V3.23 Durable Medical Equipment, Supplies, Vision and Hearing Hardware Nationwide by HCPCS Code

Home , Lanreotide, Megestrol

TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE v3.23 (January - December 2018) PAGE 1 of 95

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A0100 Blank NONEMERGENCY TRANSPORT TAXI Blank $20.81 HCPCS - Non-Drugs A0110 Blank NONEMERGENCY TRANSPORT BUS Blank $61.62 HCPCS - Non-Drugs A0120 Blank NONER TRANSPORT MINI-BUS Blank $183.09 HCPCS - Non-Drugs A0130 Blank NONER TRANSPORT WHEELCH VAN Blank $85.54 HCPCS - Non-Drugs A0140 Blank NONEMERGENCY TRANSPORT AIR Blank $1,211.38 HCPCS - Non-Drugs A0160 Blank NONER TRANSPORT CASE WORKER Blank $2.42 HCPCS - Non-Drugs A0170 Blank TRANSPORT PARKING FEES/TOLLS Blank $303.72 HCPCS - Non-Drugs A0180 Blank NONER TRANSPORT LODGNG RECIP Blank $809.69 HCPCS - Non-Drugs A0190 Blank NONER TRANSPORT MEALS RECIP Blank $181.99 HCPCS - Non-Drugs A0398 Blank ALS ROUTINE DISPOSBLE SUPPLS Blank $132.93 HCPCS - Non-Drugs A0422 Blank AMBULANCE 02 LIFE SUSTAINING Blank $126.28 HCPCS - Non-Drugs A4206 Blank 1 CC STERILE SYRINGE&NEEDLE Blank $0.94 HCPCS - Non-Drugs A4207 Blank 2 CC STERILE SYRINGE&NEEDLE Blank $0.94 HCPCS - Non-Drugs A4208 Blank 3 CC STERILE SYRINGE&NEEDLE Blank $0.94 HCPCS - Non-Drugs A4209 Blank 5+ CC STERILE SYRINGE&NEEDLE Blank $0.94 HCPCS - Non-Drugs A4210 Blank NONNEEDLE INJECTION DEVICE Blank $1,233.33 HCPCS - Non-Drugs A4211 Blank SUPP FOR SELF-ADM INJECTIONS Blank $57.07 HCPCS - Non-Drugs A4212 Blank NON CORING NEEDLE OR STYLET Blank $13.31 HCPCS - Non-Drugs A4213 Blank 20+ CC SYRINGE ONLY Blank $1.88 HCPCS - Non-Drugs A4215 Blank STERILE NEEDLE Blank $1.29 HCPCS - Non-Drugs A4216 Blank STERILE WATER/SALINE, 10 ML Blank $1.09 HCPCS - Non-Drugs A4217 Blank STERILE WATER/SALINE, 500 ML Blank $6.97 HCPCS - Non-Drugs A4217 AU STERILE WATER/SALINE, 500 ML Blank $6.97 HCPCS - Non-Drugs A4218 Blank STERILE SALINE OR WATER Blank $3.59 HCPCS - Non-Drugs A4220 Blank INFUSION PUMP REFILL KIT Blank $86.92 HCPCS - Non-Drugs A4221 Blank SUPP NON-INSULIN INF CATH/WK Blank $111.76 HCPCS - Non-Drugs A4222 Blank INFUSION SUPPLIES WITH PUMP Blank $144.04 HCPCS - Non-Drugs A4223 Blank INFUSION SUPPLIES W/O PUMP Blank $131.27 HCPCS - Non-Drugs A4224 Blank SUPPLY INSULIN INF CATH/WK Blank $111.76 HCPCS - Non-Drugs A4225 Blank SUP/EXT INSULIN INF PUMP SYR Blank $25.36 HCPCS - Non-Drugs A4230 Blank INFUS INSULIN PUMP NON NEEDL Blank $22.52 HCPCS - Non-Drugs A4231 Blank INFUSION INSULIN PUMP NEEDLE Blank $9.38 HCPCS - Non-Drugs A4232 Blank SYRINGE W/NEEDLE INSULIN 3CC Blank $5.80 HCPCS - Non-Drugs A4233 Blank ALKALIN BATT FOR GLUCOSE MON Blank $4.98 HCPCS - Non-Drugs A4233 NU ALKALIN BATT FOR GLUCOSE MON Blank $4.98 HCPCS - Non-Drugs A4234 Blank J-CELL BATT FOR GLUCOSE MON Blank $23.02 HCPCS - Non-Drugs A4234 NU J-CELL BATT FOR GLUCOSE MON Blank $23.02 HCPCS - Non-Drugs A4235 Blank LITHIUM BATT FOR GLUCOSE MON Blank $9.76 HCPCS - Non-Drugs A4235 NU LITHIUM BATT FOR GLUCOSE MON Blank $9.76 HCPCS - Non-Drugs A4236 Blank SILVR OXIDE BATT GLUCOSE MON Blank $11.32 HCPCS - Non-Drugs A4236 NU SILVR OXIDE BATT GLUCOSE MON Blank $11.32 HCPCS - Non-Drugs A4244 Blank ALCOHOL OR PEROXIDE PER PINT Blank $1.88 HCPCS - Non-Drugs A4245 Blank ALCOHOL WIPES PER BOX Blank $5.45 HCPCS - Non-Drugs A4246 Blank BETADINE/PHISOHEX SOLUTION Blank $5.45 HCPCS - Non-Drugs A4247 Blank BETADINE/IODINE SWABS/WIPES Blank $7.59 HCPCS - Non-Drugs A4248 Blank CHLORHEXIDINE ANTISEPT Blank $5.40 HCPCS - Non-Drugs A4250 Blank URINE REAGENT STRIPS/TABLETS Blank $26.16 HCPCS - Non-Drugs A4252 Blank BLOOD KETONE TEST OR STRIP Blank $11.55 HCPCS - Non-Drugs A4253 Blank BLOOD GLUCOSE/REAGENT STRIPS Blank $113.18 HCPCS - Non-Drugs A4253 NU BLOOD GLUCOSE/REAGENT STRIPS Blank $113.18 HCPCS - Non-Drugs A4255 Blank GLUCOSE MONITOR PLATFORMS Blank $43.63 HCPCS - Non-Drugs A4256 Blank CALIBRATOR SOLUTION/CHIPS Blank $32.97 HCPCS - Non-Drugs A4256 KL CALIBRATOR SOLUTION/CHIPS Blank $28.96 HCPCS - Non-Drugs A4257 Blank REPLACE LENSSHIELD CARTRIDGE Blank $102.17 HCPCS - Non-Drugs A4258 Blank LANCET DEVICE EACH Blank $20.68 HCPCS - Non-Drugs A4258 KL LANCET DEVICE EACH Blank $17.89 HCPCS - Non-Drugs A4259 Blank LANCETS PER BOX Blank $13.85 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 v3.23 (January - December 2018) PAGE 2 of 95

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A4259 KL LANCETS PER BOX Blank $12.13 HCPCS - Non-Drugs A4261 Blank CERVICAL CAP CONTRACEPTIVE Blank $77.88 HCPCS - Non-Drugs A4262 Blank TEMPORARY TEAR DUCT PLUG Blank $0.94 HCPCS - Non-Drugs A4263 Blank PERMANENT TEAR DUCT PLUG Blank $58.28 HCPCS - Non-Drugs A4264 Blank INTRATUBAL OCCLUSION DEVICE Blank $2,243.66 HCPCS - Non-Drugs A4265 Blank PARAFFIN Blank $37.05 HCPCS - Non-Drugs A4266 Blank DIAPHRAGM Blank $87.22 HCPCS - Non-Drugs A4267 Blank MALE CONDOM Blank $0.94 HCPCS - Non-Drugs A4268 Blank FEMALE CONDOM Blank $1.20 HCPCS - Non-Drugs A4269 Blank SPERMICIDE Blank $1.88 HCPCS - Non-Drugs A4270 Blank DISPOSABLE ENDOSCOPE SHEATH Blank $17.96 HCPCS - Non-Drugs A4280 Blank BRST PRSTHS ADHSV ATTCHMNT Blank $8.48 HCPCS - Non-Drugs A4281 Blank REPLACEMENT BREASTPUMP TUBE Blank $20.04 HCPCS - Non-Drugs A4282 Blank REPLACEMENT BREASTPUMP ADPT Blank $21.39 HCPCS - Non-Drugs A4283 Blank REPLACEMENT BREASTPUMP CAP Blank $116.11 HCPCS - Non-Drugs A4284 Blank REPLCMNT BREAST PUMP SHIELD Blank $26.16 HCPCS - Non-Drugs A4285 Blank REPLCMNT BREAST PUMP BOTTLE Blank $17.67 HCPCS - Non-Drugs A4286 Blank REPLCMNT BREASTPUMP LOK RING Blank $68.50 HCPCS - Non-Drugs A4290 Blank SACRAL NERVE STIM TEST LEAD Blank $703.49 HCPCS - Non-Drugs A4300 Blank CATH IMPL VASC ACCESS PORTAL Blank $40.41 HCPCS - Non-Drugs A4301 Blank IMPLANTABLE ACCESS SYST PERC Blank $19.73 HCPCS - Non-Drugs A4305 Blank DRUG DELIVERY SYSTEM >=50 ML Blank $19.73 HCPCS - Non-Drugs A4306 Blank DRUG DELIVERY SYSTEM <=50 ML Blank $26.87 HCPCS - Non-Drugs A4310 Blank INSERT TRAY W/O BAG/CATH Blank $15.90 HCPCS - Non-Drugs A4311 Blank CATHETER W/O BAG 2-WAY LATEX Blank $28.68 HCPCS - Non-Drugs A4312 Blank CATH W/O BAG 2-WAY SILICONE Blank $35.28 HCPCS - Non-Drugs A4313 Blank CATHETER W/BAG 3-WAY Blank $36.29 HCPCS - Non-Drugs A4314 Blank CATH W/DRAINAGE 2-WAY LATEX Blank $49.02 HCPCS - Non-Drugs A4315 Blank CATH W/DRAINAGE 2-WAY SILCNE Blank $51.24 HCPCS - Non-Drugs A4316 Blank CATH W/DRAINAGE 3-WAY Blank $55.32 HCPCS - Non-Drugs A4320 Blank IRRIGATION TRAY Blank $10.99 HCPCS - Non-Drugs A4321 Blank CATH THERAPEUTIC IRRIG AGENT Blank $10.00 HCPCS - Non-Drugs A4322 Blank IRRIGATION SYRINGE Blank $7.03 HCPCS - Non-Drugs A4326 Blank MALE EXTERNAL CATHETER Blank $21.44 HCPCS - Non-Drugs A4327 Blank FEM URINARY COLLECT DEV CUP Blank $87.51 HCPCS - Non-Drugs A4328 Blank FEM URINARY COLLECT POUCH Blank $21.09 HCPCS - Non-Drugs A4330 Blank STOOL COLLECTION POUCH Blank $14.54 HCPCS - Non-Drugs A4331 Blank EXTENSION DRAINAGE TUBING Blank $7.45 HCPCS - Non-Drugs A4332 Blank LUBE STERILE PACKET Blank $0.30 HCPCS - Non-Drugs A4333 Blank URINARY CATH ANCHOR DEVICE Blank $3.55 HCPCS - Non-Drugs A4334 Blank URINARY CATH LEG STRAP Blank $7.87 HCPCS - Non-Drugs A4335 Blank INCONTINENCE SUPPLY Blank $0.61 HCPCS - Non-Drugs A4336 Blank URETHRAL INSERT Blank $3.80 HCPCS - Non-Drugs A4338 Blank INDWELLING CATHETER LATEX Blank $24.51 HCPCS - Non-Drugs A4340 Blank INDWELLING CATHETER SPECIAL Blank $59.98 HCPCS - Non-Drugs A4344 Blank CATH INDW FOLEY 2 WAY SILICN Blank $31.41 HCPCS - Non-Drugs A4346 Blank CATH INDW FOLEY 3 WAY Blank $37.59 HCPCS - Non-Drugs A4349 Blank DISPOSABLE MALE EXTERNAL CAT Blank $5.16 HCPCS - Non-Drugs A4351 Blank STRAIGHT TIP URINE CATHETER Blank $4.53 HCPCS - Non-Drugs A4352 Blank COUDE TIP URINARY CATHETER Blank $13.25 HCPCS - Non-Drugs A4353 Blank INTERMITTENT URINARY CATH Blank $14.97 HCPCS - Non-Drugs A4354 Blank CATH INSERTION TRAY W/BAG Blank $23.63 HCPCS - Non-Drugs A4355 Blank BLADDER IRRIGATION TUBING Blank $18.60 HCPCS - Non-Drugs A4356 Blank EXT URETH CLMP OR COMPR DVC Blank $86.78 HCPCS - Non-Drugs A4357 Blank BEDSIDE DRAINAGE BAG Blank $19.52 HCPCS - Non-Drugs A4358 Blank URINARY LEG OR ABDOMEN BAG Blank $13.62 HCPCS - Non-Drugs A4360 Blank DISPOSABLE EXT URETHRAL DEV Blank $1.20 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A4361 Blank OSTOMY FACE PLATE Blank $36.08 HCPCS - Non-Drugs A4362 Blank SOLID SKIN BARRIER Blank $7.66 HCPCS - Non-Drugs A4363 Blank OSTOMY CLAMP, REPLACEMENT Blank $5.64 HCPCS - Non-Drugs A4364 Blank ADHESIVE, LIQUID OR EQUAL Blank $4.45 HCPCS - Non-Drugs A4366 Blank OSTOMY VENT Blank $2.08 HCPCS - Non-Drugs A4367 Blank OSTOMY BELT Blank $15.02 HCPCS - Non-Drugs A4368 Blank OSTOMY FILTER Blank $0.65 HCPCS - Non-Drugs A4369 Blank SKIN BARRIER LIQUID PER OZ Blank $5.77 HCPCS - Non-Drugs A4371 Blank SKIN BARRIER POWDER PER OZ Blank $8.35 HCPCS - Non-Drugs A4372 Blank SKIN BARRIER SOLID 4X4 EQUIV Blank $9.45 HCPCS - Non-Drugs A4373 Blank SKIN BARRIER WITH FLANGE Blank $13.55 HCPCS - Non-Drugs A4375 Blank DRAINABLE PLASTIC PCH W FCPL Blank $35.07 HCPCS - Non-Drugs A4376 Blank DRAINABLE RUBBER PCH W FCPLT Blank $95.12 HCPCS - Non-Drugs A4377 Blank DRAINABLE PLSTIC PCH W/O FP Blank $9.65 HCPCS - Non-Drugs A4378 Blank DRAINABLE RUBBER PCH W/O FP Blank $61.85 HCPCS - Non-Drugs A4379 Blank URINARY PLASTIC POUCH W FCPL Blank $30.82 HCPCS - Non-Drugs A4380 Blank URINARY RUBBER POUCH W FCPLT Blank $74.85 HCPCS - Non-Drugs A4381 Blank URINARY PLASTIC POUCH W/O FP Blank $10.30 HCPCS - Non-Drugs A4382 Blank URINARY HVY PLSTC PCH W/O FP Blank $49.76 HCPCS - Non-Drugs A4383 Blank URINARY RUBBER POUCH W/O FP Blank $56.82 HCPCS - Non-Drugs A4384 Blank OSTOMY FACEPLT/SILICONE RING Blank $20.14 HCPCS - Non-Drugs A4385 Blank OST SKN BARRIER SLD EXT WEAR Blank $11.24 HCPCS - Non-Drugs A4387 Blank OST CLSD POUCH W ATT ST BARR Blank $5.60 HCPCS - Non-Drugs A4388 Blank DRAINABLE PCH W EX WEAR BARR Blank $9.79 HCPCS - Non-Drugs A4389 Blank DRAINABLE PCH W ST WEAR BARR Blank $13.44 HCPCS - Non-Drugs A4390 Blank DRAINABLE PCH EX WEAR CONVEX Blank $20.13 HCPCS - Non-Drugs A4391 Blank URINARY POUCH W EX WEAR BARR Blank $15.13 HCPCS - Non-Drugs A4392 Blank URINARY POUCH W ST WEAR BARR Blank $17.32 HCPCS - Non-Drugs A4393 Blank URINE PCH W EX WEAR BAR CONV Blank $19.04 HCPCS - Non-Drugs A4394 Blank OSTOMY POUCH LIQ DEODORANT Blank $6.28 HCPCS - Non-Drugs A4395 Blank OSTOMY POUCH SOLID DEODORANT Blank $0.12 HCPCS - Non-Drugs A4396 Blank PERISTOMAL HERNIA SUPPRT BLT Blank $81.14 HCPCS - Non-Drugs A4397 Blank IRRIGATION SUPPLY SLEEVE Blank $9.96 HCPCS - Non-Drugs A4398 Blank OSTOMY IRRIGATION BAG Blank $27.90 HCPCS - Non-Drugs A4399 Blank OSTOMY IRRIG CONE/CATH W BRS Blank $24.00 HCPCS - Non-Drugs A4400 Blank OSTOMY IRRIGATION SET Blank $91.74 HCPCS - Non-Drugs A4402 Blank LUBRICANT PER OUNCE Blank $4.11 HCPCS - Non-Drugs A4404 Blank OSTOMY RING EACH Blank $4.34 HCPCS - Non-Drugs A4405 Blank NONPECTIN BASED OSTOMY PASTE Blank $7.91 HCPCS - Non-Drugs A4406 Blank PECTIN BASED OSTOMY PASTE Blank $12.47 HCPCS - Non-Drugs A4407 Blank EXT WEAR OST SKN BARR <=4SQ Blank $18.47 HCPCS - Non-Drugs A4408 Blank EXT WEAR OST SKN BARR >4SQ Blank $20.67 HCPCS - Non-Drugs A4409 Blank OST SKN BARR CONVEX <=4 SQ I Blank $13.45 HCPCS - Non-Drugs A4410 Blank OST SKN BARR EXTND >4 SQ Blank $19.04 HCPCS - Non-Drugs A4411 Blank OST SKN BARR EXTND =4SQ Blank $11.25 HCPCS - Non-Drugs A4412 Blank OST POUCH DRAIN HIGH OUTPUT Blank $6.51 HCPCS - Non-Drugs A4413 Blank 2 PC DRAINABLE OST POUCH Blank $12.05 HCPCS - Non-Drugs A4414 Blank OST SKNBAR W/O CONV<=4 SQ IN Blank $10.89 HCPCS - Non-Drugs A4415 Blank OST SKN BARR W/O CONV >4 SQI Blank $13.01 HCPCS - Non-Drugs A4416 Blank OST PCH CLSD W BARRIER/FILTR Blank $4.42 HCPCS - Non-Drugs A4417 Blank OST PCH W BAR/BLTINCONV/FLTR Blank $5.96 HCPCS - Non-Drugs A4418 Blank OST PCH CLSD W/O BAR W FILTR Blank $2.91 HCPCS - Non-Drugs A4419 Blank OST PCH FOR BAR W FLANGE/FLT Blank $2.78 HCPCS - Non-Drugs A4420 Blank OST PCH CLSD FOR BAR W LK FL Blank $3.89 HCPCS - Non-Drugs A4421 Blank OSTOMY SUPPLY MISC Blank $8.64 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 $2.98 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A4424 Blank OST PCH DRAIN W BAR & FILTER Blank $7.63 HCPCS - Non-Drugs A4425 Blank OST PCH DRAIN FOR BARRIER FL Blank $5.74 HCPCS - Non-Drugs A4426 Blank OST PCH DRAIN 2 PIECE SYSTEM Blank $4.38 HCPCS - Non-Drugs A4427 Blank OST PCH DRAIN/BARR LK FLNG/F Blank $4.47 HCPCS - Non-Drugs A4428 Blank URINE OST POUCH W FAUCET/TAP Blank $10.44 HCPCS - Non-Drugs A4429 Blank URINE OST POUCH W BLTINCONV Blank $12.80 HCPCS - Non-Drugs A4430 Blank OST URINE PCH W B/BLTIN CONV Blank $13.11 HCPCS - Non-Drugs A4431 Blank OST PCH URINE W BARRIER/TAPV Blank $9.97 HCPCS - Non-Drugs A4432 Blank OS PCH URINE W BAR/FANGE/TAP Blank $5.76 HCPCS - Non-Drugs A4433 Blank URINE OST PCH BAR W LOCK FLN Blank $5.37 HCPCS - Non-Drugs A4434 Blank OST PCH URINE W LOCK FLNG/FT Blank $6.02 HCPCS - Non-Drugs A4435 Blank 1PC OST PCH DRAIN HGH OUTPUT Blank $9.25 HCPCS - Non-Drugs A4450 Blank NON-WATERPROOF TAPE Blank $0.21 HCPCS - Non-Drugs A4450 AU NON-WATERPROOF TAPE Blank $0.21 HCPCS - Non-Drugs A4450 AV NON-WATERPROOF TAPE Blank $0.21 HCPCS - Non-Drugs A4450 AW NON-WATERPROOF TAPE Blank $0.28 HCPCS - Non-Drugs A4452 Blank WATERPROOF TAPE Blank $0.93 HCPCS - Non-Drugs A4452 AU WATERPROOF TAPE Blank $0.93 HCPCS - Non-Drugs A4452 AV WATERPROOF TAPE Blank $0.93 HCPCS - Non-Drugs A4452 AW WATERPROOF TAPE Blank $1.03 HCPCS - Non-Drugs A4455 Blank ADHESIVE REMOVER PER OUNCE Blank $3.52 HCPCS - Non-Drugs A4456 Blank ADHESIVE REMOVER, WIPES Blank $0.63 HCPCS - Non-Drugs A4458 Blank REUSABLE ENEMA BAG Blank $24.47 HCPCS - Non-Drugs A4459 Blank MANUAL PUMP ENEMA, REUSABLE Blank $24.47 HCPCS - Non-Drugs A4461 Blank SURGICL DRESS HOLD NON-REUSE Blank $7.68 HCPCS - Non-Drugs A4463 Blank SURGICAL DRESS HOLDER REUSE Blank $27.44 HCPCS - Non-Drugs A4465 Blank NON-ELASTIC EXTREMITY BINDER Blank $14.02 HCPCS - Non-Drugs A4467 Blank BELT STRAP SLEEV GRMNT COVER Blank $56.23 HCPCS - Non-Drugs A4470 Blank GRAVLEE JET WASHER Blank $10.45 HCPCS - Non-Drugs A4480 Blank VABRA ASPIRATOR Blank $8.31 HCPCS - Non-Drugs A4481 Blank TRACHEOSTOMA FILTER Blank $4.07 HCPCS - Non-Drugs A4483 Blank MOISTURE EXCHANGER Blank $9.20 HCPCS - Non-Drugs A4490 Blank ABOVE KNEE SURGICAL STOCKING Blank $10.45 HCPCS - Non-Drugs A4495 Blank THIGH LENGTH SURG STOCKING Blank $10.45 HCPCS - Non-Drugs A4500 Blank BELOW KNEE SURGICAL STOCKING Blank $8.31 HCPCS - Non-Drugs A4510 Blank FULL LENGTH SURG STOCKING Blank $18.30 HCPCS - Non-Drugs A4520 Blank INCONTINENCE GARMENT ANYTYPE Blank $1.53 HCPCS - Non-Drugs A4550 Blank SURGICAL TRAYS Blank $43.29 HCPCS - Non-Drugs A4554 Blank DISPOSABLE UNDERPADS Blank $5.45 HCPCS - Non-Drugs A4555 Blank CA TX E-STIM ELECTR/TRANSDUC Blank $98.93 HCPCS - Non-Drugs A4556 Blank ELECTRODES, PAIR Blank $98.93 HCPCS - Non-Drugs A4557 Blank LEAD WIRES, PAIR Blank $94.56 HCPCS - Non-Drugs A4558 Blank CONDUCTIVE GEL OR PASTE Blank $57.80 HCPCS - Non-Drugs A4559 Blank COUPLING GEL OR PASTE Blank $1.07 HCPCS - Non-Drugs A4561 Blank PESSARY RUBBER, ANY TYPE Blank $41.17 HCPCS - Non-Drugs A4562 Blank PESSARY, NON RUBBER,ANY TYPE Blank $100.67 HCPCS - Non-Drugs A4565 Blank SLINGS Blank $16.34 HCPCS - Non-Drugs A4566 Blank SHOULD SLING/VEST/ABRESTRAIN Blank $44.32 HCPCS - Non-Drugs A4570 Blank SPLINT Blank $26.16 HCPCS - Non-Drugs A4575 Blank HYPERBARIC O2 CHAMBER DISPS Blank $859.29 HCPCS - Non-Drugs A4580 Blank CAST SUPPLIES (PLASTER) Blank $77.73 HCPCS - Non-Drugs A4590 Blank SPECIAL CASTING MATERIAL Blank $56.85 HCPCS - Non-Drugs A4595 Blank TENS SUPPL 2 LEAD PER MONTH Blank $94.41 HCPCS - Non-Drugs A4600 Blank SLEEVE, INTER LIMB COMP DEV Blank $310.04 HCPCS - Non-Drugs A4601 Blank LITH ION NON PROSTH RECHARGE Blank $3.91 HCPCS - Non-Drugs A4602 Blank REPLACE LITHIUM BATTERY 1.5V Blank $40.48 HCPCS - Non-Drugs A4602 NU REPLACE LITHIUM BATTERY 1.5V Blank $40.48 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A4604 Blank TUBING WITH HEATING ELEMENT Blank $149.40 HCPCS - Non-Drugs A4604 NU TUBING WITH HEATING ELEMENT Blank $149.40 HCPCS - Non-Drugs A4605 Blank TRACH SUCTION CATH CLOSE SYS Blank $109.72 HCPCS - Non-Drugs A4605 NU TRACH SUCTION CATH CLOSE SYS Blank $109.72 HCPCS - Non-Drugs A4606 Blank OXYGEN PROBE USED W OXIMETER Blank $59.24 HCPCS - Non-Drugs A4608 Blank TRANSTRACHEAL OXYGEN CATH Blank $179.58 HCPCS - Non-Drugs A4611 Blank HEAVY DUTY BATTERY Blank $257.82 HCPCS - Non-Drugs A4611 NU HEAVY DUTY BATTERY Blank $257.82 HCPCS - Non-Drugs A4611 RR HEAVY DUTY BATTERY Blank $94.67 HCPCS - Non-Drugs A4611 UE HEAVY DUTY BATTERY Blank $212.30 HCPCS - Non-Drugs A4612 Blank BATTERY CABLES Blank $149.91 HCPCS - Non-Drugs A4612 NU BATTERY CABLES Blank $149.91 HCPCS - Non-Drugs A4612 RR BATTERY CABLES Blank $40.31 HCPCS - Non-Drugs A4612 UE BATTERY CABLES Blank $132.01 HCPCS - Non-Drugs A4613 Blank BATTERY CHARGER Blank $209.23 HCPCS - Non-Drugs A4613 NU BATTERY CHARGER Blank $209.23 HCPCS - Non-Drugs A4613 RR BATTERY CHARGER Blank $77.40 HCPCS - Non-Drugs A4613 UE BATTERY CHARGER Blank $172.41 HCPCS - Non-Drugs A4614 Blank HAND-HELD PEFR METER Blank $48.15 HCPCS - Non-Drugs A4615 Blank CANNULA NASAL Blank $2.85 HCPCS - Non-Drugs A4616 Blank TUBING (OXYGEN) PER FOOT Blank $3.78 HCPCS - Non-Drugs A4617 Blank MOUTH PIECE Blank $2.86 HCPCS - Non-Drugs A4618 Blank BREATHING CIRCUITS Blank $17.83 HCPCS - Non-Drugs A4618 NU BREATHING CIRCUITS Blank $17.83 HCPCS - Non-Drugs A4618 RR BREATHING CIRCUITS Blank $2.52 HCPCS - Non-Drugs A4618 UE BREATHING CIRCUITS Blank $13.65 HCPCS - Non-Drugs A4619 Blank FACE TENT Blank $1.38 HCPCS - Non-Drugs A4619 NU FACE TENT Blank $1.38 HCPCS - Non-Drugs A4620 Blank VARIABLE CONCENTRATION MASK Blank $3.01 HCPCS - Non-Drugs A4623 Blank TRACHEOSTOMY INNER CANNULA Blank $12.97 HCPCS - Non-Drugs A4624 Blank TRACHEAL SUCTION TUBE Blank $26.94 HCPCS - Non-Drugs A4624 NU TRACHEAL SUCTION TUBE Blank $26.94 HCPCS - Non-Drugs A4625 Blank TRACH CARE KIT FOR NEW TRACH Blank $15.04 HCPCS - Non-Drugs A4626 Blank TRACHEOSTOMY CLEANING BRUSH Blank $6.90 HCPCS - Non-Drugs A4627 Blank SPACER BAG/RESERVOIR Blank $25.44 HCPCS - Non-Drugs A4628 Blank OROPHARYNGEAL SUCTION CATH Blank $8.47 HCPCS - Non-Drugs A4628 NU OROPHARYNGEAL SUCTION CATH Blank $8.47 HCPCS - Non-Drugs A4629 Blank TRACHEOSTOMY CARE KIT Blank $10.33 HCPCS - Non-Drugs A4630 Blank REPL BAT T.E.N.S. OWN BY PT Blank $67.21 HCPCS - Non-Drugs A4630 NU REPL BAT T.E.N.S. OWN BY PT Blank $67.21 HCPCS - Non-Drugs A4633 Blank UVL REPLACEMENT BULB Blank $160.75 HCPCS - Non-Drugs A4633 NU UVL REPLACEMENT BULB Blank $160.75 HCPCS - Non-Drugs A4634 Blank REPLACEMENT BULB TH LIGHTBOX Blank $126.02 HCPCS - Non-Drugs A4635 Blank UNDERARM CRUTCH PAD Blank $52.88 HCPCS - Non-Drugs A4635 NU UNDERARM CRUTCH PAD Blank $52.88 HCPCS - Non-Drugs A4635 RR UNDERARM CRUTCH PAD Blank $7.12 HCPCS - Non-Drugs A4635 UE UNDERARM CRUTCH PAD Blank $34.77 HCPCS - Non-Drugs A4636 Blank HANDGRIP FOR CANE ETC Blank $28.80 HCPCS - Non-Drugs A4636 NU HANDGRIP FOR CANE ETC Blank $28.80 HCPCS - Non-Drugs A4636 RR HANDGRIP FOR CANE ETC Blank $2.92 HCPCS - Non-Drugs A4636 UE HANDGRIP FOR CANE ETC Blank $21.60 HCPCS - Non-Drugs A4637 Blank REPL TIP CANE/CRUTCH/WALKER Blank $16.10 HCPCS - Non-Drugs A4637 NU REPL TIP CANE/CRUTCH/WALKER Blank $16.10 HCPCS - Non-Drugs A4637 RR REPL TIP CANE/CRUTCH/WALKER Blank $1.66 HCPCS - Non-Drugs A4637 UE REPL TIP CANE/CRUTCH/WALKER Blank $12.10 HCPCS - Non-Drugs A4638 Blank REPL BATT PULSE GEN SYS Blank $17,244.97 HCPCS - Non-Drugs A4638 NU REPL BATT PULSE GEN SYS Blank $17,244.97 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A4638 RR REPL BATT PULSE GEN SYS Blank $1,809.78 HCPCS - Non-Drugs A4638 UE REPL BATT PULSE GEN SYS Blank $12,958.59 HCPCS - Non-Drugs A4639 Blank INFRARED HT SYS REPLCMNT PAD Blank $462.91 HCPCS - Non-Drugs A4639 NU INFRARED HT SYS REPLCMNT PAD Blank $462.91 HCPCS - Non-Drugs A4639 RR INFRARED HT SYS REPLCMNT PAD Blank $135.25 HCPCS - Non-Drugs A4640 Blank ALTERNATING PRESSURE PAD Blank $170.87 HCPCS - Non-Drugs A4640 NU ALTERNATING PRESSURE PAD Blank $170.87 HCPCS - Non-Drugs A4640 RR ALTERNATING PRESSURE PAD Blank $50.38 HCPCS - Non-Drugs A4640 UE ALTERNATING PRESSURE PAD Blank $147.10 HCPCS - Non-Drugs A4641 Blank RADIOPHARM DX AGENT NOC a $45.11 HCPCS - Non-Drugs A4642 Blank IN111 SATUMOMAB a $30.13 HCPCS - Non-Drugs A4648 Blank IMPLANTABLE TISSUE MARKER a $413.95 HCPCS - Non-Drugs A4649 Blank SURGICAL SUPPLIES Blank $36.73 HCPCS - Non-Drugs A4651 Blank CALIBRATED MICROCAP TUBE Blank $15.29 HCPCS - Non-Drugs A4652 Blank MICROCAPILLARY TUBE SEALANT Blank $15.32 HCPCS - Non-Drugs A4653 Blank PD CATHETER ANCHOR BELT Blank $80.22 HCPCS - Non-Drugs A4657 Blank SYRINGE W/WO NEEDLE Blank $6.61 HCPCS - Non-Drugs A4660 Blank SPHYG/BP APP W CUFF AND STET Blank $36.76 HCPCS - Non-Drugs A4663 Blank DIALYSIS BLOOD PRESSURE CUFF Blank $70.41 HCPCS - Non-Drugs A4670 Blank AUTOMATIC BP MONITOR, DIAL Blank $180.26 HCPCS - Non-Drugs A4671 Blank DISPOSABLE CYCLER SET Blank $72.47 HCPCS - Non-Drugs A4672 Blank DRAINAGE EXT LINE, DIALYSIS Blank $9.44 HCPCS - Non-Drugs A4673 Blank EXT LINE W EASY LOCK CONNECT Blank $14.84 HCPCS - Non-Drugs A4674 Blank CHEM/ANTISEPT SOLUTION, 8OZ Blank $3.22 HCPCS - Non-Drugs A4680 Blank ACTIVATED CARBON FILTER, EA Blank $183.08 HCPCS - Non-Drugs A4690 Blank DIALYZER, EACH Blank $1,647.84 HCPCS - Non-Drugs A4706 Blank BICARBONATE CONC SOL PER GAL Blank $54.84 HCPCS - Non-Drugs A4707 Blank BICARBONATE CONC POW PER PAC Blank $19.07 HCPCS - Non-Drugs A4708 Blank ACETATE CONC SOL PER GALLON Blank $23.66 HCPCS - Non-Drugs A4709 Blank ACID CONC SOL PER GALLON Blank $72.48 HCPCS - Non-Drugs A4714 Blank TREATED WATER PER GALLON Blank $8.23 HCPCS - Non-Drugs A4719 Blank Y SET TUBING Blank $27.34 HCPCS - Non-Drugs A4720 Blank DIALYSAT SOL FLD VOL > 249CC Blank $33.54 HCPCS - Non-Drugs A4721 Blank DIALYSAT SOL FLD VOL > 999CC Blank $44.65 HCPCS - Non-Drugs A4722 Blank DIALYS SOL FLD VOL > 1999CC Blank $52.42 HCPCS - Non-Drugs A4723 Blank DIALYS SOL FLD VOL > 2999CC Blank $41.11 HCPCS - Non-Drugs A4724 Blank DIALYS SOL FLD VOL > 3999CC Blank $64.54 HCPCS - Non-Drugs A4725 Blank DIALYS SOL FLD VOL > 4999CC Blank $72.28 HCPCS - Non-Drugs A4726 Blank DIALYS SOL FLD VOL > 5999CC Blank $80.35 HCPCS - Non-Drugs A4728 Blank DIALYSATE SOLUTION, NON-DEX Blank $20.72 HCPCS - Non-Drugs A4730 Blank FISTULA CANNULATION SET, EA Blank $20.10 HCPCS - Non-Drugs A4736 Blank TOPICAL ANESTHETIC, PER GRAM Blank $47.00 HCPCS - Non-Drugs A4737 Blank INJ ANESTHETIC PER 10 ML Blank $4.67 HCPCS - Non-Drugs A4740 Blank SHUNT ACCESSORY Blank $83.53 HCPCS - Non-Drugs A4750 Blank ART OR VENOUS BLOOD TUBING Blank $34.93 HCPCS - Non-Drugs A4755 Blank COMB ART/VENOUS BLOOD TUBING Blank $59.49 HCPCS - Non-Drugs A4760 Blank DIALYSATE SOL TEST KIT, EACH Blank $191.94 HCPCS - Non-Drugs A4765 Blank DIALYSATE CONC POW PER PACK Blank $22.11 HCPCS - Non-Drugs A4766 Blank DIALYSATE CONC SOL ADD 10 ML Blank $30.62 HCPCS - Non-Drugs A4770 Blank BLOOD COLLECTION TUBE/VACUUM Blank $19.35 HCPCS - Non-Drugs A4771 Blank SERUM CLOTTING TIME TUBE Blank $12.83 HCPCS - Non-Drugs A4772 Blank BLOOD GLUCOSE TEST STRIPS Blank $73.23 HCPCS - Non-Drugs A4773 Blank OCCULT BLOOD TEST STRIPS Blank $46.45 HCPCS - Non-Drugs A4774 Blank AMMONIA TEST STRIPS Blank $16.03 HCPCS - Non-Drugs A4802 Blank PROTAMINE SULFATE PER 50 MG Blank $13.21 HCPCS - Non-Drugs A4860 Blank DISPOSABLE CATHETER TIPS Blank $9.44 HCPCS - Non-Drugs A4870 Blank PLUMB/ELEC WK HM HEMO EQUIP Blank $259.00 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A4890 Blank REPAIR/MAINT CONT HEMO EQUIP Blank $357.79 HCPCS - Non-Drugs A4911 Blank DRAIN BAG/BOTTLE Blank $18.28 HCPCS - Non-Drugs A4913 Blank MISC DIALYSIS SUPPLIES NOC Blank $180.26 HCPCS - Non-Drugs A4918 Blank VENOUS PRESSURE CLAMP Blank $8.23 HCPCS - Non-Drugs A4927 Blank NON-STERILE GLOVES Blank $15.01 HCPCS - Non-Drugs A4928 Blank SURGICAL MASK Blank $1.15 HCPCS - Non-Drugs A4929 Blank TOURNIQUET FOR DIALYSIS, EA Blank $0.37 HCPCS - Non-Drugs A4930 Blank STERILE, GLOVES PER PAIR Blank $2.67 HCPCS - Non-Drugs A4931 Blank REUSABLE ORAL THERMOMETER Blank $12.63 HCPCS - Non-Drugs A5051 Blank POUCH CLSD W BARR ATTACHED Blank $5.25 HCPCS - Non-Drugs A5052 Blank CLSD OSTOMY POUCH W/O BARR Blank $3.93 HCPCS - Non-Drugs A5053 Blank CLSD OSTOMY POUCH FACEPLATE Blank $4.36 HCPCS - Non-Drugs A5054 Blank CLSD OSTOMY POUCH W/FLANGE Blank $4.72 HCPCS - Non-Drugs A5055 Blank STOMA CAP Blank $3.70 HCPCS - Non-Drugs A5056 Blank 1 PC OST POUCH W FILTER Blank $10.39 HCPCS - Non-Drugs A5057 Blank 1 PC OST POU W BUILT-IN CONV Blank $20.13 HCPCS - Non-Drugs A5061 Blank POUCH DRAINABLE W BARRIER AT Blank $8.14 HCPCS - Non-Drugs A5062 Blank DRNBLE OSTOMY POUCH W/O BARR Blank $5.42 HCPCS - Non-Drugs A5063 Blank DRAIN OSTOMY POUCH W/FLANGE Blank $6.51 HCPCS - Non-Drugs A5071 Blank URINARY POUCH W/BARRIER Blank $13.04 HCPCS - Non-Drugs A5072 Blank URINARY POUCH W/O BARRIER Blank $7.89 HCPCS - Non-Drugs A5073 Blank URINARY POUCH ON BARR W/FLNG Blank $7.30 HCPCS - Non-Drugs A5081 Blank STOMA PLUG OR SEAL, ANY TYPE Blank $7.30 HCPCS - Non-Drugs A5082 Blank CONTINENT STOMA CATHETER Blank $22.71 HCPCS - Non-Drugs A5083 Blank STOMA ABSORPTIVE COVER Blank $1.66 HCPCS - Non-Drugs A5093 Blank OSTOMY ACCESSORY CONVEX INSE Blank $4.88 HCPCS - Non-Drugs A5102 Blank BEDSIDE DRAIN BTL W/WO TUBE Blank $45.43 HCPCS - Non-Drugs A5105 Blank URINARY SUSPENSORY Blank $78.64 HCPCS - Non-Drugs A5112 Blank URINARY LEG BAG Blank $66.38 HCPCS - Non-Drugs A5113 Blank LATEX LEG STRAP Blank $9.89 HCPCS - Non-Drugs A5114 Blank FOAM/FABRIC LEG STRAP Blank $17.81 HCPCS - Non-Drugs A5120 Blank SKIN BARRIER, WIPE OR SWAB Blank $0.61 HCPCS - Non-Drugs A5120 AU SKIN BARRIER, WIPE OR SWAB Blank $0.61 HCPCS - Non-Drugs A5120 AV SKIN BARRIER, WIPE OR SWAB Blank $0.60 HCPCS - Non-Drugs A5121 Blank SOLID SKIN BARRIER 6X6 Blank $15.04 HCPCS - Non-Drugs A5122 Blank SOLID SKIN BARRIER 8X8 Blank $25.24 HCPCS - Non-Drugs A5126 Blank DISK/FOAM PAD +OR- ADHESIVE Blank $3.18 HCPCS - Non-Drugs A5131 Blank APPLIANCE CLEANER Blank $31.41 HCPCS - Non-Drugs A5200 Blank PERCUTANEOUS CATHETER ANCHOR Blank $23.50 HCPCS - Non-Drugs A5500 Blank DIAB SHOE FOR DENSITY INSERT Blank $103.59 HCPCS - Non-Drugs A5501 Blank DIABETIC CUSTOM MOLDED SHOE Blank $346.42 HCPCS - Non-Drugs A5503 Blank DIABETIC SHOE W/ROLLER/ROCKR Blank $42.05 HCPCS - Non-Drugs A5504 Blank DIABETIC SHOE WITH WEDGE Blank $42.05 HCPCS - Non-Drugs A5505 Blank DIAB SHOE W/METATARSAL BAR Blank $42.05 HCPCS - Non-Drugs A5506 Blank DIABETIC SHOE W/OFF SET HEEL Blank $42.05 HCPCS - Non-Drugs A5507 Blank MODIFICATION DIABETIC SHOE Blank $42.05 HCPCS - Non-Drugs A5508 Blank DIABETIC DELUXE SHOE Blank $42.05 HCPCS - Non-Drugs A5510 Blank COMPRESSION FORM SHOE INSERT Blank $75.15 HCPCS - Non-Drugs A5512 Blank MULTI DEN INSERT DIRECT FORM Blank $34.03 HCPCS - Non-Drugs A5513 Blank MULTI DEN INSERT CUSTOM MOLD Blank $56.09 HCPCS - Non-Drugs A6000 Blank WOUND WARMING WOUND COVER Blank $88.38 HCPCS - Non-Drugs A6010 Blank COLLAGEN BASED WOUND FILLER Blank $62.36 HCPCS - Non-Drugs A6011 Blank COLLAGEN GEL/PASTE WOUND FIL Blank $5.68 HCPCS - Non-Drugs A6021 Blank COLLAGEN DRESSING <=16 SQ IN Blank $42.70 HCPCS - Non-Drugs A6022 Blank COLLAGEN DRSG>16<=48 SQ IN Blank $42.70 HCPCS - Non-Drugs A6023 Blank COLLAGEN DRESSING >48 SQ IN Blank $377.15 HCPCS - Non-Drugs A6024 Blank COLLAGEN DSG WOUND FILLER Blank $13.40 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A6025 Blank SILICONE GEL SHEET, EACH Blank $36.15 HCPCS - Non-Drugs A6154 Blank WOUND POUCH EACH Blank $29.31 HCPCS - Non-Drugs A6196 Blank ALGINATE DRESSING <=16 SQ IN Blank $15.71 HCPCS - Non-Drugs A6197 Blank ALGINATE DRSG >16 <=48 SQ IN Blank $33.66 HCPCS - Non-Drugs A6198 Blank ALGINATE DRESSING > 48 SQ IN Blank $90.59 HCPCS - Non-Drugs A6199 Blank ALGINATE DRSG WOUND FILLER Blank $11.62 HCPCS - Non-Drugs A6203 Blank COMPOSITE DRSG <= 16 SQ IN Blank $7.83 HCPCS - Non-Drugs A6204 Blank COMPOSITE DRSG >16<=48 SQ IN Blank $13.48 HCPCS - Non-Drugs A6205 Blank COMPOSITE DRSG > 48 SQ IN Blank $23.95 HCPCS - Non-Drugs A6206 Blank CONTACT LAYER <= 16 SQ IN Blank $7.59 HCPCS - Non-Drugs A6207 Blank CONTACT LAYER >16<= 48 SQ IN Blank $15.67 HCPCS - Non-Drugs A6208 Blank CONTACT LAYER > 48 SQ IN Blank $77.42 HCPCS - Non-Drugs A6209 Blank FOAM DRSG <=16 SQ IN W/O BDR Blank $15.94 HCPCS - Non-Drugs A6210 Blank FOAM DRG >16<=48 SQ IN W/O B Blank $40.55 HCPCS - Non-Drugs A6211 Blank FOAM DRG > 48 SQ IN W/O BRDR Blank $59.22 HCPCS - Non-Drugs A6212 Blank FOAM DRG <=16 SQ IN W/BORDER Blank $20.36 HCPCS - Non-Drugs A6213 Blank FOAM DRG >16<=48 SQ IN W/BDR Blank $31.87 HCPCS - Non-Drugs A6214 Blank FOAM DRG > 48 SQ IN W/BORDER Blank $43.65 HCPCS - Non-Drugs A6215 Blank FOAM DRESSING WOUND FILLER Blank $6.87 HCPCS - Non-Drugs A6216 Blank NON-STERILE GAUZE<=16 SQ IN Blank $0.12 HCPCS - Non-Drugs A6217 Blank NON-STERILE GAUZE>16<=48 SQ Blank $0.32 HCPCS - Non-Drugs A6218 Blank NON-STERILE GAUZE > 48 SQ IN Blank $0.94 HCPCS - Non-Drugs A6219 Blank GAUZE <= 16 SQ IN W/BORDER Blank $2.51 HCPCS - Non-Drugs A6220 Blank GAUZE >16 <=48 SQ IN W/BORDR Blank $6.28 HCPCS - Non-Drugs A6221 Blank GAUZE > 48 SQ IN W/BORDER Blank $16.61 HCPCS - Non-Drugs A6222 Blank GAUZE <=16 IN NO W/SAL W/O B Blank $5.38 HCPCS - Non-Drugs A6223 Blank GAUZE >16<=48 NO W/SAL W/O B Blank $5.96 HCPCS - Non-Drugs A6224 Blank GAUZE > 48 IN NO W/SAL W/O B Blank $8.31 HCPCS - Non-Drugs A6228 Blank GAUZE <= 16 SQ IN WATER/SAL Blank $3.83 HCPCS - Non-Drugs A6229 Blank GAUZE >16<=48 SQ IN WATR/SAL Blank $8.31 HCPCS - Non-Drugs A6230 Blank GAUZE > 48 SQ IN WATER/SALNE Blank $5.45 HCPCS - Non-Drugs A6231 Blank HYDROGEL DSG<=16 SQ IN Blank $10.42 HCPCS - Non-Drugs A6232 Blank HYDROGEL DSG>16<=48 SQ IN Blank $14.73 HCPCS - Non-Drugs A6233 Blank HYDROGEL DRESSING >48 SQ IN Blank $39.06 HCPCS - Non-Drugs A6234 Blank HYDROCOLLD DRG <=16 W/O BDR Blank $14.09 HCPCS - Non-Drugs A6235 Blank HYDROCOLLD DRG >16<=48 W/O B Blank $34.40 HCPCS - Non-Drugs A6236 Blank HYDROCOLLD DRG > 48 IN W/O B Blank $55.03 HCPCS - Non-Drugs A6237 Blank HYDROCOLLD DRG <=16 IN W/BDR Blank $16.81 HCPCS - Non-Drugs A6238 Blank HYDROCOLLD DRG >16<=48 W/BDR Blank $46.23 HCPCS - Non-Drugs A6239 Blank HYDROCOLLD DRG > 48 IN W/BDR Blank $62.54 HCPCS - Non-Drugs A6240 Blank HYDROCOLLD DRG FILLER PASTE Blank $25.37 HCPCS - Non-Drugs A6241 Blank HYDROCOLLOID DRG FILLER DRY Blank $6.25 HCPCS - Non-Drugs A6242 Blank HYDROGEL DRG <=16 IN W/O BDR Blank $13.15 HCPCS - Non-Drugs A6243 Blank HYDROGEL DRG >16<=48 W/O BDR Blank $25.53 HCPCS - Non-Drugs A6244 Blank HYDROGEL DRG >48 IN W/O BDR Blank $78.80 HCPCS - Non-Drugs A6245 Blank HYDROGEL DRG <= 16 IN W/BDR Blank $15.53 HCPCS - Non-Drugs A6246 Blank HYDROGEL DRG >16<=48 IN W/B Blank $20.80 HCPCS - Non-Drugs A6247 Blank HYDROGEL DRG > 48 SQ IN W/B Blank $48.16 HCPCS - Non-Drugs A6248 Blank HYDROGEL DRSG GEL FILLER Blank $33.28 HCPCS - Non-Drugs A6250 Blank SKIN SEAL PROTECT MOISTURIZR Blank $13.01 HCPCS - Non-Drugs A6251 Blank ABSORPT DRG <=16 SQ IN W/O B Blank $5.11 HCPCS - Non-Drugs A6252 Blank ABSORPT DRG >16 <=48 W/O BDR Blank $7.62 HCPCS - Non-Drugs A6253 Blank ABSORPT DRG > 48 SQ IN W/O B Blank $13.70 HCPCS - Non-Drugs A6254 Blank ABSORPT DRG <=16 SQ IN W/BDR Blank $3.17 HCPCS - Non-Drugs A6255 Blank ABSORPT DRG >16<=48 IN W/BDR Blank $7.17 HCPCS - Non-Drugs A6256 Blank ABSORPT DRG > 48 SQ IN W/BDR Blank $16.35 HCPCS - Non-Drugs A6257 Blank TRANSPARENT FILM <= 16 SQ IN Blank $4.08 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A6258 Blank TRANSPARENT FILM >16<=48 IN Blank $9.69 HCPCS - Non-Drugs A6259 Blank TRANSPARENT FILM > 48 SQ IN Blank $22.79 HCPCS - Non-Drugs A6260 Blank WOUND CLEANSER ANY TYPE/SIZE Blank $1.88 HCPCS - Non-Drugs A6261 Blank WOUND FILLER GEL/PASTE /OZ Blank $6.88 HCPCS - Non-Drugs A6262 Blank WOUND FILLER DRY FORM / GRAM Blank $1.88 HCPCS - Non-Drugs A6266 Blank IMPREG GAUZE NO H20/SAL/YARD Blank $4.97 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 $1.10 HCPCS - Non-Drugs A6404 Blank STERILE GAUZE > 48 SQ IN Blank $0.94 HCPCS - Non-Drugs A6407 Blank PACKING STRIPS, NON-IMPREG Blank $4.88 HCPCS - Non-Drugs A6410 Blank STERILE EYE PAD Blank $1.00 HCPCS - Non-Drugs A6411 Blank NON-STERILE EYE PAD Blank $1.00 HCPCS - Non-Drugs A6412 Blank OCCLUSIVE EYE PATCH Blank $0.94 HCPCS - Non-Drugs A6413 Blank ADHESIVE BANDAGE, FIRST-AID Blank $2.07 HCPCS - Non-Drugs A6441 Blank PAD BAND W>=3 <5/YD Blank $1.77 HCPCS - Non-Drugs A6442 Blank CONFORM BAND N/S W<3/YD Blank $0.42 HCPCS - Non-Drugs A6443 Blank CONFORM BAND N/S W>=3<5/YD Blank $0.72 HCPCS - Non-Drugs A6444 Blank CONFORM BAND N/S W>=5/YD Blank $1.45 HCPCS - Non-Drugs A6445 Blank CONFORM BAND S W <3/YD Blank $0.84 HCPCS - Non-Drugs A6446 Blank CONFORM BAND S W>=3 <5/YD Blank $1.05 HCPCS - Non-Drugs A6447 Blank CONFORM BAND S W >=5/YD Blank $1.77 HCPCS - Non-Drugs A6448 Blank LT COMPRES BAND <3/YD Blank $3.05 HCPCS - Non-Drugs A6449 Blank LT COMPRES BAND >=3 <5/YD Blank $4.63 HCPCS - Non-Drugs A6450 Blank LT COMPRES BAND >=5/YD Blank $4.63 HCPCS - Non-Drugs A6451 Blank MOD COMPRES BAND W>=3<5/YD Blank $4.63 HCPCS - Non-Drugs A6452 Blank HIGH COMPRES BAND W>=3<5YD Blank $12.85 HCPCS - Non-Drugs A6453 Blank SELF-ADHER BAND W <3/YD Blank $1.61 HCPCS - Non-Drugs A6454 Blank SELF-ADHER BAND W>=3 <5/YD Blank $2.03 HCPCS - Non-Drugs A6455 Blank SELF-ADHER BAND >=5/YD Blank $3.69 HCPCS - Non-Drugs A6456 Blank ZINC PASTE BAND W >=3<5/YD Blank $3.34 HCPCS - Non-Drugs A6457 Blank TUBULAR DRESSING Blank $3.00 HCPCS - Non-Drugs A6504 Blank CMPRSBURNGARMENT GLOVE-WRIST Blank $619.92 HCPCS - Non-Drugs A6505 Blank CMPRSBURNGARMENT GLOVE-ELBOW Blank $400.83 HCPCS - Non-Drugs A6506 Blank CMPRSBURNGRMNT GLOVE-AXILLA Blank $345.00 HCPCS - Non-Drugs A6507 Blank CMPRS BURNGARMENT FOOT-KNEE Blank $317.73 HCPCS - Non-Drugs A6508 Blank CMPRS BURNGARMENT FOOT-THIGH Blank $712.20 HCPCS - Non-Drugs A6509 Blank COMPRES BURN GARMENT JACKET Blank $804.08 HCPCS - Non-Drugs A6510 Blank COMPRES BURN GARMENT LEOTARD Blank $345.42 HCPCS - Non-Drugs A6511 Blank COMPRES BURN GARMENT PANTY Blank $745.83 HCPCS - Non-Drugs A6512 Blank COMPRES BURN GARMENT, NOC Blank $333.72 HCPCS - Non-Drugs A6530 Blank COMPRESSION STOCKING BK18-30 Blank $58.92 HCPCS - Non-Drugs A6531 Blank COMPRESSION STOCKING BK30-40 Blank $86.64 HCPCS - Non-Drugs A6531 AW COMPRESSION STOCKING BK30-40 Blank $86.64 HCPCS - Non-Drugs A6532 Blank COMPRESSION STOCKING BK40-50 Blank $121.60 HCPCS - Non-Drugs A6532 AW COMPRESSION STOCKING BK40-50 Blank $121.60 HCPCS - Non-Drugs A6533 Blank GC STOCKING THIGHLNGTH 18-30 Blank $82.64 HCPCS - Non-Drugs A6534 Blank GC STOCKING THIGHLNGTH 30-40 Blank $112.79 HCPCS - Non-Drugs A6535 Blank GC STOCKING THIGHLNGTH 40-50 Blank $142.94 HCPCS - Non-Drugs A6536 Blank GC STOCKING FULL LNGTH 18-30 Blank $129.25 HCPCS - Non-Drugs A6537 Blank GC STOCKING FULL LNGTH 30-40 Blank $142.98 HCPCS - Non-Drugs A6538 Blank GC STOCKING FULL LNGTH 40-50 Blank $191.68 HCPCS - Non-Drugs A6539 Blank GC STOCKING WAISTLNGTH 18-30 Blank $205.12 HCPCS - Non-Drugs A6540 Blank GC STOCKING WAISTLNGTH 30-40 Blank $208.17 HCPCS - Non-Drugs A6541 Blank GC STOCKING WAISTLNGTH 40-50 Blank $216.97 HCPCS - Non-Drugs A6544 Blank GC STOCKING GARTER BELT Blank $82.42 HCPCS - Non-Drugs A6545 Blank GRAD COMP NON-ELASTIC BK Blank $169.46 HCPCS - Non-Drugs A6545 AW GRAD COMP NON-ELASTIC BK Blank $169.46 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A6549 Blank G COMPRESSION STOCKING Blank $254.18 HCPCS - Non-Drugs A6550 Blank NEG PRES WOUND THER DRSG SET Blank $121.97 HCPCS - Non-Drugs A7000 Blank DISPOSABLE CANISTER FOR PUMP Blank $90.95 HCPCS - Non-Drugs A7000 NU DISPOSABLE CANISTER FOR PUMP Blank $90.95 HCPCS - Non-Drugs A7001 Blank NONDISPOSABLE PUMP CANISTER Blank $140.10 HCPCS - Non-Drugs A7001 NU NONDISPOSABLE PUMP CANISTER Blank $140.10 HCPCS - Non-Drugs A7002 Blank TUBING USED W SUCTION PUMP Blank $38.69 HCPCS - Non-Drugs A7002 NU TUBING USED W SUCTION PUMP Blank $38.69 HCPCS - Non-Drugs A7003 Blank NEBULIZER ADMINISTRATION SET Blank $14.66 HCPCS - Non-Drugs A7003 NU NEBULIZER ADMINISTRATION SET Blank $14.66 HCPCS - Non-Drugs A7004 Blank DISPOSABLE NEBULIZER SML VOL Blank $12.19 HCPCS - Non-Drugs A7004 NU DISPOSABLE NEBULIZER SML VOL Blank $12.19 HCPCS - Non-Drugs A7005 Blank NONDISPOSABLE NEBULIZER SET Blank $96.98 HCPCS - Non-Drugs A7005 NU NONDISPOSABLE NEBULIZER SET Blank $96.98 HCPCS - Non-Drugs A7006 Blank FILTERED NEBULIZER ADMIN SET Blank $76.25 HCPCS - Non-Drugs A7006 NU FILTERED NEBULIZER ADMIN SET Blank $76.25 HCPCS - Non-Drugs A7007 Blank LG VOL NEBULIZER DISPOSABLE Blank $30.43 HCPCS - Non-Drugs A7007 NU LG VOL NEBULIZER DISPOSABLE Blank $30.43 HCPCS - Non-Drugs A7008 Blank DISPOSABLE NEBULIZER PREFILL Blank $97.31 HCPCS - Non-Drugs A7008 NU DISPOSABLE NEBULIZER PREFILL Blank $97.31 HCPCS - Non-Drugs A7009 Blank NEBULIZER RESERVOIR BOTTLE Blank $160.14 HCPCS - Non-Drugs A7009 NU NEBULIZER RESERVOIR BOTTLE Blank $160.14 HCPCS - Non-Drugs A7010 Blank DISPOSABLE CORRUGATED TUBING Blank $103.85 HCPCS - Non-Drugs A7010 NU DISPOSABLE CORRUGATED TUBING Blank $103.85 HCPCS - Non-Drugs A7012 Blank NEBULIZER WATER COLLEC DEVIC Blank $26.95 HCPCS - Non-Drugs A7012 NU NEBULIZER WATER COLLEC DEVIC Blank $26.95 HCPCS - Non-Drugs A7013 Blank DISPOSABLE COMPRESSOR FILTER Blank $5.38 HCPCS - Non-Drugs A7013 NU DISPOSABLE COMPRESSOR FILTER Blank $5.38 HCPCS - Non-Drugs A7014 Blank COMPRESSOR NONDISPOS FILTER Blank $31.15 HCPCS - Non-Drugs A7014 NU COMPRESSOR NONDISPOS FILTER Blank $31.15 HCPCS - Non-Drugs A7015 Blank AEROSOL MASK USED W NEBULIZE Blank $12.04 HCPCS - Non-Drugs A7015 NU AEROSOL MASK USED W NEBULIZE Blank $12.04 HCPCS - Non-Drugs A7016 Blank NEBULIZER DOME & MOUTHPIECE Blank $85.65 HCPCS - Non-Drugs A7016 NU NEBULIZER DOME & MOUTHPIECE Blank $85.65 HCPCS - Non-Drugs A7017 Blank NEBULIZER NOT USED W OXYGEN Blank $289.01 HCPCS - Non-Drugs A7017 NU NEBULIZER NOT USED W OXYGEN Blank $289.01 HCPCS - Non-Drugs A7017 RR NEBULIZER NOT USED W OXYGEN Blank $97.08 HCPCS - Non-Drugs A7017 UE NEBULIZER NOT USED W OXYGEN Blank $235.69 HCPCS - Non-Drugs A7018 Blank WATER DISTILLED W/NEBULIZER Blank $3.13 HCPCS - Non-Drugs A7020 Blank INTERFACE, COUGH STIM DEVICE Blank $105.25 HCPCS - Non-Drugs A7020 NU INTERFACE, COUGH STIM DEVICE Blank $105.25 HCPCS - Non-Drugs A7020 RR INTERFACE, COUGH STIM DEVICE Blank $10.75 HCPCS - Non-Drugs A7020 UE INTERFACE, COUGH STIM DEVICE Blank $88.34 HCPCS - Non-Drugs A7025 Blank REPLACE CHEST COMPRESS VEST Blank $1,221.58 HCPCS - Non-Drugs A7025 NU REPLACE CHEST COMPRESS VEST Blank $1,221.58 HCPCS - Non-Drugs A7025 RR REPLACE CHEST COMPRESS VEST Blank $165.86 HCPCS - Non-Drugs A7026 Blank REPLACE CHST CMPRSS SYS HOSE Blank $135.29 HCPCS - Non-Drugs A7026 NU REPLACE CHST CMPRSS SYS HOSE Blank $135.29 HCPCS - Non-Drugs A7027 Blank COMBINATION ORAL/NASAL MASK Blank $296.73 HCPCS - Non-Drugs A7027 NU COMBINATION ORAL/NASAL MASK Blank $296.73 HCPCS - Non-Drugs A7028 Blank REPL ORAL CUSHION COMBO MASK Blank $137.66 HCPCS - Non-Drugs A7028 NU REPL ORAL CUSHION COMBO MASK Blank $137.66 HCPCS - Non-Drugs A7029 Blank REPL NASAL PILLOW COMB MASK Blank $104.20 HCPCS - Non-Drugs A7029 NU REPL NASAL PILLOW COMB MASK Blank $104.20 HCPCS - Non-Drugs A7030 Blank CPAP FULL FACE MASK Blank $239.45 HCPCS - Non-Drugs A7030 NU CPAP FULL FACE MASK Blank $239.45 HCPCS - Non-Drugs A7031 Blank REPLACEMENT FACEMASK INTERFA Blank $138.12 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A7031 NU REPLACEMENT FACEMASK INTERFA Blank $138.12 HCPCS - Non-Drugs A7032 Blank REPLACEMENT NASAL CUSHION Blank $110.62 HCPCS - Non-Drugs A7032 NU REPLACEMENT NASAL CUSHION Blank $110.62 HCPCS - Non-Drugs A7033 Blank REPLACEMENT NASAL PILLOWS Blank $104.39 HCPCS - Non-Drugs A7033 NU REPLACEMENT NASAL PILLOWS Blank $104.39 HCPCS - Non-Drugs A7034 Blank NASAL APPLICATION DEVICE Blank $178.28 HCPCS - Non-Drugs A7034 NU NASAL APPLICATION DEVICE Blank $178.28 HCPCS - Non-Drugs A7035 Blank POS AIRWAY PRESS HEADGEAR Blank $109.68 HCPCS - Non-Drugs A7035 NU POS AIRWAY PRESS HEADGEAR Blank $109.68 HCPCS - Non-Drugs A7036 Blank POS AIRWAY PRESS CHINSTRAP Blank $95.36 HCPCS - Non-Drugs A7036 NU POS AIRWAY PRESS CHINSTRAP Blank $95.36 HCPCS - Non-Drugs A7037 Blank POS AIRWAY PRESSURE TUBING Blank $97.84 HCPCS - Non-Drugs A7037 NU POS AIRWAY PRESSURE TUBING Blank $97.84 HCPCS - Non-Drugs A7038 Blank POS AIRWAY PRESSURE FILTER Blank $20.24 HCPCS - Non-Drugs A7038 NU POS AIRWAY PRESSURE FILTER Blank $20.24 HCPCS - Non-Drugs A7039 Blank FILTER, NON DISPOSABLE W PAP Blank $62.80 HCPCS - Non-Drugs A7039 NU FILTER, NON DISPOSABLE W PAP Blank $62.80 HCPCS - Non-Drugs A7040 Blank ONE WAY CHEST DRAIN VALVE Blank $80.24 HCPCS - Non-Drugs A7041 Blank WATER SEAL DRAIN CONTAINER Blank $149.76 HCPCS - Non-Drugs A7044 Blank PAP ORAL INTERFACE Blank $230.43 HCPCS - Non-Drugs A7044 NU PAP ORAL INTERFACE Blank $230.43 HCPCS - Non-Drugs A7045 Blank REPL EXHALATION PORT FOR PAP Blank $98.15 HCPCS - Non-Drugs A7045 NU REPL EXHALATION PORT FOR PAP Blank $98.15 HCPCS - Non-Drugs A7045 RR REPL EXHALATION PORT FOR PAP Blank $11.76 HCPCS - Non-Drugs A7045 UE REPL EXHALATION PORT FOR PAP Blank $92.55 HCPCS - Non-Drugs A7046 Blank REPL WATER CHAMBER, PAP DEV Blank $100.32 HCPCS - Non-Drugs A7046 NU REPL WATER CHAMBER, PAP DEV Blank $100.32 HCPCS - Non-Drugs A7047 Blank RESP SUCTION ORAL INTERFACE Blank $326.20 HCPCS - Non-Drugs A7047 NU RESP SUCTION ORAL INTERFACE Blank $326.20 HCPCS - Non-Drugs A7048 Blank VACUUM DRAIN BOTTLE/TUBE KIT Blank $83.95 HCPCS - Non-Drugs A7501 Blank TRACHEOSTOMA VALVE W DIAPHRA Blank $208.65 HCPCS - Non-Drugs A7502 Blank REPLACEMENT DIAPHRAGM/FPLATE Blank $99.81 HCPCS - Non-Drugs A7503 Blank HMES FILTER HOLDER OR CAP Blank $23.58 HCPCS - Non-Drugs A7504 Blank TRACHEOSTOMA HMES FILTER Blank $1.77 HCPCS - Non-Drugs A7505 Blank HMES OR TRACH VALVE HOUSING Blank $10.43 HCPCS - Non-Drugs A7506 Blank HMES/TRACHVALVE ADHESIVEDISK Blank $0.86 HCPCS - Non-Drugs A7507 Blank INTEGRATED FILTER & HOLDER Blank $6.09 HCPCS - Non-Drugs A7508 Blank HOUSING & INTEGRATED ADHESIV Blank $6.83 HCPCS - Non-Drugs A7509 Blank HEAT & MOISTURE EXCHANGE SYS Blank $3.73 HCPCS - Non-Drugs A7520 Blank TRACH/LARYN TUBE NON-CUFFED Blank $73.06 HCPCS - Non-Drugs A7521 Blank TRACH/LARYN TUBE CUFFED Blank $72.20 HCPCS - Non-Drugs A7522 Blank TRACH/LARYN TUBE STAINLESS Blank $68.62 HCPCS - Non-Drugs A7523 Blank TRACHEOSTOMY SHOWER PROTECT Blank $33.14 HCPCS - Non-Drugs A7524 Blank TRACHEOSTOMA STENT/STUD/BTTN Blank $130.36 HCPCS - Non-Drugs A7525 Blank TRACHEOSTOMY MASK Blank $3.31 HCPCS - Non-Drugs A7526 Blank TRACHEOSTOMY TUBE COLLAR Blank $5.43 HCPCS - Non-Drugs A7527 Blank TRACH/LARYN TUBE PLUG/STOP Blank $8.25 HCPCS - Non-Drugs A8000 Blank SOFT PROTECT HELMET PREFAB Blank $393.43 HCPCS - Non-Drugs A8000 NU SOFT PROTECT HELMET PREFAB Blank $393.43 HCPCS - Non-Drugs A8000 RR SOFT PROTECT HELMET PREFAB Blank $107.51 HCPCS - Non-Drugs A8000 UE SOFT PROTECT HELMET PREFAB Blank $314.05 HCPCS - Non-Drugs A8001 Blank HARD PROTECT HELMET PREFAB Blank $393.43 HCPCS - Non-Drugs A8001 NU HARD PROTECT HELMET PREFAB Blank $393.43 HCPCS - Non-Drugs A8001 RR HARD PROTECT HELMET PREFAB Blank $107.51 HCPCS - Non-Drugs A8001 UE HARD PROTECT HELMET PREFAB Blank $314.05 HCPCS - Non-Drugs A8002 Blank SOFT PROTECT HELMET CUSTOM Blank $524.72 HCPCS - Non-Drugs A8002 NU SOFT PROTECT HELMET CUSTOM Blank $524.72 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A8002 RR SOFT PROTECT HELMET CUSTOM Blank $55.32 HCPCS - Non-Drugs A8002 UE SOFT PROTECT HELMET CUSTOM Blank $393.52 HCPCS - Non-Drugs A8003 Blank HARD PROTECT HELMET CUSTOM Blank $548.09 HCPCS - Non-Drugs A8003 NU HARD PROTECT HELMET CUSTOM Blank $548.09 HCPCS - Non-Drugs A8003 RR HARD PROTECT HELMET CUSTOM Blank $58.30 HCPCS - Non-Drugs A8003 UE HARD PROTECT HELMET CUSTOM Blank $412.06 HCPCS - Non-Drugs A8004 Blank REPL SOFT INTERFACE, HELMET Blank $65.47 HCPCS - Non-Drugs A8004 NU REPL SOFT INTERFACE, HELMET Blank $65.47 HCPCS - Non-Drugs A8004 RR REPL SOFT INTERFACE, HELMET Blank $6.97 HCPCS - Non-Drugs A8004 UE REPL SOFT INTERFACE, HELMET Blank $49.22 HCPCS - Non-Drugs A9150 Blank MISC/EXPER NON-PRESCRIPT DRU a $17.96 HCPCS - Drugs A9152 Blank SINGLE VITAMIN NOS a $27.71 HCPCS - Drugs A9153 Blank MULTI-VITAMIN NOS a $27.71 HCPCS - Drugs A9155 Blank ARTIFICIAL SALIVA Blank $8.59 HCPCS - Drugs A9180 Blank LICE TREATMENT, TOPICAL Blank $196.98 HCPCS - Drugs A9270 Blank NON-COVERED ITEM OR SERVICE Blank $137.74 HCPCS - Non-Drugs A9272 Blank DISP WOUND SUCT, DRSG/ACCESS Blank $688.11 HCPCS - Non-Drugs A9273 Blank HOT/COLD H2OBOT/CAP/COL/WRAP Blank $27.71 HCPCS - Non-Drugs A9274 Blank EXT AMB INSULIN DELIVERY SYS Blank $45.76 HCPCS - Non-Drugs A9275 Blank DISP HOME GLUCOSE MONITOR Blank $39.04 HCPCS - Non-Drugs A9276 Blank DISPOSABLE SENSOR, CGM SYS Blank $27.02 HCPCS - Non-Drugs A9277 Blank EXTERNAL TRANSMITTER, CGM Blank $1,949.26 HCPCS - Non-Drugs A9278 Blank EXTERNAL RECEIVER, CGM SYS Blank $1,821.71 HCPCS - Non-Drugs A9279 Blank MONITORING FEATURE/DEVICENOC Blank $84.45 HCPCS - Non-Drugs A9280 Blank ALERT DEVICE, NOC Blank $317.41 HCPCS - Non-Drugs A9281 Blank REACHING/GRABBING DEVICE Blank $55.75 HCPCS - Non-Drugs A9282 Blank WIG ANY TYPE Blank $835.96 HCPCS - Non-Drugs A9283 Blank FOOT PRESS OFF LOAD SUPP DEV Blank $67.61 HCPCS - Non-Drugs A9284 Blank NON-ELECTRONIC SPIROMETER Blank $38.27 HCPCS - Non-Drugs A9300 Blank EXERCISE EQUIPMENT Blank $14.72 HCPCS - Non-Drugs A9500 Blank TC99M SESTAMIBI a $319.58 HCPCS - Non-Drugs A9501 Blank TECHNETIUM TC-99M TEBOROXIME Blank $474.67 HCPCS - Non-Drugs A9502 Blank TC99M TETROFOSMIN a $299.96 HCPCS - Non-Drugs A9503 Blank TC99M MEDRONATE a $88.02 HCPCS - Non-Drugs A9504 Blank TC99M APCITIDE Blank $339.32 HCPCS - Non-Drugs A9505 Blank TL201 THALLIUM a $264.10 HCPCS - Non-Drugs A9507 Blank IN111 CAPROMAB a $4,452.24 HCPCS - Non-Drugs A9508 Blank I131 IODOBENGUATE, DX a $51.11 HCPCS - Non-Drugs A9509 Blank IODINE I-123 SOD IODIDE MIL a $374.46 HCPCS - Non-Drugs A9510 Blank TC99M DISOFENIN a $140.16 HCPCS - Non-Drugs A9512 Blank TC99M PERTECHNETATE a $17.06 HCPCS - Non-Drugs A9515 Blank CHOLINE C-11 a $10,301.94 HCPCS - Non-Drugs A9516 Blank IODINE I-123 SOD IODIDE MIC a $212.51 HCPCS - Non-Drugs A9517 Blank I131 IODIDE CAP, RX a $150.52 HCPCS - Non-Drugs A9520 Blank TC99 TILMANOCEPT DIAG 0.5MCI a $887.71 HCPCS - Non-Drugs A9521 Blank TC99M EXAMETAZIME a $1,612.65 HCPCS - Non-Drugs A9524 Blank I131 SERUM ALBUMIN, DX a $261.06 HCPCS - Non-Drugs A9526 Blank NITROGEN N-13 AMMONIA a $1,217.22 HCPCS - Non-Drugs A9527 Blank IODINE I-125 SODIUM IODIDE a $158.22 HCPCS - Non-Drugs A9528 Blank IODINE I-131 IODIDE CAP, DX a $446.31 HCPCS - Non-Drugs A9529 Blank I131 IODIDE SOL, DX a $80.69 HCPCS - Non-Drugs A9530 Blank I131 IODIDE SOL, RX a $44.54 HCPCS - Non-Drugs A9531 Blank I131 MAX 100UCI a $18.66 HCPCS - Non-Drugs A9532 Blank I125 SERUM ALBUMIN, DX Blank $967.38 HCPCS - Non-Drugs A9536 Blank TC99M DEPREOTIDE Blank $870.21 HCPCS - Non-Drugs A9537 Blank TC99M MEBROFENIN a $135.44 HCPCS - Non-Drugs A9538 Blank TC99M PYROPHOSPHATE a $114.77 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

