dme-orthotic-prosthetic fee schedule effective … · 01/01/2020 · e0110 nu - fee on file yes...

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeB9002 KR - Fee on File Yes ENTERAL NUTRITION INFUSION PUMP,

ANY TYPE0 999 07/01/2019 12/31/9999 1 2.64

B9002 NU - Fee on File Yes ENTERAL NUTRITION INFUSION PUMP, ANY TYPE

0 999 07/01/2019 12/31/9999 1 792.37

B9002 RR - Fee on File Yes ENTERAL NUTRITION INFUSION PUMP, ANY TYPE

0 999 07/01/2019 12/31/9999 1 79.24

B9002 UE - Fee on File Yes ENTERAL NUTRITION INFUSION PUMP, ANY TYPE

0 999 07/01/2019 12/31/9999 1 396.18

B9004 KR - Fee on File Yes PARENTERAL NUTRITION INFUSION PUMP, PORTABLE

0 999 07/01/2019 12/31/9999 1 8.05

B9004 NU - Fee on File Yes PARENTERAL NUTRITION INFUSION PUMP, PORTABLE

0 999 07/01/2019 12/31/9999 1 2,413.40

B9004 RR - Fee on File Yes PARENTERAL NUTRITION INFUSION PUMP, PORTABLE

0 999 07/01/2019 12/31/9999 1 241.34

B9004 UE - Fee on File Yes PARENTERAL NUTRITION INFUSION PUMP, PORTABLE

0 999 07/01/2019 12/31/9999 1 1,206.70

B9006 KR - Fee on File Yes PARENTERAL NUTRITION INFUSION PUMP, STATIONARY

0 999 07/01/2019 12/31/9999 1 8.05

B9006 NU - Fee on File Yes PARENTERAL NUTRITION INFUSION PUMP, STATIONARY

0 999 07/01/2019 12/31/9999 1 2,413.40

B9006 RR - Fee on File Yes PARENTERAL NUTRITION INFUSION PUMP, STATIONARY

0 999 07/01/2019 12/31/9999 1 241.34

B9006 UE - Fee on File Yes PARENTERAL NUTRITION INFUSION PUMP, STATIONARY

0 999 07/01/2019 12/31/9999 1 1,206.70

E0100 NU - Fee on File Yes CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIP

0 999 07/01/2019 12/31/9999 1 16.50

E0105 NU - Fee on File Yes CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED WITH TIP

0 999 07/01/2019 12/31/9999 1 45.24

E0110 NU - Fee on File Yes CRUTCHES, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR OR FIXED PAIR COMPLETE WITH TIPS AND HANDGRIPS

0 999 07/01/2019 12/31/9999 1 67.74

E0111 NU - Fee on File Yes CRUTCH, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS ADJUSTABLE OR FIXED EACH WITH TIP AND HANDGRIP

0 999 07/01/2019 12/31/9999 1 41.69

E0112 NU - Fee on File Yes CRUTCHES, UNDERARM, WOOD, ADJUSTABLE OR FIXED PAIR WITH PADS TIPS AND HANDGRIPS

0 999 07/01/2019 12/31/9999 1 34.09

E0113 NU - Fee on File Yes CRUTCH, UNDERARM, WOOD, ADJUSTABLE OR FIXED, EACH, WITH PAD, TIP AND HANDGRIP

0 999 07/01/2019 12/31/9999 1 19.47

E0114 NU - Fee on File Yes CRUTCHES, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED PAIR WITH PADS TIPS AND HANDGRIPS

0 999 07/01/2019 12/31/9999 1 43.47

E0116 NU - Fee on File Yes CRUTCH, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, WITH PAD, TIP, AND HANDGRIP

0 999 07/01/2019 12/31/9999 1 24.25

E0117 NU - Fee on File Yes CRUTCH, UNDERARM, ARTICULATING, SPRING ASSISTED, EACH

0 20 07/01/2019 12/31/9999 1 177.44

E0130 NU - Fee on File Yes WALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHT

0 999 07/01/2019 12/31/9999 1 43.18

E0135 NU - Fee on File Yes WALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIGHT

0 999 07/01/2019 12/31/9999 1 47.72

E0141 NU - Fee on File Yes WALKER, RIGID, WHEELED, ADJUSTABLE OR FIXED HEIGHT

0 999 07/01/2019 12/31/9999 1 66.00

E0143 NU - Fee on File Yes WALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED HEIGHT

0 999 07/01/2019 12/31/9999 1 63.72

E0147 KR - Fee on File Yes WALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE

0 999 07/01/2019 12/31/9999 1 1.34

DME-ORTHOTIC-PROSTHETIC FEE SCHEDULE Effective 01/01/2020Print Date 5/5/20Price does not include cutbacks, assessment fees, etc. Payment is not guaranteed.

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0147 NU - Fee on File Yes WALKER, HEAVY DUTY, MULTIPLE

BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE

0 999 07/01/2019 12/31/9999 1 402.18

E0147 RR - Fee on File Yes WALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE

0 999 07/01/2019 12/31/9999 1 40.22

E0147 UE - Fee on File Yes WALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE

0 999 07/01/2019 12/31/9999 1 201.10

E0148 KR - Fee on File Yes WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH

0 999 07/01/2019 12/31/9999 1 0.29

E0148 NU - Fee on File Yes WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH

0 999 07/01/2019 12/31/9999 1 85.71

E0148 RR - Fee on File Yes WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH

0 999 07/01/2019 12/31/9999 1 8.57

E0148 UE - Fee on File Yes WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH

0 999 07/01/2019 12/31/9999 1 42.86

E0149 KR - Fee on File Yes WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE

0 999 07/01/2019 12/31/9999 1 0.46

E0149 NU - Fee on File Yes WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE

0 999 07/01/2019 12/31/9999 1 138.64

E0149 RR - Fee on File Yes WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE

0 999 07/01/2019 12/31/9999 1 13.86

E0149 UE - Fee on File Yes WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE

0 999 07/01/2019 12/31/9999 1 69.32

E0153 NU - Fee on File Yes PLATFORM ATTACHMENT, FOREARM CRUTCH, EACH

3 20 07/01/2019 12/31/9999 2 63.92

E0154 NU - Fee on File Yes PLATFORM ATTACHMENT, WALKER EACH

0 999 07/01/2019 12/31/9999 1 48.88E0155 NU - Fee on File Yes WHEEL ATTACHMENT, RIGID PICK-UP

WALKER, PER PAIR SEAT ATTACHMENT, WALKER

0 999 07/01/2019 12/31/9999 1 19.55

E0156 NU - Fee on File Yes SEAT ATTACHMENT, WALKER 0 999 07/01/2019 12/31/9999 1 17.20E0157 NU - Fee on File Yes CRUTCH ATTACHMENT, WALKER, EACH 0 999 07/01/2019 12/31/9999 1 51.56E0158 NU - Fee on File Yes LEG EXTENSIONS FOR WALKER, PER

SET OF FOUR (4)0 999 07/01/2019 12/31/9999 1 20.07

E0159 NU - Fee on File Yes BRAKE ATTACHMENT FOR WHEELED WALKER, REPLACEMENT EACH

0 999 07/01/2019 12/31/9999 4 13.35

E0163 NU - Fee on File Yes COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED ARMS

0 999 07/01/2019 12/31/9999 1 68.37

E0165 KR - Fee on File Yes COMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS

0 999 07/01/2019 12/31/9999 1 0.42

E0165 NU - Fee on File Yes COMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS

0 999 07/01/2019 12/31/9999 1 124.96

E0165 RR - Fee on File Yes COMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS

0 999 07/01/2019 12/31/9999 1 12.50

E0165 UE - Fee on File Yes COMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS

0 999 07/01/2019 12/31/9999 1 62.48

E0167 NU - Fee on File Yes PAIL OR PAN FOR USE WITH COMMODE CHAIR, REPLACEMENT ONLY

0 999 07/01/2019 12/31/9999 1 10.15

E0168 KR - Fee on File Yes COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH

0 999 07/01/2019 12/31/9999 1 0.40

E0168 NU - Fee on File Yes COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH

0 999 07/01/2019 12/31/9999 1 119.45

E0168 RR - Fee on File Yes COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH

0 999 07/01/2019 12/31/9999 1 11.94

E0168 UE - Fee on File Yes COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH

0 999 07/01/2019 12/31/9999 1 59.73

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0181 KR - Fee on File Yes POWERED PRESSURE REDUCING

MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP,

0 999 07/01/2019 12/31/9999 1 0.62

E0181 NU - Fee on File Yes POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP,

0 999 07/01/2019 12/31/9999 1 186.32

E0181 RR - Fee on File Yes POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP,

0 999 07/01/2019 12/31/9999 1 18.63

E0181 UE - Fee on File Yes POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP,

0 999 07/01/2019 12/31/9999 1 93.16

E0184 NU - Fee on File Yes DRY PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 158.32E0185 KR - Fee on File Yes GEL OR GEL LIKE PRESSURE PAD FOR

MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 0.66

E0185 NU - Fee on File Yes GEL OR GEL LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 197.53

E0185 RR - Fee on File Yes GEL OR GEL LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 19.75

E0185 UE - Fee on File Yes GEL OR GEL LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 98.77

E0186 KR - Fee on File Yes AIR PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 0.53E0186 NU - Fee on File Yes AIR PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 158.88E0186 RR - Fee on File Yes AIR PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 15.89E0186 UE - Fee on File Yes AIR PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 79.44E0187 KR - Fee on File Yes WATER PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 0.61E0187 NU - Fee on File Yes WATER PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 181.68E0187 RR - Fee on File Yes WATER PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 18.17E0187 UE - Fee on File Yes WATER PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 90.84E0188 NU - Fee on File Yes SYNTHETIC SHEEPSKIN PAD 0 20 07/01/2019 12/31/9999 1 22.69E0189 NU - Fee on File Yes LAMBSWOOL SHEEPSKIN PAD, ANY SIZE 0 20 07/01/2019 12/31/9999 1 40.69E0191 NU - Fee on File Yes HEEL OR ELBOW PROTECTOR, EACH 0 999 07/01/2019 12/31/9999 4 8.85E0194 KR - Fee on File Yes AIR FLUIDIZED BED 0 20 07/01/2019 12/31/9999 1 99.92E0194 RR - Fee on File Yes AIR FLUIDIZED BED 0 20 07/01/2019 12/31/9999 1 2,997.58E0196 KR - Fee on File Yes GEL PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 0.85E0196 NU - Fee on File Yes GEL PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 254.32E0196 RR - Fee on File Yes GEL PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 25.43E0196 UE - Fee on File Yes GEL PRESSURE MATTRESS 0 999 07/01/2019 12/31/9999 1 127.16E0197 KR - Fee on File Yes AIR PRESSURE PAD FOR MATTRESS,

STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 0.66

E0197 NU - Fee on File Yes AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 197.12

E0197 RR - Fee on File Yes AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 19.71

E0197 UE - Fee on File Yes AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 98.56

E0198 KR - Fee on File Yes WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 0.58

E0198 NU - Fee on File Yes WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 173.44

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0198 RR - Fee on File Yes WATER PRESSURE PAD FOR MATTRESS,

STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 17.34

E0198 UE - Fee on File Yes WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 86.72

E0199 NU - Fee on File Yes DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 25.10

E0200 RR - Fee on File Yes HEAT LAMP, WITHOUT STAND (TABLE MODEL), INCLUDES BULB, OR INFRARED ELEMENT

0 20 07/01/2019 12/31/9999 1 6.05

E0200 KR - Fee on File Yes HEAT LAMP, WITHOUT STAND (TABLE MODEL), INCLUDES BULB, OR INFRARED ELEMENT

0 20 07/01/2015 12/31/9999 1 0.20

E0202 KR - Fee on File Yes PHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOTOMETER

0 1 07/01/2011 12/31/9999 1 75.00

E0205 KR - Fee on File Yes HEAT LAMP, WITH STAND, INCLUDES BULB, OR INFRARED ELEMENT

0 20 07/01/2019 12/31/9999 1 0.56

E0205 RR - Fee on File Yes HEAT LAMP, WITH STAND, INCLUDES BULB, OR INFRARED ELEMENT

0 20 07/01/2019 12/31/9999 1 16.71

E0210 NU - Fee on File Yes ELECTRIC HEAT PAD, STANDARD 0 999 07/01/2019 12/31/9999 1 25.77E0215 NU - Fee on File Yes ELECTRIC HEAT PAD, MOIST 0 999 07/01/2019 12/31/9999 1 55.46E0217 KR - Fee on File Yes WATER CIRCULATING HEAT PAD WITH

PUMP0 20 07/01/2019 12/31/9999 1 1.52

E0217 NU - Fee on File Yes WATER CIRCULATING HEAT PAD WITH PUMP

0 20 07/01/2019 12/31/9999 1 454.81

E0217 RR - Fee on File Yes WATER CIRCULATING HEAT PAD WITH PUMP

0 20 07/01/2019 12/31/9999 1 45.48

E0217 UE - Fee on File Yes WATER CIRCULATING HEAT PAD WITH PUMP

0 20 07/01/2019 12/31/9999 1 227.40

E0235 KR - Fee on File Yes PARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)

0 999 07/01/2019 12/31/9999 1 0.53

E0235 NU - Fee on File Yes PARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)

0 999 07/01/2019 12/31/9999 1 158.88

E0235 RR - Fee on File Yes PARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)

0 999 07/01/2019 12/31/9999 1 15.89

E0235 UE - Fee on File Yes PARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)

0 999 07/01/2019 12/31/9999 1 79.44

E0240 NU - Priced by PA Yes BATH/SHOWER CHAIR, WITH OR WITHOUT WHEELS, ANY SIZE

0 999 01/01/2004 12/31/9999 1 0.00

E0244 NU - Fee on File Yes RAISED TOILET SEAT 0 999 10/01/1998 12/31/9999 1 42.00E0245 NU - Fee on File Yes TUB STOOL OR BENCH 0 999 10/01/2003 12/31/9999 1 58.00E0250 KR - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITH

ANY TYPE SIDE RAILS, WITH MATTRESS0 999 07/01/2019 12/31/9999 1 1.96

E0250 NU - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 589.28

E0250 RR - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 58.93

E0250 UE - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 294.64

E0251 KR - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT

0 999 07/01/2019 12/31/9999 1 1.79

E0251 NU - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT

0 999 07/01/2019 12/31/9999 1 535.76

E0251 RR - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT

0 999 07/01/2019 12/31/9999 1 53.58

E0251 UE - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT

0 999 07/01/2019 12/31/9999 1 267.88

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0255 KR - Fee on File Yes HOSPITAL BED, VARIABLE HEIGHT, HI-

LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 2.19

E0255 NU - Fee on File Yes HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 657.76

E0255 RR - Fee on File Yes HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 65.78

E0255 UE - Fee on File Yes HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 328.88

E0256 KR - Fee on File Yes HOSPITAL BED, VARIABLE HEIGHT, HI-LO WITH ANY TYPE SIDERAILS, W/O MATTR

0 999 07/01/2019 12/31/9999 1 1.78

E0256 NU - Fee on File Yes HOSPITAL BED, VARIABLE HEIGHT, HI-LO WITH ANY TYPE SIDERAILS, W/O MATTR

0 999 07/01/2019 12/31/9999 1 534.96

E0256 RR - Fee on File Yes HOSPITAL BED, VARIABLE HEIGHT, HI-LO WITH ANY TYPE SIDERAILS, W/O MATTR

0 999 07/01/2019 12/31/9999 1 53.50

E0256 UE - Fee on File Yes HOSPITAL BED, VARIABLE HEIGHT, HI-LO WITH ANY TYPE SIDERAILS, W/O MATTR

0 999 07/01/2019 12/31/9999 1 267.48

E0260 KR - Fee on File Yes HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 2.73

E0260 NU - Fee on File Yes HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 819.20

E0260 RR - Fee on File Yes HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 81.92

E0260 UE - Fee on File Yes HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 409.60

E0261 KR - Fee on File Yes HOSP BED, SEMI ELEC HEAD AND FOOT ADJ, WITH ANY TYPE SIDE RAILS, W/O MAT

0 999 07/01/2019 12/31/9999 1 2.41

E0261 NU - Fee on File Yes HOSP BED, SEMI ELEC HEAD AND FOOT ADJ, WITH ANY TYPE SIDE RAILS, W/O MAT

0 999 07/01/2019 12/31/9999 1 723.36

E0261 RR - Fee on File Yes HOSP BED, SEMI ELEC HEAD AND FOOT ADJ, WITH ANY TYPE SIDE RAILS, W/O MAT

0 999 07/01/2019 12/31/9999 1 72.34

E0261 UE - Fee on File Yes HOSP BED, SEMI ELEC HEAD AND FOOT ADJ, WITH ANY TYPE SIDE RAILS, W/O MAT

0 999 07/01/2019 12/31/9999 1 361.68

E0265 KR - Fee on File Yes HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH A

0 999 07/01/2019 12/31/9999 1 4.38

E0265 NU - Fee on File Yes HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH A

0 999 07/01/2019 12/31/9999 1 1,313.28

E0265 RR - Fee on File Yes HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH A

0 999 07/01/2019 12/31/9999 1 131.33

E0265 UE - Fee on File Yes HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH A

0 999 07/01/2019 12/31/9999 1 656.64

E0266 KR - Fee on File Yes HOSPITAL BED, TOTAL ELEC HEAD, FOOT, AND HGHT ADJ, WITH ANY TYPE SIDE

0 999 07/01/2019 12/31/9999 1 3.66

E0266 NU - Fee on File Yes HOSPITAL BED, TOTAL ELEC HEAD, FOOT, AND HGHT ADJ, WITH ANY TYPE SIDE

0 999 07/01/2019 12/31/9999 1 1,099.36

E0266 RR - Fee on File Yes HOSPITAL BED, TOTAL ELEC HEAD, FOOT, AND HGHT ADJ, WITH ANY TYPE SIDE

0 999 07/01/2019 12/31/9999 1 109.94

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0266 UE - Fee on File Yes HOSPITAL BED, TOTAL ELEC HEAD,

FOOT, AND HGHT ADJ, WITH ANY TYPE SIDE

0 999 07/01/2019 12/31/9999 1 549.68

E0271 NU - Fee on File Yes MATTRESS, INNERSPRING 0 999 07/01/2019 12/31/9999 1 127.69E0272 NU - Fee on File Yes MATTRESS, FOAM RUBBER 0 999 07/01/2019 12/31/9999 1 128.14E0273 NU - Fee on File Yes BED BOARD 0 20 10/01/1998 12/31/9999 1 59.36E0274 KR - Fee on File Yes OVERBED TABLE 0 20 10/01/1998 12/31/9999 1 0.34E0274 NU - Fee on File Yes OVERBED TABLE 0 20 10/01/1998 12/31/9999 1 101.36E0274 RR - Fee on File Yes OVERBED TABLE 0 20 10/01/1998 12/31/9999 1 10.14E0274 UE - Fee on File Yes OVERBED TABLE 0 20 10/01/1998 12/31/9999 1 50.68E0275 NU - Fee on File Yes BED PAN, STANDARD, METAL OR

PLASTIC0 999 07/01/2019 12/31/9999 1 13.01

E0276 NU - Fee on File Yes BED PAN, FRACTURE, METAL OR PLASTIC

0 999 07/01/2019 12/31/9999 1 11.25

E0277 KR - Fee on File Yes POWERED PRESSURE REDUCING AIR MATTRESS

0 999 07/01/2019 12/31/9999 1 12.05

E0277 NU - Fee on File Yes POWERED PRESSURE REDUCING AIR MATTRESS

0 999 07/01/2019 12/31/9999 1 3,614.00

E0277 RR - Fee on File Yes POWERED PRESSURE REDUCING AIR MATTRESS

0 999 07/01/2019 12/31/9999 1 361.40

E0277 UE - Fee on File Yes POWERED PRESSURE REDUCING AIR MATTRESS

0 999 07/01/2019 12/31/9999 1 1,807.00

E0280 KR - Fee on File Yes BED, CRADLE, ANY TYPE 0 20 07/01/2019 12/31/9999 1 0.09E0280 NU - Fee on File Yes BED, CRADLE, ANY TYPE 0 20 07/01/2019 12/31/9999 1 25.78E0280 RR - Fee on File Yes BED, CRADLE, ANY TYPE 0 20 07/01/2019 12/31/9999 1 2.58E0280 UE - Fee on File Yes BED, CRADLE, ANY TYPE 0 20 07/01/2019 12/31/9999 1 12.89E0290 KR - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WEIGHT,

WITHOUT SIDE RAILS, WITH MATTRESS0 999 07/01/2019 12/31/9999 1 1.65

E0290 NU - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 495.52

E0290 RR - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 49.55

E0290 UE - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 247.76

E0291 KR - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS

0 999 07/01/2019 12/31/9999 1 1.32

E0291 NU - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS

0 999 07/01/2019 12/31/9999 1 397.12

E0291 RR - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS

0 999 07/01/2019 12/31/9999 1 39.71

E0291 UE - Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS

0 999 07/01/2019 12/31/9999 1 198.56

E0300 KR - Fee on File Yes PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED, WITH OR WITHOUT TOP ENCLOSURE

0 20 04/01/2020 12/31/9999 1 5.48

E0300 NU - Fee on File Yes PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED, WITH OR WITHOUT TOP ENCLOSURE

0 20 04/01/2020 12/31/9999 1 1,998.56

E0300 RR - Fee on File Yes PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED, WITH OR WITHOUT TOP ENCLOSURE

0 20 04/01/2020 12/31/9999 1 199.86

E0300 UE - Fee on File Yes PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED, WITH OR WITHOUT TOP ENCLOSURE

0 20 04/01/2020 12/31/9999 1 999.28

819.12E0301 UE - Fee on File Yes HOSPITAL BED, HEAVY DUTY, EXTRA WIDE WITH WEIGHT CAPACITY

0 999 07/01/2019 12/31/9999 1

1,638.24

E0301 RR - Fee on File Yes HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS BUT

0 999 07/01/2019 12/31/9999 1 163.82

E0301 NU - Fee on File Yes HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS BUT

0 999 07/01/2019 12/31/9999 1

E0301 KR - Fee on File Yes HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS BUT

0 999 07/01/2019 12/31/9999 1 5.46

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units Fee

E0302 KR - Fee on File Yes HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT

0 999 07/01/2019 12/31/9999 1 16.16

E0302 NU - Fee on File Yes HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT

0 999 07/01/2019 12/31/9999 1 4,847.84

E0302 RR - Fee on File Yes HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT

0 999 07/01/2019 12/31/9999 1 484.78

E0302 UE - Fee on File Yes HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT

0 999 07/01/2019 12/31/9999 1 2,423.92

E0304 KR - Fee on File Yes HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 17.07

E0304 NU - Fee on File Yes HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 5,122.32

E0304 RR - Fee on File Yes HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 512.23

E0304 UE - Fee on File Yes HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

0 999 07/01/2019 12/31/9999 1 2,561.16

E0305 KR - Fee on File Yes BED SIDE RAILS, HALF LENGTH 0 999 07/01/2019 12/31/9999 1 0.39E0305 NU - Fee on File Yes BED SIDE RAILS, HALF LENGTH 0 999 07/01/2019 12/31/9999 1 116.56E0305 RR - Fee on File Yes BED SIDE RAILS, HALF LENGTH 0 999 07/01/2019 12/31/9999 1 11.66E0305 UE - Fee on File Yes BED SIDE RAILS, HALF LENGTH 0 999 07/01/2019 12/31/9999 1 58.28E0310 KR - Fee on File Yes BED SIDE RAILS, FULL LENGTH 0 999 07/01/2019 12/31/9999 1 0.39E0310 NU - Fee on File Yes BED SIDE RAILS, FULL LENGTH 0 999 07/01/2019 12/31/9999 1 117.24E0310 RR - Fee on File Yes BED SIDE RAILS, FULL LENGTH 0 999 07/01/2019 12/31/9999 1 11.72E0310 UE - Fee on File Yes BED SIDE RAILS, FULL LENGTH 0 999 07/01/2019 12/31/9999 1 58.62E0325 NU - Fee on File Yes URINAL; MALE, JUG-TYPE, ANY

MATERIAL0 999 07/01/2019 12/31/9999 30 8.55

E0326 NU - Fee on File Yes URINAL, FEMALE, JUG/TYPE, ANY MATERIAL

0 999 07/01/2019 12/31/9999 30 9.00

E0328 KR - Fee on File Yes HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBRD, FOOTBRD & SIDE RAILS UP TO 24 IN ABOVE SPRING, INCL

0 20 04/01/2020 12/31/9999 1 12.36

E0328 NU - Fee on File Yes HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBRD, FOOTBRD & SIDE RAILS UP TO 24 IN ABOVE SPRING, INCL

0 20 04/01/2020 12/31/9999 1 4,510.00

889.80E0303 UE - Fee on File Yes HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS BUT

0 999 07/01/2019 12/31/9999 1

1,779.60

E0303 RR - Fee on File Yes HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS BUT

0 999 07/01/2019 12/31/9999 1 177.96

E0303 NU - Fee on File Yes HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS BUT

0 999 07/01/2019 12/31/9999 1

E0303 KR - Fee on File Yes HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS BUT

0 999 07/01/2019 12/31/9999 1 5.93

WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS BUT

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0328 RR - Fee on File Yes HOSPITAL BED, PEDIATRIC, MANUAL, 360

DEGREE SIDE ENCLOSURES, TOP OF HEADBRD, FOOTBRD & SIDE RAILS UP TO 24 IN ABOVE SPRING, INCL

0 20 04/01/2020 12/31/9999 1 451.00

E0328 UE - Fee on File Yes HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBRD, FOOTBRD & SIDE RAILS UP TO 24 IN ABOVE SPRING, INCL

0 20 04/01/2020 12/31/9999 1 2,255.00

E0329 KR - Fee on File Yes HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBRD, FOOTBRD & SIDE RAILS UP TO 24 IN ABOVE SPRING, INCL MATTRESS

0 20 04/01/2020 12/31/9999 1 16.44

E0329 NU - Fee on File Yes HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBRD, FOOTBRD & SIDE RAILS UP TO 24 IN ABOVE SPRING, INCL MATTRESS

0 20 04/01/2020 12/31/9999 1 6,000.00

E0329 RR - Fee on File Yes HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBRD, FOOTBRD & SIDE RAILS UP TO 24 IN ABOVE SPRING, INCL MATTRESS

0 20 04/01/2020 12/31/9999 1 600.00

E0329 UE - Fee on File Yes HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBRD, FOOTBRD & SIDE RAILS UP TO 24 IN ABOVE SPRING, INCL MATTRESS

0 20 04/01/2020 12/31/9999 1 3,000.00

E0371 KR - Fee on File Yes NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 20 07/01/2019 12/31/9999 1 8.01

E0371 NU - Fee on File Yes NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 20 07/01/2019 12/31/9999 1 2,401.76

E0371 RR - Fee on File Yes NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 20 07/01/2019 12/31/9999 1 240.18

E0371 UE - Fee on File Yes NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 20 07/01/2019 12/31/9999 1 1,200.88

E0372 KR - Fee on File Yes POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 9.13

E0372 NU - Fee on File Yes POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 2,740.08

E0372 RR - Fee on File Yes POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 274.01

E0372 UE - Fee on File Yes POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2019 12/31/9999 1 1,370.04

E0373 KR - Fee on File Yes NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS

0 20 07/01/2019 12/31/9999 1 10.06

E0373 RR - Fee on File Yes NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS

0 20 07/01/2019 12/31/9999 1 301.92

107.77E0424 RR - Fee on File Yes STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER CONTENTS REGULATOR

0 999 07/01/2019 12/31/9999 1

E0424 KR - Fee on File Yes STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER CONTENTS REGULATOR

0 999 07/01/2019 12/31/9999 1 3.59

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0425 NU - Fee on File Yes STATIONARY COMPRESSED GAS

SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING

0 999 05/01/1999 12/31/9999 1 303.60

E0425 UE - Fee on File Yes STATIONARY COMPRESSED GAS SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING

0 999 05/01/1999 12/31/9999 1 151.80

E0430 UE - Fee on File Yes PORTABLE GASEOUS OXYGEN SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING

0 999 05/01/1999 12/31/9999 1 98.28

E0430 NU - Fee on File Yes PORTABLE GASEOUS OXYGEN SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING

0 999 01/01/1990 12/31/9999 1 196.56

E0431 KR - Fee on File Yes PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING

0 999 07/01/2019 12/31/9999 1 0.64

E0431 RR - Fee on File Yes PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING

0 999 07/01/2019 12/31/9999 1 19.20

E0439 KR - Fee on File Yes STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING

0 999 07/01/2019 12/31/9999 1 3.59

E0439 RR - Fee on File Yes STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING

0 999 07/01/2019 12/31/9999 1 107.77

E0441 NU - Fee on File Yes STATIONARY OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT

0 999 07/01/2019 12/31/9999 1 51.36

E0442 NU - Fee on File Yes STATIONARY OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT

