.4210680.42 10680.4210680.42 10680.4210680.42 9946.09 9946.09 9946.09 9946.09 9946.09 10650.97L7165 12328.58 11056.28 11056.28 11056.2811056.28 11056.2811056.28 11056.2811056.28 11352.5111352.5111352.51 11352.51 11352.5112815.06L7170 4070.69 5166.67 5166.67 5166.67 5166.67 5166.67 5166.67 5166.67 5166.67 5427.59 5427.59 5427.59 5427.59 5427.59 4271.13L7180 24956.46 22678.90 22678.90 22678.9022678.90 22678.9022678.90 22678.9022678.90 28357.9428357.9428357.94 28357.94 28357.9424787.53L7185 4978.20 5102.17 5102.17 5102.17 5102.17 5102.17 5102.17 5102.17 5102.17 5496.17 5496.17 5496.17 5496.17 5496.17 4431.22L7186 7584.08 6140.96 6140.96 6140.96 6140.96 6140.96 6140.96 6140.96 6140.96 7932.31 7932.31 7932.31 7932.31 7932.31 8031.16L7190 6992.84 5359.03 5359.03 5359.03 5359.03 5359.03 5359.03 5359.03 5359.03 6992.84 6992.84 6992.84 6992.84 6992.84 5606.38L7191 7841.22 6416.94 6416.94 6416.94 6416.94 6416.94 6416.94 6416.94 6416.94 8431.81 8431.81 8431.81 8431.81 8431.81 8228.53L7260 1366.28 1366.28 1366.28 1366.28 1366.28 1366.28 1366.28 1366.28 1366.28 1821.71 1821.71 1821.71 1821.71 1821.71 1593.28L7261 2487.17 2487.17 2487.17 2487.17 2487.17 2487.17 2487.17 2487.17 2487.17 2915.68 2915.68 2915.68 2915.68 2915.68 3018.40L7266 687.36 916.48 916.48 916.48 916.48 916.48 916.48 916.48 916.48 713.28 713.28 713.28 713.28 713.28 687.36L7272 1545.15 1587.08 1587.08 1587.08 1587.08 1587.08 1587.08 1587.08 1587.08 1574.75 1574.75 1574.75 1574.75 1574.75 1543.58L7274 4358.53 3987.45 3987.45 3987.45 3987.45 3987.45 3987.45 3987.45 3987.45 4386.00 4386.00 4386.00 4386.00 4386.00 4606.44L7360 210.49 165.66 165.66 165.66 165.66 165.66 165.66 165.66 165.66 167.17 167.17 167.17 167.17 167.17 157.87L7362 194.00 173.93 173.93 173.93 173.93 173.93 173.93 173.93 173.93 201.05 201.05 201.05 201.05 201.05 231.91L7364 368.86 276.64 276.64 276.64 276.64 276.64 276.64 276.64 276.64 366.26 366.26 366.26 366.26 366.26 276.64L7366 496.86 372.65 372.65 372.65 372.65 372.65 372.65 372.65 372.65 496.86 496.86 496.86 496.86 496.86 372.65L8000 25.58 30.54 30.54 30.54 30.54 30.54 30.54 30.54 30.54 26.05 26.05 26.05 26.05 26.05 26.10L8010 45.12 43.43 43.43 43.43 43.43 43.43 43.43 43.43 43.43 42.13 42.13 42.13 42.13 42.13 56.15L8020 166.50 158.28 158.28 158.28 158.28 158.28 158.28 158.28 158.28 157.74 157.74 157.74 157.74 157.74 139.28L8030 224.53 228.95 228.95 228.95 228.95 228.95 228.95 228.95 228.95 231.58 231.58 231.58 231.58 231.58 247.13L8300 58.56 67.61 67.61 67.61 67.61 67.61 67.61 67.61 67.61 58.56 58.56 58.56 58.56 58.56 66.82L8310 122.59 103.96 103.96 103.96 103.96 103.96 103.96 103.96 103.96 92.46 92.46 92.46 92.46 92.46 107.78L8320 37.11 45.42 45.42 45.42 45.42 45.42 45.42 45.42 45.42 42.69 42.69 42.69 42.69 42.69 37.11L8330 34.27 45.00 45.00 45.00 45.00 45.00 45.00 45.00 45.00 45.70 45.70 45.70 45.70 45.70 34.27