A9539 Blank TC99M PENTETATE a $76.52 HCPCS - Non-Drugs A9540 Blank TC99M MAA a $39.79 HCPCS - Non-Drugs A9541 Blank TC99M SULFUR COLLOID a $176.53 HCPCS - Non-Drugs A9546 Blank CO57/58 Blank $32.79 HCPCS - Non-Drugs A9547 Blank IN111 OXYQUINOLINE a $1,394.90 HCPCS - Non-Drugs A9548 Blank IN111 PENTETATE a $836.94 HCPCS - Non-Drugs A9550 Blank TC99M GLUCEPTATE Blank $53.79 HCPCS - Non-Drugs A9551 Blank TC99M SUCCIMER a $443.02 HCPCS - Non-Drugs A9552 Blank F18 FDG a $840.04 HCPCS - Non-Drugs A9554 Blank I125 IOTHALAMATE, DX a $1,492.09 HCPCS - Non-Drugs A9555 Blank RB82 RUBIDIUM a $1,065.26 HCPCS - Non-Drugs A9556 Blank GA67 GALLIUM a $104.56 HCPCS - Non-Drugs A9557 Blank TC99M BICISATE a $395.55 HCPCS - Non-Drugs A9558 Blank XE133 XENON 10MCI a $134.73 HCPCS - Non-Drugs A9560 Blank TC99M LABELED RBC a $266.32 HCPCS - Non-Drugs A9561 Blank TC99M OXIDRONATE a $83.15 HCPCS - Non-Drugs A9562 Blank TC99M MERTIATIDE a $589.08 HCPCS - Non-Drugs A9564 Blank P32 CHROMIC PHOSPHATE a $714.19 HCPCS - Non-Drugs A9567 Blank TECHNETIUM TC-99M AEROSOL a $64.27 HCPCS - Non-Drugs A9569 Blank TECHNETIUM TC-99M AUTO WBC a $3.73 HCPCS - Non-Drugs A9570 Blank INDIUM IN-111 AUTO WBC a $366.53 HCPCS - Non-Drugs A9571 Blank INDIUM IN-111 AUTO PLATELET Blank $16.39 HCPCS - Non-Drugs A9572 Blank INDIUM IN-111 PENTETREOTIDE a $5,838.29 HCPCS - Non-Drugs A9575 Blank INJ GADOTERATE MEGLUMI 0.1ML a $3.30 HCPCS - Non-Drugs A9576 Blank INJ PROHANCE MULTIPACK a $7.61 HCPCS - Non-Drugs A9577 Blank INJ MULTIHANCE a $10.79 HCPCS - Non-Drugs A9578 Blank INJ MULTIHANCE MULTIPACK a $10.65 HCPCS - Non-Drugs A9579 Blank GAD-BASE MR CONTRAST NOS,1ML a $8.92 HCPCS - Non-Drugs A9580 Blank SODIUM FLUORIDE F-18 a $760.90 HCPCS - Non-Drugs A9581 Blank GADOXETATE DISODIUM INJ Blank $28.13 HCPCS - Non-Drugs A9582 Blank IODINE I-123 IOBENGUANE a $7,932.39 HCPCS - Non-Drugs A9583 Blank GADOFOSVESET TRISODIUM INJ a $48.36 HCPCS - Non-Drugs A9584 Blank IODINE I-123 IOFLUPANE a $3,636.11 HCPCS - Non-Drugs A9585 Blank GADOBUTROL INJECTION a $1.67 HCPCS - Non-Drugs A9587 Blank GALLIUM GA-68 a $180.00 HCPCS - Non-Drugs A9588 Blank FLUCICLOVINE F-18 a $1,050.61 HCPCS - Non-Drugs A9597 Blank PET, DX, FOR TUMOR ID, NOC Blank $35.54 HCPCS - Non-Drugs A9598 Blank PET DX FOR NON-TUMOR ID, NOC Blank $35.54 HCPCS - Non-Drugs A9600 Blank SR89 STRONTIUM a $1,805.01 HCPCS - Non-Drugs A9604 Blank SM 153 LEXIDRONAM a $14,585.52 HCPCS - Non-Drugs A9606 Blank RADIUM RA223 DICHLORIDE THER a $337.23 HCPCS - Non-Drugs A9698 Blank NON-RAD CONTRAST MATERIALNOC a $35.11 HCPCS - Non-Drugs A9699 Blank RADIOPHARM RX AGENT NOC a $35.11 HCPCS - Non-Drugs A9700 Blank ECHOCARDIOGRAPHY CONTRAST a $461.43 HCPCS - Non-Drugs A9900 Blank SUPPLY/ACCESSORY/SERVICE Blank $38.64 HCPCS - Non-Drugs B4034 Blank ENTER FEED SUPKIT SYR BY DAY Blank $7.47 HCPCS - Non-Drugs B4035 Blank ENTERAL FEED SUPP PUMP PER D Blank $12.53 HCPCS - Non-Drugs B4036 Blank ENTERAL FEED SUP KIT GRAV BY Blank $10.03 HCPCS - Non-Drugs B4081 Blank ENTERAL NG TUBING W/ STYLET Blank $35.71 HCPCS - Non-Drugs B4082 Blank ENTERAL NG TUBING W/O STYLET Blank $25.67 HCPCS - Non-Drugs B4083 Blank ENTERAL STOMACH TUBE LEVINE Blank $4.26 HCPCS - Non-Drugs B4087 Blank GASTRO/JEJUNO TUBE, STD Blank $61.98 HCPCS - Non-Drugs B4088 Blank GASTRO/JEJUNO TUBE, LOW-PRO Blank $61.98 HCPCS - Non-Drugs B4100 Blank FOOD THICKENER ORAL a $0.99 HCPCS - Non-Drugs B4102 Blank EF ADULT FLUIDS AND ELECTRO a $4.10 HCPCS - Non-Drugs B4103 Blank EF PED FLUID AND ELECTROLYTE a $14.03 HCPCS - Non-Drugs B4104 Blank ADDITIVE FOR ENTERAL FORMULA a $10.87 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

B4149 Blank EF BLENDERIZED FOODS a $2.82 HCPCS - Non-Drugs B4150 Blank EF COMPLET W/INTACT NUTRIENT a $1.36 HCPCS - Non-Drugs B4152 Blank EF CALORIE DENSE>/=1.5KCAL a $1.13 HCPCS - Non-Drugs B4153 Blank EF HYDROLYZED/AMINO ACIDS a $3.25 HCPCS - Non-Drugs B4154 Blank EF SPEC METABOLIC NONINHERIT a $2.00 HCPCS - Non-Drugs B4155 Blank EF INCOMPLETE/MODULAR a $2.16 HCPCS - Non-Drugs B4157 Blank EF SPECIAL METABOLIC INHERIT a $10.97 HCPCS - Non-Drugs B4158 Blank EF PED COMPLETE INTACT NUT a $4.84 HCPCS - Non-Drugs B4159 Blank EF PED COMPLETE SOY BASED a $5.38 HCPCS - Non-Drugs B4160 Blank EF PED CALORIC DENSE>/=0.7KC a $4.52 HCPCS - Non-Drugs B4161 Blank EF PED HYDROLYZED/AMINO ACID a $10.10 HCPCS - Non-Drugs B4162 Blank EF PED SPECMETABOLIC INHERIT a $16.70 HCPCS - Non-Drugs B4164 Blank PARENTERAL 50% DEXTROSE SOLU a $44.91 HCPCS - Non-Drugs B4168 Blank PARENTERAL SOL AMINO ACID 3. a $65.26 HCPCS - Non-Drugs B4172 Blank PARENTERAL SOL AMINO ACID 5. a $114.85 HCPCS - Non-Drugs B4176 Blank PARENTERAL SOL AMINO ACID 7- a $125.81 HCPCS - Non-Drugs B4178 Blank PARENTERAL SOL AMINO ACID > a $150.88 HCPCS - Non-Drugs B4180 Blank PARENTERAL SOL CARB > 50% a $64.26 HCPCS - Non-Drugs B4185 Blank PARENTERAL SOL 10 GM LIPIDS a $29.88 HCPCS - Non-Drugs B4189 Blank PARENTERAL SOL AMINO ACID & a $465.10 HCPCS - Non-Drugs B4193 Blank PARENTERAL SOL 52-73 GM PROT a $600.82 HCPCS - Non-Drugs B4197 Blank PARENTERAL SOL 74-100 GM PRO a $731.36 HCPCS - Non-Drugs B4199 Blank PARENTERAL SOL > 100GM PROTE a $835.63 HCPCS - Non-Drugs B4216 Blank PARENTERAL NUTRITION ADDITIV Blank $20.67 HCPCS - Non-Drugs B4220 Blank PARENTERAL SUPPLY KIT PREMIX Blank $21.42 HCPCS - Non-Drugs B4222 Blank PARENTERAL SUPPLY KIT HOMEMI Blank $26.30 HCPCS - Non-Drugs B4224 Blank PARENTERAL ADMINISTRATION KI Blank $65.85 HCPCS - Non-Drugs B5000 Blank PARENTERAL SOL RENAL-AMIROSY a $31.59 HCPCS - Non-Drugs B5100 Blank PARENTERAL SOLUTION HEPATIC a $12.65 HCPCS - Non-Drugs B5200 Blank PARENTERAL SOL HEPATIC FREAM a $654.15 HCPCS - Non-Drugs B9002 Blank ENTER NUTR INF PUMP ANY TYPE Blank $1,415.57 HCPCS - Non-Drugs B9002 MS Enter nutr inf pump any type Blank $71.26 HCPCS - Non-Drugs B9002 NU Enter nutr inf pump any type Blank $1,415.57 HCPCS - Non-Drugs B9002 RR Enter nutr inf pump any type Blank $142.01 HCPCS - Non-Drugs B9002 UE Enter nutr inf pump any type Blank $1,061.81 HCPCS - Non-Drugs B9004 Blank PARENTERAL INFUS PUMP PORTAB Blank $6,595.14 HCPCS - Non-Drugs B9004 MS Parenteral infus pump portab Blank $522.48 HCPCS - Non-Drugs B9004 NU Parenteral infus pump portab Blank $6,595.14 HCPCS - Non-Drugs B9004 RR Parenteral infus pump portab Blank $1,044.45 HCPCS - Non-Drugs B9004 UE Parenteral infus pump portab Blank $4,946.48 HCPCS - Non-Drugs B9006 Blank PARENTERAL INFUS PUMP STATIO Blank $6,595.14 HCPCS - Non-Drugs B9006 MS Parenteral infus pump statio Blank $522.48 HCPCS - Non-Drugs B9006 NU Parenteral infus pump statio Blank $6,595.14 HCPCS - Non-Drugs B9006 RR Parenteral infus pump statio Blank $1,044.45 HCPCS - Non-Drugs B9006 UE Parenteral infus pump statio Blank $4,946.48 HCPCS - Non-Drugs B9998 Blank ENTERAL SUPP NOT OTHERWISE C Blank $103.89 HCPCS - Non-Drugs B9999 Blank PARENTERAL SUPP NOT OTHRWS C Blank $103.89 HCPCS - Non-Drugs C1713 Blank ANCHOR/SCREW BN/BN,TIS/BN Blank $658.06 HCPCS - Non-Drugs C1714 Blank CATH, TRANS ATHERECTOMY, DIR Blank $289.94 HCPCS - Non-Drugs C1715 Blank BRACHYTHERAPY NEEDLE Blank $49.17 HCPCS - Non-Drugs C1717 Blank BRACHYTX, NON-STR,HDR IR-192 a $1,090.34 HCPCS - Non-Drugs C1721 Blank AICD, DUAL CHAMBER Blank $28,563.21 HCPCS - Non-Drugs C1722 Blank AICD, SINGLE CHAMBER Blank $26,806.82 HCPCS - Non-Drugs C1724 Blank CATH, TRANS ATHEREC,ROTATION Blank $2,592.85 HCPCS - Non-Drugs C1725 Blank CATH, TRANSLUMIN NON-LASER Blank $1,670.67 HCPCS - Non-Drugs C1726 Blank CATH, BAL DIL, NON-VASCULAR Blank $858.88 HCPCS - Non-Drugs C1727 Blank CATH, BAL TIS DIS, NON-VAS Blank $967.77 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

C1728 Blank CATH, BRACHYTX SEED ADM Blank $42.65 HCPCS - Non-Drugs C1729 Blank CATH, DRAINAGE Blank $296.68 HCPCS - Non-Drugs C1730 Blank CATH, EP, 19 OR FEW ELECT Blank $1,980.91 HCPCS - Non-Drugs C1731 Blank CATH, EP, 20 OR MORE ELEC Blank $5,463.40 HCPCS - Non-Drugs C1732 Blank CATH, EP, DIAG/ABL, 3D/VECT Blank $5,463.40 HCPCS - Non-Drugs C1733 Blank CATH, EP, OTHR THAN COOL-TIP Blank $1,980.91 HCPCS - Non-Drugs C1750 Blank CATH, HEMODIALYSIS,LONG-TERM Blank $773.30 HCPCS - Non-Drugs C1751 Blank CATH, INF, PER/CENT/MIDLINE Blank $984.93 HCPCS - Non-Drugs C1752 Blank CATH,HEMODIALYSIS,SHORT-TERM Blank $1,007.40 HCPCS - Non-Drugs C1753 Blank CATH, INTRAVAS ULTRASOUND Blank $1,536.51 HCPCS - Non-Drugs C1754 Blank CATHETER, INTRADISCAL Blank $796.52 HCPCS - Non-Drugs C1755 Blank CATHETER, INTRASPINAL Blank $1,393.27 HCPCS - Non-Drugs C1756 Blank CATH, PACING, TRANSESOPH Blank $1,306.94 HCPCS - Non-Drugs C1757 Blank CATH, THROMBECTOMY/EMBOLECT Blank $3,232.02 HCPCS - Non-Drugs C1758 Blank CATHETER, URETERAL Blank $490.77 HCPCS - Non-Drugs C1759 Blank CATH, INTRA ECHOCARDIOGRAPHY Blank $4,337.16 HCPCS - Non-Drugs C1760 Blank CLOSURE DEV, VASC Blank $909.11 HCPCS - Non-Drugs C1762 Blank CONN TISS, HUMAN(INC FASCIA) Blank $2,969.41 HCPCS - Non-Drugs C1763 Blank CONN TISS, NON-HUMAN Blank $2,905.34 HCPCS - Non-Drugs C1764 Blank EVENT RECORDER, CARDIAC Blank $3,722.00 HCPCS - Non-Drugs C1765 Blank ADHESION BARRIER Blank $462.59 HCPCS - Non-Drugs C1766 Blank INTRO/SHEATH,STRBLE,NON-PEEL Blank $647.57 HCPCS - Non-Drugs C1767 Blank GENERATOR, NEURO NON-RECHARG Blank $18,488.88 HCPCS - Non-Drugs C1768 Blank GRAFT, VASCULAR Blank $3,472.25 HCPCS - Non-Drugs C1769 Blank GUIDE WIRE Blank $393.11 HCPCS - Non-Drugs C1770 Blank IMAGING COIL, MR, INSERTABLE Blank $377.01 HCPCS - Non-Drugs C1771 Blank REP DEV, URINARY, W/SLING Blank $3,918.05 HCPCS - Non-Drugs C1772 Blank INFUSION PUMP, PROGRAMMABLE Blank $308.85 HCPCS - Non-Drugs C1776 Blank JOINT DEVICE (IMPLANTABLE) Blank $5,051.04 HCPCS - Non-Drugs C1777 Blank LEAD, AICD, ENDO SINGLE COIL Blank $6,475.00 HCPCS - Non-Drugs C1778 Blank LEAD, NEUROSTIMULATOR Blank $4,947.16 HCPCS - Non-Drugs C1779 Blank LEAD, PMKR, TRANSVENOUS VDD Blank $3,317.03 HCPCS - Non-Drugs C1780 Blank LENS, INTRAOCULAR (NEW TECH) Blank $314.33 HCPCS - Non-Drugs C1781 Blank MESH (IMPLANTABLE) Blank $1,110.60 HCPCS - Non-Drugs C1782 Blank MORCELLATOR Blank $422.92 HCPCS - Non-Drugs C1783 Blank OCULAR IMP, AQUEOUS DRAIN DE Blank $909.63 HCPCS - Non-Drugs C1784 Blank OCULAR DEV, INTRAOP, DET RET Blank $1,665.60 HCPCS - Non-Drugs C1785 Blank PMKR, DUAL, RATE-RESP Blank $8,957.41 HCPCS - Non-Drugs C1786 Blank PMKR, SINGLE, RATE-RESP Blank $7,445.70 HCPCS - Non-Drugs C1787 Blank PATIENT PROGR, NEUROSTIM Blank $7,230.03 HCPCS - Non-Drugs C1788 Blank PORT, INDWELLING, IMP Blank $1,081.70 HCPCS - Non-Drugs C1789 Blank PROSTHESIS, BREAST, IMP Blank $1,388.21 HCPCS - Non-Drugs C1813 Blank PROSTHESIS, PENILE, INFLATAB Blank $6,220.06 HCPCS - Non-Drugs C1815 Blank PROS, URINARY SPH, IMP Blank $5,531.15 HCPCS - Non-Drugs C1816 Blank RECEIVER/TRANSMITTER, NEURO Blank $1,936.88 HCPCS - Non-Drugs C1817 Blank SEPTAL DEFECT IMP SYS Blank $7,339.37 HCPCS - Non-Drugs C1818 Blank INTEGRATED KERATOPROSTHESIS Blank $4,440.79 HCPCS - Non-Drugs C1820 Blank GENERATOR NEURO RECHG BAT SY Blank $20,736.73 HCPCS - Non-Drugs C1821 Blank INTERSPINOUS IMPLANT Blank $2,010.72 HCPCS - Non-Drugs C1830 Blank POWER BONE MARROW BX NEEDLE Blank $214.18 HCPCS - Non-Drugs C1840 Blank TELESCOPIC INTRAOCULAR LENS Blank $444.78 HCPCS - Non-Drugs C1874 Blank STENT, COATED/COV W/DEL SYS Blank $2,609.25 HCPCS - Non-Drugs C1875 Blank STENT, COATED/COV W/O DEL SY Blank $2,798.16 HCPCS - Non-Drugs C1876 Blank STENT, NON-COA/NON-COV W/DEL Blank $2,072.90 HCPCS - Non-Drugs C1877 Blank STENT, NON-COAT/COV W/O DEL Blank $3,055.27 HCPCS - Non-Drugs C1878 Blank MATRL FOR VOCAL CORD Blank $866.69 HCPCS - Non-Drugs C1880 Blank VENA CAVA FILTER Blank $2,352.74 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

C1881 Blank DIALYSIS ACCESS SYSTEM Blank $789.32 HCPCS - Non-Drugs C1882 Blank AICD, OTHER THAN SING/DUAL Blank $34,304.24 HCPCS - Non-Drugs C1883 Blank ADAPT/EXT, PACING/NEURO LEAD Blank $2,862.58 HCPCS - Non-Drugs C1884 Blank EMBOLIZATION PROTECT SYST Blank $316.40 HCPCS - Non-Drugs C1885 Blank CATH, TRANSLUMIN ANGIO LASER Blank $360.62 HCPCS - Non-Drugs C1887 Blank CATHETER, GUIDING Blank $68.97 HCPCS - Non-Drugs C1888 Blank ENDOVAS NON-CARDIAC ABL CATH Blank $1,056.40 HCPCS - Non-Drugs C1889 Blank IMPLANT/INSERT DEVICE, NOC Blank $2,609.25 HCPCS - Non-Drugs C1891 Blank INFUSION PUMP,NON-PROG, PERM Blank $7,357.40 HCPCS - Non-Drugs C1892 Blank INTRO/SHEATH,FIXED,PEEL-AWAY Blank $1,250.20 HCPCS - Non-Drugs C1893 Blank INTRO/SHEATH, FIXED,NON-PEEL Blank $667.65 HCPCS - Non-Drugs C1894 Blank INTRO/SHEATH, NON-LASER Blank $173.72 HCPCS - Non-Drugs C1895 Blank LEAD, AICD, ENDO DUAL COIL Blank $6,142.63 HCPCS - Non-Drugs C1896 Blank LEAD, AICD, NON SING/DUAL Blank $5,998.16 HCPCS - Non-Drugs C1897 Blank LEAD, NEUROSTIM TEST KIT Blank $2,849.99 HCPCS - Non-Drugs C1898 Blank LEAD, PMKR, OTHER THAN TRANS Blank $1,019.12 HCPCS - Non-Drugs C1899 Blank LEAD, PMKR/AICD COMBINATION Blank $4,873.14 HCPCS - Non-Drugs C1900 Blank LEAD, CORONARY VENOUS Blank $4,135.80 HCPCS - Non-Drugs C2613 Blank LUNG BX PLUG W/DEL SYS Blank $122.88 HCPCS - Non-Drugs C2614 Blank PROBE, PERC LUMB DISC Blank $883.17 HCPCS - Non-Drugs C2615 Blank SEALANT, PULMONARY, LIQUID Blank $982.37 HCPCS - Non-Drugs C2617 Blank STENT, NON-COR, TEM W/O DEL Blank $3,358.62 HCPCS - Non-Drugs C2618 Blank PROBE/NEEDLE, CRYO Blank $2,759.03 HCPCS - Non-Drugs C2619 Blank PMKR, DUAL, NON RATE-RESP Blank $7,357.94 HCPCS - Non-Drugs C2620 Blank PMKR, SINGLE, NON RATE-RESP Blank $19,704.20 HCPCS - Non-Drugs C2621 Blank PMKR, OTHER THAN SING/DUAL Blank $13,078.40 HCPCS - Non-Drugs C2622 Blank PROSTHESIS, PENILE, NON-INF Blank $5,869.14 HCPCS - Non-Drugs C2623 Blank CATH, TRANSLUMIN, DRUG-COAT Blank $5,109.56 HCPCS - Non-Drugs C2625 Blank STENT, NON-COR, TEM W/DEL SY Blank $3,738.63 HCPCS - Non-Drugs C2626 Blank INFUSION PUMP, NON-PROG,TEMP Blank $1,283.71 HCPCS - Non-Drugs C2627 Blank CATH, SUPRAPUBIC/CYSTOSCOPIC Blank $944.77 HCPCS - Non-Drugs C2628 Blank CATHETER, OCCLUSION Blank $1,230.60 HCPCS - Non-Drugs C2631 Blank REP DEV, URINARY, W/O SLING Blank $3,484.90 HCPCS - Non-Drugs C2638 Blank BRACHYTX, STRANDED, I-125 a $67.39 HCPCS - Non-Drugs C2639 Blank BRACHYTX, NON-STRANDED,I-125 a $43.86 HCPCS - Non-Drugs C2640 Blank BRACHYTX, STRANDED, P-103 a $156.53 HCPCS - Non-Drugs C2641 Blank BRACHYTX, NON-STRANDED,P-103 a $80.14 HCPCS - Non-Drugs C2645 Blank BRACHYTX PLANAR, P-103 a $32.97 HCPCS - Non-Drugs C2698 Blank BRACHYTX, STRANDED, NOS a $2,609.25 HCPCS - Non-Drugs C2699 Blank BRACHYTX, NON-STRANDED, NOS a $2,609.25 HCPCS - Non-Drugs C9113 Blank INJ PANTOPRAZOLE SODIUM, VIA a $199.03 HCPCS - Drugs C9248 Blank INJ, CLEVIDIPINE BUTYRATE a $12.21 HCPCS - Drugs C9250 Blank ARTISS FIBRIN SEALANT a $839.20 HCPCS - Drugs C9254 Blank INJECTION, LACOSAMIDE a $1.31 HCPCS - Drugs C9257 Blank BEVACIZUMAB INJECTION a $25.16 HCPCS - Drugs C9285 Blank PATCH, LIDOCAINE/TETRACAINE a $108.35 HCPCS - Drugs C9290 Blank INJ, BUPIVACAINE LIPOSOME a $8.39 HCPCS - Drugs C9358 Blank SURGIMEND, FETAL Blank $90.52 HCPCS - Non-Drugs C9359 Blank IMPLNT,BON VOID FILLER-PUTTY Blank $1,034.22 HCPCS - Non-Drugs C9360 Blank SURGIMEND, NEONATAL Blank $69.69 HCPCS - Non-Drugs C9361 Blank NEUROMEND NERVE WRAP Blank $2,719.11 HCPCS - Non-Drugs C9362 Blank IMPLNT,BON VOID FILLER-STRIP Blank $310.09 HCPCS - Non-Drugs C9363 Blank INTEGRA MESHED BIL WOUND MAT Blank $358.49 HCPCS - Non-Drugs C9364 Blank PORCINE IMPLANT, PERMACOL Blank $107.70 HCPCS - Non-Drugs C9399 Blank UNCLASSIFIED DRUGS OR BIOLOG Blank $2,609.25 HCPCS - Drugs C9447 Blank INJ, PHENYLEPHRINE KETOROLAC a $1,778.83 HCPCS - Drugs C9497 Blank LOXAPINE, INHALATION POWDER a $7.70 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

