Embed Size (px)
Citation preview
This schedule reflects rate data as of : 1/1/2018
This provider type was last subject to a rate review* on : 11/2016
Note:
Proc Code Description Mod Rate Rate Begin Date
A4206 1 cc sterile syringe&needle 0.39 8/1/2011
A4208 3 cc sterile syringe&needle 0.39 8/1/2011
A4209 5+ cc sterile syringe&needle 0.40 8/1/2011
A4213 20+ cc syringe only 0.78 8/1/2011
A4221 SUPP NON-INSULIN INF CATH/WK 22.10 8/1/2011
A4222 Infusion supplies with pump 43.86 8/1/2011
A4223 Infusion supplies w/o pump 43.86 12/1/2012
A4224 SUPPLY INSULIN INF CATH/WK 19.40 1/1/2017
A4225 SUP/EXT INSULIN INF PUMP SYR 2.60 1/1/2017
A4230 Infus insulin pump non needl 10.00 8/1/2011
A4231 Infusion insulin pump needle 5.06 8/1/2011
A4232 Syringe w/needle insulin 3cc 2.59 8/1/2011
A4244 Alcohol or peroxide per pint 0.78 8/1/2011
A4245 Alcohol wipes per box 2.35 8/1/2011
A4246 Betadine/phisohex solution 2.75 8/1/2011
A4280 Brst prsths adhsv attchmnt 4.81 8/1/2011
A4305 Drug delivery system >=50 ml 13.32 8/1/2011
A4306 Drug delivery system <=50 ml 18.41 8/1/2011
A4310 Insert tray w/o bag/cath 7.67 8/1/2011
A4311 Catheter w/o bag 2-way latex 14.74 8/1/2011
A4312 Cath w/o bag 2-way silicone 17.91 8/1/2011
A4313 Catheter w/bag 3-way 18.39 8/1/2011
A4314 Cath w/drainage 2-way latex 21.35 8/1/2011
A4315 Cath w/drainage 2-way silcne 26.21 8/1/2011
If there is no fee schedule available ($0 rate), reimbursement will be the lowest of: a) manufacturer’s suggested
retail price (MSRP) less 25%, verifiable with quote or manufacturer’s invoice that clearly identifies MSRP; b) if
there is no MSRP, reimbursement will be acquisition cost plus 20%, verifiable with manufacturer’s invoice; or c)
the actual charge submitted by the provider.
Providers must use the appropriate HCPCS code. For medically necessary DMEPOS items that do not appear
on this list please refer to Medicaid Services Manual, Chapter 1300.
CPT codes, descriptions and other data only are copyright © 2008 American Medical Association. All rights reserved.
Applicable FARS/DFARS apply. CPT is a registered trademark ® of the American Medical Association.
Provider Type 33, Durable Medical Equipment, Prosthetics, Orthotics & Supplies
Reimbursement Schedule
The information contained in the schedule is made available to provide information and is not a
guarantee by the State or the Department or its employees as to the present accuracy of the information
contained herein. For example, coverage as well as an actual rate may have been revised or updated
and may no longer be the same as posted on the website.
*Rate review refers to a comprhensive review of all the rates associated with this provider type. In 2017 the NV Legislature passed
Assembly Bill 108 which, starting in 2018, requires NV Medicaid to perform a comprhensive rate review for each provider type at least once
every four years. These reviews may or may not result in changes to reimbursement amounts.
1/55
Proc Code Description Mod Rate Rate Begin Date
A4316 Cath w/drainage 3-way 28.20 8/1/2011
A4320 Irrigation tray 5.29 8/1/2011
A4322 Irrigation syringe 3.02 8/1/2011
A4326 Male external catheter 10.71 8/1/2011
A4327 Fem urinary collect dev cup 41.97 8/1/2011
A4328 Fem urinary collect pouch 10.38 8/1/2011
A4330 Stool collection pouch 7.10 8/1/2011
A4331 Extension drainage tubing 3.16 8/1/2011
A4332 Lube sterile packet 0.12 8/1/2011
A4333 Urinary cath anchor device 2.18 8/1/2011
A4334 Urinary cath leg strap 4.90 8/1/2011
A4336 Urethral insert 1.60 12/1/2015
A4338 Indwelling catheter latex 12.17 8/1/2011
A4340 Indwelling catheter special 26.80 8/1/2011
A4344 Cath indw foley 2 way silicn 15.91 8/1/2011
A4346 Cath indw foley 3 way 19.12 8/1/2011
A4349 Disposable male external cat 2.01 8/1/2011
A4351 Straight tip urine catheter 1.80 8/1/2011
A4352 Coude tip urinary catheter 6.38 8/1/2011
A4353 Intermittent urinary cath 6.95 8/1/2011
A4354 Cath insertion tray w/bag 11.72 8/1/2011
A4355 Bladder irrigation tubing 7.80 8/1/2011
A4356 Ext ureth clmp or compr dvc 39.05 8/1/2011
A4357 Bedside drainage bag 9.63 8/1/2011
A4358 Urinary leg or abdomen bag 6.58 8/1/2011
A4360 Disposable ext urethral dev 0.45 8/1/2011
A4361 Ostomy face plate 18.24 8/1/2011
A4362 Solid skin barrier 3.44 8/1/2011
A4363 Ostomy clamp, replacement 2.18 8/1/2011
A4364 Adhesive, liquid or equal 2.91 8/1/2011
A4366 Ostomy vent 1.29 8/1/2011
A4367 Ostomy belt 7.30 8/1/2011
A4368 Ostomy filter 0.26 8/1/2011
A4369 Skin barrier liquid per oz 2.05 8/1/2011
A4371 Skin barrier powder per oz 3.57 8/1/2011
A4372 Skin barrier solid 4x4 equiv 4.15 8/1/2011
A4373 Skin barrier with flange 6.24 8/1/2011
A4375 Drainable plastic pch w fcpl 17.06 8/1/2011
A4376 Drainable rubber pch w fcplt 47.25 8/1/2011
A4377 Drainable plstic pch w/o fp 4.26 8/1/2011
A4378 Drainable rubber pch w/o fp 30.53 8/1/2011
A4379 Urinary plastic pouch w fcpl 14.91 8/1/2011
A4380 Urinary rubber pouch w fcplt 37.07 8/1/2011
A4381 Urinary plastic pouch w/o fp 4.58 8/1/2011
A4382 Urinary hvy plstc pch w/o fp 24.45 8/1/2011
2/55
Proc Code Description Mod Rate Rate Begin Date
A4383 Urinary rubber pouch w/o fp 27.99 8/1/2011
A4384 Ostomy faceplt/silicone ring 9.55 8/1/2011
A4385 Ost skn barrier sld ext wear 5.06 8/1/2011
A4388 Drainable pch w ex wear barr 4.33 8/1/2011
A4389 Drainable pch w st wear barr 6.18 8/1/2011
A4390 Drainable pch ex wear convex 9.54 8/1/2011
A4391 Urinary pouch w ex wear barr 7.02 8/1/2011
A4392 Urinary pouch w st wear barr 8.12 8/1/2011
A4393 Urine pch w ex wear bar conv 8.98 8/1/2011
A4394 Ostomy pouch liq deodorant 2.56 8/1/2011
A4395 Ostomy pouch solid deodorant 0.05 8/1/2011
A4396 Peristomal hernia supprt blt 40.20 8/1/2011
A4397 Irrigation supply sleeve 4.04 8/1/2011
A4398 Ostomy irrigation bag 13.71 8/1/2011
A4399 Ostomy irrig cone/cath w brs 12.17 8/1/2011
A4400 Ostomy irrigation set 48.53 8/1/2011
A4402 Lubricant per ounce 1.59 8/1/2011
A4404 Ostomy ring each 1.62 8/1/2011
A4405 Nonpectin based ostomy paste 3.38 8/1/2011
A4406 Pectin based ostomy paste 5.70 8/1/2011
A4407 "Ext wear ost skn barr <=4sq""" 8.70 8/1/2011
A4408 "Ext wear ost skn barr >4sq""" 9.80 8/1/2011
A4409 Ost skn barr convex <=4 sq i 6.18 8/1/2011
A4410 Ost skn barr extnd >4 sq 8.98 8/1/2011
A4411 Ost skn barr extnd =4sq 5.06 8/1/2011
A4412 Ost pouch drain high output 2.68 8/1/2011
A4413 2 pc drainable ost pouch 5.46 8/1/2011
A4414 Ost sknbar w/o conv<=4 sq in 4.90 8/1/2011
A4415 Ost skn barr w/o conv >4 sqi 5.96 8/1/2011
A4416 Ost pch clsd w barrier/filtr 2.73 8/1/2011
A4417 Ost pch w bar/bltinconv/fltr 3.69 8/1/2011
A4418 Ost pch clsd w/o bar w filtr 1.80 8/1/2011
A4419 Ost pch for bar w flange/flt 1.73 8/1/2011
A4420 Ost pch clsd for bar w lk fl 0.00 1/1/2004
A4422 Ost pouch absorbent material 0.12 8/1/2011
A4423 Ost pch for bar w lk fl/fltr 1.85 8/1/2011
A4424 Ost pch drain w bar & filter 4.72 8/1/2011
A4425 Ost pch drain for barrier fl 3.55 8/1/2011
A4426 Ost pch drain 2 piece system 2.71 8/1/2011
A4427 Ost pch drain/barr lk flng/f 2.76 8/1/2011
A4428 Urine ost pouch w faucet/tap 6.46 8/1/2011
A4429 Urine ost pouch w bltinconv 8.19 8/1/2011
A4430 Ost urine pch w b/bltin conv 8.46 8/1/2011
A4431 Ost pch urine w barrier/tapv 6.18 8/1/2011
A4432 Os pch urine w bar/fange/tap 3.56 8/1/2011
3/55
Proc Code Description Mod Rate Rate Begin Date
A4433 Urine ost pch bar w lock fln 3.32 8/1/2011
A4434 Ost pch urine w lock flng/ft 3.73 8/1/2011
A4435 1pc ost pch drain hgh output 6.26 1/1/2013
A4450 Non-waterproof tape 0.09 8/1/2011
A4452 Waterproof tape 0.36 8/1/2011
A4455 Adhesive remover per ounce 1.21 8/1/2011
A4456 Adhesive remover, wipes 0.26 8/1/2011
A4461 Surgicl dress hold non-reuse 3.27 8/1/2011
A4463 Surgical dress holder reuse 13.88 8/1/2011
A4481 Tracheostoma filter 0.38 8/1/2011
A4483 Moisture exchanger 0.00 1/1/1999
A4490 Above knee surgical stocking 5.89 8/1/2011
A4495 Thigh length surg stocking 5.89 8/1/2011
A4500 Below knee surgical stocking 4.32 8/1/2011
A4510 Full length surg stocking 10.60 8/1/2011
A4556 Electrodes, pair 12.06 8/1/2011
A4557 Lead wires, pair 17.81 8/1/2011
A4565 Slings 6.28 8/1/2011
A4601 Lith ion non prosth recharge 0.00 1/1/2007
A4602 Replace lithium battery 1.5v NU 0.00 1/1/2015
A4605 Trach suction cath close sys NU 16.29 8/1/2011
A4606 Oxygen probe used w oximeter 0.00 4/1/2004
A4608 Transtracheal oxygen cath 57.74 8/1/2011
A4611 Heavy duty battery UE 124.36 8/1/2011
A4611 Heavy duty battery RR 20.23 8/1/2011
A4611 Heavy duty battery NU 165.81 8/1/2011
A4612 Battery cables UE 60.52 8/1/2011
A4612 Battery cables RR 8.08 8/1/2011
A4612 Battery cables NU 79.37 8/1/2011
A4613 Battery charger UE 103.56 8/1/2011
A4613 Battery charger RR 14.33 8/1/2011
A4613 Battery charger NU 143.20 8/1/2011
A4614 Hand-held pefr meter 23.61 8/1/2011
A4618 Breathing circuits UE 5.63 8/1/2011
A4618 Breathing circuits RR 1.01 8/1/2011
A4618 Breathing circuits NU 7.51 8/1/2011
A4619 Face tent 1.20 8/1/2011
A4620 Variable concentration mask 2.35 8/1/2011
A4623 Tracheostomy inner cannula 5.53 8/1/2011
A4624 Tracheal suction tube NU 2.61 8/1/2011
A4625 Trach care kit for new trach 6.53 8/1/2011
A4626 Tracheostomy cleaning brush 2.76 8/1/2011
A4627 Spacer bag/reservoir 14.91 8/1/2011
A4628 Oropharyngeal suction cath NU 3.62 8/1/2011
A4629 Tracheostomy care kit 4.58 8/1/2011
4/55
Proc Code Description Mod Rate Rate Begin Date
A4635 Underarm crutch pad UE 2.86 8/1/2011
A4635 Underarm crutch pad RR 0.69 8/1/2011
A4635 Underarm crutch pad NU 4.32 8/1/2011
A4636 Handgrip for cane etc UE 2.59 8/1/2011
A4636 Handgrip for cane etc RR 0.43 8/1/2011
A4636 Handgrip for cane etc NU 3.55 8/1/2011
A4637 Repl tip cane/crutch/walker UE 1.36 8/1/2011
A4637 Repl tip cane/crutch/walker RR 0.30 8/1/2011
A4637 Repl tip cane/crutch/walker NU 1.80 8/1/2011
A4638 Repl batt pulse gen sys 0.00 1/1/2004
A4640 Alternating pressure pad UE 37.86 8/1/2011
A4640 Alternating pressure pad RR 6.40 8/1/2011
A4640 Alternating pressure pad NU 53.44 8/1/2011
A4660 Sphyg/bp app w cuff and stet 49.65 8/1/2011
A4670 Automatic bp monitor, dial 49.65 8/1/2011
A5051 Pouch clsd w barr attached 2.06 8/1/2011
A5052 Clsd ostomy pouch w/o barr 1.48 8/1/2011
A5053 Clsd ostomy pouch faceplate 1.47 8/1/2011
A5054 Clsd ostomy pouch w/flange 1.78 8/1/2011
A5055 Stoma cap 1.43 8/1/2011
A5056 1 pc ost pouch w filter 4.97 1/1/2012
A5057 1 pc ost pou w built-in conv 10.24 1/1/2012
A5061 Pouch drainable w barrier at 3.50 8/1/2011
A5062 Drnble ostomy pouch w/o barr 2.08 8/1/2011
A5063 Drain ostomy pouch w/flange 2.15 8/1/2011
A5071 Urinary pouch w/barrier 5.97 8/1/2011
A5072 Urinary pouch w/o barrier 3.41 8/1/2011
A5073 Urinary pouch on barr w/flng 3.16 8/1/2011
A5081 Stoma plug or seal, any type 2.79 8/1/2011
A5082 Continent stoma catheter 10.04 8/1/2011
A5093 Ostomy accessory convex inse 1.94 8/1/2011
A5102 Bedside drain btl w/wo tube 20.55 8/1/2011
A5105 Urinary suspensory 40.47 8/1/2011
A5112 Urinary leg bag 34.38 8/1/2011
A5113 Latex leg strap 4.67 8/1/2011
A5114 Foam/fabric leg strap 8.88 8/1/2011
A5120 Skin barrier, wipe or swab AV 0.20 8/1/2011
A5120 Skin barrier, wipe or swab AU 0.20 8/1/2011
A5120 Skin barrier, wipe or swab 0.20 8/1/2011
A5121 Solid skin barrier 6x6 6.67 8/1/2011
A5122 Solid skin barrier 8x8 12.76 8/1/2011
A5126 Disk/foam pad +or- adhesive 1.31 8/1/2011
A5131 Appliance cleaner 13.66 8/1/2011
A5200 Percutaneous catheter anchor 11.21 8/1/2011
A5500 Diab shoe for density insert 58.94 8/1/2011
5/55
Proc Code Description Mod Rate Rate Begin Date
A5501 Diabetic custom molded shoe 176.79 8/1/2011
A5503 Diabetic shoe w/roller/rockr 26.22 8/1/2011
A5504 Diabetic shoe with wedge 26.22 8/1/2011
A5505 Diab shoe w/metatarsal bar 26.22 8/1/2011
A5506 Diabetic shoe w/off set heel 26.22 8/1/2011
A5507 Modification diabetic shoe 26.22 8/1/2011
A5512 Multi den insert direct form 24.05 8/1/2011
A5513 Multi den insert custom mold 35.89 8/1/2011
A6010 Collagen based wound filler 30.74 8/1/2011
A6011 Collagen gel/paste wound fil 2.26 8/1/2011
A6021 Collagen dressing <=16 sq in 20.87 8/1/2011
A6022 Collagen drsg>16<=48 sq in 20.87 8/1/2011
A6023 Collagen dressing >48 sq in 188.97 8/1/2011
A6024 Collagen dsg wound filler 6.15 8/1/2011
A6025 Silicone gel sheet, each 21.56 8/1/2011
A6154 Wound pouch each 14.26 8/1/2011
A6196 Alginate dressing <=16 sq in 7.30 8/1/2011
A6197 Alginate drsg >16 <=48 sq in 16.32 8/1/2011
A6199 Alginate drsg wound filler 5.25 8/1/2011
A6203 Composite drsg <= 16 sq in 3.33 8/1/2011
A6204 Composite drsg >16<=48 sq in 6.19 8/1/2011
A6207 Contact layer >16<= 48 sq in 7.29 8/1/2011
A6209 Foam drsg <=16 sq in w/o bdr 7.43 8/1/2011
A6210 Foam drg >16<=48 sq in w/o b 19.78 8/1/2011
A6211 Foam drg > 48 sq in w/o brdr 29.16 8/1/2011
A6212 Foam drg <=16 sq in w/border 9.63 8/1/2011
A6214 Foam drg > 48 sq in w/border 10.22 8/1/2011
A6216 Non-sterile gauze<=16 sq in 0.05 8/1/2011
A6219 Gauze <= 16 sq in w/border 0.94 8/1/2011
A6220 Gauze >16 <=48 sq in w/bordr 2.56 8/1/2011
A6222 Gauze <=16 in no w/sal w/o b 2.12 8/1/2011
A6223 Gauze >16<=48 no w/sal w/o b 2.40 8/1/2011
A6224 Gauze > 48 in no w/sal w/o b 3.58 8/1/2011
A6229 Gauze >16<=48 sq in watr/sal 3.58 8/1/2011
A6231 Hydrogel dsg<=16 sq in 4.65 8/1/2011
A6232 Hydrogel dsg>16<=48 sq in 6.83 8/1/2011
A6233 Hydrogel dressing >48 sq in 19.06 8/1/2011
A6234 Hydrocolld drg <=16 w/o bdr 6.49 8/1/2011
A6235 Hydrocolld drg >16<=48 w/o b 16.70 8/1/2011
A6236 Hydrocolld drg > 48 in w/o b 27.06 8/1/2011
A6237 Hydrocolld drg <=16 in w/bdr 7.85 8/1/2011
A6238 Hydrocolld drg >16<=48 w/bdr 22.63 8/1/2011
A6240 Hydrocolld drg filler paste 12.15 8/1/2011
A6241 Hydrocolloid drg filler dry 2.55 8/1/2011
A6242 Hydrogel drg <=16 in w/o bdr 6.03 8/1/2011
6/55
Proc Code Description Mod Rate Rate Begin Date
A6243 Hydrogel drg >16<=48 w/o bdr 12.22 8/1/2011
A6244 Hydrogel drg >48 in w/o bdr 39.01 8/1/2011
A6245 Hydrogel drg <= 16 in w/bdr 7.22 8/1/2011
A6246 Hydrogel drg >16<=48 in w/b 9.85 8/1/2011
A6247 Hydrogel drg > 48 sq in w/b 23.61 8/1/2011
A6248 Hydrogel drsg gel filler 16.13 8/1/2011
A6251 Absorpt drg <=16 sq in w/o b 1.98 8/1/2011
A6252 Absorpt drg >16 <=48 w/o bdr 3.23 8/1/2011
A6253 Absorpt drg > 48 sq in w/o b 6.30 8/1/2011
A6254 Absorpt drg <=16 sq in w/bdr 1.20 8/1/2011
A6255 Absorpt drg >16<=48 in w/bdr 3.01 8/1/2011
A6257 Transparent film <= 16 sq in 1.52 8/1/2011
A6258 Transparent film >16<=48 in 4.27 8/1/2011
A6259 Transparent film > 48 sq in 10.86 8/1/2011
A6261 Wound filler gel/paste /oz 3.54 8/1/2011
A6266 Impreg gauze no h20/sal/yard 1.91 8/1/2011
A6402 Sterile gauze <= 16 sq in 0.12 8/1/2011
A6403 Sterile gauze>16 <= 48 sq in 0.43 8/1/2011
A6407 Packing strips, non-impreg 1.87 8/1/2011
A6410 Sterile eye pad 0.39 8/1/2011
A6441 "Pad band w>=3"" <5""/yd" 0.67 8/1/2011
A6442 "Conform band n/s w<3""/yd" 0.17 8/1/2011
A6443 "Conform band n/s w>=3""<5""/yd" 0.29 8/1/2011
A6444 "Conform band n/s w>=5""/yd" 0.56 8/1/2011
A6445 "Conform band s w <3""/yd" 0.32 8/1/2011
A6446 "Conform band s w>=3"" <5""/yd" 0.41 8/1/2011
A6447 "Conform band s w >=5""/yd" 0.67 8/1/2011
A6448 "Lt compres band <3""/yd" 1.15 8/1/2011
A6449 "Lt compres band >=3"" <5""/yd" 1.74 8/1/2011
A6451 "Mod compres band w>=3""<5""/yd" 0.00 1/1/2004
A6452 "High compres band w>=3""<5""yd" 5.87 8/1/2011
A6453 "Self-adher band w <3""/yd" 0.61 8/1/2011
A6454 "Self-adher band w>=3"" <5""/yd" 0.76 8/1/2011
A6455 "Self-adher band >=5""/yd" 1.38 8/1/2011
A6456 "Zinc paste band w >=3""<5""/yd" 1.27 8/1/2011
A6457 Tubular dressing 1.13 8/1/2011
A6530 Compression stocking bk18-30 24.83 8/1/2011