HCPCS VI FL GA NC SC A KY MS TN AR LA OK TX NM CO

L8400 14.57 13.16 13.16 13.16 13.16 13.16 13.16 13.16 13.16 10.93 10.93 10.93 10.93 10.93 10.93L8410 17.64 14.97 14.97 14.97 14.97 14.97 14.97 14.97 14.97 15.99 15.99 15.99 15.99 15.99 15.21L8415 16.69 14.88 14.88 14.88 14.88 14.88 14.88 14.88 14.88 16.23 16.23 16.23 16.23 16.23 16.43L8420 15.63 17.40 17.40 17.40 17.40 17.40 17.40 17.40 17.40 14.45 14.45 14.45 14.45 14.45 13.51L8430 18.09 19.14 19.14 19.14 19.14 19.14 19.14 19.14 19.14 15.84 15.84 15.84 15.84 15.84 17.06L8435 15.26 17.17 17.17 17.17 17.17 17.17 17.17 17.17 17.17 16.74 16.74 16.74 16.74 16.74 14.60L8440 37.56 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 30.67 30.67 30.67 30.67 30.67 29.03L8460 46.27 50.65 50.65 50.65 50.65 50.65 50.65 50.65 50.65 53.36 53.36 53.36 53.36 53.36 46.27L8465 33.87 45.16 45.16 45.16 45.16 45.16 45.16 45.16 45.16 38.02 38.02 38.02 38.02 38.02 33.87L8470 4.64 4.64 4.64 4.64 4.64 4.64 4.64 4.64 4.64 5.57 5.57 5.57 5.57 5.57 6.18L8480 6.39 6.39 6.39 6.39 6.39 6.39 6.39 6.39 6.39 7.30 7.30 7.30 7.30 7.30 8.52L8485 7.77 7.72 7.72 7.72 7.72 7.72 7.72 7.72 7.72 7.72 7.72 7.72 7.72 7.72 9.24L8490 110.86 92.24 92.24 92.24 92.24 92.24 92.24 92.24 92.24 92.24 92.24 92.24 92.24 92.24 96.60L8500 527.60 458.16 458.16 458.16 458.16 458.16 458.16 458.16 458.16 539.73 539.73 539.73 539.73 539.73 458.16L8501 83.86 101.76 101.76 101.76 101.76 101.76 101.76 101.76 101.76 83.86 83.86 83.86 83.86 83.86 83.86Q0134 307.99 328.46 328.46 328.46 328.46 328.46 328.46 328.46 328.46 310.00 310.00 310.00 310.00 310.00 310.00V2020 43.52 55.97 55.97 55.97 55.97 55.97 55.97 55.97 55.97 46.74 46.74 46.74 46.74 46.74 51.00V2100 36.25 27.19 27.19 27.19 27.19 27.19 27.19 27.19 27.19 33.35 33.35 33.35 33.35 33.35 36.25V2101 38.21 28.66 28.66 28.66 28.66 28.66 28.66 28.66 28.66 38.21 38.21 38.21 38.21 38.21 38.21V2102 44.23 40.65 40.65 40.65 40.65 40.65 40.65 40.65 40.65 42.48 42.48 42.48 42.48 42.48 53.75V2103 31.49 23.62 23.62 23.62 23.62 23.62 23.62 23.62 23.62 25.26 25.26 25.26 25.26 25.26 29.23V2104 34.86 26.15 26.15 26.15 26.15 26.15 26.15 26.15 26.15 29.86 29.86 29.86 29.86 29.86 33.31V2105 37.96 32.02 32.02 32.02 32.02 32.02 32.02 32.02 32.02 29.26 29.26 29.26 29.26 29.26 28.47V2106 41.93 32.49 32.49 32.49 32.49 32.49 32.49 32.49 32.49 34.94 34.94 34.94 34.94 34.94 31.60V2107 40.06 34.15 34.15 34.15 34.15 34.15 34.15 34.15 34.15 37.68 37.68 37.68 37.68 37.68 32.41V2108 39.88 33.12 33.12 33.12 33.12 33.12 33.12 33.12 33.12 36.96 36.96 36.96 36.96 36.96 39.42V2109 44.36 38.07 38.07 38.07 38.07 38.07 38.07 38.07 38.07 35.45 35.45 35.45 35.45 35.45 34.43