0 999 07/01/2019 12/31/9999 1 51.36

E0443 NU - Fee on File Yes PORTABLE OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT

0 999 07/01/2019 12/31/9999 1 49.35

E0444 NU - Fee on File Yes PORTABLE OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT

0 999 07/01/2019 12/31/9999 1 49.35

E0445 KR - Priced by PA Yes OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY

0 999 10/01/2003 12/31/9999 1 0.00

151.80E0440 UE - Fee on File Yes STATIONARY LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES USE OF RESERVOIR CONTENTS INDICATOR

0 999 05/01/1999 12/31/9999 1

35.46

E0440 NU - Fee on File Yes STATIONARY LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES USE OF RESERVOIR CONTENTS INDICATOR

0 999 05/01/1999 12/31/9999 1 303.60

E0434 RR - Fee on File Yes PORTABLE LIQUID OXYGEN SYSTEM RENTAL, INCLUDES PORTABLE CONTAINER SUPPLY RESERVOIR

0 999 07/01/2019 12/31/9999 1

35.46

E0434 KR - Fee on File Yes PORTABLE LIQUID OXYGEN SYSTEM RENTAL, INCLUDES PORTABLE CONTAINER SUPPLY RESERVOIR

0 999 07/01/2019 12/31/9999 1 1.14

E0433 RR - Fee on File Yes PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; HOME LIQUEFIER USED TO FILL PORTABLE LIQUID OXYGEN

0 999 07/01/2019 12/31/9999 1

E0433 KR - Fee on File Yes PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; HOME LIQUEFIER USED TO FILL PORTABLE LIQUID OXYGEN

0 999 07/01/2019 12/31/9999 1 1.18

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0445 NU - Priced by PA Yes OXIMETER DEVICE FOR MEASURING

BLOOD OXYGEN LEVELS NON-INVASIVELY

0 999 10/01/2003 12/31/9999 1 0.00

E0445 RR - Priced by PA Yes OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY

0 999 10/01/2003 12/31/9999 1 0.00

E0445 UE - Priced by PA Yes OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY

0 999 10/01/2003 12/31/9999 1 0.00

E0457 KR - Fee on File Yes CHEST SHELL (CUIRASS) 0 999 07/01/2013 12/31/9999 1 1.78E0457 NU - Fee on File Yes CHEST SHELL (CUIRASS) 0 999 07/01/2013 12/31/9999 1 532.27E0457 RR - Fee on File Yes CHEST SHELL (CUIRASS) 0 999 07/01/2013 12/31/9999 1 53.22E0457 UE - Fee on File Yes CHEST SHELL (CUIRASS) 0 999 07/01/2013 12/31/9999 1 266.14E0459 KR - Fee on File Yes CHEST WRAP 0 999 07/01/2013 12/31/9999 1 1.25E0459 RR - Fee on File Yes CHEST WRAP 0 999 07/01/2013 12/31/9999 1 37.47E0465 KR - Fee on File Yes HOME VENTILATOR, ANY TYPE, USED

WITH INVASIVE INTERFACE, (E.G., TRACHEOSTOMY TUBE)

0 999 07/01/2019 12/31/9999 1 24.91

E0465 RR - Fee on File Yes HOME VENTILATOR, ANY TYPE, USED WITH INVASIVE INTERFACE, (E.G., TRACHEOSTOMY TUBE)

0 999 07/01/2019 12/31/9999 1 747.34

E0466 KR - Fee on File Yes HOME VENTILATOR, ANY TYPE, USED WITH NON-INVASIVE INTERFACE, (E.G., MASK, CHEST SHELL)

0 999 07/01/2019 12/31/9999 1 24.91

E0466 RR - Fee on File Yes HOME VENTILATOR, ANY TYPE, USED WITH NON-INVASIVE INTERFACE, (E.G., MASK, CHEST SHELL)

0 999 07/01/2019 12/31/9999 1 747.34

E0480 KR - Fee on File Yes PERCUSSOR, ELECTRIC OR PNEUMATIC; HOME MODEL

0 20 07/01/2019 12/31/9999 1 1.15

E0480 NU - Fee on File Yes PERCUSSOR, ELECTRIC OR PNEUMATIC; HOME MODEL

0 20 07/01/2019 12/31/9999 1 344.08

E0480 RR - Fee on File Yes PERCUSSOR, ELECTRIC OR PNEUMATIC; HOME MODEL

0 20 07/01/2019 12/31/9999 1 34.41

E0480 UE - Fee on File Yes PERCUSSOR, ELECTRIC OR PNEUMATIC; HOME MODEL

0 20 07/01/2019 12/31/9999 1 172.04

E0482 KR - Fee on File Yes COUGH STIMULATING DEVICE, ALTERNATING POSITIVE AND NEGATIVE AIRWAY PRESS

0 999 07/01/2019 12/31/9999 1 11.83

E0482 NU - Fee on File Yes COUGH STIMULATING DEVICE, ALTERNATING POSITIVE AND NEGATIVE AIRWAY PRESS

0 999 07/01/2019 12/31/9999 1 3,549.44

4,028.56

E0472 RR - Fee on File Yes RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE USED WITH INVASIVE

0 999 07/01/2019 12/31/9999 1 402.86

E0472 NU - Fee on File Yes RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE USED WITH INVASIVE

0 999 07/01/2019 12/31/9999 1

345.40

E0472 KR - Fee on File Yes RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE USED WITH INVASIVE

0 999 07/01/2019 12/31/9999 1 13.43

E0471 RR - Fee on File Yes RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATE FEATURE USED WITH

0 999 07/01/2019 12/31/9999 1

11.51

E0471 NU - Fee on File Yes RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATE FEATURE USED WITH

0 999 07/01/2019 12/31/9999 1 3,454.00

E0471 KR - Fee on File Yes RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATE FEATURE USED WITH

0 999 07/01/2019 12/31/9999 1

1,386.64

E0470 RR - Fee on File Yes RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE USED WITH

0 999 07/01/2019 12/31/9999 1 138.66

E0470 NU - Fee on File Yes RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE USED WITH

0 999 07/01/2019 12/31/9999 1

E0470 KR - Fee on File Yes RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE USED WITH

0 999 07/01/2019 12/31/9999 1 4.62

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0482 RR - Fee on File Yes COUGH STIMULATING DEVICE,

ALTERNATING POSITIVE AND NEGATIVE AIRWAY PRESS

0 999 07/01/2019 12/31/9999 1 354.94

E0482 UE - Fee on File Yes COUGH STIMULATING DEVICE, ALTERNATING POSITIVE AND NEGATIVE AIRWAY PRESS

0 999 07/01/2019 12/31/9999 1 1,774.72

E0483 NU - Fee on File Yes HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM, INCLUDES ALL ACCESSORIES AND SUPPLIES, EACH

0 999 07/01/2019 12/31/9999 1 9,792.56

E0483 RR - Fee on File Yes HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM, INCLUDES ALL ACCESSORIES AND SUPPLIES, EACH

0 999 07/01/2019 12/31/9999 1 979.26

E0484 NU - Fee on File Yes OSCILLATORY POSITIVE EXPIRATORY PRESSURE DEVICE, NON-ELECTRIC, ANY TYPE,

0 999 07/01/2019 12/31/9999 1 34.02

E0500 KR - Fee on File Yes IPPB MACHINE, ALL TYPES WITH BUILT-IN NEBULIZATION; MANUAL OR AUTOMATIC VALVES; INTERNAL OR EXTERNAL POWER SOURCE

0 999 07/01/2019 12/31/9999 1 2.86

E0500 NU - Fee on File Yes IPPB MACHINE, ALL TYPES WITH BUILT-IN NEBULIZATION; MANUAL OR AUTOMATIC VALVES; INTERNAL OR EXTERNAL POWER SOURCE

0 999 07/01/2019 12/31/9999 1 859.28

E0500 RR - Fee on File Yes IPPB MACHINE, ALL TYPES WITH BUILT-IN NEBULIZATION; MANUAL OR AUTOMATIC VALVES; INTERNAL OR EXTERNAL POWER SOURCE

0 999 07/01/2019 12/31/9999 1 85.93

E0500 UE - Fee on File Yes IPPB MACHINE, ALL TYPES WITH BUILT-IN NEBULIZATION; MANUAL OR AUTOMATIC VALVES; INTERNAL OR EXTERNAL POWER SOURCE

0 999 07/01/2019 12/31/9999 1 429.64

E0555 KR - Priced by PA Yes HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE

0 999 09/01/2007 12/31/9999 1 0.00

E0555 NU - Priced by PA Yes HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE

0 999 09/01/2007 12/31/9999 1 0.00

E0555 RR - Priced by PA Yes HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE

0 999 09/01/2007 12/31/9999 1 0.00

E0555 UE - Priced by PA Yes HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE

0 999 09/01/2007 12/31/9999 1 0.00

E0561 KR - Fee on File Yes HUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE

0 999 07/01/2019 12/31/9999 1 0.25

E0561 NU - Fee on File Yes HUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE

0 999 07/01/2019 12/31/9999 1 73.64

E0561 RR - Fee on File Yes HUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE

0 999 07/01/2019 12/31/9999 1 7.36

E0561 UE - Fee on File Yes HUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE

0 999 07/01/2019 12/31/9999 1 36.82

E0562 KR - Fee on File Yes HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE

0 999 07/01/2019 12/31/9999 1 0.60

E0562 NU - Fee on File Yes HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE

0 999 07/01/2019 12/31/9999 1 179.12

E0562 RR - Fee on File Yes HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE

0 999 07/01/2019 12/31/9999 1 17.91

E0562 UE - Fee on File Yes HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE

0 999 07/01/2019 12/31/9999 1 89.56

E0565 KR - Fee on File Yes COMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT SELF CONTAINED OR CYLINDER DRIVEN

0 999 07/01/2019 12/31/9999 1 1.40

E0565 NU - Fee on File Yes COMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT SELF CONTAINED OR CYLINDER DRIVEN

0 999 07/01/2019 12/31/9999 1 419.20

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0565 RR - Fee on File Yes COMPRESSOR, AIR POWER SOURCE

FOR EQUIPMENT WHICH IS NOT SELF CONTAINED OR CYLINDER DRIVEN

0 999 07/01/2019 12/31/9999 1 41.92

E0565 UE - Fee on File Yes COMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT SELF CONTAINED OR CYLINDER DRIVEN

0 999 07/01/2019 12/31/9999 1 209.60

E0570 KR - Fee on File Yes NEBULIZER, WITH COMPRESSOR 0 999 07/01/2019 12/31/9999 1 0.33E0570 NU - Fee on File Yes NEBULIZER, WITH COMPRESSOR 0 999 07/01/2019 12/31/9999 1 98.88E0570 RR - Fee on File Yes NEBULIZER, WITH COMPRESSOR 0 999 07/01/2019 12/31/9999 1 9.89E0570 UE - Fee on File Yes NEBULIZER, WITH COMPRESSOR 0 999 07/01/2019 12/31/9999 1 49.44E0575 KR - Fee on File Yes NEBULIZER, ULTRASONIC, LARGE

VOLUME0 999 07/01/2019 12/31/9999 1 2.68

E0575 NU - Fee on File Yes NEBULIZER, ULTRASONIC, LARGE VOLUME

0 999 07/01/2019 12/31/9999 1 804.72

E0575 RR - Fee on File Yes NEBULIZER, ULTRASONIC, LARGE VOLUME

0 999 07/01/2019 12/31/9999 1 80.47

E0575 UE - Fee on File Yes NEBULIZER, ULTRASONIC, LARGE VOLUME

0 999 07/01/2019 12/31/9999 1 402.36

E0580 KR - Fee on File Yes NEBULIZER, DURABLE OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER

0 999 07/01/2019 12/31/9999 1 0.35

E0580 NU - Fee on File Yes NEBULIZER, DURABLE OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER

0 999 07/01/2019 12/31/9999 1 105.37

E0580 RR - Fee on File Yes NEBULIZER, DURABLE OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER

0 999 07/01/2019 12/31/9999 1 10.54

E0580 UE - Fee on File Yes NEBULIZER, DURABLE OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER

0 999 07/01/2019 12/31/9999 1 52.68

E0585 KR - Fee on File Yes NEBULIZER WITH COMPRESSOR AND HEATER

0 999 07/01/2019 12/31/9999 1 0.86

E0585 NU - Fee on File Yes NEBULIZER WITH COMPRESSOR AND HEATER

0 999 07/01/2019 12/31/9999 1 258.80

E0585 RR - Fee on File Yes NEBULIZER WITH COMPRESSOR AND HEATER

0 999 07/01/2019 12/31/9999 1 25.88

E0585 UE - Fee on File Yes NEBULIZER WITH COMPRESSOR AND HEATER

0 999 07/01/2019 12/31/9999 1 129.40

E0600 KR - Fee on File Yes RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC

0 999 07/01/2019 12/31/9999 1 1.19

E0600 NU - Fee on File Yes RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC

0 999 07/01/2019 12/31/9999 1 358.48

E0600 RR - Fee on File Yes RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC

0 999 07/01/2019 12/31/9999 1 35.85

E0600 UE - Fee on File Yes RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC

0 999 07/01/2019 12/31/9999 1 179.24

E0601 KR - Fee on File Yes CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICE

0 999 07/01/2019 12/31/9999 1 1.92

E0601 NU - Fee on File Yes CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICE

0 999 07/01/2019 12/31/9999 1 575.92

E0601 RR - Fee on File Yes CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICE

0 999 07/01/2019 12/31/9999 1 57.59

E0601 UE - Fee on File Yes CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICE

0 999 07/01/2019 12/31/9999 1 287.96

E0602 NU - Fee on File Yes BREAST PUMP, MANUAL, ANY TYPE 0 999 07/01/2019 12/31/9999 1 27.18E0602 RR - Fee on File Yes BREAST PUMP, MANUAL, ANY TYPE 0 999 07/01/2019 12/31/9999 1 2.72

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0602 KR - Fee on File Yes BREAST PUMP, MANUAL, ANY TYPE 0 999 07/01/2016 12/31/9999 1 0.09E0603 KR - Fee on File Yes BREAST PUMP, ELECTRIC (AC AND/OR

DC), ANY TYPE0 999 04/01/2020 12/31/9999 1 0.43

E0603 NU - Fee on File Yes BREAST PUMP, ELECTRIC (AC AND/OR DC), ANY TYPE

0 999 04/01/2020 12/31/9999 1 157.15

E0603 RR - Fee on File Yes BREAST PUMP, ELECTRIC (AC AND/OR DC), ANY TYPE

0 999 04/01/2020 12/31/9999 1 15.72

E0605 NU - Fee on File Yes VAPORIZER, ROOM TYPE 0 999 07/01/2019 12/31/9999 1 24.34E0605 RR - Fee on File Yes VAPORIZER, ROOM TYPE 0 999 07/01/2019 12/31/9999 1 2.43E0605 KR - Fee on File Yes VAPORIZER, ROOM TYPE 0 999 07/01/2015 12/31/9999 1 0.08E0606 KR - Fee on File Yes POSTURAL DRAINAGE BOARD 0 999 07/01/2019 12/31/9999 1 0.70E0606 NU - Fee on File Yes POSTURAL DRAINAGE BOARD 0 999 07/01/2019 12/31/9999 1 211.44E0606 RR - Fee on File Yes POSTURAL DRAINAGE BOARD 0 999 07/01/2019 12/31/9999 1 21.14E0606 UE - Fee on File Yes POSTURAL DRAINAGE BOARD 0 999 07/01/2019 12/31/9999 1 105.72E0607 NU - Fee on File No HOME BLOOD GLUCOSE MONITOR 0 999 07/01/2019 12/31/9999 1 61.54E0607 UE - Fee on File No HOME BLOOD GLUCOSE MONITOR 0 999 07/01/2019 12/31/9999 1 30.77E0610 KR - Fee on File Yes PACEMAKER MONITOR, SELF

CONTAINED, CHECKS BATTERY DEPLETION INCLUDES AUDIBLE AND VISIBLE CHECK SYSTEMS

0 999 07/01/2019 12/31/9999 1 0.73

E0610 NU - Fee on File Yes PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION INCLUDES AUDIBLE AND VISIBLE CHECK SYSTEMS

0 999 07/01/2019 12/31/9999 1 219.09

E0610 RR - Fee on File Yes PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION INCLUDES AUDIBLE AND VISIBLE CHECK SYSTEMS

0 999 07/01/2019 12/31/9999 1 21.91

E0610 UE - Fee on File Yes PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION INCLUDES AUDIBLE AND VISIBLE CHECK SYSTEMS

0 999 07/01/2019 12/31/9999 1 109.54

E0615 KR - Fee on File Yes PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION AND OTHER PACEMAKER COMPONENTS INCLUDES DIGITAL/VISIBLE CHECK SYSTEMS

0 999 07/01/2019 12/31/9999 1 1.47

E0615 NU - Fee on File Yes PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION AND OTHER PACEMAKER COMPONENTS INCLUDES DIGITAL/VISIBLE CHECK SYSTEMS

0 999 07/01/2019 12/31/9999 1 441.02

E0615 RR - Fee on File Yes PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION AND OTHER PACEMAKER COMPONENTS INCLUDES DIGITAL/VISIBLE CHECK SYSTEMS

0 999 07/01/2019 12/31/9999 1 44.10

E0615 UE - Fee on File Yes PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION AND OTHER PACEMAKER COMPONENTS INCLUDES DIGITAL/VISIBLE CHECK SYSTEMS

0 999 07/01/2019 12/31/9999 1 220.51

E0618 KR - Fee on File Yes APNEA MONITOR, WITHOUT RECORDING FEATURE

0 999 07/01/2019 12/31/9999 1 8.61

E0618 NU - Fee on File Yes APNEA MONITOR, WITHOUT RECORDING FEATURE

0 999 07/01/2019 12/31/9999 1 2,582.48

E0618 RR - Fee on File Yes APNEA MONITOR, WITHOUT RECORDING FEATURE

0 999 07/01/2019 12/31/9999 1 258.25

E0618 UE - Fee on File Yes APNEA MONITOR, WITHOUT RECORDING FEATURE

0 999 07/01/2019 12/31/9999 1 1,291.24

E0619 KR - Fee on File Yes APNEA MONITOR, WITH RECORDING FEATURE

0 999 10/01/2003 12/31/9999 1 7.49

E0619 NU - Fee on File Yes APNEA MONITOR, WITH RECORDING FEATURE

0 999 10/01/2003 12/31/9999 1 2,246.92

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0619 RR - Fee on File Yes APNEA MONITOR, WITH RECORDING

FEATURE0 999 10/01/2003 12/31/9999 1 224.62

E0619 UE - Fee on File Yes APNEA MONITOR, WITH RECORDING FEATURE

0 999 10/01/2003 12/31/9999 1 1,123.46

E0627 KR - Fee on File Yes SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE

0 999 07/01/2019 12/31/9999 1 0.88

E0627 NU - Fee on File Yes SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE

0 999 07/01/2019 12/31/9999 1 264.38

E0627 RR - Fee on File Yes SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE

0 999 07/01/2019 12/31/9999 1 26.44

E0627 UE - Fee on File Yes SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE

0 999 07/01/2019 12/31/9999 1 132.19

E0630 KR - Fee on File Yes PATIENT LIFT, HYDRAULIC OR MECHANICAL, INCLUDES ANY SEAT, SLING, STRAP(S) OR PAD(S)

0 999 07/01/2019 12/31/9999 1 2.17

E0630 NU - Fee on File Yes PATIENT LIFT, HYDRAULIC OR MECHANICAL, INCLUDES ANY SEAT, SLING, STRAP(S) OR PAD(S)

0 999 07/01/2019 12/31/9999 1 649.76

E0630 RR - Fee on File Yes PATIENT LIFT, HYDRAULIC OR MECHANICAL, INCLUDES ANY SEAT, SLING, STRAP(S) OR PAD(S)

0 999 07/01/2019 12/31/9999 1 64.98

E0630 UE - Fee on File Yes PATIENT LIFT, HYDRAULIC OR MECHANICAL, INCLUDES ANY SEAT, SLING, STRAP(S) OR PAD(S)

0 999 07/01/2019 12/31/9999 1 324.88

E0635 KR - Fee on File Yes PATIENT LIFT, ELECTRIC WITH SEAT OR SLING

0 999 07/01/2019 12/31/9999 4 3.55

E0635 NU - Fee on File Yes PATIENT LIFT, ELECTRIC WITH SEAT OR SLING

0 999 07/01/2019 12/31/9999 1 1,064.40

E0635 RR - Fee on File Yes PATIENT LIFT, ELECTRIC WITH SEAT OR SLING

0 999 07/01/2019 12/31/9999 3 106.44

E0635 UE - Fee on File Yes PATIENT LIFT, ELECTRIC WITH SEAT OR SLING

0 999 07/01/2019 12/31/9999 2 532.20

E0637 KR - Fee on File Yes COMBINATION SIT TO STAND SYSTEM, ANY SIZE INCLUDING PEDIATRIC, WITH SEATLIFT

0 999 04/01/2020 12/31/9999 1 5.97

E0637 NU - Fee on File Yes COMBINATION SIT TO STAND SYSTEM, ANY SIZE INCLUDING PEDIATRIC, WITH SEATLIFT

0 999 04/01/2020 12/31/9999 1 2,179.95

E0637 RR - Fee on File Yes COMBINATION SIT TO STAND SYSTEM, ANY SIZE INCLUDING PEDIATRIC, WITH SEATLIFT

0 999 04/01/2020 12/31/9999 1 218.00

E0637 UE - Fee on File Yes COMBINATION SIT TO STAND SYSTEM, ANY SIZE INCLUDING PEDIATRIC, WITH SEATLIFT

0 999 04/01/2020 12/31/9999 1 1,089.98

E0638 KR - Fee on File Yes STANDING FRAME/TABLE SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS

0 999 04/01/2020 12/31/9999 1 5.01

E0638 NU - Fee on File Yes STANDING FRAME/TABLE SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS

0 999 04/01/2020 12/31/9999 1 1,828.17

E0638 RR - Fee on File Yes STANDING FRAME/TABLE SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS

0 999 04/01/2020 12/31/9999 1 182.82

E0638 UE - Fee on File Yes STANDING FRAME/TABLE SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS

0 999 04/01/2020 12/31/9999 1 914.08

E0641 KR - Fee on File Yes STANDING FRAME/TABLE SYSTEM, MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS

0 999 04/01/2020 12/31/9999 1 6.00

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0641 NU - Fee on File Yes STANDING FRAME/TABLE SYSTEM,

MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS

0 999 04/01/2020 12/31/9999 1 2,190.55

E0641 RR - Fee on File Yes STANDING FRAME/TABLE SYSTEM, MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS

0 999 04/01/2020 12/31/9999 1 219.06

E0641 UE - Fee on File Yes STANDING FRAME/TABLE SYSTEM, MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS

0 999 04/01/2020 12/31/9999 1 1,095.28

E0642 KR - Fee on File Yes STANDING FRAME/TABLE SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC

0 999 04/01/2020 12/31/9999 1 6.54

E0642 NU - Fee on File Yes STANDING FRAME/TABLE SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC

0 999 04/01/2020 12/31/9999 1 2,388.91

E0642 RR - Fee on File Yes STANDING FRAME/TABLE SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC

0 999 04/01/2020 12/31/9999 1 238.89

E0642 UE - Fee on File Yes STANDING FRAME/TABLE SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC

0 999 04/01/2020 12/31/9999 1 1,194.46

E0650 KR - Fee on File Yes PNEUMATIC COMPRESSOR, NON SEGMENTAL HOME MODEL

0 20 07/01/2019 12/31/9999 1 1.88

E0650 NU - Fee on File Yes PNEUMATIC COMPRESSOR, NON SEGMENTAL HOME MODEL

0 20 07/01/2019 12/31/9999 1 563.88

E0650 RR - Fee on File Yes PNEUMATIC COMPRESSOR, NON SEGMENTAL HOME MODEL

0 20 07/01/2019 12/31/9999 1 56.39

E0650 UE - Fee on File Yes PNEUMATIC COMPRESSOR, NON SEGMENTAL HOME MODEL

0 20 07/01/2019 12/31/9999 1 281.94

E0651 KR - Fee on File Yes PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL, WITHOUT CALIBRATED GRADIENT PRESSURE

0 999 07/01/2019 12/31/9999 1 2.82

E0651 NU - Fee on File Yes PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL, WITHOUT CALIBRATED GRADIENT PRESSURE

0 999 07/01/2019 12/31/9999 1 845.95

E0651 RR - Fee on File Yes PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL, WITHOUT CALIBRATED GRADIENT PRESSURE

0 999 07/01/2019 12/31/9999 1 84.60

E0651 UE - Fee on File Yes PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL, WITHOUT CALIBRATED GRADIENT PRESSURE

0 999 07/01/2019 12/31/9999 1 422.98

E0652 KR - Fee on File Yes PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE

0 999 07/01/2019 12/31/9999 1 13.84

E0652 NU - Fee on File Yes PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE

0 999 07/01/2019 12/31/9999 1 4,150.70

E0652 RR - Fee on File Yes PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE

0 999 07/01/2019 12/31/9999 1 415.07

E0652 UE - Fee on File Yes PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE

0 999 07/01/2019 12/31/9999 1 2,075.35

E0655 NU - Fee on File Yes NON SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF ARM

0 20 07/01/2019 12/31/9999 1 84.50

E0655 RR - Fee on File Yes NON SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF ARM

0 20 07/01/2019 12/31/9999 1 8.45

E0655 UE - Fee on File Yes NON SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF ARM

0 20 07/01/2019 12/31/9999 1 42.25

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0655 KR - Fee on File Yes NON SEGMENTAL PNEUMATIC

APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF ARM

0 20 07/01/2018 12/31/9999 1 0.28

E0660 KR - Fee on File Yes NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG

0 20 07/01/2019 12/31/9999 1 0.49

E0660 NU - Fee on File Yes NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG

0 20 07/01/2019 12/31/9999 1 147.15

E0660 RR - Fee on File Yes NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG

0 20 07/01/2019 12/31/9999 1 14.72

E0660 UE - Fee on File Yes NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG

0 20 07/01/2019 12/31/9999 1 73.58

E0665 KR - Fee on File Yes NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM

0 20 07/01/2019 12/31/9999 1 0.36

E0665 NU - Fee on File Yes NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM

0 20 07/01/2019 12/31/9999 1 107.26

E0665 RR - Fee on File Yes NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM

0 20 07/01/2019 12/31/9999 1 10.73

E0665 UE - Fee on File Yes NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM

0 20 07/01/2019 12/31/9999 1 53.63

E0666 KR - Fee on File Yes NON SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG

0 20 07/01/2019 12/31/9999 1 0.36

E0666 NU - Fee on File Yes NON SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG

0 20 07/01/2019 12/31/9999 1 108.12

E0666 RR - Fee on File Yes NON SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG

0 20 07/01/2019 12/31/9999 1 10.81

E0666 UE - Fee on File Yes NON SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG

0 20 07/01/2019 12/31/9999 1 54.06

E0667 KR - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNUEMATIC COMPRESSOR, FULL LEG

0 999 07/01/2019 12/31/9999 1 0.84

E0667 NU - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNUEMATIC COMPRESSOR, FULL LEG

0 999 07/01/2019 12/31/9999 1 253.49

E0667 RR - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNUEMATIC COMPRESSOR, FULL LEG

0 999 07/01/2019 12/31/9999 1 25.35

E0667 UE - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNUEMATIC COMPRESSOR, FULL LEG

0 999 07/01/2019 12/31/9999 1 126.74

E0668 KR - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM

0 999 07/01/2019 12/31/9999 1 1.15

E0668 NU - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM

0 999 07/01/2019 12/31/9999 1 345.96

E0668 RR - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM

0 999 07/01/2019 12/31/9999 1 34.60

E0668 UE - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM

0 999 07/01/2019 12/31/9999 1 172.98

E0669 KR - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG

0 999 07/01/2019 12/31/9999 1 0.56

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0669 NU - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE

FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG

0 999 07/01/2019 12/31/9999 1 168.86

E0669 RR - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG

0 999 07/01/2019 12/31/9999 1 16.89

E0669 UE - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG

0 999 07/01/2019 12/31/9999 1 84.43

E0670 KR - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE W/PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK

0 20 07/01/2019 12/31/9999 1 3.40

E0670 NU - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE W/PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK

0 20 07/01/2019 12/31/9999 1 1,020.82

E0670 RR - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE W/PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK

0 20 07/01/2019 12/31/9999 1 102.08

E0670 UE - Fee on File Yes SEGMENTAL PNEUMATIC APPLIANCE FOR USE W/PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK

0 20 07/01/2019 12/31/9999 1 510.41

E0671 KR - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEG

0 20 07/01/2019 12/31/9999 1 1.28

E0671 NU - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEG

0 20 07/01/2019 12/31/9999 1 382.58

E0671 RR - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEG

0 20 07/01/2019 12/31/9999 1 38.26

E0671 UE - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEG

0 20 07/01/2019 12/31/9999 1 191.29

E0672 KR - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL ARM

0 20 07/01/2019 12/31/9999 1 0.99

E0672 NU - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL ARM

0 20 07/01/2019 12/31/9999 1 297.26

E0672 RR - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL ARM

0 20 07/01/2019 12/31/9999 1 29.73

E0672 UE - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL ARM

0 20 07/01/2019 12/31/9999 1 148.63

E0673 KR - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALFLEG

0 20 07/01/2019 12/31/9999 1 0.82

E0673 NU - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALFLEG

0 20 07/01/2019 12/31/9999 1 247.01

E0673 RR - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALFLEG

0 20 07/01/2019 12/31/9999 1 24.70

E0673 UE - Fee on File Yes SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALFLEG

0 20 07/01/2019 12/31/9999 1 123.50

E0676 NU - Priced by PA Yes INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL ACCESSORIES), NOT OTHERWISE SPECIFIED

0 20 01/01/2007 12/31/9999 1 0.00

E0691 KR - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESS

0 20 07/01/2019 12/31/9999 1 2.76

E0691 NU - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESS

0 20 07/01/2019 12/31/9999 1 827.69

E0691 RR - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESS

0 20 07/01/2019 12/31/9999 1 82.77

E0691 UE - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESS

0 20 07/01/2019 12/31/9999 1 413.84

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0692 KR - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM

PANEL, INCLUDES BULBS/LAMPS, TIMER AND AND EYE PROTECTION, FOUR FOOT PANEL

0 20 07/01/2019 12/31/9999 1 3.46

E0692 NU - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND AND EYE PROTECTION, FOUR FOOT PANEL

0 20 07/01/2019 12/31/9999 1 1,039.36

E0692 RR - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND AND EYE PROTECTION, FOUR FOOT PANEL

0 20 07/01/2019 12/31/9999 1 103.94

E0692 UE - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND AND EYE PROTECTION, FOUR FOOT PANEL

0 20 07/01/2019 12/31/9999 1 519.68

E0693 KR - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, SIX FOOT PANEL

0 20 07/01/2019 12/31/9999 1 4.27

E0693 NU - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, SIX FOOT PANEL

0 20 07/01/2019 12/31/9999 1 1,281.23

E0693 RR - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, SIX FOOT PANEL

0 20 07/01/2019 12/31/9999 1 128.12

E0693 UE - Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, SIX FOOT PANEL

0 20 07/01/2019 12/31/9999 1 640.62

E0694 KR - Fee on File Yes ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION

0 20 07/01/2019 12/31/9999 1 13.59

E0694 NU - Fee on File Yes ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION

0 20 07/01/2019 12/31/9999 1 4,078.04

E0694 RR - Fee on File Yes ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION

0 20 07/01/2019 12/31/9999 1 407.80

E0694 UE - Fee on File Yes ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION

0 20 07/01/2019 12/31/9999 1 2,039.02

E0705 NU - Fee on File Yes TRANSFER DEVICE, ANY TYPE, EACH 0 999 07/01/2019 12/31/9999 1 45.12E0720 KR - Fee on File Yes TRANSCUTANEOUS ELECTRICAL NERVE

STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED STIMULATION

0 999 07/01/2019 12/31/9999 1 0.66

E0720 NU - Fee on File Yes TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED STIMULATION

0 999 07/01/2019 12/31/9999 1 197.83

E0720 RR - Fee on File Yes TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED STIMULATION

0 999 07/01/2019 12/31/9999 1 19.78

E0720 UE - Fee on File Yes TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED STIMULATION

0 999 07/01/2019 12/31/9999 1 98.92

E0730 KR - Fee on File Yes TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION

0 999 07/01/2019 12/31/9999 1 0.67

E0730 NU - Fee on File Yes TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION

0 999 07/01/2019 12/31/9999 1 199.50

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0730 RR - Fee on File Yes TRANSCUTANEOUS ELECTRICAL NERVE

STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION

0 999 07/01/2019 12/31/9999 1 19.95

E0730 UE - Fee on File Yes TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION

0 999 07/01/2019 12/31/9999 1 99.75

E0731 KR - Fee on File Yes FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES

0 999 07/01/2019 12/31/9999 1 0.67

E0731 NU - Fee on File Yes FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES

0 999 07/01/2019 12/31/9999 1 200.03

E0731 RR - Fee on File Yes FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES

0 999 07/01/2019 12/31/9999 1 20.00

E0731 UE - Fee on File Yes FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES

0 999 07/01/2019 12/31/9999 1 100.02

E0744 KR - Fee on File Yes NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS

0 20 07/01/2019 12/31/9999 1 2.39

E0744 RR - Fee on File Yes NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS

0 20 07/01/2019 12/31/9999 1 71.70

E0745 KR - Fee on File Yes NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT

0 999 07/01/2019 12/31/9999 1 2.34

E0745 RR - Fee on File Yes NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT

0 999 07/01/2019 12/31/9999 1 70.09

E0746 KR - Fee on File Yes ELECTROMYOGRAPHY (EMG) BIOFEEDBACK DEVICE

0 999 10/01/1998 12/31/9999 1 0.99

E0746 NU - Fee on File Yes ELECTROMYOGRAPHY (EMG) BIOFEEDBACK DEVICE

0 999 10/01/1998 12/31/9999 1 296.25

E0746 RR - Fee on File Yes ELECTROMYOGRAPHY (EMG) BIOFEEDBACK DEVICE

0 999 10/01/1998 12/31/9999 1 29.63

E0746 UE - Fee on File Yes ELECTROMYOGRAPHY (EMG) BIOFEEDBACK DEVICE

0 999 10/01/1998 12/31/9999 1 148.13

E0747 KR - Fee on File Yes OSTEOGENISIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINAL APPLICATIONS

0 20 07/01/2019 12/31/9999 1 12.02

E0747 RR - Fee on File Yes OSTEOGENISIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINAL APPLICATIONS

0 20 07/01/2019 12/31/9999 1 360.64

E0748 KR - Fee on File Yes OSTEGENESIS STIMULATOR, ELECTRICAL, NON INVASIVE, SPINAL APPLICATIONS

0 20 07/01/2019 12/31/9999 1 11.95

E0748 NU - Fee on File Yes OSTEGENESIS STIMULATOR, ELECTRICAL, NON INVASIVE, SPINAL APPLICATIONS

0 20 07/01/2019 12/31/9999 1 3,583.74

E0748 RR - Fee on File Yes OSTEGENESIS STIMULATOR, ELECTRICAL, NON INVASIVE, SPINAL APPLICATIONS

0 20 07/01/2019 12/31/9999 1 358.37

E0748 UE - Fee on File Yes OSTEGENESIS STIMULATOR, ELECTRICAL, NON INVASIVE, SPINAL APPLICATIONS

0 20 07/01/2019 12/31/9999 1 1,791.87

E0755 NU - Fee on File Yes ELECTRONIC SALIVARY REFLEX STIMULATOR (INTRAORAL /

0 20 10/01/1998 12/31/9999 1 31.96

E0755 UE - Fee on File Yes ELECTRONIC SALIVARY REFLEX STIMULATOR (INTRAORAL /

0 20 10/01/1998 12/31/9999 1 15.98

E0760 KR - Fee on File Yes OSTOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON INVASIVE

0 999 07/01/2019 12/31/9999 1 9.93

E0760 RR - Fee on File Yes OSTOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON INVASIVE

0 999 07/01/2019 12/31/9999 1 297.80

E0762 KR - Fee on File Yes TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES

0 20 07/01/2019 12/31/9999 1 3.38

E0762 NU - Fee on File Yes TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES

0 20 07/01/2019 12/31/9999 1 1,012.80

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0762 RR - Fee on File Yes TRANSCUTANEOUS ELECTRICAL JOINT

STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES

0 20 07/01/2019 12/31/9999 1 101.28

E0762 UE - Fee on File Yes TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES

0 20 07/01/2019 12/31/9999 1 506.40

E0770 KR - Priced by PA Yes FUNCTIONAL ELECTRICAL STIMULATOR, TRANSCUTANEOUS STIMULATION OF NERVE AND/OR MUSCLE GROUPS, ANY TYPE, COMPLETE SYSTEM, NOS

0 20 01/01/2009 12/31/9999 1 0.00

E0770 RR - Priced by PA Yes FUNCTIONAL ELECTRICAL STIMULATOR, TRANSCUTANEOUS STIMULATION OF NERVE AND/OR MUSCLE GROUPS, ANY TYPE, COMPLETE SYSTEM, NOS

0 20 01/01/2009 12/31/9999 1 0.00

E0776 KR - Fee on File Yes IV POLE 0 999 07/01/2019 12/31/9999 1 0.41E0776 NU - Fee on File Yes IV POLE 0 999 07/01/2019 12/31/9999 1 123.52E0776 RR - Fee on File Yes IV POLE 0 999 07/01/2019 12/31/9999 1 12.35E0776 UE - Fee on File Yes IV POLE 0 999 07/01/2019 12/31/9999 1 61.76E0781 KR - Fee on File Yes AMBULATORY INFUSION PUMP, SINGLE

OR MULTIPLE CHANNELS, ELECTRIC OR BATTERY OPERATED, WITH ADMINISTRATIVE EQUIPMENT WORN BY PATIENT

0 999 07/01/2019 12/31/9999 1 6.90

E0781 RR - Fee on File Yes AMBULATORY INFUSION PUMP, SINGLE OR MULTIPLE CHANNELS, ELECTRIC OR BATTERY OPERATED, WITH ADMINISTRATIVE EQUIPMENT WORN BY PATIENT

0 999 07/01/2019 12/31/9999 1 206.97

E0784 KR - Fee on File Yes EXTERNAL AMBULATORY INFUSION PUMP, INSULIN

0 999 07/01/2019 12/31/9999 1 12.24

E0784 NU - Fee on File Yes EXTERNAL AMBULATORY INFUSION PUMP, INSULIN

0 999 07/01/2019 12/31/9999 1 3,671.36

E0784 RR - Fee on File Yes EXTERNAL AMBULATORY INFUSION PUMP, INSULIN

0 999 07/01/2019 12/31/9999 1 367.14

E0784 UE - Fee on File Yes EXTERNAL AMBULATORY INFUSION PUMP, INSULIN

0 999 07/01/2019 12/31/9999 1 1,835.68

E0791 KR - Fee on File Yes PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR

0 999 07/01/2019 12/31/9999 1 7.97

E0791 NU - Fee on File Yes PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR

0 999 07/01/2019 12/31/9999 1 2,389.68

E0791 RR - Fee on File Yes PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR

0 999 07/01/2019 12/31/9999 1 238.97

E0791 UE - Fee on File Yes PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR

0 999 07/01/2019 12/31/9999 1 1,194.84

E0840 NU - Fee on File Yes TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION

0 999 07/01/2019 12/31/9999 1 67.49

E0840 RR - Fee on File Yes TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION

0 999 07/01/2019 12/31/9999 1 6.75

E0840 UE - Fee on File Yes TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION

0 999 07/01/2019 12/31/9999 1 33.74

E0840 KR - Fee on File Yes TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION

0 999 07/01/2015 12/31/9999 1 0.22

E0849 KR - Fee on File Yes TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE

0 999 07/01/2019 12/31/9999 1 1.58

E0849 NU - Fee on File Yes TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE

0 999 07/01/2019 12/31/9999 1 474.72

E0849 RR - Fee on File Yes TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE

0 999 07/01/2019 12/31/9999 1 47.47

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0849 UE - Fee on File Yes TRACTION EQUIPMENT, CERVICAL, FREE-

STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE

0 999 07/01/2019 12/31/9999 1 237.36

E0850 NU - Fee on File Yes TRACTION STAND, FREESTANDING, CERVICAL TRACTION

0 999 07/01/2019 12/31/9999 1 96.76

E0850 RR - Fee on File Yes TRACTION STAND, FREESTANDING, CERVICAL TRACTION

0 999 07/01/2019 12/31/9999 1 9.68

E0850 UE - Fee on File Yes TRACTION STAND, FREESTANDING, CERVICAL TRACTION

0 999 07/01/2019 12/31/9999 1 48.38

E0850 KR - Fee on File Yes TRACTION STAND, FREESTANDING, CERVICAL TRACTION

0 999 07/01/2018 12/31/9999 1 0.32

E0855 KR - Fee on File Yes CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME

0 999 07/01/2019 12/31/9999 1 1.54

E0855 NU - Fee on File Yes CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME

0 999 07/01/2019 12/31/9999 1 462.96

E0855 RR - Fee on File Yes CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME

0 999 07/01/2019 12/31/9999 1 46.30

E0855 UE - Fee on File Yes CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME

0 999 07/01/2019 12/31/9999 1 231.48

E0856 KR - Fee on File Yes CERVICAL TRACTION DEVICE WITH INFLATABLE AIR BLADDER(S)

0 999 07/01/2019 12/31/9999 1 0.47

E0856 NU - Fee on File Yes CERVICAL TRACTION DEVICE WITH INFLATABLE AIR BLADDER(S)

0 999 07/01/2019 12/31/9999 1 141.76

E0856 RR - Fee on File Yes CERVICAL TRACTION DEVICE WITH INFLATABLE AIR BLADDER(S)

0 999 07/01/2019 12/31/9999 1 14.18

E0856 UE - Fee on File Yes CERVICAL TRACTION DEVICE WITH INFLATABLE AIR BLADDER(S)

0 999 07/01/2019 12/31/9999 1 70.88

E0860 NU - Fee on File Yes TRACTION EQUIPMENT, OVERDOOR, CERVICAL

0 999 07/01/2019 12/31/9999 1 35.50

E0860 RR - Fee on File Yes TRACTION EQUIPMENT, OVERDOOR, CERVICAL

0 999 07/01/2019 12/31/9999 1 3.55

E0860 UE - Fee on File Yes TRACTION EQUIPMENT, OVERDOOR, CERVICAL

0 999 07/01/2019 12/31/9999 1 17.75

E0860 KR - Fee on File Yes TRACTION EQUIPMENT, OVERDOOR, CERVICAL

0 999 07/01/2018 12/31/9999 1 0.12

E0870 NU - Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE EXTREMITY (E.G., BUCK'S)

0 20 07/01/2019 12/31/9999 1 91.06

E0870 RR - Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE EXTREMITY (E.G., BUCK'S)

0 20 07/01/2019 12/31/9999 1 9.11

E0870 UE - Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE EXTREMITY (E.G., BUCK'S)

0 20 07/01/2019 12/31/9999 1 45.53

E0870 KR - Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE EXTREMITY (E.G., BUCK'S)

0 20 07/01/2018 12/31/9999 1 0.30

E0880 KR - Fee on File Yes TRACTION STAND, FREESTANDING, EXTREMITY TRACTION (E.G., BUCK'S)

0 20 07/01/2019 12/31/9999 1 0.33

E0880 NU - Fee on File Yes TRACTION STAND, FREESTANDING, EXTREMITY TRACTION (E.G., BUCK'S)

0 20 07/01/2019 12/31/9999 1 98.30

E0880 RR - Fee on File Yes TRACTION STAND, FREESTANDING, EXTREMITY TRACTION (E.G., BUCK'S)

0 20 07/01/2019 12/31/9999 1 9.83

E0880 UE - Fee on File Yes TRACTION STAND, FREESTANDING, EXTREMITY TRACTION (E.G., BUCK'S)

0 20 07/01/2019 12/31/9999 1 49.15

E0890 NU - Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTION

0 999 07/01/2019 12/31/9999 1 94.26

E0890 RR - Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTION

0 999 07/01/2019 12/31/9999 1 9.43

E0890 UE - Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTION

0 999 07/01/2019 12/31/9999 1 47.13

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0890 KR - Fee on File Yes TRACTION FRAME, ATTACHED TO

FOOTBOARD, PELVIC TRACTION0 999 07/01/2018 12/31/9999 1 0.31

E0900 NU - Fee on File Yes TRACTION STAND, FREE STANDING, PELVIC TRACTION, (E.G., BUCK'S)

0 999 07/01/2019 12/31/9999 1 100.32

E0900 RR - Fee on File Yes TRACTION STAND, FREE STANDING, PELVIC TRACTION, (E.G., BUCK'S)

0 999 07/01/2019 12/31/9999 1 10.03

E0900 UE - Fee on File Yes TRACTION STAND, FREE STANDING, PELVIC TRACTION, (E.G., BUCK'S)

0 999 07/01/2019 12/31/9999 1 50.16

E0900 KR - Fee on File Yes TRACTION STAND, FREE STANDING, PELVIC TRACTION, (E.G., BUCK'S)

0 999 07/01/2018 12/31/9999 1 0.33

E0910 KR - Fee on File Yes TRAPEZE BARS, ALSO KNOWN AS PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 0.39

E0910 NU - Fee on File Yes TRAPEZE BARS, ALSO KNOWN AS PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 117.36

E0910 RR - Fee on File Yes TRAPEZE BARS, ALSO KNOWN AS PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 11.74

E0910 UE - Fee on File Yes TRAPEZE BARS, ALSO KNOWN AS PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 58.68

E0911 KR - Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 1.26

E0911 NU - Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 377.44

E0911 RR - Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 37.74

E0911 UE - Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 188.72

E0912 KR - Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREESTANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 2.68

E0912 NU - Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREESTANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 802.96

E0912 RR - Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREESTANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 80.30

E0912 UE - Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREESTANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 401.48

E0940 KR - Fee on File Yes TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 0.69

E0940 NU - Fee on File Yes TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 207.04

E0940 RR - Fee on File Yes TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 20.70

E0940 UE - Fee on File Yes TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2019 12/31/9999 1 103.52

E0941 KR - Fee on File Yes GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE

0 20 07/01/2019 12/31/9999 1 1.13

E0941 NU - Fee on File Yes GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE

0 20 07/01/2019 12/31/9999 1 339.76

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0941 RR - Fee on File Yes GRAVITY ASSISTED TRACTION DEVICE,

ANY TYPE0 20 07/01/2019 12/31/9999 1 33.98

E0941 UE - Fee on File Yes GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE

0 20 07/01/2019 12/31/9999 1 169.88

E0950 NU - Fee on File Yes WHEELCHAIR ACCESSORY, TRAY, EACH 0 999 07/01/2019 12/31/9999 1 73.26E0950 UE - Fee on File Yes WHEELCHAIR ACCESSORY, TRAY, EACH 0 999 07/01/2019 12/31/9999 1 36.63E0951 NU - Fee on File Yes HEEL LOOP/HOLDER, ANY TYPE, WITH

OR WITHOUT ANKLE STRAP, EACH0 999 07/01/2019 12/31/9999 1 11.92

E0951 UE - Fee on File Yes HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH

0 999 07/01/2019 12/31/9999 1 5.96

E0952 NU - Fee on File Yes TOE LOOP/HOLDER, ANY TYPE, EACH 0 20 07/01/2019 12/31/9999 1 13.95E0952 UE - Fee on File Yes TOE LOOP/HOLDER, ANY TYPE, EACH 0 20 07/01/2019 12/31/9999 1 6.98E0958 NU - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY,

ONE-ARM DRIVE ATTACHMENT, EACH0 20 07/01/2019 12/31/9999 1 356.08

E0958 UE - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH

0 20 07/01/2019 12/31/9999 1 178.04

E0959 NU - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH

0 20 07/01/2019 12/31/9999 1 38.59

E0959 UE - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH

0 20 07/01/2019 12/31/9999 1 19.30

E0961 NU - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH

0 20 07/01/2019 12/31/9999 1 20.25

E0961 UE - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH

0 20 07/01/2019 12/31/9999 1 10.12

E0966 NU - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH

0 20 07/01/2019 12/31/9999 1 55.88

E0966 UE - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH

0 20 07/01/2019 12/31/9999 1 27.94

E0967 NU - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, REPLACEMENT ONLY, EACH

0 20 07/01/2019 12/31/9999 1 60.50

E0967 UE - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, REPLACEMENT ONLY, EACH

0 20 07/01/2019 12/31/9999 1 30.25

E0968 NU - Fee on File Yes COMMODE SEAT, WHEELCHAIR 0 20 07/01/2019 12/31/9999 1 165.04E0968 UE - Fee on File Yes COMMODE SEAT, WHEELCHAIR 0 20 07/01/2019 12/31/9999 1 82.52E0969 NU - Fee on File Yes NARROWING DEVICE, WHEELCHAIR 0 20 07/01/2019 12/31/9999 1 144.27E0969 UE - Fee on File Yes NARROWING DEVICE, WHEELCHAIR 0 20 07/01/2019 12/31/9999 1 72.14E0970 NU - Fee on File Yes NO. 2 FOOTPLATES, EXCEPT FOR

ELEVATING LEG REST0 20 10/01/1998 12/31/9999 1 31.24

E0970 UE - Fee on File Yes NO. 2 FOOTPLATES, EXCEPT FOR ELEVATING LEG REST

0 20 10/01/1998 12/31/9999 1 15.62

E0971 NU - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH

0 999 07/01/2019 12/31/9999 1 32.68

E0971 UE - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH

0 999 07/01/2019 12/31/9999 1 16.34

E0973 NU - Fee on File Yes WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH

0 999 07/01/2019 12/31/9999 1 61.23

E0973 UE - Fee on File Yes WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH

0 999 07/01/2019 12/31/9999 1 30.62

E0974 NU - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH

0 20 07/01/2019 12/31/9999 1 66.96

E0974 UE - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH

0 20 07/01/2019 12/31/9999 1 33.48

E0978 NU - Fee on File Yes WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH

0 999 07/01/2019 12/31/9999 1 27.23

E0978 UE - Fee on File Yes WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH

0 999 07/01/2019 12/31/9999 1 13.62

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0980 NU - Fee on File Yes SAFETY VEST, WHEELCHAIR 0 20 07/01/2019 12/31/9999 1 30.01E0980 UE - Fee on File Yes SAFETY VEST, WHEELCHAIR 0 20 07/01/2019 12/31/9999 1 15.00E0990 NU - Fee on File Yes WHEELCHAIR ACCESSORY, ELEVATING

LEG REST, COMPLETE ASSEMBLY, EACH0 999 07/01/2019 12/31/9999 2 69.13

E0990 UE - Fee on File Yes WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH

0 999 07/01/2019 12/31/9999 2 34.56

E0992 NU - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT

0 20 07/01/2019 12/31/9999 1 76.84

E0992 UE - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT

0 20 07/01/2019 12/31/9999 1 38.42

E0994 NU - Fee on File Yes ARM REST, EACH 0 20 07/01/2019 12/31/9999 2 13.81E0994 UE - Fee on File Yes ARM REST, EACH 0 20 07/01/2019 12/31/9999 2 6.90E0995 NU - Fee on File Yes WHEELCHAIR ACCESSORY, CALF

REST/PAD, REPLACEMENT ONLY, EACH0 20 07/01/2019 12/31/9999 2 20.51

E0995 UE - Fee on File Yes WHEELCHAIR ACCESSORY, CALF REST/PAD, REPLACEMENT ONLY, EACH

0 20 07/01/2019 12/31/9999 2 10.26

E1012 NU - Fee on File Yes WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH

0 20 07/01/2019 12/31/9999 1 888.72

E1012 RR - Fee on File Yes WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH

0 20 07/01/2019 12/31/9999 1 88.87

E1012 UE - Fee on File Yes WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH

0 20 07/01/2019 12/31/9999 1 444.36

E1012 KR - Fee on File Yes WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH

0 20 07/01/2018 12/31/9999 1 2.96

E1020 NU - Fee on File Yes RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE

0 20 07/01/2019 12/31/9999 1 172.00

E1020 UE - Fee on File Yes RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE

0 20 07/01/2019 12/31/9999 1 86.00

E1031 KR - Fee on File Yes ROLL ABOUT CHAIR, ANY AND ALL TYPES WITH CUSTORS 5 INCHES OR

0 20 07/01/2019 12/31/9999 1 1.26

E1031 NU - Fee on File Yes ROLL ABOUT CHAIR, ANY AND ALL TYPES WITH CUSTORS 5 INCHES OR

0 20 07/01/2019 12/31/9999 1 377.60

E1031 RR - Fee on File Yes ROLL ABOUT CHAIR, ANY AND ALL TYPES WITH CUSTORS 5 INCHES OR

0 20 07/01/2019 12/31/9999 1 37.76

E1031 UE - Fee on File Yes ROLL ABOUT CHAIR, ANY AND ALL TYPES WITH CUSTORS 5 INCHES OR

0 20 07/01/2019 12/31/9999 1 188.80

E1037 KR - Fee on File Yes TRANSPORT CHAIR, PEDIATRIC SIZE 0 999 07/01/2019 12/31/9999 9 3.17E1037 NU - Fee on File Yes TRANSPORT CHAIR, PEDIATRIC SIZE 0 999 07/01/2019 12/31/9999 6 950.40E1037 RR - Fee on File Yes TRANSPORT CHAIR, PEDIATRIC SIZE 0 999 07/01/2019 12/31/9999 8 95.04E1037 UE - Fee on File Yes TRANSPORT CHAIR, PEDIATRIC SIZE 0 999 07/01/2019 12/31/9999 7 475.20E1038 KR - Fee on File Yes TRANSPORT CHAIR, ADULT SIZE,

PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

0 999 07/01/2019 12/31/9999 14 0.48

E1038 NU - Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

0 999 07/01/2019 12/31/9999 11 144.72

E1038 RR - Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

0 999 07/01/2019 12/31/9999 13 14.47

E1038 UE - Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

0 999 07/01/2019 12/31/9999 12 72.36

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1039 KR - Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, HEAVY

DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS

0 999 07/01/2019 12/31/9999 19 0.99

E1039 NU - Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS

0 999 07/01/2019 12/31/9999 16 296.08

E1039 RR - Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS

0 999 07/01/2019 12/31/9999 18 29.61

E1039 UE - Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS

0 999 07/01/2019 12/31/9999 17 148.04

E1050 KR - Fee on File Yes FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 2.66

E1050 NU - Fee on File Yes FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 797.36

E1050 RR - Fee on File Yes FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 79.74

E1050 UE - Fee on File Yes FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 398.68

E1060 KR - Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 3.29

E1060 NU - Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 986.96

E1060 RR - Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 98.70

E1060 UE - Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 493.48

E1070 KR - Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 2.86

E1070 NU - Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 857.60

E1070 RR - Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 85.76

E1070 UE - Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 428.80

E1083 KR - Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 2.05

E1083 NU - Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 616.48

E1083 RR - Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 61.65

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1083 UE - Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH

ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 308.24

E1084 KR - Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 2.56

E1084 NU - Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 768.08

E1084 RR - Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 76.81

E1084 UE - Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 384.04

E1085 NU - Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 471.32

E1085 UE - Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 235.66

E1085 KR - Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 1.57

E1085 RR - Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 47.13

E1086 NU - Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 572.38

E1086 KR - Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 1.91

E1086 RR - Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 57.24

E1086 UE - Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 286.21

E1087 KR - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY, DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 3.30

E1087 NU - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY, DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 990.72

E1087 RR - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY, DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 99.07

E1087 UE - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY, DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 495.36

E1088 KR - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH SWING-AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 3.93

E1088 NU - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH SWING-AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 1,180.48

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1088 RR - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT

WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH SWING-AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 118.05

E1088 UE - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH SWING-AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 590.24

E1089 NU - Fee on File Yes HIGH STRENGTH WHEELCHAIR, FIXED LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 818.58

E1089 UE - Fee on File Yes HIGH STRENGTH WHEELCHAIR, FIXED LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 409.29

E1089 KR - Fee on File Yes HIGH STRENGTH WHEELCHAIR, FIXED LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 2.73

E1089 RR - Fee on File Yes HIGH STRENGTH WHEELCHAIR, FIXED LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 81.86

E1090 KR - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWINGAWAY, DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 3.09

E1090 NU - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWINGAWAY, DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 927.36

E1090 RR - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWINGAWAY, DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 92.74

E1090 UE - Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWINGAWAY, DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 463.68

E1092 KR - Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 3.86

E1092 NU - Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 1,158.56

E1092 RR - Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 115.86

E1092 UE - Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 579.28

E1093 KR - Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 3.31

E1093 NU - Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 993.20

E1093 RR - Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 99.32

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1093 UE - Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR;

DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 496.60

E1100 KR - Fee on File Yes SEMI-RECLINING WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 2.71

E1100 NU - Fee on File Yes SEMI-RECLINING WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 812.64

E1100 RR - Fee on File Yes SEMI-RECLINING WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 81.26

E1100 UE - Fee on File Yes SEMI-RECLINING WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 406.32

E1110 KR - Fee on File Yes SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 2.65

E1110 NU - Fee on File Yes SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 795.84

E1110 RR - Fee on File Yes SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 79.58

E1110 UE - Fee on File Yes SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 397.92

E1130 KR - Fee on File Yes STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 1.06

E1130 NU - Fee on File Yes STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 318.02

E1130 RR - Fee on File Yes STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 31.80

E1130 UE - Fee on File Yes STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 159.01

