TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 1 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A0080 Blank NONINTEREST ESCORT IN NON ER Blank $558.57 HCPCS - Non-Drugs A0090 Blank INTEREST ESCORT IN NON ER Blank $59.01 HCPCS - Non-Drugs A0100 Blank NONEMERGENCY TRANSPORT TAXI Blank $22.27 HCPCS - Non-Drugs A0110 Blank NONEMERGENCY TRANSPORT BUS Blank $59.59 HCPCS - Non-Drugs A0120 Blank NONER TRANSPORT MINI-BUS Blank $154.32 HCPCS - Non-Drugs A0130 Blank NONER TRANSPORT WHEELCH VAN Blank $82.40 HCPCS - Non-Drugs A0140 Blank NONEMERGENCY TRANSPORT AIR Blank $1,011.57 HCPCS - Non-Drugs A0160 Blank NONER TRANSPORT CASE WORKER Blank $3.11 HCPCS - Non-Drugs A0170 Blank TRANSPORT PARKING FEES/TOLLS Blank $298.40 HCPCS - Non-Drugs A0180 Blank NONER TRANSPORT LODGNG RECIP Blank $851.62 HCPCS - Non-Drugs A0190 Blank NONER TRANSPORT MEALS RECIP Blank $157.98 HCPCS - Non-Drugs A0398 Blank ALS ROUTINE DISPOSBLE SUPPLS Blank $112.73 HCPCS - Non-Drugs A0422 Blank AMBULANCE 02 LIFE SUSTAINING Blank $132.50 HCPCS - Non-Drugs A4206 Blank 1 CC STERILE SYRINGE&NEEDLE Blank $0.91 HCPCS - Non-Drugs A4207 Blank 2 CC STERILE SYRINGE&NEEDLE Blank $0.91 HCPCS - Non-Drugs A4208 Blank 3 CC STERILE SYRINGE&NEEDLE Blank $0.91 HCPCS - Non-Drugs A4209 Blank 5+ CC STERILE SYRINGE&NEEDLE Blank $0.91 HCPCS - Non-Drugs A4210 Blank NONNEEDLE INJECTION DEVICE Blank $1,185.99 HCPCS - Non-Drugs A4211 Blank SUPP FOR SELF-ADM INJECTIONS Blank $55.19 HCPCS - Non-Drugs A4212 Blank NON CORING NEEDLE OR STYLET Blank $12.83 HCPCS - Non-Drugs A4213 Blank 20+ CC SYRINGE ONLY Blank $1.82 HCPCS - Non-Drugs A4215 Blank STERILE NEEDLE Blank $1.26 HCPCS - Non-Drugs A4216 Blank STERILE WATER/SALINE, 10 ML Blank $1.06 HCPCS - Non-Drugs A4217 Blank STERILE WATER/SALINE, 500 ML Blank $6.72 HCPCS - Non-Drugs A4217 AU STERILE WATER/SALINE, 500 ML Blank $6.72 HCPCS - Non-Drugs A4218 Blank STERILE SALINE OR WATER Blank $1.72 HCPCS - Non-Drugs A4220 Blank INFUSION PUMP REFILL KIT Blank $85.46 HCPCS - Non-Drugs A4221 Blank SUPP NON-INSULIN INF CATH/WK Blank $105.56 HCPCS - Non-Drugs A4222 Blank INFUSION SUPPLIES WITH PUMP Blank $139.53 HCPCS - Non-Drugs A4223 Blank INFUSION SUPPLIES W/O PUMP Blank $151.39 HCPCS - Non-Drugs A4230 Blank INFUS INSULIN PUMP NON NEEDL Blank $21.78 HCPCS - Non-Drugs A4231 Blank INFUSION INSULIN PUMP NEEDLE Blank $8.94 HCPCS - Non-Drugs A4232 Blank SYRINGE W/NEEDLE INSULIN 3CC Blank $5.61 HCPCS - Non-Drugs A4233 Blank ALKALIN BATT FOR GLUCOSE MON Blank $4.66 HCPCS - Non-Drugs A4233 NU ALKALIN BATT FOR GLUCOSE MON Blank $4.66 HCPCS - Non-Drugs A4234 Blank J-CELL BATT FOR GLUCOSE MON Blank $21.55 HCPCS - Non-Drugs A4234 NU J-CELL BATT FOR GLUCOSE MON Blank $21.55 HCPCS - Non-Drugs A4235 Blank LITHIUM BATT FOR GLUCOSE MON Blank $9.13 HCPCS - Non-Drugs A4235 NU LITHIUM BATT FOR GLUCOSE MON Blank $9.13 HCPCS - Non-Drugs A4236 Blank SILVR OXIDE BATT GLUCOSE MON Blank $10.59 HCPCS - Non-Drugs A4236 NU SILVR OXIDE BATT GLUCOSE MON Blank $10.59 HCPCS - Non-Drugs A4244 Blank ALCOHOL OR PEROXIDE PER PINT Blank $1.82 HCPCS - Non-Drugs A4245 Blank ALCOHOL WIPES PER BOX Blank $5.28 HCPCS - Non-Drugs A4246 Blank BETADINE/PHISOHEX SOLUTION Blank $5.28 HCPCS - Non-Drugs A4247 Blank BETADINE/IODINE SWABS/WIPES Blank $7.34 HCPCS - Non-Drugs A4248 Blank CHLORHEXIDINE ANTISEPT Blank $5.93 HCPCS - Non-Drugs A4250 Blank URINE REAGENT STRIPS/TABLETS Blank $25.19 HCPCS - Non-Drugs A4252 Blank BLOOD KETONE TEST OR STRIP Blank $11.04 HCPCS - Non-Drugs A4253 Blank BLOOD GLUCOSE/REAGENT STRIPS Blank $109.46 HCPCS - Non-Drugs A4253 NU BLOOD GLUCOSE/REAGENT STRIPS Blank $109.46 HCPCS - Non-Drugs A4255 Blank GLUCOSE MONITOR PLATFORMS Blank $40.57 HCPCS - Non-Drugs A4256 Blank CALIBRATOR SOLUTION/CHIPS Blank $30.87 HCPCS - Non-Drugs A4256 KL CALIBRATOR SOLUTION/CHIPS Blank $28.01 HCPCS - Non-Drugs A4257 Blank REPLACE LENSSHIELD CARTRIDGE Blank $95.27 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 2 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A4258 Blank LANCET DEVICE EACH Blank $19.36 HCPCS - Non-Drugs A4258 KL LANCET DEVICE EACH Blank $17.30 HCPCS - Non-Drugs A4259 Blank LANCETS PER BOX Blank $12.97 HCPCS - Non-Drugs A4259 KL LANCETS PER BOX Blank $11.73 HCPCS - Non-Drugs A4261 Blank CERVICAL CAP CONTRACEPTIVE Blank $75.32 HCPCS - Non-Drugs A4262 Blank TEMPORARY TEAR DUCT PLUG Blank $0.91 HCPCS - Non-Drugs A4263 Blank PERMANENT TEAR DUCT PLUG Blank $56.08 HCPCS - Non-Drugs A4264 Blank INTRATUBAL OCCLUSION DEVICE Blank $2,145.18 HCPCS - Non-Drugs A4265 Blank PARAFFIN Blank $34.42 HCPCS - Non-Drugs A4266 Blank DIAPHRAGM Blank $55.15 HCPCS - Non-Drugs A4267 Blank MALE CONDOM Blank $0.91 HCPCS - Non-Drugs A4268 Blank FEMALE CONDOM Blank $1.49 HCPCS - Non-Drugs A4269 Blank SPERMICIDE Blank $1.82 HCPCS - Non-Drugs A4270 Blank DISPOSABLE ENDOSCOPE SHEATH Blank $23.36 HCPCS - Non-Drugs A4280 Blank BRST PRSTHS ADHSV ATTCHMNT Blank $9.79 HCPCS - Non-Drugs A4281 Blank REPLACEMENT BREASTPUMP TUBE Blank $20.98 HCPCS - Non-Drugs A4282 Blank REPLACEMENT BREASTPUMP ADPT Blank $7.12 HCPCS - Non-Drugs A4283 Blank REPLACEMENT BREASTPUMP CAP Blank $216.76 HCPCS - Non-Drugs A4284 Blank REPLCMNT BREAST PUMP SHIELD Blank $25.19 HCPCS - Non-Drugs A4285 Blank REPLCMNT BREAST PUMP BOTTLE Blank $11.27 HCPCS - Non-Drugs A4286 Blank REPLCMNT BREASTPUMP LOK RING Blank $109.40 HCPCS - Non-Drugs A4290 Blank SACRAL NERVE STIM TEST LEAD Blank $585.27 HCPCS - Non-Drugs A4300 Blank CATH IMPL VASC ACCESS PORTAL Blank $39.08 HCPCS - Non-Drugs A4301 Blank IMPLANTABLE ACCESS SYST PERC Blank $19.88 HCPCS - Non-Drugs A4305 Blank DRUG DELIVERY SYSTEM >=50 ML Blank $19.01 HCPCS - Non-Drugs A4306 Blank DRUG DELIVERY SYSTEM <=50 ML Blank $25.87 HCPCS - Non-Drugs A4310 Blank INSERT TRAY W/O BAG/CATH Blank $15.26 HCPCS - Non-Drugs A4311 Blank CATHETER W/O BAG 2-WAY LATEX Blank $27.48 HCPCS - Non-Drugs A4312 Blank CATH W/O BAG 2-WAY SILICONE Blank $33.80 HCPCS - Non-Drugs A4313 Blank CATHETER W/BAG 3-WAY Blank $34.76 HCPCS - Non-Drugs A4314 Blank CATH W/DRAINAGE 2-WAY LATEX Blank $46.92 HCPCS - Non-Drugs A4315 Blank CATH W/DRAINAGE 2-WAY SILCNE Blank $49.07 HCPCS - Non-Drugs A4316 Blank CATH W/DRAINAGE 3-WAY Blank $52.95 HCPCS - Non-Drugs A4320 Blank IRRIGATION TRAY Blank $10.56 HCPCS - Non-Drugs A4321 Blank CATH THERAPEUTIC IRRIG AGENT Blank $9.73 HCPCS - Non-Drugs A4322 Blank IRRIGATION SYRINGE Blank $6.77 HCPCS - Non-Drugs A4326 Blank MALE EXTERNAL CATHETER Blank $20.56 HCPCS - Non-Drugs A4327 Blank FEM URINARY COLLECT DEV CUP Blank $83.76 HCPCS - Non-Drugs A4328 Blank FEM URINARY COLLECT POUCH Blank $20.22 HCPCS - Non-Drugs A4330 Blank STOOL COLLECTION POUCH Blank $13.95 HCPCS - Non-Drugs A4331 Blank EXTENSION DRAINAGE TUBING Blank $7.18 HCPCS - Non-Drugs A4332 Blank LUBE STERILE PACKET Blank $0.30 HCPCS - Non-Drugs A4333 Blank URINARY CATH ANCHOR DEVICE Blank $4.09 HCPCS - Non-Drugs A4334 Blank URINARY CATH LEG STRAP Blank $9.08 HCPCS - Non-Drugs A4335 Blank INCONTINENCE SUPPLY Blank $0.60 HCPCS - Non-Drugs A4336 Blank URETHRAL INSERT Blank $3.68 HCPCS - Non-Drugs A4338 Blank INDWELLING CATHETER LATEX Blank $23.51 HCPCS - Non-Drugs A4340 Blank INDWELLING CATHETER SPECIAL Blank $57.45 HCPCS - Non-Drugs A4344 Blank CATH INDW FOLEY 2 WAY SILICN Blank $30.12 HCPCS - Non-Drugs A4346 Blank CATH INDW FOLEY 3 WAY Blank $36.02 HCPCS - Non-Drugs A4349 Blank DISPOSABLE MALE EXTERNAL CAT Blank $4.97 HCPCS - Non-Drugs A4351 Blank STRAIGHT TIP URINE CATHETER Blank $4.38 HCPCS - Non-Drugs A4352 Blank COUDE TIP URINARY CATHETER Blank $12.71 HCPCS - Non-Drugs A4353 Blank INTERMITTENT URINARY CATH Blank $14.38 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 3 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A4354 Blank CATH INSERTION TRAY W/BAG Blank $22.65 HCPCS - Non-Drugs A4355 Blank BLADDER IRRIGATION TUBING Blank $17.84 HCPCS - Non-Drugs A4356 Blank EXT URETH CLMP OR COMPR DVC Blank $83.11 HCPCS - Non-Drugs A4357 Blank BEDSIDE DRAINAGE BAG Blank $18.72 HCPCS - Non-Drugs A4358 Blank URINARY LEG OR ABDOMEN BAG Blank $13.08 HCPCS - Non-Drugs A4360 Blank DISPOSABLE EXT URETHRAL DEV Blank $1.17 HCPCS - Non-Drugs A4361 Blank OSTOMY FACE PLATE Blank $34.57 HCPCS - Non-Drugs A4362 Blank SOLID SKIN BARRIER Blank $7.37 HCPCS - Non-Drugs A4363 Blank OSTOMY CLAMP, REPLACEMENT Blank $5.44 HCPCS - Non-Drugs A4364 Blank ADHESIVE, LIQUID OR EQUAL Blank $5.14 HCPCS - Non-Drugs A4366 Blank OSTOMY VENT Blank $2.40 HCPCS - Non-Drugs A4367 Blank OSTOMY BELT Blank $14.42 HCPCS - Non-Drugs A4368 Blank OSTOMY FILTER Blank $0.64 HCPCS - Non-Drugs A4369 Blank SKIN BARRIER LIQUID PER OZ Blank $5.56 HCPCS - Non-Drugs A4371 Blank SKIN BARRIER POWDER PER OZ Blank $8.03 HCPCS - Non-Drugs A4372 Blank SKIN BARRIER SOLID 4X4 EQUIV Blank $9.09 HCPCS - Non-Drugs A4373 Blank SKIN BARRIER WITH FLANGE Blank $13.00 HCPCS - Non-Drugs A4375 Blank DRAINABLE PLASTIC PCH W FCPL Blank $33.61 HCPCS - Non-Drugs A4376 Blank DRAINABLE RUBBER PCH W FCPLT Blank $91.06 HCPCS - Non-Drugs A4377 Blank DRAINABLE PLSTIC PCH W/O FP Blank $9.28 HCPCS - Non-Drugs A4378 Blank DRAINABLE RUBBER PCH W/O FP Blank $59.23 HCPCS - Non-Drugs A4379 Blank URINARY PLASTIC POUCH W FCPL Blank $29.53 HCPCS - Non-Drugs A4380 Blank URINARY RUBBER POUCH W FCPLT Blank $71.67 HCPCS - Non-Drugs A4381 Blank URINARY PLASTIC POUCH W/O FP Blank $9.89 HCPCS - Non-Drugs A4382 Blank URINARY HVY PLSTC PCH W/O FP Blank $47.66 HCPCS - Non-Drugs A4383 Blank URINARY RUBBER POUCH W/O FP Blank $54.41 HCPCS - Non-Drugs A4384 Blank OSTOMY FACEPLT/SILICONE RING Blank $19.33 HCPCS - Non-Drugs A4385 Blank OST SKN BARRIER SLD EXT WEAR Blank $10.80 HCPCS - Non-Drugs A4387 Blank OST CLSD POUCH W ATT ST BARR Blank $5.40 HCPCS - Non-Drugs A4388 Blank DRAINABLE PCH W EX WEAR BARR Blank $9.41 HCPCS - Non-Drugs A4389 Blank DRAINABLE PCH W ST WEAR BARR Blank $12.90 HCPCS - Non-Drugs A4390 Blank DRAINABLE PCH EX WEAR CONVEX Blank $19.31 HCPCS - Non-Drugs A4391 Blank URINARY POUCH W EX WEAR BARR Blank $14.52 HCPCS - Non-Drugs A4392 Blank URINARY POUCH W ST WEAR BARR Blank $16.62 HCPCS - Non-Drugs A4393 Blank URINE PCH W EX WEAR BAR CONV Blank $18.26 HCPCS - Non-Drugs A4394 Blank OSTOMY POUCH LIQ DEODORANT Blank $6.05 HCPCS - Non-Drugs A4395 Blank OSTOMY POUCH SOLID DEODORANT Blank $0.11 HCPCS - Non-Drugs A4396 Blank PERISTOMAL HERNIA SUPPRT BLT Blank $77.70 HCPCS - Non-Drugs A4397 Blank IRRIGATION SUPPLY SLEEVE Blank $9.58 HCPCS - Non-Drugs A4398 Blank OSTOMY IRRIGATION BAG Blank $26.75 HCPCS - Non-Drugs A4399 Blank OSTOMY IRRIG CONE/CATH W BRS Blank $23.04 HCPCS - Non-Drugs A4400 Blank OSTOMY IRRIGATION SET Blank $87.80 HCPCS - Non-Drugs A4402 Blank LUBRICANT PER OUNCE Blank $3.97 HCPCS - Non-Drugs A4404 Blank OSTOMY RING EACH Blank $4.19 HCPCS - Non-Drugs A4405 Blank NONPECTIN BASED OSTOMY PASTE Blank $7.61 HCPCS - Non-Drugs A4406 Blank PECTIN BASED OSTOMY PASTE Blank $11.99 HCPCS - Non-Drugs A4407 Blank EXT WEAR OST SKN BARR <=4SQ Blank $17.72 HCPCS - Non-Drugs A4408 Blank EXT WEAR OST SKN BARR >4SQ Blank $19.82 HCPCS - Non-Drugs A4409 Blank OST SKN BARR CONVEX <=4 SQ I Blank $12.91 HCPCS - Non-Drugs A4410 Blank OST SKN BARR EXTND >4 SQ Blank $18.26 HCPCS - Non-Drugs A4411 Blank OST SKN BARR EXTND =4SQ Blank $10.81 HCPCS - Non-Drugs A4412 Blank OST POUCH DRAIN HIGH OUTPUT Blank $6.27 HCPCS - Non-Drugs A4413 Blank 2 PC DRAINABLE OST POUCH Blank $11.58 HCPCS - Non-Drugs A4414 Blank OST SKNBAR W/O CONV<=4 SQ IN Blank $10.46 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 4 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A4415 Blank OST SKN BARR W/O CONV >4 SQI Blank $12.48 HCPCS - Non-Drugs A4416 Blank OST PCH CLSD W BARRIER/FILTR Blank $5.11 HCPCS - Non-Drugs A4417 Blank OST PCH W BAR/BLTINCONV/FLTR Blank $6.88 HCPCS - Non-Drugs A4418 Blank OST PCH CLSD W/O BAR W FILTR Blank $3.36 HCPCS - Non-Drugs A4419 Blank OST PCH FOR BAR W FLANGE/FLT Blank $3.21 HCPCS - Non-Drugs A4420 Blank OST PCH CLSD FOR BAR W LK FL Blank $3.76 HCPCS - Non-Drugs A4421 Blank OSTOMY SUPPLY MISC Blank $8.36 HCPCS - Non-Drugs A4422 Blank OST POUCH ABSORBENT MATERIAL Blank $0.30 HCPCS - Non-Drugs A4423 Blank OST PCH FOR BAR W LK FL/FLTR Blank $3.45 HCPCS - Non-Drugs A4424 Blank OST PCH DRAIN W BAR & FILTER Blank $8.80 HCPCS - Non-Drugs A4425 Blank OST PCH DRAIN FOR BARRIER FL Blank $6.63 HCPCS - Non-Drugs A4426 Blank OST PCH DRAIN 2 PIECE SYSTEM Blank $5.06 HCPCS - Non-Drugs A4427 Blank OST PCH DRAIN/BARR LK FLNG/F Blank $5.16 HCPCS - Non-Drugs A4428 Blank URINE OST POUCH W FAUCET/TAP Blank $12.05 HCPCS - Non-Drugs A4429 Blank URINE OST POUCH W BLTINCONV Blank $15.10 HCPCS - Non-Drugs A4430 Blank OST URINE PCH W B/BLTIN CONV Blank $15.52 HCPCS - Non-Drugs A4431 Blank OST PCH URINE W BARRIER/TAPV Blank $11.51 HCPCS - Non-Drugs A4432 Blank OS PCH URINE W BAR/FANGE/TAP Blank $6.65 HCPCS - Non-Drugs A4433 Blank URINE OST PCH BAR W LOCK FLN Blank $6.19 HCPCS - Non-Drugs A4434 Blank OST PCH URINE W LOCK FLNG/FT Blank $6.95 HCPCS - Non-Drugs A4435 Blank 1PC OST PCH DRAIN HGH OUTPUT Blank $10.69 HCPCS - Non-Drugs A4450 Blank NON-WATERPROOF TAPE Blank $0.20 HCPCS - Non-Drugs A4450 AU NON-WATERPROOF TAPE Blank $0.20 HCPCS - Non-Drugs A4450 AV NON-WATERPROOF TAPE Blank $0.20 HCPCS - Non-Drugs A4450 AW NON-WATERPROOF TAPE Blank $0.27 HCPCS - Non-Drugs A4452 Blank WATERPROOF TAPE Blank $0.91 HCPCS - Non-Drugs A4452 AU WATERPROOF TAPE Blank $0.91 HCPCS - Non-Drugs A4452 AV WATERPROOF TAPE Blank $0.91 HCPCS - Non-Drugs A4452 AW WATERPROOF TAPE Blank $1.00 HCPCS - Non-Drugs A4455 Blank ADHESIVE REMOVER PER OUNCE Blank $3.40 HCPCS - Non-Drugs A4456 Blank ADHESIVE REMOVER, WIPES Blank $0.61 HCPCS - Non-Drugs A4458 Blank REUSABLE ENEMA BAG Blank $23.67 HCPCS - Non-Drugs A4459 Blank MANUAL PUMP ENEMA, REUSABLE Blank $23.67 HCPCS - Non-Drugs A4461 Blank SURGICL DRESS HOLD NON-REUSE Blank $7.39 HCPCS - Non-Drugs A4463 Blank SURGICAL DRESS HOLDER REUSE Blank $26.31 HCPCS - Non-Drugs A4465 Blank NON-ELASTIC EXTREMITY BINDER Blank $13.52 HCPCS - Non-Drugs A4466 Blank ELASTIC GARMENT/COVERING Blank $54.38 HCPCS - Non-Drugs A4470 Blank GRAVLEE JET WASHER Blank $10.08 HCPCS - Non-Drugs A4480 Blank VABRA ASPIRATOR Blank $8.02 HCPCS - Non-Drugs A4481 Blank TRACHEOSTOMA FILTER Blank $3.81 HCPCS - Non-Drugs A4483 Blank MOISTURE EXCHANGER Blank $8.77 HCPCS - Non-Drugs A4490 Blank ABOVE KNEE SURGICAL STOCKING Blank $10.08 HCPCS - Non-Drugs A4495 Blank THIGH LENGTH SURG STOCKING Blank $10.08 HCPCS - Non-Drugs A4500 Blank BELOW KNEE SURGICAL STOCKING Blank $8.02 HCPCS - Non-Drugs A4510 Blank FULL LENGTH SURG STOCKING Blank $17.63 HCPCS - Non-Drugs A4520 Blank INCONTINENCE GARMENT ANYTYPE Blank $1.50 HCPCS - Non-Drugs A4550 Blank SURGICAL TRAYS Blank $41.66 HCPCS - Non-Drugs A4554 Blank DISPOSABLE UNDERPADS Blank $5.28 HCPCS - Non-Drugs A4555 Blank CA TX E-STIM ELECTR/TRANSDUC Blank $23.66 HCPCS - Non-Drugs A4556 Blank ELECTRODES, PAIR Blank $91.90 HCPCS - Non-Drugs A4557 Blank LEAD WIRES, PAIR Blank $88.12 HCPCS - Non-Drugs A4558 Blank CONDUCTIVE GEL OR PASTE Blank $53.47 HCPCS - Non-Drugs A4559 Blank COUPLING GEL OR PASTE Blank $1.01 HCPCS - Non-Drugs A4561 Blank PESSARY RUBBER, ANY TYPE Blank $39.44 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 5 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A4562 Blank PESSARY, NON RUBBER,ANY TYPE Blank $96.38 HCPCS - Non-Drugs A4565 Blank SLINGS Blank $15.68 HCPCS - Non-Drugs A4566 Blank SHOULD SLING/VEST/ABRESTRAIN Blank $42.37 HCPCS - Non-Drugs A4570 Blank SPLINT Blank $25.19 HCPCS - Non-Drugs A4575 Blank HYPERBARIC O2 CHAMBER DISPS Blank $821.57 HCPCS - Non-Drugs A4580 Blank CAST SUPPLIES (PLASTER) Blank $75.17 HCPCS - Non-Drugs A4590 Blank SPECIAL CASTING MATERIAL Blank $54.70 HCPCS - Non-Drugs A4595 Blank TENS SUPPL 2 LEAD PER MONTH Blank $88.28 HCPCS - Non-Drugs A4600 Blank SLEEVE, INTER LIMB COMP DEV Blank $326.76 HCPCS - Non-Drugs A4601 Blank LITH ION NON PROSTH RECHARGE Blank $3.78 HCPCS - Non-Drugs A4602 Blank REPLACE LITHIUM BATTERY 1.5V Blank $37.62 HCPCS - Non-Drugs A4602 NU REPLACE LITHIUM BATTERY 1.5V Blank $37.62 HCPCS - Non-Drugs A4604 Blank TUBING WITH HEATING ELEMENT Blank $146.44 HCPCS - Non-Drugs A4604 NU TUBING WITH HEATING ELEMENT Blank $146.44 HCPCS - Non-Drugs A4605 Blank TRACH SUCTION CATH CLOSE SYS Blank $103.16 HCPCS - Non-Drugs A4605 NU TRACH SUCTION CATH CLOSE SYS Blank $103.16 HCPCS - Non-Drugs A4606 Blank OXYGEN PROBE USED W OXIMETER Blank $50.75 HCPCS - Non-Drugs A4608 Blank TRANSTRACHEAL OXYGEN CATH Blank $176.16 HCPCS - Non-Drugs A4611 Blank HEAVY DUTY BATTERY Blank $272.43 HCPCS - Non-Drugs A4611 NU HEAVY DUTY BATTERY Blank $258.34 HCPCS - Non-Drugs A4611 RR HEAVY DUTY BATTERY Blank $87.48 HCPCS - Non-Drugs A4611 UE HEAVY DUTY BATTERY Blank $210.67 HCPCS - Non-Drugs A4612 Blank BATTERY CABLES Blank $145.33 HCPCS - Non-Drugs A4612 NU BATTERY CABLES Blank $145.33 HCPCS - Non-Drugs A4612 RR BATTERY CABLES Blank $37.56 HCPCS - Non-Drugs A4612 UE BATTERY CABLES Blank $126.58 HCPCS - Non-Drugs A4613 Blank BATTERY CHARGER Blank $207.46 HCPCS - Non-Drugs A4613 NU BATTERY CHARGER Blank $207.46 HCPCS - Non-Drugs A4613 RR BATTERY CHARGER Blank $71.43 HCPCS - Non-Drugs A4613 UE BATTERY CHARGER Blank $168.90 HCPCS - Non-Drugs A4614 Blank HAND-HELD PEFR METER Blank $46.12 HCPCS - Non-Drugs A4615 Blank CANNULA NASAL Blank $2.86 HCPCS - Non-Drugs A4616 Blank TUBING (OXYGEN) PER FOOT Blank $2.89 HCPCS - Non-Drugs A4617 Blank MOUTH PIECE Blank $2.77 HCPCS - Non-Drugs A4618 Blank BREATHING CIRCUITS Blank $17.09 HCPCS - Non-Drugs A4618 NU BREATHING CIRCUITS Blank $17.09 HCPCS - Non-Drugs A4618 RR BREATHING CIRCUITS Blank $2.43 HCPCS - Non-Drugs A4618 UE BREATHING CIRCUITS Blank $13.10 HCPCS - Non-Drugs A4619 Blank FACE TENT Blank $2.82 HCPCS - Non-Drugs A4619 NU FACE TENT Blank $2.82 HCPCS - Non-Drugs A4620 Blank VARIABLE CONCENTRATION MASK Blank $2.87 HCPCS - Non-Drugs A4623 Blank TRACHEOSTOMY INNER CANNULA Blank $12.45 HCPCS - Non-Drugs A4624 Blank TRACHEAL SUCTION TUBE Blank $25.03 HCPCS - Non-Drugs A4624 NU TRACHEAL SUCTION TUBE Blank $25.03 HCPCS - Non-Drugs A4625 Blank TRACH CARE KIT FOR NEW TRACH Blank $14.45 HCPCS - Non-Drugs A4626 Blank TRACHEOSTOMY CLEANING BRUSH Blank $6.65 HCPCS - Non-Drugs A4627 Blank SPACER BAG/RESERVOIR Blank $24.50 HCPCS - Non-Drugs A4628 Blank OROPHARYNGEAL SUCTION CATH Blank $8.14 HCPCS - Non-Drugs A4628 NU OROPHARYNGEAL SUCTION CATH Blank $8.14 HCPCS - Non-Drugs A4629 Blank TRACHEOSTOMY CARE KIT Blank $9.92 HCPCS - Non-Drugs A4630 Blank REPL BAT T.E.N.S. OWN BY PT Blank $61.99 HCPCS - Non-Drugs A4630 NU REPL BAT T.E.N.S. OWN BY PT Blank $61.99 HCPCS - Non-Drugs A4633 Blank UVL REPLACEMENT BULB Blank $156.48 HCPCS - Non-Drugs A4633 NU UVL REPLACEMENT BULB Blank $156.48 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 6 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A4634 Blank REPLACEMENT BULB TH LIGHTBOX Blank $121.88 HCPCS - Non-Drugs A4635 Blank UNDERARM CRUTCH PAD Blank $48.91 HCPCS - Non-Drugs A4635 NU UNDERARM CRUTCH PAD Blank $48.91 HCPCS - Non-Drugs A4635 RR UNDERARM CRUTCH PAD Blank $6.58 HCPCS - Non-Drugs A4635 UE UNDERARM CRUTCH PAD Blank $32.31 HCPCS - Non-Drugs A4636 Blank HANDGRIP FOR CANE ETC Blank $26.68 HCPCS - Non-Drugs A4636 NU HANDGRIP FOR CANE ETC Blank $26.68 HCPCS - Non-Drugs A4636 RR HANDGRIP FOR CANE ETC Blank $2.74 HCPCS - Non-Drugs A4636 UE HANDGRIP FOR CANE ETC Blank $20.04 HCPCS - Non-Drugs A4637 Blank REPL TIP CANE/CRUTCH/WALKER Blank $14.89 HCPCS - Non-Drugs A4637 NU REPL TIP CANE/CRUTCH/WALKER Blank $14.89 HCPCS - Non-Drugs A4637 RR REPL TIP CANE/CRUTCH/WALKER Blank $1.46 HCPCS - Non-Drugs A4637 UE REPL TIP CANE/CRUTCH/WALKER Blank $11.14 HCPCS - Non-Drugs A4638 Blank REPL BATT PULSE GEN SYS Blank $16,677.92 HCPCS - Non-Drugs A4638 NU REPL BATT PULSE GEN SYS Blank $16,677.92 HCPCS - Non-Drugs A4638 RR REPL BATT PULSE GEN SYS Blank $1,750.27 HCPCS - Non-Drugs A4638 UE REPL BATT PULSE GEN SYS Blank $12,532.49 HCPCS - Non-Drugs A4639 Blank INFRARED HT SYS REPLCMNT PAD Blank $471.51 HCPCS - Non-Drugs A4639 NU INFRARED HT SYS REPLCMNT PAD Blank $471.51 HCPCS - Non-Drugs A4639 RR INFRARED HT SYS REPLCMNT PAD Blank $129.85 HCPCS - Non-Drugs A4640 Blank ALTERNATING PRESSURE PAD Blank $167.73 HCPCS - Non-Drugs A4640 NU ALTERNATING PRESSURE PAD Blank $167.73 HCPCS - Non-Drugs A4640 RR ALTERNATING PRESSURE PAD Blank $47.11 HCPCS - Non-Drugs A4640 UE ALTERNATING PRESSURE PAD Blank $142.70 HCPCS - Non-Drugs A4641 Blank RADIOPHARM DX AGENT NOC a $43.63 HCPCS - Non-Drugs A4642 Blank IN111 SATUMOMAB a $29.14 HCPCS - Non-Drugs A4648 Blank IMPLANTABLE TISSUE MARKER a $367.90 HCPCS - Non-Drugs A4649 Blank SURGICAL SUPPLIES Blank $34.69 HCPCS - Non-Drugs A4651 Blank CALIBRATED MICROCAP TUBE Blank $5.90 HCPCS - Non-Drugs A4652 Blank MICROCAPILLARY TUBE SEALANT Blank $1.98 HCPCS - Non-Drugs A4653 Blank PD CATHETER ANCHOR BELT Blank $77.58 HCPCS - Non-Drugs A4657 Blank SYRINGE W/WO NEEDLE Blank $5.51 HCPCS - Non-Drugs A4660 Blank SPHYG/BP APP W CUFF AND STET Blank $36.78 HCPCS - Non-Drugs A4663 Blank DIALYSIS BLOOD PRESSURE CUFF Blank $70.46 HCPCS - Non-Drugs A4670 Blank AUTOMATIC BP MONITOR, DIAL Blank $179.01 HCPCS - Non-Drugs A4671 Blank DISPOSABLE CYCLER SET Blank $72.52 HCPCS - Non-Drugs A4672 Blank DRAINAGE EXT LINE, DIALYSIS Blank $15.52 HCPCS - Non-Drugs A4673 Blank EXT LINE W EASY LOCK CONNECT Blank $14.85 HCPCS - Non-Drugs A4674 Blank CHEM/ANTISEPT SOLUTION, 8OZ Blank $3.11 HCPCS - Non-Drugs A4680 Blank ACTIVATED CARBON FILTER, EA Blank $183.20 HCPCS - Non-Drugs A4690 Blank DIALYZER, EACH Blank $1,680.91 HCPCS - Non-Drugs A4706 Blank BICARBONATE CONC SOL PER GAL Blank $22.52 HCPCS - Non-Drugs A4707 Blank BICARBONATE CONC POW PER PAC Blank $18.44 HCPCS - Non-Drugs A4708 Blank ACETATE CONC SOL PER GALLON Blank $22.88 HCPCS - Non-Drugs A4709 Blank ACID CONC SOL PER GALLON Blank $44.30 HCPCS - Non-Drugs A4714 Blank TREATED WATER PER GALLON Blank $7.96 HCPCS - Non-Drugs A4719 Blank Y SET TUBING Blank $24.12 HCPCS - Non-Drugs A4720 Blank DIALYSAT SOL FLD VOL > 249CC Blank $32.44 HCPCS - Non-Drugs A4721 Blank DIALYSAT SOL FLD VOL > 999CC Blank $49.11 HCPCS - Non-Drugs A4722 Blank DIALYS SOL FLD VOL > 1999CC Blank $50.70 HCPCS - Non-Drugs A4723 Blank DIALYS SOL FLD VOL > 2999CC Blank $36.75 HCPCS - Non-Drugs A4724 Blank DIALYS SOL FLD VOL > 3999CC Blank $62.42 HCPCS - Non-Drugs A4725 Blank DIALYS SOL FLD VOL > 4999CC Blank $69.90 HCPCS - Non-Drugs A4726 Blank DIALYS SOL FLD VOL > 5999CC Blank $77.71 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 7 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A4728 Blank DIALYSATE SOLUTION, NON-DEX Blank $20.04 HCPCS - Non-Drugs A4730 Blank FISTULA CANNULATION SET, EA Blank $4.86 HCPCS - Non-Drugs A4736 Blank TOPICAL ANESTHETIC, PER GRAM Blank $45.45 HCPCS - Non-Drugs A4737 Blank INJ ANESTHETIC PER 10 ML Blank $4.52 HCPCS - Non-Drugs A4740 Blank SHUNT ACCESSORY Blank $64.27 HCPCS - Non-Drugs A4750 Blank ART OR VENOUS BLOOD TUBING Blank $34.95 HCPCS - Non-Drugs A4755 Blank COMB ART/VENOUS BLOOD TUBING Blank $47.13 HCPCS - Non-Drugs A4760 Blank DIALYSATE SOL TEST KIT, EACH Blank $185.63 HCPCS - Non-Drugs A4765 Blank DIALYSATE CONC POW PER PACK Blank $27.87 HCPCS - Non-Drugs A4766 Blank DIALYSATE CONC SOL ADD 10 ML Blank $38.02 HCPCS - Non-Drugs A4770 Blank BLOOD COLLECTION TUBE/VACUUM Blank $18.71 HCPCS - Non-Drugs A4771 Blank SERUM CLOTTING TIME TUBE Blank $12.41 HCPCS - Non-Drugs A4772 Blank BLOOD GLUCOSE TEST STRIPS Blank $73.28 HCPCS - Non-Drugs A4773 Blank OCCULT BLOOD TEST STRIPS Blank $46.48 HCPCS - Non-Drugs A4774 Blank AMMONIA TEST STRIPS Blank $15.50 HCPCS - Non-Drugs A4802 Blank PROTAMINE SULFATE PER 50 MG Blank $13.22 HCPCS - Non-Drugs A4860 Blank DISPOSABLE CATHETER TIPS Blank $9.44 HCPCS - Non-Drugs A4870 Blank PLUMB/ELEC WK HM HEMO EQUIP Blank $250.48 HCPCS - Non-Drugs A4890 Blank REPAIR/MAINT CONT HEMO EQUIP Blank $39.52 HCPCS - Non-Drugs A4911 Blank DRAIN BAG/BOTTLE Blank $29.04 HCPCS - Non-Drugs A4913 Blank MISC DIALYSIS SUPPLIES NOC Blank $179.01 HCPCS - Non-Drugs A4918 Blank VENOUS PRESSURE CLAMP Blank $7.96 HCPCS - Non-Drugs A4927 Blank NON-STERILE GLOVES Blank $14.79 HCPCS - Non-Drugs A4928 Blank SURGICAL MASK Blank $1.11 HCPCS - Non-Drugs A4929 Blank TOURNIQUET FOR DIALYSIS, EA Blank $0.38 HCPCS - Non-Drugs A4930 Blank STERILE, GLOVES PER PAIR Blank $2.53 HCPCS - Non-Drugs A4931 Blank REUSABLE ORAL THERMOMETER Blank $11.49 HCPCS - Non-Drugs A5051 Blank POUCH CLSD W BARR ATTACHED Blank $5.06 HCPCS - Non-Drugs A5052 Blank CLSD OSTOMY POUCH W/O BARR Blank $3.80 HCPCS - Non-Drugs A5053 Blank CLSD OSTOMY POUCH FACEPLATE Blank $4.22 HCPCS - Non-Drugs A5054 Blank CLSD OSTOMY POUCH W/FLANGE Blank $4.56 HCPCS - Non-Drugs A5055 Blank STOMA CAP Blank $3.57 HCPCS - Non-Drugs A5056 Blank 1 PC OST POUCH W FILTER Blank $9.97 HCPCS - Non-Drugs A5057 Blank 1 PC OST POU W BUILT-IN CONV Blank $19.31 HCPCS - Non-Drugs A5061 Blank POUCH DRAINABLE W BARRIER AT Blank $7.83 HCPCS - Non-Drugs A5062 Blank DRNBLE OSTOMY POUCH W/O BARR Blank $5.22 HCPCS - Non-Drugs A5063 Blank DRAIN OSTOMY POUCH W/FLANGE Blank $6.27 HCPCS - Non-Drugs A5071 Blank URINARY POUCH W/BARRIER Blank $12.52 HCPCS - Non-Drugs A5072 Blank URINARY POUCH W/O BARRIER Blank $7.59 HCPCS - Non-Drugs A5073 Blank URINARY POUCH ON BARR W/FLNG Blank $7.02 HCPCS - Non-Drugs A5081 Blank STOMA PLUG OR SEAL, ANY TYPE Blank $7.02 HCPCS - Non-Drugs A5082 Blank CONTINENT STOMA CATHETER Blank $21.78 HCPCS - Non-Drugs A5083 Blank STOMA ABSORPTIVE COVER Blank $1.61 HCPCS - Non-Drugs A5093 Blank OSTOMY ACCESSORY CONVEX INSE Blank $4.70 HCPCS - Non-Drugs A5102 Blank BEDSIDE DRAIN BTL W/WO TUBE Blank $43.53 HCPCS - Non-Drugs A5105 Blank URINARY SUSPENSORY Blank $75.25 HCPCS - Non-Drugs A5112 Blank URINARY LEG BAG Blank $63.57 HCPCS - Non-Drugs A5113 Blank LATEX LEG STRAP Blank $9.51 HCPCS - Non-Drugs A5114 Blank FOAM/FABRIC LEG STRAP Blank $17.09 HCPCS - Non-Drugs A5120 Blank SKIN BARRIER, WIPE OR SWAB Blank $0.59 HCPCS - Non-Drugs A5120 AU SKIN BARRIER, WIPE OR SWAB Blank $0.59 HCPCS - Non-Drugs A5120 AV SKIN BARRIER, WIPE OR SWAB Blank $0.59 HCPCS - Non-Drugs A5121 Blank SOLID SKIN BARRIER 6X6 Blank $14.42 HCPCS - Non-Drugs A5122 Blank SOLID SKIN BARRIER 8X8 Blank $24.20 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 8 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A5126 Blank DISK/FOAM PAD +OR- ADHESIVE Blank $3.07 HCPCS - Non-Drugs A5131 Blank APPLIANCE CLEANER Blank $30.10 HCPCS - Non-Drugs A5200 Blank PERCUTANEOUS CATHETER ANCHOR Blank $22.52 HCPCS - Non-Drugs A5500 Blank DIAB SHOE FOR DENSITY INSERT Blank $111.17 HCPCS - Non-Drugs A5501 Blank DIABETIC CUSTOM MOLDED SHOE Blank $346.29 HCPCS - Non-Drugs A5503 Blank DIABETIC SHOE W/ROLLER/ROCKR Blank $53.41 HCPCS - Non-Drugs A5504 Blank DIABETIC SHOE WITH WEDGE Blank $53.41 HCPCS - Non-Drugs A5505 Blank DIAB SHOE W/METATARSAL BAR Blank $53.41 HCPCS - Non-Drugs A5506 Blank DIABETIC SHOE W/OFF SET HEEL Blank $53.41 HCPCS - Non-Drugs A5507 Blank MODIFICATION DIABETIC SHOE Blank $53.41 HCPCS - Non-Drugs A5508 Blank DIABETIC DELUXE SHOE Blank $47.43 HCPCS - Non-Drugs A5510 Blank COMPRESSION FORM SHOE INSERT Blank $43.16 HCPCS - Non-Drugs A5512 Blank MULTI DEN INSERT DIRECT FORM Blank $44.54 HCPCS - Non-Drugs A5513 Blank MULTI DEN INSERT CUSTOM MOLD Blank $65.83 HCPCS - Non-Drugs A6000 Blank WOUND WARMING WOUND COVER Blank $85.47 HCPCS - Non-Drugs A6010 Blank COLLAGEN BASED WOUND FILLER Blank $59.72 HCPCS - Non-Drugs A6011 Blank COLLAGEN GEL/PASTE WOUND FIL Blank $5.47 HCPCS - Non-Drugs A6021 Blank COLLAGEN DRESSING <=16 SQ IN Blank $40.91 HCPCS - Non-Drugs A6022 Blank COLLAGEN DRSG>16<=48 SQ IN Blank $40.91 HCPCS - Non-Drugs A6023 Blank COLLAGEN DRESSING >48 SQ IN Blank $360.99 HCPCS - Non-Drugs A6024 Blank COLLAGEN DSG WOUND FILLER Blank $12.86 HCPCS - Non-Drugs A6025 Blank SILICONE GEL SHEET, EACH Blank $34.80 HCPCS - Non-Drugs A6154 Blank WOUND POUCH EACH Blank $28.09 HCPCS - Non-Drugs A6196 Blank ALGINATE DRESSING <=16 SQ IN Blank $15.07 HCPCS - Non-Drugs A6197 Blank ALGINATE DRSG >16 <=48 SQ IN Blank $32.25 HCPCS - Non-Drugs A6198 Blank ALGINATE DRESSING > 48 SQ IN Blank $77.25 HCPCS - Non-Drugs A6199 Blank ALGINATE DRSG WOUND FILLER Blank $11.17 HCPCS - Non-Drugs A6203 Blank COMPOSITE DRSG <= 16 SQ IN Blank $7.53 HCPCS - Non-Drugs A6204 Blank COMPOSITE DRSG >16<=48 SQ IN Blank $12.94 HCPCS - Non-Drugs A6205 Blank COMPOSITE DRSG > 48 SQ IN Blank $23.22 HCPCS - Non-Drugs A6206 Blank CONTACT LAYER <= 16 SQ IN Blank $7.34 HCPCS - Non-Drugs A6207 Blank CONTACT LAYER >16<= 48 SQ IN Blank $15.04 HCPCS - Non-Drugs A6208 Blank CONTACT LAYER > 48 SQ IN Blank $58.46 HCPCS - Non-Drugs A6209 Blank FOAM DRSG <=16 SQ IN W/O BDR Blank $15.29 HCPCS - Non-Drugs A6210 Blank FOAM DRG >16<=48 SQ IN W/O B Blank $38.85 HCPCS - Non-Drugs A6211 Blank FOAM DRG > 48 SQ IN W/O BRDR Blank $56.71 HCPCS - Non-Drugs A6212 Blank FOAM DRG <=16 SQ IN W/BORDER Blank $19.52 HCPCS - Non-Drugs A6213 Blank FOAM DRG >16<=48 SQ IN W/BDR Blank $30.68 HCPCS - Non-Drugs A6214 Blank FOAM DRG > 48 SQ IN W/BORDER Blank $42.02 HCPCS - Non-Drugs A6215 Blank FOAM DRESSING WOUND FILLER Blank $6.64 HCPCS - Non-Drugs A6216 Blank NON-STERILE GAUZE<=16 SQ IN Blank $0.11 HCPCS - Non-Drugs A6217 Blank NON-STERILE GAUZE>16<=48 SQ Blank $0.29 HCPCS - Non-Drugs A6218 Blank NON-STERILE GAUZE > 48 SQ IN Blank $0.91 HCPCS - Non-Drugs A6219 Blank GAUZE <= 16 SQ IN W/BORDER Blank $2.42 HCPCS - Non-Drugs A6220 Blank GAUZE >16 <=48 SQ IN W/BORDR Blank $6.05 HCPCS - Non-Drugs A6221 Blank GAUZE > 48 SQ IN W/BORDER Blank $16.10 HCPCS - Non-Drugs A6222 Blank GAUZE <=16 IN NO W/SAL W/O B Blank $5.18 HCPCS - Non-Drugs A6223 Blank GAUZE >16<=48 NO W/SAL W/O B Blank $5.74 HCPCS - Non-Drugs A6224 Blank GAUZE > 48 IN NO W/SAL W/O B Blank $7.99 HCPCS - Non-Drugs A6228 Blank GAUZE <= 16 SQ IN WATER/SAL Blank $3.72 HCPCS - Non-Drugs A6229 Blank GAUZE >16<=48 SQ IN WATR/SAL Blank $7.99 HCPCS - Non-Drugs A6230 Blank GAUZE > 48 SQ IN WATER/SALNE Blank $5.28 HCPCS - Non-Drugs A6231 Blank HYDROGEL DSG<=16 SQ IN Blank $10.00 HCPCS - Non-Drugs A6232 Blank HYDROGEL DSG>16<=48 SQ IN Blank $14.14 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 9 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A6233 Blank HYDROGEL DRESSING >48 SQ IN Blank $37.42 HCPCS - Non-Drugs A6234 Blank HYDROCOLLD DRG <=16 W/O BDR Blank $13.53 HCPCS - Non-Drugs A6235 Blank HYDROCOLLD DRG >16<=48 W/O B Blank $32.97 HCPCS - Non-Drugs A6236 Blank HYDROCOLLD DRG > 48 IN W/O B Blank $52.71 HCPCS - Non-Drugs A6237 Blank HYDROCOLLD DRG <=16 IN W/BDR Blank $16.13 HCPCS - Non-Drugs A6238 Blank HYDROCOLLD DRG >16<=48 W/BDR Blank $44.28 HCPCS - Non-Drugs A6239 Blank HYDROCOLLD DRG > 48 IN W/BDR Blank $60.48 HCPCS - Non-Drugs A6240 Blank HYDROCOLLD DRG FILLER PASTE Blank $24.33 HCPCS - Non-Drugs A6241 Blank HYDROCOLLOID DRG FILLER DRY Blank $6.02 HCPCS - Non-Drugs A6242 Blank HYDROGEL DRG <=16 IN W/O BDR Blank $12.62 HCPCS - Non-Drugs A6243 Blank HYDROGEL DRG >16<=48 W/O BDR Blank $24.46 HCPCS - Non-Drugs A6244 Blank HYDROGEL DRG >48 IN W/O BDR Blank $75.46 HCPCS - Non-Drugs A6245 Blank HYDROGEL DRG <= 16 IN W/BDR Blank $14.90 HCPCS - Non-Drugs A6246 Blank HYDROGEL DRG >16<=48 IN W/B Blank $19.95 HCPCS - Non-Drugs A6247 Blank HYDROGEL DRG > 48 SQ IN W/B Blank $46.14 HCPCS - Non-Drugs A6248 Blank HYDROGEL DRSG GEL FILLER Blank $31.89 HCPCS - Non-Drugs A6250 Blank SKIN SEAL PROTECT MOISTURIZR Blank $10.15 HCPCS - Non-Drugs A6251 Blank ABSORPT DRG <=16 SQ IN W/O B Blank $4.92 HCPCS - Non-Drugs A6252 Blank ABSORPT DRG >16 <=48 W/O BDR Blank $7.33 HCPCS - Non-Drugs A6253 Blank ABSORPT DRG > 48 SQ IN W/O B Blank $13.15 HCPCS - Non-Drugs A6254 Blank ABSORPT DRG <=16 SQ IN W/BDR Blank $3.06 HCPCS - Non-Drugs A6255 Blank ABSORPT DRG >16<=48 IN W/BDR Blank $6.91 HCPCS - Non-Drugs A6256 Blank ABSORPT DRG > 48 SQ IN W/BDR Blank $15.85 HCPCS - Non-Drugs A6257 Blank TRANSPARENT FILM <= 16 SQ IN Blank $3.95 HCPCS - Non-Drugs A6258 Blank TRANSPARENT FILM >16<=48 IN Blank $9.32 HCPCS - Non-Drugs A6259 Blank TRANSPARENT FILM > 48 SQ IN Blank $21.86 HCPCS - Non-Drugs A6260 Blank WOUND CLEANSER ANY TYPE/SIZE Blank $1.82 HCPCS - Non-Drugs A6261 Blank WOUND FILLER GEL/PASTE /OZ Blank $6.65 HCPCS - Non-Drugs A6262 Blank WOUND FILLER DRY FORM / GRAM Blank $1.82 HCPCS - Non-Drugs A6266 Blank IMPREG GAUZE NO H20/SAL/YARD Blank $4.80 HCPCS - Non-Drugs A6402 Blank STERILE GAUZE <= 16 SQ IN Blank $0.30 HCPCS - Non-Drugs A6403 Blank STERILE GAUZE>16 <= 48 SQ IN Blank $1.07 HCPCS - Non-Drugs A6404 Blank STERILE GAUZE > 48 SQ IN Blank $0.91 HCPCS - Non-Drugs A6407 Blank PACKING STRIPS, NON-IMPREG Blank $4.72 HCPCS - Non-Drugs A6410 Blank STERILE EYE PAD Blank $0.98 HCPCS - Non-Drugs A6411 Blank NON-STERILE EYE PAD Blank $0.98 HCPCS - Non-Drugs A6412 Blank OCCLUSIVE EYE PATCH Blank $0.91 HCPCS - Non-Drugs A6413 Blank ADHESIVE BANDAGE, FIRST-AID Blank $1.29 HCPCS - Non-Drugs A6441 Blank PAD BAND W>=3 <5/YD Blank $1.70 HCPCS - Non-Drugs A6442 Blank CONFORM BAND N/S W<3/YD Blank $0.41 HCPCS - Non-Drugs A6443 Blank CONFORM BAND N/S W>=3<5/YD Blank $0.70 HCPCS - Non-Drugs A6444 Blank CONFORM BAND N/S W>=5/YD Blank $1.41 HCPCS - Non-Drugs A6445 Blank CONFORM BAND S W <3/YD Blank $0.82 HCPCS - Non-Drugs A6446 Blank CONFORM BAND S W>=3 <5/YD Blank $1.02 HCPCS - Non-Drugs A6447 Blank CONFORM BAND S W >=5/YD Blank $1.70 HCPCS - Non-Drugs A6448 Blank LT COMPRES BAND <3/YD Blank $2.94 HCPCS - Non-Drugs A6449 Blank LT COMPRES BAND >=3 <5/YD Blank $4.48 HCPCS - Non-Drugs A6450 Blank LT COMPRES BAND >=5/YD Blank $4.48 HCPCS - Non-Drugs A6451 Blank MOD COMPRES BAND W>=3<5/YD Blank $4.48 HCPCS - Non-Drugs A6452 Blank HIGH COMPRES BAND W>=3<5YD Blank $12.33 HCPCS - Non-Drugs A6453 Blank SELF-ADHER BAND W <3/YD Blank $1.57 HCPCS - Non-Drugs A6454 Blank SELF-ADHER BAND W>=3 <5/YD Blank $1.95 HCPCS - Non-Drugs A6455 Blank SELF-ADHER BAND >=5/YD Blank $3.56 HCPCS - Non-Drugs A6456 Blank ZINC PASTE BAND W >=3<5/YD Blank $3.23 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 10 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A6457 Blank TUBULAR DRESSING Blank $2.89 HCPCS - Non-Drugs A6504 Blank CMPRSBURNGARMENT GLOVE-WRIST Blank $505.47 HCPCS - Non-Drugs A6505 Blank CMPRSBURNGARMENT GLOVE-ELBOW Blank $263.71 HCPCS - Non-Drugs A6506 Blank CMPRSBURNGRMNT GLOVE-AXILLA Blank $149.77 HCPCS - Non-Drugs A6507 Blank CMPRS BURNGARMENT FOOT-KNEE Blank $205.23 HCPCS - Non-Drugs A6508 Blank CMPRS BURNGARMENT FOOT-THIGH Blank $592.52 HCPCS - Non-Drugs A6509 Blank COMPRES BURN GARMENT JACKET Blank $777.64 HCPCS - Non-Drugs A6510 Blank COMPRES BURN GARMENT LEOTARD Blank $334.06 HCPCS - Non-Drugs A6511 Blank COMPRES BURN GARMENT PANTY Blank $721.31 HCPCS - Non-Drugs A6512 Blank COMPRES BURN GARMENT, NOC Blank $309.69 HCPCS - Non-Drugs A6530 Blank COMPRESSION STOCKING BK18-30 Blank $60.09 HCPCS - Non-Drugs A6531 Blank COMPRESSION STOCKING BK30-40 Blank $82.96 HCPCS - Non-Drugs A6531 AW COMPRESSION STOCKING BK30-40 Blank $82.96 HCPCS - Non-Drugs A6532 Blank COMPRESSION STOCKING BK40-50 Blank $116.42 HCPCS - Non-Drugs A6532 AW COMPRESSION STOCKING BK40-50 Blank $116.42 HCPCS - Non-Drugs A6533 Blank GC STOCKING THIGHLNGTH 18-30 Blank $85.96 HCPCS - Non-Drugs A6534 Blank GC STOCKING THIGHLNGTH 30-40 Blank $55.72 HCPCS - Non-Drugs A6535 Blank GC STOCKING THIGHLNGTH 40-50 Blank $102.40 HCPCS - Non-Drugs A6536 Blank GC STOCKING FULL LNGTH 18-30 Blank $82.13 HCPCS - Non-Drugs A6537 Blank GC STOCKING FULL LNGTH 30-40 Blank $125.19 HCPCS - Non-Drugs A6538 Blank GC STOCKING FULL LNGTH 40-50 Blank $199.00 HCPCS - Non-Drugs A6539 Blank GC STOCKING WAISTLNGTH 18-30 Blank $193.49 HCPCS - Non-Drugs A6540 Blank GC STOCKING WAISTLNGTH 30-40 Blank $216.12 HCPCS - Non-Drugs A6541 Blank GC STOCKING WAISTLNGTH 40-50 Blank $225.26 HCPCS - Non-Drugs A6544 Blank GC STOCKING GARTER BELT Blank $50.16 HCPCS - Non-Drugs A6545 Blank GRAD COMP NON-ELASTIC BK Blank $162.22 HCPCS - Non-Drugs A6545 AW GRAD COMP NON-ELASTIC BK Blank $162.22 HCPCS - Non-Drugs A6549 Blank G COMPRESSION STOCKING Blank $339.21 HCPCS - Non-Drugs A6550 Blank NEG PRES WOUND THER DRSG SET Blank $116.21 HCPCS - Non-Drugs A7000 Blank DISPOSABLE CANISTER FOR PUMP Blank $83.55 HCPCS - Non-Drugs A7000 NU DISPOSABLE CANISTER FOR PUMP Blank $83.55 HCPCS - Non-Drugs A7001 Blank NONDISPOSABLE PUMP CANISTER Blank $134.89 HCPCS - Non-Drugs A7001 NU NONDISPOSABLE PUMP CANISTER Blank $134.89 HCPCS - Non-Drugs A7002 Blank TUBING USED W SUCTION PUMP Blank $35.97 HCPCS - Non-Drugs A7002 NU TUBING USED W SUCTION PUMP Blank $35.97 HCPCS - Non-Drugs A7003 Blank NEBULIZER ADMINISTRATION SET Blank $14.01 HCPCS - Non-Drugs A7003 NU NEBULIZER ADMINISTRATION SET Blank $14.01 HCPCS - Non-Drugs A7004 Blank DISPOSABLE NEBULIZER SML VOL Blank $11.45 HCPCS - Non-Drugs A7004 NU DISPOSABLE NEBULIZER SML VOL Blank $11.45 HCPCS - Non-Drugs A7005 Blank NONDISPOSABLE NEBULIZER SET Blank $90.83 HCPCS - Non-Drugs A7005 NU NONDISPOSABLE NEBULIZER SET Blank $90.83 HCPCS - Non-Drugs A7006 Blank FILTERED NEBULIZER ADMIN SET Blank $71.27 HCPCS - Non-Drugs A7006 NU FILTERED NEBULIZER ADMIN SET Blank $71.27 HCPCS - Non-Drugs A7007 Blank LG VOL NEBULIZER DISPOSABLE Blank $28.57 HCPCS - Non-Drugs A7007 NU LG VOL NEBULIZER DISPOSABLE Blank $28.57 HCPCS - Non-Drugs A7008 Blank DISPOSABLE NEBULIZER PREFILL Blank $90.19 HCPCS - Non-Drugs A7008 NU DISPOSABLE NEBULIZER PREFILL Blank $90.19 HCPCS - Non-Drugs A7009 Blank NEBULIZER RESERVOIR BOTTLE Blank $155.83 HCPCS - Non-Drugs A7009 NU NEBULIZER RESERVOIR BOTTLE Blank $155.83 HCPCS - Non-Drugs A7010 Blank DISPOSABLE CORRUGATED TUBING Blank $97.52 HCPCS - Non-Drugs A7010 NU DISPOSABLE CORRUGATED TUBING Blank $97.52 HCPCS - Non-Drugs A7012 Blank NEBULIZER WATER COLLEC DEVIC Blank $25.36 HCPCS - Non-Drugs A7012 NU NEBULIZER WATER COLLEC DEVIC Blank $25.36 HCPCS - Non-Drugs A7013 Blank DISPOSABLE COMPRESSOR FILTER Blank $5.05 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 11 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A7013 NU DISPOSABLE COMPRESSOR FILTER Blank $5.05 HCPCS - Non-Drugs A7014 Blank COMPRESSOR NONDISPOS FILTER Blank $29.41 HCPCS - Non-Drugs A7014 NU COMPRESSOR NONDISPOS FILTER Blank $29.41 HCPCS - Non-Drugs A7015 Blank AEROSOL MASK USED W NEBULIZE Blank $11.41 HCPCS - Non-Drugs A7015 NU AEROSOL MASK USED W NEBULIZE Blank $11.41 HCPCS - Non-Drugs A7016 Blank NEBULIZER DOME & MOUTHPIECE Blank $78.70 HCPCS - Non-Drugs A7016 NU NEBULIZER DOME & MOUTHPIECE Blank $78.70 HCPCS - Non-Drugs A7017 Blank NEBULIZER NOT USED W OXYGEN Blank $292.50 HCPCS - Non-Drugs A7017 NU NEBULIZER NOT USED W OXYGEN Blank $292.50 HCPCS - Non-Drugs A7017 RR NEBULIZER NOT USED W OXYGEN Blank $90.16 HCPCS - Non-Drugs A7017 UE NEBULIZER NOT USED W OXYGEN Blank $236.30 HCPCS - Non-Drugs A7018 Blank WATER DISTILLED W/NEBULIZER Blank $2.93 HCPCS - Non-Drugs A7020 Blank INTERFACE, COUGH STIM DEVICE Blank $98.49 HCPCS - Non-Drugs A7020 NU INTERFACE, COUGH STIM DEVICE Blank $98.49 HCPCS - Non-Drugs A7020 RR INTERFACE, COUGH STIM DEVICE Blank $12.46 HCPCS - Non-Drugs A7020 UE INTERFACE, COUGH STIM DEVICE Blank $74.88 HCPCS - Non-Drugs A7025 Blank REPLACE CHEST COMPRESS VEST Blank $1,278.78 HCPCS - Non-Drugs A7025 NU REPLACE CHEST COMPRESS VEST Blank $1,278.78 HCPCS - Non-Drugs A7025 RR REPLACE CHEST COMPRESS VEST Blank $161.83 HCPCS - Non-Drugs A7026 Blank REPLACE CHST CMPRSS SYS HOSE Blank $129.89 HCPCS - Non-Drugs A7026 NU REPLACE CHST CMPRSS SYS HOSE Blank $129.89 HCPCS - Non-Drugs A7027 Blank COMBINATION ORAL/NASAL MASK Blank $302.89 HCPCS - Non-Drugs A7027 NU COMBINATION ORAL/NASAL MASK Blank $302.89 HCPCS - Non-Drugs A7028 Blank REPL ORAL CUSHION COMBO MASK Blank $133.65 HCPCS - Non-Drugs A7028 NU REPL ORAL CUSHION COMBO MASK Blank $133.65 HCPCS - Non-Drugs A7029 Blank REPL NASAL PILLOW COMB MASK Blank $97.94 HCPCS - Non-Drugs A7029 NU REPL NASAL PILLOW COMB MASK Blank $97.94 HCPCS - Non-Drugs A7030 Blank CPAP FULL FACE MASK Blank $243.55 HCPCS - Non-Drugs A7030 NU CPAP FULL FACE MASK Blank $243.55 HCPCS - Non-Drugs A7031 Blank REPLACEMENT FACEMASK INTERFA Blank $134.65 HCPCS - Non-Drugs A7031 NU REPLACEMENT FACEMASK INTERFA Blank $134.65 HCPCS - Non-Drugs A7032 Blank REPLACEMENT NASAL CUSHION Blank $105.04 HCPCS - Non-Drugs A7032 NU REPLACEMENT NASAL CUSHION Blank $105.04 HCPCS - Non-Drugs A7033 Blank REPLACEMENT NASAL PILLOWS Blank $98.05 HCPCS - Non-Drugs A7033 NU REPLACEMENT NASAL PILLOWS Blank $98.05 HCPCS - Non-Drugs A7034 Blank NASAL APPLICATION DEVICE Blank $177.27 HCPCS - Non-Drugs A7034 NU NASAL APPLICATION DEVICE Blank $177.27 HCPCS - Non-Drugs A7035 Blank POS AIRWAY PRESS HEADGEAR Blank $103.87 HCPCS - Non-Drugs A7035 NU POS AIRWAY PRESS HEADGEAR Blank $103.87 HCPCS - Non-Drugs A7036 Blank POS AIRWAY PRESS CHINSTRAP Blank $88.40 HCPCS - Non-Drugs A7036 NU POS AIRWAY PRESS CHINSTRAP Blank $88.40 HCPCS - Non-Drugs A7037 Blank POS AIRWAY PRESSURE TUBING Blank $91.78 HCPCS - Non-Drugs A7037 NU POS AIRWAY PRESSURE TUBING Blank $91.78 HCPCS - Non-Drugs A7038 Blank POS AIRWAY PRESSURE FILTER Blank $19.41 HCPCS - Non-Drugs A7038 NU POS AIRWAY PRESSURE FILTER Blank $19.41 HCPCS - Non-Drugs A7039 Blank FILTER, NON DISPOSABLE W PAP Blank $59.89 HCPCS - Non-Drugs A7039 NU FILTER, NON DISPOSABLE W PAP Blank $59.89 HCPCS - Non-Drugs A7040 Blank ONE WAY CHEST DRAIN VALVE Blank $76.83 HCPCS - Non-Drugs A7041 Blank WATER SEAL DRAIN CONTAINER Blank $143.36 HCPCS - Non-Drugs A7044 Blank PAP ORAL INTERFACE Blank $230.87 HCPCS - Non-Drugs A7044 NU PAP ORAL INTERFACE Blank $230.87 HCPCS - Non-Drugs A7045 Blank REPL EXHALATION PORT FOR PAP Blank $91.56 HCPCS - Non-Drugs A7045 NU REPL EXHALATION PORT FOR PAP Blank $91.56 HCPCS - Non-Drugs A7045 RR REPL EXHALATION PORT FOR PAP Blank $11.19 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 12 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A7045 UE REPL EXHALATION PORT FOR PAP Blank $85.59 HCPCS - Non-Drugs A7046 Blank REPL WATER CHAMBER, PAP DEV Blank $93.57 HCPCS - Non-Drugs A7046 NU REPL WATER CHAMBER, PAP DEV Blank $93.57 HCPCS - Non-Drugs A7047 Blank RESP SUCTION ORAL INTERFACE Blank $329.37 HCPCS - Non-Drugs A7047 NU RESP SUCTION ORAL INTERFACE Blank $329.37 HCPCS - Non-Drugs A7048 Blank VACUUM DRAIN BOTTLE/TUBE KIT Blank $80.38 HCPCS - Non-Drugs A7501 Blank TRACHEOSTOMA VALVE W DIAPHRA Blank $199.73 HCPCS - Non-Drugs A7502 Blank REPLACEMENT DIAPHRAGM/FPLATE Blank $95.55 HCPCS - Non-Drugs A7503 Blank HMES FILTER HOLDER OR CAP Blank $22.61 HCPCS - Non-Drugs A7504 Blank TRACHEOSTOMA HMES FILTER Blank $1.70 HCPCS - Non-Drugs A7505 Blank HMES OR TRACH VALVE HOUSING Blank $10.02 HCPCS - Non-Drugs A7506 Blank HMES/TRACHVALVE ADHESIVEDISK Blank $0.84 HCPCS - Non-Drugs A7507 Blank INTEGRATED FILTER & HOLDER Blank $5.86 HCPCS - Non-Drugs A7508 Blank HOUSING & INTEGRATED ADHESIV Blank $6.58 HCPCS - Non-Drugs A7509 Blank HEAT & MOISTURE EXCHANGE SYS Blank $3.61 HCPCS - Non-Drugs A7520 Blank TRACH/LARYN TUBE NON-CUFFED Blank $81.60 HCPCS - Non-Drugs A7521 Blank TRACH/LARYN TUBE CUFFED Blank $80.78 HCPCS - Non-Drugs A7522 Blank TRACH/LARYN TUBE STAINLESS Blank $77.30 HCPCS - Non-Drugs A7523 Blank TRACHEOSTOMY SHOWER PROTECT Blank $27.57 HCPCS - Non-Drugs A7524 Blank TRACHEOSTOMA STENT/STUD/BTTN Blank $137.09 HCPCS - Non-Drugs A7525 Blank TRACHEOSTOMY MASK Blank $3.82 HCPCS - Non-Drugs A7526 Blank TRACHEOSTOMY TUBE COLLAR Blank $6.27 HCPCS - Non-Drugs A7527 Blank TRACH/LARYN TUBE PLUG/STOP Blank $7.93 HCPCS - Non-Drugs A8000 Blank SOFT PROTECT HELMET PREFAB Blank $399.62 HCPCS - Non-Drugs A8000 NU SOFT PROTECT HELMET PREFAB Blank $399.62 HCPCS - Non-Drugs A8000 RR SOFT PROTECT HELMET PREFAB Blank $100.85 HCPCS - Non-Drugs A8000 UE SOFT PROTECT HELMET PREFAB Blank $316.68 HCPCS - Non-Drugs A8001 Blank HARD PROTECT HELMET PREFAB Blank $399.62 HCPCS - Non-Drugs A8001 NU HARD PROTECT HELMET PREFAB Blank $399.62 HCPCS - Non-Drugs A8001 RR HARD PROTECT HELMET PREFAB Blank $100.85 HCPCS - Non-Drugs A8001 UE HARD PROTECT HELMET PREFAB Blank $316.68 HCPCS - Non-Drugs A8002 Blank SOFT PROTECT HELMET CUSTOM Blank $507.47 HCPCS - Non-Drugs A8002 NU SOFT PROTECT HELMET CUSTOM Blank $507.47 HCPCS - Non-Drugs A8002 RR SOFT PROTECT HELMET CUSTOM Blank $53.50 HCPCS - Non-Drugs A8002 UE SOFT PROTECT HELMET CUSTOM Blank $380.58 HCPCS - Non-Drugs A8003 Blank HARD PROTECT HELMET CUSTOM Blank $530.07 HCPCS - Non-Drugs A8003 NU HARD PROTECT HELMET CUSTOM Blank $530.07 HCPCS - Non-Drugs A8003 RR HARD PROTECT HELMET CUSTOM Blank $56.38 HCPCS - Non-Drugs A8003 UE HARD PROTECT HELMET CUSTOM Blank $398.51 HCPCS - Non-Drugs A8004 Blank REPL SOFT INTERFACE, HELMET Blank $63.32 HCPCS - Non-Drugs A8004 NU REPL SOFT INTERFACE, HELMET Blank $63.32 HCPCS - Non-Drugs A8004 RR REPL SOFT INTERFACE, HELMET Blank $6.74 HCPCS - Non-Drugs A8004 UE REPL SOFT INTERFACE, HELMET Blank $47.60 HCPCS - Non-Drugs A9150 Blank MISC/EXPER NON-PRESCRIPT DRU a $20.99 HCPCS - Drugs A9152 Blank SINGLE VITAMIN NOS a $22.98 HCPCS - Drugs A9153 Blank MULTI-VITAMIN NOS a $22.98 HCPCS - Drugs A9155 Blank ARTIFICIAL SALIVA Blank $8.31 HCPCS - Drugs A9180 Blank LICE TREATMENT, TOPICAL Blank $190.50 HCPCS - Drugs A9270 Blank NON-COVERED ITEM OR SERVICE Blank $154.19 HCPCS - Non-Drugs A9272 Blank DISP WOUND SUCT, DRSG/ACCESS Blank $487.18 HCPCS - Non-Drugs A9273 Blank HOT/COLD H2OBOT/CAP/COL/WRAP Blank $16.91 HCPCS - Non-Drugs A9274 Blank EXT AMB INSULIN DELIVERY SYS Blank $46.10 HCPCS - Non-Drugs A9275 Blank DISP HOME GLUCOSE MONITOR Blank $24.57 HCPCS - Non-Drugs A9276 Blank DISPOSABLE SENSOR, CGM SYS Blank $36.96 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 13 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A9277 Blank EXTERNAL TRANSMITTER, CGM Blank $1,616.71 HCPCS - Non-Drugs A9278 Blank EXTERNAL RECEIVER, CGM SYS Blank $1,510.91 HCPCS - Non-Drugs A9279 Blank MONITORING FEATURE/DEVICENOC Blank $81.67 HCPCS - Non-Drugs A9280 Blank ALERT DEVICE, NOC Blank $293.84 HCPCS - Non-Drugs A9281 Blank REACHING/GRABBING DEVICE Blank $41.34 HCPCS - Non-Drugs A9282 Blank WIG ANY TYPE Blank $503.28 HCPCS - Non-Drugs A9283 Blank FOOT PRESS OFF LOAD SUPP DEV Blank $56.07 HCPCS - Non-Drugs A9284 Blank NON-ELECTRONIC SPIROMETER Blank $33.38 HCPCS - Non-Drugs A9300 Blank EXERCISE EQUIPMENT Blank $14.78 HCPCS - Non-Drugs A9500 Blank TC99M SESTAMIBI a $337.01 HCPCS - Non-Drugs A9501 Blank TECHNETIUM TC-99M TEBOROXIME Blank $459.06 HCPCS - Non-Drugs A9502 Blank TC99M TETROFOSMIN a $299.65 HCPCS - Non-Drugs A9503 Blank TC99M MEDRONATE a $73.58 HCPCS - Non-Drugs A9504 Blank TC99M APCITIDE Blank $328.16 HCPCS - Non-Drugs A9505 Blank TL201 THALLIUM a $218.53 HCPCS - Non-Drugs A9507 Blank IN111 CAPROMAB a $4,071.09 HCPCS - Non-Drugs A9508 Blank I131 IODOBENGUATE, DX a $49.43 HCPCS - Non-Drugs A9509 Blank IODINE I-123 SOD IODIDE MIL a $178.64 HCPCS - Non-Drugs A9510 Blank TC99M DISOFENIN a $124.16 HCPCS - Non-Drugs A9512 Blank TC99M PERTECHNETATE a $7.35 HCPCS - Non-Drugs A9516 Blank IODINE I-123 SOD IODIDE MIC a $158.19 HCPCS - Non-Drugs A9517 Blank I131 IODIDE CAP, RX a $77.25 HCPCS - Non-Drugs A9520 Blank TC99 TILMANOCEPT DIAG 0.5MCI a $811.72 HCPCS - Non-Drugs A9521 Blank TC99M EXAMETAZIME a $1,474.60 HCPCS - Non-Drugs A9524 Blank I131 SERUM ALBUMIN, DX a $252.48 HCPCS - Non-Drugs A9526 Blank NITROGEN N-13 AMMONIA a $919.73 HCPCS - Non-Drugs A9527 Blank IODINE I-125 SODIUM IODIDE a $153.02 HCPCS - Non-Drugs A9528 Blank IODINE I-131 IODIDE CAP, DX a $461.48 HCPCS - Non-Drugs A9529 Blank I131 IODIDE SOL, DX a $78.04 HCPCS - Non-Drugs A9530 Blank I131 IODIDE SOL, RX a $43.08 HCPCS - Non-Drugs A9531 Blank I131 MAX 100UCI a $18.05 HCPCS - Non-Drugs A9532 Blank I125 SERUM ALBUMIN, DX Blank $1,000.28 HCPCS - Non-Drugs A9536 Blank TC99M DEPREOTIDE Blank $841.60 HCPCS - Non-Drugs A9537 Blank TC99M MEBROFENIN a $130.59 HCPCS - Non-Drugs A9538 Blank TC99M PYROPHOSPHATE a $111.00 HCPCS - Non-Drugs A9539 Blank TC99M PENTETATE a $74.00 HCPCS - Non-Drugs A9540 Blank TC99M MAA a $38.48 HCPCS - Non-Drugs A9541 Blank TC99M SULFUR COLLOID a $174.38 HCPCS - Non-Drugs A9546 Blank CO57/58 Blank $31.71 HCPCS - Non-Drugs A9547 Blank IN111 OXYQUINOLINE a $1,442.34 HCPCS - Non-Drugs A9548 Blank IN111 PENTETATE a $865.40 HCPCS - Non-Drugs A9550 Blank TC99M GLUCEPTATE Blank $52.02 HCPCS - Non-Drugs A9551 Blank TC99M SUCCIMER a $428.45 HCPCS - Non-Drugs A9552 Blank F18 FDG a $930.15 HCPCS - Non-Drugs A9554 Blank I125 IOTHALAMATE, DX a $1,443.03 HCPCS - Non-Drugs A9555 Blank RB82 RUBIDIUM a $1,103.68 HCPCS - Non-Drugs A9556 Blank GA67 GALLIUM a $108.11 HCPCS - Non-Drugs A9557 Blank TC99M BICISATE a $382.54 HCPCS - Non-Drugs A9558 Blank XE133 XENON 10MCI a $130.30 HCPCS - Non-Drugs A9560 Blank TC99M LABELED RBC a $252.76 HCPCS - Non-Drugs A9561 Blank TC99M OXIDRONATE a $93.53 HCPCS - Non-Drugs A9562 Blank TC99M MERTIATIDE a $569.71 HCPCS - Non-Drugs A9564 Blank P32 CHROMIC PHOSPHATE a $738.48 HCPCS - Non-Drugs A9567 Blank TECHNETIUM TC-99M AEROSOL a $62.16 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 14 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