A6531 Compression stocking bk30-40 42.97 8/1/2011
A6532 Compression stocking bk40-50 60.53 8/1/2011
A6533 Gc stocking thighlngth 18-30 29.79 8/1/2011
A6534 Gc stocking thighlngth 30-40 29.79 8/1/2011
A6535 Gc stocking thighlngth 40-50 29.79 8/1/2011
A6536 Gc stocking full lngth 18-30 39.72 8/1/2011
A6537 Gc stocking full lngth 30-40 39.72 8/1/2011
A6538 Gc stocking full lngth 40-50 39.72 8/1/2011
7/55
Proc Code Description Mod Rate Rate Begin Date
A6539 Gc stocking waistlngth 18-30 79.44 8/1/2011
A6540 Gc stocking waistlngth 30-40 79.44 8/1/2011
A6541 Gc stocking waistlngth 40-50 79.44 8/1/2011
A6544 Gc stocking garter belt 13.90 8/1/2011
A6545 Grad comp non-elastic bk 0.00 1/1/2009
A6549 G compression stocking 0.00 1/1/2006
A6550 Neg pres wound ther drsg set 27.23 8/1/2011
A7000 Disposable canister for pump NU 9.47 8/1/2011
A7001 Nondisposable pump canister NU 32.85 8/1/2011
A7002 Tubing used w suction pump NU 3.80 8/1/2011
A7003 Nebulizer administration set NU 2.72 8/1/2011
A7004 Disposable nebulizer sml vol NU 1.79 8/1/2011
A7005 Nondisposable nebulizer set NU 30.61 8/1/2011
A7006 Filtered nebulizer admin set NU 9.47 8/1/2011
A7009 Nebulizer reservoir bottle NU 41.75 8/1/2011
A7010 Disposable corrugated tubing NU 23.42 8/1/2011
A7012 Nebulizer water collec devic NU 3.75 8/1/2011
A7013 Disposable compressor filter NU 0.82 8/1/2011
A7014 Compressor nondispos filter NU 4.46 8/1/2011
A7015 Aerosol mask used w nebulize NU 1.87 8/1/2011
A7016 Nebulizer dome & mouthpiece NU 7.20 8/1/2011
A7017 Nebulizer not used w oxygen UE 99.82 8/1/2011
A7017 Nebulizer not used w oxygen RR 13.31 8/1/2011
A7017 Nebulizer not used w oxygen NU 133.10 8/1/2011
A7018 Water distilled w/nebulizer 0.38 8/1/2011
A7020 Interface, cough stim device NU 0.00 1/1/2011
A7025 Replace chest compress vest NU 431.90 8/1/2011
A7026 Replace chst cmprss sys hose NU 28.55 8/1/2011
A7027 Combination oral/nasal mask NU 178.09 8/1/2011
A7028 Repl oral cushion combo mask NU 49.19 8/1/2011
A7029 Repl nasal pillow comb mask NU 20.10 8/1/2011
A7030 Cpap full face mask NU 187.32 8/1/2011
A7031 Replacement facemask interfa NU 69.28 8/1/2011
A7032 Replacement nasal cushion NU 40.25 8/1/2011
A7033 Replacement nasal pillows NU 28.21 8/1/2011
A7034 Nasal application device NU 116.82 8/1/2011
A7035 Pos airway press headgear NU 39.47 8/1/2011
A7036 Pos airway press chinstrap NU 18.07 8/1/2011
A7037 Pos airway pressure tubing NU 40.73 8/1/2011
A7038 Pos airway pressure filter NU 5.35 8/1/2011
A7039 Filter, non disposable w pap NU 15.22 8/1/2011
A7040 One way chest drain valve 36.60 8/1/2011
A7041 Water seal drain container 68.78 8/1/2011
A7044 Pap oral interface NU 120.06 8/1/2011
A7045 Repl exhalation port for pap UE 14.50 8/1/2011
8/55
Proc Code Description Mod Rate Rate Begin Date
A7045 Repl exhalation port for pap RR 1.94 8/1/2011
A7045 Repl exhalation port for pap NU 19.33 8/1/2011
A7046 Repl water chamber, pap dev 19.37 8/1/2011
A7047 Resp suction oral interface NU 132.22 1/1/2014
A7048 Vacuum drain bottle/tube kit 45.83 1/1/2015
A7501 Tracheostoma valve w diaphra 104.29 8/1/2011
A7502 Replacement diaphragm/fplate 49.56 8/1/2011
A7503 Hmes filter holder or cap 11.25 8/1/2011
A7504 Tracheostoma hmes filter 0.67 8/1/2011
A7505 Hmes or trach valve housing 4.65 8/1/2011
A7506 Hmes/trachvalve adhesivedisk 0.33 8/1/2011
A7507 Integrated filter & holder 2.47 8/1/2011
A7508 Housing & integrated adhesiv 2.85 8/1/2011
A7509 Heat & moisture exchange sys 1.40 8/1/2011
A7520 Trach/laryn tube non-cuffed 47.15 8/1/2011
A7521 Trach/laryn tube cuffed 46.72 8/1/2011
A7522 Trach/laryn tube stainless 44.84 8/1/2011
A7524 Tracheostoma stent/stud/bttn 76.86 8/1/2011
A7525 Tracheostomy mask 2.06 8/1/2011
A7526 Tracheostomy tube collar 3.35 8/1/2011
A7527 Trach/laryn tube plug/stop 3.55 8/1/2011
A8000 Soft protect helmet prefab UE 114.22 8/1/2011
A8000 Soft protect helmet prefab RR 15.22 8/1/2011
A8000 Soft protect helmet prefab NU 152.28 8/1/2011
A8001 Hard protect helmet prefab UE 114.22 8/1/2011
A8001 Hard protect helmet prefab RR 15.22 8/1/2011
A8001 Hard protect helmet prefab NU 152.28 8/1/2011
A8003 Hard protect helmet custom UE 0.00 1/1/2007
A8003 Hard protect helmet custom RR 0.00 1/1/2007
A8003 Hard protect helmet custom NU 0.00 1/1/2007
A9900 Supply/accessory/service 0.00 1/1/2001
A9999 Dme supply or accessory, nos 0.00 1/1/2004
B4034 Enter feed supkit syr by day 5.62 8/1/2011
B4035 Enteral feed supp pump per d 10.71 8/1/2011
B4036 Enteral feed sup kit grav by 7.34 8/1/2011
B4081 Enteral ng tubing w/ stylet 19.86 8/1/2011
B4082 Enteral ng tubing w/o stylet 14.79 8/1/2011
B4083 Enteral stomach tube levine 2.25 8/1/2011
B4087 Gastro/jejuno tube, std 37.95 8/1/2011
B4088 GASTRO/JEJUNO TUBE, LOW-PRO BA 112.01 8/1/2011
B4102 Ef adult fluids and electro 0.00 1/1/2005
B4103 Ef ped fluid and electrolyte 0.00 1/1/2005
B4104 Additive for enteral formula 2.13 8/1/2011
B4149 Ef blenderized foods 1.52 8/1/2011
B4150 Ef complet w/intact nutrient 0.62 8/1/2011
9/55
Proc Code Description Mod Rate Rate Begin Date
B4152 Ef calorie dense>/=1.5kcal 0.52 8/1/2011
B4153 Ef hydrolyzed/amino acids 1.85 8/1/2011
B4154 Ef spec metabolic noninherit 1.14 8/1/2011
B4155 Ef incomplete/modular 0.87 8/1/2011
B4157 Ef special metabolic inherit 6.96 8/1/2011
B4158 Ef ped complete intact nut 1.36 8/1/2011
B4159 Ef ped complete soy based 1.62 8/1/2011
B4160 Ef ped caloric dense>/=0.7kc 1.50 8/1/2011
B4161 Ef ped hydrolyzed/amino acid 3.25 8/1/2011
B4162 Ef ped specmetabolic inherit 0.00 1/1/2005
B4220 Parenteral supply kit premix 7.13 8/1/2011
B4222 Parenteral supply kit homemi 8.79 8/1/2011
B4224 Parenteral administration ki 22.27 8/1/2011
B9002 ENTER NUTR INF PUMP ANY TYPE UE 844.77 8/1/2011
B9002 ENTER NUTR INF PUMP ANY TYPE RR 109.09 8/1/2011
B9002 ENTER NUTR INF PUMP ANY TYPE NU 1126.37 8/1/2011
B9004 Parenteral infus pump portab UE 1685.09 8/1/2011
B9004 Parenteral infus pump portab RR 355.69 8/1/2011
B9004 Parenteral infus pump portab NU 2246.79 8/1/2011
B9006 Parenteral infus pump statio UE 1685.09 8/1/2011
B9006 Parenteral infus pump statio RR 355.69 8/1/2011
B9006 Parenteral infus pump statio NU 2246.79 8/1/2011
B9998 Enteral supp not otherwise c 0.00 11/1/2001
E0100 Cane adjust/fixed with tip UE 16.68 8/1/2011
E0100 Cane adjust/fixed with tip RR 5.90 8/1/2011
E0100 Cane adjust/fixed with tip NU 20.92 8/1/2011
E0105 Cane adjust/fixed quad/3 pro UE 37.59 8/1/2011
E0105 Cane adjust/fixed quad/3 pro RR 8.80 8/1/2011
E0105 Cane adjust/fixed quad/3 pro NU 48.77 8/1/2011
E0110 Crutch forearm pair UE 49.10 8/1/2011
E0110 Crutch forearm pair RR 15.88 8/1/2011
E0110 Crutch forearm pair NU 65.49 8/1/2011
E0111 Crutch forearm each UE 34.70 8/1/2011
E0111 Crutch forearm each RR 8.37 8/1/2011
E0111 Crutch forearm each NU 44.95 8/1/2011
E0112 Crutch underarm pair wood UE 24.68 8/1/2011
E0112 Crutch underarm pair wood RR 9.86 8/1/2011
E0112 Crutch underarm pair wood NU 32.88 8/1/2011
E0113 Crutch underarm each wood UE 13.39 8/1/2011
E0113 Crutch underarm each wood RR 5.11 8/1/2011
E0113 Crutch underarm each wood NU 17.83 8/1/2011
E0114 Crutch underarm pair no wood UE 30.11 8/1/2011
E0114 Crutch underarm pair no wood RR 8.51 8/1/2011
E0114 Crutch underarm pair no wood NU 39.83 8/1/2011
E0116 Crutch underarm each no wood UE 17.63 8/1/2011
10/55
Proc Code Description Mod Rate Rate Begin Date
E0116 Crutch underarm each no wood RR 5.36 8/1/2011
E0116 Crutch underarm each no wood NU 23.41 8/1/2011
E0117 Underarm springassist crutch UE 143.54 8/1/2011
E0117 Underarm springassist crutch RR 19.13 8/1/2011
E0117 Underarm springassist crutch NU 191.36 8/1/2011
E0130 Walker rigid adjust/fixed ht UE 54.35 8/1/2011
E0130 Walker rigid adjust/fixed ht RR 16.70 8/1/2011
E0130 Walker rigid adjust/fixed ht NU 69.74 8/1/2011
E0135 Walker folding adjust/fixed UE 63.87 8/1/2011
E0135 Walker folding adjust/fixed RR 17.14 8/1/2011
E0135 Walker folding adjust/fixed NU 83.25 8/1/2011
E0140 WALKER W TRUNK SUPPORT UE 268.65 8/1/2011
E0140 WALKER W TRUNK SUPPORT RR 35.83 8/1/2011
E0140 WALKER W TRUNK SUPPORT NU 358.19 8/1/2011
E0141 Rigid wheeled walker adj/fix UE 85.47 8/1/2011
E0141 Rigid wheeled walker adj/fix RR 22.20 8/1/2011
E0141 Rigid wheeled walker adj/fix NU 113.94 8/1/2011
E0143 Walker folding wheeled w/o s UE 89.35 8/1/2011
E0143 Walker folding wheeled w/o s RR 21.44 8/1/2011
E0143 Walker folding wheeled w/o s NU 119.39 8/1/2011
E0148 Heavyduty walker no wheels UE 94.61 8/1/2011
E0148 Heavyduty walker no wheels RR 12.63 8/1/2011
E0148 Heavyduty walker no wheels NU 126.16 8/1/2011
E0149 HEAVY DUTY WHEELED WALKER UE 166.22 8/1/2011
E0149 HEAVY DUTY WHEELED WALKER RR 22.16 8/1/2011
E0149 HEAVY DUTY WHEELED WALKER NU 221.64 8/1/2011
E0153 Forearm crutch platform atta UE 51.67 8/1/2011
E0153 Forearm crutch platform atta RR 7.79 8/1/2011
E0153 Forearm crutch platform atta NU 68.89 8/1/2011
E0154 Walker platform attachment UE 53.20 8/1/2011
E0154 Walker platform attachment RR 8.50 8/1/2011
E0154 Walker platform attachment NU 70.02 8/1/2011
E0155 Walker wheel attachment,pair UE 20.30 8/1/2011
E0155 Walker wheel attachment,pair RR 3.82 8/1/2011
E0155 Walker wheel attachment,pair NU 26.64 8/1/2011
E0157 Walker crutch attachment UE 61.02 8/1/2011
E0157 Walker crutch attachment RR 8.93 8/1/2011
E0157 Walker crutch attachment NU 81.35 8/1/2011
E0158 Walker leg extenders set of4 UE 20.51 8/1/2011
E0158 Walker leg extenders set of4 RR 3.53 8/1/2011
E0158 Walker leg extenders set of4 NU 27.16 8/1/2011
E0159 Brake for wheeled walker UE 13.31 8/1/2011
E0159 Brake for wheeled walker RR 1.79 8/1/2011
E0159 Brake for wheeled walker NU 17.74 8/1/2011
E0163 Commode chair with fixed arm UE 81.94 8/1/2011
11/55
Proc Code Description Mod Rate Rate Begin Date
E0163 Commode chair with fixed arm RR 24.26 8/1/2011
E0163 Commode chair with fixed arm NU 109.26 8/1/2011
E0165 Commode chair with detacharm UE 136.37 8/1/2011
E0165 Commode chair with detacharm RR 18.18 8/1/2011
E0165 Commode chair with detacharm NU 181.82 8/1/2011
E0167 Commode chair pail or pan UE 8.98 8/1/2011
E0167 Commode chair pail or pan RR 1.25 8/1/2011
E0167 Commode chair pail or pan NU 11.92 8/1/2011
E0168 Heavyduty/wide commode chair UE 112.39 8/1/2011
E0168 Heavyduty/wide commode chair RR 14.98 8/1/2011
E0168 Heavyduty/wide commode chair NU 149.86 8/1/2011
E0181 Press pad alternating w/ pum RR 22.72 8/1/2011
E0181 Press pad alternating w/ pum NU 227.20 8/1/2011
E0181 Press pad alternating w/ pum MS 22.72 8/1/2011
E0182 Replace pump, alt press pad RR 26.00 8/1/2011
E0182 Replace pump, alt press pad NU 259.97 8/1/2011
E0182 Replace pump, alt press pad MS 26.00 8/1/2011
E0184 Dry pressure mattress UE 126.03 8/1/2011
E0184 Dry pressure mattress RR 20.73 8/1/2011
E0184 Dry pressure mattress NU 164.34 8/1/2011
E0185 Gel pressure mattress pad UE 207.20 8/1/2011
E0185 Gel pressure mattress pad RR 37.93 8/1/2011
E0185 Gel pressure mattress pad NU 269.98 8/1/2011
E0186 Air pressure mattress RR 20.16 8/1/2011
E0186 Air pressure mattress NU 201.58 8/1/2011
E0186 Air pressure mattress MS 20.16 8/1/2011
E0187 Water pressure mattress RR 23.05 8/1/2011
E0187 Water pressure mattress NU 230.48 8/1/2011
E0187 Water pressure mattress MS 23.05 8/1/2011
E0191 Protector heel or elbow UE 6.30 8/1/2011
E0191 Protector heel or elbow RR 1.01 8/1/2011
E0191 Protector heel or elbow NU 8.43 8/1/2011
E0193 Powered air flotation bed RR 862.42 8/1/2011
E0193 Powered air flotation bed MS 862.42 8/1/2011
E0194 Air fluidized bed RR 3231.56 8/1/2011
E0194 Air fluidized bed MS 3231.56 8/1/2011
E0196 Gel pressure mattress RR 27.43 8/1/2011
E0196 Gel pressure mattress NU 274.27 8/1/2011
E0196 Gel pressure mattress MS 27.43 8/1/2011
E0197 AIR PRESSURE PAD FOR MATTRES UE 164.28 8/1/2011
E0197 AIR PRESSURE PAD FOR MATTRES RR 25.80 8/1/2011
E0197 AIR PRESSURE PAD FOR MATTRES NU 217.65 8/1/2011
E0198 Water pressure pad for mattr UE 163.24 8/1/2011
E0198 Water pressure pad for mattr RR 21.76 8/1/2011
E0198 Water pressure pad for mattr NU 217.65 8/1/2011
12/55
Proc Code Description Mod Rate Rate Begin Date
E0199 Dry pressure pad for mattres UE 23.87 8/1/2011
E0199 Dry pressure pad for mattres RR 3.17 8/1/2011
E0199 Dry pressure pad for mattres NU 31.83 8/1/2011
E0202 Phototherapy light w/ photom RR 53.38 8/1/2011
E0240 Bath/shower chair NU 44.69 8/1/2011
E0244 Toilet seat raised 44.69 8/1/2011
E0245 Tub stool or bench NU 79.44 8/1/2011
E0247 Trans bench w/wo comm open 79.44 8/1/2011
E0248 Hdtrans bench w/wo comm open 99.30 8/1/2011
E0250 Hosp bed fixed ht w/ mattres RR 97.08 8/1/2011
E0250 Hosp bed fixed ht w/ mattres NU 582.45 8/1/2011
E0250 Hosp bed fixed ht w/ mattres MS 97.08 8/1/2011
E0251 Hosp bed fixd ht w/o mattres RR 73.56 8/1/2011
E0251 Hosp bed fixd ht w/o mattres NU 441.37 8/1/2011
E0251 Hosp bed fixd ht w/o mattres MS 73.56 8/1/2011
E0255 Hospital bed var ht w/ mattr RR 116.66 8/1/2011
E0255 Hospital bed var ht w/ mattr NU 699.95 8/1/2011
E0255 Hospital bed var ht w/ mattr MS 116.66 8/1/2011
E0256 Hospital bed var ht w/o matt RR 82.77 8/1/2011
E0256 Hospital bed var ht w/o matt NU 496.60 8/1/2011
E0256 Hospital bed var ht w/o matt MS 82.77 8/1/2011
E0260 Hosp bed semi-electr w/ matt RR 166.75 8/1/2011
E0260 Hosp bed semi-electr w/ matt NU 1000.53 8/1/2011
E0260 Hosp bed semi-electr w/ matt MS 166.75 8/1/2011
E0261 Hosp bed semi-electr w/o mat RR 135.98 8/1/2011
E0261 Hosp bed semi-electr w/o mat NU 815.89 8/1/2011
E0261 Hosp bed semi-electr w/o mat MS 135.98 8/1/2011
E0271 Mattress innerspring UE 172.25 8/1/2011
E0271 Mattress innerspring RR 22.90 8/1/2011
E0271 Mattress innerspring NU 220.49 8/1/2011
E0272 Mattress foam rubber UE 149.99 8/1/2011
E0272 Mattress foam rubber RR 20.98 8/1/2011
E0272 Mattress foam rubber NU 200.95 8/1/2011
E0275 Bed pan standard UE 9.96 8/1/2011
E0275 Bed pan standard RR 1.59 8/1/2011
E0275 Bed pan standard NU 13.26 8/1/2011
E0276 Bed pan fracture UE 8.88 8/1/2011
E0276 Bed pan fracture RR 1.56 8/1/2011
E0276 Bed pan fracture NU 11.23 8/1/2011
E0277 Powered pres-redu air mattrs RR 640.94 8/1/2011
E0277 Powered pres-redu air mattrs NU 3845.65 8/1/2011
E0277 Powered pres-redu air mattrs MS 640.94 8/1/2011
E0280 Bed cradle UE 24.18 8/1/2011
E0280 Bed cradle RR 4.08 8/1/2011
E0280 Bed cradle NU 32.25 8/1/2011
13/55
Proc Code Description Mod Rate Rate Begin Date
E0290 Hosp bed fx ht w/o rails w/m RR 74.22 8/1/2011
E0290 Hosp bed fx ht w/o rails w/m NU 445.30 8/1/2011
E0290 Hosp bed fx ht w/o rails w/m MS 74.22 8/1/2011
E0291 Hosp bed fx ht w/o rail w/o RR 53.92 8/1/2011
E0291 Hosp bed fx ht w/o rail w/o NU 323.52 8/1/2011
E0291 Hosp bed fx ht w/o rail w/o MS 53.92 8/1/2011
E0292 HOSP BED VAR HT NO SR W/MATT RR 83.45 8/1/2011
E0292 HOSP BED VAR HT NO SR W/MATT NU 500.71 8/1/2011
E0292 HOSP BED VAR HT NO SR W/MATT MS 83.45 8/1/2011
E0293 HOSP BED VAR HT NO SR NO MAT RR 71.01 8/1/2011
E0293 HOSP BED VAR HT NO SR NO MAT NU 426.06 8/1/2011
E0293 HOSP BED VAR HT NO SR NO MAT MS 71.01 8/1/2011
E0294 Hosp bed semi-elect w/ mattr RR 129.74 8/1/2011
E0294 Hosp bed semi-elect w/ mattr NU 778.41 8/1/2011
E0294 Hosp bed semi-elect w/ mattr MS 129.74 8/1/2011
E0295 Hosp bed semi-elect w/o matt RR 126.46 8/1/2011
E0295 Hosp bed semi-elect w/o matt NU 758.75 8/1/2011
E0295 Hosp bed semi-elect w/o matt MS 126.46 8/1/2011
E0300 Enclosed ped crib hosp grade UE 2114.06 8/1/2011
E0300 Enclosed ped crib hosp grade RR 281.87 8/1/2011
E0300 Enclosed ped crib hosp grade NU 2818.75 8/1/2011
E0301 Hd hosp bed, 350-600 lbs RR 254.51 8/1/2011
E0301 Hd hosp bed, 350-600 lbs MS 254.51 8/1/2011