E1140 KR - Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 1.63

E1140 NU - Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 489.22

E1140 RR - Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 48.92

E1140 UE - Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 244.61

E1150 KR - Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 2.13

E1150 NU - Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 638.64

E1150 RR - Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 63.86

E1150 UE - Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 319.32

E1160 KR - Fee on File Yes WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 1.63

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1160 NU - Fee on File Yes WHEELCHAIR, FIXED FULL LENGTH

ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 489.36

E1160 RR - Fee on File Yes WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 48.94

E1160 UE - Fee on File Yes WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 244.68

E1161 KR - Fee on File Yes MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE

0 999 07/01/2019 12/31/9999 1 7.26

E1161 NU - Fee on File Yes MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE

0 999 07/01/2019 12/31/9999 1 2,179.36

E1161 RR - Fee on File Yes MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE

0 999 07/01/2019 12/31/9999 1 217.94

E1161 UE - Fee on File Yes MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE

0 999 07/01/2019 12/31/9999 1 1,089.68

E1170 KR - Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESETS

0 999 07/01/2019 12/31/9999 1 2.33

E1170 NU - Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESETS

0 999 07/01/2019 12/31/9999 1 699.28

E1170 RR - Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESETS

0 999 07/01/2019 12/31/9999 1 69.93

E1170 UE - Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESETS

0 999 07/01/2019 12/31/9999 1 349.64

E1171 KR - Fee on File Yes AMPUTEE, WHEELCHAIR, FIXED FULL LENGTH ARMS WITHOUT FOOT RESTS OR LEG RESTS

0 999 07/01/2019 12/31/9999 1 2.09

E1171 NU - Fee on File Yes AMPUTEE, WHEELCHAIR, FIXED FULL LENGTH ARMS WITHOUT FOOT RESTS OR LEG RESTS

0 999 07/01/2019 12/31/9999 1 627.52

E1171 RR - Fee on File Yes AMPUTEE, WHEELCHAIR, FIXED FULL LENGTH ARMS WITHOUT FOOT RESTS OR LEG RESTS

0 999 07/01/2019 12/31/9999 1 62.75

E1171 UE - Fee on File Yes AMPUTEE, WHEELCHAIR, FIXED FULL LENGTH ARMS WITHOUT FOOT RESTS OR LEG RESTS

0 999 07/01/2019 12/31/9999 1 313.76

E1172 KR - Fee on File Yes AMPUTEE, WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH WITHOUT FOOTRESTS OR LEGRESTS

0 999 07/01/2019 12/31/9999 1 2.56

E1172 NU - Fee on File Yes AMPUTEE, WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH WITHOUT FOOTRESTS OR LEGRESTS

0 999 07/01/2019 12/31/9999 1 767.04

E1172 RR - Fee on File Yes AMPUTEE, WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH WITHOUT FOOTRESTS OR LEGRESTS

0 999 07/01/2019 12/31/9999 1 76.70

E1172 UE - Fee on File Yes AMPUTEE, WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH WITHOUT FOOTRESTS OR LEGRESTS

0 999 07/01/2019 12/31/9999 1 383.52

E1180 KR - Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 2.64

E1180 NU - Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 793.36

E1180 RR - Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 79.34

E1180 UE - Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 396.68

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1190 KR - Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE

ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 3.06

E1190 NU - Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 916.64

E1190 RR - Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 91.66

E1190 UE - Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 458.32

E1195 KR - Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 3.28

E1195 NU - Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 983.52

E1195 RR - Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 98.35

E1195 UE - Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 491.76

E1200 KR - Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 2.27

E1200 NU - Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 681.20

E1200 RR - Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 68.12

E1200 UE - Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2019 12/31/9999 1 340.60

E1220 NU - Priced by PA Yes WHEELCHAIR; SPECIALLY SIZE OR CONTRUCTED (INDICATE BRAND NAME, MODEL NUMBER, IF ANY, AND JUSTIFCATION)

0 999 10/01/1998 12/31/9999 1 0.00

E1221 KR - Fee on File Yes WHEELCHAIR WITH FIXED ARM, FOOTRESTS

0 999 07/01/2019 12/31/9999 1 1.46

E1221 NU - Fee on File Yes WHEELCHAIR WITH FIXED ARM, FOOTRESTS

0 999 07/01/2019 12/31/9999 1 437.68

E1221 RR - Fee on File Yes WHEELCHAIR WITH FIXED ARM, FOOTRESTS

0 999 07/01/2019 12/31/9999 1 43.77

E1221 UE - Fee on File Yes WHEELCHAIR WITH FIXED ARM, FOOTRESTS

0 999 07/01/2019 12/31/9999 1 218.84

E1222 KR - Fee on File Yes WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 2.08

E1222 NU - Fee on File Yes WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 624.32

E1222 RR - Fee on File Yes WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 62.43

E1222 UE - Fee on File Yes WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 312.16

E1223 KR - Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS

0 999 07/01/2019 12/31/9999 1 2.27

E1223 NU - Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS

0 999 07/01/2019 12/31/9999 1 681.76

E1223 RR - Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS

0 999 07/01/2019 12/31/9999 1 68.18

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1223 UE - Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS,

FOOTRESTS0 999 07/01/2019 12/31/9999 1 340.88

E1224 KR - Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 2.49

E1224 NU - Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 747.44

E1224 RR - Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 74.74

E1224 UE - Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 373.72

E1225 KR - Fee on File Yes WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH

0 999 07/01/2019 12/31/9999 1 1.15

E1225 NU - Fee on File Yes WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH

0 999 07/01/2019 12/31/9999 1 345.36

E1225 RR - Fee on File Yes WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH

0 999 07/01/2019 12/31/9999 1 34.54

E1225 UE - Fee on File Yes WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH

0 999 07/01/2019 12/31/9999 1 172.68

E1226 KR - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, FULLY RECLINING BACK (RECLINE GREATER THAN 80 DEGREES), EACH

0 999 07/01/2019 12/31/9999 1 1.37

E1226 NU - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, FULLY RECLINING BACK (RECLINE GREATER THAN 80 DEGREES), EACH

0 999 07/01/2019 12/31/9999 1 410.46

E1226 RR - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, FULLY RECLINING BACK (RECLINE GREATER THAN 80 DEGREES), EACH

0 999 07/01/2019 12/31/9999 1 41.05

E1226 UE - Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, FULLY RECLINING BACK (RECLINE GREATER THAN 80 DEGREES), EACH

0 999 07/01/2019 12/31/9999 1 205.23

E1227 NU - Fee on File Yes SPECIAL HEIGHT ARMS FOR WHEELCHAIR

0 999 07/01/2019 12/31/9999 1 255.61

E1228 NU - Fee on File Yes SPECIAL BACK HEIGHT FOR WHEELCHAIR

0 999 07/01/2019 12/31/9999 1 219.44

E1230 NU - Fee on File Yes POWER OPERATED VEHICLE (THREE OR FOUR WHEEL NONHIGHWAY) SPECIFY BRAND NAME AND MODEL NUMBER

0 20 07/01/2019 12/31/9999 1 1,770.85

E1230 UE - Fee on File Yes POWER OPERATED VEHICLE (THREE OR FOUR WHEEL NONHIGHWAY) SPECIFY BRAND NAME AND MODEL NUMBER

0 20 07/01/2019 12/31/9999 1 885.42

E1232 KR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEA

0 20 07/01/2019 12/31/9999 1 6.57

E1232 NU - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEA

0 20 07/01/2019 12/31/9999 1 1,969.84

E1232 RR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEA

0 20 07/01/2019 12/31/9999 1 196.98

E1232 UE - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEA

0 20 07/01/2019 12/31/9999 1 984.92

E1233 KR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SE

0 20 07/01/2019 12/31/9999 1 6.80

E1233 NU - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SE

0 20 07/01/2019 12/31/9999 1 2,040.88

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1233 RR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-

SPACE, RIGID, ADJUSTABLE, WITHOUT SE

0 20 07/01/2019 12/31/9999 1 204.09

E1233 UE - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SE

0 20 07/01/2019 12/31/9999 1 1,020.44

E1234 KR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT

0 20 07/01/2019 12/31/9999 1 5.92

E1234 NU - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT

0 20 07/01/2019 12/31/9999 1 1,776.80

E1234 RR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT

0 20 07/01/2019 12/31/9999 1 177.68

E1234 UE - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT

0 20 07/01/2019 12/31/9999 1 888.40

E1235 KR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 5.70

E1235 NU - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 1,711.04

E1235 RR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 171.10

E1235 UE - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 855.52

E1236 KR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING

0 20 07/01/2019 12/31/9999 1 5.70

E1236 NU - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING

0 20 07/01/2019 12/31/9999 1 1,711.04

E1236 RR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING

0 20 07/01/2019 12/31/9999 1 171.10

E1236 UE - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING

0 20 07/01/2019 12/31/9999 1 855.52

E1237 KR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 5.08

E1237 NU - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 1,522.64

E1237 RR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 152.26

E1237 UE - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 761.32

E1238 KR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 5.03

E1238 NU - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 1,509.44

E1238 RR - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 150.94

E1238 UE - Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2019 12/31/9999 1 754.72

E1240 KR - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 2.69

E1240 NU - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 806.64

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1240 RR - Fee on File Yes LIGHTWEIGHT WHEELCHAIR,

DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 80.66

E1240 UE - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 403.32

E1250 KR - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 2 1.73

E1250 NU - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 517.61

E1250 RR - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 51.76

E1250 UE - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 258.80

E1260 KR - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 2.12

E1260 NU - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 634.79

E1260 RR - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 63.48

E1260 UE - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 317.39

E1270 KR - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 2.06

E1270 NU - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 618.08

E1270 RR - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 61.81

E1270 UE - Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 309.04

E1280 KR - Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 3.43

E1280 NU - Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 1,027.68

E1280 RR - Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 102.77

E1280 UE - Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2019 12/31/9999 1 513.84

E1285 KR - Fee on File Yes HEAVY DUTY WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 2.74

E1285 NU - Fee on File Yes HEAVY DUTY WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 821.35

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1285 RR - Fee on File Yes HEAVY DUTY WHEELCHAIR; FIXED FULL

LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 82.14

E1285 UE - Fee on File Yes HEAVY DUTY WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 410.68

E1290 KR - Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 2.84

E1290 NU - Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 852.26

E1290 RR - Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 85.23

E1290 UE - Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 426.13

E1295 KR - Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEG RESTS

0 999 07/01/2019 12/31/9999 1 3.17

E1295 NU - Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEG RESTS

0 999 07/01/2019 12/31/9999 1 950.96

E1295 RR - Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEG RESTS

0 999 07/01/2019 12/31/9999 1 95.10

E1295 UE - Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEG RESTS

0 999 07/01/2019 12/31/9999 1 475.48

E1296 KR - Fee on File Yes SPECIAL WHEELCHAIR; SEAT HEIGHT FROM FLOOR

0 999 07/01/2019 12/31/9999 1 1.51

E1296 NU - Fee on File Yes SPECIAL WHEELCHAIR; SEAT HEIGHT FROM FLOOR

0 999 07/01/2019 12/31/9999 1 452.86

E1296 RR - Fee on File Yes SPECIAL WHEELCHAIR; SEAT HEIGHT FROM FLOOR

0 999 07/01/2019 12/31/9999 1 45.29

E1296 UE - Fee on File Yes SPECIAL WHEELCHAIR; SEAT HEIGHT FROM FLOOR

0 999 07/01/2019 12/31/9999 1 226.43

E1297 KR - Fee on File Yes SPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERY

0 999 07/01/2019 12/31/9999 1 0.32

E1297 NU - Fee on File Yes SPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERY

0 999 07/01/2019 12/31/9999 1 96.36

E1297 RR - Fee on File Yes SPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERY

0 999 07/01/2019 12/31/9999 1 9.64

E1297 UE - Fee on File Yes SPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERY

0 999 07/01/2019 12/31/9999 1 48.18

E1298 KR - Fee on File Yes SPECIAL WHEELCHAIR; SEAT DEPTH AND/OR WIDTH BY CONSTRUCTION

0 999 07/01/2019 12/31/9999 1 1.30

E1298 NU - Fee on File Yes SPECIAL WHEELCHAIR; SEAT DEPTH AND/OR WIDTH BY CONSTRUCTION

0 999 07/01/2019 12/31/9999 1 390.24

E1298 RR - Fee on File Yes SPECIAL WHEELCHAIR; SEAT DEPTH AND/OR WIDTH BY CONSTRUCTION

0 999 07/01/2019 12/31/9999 1 39.02

E1298 UE - Fee on File Yes SPECIAL WHEELCHAIR; SEAT DEPTH AND/OR WIDTH BY CONSTRUCTION

0 999 07/01/2019 12/31/9999 1 195.12

E1300 KR - Fee on File Yes WHIRLPOOL, PORTABLE (OVERTUB TYPE)

0 20 10/01/1998 12/31/9999 1 0.20

E1300 NU - Fee on File Yes WHIRLPOOL, PORTABLE (OVERTUB TYPE)

0 20 10/01/1998 12/31/9999 1 59.25

E1300 RR - Fee on File Yes WHIRLPOOL, PORTABLE (OVERTUB TYPE)

0 20 10/01/1998 12/31/9999 1 5.93

E1300 UE - Fee on File Yes WHIRLPOOL, PORTABLE (OVERTUB TYPE)

0 20 10/01/1998 12/31/9999 1 29.63

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1390 KR - Fee on File Yes OXYGEN CONCENTRATOR, SINGLE

DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE

0 999 07/01/2019 12/31/9999 1 3.59

E1390 RR - Fee on File Yes OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE

0 999 07/01/2019 12/31/9999 1 107.77

E1391 KR - Fee on File Yes OXYGEN CONCENTRATOR 0 999 07/01/2019 12/31/9999 1 3.59E1391 RR - Fee on File Yes OXYGEN CONCENTRATOR 0 999 07/01/2019 12/31/9999 1 107.77E1392 KR - Fee on File Yes PORTABLE OXYGEN CONCENTRATOR,

RENTAL0 999 07/01/2019 12/31/9999 1 1.18

E1392 RR - Fee on File Yes PORTABLE OXYGEN CONCENTRATOR, RENTAL

0 999 07/01/2019 12/31/9999 1 35.46

E1399 KR - Priced by PA Yes DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

0 999 01/01/1983 12/31/9999 1 0.00

E1399 NU - Priced by PA Yes DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

0 999 01/01/1983 12/31/9999 1 0.00

E1399 RR - Priced by PA Yes DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

0 999 01/01/1983 12/31/9999 1 0.00

E1399 UE - Priced by PA Yes DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

0 999 01/01/1983 12/31/9999 1 0.00

E1405 KR - Fee on File Yes OXYGEN AND WATER VAPOR ENRICHING SYSTEM, WITH HEATED DELIVERY

0 999 07/01/2019 12/31/9999 1 5.33

E1405 RR - Fee on File Yes OXYGEN AND WATER VAPOR ENRICHING SYSTEM, WITH HEATED DELIVERY

0 999 07/01/2019 12/31/9999 1 159.93

E1406 KR - Fee on File Yes OXYGEN AND WATER VAPOR ENRICHING SYSTEM, WITHOUT HEATED DELIVERY

0 999 07/01/2019 12/31/9999 1 4.20

E1406 RR - Fee on File Yes OXYGEN AND WATER VAPOR ENRICHING SYSTEM, WITHOUT HEATED DELIVERY

0 999 07/01/2019 12/31/9999 1 126.03

E1700 NU - Fee on File Yes JAW MOTION REHABILITATION SYSTEM 0 20 07/01/2019 12/31/9999 1 317.68E1700 UE - Fee on File Yes JAW MOTION REHABILITATION SYSTEM 0 20 07/01/2019 12/31/9999 1 158.84E1701 NU - Fee on File Yes REPLACEMENT CUSHIONS FOR JAW

MOTION REHABILITATION SYSTEM, PKG OF 6

0 20 07/01/2019 12/31/9999 1 8.30

E1702 NU - Fee on File Yes REPLACEMENT MEASURING SCALES FOR JAW MOTION REHABILITATION SYSTEM, PKG OF 200

0 20 07/01/2019 12/31/9999 1 17.66

E1800 KR - Fee on File Yes DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 3.20

E1800 NU - Fee on File Yes DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 959.12

E1800 RR - Fee on File Yes DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 95.91

E1800 UE - Fee on File Yes DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 479.56

E1801 KR - Fee on File Yes STATIC PROGRESSIVE STRETCH ELBOW DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 3.55

E1801 NU - Fee on File Yes STATIC PROGRESSIVE STRETCH ELBOW DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 1,064.88

E1801 RR - Fee on File Yes STATIC PROGRESSIVE STRETCH ELBOW DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 106.49

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1801 UE - Fee on File Yes STATIC PROGRESSIVE STRETCH ELBOW

DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 532.44

E1805 KR - Fee on File Yes DYNAMIC ADJUSTABLE WRIST EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 3.30

E1805 NU - Fee on File Yes DYNAMIC ADJUSTABLE WRIST EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 989.28

E1805 RR - Fee on File Yes DYNAMIC ADJUSTABLE WRIST EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 98.93

E1805 UE - Fee on File Yes DYNAMIC ADJUSTABLE WRIST EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 494.64

E1806 KR - Fee on File Yes STATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEX AND/OR EXT W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 2.91

E1806 NU - Fee on File Yes STATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEX AND/OR EXT W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 873.92

E1806 RR - Fee on File Yes STATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEX AND/OR EXT W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 87.39

E1806 UE - Fee on File Yes STATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEX AND/OR EXT W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 436.96

E1810 KR - Fee on File Yes DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 3.25

E1810 NU - Fee on File Yes DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 975.44

E1810 RR - Fee on File Yes DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 97.54

E1810 UE - Fee on File Yes DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 487.72

E1811 KR - Fee on File Yes STATIC PROGRESSIVE STRETCH KNEE DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 3.69

E1811 NU - Fee on File Yes STATIC PROGRESSIVE STRETCH KNEE DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 1,107.12

E1811 RR - Fee on File Yes STATIC PROGRESSIVE STRETCH KNEE DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 110.71

E1811 UE - Fee on File Yes STATIC PROGRESSIVE STRETCH KNEE DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 553.56

E1812 KR - Fee on File Yes DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROL

0 20 07/01/2019 12/31/9999 1 2.64

E1812 NU - Fee on File Yes DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROL

0 20 07/01/2019 12/31/9999 1 792.08

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1812 RR - Fee on File Yes DYNAMIC KNEE, EXTENSION/FLEXION

DEVICE WITH ACTIVE RESISTANCE CONTROL

0 20 07/01/2019 12/31/9999 1 79.21

E1812 UE - Fee on File Yes DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROL

0 20 07/01/2019 12/31/9999 1 396.04

E1815 KR - Fee on File Yes DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 3.30

E1815 NU - Fee on File Yes DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 989.28

E1815 RR - Fee on File Yes DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 98.93

E1815 UE - Fee on File Yes DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 494.64

E1816 KR - Fee on File Yes STATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEX AND/OR EXT, W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 3.75

E1816 NU - Fee on File Yes STATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEX AND/OR EXT, W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 1,124.24

E1816 RR - Fee on File Yes STATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEX AND/OR EXT, W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 112.42

E1816 UE - Fee on File Yes STATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEX AND/OR EXT, W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2019 12/31/9999 1 562.12

E1818 KR - Fee on File Yes STATIC PROGRESSIVE STRETCH FOREARM PRONATION / SUPINATION DEVICE, W/WO RANGE OF MOTION ADJ, INCL ALL COMP AND ACCS

0 20 07/01/2019 12/31/9999 1 3.83

E1818 NU - Fee on File Yes STATIC PROGRESSIVE STRETCH FOREARM PRONATION / SUPINATION DEVICE, W/WO RANGE OF MOTION ADJ, INCL ALL COMP AND ACCS

0 20 07/01/2019 12/31/9999 1 1,148.08

E1818 RR - Fee on File Yes STATIC PROGRESSIVE STRETCH FOREARM PRONATION / SUPINATION DEVICE, W/WO RANGE OF MOTION ADJ, INCL ALL COMP AND ACCS

0 20 07/01/2019 12/31/9999 1 114.81

E1818 UE - Fee on File Yes STATIC PROGRESSIVE STRETCH FOREARM PRONATION / SUPINATION DEVICE, W/WO RANGE OF MOTION ADJ, INCL ALL COMP AND ACCS

0 20 07/01/2019 12/31/9999 1 574.04

E1820 NU - Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE

0 20 07/01/2019 12/31/9999 1 75.30

E1820 RR - Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE

0 20 07/01/2019 12/31/9999 1 7.53

E1820 UE - Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE

0 20 07/01/2019 12/31/9999 1 37.65

E1820 KR - Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE

0 20 07/01/2018 12/31/9999 1 0.25

E1821 NU - Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH DEVICE

0 20 07/01/2019 12/31/9999 1 96.94

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1821 RR - Fee on File Yes REPLACEMENT SOFT INTERFACE

MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH DEVICE

0 20 07/01/2019 12/31/9999 1 9.69

E1821 UE - Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH DEVICE

0 20 07/01/2019 12/31/9999 1 48.47

E1821 KR - Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH DEVICE

0 20 07/01/2018 12/31/9999 1 0.32

E1825 KR - Fee on File Yes DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 3.30

E1825 NU - Fee on File Yes DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 989.28

E1825 RR - Fee on File Yes DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 98.93

E1825 UE - Fee on File Yes DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 494.64

E1830 KR - Fee on File Yes DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 3.30

E1830 NU - Fee on File Yes DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 989.28

E1830 RR - Fee on File Yes DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 98.93

E1830 UE - Fee on File Yes DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 494.64

E2000 KR - Fee on File Yes GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC

0 20 07/01/2019 12/31/9999 1 1.43

E2000 NU - Fee on File Yes GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC

0 20 07/01/2019 12/31/9999 1 427.68

E2000 RR - Fee on File Yes GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC

0 20 07/01/2019 12/31/9999 1 42.77

E2000 UE - Fee on File Yes GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC

0 20 07/01/2019 12/31/9999 1 213.84

E2100 KR - Fee on File Yes BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER

0 20 07/01/2019 12/31/9999 1 1.97

E2100 NU - Fee on File Yes BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER

0 20 07/01/2019 12/31/9999 1 592.44

E2100 RR - Fee on File Yes BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER

0 20 07/01/2019 12/31/9999 1 59.24

E2100 UE - Fee on File Yes BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER

0 20 07/01/2019 12/31/9999 1 296.22

E2208 NU - Fee on File Yes WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH

0 999 07/01/2019 12/31/9999 1 79.12

E2359 NU - Fee on File Yes POWER WHEELCHAIR ACCESSORY, GROUP 34 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT)

0 999 07/01/2019 12/31/9999 2 150.02

E2361 NU - Fee on File Yes POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E.G. GEL CELL, ABSORBED GLASSMAT)

0 999 07/01/2019 12/31/9999 2 103.51

E2363 NU - Fee on File Yes POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT)

0 999 07/01/2019 12/31/9999 2 134.70

E2365 NU - Fee on File Yes POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT)

0 999 07/01/2019 12/31/9999 2 76.62

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE2366 NU - Fee on File Yes POWER WHEELCHAIR ACCESSORY,

BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH

0 999 07/01/2019 12/31/9999 2 170.11

E2371 NU - Fee on File Yes POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E.G. GEL CELL, ABSORBED GLASSMAT), EACH

0 999 07/01/2019 12/31/9999 2 118.26

E2397 NU - Fee on File Yes POWER WHEELCHAIR ACCESSORY, LITHIUM-BASED BATTERY, EACH

0 999 07/01/2019 12/31/9999 1 376.73

E2402 KR - Fee on File Yes NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE

0 999 07/01/2019 12/31/9999 1 32.09

E2402 NU - Fee on File Yes NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE

0 999 07/01/2019 12/31/9999 1 9,626.16

E2402 RR - Fee on File Yes NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE

0 999 07/01/2019 12/31/9999 1 962.62

E2500 NU - Fee on File Yes SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, LESS THAN OR EQUAL TO 8 MINUTES RECORDING TIME

0 999 07/01/2019 12/31/9999 1 450.24

E2502 NU - Fee on File Yes SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 8 MINUTES BUT LESS THAN OR EQUAL TO 20 MINUTES RECORDING TIME

0 999 07/01/2019 12/31/9999 1 1,376.80

E2504 NU - Fee on File Yes SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 20 MINUTES BUT LESS THAN OR EQUAL TO 40 MINUTES RECORDING TIME

0 999 07/01/2019 12/31/9999 1 1,816.20

E2506 NU - Fee on File Yes SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 40 MINUTES RECORDING TIME

0 999 07/01/2019 12/31/9999 1 2,663.09

E2508 NU - Fee on File Yes SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, REQUIRING MESSAGE FORMULATION BY SPELLING AND ACCESS BY PHYSICAL CONTACT WITH THE DEVICE

0 999 07/01/2019 12/31/9999 1 4,118.03

E2510 NU - Fee on File Yes SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, PERMITTING MULTIPLE METHODS OF MESSAGE FORMULATION AND MULTIPLE METHODS OF DEVICE ACCESS

0 999 07/01/2019 12/31/9999 1 7,792.82

E2511 NU - Priced by PA Yes SPEECH GENERATING SOFTWARE PROGRAM, FOR PERSONAL COMPUTER OR PERSONAL DIGITAL ASSISTANT

0 999 01/01/2004 12/31/9999 1 0.00

E2512 NU - Priced by PA Yes ACCESSORY FOR SPEECH GENERATING DEVICE, MOUNTING SYSTEM

0 999 01/01/2004 12/31/9999 1 0.00

E2599 NU - Priced by PA Yes ACCESSORY FOR SPEECH GENERATING DEVICE, NOT OTHERWISE CLASSIFIED

0 999 01/01/2004 12/31/9999 1 0.00

E2601 NU - Fee on File Yes GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 40.56

E2602 NU - Fee on File Yes GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 82.51

E2603 NU - Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 103.22

E2604 NU - Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 135.74

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE2605 NU - Fee on File Yes POSITIONING WHEELCHAIR SEAT

CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 194.69

E2606 NU - Fee on File Yes POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 307.54

E2607 NU - Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 200.10

E2608 NU - Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 245.31

E2609 NU - Priced by PA Yes CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE

0 999 01/01/2005 12/31/9999 1 0.00

E2610 NU - Priced by PA Yes WHEELCHAIR SEAT CUSHION, POWERED 0 999 01/01/2005 12/31/9999 1 0.00E2611 NU - Fee on File Yes GENERAL USE WHEELCHAIR BACK

CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 07/01/2019 12/31/9999 1 189.44

E2612 NU - Fee on File Yes GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 07/01/2019 12/31/9999 1 295.47

E2613 NU - Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 07/01/2019 12/31/9999 1 285.29

E2614 NU - Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING

0 999 07/01/2019 12/31/9999 1 406.66

E2615 NU - Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 07/01/2019 12/31/9999 1 327.01

E2616 NU - Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 07/01/2019 12/31/9999 1 440.18

E2617 NU - Priced by PA Yes CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 01/01/2005 12/31/9999 1 0.00

E2619 NU - Fee on File Yes REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACH

0 999 07/01/2019 12/31/9999 1 39.51

E2622 KR - Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 0.84

E2622 NU - Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 253.01

E2622 RR - Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 25.30

E2622 UE - Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 126.50

375.46

E2621 NU - Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS WIDTH 22 INCHES OR

0 999 07/01/2019 12/31/9999 1 415.37

E2620 NU - Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS WIDTH LESS THAN 22

0 999 07/01/2019 12/31/9999 1

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE2623 KR - Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT

CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 1.07

E2623 NU - Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 320.98

E2623 RR - Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 32.10

E2623 UE - Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 160.49

E2624 KR - Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 0.85

E2624 NU - Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 256.05

E2624 RR - Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 25.60

E2624 UE - Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 128.02

E2625 KR - Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 1.07

E2625 NU - Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 320.65

E2625 RR - Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 32.06

E2625 UE - Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2019 12/31/9999 1 160.32

E8000 KR - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8000 NU - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8000 RR - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8000 UE - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8001 KR - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8001 NU - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8001 RR - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE8001 UE - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE,

UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8002 KR - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8002 NU - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8002 RR - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8002 UE - Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

K0005 KR - Fee on File Yes ULTRALIGHTWEIGHT WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 5.68K0005 NU - Fee on File Yes ULTRALIGHTWEIGHT WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 1,702.91K0005 RR - Fee on File Yes ULTRALIGHTWEIGHT WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 170.29K0005 UE - Fee on File Yes ULTRALIGHTWEIGHT WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 851.46K0006 KR - Fee on File Yes HEAVY DUTY WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 2.53K0006 NU - Fee on File Yes HEAVY DUTY WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 759.60K0006 RR - Fee on File Yes HEAVY DUTY WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 75.96K0006 UE - Fee on File Yes HEAVY DUTY WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 379.80K0007 KR - Fee on File Yes EXTRA HEAVY DUTY WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 3.75K0007 NU - Fee on File Yes EXTRA HEAVY DUTY WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 1,124.00K0007 RR - Fee on File Yes EXTRA HEAVY DUTY WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 112.40K0007 UE - Fee on File Yes EXTRA HEAVY DUTY WHEELCHAIR 0 999 07/01/2019 12/31/9999 1 562.00K0010 KR - Fee on File Yes STANDARD - WEIGHT FRAME