A9569 Blank TECHNETIUM TC-99M AUTO WBC a $3.61 HCPCS - Non-Drugs A9570 Blank INDIUM IN-111 AUTO WBC a $354.48 HCPCS - Non-Drugs A9571 Blank INDIUM IN-111 AUTO PLATELET Blank $15.85 HCPCS - Non-Drugs A9572 Blank INDIUM IN-111 PENTETREOTIDE a $5,646.32 HCPCS - Non-Drugs A9575 Blank INJ GADOTERATE MEGLUMI 0.1ML Blank $1.37 HCPCS - Non-Drugs A9576 Blank INJ PROHANCE MULTIPACK a $7.35 HCPCS - Non-Drugs A9577 Blank INJ MULTIHANCE a $11.03 HCPCS - Non-Drugs A9578 Blank INJ MULTIHANCE MULTIPACK a $8.43 HCPCS - Non-Drugs A9579 Blank GAD-BASE MR CONTRAST NOS,1ML a $8.43 HCPCS - Non-Drugs A9580 Blank SODIUM FLUORIDE F-18 a $822.30 HCPCS - Non-Drugs A9581 Blank GADOXETATE DISODIUM INJ Blank $28.13 HCPCS - Non-Drugs A9582 Blank IODINE I-123 IOBENGUANE a $5,450.18 HCPCS - Non-Drugs A9583 Blank GADOFOSVESET TRISODIUM INJ a $50.00 HCPCS - Non-Drugs A9584 Blank IODINE I-123 IOFLUPANE a $3,516.55 HCPCS - Non-Drugs A9585 Blank GADOBUTROL INJECTION a $1.85 HCPCS - Non-Drugs A9599 Blank RADIOPH DX B AMYLOID PET NOS a $34.37 HCPCS - Non-Drugs A9600 Blank SR89 STRONTIUM a $1,866.39 HCPCS - Non-Drugs A9604 Blank SM 153 LEXIDRONAM a $15,781.29 HCPCS - Non-Drugs A9606 Blank RADIUM RA223 DICHLORIDE THER a $348.69 HCPCS - Non-Drugs A9698 Blank NON-RAD CONTRAST MATERIALNOC a $33.96 HCPCS - Non-Drugs A9699 Blank RADIOPHARM RX AGENT NOC a $33.96 HCPCS - Non-Drugs A9700 Blank ECHOCARDIOGRAPHY CONTRAST a $446.26 HCPCS - Non-Drugs A9900 Blank SUPPLY/ACCESSORY/SERVICE Blank $37.37 HCPCS - Non-Drugs A9999 Blank DME SUPPLY OR ACCESSORY, NOS Blank $4.20 HCPCS - Non-Drugs B4034 Blank ENTER FEED SUPKIT SYR BY DAY Blank $11.43 HCPCS - Non-Drugs B4035 Blank ENTERAL FEED SUPP PUMP PER D Blank $19.56 HCPCS - Non-Drugs B4036 Blank ENTERAL FEED SUP KIT GRAV BY Blank $15.49 HCPCS - Non-Drugs B4081 Blank ENTERAL NG TUBING W/ STYLET Blank $55.88 HCPCS - Non-Drugs B4082 Blank ENTERAL NG TUBING W/O STYLET Blank $40.18 HCPCS - Non-Drugs B4083 Blank ENTERAL STOMACH TUBE LEVINE Blank $6.35 HCPCS - Non-Drugs B4087 Blank GASTRO/JEJUNO TUBE, STD Blank $97.52 HCPCS - Non-Drugs B4088 Blank GASTRO/JEJUNO TUBE, LOW-PRO Blank $97.52 HCPCS - Non-Drugs B4100 Blank FOOD THICKENER ORAL a $0.96 HCPCS - Non-Drugs B4102 Blank EF ADULT FLUIDS AND ELECTRO a $3.97 HCPCS - Non-Drugs B4103 Blank EF PED FLUID AND ELECTROLYTE a $13.57 HCPCS - Non-Drugs B4104 Blank ADDITIVE FOR ENTERAL FORMULA a $10.51 HCPCS - Non-Drugs B4149 Blank EF BLENDERIZED FOODS a $4.07 HCPCS - Non-Drugs B4150 Blank EF COMPLET W/INTACT NUTRIENT a $1.77 HCPCS - Non-Drugs B4152 Blank EF CALORIE DENSE>/=1.5KCAL a $1.09 HCPCS - Non-Drugs B4153 Blank EF HYDROLYZED/AMINO ACIDS a $4.76 HCPCS - Non-Drugs B4154 Blank EF SPEC METABOLIC NONINHERIT a $2.78 HCPCS - Non-Drugs B4155 Blank EF INCOMPLETE/MODULAR a $3.01 HCPCS - Non-Drugs B4157 Blank EF SPECIAL METABOLIC INHERIT a $10.61 HCPCS - Non-Drugs B4158 Blank EF PED COMPLETE INTACT NUT a $4.68 HCPCS - Non-Drugs B4159 Blank EF PED COMPLETE SOY BASED a $5.20 HCPCS - Non-Drugs B4160 Blank EF PED CALORIC DENSE>/=0.7KC a $4.37 HCPCS - Non-Drugs B4161 Blank EF PED HYDROLYZED/AMINO ACID a $9.77 HCPCS - Non-Drugs B4162 Blank EF PED SPECMETABOLIC INHERIT a $16.15 HCPCS - Non-Drugs B4164 Blank PARENTERAL 50% DEXTROSE SOLU a $47.16 HCPCS - Non-Drugs B4168 Blank PARENTERAL SOL AMINO ACID 3. a $68.59 HCPCS - Non-Drugs B4172 Blank PARENTERAL SOL AMINO ACID 5. a $119.30 HCPCS - Non-Drugs B4176 Blank PARENTERAL SOL AMINO ACID 7- a $132.32 HCPCS - Non-Drugs B4178 Blank PARENTERAL SOL AMINO ACID > a $158.74 HCPCS - Non-Drugs B4180 Blank PARENTERAL SOL CARB > 50% a $67.53 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 15 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
B4185 Blank PARENTERAL SOL 10 GM LIPIDS a $31.34 HCPCS - Non-Drugs B4189 Blank PARENTERAL SOL AMINO ACID & a $489.56 HCPCS - Non-Drugs B4193 Blank PARENTERAL SOL 52-73 GM PROT a $632.45 HCPCS - Non-Drugs B4197 Blank PARENTERAL SOL 74-100 GM PRO a $769.89 HCPCS - Non-Drugs B4199 Blank PARENTERAL SOL > 100GM PROTE a $879.68 HCPCS - Non-Drugs B4216 Blank PARENTERAL NUTRITION ADDITIV Blank $21.65 HCPCS - Non-Drugs B4220 Blank PARENTERAL SUPPLY KIT PREMIX Blank $22.44 HCPCS - Non-Drugs B4222 Blank PARENTERAL SUPPLY KIT HOMEMI Blank $27.57 HCPCS - Non-Drugs B4224 Blank PARENTERAL ADMINISTRATION KI Blank $69.21 HCPCS - Non-Drugs B5000 Blank PARENTERAL SOL RENAL-AMIROSY a $33.13 HCPCS - Non-Drugs B5100 Blank PARENTERAL SOLUTION HEPATIC a $13.19 HCPCS - Non-Drugs B5200 Blank PARENTERAL SOL HEPATIC FREAM a $632.64 HCPCS - Non-Drugs B9000 Blank ENTER INFUSION PUMP W/O ALRM Blank $2,236.22 HCPCS - Non-Drugs B9000 MS ENTER INFUSION PUMP W/O ALRM Blank $75.57 HCPCS - Non-Drugs B9000 NU ENTER INFUSION PUMP W/O ALRM Blank $2,236.22 HCPCS - Non-Drugs B9000 RR ENTER INFUSION PUMP W/O ALRM Blank $224.00 HCPCS - Non-Drugs B9000 UE ENTER INFUSION PUMP W/O ALRM Blank $1,677.27 HCPCS - Non-Drugs B9002 Blank ENTER NUTR INF PUMP ANY TYPE Blank $2,237.21 HCPCS - Non-Drugs B9002 MS ENTER NUTR INF PUMP ANY TYPE Blank $75.60 HCPCS - Non-Drugs B9002 NU ENTER NUTR INF PUMP ANY TYPE Blank $2,237.21 HCPCS - Non-Drugs B9002 RR ENTER NUTR INF PUMP ANY TYPE Blank $224.09 HCPCS - Non-Drugs B9002 UE ENTER NUTR INF PUMP ANY TYPE Blank $1,678.02 HCPCS - Non-Drugs B9004 Blank PARENTERAL INFUS PUMP PORTAB Blank $6,943.60 HCPCS - Non-Drugs B9004 MS PARENTERAL INFUS PUMP PORTAB Blank $549.99 HCPCS - Non-Drugs B9004 NU PARENTERAL INFUS PUMP PORTAB Blank $6,943.60 HCPCS - Non-Drugs B9004 RR PARENTERAL INFUS PUMP PORTAB Blank $1,099.54 HCPCS - Non-Drugs B9004 UE PARENTERAL INFUS PUMP PORTAB Blank $5,207.80 HCPCS - Non-Drugs B9006 Blank PARENTERAL INFUS PUMP STATIO Blank $6,943.60 HCPCS - Non-Drugs B9006 MS PARENTERAL INFUS PUMP STATIO Blank $549.99 HCPCS - Non-Drugs B9006 NU PARENTERAL INFUS PUMP STATIO Blank $6,943.60 HCPCS - Non-Drugs B9006 RR PARENTERAL INFUS PUMP STATIO Blank $1,099.54 HCPCS - Non-Drugs B9006 UE PARENTERAL INFUS PUMP STATIO Blank $5,207.80 HCPCS - Non-Drugs B9998 Blank ENTERAL SUPP NOT OTHERWISE C Blank $100.47 HCPCS - Non-Drugs B9999 Blank PARENTERAL SUPP NOT OTHRWS C Blank $100.47 HCPCS - Non-Drugs C1713 Blank ANCHOR/SCREW BN/BN,TIS/BN Blank $636.42 HCPCS - Non-Drugs C1714 Blank CATH, TRANS ATHERECTOMY, DIR Blank $280.41 HCPCS - Non-Drugs C1715 Blank BRACHYTHERAPY NEEDLE Blank $47.55 HCPCS - Non-Drugs C1717 Blank BRACHYTX, NON-STR,HDR IR-192 a $1,054.49 HCPCS - Non-Drugs C1721 Blank AICD, DUAL CHAMBER Blank $28,078.42 HCPCS - Non-Drugs C1722 Blank AICD, SINGLE CHAMBER Blank $24,464.24 HCPCS - Non-Drugs C1724 Blank CATH, TRANS ATHEREC,ROTATION Blank $2,507.59 HCPCS - Non-Drugs C1725 Blank CATH, TRANSLUMIN NON-LASER Blank $1,257.10 HCPCS - Non-Drugs C1726 Blank CATH, BAL DIL, NON-VASCULAR Blank $905.74 HCPCS - Non-Drugs C1727 Blank CATH, BAL TIS DIS, NON-VAS Blank $935.95 HCPCS - Non-Drugs C1728 Blank CATH, BRACHYTX SEED ADM Blank $41.25 HCPCS - Non-Drugs C1729 Blank CATH, DRAINAGE Blank $283.27 HCPCS - Non-Drugs C1730 Blank CATH, EP, 19 OR FEW ELECT Blank $1,915.77 HCPCS - Non-Drugs C1731 Blank CATH, EP, 20 OR MORE ELEC Blank $5,283.75 HCPCS - Non-Drugs C1732 Blank CATH, EP, DIAG/ABL, 3D/VECT Blank $5,283.75 HCPCS - Non-Drugs C1733 Blank CATH, EP, OTHR THAN COOL-TIP Blank $1,915.77 HCPCS - Non-Drugs C1750 Blank CATH, HEMODIALYSIS,LONG-TERM Blank $632.80 HCPCS - Non-Drugs C1751 Blank CATH, INF, PER/CENT/MIDLINE Blank $888.74 HCPCS - Non-Drugs C1752 Blank CATH,HEMODIALYSIS,SHORT-TERM Blank $974.27 HCPCS - Non-Drugs C1753 Blank CATH, INTRAVAS ULTRASOUND Blank $1,485.99 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 16 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
C1754 Blank CATHETER, INTRADISCAL Blank $770.33 HCPCS - Non-Drugs C1755 Blank CATHETER, INTRASPINAL Blank $1,347.46 HCPCS - Non-Drugs C1756 Blank CATH, PACING, TRANSESOPH Blank $1,263.97 HCPCS - Non-Drugs C1757 Blank CATH, THROMBECTOMY/EMBOLECT Blank $3,125.74 HCPCS - Non-Drugs C1758 Blank CATHETER, URETERAL Blank $496.39 HCPCS - Non-Drugs C1759 Blank CATH, INTRA ECHOCARDIOGRAPHY Blank $4,194.55 HCPCS - Non-Drugs C1760 Blank CLOSURE DEV, VASC Blank $879.22 HCPCS - Non-Drugs C1762 Blank CONN TISS, HUMAN(INC FASCIA) Blank $2,559.56 HCPCS - Non-Drugs C1763 Blank CONN TISS, NON-HUMAN Blank $2,451.22 HCPCS - Non-Drugs C1764 Blank EVENT RECORDER, CARDIAC Blank $3,599.61 HCPCS - Non-Drugs C1765 Blank ADHESION BARRIER Blank $447.38 HCPCS - Non-Drugs C1766 Blank INTRO/SHEATH,STRBLE,NON-PEEL Blank $626.28 HCPCS - Non-Drugs C1767 Blank GENERATOR, NEURO NON-RECHARG Blank $18,045.76 HCPCS - Non-Drugs C1768 Blank GRAFT, VASCULAR Blank $3,151.05 HCPCS - Non-Drugs C1769 Blank GUIDE WIRE Blank $380.18 HCPCS - Non-Drugs C1770 Blank IMAGING COIL, MR, INSERTABLE Blank $364.61 HCPCS - Non-Drugs C1771 Blank REP DEV, URINARY, W/SLING Blank $3,789.22 HCPCS - Non-Drugs C1772 Blank INFUSION PUMP, PROGRAMMABLE Blank $168.54 HCPCS - Non-Drugs C1776 Blank JOINT DEVICE (IMPLANTABLE) Blank $4,884.95 HCPCS - Non-Drugs C1777 Blank LEAD, AICD, ENDO SINGLE COIL Blank $6,514.17 HCPCS - Non-Drugs C1778 Blank LEAD, NEUROSTIMULATOR Blank $4,874.14 HCPCS - Non-Drugs C1779 Blank LEAD, PMKR, TRANSVENOUS VDD Blank $3,207.96 HCPCS - Non-Drugs C1780 Blank LENS, INTRAOCULAR (NEW TECH) Blank $303.99 HCPCS - Non-Drugs C1781 Blank MESH (IMPLANTABLE) Blank $975.68 HCPCS - Non-Drugs C1782 Blank MORCELLATOR Blank $409.01 HCPCS - Non-Drugs C1783 Blank OCULAR IMP, AQUEOUS DRAIN DE Blank $879.72 HCPCS - Non-Drugs C1784 Blank OCULAR DEV, INTRAOP, DET RET Blank $996.33 HCPCS - Non-Drugs C1785 Blank PMKR, DUAL, RATE-RESP Blank $8,445.41 HCPCS - Non-Drugs C1786 Blank PMKR, SINGLE, RATE-RESP Blank $6,879.65 HCPCS - Non-Drugs C1787 Blank PATIENT PROGR, NEUROSTIM Blank $5,107.42 HCPCS - Non-Drugs C1788 Blank PORT, INDWELLING, IMP Blank $997.99 HCPCS - Non-Drugs C1789 Blank PROSTHESIS, BREAST, IMP Blank $1,342.56 HCPCS - Non-Drugs C1813 Blank PROSTHESIS, PENILE, INFLATAB Blank $5,357.55 HCPCS - Non-Drugs C1815 Blank PROS, URINARY SPH, IMP Blank $4,823.12 HCPCS - Non-Drugs C1816 Blank RECEIVER/TRANSMITTER, NEURO Blank $1,873.19 HCPCS - Non-Drugs C1817 Blank SEPTAL DEFECT IMP SYS Blank $7,098.04 HCPCS - Non-Drugs C1818 Blank INTEGRATED KERATOPROSTHESIS Blank $4,312.57 HCPCS - Non-Drugs C1821 Blank INTERSPINOUS IMPLANT Blank $1,944.60 HCPCS - Non-Drugs C1830 Blank POWER BONE MARROW BX NEEDLE Blank $207.14 HCPCS - Non-Drugs C1840 Blank TELESCOPIC INTRAOCULAR LENS Blank $430.15 HCPCS - Non-Drugs C1874 Blank STENT, COATED/COV W/DEL SYS Blank $2,681.02 HCPCS - Non-Drugs C1875 Blank STENT, COATED/COV W/O DEL SY Blank $3,166.00 HCPCS - Non-Drugs C1876 Blank STENT, NON-COA/NON-COV W/DEL Blank $1,965.59 HCPCS - Non-Drugs C1877 Blank STENT, NON-COAT/COV W/O DEL Blank $2,807.86 HCPCS - Non-Drugs C1878 Blank MATRL FOR VOCAL CORD Blank $838.19 HCPCS - Non-Drugs C1880 Blank VENA CAVA FILTER Blank $2,518.19 HCPCS - Non-Drugs C1881 Blank DIALYSIS ACCESS SYSTEM Blank $885.92 HCPCS - Non-Drugs C1882 Blank AICD, OTHER THAN SING/DUAL Blank $35,401.51 HCPCS - Non-Drugs C1883 Blank ADAPT/EXT, PACING/NEURO LEAD Blank $2,768.45 HCPCS - Non-Drugs C1884 Blank EMBOLIZATION PROTECT SYST Blank $306.00 HCPCS - Non-Drugs C1885 Blank CATH, TRANSLUMIN ANGIO LASER Blank $348.76 HCPCS - Non-Drugs C1887 Blank CATHETER, GUIDING Blank $66.70 HCPCS - Non-Drugs C1888 Blank ENDOVAS NON-CARDIAC ABL CATH Blank $1,021.66 HCPCS - Non-Drugs C1891 Blank INFUSION PUMP,NON-PROG, PERM Blank $7,115.47 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 17 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
C1892 Blank INTRO/SHEATH,FIXED,PEEL-AWAY Blank $1,209.09 HCPCS - Non-Drugs C1893 Blank INTRO/SHEATH, FIXED,NON-PEEL Blank $645.70 HCPCS - Non-Drugs C1894 Blank INTRO/SHEATH, NON-LASER Blank $168.01 HCPCS - Non-Drugs C1895 Blank LEAD, AICD, ENDO DUAL COIL Blank $6,226.02 HCPCS - Non-Drugs C1896 Blank LEAD, AICD, NON SING/DUAL Blank $5,800.93 HCPCS - Non-Drugs C1897 Blank LEAD, NEUROSTIM TEST KIT Blank $1,909.98 HCPCS - Non-Drugs C1898 Blank LEAD, PMKR, OTHER THAN TRANS Blank $966.94 HCPCS - Non-Drugs C1899 Blank LEAD, PMKR/AICD COMBINATION Blank $4,712.90 HCPCS - Non-Drugs C1900 Blank LEAD, CORONARY VENOUS Blank $4,089.40 HCPCS - Non-Drugs C2613 Blank LUNG BX PLUG W/DEL SYS Blank $118.84 HCPCS - Non-Drugs C2614 Blank PROBE, PERC LUMB DISC Blank $854.13 HCPCS - Non-Drugs C2615 Blank SEALANT, PULMONARY, LIQUID Blank $950.07 HCPCS - Non-Drugs C2617 Blank STENT, NON-COR, TEM W/O DEL Blank $2,964.04 HCPCS - Non-Drugs C2618 Blank PROBE/NEEDLE, CRYO Blank $2,668.31 HCPCS - Non-Drugs C2619 Blank PMKR, DUAL, NON RATE-RESP Blank $6,860.96 HCPCS - Non-Drugs C2620 Blank PMKR, SINGLE, NON RATE-RESP Blank $19,056.29 HCPCS - Non-Drugs C2621 Blank PMKR, OTHER THAN SING/DUAL Blank $12,011.00 HCPCS - Non-Drugs C2622 Blank PROSTHESIS, PENILE, NON-INF Blank $5,427.28 HCPCS - Non-Drugs C2623 Blank CATH, TRANSLUMIN, DRUG-COAT Blank $4,941.55 HCPCS - Non-Drugs C2625 Blank STENT, NON-COR, TEM W/DEL SY Blank $3,382.96 HCPCS - Non-Drugs C2626 Blank INFUSION PUMP, NON-PROG,TEMP Blank $1,241.50 HCPCS - Non-Drugs C2627 Blank CATH, SUPRAPUBIC/CYSTOSCOPIC Blank $913.70 HCPCS - Non-Drugs C2628 Blank CATHETER, OCCLUSION Blank $1,190.14 HCPCS - Non-Drugs C2631 Blank REP DEV, URINARY, W/O SLING Blank $3,370.31 HCPCS - Non-Drugs C2638 Blank BRACHYTX, STRANDED, I-125 a $65.17 HCPCS - Non-Drugs C2639 Blank BRACHYTX, NON-STRANDED,I-125 a $42.42 HCPCS - Non-Drugs C2640 Blank BRACHYTX, STRANDED, P-103 a $151.38 HCPCS - Non-Drugs C2641 Blank BRACHYTX, NON-STRANDED,P-103 a $77.50 HCPCS - Non-Drugs C2645 Blank BRACHYTX PLANAR, P-103 a $31.89 HCPCS - Non-Drugs C2698 Blank BRACHYTX, STRANDED, NOS a $2,681.02 HCPCS - Non-Drugs C2699 Blank BRACHYTX, NON-STRANDED, NOS a $2,681.02 HCPCS - Non-Drugs C9113 Blank INJ PANTOPRAZOLE SODIUM, VIA a $192.49 HCPCS - Drugs C9121 Blank INJECTION, ARGATROBAN a $222.91 HCPCS - Drugs C9248 Blank INJ, CLEVIDIPINE BUTYRATE a $11.81 HCPCS - Drugs C9250 Blank ARTISS FIBRIN SEALANT a $811.61 HCPCS - Drugs C9254 Blank INJECTION, LACOSAMIDE a $1.27 HCPCS - Drugs C9257 Blank BEVACIZUMAB INJECTION a $24.33 HCPCS - Drugs C9285 Blank PATCH, LIDOCAINE/TETRACAINE a $104.79 HCPCS - Drugs C9290 Blank INJ, BUPIVACAINE LIPOSOME a $8.11 HCPCS - Drugs C9349 Blank PURAPLY, PURAPLY ANTIMIC a $460.30 HCPCS - Drugs C9358 Blank SURGIMEND, FETAL Blank $974.64 HCPCS - Non-Drugs C9359 Blank IMPLNT,BON VOID FILLER-PUTTY Blank $873.98 HCPCS - Non-Drugs C9360 Blank SURGIMEND, NEONATAL Blank $67.40 HCPCS - Non-Drugs C9361 Blank NEUROMEND NERVE WRAP Blank $2,629.70 HCPCS - Non-Drugs C9362 Blank IMPLNT,BON VOID FILLER-STRIP Blank $299.89 HCPCS - Non-Drugs C9363 Blank INTEGRA MESHED BIL WOUND MAT Blank $118.40 HCPCS - Non-Drugs C9364 Blank PORCINE IMPLANT, PERMACOL Blank $104.16 HCPCS - Non-Drugs C9399 Blank UNCLASSIFIED DRUGS OR BIOLOG Blank $2,681.02 HCPCS - Drugs C9447 Blank INJ, PHENYLEPHRINE KETOROLAC a $2,611.82 HCPCS - Drugs C9476 Blank INJECTION, DARATUMUMAB a $315.20 HCPCS - Drugs C9477 Blank INJECTION, ELOTUZUMAB a $42.49 HCPCS - Drugs C9478 Blank INJECTION, SEBELIPASE ALFA a $3,477.08 HCPCS - Drugs C9479 Blank INSTILL, CIPROFLOXACIN OTIC a $204.03 HCPCS - Drugs C9480 Blank INJECTION, TRABECTEDIN a $1,638.42 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 18 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
C9497 Blank LOXAPINE, INHALATION POWDER a $7.45 HCPCS - Drugs C9741 Blank IMPL PRESSURE SENSOR W/ANGIO Blank $14,943.18 HCPCS - Non-Drugs C9800 Blank DERMAL FILLER INJ PX/SUPPL Blank $1,715.07 HCPCS - Non-Drugs E0100 Blank CANE ADJUST/FIXED WITH TIP Blank $111.61 HCPCS - Non-Drugs E0100 NU CANE ADJUST/FIXED WITH TIP Blank $111.61 HCPCS - Non-Drugs E0100 RR CANE ADJUST/FIXED WITH TIP Blank $60.38 HCPCS - Non-Drugs E0100 UE CANE ADJUST/FIXED WITH TIP Blank $102.05 HCPCS - Non-Drugs E0105 Blank CANE ADJUST/FIXED QUAD/3 PRO Blank $172.06 HCPCS - Non-Drugs E0105 NU CANE ADJUST/FIXED QUAD/3 PRO Blank $172.06 HCPCS - Non-Drugs E0105 RR CANE ADJUST/FIXED QUAD/3 PRO Blank $85.70 HCPCS - Non-Drugs E0105 UE CANE ADJUST/FIXED QUAD/3 PRO Blank $146.98 HCPCS - Non-Drugs E0110 Blank CRUTCH FOREARM PAIR Blank $226.89 HCPCS - Non-Drugs E0110 NU CRUTCH FOREARM PAIR Blank $226.89 HCPCS - Non-Drugs E0110 RR CRUTCH FOREARM PAIR Blank $100.04 HCPCS - Non-Drugs E0110 UE CRUTCH FOREARM PAIR Blank $187.05 HCPCS - Non-Drugs E0111 Blank CRUTCH FOREARM EACH Blank $176.00 HCPCS - Non-Drugs E0111 NU CRUTCH FOREARM EACH Blank $176.00 HCPCS - Non-Drugs E0111 RR CRUTCH FOREARM EACH Blank $84.63 HCPCS - Non-Drugs E0111 UE CRUTCH FOREARM EACH Blank $150.81 HCPCS - Non-Drugs E0112 Blank CRUTCH UNDERARM PAIR WOOD Blank $143.70 HCPCS - Non-Drugs E0112 NU CRUTCH UNDERARM PAIR WOOD Blank $143.70 HCPCS - Non-Drugs E0112 RR CRUTCH UNDERARM PAIR WOOD Blank $87.61 HCPCS - Non-Drugs E0112 UE CRUTCH UNDERARM PAIR WOOD Blank $125.93 HCPCS - Non-Drugs E0113 Blank CRUTCH UNDERARM EACH WOOD Blank $110.66 HCPCS - Non-Drugs E0113 NU CRUTCH UNDERARM EACH WOOD Blank $110.66 HCPCS - Non-Drugs E0113 RR CRUTCH UNDERARM EACH WOOD Blank $49.65 HCPCS - Non-Drugs E0113 UE CRUTCH UNDERARM EACH WOOD Blank $99.91 HCPCS - Non-Drugs E0114 Blank CRUTCH UNDERARM PAIR NO WOOD Blank $163.79 HCPCS - Non-Drugs E0114 NU CRUTCH UNDERARM PAIR NO WOOD Blank $163.79 HCPCS - Non-Drugs E0114 RR CRUTCH UNDERARM PAIR NO WOOD Blank $84.96 HCPCS - Non-Drugs E0114 UE CRUTCH UNDERARM PAIR NO WOOD Blank $140.17 HCPCS - Non-Drugs E0116 Blank CRUTCH UNDERARM EACH NO WOOD Blank $121.99 HCPCS - Non-Drugs E0116 NU CRUTCH UNDERARM EACH NO WOOD Blank $121.99 HCPCS - Non-Drugs E0116 RR CRUTCH UNDERARM EACH NO WOOD Blank $51.66 HCPCS - Non-Drugs E0116 UE CRUTCH UNDERARM EACH NO WOOD Blank $108.55 HCPCS - Non-Drugs E0117 Blank UNDERARM SPRINGASSIST CRUTCH Blank $338.68 HCPCS - Non-Drugs E0117 NU UNDERARM SPRINGASSIST CRUTCH Blank $338.68 HCPCS - Non-Drugs E0117 RR UNDERARM SPRINGASSIST CRUTCH Blank $109.35 HCPCS - Non-Drugs E0117 UE UNDERARM SPRINGASSIST CRUTCH Blank $270.66 HCPCS - Non-Drugs E0118 Blank CRUTCH SUBSTITUTE Blank $561.47 HCPCS - Non-Drugs E0118 RR CRUTCH SUBSTITUTE Blank $118.26 HCPCS - Non-Drugs E0130 Blank WALKER RIGID ADJUST/FIXED HT Blank $161.15 HCPCS - Non-Drugs E0130 NU WALKER RIGID ADJUST/FIXED HT Blank $161.15 HCPCS - Non-Drugs E0130 RR WALKER RIGID ADJUST/FIXED HT Blank $43.71 HCPCS - Non-Drugs E0130 UE WALKER RIGID ADJUST/FIXED HT Blank $137.78 HCPCS - Non-Drugs E0135 Blank WALKER FOLDING ADJUST/FIXED Blank $153.83 HCPCS - Non-Drugs E0135 NU WALKER FOLDING ADJUST/FIXED Blank $153.83 HCPCS - Non-Drugs E0135 RR WALKER FOLDING ADJUST/FIXED Blank $40.30 HCPCS - Non-Drugs E0135 UE WALKER FOLDING ADJUST/FIXED Blank $132.29 HCPCS - Non-Drugs E0140 Blank WALKER W TRUNK SUPPORT Blank $954.20 HCPCS - Non-Drugs E0140 NU WALKER W TRUNK SUPPORT Blank $954.20 HCPCS - Non-Drugs E0140 RR WALKER W TRUNK SUPPORT Blank $120.75 HCPCS - Non-Drugs E0140 UE WALKER W TRUNK SUPPORT Blank $355.29 HCPCS - Non-Drugs E0141 Blank RIGID WHEELED WALKER ADJ/FIX Blank $216.56 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 19 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0141 NU RIGID WHEELED WALKER ADJ/FIX Blank $216.56 HCPCS - Non-Drugs E0141 RR RIGID WHEELED WALKER ADJ/FIX Blank $77.39 HCPCS - Non-Drugs E0141 UE RIGID WHEELED WALKER ADJ/FIX Blank $179.35 HCPCS - Non-Drugs E0143 Blank WALKER FOLDING WHEELED W/O S Blank $160.70 HCPCS - Non-Drugs E0143 NU WALKER FOLDING WHEELED W/O S Blank $160.70 HCPCS - Non-Drugs E0143 RR WALKER FOLDING WHEELED W/O S Blank $43.50 HCPCS - Non-Drugs E0143 UE WALKER FOLDING WHEELED W/O S Blank $137.44 HCPCS - Non-Drugs E0144 Blank ENCLOSED WALKER W REAR SEAT Blank $926.93 HCPCS - Non-Drugs E0144 NU ENCLOSED WALKER W REAR SEAT Blank $926.93 HCPCS - Non-Drugs E0144 RR ENCLOSED WALKER W REAR SEAT Blank $117.30 HCPCS - Non-Drugs E0144 UE ENCLOSED WALKER W REAR SEAT Blank $321.54 HCPCS - Non-Drugs E0147 Blank WALKER VARIABLE WHEEL RESIST Blank $802.78 HCPCS - Non-Drugs E0147 NU WALKER VARIABLE WHEEL RESIST Blank $802.78 HCPCS - Non-Drugs E0147 RR WALKER VARIABLE WHEEL RESIST Blank $141.18 HCPCS - Non-Drugs E0147 UE WALKER VARIABLE WHEEL RESIST Blank $619.00 HCPCS - Non-Drugs E0148 Blank HEAVYDUTY WALKER NO WHEELS Blank $226.18 HCPCS - Non-Drugs E0148 NU HEAVYDUTY WALKER NO WHEELS Blank $226.18 HCPCS - Non-Drugs E0148 RR HEAVYDUTY WALKER NO WHEELS Blank $83.37 HCPCS - Non-Drugs E0148 UE HEAVYDUTY WALKER NO WHEELS Blank $186.56 HCPCS - Non-Drugs E0149 Blank HEAVY DUTY WHEELED WALKER Blank $715.10 HCPCS - Non-Drugs E0149 NU HEAVY DUTY WHEELED WALKER Blank $715.10 HCPCS - Non-Drugs E0149 RR HEAVY DUTY WHEELED WALKER Blank $90.49 HCPCS - Non-Drugs E0149 UE HEAVY DUTY WHEELED WALKER Blank $245.49 HCPCS - Non-Drugs E0153 Blank FOREARM CRUTCH PLATFORM ATTA Blank $210.35 HCPCS - Non-Drugs E0153 NU FOREARM CRUTCH PLATFORM ATTA Blank $210.35 HCPCS - Non-Drugs E0153 RR FOREARM CRUTCH PLATFORM ATTA Blank $84.04 HCPCS - Non-Drugs E0153 UE FOREARM CRUTCH PLATFORM ATTA Blank $174.66 HCPCS - Non-Drugs E0154 Blank WALKER PLATFORM ATTACHMENT Blank $160.21 HCPCS - Non-Drugs E0154 NU WALKER PLATFORM ATTACHMENT Blank $160.21 HCPCS - Non-Drugs E0154 RR WALKER PLATFORM ATTACHMENT Blank $43.28 HCPCS - Non-Drugs E0154 UE WALKER PLATFORM ATTACHMENT Blank $137.08 HCPCS - Non-Drugs E0155 Blank WALKER WHEEL ATTACHMENT,PAIR Blank $107.88 HCPCS - Non-Drugs E0155 NU WALKER WHEEL ATTACHMENT,PAIR Blank $107.88 HCPCS - Non-Drugs E0155 RR WALKER WHEEL ATTACHMENT,PAIR Blank $18.82 HCPCS - Non-Drugs E0155 UE WALKER WHEEL ATTACHMENT,PAIR Blank $97.83 HCPCS - Non-Drugs E0156 Blank WALKER SEAT ATTACHMENT Blank $97.91 HCPCS - Non-Drugs E0156 NU WALKER SEAT ATTACHMENT Blank $97.91 HCPCS - Non-Drugs E0156 RR WALKER SEAT ATTACHMENT Blank $14.15 HCPCS - Non-Drugs E0156 UE WALKER SEAT ATTACHMENT Blank $90.36 HCPCS - Non-Drugs E0157 Blank WALKER CRUTCH ATTACHMENT Blank $172.67 HCPCS - Non-Drugs E0157 NU WALKER CRUTCH ATTACHMENT Blank $172.67 HCPCS - Non-Drugs E0157 RR WALKER CRUTCH ATTACHMENT Blank $50.21 HCPCS - Non-Drugs E0157 UE WALKER CRUTCH ATTACHMENT Blank $146.42 HCPCS - Non-Drugs E0158 Blank WALKER LEG EXTENDERS SET OF4 Blank $108.84 HCPCS - Non-Drugs E0158 NU WALKER LEG EXTENDERS SET OF4 Blank $108.84 HCPCS - Non-Drugs E0158 RR WALKER LEG EXTENDERS SET OF4 Blank $19.26 HCPCS - Non-Drugs E0158 UE WALKER LEG EXTENDERS SET OF4 Blank $98.55 HCPCS - Non-Drugs E0159 Blank BRAKE FOR WHEELED WALKER Blank $95.59 HCPCS - Non-Drugs E0159 NU BRAKE FOR WHEELED WALKER Blank $95.59 HCPCS - Non-Drugs E0159 RR BRAKE FOR WHEELED WALKER Blank $13.07 HCPCS - Non-Drugs E0159 UE BRAKE FOR WHEELED WALKER Blank $88.62 HCPCS - Non-Drugs E0160 Blank SITZ TYPE BATH OR EQUIPMENT Blank $123.00 HCPCS - Non-Drugs E0160 NU SITZ TYPE BATH OR EQUIPMENT Blank $123.00 HCPCS - Non-Drugs E0160 RR SITZ TYPE BATH OR EQUIPMENT Blank $25.92 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 20 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0160 UE SITZ TYPE BATH OR EQUIPMENT Blank $109.18 HCPCS - Non-Drugs E0161 Blank SITZ BATH/EQUIPMENT W/FAUCET Blank $114.92 HCPCS - Non-Drugs E0161 NU SITZ BATH/EQUIPMENT W/FAUCET Blank $114.92 HCPCS - Non-Drugs E0161 RR SITZ BATH/EQUIPMENT W/FAUCET Blank $22.17 HCPCS - Non-Drugs E0161 UE SITZ BATH/EQUIPMENT W/FAUCET Blank $103.10 HCPCS - Non-Drugs E0162 Blank SITZ BATH CHAIR Blank $359.89 HCPCS - Non-Drugs E0162 NU SITZ BATH CHAIR Blank $359.89 HCPCS - Non-Drugs E0162 RR SITZ BATH CHAIR Blank $98.42 HCPCS - Non-Drugs E0162 UE SITZ BATH CHAIR Blank $292.98 HCPCS - Non-Drugs E0163 Blank COMMODE CHAIR WITH FIXED ARM Blank $170.60 HCPCS - Non-Drugs E0163 NU COMMODE CHAIR WITH FIXED ARM Blank $170.60 HCPCS - Non-Drugs E0163 RR COMMODE CHAIR WITH FIXED ARM Blank $48.93 HCPCS - Non-Drugs E0163 UE COMMODE CHAIR WITH FIXED ARM Blank $144.87 HCPCS - Non-Drugs E0165 Blank COMMODE CHAIR WITH DETACHARM Blank $720.08 HCPCS - Non-Drugs E0165 RR COMMODE CHAIR WITH DETACHARM Blank $91.12 HCPCS - Non-Drugs E0167 Blank COMMODE CHAIR PAIL OR PAN Blank $88.36 HCPCS - Non-Drugs E0167 NU COMMODE CHAIR PAIL OR PAN Blank $88.36 HCPCS - Non-Drugs E0167 RR COMMODE CHAIR PAIL OR PAN Blank $9.71 HCPCS - Non-Drugs E0167 UE COMMODE CHAIR PAIL OR PAN Blank $81.34 HCPCS - Non-Drugs E0168 Blank HEAVYDUTY/WIDE COMMODE CHAIR Blank $292.60 HCPCS - Non-Drugs E0168 NU HEAVYDUTY/WIDE COMMODE CHAIR Blank $292.60 HCPCS - Non-Drugs E0168 RR HEAVYDUTY/WIDE COMMODE CHAIR Blank $90.16 HCPCS - Non-Drugs E0168 UE HEAVYDUTY/WIDE COMMODE CHAIR Blank $236.37 HCPCS - Non-Drugs E0170 Blank COMMODE CHAIR ELECTRIC Blank $3,000.80 HCPCS - Non-Drugs E0170 RR COMMODE CHAIR ELECTRIC Blank $379.74 HCPCS - Non-Drugs E0171 Blank COMMODE CHAIR NON-ELECTRIC Blank $993.94 HCPCS - Non-Drugs E0171 RR COMMODE CHAIR NON-ELECTRIC Blank $125.78 HCPCS - Non-Drugs E0172 Blank SEAT LIFT MECHANISM TOILET Blank $349.68 HCPCS - Non-Drugs E0175 Blank COMMODE CHAIR FOOT REST Blank $201.96 HCPCS - Non-Drugs E0175 NU COMMODE CHAIR FOOT REST Blank $201.96 HCPCS - Non-Drugs E0175 RR COMMODE CHAIR FOOT REST Blank $68.28 HCPCS - Non-Drugs E0175 UE COMMODE CHAIR FOOT REST Blank $166.45 HCPCS - Non-Drugs E0181 Blank PRESS PAD ALTERNATING W/ PUM Blank $775.06 HCPCS - Non-Drugs E0181 RR PRESS PAD ALTERNATING W/ PUM Blank $98.08 HCPCS - Non-Drugs E0182 Blank REPLACE PUMP, ALT PRESS PAD Blank $851.91 HCPCS - Non-Drugs E0182 RR REPLACE PUMP, ALT PRESS PAD Blank $107.81 HCPCS - Non-Drugs E0184 Blank DRY PRESSURE MATTRESS Blank $374.06 HCPCS - Non-Drugs E0184 NU DRY PRESSURE MATTRESS Blank $374.06 HCPCS - Non-Drugs E0184 RR DRY PRESSURE MATTRESS Blank $98.37 HCPCS - Non-Drugs E0184 UE DRY PRESSURE MATTRESS Blank $297.56 HCPCS - Non-Drugs E0185 Blank GEL PRESSURE MATTRESS PAD Blank $395.99 HCPCS - Non-Drugs E0185 NU GEL PRESSURE MATTRESS PAD Blank $395.99 HCPCS - Non-Drugs E0185 RR GEL PRESSURE MATTRESS PAD Blank $100.50 HCPCS - Non-Drugs E0185 UE GEL PRESSURE MATTRESS PAD Blank $313.91 HCPCS - Non-Drugs E0186 Blank AIR PRESSURE MATTRESS Blank $824.08 HCPCS - Non-Drugs E0186 RR AIR PRESSURE MATTRESS Blank $104.28 HCPCS - Non-Drugs E0187 Blank WATER PRESSURE MATTRESS Blank $864.96 HCPCS - Non-Drugs E0187 RR WATER PRESSURE MATTRESS Blank $109.46 HCPCS - Non-Drugs E0188 Blank SYNTHETIC SHEEPSKIN PAD Blank $114.94 HCPCS - Non-Drugs E0188 NU SYNTHETIC SHEEPSKIN PAD Blank $114.94 HCPCS - Non-Drugs E0188 RR SYNTHETIC SHEEPSKIN PAD Blank $22.18 HCPCS - Non-Drugs E0188 UE SYNTHETIC SHEEPSKIN PAD Blank $103.12 HCPCS - Non-Drugs E0189 Blank LAMBSWOOL SHEEPSKIN PAD Blank $163.18 HCPCS - Non-Drugs E0189 NU LAMBSWOOL SHEEPSKIN PAD Blank $163.18 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 21 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0189 RR LAMBSWOOL SHEEPSKIN PAD Blank $44.86 HCPCS - Non-Drugs E0189 UE LAMBSWOOL SHEEPSKIN PAD Blank $139.31 HCPCS - Non-Drugs E0190 Blank POSITIONING CUSHION Blank $66.82 HCPCS - Non-Drugs E0191 Blank PROTECTOR HEEL OR ELBOW Blank $87.76 HCPCS - Non-Drugs E0191 NU PROTECTOR HEEL OR ELBOW Blank $87.76 HCPCS - Non-Drugs E0191 RR PROTECTOR HEEL OR ELBOW Blank $9.62 HCPCS - Non-Drugs E0191 UE PROTECTOR HEEL OR ELBOW Blank $78.22 HCPCS - Non-Drugs E0193 Blank POWERED AIR FLOTATION BED Blank $11,321.70 HCPCS - Non-Drugs E0193 RR POWERED AIR FLOTATION BED Blank $1,432.73 HCPCS - Non-Drugs E0194 Blank AIR FLUIDIZED BED Blank $50,914.37 HCPCS - Non-Drugs E0194 RR AIR FLUIDIZED BED Blank $6,443.08 HCPCS - Non-Drugs E0194 UE AIR FLUIDIZED BED Blank $35,705.51 HCPCS - Non-Drugs E0196 Blank GEL PRESSURE MATTRESS Blank $984.58 HCPCS - Non-Drugs E0196 RR GEL PRESSURE MATTRESS Blank $124.60 HCPCS - Non-Drugs E0196 UE GEL PRESSURE MATTRESS Blank $464.69 HCPCS - Non-Drugs E0197 Blank AIR PRESSURE PAD FOR MATTRES Blank $808.61 HCPCS - Non-Drugs E0197 NU AIR PRESSURE PAD FOR MATTRES Blank $808.61 HCPCS - Non-Drugs E0197 RR AIR PRESSURE PAD FOR MATTRES Blank $102.33 HCPCS - Non-Drugs E0197 UE AIR PRESSURE PAD FOR MATTRES Blank $307.62 HCPCS - Non-Drugs E0198 Blank WATER PRESSURE PAD FOR MATTR Blank $898.49 HCPCS - Non-Drugs E0198 NU WATER PRESSURE PAD FOR MATTR Blank $898.49 HCPCS - Non-Drugs E0198 RR WATER PRESSURE PAD FOR MATTR Blank $113.70 HCPCS - Non-Drugs E0198 UE WATER PRESSURE PAD FOR MATTR Blank $301.19 HCPCS - Non-Drugs E0199 Blank DRY PRESSURE PAD FOR MATTRES Blank $127.57 HCPCS - Non-Drugs E0199 NU DRY PRESSURE PAD FOR MATTRES Blank $127.57 HCPCS - Non-Drugs E0199 RR DRY PRESSURE PAD FOR MATTRES Blank $28.00 HCPCS - Non-Drugs E0199 UE DRY PRESSURE PAD FOR MATTRES Blank $112.60 HCPCS - Non-Drugs E0200 Blank HEAT LAMP WITHOUT STAND Blank $234.55 HCPCS - Non-Drugs E0200 NU HEAT LAMP WITHOUT STAND Blank $234.55 HCPCS - Non-Drugs E0200 RR HEAT LAMP WITHOUT STAND Blank $90.51 HCPCS - Non-Drugs E0200 UE HEAT LAMP WITHOUT STAND Blank $192.89 HCPCS - Non-Drugs E0202 Blank PHOTOTHERAPY LIGHT W/ PHOTOM Blank $1,574.13 HCPCS - Non-Drugs E0202 RR PHOTOTHERAPY LIGHT W/ PHOTOM Blank $199.20 HCPCS - Non-Drugs E0203 Blank THERAPEUTIC LIGHTBOX TABLETP Blank $309.08 HCPCS - Non-Drugs E0205 Blank HEAT LAMP WITH STAND Blank $459.06 HCPCS - Non-Drugs E0205 NU HEAT LAMP WITH STAND Blank $459.06 HCPCS - Non-Drugs E0205 RR HEAT LAMP WITH STAND Blank $112.72 HCPCS - Non-Drugs E0205 UE HEAT LAMP WITH STAND Blank $361.20 HCPCS - Non-Drugs E0210 Blank ELECTRIC HEAT PAD STANDARD Blank $133.84 HCPCS - Non-Drugs E0210 NU ELECTRIC HEAT PAD STANDARD Blank $133.84 HCPCS - Non-Drugs E0210 RR ELECTRIC HEAT PAD STANDARD Blank $32.47 HCPCS - Non-Drugs E0210 UE ELECTRIC HEAT PAD STANDARD Blank $117.25 HCPCS - Non-Drugs E0215 Blank ELECTRIC HEAT PAD MOIST Blank $211.71 HCPCS - Non-Drugs E0215 NU ELECTRIC HEAT PAD MOIST Blank $211.71 HCPCS - Non-Drugs E0215 RR ELECTRIC HEAT PAD MOIST Blank $83.64 HCPCS - Non-Drugs E0215 UE ELECTRIC HEAT PAD MOIST Blank $175.89 HCPCS - Non-Drugs E0217 Blank WATER CIRC HEAT PAD W PUMP Blank $1,069.30 HCPCS - Non-Drugs E0217 NU WATER CIRC HEAT PAD W PUMP Blank $1,069.30 HCPCS - Non-Drugs E0217 RR WATER CIRC HEAT PAD W PUMP Blank $179.03 HCPCS - Non-Drugs E0217 UE WATER CIRC HEAT PAD W PUMP Blank $818.83 HCPCS - Non-Drugs E0218 Blank WATER CIRC COLD PAD W PUMP Blank $1,069.30 HCPCS - Non-Drugs E0221 Blank INFRARED HEATING PAD SYSTEM Blank $147.59 HCPCS - Non-Drugs E0225 Blank HYDROCOLLATOR UNIT Blank $853.77 HCPCS - Non-Drugs E0225 NU HYDROCOLLATOR UNIT Blank $853.77 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 22 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0225 RR HYDROCOLLATOR UNIT Blank $145.33 HCPCS - Non-Drugs E0225 UE HYDROCOLLATOR UNIT Blank $656.73 HCPCS - Non-Drugs E0231 Blank WOUND WARMING DEVICE Blank $501.71 HCPCS - Non-Drugs E0231 RR WOUND WARMING DEVICE Blank $54.90 HCPCS - Non-Drugs E0232 Blank WARMING CARD FOR NWT Blank $158.26 HCPCS - Non-Drugs E0235 Blank PARAFFIN BATH UNIT PORTABLE Blank $823.29 HCPCS - Non-Drugs E0235 RR PARAFFIN BATH UNIT PORTABLE Blank $104.18 HCPCS - Non-Drugs E0235 UE PARAFFIN BATH UNIT PORTABLE Blank $249.77 HCPCS - Non-Drugs E0236 Blank PUMP FOR WATER CIRCULATING P Blank $1,244.22 HCPCS - Non-Drugs E0236 RR PUMP FOR WATER CIRCULATING P Blank $157.45 HCPCS - Non-Drugs E0236 UE PUMP FOR WATER CIRCULATING P Blank $534.18 HCPCS - Non-Drugs E0239 Blank HYDROCOLLATOR UNIT PORTABLE Blank $996.53 HCPCS - Non-Drugs E0239 NU HYDROCOLLATOR UNIT PORTABLE Blank $996.53 HCPCS - Non-Drugs E0239 RR HYDROCOLLATOR UNIT PORTABLE Blank $161.00 HCPCS - Non-Drugs E0239 UE HYDROCOLLATOR UNIT PORTABLE Blank $764.34 HCPCS - Non-Drugs E0240 Blank BATH/SHOWER CHAIR Blank $126.76 HCPCS - Non-Drugs E0241 Blank BATH TUB WALL RAIL Blank $100.34 HCPCS - Non-Drugs E0242 Blank BATH TUB RAIL FLOOR Blank $141.04 HCPCS - Non-Drugs E0243 Blank TOILET RAIL Blank $126.05 HCPCS - Non-Drugs E0244 Blank TOILET SEAT RAISED Blank $112.12 HCPCS - Non-Drugs E0245 Blank TUB STOOL OR BENCH Blank $140.51 HCPCS - Non-Drugs E0246 Blank TRANSFER TUB RAIL ATTACHMENT Blank $167.29 HCPCS - Non-Drugs E0247 Blank TRANS BENCH W/WO COMM OPEN Blank $164.49 HCPCS - Non-Drugs E0248 Blank HDTRANS BENCH W/WO COMM OPEN Blank $166.01 HCPCS - Non-Drugs E0249 Blank PAD WATER CIRCULATING HEAT U Blank $270.31 HCPCS - Non-Drugs E0249 NU PAD WATER CIRCULATING HEAT U Blank $270.31 HCPCS - Non-Drugs E0249 RR PAD WATER CIRCULATING HEAT U Blank $89.95 HCPCS - Non-Drugs E0249 UE PAD WATER CIRCULATING HEAT U Blank $219.65 HCPCS - Non-Drugs E0250 Blank HOSP BED FIXED HT W/ MATTRES Blank $2,155.24 HCPCS - Non-Drugs E0250 RR HOSP BED FIXED HT W/ MATTRES Blank $272.74 HCPCS - Non-Drugs E0250 UE HOSP BED FIXED HT W/ MATTRES Blank $960.86 HCPCS - Non-Drugs E0251 Blank HOSP BED FIXD HT W/O MATTRES Blank $1,946.38 HCPCS - Non-Drugs E0251 RR HOSP BED FIXD HT W/O MATTRES Blank $246.31 HCPCS - Non-Drugs E0251 UE HOSP BED FIXD HT W/O MATTRES Blank $765.50 HCPCS - Non-Drugs E0255 Blank HOSPITAL BED VAR HT W/ MATTR Blank $2,200.79 HCPCS - Non-Drugs E0255 RR HOSPITAL BED VAR HT W/ MATTR Blank $278.50 HCPCS - Non-Drugs E0255 UE HOSPITAL BED VAR HT W/ MATTR Blank $1,124.03 HCPCS - Non-Drugs E0256 Blank HOSPITAL BED VAR HT W/O MATT Blank $2,014.50 HCPCS - Non-Drugs E0256 RR HOSPITAL BED VAR HT W/O MATT Blank $254.93 HCPCS - Non-Drugs E0256 UE HOSPITAL BED VAR HT W/O MATT Blank $842.09 HCPCS - Non-Drugs E0260 Blank HOSP BED SEMI-ELECTR W/ MATT Blank $2,119.75 HCPCS - Non-Drugs E0260 RR HOSP BED SEMI-ELECTR W/ MATT Blank $268.25 HCPCS - Non-Drugs E0260 UE HOSP BED SEMI-ELECTR W/ MATT Blank $1,611.56 HCPCS - Non-Drugs E0261 Blank HOSP BED SEMI-ELECTR W/O MAT Blank $2,051.71 HCPCS - Non-Drugs E0261 RR HOSP BED SEMI-ELECTR W/O MAT Blank $259.64 HCPCS - Non-Drugs E0261 UE HOSP BED SEMI-ELECTR W/O MAT Blank $1,284.43 HCPCS - Non-Drugs E0265 Blank HOSP BED TOTAL ELECTR W/ MAT Blank $3,230.38 HCPCS - Non-Drugs E0265 RR HOSP BED TOTAL ELECTR W/ MAT Blank $408.80 HCPCS - Non-Drugs E0265 UE HOSP BED TOTAL ELECTR W/ MAT Blank $1,804.46 HCPCS - Non-Drugs E0266 Blank HOSP BED TOTAL ELEC W/O MATT Blank $2,968.25 HCPCS - Non-Drugs E0266 RR HOSP BED TOTAL ELEC W/O MATT Blank $375.62 HCPCS - Non-Drugs E0266 UE HOSP BED TOTAL ELEC W/O MATT Blank $1,620.20 HCPCS - Non-Drugs E0270 Blank HOSPITAL BED INSTITUTIONAL T Blank $494.39 HCPCS - Non-Drugs E0270 RR HOSPITAL BED INSTITUTIONAL T Blank $52.08 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 23 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0270 UE HOSPITAL BED INSTITUTIONAL T Blank $371.60 HCPCS - Non-Drugs E0271 Blank MATTRESS INNERSPRING Blank $379.03 HCPCS - Non-Drugs E0271 NU MATTRESS INNERSPRING Blank $379.03 HCPCS - Non-Drugs E0271 RR MATTRESS INNERSPRING Blank $35.13 HCPCS - Non-Drugs E0271 UE MATTRESS INNERSPRING Blank $322.61 HCPCS - Non-Drugs E0272 Blank MATTRESS FOAM RUBBER Blank $410.30 HCPCS - Non-Drugs E0272 NU MATTRESS FOAM RUBBER Blank $410.30 HCPCS - Non-Drugs E0272 RR MATTRESS FOAM RUBBER Blank $43.03 HCPCS - Non-Drugs E0272 UE MATTRESS FOAM RUBBER Blank $345.85 HCPCS - Non-Drugs E0273 Blank BED BOARD Blank $66.43 HCPCS - Non-Drugs E0273 RR BED BOARD Blank $14.58 HCPCS - Non-Drugs E0273 UE BED BOARD Blank $51.01 HCPCS - Non-Drugs E0274 Blank OVER-BED TABLE Blank $131.53 HCPCS - Non-Drugs E0274 RR OVER-BED TABLE Blank $42.60 HCPCS - Non-Drugs E0274 UE OVER-BED TABLE Blank $97.24 HCPCS - Non-Drugs E0275 Blank BED PAN STANDARD Blank $94.61 HCPCS - Non-Drugs E0275 NU BED PAN STANDARD Blank $94.61 HCPCS - Non-Drugs E0275 RR BED PAN STANDARD Blank $12.63 HCPCS - Non-Drugs E0275 UE BED PAN STANDARD Blank $87.88 HCPCS - Non-Drugs E0276 Blank BED PAN FRACTURE Blank $90.85 HCPCS - Non-Drugs E0276 NU BED PAN FRACTURE Blank $90.85 HCPCS - Non-Drugs E0276 RR BED PAN FRACTURE Blank $10.86 HCPCS - Non-Drugs E0276 UE BED PAN FRACTURE Blank $85.08 HCPCS - Non-Drugs E0277 Blank POWERED PRES-REDU AIR MATTRS Blank $4,018.25 HCPCS - Non-Drugs E0277 RR POWERED PRES-REDU AIR MATTRS Blank $508.50 HCPCS - Non-Drugs E0277 UE POWERED PRES-REDU AIR MATTRS Blank $3,054.91 HCPCS - Non-Drugs E0280 Blank BED CRADLE Blank $123.68 HCPCS - Non-Drugs E0280 NU BED CRADLE Blank $123.68 HCPCS - Non-Drugs E0280 RR BED CRADLE Blank $3.38 HCPCS - Non-Drugs E0280 UE BED CRADLE Blank $87.30 HCPCS - Non-Drugs E0290 Blank HOSP BED FX HT W/O RAILS W/M Blank $1,927.13 HCPCS - Non-Drugs E0290 RR HOSP BED FX HT W/O RAILS W/M Blank $243.87 HCPCS - Non-Drugs E0290 UE HOSP BED FX HT W/O RAILS W/M Blank $770.50 HCPCS - Non-Drugs E0291 Blank HOSP BED FX HT W/O RAIL W/O Blank $1,430.12 HCPCS - Non-Drugs E0291 RR HOSP BED FX HT W/O RAIL W/O Blank $180.98 HCPCS - Non-Drugs E0291 UE HOSP BED FX HT W/O RAIL W/O Blank $601.78 HCPCS - Non-Drugs E0292 Blank HOSP BED VAR HT NO SR W/MATT Blank $2,135.73 HCPCS - Non-Drugs E0292 RR HOSP BED VAR HT W/O RAIL W/O Blank $270.27 HCPCS - Non-Drugs E0292 UE HOSP BED VAR HT W/O RAIL W/O Blank $847.64 HCPCS - Non-Drugs E0293 Blank HOSP BED VAR HT NO SR NO MAT Blank $1,886.60 HCPCS - Non-Drugs E0293 RR HOSP BED VAR HT W/O RAIL W/ Blank $238.74 HCPCS - Non-Drugs E0293 UE HOSP BED VAR HT W/O RAIL W/ Blank $743.86 HCPCS - Non-Drugs E0294 Blank HOSP BED SEMI-ELECT W/ MATTR Blank $2,228.56 HCPCS - Non-Drugs E0294 RR HOSP BED SEMI-ELECT W/ MATTR Blank $282.02 HCPCS - Non-Drugs E0294 UE HOSP BED SEMI-ELECT W/ MATTR Blank $1,232.81 HCPCS - Non-Drugs E0295 Blank HOSP BED SEMI-ELECT W/O MATT Blank $2,198.39 HCPCS - Non-Drugs E0295 RR HOSP BED SEMI-ELECT W/O MATT Blank $278.20 HCPCS - Non-Drugs E0295 UE HOSP BED SEMI-ELECT W/O MATT Blank $1,205.62 HCPCS - Non-Drugs E0296 Blank HOSP BED TOTAL ELECT W/ MATT Blank $2,786.68 HCPCS - Non-Drugs E0296 RR HOSP BED TOTAL ELECT W/ MATT Blank $352.65 HCPCS - Non-Drugs E0296 UE HOSP BED TOTAL ELECT W/ MATT Blank $1,699.57 HCPCS - Non-Drugs E0297 Blank HOSP BED TOTAL ELECT W/O MAT Blank $2,601.69 HCPCS - Non-Drugs E0297 RR HOSP BED TOTAL ELECT W/O MAT Blank $329.24 HCPCS - Non-Drugs E0297 UE HOSP BED TOTAL ELECT W/O MAT Blank $1,315.51 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 24 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0300 Blank ENCLOSED PED CRIB HOSP GRADE Blank $4,721.41 HCPCS - Non-Drugs E0300 NU ENCLOSED PED CRIB HOSP GRADE Blank $4,721.41 HCPCS - Non-Drugs E0300 RR ENCLOSED PED CRIB HOSP GRADE Blank $597.48 HCPCS - Non-Drugs E0300 UE ENCLOSED PED CRIB HOSP GRADE Blank $2,498.21 HCPCS - Non-Drugs E0301 Blank HD HOSP BED, 350-600 LBS Blank $3,600.68 HCPCS - Non-Drugs E0301 RR HD HOSP BED, 350-600 LBS Blank $455.66 HCPCS - Non-Drugs E0302 Blank EX HD HOSP BED > 600 LBS Blank $8,179.14 HCPCS - Non-Drugs E0302 RR EX HD HOSP BED > 600 LBS Blank $1,035.05 HCPCS - Non-Drugs E0303 Blank HOSP BED HVY DTY XTRA WIDE Blank $3,579.52 HCPCS - Non-Drugs E0303 RR HOSP BED HVY DTY XTRA WIDE Blank $452.98 HCPCS - Non-Drugs E0304 Blank HOSP BED XTRA HVY DTY X WIDE Blank $8,239.52 HCPCS - Non-Drugs E0304 RR HOSP BED XTRA HVY DTY X WIDE Blank $1,042.69 HCPCS - Non-Drugs E0305 Blank RAILS BED SIDE HALF LENGTH Blank $220.47 HCPCS - Non-Drugs E0305 RR RAILS BED SIDE HALF LENGTH Blank $27.90 HCPCS - Non-Drugs E0305 UE RAILS BED SIDE HALF LENGTH Blank $300.41 HCPCS - Non-Drugs E0310 Blank RAILS BED SIDE FULL LENGTH Blank $358.02 HCPCS - Non-Drugs E0310 NU RAILS BED SIDE FULL LENGTH Blank $358.02 HCPCS - Non-Drugs E0310 RR RAILS BED SIDE FULL LENGTH Blank $29.82 HCPCS - Non-Drugs E0310 UE RAILS BED SIDE FULL LENGTH Blank $306.84 HCPCS - Non-Drugs E0315 Blank BED ACCESSORY BRD/TBL/SUPPRT Blank $149.77 HCPCS - Non-Drugs E0316 Blank BED SAFETY ENCLOSURE Blank $3,727.23 HCPCS - Non-Drugs E0316 RR BED SAFETY ENCLOSURE Blank $471.67 HCPCS - Non-Drugs E0325 Blank URINAL MALE JUG-TYPE Blank $84.99 HCPCS - Non-Drugs E0325 NU URINAL MALE JUG-TYPE Blank $84.99 HCPCS - Non-Drugs E0325 RR URINAL MALE JUG-TYPE Blank $8.11 HCPCS - Non-Drugs E0325 UE URINAL MALE JUG-TYPE Blank $63.96 HCPCS - Non-Drugs E0326 Blank URINAL FEMALE JUG-TYPE Blank $86.43 HCPCS - Non-Drugs E0326 NU URINAL FEMALE JUG-TYPE Blank $86.43 HCPCS - Non-Drugs E0326 RR URINAL FEMALE JUG-TYPE Blank $8.82 HCPCS - Non-Drugs E0326 UE URINAL FEMALE JUG-TYPE Blank $72.36 HCPCS - Non-Drugs E0328 Blank PED HOSPITAL BED, MANUAL Blank $143.36 HCPCS - Non-Drugs E0329 Blank PED HOSPITAL BED SEMI/ELECT Blank $599.44 HCPCS - Non-Drugs E0352 Blank DISPOSABLE PACK W/BOWEL SYST Blank $76.83 HCPCS - Non-Drugs E0370 Blank AIR ELEVATOR FOR HEEL Blank $90.76 HCPCS - Non-Drugs E0371 Blank NONPOWER MATTRESS OVERLAY Blank $4,602.76 HCPCS - Non-Drugs E0371 RR NONPOWER MATTRESS OVERLAY Blank $582.47 HCPCS - Non-Drugs E0372 Blank POWERED AIR MATTRESS OVERLAY Blank $4,419.99 HCPCS - Non-Drugs E0372 RR POWERED AIR MATTRESS OVERLAY Blank $559.34 HCPCS - Non-Drugs E0373 Blank NONPOWERED PRESSURE MATTRESS Blank $6,021.12 HCPCS - Non-Drugs E0373 RR NONPOWERED PRESSURE MATTRESS Blank $761.96 HCPCS - Non-Drugs E0424 Blank STATIONARY COMPRESSED GAS 02 Blank $4,524.83 HCPCS - Non-Drugs E0424 RR STATIONARY COMPRESSED GAS 02 Blank $572.61 HCPCS - Non-Drugs E0425 Blank GAS SYSTEM STATIONARY COMPRE Blank $17,089.31 HCPCS - Non-Drugs E0425 NU GAS SYSTEM STATIONARY COMPRE Blank $20,738.53 HCPCS - Non-Drugs E0430 Blank OXYGEN SYSTEM GAS PORTABLE Blank $7,712.74 HCPCS - Non-Drugs E0430 NU OXYGEN SYSTEM GAS PORTABLE Blank $9,340.07 HCPCS - Non-Drugs E0430 UE OXYGEN SYSTEM GAS PORTABLE Blank $6,981.15 HCPCS - Non-Drugs E0431 Blank PORTABLE GASEOUS 02 Blank $432.04 HCPCS - Non-Drugs E0431 RR PORTABLE GASEOUS 02 Blank $54.67 HCPCS - Non-Drugs E0433 Blank PORTABLE LIQUID OXYGEN SYS Blank $1,821.40 HCPCS - Non-Drugs E0433 RR PORTABLE LIQUID OXYGEN SYS Blank $230.49 HCPCS - Non-Drugs E0434 Blank PORTABLE LIQUID 02 Blank $432.04 HCPCS - Non-Drugs E0434 RR PORTABLE LIQUID 02 Blank $54.67 HCPCS - Non-Drugs E0435 Blank OXYGEN SYSTEM LIQUID PORTABL Blank $5,287.65 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 25 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0435 NU OXYGEN SYSTEM LIQUID PORTABL Blank $6,392.06 HCPCS - Non-Drugs E0435 UE OXYGEN SYSTEM LIQUID PORTABL Blank $4,772.05 HCPCS - Non-Drugs E0439 Blank STATIONARY LIQUID 02 Blank $4,524.83 HCPCS - Non-Drugs E0439 RR STATIONARY LIQUID 02 Blank $572.61 HCPCS - Non-Drugs E0440 Blank OXYGEN SYSTEM LIQUID STATION Blank $10,785.35 HCPCS - Non-Drugs E0440 NU OXYGEN SYSTEM LIQUID STATION Blank $13,075.23 HCPCS - Non-Drugs E0440 UE OXYGEN SYSTEM LIQUID STATION Blank $9,781.89 HCPCS - Non-Drugs E0441 Blank STATIONARY O2 CONTENTS, GAS Blank $357.49 HCPCS - Non-Drugs E0442 Blank STATIONARY O2 CONTENTS, LIQ Blank $357.49 HCPCS - Non-Drugs E0443 Blank PORTABLE 02 CONTENTS, GAS Blank $312.76 HCPCS - Non-Drugs E0444 Blank PORTABLE 02 CONTENTS, LIQUID Blank $312.76 HCPCS - Non-Drugs E0445 Blank OXIMETER NON-INVASIVE Blank $265.73 HCPCS - Non-Drugs E0446 Blank TOPICAL OX DELIVER SYS, NOS Blank $312.76 HCPCS - Non-Drugs E0455 Blank OXYGEN TENT EXCL CROUP/PED T Blank $27.28 HCPCS - Non-Drugs E0457 Blank CHEST SHELL Blank $1,110.09 HCPCS - Non-Drugs E0457 NU CHEST SHELL Blank $825.55 HCPCS - Non-Drugs E0457 RR CHEST SHELL Blank $143.19 HCPCS - Non-Drugs E0457 UE CHEST SHELL Blank $635.95 HCPCS - Non-Drugs E0459 Blank CHEST WRAP Blank $917.87 HCPCS - Non-Drugs E0459 NU CHEST WRAP Blank $695.40 HCPCS - Non-Drugs E0459 RR CHEST WRAP Blank $130.33 HCPCS - Non-Drugs E0459 UE CHEST WRAP Blank $538.47 HCPCS - Non-Drugs E0462 Blank ROCKING BED W/ OR W/O SIDE R Blank $5,777.74 HCPCS - Non-Drugs E0462 NU ROCKING BED W/ OR W/O SIDE R Blank $5,777.74 HCPCS - Non-Drugs E0462 RR ROCKING BED W/ OR W/O SIDE R Blank $731.16 HCPCS - Non-Drugs E0462 UE ROCKING BED W/ OR W/O SIDE R Blank $3,336.81 HCPCS - Non-Drugs E0465 Blank HOME VENT INVASIVE INTERFACE Blank $16,196.61 HCPCS - Non-Drugs E0465 RR HOME VENT INVASIVE INTERFACE Blank $2,049.64 HCPCS - Non-Drugs E0466 Blank HOME VENT NON-INVASIVE INTER Blank $16,196.61 HCPCS - Non-Drugs E0466 RR HOME VENT NON-INVASIVE INTER Blank $2,049.64 HCPCS - Non-Drugs E0470 Blank RAD W/O BACKUP NON-INV INTFC Blank $2,195.55 HCPCS - Non-Drugs E0470 RR RAD W/O BACKUP NON-INV INTFC Blank $277.84 HCPCS - Non-Drugs E0471 Blank RAD W/BACKUP NON INV INTRFC Blank $4,662.24 HCPCS - Non-Drugs E0471 RR RAD W/BACKUP NON INV INTRFC Blank $589.99 HCPCS - Non-Drugs E0472 Blank RAD W BACKUP INVASIVE INTRFC Blank $6,735.42 HCPCS - Non-Drugs E0472 RR RAD W BACKUP INVASIVE INTRFC Blank $852.35 HCPCS - Non-Drugs E0480 Blank PERCUSSOR ELECT/PNEUM HOME M Blank $1,242.59 HCPCS - Non-Drugs E0480 NU PERCUSSOR ELECT/PNEUM HOME M Blank $1,242.59 HCPCS - Non-Drugs E0480 RR PERCUSSOR ELECT/PNEUM HOME M Blank $157.25 HCPCS - Non-Drugs E0480 UE PERCUSSOR ELECT/PNEUM HOME M Blank $530.97 HCPCS - Non-Drugs E0481 Blank INTRPULMNRY PERCUSS VENT SYS Blank $617.30 HCPCS - Non-Drugs E0482 Blank COUGH STIMULATING DEVICE Blank $7,680.80 HCPCS - Non-Drugs E0482 RR COUGH STIMULATING DEVICE Blank $971.98 HCPCS - Non-Drugs E0483 Blank CHEST COMPRESSION GEN SYSTEM Blank $18,719.39 HCPCS - Non-Drugs E0483 RR CHEST COMPRESSION GEN SYSTEM Blank $2,368.89 HCPCS - Non-Drugs E0484 Blank NON-ELEC OSCILLATORY PEP DVC Blank $147.61 HCPCS - Non-Drugs E0484 NU NON-ELEC OSCILLATORY PEP DVC Blank $147.61 HCPCS - Non-Drugs E0484 RR NON-ELEC OSCILLATORY PEP DVC Blank $37.26 HCPCS - Non-Drugs E0484 UE NON-ELEC OSCILLATORY PEP DVC Blank $127.64 HCPCS - Non-Drugs E0485 Blank ORAL DEVICE/APPLIANCE PREFAB Blank $1,058.62 HCPCS - Non-Drugs E0485 NU ORAL DEVICE/APPLIANCE PREFAB Blank $1,058.62 HCPCS - Non-Drugs E0485 RR ORAL DEVICE/APPLIANCE PREFAB Blank $116.53 HCPCS - Non-Drugs E0485 UE ORAL DEVICE/APPLIANCE PREFAB Blank $797.21 HCPCS - Non-Drugs E0486 Blank ORAL DEVICE/APPLIANCE CUSFAB Blank $4,398.43 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 26 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0486 NU ORAL DEVICE/APPLIANCE CUSFAB Blank $4,398.43 HCPCS - Non-Drugs E0486 RR ORAL DEVICE/APPLIANCE CUSFAB Blank $393.44 HCPCS - Non-Drugs E0486 UE ORAL DEVICE/APPLIANCE CUSFAB Blank $2,707.29 HCPCS - Non-Drugs E0487 Blank ELECTRONIC SPIROMETER Blank $310.16 HCPCS - Non-Drugs E0500 Blank IPPB ALL TYPES Blank $2,348.01 HCPCS - Non-Drugs E0500 NU IPPB ALL TYPES Blank $2,348.01 HCPCS - Non-Drugs E0500 RR IPPB ALL TYPES Blank $297.13 HCPCS - Non-Drugs E0500 UE IPPB ALL TYPES Blank $1,224.58 HCPCS - Non-Drugs E0550 Blank HUMIDIF EXTENS SUPPLE W IPPB Blank $1,355.32 HCPCS - Non-Drugs E0550 NU HUMIDIF EXTENS SUPPLE W IPPB Blank $1,355.32 HCPCS - Non-Drugs E0550 RR HUMIDIF EXTENS SUPPLE W IPPB Blank $171.51 HCPCS - Non-Drugs E0550 UE HUMIDIF EXTENS SUPPLE W IPPB Blank $596.31 HCPCS - Non-Drugs E0555 Blank HUMIDIFIER FOR USE W/ REGULA Blank $6.66 HCPCS - Non-Drugs E0555 NU HUMIDIFIER FOR USE W/ REGULA Blank $6.29 HCPCS - Non-Drugs E0555 RR HUMIDIFIER FOR USE W/ REGULA Blank $0.64 HCPCS - Non-Drugs E0555 UE HUMIDIFIER FOR USE W/ REGULA Blank $5.80 HCPCS - Non-Drugs E0560 Blank HUMIDIFIER SUPPLEMENTAL W/ I Blank $365.02 HCPCS - Non-Drugs E0560 NU HUMIDIFIER SUPPLEMENTAL W/ I Blank $365.02 HCPCS - Non-Drugs E0560 RR HUMIDIFIER SUPPLEMENTAL W/ I Blank $103.37 HCPCS - Non-Drugs E0560 UE HUMIDIFIER SUPPLEMENTAL W/ I Blank $290.69 HCPCS - Non-Drugs E0561 Blank HUMIDIFIER NONHEATED W PAP Blank $208.66 HCPCS - Non-Drugs E0561 NU HUMIDIFIER NONHEATED W PAP Blank $208.66 HCPCS - Non-Drugs E0561 RR HUMIDIFIER NONHEATED W PAP Blank $72.51 HCPCS - Non-Drugs E0561 UE HUMIDIFIER NONHEATED W PAP Blank $173.41 HCPCS - Non-Drugs E0562 Blank HUMIDIFIER HEATED USED W PAP Blank $336.82 HCPCS - Non-Drugs E0562 NU HUMIDIFIER HEATED USED W PAP Blank $336.82 HCPCS - Non-Drugs E0562 RR HUMIDIFIER HEATED USED W PAP Blank $94.58 HCPCS - Non-Drugs E0562 UE HUMIDIFIER HEATED USED W PAP Blank $269.53 HCPCS - Non-Drugs E0565 Blank COMPRESSOR AIR POWER SOURCE Blank $1,180.94 HCPCS - Non-Drugs E0565 NU COMPRESSOR AIR POWER SOURCE Blank $1,180.94 HCPCS - Non-Drugs E0565 RR COMPRESSOR AIR POWER SOURCE Blank $149.45 HCPCS - Non-Drugs E0565 UE COMPRESSOR AIR POWER SOURCE Blank $632.20 HCPCS - Non-Drugs E0570 Blank NEBULIZER WITH COMPRESSION Blank $441.61 HCPCS - Non-Drugs E0570 NU NEBULIZER WITH COMPRESSION Blank $441.61 HCPCS - Non-Drugs E0570 RR NEBULIZER WITH COMPRESSION Blank $55.88 HCPCS - Non-Drugs E0570 UE NEBULIZER WITH COMPRESSION Blank $335.74 HCPCS - Non-Drugs E0572 Blank AEROSOL COMPRESSOR ADJUST PR Blank $1,153.75 HCPCS - Non-Drugs E0572 RR AEROSOL COMPRESSOR ADJUST PR Blank $146.00 HCPCS - Non-Drugs E0574 Blank ULTRASONIC GENERATOR W SVNEB Blank $1,449.72 HCPCS - Non-Drugs E0574 RR ULTRASONIC GENERATOR W SVNEB Blank $183.46 HCPCS - Non-Drugs E0575 Blank NEBULIZER ULTRASONIC Blank $2,225.45 HCPCS - Non-Drugs E0575 NU NEBULIZER ULTRASONIC Blank $2,225.45 HCPCS - Non-Drugs E0575 RR NEBULIZER ULTRASONIC Blank $281.62 HCPCS - Non-Drugs E0575 UE NEBULIZER ULTRASONIC Blank $1,151.20 HCPCS - Non-Drugs E0580 Blank NEBULIZER FOR USE W/ REGULAT Blank $316.66 HCPCS - Non-Drugs E0580 NU NEBULIZER FOR USE W/ REGULAT Blank $316.66 HCPCS - Non-Drugs E0580 RR NEBULIZER FOR USE W/ REGULAT Blank $92.57 HCPCS - Non-Drugs E0580 UE NEBULIZER FOR USE W/ REGULAT Blank $254.40 HCPCS - Non-Drugs E0585 Blank NEBULIZER W/ COMPRESSOR & HE Blank $969.65 HCPCS - Non-Drugs E0585 NU NEBULIZER W/ COMPRESSOR & HE Blank $969.65 HCPCS - Non-Drugs E0585 RR NEBULIZER W/ COMPRESSOR & HE Blank $122.71 HCPCS - Non-Drugs E0585 UE NEBULIZER W/ COMPRESSOR & HE Blank $392.24 HCPCS - Non-Drugs E0600 Blank SUCTION PUMP PORTAB HOM MODL Blank $1,281.88 HCPCS - Non-Drugs E0600 NU SUCTION PUMP PORTAB HOM MODL Blank $1,281.88 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 27 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0600 RR SUCTION PUMP PORTAB HOM MODL Blank $162.22 HCPCS - Non-Drugs E0600 UE SUCTION PUMP PORTAB HOM MODL Blank $550.25 HCPCS - Non-Drugs E0601 Blank CONT AIRWAY PRESSURE DEVICE Blank $1,172.54 HCPCS - Non-Drugs E0601 NU CONT AIRWAY PRESSURE DEVICE Blank $1,172.54 HCPCS - Non-Drugs E0601 RR CONT AIRWAY PRESSURE DEVICE Blank $148.38 HCPCS - Non-Drugs E0601 UE CONT AIRWAY PRESSURE DEVICE Blank $958.38 HCPCS - Non-Drugs E0602 Blank MANUAL BREAST PUMP Blank $131.56 HCPCS - Non-Drugs E0602 NU MANUAL BREAST PUMP Blank $131.56 HCPCS - Non-Drugs E0602 RR MANUAL BREAST PUMP Blank $30.02 HCPCS - Non-Drugs E0602 UE MANUAL BREAST PUMP Blank $115.60 HCPCS - Non-Drugs E0603 Blank ELECTRIC BREAST PUMP Blank $171.57 HCPCS - Non-Drugs E0603 NU ELECTRIC BREAST PUMP Blank $171.57 HCPCS - Non-Drugs E0603 RR ELECTRIC BREAST PUMP Blank $102.48 HCPCS - Non-Drugs E0603 UE ELECTRIC BREAST PUMP Blank $150.69 HCPCS - Non-Drugs E0604 Blank HOSP GRADE ELEC BREAST PUMP Blank $431.41 HCPCS - Non-Drugs E0604 NU HOSP GRADE ELEC BREAST PUMP Blank $366.00 HCPCS - Non-Drugs E0604 RR HOSP GRADE ELEC BREAST PUMP Blank $182.29 HCPCS - Non-Drugs E0604 UE HOSP GRADE ELEC BREAST PUMP Blank $291.55 HCPCS - Non-Drugs E0605 Blank VAPORIZER ROOM TYPE Blank $123.83 HCPCS - Non-Drugs E0605 NU VAPORIZER ROOM TYPE Blank $123.83 HCPCS - Non-Drugs E0605 RR VAPORIZER ROOM TYPE Blank $32.19 HCPCS - Non-Drugs E0605 UE VAPORIZER ROOM TYPE Blank $112.77 HCPCS - Non-Drugs E0606 Blank DRAINAGE BOARD POSTURAL Blank $902.19 HCPCS - Non-Drugs E0606 NU DRAINAGE BOARD POSTURAL Blank $902.19 HCPCS - Non-Drugs E0606 RR DRAINAGE BOARD POSTURAL Blank $114.17 HCPCS - Non-Drugs E0606 UE DRAINAGE BOARD POSTURAL Blank $309.76 HCPCS - Non-Drugs E0607 Blank BLOOD GLUCOSE MONITOR HOME Blank $212.31 HCPCS - Non-Drugs E0607 NU BLOOD GLUCOSE MONITOR HOME Blank $212.31 HCPCS - Non-Drugs E0607 RR BLOOD GLUCOSE MONITOR HOME Blank $74.70 HCPCS - Non-Drugs E0607 UE BLOOD GLUCOSE MONITOR HOME Blank $176.14 HCPCS - Non-Drugs E0610 Blank PACEMAKER MONITR AUDIBLE/VIS Blank $574.66 HCPCS - Non-Drugs E0610 NU PACEMAKER MONITR AUDIBLE/VIS Blank $574.66 HCPCS - Non-Drugs E0610 RR PACEMAKER MONITR AUDIBLE/VIS Blank $121.22 HCPCS - Non-Drugs E0610 UE PACEMAKER MONITR AUDIBLE/VIS Blank $447.82 HCPCS - Non-Drugs E0615 Blank PACEMAKER MONITR DIGITAL/VIS Blank $1,054.19 HCPCS - Non-Drugs E0615 NU PACEMAKER MONITR DIGITAL/VIS Blank $1,054.19 HCPCS - Non-Drugs E0615 RR PACEMAKER MONITR DIGITAL/VIS Blank $186.72 HCPCS - Non-Drugs E0615 UE PACEMAKER MONITR DIGITAL/VIS Blank $806.17 HCPCS - Non-Drugs E0616 Blank CARDIAC EVENT RECORDER Blank $6,587.84 HCPCS - Non-Drugs E0617 Blank AUTOMATIC EXT DEFIBRILLATOR Blank $5,735.29 HCPCS - Non-Drugs E0617 RR AUTOMATIC EXT DEFIBRILLATOR Blank $725.79 HCPCS - Non-Drugs E0618 Blank APNEA MONITOR Blank $5,048.50 HCPCS - Non-Drugs E0618 RR APNEA MONITOR Blank $638.87 HCPCS - Non-Drugs E0619 Blank APNEA MONITOR W RECORDER Blank $5,048.50 HCPCS - Non-Drugs E0619 RR APNEA MONITOR W RECORDER Blank $638.87 HCPCS - Non-Drugs E0620 Blank CAP BLD SKIN PIERCING LASER Blank $2,030.12 HCPCS - Non-Drugs E0620 NU CAP BLD SKIN PIERCING LASER Blank $2,030.12 HCPCS - Non-Drugs E0620 RR CAP BLD SKIN PIERCING LASER Blank $256.91 HCPCS - Non-Drugs E0620 UE CAP BLD SKIN PIERCING LASER Blank $989.45 HCPCS - Non-Drugs E0621 Blank PATIENT LIFT SLING OR SEAT Blank $227.55 HCPCS - Non-Drugs E0621 NU PATIENT LIFT SLING OR SEAT Blank $227.55 HCPCS - Non-Drugs E0621 RR PATIENT LIFT SLING OR SEAT Blank $83.63 HCPCS - Non-Drugs E0621 UE PATIENT LIFT SLING OR SEAT Blank $187.58 HCPCS - Non-Drugs E0625 Blank PATIENT LIFT BATHROOM OR TOI Blank $1,363.68 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 28 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0625 NU PATIENT LIFT BATHROOM OR TOI Blank $1,363.68 HCPCS - Non-Drugs E0625 RR PATIENT LIFT BATHROOM OR TOI Blank $172.57 HCPCS - Non-Drugs E0625 UE PATIENT LIFT BATHROOM OR TOI Blank $1,036.75 HCPCS - Non-Drugs E0627 Blank SEAT LIFT MECH, ELECTRIC ANY Blank $563.06 HCPCS - Non-Drugs E0627 NU SEAT LIFT INCORP LIFT-CHAIR Blank $563.06 HCPCS - Non-Drugs E0627 RR SEAT LIFT INCORP LIFT-CHAIR Blank $117.20 HCPCS - Non-Drugs E0627 UE SEAT LIFT INCORP LIFT-CHAIR Blank $439.21 HCPCS - Non-Drugs E0628 Blank SEAT LIFT FOR PT FURN-ELECTR Blank $605.66 HCPCS - Non-Drugs E0628 NU SEAT LIFT FOR PT FURN-ELECTR Blank $605.66 HCPCS - Non-Drugs E0628 RR SEAT LIFT FOR PT FURN-ELECTR Blank $121.47 HCPCS - Non-Drugs E0628 UE SEAT LIFT FOR PT FURN-ELECTR Blank $471.16 HCPCS - Non-Drugs E0629 Blank SEAT LIFT MECH, NON-ELECTRIC Blank $605.53 HCPCS - Non-Drugs E0629 NU SEAT LIFT FOR PT FURN-NON-EL Blank $605.53 HCPCS - Non-Drugs E0629 RR SEAT LIFT FOR PT FURN-NON-EL Blank $121.45 HCPCS - Non-Drugs E0629 UE SEAT LIFT FOR PT FURN-NON-EL Blank $471.07 HCPCS - Non-Drugs E0630 Blank PATIENT LIFT HYDRAULIC Blank $1,432.14 HCPCS - Non-Drugs E0630 NU PATIENT LIFT HYDRAULIC Blank $1,432.14 HCPCS - Non-Drugs E0630 RR PATIENT LIFT HYDRAULIC Blank $181.23 HCPCS - Non-Drugs E0630 UE PATIENT LIFT HYDRAULIC Blank $1,010.34 HCPCS - Non-Drugs E0635 Blank PATIENT LIFT ELECTRIC Blank $2,319.55 HCPCS - Non-Drugs E0635 NU PATIENT LIFT ELECTRIC Blank $2,319.55 HCPCS - Non-Drugs E0635 RR PATIENT LIFT ELECTRIC Blank $293.53 HCPCS - Non-Drugs E0635 UE PATIENT LIFT ELECTRIC Blank $1,199.41 HCPCS - Non-Drugs E0636 Blank PT SUPPORT & POSITIONING SYS Blank $15,469.59 HCPCS - Non-Drugs E0636 RR PT SUPPORT & POSITIONING SYS Blank $1,957.64 HCPCS - Non-Drugs E0637 Blank COMBINATION SIT TO STAND SYS Blank $1,949.26 HCPCS - Non-Drugs E0638 Blank STANDING FRAME SYS Blank $1,559.56 HCPCS - Non-Drugs E0639 Blank MOVEABLE PATIENT LIFT SYSTEM Blank $2,356.86 HCPCS - Non-Drugs E0639 RR MOVEABLE PATIENT LIFT SYSTEM Blank $298.25 HCPCS - Non-Drugs E0640 Blank FIXED PATIENT LIFT SYSTEM Blank $2,356.86 HCPCS - Non-Drugs E0640 RR FIXED PATIENT LIFT SYSTEM Blank $298.25 HCPCS - Non-Drugs E0641 Blank MULTI-POSITION STND FRAM SYS Blank $1,197.90 HCPCS - Non-Drugs E0642 Blank DYNAMIC STANDING FRAME Blank $2,460.38 HCPCS - Non-Drugs E0650 Blank PNEUMA COMPRESOR NON-SEGMENT Blank $1,549.49 HCPCS - Non-Drugs E0650 NU PNEUMA COMPRESOR NON-SEGMENT Blank $1,549.49 HCPCS - Non-Drugs E0650 RR PNEUMA COMPRESOR NON-SEGMENT Blank $250.69 HCPCS - Non-Drugs E0650 UE PNEUMA COMPRESOR NON-SEGMENT Blank $1,162.12 HCPCS - Non-Drugs E0651 Blank PNEUM COMPRESSOR SEGMENTAL Blank $1,942.88 HCPCS - Non-Drugs E0651 NU PNEUM COMPRESSOR SEGMENTAL Blank $1,942.88 HCPCS - Non-Drugs E0651 RR PNEUM COMPRESSOR SEGMENTAL Blank $261.63 HCPCS - Non-Drugs E0651 UE PNEUM COMPRESSOR SEGMENTAL Blank $1,474.11 HCPCS - Non-Drugs E0652 Blank PNEUM COMPRES W/CAL PRESSURE Blank $11,227.80 HCPCS - Non-Drugs E0652 NU PNEUM COMPRES W/CAL PRESSURE Blank $11,227.80 HCPCS - Non-Drugs E0652 RR PNEUM COMPRES W/CAL PRESSURE Blank $1,162.24 HCPCS - Non-Drugs E0652 UE PNEUM COMPRES W/CAL PRESSURE Blank $8,350.78 HCPCS - Non-Drugs E0655 Blank PNEUMATIC APPLIANCE HALF ARM Blank $290.39 HCPCS - Non-Drugs E0655 NU PNEUMATIC APPLIANCE HALF ARM Blank $290.39 HCPCS - Non-Drugs E0655 RR PNEUMATIC APPLIANCE HALF ARM Blank $92.76 HCPCS - Non-Drugs E0655 UE PNEUMATIC APPLIANCE HALF ARM Blank $235.67 HCPCS - Non-Drugs E0656 Blank SEGMENTAL PNEUMATIC TRUNK Blank $1,523.08 HCPCS - Non-Drugs E0656 NU SEGMENTAL PNEUMATIC TRUNK Blank $1,523.08 HCPCS - Non-Drugs E0656 RR SEGMENTAL PNEUMATIC TRUNK Blank $192.74 HCPCS - Non-Drugs E0656 UE SEGMENTAL PNEUMATIC TRUNK Blank $676.65 HCPCS - Non-Drugs E0657 Blank SEGMENTAL PNEUMATIC CHEST Blank $1,463.20 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 29 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0657 NU SEGMENTAL PNEUMATIC CHEST Blank $1,463.20 HCPCS - Non-Drugs E0657 RR SEGMENTAL PNEUMATIC CHEST Blank $185.16 HCPCS - Non-Drugs E0657 UE SEGMENTAL PNEUMATIC CHEST Blank $640.23 HCPCS - Non-Drugs E0660 Blank PNEUMATIC APPLIANCE FULL LEG Blank $394.51 HCPCS - Non-Drugs E0660 NU PNEUMATIC APPLIANCE FULL LEG Blank $394.51 HCPCS - Non-Drugs E0660 RR PNEUMATIC APPLIANCE FULL LEG Blank $101.53 HCPCS - Non-Drugs E0660 UE PNEUMATIC APPLIANCE FULL LEG Blank $312.30 HCPCS - Non-Drugs E0665 Blank PNEUMATIC APPLIANCE FULL ARM Blank $346.79 HCPCS - Non-Drugs E0665 NU PNEUMATIC APPLIANCE FULL ARM Blank $346.79 HCPCS - Non-Drugs E0665 RR PNEUMATIC APPLIANCE FULL ARM Blank $96.54 HCPCS - Non-Drugs E0665 UE PNEUMATIC APPLIANCE FULL ARM Blank $275.62 HCPCS - Non-Drugs E0666 Blank PNEUMATIC APPLIANCE HALF LEG Blank $350.17 HCPCS - Non-Drugs E0666 NU PNEUMATIC APPLIANCE HALF LEG Blank $350.17 HCPCS - Non-Drugs E0666 RR PNEUMATIC APPLIANCE HALF LEG Blank $96.89 HCPCS - Non-Drugs E0666 UE PNEUMATIC APPLIANCE HALF LEG Blank $280.01 HCPCS - Non-Drugs E0667 Blank SEG PNEUMATIC APPL FULL LEG Blank $756.58 HCPCS - Non-Drugs E0667 NU SEG PNEUMATIC APPL FULL LEG Blank $756.58 HCPCS - Non-Drugs E0667 RR SEG PNEUMATIC APPL FULL LEG Blank $144.41 HCPCS - Non-Drugs E0667 UE SEG PNEUMATIC APPL FULL LEG Blank $584.35 HCPCS - Non-Drugs E0668 Blank SEG PNEUMATIC APPL FULL ARM Blank $969.53 HCPCS - Non-Drugs E0668 NU SEG PNEUMATIC APPL FULL ARM Blank $969.53 HCPCS - Non-Drugs E0668 RR SEG PNEUMATIC APPL FULL ARM Blank $156.81 HCPCS - Non-Drugs E0668 UE SEG PNEUMATIC APPL FULL ARM Blank $744.87 HCPCS - Non-Drugs E0669 Blank SEG PNEUMATIC APPLI HALF LEG Blank $456.06 HCPCS - Non-Drugs E0669 NU SEG PNEUMATIC APPLI HALF LEG Blank $456.06 HCPCS - Non-Drugs E0669 RR SEG PNEUMATIC APPLI HALF LEG Blank $106.52 HCPCS - Non-Drugs E0669 UE SEG PNEUMATIC APPLI HALF LEG Blank $358.99 HCPCS - Non-Drugs E0670 Blank SEG PNEUM INT LEGS/TRUNK Blank $2,723.25 HCPCS - Non-Drugs E0670 NU SEG PNEUM INT LEGS/TRUNK Blank $2,723.25 HCPCS - Non-Drugs E0670 RR SEG PNEUM INT LEGS/TRUNK Blank $350.24 HCPCS - Non-Drugs E0670 UE SEG PNEUM INT LEGS/TRUNK Blank $2,059.30 HCPCS - Non-Drugs E0671 Blank PRESSURE PNEUM APPL FULL LEG Blank $967.07 HCPCS - Non-Drugs E0671 NU PRESSURE PNEUM APPL FULL LEG Blank $967.07 HCPCS - Non-Drugs E0671 RR PRESSURE PNEUM APPL FULL LEG Blank $157.65 HCPCS - Non-Drugs E0671 UE PRESSURE PNEUM APPL FULL LEG Blank $742.19 HCPCS - Non-Drugs E0672 Blank PRESSURE PNEUM APPL FULL ARM Blank $766.48 HCPCS - Non-Drugs E0672 NU PRESSURE PNEUM APPL FULL ARM Blank $766.48 HCPCS - Non-Drugs E0672 RR PRESSURE PNEUM APPL FULL ARM Blank $137.57 HCPCS - Non-Drugs E0672 UE PRESSURE PNEUM APPL FULL ARM Blank $591.82 HCPCS - Non-Drugs E0673 Blank PRESSURE PNEUM APPL HALF LEG Blank $648.35 HCPCS - Non-Drugs E0673 NU PRESSURE PNEUM APPL HALF LEG Blank $648.35 HCPCS - Non-Drugs E0673 RR PRESSURE PNEUM APPL HALF LEG Blank $125.74 HCPCS - Non-Drugs E0673 UE PRESSURE PNEUM APPL HALF LEG Blank $503.24 HCPCS - Non-Drugs E0675 Blank PNEUMATIC COMPRESSION DEVICE Blank $7,096.69 HCPCS - Non-Drugs E0675 RR PNEUMATIC COMPRESSION DEVICE Blank $898.07 HCPCS - Non-Drugs E0676 Blank INTER LIMB COMPRESS DEV NOS Blank $186.10 HCPCS - Non-Drugs E0691 Blank UVL PNL 2 SQ FT OR LESS Blank $2,012.73 HCPCS - Non-Drugs E0691 NU UVL PNL 2 SQ FT OR LESS Blank $2,012.73 HCPCS - Non-Drugs E0691 RR UVL PNL 2 SQ FT OR LESS Blank $262.15 HCPCS - Non-Drugs E0691 UE UVL PNL 2 SQ FT OR LESS Blank $1,526.47 HCPCS - Non-Drugs E0692 Blank UVL SYS PANEL 4 FT Blank $2,510.14 HCPCS - Non-Drugs E0692 NU UVL SYS PANEL 4 FT Blank $2,510.14 HCPCS - Non-Drugs E0692 RR UVL SYS PANEL 4 FT Blank $311.84 HCPCS - Non-Drugs E0692 UE UVL SYS PANEL 4 FT Blank $1,899.50 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 30 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0693 Blank UVL SYS PANEL 6 FT Blank $3,078.54 HCPCS - Non-Drugs E0693 NU UVL SYS PANEL 6 FT Blank $3,078.54 HCPCS - Non-Drugs E0693 RR UVL SYS PANEL 6 FT Blank $368.77 HCPCS - Non-Drugs E0693 UE UVL SYS PANEL 6 FT Blank $2,325.81 HCPCS - Non-Drugs E0694 Blank UVL MD CABINET SYS 6 FT Blank $9,650.96 HCPCS - Non-Drugs E0694 NU UVL MD CABINET SYS 6 FT Blank $9,650.96 HCPCS - Non-Drugs E0694 RR UVL MD CABINET SYS 6 FT Blank $1,025.98 HCPCS - Non-Drugs E0694 UE UVL MD CABINET SYS 6 FT Blank $7,255.19 HCPCS - Non-Drugs E0700 Blank SAFETY EQUIPMENT Blank $54.51 HCPCS - Non-Drugs E0705 Blank TRANSFER DEVICE Blank $156.13 HCPCS - Non-Drugs E0705 NU TRANSFER DEVICE Blank $156.13 HCPCS - Non-Drugs E0705 RR TRANSFER DEVICE Blank $41.39 HCPCS - Non-Drugs E0705 UE TRANSFER DEVICE Blank $134.01 HCPCS - Non-Drugs E0710 Blank RESTRAINTS ANY TYPE Blank $97.42 HCPCS - Non-Drugs E0720 Blank TENS TWO LEAD Blank $222.51 HCPCS - Non-Drugs E0720 NU TENS TWO LEAD Blank $222.51 HCPCS - Non-Drugs E0720 RR TENS TWO LEAD Blank $113.19 HCPCS - Non-Drugs E0720 UE TENS TWO LEAD Blank $407.78 HCPCS - Non-Drugs E0730 Blank TENS FOUR LEAD Blank $209.58 HCPCS - Non-Drugs E0730 NU TENS FOUR LEAD Blank $209.58 HCPCS - Non-Drugs E0730 RR TENS FOUR LEAD Blank $113.19 HCPCS - Non-Drugs E0730 UE TENS FOUR LEAD Blank $410.46 HCPCS - Non-Drugs E0731 Blank CONDUCTIVE GARMENT FOR TENS/ Blank $246.57 HCPCS - Non-Drugs E0731 NU CONDUCTIVE GARMENT FOR TENS/ Blank $246.57 HCPCS - Non-Drugs E0731 RR CONDUCTIVE GARMENT FOR TENS/ Blank $31.20 HCPCS - Non-Drugs E0740 Blank NON-IMPLANT PELV FLR E-STIM Blank $1,429.32 HCPCS - Non-Drugs E0740 NU INCONTINENCE TREATMENT SYSTM Blank $1,429.32 HCPCS - Non-Drugs E0740 RR INCONTINENCE TREATMENT SYSTM Blank $180.88 HCPCS - Non-Drugs E0740 UE INCONTINENCE TREATMENT SYSTM Blank $619.34 HCPCS - Non-Drugs E0744 Blank NEUROMUSCULAR STIM FOR SCOLI Blank $2,014.30 HCPCS - Non-Drugs E0744 NU NEUROMUSCULAR STIM FOR SCOLI Blank $2,014.30 HCPCS - Non-Drugs E0744 RR NEUROMUSCULAR STIM FOR SCOLI Blank $254.90 HCPCS - Non-Drugs E0744 UE NEUROMUSCULAR STIM FOR SCOLI Blank $1,033.37 HCPCS - Non-Drugs E0745 Blank NEUROMUSCULAR STIM FOR SHOCK Blank $1,986.30 HCPCS - Non-Drugs E0745 NU NEUROMUSCULAR STIM FOR SHOCK Blank $1,986.30 HCPCS - Non-Drugs E0745 RR NEUROMUSCULAR STIM FOR SHOCK Blank $251.36 HCPCS - Non-Drugs E0745 UE NEUROMUSCULAR STIM FOR SHOCK Blank $1,011.41 HCPCS - Non-Drugs E0746 Blank ELECTROMYOGRAPH BIOFEEDBACK Blank $235.56 HCPCS - Non-Drugs E0746 NU ELECTROMYOGRAPH BIOFEEDBACK Blank $235.56 HCPCS - Non-Drugs E0746 RR ELECTROMYOGRAPH BIOFEEDBACK Blank $25.78 HCPCS - Non-Drugs E0746 UE ELECTROMYOGRAPH BIOFEEDBACK Blank $177.38 HCPCS - Non-Drugs E0747 Blank ELEC OSTEOGEN STIM NOT SPINE Blank $8,126.92 HCPCS - Non-Drugs E0747 NU ELEC OSTEOGEN STIM NOT SPINE Blank $8,126.92 HCPCS - Non-Drugs E0747 RR ELEC OSTEOGEN STIM NOT SPINE Blank $875.99 HCPCS - Non-Drugs E0747 UE ELEC OSTEOGEN STIM NOT SPINE Blank $6,014.01 HCPCS - Non-Drugs E0748 Blank ELEC OSTEOGEN STIM SPINAL Blank $8,492.50 HCPCS - Non-Drugs E0748 NU ELEC OSTEOGEN STIM SPINAL Blank $8,492.50 HCPCS - Non-Drugs E0748 RR ELEC OSTEOGEN STIM SPINAL Blank $910.11 HCPCS - Non-Drugs E0748 UE ELEC OSTEOGEN STIM SPINAL Blank $6,386.30 HCPCS - Non-Drugs E0749 Blank ELEC OSTEOGEN STIM IMPLANTED Blank $5,135.79 HCPCS - Non-Drugs E0749 RR ELEC OSTEOGEN STIM IMPLANTED Blank $649.92 HCPCS - Non-Drugs E0760 Blank OSTEOGEN ULTRASOUND STIMLTOR Blank $7,065.97 HCPCS - Non-Drugs E0760 NU OSTEOGEN ULTRASOUND STIMLTOR Blank $7,065.97 HCPCS - Non-Drugs E0760 RR OSTEOGEN ULTRASOUND STIMLTOR Blank $767.51 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 31 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0760 UE OSTEOGEN ULTRASOUND STIMLTOR Blank $5,316.35 HCPCS - Non-Drugs E0761 Blank NONTHERM ELECTROMGNTC DEVICE Blank $2,029.13 HCPCS - Non-Drugs E0762 Blank TRANS ELEC JT STIM DEV SYS Blank $2,289.26 HCPCS - Non-Drugs E0762 NU TRANS ELEC JT STIM DEV SYS Blank $2,289.26 HCPCS - Non-Drugs E0762 RR TRANS ELEC JT STIM DEV SYS Blank $289.70 HCPCS - Non-Drugs E0762 UE TRANS ELEC JT STIM DEV SYS Blank $1,226.72 HCPCS - Non-Drugs E0764 Blank FUNCTIONAL NEUROMUSCULARSTIM Blank $19,464.08 HCPCS - Non-Drugs E0764 NU FUNCTIONAL NEUROMUSCULARSTIM Blank $19,464.08 HCPCS - Non-Drugs E0764 RR FUNCTIONAL NEUROMUSCULARSTIM Blank $2,463.13 HCPCS - Non-Drugs E0764 UE FUNCTIONAL NEUROMUSCULARSTIM Blank $11,734.83 HCPCS - Non-Drugs E0765 Blank NERVE STIMULATOR FOR TX N&V Blank $249.78 HCPCS - Non-Drugs E0765 NU NERVE STIMULATOR FOR TX N&V Blank $249.78 HCPCS - Non-Drugs E0765 RR NERVE STIMULATOR FOR TX N&V Blank $85.89 HCPCS - Non-Drugs E0765 UE NERVE STIMULATOR FOR TX N&V Blank $204.29 HCPCS - Non-Drugs E0766 Blank ELEC STIM CANCER TREATMENT Blank $316.71 HCPCS - Non-Drugs E0769 Blank ELECTRIC WOUND TREATMENT DEV Blank $209.58 HCPCS - Non-Drugs E0770 Blank FUNCTIONAL ELECTRIC STIM NOS Blank $209.58 HCPCS - Non-Drugs E0776 Blank IV POLE Blank $334.69 HCPCS - Non-Drugs E0776 NU IV POLE Blank $334.69 HCPCS - Non-Drugs E0776 RR IV POLE Blank $94.58 HCPCS - Non-Drugs E0776 UE IV POLE Blank $266.66 HCPCS - Non-Drugs E0779 Blank AMB INFUSION PUMP MECHANICAL Blank $808.32 HCPCS - Non-Drugs E0779 RR AMB INFUSION PUMP MECHANICAL Blank $102.29 HCPCS - Non-Drugs E0780 Blank MECH AMB INFUSION PUMP <8HRS Blank $89.86 HCPCS - Non-Drugs E0780 NU MECH AMB INFUSION PUMP <8HRS Blank $89.86 HCPCS - Non-Drugs E0781 Blank EXTERNAL AMBULATORY INFUS PU Blank $4,114.99 HCPCS - Non-Drugs E0781 RR EXTERNAL AMBULATORY INFUS PU Blank $520.74 HCPCS - Non-Drugs E0782 Blank NON-PROGRAMBLE INFUSION PUMP Blank $8,882.08 HCPCS - Non-Drugs E0782 NU NON-PROGRAMBLE INFUSION PUMP Blank $8,882.08 HCPCS - Non-Drugs E0782 RR NON-PROGRAMBLE INFUSION PUMP Blank $949.13 HCPCS - Non-Drugs E0782 UE NON-PROGRAMBLE INFUSION PUMP Blank $6,678.47 HCPCS - Non-Drugs E0783 Blank PROGRAMMABLE INFUSION PUMP Blank $17,426.82 HCPCS - Non-Drugs E0783 NU PROGRAMMABLE INFUSION PUMP Blank $17,426.82 HCPCS - Non-Drugs E0783 RR PROGRAMMABLE INFUSION PUMP Blank $1,803.62 HCPCS - Non-Drugs E0783 UE PROGRAMMABLE INFUSION PUMP Blank $13,087.05 HCPCS - Non-Drugs E0784 Blank EXT AMB INFUSN PUMP INSULIN Blank $6,990.34 HCPCS - Non-Drugs E0784 RR EXT AMB INFUSN PUMP INSULIN Blank $884.61 HCPCS - Non-Drugs E0785 Blank REPLACEMENT IMPL PUMP CATHET Blank $1,049.09 HCPCS - Non-Drugs E0785 KF REPLACEMENT IMPL PUMP CATHET Blank $1,049.09 HCPCS - Non-Drugs E0786 Blank IMPLANTABLE PUMP REPLACEMENT Blank $16,986.21 HCPCS - Non-Drugs E0786 NU IMPLANTABLE PUMP REPLACEMENT Blank $16,986.21 HCPCS - Non-Drugs E0786 RR IMPLANTABLE PUMP REPLACEMENT Blank $1,759.50 HCPCS - Non-Drugs E0786 UE IMPLANTABLE PUMP REPLACEMENT Blank $12,756.60 HCPCS - Non-Drugs E0791 Blank PARENTERAL INFUSION PUMP STA Blank $8,014.52 HCPCS - Non-Drugs E0791 RR PARENTERAL INFUSION PUMP STA Blank $671.34 HCPCS - Non-Drugs E0791 UE PARENTERAL INFUSION PUMP STA Blank $5,033.25 HCPCS - Non-Drugs E0830 Blank AMBULATORY TRACTION DEVICE Blank $1,684.11 HCPCS - Non-Drugs E0840 Blank TRACT FRAME ATTACH HEADBOARD Blank $298.21 HCPCS - Non-Drugs E0840 NU TRACT FRAME ATTACH HEADBOARD Blank $298.21 HCPCS - Non-Drugs E0840 RR TRACT FRAME ATTACH HEADBOARD Blank $61.97 HCPCS - Non-Drugs E0840 UE TRACT FRAME ATTACH HEADBOARD Blank $251.48 HCPCS - Non-Drugs E0849 Blank CERVICAL PNEUM TRAC EQUIP Blank $1,416.32 HCPCS - Non-Drugs E0849 NU CERVICAL PNEUM TRAC EQUIP Blank $1,416.32 HCPCS - Non-Drugs E0849 RR CERVICAL PNEUM TRAC EQUIP Blank $179.23 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 32 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0849 UE CERVICAL PNEUM TRAC EQUIP Blank $610.77 HCPCS - Non-Drugs E0850 Blank TRACTION STAND FREE STANDING Blank $359.39 HCPCS - Non-Drugs E0850 NU TRACTION STAND FREE STANDING Blank $359.39 HCPCS - Non-Drugs E0850 RR TRACTION STAND FREE STANDING Blank $50.29 HCPCS - Non-Drugs E0850 UE TRACTION STAND FREE STANDING Blank $308.63 HCPCS - Non-Drugs E0855 Blank CERVICAL TRACTION EQUIPMENT Blank $1,387.76 HCPCS - Non-Drugs E0855 NU CERVICAL TRACTION EQUIPMENT Blank $1,387.76 HCPCS - Non-Drugs E0855 RR CERVICAL TRACTION EQUIPMENT Blank $175.62 HCPCS - Non-Drugs E0855 UE CERVICAL TRACTION EQUIPMENT Blank $597.38 HCPCS - Non-Drugs E0856 Blank CERVIC COLLAR W AIR BLADDERS Blank $797.90 HCPCS - Non-Drugs E0856 NU CERVIC COLLAR W AIR BLADDER Blank $797.90 HCPCS - Non-Drugs E0856 RR CERVIC COLLAR W AIR BLADDERS Blank $100.97 HCPCS - Non-Drugs E0856 UE CERVIC COLLAR W AIR BLADDER Blank $229.96 HCPCS - Non-Drugs E0860 Blank TRACT EQUIP CERVICAL TRACT Blank $166.56 HCPCS - Non-Drugs E0860 NU TRACT EQUIP CERVICAL TRACT Blank $166.56 HCPCS - Non-Drugs E0860 RR TRACT EQUIP CERVICAL TRACT Blank $10.42 HCPCS - Non-Drugs E0860 UE TRACT EQUIP CERVICAL TRACT Blank $123.35 HCPCS - Non-Drugs E0870 Blank TRACT FRAME ATTACH FOOTBOARD Blank $378.69 HCPCS - Non-Drugs E0870 NU TRACT FRAME ATTACH FOOTBOARD Blank $378.69 HCPCS - Non-Drugs E0870 RR TRACT FRAME ATTACH FOOTBOARD Blank $47.46 HCPCS - Non-Drugs E0870 UE TRACT FRAME ATTACH FOOTBOARD Blank $323.09 HCPCS - Non-Drugs E0880 Blank TRAC STAND FREE STAND EXTREM Blank $393.20 HCPCS - Non-Drugs E0880 NU TRAC STAND FREE STAND EXTREM Blank $393.20 HCPCS - Non-Drugs E0880 RR TRAC STAND FREE STAND EXTREM Blank $75.52 HCPCS - Non-Drugs E0880 UE TRAC STAND FREE STAND EXTREM Blank $335.05 HCPCS - Non-Drugs E0890 Blank TRACTION FRAME ATTACH PELVIC Blank $384.52 HCPCS - Non-Drugs E0890 NU TRACTION FRAME ATTACH PELVIC Blank $384.52 HCPCS - Non-Drugs E0890 RR TRACTION FRAME ATTACH PELVIC Blank $141.38 HCPCS - Non-Drugs E0890 UE TRACTION FRAME ATTACH PELVIC Blank $338.02 HCPCS - Non-Drugs E0900 Blank TRAC STAND FREE STAND PELVIC Blank $401.71 HCPCS - Non-Drugs E0900 NU TRAC STAND FREE STAND PELVIC Blank $401.71 HCPCS - Non-Drugs E0900 RR TRAC STAND FREE STAND PELVIC Blank $113.26 HCPCS - Non-Drugs E0900 UE TRAC STAND FREE STAND PELVIC Blank $340.61 HCPCS - Non-Drugs E0910 Blank TRAPEZE BAR ATTACHED TO BED Blank $234.56 HCPCS - Non-Drugs E0910 RR TRAPEZE BAR ATTACHED TO BED Blank $29.68 HCPCS - Non-Drugs E0910 UE TRAPEZE BAR ATTACHED TO BED Blank $318.73 HCPCS - Non-Drugs E0911 Blank HD TRAPEZE BAR ATTACH TO BED Blank $1,373.79 HCPCS - Non-Drugs E0911 RR HD TRAPEZE BAR ATTACH TO BED Blank $173.85 HCPCS - Non-Drugs E0912 Blank HD TRAPEZE BAR FREE STANDING Blank $2,406.53 HCPCS - Non-Drugs E0912 RR HD TRAPEZE BAR FREE STANDING Blank $304.54 HCPCS - Non-Drugs E0920 Blank FRACTURE FRAME ATTACHED TO B Blank $1,636.51 HCPCS - Non-Drugs E0920 RR FRACTURE FRAME ATTACHED TO B Blank $207.10 HCPCS - Non-Drugs E0920 UE FRACTURE FRAME ATTACHED TO B Blank $657.28 HCPCS - Non-Drugs E0930 Blank FRACTURE FRAME FREE STANDING Blank $1,616.37 HCPCS - Non-Drugs E0930 RR FRACTURE FRAME FREE STANDING Blank $204.55 HCPCS - Non-Drugs E0930 UE FRACTURE FRAME FREE STANDING Blank $1,228.86 HCPCS - Non-Drugs E0935 Blank CONT PAS MOTION EXERCISE DEV Blank $899.56 HCPCS - Non-Drugs E0935 RR CONT PAS MOTION EXERCISE DEV Blank $113.84 HCPCS - Non-Drugs E0936 Blank CPM DEVICE, OTHER THAN KNEE Blank $91.68 HCPCS - Non-Drugs E0936 RR CPM DEVICE, OTHER THAN KNEE Blank $7.54 HCPCS - Non-Drugs E0940 Blank TRAPEZE BAR FREE STANDING Blank $597.11 HCPCS - Non-Drugs E0940 RR TRAPEZE BAR FREE STANDING Blank $75.56 HCPCS - Non-Drugs E0940 UE TRAPEZE BAR FREE STANDING Blank $440.83 HCPCS - Non-Drugs E0941 Blank GRAVITY ASSISTED TRACTION DE Blank $1,569.64 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 33 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0941 NU GRAVITY ASSISTED TRACTION DE Blank $1,569.64 HCPCS - Non-Drugs E0941 RR GRAVITY ASSISTED TRACTION DE Blank $198.63 HCPCS - Non-Drugs E0941 UE GRAVITY ASSISTED TRACTION DE Blank $1,193.33 HCPCS - Non-Drugs E0942 Blank CERVICAL HEAD HARNESS/HALTER Blank $76.63 HCPCS - Non-Drugs E0942 NU CERVICAL HEAD HARNESS/HALTER Blank $76.63 HCPCS - Non-Drugs E0942 RR CERVICAL HEAD HARNESS/HALTER Blank $2.68 HCPCS - Non-Drugs E0942 UE CERVICAL HEAD HARNESS/HALTER Blank $51.91 HCPCS - Non-Drugs E0944 Blank PELVIC BELT/HARNESS/BOOT Blank $115.55 HCPCS - Non-Drugs E0944 NU PELVIC BELT/HARNESS/BOOT Blank $115.55 HCPCS - Non-Drugs E0944 RR PELVIC BELT/HARNESS/BOOT Blank $12.49 HCPCS - Non-Drugs E0944 UE PELVIC BELT/HARNESS/BOOT Blank $94.38 HCPCS - Non-Drugs E0945 Blank BELT/HARNESS EXTREMITY Blank $114.35 HCPCS - Non-Drugs E0945 NU BELT/HARNESS EXTREMITY Blank $114.35 HCPCS - Non-Drugs E0945 RR BELT/HARNESS EXTREMITY Blank $12.23 HCPCS - Non-Drugs E0945 UE BELT/HARNESS EXTREMITY Blank $95.00 HCPCS - Non-Drugs E0946 Blank FRACTURE FRAME DUAL W CROSS Blank $2,091.32 HCPCS - Non-Drugs E0946 NU FRACTURE FRAME DUAL W CROSS Blank $2,091.32 HCPCS - Non-Drugs E0946 RR FRACTURE FRAME DUAL W CROSS Blank $264.65 HCPCS - Non-Drugs E0946 UE FRACTURE FRAME DUAL W CROSS Blank $1,589.95 HCPCS - Non-Drugs E0947 Blank FRACTURE FRAME ATTACHMNTS PE Blank $1,315.05 HCPCS - Non-Drugs E0947 NU FRACTURE FRAME ATTACHMNTS PE Blank $1,315.05 HCPCS - Non-Drugs E0947 RR FRACTURE FRAME ATTACHMNTS PE Blank $275.22 HCPCS - Non-Drugs E0947 UE FRACTURE FRAME ATTACHMNTS PE Blank $1,024.60 HCPCS - Non-Drugs E0948 Blank FRACTURE FRAME ATTACHMNTS CE Blank $1,291.77 HCPCS - Non-Drugs E0948 NU FRACTURE FRAME ATTACHMNTS CE Blank $1,291.77 HCPCS - Non-Drugs E0948 RR FRACTURE FRAME ATTACHMNTS CE Blank $266.38 HCPCS - Non-Drugs E0948 UE FRACTURE FRAME ATTACHMNTS CE Blank $964.49 HCPCS - Non-Drugs E0950 Blank TRAY Blank $230.46 HCPCS - Non-Drugs E0950 NU TRAY Blank $230.46 HCPCS - Non-Drugs E0950 RR TRAY Blank $19.43 HCPCS - Non-Drugs E0950 UE TRAY Blank $180.42 HCPCS - Non-Drugs E0951 Blank LOOP HEEL Blank $47.15 HCPCS - Non-Drugs E0951 NU LOOP HEEL Blank $47.15 HCPCS - Non-Drugs E0951 RR LOOP HEEL Blank $3.36 HCPCS - Non-Drugs E0951 UE LOOP HEEL Blank $25.17 HCPCS - Non-Drugs E0952 Blank TOE LOOP/HOLDER, EACH Blank $45.17 HCPCS - Non-Drugs E0952 NU TOE LOOP/HOLDER, EACH Blank $45.17 HCPCS - Non-Drugs E0952 RR TOE LOOP/HOLDER, EACH Blank $4.06 HCPCS - Non-Drugs E0952 UE TOE LOOP/HOLDER, EACH Blank $31.75 HCPCS - Non-Drugs E0955 Blank CUSHIONED HEADREST Blank $420.55 HCPCS - Non-Drugs E0955 NU CUSHIONED HEADREST Blank $420.55 HCPCS - Non-Drugs E0955 RR CUSHIONED HEADREST Blank $53.22 HCPCS - Non-Drugs E0955 UE CUSHIONED HEADREST Blank $314.92 HCPCS - Non-Drugs E0956 Blank W/C LATERAL TRUNK/HIP SUPPOR Blank $232.69 HCPCS - Non-Drugs E0956 NU W/C LATERAL TRUNK/HIP SUPPOR Blank $232.69 HCPCS - Non-Drugs E0956 RR W/C LATERAL TRUNK/HIP SUPPOR Blank $19.65 HCPCS - Non-Drugs E0956 UE W/C LATERAL TRUNK/HIP SUPPOR Blank $182.09 HCPCS - Non-Drugs E0957 Blank W/C MEDIAL THIGH SUPPORT Blank $346.38 HCPCS - Non-Drugs E0957 NU W/C MEDIAL THIGH SUPPORT Blank $346.38 HCPCS - Non-Drugs E0957 RR W/C MEDIAL THIGH SUPPORT Blank $42.38 HCPCS - Non-Drugs E0957 UE W/C MEDIAL THIGH SUPPORT Blank $267.36 HCPCS - Non-Drugs E0958 Blank WHLCHR ATT- CONV 1 ARM DRIVE Blank $1,104.99 HCPCS - Non-Drugs E0958 NU WHLCHR ATT- CONV 1 ARM DRIVE Blank $1,104.99 HCPCS - Non-Drugs E0958 RR WHLCHR ATT- CONV 1 ARM DRIVE Blank $139.83 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 34 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0958 UE WHLCHR ATT- CONV 1 ARM DRIVE Blank $742.37 HCPCS - Non-Drugs E0959 Blank AMPUTEE ADAPTER Blank $108.21 HCPCS - Non-Drugs E0959 NU AMPUTEE ADAPTER Blank $108.21 HCPCS - Non-Drugs E0959 RR AMPUTEE ADAPTER Blank $11.25 HCPCS - Non-Drugs E0959 UE AMPUTEE ADAPTER Blank $88.76 HCPCS - Non-Drugs E0960 Blank W/C SHOULDER HARNESS/STRAPS Blank $222.93 HCPCS - Non-Drugs E0960 NU W/C SHOULDER HARNESS/STRAPS Blank $222.93 HCPCS - Non-Drugs E0960 RR W/C SHOULDER HARNESS/STRAPS Blank $18.70 HCPCS - Non-Drugs E0960 UE W/C SHOULDER HARNESS/STRAPS Blank $174.77 HCPCS - Non-Drugs E0961 Blank WHEELCHAIR BRAKE EXTENSION Blank $78.38 HCPCS - Non-Drugs E0961 NU WHEELCHAIR BRAKE EXTENSION Blank $78.38 HCPCS - Non-Drugs E0961 RR WHEELCHAIR BRAKE EXTENSION Blank $5.25 HCPCS - Non-Drugs E0961 UE WHEELCHAIR BRAKE EXTENSION Blank $42.30 HCPCS - Non-Drugs E0966 Blank WHEELCHAIR HEAD REST EXTENSI Blank $215.04 HCPCS - Non-Drugs E0966 NU WHEELCHAIR HEAD REST EXTENSI Blank $215.04 HCPCS - Non-Drugs E0966 RR WHEELCHAIR HEAD REST EXTENSI Blank $17.92 HCPCS - Non-Drugs E0966 UE WHEELCHAIR HEAD REST EXTENSI Blank $168.86 HCPCS - Non-Drugs E0967 Blank MAN WC RIM/PROJECTION REP EA Blank $156.67 HCPCS - Non-Drugs E0967 NU MANUAL WC HAND RIM W PROJECT Blank $156.67 HCPCS - Non-Drugs E0967 RR MANUAL WC HAND RIM W PROJECT Blank $18.25 HCPCS - Non-Drugs E0967 UE MANUAL WC HAND RIM W PROJECT Blank $125.07 HCPCS - Non-Drugs E0968 Blank WHEELCHAIR COMMODE SEAT Blank $466.08 HCPCS - Non-Drugs E0968 NU WHEELCHAIR COMMODE SEAT Blank $466.08 HCPCS - Non-Drugs E0968 RR WHEELCHAIR COMMODE SEAT Blank $58.98 HCPCS - Non-Drugs E0968 UE WHEELCHAIR COMMODE SEAT Blank $364.10 HCPCS - Non-Drugs E0969 Blank WHEELCHAIR NARROWING DEVICE Blank $337.53 HCPCS - Non-Drugs E0969 NU WHEELCHAIR NARROWING DEVICE Blank $337.53 HCPCS - Non-Drugs E0969 RR WHEELCHAIR NARROWING DEVICE Blank $49.89 HCPCS - Non-Drugs E0969 UE WHEELCHAIR NARROWING DEVICE Blank $262.04 HCPCS - Non-Drugs E0970 Blank WHEELCHAIR NO. 2 FOOTPLATES Blank $138.85 HCPCS - Non-Drugs E0970 NU WHEELCHAIR NO. 2 FOOTPLATES Blank $153.21 HCPCS - Non-Drugs E0970 RR WHEELCHAIR NO. 2 FOOTPLATES Blank $16.38 HCPCS - Non-Drugs E0970 UE WHEELCHAIR NO. 2 FOOTPLATES Blank $122.95 HCPCS - Non-Drugs E0971 Blank WHEELCHAIR ANTI-TIPPING DEVI Blank $110.33 HCPCS - Non-Drugs E0971 NU WHEELCHAIR ANTI-TIPPING DEVI Blank $110.33 HCPCS - Non-Drugs E0971 RR WHEELCHAIR ANTI-TIPPING DEVI Blank $7.77 HCPCS - Non-Drugs E0971 UE WHEELCHAIR ANTI-TIPPING DEVI Blank $88.25 HCPCS - Non-Drugs E0973 Blank W/CH ACCESS DET ADJ ARMREST Blank $174.86 HCPCS - Non-Drugs E0973 NU W/CH ACCESS DET ADJ ARMREST Blank $174.86 HCPCS - Non-Drugs E0973 RR W/CH ACCESS DET ADJ ARMREST Blank $14.03 HCPCS - Non-Drugs E0973 UE W/CH ACCESS DET ADJ ARMREST Blank $138.71 HCPCS - Non-Drugs E0974 Blank W/CH ACCESS ANTI-ROLLBACK Blank $222.33 HCPCS - Non-Drugs E0974 NU W/CH ACCESS ANTI-ROLLBACK Blank $222.33 HCPCS - Non-Drugs E0974 RR W/CH ACCESS ANTI-ROLLBACK Blank $18.72 HCPCS - Non-Drugs E0974 UE W/CH ACCESS ANTI-ROLLBACK Blank $174.39 HCPCS - Non-Drugs E0978 Blank W/C ACC,SAF BELT PELV STRAP Blank $94.83 HCPCS - Non-Drugs E0978 NU W/C ACC,SAF BELT PELV STRAP Blank $94.83 HCPCS - Non-Drugs E0978 RR W/C ACC,SAF BELT PELV STRAP Blank $6.27 HCPCS - Non-Drugs E0978 UE W/C ACC,SAF BELT PELV STRAP Blank $69.48 HCPCS - Non-Drugs E0980 Blank WHEELCHAIR SAFETY VEST Blank $92.43 HCPCS - Non-Drugs E0980 NU WHEELCHAIR SAFETY VEST Blank $92.43 HCPCS - Non-Drugs E0980 RR WHEELCHAIR SAFETY VEST Blank $9.00 HCPCS - Non-Drugs E0980 UE WHEELCHAIR SAFETY VEST Blank $76.72 HCPCS - Non-Drugs E0981 Blank SEAT UPHOLSTERY, REPLACEMENT Blank $135.18 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 35 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E0981 NU SEAT UPHOLSTERY, REPLACEMENT Blank $135.18 HCPCS - Non-Drugs E0981 RR SEAT UPHOLSTERY, REPLACEMENT Blank $10.18 HCPCS - Non-Drugs E0981 UE SEAT UPHOLSTERY, REPLACEMENT Blank $109.04 HCPCS - Non-Drugs E0982 Blank BACK UPHOLSTERY, REPLACEMENT Blank $107.84 HCPCS - Non-Drugs E0982 NU BACK UPHOLSTERY, REPLACEMENT Blank $107.84 HCPCS - Non-Drugs E0982 RR BACK UPHOLSTERY, REPLACEMENT Blank $11.18 HCPCS - Non-Drugs E0982 UE BACK UPHOLSTERY, REPLACEMENT Blank $88.45 HCPCS - Non-Drugs E0983 Blank ADD PWR JOYSTICK Blank $4,157.59 HCPCS - Non-Drugs E0983 RR ADD PWR JOYSTICK Blank $526.13 HCPCS - Non-Drugs E0984 Blank ADD PWR TILLER Blank $3,107.01 HCPCS - Non-Drugs E0984 NU ADD PWR TILLER Blank $3,107.01 HCPCS - Non-Drugs E0984 RR ADD PWR TILLER Blank $393.18 HCPCS - Non-Drugs E0984 UE ADD PWR TILLER Blank $3,585.99 HCPCS - Non-Drugs E0985 Blank W/C SEAT LIFT MECHANISM Blank $504.94 HCPCS - Non-Drugs E0985 NU W/C SEAT LIFT MECHANISM Blank $504.94 HCPCS - Non-Drugs E0985 RR W/C SEAT LIFT MECHANISM Blank $63.90 HCPCS - Non-Drugs E0985 UE W/C SEAT LIFT MECHANISM Blank $361.26 HCPCS - Non-Drugs E0986 Blank MAN W/C PUSH-RIM POWR SYSTEM Blank $8,065.41 HCPCS - Non-Drugs E0986 NU MAN W/C PUSH-RIM POW ASSIST Blank $8,065.41 HCPCS - Non-Drugs E0986 RR MAN W/C PUSH-RIM POWR SYSTEM Blank $1,020.66 HCPCS - Non-Drugs E0986 UE MAN W/C PUSH-RIM POW ASSIST Blank $9,085.06 HCPCS - Non-Drugs E0988 Blank LEVER-ACTIVATED WHEEL DRIVE Blank $4,964.10 HCPCS - Non-Drugs E0988 RR LEVER-ACTIVATED WHEEL DRIVE Blank $628.19 HCPCS - Non-Drugs E0990 Blank WHEELCHAIR ELEVATING LEG RES Blank $216.05 HCPCS - Non-Drugs E0990 NU WHEELCHAIR ELEVATING LEG RES Blank $216.05 HCPCS - Non-Drugs E0990 RR WHEELCHAIR ELEVATING LEG RES Blank $18.03 HCPCS - Non-Drugs E0990 UE WHEELCHAIR ELEVATING LEG RES Blank $169.61 HCPCS - Non-Drugs E0992 Blank WHEELCHAIR SOLID SEAT INSERT Blank $243.01 HCPCS - Non-Drugs E0992 NU WHEELCHAIR SOLID SEAT INSERT Blank $243.01 HCPCS - Non-Drugs E0992 RR WHEELCHAIR SOLID SEAT INSERT Blank $20.65 HCPCS - Non-Drugs E0992 UE WHEELCHAIR SOLID SEAT INSERT Blank $189.84 HCPCS - Non-Drugs E0994 Blank WHEELCHAIR ARM REST Blank $56.17 HCPCS - Non-Drugs E0994 NU WHEELCHAIR ARM REST Blank $56.17 HCPCS - Non-Drugs E0994 RR WHEELCHAIR ARM REST Blank $4.95 HCPCS - Non-Drugs E0994 UE WHEELCHAIR ARM REST Blank $40.08 HCPCS - Non-Drugs E0995 Blank WC CALF REST, PAD REPLACEMNT Blank $75.60 HCPCS - Non-Drugs E0995 NU WHEELCHAIR CALF REST Blank $75.60 HCPCS - Non-Drugs E0995 RR WHEELCHAIR CALF REST Blank $6.55 HCPCS - Non-Drugs E0995 UE WHEELCHAIR CALF REST Blank $56.34 HCPCS - Non-Drugs E1002 Blank PWR SEAT TILT Blank $7,638.40 HCPCS - Non-Drugs E1002 NU PWR SEAT TILT Blank $7,638.40 HCPCS - Non-Drugs E1002 RR PWR SEAT TILT Blank $966.62 HCPCS - Non-Drugs E1002 UE PWR SEAT TILT Blank $5,735.50 HCPCS - Non-Drugs E1003 Blank PWR SEAT RECLINE Blank $6,063.56 HCPCS - Non-Drugs E1003 NU PWR SEAT RECLINE Blank $6,063.56 HCPCS - Non-Drugs E1003 RR PWR SEAT RECLINE Blank $767.33 HCPCS - Non-Drugs E1003 UE PWR SEAT RECLINE Blank $6,211.17 HCPCS - Non-Drugs E1004 Blank PWR SEAT RECLINE MECH Blank $6,640.97 HCPCS - Non-Drugs E1004 NU PWR SEAT RECLINE MECH Blank $6,640.97 HCPCS - Non-Drugs E1004 RR PWR SEAT RECLINE MECH Blank $840.40 HCPCS - Non-Drugs E1004 UE PWR SEAT RECLINE MECH Blank $6,884.49 HCPCS - Non-Drugs E1005 Blank PWR SEAT RECLINE PWR Blank $7,242.33 HCPCS - Non-Drugs E1005 NU PWR SEAT RECLINE PWR Blank $7,242.33 HCPCS - Non-Drugs E1005 RR PWR SEAT RECLINE PWR Blank $916.50 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 36 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E1005 UE PWR SEAT RECLINE PWR Blank $7,449.05 HCPCS - Non-Drugs E1006 Blank PWR SEAT COMBO W/O SHEAR Blank $8,873.79 HCPCS - Non-Drugs E1006 NU PWR SEAT COMBO W/O SHEAR Blank $8,873.79 HCPCS - Non-Drugs E1006 RR PWR SEAT COMBO W/O SHEAR Blank $1,122.95 HCPCS - Non-Drugs E1006 UE PWR SEAT COMBO W/O SHEAR Blank $9,117.21 HCPCS - Non-Drugs E1007 Blank PWR SEAT COMBO W/SHEAR Blank $16,176.10 HCPCS - Non-Drugs E1007 NU PWR SEAT COMBO W/SHEAR Blank $16,176.10 HCPCS - Non-Drugs E1007 RR PWR SEAT COMBO W/SHEAR Blank $2,047.04 HCPCS - Non-Drugs E1007 UE PWR SEAT COMBO W/SHEAR Blank $12,334.38 HCPCS - Non-Drugs E1008 Blank PWR SEAT COMBO PWR SHEAR Blank $11,232.92 HCPCS - Non-Drugs E1008 NU PWR SEAT COMBO PWR SHEAR Blank $11,232.92 HCPCS - Non-Drugs E1008 RR PWR SEAT COMBO PWR SHEAR Blank $1,421.50 HCPCS - Non-Drugs E1008 UE PWR SEAT COMBO PWR SHEAR Blank $12,336.27 HCPCS - Non-Drugs E1009 Blank ADD MECH LEG ELEVATION Blank $2,937.37 HCPCS - Non-Drugs E1009 NU ADD MECH LEG ELEVATION Blank $2,937.37 HCPCS - Non-Drugs E1009 RR ADD MECH LEG ELEVATION Blank $319.28 HCPCS - Non-Drugs E1009 UE ADD MECH LEG ELEVATION Blank $2,211.28 HCPCS - Non-Drugs E1010 Blank ADD PWR LEG ELEVATION Blank $1,733.23 HCPCS - Non-Drugs E1010 NU ADD PWR LEG ELEVATION Blank $1,733.23 HCPCS - Non-Drugs E1010 RR ADD PWR LEG ELEVATION Blank $219.34 HCPCS - Non-Drugs E1010 UE ADD PWR LEG ELEVATION Blank $1,640.75 HCPCS - Non-Drugs E1012 Blank CTR MOUNT PWR ELEV LEG REST Blank $1,733.23 HCPCS - Non-Drugs E1012 RR CTR MOUNT PWR ELEV LEG REST Blank $219.34 HCPCS - Non-Drugs E1014 Blank RECLINING BACK ADD PED W/C Blank $826.92 HCPCS - Non-Drugs E1014 NU RECLINING BACK ADD PED W/C Blank $826.92 HCPCS - Non-Drugs E1014 RR RECLINING BACK ADD PED W/C Blank $104.64 HCPCS - Non-Drugs E1014 UE RECLINING BACK ADD PED W/C Blank $710.21 HCPCS - Non-Drugs E1015 Blank SHOCK ABSORBER FOR MAN W/C Blank $342.31 HCPCS - Non-Drugs E1015 NU SHOCK ABSORBER FOR MAN W/C Blank $342.31 HCPCS - Non-Drugs E1015 RR SHOCK ABSORBER FOR MAN W/C Blank $41.72 HCPCS - Non-Drugs E1015 UE SHOCK ABSORBER FOR MAN W/C Blank $264.30 HCPCS - Non-Drugs E1016 Blank SHOCK ABSORBER FOR POWER W/C Blank $323.76 HCPCS - Non-Drugs E1016 NU SHOCK ABSORBER FOR POWER W/C Blank $323.76 HCPCS - Non-Drugs E1016 RR SHOCK ABSORBER FOR POWER W/C Blank $38.74 HCPCS - Non-Drugs E1016 UE SHOCK ABSORBER FOR POWER W/C Blank $250.39 HCPCS - Non-Drugs E1017 Blank HD SHCK ABSRBR FOR HD MAN WC Blank $728.77 HCPCS - Non-Drugs E1017 NU HD SHCK ABSRBR FOR HD MAN WC Blank $728.77 HCPCS - Non-Drugs E1017 RR HD SHCK ABSRBR FOR HD MAN WC Blank $77.48 HCPCS - Non-Drugs E1017 UE HD SHCK ABSRBR FOR HD MAN WC Blank $547.91 HCPCS - Non-Drugs E1018 Blank HD SHCK ABSRBER FOR HD POWWC Blank $153.58 HCPCS - Non-Drugs E1018 NU HD SHCK ABSRBER FOR HD POWWC Blank $153.58 HCPCS - Non-Drugs E1018 RR HD SHCK ABSRBER FOR HD POWWC Blank $16.34 HCPCS - Non-Drugs E1018 UE HD SHCK ABSRBER FOR HD POWWC Blank $115.46 HCPCS - Non-Drugs E1020 Blank RESIDUAL LIMB SUPPORT SYSTEM Blank $539.88 HCPCS - Non-Drugs E1020 NU RESIDUAL LIMB SUPPORT SYSTEM Blank $539.88 HCPCS - Non-Drugs E1020 RR RESIDUAL LIMB SUPPORT SYSTEM Blank $68.32 HCPCS - Non-Drugs E1020 UE RESIDUAL LIMB SUPPORT SYSTEM Blank $372.61 HCPCS - Non-Drugs E1028 Blank W/C MANUAL SWINGAWAY Blank $385.72 HCPCS - Non-Drugs E1028 NU W/C MANUAL SWINGAWAY Blank $385.72 HCPCS - Non-Drugs E1028 RR W/C MANUAL SWINGAWAY Blank $48.81 HCPCS - Non-Drugs E1028 UE W/C MANUAL SWINGAWAY Blank $320.60 HCPCS - Non-Drugs E1029 Blank W/C VENT TRAY FIXED Blank $742.62 HCPCS - Non-Drugs E1029 RR W/C VENT TRAY FIXED Blank $93.98 HCPCS - Non-Drugs E1030 Blank W/C VENT TRAY GIMBALED Blank $1,811.48 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 37 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E1030 NU W/C VENT TRAY GIMBALED Blank $1,811.48 HCPCS - Non-Drugs E1030 RR W/C VENT TRAY GIMBALED Blank $229.24 HCPCS - Non-Drugs E1030 UE W/C VENT TRAY GIMBALED Blank $1,671.01 HCPCS - Non-Drugs E1031 Blank ROLLABOUT CHAIR WITH CASTERS Blank $1,133.40 HCPCS - Non-Drugs E1031 NU ROLLABOUT CHAIR WITH CASTERS Blank $1,133.40 HCPCS - Non-Drugs E1031 RR ROLLABOUT CHAIR WITH CASTERS Blank $143.43 HCPCS - Non-Drugs E1031 UE ROLLABOUT CHAIR WITH CASTERS Blank $854.90 HCPCS - Non-Drugs E1035 Blank PATIENT TRANSFER SYSTEM <300 Blank $12,464.21 HCPCS - Non-Drugs E1035 RR PATIENT TRANSFER SYSTEM <300 Blank $1,577.31 HCPCS - Non-Drugs E1036 Blank PATIENT TRANSFER SYSTEM >300 Blank $18,108.67 HCPCS - Non-Drugs E1036 RR PATIENT TRANSFER SYSTEM >300 Blank $2,291.61 HCPCS - Non-Drugs E1037 Blank TRANSPORT CHAIR, PED SIZE Blank $2,456.53 HCPCS - Non-Drugs E1037 RR TRANSPORT CHAIR, PED SIZE Blank $310.87 HCPCS - Non-Drugs E1038 Blank TRANSPORT CHAIR PT WT<=300LB Blank $422.82 HCPCS - Non-Drugs E1038 RR TRANSPORT CHAIR PT WT<=300LB Blank $53.51 HCPCS - Non-Drugs E1039 Blank TRANSPORT CHAIR PT WT >300LB Blank $923.34 HCPCS - Non-Drugs E1039 RR TRANSPORT CHAIR PT WT >300LB Blank $116.85 HCPCS - Non-Drugs E1050 Blank WHELCHR FXD FULL LENGTH ARMS Blank $1,810.79 HCPCS - Non-Drugs E1050 NU WHELCHR FXD FULL LENGTH ARMS Blank $1,810.79 HCPCS - Non-Drugs E1050 RR WHELCHR FXD FULL LENGTH ARMS Blank $229.15 HCPCS - Non-Drugs E1050 UE WHELCHR FXD FULL LENGTH ARMS Blank $1,925.40 HCPCS - Non-Drugs E1060 Blank WHEELCHAIR DETACHABLE ARMS Blank $2,133.93 HCPCS - Non-Drugs E1060 NU WHEELCHAIR DETACHABLE ARMS Blank $2,133.93 HCPCS - Non-Drugs E1060 RR WHEELCHAIR DETACHABLE ARMS Blank $270.04 HCPCS - Non-Drugs E1060 UE WHEELCHAIR DETACHABLE ARMS Blank $2,376.48 HCPCS - Non-Drugs E1070 Blank WHEELCHAIR DETACHABLE FOOT R Blank $1,925.70 HCPCS - Non-Drugs E1070 NU WHEELCHAIR DETACHABLE FOOT R Blank $1,925.70 HCPCS - Non-Drugs E1070 RR WHEELCHAIR DETACHABLE FOOT R Blank $243.69 HCPCS - Non-Drugs E1070 UE WHEELCHAIR DETACHABLE FOOT R Blank $2,069.14 HCPCS - Non-Drugs E1083 Blank HEMI-WHEELCHAIR FIXED ARMS Blank $1,411.67 HCPCS - Non-Drugs E1083 NU HEMI-WHEELCHAIR FIXED ARMS Blank $1,411.67 HCPCS - Non-Drugs E1083 RR HEMI-WHEELCHAIR FIXED ARMS Blank $178.64 HCPCS - Non-Drugs E1083 UE HEMI-WHEELCHAIR FIXED ARMS Blank $1,496.06 HCPCS - Non-Drugs E1084 Blank HEMI-WHEELCHAIR DETACHABLE A Blank $1,753.43 HCPCS - Non-Drugs E1084 NU HEMI-WHEELCHAIR DETACHABLE A Blank $1,753.43 HCPCS - Non-Drugs E1084 RR HEMI-WHEELCHAIR DETACHABLE A Blank $221.89 HCPCS - Non-Drugs E1084 UE HEMI-WHEELCHAIR DETACHABLE A Blank $1,856.36 HCPCS - Non-Drugs E1085 Blank HEMI-WHEELCHAIR FIXED ARMS Blank $1,844.38 HCPCS - Non-Drugs E1085 NU HEMI-WHEELCHAIR FIXED ARMS Blank $1,932.96 HCPCS - Non-Drugs E1085 RR HEMI-WHEELCHAIR FIXED ARMS Blank $220.36 HCPCS - Non-Drugs E1085 UE HEMI-WHEELCHAIR FIXED ARMS Blank $1,396.77 HCPCS - Non-Drugs E1086 Blank HEMI-WHEELCHAIR DETACHABLE A Blank $2,237.05 HCPCS - Non-Drugs E1086 NU HEMI-WHEELCHAIR DETACHABLE A Blank $2,348.11 HCPCS - Non-Drugs E1086 RR HEMI-WHEELCHAIR DETACHABLE A Blank $241.16 HCPCS - Non-Drugs E1086 UE HEMI-WHEELCHAIR DETACHABLE A Blank $1,713.57 HCPCS - Non-Drugs E1087 Blank WHEELCHAIR LIGHTWT FIXED ARM Blank $2,185.06 HCPCS - Non-Drugs E1087 NU WHEELCHAIR LIGHTWT FIXED ARM Blank $2,185.06 HCPCS - Non-Drugs E1087 RR WHEELCHAIR LIGHTWT FIXED ARM Blank $276.51 HCPCS - Non-Drugs E1087 UE WHEELCHAIR LIGHTWT FIXED ARM Blank $2,385.94 HCPCS - Non-Drugs E1088 Blank WHEELCHAIR LIGHTWEIGHT DET A Blank $2,509.04 HCPCS - Non-Drugs E1088 NU WHEELCHAIR LIGHTWEIGHT DET A Blank $2,509.04 HCPCS - Non-Drugs E1088 RR WHEELCHAIR LIGHTWEIGHT DET A Blank $317.51 HCPCS - Non-Drugs E1088 UE WHEELCHAIR LIGHTWEIGHT DET A Blank $2,837.02 HCPCS - Non-Drugs E1089 Blank WHEELCHAIR LIGHTWT FIXED ARM Blank $2,954.39 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 38 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E1089 NU WHEELCHAIR LIGHTWT FIXED ARM Blank $3,106.54 HCPCS - Non-Drugs E1089 RR WHEELCHAIR LIGHTWT FIXED ARM Blank $337.62 HCPCS - Non-Drugs E1089 UE WHEELCHAIR LIGHTWT FIXED ARM Blank $2,337.71 HCPCS - Non-Drugs E1090 Blank WHEELCHAIR LIGHTWEIGHT DET A Blank $3,044.73 HCPCS - Non-Drugs E1090 NU WHEELCHAIR LIGHTWEIGHT DET A Blank $3,202.05 HCPCS - Non-Drugs E1090 RR WHEELCHAIR LIGHTWEIGHT DET A Blank $337.62 