E0302 Ex hd hosp bed > 600 lbs RR 710.43 8/1/2011
E0302 Ex hd hosp bed > 600 lbs MS 710.43 8/1/2011
E0303 Hosp bed hvy dty xtra wide RR 287.49 8/1/2011
E0303 Hosp bed hvy dty xtra wide NU 2874.90 8/1/2015
E0303 Hosp bed hvy dty xtra wide MS 287.49 8/1/2011
E0304 Hosp bed xtra hvy dty x wide RR 765.28 8/1/2011
E0304 Hosp bed xtra hvy dty x wide MS 765.28 8/1/2011
E0305 Rails bed side half length RR 17.67 8/1/2011
E0305 Rails bed side half length NU 105.99 8/1/2011
E0305 Rails bed side half length MS 17.67 8/1/2011
E0310 Rails bed side full length UE 145.88 8/1/2011
E0310 Rails bed side full length RR 20.94 8/1/2011
E0310 Rails bed side full length NU 192.78 8/1/2011
E0316 Bed safety enclosure RR 184.70 8/1/2011
E0316 Bed safety enclosure NU 1108.19 8/1/2011
E0316 Bed safety enclosure MS 184.70 8/1/2011
E0325 Urinal male jug-type UE 5.65 8/1/2011
E0325 Urinal male jug-type RR 1.50 8/1/2011
E0325 Urinal male jug-type NU 8.53 8/1/2011
E0326 Urinal female jug-type UE 6.64 8/1/2011
E0326 Urinal female jug-type RR 1.18 8/1/2011
E0326 Urinal female jug-type NU 8.87 8/1/2011
14/55
Proc Code Description Mod Rate Rate Begin Date
E0328 Ped hospital bed, manual 0.00 1/1/2008
E0371 Nonpower mattress overlay RR 419.53 8/1/2011
E0371 Nonpower mattress overlay NU 2517.20 8/1/2011
E0371 Nonpower mattress overlay MS 419.53 8/1/2011
E0372 Powered air mattress overlay RR 509.05 8/1/2011
E0372 Powered air mattress overlay NU 3054.31 8/1/2011
E0372 Powered air mattress overlay MS 509.05 8/1/2011
E0373 Nonpowered pressure mattress RR 583.15 8/1/2011
E0373 Nonpowered pressure mattress NU 3498.90 8/1/2011
E0373 Nonpowered pressure mattress MS 583.15 8/1/2011
E0424 Stationary compressed gas 02 RR 171.96 8/1/2011
E0430 Oxygen system gas portable NU 214.31 8/1/2011
E0431 Portable gaseous 02 RR 35.72 8/1/2011
E0439 Stationary liquid 02 RR 171.96 8/1/2011
E0441 Stationary o2 contents, gas 76.91 8/1/2011
E0443 Portable 02 contents, gas 76.91 8/1/2011
E0444 Portable 02 contents, liquid 76.91 8/1/2011
E0445 Oximeter non-invasive RR 19.81 8/1/2011
E0445 Oximeter non-invasive NU 198.10 8/1/2015
E0457 Chest shell UE 457.62 8/1/2011
E0457 Chest shell RR 61.02 8/1/2011
E0457 Chest shell NU 610.21 8/1/2011
E0459 Chest wrap RR 50.53 8/1/2011
E0459 Chest wrap NU 505.34 8/1/2011
E0459 Chest wrap MS 50.53 8/1/2011
E0462 Rocking bed w/ or w/o side r RR 289.36 8/1/2011
E0462 Rocking bed w/ or w/o side r NU 1736.16 8/1/2011
E0462 Rocking bed w/ or w/o side r MS 289.36 8/1/2011
E0465 Home vent invasive interface RR 1055.23 1/1/2016
E0466 Home vent non-invasive inter RR 1055.23 1/1/2016
E0470 Rad w/o backup non-inv intfc RR 216.58 8/1/2011
E0470 Rad w/o backup non-inv intfc NU 2165.83 8/1/2011
E0470 Rad w/o backup non-inv intfc MS 216.58 8/1/2011
E0471 Rad w/backup non inv intrfc RR 637.67 8/1/2011
E0471 Rad w/backup non inv intrfc NU 6376.70 8/1/2015
E0471 Rad w/backup non inv intrfc MS 637.67 8/1/2011
E0472 Rad w backup invasive intrfc RR 637.67 8/1/2011
E0472 Rad w backup invasive intrfc MS 637.67 8/1/2011
E0480 Percussor elect/pneum home m RR 43.63 8/1/2011
E0480 Percussor elect/pneum home m NU 436.32 8/1/2011
E0480 Percussor elect/pneum home m MS 43.63 8/1/2011
E0482 Cough stimulating device RR 405.90 8/1/2011
E0482 Cough stimulating device NU 4058.99 8/1/2011
E0482 Cough stimulating device MS 405.90 8/1/2011
E0483 Chest compression gen system RR 1055.69 8/1/2011
15/55
Proc Code Description Mod Rate Rate Begin Date
E0483 Chest compression gen system NU 10556.88 8/1/2011
E0483 Chest compression gen system MS 1055.69 8/1/2011
E0484 Non-elec oscillatory pep dvc UE 27.51 8/1/2011
E0484 Non-elec oscillatory pep dvc RR 3.66 8/1/2011
E0484 Non-elec oscillatory pep dvc NU 36.66 8/1/2011
E0500 Ippb all types RR 107.43 8/1/2011
E0550 Humidif extens supple w ippb RR 49.78 8/1/2011
E0550 Humidif extens supple w ippb NU 497.79 8/1/2011
E0550 Humidif extens supple w ippb MS 49.78 8/1/2011
E0560 Humidifier supplemental w/ i UE 127.74 8/1/2011
E0560 Humidifier supplemental w/ i RR 19.96 8/1/2011
E0560 Humidifier supplemental w/ i NU 170.32 8/1/2011
E0561 Humidifier nonheated w pap UE 79.68 8/1/2011
E0561 Humidifier nonheated w pap RR 10.62 8/1/2011
E0561 Humidifier nonheated w pap NU 106.25 8/1/2011
E0562 Humidifier heated used w pap UE 224.33 8/1/2011
E0562 Humidifier heated used w pap RR 29.90 8/1/2011
E0562 Humidifier heated used w pap NU 299.11 8/1/2011
E0565 Compressor air power source RR 51.50 8/1/2011
E0565 Compressor air power source NU 514.97 8/1/2011
E0565 Compressor air power source MS 51.50 8/1/2011
E0570 Nebulizer with compression RR 16.65 8/1/2011
E0570 Nebulizer with compression NU 166.53 8/1/2011
E0570 Nebulizer with compression MS 16.65 8/1/2011
E0572 Aerosol compressor adjust pr RR 36.17 8/1/2011
E0572 Aerosol compressor adjust pr NU 361.65 8/1/2011
E0572 Aerosol compressor adjust pr MS 36.17 8/1/2011
E0580 Nebulizer for use w/ regulat UE 99.82 8/1/2011
E0580 Nebulizer for use w/ regulat RR 13.31 8/1/2011
E0580 Nebulizer for use w/ regulat NU 133.10 8/1/2011
E0585 Nebulizer w/ compressor & he RR 29.60 8/1/2011
E0585 Nebulizer w/ compressor & he NU 296.01 8/1/2011
E0585 Nebulizer w/ compressor & he MS 29.60 8/1/2011
E0600 Suction pump portab hom modl RR 43.03 8/1/2011
E0600 Suction pump portab hom modl NU 323.19 8/1/2011
E0600 Suction pump portab hom modl MS 43.03 8/1/2011
E0601 Cont airway pressure device RR 110.93 8/1/2011
E0601 Cont airway pressure device NU 1109.28 8/1/2011
E0601 Cont airway pressure device MS 110.93 8/1/2011
E0606 Drainage board postural RR 22.78 8/1/2011
E0606 Drainage board postural NU 227.79 8/1/2011
E0606 Drainage board postural MS 22.78 8/1/2011
E0618 Apnea monitor RR 277.29 8/1/2011
E0618 Apnea monitor NU 2772.90 8/1/2015
E0618 Apnea monitor MS 277.29 8/1/2011
16/55
Proc Code Description Mod Rate Rate Begin Date
E0619 Apnea monitor w recorder RR 277.29 8/1/2011
E0619 Apnea monitor w recorder NU 2772.90 8/1/2015
E0621 Patient lift sling or seat UE 71.85 8/1/2011
E0621 Patient lift sling or seat RR 9.19 8/1/2011
E0621 Patient lift sling or seat NU 95.32 8/1/2011
E0630 Patient lift hydraulic RR 101.18 8/1/2011
E0630 Patient lift hydraulic NU 607.06 8/1/2011
E0630 Patient lift hydraulic MS 101.18 8/1/2011
E0635 Patient lift electric RR 121.50 8/1/2011
E0635 Patient lift electric NU 729.02 8/1/2011
E0635 Patient lift electric MS 121.50 8/1/2011
E0637 Combination sit to stand sys UE 1567.67 8/1/2011
E0637 Combination sit to stand sys RR 209.04 8/1/2011
E0637 Combination sit to stand sys NU 2090.24 8/1/2011
E0638 Standing frame sys UE 635.70 8/1/2011
E0638 Standing frame sys RR 84.76 8/1/2011
E0638 Standing frame sys NU 847.60 8/1/2011
E0650 Pneuma compresor non-segment UE 536.38 8/1/2011
E0650 Pneuma compresor non-segment RR 86.04 8/1/2011
E0650 Pneuma compresor non-segment NU 715.18 8/1/2011
E0651 Pneum compressor segmental UE 675.60 8/1/2011
E0651 Pneum compressor segmental RR 90.08 8/1/2011
E0651 Pneum compressor segmental NU 900.79 8/1/2011
E0652 Pneum compres w/cal pressure UE 3944.72 8/1/2011
E0652 Pneum compres w/cal pressure RR 520.28 8/1/2011
E0652 Pneum compres w/cal pressure NU 5264.34 8/1/2011
E0655 Pneumatic appliance half arm UE 80.48 8/1/2011
E0655 Pneumatic appliance half arm RR 12.59 8/1/2011
E0655 Pneumatic appliance half arm NU 107.16 8/1/2011
E0660 Pneumatic appliance full leg UE 118.91 8/1/2011
E0660 Pneumatic appliance full leg RR 16.51 8/1/2011
E0660 Pneumatic appliance full leg NU 158.54 8/1/2011
E0665 Pneumatic appliance full arm UE 102.04 8/1/2011
E0665 Pneumatic appliance full arm RR 13.97 8/1/2011
E0665 Pneumatic appliance full arm NU 136.03 8/1/2011
E0666 Pneumatic appliance half leg UE 102.86 8/1/2011
E0666 Pneumatic appliance half leg RR 14.13 8/1/2011
E0666 Pneumatic appliance half leg NU 137.11 8/1/2011
E0667 Seg pneumatic appl full leg UE 241.13 8/1/2011
E0667 Seg pneumatic appl full leg RR 36.30 8/1/2011
E0667 Seg pneumatic appl full leg NU 321.50 8/1/2011
E0668 Seg pneumatic appl full arm UE 329.10 8/1/2011
E0668 Seg pneumatic appl full arm RR 43.30 8/1/2011
E0668 Seg pneumatic appl full arm NU 438.79 8/1/2011
E0669 Seg pneumatic appli half leg UE 136.55 8/1/2011
17/55
Proc Code Description Mod Rate Rate Begin Date
E0669 Seg pneumatic appli half leg RR 18.21 8/1/2011
E0669 Seg pneumatic appli half leg NU 182.03 8/1/2011
E0670 Seg pneum int legs/trunk UE 1020.72 1/1/2013
E0670 Seg pneum int legs/trunk RR 144.68 1/1/2013
E0670 Seg pneum int legs/trunk NU 1351.50 1/1/2013
E0671 Pressure pneum appl full leg UE 309.32 8/1/2011
E0671 Pressure pneum appl full leg RR 41.25 8/1/2011
E0671 Pressure pneum appl full leg NU 412.44 8/1/2011
E0672 Pressure pneum appl full arm UE 240.37 8/1/2011
E0672 Pressure pneum appl full arm RR 32.05 8/1/2011
E0672 Pressure pneum appl full arm NU 320.47 8/1/2011
E0673 Pressure pneum appl half leg UE 199.74 8/1/2011
E0673 Pressure pneum appl half leg RR 26.63 8/1/2011
E0673 Pressure pneum appl half leg NU 266.29 8/1/2011
E0675 Pneumatic compression device RR 319.74 8/1/2011
E0675 Pneumatic compression device MS 319.74 8/1/2011
E0700 Safety equipment NU 0.00 1/1/1986
E0705 Transfer device NU 54.73 8/1/2011
E0747 Elec osteogen stim not spine UE 2602.31 8/1/2011
E0747 Elec osteogen stim not spine RR 348.06 8/1/2011
E0747 Elec osteogen stim not spine NU 3502.52 8/1/2011
E0748 Elec osteogen stim spinal UE 2609.88 8/1/2011
E0748 Elec osteogen stim spinal RR 347.98 8/1/2011
E0748 Elec osteogen stim spinal NU 3479.82 8/1/2011
E0776 Iv pole RR 9.36 8/1/2011
E0776 Iv pole NU 93.67 8/1/2011
E0779 Amb infusion pump mechanical NU 249.97 8/1/2011
E0780 Mech amb infusion pump <8hrs NU 10.30 8/1/2011
E0781 External ambulatory infus pu RR 249.97 8/1/2011
E0781 External ambulatory infus pu NU 2499.68 8/1/2011
E0781 External ambulatory infus pu MS 249.97 8/1/2011
E0784 Ext amb infusn pump insulin RR 414.57 8/1/2011
E0784 Ext amb infusn pump insulin NU 4145.68 8/1/2011
E0784 Ext amb infusn pump insulin MS 414.57 8/1/2011
E0791 Parenteral infusion pump sta RR 313.99 8/1/2011
E0791 Parenteral infusion pump sta NU 3139.87 8/1/2011
E0791 Parenteral infusion pump sta MS 313.99 8/1/2011
E0910 Trapeze bar attached to bed RR 19.86 8/1/2011
E0910 Trapeze bar attached to bed NU 198.60 8/1/2011
E0910 Trapeze bar attached to bed MS 19.86 8/1/2011
E0911 Hd trapeze bar attach to bed RR 49.50 8/1/2011
E0912 Hd trapeze bar free standing RR 113.67 8/1/2011
E0935 Cont pas motion exercise dev RR 19.18 8/1/2011
E0936 Cpm device, other than knee 0.00 1/1/2007
E0940 Trapeze bar free standing RR 34.53 8/1/2011
18/55
Proc Code Description Mod Rate Rate Begin Date
E0940 Trapeze bar free standing NU 345.27 8/1/2011
E0940 Trapeze bar free standing MS 34.53 8/1/2011
E0951 Loop heel UE 14.03 8/1/2011
E0951 Loop heel RR 1.94 8/1/2011
E0951 Loop heel NU 18.70 8/1/2011
E0955 CUSHIONED HEADREST UE 150.57 8/1/2011
E0955 CUSHIONED HEADREST RR 20.09 8/1/2011
E0955 CUSHIONED HEADREST NU 200.76 8/1/2011
E0956 W/c lateral trunk/hip suppor UE 73.41 8/1/2011
E0956 W/c lateral trunk/hip suppor RR 9.80 8/1/2011
E0956 W/c lateral trunk/hip suppor NU 97.87 8/1/2011
E0957 W/c medial thigh support UE 102.73 8/1/2011
E0957 W/c medial thigh support RR 13.69 8/1/2011
E0957 W/c medial thigh support NU 136.96 8/1/2011
E0958 Whlchr att- conv 1 arm drive RR 43.32 8/1/2011
E0958 Whlchr att- conv 1 arm drive MS 43.32 8/1/2011
E0960 W/c shoulder harness/straps UE 67.76 8/1/2011
E0960 W/c shoulder harness/straps RR 9.04 8/1/2011
E0960 W/c shoulder harness/straps NU 90.34 8/1/2011
E0967 MAN WC RIM/PROJECTION REP EA UE 98.44 8/1/2011
E0967 MAN WC RIM/PROJECTION REP EA RR 13.47 8/1/2011
E0967 MAN WC RIM/PROJECTION REP EA NU 131.21 8/1/2011
E0968 Wheelchair commode seat RR 17.78 8/1/2011
E0968 Wheelchair commode seat MS 17.78 8/1/2011
E0969 Wheelchair narrowing device UE 116.66 8/1/2011
E0969 Wheelchair narrowing device RR 15.40 8/1/2011
E0969 Wheelchair narrowing device NU 155.53 8/1/2011
E0971 Wheelchair anti-tipping devi UE 41.62 8/1/2011
E0971 Wheelchair anti-tipping devi RR 7.41 8/1/2011
E0971 Wheelchair anti-tipping devi NU 55.50 8/1/2011
E0973 W/ch access det adj armrest UE 85.63 8/1/2011
E0973 W/ch access det adj armrest RR 10.87 8/1/2011
E0973 W/ch access det adj armrest NU 114.17 8/1/2011
E0978 W/c acc,saf belt pelv strap UE 30.80 8/1/2011
E0978 W/c acc,saf belt pelv strap RR 4.25 8/1/2011
E0978 W/c acc,saf belt pelv strap NU 41.07 8/1/2011
E0980 Wheelchair safety vest UE 20.81 8/1/2011
E0980 Wheelchair safety vest RR 3.28 8/1/2011
E0980 Wheelchair safety vest NU 27.90 8/1/2011
E0981 Seat upholstery, replacement UE 33.88 8/1/2011
E0981 Seat upholstery, replacement RR 4.77 8/1/2011
E0981 Seat upholstery, replacement NU 45.19 8/1/2011
E0982 Back upholstery, replacement UE 32.61 8/1/2011
E0982 Back upholstery, replacement RR 5.11 8/1/2011
E0982 Back upholstery, replacement NU 43.49 8/1/2011
19/55
Proc Code Description Mod Rate Rate Begin Date
E0983 Add pwr joystick RR 236.38 8/1/2011
E0983 Add pwr joystick MS 236.38 8/1/2011
E0984 Add pwr tiller UE 1407.49 8/1/2011
E0984 Add pwr tiller RR 176.35 8/1/2011
E0984 Add pwr tiller NU 1876.69 8/1/2011
E0985 W/C SEAT LIFT MECHANISM UE 151.06 8/1/2011
E0985 W/C SEAT LIFT MECHANISM RR 20.16 8/1/2011
E0985 W/C SEAT LIFT MECHANISM NU 201.43 8/1/2011
E0986 Man w/c push-rim powr system UE 3622.66 8/1/2011
E0986 Man w/c push-rim powr system RR 483.02 8/1/2011
E0986 Man w/c push-rim powr system NU 4830.19 8/1/2011
E0992 Wheelchair solid seat insert RR 9.19 8/1/2011
E0992 Wheelchair solid seat insert NU 94.48 8/1/2011
E0994 Wheelchair arm rest UE 13.14 8/1/2011
E0994 Wheelchair arm rest RR 1.77 8/1/2011
E0994 Wheelchair arm rest NU 17.51 8/1/2011
E0995 WC CALF REST, PAD REPLACEMNT UE 22.62 8/1/2011
E0995 WC CALF REST, PAD REPLACEMNT RR 3.03 8/1/2011
E0995 WC CALF REST, PAD REPLACEMNT NU 30.19 8/1/2011
E1002 Pwr seat tilt UE 3063.17 8/1/2011
E1002 Pwr seat tilt RR 408.44 8/1/2011
E1002 Pwr seat tilt NU 4084.23 8/1/2011
E1003 Pwr seat recline UE 3270.43 8/1/2011
E1003 Pwr seat recline RR 436.07 8/1/2011
E1003 Pwr seat recline NU 4360.56 8/1/2011
E1004 Pwr seat recline mech UE 3626.21 8/1/2011
E1004 Pwr seat recline mech RR 483.49 8/1/2011
E1004 Pwr seat recline mech NU 4834.97 8/1/2011
E1005 Pwr seat recline pwr UE 3925.11 8/1/2011
E1005 Pwr seat recline pwr RR 523.34 8/1/2011
E1005 Pwr seat recline pwr NU 5233.47 8/1/2011
E1006 Pwr seat combo w/o shear UE 4807.89 8/1/2011
E1006 Pwr seat combo w/o shear RR 641.03 8/1/2011
E1006 Pwr seat combo w/o shear NU 6410.51 8/1/2011
E1007 Pwr seat combo w/shear UE 6510.05 8/1/2011
E1007 Pwr seat combo w/shear RR 868.01 8/1/2011
E1007 Pwr seat combo w/shear NU 8680.08 8/1/2011
E1008 Pwr seat combo pwr shear UE 6510.65 8/1/2011
E1008 Pwr seat combo pwr shear RR 868.08 8/1/2011
E1008 Pwr seat combo pwr shear NU 8680.86 8/1/2011
E1009 Add mech leg elevation UE 0.00 1/1/2004
E1009 Add mech leg elevation RR 0.00 1/1/2004
E1009 Add mech leg elevation NU 0.00 1/1/2004
E1010 Add pwr leg elevation UE 857.47 8/1/2011
E1010 Add pwr leg elevation RR 114.32 8/1/2011
20/55
Proc Code Description Mod Rate Rate Begin Date
E1010 Add pwr leg elevation NU 1143.30 8/1/2011
E1014 Reclining back add ped w/c UE 271.93 8/1/2011
E1014 Reclining back add ped w/c RR 36.26 8/1/2011
E1014 Reclining back add ped w/c NU 362.58 8/1/2011
E1015 Shock absorber for man w/c UE 85.42 8/1/2011
E1015 Shock absorber for man w/c RR 11.38 8/1/2011
E1015 Shock absorber for man w/c NU 113.90 8/1/2011
E1016 Shock absorber for power w/c UE 97.79 8/1/2011