V2110 45.29 44.44 44.44 44.44 44.44 44.44 44.44 44.44 44.44 34.04 34.04 34.04 34.04 34.04 33.97V2111 47.21 39.18 39.18 39.18 39.18 39.18 39.18 39.18 39.18 39.85 39.85 39.85 39.85 39.85 35.41V2112 51.53 38.65 38.65 38.65 38.65 38.65 38.65 38.65 38.65 51.53 51.53 51.53 51.53 51.53 38.65V2113 56.64 53.40 53.40 53.40 53.40 53.40 53.40 53.40 53.40 55.46 55.46 55.46 55.46 55.46 44.16V2114 62.92 47.23 47.23 47.23 47.23 47.23 47.23 47.23 47.23 62.92 62.92 62.92 62.92 62.92 57.93V2115 53.03 51.35 51.35 51.35 51.35 51.35 51.35 51.35 51.35 68.47 68.47 68.47 68.47 68.47 61.22V2116 50.20 46.03 46.03 46.03 46.03 46.03 46.03 46.03 46.03 46.70 46.70 46.70 46.70 46.70 45.65V2117 59.15 53.07 53.07 53.07 53.07 53.07 53.07 53.07 53.07 70.76 70.76 70.76 70.76 70.76 55.05V2118 58.17 50.90 50.90 50.90 50.90 50.90 50.90 50.90 50.90 50.90 50.90 50.90 50.90 50.90 50.90V2200 47.45 35.59 35.59 35.59 35.59 35.59 35.59 35.59 35.59 41.10 41.10 41.10 41.10 41.10 38.15V2201 51.39 38.79 38.79 38.79 38.79 38.79 38.79 38.79 38.79 43.29 43.29 43.29 43.29 43.29 44.74V2202 58.30 45.65 45.65 45.65 45.65 45.65 45.65 45.65 45.65 49.18 49.18 49.18 49.18 49.18 59.16V2203 47.88 35.91 35.91 35.91 35.91 35.91 35.91 35.91 35.91 40.36 40.36 40.36 40.36 40.36 38.07V2204 49.15 38.94 38.94 38.94 38.94 38.94 38.94 38.94 38.94 41.09 41.09 41.09 41.09 41.09 39.55V2205 53.58 42.73 42.73 42.73 42.73 42.73 42.73 42.73 42.73 42.87 42.87 42.87 42.87 42.87 46.10V2206 54.14 52.01 52.01 52.01 52.01 52.01 52.01 52.01 52.01 43.83 43.83 43.83 43.83 43.83 43.61V2207 49.83 43.42 43.42 43.42 43.42 43.42 43.42 43.42 43.42 40.83 40.83 40.83 40.83 40.83 44.44V2208 51.46 43.94 43.94 43.94 43.94 43.94 43.94 43.94 43.94 45.33 45.33 45.33 45.33 45.33 47.80V2209 52.31 48.34 48.34 48.34 48.34 48.34 48.34 48.34 48.34 44.82 44.82 44.82 44.82 44.82 48.43V2210 55.88 62.19 62.19 62.19 62.19 62.19 62.19 62.19 62.19 51.24 51.24 51.24 51.24 51.24 51.65V2211 58.05 53.03 53.03 53.03 53.03 53.03 53.03 53.03 53.03 51.27 51.27 51.27 51.27 51.27 68.36V2212 58.96 57.71 57.71 57.71 57.71 57.71 57.71 57.71 57.71 52.94 52.94 52.94 52.94 52.94 70.58V2213 61.17 59.17 59.17 59.17 59.17 59.17 59.17 59.17 59.17 56.57 56.57 56.57 56.57 56.57 71.30V2214 74.52 63.43 63.43 63.43 63.43 63.43 63.43 63.43 63.43 58.13 58.13 58.13 58.13 58.13 67.78V2215 69.27 68.64 68.64 68.64 68.64 68.64 68.64 68.64 68.64 66.29 66.29 66.29 66.29 66.29 60.38V2216 63.91 71.19 71.19 71.19 71.19 71.19 71.19 71.19 71.19 64.71 64.71 64.71 64.71 64.71 74.13V2217 68.76 65.48 65.48 65.48 65.48 65.48 65.48 65.48 65.48 71.64 71.64 71.64 71.64 71.64 60.40V2218 90.11 70.22 70.22 70.22 70.22 70.22 70.22 70.22 70.22 70.22 70.22 70.22 70.22 70.22 70.22V2219 38.78 30.92 30.92 30.92 30.92 30.92 30.92 30.92 30.92 35.71 35.71 35.71 35.71 35.71 41.22V2220 33.43 25.07 25.07 25.07 25.07 25.07 25.07 25.07 25.07 32.68 32.68 32.68 32.68 32.68 25.92V2300 58.54 46.22 46.22 46.22 46.22 46.22 46.22 46.22 46.22 53.68 53.68 53.68 53.68 53.68 50.18V2301 56.53 53.60 53.60 53.60 53.60 53.60 53.60 53.60 53.60 70.30 70.30 70.30 70.30 70.30 53.40V2302 57.34 58.74 58.74 58.74 58.74 58.74 58.74 58.74 58.74 70.63 70.63 70.63 70.63 70.63 56.93V2303 55.88 48.64 48.64 48.64 48.64 48.64 48.64 48.64 48.64 51.02 51.02 51.02 51.02 51.02 47.76V2304 60.26 50.91 50.91 50.91 50.91 50.91 50.91 