C9741 Blank IMPL PRESSURE SENSOR W/ANGIO Blank $15,451.25 HCPCS - Non-Drugs E0100 Blank CANE ADJUST/FIXED WITH TIP Blank $117.78 HCPCS - Non-Drugs E0100 NU CANE ADJUST/FIXED WITH TIP Blank $117.78 HCPCS - Non-Drugs E0100 RR CANE ADJUST/FIXED WITH TIP Blank $65.49 HCPCS - Non-Drugs E0100 UE CANE ADJUST/FIXED WITH TIP Blank $108.63 HCPCS - Non-Drugs E0105 Blank CANE ADJUST/FIXED QUAD/3 PRO Blank $175.64 HCPCS - Non-Drugs E0105 NU CANE ADJUST/FIXED QUAD/3 PRO Blank $175.64 HCPCS - Non-Drugs E0105 RR CANE ADJUST/FIXED QUAD/3 PRO Blank $93.02 HCPCS - Non-Drugs E0105 UE CANE ADJUST/FIXED QUAD/3 PRO Blank $151.63 HCPCS - Non-Drugs E0110 Blank CRUTCH FOREARM PAIR Blank $228.14 HCPCS - Non-Drugs E0110 NU CRUTCH FOREARM PAIR Blank $228.14 HCPCS - Non-Drugs E0110 RR CRUTCH FOREARM PAIR Blank $106.72 HCPCS - Non-Drugs E0110 UE CRUTCH FOREARM PAIR Blank $189.97 HCPCS - Non-Drugs E0111 Blank CRUTCH FOREARM EACH Blank $179.43 HCPCS - Non-Drugs E0111 NU CRUTCH FOREARM EACH Blank $179.43 HCPCS - Non-Drugs E0111 RR CRUTCH FOREARM EACH Blank $92.00 HCPCS - Non-Drugs E0111 UE CRUTCH FOREARM EACH Blank $155.32 HCPCS - Non-Drugs E0112 Blank CRUTCH UNDERARM PAIR WOOD Blank $148.56 HCPCS - Non-Drugs E0112 NU CRUTCH UNDERARM PAIR WOOD Blank $148.56 HCPCS - Non-Drugs E0112 RR CRUTCH UNDERARM PAIR WOOD Blank $94.85 HCPCS - Non-Drugs E0112 UE CRUTCH UNDERARM PAIR WOOD Blank $131.54 HCPCS - Non-Drugs E0113 Blank CRUTCH UNDERARM EACH WOOD Blank $116.89 HCPCS - Non-Drugs E0113 NU CRUTCH UNDERARM EACH WOOD Blank $116.89 HCPCS - Non-Drugs E0113 RR CRUTCH UNDERARM EACH WOOD Blank $53.62 HCPCS - Non-Drugs E0113 UE CRUTCH UNDERARM EACH WOOD Blank $106.61 HCPCS - Non-Drugs E0114 Blank CRUTCH UNDERARM PAIR NO WOOD Blank $167.75 HCPCS - Non-Drugs E0114 NU CRUTCH UNDERARM PAIR NO WOOD Blank $167.75 HCPCS - Non-Drugs E0114 RR CRUTCH UNDERARM PAIR NO WOOD Blank $92.31 HCPCS - Non-Drugs E0114 UE CRUTCH UNDERARM PAIR NO WOOD Blank $145.14 HCPCS - Non-Drugs E0116 Blank CRUTCH UNDERARM EACH NO WOOD Blank $127.71 HCPCS - Non-Drugs E0116 NU CRUTCH UNDERARM EACH NO WOOD Blank $127.71 HCPCS - Non-Drugs E0116 RR CRUTCH UNDERARM EACH NO WOOD Blank $55.85 HCPCS - Non-Drugs E0116 UE CRUTCH UNDERARM EACH NO WOOD Blank $114.85 HCPCS - Non-Drugs E0117 Blank UNDERARM SPRINGASSIST CRUTCH Blank $335.56 HCPCS - Non-Drugs E0117 NU UNDERARM SPRINGASSIST CRUTCH Blank $335.56 HCPCS - Non-Drugs E0117 RR UNDERARM SPRINGASSIST CRUTCH Blank $115.64 HCPCS - Non-Drugs E0117 UE UNDERARM SPRINGASSIST CRUTCH Blank $270.61 HCPCS - Non-Drugs E0118 Blank CRUTCH SUBSTITUTE Blank $553.47 HCPCS - Non-Drugs E0118 RR CRUTCH SUBSTITUTE Blank $94.26 HCPCS - Non-Drugs E0130 Blank WALKER RIGID ADJUST/FIXED HT Blank $158.81 HCPCS - Non-Drugs E0130 NU WALKER RIGID ADJUST/FIXED HT Blank $158.81 HCPCS - Non-Drugs E0130 RR WALKER RIGID ADJUST/FIXED HT Blank $43.66 HCPCS - Non-Drugs E0130 UE WALKER RIGID ADJUST/FIXED HT Blank $138.04 HCPCS - Non-Drugs E0135 Blank WALKER FOLDING ADJUST/FIXED Blank $158.98 HCPCS - Non-Drugs E0135 NU WALKER FOLDING ADJUST/FIXED Blank $158.98 HCPCS - Non-Drugs E0135 RR WALKER FOLDING ADJUST/FIXED Blank $43.74 HCPCS - Non-Drugs E0135 UE WALKER FOLDING ADJUST/FIXED Blank $138.17 HCPCS - Non-Drugs E0140 Blank WALKER W TRUNK SUPPORT Blank $933.18 HCPCS - Non-Drugs E0140 NU WALKER W TRUNK SUPPORT Blank $933.18 HCPCS - Non-Drugs E0140 RR WALKER W TRUNK SUPPORT Blank $126.71 HCPCS - Non-Drugs E0140 UE WALKER W TRUNK SUPPORT Blank $350.39 HCPCS - Non-Drugs E0141 Blank RIGID WHEELED WALKER ADJ/FIX Blank $162.91 HCPCS - Non-Drugs E0141 NU RIGID WHEELED WALKER ADJ/FIX Blank $162.91 HCPCS - Non-Drugs E0141 RR RIGID WHEELED WALKER ADJ/FIX Blank $45.81 HCPCS - Non-Drugs E0141 UE RIGID WHEELED WALKER ADJ/FIX Blank $141.12 HCPCS - Non-Drugs E0143 Blank WALKER FOLDING WHEELED W/O S Blank $162.91 HCPCS - Non-Drugs E0143 NU WALKER FOLDING WHEELED W/O S Blank $162.91 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0143 RR WALKER FOLDING WHEELED W/O S Blank $45.81 HCPCS - Non-Drugs E0143 UE WALKER FOLDING WHEELED W/O S Blank $141.12 HCPCS - Non-Drugs E0144 Blank ENCLOSED WALKER W REAR SEAT Blank $908.71 HCPCS - Non-Drugs E0144 NU ENCLOSED WALKER W REAR SEAT Blank $908.71 HCPCS - Non-Drugs E0144 RR ENCLOSED WALKER W REAR SEAT Blank $123.38 HCPCS - Non-Drugs E0144 UE ENCLOSED WALKER W REAR SEAT Blank $318.17 HCPCS - Non-Drugs E0147 Blank WALKER VARIABLE WHEEL RESIST Blank $773.80 HCPCS - Non-Drugs E0147 NU WALKER VARIABLE WHEEL RESIST Blank $773.80 HCPCS - Non-Drugs E0147 RR WALKER VARIABLE WHEEL RESIST Blank $145.55 HCPCS - Non-Drugs E0147 UE WALKER VARIABLE WHEEL RESIST Blank $599.29 HCPCS - Non-Drugs E0148 Blank HEAVYDUTY WALKER NO WHEELS Blank $226.12 HCPCS - Non-Drugs E0148 NU HEAVYDUTY WALKER NO WHEELS Blank $226.12 HCPCS - Non-Drugs E0148 RR HEAVYDUTY WALKER NO WHEELS Blank $89.82 HCPCS - Non-Drugs E0148 UE HEAVYDUTY WALKER NO WHEELS Blank $188.53 HCPCS - Non-Drugs E0149 Blank HEAVY DUTY WHEELED WALKER Blank $716.98 HCPCS - Non-Drugs E0149 NU HEAVY DUTY WHEELED WALKER Blank $716.98 HCPCS - Non-Drugs E0149 RR HEAVY DUTY WHEELED WALKER Blank $97.35 HCPCS - Non-Drugs E0149 UE HEAVY DUTY WHEELED WALKER Blank $245.55 HCPCS - Non-Drugs E0153 Blank FOREARM CRUTCH PLATFORM ATTA Blank $212.36 HCPCS - Non-Drugs E0153 NU FOREARM CRUTCH PLATFORM ATTA Blank $212.36 HCPCS - Non-Drugs E0153 RR FOREARM CRUTCH PLATFORM ATTA Blank $91.43 HCPCS - Non-Drugs E0153 UE FOREARM CRUTCH PLATFORM ATTA Blank $178.18 HCPCS - Non-Drugs E0154 Blank WALKER PLATFORM ATTACHMENT Blank $164.68 HCPCS - Non-Drugs E0154 NU WALKER PLATFORM ATTACHMENT Blank $164.68 HCPCS - Non-Drugs E0154 RR WALKER PLATFORM ATTACHMENT Blank $46.74 HCPCS - Non-Drugs E0154 UE WALKER PLATFORM ATTACHMENT Blank $142.45 HCPCS - Non-Drugs E0155 Blank WALKER WHEEL ATTACHMENT,PAIR Blank $113.92 HCPCS - Non-Drugs E0155 NU WALKER WHEEL ATTACHMENT,PAIR Blank $113.92 HCPCS - Non-Drugs E0155 RR WALKER WHEEL ATTACHMENT,PAIR Blank $20.05 HCPCS - Non-Drugs E0155 UE WALKER WHEEL ATTACHMENT,PAIR Blank $104.38 HCPCS - Non-Drugs E0156 Blank WALKER SEAT ATTACHMENT Blank $104.47 HCPCS - Non-Drugs E0156 NU WALKER SEAT ATTACHMENT Blank $104.47 HCPCS - Non-Drugs E0156 RR WALKER SEAT ATTACHMENT Blank $15.11 HCPCS - Non-Drugs E0156 UE WALKER SEAT ATTACHMENT Blank $97.30 HCPCS - Non-Drugs E0157 Blank WALKER CRUTCH ATTACHMENT Blank $176.73 HCPCS - Non-Drugs E0157 NU WALKER CRUTCH ATTACHMENT Blank $176.73 HCPCS - Non-Drugs E0157 RR WALKER CRUTCH ATTACHMENT Blank $54.59 HCPCS - Non-Drugs E0157 UE WALKER CRUTCH ATTACHMENT Blank $151.49 HCPCS - Non-Drugs E0158 Blank WALKER LEG EXTENDERS SET OF4 Blank $115.08 HCPCS - Non-Drugs E0158 NU WALKER LEG EXTENDERS SET OF4 Blank $115.08 HCPCS - Non-Drugs E0158 RR WALKER LEG EXTENDERS SET OF4 Blank $20.67 HCPCS - Non-Drugs E0158 UE WALKER LEG EXTENDERS SET OF4 Blank $105.25 HCPCS - Non-Drugs E0159 Blank BRAKE FOR WHEELED WALKER Blank $102.42 HCPCS - Non-Drugs E0159 NU BRAKE FOR WHEELED WALKER Blank $102.42 HCPCS - Non-Drugs E0159 RR BRAKE FOR WHEELED WALKER Blank $14.02 HCPCS - Non-Drugs E0159 UE BRAKE FOR WHEELED WALKER Blank $95.76 HCPCS - Non-Drugs E0160 Blank SITZ TYPE BATH OR EQUIPMENT Blank $128.39 HCPCS - Non-Drugs E0160 NU SITZ TYPE BATH OR EQUIPMENT Blank $128.39 HCPCS - Non-Drugs E0160 RR SITZ TYPE BATH OR EQUIPMENT Blank $27.72 HCPCS - Non-Drugs E0160 UE SITZ TYPE BATH OR EQUIPMENT Blank $115.24 HCPCS - Non-Drugs E0161 Blank SITZ BATH/EQUIPMENT W/FAUCET Blank $120.66 HCPCS - Non-Drugs E0161 NU SITZ BATH/EQUIPMENT W/FAUCET Blank $120.66 HCPCS - Non-Drugs E0161 RR SITZ BATH/EQUIPMENT W/FAUCET Blank $23.67 HCPCS - Non-Drugs E0161 UE SITZ BATH/EQUIPMENT W/FAUCET Blank $109.43 HCPCS - Non-Drugs E0162 Blank SITZ BATH CHAIR Blank $355.11 HCPCS - Non-Drugs E0162 NU SITZ BATH CHAIR Blank $355.11 HCPCS - Non-Drugs E0162 RR SITZ BATH CHAIR Blank $105.15 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0162 UE SITZ BATH CHAIR Blank $291.15 HCPCS - Non-Drugs E0163 Blank COMMODE CHAIR WITH FIXED ARM Blank $171.85 HCPCS - Non-Drugs E0163 NU COMMODE CHAIR WITH FIXED ARM Blank $171.85 HCPCS - Non-Drugs E0163 RR COMMODE CHAIR WITH FIXED ARM Blank $51.12 HCPCS - Non-Drugs E0163 UE COMMODE CHAIR WITH FIXED ARM Blank $147.82 HCPCS - Non-Drugs E0165 Blank COMMODE CHAIR WITH DETACHARM Blank $722.13 HCPCS - Non-Drugs E0165 RR COMMODE CHAIR WITH DETACHARM Blank $98.05 HCPCS - Non-Drugs E0167 Blank COMMODE CHAIR PAIL OR PAN Blank $95.42 HCPCS - Non-Drugs E0167 NU COMMODE CHAIR PAIL OR PAN Blank $95.42 HCPCS - Non-Drugs E0167 RR COMMODE CHAIR PAIL OR PAN Blank $10.36 HCPCS - Non-Drugs E0167 UE COMMODE CHAIR PAIL OR PAN Blank $87.86 HCPCS - Non-Drugs E0168 Blank HEAVYDUTY/WIDE COMMODE CHAIR Blank $288.16 HCPCS - Non-Drugs E0168 NU HEAVYDUTY/WIDE COMMODE CHAIR Blank $288.16 HCPCS - Non-Drugs E0168 RR HEAVYDUTY/WIDE COMMODE CHAIR Blank $96.99 HCPCS - Non-Drugs E0168 UE HEAVYDUTY/WIDE COMMODE CHAIR Blank $235.06 HCPCS - Non-Drugs E0170 Blank COMMODE CHAIR ELECTRIC Blank $2,747.58 HCPCS - Non-Drugs E0170 RR COMMODE CHAIR ELECTRIC Blank $373.06 HCPCS - Non-Drugs E0171 Blank COMMODE CHAIR NON-ELECTRIC Blank $966.63 HCPCS - Non-Drugs E0171 RR COMMODE CHAIR NON-ELECTRIC Blank $131.25 HCPCS - Non-Drugs E0172 Blank SEAT LIFT MECHANISM TOILET Blank $361.57 HCPCS - Non-Drugs E0175 Blank COMMODE CHAIR FOOT REST Blank $204.25 HCPCS - Non-Drugs E0175 NU COMMODE CHAIR FOOT REST Blank $204.25 HCPCS - Non-Drugs E0175 RR COMMODE CHAIR FOOT REST Blank $74.11 HCPCS - Non-Drugs E0175 UE COMMODE CHAIR FOOT REST Blank $170.28 HCPCS - Non-Drugs E0181 Blank PRESS PAD ALTERNATING W/ PUM Blank $768.24 HCPCS - Non-Drugs E0181 RR PRESS PAD ALTERNATING W/ PUM Blank $104.31 HCPCS - Non-Drugs E0182 Blank REPLACE PUMP, ALT PRESS PAD Blank $840.50 HCPCS - Non-Drugs E0182 RR REPLACE PUMP, ALT PRESS PAD Blank $114.12 HCPCS - Non-Drugs E0184 Blank DRY PRESSURE MATTRESS Blank $366.08 HCPCS - Non-Drugs E0184 NU DRY PRESSURE MATTRESS Blank $366.08 HCPCS - Non-Drugs E0184 RR DRY PRESSURE MATTRESS Blank $104.84 HCPCS - Non-Drugs E0184 UE DRY PRESSURE MATTRESS Blank $293.59 HCPCS - Non-Drugs E0185 Blank GEL PRESSURE MATTRESS PAD Blank $385.08 HCPCS - Non-Drugs E0185 NU GEL PRESSURE MATTRESS PAD Blank $385.08 HCPCS - Non-Drugs E0185 RR GEL PRESSURE MATTRESS PAD Blank $106.68 HCPCS - Non-Drugs E0185 UE GEL PRESSURE MATTRESS PAD Blank $307.75 HCPCS - Non-Drugs E0186 Blank AIR PRESSURE MATTRESS Blank $815.13 HCPCS - Non-Drugs E0186 RR AIR PRESSURE MATTRESS Blank $110.68 HCPCS - Non-Drugs E0187 Blank WATER PRESSURE MATTRESS Blank $851.95 HCPCS - Non-Drugs E0187 RR WATER PRESSURE MATTRESS Blank $115.68 HCPCS - Non-Drugs E0188 Blank SYNTHETIC SHEEPSKIN PAD Blank $121.06 HCPCS - Non-Drugs E0188 NU SYNTHETIC SHEEPSKIN PAD Blank $121.06 HCPCS - Non-Drugs E0188 RR SYNTHETIC SHEEPSKIN PAD Blank $23.87 HCPCS - Non-Drugs E0188 UE SYNTHETIC SHEEPSKIN PAD Blank $109.73 HCPCS - Non-Drugs E0189 Blank LAMBSWOOL SHEEPSKIN PAD Blank $167.32 HCPCS - Non-Drugs E0189 NU LAMBSWOOL SHEEPSKIN PAD Blank $167.32 HCPCS - Non-Drugs E0189 RR LAMBSWOOL SHEEPSKIN PAD Blank $48.32 HCPCS - Non-Drugs E0189 UE LAMBSWOOL SHEEPSKIN PAD Blank $144.43 HCPCS - Non-Drugs E0190 Blank POSITIONING CUSHION Blank $75.08 HCPCS - Non-Drugs E0191 Blank PROTECTOR HEEL OR ELBOW Blank $94.97 HCPCS - Non-Drugs E0191 NU PROTECTOR HEEL OR ELBOW Blank $94.97 HCPCS - Non-Drugs E0191 RR PROTECTOR HEEL OR ELBOW Blank $10.37 HCPCS - Non-Drugs E0191 UE PROTECTOR HEEL OR ELBOW Blank $85.11 HCPCS - Non-Drugs E0193 Blank POWERED AIR FLOTATION BED Blank $11,203.24 HCPCS - Non-Drugs E0193 RR POWERED AIR FLOTATION BED Blank $1,521.15 HCPCS - Non-Drugs E0194 Blank AIR FLUIDIZED BED Blank $51,146.58 HCPCS - Non-Drugs E0194 RR AIR FLUIDIZED BED Blank $6,944.56 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0194 UE AIR FLUIDIZED BED Blank $37,170.05 HCPCS - Non-Drugs E0196 Blank GEL PRESSURE MATTRESS Blank $907.75 HCPCS - Non-Drugs E0196 RR GEL PRESSURE MATTRESS Blank $123.25 HCPCS - Non-Drugs E0196 UE GEL PRESSURE MATTRESS Blank $461.05 HCPCS - Non-Drugs E0197 Blank AIR PRESSURE PAD FOR MATTRES Blank $800.41 HCPCS - Non-Drugs E0197 NU AIR PRESSURE PAD FOR MATTRES Blank $800.41 HCPCS - Non-Drugs E0197 RR AIR PRESSURE PAD FOR MATTRES Blank $108.68 HCPCS - Non-Drugs E0197 UE AIR PRESSURE PAD FOR MATTRES Blank $304.87 HCPCS - Non-Drugs E0198 Blank WATER PRESSURE PAD FOR MATTR Blank $882.12 HCPCS - Non-Drugs E0198 NU WATER PRESSURE PAD FOR MATTR Blank $882.12 HCPCS - Non-Drugs E0198 RR WATER PRESSURE PAD FOR MATTR Blank $119.77 HCPCS - Non-Drugs E0198 UE WATER PRESSURE PAD FOR MATTR Blank $299.76 HCPCS - Non-Drugs E0199 Blank DRY PRESSURE PAD FOR MATTRES Blank $132.86 HCPCS - Non-Drugs E0199 NU DRY PRESSURE PAD FOR MATTRES Blank $132.86 HCPCS - Non-Drugs E0199 RR DRY PRESSURE PAD FOR MATTRES Blank $30.01 HCPCS - Non-Drugs E0199 UE DRY PRESSURE PAD FOR MATTRES Blank $118.59 HCPCS - Non-Drugs E0200 Blank HEAT LAMP WITHOUT STAND Blank $235.51 HCPCS - Non-Drugs E0200 NU HEAT LAMP WITHOUT STAND Blank $235.51 HCPCS - Non-Drugs E0200 RR HEAT LAMP WITHOUT STAND Blank $97.62 HCPCS - Non-Drugs E0200 UE HEAT LAMP WITHOUT STAND Blank $195.64 HCPCS - Non-Drugs E0202 Blank PHOTOTHERAPY LIGHT W/ PHOTOM Blank $1,484.41 HCPCS - Non-Drugs E0202 RR PHOTOTHERAPY LIGHT W/ PHOTOM Blank $201.55 HCPCS - Non-Drugs E0203 Blank THERAPEUTIC LIGHTBOX TABLETP Blank $300.35 HCPCS - Non-Drugs E0205 Blank HEAT LAMP WITH STAND Blank $450.45 HCPCS - Non-Drugs E0205 NU HEAT LAMP WITH STAND Blank $450.45 HCPCS - Non-Drugs E0205 RR HEAT LAMP WITH STAND Blank $118.89 HCPCS - Non-Drugs E0205 UE HEAT LAMP WITH STAND Blank $356.78 HCPCS - Non-Drugs E0210 Blank ELECTRIC HEAT PAD STANDARD Blank $139.09 HCPCS - Non-Drugs E0210 NU ELECTRIC HEAT PAD STANDARD Blank $139.09 HCPCS - Non-Drugs E0210 RR ELECTRIC HEAT PAD STANDARD Blank $34.95 HCPCS - Non-Drugs E0210 UE ELECTRIC HEAT PAD STANDARD Blank $123.21 HCPCS - Non-Drugs E0215 Blank ELECTRIC HEAT PAD MOIST Blank $213.66 HCPCS - Non-Drugs E0215 NU ELECTRIC HEAT PAD MOIST Blank $213.66 HCPCS - Non-Drugs E0215 RR ELECTRIC HEAT PAD MOIST Blank $91.05 HCPCS - Non-Drugs E0215 UE ELECTRIC HEAT PAD MOIST Blank $179.36 HCPCS - Non-Drugs E0217 Blank WATER CIRC HEAT PAD W PUMP Blank $1,035.10 HCPCS - Non-Drugs E0217 NU WATER CIRC HEAT PAD W PUMP Blank $1,035.10 HCPCS - Non-Drugs E0217 RR WATER CIRC HEAT PAD W PUMP Blank $182.40 HCPCS - Non-Drugs E0217 UE WATER CIRC HEAT PAD W PUMP Blank $795.21 HCPCS - Non-Drugs E0218 Blank WATER CIRC COLD PAD W PUMP Blank $1,035.10 HCPCS - Non-Drugs E0221 Blank INFRARED HEATING PAD SYSTEM Blank $138.80 HCPCS - Non-Drugs E0225 Blank HYDROCOLLATOR UNIT Blank $828.52 HCPCS - Non-Drugs E0225 NU HYDROCOLLATOR UNIT Blank $828.52 HCPCS - Non-Drugs E0225 RR HYDROCOLLATOR UNIT Blank $150.12 HCPCS - Non-Drugs E0225 UE HYDROCOLLATOR UNIT Blank $639.83 HCPCS - Non-Drugs E0231 Blank WOUND WARMING DEVICE Blank $518.77 HCPCS - Non-Drugs E0231 RR WOUND WARMING DEVICE Blank $56.77 HCPCS - Non-Drugs E0232 Blank WARMING CARD FOR NWT Blank $163.64 HCPCS - Non-Drugs E0235 Blank PARAFFIN BATH UNIT PORTABLE Blank $815.29 HCPCS - Non-Drugs E0235 RR PARAFFIN BATH UNIT PORTABLE Blank $110.70 HCPCS - Non-Drugs E0235 UE PARAFFIN BATH UNIT PORTABLE Blank $250.15 HCPCS - Non-Drugs E0236 Blank PUMP FOR WATER CIRCULATING P Blank $1,191.16 HCPCS - Non-Drugs E0236 RR PUMP FOR WATER CIRCULATING P Blank $161.73 HCPCS - Non-Drugs E0236 UE PUMP FOR WATER CIRCULATING P Blank $523.26 HCPCS - Non-Drugs E0239 Blank HYDROCOLLATOR UNIT PORTABLE Blank $965.10 HCPCS - Non-Drugs E0239 NU HYDROCOLLATOR UNIT PORTABLE Blank $965.10 HCPCS - Non-Drugs E0239 RR HYDROCOLLATOR UNIT PORTABLE Blank $165.11 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0239 UE HYDROCOLLATOR UNIT PORTABLE Blank $742.78 HCPCS - Non-Drugs E0240 Blank BATH/SHOWER CHAIR Blank $136.35 HCPCS - Non-Drugs E0241 Blank BATH TUB WALL RAIL Blank $106.95 HCPCS - Non-Drugs E0242 Blank BATH TUB RAIL FLOOR Blank $145.82 HCPCS - Non-Drugs E0243 Blank TOILET RAIL Blank $131.49 HCPCS - Non-Drugs E0244 Blank TOILET SEAT RAISED Blank $118.20 HCPCS - Non-Drugs E0245 Blank TUB STOOL OR BENCH Blank $145.30 HCPCS - Non-Drugs E0246 Blank TRANSFER TUB RAIL ATTACHMENT Blank $170.88 HCPCS - Non-Drugs E0247 Blank TRANS BENCH W/WO COMM OPEN Blank $154.72 HCPCS - Non-Drugs E0248 Blank HDTRANS BENCH W/WO COMM OPEN Blank $200.60 HCPCS - Non-Drugs E0249 Blank PAD WATER CIRCULATING HEAT U Blank $269.80 HCPCS - Non-Drugs E0249 NU PAD WATER CIRCULATING HEAT U Blank $269.80 HCPCS - Non-Drugs E0249 RR PAD WATER CIRCULATING HEAT U Blank $97.08 HCPCS - Non-Drugs E0249 UE PAD WATER CIRCULATING HEAT U Blank $221.28 HCPCS - Non-Drugs E0250 Blank HOSP BED FIXED HT W/ MATTRES Blank $1,896.46 HCPCS - Non-Drugs E0250 RR HOSP BED FIXED HT W/ MATTRES Blank $257.50 HCPCS - Non-Drugs E0250 UE HOSP BED FIXED HT W/ MATTRES Blank $975.50 HCPCS - Non-Drugs E0251 Blank HOSP BED FIXD HT W/O MATTRES Blank $1,766.41 HCPCS - Non-Drugs E0251 RR HOSP BED FIXD HT W/O MATTRES Blank $239.84 HCPCS - Non-Drugs E0251 UE HOSP BED FIXD HT W/O MATTRES Blank $772.94 HCPCS - Non-Drugs E0255 Blank HOSPITAL BED VAR HT W/ MATTR Blank $1,913.52 HCPCS - Non-Drugs E0255 RR HOSPITAL BED VAR HT W/ MATTR Blank $259.81 HCPCS - Non-Drugs E0255 UE HOSPITAL BED VAR HT W/ MATTR Blank $1,144.68 HCPCS - Non-Drugs E0256 Blank HOSPITAL BED VAR HT W/O MATT Blank $1,843.21 HCPCS - Non-Drugs E0256 RR HOSPITAL BED VAR HT W/O MATT Blank $250.27 HCPCS - Non-Drugs E0256 UE HOSPITAL BED VAR HT W/O MATT Blank $852.35 HCPCS - Non-Drugs E0260 Blank HOSP BED SEMI-ELECTR W/ MATT Blank $1,915.03 HCPCS - Non-Drugs E0260 RR HOSP BED SEMI-ELECTR W/ MATT Blank $260.02 HCPCS - Non-Drugs E0260 UE HOSP BED SEMI-ELECTR W/ MATT Blank $1,465.30 HCPCS - Non-Drugs E0261 Blank HOSP BED SEMI-ELECTR W/O MAT Blank $1,912.99 HCPCS - Non-Drugs E0261 RR HOSP BED SEMI-ELECTR W/O MAT Blank $259.74 HCPCS - Non-Drugs E0261 UE HOSP BED SEMI-ELECTR W/O MAT Blank $1,310.98 HCPCS - Non-Drugs E0265 Blank HOSP BED TOTAL ELECTR W/ MAT Blank $3,060.05 HCPCS - Non-Drugs E0265 RR HOSP BED TOTAL ELECTR W/ MAT Blank $415.49 HCPCS - Non-Drugs E0265 UE HOSP BED TOTAL ELECTR W/ MAT Blank $1,850.16 HCPCS - Non-Drugs E0266 Blank HOSP BED TOTAL ELEC W/O MATT Blank $2,794.72 HCPCS - Non-Drugs E0266 RR HOSP BED TOTAL ELEC W/O MATT Blank $379.46 HCPCS - Non-Drugs E0266 UE HOSP BED TOTAL ELEC W/O MATT Blank $1,659.12 HCPCS - Non-Drugs E0270 Blank HOSPITAL BED INSTITUTIONAL T Blank $511.20 HCPCS - Non-Drugs E0270 RR HOSPITAL BED INSTITUTIONAL T Blank $53.85 HCPCS - Non-Drugs E0270 UE HOSPITAL BED INSTITUTIONAL T Blank $384.23 HCPCS - Non-Drugs E0271 Blank MATTRESS INNERSPRING Blank $381.10 HCPCS - Non-Drugs E0271 NU MATTRESS INNERSPRING Blank $381.10 HCPCS - Non-Drugs E0271 RR MATTRESS INNERSPRING Blank $34.38 HCPCS - Non-Drugs E0271 UE MATTRESS INNERSPRING Blank $320.38 HCPCS - Non-Drugs E0272 Blank MATTRESS FOAM RUBBER Blank $415.00 HCPCS - Non-Drugs E0272 NU MATTRESS FOAM RUBBER Blank $415.00 HCPCS - Non-Drugs E0272 RR MATTRESS FOAM RUBBER Blank $42.24 HCPCS - Non-Drugs E0272 UE MATTRESS FOAM RUBBER Blank $345.59 HCPCS - Non-Drugs E0273 Blank BED BOARD Blank $68.69 HCPCS - Non-Drugs E0273 RR BED BOARD Blank $12.80 HCPCS - Non-Drugs E0273 UE BED BOARD Blank $47.43 HCPCS - Non-Drugs E0274 Blank OVER-BED TABLE Blank $118.35 HCPCS - Non-Drugs E0274 RR OVER-BED TABLE Blank $39.44 HCPCS - Non-Drugs E0274 UE OVER-BED TABLE Blank $91.37 HCPCS - Non-Drugs E0275 Blank BED PAN STANDARD Blank $101.34 HCPCS - Non-Drugs E0275 NU BED PAN STANDARD Blank $101.34 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0275 RR BED PAN STANDARD Blank $13.48 HCPCS - Non-Drugs E0275 UE BED PAN STANDARD Blank $94.95 HCPCS - Non-Drugs E0276 Blank BED PAN FRACTURE Blank $97.81 HCPCS - Non-Drugs E0276 NU BED PAN FRACTURE Blank $97.81 HCPCS - Non-Drugs E0276 RR BED PAN FRACTURE Blank $11.60 HCPCS - Non-Drugs E0276 UE BED PAN FRACTURE Blank $92.31 HCPCS - Non-Drugs E0277 Blank POWERED PRES-REDU AIR MATTRS Blank $3,809.81 HCPCS - Non-Drugs E0277 RR POWERED PRES-REDU AIR MATTRS Blank $517.29 HCPCS - Non-Drugs E0277 UE POWERED PRES-REDU AIR MATTRS Blank $2,915.12 HCPCS - Non-Drugs E0280 Blank BED CRADLE Blank $122.48 HCPCS - Non-Drugs E0280 NU BED CRADLE Blank $122.48 HCPCS - Non-Drugs E0280 RR BED CRADLE Blank $3.20 HCPCS - Non-Drugs E0280 UE BED CRADLE Blank $86.42 HCPCS - Non-Drugs E0290 Blank HOSP BED FX HT W/O RAILS W/M Blank $1,754.48 HCPCS - Non-Drugs E0290 RR HOSP BED FX HT W/O RAILS W/M Blank $238.22 HCPCS - Non-Drugs E0290 UE HOSP BED FX HT W/O RAILS W/M Blank $778.12 HCPCS - Non-Drugs E0291 Blank HOSP BED FX HT W/O RAIL W/O Blank $1,321.97 HCPCS - Non-Drugs E0291 RR HOSP BED FX HT W/O RAIL W/O Blank $179.49 HCPCS - Non-Drugs E0291 UE HOSP BED FX HT W/O RAIL W/O Blank $603.19 HCPCS - Non-Drugs E0292 Blank HOSP BED VAR HT NO SR W/MATT Blank $1,869.55 HCPCS - Non-Drugs E0292 RR HOSP BED VAR HT NO SR W/MATT Blank $253.84 HCPCS - Non-Drugs E0292 UE HOSP BED VAR HT W/O RAIL W/O Blank $858.11 HCPCS - Non-Drugs E0293 Blank HOSP BED VAR HT NO SR NO MAT Blank $1,727.60 HCPCS - Non-Drugs E0293 RR HOSP BED VAR HT NO SR NO MAT Blank $234.57 HCPCS - Non-Drugs E0293 UE HOSP BED VAR HT W/O RAIL W/ Blank $750.50 HCPCS - Non-Drugs E0294 Blank HOSP BED SEMI-ELECT W/ MATTR Blank $1,914.11 HCPCS - Non-Drugs E0294 RR HOSP BED SEMI-ELECT W/ MATTR Blank $259.89 HCPCS - Non-Drugs E0294 UE HOSP BED SEMI-ELECT W/ MATTR Blank $1,257.46 HCPCS - Non-Drugs E0295 Blank HOSP BED SEMI-ELECT W/O MATT Blank $1,912.99 HCPCS - Non-Drugs E0295 RR HOSP BED SEMI-ELECT W/O MATT Blank $259.74 HCPCS - Non-Drugs E0295 UE HOSP BED SEMI-ELECT W/O MATT Blank $1,229.27 HCPCS - Non-Drugs E0296 Blank HOSP BED TOTAL ELECT W/ MATT Blank $2,611.25 HCPCS - Non-Drugs E0296 RR HOSP BED TOTAL ELECT W/ MATT Blank $354.55 HCPCS - Non-Drugs E0296 UE HOSP BED TOTAL ELECT W/ MATT Blank $1,741.41 HCPCS - Non-Drugs E0297 Blank HOSP BED TOTAL ELECT W/O MAT Blank $2,423.92 HCPCS - Non-Drugs E0297 RR HOSP BED TOTAL ELECT W/O MAT Blank $329.11 HCPCS - Non-Drugs E0297 UE HOSP BED TOTAL ELECT W/O MAT Blank $1,343.20 HCPCS - Non-Drugs E0300 Blank ENCLOSED PED CRIB HOSP GRADE Blank $4,568.09 HCPCS - Non-Drugs E0300 NU ENCLOSED PED CRIB HOSP GRADE Blank $4,568.09 HCPCS - Non-Drugs E0300 RR ENCLOSED PED CRIB HOSP GRADE Blank $620.24 HCPCS - Non-Drugs E0300 UE ENCLOSED PED CRIB HOSP GRADE Blank $2,569.46 HCPCS - Non-Drugs E0301 Blank HD HOSP BED, 350-600 LBS Blank $3,361.20 HCPCS - Non-Drugs E0301 RR HD HOSP BED, 350-600 LBS Blank $456.38 HCPCS - Non-Drugs E0302 Blank EX HD HOSP BED > 600 LBS Blank $7,887.15 HCPCS - Non-Drugs E0302 RR EX HD HOSP BED > 600 LBS Blank $1,070.90 HCPCS - Non-Drugs E0303 Blank HOSP BED HVY DTY XTRA WIDE Blank $3,393.93 HCPCS - Non-Drugs E0303 RR HOSP BED HVY DTY XTRA WIDE Blank $460.82 HCPCS - Non-Drugs E0304 Blank HOSP BED XTRA HVY DTY X WIDE Blank $8,070.22 HCPCS - Non-Drugs E0304 RR HOSP BED XTRA HVY DTY X WIDE Blank $1,095.75 HCPCS - Non-Drugs E0305 Blank RAILS BED SIDE HALF LENGTH Blank $201.23 HCPCS - Non-Drugs E0305 RR RAILS BED SIDE HALF LENGTH Blank $27.32 HCPCS - Non-Drugs E0305 UE RAILS BED SIDE HALF LENGTH Blank $290.72 HCPCS - Non-Drugs E0310 Blank RAILS BED SIDE FULL LENGTH Blank $358.00 HCPCS - Non-Drugs E0310 NU RAILS BED SIDE FULL LENGTH Blank $358.00 HCPCS - Non-Drugs E0310 RR RAILS BED SIDE FULL LENGTH Blank $29.03 HCPCS - Non-Drugs E0310 UE RAILS BED SIDE FULL LENGTH Blank $303.06 HCPCS - Non-Drugs E0315 Blank BED ACCESSORY BRD/TBL/SUPPRT Blank $168.88 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0316 Blank BED SAFETY ENCLOSURE Blank $3,535.78 HCPCS - Non-Drugs E0316 RR BED SAFETY ENCLOSURE Blank $480.08 HCPCS - Non-Drugs E0325 Blank URINAL MALE JUG-TYPE Blank $92.25 HCPCS - Non-Drugs E0325 NU URINAL MALE JUG-TYPE Blank $92.25 HCPCS - Non-Drugs E0325 RR URINAL MALE JUG-TYPE Blank $8.70 HCPCS - Non-Drugs E0325 UE URINAL MALE JUG-TYPE Blank $69.17 HCPCS - Non-Drugs E0326 Blank URINAL FEMALE JUG-TYPE Blank $93.60 HCPCS - Non-Drugs E0326 NU URINAL FEMALE JUG-TYPE Blank $93.60 HCPCS - Non-Drugs E0326 RR URINAL FEMALE JUG-TYPE Blank $9.43 HCPCS - Non-Drugs E0326 UE URINAL FEMALE JUG-TYPE Blank $78.06 HCPCS - Non-Drugs E0328 Blank PED HOSPITAL BED, MANUAL Blank $148.23 HCPCS - Non-Drugs E0329 Blank PED HOSPITAL BED SEMI/ELECT Blank $619.82 HCPCS - Non-Drugs E0352 Blank DISPOSABLE PACK W/BOWEL SYST Blank $79.44 HCPCS - Non-Drugs E0370 Blank AIR ELEVATOR FOR HEEL Blank $93.85 HCPCS - Non-Drugs E0371 Blank NONPOWER MATTRESS OVERLAY Blank $3,125.40 HCPCS - Non-Drugs E0371 RR NONPOWER MATTRESS OVERLAY Blank $424.36 HCPCS - Non-Drugs E0372 Blank POWERED AIR MATTRESS OVERLAY Blank $3,127.16 HCPCS - Non-Drugs E0372 RR POWERED AIR MATTRESS OVERLAY Blank $424.60 HCPCS - Non-Drugs E0373 Blank NONPOWERED PRESSURE MATTRESS Blank $3,127.16 HCPCS - Non-Drugs E0373 RR NONPOWERED PRESSURE MATTRESS Blank $424.60 HCPCS - Non-Drugs E0424 Blank STATIONARY COMPRESSED GAS 02 Blank $3,727.93 HCPCS - Non-Drugs E0424 RR STATIONARY COMPRESSED GAS 02 Blank $484.58 HCPCS - Non-Drugs E0425 Blank GAS SYSTEM STATIONARY COMPRE Blank $22,233.28 HCPCS - Non-Drugs E0425 NU GAS SYSTEM STATIONARY COMPRE Blank $22,233.28 HCPCS - Non-Drugs E0430 Blank OXYGEN SYSTEM GAS PORTABLE Blank $10,001.89 HCPCS - Non-Drugs E0430 NU OXYGEN SYSTEM GAS PORTABLE Blank $10,001.89 HCPCS - Non-Drugs E0430 UE OXYGEN SYSTEM GAS PORTABLE Blank $7,470.60 HCPCS - Non-Drugs E0431 Blank PORTABLE GASEOUS 02 Blank $446.74 HCPCS - Non-Drugs E0431 RR STATIONARY COMPRESSED GAS 02 Blank $56.53 HCPCS - Non-Drugs E0433 Blank PORTABLE LIQUID OXYGEN SYS Blank $1,531.54 HCPCS - Non-Drugs E0433 RR STATIONARY COMPRESSED GAS 02 Blank $193.81 HCPCS - Non-Drugs E0434 Blank PORTABLE LIQUID 02 Blank $446.74 HCPCS - Non-Drugs E0434 RR STATIONARY COMPRESSED GAS 02 Blank $56.53 HCPCS - Non-Drugs E0435 Blank OXYGEN SYSTEM LIQUID PORTABL Blank $6,838.45 HCPCS - Non-Drugs E0435 NU OXYGEN SYSTEM LIQUID PORTABL Blank $6,838.45 HCPCS - Non-Drugs E0435 UE OXYGEN SYSTEM LIQUID PORTABL Blank $5,100.06 HCPCS - Non-Drugs E0439 Blank STATIONARY LIQUID 02 Blank $3,829.21 HCPCS - Non-Drugs E0439 RR STATIONARY LIQUID 02 Blank $484.58 HCPCS - Non-Drugs E0440 Blank OXYGEN SYSTEM LIQUID STATION Blank $14,009.99 HCPCS - Non-Drugs E0440 NU OXYGEN SYSTEM LIQUID STATION Blank $14,009.99 HCPCS - Non-Drugs E0440 UE OXYGEN SYSTEM LIQUID STATION Blank $10,475.99 HCPCS - Non-Drugs E0441 Blank STATIONARY O2 CONTENTS, GAS Blank $312.13 HCPCS - Non-Drugs E0442 Blank STATIONARY O2 CONTENTS, LIQ Blank $312.13 HCPCS - Non-Drugs E0443 Blank PORTABLE 02 CONTENTS, GAS Blank $270.54 HCPCS - Non-Drugs E0444 Blank PORTABLE 02 CONTENTS, LIQUID Blank $270.54 HCPCS - Non-Drugs E0445 Blank OXIMETER NON-INVASIVE Blank $228.60 HCPCS - Non-Drugs E0446 Blank TOPICAL OX DELIVER SYS, NOS Blank $270.54 HCPCS - Non-Drugs E0455 Blank OXYGEN TENT EXCL CROUP/PED T Blank $28.21 HCPCS - Non-Drugs E0457 Blank CHEST SHELL Blank $799.44 HCPCS - Non-Drugs E0457 NU CHEST SHELL Blank $799.44 HCPCS - Non-Drugs E0457 RR CHEST SHELL Blank $147.86 HCPCS - Non-Drugs E0457 UE CHEST SHELL Blank $618.39 HCPCS - Non-Drugs E0459 Blank CHEST WRAP Blank $675.16 HCPCS - Non-Drugs E0459 NU CHEST WRAP Blank $675.16 HCPCS - Non-Drugs E0459 RR CHEST WRAP Blank $135.59 HCPCS - Non-Drugs E0459 UE CHEST WRAP Blank $525.31 HCPCS - Non-Drugs E0462 Blank ROCKING BED W/ OR W/O SIDE R Blank $5,624.04 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0462 NU ROCKING BED W/ OR W/O SIDE R Blank $5,624.04 HCPCS - Non-Drugs E0462 RR ROCKING BED W/ OR W/O SIDE R Blank $763.62 HCPCS - Non-Drugs E0462 UE ROCKING BED W/ OR W/O SIDE R Blank $3,454.49 HCPCS - Non-Drugs E0465 Blank HOME VENT INVASIVE INTERFACE Blank $14,519.57 HCPCS - Non-Drugs E0465 RR HOME VENT INVASIVE INTERFACE Blank $1,971.43 HCPCS - Non-Drugs E0466 Blank HOME VENT NON-INVASIVE INTER Blank $14,519.57 HCPCS - Non-Drugs E0466 RR HOME VENT NON-INVASIVE INTER Blank $1,971.43 HCPCS - Non-Drugs E0470 Blank RAD W/O BACKUP NON-INV INTFC Blank $2,007.34 HCPCS - Non-Drugs E0470 RR RAD W/O BACKUP NON-INV INTFC Blank $272.55 HCPCS - Non-Drugs E0471 Blank RAD W/BACKUP NON INV INTRFC Blank $4,161.64 HCPCS - Non-Drugs E0471 RR RAD W/BACKUP NON INV INTRFC Blank $565.06 HCPCS - Non-Drugs E0472 Blank RAD W BACKUP INVASIVE INTRFC Blank $6,031.78 HCPCS - Non-Drugs E0472 RR RAD W BACKUP INVASIVE INTRFC Blank $818.98 HCPCS - Non-Drugs E0480 Blank PERCUSSOR ELECT/PNEUM HOME M Blank $1,189.58 HCPCS - Non-Drugs E0480 NU PERCUSSOR ELECT/PNEUM HOME M Blank $1,189.58 HCPCS - Non-Drugs E0480 RR PERCUSSOR ELECT/PNEUM HOME M Blank $161.52 HCPCS - Non-Drugs E0480 UE PERCUSSOR ELECT/PNEUM HOME M Blank $520.19 HCPCS - Non-Drugs E0481 Blank INTRPULMNRY PERCUSS VENT SYS Blank $638.29 HCPCS - Non-Drugs E0482 Blank COUGH STIMULATING DEVICE Blank $6,933.26 HCPCS - Non-Drugs E0482 RR COUGH STIMULATING DEVICE Blank $941.38 HCPCS - Non-Drugs E0483 Blank CHEST COMPRESSION GEN SYSTEM Blank $16,777.38 HCPCS - Non-Drugs E0483 RR CHEST COMPRESSION GEN SYSTEM Blank $2,277.99 HCPCS - Non-Drugs E0484 Blank NON-ELEC OSCILLATORY PEP DVC Blank $152.26 HCPCS - Non-Drugs E0484 NU NON-ELEC OSCILLATORY PEP DVC Blank $152.26 HCPCS - Non-Drugs E0484 RR NON-ELEC OSCILLATORY PEP DVC Blank $40.09 HCPCS - Non-Drugs E0484 UE NON-ELEC OSCILLATORY PEP DVC Blank $133.13 HCPCS - Non-Drugs E0485 Blank ORAL DEVICE/APPLIANCE PREFAB Blank $787.07 HCPCS - Non-Drugs E0485 NU ORAL DEVICE/APPLIANCE PREFAB Blank $787.07 HCPCS - Non-Drugs E0485 RR ORAL DEVICE/APPLIANCE PREFAB Blank $103.51 HCPCS - Non-Drugs E0485 UE ORAL DEVICE/APPLIANCE PREFAB Blank $791.83 HCPCS - Non-Drugs E0486 Blank ORAL DEVICE/APPLIANCE CUSFAB Blank $5,244.85 HCPCS - Non-Drugs E0486 NU ORAL DEVICE/APPLIANCE CUSFAB Blank $5,244.85 HCPCS - Non-Drugs E0486 RR ORAL DEVICE/APPLIANCE CUSFAB Blank $538.69 HCPCS - Non-Drugs E0486 UE ORAL DEVICE/APPLIANCE CUSFAB Blank $4,040.16 HCPCS - Non-Drugs E0487 Blank ELECTRONIC SPIROMETER Blank $320.71 HCPCS - Non-Drugs E0500 Blank IPPB ALL TYPES Blank $2,175.02 HCPCS - Non-Drugs E0500 NU IPPB ALL TYPES Blank $2,175.02 HCPCS - Non-Drugs E0500 RR IPPB ALL TYPES Blank $295.32 HCPCS - Non-Drugs E0500 UE IPPB ALL TYPES Blank $1,185.58 HCPCS - Non-Drugs E0550 Blank HUMIDIF EXTENS SUPPLE W IPPB Blank $1,289.90 HCPCS - Non-Drugs E0550 NU HUMIDIF EXTENS SUPPLE W IPPB Blank $1,289.90 HCPCS - Non-Drugs E0550 RR HUMIDIF EXTENS SUPPLE W IPPB Blank $175.14 HCPCS - Non-Drugs E0550 UE HUMIDIF EXTENS SUPPLE W IPPB Blank $582.59 HCPCS - Non-Drugs E0555 Blank HUMIDIFIER FOR USE W/ REGULA Blank $6.50 HCPCS - Non-Drugs E0555 NU HUMIDIFIER FOR USE W/ REGULA Blank $6.50 HCPCS - Non-Drugs E0555 RR HUMIDIFIER FOR USE W/ REGULA Blank $0.66 HCPCS - Non-Drugs E0555 UE HUMIDIFIER FOR USE W/ REGULA Blank $6.00 HCPCS - Non-Drugs E0560 Blank HUMIDIFIER SUPPLEMENTAL W/ I Blank $360.31 HCPCS - Non-Drugs E0560 NU HUMIDIFIER SUPPLEMENTAL W/ I Blank $360.31 HCPCS - Non-Drugs E0560 RR HUMIDIFIER SUPPLEMENTAL W/ I Blank $109.90 HCPCS - Non-Drugs E0560 UE HUMIDIFIER SUPPLEMENTAL W/ I Blank $289.18 HCPCS - Non-Drugs E0561 Blank HUMIDIFIER NONHEATED W PAP Blank $209.65 HCPCS - Non-Drugs E0561 NU HUMIDIFIER NONHEATED W PAP Blank $209.65 HCPCS - Non-Drugs E0561 RR HUMIDIFIER NONHEATED W PAP Blank $78.08 HCPCS - Non-Drugs E0561 UE HUMIDIFIER NONHEATED W PAP Blank $176.18 HCPCS - Non-Drugs E0562 Blank HUMIDIFIER HEATED USED W PAP Blank $328.04 HCPCS - Non-Drugs E0562 NU HUMIDIFIER HEATED USED W PAP Blank $328.04 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0562 RR HUMIDIFIER HEATED USED W PAP Blank $100.98 HCPCS - Non-Drugs E0562 UE HUMIDIFIER HEATED USED W PAP Blank $264.97 HCPCS - Non-Drugs E0565 Blank COMPRESSOR AIR POWER SOURCE Blank $1,126.05 HCPCS - Non-Drugs E0565 NU COMPRESSOR AIR POWER SOURCE Blank $1,126.05 HCPCS - Non-Drugs E0565 RR COMPRESSOR AIR POWER SOURCE Blank $152.89 HCPCS - Non-Drugs E0565 UE COMPRESSOR AIR POWER SOURCE Blank $614.81 HCPCS - Non-Drugs E0570 Blank NEBULIZER WITH COMPRESSION Blank $417.98 HCPCS - Non-Drugs E0570 NU NEBULIZER WITH COMPRESSION Blank $417.98 HCPCS - Non-Drugs E0570 RR NEBULIZER WITH COMPRESSION Blank $56.75 HCPCS - Non-Drugs E0570 UE NEBULIZER WITH COMPRESSION Blank $319.82 HCPCS - Non-Drugs E0572 Blank AEROSOL COMPRESSOR ADJUST PR Blank $907.99 HCPCS - Non-Drugs E0572 RR AEROSOL COMPRESSOR ADJUST PR Blank $114.90 HCPCS - Non-Drugs E0574 Blank ULTRASONIC GENERATOR W SVNEB Blank $1,381.19 HCPCS - Non-Drugs E0574 RR ULTRASONIC GENERATOR W SVNEB Blank $187.53 HCPCS - Non-Drugs E0575 Blank NEBULIZER ULTRASONIC Blank $2,066.00 HCPCS - Non-Drugs E0575 NU NEBULIZER ULTRASONIC Blank $2,066.00 HCPCS - Non-Drugs E0575 RR NEBULIZER ULTRASONIC Blank $280.52 HCPCS - Non-Drugs E0575 UE NEBULIZER ULTRASONIC Blank $1,115.51 HCPCS - Non-Drugs E0580 Blank NEBULIZER FOR USE W/ REGULAT Blank $314.52 HCPCS - Non-Drugs E0580 NU NEBULIZER FOR USE W/ REGULAT Blank $314.52 HCPCS - Non-Drugs E0580 RR NEBULIZER FOR USE W/ REGULAT Blank $99.64 HCPCS - Non-Drugs E0580 UE NEBULIZER FOR USE W/ REGULAT Blank $254.80 HCPCS - Non-Drugs E0585 Blank NEBULIZER W/ COMPRESSOR & HE Blank $941.45 HCPCS - Non-Drugs E0585 NU NEBULIZER W/ COMPRESSOR & HE Blank $941.45 HCPCS - Non-Drugs E0585 RR NEBULIZER W/ COMPRESSOR & HE Blank $127.83 HCPCS - Non-Drugs E0585 UE NEBULIZER W/ COMPRESSOR & HE Blank $385.68 HCPCS - Non-Drugs E0600 Blank SUCTION PUMP PORTAB HOM MODL Blank $1,224.30 HCPCS - Non-Drugs E0600 NU SUCTION PUMP PORTAB HOM MODL Blank $1,224.30 HCPCS - Non-Drugs E0600 RR SUCTION PUMP PORTAB HOM MODL Blank $166.23 HCPCS - Non-Drugs E0600 UE SUCTION PUMP PORTAB HOM MODL Blank $538.60 HCPCS - Non-Drugs E0601 Blank CONT AIRWAY PRESSURE DEVICE Blank $1,112.86 HCPCS - Non-Drugs E0601 NU CONT AIRWAY PRESSURE DEVICE Blank $1,112.86 HCPCS - Non-Drugs E0601 RR CONT AIRWAY PRESSURE DEVICE Blank $151.10 HCPCS - Non-Drugs E0601 UE CONT AIRWAY PRESSURE DEVICE Blank $926.28 HCPCS - Non-Drugs E0602 Blank MANUAL BREAST PUMP Blank $136.89 HCPCS - Non-Drugs E0602 NU MANUAL BREAST PUMP Blank $136.89 HCPCS - Non-Drugs E0602 RR MANUAL BREAST PUMP Blank $32.27 HCPCS - Non-Drugs E0602 UE MANUAL BREAST PUMP Blank $121.61 HCPCS - Non-Drugs E0603 Blank ELECTRIC BREAST PUMP Blank $174.97 HCPCS - Non-Drugs E0603 NU ELECTRIC BREAST PUMP Blank $174.97 HCPCS - Non-Drugs E0603 RR ELECTRIC BREAST PUMP Blank $108.99 HCPCS - Non-Drugs E0603 UE ELECTRIC BREAST PUMP Blank $155.02 HCPCS - Non-Drugs E0604 Blank HOSP GRADE ELEC BREAST PUMP Blank $360.62 HCPCS - Non-Drugs E0604 NU HOSP GRADE ELEC BREAST PUMP Blank $360.62 HCPCS - Non-Drugs E0604 RR HOSP GRADE ELEC BREAST PUMP Blank $185.20 HCPCS - Non-Drugs E0604 UE HOSP GRADE ELEC BREAST PUMP Blank $289.53 HCPCS - Non-Drugs E0605 Blank VAPORIZER ROOM TYPE Blank $129.50 HCPCS - Non-Drugs E0605 NU VAPORIZER ROOM TYPE Blank $129.50 HCPCS - Non-Drugs E0605 RR VAPORIZER ROOM TYPE Blank $34.63 HCPCS - Non-Drugs E0605 UE VAPORIZER ROOM TYPE Blank $118.94 HCPCS - Non-Drugs E0606 Blank DRAINAGE BOARD POSTURAL Blank $885.78 HCPCS - Non-Drugs E0606 NU DRAINAGE BOARD POSTURAL Blank $885.78 HCPCS - Non-Drugs E0606 RR DRAINAGE BOARD POSTURAL Blank $120.27 HCPCS - Non-Drugs E0606 UE DRAINAGE BOARD POSTURAL Blank $307.94 HCPCS - Non-Drugs E0607 Blank BLOOD GLUCOSE MONITOR HOME Blank $214.18 HCPCS - Non-Drugs E0607 NU BLOOD GLUCOSE MONITOR HOME Blank $214.18 HCPCS - Non-Drugs E0607 RR BLOOD GLUCOSE MONITOR HOME Blank $81.19 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0607 UE BLOOD GLUCOSE MONITOR HOME Blank $179.56 HCPCS - Non-Drugs E0610 Blank PACEMAKER MONITR AUDIBLE/VIS Blank $560.89 HCPCS - Non-Drugs E0610 NU PACEMAKER MONITR AUDIBLE/VIS Blank $560.89 HCPCS - Non-Drugs E0610 RR PACEMAKER MONITR AUDIBLE/VIS Blank $126.98 HCPCS - Non-Drugs E0610 UE PACEMAKER MONITR AUDIBLE/VIS Blank $439.51 HCPCS - Non-Drugs E0615 Blank PACEMAKER MONITR DIGITAL/VIS Blank $1,020.03 HCPCS - Non-Drugs E0615 NU PACEMAKER MONITR DIGITAL/VIS Blank $1,020.03 HCPCS - Non-Drugs E0615 RR PACEMAKER MONITR DIGITAL/VIS Blank $189.65 HCPCS - Non-Drugs E0615 UE PACEMAKER MONITR DIGITAL/VIS Blank $782.64 HCPCS - Non-Drugs E0616 Blank CARDIAC EVENT RECORDER Blank $6,729.34 HCPCS - Non-Drugs E0617 Blank AUTOMATIC EXT DEFIBRILLATOR Blank $5,196.39 HCPCS - Non-Drugs E0617 RR AUTOMATIC EXT DEFIBRILLATOR Blank $705.55 HCPCS - Non-Drugs E0618 Blank APNEA MONITOR Blank $4,583.86 HCPCS - Non-Drugs E0618 RR APNEA MONITOR Blank $622.38 HCPCS - Non-Drugs E0619 Blank APNEA MONITOR W RECORDER Blank $4,583.86 HCPCS - Non-Drugs E0619 RR APNEA MONITOR W RECORDER Blank $622.38 HCPCS - Non-Drugs E0620 Blank CAP BLD SKIN PIERCING LASER Blank $1,891.73 HCPCS - Non-Drugs E0620 NU CAP BLD SKIN PIERCING LASER Blank $1,891.73 HCPCS - Non-Drugs E0620 RR CAP BLD SKIN PIERCING LASER Blank $256.85 HCPCS - Non-Drugs E0620 UE CAP BLD SKIN PIERCING LASER Blank $960.03 HCPCS - Non-Drugs E0621 Blank PATIENT LIFT SLING OR SEAT Blank $227.66 HCPCS - Non-Drugs E0621 NU PATIENT LIFT SLING OR SEAT Blank $227.66 HCPCS - Non-Drugs E0621 RR PATIENT LIFT SLING OR SEAT Blank $90.83 HCPCS - Non-Drugs E0621 UE PATIENT LIFT SLING OR SEAT Blank $189.68 HCPCS - Non-Drugs E0625 Blank PATIENT LIFT BATHROOM OR TOI Blank $1,499.01 HCPCS - Non-Drugs E0625 NU PATIENT LIFT BATHROOM OR TOI Blank $1,499.01 HCPCS - Non-Drugs E0625 RR PATIENT LIFT BATHROOM OR TOI Blank $203.53 HCPCS - Non-Drugs E0625 UE PATIENT LIFT BATHROOM OR TOI Blank $1,146.98 HCPCS - Non-Drugs E0627 Blank SEAT LIFT MECH, ELECTRIC ANY Blank $550.61 HCPCS - Non-Drugs E0627 NU SEAT LIFT MECH, ELECTRIC ANY Blank $550.61 HCPCS - Non-Drugs E0627 RR SEAT LIFT MECH, ELECTRIC ANY Blank $123.23 HCPCS - Non-Drugs E0627 UE SEAT LIFT MECH, ELECTRIC ANY Blank $431.89 HCPCS - Non-Drugs E0629 Blank SEAT LIFT MECH, NON-ELECTRIC Blank $545.85 HCPCS - Non-Drugs E0629 NU SEAT LIFT MECH, NON-ELECTRIC Blank $545.85 HCPCS - Non-Drugs E0629 RR SEAT LIFT MECH, NON-ELECTRIC Blank $122.76 HCPCS - Non-Drugs E0629 UE SEAT LIFT MECH, NON-ELECTRIC Blank $428.32 HCPCS - Non-Drugs E0630 Blank PATIENT LIFT HYDRAULIC Blank $1,345.17 HCPCS - Non-Drugs E0630 NU PATIENT LIFT HYDRAULIC Blank $1,345.17 HCPCS - Non-Drugs E0630 RR PATIENT LIFT HYDRAULIC Blank $182.64 HCPCS - Non-Drugs E0630 UE PATIENT LIFT HYDRAULIC Blank $975.89 HCPCS - Non-Drugs E0635 Blank PATIENT LIFT ELECTRIC Blank $2,143.83 HCPCS - Non-Drugs E0635 NU PATIENT LIFT ELECTRIC Blank $2,143.83 HCPCS - Non-Drugs E0635 RR PATIENT LIFT ELECTRIC Blank $291.08 HCPCS - Non-Drugs E0635 UE PATIENT LIFT ELECTRIC Blank $1,156.42 HCPCS - Non-Drugs E0636 Blank PT SUPPORT & POSITIONING SYS Blank $13,803.14 HCPCS - Non-Drugs E0636 RR PT SUPPORT & POSITIONING SYS Blank $1,874.16 HCPCS - Non-Drugs E0637 Blank COMBINATION SIT TO STAND SYS Blank $1,930.23 HCPCS - Non-Drugs E0638 Blank STANDING FRAME SYS Blank $1,735.76 HCPCS - Non-Drugs E0639 Blank MOVEABLE PATIENT LIFT SYSTEM Blank $2,184.01 HCPCS - Non-Drugs E0639 RR MOVEABLE PATIENT LIFT SYSTEM Blank $296.54 HCPCS - Non-Drugs E0640 Blank FIXED PATIENT LIFT SYSTEM Blank $2,184.01 HCPCS - Non-Drugs E0640 RR FIXED PATIENT LIFT SYSTEM Blank $296.54 HCPCS - Non-Drugs E0641 Blank MULTI-POSITION STND FRAM SYS Blank $1,238.63 HCPCS - Non-Drugs E0642 Blank DYNAMIC STANDING FRAME Blank $2,544.03 HCPCS - Non-Drugs E0650 Blank PNEUMA COMPRESOR NON-SEGMENT Blank $1,494.16 HCPCS - Non-Drugs E0650 NU PNEUMA COMPRESOR NON-SEGMENT Blank $1,494.16 HCPCS - Non-Drugs E0650 RR PNEUMA COMPRESOR NON-SEGMENT Blank $250.90 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0650 UE PNEUMA COMPRESOR NON-SEGMENT Blank $1,123.65 HCPCS - Non-Drugs E0651 Blank PNEUM COMPRESSOR SEGMENTAL Blank $1,870.05 HCPCS - Non-Drugs E0651 NU PNEUM COMPRESSOR SEGMENTAL Blank $1,870.05 HCPCS - Non-Drugs E0651 RR PNEUM COMPRESSOR SEGMENTAL Blank $261.32 HCPCS - Non-Drugs E0651 UE PNEUM COMPRESSOR SEGMENTAL Blank $1,421.50 HCPCS - Non-Drugs E0652 Blank PNEUM COMPRES W/CAL PRESSURE Blank $10,755.50 HCPCS - Non-Drugs E0652 NU PNEUM COMPRES W/CAL PRESSURE Blank $10,755.50 HCPCS - Non-Drugs E0652 RR PNEUM COMPRES W/CAL PRESSURE Blank $1,123.19 HCPCS - Non-Drugs E0652 UE PNEUM COMPRES W/CAL PRESSURE Blank $8,003.85 HCPCS - Non-Drugs E0655 Blank PNEUMATIC APPLIANCE HALF ARM Blank $288.97 HCPCS - Non-Drugs E0655 NU PNEUMATIC APPLIANCE HALF ARM Blank $288.97 HCPCS - Non-Drugs E0655 RR PNEUMATIC APPLIANCE HALF ARM Blank $99.75 HCPCS - Non-Drugs E0655 UE PNEUMATIC APPLIANCE HALF ARM Blank $236.60 HCPCS - Non-Drugs E0656 Blank SEGMENTAL PNEUMATIC TRUNK Blank $1,439.48 HCPCS - Non-Drugs E0656 NU SEGMENTAL PNEUMATIC TRUNK Blank $1,439.48 HCPCS - Non-Drugs E0656 RR SEGMENTAL PNEUMATIC TRUNK Blank $195.45 HCPCS - Non-Drugs E0656 UE SEGMENTAL PNEUMATIC TRUNK Blank $660.33 HCPCS - Non-Drugs E0657 Blank SEGMENTAL PNEUMATIC CHEST Blank $1,386.03 HCPCS - Non-Drugs E0657 NU SEGMENTAL PNEUMATIC CHEST Blank $1,386.03 HCPCS - Non-Drugs E0657 RR SEGMENTAL PNEUMATIC CHEST Blank $188.19 HCPCS - Non-Drugs E0657 UE SEGMENTAL PNEUMATIC CHEST Blank $625.04 HCPCS - Non-Drugs E0660 Blank PNEUMATIC APPLIANCE FULL LEG Blank $388.59 HCPCS - Non-Drugs E0660 NU PNEUMATIC APPLIANCE FULL LEG Blank $388.59 HCPCS - Non-Drugs E0660 RR PNEUMATIC APPLIANCE FULL LEG Blank $108.16 HCPCS - Non-Drugs E0660 UE PNEUMATIC APPLIANCE FULL LEG Blank $309.91 HCPCS - Non-Drugs E0665 Blank PNEUMATIC APPLIANCE FULL ARM Blank $342.94 HCPCS - Non-Drugs E0665 NU PNEUMATIC APPLIANCE FULL ARM Blank $342.94 HCPCS - Non-Drugs E0665 RR PNEUMATIC APPLIANCE FULL ARM Blank $103.38 HCPCS - Non-Drugs E0665 UE PNEUMATIC APPLIANCE FULL ARM Blank $274.78 HCPCS - Non-Drugs E0666 Blank PNEUMATIC APPLIANCE HALF LEG Blank $346.07 HCPCS - Non-Drugs E0666 NU PNEUMATIC APPLIANCE HALF LEG Blank $346.07 HCPCS - Non-Drugs E0666 RR PNEUMATIC APPLIANCE HALF LEG Blank $103.70 HCPCS - Non-Drugs E0666 UE PNEUMATIC APPLIANCE HALF LEG Blank $278.92 HCPCS - Non-Drugs E0667 Blank SEG PNEUMATIC APPL FULL LEG Blank $735.08 HCPCS - Non-Drugs E0667 NU SEG PNEUMATIC APPL FULL LEG Blank $735.08 HCPCS - Non-Drugs E0667 RR SEG PNEUMATIC APPL FULL LEG Blank $149.19 HCPCS - Non-Drugs E0667 UE SEG PNEUMATIC APPL FULL LEG Blank $570.25 HCPCS - Non-Drugs E0668 Blank SEG PNEUMATIC APPL FULL ARM Blank $939.19 HCPCS - Non-Drugs E0668 NU SEG PNEUMATIC APPL FULL ARM Blank $939.19 HCPCS - Non-Drugs E0668 RR SEG PNEUMATIC APPL FULL ARM Blank $161.10 HCPCS - Non-Drugs E0668 UE SEG PNEUMATIC APPL FULL ARM Blank $724.09 HCPCS - Non-Drugs E0669 Blank SEG PNEUMATIC APPLI HALF LEG Blank $447.47 HCPCS - Non-Drugs E0669 NU SEG PNEUMATIC APPLI HALF LEG Blank $447.47 HCPCS - Non-Drugs E0669 RR SEG PNEUMATIC APPLI HALF LEG Blank $112.93 HCPCS - Non-Drugs E0669 UE SEG PNEUMATIC APPLI HALF LEG Blank $354.56 HCPCS - Non-Drugs E0670 Blank SEG PNEUM INT LEGS/TRUNK Blank $2,617.34 HCPCS - Non-Drugs E0670 NU SEG PNEUM INT LEGS/TRUNK Blank $2,617.34 HCPCS - Non-Drugs E0670 RR SEG PNEUM INT LEGS/TRUNK Blank $346.20 HCPCS - Non-Drugs E0670 UE SEG PNEUM INT LEGS/TRUNK Blank $1,981.88 HCPCS - Non-Drugs E0671 Blank PRESSURE PNEUM APPL FULL LEG Blank $936.45 HCPCS - Non-Drugs E0671 NU PRESSURE PNEUM APPL FULL LEG Blank $936.45 HCPCS - Non-Drugs E0671 RR PRESSURE PNEUM APPL FULL LEG Blank $161.86 HCPCS - Non-Drugs E0671 UE PRESSURE PNEUM APPL FULL LEG Blank $721.25 HCPCS - Non-Drugs E0672 Blank PRESSURE PNEUM APPL FULL ARM Blank $744.50 HCPCS - Non-Drugs E0672 NU PRESSURE PNEUM APPL FULL ARM Blank $744.50 HCPCS - Non-Drugs E0672 RR PRESSURE PNEUM APPL FULL ARM Blank $142.65 HCPCS - Non-Drugs E0672 UE PRESSURE PNEUM APPL FULL ARM Blank $577.35 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0673 Blank PRESSURE PNEUM APPL HALF LEG Blank $631.46 HCPCS - Non-Drugs E0673 NU PRESSURE PNEUM APPL HALF LEG Blank $631.46 HCPCS - Non-Drugs E0673 RR PRESSURE PNEUM APPL HALF LEG Blank $131.33 HCPCS - Non-Drugs E0673 UE PRESSURE PNEUM APPL HALF LEG Blank $492.59 HCPCS - Non-Drugs E0675 Blank PNEUMATIC COMPRESSION DEVICE Blank $6,411.00 HCPCS - Non-Drugs E0675 RR PNEUMATIC COMPRESSION DEVICE Blank $870.47 HCPCS - Non-Drugs E0676 Blank INTER LIMB COMPRESS DEV NOS Blank $260.56 HCPCS - Non-Drugs E0691 Blank UVL PNL 2 SQ FT OR LESS Blank $1,937.14 HCPCS - Non-Drugs E0691 NU UVL PNL 2 SQ FT OR LESS Blank $1,937.14 HCPCS - Non-Drugs E0691 RR UVL PNL 2 SQ FT OR LESS Blank $261.88 HCPCS - Non-Drugs E0691 UE UVL PNL 2 SQ FT OR LESS Blank $1,471.81 HCPCS - Non-Drugs E0692 Blank UVL SYS PANEL 4 FT Blank $2,413.16 HCPCS - Non-Drugs E0692 NU UVL SYS PANEL 4 FT Blank $2,413.16 HCPCS - Non-Drugs E0692 RR UVL SYS PANEL 4 FT Blank $309.41 HCPCS - Non-Drugs E0692 UE UVL SYS PANEL 4 FT Blank $1,828.79 HCPCS - Non-Drugs E0693 Blank UVL SYS PANEL 6 FT Blank $2,957.11 HCPCS - Non-Drugs E0693 NU UVL SYS PANEL 6 FT Blank $2,957.11 HCPCS - Non-Drugs E0693 RR UVL SYS PANEL 6 FT Blank $363.90 HCPCS - Non-Drugs E0693 UE UVL SYS PANEL 6 FT Blank $2,236.76 HCPCS - Non-Drugs E0694 Blank UVL MD CABINET SYS 6 FT Blank $9,246.82 HCPCS - Non-Drugs E0694 NU UVL MD CABINET SYS 6 FT Blank $9,246.82 HCPCS - Non-Drugs E0694 RR UVL MD CABINET SYS 6 FT Blank $992.85 HCPCS - Non-Drugs E0694 UE UVL MD CABINET SYS 6 FT Blank $6,954.11 HCPCS - Non-Drugs E0700 Blank SAFETY EQUIPMENT Blank $53.59 HCPCS - Non-Drugs E0705 Blank TRANSFER DEVICE Blank $159.75 HCPCS - Non-Drugs E0705 NU TRANSFER DEVICE Blank $159.75 HCPCS - Non-Drugs E0705 RR TRANSFER DEVICE Blank $44.15 HCPCS - Non-Drugs E0705 UE TRANSFER DEVICE Blank $138.76 HCPCS - Non-Drugs E0710 Blank RESTRAINTS ANY TYPE Blank $95.78 HCPCS - Non-Drugs E0720 Blank TENS TWO LEAD Blank $198.02 HCPCS - Non-Drugs E0720 NU TENS TWO LEAD Blank $198.02 HCPCS - Non-Drugs E0720 RR TENS TWO LEAD Blank $119.22 HCPCS - Non-Drugs E0720 UE TENS TWO LEAD Blank $400.51 HCPCS - Non-Drugs E0730 Blank TENS FOUR LEAD Blank $198.98 HCPCS - Non-Drugs E0730 NU TENS FOUR LEAD Blank $198.98 HCPCS - Non-Drugs E0730 RR TENS FOUR LEAD Blank $119.22 HCPCS - Non-Drugs E0730 UE TENS FOUR LEAD Blank $403.07 HCPCS - Non-Drugs E0731 Blank CONDUCTIVE GARMENT FOR TENS/ Blank $228.77 HCPCS - Non-Drugs E0731 NU CONDUCTIVE GARMENT FOR TENS/ Blank $228.77 HCPCS - Non-Drugs E0731 RR CONDUCTIVE GARMENT FOR TENS/ Blank $31.06 HCPCS - Non-Drugs E0740 Blank NON-IMPLANT PELV FLR E-STIM Blank $1,355.75 HCPCS - Non-Drugs E0740 NU INCONTINENCE TREATMENT SYSTM Blank $1,355.75 HCPCS - Non-Drugs E0740 RR NON-IMPLANT PELV FLR E-STIM Blank $184.08 HCPCS - Non-Drugs E0740 UE INCONTINENCE TREATMENT SYSTM Blank $604.58 HCPCS - Non-Drugs E0744 Blank NEUROMUSCULAR STIM FOR SCOLI Blank $1,876.89 HCPCS - Non-Drugs E0744 NU NEUROMUSCULAR STIM FOR SCOLI Blank $1,876.89 HCPCS - Non-Drugs E0744 RR NEUROMUSCULAR STIM FOR SCOLI Blank $254.84 HCPCS - Non-Drugs E0744 UE NEUROMUSCULAR STIM FOR SCOLI Blank $1,001.97 HCPCS - Non-Drugs E0745 Blank NEUROMUSCULAR STIM FOR SHOCK Blank $1,852.19 HCPCS - Non-Drugs E0745 NU NEUROMUSCULAR STIM FOR SHOCK Blank $1,852.19 HCPCS - Non-Drugs E0745 RR NEUROMUSCULAR STIM FOR SHOCK Blank $251.49 HCPCS - Non-Drugs E0745 UE NEUROMUSCULAR STIM FOR SHOCK Blank $981.00 HCPCS - Non-Drugs E0746 Blank ELECTROMYOGRAPH BIOFEEDBACK Blank $243.57 HCPCS - Non-Drugs E0746 NU ELECTROMYOGRAPH BIOFEEDBACK Blank $243.57 HCPCS - Non-Drugs E0746 RR ELECTROMYOGRAPH BIOFEEDBACK Blank $26.66 HCPCS - Non-Drugs E0746 UE ELECTROMYOGRAPH BIOFEEDBACK Blank $183.41 HCPCS - Non-Drugs E0747 Blank ELEC OSTEOGEN STIM NOT SPINE Blank $7,786.65 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0747 NU ELEC OSTEOGEN STIM NOT SPINE Blank $7,786.65 HCPCS - Non-Drugs E0747 RR ELEC OSTEOGEN STIM NOT SPINE Blank $849.04 HCPCS - Non-Drugs E0747 UE ELEC OSTEOGEN STIM NOT SPINE Blank $5,765.86 HCPCS - Non-Drugs E0748 Blank ELEC OSTEOGEN STIM SPINAL Blank $8,138.17 HCPCS - Non-Drugs E0748 NU ELEC OSTEOGEN STIM SPINAL Blank $8,138.17 HCPCS - Non-Drugs E0748 RR ELEC OSTEOGEN STIM SPINAL Blank $881.95 HCPCS - Non-Drugs E0748 UE ELEC OSTEOGEN STIM SPINAL Blank $6,122.56 HCPCS - Non-Drugs E0749 Blank ELEC OSTEOGEN STIM IMPLANTED Blank $4,664.42 HCPCS - Non-Drugs E0749 RR ELEC OSTEOGEN STIM IMPLANTED Blank $633.32 HCPCS - Non-Drugs E0760 Blank OSTEOGEN ULTRASOUND STIMLTOR Blank $6,773.02 HCPCS - Non-Drugs E0760 NU OSTEOGEN ULTRASOUND STIMLTOR Blank $6,773.02 HCPCS - Non-Drugs E0760 RR OSTEOGEN ULTRASOUND STIMLTOR Blank $745.48 HCPCS - Non-Drugs E0760 UE OSTEOGEN ULTRASOUND STIMLTOR Blank $5,098.65 HCPCS - Non-Drugs E0761 Blank NONTHERM ELECTROMGNTC DEVICE Blank $2,098.12 HCPCS - Non-Drugs E0762 Blank TRANS ELEC JT STIM DEV SYS Blank $2,122.72 HCPCS - Non-Drugs E0762 NU TRANS ELEC JT STIM DEV SYS Blank $2,122.72 HCPCS - Non-Drugs E0762 RR TRANS ELEC JT STIM DEV SYS Blank $288.22 HCPCS - Non-Drugs E0762 UE TRANS ELEC JT STIM DEV SYS Blank $1,187.62 HCPCS - Non-Drugs E0764 Blank FUNCTIONAL NEUROMUSCULARSTIM Blank $17,441.49 HCPCS - Non-Drugs E0764 NU FUNCTIONAL NEUROMUSCULARSTIM Blank $17,441.49 HCPCS - Non-Drugs E0764 RR FUNCTIONAL NEUROMUSCULARSTIM Blank $2,368.16 HCPCS - Non-Drugs E0764 UE FUNCTIONAL NEUROMUSCULARSTIM Blank $11,268.15 HCPCS - Non-Drugs E0765 Blank NERVE STIMULATOR FOR TX N&V Blank $250.02 HCPCS - Non-Drugs E0765 NU NERVE STIMULATOR FOR TX N&V Blank $250.02 HCPCS - Non-Drugs E0765 RR NERVE STIMULATOR FOR TX N&V Blank $93.20 HCPCS - Non-Drugs E0765 UE NERVE STIMULATOR FOR TX N&V Blank $206.50 HCPCS - Non-Drugs E0766 Blank ELEC STIM CANCER TREATMENT Blank $327.48 HCPCS - Non-Drugs E0769 Blank ELECTRIC WOUND TREATMENT DEV Blank $198.98 HCPCS - Non-Drugs E0770 Blank FUNCTIONAL ELECTRIC STIM NOS Blank $198.98 HCPCS - Non-Drugs E0776 Blank IV POLE Blank $330.08 HCPCS - Non-Drugs E0776 NU IV POLE Blank $330.08 HCPCS - Non-Drugs E0776 RR IV POLE Blank $101.33 HCPCS - Non-Drugs E0776 UE IV POLE Blank $265.29 HCPCS - Non-Drugs E0779 Blank AMB INFUSION PUMP MECHANICAL Blank $800.81 HCPCS - Non-Drugs E0779 RR AMB INFUSION PUMP MECHANICAL Blank $108.73 HCPCS - Non-Drugs E0780 Blank MECH AMB INFUSION PUMP <8HRS Blank $96.84 HCPCS - Non-Drugs E0780 NU MECH AMB INFUSION PUMP <8HRS Blank $96.84 HCPCS - Non-Drugs E0781 Blank EXTERNAL AMBULATORY INFUS PU Blank $3,729.17 HCPCS - Non-Drugs E0781 RR EXTERNAL AMBULATORY INFUS PU Blank $506.34 HCPCS - Non-Drugs E0782 Blank NON-PROGRAMBLE INFUSION PUMP Blank $8,509.01 HCPCS - Non-Drugs E0782 NU NON-PROGRAMBLE INFUSION PUMP Blank $8,509.01 HCPCS - Non-Drugs E0782 RR NON-PROGRAMBLE INFUSION PUMP Blank $919.09 HCPCS - Non-Drugs E0782 UE NON-PROGRAMBLE INFUSION PUMP Blank $6,400.68 HCPCS - Non-Drugs E0783 Blank PROGRAMMABLE INFUSION PUMP Blank $16,689.45 HCPCS - Non-Drugs E0783 NU PROGRAMMABLE INFUSION PUMP Blank $16,689.45 HCPCS - Non-Drugs E0783 RR PROGRAMMABLE INFUSION PUMP Blank $1,737.16 HCPCS - Non-Drugs E0783 UE PROGRAMMABLE INFUSION PUMP Blank $12,536.05 HCPCS - Non-Drugs E0784 Blank EXT AMB INFUSN PUMP INSULIN Blank $6,276.05 HCPCS - Non-Drugs E0784 RR EXT AMB INFUSN PUMP INSULIN Blank $852.15 HCPCS - Non-Drugs E0785 Blank REPLACEMENT IMPL PUMP CATHET Blank $1,015.30 HCPCS - Non-Drugs E0785 KF REPLACEMENT IMPL PUMP CATHET Blank $1,015.30 HCPCS - Non-Drugs E0786 Blank IMPLANTABLE PUMP REPLACEMENT Blank $16,265.24 HCPCS - Non-Drugs E0786 NU IMPLANTABLE PUMP REPLACEMENT Blank $16,265.24 HCPCS - Non-Drugs E0786 RR IMPLANTABLE PUMP REPLACEMENT Blank $1,694.68 HCPCS - Non-Drugs E0786 UE IMPLANTABLE PUMP REPLACEMENT Blank $12,217.89 HCPCS - Non-Drugs E0791 Blank PARENTERAL INFUSION PUMP STA Blank $7,709.86 HCPCS - Non-Drugs E0791 RR PARENTERAL INFUSION PUMP STA Blank $645.82 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0791 UE PARENTERAL INFUSION PUMP STA Blank $4,841.23 HCPCS - Non-Drugs E0830 Blank AMBULATORY TRACTION DEVICE Blank $1,741.37 HCPCS - Non-Drugs E0840 Blank TRACT FRAME ATTACH HEADBOARD Blank $294.92 HCPCS - Non-Drugs E0840 NU TRACT FRAME ATTACH HEADBOARD Blank $294.92 HCPCS - Non-Drugs E0840 RR TRACT FRAME ATTACH HEADBOARD Blank $61.33 HCPCS - Non-Drugs E0840 UE TRACT FRAME ATTACH HEADBOARD Blank $249.18 HCPCS - Non-Drugs E0849 Blank CERVICAL PNEUM TRAC EQUIP Blank $1,344.23 HCPCS - Non-Drugs E0849 NU CERVICAL PNEUM TRAC EQUIP Blank $1,344.23 HCPCS - Non-Drugs E0849 RR CERVICAL PNEUM TRAC EQUIP Blank $182.52 HCPCS - Non-Drugs E0849 UE CERVICAL PNEUM TRAC EQUIP Blank $596.91 HCPCS - Non-Drugs E0850 Blank TRACTION STAND FREE STANDING Blank $361.12 HCPCS - Non-Drugs E0850 NU TRACTION STAND FREE STANDING Blank $361.12 HCPCS - Non-Drugs E0850 RR TRACTION STAND FREE STANDING Blank $49.70 HCPCS - Non-Drugs E0850 UE TRACTION STAND FREE STANDING Blank $306.26 HCPCS - Non-Drugs E0855 Blank CERVICAL TRACTION EQUIPMENT Blank $1,318.71 HCPCS - Non-Drugs E0855 NU CERVICAL TRACTION EQUIPMENT Blank $1,318.71 HCPCS - Non-Drugs E0855 RR CERVICAL TRACTION EQUIPMENT Blank $179.05 HCPCS - Non-Drugs E0855 UE CERVICAL TRACTION EQUIPMENT Blank $584.12 HCPCS - Non-Drugs E0856 Blank CERVIC COLLAR W AIR BLADDERS Blank $792.64 HCPCS - Non-Drugs E0856 NU CERVIC COLLAR W AIR BLADDER Blank $792.64 HCPCS - Non-Drugs E0856 RR CERVIC COLLAR W AIR BLADDERS Blank $107.62 HCPCS - Non-Drugs E0856 UE CERVIC COLLAR W AIR BLADDER Blank $231.23 HCPCS - Non-Drugs E0860 Blank TRACT EQUIP CERVICAL TRACT Blank $165.04 HCPCS - Non-Drugs E0860 NU TRACT EQUIP CERVICAL TRACT Blank $165.04 HCPCS - Non-Drugs E0860 RR TRACT EQUIP CERVICAL TRACT Blank $10.19 HCPCS - Non-Drugs E0860 UE TRACT EQUIP CERVICAL TRACT Blank $122.17 HCPCS - Non-Drugs E0870 Blank TRACT FRAME ATTACH FOOTBOARD Blank $382.07 HCPCS - Non-Drugs E0870 NU TRACT FRAME ATTACH FOOTBOARD Blank $382.07 HCPCS - Non-Drugs E0870 RR TRACT FRAME ATTACH FOOTBOARD Blank $46.91 HCPCS - Non-Drugs E0870 UE TRACT FRAME ATTACH FOOTBOARD Blank $321.92 HCPCS - Non-Drugs E0880 Blank TRAC STAND FREE STAND EXTREM Blank $397.57 HCPCS - Non-Drugs E0880 NU TRAC STAND FREE STAND EXTREM Blank $397.57 HCPCS - Non-Drugs E0880 RR TRAC STAND FREE STAND EXTREM Blank $74.73 HCPCS - Non-Drugs E0880 UE TRAC STAND FREE STAND EXTREM Blank $334.71 HCPCS - Non-Drugs E0890 Blank TRACTION FRAME ATTACH PELVIC Blank $388.38 HCPCS - Non-Drugs E0890 NU TRACTION FRAME ATTACH PELVIC Blank $388.38 HCPCS - Non-Drugs E0890 RR TRACTION FRAME ATTACH PELVIC Blank $140.07 HCPCS - Non-Drugs E0890 UE TRACTION FRAME ATTACH PELVIC Blank $338.07 HCPCS - Non-Drugs E0900 Blank TRAC STAND FREE STAND PELVIC Blank $407.06 HCPCS - Non-Drugs E0900 NU TRAC STAND FREE STAND PELVIC Blank $407.06 HCPCS - Non-Drugs E0900 RR TRAC STAND FREE STAND PELVIC Blank $112.15 HCPCS - Non-Drugs E0900 UE TRAC STAND FREE STAND PELVIC Blank $340.92 HCPCS - Non-Drugs E0910 Blank TRAPEZE BAR ATTACHED TO BED Blank $213.26 HCPCS - Non-Drugs E0910 RR TRAPEZE BAR ATTACHED TO BED Blank $28.96 HCPCS - Non-Drugs E0910 UE TRAPEZE BAR ATTACHED TO BED Blank $309.71 HCPCS - Non-Drugs E0911 Blank HD TRAPEZE BAR ATTACH TO BED Blank $1,255.88 HCPCS - Non-Drugs E0911 RR HD TRAPEZE BAR ATTACH TO BED Blank $170.52 HCPCS - Non-Drugs E0912 Blank HD TRAPEZE BAR FREE STANDING Blank $2,212.24 HCPCS - Non-Drugs E0912 RR HD TRAPEZE BAR FREE STANDING Blank $300.37 HCPCS - Non-Drugs E0920 Blank FRACTURE FRAME ATTACHED TO B Blank $1,510.99 HCPCS - Non-Drugs E0920 RR FRACTURE FRAME ATTACHED TO B Blank $205.16 HCPCS - Non-Drugs E0920 UE FRACTURE FRAME ATTACHED TO B Blank $663.61 HCPCS - Non-Drugs E0930 Blank FRACTURE FRAME FREE STANDING Blank $1,492.63 HCPCS - Non-Drugs E0930 RR FRACTURE FRAME FREE STANDING Blank $202.67 HCPCS - Non-Drugs E0930 UE FRACTURE FRAME FREE STANDING Blank $1,142.10 HCPCS - Non-Drugs E0935 Blank CONT PAS MOTION EXERCISE DEV Blank $883.24 HCPCS - Non-Drugs E0935 RR CONT PAS MOTION EXERCISE DEV Blank $119.92 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0936 Blank CPM DEVICE, OTHER THAN KNEE Blank $77.65 HCPCS - Non-Drugs E0936 RR CPM DEVICE, OTHER THAN KNEE Blank $6.39 HCPCS - Non-Drugs E0940 Blank TRAPEZE BAR FREE STANDING Blank $545.44 HCPCS - Non-Drugs E0940 RR TRAPEZE BAR FREE STANDING Blank $74.06 HCPCS - Non-Drugs E0940 UE TRAPEZE BAR FREE STANDING Blank $436.31 HCPCS - Non-Drugs E0941 Blank GRAVITY ASSISTED TRACTION DE Blank $1,450.43 HCPCS - Non-Drugs E0941 NU GRAVITY ASSISTED TRACTION DE Blank $1,450.43 HCPCS - Non-Drugs E0941 RR GRAVITY ASSISTED TRACTION DE Blank $196.94 HCPCS - Non-Drugs E0941 UE GRAVITY ASSISTED TRACTION DE Blank $1,109.81 HCPCS - Non-Drugs E0942 Blank CERVICAL HEAD HARNESS/HALTER Blank $75.86 HCPCS - Non-Drugs E0942 NU CERVICAL HEAD HARNESS/HALTER Blank $75.86 HCPCS - Non-Drugs E0942 RR CERVICAL HEAD HARNESS/HALTER Blank $2.54 HCPCS - Non-Drugs E0942 UE CERVICAL HEAD HARNESS/HALTER Blank $51.37 HCPCS - Non-Drugs E0944 Blank PELVIC BELT/HARNESS/BOOT Blank $165.72 HCPCS - Non-Drugs E0944 NU PELVIC BELT/HARNESS/BOOT Blank $165.72 HCPCS - Non-Drugs E0944 RR PELVIC BELT/HARNESS/BOOT Blank $18.07 HCPCS - Non-Drugs E0944 UE PELVIC BELT/HARNESS/BOOT Blank $139.91 HCPCS - Non-Drugs E0945 Blank BELT/HARNESS EXTREMITY Blank $164.27 HCPCS - Non-Drugs E0945 NU BELT/HARNESS EXTREMITY Blank $164.27 HCPCS - Non-Drugs E0945 RR BELT/HARNESS EXTREMITY Blank $17.68 HCPCS - Non-Drugs E0945 UE BELT/HARNESS EXTREMITY Blank $140.67 HCPCS - Non-Drugs E0946 Blank FRACTURE FRAME DUAL W CROSS Blank $1,922.50 HCPCS - Non-Drugs E0946 NU FRACTURE FRAME DUAL W CROSS Blank $1,922.50 HCPCS - Non-Drugs E0946 RR FRACTURE FRAME DUAL W CROSS Blank $261.03 HCPCS - Non-Drugs E0946 UE FRACTURE FRAME DUAL W CROSS Blank $1,471.02 HCPCS - Non-Drugs E0947 Blank FRACTURE FRAME ATTACHMNTS PE Blank $1,395.14 HCPCS - Non-Drugs E0947 NU FRACTURE FRAME ATTACHMNTS PE Blank $1,395.14 HCPCS - Non-Drugs E0947 RR FRACTURE FRAME ATTACHMNTS PE Blank $270.11 HCPCS - Non-Drugs E0947 UE FRACTURE FRAME ATTACHMNTS PE Blank $1,080.89 HCPCS - Non-Drugs E0948 Blank FRACTURE FRAME ATTACHMNTS CE Blank $1,369.98 HCPCS - Non-Drugs E0948 NU FRACTURE FRAME ATTACHMNTS CE Blank $1,369.98 HCPCS - Non-Drugs E0948 RR FRACTURE FRAME ATTACHMNTS CE Blank $261.75 HCPCS - Non-Drugs E0948 UE FRACTURE FRAME ATTACHMNTS CE Blank $1,015.89 HCPCS - Non-Drugs E0950 Blank TRAY Blank $225.04 HCPCS - Non-Drugs E0950 NU TRAY Blank $225.04 HCPCS - Non-Drugs E0950 RR TRAY Blank $27.95 HCPCS - Non-Drugs E0950 UE TRAY Blank $184.22 HCPCS - Non-Drugs E0951 Blank LOOP HEEL Blank $53.76 HCPCS - Non-Drugs E0951 NU LOOP HEEL Blank $53.76 HCPCS - Non-Drugs E0951 RR LOOP HEEL Blank $4.84 HCPCS - Non-Drugs E0951 UE LOOP HEEL Blank $36.26 HCPCS - Non-Drugs E0952 Blank TOE LOOP/HOLDER, EACH Blank $69.87 HCPCS - Non-Drugs E0952 NU TOE LOOP/HOLDER, EACH Blank $69.87 HCPCS - Non-Drugs E0952 RR TOE LOOP/HOLDER, EACH Blank $5.90 HCPCS - Non-Drugs E0952 UE TOE LOOP/HOLDER, EACH Blank $47.37 HCPCS - Non-Drugs E0955 Blank CUSHIONED HEADREST Blank $451.92 HCPCS - Non-Drugs E0955 NU CUSHIONED HEADREST Blank $451.92 HCPCS - Non-Drugs E0955 RR CUSHIONED HEADREST Blank $61.36 HCPCS - Non-Drugs E0955 UE CUSHIONED HEADREST Blank $307.02 HCPCS - Non-Drugs E0956 Blank W/C LATERAL TRUNK/HIP SUPPOR Blank $226.19 HCPCS - Non-Drugs E0956 NU W/C LATERAL TRUNK/HIP SUPPOR Blank $226.19 HCPCS - Non-Drugs E0956 RR W/C LATERAL TRUNK/HIP SUPPOR Blank $28.14 HCPCS - Non-Drugs E0956 UE W/C LATERAL TRUNK/HIP SUPPOR Blank $185.08 HCPCS - Non-Drugs E0957 Blank W/C MEDIAL THIGH SUPPORT Blank $320.24 HCPCS - Non-Drugs E0957 NU W/C MEDIAL THIGH SUPPORT Blank $320.24 HCPCS - Non-Drugs E0957 RR W/C MEDIAL THIGH SUPPORT Blank $47.51 HCPCS - Non-Drugs E0957 UE W/C MEDIAL THIGH SUPPORT Blank $255.61 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0958 Blank WHLCHR ATT- CONV 1 ARM DRIVE Blank $1,111.11 HCPCS - Non-Drugs E0958 NU WHLCHR ATT- CONV 1 ARM DRIVE Blank $1,111.11 HCPCS - Non-Drugs E0958 RR WHLCHR ATT- CONV 1 ARM DRIVE Blank $150.86 HCPCS - Non-Drugs E0958 UE WHLCHR ATT- CONV 1 ARM DRIVE Blank $675.39 HCPCS - Non-Drugs E0959 Blank AMPUTEE ADAPTER Blank $156.28 HCPCS - Non-Drugs E0959 NU AMPUTEE ADAPTER Blank $156.28 HCPCS - Non-Drugs E0959 RR AMPUTEE ADAPTER Blank $16.19 HCPCS - Non-Drugs E0959 UE AMPUTEE ADAPTER Blank $132.68 HCPCS - Non-Drugs E0960 Blank W/C SHOULDER HARNESS/STRAPS Blank $218.37 HCPCS - Non-Drugs E0960 NU W/C SHOULDER HARNESS/STRAPS Blank $218.37 HCPCS - Non-Drugs E0960 RR W/C SHOULDER HARNESS/STRAPS Blank $26.82 HCPCS - Non-Drugs E0960 UE W/C SHOULDER HARNESS/STRAPS Blank $179.21 HCPCS - Non-Drugs E0961 Blank WHEELCHAIR BRAKE EXTENSION Blank $94.68 HCPCS - Non-Drugs E0961 NU WHEELCHAIR BRAKE EXTENSION Blank $94.68 HCPCS - Non-Drugs E0961 RR WHEELCHAIR BRAKE EXTENSION Blank $7.51 HCPCS - Non-Drugs E0961 UE WHEELCHAIR BRAKE EXTENSION Blank $64.41 HCPCS - Non-Drugs E0966 Blank WHEELCHAIR HEAD REST EXTENSI Blank $213.10 HCPCS - Non-Drugs E0966 NU WHEELCHAIR HEAD REST EXTENSI Blank $213.10 HCPCS - Non-Drugs E0966 RR WHEELCHAIR HEAD REST EXTENSI Blank $25.89 HCPCS - Non-Drugs E0966 UE WHEELCHAIR HEAD REST EXTENSI Blank $175.26 HCPCS - Non-Drugs E0967 Blank MAN WC RIM/PROJECTION REP EA Blank $215.90 HCPCS - Non-Drugs E0967 NU MAN WC RIM/PROJECTION REP EA Blank $215.90 HCPCS - Non-Drugs E0967 RR MAN WC RIM/PROJECTION REP EA Blank $26.38 HCPCS - Non-Drugs E0967 UE MAN WC RIM/PROJECTION REP EA Blank $177.35 HCPCS - Non-Drugs E0968 Blank WHEELCHAIR COMMODE SEAT Blank $683.13 HCPCS - Non-Drugs E0968 NU WHEELCHAIR COMMODE SEAT Blank $683.13 HCPCS - Non-Drugs E0968 RR WHEELCHAIR COMMODE SEAT Blank $92.75 HCPCS - Non-Drugs E0968 UE WHEELCHAIR COMMODE SEAT Blank $350.22 HCPCS - Non-Drugs E0969 Blank WHEELCHAIR NARROWING DEVICE Blank $436.51 HCPCS - Non-Drugs E0969 NU WHEELCHAIR NARROWING DEVICE Blank $436.51 HCPCS - Non-Drugs E0969 RR WHEELCHAIR NARROWING DEVICE Blank $77.55 HCPCS - Non-Drugs E0969 UE WHEELCHAIR NARROWING DEVICE Blank $344.40 HCPCS - Non-Drugs E0970 Blank WHEELCHAIR NO. 2 FOOTPLATES Blank $167.66 HCPCS - Non-Drugs E0970 NU WHEELCHAIR NO. 2 FOOTPLATES Blank $167.66 HCPCS - Non-Drugs E0970 RR WHEELCHAIR NO. 2 FOOTPLATES Blank $16.73 HCPCS - Non-Drugs E0970 UE WHEELCHAIR NO. 2 FOOTPLATES Blank $141.59 HCPCS - Non-Drugs E0971 Blank WHEELCHAIR ANTI-TIPPING DEVI Blank $126.58 HCPCS - Non-Drugs E0971 NU WHEELCHAIR ANTI-TIPPING DEVI Blank $126.58 HCPCS - Non-Drugs E0971 RR WHEELCHAIR ANTI-TIPPING DEVI Blank $11.11 HCPCS - Non-Drugs E0971 UE WHEELCHAIR ANTI-TIPPING DEVI Blank $107.22 HCPCS - Non-Drugs E0973 Blank W/CH ACCESS DET ADJ ARMREST Blank $178.37 HCPCS - Non-Drugs E0973 NU W/CH ACCESS DET ADJ ARMREST Blank $178.37 HCPCS - Non-Drugs E0973 RR W/CH ACCESS DET ADJ ARMREST Blank $19.96 HCPCS - Non-Drugs E0973 UE W/CH ACCESS DET ADJ ARMREST Blank $149.21 HCPCS - Non-Drugs E0974 Blank W/CH ACCESS ANTI-ROLLBACK Blank $218.44 HCPCS - Non-Drugs E0974 NU W/CH ACCESS ANTI-ROLLBACK Blank $218.44 HCPCS - Non-Drugs E0974 RR W/CH ACCESS ANTI-ROLLBACK Blank $26.92 HCPCS - Non-Drugs E0974 UE W/CH ACCESS ANTI-ROLLBACK Blank $179.32 HCPCS - Non-Drugs E0978 Blank W/C ACC,SAF BELT PELV STRAP Blank $114.12 HCPCS - Non-Drugs E0978 NU W/C ACC,SAF BELT PELV STRAP Blank $114.12 HCPCS - Non-Drugs E0978 RR W/C ACC,SAF BELT PELV STRAP Blank $8.97 HCPCS - Non-Drugs E0978 UE W/C ACC,SAF BELT PELV STRAP Blank $82.74 HCPCS - Non-Drugs E0980 Blank WHEELCHAIR SAFETY VEST Blank $137.54 HCPCS - Non-Drugs E0980 NU WHEELCHAIR SAFETY VEST Blank $137.54 HCPCS - Non-Drugs E0980 RR WHEELCHAIR SAFETY VEST Blank $13.03 HCPCS - Non-Drugs E0980 UE WHEELCHAIR SAFETY VEST Blank $118.37 HCPCS - Non-Drugs E0981 Blank SEAT UPHOLSTERY, REPLACEMENT Blank $147.98 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E0981 NU SEAT UPHOLSTERY, REPLACEMENT Blank $147.98 HCPCS - Non-Drugs E0981 RR SEAT UPHOLSTERY, REPLACEMENT Blank $14.78 HCPCS - Non-Drugs E0981 UE SEAT UPHOLSTERY, REPLACEMENT Blank $126.53 HCPCS - Non-Drugs E0982 Blank BACK UPHOLSTERY, REPLACEMENT Blank $156.48 HCPCS - Non-Drugs E0982 NU BACK UPHOLSTERY, REPLACEMENT Blank $156.48 HCPCS - Non-Drugs E0982 RR BACK UPHOLSTERY, REPLACEMENT Blank $16.22 HCPCS - Non-Drugs E0982 UE BACK UPHOLSTERY, REPLACEMENT Blank $132.81 HCPCS - Non-Drugs E0983 Blank ADD PWR JOYSTICK Blank $4,909.73 HCPCS - Non-Drugs E0983 RR ADD PWR JOYSTICK Blank $666.63 HCPCS - Non-Drugs E0984 Blank ADD PWR TILLER Blank $3,714.29 HCPCS - Non-Drugs E0984 NU ADD PWR TILLER Blank $3,714.29 HCPCS - Non-Drugs E0984 RR ADD PWR TILLER Blank $504.32 HCPCS - Non-Drugs E0984 UE ADD PWR TILLER Blank $3,140.65 HCPCS - Non-Drugs E0985 Blank W/C SEAT LIFT MECHANISM Blank $741.84 HCPCS - Non-Drugs E0985 NU W/C SEAT LIFT MECHANISM Blank $741.84 HCPCS - Non-Drugs E0985 RR W/C SEAT LIFT MECHANISM Blank $100.73 HCPCS - Non-Drugs E0985 UE W/C SEAT LIFT MECHANISM Blank $346.96 HCPCS - Non-Drugs E0986 Blank MAN W/C PUSH-RIM POWR SYSTEM Blank $9,352.27 HCPCS - Non-Drugs E0986 NU MAN W/C PUSH-RIM POW ASSIST Blank $9,352.27 HCPCS - Non-Drugs E0986 RR MAN W/C PUSH-RIM POWR SYSTEM Blank $1,269.83 HCPCS - Non-Drugs E0986 UE MAN W/C PUSH-RIM POW ASSIST Blank $7,900.86 HCPCS - Non-Drugs E0988 Blank LEVER-ACTIVATED WHEEL DRIVE Blank $5,827.09 HCPCS - Non-Drugs E0988 RR LEVER-ACTIVATED WHEEL DRIVE Blank $791.19 HCPCS - Non-Drugs E0990 Blank WHEELCHAIR ELEVATING LEG RES Blank $213.36 HCPCS - Non-Drugs E0990 NU WHEELCHAIR ELEVATING LEG RES Blank $213.36 HCPCS - Non-Drugs E0990 RR WHEELCHAIR ELEVATING LEG RES Blank $25.95 HCPCS - Non-Drugs E0990 UE WHEELCHAIR ELEVATING LEG RES Blank $175.45 HCPCS - Non-Drugs E0992 Blank WHEELCHAIR SOLID SEAT INSERT Blank $234.47 HCPCS - Non-Drugs E0992 NU WHEELCHAIR SOLID SEAT INSERT Blank $234.47 HCPCS - Non-Drugs E0992 RR WHEELCHAIR SOLID SEAT INSERT Blank $29.57 HCPCS - Non-Drugs E0992 UE WHEELCHAIR SOLID SEAT INSERT Blank $191.28 HCPCS - Non-Drugs E0994 Blank WHEELCHAIR ARM REST Blank $88.08 HCPCS - Non-Drugs E0994 NU WHEELCHAIR ARM REST Blank $88.08 HCPCS - Non-Drugs E0994 RR WHEELCHAIR ARM REST Blank $7.14 HCPCS - Non-Drugs E0994 UE WHEELCHAIR ARM REST Blank $61.15 HCPCS - Non-Drugs E0995 Blank WC CALF REST, PAD REPLACEMNT Blank $117.10 HCPCS - Non-Drugs E0995 NU WC CALF REST, PAD REPLACEMNT Blank $117.10 HCPCS - Non-Drugs E0995 RR WC CALF REST, PAD REPLACEMNT Blank $9.48 HCPCS - Non-Drugs E0995 UE WC CALF REST, PAD REPLACEMNT Blank $88.58 HCPCS - Non-Drugs E1002 Blank PWR SEAT TILT Blank $6,129.02 HCPCS - Non-Drugs E1002 NU PWR SEAT TILT Blank $6,129.02 HCPCS - Non-Drugs E1002 RR PWR SEAT TILT Blank $832.18 HCPCS - Non-Drugs E1002 UE PWR SEAT TILT Blank $4,978.40 HCPCS - Non-Drugs E1003 Blank PWR SEAT RECLINE Blank $7,096.35 HCPCS - Non-Drugs E1003 NU PWR SEAT RECLINE Blank $7,096.35 HCPCS - Non-Drugs E1003 RR PWR SEAT RECLINE Blank $963.53 HCPCS - Non-Drugs E1003 UE PWR SEAT RECLINE Blank $5,388.33 HCPCS - Non-Drugs E1004 Blank PWR SEAT RECLINE MECH Blank $7,754.84 HCPCS - Non-Drugs E1004 NU PWR SEAT RECLINE MECH Blank $7,754.84 HCPCS - Non-Drugs E1004 RR PWR SEAT RECLINE MECH Blank $1,052.93 HCPCS - Non-Drugs E1004 UE PWR SEAT RECLINE MECH Blank $5,968.58 HCPCS - Non-Drugs E1005 Blank PWR SEAT RECLINE PWR Blank $8,440.54 HCPCS - Non-Drugs E1005 NU PWR SEAT RECLINE PWR Blank $8,440.54 HCPCS - Non-Drugs E1005 RR PWR SEAT RECLINE PWR Blank $1,146.04 HCPCS - Non-Drugs E1005 UE PWR SEAT RECLINE PWR Blank $6,455.11 HCPCS - Non-Drugs E1006 Blank PWR SEAT COMBO W/O SHEAR Blank $10,301.10 HCPCS - Non-Drugs E1006 NU PWR SEAT COMBO W/O SHEAR Blank $10,301.10 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E1006 RR PWR SEAT COMBO W/O SHEAR Blank $1,398.66 HCPCS - Non-Drugs E1006 UE PWR SEAT COMBO W/O SHEAR Blank $7,892.71 HCPCS - Non-Drugs E1007 Blank PWR SEAT COMBO W/SHEAR Blank $12,677.05 HCPCS - Non-Drugs E1007 NU PWR SEAT COMBO W/SHEAR Blank $12,677.05 HCPCS - Non-Drugs E1007 RR PWR SEAT COMBO W/SHEAR Blank $1,721.26 HCPCS - Non-Drugs E1007 UE PWR SEAT COMBO W/SHEAR Blank $10,665.22 HCPCS - Non-Drugs E1008 Blank PWR SEAT COMBO PWR SHEAR Blank $12,991.46 HCPCS - Non-Drugs E1008 NU PWR SEAT COMBO PWR SHEAR Blank $12,991.46 HCPCS - Non-Drugs E1008 RR PWR SEAT COMBO PWR SHEAR Blank $1,763.95 HCPCS - Non-Drugs E1008 UE PWR SEAT COMBO PWR SHEAR Blank $10,666.85 HCPCS - Non-Drugs E1009 Blank ADD MECH LEG ELEVATION Blank $3,037.24 HCPCS - Non-Drugs E1009 NU ADD MECH LEG ELEVATION Blank $3,037.24 HCPCS - Non-Drugs E1009 RR ADD MECH LEG ELEVATION Blank $330.14 HCPCS - Non-Drugs E1009 UE ADD MECH LEG ELEVATION Blank $2,286.46 HCPCS - Non-Drugs E1010 Blank ADD PWR LEG ELEVATION Blank $2,158.24 HCPCS - Non-Drugs E1010 NU ADD PWR LEG ELEVATION Blank $2,158.24 HCPCS - Non-Drugs E1010 RR ADD PWR LEG ELEVATION Blank $293.04 HCPCS - Non-Drugs E1010 UE ADD PWR LEG ELEVATION Blank $1,449.60 HCPCS - Non-Drugs E1012 Blank CTR MOUNT PWR ELEV LEG REST Blank $2,158.24 HCPCS - Non-Drugs E1012 RR CTR MOUNT PWR ELEV LEG REST Blank $293.04 HCPCS - Non-Drugs E1014 Blank RECLINING BACK ADD PED W/C Blank $1,122.64 HCPCS - Non-Drugs E1014 NU RECLINING BACK ADD PED W/C Blank $1,122.64 HCPCS - Non-Drugs E1014 RR RECLINING BACK ADD PED W/C Blank $152.43 HCPCS - Non-Drugs E1014 UE RECLINING BACK ADD PED W/C Blank $650.12 HCPCS - Non-Drugs E1015 Blank SHOCK ABSORBER FOR MAN W/C Blank $316.63 HCPCS - Non-Drugs E1015 NU SHOCK ABSORBER FOR MAN W/C Blank $316.63 HCPCS - Non-Drugs E1015 RR SHOCK ABSORBER FOR MAN W/C Blank $46.56 HCPCS - Non-Drugs E1015 UE SHOCK ABSORBER FOR MAN W/C Blank $252.91 HCPCS - Non-Drugs E1016 Blank SHOCK ABSORBER FOR POWER W/C Blank $302.12 HCPCS - Non-Drugs E1016 NU SHOCK ABSORBER FOR POWER W/C Blank $302.12 HCPCS - Non-Drugs E1016 RR SHOCK ABSORBER FOR POWER W/C Blank $42.76 HCPCS - Non-Drugs E1016 UE SHOCK ABSORBER FOR POWER W/C Blank $242.02 HCPCS - Non-Drugs E1017 Blank HD SHCK ABSRBR FOR HD MAN WC Blank $753.55 HCPCS - Non-Drugs E1017 NU HD SHCK ABSRBR FOR HD MAN WC Blank $753.55 HCPCS - Non-Drugs E1017 RR HD SHCK ABSRBR FOR HD MAN WC Blank $80.11 HCPCS - Non-Drugs E1017 UE HD SHCK ABSRBR FOR HD MAN WC Blank $566.54 HCPCS - Non-Drugs E1018 Blank HD SHCK ABSRBER FOR HD POWWC Blank $158.80 HCPCS - Non-Drugs E1018 NU HD SHCK ABSRBER FOR HD POWWC Blank $158.80 HCPCS - Non-Drugs E1018 RR HD SHCK ABSRBER FOR HD POWWC Blank $16.90 HCPCS - Non-Drugs E1018 UE HD SHCK ABSRBER FOR HD POWWC Blank $119.39 HCPCS - Non-Drugs E1020 Blank RESIDUAL LIMB SUPPORT SYSTEM Blank $596.99 HCPCS - Non-Drugs E1020 NU RESIDUAL LIMB SUPPORT SYSTEM Blank $596.99 HCPCS - Non-Drugs E1020 RR RESIDUAL LIMB SUPPORT SYSTEM Blank $81.06 HCPCS - Non-Drugs E1020 UE RESIDUAL LIMB SUPPORT SYSTEM Blank $356.74 HCPCS - Non-Drugs E1028 Blank W/C MANUAL SWINGAWAY Blank $408.98 HCPCS - Non-Drugs E1028 NU W/C MANUAL SWINGAWAY Blank $408.98 HCPCS - Non-Drugs E1028 RR W/C MANUAL SWINGAWAY Blank $55.53 HCPCS - Non-Drugs E1028 UE W/C MANUAL SWINGAWAY Blank $311.91 HCPCS - Non-Drugs E1029 Blank W/C VENT TRAY FIXED Blank $1,028.63 HCPCS - Non-Drugs E1029 RR W/C VENT TRAY FIXED Blank $139.66 HCPCS - Non-Drugs E1030 Blank W/C VENT TRAY GIMBALED Blank $2,247.42 HCPCS - Non-Drugs E1030 NU W/C VENT TRAY GIMBALED Blank $2,247.42 HCPCS - Non-Drugs E1030 RR W/C VENT TRAY GIMBALED Blank $305.15 HCPCS - Non-Drugs E1030 UE W/C VENT TRAY GIMBALED Blank $1,475.68 HCPCS - Non-Drugs E1031 Blank ROLLABOUT CHAIR WITH CASTERS Blank $1,134.66 HCPCS - Non-Drugs E1031 NU ROLLABOUT CHAIR WITH CASTERS Blank $1,134.66 HCPCS - Non-Drugs E1031 RR ROLLABOUT CHAIR WITH CASTERS Blank $154.06 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E1031 UE ROLLABOUT CHAIR WITH CASTERS Blank $772.37 HCPCS - Non-Drugs E1035 Blank PATIENT TRANSFER SYSTEM <300 Blank $9,746.10 HCPCS - Non-Drugs E1035 RR PATIENT TRANSFER SYSTEM <300 Blank $1,323.30 HCPCS - Non-Drugs E1036 Blank PATIENT TRANSFER SYSTEM >300 Blank $14,047.27 HCPCS - Non-Drugs E1036 RR PATIENT TRANSFER SYSTEM >300 Blank $1,907.30 HCPCS - Non-Drugs E1037 Blank TRANSPORT CHAIR, PED SIZE Blank $2,142.04 HCPCS - Non-Drugs E1037 RR TRANSPORT CHAIR, PED SIZE Blank $290.84 HCPCS - Non-Drugs E1038 Blank TRANSPORT CHAIR PT WT<=300LB Blank $458.39 HCPCS - Non-Drugs E1038 RR TRANSPORT CHAIR PT WT<=300LB Blank $62.24 HCPCS - Non-Drugs E1039 Blank TRANSPORT CHAIR PT WT >300LB Blank $974.68 HCPCS - Non-Drugs E1039 RR TRANSPORT CHAIR PT WT >300LB Blank $132.34 HCPCS - Non-Drugs E1050 Blank WHELCHR FXD FULL LENGTH ARMS Blank $2,242.03 HCPCS - Non-Drugs E1050 NU WHELCHR FXD FULL LENGTH ARMS Blank $2,242.03 HCPCS - Non-Drugs E1050 RR WHELCHR FXD FULL LENGTH ARMS Blank $304.42 HCPCS - Non-Drugs E1050 UE WHELCHR FXD FULL LENGTH ARMS Blank $1,703.06 HCPCS - Non-Drugs E1060 Blank WHEELCHAIR DETACHABLE ARMS Blank $2,609.08 HCPCS - Non-Drugs E1060 NU WHEELCHAIR DETACHABLE ARMS Blank $2,609.08 HCPCS - Non-Drugs E1060 RR WHEELCHAIR DETACHABLE ARMS Blank $354.25 HCPCS - Non-Drugs E1060 UE WHEELCHAIR DETACHABLE ARMS Blank $2,093.42 HCPCS - Non-Drugs E1070 Blank WHEELCHAIR DETACHABLE FOOT R Blank $2,372.33 HCPCS - Non-Drugs E1070 NU WHEELCHAIR DETACHABLE FOOT R Blank $2,372.33 HCPCS - Non-Drugs E1070 RR WHEELCHAIR DETACHABLE FOOT R Blank $322.11 HCPCS - Non-Drugs E1070 UE WHEELCHAIR DETACHABLE FOOT R Blank $1,826.93 HCPCS - Non-Drugs E1083 Blank HEMI-WHEELCHAIR FIXED ARMS Blank $1,787.00 HCPCS - Non-Drugs E1083 NU HEMI-WHEELCHAIR FIXED ARMS Blank $1,787.00 HCPCS - Non-Drugs E1083 RR HEMI-WHEELCHAIR FIXED ARMS Blank $242.63 HCPCS - Non-Drugs E1083 UE HEMI-WHEELCHAIR FIXED ARMS Blank $1,330.62 HCPCS - Non-Drugs E1084 Blank HEMI-WHEELCHAIR DETACHABLE A Blank $2,176.82 HCPCS - Non-Drugs E1084 NU HEMI-WHEELCHAIR DETACHABLE A Blank $2,176.82 HCPCS - Non-Drugs E1084 RR HEMI-WHEELCHAIR DETACHABLE A Blank $295.56 HCPCS - Non-Drugs E1084 UE HEMI-WHEELCHAIR DETACHABLE A Blank $1,642.75 HCPCS - Non-Drugs E1085 Blank HEMI-WHEELCHAIR FIXED ARMS Blank $1,701.43 HCPCS - Non-Drugs E1085 NU HEMI-WHEELCHAIR FIXED ARMS Blank $1,701.43 HCPCS - Non-Drugs E1085 RR HEMI-WHEELCHAIR FIXED ARMS Blank $225.53 HCPCS - Non-Drugs E1085 UE HEMI-WHEELCHAIR FIXED ARMS Blank $1,239.34 HCPCS - Non-Drugs E1086 Blank HEMI-WHEELCHAIR DETACHABLE A Blank $2,059.20 HCPCS - Non-Drugs E1086 NU HEMI-WHEELCHAIR DETACHABLE A Blank $2,059.20 HCPCS - Non-Drugs E1086 RR HEMI-WHEELCHAIR DETACHABLE A Blank $243.46 HCPCS - Non-Drugs E1086 UE HEMI-WHEELCHAIR DETACHABLE A Blank $1,512.36 HCPCS - Non-Drugs E1087 Blank WHEELCHAIR LIGHTWT FIXED ARM Blank $2,667.97 HCPCS - Non-Drugs E1087 NU WHEELCHAIR LIGHTWT FIXED ARM Blank $2,667.97 HCPCS - Non-Drugs E1087 RR WHEELCHAIR LIGHTWT FIXED ARM Blank $362.25 HCPCS - Non-Drugs E1087 UE WHEELCHAIR LIGHTWT FIXED ARM Blank $2,100.76 HCPCS - Non-Drugs E1088 Blank WHEELCHAIR LIGHTWEIGHT DET A Blank $3,035.61 HCPCS - Non-Drugs E1088 NU WHEELCHAIR LIGHTWEIGHT DET A Blank $3,035.61 HCPCS - Non-Drugs E1088 RR WHEELCHAIR LIGHTWEIGHT DET A Blank $412.17 HCPCS - Non-Drugs E1088 UE WHEELCHAIR LIGHTWEIGHT DET A Blank $2,491.94 HCPCS - Non-Drugs E1089 Blank WHEELCHAIR LIGHTWT FIXED ARM Blank $2,712.80 HCPCS - Non-Drugs E1089 NU WHEELCHAIR LIGHTWT FIXED ARM Blank $2,712.80 HCPCS - Non-Drugs E1089 RR WHEELCHAIR LIGHTWT FIXED ARM Blank $326.58 HCPCS - Non-Drugs E1089 UE WHEELCHAIR LIGHTWT FIXED ARM Blank $2,050.23 HCPCS - Non-Drugs E1090 Blank WHEELCHAIR LIGHTWEIGHT DET A Blank $2,795.11 HCPCS - Non-Drugs E1090 NU WHEELCHAIR LIGHTWEIGHT DET A Blank $2,795.11 HCPCS - Non-Drugs E1090 RR WHEELCHAIR LIGHTWEIGHT DET A Blank $326.58 HCPCS - Non-Drugs E1090 UE WHEELCHAIR LIGHTWEIGHT DET A Blank $2,059.20 HCPCS - Non-Drugs E1092 Blank WHEELCHAIR WIDE W/ LEG RESTS Blank $2,671.95 HCPCS - Non-Drugs E1092 NU WHEELCHAIR WIDE W/ LEG RESTS Blank $2,671.95 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E1092 RR WHEELCHAIR WIDE W/ LEG RESTS Blank $362.79 HCPCS - Non-Drugs E1092 UE WHEELCHAIR WIDE W/ LEG RESTS Blank $2,132.54 HCPCS - Non-Drugs E1093 Blank WHEELCHAIR WIDE W/ FOOT REST Blank $2,376.35 HCPCS - Non-Drugs E1093 NU WHEELCHAIR WIDE W/ FOOT REST Blank $2,376.35 HCPCS - Non-Drugs E1093 RR WHEELCHAIR WIDE W/ FOOT REST Blank $322.65 HCPCS - Non-Drugs E1093 UE WHEELCHAIR WIDE W/ FOOT REST Blank $1,843.23 HCPCS - Non-Drugs E1100 Blank WHCHR S-RECL FXD ARM LEG RES Blank $2,251.72 HCPCS - Non-Drugs E1100 NU WHCHR S-RECL FXD ARM LEG RES Blank $2,251.72 HCPCS - Non-Drugs E1100 RR WHCHR S-RECL FXD ARM LEG RES Blank $305.73 HCPCS - Non-Drugs E1100 UE WHCHR S-RECL FXD ARM LEG RES Blank $1,734.84 HCPCS - Non-Drugs E1110 Blank WHEELCHAIR SEMI-RECL DETACH Blank $2,197.98 HCPCS - Non-Drugs E1110 NU WHEELCHAIR SEMI-RECL DETACH Blank $2,197.98 HCPCS - Non-Drugs E1110 RR WHEELCHAIR SEMI-RECL DETACH Blank $298.44 HCPCS - Non-Drugs E1110 UE WHEELCHAIR SEMI-RECL DETACH Blank $1,699.80 HCPCS - Non-Drugs E1130 Blank WHLCHR STAND FXD ARM FT REST Blank $1,113.02 HCPCS - Non-Drugs E1130 NU WHLCHR STAND FXD ARM FT REST Blank $1,113.02 HCPCS - Non-Drugs E1130 RR WHLCHR STAND FXD ARM FT REST Blank $166.85 HCPCS - Non-Drugs E1130 UE WHLCHR STAND FXD ARM FT REST Blank $860.38 HCPCS - Non-Drugs E1140 Blank WHEELCHAIR STANDARD DETACH A Blank $1,575.92 HCPCS - Non-Drugs E1140 NU WHEELCHAIR STANDARD DETACH A Blank $1,575.92 HCPCS - Non-Drugs E1140 RR WHEELCHAIR STANDARD DETACH A Blank $213.30 HCPCS - Non-Drugs E1140 UE WHEELCHAIR STANDARD DETACH A Blank $1,134.21 HCPCS - Non-Drugs E1150 Blank WHEELCHAIR STANDARD W/ LEG R Blank $1,873.15 HCPCS - Non-Drugs E1150 NU WHEELCHAIR STANDARD W/ LEG R Blank $1,873.15 HCPCS - Non-Drugs E1150 RR WHEELCHAIR STANDARD W/ LEG R Blank $254.33 HCPCS - Non-Drugs E1150 UE WHEELCHAIR STANDARD W/ LEG R Blank $1,376.26 HCPCS - Non-Drugs E1160 Blank WHEELCHAIR FIXED ARMS Blank $1,554.81 HCPCS - Non-Drugs E1160 NU WHEELCHAIR FIXED ARMS Blank $1,554.81 HCPCS - Non-Drugs E1160 RR WHEELCHAIR FIXED ARMS Blank $211.11 HCPCS - Non-Drugs E1160 UE WHEELCHAIR FIXED ARMS Blank $1,069.01 HCPCS - Non-Drugs E1161 Blank MANUAL ADULT WC W TILTINSPAC Blank $4,782.48 HCPCS - Non-Drugs E1161 NU MANUAL ADULT WC W TILTINSPAC Blank $4,782.48 HCPCS - Non-Drugs E1161 RR MANUAL ADULT WC W TILTINSPAC Blank $649.35 HCPCS - Non-Drugs E1161 UE MANUAL ADULT WC W TILTINSPAC Blank $3,874.94 HCPCS - Non-Drugs E1170 Blank WHLCHR AMPU FXD ARM LEG REST Blank $1,965.06 HCPCS - Non-Drugs E1170 NU WHLCHR AMPU FXD ARM LEG REST Blank $1,965.06 HCPCS - Non-Drugs E1170 RR WHLCHR AMPU FXD ARM LEG REST Blank $266.81 HCPCS - Non-Drugs E1170 UE WHLCHR AMPU FXD ARM LEG REST Blank $1,500.95 HCPCS - Non-Drugs E1171 Blank WHEELCHAIR AMPUTEE W/O LEG R Blank $1,842.74 HCPCS - Non-Drugs E1171 NU WHEELCHAIR AMPUTEE W/O LEG R Blank $1,842.74 HCPCS - Non-Drugs E1171 RR WHEELCHAIR AMPUTEE W/O LEG R Blank $250.20 HCPCS - Non-Drugs E1171 UE WHEELCHAIR AMPUTEE W/O LEG R Blank $1,353.44 HCPCS - Non-Drugs E1172 Blank WHEELCHAIR AMPUTEE DETACH AR Blank $2,163.17 HCPCS - Non-Drugs E1172 NU WHEELCHAIR AMPUTEE DETACH AR Blank $2,163.17 HCPCS - Non-Drugs E1172 RR WHEELCHAIR AMPUTEE DETACH AR Blank $293.71 HCPCS - Non-Drugs E1172 UE WHEELCHAIR AMPUTEE DETACH AR Blank $1,640.30 HCPCS - Non-Drugs E1180 Blank WHEELCHAIR AMPUTEE W/ FOOT R Blank $2,209.10 HCPCS - Non-Drugs E1180 NU WHEELCHAIR AMPUTEE W/ FOOT R Blank $2,209.10 HCPCS - Non-Drugs E1180 RR WHEELCHAIR AMPUTEE W/ FOOT R Blank $299.95 HCPCS - Non-Drugs E1180 UE WHEELCHAIR AMPUTEE W/ FOOT R Blank $1,694.91 HCPCS - Non-Drugs E1190 Blank WHEELCHAIR AMPUTEE W/ LEG RE Blank $2,456.92 HCPCS - Non-Drugs E1190 NU WHEELCHAIR AMPUTEE W/ LEG RE Blank $2,456.92 HCPCS - Non-Drugs E1190 RR WHEELCHAIR AMPUTEE W/ LEG RE Blank $333.59 HCPCS - Non-Drugs E1190 UE WHEELCHAIR AMPUTEE W/ LEG RE Blank $1,948.36 HCPCS - Non-Drugs E1195 Blank WHEELCHAIR AMPUTEE HEAVY DUT Blank $2,597.29 HCPCS - Non-Drugs E1195 NU WHEELCHAIR AMPUTEE HEAVY DUT Blank $2,597.29 HCPCS - Non-Drugs E1195 RR WHEELCHAIR AMPUTEE HEAVY DUT Blank $352.65 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E1195 UE WHEELCHAIR AMPUTEE HEAVY DUT Blank $2,086.09 HCPCS - Non-Drugs E1200 Blank WHEELCHAIR AMPUTEE FIXED ARM Blank $1,975.96 HCPCS - Non-Drugs E1200 NU WHEELCHAIR AMPUTEE FIXED ARM Blank $1,975.96 HCPCS - Non-Drugs E1200 RR WHEELCHAIR AMPUTEE FIXED ARM Blank $268.29 HCPCS - Non-Drugs E1200 UE WHEELCHAIR AMPUTEE FIXED ARM Blank $1,464.27 HCPCS - Non-Drugs E1220 Blank WHLCHR SPECIAL SIZE/CONSTRC Blank $5,555.56 HCPCS - Non-Drugs E1221 Blank WHEELCHAIR SPEC SIZE W FOOT Blank $1,279.12 HCPCS - Non-Drugs E1221 NU WHEELCHAIR SPEC SIZE W FOOT Blank $1,279.12 HCPCS - Non-Drugs E1221 RR WHEELCHAIR SPEC SIZE W FOOT Blank $173.68 HCPCS - Non-Drugs E1221 UE WHEELCHAIR SPEC SIZE W FOOT Blank $827.79 HCPCS - Non-Drugs E1222 Blank WHEELCHAIR SPEC SIZE W/ LEG Blank $1,650.27 HCPCS - Non-Drugs E1222 NU WHEELCHAIR SPEC SIZE W/ LEG Blank $1,650.27 HCPCS - Non-Drugs E1222 RR WHEELCHAIR SPEC SIZE W/ LEG Blank $224.07 HCPCS - Non-Drugs E1222 UE WHEELCHAIR SPEC SIZE W/ LEG Blank $1,153.77 HCPCS - Non-Drugs E1223 Blank WHEELCHAIR SPEC SIZE W FOOT Blank $1,728.08 HCPCS - Non-Drugs E1223 NU WHEELCHAIR SPEC SIZE W FOOT Blank $1,728.08 HCPCS - Non-Drugs E1223 RR WHEELCHAIR SPEC SIZE W FOOT Blank $234.64 HCPCS - Non-Drugs E1223 UE WHEELCHAIR SPEC SIZE W FOOT Blank $1,254.01 HCPCS - Non-Drugs E1224 Blank WHEELCHAIR SPEC SIZE W/ LEG Blank $1,848.33 HCPCS - Non-Drugs E1224 NU WHEELCHAIR SPEC SIZE W/ LEG Blank $1,848.33 HCPCS - Non-Drugs E1224 RR WHEELCHAIR SPEC SIZE W/ LEG Blank $250.96 HCPCS - Non-Drugs E1224 UE WHEELCHAIR SPEC SIZE W/ LEG Blank $1,369.74 HCPCS - Non-Drugs E1225 Blank MANUAL SEMI-RECLINING BACK Blank $1,052.11 HCPCS - Non-Drugs E1225 NU MANUAL SEMI-RECLINING BACK Blank $1,052.11 HCPCS - Non-Drugs E1225 RR MANUAL SEMI-RECLINING BACK Blank $142.85 HCPCS - Non-Drugs E1225 UE MANUAL SEMI-RECLINING BACK Blank $698.21 HCPCS - Non-Drugs E1226 Blank MANUAL FULLY RECLINING BACK Blank $872.66 HCPCS - Non-Drugs E1226 NU MANUAL FULLY RECLINING BACK Blank $872.66 HCPCS - Non-Drugs E1226 RR MANUAL FULLY RECLINING BACK Blank $142.81 HCPCS - Non-Drugs E1226 UE MANUAL FULLY RECLINING BACK Blank $669.92 HCPCS - Non-Drugs E1227 Blank WHEELCHAIR SPEC SZ SPEC HT A Blank $708.37 HCPCS - Non-Drugs E1227 NU WHEELCHAIR SPEC SZ SPEC HT A Blank $708.37 HCPCS - Non-Drugs E1227 RR WHEELCHAIR SPEC SZ SPEC HT A Blank $126.65 HCPCS - Non-Drugs E1227 UE WHEELCHAIR SPEC SZ SPEC HT A Blank $547.10 HCPCS - Non-Drugs E1228 Blank WHEELCHAIR SPEC SZ SPEC HT B Blank $923.35 HCPCS - Non-Drugs E1228 NU WHEELCHAIR SPEC SZ SPEC HT B Blank $923.35 HCPCS - Non-Drugs E1228 RR WHEELCHAIR SPEC SZ SPEC HT B Blank $125.37 HCPCS - Non-Drugs E1228 UE WHEELCHAIR SPEC SZ SPEC HT B Blank $513.21 HCPCS - Non-Drugs E1229 Blank PEDIATRIC WHEELCHAIR NOS Blank $1,792.41 HCPCS - Non-Drugs E1230 Blank POWER OPERATED VEHICLE Blank $5,260.46 HCPCS - Non-Drugs E1230 NU POWER OPERATED VEHICLE Blank $5,260.46 HCPCS - Non-Drugs E1230 RR POWER OPERATED VEHICLE Blank $579.28 HCPCS - Non-Drugs E1230 UE POWER OPERATED VEHICLE Blank $4,106.59 HCPCS - Non-Drugs E1231 Blank RIGID PED W/C TILT-IN-SPACE Blank $3,434.65 HCPCS - Non-Drugs E1231 NU RIGID PED W/C TILT-IN-SPACE Blank $3,434.65 HCPCS - Non-Drugs E1231 RR RIGID PED W/C TILT-IN-SPACE Blank $375.90 HCPCS - Non-Drugs E1231 UE RIGID PED W/C TILT-IN-SPACE Blank $2,586.50 HCPCS - Non-Drugs E1232 Blank FOLDING PED WC TILT-IN-SPACE Blank $4,366.29 HCPCS - Non-Drugs E1232 NU FOLDING PED WC TILT-IN-SPACE Blank $4,366.29 HCPCS - Non-Drugs E1232 RR FOLDING PED WC TILT-IN-SPACE Blank $592.84 HCPCS - Non-Drugs E1232 UE FOLDING PED WC TILT-IN-SPACE Blank $3,508.20 HCPCS - Non-Drugs E1233 Blank RIG PED WC TLTNSPC W/O SEAT Blank $4,507.43 HCPCS - Non-Drugs E1233 NU RIG PED WC TLTNSPC W/O SEAT Blank $4,507.43 HCPCS - Non-Drugs E1233 RR RIG PED WC TLTNSPC W/O SEAT Blank $612.01 HCPCS - Non-Drugs E1233 UE RIG PED WC TLTNSPC W/O SEAT Blank $3,632.08 HCPCS - Non-Drugs E1234 Blank FLD PED WC TLTNSPC W/O SEAT Blank $3,983.12 HCPCS - Non-Drugs E1234 NU FLD PED WC TLTNSPC W/O SEAT Blank $3,983.12 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E1234 RR FLD PED WC TLTNSPC W/O SEAT Blank $540.82 HCPCS - Non-Drugs E1234 UE FLD PED WC TLTNSPC W/O SEAT Blank $3,170.81 HCPCS - Non-Drugs E1235 Blank RIGID PED WC ADJUSTABLE Blank $3,852.49 HCPCS - Non-Drugs E1235 NU RIGID PED WC ADJUSTABLE Blank $3,852.49 HCPCS - Non-Drugs E1235 RR RIGID PED WC ADJUSTABLE Blank $523.08 HCPCS - Non-Drugs E1235 UE RIGID PED WC ADJUSTABLE Blank $3,055.08 HCPCS - Non-Drugs E1236 Blank FOLDING PED WC ADJUSTABLE Blank $3,452.07 HCPCS - Non-Drugs E1236 NU FOLDING PED WC ADJUSTABLE Blank $3,452.07 HCPCS - Non-Drugs E1236 RR FOLDING PED WC ADJUSTABLE Blank $468.71 HCPCS - Non-Drugs E1236 UE FOLDING PED WC ADJUSTABLE Blank $2,703.02 HCPCS - Non-Drugs E1237 Blank RGD PED WC ADJSTABL W/O SEAT Blank $3,478.35 HCPCS - Non-Drugs E1237 NU RGD PED WC ADJSTABL W/O SEAT Blank $3,478.35 HCPCS - Non-Drugs E1237 RR RGD PED WC ADJSTABL W/O SEAT Blank $472.28 HCPCS - Non-Drugs E1237 UE RGD PED WC ADJSTABL W/O SEAT Blank $2,725.84 HCPCS - Non-Drugs E1238 Blank FLD PED WC ADJSTABL W/O SEAT Blank $3,452.07 HCPCS - Non-Drugs E1238 NU FLD PED WC ADJSTABL W/O SEAT Blank $3,452.07 HCPCS - Non-Drugs E1238 RR FLD PED WC ADJSTABL W/O SEAT Blank $468.71 HCPCS - Non-Drugs E1238 UE FLD PED WC ADJSTABL W/O SEAT Blank $2,703.02 HCPCS - Non-Drugs E1239 Blank PED POWER WHEELCHAIR NOS Blank $3,798.67 HCPCS - Non-Drugs E1240 Blank WHCHR LITWT DET ARM LEG REST Blank $2,217.93 HCPCS - Non-Drugs E1240 NU WHCHR LITWT DET ARM LEG REST Blank $2,217.93 HCPCS - Non-Drugs E1240 RR WHCHR LITWT DET ARM LEG REST Blank $301.15 HCPCS - Non-Drugs E1240 UE WHCHR LITWT DET ARM LEG REST Blank $1,721.80 HCPCS - Non-Drugs E1250 Blank WHEELCHAIR LIGHTWT FIXED ARM Blank $1,681.05 HCPCS - Non-Drugs E1250 NU WHEELCHAIR LIGHTWT FIXED ARM Blank $1,681.05 HCPCS - Non-Drugs E1250 RR WHEELCHAIR LIGHTWT FIXED ARM Blank $209.23 HCPCS - Non-Drugs E1250 UE WHEELCHAIR LIGHTWT FIXED ARM Blank $1,344.47 HCPCS - Non-Drugs E1260 Blank WHEELCHAIR LIGHTWT FOOT REST Blank $1,954.07 HCPCS - Non-Drugs E1260 NU WHEELCHAIR LIGHTWT FOOT REST Blank $1,954.07 HCPCS - Non-Drugs E1260 RR WHEELCHAIR LIGHTWT FOOT REST Blank $250.79 HCPCS - Non-Drugs E1260 UE WHEELCHAIR LIGHTWT FOOT REST Blank $1,554.73 HCPCS - Non-Drugs E1270 Blank WHEELCHAIR LIGHTWEIGHT LEG R Blank $1,805.91 HCPCS - Non-Drugs E1270 NU WHEELCHAIR LIGHTWEIGHT LEG R Blank $1,805.91 HCPCS - Non-Drugs E1270 RR WHEELCHAIR LIGHTWEIGHT LEG R Blank $245.20 HCPCS - Non-Drugs E1270 UE WHEELCHAIR LIGHTWEIGHT LEG R Blank $1,333.88 HCPCS - Non-Drugs E1280 Blank WHCHR H-DUTY DET ARM LEG RES Blank $2,713.87 HCPCS - Non-Drugs E1280 NU WHCHR H-DUTY DET ARM LEG RES Blank $2,713.87 HCPCS - Non-Drugs E1280 RR WHCHR H-DUTY DET ARM LEG RES Blank $368.48 HCPCS - Non-Drugs E1280 UE WHCHR H-DUTY DET ARM LEG RES Blank $2,177.37 HCPCS - Non-Drugs E1285 Blank WHEELCHAIR HEAVY DUTY FIXED Blank $2,500.91 HCPCS - Non-Drugs E1285 NU WHEELCHAIR HEAVY DUTY FIXED Blank $2,500.91 HCPCS - Non-Drugs E1285 RR WHEELCHAIR HEAVY DUTY FIXED Blank $305.39 HCPCS - Non-Drugs E1285 UE WHEELCHAIR HEAVY DUTY FIXED Blank $1,848.94 HCPCS - Non-Drugs E1290 Blank WHEELCHAIR HVY DUTY DETACH A Blank $2,584.85 HCPCS - Non-Drugs E1290 NU WHEELCHAIR HVY DUTY DETACH A Blank $2,584.85 HCPCS - Non-Drugs E1290 RR WHEELCHAIR HVY DUTY DETACH A Blank $314.36 HCPCS - Non-Drugs E1290 UE WHEELCHAIR HVY DUTY DETACH A Blank $1,901.91 HCPCS - Non-Drugs E1295 Blank WHEELCHAIR HEAVY DUTY FIXED Blank $2,586.90 HCPCS - Non-Drugs E1295 NU WHEELCHAIR HEAVY DUTY FIXED Blank $2,586.90 HCPCS - Non-Drugs E1295 RR WHEELCHAIR HEAVY DUTY FIXED Blank $351.24 HCPCS - Non-Drugs E1295 UE WHEELCHAIR HEAVY DUTY FIXED Blank $2,019.26 HCPCS - Non-Drugs E1296 Blank WHEELCHAIR SPECIAL SEAT HEIG Blank $1,181.23 HCPCS - Non-Drugs E1296 NU WHEELCHAIR SPECIAL SEAT HEIG Blank $1,181.23 HCPCS - Non-Drugs E1296 RR WHEELCHAIR SPECIAL SEAT HEIG Blank $176.13 HCPCS - Non-Drugs E1296 UE WHEELCHAIR SPECIAL SEAT HEIG Blank $901.32 HCPCS - Non-Drugs E1297 Blank WHEELCHAIR SPECIAL SEAT DEPT Blank $300.12 HCPCS - Non-Drugs E1297 NU WHEELCHAIR SPECIAL SEAT DEPT Blank $300.12 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E1297 RR WHEELCHAIR SPECIAL SEAT DEPT Blank $51.30 HCPCS - Non-Drugs E1297 UE WHEELCHAIR SPECIAL SEAT DEPT Blank $240.50 HCPCS - Non-Drugs E1298 Blank WHEELCHAIR SPEC SEAT DEPTH/W Blank $1,041.75 HCPCS - Non-Drugs E1298 NU WHEELCHAIR SPEC SEAT DEPTH/W Blank $1,041.75 HCPCS - Non-Drugs E1298 RR WHEELCHAIR SPEC SEAT DEPTH/W Blank $161.58 HCPCS - Non-Drugs E1298 UE WHEELCHAIR SPEC SEAT DEPTH/W Blank $796.72 HCPCS - Non-Drugs E1300 Blank WHIRLPOOL PORTABLE Blank $279.74 HCPCS - Non-Drugs E1300 NU WHIRLPOOL PORTABLE Blank $279.74 HCPCS - Non-Drugs E1300 RR WHIRLPOOL PORTABLE Blank $29.75 HCPCS - Non-Drugs E1300 UE WHIRLPOOL PORTABLE Blank $210.32 HCPCS - Non-Drugs E1310 Blank WHIRLPOOL NON-PORTABLE Blank $4,244.40 HCPCS - Non-Drugs E1310 NU WHIRLPOOL NON-PORTABLE Blank $4,244.40 HCPCS - Non-Drugs E1310 RR WHIRLPOOL NON-PORTABLE Blank $437.16 HCPCS - Non-Drugs E1310 UE WHIRLPOOL NON-PORTABLE Blank $3,202.25 HCPCS - Non-Drugs E1352 Blank O2 FLOW REG POS INSPIR PRESS Blank $101.79 HCPCS - Non-Drugs E1353 Blank OXYGEN SUPPLIES REGULATOR Blank $101.79 HCPCS - Non-Drugs E1353 NU OXYGEN SUPPLIES REGULATOR Blank $101.79 HCPCS - Non-Drugs E1353 RR OXYGEN SUPPLIES REGULATOR Blank $6.22 HCPCS - Non-Drugs E1353 UE OXYGEN SUPPLIES REGULATOR Blank $46.63 HCPCS - Non-Drugs E1354 Blank WHEELED CART, PORT CYL/CONC Blank $32.40 HCPCS - Non-Drugs E1355 Blank OXYGEN SUPPLIES STAND/RACK Blank $47.00 HCPCS - Non-Drugs E1355 NU OXYGEN SUPPLIES STAND/RACK Blank $47.00 HCPCS - Non-Drugs E1355 RR OXYGEN SUPPLIES STAND/RACK Blank $4.67 HCPCS - Non-Drugs E1355 UE OXYGEN SUPPLIES STAND/RACK Blank $35.10 HCPCS - Non-Drugs E1356 Blank BATT PACK/CART, PORT CONC Blank $40.30 HCPCS - Non-Drugs E1357 Blank BATTERY CHARGER, PORT CONC Blank $201.91 HCPCS - Non-Drugs E1358 Blank DC POWER ADAPTER, PORT CONC Blank $132.78 HCPCS - Non-Drugs E1372 Blank OXY SUPPL HEATER FOR NEBULIZ Blank $300.02 HCPCS - Non-Drugs E1372 NU OXY SUPPL HEATER FOR NEBULIZ Blank $300.02 HCPCS - Non-Drugs E1372 RR OXY SUPPL HEATER FOR NEBULIZ Blank $98.17 HCPCS - Non-Drugs E1372 UE OXY SUPPL HEATER FOR NEBULIZ Blank $243.95 HCPCS - Non-Drugs E1390 Blank OXYGEN CONCENTRATOR Blank $4,044.84 HCPCS - Non-Drugs E1390 NU OXYGEN CONCENTRATOR Blank $4,044.84 HCPCS - Non-Drugs E1390 RR OXYGEN CONCENTRATOR Blank $520.41 HCPCS - Non-Drugs E1391 Blank OXYGEN CONCENTRATOR, DUAL Blank $3,727.93 HCPCS - Non-Drugs E1391 RR OXYGEN CONCENTRATOR, DUAL Blank $484.58 HCPCS - Non-Drugs E1392 Blank PORTABLE OXYGEN CONCENTRATOR Blank $1,491.41 HCPCS - Non-Drugs E1392 RR STATIONARY COMPRESSED GAS 02 Blank $193.81 HCPCS - Non-Drugs E1399 Blank DURABLE MEDICAL EQUIPMENT MI Blank $86.94 HCPCS - Non-Drugs E1405 Blank O2/WATER VAPOR ENRICH W/HEAT Blank $5,574.21 HCPCS - Non-Drugs E1405 NU O2/WATER VAPOR ENRICH W/HEAT Blank $5,574.21 HCPCS - Non-Drugs E1405 RR O2/WATER VAPOR ENRICH W/HEAT Blank $705.40 HCPCS - Non-Drugs E1405 UE O2/WATER VAPOR ENRICH W/HEAT Blank $4,237.85 HCPCS - Non-Drugs E1406 Blank O2/WATER VAPOR ENRICH W/O HE Blank $4,185.05 HCPCS - Non-Drugs E1406 NU O2/WATER VAPOR ENRICH W/O HE Blank $4,185.05 HCPCS - Non-Drugs E1406 RR O2/WATER VAPOR ENRICH W/O HE Blank $529.61 HCPCS - Non-Drugs E1406 UE O2/WATER VAPOR ENRICH W/O HE Blank $3,181.73 HCPCS - Non-Drugs E1500 Blank CENTRIFUGE Blank $320.98 HCPCS - Non-Drugs E1510 Blank KIDNEY DIALYSATE DELIVRY SYS Blank $2,861.39 HCPCS - Non-Drugs E1510 NU KIDNEY DIALYSATE DELIVRY SYS Blank $2,861.39 HCPCS - Non-Drugs E1510 RR KIDNEY DIALYSATE DELIVRY SYS Blank $301.41 HCPCS - Non-Drugs E1510 UE KIDNEY DIALYSATE DELIVRY SYS Blank $2,154.80 HCPCS - Non-Drugs E1520 Blank HEPARIN INFUSION PUMP Blank $2,160.97 HCPCS - Non-Drugs E1520 NU HEPARIN INFUSION PUMP Blank $2,160.97 HCPCS - Non-Drugs E1520 RR HEPARIN INFUSION PUMP Blank $229.86 HCPCS - Non-Drugs E1520 UE HEPARIN INFUSION PUMP Blank $1,624.65 HCPCS - Non-Drugs E1530 Blank REPLACEMENT AIR BUBBLE DETEC Blank $2,096.86 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E1530 NU REPLACEMENT AIR BUBBLE DETEC Blank $2,096.86 HCPCS - Non-Drugs E1530 RR REPLACEMENT AIR BUBBLE DETEC Blank $216.22 HCPCS - Non-Drugs E1530 UE REPLACEMENT AIR BUBBLE DETEC Blank $1,573.09 HCPCS - Non-Drugs E1540 Blank REPLACEMENT PRESSURE ALARM Blank $243.28 HCPCS - Non-Drugs E1540 NU REPLACEMENT PRESSURE ALARM Blank $243.28 HCPCS - Non-Drugs E1540 RR REPLACEMENT PRESSURE ALARM Blank $25.47 HCPCS - Non-Drugs E1540 UE REPLACEMENT PRESSURE ALARM Blank $182.36 HCPCS - Non-Drugs E1550 Blank BATH CONDUCTIVITY METER Blank $119.21 HCPCS - Non-Drugs E1550 NU BATH CONDUCTIVITY METER Blank $119.21 HCPCS - Non-Drugs E1550 RR BATH CONDUCTIVITY METER Blank $12.68 HCPCS - Non-Drugs E1550 UE BATH CONDUCTIVITY METER Blank $89.63 HCPCS - Non-Drugs E1560 Blank REPLACE BLOOD LEAK DETECTOR Blank $2,426.38 HCPCS - Non-Drugs E1560 NU REPLACE BLOOD LEAK DETECTOR Blank $2,426.38 HCPCS - Non-Drugs E1560 RR REPLACE BLOOD LEAK DETECTOR Blank $250.18 HCPCS - Non-Drugs E1560 UE REPLACE BLOOD LEAK DETECTOR Blank $1,795.51 HCPCS - Non-Drugs E1570 Blank ADJUSTABLE CHAIR FOR ESRD PT Blank $731.40 HCPCS - Non-Drugs E1570 NU ADJUSTABLE CHAIR FOR ESRD PT Blank $731.40 HCPCS - Non-Drugs E1570 RR ADJUSTABLE CHAIR FOR ESRD PT Blank $77.80 HCPCS - Non-Drugs E1570 UE ADJUSTABLE CHAIR FOR ESRD PT Blank $549.87 HCPCS - Non-Drugs E1575 Blank TRANSDUCER PROTECT/FLD BAR Blank $127.28 HCPCS - Non-Drugs E1575 NU TRANSDUCER PROTECT/FLD BAR Blank $127.28 HCPCS - Non-Drugs E1575 RR TRANSDUCER PROTECT/FLD BAR Blank $13.12 HCPCS - Non-Drugs E1575 UE TRANSDUCER PROTECT/FLD BAR Blank $94.19 HCPCS - Non-Drugs E1590 Blank HEMODIALYSIS MACHINE Blank $3,236.87 HCPCS - Non-Drugs E1590 NU HEMODIALYSIS MACHINE Blank $3,236.87 HCPCS - Non-Drugs E1590 RR HEMODIALYSIS MACHINE Blank $186.13 HCPCS - Non-Drugs E1590 UE HEMODIALYSIS MACHINE Blank $2,437.56 HCPCS - Non-Drugs E1592 Blank AUTO INTERM PERITONEAL DIALY Blank $7.68 HCPCS - Non-Drugs E1594 Blank CYCLER DIALYSIS MACHINE Blank $8,544.36 HCPCS - Non-Drugs E1594 NU CYCLER DIALYSIS MACHINE Blank $8,544.36 HCPCS - Non-Drugs E1594 RR CYCLER DIALYSIS MACHINE Blank $935.10 HCPCS - Non-Drugs E1594 UE CYCLER DIALYSIS MACHINE Blank $6,434.45 HCPCS - Non-Drugs E1600 Blank DELI/INSTALL CHRG HEMO EQUIP Blank $630.35 HCPCS - Non-Drugs E1610 Blank REVERSE OSMOSIS H2O PURI SYS Blank $5,679.03 HCPCS - Non-Drugs E1610 NU REVERSE OSMOSIS H2O PURI SYS Blank $5,679.03 HCPCS - Non-Drugs E1610 RR REVERSE OSMOSIS H2O PURI SYS Blank $593.48 HCPCS - Non-Drugs E1610 UE REVERSE OSMOSIS H2O PURI SYS Blank $4,266.23 HCPCS - Non-Drugs E1615 Blank DEIONIZER H2O PURI SYSTEM Blank $342.13 HCPCS - Non-Drugs E1620 Blank REPLACEMENT BLOOD PUMP Blank $713.03 HCPCS - Non-Drugs E1625 Blank WATER SOFTENING SYSTEM Blank $1,842.47 HCPCS - Non-Drugs E1630 Blank RECIPROCATING PERITONEAL DIA Blank $199.28 HCPCS - Non-Drugs E1634 Blank PERITONEAL DIALYSIS CLAMP Blank $14.44 HCPCS - Non-Drugs E1635 Blank COMPACT TRAVEL HEMODIALYZER Blank $622.26 HCPCS - Non-Drugs E1636 Blank SORBENT CARTRIDGES PER 10 Blank $268.06 HCPCS - Non-Drugs E1637 Blank HEMOSTATS FOR DIALYSIS, EACH Blank $52.96 HCPCS - Non-Drugs E1639 Blank SCALE, EACH Blank $156.91 HCPCS - Non-Drugs E1699 Blank DIALYSIS EQUIPMENT NOC Blank $268.06 HCPCS - Non-Drugs E1700 Blank JAW MOTION REHAB SYSTEM Blank $1,054.72 HCPCS - Non-Drugs E1700 NU JAW MOTION REHAB SYSTEM Blank $1,054.72 HCPCS - Non-Drugs E1700 RR JAW MOTION REHAB SYSTEM Blank $143.21 HCPCS - Non-Drugs E1700 UE JAW MOTION REHAB SYSTEM Blank $424.55 HCPCS - Non-Drugs E1701 Blank REPL CUSHIONS FOR JAW MOTION Blank $97.04 HCPCS - Non-Drugs E1702 Blank REPL MEASR SCALES JAW MOTION Blank $119.87 HCPCS - Non-Drugs E1800 Blank ADJUST ELBOW EXT/FLEX DEVICE Blank $2,279.79 HCPCS - Non-Drugs E1800 RR ADJUST ELBOW EXT/FLEX DEVICE Blank $309.54 HCPCS - Non-Drugs E1801 Blank SPS ELBOW DEVICE Blank $2,470.58 HCPCS - Non-Drugs E1801 RR SPS ELBOW DEVICE Blank $335.45 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E1802 Blank ADJST FOREARM PRO/SUP DEVICE Blank $5,543.79 HCPCS - Non-Drugs E1802 RR ADJST FOREARM PRO/SUP DEVICE Blank $752.72 HCPCS - Non-Drugs E1805 Blank ADJUST WRIST EXT/FLEX DEVICE Blank $2,353.77 HCPCS - Non-Drugs E1805 RR ADJUST WRIST EXT/FLEX DEVICE Blank $319.59 HCPCS - Non-Drugs E1806 Blank SPS WRIST DEVICE Blank $2,128.03 HCPCS - Non-Drugs E1806 RR SPS WRIST DEVICE Blank $288.94 HCPCS - Non-Drugs E1810 Blank ADJUST KNEE EXT/FLEX DEVICE Blank $2,328.08 HCPCS - Non-Drugs E1810 RR ADJUST KNEE EXT/FLEX DEVICE Blank $316.10 HCPCS - Non-Drugs E1811 Blank SPS KNEE DEVICE Blank $2,546.45 HCPCS - Non-Drugs E1811 RR SPS KNEE DEVICE Blank $345.75 HCPCS - Non-Drugs E1812 Blank KNEE EXT/FLEX W ACT RES CTRL Blank $1,869.80 HCPCS - Non-Drugs E1812 RR KNEE EXT/FLEX W ACT RES CTRL Blank $253.88 HCPCS - Non-Drugs E1815 Blank ADJUST ANKLE EXT/FLEX DEVICE Blank $2,357.69 HCPCS - Non-Drugs E1815 RR ADJUST ANKLE EXT/FLEX DEVICE Blank $320.12 HCPCS - Non-Drugs E1816 Blank SPS ANKLE DEVICE Blank $2,577.72 HCPCS - Non-Drugs E1816 RR SPS ANKLE DEVICE Blank $350.00 HCPCS - Non-Drugs E1818 Blank SPS FOREARM DEVICE Blank $2,619.91 HCPCS - Non-Drugs E1818 RR SPS FOREARM DEVICE Blank $355.72 HCPCS - Non-Drugs E1820 Blank SOFT INTERFACE MATERIAL Blank $241.53 HCPCS - Non-Drugs E1820 NU SOFT INTERFACE MATERIAL Blank $241.53 HCPCS - Non-Drugs E1820 RR SOFT INTERFACE MATERIAL Blank $92.33 HCPCS - Non-Drugs E1820 UE SOFT INTERFACE MATERIAL Blank $200.10 HCPCS - Non-Drugs E1821 Blank REPLACEMENT INTERFACE SPSD Blank $293.75 HCPCS - Non-Drugs E1821 NU REPLACEMENT INTERFACE SPSD Blank $293.75 HCPCS - Non-Drugs E1821 RR REPLACEMENT INTERFACE SPSD Blank $97.50 HCPCS - Non-Drugs E1821 UE REPLACEMENT INTERFACE SPSD Blank $239.31 HCPCS - Non-Drugs E1825 Blank ADJUST FINGER EXT/FLEX DEVC Blank $2,353.77 HCPCS - Non-Drugs E1825 RR ADJUST FINGER EXT/FLEX DEVC Blank $319.59 HCPCS - Non-Drugs E1830 Blank ADJUST TOE EXT/FLEX DEVICE Blank $2,353.77 HCPCS - Non-Drugs E1830 RR ADJUST TOE EXT/FLEX DEVICE Blank $319.59 HCPCS - Non-Drugs E1831 Blank STATIC STR TOE DEV EXT/FLEX Blank $1,548.56 HCPCS - Non-Drugs E1831 RR STATIC STR TOE DEV EXT/FLEX Blank $210.26 HCPCS - Non-Drugs E1840 Blank ADJ SHOULDER EXT/FLEX DEVICE Blank $6,275.48 HCPCS - Non-Drugs E1840 RR ADJ SHOULDER EXT/FLEX DEVICE Blank $852.07 HCPCS - Non-Drugs E1841 Blank STATIC STR SHLDR DEV ROM ADJ Blank $7,468.84 HCPCS - Non-Drugs E1841 RR STATIC STR SHLDR DEV ROM ADJ Blank $1,014.10 HCPCS - Non-Drugs E1902 Blank AAC NON-ELECTRONIC BOARD Blank $1,214.95 HCPCS - Non-Drugs E2000 Blank GASTRIC SUCTION PUMP HME MDL Blank $1,326.15 HCPCS - Non-Drugs E2000 RR GASTRIC SUCTION PUMP HME MDL Blank $180.06 HCPCS - Non-Drugs E2100 Blank BLD GLUCOSE MONITOR W VOICE Blank $1,296.15 HCPCS - Non-Drugs E2100 NU BLD GLUCOSE MONITOR W VOICE Blank $1,296.15 HCPCS - Non-Drugs E2100 RR BLD GLUCOSE MONITOR W VOICE Blank $199.35 HCPCS - Non-Drugs E2100 UE BLD GLUCOSE MONITOR W VOICE Blank $993.90 HCPCS - Non-Drugs E2101 Blank BLD GLUCOSE MONITOR W LANCE Blank $466.34 HCPCS - Non-Drugs E2101 NU BLD GLUCOSE MONITOR W LANCE Blank $466.34 HCPCS - Non-Drugs E2101 RR BLD GLUCOSE MONITOR W LANCE Blank $114.80 HCPCS - Non-Drugs E2101 UE BLD GLUCOSE MONITOR W LANCE Blank $368.68 HCPCS - Non-Drugs E2120 Blank PULSE GEN SYS TX ENDOLYMP FL Blank $4,883.38 HCPCS - Non-Drugs E2120 RR PULSE GEN SYS TX ENDOLYMP FL Blank $663.05 HCPCS - Non-Drugs E2201 Blank MAN W/CH ACC SEAT W>=20<24 Blank $720.44 HCPCS - Non-Drugs E2201 NU MAN W/CH ACC SEAT W>=20<24 Blank $720.44 HCPCS - Non-Drugs E2201 RR MAN W/CH ACC SEAT W>=20<24 Blank $127.60 HCPCS - Non-Drugs E2201 UE MAN W/CH ACC SEAT W>=20<24 Blank $555.76 HCPCS - Non-Drugs E2202 Blank SEAT WIDTH 24-27 IN Blank $1,017.70 HCPCS - Non-Drugs E2202 NU SEAT WIDTH 24-27 IN Blank $1,017.70 HCPCS - Non-Drugs E2202 RR SEAT WIDTH 24-27 IN Blank $157.32 HCPCS - Non-Drugs E2202 UE SEAT WIDTH 24-27 IN Blank $778.70 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E2203 Blank FRAME DEPTH LESS THAN 22 IN Blank $962.86 HCPCS - Non-Drugs E2203 NU FRAME DEPTH LESS THAN 22 IN Blank $962.86 HCPCS - Non-Drugs E2203 RR FRAME DEPTH LESS THAN 22 IN Blank $151.84 HCPCS - Non-Drugs E2203 UE FRAME DEPTH LESS THAN 22 IN Blank $737.58 HCPCS - Non-Drugs E2204 Blank FRAME DEPTH 22 TO 25 IN Blank $1,636.40 HCPCS - Non-Drugs E2204 NU FRAME DEPTH 22 TO 25 IN Blank $1,636.40 HCPCS - Non-Drugs E2204 RR FRAME DEPTH 22 TO 25 IN Blank $219.19 HCPCS - Non-Drugs E2204 UE FRAME DEPTH 22 TO 25 IN Blank $1,242.73 HCPCS - Non-Drugs E2205 Blank MANUAL WC ACCESSORY, HANDRIM Blank $135.57 HCPCS - Non-Drugs E2205 NU MANUAL WC ACCESSORY, HANDRIM Blank $135.57 HCPCS - Non-Drugs E2205 RR MANUAL WC ACCESSORY, HANDRIM Blank $12.64 HCPCS - Non-Drugs E2205 UE MANUAL WC ACCESSORY, HANDRIM Blank $117.12 HCPCS - Non-Drugs E2206 Blank MAN WC WHL LOCK COMP REPL EA Blank $143.05 HCPCS - Non-Drugs E2206 NU MAN WC WHL LOCK COMP REPL EA Blank $143.05 HCPCS - Non-Drugs E2206 RR MAN WC WHL LOCK COMP REPL EA Blank $13.91 HCPCS - Non-Drugs E2206 UE MAN WC WHL LOCK COMP REPL EA Blank $122.71 HCPCS - Non-Drugs E2207 Blank CRUTCH AND CANE HOLDER Blank $158.72 HCPCS - Non-Drugs E2207 NU CRUTCH AND CANE HOLDER Blank $158.72 HCPCS - Non-Drugs E2207 RR CRUTCH AND CANE HOLDER Blank $16.59 HCPCS - Non-Drugs E2207 UE CRUTCH AND CANE HOLDER Blank $134.48 HCPCS - Non-Drugs E2208 Blank CYLINDER TANK CARRIER Blank $225.80 HCPCS - Non-Drugs E2208 NU CYLINDER TANK CARRIER Blank $225.80 HCPCS - Non-Drugs E2208 RR CYLINDER TANK CARRIER Blank $28.08 HCPCS - Non-Drugs E2208 UE CYLINDER TANK CARRIER Blank $184.78 HCPCS - Non-Drugs E2209 Blank ARM TROUGH EACH Blank $240.19 HCPCS - Non-Drugs E2209 NU ARM TROUGH EACH Blank $240.19 HCPCS - Non-Drugs E2209 RR ARM TROUGH EACH Blank $30.55 HCPCS - Non-Drugs E2209 UE ARM TROUGH EACH Blank $195.58 HCPCS - Non-Drugs E2210 Blank WHEELCHAIR BEARINGS Blank $19.63 HCPCS - Non-Drugs E2210 NU WHEELCHAIR BEARINGS Blank $19.63 HCPCS - Non-Drugs E2210 RR WHEELCHAIR BEARINGS Blank $1.97 HCPCS - Non-Drugs E2210 UE WHEELCHAIR BEARINGS Blank $14.73 HCPCS - Non-Drugs E2211 Blank PNEUMATIC PROPULSION TIRE Blank $135.13 HCPCS - Non-Drugs E2211 NU PNEUMATIC PROPULSION TIRE Blank $135.13 HCPCS - Non-Drugs E2211 RR PNEUMATIC PROPULSION TIRE Blank $12.57 HCPCS - Non-Drugs E2211 UE PNEUMATIC PROPULSION TIRE Blank $116.78 HCPCS - Non-Drugs E2212 Blank PNEUMATIC PROP TIRE TUBE Blank $22.63 HCPCS - Non-Drugs E2212 NU PNEUMATIC PROP TIRE TUBE Blank $22.63 HCPCS - Non-Drugs E2212 RR PNEUMATIC PROP TIRE TUBE Blank $2.27 HCPCS - Non-Drugs E2212 UE PNEUMATIC PROP TIRE TUBE Blank $16.99 HCPCS - Non-Drugs E2213 Blank PNEUMATIC PROP TIRE INSERT Blank $125.08 HCPCS - Non-Drugs E2213 NU PNEUMATIC PROP TIRE INSERT Blank $125.08 HCPCS - Non-Drugs E2213 RR PNEUMATIC PROP TIRE INSERT Blank $10.84 HCPCS - Non-Drugs E2213 UE PNEUMATIC PROP TIRE INSERT Blank $104.27 HCPCS - Non-Drugs E2214 Blank PNEUMATIC CASTER TIRE EACH Blank $131.37 HCPCS - Non-Drugs E2214 NU PNEUMATIC CASTER TIRE EACH Blank $131.37 HCPCS - Non-Drugs E2214 RR PNEUMATIC CASTER TIRE EACH Blank $11.93 HCPCS - Non-Drugs E2214 UE PNEUMATIC CASTER TIRE EACH Blank $113.96 HCPCS - Non-Drugs E2215 Blank PNEUMATIC CASTER TIRE TUBE Blank $37.26 HCPCS - Non-Drugs E2215 NU PNEUMATIC CASTER TIRE TUBE Blank $37.26 HCPCS - Non-Drugs E2215 RR PNEUMATIC CASTER TIRE TUBE Blank $3.72 HCPCS - Non-Drugs E2215 UE PNEUMATIC CASTER TIRE TUBE Blank $27.93 HCPCS - Non-Drugs E2216 Blank FOAM FILLED PROPULSION TIRE Blank $199.69 HCPCS - Non-Drugs E2216 NU FOAM FILLED PROPULSION TIRE Blank $199.69 HCPCS - Non-Drugs E2216 RR FOAM FILLED PROPULSION TIRE Blank $21.24 HCPCS - Non-Drugs E2216 UE FOAM FILLED PROPULSION TIRE Blank $150.12 HCPCS - Non-Drugs E2217 Blank FOAM FILLED CASTER TIRE EACH Blank $214.63 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E2217 NU FOAM FILLED CASTER TIRE EACH Blank $214.63 HCPCS - Non-Drugs E2217 RR FOAM FILLED CASTER TIRE EACH Blank $12.94 HCPCS - Non-Drugs E2217 UE FOAM FILLED CASTER TIRE EACH Blank $90.15 HCPCS - Non-Drugs E2218 Blank FOAM PROPULSION TIRE EACH Blank $172.81 HCPCS - Non-Drugs E2218 NU FOAM PROPULSION TIRE EACH Blank $172.81 HCPCS - Non-Drugs E2218 RR FOAM PROPULSION TIRE EACH Blank $8.60 HCPCS - Non-Drugs E2218 UE FOAM PROPULSION TIRE EACH Blank $51.77 HCPCS - Non-Drugs E2219 Blank FOAM CASTER TIRE ANY SIZE EA Blank $147.74 HCPCS - Non-Drugs E2219 NU FOAM CASTER TIRE ANY SIZE EA Blank $147.74 HCPCS - Non-Drugs E2219 RR FOAM CASTER TIRE ANY SIZE EA Blank $14.77 HCPCS - Non-Drugs E2219 UE FOAM CASTER TIRE ANY SIZE EA Blank $126.24 HCPCS - Non-Drugs E2220 Blank SOLID PROPULS TIRE, REPL, EA Blank $122.76 HCPCS - Non-Drugs E2220 NU SOLID PROPULS TIRE, REPL, EA Blank $122.76 HCPCS - Non-Drugs E2220 RR SOLID PROPULS TIRE, REPL, EA Blank $10.42 HCPCS - Non-Drugs E2220 UE SOLID PROPULS TIRE, REPL, EA Blank $100.11 HCPCS - Non-Drugs E2221 Blank SOLID CASTER TIRE REPL, EACH Blank $118.31 HCPCS - Non-Drugs E2221 NU SOLID CASTER TIRE REPL, EACH Blank $118.31 HCPCS - Non-Drugs E2221 RR SOLID CASTER TIRE REPL, EACH Blank $9.68 HCPCS - Non-Drugs E2221 UE SOLID CASTER TIRE REPL, EACH Blank $90.96 HCPCS - Non-Drugs E2222 Blank SOLID CASTER INTEG WHL, REPL Blank $103.83 HCPCS - Non-Drugs E2222 NU SOLID CASTER INTEG WHL, REPL Blank $103.83 HCPCS - Non-Drugs E2222 RR SOLID CASTER INTEG WHL, REPL Blank $8.11 HCPCS - Non-Drugs E2222 UE SOLID CASTER INTEG WHL, REPL Blank $72.82 HCPCS - Non-Drugs E2224 Blank PROPULSION WHL EXCL TIRE REP Blank $258.87 HCPCS - Non-Drugs E2224 NU PROPULSION WHL EXCL TIRE REP Blank $258.87 HCPCS - Non-Drugs E2224 RR PROPULSION WHL EXCL TIRE REP Blank $33.86 HCPCS - Non-Drugs E2224 UE PROPULSION WHL EXCL TIRE REP Blank $209.55 HCPCS - Non-Drugs E2225 Blank CASTER WHEEL EXCLUDES TIRE Blank $83.80 HCPCS - Non-Drugs E2225 NU CASTER WHEEL EXCLUDES TIRE Blank $83.80 HCPCS - Non-Drugs E2225 RR CASTER WHEEL EXCLUDES TIRE Blank $6.79 HCPCS - Non-Drugs E2225 UE CASTER WHEEL EXCLUDES TIRE Blank $57.79 HCPCS - Non-Drugs E2226 Blank CASTER FORK REPLACEMENT ONLY Blank $145.48 HCPCS - Non-Drugs E2226 NU CASTER FORK REPLACEMENT ONLY Blank $145.48 HCPCS - Non-Drugs E2226 RR CASTER FORK REPLACEMENT ONLY Blank $14.33 HCPCS - Non-Drugs E2226 UE CASTER FORK REPLACEMENT ONLY Blank $124.54 HCPCS - Non-Drugs E2227 Blank GEAR REDUCTION DRIVE WHEEL Blank $3,812.02 HCPCS - Non-Drugs E2227 NU GEAR REDUCTION DRIVE WHEEL Blank $3,812.02 HCPCS - Non-Drugs E2227 RR GEAR REDUCTION DRIVE WHEEL Blank $517.59 HCPCS - Non-Drugs E2227 UE GEAR REDUCTION DRIVE WHEEL Blank $3,077.09 HCPCS - Non-Drugs E2228 Blank MWC ACC, WHEELCHAIR BRAKE Blank $1,947.03 HCPCS - Non-Drugs E2228 NU MWC ACC, WHEELCHAIR BRAKE Blank $1,947.03 HCPCS - Non-Drugs E2228 RR MWC ACC, WHEELCHAIR BRAKE Blank $264.36 HCPCS - Non-Drugs E2228 UE MWC ACC, WHEELCHAIR BRAKE Blank $1,379.52 HCPCS - Non-Drugs E2230 Blank MANUAL STANDING SYSTEM Blank $1,600.13 HCPCS - Non-Drugs E2231 Blank SOLID SEAT SUPPORT BASE Blank $358.57 HCPCS - Non-Drugs E2231 NU SOLID SEAT SUPPORT BASE Blank $358.57 HCPCS - Non-Drugs E2231 RR SOLID SEAT SUPPORT BASE Blank $57.56 HCPCS - Non-Drugs E2231 UE SOLID SEAT SUPPORT BASE Blank $284.36 HCPCS - Non-Drugs E2295 Blank PED DYNAMIC SEATING FRAME Blank $93.67 HCPCS - Non-Drugs E2300 Blank PWR SEAT ELEVATION SYS Blank $878.23 HCPCS - Non-Drugs E2301 Blank PWR STANDING Blank $1,119.43 HCPCS - Non-Drugs E2310 Blank ELECTRO CONNECT BTW CONTROL Blank $2,116.11 HCPCS - Non-Drugs E2310 NU ELECTRO CONNECT BTW CONTROL Blank $2,116.11 HCPCS - Non-Drugs E2310 RR ELECTRO CONNECT BTW CONTROL Blank $287.32 HCPCS - Non-Drugs E2310 UE ELECTRO CONNECT BTW CONTROL Blank $1,481.39 HCPCS - Non-Drugs E2311 Blank ELECTRO CONNECT BTW 2 SYS Blank $3,807.50 HCPCS - Non-Drugs E2311 NU ELECTRO CONNECT BTW 2 SYS Blank $3,807.50 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E2311 RR ELECTRO CONNECT BTW 2 SYS Blank $516.97 HCPCS - Non-Drugs E2311 UE ELECTRO CONNECT BTW 2 SYS Blank $2,936.10 HCPCS - Non-Drugs E2312 Blank MINI-PROP REMOTE JOYSTICK Blank $4,074.08 HCPCS - Non-Drugs E2312 NU MINI-PROP REMOTE JOYSTICK Blank $4,074.08 HCPCS - Non-Drugs E2312 RR MINI-PROP REMOTE JOYSTICK Blank $553.17 HCPCS - Non-Drugs E2312 UE MINI-PROP REMOTE JOYSTICK Blank $3,311.80 HCPCS - Non-Drugs E2313 Blank PWC HARNESS, EXPAND CONTROL Blank $1,029.71 HCPCS - Non-Drugs E2313 NU PWC HARNESS, EXPAND CONTROL Blank $1,029.71 HCPCS - Non-Drugs E2313 RR PWC HARNESS, EXPAND CONTROL Blank $139.81 HCPCS - Non-Drugs E2313 UE PWC HARNESS, EXPAND CONTROL Blank $578.41 HCPCS - Non-Drugs E2321 Blank HAND INTERFACE JOYSTICK Blank $2,712.15 HCPCS - Non-Drugs E2321 NU HAND INTERFACE JOYSTICK Blank $2,712.15 HCPCS - Non-Drugs E2321 RR HAND INTERFACE JOYSTICK Blank $368.25 HCPCS - Non-Drugs E2321 UE HAND INTERFACE JOYSTICK Blank $1,989.11 HCPCS - Non-Drugs E2322 Blank MULT MECH SWITCHES Blank $2,587.56 HCPCS - Non-Drugs E2322 NU MULT MECH SWITCHES Blank $2,587.56 HCPCS - Non-Drugs E2322 RR MULT MECH SWITCHES Blank $351.33 HCPCS - Non-Drugs E2322 UE MULT MECH SWITCHES Blank $1,772.33 HCPCS - Non-Drugs E2323 Blank SPECIAL JOYSTICK HANDLE Blank $202.90 HCPCS - Non-Drugs E2323 NU SPECIAL JOYSTICK HANDLE Blank $202.90 HCPCS - Non-Drugs E2323 RR SPECIAL JOYSTICK HANDLE Blank $24.15 HCPCS - Non-Drugs E2323 UE SPECIAL JOYSTICK HANDLE Blank $167.60 HCPCS - Non-Drugs E2324 Blank CHIN CUP INTERFACE Blank $154.93 HCPCS - Non-Drugs E2324 NU CHIN CUP INTERFACE Blank $154.93 HCPCS - Non-Drugs E2324 RR CHIN CUP INTERFACE Blank $15.92 HCPCS - Non-Drugs E2324 UE CHIN CUP INTERFACE Blank $131.63 HCPCS - Non-Drugs E2325 Blank SIP AND PUFF INTERFACE Blank $2,493.14 HCPCS - Non-Drugs E2325 NU SIP AND PUFF INTERFACE Blank $2,493.14 HCPCS - Non-Drugs E2325 RR SIP AND PUFF INTERFACE Blank $338.51 HCPCS - Non-Drugs E2325 UE SIP AND PUFF INTERFACE Blank $1,695.72 HCPCS - Non-Drugs E2326 Blank BREATH TUBE KIT Blank $989.28 HCPCS - Non-Drugs E2326 NU BREATH TUBE KIT Blank $989.28 HCPCS - Non-Drugs E2326 RR BREATH TUBE KIT Blank $134.32 HCPCS - Non-Drugs E2326 UE BREATH TUBE KIT Blank $483.06 HCPCS - Non-Drugs E2327 Blank HEAD CONTROL INTERFACE MECH Blank $4,442.22 HCPCS - Non-Drugs E2327 NU HEAD CONTROL INTERFACE MECH Blank $4,442.22 HCPCS - Non-Drugs E2327 RR HEAD CONTROL INTERFACE MECH Blank $603.15 HCPCS - Non-Drugs E2327 UE HEAD CONTROL INTERFACE MECH Blank $3,231.11 HCPCS - Non-Drugs E2328 Blank HEAD/EXTREMITY CONTROL INTER Blank $7,981.22 HCPCS - Non-Drugs E2328 NU HEAD/EXTREMITY CONTROL INTER Blank $7,981.22 HCPCS - Non-Drugs E2328 RR HEAD/EXTREMITY CONTROL INTER Blank $1,083.67 HCPCS - Non-Drugs E2328 UE HEAD/EXTREMITY CONTROL INTER Blank $6,072.90 HCPCS - Non-Drugs E2329 Blank HEAD CONTROL NONPROPORTIONAL Blank $3,172.62 HCPCS - Non-Drugs E2329 NU HEAD CONTROL NONPROPORTIONAL Blank $3,172.62 HCPCS - Non-Drugs E2329 RR HEAD CONTROL NONPROPORTIONAL Blank $430.77 HCPCS - Non-Drugs E2329 UE HEAD CONTROL NONPROPORTIONAL Blank $2,204.26 HCPCS - Non-Drugs E2330 Blank HEAD CONTROL PROXIMITY SWITC Blank $5,673.14 HCPCS - Non-Drugs E2330 NU HEAD CONTROL PROXIMITY SWITC Blank $5,673.14 HCPCS - Non-Drugs E2330 RR HEAD CONTROL PROXIMITY SWITC Blank $770.29 HCPCS - Non-Drugs E2330 UE HEAD CONTROL PROXIMITY SWITC Blank $4,213.15 HCPCS - Non-Drugs E2331 Blank ATTENDANT CONTROL Blank $1,863.80 HCPCS - Non-Drugs E2340 Blank W/C WDTH 20-23 IN SEAT FRAME Blank $951.74 HCPCS - Non-Drugs E2340 NU W/C WDTH 20-23 IN SEAT FRAME Blank $951.74 HCPCS - Non-Drugs E2340 RR W/C WDTH 20-23 IN SEAT FRAME Blank $150.76 HCPCS - Non-Drugs E2340 UE W/C WDTH 20-23 IN SEAT FRAME Blank $729.31 HCPCS - Non-Drugs E2341 Blank W/C WDTH 24-27 IN SEAT FRAME Blank $1,396.86 HCPCS - Non-Drugs E2341 NU W/C WDTH 24-27 IN SEAT FRAME Blank $1,396.86 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E2341 RR W/C WDTH 24-27 IN SEAT FRAME Blank $195.22 HCPCS - Non-Drugs E2341 UE W/C WDTH 24-27 IN SEAT FRAME Blank $1,063.09 HCPCS - Non-Drugs E2342 Blank W/C DPTH 20-21 IN SEAT FRAME Blank $1,174.34 HCPCS - Non-Drugs E2342 NU W/C DPTH 20-21 IN SEAT FRAME Blank $1,174.34 HCPCS - Non-Drugs E2342 RR W/C DPTH 20-21 IN SEAT FRAME Blank $172.98 HCPCS - Non-Drugs E2342 UE W/C DPTH 20-21 IN SEAT FRAME Blank $896.21 HCPCS - Non-Drugs E2343 Blank W/C DPTH 22-25 IN SEAT FRAME Blank $1,841.94 HCPCS - Non-Drugs E2343 NU W/C DPTH 22-25 IN SEAT FRAME Blank $1,841.94 HCPCS - Non-Drugs E2343 RR W/C DPTH 22-25 IN SEAT FRAME Blank $239.71 HCPCS - Non-Drugs E2343 UE W/C DPTH 22-25 IN SEAT FRAME Blank $1,396.86 HCPCS - Non-Drugs E2351 Blank ELECTRONIC SGD INTERFACE Blank $1,529.53 HCPCS - Non-Drugs E2351 NU ELECTRONIC SGD INTERFACE Blank $1,529.53 HCPCS - Non-Drugs E2351 RR ELECTRONIC SGD INTERFACE Blank $208.51 HCPCS - Non-Drugs E2351 UE ELECTRONIC SGD INTERFACE Blank $1,162.60 HCPCS - Non-Drugs E2358 Blank GR 34 NONSEALED LEADACID Blank $339.49 HCPCS - Non-Drugs E2359 Blank GR34 SEALED LEADACID BATTERY Blank $420.24 HCPCS - Non-Drugs E2359 NU GR34 SEALED LEADACID BATTERY Blank $420.24 HCPCS - Non-Drugs E2359 RR GR34 SEALED LEADACID BATTERY Blank $73.70 HCPCS - Non-Drugs E2359 UE GR34 SEALED LEADACID BATTERY Blank $330.61 HCPCS - Non-Drugs E2360 Blank 22NF NONSEALED LEADACID Blank $280.96 HCPCS - Non-Drugs E2360 NU 22NF NONSEALED LEADACID Blank $280.96 HCPCS - Non-Drugs E2360 RR 22NF NONSEALED LEADACID Blank $37.55 HCPCS - Non-Drugs E2360 UE 22NF NONSEALED LEADACID Blank $226.15 HCPCS - Non-Drugs E2361 Blank 22NF SEALED LEADACID BATTERY Blank $308.08 HCPCS - Non-Drugs E2361 NU 22NF SEALED LEADACID BATTERY Blank $308.08 HCPCS - Non-Drugs E2361 RR 22NF SEALED LEADACID BATTERY Blank $44.34 HCPCS - Non-Drugs E2361 UE 22NF SEALED LEADACID BATTERY Blank $246.49 HCPCS - Non-Drugs E2362 Blank GR24 NONSEALED LEADACID Blank $261.12 HCPCS - Non-Drugs E2362 NU GR24 NONSEALED LEADACID Blank $261.12 HCPCS - Non-Drugs E2362 RR GR24 NONSEALED LEADACID Blank $34.12 HCPCS - Non-Drugs E2362 UE GR24 NONSEALED LEADACID Blank $211.26 HCPCS - Non-Drugs E2363 Blank GR24 SEALED LEADACID BATTERY Blank $373.70 HCPCS - Non-Drugs E2363 NU GR24 SEALED LEADACID BATTERY Blank $373.70 HCPCS - Non-Drugs E2363 RR GR24 SEALED LEADACID BATTERY Blank $61.51 HCPCS - Non-Drugs E2363 UE GR24 SEALED LEADACID BATTERY Blank $295.71 HCPCS - Non-Drugs E2364 Blank U1NONSEALED LEADACID BATTERY Blank $274.62 HCPCS - Non-Drugs E2364 NU U1NONSEALED LEADACID BATTERY Blank $274.62 HCPCS - Non-Drugs E2364 RR U1NONSEALED LEADACID BATTERY Blank $36.43 HCPCS - Non-Drugs E2364 UE U1NONSEALED LEADACID BATTERY Blank $221.40 HCPCS - Non-Drugs E2365 Blank U1 SEALED LEADACID BATTERY Blank $225.84 HCPCS - Non-Drugs E2365 NU U1 SEALED LEADACID BATTERY Blank $225.84 HCPCS - Non-Drugs E2365 RR U1 SEALED LEADACID BATTERY Blank $28.08 HCPCS - Non-Drugs E2365 UE U1 SEALED LEADACID BATTERY Blank $184.82 HCPCS - Non-Drugs E2366 Blank BATTERY CHARGER, SINGLE MODE Blank $399.68 HCPCS - Non-Drugs E2366 NU BATTERY CHARGER, SINGLE MODE Blank $399.68 HCPCS - Non-Drugs E2366 RR BATTERY CHARGER, SINGLE MODE Blank $68.46 HCPCS - Non-Drugs E2366 UE BATTERY CHARGER, SINGLE MODE Blank $315.63 HCPCS - Non-Drugs E2367 Blank BATTERY CHARGER, DUAL MODE Blank $750.59 HCPCS - Non-Drugs E2367 NU BATTERY CHARGER, DUAL MODE Blank $750.59 HCPCS - Non-Drugs E2367 RR BATTERY CHARGER, DUAL MODE Blank $130.61 HCPCS - Non-Drugs E2367 UE BATTERY CHARGER, DUAL MODE Blank $578.38 HCPCS - Non-Drugs E2368 Blank PWR WC DRIVEWHEEL MOTOR REPL Blank $1,105.10 HCPCS - Non-Drugs E2368 NU PWR WC DRIVEWHEEL MOTOR REPL Blank $1,105.10 HCPCS - Non-Drugs E2368 RR PWR WC DRIVEWHEEL MOTOR REPL Blank $150.05 HCPCS - Non-Drugs E2368 UE PWR WC DRIVEWHEEL MOTOR REPL Blank $688.43 HCPCS - Non-Drugs E2369 Blank PWR WC DRIVEWHEEL GEAR REPL Blank $1,064.22 HCPCS - Non-Drugs E2369 NU PWR WC DRIVEWHEEL GEAR REPL Blank $1,064.22 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E2369 RR PWR WC DRIVEWHEEL GEAR REPL Blank $144.50 HCPCS - Non-Drugs E2369 UE PWR WC DRIVEWHEEL GEAR REPL Blank $607.74 HCPCS - Non-Drugs E2370 Blank PWR WC DR WH MOTOR/GEAR COMB Blank $1,290.96 HCPCS - Non-Drugs E2370 NU PWR WC DR WH MOTOR/GEAR COMB Blank $1,290.96 HCPCS - Non-Drugs E2370 RR PWR WC DR WH MOTOR/GEAR COMB Blank $175.28 HCPCS - Non-Drugs E2370 UE PWR WC DR WH MOTOR/GEAR COMB Blank $1,035.60 HCPCS - Non-Drugs E2371 Blank GR27 SEALED LEADACID BATTERY Blank $359.24 HCPCS - Non-Drugs E2371 NU GR27 SEALED LEADACID BATTERY Blank $359.24 HCPCS - Non-Drugs E2371 RR GR27 SEALED LEADACID BATTERY Blank $57.73 HCPCS - Non-Drugs E2371 UE GR27 SEALED LEADACID BATTERY Blank $284.86 HCPCS - Non-Drugs E2372 Blank GR27 NON-SEALED LEADACID Blank $205.44 HCPCS - Non-Drugs E2372 NU GR27 NON-SEALED LEADACID Blank $205.44 HCPCS - Non-Drugs E2372 RR GR27 NON-SEALED LEADACID Blank $21.86 HCPCS - Non-Drugs E2372 UE GR27 NON-SEALED LEADACID Blank $154.46 HCPCS - Non-Drugs E2373 Blank HAND/CHIN CTRL SPEC JOYSTICK Blank $1,664.99 HCPCS - Non-Drugs E2373 NU HAND/CHIN CTRL SPEC JOYSTICK Blank $1,664.99 HCPCS - Non-Drugs E2373 RR HAND/CHIN CTRL SPEC JOYSTICK Blank $226.07 HCPCS - Non-Drugs E2373 UE HAND/CHIN CTRL SPEC JOYSTICK Blank $1,189.63 HCPCS - Non-Drugs E2374 Blank HAND/CHIN CTRL STD JOYSTICK Blank $1,220.26 HCPCS - Non-Drugs E2374 NU HAND/CHIN CTRL STD JOYSTICK Blank $1,220.26 HCPCS - Non-Drugs E2374 RR HAND/CHIN CTRL STD JOYSTICK Blank $165.68 HCPCS - Non-Drugs E2374 UE HAND/CHIN CTRL STD JOYSTICK Blank $709.62 HCPCS - Non-Drugs E2375 Blank NON-EXPANDABLE CONTROLLER Blank $1,519.17 HCPCS - Non-Drugs E2375 NU NON-EXPANDABLE CONTROLLER Blank $1,519.17 HCPCS - Non-Drugs E2375 RR NON-EXPANDABLE CONTROLLER Blank $206.27 HCPCS - Non-Drugs E2375 UE NON-EXPANDABLE CONTROLLER Blank $1,100.80 HCPCS - Non-Drugs E2376 Blank EXPANDABLE CONTROLLER, REPL Blank $2,356.75 HCPCS - Non-Drugs E2376 NU EXPANDABLE CONTROLLER, REPL Blank $2,356.75 HCPCS - Non-Drugs E2376 RR EXPANDABLE CONTROLLER, REPL Blank $319.99 HCPCS - Non-Drugs E2376 UE EXPANDABLE CONTROLLER, REPL Blank $1,690.02 HCPCS - Non-Drugs E2377 Blank EXPANDABLE CONTROLLER, INITL Blank $1,159.27 HCPCS - Non-Drugs E2377 NU EXPANDABLE CONTROLLER, INITL Blank $1,159.27 HCPCS - Non-Drugs E2377 RR EXPANDABLE CONTROLLER, INITL Blank $157.40 HCPCS - Non-Drugs E2377 UE EXPANDABLE CONTROLLER, INITL Blank $650.94 HCPCS - Non-Drugs E2378 Blank PW ACTUATOR REPLACEMENT Blank $1,341.80 HCPCS - Non-Drugs E2378 NU PW ACTUATOR REPLACEMENT Blank $1,341.80 HCPCS - Non-Drugs E2378 RR PW ACTUATOR REPLACEMENT Blank $182.19 HCPCS - Non-Drugs E2378 UE PW ACTUATOR REPLACEMENT Blank $881.57 HCPCS - Non-Drugs E2381 Blank PNEUM DRIVE WHEEL TIRE Blank $192.33 HCPCS - Non-Drugs E2381 NU PNEUM DRIVE WHEEL TIRE Blank $192.33 HCPCS - Non-Drugs E2381 RR PNEUM DRIVE WHEEL TIRE Blank $22.35 HCPCS - Non-Drugs E2381 UE PNEUM DRIVE WHEEL TIRE Blank $159.68 HCPCS - Non-Drugs E2382 Blank TUBE, PNEUM WHEEL DRIVE TIRE Blank $79.07 HCPCS - Non-Drugs E2382 NU TUBE, PNEUM WHEEL DRIVE TIRE Blank $79.07 HCPCS - Non-Drugs E2382 RR TUBE, PNEUM WHEEL DRIVE TIRE Blank $6.47 HCPCS - Non-Drugs E2382 UE TUBE, PNEUM WHEEL DRIVE TIRE Blank $54.24 HCPCS - Non-Drugs E2383 Blank INSERT, PNEUM WHEEL DRIVE Blank $334.45 HCPCS - Non-Drugs E2383 NU INSERT, PNEUM WHEEL DRIVE Blank $334.45 HCPCS - Non-Drugs E2383 RR INSERT, PNEUM WHEEL DRIVE Blank $51.22 HCPCS - Non-Drugs E2383 UE INSERT, PNEUM WHEEL DRIVE Blank $266.27 HCPCS - Non-Drugs E2384 Blank PNEUMATIC CASTER TIRE Blank $193.52 HCPCS - Non-Drugs E2384 NU PNEUMATIC CASTER TIRE Blank $193.52 HCPCS - Non-Drugs E2384 RR PNEUMATIC CASTER TIRE Blank $22.56 HCPCS - Non-Drugs E2384 UE PNEUMATIC CASTER TIRE Blank $160.57 HCPCS - Non-Drugs E2385 Blank TUBE, PNEUMATIC CASTER TIRE Blank $152.64 HCPCS - Non-Drugs E2385 NU TUBE, PNEUMATIC CASTER TIRE Blank $152.64 HCPCS - Non-Drugs E2385 RR TUBE, PNEUMATIC CASTER TIRE Blank $15.58 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E2385 UE TUBE, PNEUMATIC CASTER TIRE Blank $129.92 HCPCS - Non-Drugs E2386 Blank FOAM FILLED DRIVE WHEEL TIRE Blank $281.99 HCPCS - Non-Drugs E2386 NU FOAM FILLED DRIVE WHEEL TIRE Blank $281.99 HCPCS - Non-Drugs E2386 RR FOAM FILLED DRIVE WHEEL TIRE Blank $37.70 HCPCS - Non-Drugs E2386 UE FOAM FILLED DRIVE WHEEL TIRE Blank $226.93 HCPCS - Non-Drugs E2387 Blank FOAM FILLED CASTER TIRE Blank $167.54 HCPCS - Non-Drugs E2387 NU FOAM FILLED CASTER TIRE Blank $167.54 HCPCS - Non-Drugs E2387 RR FOAM FILLED CASTER TIRE Blank $18.11 HCPCS - Non-Drugs E2387 UE FOAM FILLED CASTER TIRE Blank $141.08 HCPCS - Non-Drugs E2388 Blank FOAM DRIVE WHEEL TIRE Blank $160.68 HCPCS - Non-Drugs E2388 NU FOAM DRIVE WHEEL TIRE Blank $160.68 HCPCS - Non-Drugs E2388 RR FOAM DRIVE WHEEL TIRE Blank $16.95 HCPCS - Non-Drugs E2388 UE FOAM DRIVE WHEEL TIRE Blank $135.93 HCPCS - Non-Drugs E2389 Blank FOAM CASTER TIRE Blank $117.03 HCPCS - Non-Drugs E2389 NU FOAM CASTER TIRE Blank $117.03 HCPCS - Non-Drugs E2389 RR FOAM CASTER TIRE Blank $9.45 HCPCS - Non-Drugs E2389 UE FOAM CASTER TIRE Blank $88.46 HCPCS - Non-Drugs E2390 Blank SOLID DRIVE WHEEL TIRE Blank $147.34 HCPCS - Non-Drugs E2390 NU SOLID DRIVE WHEEL TIRE Blank $147.34 HCPCS - Non-Drugs E2390 RR SOLID DRIVE WHEEL TIRE Blank $14.66 HCPCS - Non-Drugs E2390 UE SOLID DRIVE WHEEL TIRE Blank $125.95 HCPCS - Non-Drugs E2391 Blank SOLID CASTER TIRE Blank $78.63 HCPCS - Non-Drugs E2391 NU SOLID CASTER TIRE Blank $78.63 HCPCS - Non-Drugs E2391 RR SOLID CASTER TIRE Blank $6.46 HCPCS - Non-Drugs E2391 UE SOLID CASTER TIRE Blank $53.91 HCPCS - Non-Drugs E2392 Blank SOLID CASTER TIRE, INTEGRATE Blank $153.05 HCPCS - Non-Drugs E2392 NU SOLID CASTER TIRE, INTEGRATE Blank $153.05 HCPCS - Non-Drugs E2392 RR SOLID CASTER TIRE, INTEGRATE Blank $15.64 HCPCS - Non-Drugs E2392 UE SOLID CASTER TIRE, INTEGRATE Blank $130.22 HCPCS - Non-Drugs E2394 Blank DRIVE WHEEL EXCLUDES TIRE Blank $186.88 HCPCS - Non-Drugs E2394 NU DRIVE WHEEL EXCLUDES TIRE Blank $186.88 HCPCS - Non-Drugs E2394 RR DRIVE WHEEL EXCLUDES TIRE Blank $21.42 HCPCS - Non-Drugs E2394 UE DRIVE WHEEL EXCLUDES TIRE Blank $155.59 HCPCS - Non-Drugs E2395 Blank CASTER WHEEL EXCLUDES TIRE Blank $155.68 HCPCS - Non-Drugs E2395 NU CASTER WHEEL EXCLUDES TIRE Blank $155.68 HCPCS - Non-Drugs E2395 RR CASTER WHEEL EXCLUDES TIRE Blank $16.08 HCPCS - Non-Drugs E2395 UE CASTER WHEEL EXCLUDES TIRE Blank $132.20 HCPCS - Non-Drugs E2396 Blank CASTER FORK Blank $173.02 HCPCS - Non-Drugs E2396 NU CASTER FORK Blank $173.02 HCPCS - Non-Drugs E2396 RR CASTER FORK Blank $19.06 HCPCS - Non-Drugs E2396 UE CASTER FORK Blank $145.20 HCPCS - Non-Drugs E2397 Blank PWC ACC, LITH-BASED BATTERY Blank $1,004.01 HCPCS - Non-Drugs E2397 NU PWC ACC, LITH-BASED BATTERY Blank $1,004.01 HCPCS - Non-Drugs E2397 RR PWC ACC, LITH-BASED BATTERY Blank $155.95 HCPCS - Non-Drugs E2397 UE PWC ACC, LITH-BASED BATTERY Blank $768.43 HCPCS - Non-Drugs E2402 Blank NEG PRESS WOUND THERAPY PUMP Blank $9,493.11 HCPCS - Non-Drugs E2402 RR NEG PRESS WOUND THERAPY PUMP Blank $1,288.95 HCPCS - Non-Drugs E2500 Blank SGD DIGITIZED PRE-REC <=8MIN Blank $885.78 HCPCS - Non-Drugs E2500 NU SGD DIGITIZED PRE-REC <=8MIN Blank $885.78 HCPCS - Non-Drugs E2500 RR SGD DIGITIZED PRE-REC <=8MIN Blank $156.76 HCPCS - Non-Drugs E2500 UE SGD DIGITIZED PRE-REC <=8MIN Blank $683.28 HCPCS - Non-Drugs E2502 Blank SGD PREREC MSG >8MIN <=20MIN Blank $2,552.79 HCPCS - Non-Drugs E2502 NU SGD PREREC MSG >8MIN <=20MIN Blank $2,552.79 HCPCS - Non-Drugs E2502 RR SGD PREREC MSG >8MIN <=20MIN Blank $323.47 HCPCS - Non-Drugs E2502 UE SGD PREREC MSG >8MIN <=20MIN Blank $1,933.57 HCPCS - Non-Drugs E2504 Blank SGD PREREC MSG>20MIN <=40MIN Blank $3,343.30 HCPCS - Non-Drugs E2504 NU SGD PREREC MSG>20MIN <=40MIN Blank $3,343.30 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E2504 RR SGD PREREC MSG>20MIN <=40MIN Blank $402.55 HCPCS - Non-Drugs E2504 UE SGD PREREC MSG>20MIN <=40MIN Blank $2,526.42 HCPCS - Non-Drugs E2506 Blank SGD PREREC MSG > 40 MIN Blank $4,866.97 HCPCS - Non-Drugs E2506 NU SGD PREREC MSG > 40 MIN Blank $4,866.97 HCPCS - Non-Drugs E2506 RR SGD PREREC MSG > 40 MIN Blank $554.83 HCPCS - Non-Drugs E2506 UE SGD PREREC MSG > 40 MIN Blank $3,669.08 HCPCS - Non-Drugs E2508 Blank SGD SPELLING PHYS CONTACT Blank $7,484.55 HCPCS - Non-Drugs E2508 NU SGD SPELLING PHYS CONTACT Blank $7,484.55 HCPCS - Non-Drugs E2508 RR SGD SPELLING PHYS CONTACT Blank $816.62 HCPCS - Non-Drugs E2508 UE SGD SPELLING PHYS CONTACT Blank $5,632.37 HCPCS - Non-Drugs E2510 Blank SGD W MULTI METHODS MSG/ACCS Blank $14,095.93 HCPCS - Non-Drugs E2510 NU SGD W MULTI METHODS MSG/ACCS Blank $14,095.93 HCPCS - Non-Drugs E2510 RR SGD W MULTI METHODS MSG/ACCS Blank $1,477.78 HCPCS - Non-Drugs E2510 UE SGD W MULTI METHODS MSG/ACCS Blank $10,590.87 HCPCS - Non-Drugs E2511 Blank SGD SFTWRE PRGRM FOR PC/PDA Blank $993.10 HCPCS - Non-Drugs E2511 NU SGD SFTWRE PRGRM FOR PC/PDA Blank $993.10 HCPCS - Non-Drugs E2511 RR SGD SFTWRE PRGRM FOR PC/PDA Blank $118.00 HCPCS - Non-Drugs E2511 UE SGD SFTWRE PRGRM FOR PC/PDA Blank $756.90 HCPCS - Non-Drugs E2512 Blank SGD ACCESSORY, MOUNTING SYS Blank $2,169.75 HCPCS - Non-Drugs E2512 NU SGD ACCESSORY, MOUNTING SYS Blank $2,169.75 HCPCS - Non-Drugs E2512 RR SGD ACCESSORY, MOUNTING SYS Blank $294.60 HCPCS - Non-Drugs E2512 UE SGD ACCESSORY, MOUNTING SYS Blank $1,660.21 HCPCS - Non-Drugs E2599 Blank SGD ACCESSORY NOC Blank $652.74 HCPCS - Non-Drugs E2601 Blank GEN W/C CUSHION WDTH < 22 IN Blank $144.66 HCPCS - Non-Drugs E2601 NU GEN W/C CUSHION WDTH < 22 IN Blank $144.66 HCPCS - Non-Drugs E2601 RR GEN W/C CUSHION WDTH < 22 IN Blank $14.20 HCPCS - Non-Drugs E2601 UE GEN W/C CUSHION WDTH < 22 IN Blank $123.93 HCPCS - Non-Drugs E2602 Blank GEN W/C CUSHION WDTH >=22 IN Blank $241.33 HCPCS - Non-Drugs E2602 NU GEN W/C CUSHION WDTH >=22 IN Blank $241.33 HCPCS - Non-Drugs E2602 RR GEN W/C CUSHION WDTH >=22 IN Blank $30.74 HCPCS - Non-Drugs E2602 UE GEN W/C CUSHION WDTH >=22 IN Blank $196.44 HCPCS - Non-Drugs E2603 Blank SKIN PROTECT WC CUS WD <22IN Blank $282.21 HCPCS - Non-Drugs E2603 NU SKIN PROTECT WC CUS WD <22IN Blank $282.21 HCPCS - Non-Drugs E2603 RR SKIN PROTECT WC CUS WD <22IN Blank $37.74 HCPCS - Non-Drugs E2603 UE SKIN PROTECT WC CUS WD <22IN Blank $227.09 HCPCS - Non-Drugs E2604 Blank SKIN PROTECT WC CUS WD>=22IN Blank $375.07 HCPCS - Non-Drugs E2604 NU SKIN PROTECT WC CUS WD>=22IN Blank $375.07 HCPCS - Non-Drugs E2604 RR SKIN PROTECT WC CUS WD>=22IN Blank $61.87 HCPCS - Non-Drugs E2604 UE SKIN PROTECT WC CUS WD>=22IN Blank $296.74 HCPCS - Non-Drugs E2605 Blank POSITION WC CUSH WDTH <22 IN Blank $512.30 HCPCS - Non-Drugs E2605 NU POSITION WC CUSH WDTH <22 IN Blank $512.30 HCPCS - Non-Drugs E2605 RR POSITION WC CUSH WDTH <22 IN Blank $97.81 HCPCS - Non-Drugs E2605 UE POSITION WC CUSH WDTH <22 IN Blank $399.65 HCPCS - Non-Drugs E2606 Blank POSITION WC CUSH WDTH>=22 IN Blank $785.72 HCPCS - Non-Drugs E2606 NU POSITION WC CUSH WDTH>=22 IN Blank $785.72 HCPCS - Non-Drugs E2606 RR POSITION WC CUSH WDTH>=22 IN Blank $134.12 HCPCS - Non-Drugs E2606 UE POSITION WC CUSH WDTH>=22 IN Blank $604.73 HCPCS - Non-Drugs E2607 Blank SKIN PRO/POS WC CUS WD <22IN Blank $499.65 HCPCS - Non-Drugs E2607 NU SKIN PRO/POS WC CUS WD <22IN Blank $499.65 HCPCS - Non-Drugs E2607 RR SKIN PRO/POS WC CUS WD <22IN Blank $94.49 HCPCS - Non-Drugs E2607 UE SKIN PRO/POS WC CUS WD <22IN Blank $390.17 HCPCS - Non-Drugs E2608 Blank SKIN PRO/POS WC CUS WD>=22IN Blank $617.51 HCPCS - Non-Drugs E2608 NU SKIN PRO/POS WC CUS WD>=22IN Blank $617.51 HCPCS - Non-Drugs E2608 RR SKIN PRO/POS WC CUS WD>=22IN Blank $117.30 HCPCS - Non-Drugs E2608 UE SKIN PRO/POS WC CUS WD>=22IN Blank $478.57 HCPCS - Non-Drugs E2609 Blank CUSTOM FABRICATE W/C CUSHION Blank $873.05 HCPCS - Non-Drugs E2610 Blank POWERED W/C CUSHION Blank $384.67 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E2611 Blank GEN USE BACK CUSH WDTH <22IN Blank $396.21 HCPCS - Non-Drugs E2611 NU GEN USE BACK CUSH WDTH <22IN Blank $396.21 HCPCS - Non-Drugs E2611 RR GEN USE BACK CUSH WDTH <22IN Blank $67.40 HCPCS - Non-Drugs E2611 UE GEN USE BACK CUSH WDTH <22IN Blank $312.59 HCPCS - Non-Drugs E2612 Blank GEN USE BACK CUSH WDTH>=22IN Blank $719.72 HCPCS - Non-Drugs E2612 NU GEN USE BACK CUSH WDTH>=22IN Blank $719.72 HCPCS - Non-Drugs E2612 RR GEN USE BACK CUSH WDTH>=22IN Blank $127.53 HCPCS - Non-Drugs E2612 UE GEN USE BACK CUSH WDTH>=22IN Blank $555.22 HCPCS - Non-Drugs E2613 Blank POSITION BACK CUSH WD <22IN Blank $719.51 HCPCS - Non-Drugs E2613 NU POSITION BACK CUSH WD <22IN Blank $719.51 HCPCS - Non-Drugs E2613 RR POSITION BACK CUSH WD <22IN Blank $127.50 HCPCS - Non-Drugs E2613 UE POSITION BACK CUSH WD <22IN Blank $555.06 HCPCS - Non-Drugs E2614 Blank POSITION BACK CUSH WD>=22IN Blank $1,038.05 HCPCS - Non-Drugs E2614 NU POSITION BACK CUSH WD>=22IN Blank $1,038.05 HCPCS - Non-Drugs E2614 RR POSITION BACK CUSH WD>=22IN Blank $159.35 HCPCS - Non-Drugs E2614 UE POSITION BACK CUSH WD>=22IN Blank $793.97 HCPCS - Non-Drugs E2615 Blank POS BACK POST/LAT WDTH <22IN Blank $815.04 HCPCS - Non-Drugs E2615 NU POS BACK POST/LAT WDTH <22IN Blank $815.04 HCPCS - Non-Drugs E2615 RR POS BACK POST/LAT WDTH <22IN Blank $137.06 HCPCS - Non-Drugs E2615 UE POS BACK POST/LAT WDTH <22IN Blank $626.71 HCPCS - Non-Drugs E2616 Blank POS BACK POST/LAT WDTH>=22IN Blank $1,081.89 HCPCS - Non-Drugs E2616 NU POS BACK POST/LAT WDTH>=22IN Blank $1,081.89 HCPCS - Non-Drugs E2616 RR POS BACK POST/LAT WDTH>=22IN Blank $163.74 HCPCS - Non-Drugs E2616 UE POS BACK POST/LAT WDTH>=22IN Blank $826.85 HCPCS - Non-Drugs E2617 Blank CUSTOM FAB W/C BACK CUSHION Blank $1,654.45 HCPCS - Non-Drugs E2619 Blank REPLACE COVER W/C SEAT CUSH Blank $163.61 HCPCS - Non-Drugs E2619 NU REPLACE COVER W/C SEAT CUSH Blank $163.61 HCPCS - Non-Drugs E2619 RR REPLACE COVER W/C SEAT CUSH Blank $17.44 HCPCS - Non-Drugs E2619 UE REPLACE COVER W/C SEAT CUSH Blank $138.13 HCPCS - Non-Drugs E2620 Blank WC PLANAR BACK CUSH WD <22IN Blank $872.06 HCPCS - Non-Drugs E2620 NU WC PLANAR BACK CUSH WD <22IN Blank $872.06 HCPCS - Non-Drugs E2620 RR WC PLANAR BACK CUSH WD <22IN Blank $142.75 HCPCS - Non-Drugs E2620 UE WC PLANAR BACK CUSH WD <22IN Blank $669.48 HCPCS - Non-Drugs E2621 Blank WC PLANAR BACK CUSH WD>=22IN Blank $1,024.66 HCPCS - Non-Drugs E2621 NU WC PLANAR BACK CUSH WD>=22IN Blank $1,024.66 HCPCS - Non-Drugs E2621 RR WC PLANAR BACK CUSH WD>=22IN Blank $158.01 HCPCS - Non-Drugs E2621 UE WC PLANAR BACK CUSH WD>=22IN Blank $783.93 HCPCS - Non-Drugs E2622 Blank ADJ SKIN PRO W/C CUS WD<22IN Blank $708.01 HCPCS - Non-Drugs E2622 NU ADJ SKIN PRO W/C CUS WD<22IN Blank $708.01 HCPCS - Non-Drugs E2622 RR ADJ SKIN PRO W/C CUS WD<22IN Blank $126.35 HCPCS - Non-Drugs E2622 UE ADJ SKIN PRO W/C CUS WD<22IN Blank $546.44 HCPCS - Non-Drugs E2623 Blank ADJ SKIN PRO WC CUS WD>=22IN Blank $879.01 HCPCS - Non-Drugs E2623 NU ADJ SKIN PRO WC CUS WD>=22IN Blank $879.01 HCPCS - Non-Drugs E2623 RR ADJ SKIN PRO WC CUS WD>=22IN Blank $143.45 HCPCS - Non-Drugs E2623 UE ADJ SKIN PRO WC CUS WD>=22IN Blank $674.69 HCPCS - Non-Drugs E2624 Blank ADJ SKIN PRO/POS CUS<22IN Blank $718.47 HCPCS - Non-Drugs E2624 NU ADJ SKIN PRO/POS CUS<22IN Blank $718.47 HCPCS - Non-Drugs E2624 RR ADJ SKIN PRO/POS CUS<22IN Blank $127.40 HCPCS - Non-Drugs E2624 UE ADJ SKIN PRO/POS CUS<22IN Blank $554.28 HCPCS - Non-Drugs E2625 Blank ADJ SKIN PRO/POS WC CUS>=22 Blank $874.52 HCPCS - Non-Drugs E2625 NU ADJ SKIN PRO/POS WC CUS>=22 Blank $874.52 HCPCS - Non-Drugs E2625 RR ADJ SKIN PRO/POS WC CUS>=22 Blank $143.00 HCPCS - Non-Drugs E2625 UE ADJ SKIN PRO/POS WC CUS>=22 Blank $671.31 HCPCS - Non-Drugs E2626 Blank SEO MOBILE ARM SUP ATT TO WC Blank $1,426.56 HCPCS - Non-Drugs E2626 NU SEO MOBILE ARM SUP ATT TO WC Blank $1,426.56 HCPCS - Non-Drugs E2626 RR SEO MOBILE ARM SUP ATT TO WC Blank $198.20 HCPCS - Non-Drugs E2626 UE SEO MOBILE ARM SUP ATT TO WC Blank $1,085.35 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