E1016 Shock absorber for power w/c RR 13.05 8/1/2011
E1016 Shock absorber for power w/c NU 130.39 8/1/2011
E1020 RESIDUAL LIMB SUPPORT SYSTEM UE 181.27 8/1/2011
E1020 RESIDUAL LIMB SUPPORT SYSTEM RR 24.15 8/1/2011
E1020 RESIDUAL LIMB SUPPORT SYSTEM NU 241.71 8/1/2011
E1028 W/C MANUAL SWINGAWAY UE 153.81 8/1/2011
E1028 W/C MANUAL SWINGAWAY RR 20.51 8/1/2011
E1028 W/C MANUAL SWINGAWAY NU 205.09 8/1/2011
E1029 W/c vent tray fixed UE 275.21 8/1/2011
E1029 W/c vent tray fixed RR 36.69 8/1/2011
E1029 W/c vent tray fixed NU 366.95 8/1/2011
E1031 Rollabout chair with casters RR 50.16 8/1/2011
E1031 Rollabout chair with casters NU 501.56 8/1/2011
E1035 Patient transfer system <300 RR 608.91 8/1/2011
E1035 Patient transfer system <300 NU 6089.08 8/1/2011
E1037 Transport chair, ped size RR 107.73 8/1/2011
E1037 Transport chair, ped size NU 1077.31 8/1/2011
E1038 Transport chair pt wt<=300lb RR 39.73 8/1/2011
E1038 Transport chair pt wt<=300lb NU 397.30 8/1/2011
E1039 Transport chair pt wt >300lb RR 22.49 8/1/2011
E1050 Whelchr fxd full length arms RR 101.13 8/1/2011
E1060 Wheelchair detachable arms RR 125.19 8/1/2011
E1070 Wheelchair detachable foot r RR 92.68 8/1/2011
E1083 Hemi-wheelchair fixed arms RR 72.61 8/1/2011
E1084 Hemi-wheelchair detachable a RR 97.41 8/1/2011
E1087 Wheelchair lightwt fixed arm RR 106.78 8/1/2011
E1088 Wheelchair lightweight det a RR 149.71 8/1/2011
E1092 Wheelchair wide w/ leg rests RR 127.61 8/1/2011
E1093 Wheelchair wide w/ foot rest RR 109.75 8/1/2011
E1100 Whchr s-recl fxd arm leg res RR 97.14 8/1/2011
E1110 Wheelchair semi-recl detach RR 97.14 8/1/2011
E1150 Wheelchair standard w/ leg r RR 81.01 8/1/2011
E1160 Wheelchair fixed arms RR 62.06 8/1/2011
E1161 Manual adult wc w tiltinspac RR 234.27 8/1/2011
E1161 Manual adult wc w tiltinspac NU 2349.53 8/1/2011
E1170 Whlchr ampu fxd arm leg rest RR 88.68 8/1/2011
E1171 Wheelchair amputee w/o leg r RR 79.59 8/1/2011
21/55
Proc Code Description Mod Rate Rate Begin Date
E1172 Wheelchair amputee detach ar RR 95.00 8/1/2011
E1180 Wheelchair amputee w/ foot r RR 100.63 8/1/2011
E1190 Wheelchair amputee w/ leg re RR 98.81 8/1/2011
E1195 Wheelchair amputee heavy dut RR 124.75 8/1/2011
E1200 Wheelchair amputee fixed arm RR 86.40 8/1/2011
E1221 Wheelchair spec size w foot RR 47.18 8/1/2011
E1222 Wheelchair spec size w/ leg RR 67.32 8/1/2011
E1223 Wheelchair spec size w foot RR 73.50 8/1/2011
E1224 Wheelchair spec size w/ leg RR 80.58 8/1/2011
E1225 Manual semi-reclining back RR 44.88 8/1/2011
E1226 Manual fully reclining back UE 365.12 8/1/2011
E1226 Manual fully reclining back RR 48.70 8/1/2011
E1226 Manual fully reclining back NU 486.82 8/1/2011
E1227 Wheelchair spec sz spec ht a UE 175.69 8/1/2011
E1227 Wheelchair spec sz spec ht a RR 23.42 8/1/2011
E1227 Wheelchair spec sz spec ht a NU 234.23 8/1/2011
E1228 Wheelchair spec sz spec ht b RR 27.82 8/1/2011
E1230 Power operated vehicle UE 1776.29 8/1/2011
E1230 Power operated vehicle RR 220.89 8/1/2011
E1230 Power operated vehicle NU 2245.96 8/1/2011
E1232 Folding ped wc tilt-in-space RR 211.93 8/1/2011
E1232 Folding ped wc tilt-in-space NU 2119.26 8/1/2011
E1233 Rig ped wc tltnspc w/o seat RR 219.30 8/1/2011
E1233 Rig ped wc tltnspc w/o seat NU 2193.04 8/1/2011
E1234 Fld ped wc tltnspc w/o seat RR 190.97 8/1/2011
E1234 Fld ped wc tltnspc w/o seat NU 1909.74 8/1/2011
E1235 Rigid ped wc adjustable RR 183.89 8/1/2011
E1235 Rigid ped wc adjustable NU 1838.94 8/1/2011
E1236 Folding ped wc adjustable RR 162.20 8/1/2011
E1236 Folding ped wc adjustable NU 1621.97 8/1/2011
E1237 Rgd ped wc adjstabl w/o seat RR 163.66 8/1/2011
E1237 Rgd ped wc adjstabl w/o seat NU 1636.56 8/1/2011
E1238 Fld ped wc adjstabl w/o seat RR 170.66 8/1/2011
E1238 Fld ped wc adjstabl w/o seat NU 1706.57 8/1/2011
E1240 Whchr litwt det arm leg rest RR 91.39 8/1/2011
E1270 Wheelchair lightweight leg r RR 75.56 8/1/2011
E1280 Whchr h-duty det arm leg res RR 130.34 8/1/2011
E1295 Wheelchair heavy duty fixed RR 120.62 8/1/2011
E1296 Wheelchair special seat heig UE 311.25 8/1/2011
E1296 Wheelchair special seat heig RR 42.15 8/1/2011
E1296 Wheelchair special seat heig NU 414.99 8/1/2011
E1297 Wheelchair special seat dept UE 77.90 8/1/2011
E1297 Wheelchair special seat dept RR 11.54 8/1/2011
E1297 Wheelchair special seat dept NU 103.88 8/1/2011
E1298 Wheelchair spec seat depth/w UE 315.51 8/1/2011
22/55
Proc Code Description Mod Rate Rate Begin Date
E1298 Wheelchair spec seat depth/w RR 43.05 8/1/2011
E1298 Wheelchair spec seat depth/w NU 420.68 8/1/2011
E1372 Oxy suppl heater for nebuliz UE 101.86 8/1/2011
E1372 Oxy suppl heater for nebuliz RR 20.00 8/1/2011
E1372 Oxy suppl heater for nebuliz NU 137.61 8/1/2011
E1390 Oxygen concentrator RR 171.96 8/1/2011
E1391 Oxygen concentrator, dual RR 171.96 8/1/2011
E1392 Portable oxygen concentrator RR 31.85 8/1/2011
E1399 Durable medical equipment mi 0.00 1/1/1980
E1405 O2/water vapor enrich w/heat RR 256.80 8/1/2011
E1406 O2/water vapor enrich w/o he RR 243.85 8/1/2011
E1702 Repl measr scales jaw motion 22.41 8/1/2011
E1800 Adjust elbow ext/flex device RR 121.64 8/1/2011
E1801 Sps elbow device RR 121.77 8/1/2011
E1802 Adjst forearm pro/sup device RR 324.51 8/1/2011
E1805 Adjust wrist ext/flex device RR 125.46 8/1/2011
E1806 Sps wrist device RR 99.97 8/1/2011
E1810 Adjust knee ext/flex device RR 123.71 8/1/2011
E1811 Sps knee device RR 126.60 8/1/2011
E1812 Knee ext/flex w act res ctrl RR 85.39 8/1/2011
E1815 Adjust ankle ext/flex device RR 125.46 8/1/2011
E1816 Sps ankle device RR 128.58 8/1/2011
E1818 Sps forearm device RR 131.24 8/1/2011
E1820 Soft interface material UE 57.43 8/1/2011
E1820 Soft interface material RR 7.67 8/1/2011
E1820 Soft interface material NU 76.57 8/1/2011
E1821 Replacement interface spsd UE 78.40 8/1/2011
E1821 Replacement interface spsd RR 10.44 8/1/2011
E1821 Replacement interface spsd NU 104.51 8/1/2011
E1825 Adjust finger ext/flex devc RR 125.46 8/1/2011
E1830 Adjust toe ext/flex device RR 125.46 8/1/2011
E1840 Adj shoulder ext/flex device RR 372.55 8/1/2011
E2000 Gastric suction pump hme mdl RR 48.91 8/1/2011
E2000 Gastric suction pump hme mdl NU 489.05 8/1/2011
E2201 "Man w/ch acc seat w>=20""<24""" UE 277.87 8/1/2011
E2201 "Man w/ch acc seat w>=20""<24""" RR 37.05 8/1/2011
E2201 "Man w/ch acc seat w>=20""<24""" NU 370.49 8/1/2011
E2202 Seat width 24-27 in UE 353.01 8/1/2011
E2202 Seat width 24-27 in RR 47.07 8/1/2011
E2202 Seat width 24-27 in NU 470.66 8/1/2011
E2203 Frame depth less than 22 in UE 356.77 8/1/2011
E2203 Frame depth less than 22 in RR 47.55 8/1/2011
E2203 Frame depth less than 22 in NU 475.70 8/1/2011
E2204 Frame depth 22 to 25 in UE 605.78 8/1/2011
E2204 Frame depth 22 to 25 in RR 80.78 8/1/2011
23/55
Proc Code Description Mod Rate Rate Begin Date
E2204 Frame depth 22 to 25 in NU 807.71 8/1/2011
E2205 Manual wc accessory, handrim UE 23.93 8/1/2011
E2205 Manual wc accessory, handrim RR 3.17 8/1/2011
E2205 Manual wc accessory, handrim NU 31.88 8/1/2011
E2206 MAN WC WHL LOCK COMP REPL EA UE 29.80 8/1/2011
E2206 MAN WC WHL LOCK COMP REPL EA RR 3.96 8/1/2011
E2206 MAN WC WHL LOCK COMP REPL EA NU 39.73 8/1/2011
E2207 Crutch and cane holder UE 31.75 8/1/2011
E2207 Crutch and cane holder RR 4.24 8/1/2011
E2207 Crutch and cane holder NU 42.32 8/1/2011
E2208 Cylinder tank carrier UE 86.98 8/1/2011
E2208 Cylinder tank carrier RR 11.60 8/1/2011
E2208 Cylinder tank carrier NU 115.39 8/1/2011
E2209 Arm trough each UE 78.49 8/1/2011
E2209 Arm trough each RR 10.45 8/1/2011
E2209 Arm trough each NU 104.65 8/1/2011
E2210 Wheelchair bearings UE 4.89 8/1/2011
E2210 Wheelchair bearings RR 0.66 8/1/2011
E2210 Wheelchair bearings NU 6.50 8/1/2011
E2211 Pneumatic propulsion tire UE 24.74 8/1/2011
E2211 Pneumatic propulsion tire RR 3.98 8/1/2011
E2211 Pneumatic propulsion tire NU 34.53 8/1/2011
E2212 Pneumatic prop tire tube UE 4.31 8/1/2011
E2212 Pneumatic prop tire tube RR 0.61 8/1/2011
E2212 Pneumatic prop tire tube NU 5.74 8/1/2011
E2213 Pneumatic prop tire insert UE 22.25 8/1/2011
E2213 Pneumatic prop tire insert RR 2.99 8/1/2011
E2213 Pneumatic prop tire insert NU 29.70 8/1/2011
E2214 Pneumatic caster tire each UE 22.94 8/1/2011
E2214 Pneumatic caster tire each RR 3.93 8/1/2011
E2214 Pneumatic caster tire each NU 30.60 8/1/2011
E2215 Pneumatic caster tire tube UE 7.03 8/1/2011
E2215 Pneumatic caster tire tube RR 0.93 8/1/2011
E2215 Pneumatic caster tire tube NU 9.38 8/1/2011
E2216 Foam filled propulsion tire UE 21.17 8/1/2011
E2216 Foam filled propulsion tire RR 2.82 8/1/2011
E2216 Foam filled propulsion tire NU 28.22 8/1/2011
E2217 Foam filled caster tire each UE 0.00 1/1/2006
E2217 Foam filled caster tire each RR 0.00 1/1/2006
E2217 Foam filled caster tire each NU 0.00 1/1/2006
E2218 Foam propulsion tire each UE 12.47 8/1/2011
E2218 Foam propulsion tire each RR 1.66 8/1/2011
E2218 Foam propulsion tire each NU 16.62 8/1/2011
E2219 Foam caster tire any size ea UE 26.49 8/1/2011
E2219 Foam caster tire any size ea RR 4.69 8/1/2011
24/55
Proc Code Description Mod Rate Rate Begin Date
E2219 Foam caster tire any size ea NU 35.32 8/1/2011
E2220 SOLID PROPULS TIRE, REPL, EA UE 21.66 8/1/2011
E2220 SOLID PROPULS TIRE, REPL, EA RR 2.73 8/1/2011
E2220 SOLID PROPULS TIRE, REPL, EA NU 28.32 8/1/2011
E2221 SOLID CASTER TIRE REPL, EACH UE 18.73 8/1/2011
E2221 SOLID CASTER TIRE REPL, EACH RR 2.47 8/1/2011
E2221 SOLID CASTER TIRE REPL, EACH NU 24.94 8/1/2011
E2222 SOLID CASTER INTEG WHL, REPL UE 15.70 8/1/2011
E2222 SOLID CASTER INTEG WHL, REPL RR 2.08 8/1/2011
E2222 SOLID CASTER INTEG WHL, REPL NU 20.88 8/1/2011
E2224 PROPULSION WHL EXCL TIRE REP UE 62.08 8/1/2011
E2224 PROPULSION WHL EXCL TIRE REP RR 10.22 8/1/2011
E2224 PROPULSION WHL EXCL TIRE REP NU 83.26 8/1/2011
E2225 Caster wheel excludes tire UE 12.95 8/1/2011
E2225 Caster wheel excludes tire RR 1.70 8/1/2011
E2225 Caster wheel excludes tire NU 17.28 8/1/2011
E2226 Caster fork replacement only UE 28.26 8/1/2011
E2226 Caster fork replacement only RR 3.76 8/1/2011
E2226 Caster fork replacement only NU 37.67 8/1/2011
E2231 Solid seat support base UE 120.16 8/1/2011
E2231 Solid seat support base RR 16.03 8/1/2011
E2231 Solid seat support base NU 160.23 8/1/2011
E2291 Planar back for ped size wc UE 127.01 8/1/2011
E2291 Planar back for ped size wc RR 16.94 8/1/2011
E2291 Planar back for ped size wc NU 169.36 8/1/2011
E2292 Planar seat for ped size wc UE 127.01 8/1/2011
E2292 Planar seat for ped size wc RR 16.94 8/1/2011
E2292 Planar seat for ped size wc NU 169.36 8/1/2011
E2293 Contour back for ped size wc UE 169.36 8/1/2011
E2293 Contour back for ped size wc RR 22.58 8/1/2011
E2293 Contour back for ped size wc NU 225.81 8/1/2011
E2294 Contour seat for ped size wc UE 169.36 8/1/2011
E2294 Contour seat for ped size wc RR 22.58 8/1/2011
E2294 Contour seat for ped size wc NU 225.81 8/1/2011
E2295 Ped dynamic seating frame 0.00 1/1/2009
E2310 Electro connect btw control UE 871.54 8/1/2011
E2310 Electro connect btw control RR 116.20 8/1/2011
E2310 Electro connect btw control NU 1162.05 8/1/2011
E2311 Electro connect btw 2 sys UE 1764.46 8/1/2011
E2311 Electro connect btw 2 sys RR 235.27 8/1/2011
E2311 Electro connect btw 2 sys NU 2352.62 8/1/2011
E2312 Mini-prop remote joystick UE 1444.18 8/1/2011
E2312 Mini-prop remote joystick RR 192.56 8/1/2011
E2312 Mini-prop remote joystick NU 1925.61 8/1/2011
E2313 Pwc harness, expand control UE 229.33 8/1/2011
25/55
Proc Code Description Mod Rate Rate Begin Date
E2313 Pwc harness, expand control RR 30.59 8/1/2011
E2313 Pwc harness, expand control NU 305.77 8/1/2011
E2321 Hand interface joystick UE 1141.63 8/1/2011
E2321 Hand interface joystick RR 152.21 8/1/2011
E2321 Hand interface joystick NU 1522.17 8/1/2011
E2322 Mult mech switches UE 1050.38 8/1/2011
E2322 Mult mech switches RR 140.04 8/1/2011
E2322 Mult mech switches NU 1400.49 8/1/2011
E2323 Special joystick handle UE 48.14 8/1/2011
E2323 Special joystick handle RR 6.42 8/1/2011
E2323 Special joystick handle NU 64.19 8/1/2011
E2324 Chin cup interface UE 33.14 8/1/2011
E2324 Chin cup interface RR 4.42 8/1/2011
E2324 Chin cup interface NU 44.18 8/1/2011
E2325 Sip and puff interface UE 1003.06 8/1/2011
E2325 Sip and puff interface RR 133.76 8/1/2011
E2325 Sip and puff interface NU 1337.40 8/1/2011
E2326 Breath tube kit UE 238.04 8/1/2011
E2326 Breath tube kit RR 31.74 8/1/2011
E2326 Breath tube kit NU 317.36 8/1/2011
E2327 Head control interface mech UE 1717.47 8/1/2011
E2327 Head control interface mech RR 229.01 8/1/2011
E2327 Head control interface mech NU 2290.00 8/1/2011
E2328 Head/extremity control inter UE 2887.65 8/1/2011
E2328 Head/extremity control inter RR 384.73 8/1/2011
E2328 Head/extremity control inter NU 3850.08 8/1/2011
E2329 Head control nonproportional UE 1288.64 8/1/2011
E2329 Head control nonproportional RR 171.83 8/1/2011
E2329 Head control nonproportional NU 1718.10 8/1/2011
E2330 Head control proximity switc UE 2482.46 8/1/2011
E2330 Head control proximity switc RR 330.99 8/1/2011
E2330 Head control proximity switc NU 3309.94 8/1/2011
E2340 W/c wdth 20-23 in seat frame UE 234.02 8/1/2011
E2340 W/c wdth 20-23 in seat frame RR 31.20 8/1/2011
E2340 W/c wdth 20-23 in seat frame NU 312.02 8/1/2011
E2341 W/c wdth 24-27 in seat frame UE 344.80 8/1/2011
E2341 W/c wdth 24-27 in seat frame RR 45.98 8/1/2011
E2341 W/c wdth 24-27 in seat frame NU 459.73 8/1/2011
E2342 W/c dpth 20-21 in seat frame UE 333.68 8/1/2011
E2342 W/c dpth 20-21 in seat frame RR 44.49 8/1/2011
E2342 W/c dpth 20-21 in seat frame NU 444.89 8/1/2011
E2343 W/c dpth 22-25 in seat frame UE 193.08 8/1/2011
E2343 W/c dpth 22-25 in seat frame RR 25.75 8/1/2011
E2343 W/c dpth 22-25 in seat frame NU 257.46 8/1/2011
E2351 Electronic sgd interface UE 520.29 8/1/2011
26/55
Proc Code Description Mod Rate Rate Begin Date
E2351 Electronic sgd interface RR 69.39 8/1/2011
E2351 Electronic sgd interface NU 693.74 8/1/2011
E2358 Gr 34 nonsealed leadacid 0.00 1/1/2012
E2359 Gr34 sealed leadacid battery 185.83 12/1/2015
E2360 22nf nonsealed leadacid UE 83.67 8/1/2011
E2360 22nf nonsealed leadacid RR 11.21 8/1/2011
E2360 22nf nonsealed leadacid NU 111.55 8/1/2011
E2361 22nf sealed leadacid battery UE 102.14 8/1/2011
E2361 22nf sealed leadacid battery RR 13.62 8/1/2011
E2361 22nf sealed leadacid battery NU 136.19 8/1/2011
E2362 Gr24 nonsealed leadacid UE 67.35 8/1/2011
E2362 Gr24 nonsealed leadacid RR 8.98 8/1/2011
E2362 Gr24 nonsealed leadacid NU 89.81 8/1/2011
E2363 Gr24 sealed leadacid battery UE 136.21 8/1/2011
E2363 Gr24 sealed leadacid battery RR 18.17 8/1/2011
E2363 Gr24 sealed leadacid battery NU 181.61 8/1/2011
E2364 U1nonsealed leadacid battery UE 83.67 8/1/2011
E2364 U1nonsealed leadacid battery RR 11.21 8/1/2011
E2364 U1nonsealed leadacid battery NU 111.55 8/1/2011
E2365 U1 sealed leadacid battery UE 82.17 8/1/2011
E2365 U1 sealed leadacid battery RR 10.95 8/1/2011
E2365 U1 sealed leadacid battery NU 109.54 8/1/2011
E2366 Battery charger, single mode UE 166.88 8/1/2011
E2366 Battery charger, single mode RR 22.31 8/1/2011
E2366 Battery charger, single mode NU 222.51 8/1/2011
E2367 Battery charger, dual mode UE 312.11 8/1/2011
E2367 Battery charger, dual mode RR 41.62 8/1/2011
E2367 Battery charger, dual mode NU 416.15 8/1/2011
E2368 PWR WC DRIVEWHEEL MOTOR REPL UE 384.73 8/1/2011
E2368 PWR WC DRIVEWHEEL MOTOR REPL RR 51.31 8/1/2011
E2368 PWR WC DRIVEWHEEL MOTOR REPL NU 512.95 8/1/2011
E2369 PWR WC DRIVEWHEEL GEAR REPL UE 335.09 8/1/2011
E2369 PWR WC DRIVEWHEEL GEAR REPL RR 44.69 8/1/2011