HCPCS - Non-Drugs E1090 UE WHEELCHAIR LIGHTWEIGHT DET A Blank $2,348.11 HCPCS - Non-Drugs E1092 Blank WHEELCHAIR WIDE W/ LEG RESTS Blank $2,189.18 HCPCS - Non-Drugs E1092 NU WHEELCHAIR WIDE W/ LEG RESTS Blank $2,189.18 HCPCS - Non-Drugs E1092 RR WHEELCHAIR WIDE W/ LEG RESTS Blank $277.04 HCPCS - Non-Drugs E1092 UE WHEELCHAIR WIDE W/ LEG RESTS Blank $2,422.82 HCPCS - Non-Drugs E1093 Blank WHEELCHAIR WIDE W/ FOOT REST Blank $1,929.13 HCPCS - Non-Drugs E1093 NU WHEELCHAIR WIDE W/ FOOT REST Blank $1,929.13 HCPCS - Non-Drugs E1093 RR WHEELCHAIR WIDE W/ FOOT REST Blank $244.13 HCPCS - Non-Drugs E1093 UE WHEELCHAIR WIDE W/ FOOT REST Blank $2,087.11 HCPCS - Non-Drugs E1100 Blank WHCHR S-RECL FXD ARM LEG RES Blank $1,819.42 HCPCS - Non-Drugs E1100 NU WHCHR S-RECL FXD ARM LEG RES Blank $1,819.42 HCPCS - Non-Drugs E1100 RR WHCHR S-RECL FXD ARM LEG RES Blank $230.24 HCPCS - Non-Drugs E1100 UE WHCHR S-RECL FXD ARM LEG RES Blank $1,962.28 HCPCS - Non-Drugs E1110 Blank WHEELCHAIR SEMI-RECL DETACH Blank $1,772.69 HCPCS - Non-Drugs E1110 NU WHEELCHAIR SEMI-RECL DETACH Blank $1,772.69 HCPCS - Non-Drugs E1110 RR WHEELCHAIR SEMI-RECL DETACH Blank $224.33 HCPCS - Non-Drugs E1110 UE WHEELCHAIR SEMI-RECL DETACH Blank $1,922.56 HCPCS - Non-Drugs E1130 Blank WHLCHR STAND FXD ARM FT REST Blank $1,198.60 HCPCS - Non-Drugs E1130 NU WHLCHR STAND FXD ARM FT REST Blank $1,250.19 HCPCS - Non-Drugs E1130 RR WHLCHR STAND FXD ARM FT REST Blank $152.27 HCPCS - Non-Drugs E1130 UE WHLCHR STAND FXD ARM FT REST Blank $957.03 HCPCS - Non-Drugs E1140 Blank WHEELCHAIR STANDARD DETACH A Blank $1,706.65 HCPCS - Non-Drugs E1140 NU WHEELCHAIR STANDARD DETACH A Blank $1,787.33 HCPCS - Non-Drugs E1140 RR WHEELCHAIR STANDARD DETACH A Blank $206.17 HCPCS - Non-Drugs E1140 UE WHEELCHAIR STANDARD DETACH A Blank $1,274.78 HCPCS - Non-Drugs E1150 Blank WHEELCHAIR STANDARD W/ LEG R Blank $1,486.76 HCPCS - Non-Drugs E1150 NU WHEELCHAIR STANDARD W/ LEG R Blank $1,486.76 HCPCS - Non-Drugs E1150 RR WHEELCHAIR STANDARD W/ LEG R Blank $188.15 HCPCS - Non-Drugs E1150 UE WHEELCHAIR STANDARD W/ LEG R Blank $1,549.02 HCPCS - Non-Drugs E1160 Blank WHEELCHAIR FIXED ARMS Blank $1,206.75 HCPCS - Non-Drugs E1160 NU WHEELCHAIR FIXED ARMS Blank $1,206.75 HCPCS - Non-Drugs E1160 RR WHEELCHAIR FIXED ARMS Blank $152.71 HCPCS - Non-Drugs E1160 UE WHEELCHAIR FIXED ARMS Blank $1,193.45 HCPCS - Non-Drugs E1161 Blank MANUAL ADULT WC W TILTINSPAC Blank $4,045.95 HCPCS - Non-Drugs E1161 NU MANUAL ADULT WC W TILTINSPAC Blank $4,045.95 HCPCS - Non-Drugs E1161 RR MANUAL ADULT WC W TILTINSPAC Blank $512.00 HCPCS - Non-Drugs E1161 UE MANUAL ADULT WC W TILTINSPAC Blank $4,434.26 HCPCS - Non-Drugs E1170 Blank WHLCHR AMPU FXD ARM LEG REST Blank $1,567.61 HCPCS - Non-Drugs E1170 NU WHLCHR AMPU FXD ARM LEG REST Blank $1,567.61 HCPCS - Non-Drugs E1170 RR WHLCHR AMPU FXD ARM LEG REST Blank $198.38 HCPCS - Non-Drugs E1170 UE WHLCHR AMPU FXD ARM LEG REST Blank $1,692.76 HCPCS - Non-Drugs E1171 Blank WHEELCHAIR AMPUTEE W/O LEG R Blank $1,459.67 HCPCS - Non-Drugs E1171 NU WHEELCHAIR AMPUTEE W/O LEG R Blank $1,459.67 HCPCS - Non-Drugs E1171 RR WHEELCHAIR AMPUTEE W/O LEG R Blank $184.72 HCPCS - Non-Drugs E1171 UE WHEELCHAIR AMPUTEE W/O LEG R Blank $1,522.54 HCPCS - Non-Drugs E1172 Blank WHEELCHAIR AMPUTEE DETACH AR Blank $1,741.03 HCPCS - Non-Drugs E1172 NU WHEELCHAIR AMPUTEE DETACH AR Blank $1,741.03 HCPCS - Non-Drugs E1172 RR WHEELCHAIR AMPUTEE DETACH AR Blank $220.32 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 39 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E1172 UE WHEELCHAIR AMPUTEE DETACH AR Blank $1,853.53 HCPCS - Non-Drugs E1180 Blank WHEELCHAIR AMPUTEE W/ FOOT R Blank $1,781.76 HCPCS - Non-Drugs E1180 NU WHEELCHAIR AMPUTEE W/ FOOT R Blank $1,781.76 HCPCS - Non-Drugs E1180 RR WHEELCHAIR AMPUTEE W/ FOOT R Blank $225.48 HCPCS - Non-Drugs E1180 UE WHEELCHAIR AMPUTEE W/ FOOT R Blank $1,916.89 HCPCS - Non-Drugs E1190 Blank WHEELCHAIR AMPUTEE W/ LEG RE Blank $2,000.12 HCPCS - Non-Drugs E1190 NU WHEELCHAIR AMPUTEE W/ LEG RE Blank $2,000.12 HCPCS - Non-Drugs E1190 RR WHEELCHAIR AMPUTEE W/ LEG RE Blank $253.11 HCPCS - Non-Drugs E1190 UE WHEELCHAIR AMPUTEE W/ LEG RE Blank $2,210.04 HCPCS - Non-Drugs E1195 Blank WHEELCHAIR AMPUTEE HEAVY DUT Blank $2,122.78 HCPCS - Non-Drugs E1195 NU WHEELCHAIR AMPUTEE HEAVY DUT Blank $2,122.78 HCPCS - Non-Drugs E1195 RR WHEELCHAIR AMPUTEE HEAVY DUT Blank $268.63 HCPCS - Non-Drugs E1195 UE WHEELCHAIR AMPUTEE HEAVY DUT Blank $2,368.92 HCPCS - Non-Drugs E1200 Blank WHEELCHAIR AMPUTEE FIXED ARM Blank $1,576.95 HCPCS - Non-Drugs E1200 NU WHEELCHAIR AMPUTEE FIXED ARM Blank $1,576.95 HCPCS - Non-Drugs E1200 RR WHEELCHAIR AMPUTEE FIXED ARM Blank $199.56 HCPCS - Non-Drugs E1200 UE WHEELCHAIR AMPUTEE FIXED ARM Blank $1,650.21 HCPCS - Non-Drugs E1220 Blank WHLCHR SPECIAL SIZE/CONSTRC Blank $5,372.88 HCPCS - Non-Drugs E1221 Blank WHEELCHAIR SPEC SIZE W FOOT Blank $963.99 HCPCS - Non-Drugs E1221 NU WHEELCHAIR SPEC SIZE W FOOT Blank $963.99 HCPCS - Non-Drugs E1221 RR WHEELCHAIR SPEC SIZE W FOOT Blank $121.99 HCPCS - Non-Drugs E1221 UE WHEELCHAIR SPEC SIZE W FOOT Blank $914.48 HCPCS - Non-Drugs E1222 Blank WHEELCHAIR SPEC SIZE W/ LEG Blank $1,290.61 HCPCS - Non-Drugs E1222 NU WHEELCHAIR SPEC SIZE W/ LEG Blank $1,290.61 HCPCS - Non-Drugs E1222 RR WHEELCHAIR SPEC SIZE W/ LEG Blank $163.32 HCPCS - Non-Drugs E1222 UE WHEELCHAIR SPEC SIZE W/ LEG Blank $1,291.80 HCPCS - Non-Drugs E1223 Blank WHEELCHAIR SPEC SIZE W FOOT Blank $1,359.18 HCPCS - Non-Drugs E1223 NU WHEELCHAIR SPEC SIZE W FOOT Blank $1,359.18 HCPCS - Non-Drugs E1223 RR WHEELCHAIR SPEC SIZE W FOOT Blank $172.00 HCPCS - Non-Drugs E1223 UE WHEELCHAIR SPEC SIZE W FOOT Blank $1,408.12 HCPCS - Non-Drugs E1224 Blank WHEELCHAIR SPEC SIZE W/ LEG Blank $1,464.67 HCPCS - Non-Drugs E1224 NU WHEELCHAIR SPEC SIZE W/ LEG Blank $1,464.67 HCPCS - Non-Drugs E1224 RR WHEELCHAIR SPEC SIZE W/ LEG Blank $185.35 HCPCS - Non-Drugs E1224 UE WHEELCHAIR SPEC SIZE W/ LEG Blank $1,540.51 HCPCS - Non-Drugs E1225 Blank MANUAL SEMI-RECLINING BACK Blank $1,023.53 HCPCS - Non-Drugs E1225 NU MANUAL SEMI-RECLINING BACK Blank $1,023.53 HCPCS - Non-Drugs E1225 RR MANUAL SEMI-RECLINING BACK Blank $129.52 HCPCS - Non-Drugs E1225 UE MANUAL SEMI-RECLINING BACK Blank $768.85 HCPCS - Non-Drugs E1226 Blank MANUAL FULLY RECLINING BACK Blank $1,029.20 HCPCS - Non-Drugs E1226 NU MANUAL FULLY RECLINING BACK Blank $1,029.20 HCPCS - Non-Drugs E1226 RR MANUAL FULLY RECLINING BACK Blank $130.17 HCPCS - Non-Drugs E1226 UE MANUAL FULLY RECLINING BACK Blank $779.47 HCPCS - Non-Drugs E1227 Blank WHEELCHAIR SPEC SZ SPEC HT A Blank $560.75 HCPCS - Non-Drugs E1227 NU WHEELCHAIR SPEC SZ SPEC HT A Blank $560.75 HCPCS - Non-Drugs E1227 RR WHEELCHAIR SPEC SZ SPEC HT A Blank $83.55 HCPCS - Non-Drugs E1227 UE WHEELCHAIR SPEC SZ SPEC HT A Blank $428.46 HCPCS - Non-Drugs E1228 Blank WHEELCHAIR SPEC SZ SPEC HT B Blank $651.47 HCPCS - Non-Drugs E1228 NU WHEELCHAIR SPEC SZ SPEC HT B Blank $651.47 HCPCS - Non-Drugs E1228 RR WHEELCHAIR SPEC SZ SPEC HT B Blank $82.44 HCPCS - Non-Drugs E1228 UE WHEELCHAIR SPEC SZ SPEC HT B Blank $552.29 HCPCS - Non-Drugs E1229 Blank PEDIATRIC WHEELCHAIR NOS Blank $1,733.47 HCPCS - Non-Drugs E1230 Blank POWER OPERATED VEHICLE Blank $4,292.29 HCPCS - Non-Drugs E1230 NU POWER OPERATED VEHICLE Blank $4,292.29 HCPCS - Non-Drugs E1230 RR POWER OPERATED VEHICLE Blank $454.55 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 40 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E1230 UE POWER OPERATED VEHICLE Blank $3,346.34 HCPCS - Non-Drugs E1231 Blank RIGID PED W/C TILT-IN-SPACE Blank $3,321.71 HCPCS - Non-Drugs E1231 NU RIGID PED W/C TILT-IN-SPACE Blank $3,321.71 HCPCS - Non-Drugs E1231 RR RIGID PED W/C TILT-IN-SPACE Blank $363.54 HCPCS - Non-Drugs E1231 UE RIGID PED W/C TILT-IN-SPACE Blank $2,501.45 HCPCS - Non-Drugs E1232 Blank FOLDING PED WC TILT-IN-SPACE Blank $3,679.94 HCPCS - Non-Drugs E1232 NU FOLDING PED WC TILT-IN-SPACE Blank $3,679.94 HCPCS - Non-Drugs E1232 RR FOLDING PED WC TILT-IN-SPACE Blank $465.69 HCPCS - Non-Drugs E1232 UE FOLDING PED WC TILT-IN-SPACE Blank $4,011.54 HCPCS - Non-Drugs E1233 Blank RIG PED WC TLTNSPC W/O SEAT Blank $3,804.08 HCPCS - Non-Drugs E1233 NU RIG PED WC TLTNSPC W/O SEAT Blank $3,804.08 HCPCS - Non-Drugs E1233 RR RIG PED WC TLTNSPC W/O SEAT Blank $481.40 HCPCS - Non-Drugs E1233 UE RIG PED WC TLTNSPC W/O SEAT Blank $4,154.34 HCPCS - Non-Drugs E1234 Blank FLD PED WC TLTNSPC W/O SEAT Blank $3,342.89 HCPCS - Non-Drugs E1234 NU FLD PED WC TLTNSPC W/O SEAT Blank $3,342.89 HCPCS - Non-Drugs E1234 RR FLD PED WC TLTNSPC W/O SEAT Blank $423.03 HCPCS - Non-Drugs E1234 UE FLD PED WC TLTNSPC W/O SEAT Blank $3,620.98 HCPCS - Non-Drugs E1235 Blank RIGID PED WC ADJUSTABLE Blank $3,227.92 HCPCS - Non-Drugs E1235 NU RIGID PED WC ADJUSTABLE Blank $3,227.92 HCPCS - Non-Drugs E1235 RR RIGID PED WC ADJUSTABLE Blank $408.48 HCPCS - Non-Drugs E1235 UE RIGID PED WC ADJUSTABLE Blank $3,488.59 HCPCS - Non-Drugs E1236 Blank FOLDING PED WC ADJUSTABLE Blank $2,875.73 HCPCS - Non-Drugs E1236 NU FOLDING PED WC ADJUSTABLE Blank $2,875.73 HCPCS - Non-Drugs E1236 RR FOLDING PED WC ADJUSTABLE Blank $363.92 HCPCS - Non-Drugs E1236 UE FOLDING PED WC ADJUSTABLE Blank $3,081.01 HCPCS - Non-Drugs E1237 Blank RGD PED WC ADJSTABL W/O SEAT Blank $2,898.86 HCPCS - Non-Drugs E1237 NU RGD PED WC ADJSTABL W/O SEAT Blank $2,898.86 HCPCS - Non-Drugs E1237 RR RGD PED WC ADJSTABL W/O SEAT Blank $366.84 HCPCS - Non-Drugs E1237 UE RGD PED WC ADJSTABL W/O SEAT Blank $3,107.48 HCPCS - Non-Drugs E1238 Blank FLD PED WC ADJSTABL W/O SEAT Blank $2,875.73 HCPCS - Non-Drugs E1238 NU FLD PED WC ADJSTABL W/O SEAT Blank $2,875.73 HCPCS - Non-Drugs E1238 RR FLD PED WC ADJSTABL W/O SEAT Blank $363.92 HCPCS - Non-Drugs E1238 UE FLD PED WC ADJSTABL W/O SEAT Blank $3,081.01 HCPCS - Non-Drugs E1239 Blank PED POWER WHEELCHAIR NOS Blank $3,673.76 HCPCS - Non-Drugs E1240 Blank WHCHR LITWT DET ARM LEG REST Blank $1,789.87 HCPCS - Non-Drugs E1240 NU WHCHR LITWT DET ARM LEG REST Blank $1,789.87 HCPCS - Non-Drugs E1240 RR WHCHR LITWT DET ARM LEG REST Blank $226.50 HCPCS - Non-Drugs E1240 UE WHCHR LITWT DET ARM LEG REST Blank $1,948.09 HCPCS - Non-Drugs E1250 Blank WHEELCHAIR LIGHTWT FIXED ARM Blank $1,822.02 HCPCS - Non-Drugs E1250 NU WHEELCHAIR LIGHTWT FIXED ARM Blank $1,909.32 HCPCS - Non-Drugs E1250 RR WHEELCHAIR LIGHTWT FIXED ARM Blank $201.44 HCPCS - Non-Drugs E1250 UE WHEELCHAIR LIGHTWT FIXED ARM Blank $1,518.76 HCPCS - Non-Drugs E1260 Blank WHEELCHAIR LIGHTWT FOOT REST Blank $2,121.66 HCPCS - Non-Drugs E1260 NU WHEELCHAIR LIGHTWT FOOT REST Blank $2,226.12 HCPCS - Non-Drugs E1260 RR WHEELCHAIR LIGHTWT FOOT REST Blank $249.67 HCPCS - Non-Drugs E1260 UE WHEELCHAIR LIGHTWT FOOT REST Blank $1,762.74 HCPCS - Non-Drugs E1270 Blank WHEELCHAIR LIGHTWEIGHT LEG R Blank $1,427.57 HCPCS - Non-Drugs E1270 NU WHEELCHAIR LIGHTWEIGHT LEG R Blank $1,427.57 HCPCS - Non-Drugs E1270 RR WHEELCHAIR LIGHTWEIGHT LEG R Blank $180.66 HCPCS - Non-Drugs E1270 UE WHEELCHAIR LIGHTWEIGHT LEG R Blank $1,499.85 HCPCS - Non-Drugs E1280 Blank WHCHR H-DUTY DET ARM LEG RES Blank $2,226.44 HCPCS - Non-Drugs E1280 NU WHCHR H-DUTY DET ARM LEG RES Blank $2,226.44 HCPCS - Non-Drugs E1280 RR WHCHR H-DUTY DET ARM LEG RES Blank $281.75 HCPCS - Non-Drugs E1280 UE WHCHR H-DUTY DET ARM LEG RES Blank $2,473.89 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 41 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E1285 Blank WHEELCHAIR HEAVY DUTY FIXED Blank $2,721.83 HCPCS - Non-Drugs E1285 NU WHEELCHAIR HEAVY DUTY FIXED Blank $2,860.66 HCPCS - Non-Drugs E1285 RR WHEELCHAIR HEAVY DUTY FIXED Blank $313.03 HCPCS - Non-Drugs E1285 UE WHEELCHAIR HEAVY DUTY FIXED Blank $2,104.13 HCPCS - Non-Drugs E1290 Blank WHEELCHAIR HVY DUTY DETACH A Blank $2,813.96 HCPCS - Non-Drugs E1290 NU WHEELCHAIR HVY DUTY DETACH A Blank $2,958.07 HCPCS - Non-Drugs E1290 RR WHEELCHAIR HVY DUTY DETACH A Blank $323.44 HCPCS - Non-Drugs E1290 UE WHEELCHAIR HVY DUTY DETACH A Blank $2,165.60 HCPCS - Non-Drugs E1295 Blank WHEELCHAIR HEAVY DUTY FIXED Blank $2,113.94 HCPCS - Non-Drugs E1295 NU WHEELCHAIR HEAVY DUTY FIXED Blank $2,113.94 HCPCS - Non-Drugs E1295 RR WHEELCHAIR HEAVY DUTY FIXED Blank $267.51 HCPCS - Non-Drugs E1295 UE WHEELCHAIR HEAVY DUTY FIXED Blank $2,291.37 HCPCS - Non-Drugs E1296 Blank WHEELCHAIR SPECIAL SEAT HEIG Blank $948.19 HCPCS - Non-Drugs E1296 NU WHEELCHAIR SPECIAL SEAT HEIG Blank $948.19 HCPCS - Non-Drugs E1296 RR WHEELCHAIR SPECIAL SEAT HEIG Blank $124.09 HCPCS - Non-Drugs E1296 UE WHEELCHAIR SPECIAL SEAT HEIG Blank $718.67 HCPCS - Non-Drugs E1297 Blank WHEELCHAIR SPECIAL SEAT DEPT Blank $225.78 HCPCS - Non-Drugs E1297 NU WHEELCHAIR SPECIAL SEAT DEPT Blank $225.78 HCPCS - Non-Drugs E1297 RR WHEELCHAIR SPECIAL SEAT DEPT Blank $34.16 HCPCS - Non-Drugs E1297 UE WHEELCHAIR SPECIAL SEAT DEPT Blank $176.88 HCPCS - Non-Drugs E1298 Blank WHEELCHAIR SPEC SEAT DEPTH/W Blank $833.51 HCPCS - Non-Drugs E1298 NU WHEELCHAIR SPEC SEAT DEPTH/W Blank $833.51 HCPCS - Non-Drugs E1298 RR WHEELCHAIR SPEC SEAT DEPTH/W Blank $112.12 HCPCS - Non-Drugs E1298 UE WHEELCHAIR SPEC SEAT DEPTH/W Blank $632.69 HCPCS - Non-Drugs E1300 Blank WHIRLPOOL PORTABLE Blank $270.54 HCPCS - Non-Drugs E1300 NU WHIRLPOOL PORTABLE Blank $270.54 HCPCS - Non-Drugs E1300 RR WHIRLPOOL PORTABLE Blank $28.77 HCPCS - Non-Drugs E1300 UE WHIRLPOOL PORTABLE Blank $203.40 HCPCS - Non-Drugs E1310 Blank WHIRLPOOL NON-PORTABLE Blank $4,420.84 HCPCS - Non-Drugs E1310 NU WHIRLPOOL NON-PORTABLE Blank $4,420.84 HCPCS - Non-Drugs E1310 RR WHIRLPOOL NON-PORTABLE Blank $445.15 HCPCS - Non-Drugs E1310 UE WHIRLPOOL NON-PORTABLE Blank $3,332.57 HCPCS - Non-Drugs E1352 Blank O2 FLOW REG POS INSPIR PRESS Blank $95.01 HCPCS - Non-Drugs E1353 Blank OXYGEN SUPPLIES REGULATOR Blank $106.54 HCPCS - Non-Drugs E1353 NU OXYGEN SUPPLIES REGULATOR Blank $95.01 HCPCS - Non-Drugs E1353 RR OXYGEN SUPPLIES REGULATOR Blank $6.41 HCPCS - Non-Drugs E1353 UE OXYGEN SUPPLIES REGULATOR Blank $48.08 HCPCS - Non-Drugs E1354 Blank WHEELED CART, PORT CYL/CONC Blank $29.79 HCPCS - Non-Drugs E1355 Blank OXYGEN SUPPLIES STAND/RACK Blank $57.33 HCPCS - Non-Drugs E1355 NU OXYGEN SUPPLIES STAND/RACK Blank $57.33 HCPCS - Non-Drugs E1355 RR OXYGEN SUPPLIES STAND/RACK Blank $4.82 HCPCS - Non-Drugs E1355 UE OXYGEN SUPPLIES STAND/RACK Blank $36.20 HCPCS - Non-Drugs E1356 Blank BATT PACK/CART, PORT CONC Blank $55.36 HCPCS - Non-Drugs E1357 Blank BATTERY CHARGER, PORT CONC Blank $180.71 HCPCS - Non-Drugs E1358 Blank DC POWER ADAPTER, PORT CONC Blank $104.44 HCPCS - Non-Drugs E1372 Blank OXY SUPPL HEATER FOR NEBULIZ Blank $303.70 HCPCS - Non-Drugs E1372 NU OXY SUPPL HEATER FOR NEBULIZ Blank $303.70 HCPCS - Non-Drugs E1372 RR OXY SUPPL HEATER FOR NEBULIZ Blank $91.27 HCPCS - Non-Drugs E1372 UE OXY SUPPL HEATER FOR NEBULIZ Blank $244.69 HCPCS - Non-Drugs E1390 Blank OXYGEN CONCENTRATOR Blank $4,524.83 HCPCS - Non-Drugs E1390 NU OXYGEN CONCENTRATOR Blank $4,524.83 HCPCS - Non-Drugs E1390 RR OXYGEN CONCENTRATOR Blank $572.61 HCPCS - Non-Drugs E1391 Blank OXYGEN CONCENTRATOR, DUAL Blank $4,524.83 HCPCS - Non-Drugs E1391 RR OXYGEN CONCENTRATOR, DUAL Blank $572.61 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 42 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E1392 Blank PORTABLE OXYGEN CONCENTRATOR Blank $1,821.40 HCPCS - Non-Drugs E1392 RR PORTABLE OXYGEN CONCENTRATOR Blank $230.49 HCPCS - Non-Drugs E1399 Blank DURABLE MEDICAL EQUIPMENT MI Blank $84.08 HCPCS - Non-Drugs E1405 Blank O2/WATER VAPOR ENRICH W/HEAT Blank $6,391.61 HCPCS - Non-Drugs E1405 NU O2/WATER VAPOR ENRICH W/HEAT Blank $6,391.61 HCPCS - Non-Drugs E1405 RR O2/WATER VAPOR ENRICH W/HEAT Blank $808.84 HCPCS - Non-Drugs E1405 UE O2/WATER VAPOR ENRICH W/HEAT Blank $4,859.29 HCPCS - Non-Drugs E1406 Blank O2/WATER VAPOR ENRICH W/O HE Blank $4,911.97 HCPCS - Non-Drugs E1406 NU O2/WATER VAPOR ENRICH W/O HE Blank $4,911.97 HCPCS - Non-Drugs E1406 RR O2/WATER VAPOR ENRICH W/O HE Blank $621.60 HCPCS - Non-Drugs E1406 UE O2/WATER VAPOR ENRICH W/O HE Blank $3,734.38 HCPCS - Non-Drugs E1500 Blank CENTRIFUGE Blank $310.43 HCPCS - Non-Drugs E1510 Blank KIDNEY DIALYSATE DELIVRY SYS Blank $2,767.30 HCPCS - Non-Drugs E1510 NU KIDNEY DIALYSATE DELIVRY SYS Blank $2,767.30 HCPCS - Non-Drugs E1510 RR KIDNEY DIALYSATE DELIVRY SYS Blank $291.50 HCPCS - Non-Drugs E1510 UE KIDNEY DIALYSATE DELIVRY SYS Blank $2,083.95 HCPCS - Non-Drugs E1520 Blank HEPARIN INFUSION PUMP Blank $2,089.91 HCPCS - Non-Drugs E1520 NU HEPARIN INFUSION PUMP Blank $2,089.91 HCPCS - Non-Drugs E1520 RR HEPARIN INFUSION PUMP Blank $222.30 HCPCS - Non-Drugs E1520 UE HEPARIN INFUSION PUMP Blank $1,571.23 HCPCS - Non-Drugs E1530 Blank REPLACEMENT AIR BUBBLE DETEC Blank $2,027.91 HCPCS - Non-Drugs E1530 NU REPLACEMENT AIR BUBBLE DETEC Blank $2,027.91 HCPCS - Non-Drugs E1530 RR REPLACEMENT AIR BUBBLE DETEC Blank $209.11 HCPCS - Non-Drugs E1530 UE REPLACEMENT AIR BUBBLE DETEC Blank $1,521.36 HCPCS - Non-Drugs E1540 Blank REPLACEMENT PRESSURE ALARM Blank $235.28 HCPCS - Non-Drugs E1540 NU REPLACEMENT PRESSURE ALARM Blank $235.28 HCPCS - Non-Drugs E1540 RR REPLACEMENT PRESSURE ALARM Blank $24.63 HCPCS - Non-Drugs E1540 UE REPLACEMENT PRESSURE ALARM Blank $176.36 HCPCS - Non-Drugs E1550 Blank BATH CONDUCTIVITY METER Blank $115.29 HCPCS - Non-Drugs E1550 NU BATH CONDUCTIVITY METER Blank $115.29 HCPCS - Non-Drugs E1550 RR BATH CONDUCTIVITY METER Blank $12.26 HCPCS - Non-Drugs E1550 UE BATH CONDUCTIVITY METER Blank $86.68 HCPCS - Non-Drugs E1560 Blank REPLACE BLOOD LEAK DETECTOR Blank $2,346.60 HCPCS - Non-Drugs E1560 NU REPLACE BLOOD LEAK DETECTOR Blank $2,346.60 HCPCS - Non-Drugs E1560 RR REPLACE BLOOD LEAK DETECTOR Blank $241.95 HCPCS - Non-Drugs E1560 UE REPLACE BLOOD LEAK DETECTOR Blank $1,736.47 HCPCS - Non-Drugs E1570 Blank ADJUSTABLE CHAIR FOR ESRD PT Blank $707.35 HCPCS - Non-Drugs E1570 NU ADJUSTABLE CHAIR FOR ESRD PT Blank $707.35 HCPCS - Non-Drugs E1570 RR ADJUSTABLE CHAIR FOR ESRD PT Blank $75.24 HCPCS - Non-Drugs E1570 UE ADJUSTABLE CHAIR FOR ESRD PT Blank $531.79 HCPCS - Non-Drugs E1575 Blank TRANSDUCER PROTECT/FLD BAR Blank $123.09 HCPCS - Non-Drugs E1575 NU TRANSDUCER PROTECT/FLD BAR Blank $123.09 HCPCS - Non-Drugs E1575 RR TRANSDUCER PROTECT/FLD BAR Blank $12.69 HCPCS - Non-Drugs E1575 UE TRANSDUCER PROTECT/FLD BAR Blank $91.09 HCPCS - Non-Drugs E1590 Blank HEMODIALYSIS MACHINE Blank $3,130.44 HCPCS - Non-Drugs E1590 NU HEMODIALYSIS MACHINE Blank $3,130.44 HCPCS - Non-Drugs E1590 RR HEMODIALYSIS MACHINE Blank $180.01 HCPCS - Non-Drugs E1590 UE HEMODIALYSIS MACHINE Blank $2,357.41 HCPCS - Non-Drugs E1592 Blank AUTO INTERM PERITONEAL DIALY Blank $7.81 HCPCS - Non-Drugs E1594 Blank CYCLER DIALYSIS MACHINE Blank $8,263.40 HCPCS - Non-Drugs E1594 NU CYCLER DIALYSIS MACHINE Blank $8,263.40 HCPCS - Non-Drugs E1594 RR CYCLER DIALYSIS MACHINE Blank $904.35 HCPCS - Non-Drugs E1594 UE CYCLER DIALYSIS MACHINE Blank $6,222.87 HCPCS - Non-Drugs E1600 Blank DELI/INSTALL CHRG HEMO EQUIP Blank $449.13 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 43 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E1610 Blank REVERSE OSMOSIS H2O PURI SYS Blank $5,492.29 HCPCS - Non-Drugs E1610 NU REVERSE OSMOSIS H2O PURI SYS Blank $5,492.29 HCPCS - Non-Drugs E1610 RR REVERSE OSMOSIS H2O PURI SYS Blank $573.97 HCPCS - Non-Drugs E1610 UE REVERSE OSMOSIS H2O PURI SYS Blank $4,125.95 HCPCS - Non-Drugs E1615 Blank DEIONIZER H2O PURI SYSTEM Blank $330.88 HCPCS - Non-Drugs E1620 Blank REPLACEMENT BLOOD PUMP Blank $689.58 HCPCS - Non-Drugs E1625 Blank WATER SOFTENING SYSTEM Blank $1,781.89 HCPCS - Non-Drugs E1630 Blank RECIPROCATING PERITONEAL DIA Blank $192.73 HCPCS - Non-Drugs E1634 Blank PERITONEAL DIALYSIS CLAMP Blank $13.97 HCPCS - Non-Drugs E1635 Blank COMPACT TRAVEL HEMODIALYZER Blank $601.80 HCPCS - Non-Drugs E1636 Blank SORBENT CARTRIDGES PER 10 Blank $259.25 HCPCS - Non-Drugs E1637 Blank HEMOSTATS FOR DIALYSIS, EACH Blank $51.22 HCPCS - Non-Drugs E1639 Blank DIALYSIS SCALE Blank $151.75 HCPCS - Non-Drugs E1699 Blank DIALYSIS EQUIPMENT NOC Blank $271.40 HCPCS - Non-Drugs E1700 Blank JAW MOTION REHAB SYSTEM Blank $1,091.79 HCPCS - Non-Drugs E1700 NU JAW MOTION REHAB SYSTEM Blank $1,091.79 HCPCS - Non-Drugs E1700 RR JAW MOTION REHAB SYSTEM Blank $138.16 HCPCS - Non-Drugs E1700 UE JAW MOTION REHAB SYSTEM Blank $431.34 HCPCS - Non-Drugs E1701 Blank REPL CUSHIONS FOR JAW MOTION Blank $89.92 HCPCS - Non-Drugs E1702 Blank REPL MEASR SCALES JAW MOTION Blank $113.78 HCPCS - Non-Drugs E1800 Blank ADJUST ELBOW EXT/FLEX DEVICE Blank $2,464.41 HCPCS - Non-Drugs E1800 RR ADJUST ELBOW EXT/FLEX DEVICE Blank $311.87 HCPCS - Non-Drugs E1801 Blank SPS ELBOW DEVICE Blank $2,678.62 HCPCS - Non-Drugs E1801 RR SPS ELBOW DEVICE Blank $338.97 HCPCS - Non-Drugs E1802 Blank ADJST FOREARM PRO/SUP DEVICE Blank $6,124.72 HCPCS - Non-Drugs E1802 RR ADJST FOREARM PRO/SUP DEVICE Blank $775.07 HCPCS - Non-Drugs E1805 Blank ADJUST WRIST EXT/FLEX DEVICE Blank $2,547.68 HCPCS - Non-Drugs E1805 RR ADJUST WRIST EXT/FLEX DEVICE Blank $322.40 HCPCS - Non-Drugs E1806 Blank SPS WRIST DEVICE Blank $2,294.68 HCPCS - Non-Drugs E1806 RR SPS WRIST DEVICE Blank $290.39 HCPCS - Non-Drugs E1810 Blank ADJUST KNEE EXT/FLEX DEVICE Blank $2,518.82 HCPCS - Non-Drugs E1810 RR ADJUST KNEE EXT/FLEX DEVICE Blank $318.75 HCPCS - Non-Drugs E1811 Blank SPS KNEE DEVICE Blank $2,763.66 HCPCS - Non-Drugs E1811 RR SPS KNEE DEVICE Blank $349.73 HCPCS - Non-Drugs E1812 Blank KNEE EXT/FLEX W ACT RES CTRL Blank $2,005.52 HCPCS - Non-Drugs E1812 RR KNEE EXT/FLEX W ACT RES CTRL Blank $253.79 HCPCS - Non-Drugs E1815 Blank ADJUST ANKLE EXT/FLEX DEVICE Blank $2,552.13 HCPCS - Non-Drugs E1815 RR ADJUST ANKLE EXT/FLEX DEVICE Blank $322.97 HCPCS - Non-Drugs E1816 Blank SPS ANKLE DEVICE Blank $2,798.77 HCPCS - Non-Drugs E1816 RR SPS ANKLE DEVICE Blank $354.18 HCPCS - Non-Drugs E1818 Blank SPS FOREARM DEVICE Blank $2,845.98 HCPCS - Non-Drugs E1818 RR SPS FOREARM DEVICE Blank $360.15 HCPCS - Non-Drugs E1820 Blank SOFT INTERFACE MATERIAL Blank $240.92 HCPCS - Non-Drugs E1820 NU SOFT INTERFACE MATERIAL Blank $240.92 HCPCS - Non-Drugs E1820 RR SOFT INTERFACE MATERIAL Blank $85.00 HCPCS - Non-Drugs E1820 UE SOFT INTERFACE MATERIAL Blank $197.62 HCPCS - Non-Drugs E1821 Blank REPLACEMENT INTERFACE SPSD Blank $295.48 HCPCS - Non-Drugs E1821 NU REPLACEMENT INTERFACE SPSD Blank $295.48 HCPCS - Non-Drugs E1821 RR REPLACEMENT INTERFACE SPSD Blank $90.40 HCPCS - Non-Drugs E1821 UE REPLACEMENT INTERFACE SPSD Blank $238.58 HCPCS - Non-Drugs E1825 Blank ADJUST FINGER EXT/FLEX DEVC Blank $2,547.68 HCPCS - Non-Drugs E1825 RR ADJUST FINGER EXT/FLEX DEVC Blank $322.40 HCPCS - Non-Drugs E1830 Blank ADJUST TOE EXT/FLEX DEVICE Blank $2,547.68 HCPCS - Non-Drugs E1830 RR ADJUST TOE EXT/FLEX DEVICE Blank $322.40 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 44 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E1831 Blank STATIC STR TOE DEV EXT/FLEX Blank $1,645.34 HCPCS - Non-Drugs E1831 RR STATIC STR TOE DEV EXT/FLEX Blank $208.21 HCPCS - Non-Drugs E1840 Blank ADJ SHOULDER EXT/FLEX DEVICE Blank $6,943.83 HCPCS - Non-Drugs E1840 RR ADJ SHOULDER EXT/FLEX DEVICE Blank $878.72 HCPCS - Non-Drugs E1841 Blank STATIC STR SHLDR DEV ROM ADJ Blank $8,282.96 HCPCS - Non-Drugs E1841 RR STATIC STR SHLDR DEV ROM ADJ Blank $1,048.19 HCPCS - Non-Drugs E1902 Blank AAC NON-ELECTRONIC BOARD Blank $1,175.00 HCPCS - Non-Drugs E2000 Blank GASTRIC SUCTION PUMP HME MDL Blank $1,395.87 HCPCS - Non-Drugs E2000 RR GASTRIC SUCTION PUMP HME MDL Blank $176.64 HCPCS - Non-Drugs E2100 Blank BLD GLUCOSE MONITOR W VOICE Blank $1,343.25 HCPCS - Non-Drugs E2100 NU BLD GLUCOSE MONITOR W VOICE Blank $1,343.25 HCPCS - Non-Drugs E2100 RR BLD GLUCOSE MONITOR W VOICE Blank $196.87 HCPCS - Non-Drugs E2100 UE BLD GLUCOSE MONITOR W VOICE Blank $1,027.41 HCPCS - Non-Drugs E2101 Blank BLD GLUCOSE MONITOR W LANCE Blank $475.81 HCPCS - Non-Drugs E2101 NU BLD GLUCOSE MONITOR W LANCE Blank $475.81 HCPCS - Non-Drugs E2101 RR BLD GLUCOSE MONITOR W LANCE Blank $108.47 HCPCS - Non-Drugs E2101 UE BLD GLUCOSE MONITOR W LANCE Blank $373.78 HCPCS - Non-Drugs E2120 Blank PULSE GEN SYS TX ENDOLYMP FL Blank $5,384.37 HCPCS - Non-Drugs E2120 RR PULSE GEN SYS TX ENDOLYMP FL Blank $681.38 HCPCS - Non-Drugs E2201 Blank MAN W/CH ACC SEAT W>=20<24 Blank $839.39 HCPCS - Non-Drugs E2201 NU MAN W/CH ACC SEAT W>=20<24 Blank $839.39 HCPCS - Non-Drugs E2201 RR MAN W/CH ACC SEAT W>=20<24 Blank $111.20 HCPCS - Non-Drugs E2201 UE MAN W/CH ACC SEAT W>=20<24 Blank $637.11 HCPCS - Non-Drugs E2202 Blank SEAT WIDTH 24-27 IN Blank $1,192.90 HCPCS - Non-Drugs E2202 NU SEAT WIDTH 24-27 IN Blank $1,192.90 HCPCS - Non-Drugs E2202 RR SEAT WIDTH 24-27 IN Blank $146.54 HCPCS - Non-Drugs E2202 UE SEAT WIDTH 24-27 IN Blank $902.25 HCPCS - Non-Drugs E2203 Blank FRAME DEPTH LESS THAN 22 IN Blank $1,135.70 HCPCS - Non-Drugs E2203 NU FRAME DEPTH LESS THAN 22 IN Blank $1,135.70 HCPCS - Non-Drugs E2203 RR FRAME DEPTH LESS THAN 22 IN Blank $140.82 HCPCS - Non-Drugs E2203 UE FRAME DEPTH LESS THAN 22 IN Blank $859.35 HCPCS - Non-Drugs E2204 Blank FRAME DEPTH 22 TO 25 IN Blank $1,955.36 HCPCS - Non-Drugs E2204 NU FRAME DEPTH 22 TO 25 IN Blank $1,955.36 HCPCS - Non-Drugs E2204 RR FRAME DEPTH 22 TO 25 IN Blank $222.79 HCPCS - Non-Drugs E2204 UE FRAME DEPTH 22 TO 25 IN Blank $1,474.10 HCPCS - Non-Drugs E2205 Blank MANUAL WC ACCESSORY, HANDRIM Blank $91.10 HCPCS - Non-Drugs E2205 NU MANUAL WC ACCESSORY, HANDRIM Blank $91.10 HCPCS - Non-Drugs E2205 RR MANUAL WC ACCESSORY, HANDRIM Blank $8.77 HCPCS - Non-Drugs E2205 UE MANUAL WC ACCESSORY, HANDRIM Blank $75.91 HCPCS - Non-Drugs E2206 Blank MAN WC WHL LOCK COMP REPL EA Blank $129.98 HCPCS - Non-Drugs E2206 NU COMPLETE WHEEL LOCK ASSEMBLY Blank $129.98 HCPCS - Non-Drugs E2206 RR COMPLETE WHEEL LOCK ASSEMBLY Blank $9.68 HCPCS - Non-Drugs E2206 UE COMPLETE WHEEL LOCK ASSEMBLY Blank $105.05 HCPCS - Non-Drugs E2207 Blank CRUTCH AND CANE HOLDER Blank $110.16 HCPCS - Non-Drugs E2207 NU CRUTCH AND CANE HOLDER Blank $110.16 HCPCS - Non-Drugs E2207 RR CRUTCH AND CANE HOLDER Blank $11.53 HCPCS - Non-Drugs E2207 UE CRUTCH AND CANE HOLDER Blank $90.19 HCPCS - Non-Drugs E2208 Blank CYLINDER TANK CARRIER Blank $232.73 HCPCS - Non-Drugs E2208 NU CYLINDER TANK CARRIER Blank $232.73 HCPCS - Non-Drugs E2208 RR CYLINDER TANK CARRIER Blank $19.65 HCPCS - Non-Drugs E2208 UE CYLINDER TANK CARRIER Blank $182.12 HCPCS - Non-Drugs E2209 Blank ARM TROUGH EACH Blank $250.02 HCPCS - Non-Drugs E2209 NU ARM TROUGH EACH Blank $250.02 HCPCS - Non-Drugs E2209 RR ARM TROUGH EACH Blank $21.33 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 45 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E2209 UE ARM TROUGH EACH Blank $195.09 HCPCS - Non-Drugs E2210 Blank WHEELCHAIR BEARINGS Blank $13.60 HCPCS - Non-Drugs E2210 NU WHEELCHAIR BEARINGS Blank $13.60 HCPCS - Non-Drugs E2210 RR WHEELCHAIR BEARINGS Blank $1.36 HCPCS - Non-Drugs E2210 UE WHEELCHAIR BEARINGS Blank $10.21 HCPCS - Non-Drugs E2211 Blank PNEUMATIC PROPULSION TIRE Blank $120.42 HCPCS - Non-Drugs E2211 NU PNEUMATIC PROPULSION TIRE Blank $120.42 HCPCS - Non-Drugs E2211 RR PNEUMATIC PROPULSION TIRE Blank $8.75 HCPCS - Non-Drugs E2211 UE PNEUMATIC PROPULSION TIRE Blank $97.89 HCPCS - Non-Drugs E2212 Blank PNEUMATIC PROP TIRE TUBE Blank $15.71 HCPCS - Non-Drugs E2212 NU PNEUMATIC PROP TIRE TUBE Blank $15.71 HCPCS - Non-Drugs E2212 RR PNEUMATIC PROP TIRE TUBE Blank $1.57 HCPCS - Non-Drugs E2212 UE PNEUMATIC PROP TIRE TUBE Blank $11.79 HCPCS - Non-Drugs E2213 Blank PNEUMATIC PROP TIRE INSERT Blank $108.11 HCPCS - Non-Drugs E2213 NU PNEUMATIC PROP TIRE INSERT Blank $108.11 HCPCS - Non-Drugs E2213 RR PNEUMATIC PROP TIRE INSERT Blank $7.56 HCPCS - Non-Drugs E2213 UE PNEUMATIC PROP TIRE INSERT Blank $85.55 HCPCS - Non-Drugs E2214 Blank PNEUMATIC CASTER TIRE EACH Blank $115.74 HCPCS - Non-Drugs E2214 NU PNEUMATIC CASTER TIRE EACH Blank $115.74 HCPCS - Non-Drugs E2214 RR PNEUMATIC CASTER TIRE EACH Blank $8.30 HCPCS - Non-Drugs E2214 UE PNEUMATIC CASTER TIRE EACH Blank $94.38 HCPCS - Non-Drugs E2215 Blank PNEUMATIC CASTER TIRE TUBE Blank $25.81 HCPCS - Non-Drugs E2215 NU PNEUMATIC CASTER TIRE TUBE Blank $25.81 HCPCS - Non-Drugs E2215 RR PNEUMATIC CASTER TIRE TUBE Blank $2.59 HCPCS - Non-Drugs E2215 UE PNEUMATIC CASTER TIRE TUBE Blank $19.36 HCPCS - Non-Drugs E2216 Blank FOAM FILLED PROPULSION TIRE Blank $193.12 HCPCS - Non-Drugs E2216 NU FOAM FILLED PROPULSION TIRE Blank $193.12 HCPCS - Non-Drugs E2216 RR FOAM FILLED PROPULSION TIRE Blank $20.54 HCPCS - Non-Drugs E2216 UE FOAM FILLED PROPULSION TIRE Blank $145.18 HCPCS - Non-Drugs E2217 Blank FOAM FILLED CASTER TIRE EACH Blank $207.57 HCPCS - Non-Drugs E2217 NU FOAM FILLED CASTER TIRE EACH Blank $207.57 HCPCS - Non-Drugs E2217 RR FOAM FILLED CASTER TIRE EACH Blank $14.78 HCPCS - Non-Drugs E2217 UE FOAM FILLED CASTER TIRE EACH Blank $104.44 HCPCS - Non-Drugs E2218 Blank FOAM PROPULSION TIRE EACH Blank $167.13 HCPCS - Non-Drugs E2218 NU FOAM PROPULSION TIRE EACH Blank $167.13 HCPCS - Non-Drugs E2218 RR FOAM PROPULSION TIRE EACH Blank $11.90 HCPCS - Non-Drugs E2218 UE FOAM PROPULSION TIRE EACH Blank $84.09 HCPCS - Non-Drugs E2219 Blank FOAM CASTER TIRE ANY SIZE EA Blank $135.53 HCPCS - Non-Drugs E2219 NU FOAM CASTER TIRE ANY SIZE EA Blank $135.53 HCPCS - Non-Drugs E2219 RR FOAM CASTER TIRE ANY SIZE EA Blank $10.26 HCPCS - Non-Drugs E2219 UE FOAM CASTER TIRE ANY SIZE EA Blank $109.22 HCPCS - Non-Drugs E2220 Blank SOLID PROPULS TIRE, REPL, EA Blank $80.60 HCPCS - Non-Drugs E2220 NU SOLID PROPULSION TIRE EACH Blank $80.60 HCPCS - Non-Drugs E2220 RR SOLID PROPULSION TIRE EACH Blank $7.25 HCPCS - Non-Drugs E2220 UE SOLID PROPULSION TIRE EACH Blank $63.82 HCPCS - Non-Drugs E2221 Blank SOLID CASTER TIRE REPL, EACH Blank $99.66 HCPCS - Non-Drugs E2221 NU SOLID CASTER TIRE EACH Blank $99.66 HCPCS - Non-Drugs E2221 RR SOLID CASTER TIRE EACH Blank $6.73 HCPCS - Non-Drugs E2221 UE SOLID CASTER TIRE EACH Blank $75.32 HCPCS - Non-Drugs E2222 Blank SOLID CASTER INTEG WHL, REPL Blank $65.96 HCPCS - Non-Drugs E2222 NU SOLID CASTER INTEGRATED WHL Blank $65.96 HCPCS - Non-Drugs E2222 RR SOLID CASTER INTEGRATED WHL Blank $5.63 HCPCS - Non-Drugs E2222 UE SOLID CASTER INTEGRATED WHL Blank $47.33 HCPCS - Non-Drugs E2224 Blank PROPULSION WHL EXCL TIRE REP Blank $271.71 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 46 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E2224 NU PROPULSION WHL EXCLUDES TIRE Blank $271.71 HCPCS - Non-Drugs E2224 RR PROPULSION WHL EXCLUDES TIRE Blank $23.52 HCPCS - Non-Drugs E2224 UE PROPULSION WHL EXCLUDES TIRE Blank $211.31 HCPCS - Non-Drugs E2225 Blank CASTER WHEEL EXCLUDES TIRE Blank $53.77 HCPCS - Non-Drugs E2225 NU CASTER WHEEL EXCLUDES TIRE Blank $53.77 HCPCS - Non-Drugs E2225 RR CASTER WHEEL EXCLUDES TIRE Blank $4.71 HCPCS - Non-Drugs E2225 UE CASTER WHEEL EXCLUDES TIRE Blank $38.16 HCPCS - Non-Drugs E2226 Blank CASTER FORK REPLACEMENT ONLY Blank $133.26 HCPCS - Non-Drugs E2226 NU CASTER FORK REPLACEMENT ONLY Blank $133.26 HCPCS - Non-Drugs E2226 RR CASTER FORK REPLACEMENT ONLY Blank $10.00 HCPCS - Non-Drugs E2226 UE CASTER FORK REPLACEMENT ONLY Blank $107.51 HCPCS - Non-Drugs E2227 Blank GEAR REDUCTION DRIVE WHEEL Blank $3,191.98 HCPCS - Non-Drugs E2227 NU GEAR REDUCTION DRIVE WHEEL Blank $3,191.98 HCPCS - Non-Drugs E2227 RR GEAR REDUCTION DRIVE WHEEL Blank $403.94 HCPCS - Non-Drugs E2227 UE GEAR REDUCTION DRIVE WHEEL Blank $3,513.18 HCPCS - Non-Drugs E2228 Blank MWC ACC, WHEELCHAIR BRAKE Blank $2,203.56 HCPCS - Non-Drugs E2228 NU MWC ACC, WHEELCHAIR BRAKE Blank $2,203.56 HCPCS - Non-Drugs E2228 RR MWC ACC, WHEELCHAIR BRAKE Blank $278.86 HCPCS - Non-Drugs E2228 UE MWC ACC, WHEELCHAIR BRAKE Blank $1,559.42 HCPCS - Non-Drugs E2230 Blank MANUAL STANDING SYSTEM Blank $1,547.51 HCPCS - Non-Drugs E2231 Blank SOLID SEAT SUPPORT BASE Blank $394.05 HCPCS - Non-Drugs E2231 NU SOLID SEAT SUPPORT BASE Blank $394.05 HCPCS - Non-Drugs E2231 RR SOLID SEAT SUPPORT BASE Blank $50.07 HCPCS - Non-Drugs E2231 UE SOLID SEAT SUPPORT BASE Blank $303.11 HCPCS - Non-Drugs E2295 Blank PED DYNAMIC SEATING FRAME Blank $90.59 HCPCS - Non-Drugs E2300 Blank PWR SEAT ELEVATION SYS Blank $1,049.03 HCPCS - Non-Drugs E2301 Blank PWR STANDING Blank $1,082.62 HCPCS - Non-Drugs E2310 Blank ELECTRO CONNECT BTW CONTROL Blank $2,405.85 HCPCS - Non-Drugs E2310 NU ELECTRO CONNECT BTW CONTROL Blank $2,405.85 HCPCS - Non-Drugs E2310 RR ELECTRO CONNECT BTW CONTROL Blank $304.45 HCPCS - Non-Drugs E2310 UE ELECTRO CONNECT BTW CONTROL Blank $1,677.63 HCPCS - Non-Drugs E2311 Blank ELECTRO CONNECT BTW 2 SYS Blank $4,611.30 HCPCS - Non-Drugs E2311 NU ELECTRO CONNECT BTW 2 SYS Blank $4,611.30 HCPCS - Non-Drugs E2311 RR ELECTRO CONNECT BTW 2 SYS Blank $583.55 HCPCS - Non-Drugs E2311 UE ELECTRO CONNECT BTW 2 SYS Blank $3,365.65 HCPCS - Non-Drugs E2312 Blank MINI-PROP REMOTE JOYSTICK Blank $3,422.46 HCPCS - Non-Drugs E2312 NU MINI-PROP REMOTE JOYSTICK Blank $3,422.46 HCPCS - Non-Drugs E2312 RR MINI-PROP REMOTE JOYSTICK Blank $433.10 HCPCS - Non-Drugs E2312 UE MINI-PROP REMOTE JOYSTICK Blank $3,783.64 HCPCS - Non-Drugs E2313 Blank PWC HARNESS, EXPAND CONTROL Blank $745.05 HCPCS - Non-Drugs E2313 NU PWC HARNESS, EXPAND CONTROL Blank $745.05 HCPCS - Non-Drugs E2313 RR PWC HARNESS, EXPAND CONTROL Blank $94.28 HCPCS - Non-Drugs E2313 UE PWC HARNESS, EXPAND CONTROL Blank $626.99 HCPCS - Non-Drugs E2321 Blank HAND INTERFACE JOYSTICK Blank $3,183.03 HCPCS - Non-Drugs E2321 NU HAND INTERFACE JOYSTICK Blank $3,183.03 HCPCS - Non-Drugs E2321 RR HAND INTERFACE JOYSTICK Blank $402.80 HCPCS - Non-Drugs E2321 UE HAND INTERFACE JOYSTICK Blank $2,266.78 HCPCS - Non-Drugs E2322 Blank MULT MECH SWITCHES Blank $2,109.70 HCPCS - Non-Drugs E2322 NU MULT MECH SWITCHES Blank $2,109.70 HCPCS - Non-Drugs E2322 RR MULT MECH SWITCHES Blank $266.98 HCPCS - Non-Drugs E2322 UE MULT MECH SWITCHES Blank $2,015.24 HCPCS - Non-Drugs E2323 Blank SPECIAL JOYSTICK HANDLE Blank $145.66 HCPCS - Non-Drugs E2323 NU SPECIAL JOYSTICK HANDLE Blank $145.66 HCPCS - Non-Drugs E2323 RR SPECIAL JOYSTICK HANDLE Blank $16.65 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 47 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E2323 UE SPECIAL JOYSTICK HANDLE Blank $116.81 HCPCS - Non-Drugs E2324 Blank CHIN CUP INTERFACE Blank $106.45 HCPCS - Non-Drugs E2324 NU CHIN CUP INTERFACE Blank $106.45 HCPCS - Non-Drugs E2324 RR CHIN CUP INTERFACE Blank $11.00 HCPCS - Non-Drugs E2324 UE CHIN CUP INTERFACE Blank $87.42 HCPCS - Non-Drugs E2325 Blank SIP AND PUFF INTERFACE Blank $2,026.94 HCPCS - Non-Drugs E2325 NU SIP AND PUFF INTERFACE Blank $2,026.94 HCPCS - Non-Drugs E2325 RR SIP AND PUFF INTERFACE Blank $256.50 HCPCS - Non-Drugs E2325 UE SIP AND PUFF INTERFACE Blank $1,926.34 HCPCS - Non-Drugs E2326 Blank BREATH TUBE KIT Blank $708.21 HCPCS - Non-Drugs E2326 NU BREATH TUBE KIT Blank $708.21 HCPCS - Non-Drugs E2326 RR BREATH TUBE KIT Blank $89.62 HCPCS - Non-Drugs E2326 UE BREATH TUBE KIT Blank $519.19 HCPCS - Non-Drugs E2327 Blank HEAD CONTROL INTERFACE MECH Blank $3,736.22 HCPCS - Non-Drugs E2327 NU HEAD CONTROL INTERFACE MECH Blank $3,736.22 HCPCS - Non-Drugs E2327 RR HEAD CONTROL INTERFACE MECH Blank $472.81 HCPCS - Non-Drugs E2327 UE HEAD CONTROL INTERFACE MECH Blank $3,707.98 HCPCS - Non-Drugs E2328 Blank HEAD/EXTREMITY CONTROL INTER Blank $6,839.44 HCPCS - Non-Drugs E2328 NU HEAD/EXTREMITY CONTROL INTER Blank $6,839.44 HCPCS - Non-Drugs E2328 RR HEAD/EXTREMITY CONTROL INTER Blank $865.51 HCPCS - Non-Drugs E2328 UE HEAD/EXTREMITY CONTROL INTER Blank $7,005.53 HCPCS - Non-Drugs E2329 Blank HEAD CONTROL NONPROPORTIONAL Blank $2,622.79 HCPCS - Non-Drugs E2329 NU HEAD CONTROL NONPROPORTIONAL Blank $2,622.79 HCPCS - Non-Drugs E2329 RR HEAD CONTROL NONPROPORTIONAL Blank $331.91 HCPCS - Non-Drugs E2329 UE HEAD CONTROL NONPROPORTIONAL Blank $2,516.44 HCPCS - Non-Drugs E2330 Blank HEAD CONTROL PROXIMITY SWITC Blank $4,815.39 HCPCS - Non-Drugs E2330 NU HEAD CONTROL PROXIMITY SWITC Blank $4,815.39 HCPCS - Non-Drugs E2330 RR HEAD CONTROL PROXIMITY SWITC Blank $609.38 HCPCS - Non-Drugs E2330 UE HEAD CONTROL PROXIMITY SWITC Blank $4,847.52 HCPCS - Non-Drugs E2331 Blank ATTENDANT CONTROL Blank $1,116.55 HCPCS - Non-Drugs E2340 Blank W/C WDTH 20-23 IN SEAT FRAME Blank $759.89 HCPCS - Non-Drugs E2340 NU W/C WDTH 20-23 IN SEAT FRAME Blank $759.89 HCPCS - Non-Drugs E2340 RR W/C WDTH 20-23 IN SEAT FRAME Blank $103.26 HCPCS - Non-Drugs E2340 UE W/C WDTH 20-23 IN SEAT FRAME Blank $577.55 HCPCS - Non-Drugs E2341 Blank W/C WDTH 24-27 IN SEAT FRAME Blank $1,124.78 HCPCS - Non-Drugs E2341 NU W/C WDTH 24-27 IN SEAT FRAME Blank $1,124.78 HCPCS - Non-Drugs E2341 RR W/C WDTH 24-27 IN SEAT FRAME Blank $139.71 HCPCS - Non-Drugs E2341 UE W/C WDTH 24-27 IN SEAT FRAME Blank $851.17 HCPCS - Non-Drugs E2342 Blank W/C DPTH 20-21 IN SEAT FRAME Blank $942.37 HCPCS - Non-Drugs E2342 NU W/C DPTH 20-21 IN SEAT FRAME Blank $942.37 HCPCS - Non-Drugs E2342 RR W/C DPTH 20-21 IN SEAT FRAME Blank $121.48 HCPCS - Non-Drugs E2342 UE W/C DPTH 20-21 IN SEAT FRAME Blank $714.37 HCPCS - Non-Drugs E2343 Blank W/C DPTH 22-25 IN SEAT FRAME Blank $1,489.64 HCPCS - Non-Drugs E2343 NU W/C DPTH 22-25 IN SEAT FRAME Blank $1,489.64 HCPCS - Non-Drugs E2343 RR W/C DPTH 22-25 IN SEAT FRAME Blank $176.19 HCPCS - Non-Drugs E2343 UE W/C DPTH 22-25 IN SEAT FRAME Blank $1,124.78 HCPCS - Non-Drugs E2351 Blank ELECTRONIC SGD INTERFACE Blank $1,229.92 HCPCS - Non-Drugs E2351 NU ELECTRONIC SGD INTERFACE Blank $1,229.92 HCPCS - Non-Drugs E2351 RR ELECTRONIC SGD INTERFACE Blank $150.23 HCPCS - Non-Drugs E2351 UE ELECTRONIC SGD INTERFACE Blank $930.02 HCPCS - Non-Drugs E2358 Blank GR 34 NONSEALED LEADACID Blank $328.33 HCPCS - Non-Drugs E2359 Blank GR34 SEALED LEADACID BATTERY Blank $469.88 HCPCS - Non-Drugs E2359 NU GR34 SEALED LEADACID BATTERY Blank $469.88 HCPCS - Non-Drugs E2359 RR GR34 SEALED LEADACID BATTERY Blank $62.30 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 48 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E2359 UE GR34 SEALED LEADACID BATTERY Blank $359.98 HCPCS - Non-Drugs E2360 Blank 22NF NONSEALED LEADACID Blank $299.39 HCPCS - Non-Drugs E2360 NU 22NF NONSEALED LEADACID Blank $299.39 HCPCS - Non-Drugs E2360 RR 22NF NONSEALED LEADACID Blank $26.15 HCPCS - Non-Drugs E2360 UE 22NF NONSEALED LEADACID Blank $232.11 HCPCS - Non-Drugs E2361 Blank 22NF SEALED LEADACID BATTERY Blank $330.63 HCPCS - Non-Drugs E2361 NU 22NF SEALED LEADACID BATTERY Blank $330.63 HCPCS - Non-Drugs E2361 RR 22NF SEALED LEADACID BATTERY Blank $39.84 HCPCS - Non-Drugs E2361 UE 22NF SEALED LEADACID BATTERY Blank $255.55 HCPCS - Non-Drugs E2362 Blank GR24 NONSEALED LEADACID Blank $275.17 HCPCS - Non-Drugs E2362 NU GR24 NONSEALED LEADACID Blank $275.17 HCPCS - Non-Drugs E2362 RR GR24 NONSEALED LEADACID Blank $23.77 HCPCS - Non-Drugs E2362 UE GR24 NONSEALED LEADACID Blank $213.94 HCPCS - Non-Drugs E2363 Blank GR24 SEALED LEADACID BATTERY Blank $409.40 HCPCS - Non-Drugs E2363 NU GR24 SEALED LEADACID BATTERY Blank $409.40 HCPCS - Non-Drugs E2363 RR GR24 SEALED LEADACID BATTERY Blank $52.55 HCPCS - Non-Drugs E2363 UE GR24 SEALED LEADACID BATTERY Blank $314.62 HCPCS - Non-Drugs E2364 Blank U1NONSEALED LEADACID BATTERY Blank $291.69 HCPCS - Non-Drugs E2364 NU U1NONSEALED LEADACID BATTERY Blank $291.69 HCPCS - Non-Drugs E2364 RR U1NONSEALED LEADACID BATTERY Blank $25.37 HCPCS - Non-Drugs E2364 UE U1NONSEALED LEADACID BATTERY Blank $226.34 HCPCS - Non-Drugs E2365 Blank U1 SEALED LEADACID BATTERY Blank $231.83 HCPCS - Non-Drugs E2365 NU U1 SEALED LEADACID BATTERY Blank $231.83 HCPCS - Non-Drugs E2365 RR U1 SEALED LEADACID BATTERY Blank $19.56 HCPCS - Non-Drugs E2365 UE U1 SEALED LEADACID BATTERY Blank $181.44 HCPCS - Non-Drugs E2366 Blank BATTERY CHARGER, SINGLE MODE Blank $446.70 HCPCS - Non-Drugs E2366 NU BATTERY CHARGER, SINGLE MODE Blank $446.70 HCPCS - Non-Drugs E2366 RR BATTERY CHARGER, SINGLE MODE Blank $58.67 HCPCS - Non-Drugs E2366 UE BATTERY CHARGER, SINGLE MODE Blank $343.15 HCPCS - Non-Drugs E2367 Blank BATTERY CHARGER, DUAL MODE Blank $876.19 HCPCS - Non-Drugs E2367 NU BATTERY CHARGER, DUAL MODE Blank $876.19 HCPCS - Non-Drugs E2367 RR BATTERY CHARGER, DUAL MODE Blank $114.87 HCPCS - Non-Drugs E2367 UE BATTERY CHARGER, DUAL MODE Blank $664.72 HCPCS - Non-Drugs E2368 Blank PWR WC DRIVEWHEEL MOTOR REPL Blank $1,096.50 HCPCS - Non-Drugs E2368 NU PWR WC DRIVEWHEEL MOTOR REPL Blank $1,096.50 HCPCS - Non-Drugs E2368 RR PWR WC DRIVEWHEEL MOTOR REPL Blank $138.76 HCPCS - Non-Drugs E2368 UE PWR WC DRIVEWHEEL MOTOR REPL Blank $757.50 HCPCS - Non-Drugs E2369 Blank PWR WC DRIVEWHEEL GEAR REPL Blank $1,037.75 HCPCS - Non-Drugs E2369 NU PWR WC DRIVEWHEEL GEAR REPL Blank $1,037.75 HCPCS - Non-Drugs E2369 RR PWR WC DRIVEWHEEL GEAR REPL Blank $131.32 HCPCS - Non-Drugs E2369 UE PWR WC DRIVEWHEEL GEAR REPL Blank $663.88 HCPCS - Non-Drugs E2370 Blank PWR WC DR WH MOTOR/GEAR COMB Blank $1,345.53 HCPCS - Non-Drugs E2370 NU PWR WC DR WH MOTOR/GEAR COMB Blank $1,345.53 HCPCS - Non-Drugs E2370 RR PWR WC DR WH MOTOR/GEAR COMB Blank $170.27 HCPCS - Non-Drugs E2370 UE PWR WC DR WH MOTOR/GEAR COMB Blank $1,160.35 HCPCS - Non-Drugs E2371 Blank GR27 SEALED LEADACID BATTERY Blank $274.48 HCPCS - Non-Drugs E2371 NU GR27 SEALED LEADACID BATTERY Blank $274.48 HCPCS - Non-Drugs E2371 RR GR27 SEALED LEADACID BATTERY Blank $38.08 HCPCS - Non-Drugs E2371 UE GR27 SEALED LEADACID BATTERY Blank $213.43 HCPCS - Non-Drugs E2372 Blank GR27 NON-SEALED LEADACID Blank $198.68 HCPCS - Non-Drugs E2372 NU GR27 NON-SEALED LEADACID Blank $198.68 HCPCS - Non-Drugs E2372 RR GR27 NON-SEALED LEADACID Blank $21.14 HCPCS - Non-Drugs E2372 UE GR27 NON-SEALED LEADACID Blank $149.38 HCPCS - Non-Drugs E2373 Blank HAND/CHIN CTRL SPEC JOYSTICK Blank $1,300.72 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 49 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E2373 NU HAND/CHIN CTRL SPEC JOYSTICK Blank $1,300.72 HCPCS - Non-Drugs E2373 RR HAND/CHIN CTRL SPEC JOYSTICK Blank $164.60 HCPCS - Non-Drugs E2373 UE HAND/CHIN CTRL SPEC JOYSTICK Blank $1,339.08 HCPCS - Non-Drugs E2374 Blank HAND/CHIN CTRL STD JOYSTICK Blank $910.60 HCPCS - Non-Drugs E2374 NU HAND/CHIN CTRL STD JOYSTICK Blank $910.60 HCPCS - Non-Drugs E2374 RR HAND/CHIN CTRL STD JOYSTICK Blank $115.23 HCPCS - Non-Drugs E2374 UE HAND/CHIN CTRL STD JOYSTICK Blank $782.08 HCPCS - Non-Drugs E2375 Blank NON-EXPANDABLE CONTROLLER Blank $1,645.23 HCPCS - Non-Drugs E2375 NU NON-EXPANDABLE CONTROLLER Blank $1,645.23 HCPCS - Non-Drugs E2375 RR NON-EXPANDABLE CONTROLLER Blank $208.20 HCPCS - Non-Drugs E2375 UE NON-EXPANDABLE CONTROLLER Blank $1,236.01 HCPCS - Non-Drugs E2376 Blank EXPANDABLE CONTROLLER, REPL Blank $2,719.53 HCPCS - Non-Drugs E2376 NU EXPANDABLE CONTROLLER, REPL Blank $2,719.53 HCPCS - Non-Drugs E2376 RR EXPANDABLE CONTROLLER, REPL Blank $344.15 HCPCS - Non-Drugs E2376 UE EXPANDABLE CONTROLLER, REPL Blank $1,919.72 HCPCS - Non-Drugs E2377 Blank EXPANDABLE CONTROLLER, INITL Blank $857.17 HCPCS - Non-Drugs E2377 NU EXPANDABLE CONTROLLER, INITL Blank $857.17 HCPCS - Non-Drugs E2377 RR EXPANDABLE CONTROLLER, INITL Blank $108.47 HCPCS - Non-Drugs E2377 UE EXPANDABLE CONTROLLER, INITL Blank $714.00 HCPCS - Non-Drugs E2378 Blank PW ACTUATOR REPLACEMENT Blank $1,025.04 HCPCS - Non-Drugs E2378 NU PW ACTUATOR REPLACEMENT Blank $1,025.04 HCPCS - Non-Drugs E2378 RR PW ACTUATOR REPLACEMENT Blank $129.72 HCPCS - Non-Drugs E2378 UE PW ACTUATOR REPLACEMENT Blank $982.57 HCPCS - Non-Drugs E2381 Blank PNEUM DRIVE WHEEL TIRE Blank $189.82 HCPCS - Non-Drugs E2381 NU PNEUM DRIVE WHEEL TIRE Blank $189.82 HCPCS - Non-Drugs E2381 RR PNEUM DRIVE WHEEL TIRE Blank $15.48 HCPCS - Non-Drugs E2381 UE PNEUM DRIVE WHEEL TIRE Blank $149.94 HCPCS - Non-Drugs E2382 Blank TUBE, PNEUM WHEEL DRIVE TIRE Blank $65.68 HCPCS - Non-Drugs E2382 NU TUBE, PNEUM WHEEL DRIVE TIRE Blank $65.68 HCPCS - Non-Drugs E2382 RR TUBE, PNEUM WHEEL DRIVE TIRE Blank $4.48 HCPCS - Non-Drugs E2382 UE TUBE, PNEUM WHEEL DRIVE TIRE Blank $47.14 HCPCS - Non-Drugs E2383 Blank INSERT, PNEUM WHEEL DRIVE Blank $363.31 HCPCS - Non-Drugs E2383 NU INSERT, PNEUM WHEEL DRIVE Blank $363.31 HCPCS - Non-Drugs E2383 RR INSERT, PNEUM WHEEL DRIVE Blank $45.11 HCPCS - Non-Drugs E2383 UE INSERT, PNEUM WHEEL DRIVE Blank $280.06 HCPCS - Non-Drugs E2384 Blank PNEUMATIC CASTER TIRE Blank $191.53 HCPCS - Non-Drugs E2384 NU PNEUMATIC CASTER TIRE Blank $191.53 HCPCS - Non-Drugs E2384 RR PNEUMATIC CASTER TIRE Blank $15.65 HCPCS - Non-Drugs E2384 UE PNEUMATIC CASTER TIRE Blank $151.22 HCPCS - Non-Drugs E2385 Blank TUBE, PNEUMATIC CASTER TIRE Blank $140.78 HCPCS - Non-Drugs E2385 NU TUBE, PNEUMATIC CASTER TIRE Blank $140.78 HCPCS - Non-Drugs E2385 RR TUBE, PNEUMATIC CASTER TIRE Blank $10.74 HCPCS - Non-Drugs E2385 UE TUBE, PNEUMATIC CASTER TIRE Blank $113.16 HCPCS - Non-Drugs E2386 Blank FOAM FILLED DRIVE WHEEL TIRE Blank $301.39 HCPCS - Non-Drugs E2386 NU FOAM FILLED DRIVE WHEEL TIRE Blank $301.39 HCPCS - Non-Drugs E2386 RR FOAM FILLED DRIVE WHEEL TIRE Blank $26.31 HCPCS - Non-Drugs E2386 UE FOAM FILLED DRIVE WHEEL TIRE Blank $233.62 HCPCS - Non-Drugs E2387 Blank FOAM FILLED CASTER TIRE Blank $159.98 HCPCS - Non-Drugs E2387 NU FOAM FILLED CASTER TIRE Blank $159.98 HCPCS - Non-Drugs E2387 RR FOAM FILLED CASTER TIRE Blank $12.59 HCPCS - Non-Drugs E2387 UE FOAM FILLED CASTER TIRE Blank $127.57 HCPCS - Non-Drugs E2388 Blank FOAM DRIVE WHEEL TIRE Blank $111.16 HCPCS - Non-Drugs E2388 NU FOAM DRIVE WHEEL TIRE Blank $111.16 HCPCS - Non-Drugs E2388 RR FOAM DRIVE WHEEL TIRE Blank $11.67 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 50 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E2388 UE FOAM DRIVE WHEEL TIRE Blank $90.93 HCPCS - Non-Drugs E2389 Blank FOAM CASTER TIRE Blank $75.48 HCPCS - Non-Drugs E2389 NU FOAM CASTER TIRE Blank $75.48 HCPCS - Non-Drugs E2389 RR FOAM CASTER TIRE Blank $6.52 HCPCS - Non-Drugs E2389 UE FOAM CASTER TIRE Blank $56.18 HCPCS - Non-Drugs E2390 Blank SOLID DRIVE WHEEL TIRE Blank $100.26 HCPCS - Non-Drugs E2390 NU SOLID DRIVE WHEEL TIRE Blank $100.26 HCPCS - Non-Drugs E2390 RR SOLID DRIVE WHEEL TIRE Blank $10.10 HCPCS - Non-Drugs E2390 UE SOLID DRIVE WHEEL TIRE Blank $82.77 HCPCS - Non-Drugs E2391 Blank SOLID CASTER TIRE Blank $65.76 HCPCS - Non-Drugs E2391 NU SOLID CASTER TIRE Blank $65.76 HCPCS - Non-Drugs E2391 RR SOLID CASTER TIRE Blank $4.48 HCPCS - Non-Drugs E2391 UE SOLID CASTER TIRE Blank $47.17 HCPCS - Non-Drugs E2392 Blank SOLID CASTER TIRE, INTEGRATE Blank $141.89 HCPCS - Non-Drugs E2392 NU SOLID CASTER TIRE, INTEGRATE Blank $141.89 HCPCS - Non-Drugs E2392 RR SOLID CASTER TIRE, INTEGRATE Blank $10.84 HCPCS - Non-Drugs E2392 UE SOLID CASTER TIRE, INTEGRATE Blank $113.99 HCPCS - Non-Drugs E2394 Blank DRIVE WHEEL EXCLUDES TIRE Blank $184.24 HCPCS - Non-Drugs E2394 NU DRIVE WHEEL EXCLUDES TIRE Blank $184.24 HCPCS - Non-Drugs E2394 RR DRIVE WHEEL EXCLUDES TIRE Blank $14.94 HCPCS - Non-Drugs E2394 UE DRIVE WHEEL EXCLUDES TIRE Blank $145.75 HCPCS - Non-Drugs E2395 Blank CASTER WHEEL EXCLUDES TIRE Blank $145.03 HCPCS - Non-Drugs E2395 NU CASTER WHEEL EXCLUDES TIRE Blank $145.03 HCPCS - Non-Drugs E2395 RR CASTER WHEEL EXCLUDES TIRE Blank $11.14 HCPCS - Non-Drugs E2395 UE CASTER WHEEL EXCLUDES TIRE Blank $116.35 HCPCS - Non-Drugs E2396 Blank CASTER FORK Blank $166.43 HCPCS - Non-Drugs E2396 NU CASTER FORK Blank $166.43 HCPCS - Non-Drugs E2396 RR CASTER FORK Blank $13.22 HCPCS - Non-Drugs E2396 UE CASTER FORK Blank $132.39 HCPCS - Non-Drugs E2397 Blank PWC ACC, LITH-BASED BATTERY Blank $805.60 HCPCS - Non-Drugs E2397 NU PWC ACC, LITH-BASED BATTERY Blank $805.60 HCPCS - Non-Drugs E2397 RR PWC ACC, LITH-BASED BATTERY Blank $107.81 HCPCS - Non-Drugs E2397 UE PWC ACC, LITH-BASED BATTERY Blank $611.77 HCPCS - Non-Drugs E2402 Blank NEG PRESS WOUND THERAPY PUMP Blank $10,776.15 HCPCS - Non-Drugs E2402 RR NEG PRESS WOUND THERAPY PUMP Blank $1,363.69 HCPCS - Non-Drugs E2500 Blank SGD DIGITIZED PRE-REC <=8MIN Blank $914.10 HCPCS - Non-Drugs E2500 NU SGD DIGITIZED PRE-REC <=8MIN Blank $914.10 HCPCS - Non-Drugs E2500 RR SGD DIGITIZED PRE-REC <=8MIN Blank $152.33 HCPCS - Non-Drugs E2500 UE SGD DIGITIZED PRE-REC <=8MIN Blank $702.50 HCPCS - Non-Drugs E2502 Blank SGD PREREC MSG >8MIN <=20MIN Blank $2,656.05 HCPCS - Non-Drugs E2502 NU SGD PREREC MSG >8MIN <=20MIN Blank $2,656.05 HCPCS - Non-Drugs E2502 RR SGD PREREC MSG >8MIN <=20MIN Blank $326.51 HCPCS - Non-Drugs E2502 UE SGD PREREC MSG >8MIN <=20MIN Blank $2,008.99 HCPCS - Non-Drugs E2504 Blank SGD PREREC MSG>20MIN <=40MIN Blank $3,482.08 HCPCS - Non-Drugs E2504 NU SGD PREREC MSG>20MIN <=40MIN Blank $3,482.08 HCPCS - Non-Drugs E2504 RR SGD PREREC MSG>20MIN <=40MIN Blank $409.16 HCPCS - Non-Drugs E2504 UE SGD PREREC MSG>20MIN <=40MIN Blank $2,628.48 HCPCS - Non-Drugs E2506 Blank SGD PREREC MSG > 40 MIN Blank $5,074.24 HCPCS - Non-Drugs E2506 NU SGD PREREC MSG > 40 MIN Blank $5,074.24 HCPCS - Non-Drugs E2506 RR SGD PREREC MSG > 40 MIN Blank $568.29 HCPCS - Non-Drugs E2506 UE SGD PREREC MSG > 40 MIN Blank $3,822.52 HCPCS - Non-Drugs E2508 Blank SGD SPELLING PHYS CONTACT Blank $7,809.47 HCPCS - Non-Drugs E2508 NU SGD SPELLING PHYS CONTACT Blank $7,809.47 HCPCS - Non-Drugs E2508 RR SGD SPELLING PHYS CONTACT Blank $841.84 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 51 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E2508 UE SGD SPELLING PHYS CONTACT Blank $5,874.04 HCPCS - Non-Drugs E2510 Blank SGD W MULTI METHODS MSG/ACCS Blank $14,718.02 HCPCS - Non-Drugs E2510 NU SGD W MULTI METHODS MSG/ACCS Blank $14,718.02 HCPCS - Non-Drugs E2510 RR SGD W MULTI METHODS MSG/ACCS Blank $1,532.71 HCPCS - Non-Drugs E2510 UE SGD W MULTI METHODS MSG/ACCS Blank $11,055.43 HCPCS - Non-Drugs E2511 Blank SGD SFTWRE PRGRM FOR PC/PDA Blank $1,174.97 HCPCS - Non-Drugs E2511 NU SGD SFTWRE PRGRM FOR PC/PDA Blank $1,174.97 HCPCS - Non-Drugs E2511 RR SGD SFTWRE PRGRM FOR PC/PDA Blank $126.96 HCPCS - Non-Drugs E2511 UE SGD SFTWRE PRGRM FOR PC/PDA Blank $893.28 HCPCS - Non-Drugs E2512 Blank SGD ACCESSORY, MOUNTING SYS Blank $1,798.04 HCPCS - Non-Drugs E2512 NU SGD ACCESSORY, MOUNTING SYS Blank $1,798.04 HCPCS - Non-Drugs E2512 RR SGD ACCESSORY, MOUNTING SYS Blank $227.54 HCPCS - Non-Drugs E2512 UE SGD ACCESSORY, MOUNTING SYS Blank $1,366.98 HCPCS - Non-Drugs E2599 Blank SGD ACCESSORY NOC Blank $699.36 HCPCS - Non-Drugs E2601 Blank GEN W/C CUSHION WDTH < 22 IN Blank $132.76 HCPCS - Non-Drugs E2601 NU GEN W/C CUSHION WDTH < 22 IN Blank $132.76 HCPCS - Non-Drugs E2601 RR GEN W/C CUSHION WDTH < 22 IN Blank $9.95 HCPCS - Non-Drugs E2601 UE GEN W/C CUSHION WDTH < 22 IN Blank $107.14 HCPCS - Non-Drugs E2602 Blank GEN W/C CUSHION WDTH >=22 IN Blank $251.66 HCPCS - Non-Drugs E2602 NU GEN W/C CUSHION WDTH >=22 IN Blank $251.66 HCPCS - Non-Drugs E2602 RR GEN W/C CUSHION WDTH >=22 IN Blank $21.49 HCPCS - Non-Drugs E2602 UE GEN W/C CUSHION WDTH >=22 IN Blank $196.32 HCPCS - Non-Drugs E2603 Blank SKIN PROTECT WC CUS WD <22IN Blank $301.76 HCPCS - Non-Drugs E2603 NU SKIN PROTECT WC CUS WD <22IN Blank $301.76 HCPCS - Non-Drugs E2603 RR SKIN PROTECT WC CUS WD <22IN Blank $26.34 HCPCS - Non-Drugs E2603 UE SKIN PROTECT WC CUS WD <22IN Blank $233.89 HCPCS - Non-Drugs E2604 Blank SKIN PROTECT WC CUS WD>=22IN Blank $416.02 HCPCS - Non-Drugs E2604 NU SKIN PROTECT WC CUS WD>=22IN Blank $416.02 HCPCS - Non-Drugs E2604 RR SKIN PROTECT WC CUS WD>=22IN Blank $53.62 HCPCS - Non-Drugs E2604 UE SKIN PROTECT WC CUS WD>=22IN Blank $319.59 HCPCS - Non-Drugs E2605 Blank POSITION WC CUSH WDTH <22 IN Blank $583.06 HCPCS - Non-Drugs E2605 NU POSITION WC CUSH WDTH <22 IN Blank $583.06 HCPCS - Non-Drugs E2605 RR POSITION WC CUSH WDTH <22 IN Blank $80.56 HCPCS - Non-Drugs E2605 UE POSITION WC CUSH WDTH <22 IN Blank $444.87 HCPCS - Non-Drugs E2606 Blank POSITION WC CUSH WDTH>=22 IN Blank $918.19 HCPCS - Non-Drugs E2606 NU POSITION WC CUSH WDTH>=22 IN Blank $918.19 HCPCS - Non-Drugs E2606 RR POSITION WC CUSH WDTH>=22 IN Blank $119.07 HCPCS - Non-Drugs E2606 UE POSITION WC CUSH WDTH>=22 IN Blank $696.22 HCPCS - Non-Drugs E2607 Blank SKIN PRO/POS WC CUS WD <22IN Blank $569.58 HCPCS - Non-Drugs E2607 NU SKIN PRO/POS WC CUS WD <22IN Blank $569.58 HCPCS - Non-Drugs E2607 RR SKIN PRO/POS WC CUS WD <22IN Blank $78.37 HCPCS - Non-Drugs E2607 UE SKIN PRO/POS WC CUS WD <22IN Blank $434.76 HCPCS - Non-Drugs E2608 Blank SKIN PRO/POS WC CUS WD>=22IN Blank $715.89 HCPCS - Non-Drugs E2608 NU SKIN PRO/POS WC CUS WD>=22IN Blank $715.89 HCPCS - Non-Drugs E2608 RR SKIN PRO/POS WC CUS WD>=22IN Blank $98.84 HCPCS - Non-Drugs E2608 UE SKIN PRO/POS WC CUS WD>=22IN Blank $544.48 HCPCS - Non-Drugs E2609 Blank CUSTOM FABRICATE W/C CUSHION Blank $508.36 HCPCS - Non-Drugs E2610 Blank POWERED W/C CUSHION Blank $481.14 HCPCS - Non-Drugs E2611 Blank GEN USE BACK CUSH WDTH <22IN Blank $450.07 HCPCS - Non-Drugs E2611 NU GEN USE BACK CUSH WDTH <22IN Blank $450.07 HCPCS - Non-Drugs E2611 RR GEN USE BACK CUSH WDTH <22IN Blank $59.11 HCPCS - Non-Drugs E2611 UE GEN USE BACK CUSH WDTH <22IN Blank $345.12 HCPCS - Non-Drugs E2612 Blank GEN USE BACK CUSH WDTH>=22IN Blank $839.92 HCPCS - Non-Drugs E2612 NU GEN USE BACK CUSH WDTH>=22IN Blank $839.92 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 52 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E2612 RR GEN USE BACK CUSH WDTH>=22IN Blank $111.25 HCPCS - Non-Drugs E2612 UE GEN USE BACK CUSH WDTH>=22IN Blank $637.51 HCPCS - Non-Drugs E2613 Blank POSITION BACK CUSH WD <22IN Blank $835.83 HCPCS - Non-Drugs E2613 NU POSITION BACK CUSH WD <22IN Blank $835.83 HCPCS - Non-Drugs E2613 RR POSITION BACK CUSH WD <22IN Blank $110.83 HCPCS - Non-Drugs E2613 UE POSITION BACK CUSH WD <22IN Blank $634.45 HCPCS - Non-Drugs E2614 Blank POSITION BACK CUSH WD>=22IN Blank $1,225.98 HCPCS - Non-Drugs E2614 NU POSITION BACK CUSH WD>=22IN Blank $1,225.98 HCPCS - Non-Drugs E2614 RR POSITION BACK CUSH WD>=22IN Blank $149.85 HCPCS - Non-Drugs E2614 UE POSITION BACK CUSH WD>=22IN Blank $927.06 HCPCS - Non-Drugs E2615 Blank POS BACK POST/LAT WDTH <22IN Blank $954.16 HCPCS - Non-Drugs E2615 NU POS BACK POST/LAT WDTH <22IN Blank $954.16 HCPCS - Non-Drugs E2615 RR POS BACK POST/LAT WDTH <22IN Blank $122.67 HCPCS - Non-Drugs E2615 UE POS BACK POST/LAT WDTH <22IN Blank $723.20 HCPCS - Non-Drugs E2616 Blank POS BACK POST/LAT WDTH>=22IN Blank $1,277.15 HCPCS - Non-Drugs E2616 NU POS BACK POST/LAT WDTH>=22IN Blank $1,277.15 HCPCS - Non-Drugs E2616 RR POS BACK POST/LAT WDTH>=22IN Blank $154.96 HCPCS - Non-Drugs E2616 UE POS BACK POST/LAT WDTH>=22IN Blank $965.44 HCPCS - Non-Drugs E2617 Blank CUSTOM FAB W/C BACK CUSHION Blank $902.25 HCPCS - Non-Drugs E2619 Blank REPLACE COVER W/C SEAT CUSH Blank $113.54 HCPCS - Non-Drugs E2619 NU REPLACE COVER W/C SEAT CUSH Blank $113.54 HCPCS - Non-Drugs E2619 RR REPLACE COVER W/C SEAT CUSH Blank $12.01 HCPCS - Non-Drugs E2619 UE REPLACE COVER W/C SEAT CUSH Blank $92.73 HCPCS - Non-Drugs E2620 Blank WC PLANAR BACK CUSH WD <22IN Blank $1,027.74 HCPCS - Non-Drugs E2620 NU WC PLANAR BACK CUSH WD <22IN Blank $1,027.74 HCPCS - Non-Drugs E2620 RR WC PLANAR BACK CUSH WD <22IN Blank $130.03 HCPCS - Non-Drugs E2620 UE WC PLANAR BACK CUSH WD <22IN Blank $778.38 HCPCS - Non-Drugs E2621 Blank WC PLANAR BACK CUSH WD>=22IN Blank $1,207.91 HCPCS - Non-Drugs E2621 NU WC PLANAR BACK CUSH WD>=22IN Blank $1,207.91 HCPCS - Non-Drugs E2621 RR WC PLANAR BACK CUSH WD>=22IN Blank $148.04 HCPCS - Non-Drugs E2621 UE WC PLANAR BACK CUSH WD>=22IN Blank $913.51 HCPCS - Non-Drugs E2622 Blank ADJ SKIN PRO W/C CUS WD<22IN Blank $558.50 HCPCS - Non-Drugs E2622 NU ADJ SKIN PRO W/C CUS WD<22IN Blank $558.50 HCPCS - Non-Drugs E2622 RR ADJ SKIN PRO W/C CUS WD<22IN Blank $83.10 HCPCS - Non-Drugs E2622 UE ADJ SKIN PRO W/C CUS WD<22IN Blank $426.45 HCPCS - Non-Drugs E2623 Blank ADJ SKIN PRO WC CUS WD>=22IN Blank $698.25 HCPCS - Non-Drugs E2623 NU ADJ SKIN PRO WC CUS WD>=22IN Blank $698.25 HCPCS - Non-Drugs E2623 RR ADJ SKIN PRO WC CUS WD>=22IN Blank $97.08 HCPCS - Non-Drugs E2623 UE ADJ SKIN PRO WC CUS WD>=22IN Blank $531.25 HCPCS - Non-Drugs E2624 Blank ADJ SKIN PRO/POS CUS<22IN Blank $567.04 HCPCS - Non-Drugs E2624 NU ADJ SKIN PRO/POS CUS<22IN Blank $567.04 HCPCS - Non-Drugs E2624 RR ADJ SKIN PRO/POS CUS<22IN Blank $83.96 HCPCS - Non-Drugs E2624 UE ADJ SKIN PRO/POS CUS<22IN Blank $432.85 HCPCS - Non-Drugs E2625 Blank ADJ SKIN PRO/POS WC CUS>=22 Blank $1,018.03 HCPCS - Non-Drugs E2625 NU ADJ SKIN PRO/POS WC CUS>=22 Blank $1,018.03 HCPCS - Non-Drugs E2625 RR ADJ SKIN PRO/POS WC CUS>=22 Blank $129.06 HCPCS - Non-Drugs E2625 UE ADJ SKIN PRO/POS WC CUS>=22 Blank $771.10 HCPCS - Non-Drugs E2626 Blank SEO MOBILE ARM SUP ATT TO WC Blank $1,152.70 HCPCS - Non-Drugs E2626 NU SEO MOBILE ARM SUP ATT TO WC Blank $1,152.70 HCPCS - Non-Drugs E2626 RR SEO MOBILE ARM SUP ATT TO WC Blank $142.52 HCPCS - Non-Drugs E2626 UE SEO MOBILE ARM SUP ATT TO WC Blank $872.10 HCPCS - Non-Drugs E2627 Blank ARM SUPP ATT TO WC RANCHO TY Blank $1,766.94 HCPCS - Non-Drugs E2627 NU ARM SUPP ATT TO WC RANCHO TY Blank $1,766.94 HCPCS - Non-Drugs E2627 RR ARM SUPP ATT TO WC RANCHO TY Blank $203.95 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 53 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
E2627 UE ARM SUPP ATT TO WC RANCHO TY Blank $1,332.77 HCPCS - Non-Drugs E2628 Blank MOBILE ARM SUPPORTS RECLININ Blank $1,370.42 HCPCS - Non-Drugs E2628 NU MOBILE ARM SUPPORTS RECLININ Blank $1,370.42 HCPCS - Non-Drugs E2628 RR MOBILE ARM SUPPORTS RECLININ Blank $164.29 HCPCS - Non-Drugs E2628 UE MOBILE ARM SUPPORTS RECLININ Blank $1,035.39 HCPCS - Non-Drugs E2629 Blank FRICTION DAMPENING ARM SUPP Blank $1,739.85 HCPCS - Non-Drugs E2629 NU FRICTION DAMPENING ARM SUPP Blank $1,739.85 HCPCS - Non-Drugs E2629 RR FRICTION DAMPENING ARM SUPP Blank $201.23 HCPCS - Non-Drugs E2629 UE FRICTION DAMPENING ARM SUPP Blank $1,312.46 HCPCS - Non-Drugs E2630 Blank MONOSUSPENSION ARM/HAND SUPP Blank $1,752.75 HCPCS - Non-Drugs E2630 NU MONOSUSPENSION ARM/HAND SUPP Blank $1,752.75 HCPCS - Non-Drugs E2630 RR MONOSUSPENSION ARM/HAND SUPP Blank $202.53 HCPCS - Non-Drugs E2630 UE MONOSUSPENSION ARM/HAND SUPP Blank $1,322.13 HCPCS - Non-Drugs E2631 Blank ELEVAT PROXIMAL ARM SUPPORT Blank $509.63 HCPCS - Non-Drugs E2631 NU ELEVAT PROXIMAL ARM SUPPORT Blank $509.63 HCPCS - Non-Drugs E2631 RR ELEVAT PROXIMAL ARM SUPPORT Blank $78.22 HCPCS - Non-Drugs E2631 UE ELEVAT PROXIMAL ARM SUPPORT Blank $389.80 HCPCS - Non-Drugs E2632 Blank OFFSET/LAT ROCKER ARM W/ELA Blank $330.26 HCPCS - Non-Drugs E2632 NU OFFSET/LAT ROCKER ARM W/ELA Blank $330.26 HCPCS - Non-Drugs E2632 RR OFFSET/LAT ROCKER ARM W/ELA Blank $48.73 HCPCS - Non-Drugs E2632 UE OFFSET/LAT ROCKER ARM W/ELA Blank $255.27 HCPCS - Non-Drugs E2633 Blank MOBILE ARM SUPPORT SUPINATOR Blank $399.34 HCPCS - Non-Drugs E2633 NU MOBILE ARM SUPPORT SUPINATOR Blank $399.34 HCPCS - Non-Drugs E2633 RR MOBILE ARM SUPPORT SUPINATOR Blank $50.93 HCPCS - Non-Drugs E2633 UE MOBILE ARM SUPPORT SUPINATOR Blank $307.08 HCPCS - Non-Drugs G0333 Blank DISPENSE FEE INITIAL 30 DAY Blank $84.26 HCPCS - Non-Drugs G9017 Blank AMANTADINE HCL 100MG ORAL Blank $11.31 HCPCS - Drugs G9018 Blank ZANAMIVIR,INHALATION PWD 10M Blank $21.77 HCPCS - Drugs G9019 Blank OSELTAMIVIR PHOSPHATE 75MG Blank $22.57 HCPCS - Drugs G9020 Blank RIMANTADINE HCL 100MG ORAL Blank $12.92 HCPCS - Drugs G9033 Blank AMANTADINE HCL ORAL BRAND Blank $72.03 HCPCS - Drugs G9034 Blank ZANAMIVIR, INH PWDR, BRAND Blank $57.49 HCPCS - Drugs G9036 Blank RIMANTADINE HCL, BRAND Blank $222.96 HCPCS - Drugs J0120 Blank TETRACYCLIN INJECTION a $90.02 HCPCS - Drugs J0129 Blank ABATACEPT INJECTION a $101.40 HCPCS - Drugs J0130 Blank ABCIXIMAB INJECTION a $2,441.23 HCPCS - Drugs J0131 Blank ACETAMINOPHEN INJECTION a $0.94 HCPCS - Drugs J0132 Blank ACETYLCYSTEINE INJECTION a $12.92 HCPCS - Drugs J0133 Blank ACYCLOVIR INJECTION a $5.25 HCPCS - Drugs J0135 Blank ADALIMUMAB INJECTION a $1,798.56 HCPCS - Drugs J0153 Blank ADENOSINE INJ 1MG a $10.51 HCPCS - Drugs J0171 Blank ADRENALIN EPINEPHRINE INJECT a $5.25 HCPCS - Drugs J0178 Blank AFLIBERCEPT INJECTION a $2,211.18 HCPCS - Drugs J0180 Blank AGALSIDASE BETA INJECTION a $367.63 HCPCS - Drugs J0190 Blank INJ BIPERIDEN LACTATE/5 MG Blank $4.59 HCPCS - Drugs J0200 Blank ALATROFLOXACIN MESYLATE a $37.92 HCPCS - Drugs J0202 Blank INJECTION, ALEMTUZUMAB a $3,914.78 HCPCS - Drugs J0205 Blank ALGLUCERASE INJECTION a $83.70 HCPCS - Drugs J0207 Blank AMIFOSTINE a $1,377.88 HCPCS - Drugs J0210 Blank METHYLDOPATE HCL INJECTION a $32.22 HCPCS - Drugs J0215 Blank ALEFACEPT a $71.64 HCPCS - Drugs J0220 Blank ALGLUCOSIDASE ALFA INJECTION a $473.00 HCPCS - Drugs J0221 Blank LUMIZYME INJECTION a $356.37 HCPCS - Drugs J0256 Blank ALPHA 1 PROTEINASE INHIBITOR a $19.35 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 54 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J0257 Blank GLASSIA INJECTION a $18.55 HCPCS - Drugs J0270 Blank ALPROSTADIL FOR INJECTION a $14.53 HCPCS - Drugs J0275 Blank ALPROSTADIL URETHRAL SUPPOS a $65.09 HCPCS - Drugs J0278 Blank AMIKACIN SULFATE INJECTION a $12.92 HCPCS - Drugs J0280 Blank AMINOPHYLLIN 250 MG INJ a $27.40 HCPCS - Drugs J0282 Blank AMIODARONE HCL a $10.51 HCPCS - Drugs J0285 Blank AMPHOTERICIN B a $56.35 HCPCS - Drugs J0287 Blank AMPHOTERICIN B LIPID COMPLEX a $39.46 HCPCS - Drugs J0288 Blank AMPHO B CHOLESTERYL SULFATE a $185.05 HCPCS - Drugs J0289 Blank AMPHOTERICIN B LIPOSOME INJ a $49.11 HCPCS - Drugs J0290 Blank AMPICILLIN 500 MG INJ a $12.92 HCPCS - Drugs J0295 Blank AMPICILLIN SODIUM PER 1.5 GM a $15.33 HCPCS - Drugs J0300 Blank AMOBARBITAL 125 MG INJ a $37.05 HCPCS - Drugs J0330 Blank SUCCINYCHOLINE CHLORIDE INJ a $10.51 HCPCS - Drugs J0348 Blank ANIDULAFUNGIN INJECTION a $10.51 HCPCS - Drugs J0350 Blank INJECTION ANISTREPLASE 30 U Blank $280.76 HCPCS - Drugs J0360 Blank HYDRALAZINE HCL INJECTION a $29.81 HCPCS - Drugs J0364 Blank APOMORPHINE HYDROCHLORIDE Blank $16.14 HCPCS - Drugs J0365 Blank APROTONIN, 10,000 KIU a $15.33 HCPCS - Drugs J0380 Blank INJ METARAMINOL BITARTRATE a $11.31 HCPCS - Drugs J0390 Blank CHLOROQUINE INJECTION Blank $237.93 HCPCS - Drugs J0395 Blank ARBUTAMINE HCL INJECTION a $31.72 HCPCS - Drugs J0400 Blank ARIPIPRAZOLE INJECTION Blank $10.51 HCPCS - Drugs J0401 Blank INJ ARIPIPRAZOLE EXT REL 1MG a $18.55 HCPCS - Drugs J0456 Blank AZITHROMYCIN a $16.94 HCPCS - Drugs J0461 Blank ATROPINE SULFATE INJECTION a $5.25 HCPCS - Drugs J0470 Blank DIMECAPROL INJECTION Blank $94.96 HCPCS - Drugs J0475 Blank BACLOFEN 10 MG INJECTION a $419.11 HCPCS - Drugs J0476 Blank BACLOFEN INTRATHECAL TRIAL a $182.63 HCPCS - Drugs J0480 Blank BASILIXIMAB a $6,837.76 HCPCS - Drugs J0485 Blank BELATACEPT INJECTION a $17.74 HCPCS - Drugs J0490 Blank BELIMUMAB INJECTION a $102.20 HCPCS - Drugs J0500 Blank DICYCLOMINE INJECTION a $139.20 HCPCS - Drugs J0515 Blank INJ BENZTROPINE MESYLATE a $74.85 HCPCS - Drugs J0520 Blank BETHANECHOL CHLORIDE INJECT Blank $8.86 HCPCS - Drugs J0558 Blank PENG BENZATHINE/PROCAINE INJ a $23.38 HCPCS - Drugs J0561 Blank PENICILLIN G BENZATHINE INJ a $27.40 HCPCS - Drugs J0575 Blank BUPREN/NAL OVER 10MG BUPRENO Blank $28.65 HCPCS - Drugs J0583 Blank BIVALIRUDIN a $14.53 HCPCS - Drugs J0585 Blank INJECTION,ONABOTULINUMTOXINA a $21.77 HCPCS - Drugs J0586 Blank ABOBOTULINUMTOXINA a $26.59 HCPCS - Drugs J0587 Blank INJ, RIMABOTULINUMTOXINB a $35.44 HCPCS - Drugs J0588 Blank INCOBOTULINUMTOXIN A a $19.35 HCPCS - Drugs J0592 Blank BUPRENORPHINE HYDROCHLORIDE a $16.14 HCPCS - Drugs J0594 Blank BUSULFAN INJECTION a $83.70 HCPCS - Drugs J0595 Blank BUTORPHANOL TARTRATE 1 MG a $13.72 HCPCS - Drugs J0596 Blank INJECTION, RUCONEST a $109.90 HCPCS - Drugs J0597 Blank C-1 ESTERASE, BERINERT a $112.66 HCPCS - Drugs J0598 Blank C-1 ESTERASE, CINRYZE a $131.16 HCPCS - Drugs J0600 Blank EDETATE CALCIUM DISODIUM INJ a $12,576.73 HCPCS - Drugs J0610 Blank CALCIUM GLUCONATE INJECTION a $14.53 HCPCS - Drugs J0620 Blank CALCIUM GLYCER & LACT/10 ML a $36.24 HCPCS - Drugs J0630 Blank CALCITONIN SALMON INJECTION a $5,331.22 HCPCS - Drugs J0636 Blank INJ CALCITRIOL PER 0.1 MCG a $5.25 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 55 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J0637 Blank CASPOFUNGIN ACETATE a $38.66 HCPCS - Drugs J0638 Blank CANAKINUMAB INJECTION a $216.42 HCPCS - Drugs J0640 Blank LEUCOVORIN CALCIUM INJECTION a $16.94 HCPCS - Drugs J0641 Blank LEVOLEUCOVORIN INJECTION a $12.11 HCPCS - Drugs J0670 Blank INJ MEPIVACAINE HCL/10 ML a $13.72 HCPCS - Drugs J0690 Blank CEFAZOLIN SODIUM INJECTION a $10.51 HCPCS - Drugs J0692 Blank CEFEPIME HCL FOR INJECTION a $14.53 HCPCS - Drugs J0694 Blank CEFOXITIN SODIUM INJECTION a $19.35 HCPCS - Drugs J0695 Blank INJ CEFTOLOZANE TAZOBACTAM a $2.03 HCPCS - Drugs J0696 Blank CEFTRIAXONE SODIUM INJECTION a $10.51 HCPCS - Drugs J0697 Blank STERILE CEFUROXIME INJECTION a $14.53 HCPCS - Drugs J0698 Blank CEFOTAXIME SODIUM INJECTION a $10.51 HCPCS - Drugs J0702 Blank BETAMETHASONE ACET&SOD PHOSP a $21.77 HCPCS - Drugs J0706 Blank CAFFEINE CITRATE INJECTION a $16.14 HCPCS - Drugs J0710 Blank CEPHAPIRIN SODIUM INJECTION a $16.79 HCPCS - Drugs J0712 Blank CEFTAROLINE FOSAMIL INJ a $13.72 HCPCS - Drugs J0713 Blank INJ CEFTAZIDIME PER 500 MG a $14.53 HCPCS - Drugs J0714 Blank CEFTAZIDIME AND AVIBACTAM a $228.92 HCPCS - Drugs J0715 Blank CEFTIZOXIME SODIUM / 500 MG a $47.24 HCPCS - Drugs J0716 Blank CENTRUROIDES IMMUNE F(AB) a $9,997.68 HCPCS - Drugs J0717 Blank CERTOLIZUMAB PEGOL INJ 1MG a $23.38 HCPCS - Drugs J0720 Blank CHLORAMPHENICOL SODIUM INJEC a $80.48 HCPCS - Drugs J0725 Blank CHORIONIC GONADOTROPIN/1000U a $45.09 HCPCS - Drugs J0735 Blank CLONIDINE HYDROCHLORIDE a $38.66 HCPCS - Drugs J0740 Blank CIDOFOVIR INJECTION a $1,343.30 HCPCS - Drugs J0743 Blank CILASTATIN SODIUM INJECTION a $25.79 HCPCS - Drugs J0744 Blank CIPROFLOXACIN IV a $12.11 HCPCS - Drugs J0745 Blank INJ CODEINE PHOSPHATE /30 MG a $11.31 HCPCS - Drugs J0760 Blank COLCHICINE INJECTION Blank $22.57 HCPCS - Drugs J0770 Blank COLISTIMETHATE SODIUM INJ a $33.83 HCPCS - Drugs J0775 Blank COLLAGENASE, CLOST HIST INJ a $95.77 HCPCS - Drugs J0780 Blank PROCHLORPERAZINE INJECTION a $36.24 HCPCS - Drugs J0795 Blank CORTICORELIN OVINE TRIFLUTAL a $26.59 HCPCS - Drugs J0800 Blank CORTICOTROPIN INJECTION a $8,048.29 HCPCS - Drugs J0833 Blank COSYNTROPIN INJECTION NOS a $235.72 HCPCS - Drugs J0834 Blank COSYNTROPIN CORTROSYN INJ a $107.03 HCPCS - Drugs J0840 Blank CROTALIDAE POLY IMMUNE FAB a $6,007.68 HCPCS - Drugs J0850 Blank CYTOMEGALOVIRUS IMM IV /VIAL a $2,401.01 HCPCS - Drugs J0875 Blank INJECTION, DALBAVANCIN a $41.88 HCPCS - Drugs J0878 Blank DAPTOMYCIN INJECTION a $10.51 HCPCS - Drugs J0881 Blank DARBEPOETIN ALFA, NON-ESRD a $18.55 HCPCS - Drugs J0882 Blank DARBEPOETIN ALFA, ESRD USE a $18.55 HCPCS - Drugs J0883 Blank ARGATROBAN NONESRD USE 1MG a $44.58 HCPCS - Drugs J0884 Blank ARGATROBAN ESRD DIALYSIS 1MG a $44.58 HCPCS - Drugs J0885 Blank EPOETIN ALFA, NON-ESRD a $37.05 HCPCS - Drugs J0887 Blank EPOETIN BETA ESRD USE Blank $12.92 HCPCS - Non-Drugs J0888 Blank EPOETIN BETA NON ESRD a $12.92 HCPCS - Drugs J0890 Blank PEGINESATIDE INJECTION a $27.20 HCPCS - Drugs J0894 Blank DECITABINE INJECTION a $61.98 HCPCS - Drugs J0895 Blank DEFEROXAMINE MESYLATE INJ a $26.59 HCPCS - Drugs J0897 Blank DENOSUMAB INJECTION a $44.29 HCPCS - Drugs J0945 Blank BROMPHENIRAMINE MALEATE INJ Blank $5.25 HCPCS - Drugs J1000 Blank DEPO-ESTRADIOL CYPIONATE INJ a $40.27 HCPCS - Drugs J1020 Blank METHYLPREDNISOLONE 20 MG INJ a $19.35 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 56 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J1030 Blank METHYLPREDNISOLONE 40 MG INJ a $19.35 HCPCS - Drugs J1040 Blank METHYLPREDNISOLONE 80 MG INJ a $28.20 HCPCS - Drugs J1050 Blank MEDROXYPROGESTERONE ACETATE a $5.25 HCPCS - Drugs J1071 Blank INJ TESTOSTERONE CYPIONATE a $5.25 HCPCS - Drugs J1094 Blank INJ DEXAMETHASONE ACETATE a $5.25 HCPCS - Drugs J1100 Blank DEXAMETHASONE SODIUM PHOS a $5.25 HCPCS - Drugs J1110 Blank INJ DIHYDROERGOTAMINE MESYLT a $160.92 HCPCS - Drugs J1120 Blank ACETAZOLAMID SODIUM INJECTIO a $55.55 HCPCS - Drugs J1160 Blank DIGOXIN INJECTION a $20.16 HCPCS - Drugs J1162 Blank DIGOXIN IMMUNE FAB (OVINE) a $6,837.76 HCPCS - Drugs J1165 Blank PHENYTOIN SODIUM INJECTION a $5.25 HCPCS - Drugs J1170 Blank HYDROMORPHONE INJECTION a $12.92 HCPCS - Drugs J1180 Blank DYPHYLLINE INJECTION Blank $20.15 HCPCS - Drugs J1190 Blank DEXRAZOXANE HCL INJECTION a $376.48 HCPCS - Drugs J1200 Blank DIPHENHYDRAMINE HCL INJECTIO a $5.25 HCPCS - Drugs J1205 Blank CHLOROTHIAZIDE SODIUM INJ a $254.22 HCPCS - Drugs J1212 Blank DIMETHYL SULFOXIDE 50% 50 ML a $717.52 HCPCS - Drugs J1230 Blank METHADONE INJECTION a $35.44 HCPCS - Drugs J1240 Blank DIMENHYDRINATE INJECTION a $22.57 HCPCS - Drugs J1245 Blank DIPYRIDAMOLE INJECTION a $10.51 HCPCS - Drugs J1250 Blank INJ DOBUTAMINE HCL/250 MG a $21.77 HCPCS - Drugs J1260 Blank DOLASETRON MESYLATE a $33.88 HCPCS - Drugs J1265 Blank DOPAMINE INJECTION a $10.51 HCPCS - Drugs J1267 Blank DORIPENEM INJECTION a $10.51 HCPCS - Drugs J1270 Blank INJECTION, DOXERCALCIFEROL a $11.31 HCPCS - Drugs J1290 Blank ECALLANTIDE INJECTION a $908.15 HCPCS - Drugs J1300 Blank ECULIZUMAB INJECTION a $493.92 HCPCS - Drugs J1320 Blank AMITRIPTYLINE INJECTION Blank $91.75 HCPCS - Drugs J1322 Blank ELOSULFASE ALFA, INJECTION a $361.06 HCPCS - Drugs J1324 Blank ENFUVIRTIDE INJECTION a $5.25 HCPCS - Drugs J1325 Blank EPOPROSTENOL INJECTION a $43.48 HCPCS - Drugs J1327 Blank EPTIFIBATIDE INJECTION a $59.57 HCPCS - Drugs J1330 Blank ERGONOVINE MALEATE INJECTION a $10.28 HCPCS - Drugs J1335 Blank ERTAPENEM INJECTION a $103.01 HCPCS - Drugs J1364 Blank ERYTHRO LACTOBIONATE /500 MG a $119.90 HCPCS - Drugs J1380 Blank ESTRADIOL VALERATE 10 MG INJ a $31.42 HCPCS - Drugs J1410 Blank INJ ESTROGEN CONJUGATE 25 MG a $522.07 HCPCS - Drugs J1430 Blank ETHANOLAMINE OLEATE 100 MG a $917.00 HCPCS - Drugs J1435 Blank INJECTION ESTRONE PER 1 MG a $5.25 HCPCS - Drugs J1436 Blank ETIDRONATE DISODIUM INJ Blank $226.62 HCPCS - Drugs J1438 Blank ETANERCEPT INJECTION a $860.69 HCPCS - Drugs J1439 Blank INJ FERRIC CARBOXYMALTOS 1MG a $11.31 HCPCS - Drugs J1442 Blank INJ FILGRASTIM EXCL BIOSIMIL a $11.31 HCPCS - Drugs J1443 Blank INJ FERRIC PYROPHOSPHATE CIT a $3.05 HCPCS - Drugs J1447 Blank INJ TBO FILGRASTIM 1 MICROG a $10.51 HCPCS - Drugs J1450 Blank FLUCONAZOLE a $20.16 HCPCS - Drugs J1451 Blank FOMEPIZOLE, 15 MG a $25.79 HCPCS - Drugs J1452 Blank INTRAOCULAR FOMIVIRSEN NA a $2,530.30 HCPCS - Drugs J1453 Blank FOSAPREPITANT INJECTION a $12.92 HCPCS - Drugs J1455 Blank FOSCARNET SODIUM INJECTION a $56.35 HCPCS - Drugs J1457 Blank GALLIUM NITRATE INJECTION a $12.11 HCPCS - Drugs J1458 Blank GALSULFASE INJECTION a $826.91 HCPCS - Drugs J1459 Blank INJ IVIG PRIVIGEN 500 MG a $94.96 HCPCS - Drugs J1460 Blank GAMMA GLOBULIN 1 CC INJ a $83.70 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 57 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J1556 Blank INJ, IMM GLOB BIVIGAM, 500MG a $97.37 HCPCS - Drugs J1557 Blank GAMMAPLEX INJECTION a $92.55 HCPCS - Drugs J1559 Blank HIZENTRA INJECTION a $28.20 HCPCS - Drugs J1560 Blank GAMMA GLOBULIN > 10 CC INJ a $757.74 HCPCS - Drugs J1561 Blank GAMUNEX-C/GAMMAKED a $103.01 HCPCS - Drugs J1562 Blank VIVAGLOBIN, INJ a $31.42 HCPCS - Drugs J1566 Blank IMMUNE GLOBULIN, POWDER a $87.72 HCPCS - Drugs J1568 Blank OCTAGAM INJECTION a $111.85 HCPCS - Drugs J1569 Blank GAMMAGARD LIQUID INJECTION a $95.77 HCPCS - Drugs J1570 Blank GANCICLOVIR SODIUM INJECTION a $166.55 HCPCS - Drugs J1571 Blank HEPAGAM B IM INJECTION a $132.77 HCPCS - Drugs J1572 Blank FLEBOGAMMA INJECTION a $96.57 HCPCS - Drugs J1573 Blank HEPAGAM B INTRAVENOUS, INJ a $103.72 HCPCS - Drugs J1575 Blank HYQVIA 100MG IMMUNEGLOBULIN a $34.64 HCPCS - Drugs J1580 Blank GARAMYCIN GENTAMICIN INJ a $12.11 HCPCS - Drugs J1590 Blank GATIFLOXACIN INJECTION a $3.05 HCPCS - Drugs J1595 Blank INJECTION GLATIRAMER ACETATE a $3,869.74 HCPCS - Drugs J1599 Blank IVIG NON-LYOPHILIZED, NOS a $106.86 HCPCS - Drugs J1600 Blank GOLD SODIUM THIOMALEATE INJ a $41.88 HCPCS - Drugs J1602 Blank GOLIMUMAB FOR IV USE 1MG a $64.40 HCPCS - Drugs J1610 Blank GLUCAGON HYDROCHLORIDE/1 MG a $450.48 HCPCS - Drugs J1620 Blank GONADORELIN HYDROCH/ 100 MCG a $715.37 HCPCS - Drugs J1626 Blank GRANISETRON HCL INJECTION a $5.25 HCPCS - Drugs J1630 Blank HALOPERIDOL INJECTION a $13.72 HCPCS - Drugs J1631 Blank HALOPERIDOL DECANOATE INJ a $51.53 HCPCS - Drugs J1640 Blank HEMIN, 1 MG a $57.96 HCPCS - Drugs J1642 Blank INJ HEPARIN SODIUM PER 10 U a $5.25 HCPCS - Drugs J1644 Blank INJ HEPARIN SODIUM PER 1000U a $5.25 HCPCS - Drugs J1645 Blank DALTEPARIN SODIUM a $43.48 HCPCS - Drugs J1650 Blank INJ ENOXAPARIN SODIUM a $11.31 HCPCS - Drugs J1652 Blank FONDAPARINUX SODIUM a $14.53 HCPCS - Drugs J1655 Blank TINZAPARIN SODIUM INJECTION Blank $17.74 HCPCS - Drugs J1670 Blank TETANUS IMMUNE GLOBULIN INJ a $916.19 HCPCS - Drugs J1675 Blank HISTRELIN ACETATE Blank $11.31 HCPCS - Drugs J1700 Blank HYDROCORTISONE ACETATE INJ a $1.61 HCPCS - Drugs J1710 Blank HYDROCORTISONE SODIUM PH INJ a $23.54 HCPCS - Drugs J1720 Blank HYDROCORTISONE SODIUM SUCC I a $25.79 HCPCS - Drugs J1725 Blank HYDROXYPROGESTERONE CAPROATE a $5.25 HCPCS - Drugs J1730 Blank DIAZOXIDE INJECTION a $253.42 HCPCS - Drugs J1740 Blank IBANDRONATE SODIUM INJECTION a $242.96 HCPCS - Drugs J1741 Blank IBUPROFEN INJECTION a $12.01 HCPCS - Drugs J1742 Blank IBUTILIDE FUMARATE INJECTION a $254.22 HCPCS - Drugs J1743 Blank IDURSULFASE INJECTION a $1,183.24 HCPCS - Drugs J1744 Blank ICATIBANT INJECTION a $646.35 HCPCS - Drugs J1745 Blank INFLIXIMAB NOT BIOSIMIL 10MG a $192.29 HCPCS - Drugs J1750 Blank INJ IRON DEXTRAN a $36.24 HCPCS - Drugs J1756 Blank IRON SUCROSE INJECTION a $5.25 HCPCS - Drugs J1786 Blank IMUGLUCERASE INJECTION a $103.01 HCPCS - Drugs J1790 Blank DROPERIDOL INJECTION a $16.14 HCPCS - Drugs J1800 Blank PROPRANOLOL INJECTION a $15.33 HCPCS - Drugs J1810 Blank DROPERIDOL/FENTANYL INJ a $151.59 HCPCS - Drugs J1815 Blank INSULIN INJECTION a $10.51 HCPCS - Drugs J1817 Blank INSULIN FOR INSULIN PUMP USE a $27.40 HCPCS - Drugs J1826 Blank INTERFERON BETA-1A INJ a $1,409.26 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 58 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J1830 Blank INTERFERON BETA-1B / .25 MG a $435.44 HCPCS - Drugs J1833 Blank INJECTION, ISAVUCONAZONIUM a $2.06 HCPCS - Drugs J1835 Blank ITRACONAZOLE INJECTION a $2,270.71 HCPCS - Drugs J1840 Blank KANAMYCIN SULFATE 500 MG INJ a $20.96 HCPCS - Drugs J1850 Blank KANAMYCIN SULFATE 75 MG INJ Blank $10.51 HCPCS - Drugs J1885 Blank KETOROLAC TROMETHAMINE INJ a $10.51 HCPCS - Drugs J1890 Blank CEPHALOTHIN SODIUM INJECTION a $20.24 HCPCS - Drugs J1930 Blank LANREOTIDE INJECTION a $117.48 HCPCS - Drugs J1931 Blank LARONIDASE INJECTION a $75.66 HCPCS - Drugs J1940 Blank FUROSEMIDE INJECTION a $19.35 HCPCS - Drugs J1945 Blank LEPIRUDIN a $370.05 HCPCS - Drugs J1950 Blank LEUPROLIDE ACETATE /3.75 MG a $2,108.23 HCPCS - Drugs J1953 Blank LEVETIRACETAM INJECTION a $5.25 HCPCS - Drugs J1955 Blank INJ LEVOCARNITINE PER 1 GM a $53.14 HCPCS - Drugs J1956 Blank LEVOFLOXACIN INJECTION a $14.53 HCPCS - Drugs J1960 Blank LEVORPHANOL TARTRATE INJ Blank $16.14 HCPCS - Drugs J1980 Blank HYOSCYAMINE SULFATE INJ a $64.40 HCPCS - Drugs J1990 Blank CHLORDIAZEPOXIDE INJECTION Blank $58.77 HCPCS - Drugs J2001 Blank LIDOCAINE INJECTION a $5.25 HCPCS - Drugs J2010 Blank LINCOMYCIN INJECTION a $33.83 HCPCS - Drugs J2020 Blank LINEZOLID INJECTION a $48.31 HCPCS - Drugs J2060 Blank LORAZEPAM INJECTION a $10.51 HCPCS - Drugs J2150 Blank MANNITOL INJECTION a $11.31 HCPCS - Drugs J2170 Blank MECASERMIN INJECTION a $25.79 HCPCS - Drugs J2175 Blank MEPERIDINE HYDROCHL /100 MG a $18.55 HCPCS - Drugs J2180 Blank MEPERIDINE/PROMETHAZINE INJ a $27.40 HCPCS - Drugs J2185 Blank MEROPENEM a $12.11 HCPCS - Drugs J2210 Blank METHYLERGONOVIN MALEATE INJ a $24.98 HCPCS - Drugs J2212 Blank METHYLNALTREXONE INJECTION a $1.03 HCPCS - Drugs J2248 Blank MICAFUNGIN SODIUM INJECTION a $11.31 HCPCS - Drugs J2250 Blank INJ MIDAZOLAM HYDROCHLORIDE a $5.25 HCPCS - Drugs J2260 Blank INJ MILRINONE LACTATE / 5 MG a $110.24 HCPCS - Drugs J2265 Blank MINOCYCLINE HYDROCHLORIDE a $1.58 HCPCS - Drugs J2270 Blank MORPHINE SULFATE INJECTION a $11.31 HCPCS - Drugs J2274 Blank IN MORPHINE PRESERVATIV FREE a $27.40 HCPCS - Drugs J2278 Blank ZICONOTIDE INJECTION a $24.98 HCPCS - Drugs J2280 Blank INJ, MOXIFLOXACIN 100 MG a $27.40 HCPCS - Drugs J2300 Blank INJ NALBUPHINE HYDROCHLORIDE a $14.53 HCPCS - Drugs J2310 Blank INJ NALOXONE HYDROCHLORIDE a $78.07 HCPCS - Drugs J2315 Blank NALTREXONE, DEPOT FORM a $16.14 HCPCS - Drugs J2320 Blank NANDROLONE DECANOATE 50 MG a $18.55 HCPCS - Drugs J2323 Blank NATALIZUMAB INJECTION a $47.51 HCPCS - Drugs J2325 Blank NESIRITIDE INJECTION a $81.29 HCPCS - Drugs J2353 Blank OCTREOTIDE INJECTION, DEPOT a $369.24 HCPCS - Drugs J2354 Blank OCTREOTIDE INJ, NON-DEPOT a $11.31 HCPCS - Drugs J2355 Blank OPRELVEKIN INJECTION a $997.43 HCPCS - Drugs J2357 Blank OMALIZUMAB INJECTION a $78.87 HCPCS - Drugs J2358 Blank OLANZAPINE LONG-ACTING INJ a $15.33 HCPCS - Drugs J2360 Blank ORPHENADRINE INJECTION a $20.16 HCPCS - Drugs J2370 Blank PHENYLEPHRINE HCL INJECTION a $12.92 HCPCS - Drugs J2400 Blank CHLOROPROCAINE HCL INJECTION a $60.38 HCPCS - Drugs J2405 Blank ONDANSETRON HCL INJECTION a $5.25 HCPCS - Drugs J2407 Blank INJECTION, ORITAVANCIN a $64.40 HCPCS - Drugs J2410 Blank OXYMORPHONE HCL INJECTION a $15.33 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 59 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J2425 Blank PALIFERMIN INJECTION a $45.90 HCPCS - Drugs J2426 Blank PALIPERIDONE PALMITATE INJ a $28.20 HCPCS - Drugs J2430 Blank PAMIDRONATE DISODIUM /30 MG a $36.24 HCPCS - Drugs J2440 Blank PAPAVERIN HCL INJECTION a $15.33 HCPCS - Drugs J2460 Blank OXYTETRACYCLINE INJECTION Blank $2.36 HCPCS - Drugs J2469 Blank PALONOSETRON HCL a $58.77 HCPCS - Drugs J2501 Blank PARICALCITOL a $12.92 HCPCS - Drugs J2502 Blank INJ, PASIREOTIDE LONG ACTING a $887.42 HCPCS - Drugs J2503 Blank PEGAPTANIB SODIUM INJECTION a $2,378.49 HCPCS - Drugs J2504 Blank PEGADEMASE BOVINE, 25 IU a $641.11 HCPCS - Drugs J2505 Blank INJECTION, PEGFILGRASTIM 6MG a $8,766.57 HCPCS - Drugs J2507 Blank PEGLOTICASE INJECTION a $3,108.83 HCPCS - Drugs J2510 Blank PENICILLIN G PROCAINE INJ a $60.38 HCPCS - Drugs J2513 Blank PENTASTARCH 10% SOLUTION Blank $10.24 HCPCS - Drugs J2515 Blank PENTOBARBITAL SODIUM INJ a $106.22 HCPCS - Drugs J2540 Blank PENICILLIN G POTASSIUM INJ a $11.31 HCPCS - Drugs J2543 Blank PIPERACILLIN/TAZOBACTAM a $15.33 HCPCS - Drugs J2545 Blank PENTAMIDINE NON-COMP UNIT a $251.81 HCPCS - Drugs J2547 Blank INJECTION, PERAMIVIR a $7.93 HCPCS - Drugs J2550 Blank PROMETHAZINE HCL INJECTION a $12.92 HCPCS - Drugs J2560 Blank PHENOBARBITAL SODIUM INJ a $75.66 HCPCS - Drugs J2562 Blank PLERIXAFOR INJECTION a $701.44 HCPCS - Drugs J2590 Blank OXYTOCIN INJECTION a $17.74 HCPCS - Drugs J2597 Blank INJ DESMOPRESSIN ACETATE a $40.27 HCPCS - Drugs J2650 Blank PREDNISOLONE ACETATE INJ a $7.88 HCPCS - Drugs J2670 Blank TOTAZOLINE HCL INJECTION a $13.06 HCPCS - Drugs J2675 Blank INJ PROGESTERONE PER 50 MG a $11.31 HCPCS - Drugs J2680 Blank FLUPHENAZINE DECANOATE 25 MG a $57.16 HCPCS - Drugs J2690 Blank PROCAINAMIDE HCL INJECTION a $122.31 HCPCS - Drugs J2700 Blank OXACILLIN SODIUM INJECITON a $12.92 HCPCS - Drugs J2704 Blank INJ, PROPOFOL, 10 MG Blank $5.25 HCPCS - Drugs J2710 Blank NEOSTIGMINE METHYLSLFTE INJ a $5.25 HCPCS - Drugs J2720 Blank INJ PROTAMINE SULFATE/10 MG a $11.31 HCPCS - Drugs J2724 Blank PROTEIN C CONCENTRATE a $42.68 HCPCS - Drugs J2725 Blank INJ PROTIRELIN PER 250 MCG a $115.67 HCPCS - Drugs J2730 Blank PRALIDOXIME CHLORIDE INJ a $205.16 HCPCS - Drugs J2760 Blank PHENTOLAINE MESYLATE INJ a $131.16 HCPCS - Drugs J2765 Blank METOCLOPRAMIDE HCL INJECTION a $10.51 HCPCS - Drugs J2770 Blank QUINUPRISTIN/DALFOPRISTIN a $755.33 HCPCS - Drugs J2778 Blank RANIBIZUMAB INJECTION a $876.78 HCPCS - Drugs J2780 Blank RANITIDINE HYDROCHLORIDE INJ a $11.31 HCPCS - Drugs J2783 Blank RASBURICASE a $552.63 HCPCS - Drugs J2785 Blank REGADENOSON INJECTION a $130.35 HCPCS - Drugs J2788 Blank RHO D IMMUNE GLOBULIN 50 MCG a $66.81 HCPCS - Drugs J2790 Blank RHO D IMMUNE GLOBULIN INJ a $197.11 HCPCS - Drugs J2791 Blank RHOPHYLAC INJECTION a $19.35 HCPCS - Drugs J2792 Blank RHO(D) IMMUNE GLOBULIN H, SD a $54.74 HCPCS - Drugs J2793 Blank RILONACEPT INJECTION a $60.38 HCPCS - Drugs J2794 Blank RISPERIDONE, LONG ACTING a $24.98 HCPCS - Drugs J2795 Blank ROPIVACAINE HCL INJECTION a $5.25 HCPCS - Drugs J2796 Blank ROMIPLOSTIM INJECTION a $143.22 HCPCS - Drugs J2800 Blank METHOCARBAMOL INJECTION a $99.79 HCPCS - Drugs J2805 Blank SINCALIDE INJECTION a $214.81 HCPCS - Drugs J2810 Blank INJ THEOPHYLLINE PER 40 MG a $5.25 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 60 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J2820 Blank SARGRAMOSTIM INJECTION a $87.72 HCPCS - Drugs J2850 Blank INJ SECRETIN SYNTHETIC HUMAN a $86.92 HCPCS - Drugs J2860 Blank INJECTION, SILTUXIMAB a $41.24 HCPCS - Drugs J2910 Blank AUROTHIOGLUCOSE INJECITON Blank $87.31 HCPCS - Drugs J2916 Blank NA FERRIC GLUCONATE COMPLEX a $14.53 HCPCS - Drugs J2920 Blank METHYLPREDNISOLONE INJECTION a $15.33 HCPCS - Drugs J2930 Blank METHYLPREDNISOLONE INJECTION a $18.55 HCPCS - Drugs J2940 Blank SOMATREM INJECTION a $142.14 HCPCS - Drugs J2941 Blank SOMATROPIN INJECTION a $116.68 HCPCS - Drugs J2950 Blank PROMAZINE HCL INJECTION a $29.23 HCPCS - Drugs J2993 Blank RETEPLASE INJECTION a $2,742.85 HCPCS - Drugs J2995 Blank INJ STREPTOKINASE /250000 IU Blank $185.85 HCPCS - Drugs J2997 Blank ALTEPLASE RECOMBINANT a $177.00 HCPCS - Drugs J3000 Blank STREPTOMYCIN INJECTION a $35.44 HCPCS - Drugs J3010 Blank FENTANYL CITRATE INJECITON a $5.25 HCPCS - Drugs J3030 Blank SUMATRIPTAN SUCCINATE / 6 MG a $137.59 HCPCS - Drugs J3060 Blank INJ, TALIGLUCERACE ALFA 10 U a $95.77 HCPCS - Drugs J3070 Blank PENTAZOCINE INJECTION a $290.42 HCPCS - Drugs J3090 Blank INJ TEDIZOLID PHOSPHATE a $11.31 HCPCS - Drugs J3095 Blank TELAVANCIN INJECTION a $20.96 HCPCS - Drugs J3101 Blank TENECTEPLASE INJECTION a $219.63 HCPCS - Drugs J3105 Blank TERBUTALINE SULFATE INJ a $12.11 HCPCS - Drugs J3110 Blank TERIPARATIDE INJECTION a $28.20 HCPCS - Drugs J3121 Blank INJ TESTOSTERO ENANTHATE 1MG a $5.25 HCPCS - Drugs J3145 Blank TESTOSTERONE UNDECANOATE 1MG a $1.85 HCPCS - Drugs J3230 Blank CHLORPROMAZINE HCL INJECTION a $64.40 HCPCS - Drugs J3240 Blank THYROTROPIN INJECTION a $3,284.18 HCPCS - Drugs J3243 Blank TIGECYCLINE INJECTION a $14.53 HCPCS - Drugs J3246 Blank TIROFIBAN HCL a $29.01 HCPCS - Drugs J3250 Blank TRIMETHOBENZAMIDE HCL INJ a $61.98 HCPCS - Drugs J3260 Blank TOBRAMYCIN SULFATE INJECTION a $15.33 HCPCS - Drugs J3262 Blank TOCILIZUMAB INJECTION a $17.74 HCPCS - Drugs J3265 Blank INJECTION TORSEMIDE 10 MG/ML a $15.76 HCPCS - Drugs J3280 Blank THIETHYLPERAZINE MALEATE INJ Blank $20.16 HCPCS - Drugs J3285 Blank TREPROSTINIL INJECTION a $146.44 HCPCS - Drugs J3300 Blank TRIAMCINOLONE A INJ PRS-FREE a $16.94 HCPCS - Drugs J3301 Blank TRIAMCINOLONE ACET INJ NOS a $12.92 HCPCS - Drugs J3302 Blank TRIAMCINOLONE DIACETATE INJ a $5.25 HCPCS - Drugs J3303 Blank TRIAMCINOLONE HEXACETONL INJ a $12.92 HCPCS - Drugs J3305 Blank INJ TRIMETREXATE GLUCORONATE a $118.96 HCPCS - Drugs J3310 Blank PERPHENAZINE INJECITON Blank $35.24 HCPCS - Drugs J3315 Blank TRIPTORELIN PAMOATE a $536.55 HCPCS - Drugs J3320 Blank SPECTINOMYCN DI-HCL INJ a $95.94 HCPCS - Drugs J3350 Blank UREA INJECTION a $33.31 HCPCS - Drugs J3355 Blank UROFOLLITROPIN, 75 IU a $156.09 HCPCS - Drugs J3357 Blank USTEKINUMAB SUB CU INJ, 1 MG a $389.35 HCPCS - Drugs J3360 Blank DIAZEPAM INJECTION a $23.38 HCPCS - Drugs J3364 Blank UROKINASE 5000 IU INJECTION a $26.33 HCPCS - Drugs J3365 Blank UROKINASE 250,000 IU INJ a $1,296.27 HCPCS - Drugs J3370 Blank VANCOMYCIN HCL INJECTION a $15.33 HCPCS - Drugs J3380 Blank INJECTION, VEDOLIZUMAB a $47.51 HCPCS - Drugs J3385 Blank VELAGLUCERASE ALFA a $777.85 HCPCS - Drugs J3396 Blank VERTEPORFIN INJECTION a $33.83 HCPCS - Drugs J3400 Blank TRIFLUPROMAZINE HCL INJ Blank $43.07 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 61 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J3410 Blank HYDROXYZINE HCL INJECTION a $14.53 HCPCS - Drugs J3411 Blank THIAMINE HCL 100 MG a $16.14 HCPCS - Drugs J3415 Blank PYRIDOXINE HCL 100 MG a $30.61 HCPCS - Drugs J3420 Blank VITAMIN B12 INJECTION a $16.94 HCPCS - Drugs J3430 Blank VITAMIN K PHYTONADIONE INJ a $15.33 HCPCS - Drugs J3465 Blank INJECTION, VORICONAZOLE a $19.35 HCPCS - Drugs J3470 Blank HYALURONIDASE INJECTION a $66.01 HCPCS - Drugs J3471 Blank OVINE, UP TO 999 USP UNITS a $5.25 HCPCS - Drugs J3472 Blank OVINE, 1000 USP UNITS a $273.53 HCPCS - Drugs J3473 Blank HYALURONIDASE RECOMBINANT a $5.25 HCPCS - Drugs J3475 Blank INJ MAGNESIUM SULFATE a $5.25 HCPCS - Drugs J3480 Blank INJ POTASSIUM CHLORIDE a $5.25 HCPCS - Drugs J3485 Blank ZIDOVUDINE a $12.11 HCPCS - Drugs J3486 Blank ZIPRASIDONE MESYLATE a $43.48 HCPCS - Drugs J3489 Blank ZOLEDRONIC ACID 1MG a $56.35 HCPCS - Drugs J3490 Blank DRUGS UNCLASSIFIED INJECTION a $0.89 HCPCS - Drugs J3520 Blank EDETATE DISODIUM PER 150 MG Blank $5.25 HCPCS - Drugs J3530 Blank NASAL VACCINE INHALATION Blank $57.74 HCPCS - Drugs J3535 Blank METERED DOSE INHALER DRUG a $13.44 HCPCS - Drugs J3570 Blank LAETRILE AMYGDALIN VIT B17 Blank $41.05 HCPCS - Drugs J3590 Blank UNCLASSIFIED BIOLOGICS a $137.27 HCPCS - Drugs J7030 Blank NORMAL SALINE SOLUTION INFUS a $13.72 HCPCS - Drugs J7040 Blank NORMAL SALINE SOLUTION INFUS a $11.31 HCPCS - Drugs J7042 Blank 5% DEXTROSE/NORMAL SALINE a $10.51 HCPCS - Drugs J7050 Blank NORMAL SALINE SOLUTION INFUS a $5.25 HCPCS - Drugs J7060 Blank 5% DEXTROSE/WATER a $12.92 HCPCS - Drugs J7070 Blank D5W INFUSION a $16.14 HCPCS - Drugs J7100 Blank DEXTRAN 40 INFUSION a $197.11 HCPCS - Drugs J7110 Blank DEXTRAN 75 INFUSION a $123.82 HCPCS - Drugs J7120 Blank RINGERS LACTATE INFUSION a $12.92 HCPCS - Drugs J7121 Blank 5% DEXTROSE IN LAC RINGERS a $27.21 HCPCS - Drugs J7131 Blank HYPERTONIC SALINE SOL a $4.33 HCPCS - Drugs J7178 Blank HUMAN FIBRINOGEN CONC INJ a $1.13 HCPCS - Drugs J7180 Blank FACTOR XIII ANTI-HEM FACTOR a $26.59 HCPCS - Drugs J7181 Blank FACTOR XIII RECOMB A-SUBUNIT a $22.27 HCPCS - Drugs J7182 Blank FACTOR VIII RECOMB NOVOEIGHT a $12.11 HCPCS - Drugs J7183 Blank WILATE INJECTION a $11.31 HCPCS - Drugs J7185 Blank XYNTHA INJ a $11.31 HCPCS - Drugs J7186 Blank ANTIHEMOPHILIC VIII/VWF COMP a $11.31 HCPCS - Drugs J7187 Blank HUMATE-P, INJ a $11.31 HCPCS - Drugs J7188 Blank FACTOR VIII RECOMB OBIZUR a $14.86 HCPCS - Drugs J7189 Blank FACTOR VIIA a $12.92 HCPCS - Drugs J7190 Blank FACTOR VIII a $11.31 HCPCS - Drugs J7191 Blank FACTOR VIII (PORCINE) a $6.95 HCPCS - Drugs J7192 Blank FACTOR VIII RECOMBINANT NOS a $11.31 HCPCS - Drugs J7193 Blank FACTOR IX NON-RECOMBINANT a $11.31 HCPCS - Drugs J7194 Blank FACTOR IX COMPLEX a $11.31 HCPCS - Drugs J7195 Blank FACTOR IX RECOMBINANT NOS a $12.11 HCPCS - Drugs J7196 Blank ANTITHROMBIN RECOMBINANT a $9.17 HCPCS - Drugs J7197 Blank ANTITHROMBIN III INJECTION a $16.94 HCPCS - Drugs J7198 Blank ANTI-INHIBITOR a $12.92 HCPCS - Drugs J7199 Blank HEMOPHILIA CLOT FACTOR NOC a $1.52 HCPCS - Drugs J7200 Blank FACTOR IX RECOMBINAN RIXUBIS a $11.31 HCPCS - Drugs J7201 Blank FACTOR IX ALPROLIX RECOMB a $15.33 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 62 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J7205 Blank FACTOR VIII FC FUSION RECOMB a $12.92 HCPCS - Drugs J7297 Blank LILETTA, 52 MG a $1,057.99 HCPCS - Drugs J7298 Blank MIRENA, 52 MG a $1,057.99 HCPCS - Drugs J7300 Blank INTRAUT COPPER CONTRACEPTIVE a $906.54 HCPCS - Drugs J7301 Blank SKYLA, 13.5 MG a $1,665.60 HCPCS - Drugs J7303 Blank CONTRACEPTIVE VAGINAL RING Blank $95.77 HCPCS - Drugs J7304 Blank CONTRACEPTIVE HORMONE PATCH Blank $76.38 HCPCS - Drugs J7306 Blank LEVONORGESTREL IMPLANT SYS a $943.54 HCPCS - Drugs J7307 Blank ETONOGESTREL IMPLANT SYSTEM a $1,687.08 HCPCS - Drugs J7308 Blank AMINOLEVULINIC ACID HCL TOP a $744.07 HCPCS - Drugs J7309 Blank METHYL AMINOLEVULINATE, TOP a $223.12 HCPCS - Drugs J7310 Blank GANCICLOVIR LONG ACT IMPLANT a $10,215.99 HCPCS - Drugs J7311 Blank FLUOCINOLONE ACETONIDE IMPLT a $45,245.06 HCPCS - Drugs J7312 Blank DEXAMETHASONE INTRA IMPLANT a $460.94 HCPCS - Drugs J7313 Blank FLUOCINOL ACET INTRAVIT IMP a $1,111.65 HCPCS - Drugs J7315 Blank OPHTHALMIC MITOMYCIN a $719.18 HCPCS - Drugs J7316 Blank INJ, OCRIPLASMIN, 0.125 MG a $2,360.79 HCPCS - Drugs J7321 Blank HYALGAN/SUPARTZ INJ PER DOSE a $207.57 HCPCS - Drugs J7323 Blank EUFLEXXA INJ PER DOSE a $361.20 HCPCS - Drugs J7324 Blank ORTHOVISC INJ PER DOSE a $386.13 HCPCS - Drugs J7325 Blank SYNVISC OR SYNVISC-ONE a $37.85 HCPCS - Drugs J7326 Blank GEL-ONE a $1,293.43 HCPCS - Drugs J7327 Blank MONOVISC INJ PER DOSE a $2,108.23 HCPCS - Drugs J7330 Blank CULTURED CHONDROCYTES IMPLNT Blank $78,747.07 HCPCS - Drugs J7336 Blank CAPSAICIN 8% PATCH a $15.33 HCPCS - Drugs J7340 Blank CARBIDOPA LEVODOPA ENT 100ML a $6.48 HCPCS - Drugs J7500 Blank AZATHIOPRINE ORAL 50MG a $5.25 HCPCS - Drugs J7501 Blank AZATHIOPRINE PARENTERAL a $163.33 HCPCS - Drugs J7502 Blank CYCLOSPORINE ORAL 100 MG a $16.94 HCPCS - Drugs J7503 Blank TACROL ENVARSUS EX REL ORAL a $7.01 HCPCS - Drugs J7504 Blank LYMPHOCYTE IMMUNE GLOBULIN a $2,563.49 HCPCS - Drugs J7505 Blank MONOCLONAL ANTIBODIES a $2,168.55 HCPCS - Drugs J7507 Blank TACROLIMUS IMME REL ORAL 1MG a $10.51 HCPCS - Drugs J7508 Blank TACROL ASTAGRAF EX REL ORAL a $5.25 HCPCS - Drugs J7509 Blank METHYLPREDNISOLONE ORAL a $5.25 HCPCS - Drugs J7510 Blank PREDNISOLONE ORAL PER 5 MG a $5.25 HCPCS - Drugs J7511 Blank ANTITHYMOCYTE GLOBULN RABBIT a $1,467.97 HCPCS - Drugs J7512 Blank PREDNISONE IR OR DR ORAL 1MG a $5.25 HCPCS - Drugs J7513 Blank DACLIZUMAB, PARENTERAL a $941.13 HCPCS - Drugs J7515 Blank CYCLOSPORINE ORAL 25 MG a $11.31 HCPCS - Drugs J7516 Blank CYCLOSPORIN PARENTERAL 250MG a $98.18 HCPCS - Drugs J7517 Blank MYCOPHENOLATE MOFETIL ORAL a $11.31 HCPCS - Drugs J7518 Blank MYCOPHENOLIC ACID a $16.14 HCPCS - Drugs J7520 Blank SIROLIMUS, ORAL a $29.81 HCPCS - Drugs J7525 Blank TACROLIMUS INJECTION a $377.29 HCPCS - Drugs J7527 Blank ORAL EVEROLIMUS a $25.79 HCPCS - Drugs J7599 Blank IMMUNOSUPPRESSIVE DRUG NOC a $8.78 HCPCS - Drugs J7604 Blank ACETYLCYSTEINE COMP UNIT Blank $21.76 HCPCS - Drugs J7605 Blank ARFORMOTEROL NON-COMP UNIT Blank $28.20 HCPCS - Drugs J7606 Blank FORMOTEROL FUMARATE, INH a $30.61 HCPCS - Drugs J7607 Blank LEVALBUTEROL COMP CON a $40.93 HCPCS - Drugs J7608 Blank ACETYLCYSTEINE NON-COMP UNIT a $20.96 HCPCS - Drugs J7609 Blank ALBUTEROL COMP UNIT a $16.40 HCPCS - Drugs J7610 Blank ALBUTEROL COMP CON a $16.24 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 63 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J7611 Blank ALBUTEROL NON-COMP CON a $5.25 HCPCS - Drugs J7612 Blank LEVALBUTEROL NON-COMP CON a $5.25 HCPCS - Drugs J7613 Blank ALBUTEROL NON-COMP UNIT a $5.25 HCPCS - Drugs J7614 Blank LEVALBUTEROL NON-COMP UNIT a $5.25 HCPCS - Drugs J7615 Blank LEVALBUTEROL COMP UNIT a $13.72 HCPCS - Drugs J7620 Blank ALBUTEROL IPRATROP NON-COMP a $5.25 HCPCS - Drugs J7622 Blank BECLOMETHASONE COMP UNIT Blank $15.86 HCPCS - Drugs J7624 Blank BETAMETHASONE COMP UNIT Blank $4.59 HCPCS - Drugs J7626 Blank BUDESONIDE NON-COMP UNIT a $19.35 HCPCS - Drugs J7627 Blank BUDESONIDE COMP UNIT a $20.16 HCPCS - Drugs J7628 Blank BITOLTEROL MESYLATE COMP CON Blank $6.44 HCPCS - Drugs J7629 Blank BITOLTEROL MESYLATE COMP UNT Blank $6.44 HCPCS - Drugs J7631 Blank CROMOLYN SODIUM NONCOMP UNIT Blank $10.51 HCPCS - Drugs J7632 Blank CROMOLYN SODIUM COMP UNIT Blank $5.25 HCPCS - Drugs J7633 Blank BUDESONIDE NON-COMP CON a $25.36 HCPCS - Drugs J7634 Blank BUDESONIDE COMP CON Blank $53.54 HCPCS - Drugs J7635 Blank ATROPINE COMP CON Blank $40.09 HCPCS - Drugs J7636 Blank ATROPINE COMP UNIT a $28.65 HCPCS - Drugs J7637 Blank DEXAMETHASONE COMP CON a $1.39 HCPCS - Drugs J7638 Blank DEXAMETHASONE COMP UNIT a $1.39 HCPCS - Drugs J7639 Blank DORNASE ALFA NON-COMP UNIT a $96.57 HCPCS - Drugs J7640 Blank FORMOTEROL COMP UNIT Blank $27.46 HCPCS - Drugs J7641 Blank FLUNISOLIDE COMP UNIT Blank $33.83 HCPCS - Drugs J7642 Blank GLYCOPYRROLATE COMP CON a $1.02 HCPCS - Drugs J7643 Blank GLYCOPYRROLATE COMP UNIT a $1.02 HCPCS - Drugs J7644 Blank IPRATROPIUM BROMIDE NON-COMP a $5.25 HCPCS - Drugs J7645 Blank IPRATROPIUM BROMIDE COMP a $9.45 HCPCS - Drugs J7647 Blank ISOETHARINE COMP CON Blank $6.99 HCPCS - Drugs J7648 Blank ISOETHARINE NON-COMP CON Blank $2.36 HCPCS - Drugs J7649 Blank ISOETHARINE NON-COMP UNIT a $2.36 HCPCS - Drugs J7650 Blank ISOETHARINE COMP UNIT Blank $6.99 HCPCS - Drugs J7657 Blank ISOPROTERENOL COMP CON Blank $9.51 HCPCS - Drugs J7658 Blank ISOPROTERENOL NON-COMP CON a $13.06 HCPCS - Drugs J7659 Blank ISOPROTERENOL NON-COMP UNIT a $13.06 HCPCS - Drugs J7660 Blank ISOPROTERENOL COMP UNIT a $1.58 HCPCS - Drugs J7665 Blank MANNITOL FOR INHALER a $5.85 HCPCS - Drugs J7667 Blank METAPROTERENOL COMP CON Blank $12.68 HCPCS - Drugs J7668 Blank METAPROTERENOL NON-COMP CON Blank $0.27 HCPCS - Drugs J7669 Blank METAPROTERENOL NON-COMP UNIT Blank $1.30 HCPCS - Drugs J7670 Blank METAPROTERENOL COMP UNIT Blank $8.22 HCPCS - Drugs J7674 Blank METHACHOLINE CHLORIDE, NEB a $5.25 HCPCS - Drugs J7676 Blank PENTAMIDINE COMP UNIT DOSE a $575.05 HCPCS - Drugs J7680 