E2627 Blank ARM SUPP ATT TO WC RANCHO TY Blank $2,174.44 HCPCS - Non-Drugs E2627 NU ARM SUPP ATT TO WC RANCHO TY Blank $2,174.44 HCPCS - Non-Drugs E2627 RR ARM SUPP ATT TO WC RANCHO TY Blank $272.99 HCPCS - Non-Drugs E2627 UE ARM SUPP ATT TO WC RANCHO TY Blank $1,646.26 HCPCS - Non-Drugs E2628 Blank MOBILE ARM SUPPORTS RECLININ Blank $1,690.47 HCPCS - Non-Drugs E2628 NU MOBILE ARM SUPPORTS RECLININ Blank $1,690.47 HCPCS - Non-Drugs E2628 RR MOBILE ARM SUPPORTS RECLININ Blank $224.60 HCPCS - Non-Drugs E2628 UE MOBILE ARM SUPPORTS RECLININ Blank $1,283.29 HCPCS - Non-Drugs E2629 Blank FRICTION DAMPENING ARM SUPP Blank $2,137.00 HCPCS - Non-Drugs E2629 NU FRICTION DAMPENING ARM SUPP Blank $2,137.00 HCPCS - Non-Drugs E2629 RR FRICTION DAMPENING ARM SUPP Blank $269.24 HCPCS - Non-Drugs E2629 UE FRICTION DAMPENING ARM SUPP Blank $1,618.18 HCPCS - Non-Drugs E2630 Blank MONOSUSPENSION ARM/HAND SUPP Blank $1,470.35 HCPCS - Non-Drugs E2630 NU MONOSUSPENSION ARM/HAND SUPP Blank $1,470.35 HCPCS - Non-Drugs E2630 RR MONOSUSPENSION ARM/HAND SUPP Blank $202.59 HCPCS - Non-Drugs E2630 UE MONOSUSPENSION ARM/HAND SUPP Blank $1,118.20 HCPCS - Non-Drugs E2631 Blank ELEVAT PROXIMAL ARM SUPPORT Blank $645.71 HCPCS - Non-Drugs E2631 NU ELEVAT PROXIMAL ARM SUPPORT Blank $645.71 HCPCS - Non-Drugs E2631 RR ELEVAT PROXIMAL ARM SUPPORT Blank $120.12 HCPCS - Non-Drugs E2631 UE ELEVAT PROXIMAL ARM SUPPORT Blank $499.71 HCPCS - Non-Drugs E2632 Blank OFFSET/LAT ROCKER ARM W/ELA Blank $427.10 HCPCS - Non-Drugs E2632 NU OFFSET/LAT ROCKER ARM W/ELA Blank $427.10 HCPCS - Non-Drugs E2632 RR OFFSET/LAT ROCKER ARM W/ELA Blank $75.49 HCPCS - Non-Drugs E2632 UE OFFSET/LAT ROCKER ARM W/ELA Blank $335.75 HCPCS - Non-Drugs E2633 Blank MOBILE ARM SUPPORT SUPINATOR Blank $363.35 HCPCS - Non-Drugs E2633 NU MOBILE ARM SUPPORT SUPINATOR Blank $363.35 HCPCS - Non-Drugs E2633 RR MOBILE ARM SUPPORT SUPINATOR Blank $58.80 HCPCS - Non-Drugs E2633 UE MOBILE ARM SUPPORT SUPINATOR Blank $287.95 HCPCS - Non-Drugs G0333 Blank DISPENSE FEE INITIAL 30 DAY Blank $83.89 HCPCS - Non-Drugs G9017 Blank AMANTADINE HCL 100MG ORAL Blank $14.95 HCPCS - Drugs G9018 Blank ZANAMIVIR,INHALATION PWD 10M Blank $24.33 HCPCS - Drugs G9019 Blank OSELTAMIVIR PHOSPHATE 75MG Blank $25.05 HCPCS - Drugs G9020 Blank RIMANTADINE HCL 100MG ORAL Blank $16.39 HCPCS - Drugs G9033 Blank AMANTADINE HCL ORAL BRAND Blank $74.48 HCPCS - Drugs G9034 Blank ZANAMIVIR, INH PWDR, BRAND Blank $59.44 HCPCS - Drugs G9036 Blank RIMANTADINE HCL, BRAND Blank $230.54 HCPCS - Drugs J0120 Blank TETRACYCLIN INJECTION a $101.59 HCPCS - Drugs J0129 Blank ABATACEPT INJECTION a $107.30 HCPCS - Drugs J0130 Blank ABCIXIMAB INJECTION a $2,328.87 HCPCS - Drugs J0131 Blank ACETAMINOPHEN INJECTION a $1.79 HCPCS - Drugs J0132 Blank ACETYLCYSTEINE INJECTION a $15.67 HCPCS - Drugs J0133 Blank ACYCLOVIR INJECTION a $7.11 HCPCS - Drugs J0135 Blank ADALIMUMAB INJECTION a $582.79 HCPCS - Drugs J0153 Blank ADENOSINE INJ 1MG a $14.23 HCPCS - Drugs J0171 Blank ADRENALIN EPINEPHRINE INJECT a $7.11 HCPCS - Drugs J0178 Blank AFLIBERCEPT INJECTION a $1,983.26 HCPCS - Drugs J0180 Blank AGALSIDASE BETA INJECTION a $346.85 HCPCS - Drugs J0190 Blank INJ BIPERIDEN LACTATE/5 MG Blank $4.75 HCPCS - Drugs J0200 Blank ALATROFLOXACIN MESYLATE a $39.21 HCPCS - Drugs J0202 Blank INJECTION, ALEMTUZUMAB a $3,537.41 HCPCS - Drugs J0205 Blank ALGLUCERASE INJECTION a $79.89 HCPCS - Drugs J0207 Blank AMIFOSTINE a $1,740.47 HCPCS - Drugs J0210 Blank METHYLDOPATE HCL INJECTION a $33.71 HCPCS - Drugs J0215 Blank ALEFACEPT a $69.06 HCPCS - Drugs J0220 Blank ALGLUCOSIDASE ALFA INJECTION a $489.08 HCPCS - Drugs J0221 Blank LUMIZYME INJECTION a $333.86 HCPCS - Drugs J0256 Blank ALPHA 1 PROTEINASE INHIBITOR a $22.16 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J0257 Blank GLASSIA INJECTION a $21.44 HCPCS - Drugs J0270 Blank ALPROSTADIL FOR INJECTION a $17.83 HCPCS - Drugs J0275 Blank ALPROSTADIL URETHRAL SUPPOS a $67.30 HCPCS - Drugs J0278 Blank AMIKACIN SULFATE INJECTION a $16.39 HCPCS - Drugs J0280 Blank AMINOPHYLLIN 250 MG INJ a $30.10 HCPCS - Drugs J0282 Blank AMIODARONE HCL a $14.23 HCPCS - Drugs J0285 Blank AMPHOTERICIN B a $79.16 HCPCS - Drugs J0287 Blank AMPHOTERICIN B LIPID COMPLEX a $39.48 HCPCS - Drugs J0288 Blank AMPHO B CHOLESTERYL SULFATE a $170.80 HCPCS - Drugs J0289 Blank AMPHOTERICIN B LIPOSOME INJ a $51.75 HCPCS - Drugs J0290 Blank AMPICILLIN 500 MG INJ a $14.95 HCPCS - Drugs J0295 Blank AMPICILLIN SODIUM PER 1.5 GM a $17.83 HCPCS - Drugs J0300 Blank AMOBARBITAL 125 MG INJ a $38.04 HCPCS - Drugs J0330 Blank SUCCINYCHOLINE CHLORIDE INJ a $14.23 HCPCS - Drugs J0348 Blank ANIDULAFUNGIN INJECTION a $7.11 HCPCS - Drugs J0350 Blank INJECTION ANISTREPLASE 30 U Blank $290.31 HCPCS - Drugs J0360 Blank HYDRALAZINE HCL INJECTION a $19.28 HCPCS - Drugs J0364 Blank APOMORPHINE HYDROCHLORIDE Blank $19.28 HCPCS - Drugs J0365 Blank APROTONIN, 10,000 KIU a $18.56 HCPCS - Drugs J0380 Blank INJ METARAMINOL BITARTRATE a $14.95 HCPCS - Drugs J0390 Blank CHLOROQUINE INJECTION Blank $246.02 HCPCS - Drugs J0395 Blank ARBUTAMINE HCL INJECTION a $32.80 HCPCS - Drugs J0400 Blank ARIPIPRAZOLE INJECTION a $7.11 HCPCS - Drugs J0401 Blank INJ ARIPIPRAZOLE EXT REL 1MG a $22.16 HCPCS - Drugs J0456 Blank AZITHROMYCIN a $20.00 HCPCS - Drugs J0461 Blank ATROPINE SULFATE INJECTION a $7.11 HCPCS - Drugs J0470 Blank DIMECAPROL INJECTION a $106.58 HCPCS - Drugs J0475 Blank BACLOFEN 10 MG INJECTION a $351.90 HCPCS - Drugs J0476 Blank BACLOFEN INTRATHECAL TRIAL a $167.19 HCPCS - Drugs J0480 Blank BASILIXIMAB a $6,762.61 HCPCS - Drugs J0485 Blank BELATACEPT INJECTION a $20.72 HCPCS - Drugs J0490 Blank BELIMUMAB INJECTION a $98.65 HCPCS - Drugs J0500 Blank DICYCLOMINE INJECTION a $152.04 HCPCS - Drugs J0515 Blank INJ BENZTROPINE MESYLATE a $64.01 HCPCS - Drugs J0520 Blank BETHANECHOL CHLORIDE INJECT Blank $9.16 HCPCS - Drugs J0558 Blank PENG BENZATHINE/PROCAINE INJ a $30.10 HCPCS - Drugs J0561 Blank PENICILLIN G BENZATHINE INJ a $34.43 HCPCS - Drugs J0570 Blank BUPRENORPHINE IMPLANT 74.2MG a $2,547.49 HCPCS - Drugs J0575 Blank BUPREN/NAL OVER 10MG BUPRENO Blank $31.21 HCPCS - Drugs J0583 Blank BIVALIRUDIN a $15.67 HCPCS - Drugs J0585 Blank INJECTION,ONABOTULINUMTOXINA a $25.05 HCPCS - Drugs J0586 Blank ABOBOTULINUMTOXINA a $28.66 HCPCS - Drugs J0587 Blank INJ, RIMABOTULINUMTOXINB a $36.59 HCPCS - Drugs J0588 Blank INCOBOTULINUMTOXIN A a $22.89 HCPCS - Drugs J0592 Blank BUPRENORPHINE HYDROCHLORIDE a $20.00 HCPCS - Drugs J0594 Blank BUSULFAN INJECTION a $86.38 HCPCS - Drugs J0595 Blank BUTORPHANOL TARTRATE 1 MG a $17.11 HCPCS - Drugs J0596 Blank INJECTION, RUCONEST a $76.88 HCPCS - Drugs J0597 Blank C-1 ESTERASE, BERINERT a $110.91 HCPCS - Drugs J0598 Blank C-1 ESTERASE, CINRYZE a $124.62 HCPCS - Drugs J0600 Blank EDETATE CALCIUM DISODIUM INJ a $11,259.85 HCPCS - Drugs J0610 Blank CALCIUM GLUCONATE INJECTION a $20.00 HCPCS - Drugs J0620 Blank CALCIUM GLYCER & LACT/10 ML a $37.32 HCPCS - Drugs J0630 Blank CALCITONIN SALMON INJECTION a $4,572.07 HCPCS - Drugs J0636 Blank INJ CALCITRIOL PER 0.1 MCG a $14.23 HCPCS - Drugs J0637 Blank CASPOFUNGIN ACETATE a $33.71 HCPCS - Drugs J0638 Blank CANAKINUMAB INJECTION a $198.94 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J0640 Blank LEUCOVORIN CALCIUM INJECTION a $18.56 HCPCS - Drugs J0641 Blank LEVOLEUCOVORIN INJECTION a $14.23 HCPCS - Drugs J0670 Blank INJ MEPIVACAINE HCL/10 ML a $18.56 HCPCS - Drugs J0690 Blank CEFAZOLIN SODIUM INJECTION a $14.23 HCPCS - Drugs J0692 Blank CEFEPIME HCL FOR INJECTION a $17.11 HCPCS - Drugs J0694 Blank CEFOXITIN SODIUM INJECTION a $22.16 HCPCS - Drugs J0695 Blank INJ CEFTOLOZANE TAZOBACTAM a $1.38 HCPCS - Drugs J0696 Blank CEFTRIAXONE SODIUM INJECTION a $14.23 HCPCS - Drugs J0697 Blank STERILE CEFUROXIME INJECTION a $17.83 HCPCS - Drugs J0698 Blank CEFOTAXIME SODIUM INJECTION a $28.66 HCPCS - Drugs J0702 Blank BETAMETHASONE ACET&SOD PHOSP a $25.05 HCPCS - Drugs J0706 Blank CAFFEINE CITRATE INJECTION a $19.28 HCPCS - Drugs J0710 Blank CEPHAPIRIN SODIUM INJECTION a $17.36 HCPCS - Drugs J0712 Blank CEFTAROLINE FOSAMIL INJ a $17.83 HCPCS - Drugs J0713 Blank INJ CEFTAZIDIME PER 500 MG a $17.11 HCPCS - Drugs J0714 Blank CEFTAZIDIME AND AVIBACTAM a $249.37 HCPCS - Drugs J0715 Blank CEFTIZOXIME SODIUM / 500 MG a $75.46 HCPCS - Drugs J0716 Blank CENTRUROIDES IMMUNE F(AB) a $10,890.42 HCPCS - Drugs J0717 Blank CERTOLIZUMAB PEGOL INJ 1MG a $27.21 HCPCS - Drugs J0720 Blank CHLORAMPHENICOL SODIUM INJEC a $92.15 HCPCS - Drugs J0725 Blank CHORIONIC GONADOTROPIN/1000U a $56.80 HCPCS - Drugs J0735 Blank CLONIDINE HYDROCHLORIDE a $40.92 HCPCS - Drugs J0740 Blank CIDOFOVIR INJECTION a $1,062.60 HCPCS - Drugs J0743 Blank CILASTATIN SODIUM INJECTION a $20.72 HCPCS - Drugs J0744 Blank CIPROFLOXACIN IV a $15.67 HCPCS - Drugs J0745 Blank INJ CODEINE PHOSPHATE /30 MG a $14.95 HCPCS - Drugs J0770 Blank COLISTIMETHATE SODIUM INJ a $38.76 HCPCS - Drugs J0775 Blank COLLAGENASE, CLOST HIST INJ a $94.32 HCPCS - Drugs J0780 Blank PROCHLORPERAZINE INJECTION a $38.04 HCPCS - Drugs J0795 Blank CORTICORELIN OVINE TRIFLUTAL a $29.38 HCPCS - Drugs J0800 Blank CORTICOTROPIN INJECTION a $7,124.09 HCPCS - Drugs J0833 Blank COSYNTROPIN INJECTION NOS a $216.25 HCPCS - Drugs J0834 Blank COSYNTROPIN CORTROSYN INJ a $105.14 HCPCS - Drugs J0840 Blank CROTALIDAE POLY IMMUNE FAB a $5,782.79 HCPCS - Drugs J0850 Blank CYTOMEGALOVIRUS IMM IV /VIAL a $2,279.80 HCPCS - Drugs J0875 Blank INJECTION, DALBAVANCIN a $42.37 HCPCS - Drugs J0878 Blank DAPTOMYCIN INJECTION a $14.23 HCPCS - Drugs J0881 Blank DARBEPOETIN ALFA, NON-ESRD a $20.72 HCPCS - Drugs J0882 Blank DARBEPOETIN ALFA, ESRD USE a $20.72 HCPCS - Drugs J0883 Blank ARGATROBAN NONESRD USE 1MG a $46.10 HCPCS - Drugs J0884 Blank ARGATROBAN ESRD DIALYSIS 1MG a $46.10 HCPCS - Drugs J0885 Blank EPOETIN ALFA, NON-ESRD a $40.20 HCPCS - Drugs J0887 Blank EPOETIN BETA ESRD USE Blank $15.67 HCPCS - Non-Drugs J0888 Blank EPOETIN BETA NON ESRD a $15.67 HCPCS - Drugs J0890 Blank PEGINESATIDE INJECTION a $28.12 HCPCS - Drugs J0894 Blank DECITABINE INJECTION a $48.86 HCPCS - Drugs J0895 Blank DEFEROXAMINE MESYLATE INJ a $29.38 HCPCS - Drugs J0897 Blank DENOSUMAB INJECTION a $45.97 HCPCS - Drugs J0945 Blank BROMPHENIRAMINE MALEATE INJ Blank $7.11 HCPCS - Drugs J1000 Blank DEPO-ESTRADIOL CYPIONATE INJ a $48.14 HCPCS - Drugs J1020 Blank METHYLPREDNISOLONE 20 MG INJ a $22.89 HCPCS - Drugs J1030 Blank METHYLPREDNISOLONE 40 MG INJ a $24.33 HCPCS - Drugs J1040 Blank METHYLPREDNISOLONE 80 MG INJ a $34.43 HCPCS - Drugs J1050 Blank MEDROXYPROGESTERONE ACETATE a $7.11 HCPCS - Drugs J1071 Blank INJ TESTOSTERONE CYPIONATE a $7.11 HCPCS - Drugs J1094 Blank INJ DEXAMETHASONE ACETATE a $7.11 HCPCS - Drugs J1100 Blank DEXAMETHASONE SODIUM PHOS a $7.11 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J1110 Blank INJ DIHYDROERGOTAMINE MESYLT a $337.47 HCPCS - Drugs J1120 Blank ACETAZOLAMID SODIUM INJECTIO a $62.57 HCPCS - Drugs J1130 Blank INJ DICLOFENAC SODIUM 0.5MG a $0.37 HCPCS - Drugs J1160 Blank DIGOXIN INJECTION a $24.33 HCPCS - Drugs J1162 Blank DIGOXIN IMMUNE FAB (OVINE) a $6,582.23 HCPCS - Drugs J1165 Blank PHENYTOIN SODIUM INJECTION a $14.23 HCPCS - Drugs J1170 Blank HYDROMORPHONE INJECTION a $16.39 HCPCS - Drugs J1180 Blank DYPHYLLINE INJECTION Blank $20.84 HCPCS - Drugs J1190 Blank DEXRAZOXANE HCL INJECTION a $427.66 HCPCS - Drugs J1200 Blank DIPHENHYDRAMINE HCL INJECTIO a $14.23 HCPCS - Drugs J1205 Blank CHLOROTHIAZIDE SODIUM INJ a $169.35 HCPCS - Drugs J1212 Blank DIMETHYL SULFOXIDE 50% 50 ML a $1,085.69 HCPCS - Drugs J1230 Blank METHADONE INJECTION a $51.02 HCPCS - Drugs J1240 Blank DIMENHYDRINATE INJECTION a $27.21 HCPCS - Drugs J1245 Blank DIPYRIDAMOLE INJECTION a $14.23 HCPCS - Drugs J1250 Blank INJ DOBUTAMINE HCL/250 MG a $23.61 HCPCS - Drugs J1260 Blank DOLASETRON MESYLATE a $18.71 HCPCS - Drugs J1265 Blank DOPAMINE INJECTION a $14.23 HCPCS - Drugs J1267 Blank DORIPENEM INJECTION a $7.11 HCPCS - Drugs J1270 Blank INJECTION, DOXERCALCIFEROL a $14.23 HCPCS - Drugs J1290 Blank ECALLANTIDE INJECTION a $860.57 HCPCS - Drugs J1300 Blank ECULIZUMAB INJECTION a $468.06 HCPCS - Drugs J1320 Blank AMITRIPTYLINE INJECTION Blank $94.87 HCPCS - Drugs J1322 Blank ELOSULFASE ALFA, INJECTION a $393.30 HCPCS - Drugs J1324 Blank ENFUVIRTIDE INJECTION a $7.11 HCPCS - Drugs J1325 Blank EPOPROSTENOL INJECTION a $43.81 HCPCS - Drugs J1327 Blank EPTIFIBATIDE INJECTION a $58.24 HCPCS - Drugs J1330 Blank ERGONOVINE MALEATE INJECTION a $16.33 HCPCS - Drugs J1335 Blank ERTAPENEM INJECTION a $109.47 HCPCS - Drugs J1364 Blank ERYTHRO LACTOBIONATE /500 MG a $132.56 HCPCS - Drugs J1380 Blank ESTRADIOL VALERATE 10 MG INJ a $27.94 HCPCS - Drugs J1410 Blank INJ ESTROGEN CONJUGATE 25 MG a $572.68 HCPCS - Drugs J1430 Blank ETHANOLAMINE OLEATE 100 MG a $862.01 HCPCS - Drugs J1435 Blank INJECTION ESTRONE PER 1 MG a $7.11 HCPCS - Drugs J1436 Blank ETIDRONATE DISODIUM INJ Blank $234.33 HCPCS - Drugs J1438 Blank ETANERCEPT INJECTION a $326.65 HCPCS - Drugs J1439 Blank INJ FERRIC CARBOXYMALTOS 1MG a $14.95 HCPCS - Drugs J1442 Blank INJ FILGRASTIM EXCL BIOSIMIL a $14.95 HCPCS - Drugs J1443 Blank INJ FERRIC PYROPHOSPHATE CIT a $3.15 HCPCS - Drugs J1447 Blank INJ TBO FILGRASTIM 1 MICROG a $14.23 HCPCS - Drugs J1450 Blank FLUCONAZOLE a $21.44 HCPCS - Drugs J1451 Blank FOMEPIZOLE, 15 MG a $27.94 HCPCS - Drugs J1452 Blank INTRAOCULAR FOMIVIRSEN NA a $2,616.33 HCPCS - Drugs J1453 Blank FOSAPREPITANT INJECTION a $16.39 HCPCS - Drugs J1455 Blank FOSCARNET SODIUM INJECTION a $55.35 HCPCS - Drugs J1457 Blank GALLIUM NITRATE INJECTION a $15.67 HCPCS - Drugs J1458 Blank GALSULFASE INJECTION a $755.23 HCPCS - Drugs J1459 Blank INJ IVIG PRIVIGEN 500 MG a $90.71 HCPCS - Drugs J1460 Blank GAMMA GLOBULIN 1 CC INJ a $84.94 HCPCS - Drugs J1556 Blank INJ, IMM GLOB BIVIGAM, 500MG a $89.99 HCPCS - Drugs J1557 Blank GAMMAPLEX INJECTION a $96.48 HCPCS - Drugs J1559 Blank HIZENTRA INJECTION a $32.27 HCPCS - Drugs J1560 Blank GAMMA GLOBULIN > 10 CC INJ a $731.42 HCPCS - Drugs J1561 Blank GAMUNEX-C/GAMMAKED a $81.33 HCPCS - Drugs J1562 Blank VIVAGLOBIN, INJ a $32.99 HCPCS - Drugs J1566 Blank IMMUNE GLOBULIN, POWDER a $78.44 HCPCS - Drugs J1568 Blank OCTAGAM INJECTION a $85.66 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J1569 Blank GAMMAGARD LIQUID INJECTION a $94.32 HCPCS - Drugs J1570 Blank GANCICLOVIR SODIUM INJECTION a $147.71 HCPCS - Drugs J1571 Blank HEPAGAM B IM INJECTION a $130.39 HCPCS - Drugs J1572 Blank FLEBOGAMMA INJECTION a $73.39 HCPCS - Drugs J1573 Blank HEPAGAM B INTRAVENOUS, INJ a $112.98 HCPCS - Drugs J1575 Blank HYQVIA 100MG IMMUNEGLOBULIN a $38.76 HCPCS - Drugs J1580 Blank GARAMYCIN GENTAMICIN INJ a $15.67 HCPCS - Drugs J1595 Blank INJECTION GLATIRAMER ACETATE a $3,476.08 HCPCS - Drugs J1599 Blank IVIG NON-LYOPHILIZED, NOS a $102.26 HCPCS - Drugs J1600 Blank GOLD SODIUM THIOMALEATE INJ a $42.37 HCPCS - Drugs J1602 Blank GOLIMUMAB FOR IV USE 1MG a $63.29 HCPCS - Drugs J1610 Blank GLUCAGON HYDROCHLORIDE/1 MG a $416.84 HCPCS - Drugs J1620 Blank GONADORELIN HYDROCH/ 100 MCG a $739.69 HCPCS - Drugs J1626 Blank GRANISETRON HCL INJECTION a $7.11 HCPCS - Drugs J1630 Blank HALOPERIDOL INJECTION a $14.95 HCPCS - Drugs J1631 Blank HALOPERIDOL DECANOATE INJ a $48.86 HCPCS - Drugs J1640 Blank HEMIN, 1 MG a $58.96 HCPCS - Drugs J1642 Blank INJ HEPARIN SODIUM PER 10 U a $7.11 HCPCS - Drugs J1644 Blank INJ HEPARIN SODIUM PER 1000U a $7.11 HCPCS - Drugs J1645 Blank DALTEPARIN SODIUM a $43.81 HCPCS - Drugs J1650 Blank INJ ENOXAPARIN SODIUM a $14.95 HCPCS - Drugs J1652 Blank FONDAPARINUX SODIUM a $17.11 HCPCS - Drugs J1655 Blank TINZAPARIN SODIUM INJECTION Blank $20.72 HCPCS - Drugs J1670 Blank TETANUS IMMUNE GLOBULIN INJ a $746.57 HCPCS - Drugs J1675 Blank HISTRELIN ACETATE Blank $14.95 HCPCS - Drugs J1700 Blank HYDROCORTISONE ACETATE INJ a $12.34 HCPCS - Drugs J1710 Blank HYDROCORTISONE SODIUM PH INJ a $25.64 HCPCS - Drugs J1720 Blank HYDROCORTISONE SODIUM SUCC I a $30.82 HCPCS - Drugs J1730 Blank DIAZOXIDE INJECTION a $232.13 HCPCS - Drugs J1740 Blank IBANDRONATE SODIUM INJECTION a $170.08 HCPCS - Drugs J1741 Blank IBUPROFEN INJECTION a $13.08 HCPCS - Drugs J1742 Blank IBUTILIDE FUMARATE INJECTION a $399.52 HCPCS - Drugs J1743 Blank IDURSULFASE INJECTION a $1,062.60 HCPCS - Drugs J1744 Blank ICATIBANT INJECTION a $704.07 HCPCS - Drugs J1745 Blank INFLIXIMAB NOT BIOSIMIL 10MG a $184.51 HCPCS - Drugs J1750 Blank INJ IRON DEXTRAN a $38.04 HCPCS - Drugs J1756 Blank IRON SUCROSE INJECTION a $7.11 HCPCS - Drugs J1786 Blank IMUGLUCERASE INJECTION a $96.48 HCPCS - Drugs J1790 Blank DROPERIDOL INJECTION a $19.28 HCPCS - Drugs J1800 Blank PROPRANOLOL INJECTION a $17.11 HCPCS - Drugs J1810 Blank DROPERIDOL/FENTANYL INJ a $165.12 HCPCS - Drugs J1815 Blank INSULIN INJECTION a $14.23 HCPCS - Drugs J1817 Blank INSULIN FOR INSULIN PUMP USE a $32.27 HCPCS - Drugs J1826 Blank INTERFERON BETA-1A INJ a $1,268.95 HCPCS - Drugs J1830 Blank INTERFERON BETA-1B / .25 MG a $450.24 HCPCS - Drugs J1833 Blank INJECTION, ISAVUCONAZONIUM a $2.24 HCPCS - Drugs J1835 Blank ITRACONAZOLE INJECTION a $2,041.70 HCPCS - Drugs J1840 Blank KANAMYCIN SULFATE 500 MG INJ a $23.61 HCPCS - Drugs J1850 Blank KANAMYCIN SULFATE 75 MG INJ Blank $14.23 HCPCS - Drugs J1885 Blank KETOROLAC TROMETHAMINE INJ a $14.23 HCPCS - Drugs J1890 Blank CEPHALOTHIN SODIUM INJECTION a $22.05 HCPCS - Drugs J1930 Blank LANREOTIDE INJECTION a $121.01 HCPCS - Drugs J1931 Blank LARONIDASE INJECTION a $74.11 HCPCS - Drugs J1940 Blank FUROSEMIDE INJECTION a $14.95 HCPCS - Drugs J1942 Blank ARIPIPRAZOLE LAUROXIL 1MG a $17.83 HCPCS - Drugs J1945 Blank LEPIRUDIN a $336.75 HCPCS - Drugs J1950 Blank LEUPROLIDE ACETATE /3.75 MG a $2,072.73 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J1953 Blank LEVETIRACETAM INJECTION a $7.11 HCPCS - Drugs J1955 Blank INJ LEVOCARNITINE PER 1 GM a $52.47 HCPCS - Drugs J1956 Blank LEVOFLOXACIN INJECTION a $15.67 HCPCS - Drugs J1960 Blank LEVORPHANOL TARTRATE INJ Blank $19.28 HCPCS - Drugs J1980 Blank HYOSCYAMINE SULFATE INJ a $68.34 HCPCS - Drugs J1990 Blank CHLORDIAZEPOXIDE INJECTION Blank $57.52 HCPCS - Drugs J2001 Blank LIDOCAINE INJECTION a $7.11 HCPCS - Drugs J2010 Blank LINCOMYCIN INJECTION a $37.32 HCPCS - Drugs J2020 Blank LINEZOLID INJECTION a $45.97 HCPCS - Drugs J2060 Blank LORAZEPAM INJECTION a $14.23 HCPCS - Drugs J2150 Blank MANNITOL INJECTION a $16.39 HCPCS - Drugs J2170 Blank MECASERMIN INJECTION a $27.94 HCPCS - Drugs J2175 Blank MEPERIDINE HYDROCHL /100 MG a $22.16 HCPCS - Drugs J2180 Blank MEPERIDINE/PROMETHAZINE INJ a $29.38 HCPCS - Drugs J2182 Blank INJECTION, MEPOLIZUMAB, 1MG a $38.96 HCPCS - Drugs J2185 Blank MEROPENEM a $14.95 HCPCS - Drugs J2210 Blank METHYLERGONOVIN MALEATE INJ a $40.92 HCPCS - Drugs J2212 Blank METHYLNALTREXONE INJECTION a $1.12 HCPCS - Drugs J2248 Blank MICAFUNGIN SODIUM INJECTION a $14.95 HCPCS - Drugs J2250 Blank INJ MIDAZOLAM HYDROCHLORIDE a $7.11 HCPCS - Drugs J2260 Blank INJ MILRINONE LACTATE / 5 MG a $17.83 HCPCS - Drugs J2265 Blank MINOCYCLINE HYDROCHLORIDE a $1.72 HCPCS - Drugs J2270 Blank MORPHINE SULFATE INJECTION a $15.67 HCPCS - Drugs J2274 Blank INJ MORPHINE PF EPID ITHC a $34.43 HCPCS - Drugs J2278 Blank ZICONOTIDE INJECTION a $27.21 HCPCS - Drugs J2280 Blank INJ, MOXIFLOXACIN 100 MG a $29.38 HCPCS - Drugs J2300 Blank INJ NALBUPHINE HYDROCHLORIDE a $17.83 HCPCS - Drugs J2310 Blank INJ NALOXONE HYDROCHLORIDE a $67.62 HCPCS - Drugs J2315 Blank NALTREXONE, DEPOT FORM a $19.28 HCPCS - Drugs J2320 Blank NANDROLONE DECANOATE 50 MG a $21.44 HCPCS - Drugs J2323 Blank NATALIZUMAB INJECTION a $50.30 HCPCS - Drugs J2325 Blank NESIRITIDE INJECTION a $77.72 HCPCS - Drugs J2353 Blank OCTREOTIDE INJECTION, DEPOT a $365.61 HCPCS - Drugs J2354 Blank OCTREOTIDE INJ, NON-DEPOT a $14.95 HCPCS - Drugs J2355 Blank OPRELVEKIN INJECTION a $952.20 HCPCS - Drugs J2357 Blank OMALIZUMAB INJECTION a $80.61 HCPCS - Drugs J2358 Blank OLANZAPINE LONG-ACTING INJ a $18.56 HCPCS - Drugs J2360 Blank ORPHENADRINE INJECTION a $23.61 HCPCS - Drugs J2370 Blank PHENYLEPHRINE HCL INJECTION a $16.39 HCPCS - Drugs J2400 Blank CHLOROPROCAINE HCL INJECTION a $71.23 HCPCS - Drugs J2405 Blank ONDANSETRON HCL INJECTION a $7.11 HCPCS - Drugs J2407 Blank INJECTION, ORITAVANCIN a $61.85 HCPCS - Drugs J2410 Blank OXYMORPHONE HCL INJECTION a $18.56 HCPCS - Drugs J2425 Blank PALIFERMIN INJECTION a $48.14 HCPCS - Drugs J2426 Blank PALIPERIDONE PALMITATE INJ a $31.54 HCPCS - Drugs J2430 Blank PAMIDRONATE DISODIUM /30 MG a $32.99 HCPCS - Drugs J2440 Blank PAPAVERIN HCL INJECTION a $18.56 HCPCS - Drugs J2460 Blank OXYTETRACYCLINE INJECTION Blank $2.44 HCPCS - Drugs J2469 Blank PALONOSETRON HCL a $58.24 HCPCS - Drugs J2501 Blank PARICALCITOL a $14.95 HCPCS - Drugs J2502 Blank INJ, PASIREOTIDE LONG ACTING a $829.57 HCPCS - Drugs J2503 Blank PEGAPTANIB SODIUM INJECTION a $2,133.33 HCPCS - Drugs J2504 Blank PEGADEMASE BOVINE, 25 IU a $706.89 HCPCS - Drugs J2505 Blank INJECTION, PEGFILGRASTIM 6MG a $8,439.43 HCPCS - Drugs J2507 Blank PEGLOTICASE INJECTION a $3,674.50 HCPCS - Drugs J2510 Blank PENICILLIN G PROCAINE INJ a $66.90 HCPCS - Drugs J2513 Blank PENTASTARCH 10% SOLUTION Blank $10.59 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J2515 Blank PENTOBARBITAL SODIUM INJ a $108.03 HCPCS - Drugs J2540 Blank PENICILLIN G POTASSIUM INJ a $14.95 HCPCS - Drugs J2543 Blank PIPERACILLIN/TAZOBACTAM a $18.56 HCPCS - Drugs J2545 Blank PENTAMIDINE NON-COMP UNIT a $258.82 HCPCS - Drugs J2547 Blank INJECTION, PERAMIVIR a $5.53 HCPCS - Drugs J2550 Blank PROMETHAZINE HCL INJECTION a $17.11 HCPCS - Drugs J2560 Blank PHENOBARBITAL SODIUM INJ a $89.99 HCPCS - Drugs J2562 Blank PLERIXAFOR INJECTION a $640.51 HCPCS - Drugs J2590 Blank OXYTOCIN INJECTION a $20.72 HCPCS - Drugs J2597 Blank INJ DESMOPRESSIN ACETATE a $39.48 HCPCS - Drugs J2650 Blank PREDNISOLONE ACETATE INJ a $8.15 HCPCS - Drugs J2670 Blank TOTAZOLINE HCL INJECTION a $13.50 HCPCS - Drugs J2675 Blank INJ PROGESTERONE PER 50 MG a $15.67 HCPCS - Drugs J2680 Blank FLUPHENAZINE DECANOATE 25 MG a $55.35 HCPCS - Drugs J2690 Blank PROCAINAMIDE HCL INJECTION a $131.84 HCPCS - Drugs J2700 Blank OXACILLIN SODIUM INJECITON a $7.11 HCPCS - Drugs J2704 Blank INJ, PROPOFOL, 10 MG a $7.11 HCPCS - Drugs J2710 Blank NEOSTIGMINE METHYLSLFTE INJ a $7.11 HCPCS - Drugs J2720 Blank INJ PROTAMINE SULFATE/10 MG a $14.95 HCPCS - Drugs J2724 Blank PROTEIN C CONCENTRATE a $43.09 HCPCS - Drugs J2725 Blank INJ PROTIRELIN PER 250 MCG a $177.53 HCPCS - Drugs J2730 Blank PRALIDOXIME CHLORIDE INJ a $188.84 HCPCS - Drugs J2760 Blank PHENTOLAINE MESYLATE INJ a $122.46 HCPCS - Drugs J2765 Blank METOCLOPRAMIDE HCL INJECTION a $14.23 HCPCS - Drugs J2770 Blank QUINUPRISTIN/DALFOPRISTIN a $890.88 HCPCS - Drugs J2778 Blank RANIBIZUMAB INJECTION a $766.77 HCPCS - Drugs J2780 Blank RANITIDINE HYDROCHLORIDE INJ a $15.67 HCPCS - Drugs J2783 Blank RASBURICASE a $533.72 HCPCS - Drugs J2785 Blank REGADENOSON INJECTION a $123.90 HCPCS - Drugs J2786 Blank INJECTION, RESLIZUMAB, 1MG a $17.42 HCPCS - Drugs J2788 Blank RHO D IMMUNE GLOBULIN 50 MCG a $63.29 HCPCS - Drugs J2790 Blank RHO D IMMUNE GLOBULIN INJ a $170.80 HCPCS - Drugs J2791 Blank RHOPHYLAC INJECTION a $22.16 HCPCS - Drugs J2792 Blank RHO(D) IMMUNE GLOBULIN H, SD a $58.24 HCPCS - Drugs J2793 Blank RILONACEPT INJECTION a $58.96 HCPCS - Drugs J2794 Blank RISPERIDONE, LONG ACTING a $29.38 HCPCS - Drugs J2795 Blank ROPIVACAINE HCL INJECTION a $7.11 HCPCS - Drugs J2796 Blank ROMIPLOSTIM INJECTION a $143.38 HCPCS - Drugs J2800 Blank METHOCARBAMOL INJECTION a $90.71 HCPCS - Drugs J2805 Blank SINCALIDE INJECTION a $209.76 HCPCS - Drugs J2810 Blank INJ THEOPHYLLINE PER 40 MG a $7.11 HCPCS - Drugs J2820 Blank SARGRAMOSTIM INJECTION a $87.10 HCPCS - Drugs J2840 Blank INJ SEBELIPASE ALFA 1 MG a $2,329.74 HCPCS - Drugs J2850 Blank INJ SECRETIN SYNTHETIC HUMAN a $82.77 HCPCS - Drugs J2860 Blank INJECTION, SILTUXIMAB a $29.38 HCPCS - Drugs J2910 Blank AUROTHIOGLUCOSE INJECITON Blank $90.28 HCPCS - Drugs J2916 Blank NA FERRIC GLUCONATE COMPLEX a $17.11 HCPCS - Drugs J2920 Blank METHYLPREDNISOLONE INJECTION a $20.72 HCPCS - Drugs J2930 Blank METHYLPREDNISOLONE INJECTION a $24.33 HCPCS - Drugs J2940 Blank SOMATREM INJECTION a $146.97 HCPCS - Drugs J2941 Blank SOMATROPIN INJECTION a $109.47 HCPCS - Drugs J2950 Blank PROMAZINE HCL INJECTION a $31.84 HCPCS - Drugs J2993 Blank RETEPLASE INJECTION a $2,465.23 HCPCS - Drugs J2995 Blank INJ STREPTOKINASE /250000 IU Blank $171.52 HCPCS - Drugs J2997 Blank ALTEPLASE RECOMBINANT a $176.57 HCPCS - Drugs J3000 Blank STREPTOMYCIN INJECTION a $39.48 HCPCS - Drugs J3010 Blank FENTANYL CITRATE INJECTION a $7.11 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J3030 Blank SUMATRIPTAN SUCCINATE / 6 MG a $128.23 HCPCS - Drugs J3060 Blank INJ, TALIGLUCERASE ALFA 10 U a $94.32 HCPCS - Drugs J3070 Blank PENTAZOCINE INJECTION a $287.68 HCPCS - Drugs J3090 Blank INJ TEDIZOLID PHOSPHATE a $15.67 HCPCS - Drugs J3095 Blank TELAVANCIN INJECTION a $22.89 HCPCS - Drugs J3101 Blank TENECTEPLASE INJECTION a $218.42 HCPCS - Drugs J3105 Blank TERBUTALINE SULFATE INJ a $20.72 HCPCS - Drugs J3110 Blank TERIPARATIDE INJECTION a $30.10 HCPCS - Drugs J3121 Blank INJ TESTOSTERO ENANTHATE 1MG a $7.11 HCPCS - Drugs J3145 Blank TESTOSTERONE UNDECANOATE 1MG a $2.64 HCPCS - Drugs J3230 Blank CHLORPROMAZINE HCL INJECTION a $66.90 HCPCS - Drugs J3240 Blank THYROTROPIN INJECTION a $3,162.94 HCPCS - Drugs J3243 Blank TIGECYCLINE INJECTION a $19.28 HCPCS - Drugs J3246 Blank TIROFIBAN HCL a $30.82 HCPCS - Drugs J3250 Blank TRIMETHOBENZAMIDE HCL INJ a $67.62 HCPCS - Drugs J3260 Blank TOBRAMYCIN SULFATE INJECTION a $18.56 HCPCS - Drugs J3262 Blank TOCILIZUMAB INJECTION a $21.44 HCPCS - Drugs J3265 Blank INJECTION TORSEMIDE 10 MG/ML a $16.30 HCPCS - Drugs J3280 Blank THIETHYLPERAZINE MALEATE INJ Blank $22.89 HCPCS - Drugs J3285 Blank TREPROSTINIL INJECTION a $136.16 HCPCS - Drugs J3300 Blank TRIAMCINOLONE A INJ PRS-FREE a $20.00 HCPCS - Drugs J3301 Blank TRIAMCINOLONE ACET INJ NOS a $16.39 HCPCS - Drugs J3302 Blank TRIAMCINOLONE DIACETATE INJ a $7.11 HCPCS - Drugs J3303 Blank TRIAMCINOLONE HEXACETONL INJ a $17.83 HCPCS - Drugs J3305 Blank INJ TRIMETREXATE GLUCORONATE a $123.00 HCPCS - Drugs J3310 Blank PERPHENAZINE INJECITON Blank $38.38 HCPCS - Drugs J3315 Blank TRIPTORELIN PAMOATE a $747.29 HCPCS - Drugs J3320 Blank SPECTINOMYCN DI-HCL INJ a $99.20 HCPCS - Drugs J3350 Blank UREA INJECTION a $34.44 HCPCS - Drugs J3355 Blank UROFOLLITROPIN, 75 IU a $144.82 HCPCS - Drugs J3357 Blank USTEKINUMAB SUB CU INJ, 1 MG a $362.72 HCPCS - Drugs J3360 Blank DIAZEPAM INJECTION a $31.54 HCPCS - Drugs J3364 Blank UROKINASE 5000 IU INJECTION a $27.23 HCPCS - Drugs J3365 Blank UROKINASE 250,000 IU INJ a $1,340.34 HCPCS - Drugs J3370 Blank VANCOMYCIN HCL INJECTION a $18.56 HCPCS - Drugs J3380 Blank INJECTION, VEDOLIZUMAB a $49.58 HCPCS - Drugs J3385 Blank VELAGLUCERASE ALFA a $701.84 HCPCS - Drugs J3396 Blank VERTEPORFIN INJECTION a $34.43 HCPCS - Drugs J3400 Blank TRIFLUPROMAZINE HCL INJ Blank $44.53 HCPCS - Drugs J3410 Blank HYDROXYZINE HCL INJECTION a $17.11 HCPCS - Drugs J3411 Blank THIAMINE HCL 100 MG a $19.28 HCPCS - Drugs J3415 Blank PYRIDOXINE HCL 100 MG a $35.15 HCPCS - Drugs J3420 Blank VITAMIN B12 INJECTION a $19.28 HCPCS - Drugs J3430 Blank VITAMIN K PHYTONADIONE INJ a $20.00 HCPCS - Drugs J3465 Blank INJECTION, VORICONAZOLE a $20.00 HCPCS - Drugs J3470 Blank HYALURONIDASE INJECTION a $64.01 HCPCS - Drugs J3471 Blank OVINE, UP TO 999 USP UNITS a $7.11 HCPCS - Drugs J3472 Blank OVINE, 1000 USP UNITS a $250.16 HCPCS - Drugs J3473 Blank HYALURONIDASE RECOMBINANT a $7.11 HCPCS - Drugs J3475 Blank INJ MAGNESIUM SULFATE a $7.11 HCPCS - Drugs J3480 Blank INJ POTASSIUM CHLORIDE a $7.11 HCPCS - Drugs J3485 Blank ZIDOVUDINE a $15.67 HCPCS - Drugs J3486 Blank ZIPRASIDONE MESYLATE a $52.47 HCPCS - Drugs J3489 Blank ZOLEDRONIC ACID 1MG a $39.48 HCPCS - Drugs J3490 Blank DRUGS UNCLASSIFIED INJECTION a $5.36 HCPCS - Drugs J3520 Blank EDETATE DISODIUM PER 150 MG Blank $7.11 HCPCS - Drugs J3530 Blank NASAL VACCINE INHALATION Blank $59.70 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J3535 Blank METERED DOSE INHALER DRUG a $13.90 HCPCS - Drugs J3570 Blank LAETRILE AMYGDALIN VIT B17 Blank $36.74 HCPCS - Drugs J3590 Blank UNCLASSIFIED BIOLOGICS a $122.43 HCPCS - Drugs J7030 Blank NORMAL SALINE SOLUTION INFUS a $17.11 HCPCS - Drugs J7040 Blank NORMAL SALINE SOLUTION INFUS a $14.95 HCPCS - Drugs J7042 Blank 5% DEXTROSE/NORMAL SALINE a $14.23 HCPCS - Drugs J7050 Blank NORMAL SALINE SOLUTION INFUS a $7.11 HCPCS - Drugs J7060 Blank 5% DEXTROSE/WATER a $16.39 HCPCS - Drugs J7070 Blank D5W INFUSION a $20.00 HCPCS - Drugs J7100 Blank DEXTRAN 40 INFUSION a $181.62 HCPCS - Drugs J7110 Blank DEXTRAN 75 INFUSION a $201.63 HCPCS - Drugs J7120 Blank RINGERS LACTATE INFUSION a $17.11 HCPCS - Drugs J7121 Blank 5% DEXTROSE IN LAC RINGERS a $37.34 HCPCS - Drugs J7131 Blank HYPERTONIC SALINE SOL a $2.13 HCPCS - Drugs J7175 Blank INJ, FACTOR X, (HUMAN), 1IU a $13.08 HCPCS - Drugs J7178 Blank HUMAN FIBRINOGEN CONC INJ a $1.23 HCPCS - Drugs J7179 Blank VONVENDI INJ 1 IU VWF:RCO a $4.63 HCPCS - Drugs J7180 Blank FACTOR XIII ANTI-HEM FACTOR a $29.38 HCPCS - Drugs J7181 Blank FACTOR XIII RECOMB A-SUBUNIT a $24.26 HCPCS - Drugs J7182 Blank FACTOR VIII RECOMB NOVOEIGHT a $15.67 HCPCS - Drugs J7183 Blank WILATE INJECTION a $14.95 HCPCS - Drugs J7185 Blank XYNTHA INJ a $14.95 HCPCS - Drugs J7186 Blank ANTIHEMOPHILIC VIII/VWF COMP a $14.95 HCPCS - Drugs J7187 Blank HUMATE-P, INJ a $14.95 HCPCS - Drugs J7188 Blank FACTOR VIII RECOMB OBIZUR a $16.18 HCPCS - Drugs J7189 Blank FACTOR VIIA a $16.39 HCPCS - Drugs J7190 Blank FACTOR VIII a $14.95 HCPCS - Drugs J7191 Blank FACTOR VIII (PORCINE) a $7.19 HCPCS - Drugs J7192 Blank FACTOR VIII RECOMBINANT NOS a $14.95 HCPCS - Drugs J7193 Blank FACTOR IX NON-RECOMBINANT a $14.95 HCPCS - Drugs J7194 Blank FACTOR IX COMPLEX a $15.67 HCPCS - Drugs J7195 Blank FACTOR IX RECOMBINANT NOS a $15.67 HCPCS - Drugs J7196 Blank ANTITHROMBIN RECOMBINANT a $9.48 HCPCS - Drugs J7197 Blank ANTITHROMBIN III INJECTION a $19.28 HCPCS - Drugs J7198 Blank ANTI-INHIBITOR a $16.39 HCPCS - Drugs J7199 Blank HEMOPHILIA CLOT FACTOR NOC a $1.57 HCPCS - Drugs J7200 Blank FACTOR IX RECOMBINAN RIXUBIS a $14.95 HCPCS - Drugs J7201 Blank FACTOR IX ALPROLIX RECOMB a $18.56 HCPCS - Drugs J7202 Blank FACTOR IX IDELVION INJ a $8.41 HCPCS - Drugs J7205 Blank FACTOR VIII FC FUSION RECOMB a $17.11 HCPCS - Drugs J7207 Blank FACTOR VIII PEGYLATED RECOMB a $3.10 HCPCS - Drugs J7209 Blank FACTOR VIII NUWIQ RECOMB 1IU a $3.03 HCPCS - Drugs J7297 Blank LILETTA, 52 MG a $1,713.64 HCPCS - Drugs J7298 Blank MIRENA, 52 MG a $1,778.64 HCPCS - Drugs J7300 Blank INTRAUT COPPER CONTRACEPTIVE a $818.00 HCPCS - Drugs J7301 Blank SKYLA, 13.5 MG a $1,814.33 HCPCS - Drugs J7303 Blank CONTRACEPTIVE VAGINAL RING Blank $90.71 HCPCS - Drugs J7304 Blank CONTRACEPTIVE HORMONE PATCH Blank $83.20 HCPCS - Drugs J7306 Blank LEVONORGESTREL IMPLANT SYS a $851.19 HCPCS - Drugs J7307 Blank ETONOGESTREL IMPLANT SYSTEM a $1,837.72 HCPCS - Drugs J7308 Blank AMINOLEVULINIC ACID HCL TOP a $752.34 HCPCS - Drugs J7309 Blank METHYL AMINOLEVULINATE, TOP a $230.71 HCPCS - Drugs J7310 Blank GANCICLOVIR LONG ACT IMPLANT a $9,168.88 HCPCS - Drugs J7311 Blank FLUOCINOLONE ACETONIDE IMPLT a $40,443.20 HCPCS - Drugs J7312 Blank DEXAMETHASONE INTRA IMPLANT a $416.11 HCPCS - Drugs J7313 Blank FLUOCINOL ACET INTRAVIT IMP a $999.82 HCPCS - Drugs J7315 Blank OPHTHALMIC MITOMYCIN a $911.42 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J7316 Blank INJ, OCRIPLASMIN, 0.125 MG a $2,117.46 HCPCS - Drugs J7320 Blank GENVISC 850, INJ, 1MG a $26.49 HCPCS - Drugs J7321 Blank HYALGAN SUPARTZ VISCO-3 DOSE a $188.11 HCPCS - Drugs J7322 Blank HYMOVIS INJECTION 1 MG a $32.96 HCPCS - Drugs J7323 Blank EUFLEXXA INJ PER DOSE a $322.32 HCPCS - Drugs J7324 Blank ORTHOVISC INJ PER DOSE a $321.60 HCPCS - Drugs J7325 Blank SYNVISC OR SYNVISC-ONE a $38.04 HCPCS - Drugs J7326 Blank GEL-ONE a $1,105.89 HCPCS - Drugs J7327 Blank MONOVISC INJ PER DOSE a $1,812.26 HCPCS - Drugs J7328 Blank GELSYN-3 INJECTION 0.1 MG a $1.11 HCPCS - Drugs J7330 Blank CULTURED CHONDROCYTES IMPLNT Blank $81,424.47 HCPCS - Drugs J7336 Blank CAPSAICIN 8% PATCH a $18.56 HCPCS - Drugs J7340 Blank CARBIDOPA LEVODOPA ENT 100ML a $6.70 HCPCS - Drugs J7342 Blank CIPROFLOXACIN OTIC SUSP 6 MG a $135.61 HCPCS - Drugs J7500 Blank AZATHIOPRINE ORAL 50MG a $7.11 HCPCS - Drugs J7501 Blank AZATHIOPRINE PARENTERAL a $151.32 HCPCS - Drugs J7502 Blank CYCLOSPORINE ORAL 100 MG a $18.56 HCPCS - Drugs J7503 Blank TACROL ENVARSUS EX REL ORAL a $14.95 HCPCS - Drugs J7504 Blank LYMPHOCYTE IMMUNE GLOBULIN a $2,986.17 HCPCS - Drugs J7505 Blank MONOCLONAL ANTIBODIES a $1,950.07 HCPCS - Drugs J7507 Blank TACROLIMUS IMME REL ORAL 1MG a $14.23 HCPCS - Drugs J7508 Blank TACROL ASTAGRAF EX REL ORAL a $7.11 HCPCS - Drugs J7509 Blank METHYLPREDNISOLONE ORAL a $7.11 HCPCS - Drugs J7510 Blank PREDNISOLONE ORAL PER 5 MG a $7.11 HCPCS - Drugs J7511 Blank ANTITHYMOCYTE GLOBULN RABBIT a $1,395.22 HCPCS - Drugs J7512 Blank PREDNISONE IR OR DR ORAL 1MG a $7.11 HCPCS - Drugs J7513 Blank DACLIZUMAB, PARENTERAL a $849.03 HCPCS - Drugs J7515 Blank CYCLOSPORINE ORAL 25 MG a $14.23 HCPCS - Drugs J7516 Blank CYCLOSPORIN PARENTERAL 250MG a $92.15 HCPCS - Drugs J7517 Blank MYCOPHENOLATE MOFETIL ORAL a $14.95 HCPCS - Drugs J7518 Blank MYCOPHENOLIC ACID a $18.56 HCPCS - Drugs J7520 Blank SIROLIMUS, ORAL a $28.66 HCPCS - Drugs J7525 Blank TACROLIMUS INJECTION a $356.23 HCPCS - Drugs J7527 Blank ORAL EVEROLIMUS a $28.66 HCPCS - Drugs J7599 Blank IMMUNOSUPPRESSIVE DRUG NOC a $9.08 HCPCS - Drugs J7604 Blank ACETYLCYSTEINE COMP UNIT Blank $84.03 HCPCS - Drugs J7605 Blank ARFORMOTEROL NON-COMP UNIT Blank $32.27 HCPCS - Drugs J7606 Blank FORMOTEROL FUMARATE, INH a $33.71 HCPCS - Drugs J7607 Blank LEVALBUTEROL COMP CON a $44.59 HCPCS - Drugs J7608 Blank ACETYLCYSTEINE NON-COMP UNIT a $21.44 HCPCS - Drugs J7609 Blank ALBUTEROL COMP UNIT a $17.23 HCPCS - Drugs J7610 Blank ALBUTEROL COMP CON a $17.79 HCPCS - Drugs J7611 Blank ALBUTEROL NON-COMP CON a $7.11 HCPCS - Drugs J7612 Blank LEVALBUTEROL NON-COMP CON a $7.11 HCPCS - Drugs J7613 Blank ALBUTEROL NON-COMP UNIT a $7.11 HCPCS - Drugs J7614 Blank LEVALBUTEROL NON-COMP UNIT a $7.11 HCPCS - Drugs J7615 Blank LEVALBUTEROL COMP UNIT a $17.11 HCPCS - Drugs J7620 Blank ALBUTEROL IPRATROP NON-COMP a $7.11 HCPCS - Drugs J7622 Blank BECLOMETHASONE COMP UNIT Blank $16.40 HCPCS - Drugs J7624 Blank BETAMETHASONE COMP UNIT Blank $4.75 HCPCS - Drugs J7626 Blank BUDESONIDE NON-COMP UNIT a $20.00 HCPCS - Drugs J7627 Blank BUDESONIDE COMP UNIT a $22.89 HCPCS - Drugs J7628 Blank BITOLTEROL MESYLATE COMP CON Blank $6.66 HCPCS - Drugs J7629 Blank BITOLTEROL MESYLATE COMP UNT Blank $6.66 HCPCS - Drugs J7631 Blank CROMOLYN SODIUM NONCOMP UNIT Blank $14.23 HCPCS - Drugs J7632 Blank CROMOLYN SODIUM COMP UNIT Blank $7.11 HCPCS - Drugs J7633 Blank BUDESONIDE NON-COMP CON a $27.62 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J7634 Blank BUDESONIDE COMP CON Blank $55.36 HCPCS - Drugs J7635 Blank ATROPINE COMP CON Blank $41.45 HCPCS - Drugs J7636 Blank ATROPINE COMP UNIT a $31.21 HCPCS - Drugs J7637 Blank DEXAMETHASONE COMP CON a $5.69 HCPCS - Drugs J7638 Blank DEXAMETHASONE COMP UNIT a $5.69 HCPCS - Drugs J7639 Blank DORNASE ALFA NON-COMP UNIT a $97.92 HCPCS - Drugs J7640 Blank FORMOTEROL COMP UNIT Blank $34.12 HCPCS - Drugs J7641 Blank FLUNISOLIDE COMP UNIT Blank $35.15 HCPCS - Drugs J7642 Blank GLYCOPYRROLATE COMP CON a $2.56 HCPCS - Drugs J7643 Blank GLYCOPYRROLATE COMP UNIT a $2.56 HCPCS - Drugs J7644 Blank IPRATROPIUM BROMIDE NON-COMP a $7.11 HCPCS - Drugs J7645 Blank IPRATROPIUM BROMIDE COMP a $18.43 HCPCS - Drugs J7647 Blank ISOETHARINE COMP CON Blank $7.23 HCPCS - Drugs J7648 Blank ISOETHARINE NON-COMP CON Blank $2.44 HCPCS - Drugs J7649 Blank ISOETHARINE NON-COMP UNIT a $2.44 HCPCS - Drugs J7650 Blank ISOETHARINE COMP UNIT Blank $7.23 HCPCS - Drugs J7657 Blank ISOPROTERENOL COMP CON Blank $9.83 HCPCS - Drugs J7658 Blank ISOPROTERENOL NON-COMP CON a $13.50 HCPCS - Drugs J7659 Blank ISOPROTERENOL NON-COMP UNIT a $13.50 HCPCS - Drugs J7660 Blank ISOPROTERENOL COMP UNIT a $1.63 HCPCS - Drugs J7665 Blank MANNITOL FOR INHALER a $6.05 HCPCS - Drugs J7667 Blank METAPROTERENOL COMP CON Blank $13.11 HCPCS - Drugs J7668 Blank METAPROTERENOL NON-COMP CON Blank $0.28 HCPCS - Drugs J7669 Blank METAPROTERENOL NON-COMP UNIT Blank $1.34 HCPCS - Drugs J7670 Blank METAPROTERENOL COMP UNIT Blank $8.50 HCPCS - Drugs J7674 Blank METHACHOLINE CHLORIDE, NEB a $7.11 HCPCS - Drugs J7676 Blank PENTAMIDINE COMP UNIT DOSE a $594.60 HCPCS - Drugs J7680 Blank TERBUTALINE SULF COMP CON a $40.92 HCPCS - Drugs J7681 Blank TERBUTALINE SULF COMP UNIT Blank $40.92 HCPCS - Drugs J7682 Blank TOBRAMYCIN NON-COMP UNIT a $97.92 HCPCS - Drugs J7683 Blank TRIAMCINOLONE COMP CON Blank $22.89 HCPCS - Drugs J7684 Blank TRIAMCINOLONE COMP UNIT Blank $12.36 HCPCS - Drugs J7685 Blank TOBRAMYCIN COMP UNIT Blank $141.94 HCPCS - Drugs J7686 Blank TREPROSTINIL, NON-COMP UNIT Blank $1,080.64 HCPCS - Drugs J7699 Blank INHALATION SOLUTION FOR DME a $5.64 HCPCS - Drugs J7799 Blank NON-INHALATION DRUG FOR DME a $7.07 HCPCS - Drugs J7999 Blank COMPOUNDED DRUG, NOC a $3.15 HCPCS - Drugs J8498 Blank ANTIEMETIC RECTAL/SUPP NOS a $1.57 HCPCS - Drugs J8499 Blank ORAL PRESCRIP DRUG NON CHEMO a $1.63 HCPCS - Drugs J8501 Blank ORAL APREPITANT a $36.59 HCPCS - Drugs J8510 Blank ORAL BUSULFAN a $107.89 HCPCS - Drugs J8515 Blank CABERGOLINE, ORAL 0.25MG Blank $43.09 HCPCS - Drugs J8520 Blank CAPECITABINE, ORAL, 150 MG a $18.71 HCPCS - Drugs J8521 Blank CAPECITABINE, ORAL, 500 MG a $52.73 HCPCS - Drugs J8530 Blank CYCLOPHOSPHAMIDE ORAL 25 MG a $15.31 HCPCS - Drugs J8540 Blank ORAL DEXAMETHASONE a $7.11 HCPCS - Drugs J8560 Blank ETOPOSIDE ORAL 50 MG a $309.24 HCPCS - Drugs J8562 Blank ORAL FLUDARABINE PHOSPHATE a $293.23 HCPCS - Drugs J8565 Blank GEFITINIB ORAL a $128.23 HCPCS - Drugs J8597 Blank ANTIEMETIC DRUG ORAL NOS a $151.33 HCPCS - Drugs J8600 Blank MELPHALAN ORAL 2 MG Blank $56.13 HCPCS - Drugs J8610 Blank METHOTREXATE ORAL 2.5 MG a $3.40 HCPCS - Drugs J8650 Blank NABILONE ORAL a $46.70 HCPCS - Drugs J8655 Blank NETUPITANT PALONOSETRON ORAL a $907.47 HCPCS - Drugs J8670 Blank ROLAPITANT, ORAL, 1MG a $50.81 HCPCS - Drugs J8700 Blank TEMOZOLOMIDE a $8.50 HCPCS - Drugs J8705 Blank TOPOTECAN ORAL a $426.34 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J8999 Blank ORAL PRESCRIPTION DRUG CHEMO a $55.14 HCPCS - Drugs J9000 Blank DOXORUBICIN HCL INJECTION a $23.81 HCPCS - Drugs J9015 Blank ALDESLEUKIN INJECTION a $2,262.40 HCPCS - Drugs J9017 Blank ARSENIC TRIOXIDE INJECTION a $272.11 HCPCS - Drugs J9019 Blank ERWINAZE INJECTION a $1,523.39 HCPCS - Drugs J9020 Blank ASPARAGINASE, NOS a $239.27 HCPCS - Drugs J9025 Blank AZACITIDINE INJECTION a $10.21 HCPCS - Drugs J9027 Blank CLOFARABINE INJECTION a $319.43 HCPCS - Drugs J9031 Blank BCG LIVE INTRAVESICAL VAC a $524.87 HCPCS - Drugs J9032 Blank INJECTION, BELINOSTAT, 10MG a $150.73 HCPCS - Drugs J9033 Blank INJ., TREANDA 1 MG a $125.03 HCPCS - Drugs J9034 Blank INJ., BENDEKA 1 MG a $106.47 HCPCS - Drugs J9035 Blank BEVACIZUMAB INJECTION a $160.70 HCPCS - Drugs J9039 Blank INJECTION, BLINATUMOMAB a $346.16 HCPCS - Drugs J9040 Blank BLEOMYCIN SULFATE INJECTION a $196.43 HCPCS - Drugs J9041 Blank BORTEZOMIB INJECTION a $105.86 HCPCS - Drugs J9042 Blank BRENTUXIMAB VEDOTIN INJ a $547.72 HCPCS - Drugs J9043 Blank CABAZITAXEL INJECTION a $637.68 HCPCS - Drugs J9045 Blank CARBOPLATIN INJECTION a $17.01 HCPCS - Drugs J9047 Blank INJECTION, CARFILZOMIB, 1 MG a $142.17 HCPCS - Drugs J9050 Blank CARMUSTINE INJECTION a $7,953.33 HCPCS - Drugs J9055 Blank CETUXIMAB INJECTION a $126.06 HCPCS - Drugs J9060 Blank CISPLATIN 10 MG INJECTION a $10.21 HCPCS - Drugs J9065 Blank INJ CLADRIBINE PER 1 MG a $93.61 HCPCS - Drugs J9070 Blank CYCLOPHOSPHAMIDE 100 MG INJ a $182.15 HCPCS - Drugs J9098 Blank CYTARABINE LIPOSOME INJ a $1,206.90 HCPCS - Drugs J9100 Blank CYTARABINE HCL 100 MG INJ a $3.40 HCPCS - Drugs J9120 Blank DACTINOMYCIN INJECTION a $3,154.16 HCPCS - Drugs J9130 Blank DACARBAZINE 100 MG INJ a $18.71 HCPCS - Drugs J9145 Blank INJECTION, DARATUMUMAB 10 MG a $265.46 HCPCS - Drugs J9150 Blank DAUNORUBICIN INJECTION a $169.30 HCPCS - Drugs J9151 Blank DAUNORUBICIN CITRATE INJ a $242.13 HCPCS - Drugs J9155 Blank DEGARELIX INJECTION a $20.00 HCPCS - Drugs J9160 Blank DENILEUKIN DIFTITOX INJ a $2,820.94 HCPCS - Drugs J9165 Blank DIETHYLSTILBESTROL INJECTION a $67.26 HCPCS - Drugs J9171 Blank DOCETAXEL INJECTION a $16.39 HCPCS - Drugs J9175 Blank ELLIOTTS B SOLUTION PER ML a $20.72 HCPCS - Drugs J9176 Blank INJECTION, ELOTUZUMAB, 1MG a $25.05 HCPCS - Drugs J9178 Blank INJ, EPIRUBICIN HCL, 2 MG a $15.67 HCPCS - Drugs J9179 Blank ERIBULIN MESYLATE INJECTION a $444.90 HCPCS - Drugs J9181 Blank ETOPOSIDE INJECTION a $3.40 HCPCS - Drugs J9185 Blank FLUDARABINE PHOSPHATE INJ a $283.54 HCPCS - Drugs J9190 Blank FLUOROURACIL INJECTION a $8.50 HCPCS - Drugs J9200 Blank FLOXURIDINE INJECTION a $254.98 HCPCS - Drugs J9201 Blank GEMCITABINE HCL INJECTION a $30.62 HCPCS - Drugs J9202 Blank GOSERELIN ACETATE IMPLANT a $1,405.95 HCPCS - Drugs J9205 Blank INJ IRINOTECAN LIPOSOME 1 MG a $170.73 HCPCS - Drugs J9206 Blank IRINOTECAN INJECTION a $17.01 HCPCS - Drugs J9207 Blank IXABEPILONE INJECTION a $313.53 HCPCS - Drugs J9208 Blank IFOSFAMIDE INJECTION a $125.03 HCPCS - Drugs J9209 Blank MESNA INJECTION a $10.21 HCPCS - Drugs J9211 Blank IDARUBICIN HCL INJECTION a $179.29 HCPCS - Drugs J9212 Blank INTERFERON ALFACON-1 INJ a $26.49 HCPCS - Drugs J9213 Blank INTERFERON ALFA-2A INJ a $163.59 HCPCS - Drugs J9214 Blank INTERFERON ALFA-2B INJ a $126.46 HCPCS - Drugs J9215 Blank INTERFERON ALFA-N3 INJ a $86.47 HCPCS - Drugs J9216 Blank INTERFERON GAMMA 1-B INJ a $1,291.71 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