E2369 PWR WC DRIVEWHEEL GEAR REPL NU 446.79 8/1/2011
E2370 PWR WC DR WH MOTOR/GEAR COMB UE 597.91 8/1/2011
E2370 PWR WC DR WH MOTOR/GEAR COMB RR 79.73 8/1/2011
E2370 PWR WC DR WH MOTOR/GEAR COMB NU 797.22 8/1/2011
E2371 Gr27 sealed leadacid battery UE 112.27 8/1/2011
E2371 Gr27 sealed leadacid battery RR 14.97 8/1/2011
E2371 Gr27 sealed leadacid battery NU 149.68 8/1/2011
E2373 Hand/chin ctrl spec joystick UE 503.41 8/1/2011
E2373 Hand/chin ctrl spec joystick RR 67.14 8/1/2011
E2373 Hand/chin ctrl spec joystick NU 671.19 8/1/2011
E2374 Hand/chin ctrl std joystick UE 397.73 8/1/2011
E2374 Hand/chin ctrl std joystick RR 53.03 8/1/2011
27/55
Proc Code Description Mod Rate Rate Begin Date
E2374 Hand/chin ctrl std joystick NU 530.28 8/1/2011
E2375 NON-EXPANDABLE CONTROLLER UE 637.90 8/1/2011
E2375 NON-EXPANDABLE CONTROLLER RR 85.05 8/1/2011
E2375 NON-EXPANDABLE CONTROLLER NU 850.56 8/1/2011
E2376 Expandable controller, repl UE 999.67 8/1/2011
E2376 Expandable controller, repl RR 133.29 8/1/2011
E2376 Expandable controller, repl NU 1332.87 8/1/2011
E2377 Expandable controller, initl UE 361.75 8/1/2011
E2377 Expandable controller, initl RR 48.22 8/1/2011
E2377 Expandable controller, initl NU 482.31 8/1/2011
E2381 Pneum drive wheel tire UE 55.79 8/1/2011
E2381 Pneum drive wheel tire RR 7.42 8/1/2011
E2381 Pneum drive wheel tire NU 74.38 8/1/2011
E2382 Tube, pneum wheel drive tire UE 15.21 8/1/2011
E2382 Tube, pneum wheel drive tire RR 2.01 8/1/2011
E2382 Tube, pneum wheel drive tire NU 20.27 8/1/2011
E2383 Insert, pneum wheel drive UE 111.24 8/1/2011
E2383 Insert, pneum wheel drive RR 14.83 8/1/2011
E2383 Insert, pneum wheel drive NU 148.29 8/1/2011
E2384 Pneumatic caster tire UE 59.25 8/1/2011
E2384 Pneumatic caster tire RR 7.88 8/1/2011
E2384 Pneumatic caster tire NU 79.01 8/1/2011
E2385 Tube, pneumatic caster tire UE 36.24 8/1/2011
E2385 Tube, pneumatic caster tire RR 4.82 8/1/2011
E2385 Tube, pneumatic caster tire NU 48.33 8/1/2011
E2386 Foam filled drive wheel tire UE 110.23 8/1/2011
E2386 Foam filled drive wheel tire RR 14.70 8/1/2011
E2386 Foam filled drive wheel tire NU 146.94 8/1/2011
E2387 Foam filled caster tire UE 47.53 8/1/2011
E2387 Foam filled caster tire RR 6.33 8/1/2011
E2387 Foam filled caster tire NU 63.39 8/1/2011
E2388 Foam drive wheel tire UE 37.54 8/1/2011
E2388 Foam drive wheel tire RR 5.00 8/1/2011
E2388 Foam drive wheel tire NU 50.04 8/1/2011
E2389 Foam caster tire UE 20.37 8/1/2011
E2389 Foam caster tire RR 2.72 8/1/2011
E2389 Foam caster tire NU 27.17 8/1/2011
E2390 Solid drive wheel tire UE 31.85 8/1/2011
E2390 Solid drive wheel tire RR 4.25 8/1/2011
E2390 Solid drive wheel tire NU 42.49 8/1/2011
E2391 Solid caster tire UE 15.27 8/1/2011
E2391 Solid caster tire RR 2.04 8/1/2011
E2391 Solid caster tire NU 20.36 8/1/2011
E2392 Solid caster tire, integrate UE 40.13 8/1/2011
E2392 Solid caster tire, integrate RR 5.36 8/1/2011
28/55
Proc Code Description Mod Rate Rate Begin Date
E2392 Solid caster tire, integrate NU 53.50 8/1/2011
E2394 Drive wheel excludes tire UE 57.17 8/1/2011
E2394 Drive wheel excludes tire RR 7.64 8/1/2011
E2394 Drive wheel excludes tire NU 76.21 8/1/2011
E2395 Caster wheel excludes tire UE 40.64 8/1/2011
E2395 Caster wheel excludes tire RR 5.42 8/1/2011
E2395 Caster wheel excludes tire NU 54.17 8/1/2011
E2396 Caster fork UE 42.11 8/1/2011
E2396 Caster fork RR 7.08 8/1/2011
E2396 Caster fork NU 56.13 8/1/2011
E2402 Neg press wound therapy pump RR 1542.53 8/1/2011
E2500 Sgd digitized pre-rec <=8min UE 291.24 8/1/2011
E2500 Sgd digitized pre-rec <=8min RR 38.84 8/1/2011
E2500 Sgd digitized pre-rec <=8min NU 388.32 8/1/2011
E2502 Sgd prerec msg >8min <=20min UE 890.58 8/1/2011
E2502 Sgd prerec msg >8min <=20min RR 118.75 8/1/2011
E2502 Sgd prerec msg >8min <=20min NU 1187.43 8/1/2011
E2504 Sgd prerec msg>20min <=40min UE 1174.77 8/1/2011
E2504 Sgd prerec msg>20min <=40min RR 156.66 8/1/2011
E2504 Sgd prerec msg>20min <=40min NU 1566.38 8/1/2011
E2506 Sgd prerec msg > 40 min UE 1722.55 8/1/2011
E2506 Sgd prerec msg > 40 min RR 229.67 8/1/2011
E2506 Sgd prerec msg > 40 min NU 2296.77 8/1/2011
E2508 Sgd spelling phys contact UE 2663.69 8/1/2011
E2508 Sgd spelling phys contact RR 355.17 8/1/2011
E2508 Sgd spelling phys contact NU 3551.57 8/1/2011
E2510 Sgd w multi methods msg/accs UE 5040.65 8/1/2011
E2510 Sgd w multi methods msg/accs RR 672.08 8/1/2011
E2510 Sgd w multi methods msg/accs NU 6720.87 8/1/2011
E2512 Sgd accessory, mounting sys 0.00 8/1/2008
E2599 Sgd accessory noc 0.00 8/1/2008
E2601 Gen w/c cushion wdth < 22 in UE 66.02 8/1/2011
E2601 Gen w/c cushion wdth < 22 in RR 8.80 8/1/2011
E2601 Gen w/c cushion wdth < 22 in NU 88.03 8/1/2011
E2602 Gen w/c cushion wdth >=22 in UE 120.58 8/1/2011
E2602 Gen w/c cushion wdth >=22 in RR 16.09 8/1/2011
E2602 Gen w/c cushion wdth >=22 in NU 160.75 8/1/2011
E2603 Skin protect wc cus wd <22in UE 166.11 8/1/2011
E2603 Skin protect wc cus wd <22in RR 22.15 8/1/2011
E2603 Skin protect wc cus wd <22in NU 221.48 8/1/2011
E2604 Skin protect wc cus wd>=22in UE 235.17 8/1/2011
E2604 Skin protect wc cus wd>=22in RR 31.34 8/1/2011
E2604 Skin protect wc cus wd>=22in NU 313.55 8/1/2011
E2605 Position wc cush wdth <22 in UE 239.60 8/1/2011
E2605 Position wc cush wdth <22 in RR 31.96 8/1/2011
29/55
Proc Code Description Mod Rate Rate Begin Date
E2605 Position wc cush wdth <22 in NU 319.44 8/1/2011
E2606 Position wc cush wdth>=22 in UE 324.77 8/1/2011
E2606 Position wc cush wdth>=22 in RR 43.30 8/1/2011
E2606 Position wc cush wdth>=22 in NU 433.02 8/1/2011
E2607 Skin pro/pos wc cus wd <22in UE 220.15 8/1/2011
E2607 Skin pro/pos wc cus wd <22in RR 29.35 8/1/2011
E2607 Skin pro/pos wc cus wd <22in NU 293.53 8/1/2011
E2608 Skin pro/pos wc cus wd>=22in UE 263.65 8/1/2011
E2608 Skin pro/pos wc cus wd>=22in RR 35.17 8/1/2011
E2608 Skin pro/pos wc cus wd>=22in NU 351.52 8/1/2011
E2609 Custom fabricate w/c cushion UE 0.00 9/2/2008
E2609 Custom fabricate w/c cushion RR 0.00 9/2/2008
E2609 Custom fabricate w/c cushion NU 0.00 9/2/2008
E2609 Custom fabricate w/c cushion 0.00 9/1/2008
E2611 Gen use back cush wdth <22in UE 232.65 8/1/2011
E2611 Gen use back cush wdth <22in RR 31.01 8/1/2011
E2611 Gen use back cush wdth <22in NU 310.16 8/1/2011
E2612 Gen use back cush wdth>=22in UE 314.65 8/1/2011
E2612 Gen use back cush wdth>=22in RR 41.95 8/1/2011
E2612 Gen use back cush wdth>=22in NU 419.58 8/1/2011
E2613 Position back cush wd <22in UE 292.72 8/1/2011
E2613 Position back cush wd <22in RR 39.03 8/1/2011
E2613 Position back cush wd <22in NU 390.29 8/1/2011
E2614 Position back cush wd>=22in UE 405.11 8/1/2011
E2614 Position back cush wd>=22in RR 54.02 8/1/2011
E2614 Position back cush wd>=22in NU 540.12 8/1/2011
E2615 Pos back post/lat wdth <22in UE 336.86 8/1/2011
E2615 Pos back post/lat wdth <22in RR 44.92 8/1/2011
E2615 Pos back post/lat wdth <22in NU 449.15 8/1/2011
E2616 Pos back post/lat wdth>=22in UE 453.25 8/1/2011
E2616 Pos back post/lat wdth>=22in RR 60.43 8/1/2011
E2616 Pos back post/lat wdth>=22in NU 604.32 8/1/2011
E2617 Custom fab w/c back cushion UE 0.00 9/2/2008
E2617 Custom fab w/c back cushion RR 0.00 9/2/2008
E2617 Custom fab w/c back cushion NU 0.00 9/2/2008
E2617 Custom fab w/c back cushion 0.00 9/1/2008
E2619 Replace cover w/c seat cush UE 38.24 8/1/2011
E2619 Replace cover w/c seat cush RR 5.09 8/1/2011
E2619 Replace cover w/c seat cush NU 50.96 8/1/2011
E2620 Wc planar back cush wd <22in UE 428.06 8/1/2011
E2620 Wc planar back cush wd <22in RR 57.07 8/1/2011
E2620 Wc planar back cush wd <22in NU 570.74 8/1/2011
E2621 Wc planar back cush wd>=22in UE 407.91 8/1/2011
E2621 Wc planar back cush wd>=22in RR 54.39 8/1/2011
E2621 Wc planar back cush wd>=22in NU 543.87 8/1/2011
30/55
Proc Code Description Mod Rate Rate Begin Date
E2622 Adj skin pro w/c cus wd<22in UE 223.18 8/1/2011
E2622 Adj skin pro w/c cus wd<22in RR 29.76 8/1/2011
E2622 Adj skin pro w/c cus wd<22in NU 297.57 8/1/2011
E2623 Adj skin pro wc cus wd>=22in UE 283.98 8/1/2011
E2623 Adj skin pro wc cus wd>=22in RR 37.86 8/1/2011
E2623 Adj skin pro wc cus wd>=22in NU 378.65 8/1/2011
E2624 Adj skin pro/pos cus<22in UE 225.02 8/1/2011
E2624 Adj skin pro/pos cus<22in RR 30.00 8/1/2011
E2624 Adj skin pro/pos cus<22in NU 300.03 8/1/2011
E2625 Adj skin pro/pos wc cus>=22 UE 284.84 8/1/2011
E2625 Adj skin pro/pos wc cus>=22 RR 37.97 8/1/2011
E2625 Adj skin pro/pos wc cus>=22 NU 379.81 8/1/2011
E2626 Seo mobile arm sup att to wc UE 496.82 1/1/2012
E2626 Seo mobile arm sup att to wc RR 66.23 1/1/2012
E2626 Seo mobile arm sup att to wc NU 662.48 1/1/2012
E2627 Arm supp att to wc rancho ty UE 792.84 1/1/2012
E2627 Arm supp att to wc rancho ty RR 105.74 1/1/2012
E2627 Arm supp att to wc rancho ty NU 1057.12 1/1/2012
E2628 Mobile arm supports reclinin UE 597.27 1/1/2012
E2628 Mobile arm supports reclinin RR 79.63 1/1/2012
E2628 Mobile arm supports reclinin NU 796.37 1/1/2012
E2629 Friction dampening arm supp UE 755.85 1/1/2012
E2629 Friction dampening arm supp RR 100.76 1/1/2012
E2629 Friction dampening arm supp NU 1007.79 1/1/2012
E2630 Monosuspension arm/hand supp UE 528.55 1/1/2012
E2630 Monosuspension arm/hand supp RR 70.47 1/1/2012
E2630 Monosuspension arm/hand supp NU 704.75 1/1/2012
E2631 Elevat proximal arm support UE 211.42 1/1/2012
E2631 Elevat proximal arm support RR 28.19 1/1/2012
E2631 Elevat proximal arm support NU 281.91 1/1/2012
E2632 Offset/lat rocker arm w/ela UE 132.13 1/1/2012
E2632 Offset/lat rocker arm w/ela RR 17.61 1/1/2012
E2632 Offset/lat rocker arm w/ela NU 176.18 1/1/2012
E2633 Mobile arm support supinator UE 114.03 1/1/2012
E2633 Mobile arm support supinator RR 15.22 1/1/2012
E2633 Mobile arm support supinator NU 152.04 1/1/2012
K0001 Standard wheelchair RR 52.74 8/1/2011
K0001 Standard wheelchair NU 316.43 8/1/2011
K0002 Stnd hemi (low seat) whlchr RR 81.26 8/1/2011
K0002 Stnd hemi (low seat) whlchr NU 487.54 8/1/2011
K0003 Lightweight wheelchair RR 79.20 8/1/2011
K0003 Lightweight wheelchair NU 475.21 8/1/2011
K0004 High strength ltwt whlchr RR 132.70 8/1/2011
K0004 High strength ltwt whlchr NU 796.23 8/1/2011
K0005 Ultralightweight wheelchair UE 1353.85 8/1/2011
31/55
Proc Code Description Mod Rate Rate Begin Date
K0005 Ultralightweight wheelchair RR 180.51 8/1/2011
K0005 Ultralightweight wheelchair NU 1805.12 8/1/2011
K0006 Heavy duty wheelchair RR 124.53 8/1/2011
K0006 Heavy duty wheelchair NU 747.19 8/1/2011
K0007 Extra heavy duty wheelchair RR 167.95 8/1/2011
K0007 Extra heavy duty wheelchair NU 1007.68 8/1/2011
K0008 Cstm manual wheelchair/base NU 0.00 1/1/2014
K0010 Stnd wt frame power whlchr RR 423.01 8/1/2011
K0010 Stnd wt frame power whlchr NU 4230.08 8/1/2011
K0011 Stnd wt pwr whlchr w control RR 499.96 8/1/2011
K0011 Stnd wt pwr whlchr w control NU 4999.56 8/1/2011
K0012 Ltwt portbl power whlchr RR 306.68 8/1/2011
K0012 Ltwt portbl power whlchr NU 3066.78 8/1/2011
K0014 Other power whlchr base 0.00 1/1/1980
K0015 DETACH NON-ADJ HT ARMRST REP UE 133.07 8/1/2011
K0015 DETACH NON-ADJ HT ARMRST REP RR 17.73 8/1/2011
K0015 DETACH NON-ADJ HT ARMRST REP NU 177.42 8/1/2011
K0017 DETACH ADJUST ARMREST BASE UE 37.42 8/1/2011
K0017 DETACH ADJUST ARMREST BASE RR 4.99 8/1/2011
K0017 DETACH ADJUST ARMREST BASE NU 49.90 8/1/2011
K0018 DETACH ADJUST ARMRST UPPER UE 20.91 8/1/2011
K0018 DETACH ADJUST ARMRST UPPER RR 2.78 8/1/2011
K0018 DETACH ADJUST ARMRST UPPER NU 27.89 8/1/2011
K0019 ARM PAD REPL, EACH UE 12.84 8/1/2011
K0019 ARM PAD REPL, EACH RR 1.71 8/1/2011
K0019 ARM PAD REPL, EACH NU 17.12 8/1/2011
K0020 Fixed adjust armrest pair UE 34.02 8/1/2011
K0020 Fixed adjust armrest pair RR 4.55 8/1/2011
K0020 Fixed adjust armrest pair NU 45.35 8/1/2011
K0037 HI MOUNT FLIP-UP FTREST REPL UE 35.88 8/1/2011
K0037 HI MOUNT FLIP-UP FTREST REPL RR 4.27 8/1/2011
K0037 HI MOUNT FLIP-UP FTREST REPL NU 47.82 8/1/2011
K0038 Leg strap each UE 17.75 8/1/2011
K0038 Leg strap each RR 2.36 8/1/2011
K0038 Leg strap each NU 23.67 8/1/2011
K0039 Leg strap h style each UE 39.45 8/1/2011
K0039 Leg strap h style each RR 5.28 8/1/2011
K0039 Leg strap h style each NU 52.62 8/1/2011
K0040 Adjustable angle footplate UE 54.68 8/1/2011
K0040 Adjustable angle footplate RR 7.30 8/1/2011
K0040 Adjustable angle footplate NU 72.90 8/1/2011
K0041 Large size footplate each UE 38.75 8/1/2011
K0041 Large size footplate each RR 5.15 8/1/2011
K0041 Large size footplate each NU 51.69 8/1/2011
K0042 STANDARD SIZE FTPLATE REP EA UE 23.06 8/1/2011
32/55
Proc Code Description Mod Rate Rate Begin Date
K0042 STANDARD SIZE FTPLATE REP EA RR 3.07 8/1/2011
K0042 STANDARD SIZE FTPLATE REP EA NU 30.75 8/1/2011
K0043 FTRST LOWR EXTEN TUBE REP EA UE 14.31 8/1/2011
K0043 FTRST LOWR EXTEN TUBE REP EA RR 1.91 8/1/2011
K0043 FTRST LOWR EXTEN TUBE REP EA NU 19.07 8/1/2011
K0044 FTRST UPR HANGER BRAC REP EA UE 12.16 8/1/2011
K0044 FTRST UPR HANGER BRAC REP EA RR 1.63 8/1/2011
K0044 FTRST UPR HANGER BRAC REP EA NU 16.26 8/1/2011
K0045 FTRST COMPL ASSEMBLY REPL EA UE 42.17 8/1/2011
K0045 FTRST COMPL ASSEMBLY REPL EA RR 5.80 8/1/2011
K0045 FTRST COMPL ASSEMBLY REPL EA NU 56.22 8/1/2011
K0046 ELEV LGRST LWR EXTEN REPL EA UE 14.31 8/1/2011
K0046 ELEV LGRST LWR EXTEN REPL EA RR 1.91 8/1/2011
K0046 ELEV LGRST LWR EXTEN REPL EA NU 19.07 8/1/2011
K0047 ELEV LEGRST UPR HANGR REP EA UE 56.01 8/1/2011
K0047 ELEV LEGRST UPR HANGR REP EA RR 7.47 8/1/2011
K0047 ELEV LEGRST UPR HANGR REP EA NU 74.65 8/1/2011
K0050 RATCHET ASSEMBLY REPLACEMENT UE 23.81 8/1/2011
K0050 RATCHET ASSEMBLY REPLACEMENT RR 3.16 8/1/2011
K0050 RATCHET ASSEMBLY REPLACEMENT NU 31.74 8/1/2011
K0051 CAM REL ASM FT/LEGRST REP EA UE 38.52 8/1/2011
K0051 CAM REL ASM FT/LEGRST REP EA RR 5.12 8/1/2011
K0051 CAM REL ASM FT/LEGRST REP EA NU 51.36 8/1/2011
K0052 SWINGAWAY DETACH FTREST REPL UE 67.68 8/1/2011
K0052 SWINGAWAY DETACH FTREST REPL RR 9.04 8/1/2011
K0052 SWINGAWAY DETACH FTREST REPL NU 90.26 8/1/2011
K0053 Elevate footrest articulate UE 74.69 8/1/2011
K0053 Elevate footrest articulate RR 9.97 8/1/2011
K0053 Elevate footrest articulate NU 99.61 8/1/2011
K0056 Seat ht <17 or >=21 ltwt wc UE 69.66 8/1/2011
K0056 Seat ht <17 or >=21 ltwt wc RR 9.29 8/1/2011
K0056 Seat ht <17 or >=21 ltwt wc NU 92.86 8/1/2011
K0065 Spoke protectors UE 32.56 8/1/2011
K0065 Spoke protectors RR 4.33 8/1/2011
K0065 Spoke protectors NU 43.40 8/1/2011
K0069 RR WHL COMPL SOL TIRE REP EA UE 73.16 8/1/2011
K0069 RR WHL COMPL SOL TIRE REP EA RR 9.77 8/1/2011
K0069 RR WHL COMPL SOL TIRE REP EA NU 97.54 8/1/2011
K0070 RR WHL COMPL PNE TIRE REP EA UE 134.14 8/1/2011
K0070 RR WHL COMPL PNE TIRE REP EA RR 17.89 8/1/2011
K0070 RR WHL COMPL PNE TIRE REP EA NU 178.85 8/1/2011
K0071 FR CSTR COMP PNE TIRE REP EA UE 80.00 8/1/2011
K0071 FR CSTR COMP PNE TIRE REP EA RR 10.69 8/1/2011
K0071 FR CSTR COMP PNE TIRE REP EA NU 106.66 8/1/2011
K0072 FR CSTR SEMI-PNE TIRE REP EA UE 45.26 8/1/2011
33/55
Proc Code Description Mod Rate Rate Begin Date
K0072 FR CSTR SEMI-PNE TIRE REP EA RR 6.04 8/1/2011
K0072 FR CSTR SEMI-PNE TIRE REP EA NU 60.33 8/1/2011
K0073 Caster pin lock each UE 24.51 8/1/2011
K0073 Caster pin lock each RR 3.27 8/1/2011
K0073 Caster pin lock each NU 32.67 8/1/2011
K0077 FR CSTR ASMB SOL TIRE REP EA UE 43.08 8/1/2011
K0077 FR CSTR ASMB SOL TIRE REP EA RR 5.74 8/1/2011
K0077 FR CSTR ASMB SOL TIRE REP EA NU 57.44 8/1/2011
K0098 DRIVE BELT FOR PWC, REPL UE 19.34 8/1/2011
K0098 DRIVE BELT FOR PWC, REPL RR 2.59 8/1/2011
K0098 DRIVE BELT FOR PWC, REPL NU 25.78 8/1/2011
K0105 Iv hanger UE 72.83 8/1/2011
K0105 Iv hanger RR 9.69 8/1/2011
K0105 Iv hanger NU 97.08 8/1/2011