Blank TERBUTALINE SULF COMP CON a $40.27 HCPCS - Drugs J7681 Blank TERBUTALINE SULF COMP UNIT Blank $40.27 HCPCS - Drugs J7682 Blank TOBRAMYCIN NON-COMP UNIT a $123.11 HCPCS - Drugs J7683 Blank TRIAMCINOLONE COMP CON Blank $20.16 HCPCS - Drugs J7684 Blank TRIAMCINOLONE COMP UNIT Blank $11.95 HCPCS - Drugs J7685 Blank TOBRAMYCIN COMP UNIT Blank $152.87 HCPCS - Drugs J7686 Blank TREPROSTINIL, NON-COMP UNIT Blank $1,146.24 HCPCS - Drugs J7699 Blank INHALATION SOLUTION FOR DME a $5.45 HCPCS - Drugs J7799 Blank NON-INHALATION DRUG FOR DME a $9.69 HCPCS - Drugs J7999 Blank COMPOUNDED DRUG, NOC a $3.05 HCPCS - Drugs J8498 Blank ANTIEMETIC RECTAL/SUPP NOS a $1.52 HCPCS - Drugs J8499 Blank ORAL PRESCRIP DRUG NON CHEMO a $1.52 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 64 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J8501 Blank ORAL APREPITANT a $31.42 HCPCS - Drugs J8510 Blank ORAL BUSULFAN a $76.23 HCPCS - Drugs J8515 Blank CABERGOLINE, ORAL 0.25MG Blank $42.68 HCPCS - Drugs J8520 Blank CAPECITABINE, ORAL, 150 MG a $23.72 HCPCS - Drugs J8521 Blank CAPECITABINE, ORAL, 500 MG a $74.54 HCPCS - Drugs J8530 Blank CYCLOPHOSPHAMIDE ORAL 25 MG a $16.94 HCPCS - Drugs J8540 Blank ORAL DEXAMETHASONE a $5.25 HCPCS - Drugs J8560 Blank ETOPOSIDE ORAL 50 MG a $264.60 HCPCS - Drugs J8562 Blank ORAL FLUDARABINE PHOSPHATE a $283.59 HCPCS - Drugs J8565 Blank GEFITINIB ORAL a $137.59 HCPCS - Drugs J8597 Blank ANTIEMETIC DRUG ORAL NOS a $146.35 HCPCS - Drugs J8600 Blank MELPHALAN ORAL 2 MG Blank $50.82 HCPCS - Drugs J8610 Blank METHOTREXATE ORAL 2.5 MG a $5.08 HCPCS - Drugs J8650 Blank NABILONE ORAL a $46.70 HCPCS - Drugs J8655 Blank NETUPITANT PALONOSETRON ORAL a $897.69 HCPCS - Drugs J8670 Blank ROLAPITANT, ORAL, 1MG a $73.70 HCPCS - Drugs J8700 Blank TEMOZOLOMIDE a $16.94 HCPCS - Drugs J8705 Blank TOPOTECAN ORAL a $387.13 HCPCS - Drugs J8999 Blank ORAL PRESCRIPTION DRUG CHEMO a $53.33 HCPCS - Drugs J9000 Blank DOXORUBICIN HCL INJECTION a $13.55 HCPCS - Drugs J9015 Blank ALDESLEUKIN INJECTION a $2,068.77 HCPCS - Drugs J9017 Blank ARSENIC TRIOXIDE INJECTION a $234.61 HCPCS - Drugs J9019 Blank ERWINAZE INJECTION a $1,379.10 HCPCS - Drugs J9020 Blank ASPARAGINASE, NOS a $225.49 HCPCS - Drugs J9025 Blank AZACITIDINE INJECTION a $13.55 HCPCS - Drugs J9027 Blank CLOFARABINE INJECTION a $319.37 HCPCS - Drugs J9031 Blank BCG LIVE INTRAVESICAL VAC a $467.95 HCPCS - Drugs J9032 Blank INJECTION, BELINOSTAT, 10MG a $138.15 HCPCS - Drugs J9033 Blank INJ., TREANDA 1 MG a $109.47 HCPCS - Drugs J9035 Blank BEVACIZUMAB INJECTION a $168.16 HCPCS - Drugs J9039 Blank INJECTION, BLINATUMOMAB a $451.99 HCPCS - Drugs J9040 Blank BLEOMYCIN SULFATE INJECTION a $76.23 HCPCS - Drugs J9041 Blank BORTEZOMIB INJECTION a $114.27 HCPCS - Drugs J9042 Blank BRENTUXIMAB VEDOTIN INJ a $471.86 HCPCS - Drugs J9043 Blank CABAZITAXEL INJECTION a $567.03 HCPCS - Drugs J9045 Blank CARBOPLATIN INJECTION a $16.94 HCPCS - Drugs J9047 Blank INJECTION, CARFILZOMIB, 1 MG a $136.85 HCPCS - Drugs J9050 Blank CARMUSTINE INJECTION a $7,278.10 HCPCS - Drugs J9055 Blank CETUXIMAB INJECTION a $131.16 HCPCS - Drugs J9060 Blank CISPLATIN 10 MG INJECTION a $6.78 HCPCS - Drugs J9065 Blank INJ CLADRIBINE PER 1 MG a $99.04 HCPCS - Drugs J9070 Blank CYCLOPHOSPHAMIDE 100 MG INJ a $178.56 HCPCS - Drugs J9098 Blank CYTARABINE LIPOSOME INJ a $1,303.08 HCPCS - Drugs J9100 Blank CYTARABINE HCL 100 MG INJ a $3.39 HCPCS - Drugs J9120 Blank DACTINOMYCIN INJECTION a $2,687.22 HCPCS - Drugs J9130 Blank DACARBAZINE 100 MG INJ a $20.33 HCPCS - Drugs J9145 Blank INJECTION, DARATUMUMAB 10 MG a $315.20 HCPCS - Drugs J9150 Blank DAUNORUBICIN INJECTION a $161.61 HCPCS - Drugs J9151 Blank DAUNORUBICIN CITRATE INJ a $228.10 HCPCS - Drugs J9155 Blank DEGARELIX INJECTION a $16.94 HCPCS - Drugs J9160 Blank DENILEUKIN DIFTITOX INJ a $3,139.39 HCPCS - Drugs J9165 Blank DIETHYLSTILBESTROL INJECTION a $65.05 HCPCS - Drugs J9171 Blank DOCETAXEL INJECTION a $14.53 HCPCS - Drugs J9175 Blank ELLIOTTS B SOLUTION PER ML a $17.74 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 65 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J9176 Blank INJECTION, ELOTUZUMAB, 1MG a $42.49 HCPCS - Drugs J9178 Blank INJ, EPIRUBICIN HCL, 2 MG a $12.11 HCPCS - Drugs J9179 Blank ERIBULIN MESYLATE INJECTION a $401.47 HCPCS - Drugs J9181 Blank ETOPOSIDE INJECTION a $3.39 HCPCS - Drugs J9185 Blank FLUDARABINE PHOSPHATE INJ a $276.33 HCPCS - Drugs J9190 Blank FLUOROURACIL INJECTION a $8.47 HCPCS - Drugs J9200 Blank FLOXURIDINE INJECTION a $192.90 HCPCS - Drugs J9201 Blank GEMCITABINE HCL INJECTION a $38.96 HCPCS - Drugs J9202 Blank GOSERELIN ACETATE IMPLANT a $1,049.35 HCPCS - Drugs J9206 Blank IRINOTECAN INJECTION a $18.63 HCPCS - Drugs J9207 Blank IXABEPILONE INJECTION a $288.06 HCPCS - Drugs J9208 Blank IFOSFAMIDE INJECTION a $127.72 HCPCS - Drugs J9209 Blank MESNA INJECTION a $15.25 HCPCS - Drugs J9211 Blank IDARUBICIN HCL INJECTION a $153.79 HCPCS - Drugs J9212 Blank INTERFERON ALFACON-1 INJ a $24.18 HCPCS - Drugs J9213 Blank INTERFERON ALFA-2A INJ a $156.40 HCPCS - Drugs J9214 Blank INTERFERON ALFA-2B INJ a $112.08 HCPCS - Drugs J9215 Blank INTERFERON ALFA-N3 INJ a $86.01 HCPCS - Drugs J9216 Blank INTERFERON GAMMA 1-B INJ a $1,186.22 HCPCS - Drugs J9217 Blank LEUPROLIDE ACETATE SUSPNSION a $862.94 HCPCS - Drugs J9218 Blank LEUPROLIDE ACETATE INJECITON a $88.61 HCPCS - Drugs J9219 Blank LEUPROLIDE ACETATE IMPLANT a $7,230.91 HCPCS - Drugs J9225 Blank VANTAS IMPLANT a $5,904.85 HCPCS - Drugs J9226 Blank SUPPRELIN LA IMPLANT a $41,633.66 HCPCS - Drugs J9228 Blank IPILIMUMAB INJECTION a $531.83 HCPCS - Drugs J9230 Blank MECHLORETHAMINE HCL INJ a $899.44 HCPCS - Drugs J9245 Blank INJ MELPHALAN HYDROCHL 50 MG a $3,917.42 HCPCS - Drugs J9250 Blank METHOTREXATE SODIUM INJ a $1.69 HCPCS - Drugs J9260 Blank METHOTREXATE SODIUM INJ a $11.86 HCPCS - Drugs J9261 Blank NELARABINE INJECTION a $341.09 HCPCS - Drugs J9262 Blank INJ, OMACETAXINE MEP, 0.01MG a $27.66 HCPCS - Drugs J9263 Blank OXALIPLATIN a $1.69 HCPCS - Drugs J9264 Blank PACLITAXEL PROTEIN BOUND a $31.42 HCPCS - Drugs J9266 Blank PEGASPARGASE INJECTION a $24,983.63 HCPCS - Drugs J9267 Blank PACLITAXEL INJECTION a $1.69 HCPCS - Drugs J9268 Blank PENTOSTATIN INJECTION a $3,487.06 HCPCS - Drugs J9270 Blank PLICAMYCIN (MITHRAMYCIN) INJ Blank $349.18 HCPCS - Drugs J9271 Blank INJ PEMBROLIZUMAB a $186.38 HCPCS - Drugs J9280 Blank MITOMYCIN INJECTION a $392.35 HCPCS - Drugs J9293 Blank MITOXANTRONE HYDROCHL / 5 MG a $142.06 HCPCS - Drugs J9299 Blank INJECTION, NIVOLUMAB a $113.38 HCPCS - Drugs J9300 Blank GEMTUZUMAB OZOGAMICIN INJ a $4,941.88 HCPCS - Drugs J9301 Blank OBINUTUZUMAB INJ a $220.27 HCPCS - Drugs J9302 Blank OFATUMUMAB INJECTION a $203.33 HCPCS - Drugs J9303 Blank PANITUMUMAB INJECTION a $398.86 HCPCS - Drugs J9305 Blank PEMETREXED INJECTION a $147.24 HCPCS - Drugs J9306 Blank INJECTION, PERTUZUMAB, 1 MG a $49.13 HCPCS - Drugs J9307 Blank PRALATREXATE INJECTION a $823.83 HCPCS - Drugs J9308 Blank INJECTION, RAMUCIRUMAB a $216.36 HCPCS - Drugs J9310 Blank RITUXIMAB INJECTION a $2,023.11 HCPCS - Drugs J9315 Blank ROMIDEPSIN INJECTION a $1,105.40 HCPCS - Drugs J9320 Blank STREPTOZOCIN INJECTION a $1,165.37 HCPCS - Drugs J9328 Blank TEMOZOLOMIDE INJECTION a $33.88 HCPCS - Drugs J9330 Blank TEMSIROLIMUS INJECTION a $251.56 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 66 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
J9340 Blank THIOTEPA INJECTION a $381.92 HCPCS - Drugs J9351 Blank TOPOTECAN INJECTION a $10.16 HCPCS - Drugs J9352 Blank INJECTION TRABECTEDIN 0.1MG a $1,638.42 HCPCS - Drugs J9354 Blank INJ, ADO-TRASTUZUMAB EMT 1MG a $126.42 HCPCS - Drugs J9355 Blank TRASTUZUMAB INJECTION a $209.98 HCPCS - Drugs J9357 Blank VALRUBICIN INJECTION a $2,557.05 HCPCS - Drugs J9360 Blank VINBLASTINE SULFATE INJ a $15.25 HCPCS - Drugs J9370 Blank VINCRISTINE SULFATE 1 MG INJ a $30.49 HCPCS - Drugs J9371 Blank INJ, VINCRISTINE SUL LIP 1MG a $4,815.87 HCPCS - Drugs J9390 Blank VINORELBINE TARTRATE INJ a $47.43 HCPCS - Drugs J9395 Blank INJECTION, FULVESTRANT a $220.44 HCPCS - Drugs J9400 Blank INJ, ZIV-AFLIBERCEPT, 1MG a $27.40 HCPCS - Drugs J9600 Blank PORFIMER SODIUM INJECTION a $4,854.22 HCPCS - Drugs J9999 Blank CHEMOTHERAPY DRUG a $138.22 HCPCS - Drugs K0001 Blank STANDARD WHEELCHAIR Blank $740.65 HCPCS - Non-Drugs K0001 NU STANDARD WHEELCHAIR Blank $740.65 HCPCS - Non-Drugs K0001 RR STANDARD WHEELCHAIR Blank $93.73 HCPCS - Non-Drugs K0001 UE STANDARD WHEELCHAIR Blank $563.08 HCPCS - Non-Drugs K0002 Blank STND HEMI (LOW SEAT) WHLCHR Blank $1,114.16 HCPCS - Non-Drugs K0002 NU STND HEMI (LOW SEAT) WHLCHR Blank $1,114.16 HCPCS - Non-Drugs K0002 RR STND HEMI (LOW SEAT) WHLCHR Blank $140.99 HCPCS - Non-Drugs K0002 UE STND HEMI (LOW SEAT) WHLCHR Blank $983.51 HCPCS - Non-Drugs K0003 Blank LIGHTWEIGHT WHEELCHAIR Blank $999.30 HCPCS - Non-Drugs K0003 NU LIGHTWEIGHT WHEELCHAIR Blank $999.30 HCPCS - Non-Drugs K0003 RR LIGHTWEIGHT WHEELCHAIR Blank $126.46 HCPCS - Non-Drugs K0003 UE LIGHTWEIGHT WHEELCHAIR Blank $1,073.35 HCPCS - Non-Drugs K0004 Blank HIGH STRENGTH LTWT WHLCHR Blank $1,172.98 HCPCS - Non-Drugs K0004 NU HIGH STRENGTH LTWT WHLCHR Blank $1,172.98 HCPCS - Non-Drugs K0004 RR HIGH STRENGTH LTWT WHLCHR Blank $148.44 HCPCS - Non-Drugs K0004 UE HIGH STRENGTH LTWT WHLCHR Blank $1,586.85 HCPCS - Non-Drugs K0005 Blank ULTRALIGHTWEIGHT WHEELCHAIR Blank $3,773.94 HCPCS - Non-Drugs K0005 NU ULTRALIGHTWEIGHT WHEELCHAIR Blank $3,773.94 HCPCS - Non-Drugs K0005 RR ULTRALIGHTWEIGHT WHEELCHAIR Blank $404.47 HCPCS - Non-Drugs K0005 UE ULTRALIGHTWEIGHT WHEELCHAIR Blank $2,837.97 HCPCS - Non-Drugs K0006 Blank HEAVY DUTY WHEELCHAIR Blank $1,614.45 HCPCS - Non-Drugs K0006 NU HEAVY DUTY WHEELCHAIR Blank $1,614.45 HCPCS - Non-Drugs K0006 RR HEAVY DUTY WHEELCHAIR Blank $204.30 HCPCS - Non-Drugs K0006 UE HEAVY DUTY WHEELCHAIR Blank $1,491.34 HCPCS - Non-Drugs K0007 Blank EXTRA HEAVY DUTY WHEELCHAIR Blank $2,154.92 HCPCS - Non-Drugs K0007 NU EXTRA HEAVY DUTY WHEELCHAIR Blank $2,154.92 HCPCS - Non-Drugs K0007 RR EXTRA HEAVY DUTY WHEELCHAIR Blank $272.70 HCPCS - Non-Drugs K0007 UE EXTRA HEAVY DUTY WHEELCHAIR Blank $2,109.80 HCPCS - Non-Drugs K0008 Blank CSTM MANUAL WHEELCHAIR/BASE Blank $597.13 HCPCS - Non-Drugs K0009 Blank OTHER MANUAL WHEELCHAIR/BASE Blank $1,414.42 HCPCS - Non-Drugs K0009 RR OTHER MANUAL WHEELCHAIR/BASE Blank $178.99 HCPCS - Non-Drugs K0010 Blank STND WT FRAME POWER WHLCHR Blank $6,565.50 HCPCS - Non-Drugs K0010 NU STND WT FRAME POWER WHLCHR Blank $6,565.50 HCPCS - Non-Drugs K0010 RR STND WT FRAME POWER WHLCHR Blank $830.85 HCPCS - Non-Drugs K0010 UE STND WT FRAME POWER WHLCHR Blank $7,959.71 HCPCS - Non-Drugs K0011 Blank STND WT PWR WHLCHR W CONTROL Blank $8,368.28 HCPCS - Non-Drugs K0011 NU STND WT PWR WHLCHR W CONTROL Blank $8,368.28 HCPCS - Non-Drugs K0011 RR STND WT PWR WHLCHR W CONTROL Blank $1,058.98 HCPCS - Non-Drugs K0012 Blank LTWT PORTBL POWER WHLCHR Blank $5,319.80 HCPCS - Non-Drugs K0012 RR LTWT PORTBL POWER WHLCHR Blank $673.21 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 67 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
K0013 Blank CUSTOM POWER WHLCHR BASE Blank $1,033.64 HCPCS - Non-Drugs K0014 Blank OTHER POWER WHLCHR BASE Blank $421.98 HCPCS - Non-Drugs K0015 Blank DETACH NON-ADJ HT ARMRST REP Blank $406.32 HCPCS - Non-Drugs K0015 NU DETACH NON-ADJUS HGHT ARMRST Blank $406.32 HCPCS - Non-Drugs K0015 RR DETACH NON-ADJUS HGHT ARMRST Blank $51.42 HCPCS - Non-Drugs K0015 UE DETACH NON-ADJUS HGHT ARMRST Blank $212.79 HCPCS - Non-Drugs K0017 Blank DETACH ADJUST ARMREST BASE Blank $149.47 HCPCS - Non-Drugs K0017 NU DETACH ADJUST ARMREST BASE Blank $149.47 HCPCS - Non-Drugs K0017 RR DETACH ADJUST ARMREST BASE Blank $11.56 HCPCS - Non-Drugs K0017 UE DETACH ADJUST ARMREST BASE Blank $119.67 HCPCS - Non-Drugs K0018 Blank DETACH ADJUST ARMRST UPPER Blank $75.59 HCPCS - Non-Drugs K0018 NU DETACH ADJUST ARMRST UPPER Blank $75.59 HCPCS - Non-Drugs K0018 RR DETACH ADJUST ARMRST UPPER Blank $6.55 HCPCS - Non-Drugs K0018 UE DETACH ADJUST ARMRST UPPER Blank $56.36 HCPCS - Non-Drugs K0019 Blank ARM PAD REPL, EACH Blank $47.87 HCPCS - Non-Drugs K0019 NU ARM PAD EACH Blank $47.87 HCPCS - Non-Drugs K0019 RR ARM PAD EACH Blank $3.40 HCPCS - Non-Drugs K0019 UE ARM PAD EACH Blank $25.48 HCPCS - Non-Drugs K0020 Blank FIXED ADJUST ARMREST PAIR Blank $108.82 HCPCS - Non-Drugs K0020 NU FIXED ADJUST ARMREST PAIR Blank $108.82 HCPCS - Non-Drugs K0020 RR FIXED ADJUST ARMREST PAIR Blank $11.31 HCPCS - Non-Drugs K0020 UE FIXED ADJUST ARMREST PAIR Blank $89.18 HCPCS - Non-Drugs K0037 Blank HI MOUNT FLIP-UP FTREST REPL Blank $104.56 HCPCS - Non-Drugs K0037 NU HIGH MOUNT FLIP-UP FOOTREST Blank $104.56 HCPCS - Non-Drugs K0037 RR HIGH MOUNT FLIP-UP FOOTREST Blank $10.35 HCPCS - Non-Drugs K0037 UE HIGH MOUNT FLIP-UP FOOTREST Blank $86.00 HCPCS - Non-Drugs K0038 Blank LEG STRAP EACH Blank $67.98 HCPCS - Non-Drugs K0038 NU LEG STRAP EACH Blank $67.98 HCPCS - Non-Drugs K0038 RR LEG STRAP EACH Blank $5.78 HCPCS - Non-Drugs K0038 UE LEG STRAP EACH Blank $48.84 HCPCS - Non-Drugs K0039 Blank LEG STRAP H STYLE EACH Blank $116.32 HCPCS - Non-Drugs K0039 NU LEG STRAP H STYLE EACH Blank $116.32 HCPCS - Non-Drugs K0039 RR LEG STRAP H STYLE EACH Blank $12.41 HCPCS - Non-Drugs K0039 UE LEG STRAP H STYLE EACH Blank $94.80 HCPCS - Non-Drugs K0040 Blank ADJUSTABLE ANGLE FOOTPLATE Blank $169.22 HCPCS - Non-Drugs K0040 NU ADJUSTABLE ANGLE FOOTPLATE Blank $169.22 HCPCS - Non-Drugs K0040 RR ADJUSTABLE ANGLE FOOTPLATE Blank $13.49 HCPCS - Non-Drugs K0040 UE ADJUSTABLE ANGLE FOOTPLATE Blank $134.49 HCPCS - Non-Drugs K0041 Blank LARGE SIZE FOOTPLATE EACH Blank $152.53 HCPCS - Non-Drugs K0041 NU LARGE SIZE FOOTPLATE EACH Blank $152.53 HCPCS - Non-Drugs K0041 RR LARGE SIZE FOOTPLATE EACH Blank $11.88 HCPCS - Non-Drugs K0041 UE LARGE SIZE FOOTPLATE EACH Blank $121.96 HCPCS - Non-Drugs K0042 Blank STANDARD SIZE FTPLATE REP EA Blank $108.74 HCPCS - Non-Drugs K0042 NU STANDARD SIZE FOOTPLATE EACH Blank $108.74 HCPCS - Non-Drugs K0042 RR STANDARD SIZE FOOTPLATE EACH Blank $7.63 HCPCS - Non-Drugs K0042 UE STANDARD SIZE FOOTPLATE EACH Blank $86.33 HCPCS - Non-Drugs K0043 Blank FTRST LOWR EXTEN TUBE REP EA Blank $53.69 HCPCS - Non-Drugs K0043 NU FTRST LOWER EXTENSION TUBE Blank $53.69 HCPCS - Non-Drugs K0043 RR FTRST LOWER EXTENSION TUBE Blank $4.69 HCPCS - Non-Drugs K0043 UE FTRST LOWER EXTENSION TUBE Blank $38.14 HCPCS - Non-Drugs K0044 Blank FTRST UPR HANGER BRAC REP EA Blank $45.61 HCPCS - Non-Drugs K0044 NU FTRST UPPER HANGER BRACKET Blank $45.61 HCPCS - Non-Drugs K0044 RR FTRST UPPER HANGER BRACKET Blank $4.11 HCPCS - Non-Drugs K0044 UE FTRST UPPER HANGER BRACKET Blank $32.06 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 68 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
K0045 Blank FTRST COMPL ASSEMBLY REPL EA Blank $122.97 HCPCS - Non-Drugs K0045 NU FOOTREST COMPLETE ASSEMBLY Blank $122.97 HCPCS - Non-Drugs K0045 RR FOOTREST COMPLETE ASSEMBLY Blank $13.42 HCPCS - Non-Drugs K0045 UE FOOTREST COMPLETE ASSEMBLY Blank $99.79 HCPCS - Non-Drugs K0046 Blank ELEV LGRST LWR EXTEN REPL EA Blank $54.11 HCPCS - Non-Drugs K0046 NU ELEVAT LEGRST LOW EXTENSION Blank $54.11 HCPCS - Non-Drugs K0046 RR ELEVAT LEGRST LOW EXTENSION Blank $4.75 HCPCS - Non-Drugs K0046 UE ELEVAT LEGRST LOW EXTENSION Blank $38.45 HCPCS - Non-Drugs K0047 Blank ELEV LEGRST UPR HANGR REP EA Blank $202.66 HCPCS - Non-Drugs K0047 NU ELEVAT LEGRST UP HANGR BRACK Blank $202.66 HCPCS - Non-Drugs K0047 RR ELEVAT LEGRST UP HANGR BRACK Blank $16.73 HCPCS - Non-Drugs K0047 UE ELEVAT LEGRST UP HANGR BRACK Blank $159.58 HCPCS - Non-Drugs K0050 Blank RATCHET ASSEMBLY REPLACEMENT Blank $84.07 HCPCS - Non-Drugs K0050 NU RATCHET ASSEMBLY Blank $84.07 HCPCS - Non-Drugs K0050 RR RATCHET ASSEMBLY Blank $7.77 HCPCS - Non-Drugs K0050 UE RATCHET ASSEMBLY Blank $68.51 HCPCS - Non-Drugs K0051 Blank CAM REL ASM FT/LEGRST REP EA Blank $115.38 HCPCS - Non-Drugs K0051 NU CAM RELESE ASSEM FTRST/LGRST Blank $115.38 HCPCS - Non-Drugs K0051 RR CAM RELESE ASSEM FTRST/LGRST Blank $12.28 HCPCS - Non-Drugs K0051 UE CAM RELESE ASSEM FTRST/LGRST Blank $94.11 HCPCS - Non-Drugs K0052 Blank SWINGAWAY DETACH FTREST REPL Blank $216.08 HCPCS - Non-Drugs K0052 NU SWINGAWAY DETACH FOOTREST Blank $216.08 HCPCS - Non-Drugs K0052 RR SWINGAWAY DETACH FOOTREST Blank $18.03 HCPCS - Non-Drugs K0052 UE SWINGAWAY DETACH FOOTREST Blank $169.63 HCPCS - Non-Drugs K0053 Blank ELEVATE FOOTREST ARTICULATE Blank $252.39 HCPCS - Non-Drugs K0053 NU ELEVATE FOOTREST ARTICULATE Blank $252.39 HCPCS - Non-Drugs K0053 RR ELEVATE FOOTREST ARTICULATE Blank $21.56 HCPCS - Non-Drugs K0053 UE ELEVATE FOOTREST ARTICULATE Blank $196.87 HCPCS - Non-Drugs K0056 Blank SEAT HT <17 OR >=21 LTWT WC Blank $275.36 HCPCS - Non-Drugs K0056 NU SEAT HT <17 OR >=21 LTWT WC Blank $275.36 HCPCS - Non-Drugs K0056 RR SEAT HT <17 OR >=21 LTWT WC Blank $23.79 HCPCS - Non-Drugs K0056 UE SEAT HT <17 OR >=21 LTWT WC Blank $214.09 HCPCS - Non-Drugs K0065 Blank SPOKE PROTECTORS Blank $111.95 HCPCS - Non-Drugs K0065 NU SPOKE PROTECTORS Blank $111.95 HCPCS - Non-Drugs K0065 RR SPOKE PROTECTORS Blank $11.79 HCPCS - Non-Drugs K0065 UE SPOKE PROTECTORS Blank $91.53 HCPCS - Non-Drugs K0069 Blank RR WHL COMPL SOL TIRE REP EA Blank $279.77 HCPCS - Non-Drugs K0069 NU REAR WHL COMPLETE SOLID TIRE Blank $279.77 HCPCS - Non-Drugs K0069 RR REAR WHL COMPLETE SOLID TIRE Blank $24.22 HCPCS - Non-Drugs K0069 UE REAR WHL COMPLETE SOLID TIRE Blank $217.40 HCPCS - Non-Drugs K0070 Blank RR WHL COMPL PNE TIRE REP EA Blank $468.33 HCPCS - Non-Drugs K0070 NU REAR WHL COMPL PNEUM TIRE Blank $468.33 HCPCS - Non-Drugs K0070 RR REAR WHL COMPL PNEUM TIRE Blank $59.27 HCPCS - Non-Drugs K0070 UE REAR WHL COMPL PNEUM TIRE Blank $244.00 HCPCS - Non-Drugs K0071 Blank FR CSTR COMP PNE TIRE REP EA Blank $317.19 HCPCS - Non-Drugs K0071 NU FRONT CASTR COMPL PNEUM TIRE Blank $317.19 HCPCS - Non-Drugs K0071 RR FRONT CASTR COMPL PNEUM TIRE Blank $37.68 HCPCS - Non-Drugs K0071 UE FRONT CASTR COMPL PNEUM TIRE Blank $245.47 HCPCS - Non-Drugs K0072 Blank FR CSTR SEMI-PNE TIRE REP EA Blank $207.92 HCPCS - Non-Drugs K0072 NU FRNT CSTR CMPL SEM-PNEUM TIR Blank $207.92 HCPCS - Non-Drugs K0072 RR FRNT CSTR CMPL SEM-PNEUM TIR Blank $17.24 HCPCS - Non-Drugs K0072 UE FRNT CSTR CMPL SEM-PNEUM TIR Blank $163.52 HCPCS - Non-Drugs K0073 Blank CASTER PIN LOCK EACH Blank $123.08 HCPCS - Non-Drugs K0073 NU CASTER PIN LOCK EACH Blank $123.08 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 69 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
K0073 RR CASTER PIN LOCK EACH Blank $9.01 HCPCS - Non-Drugs K0073 UE CASTER PIN LOCK EACH Blank $77.09 HCPCS - Non-Drugs K0077 Blank FR CSTR ASMB SOL TIRE REP EA Blank $171.69 HCPCS - Non-Drugs K0077 NU FRONT CASTER ASSEM COMPLETE Blank $171.69 HCPCS - Non-Drugs K0077 RR FRONT CASTER ASSEM COMPLETE Blank $13.72 HCPCS - Non-Drugs K0077 UE FRONT CASTER ASSEM COMPLETE Blank $136.34 HCPCS - Non-Drugs K0098 Blank DRIVE BELT FOR PWC, REPL Blank $91.95 HCPCS - Non-Drugs K0098 NU DRIVE BELT POWER WHEELCHAIR Blank $91.95 HCPCS - Non-Drugs K0098 RR DRIVE BELT POWER WHEELCHAIR Blank $6.05 HCPCS - Non-Drugs K0098 UE DRIVE BELT POWER WHEELCHAIR Blank $66.82 HCPCS - Non-Drugs K0105 Blank IV HANGER Blank $292.22 HCPCS - Non-Drugs K0105 NU IV HANGER Blank $292.22 HCPCS - Non-Drugs K0105 RR IV HANGER Blank $25.42 HCPCS - Non-Drugs K0105 UE IV HANGER Blank $226.74 HCPCS - Non-Drugs K0108 Blank W/C COMPONENT-ACCESSORY NOS Blank $69.32 HCPCS - Non-Drugs K0195 Blank ELEVATING WHLCHAIR LEG RESTS Blank $303.00 HCPCS - Non-Drugs K0195 RR ELEVATING WHLCHAIR LEG RESTS Blank $38.34 HCPCS - Non-Drugs K0455 Blank PUMP UNINTERRUPTED INFUSION Blank $4,886.82 HCPCS - Non-Drugs K0455 RR PUMP UNINTERRUPTED INFUSION Blank $618.41 HCPCS - Non-Drugs K0462 Blank TEMPORARY REPLACEMENT EQPMNT Blank $739.11 HCPCS - Non-Drugs K0552 Blank SUP/EXT NON-INS INF PUMP SYR Blank $23.74 HCPCS - Non-Drugs K0601 Blank REPL BATT SILVER OXIDE 1.5 V Blank $5.01 HCPCS - Non-Drugs K0601 NU REPL BATT SILVER OXIDE 1.5 V Blank $5.01 HCPCS - Non-Drugs K0602 Blank REPL BATT SILVER OXIDE 3 V Blank $25.04 HCPCS - Non-Drugs K0602 NU REPL BATT SILVER OXIDE 3 V Blank $25.04 HCPCS - Non-Drugs K0603 Blank REPL BATT ALKALINE 1.5 V Blank $2.50 HCPCS - Non-Drugs K0603 NU REPL BATT ALKALINE 1.5 V Blank $2.50 HCPCS - Non-Drugs K0604 Blank REPL BATT LITHIUM 3.6 V Blank $25.04 HCPCS - Non-Drugs K0604 NU REPL BATT LITHIUM 3.6 V Blank $25.04 HCPCS - Non-Drugs K0605 Blank REPL BATT LITHIUM 4.5 V Blank $64.79 HCPCS - Non-Drugs K0605 NU REPL BATT LITHIUM 4.5 V Blank $64.79 HCPCS - Non-Drugs K0606 Blank AED GARMENT W ELEC ANALYSIS Blank $43,507.09 HCPCS - Non-Drugs K0606 KF AED GARMENT W ELEC ANALYSIS Blank $43,507.09 HCPCS - Non-Drugs K0606 RR AED GARMENT W ELEC ANALYSIS Blank $5,505.71 HCPCS - Non-Drugs K0607 Blank REPL BATT FOR AED Blank $867.06 HCPCS - Non-Drugs K0607 NU REPL BATT FOR AED Blank $867.06 HCPCS - Non-Drugs K0607 RR REPL BATT FOR AED Blank $109.72 HCPCS - Non-Drugs K0607 UE REPL BATT FOR AED Blank $642.82 HCPCS - Non-Drugs K0608 Blank REPL GARMENT FOR AED Blank $330.02 HCPCS - Non-Drugs K0608 NU REPL GARMENT FOR AED Blank $330.02 HCPCS - Non-Drugs K0608 RR REPL GARMENT FOR AED Blank $93.96 HCPCS - Non-Drugs K0608 UE REPL GARMENT FOR AED Blank $264.44 HCPCS - Non-Drugs K0609 Blank REPL ELECTRODE FOR AED Blank $1,812.49 HCPCS - Non-Drugs K0609 KF REPL ELECTRODE FOR AED Blank $1,812.49 HCPCS - Non-Drugs K0669 Blank SEAT/BACK CUS NO DMEPDAC VER Blank $743.11 HCPCS - Non-Drugs K0669 NU SEAT/BACK CUS NO DMEPDAC VER Blank $743.11 HCPCS - Non-Drugs K0672 Blank REMOVABLE SOFT INTERFACE LE Blank $224.62 HCPCS - Non-Drugs K0730 Blank CTRL DOSE INH DRUG DELIV SYS Blank $3,476.58 HCPCS - Non-Drugs K0730 NU CTRL DOSE INH DRUG DELIV SYS Blank $3,476.58 HCPCS - Non-Drugs K0730 RR CTRL DOSE INH DRUG DELIV SYS Blank $439.95 HCPCS - Non-Drugs K0730 UE CTRL DOSE INH DRUG DELIV SYS Blank $1,884.99 HCPCS - Non-Drugs K0733 Blank 12-24HR SEALED LEAD ACID Blank $79.90 HCPCS - Non-Drugs K0733 NU 12-24HR SEALED LEAD ACID Blank $79.90 HCPCS - Non-Drugs K0733 RR 12-24HR SEALED LEAD ACID Blank $7.17 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 70 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
K0733 UE 12-24HR SEALED LEAD ACID Blank $62.52 HCPCS - Non-Drugs K0738 Blank PORTABLE GAS OXYGEN SYSTEM Blank $1,821.40 HCPCS - Non-Drugs K0738 RR PORTABLE GAS OXYGEN SYSTEM Blank $230.49 HCPCS - Non-Drugs K0739 Blank REPAIR/SVC DME NON-OXYGEN EQ Blank $35.88 HCPCS - Non-Drugs K0740 Blank REPAIR/SVC OXYGEN EQUIPMENT Blank $84.10 HCPCS - Non-Drugs K0743 Blank PORTABLE HOME SUCTION PUMP Blank $241.95 HCPCS - Non-Drugs K0744 Blank ABSORP DRG <= 16 SUC PUMP Blank $4.88 HCPCS - Non-Drugs K0745 Blank ABSORP DRG >16<=48 SUC PUMP Blank $6.42 HCPCS - Non-Drugs K0746 Blank ABSORP DRG >48 SUC PUMP Blank $15.87 HCPCS - Non-Drugs K0800 Blank POV GROUP 1 STD UP TO 300LBS Blank $2,263.28 HCPCS - Non-Drugs K0800 NU POV GROUP 1 STD UP TO 300LBS Blank $2,263.28 HCPCS - Non-Drugs K0800 RR POV GROUP 1 STD UP TO 300LBS Blank $253.58 HCPCS - Non-Drugs K0800 UE POV GROUP 1 STD UP TO 300LBS Blank $1,705.03 HCPCS - Non-Drugs K0801 Blank POV GROUP 1 HD 301-450 LBS Blank $4,080.45 HCPCS - Non-Drugs K0801 NU POV GROUP 1 HD 301-450 LBS Blank $4,080.45 HCPCS - Non-Drugs K0801 RR POV GROUP 1 HD 301-450 LBS Blank $435.30 HCPCS - Non-Drugs K0801 UE POV GROUP 1 HD 301-450 LBS Blank $3,067.91 HCPCS - Non-Drugs K0802 Blank POV GROUP 1 VHD 451-600 LBS Blank $5,397.50 HCPCS - Non-Drugs K0802 NU POV GROUP 1 VHD 451-600 LBS Blank $5,397.50 HCPCS - Non-Drugs K0802 RR POV GROUP 1 VHD 451-600 LBS Blank $567.00 HCPCS - Non-Drugs K0802 UE POV GROUP 1 VHD 451-600 LBS Blank $4,055.70 HCPCS - Non-Drugs K0806 Blank POV GROUP 2 STD UP TO 300LBS Blank $3,563.62 HCPCS - Non-Drugs K0806 NU POV GROUP 2 STD UP TO 300LBS Blank $3,563.62 HCPCS - Non-Drugs K0806 RR POV GROUP 2 STD UP TO 300LBS Blank $383.63 HCPCS - Non-Drugs K0806 UE POV GROUP 2 STD UP TO 300LBS Blank $2,680.28 HCPCS - Non-Drugs K0807 Blank POV GROUP 2 HD 301-450 LBS Blank $5,506.08 HCPCS - Non-Drugs K0807 NU POV GROUP 2 HD 301-450 LBS Blank $5,506.08 HCPCS - Non-Drugs K0807 RR POV GROUP 2 HD 301-450 LBS Blank $577.87 HCPCS - Non-Drugs K0807 UE POV GROUP 2 HD 301-450 LBS Blank $4,137.13 HCPCS - Non-Drugs K0808 Blank POV GROUP 2 VHD 451-600 LBS Blank $8,494.97 HCPCS - Non-Drugs K0808 NU POV GROUP 2 VHD 451-600 LBS Blank $8,494.97 HCPCS - Non-Drugs K0808 RR POV GROUP 2 VHD 451-600 LBS Blank $876.74 HCPCS - Non-Drugs K0808 UE POV GROUP 2 VHD 451-600 LBS Blank $6,378.79 HCPCS - Non-Drugs K0812 Blank POWER OPERATED VEHICLE NOC Blank $1,161.04 HCPCS - Non-Drugs K0813 Blank PWC GP 1 STD PORT SEAT/BACK Blank $5,732.29 HCPCS - Non-Drugs K0813 RR PWC GP 1 STD PORT SEAT/BACK Blank $725.41 HCPCS - Non-Drugs K0814 Blank PWC GP 1 STD PORT CAP CHAIR Blank $6,008.89 HCPCS - Non-Drugs K0814 RR PWC GP 1 STD PORT CAP CHAIR Blank $760.41 HCPCS - Non-Drugs K0815 Blank PWC GP 1 STD SEAT/BACK Blank $5,889.42 HCPCS - Non-Drugs K0815 RR PWC GP 1 STD SEAT/BACK Blank $745.29 HCPCS - Non-Drugs K0816 Blank PWC GP 1 STD CAP CHAIR Blank $6,192.81 HCPCS - Non-Drugs K0816 RR PWC GP 1 STD CAP CHAIR Blank $783.68 HCPCS - Non-Drugs K0820 Blank PWC GP 2 STD PORT SEAT/BACK Blank $5,889.42 HCPCS - Non-Drugs K0820 RR PWC GP 2 STD PORT SEAT/BACK Blank $745.29 HCPCS - Non-Drugs K0821 Blank PWC GP 2 STD PORT CAP CHAIR Blank $6,208.78 HCPCS - Non-Drugs K0821 RR PWC GP 2 STD PORT CAP CHAIR Blank $785.71 HCPCS - Non-Drugs K0822 Blank PWC GP 2 STD SEAT/BACK Blank $6,587.50 HCPCS - Non-Drugs K0822 RR PWC GP 2 STD SEAT/BACK Blank $833.63 HCPCS - Non-Drugs K0823 Blank PWC GP 2 STD CAP CHAIR Blank $6,221.29 HCPCS - Non-Drugs K0823 RR PWC GP 2 STD CAP CHAIR Blank $787.29 HCPCS - Non-Drugs K0824 Blank PWC GP 2 HD SEAT/BACK Blank $9,367.60 HCPCS - Non-Drugs K0824 RR PWC GP 2 HD SEAT/BACK Blank $1,185.44 HCPCS - Non-Drugs K0825 Blank PWC GP 2 HD CAP CHAIR Blank $8,696.85 HCPCS - Non-Drugs K0825 RR PWC GP 2 HD CAP CHAIR Blank $1,100.56 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 71 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
K0826 Blank PWC GP 2 VHD SEAT/BACK Blank $15,470.82 HCPCS - Non-Drugs K0826 RR PWC GP 2 VHD SEAT/BACK Blank $1,957.79 HCPCS - Non-Drugs K0827 Blank PWC GP VHD CAP CHAIR Blank $13,513.44 HCPCS - Non-Drugs K0827 RR PWC GP VHD CAP CHAIR Blank $1,710.09 HCPCS - Non-Drugs K0828 Blank PWC GP 2 XTRA HD SEAT/BACK Blank $18,839.21 HCPCS - Non-Drugs K0828 RR PWC GP 2 XTRA HD SEAT/BACK Blank $2,384.05 HCPCS - Non-Drugs K0829 Blank PWC GP 2 XTRA HD CAP CHAIR Blank $12,311.85 HCPCS - Non-Drugs K0829 RR PWC GP 2 XTRA HD CAP CHAIR Blank $1,558.03 HCPCS - Non-Drugs K0830 Blank PWC GP2 STD SEAT ELEVATE S/B Blank $474.94 HCPCS - Non-Drugs K0831 Blank PWC GP2 STD SEAT ELEVATE CAP Blank $999.11 HCPCS - Non-Drugs K0835 Blank PWC GP2 STD SING POW OPT S/B Blank $7,413.45 HCPCS - Non-Drugs K0835 RR PWC GP2 STD SING POW OPT S/B Blank $938.15 HCPCS - Non-Drugs K0836 Blank PWC GP2 STD SING POW OPT CAP Blank $7,680.28 HCPCS - Non-Drugs K0836 RR PWC GP2 STD SING POW OPT CAP Blank $971.92 HCPCS - Non-Drugs K0837 Blank PWC GP 2 HD SING POW OPT S/B Blank $9,440.80 HCPCS - Non-Drugs K0837 RR PWC GP 2 HD SING POW OPT S/B Blank $1,194.71 HCPCS - Non-Drugs K0838 Blank PWC GP 2 HD SING POW OPT CAP Blank $8,395.07 HCPCS - Non-Drugs K0838 RR PWC GP 2 HD SING POW OPT CAP Blank $1,062.37 HCPCS - Non-Drugs K0839 Blank PWC GP2 VHD SING POW OPT S/B Blank $12,462.07 HCPCS - Non-Drugs K0839 RR PWC GP2 VHD SING POW OPT S/B Blank $1,577.04 HCPCS - Non-Drugs K0840 Blank PWC GP2 XHD SING POW OPT S/B Blank $19,005.45 HCPCS - Non-Drugs K0840 RR PWC GP2 XHD SING POW OPT S/B Blank $2,405.09 HCPCS - Non-Drugs K0841 Blank PWC GP2 STD MULT POW OPT S/B Blank $8,323.83 HCPCS - Non-Drugs K0841 RR PWC GP2 STD MULT POW OPT S/B Blank $1,053.36 HCPCS - Non-Drugs K0842 Blank PWC GP2 STD MULT POW OPT CAP Blank $8,312.17 HCPCS - Non-Drugs K0842 RR PWC GP2 STD MULT POW OPT CAP Blank $1,051.88 HCPCS - Non-Drugs K0843 Blank PWC GP2 HD MULT POW OPT S/B Blank $9,822.70 HCPCS - Non-Drugs K0843 RR PWC GP2 HD MULT POW OPT S/B Blank $1,243.04 HCPCS - Non-Drugs K0848 Blank PWC GP 3 STD SEAT/BACK Blank $11,217.97 HCPCS - Non-Drugs K0848 RR PWC GP 3 STD SEAT/BACK Blank $1,419.60 HCPCS - Non-Drugs K0849 Blank PWC GP 3 STD CAP CHAIR Blank $10,794.68 HCPCS - Non-Drugs K0849 RR PWC GP 3 STD CAP CHAIR Blank $1,366.04 HCPCS - Non-Drugs K0850 Blank PWC GP 3 HD SEAT/BACK Blank $12,974.20 HCPCS - Non-Drugs K0850 RR PWC GP 3 HD SEAT/BACK Blank $1,641.85 HCPCS - Non-Drugs K0851 Blank PWC GP 3 HD CAP CHAIR Blank $12,483.90 HCPCS - Non-Drugs K0851 RR PWC GP 3 HD CAP CHAIR Blank $1,579.81 HCPCS - Non-Drugs K0852 Blank PWC GP 3 VHD SEAT/BACK Blank $14,953.57 HCPCS - Non-Drugs K0852 RR PWC GP 3 VHD SEAT/BACK Blank $1,892.33 HCPCS - Non-Drugs K0853 Blank PWC GP 3 VHD CAP CHAIR Blank $15,354.61 HCPCS - Non-Drugs K0853 RR PWC GP 3 VHD CAP CHAIR Blank $1,943.09 HCPCS - Non-Drugs K0854 Blank PWC GP 3 XHD SEAT/BACK Blank $20,263.83 HCPCS - Non-Drugs K0854 RR PWC GP 3 XHD SEAT/BACK Blank $2,564.33 HCPCS - Non-Drugs K0855 Blank PWC GP 3 XHD CAP CHAIR Blank $19,155.47 HCPCS - Non-Drugs K0855 RR PWC GP 3 XHD CAP CHAIR Blank $2,424.07 HCPCS - Non-Drugs K0856 Blank PWC GP3 STD SING POW OPT S/B Blank $12,023.70 HCPCS - Non-Drugs K0856 RR PWC GP3 STD SING POW OPT S/B Blank $1,521.57 HCPCS - Non-Drugs K0857 Blank PWC GP3 STD SING POW OPT CAP Blank $12,259.90 HCPCS - Non-Drugs K0857 RR PWC GP3 STD SING POW OPT CAP Blank $1,551.46 HCPCS - Non-Drugs K0858 Blank PWC GP3 HD SING POW OPT S/B Blank $14,860.39 HCPCS - Non-Drugs K0858 RR PWC GP3 HD SING POW OPT S/B Blank $1,880.54 HCPCS - Non-Drugs K0859 Blank PWC GP3 HD SING POW OPT CAP Blank $14,183.30 HCPCS - Non-Drugs K0859 RR PWC GP3 HD SING POW OPT CAP Blank $1,794.86 HCPCS - Non-Drugs K0860 Blank PWC GP3 VHD SING POW OPT S/B Blank $21,127.27 HCPCS - Non-Drugs K0860 RR PWC GP3 VHD SING POW OPT S/B Blank $2,673.60 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 72 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
K0861 Blank PWC GP3 STD MULT POW OPT S/B Blank $12,042.59 HCPCS - Non-Drugs K0861 RR PWC GP3 STD MULT POW OPT S/B Blank $1,523.96 HCPCS - Non-Drugs K0862 Blank PWC GP3 HD MULT POW OPT S/B Blank $14,860.39 HCPCS - Non-Drugs K0862 RR PWC GP3 HD MULT POW OPT S/B Blank $1,880.54 HCPCS - Non-Drugs K0863 Blank PWC GP3 VHD MULT POW OPT S/B Blank $21,127.27 HCPCS - Non-Drugs K0863 RR PWC GP3 VHD MULT POW OPT S/B Blank $2,673.60 HCPCS - Non-Drugs K0864 Blank PWC GP3 XHD MULT POW OPT S/B Blank $25,096.16 HCPCS - Non-Drugs K0864 RR PWC GP3 XHD MULT POW OPT S/B Blank $3,175.85 HCPCS - Non-Drugs K0868 Blank PWC GP 4 STD SEAT/BACK Blank $845.18 HCPCS - Non-Drugs K0869 Blank PWC GP 4 STD CAP CHAIR Blank $2,635.55 HCPCS - Non-Drugs K0870 Blank PWC GP 4 HD SEAT/BACK Blank $2,773.82 HCPCS - Non-Drugs K0871 Blank PWC GP 4 VHD SEAT/BACK Blank $7,213.01 HCPCS - Non-Drugs K0877 Blank PWC GP4 STD SING POW OPT S/B Blank $925.22 HCPCS - Non-Drugs K0878 Blank PWC GP4 STD SING POW OPT CAP Blank $1,899.87 HCPCS - Non-Drugs K0879 Blank PWC GP4 HD SING POW OPT S/B Blank $2,298.02 HCPCS - Non-Drugs K0880 Blank PWC GP4 VHD SING POW OPT S/B Blank $2,459.48 HCPCS - Non-Drugs K0884 Blank PWC GP4 STD MULT POW OPT S/B Blank $1,229.29 HCPCS - Non-Drugs K0885 Blank PWC GP4 STD MULT POW OPT CAP Blank $3,509.96 HCPCS - Non-Drugs K0886 Blank PWC GP4 HD MULT POW S/B Blank $2,939.09 HCPCS - Non-Drugs K0890 Blank PWC GP5 PED SING POW OPT S/B Blank $2,244.99 HCPCS - Non-Drugs K0891 Blank PWC GP5 PED MULT POW OPT S/B Blank $1,422.61 HCPCS - Non-Drugs K0898 Blank POWER WHEELCHAIR NOC Blank $1,308.69 HCPCS - Non-Drugs K0899 Blank POW MOBIL DEV NO DMEPDAC Blank $2,082.01 HCPCS - Non-Drugs K0901 Blank KO SINGLE UPRIGHT PRE OTS Blank $1,413.99 HCPCS - Non-Drugs K0902 Blank KO DOUBLE UPRIGHT PRE OTS Blank $1,369.33 HCPCS - Non-Drugs L0112 Blank CRANIAL CERVICAL ORTHOSIS Blank $2,209.24 HCPCS - Non-Drugs L0113 Blank CRANIAL CERVICAL TORTICOLLIS Blank $445.69 HCPCS - Non-Drugs L0120 Blank CERV FLEX N/ADJ FOAM PRE OTS Blank $41.82 HCPCS - Non-Drugs L0130 Blank FLEX THERMOPLASTIC COLLAR MO Blank $279.09 HCPCS - Non-Drugs L0140 Blank CERVICAL SEMI-RIGID ADJUSTAB Blank $98.05 HCPCS - Non-Drugs L0150 Blank CERV SEMI-RIG ADJ MOLDED CHN Blank $177.70 HCPCS - Non-Drugs L0160 Blank CERV SR WIRE OCC/MAN PRE OTS Blank $256.62 HCPCS - Non-Drugs L0170 Blank CERVICAL COLLAR MOLDED TO PT Blank $1,115.35 HCPCS - Non-Drugs L0172 Blank CERV COL SR FOAM 2PC PRE OTS Blank $212.11 HCPCS - Non-Drugs L0174 Blank CERV SR 2PC THOR EXT PRE OTS Blank $440.54 HCPCS - Non-Drugs L0180 Blank CER POST COL OCC/MAN SUP ADJ Blank $625.16 HCPCS - Non-Drugs L0190 Blank CERV COLLAR SUPP ADJ CERV BA Blank $839.43 HCPCS - Non-Drugs L0200 Blank CERV COL SUPP ADJ BAR & THOR Blank $878.28 HCPCS - Non-Drugs L0220 Blank THOR RIB BELT CUSTOM FABRICA Blank $196.95 HCPCS - Non-Drugs L0450 Blank TLSO FLEX TRUNK/THOR PRE OTS Blank $288.72 HCPCS - Non-Drugs L0452 Blank TLSO FLEX CUSTOM FAB THORACI Blank $513.71 HCPCS - Non-Drugs L0454 Blank TLSO TRNK SJ-T9 PRE CST Blank $542.61 HCPCS - Non-Drugs L0455 Blank TLSO FLEX TRNK SJ-T9 PRE OTS Blank $542.61 HCPCS - Non-Drugs L0456 Blank TLSO FLEX TRNK SJ-SS PRE CST Blank $1,568.04 HCPCS - Non-Drugs L0457 Blank TLSO FLEX TRNK SJ-SS PRE OTS Blank $1,568.04 HCPCS - Non-Drugs L0458 Blank TLSO 2MOD SYMPHIS-XIPHO PRE Blank $1,405.40 HCPCS - Non-Drugs L0460 Blank TLSO 2 SHL SYMPHYS-STERN CST Blank $1,582.69 HCPCS - Non-Drugs L0462 Blank TLSO 3MOD SACRO-SCAP PRE Blank $1,970.16 HCPCS - Non-Drugs L0464 Blank TLSO 4MOD SACRO-SCAP PRE Blank $2,346.68 HCPCS - Non-Drugs L0466 Blank TLSO R FRAM SOFT ANT PRE CST Blank $618.40 HCPCS - Non-Drugs L0467 Blank TLSO R FRAM SOFT PRE OTS Blank $618.40 HCPCS - Non-Drugs L0468 Blank TLSO RIG FRAM PELVIC PRE CST Blank $780.10 HCPCS - Non-Drugs L0469 Blank TLSO RIG FRAM PELVIC PRE OTS Blank $780.10 HCPCS - Non-Drugs L0470 Blank TLSO RIGID FRAME PRE SUBCLAV Blank $1,068.66 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 73 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L0472 Blank TLSO RIGID FRAME HYPEREX PRE Blank $693.59 HCPCS - Non-Drugs L0480 Blank TLSO RIGID PLASTIC CUSTOM FA Blank $2,352.13 HCPCS - Non-Drugs L0482 Blank TLSO RIGID LINED CUSTOM FAB Blank $2,589.03 HCPCS - Non-Drugs L0484 Blank TLSO RIGID PLASTIC CUST FAB Blank $2,880.33 HCPCS - Non-Drugs L0486 Blank TLSO RIGIDLINED CUST FAB TWO Blank $3,072.13 HCPCS - Non-Drugs L0488 Blank TLSO RIGID LINED PRE ONE PIE Blank $1,582.69 HCPCS - Non-Drugs L0490 Blank TLSO RIGID PLASTIC PRE ONE Blank $441.91 HCPCS - Non-Drugs L0491 Blank TLSO 2 PIECE RIGID SHELL Blank $1,209.35 HCPCS - Non-Drugs L0492 Blank TLSO 3 PIECE RIGID SHELL Blank $790.20 HCPCS - Non-Drugs L0621 Blank SIO FLEX PELVIC/SACR PRE OTS Blank $147.12 HCPCS - Non-Drugs L0622 Blank SIO FLEX PELVISACRAL CUSTOM Blank $425.32 HCPCS - Non-Drugs L0623 Blank SIO RIG PNL PELV/SAC PRE OTS Blank $63.17 HCPCS - Non-Drugs L0624 Blank SIO PANEL CUSTOM Blank $112.64 HCPCS - Non-Drugs L0625 Blank LO FLEX L1-BELOW L5 PRE OTS Blank $80.78 HCPCS - Non-Drugs L0626 Blank LO SAG RIG PNL STAYS PRE CST Blank $116.97 HCPCS - Non-Drugs L0627 Blank LO SAG RI AN/POS PNL PRE CST Blank $644.34 HCPCS - Non-Drugs L0628 Blank LSO FLEX NO RI STAYS PRE OTS Blank $126.38 HCPCS - Non-Drugs L0629 Blank LSO FLEX W/RIGID STAYS CUST Blank $121.97 HCPCS - Non-Drugs L0630 Blank LSO R POST PNL SJ-T9 PRE CST Blank $249.97 HCPCS - Non-Drugs L0631 Blank LSO SAG R AN/POS PNL PRE CST Blank $1,618.81 HCPCS - Non-Drugs L0632 Blank LSO SAG RIGID FRAME CUST Blank $2,333.75 HCPCS - Non-Drugs L0633 Blank LSO SC R POS/LAT PNL PRE CST Blank $447.56 HCPCS - Non-Drugs L0634 Blank LSO FLEXION CONTROL CUSTOM Blank $656.14 HCPCS - Non-Drugs L0635 Blank LSO SAGIT RIGID PANEL PREFAB Blank $1,630.21 HCPCS - Non-Drugs L0636 Blank LSO SAGITTAL RIGID PANEL CUS Blank $2,369.83 HCPCS - Non-Drugs L0637 Blank LSO SC R ANT/POS PNL PRE CST Blank $1,920.09 HCPCS - Non-Drugs L0638 Blank LSO SAG-CORONAL PANEL CUSTOM Blank $2,081.48 HCPCS - Non-Drugs L0639 Blank LSO S/C SHELL/PANEL PREFAB Blank $1,920.09 HCPCS - Non-Drugs L0640 Blank LSO S/C SHELL/PANEL CUSTOM Blank $1,650.08 HCPCS - Non-Drugs L0641 Blank LO RIG POS PNL L1-L5 PRE OTS Blank $116.97 HCPCS - Non-Drugs L0642 Blank LO SAG RI AN/POS PNL PRE OTS Blank $644.34 HCPCS - Non-Drugs L0643 Blank LSO SAG CTR RIGI POS PRE OTS Blank $249.97 HCPCS - Non-Drugs L0648 Blank LSO SAG R AN/POS PNL PRE OTS Blank $1,618.81 HCPCS - Non-Drugs L0649 Blank LSO SC R POS/LAT PNL PRE OTS Blank $447.56 HCPCS - Non-Drugs L0650 Blank LSO SC R ANT/POS PNL PRE OTS Blank $1,920.09 HCPCS - Non-Drugs L0651 Blank LSO SAG-CO SHELL PNL PRE OTS Blank $1,920.09 HCPCS - Non-Drugs L0700 Blank CTLSO A-P-L CONTROL MOLDED Blank $3,337.10 HCPCS - Non-Drugs L0710 Blank CTLSO A-P-L CONTROL W/ INTER Blank $3,533.69 HCPCS - Non-Drugs L0810 Blank HALO CERVICAL INTO JCKT VEST Blank $4,261.89 HCPCS - Non-Drugs L0820 Blank HALO CERVICAL INTO BODY JACK Blank $3,503.14 HCPCS - Non-Drugs L0830 Blank HALO CERV INTO MILWAUKEE TYP Blank $5,210.05 HCPCS - Non-Drugs L0859 Blank MRI COMPATIBLE SYSTEM Blank $1,933.10 HCPCS - Non-Drugs L0861 Blank HALO REPL LINER/INTERFACE Blank $334.78 HCPCS - Non-Drugs L0970 Blank TLSO CORSET FRONT Blank $183.49 HCPCS - Non-Drugs L0972 Blank LSO CORSET FRONT Blank $169.11 HCPCS - Non-Drugs L0974 Blank TLSO FULL CORSET Blank $299.25 HCPCS - Non-Drugs L0976 Blank LSO FULL CORSET Blank $258.94 HCPCS - Non-Drugs L0978 Blank AXILLARY CRUTCH EXTENSION Blank $308.10 HCPCS - Non-Drugs L0980 Blank PERONEAL STRAPS PAIR PRE OTS Blank $27.00 HCPCS - Non-Drugs L0982 Blank STOCKING SUP GRIPS 4 PRE OTS Blank $25.65 HCPCS - Non-Drugs L0984 Blank PROTECT BODY SOCK EA PRE OTS Blank $92.60 HCPCS - Non-Drugs L0999 Blank ADD TO SPINAL ORTHOSIS NOS Blank $146.26 HCPCS - Non-Drugs L1000 Blank CTLSO MILWAUKE INITIAL MODEL Blank $3,346.94 HCPCS - Non-Drugs L1001 Blank CTLSO INFANT IMMOBILIZER Blank $68.31 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 74 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L1005 Blank TENSION BASED SCOLIOSIS ORTH Blank $5,060.37 HCPCS - Non-Drugs L1010 Blank CTLSO AXILLA SLING Blank $108.43 HCPCS - Non-Drugs L1020 Blank KYPHOSIS PAD Blank $148.67 HCPCS - Non-Drugs L1025 Blank KYPHOSIS PAD FLOATING Blank $212.31 HCPCS - Non-Drugs L1030 Blank LUMBAR BOLSTER PAD Blank $104.28 HCPCS - Non-Drugs L1040 Blank LUMBAR OR LUMBAR RIB PAD Blank $130.68 HCPCS - Non-Drugs L1050 Blank STERNAL PAD Blank $138.95 HCPCS - Non-Drugs L1060 Blank THORACIC PAD Blank $155.99 HCPCS - Non-Drugs L1070 Blank TRAPEZIUS SLING Blank $151.87 HCPCS - Non-Drugs L1080 Blank OUTRIGGER Blank $85.47 HCPCS - Non-Drugs L1085 Blank OUTRIGGER BIL W/ VERT EXTENS Blank $263.86 HCPCS - Non-Drugs L1090 Blank LUMBAR SLING Blank $148.82 HCPCS - Non-Drugs L1100 Blank RING FLANGE PLASTIC/LEATHER Blank $266.14 HCPCS - Non-Drugs L1110 Blank RING FLANGE PLAS/LEATHER MOL Blank $430.38 HCPCS - Non-Drugs L1120 Blank COVERS FOR UPRIGHT EACH Blank $61.10 HCPCS - Non-Drugs L1200 Blank FURNSH INITIAL ORTHOSIS ONLY Blank $2,721.12 HCPCS - Non-Drugs L1210 Blank LATERAL THORACIC EXTENSION Blank $425.70 HCPCS - Non-Drugs L1220 Blank ANTERIOR THORACIC EXTENSION Blank $379.40 HCPCS - Non-Drugs L1230 Blank MILWAUKEE TYPE SUPERSTRUCTUR Blank $940.89 HCPCS - Non-Drugs L1240 Blank LUMBAR DEROTATION PAD Blank $129.49 HCPCS - Non-Drugs L1250 Blank ANTERIOR ASIS PAD Blank $118.25 HCPCS - Non-Drugs L1260 Blank ANTERIOR THORACIC DEROTATION Blank $126.30 HCPCS - Non-Drugs L1270 Blank ABDOMINAL PAD Blank $126.68 HCPCS - Non-Drugs L1280 Blank RIB GUSSET (ELASTIC) EACH Blank $136.98 HCPCS - Non-Drugs L1290 Blank LATERAL TROCHANTERIC PAD Blank $125.83 HCPCS - Non-Drugs L1300 Blank BODY JACKET MOLD TO PATIENT Blank $2,856.91 HCPCS - Non-Drugs L1310 Blank POST-OPERATIVE BODY JACKET Blank $2,876.65 HCPCS - Non-Drugs L1499 Blank SPINAL ORTHOSIS NOS Blank $2,866.78 HCPCS - Non-Drugs L1600 Blank HO FLEX FREJKA W/COV PRE CST Blank $208.72 HCPCS - Non-Drugs L1610 Blank HO FREJKA COV ONLY PRE CST Blank $69.74 HCPCS - Non-Drugs L1620 Blank HO FLEX PAVLIK HARNS PRE CST Blank $220.56 HCPCS - Non-Drugs L1630 Blank ABDUCT CONTROL HIP SEMI-FLEX Blank $270.01 HCPCS - Non-Drugs L1640 Blank PELV BAND/SPREAD BAR THIGH C Blank $753.96 HCPCS - Non-Drugs L1650 Blank HO ABDUCTION HIP ADJUSTABLE Blank $372.38 HCPCS - Non-Drugs L1652 Blank HO BI THIGHCUFFS W SPRDR BAR Blank $557.89 HCPCS - Non-Drugs L1660 Blank HO ABDUCTION STATIC PLASTIC Blank $267.99 HCPCS - Non-Drugs L1680 Blank PELVIC & HIP CONTROL THIGH C Blank $2,052.41 HCPCS - Non-Drugs L1685 Blank POST-OP HIP ABDUCT CUSTOM FA Blank $1,991.41 HCPCS - Non-Drugs L1686 Blank HO POST-OP HIP ABDUCTION Blank $1,568.37 HCPCS - Non-Drugs L1690 Blank COMBINATION BILATERAL HO Blank $3,058.39 HCPCS - Non-Drugs L1700 Blank LEG PERTHES ORTH TORONTO TYP Blank $2,569.50 HCPCS - Non-Drugs L1710 Blank LEGG PERTHES ORTH NEWINGTON Blank $3,088.13 HCPCS - Non-Drugs L1720 Blank LEGG PERTHES ORTHOSIS TRILAT Blank $2,250.94 HCPCS - Non-Drugs L1730 Blank LEGG PERTHES ORTH SCOTTISH R Blank $1,891.03 HCPCS - Non-Drugs L1755 Blank LEGG PERTHES PATTEN BOTTOM T Blank $2,656.19 HCPCS - Non-Drugs L1810 Blank KO ELASTIC WITH JOINTS Blank $164.50 HCPCS - Non-Drugs L1812 Blank KO ELASTIC W/JOINTS PRE OTS Blank $164.50 HCPCS - Non-Drugs L1820 Blank KO ELAS W/ CONDYLE PADS & JO Blank $210.95 HCPCS - Non-Drugs L1830 Blank KO IMMOB CANVAS LONG PRE OTS Blank $143.23 HCPCS - Non-Drugs L1831 Blank KNEE ORTH POS LOCKING JOINT Blank $459.49 HCPCS - Non-Drugs L1832 Blank KO ADJ JNT POS R SUP PRE CST Blank $1,086.93 HCPCS - Non-Drugs L1833 Blank KO ADJ JNT POS R SUP PRE OTS Blank $1,086.93 HCPCS - Non-Drugs L1834 Blank KO W/0 JOINT RIGID MOLDED TO Blank $1,302.44 HCPCS - Non-Drugs L1836 Blank KO RIGID W/O JOINTS PRE OTS Blank $204.79 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 75 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L1840 Blank KO DEROT ANT CRUCIATE CUSTOM Blank $1,573.76 HCPCS - Non-Drugs L1843 Blank KO SINGLE UPRIGHT PRE CST Blank $1,413.99 HCPCS - Non-Drugs L1844 Blank KO W/ADJ JT ROT CNTRL MOLDED Blank $2,625.99 HCPCS - Non-Drugs L1845 Blank KO DOUBLE UPRIGHT PRE CST Blank $1,369.33 HCPCS - Non-Drugs L1846 Blank KO W ADJ FLEX/EXT ROTAT MOLD Blank $1,907.30 HCPCS - Non-Drugs L1847 Blank KO DBL UPRIGHT W/AIR PRE CST Blank $905.17 HCPCS - Non-Drugs L1848 Blank KO DBL UPRIGHT W/AIR PRE OTS Blank $905.17 HCPCS - Non-Drugs L1850 Blank KO SWEDISH TYPE PRE OTS Blank $475.97 HCPCS - Non-Drugs L1860 Blank KO SUPRACONDYLAR SOCKET MOLD Blank $1,834.39 HCPCS - Non-Drugs L1900 Blank AFO SPRNG WIR DRSFLX CALF BD Blank $444.02 HCPCS - Non-Drugs L1902 Blank AFO ANKLE GAUNTLET PRE OTS Blank $128.24 HCPCS - Non-Drugs L1904 Blank AFO MOLDED ANKLE GAUNTLET Blank $763.05 HCPCS - Non-Drugs L1906 Blank AFO MULTILIG ANK SUP PRE OTS Blank $191.57 HCPCS - Non-Drugs L1907 Blank AFO SUPRAMALLEOLAR CUSTOM Blank $884.34 HCPCS - Non-Drugs L1910 Blank AFO SING BAR CLASP ATTACH SH Blank $449.73 HCPCS - Non-Drugs L1920 Blank AFO SING UPRIGHT W/ ADJUST S Blank $569.71 HCPCS - Non-Drugs L1930 Blank AFO PLASTIC Blank $395.72 HCPCS - Non-Drugs L1932 Blank AFO RIG ANT TIB PREFAB TCF/= Blank $1,406.22 HCPCS - Non-Drugs L1940 Blank AFO MOLDED TO PATIENT PLASTI Blank $839.39 HCPCS - Non-Drugs L1945 Blank AFO MOLDED PLAS RIG ANT TIB Blank $1,592.42 HCPCS - Non-Drugs L1950 Blank AFO SPIRAL MOLDED TO PT PLAS Blank $1,261.54 HCPCS - Non-Drugs L1951 Blank AFO SPIRAL PREFABRICATED Blank $1,323.06 HCPCS - Non-Drugs L1960 Blank AFO POS SOLID ANK PLASTIC MO Blank $947.15 HCPCS - Non-Drugs L1970 Blank AFO PLASTIC MOLDED W/ANKLE J Blank $1,175.08 HCPCS - Non-Drugs L1971 Blank AFO W/ANKLE JOINT, PREFAB Blank $735.60 HCPCS - Non-Drugs L1980 Blank AFO SING SOLID STIRRUP CALF Blank $613.37 HCPCS - Non-Drugs L1990 Blank AFO DOUB SOLID STIRRUP CALF Blank $757.99 HCPCS - Non-Drugs L2000 Blank KAFO SING FRE STIRR THI/CALF Blank $1,693.08 HCPCS - Non-Drugs L2005 Blank KAFO SNG/DBL MECHANICAL ACT Blank $6,480.96 HCPCS - Non-Drugs L2010 Blank KAFO SNG SOLID STIRRUP W/O J Blank $1,551.97 HCPCS - Non-Drugs L2020 Blank KAFO DBL SOLID STIRRUP BAND/ Blank $1,915.45 HCPCS - Non-Drugs L2030 Blank KAFO DBL SOLID STIRRUP W/O J Blank $1,718.68 HCPCS - Non-Drugs L2034 Blank KAFO PLA SIN UP W/WO K/A CUS Blank $3,238.51 HCPCS - Non-Drugs L2035 Blank KAFO PLASTIC PEDIATRIC SIZE Blank $269.20 HCPCS - Non-Drugs L2036 Blank KAFO PLAS DOUB FREE KNEE MOL Blank $3,100.62 HCPCS - Non-Drugs L2037 Blank KAFO PLAS SING FREE KNEE MOL Blank $2,807.98 HCPCS - Non-Drugs L2038 Blank KAFO W/O JOINT MULTI-AXIS AN Blank $2,342.17 HCPCS - Non-Drugs L2040 Blank HKAFO TORSION BIL ROT STRAPS Blank $283.82 HCPCS - Non-Drugs L2050 Blank HKAFO TORSION CABLE HIP PELV Blank $790.08 HCPCS - Non-Drugs L2060 Blank HKAFO TORSION BALL BEARING J Blank $971.49 HCPCS - Non-Drugs L2070 Blank HKAFO TORSION UNILAT ROT STR Blank $222.71 HCPCS - Non-Drugs L2080 Blank HKAFO UNILAT TORSION CABLE Blank $597.52 HCPCS - Non-Drugs L2090 Blank HKAFO UNILAT TORSION BALL BR Blank $736.51 HCPCS - Non-Drugs L2106 Blank AFO TIB FX CAST PLASTER MOLD Blank $1,176.99 HCPCS - Non-Drugs L2108 Blank AFO TIB FX CAST MOLDED TO PT Blank $1,782.53 HCPCS - Non-Drugs L2112 Blank AFO TIBIAL FRACTURE SOFT Blank $800.52 HCPCS - Non-Drugs L2114 Blank AFO TIB FX SEMI-RIGID Blank $999.81 HCPCS - Non-Drugs L2116 Blank AFO TIBIAL FRACTURE RIGID Blank $1,219.50 HCPCS - Non-Drugs L2126 Blank KAFO FEM FX CAST THERMOPLAS Blank $2,008.23 HCPCS - Non-Drugs L2128 Blank KAFO FEM FX CAST MOLDED TO P Blank $2,792.03 HCPCS - Non-Drugs L2132 Blank KAFO FEMORAL FX CAST SOFT Blank $1,367.32 HCPCS - Non-Drugs L2134 Blank KAFO FEM FX CAST SEMI-RIGID Blank $1,694.68 HCPCS - Non-Drugs L2136 Blank KAFO FEMORAL FX CAST RIGID Blank $2,021.31 HCPCS - Non-Drugs L2180 Blank PLAS SHOE INSERT W ANK JOINT Blank $193.94 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 76 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L2182 Blank DROP LOCK KNEE Blank $150.34 HCPCS - Non-Drugs L2184 Blank LIMITED MOTION KNEE JOINT Blank $196.17 HCPCS - Non-Drugs L2186 Blank ADJ MOTION KNEE JNT LERMAN T Blank $240.96 HCPCS - Non-Drugs L2188 Blank QUADRILATERAL BRIM Blank $502.09 HCPCS - Non-Drugs L2190 Blank WAIST BELT Blank $135.72 HCPCS - Non-Drugs L2192 Blank PELVIC BAND & BELT THIGH FLA Blank $592.71 HCPCS - Non-Drugs L2200 Blank LIMITED ANKLE MOTION EA JNT Blank $75.21 HCPCS - Non-Drugs L2210 Blank DORSIFLEXION ASSIST EACH JOI Blank $104.63 HCPCS - Non-Drugs L2220 Blank DORSI & PLANTAR FLEX ASS/RES Blank $130.43 HCPCS - Non-Drugs L2230 Blank SPLIT FLAT CALIPER STIRR & P Blank $122.74 HCPCS - Non-Drugs L2232 Blank ROCKER BOTTOM, CONTACT AFO Blank $148.49 