50.91 50.91 49.81 49.81 49.81 49.81 49.81 51.21V2305 62.17 62.44 62.44 62.44 62.44 62.44 62.44 62.44 62.44 61.85 61.85 61.85 61.85 61.85 57.23V2306 63.80 58.22 58.22 58.22 58.22 58.22 58.22 58.22 58.22 74.21 74.21 74.21 74.21 74.21 64.37V2307 61.50 57.73 57.73 57.73 57.73 57.73 57.73 57.73 57.73 55.78 55.78 55.78 55.78 55.78 54.54V2308 61.57 61.59 61.59 61.59 61.59 61.59 61.59 61.59 61.59 58.03 58.03 58.03 58.03 58.03 56.82V2309 63.34 72.05 72.05 72.05 72.05 72.05 72.05 72.05 72.05 64.90 64.90 64.90 64.90 64.90 60.17V2310 64.40 79.26 79.26 79.26 79.26 79.26 79.26 79.26 79.26 59.45 59.45 59.45 59.45 59.45 59.45V2311 62.09 75.48 75.48 75.48 75.48 75.48 75.48 75.48 75.48 74.34 74.34 74.34 74.34 74.34 61.86V2312 62.48 66.54 66.54 66.54 66.54 66.54 66.54 66.54 66.54 70.27 70.27 70.27 70.27 70.27 62.21V2313 70.37 90.83 90.83 90.83 90.83 90.83 90.83 90.83 90.83 73.40 73.40 73.40 73.40 73.40 69.48V2314 80.22 99.49 99.49 99.49 99.49 99.49 99.49 99.49 99.49 74.62 74.62 74.62 74.62 74.62 74.62V2315 99.96 110.45 110.45 110.45 110.45 110.45 110.45 110.45 110.45 82.84 82.84 82.84 82.84 82.84 82.84V2316 101.58 103.55 103.55 103.55 103.55 103.55 103.55 103.55 103.55 77.66 77.66 77.66 77.66 77.66 84.36V2317 97.36 111.44 111.44 111.44 111.44 111.44 111.44 111.44 111.44 90.52 90.52 90.52 90.52 90.52 83.58V2318 135.78 101.84 101.84 101.84 101.84 101.84 101.84 101.84 101.84 101.84 101.84 101.84 101.84 101.84 101.84V2319 39.50 34.47 34.47 34.47 34.47 34.47 34.47 34.47 34.47 38.91 38.91 38.91 38.91 38.91 34.47V2320 48.49 36.37 36.37 36.37 36.37 36.37 36.37 36.37 36.37 48.49 48.49 48.49 48.49 48.49 36.37V2410 76.77 62.24 62.24 62.24 62.24 62.24 62.24 62.24 62.24 73.45 73.45 73.45 73.45 73.45 82.99V2430 100.02 81.03 81.03 81.03 81.03 81.03 81.03 81.03 81.03 85.07 85.07 85.07 85.07 85.07 85.37V2500 75.24 56.43 56.43 56.43 56.43 56.43 56.43 56.43 56.43 70.54 70.54 70.54 70.54 70.54 59.71V2501 114.60 85.95 85.95 85.95 85.95 85.95 85.95 85.95 85.95 85.95 85.95 85.95 85.95 85.95 105.04V2502 141.18 105.89 105.89 105.89 105.89 105.89 105.89 105.89 105.89 105.89 105.89 105.89 105.89 105.89 118.57V2503 130.03 101.31 101.31 101.31 101.31 101.31 101.31 101.31 101.31 97.52 97.52 97.52 97.52 97.52 97.52V2510 87.70 77.03 77.03 77.03 77.03 77.03 77.03 77.03 77.03 101.86 101.86 101.86 101.86 101.86 86.00V2511 147.58 110.68 110.68 110.68 110.68 110.68 110.68 110.68 110.68 132.11 132.11 132.11 132.11 132.11 110.68V2512 174.37 130.78 130.78 130.78 130.78 130.78 130.78 130.78 130.78 174.37 174.37 174.37 174.37 174.37 130.78V2513 146.40 109.80 109.80 109.80 109.80 109.80 109.80 109.80 109.80 146.40 146.40 146.40 146.40 146.40 109.80V2520 96.54 72.41 72.41 72.41 72.41 72.41 72.41 72.41 72.41 87.65 87.65 87.65 87.65 87.65 72.41V2521 168.07 126.05 126.05 126.05 126.05 126.05 126.05 126.05 126.05 134.03 134.03 134.03 134.03 134.03 140.21V2522 163.56 122.67 122.67 122.67 122.67 122.67 122.67 122.67 122.67 163.56 163.56 163.56 163.56 163.56 122.67V2523 130.31 104.54 104.54 104.54 104.54 104.54 104.54 104.54 104.54 127.76 127.76 127.76 127.76 127.76 104.54V2530 154.84 154.84 154.84 154.84 154.84 154.84 154.84 154.84 154.84 197.38 197.38 197.38 197.38 197.38 168.52V2623 804.61 623.19 623.19 623.19 623.19 623.19 623.19 623.19 623.19 830.92 830.92 830.92 830.92 830.92 659.39