K0108 W/c component-accessory nos UE 0.00 9/2/2008
K0108 W/c component-accessory nos RR 0.00 9/2/2008
K0108 W/c component-accessory nos NU 0.00 9/2/2008
K0108 W/c component-accessory nos 0.00 9/1/2008
K0195 Elevating whlchair leg rests RR 20.33 8/1/2011
K0195 Elevating whlchair leg rests NU 203.27 8/1/2011
K0455 Pump uninterrupted infusion RR 249.97 8/1/2011
K0462 Temporary replacement eqpmnt 0.00 12/10/2012
K0552 SUP/EXT NON-INS INF PUMP SYR NU 2.59 8/1/2011
K0601 Repl batt silver oxide 1.5 v NU 1.09 8/1/2011
K0602 Repl batt silver oxide 3 v NU 6.32 8/1/2011
K0603 Repl batt alkaline 1.5 v NU 0.57 8/1/2011
K0604 Repl batt lithium 3.6 v NU 6.05 8/1/2011
K0605 Repl batt lithium 4.5 v NU 14.50 8/1/2011
K0669 Seat/back cus no dmepdac ver UE 180.04 8/1/2011
K0669 Seat/back cus no dmepdac ver RR 24.00 8/1/2011
K0669 Seat/back cus no dmepdac ver NU 240.05 8/1/2011
K0672 Removable soft interface le 74.40 8/1/2011
K0730 Ctrl dose inh drug deliv sys RR 171.19 8/1/2011
K0733 12-24hr sealed lead acid UE 22.51 8/1/2011
K0733 12-24hr sealed lead acid RR 3.02 8/1/2011
K0733 12-24hr sealed lead acid NU 30.00 8/1/2011
K0738 Portable gas oxygen system RR 51.63 8/1/2015
K0739 Repair/svc dme non-oxygen eq 21.22 8/1/2011
K0800 Pov group 1 std up to 300lbs UE 962.79 8/1/2011
K0800 Pov group 1 std up to 300lbs RR 128.38 8/1/2011
K0800 Pov group 1 std up to 300lbs NU 1283.72 8/1/2011
K0801 Pov group 1 hd 301-450 lbs UE 1552.21 8/1/2011
K0801 Pov group 1 hd 301-450 lbs RR 206.94 8/1/2011
K0801 Pov group 1 hd 301-450 lbs NU 2069.63 8/1/2011
K0802 Pov group 1 vhd 451-600 lbs UE 1756.63 8/1/2011
34/55
Proc Code Description Mod Rate Rate Begin Date
K0802 Pov group 1 vhd 451-600 lbs RR 234.21 8/1/2011
K0802 Pov group 1 vhd 451-600 lbs NU 2342.15 8/1/2011
K0815 Pwc gp 1 std seat/back RR 349.17 8/1/2011
K0815 Pwc gp 1 std seat/back NU 3491.69 8/1/2011
K0816 Pwc gp 1 std cap chair RR 334.38 8/1/2011
K0816 Pwc gp 1 std cap chair NU 3343.83 8/1/2011
K0822 Pwc gp 2 std seat/back RR 398.00 8/1/2011
K0822 Pwc gp 2 std seat/back NU 3980.04 8/1/2011
K0823 Pwc gp 2 std cap chair RR 399.55 8/1/2011
K0823 Pwc gp 2 std cap chair NU 3995.53 8/1/2011
K0824 Pwc gp 2 hd seat/back RR 480.88 8/1/2011
K0824 Pwc gp 2 hd seat/back NU 4808.80 8/1/2011
K0825 Pwc gp 2 hd cap chair RR 420.00 8/1/2011
K0825 Pwc gp 2 hd cap chair NU 4199.99 8/1/2011
K0826 Pwc gp 2 vhd seat/back RR 622.54 8/1/2011
K0826 Pwc gp 2 vhd seat/back NU 6225.41 8/1/2011
K0827 Pwc gp vhd cap chair RR 477.56 8/1/2011
K0827 Pwc gp vhd cap chair NU 4775.63 8/1/2011
K0828 Pwc gp 2 xtra hd seat/back RR 685.98 8/1/2011
K0828 Pwc gp 2 xtra hd seat/back NU 6859.84 8/1/2011
K0829 Pwc gp 2 xtra hd cap chair RR 596.97 8/1/2011
K0829 Pwc gp 2 xtra hd cap chair NU 5969.72 8/1/2011
K0835 Pwc gp2 std sing pow opt s/b RR 409.34 8/1/2011
K0835 Pwc gp2 std sing pow opt s/b NU 4093.44 8/1/2011
K0841 Pwc gp2 std mult pow opt s/b RR 428.84 8/1/2011
K0841 Pwc gp2 std mult pow opt s/b NU 4288.37 8/1/2011
K0843 Pwc gp2 hd mult pow opt s/b RR 516.32 8/1/2011
K0843 Pwc gp2 hd mult pow opt s/b NU 5163.20 8/1/2011
K0848 Pwc gp 3 std seat/back RR 539.56 8/1/2011
K0848 Pwc gp 3 std seat/back NU 5395.56 8/1/2011
K0849 Pwc gp 3 std cap chair RR 504.51 8/1/2011
K0849 Pwc gp 3 std cap chair NU 5045.14 8/1/2011
K0850 Pwc gp 3 hd seat/back RR 609.69 8/1/2011
K0850 Pwc gp 3 hd seat/back NU 6096.92 8/1/2011
K0851 Pwc gp 3 hd cap chair RR 570.12 8/1/2011
K0851 Pwc gp 3 hd cap chair NU 5701.21 8/1/2011
K0852 Pwc gp 3 vhd seat/back RR 703.30 8/1/2011
K0852 Pwc gp 3 vhd seat/back NU 7033.02 8/1/2011
K0853 Pwc gp 3 vhd cap chair RR 722.47 8/1/2011
K0853 Pwc gp 3 vhd cap chair NU 7224.67 8/1/2011
K0854 Pwc gp 3 xhd seat/back RR 957.11 8/1/2011
K0854 Pwc gp 3 xhd seat/back NU 9571.13 8/1/2011
K0855 Pwc gp 3 xhd cap chair RR 904.14 8/1/2011
K0855 Pwc gp 3 xhd cap chair NU 9041.36 8/1/2011
K0856 Pwc gp3 std sing pow opt s/b RR 563.26 8/1/2011
35/55
Proc Code Description Mod Rate Rate Begin Date
K0856 Pwc gp3 std sing pow opt s/b NU 5632.59 8/1/2011
K0857 Pwc gp3 std sing pow opt cap RR 574.55 8/1/2011
K0857 Pwc gp3 std sing pow opt cap NU 5745.50 8/1/2011
K0858 Pwc gp3 hd sing pow opt s/b RR 698.83 8/1/2011
K0858 Pwc gp3 hd sing pow opt s/b NU 6988.34 8/1/2011
K0859 Pwc gp3 hd sing pow opt cap RR 649.23 8/1/2011
K0859 Pwc gp3 hd sing pow opt cap NU 6492.33 8/1/2011
K0860 Pwc gp3 vhd sing pow opt s/b RR 998.37 8/1/2011
K0860 Pwc gp3 vhd sing pow opt s/b NU 9983.72 8/1/2011
K0861 Pwc gp3 std mult pow opt s/b RR 564.16 8/1/2011
K0861 Pwc gp3 std mult pow opt s/b NU 5641.63 8/1/2011
K0862 Pwc gp3 hd mult pow opt s/b RR 698.83 8/1/2011
K0862 Pwc gp3 hd mult pow opt s/b NU 6988.34 8/1/2011
K0863 Pwc gp3 vhd mult pow opt s/b RR 998.37 8/1/2011
K0863 Pwc gp3 vhd mult pow opt s/b NU 9983.72 8/1/2011
K0864 Pwc gp3 xhd mult pow opt s/b RR 1247.95 8/1/2011
K0864 Pwc gp3 xhd mult pow opt s/b NU 12479.53 8/1/2011
K0890 Pwc gp5 ped sing pow opt s/b RR 913.31 8/1/2011
K0890 Pwc gp5 ped sing pow opt s/b NU 9133.12 8/1/2011
K0891 Pwc gp5 ped mult pow opt s/b RR 1209.51 8/1/2011
K0891 Pwc gp5 ped mult pow opt s/b NU 12095.14 8/1/2011
L0112 Cranial cervical orthosis 1092.07 8/1/2011
L0113 Cranial cervical torticollis 266.41 12/1/2015
L0120 Cerv flex n/adj foam pre ots 26.44 8/1/2011
L0130 Flex thermoplastic collar mo 132.09 8/1/2011
L0140 Cervical semi-rigid adjustab 47.85 8/1/2011
L0150 Cerv semi-rig adj molded chn 107.70 8/1/2011
L0160 Cerv sr wire occ/man pre ots 132.13 8/1/2011
L0170 Cervical collar molded to pt 637.31 8/1/2011
L0172 Cerv col sr foam 2pc pre ots 118.98 8/1/2011
L0174 Cerv sr 2pc thor ext pre ots 273.79 8/1/2011
L0180 Cer post col occ/man sup adj 354.94 8/1/2011
L0190 Cerv collar supp adj cerv ba 493.70 8/1/2011
L0200 Cerv col supp adj bar & thor 514.67 8/1/2011
L0220 Thor rib belt custom fabrica 91.54 8/1/2011
L0450 Tlso flex trunk/thor pre ots 173.22 8/1/2011
L0452 Tlso flex custom fab thoraci 328.53 8/1/2011
L0454 Tlso trnk sj-t9 pre cst 348.37 8/1/2011
L0455 Tlso flex trnk sj-t9 pre ots NU 319.22 1/1/2014
L0456 Tlso flex trnk sj-ss pre cst 348.37 8/1/2011
L0457 Tlso flex trnk sj-ss pre ots NU 915.41 1/1/2014
L0458 Tlso 2mod symphis-xipho pre 543.30 8/1/2011
L0460 Tlso 2 shl symphys-stern cst 543.30 8/1/2011
L0462 Tlso 3mod sacro-scap pre 543.30 8/1/2011
L0464 Tlso 4mod sacro-scap pre 543.30 8/1/2011
36/55
Proc Code Description Mod Rate Rate Begin Date
L0466 Tlso r fram soft ant pre cst 372.37 8/1/2011
L0467 Tlso r fram soft pre ots NU 439.25 1/1/2014
L0468 Tlso rig fram pelvic pre cst 451.32 8/1/2011
L0469 Tlso rig fram pelvic pre ots NU 532.38 1/1/2014
L0470 Tlso rigid frame pre subclav 635.42 8/1/2011
L0472 Tlso rigid frame hyperex pre 402.99 8/1/2011
L0480 Tlso rigid plastic custom fa 1209.27 8/1/2011
L0482 Tlso rigid lined custom fab 1379.04 8/1/2011
L0484 Tlso rigid plastic cust fab 1551.92 8/1/2011
L0486 Tlso rigidlined cust fab two 1680.76 8/1/2011
L0488 Tlso rigid lined pre one pie 1203.92 8/1/2011
L0490 Tlso rigid plastic pre one 1116.56 8/1/2011
L0491 Tlso 2 piece rigid shell 599.25 8/1/2011
L0492 Tlso 3 piece rigid shell 413.51 8/1/2011
L0621 Sio flex pelvic/sacr pre ots 91.90 8/1/2011
L0622 Sio flex pelvisacral custom 257.47 8/1/2011
L0623 Sio rig pnl pelv/sac pre ots 56.83 8/1/2011
L0625 Lo flex l1-below l5 pre ots 42.97 8/1/2011
L0626 Lo sag rig pnl stays pre cst 60.82 8/1/2011
L0627 Lo sag ri an/pos pnl pre cst 320.72 8/1/2011
L0628 Lso flex no ri stays pre ots 65.46 8/1/2011
L0630 Lso r post pnl sj-t9 pre cst 126.37 8/1/2011
L0631 Lso sag r an/pos pnl pre cst 800.99 8/1/2011
L0632 Lso sag rigid frame cust 0.00 1/1/2006
L0633 Lso sc r pos/lat pnl pre cst 223.73 8/1/2011
L0635 Lso sagit rigid panel prefab 953.99 8/1/2011
L0636 Lso sagittal rigid panel cus 1412.25 8/1/2011
L0637 Lso sc r ant/pos pnl pre cst 984.58 8/1/2011
L0638 Lso sag-coronal panel custom 1029.10 8/1/2011
L0639 Lso s/c shell/panel prefab 943.99 8/1/2011
L0640 Lso s/c shell/panel custom 816.45 8/1/2011
L0641 Lo rig pos pnl l1-l5 pre ots NU 71.73 1/1/2014
L0642 Lo sag ri an/pos pnl pre ots NU 378.33 1/1/2014
L0643 Lso sag ctr rigi pos pre ots NU 149.07 1/1/2014
L0648 Lso sag r an/pos pnl pre ots NU 944.86 1/1/2014
L0649 Lso sc r pos/lat pnl pre ots NU 263.92 1/1/2014
L0650 Lso sc r ant/pos pnl pre ots NU 1113.55 1/1/2014
L0651 Lso sag-co shell pnl pre ots NU 1113.55 1/1/2014
L0700 Ctlso a-p-l control molded 2014.93 8/1/2011
L0710 Ctlso a-p-l control w/ inter 2081.51 8/1/2011
L0810 Halo cervical into jckt vest 2570.77 8/1/2011
L0820 Halo cervical into body jack 2026.57 8/1/2011
L0830 Halo cerv into milwaukee typ 3125.28 8/1/2011
L0859 Mri compatible system 910.61 8/1/2011
L0861 Halo repl liner/interface 168.17 8/1/2011
37/55
Proc Code Description Mod Rate Rate Begin Date
L0970 Tlso corset front 113.91 8/1/2011
L0972 Lso corset front 102.57 8/1/2011
L0974 Tlso full corset 172.48 8/1/2011
L0976 Lso full corset 121.75 8/1/2011
L0978 Axillary crutch extension 191.85 8/1/2011
L0980 Peroneal straps pair pre ots 13.05 8/1/2011
L0982 Stocking sup grips 4 pre ots 12.94 8/1/2011
L0984 Protect body sock ea pre ots 51.10 8/1/2011
L0999 Add to spinal orthosis nos 0.00 1/1/1998
L1000 Ctlso milwauke initial model 2023.44 8/1/2011
L1005 Tension based scoliosis orth 2497.33 8/1/2011
L1010 Ctlso axilla sling 56.78 8/1/2011
L1020 Kyphosis pad 86.14 8/1/2011
L1025 Kyphosis pad floating 116.05 8/1/2011
L1030 Lumbar bolster pad 49.81 8/1/2011
L1040 Lumbar or lumbar rib pad 77.75 8/1/2011
L1050 Sternal pad 82.98 8/1/2011
L1060 Thoracic pad 95.32 8/1/2011
L1070 Trapezius sling 89.68 8/1/2011
L1080 Outrigger 47.70 8/1/2011
L1085 Outrigger bil w/ vert extens 153.41 8/1/2011
L1090 Lumbar sling 91.36 8/1/2011
L1100 Ring flange plastic/leather 158.49 8/1/2011
L1110 Ring flange plas/leather mol 254.54 8/1/2011
L1120 Covers for upright each 39.58 8/1/2011
L1200 Furnsh initial orthosis only 1561.57 8/1/2011
L1210 Lateral thoracic extension 260.78 8/1/2011
L1220 Anterior thoracic extension 220.79 8/1/2011
L1230 Milwaukee type superstructur 443.68 8/1/2011
L1240 Lumbar derotation pad 77.38 8/1/2011
L1250 Anterior asis pad 61.38 8/1/2011
L1260 Anterior thoracic derotation 67.13 8/1/2011
L1270 Abdominal pad 77.22 8/1/2011
L1280 Rib gusset (elastic) each 85.97 8/1/2011
L1290 Lateral trochanteric pad 78.34 8/1/2011
L1300 Body jacket mold to patient 1664.83 8/1/2011
L1310 Post-operative body jacket 1564.50 8/1/2011
L1499 Spinal orthosis nos 0.00 1/1/1982
L1600 Ho flex frejka w/cov pre cst 122.40 8/1/2011
L1610 Ho frejka cov only pre cst 43.75 8/1/2011
L1620 Ho flex pavlik harns pre cst 124.16 8/1/2011
L1630 Abduct control hip semi-flex 137.79 8/1/2011
L1640 Pelv band/spread bar thigh c 344.91 8/1/2011
L1650 Ho abduction hip adjustable 201.94 8/1/2011
L1652 Ho bi thighcuffs w sprdr bar 278.14 8/1/2011
38/55
Proc Code Description Mod Rate Rate Begin Date
L1660 Ho abduction static plastic 127.92 8/1/2011
L1680 Pelvic & hip control thigh c 1214.34 8/1/2011
L1685 Post-op hip abduct custom fa 1185.49 8/1/2011
L1686 Ho post-op hip abduction 909.14 8/1/2011
L1690 Combination bilateral ho 1508.81 8/1/2011
L1700 Leg perthes orth toronto typ 1521.99 8/1/2011
L1710 Legg perthes orth newington 1781.66 8/1/2011
L1720 Legg perthes orthosis trilat 1313.30 8/1/2011
L1730 Legg perthes orth scottish r 1128.00 8/1/2011
L1755 Legg perthes patten bottom t 1569.90 8/1/2011
L1810 Ko elastic with joints 97.12 8/1/2011
L1812 Ko elastic w/joints pre ots NU 114.55 1/1/2014
L1820 Ko elas w/ condyle pads & jo 118.25 8/1/2011
L1830 Ko immob canvas long pre ots 87.19 8/1/2011
L1831 Knee orth pos locking joint 229.64 8/1/2011
L1832 Ko adj jnt pos r sup pre cst 542.64 8/1/2011
L1833 Ko adj jnt pos r sup pre ots NU 640.13 1/1/2014
L1834 Ko w/0 joint rigid molded to 731.24 8/1/2011
L1836 Ko rigid w/o joints pre ots 104.11 8/1/2011
L1840 Ko derot ant cruciate custom 916.40 8/1/2011
L1843 Ko single upright pre cst 700.09 8/1/2011
L1844 Ko w/adj jt rot cntrl molded 1584.74 8/1/2011
L1845 Ko double upright pre cst 610.96 8/1/2011
L1846 Ko w adj flex/ext rotat mold 1058.14 8/1/2011
L1847 Ko dbl upright w/air pre cst 448.78 8/1/2011
L1848 Ko dbl upright w/air pre ots NU 529.39 1/1/2014
L1850 Ko swedish type pre ots 286.88 8/1/2011
L1851 KO SINGLE UPRIGHT PREFAB OTS NU 840.73 1/1/2017
L1852 KO DOUBLE UPRIGHT PREFAB OTS NU 733.69 1/1/2017
L1860 Ko supracondylar socket mold 1069.46 8/1/2011
L1900 Afo sprng wir drsflx calf bd 228.10 8/1/2011
L1902 AFO ANKLE GAUNTLET PRE OTS 68.38 8/1/2011
L1904 AFO MOLDED ANKLE GAUNTLET 468.68 8/1/2011
L1906 AFO MULTILIG ANK SUP PRE OTS 119.86 8/1/2011
L1907 Afo supramalleolar custom 439.05 8/1/2011
L1910 Afo sing bar clasp attach sh 266.53 8/1/2011
L1920 Afo sing upright w/ adjust s 272.51 8/1/2011
L1930 Afo plastic 235.78 8/1/2011
L1932 Afo rig ant tib prefab tcf/= 696.27 8/1/2011
L1940 Afo molded to patient plasti 492.90 8/1/2011
L1945 Afo molded plas rig ant tib 922.60 8/1/2011
L1950 Afo spiral molded to pt plas 742.35 8/1/2011
L1951 Afo spiral prefabricated 655.29 8/1/2011
L1960 Afo pos solid ank plastic mo 552.44 8/1/2011
L1970 Afo plastic molded w/ankle j 577.65 8/1/2011
39/55
Proc Code Description Mod Rate Rate Begin Date
L1971 Afo w/ankle joint, prefab 365.72 8/1/2011
L1980 Afo sing solid stirrup calf 365.78 8/1/2011
L1990 Afo doub solid stirrup calf 444.26 8/1/2011
L2000 Kafo sing fre stirr thi/calf 1010.88 8/1/2011
L2005 Kafo sng/dbl mechanical act 2808.67 8/1/2011
L2010 Kafo sng solid stirrup w/o j 921.51 8/1/2011
L2020 Kafo dbl solid stirrup band/ 1163.74 8/1/2011
L2030 Kafo dbl solid stirrup w/o j 1009.65 8/1/2011
L2034 Kafo pla sin up w/wo k/a cus 1563.23 8/1/2011
L2035 Kafo plastic pediatric size 135.16 8/1/2011
L2036 Kafo plas doub free knee mol 1658.15 8/1/2011
L2037 Kafo plas sing free knee mol 1660.02 8/1/2011
L2038 Kafo w/o joint multi-axis an 1219.87 8/1/2011
L2040 Hkafo torsion bil rot straps 132.71 8/1/2011
L2050 Hkafo torsion cable hip pelv 474.76 8/1/2011
L2060 Hkafo torsion ball bearing j 578.64 8/1/2011
L2070 Hkafo torsion unilat rot str 110.82 8/1/2011
L2080 Hkafo unilat torsion cable 358.47 8/1/2011
L2090 Hkafo unilat torsion ball br 437.02 8/1/2011
L2106 Afo tib fx cast plaster mold 677.63 8/1/2011
L2108 Afo tib fx cast molded to pt 984.82 8/1/2011
L2112 Afo tibial fracture soft 429.02 8/1/2011
L2114 Afo tib fx semi-rigid 578.49 8/1/2011
L2116 Afo tibial fracture rigid 709.52 8/1/2011
L2126 Kafo fem fx cast thermoplas 1024.01 8/1/2011
L2128 Kafo fem fx cast molded to p 1608.50 8/1/2011
L2132 Kafo femoral fx cast soft 621.41 8/1/2011
L2134 Kafo fem fx cast semi-rigid 963.93 8/1/2011
L2136 Kafo femoral fx cast rigid 1178.64 8/1/2011
L2180 Plas shoe insert w ank joint 116.71 8/1/2011
L2182 Drop lock knee 79.90 8/1/2011
L2184 Limited motion knee joint 92.60 8/1/2011
L2186 Adj motion knee jnt lerman t 112.54 8/1/2011
L2188 Quadrilateral brim 223.86 8/1/2011
L2190 Waist belt 65.28 8/1/2011
L2192 Pelvic band & belt thigh fla 355.36 8/1/2011
L2200 Limited ankle motion ea jnt 47.39 8/1/2011
L2210 Dorsiflexion assist each joi 67.00 8/1/2011
L2220 Dorsi & plantar flex ass/res 81.61 8/1/2011
L2230 Split flat caliper stirr & p 76.47 8/1/2011
L2232 Rocker bottom, contact afo 87.33 8/1/2011
L2240 Round caliper and plate atta 83.34 8/1/2011
L2250 Foot plate molded stirrup at 354.14 8/1/2011
L2260 Reinforced solid stirrup 199.79 8/1/2011
L2265 Long tongue stirrup 117.37 8/1/2011
40/55
Proc Code Description Mod Rate Rate Begin Date
L2270 Varus/valgus strap padded/li 53.52 8/1/2011
L2275 Plastic mod low ext pad/line 116.91 8/1/2011