J9217 Blank LEUPROLIDE ACETATE SUSPNSION a $873.31 HCPCS - Drugs J9218 Blank LEUPROLIDE ACETATE INJECITON a $116.46 HCPCS - Drugs J9219 Blank LEUPROLIDE ACETATE IMPLANT a $7,476.76 HCPCS - Drugs J9225 Blank VANTAS IMPLANT a $6,612.67 HCPCS - Drugs J9226 Blank SUPPRELIN LA IMPLANT a $52,552.89 HCPCS - Drugs J9228 Blank IPILIMUMAB INJECTION a $589.13 HCPCS - Drugs J9230 Blank MECHLORETHAMINE HCL INJ a $1,071.80 HCPCS - Drugs J9245 Blank INJ MELPHALAN HYDROCHL 50 MG a $4,139.72 HCPCS - Drugs J9250 Blank METHOTREXATE SODIUM INJ a $1.70 HCPCS - Drugs J9260 Blank METHOTREXATE SODIUM INJ a $11.91 HCPCS - Drugs J9261 Blank NELARABINE INJECTION a $318.71 HCPCS - Drugs J9262 Blank INJ, OMACETAXINE MEP, 0.01MG a $18.12 HCPCS - Drugs J9263 Blank OXALIPLATIN a $1.70 HCPCS - Drugs J9264 Blank PACLITAXEL PROTEIN BOUND a $33.71 HCPCS - Drugs J9266 Blank PEGASPARGASE INJECTION a $26,744.01 HCPCS - Drugs J9267 Blank PACLITAXEL INJECTION a $1.70 HCPCS - Drugs J9268 Blank PENTOSTATIN INJECTION a $4,287.12 HCPCS - Drugs J9270 Blank PLICAMYCIN (MITHRAMYCIN) INJ Blank $361.05 HCPCS - Drugs J9271 Blank INJ PEMBROLIZUMAB a $202.14 HCPCS - Drugs J9280 Blank MITOMYCIN INJECTION a $473.46 HCPCS - Drugs J9293 Blank MITOXANTRONE HYDROCHL / 5 MG a $145.02 HCPCS - Drugs J9295 Blank INJECTION, NECITUMUMAB, 1 MG a $25.51 HCPCS - Drugs J9299 Blank INJECTION, NIVOLUMAB a $119.32 HCPCS - Drugs J9301 Blank OBINUTUZUMAB INJ a $242.13 HCPCS - Drugs J9302 Blank OFATUMUMAB INJECTION a $226.42 HCPCS - Drugs J9303 Blank PANITUMUMAB INJECTION a $442.05 HCPCS - Drugs J9305 Blank PEMETREXED INJECTION a $141.21 HCPCS - Drugs J9306 Blank INJECTION, PERTUZUMAB, 1 MG a $51.03 HCPCS - Drugs J9307 Blank PRALATREXATE INJECTION a $963.27 HCPCS - Drugs J9308 Blank INJECTION, RAMUCIRUMAB a $237.84 HCPCS - Drugs J9310 Blank RITUXIMAB INJECTION a $2,299.25 HCPCS - Drugs J9315 Blank ROMIDEPSIN INJECTION a $1,277.43 HCPCS - Drugs J9320 Blank STREPTOZOCIN INJECTION a $1,287.43 HCPCS - Drugs J9325 Blank INJ TALIMOGENE LAHERPAREPVEC a $105.14 HCPCS - Drugs J9328 Blank TEMOZOLOMIDE INJECTION a $42.52 HCPCS - Drugs J9330 Blank TEMSIROLIMUS INJECTION a $282.11 HCPCS - Drugs J9340 Blank THIOTEPA INJECTION a $410.63 HCPCS - Drugs J9351 Blank TOPOTECAN INJECTION a $6.80 HCPCS - Drugs J9352 Blank INJECTION TRABECTEDIN 0.1MG a $1,141.77 HCPCS - Drugs J9354 Blank INJ, ADO-TRASTUZUMAB EMT 1MG a $130.74 HCPCS - Drugs J9355 Blank TRASTUZUMAB INJECTION a $202.54 HCPCS - Drugs J9357 Blank VALRUBICIN INJECTION a $2,341.13 HCPCS - Drugs J9360 Blank VINBLASTINE SULFATE INJ a $17.01 HCPCS - Drugs J9370 Blank VINCRISTINE SULFATE 1 MG INJ a $20.41 HCPCS - Drugs J9371 Blank INJ, VINCRISTINE SUL LIP 1MG a $5,626.44 HCPCS - Drugs J9390 Blank VINORELBINE TARTRATE INJ a $35.72 HCPCS - Drugs J9395 Blank INJECTION, FULVESTRANT a $206.15 HCPCS - Drugs J9400 Blank INJ, ZIV-AFLIBERCEPT, 1MG a $29.38 HCPCS - Drugs J9600 Blank PORFIMER SODIUM INJECTION a $5,328.29 HCPCS - Drugs K0001 Blank STANDARD WHEELCHAIR Blank $827.20 HCPCS - Non-Drugs K0001 NU STANDARD WHEELCHAIR Blank $827.20 HCPCS - Non-Drugs K0001 RR STANDARD WHEELCHAIR Blank $112.32 HCPCS - Non-Drugs K0001 UE STANDARD WHEELCHAIR Blank $632.94 HCPCS - Non-Drugs K0002 Blank STND HEMI (LOW SEAT) WHLCHR Blank $1,105.64 HCPCS - Non-Drugs K0002 NU STND HEMI (LOW SEAT) WHLCHR Blank $1,105.64 HCPCS - Non-Drugs K0002 RR STND HEMI (LOW SEAT) WHLCHR Blank $150.12 HCPCS - Non-Drugs K0002 UE STND HEMI (LOW SEAT) WHLCHR Blank $883.20 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