HCPCS VI FL GA NC SC A KY MS TN AR LA OK TX NM CO

V2624 42.26 42.26 42.26 42.26 42.26 42.26 42.26 42.26 42.26 55.44 55.44 55.44 55.44 55.44 53.76V2625 256.95 273.74 273.74 273.74 273.74 273.74 273.74 273.74 273.74 266.30 266.30 266.30 266.30 266.30 338.83V2626 138.51 173.67 173.67 173.67 173.67 173.67 173.67 173.67 173.67 184.68 184.68 184.68 184.68 184.68 138.51

V2627 1097.57 994.33 994.33 994.33 994.33 994.33 994.33 994.33 994.33 1005.40 1005.40 1005.40 1005.40 1005.40 1147.97V2628 214.55 227.33 227.33 227.33 227.33 227.33 227.33 227.33 227.33 261.54 261.54 261.54 261.54 261.54 281.63V2700 35.06 30.41 30.41 30.41 30.41 30.41 30.41 30.41 30.41 36.78 36.78 36.78 36.78 36.78 35.87V2710 59.35 44.51 44.51 44.51 44.51 44.51 44.51 44.51 44.51 55.22 55.22 55.22 55.22 55.22 53.67V2715 10.75 8.06 8.06 8.06 8.06 8.06 8.06 8.06 8.06 9.12 9.12 9.12 9.12 9.12 8.06V2718 24.53 19.83 19.83 19.83 19.83 19.83 19.83 19.83 19.83 22.65 22.65 22.65 22.65 22.65 19.83V2730 14.64 14.64 14.64 14.64 14.64 14.64 14.64 14.64 14.64 19.52 19.52 19.52 19.52 19.52 14.64V2740 9.44 9.71 9.71 9.71 9.71 9.71 9.71 9.71 9.71 9.71 9.71 9.71 9.71 9.71 7.28V2741 9.11 7.05 7.05 7.05 7.05 7.05 7.05 7.05 7.05 9.31 9.31 9.31 9.31 9.31 8.18V2742 9.28 7.99 7.99 7.99 7.99 7.99 7.99 7.99 7.99 6.96 6.96 6.96 6.96 6.96 6.96V2743 9.63 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 11.00 11.00 11.00 11.00 11.00 11.87V2744 11.54 15.18 15.18 15.18 15.18 15.18 15.18 15.18 15.18 14.50 14.50 14.50 14.50 14.50 11.39V2750 14.22 17.66 17.66 17.66 17.66 17.66 17.66 17.66 17.66 17.66 17.66 17.66 17.66 17.66 13.25V2755 11.53 12.76 12.76 12.76 12.76 12.76 12.76 12.76 12.76 15.37 15.37 15.37 15.37 15.37 12.18V2760 11.78 11.12 11.12 11.12 11.12 11.12 11.12 11.12 11.12 12.32 12.32 12.32 12.32 12.32 14.83V2770 17.38 14.37 14.37 14.37 14.37 14.37 14.37 14.37 14.37 14.84 14.84 14.84 14.84 14.84 13.86V2780 8.69 11.59 11.59 11.59 11.59 11.59 11.59 11.59 11.59 8.69 8.69 8.69 8.69 8.69 8.69