L2280 Molded inner boot 451.30 8/1/2011
L2300 Abduction bar jointed adjust 268.34 8/1/2011
L2310 Abduction bar-straight 122.61 8/1/2011
L2320 Non-molded lacer 205.05 8/1/2011
L2330 Lacer molded to patient mode 391.34 8/1/2011
L2335 Anterior swing band 226.41 8/1/2011
L2340 Pre-tibial shell molded to p 445.44 8/1/2011
L2350 Prosthetic type socket molde 888.06 8/1/2011
L2360 Extended steel shank 51.00 8/1/2011
L2370 Patten bottom 255.85 8/1/2011
L2375 Torsion ank & half solid sti 112.62 8/1/2011
L2380 Torsion straight knee joint 122.70 8/1/2011
L2385 Straight knee joint heavy du 133.49 8/1/2011
L2387 Add le poly knee custom kafo 164.94 8/1/2011
L2390 Offset knee joint each 109.09 8/1/2011
L2395 Offset knee joint heavy duty 142.92 8/1/2011
L2397 Suspension sleeve lower ext 98.78 8/1/2011
L2405 Knee joint drop lock ea jnt 68.02 8/1/2011
L2415 Knee joint cam lock each joi 94.76 8/1/2011
L2425 Knee disc/dial lock/adj flex 111.85 8/1/2011
L2430 Knee jnt ratchet lock ea jnt 111.85 8/1/2011
L2492 Knee lift loop drop lock rin 88.36 8/1/2011
L2500 Thi/glut/ischia wgt bearing 314.41 8/1/2011
L2510 Th/wght bear quad-lat brim m 723.95 8/1/2011
L2520 Th/wght bear quad-lat brim c 459.13 8/1/2011
L2525 Th/wght bear nar m-l brim mo 1134.10 8/1/2011
L2526 Th/wght bear nar m-l brim cu 633.05 8/1/2011
L2530 Thigh/wght bear lacer non-mo 234.17 8/1/2011
L2540 Thigh/wght bear lacer molded 421.37 8/1/2011
L2550 Thigh/wght bear high roll cu 286.24 8/1/2011
L2570 Hip clevis type 2 posit jnt 474.71 8/1/2011
L2580 Pelvic control pelvic sling 462.55 8/1/2011
L2600 Hip clevis/thrust bearing fr 204.69 8/1/2011
L2610 Hip clevis/thrust bearing lo 242.03 8/1/2011
L2620 Pelvic control hip heavy dut 266.48 8/1/2011
L2622 Hip joint adjustable flexion 305.64 8/1/2011
L2624 Hip adj flex ext abduct cont 330.03 8/1/2011
L2627 Plastic mold recipro hip & c 1281.41 8/1/2011
L2628 Metal frame recipro hip & ca 1252.33 8/1/2011
L2630 Pelvic control band & belt u 246.79 8/1/2011
L2640 Pelvic control band & belt b 334.93 8/1/2011
L2650 Pelv & thor control gluteal 99.95 8/1/2011
L2660 Thoracic control thoracic ba 185.75 8/1/2011
41/55
Proc Code Description Mod Rate Rate Begin Date
L2670 Thorac cont paraspinal uprig 152.44 8/1/2011
L2680 Thorac cont lat support upri 141.52 8/1/2011
L2750 Plating chrome/nickel pr bar 62.48 8/1/2011
L2755 Carbon graphite lamination 101.96 8/1/2011
L2760 Extension per extension per 60.55 8/1/2011
L2768 Ortho sidebar disconnect 101.66 8/1/2011
L2780 Non-corrosive finish 67.44 8/1/2011
L2785 Drop lock retainer each 31.59 8/1/2011
L2795 Knee control full kneecap 84.68 8/1/2011
L2800 Knee cap medial or lateral p 106.31 8/1/2011
L2810 Knee control condylar pad 77.84 8/1/2011
L2820 Soft interface below knee se 86.55 8/1/2011
L2830 Soft interface above knee se 93.64 8/1/2011
L2840 Tibial length sock fx or equ 32.66 8/1/2011
L2850 Femoral lgth sock fx or equa 55.95 8/1/2011
L2999 Lower extremity orthosis nos 0.00 1/1/1980
L3000 Ft insert ucb berkeley shell 245.10 8/1/2011
L3001 Foot insert remov molded spe 84.41 8/1/2011
L3002 Foot insert plastazote or eq 126.01 8/1/2011
L3003 Foot insert silicone gel eac 135.96 8/1/2011
L3010 Foot longitudinal arch suppo 135.96 8/1/2011
L3020 Foot longitud/metatarsal sup 154.82 8/1/2011
L3030 Foot arch support remov prem 59.55 8/1/2011
L3040 Ft arch suprt premold longit 36.71 8/1/2011
L3050 Foot arch supp premold metat 36.71 8/1/2011
L3060 Foot arch supp longitud/meta 57.56 8/1/2011
L3070 Arch suprt att to sho longit 24.79 8/1/2011
L3080 Arch supp att to shoe metata 24.79 8/1/2011
L3090 Arch supp att to shoe long/m 31.77 8/1/2011
L3100 Hallus-valgus nt dyn pre ots 33.73 8/1/2011
L3140 Abduction rotation bar shoe 32.77 8/1/2011
L3150 Abduct rotation bar w/o shoe 32.77 8/1/2011
L3160 Shoe styled positioning dev 11.78 8/1/2011
L3170 Foot plas heel stabi pre ots 39.71 8/1/2011
L3201 Oxford w supinat/pronat inf 42.20 8/1/2011
L3202 Oxford w/ supinat/pronator c 42.20 8/1/2011
L3203 Oxford w/ supinator/pronator 42.20 8/1/2011
L3204 Hightop w/ supp/pronator inf 42.20 8/1/2011
L3206 Hightop w/ supp/pronator chi 42.20 8/1/2011
L3207 Hightop w/ supp/pronator jun 42.20 8/1/2011
L3208 Surgical boot each infant 23.55 8/1/2011
L3209 Surgical boot each child 33.36 8/1/2011
L3211 Surgical boot each junior 35.72 8/1/2011
L3212 Benesch boot pair infant 49.85 8/1/2011
L3213 Benesch boot pair child 60.06 8/1/2011
42/55
Proc Code Description Mod Rate Rate Begin Date
L3214 Benesch boot pair junior 63.98 8/1/2011
L3215 Orthopedic ftwear ladies oxf 47.17 8/1/2011
L3216 Orthoped ladies shoes dpth i 47.17 8/1/2011
L3217 Ladies shoes hightop depth i 47.17 8/1/2011
L3219 Orthopedic mens shoes oxford 62.06 8/1/2011
L3221 Orthopedic mens shoes dpth i 62.06 8/1/2011
L3222 Mens shoes hightop depth inl 62.06 8/1/2011
L3224 Woman's shoe oxford brace 47.17 8/1/2011
L3225 Man's shoe oxford brace 67.41 8/1/2011
L3230 Custom shoes depth inlay 156.31 8/1/2011
L3250 Custom mold shoe remov prost 276.72 8/1/2011
L3251 Shoe molded to pt silicone s 38.07 8/1/2011
L3252 Shoe molded plastazote cust 151.50 8/1/2011
L3253 Shoe molded plastazote cust 38.07 8/1/2011
L3255 Orth foot non-standard size/ 0.00 1/1/1980
L3257 Orth foot add charge split s 27.48 8/1/2011
L3260 Ambulatory surgical boot eac 15.31 8/1/2011
L3265 Plastazote sandal each 16.88 8/1/2011
L3300 Sho lift taper to metatarsal 40.68 8/1/2011
L3310 Shoe lift elev heel/sole neo 63.51 8/1/2011
L3320 Shoe lift elev heel/sole cor 102.45 8/1/2011
L3330 Lifts elevation metal extens 441.59 8/1/2011
L3332 Shoe lifts tapered to one-ha 57.56 8/1/2011
L3334 Shoe lifts elevation heel /i 29.77 8/1/2011
L3340 Shoe wedge sach 66.49 8/1/2011
L3350 Shoe heel wedge 17.87 8/1/2011
L3360 Shoe sole wedge outside sole 27.78 8/1/2011
L3370 Shoe sole wedge between sole 38.68 8/1/2011
L3380 Shoe clubfoot wedge 38.68 8/1/2011
L3390 Shoe outflare wedge 38.68 8/1/2011
L3400 Shoe metatarsal bar wedge ro 31.77 8/1/2011
L3410 Shoe metatarsal bar between 72.43 8/1/2011
L3420 Full sole/heel wedge btween 42.67 8/1/2011
L3430 Sho heel count plast reinfor 125.04 8/1/2011
L3440 Heel leather reinforced 59.55 8/1/2011
L3450 Shoe heel sach cushion type 82.36 8/1/2011
L3455 Shoe heel new leather standa 31.77 8/1/2011
L3460 Shoe heel new rubber standar 26.78 8/1/2011
L3465 Shoe heel thomas with wedge 9.93 8/1/2011
L3470 Shoe heel thomas extend to b 48.62 8/1/2011
L3480 Shoe heel pad & depress for 48.62 8/1/2011
L3485 Shoe heel pad removable for 15.31 8/1/2011
L3500 Ortho shoe add leather insol 22.82 8/1/2011
L3510 Orthopedic shoe add rub insl 22.82 8/1/2011
L3520 O shoe add felt w leath insl 24.79 8/1/2011
43/55
Proc Code Description Mod Rate Rate Begin Date
L3530 Ortho shoe add half sole 24.79 8/1/2011
L3540 Ortho shoe add full sole 39.71 8/1/2011
L3550 O shoe add standard toe tap 6.93 8/1/2011
L3560 O shoe add horseshoe toe tap 17.87 8/1/2011
L3570 O shoe add instep extension 66.49 8/1/2011
L3580 O shoe add instep velcro clo 50.60 8/1/2011
L3590 O shoe convert to sof counte 41.68 8/1/2011
L3595 Ortho shoe add march bar 32.74 8/1/2011
L3600 Trans shoe calip plate exist 59.55 8/1/2011
L3610 Trans shoe caliper plate new 78.39 8/1/2011
L3620 Trans shoe solid stirrup exi 59.55 8/1/2011
L3630 Trans shoe solid stirrup new 78.39 8/1/2011
L3640 Shoe dennis browne splint bo 33.73 8/1/2011
L3649 Orthopedic shoe modifica nos 0.00 1/1/1980
L3650 So 8 abd restraint pre ots 57.84 8/1/2011
L3660 So 8 ab rstr can/web pre ots 88.99 8/1/2011
L3670 So acro/clav can web pre ots 110.28 8/1/2011
L3671 So cap design w/o jnts cf 639.86 8/1/2011
L3674 So airplane w/wo joint cf 943.12 8/1/2011
L3675 So vest canvas/web pre ots 124.61 8/1/2011
L3677 So hard plas stabili pre cst 67.39 8/1/2011
L3702 Eo w/o joints cf 205.04 8/1/2011
L3710 Eo elas w/metal jnts pre ots 101.24 8/1/2011
L3720 Forearm/arm cuffs free motio 637.90 8/1/2011
L3730 Forearm/arm cuffs ext/flex a 879.16 8/1/2011
L3740 Cuffs adj lock w/ active con 1042.32 8/1/2011
L3760 Eo withjoint, prefabricated 355.12 8/1/2011
L3762 Eo rigid w/o joints pre ots 76.35 8/1/2011
L3763 Ewho rigid w/o jnts cf 910.52 8/1/2011
L3764 Ewho w/joint(s) cf 964.18 8/1/2011
L3765 Ewhfo rigid w/o jnts cf 910.52 8/1/2011
L3766 Ewhfo w/joint(s) cf 964.18 8/1/2011
L3806 Whfo w/joint(s) custom fab 362.79 8/1/2011
L3807 Whfo w/o joints pre cst 177.56 8/1/2011
L3808 Whfo, rigid w/o joints 363.23 8/1/2011
L3900 Hinge extension/flex wrist/f 1158.78 8/1/2011
L3901 Hinge ext/flex wrist finger 1426.35 8/1/2011
L3904 Whfo electric custom fitted 2856.03 8/1/2011
L3905 Who w/nontorsion jnt(s) cf 704.23 8/1/2011
L3906 Who w/o joints cf 385.36 8/1/2011
L3908 Who cock-up nonmolde pre ots 58.44 8/1/2011
L3912 Hfo flexion glove pre ots 92.49 8/1/2011
L3913 Hfo w/o joints cf 192.33 8/1/2011
L3915 Who nontorsion jnts pre cst 424.54 8/1/2011
L3916 Who nontorsion jnts pre ots NU 445.26 1/1/2014
44/55
Proc Code Description Mod Rate Rate Begin Date
L3917 Metacarp fx orthosis pre cst 75.01 8/1/2011
L3918 Metacarp fx orthosis pre ots NU 88.51 1/1/2014
L3919 Ho w/o joints cf 192.33 8/1/2011
L3921 Hfo w/joint(s) cf 228.10 8/1/2011
L3923 Hfo without joints pre cst 27.63 8/1/2011
L3924 Hfo without joints pre ots NU 75.05 1/1/2014
L3925 Fo pip dip jnt/sprng pre ots 49.96 8/1/2011
L3927 Fo pip dip no jt spr pre ots 29.72 12/1/2015
L3929 Hfo nontorsion jnts pre cst 81.66 8/1/2011
L3930 Hfo nontorsion jnts pre ots NU 89.93 1/1/2014
L3931 Whfo nontorsion joint prefab 182.38 8/1/2011
L3933 Fo w/o joints cf 151.51 8/1/2011
L3935 Fo nontorsion joint cf 156.87 8/1/2011
L3956 Add joint upper ext orthosis 0.00 1/1/1997
L3960 Sewho airplan desig abdu pos 716.76 8/1/2011
L3961 Sewho cap design w/o jnts cf 1193.06 8/1/2011
L3962 Sewho erbs palsey design abd 699.75 8/1/2011
L3967 Sewho airplane w/o jnts cf 1584.28 8/1/2011
L3971 Sewho cap design w/jnt(s) cf 1503.85 8/1/2011
L3973 Sewho airplane w/jnt(s) cf 1408.60 8/1/2011
L3975 Sewhfo cap design w/o jnt cf 1193.06 8/1/2011
L3976 Sewhfo airplane w/o jnts cf 1193.06 8/1/2011
L3977 Sewhfo cap desgn w/jnt(s) cf 1337.08 8/1/2011
L3978 Sewhfo airplane w/jnt(s) cf 1408.60 8/1/2011
L3980 Up ext fx orthos humeral nos 301.50 8/1/2011
L3981 Ue fx orth shoul cap forearm NU 855.80 1/1/2015
L3982 Upper ext fx orthosis rad/ul 364.08 8/1/2011
L3984 Upper ext fx orthosis wrist 335.68 8/1/2011
L3995 Sock fracture or equal each 27.86 8/1/2011
L3999 Upper limb orthosis nos 0.00 1/1/1982
L4000 Repl girdle milwaukee orth 1270.77 8/1/2011
L4002 Replace strap, any orthosis 0.00 1/1/2005
L4010 Replace trilateral socket br 668.87 8/1/2011
L4020 Replace quadlat socket brim 858.44 8/1/2011
L4030 Replace socket brim cust fit 503.19 8/1/2011
L4040 Replace molded thigh lacer 406.83 8/1/2011
L4045 Replace non-molded thigh lac 326.94 8/1/2011
L4050 Replace molded calf lacer 411.46 8/1/2011
L4055 Replace non-molded calf lace 266.43 8/1/2011
L4060 Replace high roll cuff 316.74 8/1/2011
L4070 Replace prox & dist upright 280.48 8/1/2011
L4080 Repl met band kafo-afo prox 86.38 8/1/2011
L4090 Repl met band kafo-afo calf/ 82.26 8/1/2011
L4100 Repl leath cuff kafo prox th 103.96 8/1/2011
L4110 Repl leath cuff kafo-afo cal 84.51 8/1/2011
45/55
Proc Code Description Mod Rate Rate Begin Date
L4130 Replace pretibial shell 494.47 8/1/2011
L4205 Ortho dvc repair per 15 min 7.94 8/1/2011
L4210 Orth dev repair/repl minor p 7.94 8/1/2011
L4350 Ankle control ortho pre ots 89.09 8/1/2011
L4360 Pneumat walking boot pre cst 241.47 8/1/2011
L4361 Pneuma/vac walk boot pre ots NU 284.85 1/1/2014
L4370 Pneum full leg splnt pre ots 141.12 8/1/2011
L4386 Non-pneum walk boot pre cst 123.71 8/1/2011
L4387 Non-pneum walk boot pre ots NU 145.92 1/1/2014
L4392 Replace afo soft interface 18.06 8/1/2011
L4394 Replace foot drop spint 13.16 8/1/2011
L4396 Static or dynami afo pre cst 128.75 8/1/2011
L4397 Static or dynami afo pre ots NU 151.86 1/1/2014
L4398 Foot drop splint pre ots 59.27 8/1/2011
L4631 Afo, walk boot type, cus fab 1650.02 8/1/2011
L5000 Sho insert w arch toe filler 478.58 8/1/2011
L5010 Mold socket ank hgt w/ toe f 1074.43 8/1/2011
L5020 Tibial tubercle hgt w/ toe f 2104.24 8/1/2011
L5050 Ank symes mold sckt sach ft 2120.41 8/1/2011
L5060 Symes met fr leath socket ar 2932.72 8/1/2011
L5100 Molded socket shin sach foot 2140.97 8/1/2011
L5105 Plast socket jts/thgh lacer 3688.66 8/1/2011
L5150 Mold sckt ext knee shin sach 3728.73 8/1/2011
L5160 Mold socket bent knee shin s 4055.67 8/1/2011
L5200 Kne sing axis fric shin sach 3195.90 8/1/2011
L5210 No knee/ankle joints w/ ft b 2357.99 8/1/2011
L5220 No knee joint with artic ali 2928.72 8/1/2011
L5230 Fem focal defic constant fri 4039.30 8/1/2011
L5250 Hip canad sing axi cons fric 5509.23 8/1/2011
L5270 Tilt table locking hip sing 5460.97 8/1/2011
L5280 Hemipelvect canad sing axis 5406.36 8/1/2011
L5301 Bk mold socket sach ft endo 2906.50 12/1/2015
L5312 Knee disart, sach ft, endo 3610.36 1/1/2012
L5321 Ak open end sach 3489.84 8/1/2011
L5331 Hip disart canadian sach ft 4637.72 8/1/2011
L5341 Hemipelvectomy canadian sach 5366.32 8/1/2011
L5400 Postop dress & 1 cast chg bk 1263.64 8/1/2011
L5410 Postop dsg bk ea add cast ch 332.73 8/1/2011
L5420 Postop dsg & 1 cast chg ak/d 1613.96 8/1/2011
L5430 Postop dsg ak ea add cast ch 449.82 8/1/2011
L5450 Postop app non-wgt bear dsg 324.44 8/1/2011
L5460 Postop app non-wgt bear dsg 434.24 8/1/2011
L5500 Init bk ptb plaster direct 1358.11 8/1/2011
L5505 Init ak ischal plstr direct 1846.82 8/1/2011
L5510 Prep bk ptb plaster molded 1400.95 8/1/2011
46/55
Proc Code Description Mod Rate Rate Begin Date
L5520 Perp bk ptb thermopls direct 1525.99 8/1/2011
L5530 Prep bk ptb thermopls molded 1833.99 8/1/2011
L5535 Prep bk ptb open end socket 1800.62 8/1/2011
L5540 Prep bk ptb laminated socket 1920.56 8/1/2011
L5560 Prep ak ischial plast molded 1872.12 8/1/2011
L5570 Prep ak ischial direct form 2052.48 8/1/2011
L5580 Prep ak ischial thermo mold 2491.18 8/1/2011
L5585 Prep ak ischial open end 2206.24 8/1/2011
L5590 Prep ak ischial laminated 2552.52 8/1/2011
L5595 Hip disartic sach thermopls 4275.36 8/1/2011
L5600 Hip disart sach laminat mold 4721.28 8/1/2011
L5610 Above knee hydracadence 1951.47 8/1/2011
L5611 Ak 4 bar link w/fric swing 1578.19 8/1/2011
L5613 Ak 4 bar ling w/hydraul swig 2602.17 8/1/2011
L5614 4-bar link above knee w/swng 1319.21 8/1/2011
L5616 Ak univ multiplex sys frict 1123.83 8/1/2011
L5617 Ak/bk self-aligning unit ea 437.42 8/1/2011
L5618 Test socket symes 229.96 8/1/2011
L5620 Test socket below knee 232.92 8/1/2011
L5622 Test socket knee disarticula 301.89 8/1/2011
L5624 Test socket above knee 331.13 8/1/2011
L5626 Test socket hip disarticulat 434.99 8/1/2011
L5628 Test socket hemipelvectomy 384.96 8/1/2011
L5629 Below knee acrylic socket 253.09 8/1/2011
L5630 Syme typ expandabl wall sckt 438.77 8/1/2011
L5631 Ak/knee disartic acrylic soc 349.90 8/1/2011
L5632 Symes type ptb brim design s 188.18 8/1/2011
L5634 Symes type poster opening so 322.98 8/1/2011
L5636 Symes type medial opening so 202.91 8/1/2011
L5637 Below knee total contact 305.54 8/1/2011
L5638 Below knee leather socket 516.75 8/1/2011
L5639 Below knee wood socket 1190.48 8/1/2011
L5640 Knee disarticulat leather so 617.86 8/1/2011
L5642 Above knee leather socket 493.39 8/1/2011
L5643 Hip flex inner socket ext fr 1239.48 8/1/2011
L5644 Above knee wood socket 470.36 8/1/2011
L5645 Bk flex inner socket ext fra 719.25 8/1/2011
L5646 Below knee cushion socket 436.33 8/1/2011
L5647 Below knee suction socket 844.63 8/1/2011
L5648 Above knee cushion socket 524.30 8/1/2011