K0003 Blank LIGHTWEIGHT WHEELCHAIR Blank $1,014.06 HCPCS - Non-Drugs K0003 NU LIGHTWEIGHT WHEELCHAIR Blank $1,014.06 HCPCS - Non-Drugs K0003 RR LIGHTWEIGHT WHEELCHAIR Blank $137.69 HCPCS - Non-Drugs K0003 UE LIGHTWEIGHT WHEELCHAIR Blank $960.62 HCPCS - Non-Drugs K0004 Blank HIGH STRENGTH LTWT WHLCHR Blank $1,140.51 HCPCS - Non-Drugs K0004 NU HIGH STRENGTH LTWT WHLCHR Blank $1,140.51 HCPCS - Non-Drugs K0004 RR HIGH STRENGTH LTWT WHLCHR Blank $154.86 HCPCS - Non-Drugs K0004 UE HIGH STRENGTH LTWT WHLCHR Blank $1,403.15 HCPCS - Non-Drugs K0005 Blank ULTRALIGHTWEIGHT WHEELCHAIR Blank $4,628.49 HCPCS - Non-Drugs K0005 NU ULTRALIGHTWEIGHT WHEELCHAIR Blank $4,628.49 HCPCS - Non-Drugs K0005 RR ULTRALIGHTWEIGHT WHEELCHAIR Blank $518.19 HCPCS - Non-Drugs K0005 UE ULTRALIGHTWEIGHT WHEELCHAIR Blank $3,486.72 HCPCS - Non-Drugs K0006 Blank HEAVY DUTY WHEELCHAIR Blank $1,480.97 HCPCS - Non-Drugs K0006 NU HEAVY DUTY WHEELCHAIR Blank $1,480.97 HCPCS - Non-Drugs K0006 RR HEAVY DUTY WHEELCHAIR Blank $201.08 HCPCS - Non-Drugs K0006 UE HEAVY DUTY WHEELCHAIR Blank $1,320.84 HCPCS - Non-Drugs K0007 Blank EXTRA HEAVY DUTY WHEELCHAIR Blank $1,887.87 HCPCS - Non-Drugs K0007 NU EXTRA HEAVY DUTY WHEELCHAIR Blank $1,887.87 HCPCS - Non-Drugs K0007 RR EXTRA HEAVY DUTY WHEELCHAIR Blank $256.33 HCPCS - Non-Drugs K0007 UE EXTRA HEAVY DUTY WHEELCHAIR Blank $1,853.83 HCPCS - Non-Drugs K0008 Blank CSTM MANUAL WHEELCHAIR/BASE Blank $562.73 HCPCS - Non-Drugs K0009 Blank OTHER MANUAL WHEELCHAIR/BASE Blank $1,790.78 HCPCS - Non-Drugs K0009 RR OTHER MANUAL WHEELCHAIR/BASE Blank $243.15 HCPCS - Non-Drugs K0010 Blank STND WT FRAME POWER WHLCHR Blank $7,650.56 HCPCS - Non-Drugs K0010 NU STND WT FRAME POWER WHLCHR Blank $7,650.56 HCPCS - Non-Drugs K0010 RR STND WT FRAME POWER WHLCHR Blank $1,038.77 HCPCS - Non-Drugs K0010 UE STND WT FRAME POWER WHLCHR Blank $6,926.98 HCPCS - Non-Drugs K0011 Blank STND WT PWR WHLCHR W CONTROL Blank $9,698.44 HCPCS - Non-Drugs K0011 NU STND WT PWR WHLCHR W CONTROL Blank $9,698.44 HCPCS - Non-Drugs K0011 RR STND WT PWR WHLCHR W CONTROL Blank $1,316.83 HCPCS - Non-Drugs K0012 Blank LTWT PORTBL POWER WHLCHR Blank $6,232.15 HCPCS - Non-Drugs K0012 RR LTWT PORTBL POWER WHLCHR Blank $846.19 HCPCS - Non-Drugs K0013 Blank CUSTOM POWER WHLCHR BASE Blank $900.30 HCPCS - Non-Drugs K0014 Blank OTHER POWER WHLCHR BASE Blank $436.33 HCPCS - Non-Drugs K0015 Blank DETACH NON-ADJ HT ARMRST REP Blank $440.70 HCPCS - Non-Drugs K0015 NU DETACH NON-ADJUS HGHT ARMRST Blank $440.70 HCPCS - Non-Drugs K0015 RR DETACH NON-ADJ HT ARMRST REP Blank $59.84 HCPCS - Non-Drugs K0015 UE DETACH NON-ADJUS HGHT ARMRST Blank $219.01 HCPCS - Non-Drugs K0017 Blank DETACH ADJUST ARMREST BASE Blank $159.81 HCPCS - Non-Drugs K0017 NU DETACH ADJUST ARMREST BASE Blank $159.81 HCPCS - Non-Drugs K0017 RR DETACH ADJUST ARMREST BASE Blank $16.80 HCPCS - Non-Drugs K0017 UE DETACH ADJUST ARMREST BASE Blank $135.28 HCPCS - Non-Drugs K0018 Blank DETACH ADJUST ARMRST UPPER Blank $117.16 HCPCS - Non-Drugs K0018 NU DETACH ADJUST ARMRST UPPER Blank $117.16 HCPCS - Non-Drugs K0018 RR DETACH ADJUST ARMRST UPPER Blank $9.48 HCPCS - Non-Drugs K0018 UE DETACH ADJUST ARMRST UPPER Blank $88.75 HCPCS - Non-Drugs K0019 Blank ARM PAD REPL, EACH Blank $54.45 HCPCS - Non-Drugs K0019 NU ARM PAD REPL, EACH Blank $54.45 HCPCS - Non-Drugs K0019 RR ARM PAD REPL, EACH Blank $4.88 HCPCS - Non-Drugs K0019 UE ARM PAD REPL, EACH Blank $36.59 HCPCS - Non-Drugs K0020 Blank FIXED ADJUST ARMREST PAIR Blank $157.83 HCPCS - Non-Drugs K0020 NU FIXED ADJUST ARMREST PAIR Blank $157.83 HCPCS - Non-Drugs K0020 RR FIXED ADJUST ARMREST PAIR Blank $16.44 HCPCS - Non-Drugs K0020 UE FIXED ADJUST ARMREST PAIR Blank $133.79 HCPCS - Non-Drugs K0037 Blank HI MOUNT FLIP-UP FTREST REPL Blank $152.53 HCPCS - Non-Drugs K0037 NU HI MOUNT FLIP-UP FTREST REPL Blank $152.53 HCPCS - Non-Drugs K0037 RR HI MOUNT FLIP-UP FTREST REPL Blank $14.98 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

K0037 UE HI MOUNT FLIP-UP FTREST REPL Blank $129.84 HCPCS - Non-Drugs K0038 Blank LEG STRAP EACH Blank $108.16 HCPCS - Non-Drugs K0038 NU LEG STRAP EACH Blank $108.16 HCPCS - Non-Drugs K0038 RR LEG STRAP EACH Blank $8.38 HCPCS - Non-Drugs K0038 UE LEG STRAP EACH Blank $76.10 HCPCS - Non-Drugs K0039 Blank LEG STRAP H STYLE EACH Blank $166.97 HCPCS - Non-Drugs K0039 NU LEG STRAP H STYLE EACH Blank $166.97 HCPCS - Non-Drugs K0039 RR LEG STRAP H STYLE EACH Blank $18.02 HCPCS - Non-Drugs K0039 UE LEG STRAP H STYLE EACH Blank $140.67 HCPCS - Non-Drugs K0040 Blank ADJUSTABLE ANGLE FOOTPLATE Blank $174.72 HCPCS - Non-Drugs K0040 NU ADJUSTABLE ANGLE FOOTPLATE Blank $174.72 HCPCS - Non-Drugs K0040 RR ADJUSTABLE ANGLE FOOTPLATE Blank $19.34 HCPCS - Non-Drugs K0040 UE ADJUSTABLE ANGLE FOOTPLATE Blank $146.47 HCPCS - Non-Drugs K0041 Blank LARGE SIZE FOOTPLATE EACH Blank $162.32 HCPCS - Non-Drugs K0041 NU LARGE SIZE FOOTPLATE EACH Blank $162.32 HCPCS - Non-Drugs K0041 RR LARGE SIZE FOOTPLATE EACH Blank $17.22 HCPCS - Non-Drugs K0041 UE LARGE SIZE FOOTPLATE EACH Blank $137.17 HCPCS - Non-Drugs K0042 Blank STANDARD SIZE FTPLATE REP EA Blank $126.29 HCPCS - Non-Drugs K0042 NU STANDARD SIZE FTPLATE REP EA Blank $126.29 HCPCS - Non-Drugs K0042 RR STANDARD SIZE FTPLATE REP EA Blank $11.04 HCPCS - Non-Drugs K0042 UE STANDARD SIZE FTPLATE REP EA Blank $106.62 HCPCS - Non-Drugs K0043 Blank FTRST LOWR EXTEN TUBE REP EA Blank $84.26 HCPCS - Non-Drugs K0043 NU FTRST LOWR EXTEN TUBE REP EA Blank $84.26 HCPCS - Non-Drugs K0043 RR FTRST LOWR EXTEN TUBE REP EA Blank $6.82 HCPCS - Non-Drugs K0043 UE FTRST LOWR EXTEN TUBE REP EA Blank $58.14 HCPCS - Non-Drugs K0044 Blank FTRST UPR HANGER BRAC REP EA Blank $70.68 HCPCS - Non-Drugs K0044 NU FTRST UPR HANGER BRAC REP EA Blank $70.68 HCPCS - Non-Drugs K0044 RR FTRST UPR HANGER BRAC REP EA Blank $5.94 HCPCS - Non-Drugs K0044 UE FTRST UPR HANGER BRAC REP EA Blank $47.94 HCPCS - Non-Drugs K0045 Blank FTRST COMPL ASSEMBLY REPL EA Blank $175.09 HCPCS - Non-Drugs K0045 NU FTRST COMPL ASSEMBLY REPL EA Blank $175.09 HCPCS - Non-Drugs K0045 RR FTRST COMPL ASSEMBLY REPL EA Blank $19.47 HCPCS - Non-Drugs K0045 UE FTRST COMPL ASSEMBLY REPL EA Blank $146.76 HCPCS - Non-Drugs K0046 Blank ELEV LGRST LWR EXTEN REPL EA Blank $84.96 HCPCS - Non-Drugs K0046 NU ELEV LGRST LWR EXTEN REPL EA Blank $84.96 HCPCS - Non-Drugs K0046 RR ELEV LGRST LWR EXTEN REPL EA Blank $6.86 HCPCS - Non-Drugs K0046 UE ELEV LGRST LWR EXTEN REPL EA Blank $58.67 HCPCS - Non-Drugs K0047 Blank ELEV LEGRST UPR HANGR REP EA Blank $203.59 HCPCS - Non-Drugs K0047 NU ELEV LEGRST UPR HANGR REP EA Blank $203.59 HCPCS - Non-Drugs K0047 RR ELEV LEGRST UPR HANGR REP EA Blank $24.26 HCPCS - Non-Drugs K0047 UE ELEV LEGRST UPR HANGR REP EA Blank $168.11 HCPCS - Non-Drugs K0050 Blank RATCHET ASSEMBLY REPLACEMENT Blank $127.53 HCPCS - Non-Drugs K0050 NU RATCHET ASSEMBLY REPLACEMENT Blank $127.53 HCPCS - Non-Drugs K0050 RR RATCHET ASSEMBLY REPLACEMENT Blank $11.27 HCPCS - Non-Drugs K0050 UE RATCHET ASSEMBLY REPLACEMENT Blank $109.09 HCPCS - Non-Drugs K0051 Blank CAM REL ASM FT/LEGRST REP EA Blank $165.84 HCPCS - Non-Drugs K0051 NU CAM REL ASM FT/LEGRST REP EA Blank $165.84 HCPCS - Non-Drugs K0051 RR CAM REL ASM FT/LEGRST REP EA Blank $17.82 HCPCS - Non-Drugs K0051 UE CAM REL ASM FT/LEGRST REP EA Blank $139.82 HCPCS - Non-Drugs K0052 Blank SWINGAWAY DETACH FTREST REPL Blank $213.98 HCPCS - Non-Drugs K0052 NU SWINGAWAY DETACH FTREST REPL Blank $213.98 HCPCS - Non-Drugs K0052 RR SWINGAWAY DETACH FTREST REPL Blank $26.06 HCPCS - Non-Drugs K0052 UE SWINGAWAY DETACH FTREST REPL Blank $175.92 HCPCS - Non-Drugs K0053 Blank ELEVATE FOOTREST ARTICULATE Blank $242.52 HCPCS - Non-Drugs K0053 NU ELEVATE FOOTREST ARTICULATE Blank $242.52 HCPCS - Non-Drugs K0053 RR ELEVATE FOOTREST ARTICULATE Blank $30.94 HCPCS - Non-Drugs K0053 UE ELEVATE FOOTREST ARTICULATE Blank $197.33 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

K0056 Blank SEAT HT <17 OR >=21 LTWT WC Blank $262.98 HCPCS - Non-Drugs K0056 NU SEAT HT <17 OR >=21 LTWT WC Blank $262.98 HCPCS - Non-Drugs K0056 RR SEAT HT <17 OR >=21 LTWT WC Blank $34.44 HCPCS - Non-Drugs K0056 UE SEAT HT <17 OR >=21 LTWT WC Blank $212.67 HCPCS - Non-Drugs K0065 Blank SPOKE PROTECTORS Blank $161.45 HCPCS - Non-Drugs K0065 NU SPOKE PROTECTORS Blank $161.45 HCPCS - Non-Drugs K0065 RR SPOKE PROTECTORS Blank $17.07 HCPCS - Non-Drugs K0065 UE SPOKE PROTECTORS Blank $136.52 HCPCS - Non-Drugs K0069 Blank RR WHL COMPL SOL TIRE REP EA Blank $265.23 HCPCS - Non-Drugs K0069 NU RR WHL COMPL SOL TIRE REP EA Blank $265.23 HCPCS - Non-Drugs K0069 RR RR WHL COMPL SOL TIRE REP EA Blank $34.82 HCPCS - Non-Drugs K0069 UE RR WHL COMPL SOL TIRE REP EA Blank $214.36 HCPCS - Non-Drugs K0070 Blank RR WHL COMPL PNE TIRE REP EA Blank $511.59 HCPCS - Non-Drugs K0070 NU REAR WHL COMPL PNEUM TIRE Blank $511.59 HCPCS - Non-Drugs K0070 RR RR WHL COMPL PNE TIRE REP EA Blank $69.46 HCPCS - Non-Drugs K0070 UE REAR WHL COMPL PNEUM TIRE Blank $245.90 HCPCS - Non-Drugs K0071 Blank FR CSTR COMP PNE TIRE REP EA Blank $295.22 HCPCS - Non-Drugs K0071 NU FR CSTR COMP PNE TIRE REP EA Blank $295.22 HCPCS - Non-Drugs K0071 RR FR CSTR COMP PNE TIRE REP EA Blank $40.95 HCPCS - Non-Drugs K0071 UE FR CSTR COMP PNE TIRE REP EA Blank $236.86 HCPCS - Non-Drugs K0072 Blank FR CSTR SEMI-PNE TIRE REP EA Blank $206.71 HCPCS - Non-Drugs K0072 NU FR CSTR SEMI-PNE TIRE REP EA Blank $206.71 HCPCS - Non-Drugs K0072 RR FR CSTR SEMI-PNE TIRE REP EA Blank $24.82 HCPCS - Non-Drugs K0072 UE FR CSTR SEMI-PNE TIRE REP EA Blank $170.47 HCPCS - Non-Drugs K0073 Blank CASTER PIN LOCK EACH Blank $137.46 HCPCS - Non-Drugs K0073 NU CASTER PIN LOCK EACH Blank $137.46 HCPCS - Non-Drugs K0073 RR CASTER PIN LOCK EACH Blank $12.96 HCPCS - Non-Drugs K0073 UE CASTER PIN LOCK EACH Blank $118.53 HCPCS - Non-Drugs K0077 Blank FR CSTR ASMB SOL TIRE REP EA Blank $177.26 HCPCS - Non-Drugs K0077 NU FR CSTR ASMB SOL TIRE REP EA Blank $177.26 HCPCS - Non-Drugs K0077 RR FR CSTR ASMB SOL TIRE REP EA Blank $19.77 HCPCS - Non-Drugs K0077 UE FR CSTR ASMB SOL TIRE REP EA Blank $148.38 HCPCS - Non-Drugs K0098 Blank DRIVE BELT FOR PWC, REPL Blank $112.95 HCPCS - Non-Drugs K0098 NU DRIVE BELT FOR PWC, REPL Blank $112.95 HCPCS - Non-Drugs K0098 RR DRIVE BELT FOR PWC, REPL Blank $8.78 HCPCS - Non-Drugs K0098 UE DRIVE BELT FOR PWC, REPL Blank $80.45 HCPCS - Non-Drugs K0105 Blank IV HANGER Blank $274.84 HCPCS - Non-Drugs K0105 NU IV HANGER Blank $274.84 HCPCS - Non-Drugs K0105 RR IV HANGER Blank $36.47 HCPCS - Non-Drugs K0105 UE IV HANGER Blank $221.56 HCPCS - Non-Drugs K0108 Blank W/C COMPONENT-ACCESSORY NOS Blank $71.68 HCPCS - Non-Drugs K0195 Blank ELEVATING WHLCHAIR LEG RESTS Blank $303.71 HCPCS - Non-Drugs K0195 RR ELEVATING WHLCHAIR LEG RESTS Blank $41.24 HCPCS - Non-Drugs K0455 Blank PUMP UNINTERRUPTED INFUSION Blank $4,441.81 HCPCS - Non-Drugs K0455 RR PUMP UNINTERRUPTED INFUSION Blank $603.10 HCPCS - Non-Drugs K0462 Blank TEMPORARY REPLACEMENT EQPMNT Blank $731.53 HCPCS - Non-Drugs K0552 Blank SUP/EXT NON-INS INF PUMP SYR Blank $25.36 HCPCS - Non-Drugs K0553 Blank THER CGM SUPPLY ALLOWANCE Blank $536.84 HCPCS - Non-Drugs K0554 Blank THER CGM RECEIVER/MONITOR Blank $549.29 HCPCS - Non-Drugs K0554 NU 0 Blank $549.29 HCPCS - Non-Drugs K0554 RR 0 Blank $123.10 HCPCS - Non-Drugs K0554 UE 0 Blank $430.91 HCPCS - Non-Drugs K0601 Blank REPL BATT SILVER OXIDE 1.5 V Blank $5.38 HCPCS - Non-Drugs K0601 NU REPL BATT SILVER OXIDE 1.5 V Blank $5.38 HCPCS - Non-Drugs K0602 Blank REPL BATT SILVER OXIDE 3 V Blank $26.88 HCPCS - Non-Drugs K0602 NU REPL BATT SILVER OXIDE 3 V Blank $26.88 HCPCS - Non-Drugs K0603 Blank REPL BATT ALKALINE 1.5 V Blank $2.69 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

K0603 NU REPL BATT ALKALINE 1.5 V Blank $2.69 HCPCS - Non-Drugs K0604 Blank REPL BATT LITHIUM 3.6 V Blank $26.88 HCPCS - Non-Drugs K0604 NU REPL BATT LITHIUM 3.6 V Blank $26.88 HCPCS - Non-Drugs K0605 Blank REPL BATT LITHIUM 4.5 V Blank $70.11 HCPCS - Non-Drugs K0605 NU REPL BATT LITHIUM 4.5 V Blank $70.11 HCPCS - Non-Drugs K0606 Blank AED GARMENT W ELEC ANALYSIS Blank $38,887.80 HCPCS - Non-Drugs K0606 KF AED GARMENT W ELEC ANALYSIS Blank $38,887.80 HCPCS - Non-Drugs K0606 RR AED GARMENT W ELEC ANALYSIS Blank $5,280.09 HCPCS - Non-Drugs K0607 Blank REPL BATT FOR AED Blank $854.31 HCPCS - Non-Drugs K0607 NU REPL BATT FOR AED Blank $854.31 HCPCS - Non-Drugs K0607 RR REPL BATT FOR AED Blank $116.00 HCPCS - Non-Drugs K0607 UE REPL BATT FOR AED Blank $633.37 HCPCS - Non-Drugs K0608 Blank REPL GARMENT FOR AED Blank $326.82 HCPCS - Non-Drugs K0608 NU REPL GARMENT FOR AED Blank $326.82 HCPCS - Non-Drugs K0608 RR REPL GARMENT FOR AED Blank $100.90 HCPCS - Non-Drugs K0608 UE REPL GARMENT FOR AED Blank $264.05 HCPCS - Non-Drugs K0609 Blank REPL ELECTRODE FOR AED Blank $1,745.52 HCPCS - Non-Drugs K0609 KF REPL ELECTRODE FOR AED Blank $1,745.52 HCPCS - Non-Drugs K0669 Blank SEAT/BACK CUS NO DMEPDAC VER Blank $768.38 HCPCS - Non-Drugs K0669 NU SEAT/BACK CUS NO DMEPDAC VER Blank $768.38 HCPCS - Non-Drugs K0672 Blank REMOVABLE SOFT INTERFACE LE Blank $225.95 HCPCS - Non-Drugs K0730 Blank CTRL DOSE INH DRUG DELIV SYS Blank $3,181.87 HCPCS - Non-Drugs K0730 NU CTRL DOSE INH DRUG DELIV SYS Blank $3,181.87 HCPCS - Non-Drugs K0730 RR CTRL DOSE INH DRUG DELIV SYS Blank $432.03 HCPCS - Non-Drugs K0730 UE CTRL DOSE INH DRUG DELIV SYS Blank $1,819.25 HCPCS - Non-Drugs K0733 Blank 12-24HR SEALED LEAD ACID Blank $122.16 HCPCS - Non-Drugs K0733 NU 12-24HR SEALED LEAD ACID Blank $122.16 HCPCS - Non-Drugs K0733 RR 12-24HR SEALED LEAD ACID Blank $10.36 HCPCS - Non-Drugs K0733 UE 12-24HR SEALED LEAD ACID Blank $98.54 HCPCS - Non-Drugs K0738 Blank PORTABLE GAS OXYGEN SYSTEM Blank $1,531.54 HCPCS - Non-Drugs K0738 RR STATIONARY COMPRESSED GAS 02 Blank $193.81 HCPCS - Non-Drugs K0739 Blank REPAIR/SVC DME NON-OXYGEN EQ Blank $35.39 HCPCS - Non-Drugs K0740 Blank REPAIR/SVC OXYGEN EQUIPMENT Blank $73.64 HCPCS - Non-Drugs K0743 Blank PORTABLE HOME SUCTION PUMP Blank $193.42 HCPCS - Non-Drugs K0744 Blank ABSORP DRG <= 16 SUC PUMP Blank $5.05 HCPCS - Non-Drugs K0745 Blank ABSORP DRG >16<=48 SUC PUMP Blank $6.64 HCPCS - Non-Drugs K0746 Blank ABSORP DRG >48 SUC PUMP Blank $16.41 HCPCS - Non-Drugs K0800 Blank POV GROUP 1 STD UP TO 300LBS Blank $1,873.57 HCPCS - Non-Drugs K0800 NU POV GROUP 1 STD UP TO 300LBS Blank $1,873.57 HCPCS - Non-Drugs K0800 RR POV GROUP 1 STD UP TO 300LBS Blank $242.91 HCPCS - Non-Drugs K0800 UE POV GROUP 1 STD UP TO 300LBS Blank $1,420.62 HCPCS - Non-Drugs K0801 Blank POV GROUP 1 HD 301-450 LBS Blank $3,351.45 HCPCS - Non-Drugs K0801 NU POV GROUP 1 HD 301-450 LBS Blank $3,351.45 HCPCS - Non-Drugs K0801 RR POV GROUP 1 HD 301-450 LBS Blank $390.69 HCPCS - Non-Drugs K0801 UE POV GROUP 1 HD 301-450 LBS Blank $2,529.02 HCPCS - Non-Drugs K0802 Blank POV GROUP 1 VHD 451-600 LBS Blank $4,462.00 HCPCS - Non-Drugs K0802 NU POV GROUP 1 VHD 451-600 LBS Blank $4,462.00 HCPCS - Non-Drugs K0802 RR POV GROUP 1 VHD 451-600 LBS Blank $501.75 HCPCS - Non-Drugs K0802 UE POV GROUP 1 VHD 451-600 LBS Blank $3,361.94 HCPCS - Non-Drugs K0806 Blank POV GROUP 2 STD UP TO 300LBS Blank $2,969.19 HCPCS - Non-Drugs K0806 NU POV GROUP 2 STD UP TO 300LBS Blank $2,969.19 HCPCS - Non-Drugs K0806 RR POV GROUP 2 STD UP TO 300LBS Blank $352.47 HCPCS - Non-Drugs K0806 UE POV GROUP 2 STD UP TO 300LBS Blank $2,242.31 HCPCS - Non-Drugs K0807 Blank POV GROUP 2 HD 301-450 LBS Blank $4,567.57 HCPCS - Non-Drugs K0807 NU POV GROUP 2 HD 301-450 LBS Blank $4,567.57 HCPCS - Non-Drugs K0807 RR POV GROUP 2 HD 301-450 LBS Blank $512.30 HCPCS - Non-Drugs K0807 UE POV GROUP 2 HD 301-450 LBS Blank $3,441.12 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

K0808 Blank POV GROUP 2 VHD 451-600 LBS Blank $7,027.00 HCPCS - Non-Drugs K0808 NU POV GROUP 2 VHD 451-600 LBS Blank $7,027.00 HCPCS - Non-Drugs K0808 RR POV GROUP 2 VHD 451-600 LBS Blank $758.24 HCPCS - Non-Drugs K0808 UE POV GROUP 2 VHD 451-600 LBS Blank $5,285.68 HCPCS - Non-Drugs K0812 Blank POWER OPERATED VEHICLE NOC Blank $1,021.17 HCPCS - Non-Drugs K0813 Blank PWC GP 1 STD PORT SEAT/BACK Blank $4,638.88 HCPCS - Non-Drugs K0813 RR PWC GP 1 STD PORT SEAT/BACK Blank $629.86 HCPCS - Non-Drugs K0814 Blank PWC GP 1 STD PORT CAP CHAIR Blank $4,770.85 HCPCS - Non-Drugs K0814 RR PWC GP 1 STD PORT CAP CHAIR Blank $647.77 HCPCS - Non-Drugs K0815 Blank PWC GP 1 STD SEAT/BACK Blank $5,208.04 HCPCS - Non-Drugs K0815 RR PWC GP 1 STD SEAT/BACK Blank $707.14 HCPCS - Non-Drugs K0816 Blank PWC GP 1 STD CAP CHAIR Blank $4,897.72 HCPCS - Non-Drugs K0816 RR PWC GP 1 STD CAP CHAIR Blank $665.00 HCPCS - Non-Drugs K0820 Blank PWC GP 2 STD PORT SEAT/BACK Blank $4,754.82 HCPCS - Non-Drugs K0820 RR PWC GP 2 STD PORT SEAT/BACK Blank $645.60 HCPCS - Non-Drugs K0821 Blank PWC GP 2 STD PORT CAP CHAIR Blank $4,909.31 HCPCS - Non-Drugs K0821 RR PWC GP 2 STD PORT CAP CHAIR Blank $666.57 HCPCS - Non-Drugs K0822 Blank PWC GP 2 STD SEAT/BACK Blank $5,217.91 HCPCS - Non-Drugs K0822 RR PWC GP 2 STD SEAT/BACK Blank $708.47 HCPCS - Non-Drugs K0823 Blank PWC GP 2 STD CAP CHAIR Blank $4,914.97 HCPCS - Non-Drugs K0823 RR PWC GP 2 STD CAP CHAIR Blank $667.34 HCPCS - Non-Drugs K0824 Blank PWC GP 2 HD SEAT/BACK Blank $7,334.24 HCPCS - Non-Drugs K0824 RR PWC GP 2 HD SEAT/BACK Blank $995.83 HCPCS - Non-Drugs K0825 Blank PWC GP 2 HD CAP CHAIR Blank $6,841.57 HCPCS - Non-Drugs K0825 RR PWC GP 2 HD CAP CHAIR Blank $928.93 HCPCS - Non-Drugs K0826 Blank PWC GP 2 VHD SEAT/BACK Blank $12,098.62 HCPCS - Non-Drugs K0826 RR PWC GP 2 VHD SEAT/BACK Blank $1,642.72 HCPCS - Non-Drugs K0827 Blank PWC GP VHD CAP CHAIR Blank $10,630.29 HCPCS - Non-Drugs K0827 RR PWC GP VHD CAP CHAIR Blank $1,443.36 HCPCS - Non-Drugs K0828 Blank PWC GP 2 XTRA HD SEAT/BACK Blank $14,769.59 HCPCS - Non-Drugs K0828 RR PWC GP 2 XTRA HD SEAT/BACK Blank $2,005.38 HCPCS - Non-Drugs K0829 Blank PWC GP 2 XTRA HD CAP CHAIR Blank $14,270.40 HCPCS - Non-Drugs K0829 RR PWC GP 2 XTRA HD CAP CHAIR Blank $1,937.60 HCPCS - Non-Drugs K0830 Blank PWC GP2 STD SEAT ELEVATE S/B Blank $491.09 HCPCS - Non-Drugs K0831 Blank PWC GP2 STD SEAT ELEVATE CAP Blank $1,033.08 HCPCS - Non-Drugs K0835 Blank PWC GP2 STD SING POW OPT S/B Blank $5,956.57 HCPCS - Non-Drugs K0835 RR PWC GP2 STD SING POW OPT S/B Blank $808.77 HCPCS - Non-Drugs K0836 Blank PWC GP2 STD SING POW OPT CAP Blank $6,161.32 HCPCS - Non-Drugs K0836 RR PWC GP2 STD SING POW OPT CAP Blank $836.57 HCPCS - Non-Drugs K0837 Blank PWC GP 2 HD SING POW OPT S/B Blank $7,511.57 HCPCS - Non-Drugs K0837 RR PWC GP 2 HD SING POW OPT S/B Blank $1,019.90 HCPCS - Non-Drugs K0838 Blank PWC GP 2 HD SING POW OPT CAP Blank $6,709.32 HCPCS - Non-Drugs K0838 RR PWC GP 2 HD SING POW OPT CAP Blank $910.98 HCPCS - Non-Drugs K0839 Blank PWC GP2 VHD SING POW OPT S/B Blank $9,828.67 HCPCS - Non-Drugs K0839 RR PWC GP2 VHD SING POW OPT S/B Blank $1,334.51 HCPCS - Non-Drugs K0840 Blank PWC GP2 XHD SING POW OPT S/B Blank $14,846.78 HCPCS - Non-Drugs K0840 RR PWC GP2 XHD SING POW OPT S/B Blank $2,015.86 HCPCS - Non-Drugs K0841 Blank PWC GP2 STD MULT POW OPT S/B Blank $6,654.90 HCPCS - Non-Drugs K0841 RR PWC GP2 STD MULT POW OPT S/B Blank $903.59 HCPCS - Non-Drugs K0842 Blank PWC GP2 STD MULT POW OPT CAP Blank $6,645.88 HCPCS - Non-Drugs K0842 RR PWC GP2 STD MULT POW OPT CAP Blank $902.36 HCPCS - Non-Drugs K0843 Blank PWC GP2 HD MULT POW OPT S/B Blank $7,804.35 HCPCS - Non-Drugs K0843 RR PWC GP2 HD MULT POW OPT S/B Blank $1,059.66 HCPCS - Non-Drugs K0848 Blank PWC GP 3 STD SEAT/BACK Blank $12,936.89 HCPCS - Non-Drugs K0848 RR PWC GP 3 STD SEAT/BACK Blank $1,756.54 HCPCS - Non-Drugs K0849 Blank PWC GP 3 STD CAP CHAIR Blank $12,455.53 HCPCS - Non-Drugs K0849 RR PWC GP 3 STD CAP CHAIR Blank $1,691.18 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