MOTORIZED/POWER WHEELCHAIR0 999 07/01/2019 12/31/9999 1 11.12

K0010 NU - Fee on File Yes STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR

0 999 07/01/2019 12/31/9999 1 3,335.28

K0010 RR - Fee on File Yes STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR

0 999 07/01/2019 12/31/9999 1 333.53

K0010 UE - Fee on File Yes STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR

0 999 07/01/2019 12/31/9999 1 1,667.64

K0037 NU - Fee on File Yes HIGH MOUNT FLIP-UP FOOTREST, EACH 0 20 07/01/2019 12/31/9999 1 32.50K0038 NU - Fee on File Yes LEG STRAP, EACH 0 20 07/01/2019 12/31/9999 1 18.85K0039 NU - Fee on File Yes LEG STRAP, H STYLE, EACH 0 20 07/01/2019 12/31/9999 1 41.16K0040 NU - Fee on File Yes ADJUSTABLE ANGLE FOOTPLATE, EACH 0 20 07/01/2019 12/31/9999 1 51.61K0041 NU - Fee on File Yes LARGE SIZE FOOTPLATE, EACH 0 20 07/01/2019 12/31/9999 1 39.90K0043 NU - Fee on File Yes FOOTREST, LOWER EXTENSION TUBE,

REPLACEMENT ONLY, EACH0 20 07/01/2019 12/31/9999 1 15.24

K0105 NU - Fee on File Yes IV HANGER, EACH 0 20 07/01/2019 12/31/9999 1 87.51K0554 KR - Fee on File No RECEIVER (MONITOR), DEDICATED, FOR

USE WITH THERAPEUTIC GLUCOSE CONTINUOUS MONITOR SYSTEM

0 999 07/01/2019 12/31/9999 1 0.72

K0554 NU - Fee on File No RECEIVER (MONITOR), DEDICATED, FOR USE WITH THERAPEUTIC GLUCOSE CONTINUOUS MONITOR SYSTEM

0 999 07/01/2019 12/31/9999 1 216.19

K0554 RR - Fee on File No RECEIVER (MONITOR), DEDICATED, FOR USE WITH THERAPEUTIC GLUCOSE CONTINUOUS MONITOR SYSTEM

0 999 07/01/2019 12/31/9999 1 21.62

K0603 NU - Fee on File No Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each

0 999 07/01/2019 12/31/9999 2 0.51

K0606 NU - Fee on File Yes Automatic external defibrillator, with integrated electrocardiogram analysis, garment type

0 999 07/01/2019 12/31/9999 1 23,196.00

K0606 RR - Fee on File Yes Automatic external defibrillator, with integrated electrocardiogram analysis, garment type

0 999 07/01/2019 12/31/9999 1 2,319.60

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeK0672 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY

ORTHOSIS, REMOVABLE SOFT INTERFACE, ALL COMPONENTS, REPLACEMENT ONLY , EACH

0 20 07/01/2019 12/31/9999 2 67.72

K0733 NU - Fee on File Yes POWER WHEELCHAIR ACCESSORY 12 TO 24 AMP HR SEALED LEAD ACID BATTERY EA

0 999 07/01/2019 12/31/9999 2 23.94

L0120 NU - Fee on File Yes CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)

0 20 07/01/2019 12/31/9999 1 22.34

L0130 NU - Fee on File Yes CERVICAL, FLEXIBLE, THERMOPLASTIC COLLAR, MOLDED TO PATIENT

0 20 07/01/2019 12/31/9999 1 161.56

L0140 NU - Fee on File Yes CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTIC COLLAR)

0 20 07/01/2019 12/31/9999 1 55.75

L0150 NU - Fee on File Yes CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDED CHIN CUP (PLASTIC COLLAR)

0 20 07/01/2019 12/31/9999 1 92.97

L0160 NU - Fee on File Yes CERVICAL, SEMI-RIGID, WIRE FRAME OCCIPITAL/MANDIBULAR SUPPORT, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 1 132.37

L0170 NU - Fee on File Yes CERVICAL, COLLAR, MOLDED TO PATIENT MODEL

0 20 07/01/2019 12/31/9999 1 560.14

L0172 NU - Fee on File Yes CERVICAL, COLLAR, SEMI-RIGID THERMOPLASTIC FOAM, TWO-PIECE, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 1 113.57

L0174 NU - Fee on File Yes CERVICAL, COLLAR, SEMI-RIGID, THERMOPLASTIC FOAM, TWO PIECE WITH THORACIC EXTENSION, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 1 204.02

L0180 NU - Fee on File Yes CERVICAL,MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLE

0 20 07/01/2019 12/31/9999 1 277.47

L0190 NU - Fee on File Yes CERVICAL,MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS,

0 20 07/01/2019 12/31/9999 1 417.70

L0200 NU - Fee on File Yes CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABL

0 20 07/01/2019 12/31/9999 1 383.54

L0220 NU - Fee on File Yes THORACIC, RIB BELT, CUSTOM FABRICATED

0 20 07/01/2019 12/31/9999 1 90.96

L0452 NU - Priced by PA Yes TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES

0 20 10/01/2003 12/31/9999 1 0.00

L0454 NU - Fee on File Yes TLSO FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM SACROCOCCYGEAL JUNCT

0 20 07/01/2019 12/31/9999 1 276.97

L0456 NU - Fee on File Yes TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC REGION, RIGID POSTERIOR

0 20 07/01/2019 12/31/9999 1 794.28

276.97

L0457 NU - Fee on File Yes TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC REGION, RIGID POSTERIOR PANEL AND SOFT ANTERIOR APRON, EXTENDS FROM THE

0 20 07/01/2019 12/31/9999 1 794.28

L0455 NU - Fee on File Yes TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM SACROCOCCYGEAL JUNCTION TO ABOVE T-9 VERTEBRA, RESTRICTS

0 20 07/01/2019 12/31/9999 1

1,117.75

L0450 NU - Fee on File Yes TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES INTRACAVITARY PRESSURE

0 20 07/01/2019 12/31/9999 1 150.17

L0112 NU - Fee on File Yes CRANIAL CERVICAL ORTHOSIS, CONGENITAL TORTICOLLIS TYPE, WITH OR WITHOUT SOFT INTERFACE

0 20 07/01/2019 12/31/9999 1

1.18

K0738 RR - Fee on File Yes PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; HOME COMPRESSOR USED TO FILL PORTABLE OXYGEN CYLINDERS

0 999 07/01/2019 12/31/9999 1 35.46

K0738 KR - Fee on File Yes PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; HOME COMPRESSOR USED TO FILL PORTABLE OXYGEN CYLINDERS

0 999 07/01/2019 12/31/9999 1

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL0458 NU - Fee on File Yes TLSO, TRIPLANAR CONTROL, MODULAR

SEGMENTED SPINAL SYSTEM, TWO RIGID PLAS

0 20 07/01/2019 12/31/9999 1 712.23

L0460 NU - Fee on File Yes TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLAS

0 20 07/01/2019 12/31/9999 1 801.69

L0462 NU - Fee on File Yes TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PL

0 20 07/01/2019 12/31/9999 1 997.14

L0464 NU - Fee on File Yes TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, FOUR RIGID PLA

0 20 07/01/2019 12/31/9999 1 1,187.08

L0466 NU - Fee on File Yes TLSO, SAGITTAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR

0 20 07/01/2019 12/31/9999 1 305.25

L0468 NU - Fee on File Yes TLSO, SAGITTAL-CORONAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT

0 20 07/01/2019 12/31/9999 1 382.71

L0470 NU - Fee on File Yes TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIO

0 20 07/01/2019 12/31/9999 1 544.86

L0472 NU - Fee on File Yes TLSO, TRIPLANAR CONTROL, HYPEREXTENSION, RIGID ANTERIOR AND LATERAL FRAM

0 20 07/01/2019 12/31/9999 1 342.01

L0480 NU - Fee on File Yes TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE

0 20 07/01/2019 12/31/9999 1 1,057.57

L0482 NU - Fee on File Yes TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE

0 20 07/01/2019 12/31/9999 1 1,212.37

L0484 NU - Fee on File Yes TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE

0 20 07/01/2019 12/31/9999 1 1,413.59

L0486 NU - Fee on File Yes TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITH INTERFACE

0 20 07/01/2019 12/31/9999 1 1,400.34

L0488 NU - Fee on File Yes TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE

0 20 07/01/2019 12/31/9999 1 801.69

L0490 NU - Fee on File Yes TLSO, SAGITTAL-CORONAL CONTROL, ONE PIECE RIGID PLASTIC SHELL, WITH OVER

0 20 07/01/2019 12/31/9999 1 225.90

L0491 NU - Fee on File Yes TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC SHELLS

0 20 07/01/2019 12/31/9999 1 613.31

L0492 NU - Fee on File Yes TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PLASTIC SHELLS

0 20 07/01/2019 12/31/9999 1 397.49

L0621 NU - Fee on File Yes SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION ABOUT THE SACROILIAC JOINT

0 20 07/01/2019 12/31/9999 1 71.22

L0622 NU - Fee on File Yes SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION ABOUT THE SACROILIAC JOINT

0 20 07/01/2019 12/31/9999 1 193.10

44.02L0625 NU - Fee on File Yes LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMBAR SUPPORT

0 20 07/01/2019 12/31/9999 1

0.00

L0624 NU - Priced by PA Yes SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID PANELS PLACED OVER

0 20 01/01/2006 12/31/9999 1 0.00

L0623 NU - Priced by PA Yes SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID PANELS OVER THE

0 20 01/01/2006 12/31/9999 1

305.25

L0469 NU - Fee on File Yes TLSO, SAGITTAL-CORONAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON WITH STRAPS, CLOSURES AND PADDING, EXTENDS

0 20 07/01/2019 12/31/9999 1 382.71

L0467 NU - Fee on File Yes TLSO, SAGITTAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON WITH STRAPS

0 20 07/01/2019 12/31/9999 1


L0631 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,

0 20 07/01/2019 12/31/9999 1 819.84

L0633 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PANEL(S)

0 20 07/01/2019 12/31/9999 1 229.01

L0634 NU - Priced by PA Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PANEL(S)

0 20 01/01/2006 12/31/9999 1 0.00

L0635 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION,RIGID POSTERIOR FRAME/PANEL(S)

0 20 07/01/2019 12/31/9999 1 849.22

L0638 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANELS

0 20 07/01/2019 12/31/9999 1 1,053.30

L0639 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S)

0 20 07/01/2019 12/31/9999 1 1,087.19

L0640 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S)

0 20 07/01/2019 12/31/9999 1 835.67

819.84

L0649 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PANEL(S), POSTERIOR EXTENDS FROM

0 20 07/01/2019 12/31/9999 1 229.01

L0648 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL

0 20 07/01/2019 12/31/9999 1

328.29

L0643 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9

0 20 07/01/2019 12/31/9999 1 129.32

L0642 NU - Fee on File Yes LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM L-1 TO BELOW L-5

0 20 07/01/2019 12/31/9999 1

1,087.19

L0641 NU - Fee on File Yes LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES

0 20 07/01/2019 12/31/9999 1 62.26

L0637 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR

0 20 07/01/2019 12/31/9999 1

0.00

L0636 NU - Fee on File Yes LUMBAR SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGID POSTERIOR FRAME/PANELS

0 20 07/01/2019 12/31/9999 1 1,253.07

L0632 NU - Priced by PA Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS POSTERIOR

0 20 01/01/2006 12/31/9999 1

0.00

L0630 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S) POSTERIOR EXTENDS FROM

0 20 07/01/2019 12/31/9999 1 129.32

L0629 NU - Priced by PA Yes LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR EXTENDS FROM

0 20 01/01/2006 12/31/9999 1

328.29

L0628 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR EXTENDS FROM

0 20 07/01/2019 12/31/9999 1 66.98

L0627 NU - Fee on File Yes LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS POSTERIOR

0 20 07/01/2019 12/31/9999 1

L0626 NU - Fee on File Yes LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S) POSTEROR EXTENDS FROM L-

0 20 07/01/2019 12/31/9999 1 62.26

PROVIDES LUMBAR SUPPORT, POSTERIOR EXTENDS FOM L-1 TO


L0700 NU - Fee on File Yes CTLSO,ANTERIOR-POSTERIOR-LATERALCONTROL,MOULDEDTOPATIENTMODEL

0 20 07/01/2019 12/31/9999 1 1,719.43

L0710 NU - Fee on File Yes CTLSO, ANTERIOR-POSTERIOR-LATERAL-CONTROL, MOLDED TO PATIEN MODED, WITH

0 20 07/01/2019 12/31/9999 1 1,876.87

L0810 NU - Fee on File Yes HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO JACKET VEST

0 20 07/01/2019 12/31/9999 1 1,993.90

L0820 NU - Fee on File Yes HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO PLASTER BODY

0 20 07/01/2019 12/31/9999 1 1,612.98

L0830 NU - Fee on File Yes HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE

0 20 07/01/2019 12/31/9999 1 2,328.97

L0859 NU - Fee on File Yes ADDITION TO HALO PROCEDURE, MAGNETIC RESONANCE IMAGE COMPATIBLE SYSTEMS,RINGS AND PINS, ANY MATERIAL

0 20 07/01/2019 12/31/9999 1 904.79

L0861 NU - Fee on File Yes ADDITION TO HALO PROCEDURE, REPLACEMENT LINER/INTERFACE MATERIAL

0 20 07/01/2019 12/31/9999 1 172.14

L0970 NU - Fee on File Yes TLSO, CORSET FRONT 0 20 07/01/2019 12/31/9999 1 84.89L0972 NU - Fee on File Yes LSO, CORSET FRONT 0 20 07/01/2019 12/31/9999 1 86.77L0974 NU - Fee on File Yes TLSO, FULL CORSET 0 20 07/01/2019 12/31/9999 1 177.29L0976 NU - Fee on File Yes LSO, FULL CORSET 0 20 07/01/2019 12/31/9999 1 158.34L0978 NU - Fee on File Yes AXILLARY CRUTCH EXTENSION 0 20 07/01/2019 12/31/9999 2 142.97L0980 NU - Fee on File Yes PERONEAL STRAPS, PREFABRICATED,

OFF-THE-SHELF, PAIR0 20 07/01/2019 12/31/9999 2 12.97

L0982 NU - Fee on File Yes STOCKING SUPPORTER GRIPS, PREFABRICATED, OFF-THE-SHELF, SET OF FOUR (4)

0 20 07/01/2019 12/31/9999 2 14.14

L0984 NU - Fee on File Yes PROTECTIVE BODY SOCK, PREFABRICATED, OFF-THE-SHELF, EACH

0 20 07/01/2019 12/31/9999 6 45.10

L1000 NU - Fee on File Yes CTLSO (MILWAUKEE), INCLUSIVE OF FURNISHING INITIAL ORHTOSIS, INCLUDING M

0 20 07/01/2019 12/31/9999 2 1,507.86

L1001 NU - Priced by PA Yes CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS, IMMOBILIZER, INFANT SIZE,

0 20 01/01/2007 12/31/9999 1 0.00

L1010 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, AXILLA SLING

0 20 07/01/2019 12/31/9999 4 60.73

L1020 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD

0 20 07/01/2019 12/31/9999 4 82.97

L1025 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD, FLOATING

0 20 07/01/2019 12/31/9999 4 94.30

L1030 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLOSIS ORHTOSIS, LUMBAR BOLSTER PAD

0 20 07/01/2019 12/31/9999 4 62.99

L1040 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS, LUMBAR OR LUMBAR RIB PAD

0 20 07/01/2019 12/31/9999 4 75.82

L1050 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, STERNAL PAD

0 20 07/01/2019 12/31/9999 4 65.64

L1060 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, THORACIC PAD

0 20 07/01/2019 12/31/9999 1 74.05

L1070 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, TRAPEZIUS SLING

0 20 07/01/2019 12/31/9999 4 75.72

L1080 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER

0 20 07/01/2019 12/31/9999 4 52.46

L1085 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSOS ORTHOSIS,OUTRIGGER,BILATERAL WITH VERTICA

0 20 07/01/2019 12/31/9999 4 145.74

1,087.19

L0651 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL

0 20 07/01/2019 12/31/9999 1 1,087.19

L0650 NU - Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANEL(S), POSTERIOR EXTENDS

0 20 07/01/2019 12/31/9999 1

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL1090 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS

ORTHOSIS, LUMBAR SLING0 20 07/01/2019 12/31/9999 4 68.08

L1100 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE,

0 20 07/01/2019 12/31/9999 4 120.18

L1110 NU - Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RIGN FLANGE,

0 20 07/01/2019 12/31/9999 4 203.55

L1120 NU - Fee on File Yes ADDITION TO CTLSO, SCOLIOSIS, ORTHOSIS, COVER FOR UPRIGHT, EACH

0 20 07/01/2019 12/31/9999 4 32.42

L1200 NU - Fee on File Yes TLSO, INCLUSIVE OF FURNISHING ORTHOSIS ONLY

0 20 07/01/2019 12/31/9999 4 1,290.73

L1210 NU - Fee on File Yes ADDITION TO TLSO, (LOW PROFILE), LATERAL THORACIC EXTENSION

0 20 07/01/2019 12/31/9999 4 194.34

L1220 NU - Fee on File Yes ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC EXTENSION

0 20 07/01/2019 12/31/9999 4 164.54

L1230 NU - Fee on File Yes ADDITION TO TLSO, (LOW PROFILE), MILWAUKEE TYPE SUPERSTRUCTURE

0 20 07/01/2019 12/31/9999 4 422.19

L1240 NU - Fee on File Yes ADDITION TO TLSO (LOW PROFILE) LUMBAR DEROTATION PAD

0 20 07/01/2019 12/31/9999 4 72.66

L1250 NU - Fee on File Yes ADDITION TO TLSO (LOW PROFILE), ANTERIOR ASIS PAD

0 20 07/01/2019 12/31/9999 4 71.54

L1260 NU - Fee on File Yes ADDITION TO TLSO (LOW PROFILE, ANTERIOR THORACIC DEROTATION PAD

0 20 07/01/2019 12/31/9999 4 73.53

L1270 NU - Fee on File Yes ADDITION TO TLSO (LOW PROFILE), ABDOMINAL PAD

0 20 07/01/2019 12/31/9999 4 73.44

L1280 NU - Fee on File Yes ADDITION TO TLSO (LOW PROFILE), RIB GUSSET (ELASTIC), EACH

0 20 07/01/2019 12/31/9999 4 65.46

L1290 NU - Fee on File Yes ADDITION TO TLSO (LOW PROFILE), LATERAL TROCHANTERIC PAD

0 20 07/01/2019 12/31/9999 4 74.22

L1300 NU - Fee on File Yes OTHER SCOLIOSIS PROCEDURE, BODY JACKET MOLDED TO PATIENT

0 20 07/01/2019 12/31/9999 1 1,240.64

L1310 NU - Fee on File Yes OTHER SCOLIOSIS PROCEDURE, POST-OPERATIVE BODY JACKET

0 20 07/01/2019 12/31/9999 1 1,276.62

L1499 NU - Priced by PA Yes SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED SPINAL ORTHOSIS, NOT OTHERWISE

0 20 05/01/2004 12/31/9999 1 0.00

L1600 NU - Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, FREJKA TYPE

0 20 07/01/2019 12/31/9999 1 95.70

L1610 NU - Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (FREJKA

0 20 07/01/2019 12/31/9999 2 32.60

L1620 NU - Fee on File Yes HO, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (PAVLIK HARNESS), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 107.37

L1630 NU - Fee on File Yes HO, ABDUCTION CONTROL OF HIP JOINTS, SEMI-FLEXIBLE (VON ROSEN TYPE), CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 2 128.13

L1640 NU - Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PELVIC BAND OR

0 20 07/01/2019 12/31/9999 2 342.70

L1650 NU - Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, ADJUSTABLE,

0 20 07/01/2019 12/31/9999 2 181.75

L1652 NU - Fee on File Yes HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH ADJUSTABLE ABDUCTOR SPREADER BA

0 20 07/01/2019 12/31/9999 1 284.69

L1660 NU - Fee on File Yes HO, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PLASTIC, PREFABRICATED, INCLUDES FITTING

0 20 07/01/2019 12/31/9999 2 127.10

L1680 NU - Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, DYNAMIC, PELVIC

0 20 07/01/2019 12/31/9999 2 1,044.98

L1685 NU - Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTIO

0 20 07/01/2019 12/31/9999 2 1,102.63

L1686 NU - Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTIO

0 20 07/01/2019 12/31/9999 2 739.71

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL1690 NU - Fee on File Yes COMBINATION, BILATERAL, LUMBO-

SACRAL, HIP, FEMUR ORTHOSIS PROVIDING ADDU

0 20 07/01/2019 12/31/9999 1 1,544.32

L1700 NU - Fee on File Yes LEGG PERTHES ORTHOSIS, (TORONTO TYPE), CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 2 1,284.78

L1710 NU - Fee on File Yes LEGG PERTHES ORTHOSIS, (NEWINGTON TYPE), CUSTOM

0 20 07/01/2019 12/31/9999 2 1,510.18

L1720 NU - Fee on File Yes LEGG PERTHES ORTHOSIS, TRILATERAL, (TACHDIJAN TYPE), CUSTOM-

0 20 07/01/2019 12/31/9999 2 1,115.57

L1730 NU - Fee on File Yes LEGG PERTHES ORTHOSIS, (SCOTTISH RITE TYPE), CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 1 841.66

L1755 NU - Fee on File Yes LEGG PERTHES ORTHOSIS, (PATTEN BOTTOM TYPE), CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 1 1,225.07

L1810 NU - Fee on File Yes KO, ELASTIC WITH JOINTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 96.69

L1812 NU - Fee on File Yes KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 96.69

L1820 NU - Fee on File Yes KO, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 96.30

L1830 NU - Fee on File Yes KNEE ORTHOSIS, IMMOBILIZER, CANVAS LONGITUDINAL, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 80.55

L1831 NU - Fee on File Yes KNEE ORTHOSIS, LOCKING KNEE JOINT(S), POSITIONAL ORTHOSIS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 1 235.03

L1832 NU - Fee on File Yes KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 602.06

L1833 NU - Fee on File Yes KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, OFF-THE SHELF

0 20 07/01/2019 12/31/9999 2 602.06

L1834 NU - Fee on File Yes KO, WITHOUT KNEE JOINT, RIGID, CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 2 708.31

L1836 NU - Fee on File Yes KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 106.55

L1840 NU - Fee on File Yes KNEE ORTHOSIS, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, C

0 20 07/01/2019 12/31/9999 2 744.55

L1844 NU - Fee on File Yes KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND

0 20 07/01/2019 12/31/9999 2 1,241.63

L1845 NU - Fee on File Yes KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND

0 20 07/01/2019 12/31/9999 2 748.02

L1846 NU - Fee on File Yes KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND

0 20 07/01/2019 12/31/9999 2 949.11

L1847 NU - Fee on File Yes KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH INFLATABLE AIR

0 20 07/01/2019 12/31/9999 1 459.35

L1848 NU - Fee on File Yes KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH INFLATABLE AIR SUPPORT CHAMBER(S), PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 459.35

716.56L1843 NU - Fee on File Yes KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT

0 20 07/01/2019 12/31/9999 1

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL1850 NU - Fee on File Yes KNEE ORTHOSIS, SWEDISH TYPE,

PREFABRICATED, OFF-THE-SHELF0 20 07/01/2019 12/31/9999 2 213.78

L1860 NU - Fee on File Yes KO, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET, CUSTOM-FABRICATED (SK)

0 20 07/01/2019 12/31/9999 2 829.18

L1900 NU - Fee on File Yes AFO, SPRING WIRE, DORSIFLEXION ASSIST CALF BAND, CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 2 224.63

L1902 NU - Fee on File Yes ANKLE ORTHOSIS ANKLE GUANTLET OR SIMILAR WITH OR WITHOUT JOINTS PREFABRICATED OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 61.01

L1904 NU - Fee on File Yes ANKLE ORTHOSIS ANKLE GUANTLET OR SIMILAR WITH OR WITHOUT JOINTS CUSTOM FABRICATED

0 20 07/01/2019 12/31/9999 2 349.25

L1906 NU - Fee on File Yes ANKLE FOOT ORTHOSIS, MULTILIGAMENTOUS ANKLE SUPPORT, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 102.06

L1907 NU - Fee on File Yes ANKLE ORTHOSIS, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM FABRICATED

0 20 07/01/2019 12/31/9999 2 449.37

L1910 NU - Fee on File Yes AFO, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 198.62

L1920 NU - Fee on File Yes ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHEL

0 20 07/01/2019 12/31/9999 2 259.65

L1930 NU - Fee on File Yes AFO, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 175.70

L1932 NU - Fee on File Yes AFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 712.65

L1940 NU - Fee on File Yes AFO, PLASTIC OR OTHER MATERIAL, CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 2 397.06

L1945 NU - Fee on File Yes ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACT

0 20 07/01/2019 12/31/9999 2 729.15

L1950 NU - Fee on File Yes ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC, CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 2 553.20

L1951 NU - Fee on File Yes ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 1 670.70

L1960 NU - Fee on File Yes AFO, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 4 411.67

L1970 NU - Fee on File Yes AFO, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 2 608.90

L1971 NU - Fee on File Yes ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 1 374.33

74.80L1852 RR - Fee on File Yes KNEE ORTHOSIS (KO), DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION

0 20 07/01/2019 12/31/9999 2

71.66

L1852 NU - Fee on File Yes KNEE ORTHOSIS (KO), DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION

0 20 07/01/2019 12/31/9999 2 748.02

L1851 RR - Fee on File Yes KNEE ORTHOSIS (KO), SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT

0 20 07/01/2019 12/31/9999 2

L1851 NU - Fee on File Yes KNEE ORTHOSIS (KO), SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT

0 20 07/01/2019 12/31/9999 2 716.56

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL1980 NU - Fee on File Yes ANKLE FOOT ORTHOSIS, SINGLE

UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STI

0 20 07/01/2019 12/31/9999 2 272.58

L1990 NU - Fee on File Yes ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STI

0 20 07/01/2019 12/31/9999 2 350.22

L2000 NU - Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID S

0 20 07/01/2019 12/31/9999 2 753.32

L2010 NU - Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THI

0 20 07/01/2019 12/31/9999 2 686.72

L2020 NU - Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THI

0 20 07/01/2019 12/31/9999 2 867.22

L2030 NU - Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THI

0 20 07/01/2019 12/31/9999 2 752.39

L2035 NU - Fee on File Yes KAFO, FULL PLASTIC, STATIC, (PEDIATRIC SIZE), WITHOUT FREE MOTION ANKLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 138.34

L2036 NU - Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLE UPRIGHT, WITH OR WITHOUT FREE

0 20 07/01/2019 12/31/9999 2 1,377.96

L2037 NU - Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE

0 20 07/01/2019 12/31/9999 2 1,269.87

L2038 NU - Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, WITH OR WITHOUT FREE MOTION KNEE,

0 20 07/01/2019 12/31/9999 2 1,061.87

L2040 NU - Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL ROTATION STRAPS

0 20 07/01/2019 12/31/9999 1 135.64

L2050 NU - Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES,

0 20 07/01/2019 12/31/9999 1 361.22

L2060 NU - Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES,

0 20 07/01/2019 12/31/9999 1 463.60

L2070 NU - Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL ROTATION STRAP

0 20 07/01/2019 12/31/9999 1 133.18

L2080 NU - Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE,

0 20 07/01/2019 12/31/9999 1 284.02

L2090 NU - Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE,

0 20 07/01/2019 12/31/9999 1 350.07

L2106 NU - Fee on File Yes ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS,

0 20 07/01/2019 12/31/9999 2 504.98

L2108 NU - Fee on File Yes AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 2 793.54

L2112 NU - Fee on File Yes AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 376.79

1,639.80L2034 NU - Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE MEDIAL

0 20 07/01/2019 12/31/9999 2

L2005 NU - Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT STANCE CONTROL

0 20 07/01/2019 12/31/9999 2 3,272.50

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL2114 NU - Fee on File Yes AFO, FRACTURE ORTHOSIS, TIBIAL

FRACTURE ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 431.09

L2116 NU - Fee on File Yes AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 567.97

L2126 NU - Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHO

0 20 07/01/2019 12/31/9999 2 1,010.58

L2128 NU - Fee on File Yes KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 2 1,273.54

L2132 NU - Fee on File Yes KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 599.13

L2134 NU - Fee on File Yes KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 718.33

L2136 NU - Fee on File Yes KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 878.32

L2180 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC SHOE INSERT WITH

0 20 07/01/2019 12/31/9999 4 86.98

L2182 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROP LOCK KNEE JOINT

0 20 07/01/2019 12/31/9999 4 68.07

L2184 NU - Fee on File Yes ADDITION TO LOWE EXTREMITY FRACTURE ORTHOSIS, LIMITED MOTION KNEE JOINT

0 20 07/01/2019 12/31/9999 4 122.67

L2186 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, ADJUSTABLE MOTION KNEE JO