HCPCS - Non-Drugs L2240 Blank ROUND CALIPER AND PLATE ATTA Blank $132.16 HCPCS - Non-Drugs L2250 Blank FOOT PLATE MOLDED STIRRUP AT Blank $572.49 HCPCS - Non-Drugs L2260 Blank REINFORCED SOLID STIRRUP Blank $331.95 HCPCS - Non-Drugs L2265 Blank LONG TONGUE STIRRUP Blank $196.57 HCPCS - Non-Drugs L2270 Blank VARUS/VALGUS STRAP PADDED/LI Blank $85.06 HCPCS - Non-Drugs L2275 Blank PLASTIC MOD LOW EXT PAD/LINE Blank $201.06 HCPCS - Non-Drugs L2280 Blank MOLDED INNER BOOT Blank $766.89 HCPCS - Non-Drugs L2300 Blank ABDUCTION BAR JOINTED ADJUST Blank $450.59 HCPCS - Non-Drugs L2310 Blank ABDUCTION BAR-STRAIGHT Blank $199.79 HCPCS - Non-Drugs L2320 Blank NON-MOLDED LACER Blank $335.98 HCPCS - Non-Drugs L2330 Blank LACER MOLDED TO PATIENT MODE Blank $649.81 HCPCS - Non-Drugs L2335 Blank ANTERIOR SWING BAND Blank $385.51 HCPCS - Non-Drugs L2340 Blank PRE-TIBIAL SHELL MOLDED TO P Blank $774.06 HCPCS - Non-Drugs L2350 Blank PROSTHETIC TYPE SOCKET MOLDE Blank $1,489.97 HCPCS - Non-Drugs L2360 Blank EXTENDED STEEL SHANK Blank $83.00 HCPCS - Non-Drugs L2370 Blank PATTEN BOTTOM Blank $458.22 HCPCS - Non-Drugs L2375 Blank TORSION ANK & HALF SOLID STI Blank $187.04 HCPCS - Non-Drugs L2380 Blank TORSION STRAIGHT KNEE JOINT Blank $200.91 HCPCS - Non-Drugs L2385 Blank STRAIGHT KNEE JOINT HEAVY DU Blank $220.06 HCPCS - Non-Drugs L2387 Blank ADD LE POLY KNEE CUSTOM KAFO Blank $275.90 HCPCS - Non-Drugs L2390 Blank OFFSET KNEE JOINT EACH Blank $170.72 HCPCS - Non-Drugs L2395 Blank OFFSET KNEE JOINT HEAVY DUTY Blank $251.87 HCPCS - Non-Drugs L2397 Blank SUSPENSION SLEEVE LOWER EXT Blank $179.34 HCPCS - Non-Drugs L2405 Blank KNEE JOINT DROP LOCK EA JNT Blank $131.58 HCPCS - Non-Drugs L2415 Blank KNEE JOINT CAM LOCK EACH JOI Blank $185.87 HCPCS - Non-Drugs L2425 Blank KNEE DISC/DIAL LOCK/ADJ FLEX Blank $220.49 HCPCS - Non-Drugs L2430 Blank KNEE JNT RATCHET LOCK EA JNT Blank $220.49 HCPCS - Non-Drugs L2492 Blank KNEE LIFT LOOP DROP LOCK RIN Blank $166.98 HCPCS - Non-Drugs L2500 Blank THI/GLUT/ISCHIA WGT BEARING Blank $511.14 HCPCS - Non-Drugs L2510 Blank TH/WGHT BEAR QUAD-LAT BRIM M Blank $1,262.27 HCPCS - Non-Drugs L2520 Blank TH/WGHT BEAR QUAD-LAT BRIM C Blank $791.54 HCPCS - Non-Drugs L2525 Blank TH/WGHT BEAR NAR M-L BRIM MO Blank $2,073.92 HCPCS - Non-Drugs L2526 Blank TH/WGHT BEAR NAR M-L BRIM CU Blank $1,169.88 HCPCS - Non-Drugs L2530 Blank THIGH/WGHT BEAR LACER NON-MO Blank $388.55 HCPCS - Non-Drugs L2540 Blank THIGH/WGHT BEAR LACER MOLDED Blank $699.71 HCPCS - Non-Drugs L2550 Blank THIGH/WGHT BEAR HIGH ROLL CU Blank $476.15 HCPCS - Non-Drugs L2570 Blank HIP CLEVIS TYPE 2 POSIT JNT Blank $824.82 HCPCS - Non-Drugs L2580 Blank PELVIC CONTROL PELVIC SLING Blank $789.57 HCPCS - Non-Drugs L2600 Blank HIP CLEVIS/THRUST BEARING FR Blank $343.24 HCPCS - Non-Drugs L2610 Blank HIP CLEVIS/THRUST BEARING LO Blank $403.36 HCPCS - Non-Drugs L2620 Blank PELVIC CONTROL HIP HEAVY DUT Blank $451.30 HCPCS - Non-Drugs L2622 Blank HIP JOINT ADJUSTABLE FLEXION Blank $514.02 HCPCS - Non-Drugs L2624 Blank HIP ADJ FLEX EXT ABDUCT CONT Blank $571.80 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 77 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L2627 Blank PLASTIC MOLD RECIPRO HIP & C Blank $2,822.93 HCPCS - Non-Drugs L2628 Blank METAL FRAME RECIPRO HIP & CA Blank $2,755.04 HCPCS - Non-Drugs L2630 Blank PELVIC CONTROL BAND & BELT U Blank $415.35 HCPCS - Non-Drugs L2640 Blank PELVIC CONTROL BAND & BELT B Blank $566.27 HCPCS - Non-Drugs L2650 Blank PELV & THOR CONTROL GLUTEAL Blank $193.81 HCPCS - Non-Drugs L2660 Blank THORACIC CONTROL THORACIC BA Blank $299.83 HCPCS - Non-Drugs L2670 Blank THORAC CONT PARASPINAL UPRIG Blank $274.33 HCPCS - Non-Drugs L2680 Blank THORAC CONT LAT SUPPORT UPRI Blank $252.94 HCPCS - Non-Drugs L2750 Blank PLATING CHROME/NICKEL PR BAR Blank $127.48 HCPCS - Non-Drugs L2755 Blank CARBON GRAPHITE LAMINATION Blank $200.50 HCPCS - Non-Drugs L2760 Blank EXTENSION PER EXTENSION PER Blank $95.80 HCPCS - Non-Drugs L2768 Blank ORTHO SIDEBAR DISCONNECT Blank $199.82 HCPCS - Non-Drugs L2780 Blank NON-CORROSIVE FINISH Blank $105.24 HCPCS - Non-Drugs L2785 Blank DROP LOCK RETAINER EACH Blank $50.36 HCPCS - Non-Drugs L2795 Blank KNEE CONTROL FULL KNEECAP Blank $134.53 HCPCS - Non-Drugs L2800 Blank KNEE CAP MEDIAL OR LATERAL P Blank $168.83 HCPCS - Non-Drugs L2810 Blank KNEE CONTROL CONDYLAR PAD Blank $125.84 HCPCS - Non-Drugs L2820 Blank SOFT INTERFACE BELOW KNEE SE Blank $140.64 HCPCS - Non-Drugs L2830 Blank SOFT INTERFACE ABOVE KNEE SE Blank $153.80 HCPCS - Non-Drugs L2840 Blank TIBIAL LENGTH SOCK FX OR EQU Blank $68.52 HCPCS - Non-Drugs L2850 Blank FEMORAL LGTH SOCK FX OR EQUA Blank $94.62 HCPCS - Non-Drugs L2861 Blank TORSION MECHANISM KNEE/ANKLE Blank $754.04 HCPCS - Non-Drugs L2999 Blank LOWER EXTREMITY ORTHOSIS NOS Blank $80.81 HCPCS - Non-Drugs L3000 Blank FT INSERT UCB BERKELEY SHELL Blank $490.86 HCPCS - Non-Drugs L3001 Blank FOOT INSERT REMOV MOLDED SPE Blank $202.96 HCPCS - Non-Drugs L3002 Blank FOOT INSERT PLASTAZOTE OR EQ Blank $249.24 HCPCS - Non-Drugs L3003 Blank FOOT INSERT SILICONE GEL EAC Blank $269.41 HCPCS - Non-Drugs L3010 Blank FOOT LONGITUDINAL ARCH SUPPO Blank $269.41 HCPCS - Non-Drugs L3020 Blank FOOT LONGITUD/METATARSAL SUP Blank $307.65 HCPCS - Non-Drugs L3030 Blank FOOT ARCH SUPPORT REMOV PREM Blank $114.38 HCPCS - Non-Drugs L3031 Blank FOOT LAMIN/PREPREG COMPOSITE Blank $187.75 HCPCS - Non-Drugs L3040 Blank FT ARCH SUPRT PREMOLD LONGIT Blank $68.45 HCPCS - Non-Drugs L3050 Blank FOOT ARCH SUPP PREMOLD METAT Blank $68.45 HCPCS - Non-Drugs L3060 Blank FOOT ARCH SUPP LONGITUD/META Blank $110.33 HCPCS - Non-Drugs L3070 Blank ARCH SUPRT ATT TO SHO LONGIT Blank $46.65 HCPCS - Non-Drugs L3080 Blank ARCH SUPP ATT TO SHOE METATA Blank $46.65 HCPCS - Non-Drugs L3090 Blank ARCH SUPP ATT TO SHOE LONG/M Blank $59.38 HCPCS - Non-Drugs L3100 Blank HALLUS-VALGUS NT DYN PRE OTS Blank $62.99 HCPCS - Non-Drugs L3140 Blank ABDUCTION ROTATION BAR SHOE Blank $134.52 HCPCS - Non-Drugs L3150 Blank ABDUCT ROTATION BAR W/O SHOE Blank $122.44 HCPCS - Non-Drugs L3160 Blank SHOE STYLED POSITIONING DEV Blank $27.67 HCPCS - Non-Drugs L3170 Blank FOOT PLAS HEEL STABI PRE OTS Blank $74.13 HCPCS - Non-Drugs L3201 Blank OXFORD W SUPINAT/PRONAT INF Blank $65.77 HCPCS - Non-Drugs L3202 Blank OXFORD W/ SUPINAT/PRONATOR C Blank $64.55 HCPCS - Non-Drugs L3203 Blank OXFORD W/ SUPINATOR/PRONATOR Blank $62.73 HCPCS - Non-Drugs L3204 Blank HIGHTOP W/ SUPP/PRONATOR INF Blank $62.73 HCPCS - Non-Drugs L3206 Blank HIGHTOP W/ SUPP/PRONATOR CHI Blank $65.16 HCPCS - Non-Drugs L3207 Blank HIGHTOP W/ SUPP/PRONATOR JUN Blank $66.37 HCPCS - Non-Drugs L3208 Blank SURGICAL BOOT EACH INFANT Blank $35.36 HCPCS - Non-Drugs L3209 Blank SURGICAL BOOT EACH CHILD Blank $49.96 HCPCS - Non-Drugs L3211 Blank SURGICAL BOOT EACH JUNIOR Blank $53.00 HCPCS - Non-Drugs L3212 Blank BENESCH BOOT PAIR INFANT Blank $73.19 HCPCS - Non-Drugs L3213 Blank BENESCH BOOT PAIR CHILD Blank $90.05 HCPCS - Non-Drugs L3214 Blank BENESCH BOOT PAIR JUNIOR Blank $96.13 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 78 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L3215 Blank ORTHOPEDIC FTWEAR LADIES OXF Blank $123.79 HCPCS - Non-Drugs L3216 Blank ORTHOPED LADIES SHOES DPTH I Blank $151.45 HCPCS - Non-Drugs L3217 Blank LADIES SHOES HIGHTOP DEPTH I Blank $164.27 HCPCS - Non-Drugs L3219 Blank ORTHOPEDIC MENS SHOES OXFORD Blank $139.98 HCPCS - Non-Drugs L3221 Blank ORTHOPEDIC MENS SHOES DPTH I Blank $168.99 HCPCS - Non-Drugs L3222 Blank MENS SHOES HIGHTOP DEPTH INL Blank $187.89 HCPCS - Non-Drugs L3224 Blank WOMAN'S SHOE OXFORD BRACE Blank $94.65 HCPCS - Non-Drugs L3225 Blank MAN'S SHOE OXFORD BRACE Blank $108.01 HCPCS - Non-Drugs L3230 Blank CUSTOM SHOES DEPTH INLAY Blank $222.29 HCPCS - Non-Drugs L3250 Blank CUSTOM MOLD SHOE REMOV PROST Blank $438.20 HCPCS - Non-Drugs L3251 Blank SHOE MOLDED TO PT SILICONE S Blank $56.65 HCPCS - Non-Drugs L3252 Blank SHOE MOLDED PLASTAZOTE CUST Blank $237.14 HCPCS - Non-Drugs L3253 Blank SHOE MOLDED PLASTAZOTE CUST Blank $56.04 HCPCS - Non-Drugs L3254 Blank ORTH FOOT NON-STNDARD SIZE/W Blank $27.54 HCPCS - Non-Drugs L3255 Blank ORTH FOOT NON-STANDARD SIZE/ Blank $166.36 HCPCS - Non-Drugs L3257 Blank ORTH FOOT ADD CHARGE SPLIT S Blank $40.84 HCPCS - Non-Drugs L3260 Blank AMBULATORY SURGICAL BOOT EAC Blank $23.81 HCPCS - Non-Drugs L3265 Blank PLASTAZOTE SANDAL EACH Blank $25.63 HCPCS - Non-Drugs L3300 Blank SHO LIFT TAPER TO METATARSAL Blank $76.11 HCPCS - Non-Drugs L3310 Blank SHOE LIFT ELEV HEEL/SOLE NEO Blank $122.44 HCPCS - Non-Drugs L3320 Blank SHOE LIFT ELEV HEEL/SOLE COR Blank $158.20 HCPCS - Non-Drugs L3330 Blank LIFTS ELEVATION METAL EXTENS Blank $889.49 HCPCS - Non-Drugs L3332 Blank SHOE LIFTS TAPERED TO ONE-HA Blank $110.33 HCPCS - Non-Drugs L3334 Blank SHOE LIFTS ELEVATION HEEL /I Blank $55.75 HCPCS - Non-Drugs L3340 Blank SHOE WEDGE SACH Blank $128.50 HCPCS - Non-Drugs L3350 Blank SHOE HEEL WEDGE Blank $33.97 HCPCS - Non-Drugs L3360 Blank SHOE SOLE WEDGE OUTSIDE SOLE Blank $52.11 HCPCS - Non-Drugs L3370 Blank SHOE SOLE WEDGE BETWEEN SOLE Blank $72.07 HCPCS - Non-Drugs L3380 Blank SHOE CLUBFOOT WEDGE Blank $72.07 HCPCS - Non-Drugs L3390 Blank SHOE OUTFLARE WEDGE Blank $72.07 HCPCS - Non-Drugs L3400 Blank SHOE METATARSAL BAR WEDGE RO Blank $59.38 HCPCS - Non-Drugs L3410 Blank SHOE METATARSAL BAR BETWEEN Blank $140.55 HCPCS - Non-Drugs L3420 Blank FULL SOLE/HEEL WEDGE BTWEEN Blank $80.15 HCPCS - Non-Drugs L3430 Blank SHO HEEL COUNT PLAST REINFOR Blank $247.26 HCPCS - Non-Drugs L3440 Blank HEEL LEATHER REINFORCED Blank $114.38 HCPCS - Non-Drugs L3450 Blank SHOE HEEL SACH CUSHION TYPE Blank $160.66 HCPCS - Non-Drugs L3455 Blank SHOE HEEL NEW LEATHER STANDA Blank $59.38 HCPCS - Non-Drugs L3460 Blank SHOE HEEL NEW RUBBER STANDAR Blank $50.29 HCPCS - Non-Drugs L3465 Blank SHOE HEEL THOMAS WITH WEDGE Blank $86.20 HCPCS - Non-Drugs L3470 Blank SHOE HEEL THOMAS EXTEND TO B Blank $92.21 HCPCS - Non-Drugs L3480 Blank SHOE HEEL PAD & DEPRESS FOR Blank $92.21 HCPCS - Non-Drugs L3485 Blank SHOE HEEL PAD REMOVABLE FOR Blank $23.81 HCPCS - Non-Drugs L3500 Blank ORTHO SHOE ADD LEATHER INSOL Blank $43.05 HCPCS - Non-Drugs L3510 Blank ORTHOPEDIC SHOE ADD RUB INSL Blank $43.05 HCPCS - Non-Drugs L3520 Blank O SHOE ADD FELT W LEATH INSL Blank $46.65 HCPCS - Non-Drugs L3530 Blank ORTHO SHOE ADD HALF SOLE Blank $46.65 HCPCS - Non-Drugs L3540 Blank ORTHO SHOE ADD FULL SOLE Blank $74.13 HCPCS - Non-Drugs L3550 Blank O SHOE ADD STANDARD TOE TAP Blank $14.02 HCPCS - Non-Drugs L3560 Blank O SHOE ADD HORSESHOE TOE TAP Blank $33.97 HCPCS - Non-Drugs L3570 Blank O SHOE ADD INSTEP EXTENSION Blank $128.50 HCPCS - Non-Drugs L3580 Blank O SHOE ADD INSTEP VELCRO CLO Blank $96.25 HCPCS - Non-Drugs L3590 Blank O SHOE CONVERT TO SOF COUNTE Blank $78.13 HCPCS - Non-Drugs L3595 Blank ORTHO SHOE ADD MARCH BAR Blank $61.17 HCPCS - Non-Drugs L3600 Blank TRANS SHOE CALIP PLATE EXIST Blank $114.38 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 79 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L3610 Blank TRANS SHOE CALIPER PLATE NEW Blank $152.62 HCPCS - Non-Drugs L3620 Blank TRANS SHOE SOLID STIRRUP EXI Blank $114.38 HCPCS - Non-Drugs L3630 Blank TRANS SHOE SOLID STIRRUP NEW Blank $152.62 HCPCS - Non-Drugs L3640 Blank SHOE DENNIS BROWNE SPLINT BO Blank $62.99 HCPCS - Non-Drugs L3649 Blank ORTHOPEDIC SHOE MODIFICA NOS Blank $79.21 HCPCS - Non-Drugs L3650 Blank SO 8 ABD RESTRAINT PRE OTS Blank $93.57 HCPCS - Non-Drugs L3660 Blank SO 8 AB RSTR CAN/WEB PRE OTS Blank $153.70 HCPCS - Non-Drugs L3670 Blank SO ACRO/CLAV CAN WEB PRE OTS Blank $185.70 HCPCS - Non-Drugs L3671 Blank SO CAP DESIGN W/O JNTS CF Blank $1,291.76 HCPCS - Non-Drugs L3674 Blank SO AIRPLANE W/WO JOINT CF Blank $1,696.56 HCPCS - Non-Drugs L3675 Blank SO VEST CANVAS/WEB PRE OTS Blank $246.71 HCPCS - Non-Drugs L3677 Blank SO HARD PLAS STABILI PRE CST Blank $173.72 HCPCS - Non-Drugs L3678 Blank SO HARD PLAS STABILI PRE OTS Blank $141.98 HCPCS - Non-Drugs L3702 Blank EO W/O JOINTS CF Blank $409.59 HCPCS - Non-Drugs L3710 Blank EO ELAS W/METAL JNTS PRE OTS Blank $198.46 HCPCS - Non-Drugs L3720 Blank FOREARM/ARM CUFFS FREE MOTIO Blank $1,084.99 HCPCS - Non-Drugs L3730 Blank FOREARM/ARM CUFFS EXT/FLEX A Blank $1,498.20 HCPCS - Non-Drugs L3740 Blank CUFFS ADJ LOCK W/ ACTIVE CON Blank $1,767.04 HCPCS - Non-Drugs L3760 Blank EO WITHJOINT, PREFABRICATED Blank $714.91 HCPCS - Non-Drugs L3762 Blank EO RIGID W/O JOINTS PRE OTS Blank $148.49 HCPCS - Non-Drugs L3763 Blank EWHO RIGID W/O JNTS CF Blank $1,078.46 HCPCS - Non-Drugs L3764 Blank EWHO W/JOINT(S) CF Blank $1,209.47 HCPCS - Non-Drugs L3765 Blank EWHFO RIGID W/O JNTS CF Blank $1,840.93 HCPCS - Non-Drugs L3766 Blank EWHFO W/JOINT(S) CF Blank $1,949.79 HCPCS - Non-Drugs L3806 Blank WHFO W/JOINT(S) CUSTOM FAB Blank $648.01 HCPCS - Non-Drugs L3807 Blank WHFO W/O JOINTS PRE CST Blank $354.25 HCPCS - Non-Drugs L3808 Blank WHFO, RIGID W/O JOINTS Blank $532.80 HCPCS - Non-Drugs L3809 Blank WHFO W/O JOINTS PRE OTS Blank $354.25 HCPCS - Non-Drugs L3891 Blank TORSION MECHANISM WRIST/ELBO Blank $280.90 HCPCS - Non-Drugs L3900 Blank HINGE EXTENSION/FLEX WRIST/F Blank $2,143.22 HCPCS - Non-Drugs L3901 Blank HINGE EXT/FLEX WRIST FINGER Blank $2,645.39 HCPCS - Non-Drugs L3904 Blank WHFO ELECTRIC CUSTOM FITTED Blank $4,834.32 HCPCS - Non-Drugs L3905 Blank WHO W/NONTORSION JNT(S) CF Blank $1,422.34 HCPCS - Non-Drugs L3906 Blank WHO W/O JOINTS CF Blank $646.63 HCPCS - Non-Drugs L3908 Blank WHO COCK-UP NONMOLDE PRE OTS Blank $94.87 HCPCS - Non-Drugs L3912 Blank HFO FLEXION GLOVE PRE OTS Blank $153.08 HCPCS - Non-Drugs L3913 Blank HFO W/O JOINTS CF Blank $383.78 HCPCS - Non-Drugs L3915 Blank WHO NONTORSION JNTS PRE CST Blank $759.41 HCPCS - Non-Drugs L3916 Blank WHO NONTORSION JNTS PRE OTS Blank $759.41 HCPCS - Non-Drugs L3917 Blank METACARP FX ORTHOSIS PRE CST Blank $145.77 HCPCS - Non-Drugs L3918 Blank METACARP FX ORTHOSIS PRE OTS Blank $145.77 HCPCS - Non-Drugs L3919 Blank HO W/O JOINTS CF Blank $383.78 HCPCS - Non-Drugs L3921 Blank HFO W/JOINT(S) CF Blank $456.33 HCPCS - Non-Drugs L3923 Blank HFO WITHOUT JOINTS PRE CST Blank $125.75 HCPCS - Non-Drugs L3924 Blank HFO WITHOUT JOINTS PRE OTS Blank $125.75 HCPCS - Non-Drugs L3925 Blank FO PIP DIP JNT/SPRNG PRE OTS Blank $76.30 HCPCS - Non-Drugs L3927 Blank FO PIP DIP NO JT SPR PRE OTS Blank $46.73 HCPCS - Non-Drugs L3929 Blank HFO NONTORSION JNTS PRE CST Blank $124.82 HCPCS - Non-Drugs L3930 Blank HFO NONTORSION JNTS PRE OTS Blank $124.82 HCPCS - Non-Drugs L3931 Blank WHFO NONTORSION JOINT PREFAB Blank $292.87 HCPCS - Non-Drugs L3933 Blank FO W/O JOINTS CF Blank $300.97 HCPCS - Non-Drugs L3935 Blank FO NONTORSION JOINT CF Blank $311.87 HCPCS - Non-Drugs L3956 Blank ADD JOINT UPPER EXT ORTHOSIS Blank $108.57 HCPCS - Non-Drugs L3960 Blank SEWHO AIRPLAN DESIG ABDU POS Blank $1,211.17 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 80 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L3961 Blank SEWHO CAP DESIGN W/O JNTS CF Blank $2,414.16 HCPCS - Non-Drugs L3962 Blank SEWHO ERBS PALSEY DESIGN ABD Blank $1,165.57 HCPCS - Non-Drugs L3967 Blank SEWHO AIRPLANE W/O JNTS CF Blank $2,851.46 HCPCS - Non-Drugs L3971 Blank SEWHO CAP DESIGN W/JNT(S) CF Blank $2,706.37 HCPCS - Non-Drugs L3973 Blank SEWHO AIRPLANE W/JNT(S) CF Blank $2,851.46 HCPCS - Non-Drugs L3975 Blank SEWHFO CAP DESIGN W/O JNT CF Blank $2,414.16 HCPCS - Non-Drugs L3976 Blank SEWHFO AIRPLANE W/O JNTS CF Blank $2,414.16 HCPCS - Non-Drugs L3977 Blank SEWHFO CAP DESGN W/JNT(S) CF Blank $2,706.37 HCPCS - Non-Drugs L3978 Blank SEWHFO AIRPLANE W/JNT(S) CF Blank $2,851.46 HCPCS - Non-Drugs L3980 Blank UP EXT FX ORTHOS HUMERAL NOS Blank $530.45 HCPCS - Non-Drugs L3981 Blank UE FX ORTH SHOUL CAP FOREARM Blank $1,443.85 HCPCS - Non-Drugs L3982 Blank UPPER EXT FX ORTHOSIS RAD/UL Blank $618.90 HCPCS - Non-Drugs L3984 Blank UPPER EXT FX ORTHOSIS WRIST Blank $557.70 HCPCS - Non-Drugs L3995 Blank SOCK FRACTURE OR EQUAL EACH Blank $52.01 HCPCS - Non-Drugs L3999 Blank UPPER LIMB ORTHOSIS NOS Blank $46.43 HCPCS - Non-Drugs L4000 Blank REPL GIRDLE MILWAUKEE ORTH Blank $2,109.11 HCPCS - Non-Drugs L4002 Blank REPLACE STRAP, ANY ORTHOSIS Blank $40.81 HCPCS - Non-Drugs L4010 Blank REPLACE TRILATERAL SOCKET BR Blank $1,153.66 HCPCS - Non-Drugs L4020 Blank REPLACE QUADLAT SOCKET BRIM Blank $1,493.03 HCPCS - Non-Drugs L4030 Blank REPLACE SOCKET BRIM CUST FIT Blank $893.29 HCPCS - Non-Drugs L4040 Blank REPLACE MOLDED THIGH LACER Blank $685.53 HCPCS - Non-Drugs L4045 Blank REPLACE NON-MOLDED THIGH LAC Blank $523.53 HCPCS - Non-Drugs L4050 Blank REPLACE MOLDED CALF LACER Blank $694.76 HCPCS - Non-Drugs L4055 Blank REPLACE NON-MOLDED CALF LACE Blank $426.93 HCPCS - Non-Drugs L4060 Blank REPLACE HIGH ROLL CUFF Blank $512.13 HCPCS - Non-Drugs L4070 Blank REPLACE PROX & DIST UPRIGHT Blank $466.46 HCPCS - Non-Drugs L4080 Blank REPL MET BAND KAFO-AFO PROX Blank $158.24 HCPCS - Non-Drugs L4090 Blank REPL MET BAND KAFO-AFO CALF/ Blank $145.93 HCPCS - Non-Drugs L4100 Blank REPL LEATH CUFF KAFO PROX TH Blank $171.06 HCPCS - Non-Drugs L4110 Blank REPL LEATH CUFF KAFO-AFO CAL Blank $137.24 HCPCS - Non-Drugs L4130 Blank REPLACE PRETIBIAL SHELL Blank $833.94 HCPCS - Non-Drugs L4205 Blank ORTHO DVC REPAIR PER 15 MIN Blank $45.32 HCPCS - Non-Drugs L4210 Blank ORTH DEV REPAIR/REPL MINOR P Blank $34.01 HCPCS - Non-Drugs L4350 Blank ANKLE CONTROL ORTHO PRE OTS Blank $145.55 HCPCS - Non-Drugs L4360 Blank PNEUMAT WALKING BOOT PRE CST Blank $441.77 HCPCS - Non-Drugs L4361 Blank PNEUMA/VAC WALK BOOT PRE OTS Blank $441.77 HCPCS - Non-Drugs L4370 Blank PNEUM FULL LEG SPLNT PRE OTS Blank $301.57 HCPCS - Non-Drugs L4386 Blank NON-PNEUM WALK BOOT PRE CST Blank $244.57 HCPCS - Non-Drugs L4387 Blank NON-PNEUM WALK BOOT PRE OTS Blank $244.57 HCPCS - Non-Drugs L4392 Blank REPLACE AFO SOFT INTERFACE Blank $34.81 HCPCS - Non-Drugs L4394 Blank REPLACE FOOT DROP SPINT Blank $25.76 HCPCS - Non-Drugs L4396 Blank STATIC OR DYNAMI AFO PRE CST Blank $258.66 HCPCS - Non-Drugs L4397 Blank STATIC OR DYNAMI AFO PRE OTS Blank $258.66 HCPCS - Non-Drugs L4398 Blank FOOT DROP SPLINT PRE OTS Blank $115.60 HCPCS - Non-Drugs L4631 Blank AFO, WALK BOOT TYPE, CUS FAB Blank $2,522.33 HCPCS - Non-Drugs L5000 Blank SHO INSERT W ARCH TOE FILLER Blank $894.45 HCPCS - Non-Drugs L5010 Blank MOLD SOCKET ANK HGT W/ TOE F Blank $2,203.75 HCPCS - Non-Drugs L5020 Blank TIBIAL TUBERCLE HGT W/ TOE F Blank $3,598.66 HCPCS - Non-Drugs L5050 Blank ANK SYMES MOLD SCKT SACH FT Blank $4,107.81 HCPCS - Non-Drugs L5060 Blank SYMES MET FR LEATH SOCKET AR Blank $5,075.07 HCPCS - Non-Drugs L5100 Blank MOLDED SOCKET SHIN SACH FOOT Blank $4,153.60 HCPCS - Non-Drugs L5105 Blank PLAST SOCKET JTS/THGH LACER Blank $6,227.72 HCPCS - Non-Drugs L5150 Blank MOLD SCKT EXT KNEE SHIN SACH Blank $6,393.80 HCPCS - Non-Drugs L5160 Blank MOLD SOCKET BENT KNEE SHIN S Blank $6,925.15 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 81 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L5200 Blank KNE SING AXIS FRIC SHIN SACH Blank $5,875.60 HCPCS - Non-Drugs L5210 Blank NO KNEE/ANKLE JOINTS W/ FT B Blank $4,425.09 HCPCS - Non-Drugs L5220 Blank NO KNEE JOINT WITH ARTIC ALI Blank $5,028.68 HCPCS - Non-Drugs L5230 Blank FEM FOCAL DEFIC CONSTANT FRI Blank $6,859.55 HCPCS - Non-Drugs L5250 Blank HIP CANAD SING AXI CONS FRIC Blank $9,253.05 HCPCS - Non-Drugs L5270 Blank TILT TABLE LOCKING HIP SING Blank $9,213.86 HCPCS - Non-Drugs L5280 Blank HEMIPELVECT CANAD SING AXIS Blank $9,383.22 HCPCS - Non-Drugs L5301 Blank BK MOLD SOCKET SACH FT ENDO Blank $4,255.59 HCPCS - Non-Drugs L5312 Blank KNEE DISART, SACH FT, ENDO Blank $6,053.66 HCPCS - Non-Drugs L5321 Blank AK OPEN END SACH Blank $6,020.19 HCPCS - Non-Drugs L5331 Blank HIP DISART CANADIAN SACH FT Blank $8,420.77 HCPCS - Non-Drugs L5341 Blank HEMIPELVECTOMY CANADIAN SACH Blank $9,070.20 HCPCS - Non-Drugs L5400 Blank POSTOP DRESS & 1 CAST CHG BK Blank $2,210.31 HCPCS - Non-Drugs L5410 Blank POSTOP DSG BK EA ADD CAST CH Blank $718.27 HCPCS - Non-Drugs L5420 Blank POSTOP DSG & 1 CAST CHG AK/D Blank $2,803.20 HCPCS - Non-Drugs L5430 Blank POSTOP DSG AK EA ADD CAST CH Blank $916.16 HCPCS - Non-Drugs L5450 Blank POSTOP APP NON-WGT BEAR DSG Blank $705.61 HCPCS - Non-Drugs L5460 Blank POSTOP APP NON-WGT BEAR DSG Blank $939.42 HCPCS - Non-Drugs L5500 Blank INIT BK PTB PLASTER DIRECT Blank $2,294.80 HCPCS - Non-Drugs L5505 Blank INIT AK ISCHAL PLSTR DIRECT Blank $3,196.89 HCPCS - Non-Drugs L5510 Blank PREP BK PTB PLASTER MOLDED Blank $2,599.72 HCPCS - Non-Drugs L5520 Blank PERP BK PTB THERMOPLS DIRECT Blank $2,651.68 HCPCS - Non-Drugs L5530 Blank PREP BK PTB THERMOPLS MOLDED Blank $3,087.17 HCPCS - Non-Drugs L5535 Blank PREP BK PTB OPEN END SOCKET Blank $3,098.29 HCPCS - Non-Drugs L5540 Blank PREP BK PTB LAMINATED SOCKET Blank $3,260.53 HCPCS - Non-Drugs L5560 Blank PREP AK ISCHIAL PLAST MOLDED Blank $3,545.31 HCPCS - Non-Drugs L5570 Blank PREP AK ISCHIAL DIRECT FORM Blank $3,628.09 HCPCS - Non-Drugs L5580 Blank PREP AK ISCHIAL THERMO MOLD Blank $4,231.38 HCPCS - Non-Drugs L5585 Blank PREP AK ISCHIAL OPEN END Blank $4,561.91 HCPCS - Non-Drugs L5590 Blank PREP AK ISCHIAL LAMINATED Blank $4,390.89 HCPCS - Non-Drugs L5595 Blank HIP DISARTIC SACH THERMOPLS Blank $7,209.67 HCPCS - Non-Drugs L5600 Blank HIP DISART SACH LAMINAT MOLD Blank $8,015.06 HCPCS - Non-Drugs L5610 Blank ABOVE KNEE HYDRACADENCE Blank $3,730.50 HCPCS - Non-Drugs L5611 Blank AK 4 BAR LINK W/FRIC SWING Blank $2,742.22 HCPCS - Non-Drugs L5613 Blank AK 4 BAR LING W/HYDRAUL SWIG Blank $4,243.62 HCPCS - Non-Drugs L5614 Blank 4-BAR LINK ABOVE KNEE W/SWNG Blank $2,671.10 HCPCS - Non-Drugs L5616 Blank AK UNIV MULTIPLEX SYS FRICT Blank $2,334.88 HCPCS - Non-Drugs L5617 Blank AK/BK SELF-ALIGNING UNIT EA Blank $884.83 HCPCS - Non-Drugs L5618 Blank TEST SOCKET SYMES Blank $483.52 HCPCS - Non-Drugs L5620 Blank TEST SOCKET BELOW KNEE Blank $480.21 HCPCS - Non-Drugs L5622 Blank TEST SOCKET KNEE DISARTICULA Blank $656.89 HCPCS - Non-Drugs L5624 Blank TEST SOCKET ABOVE KNEE Blank $645.80 HCPCS - Non-Drugs L5626 Blank TEST SOCKET HIP DISARTICULAT Blank $862.14 HCPCS - Non-Drugs L5628 Blank TEST SOCKET HEMIPELVECTOMY Blank $864.98 HCPCS - Non-Drugs L5629 Blank BELOW KNEE ACRYLIC SOCKET Blank $558.53 HCPCS - Non-Drugs L5630 Blank SYME TYP EXPANDABL WALL SCKT Blank $789.90 HCPCS - Non-Drugs L5631 Blank AK/KNEE DISARTIC ACRYLIC SOC Blank $771.86 HCPCS - Non-Drugs L5632 Blank SYMES TYPE PTB BRIM DESIGN S Blank $382.05 HCPCS - Non-Drugs L5634 Blank SYMES TYPE POSTER OPENING SO Blank $533.12 HCPCS - Non-Drugs L5636 Blank SYMES TYPE MEDIAL OPENING SO Blank $423.32 HCPCS - Non-Drugs L5637 Blank BELOW KNEE TOTAL CONTACT Blank $556.74 HCPCS - Non-Drugs L5638 Blank BELOW KNEE LEATHER SOCKET Blank $879.40 HCPCS - Non-Drugs L5639 Blank BELOW KNEE WOOD SOCKET Blank $2,010.90 HCPCS - Non-Drugs L5640 Blank KNEE DISARTICULAT LEATHER SO Blank $1,126.93 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 82 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L5642 Blank ABOVE KNEE LEATHER SOCKET Blank $1,033.97 HCPCS - Non-Drugs L5643 Blank HIP FLEX INNER SOCKET EXT FR Blank $2,683.41 HCPCS - Non-Drugs L5644 Blank ABOVE KNEE WOOD SOCKET Blank $981.59 HCPCS - Non-Drugs L5645 Blank BK FLEX INNER SOCKET EXT FRA Blank $1,355.14 HCPCS - Non-Drugs L5646 Blank BELOW KNEE CUSHION SOCKET Blank $943.52 HCPCS - Non-Drugs L5647 Blank BELOW KNEE SUCTION SOCKET Blank $1,377.06 HCPCS - Non-Drugs L5648 Blank ABOVE KNEE CUSHION SOCKET Blank $1,107.11 HCPCS - Non-Drugs L5649 Blank ISCH CONTAINMT/NARROW M-L SO Blank $3,449.10 HCPCS - Non-Drugs L5650 Blank TOT CONTACT AK/KNEE DISART S Blank $875.27 HCPCS - Non-Drugs L5651 Blank AK FLEX INNER SOCKET EXT FRA Blank $2,088.42 HCPCS - Non-Drugs L5652 Blank SUCTION SUSP AK/KNEE DISART Blank $727.60 HCPCS - Non-Drugs L5653 Blank KNEE DISART EXPAND WALL SOCK Blank $1,009.83 HCPCS - Non-Drugs L5654 Blank SOCKET INSERT SYMES Blank $585.13 HCPCS - Non-Drugs L5655 Blank SOCKET INSERT BELOW KNEE Blank $488.20 HCPCS - Non-Drugs L5656 Blank SOCKET INSERT KNEE ARTICULAT Blank $668.68 HCPCS - Non-Drugs L5658 Blank SOCKET INSERT ABOVE KNEE Blank $635.38 HCPCS - Non-Drugs L5661 Blank MULTI-DUROMETER SYMES Blank $1,037.56 HCPCS - Non-Drugs L5665 Blank MULTI-DUROMETER BELOW KNEE Blank $900.60 HCPCS - Non-Drugs L5666 Blank BELOW KNEE CUFF SUSPENSION Blank $121.05 HCPCS - Non-Drugs L5668 Blank BK MOLDED DISTAL CUSHION Blank $179.61 HCPCS - Non-Drugs L5670 Blank BK MOLDED SUPRACONDYLAR SUSP Blank $477.69 HCPCS - Non-Drugs L5671 Blank BK/AK LOCKING MECHANISM Blank $904.92 HCPCS - Non-Drugs L5672 Blank BK REMOVABLE MEDIAL BRIM SUS Blank $508.70 HCPCS - Non-Drugs L5673 Blank SOCKET INSERT W LOCK MECH Blank $1,169.94 HCPCS - Non-Drugs L5676 Blank BK KNEE JOINTS SINGLE AXIS P Blank $644.68 HCPCS - Non-Drugs L5677 Blank BK KNEE JOINTS POLYCENTRIC P Blank $879.74 HCPCS - Non-Drugs L5678 Blank BK JOINT COVERS PAIR Blank $64.66 HCPCS - Non-Drugs L5679 Blank SOCKET INSERT W/O LOCK MECH Blank $973.86 HCPCS - Non-Drugs L5680 Blank BK THIGH LACER NON-MOLDED Blank $524.21 HCPCS - Non-Drugs L5681 Blank INTL CUSTM CONG/LATYP INSERT Blank $2,080.13 HCPCS - Non-Drugs L5682 Blank BK THIGH LACER GLUT/ISCHIA M Blank $1,064.73 HCPCS - Non-Drugs L5683 Blank INITIAL CUSTOM SOCKET INSERT Blank $2,080.13 HCPCS - Non-Drugs L5684 Blank BK FORK STRAP Blank $77.65 HCPCS - Non-Drugs L5685 Blank BELOW KNEE SUS/SEAL SLEEVE Blank $196.73 HCPCS - Non-Drugs L5686 Blank BK BACK CHECK Blank $86.28 HCPCS - Non-Drugs L5688 Blank BK WAIST BELT WEBBING Blank $104.67 HCPCS - Non-Drugs L5690 Blank BK WAIST BELT PADDED AND LIN Blank $173.27 HCPCS - Non-Drugs L5692 Blank AK PELVIC CONTROL BELT LIGHT Blank $230.08 HCPCS - Non-Drugs L5694 Blank AK PELVIC CONTROL BELT PAD/L Blank $318.71 HCPCS - Non-Drugs L5695 Blank AK SLEEVE SUSP NEOPRENE/EQUA Blank $289.30 HCPCS - Non-Drugs L5696 Blank AK/KNEE DISARTIC PELVIC JOIN Blank $327.61 HCPCS - Non-Drugs L5697 Blank AK/KNEE DISARTIC PELVIC BAND Blank $136.03 HCPCS - Non-Drugs L5698 Blank AK/KNEE DISARTIC SILESIAN BA Blank $191.26 HCPCS - Non-Drugs L5699 Blank SHOULDER HARNESS Blank $332.79 HCPCS - Non-Drugs L5700 Blank REPLACE SOCKET BELOW KNEE Blank $4,881.78 HCPCS - Non-Drugs L5701 Blank REPLACE SOCKET ABOVE KNEE Blank $5,996.26 HCPCS - Non-Drugs L5702 Blank REPLACE SOCKET HIP Blank $7,660.00 HCPCS - Non-Drugs L5703 Blank SYMES ANKLE W/O (SACH) FOOT Blank $3,774.84 HCPCS - Non-Drugs L5704 Blank CUSTOM SHAPE COVER BK Blank $920.94 HCPCS - Non-Drugs L5705 Blank CUSTOM SHAPE COVER AK Blank $1,631.51 HCPCS - Non-Drugs L5706 Blank CUSTOM SHAPE CVR KNEE DISART Blank $1,600.24 HCPCS - Non-Drugs L5707 Blank CUSTOM SHAPE CVR HIP DISART Blank $2,170.06 HCPCS - Non-Drugs L5710 Blank KNE-SHIN EXO SNG AXI MNL LOC Blank $636.88 HCPCS - Non-Drugs L5711 Blank KNEE-SHIN EXO MNL LOCK ULTRA Blank $923.45 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 83 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L5712 Blank KNEE-SHIN EXO FRICT SWG & ST Blank $771.09 HCPCS - Non-Drugs L5714 Blank KNEE-SHIN EXO VARIABLE FRICT Blank $721.54 HCPCS - Non-Drugs L5716 Blank KNEE-SHIN EXO MECH STANCE PH Blank $1,295.79 HCPCS - Non-Drugs L5718 Blank KNEE-SHIN EXO FRCT SWG & STA Blank $1,562.41 HCPCS - Non-Drugs L5722 Blank KNEE-SHIN PNEUM SWG FRCT EXO Blank $1,591.06 HCPCS - Non-Drugs L5724 Blank KNEE-SHIN EXO FLUID SWING PH Blank $2,768.58 HCPCS - Non-Drugs L5726 Blank KNEE-SHIN EXT JNTS FLD SWG E Blank $3,114.59 HCPCS - Non-Drugs L5728 Blank KNEE-SHIN FLUID SWG & STANCE Blank $4,171.66 HCPCS - Non-Drugs L5780 Blank KNEE-SHIN PNEUM/HYDRA PNEUM Blank $2,025.09 HCPCS - Non-Drugs L5781 Blank LOWER LIMB PROS VACUUM PUMP Blank $6,340.02 HCPCS - Non-Drugs L5782 Blank HD LOW LIMB PROS VACUUM PUMP Blank $6,684.16 HCPCS - Non-Drugs L5785 Blank EXOSKELETAL BK ULTRALT MATER Blank $897.03 HCPCS - Non-Drugs L5790 Blank EXOSKELETAL AK ULTRA-LIGHT M Blank $1,256.86 HCPCS - Non-Drugs L5795 Blank EXOSKEL HIP ULTRA-LIGHT MATE Blank $1,921.33 HCPCS - Non-Drugs L5810 Blank ENDOSKEL KNEE-SHIN MNL LOCK Blank $863.54 HCPCS - Non-Drugs L5811 Blank ENDO KNEE-SHIN MNL LCK ULTRA Blank $1,284.56 HCPCS - Non-Drugs L5812 Blank ENDO KNEE-SHIN FRCT SWG & ST Blank $985.54 HCPCS - Non-Drugs L5814 Blank ENDO KNEE-SHIN HYDRAL SWG PH Blank $5,886.45 HCPCS - Non-Drugs L5816 Blank ENDO KNEE-SHIN POLYC MCH STA Blank $1,458.39 HCPCS - Non-Drugs L5818 Blank ENDO KNEE-SHIN FRCT SWG & ST Blank $1,669.56 HCPCS - Non-Drugs L5822 Blank ENDO KNEE-SHIN PNEUM SWG FRC Blank $2,837.89 HCPCS - Non-Drugs L5824 Blank ENDO KNEE-SHIN FLUID SWING P Blank $2,757.60 HCPCS - Non-Drugs L5826 Blank MINIATURE KNEE JOINT Blank $4,972.04 HCPCS - Non-Drugs L5828 Blank ENDO KNEE-SHIN FLUID SWG/STA Blank $4,956.57 HCPCS - Non-Drugs L5830 Blank ENDO KNEE-SHIN PNEUM/SWG PHA Blank $3,373.39 HCPCS - Non-Drugs L5840 Blank MULTI-AXIAL KNEE/SHIN SYSTEM Blank $5,960.79 HCPCS - Non-Drugs L5845 Blank KNEE-SHIN SYS STANCE FLEXION Blank $2,836.54 HCPCS - Non-Drugs L5848 Blank KNEE-SHIN SYS HYDRAUL STANCE Blank $1,699.18 HCPCS - Non-Drugs L5850 Blank ENDO AK/HIP KNEE EXTENS ASSI Blank $208.66 HCPCS - Non-Drugs L5855 Blank MECH HIP EXTENSION ASSIST Blank $548.14 HCPCS - Non-Drugs L5856 Blank ELEC KNEE-SHIN SWING/STANCE Blank $38,107.18 HCPCS - Non-Drugs L5857 Blank ELEC KNEE-SHIN SWING ONLY Blank $13,541.48 HCPCS - Non-Drugs L5858 Blank STANCE PHASE ONLY Blank $29,472.41 HCPCS - Non-Drugs L5859 Blank KNEE-SHIN PRO FLEX/EXT CONT Blank $23,059.88 HCPCS - Non-Drugs L5910 Blank ENDO BELOW KNEE ALIGNABLE SY Blank $619.35 HCPCS - Non-Drugs L5920 Blank ENDO AK/HIP ALIGNABLE SYSTEM Blank $909.95 HCPCS - Non-Drugs L5925 Blank ABOVE KNEE MANUAL LOCK Blank $634.03 HCPCS - Non-Drugs L5930 Blank HIGH ACTIVITY KNEE FRAME Blank $5,355.26 HCPCS - Non-Drugs L5940 Blank ENDO BK ULTRA-LIGHT MATERIAL Blank $873.73 HCPCS - Non-Drugs L5950 Blank ENDO AK ULTRA-LIGHT MATERIAL Blank $1,340.18 HCPCS - Non-Drugs L5960 Blank ENDO HIP ULTRA-LIGHT MATERIA Blank $1,730.40 HCPCS - Non-Drugs L5961 Blank ENDO POLY HIP, PNEU/HYD/ROT Blank $7,536.36 HCPCS - Non-Drugs L5962 Blank BELOW KNEE FLEX COVER SYSTEM Blank $1,036.98 HCPCS - Non-Drugs L5964 Blank ABOVE KNEE FLEX COVER SYSTEM Blank $1,654.89 HCPCS - Non-Drugs L5966 Blank HIP FLEXIBLE COVER SYSTEM Blank $2,128.22 HCPCS - Non-Drugs L5968 Blank MULTIAXIAL ANKLE W DORSIFLEX Blank $5,764.24 HCPCS - Non-Drugs L5969 Blank AK/FT POWER ASST INCL MOTORS Blank $17,986.48 HCPCS - Non-Drugs L5970 Blank FOOT EXTERNAL KEEL SACH FOOT Blank $351.38 HCPCS - Non-Drugs L5971 Blank SACH FOOT, REPLACEMENT Blank $351.38 HCPCS - Non-Drugs L5972 Blank FLEXIBLE KEEL FOOT Blank $631.53 HCPCS - Non-Drugs L5973 Blank ANK-FOOT SYS DORS-PLANT FLEX Blank $27,667.93 HCPCS - Non-Drugs L5974 Blank FOOT SINGLE AXIS ANKLE/FOOT Blank $414.69 HCPCS - Non-Drugs L5975 Blank COMBO ANKLE/FOOT PROSTHESIS Blank $729.76 HCPCS - Non-Drugs L5976 Blank ENERGY STORING FOOT Blank $995.40 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 84 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L5978 Blank FT PROSTH MULTIAXIAL ANKL/FT Blank $512.12 HCPCS - Non-Drugs L5979 Blank MULTI-AXIAL ANKLE/FT PROSTH Blank $4,005.66 HCPCS - Non-Drugs L5980 Blank FLEX FOOT SYSTEM Blank $6,455.82 HCPCS - Non-Drugs L5981 Blank FLEX-WALK SYS LOW EXT PROSTH Blank $5,068.94 HCPCS - Non-Drugs L5982 Blank EXOSKELETAL AXIAL ROTATION U Blank $1,024.08 HCPCS - Non-Drugs L5984 Blank ENDOSKELETAL AXIAL ROTATION Blank $1,012.07 HCPCS - Non-Drugs L5985 Blank LWR EXT DYNAMIC PROSTH PYLON Blank $443.39 HCPCS - Non-Drugs L5986 Blank MULTI-AXIAL ROTATION UNIT Blank $1,120.46 HCPCS - Non-Drugs L5987 Blank SHANK FT W VERT LOAD PYLON Blank $11,408.06 HCPCS - Non-Drugs L5988 Blank VERTICAL SHOCK REDUCING PYLO Blank $3,165.93 HCPCS - Non-Drugs L5990 Blank USER ADJUSTABLE HEEL HEIGHT Blank $2,871.16 HCPCS - Non-Drugs L5999 Blank LOWR EXTREMITY PROSTHES NOS Blank $1,116.86 HCPCS - Non-Drugs L6000 Blank PART HAND THUMB REM Blank $2,420.69 HCPCS - Non-Drugs L6010 Blank PART HAND LITTLE/RING Blank $2,673.34 HCPCS - Non-Drugs L6020 Blank PART HAND NO FINGERS Blank $2,501.33 HCPCS - Non-Drugs L6026 Blank PART HAND MYO EXCLU TERM DEV Blank $7,029.30 HCPCS - Non-Drugs L6050 Blank WRST MLD SCK FLX HNG TRI PAD Blank $3,498.60 HCPCS - Non-Drugs L6055 Blank WRST MOLD SOCK W/EXP INTERFA Blank $4,728.42 HCPCS - Non-Drugs L6100 Blank ELB MOLD SOCK FLEX HINGE PAD Blank $3,492.95 HCPCS - Non-Drugs L6110 Blank ELBOW MOLD SOCK SUSPENSION T Blank $3,810.29 HCPCS - Non-Drugs L6120 Blank ELBOW MOLD DOUB SPLT SOC STE Blank $4,375.19 HCPCS - Non-Drugs L6130 Blank ELBOW STUMP ACTIVATED LOCK H Blank $4,673.13 HCPCS - Non-Drugs L6200 Blank ELBOW MOLD OUTSID LOCK HINGE Blank $4,920.83 HCPCS - Non-Drugs L6205 Blank ELBOW MOLDED W/ EXPAND INTER Blank $6,553.34 HCPCS - Non-Drugs L6250 Blank ELBOW INTER LOC ELBOW FORARM Blank $4,886.47 HCPCS - Non-Drugs L6300 Blank SHLDER DISART INT LOCK ELBOW Blank $6,747.25 HCPCS - Non-Drugs L6310 Blank SHOULDER PASSIVE RESTOR COMP Blank $5,515.85 HCPCS - Non-Drugs L6320 Blank SHOULDER PASSIVE RESTOR CAP Blank $3,046.41 HCPCS - Non-Drugs L6350 Blank THORACIC INTERN LOCK ELBOW Blank $7,123.04 HCPCS - Non-Drugs L6360 Blank THORACIC PASSIVE RESTOR COMP Blank $5,753.13 HCPCS - Non-Drugs L6370 Blank THORACIC PASSIVE RESTOR CAP Blank $3,721.68 HCPCS - Non-Drugs L6380 Blank POSTOP DSG CAST CHG WRST/ELB Blank $2,076.64 HCPCS - Non-Drugs L6382 Blank POSTOP DSG CAST CHG ELB DIS/ Blank $2,693.34 HCPCS - Non-Drugs L6384 Blank POSTOP DSG CAST CHG SHLDER/T Blank $3,481.12 HCPCS - Non-Drugs L6386 Blank POSTOP EA CAST CHG & REALIGN Blank $745.24 HCPCS - Non-Drugs L6388 Blank POSTOP APPLICAT RIGID DSG ON Blank $770.67 HCPCS - Non-Drugs L6400 Blank BELOW ELBOW PROSTH TISS SHAP Blank $4,125.53 HCPCS - Non-Drugs L6450 Blank ELB DISART PROSTH TISS SHAP Blank $5,355.19 HCPCS - Non-Drugs L6500 Blank ABOVE ELBOW PROSTH TISS SHAP Blank $5,295.39 HCPCS - Non-Drugs L6550 Blank SHLDR DISAR PROSTH TISS SHAP Blank $6,730.31 HCPCS - Non-Drugs L6570 Blank SCAP THORAC PROSTH TISS SHAP Blank $7,745.95 HCPCS - Non-Drugs L6580 Blank WRIST/ELBOW BOWDEN CABLE MOL Blank $2,759.20 HCPCS - Non-Drugs L6582 Blank WRIST/ELBOW BOWDEN CBL DIR F Blank $2,392.38 HCPCS - Non-Drugs L6584 Blank ELBOW FAIR LEAD CABLE MOLDED Blank $3,655.15 HCPCS - Non-Drugs L6586 Blank ELBOW FAIR LEAD CABLE DIR FO Blank $3,316.53 HCPCS - Non-Drugs L6588 Blank SHDR FAIR LEAD CABLE MOLDED Blank $5,026.83 HCPCS - Non-Drugs L6590 Blank SHDR FAIR LEAD CABLE DIRECT Blank $4,606.80 HCPCS - Non-Drugs L6600 Blank POLYCENTRIC HINGE PAIR Blank $341.18 HCPCS - Non-Drugs L6605 Blank SINGLE PIVOT HINGE PAIR Blank $336.95 HCPCS - Non-Drugs L6610 Blank FLEXIBLE METAL HINGE PAIR Blank $298.23 HCPCS - Non-Drugs L6611 Blank ADDITIONAL SWITCH, EXT POWER Blank $646.62 HCPCS - Non-Drugs L6615 Blank DISCONNECT LOCKING WRIST UNI Blank $302.18 HCPCS - Non-Drugs L6616 Blank DISCONNECT INSERT LOCKING WR Blank $108.08 HCPCS - Non-Drugs L6620 Blank FLEXION/EXTENSION WRIST UNIT Blank $533.67 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 85 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L6621 Blank FLEX/EXT WRIST W/WO FRICTION Blank $3,621.56 HCPCS - Non-Drugs L6623 Blank SPRING-ASS ROT WRST W/ LATCH Blank $1,124.91 HCPCS - Non-Drugs L6624 Blank FLEX/EXT/ROTATION WRIST UNIT Blank $5,967.15 HCPCS - Non-Drugs L6625 Blank ROTATION WRST W/ CABLE LOCK Blank $956.21 HCPCS - Non-Drugs L6628 Blank QUICK DISCONN HOOK ADAPTER O Blank $817.31 HCPCS - Non-Drugs L6629 Blank LAMINATION COLLAR W/ COUPLIN Blank $257.86 HCPCS - Non-Drugs L6630 Blank STAINLESS STEEL ANY WRIST Blank $370.38 HCPCS - Non-Drugs L6632 Blank LATEX SUSPENSION SLEEVE EACH Blank $102.66 HCPCS - Non-Drugs L6635 Blank LIFT ASSIST FOR ELBOW Blank $315.89 HCPCS - Non-Drugs L6637 Blank NUDGE CONTROL ELBOW LOCK Blank $634.39 HCPCS - Non-Drugs L6638 Blank ELEC LOCK ON MANUAL PW ELBOW Blank $3,960.10 HCPCS - Non-Drugs L6640 Blank SHOULDER ABDUCTION JOINT PAI Blank $502.55 HCPCS - Non-Drugs L6641 Blank EXCURSION AMPLIFIER PULLEY T Blank $294.34 HCPCS - Non-Drugs L6642 Blank EXCURSION AMPLIFIER LEVER TY Blank $403.88 HCPCS - Non-Drugs L6645 Blank SHOULDER FLEXION-ABDUCTION J Blank $588.48 HCPCS - Non-Drugs L6646 Blank MULTIPO LOCKING SHOULDER JNT Blank $4,996.27 HCPCS - Non-Drugs L6647 Blank SHOULDER LOCK ACTUATOR Blank $817.16 HCPCS - Non-Drugs L6648 Blank EXT PWRD SHLDER LOCK/UNLOCK Blank $5,153.13 HCPCS - Non-Drugs L6650 Blank SHOULDER UNIVERSAL JOINT Blank $625.58 HCPCS - Non-Drugs L6655 Blank STANDARD CONTROL CABLE EXTRA Blank $129.22 HCPCS - Non-Drugs L6660 Blank HEAVY DUTY CONTROL CABLE Blank $156.84 HCPCS - Non-Drugs L6665 Blank TEFLON OR EQUAL CABLE LINING Blank $73.09 HCPCS - Non-Drugs L6670 Blank HOOK TO HAND CABLE ADAPTER Blank $80.88 HCPCS - Non-Drugs L6672 Blank HARNESS CHEST/SHLDER SADDLE Blank $315.71 HCPCS - Non-Drugs L6675 Blank HARNESS FIGURE OF 8 SING CON Blank $199.31 HCPCS - Non-Drugs L6676 Blank HARNESS FIGURE OF 8 DUAL CON Blank $212.81 HCPCS - Non-Drugs L6677 Blank UE TRIPLE CONTROL HARNESS Blank $464.11 HCPCS - Non-Drugs L6680 Blank TEST SOCK WRIST DISART/BEL E Blank $435.57 HCPCS - Non-Drugs L6682 Blank TEST SOCK ELBW DISART/ABOVE Blank $470.41 HCPCS - Non-Drugs L6684 Blank TEST SOCKET SHLDR DISART/THO Blank $640.05 HCPCS - Non-Drugs L6686 Blank SUCTION SOCKET Blank $1,118.15 HCPCS - Non-Drugs L6687 Blank FRAME TYP SOCKET BEL ELBOW/W Blank $936.73 HCPCS - Non-Drugs L6688 Blank FRAME TYP SOCK ABOVE ELB/DIS Blank $967.61 HCPCS - Non-Drugs L6689 Blank FRAME TYP SOCKET SHOULDER DI Blank $1,184.17 HCPCS - Non-Drugs L6690 Blank FRAME TYP SOCK INTERSCAP-THO Blank $1,267.27 HCPCS - Non-Drugs L6691 Blank REMOVABLE INSERT EACH Blank $612.40 HCPCS - Non-Drugs L6692 Blank SILICONE GEL INSERT OR EQUAL Blank $1,002.01 HCPCS - Non-Drugs L6693 Blank LOCKINGELBOW FOREARM CNTRBAL Blank $4,501.91 HCPCS - Non-Drugs L6694 Blank ELBOW SOCKET INS USE W/LOCK Blank $1,169.94 HCPCS - Non-Drugs L6695 Blank ELBOW SOCKET INS USE W/O LCK Blank $973.86 HCPCS - Non-Drugs L6696 Blank CUS ELBO SKT IN FOR CON/ATYP Blank $2,080.13 HCPCS - Non-Drugs L6697 Blank CUS ELBO SKT IN NOT CON/ATYP Blank $2,080.13 HCPCS - Non-Drugs L6698 Blank BELOW/ABOVE ELBOW LOCK MECH Blank $904.92 HCPCS - Non-Drugs L6703 Blank TERM DEV, PASSIVE HAND MITT Blank $567.94 HCPCS - Non-Drugs L6704 Blank TERM DEV, SPORT/REC/WORK ATT Blank $1,045.87 HCPCS - Non-Drugs L6706 Blank TERM DEV MECH HOOK VOL OPEN Blank $613.88 HCPCS - Non-Drugs L6707 Blank TERM DEV MECH HOOK VOL CLOSE Blank $2,294.05 HCPCS - Non-Drugs L6708 Blank TERM DEV MECH HAND VOL OPEN Blank $1,508.65 HCPCS - Non-Drugs L6709 Blank TERM DEV MECH HAND VOL CLOSE Blank $2,181.60 HCPCS - Non-Drugs L6711 Blank PED TERM DEV, HOOK, VOL OPEN Blank $1,059.95 HCPCS - Non-Drugs L6712 Blank PED TERM DEV, HOOK, VOL CLOS Blank $1,957.01 HCPCS - Non-Drugs L6713 Blank PED TERM DEV, HAND, VOL OPEN Blank $2,471.61 HCPCS - Non-Drugs L6714 Blank PED TERM DEV, HAND, VOL CLOS Blank $2,092.46 HCPCS - Non-Drugs L6715 Blank TERM DEVICE, MULTI ART DIGIT Blank $5,001.62 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 86 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L6721 Blank HOOK/HAND, HVY DTY, VOL OPEN Blank $3,724.13 HCPCS - Non-Drugs L6722 Blank HOOK/HAND, HVY DTY, VOL CLOS Blank $3,209.59 HCPCS - Non-Drugs L6805 Blank TERM DEV MODIFIER WRIST UNIT Blank $607.24 HCPCS - Non-Drugs L6810 Blank TERM DEV PRECISION PINCH DEV Blank $322.18 HCPCS - Non-Drugs L6880 Blank ELEC HAND IND ART DIGITS Blank $37,893.24 HCPCS - Non-Drugs L6881 Blank TERM DEV AUTO GRASP FEATURE Blank $6,478.12 HCPCS - Non-Drugs L6882 Blank MICROPROCESSOR CONTROL UPLMB Blank $4,912.42 HCPCS - Non-Drugs L6883 Blank REPLC SOCKT BELOW E/W DISA Blank $2,846.18 HCPCS - Non-Drugs L6884 Blank REPLC SOCKT ABOVE ELBOW DISA Blank $4,072.13 HCPCS - Non-Drugs L6885 Blank REPLC SOCKT SHLDR DIS/INTERC Blank $5,753.13 HCPCS - Non-Drugs L6890 Blank PREFAB GLOVE FOR TERM DEVICE Blank $313.77 HCPCS - Non-Drugs L6895 Blank CUSTOM GLOVE FOR TERM DEVICE Blank $958.94 HCPCS - Non-Drugs L6900 Blank HAND RESTORAT THUMB/1 FINGER Blank $2,841.56 HCPCS - Non-Drugs L6905 Blank HAND RESTORATION MULTIPLE FI Blank $2,767.46 HCPCS - Non-Drugs L6910 Blank HAND RESTORATION NO FINGERS Blank $2,702.31 HCPCS - Non-Drugs L6915 Blank HAND RESTORATION REPLACMNT G Blank $1,154.65 HCPCS - Non-Drugs L6920 Blank WRIST DISARTICUL SWITCH CTRL Blank $11,850.65 HCPCS - Non-Drugs L6925 Blank WRIST DISART MYOELECTRONIC C Blank $13,517.76 HCPCS - Non-Drugs L6930 Blank BELOW ELBOW SWITCH CONTROL Blank $11,690.54 HCPCS - Non-Drugs L6935 Blank BELOW ELBOW MYOELECTRONIC CT Blank $13,705.21 HCPCS - Non-Drugs L6940 Blank ELBOW DISARTICULATION SWITCH Blank $15,123.33 HCPCS - Non-Drugs L6945 Blank ELBOW DISART MYOELECTRONIC C Blank $17,411.96 HCPCS - Non-Drugs L6950 Blank ABOVE ELBOW SWITCH CONTROL Blank $16,382.77 HCPCS - Non-Drugs L6955 Blank ABOVE ELBOW MYOELECTRONIC CT Blank $19,583.75 HCPCS - Non-Drugs L6960 Blank SHLDR DISARTIC SWITCH CONTRO Blank $20,739.74 HCPCS - Non-Drugs L6965 Blank SHLDR DISARTIC MYOELECTRONIC Blank $24,386.81 HCPCS - Non-Drugs L6970 Blank INTERSCAPULAR-THOR SWITCH CT Blank $25,497.54 HCPCS - Non-Drugs L6975 Blank INTERSCAP-THOR MYOELECTRONIC Blank $27,994.54 HCPCS - Non-Drugs L7007 Blank ADULT ELECTRIC HAND Blank $5,871.83 HCPCS - Non-Drugs L7008 Blank PEDIATRIC ELECTRIC HAND Blank $9,464.82 HCPCS - Non-Drugs L7009 Blank ADULT ELECTRIC HOOK Blank $5,972.97 HCPCS - Non-Drugs L7040 Blank PREHENSILE ACTUATOR Blank $4,798.67 HCPCS - Non-Drugs L7045 Blank PEDIATRIC ELECTRIC HOOK Blank $2,662.93 HCPCS - Non-Drugs L7170 Blank ELECTRONIC ELBOW HOSMER SWIT Blank $10,265.57 HCPCS - Non-Drugs L7180 Blank ELECTRONIC ELBOW SEQUENTIAL Blank $57,587.98 HCPCS - Non-Drugs L7181 Blank ELECTRONIC ELBO SIMULTANEOUS Blank $63,547.38 HCPCS - Non-Drugs L7185 Blank ELECTRON ELBOW ADOLESCENT SW Blank $10,659.78 HCPCS - Non-Drugs L7186 Blank ELECTRON ELBOW CHILD SWITCH Blank $15,781.80 HCPCS - Non-Drugs L7190 Blank ELBOW ADOLESCENT MYOELECTRON Blank $13,423.42 HCPCS - Non-Drugs L7191 Blank ELBOW CHILD MYOELECTRONIC CT Blank $16,508.75 HCPCS - Non-Drugs L7259 Blank ELECTRONIC WRIST ROTATOR ANY Blank $6,000.54 HCPCS - Non-Drugs L7360 Blank SIX VOLT BAT OTTO BOCK/EQ EA Blank $405.51 HCPCS - Non-Drugs L7362 Blank BATTERY CHRGR SIX VOLT OTTO Blank $436.75 HCPCS - Non-Drugs L7364 Blank TWELVE VOLT BATTERY UTAH/EQU Blank $762.84 HCPCS - Non-Drugs L7366 Blank BATTERY CHRGR 12 VOLT UTAH/E Blank $1,020.39 HCPCS - Non-Drugs L7367 Blank REPLACEMNT LITHIUM IONBATTER Blank $611.10 HCPCS - Non-Drugs L7368 Blank LITHIUM ION BATTERY CHARGER Blank $794.09 HCPCS - Non-Drugs L7400 Blank ADD UE PROST BE/WD, ULTLITE Blank $479.71 HCPCS - Non-Drugs L7401 Blank ADD UE PROST A/E ULTLITE MAT Blank $537.80 HCPCS - Non-Drugs L7402 Blank ADD UE PROST S/D ULTLITE MAT Blank $581.29 HCPCS - Non-Drugs L7403 Blank ADD UE PROST B/E ACRYLIC Blank $577.69 HCPCS - Non-Drugs L7404 Blank ADD UE PROST A/E ACRYLIC Blank $875.18 HCPCS - Non-Drugs L7405 Blank ADD UE PROST S/D ACRYLIC Blank $1,146.58 HCPCS - Non-Drugs L7499 Blank UPPER EXTREMITY PROSTHES NOS Blank $1,786.38 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 87 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L7510 Blank PROSTHETIC DEVICE REPAIR REP Blank $46.97 HCPCS - Non-Drugs L7520 Blank REPAIR PROSTHESIS PER 15 MIN Blank $53.14 HCPCS - Non-Drugs L7600 Blank PROSTHETIC DONNING SLEEVE Blank $70.23 HCPCS - Non-Drugs L7900 Blank MALE VACUUM ERECTION SYSTEM Blank $533.33 HCPCS - Non-Drugs L7902 Blank TENSION RING, VAC ERECT DEV Blank $35.13 HCPCS - Non-Drugs L8000 Blank MASTECTOMY BRA Blank $60.96 HCPCS - Non-Drugs L8001 Blank BREAST PROSTHESIS BRA & FORM Blank $192.53 HCPCS - Non-Drugs L8002 Blank BRST PRSTH BRA & BILAT FORM Blank $255.26 HCPCS - Non-Drugs L8010 Blank MASTECTOMY SLEEVE Blank $51.78 HCPCS - Non-Drugs L8015 Blank EXT BREASTPROSTHESIS GARMENT Blank $88.79 HCPCS - Non-Drugs L8020 Blank MASTECTOMY FORM Blank $355.29 HCPCS - Non-Drugs L8030 Blank BREAST PROSTHES W/O ADHESIVE Blank $544.52 HCPCS - Non-Drugs L8031 Blank BREAST PROSTHESIS W ADHESIVE Blank $544.52 HCPCS - Non-Drugs L8032 Blank REUSABLE NIPPLE PROSTHESIS Blank $57.39 HCPCS - Non-Drugs L8035 Blank CUSTOM BREAST PROSTHESIS Blank $5,811.43 HCPCS - Non-Drugs L8039 Blank BREAST PROSTHESIS NOS Blank $52.98 HCPCS - Non-Drugs L8040 Blank NASAL PROSTHESIS Blank $3,961.48 HCPCS - Non-Drugs L8040 KM NASAL PROSTHESIS Blank $3,763.08 HCPCS - Non-Drugs L8040 KN NASAL PROSTHESIS Blank $1,580.73 HCPCS - Non-Drugs L8041 Blank MIDFACIAL PROSTHESIS Blank $4,776.19 HCPCS - Non-Drugs L8041 KM MIDFACIAL PROSTHESIS Blank $4,537.04 HCPCS - Non-Drugs L8041 KN MIDFACIAL PROSTHESIS Blank $1,906.64 HCPCS - Non-Drugs L8042 Blank ORBITAL PROSTHESIS Blank $5,367.29 HCPCS - Non-Drugs L8042 KM ORBITAL PROSTHESIS Blank $5,098.59 HCPCS - Non-Drugs L8042 KN ORBITAL PROSTHESIS Blank $2,143.06 HCPCS - Non-Drugs L8043 Blank UPPER FACIAL PROSTHESIS Blank $6,012.16 HCPCS - Non-Drugs L8043 KM UPPER FACIAL PROSTHESIS Blank $5,711.21 HCPCS - Non-Drugs L8043 KN UPPER FACIAL PROSTHESIS Blank $2,401.00 HCPCS - Non-Drugs L8044 Blank HEMI-FACIAL PROSTHESIS Blank $6,656.98 HCPCS - Non-Drugs L8044 KM HEMI-FACIAL PROSTHESIS Blank $6,323.82 HCPCS - Non-Drugs L8044 KN HEMI-FACIAL PROSTHESIS Blank $2,658.94 HCPCS - Non-Drugs L8045 Blank AURICULAR PROSTHESIS Blank $4,392.91 HCPCS - Non-Drugs L8045 KM AURICULAR PROSTHESIS Blank $4,172.95 HCPCS - Non-Drugs L8045 KN AURICULAR PROSTHESIS Blank $1,753.31 HCPCS - Non-Drugs L8046 Blank PARTIAL FACIAL PROSTHESIS Blank $4,292.55 HCPCS - Non-Drugs L8046 KM PARTIAL FACIAL PROSTHESIS Blank $4,077.60 HCPCS - Non-Drugs L8046 KN PARTIAL FACIAL PROSTHESIS Blank $1,713.15 HCPCS - Non-Drugs L8047 Blank NASAL SEPTAL PROSTHESIS Blank $2,196.79 HCPCS - Non-Drugs L8047 KM NASAL SEPTAL PROSTHESIS Blank $2,086.64 HCPCS - Non-Drugs L8047 KN NASAL SEPTAL PROSTHESIS Blank $874.87 HCPCS - Non-Drugs L8048 Blank UNSPEC MAXILLOFACIAL PROSTH Blank $970.27 HCPCS - Non-Drugs L8049 Blank REPAIR MAXILLOFACIAL PROSTH Blank $66.39 HCPCS - Non-Drugs L8300 Blank TRUSS SINGLE W/ STANDARD PAD Blank $144.50 HCPCS - Non-Drugs L8310 Blank TRUSS DOUBLE W/ STANDARD PAD Blank $238.47 HCPCS - Non-Drugs L8320 Blank TRUSS ADDITION TO STD PAD WA Blank $92.66 HCPCS - Non-Drugs L8330 Blank TRUSS ADD TO STD PAD SCROTAL Blank $85.52 HCPCS - Non-Drugs L8400 Blank SHEATH BELOW KNEE Blank $27.47 HCPCS - Non-Drugs L8410 Blank SHEATH ABOVE KNEE Blank $34.96 HCPCS - Non-Drugs L8415 Blank SHEATH UPPER LIMB Blank $34.60 HCPCS - Non-Drugs L8417 Blank PROS SHEATH/SOCK W GEL CUSHN Blank $112.86 HCPCS - Non-Drugs L8420 Blank PROSTHETIC SOCK MULTI PLY BK Blank $33.91 HCPCS - Non-Drugs L8430 Blank PROSTHETIC SOCK MULTI PLY AK Blank $37.56 HCPCS - Non-Drugs L8435 Blank PROS SOCK MULTI PLY UPPER LM Blank $35.59 HCPCS - Non-Drugs L8440 Blank SHRINKER BELOW KNEE Blank $71.17 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 88 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L8460 Blank SHRINKER ABOVE KNEE Blank $112.31 HCPCS - Non-Drugs L8465 Blank SHRINKER UPPER LIMB Blank $82.02 HCPCS - Non-Drugs L8470 Blank PROS SOCK SINGLE PLY BK Blank $11.47 HCPCS - Non-Drugs L8480 Blank PROS SOCK SINGLE PLY AK Blank $15.46 HCPCS - Non-Drugs L8485 Blank PROS SOCK SINGLE PLY UPPER L Blank $18.92 HCPCS - Non-Drugs L8499 Blank UNLISTED MISC PROSTHETIC SER Blank $6.99 HCPCS - Non-Drugs L8500 Blank ARTIFICIAL LARYNX Blank $1,133.26 HCPCS - Non-Drugs L8501 Blank TRACHEOSTOMY SPEAKING VALVE Blank $196.22 HCPCS - Non-Drugs L8505 Blank ARTIFICIAL LARYNX, ACCESSORY Blank $87.77 HCPCS - Non-Drugs L8507 Blank TRACH-ESOPH VOICE PROS PT IN Blank $61.19 HCPCS - Non-Drugs L8509 Blank TRACH-ESOPH VOICE PROS MD IN Blank $166.80 HCPCS - Non-Drugs L8510 Blank VOICE AMPLIFIER Blank $394.39 HCPCS - Non-Drugs L8511 Blank INDWELLING TRACH INSERT Blank $109.07 HCPCS - Non-Drugs L8512 Blank GEL CAP FOR TRACH VOICE PROS Blank $3.46 HCPCS - Non-Drugs L8513 Blank TRACH PROS CLEANING DEVICE Blank $8.25 HCPCS - Non-Drugs L8514 Blank REPL TRACH PUNCTURE DILATOR Blank $143.32 HCPCS - Non-Drugs L8515 Blank GEL CAP APP DEVICE FOR TRACH Blank $93.68 HCPCS - Non-Drugs L8600 Blank IMPLANT BREAST SILICONE/EQ Blank $1,073.86 HCPCS - Non-Drugs L8603 Blank COLLAGEN IMP URINARY 2.5 ML Blank $689.64 HCPCS - Non-Drugs L8605 Blank INJ BULKING AGENT ANAL CANAL Blank $1,129.70 HCPCS - Non-Drugs L8606 Blank SYNTHETIC IMPLNT URINARY 1ML Blank $343.42 HCPCS - Non-Drugs L8607 Blank INJ VOCAL CORD BULKING AGENT Blank $62.63 HCPCS - Non-Drugs L8609 Blank ARTIFICIAL CORNEA Blank $10,319.67 HCPCS - Non-Drugs L8610 Blank OCULAR IMPLANT Blank $1,014.98 HCPCS - Non-Drugs L8612 Blank AQUEOUS SHUNT PROSTHESIS Blank $1,111.50 HCPCS - Non-Drugs L8613 Blank OSSICULAR IMPLANT Blank $483.92 HCPCS - Non-Drugs L8614 Blank COCHLEAR DEVICE Blank $30,777.52 HCPCS - Non-Drugs L8615 Blank COCH IMPLANT HEADSET REPLACE Blank $708.37 HCPCS - Non-Drugs L8616 Blank COCH IMPLANT MICROPHONE REPL Blank $160.05 HCPCS - Non-Drugs L8617 Blank COCH IMPLANT TRANS COIL REPL Blank $138.99 HCPCS - Non-Drugs L8618 Blank COCH IMPLANT TRAN CABLE REPL Blank $38.76 HCPCS - Non-Drugs L8619 Blank COCH IMP EXT PROC/CONTR RPLC Blank $13,206.88 HCPCS - Non-Drugs L8621 Blank REPL ZINC AIR BATTERY Blank $0.98 HCPCS - Non-Drugs L8622 Blank REPL ALKALINE BATTERY Blank $0.51 HCPCS - Non-Drugs L8623 Blank LITH ION BATT CID,NON-EARLVL Blank $96.09 HCPCS - Non-Drugs L8624 Blank LITH ION BATT CID, EAR LEVEL Blank $249.14 HCPCS - Non-Drugs L8627 Blank CID EXT SPEECH PROCESS REPL Blank $11,208.99 HCPCS - Non-Drugs L8628 Blank CID EXT CONTROLLER REPL Blank $1,984.04 HCPCS - Non-Drugs L8629 Blank CID TRANSMIT COIL AND CABLE Blank $277.60 HCPCS - Non-Drugs L8630 Blank METACARPOPHALANGEAL IMPLANT Blank $573.30 HCPCS - Non-Drugs L8631 Blank MCP JOINT REPL 2 PC OR MORE Blank $3,498.25 HCPCS - Non-Drugs L8641 Blank METATARSAL JOINT IMPLANT Blank $578.24 HCPCS - Non-Drugs L8642 Blank HALLUX IMPLANT Blank $493.41 HCPCS - Non-Drugs L8658 Blank INTERPHALANGEAL JOINT SPACER Blank $504.60 HCPCS - Non-Drugs L8659 Blank INTERPHALANGEAL JOINT REPL Blank $3,051.86 HCPCS - Non-Drugs L8670 Blank VASCULAR GRAFT, SYNTHETIC Blank $877.99 HCPCS - Non-Drugs L8679 Blank IMP NEUROSTI PLS GN ANY TYPE Blank $13,412.90 HCPCS - Non-Drugs L8680 Blank IMPLT NEUROSTIM ELCTR EACH Blank $461.14 HCPCS - Non-Drugs L8681 Blank PT PRGRM FOR IMPLT NEUROSTIM Blank $1,823.98 HCPCS - Non-Drugs L8682 Blank IMPLT NEUROSTIM RADIOFQ REC Blank $9,581.42 HCPCS - Non-Drugs L8683 Blank RADIOFQ TRSMTR FOR IMPLT NEU Blank $8,433.06 HCPCS - Non-Drugs L8684 Blank RADIOF TRSMTR IMPLT SCRL NEU Blank $1,214.53 HCPCS - Non-Drugs L8685 Blank IMPLT NROSTM PLS GEN SNG REC Blank $13,302.71 HCPCS - Non-Drugs L8686 Blank IMPLT NROSTM PLS GEN SNG NON Blank $8,486.03 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 89 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