K0850 Blank PWC GP 3 HD SEAT/BACK Blank $14,933.55 HCPCS - Non-Drugs K0850 RR PWC GP 3 HD SEAT/BACK Blank $2,027.64 HCPCS - Non-Drugs K0851 Blank PWC GP 3 HD CAP CHAIR Blank $14,376.20 HCPCS - Non-Drugs K0851 RR PWC GP 3 HD CAP CHAIR Blank $1,951.97 HCPCS - Non-Drugs K0852 Blank PWC GP 3 VHD SEAT/BACK Blank $17,184.10 HCPCS - Non-Drugs K0852 RR PWC GP 3 VHD SEAT/BACK Blank $2,333.22 HCPCS - Non-Drugs K0853 Blank PWC GP 3 VHD CAP CHAIR Blank $17,640.02 HCPCS - Non-Drugs K0853 RR PWC GP 3 VHD CAP CHAIR Blank $2,395.12 HCPCS - Non-Drugs K0854 Blank PWC GP 3 XHD SEAT/BACK Blank $23,221.51 HCPCS - Non-Drugs K0854 RR PWC GP 3 XHD SEAT/BACK Blank $3,152.96 HCPCS - Non-Drugs K0855 Blank PWC GP 3 XHD CAP CHAIR Blank $21,961.41 HCPCS - Non-Drugs K0855 RR PWC GP 3 XHD CAP CHAIR Blank $2,981.87 HCPCS - Non-Drugs K0856 Blank PWC GP3 STD SING POW OPT S/B Blank $13,852.83 HCPCS - Non-Drugs K0856 RR PWC GP3 STD SING POW OPT S/B Blank $1,880.90 HCPCS - Non-Drugs K0857 Blank PWC GP3 STD SING POW OPT CAP Blank $14,121.49 HCPCS - Non-Drugs K0857 RR PWC GP3 STD SING POW OPT CAP Blank $1,917.38 HCPCS - Non-Drugs K0858 Blank PWC GP3 HD SING POW OPT S/B Blank $17,078.08 HCPCS - Non-Drugs K0858 RR PWC GP3 HD SING POW OPT S/B Blank $2,318.82 HCPCS - Non-Drugs K0859 Blank PWC GP3 HD SING POW OPT CAP Blank $16,308.19 HCPCS - Non-Drugs K0859 RR PWC GP3 HD SING POW OPT CAP Blank $2,214.29 HCPCS - Non-Drugs K0860 Blank PWC GP3 VHD SING POW OPT S/B Blank $24,203.27 HCPCS - Non-Drugs K0860 RR PWC GP3 VHD SING POW OPT S/B Blank $3,286.26 HCPCS - Non-Drugs K0861 Blank PWC GP3 STD MULT POW OPT S/B Blank $13,874.33 HCPCS - Non-Drugs K0861 RR PWC GP3 STD MULT POW OPT S/B Blank $1,883.82 HCPCS - Non-Drugs K0862 Blank PWC GP3 HD MULT POW OPT S/B Blank $17,078.08 HCPCS - Non-Drugs K0862 RR PWC GP3 HD MULT POW OPT S/B Blank $2,318.82 HCPCS - Non-Drugs K0863 Blank PWC GP3 VHD MULT POW OPT S/B Blank $24,203.27 HCPCS - Non-Drugs K0863 RR PWC GP3 VHD MULT POW OPT S/B Blank $3,286.26 HCPCS - Non-Drugs K0864 Blank PWC GP3 XHD MULT POW OPT S/B Blank $28,715.69 HCPCS - Non-Drugs K0864 RR PWC GP3 XHD MULT POW OPT S/B Blank $3,898.95 HCPCS - Non-Drugs K0868 Blank PWC GP 4 STD SEAT/BACK Blank $759.95 HCPCS - Non-Drugs K0869 Blank PWC GP 4 STD CAP CHAIR Blank $2,725.16 HCPCS - Non-Drugs K0870 Blank PWC GP 4 HD SEAT/BACK Blank $1,906.81 HCPCS - Non-Drugs K0871 Blank PWC GP 4 VHD SEAT/BACK Blank $7,458.25 HCPCS - Non-Drugs K0877 Blank PWC GP4 STD SING POW OPT S/B Blank $901.53 HCPCS - Non-Drugs K0878 Blank PWC GP4 STD SING POW OPT CAP Blank $1,964.47 HCPCS - Non-Drugs K0879 Blank PWC GP4 HD SING POW OPT S/B Blank $2,376.15 HCPCS - Non-Drugs K0880 Blank PWC GP4 VHD SING POW OPT S/B Blank $2,543.10 HCPCS - Non-Drugs K0884 Blank PWC GP4 STD MULT POW OPT S/B Blank $1,208.23 HCPCS - Non-Drugs K0885 Blank PWC GP4 STD MULT POW OPT CAP Blank $3,629.30 HCPCS - Non-Drugs K0886 Blank PWC GP4 HD MULT POW S/B Blank $3,039.02 HCPCS - Non-Drugs K0890 Blank PWC GP5 PED SING POW OPT S/B Blank $2,321.32 HCPCS - Non-Drugs K0891 Blank PWC GP5 PED MULT POW OPT S/B Blank $1,470.98 HCPCS - Non-Drugs K0898 Blank POWER WHEELCHAIR NOC Blank $1,206.98 HCPCS - Non-Drugs K0899 Blank POW MOBIL DEV NO DMEPDAC Blank $2,152.80 HCPCS - Non-Drugs L0112 Blank CRANIAL CERVICAL ORTHOSIS Blank $2,270.25 HCPCS - Non-Drugs L0113 Blank CRANIAL CERVICAL TORTICOLLIS Blank $449.05 HCPCS - Non-Drugs L0120 Blank CERV FLEX N/ADJ FOAM PRE OTS Blank $32.08 HCPCS - Non-Drugs L0130 Blank FLEX THERMOPLASTIC COLLAR MO Blank $276.62 HCPCS - Non-Drugs L0140 Blank CERVICAL SEMI-RIGID ADJUSTAB Blank $89.98 HCPCS - Non-Drugs L0150 Blank CERV SEMI-RIG ADJ MOLDED CHN Blank $172.29 HCPCS - Non-Drugs L0160 Blank CERV SR WIRE OCC/MAN PRE OTS Blank $253.91 HCPCS - Non-Drugs L0170 Blank CERVICAL COLLAR MOLDED TO PT Blank $1,140.78 HCPCS - Non-Drugs L0172 Blank CERV COL SR FOAM 2PC PRE OTS Blank $207.86 HCPCS - Non-Drugs L0174 Blank CERV SR 2PC THOR EXT PRE OTS Blank $444.02 HCPCS - Non-Drugs L0180 Blank CER POST COL OCC/MAN SUP ADJ Blank $634.66 HCPCS - Non-Drugs L0190 Blank CERV COLLAR SUPP ADJ CERV BA Blank $855.96 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L0200 Blank CERV COL SUPP ADJ BAR & THOR Blank $896.52 HCPCS - Non-Drugs L0220 Blank THOR RIB BELT CUSTOM FABRICA Blank $192.24 HCPCS - Non-Drugs L0450 Blank TLSO FLEX TRUNK/THOR PRE OTS Blank $286.95 HCPCS - Non-Drugs L0452 Blank TLSO FLEX CUSTOM FAB THORACI Blank $422.27 HCPCS - Non-Drugs L0454 Blank TLSO TRNK SJ-T9 PRE CST Blank $549.14 HCPCS - Non-Drugs L0455 Blank TLSO FLEX TRNK SJ-T9 PRE OTS Blank $549.14 HCPCS - Non-Drugs L0456 Blank TLSO FLEX TRNK SJ-SS PRE CST Blank $1,608.09 HCPCS - Non-Drugs L0457 Blank TLSO FLEX TRNK SJ-SS PRE OTS Blank $1,608.09 HCPCS - Non-Drugs L0458 Blank TLSO 2MOD SYMPHIS-XIPHO PRE Blank $1,440.13 HCPCS - Non-Drugs L0460 Blank TLSO 2 SHL SYMPHYS-STERN CST Blank $1,623.21 HCPCS - Non-Drugs L0462 Blank TLSO 3MOD SACRO-SCAP PRE Blank $2,023.35 HCPCS - Non-Drugs L0464 Blank TLSO 4MOD SACRO-SCAP PRE Blank $2,412.17 HCPCS - Non-Drugs L0466 Blank TLSO R FRAM SOFT ANT PRE CST Blank $627.90 HCPCS - Non-Drugs L0467 Blank TLSO R FRAM SOFT PRE OTS Blank $627.90 HCPCS - Non-Drugs L0468 Blank TLSO RIG FRAM PELVIC PRE CST Blank $794.43 HCPCS - Non-Drugs L0469 Blank TLSO RIG FRAM PELVIC PRE OTS Blank $794.43 HCPCS - Non-Drugs L0470 Blank TLSO RIGID FRAME PRE SUBCLAV Blank $1,092.57 HCPCS - Non-Drugs L0472 Blank TLSO RIGID FRAME HYPEREX PRE Blank $705.12 HCPCS - Non-Drugs L0480 Blank TLSO RIGID PLASTIC CUSTOM FA Blank $2,418.35 HCPCS - Non-Drugs L0482 Blank TLSO RIGID LINED CUSTOM FAB Blank $2,662.63 HCPCS - Non-Drugs L0484 Blank TLSO RIGID PLASTIC CUST FAB Blank $2,963.34 HCPCS - Non-Drugs L0486 Blank TLSO RIGIDLINED CUST FAB TWO Blank $3,161.75 HCPCS - Non-Drugs L0488 Blank TLSO RIGID LINED PRE ONE PIE Blank $1,623.21 HCPCS - Non-Drugs L0490 Blank TLSO RIGID PLASTIC PRE ONE Blank $445.14 HCPCS - Non-Drugs L0491 Blank TLSO 2 PIECE RIGID SHELL Blank $1,237.67 HCPCS - Non-Drugs L0492 Blank TLSO 3 PIECE RIGID SHELL Blank $804.92 HCPCS - Non-Drugs L0621 Blank SIO FLEX PELVIC/SACR PRE OTS Blank $140.84 HCPCS - Non-Drugs L0622 Blank SIO FLEX PELVISACRAL CUSTOM Blank $428.14 HCPCS - Non-Drugs L0623 Blank SIO RIG PNL PELV/SAC PRE OTS Blank $62.48 HCPCS - Non-Drugs L0624 Blank SIO PANEL CUSTOM Blank $116.47 HCPCS - Non-Drugs L0625 Blank LO FLEX L1-BELOW L5 PRE OTS Blank $72.22 HCPCS - Non-Drugs L0626 Blank LO SAG RIG PNL STAYS PRE CST Blank $109.59 HCPCS - Non-Drugs L0627 Blank LO SAG RI AN/POS PNL PRE CST Blank $654.20 HCPCS - Non-Drugs L0628 Blank LSO FLEX NO RI STAYS PRE OTS Blank $119.30 HCPCS - Non-Drugs L0629 Blank LSO FLEX W/RIGID STAYS CUST Blank $133.15 HCPCS - Non-Drugs L0630 Blank LSO R POST PNL SJ-T9 PRE CST Blank $246.93 HCPCS - Non-Drugs L0631 Blank LSO SAG R AN/POS PNL PRE CST Blank $1,660.52 HCPCS - Non-Drugs L0632 Blank LSO SAG RIGID FRAME CUST Blank $2,413.10 HCPCS - Non-Drugs L0633 Blank LSO SC R POS/LAT PNL PRE CST Blank $450.98 HCPCS - Non-Drugs L0634 Blank LSO FLEXION CONTROL CUSTOM Blank $678.45 HCPCS - Non-Drugs L0635 Blank LSO SAGIT RIGID PANEL PREFAB Blank $1,672.93 HCPCS - Non-Drugs L0636 Blank LSO SAGITTAL RIGID PANEL CUS Blank $2,436.73 HCPCS - Non-Drugs L0637 Blank LSO SC R ANT/POS PNL PRE CST Blank $1,971.17 HCPCS - Non-Drugs L0638 Blank LSO SAG-CORONAL PANEL CUSTOM Blank $2,138.30 HCPCS - Non-Drugs L0639 Blank LSO S/C SHELL/PANEL PREFAB Blank $1,971.17 HCPCS - Non-Drugs L0640 Blank LSO S/C SHELL/PANEL CUSTOM Blank $1,692.80 HCPCS - Non-Drugs L0641 Blank LO RIG POS PNL L1-L5 PRE OTS Blank $109.59 HCPCS - Non-Drugs L0642 Blank LO SAG RI AN/POS PNL PRE OTS Blank $654.20 HCPCS - Non-Drugs L0643 Blank LSO SAG CTR RIGI POS PRE OTS Blank $246.93 HCPCS - Non-Drugs L0648 Blank LSO SAG R AN/POS PNL PRE OTS Blank $1,660.52 HCPCS - Non-Drugs L0649 Blank LSO SC R POS/LAT PNL PRE OTS Blank $450.98 HCPCS - Non-Drugs L0650 Blank LSO SC R ANT/POS PNL PRE OTS Blank $1,971.17 HCPCS - Non-Drugs L0651 Blank LSO SAG-CO SHELL PNL PRE OTS Blank $1,971.17 HCPCS - Non-Drugs L0700 Blank CTLSO A-P-L CONTROL MOLDED Blank $3,435.85 HCPCS - Non-Drugs L0710 Blank CTLSO A-P-L CONTROL W/ INTER Blank $3,639.24 HCPCS - Non-Drugs L0810 Blank HALO CERVICAL INTO JCKT VEST Blank $4,392.40 HCPCS - Non-Drugs L0820 Blank HALO CERVICAL INTO BODY JACK Blank $3,608.40 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L0830 Blank HALO CERV INTO MILWAUKEE TYP Blank $5,374.30 HCPCS - Non-Drugs L0859 Blank MRI COMPATIBLE SYSTEM Blank $1,986.74 HCPCS - Non-Drugs L0861 Blank HALO REPL LINER/INTERFACE Blank $334.51 HCPCS - Non-Drugs L0970 Blank TLSO CORSET FRONT Blank $178.56 HCPCS - Non-Drugs L0972 Blank LSO CORSET FRONT Blank $163.60 HCPCS - Non-Drugs L0974 Blank TLSO FULL CORSET Blank $297.84 HCPCS - Non-Drugs L0976 Blank LSO FULL CORSET Blank $256.17 HCPCS - Non-Drugs L0978 Blank AXILLARY CRUTCH EXTENSION Blank $307.20 HCPCS - Non-Drugs L0980 Blank PERONEAL STRAPS PAIR PRE OTS Blank $21.40 HCPCS - Non-Drugs L0982 Blank STOCKING SUP GRIPS 4 PRE OTS Blank $20.42 HCPCS - Non-Drugs L0984 Blank PROTECT BODY SOCK EA PRE OTS Blank $84.42 HCPCS - Non-Drugs L0999 Blank ADD TO SPINAL ORTHOSIS NOS Blank $163.60 HCPCS - Non-Drugs L1000 Blank CTLSO MILWAUKE INITIAL MODEL Blank $3,447.86 HCPCS - Non-Drugs L1001 Blank CTLSO INFANT IMMOBILIZER Blank $70.63 HCPCS - Non-Drugs L1005 Blank TENSION BASED SCOLIOSIS ORTH Blank $5,214.55 HCPCS - Non-Drugs L1010 Blank CTLSO AXILLA SLING Blank $100.76 HCPCS - Non-Drugs L1020 Blank KYPHOSIS PAD Blank $142.41 HCPCS - Non-Drugs L1025 Blank KYPHOSIS PAD FLOATING Blank $207.97 HCPCS - Non-Drugs L1030 Blank LUMBAR BOLSTER PAD Blank $96.48 HCPCS - Non-Drugs L1040 Blank LUMBAR OR LUMBAR RIB PAD Blank $123.79 HCPCS - Non-Drugs L1050 Blank STERNAL PAD Blank $132.43 HCPCS - Non-Drugs L1060 Blank THORACIC PAD Blank $149.97 HCPCS - Non-Drugs L1070 Blank TRAPEZIUS SLING Blank $145.69 HCPCS - Non-Drugs L1080 Blank OUTRIGGER Blank $77.05 HCPCS - Non-Drugs L1085 Blank OUTRIGGER BIL W/ VERT EXTENS Blank $261.32 HCPCS - Non-Drugs L1090 Blank LUMBAR SLING Blank $142.59 HCPCS - Non-Drugs L1100 Blank RING FLANGE PLASTIC/LEATHER Blank $263.79 HCPCS - Non-Drugs L1110 Blank RING FLANGE PLAS/LEATHER MOL Blank $433.38 HCPCS - Non-Drugs L1120 Blank COVERS FOR UPRIGHT EACH Blank $50.73 HCPCS - Non-Drugs L1200 Blank FURNSH INITIAL ORTHOSIS ONLY Blank $2,800.73 HCPCS - Non-Drugs L1210 Blank LATERAL THORACIC EXTENSION Blank $428.67 HCPCS - Non-Drugs L1220 Blank ANTERIOR THORACIC EXTENSION Blank $380.77 HCPCS - Non-Drugs L1230 Blank MILWAUKEE TYPE SUPERSTRUCTUR Blank $960.18 HCPCS - Non-Drugs L1240 Blank LUMBAR DEROTATION PAD Blank $122.53 HCPCS - Non-Drugs L1250 Blank ANTERIOR ASIS PAD Blank $110.86 HCPCS - Non-Drugs L1260 Blank ANTERIOR THORACIC DEROTATION Blank $119.17 HCPCS - Non-Drugs L1270 Blank ABDOMINAL PAD Blank $119.61 HCPCS - Non-Drugs L1280 Blank RIB GUSSET (ELASTIC) EACH Blank $130.29 HCPCS - Non-Drugs L1290 Blank LATERAL TROCHANTERIC PAD Blank $118.75 HCPCS - Non-Drugs L1300 Blank BODY JACKET MOLD TO PATIENT Blank $2,941.28 HCPCS - Non-Drugs L1310 Blank POST-OPERATIVE BODY JACKET Blank $2,960.71 HCPCS - Non-Drugs L1499 Blank SPINAL ORTHOSIS NOS Blank $2,964.25 HCPCS - Non-Drugs L1600 Blank HO FLEX FREJKA W/COV PRE CST Blank $204.54 HCPCS - Non-Drugs L1610 Blank HO FREJKA COV ONLY PRE CST Blank $60.58 HCPCS - Non-Drugs L1620 Blank HO FLEX PAVLIK HARNS PRE CST Blank $216.54 HCPCS - Non-Drugs L1630 Blank ABDUCT CONTROL HIP SEMI-FLEX Blank $267.58 HCPCS - Non-Drugs L1640 Blank PELV BAND/SPREAD BAR THIGH C Blank $767.26 HCPCS - Non-Drugs L1650 Blank HO ABDUCTION HIP ADJUSTABLE Blank $373.40 HCPCS - Non-Drugs L1652 Blank HO BI THIGHCUFFS W SPRDR BAR Blank $564.91 HCPCS - Non-Drugs L1660 Blank HO ABDUCTION STATIC PLASTIC Blank $265.72 HCPCS - Non-Drugs L1680 Blank PELVIC & HIP CONTROL THIGH C Blank $2,109.85 HCPCS - Non-Drugs L1685 Blank POST-OP HIP ABDUCT CUSTOM FA Blank $2,045.20 HCPCS - Non-Drugs L1686 Blank HO POST-OP HIP ABDUCTION Blank $1,608.52 HCPCS - Non-Drugs L1690 Blank COMBINATION BILATERAL HO Blank $3,147.08 HCPCS - Non-Drugs L1700 Blank LEG PERTHES ORTH TORONTO TYP Blank $2,643.55 HCPCS - Non-Drugs L1710 Blank LEGG PERTHES ORTH NEWINGTON Blank $3,179.94 HCPCS - Non-Drugs L1720 Blank LEGG PERTHES ORTHOSIS TRILAT Blank $2,315.39 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L1730 Blank LEGG PERTHES ORTH SCOTTISH R Blank $1,943.08 HCPCS - Non-Drugs L1755 Blank LEGG PERTHES PATTEN BOTTOM T Blank $2,732.25 HCPCS - Non-Drugs L1810 Blank KO ELASTIC WITH JOINTS Blank $158.67 HCPCS - Non-Drugs L1812 Blank KO ELASTIC W/JOINTS PRE OTS Blank $158.67 HCPCS - Non-Drugs L1820 Blank KO ELAS W/ CONDYLE PADS & JO Blank $206.72 HCPCS - Non-Drugs L1830 Blank KO IMMOB CANVAS LONG PRE OTS Blank $136.72 HCPCS - Non-Drugs L1831 Blank KNEE ORTH POS LOCKING JOINT Blank $463.30 HCPCS - Non-Drugs L1832 Blank KO ADJ JNT POS R SUP PRE CST Blank $1,110.13 HCPCS - Non-Drugs L1833 Blank KO ADJ JNT POS R SUP PRE OTS Blank $1,110.13 HCPCS - Non-Drugs L1834 Blank KO W/0 JOINT RIGID MOLDED TO Blank $1,333.32 HCPCS - Non-Drugs L1836 Blank KO RIGID W/O JOINTS PRE OTS Blank $200.29 HCPCS - Non-Drugs L1840 Blank KO DEROT ANT CRUCIATE CUSTOM Blank $1,615.10 HCPCS - Non-Drugs L1843 Blank KO SINGLE UPRIGHT PRE CST Blank $1,448.99 HCPCS - Non-Drugs L1844 Blank KO W/ADJ JT ROT CNTRL MOLDED Blank $2,702.16 HCPCS - Non-Drugs L1845 Blank KO DOUBLE UPRIGHT PRE CST Blank $1,402.16 HCPCS - Non-Drugs L1846 Blank KO W ADJ FLEX/EXT ROTAT MOLD Blank $1,958.79 HCPCS - Non-Drugs L1847 Blank KO DBL UPRIGHT W/AIR PRE CST Blank $923.53 HCPCS - Non-Drugs L1848 Blank KO DBL UPRIGHT W/AIR PRE OTS Blank $923.53 HCPCS - Non-Drugs L1850 Blank KO SWEDISH TYPE PRE OTS Blank $480.73 HCPCS - Non-Drugs L1851 Blank KO SINGLE UPRIGHT PREFAB OTS Blank $1,448.99 HCPCS - Non-Drugs L1852 Blank KO DOUBLE UPRIGHT PREFAB OTS Blank $1,402.16 HCPCS - Non-Drugs L1860 Blank KO SUPRACONDYLAR SOCKET MOLD Blank $1,883.65 HCPCS - Non-Drugs L1900 Blank AFO SPRNG WIR DRSFLX CALF BD Blank $447.56 HCPCS - Non-Drugs L1902 Blank AFO ANKLE GAUNTLET PRE OTS Blank $121.31 HCPCS - Non-Drugs L1904 Blank AFO MOLDED ANKLE GAUNTLET Blank $777.06 HCPCS - Non-Drugs L1906 Blank AFO MULTILIG ANK SUP PRE OTS Blank $186.75 HCPCS - Non-Drugs L1907 Blank AFO SUPRAMALLEOLAR CUSTOM Blank $902.04 HCPCS - Non-Drugs L1910 Blank AFO SING BAR CLASP ATTACH SH Blank $453.49 HCPCS - Non-Drugs L1920 Blank AFO SING UPRIGHT W/ ADJUST S Blank $577.05 HCPCS - Non-Drugs L1930 Blank AFO PLASTIC Blank $397.99 HCPCS - Non-Drugs L1932 Blank AFO RIG ANT TIB PREFAB TCF/= Blank $1,440.98 HCPCS - Non-Drugs L1940 Blank AFO MOLDED TO PATIENT PLASTI Blank $855.56 HCPCS - Non-Drugs L1945 Blank AFO MOLDED PLAS RIG ANT TIB Blank $1,633.45 HCPCS - Non-Drugs L1950 Blank AFO SPIRAL MOLDED TO PT PLAS Blank $1,291.98 HCPCS - Non-Drugs L1951 Blank AFO SPIRAL PREFABRICATED Blank $1,355.10 HCPCS - Non-Drugs L1960 Blank AFO POS SOLID ANK PLASTIC MO Blank $966.90 HCPCS - Non-Drugs L1970 Blank AFO PLASTIC MOLDED W/ANKLE J Blank $1,201.54 HCPCS - Non-Drugs L1971 Blank AFO W/ANKLE JOINT, PREFAB Blank $748.43 HCPCS - Non-Drugs L1980 Blank AFO SING SOLID STIRRUP CALF Blank $622.57 HCPCS - Non-Drugs L1990 Blank AFO DOUB SOLID STIRRUP CALF Blank $771.58 HCPCS - Non-Drugs L2000 Blank KAFO SING FRE STIRR THI/CALF Blank $1,738.16 HCPCS - Non-Drugs L2005 Blank KAFO SNG/DBL MECHANICAL ACT Blank $6,681.58 HCPCS - Non-Drugs L2010 Blank KAFO SNG SOLID STIRRUP W/O J Blank $1,592.63 HCPCS - Non-Drugs L2020 Blank KAFO DBL SOLID STIRRUP BAND/ Blank $1,967.82 HCPCS - Non-Drugs L2030 Blank KAFO DBL SOLID STIRRUP W/O J Blank $1,764.21 HCPCS - Non-Drugs L2034 Blank KAFO PLA SIN UP W/WO K/A CUS Blank $3,333.18 HCPCS - Non-Drugs L2035 Blank KAFO PLASTIC PEDIATRIC SIZE Blank $266.78 HCPCS - Non-Drugs L2036 Blank KAFO PLAS DOUB FREE KNEE MOL Blank $3,190.99 HCPCS - Non-Drugs L2037 Blank KAFO PLAS SING FREE KNEE MOL Blank $2,889.02 HCPCS - Non-Drugs L2038 Blank KAFO W/O JOINT MULTI-AXIS AN Blank $2,406.89 HCPCS - Non-Drugs L2040 Blank HKAFO TORSION BIL ROT STRAPS Blank $281.82 HCPCS - Non-Drugs L2050 Blank HKAFO TORSION CABLE HIP PELV Blank $805.43 HCPCS - Non-Drugs L2060 Blank HKAFO TORSION BALL BEARING J Blank $992.68 HCPCS - Non-Drugs L2070 Blank HKAFO TORSION UNILAT ROT STR Blank $218.60 HCPCS - Non-Drugs L2080 Blank HKAFO UNILAT TORSION CABLE Blank $606.09 HCPCS - Non-Drugs L2090 Blank HKAFO UNILAT TORSION BALL BR Blank $749.84 HCPCS - Non-Drugs L2106 Blank AFO TIB FX CAST PLASTER MOLD Blank $1,205.18 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L2108 Blank AFO TIB FX CAST MOLDED TO PT Blank $1,830.35 HCPCS - Non-Drugs L2112 Blank AFO TIBIAL FRACTURE SOFT Blank $815.72 HCPCS - Non-Drugs L2114 Blank AFO TIB FX SEMI-RIGID Blank $1,021.70 HCPCS - Non-Drugs L2116 Blank AFO TIBIAL FRACTURE RIGID Blank $1,248.51 HCPCS - Non-Drugs L2126 Blank KAFO FEM FX CAST THERMOPLAS Blank $2,062.00 HCPCS - Non-Drugs L2128 Blank KAFO FEM FX CAST MOLDED TO P Blank $2,872.85 HCPCS - Non-Drugs L2132 Blank KAFO FEMORAL FX CAST SOFT Blank $1,400.73 HCPCS - Non-Drugs L2134 Blank KAFO FEM FX CAST SEMI-RIGID Blank $1,739.72 HCPCS - Non-Drugs L2136 Blank KAFO FEMORAL FX CAST RIGID Blank $2,077.06 HCPCS - Non-Drugs L2180 Blank PLAS SHOE INSERT W ANK JOINT Blank $189.36 HCPCS - Non-Drugs L2182 Blank DROP LOCK KNEE Blank $144.14 HCPCS - Non-Drugs L2184 Blank LIMITED MOTION KNEE JOINT Blank $191.34 HCPCS - Non-Drugs L2186 Blank ADJ MOTION KNEE JNT LERMAN T Blank $237.48 HCPCS - Non-Drugs L2188 Blank QUADRILATERAL BRIM Blank $506.94 HCPCS - Non-Drugs L2190 Blank WAIST BELT Blank $128.90 HCPCS - Non-Drugs L2192 Blank PELVIC BAND & BELT THIGH FLA Blank $601.20 HCPCS - Non-Drugs L2200 Blank LIMITED ANKLE MOTION EA JNT Blank $66.60 HCPCS - Non-Drugs L2210 Blank DORSIFLEXION ASSIST EACH JOI Blank $96.92 HCPCS - Non-Drugs L2220 Blank DORSI & PLANTAR FLEX ASS/RES Blank $123.60 HCPCS - Non-Drugs L2230 Blank SPLIT FLAT CALIPER STIRR & P Blank $115.66 HCPCS - Non-Drugs L2232 Blank ROCKER BOTTOM, CONTACT AFO Blank $142.15 HCPCS - Non-Drugs L2240 Blank ROUND CALIPER AND PLATE ATTA Blank $125.35 HCPCS - Non-Drugs L2250 Blank FOOT PLATE MOLDED STIRRUP AT Blank $580.47 HCPCS - Non-Drugs L2260 Blank REINFORCED SOLID STIRRUP Blank $331.74 HCPCS - Non-Drugs L2265 Blank LONG TONGUE STIRRUP Blank $192.02 HCPCS - Non-Drugs L2270 Blank VARUS/VALGUS STRAP PADDED/LI Blank $76.67 HCPCS - Non-Drugs L2275 Blank PLASTIC MOD LOW EXT PAD/LINE Blank $196.52 HCPCS - Non-Drugs L2280 Blank MOLDED INNER BOOT Blank $780.93 HCPCS - Non-Drugs L2300 Blank ABDUCTION BAR JOINTED ADJUST Blank $454.75 HCPCS - Non-Drugs L2310 Blank ABDUCTION BAR-STRAIGHT Blank $195.44 HCPCS - Non-Drugs L2320 Blank NON-MOLDED LACER Blank $336.05 HCPCS - Non-Drugs L2330 Blank LACER MOLDED TO PATIENT MODE Blank $660.27 HCPCS - Non-Drugs L2335 Blank ANTERIOR SWING BAND Blank $386.99 HCPCS - Non-Drugs L2340 Blank PRE-TIBIAL SHELL MOLDED TO P Blank $788.51 HCPCS - Non-Drugs L2350 Blank PROSTHETIC TYPE SOCKET MOLDE Blank $1,528.51 HCPCS - Non-Drugs L2360 Blank EXTENDED STEEL SHANK Blank $74.61 HCPCS - Non-Drugs L2370 Blank PATTEN BOTTOM Blank $462.13 HCPCS - Non-Drugs L2375 Blank TORSION ANK & HALF SOLID STI Blank $182.17 HCPCS - Non-Drugs L2380 Blank TORSION STRAIGHT KNEE JOINT Blank $196.61 HCPCS - Non-Drugs L2385 Blank STRAIGHT KNEE JOINT HEAVY DU Blank $216.37 HCPCS - Non-Drugs L2387 Blank ADD LE POLY KNEE CUSTOM KAFO Blank $273.77 HCPCS - Non-Drugs L2390 Blank OFFSET KNEE JOINT EACH Blank $165.23 HCPCS - Non-Drugs L2395 Blank OFFSET KNEE JOINT HEAVY DUTY Blank $249.19 HCPCS - Non-Drugs L2397 Blank SUSPENSION SLEEVE LOWER EXT Blank $174.02 HCPCS - Non-Drugs L2405 Blank KNEE JOINT DROP LOCK EA JNT Blank $124.67 HCPCS - Non-Drugs L2415 Blank KNEE JOINT CAM LOCK EACH JOI Blank $180.74 HCPCS - Non-Drugs L2425 Blank KNEE DISC/DIAL LOCK/ADJ FLEX Blank $216.49 HCPCS - Non-Drugs L2430 Blank KNEE JNT RATCHET LOCK EA JNT Blank $216.49 HCPCS - Non-Drugs L2492 Blank KNEE LIFT LOOP DROP LOCK RIN Blank $161.27 HCPCS - Non-Drugs L2500 Blank THI/GLUT/ISCHIA WGT BEARING Blank $517.14 HCPCS - Non-Drugs L2510 Blank TH/WGHT BEAR QUAD-LAT BRIM M Blank $1,292.70 HCPCS - Non-Drugs L2520 Blank TH/WGHT BEAR QUAD-LAT BRIM C Blank $806.64 HCPCS - Non-Drugs L2525 Blank TH/WGHT BEAR NAR M-L BRIM MO Blank $2,129.68 HCPCS - Non-Drugs L2526 Blank TH/WGHT BEAR NAR M-L BRIM CU Blank $1,196.47 HCPCS - Non-Drugs L2530 Blank THIGH/WGHT BEAR LACER NON-MO Blank $390.29 HCPCS - Non-Drugs L2540 Blank THIGH/WGHT BEAR LACER MOLDED Blank $711.89 HCPCS - Non-Drugs L2550 Blank THIGH/WGHT BEAR HIGH ROLL CU Blank $480.92 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L2570 Blank HIP CLEVIS TYPE 2 POSIT JNT Blank $841.14 HCPCS - Non-Drugs L2580 Blank PELVIC CONTROL PELVIC SLING Blank $804.28 HCPCS - Non-Drugs L2600 Blank HIP CLEVIS/THRUST BEARING FR Blank $343.75 HCPCS - Non-Drugs L2610 Blank HIP CLEVIS/THRUST BEARING LO Blank $405.93 HCPCS - Non-Drugs L2620 Blank PELVIC CONTROL HIP HEAVY DUT Blank $455.15 HCPCS - Non-Drugs L2622 Blank HIP JOINT ADJUSTABLE FLEXION Blank $520.24 HCPCS - Non-Drugs L2624 Blank HIP ADJ FLEX EXT ABDUCT CONT Blank $579.40 HCPCS - Non-Drugs L2627 Blank PLASTIC MOLD RECIPRO HIP & C Blank $2,903.17 HCPCS - Non-Drugs L2628 Blank METAL FRAME RECIPRO HIP & CA Blank $2,832.55 HCPCS - Non-Drugs L2630 Blank PELVIC CONTROL BAND & BELT U Blank $418.05 HCPCS - Non-Drugs L2640 Blank PELVIC CONTROL BAND & BELT B Blank $573.92 HCPCS - Non-Drugs L2650 Blank PELV & THOR CONTROL GLUTEAL Blank $189.03 HCPCS - Non-Drugs L2660 Blank THORACIC CONTROL THORACIC BA Blank $298.83 HCPCS - Non-Drugs L2670 Blank THORAC CONT PARASPINAL UPRIG Blank $272.48 HCPCS - Non-Drugs L2680 Blank THORAC CONT LAT SUPPORT UPRI Blank $250.35 HCPCS - Non-Drugs L2750 Blank PLATING CHROME/NICKEL PR BAR Blank $120.52 HCPCS - Non-Drugs L2755 Blank CARBON GRAPHITE LAMINATION Blank $195.84 HCPCS - Non-Drugs L2760 Blank EXTENSION PER EXTENSION PER Blank $87.90 HCPCS - Non-Drugs L2768 Blank ORTHO SIDEBAR DISCONNECT Blank $195.15 HCPCS - Non-Drugs L2780 Blank NON-CORROSIVE FINISH Blank $97.52 HCPCS - Non-Drugs L2785 Blank DROP LOCK RETAINER EACH Blank $38.35 HCPCS - Non-Drugs L2795 Blank KNEE CONTROL FULL KNEECAP Blank $127.85 HCPCS - Non-Drugs L2800 Blank KNEE CAP MEDIAL OR LATERAL P Blank $163.23 HCPCS - Non-Drugs L2810 Blank KNEE CONTROL CONDYLAR PAD Blank $118.81 HCPCS - Non-Drugs L2820 Blank SOFT INTERFACE BELOW KNEE SE Blank $134.06 HCPCS - Non-Drugs L2830 Blank SOFT INTERFACE ABOVE KNEE SE Blank $147.64 HCPCS - Non-Drugs L2840 Blank TIBIAL LENGTH SOCK FX OR EQU Blank $59.16 HCPCS - Non-Drugs L2850 Blank FEMORAL LGTH SOCK FX OR EQUA Blank $86.55 HCPCS - Non-Drugs L2861 Blank TORSION MECHANISM KNEE/ANKLE Blank $451.01 HCPCS - Non-Drugs L2999 Blank LOWER EXTREMITY ORTHOSIS NOS Blank $127.85 HCPCS - Non-Drugs L3000 Blank FT INSERT UCB BERKELEY SHELL Blank $495.70 HCPCS - Non-Drugs L3001 Blank FOOT INSERT REMOV MOLDED SPE Blank $198.38 HCPCS - Non-Drugs L3002 Blank FOOT INSERT PLASTAZOTE OR EQ Blank $246.18 HCPCS - Non-Drugs L3003 Blank FOOT INSERT SILICONE GEL EAC Blank $267.02 HCPCS - Non-Drugs L3010 Blank FOOT LONGITUDINAL ARCH SUPPO Blank $267.02 HCPCS - Non-Drugs L3020 Blank FOOT LONGITUD/METATARSAL SUP Blank $306.50 HCPCS - Non-Drugs L3030 Blank FOOT ARCH SUPPORT REMOV PREM Blank $106.92 HCPCS - Non-Drugs L3031 Blank FOOT LAMIN/PREPREG COMPOSITE Blank $182.68 HCPCS - Non-Drugs L3040 Blank FT ARCH SUPRT PREMOLD LONGIT Blank $59.09 HCPCS - Non-Drugs L3050 Blank FOOT ARCH SUPP PREMOLD METAT Blank $59.09 HCPCS - Non-Drugs L3060 Blank FOOT ARCH SUPP LONGITUD/META Blank $102.72 HCPCS - Non-Drugs L3070 Blank ARCH SUPRT ATT TO SHO LONGIT Blank $35.56 HCPCS - Non-Drugs L3080 Blank ARCH SUPP ATT TO SHOE METATA Blank $35.56 HCPCS - Non-Drugs L3090 Blank ARCH SUPP ATT TO SHOE LONG/M Blank $48.70 HCPCS - Non-Drugs L3100 Blank HALLUS-VALGUS NT DYN PRE OTS Blank $52.83 HCPCS - Non-Drugs L3140 Blank ABDUCTION ROTATION BAR SHOE Blank $127.71 HCPCS - Non-Drugs L3150 Blank ABDUCT ROTATION BAR W/O SHOE Blank $115.23 HCPCS - Non-Drugs L3160 Blank SHOE STYLED POSITIONING DEV Blank $27.60 HCPCS - Non-Drugs L3170 Blank FOOT PLAS HEEL STABI PRE OTS Blank $65.34 HCPCS - Non-Drugs L3201 Blank OXFORD W SUPINAT/PRONAT INF Blank $55.89 HCPCS - Non-Drugs L3202 Blank OXFORD W/ SUPINAT/PRONATOR C Blank $54.50 HCPCS - Non-Drugs L3203 Blank OXFORD W/ SUPINATOR/PRONATOR Blank $52.41 HCPCS - Non-Drugs L3204 Blank HIGHTOP W/ SUPP/PRONATOR INF Blank $52.41 HCPCS - Non-Drugs L3206 Blank HIGHTOP W/ SUPP/PRONATOR CHI Blank $55.19 HCPCS - Non-Drugs L3207 Blank HIGHTOP W/ SUPP/PRONATOR JUN Blank $56.59 HCPCS - Non-Drugs L3208 Blank SURGICAL BOOT EACH INFANT Blank $27.38 HCPCS - Non-Drugs L3209 Blank SURGICAL BOOT EACH CHILD Blank $37.88 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L3211 Blank SURGICAL BOOT EACH JUNIOR Blank $41.28 HCPCS - Non-Drugs L3212 Blank BENESCH BOOT PAIR INFANT Blank $64.24 HCPCS - Non-Drugs L3213 Blank BENESCH BOOT PAIR CHILD Blank $81.63 HCPCS - Non-Drugs L3214 Blank BENESCH BOOT PAIR JUNIOR Blank $87.89 HCPCS - Non-Drugs L3215 Blank ORTHOPEDIC FTWEAR LADIES OXF Blank $116.41 HCPCS - Non-Drugs L3216 Blank ORTHOPED LADIES SHOES DPTH I Blank $144.93 HCPCS - Non-Drugs L3217 Blank LADIES SHOES HIGHTOP DEPTH I Blank $158.15 HCPCS - Non-Drugs L3219 Blank ORTHOPEDIC MENS SHOES OXFORD Blank $133.10 HCPCS - Non-Drugs L3221 Blank ORTHOPEDIC MENS SHOES DPTH I Blank $163.01 HCPCS - Non-Drugs L3222 Blank MENS SHOES HIGHTOP DEPTH INL Blank $182.49 HCPCS - Non-Drugs L3224 Blank WOMAN'S SHOE OXFORD BRACE Blank $86.53 HCPCS - Non-Drugs L3225 Blank MAN'S SHOE OXFORD BRACE Blank $100.38 HCPCS - Non-Drugs L3230 Blank CUSTOM SHOES DEPTH INLAY Blank $217.97 HCPCS - Non-Drugs L3250 Blank CUSTOM MOLD SHOE REMOV PROST Blank $440.56 HCPCS - Non-Drugs L3251 Blank SHOE MOLDED TO PT SILICONE S Blank $45.46 HCPCS - Non-Drugs L3252 Blank SHOE MOLDED PLASTAZOTE CUST Blank $233.27 HCPCS - Non-Drugs L3253 Blank SHOE MOLDED PLASTAZOTE CUST Blank $44.76 HCPCS - Non-Drugs L3254 Blank ORTH FOOT NON-STNDARD SIZE/W Blank $27.47 HCPCS - Non-Drugs L3255 Blank ORTH FOOT NON-STANDARD SIZE/ Blank $101.76 HCPCS - Non-Drugs L3257 Blank ORTH FOOT ADD CHARGE SPLIT S Blank $31.32 HCPCS - Non-Drugs L3260 Blank AMBULATORY SURGICAL BOOT EAC Blank $19.06 HCPCS - Non-Drugs L3265 Blank PLASTAZOTE SANDAL EACH Blank $20.37 HCPCS - Non-Drugs L3300 Blank SHO LIFT TAPER TO METATARSAL Blank $67.39 HCPCS - Non-Drugs L3310 Blank SHOE LIFT ELEV HEEL/SOLE NEO Blank $115.23 HCPCS - Non-Drugs L3320 Blank SHOE LIFT ELEV HEEL/SOLE COR Blank $151.88 HCPCS - Non-Drugs L3330 Blank LIFTS ELEVATION METAL EXTENS Blank $907.36 HCPCS - Non-Drugs L3332 Blank SHOE LIFTS TAPERED TO ONE-HA Blank $102.72 HCPCS - Non-Drugs L3334 Blank SHOE LIFTS ELEVATION HEEL /I Blank $44.54 HCPCS - Non-Drugs L3340 Blank SHOE WEDGE SACH Blank $121.49 HCPCS - Non-Drugs L3350 Blank SHOE HEEL WEDGE Blank $26.41 HCPCS - Non-Drugs L3360 Blank SHOE SOLE WEDGE OUTSIDE SOLE Blank $40.36 HCPCS - Non-Drugs L3370 Blank SHOE SOLE WEDGE BETWEEN SOLE Blank $63.22 HCPCS - Non-Drugs L3380 Blank SHOE CLUBFOOT WEDGE Blank $63.22 HCPCS - Non-Drugs L3390 Blank SHOE OUTFLARE WEDGE Blank $63.22 HCPCS - Non-Drugs L3400 Blank SHOE METATARSAL BAR WEDGE RO Blank $48.70 HCPCS - Non-Drugs L3410 Blank SHOE METATARSAL BAR BETWEEN Blank $133.94 HCPCS - Non-Drugs L3420 Blank FULL SOLE/HEEL WEDGE BTWEEN Blank $71.56 HCPCS - Non-Drugs L3430 Blank SHO HEEL COUNT PLAST REINFOR Blank $244.13 HCPCS - Non-Drugs L3440 Blank HEEL LEATHER REINFORCED Blank $106.92 HCPCS - Non-Drugs L3450 Blank SHOE HEEL SACH CUSHION TYPE Blank $154.71 HCPCS - Non-Drugs L3455 Blank SHOE HEEL NEW LEATHER STANDA Blank $48.70 HCPCS - Non-Drugs L3460 Blank SHOE HEEL NEW RUBBER STANDAR Blank $38.27 HCPCS - Non-Drugs L3465 Blank SHOE HEEL THOMAS WITH WEDGE Blank $77.80 HCPCS - Non-Drugs L3470 Blank SHOE HEEL THOMAS EXTEND TO B Blank $84.02 HCPCS - Non-Drugs L3480 Blank SHOE HEEL PAD & DEPRESS FOR Blank $84.02 HCPCS - Non-Drugs L3485 Blank SHOE HEEL PAD REMOVABLE FOR Blank $19.06 HCPCS - Non-Drugs L3500 Blank ORTHO SHOE ADD LEATHER INSOL Blank $32.96 HCPCS - Non-Drugs L3510 Blank ORTHOPEDIC SHOE ADD RUB INSL Blank $32.96 HCPCS - Non-Drugs L3520 Blank O SHOE ADD FELT W LEATH INSL Blank $35.56 HCPCS - Non-Drugs L3530 Blank ORTHO SHOE ADD HALF SOLE Blank $35.56 HCPCS - Non-Drugs L3540 Blank ORTHO SHOE ADD FULL SOLE Blank $65.34 HCPCS - Non-Drugs L3550 Blank O SHOE ADD STANDARD TOE TAP Blank $12.03 HCPCS - Non-Drugs L3560 Blank O SHOE ADD HORSESHOE TOE TAP Blank $26.41 HCPCS - Non-Drugs L3570 Blank O SHOE ADD INSTEP EXTENSION Blank $121.49 HCPCS - Non-Drugs L3580 Blank O SHOE ADD INSTEP VELCRO CLO Blank $88.19 HCPCS - Non-Drugs L3590 Blank O SHOE CONVERT TO SOF COUNTE Blank $69.48 HCPCS - Non-Drugs L3595 Blank ORTHO SHOE ADD MARCH BAR Blank $50.74 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L3600 Blank TRANS SHOE CALIP PLATE EXIST Blank $106.92 HCPCS - Non-Drugs L3610 Blank TRANS SHOE CALIPER PLATE NEW Blank $146.40 HCPCS - Non-Drugs L3620 Blank TRANS SHOE SOLID STIRRUP EXI Blank $106.92 HCPCS - Non-Drugs L3630 Blank TRANS SHOE SOLID STIRRUP NEW Blank $146.40 HCPCS - Non-Drugs L3640 Blank SHOE DENNIS BROWNE SPLINT BO Blank $52.83 HCPCS - Non-Drugs L3649 Blank ORTHOPEDIC SHOE MODIFICA NOS Blank $114.15 HCPCS - Non-Drugs L3650 Blank SO 8 ABD RESTRAINT PRE OTS Blank $85.46 HCPCS - Non-Drugs L3660 Blank SO 8 AB RSTR CAN/WEB PRE OTS Blank $147.57 HCPCS - Non-Drugs L3670 Blank SO ACRO/CLAV CAN WEB PRE OTS Blank $180.53 HCPCS - Non-Drugs L3671 Blank SO CAP DESIGN W/O JNTS CF Blank $1,322.77 HCPCS - Non-Drugs L3674 Blank SO AIRPLANE W/WO JOINT CF Blank $1,740.81 HCPCS - Non-Drugs L3675 Blank SO VEST CANVAS/WEB PRE OTS Blank $243.56 HCPCS - Non-Drugs L3677 Blank SO HARD PLAS STABILI PRE CST Blank $167.88 HCPCS - Non-Drugs L3678 Blank SO HARD PLAS STABILI PRE OTS Blank $146.81 HCPCS - Non-Drugs L3702 Blank EO W/O JOINTS CF Blank $411.77 HCPCS - Non-Drugs L3710 Blank EO ELAS W/METAL JNTS PRE OTS Blank $193.75 HCPCS - Non-Drugs L3720 Blank FOREARM/ARM CUFFS FREE MOTIO Blank $1,110.05 HCPCS - Non-Drugs L3730 Blank FOREARM/ARM CUFFS EXT/FLEX A Blank $1,537.22 HCPCS - Non-Drugs L3740 Blank CUFFS ADJ LOCK W/ ACTIVE CON Blank $1,815.66 HCPCS - Non-Drugs L3760 Blank EO ADJ JT PREFAB CUSTOM FIT Blank $727.05 HCPCS - Non-Drugs L3762 Blank EO RIGID W/O JOINTS PRE OTS Blank $142.14 HCPCS - Non-Drugs L3763 Blank EWHO RIGID W/O JNTS CF Blank $1,102.60 HCPCS - Non-Drugs L3764 Blank EWHO W/JOINT(S) CF Blank $1,237.95 HCPCS - Non-Drugs L3765 Blank EWHFO RIGID W/O JNTS CF Blank $1,889.89 HCPCS - Non-Drugs L3766 Blank EWHFO W/JOINT(S) CF Blank $2,002.31 HCPCS - Non-Drugs L3806 Blank WHFO W/JOINT(S) CUSTOM FAB Blank $657.98 HCPCS - Non-Drugs L3807 Blank WHFO W/O JOINTS PRE CST Blank $354.61 HCPCS - Non-Drugs L3808 Blank WHFO, RIGID W/O JOINTS Blank $539.23 HCPCS - Non-Drugs L3809 Blank WHFO W/O JOINTS PRE OTS Blank $354.61 HCPCS - Non-Drugs L3891 Blank TORSION MECHANISM WRIST/ELBO Blank $429.89 HCPCS - Non-Drugs L3900 Blank HINGE EXTENSION/FLEX WRIST/F Blank $2,201.71 HCPCS - Non-Drugs L3901 Blank HINGE EXT/FLEX WRIST FINGER Blank $2,721.30 HCPCS - Non-Drugs L3904 Blank WHFO ELECTRIC CUSTOM FITTED Blank $4,983.18 HCPCS - Non-Drugs L3905 Blank WHO W/NONTORSION JNT(S) CF Blank $1,457.62 HCPCS - Non-Drugs L3906 Blank WHO W/O JOINTS CF Blank $656.76 HCPCS - Non-Drugs L3908 Blank WHO COCK-UP NONMOLDE PRE OTS Blank $86.80 HCPCS - Non-Drugs L3912 Blank HFO FLEXION GLOVE PRE OTS Blank $147.06 HCPCS - Non-Drugs L3913 Blank HFO W/O JOINTS CF Blank $385.12 HCPCS - Non-Drugs L3915 Blank WHO NONTORSION JNTS PRE CST Blank $773.03 HCPCS - Non-Drugs L3916 Blank WHO NONTORSION JNTS PRE OTS Blank $773.03 HCPCS - Non-Drugs L3917 Blank METACARP FX ORTHOSIS PRE CST Blank $139.33 HCPCS - Non-Drugs L3918 Blank METACARP FX ORTHOSIS PRE OTS Blank $139.33 HCPCS - Non-Drugs L3919 Blank HO W/O JOINTS CF Blank $385.12 HCPCS - Non-Drugs L3921 Blank HFO W/JOINT(S) CF Blank $460.04 HCPCS - Non-Drugs L3923 Blank HFO WITHOUT JOINTS PRE CST Blank $118.62 HCPCS - Non-Drugs L3924 Blank HFO WITHOUT JOINTS PRE OTS Blank $118.62 HCPCS - Non-Drugs L3925 Blank FO PIP DIP JNT/SPRNG PRE OTS Blank $67.62 HCPCS - Non-Drugs L3927 Blank FO PIP DIP NO JT SPR PRE OTS Blank $35.61 HCPCS - Non-Drugs L3929 Blank HFO NONTORSION JNTS PRE CST Blank $117.77 HCPCS - Non-Drugs L3930 Blank HFO NONTORSION JNTS PRE OTS Blank $117.77 HCPCS - Non-Drugs L3931 Blank WHFO NONTORSION JOINT PREFAB Blank $291.38 HCPCS - Non-Drugs L3933 Blank FO W/O JOINTS CF Blank $299.60 HCPCS - Non-Drugs L3935 Blank FO NONTORSION JOINT CF Blank $310.86 HCPCS - Non-Drugs L3956 Blank ADD JOINT UPPER EXT ORTHOSIS Blank $107.76 HCPCS - Non-Drugs L3960 Blank SEWHO AIRPLAN DESIG ABDU POS Blank $1,240.49 HCPCS - Non-Drugs L3961 Blank SEWHO CAP DESIGN W/O JNTS CF Blank $2,481.85 HCPCS - Non-Drugs L3962 Blank SEWHO ERBS PALSEY DESIGN ABD Blank $1,192.59 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L3967 Blank SEWHO AIRPLANE W/O JNTS CF Blank $2,933.45 HCPCS - Non-Drugs L3971 Blank SEWHO CAP DESIGN W/JNT(S) CF Blank $2,783.61 HCPCS - Non-Drugs L3973 Blank SEWHO AIRPLANE W/JNT(S) CF Blank $2,933.45 HCPCS - Non-Drugs L3975 Blank SEWHFO CAP DESIGN W/O JNT CF Blank $2,481.85 HCPCS - Non-Drugs L3976 Blank SEWHFO AIRPLANE W/O JNTS CF Blank $2,481.85 HCPCS - Non-Drugs L3977 Blank SEWHFO CAP DESGN W/JNT(S) CF Blank $2,783.61 HCPCS - Non-Drugs L3978 Blank SEWHFO AIRPLANE W/JNT(S) CF Blank $2,933.45 HCPCS - Non-Drugs L3980 Blank UP EXT FX ORTHOS HUMERAL NOS Blank $536.68 HCPCS - Non-Drugs L3981 Blank UE FX ORTH SHOUL CAP FOREARM Blank $1,479.84 HCPCS - Non-Drugs L3982 Blank UPPER EXT FX ORTHOSIS RAD/UL Blank $628.12 HCPCS - Non-Drugs L3984 Blank UPPER EXT FX ORTHOSIS WRIST Blank $564.93 HCPCS - Non-Drugs L3995 Blank SOCK FRACTURE OR EQUAL EACH Blank $40.27 HCPCS - Non-Drugs L3999 Blank UPPER LIMB ORTHOSIS NOS Blank $40.27 HCPCS - Non-Drugs L4000 Blank REPL GIRDLE MILWAUKEE ORTH Blank $2,168.20 HCPCS - Non-Drugs L4002 Blank REPLACE STRAP, ANY ORTHOSIS Blank $40.70 HCPCS - Non-Drugs L4010 Blank REPLACE TRILATERAL SOCKET BR Blank $1,180.50 HCPCS - Non-Drugs L4020 Blank REPLACE QUADLAT SOCKET BRIM Blank $1,531.39 HCPCS - Non-Drugs L4030 Blank REPLACE SOCKET BRIM CUST FIT Blank $912.08 HCPCS - Non-Drugs L4040 Blank REPLACE MOLDED THIGH LACER Blank $696.97 HCPCS - Non-Drugs L4045 Blank REPLACE NON-MOLDED THIGH LAC Blank $529.77 HCPCS - Non-Drugs L4050 Blank REPLACE MOLDED CALF LACER Blank $706.37 HCPCS - Non-Drugs L4055 Blank REPLACE NON-MOLDED CALF LACE Blank $429.88 HCPCS - Non-Drugs L4060 Blank REPLACE HIGH ROLL CUFF Blank $518.15 HCPCS - Non-Drugs L4070 Blank REPLACE PROX & DIST UPRIGHT Blank $471.03 HCPCS - Non-Drugs L4080 Blank REPL MET BAND KAFO-AFO PROX Blank $152.16 HCPCS - Non-Drugs L4090 Blank REPL MET BAND KAFO-AFO CALF/ Blank $139.59 HCPCS - Non-Drugs L4100 Blank REPL LEATH CUFF KAFO PROX TH Blank $165.55 HCPCS - Non-Drugs L4110 Blank REPL LEATH CUFF KAFO-AFO CAL Blank $130.60 HCPCS - Non-Drugs L4130 Blank REPLACE PRETIBIAL SHELL Blank $850.62 HCPCS - Non-Drugs L4205 Blank ORTHO DVC REPAIR PER 15 MIN Blank $47.51 HCPCS - Non-Drugs L4210 Blank ORTH DEV REPAIR/REPL MINOR P Blank $40.70 HCPCS - Non-Drugs L4350 Blank ANKLE CONTROL ORTHO PRE OTS Blank $139.14 HCPCS - Non-Drugs L4360 Blank PNEUMAT WALKING BOOT PRE CST Blank $445.00 HCPCS - Non-Drugs L4361 Blank PNEUMA/VAC WALK BOOT PRE OTS Blank $445.00 HCPCS - Non-Drugs L4370 Blank PNEUM FULL LEG SPLNT PRE OTS Blank $300.13 HCPCS - Non-Drugs L4386 Blank NON-PNEUM WALK BOOT PRE CST Blank $241.35 HCPCS - Non-Drugs L4387 Blank NON-PNEUM WALK BOOT PRE OTS Blank $241.35 HCPCS - Non-Drugs L4392 Blank REPLACE AFO SOFT INTERFACE Blank $27.02 HCPCS - Non-Drugs L4394 Blank REPLACE FOOT DROP SPINT Blank $20.49 HCPCS - Non-Drugs L4396 Blank STATIC OR DYNAMI AFO PRE CST Blank $255.88 HCPCS - Non-Drugs L4397 Blank STATIC OR DYNAMI AFO PRE OTS Blank $255.88 HCPCS - Non-Drugs L4398 Blank FOOT DROP SPLINT PRE OTS Blank $108.17 HCPCS - Non-Drugs L4631 Blank AFO, WALK BOOT TYPE, CUS FAB Blank $2,594.07 HCPCS - Non-Drugs L5000 Blank SHO INSERT W ARCH TOE FILLER Blank $913.17 HCPCS - Non-Drugs L5010 Blank MOLD SOCKET ANK HGT W/ TOE F Blank $2,265.63 HCPCS - Non-Drugs L5020 Blank TIBIAL TUBERCLE HGT W/ TOE F Blank $3,708.30 HCPCS - Non-Drugs L5050 Blank ANK SYMES MOLD SCKT SACH FT Blank $4,233.34 HCPCS - Non-Drugs L5060 Blank SYMES MET FR LEATH SOCKET AR Blank $5,235.27 HCPCS - Non-Drugs L5100 Blank MOLDED SOCKET SHIN SACH FOOT Blank $4,279.82 HCPCS - Non-Drugs L5105 Blank PLAST SOCKET JTS/THGH LACER Blank $6,422.02 HCPCS - Non-Drugs L5150 Blank MOLD SCKT EXT KNEE SHIN SACH Blank $6,596.96 HCPCS - Non-Drugs L5160 Blank MOLD SOCKET BENT KNEE SHIN S Blank $7,145.91 HCPCS - Non-Drugs L5200 Blank KNE SING AXIS FRIC SHIN SACH Blank $6,057.97 HCPCS - Non-Drugs L5210 Blank NO KNEE/ANKLE JOINTS W/ FT B Blank $4,560.36 HCPCS - Non-Drugs L5220 Blank NO KNEE JOINT WITH ARTIC ALI Blank $5,187.51 HCPCS - Non-Drugs L5230 Blank FEM FOCAL DEFIC CONSTANT FRI Blank $7,079.23 HCPCS - Non-Drugs L5250 Blank HIP CANAD SING AXI CONS FRIC Blank $9,551.42 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L5270 Blank TILT TABLE LOCKING HIP SING Blank $9,510.46 HCPCS - Non-Drugs L5280 Blank HEMIPELVECT CANAD SING AXIS Blank $9,686.33 HCPCS - Non-Drugs L5301 Blank BK MOLD SOCKET SACH FT ENDO Blank $4,385.39 HCPCS - Non-Drugs L5312 Blank KNEE DISART, SACH FT, ENDO Blank $6,241.09 HCPCS - Non-Drugs L5321 Blank AK OPEN END SACH Blank $6,208.51 HCPCS - Non-Drugs L5331 Blank HIP DISART CANADIAN SACH FT Blank $8,691.96 HCPCS - Non-Drugs L5341 Blank HEMIPELVECTOMY CANADIAN SACH Blank $9,365.66 HCPCS - Non-Drugs L5400 Blank POSTOP DRESS & 1 CAST CHG BK Blank $2,272.84 HCPCS - Non-Drugs L5410 Blank POSTOP DSG BK EA ADD CAST CH Blank $730.89 HCPCS - Non-Drugs L5420 Blank POSTOP DSG & 1 CAST CHG AK/D Blank $2,885.90 HCPCS - Non-Drugs L5430 Blank POSTOP DSG AK EA ADD CAST CH Blank $935.22 HCPCS - Non-Drugs L5450 Blank POSTOP APP NON-WGT BEAR DSG Blank $717.95 HCPCS - Non-Drugs L5460 Blank POSTOP APP NON-WGT BEAR DSG Blank $959.41 HCPCS - Non-Drugs L5500 Blank INIT BK PTB PLASTER DIRECT Blank $2,360.43 HCPCS - Non-Drugs L5505 Blank INIT AK ISCHAL PLSTR DIRECT Blank $3,293.53 HCPCS - Non-Drugs L5510 Blank PREP BK PTB PLASTER MOLDED Blank $2,674.76 HCPCS - Non-Drugs L5520 Blank PERP BK PTB THERMOPLS DIRECT Blank $2,729.46 HCPCS - Non-Drugs L5530 Blank PREP BK PTB THERMOPLS MOLDED Blank $3,179.71 HCPCS - Non-Drugs L5535 Blank PREP BK PTB OPEN END SOCKET Blank $3,190.26 HCPCS - Non-Drugs L5540 Blank PREP BK PTB LAMINATED SOCKET Blank $3,358.60 HCPCS - Non-Drugs L5560 Blank PREP AK ISCHIAL PLAST MOLDED Blank $3,653.13 HCPCS - Non-Drugs L5570 Blank PREP AK ISCHIAL DIRECT FORM Blank $3,739.55 HCPCS - Non-Drugs L5580 Blank PREP AK ISCHIAL THERMO MOLD Blank $4,363.34 HCPCS - Non-Drugs L5585 Blank PREP AK ISCHIAL OPEN END Blank $4,699.45 HCPCS - Non-Drugs L5590 Blank PREP AK ISCHIAL LAMINATED Blank $4,526.74 HCPCS - Non-Drugs L5595 Blank HIP DISARTIC SACH THERMOPLS Blank $7,436.10 HCPCS - Non-Drugs L5600 Blank HIP DISART SACH LAMINAT MOLD Blank $8,267.94 HCPCS - Non-Drugs L5610 Blank ABOVE KNEE HYDRACADENCE Blank $3,843.15 HCPCS - Non-Drugs L5611 Blank AK 4 BAR LINK W/FRIC SWING Blank $2,822.01 HCPCS - Non-Drugs L5613 Blank AK 4 BAR LING W/HYDRAUL SWIG Blank $4,373.77 HCPCS - Non-Drugs L5614 Blank 4-BAR LINK ABOVE KNEE W/SWNG Blank $2,747.18 HCPCS - Non-Drugs L5616 Blank AK UNIV MULTIPLEX SYS FRICT Blank $2,402.10 HCPCS - Non-Drugs L5617 Blank AK/BK SELF-ALIGNING UNIT EA Blank $902.51 HCPCS - Non-Drugs L5618 Blank TEST SOCKET SYMES Blank $487.96 HCPCS - Non-Drugs L5620 Blank TEST SOCKET BELOW KNEE Blank $484.94 HCPCS - Non-Drugs L5622 Blank TEST SOCKET KNEE DISARTICULA Blank $667.19 HCPCS - Non-Drugs L5624 Blank TEST SOCKET ABOVE KNEE Blank $656.07 HCPCS - Non-Drugs L5626 Blank TEST SOCKET HIP DISARTICULAT Blank $878.98 HCPCS - Non-Drugs L5628 Blank TEST SOCKET HEMIPELVECTOMY Blank $881.83 HCPCS - Non-Drugs L5629 Blank BELOW KNEE ACRYLIC SOCKET Blank $565.64 HCPCS - Non-Drugs L5630 Blank SYME TYP EXPANDABL WALL SCKT Blank $805.03 HCPCS - Non-Drugs L5631 Blank AK/KNEE DISARTIC ACRYLIC SOC Blank $785.99 HCPCS - Non-Drugs L5632 Blank SYMES TYPE PTB BRIM DESIGN S Blank $383.31 HCPCS - Non-Drugs L5634 Blank SYMES TYPE POSTER OPENING SO Blank $539.75 HCPCS - Non-Drugs L5636 Blank SYMES TYPE MEDIAL OPENING SO Blank $425.96 HCPCS - Non-Drugs L5637 Blank BELOW KNEE TOTAL CONTACT Blank $563.98 HCPCS - Non-Drugs L5638 Blank BELOW KNEE LEATHER SOCKET Blank $897.67 HCPCS - Non-Drugs L5639 Blank BELOW KNEE WOOD SOCKET Blank $2,066.10 HCPCS - Non-Drugs L5640 Blank KNEE DISARTICULAT LEATHER SO Blank $1,153.14 HCPCS - Non-Drugs L5642 Blank ABOVE KNEE LEATHER SOCKET Blank $1,056.85 HCPCS - Non-Drugs L5643 Blank HIP FLEX INNER SOCKET EXT FR Blank $2,760.29 HCPCS - Non-Drugs L5644 Blank ABOVE KNEE WOOD SOCKET Blank $1,003.02 HCPCS - Non-Drugs L5645 Blank BK FLEX INNER SOCKET EXT FRA Blank $1,388.75 HCPCS - Non-Drugs L5646 Blank BELOW KNEE CUSHION SOCKET Blank $963.74 HCPCS - Non-Drugs L5647 Blank BELOW KNEE SUCTION SOCKET Blank $1,411.63 HCPCS - Non-Drugs L5648 Blank ABOVE KNEE CUSHION SOCKET Blank $1,132.62 HCPCS - Non-Drugs L5649 Blank ISCH CONTAINMT/NARROW M-L SO Blank $3,550.68 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L5650 Blank TOT CONTACT AK/KNEE DISART S Blank $893.50 HCPCS - Non-Drugs L5651 Blank AK FLEX INNER SOCKET EXT FRA Blank $2,146.99 HCPCS - Non-Drugs L5652 Blank SUCTION SUSP AK/KNEE DISART Blank $740.27 HCPCS - Non-Drugs L5653 Blank KNEE DISART EXPAND WALL SOCK Blank $1,031.69 HCPCS - Non-Drugs L5654 Blank SOCKET INSERT SYMES Blank $593.40 HCPCS - Non-Drugs L5655 Blank SOCKET INSERT BELOW KNEE Blank $493.06 HCPCS - Non-Drugs L5656 Blank SOCKET INSERT KNEE ARTICULAT Blank $679.59 HCPCS - Non-Drugs L5658 Blank SOCKET INSERT ABOVE KNEE Blank $644.67 HCPCS - Non-Drugs L5661 Blank MULTI-DUROMETER SYMES Blank $1,060.45 HCPCS - Non-Drugs L5665 Blank MULTI-DUROMETER BELOW KNEE Blank $919.28 HCPCS - Non-Drugs L5666 Blank BELOW KNEE CUFF SUSPENSION Blank $113.94 HCPCS - Non-Drugs L5668 Blank BK MOLDED DISTAL CUSHION Blank $174.45 HCPCS - Non-Drugs L5670 Blank BK MOLDED SUPRACONDYLAR SUSP Blank $482.87 HCPCS - Non-Drugs L5671 Blank BK/AK LOCKING MECHANISM Blank $923.91 HCPCS - Non-Drugs L5672 Blank BK REMOVABLE MEDIAL BRIM SUS Blank $514.13 HCPCS - Non-Drugs L5673 Blank SOCKET INSERT W LOCK MECH Blank $1,197.30 HCPCS - Non-Drugs L5676 Blank BK KNEE JOINTS SINGLE AXIS P Blank $655.32 HCPCS - Non-Drugs L5677 Blank BK KNEE JOINTS POLYCENTRIC P Blank $898.46 HCPCS - Non-Drugs L5678 Blank BK JOINT COVERS PAIR Blank $54.87 HCPCS - Non-Drugs L5679 Blank SOCKET INSERT W/O LOCK MECH Blank $994.75 HCPCS - Non-Drugs L5680 Blank BK THIGH LACER NON-MOLDED Blank $530.06 HCPCS - Non-Drugs L5681 Blank INTL CUSTM CONG/LATYP INSERT Blank $2,136.91 HCPCS - Non-Drugs L5682 Blank BK THIGH LACER GLUT/ISCHIA M Blank $1,088.95 HCPCS - Non-Drugs L5683 Blank INITIAL CUSTOM SOCKET INSERT Blank $2,136.91 HCPCS - Non-Drugs L5684 Blank BK FORK STRAP Blank $69.06 HCPCS - Non-Drugs L5685 Blank BELOW KNEE SUS/SEAL SLEEVE Blank $191.96 HCPCS - Non-Drugs L5686 Blank BK BACK CHECK Blank $77.91 HCPCS - Non-Drugs L5688 Blank BK WAIST BELT WEBBING Blank $96.99 HCPCS - Non-Drugs L5690 Blank BK WAIST BELT PADDED AND LIN Blank $167.80 HCPCS - Non-Drugs L5692 Blank AK PELVIC CONTROL BELT LIGHT Blank $226.72 HCPCS - Non-Drugs L5694 Blank AK PELVIC CONTROL BELT PAD/L Blank $318.37 HCPCS - Non-Drugs L5695 Blank AK SLEEVE SUSP NEOPRENE/EQUA Blank $287.92 HCPCS - Non-Drugs L5696 Blank AK/KNEE DISARTIC PELVIC JOIN Blank $327.40 HCPCS - Non-Drugs L5697 Blank AK/KNEE DISARTIC PELVIC BAND Blank $129.34 HCPCS - Non-Drugs L5698 Blank AK/KNEE DISARTIC SILESIAN BA Blank $186.31 HCPCS - Non-Drugs L5699 Blank SHOULDER HARNESS Blank $332.48 HCPCS - Non-Drugs L5700 Blank REPLACE SOCKET BELOW KNEE Blank $5,032.39 HCPCS - Non-Drugs L5701 Blank REPLACE SOCKET ABOVE KNEE Blank $6,184.38 HCPCS - Non-Drugs L5702 Blank REPLACE SOCKET HIP Blank $7,903.68 HCPCS - Non-Drugs L5703 Blank SYMES ANKLE W/O (SACH) FOOT Blank $3,889.07 HCPCS - Non-Drugs L5704 Blank CUSTOM SHAPE COVER BK Blank $939.87 HCPCS - Non-Drugs L5705 Blank CUSTOM SHAPE COVER AK Blank $1,673.24 HCPCS - Non-Drugs L5706 Blank CUSTOM SHAPE CVR KNEE DISART Blank $1,641.01 HCPCS - Non-Drugs L5707 Blank CUSTOM SHAPE CVR HIP DISART Blank $2,229.63 HCPCS - Non-Drugs L5710 Blank KNE-SHIN EXO SNG AXI MNL LOC Blank $647.11 HCPCS - Non-Drugs L5711 Blank KNEE-SHIN EXO MNL LOCK ULTRA Blank $942.86 HCPCS - Non-Drugs L5712 Blank KNEE-SHIN EXO FRICT SWG & ST Blank $786.00 HCPCS - Non-Drugs L5714 Blank KNEE-SHIN EXO VARIABLE FRICT Blank $734.34 HCPCS - Non-Drugs L5716 Blank KNEE-SHIN EXO MECH STANCE PH Blank $1,328.45 HCPCS - Non-Drugs L5718 Blank KNEE-SHIN EXO FRCT SWG & STA Blank $1,603.70 HCPCS - Non-Drugs L5722 Blank KNEE-SHIN PNEUM SWG FRCT EXO Blank $1,632.07 HCPCS - Non-Drugs L5724 Blank KNEE-SHIN EXO FLUID SWING PH Blank $2,850.43 HCPCS - Non-Drugs L5726 Blank KNEE-SHIN EXT JNTS FLD SWG E Blank $3,207.24 HCPCS - Non-Drugs L5728 Blank KNEE-SHIN FLUID SWG & STANCE Blank $4,299.52 HCPCS - Non-Drugs L5780 Blank KNEE-SHIN PNEUM/HYDRA PNEUM Blank $2,081.82 HCPCS - Non-Drugs L5781 Blank LOWER LIMB PROS VACUUM PUMP Blank $6,536.02 HCPCS - Non-Drugs L5782 Blank HD LOW LIMB PROS VACUUM PUMP Blank $6,891.41 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L5785 Blank EXOSKELETAL BK ULTRALT MATER Blank $914.84 HCPCS - Non-Drugs L5790 Blank EXOSKELETAL AK ULTRA-LIGHT M Blank $1,287.99 HCPCS - Non-Drugs L5795 Blank EXOSKEL HIP ULTRA-LIGHT MATE Blank $1,972.73 HCPCS - Non-Drugs L5810 Blank ENDOSKEL KNEE-SHIN MNL LOCK Blank $881.25 HCPCS - Non-Drugs L5811 Blank ENDO KNEE-SHIN MNL LCK ULTRA Blank $1,316.37 HCPCS - Non-Drugs L5812 Blank ENDO KNEE-SHIN FRCT SWG & ST Blank $1,007.32 HCPCS - Non-Drugs L5814 Blank ENDO KNEE-SHIN HYDRAL SWG PH Blank $6,067.61 HCPCS - Non-Drugs L5816 Blank ENDO KNEE-SHIN POLYC MCH STA Blank $1,496.80 HCPCS - Non-Drugs L5818 Blank ENDO KNEE-SHIN FRCT SWG & ST Blank $1,714.04 HCPCS - Non-Drugs L5822 Blank ENDO KNEE-SHIN PNEUM SWG FRC Blank $2,918.71 HCPCS - Non-Drugs L5824 Blank ENDO KNEE-SHIN FLUID SWING P Blank $2,839.64 HCPCS - Non-Drugs L5826 Blank MINIATURE KNEE JOINT Blank $5,123.20 HCPCS - Non-Drugs L5828 Blank ENDO KNEE-SHIN FLUID SWG/STA Blank $5,108.82 HCPCS - Non-Drugs L5830 Blank ENDO KNEE-SHIN PNEUM/SWG PHA Blank $3,474.62 HCPCS - Non-Drugs L5840 Blank MULTI-AXIAL KNEE/SHIN SYSTEM Blank $6,145.48 HCPCS - Non-Drugs L5845 Blank KNEE-SHIN SYS STANCE FLEXION Blank $2,918.04 HCPCS - Non-Drugs L5848 Blank KNEE-SHIN SYS HYDRAUL STANCE Blank $1,743.51 HCPCS - Non-Drugs L5850 Blank ENDO AK/HIP KNEE EXTENS ASSI Blank $204.49 HCPCS - Non-Drugs L5855 Blank MECH HIP EXTENSION ASSIST Blank $555.25 HCPCS - Non-Drugs L5856 Blank ELEC KNEE-SHIN SWING/STANCE Blank $39,341.05 HCPCS - Non-Drugs L5857 Blank ELEC KNEE-SHIN SWING ONLY Blank $13,972.47 HCPCS - Non-Drugs L5858 Blank STANCE PHASE ONLY Blank $30,424.46 HCPCS - Non-Drugs L5859 Blank KNEE-SHIN PRO FLEX/EXT CONT Blank $23,802.48 HCPCS - Non-Drugs L5910 Blank ENDO BELOW KNEE ALIGNABLE SY Blank $628.74 HCPCS - Non-Drugs L5920 Blank ENDO AK/HIP ALIGNABLE SYSTEM Blank $928.93 HCPCS - Non-Drugs L5925 Blank ABOVE KNEE MANUAL LOCK Blank $643.91 HCPCS - Non-Drugs L5930 Blank HIGH ACTIVITY KNEE FRAME Blank $5,518.85 HCPCS - Non-Drugs L5940 Blank ENDO BK ULTRA-LIGHT MATERIAL Blank $891.79 HCPCS - Non-Drugs L5950 Blank ENDO AK ULTRA-LIGHT MATERIAL Blank $1,373.36 HCPCS - Non-Drugs L5960 Blank ENDO HIP ULTRA-LIGHT MATERIA Blank $1,776.07 HCPCS - Non-Drugs L5961 Blank ENDO POLY HIP, PNEU/HYD/ROT Blank $7,774.76 HCPCS - Non-Drugs L5962 Blank BELOW KNEE FLEX COVER SYSTEM Blank $1,060.42 HCPCS - Non-Drugs L5964 Blank ABOVE KNEE FLEX COVER SYSTEM Blank $1,697.96 HCPCS - Non-Drugs L5966 Blank HIP FLEXIBLE COVER SYSTEM Blank $2,186.84 HCPCS - Non-Drugs L5968 Blank MULTIAXIAL ANKLE W DORSIFLEX Blank $5,941.32 HCPCS - Non-Drugs L5969 Blank AK/FT POWER ASST INCL MOTORS Blank $18,598.02 HCPCS - Non-Drugs L5970 Blank FOOT EXTERNAL KEEL SACH FOOT Blank $351.86 HCPCS - Non-Drugs L5971 Blank SACH FOOT, REPLACEMENT Blank $351.86 HCPCS - Non-Drugs L5972 Blank FLEXIBLE KEEL FOOT Blank $641.63 HCPCS - Non-Drugs L5973 Blank ANK-FOOT SYS DORS-PLANT FLEX Blank $28,560.86 HCPCS - Non-Drugs L5974 Blank FOOT SINGLE AXIS ANKLE/FOOT Blank $417.27 HCPCS - Non-Drugs L5975 Blank COMBO ANKLE/FOOT PROSTHESIS Blank $742.40 HCPCS - Non-Drugs L5976 Blank ENERGY STORING FOOT Blank $1,017.31 HCPCS - Non-Drugs L5978 Blank FT PROSTH MULTIAXIAL ANKL/FT Blank $518.11 HCPCS - Non-Drugs L5979 Blank MULTI-AXIAL ANKLE/FT PROSTH Blank $4,127.72 HCPCS - Non-Drugs L5980 Blank FLEX FOOT SYSTEM Blank $6,657.38 HCPCS - Non-Drugs L5981 Blank FLEX-WALK SYS LOW EXT PROSTH Blank $5,223.37 HCPCS - Non-Drugs L5982 Blank EXOSKELETAL AXIAL ROTATION U Blank $1,047.32 HCPCS - Non-Drugs L5984 Blank ENDOSKELETAL AXIAL ROTATION Blank $1,034.95 HCPCS - Non-Drugs L5985 Blank LWR EXT DYNAMIC PROSTH PYLON Blank $446.66 HCPCS - Non-Drugs L5986 Blank MULTI-AXIAL ROTATION UNIT Blank $1,147.03 HCPCS - Non-Drugs L5987 Blank SHANK FT W VERT LOAD PYLON Blank $11,769.66 HCPCS - Non-Drugs L5988 Blank VERTICAL SHOCK REDUCING PYLO Blank $3,258.13 HCPCS - Non-Drugs L5990 Blank USER ADJUSTABLE HEEL HEIGHT Blank $2,953.80 HCPCS - Non-Drugs L5999 Blank LOWR EXTREMITY PROSTHES NOS Blank $1,154.83 HCPCS - Non-Drugs L6000 Blank PART HAND THUMB REM Blank $2,490.53 HCPCS - Non-Drugs L6010 Blank PART HAND LITTLE/RING Blank $2,751.12 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L6020 Blank PART HAND NO FINGERS Blank $2,573.67 HCPCS - Non-Drugs L6026 Blank PART HAND MYO EXCLU TERM DEV Blank $7,244.83 HCPCS - Non-Drugs L6050 Blank WRST MLD SCK FLX HNG TRI PAD Blank $3,605.02 HCPCS - Non-Drugs L6055 Blank WRST MOLD SOCK W/EXP INTERFA Blank $4,873.12 HCPCS - Non-Drugs L6100 Blank ELB MOLD SOCK FLEX HINGE PAD Blank $3,597.29 HCPCS - Non-Drugs L6110 Blank ELBOW MOLD SOCK SUSPENSION T Blank $3,926.98 HCPCS - Non-Drugs L6120 Blank ELBOW MOLD DOUB SPLT SOC STE Blank $4,510.65 HCPCS - Non-Drugs L6130 Blank ELBOW STUMP ACTIVATED LOCK H Blank $4,817.47 HCPCS - Non-Drugs L6200 Blank ELBOW MOLD OUTSID LOCK HINGE Blank $5,075.18 HCPCS - Non-Drugs L6205 Blank ELBOW MOLDED W/ EXPAND INTER Blank $6,756.19 HCPCS - Non-Drugs L6250 Blank ELBOW INTER LOC ELBOW FORARM Blank $5,039.69 HCPCS - Non-Drugs L6300 Blank SHLDER DISART INT LOCK ELBOW Blank $6,960.57 HCPCS - Non-Drugs L6310 Blank SHOULDER PASSIVE RESTOR COMP Blank $5,687.95 HCPCS - Non-Drugs L6320 Blank SHOULDER PASSIVE RESTOR CAP Blank $3,137.31 HCPCS - Non-Drugs L6350 Blank THORACIC INTERN LOCK ELBOW Blank $7,348.48 HCPCS - Non-Drugs L6360 Blank THORACIC PASSIVE RESTOR COMP Blank $5,932.71 HCPCS - Non-Drugs L6370 Blank THORACIC PASSIVE RESTOR CAP Blank $3,833.87 HCPCS - Non-Drugs L6380 Blank POSTOP DSG CAST CHG WRST/ELB Blank $2,133.35 HCPCS - Non-Drugs L6382 Blank POSTOP DSG CAST CHG ELB DIS/ Blank $2,768.61 HCPCS - Non-Drugs L6384 Blank POSTOP DSG CAST CHG SHLDER/T Blank $3,581.31 HCPCS - Non-Drugs L6386 Blank POSTOP EA CAST CHG & REALIGN Blank $758.51 HCPCS - Non-Drugs L6388 Blank POSTOP APPLICAT RIGID DSG ON Blank $785.17 HCPCS - Non-Drugs L6400 Blank BELOW ELBOW PROSTH TISS SHAP Blank $4,253.38 HCPCS - Non-Drugs L6450 Blank ELB DISART PROSTH TISS SHAP Blank $5,521.68 HCPCS - Non-Drugs L6500 Blank ABOVE ELBOW PROSTH TISS SHAP Blank $5,458.39 HCPCS - Non-Drugs L6550 Blank SHLDR DISAR PROSTH TISS SHAP Blank $6,944.65 HCPCS - Non-Drugs L6570 Blank SCAP THORAC PROSTH TISS SHAP Blank $7,992.94 HCPCS - Non-Drugs L6580 Blank WRIST/ELBOW BOWDEN CABLE MOL Blank $2,838.73 HCPCS - Non-Drugs L6582 Blank WRIST/ELBOW BOWDEN CBL DIR F Blank $2,459.32 HCPCS - Non-Drugs L6584 Blank ELBOW FAIR LEAD CABLE MOLDED Blank $3,762.37 HCPCS - Non-Drugs L6586 Blank ELBOW FAIR LEAD CABLE DIR FO Blank $3,413.22 HCPCS - Non-Drugs L6588 Blank SHDR FAIR LEAD CABLE MOLDED Blank $5,179.95 HCPCS - Non-Drugs L6590 Blank SHDR FAIR LEAD CABLE DIRECT Blank $4,746.68 HCPCS - Non-Drugs L6600 Blank POLYCENTRIC HINGE PAIR Blank $341.54 HCPCS - Non-Drugs L6605 Blank SINGLE PIVOT HINGE PAIR Blank $337.18 HCPCS - Non-Drugs L6610 Blank FLEXIBLE METAL HINGE PAIR Blank $297.06 HCPCS - Non-Drugs L6611 Blank ADDITIONAL SWITCH, EXT POWER Blank $656.55 HCPCS - Non-Drugs L6615 Blank DISCONNECT LOCKING WRIST UNI Blank $300.85 HCPCS - Non-Drugs L6616 Blank DISCONNECT INSERT LOCKING WR Blank $100.41 HCPCS - Non-Drugs L6620 Blank FLEXION/EXTENSION WRIST UNIT Blank $540.24 HCPCS - Non-Drugs L6621 Blank FLEX/EXT WRIST W/WO FRICTION Blank $3,728.72 HCPCS - Non-Drugs L6623 Blank SPRING-ASS ROT WRST W/ LATCH Blank $1,149.62 HCPCS - Non-Drugs L6624 Blank FLEX/EXT/ROTATION WRIST UNIT Blank $6,150.97 HCPCS - Non-Drugs L6625 Blank ROTATION WRST W/ CABLE LOCK Blank $977.30 HCPCS - Non-Drugs L6628 Blank QUICK DISCONN HOOK ADAPTER O Blank $832.95 HCPCS - Non-Drugs L6629 Blank LAMINATION COLLAR W/ COUPLIN Blank $255.30 HCPCS - Non-Drugs L6630 Blank STAINLESS STEEL ANY WRIST Blank $371.50 HCPCS - Non-Drugs L6632 Blank LATEX SUSPENSION SLEEVE EACH Blank $94.78 HCPCS - Non-Drugs L6635 Blank LIFT ASSIST FOR ELBOW Blank $315.37 HCPCS - Non-Drugs L6637 Blank NUDGE CONTROL ELBOW LOCK Blank $644.25 HCPCS - Non-Drugs L6638 Blank ELEC LOCK ON MANUAL PW ELBOW Blank $4,078.32 HCPCS - Non-Drugs L6640 Blank SHOULDER ABDUCTION JOINT PAI Blank $507.84 HCPCS - Non-Drugs L6641 Blank EXCURSION AMPLIFIER PULLEY T Blank $292.84 HCPCS - Non-Drugs L6642 Blank EXCURSION AMPLIFIER LEVER TY Blank $405.73 HCPCS - Non-Drugs L6645 Blank SHOULDER FLEXION-ABDUCTION J Blank $596.88 HCPCS - Non-Drugs L6646 Blank MULTIPO LOCKING SHOULDER JNT Blank $5,148.35 HCPCS - Non-Drugs L6647 Blank SHOULDER LOCK ACTUATOR Blank $832.66 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L6648 Blank EXT PWRD SHLDER LOCK/UNLOCK Blank $5,310.35 HCPCS - Non-Drugs L6650 Blank SHOULDER UNIVERSAL JOINT Blank $635.17 HCPCS - Non-Drugs L6655 Blank STANDARD CONTROL CABLE EXTRA Blank $122.36 HCPCS - Non-Drugs L6660 Blank HEAVY DUTY CONTROL CABLE Blank $150.88 HCPCS - Non-Drugs L6665 Blank TEFLON OR EQUAL CABLE LINING Blank $64.33 HCPCS - Non-Drugs L6670 Blank HOOK TO HAND CABLE ADAPTER Blank $72.42 HCPCS - Non-Drugs L6672 Blank HARNESS CHEST/SHLDER SADDLE Blank $314.81 HCPCS - Non-Drugs L6675 Blank HARNESS FIGURE OF 8 SING CON Blank $194.70 HCPCS - Non-Drugs L6676 Blank HARNESS FIGURE OF 8 DUAL CON Blank $208.67 HCPCS - Non-Drugs L6677 Blank UE TRIPLE CONTROL HARNESS Blank $468.07 HCPCS - Non-Drugs L6680 Blank TEST SOCK WRIST DISART/BEL E Blank $438.97 HCPCS - Non-Drugs L6682 Blank TEST SOCK ELBW DISART/ABOVE Blank $474.65 HCPCS - Non-Drugs L6684 Blank TEST SOCKET SHLDR DISART/THO Blank $649.96 HCPCS - Non-Drugs L6686 Blank SUCTION SOCKET Blank $1,143.18 HCPCS - Non-Drugs L6687 Blank FRAME TYP SOCKET BEL ELBOW/W Blank $956.17 HCPCS - Non-Drugs L6688 Blank FRAME TYP SOCK ABOVE ELB/DIS Blank $988.46 HCPCS - Non-Drugs L6689 Blank FRAME TYP SOCKET SHOULDER DI Blank $1,211.72 HCPCS - Non-Drugs L6690 Blank FRAME TYP SOCK INTERSCAP-THO Blank $1,297.55 HCPCS - Non-Drugs L6691 Blank REMOVABLE INSERT EACH Blank $621.23 HCPCS - Non-Drugs L6692 Blank SILICONE GEL INSERT OR EQUAL Blank $1,024.77 HCPCS - Non-Drugs L6693 Blank LOCKINGELBOW FOREARM CNTRBAL Blank $4,637.74 HCPCS - Non-Drugs L6694 Blank ELBOW SOCKET INS USE W/LOCK Blank $1,197.30 HCPCS - Non-Drugs L6695 Blank ELBOW SOCKET INS USE W/O LCK Blank $994.75 HCPCS - Non-Drugs L6696 Blank CUS ELBO SKT IN FOR CON/ATYP Blank $2,136.91 HCPCS - Non-Drugs L6697 Blank CUS ELBO SKT IN NOT CON/ATYP Blank $2,136.91 HCPCS - Non-Drugs L6698 Blank BELOW/ABOVE ELBOW LOCK MECH Blank $923.91 HCPCS - Non-Drugs L6703 Blank TERM DEV, PASSIVE HAND MITT Blank $575.12 HCPCS - Non-Drugs L6704 Blank TERM DEV, SPORT/REC/WORK ATT Blank $1,070.46 HCPCS - Non-Drugs L6706 Blank TERM DEV MECH HOOK VOL OPEN Blank $623.28 HCPCS - Non-Drugs L6707 Blank TERM DEV MECH HOOK VOL CLOSE Blank $2,359.09 HCPCS - Non-Drugs L6708 Blank TERM DEV MECH HAND VOL OPEN Blank $1,548.01 HCPCS - Non-Drugs L6709 Blank TERM DEV MECH HAND VOL CLOSE Blank $2,243.86 HCPCS - Non-Drugs L6711 Blank PED TERM DEV, HOOK, VOL OPEN Blank $1,083.39 HCPCS - Non-Drugs L6712 Blank PED TERM DEV, HOOK, VOL CLOS Blank $2,009.77 HCPCS - Non-Drugs L6713 Blank PED TERM DEV, HAND, VOL OPEN Blank $2,541.19 HCPCS - Non-Drugs L6714 Blank PED TERM DEV, HAND, VOL CLOS Blank $2,149.65 HCPCS - Non-Drugs L6715 Blank TERM DEVICE, MULTI ART DIGIT Blank $5,153.88 HCPCS - Non-Drugs L6721 Blank HOOK/HAND, HVY DTY, VOL OPEN Blank $3,834.64 HCPCS - Non-Drugs L6722 Blank HOOK/HAND, HVY DTY, VOL CLOS Blank $3,303.28 HCPCS - Non-Drugs L6805 Blank TERM DEV MODIFIER WRIST UNIT Blank $616.40 HCPCS - Non-Drugs L6810 Blank TERM DEV PRECISION PINCH DEV Blank $321.84 HCPCS - Non-Drugs L6880 Blank ELEC HAND IND ART DIGITS Blank $39,120.55 HCPCS - Non-Drugs L6881 Blank TERM DEV AUTO GRASP FEATURE Blank $6,678.64 HCPCS - Non-Drugs L6882 Blank MICROPROCESSOR CONTROL UPLMB Blank $5,061.77 HCPCS - Non-Drugs L6883 Blank REPLC SOCKT BELOW E/W DISA Blank $2,928.92 HCPCS - Non-Drugs L6884 Blank REPLC SOCKT ABOVE ELBOW DISA Blank $4,198.31 HCPCS - Non-Drugs L6885 Blank REPLC SOCKT SHLDR DIS/INTERC Blank $5,932.71 HCPCS - Non-Drugs L6890 Blank PREFAB GLOVE FOR TERM DEVICE Blank $312.80 HCPCS - Non-Drugs L6895 Blank CUSTOM GLOVE FOR TERM DEVICE Blank $978.52 HCPCS - Non-Drugs L6900 Blank HAND RESTORAT THUMB/1 FINGER Blank $2,923.11 HCPCS - Non-Drugs L6905 Blank HAND RESTORATION MULTIPLE FI Blank $2,846.54 HCPCS - Non-Drugs L6910 Blank HAND RESTORATION NO FINGERS Blank $2,779.06 HCPCS - Non-Drugs L6915 Blank HAND RESTORATION REPLACMNT G Blank $1,180.93 HCPCS - Non-Drugs L6920 Blank WRIST DISARTICUL SWITCH CTRL Blank $12,229.10 HCPCS - Non-Drugs L6925 Blank WRIST DISART MYOELECTRONIC C Blank $13,944.45 HCPCS - Non-Drugs L6930 Blank BELOW ELBOW SWITCH CONTROL Blank $12,066.44 HCPCS - Non-Drugs L6935 Blank BELOW ELBOW MYOELECTRONIC CT Blank $14,139.74 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L6940 Blank ELBOW DISARTICULATION SWITCH Blank $15,609.99 HCPCS - Non-Drugs L6945 Blank ELBOW DISART MYOELECTRONIC C Blank $17,971.64 HCPCS - Non-Drugs L6950 Blank ABOVE ELBOW SWITCH CONTROL Blank $16,910.88 HCPCS - Non-Drugs L6955 Blank ABOVE ELBOW MYOELECTRONIC CT Blank $20,220.23 HCPCS - Non-Drugs L6960 Blank SHLDR DISARTIC SWITCH CONTRO Blank $21,407.34 HCPCS - Non-Drugs L6965 Blank SHLDR DISARTIC MYOELECTRONIC Blank $25,193.29 HCPCS - Non-Drugs L6970 Blank INTERSCAPULAR-THOR SWITCH CT Blank $26,338.28 HCPCS - Non-Drugs L6975 Blank INTERSCAP-THOR MYOELECTRONIC Blank $28,915.87 HCPCS - Non-Drugs L7007 Blank ADULT ELECTRIC HAND Blank $6,055.92 HCPCS - Non-Drugs L7008 Blank PEDIATRIC ELECTRIC HAND Blank $9,769.34 HCPCS - Non-Drugs L7009 Blank ADULT ELECTRIC HOOK Blank $6,160.80 HCPCS - Non-Drugs L7040 Blank PREHENSILE ACTUATOR Blank $4,947.36 HCPCS - Non-Drugs L7045 Blank PEDIATRIC ELECTRIC HOOK Blank $2,740.94 HCPCS - Non-Drugs L7170 Blank ELECTRONIC ELBOW HOSMER SWIT Blank $10,591.75 HCPCS - Non-Drugs L7180 Blank ELECTRONIC ELBOW SEQUENTIAL Blank $59,497.12 HCPCS - Non-Drugs L7181 Blank ELECTRONIC ELBO SIMULTANEOUS Blank $65,613.10 HCPCS - Non-Drugs L7185 Blank ELECTRON ELBOW ADOLESCENT SW Blank $10,998.18 HCPCS - Non-Drugs L7186 Blank ELECTRON ELBOW CHILD SWITCH Blank $16,293.22 HCPCS - Non-Drugs L7190 Blank ELBOW ADOLESCENT MYOELECTRON Blank $13,857.32 HCPCS - Non-Drugs L7191 Blank ELBOW CHILD MYOELECTRONIC CT Blank $17,044.86 HCPCS - Non-Drugs L7259 Blank ELECTRONIC WRIST ROTATOR ANY Blank $6,188.61 HCPCS - Non-Drugs L7360 Blank SIX VOLT BAT OTTO BOCK/EQ EA Blank $407.35 HCPCS - Non-Drugs L7362 Blank BATTERY CHRGR SIX VOLT OTTO Blank $439.83 HCPCS - Non-Drugs L7364 Blank TWELVE VOLT BATTERY UTAH/EQU Blank $776.78 HCPCS - Non-Drugs L7366 Blank BATTERY CHRGR 12 VOLT UTAH/E Blank $1,042.81 HCPCS - Non-Drugs L7367 Blank REPLACEMNT LITHIUM IONBATTER Blank $619.86 HCPCS - Non-Drugs L7368 Blank LITHIUM ION BATTERY CHARGER Blank $808.83 HCPCS - Non-Drugs L7400 Blank ADD UE PROST BE/WD, ULTLITE Blank $484.18 HCPCS - Non-Drugs L7401 Blank ADD UE PROST A/E ULTLITE MAT Blank $544.17 HCPCS - Non-Drugs L7402 Blank ADD UE PROST S/D ULTLITE MAT Blank $589.08 HCPCS - Non-Drugs L7403 Blank ADD UE PROST B/E ACRYLIC Blank $585.36 HCPCS - Non-Drugs L7404 Blank ADD UE PROST A/E ACRYLIC Blank $892.58 HCPCS - Non-Drugs L7405 Blank ADD UE PROST S/D ACRYLIC Blank $1,172.84 HCPCS - Non-Drugs L7499 Blank UPPER EXTREMITY PROSTHES NOS Blank $1,371.20 HCPCS - Non-Drugs L7510 Blank PROSTHETIC DEVICE REPAIR REP Blank $64.30 HCPCS - Non-Drugs L7520 Blank REPAIR PROSTHESIS PER 15 MIN Blank $56.02 HCPCS - Non-Drugs L7600 Blank PROSTHETIC DONNING SLEEVE Blank $116.92 HCPCS - Non-Drugs L7900 Blank MALE VACUUM ERECTION SYSTEM Blank $538.65 HCPCS - Non-Drugs L7902 Blank TENSION RING, VAC ERECT DEV Blank $36.19 HCPCS - Non-Drugs L8000 Blank MASTECTOMY BRA Blank $50.51 HCPCS - Non-Drugs L8001 Blank BREAST PROSTHESIS BRA & FORM Blank $187.62 HCPCS - Non-Drugs L8002 Blank BRST PRSTH BRA & BILAT FORM Blank $252.39 HCPCS - Non-Drugs L8010 Blank MASTECTOMY SLEEVE Blank $39.89 HCPCS - Non-Drugs L8015 Blank EXT BREASTPROSTHESIS GARMENT Blank $80.49 HCPCS - Non-Drugs L8020 Blank MASTECTOMY FORM Blank $355.55 HCPCS - Non-Drugs L8030 Blank BREAST PROSTHES W/O ADHESIVE Blank $551.24 HCPCS - Non-Drugs L8031 Blank BREAST PROSTHESIS W ADHESIVE Blank $551.24 HCPCS - Non-Drugs L8032 Blank REUSABLE NIPPLE PROSTHESIS Blank $46.41 HCPCS - Non-Drugs L8035 Blank CUSTOM BREAST PROSTHESIS Blank $5,990.04 HCPCS - Non-Drugs L8039 Blank BREAST PROSTHESIS NOS Blank $50.51 HCPCS - Non-Drugs L8040 Blank NASAL PROSTHESIS Blank $4,079.72 HCPCS - Non-Drugs L8040 KM NASAL PROSTHESIS Blank $3,874.84 HCPCS - Non-Drugs L8040 KN NASAL PROSTHESIS Blank $1,621.18 HCPCS - Non-Drugs L8041 Blank MIDFACIAL PROSTHESIS Blank $4,921.06 HCPCS - Non-Drugs L8041 KM MIDFACIAL PROSTHESIS Blank $4,674.10 HCPCS - Non-Drugs L8041 KN MIDFACIAL PROSTHESIS Blank $1,957.73 HCPCS - Non-Drugs L8042 Blank ORBITAL PROSTHESIS Blank $5,531.48 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L8042 KM ORBITAL PROSTHESIS Blank $5,254.00 HCPCS - Non-Drugs L8042 KN ORBITAL PROSTHESIS Blank $2,201.89 HCPCS - Non-Drugs L8043 Blank UPPER FACIAL PROSTHESIS Blank $6,197.41 HCPCS - Non-Drugs L8043 KM UPPER FACIAL PROSTHESIS Blank $5,886.64 HCPCS - Non-Drugs L8043 KN UPPER FACIAL PROSTHESIS Blank $2,468.25 HCPCS - Non-Drugs L8044 Blank HEMI-FACIAL PROSTHESIS Blank $6,863.31 HCPCS - Non-Drugs L8044 KM HEMI-FACIAL PROSTHESIS Blank $6,519.26 HCPCS - Non-Drugs L8044 KN HEMI-FACIAL PROSTHESIS Blank $2,734.62 HCPCS - Non-Drugs L8045 Blank AURICULAR PROSTHESIS Blank $4,524.26 HCPCS - Non-Drugs L8045 KM AURICULAR PROSTHESIS Blank $4,297.15 HCPCS - Non-Drugs L8045 KN AURICULAR PROSTHESIS Blank $1,799.00 HCPCS - Non-Drugs L8046 Blank PARTIAL FACIAL PROSTHESIS Blank $4,421.62 HCPCS - Non-Drugs L8046 KM PARTIAL FACIAL PROSTHESIS Blank $4,199.64 HCPCS - Non-Drugs L8046 KN PARTIAL FACIAL PROSTHESIS Blank $1,757.93 HCPCS - Non-Drugs L8047 Blank NASAL SEPTAL PROSTHESIS Blank $2,257.37 HCPCS - Non-Drugs L8047 KM NASAL SEPTAL PROSTHESIS Blank $2,143.62 HCPCS - Non-Drugs L8047 KN NASAL SEPTAL PROSTHESIS Blank $892.25 HCPCS - Non-Drugs L8048 Blank UNSPEC MAXILLOFACIAL PROSTH Blank $1,003.26 HCPCS - Non-Drugs L8049 Blank REPAIR MAXILLOFACIAL PROSTH Blank $68.65 HCPCS - Non-Drugs L8300 Blank TRUSS SINGLE W/ STANDARD PAD Blank $138.07 HCPCS - Non-Drugs L8310 Blank TRUSS DOUBLE W/ STANDARD PAD Blank $235.09 HCPCS - Non-Drugs L8320 Blank TRUSS ADDITION TO STD PAD WA Blank $84.50 HCPCS - Non-Drugs L8330 Blank TRUSS ADD TO STD PAD SCROTAL Blank $77.16 HCPCS - Non-Drugs L8400 Blank SHEATH BELOW KNEE Blank $21.73 HCPCS - Non-Drugs L8410 Blank SHEATH ABOVE KNEE Blank $27.14 HCPCS - Non-Drugs L8415 Blank SHEATH UPPER LIMB Blank $26.87 HCPCS - Non-Drugs L8417 Blank PROS SHEATH/SOCK W GEL CUSHN Blank $105.34 HCPCS - Non-Drugs L8420 Blank PROSTHETIC SOCK MULTI PLY BK Blank $26.37 HCPCS - Non-Drugs L8430 Blank PROSTHETIC SOCK MULTI PLY AK Blank $29.00 HCPCS - Non-Drugs L8435 Blank PROS SOCK MULTI PLY UPPER LM Blank $27.58 HCPCS - Non-Drugs L8440 Blank SHRINKER BELOW KNEE Blank $62.21 HCPCS - Non-Drugs L8460 Blank SHRINKER ABOVE KNEE Blank $104.86 HCPCS - Non-Drugs L8465 Blank SHRINKER UPPER LIMB Blank $73.44 HCPCS - Non-Drugs L8470 Blank PROS SOCK SINGLE PLY BK Blank $9.95 HCPCS - Non-Drugs L8480 Blank PROS SOCK SINGLE PLY AK Blank $13.08 HCPCS - Non-Drugs L8485 Blank PROS SOCK SINGLE PLY UPPER L Blank $15.57 HCPCS - Non-Drugs L8499 Blank UNLISTED MISC PROSTHETIC SER Blank $7.53 HCPCS - Non-Drugs L8500 Blank ARTIFICIAL LARYNX Blank $1,159.02 HCPCS - Non-Drugs L8501 Blank TRACHEOSTOMY SPEAKING VALVE Blank $191.29 HCPCS - Non-Drugs L8505 Blank ARTIFICIAL LARYNX, ACCESSORY Blank $62.90 HCPCS - Non-Drugs L8507 Blank TRACH-ESOPH VOICE PROS PT IN Blank $50.76 HCPCS - Non-Drugs L8509 Blank TRACH-ESOPH VOICE PROS MD IN Blank $161.05 HCPCS - Non-Drugs L8510 Blank VOICE AMPLIFIER Blank $396.07 HCPCS - Non-Drugs L8511 Blank INDWELLING TRACH INSERT Blank $101.42 HCPCS - Non-Drugs L8512 Blank GEL CAP FOR TRACH VOICE PROS Blank $2.99 HCPCS - Non-Drugs L8513 Blank TRACH PROS CLEANING DEVICE Blank $7.15 HCPCS - Non-Drugs L8514 Blank REPL TRACH PUNCTURE DILATOR Blank $136.80 HCPCS - Non-Drugs L8515 Blank GEL CAP APP DEVICE FOR TRACH Blank $85.53 HCPCS - Non-Drugs L8600 Blank IMPLANT BREAST SILICONE/EQ Blank $1,098.04 HCPCS - Non-Drugs L8603 Blank COLLAGEN IMP URINARY 2.5 ML Blank $700.98 HCPCS - Non-Drugs L8605 Blank INJ BULKING AGENT ANAL CANAL Blank $1,155.41 HCPCS - Non-Drugs L8606 Blank SYNTHETIC IMPLNT URINARY 1ML Blank $343.45 HCPCS - Non-Drugs L8607 Blank INJ VOCAL CORD BULKING AGENT Blank $52.42 HCPCS - Non-Drugs L8609 Blank ARTIFICIAL CORNEA Blank $10,645.95 HCPCS - Non-Drugs L8610 Blank OCULAR IMPLANT Blank $1,037.11 HCPCS - Non-Drugs L8612 Blank AQUEOUS SHUNT PROSTHESIS Blank $1,136.95 HCPCS - Non-Drugs L8613 Blank OSSICULAR IMPLANT Blank $488.40 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