Please retain the list below as your new DMERC telephone directory.

Elaine Myers (803) 735-1034, Ext. 35707 Senior OmbudsmanDoris Powell, R.N. (803) 735-1034, Ext. 35738, DMERC Medical Affairs CoordinatorRobin Robertson (803) 735-1034, Ext. 35704, DMERC Professional Relations Director

Dedicated Work Teamsand DMERC GeneralInformation (803) 691-4300

Professional Relations (PR) Palmetto GBAProfessional Relations, Medicare Region C DMERCP.O. Box 100141Columbia, SC 29202-3141

PR General Information Number: (803) 735-1034

Individual extensions in Professional Relations may be reached by adding the number threein front of the person's extension. (Ombudsmen addresses and telephone numbers follow.)

Anti-Fraud Unit Palmetto GBAAnti-Fraud Unit, Medicare Region C DMERCP.O. Box 100236Columbia, SC 29202-3236

Anti-Fraud Hot-Line: (803) 788-5414

Individual extensions in the Anti-Fraud Unit may be reached by adding the number four infront of the person's extension.

Hearings Palmetto GBAHearings Department, Medicare Region C DMERCP.O. Box 100249Columbia, SC 29202

Written Prior Authorization Palmetto GBAPrior Authorization Dept., Medicare Region C DMERCP.O. Box 100235Columbia, SC 29202-3235

Electronic Data Interchange Palmetto GBA(EDI) Electronic Data Interchange, Medicare Region CDMERC

P.O. Box 100145Columbia, SC 29202-3145

EDI Help-Line: (803) 788-9751

DMERC Region A (717) 735-9445DMERC Region B (317) 577-5722DMERC Region D (615) 251-8182

National Supplier Palmetto GBAClearinghouse (NSC) National Supplier Clearinghouse

P.O. Box 100142Columbia, SC 29202-3142(803) 754-3951

Statistical Analysis Durable Palmetto GBAMedical Equipment Regional Statistical Analysis Durable MedicalCarrier (SADMERC) Equipment Regional Carrier (SADMERC)


HCPCS Help-Line: (803) 736-6809

Due to the rapid growth of Palmetto GBA, effective December 5, 1994, telephoneextensions for individuals in the various Region C departments were modified. If youdo not know the new extension of the individual you are trying to reach, you may stillcontact each department by dialing the department's general information numberlisted above.

Upon calling the general information telephone numbers, the system will offer you amenu of departments by their physical location. Please stay on the line, as the menuwill then give you the option to speak with an operator. The operator will be able todirect your call accordingly.

National Numbers

REGION CDIRECTORY

Palmetto GBARegion C DMERCContacts


Keith Smith10991-55 San Jose Blvd.Suite 139Jacksonville, FL 32223(904) 287-6860

Sheri ThompsonP.O. Box 99247Raleigh, NC 27624-9247(919) 848-3203

To Be AnnouncedIn the interim, contactCheryl Heller17194 Preston RoadSuite 123 #222Dallas, TX 75248-1203(214) 661-0360