L5649 Isch containmt/narrow m-l so 1526.08 8/1/2011
L5650 Tot contact ak/knee disart s 518.36 8/1/2011
L5651 Ak flex inner socket ext fra 956.36 8/1/2011
L5652 Suction susp ak/knee disart 347.19 8/1/2011
L5653 Knee disart expand wall sock 518.81 8/1/2011
47/55
Proc Code Description Mod Rate Rate Begin Date
L5654 Socket insert symes 324.48 8/1/2011
L5655 Socket insert below knee 281.63 8/1/2011
L5656 Socket insert knee articulat 393.88 8/1/2011
L5658 Socket insert above knee 299.77 8/1/2011
L5661 Multi-durometer symes 599.00 8/1/2011
L5665 Multi-durometer below knee 543.68 8/1/2011
L5666 Below knee cuff suspension 74.33 8/1/2011
L5668 Bk molded distal cushion 107.22 8/1/2011
L5670 Bk molded supracondylar susp 288.12 8/1/2011
L5671 Bk/ak locking mechanism 528.15 8/1/2011
L5672 Bk removable medial brim sus 251.00 8/1/2011
L5673 Socket insert w lock mech 624.07 8/1/2011
L5676 Bk knee joints single axis p 384.77 8/1/2011
L5677 Bk knee joints polycentric p 523.53 8/1/2011
L5678 Bk joint covers pair 42.16 8/1/2011
L5679 Socket insert w/o lock mech 520.00 8/1/2011
L5680 Bk thigh lacer non-molded 253.96 8/1/2011
L5681 Intl custm cong/latyp insert 1028.34 8/1/2011
L5682 Bk thigh lacer glut/ischia m 664.05 8/1/2011
L5683 Initial custom socket insert 1028.34 8/1/2011
L5684 Bk fork strap 51.10 8/1/2011
L5685 Below knee sus/seal sleeve 100.12 8/1/2011
L5686 Bk back check 49.44 8/1/2011
L5688 Bk waist belt webbing 64.85 8/1/2011
L5690 Bk waist belt padded and lin 103.90 8/1/2011
L5692 Ak pelvic control belt light 141.09 8/1/2011
L5694 Ak pelvic control belt pad/l 192.62 8/1/2011
L5695 Ak sleeve susp neoprene/equa 173.16 8/1/2011
L5696 Ak/knee disartic pelvic join 196.46 8/1/2011
L5697 Ak/knee disartic pelvic band 85.24 8/1/2011
L5698 Ak/knee disartic silesian ba 109.25 8/1/2011
L5699 Shoulder harness 197.97 8/1/2011
L5700 Replace socket below knee 2907.80 8/1/2011
L5701 Replace socket above knee 3610.27 8/1/2011
L5702 Replace socket hip 4613.18 8/1/2011
L5703 Symes ankle w/o (sach) foot 1916.99 8/1/2011
L5704 Custom shape cover bk 485.63 8/1/2011
L5705 Custom shape cover ak 797.24 8/1/2011
L5706 Custom shape cvr knee disart 790.16 8/1/2011
L5707 Custom shape cvr hip disart 1123.26 8/1/2011
L5710 Kne-shin exo sng axi mnl loc 381.89 8/1/2011
L5711 Knee-shin exo mnl lock ultra 554.43 8/1/2011
L5712 Knee-shin exo frict swg & st 457.52 8/1/2011
L5714 Knee-shin exo variable frict 397.63 8/1/2011
L5716 Knee-shin exo mech stance ph 773.88 8/1/2011
48/55
Proc Code Description Mod Rate Rate Begin Date
L5718 Knee-shin exo frct swg & sta 967.27 8/1/2011
L5722 Knee-shin pneum swg frct exo 864.08 8/1/2011
L5724 Knee-shin exo fluid swing ph 1535.82 8/1/2011
L5726 Knee-shin ext jnts fld swg e 1570.62 8/1/2011
L5728 Knee-shin fluid swg & stance 2526.56 8/1/2011
L5780 Knee-shin pneum/hydra pneum 1215.67 8/1/2011
L5781 Lower limb pros vacuum pump 3128.03 8/1/2011
L5785 Exoskeletal bk ultralt mater 437.44 8/1/2011
L5790 Exoskeletal ak ultra-light m 704.29 8/1/2011
L5795 Exoskel hip ultra-light mate 888.72 8/1/2011
L5810 Endoskel knee-shin mnl lock 516.96 8/1/2011
L5811 Endo knee-shin mnl lck ultra 774.39 8/1/2011
L5812 Endo knee-shin frct swg & st 600.23 8/1/2011
L5814 Endo knee-shin hydral swg ph 2903.44 8/1/2011
L5816 Endo knee-shin polyc mch sta 903.00 8/1/2011
L5818 Endo knee-shin frct swg & st 1019.68 8/1/2011
L5822 Endo knee-shin pneum swg frc 1356.11 8/1/2011
L5824 Endo knee-shin fluid swing p 1628.34 8/1/2011
L5826 Miniature knee joint 2441.43 8/1/2011
L5828 Endo knee-shin fluid swg/sta 2913.10 8/1/2011
L5830 Endo knee-shin pneum/swg pha 2014.81 8/1/2011
L5840 Multi-axial knee/shin system 3214.23 8/1/2011
L5845 Knee-shin sys stance flexion 1401.23 8/1/2011
L5848 Knee-shin sys hydraul stance 840.67 8/1/2011
L5850 Endo ak/hip knee extens assi 101.87 8/1/2011
L5855 Mech hip extension assist 327.92 8/1/2011
L5856 Elec knee-shin swing/stance 18767.31 8/1/2011
L5857 Elec knee-shin swing only 6659.36 8/1/2011
L5910 Endo below knee alignable sy 288.42 8/1/2011
L5920 Endo ak/hip alignable system 422.53 8/1/2011
L5925 Above knee manual lock 347.31 8/1/2011
L5930 High activity knee frame 2631.40 8/1/2011
L5940 Endo bk ultra-light material 424.55 8/1/2011
L5950 Endo ak ultra-light material 619.57 8/1/2011
L5960 Endo hip ultra-light materia 767.72 8/1/2011
L5962 Below knee flex cover system 624.12 8/1/2011
L5964 Above knee flex cover system 898.47 8/1/2011
L5966 Hip flexible cover system 1164.83 8/1/2011
L5968 Multiaxial ankle w dorsiflex 2840.93 8/1/2011
L5970 Foot external keel sach foot 203.47 8/1/2011
L5971 Sach foot, replacement 203.47 8/1/2011
L5972 Flexible keel foot 374.21 8/1/2011
L5974 Foot single axis ankle/foot 247.43 8/1/2011
L5975 Combo ankle/foot prosthesis 362.43 8/1/2011
L5976 Energy storing foot 594.64 8/1/2011
49/55
Proc Code Description Mod Rate Rate Begin Date
L5978 Ft prosth multiaxial ankl/ft 309.87 8/1/2011
L5979 Multi-axial ankle/ft prosth 2400.41 8/1/2011
L5980 Flex foot system 3360.88 8/1/2011
L5981 Flex-walk sys low ext prosth 2608.55 8/1/2011
L5982 Exoskeletal axial rotation u 613.84 8/1/2011
L5984 Endoskeletal axial rotation 604.89 8/1/2011
L5985 Lwr ext dynamic prosth pylon 220.76 8/1/2011
L5986 Multi-axial rotation unit 672.85 8/1/2011
L5987 Shank ft w vert load pylon 5623.93 8/1/2011
L5988 Vertical shock reducing pylo 1561.77 8/1/2011
L5990 User adjustable heel height 1418.31 8/1/2011
L5999 Lowr extremity prosthes nos 0.00 1/1/1982
L6000 Part hand thumb rem 1410.81 8/1/2011
L6010 Part hand little/ring 1570.00 8/1/2011
L6020 Part hand no fingers 1463.78 8/1/2011
L6026 Part hand myo exclu term dev 4418.92 1/1/2015
L6050 Wrst mld sck flx hng tri pad 2010.64 8/1/2011
L6055 Wrst mold sock w/exp interfa 2578.55 8/1/2011
L6100 Elb mold sock flex hinge pad 1673.21 8/1/2011
L6110 Elbow mold sock suspension t 2166.90 8/1/2011
L6120 Elbow mold doub splt soc ste 2460.47 8/1/2011
L6130 Elbow stump activated lock h 2748.71 8/1/2011
L6200 Elbow mold outsid lock hinge 2896.70 8/1/2011
L6205 Elbow molded w/ expand inter 3536.00 8/1/2011
L6250 Elbow inter loc elbow forarm 2851.32 8/1/2011
L6300 Shlder disart int lock elbow 3955.89 8/1/2011
L6310 Shoulder passive restor comp 3222.16 8/1/2011
L6320 Shoulder passive restor cap 1814.56 8/1/2011
L6350 Thoracic intern lock elbow 4127.66 8/1/2011
L6360 Thoracic passive restor comp 3382.04 8/1/2011
L6370 Thoracic passive restor cap 2156.61 8/1/2011
L6380 Postop dsg cast chg wrst/elb 1030.12 8/1/2011
L6382 Postop dsg cast chg elb dis/ 1295.89 8/1/2011
L6384 Postop dsg cast chg shlder/t 1680.40 8/1/2011
L6386 Postop ea cast chg & realign 426.40 8/1/2011
L6388 Postop applicat rigid dsg on 435.34 8/1/2011
L6400 Below elbow prosth tiss shap 2463.81 8/1/2011
L6450 Elb disart prosth tiss shap 3003.27 8/1/2011
L6500 Above elbow prosth tiss shap 2730.23 8/1/2011
L6550 Shldr disar prosth tiss shap 4048.93 8/1/2011
L6570 Scap thorac prosth tiss shap 4647.39 8/1/2011
L6580 Wrist/elbow bowden cable mol 1423.20 8/1/2011
L6582 Wrist/elbow bowden cbl dir f 1096.02 8/1/2011
L6584 Elbow fair lead cable molded 1779.41 8/1/2011
L6586 Elbow fair lead cable dir fo 1513.63 8/1/2011
50/55
Proc Code Description Mod Rate Rate Begin Date
L6588 Shdr fair lead cable molded 2575.12 8/1/2011
L6590 Shdr fair lead cable direct 2262.43 8/1/2011
L6600 Polycentric hinge pair 199.17 8/1/2011
L6605 Single pivot hinge pair 196.66 8/1/2011
L6610 Flexible metal hinge pair 176.77 8/1/2011
L6615 Disconnect locking wrist uni 145.90 8/1/2011
L6616 Disconnect insert locking wr 51.66 8/1/2011
L6620 Flexion/extension wrist unit 304.32 8/1/2011
L6621 Flex/ext wrist w/wo friction 1788.17 8/1/2011
L6623 Spring-ass rot wrst w/ latch 510.83 8/1/2011
L6624 Flex/ext/rotation wrist unit 3311.47 8/1/2011
L6625 Rotation wrst w/ cable lock 564.73 8/1/2011
L6628 Quick disconn hook adapter o 381.49 8/1/2011
L6629 Lamination collar w/ couplin 139.45 8/1/2011
L6630 Stainless steel any wrist 171.63 8/1/2011
L6632 Latex suspension sleeve each 51.74 8/1/2011
L6635 Lift assist for elbow 187.01 8/1/2011
L6637 Nudge control elbow lock 341.48 8/1/2011
L6638 Elec lock on manual pw elbow 1955.03 8/1/2011
L6640 Shoulder abduction joint pai 223.07 8/1/2011
L6641 Excursion amplifier pulley t 159.98 8/1/2011
L6642 Excursion amplifier lever ty 207.49 8/1/2011
L6645 Shoulder flexion-abduction j 338.96 8/1/2011
L6646 Multipo locking shoulder jnt 2465.73 8/1/2011
L6647 Shoulder lock actuator 405.93 8/1/2011
L6648 Ext pwrd shlder lock/unlock 2543.05 8/1/2011
L6650 Shoulder universal joint 359.41 8/1/2011
L6655 Standard control cable extra 79.76 8/1/2011
L6660 Heavy duty control cable 97.46 8/1/2011
L6665 Teflon or equal cable lining 39.49 8/1/2011
L6670 Hook to hand cable adapter 50.92 8/1/2011
L6672 Harness chest/shlder saddle 179.04 8/1/2011
L6675 Harness figure of 8 sing con 121.56 8/1/2011
L6676 Harness figure of 8 dual con 128.77 8/1/2011
L6677 Ue triple control harness 231.91 8/1/2011
L6680 Test sock wrist disart/bel e 246.35 8/1/2011
L6682 Test sock elbw disart/above 245.30 8/1/2011
L6684 Test socket shldr disart/tho 370.12 8/1/2011
L6686 Suction socket 626.85 8/1/2011
L6687 Frame typ socket bel elbow/w 464.59 8/1/2011
L6688 Frame typ sock above elb/dis 503.29 8/1/2011
L6689 Frame typ socket shoulder di 573.92 8/1/2011
L6690 Frame typ sock interscap-tho 664.85 8/1/2011
L6691 Removable insert each 365.83 8/1/2011
L6692 Silicone gel insert or equal 593.79 8/1/2011
51/55
Proc Code Description Mod Rate Rate Begin Date
L6693 Lockingelbow forearm cntrbal 2219.48 8/1/2011
L6694 Elbow socket ins use w/lock 624.01 8/1/2011
L6695 Elbow socket ins use w/o lck 520.00 8/1/2011
L6696 Cus elbo skt in for con/atyp 1028.34 8/1/2011
L6697 Cus elbo skt in not con/atyp 1028.34 8/1/2011
L6698 Below/above elbow lock mech 528.15 8/1/2011
L6703 Term dev, passive hand mitt 298.52 8/1/2011
L6704 Term dev, sport/rec/work att 648.57 8/1/2011
L6706 Term dev mech hook vol open 358.46 8/1/2011
L6707 Term dev mech hook vol close 1368.75 8/1/2011
L6708 Term dev mech hand vol open 926.35 8/1/2011
L6709 Term dev mech hand vol close 1341.72 8/1/2011
L6711 Ped term dev, hook, vol open 591.16 8/1/2011
L6712 Ped term dev, hook, vol clos 1088.43 8/1/2011
L6713 Ped term dev, hand, vol open 1373.72 8/1/2011
L6714 Ped term dev, hand, vol clos 1163.54 8/1/2011
L6721 Hook/hand, hvy dty, vol open 2068.04 8/1/2011
L6722 Hook/hand, hvy dty, vol clos 1782.81 8/1/2011
L6805 Term dev modifier wrist unit 337.19 8/1/2011
L6810 Term dev precision pinch dev 173.33 8/1/2011
L6881 Term dev auto grasp feature 3196.12 8/1/2011
L6882 Microprocessor control uplmb 2424.40 8/1/2011
L6883 Replc sockt below e/w disa 1368.94 8/1/2011
L6884 Replc sockt above elbow disa 2370.50 8/1/2011
L6885 Replc sockt shldr dis/interc 3382.04 8/1/2011
L6890 Prefab glove for term device 180.60 8/1/2011
L6895 Custom glove for term device 444.68 8/1/2011
L6900 Hand restorat thumb/1 finger 1597.57 8/1/2011
L6905 Hand restoration multiple fi 1558.95 8/1/2011
L6910 Hand restoration no fingers 1518.74 8/1/2011
L6915 Hand restoration replacmnt g 642.99 8/1/2011
L7259 Electronic wrist rotator any NU 3846.85 1/1/2015
L7360 Six volt bat otto bock/eq ea 193.46 8/1/2011
L7362 Battery chrgr six volt otto 205.58 8/1/2011
L7364 Twelve volt battery utah/equ 378.25 8/1/2011
L7366 Battery chrgr 12 volt utah/e 488.71 8/1/2011
L7367 Replacemnt lithium ionbatter 304.36 8/1/2011
L7368 Lithium ion battery charger 394.56 8/1/2011
L7400 Add ue prost be/wd, ultlite 239.60 8/1/2011
L7401 Add ue prost a/e ultlite mat 268.23 8/1/2011
L7402 Add ue prost s/d ultlite mat 289.68 8/1/2011
L7403 Add ue prost b/e acrylic 289.93 8/24/2015
L7404 Add ue prost a/e acrylic 434.52 8/1/2011
L7405 Add ue prost s/d acrylic 568.29 8/1/2011
L7499 Upper extremity prosthes nos 0.00 1/1/1985
52/55
Proc Code Description Mod Rate Rate Begin Date
L7510 Prosthetic device repair rep 7.94 8/1/2011
L7520 Repair prosthesis per 15 min 7.94 8/1/2011
L7600 Prosthetic donning sleeve 0.00 1/1/2006
L8000 Mastectomy bra 38.77 8/1/2011
L8001 Breast prosthesis bra & form 98.05 8/1/2011
L8002 Brst prsth bra & bilat form 128.97 8/1/2011
L8010 Mastectomy sleeve 34.93 8/1/2011
L8015 Ext breastprosthesis garment 46.86 8/1/2011
L8020 Mastectomy form 166.47 8/1/2011
L8030 Breast prosthes w/o adhesive 304.14 8/1/2011
L8035 Custom breast prosthesis 2864.16 8/1/2011
L8300 Truss single w/ standard pad 89.57 8/1/2011
L8310 Truss double w/ standard pad 141.41 8/1/2011
L8320 Truss addition to std pad wa 56.76 8/1/2011
L8330 Truss add to std pad scrotal 52.42 8/1/2011
L8400 Sheath below knee 16.71 8/1/2011
L8410 Sheath above knee 21.57 8/1/2011
L8415 Sheath upper limb 19.07 8/1/2011
L8417 Pros sheath/sock w gel cushn 58.79 8/1/2011
L8420 Prosthetic sock multi ply bk 20.65 8/1/2011
L8430 Prosthetic sock multi ply ak 22.16 8/1/2011
L8435 Pros sock multi ply upper lm 20.57 8/1/2011
L8440 Shrinker below knee 44.41 8/1/2011
L8460 Shrinker above knee 70.77 8/1/2011
L8465 Shrinker upper limb 38.85 8/1/2011
L8470 Pros sock single ply bk 7.09 8/1/2011
L8480 Pros sock single ply ak 8.45 8/1/2011
L8485 Pros sock single ply upper l 11.45 8/1/2011
L8501 Tracheostomy speaking valve 96.20 8/1/2011
L8615 Coch implant headset replace 367.75 8/1/2011
L8616 Coch implant microphone repl 85.66 8/1/2011
L8617 Coch implant trans coil repl 74.81 8/1/2011
L8618 Coch implant tran cable repl 21.38 8/1/2011
L8619 Coch imp ext proc/contr rplc 6743.61 8/1/2011
L8621 REPL ZINC AIR BATTERY 0.51 8/1/2011
L8622 Repl alkaline battery 0.27 8/1/2011
L8623 Lith ion batt cid,non-earlvl 50.57 8/1/2011
L8624 Lith ion batt cid, ear level 126.07 8/1/2011
L8627 Cid ext speech process repl 6442.48 8/1/2011
L8628 Cid ext controller repl 1142.16 8/1/2011
L8629 Cid transmit coil and cable 167.60 12/1/2015
L8691 Osseointegrated snd proc rpl 2086.25 8/1/2011
L8692 Non-osseointegrated snd proc 0.00 1/1/2010
L8693 Aud osseo dev, abutment 1331.93 8/1/2011
L9900 O&p supply/accessory/service 0.00 1/1/1980
53/55
Proc Code Description Mod Rate Rate Begin Date
S9349 Hit tocolysis diem 238.32 8/1/2011
S9364 Hit tpn total diem 295.91 8/1/2011
S9365 Hit tpn 1 liter diem 295.91 8/1/2011
S9366 Hit tpn 2 liter diem 295.91 8/1/2011
S9367 Hit tpn 3 liter diem 322.73 8/1/2011
S9368 Hit tpn over 3l diem 322.73 8/1/2011
S9435 Medical foods for inborn err 0.00 11/1/2005
T4521 Adult size brief/diaper sm 0.56 8/1/2011
T4522 Adult size brief/diaper med 0.60 8/1/2011
T4523 Adult size brief/diaper lg 0.80 8/1/2011
T4524 Adult size brief/diaper xl 0.96 8/1/2011
T4525 Adult size pull-on sm 0.83 8/1/2011
T4526 Adult size pull-on med 0.83 8/1/2011
T4527 Adult size pull-on lg 0.87 8/1/2011
T4528 Adult size pull-on xl 1.00 8/1/2011
T4529 Ped size brief/diaper sm/med 0.43 8/1/2011
T4530 Ped size brief/diaper lg 0.47 8/1/2011
T4531 Ped size pull-on sm/med 0.54 8/1/2011
T4532 Ped size pull-on lg 0.54 8/1/2011
T4533 Youth size brief/diaper 0.56 8/1/2011
T4534 Youth size pull-on 0.79 8/1/2011
T4535 Disposable liner/shield/pad 0.37 8/1/2011
T4541 Large disposable underpad 0.41 8/1/2011
T4542 Small disposable underpad 0.41 8/1/2011
T4543 Adult disp brief/diap abv xl 1.95 8/1/2011
V5266 Battery for hearing device 5.96 8/1/2011
54/55
Proc Code Description Mod Rate Rate Begin Date
55/55
![Untitled-1 [] · SOLARE 2 5rnL Sculpt Sculpt . Title: Untitled-1 Author: Marcomm Supprt Created Date: 6/24/2019 3:32:03 PM](https://img.dokumen.tips/doc/110x75/5fbabd525d3f6d19fd165bb5/untitled-1-solare-2-5rnl-sculpt-sculpt-title-untitled-1-author-marcomm-supprt.jpg)