0 20 07/01/2019 12/31/9999 4 135.94

L2188 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE OTHOSIS, QUADRILATERAL BRIM

0 20 07/01/2019 12/31/9999 4 296.58

L2190 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, WAIST BELT

0 20 07/01/2019 12/31/9999 4 77.03

L2192 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIP JOINT, PELVIC BAND,

0 20 07/01/2019 12/31/9999 4 264.82

L2200 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINT

0 20 07/01/2019 12/31/9999 4 35.31

L2210 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST

0 20 07/01/2019 12/31/9999 4 57.30

L2220 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR FLEXION ASSIST/RES

0 20 07/01/2019 12/31/9999 4 65.78

L2230 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRUPS

0 20 07/01/2019 12/31/9999 4 56.98

L2232 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOT ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2019 12/31/9999 2 77.16

L2240 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, ROUND CALIPER AND PLATE

0 20 07/01/2019 12/31/9999 1 62.12

L2250 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, FOOT PLATE, MOLDED TO PATIENT

0 20 07/01/2019 12/31/9999 4 263.90

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL2260 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,

REINFORCED SOLID STIRRUP(SCOTT-CRAIG TYPE)

0 20 07/01/2019 12/31/9999 4 148.88

L2265 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRUP

0 20 07/01/2019 12/31/9999 4 87.46

L2270 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION

0 20 07/01/2019 12/31/9999 4 39.89

L2275 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATI

0 20 07/01/2019 12/31/9999 4 97.06

L2280 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, MOLDED INNER BOOT

0 20 07/01/2019 12/31/9999 4 360.54

L2300 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, ABDUCTION BAR (BILATERAL HIP

0 20 07/01/2019 12/31/9999 4 203.52

L2310 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHT

0 20 07/01/2019 12/31/9999 4 91.37

L2320 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2019 12/31/9999 4 152.82

L2330 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS

0 20 07/01/2019 12/31/9999 4 291.63

L2335 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, ANTERIOR SWING BAND

0 20 07/01/2019 12/31/9999 4 171.56

L2340 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL

0 20 07/01/2019 12/31/9999 4 404.84

L2350 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOCKET, MOLDED

0 20 07/01/2019 12/31/9999 4 661.79

L2360 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANK

0 20 07/01/2019 12/31/9999 4 38.42

L2370 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, PATTEN BOTTOM

0 20 07/01/2019 12/31/9999 4 190.66

L2375 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOINT AND HALF SOLID

0 20 07/01/2019 12/31/9999 4 83.92

L2380 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT KNEE JOINT, EACH

0 20 07/01/2019 12/31/9999 4 91.43

L2385 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT

0 20 07/01/2019 12/31/9999 4 99.48

L2387 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS, EACH JOINT

0 20 07/01/2019 12/31/9999 4 135.00

L2390 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINT

0 20 07/01/2019 12/31/9999 4 81.30

L2395 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT

0 20 07/01/2019 12/31/9999 4 124.13

L2397 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE

0 20 07/01/2019 12/31/9999 4 87.05

L2405 NU - Fee on File Yes ADDITION TO KNEE JOINT, DROP LOCK, EACH

0 20 07/01/2019 12/31/9999 8 69.63

L2415 NU - Fee on File Yes ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM ( BAIL, CABLE, OR EQUAL), ANY MATERIAL, EACH JOINT

0 20 07/01/2019 12/31/9999 4 97.02

L2425 NU - Fee on File Yes ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION,

0 20 07/01/2019 12/31/9999 4 114.47

L2430 NU - Fee on File Yes ADDITIONS TO KNEE JNTM RATCHET LOCK FOR ACT AND PROG KNEE EXT, EACH JNT

0 20 07/01/2019 12/31/9999 1 114.47

L2492 NU - Fee on File Yes ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING

0 20 07/01/2019 12/31/9999 1 75.74


THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIAL WEIGHT BEARING, RING

0 20 07/01/2019 12/31/9999 4 234.30

L2510 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI-

0 20 07/01/2019 12/31/9999 4 627.33

L2520 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI-

0 20 07/01/2019 12/31/9999 4 342.15

L2525 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,ISCHIAL CONTAINMENT/NAR

0 20 07/01/2019 12/31/9999 4 1,173.84

L2526 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,ISCHIAL CONTAINMENT/NAR

0 20 07/01/2019 12/31/9999 4 632.71

L2530 NU - Fee on File Yes ADDITION TO LOWR EXTREMITY, THIGH-WEIGHT BEARING, LACER

0 20 07/01/2019 12/31/9999 4 174.50

L2540 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LACER,

0 20 07/01/2019 12/31/9999 4 314.00

L2550 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, HIGH

0 20 07/01/2019 12/31/9999 4 213.31

L2570 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS

0 20 07/01/2019 12/31/9999 1 471.67

L2580 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PELVIC SLING

0 20 07/01/2019 12/31/9999 1 447.12

L2600 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT,

0 20 07/01/2019 12/31/9999 4 152.54


0 20 07/01/2019 12/31/9999 2 180.37


0 20 07/01/2019 12/31/9999 2 198.58

L2622 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP

0 20 07/01/2019 12/31/9999 4 227.76

L2624 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL,HIP JOINT,ADJUSTABLE FLEXION

0 20 07/01/2019 12/31/9999 4 309.63

L2627 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,PLASTIC,MOLDED TO PATIENT MOD

0 20 07/01/2019 12/31/9999 1 1,275.66

L2628 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,METAL FRAME,RECIPROCATING HIP

0 20 07/01/2019 12/31/9999 1 1,498.50

L2630 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND ADN BELT,

0 20 07/01/2019 12/31/9999 1 183.91

L2640 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND BELT,

0 20 07/01/2019 12/31/9999 1 249.59

L2650 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC AND THORACIC CONTROL,

0 20 07/01/2019 12/31/9999 4 89.13

L2660 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, THORACUC CONTROL, THORACIC BAND

0 20 07/01/2019 12/31/9999 2 138.42

L2670 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, THORACIC CONTROL,

0 20 07/01/2019 12/31/9999 4 126.69

L2680 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, THORACIC CONTROL,

0 20 07/01/2019 12/31/9999 4 116.22

L2750 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OF NICKEL, PER BAR

0 20 07/01/2019 12/31/9999 2 62.08

L2760 NU - Fee on File Yes ADDITION TO LOWER EXTREMTY ORTHOSIS, EXTENSION, PER

0 20 07/01/2019 12/31/9999 8 45.13

L2780 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, NON-CORROSIVE FINISH, PER BAR

0 20 07/01/2019 12/31/9999 8 53.38

L2785 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER,

0 20 07/01/2019 12/31/9999 2 31.38

L2755 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL ALL HYBRID

0 20 07/01/2019 12/31/9999 4 104.38

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL2795 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY

ORTHOSIS, KNEE CONTROL, FULL KNEECAP

0 20 07/01/2019 12/31/9999 2 63.11

L2800 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL OR LATERAL PULL, FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2019 12/31/9999 2 79.22

L2810 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PAD

0 20 07/01/2019 12/31/9999 4 58.01

L2820 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS,SOFT INTERFACE FOR MOLDED PLASTIC

0 20 07/01/2019 12/31/9999 2 64.50

L2830 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS,SOFT INTERFACE FOR MOLDED PLASTIC

0 20 07/01/2019 12/31/9999 4 72.53

L2840 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS,TIBIAL LENGTH SOCK, FRACTURE

0 20 07/01/2019 12/31/9999 4 40.48

L2850 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS,FEMORAL LENGTH SOCK,FRACTURE OR EQU

0 20 07/01/2019 12/31/9999 4 45.98

L2861 NU - Priced by PA Yes ADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, EACH

0 20 01/01/2010 12/31/9999 2 0.00

L2999 NU - Priced by PA Yes LOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIED LOWER EXTREMITY ORTHOS

0 20 05/01/2004 12/31/9999 2 0.00

L3000 NU - Fee on File Yes FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, 'UCB' TYPE, BERKELEY S

0 20 07/01/2019 12/31/9999 2 250.88

L3001 NU - Fee on File Yes FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SPENCO, EACH

0 20 07/01/2019 12/31/9999 2 105.62

L3002 NU - Fee on File Yes FOOT, INSERT. REMOVABLE, MOLDED TO PATIENT MODEL, PLASTAZOTE OR EQUAL, E

0 20 07/01/2019 12/31/9999 2 128.98

L3003 NU - Fee on File Yes FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SILICON GEL, EACH

0 20 07/01/2019 12/31/9999 2 139.14

L3010 NU - Fee on File Yes FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL ARCH SUPP

0 20 07/01/2019 12/31/9999 2 139.14

L3020 NU - Fee on File Yes FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL/METATARS

0 20 07/01/2019 12/31/9999 2 158.45

L3030 NU - Fee on File Yes FOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT, EACH

0 20 07/01/2019 12/31/9999 2 60.95

L3040 NU - Fee on File Yes FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL, EACH

0 20 07/01/2019 12/31/9999 2 37.59

L3050 NU - Fee on File Yes FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, METATARSAL, EACH

0 20 07/01/2019 12/31/9999 2 37.59

L3060 NU - Fee on File Yes FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL/METATARSAL, EACH

0 20 07/01/2019 12/31/9999 2 58.90

L3070 NU - Fee on File Yes FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL, EACH

0 20 07/01/2019 12/31/9999 2 25.39

L3080 NU - Fee on File Yes FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, METATARSAL, EACH

0 20 07/01/2019 12/31/9999 2 25.39

97.80L3031 NU - Fee on File Yes FOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY ORTHOSIS HIGH STRENGTH

0 20 07/01/2019 12/31/9999 2

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL3090 NU - Fee on File Yes FOOT, ARCH SUPPORT, NON-

REMOVABLE ATTACHED TO SHOE, LONGITUDINAL/METATAR

0 20 07/01/2019 12/31/9999 2 32.50

L3100 NU - Fee on File Yes HALLUS-VALGUS NIGHT DYNAMIC SPLINT, PREFABRICATED, OFF-THE-

0 20 07/01/2019 12/31/9999 1 34.51

L3140 NU - Fee on File Yes FOOT, ABDUCTION ROTATION BAR, INCLUDING SHOES

0 20 07/01/2019 12/31/9999 1 71.11

L3150 NU - Fee on File Yes FOOT, ABDUCTION ROTATION BAR, WITHOUT SHOES

0 20 07/01/2019 12/31/9999 1 65.02

L3160 NU - Priced by PA Yes FOOT, ADJUSTABLE SHOE-STYLED POSITIONING DEVICE

0 20 05/01/1999 12/31/9999 2 0.00

L3170 NU - Fee on File Yes FOOT, PLASTIC, SILICONE OR EQUAL, HEEL STABILIZER, PRAFABRICATED, OFF-THE-SHELF, EACH

0 20 07/01/2019 12/31/9999 1 40.63

L3201 NU - Fee on File Yes ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, INFANT

0 20 10/01/1998 12/31/9999 2 23.00

L3202 NU - Fee on File Yes ORTHOPEDIC SHOE/ OXFORD WITH SUPINATOR OR PRONATOR, CHILD

0 20 10/01/1998 12/31/9999 2 25.00

L3203 NU - Fee on File Yes ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, JUNIOR

0 20 10/01/1998 12/31/9999 2 28.00

L3204 NU - Fee on File Yes ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, INFANT

0 20 10/01/1998 12/31/9999 2 24.00

L3206 NU - Fee on File Yes ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, CHILD

0 20 10/01/1998 12/31/9999 2 25.00

L3207 NU - Fee on File Yes ORTHOPEDIC SHOE, HIGHTOP WIT SUPINATOR OR PRONATOR, JUNIOR

0 20 10/01/1998 12/31/9999 2 27.00

L3208 NU - Fee on File Yes SURGICAL BOOT, EACH, INFANT 0 20 10/01/1998 12/31/9999 2 21.00L3209 NU - Fee on File Yes SURGICAL BOOT, EACH, CHILD 0 20 10/01/1998 12/31/9999 2 23.00L3211 NU - Fee on File Yes SURGICAL BOOT, EACH, JUNIOR 0 20 10/01/1998 12/31/9999 8 26.00L3212 NU - Fee on File Yes BENESCH BOOT, PAIR, INFANT 0 20 10/01/1998 12/31/9999 1 59.00L3213 NU - Fee on File Yes BENESCH BOOT, PAIR, CHILD 0 20 10/01/1998 12/31/9999 1 62.00L3214 NU - Fee on File Yes BENESCH BOOT, PAIR, JUNIOR 0 20 10/01/1998 12/31/9999 1 68.00L3215 NU - Fee on File Yes ORTHOPEDIC FOOTWEAR, LADIES SHOE,

OXFORD, EACH0 20 10/01/1998 12/31/9999 1 63.15

L3217 NU - Fee on File Yes ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTOP, DEPTH INLAY, EACH

0 20 05/01/1999 12/31/9999 1 86.16

L3219 NU - Fee on File Yes ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACH

0 20 10/01/1998 12/31/9999 1 72.64

L3222 NU - Fee on File Yes ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, DEPTH INLAY, EACH

0 20 05/01/1999 12/31/9999 1 104.30

L3224 NU - Fee on File Yes ORTHOPEDIC FOOTWEAR WOMAN'S SHOE, OXFORD, INTEGRAL PART OF BRACE

0 20 07/01/2019 12/31/9999 2 43.68

L3225 NU - Fee on File Yes ORTHOPEDIC FOOTWEAR, MAN'S SHOE OXFORD, INTEGRAL PAR OF BRACE

0 20 07/01/2019 12/31/9999 2 50.24

L3230 NU - Fee on File Yes ORTHOPEDIC FOOTWEAR, CUSTOM SHOE, DEPTH INLAY, EACH

0 20 05/01/1999 12/31/9999 1 249.00

L3250 NU - Fee on File Yes ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, REMOVABLE INNER MOLD, PROSTHETI

0 20 10/01/1998 12/31/9999 2 190.98

L3251 NU - Fee on File Yes FOOT, SHOE MOLDED TO PATIENT MODEL, SILICONE SHOE, EACH

0 20 05/01/1999 12/31/9999 2 261.18

L3252 NU - Fee on File Yes FOOT, SHOE MOLDED TO PATIENT MODEL, PLASTAZOTE (OR SIMILAR), CUSTOM FABR

0 20 05/01/1999 12/31/9999 2 169.77

L3253 NU - Fee on File Yes FOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR) CUSTOM FITTED, EACH

0 20 05/01/1999 12/31/9999 2 80.71

L3300 NU - Fee on File Yes LIFT, ELEVATION, HEEL, TAPERED TO METATARSALS, PER INCH LIFT, ELEVATION,

0 20 07/01/2019 12/31/9999 4 41.63

L3310 NU - Fee on File Yes LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE, PER INCH LIFT, ELEVATION, HEEL

0 20 07/01/2019 12/31/9999 4 65.02

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL3320 NU - Fee on File Yes LIFT, ELEVATION, HEEL AND SOLE,

CORK, PER INCH LIFT, ELEVATION, HEEL AND

0 20 07/01/2005 12/31/9999 4 58.78

L3330 NU - Fee on File Yes LIFT, ELEVATION, METAL EXTENSION (SKATE) LIFT, ELEVATION, METAL EXTENSIO

0 20 07/01/2019 12/31/9999 4 451.96

L3332 NU - Fee on File Yes LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO ONE-HALF INCH

0 20 07/01/2019 12/31/9999 4 58.90

L3334 NU - Fee on File Yes LIFT, ELEVATION, HEEL, PER INCH LIFT, ELEVATION, HEEL, PER INCH

0 20 07/01/2019 12/31/9999 4 30.47

L3340 NU - Fee on File Yes HEEL WEDGE, SACH HEEL WEDGE, SACH

0 20 07/01/2019 12/31/9999 4 68.06

L3350 NU - Fee on File Yes HEEL WEDGE HEEL WEDGE 0 20 07/01/2019 12/31/9999 4 18.26L3360 NU - Fee on File Yes SOLE WEDGE, OUTSIDE SOLE SOLE

WEDGE, OUTSIDE SOLE0 20 07/01/2019 12/31/9999 4 28.44

L3370 NU - Fee on File Yes SOLE WEDGE, BETWEEN SOLE SOLE WEDGE, BETWEEN SOLE

0 20 07/01/2019 12/31/9999 4 39.62

L3380 NU - Fee on File Yes CLUBFOOT WEDGE CLUBFOOT WEDGE 0 20 07/01/2019 12/31/9999 4 39.62L3390 NU - Fee on File Yes OUTFLARE WEDGE OUTFLARE WEDGE 0 20 07/01/2019 12/31/9999 4 39.62L3400 NU - Fee on File Yes METATARSAL BAR WEDGE, ROCKER

METATARSAL BAR WEDGE, ROCKER0 20 07/01/2019 12/31/9999 4 32.50

L3410 NU - Fee on File Yes METATARSAL BAR WEDGE, BETWEEN SOLE METATARSAL BAR WEDGE, BETWEEN SOLE

0 20 07/01/2019 12/31/9999 2 74.16

L3420 NU - Fee on File Yes FULL SOLE AND HEEL WEDGE, BETWEEN SOLE FULL SOLE AND HEEL WEDGE, BETWEEN

0 20 07/01/2019 12/31/9999 4 43.66

L3430 NU - Fee on File Yes HEEL, COUNTER, PLASTIC REINFORCED 0 20 07/01/2019 12/31/9999 2 127.98L3440 NU - Fee on File Yes HEEL, COUNTERR, LEATHER

REINFORCED HEEL, COUNTER, LEATHER REINFORCED

0 20 07/01/2019 12/31/9999 2 60.95

L3450 NU - Fee on File Yes HEEL, SACH CUSHION TYPE HEEL, SACH CUSHION TYPE

0 20 07/01/2019 12/31/9999 2 84.28

L3455 NU - Fee on File Yes HEEL, NEW LEATHER, STANDARD HEEL, NEW LEATHER, STANDARD

0 20 07/01/2019 12/31/9999 2 32.50

L3460 NU - Fee on File Yes HEEL, NEW RUBBER, STANDARD HEEL, NEW RUBBER, STANDARD

0 20 07/01/2019 12/31/9999 2 27.41

L3465 NU - Fee on File Yes HEEL, THOMAS WITH WEDGE HEEL, THOMAS WITH WEDGE

0 20 07/01/2019 12/31/9999 2 46.71

L3470 NU - Fee on File Yes HEEL, THOMAS EXTENDED TO BALL HEEL, THOMAS EXTENDED TO BALL

0 20 07/01/2019 12/31/9999 2 49.75

L3480 NU - Fee on File Yes HEEL, PAD AND DEPRESSION FOR SPUR HEEL, PAD AND DEPRESSION FOR SPUR

0 20 07/01/2019 12/31/9999 2 49.75

L3485 NU - Fee on File Yes HEEL, PAD, REMOVABLE FOR SPUR HEEL, PAD, REMOVABLE FOR SPUR

0 20 07/01/2005 12/31/9999 2 18.62

L3500 NU - Fee on File Yes ORTHOPEDIC SHOE ADDITION, INSOLE, LEATHER ORTHOPEDIC SHOE ADDITION, INSO

0 20 07/01/2019 12/31/9999 4 23.38

L3510 NU - Fee on File Yes ORTHOPEDIC SHOE ADDITION, INSOLE, RUBBER ORTHOPEDIC SHOE ADDITION, INSOL

0 20 07/01/2019 12/31/9999 4 23.38

L3520 NU - Fee on File Yes ORTHOPEDIC SHOE ADDITION, INSOLE, FELT COVERED WITH LEATHER ORTHOPEDIC S

0 20 07/01/2019 12/31/9999 4 25.39

L3530 NU - Fee on File Yes ORTHOPEDIC SHOE ADDITION, SOLE, HALF ORTHOPEDIC SHOE ADDITION, SOLE, HAL

0 20 07/01/2019 12/31/9999 4 25.39

L3540 NU - Fee on File Yes ORTHOPEDIC SHOE ADDITION, SOLE, FULL ORTHOPEDIC SHOE ADDITION, SOLE, FUL

0 20 07/01/2019 12/31/9999 4 40.63

L3550 NU - Fee on File Yes ORTHOPEDIC SHOE ADDITION, TOE TAP STANDARD ORTHOPEDIC SHOE ADDITION, TOE

0 20 07/01/2019 12/31/9999 4 7.12

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL3560 NU - Fee on File Yes ORTHOPEDIC SHOE ADDITION, TOE TAP,

HORSESHOE ORTHOPEDIC SHOE ADDITION, T

0 20 07/01/2019 12/31/9999 4 18.26

L3570 NU - Fee on File Yes ORTHOPEDIC SHOE ADDITION, SPECIAL EXTENSION TO INSTEP (LEATHER WITH EYEL

0 20 07/01/2019 12/31/9999 4 68.06

L3580 NU - Fee on File Yes ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP TO VELCRO CLOSURE ORTHOPEDIC SH

0 20 07/01/2019 12/31/9999 4 51.80

L3590 NU - Fee on File Yes ORTHOPEDIC SHOE ADDITION, CONVERT FIRM SHOE COUNTER TO SOFT COUNTER ORTH

0 20 07/01/2019 12/31/9999 4 42.66

L3595 NU - Fee on File Yes ORTHOPEDIC SHOE ADDITION, MARCH BAR ORTHOPEDIC SHOE ADDITION, MARCH BAR

0 20 07/01/2019 12/31/9999 2 33.51

L3600 NU - Fee on File Yes TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, EXISTI

0 20 07/01/2019 12/31/9999 2 60.95

L3650 NU - Fee on File Yes SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-

0 20 07/01/2019 12/31/9999 1 43.50

L3671 NU - Fee on File Yes SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 1 654.88

L3678 NU - Priced by PA Yes SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, OFF-THE-SHELF

0 20 01/01/2014 12/31/9999 2 0.00

L3702 NU - Fee on File Yes ELBOW ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 1 209.87

L3710 NU - Fee on File Yes ELBOW ORTHOSIS, ELASTIC WITH METAL JOINTS, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 1 105.38

L3720 NU - Fee on File Yes EO, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, FREE MOTION, CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 1 525.73

L3730 NU - Fee on File Yes EO, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, EXTENSION/ FLEXION ASSIST, CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 1 692.05

L3740 NU - Fee on File Yes ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, ADJUSTABLE POSITI

0 20 07/01/2019 12/31/9999 1 777.76

L3762 NU - Fee on File Yes ELBOW ORTHOSIS, RIGID, WITHOUT JOINTS, INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 78.16

L3763 NU - Fee on File Yes ELBOW WRIST HAND ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 577.05

L3765 NU - Fee on File Yes ELBOW WRIST HAND FINGER ORTHOSIS, RIGID, WITHOUT JOINTS,MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTINGAND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 931.94

575.48

L3766 NU - Fee on File Yes ELBOW WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION

0 20 07/01/2019 12/31/9999 2 986.86

L3764 NU - Fee on File Yes ELBOW WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS ELASTIC BANDS

0 20 07/01/2019 12/31/9999 2

L3674 NU - Fee on File Yes SHOULDER ORTHOSIS, ABDUCTION POSITIONING, THORACIC CMPONNT & SUPPORT BAR WITH OR W/O

0 20 07/01/2019 12/31/9999 1 859.11


L3808 NU - Fee on File Yes WRIST HAND FINGER ORTHOSIS, RIGID WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE

0 20 07/01/2019 12/31/9999 1 242.76

L3809 NU - Fee on File Yes WRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED, OFF-THE-SHELF, ANY TYPE

0 20 07/01/2019 12/31/9999 2 181.75

L3891 NU - Priced by PA Yes ADDITION TO UPPER EXTREMITY JOINT, WRIST OR ELBOW, CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, EACH

0 20 01/01/2010 12/31/9999 2 0.00

L3900 NU - Fee on File Yes WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTEN

0 20 07/01/2019 12/31/9999 1 1,135.40

L3901 NU - Fee on File Yes WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTEN

0 20 07/01/2019 12/31/9999 1 1,273.09

L3904 NU - Fee on File Yes WHFO, EXTERNAL POWERED, ELECTRIC, CUSTOM-FABRICATED

0 20 07/01/2019 12/31/9999 1 2,591.63

L3906 NU - Fee on File Yes WRIST HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM

0 20 07/01/2019 12/31/9999 2 306.61

L3908 NU - Fee on File Yes WRIST HAND ORTHOSIS, WRIST EXTENSION CONTROL COCK-UP, NON MOLDED, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 43.54

L3912 NU - Fee on File Yes HAND FINGER ORTHOSIS (HFO), FLEXION GLOVE WITH ELASTIC FINGER CONTROL, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 69.85

L3913 NU - Fee on File Yes HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 196.86

L3916 NU - Fee on File Yes WHO NONTORSION JNTS PRE OTS 0 20 07/01/2019 12/31/9999 2 386.36

L3918 NU - Fee on File Yes METACARP FX ORTHOSIS PRE OTS 0 20 07/01/2019 12/31/9999 2 76.78L3919 NU - Fee on File Yes HAND ORTHOSIS, WITHOUT JOINTS, MAY

INCLUDE SOFT INTERFACE, STRAPS,CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 196.86

L3924 NU - Fee on File Yes HFO WITHOUT JOINTS PRE OTS 0 20 07/01/2019 12/31/9999 2 63.22

25.43

L3929 NU - Fee on File Yes HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S)

0 20 07/01/2019 12/31/9999 2 61.18

L3927 NU - Fee on File Yes FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP) WITHOUT

0 20 07/01/2019 12/31/9999 2

63.22

L3925 NU - Fee on File Yes FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP) NON TORSION

0 20 07/01/2019 12/31/9999 2 38.39

L3923 NU - Fee on File Yes HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS PREFABRICATED ITEM THAT

0 20 07/01/2019 12/31/9999 1

76.78

L3921 NU - Fee on File Yes HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS TURNBUCKLES MAY

0 20 07/01/2019 12/31/9999 2 233.43

L3917 NU - Fee on File Yes HAND ORTHOSIS, METACARPAL FRACTURE ORTHOSIS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT

0 20 07/01/2019 12/31/9999 1

720.78

L3915 NU - Fee on File Yes WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), ELASTIC BANDS TURNBUCKLES MAY

0 20 07/01/2019 12/31/9999 1 386.36

L3905 NU - Fee on File Yes WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS TURNBUCKLES MAY

0 20 07/01/2019 12/31/9999 2

330.14

L3807 NU - Fee on File Yes WRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT

0 20 07/01/2019 12/31/9999 2 181.75

L3806 NU - Fee on File Yes WRIST HAND FINGER ORTHOSIS, INCL ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES ELASTIC

0 20 07/01/2019 12/31/9999 1

INCLUDES ONE OR MORE NONTORSION JOINTS ELASTIC BANDS


L3930 NU - Fee on File Yes HFO NONTORSION JNTS PRE OTS 0 20 07/01/2019 12/31/9999 2 61.18

L3933 NU - Fee on File Yes FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 155.08

L3935 NU - Fee on File Yes FINGER ORTHOSIS, NONTORSION JOINT, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 160.58

L3956 NU - Priced by PA Yes ADDITION OF JOINT TO UPPER EXTREMITY ORTHOSIS, ANY MATERIAL;

0 20 05/01/1999 12/31/9999 1 0.00

L3960 NU - Fee on File Yes SEWHO, ABDUCTION POSITIONING, AIRPLANE DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 1 599.09

L3962 NU - Fee on File Yes SEWHO, ABDUCTION POSITIONING, ERBS PALSEY DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 1 623.78

L3980 NU - Fee on File Yes UPPER EXTREMITY FRACTURE ORTHOSIS, HUMERAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 1 224.68

L3982 NU - Fee on File Yes UPPER EXTREMITY FRACTURE ORTHOSIS, RADIUS/ULNAR, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 1 277.58

L3984 NU - Fee on File Yes UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 1 296.30

L3995 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY ORTHOSIS,SOCK,FRACTURE OR EQUAL,EACH

0 20 07/01/2019 12/31/9999 2 24.86

L3999 NU - Priced by PA Yes UPPER LIMB ORTHOSIS, NOT OTHERWISE SPECIFIED UPPER LIMB ORHTOSIS, NOT OT

0 20 05/01/2004 12/31/9999 2 0.00

L4000 NU - Fee on File Yes REPLACE GIRDLE FOR SPINAL ORTHOSIS (CTLSO OR SO)

0 20 07/01/2019 12/31/9999 1 968.89

L4002 NU - Priced by PA Yes REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE

0 20 01/01/2005 12/31/9999 2 0.00

L4010 NU - Fee on File Yes REPLACE TRILATERAL SOCKET BRIM 0 20 07/01/2019 12/31/9999 1 545.23

1,441.73

L3981 NU - Fee on File Yes UPPER EXTREMITY FRACTURE ORTHOSIS, HUMERAL, PREFABBRICATED INCLUDES

0 20 07/01/2019 12/31/9999 2 731.58

L3978 NU - Fee on File Yes SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN) THORACIC