L8687 Blank IMPLT NROSTM PLS GEN DUA REC Blank $17,314.48 HCPCS - Non-Drugs L8688 Blank IMPLT NROSTM PLS GEN DUA NON Blank $11,045.84 HCPCS - Non-Drugs L8689 Blank EXTERNAL RECHARG SYS INTERN Blank $2,729.78 HCPCS - Non-Drugs L8690 Blank AUD OSSEO DEV, INT/EXT COMP Blank $7,539.66 HCPCS - Non-Drugs L8691 Blank OSSEOINTEGRATED SND PROC RPL Blank $4,223.41 HCPCS - Non-Drugs L8692 Blank NON-OSSEOINTEGRATED SND PROC Blank $317.53 HCPCS - Non-Drugs L8693 Blank AUD OSSEO DEV, ABUTMENT Blank $2,396.75 HCPCS - Non-Drugs L8695 Blank EXTERNAL RECHARG SYS EXTERN Blank $25.11 HCPCS - Non-Drugs L8696 Blank EXT ANTENNA PHREN NERVE STIM Blank $337.39 HCPCS - Non-Drugs L8699 Blank PROSTHETIC IMPLANT NOS Blank $257.20 HCPCS - Non-Drugs L9900 Blank O&P SUPPLY/ACCESSORY/SERVICE Blank $305.90 HCPCS - Non-Drugs Q0138 Blank FERUMOXYTOL, NON-ESRD a $10.51 HCPCS - Drugs Q0139 Blank FERUMOXYTOL, ESRD USE a $2.36 HCPCS - Non-Drugs Q0144 Blank AZITHROMYCIN DIHYDRATE, ORAL a $40.27 HCPCS - Drugs Q0161 Blank CHLORPROMAZINE HCL 5MG ORAL a $1.67 HCPCS - Drugs Q0162 Blank ONDANSETRON ORAL a $1.69 HCPCS - Drugs Q0163 Blank DIPHENHYDRAMINE HCL 50MG a $1.69 HCPCS - Drugs Q0164 Blank PROCHLORPERAZINE MALEATE 5MG a $1.69 HCPCS - Drugs Q0166 Blank GRANISETRON HCL 1 MG ORAL a $5.08 HCPCS - Drugs Q0167 Blank DRONABINOL 2.5MG ORAL a $10.16 HCPCS - Drugs Q0169 Blank PROMETHAZINE HCL 12.5MG ORAL a $1.69 HCPCS - Drugs Q0173 Blank TRIMETHOBENZAMIDE HCL 250MG Blank $3.39 HCPCS - Drugs Q0174 Blank THIETHYLPERAZINE MALEATE10MG Blank $3.39 HCPCS - Drugs Q0175 Blank PERPHENAZINE 4MG ORAL a $3.39 HCPCS - Drugs Q0177 Blank HYDROXYZINE PAMOATE 25MG a $10.16 HCPCS - Drugs Q0180 Blank DOLASETRON MESYLATE ORAL a $372.79 HCPCS - Drugs Q0181 Blank UNSPECIFIED ORAL ANTI-EMETIC a $52.79 HCPCS - Drugs Q0478 Blank POWER ADAPTER, COMBO VAD Blank $284.81 HCPCS - Non-Drugs Q0479 Blank POWER MODULE COMBO VAD, REP Blank $19,135.12 HCPCS - Non-Drugs Q0480 Blank DRIVER PNEUMATIC VAD, REP Blank $142,859.19 HCPCS - Non-Drugs Q0481 Blank MICROPRCSR CU ELEC VAD, REP Blank $23,043.28 HCPCS - Non-Drugs Q0482 Blank MICROPRCSR CU COMBO VAD, REP Blank $7,213.18 HCPCS - Non-Drugs Q0483 Blank MONITOR ELEC VAD, REP Blank $29,735.09 HCPCS - Non-Drugs Q0484 Blank MONITOR ELEC OR COMB VAD REP Blank $5,769.28 HCPCS - Non-Drugs Q0485 Blank MONITOR CABLE ELEC VAD, REP Blank $551.21 HCPCS - Non-Drugs Q0486 Blank MON CABLE ELEC/PNEUM VAD REP Blank $457.68 HCPCS - Non-Drugs Q0487 Blank LEADS ANY TYPE VAD, REP ONLY Blank $535.04 HCPCS - Non-Drugs Q0488 Blank PWR PACK BASE ELEC VAD, REP Blank $24,415.53 HCPCS - Non-Drugs Q0489 Blank PWR PCK BASE COMBO VAD, REP Blank $25,777.85 HCPCS - Non-Drugs Q0490 Blank EMR PWR SOURCE ELEC VAD, REP Blank $1,108.89 HCPCS - Non-Drugs Q0491 Blank EMR PWR SOURCE COMBO VAD REP Blank $1,746.94 HCPCS - Non-Drugs Q0492 Blank EMR PWR CBL ELEC VAD, REP Blank $134.84 HCPCS - Non-Drugs Q0493 Blank EMR PWR CBL COMBO VAD, REP Blank $395.78 HCPCS - Non-Drugs Q0494 Blank EMR HD PMP ELEC/COMBO, REP Blank $333.93 HCPCS - Non-Drugs Q0495 Blank CHARGER ELEC/COMBO VAD, REP Blank $6,619.48 HCPCS - Non-Drugs Q0496 Blank BATTERY ELEC/COMBO VAD, REP Blank $2,371.72 HCPCS - Non-Drugs Q0497 Blank BAT CLPS ELEC/COMB VAD, REP Blank $736.16 HCPCS - Non-Drugs Q0498 Blank HOLSTER ELEC/COMBO VAD, REP Blank $808.36 HCPCS - Non-Drugs Q0499 Blank BELT/VEST ELEC/COMBO VAD REP Blank $258.30 HCPCS - Non-Drugs Q0500 Blank FILTERS ELEC/COMBO VAD, REP Blank $44.97 HCPCS - Non-Drugs Q0501 Blank SHWR COV ELEC/COMBO VAD, REP Blank $803.66 HCPCS - Non-Drugs Q0502 Blank MOBILITY CART PNEUM VAD, REP Blank $1,024.92 HCPCS - Non-Drugs Q0503 Blank BATTERY PNEUM VAD REPLACEMNT Blank $2,056.30 HCPCS - Non-Drugs Q0504 Blank PWR ADPT PNEUM VAD, REP VEH Blank $1,082.02 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 90 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
Q0506 Blank LITH-ION BATT ELEC/PNEUM VAD Blank $1,348.44 HCPCS - Non-Drugs Q0507 Blank MISC SUP/ACC EXT VAD Blank $324.96 HCPCS - Non-Drugs Q0508 Blank MIS SUP/ACC IMP VAD Blank $15.60 HCPCS - Non-Drugs Q0509 Blank MIS SUP/AC IMP VAD NOPAY MED Blank $192.47 HCPCS - Non-Drugs Q0510 Blank DISPENS FEE IMMUNOSUPRESSIVE Blank $80.75 HCPCS - Drugs Q0511 Blank SUP FEE ANTIEM,ANTICA,IMMUNO Blank $38.76 HCPCS - Drugs Q0512 Blank PX SUP FEE ANTI-CAN SUB PRES a $25.84 HCPCS - Drugs Q0513 Blank DISP FEE INHAL DRUGS/30 DAYS Blank $53.29 HCPCS - Drugs Q0514 Blank DISP FEE INHAL DRUGS/90 DAYS Blank $106.59 HCPCS - Drugs Q0515 Blank SERMORELIN ACETATE INJECTION a $12.11 HCPCS - Drugs Q2004 Blank BLADDER CALCULI IRRIG SOL Blank $43.48 HCPCS - Drugs Q2009 Blank FOSPHENYTOIN INJ PE a $15.33 HCPCS - Drugs Q2017 Blank TENIPOSIDE, 50 MG a $882.49 HCPCS - Drugs Q2034 Blank AGRIFLU VACCINE a $40.82 HCPCS - Drugs Q2043 Blank SIPULEUCEL-T AUTO CD54+ a $86,156.27 HCPCS - Drugs Q2049 Blank IMPORTED LIPODOX INJ a $1,539.48 HCPCS - Drugs Q2050 Blank DOXORUBICIN INJ 10MG a $1,455.80 HCPCS - Drugs Q3001 Blank BRACHYTHERAPY RADIOELEMENTS a $101.51 HCPCS - Non-Drugs Q3027 Blank INJ BETA INTERFERON IM 1 MCG a $106.22 HCPCS - Drugs Q3028 Blank INJ BETA INTERFERON SQ 1 MCG a $17.34 HCPCS - Drugs Q4001 Blank CAST SUP BODY CAST PLASTER Blank $83.71 HCPCS - Non-Drugs Q4002 Blank CAST SUP BODY CAST FIBERGLAS Blank $313.06 HCPCS - Non-Drugs Q4003 Blank CAST SUP SHOULDER CAST PLSTR Blank $60.43 HCPCS - Non-Drugs Q4004 Blank CAST SUP SHOULDER CAST FBRGL Blank $206.35 HCPCS - Non-Drugs Q4005 Blank CAST SUP LONG ARM ADULT PLST Blank $23.02 HCPCS - Non-Drugs Q4006 Blank CAST SUP LONG ARM ADULT FBRG Blank $50.40 HCPCS - Non-Drugs Q4007 Blank CAST SUP LONG ARM PED PLSTER Blank $12.10 HCPCS - Non-Drugs Q4008 Blank CAST SUP LONG ARM PED FBRGLS Blank $25.76 HCPCS - Non-Drugs Q4009 Blank CAST SUP SHT ARM ADULT PLSTR Blank $15.77 HCPCS - Non-Drugs Q4010 Blank CAST SUP SHT ARM ADULT FBRGL Blank $34.00 HCPCS - Non-Drugs Q4011 Blank CAST SUP SHT ARM PED PLASTER Blank $8.43 HCPCS - Non-Drugs Q4012 Blank CAST SUP SHT ARM PED FBRGLAS Blank $17.59 HCPCS - Non-Drugs Q4013 Blank CAST SUP GAUNTLET PLASTER Blank $27.73 HCPCS - Non-Drugs Q4014 Blank CAST SUP GAUNTLET FIBERGLASS Blank $45.95 HCPCS - Non-Drugs Q4015 Blank CAST SUP GAUNTLET PED PLSTER Blank $14.47 HCPCS - Non-Drugs Q4016 Blank CAST SUP GAUNTLET PED FBRGLS Blank $23.55 HCPCS - Non-Drugs Q4017 Blank CAST SUP LNG ARM SPLINT PLST Blank $16.52 HCPCS - Non-Drugs Q4018 Blank CAST SUP LNG ARM SPLINT FBRG Blank $25.63 HCPCS - Non-Drugs Q4019 Blank CAST SUP LNG ARM SPLNT PED P Blank $8.85 HCPCS - Non-Drugs Q4020 Blank CAST SUP LNG ARM SPLNT PED F Blank $13.43 HCPCS - Non-Drugs Q4021 Blank CAST SUP SHT ARM SPLINT PLST Blank $12.52 HCPCS - Non-Drugs Q4022 Blank CAST SUP SHT ARM SPLINT FBRG Blank $21.67 HCPCS - Non-Drugs Q4023 Blank CAST SUP SHT ARM SPLNT PED P Blank $6.88 HCPCS - Non-Drugs Q4024 Blank CAST SUP SHT ARM SPLNT PED F Blank $11.43 HCPCS - Non-Drugs Q4025 Blank CAST SUP HIP SPICA PLASTER Blank $64.87 HCPCS - Non-Drugs Q4026 Blank CAST SUP HIP SPICA FIBERGLAS Blank $200.11 HCPCS - Non-Drugs Q4027 Blank CAST SUP HIP SPICA PED PLSTR Blank $33.03 HCPCS - Non-Drugs Q4028 Blank CAST SUP HIP SPICA PED FBRGL Blank $100.68 HCPCS - Non-Drugs Q4029 Blank CAST SUP LONG LEG PLASTER Blank $49.89 HCPCS - Non-Drugs Q4030 Blank CAST SUP LONG LEG FIBERGLASS Blank $129.43 HCPCS - Non-Drugs Q4031 Blank CAST SUP LNG LEG PED PLASTER Blank $25.51 HCPCS - Non-Drugs Q4032 Blank CAST SUP LNG LEG PED FBRGLS Blank $65.30 HCPCS - Non-Drugs Q4033 Blank CAST SUP LNG LEG CYLINDER PL Blank $46.61 HCPCS - Non-Drugs Q4034 Blank CAST SUP LNG LEG CYLINDER FB Blank $114.20 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 91 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
Q4035 Blank CAST SUP LNGLEG CYLNDR PED P Blank $23.89 HCPCS - Non-Drugs Q4036 Blank CAST SUP LNGLEG CYLNDR PED F Blank $57.70 HCPCS - Non-Drugs Q4037 Blank CAST SUP SHRT LEG PLASTER Blank $28.87 HCPCS - Non-Drugs Q4038 Blank CAST SUP SHRT LEG FIBERGLASS Blank $70.62 HCPCS - Non-Drugs Q4039 Blank CAST SUP SHRT LEG PED PLSTER Blank $15.05 HCPCS - Non-Drugs Q4040 Blank CAST SUP SHRT LEG PED FBRGLS Blank $35.88 HCPCS - Non-Drugs Q4041 Blank CAST SUP LNG LEG SPLNT PLSTR Blank $34.87 HCPCS - Non-Drugs Q4042 Blank CAST SUP LNG LEG SPLNT FBRGL Blank $58.71 HCPCS - Non-Drugs Q4043 Blank CAST SUP LNG LEG SPLNT PED P Blank $18.03 HCPCS - Non-Drugs Q4044 Blank CAST SUP LNG LEG SPLNT PED F Blank $29.94 HCPCS - Non-Drugs Q4045 Blank CAST SUP SHT LEG SPLNT PLSTR Blank $20.73 HCPCS - Non-Drugs Q4046 Blank CAST SUP SHT LEG SPLNT FBRGL Blank $32.64 HCPCS - Non-Drugs Q4047 Blank CAST SUP SHT LEG SPLNT PED P Blank $10.92 HCPCS - Non-Drugs Q4048 Blank CAST SUP SHT LEG SPLNT PED F Blank $16.91 HCPCS - Non-Drugs Q4049 Blank FINGER SPLINT, STATIC Blank $4.73 HCPCS - Non-Drugs Q4050 Blank CAST SUPPLIES UNLISTED Blank $36.28 HCPCS - Non-Drugs Q4051 Blank SPLINT SUPPLIES MISC Blank $34.89 HCPCS - Non-Drugs Q4074 Blank ILOPROST NON-COMP UNIT DOSE a $263.87 HCPCS - Drugs Q4081 Blank EPOETIN ALFA, 100 UNITS ESRD a $11.31 HCPCS - Drugs Q4082 Blank DRUG/BIO NOC PART B DRUG CAP Blank $3,129.60 HCPCS - Drugs Q4100 Blank SKIN SUBSTITUTE, NOS a $2,211.52 HCPCS - Drugs Q4101 Blank APLIGRAF a $78.87 HCPCS - Drugs Q4102 Blank OASIS WOUND MATRIX a $32.22 HCPCS - Drugs Q4103 Blank OASIS BURN MATRIX a $32.22 HCPCS - Drugs Q4104 Blank INTEGRA BMWD a $86.11 HCPCS - Drugs Q4105 Blank INTEGRA DRT OR OMNIGRAFT a $66.01 HCPCS - Drugs Q4106 Blank DERMAGRAFT a $82.90 HCPCS - Drugs Q4107 Blank GRAFTJACKET a $225.27 HCPCS - Drugs Q4108 Blank INTEGRA MATRIX a $80.48 HCPCS - Drugs Q4110 Blank PRIMATRIX a $92.55 HCPCS - Drugs Q4111 Blank GAMMAGRAFT a $24.98 HCPCS - Drugs Q4112 Blank CYMETRA INJECTABLE a $578.37 HCPCS - Drugs Q4113 Blank GRAFTJACKET XPRESS a $578.37 HCPCS - Drugs Q4114 Blank INTEGRA FLOWABLE WOUND MATRI a $3,408.03 HCPCS - Drugs Q4115 Blank ALLOSKIN a $41.88 HCPCS - Drugs Q4116 Blank ALLODERM a $81.29 HCPCS - Drugs Q4118 Blank MATRISTEM MICROMATRIX a $7.60 HCPCS - Drugs Q4119 Blank MATRISTEM WOUND MATRIX a $15.21 HCPCS - Drugs Q4120 Blank MATRISTEM BURN MATRIX Blank $3,459.33 HCPCS - Drugs Q4121 Blank THERASKIN a $98.18 HCPCS - Drugs Q4122 Blank DERMACELL a $1,978.01 HCPCS - Drugs Q4123 Blank ALLOSKIN a $37.05 HCPCS - Drugs Q4125 Blank ARTHROFLEX a $2,632.09 HCPCS - Drugs Q4126 Blank MEMODERM/DERMA/TRANZ/INTEGUP a $408.39 HCPCS - Drugs Q4127 Blank TALYMED a $3.06 HCPCS - Drugs Q4128 Blank FLEXHD/ALLOPATCHHD/MATRIXHD a $321.31 HCPCS - Drugs Q4129 Blank UNITE BIOMATRIX a $259.33 HCPCS - Drugs Q4130 Blank STRATTICE TM a $19,828.73 HCPCS - Drugs Q4131 Blank EPIFIX OR EPICORD a $411.87 HCPCS - Drugs Q4132 Blank GRAFIX CORE a $3,327.89 HCPCS - Drugs Q4133 Blank GRAFIX PRIME a $3,173.12 HCPCS - Drugs Q4134 Blank HMATRIX a $4,244.80 HCPCS - Drugs Q4137 Blank AMNIOEXCEL OR BIODEXCEL, 1CM a $1,281.32 HCPCS - Drugs Q4139 Blank AMNIO OR BIODMATRIX, INJ 1CC a $3,279.00 HCPCS - Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 92 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
Q4140 Blank BIODFENCE 1CM Blank $4,091.18 HCPCS - Drugs Q4141 Blank ALLOSKIN AC, 1 CM a $28.97 HCPCS - Drugs Q4142 Blank XCM BIOLOGIC TISS MATRIX 1CM Blank $2,856.63 HCPCS - Drugs Q4145 Blank EPIFIX, INJ, 1MG a $61.58 HCPCS - Drugs Q4146 Blank TENSIX, 1CM Blank $224.59 HCPCS - Drugs Q4147 Blank ARCHITECT ECM PX FX 1 SQ CM Blank $3,917.87 HCPCS - Drugs Q4148 Blank NEOX 1K, 1CM a $249.32 HCPCS - Drugs Q4155 Blank NEOXFLO OR CLARIXFLO 1 MG Blank $40.72 HCPCS - Drugs Q4156 Blank NEOX 100 1 SQUARE CM Blank $241.71 HCPCS - Drugs Q5101 Blank INJ FILGRASTIM GCSF BIOSIMIL a $11.31 HCPCS - Drugs Q9951 Blank LOCM >= 400 MG/ML IODINE,1ML a $5.92 HCPCS - Non-Drugs Q9953 Blank INJ FE-BASED MR CONTRAST,1ML a $44.40 HCPCS - Non-Drugs Q9954 Blank ORAL MR CONTRAST, 100 ML a $14.84 HCPCS - Non-Drugs Q9955 Blank INJ PERFLEXANE LIP MICROS,ML a $4.59 HCPCS - Non-Drugs Q9956 Blank INJ OCTAFLUOROPROPANE MIC,ML a $111.00 HCPCS - Non-Drugs Q9957 Blank INJ PERFLUTREN LIP MICROS,ML a $269.08 HCPCS - Non-Drugs Q9958 Blank HOCM <=149 MG/ML IODINE, 1ML a $0.27 HCPCS - Non-Drugs Q9959 Blank HOCM 150-199MG/ML IODINE,1ML a $0.58 HCPCS - Non-Drugs Q9960 Blank HOCM 200-249MG/ML IODINE,1ML a $1.15 HCPCS - Non-Drugs Q9961 Blank HOCM 250-299MG/ML IODINE,1ML a $1.69 HCPCS - Non-Drugs Q9962 Blank HOCM 300-349MG/ML IODINE,1ML a $1.78 HCPCS - Non-Drugs Q9963 Blank HOCM 350-399MG/ML IODINE,1ML a $2.26 HCPCS - Non-Drugs Q9964 Blank HOCM>= 400MG/ML IODINE, 1ML a $2.72 HCPCS - Non-Drugs Q9965 Blank LOCM 100-199MG/ML IODINE,1ML a $3.37 HCPCS - Non-Drugs Q9966 Blank LOCM 200-299MG/ML IODINE,1ML a $3.37 HCPCS - Non-Drugs Q9967 Blank LOCM 300-399MG/ML IODINE,1ML a $2.80 HCPCS - Non-Drugs Q9981 Blank ROLAPITANT, ORAL, 1MG a $73.70 HCPCS - Drugs Q9982 Blank FLUTEMETAMOL F18 DIAGNOSTIC a $17,336.40 HCPCS - Drugs Q9983 Blank FLORBETABEN F18 DIAGNOSTIC a $6,276.10 HCPCS - Drugs S0012 Blank BUTORPHANOL TARTRATE, NASAL Blank $378.54 HCPCS - Non-Drugs S0014 Blank TACRINE HYDROCHLORIDE, 10 MG Blank $12.96 HCPCS - Non-Drugs S0017 Blank INJECTION, AMINOCAPROIC ACID a $31.72 HCPCS - Non-Drugs S0020 Blank INJECTION, BUPIVICAINE HYDRO a $19.17 HCPCS - Non-Drugs S0021 Blank INJECTION, CEFOPERAZONE SOD Blank $7.70 HCPCS - Non-Drugs S0023 Blank INJECTION, CIMETIDINE HYDROC a $13.49 HCPCS - Non-Drugs S0028 Blank INJECTION, FAMOTIDINE, 20 MG a $16.73 HCPCS - Non-Drugs S0030 Blank INJECTION, METRONIDAZOLE a $49.87 HCPCS - Non-Drugs S0032 Blank INJECTION, NAFCILLIN SODIUM a $115.52 HCPCS - Non-Drugs S0034 Blank INJECTION, OFLOXACIN, 400 MG a $34.55 HCPCS - Non-Drugs S0039 Blank INJECTION, SULFAMETHOXAZOLE a $18.19 HCPCS - Non-Drugs S0040 Blank INJECTION, TICARCILLIN DISOD a $71.70 HCPCS - Non-Drugs S0073 Blank INJECTION, AZTREONAM, 500 MG a $88.56 HCPCS - Non-Drugs S0074 Blank INJECTION, CEFOTETAN DISODIU a $59.98 HCPCS - Non-Drugs S0077 Blank INJECTION, CLINDAMYCIN PHOSP a $18.54 HCPCS - Non-Drugs S0078 Blank INJECTION, FOSPHENYTOIN SODI a $868.52 HCPCS - Non-Drugs S0080 Blank INJECTION, PENTAMIDINE ISETH a $337.63 HCPCS - Non-Drugs S0081 Blank INJECTION, PIPERACILLIN SODI Blank $9.27 HCPCS - Non-Drugs S0088 Blank IMATINIB 100 MG Blank $113.83 HCPCS - Non-Drugs S0090 Blank SILDENAFIL CITRATE, 25 MG Blank $83.81 HCPCS - Non-Drugs S0091 Blank GRANISETRON 1MG a $409.15 HCPCS - Non-Drugs S0092 Blank HYDROMORPHONE 250 MG a $509.33 HCPCS - Non-Drugs S0093 Blank MORPHINE 500 MG a $719.86 HCPCS - Non-Drugs S0104 Blank ZIDOVUDINE, ORAL, 100 MG Blank $8.96 HCPCS - Non-Drugs S0106 Blank BUPROPION HCL SR 60 TABLETS a $538.79 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 93 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
S0108 Blank MERCAPTOPURINE 50 MG a $18.59 HCPCS - Non-Drugs S0109 Blank METHADONE ORAL 5MG a $1.38 HCPCS - Non-Drugs S0119 Blank ONDANSETRON 4 MG a $48.59 HCPCS - Non-Drugs S0122 Blank INJ MENOTROPINS 75 IU Blank $346.06 HCPCS - Non-Drugs S0126 Blank INJ FOLLITROPIN ALFA 75 IU Blank $395.04 HCPCS - Non-Drugs S0128 Blank INJ FOLLITROPIN BETA 75 IU Blank $375.87 HCPCS - Non-Drugs S0132 Blank INJ GANIRELIX ACETAT 250 MCG a $520.46 HCPCS - Non-Drugs S0136 Blank CLOZAPINE, 25 MG a $6.39 HCPCS - Non-Drugs S0137 Blank DIDANOSINE, 25 MG a $17.29 HCPCS - Non-Drugs S0138 Blank FINASTERIDE, 5 MG a $13.89 HCPCS - Non-Drugs S0139 Blank MINOXIDIL, 10 MG Blank $5.50 HCPCS - Non-Drugs S0140 Blank SAQUINAVIR, 200 MG Blank $9.27 HCPCS - Non-Drugs S0142 Blank COLISTIMETHATE INH SOL MG Blank $15.79 HCPCS - Non-Drugs S0145 Blank PEG INTERFERON ALFA-2A/180 a $57.87 HCPCS - Non-Drugs S0148 Blank PEG INTERFERON ALFA-2B/10 Blank $391.09 HCPCS - Non-Drugs S0155 Blank EPOPROSTENOL DILUTANT Blank $23.23 HCPCS - Non-Drugs S0156 Blank EXEMESTANE, 25 MG Blank $41.44 HCPCS - Non-Drugs S0157 Blank BECAPLERMIN GEL 1%, 0.5 GM a $86.65 HCPCS - Non-Drugs S0160 Blank DEXTROAMPHETAMINE Blank $1.95 HCPCS - Non-Drugs S0164 Blank INJECTION PANTROPRAZOLE a $63.89 HCPCS - Non-Drugs S0166 Blank INJ OLANZAPINE 2.5MG a $29.02 HCPCS - Non-Drugs S0170 Blank ANASTROZOLE 1 MG a $39.84 HCPCS - Non-Drugs S0171 Blank BUMETANIDE 0.5 MG a $5.86 HCPCS - Non-Drugs S0172 Blank CHLORAMBUCIL 2 MG Blank $10.91 HCPCS - Non-Drugs S0174 Blank DOLASETRON 50 MG a $255.20 HCPCS - Non-Drugs S0175 Blank FLUTAMIDE 125 MG Blank $10.56 HCPCS - Non-Drugs S0176 Blank HYDROXYUREA 500 MG Blank $5.63 HCPCS - Non-Drugs S0177 Blank LEVAMISOLE 50 MG Blank $24.53 HCPCS - Non-Drugs S0178 Blank LOMUSTINE 10 MG Blank $129.02 HCPCS - Non-Drugs S0179 Blank MEGESTROL 20 MG a $2.90 HCPCS - Non-Drugs S0182 Blank PROCARBAZINE, ORAL Blank $254.44 HCPCS - Non-Drugs S0183 Blank PROCHLORPERAZINE 5 MG a $3.24 HCPCS - Non-Drugs S0187 Blank TAMOXIFEN 10 MG a $10.77 HCPCS - Non-Drugs S0189 Blank TESTOSTERONE PELLET 75 MG a $136.64 HCPCS - Non-Drugs S0190 Blank MIFEPRISTONE, ORAL, 200 MG Blank $334.27 HCPCS - Non-Drugs S0191 Blank MISOPROSTOL, ORAL, 200 MCG a $12.09 HCPCS - Non-Drugs S0395 Blank IMPRESSION CASTING FT Blank $140.99 HCPCS - Non-Drugs S0500 Blank DISPOS CONT LENS Blank $117.30 HCPCS - Non-Drugs S0504 Blank SINGL PRSCRP LENS Blank $152.51 HCPCS - Non-Drugs S0506 Blank BIFOC PRSCP LENS Blank $152.56 HCPCS - Non-Drugs S0508 Blank TRIFOC PRSCRP LENS Blank $106.47 HCPCS - Non-Drugs S0510 Blank NON-PRSCRP LENS Blank $66.41 HCPCS - Non-Drugs S0512 Blank DAILY CONT LENS a $85.65 HCPCS - Non-Drugs S0514 Blank COLOR CONT LENS Blank $211.67 HCPCS - Non-Drugs S0515 Blank SCLERAL LENS LIQUID BANDAGE Blank $421.44 HCPCS - Non-Drugs S0516 Blank SAFETY FRAMES Blank $109.64 HCPCS - Non-Drugs S0518 Blank SUNGLASS FRAMES Blank $87.07 HCPCS - Non-Drugs S0580 Blank POLYCARB LENS Blank $87.77 HCPCS - Non-Drugs S0581 Blank NONSTND LENS Blank $794.04 HCPCS - Non-Drugs S0595 Blank NEW LENSES IN PTS OLD FRAME Blank $8.14 HCPCS - Non-Drugs S1001 Blank DELUXE ITEM Blank $25.56 HCPCS - Non-Drugs S1002 Blank CUSTOM ITEM Blank $25.93 HCPCS - Non-Drugs S1015 Blank IV TUBING EXTENSION SET a $41.41 HCPCS - Non-Drugs S1016 Blank NON-PVC INTRAVENOUS ADMINIST a $58.12 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 94 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
S1040 Blank CRANIAL REMOLDING ORTHOSIS a $446.48 HCPCS - Non-Drugs S4989 Blank CONTRACEPT IUD a $765.58 HCPCS - Non-Drugs S4990 Blank NICOTINE PATCH LEGEND a $33.15 HCPCS - Non-Drugs S4993 Blank CONTRACEPTIVE PILLS FOR BC a $35.96 HCPCS - Non-Drugs S4995 Blank SMOKING CESSATION GUM a $70.60 HCPCS - Non-Drugs S5000 Blank PRESCRIPTION DRUG, GENERIC a $24.68 HCPCS - Non-Drugs S5001 Blank PRESCRIPTION DRUG,BRAND NAME a $105.48 HCPCS - Non-Drugs S5010 Blank 5% DEXTROSE AND 0.45% SALINE a $25.27 HCPCS - Non-Drugs S5012 Blank 5% DEXTROSE WITH POTASSIUM a $87.87 HCPCS - Non-Drugs S5013 Blank 5%DEXTROSE/0.45%SALINE1000ML a $24.51 HCPCS - Non-Drugs S5014 Blank D5W/0.45NS W KCL AND MGS04 a $14.77 HCPCS - Non-Drugs S5199 Blank PERSONAL CARE ITEM NOS EACH a $59.19 HCPCS - Non-Drugs S5497 Blank HIT CATH CARE NOC a $59.19 HCPCS - Non-Drugs S5498 Blank HIT SIMPLE CATH CARE a $42.79 HCPCS - Non-Drugs S5501 Blank HIT COMPLEX CATH CARE a $46.13 HCPCS - Non-Drugs S5502 Blank HIT INTERIM CATH CARE a $81.26 HCPCS - Non-Drugs S5517 Blank HIT DECLOTTING KIT a $93.95 HCPCS - Non-Drugs S5520 Blank HIT PICC INSERT KIT a $113.74 HCPCS - Non-Drugs S5521 Blank HIT MIDLINE CATH INSERT KIT Blank $168.21 HCPCS - Non-Drugs S5550 Blank INSULIN RAPID 5 U a $0.16 HCPCS - Non-Drugs S5551 Blank INSULIN MOST RAPID 5 U a $0.16 HCPCS - Non-Drugs S5552 Blank INSULIN INTERMED 5 U Blank $0.16 HCPCS - Non-Drugs S5553 Blank INSULIN LONG ACTING 5 U a $0.16 HCPCS - Non-Drugs S5560 Blank INSULIN REUSE PEN 1.5 ML Blank $4.08 HCPCS - Non-Drugs S8096 Blank PORTABLE PEAK FLOW METER a $61.58 HCPCS - Non-Drugs S8097 Blank ASTHMA KIT Blank $63.81 HCPCS - Non-Drugs S8100 Blank SPACER WITHOUT MASK a $63.48 HCPCS - Non-Drugs S8101 Blank SPACER WITH MASK a $207.01 HCPCS - Non-Drugs S8130 Blank INTERFERENTIAL STIM 2 CHAN Blank $5,794.54 HCPCS - Non-Drugs S8131 Blank INTERFERENTIAL STIM 4 CHAN Blank $1,675.23 HCPCS - Non-Drugs S8185 Blank FLUTTER DEVICE Blank $81.30 HCPCS - Non-Drugs S8186 Blank SWIVEL ADAPTOR Blank $5.76 HCPCS - Non-Drugs S8189 Blank TRACH SUPPLY NOC Blank $59.19 HCPCS - Non-Drugs S8210 Blank MUCUS TRAP a $1.44 HCPCS - Non-Drugs S8265 Blank HABERMAN FEEDER Blank $75.15 HCPCS - Non-Drugs S8301 Blank INFECT CONTROL SUPPLIES NOS Blank $59.19 HCPCS - Non-Drugs S8415 Blank SUPPLIES FOR HOME DELIVERY Blank $177.12 HCPCS - Non-Drugs S8420 Blank CUSTOM GRADIENT SLEEV/GLOV Blank $129.05 HCPCS - Non-Drugs S8421 Blank READY GRADIENT SLEEV/GLOV Blank $59.19 HCPCS - Non-Drugs S8422 Blank CUSTOM GRAD SLEEVE MED Blank $165.55 HCPCS - Non-Drugs S8423 Blank CUSTOM GRAD SLEEVE HEAVY a $235.39 HCPCS - Non-Drugs S8424 Blank READY GRADIENT SLEEVE a $79.73 HCPCS - Non-Drugs S8425 Blank CUSTOM GRAD GLOVE MED Blank $116.30 HCPCS - Non-Drugs S8426 Blank CUSTOM GRAD GLOVE HEAVY a $144.50 HCPCS - Non-Drugs S8427 Blank READY GRADIENT GLOVE a $30.21 HCPCS - Non-Drugs S8428 Blank READY GRADIENT GAUNTLET Blank $81.06 HCPCS - Non-Drugs S8429 Blank GRADIENT PRESSURE WRAP Blank $105.44 HCPCS - Non-Drugs S8430 Blank PADDING FOR COMPRSSN BDG Blank $25.73 HCPCS - Non-Drugs S8431 Blank COMPRESSION BANDAGE a $18.23 HCPCS - Non-Drugs S8450 Blank SPLINT DIGIT a $36.36 HCPCS - Non-Drugs S8451 Blank SPLINT WRIST OR ANKLE a $51.72 HCPCS - Non-Drugs S8452 Blank SPLINT ELBOW Blank $45.53 HCPCS - Non-Drugs S8460 Blank CAMISOLE POST-MAST Blank $96.32 HCPCS - Non-Drugs S8490 Blank 100 INSULIN SYRINGES a $1.44 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 95 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
S8999 Blank RESUSCITATION BAG Blank $260.11 HCPCS - Non-Drugs S9001 Blank HOME UTERINE MONITOR WITH OR Blank $132.37 HCPCS - Non-Drugs S9061 Blank MEDICAL SUPPLIES AND EQUIPME a $76.96 HCPCS - Non-Drugs S9208 Blank HOME MGMT PRETERM LABOR a $287.66 HCPCS - Non-Drugs S9211 Blank HOME MGMT GEST HYPERTENSION a $121.92 HCPCS - Non-Drugs S9212 Blank HM POSTPAR HYPER PER DIEM Blank $144.10 HCPCS - Non-Drugs S9213 Blank HM PREECLAMP PER DIEM a $284.43 HCPCS - Non-Drugs S9214 Blank HM GEST DM PER DIEM a $263.38 HCPCS - Non-Drugs S9325 Blank HIT PAIN MGMT PER DIEM Blank $146.93 HCPCS - Non-Drugs S9326 Blank HIT CONT PAIN PER DIEM a $208.61 HCPCS - Non-Drugs S9327 Blank HIT INT PAIN PER DIEM a $206.99 HCPCS - Non-Drugs S9328 Blank HIT PAIN IMP PUMP DIEM Blank $150.32 HCPCS - Non-Drugs S9329 Blank HIT CHEMO PER DIEM a $224.32 HCPCS - Non-Drugs S9330 Blank HIT CONT CHEM DIEM a $220.62 HCPCS - Non-Drugs S9331 Blank HIT INTERMIT CHEMO DIEM a $245.67 HCPCS - Non-Drugs S9335 Blank HT HEMODIALYSIS DIEM a $673.64 HCPCS - Non-Drugs S9336 Blank HIT CONT ANTICOAG DIEM a $210.99 HCPCS - Non-Drugs S9338 Blank HIT IMMUNOTHERAPY DIEM a $261.42 HCPCS - Non-Drugs S9339 Blank HIT PERITON DIALYSIS DIEM Blank $542.93 HCPCS - Non-Drugs S9340 Blank HIT ENTERAL PER DIEM a $87.19 HCPCS - Non-Drugs S9341 Blank HIT ENTERAL GRAV DIEM a $59.85 HCPCS - Non-Drugs S9342 Blank HIT ENTERAL PUMP DIEM a $64.29 HCPCS - Non-Drugs S9343 Blank HIT ENTERAL BOLUS NURS a $39.88 HCPCS - Non-Drugs S9345 Blank HIT ANTI-HEMOPHIL DIEM a $133.07 HCPCS - Non-Drugs S9346 Blank HIT ALPHA-1-PROTEINAS DIEM a $93.12 HCPCS - Non-Drugs S9347 Blank HIT LONGTERM INFUSION DIEM Blank $103.82 HCPCS - Non-Drugs S9348 Blank HIT SYMPATHOMIM DIEM a $230.32 HCPCS - Non-Drugs S9349 Blank HIT TOCOLYSIS DIEM a $332.21 HCPCS - Non-Drugs S9351 Blank HIT CONT ANTIEMETIC DIEM a $422.63 HCPCS - Non-Drugs S9353 Blank HIT CONT INSULIN DIEM a $577.88 HCPCS - Non-Drugs S9355 Blank HIT CHELATION DIEM a $172.58 HCPCS - Non-Drugs S9357 Blank HIT ENZYME REPLACE DIEM a $187.52 HCPCS - Non-Drugs S9359 Blank HIT ANTI-TNF PER DIEM a $343.18 HCPCS - Non-Drugs S9361 Blank HIT DIURETIC INFUS DIEM Blank $124.93 HCPCS - Non-Drugs S9363 Blank HIT ANTI-SPASMOTIC DIEM Blank $251.93 HCPCS - Non-Drugs S9364 Blank HIT TPN TOTAL DIEM a $392.81 HCPCS - Non-Drugs S9365 Blank HIT TPN 1 LITER DIEM a $452.72 HCPCS - Non-Drugs S9366 Blank HIT TPN 2 LITER DIEM a $552.46 HCPCS - Non-Drugs S9367 Blank HIT TPN 3 LITER DIEM a $615.14 HCPCS - Non-Drugs S9368 Blank HIT TPN OVER 3L DIEM a $788.07 HCPCS - Non-Drugs S9370 Blank HT INJ ANTIEMETIC DIEM a $159.64 HCPCS - Non-Drugs S9372 Blank HT INJ ANTICOAG DIEM Blank $108.25 HCPCS - Non-Drugs S9373 Blank HIT HYDRA TOTAL DIEM a $121.21 HCPCS - Non-Drugs S9374 Blank HIT HYDRA 1 LITER DIEM a $175.19 HCPCS - Non-Drugs S9375 Blank HIT HYDRA 2 LITER DIEM a $224.43 HCPCS - Non-Drugs S9376 Blank HIT HYDRA 3 LITER DIEM a $244.61 HCPCS - Non-Drugs S9377 Blank HIT HYDRA OVER 3L DIEM a $264.79 HCPCS - Non-Drugs S9379 Blank HIT NOC PER DIEM a $59.19 HCPCS - Non-Drugs S9433 Blank MEDICAL FOOD ORAL 100% NUTR Blank $37.46 HCPCS - Non-Drugs S9434 Blank MOD SOLID FOOD SUPPL Blank $57.33 HCPCS - Non-Drugs S9435 Blank MEDICAL FOODS FOR INBORN ERR Blank $36.10 HCPCS - Non-Drugs S9490 Blank HIT CORTICOSTEROID/DIEM a $271.57 HCPCS - Non-Drugs S9494 Blank HIT ANTIBIOTIC TOTAL DIEM a $216.73 HCPCS - Non-Drugs S9497 Blank HIT ANTIBIOTIC Q3H DIEM a $270.25 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 96 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
S9500 Blank HIT ANTIBIOTIC Q24H DIEM a $310.20 HCPCS - Non-Drugs S9501 Blank HIT ANTIBIOTIC Q12H DIEM a $303.18 HCPCS - Non-Drugs S9502 Blank HIT ANTIBIOTIC Q8H DIEM a $378.38 HCPCS - Non-Drugs S9503 Blank HIT ANTIBIOTIC Q6H DIEM a $348.87 HCPCS - Non-Drugs S9504 Blank HIT ANTIBIOTIC Q4H DIEM a $321.67 HCPCS - Non-Drugs S9529 Blank VENIPUNCTURE HOME/SNF a $108.08 HCPCS - Non-Drugs S9537 Blank HT HEM HORM INJ DIEM a $89.99 HCPCS - Non-Drugs S9538 Blank HIT BLOOD PRODUCTS DIEM Blank $291.82 HCPCS - Non-Drugs S9542 Blank HT INJ NOC PER DIEM a $59.19 HCPCS - Non-Drugs S9558 Blank HT INJ GROWTH HORM DIEM Blank $39.10 HCPCS - Non-Drugs S9559 Blank HIT INJ INTERFERON DIEM Blank $367.46 HCPCS - Non-Drugs S9560 Blank HT INJ HORMONE DIEM a $100.07 HCPCS - Non-Drugs S9562 Blank HT INJ PALIVIZUMAB DIEM a $100.07 HCPCS - Non-Drugs S9590 Blank HT IRRIGATION DIEM a $143.61 HCPCS - Non-Drugs S9810 Blank HT PHARM PER HOUR Blank $85.12 HCPCS - Non-Drugs T4521 Blank ADULT SIZE BRIEF/DIAPER SM Blank $1.52 HCPCS - Non-Drugs T4522 Blank ADULT SIZE BRIEF/DIAPER MED Blank $1.55 HCPCS - Non-Drugs T4523 Blank ADULT SIZE BRIEF/DIAPER LG Blank $1.67 HCPCS - Non-Drugs T4524 Blank ADULT SIZE BRIEF/DIAPER XL Blank $2.04 HCPCS - Non-Drugs T4525 Blank ADULT SIZE PULL-ON SM Blank $1.85 HCPCS - Non-Drugs T4526 Blank ADULT SIZE PULL-ON MED Blank $1.86 HCPCS - Non-Drugs T4527 Blank ADULT SIZE PULL-ON LG Blank $1.88 HCPCS - Non-Drugs T4528 Blank ADULT SIZE PULL-ON XL Blank $2.03 HCPCS - Non-Drugs T4529 Blank PED SIZE BRIEF/DIAPER SM/MED Blank $1.51 HCPCS - Non-Drugs T4530 Blank PED SIZE BRIEF/DIAPER LG Blank $1.73 HCPCS - Non-Drugs T4531 Blank PED SIZE PULL-ON SM/MED Blank $1.98 HCPCS - Non-Drugs T4532 Blank PED SIZE PULL-ON LG Blank $2.25 HCPCS - Non-Drugs T4533 Blank YOUTH SIZE BRIEF/DIAPER Blank $1.62 HCPCS - Non-Drugs T4534 Blank YOUTH SIZE PULL-ON Blank $2.00 HCPCS - Non-Drugs T4535 Blank DISPOSABLE LINER/SHIELD/PAD Blank $1.38 HCPCS - Non-Drugs T4536 Blank REUSABLE PULL-ON ANY SIZE Blank $1.58 HCPCS - Non-Drugs T4537 Blank REUSABLE UNDERPAD BED SIZE Blank $26.22 HCPCS - Non-Drugs T4539 Blank REUSE DIAPER/BRIEF ANY SIZE Blank $11.10 HCPCS - Non-Drugs T4540 Blank REUSABLE UNDERPAD CHAIR SIZE Blank $10.13 HCPCS - Non-Drugs T4541 Blank LARGE DISPOSABLE UNDERPAD Blank $1.31 HCPCS - Non-Drugs T4542 Blank SMALL DISPOSABLE UNDERPAD Blank $1.51 HCPCS - Non-Drugs T4543 Blank ADULT DISP BRIEF/DIAP ABV XL Blank $2.34 HCPCS - Non-Drugs T4544 Blank ADLT DISP UND/PULL ON ABV XL Blank $2.53 HCPCS - Non-Drugs T5001 Blank POSITION SEAT SPEC ORTH NEED Blank $774.28 HCPCS - Non-Drugs T5999 Blank SUPPLY, NOS Blank $25.61 HCPCS - Non-Drugs V2020 Blank VISION SVCS FRAMES PURCHASES Blank $112.88 HCPCS - Non-Drugs V2025 Blank EYEGLASSES DELUX FRAMES Blank $107.82 HCPCS - Non-Drugs V2100 Blank LENS SPHER SINGLE PLANO 4.00 Blank $76.91 HCPCS - Non-Drugs V2101 Blank SINGLE VISN SPHERE 4.12-7.00 Blank $81.21 HCPCS - Non-Drugs V2102 Blank SINGL VISN SPHERE 7.12-20.00 Blank $99.84 HCPCS - Non-Drugs V2103 Blank SPHEROCYLINDR 4.00D/12-2.00D Blank $70.59 HCPCS - Non-Drugs V2104 Blank SPHEROCYLINDR 4.00D/2.12-4D Blank $74.41 HCPCS - Non-Drugs V2105 Blank SPHEROCYLINDER 4.00D/4.25-6D Blank $79.51 HCPCS - Non-Drugs V2106 Blank SPHEROCYLINDER 4.00D/>6.00D Blank $85.36 HCPCS - Non-Drugs V2107 Blank SPHEROCYLINDER 4.25D/12-2D Blank $84.64 HCPCS - Non-Drugs V2108 Blank SPHEROCYLINDER 4.25D/2.12-4D Blank $84.56 HCPCS - Non-Drugs V2109 Blank SPHEROCYLINDER 4.25D/4.25-6D Blank $92.29 HCPCS - Non-Drugs V2110 Blank SPHEROCYLINDER 4.25D/OVER 6D Blank $89.96 HCPCS - Non-Drugs V2111 Blank SPHEROCYLINDR 7.25D/.25-2.25 Blank $94.02 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 97 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
V2112 Blank SPHEROCYLINDR 7.25D/2.25-4D Blank $100.26 HCPCS - Non-Drugs V2113 Blank SPHEROCYLINDR 7.25D/4.25-6D Blank $107.90 HCPCS - Non-Drugs V2114 Blank SPHEROCYLINDER OVER 12.00D Blank $114.40 HCPCS - Non-Drugs V2115 Blank LENS LENTICULAR BIFOCAL Blank $120.46 HCPCS - Non-Drugs V2118 Blank LENS ANISEIKONIC SINGLE Blank $121.40 HCPCS - Non-Drugs V2121 Blank LENTICULAR LENS, SINGLE Blank $123.31 HCPCS - Non-Drugs V2199 Blank LENS SINGLE VISION NOT OTH C Blank $76.91 HCPCS - Non-Drugs V2200 Blank LENS SPHER BIFOC PLANO 4.00D Blank $91.56 HCPCS - Non-Drugs V2201 Blank LENS SPHERE BIFOCAL 4.12-7.0 Blank $97.71 HCPCS - Non-Drugs V2202 Blank LENS SPHERE BIFOCAL 7.12-20. Blank $106.60 HCPCS - Non-Drugs V2203 Blank LENS SPHCYL BIFOCAL 4.00D/.1 Blank $92.83 HCPCS - Non-Drugs V2204 Blank LENS SPHCY BIFOCAL 4.00D/2.1 Blank $95.21 HCPCS - Non-Drugs V2205 Blank LENS SPHCY BIFOCAL 4.00D/4.2 Blank $99.63 HCPCS - Non-Drugs V2206 Blank LENS SPHCY BIFOCAL 4.00D/OVE Blank $106.67 HCPCS - Non-Drugs V2207 Blank LENS SPHCY BIFOCAL 4.25-7D/. Blank $99.14 HCPCS - Non-Drugs V2208 Blank LENS SPHCY BIFOCAL 4.25-7/2. Blank $102.36 HCPCS - Non-Drugs V2209 Blank LENS SPHCY BIFOCAL 4.25-7/4. Blank $106.61 HCPCS - Non-Drugs V2210 Blank LENS SPHCY BIFOCAL 4.25-7/OV Blank $115.79 HCPCS - Non-Drugs V2211 Blank LENS SPHCY BIFO 7.25-12/.25- Blank $116.97 HCPCS - Non-Drugs V2212 Blank LENS SPHCYL BIFO 7.25-12/2.2 Blank $119.47 HCPCS - Non-Drugs V2213 Blank LENS SPHCYL BIFO 7.25-12/4.2 Blank $119.67 HCPCS - Non-Drugs V2214 Blank LENS SPHCYL BIFOCAL OVER 12. Blank $128.67 HCPCS - Non-Drugs V2215 Blank LENS LENTICULAR BIFOCAL Blank $137.17 HCPCS - Non-Drugs V2218 Blank LENS ANISEIKONIC BIFOCAL Blank $149.15 HCPCS - Non-Drugs V2219 Blank LENS BIFOCAL SEG WIDTH OVER Blank $82.09 HCPCS - Non-Drugs V2220 Blank LENS BIFOCAL ADD OVER 3.25D Blank $75.57 HCPCS - Non-Drugs V2221 Blank LENTICULAR LENS, BIFOCAL Blank $136.09 HCPCS - Non-Drugs V2299 Blank LENS BIFOCAL SPECIALITY Blank $73.42 HCPCS - Non-Drugs V2300 Blank LENS SPHERE TRIFOCAL 4.00D Blank $108.54 HCPCS - Non-Drugs V2301 Blank LENS SPHERE TRIFOCAL 4.12-7. Blank $122.85 HCPCS - Non-Drugs V2302 Blank LENS SPHERE TRIFOCAL 7.12-20 Blank $124.96 HCPCS - Non-Drugs V2303 Blank LENS SPHCY TRIFOCAL 4.0/.12- Blank $108.03 HCPCS - Non-Drugs V2304 Blank LENS SPHCY TRIFOCAL 4.0/2.25 Blank $111.16 HCPCS - Non-Drugs V2305 Blank LENS SPHCY TRIFOCAL 4.0/4.25 Blank $122.12 HCPCS - Non-Drugs V2306 Blank LENS SPHCYL TRIFOCAL 4.00/>6 Blank $124.97 HCPCS - Non-Drugs V2307 Blank LENS SPHCY TRIFOCAL 4.25-7/. Blank $120.21 HCPCS - Non-Drugs V2308 Blank LENS SPHC TRIFOCAL 4.25-7/2. Blank $123.89 HCPCS - Non-Drugs V2309 Blank LENS SPHC TRIFOCAL 4.25-7/4. Blank $134.09 HCPCS - Non-Drugs V2310 Blank LENS SPHC TRIFOCAL 4.25-7/>6 Blank $132.87 HCPCS - Non-Drugs V2311 Blank LENS SPHC TRIFO 7.25-12/.25- Blank $140.13 HCPCS - Non-Drugs V2312 Blank LENS SPHC TRIFO 7.25-12/2.25 Blank $137.92 HCPCS - Non-Drugs V2313 Blank LENS SPHC TRIFO 7.25-12/4.25 Blank $153.00 HCPCS - Non-Drugs V2314 Blank LENS SPHCYL TRIFOCAL OVER 12 Blank $158.67 HCPCS - Non-Drugs V2315 Blank LENS LENTICULAR TRIFOCAL Blank $176.78 HCPCS - Non-Drugs V2318 Blank LENS ANISEIKONIC TRIFOCAL Blank $208.71 HCPCS - Non-Drugs V2319 Blank LENS TRIFOCAL SEG WIDTH > 28 Blank $89.15 HCPCS - Non-Drugs V2320 Blank LENS TRIFOCAL ADD OVER 3.25D Blank $96.34 HCPCS - Non-Drugs V2321 Blank LENTICULAR LENS, TRIFOCAL Blank $173.75 HCPCS - Non-Drugs V2399 Blank LENS TRIFOCAL SPECIALITY Blank $178.87 HCPCS - Non-Drugs V2410 Blank LENS VARIAB ASPHERICITY SING Blank $141.36 HCPCS - Non-Drugs V2430 Blank LENS VARIABLE ASPHERICITY BI Blank $162.07 HCPCS - Non-Drugs V2499 Blank VARIABLE ASPHERICITY LENS Blank $132.01 HCPCS - Non-Drugs V2500 Blank CONTACT LENS PMMA SPHERICAL Blank $132.67 HCPCS - Non-Drugs V2501 Blank CNTCT LENS PMMA-TORIC/PRISM Blank $180.57 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 98 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
V2502 Blank CONTACT LENS PMMA BIFOCAL Blank $221.92 HCPCS - Non-Drugs V2503 Blank CNTCT LENS PMMA COLOR VISION Blank $199.50 HCPCS - Non-Drugs V2510 Blank CNTCT GAS PERMEABLE SPHERICL Blank $167.36 HCPCS - Non-Drugs V2511 Blank CNTCT TORIC PRISM BALLAST Blank $228.93 HCPCS - Non-Drugs V2512 Blank CNTCT LENS GAS PERMBL BIFOCL Blank $265.60 HCPCS - Non-Drugs V2513 Blank CONTACT LENS EXTENDED WEAR Blank $235.15 HCPCS - Non-Drugs V2520 Blank CONTACT LENS HYDROPHILIC Blank $159.17 HCPCS - Non-Drugs V2521 Blank CNTCT LENS HYDROPHILIC TORIC Blank $250.47 HCPCS - Non-Drugs V2522 Blank CNTCT LENS HYDROPHIL BIFOCL Blank $252.04 HCPCS - Non-Drugs V2523 Blank CNTCT LENS HYDROPHIL EXTEND Blank $213.74 HCPCS - Non-Drugs V2530 Blank CONTACT LENS GAS IMPERMEABLE Blank $296.43 HCPCS - Non-Drugs V2531 Blank CONTACT LENS GAS PERMEABLE Blank $610.37 HCPCS - Non-Drugs V2599 Blank CONTACT LENS/ES OTHER TYPE Blank $87.13 HCPCS - Non-Drugs V2600 Blank HAND HELD LOW VISION AIDS Blank $145.18 HCPCS - Non-Drugs V2610 Blank SINGLE LENS SPECTACLE MOUNT Blank $156.75 HCPCS - Non-Drugs V2615 Blank TELESCOP/OTHR COMPOUND LENS Blank $417.71 HCPCS - Non-Drugs V2623 Blank PLASTIC EYE PROSTH CUSTOM Blank $2,998.21 HCPCS - Non-Drugs V2624 Blank POLISHING ARTIFICAL EYE Blank $52.95 HCPCS - Non-Drugs V2625 Blank ENLARGEMNT OF EYE PROSTHESIS Blank $1,414.59 HCPCS - Non-Drugs V2626 Blank REDUCTION OF EYE PROSTHESIS Blank $933.30 HCPCS - Non-Drugs V2627 Blank SCLERAL COVER SHELL Blank $4,005.52 HCPCS - Non-Drugs V2628 Blank FABRICATION & FITTING Blank $1,199.98 HCPCS - Non-Drugs V2629 Blank PROSTHETIC EYE OTHER TYPE Blank $1,268.63 HCPCS - Non-Drugs V2630 Blank ANTER CHAMBER INTRAOCUL LENS Blank $527.58 HCPCS - Non-Drugs V2631 Blank IRIS SUPPORT INTRAOCLR LENS Blank $527.58 HCPCS - Non-Drugs V2632 Blank POST CHMBR INTRAOCULAR LENS Blank $527.58 HCPCS - Non-Drugs V2700 Blank BALANCE LENS Blank $82.80 HCPCS - Non-Drugs V2702 Blank DELUXE LENS FEATURE Blank $28.41 HCPCS - Non-Drugs V2710 Blank GLASS/PLASTIC SLAB OFF PRISM Blank $110.20 HCPCS - Non-Drugs V2715 Blank PRISM LENS/ES Blank $43.76 HCPCS - Non-Drugs V2718 Blank FRESNELL PRISM PRESS-ON LENS Blank $63.83 HCPCS - Non-Drugs V2730 Blank SPECIAL BASE CURVE Blank $54.03 HCPCS - Non-Drugs V2744 Blank TINT PHOTOCHROMATIC LENS/ES Blank $48.13 HCPCS - Non-Drugs V2745 Blank TINT, ANY COLOR/SOLID/GRAD Blank $18.55 HCPCS - Non-Drugs V2750 Blank ANTI-REFLECTIVE COATING Blank $53.04 HCPCS - Non-Drugs V2755 Blank UV LENS/ES Blank $47.74 HCPCS - Non-Drugs V2756 Blank EYE GLASS CASE Blank $3.53 HCPCS - Non-Drugs V2760 Blank SCRATCH RESISTANT COATING Blank $47.64 HCPCS - Non-Drugs V2761 Blank MIRROR COATING Blank $43.45 HCPCS - Non-Drugs V2762 Blank POLARIZATION, ANY LENS Blank $93.69 HCPCS - Non-Drugs V2770 Blank OCCLUDER LENS/ES Blank $52.47 HCPCS - Non-Drugs V2780 Blank OVERSIZE LENS/ES Blank $43.73 HCPCS - Non-Drugs V2781 Blank PROGRESSIVE LENS PER LENS Blank $99.12 HCPCS - Non-Drugs V2782 Blank LENS, 1.54-1.65 P/1.60-1.79G Blank $98.78 HCPCS - Non-Drugs V2783 Blank LENS, >= 1.66 P/>=1.80 G Blank $107.54 HCPCS - Non-Drugs V2784 Blank LENS POLYCARB OR EQUAL Blank $80.06 HCPCS - Non-Drugs V2785 Blank CORNEAL TISSUE PROCESSING Blank $5,735.17 HCPCS - Non-Drugs V2786 Blank OCCUPATIONAL MULTIFOCAL LENS Blank $134.44 HCPCS - Non-Drugs V2787 Blank ASTIGMATISM-CORRECT FUNCTION Blank $892.07 HCPCS - Non-Drugs V2788 Blank PRESBYOPIA-CORRECT FUNCTION Blank $1,569.38 HCPCS - Non-Drugs V2790 Blank AMNIOTIC MEMBRANE Blank $1,071.33 HCPCS - Non-Drugs V2797 Blank VIS ITEM/SVC IN OTHER CODE Blank $259.46 HCPCS - Non-Drugs V2799 Blank MISC VISION ITEM OR SERVICE Blank $54.04 HCPCS - Non-Drugs V5011 Blank HEARING AID FITTING/CHECKING Blank $198.65 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 99 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
V5014 Blank HEARING AID REPAIR/MODIFYING Blank $239.92 HCPCS - Non-Drugs V5020 Blank CONFORMITY EVALUATION Blank $111.79 HCPCS - Non-Drugs V5030 Blank BODY-WORN HEARING AID AIR Blank $2,505.66 HCPCS - Non-Drugs V5040 Blank BODY-WORN HEARING AID BONE Blank $1,847.22 HCPCS - Non-Drugs V5050 Blank HEARING AID MONAURAL IN EAR Blank $2,172.43 HCPCS - Non-Drugs V5060 Blank BEHIND EAR HEARING AID Blank $1,776.29 HCPCS - Non-Drugs V5070 Blank GLASSES AIR CONDUCTION Blank $880.98 HCPCS - Non-Drugs V5080 Blank GLASSES BONE CONDUCTION Blank $2,575.25 HCPCS - Non-Drugs V5090 Blank HEARING AID DISPENSING FEE Blank $761.87 HCPCS - Non-Drugs V5100 Blank BODY-WORN BILAT HEARING AID Blank $7,020.67 HCPCS - Non-Drugs V5110 Blank HEARING AID DISPENSING FEE Blank $779.27 HCPCS - Non-Drugs V5120 Blank BODY-WORN BINAUR HEARING AID Blank $4,419.86 HCPCS - Non-Drugs V5130 Blank IN EAR BINAURAL HEARING AID Blank $5,576.45 HCPCS - Non-Drugs V5140 Blank BEHIND EAR BINAUR HEARING AI Blank $6,341.40 HCPCS - Non-Drugs V5150 Blank GLASSES BINAURAL HEARING AID Blank $7,693.82 HCPCS - Non-Drugs V5160 Blank DISPENSING FEE BINAURAL Blank $980.01 HCPCS - Non-Drugs V5170 Blank WITHIN EAR CROS HEARING AID Blank $3,003.51 HCPCS - Non-Drugs V5180 Blank BEHIND EAR CROS HEARING AID Blank $2,505.66 HCPCS - Non-Drugs V5190 Blank GLASSES CROS HEARING AID Blank $2,968.71 HCPCS - Non-Drugs V5200 Blank CROS HEARING AID DISPENS FEE Blank $769.90 HCPCS - Non-Drugs V5210 Blank IN EAR BICROS HEARING AID Blank $3,284.55 HCPCS - Non-Drugs V5220 Blank BEHIND EAR BICROS HEARING AI Blank $3,146.70 HCPCS - Non-Drugs V5230 Blank GLASSES BICROS HEARING AID Blank $3,260.46 HCPCS - Non-Drugs V5240 Blank DISPENSING FEE BICROS Blank $806.03 HCPCS - Non-Drugs V5241 Blank DISPENSING FEE, MONAURAL Blank $481.75 HCPCS - Non-Drugs V5242 Blank HEARING AID, MONAURAL, CIC Blank $2,053.90 HCPCS - Non-Drugs V5243 Blank HEARING AID, MONAURAL, ITC Blank $2,163.37 HCPCS - Non-Drugs V5244 Blank HEARING AID, PROG, MON, CIC Blank $2,845.17 HCPCS - Non-Drugs V5245 Blank HEARING AID, PROG, MON, ITC Blank $3,305.28 HCPCS - Non-Drugs V5246 Blank HEARING AID, PROG, MON, ITE Blank $2,402.78 HCPCS - Non-Drugs V5247 Blank HEARING AID, PROG, MON, BTE Blank $2,862.27 HCPCS - Non-Drugs V5248 Blank HEARING AID, BINAURAL, CIC Blank $2,644.38 HCPCS - Non-Drugs V5249 Blank HEARING AID, BINAURAL, ITC Blank $2,120.25 HCPCS - Non-Drugs V5250 Blank HEARING AID, PROG, BIN, CIC Blank $6,872.14 HCPCS - Non-Drugs V5251 Blank HEARING AID, PROG, BIN, ITC Blank $6,146.02 HCPCS - Non-Drugs V5252 Blank HEARING AID, PROG, BIN, ITE Blank $8,780.26 HCPCS - Non-Drugs V5253 Blank HEARING AID, PROG, BIN, BTE Blank $4,079.77 HCPCS - Non-Drugs V5254 Blank HEARING ID, DIGIT, MON, CIC Blank $3,071.98 HCPCS - Non-Drugs V5255 Blank HEARING AID, DIGIT, MON, ITC Blank $1,958.61 HCPCS - Non-Drugs V5256 Blank HEARING AID, DIGIT, MON, ITE Blank $1,612.03 HCPCS - Non-Drugs V5257 Blank HEARING AID, DIGIT, MON, BTE Blank $3,916.59 HCPCS - Non-Drugs V5258 Blank HEARING AID, DIGIT, BIN, CIC Blank $6,407.30 HCPCS - Non-Drugs V5259 Blank HEARING AID, DIGIT, BIN, ITC Blank $4,817.52 HCPCS - Non-Drugs V5260 Blank HEARING AID, DIGIT, BIN, ITE Blank $4,496.35 HCPCS - Non-Drugs V5261 Blank HEARING AID, DIGIT, BIN, BTE Blank $6,188.10 HCPCS - Non-Drugs V5262 Blank HEARING AID, DISP, MONAURAL Blank $289.94 HCPCS - Non-Drugs V5263 Blank HEARING AID, DISP, BINAURAL Blank $221.16 HCPCS - Non-Drugs V5264 Blank EAR MOLD/INSERT Blank $130.55 HCPCS - Non-Drugs V5265 Blank EAR MOLD/INSERT, DISP Blank $79.83 HCPCS - Non-Drugs V5266 Blank BATTERY FOR HEARING DEVICE Blank $2.18 HCPCS - Non-Drugs V5267 Blank HEARING AID SUP/ACCESS/DEV Blank $13.97 HCPCS - Non-Drugs V5268 Blank ALD TELEPHONE AMPLIFIER Blank $124.02 HCPCS - Non-Drugs V5269 Blank ALERTING DEVICE, ANY TYPE Blank $115.29 HCPCS - Non-Drugs V5270 Blank ALD, TV AMPLIFIER, ANY TYPE Blank $301.74 HCPCS - Non-Drugs
1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE
PAGE 100 of 100
Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2
V5271 Blank ALD, TV CAPTION DECODER Blank $506.28 HCPCS - Non-Drugs V5272 Blank TDD Blank $359.09 HCPCS - Non-Drugs V5273 Blank ALD FOR COCHLEAR IMPLANT Blank $819.03 HCPCS - Non-Drugs V5274 Blank ALD UNSPECIFIED Blank $181.56 HCPCS - Non-Drugs V5275 Blank EAR IMPRESSION Blank $59.87 HCPCS - Non-Drugs V5281 Blank ALD FM/DM SYSTEM, MONAURAL Blank $165.84 HCPCS - Non-Drugs V5282 Blank ALD FM/DM SYSTEM BINAURAL Blank $588.95 HCPCS - Non-Drugs V5283 Blank ALD NECK, LOOP IND RECEIVER Blank $412.06 HCPCS - Non-Drugs V5284 Blank ALD FM/DM EAR LEVEL RECEIVER Blank $574.62 HCPCS - Non-Drugs V5285 Blank ALD FM/DM AUD INPUT RECEIVER Blank $762.03 HCPCS - Non-Drugs V5286 Blank ALD BLU TOOTH FM/DM RECEIVER Blank $238.07 HCPCS - Non-Drugs V5287 Blank ALD FM/DM RECEIVER, NOS Blank $433.27 HCPCS - Non-Drugs V5288 Blank ALD FM/DM TRANSMITTER ALD Blank $314.44 HCPCS - Non-Drugs V5289 Blank ALD FM/DM ADAPT/BOOT COUPLIN Blank $130.83 HCPCS - Non-Drugs V5290 Blank ALD TRANSMITTER MICROPHONE Blank $410.37 HCPCS - Non-Drugs V5298 Blank HEARING AID NOC Blank $1,433.72 HCPCS - Non-Drugs V5299 Blank HEARING SERVICE Blank $110.56 HCPCS - Non-Drugs 1 Key to Modifiers: AU: Item furnished in conjunction with a urological, ostomy, or tracheostomy supply AV: Item furnished in conjunction with a prosthetic device, prosthetic or orthotic AW: Item furnished in conjunction with a surgical dressing KF: Item designated by FDA as class III device KL: DMEPOS item delivered via mail KM: Replacement of facial prosthesis including new impression/moulage KN: Replacement of facial prosthesis using previous master model MS: Maintenance and servicing of item NU: New equipment RR: Rented equipment UE: Used equipment 2 Key to Status/Usage Indicators for new items: a: Cannot be billed by VA hospital outpatients and provider-based clinics because the service is separately priced as an outpatient facility charge. (See Table F for these charges.)
1, 2 - See end of the table for notes regarding these fields.