L8614 Blank COCHLEAR DEVICE Blank $31,775.05 HCPCS - Non-Drugs L8615 Blank COCH IMPLANT HEADSET REPLACE Blank $720.33 HCPCS - Non-Drugs L8616 Blank COCH IMPLANT MICROPHONE REPL Blank $154.09 HCPCS - Non-Drugs L8617 Blank COCH IMPLANT TRANS COIL REPL Blank $132.34 HCPCS - Non-Drugs L8618 Blank COCH IMPLANT TRAN CABLE REPL Blank $29.87 HCPCS - Non-Drugs L8619 Blank COCH IMP EXT PROC/CONTR RPLC Blank $13,628.56 HCPCS - Non-Drugs L8621 Blank REPL ZINC AIR BATTERY Blank $0.84 HCPCS - Non-Drugs L8622 Blank REPL ALKALINE BATTERY Blank $0.44 HCPCS - Non-Drugs L8623 Blank LITH ION BATT CID,NON-EARLVL Blank $88.02 HCPCS - Non-Drugs L8624 Blank LITH ION BATT CID, EAR LEVEL Blank $246.08 HCPCS - Non-Drugs L8627 Blank CID EXT SPEECH PROCESS REPL Blank $11,565.19 HCPCS - Non-Drugs L8628 Blank CID EXT CONTROLLER REPL Blank $2,037.89 HCPCS - Non-Drugs L8629 Blank CID TRANSMIT COIL AND CABLE Blank $275.47 HCPCS - Non-Drugs L8630 Blank METACARPOPHALANGEAL IMPLANT Blank $580.75 HCPCS - Non-Drugs L8631 Blank MCP JOINT REPL 2 PC OR MORE Blank $3,601.46 HCPCS - Non-Drugs L8641 Blank METATARSAL JOINT IMPLANT Blank $585.94 HCPCS - Non-Drugs L8642 Blank HALLUX IMPLANT Blank $498.37 HCPCS - Non-Drugs L8658 Blank INTERPHALANGEAL JOINT SPACER Blank $509.86 HCPCS - Non-Drugs L8659 Blank INTERPHALANGEAL JOINT REPL Blank $3,140.46 HCPCS - Non-Drugs L8670 Blank VASCULAR GRAFT, SYNTHETIC Blank $895.50 HCPCS - Non-Drugs L8679 Blank IMP NEUROSTI PLS GN ANY TYPE Blank $13,841.67 HCPCS - Non-Drugs L8680 Blank IMPLT NEUROSTIM ELCTR EACH Blank $464.21 HCPCS - Non-Drugs L8681 Blank PT PRGRM FOR IMPLT NEUROSTIM Blank $1,871.55 HCPCS - Non-Drugs L8682 Blank IMPLT NEUROSTIM RADIOFQ REC Blank $9,884.52 HCPCS - Non-Drugs L8683 Blank RADIOFQ TRSMTR FOR IMPLT NEU Blank $8,698.49 HCPCS - Non-Drugs L8684 Blank RADIOF TRSMTR IMPLT SCRL NEU Blank $1,243.46 HCPCS - Non-Drugs L8685 Blank IMPLT NROSTM PLS GEN SNG REC Blank $13,703.80 HCPCS - Non-Drugs L8686 Blank IMPLT NROSTM PLS GEN SNG NON Blank $8,737.82 HCPCS - Non-Drugs L8687 Blank IMPLT NROSTM PLS GEN DUA REC Blank $17,839.91 HCPCS - Non-Drugs L8688 Blank IMPLT NROSTM PLS GEN DUA NON Blank $11,376.98 HCPCS - Non-Drugs L8689 Blank EXTERNAL RECHARG SYS INTERN Blank $2,807.80 HCPCS - Non-Drugs L8690 Blank AUD OSSEO DEV, INT/EXT COMP Blank $7,774.89 HCPCS - Non-Drugs L8691 Blank AOI SND PROC REPL EXCL ACTUA Blank $4,350.24 HCPCS - Non-Drugs L8692 Blank NON-OSSEOINTEGRATED SND PROC Blank $328.33 HCPCS - Non-Drugs L8693 Blank AUD OSSEO DEV, ABUTMENT Blank $2,463.93 HCPCS - Non-Drugs L8695 Blank EXTERNAL RECHARG SYS EXTERN Blank $20.02 HCPCS - Non-Drugs L8696 Blank EXT ANTENNA PHREN NERVE STIM Blank $337.21 HCPCS - Non-Drugs L8699 Blank PROSTHETIC IMPLANT NOS Blank $305.01 HCPCS - Non-Drugs L9900 Blank O&P SUPPLY/ACCESSORY/SERVICE Blank $305.01 HCPCS - Non-Drugs Q0138 Blank FERUMOXYTOL, NON-ESRD a $14.23 HCPCS - Drugs Q0139 Blank FERUMOXYTOL, ESRD USE a $2.44 HCPCS - Non-Drugs Q0144 Blank AZITHROMYCIN DIHYDRATE, ORAL a $40.92 HCPCS - Drugs Q0161 Blank CHLORPROMAZINE HCL 5MG ORAL a $1.73 HCPCS - Drugs Q0162 Blank ONDANSETRON ORAL a $1.70 HCPCS - Drugs Q0163 Blank DIPHENHYDRAMINE HCL 50MG a $1.70 HCPCS - Drugs Q0164 Blank PROCHLORPERAZINE MALEATE 5MG a $1.70 HCPCS - Drugs Q0166 Blank GRANISETRON HCL 1 MG ORAL a $11.91 HCPCS - Drugs Q0167 Blank DRONABINOL 2.5MG ORAL a $27.21 HCPCS - Drugs Q0169 Blank PROMETHAZINE HCL 12.5MG ORAL a $1.70 HCPCS - Drugs Q0173 Blank TRIMETHOBENZAMIDE HCL 250MG Blank $3.40 HCPCS - Drugs Q0174 Blank THIETHYLPERAZINE MALEATE10MG Blank $3.40 HCPCS - Drugs Q0175 Blank PERPHENAZINE 4MG ORAL a $3.40 HCPCS - Drugs Q0177 Blank HYDROXYZINE PAMOATE 25MG a $10.21 HCPCS - Drugs Q0180 Blank DOLASETRON MESYLATE ORAL a $257.83 HCPCS - Drugs Q0181 Blank UNSPECIFIED ORAL ANTI-EMETIC a $54.58 HCPCS - Drugs Q0478 Blank POWER ADAPTER, COMBO VAD Blank $282.92 HCPCS - Non-Drugs Q0479 Blank POWER MODULE COMBO VAD, REP Blank $19,749.69 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

Q0480 Blank DRIVER PNEUMATIC VAD, REP Blank $147,517.25 HCPCS - Non-Drugs Q0481 Blank MICROPRCSR CU ELEC VAD, REP Blank $23,785.23 HCPCS - Non-Drugs Q0482 Blank MICROPRCSR CU COMBO VAD, REP Blank $7,437.73 HCPCS - Non-Drugs Q0483 Blank MONITOR ELEC VAD, REP Blank $30,695.75 HCPCS - Non-Drugs Q0484 Blank MONITOR ELEC OR COMB VAD REP Blank $5,946.65 HCPCS - Non-Drugs Q0485 Blank MONITOR CABLE ELEC VAD, REP Blank $558.02 HCPCS - Non-Drugs Q0486 Blank MON CABLE ELEC/PNEUM VAD REP Blank $461.44 HCPCS - Non-Drugs Q0487 Blank LEADS ANY TYPE VAD, REP ONLY Blank $541.32 HCPCS - Non-Drugs Q0488 Blank PWR PACK BASE ELEC VAD, REP Blank $25,245.66 HCPCS - Non-Drugs Q0489 Blank PWR PCK BASE COMBO VAD, REP Blank $26,609.18 HCPCS - Non-Drugs Q0490 Blank EMR PWR SOURCE ELEC VAD, REP Blank $1,133.93 HCPCS - Non-Drugs Q0491 Blank EMR PWR SOURCE COMBO VAD REP Blank $1,792.83 HCPCS - Non-Drugs Q0492 Blank EMR PWR CBL ELEC VAD, REP Blank $128.04 HCPCS - Non-Drugs Q0493 Blank EMR PWR CBL COMBO VAD, REP Blank $397.50 HCPCS - Non-Drugs Q0494 Blank EMR HD PMP ELEC/COMBO, REP Blank $333.63 HCPCS - Non-Drugs Q0495 Blank CHARGER ELEC/COMBO VAD, REP Blank $6,824.63 HCPCS - Non-Drugs Q0496 Blank BATTERY ELEC/COMBO VAD, REP Blank $2,438.03 HCPCS - Non-Drugs Q0497 Blank BAT CLPS ELEC/COMB VAD, REP Blank $749.02 HCPCS - Non-Drugs Q0498 Blank HOLSTER ELEC/COMBO VAD, REP Blank $823.57 HCPCS - Non-Drugs Q0499 Blank BELT/VEST ELEC/COMBO VAD REP Blank $255.54 HCPCS - Non-Drugs Q0500 Blank FILTERS ELEC/COMBO VAD, REP Blank $34.34 HCPCS - Non-Drugs Q0501 Blank SHWR COV ELEC/COMBO VAD, REP Blank $818.71 HCPCS - Non-Drugs Q0502 Blank MOBILITY CART PNEUM VAD, REP Blank $1,047.21 HCPCS - Non-Drugs Q0503 Blank BATTERY PNEUM VAD REPLACEMNT Blank $2,112.31 HCPCS - Non-Drugs Q0504 Blank PWR ADPT PNEUM VAD, REP VEH Blank $1,106.18 HCPCS - Non-Drugs Q0506 Blank LITH-ION BATT ELEC/PNEUM VAD Blank $1,381.30 HCPCS - Non-Drugs Q0507 Blank MISC SUP/ACC EXT VAD Blank $219.84 HCPCS - Non-Drugs Q0508 Blank MIS SUP/ACC IMP VAD Blank $44.67 HCPCS - Non-Drugs Q0509 Blank MIS SUP/AC IMP VAD NOPAY MED Blank $199.01 HCPCS - Non-Drugs Q0510 Blank DISPENS FEE IMMUNOSUPRESSIVE Blank $81.62 HCPCS - Drugs Q0511 Blank SUP FEE ANTIEM,ANTICA,IMMUNO Blank $39.18 HCPCS - Drugs Q0512 Blank PX SUP FEE ANTI-CAN SUB PRES a $26.12 HCPCS - Drugs Q0513 Blank DISP FEE INHAL DRUGS/30 DAYS Blank $53.87 HCPCS - Drugs Q0514 Blank DISP FEE INHAL DRUGS/90 DAYS Blank $107.74 HCPCS - Drugs Q0515 Blank SERMORELIN ACETATE INJECTION a $15.67 HCPCS - Drugs Q2004 Blank BLADDER CALCULI IRRIG SOL Blank $43.81 HCPCS - Drugs Q2009 Blank FOSPHENYTOIN INJ PE a $18.56 HCPCS - Drugs Q2017 Blank TENIPOSIDE, 50 MG a $958.99 HCPCS - Drugs Q2034 Blank AGRIFLU VACCINE a $33.65 HCPCS - Drugs Q2043 Blank SIPULEUCEL-T AUTO CD54+ a $80,267.54 HCPCS - Drugs Q2049 Blank IMPORTED LIPODOX INJ a $1,671.92 HCPCS - Drugs Q2050 Blank DOXORUBICIN INJ 10MG a $1,533.44 HCPCS - Drugs Q2052 Blank IVIG DEMO, SERVICES/SUPPLIES Blank $1,302.83 HCPCS - Drugs Q3001 Blank BRACHYTHERAPY RADIOELEMENTS a $91.96 HCPCS - Non-Drugs Q3027 Blank INJ BETA INTERFERON IM 1 MCG a $105.86 HCPCS - Drugs Q3028 Blank INJ BETA INTERFERON SQ 1 MCG a $17.93 HCPCS - Drugs Q4001 Blank CAST SUP BODY CAST PLASTER Blank $87.43 HCPCS - Non-Drugs Q4002 Blank CAST SUP BODY CAST FIBERGLAS Blank $327.09 HCPCS - Non-Drugs Q4003 Blank CAST SUP SHOULDER CAST PLSTR Blank $63.10 HCPCS - Non-Drugs Q4004 Blank CAST SUP SHOULDER CAST FBRGL Blank $215.58 HCPCS - Non-Drugs Q4005 Blank CAST SUP LONG ARM ADULT PLST Blank $24.01 HCPCS - Non-Drugs Q4006 Blank CAST SUP LONG ARM ADULT FBRG Blank $52.62 HCPCS - Non-Drugs Q4007 Blank CAST SUP LONG ARM PED PLSTER Blank $12.59 HCPCS - Non-Drugs Q4008 Blank CAST SUP LONG ARM PED FBRGLS Blank $26.88 HCPCS - Non-Drugs Q4009 Blank CAST SUP SHT ARM ADULT PLSTR Blank $16.43 HCPCS - Non-Drugs Q4010 Blank CAST SUP SHT ARM ADULT FBRGL Blank $35.48 HCPCS - Non-Drugs Q4011 Blank CAST SUP SHT ARM PED PLASTER Blank $8.77 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

Q4012 Blank CAST SUP SHT ARM PED FBRGLAS Blank $18.34 HCPCS - Non-Drugs Q4013 Blank CAST SUP GAUNTLET PLASTER Blank $28.93 HCPCS - Non-Drugs Q4014 Blank CAST SUP GAUNTLET FIBERGLASS Blank $47.96 HCPCS - Non-Drugs Q4015 Blank CAST SUP GAUNTLET PED PLSTER Blank $15.07 HCPCS - Non-Drugs Q4016 Blank CAST SUP GAUNTLET PED FBRGLS Blank $24.56 HCPCS - Non-Drugs Q4017 Blank CAST SUP LNG ARM SPLINT PLST Blank $17.21 HCPCS - Non-Drugs Q4018 Blank CAST SUP LNG ARM SPLINT FBRG Blank $26.74 HCPCS - Non-Drugs Q4019 Blank CAST SUP LNG ARM SPLNT PED P Blank $9.21 HCPCS - Non-Drugs Q4020 Blank CAST SUP LNG ARM SPLNT PED F Blank $13.99 HCPCS - Non-Drugs Q4021 Blank CAST SUP SHT ARM SPLINT PLST Blank $13.05 HCPCS - Non-Drugs Q4022 Blank CAST SUP SHT ARM SPLINT FBRG Blank $22.59 HCPCS - Non-Drugs Q4023 Blank CAST SUP SHT ARM SPLNT PED P Blank $7.14 HCPCS - Non-Drugs Q4024 Blank CAST SUP SHT ARM SPLNT PED F Blank $11.90 HCPCS - Non-Drugs Q4025 Blank CAST SUP HIP SPICA PLASTER Blank $67.74 HCPCS - Non-Drugs Q4026 Blank CAST SUP HIP SPICA FIBERGLAS Blank $209.07 HCPCS - Non-Drugs Q4027 Blank CAST SUP HIP SPICA PED PLSTR Blank $34.47 HCPCS - Non-Drugs Q4028 Blank CAST SUP HIP SPICA PED FBRGL Blank $105.17 HCPCS - Non-Drugs Q4029 Blank CAST SUP LONG LEG PLASTER Blank $52.09 HCPCS - Non-Drugs Q4030 Blank CAST SUP LONG LEG FIBERGLASS Blank $135.22 HCPCS - Non-Drugs Q4031 Blank CAST SUP LNG LEG PED PLASTER Blank $26.61 HCPCS - Non-Drugs Q4032 Blank CAST SUP LNG LEG PED FBRGLS Blank $68.18 HCPCS - Non-Drugs Q4033 Blank CAST SUP LNG LEG CYLINDER PL Blank $48.67 HCPCS - Non-Drugs Q4034 Blank CAST SUP LNG LEG CYLINDER FB Blank $119.28 HCPCS - Non-Drugs Q4035 Blank CAST SUP LNGLEG CYLNDR PED P Blank $24.91 HCPCS - Non-Drugs Q4036 Blank CAST SUP LNGLEG CYLNDR PED F Blank $60.25 HCPCS - Non-Drugs Q4037 Blank CAST SUP SHRT LEG PLASTER Blank $30.12 HCPCS - Non-Drugs Q4038 Blank CAST SUP SHRT LEG FIBERGLASS Blank $73.74 HCPCS - Non-Drugs Q4039 Blank CAST SUP SHRT LEG PED PLSTER Blank $15.69 HCPCS - Non-Drugs Q4040 Blank CAST SUP SHRT LEG PED FBRGLS Blank $37.45 HCPCS - Non-Drugs Q4041 Blank CAST SUP LNG LEG SPLNT PLSTR Blank $36.40 HCPCS - Non-Drugs Q4042 Blank CAST SUP LNG LEG SPLNT FBRGL Blank $61.31 HCPCS - Non-Drugs Q4043 Blank CAST SUP LNG LEG SPLNT PED P Blank $18.80 HCPCS - Non-Drugs Q4044 Blank CAST SUP LNG LEG SPLNT PED F Blank $31.25 HCPCS - Non-Drugs Q4045 Blank CAST SUP SHT LEG SPLNT PLSTR Blank $21.62 HCPCS - Non-Drugs Q4046 Blank CAST SUP SHT LEG SPLNT FBRGL Blank $34.07 HCPCS - Non-Drugs Q4047 Blank CAST SUP SHT LEG SPLNT PED P Blank $11.37 HCPCS - Non-Drugs Q4048 Blank CAST SUP SHT LEG SPLNT PED F Blank $17.62 HCPCS - Non-Drugs Q4049 Blank FINGER SPLINT, STATIC Blank $4.89 HCPCS - Non-Drugs Q4050 Blank CAST SUPPLIES UNLISTED Blank $37.51 HCPCS - Non-Drugs Q4051 Blank SPLINT SUPPLIES MISC Blank $36.08 HCPCS - Non-Drugs Q4074 Blank ILOPROST NON-COMP UNIT DOSE a $261.71 HCPCS - Drugs Q4081 Blank EPOETIN ALFA, 100 UNITS ESRD a $15.67 HCPCS - Drugs Q4082 Blank DRUG/BIO NOC PART B DRUG CAP Blank $3,236.01 HCPCS - Drugs Q4100 Blank SKIN SUBSTITUTE, NOS a $3,121.42 HCPCS - Drugs Q4101 Blank APLIGRAF a $74.84 HCPCS - Drugs Q4102 Blank OASIS WOUND MATRIX a $34.43 HCPCS - Drugs Q4103 Blank OASIS BURN MATRIX a $34.43 HCPCS - Drugs Q4104 Blank INTEGRA BMWD a $89.27 HCPCS - Drugs Q4105 Blank INTEGRA DRT OR OMNIGRAFT a $89.27 HCPCS - Drugs Q4106 Blank DERMAGRAFT a $78.44 HCPCS - Drugs Q4107 Blank GRAFTJACKET a $195.33 HCPCS - Drugs Q4108 Blank INTEGRA MATRIX a $89.27 HCPCS - Drugs Q4110 Blank PRIMATRIX a $73.39 HCPCS - Drugs Q4111 Blank GAMMAGRAFT a $27.21 HCPCS - Drugs Q4112 Blank CYMETRA INJECTABLE a $906.75 HCPCS - Drugs Q4113 Blank GRAFTJACKET XPRESS a $906.75 HCPCS - Drugs Q4114 Blank INTEGRA FLOWABLE WOUND MATRI a $3,579.73 HCPCS - Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

Q4115 Blank ALLOSKIN a $30.10 HCPCS - Drugs Q4116 Blank ALLODERM a $76.28 HCPCS - Drugs Q4118 Blank MATRISTEM MICROMATRIX a $7.86 HCPCS - Drugs Q4121 Blank THERASKIN a $97.92 HCPCS - Drugs Q4122 Blank DERMACELL a $2,045.26 HCPCS - Drugs Q4123 Blank ALLOSKIN a $63.29 HCPCS - Drugs Q4125 Blank ARTHROFLEX a $2,721.58 HCPCS - Drugs Q4126 Blank MEMODERM/DERMA/TRANZ/INTEGUP a $422.28 HCPCS - Drugs Q4127 Blank TALYMED a $3.16 HCPCS - Drugs Q4128 Blank FLEXHD/ALLOPATCHHD/MATRIXHD a $332.23 HCPCS - Drugs Q4130 Blank STRATTICE TM a $20,502.91 HCPCS - Drugs Q4131 Blank EPIFIX OR EPICORD a $331.70 HCPCS - Drugs Q4132 Blank GRAFIX CORE, GRAFIXPL CORE a $188.31 HCPCS - Drugs Q4133 Blank GRAFIX PRIME GRAFIX PL PRIME a $165.87 HCPCS - Drugs Q4134 Blank HMATRIX a $4,389.12 HCPCS - Drugs Q4137 Blank AMNIOEXCEL OR BIODEXCEL, 1CM a $66.42 HCPCS - Drugs Q4139 Blank AMNIO OR BIODMATRIX, INJ 1CC a $3,373.22 HCPCS - Drugs Q4140 Blank BIODFENCE 1CM Blank $4,230.28 HCPCS - Drugs Q4141 Blank ALLOSKIN AC, 1 CM a $29.95 HCPCS - Drugs Q4142 Blank XCM BIOLOGIC TISS MATRIX 1CM Blank $2,953.76 HCPCS - Drugs Q4145 Blank EPIFIX, INJ, 1MG a $63.67 HCPCS - Drugs Q4146 Blank TENSIX, 1CM Blank $232.23 HCPCS - Drugs Q4147 Blank ARCHITECT ECM PX FX 1 SQ CM Blank $4,051.08 HCPCS - Drugs Q4148 Blank NEOX NEOX RT OR CLARIX CORD a $170.48 HCPCS - Drugs Q4155 Blank NEOXFLO OR CLARIXFLO 1 MG Blank $42.10 HCPCS - Drugs Q4156 Blank NEOX 100 OR CLARIX 100 Blank $249.93 HCPCS - Drugs Q4158 Blank KERECIS OMEGA3, PER SQ CM Blank $42.96 HCPCS - Drugs Q4172 Blank PURAPLY OR PURAPLY AM a $475.95 HCPCS - Drugs Q5101 Blank INJ FILGRASTIM GCSF BIOSIMIL a $14.23 HCPCS - Drugs Q5102 Blank INJ., INFLIXIMAB BIOSIMILAR a $214.09 HCPCS - Drugs Q9951 Blank LOCM >= 400 MG/ML IODINE,1ML a $6.12 HCPCS - Non-Drugs Q9953 Blank INJ FE-BASED MR CONTRAST,1ML a $45.91 HCPCS - Non-Drugs Q9954 Blank ORAL MR CONTRAST, 100 ML a $15.34 HCPCS - Non-Drugs Q9955 Blank INJ PERFLEXANE LIP MICROS,ML a $4.75 HCPCS - Non-Drugs Q9956 Blank INJ OCTAFLUOROPROPANE MIC,ML a $114.77 HCPCS - Non-Drugs Q9957 Blank INJ PERFLUTREN LIP MICROS,ML a $200.99 HCPCS - Non-Drugs Q9958 Blank HOCM <=149 MG/ML IODINE, 1ML a $0.28 HCPCS - Non-Drugs Q9959 Blank HOCM 150-199MG/ML IODINE,1ML a $0.60 HCPCS - Non-Drugs Q9960 Blank HOCM 200-249MG/ML IODINE,1ML a $1.19 HCPCS - Non-Drugs Q9961 Blank HOCM 250-299MG/ML IODINE,1ML a $1.52 HCPCS - Non-Drugs Q9962 Blank HOCM 300-349MG/ML IODINE,1ML a $1.84 HCPCS - Non-Drugs Q9963 Blank HOCM 350-399MG/ML IODINE,1ML a $2.34 HCPCS - Non-Drugs Q9964 Blank HOCM>= 400MG/ML IODINE, 1ML a $2.81 HCPCS - Non-Drugs Q9965 Blank LOCM 100-199MG/ML IODINE,1ML a $3.42 HCPCS - Non-Drugs Q9966 Blank LOCM 200-299MG/ML IODINE,1ML a $3.04 HCPCS - Non-Drugs Q9967 Blank LOCM 300-399MG/ML IODINE,1ML a $1.52 HCPCS - Non-Drugs Q9982 Blank FLUTEMETAMOL F18 DIAGNOSTIC a $10,752.09 HCPCS - Drugs Q9983 Blank FLORBETABEN F18 DIAGNOSTIC a $4,938.60 HCPCS - Drugs S0012 Blank BUTORPHANOL TARTRATE, NASAL Blank $419.41 HCPCS - Non-Drugs S0014 Blank TACRINE HYDROCHLORIDE, 10 MG Blank $14.35 HCPCS - Non-Drugs S0017 Blank INJECTION, AMINOCAPROIC ACID a $35.15 HCPCS - Non-Drugs S0020 Blank INJECTION, BUPIVICAINE HYDRO a $16.40 HCPCS - Non-Drugs S0021 Blank INJECTION, CEFOPERAZONE SOD Blank $7.96 HCPCS - Non-Drugs S0023 Blank INJECTION, CIMETIDINE HYDROC a $14.94 HCPCS - Non-Drugs S0028 Blank INJECTION, FAMOTIDINE, 20 MG a $11.14 HCPCS - Non-Drugs S0030 Blank INJECTION, METRONIDAZOLE a $55.25 HCPCS - Non-Drugs S0032 Blank INJECTION, NAFCILLIN SODIUM a $87.11 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

S0034 Blank INJECTION, OFLOXACIN, 400 MG a $35.72 HCPCS - Non-Drugs S0039 Blank INJECTION, SULFAMETHOXAZOLE a $11.84 HCPCS - Non-Drugs S0040 Blank INJECTION, TICARCILLIN DISOD a $79.44 HCPCS - Non-Drugs S0073 Blank INJECTION, AZTREONAM, 500 MG a $98.12 HCPCS - Non-Drugs S0074 Blank INJECTION, CEFOTETAN DISODIU a $62.02 HCPCS - Non-Drugs S0077 Blank INJECTION, CLINDAMYCIN PHOSP a $17.73 HCPCS - Non-Drugs S0078 Blank INJECTION, FOSPHENYTOIN SODI a $962.31 HCPCS - Non-Drugs S0080 Blank INJECTION, PENTAMIDINE ISETH a $374.09 HCPCS - Non-Drugs S0081 Blank INJECTION, PIPERACILLIN SODI Blank $10.27 HCPCS - Non-Drugs S0088 Blank IMATINIB 100 MG Blank $117.70 HCPCS - Non-Drugs S0090 Blank SILDENAFIL CITRATE, 25 MG Blank $92.86 HCPCS - Non-Drugs S0091 Blank GRANISETRON 1MG a $295.87 HCPCS - Non-Drugs S0092 Blank HYDROMORPHONE 250 MG a $564.33 HCPCS - Non-Drugs S0093 Blank MORPHINE 500 MG a $1,297.76 HCPCS - Non-Drugs S0104 Blank ZIDOVUDINE, ORAL, 100 MG Blank $9.93 HCPCS - Non-Drugs S0106 Blank BUPROPION HCL SR 60 TABLETS a $596.97 HCPCS - Non-Drugs S0108 Blank MERCAPTOPURINE 50 MG a $20.60 HCPCS - Non-Drugs S0109 Blank METHADONE ORAL 5MG a $1.52 HCPCS - Non-Drugs S0119 Blank ONDANSETRON 4 MG a $50.24 HCPCS - Non-Drugs S0122 Blank INJ MENOTROPINS 75 IU Blank $383.43 HCPCS - Non-Drugs S0126 Blank INJ FOLLITROPIN ALFA 75 IU Blank $437.70 HCPCS - Non-Drugs S0128 Blank INJ FOLLITROPIN BETA 75 IU Blank $416.46 HCPCS - Non-Drugs S0132 Blank INJ GANIRELIX ACETAT 250 MCG a $576.67 HCPCS - Non-Drugs S0136 Blank CLOZAPINE, 25 MG a $7.08 HCPCS - Non-Drugs S0137 Blank DIDANOSINE, 25 MG a $17.88 HCPCS - Non-Drugs S0138 Blank FINASTERIDE, 5 MG a $15.39 HCPCS - Non-Drugs S0139 Blank MINOXIDIL, 10 MG Blank $6.10 HCPCS - Non-Drugs S0140 Blank SAQUINAVIR, 200 MG Blank $10.27 HCPCS - Non-Drugs S0142 Blank COLISTIMETHATE INH SOL MG Blank $8.85 HCPCS - Non-Drugs S0145 Blank PEG INTERFERON ALFA-2A/180 a $59.84 HCPCS - Non-Drugs S0148 Blank PEG INTERFERON ALFA-2B/10 Blank $433.33 HCPCS - Non-Drugs S0155 Blank EPOPROSTENOL DILUTANT Blank $13.24 HCPCS - Non-Drugs S0156 Blank EXEMESTANE, 25 MG Blank $45.91 HCPCS - Non-Drugs S0157 Blank BECAPLERMIN GEL 1%, 0.5 GM a $96.01 HCPCS - Non-Drugs S0160 Blank DEXTROAMPHETAMINE Blank $2.16 HCPCS - Non-Drugs S0164 Blank INJECTION PANTROPRAZOLE a $70.79 HCPCS - Non-Drugs S0166 Blank INJ OLANZAPINE 2.5MG a $32.15 HCPCS - Non-Drugs S0170 Blank ANASTROZOLE 1 MG a $44.14 HCPCS - Non-Drugs S0171 Blank BUMETANIDE 0.5 MG a $6.49 HCPCS - Non-Drugs S0172 Blank CHLORAMBUCIL 2 MG Blank $12.09 HCPCS - Non-Drugs S0174 Blank DOLASETRON 50 MG a $282.76 HCPCS - Non-Drugs S0175 Blank FLUTAMIDE 125 MG Blank $11.70 HCPCS - Non-Drugs S0176 Blank HYDROXYUREA 500 MG Blank $6.24 HCPCS - Non-Drugs S0177 Blank LEVAMISOLE 50 MG Blank $27.18 HCPCS - Non-Drugs S0178 Blank LOMUSTINE 10 MG Blank $93.30 HCPCS - Non-Drugs S0179 Blank MEGESTROL 20 MG a $2.10 HCPCS - Non-Drugs S0182 Blank PROCARBAZINE, ORAL Blank $281.92 HCPCS - Non-Drugs S0183 Blank PROCHLORPERAZINE 5 MG a $3.59 HCPCS - Non-Drugs S0187 Blank TAMOXIFEN 10 MG a $7.79 HCPCS - Non-Drugs S0189 Blank TESTOSTERONE PELLET 75 MG a $141.29 HCPCS - Non-Drugs S0190 Blank MIFEPRISTONE, ORAL, 200 MG Blank $275.72 HCPCS - Non-Drugs S0191 Blank MISOPROSTOL, ORAL, 200 MCG a $11.33 HCPCS - Non-Drugs S0395 Blank IMPRESSION CASTING FT Blank $145.78 HCPCS - Non-Drugs S0500 Blank DISPOS CONT LENS Blank $152.79 HCPCS - Non-Drugs S0504 Blank SINGL PRSCRP LENS Blank $144.53 HCPCS - Non-Drugs S0506 Blank BIFOC PRSCP LENS Blank $145.90 HCPCS - Non-Drugs S0508 Blank TRIFOC PRSCRP LENS Blank $191.26 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

S0510 Blank NON-PRSCRP LENS Blank $70.74 HCPCS - Non-Drugs S0512 Blank DAILY CONT LENS a $92.20 HCPCS - Non-Drugs S0514 Blank COLOR CONT LENS Blank $218.87 HCPCS - Non-Drugs S0515 Blank SCLERAL LENS LIQUID BANDAGE Blank $435.77 HCPCS - Non-Drugs S0516 Blank SAFETY FRAMES Blank $113.37 HCPCS - Non-Drugs S0518 Blank SUNGLASS FRAMES Blank $72.87 HCPCS - Non-Drugs S0580 Blank POLYCARB LENS Blank $90.75 HCPCS - Non-Drugs S0581 Blank NONSTND LENS Blank $821.04 HCPCS - Non-Drugs S0595 Blank NEW LENSES IN PTS OLD FRAME Blank $8.42 HCPCS - Non-Drugs S1001 Blank DELUXE ITEM Blank $26.43 HCPCS - Non-Drugs S1002 Blank CUSTOM ITEM Blank $26.81 HCPCS - Non-Drugs S1015 Blank IV TUBING EXTENSION SET a $42.82 HCPCS - Non-Drugs S1016 Blank NON-PVC INTRAVENOUS ADMINIST a $60.10 HCPCS - Non-Drugs S1040 Blank CRANIAL REMOLDING ORTHOSIS a $461.66 HCPCS - Non-Drugs S4989 Blank CONTRACEPT IUD a $747.33 HCPCS - Non-Drugs S4990 Blank NICOTINE PATCH LEGEND a $34.28 HCPCS - Non-Drugs S4993 Blank CONTRACEPTIVE PILLS FOR BC a $37.18 HCPCS - Non-Drugs S4995 Blank SMOKING CESSATION GUM a $73.00 HCPCS - Non-Drugs S5000 Blank PRESCRIPTION DRUG, GENERIC a $25.52 HCPCS - Non-Drugs S5001 Blank PRESCRIPTION DRUG,BRAND NAME a $109.07 HCPCS - Non-Drugs S5010 Blank 5% DEXTROSE AND 0.45% SALINE a $26.13 HCPCS - Non-Drugs S5012 Blank 5% DEXTROSE WITH POTASSIUM a $90.86 HCPCS - Non-Drugs S5013 Blank 5%DEXTROSE/0.45%SALINE1000ML a $25.34 HCPCS - Non-Drugs S5014 Blank D5W/0.45NS W KCL AND MGS04 a $15.27 HCPCS - Non-Drugs S5199 Blank PERSONAL CARE ITEM NOS EACH a $87.10 HCPCS - Non-Drugs S5497 Blank HIT CATH CARE NOC a $87.10 HCPCS - Non-Drugs S5498 Blank HIT SIMPLE CATH CARE a $44.24 HCPCS - Non-Drugs S5501 Blank HIT COMPLEX CATH CARE a $47.70 HCPCS - Non-Drugs S5502 Blank HIT INTERIM CATH CARE a $84.02 HCPCS - Non-Drugs S5517 Blank HIT DECLOTTING KIT a $97.14 HCPCS - Non-Drugs S5520 Blank HIT PICC INSERT KIT a $117.61 HCPCS - Non-Drugs S5521 Blank HIT MIDLINE CATH INSERT KIT Blank $173.93 HCPCS - Non-Drugs S5550 Blank INSULIN RAPID 5 U a $0.17 HCPCS - Non-Drugs S5551 Blank INSULIN MOST RAPID 5 U a $0.17 HCPCS - Non-Drugs S5552 Blank INSULIN INTERMED 5 U Blank $0.17 HCPCS - Non-Drugs S5553 Blank INSULIN LONG ACTING 5 U a $0.17 HCPCS - Non-Drugs S5560 Blank INSULIN REUSE PEN 1.5 ML Blank $4.22 HCPCS - Non-Drugs S8096 Blank PORTABLE PEAK FLOW METER a $63.67 HCPCS - Non-Drugs S8097 Blank ASTHMA KIT Blank $65.98 HCPCS - Non-Drugs S8100 Blank SPACER WITHOUT MASK a $65.64 HCPCS - Non-Drugs S8101 Blank SPACER WITH MASK a $214.05 HCPCS - Non-Drugs S8130 Blank INTERFERENTIAL STIM 2 CHAN Blank $5,991.55 HCPCS - Non-Drugs S8131 Blank INTERFERENTIAL STIM 4 CHAN Blank $1,659.92 HCPCS - Non-Drugs S8185 Blank FLUTTER DEVICE Blank $71.82 HCPCS - Non-Drugs S8186 Blank SWIVEL ADAPTOR Blank $5.76 HCPCS - Non-Drugs S8189 Blank TRACH SUPPLY NOC Blank $87.10 HCPCS - Non-Drugs S8210 Blank MUCUS TRAP a $1.49 HCPCS - Non-Drugs S8265 Blank HABERMAN FEEDER Blank $77.71 HCPCS - Non-Drugs S8301 Blank INFECT CONTROL SUPPLIES NOS Blank $87.10 HCPCS - Non-Drugs S8415 Blank SUPPLIES FOR HOME DELIVERY Blank $183.14 HCPCS - Non-Drugs S8420 Blank CUSTOM GRADIENT SLEEV/GLOV Blank $148.81 HCPCS - Non-Drugs S8421 Blank READY GRADIENT SLEEV/GLOV Blank $51.78 HCPCS - Non-Drugs S8422 Blank CUSTOM GRAD SLEEVE MED Blank $105.66 HCPCS - Non-Drugs S8423 Blank CUSTOM GRAD SLEEVE HEAVY a $243.39 HCPCS - Non-Drugs S8424 Blank READY GRADIENT SLEEVE a $64.95 HCPCS - Non-Drugs S8425 Blank CUSTOM GRAD GLOVE MED Blank $120.25 HCPCS - Non-Drugs S8426 Blank CUSTOM GRAD GLOVE HEAVY a $149.41 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

S8427 Blank READY GRADIENT GLOVE a $34.13 HCPCS - Non-Drugs S8428 Blank READY GRADIENT GAUNTLET Blank $83.82 HCPCS - Non-Drugs S8429 Blank GRADIENT PRESSURE WRAP Blank $87.10 HCPCS - Non-Drugs S8430 Blank PADDING FOR COMPRSSN BDG Blank $26.60 HCPCS - Non-Drugs S8431 Blank COMPRESSION BANDAGE a $18.85 HCPCS - Non-Drugs S8450 Blank SPLINT DIGIT a $40.21 HCPCS - Non-Drugs S8451 Blank SPLINT WRIST OR ANKLE a $51.92 HCPCS - Non-Drugs S8452 Blank SPLINT ELBOW Blank $45.92 HCPCS - Non-Drugs S8460 Blank CAMISOLE POST-MAST Blank $99.59 HCPCS - Non-Drugs S8490 Blank 100 INSULIN SYRINGES a $1.49 HCPCS - Non-Drugs S8999 Blank RESUSCITATION BAG Blank $268.95 HCPCS - Non-Drugs S9001 Blank HOME UTERINE MONITOR WITH OR Blank $136.87 HCPCS - Non-Drugs S9061 Blank MEDICAL SUPPLIES AND EQUIPME a $79.58 HCPCS - Non-Drugs S9208 Blank HOME MGMT PRETERM LABOR a $297.44 HCPCS - Non-Drugs S9211 Blank HOME MGMT GEST HYPERTENSION a $126.07 HCPCS - Non-Drugs S9212 Blank HM POSTPAR HYPER PER DIEM Blank $149.00 HCPCS - Non-Drugs S9213 Blank HM PREECLAMP PER DIEM a $294.10 HCPCS - Non-Drugs S9214 Blank HM GEST DM PER DIEM a $272.33 HCPCS - Non-Drugs S9325 Blank HIT PAIN MGMT PER DIEM Blank $151.93 HCPCS - Non-Drugs S9326 Blank HIT CONT PAIN PER DIEM a $215.70 HCPCS - Non-Drugs S9327 Blank HIT INT PAIN PER DIEM a $214.03 HCPCS - Non-Drugs S9328 Blank HIT PAIN IMP PUMP DIEM Blank $155.43 HCPCS - Non-Drugs S9329 Blank HIT CHEMO PER DIEM a $231.95 HCPCS - Non-Drugs S9330 Blank HIT CONT CHEM DIEM a $228.12 HCPCS - Non-Drugs S9331 Blank HIT INTERMIT CHEMO DIEM a $254.02 HCPCS - Non-Drugs S9335 Blank HT HEMODIALYSIS DIEM a $696.54 HCPCS - Non-Drugs S9336 Blank HIT CONT ANTICOAG DIEM a $218.16 HCPCS - Non-Drugs S9338 Blank HIT IMMUNOTHERAPY DIEM a $270.31 HCPCS - Non-Drugs S9339 Blank HIT PERITON DIALYSIS DIEM Blank $561.39 HCPCS - Non-Drugs S9340 Blank HIT ENTERAL PER DIEM a $90.15 HCPCS - Non-Drugs S9341 Blank HIT ENTERAL GRAV DIEM a $61.88 HCPCS - Non-Drugs S9342 Blank HIT ENTERAL PUMP DIEM a $66.48 HCPCS - Non-Drugs S9343 Blank HIT ENTERAL BOLUS NURS a $41.24 HCPCS - Non-Drugs S9345 Blank HIT ANTI-HEMOPHIL DIEM a $137.59 HCPCS - Non-Drugs S9346 Blank HIT ALPHA-1-PROTEINAS DIEM a $96.29 HCPCS - Non-Drugs S9347 Blank HIT LONGTERM INFUSION DIEM Blank $107.35 HCPCS - Non-Drugs S9348 Blank HIT SYMPATHOMIM DIEM a $238.15 HCPCS - Non-Drugs S9349 Blank HIT TOCOLYSIS DIEM a $343.51 HCPCS - Non-Drugs S9351 Blank HIT CONT ANTIEMETIC DIEM a $437.00 HCPCS - Non-Drugs S9353 Blank HIT CONT INSULIN DIEM a $597.53 HCPCS - Non-Drugs S9355 Blank HIT CHELATION DIEM a $178.45 HCPCS - Non-Drugs S9357 Blank HIT ENZYME REPLACE DIEM a $193.90 HCPCS - Non-Drugs S9359 Blank HIT ANTI-TNF PER DIEM a $354.85 HCPCS - Non-Drugs S9361 Blank HIT DIURETIC INFUS DIEM Blank $129.18 HCPCS - Non-Drugs S9363 Blank HIT ANTI-SPASMOTIC DIEM Blank $260.50 HCPCS - Non-Drugs S9364 Blank HIT TPN TOTAL DIEM a $406.17 HCPCS - Non-Drugs S9365 Blank HIT TPN 1 LITER DIEM a $468.11 HCPCS - Non-Drugs S9366 Blank HIT TPN 2 LITER DIEM a $571.24 HCPCS - Non-Drugs S9367 Blank HIT TPN 3 LITER DIEM a $636.05 HCPCS - Non-Drugs S9368 Blank HIT TPN OVER 3L DIEM a $814.86 HCPCS - Non-Drugs S9370 Blank HT INJ ANTIEMETIC DIEM a $165.07 HCPCS - Non-Drugs S9372 Blank HT INJ ANTICOAG DIEM Blank $111.93 HCPCS - Non-Drugs S9373 Blank HIT HYDRA TOTAL DIEM a $125.33 HCPCS - Non-Drugs S9374 Blank HIT HYDRA 1 LITER DIEM a $181.15 HCPCS - Non-Drugs S9375 Blank HIT HYDRA 2 LITER DIEM a $232.06 HCPCS - Non-Drugs S9376 Blank HIT HYDRA 3 LITER DIEM a $252.93 HCPCS - Non-Drugs S9377 Blank HIT HYDRA OVER 3L DIEM a $273.79 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

S9379 Blank HIT NOC PER DIEM a $87.10 HCPCS - Non-Drugs S9433 Blank MEDICAL FOOD ORAL 100% NUTR Blank $38.73 HCPCS - Non-Drugs S9434 Blank MOD SOLID FOOD SUPPL Blank $59.28 HCPCS - Non-Drugs S9435 Blank MEDICAL FOODS FOR INBORN ERR Blank $37.33 HCPCS - Non-Drugs S9490 Blank HIT CORTICOSTEROID/DIEM a $280.80 HCPCS - Non-Drugs S9494 Blank HIT ANTIBIOTIC TOTAL DIEM a $224.10 HCPCS - Non-Drugs S9497 Blank HIT ANTIBIOTIC Q3H DIEM a $279.44 HCPCS - Non-Drugs S9500 Blank HIT ANTIBIOTIC Q24H DIEM a $320.75 HCPCS - Non-Drugs S9501 Blank HIT ANTIBIOTIC Q12H DIEM a $313.49 HCPCS - Non-Drugs S9502 Blank HIT ANTIBIOTIC Q8H DIEM a $391.24 HCPCS - Non-Drugs S9503 Blank HIT ANTIBIOTIC Q6H DIEM a $360.73 HCPCS - Non-Drugs S9504 Blank HIT ANTIBIOTIC Q4H DIEM a $332.61 HCPCS - Non-Drugs S9529 Blank VENIPUNCTURE HOME/SNF a $111.75 HCPCS - Non-Drugs S9537 Blank HT HEM HORM INJ DIEM a $93.05 HCPCS - Non-Drugs S9538 Blank HIT BLOOD PRODUCTS DIEM Blank $301.74 HCPCS - Non-Drugs S9542 Blank HT INJ NOC PER DIEM a $87.10 HCPCS - Non-Drugs S9558 Blank HT INJ GROWTH HORM DIEM Blank $40.43 HCPCS - Non-Drugs S9559 Blank HIT INJ INTERFERON DIEM Blank $379.95 HCPCS - Non-Drugs S9560 Blank HT INJ HORMONE DIEM a $103.47 HCPCS - Non-Drugs S9562 Blank HT INJ PALIVIZUMAB DIEM a $103.47 HCPCS - Non-Drugs S9590 Blank HT IRRIGATION DIEM a $148.49 HCPCS - Non-Drugs S9810 Blank HT PHARM PER HOUR Blank $88.01 HCPCS - Non-Drugs T4521 Blank ADULT SIZE BRIEF/DIAPER SM Blank $1.57 HCPCS - Non-Drugs T4522 Blank ADULT SIZE BRIEF/DIAPER MED Blank $1.60 HCPCS - Non-Drugs T4523 Blank ADULT SIZE BRIEF/DIAPER LG Blank $1.73 HCPCS - Non-Drugs T4524 Blank ADULT SIZE BRIEF/DIAPER XL Blank $2.11 HCPCS - Non-Drugs T4525 Blank ADULT SIZE PULL-ON SM Blank $1.91 HCPCS - Non-Drugs T4526 Blank ADULT SIZE PULL-ON MED Blank $1.92 HCPCS - Non-Drugs T4527 Blank ADULT SIZE PULL-ON LG Blank $1.94 HCPCS - Non-Drugs T4528 Blank ADULT SIZE PULL-ON XL Blank $2.10 HCPCS - Non-Drugs T4529 Blank PED SIZE BRIEF/DIAPER SM/MED Blank $1.56 HCPCS - Non-Drugs T4530 Blank PED SIZE BRIEF/DIAPER LG Blank $1.79 HCPCS - Non-Drugs T4531 Blank PED SIZE PULL-ON SM/MED Blank $2.05 HCPCS - Non-Drugs T4532 Blank PED SIZE PULL-ON LG Blank $2.33 HCPCS - Non-Drugs T4533 Blank YOUTH SIZE BRIEF/DIAPER Blank $1.68 HCPCS - Non-Drugs T4534 Blank YOUTH SIZE PULL-ON Blank $2.07 HCPCS - Non-Drugs T4535 Blank DISPOSABLE LINER/SHIELD/PAD Blank $1.43 HCPCS - Non-Drugs T4536 Blank REUSABLE PULL-ON ANY SIZE Blank $1.63 HCPCS - Non-Drugs T4537 Blank REUSABLE UNDERPAD BED SIZE Blank $27.11 HCPCS - Non-Drugs T4539 Blank REUSE DIAPER/BRIEF ANY SIZE Blank $11.48 HCPCS - Non-Drugs T4540 Blank REUSABLE UNDERPAD CHAIR SIZE Blank $10.47 HCPCS - Non-Drugs T4541 Blank LARGE DISPOSABLE UNDERPAD Blank $1.35 HCPCS - Non-Drugs T4542 Blank SMALL DISPOSABLE UNDERPAD Blank $1.56 HCPCS - Non-Drugs T4543 Blank ADULT DISP BRIEF/DIAP ABV XL Blank $2.42 HCPCS - Non-Drugs T4544 Blank ADLT DISP UND/PULL ON ABV XL Blank $2.62 HCPCS - Non-Drugs T5001 Blank POSITION SEAT SPEC ORTH NEED Blank $800.61 HCPCS - Non-Drugs T5999 Blank SUPPLY, NOS Blank $26.48 HCPCS - Non-Drugs V2020 Blank VISION SVCS FRAMES PURCHASES Blank $116.64 HCPCS - Non-Drugs V2025 Blank EYEGLASSES DELUX FRAMES Blank $110.20 HCPCS - Non-Drugs V2100 Blank LENS SPHER SINGLE PLANO 4.00 Blank $78.61 HCPCS - Non-Drugs V2101 Blank SINGLE VISN SPHERE 4.12-7.00 Blank $83.02 HCPCS - Non-Drugs V2102 Blank SINGL VISN SPHERE 7.12-20.00 Blank $103.15 HCPCS - Non-Drugs V2103 Blank SPHEROCYLINDR 4.00D/12-2.00D Blank $72.21 HCPCS - Non-Drugs V2104 Blank SPHEROCYLINDR 4.00D/2.12-4D Blank $76.08 HCPCS - Non-Drugs V2105 Blank SPHEROCYLINDER 4.00D/4.25-6D Blank $81.21 HCPCS - Non-Drugs V2106 Blank SPHEROCYLINDER 4.00D/>6.00D Blank $87.16 HCPCS - Non-Drugs V2107 Blank SPHEROCYLINDER 4.25D/12-2D Blank $86.46 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

V2108 Blank SPHEROCYLINDER 4.25D/2.12-4D Blank $86.38 HCPCS - Non-Drugs V2109 Blank SPHEROCYLINDER 4.25D/4.25-6D Blank $94.28 HCPCS - Non-Drugs V2110 Blank SPHEROCYLINDER 4.25D/OVER 6D Blank $91.76 HCPCS - Non-Drugs V2111 Blank SPHEROCYLINDR 7.25D/.25-2.25 Blank $96.31 HCPCS - Non-Drugs V2112 Blank SPHEROCYLINDR 7.25D/2.25-4D Blank $103.66 HCPCS - Non-Drugs V2113 Blank SPHEROCYLINDR 7.25D/4.25-6D Blank $112.56 HCPCS - Non-Drugs V2114 Blank SPHEROCYLINDER OVER 12.00D Blank $120.23 HCPCS - Non-Drugs V2115 Blank LENS LENTICULAR BIFOCAL Blank $127.44 HCPCS - Non-Drugs V2118 Blank LENS ANISEIKONIC SINGLE Blank $128.41 HCPCS - Non-Drugs V2121 Blank LENTICULAR LENS, SINGLE Blank $130.78 HCPCS - Non-Drugs V2199 Blank LENS SINGLE VISION NOT OTH C Blank $78.61 HCPCS - Non-Drugs V2200 Blank LENS SPHER BIFOC PLANO 4.00D Blank $93.46 HCPCS - Non-Drugs V2201 Blank LENS SPHERE BIFOCAL 4.12-7.0 Blank $100.69 HCPCS - Non-Drugs V2202 Blank LENS SPHERE BIFOCAL 7.12-20. Blank $111.06 HCPCS - Non-Drugs V2203 Blank LENS SPHCYL BIFOCAL 4.00D/.1 Blank $94.95 HCPCS - Non-Drugs V2204 Blank LENS SPHCY BIFOCAL 4.00D/2.1 Blank $97.72 HCPCS - Non-Drugs V2205 Blank LENS SPHCY BIFOCAL 4.00D/4.2 Blank $102.88 HCPCS - Non-Drugs V2206 Blank LENS SPHCY BIFOCAL 4.00D/OVE Blank $111.10 HCPCS - Non-Drugs V2207 Blank LENS SPHCY BIFOCAL 4.25-7D/. Blank $102.32 HCPCS - Non-Drugs V2208 Blank LENS SPHCY BIFOCAL 4.25-7/2. Blank $106.12 HCPCS - Non-Drugs V2209 Blank LENS SPHCY BIFOCAL 4.25-7/4. Blank $111.05 HCPCS - Non-Drugs V2210 Blank LENS SPHCY BIFOCAL 4.25-7/OV Blank $121.78 HCPCS - Non-Drugs V2211 Blank LENS SPHCY BIFO 7.25-12/.25- Blank $123.26 HCPCS - Non-Drugs V2212 Blank LENS SPHCYL BIFO 7.25-12/2.2 Blank $126.14 HCPCS - Non-Drugs V2213 Blank LENS SPHCYL BIFO 7.25-12/4.2 Blank $126.39 HCPCS - Non-Drugs V2214 Blank LENS SPHCYL BIFOCAL OVER 12. Blank $136.90 HCPCS - Non-Drugs V2215 Blank LENS LENTICULAR BIFOCAL Blank $146.94 HCPCS - Non-Drugs V2218 Blank LENS ANISEIKONIC BIFOCAL Blank $160.87 HCPCS - Non-Drugs V2219 Blank LENS BIFOCAL SEG WIDTH OVER Blank $83.85 HCPCS - Non-Drugs V2220 Blank LENS BIFOCAL ADD OVER 3.25D Blank $77.25 HCPCS - Non-Drugs V2221 Blank LENTICULAR LENS, BIFOCAL Blank $145.71 HCPCS - Non-Drugs V2299 Blank LENS BIFOCAL SPECIALITY Blank $75.92 HCPCS - Non-Drugs V2300 Blank LENS SPHERE TRIFOCAL 4.00D Blank $113.35 HCPCS - Non-Drugs V2301 Blank LENS SPHERE TRIFOCAL 4.12-7. Blank $130.17 HCPCS - Non-Drugs V2302 Blank LENS SPHERE TRIFOCAL 7.12-20 Blank $132.58 HCPCS - Non-Drugs V2303 Blank LENS SPHCY TRIFOCAL 4.0/.12- Blank $112.76 HCPCS - Non-Drugs V2304 Blank LENS SPHCY TRIFOCAL 4.0/2.25 Blank $116.41 HCPCS - Non-Drugs V2305 Blank LENS SPHCY TRIFOCAL 4.0/4.25 Blank $129.22 HCPCS - Non-Drugs V2306 Blank LENS SPHCYL TRIFOCAL 4.00/>6 Blank $132.63 HCPCS - Non-Drugs V2307 Blank LENS SPHCY TRIFOCAL 4.25-7/. Blank $127.00 HCPCS - Non-Drugs V2308 Blank LENS SPHC TRIFOCAL 4.25-7/2. Blank $131.28 HCPCS - Non-Drugs V2309 Blank LENS SPHC TRIFOCAL 4.25-7/4. Blank $143.25 HCPCS - Non-Drugs V2310 Blank LENS SPHC TRIFOCAL 4.25-7/>6 Blank $141.73 HCPCS - Non-Drugs V2311 Blank LENS SPHC TRIFO 7.25-12/.25- Blank $150.36 HCPCS - Non-Drugs V2312 Blank LENS SPHC TRIFO 7.25-12/2.25 Blank $147.84 HCPCS - Non-Drugs V2313 Blank LENS SPHC TRIFO 7.25-12/4.25 Blank $165.44 HCPCS - Non-Drugs V2314 Blank LENS SPHCYL TRIFOCAL OVER 12 Blank $171.99 HCPCS - Non-Drugs V2315 Blank LENS LENTICULAR TRIFOCAL Blank $193.24 HCPCS - Non-Drugs V2318 Blank LENS ANISEIKONIC TRIFOCAL Blank $230.74 HCPCS - Non-Drugs V2319 Blank LENS TRIFOCAL SEG WIDTH > 28 Blank $90.98 HCPCS - Non-Drugs V2320 Blank LENS TRIFOCAL ADD OVER 3.25D Blank $99.03 HCPCS - Non-Drugs V2321 Blank LENTICULAR LENS, TRIFOCAL Blank $189.67 HCPCS - Non-Drugs V2399 Blank LENS TRIFOCAL SPECIALITY Blank $184.95 HCPCS - Non-Drugs V2410 Blank LENS VARIAB ASPHERICITY SING Blank $151.92 HCPCS - Non-Drugs V2430 Blank LENS VARIABLE ASPHERICITY BI Blank $176.15 HCPCS - Non-Drugs V2499 Blank VARIABLE ASPHERICITY LENS Blank $136.50 HCPCS - Non-Drugs V2500 Blank CONTACT LENS PMMA SPHERICAL Blank $141.59 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

V2501 Blank CNTCT LENS PMMA-TORIC/PRISM Blank $197.64 HCPCS - Non-Drugs V2502 Blank CONTACT LENS PMMA BIFOCAL Blank $246.18 HCPCS - Non-Drugs V2503 Blank CNTCT LENS PMMA COLOR VISION Blank $219.77 HCPCS - Non-Drugs V2510 Blank CNTCT GAS PERMEABLE SPHERICL Blank $182.29 HCPCS - Non-Drugs V2511 Blank CNTCT TORIC PRISM BALLAST Blank $254.41 HCPCS - Non-Drugs V2512 Blank CNTCT LENS GAS PERMBL BIFOCL Blank $297.49 HCPCS - Non-Drugs V2513 Blank CONTACT LENS EXTENDED WEAR Blank $261.84 HCPCS - Non-Drugs V2520 Blank CONTACT LENS HYDROPHILIC Blank $172.59 HCPCS - Non-Drugs V2521 Blank CNTCT LENS HYDROPHILIC TORIC Blank $279.54 HCPCS - Non-Drugs V2522 Blank CNTCT LENS HYDROPHIL BIFOCL Blank $281.69 HCPCS - Non-Drugs V2523 Blank CNTCT LENS HYDROPHIL EXTEND Blank $236.56 HCPCS - Non-Drugs V2530 Blank CONTACT LENS GAS IMPERMEABLE Blank $333.58 HCPCS - Non-Drugs V2531 Blank CONTACT LENS GAS PERMEABLE Blank $701.39 HCPCS - Non-Drugs V2599 Blank CONTACT LENS/ES OTHER TYPE Blank $118.29 HCPCS - Non-Drugs V2600 Blank HAND HELD LOW VISION AIDS Blank $109.18 HCPCS - Non-Drugs V2610 Blank SINGLE LENS SPECTACLE MOUNT Blank $172.26 HCPCS - Non-Drugs V2615 Blank TELESCOP/OTHR COMPOUND LENS Blank $393.99 HCPCS - Non-Drugs V2623 Blank PLASTIC EYE PROSTH CUSTOM Blank $3,229.10 HCPCS - Non-Drugs V2624 Blank POLISHING ARTIFICAL EYE Blank $49.03 HCPCS - Non-Drugs V2625 Blank ENLARGEMNT OF EYE PROSTHESIS Blank $1,383.53 HCPCS - Non-Drugs V2626 Blank REDUCTION OF EYE PROSTHESIS Blank $823.93 HCPCS - Non-Drugs V2627 Blank SCLERAL COVER SHELL Blank $4,397.35 HCPCS - Non-Drugs V2628 Blank FABRICATION & FITTING Blank $1,133.74 HCPCS - Non-Drugs V2629 Blank PROSTHETIC EYE OTHER TYPE Blank $1,729.60 HCPCS - Non-Drugs V2630 Blank ANTER CHAMBER INTRAOCUL LENS Blank $477.38 HCPCS - Non-Drugs V2631 Blank IRIS SUPPORT INTRAOCLR LENS Blank $477.38 HCPCS - Non-Drugs V2632 Blank POST CHMBR INTRAOCULAR LENS Blank $477.38 HCPCS - Non-Drugs V2700 Blank BALANCE LENS Blank $84.63 HCPCS - Non-Drugs V2702 Blank DELUXE LENS FEATURE Blank $34.67 HCPCS - Non-Drugs V2710 Blank GLASS/PLASTIC SLAB OFF PRISM Blank $115.34 HCPCS - Non-Drugs V2715 Blank PRISM LENS/ES Blank $45.03 HCPCS - Non-Drugs V2718 Blank FRESNELL PRISM PRESS-ON LENS Blank $65.39 HCPCS - Non-Drugs V2730 Blank SPECIAL BASE CURVE Blank $55.47 HCPCS - Non-Drugs V2744 Blank TINT PHOTOCHROMATIC LENS/ES Blank $49.46 HCPCS - Non-Drugs V2745 Blank TINT, ANY COLOR/SOLID/GRAD Blank $26.82 HCPCS - Non-Drugs V2750 Blank ANTI-REFLECTIVE COATING Blank $54.44 HCPCS - Non-Drugs V2755 Blank UV LENS/ES Blank $49.07 HCPCS - Non-Drugs V2756 Blank EYE GLASS CASE Blank $3.85 HCPCS - Non-Drugs V2760 Blank SCRATCH RESISTANT COATING Blank $48.99 HCPCS - Non-Drugs V2761 Blank MIRROR COATING Blank $44.64 HCPCS - Non-Drugs V2762 Blank POLARIZATION, ANY LENS Blank $95.94 HCPCS - Non-Drugs V2770 Blank OCCLUDER LENS/ES Blank $53.87 HCPCS - Non-Drugs V2780 Blank OVERSIZE LENS/ES Blank $45.00 HCPCS - Non-Drugs V2781 Blank PROGRESSIVE LENS PER LENS Blank $89.69 HCPCS - Non-Drugs V2782 Blank LENS, 1.54-1.65 P/1.60-1.79G Blank $101.90 HCPCS - Non-Drugs V2783 Blank LENS, >= 1.66 P/>=1.80 G Blank $112.17 HCPCS - Non-Drugs V2784 Blank LENS POLYCARB OR EQUAL Blank $81.80 HCPCS - Non-Drugs V2785 Blank CORNEAL TISSUE PROCESSING Blank $5,888.66 HCPCS - Non-Drugs V2786 Blank OCCUPATIONAL MULTIFOCAL LENS Blank $139.01 HCPCS - Non-Drugs V2787 Blank ASTIGMATISM-CORRECT FUNCTION Blank $931.45 HCPCS - Non-Drugs V2788 Blank PRESBYOPIA-CORRECT FUNCTION Blank $1,604.16 HCPCS - Non-Drugs V2790 Blank AMNIOTIC MEMBRANE Blank $1,107.76 HCPCS - Non-Drugs V2797 Blank VIS ITEM/SVC IN OTHER CODE Blank $268.28 HCPCS - Non-Drugs V2799 Blank MISC VISION ITEM OR SERVICE Blank $35.79 HCPCS - Non-Drugs V5011 Blank HEARING AID FITTING/CHECKING Blank $226.10 HCPCS - Non-Drugs V5014 Blank HEARING AID REPAIR/MODIFYING Blank $273.08 HCPCS - Non-Drugs V5020 Blank CONFORMITY EVALUATION Blank $127.24 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

V5030 Blank BODY-WORN HEARING AID AIR Blank $2,495.94 HCPCS - Non-Drugs V5040 Blank BODY-WORN HEARING AID BONE Blank $1,859.44 HCPCS - Non-Drugs V5050 Blank HEARING AID MONAURAL IN EAR Blank $2,173.81 HCPCS - Non-Drugs V5060 Blank BEHIND EAR HEARING AID Blank $1,790.87 HCPCS - Non-Drugs V5070 Blank GLASSES AIR CONDUCTION Blank $925.38 HCPCS - Non-Drugs V5080 Blank GLASSES BONE CONDUCTION Blank $2,563.21 HCPCS - Non-Drugs V5090 Blank HEARING AID DISPENSING FEE Blank $810.24 HCPCS - Non-Drugs V5100 Blank BODY-WORN BILAT HEARING AID Blank $6,765.04 HCPCS - Non-Drugs V5110 Blank HEARING AID DISPENSING FEE Blank $827.06 HCPCS - Non-Drugs V5120 Blank BODY-WORN BINAUR HEARING AID Blank $3,657.69 HCPCS - Non-Drugs V5130 Blank IN EAR BINAURAL HEARING AID Blank $4,845.89 HCPCS - Non-Drugs V5140 Blank BEHIND EAR BINAUR HEARING AI Blank $5,862.39 HCPCS - Non-Drugs V5150 Blank GLASSES BINAURAL HEARING AID Blank $7,659.56 HCPCS - Non-Drugs V5160 Blank DISPENSING FEE BINAURAL Blank $1,021.11 HCPCS - Non-Drugs V5170 Blank WITHIN EAR CROS HEARING AID Blank $2,977.20 HCPCS - Non-Drugs V5180 Blank BEHIND EAR CROS HEARING AID Blank $2,495.94 HCPCS - Non-Drugs V5190 Blank GLASSES CROS HEARING AID Blank $2,943.56 HCPCS - Non-Drugs V5200 Blank CROS HEARING AID DISPENS FEE Blank $818.00 HCPCS - Non-Drugs V5210 Blank IN EAR BICROS HEARING AID Blank $3,248.88 HCPCS - Non-Drugs V5220 Blank BEHIND EAR BICROS HEARING AI Blank $3,115.63 HCPCS - Non-Drugs V5230 Blank GLASSES BICROS HEARING AID Blank $3,225.59 HCPCS - Non-Drugs V5240 Blank DISPENSING FEE BICROS Blank $852.93 HCPCS - Non-Drugs V5241 Blank DISPENSING FEE, MONAURAL Blank $498.13 HCPCS - Non-Drugs V5242 Blank HEARING AID, MONAURAL, CIC Blank $2,123.73 HCPCS - Non-Drugs V5243 Blank HEARING AID, MONAURAL, ITC Blank $2,236.92 HCPCS - Non-Drugs V5244 Blank HEARING AID, PROG, MON, CIC Blank $2,941.91 HCPCS - Non-Drugs V5245 Blank HEARING AID, PROG, MON, ITC Blank $3,417.66 HCPCS - Non-Drugs V5246 Blank HEARING AID, PROG, MON, ITE Blank $2,484.47 HCPCS - Non-Drugs V5247 Blank HEARING AID, PROG, MON, BTE Blank $2,959.59 HCPCS - Non-Drugs V5248 Blank HEARING AID, BINAURAL, CIC Blank $2,734.29 HCPCS - Non-Drugs V5249 Blank HEARING AID, BINAURAL, ITC Blank $2,192.34 HCPCS - Non-Drugs V5250 Blank HEARING AID, PROG, BIN, CIC Blank $7,105.79 HCPCS - Non-Drugs V5251 Blank HEARING AID, PROG, BIN, ITC Blank $6,354.98 HCPCS - Non-Drugs V5252 Blank HEARING AID, PROG, BIN, ITE Blank $9,078.79 HCPCS - Non-Drugs V5253 Blank HEARING AID, PROG, BIN, BTE Blank $4,218.48 HCPCS - Non-Drugs V5254 Blank HEARING ID, DIGIT, MON, CIC Blank $1,880.28 HCPCS - Non-Drugs V5255 Blank HEARING AID, DIGIT, MON, ITC Blank $1,299.53 HCPCS - Non-Drugs V5256 Blank HEARING AID, DIGIT, MON, ITE Blank $1,121.12 HCPCS - Non-Drugs V5257 Blank HEARING AID, DIGIT, MON, BTE Blank $3,514.86 HCPCS - Non-Drugs V5258 Blank HEARING AID, DIGIT, BIN, CIC Blank $6,625.15 HCPCS - Non-Drugs V5259 Blank HEARING AID, DIGIT, BIN, ITC Blank $4,981.32 HCPCS - Non-Drugs V5260 Blank HEARING AID, DIGIT, BIN, ITE Blank $4,649.23 HCPCS - Non-Drugs V5261 Blank HEARING AID, DIGIT, BIN, BTE Blank $6,363.25 HCPCS - Non-Drugs V5262 Blank HEARING AID, DISP, MONAURAL Blank $299.80 HCPCS - Non-Drugs V5263 Blank HEARING AID, DISP, BINAURAL Blank $228.68 HCPCS - Non-Drugs V5264 Blank EAR MOLD/INSERT Blank $122.24 HCPCS - Non-Drugs V5265 Blank EAR MOLD/INSERT, DISP Blank $118.45 HCPCS - Non-Drugs V5266 Blank BATTERY FOR HEARING DEVICE Blank $2.09 HCPCS - Non-Drugs V5267 Blank HEARING AID SUP/ACCESS/DEV Blank $14.44 HCPCS - Non-Drugs V5268 Blank ALD TELEPHONE AMPLIFIER Blank $123.98 HCPCS - Non-Drugs V5269 Blank ALERTING DEVICE, ANY TYPE Blank $155.84 HCPCS - Non-Drugs V5270 Blank ALD, TV AMPLIFIER, ANY TYPE Blank $300.76 HCPCS - Non-Drugs V5271 Blank ALD, TV CAPTION DECODER Blank $523.49 HCPCS - Non-Drugs V5272 Blank TDD Blank $371.30 HCPCS - Non-Drugs V5273 Blank ALD FOR COCHLEAR IMPLANT Blank $681.93 HCPCS - Non-Drugs V5274 Blank ALD UNSPECIFIED Blank $188.54 HCPCS - Non-Drugs V5275 Blank EAR IMPRESSION Blank $84.04 HCPCS - Non-Drugs

Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2

V5281 Blank ALD FM/DM SYSTEM, MONAURAL Blank $165.98 HCPCS - Non-Drugs V5282 Blank ALD FM/DM SYSTEM BINAURAL Blank $608.97 HCPCS - Non-Drugs V5283 Blank ALD NECK, LOOP IND RECEIVER Blank $516.10 HCPCS - Non-Drugs V5284 Blank ALD FM/DM EAR LEVEL RECEIVER Blank $594.16 HCPCS - Non-Drugs V5285 Blank ALD FM/DM AUD INPUT RECEIVER Blank $533.78 HCPCS - Non-Drugs V5286 Blank ALD BLU TOOTH FM/DM RECEIVER Blank $221.71 HCPCS - Non-Drugs V5287 Blank ALD FM/DM RECEIVER, NOS Blank $448.00 HCPCS - Non-Drugs V5288 Blank ALD FM/DM TRANSMITTER ALD Blank $487.69 HCPCS - Non-Drugs V5289 Blank ALD FM/DM ADAPT/BOOT COUPLIN Blank $135.28 HCPCS - Non-Drugs V5290 Blank ALD TRANSMITTER MICROPHONE Blank $309.86 HCPCS - Non-Drugs V5298 Blank HEARING AID NOC Blank $868.01 HCPCS - Non-Drugs V5299 Blank HEARING SERVICE Blank $168.58 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.