0 20 07/01/2019 12/31/9999 1

1,221.12

L3977 NU - Fee on File Yes SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION

0 20 07/01/2019 12/31/9999 1 1,368.51

L3976 NU - Fee on File Yes SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN) THORACIC

0 20 07/01/2019 12/31/9999 1

1,441.73

L3975 NU - Fee on File Yes SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUTJOINTS MAY INCLUDE SOFT

0 20 07/01/2019 12/31/9999 1 1,221.12

L3973 NU - Fee on File Yes SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN) THORACIC

0 20 07/01/2019 12/31/9999 1

1,441.73

L3971 NU - Fee on File Yes SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION

0 20 07/01/2019 12/31/9999 1 1,368.51

L3967 NU - Fee on File Yes SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN) THORACIC

0 20 07/01/2019 12/31/9999 1

148.02

L3961 NU - Fee on File Yes SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN WITHOUT JOINTS MAY INCLUDE

0 20 07/01/2019 12/31/9999 1 1,221.12

L3931 NU - Fee on File Yes WRIST HAND FINGER ORTHOSIS, INCL ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES ELASTIC

0 20 07/01/2019 12/31/9999 2

ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES ELASTIC

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL4020 NU - Fee on File Yes REPLACE QUADRILATERAL SOCKET

BRIM, MOLDED TO PATIENT MODEL0 20 07/01/2019 12/31/9999 1 681.04

L4030 NU - Fee on File Yes REPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTED

0 20 07/01/2019 12/31/9999 1 374.98

L4040 NU - Fee on File Yes REPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2019 12/31/9999 1 303.17

L4045 NU - Fee on File Yes REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2019 12/31/9999 1 243.63

L4050 NU - Fee on File Yes REPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2019 12/31/9999 1 306.62

L4055 NU - Fee on File Yes REPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2019 12/31/9999 1 198.55

L4060 NU - Fee on File Yes REPLACE HIGH ROLL CUFF 0 20 07/01/2019 12/31/9999 1 236.03L4070 NU - Fee on File Yes REPLACE PROXIMAL AND DISTAL

UPRIGHT FOR KAFO0 20 07/01/2019 12/31/9999 1 225.18

L4080 NU - Fee on File Yes REPLACE METAL BANDS KAFO, PROXIMAL THIGH

0 20 07/01/2019 12/31/9999 1 79.39

L4090 NU - Fee on File Yes REPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGH

0 20 07/01/2019 12/31/9999 1 70.26

L4100 NU - Fee on File Yes REPLACE LEATHER CUFF KAFO, PROXIMAL THIGH

0 20 07/01/2019 12/31/9999 1 79.26

L4110 NU - Fee on File Yes REPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGH

0 20 07/01/2019 12/31/9999 1 62.98

L4130 NU - Fee on File Yes REPLACE PRETIBIAL SHELL 0 20 07/01/2019 12/31/9999 1 433.48L4350 NU - Fee on File Yes ANKLE CONTROL ORTHOSIS, STIRRUP

STYLE, RIGID, INCLUDES ANY TYPE INTERFACE (E.G., PNEUMATIC, GEL), PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 78.10

L4361 NU - Fee on File Yes WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-

0 20 07/01/2019 12/31/9999 2 218.50

L4370 NU - Fee on File Yes PNEUMATIC FULL LEG SPLINT, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 140.22

L4387 NU - Fee on File Yes WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 2 126.62

L4392 NU - Fee on File Yes REPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO

0 20 07/01/2019 12/31/9999 1 18.81

L4394 NU - Fee on File Yes REPALCE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT

0 20 07/01/2019 12/31/9999 1 13.73

L4398 NU - Fee on File Yes FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2019 12/31/9999 1 61.69

L5000 NU - Fee on File Yes PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLER

0 20 07/01/2019 12/31/9999 2 418.75

L5010 NU - Fee on File Yes PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGHT, WITH TOE FILLER

0 20 07/01/2019 12/31/9999 2 1,011.38

L5020 NU - Fee on File Yes PARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBERCLE HEIGHT WITH TOE FILLER

0 20 07/01/2019 12/31/9999 2 1,717.55

L5050 NU - Fee on File Yes SYMES PROSTHESIS PLASTVAPC WITH PTB WEIGHT BEARING

0 20 07/01/2019 12/31/9999 2 1,899.92

134.05

L4631 NU - Fee on File Yes ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM ANTERIOR TIBIAL

0 20 07/01/2019 12/31/9999 2 1,191.78

L4397 NU - Fee on File Yes STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL ADJUSTABLE FOR FIT FOR

0 20 07/01/2019 12/31/9999 2

218.50

L4396 NU - Fee on File Yes STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL ADJUSTABLE FOR FIT FOR

0 20 07/01/2019 12/31/9999 1 134.05

L4360 NU - Fee on File Yes WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE

0 20 07/01/2019 12/31/9999 2

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5060 NU - Fee on File Yes ANKLE, SYMES, METAL FRAME, MOLDED

LEATHER SOCKET,0 20 07/01/2019 12/31/9999 2 2,185.47

L5100 NU - Fee on File Yes PATELLAR TENDON BEARING (P T B ) CUFF

0 20 07/01/2019 12/31/9999 2 1,904.12

L5105 NU - Fee on File Yes BELOW KNEE, PLASTIC SOCKET, JOINTS AND THIGH LACER, SACH FOOT

0 20 07/01/2019 12/31/9999 2 2,748.81

L5150 NU - Fee on File Yes KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL

0 20 07/01/2019 12/31/9999 2 2,778.66

L5160 NU - Fee on File Yes KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, BENT KNEE

0 20 07/01/2019 12/31/9999 2 3,022.30

L5200 NU - Fee on File Yes QUAD SOCKET OPEN END, CONSTANT FRIC KNEE SACH FOOT WOOD, PLASTIC

0 20 07/01/2019 12/31/9999 2 2,894.28

L5210 NU - Fee on File Yes ABOVE KNEE, SHORT PROTHESIS, NO KNEE JOINT ("STUBBIES") , WITH

0 20 07/01/2019 12/31/9999 2 1,920.06

L5220 NU - Fee on File Yes ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ("STUBBIES"), WITH

0 20 07/01/2019 12/31/9999 2 2,182.50

L5230 NU - Fee on File Yes ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL DEFICIENCY, CONSTANT

0 20 07/01/2019 12/31/9999 1 3,010.10

L5250 NU - Fee on File Yes HIP DISARTICULATION PROTHESIS CANADIAN

0 20 07/01/2019 12/31/9999 1 4,105.50

L5270 NU - Fee on File Yes HIP DISARTICULATION PROTHESIS TILT TABLE TYPE

0 20 07/01/2019 12/31/9999 1 4,087.29

L5280 NU - Fee on File Yes HEMIPELVECTOMY, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE

0 20 07/01/2019 12/31/9999 1 4,055.99

L5301 NU - Fee on File Yes BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM

0 20 07/01/2019 12/31/9999 2 2,176.54

L5312 NU - Fee on File Yes KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, SINGLE AXIS KNEE, PYLON, SACH FOOT, ENDOSKELETAL SYSTEM

0 20 07/01/2019 12/31/9999 2 3,115.56

L5321 NU - Fee on File Yes ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SIN

0 20 07/01/2019 12/31/9999 2 3,154.94

L5331 NU - Fee on File Yes HIP DISARTICULATION, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM,

0 20 07/01/2019 12/31/9999 2 4,020.02

L5341 NU - Fee on File Yes HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP J

0 20 07/01/2019 12/31/9999 2 4,184.87

L5500 NU - Fee on File Yes INITIAL, BELOW KNEE "PTB" TYPE SOCKET, "USMC" OR EQUAL PYLON, NO COVER,

0 20 07/01/2019 12/31/9999 1 1,016.24

L5505 NU - Fee on File Yes INITIAL, ABOVE KNEE-KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, `USMC`

0 20 07/01/2019 12/31/9999 1 1,405.50

L5510 NU - Fee on File Yes PREPARATORY, BELOW KNEE "PTB" TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON,

0 20 07/01/2019 12/31/9999 2 1,151.98


0 20 07/01/2019 12/31/9999 2 1,137.88


0 20 07/01/2019 12/31/9999 2 1,366.70

L5535 NU - Fee on File Yes PREPARATORY,BELOW KNEE "PTB" TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, N

0 20 07/01/2019 12/31/9999 2 1,341.83

L5540 NU - Fee on File Yes PREPARATORY, BELOW KNEE "PTB" TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON C

0 20 07/01/2019 12/31/9999 2 1,432.15

L5560 NU - Fee on File Yes PREPARATORY, ABOVE KNEE- KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, "US

0 20 07/01/2019 12/31/9999 2 1,537.88

L5570 NU - Fee on File Yes PREPARATORY, ABOVE KNEE-KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, (NON

0 20 07/01/2019 12/31/9999 2 1,598.86

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5580 NU - Fee on File Yes PREPRATORY, ABOVE KNEE-KNEE

DISARTICULATION ISCHIAL LEVEL SOCKET, (NON-

0 20 07/01/2019 12/31/9999 2 1,866.55

L5585 NU - Fee on File Yes PREPARATORY,ABOVE KNEE-KNEE DISARTICULATION,ISCHIAL LEVEL SOCKET,(NON-AL

0 20 07/01/2019 12/31/9999 2 2,297.10

L5590 NU - Fee on File Yes PREPARATORY, ABOVE KNEE-KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, (NON-

0 20 07/01/2019 12/31/9999 2 1,902.14

L5595 NU - Fee on File Yes PREPARATORY,HIP DISARTICULATION-HEMIPELVECTOMY,PYLON,NO COVER, SACH FOOT

0 20 07/01/2019 12/31/9999 2 3,360.39

L5600 NU - Fee on File Yes PREPARATORY,HIP DISARTICULATION-HEMIPELVECTOMY,PLYON,NO COVER,SACH FOOT

0 20 07/01/2019 12/31/9999 2 3,612.26

L5610 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, HYDRACADENCE SYSTEM

0 20 07/01/2019 12/31/9999 2 1,638.22

L5611 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, "ENDOSKELETAL SYSTEM" ABOVE KNEE-KNEE DISAR

0 20 07/01/2019 12/31/9999 2 1,274.86

L5613 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,"ENDOSKELETAL SYSTEM," ABOVE KNEE-KNEE DISAR

0 20 07/01/2019 12/31/9999 2 1,993.21

L5614 NU - Fee on File Yes ADDITIONS TO LOWER EXTREMITY, "ENDOSKELETAL SYSTEM," ABOVE KNEE, KNEE DI

0 20 07/01/2019 12/31/9999 2 1,350.26

L5616 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, "ENDOSKELETAL SYSTEM" ABOVE KNEE, UNIVERSAL

0 20 07/01/2019 12/31/9999 2 1,077.11

L5617 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, QUICK CHANGE SELF-ALIGNING UNIT, ABOVE OR B

0 20 07/01/2019 12/31/9999 2 447.70

L5618 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST SOCKET, SYMES

0 20 07/01/2019 12/31/9999 2 236.85

L5620 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEE

0 20 07/01/2019 12/31/9999 2 219.98

L5622 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST SOCKET, KNEE DISARTICULATION

0 20 07/01/2019 12/31/9999 2 286.86

L5624 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEE

0 20 07/01/2019 12/31/9999 2 287.66

L5626 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST SOCKET, HIP DISARTICULATION

0 20 07/01/2019 12/31/9999 2 377.26

L5628 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVECTOMY

0 20 07/01/2019 12/31/9999 2 403.39

L5629 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,BELOW KNEE,ACRYLIC

0 20 07/01/2019 12/31/9999 2 251.46

L5630 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, SYMES TYPE, EXPANDABLE WALL

0 20 07/01/2019 12/31/9999 2 355.11

L5631 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,ABOVE KNEE OR KNEE DISARTICULATION

0 20 07/01/2019 12/31/9999 2 347.66

L5632 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, SYMES TYPE, "PTB" BRIM DESIGN

0 20 07/01/2019 12/31/9999 2 194.03

L5634 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPENING

0 20 07/01/2019 12/31/9999 2 240.69

L5636 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, SYMES TYPE, MEDIAL OPENING SOCKET

0 20 07/01/2019 12/31/9999 2 201.62

L5637 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,BELOW KNEE, TOTAL

0 20 07/01/2019 12/31/9999 2 228.58

L5638 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, LEATHER SOCKET

0 20 07/01/2019 12/31/9999 2 398.19

L5639 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,BELOW KNEE,WOOD

0 20 07/01/2019 12/31/9999 2 887.14

L5640 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, LEATHER SOCKET

0 20 07/01/2019 12/31/9999 2 505.96


ABOVE KNEE, LEATHER SOCKET0 20 07/01/2019 12/31/9999 2 490.24

L5643 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,HIP DISARTICULATION,FLEXIBLE INNER SOCKET,EX

0 20 07/01/2019 12/31/9999 2 1,231.55

L5644 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKET

0 20 07/01/2019 12/31/9999 2 467.35

L5645 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,BELOW KNEE,FLEXIBLE INNER SOCKET,EXTERNAL FR

0 20 07/01/2019 12/31/9999 2 631.34

L5646 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET

0 20 07/01/2019 12/31/9999 2 433.54

L5647 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,BELOW KNEE SUCTION

0 20 07/01/2019 12/31/9999 2 629.42

L5648 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET

0 20 07/01/2019 12/31/9999 2 520.94

L5649 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M-L SOCKET

0 20 07/01/2019 12/31/9999 2 1,887.69

L5650 NU - Fee on File Yes ADDITIONS TO LOWER EXTREMITY, TOTAL CONTACT, ABOVE KNEE OR KNEE DISARTIC

0 20 07/01/2019 12/31/9999 2 386.28

L5651 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,ABOVE KNEE,FLEXIBLE INNER SOCKET,EXTERNAL FR

0 20 07/01/2019 12/31/9999 2 950.24

L5652 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, SUCTION SUSPENSION, ABOVE KNEE

0 20 07/01/2019 12/31/9999 2 344.98

L5653 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, EXPANDABLE

0 20 07/01/2019 12/31/9999 2 460.51

L5654 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, SOCKET INSERT, SYMES, (KEMBLO,

0 20 07/01/2019 12/31/9999 2 262.42

L5655 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, SOCKET INSERT, BELOW KNEE

0 20 07/01/2019 12/31/9999 2 222.38

L5656 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, SOCKET INSERT, KNEE DISARTICULATION (KEMBL

0 20 07/01/2019 12/31/9999 2 298.32

L5658 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, SOCKET INSERT, ABOVE KNEE

0 20 07/01/2019 12/31/9999 2 287.70

L5661 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY,SOCKET INSERT,MULTI-

0 20 07/01/2019 12/31/9999 2 481.52

L5665 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER, BELOW KNEE

0 20 07/01/2019 12/31/9999 2 405.14

L5666 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, CUFF SUSPENSION

0 20 07/01/2019 12/31/9999 2 55.38

L5668 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED DISTAL

0 20 07/01/2019 12/31/9999 2 89.34

L5670 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED

0 20 07/01/2019 12/31/9999 2 214.70

L5671 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE / ABOVE KNEE SUSPENSION LOCKING

0 20 07/01/2019 12/31/9999 2 454.99

L5672 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, REMOVABLE MEDIAL

0 20 07/01/2019 12/31/9999 2 235.94

L5676 NU - Fee on File Yes ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, SINGLE AXIS, PAIR

0 20 07/01/2019 12/31/9999 2 286.73

L5677 NU - Fee on File Yes ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, POLYCENTRIC, PAIR

0 20 07/01/2019 12/31/9999 2 390.14

L5678 NU - Fee on File Yes ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, JOINT COVERS, PAIR

0 20 07/01/2019 12/31/9999 2 31.42

562.63L5673 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR

0 20 07/01/2019 12/31/9999 2


L5680 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, NON-

0 20 07/01/2019 12/31/9999 2 262.26

L5681 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE

0 20 07/01/2019 12/31/9999 1 1,052.54

L5682 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER,

0 20 07/01/2019 12/31/9999 2 494.85

L5683 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE

0 20 07/01/2019 12/31/9999 1 1,052.54

L5684 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, FORK STRAP

0 20 07/01/2019 12/31/9999 1 38.08

L5685 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY PROSTHESIS, BELOW KNEE, SUSPENSION/SEALING SLEEVE, WITH OR WITHOUT VALVE, ANY MATERIAL, EACH

0 20 07/01/2019 12/31/9999 2 102.49

L5686 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, BACK CHECK (EXTENS-

0 20 07/01/2019 12/31/9999 2 40.42

L5688 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, WEBBING

0 20 07/01/2019 12/31/9999 2 48.34

L5690 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, PADDED

0 20 07/01/2019 12/31/9999 2 77.42

L5692 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT,

0 20 07/01/2019 12/31/9999 2 105.14

L5694 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, PADDED AND

0 20 07/01/2019 12/31/9999 2 143.54

L5695 NU - Fee on File Yes ADDITION ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL, SLEEVE

0 20 07/01/2019 12/31/9999 2 132.51

L5696 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULAT-

0 20 07/01/2019 12/31/9999 2 146.40


0 20 07/01/2019 12/31/9999 2 63.52


0 20 07/01/2019 12/31/9999 2 103.87

L5699 NU - Fee on File Yes ALL LOWER EXTREMITY PROTHESES, SHOULDER HARNESS

0 20 07/01/2019 12/31/9999 2 187.12

L5700 NU - Fee on File Yes REPLACEMENT, SOCKET, BELOW KNEE, MOLDED TO PATIENT MODEL

0 20 07/01/2019 12/31/9999 2 2,267.11

L5701 NU - Fee on File Yes REPLACEMENT,SOCKET,ABOVE KNEE/KNEE DISARTICULATION, INCLUDING ATTACHMENT

0 20 07/01/2019 12/31/9999 2 2,722.64

L5702 NU - Fee on File Yes REPLACEMENT,SOCKET HIP DISARTICULATION,INCLUDING HIP JOINT,MOLDED TO PAT

0 20 07/01/2019 12/31/9999 2 3,444.53

L5703 NU - Fee on File Yes ANKLE, SYMES, MOLDED TO PATIENT MODEL, SOCKET WITHOUT SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY

0 20 07/01/2019 12/31/9999 1 1,782.58

L5704 NU - Fee on File Yes CUSTOM SHAPED PROTECTIVE COVER, BELOW KNEE

0 20 07/01/2019 12/31/9999 2 424.13

L5705 NU - Fee on File Yes CUSTOM SHAPED PROTECTIVE COVER, ABOVE KNEE

0 20 07/01/2019 12/31/9999 2 757.85

L5706 NU - Fee on File Yes CUSTOM SHAPED PROTECTIVE COVER, KNEE DISARTICULATION

0 20 07/01/2019 12/31/9999 2 742.88

L5707 NU - Fee on File Yes CUSTOM SHAPED PROTECTIVE COVER, HIP DISARTICULATION

0 20 07/01/2019 12/31/9999 2 979.37

L5679 NU - Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR

0 20 07/01/2019 12/31/9999 4 468.84

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5710 NU - Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN

SYSTEM, SINGLE AXIS, MANUAL LOCK0 20 07/01/2019 12/31/9999 2 295.92

L5711 NU - Fee on File Yes ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL LOCK,ULTA-LIGH

0 20 07/01/2019 12/31/9999 2 413.58

L5712 NU - Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND

0 20 07/01/2019 12/31/9999 2 346.54

L5714 NU - Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, VARIABLE FRICTION

0 20 07/01/2019 12/31/9999 2 355.94

L5716 NU - Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE

0 20 07/01/2019 12/31/9999 2 576.70

L5718 NU - Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING AN

0 20 07/01/2019 12/31/9999 2 720.82

L5722 NU - Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING,

0 20 07/01/2019 12/31/9999 2 761.51

L5724 NU - Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE

0 20 07/01/2019 12/31/9999 2 1,194.34

L5726 NU - Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, EXTERNAL JOINTS FL

0 20 07/01/2019 12/31/9999 2 1,376.45

L5728 NU - Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND ST

0 20 07/01/2019 12/31/9999 2 1,882.80

L5780 NU - Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/HYDRA PN

0 20 07/01/2019 12/31/9999 2 905.93

L5781 NU - Fee on File Yes ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MAN

0 20 07/01/2019 12/31/9999 1 3,201.62

L5782 NU - Fee on File Yes ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MAN

0 20 07/01/2019 12/31/9999 1 3,375.25

L5785 NU - Fee on File Yes ADDITION,EXOSKELETAL SYSTEM,BELOW KNEE,ULTRA-LIGHT MATERIAL (TITANIUM,CA

0 20 07/01/2019 12/31/9999 2 509.24

L5790 NU - Fee on File Yes ADDITION,EXOSKELETAL SYSTEM,ABOVE KNEE,ULTRA-LIGHT MATERIAL (TITANIUM,CA

0 20 07/01/2019 12/31/9999 2 568.94

L5795 NU - Fee on File Yes ADDITION,EXOSKELETAL SYSTEM,HIP DISARTICULATION,ULTRA-LIGHT MATERIAL(TIT

0 20 07/01/2019 12/31/9999 2 1,132.76

L5810 NU - Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, MANUAL LOCK

0 20 07/01/2019 12/31/9999 2 385.23

L5811 NU - Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL LOCK,ULTRA-LIG

0 20 07/01/2019 12/31/9999 2 577.08

L5812 NU - Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FRICTION SWING AND ST

0 20 07/01/2019 12/31/9999 2 447.30

L5814 NU - Fee on File Yes ADD. ENDOSKTL KNEE-SHIN SYST, POLY HYDRAUL,SWG PHASE CNTRL MECH PHS LOCK

0 20 07/01/2019 12/31/9999 1 2,971.74

L5816 NU - Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC,MECHANICAL STANCE PHA

0 20 07/01/2019 12/31/9999 2 676.98

L5818 NU - Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC,FRICTION SWING,AND ST

0 20 07/01/2019 12/31/9999 2 759.86

L5822 NU - Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,PNEUMATIC SWING,FRICT

0 20 07/01/2019 12/31/9999 2 1,347.44

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5824 NU - Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN

SYSTEM,SINGLE AXIS,FLUID SWING PHASE CON

0 20 07/01/2019 12/31/9999 2 1,213.45

L5826 NU - Fee on File Yes ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, HYDRAULIC SWING PH

0 20 07/01/2019 12/31/9999 1 2,498.84

L5828 NU - Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID SWING AND STANC

0 20 07/01/2019 12/31/9999 2 2,234.47

L5830 NU - Fee on File Yes ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/ SWING P

0 20 07/01/2019 12/31/9999 2 1,501.45

L5840 NU - Fee on File Yes ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, 4-BAR LINKAGE OR MULTIAXIAL, PN

0 20 07/01/2019 12/31/9999 2 2,776.18

L5845 NU - Fee on File Yes ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION FEATURE, ADJUST

0 20 07/01/2019 12/31/9999 2 1,434.22

L5848 NU - Fee on File Yes ADDITION TO ENDOSKELETAL KNEE-SHIN SYSTEM, FLUID STANCE EXTENSION, DAMPENING FEATURE, WITH OR WITHOUT ADJUSTABILITY

0 20 07/01/2019 12/31/9999 1 860.42

L5850 NU - Fee on File Yes ADDITION,ENDOSKELETAL SYSTEM,ABOVE KNEE OR HIP DISARTICULATION,KNEE EXTE

0 20 07/01/2019 12/31/9999 2 101.22

L5855 NU - Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, MECHANICAL HIP EXTEN

0 20 07/01/2019 12/31/9999 1 271.99

L5910 NU - Fee on File Yes ADDITION,ENDOSKELETAL SYSTEM,BELOW KNEE,ALIGNABLE SYSTEM

0 20 07/01/2019 12/31/9999 2 286.58

L5920 NU - Fee on File Yes ADDITION,ENDOSKELETAL SYSTEM,ABOVE KNEE OR HIP DISARTICULATION,ALIGNABLE

0 20 07/01/2019 12/31/9999 2 419.84

L5925 NU - Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE DISARTICULATION OR HIP

0 20 07/01/2019 12/31/9999 2 354.50

L5930 NU - Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAME

0 20 07/01/2019 12/31/9999 2 2,693.29

L5940 NU - Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIU

0 20 07/01/2019 12/31/9999 2 396.90

L5950 NU - Fee on File Yes ADDITION,ENDOSKELETAL SYSTEM,ABOVE KNEE,ULTRA-LIGHT MATERIAL(TITANIUM,CA

0 20 07/01/2019 12/31/9999 2 620.58

L5960 NU - Fee on File Yes ADDITION,ENDOSKELETAL SYSTEM,HIP DISARTICULATION,ULTRA-LIGHT MATERIAL(TI

0 20 07/01/2019 12/31/9999 2 762.81

L5962 NU - Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, FLEXIBLE PROCTECTIVE OUTER SU

0 20 07/01/2019 12/31/9999 2 502.01

L5964 NU - Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, FLEXIBLE PROTECTIVE OUTER SUR

0 20 07/01/2019 12/31/9999 2 741.03

L5966 NU - Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, FLEXIBLE

0 20 07/01/2019 12/31/9999 2 944.26

L5968 NU - Fee on File Yes ADDITION TO LOWER LIMB PROSTHESIS, MULTIAXIAL ANKLE WITH SWING PHASE ACT

0 20 07/01/2019 12/31/9999 1 2,907.77

L5969 NU - Fee on File Yes ADDITION, ENDOSKELETAL ANKLE-FOOT OR ANKLE SYSTEM, POWER ASSIST, INCLUDES ANY TYPE MOTOR(S)

0 20 01/01/2014 12/31/9999 2 11,026.77

L5970 NU - Fee on File Yes ALL LOWER EXTREMITY PROTHESE, FOOT, EXTERNAL KEEL, SACH FOOT

0 20 07/01/2019 12/31/9999 1 160.70

3,637.38L5961 NU - Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, POLYCENTRIC HIP JOINT, PNEUMATIC OR HYDRAULIC CONTROL ROTATION

0 20 07/01/2019 12/31/9999 2

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5971 NU - Fee on File Yes ALL LOWER EXTREMITY PROSTHESIS,

SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY

0 20 07/01/2019 12/31/9999 1 160.70

L5972 NU - Fee on File Yes ALL LOWER EXTREMITY PROSTHESES, FOOT, FLEXIBLE KEEL

0 20 07/01/2019 12/31/9999 2 300.17

L5974 NU - Fee on File Yes ALL LOWER EXTREMITY PROTHESES, FOOT, SINGLE AXIS ANKLE/FOOT

0 20 07/01/2019 12/31/9999 2 184.39

L5975 NU - Fee on File Yes ALL LOWER EXTREMITY PROSTHESIS, COMBINATION SINGLE AXIS ANKLE AND FLEXIB

0 20 07/01/2019 12/31/9999 1 370.98

L5976 NU - Fee on File Yes ALL LOWER EXTREMITY PROTHESES, ENERGY STORING FOOT

0 20 07/01/2019 12/31/9999 2 443.13

L5978 NU - Fee on File Yes ALL LOWER EXTREMITY PROTHESES, FOOT, MULTIAXIAL ANKLE/FOOT

0 20 07/01/2019 12/31/9999 2 230.91

L5979 NU - Fee on File Yes ALL LOWER EXTREMITY PROSTHESIS, MULTI-AXIAL ANKLE, DYNAMIC RESPONSE FOOT

0 20 07/01/2019 12/31/9999 2 1,805.47

L5980 NU - Fee on File Yes ALL LOWER EXTREMITY PROTHESES, FLEX FOOT SYSTEM

0 20 07/01/2019 12/31/9999 2 2,933.77

L5981 NU - Fee on File Yes ALL LOWER EXTREMITY PROTHESES, FLEX-WALK SYSTEM OR EQUAL

0 20 07/01/2019 12/31/9999 2 2,370.09

L5982 NU - Fee on File Yes ALL EXOSKELETAL LOWER EXTREMITY PROTHESES, AXIAL ROTATION UNIT

0 20 07/01/2019 12/31/9999 2 457.44

L5984 NU - Fee on File Yes ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESIS, AXIAL ROTATION UNIT, WITH OR WITHOUT ADJUSTABILITY

0 20 07/01/2019 12/31/9999 2 450.76

L5985 NU - Fee on File Yes ALL ENDOSKELETAL LOWER EXTREMITY PROTHESES, SYNAMIC PROTHETIC PYLON

0 20 07/01/2019 12/31/9999 2 225.95

L5986 NU - Fee on File Yes ALL LOWER EXTREMITY PROTHESES, MULTI-AXIAL ROTATION UNIT

0 20 07/01/2019 12/31/9999 2 501.42

L5987 NU - Fee on File Yes ALL LOWER EXTREMITY PROTHESES, SHANK FOOT SYSTEM WITH VERTICAL LOADING

0 20 07/01/2019 12/31/9999 1 5,756.22

L5988 NU - Fee on File Yes ADDITION TO LOWER LIMB PROSTHESIS, VERTICAL SHOCK REDUCING PYLON FEATURE

0 20 07/01/2019 12/31/9999 1 1,598.50

L5999 NU - Priced by PA Yes LOWER EXTREMITY PROTHESIS, NOT OTHERWWISE SPECIFIED LOWER EXTREMITY PROS

0 20 05/01/2004 12/31/9999 2 0.00

L6000 NU - Fee on File Yes PARTIAL HAND, THUMB REMAINING 0 20 07/01/2019 12/31/9999 2 1,051.34L6010 NU - Fee on File Yes PARTIAL HAND, LITTLE AND/OR RING