TX

CO

GA

TNPR

FL

VI

NM

OK

TX

SC

KY

Claudia AmorteguiP.O. Box 100141Columbia, SC 29202-3141(803) 735-1034 Ext. 35714

AR

MS

LA

Bobby SmithP.O. Box 9225Jackson, MS 39286(601) 366-4983

Cheryl Heller17194 Preston RoadSuite 123 #222Dallas, TX 75248-1203(214) 661-0360

Vince TemplesP.O. Box 100141Columbia, SC 29202-3141(803) 735-1034, Ext. 35728(Will relocate to Georgia,February 1995)

Alison SantoroP.O Box 100141Columbia, SC 29202-3141(803) 735-1034, Ext. 35715(Will relocate to Florida,April 1995)

AL

FL

*Ombudsmen Addresses and Their Territories

NC

* Ombudsmen are those who investigate reported complaints, reports findings, and help to achieve equitablesettlements, through training and educating of the supplier community.

The portion of the state (Texas and Florida) which the ombudsman covers.


The Region C DMERC Medicare Advisory is published by Palmetto Government Benefits Administrator's Professional RelationsDepartment for suppliers and providers of DMEPOS. Questions regarding information in Palmetto GBA publications can be addressedto:

Palmetto Government Benefits AdministratorsProfessional Relations Department


or call (803) 735-1034, Ext. 35740 or Ext. 35741

GLOSSARY

AARP American Association of Retired PersonsAKA Also Known AsALJ Administrative Law JudgeANSI American National Standards InstituteARU Audio Response UnitAWP Average Wholesale PriceCMN Certificate of Medical NecessityCPAP Continuous Positive Airway PressureCPM Continuous Passive MotionCWF Common Working FileDME Durable Medical EquipmentDMEPOS Durable Medical Equipment, Prosthetics, Orthotics, and SuppliesDMERC Durable Medical Equipment Regional CarrierDOB Date of BirthEDI Electronic Data InterchangeEFT Electronic Funds TransferEMC Electronic Media ClaimEOB Explanation of BenefitsEOMB Explanation of Medicare BenefitsEPO Epoetin AlphaERN Electronic Remittance NoticeESRD End-Stage Renal DiseaseFDA Food and Drug AdministrationGHP Group Health PlanHCFA Health Care Financing AdministrationHCPCS HCFA Common Procedure Coding SystemHCT HematocritHICN Health Insurance Claim NumberHA0 Record NSF record that allows electronic submission of extra marrative data.ICD-9-CM International Classification of Diseases-9th Revision-Clinical ModificationIPPB Intermittent Positive Pressure BreathingMCM Medicare Carrier's ManualMSP Medicare Secondary PayerNDC National Drug CodeNSC National Supplier ClearinghouseNSF National Standard FormatNTIS National Technical Information ServiceOBRA 93 Omnibus Budget Reconciliation Act of 1993OCNA Other Carrier Name & AddressOIG Office of Inspector GeneralP & O Prosthetics & OrthoticsPalmetto GBA Palmetto Government Benefits AdministratorsPDR Physician's Desk ReferencePEN Parenteral and Enteral NutritionPOS Place of ServicePOV Power Operated VehicleRMRP Regional Medical Review PoliciesRRB Railroad Retirement BoardSAC Supplier Advisory CommitteeSADMERC Statistical Analysis Durable Medical Equipment Regional CarrierTENS Transcutaneous Electrical Nerve StimulatorUPIN Unique Physician Identification Number


- NOTES -


- NOTES -


- NOTES -


CUMULATIVE INDEX

1993 Reasonable Charge Pricing K Codes ............................................................................................94-281994 Durable Medical Equipment Fee Schedule Corrections ................................................................94-961994 Durable Medical Equipment Fee Schedule Revisions......................................................... 94-199-2001994 HCFA Common Procedure Coding System HCPCS Update ........................................................94-631994 Pricing Matrix

1994 Pricing Matrix ...................................................................................................................... 94-33-521994 Pricing Matrix for Virgin Islands and Puerto Rico ............................................................ 94-97-107

Advantis Network.....................................................................................................................................94-76Alternating Pressure Mattresses (E0277) Update ................................................................................94-181Anti-Fraud and Abuse Unit .................................................................................................94-90, 94-196-198Audio Response Unit (ARU) For Claim Status .....................................................................................94-178Certificate of Medical Necessity

Certificate of Medical Necessity: Deferred Implementation ..............................................................94-4Certificate of Medical Necessity Submission .............................................................................. 94-11-12

Certified Software Vendors, Billing Services & Clearinghouses ....................................................... 94-77-84Claim Payment .................................................................................................................................. 94-14-15Claims Jurisdiction ............................................................................................................................ 94-15-18Coding: How to Obtain Reference Material .............................................................................................94-6Complementary Insurers ................................................................................................94-20, 94-63, 94-192Continuous Passive Motion (CPM) Device Units Billing Instruction .....................................................94-181Crossover Problem Identified ..................................................................................................................94-57Crossover Update .......................................................................................................................... 94-189-190DMEPOS Supplier Specialty Workshops Notice ....................................................................................94-85DMERC Certified Software Vendors ................................................................................................. 94-22-26DMERC Medicare Advisory Update......................................................................................................94-184Electronic Data Interchange (EDI)

Added Benefit ..................................................................................................................................94-178Help-Line: Commonly Asked Questions ...........................................................................................94-75Remittance Advices Notices, Standard Reason Codes .................................................................94-181Update ...............................................................................................................................................94-76Agreements ................................................................................................................................. 94-21-22

Glossary........................................................................................................................94-54, 94-109, 94-202Grandfathering Policy.......................................................................................................................... 94-7-10HCFA Common Procedure Coding System (HCPCS)

Coding Help-Line: Commonly Asked Questions .....................................................94-64-65, 94-185-186Additions/Changes ...................................................................................................................... 94-65-66Codes Requiring A CMN ............................................................................................................. 94-67-71

Helpful Hints .................................................................................................................................. 94-179-180ICD-9-CM Information .............................................................................................................................94-26Level II HCPCS Codes for Elevating Leg Rests .......................................................................................94-5Lymphedema Pumps/Pneumatic Compressors ....................................................................... 94-19, 94-187Medical Policy

Medical Policy: Where DMERC Medical Policy Does Not Exist ......................................................94-13Medical Policy Important Update ......................................................................................................94-20

Medicare Part B Carrier's Manual: How To Obtain ...............................................................................94-90National K Code Pricing ..........................................................................................................................94-27National Supplier Clearinghouse

NSC Change of Address Notification ................................................................................................94-29NSC Change of Address Notification Form ......................................................................................94-29

New HCPCS Level III Codes for Enteral Products ............................................................................... 94-6-7New Interest Rate Payable on Clean Claims........................................................................................94-181Notice of Transition Delays .....................................................................................................................94-58OBRA 93 Changes ................................................................................................................................ 94-1-3OBRA 93 Supplemental Plans ...................................................................................................... 94-182-183Ombudsmen Addresses and Their Territories ........................................................................................94-87


CUMULATIVE INDEX (CONT'D)

Oral Anticancer Drugs ....................................................................................................................94-60-63PEN Supply and Administration Kits ...................................................................................................94-90Physician Order .....................................................................................................................................94-4Place of Service (POS) .......................................................................................................................94-85Prescription Before Delivery................................................................................................................94-71Prior Authorization Process .................................................................................................................94-88Professional Relations Staff ................................................................................................................94-86Questions & Answers .................................................................................... 94-30-32, 94-89, 94-187-188Recategorization of New Wheelchair Codes ........................................................................................94-5Recategorization of Orthotic Seating Systems .................................................................................94-199Resubmittals vs. Reviews .................................................................................................................94-180Revised State-By-State Transition Schedule .....................................................................................94-59SADMERC's HCPCS Functions ........................................................................................................94-4-5Service Access ....................................................................................................................................94-89Supplier Advisory Committee ..............................................................................................................94-85Supplier Signature Requirements Reminder ....................................................................................94-180Team Tips .................................................................................................................................. 94-185-186Telephone Directory .............................................................................................................. 94-53, 94-108Telephone Service.............................................................................................................................94-179Transition Tips ................................................................................................................................94-72-74Transition Update ..............................................................................................................................94-177Transtracheal Catheters ....................................................................................................................94-183Unique Physician Identification Number (UPIN) Directory: How To Obtain ......................................94-90Using the OCNA Matrix .............................................................................................94-91-95, 94-191-195Workload Transition Reminder ...........................................................................................................94-19Workshop Series Success ................................................................................................................94-184


Documents

Palmetto Government Benefits Administrators DMERC MEDICARE ... · Palmetto GBA Announces a New Medical Director Palmetto Government Benefits Administrators (Palmetto GBA) is proud