FINGER REMAINING0 20 07/01/2019 12/31/9999 2 1,169.97

L6020 NU - Fee on File Yes PARTIAL HAND, NO FINGER REMAINING 0 20 07/01/2019 12/31/9999 2 1,090.82L6050 NU - Fee on File Yes WRIST DISARTICULATION, MOLDED

SOCKET, FLEXIBLE ELBOW HINGES,0 20 07/01/2019 12/31/9999 2 1,503.10

L6055 NU - Fee on File Yes WRIST DISARTICULATION,MOLDED SOCKET WITH EXPANDABLE INTERFACE,FLEXIBLE E

0 20 07/01/2019 12/31/9999 2 2,094.94

L6100 NU - Fee on File Yes BELOW ELBOW PROTHESIS PLASTIC DOUBLE WALL

0 20 07/01/2019 12/31/9999 2 1,522.87

L6110 NU - Fee on File Yes BELOW ELBOW PROTHES-MUNSTER 0 20 07/01/2019 12/31/9999 2 1,615.26L6120 NU - Fee on File Yes BELOW ELBOW, MOLDED DOUBLE WALL

SPLIT SOCKET, STEP-UP HINGES,0 20 07/01/2019 12/31/9999 2 1,882.35

L6130 NU - Fee on File Yes BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STUMP ACTIVATED

0 20 07/01/2019 12/31/9999 2 2,048.35

L6200 NU - Fee on File Yes ELBOW DISARTICULATION PROTHESIS 0 20 07/01/2019 12/31/9999 2 2,158.63L6205 NU - Fee on File Yes ELBOW DISARTICULATION, MOLDED

SOCKET WITH EXPANDABLE INTERFACE, OUTSIDE

0 20 07/01/2019 12/31/9999 2 2,881.43

L6250 NU - Fee on File Yes ABOVE ELBOW PROTHESIS PLASTIC DOUBLE WALL

0 20 07/01/2019 12/31/9999 2 2,261.74

L6300 NU - Fee on File Yes SHOULDER DISARTICULATION PROTHESIS

0 20 07/01/2019 12/31/9999 2 2,947.94L6310 NU - Fee on File Yes SHOULDER DISARTICULATION, PASSIVE

RESTORATION (COMPLETE PROS-0 20 07/01/2019 12/31/9999 2 2,545.42

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL6320 NU - Fee on File Yes SHOULDER DISARTICULATION, PASSIVE

RESTORATION (SHOULDER CAP0 20 07/01/2019 12/31/9999 2 1,390.50

L6350 NU - Fee on File Yes INTERSCAPULAR THORACIC, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTIO

0 20 07/01/2019 12/31/9999 2 3,099.31

L6360 NU - Fee on File Yes INTERSCAPULAR THORACIC, PASSIVE RESTORATION (COMPLETE PROS-

0 20 07/01/2019 12/31/9999 2 2,787.34

L6370 NU - Fee on File Yes INTERSCAPULAR THORACIC, PASSIVE RESTORATION (SHOULDER CAP ONLY)

0 20 07/01/2019 12/31/9999 2 1,667.86

L6400 NU - Fee on File Yes BELOW ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING

0 20 07/01/2019 12/31/9999 2 1,836.04

L6450 NU - Fee on File Yes ELBOW DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM,

0 20 07/01/2019 12/31/9999 2 2,452.90

L6500 NU - Fee on File Yes ABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING

0 20 07/01/2019 12/31/9999 2 2,566.25

L6550 NU - Fee on File Yes SHOULDER DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING

0 20 07/01/2019 12/31/9999 2 3,084.67

L6570 NU - Fee on File Yes INTERSCAPULAR THORACIC, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SO

0 20 07/01/2019 12/31/9999 2 3,463.26

L6580 NU - Fee on File Yes PREPARATORY,WRIST DISARTICULATION OR BELOW ELBOW,SINGLE WALL PLASTIC SOC

0 20 07/01/2019 12/31/9999 2 1,322.20

L6582 NU - Fee on File Yes PREPARATORY,WRIST DISARTICULATION OR BELOW ELBOW,SINGLE WALL SOCKET,FRIC

0 20 07/01/2019 12/31/9999 2 1,197.56

L6584 NU - Fee on File Yes PREPARATORY,ELBOW DISARTICULATION OR ABOVE ELBOW,SINGLE WALL PLASTIC SOC

0 20 07/01/2019 12/31/9999 2 1,878.08

L6586 NU - Fee on File Yes PREPARATORY,ELBOW DISARTICULATION OR ABOVE ELBOW,SINGLE WALL SOCKET,FRIC

0 20 07/01/2019 12/31/9999 2 1,757.58

L6588 NU - Fee on File Yes PREPARATORY,SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC,SINGLE WA

0 20 07/01/2019 12/31/9999 2 2,309.42

L6590 NU - Fee on File Yes PREPARATORY,SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC,SINGLE WA

0 20 07/01/2019 12/31/9999 2 2,193.58

L6600 NU - Fee on File Yes UPPER EXTREMITY ADDITIONS, POLYCENTRIC HINGE, PAIR

0 20 07/01/2019 12/31/9999 2 148.42

L6605 NU - Fee on File Yes UPPER EXTREMITY ADDITIONS, SINGLE PIVOT HINGE, PAIR

0 20 07/01/2019 12/31/9999 2 146.55

L6610 NU - Fee on File Yes UPPER EXTREMITY ADDITIONS, FLEXIBLE METAL HINGE, PAIR

0 20 07/01/2019 12/31/9999 2 140.74

L6615 NU - Fee on File Yes UPPER EXTREMITY ADDITION, DISCONNECT LOCKING WRIST UNIT

0 20 07/01/2019 12/31/9999 2 151.64

L6616 NU - Fee on File Yes UPPER EXTREMITY ADDITION, ADDITIONAL DISCONNECT INSERT FOR LOCKING WRIST

0 20 07/01/2019 12/31/9999 2 56.19

L6620 NU - Fee on File Yes UPPER EXTREMITY ADDITION, FLEXION/EXTENSION WRIST UNIT, WITH OR WITHOUT FRICTION

0 20 07/01/2019 12/31/9999 2 242.62

L6621 NU - Fee on File Yes UPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION WRIST WITH ORWITHOUT FRICTION, FOR USE WITH EXTERNAL POWERED TERMINAL DEVICE

0 20 07/01/2019 12/31/9999 1 1,830.21

L6623 NU - Fee on File Yes UPPER EXTREMITY ADDITION,SPRING ASSISTED ROTATIONAL WRIST UNIT WITH LATC

0 20 07/01/2019 12/31/9999 2 676.75

L6625 NU - Fee on File Yes UPPER EXTREMITY ADDITION, ROTATION WRIST UNIT WITH CABLE

0 20 07/01/2019 12/31/9999 2 480.84

L6628 NU - Fee on File Yes UPPER EXTREMITY ADDITION,QUICK DISCONNECT HOOK ADAPTER,OTTO BOCK OR EQUA

0 20 07/01/2019 12/31/9999 2 379.06

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL6629 NU - Fee on File Yes UPPER EXTREMITY ADDITION,QUICK

DISCONNECT LAMINATION COLLAR WITH COUPLIN

0 20 07/01/2019 12/31/9999 2 115.77

L6630 NU - Fee on File Yes UPPER EXTREMITY ADDITION, STAINLESS STEEL, ANY WRIST

0 20 07/01/2019 12/31/9999 2 170.54

L6632 NU - Fee on File Yes UPPER EXTREMITY ADDITION, LATEX SUSPENSION SLEEVE, EACH

0 20 07/01/2019 12/31/9999 2 59.22

L6635 NU - Fee on File Yes UPPER EXTREMITY ADDITION, LIFT ASSIST FOR ELBOW

0 20 07/01/2019 12/31/9999 2 139.37

L6637 NU - Fee on File Yes UPPER EXTREMITY ADDITION, NUDGE CONTROL ELBOW LOCK

0 20 07/01/2019 12/31/9999 2 297.26

L6640 NU - Fee on File Yes UPPER EXTREMITY ADDITIONS SHOULDER ABDUCTION JOINT, PAIR

0 20 07/01/2019 12/31/9999 1 264.08

L6641 NU - Fee on File Yes UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, PULLEY TYPE

0 20 07/01/2019 12/31/9999 2 126.94

L6642 NU - Fee on File Yes UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, LEVER TYPE

0 20 07/01/2019 12/31/9999 2 172.06

L6645 NU - Fee on File Yes UPPER EXTREMITY ADDITION, SHOULDER FLEXION-ABDUCTION

0 20 07/01/2019 12/31/9999 2 317.59

L6650 NU - Fee on File Yes UPPER EXTREMITY ADDITION, SHOULDER UNIVERSAL JOINT, EACH

0 20 07/01/2019 12/31/9999 2 329.74

L6655 NU - Fee on File Yes UPPER EXTREMITY ADDITION, STANDARD CONTROL CABLE, EXTRA

0 20 07/01/2019 12/31/9999 2 64.80

L6660 NU - Fee on File Yes UPPER EXTREMITY ADDITION, HEAVY DUTY CONTROL CABLE

0 20 07/01/2019 12/31/9999 2 72.63

L6665 NU - Fee on File Yes UPPER EXTREMITY ADDITION, TEFLON, OR EQUAL, CABLE LINING

0 20 07/01/2019 12/31/9999 2 36.44

L6670 NU - Fee on File Yes UPPER EXTREMITY ADDITION, HOOK TO HAND, CABLE ADAPTER

0 20 07/01/2019 12/31/9999 2 40.30

L6672 NU - Fee on File Yes UPPER EXTREMITY ADDITION, HARNESS, CHEST OR

0 20 07/01/2019 12/31/9999 2 159.90

L6675 NU - Fee on File Yes UPPER EXTREMITY ADDITION, HARNESS, (E.G. FIGURE OF EIGHT TYPE), SINGLE CABLE DESIGN

0 20 07/01/2019 12/31/9999 2 95.02

L6676 NU - Fee on File Yes UPPER EXTREMITY ADDITION, HARNESS, (E.G. FIGURE OF EIGHT TYPE), DUAL CABLE DESIGN

0 20 07/01/2019 12/31/9999 2 109.84

L6677 NU - Fee on File Yes UPPER EXTREMITY ADDITION, HARNESS, TRIPLE CONTROL, SIMULTANEOUS OPERATION OF TERMINAL DEVICE AND ELBOW

0 20 07/01/2019 12/31/9999 1 237.40

L6680 NU - Fee on File Yes UPPER EXTREMITY ADDITION, TEST SOCKET, WRIST DISARTICULAT-

0 20 07/01/2019 12/31/9999 2 183.58

L6682 NU - Fee on File Yes UPPER EXTREMITY ADDITION, TEST SOCKET, ELBOW DISARTICULAT-

0 20 07/01/2019 12/31/9999 2 202.97

L6684 NU - Fee on File Yes UPPER EXTREMITY ADDITION, TEST SOCKET, SHOULDER DIS-

0 20 07/01/2019 12/31/9999 2 275.81

L6686 NU - Fee on File Yes UPPER EXTREMITY ADDITION,SUCTION SOCKET

0 20 07/01/2019 12/31/9999 2 622.84

L6687 NU - Fee on File Yes UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, BELOW ELBOW OR WRIST DISART

0 20 07/01/2019 12/31/9999 2 456.41

L6688 NU - Fee on File Yes UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, ABOVE ELBOW OR ELBOW DISART

0 20 07/01/2019 12/31/9999 2 453.66

L6689 NU - Fee on File Yes UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET,SHOULDER DISARTICULATION

0 20 07/01/2019 12/31/9999 2 543.54

L6690 NU - Fee on File Yes UPPER EXTREMITY ADDITION,FRAME TYPE SOCKET,INTERSCAPULAR-THORACIC

0 20 07/01/2019 12/31/9999 2 592.30

L6691 NU - Fee on File Yes UPPER EXTREMITY ADDITION, REMOVABLE INSERT,EACH

0 20 07/01/2019 12/31/9999 4 274.14

L6692 NU - Fee on File Yes UPPER EXTREMITY ADDITION, SILICONE GEL INSERT OR EQUAL, EACH

0 20 07/01/2019 12/31/9999 4 442.50

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL6693 NU - Fee on File Yes UPPER EXTREMITY ADDITION, LOCKING

ELBOW, FOREARM COUNTERBALANCE UPPER EX

0 20 07/01/2019 12/31/9999 1 2,271.66

L6696 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE

0 20 07/01/2019 12/31/9999 2 1,052.54

L6698 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, LOCK MECHANISM, EXCLUDES SOCKET INSERT

0 20 07/01/2019 12/31/9999 2 454.99

L6703 NU - Fee on File Yes TERMINAL DEVICE, PASSIVE HAND/MITT, ANY MATERIAL, ANY SIZE

0 20 07/01/2019 12/31/9999 2 287.65

L6704 NU - Fee on File Yes TERMINAL DEVICE, SPORT/RECREATIONAL/WORK ATTACHMENT, ANY MATERIAL, ANY SIZE

0 20 07/01/2019 12/31/9999 2 463.39

L6706 NU - Fee on File Yes TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,

0 20 07/01/2019 12/31/9999 2 276.09

L6707 NU - Fee on File Yes TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,

0 20 07/01/2019 12/31/9999 2 1,017.62

L6708 NU - Fee on File Yes TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE

0 20 07/01/2019 12/31/9999 2 665.25

L6709 NU - Fee on File Yes TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE

0 20 07/01/2019 12/31/9999 2 958.64

L6711 NU - Fee on File Yes TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED PEDIATRIC

0 20 07/01/2019 12/31/9999 2 537.96

L6712 NU - Fee on File Yes 'TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED PEDIATRIC

0 20 07/01/2019 12/31/9999 2 990.51

L6713 NU - Fee on File Yes 'TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, PEDIATRIC

0 20 07/01/2019 12/31/9999 2 1,250.09

L6714 NU - Fee on File Yes 'TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, PEDIATRIC

0 20 07/01/2019 12/31/9999 2 1,058.86

L6721 NU - Fee on File Yes 'TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY OPENING, ANY SIZE LINED OR UNLINED

0 20 07/01/2019 12/31/9999 2 1,881.98

L6722 NU - Fee on File Yes 'TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY CLOSING, ANY SIZE LINES OR UNLINED

0 20 07/01/2019 12/31/9999 2 1,622.40

L6805 NU - Fee on File Yes ADDITION TO TERMINAL DEVICE, MODIFIER WRIST UNIT ADDITION TO TERMINAL DEVICE, MODIFIER WRIST

0 20 07/01/2019 12/31/9999 2 269.22

L6810 NU - Fee on File Yes ADDITION TO TERMINAL DEVICE, PRECISION PINCH DEVICE ADDITION TO TERMINAL DEVICE, PRECISION PINCH DEVICE

0 20 07/01/2019 12/31/9999 2 152.59

L6883 NU - Fee on File Yes REPLACEMENT SOCKET, BELOW ELBOW/WRIST DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER

0 20 07/01/2019 12/31/9999 1 1,255.64

468.84

L6697 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW CUSTOM FABRICATED SOCKET

0 20 07/01/2019 12/31/9999 2 1,052.54

L6695 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW CUSTOM FABRICATED FROM

0 20 07/01/2019 12/31/9999 2

L6694 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW CUSTOM FABRICATED

0 20 07/01/2019 12/31/9999 2 562.63

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL6884 NU - Fee on File Yes REPLACEMENT SOCKET, ABOVE

ELBOW/ELBOW DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER

0 20 07/01/2019 12/31/9999 1 1,863.63

L6885 NU - Fee on File Yes REPLACEMENT SOCKET, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER

0 20 07/01/2019 12/31/9999 1 2,787.34

L6890 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2019 12/31/9999 2 134.58

L6895 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY MATERIAL, CUSTOM FABRICATED

0 20 07/01/2019 12/31/9999 2 495.10

L6900 NU - Fee on File Yes HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED),

0 20 07/01/2019 12/31/9999 2 1,412.89


0 20 07/01/2019 12/31/9999 2 1,404.86


0 20 07/01/2019 12/31/9999 2 1,201.29

L6915 NU - Fee on File Yes HAND RESTORATION (SHADING, AND MEASUREMENTS INCLUDED),

0 20 07/01/2019 12/31/9999 2 605.67

L6920 NU - Fee on File Yes WRIST DISARTICULATION,EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET,REMOVAB

0 20 07/01/2019 12/31/9999 2 5,280.66

L6925 NU - Fee on File Yes WRIST DISARTICULATION,EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET,REMOVAB

0 20 07/01/2019 12/31/9999 2 7,108.70

L6930 NU - Fee on File Yes BELOW ELBOW,EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET,REMOVABLE FOREARM

0 20 07/01/2019 12/31/9999 2 5,313.41

L6935 NU - Fee on File Yes BELOW ELBOW,EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET,REMOVABLE FOREARM

0 20 07/01/2019 12/31/9999 2 7,219.01

L6940 NU - Fee on File Yes ELBOW DISARTICULATION,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE HUMER

0 20 07/01/2019 12/31/9999 2 6,942.32

L6945 NU - Fee on File Yes ELBOW DISARTICULATION,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE HUMER

0 20 07/01/2019 12/31/9999 2 8,482.68

L6950 NU - Fee on File Yes ABOVE ELBOW,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE HUMERAL SHELL

0 20 07/01/2019 12/31/9999 2 7,890.93

L6955 NU - Fee on File Yes ABOVE ELBOW,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE HUMERAL SHELL

0 20 07/01/2019 12/31/9999 2 9,450.46

L6960 NU - Fee on File Yes SHOULDER DISARTICULATION,EXTERNAL POWER,MOLDED INNER

0 20 07/01/2019 12/31/9999 2 10,705.02

L6965 NU - Fee on File Yes SHOULDER DISARTICULATION,EXTERNAL POWER,MOLDED INNER

0 20 07/01/2019 12/31/9999 2 11,417.29

L6970 NU - Fee on File Yes INTERSCAPULAR-THORACIC,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE SHOU

0 20 07/01/2019 12/31/9999 2 11,897.00

L6975 NU - Fee on File Yes INTERSCAPULAR-THORACIC,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE SHOU

0 20 07/01/2019 12/31/9999 2 13,011.47

L7040 NU - Fee on File Yes PREHENSILE ACTUATOR, SWITCH CONTROLLED

0 20 07/01/2019 12/31/9999 2 2,230.70

L7045 NU - Fee on File Yes ELECTRIC HOOK, SWITCH OR MYOELECTRIC ONTROLLED, PEDIATRIC

0 20 07/01/2019 12/31/9999 2 1,278.94

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL7170 NU - Fee on File Yes ELECTRONIC ELBOW. HOSMER OR

EQUAL, SWITCH CONTROLLED0 20 07/01/2019 12/31/9999 1 5,888.73

L7180 NU - Fee on File Yes ELECTRONIC ELBOW, MICROPROCESSOR SEQUENTIAL CONTROL OF ELBOW AND TERMINAL DEVICE

0 20 07/01/2019 12/31/9999 2 25,848.23

L7185 NU - Fee on File Yes ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLE

0 20 07/01/2019 12/31/9999 2 5,815.20

L7186 NU - Fee on File Yes ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED

0 20 07/01/2019 12/31/9999 2 6,999.15

L7190 NU - Fee on File Yes ELECTRONIC ELBOW, ADOLESCENT,VARIETY VILLAGE OR EQUAL, MYOELECTRONICALL

0 20 07/01/2019 12/31/9999 2 6,107.94

L7191 NU - Fee on File Yes ELECTRONIC ELBOW,CHILD,VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTR

0 20 07/01/2019 12/31/9999 2 7,313.70

L7259 NU - Fee on File Yes ELECTRONIC WRIST ROTATOR, ANY TYPE

0 20 07/01/2019 12/31/9999 2 2,528.81L7360 NU - Fee on File Yes SIX VOLT BATTERY, EACH 0 20 07/01/2019 12/31/9999 2 188.81L7362 NU - Fee on File Yes BATTERY CHARGER, SIX VOLT, EACH 0 20 07/01/2019 12/31/9999 2 198.25L7364 NU - Fee on File Yes TWELVE VOLT BATTERY, EACH 0 20 07/01/2019 12/31/9999 2 315.30L7366 NU - Fee on File Yes BATTERY CHARGER, TWELVE VOLT,

EACH0 20 07/01/2019 12/31/9999 2 424.72

L7400 NU - Fee on File Yes DDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR

0 20 07/01/2019 12/31/9999 1 245.25

L7401 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR

0 20 07/01/2019 12/31/9999 1 274.56

L7402 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL)

0 20 07/01/2019 12/31/9999 1 296.46

L7403 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ACRYLIC MATERIAL

0 20 07/01/2019 12/31/9999 1 294.69

L7404 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ACRYLIC MATERIAL

0 20 07/01/2019 12/31/9999 1 444.73

L7405 NU - Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, ACRYLIC MATERIAL

0 20 07/01/2019 12/31/9999 1 581.66

L7499 NU - Priced by PA Yes UPPER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED UPPER EXTREMITY PROS

0 20 05/01/2004 12/31/9999 2 0.00

L7600 NU - Priced by PA Yes PROSTHETIC DONNING SLEEVE, ANY MATERIAL, EACH

0 20 01/01/2006 12/31/9999 1 0.00

L8000 NU - Fee on File Yes BREAST PROSTHESES, MASTECTOMY BRA, WITHOUT INTEGRATED BREAST PROSTHESES FORM, ANY SIZE, ANY TYPE

0 20 07/01/2019 12/31/9999 2 34.80

L8010 NU - Fee on File Yes BREAST PROSTHESIS, MASTECOMY SLEEVE

0 20 05/01/1999 12/31/9999 2 37.52

L8015 NU - Fee on File Yes EXTERNAL BREAST PROSTHESIS GARMENT, WITH MASTECTOMY FORM, POST MASTECTOM

0 20 07/01/2019 12/31/9999 1 47.96

L8020 NU - Fee on File Yes BREAST PROSTHESIS, MASTECTOMY FORM

0 20 07/01/2019 12/31/9999 2 180.39

L8030 NU - Fee on File Yes BREAST PROSTHESIS, SILICONE OR EQUAL, WITHOUT INTEGRAL ADHESIVE

0 20 07/01/2019 12/31/9999 2 260.93

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL8035 NU - Fee on File Yes CUSTOM BREAST PROSTHESIS, POST

MASTECTOMY, MOLDED TO PATIENT MODEL

0 20 07/01/2019 12/31/9999 1 2,931.53

L8039 NU - Priced by PA Yes BREAST PROSTHESIS, NOT OTHERWISE SPECIFIED

0 20 05/01/2004 12/31/9999 2 0.00

L8300 NU - Fee on File Yes TRUSS, SINGLE WITH STANDARD PAD 0 20 07/01/2019 12/31/9999 1 77.06L8310 NU - Fee on File Yes TRUSS, DOUBLE WITH STANDARD PADS 0 20 07/01/2019 12/31/9999 2 118.50L8320 NU - Fee on File Yes TRUSS, ADDITION TO STANDARD PAD,

WATER PAD0 20 07/01/2019 12/31/9999 2 51.75

L8330 NU - Fee on File Yes TRUSS, ADDITION TO STANDARD PAD, SCROTAL PAD

0 20 07/01/2019 12/31/9999 2 51.30

L8400 NU - Fee on File Yes PROSTHETIC SHEATH, BELOW KNEE, EACH

0 20 07/01/2019 12/31/9999 24 15.00

L8410 NU - Fee on File Yes PROSTHETIC SHEATH, ABOVE KNEE, EACH

0 20 07/01/2019 12/31/9999 24 17.06

L8415 NU - Fee on File Yes PROSTHETIC SHEATH,UPPER LIMB,EACH 0 20 07/01/2019 12/31/9999 24 16.96L8417 NU - Fee on File Yes PROSTHETIC SHEATH/SOCK, INCLUDING

A GEL CUSHION LAYER, BELOW KNEE OR ABO

0 20 07/01/2019 12/31/9999 3 60.17

L8420 NU - Fee on File Yes PROSTHETIC SOCK, MULTIPLE PLY, BELOW KNEE, EACH PROSTHETIC SOCK, MULTIPL

0 20 07/01/2019 12/31/9999 24 19.83

L8430 NU - Fee on File Yes PROSTHETIC SOCK, MULTIPLE PLY, ABOVE KNEE, EACH PROSTHETIC SOCK, MULTIPL

0 20 07/01/2019 12/31/9999 24 21.80

L8435 NU - Fee on File Yes PROSTHETIC SOCK, MULTIPLE PLY, UPPER LIMB, EACH PROSTHETIC SOCK, MULTIP

0 20 07/01/2019 12/31/9999 24 19.57

L8440 NU - Fee on File Yes PROSTHETIC SHRINKER, BELOW KNEE, EACH

0 20 07/01/2019 12/31/9999 10 41.49

L8460 NU - Fee on File Yes PROSTHETIC SHRINKER, ABOVE KNEE, EACH

0 20 07/01/2019 12/31/9999 10 57.74

L8465 NU - Fee on File Yes PROSTHETIC SHRINKER,UPPER LIMB,EACH

0 20 07/01/2019 12/31/9999 10 51.46

L8470 NU - Fee on File Yes PROSTHETIC SOCK, SINGLE PLY, FITTING, BELOW KNEE, EACH

0 20 07/01/2019 12/31/9999 12 5.28

L8480 NU - Fee on File Yes PROSTHETIC SOCK, SINGLE PLY, FITTING, ABOVE KNEE, EACH

0 20 07/01/2019 12/31/9999 12 7.28

L8485 NU - Fee on File Yes PROSTHETIC SOCK, SINGLE PLY, FITTING, UPPER LIMB, EACH

0 20 07/01/2019 12/31/9999 12 8.80

L8500 NU - Fee on File Yes ARTIFICIAL LARYNX, ANY TYPE 0 20 07/01/2019 12/31/9999 2 522.20L8501 NU - Fee on File Yes TRACHEOSTOMY SPEAKING VALVE 0 20 07/01/2019 12/31/9999 1 115.98L8615 NU - Fee on File Yes HEADSET/HEADPIECE FOR USE WITH

COCHLEAR IMPLANT DEVICE, REPLACEMENT

0 999 07/01/2019 12/31/9999 1 360.89

L8616 NU - Fee on File Yes MICROPHONE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT

0 999 07/01/2019 12/31/9999 1 84.06

L8617 NU - Fee on File Yes TRANSMITTING COIL FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT

0 999 07/01/2019 12/31/9999 1 73.44

L8618 NU - Fee on File Yes TRANSMITTER CABLE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT

0 999 07/01/2019 12/31/9999 1 20.98

L8619 NU - Fee on File Yes COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR AND CONTROLLER, INTEGRATED SYSTEM,

0 999 07/01/2019 12/31/9999 2 6,498.14

L8619 UE - Fee on File Yes COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR AND CONTROLLER, INTEGRATED SYSTEM,

0 999 07/01/2019 12/31/9999 2 3,249.07

L8621 NU - Fee on File Yes ZINC AIR BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT, EACH

0 999 07/01/2019 12/31/9999 300 0.49

L8622 NU - Fee on File Yes ALKALINE BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, ANY SIZE, REPLACEMENT

0 999 07/01/2019 12/31/9999 1 0.26

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL8623 NU - Fee on File Yes LITHIUM ION BATTERY FOR USE WITH

COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR, OTHER THAN EAR LEVEL, REPLACEMENT, EACH

0 999 07/01/2019 12/31/9999 4 51.75

L8624 NU - Fee on File Yes LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOOR, EAR LEVEL, REPLACEMENT, EACH

0 999 07/01/2019 12/31/9999 4 129.02

L8625 NU - Fee on File Yes EXTERNAL RECHARGING SYSTEM FOR BATTERY FOR USE WITH COCHLEAR IMPLANT OR AUDITORY OSSEOINTEGRATED DEVICE, REPLACEMENT ONLY, EACH

0 999 07/01/2019 12/31/9999 1 151.13

L8627 NU - Fee on File Yes COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR, COMPONENT, REPLACEMENT

0 999 07/01/2019 12/31/9999 1 5,508.26

L8628 NU - Fee on File Yes COCHLEAR IMPLANT, EXTERNAL CONTROLLER COMPONENT, REPLACEMENT

0 999 07/01/2019 12/31/9999 1 989.89

L8629 NU - Fee on File Yes TRANSMITTING COIL AND CABLE, INTEGRATED, FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT

0 999 07/01/2019 12/31/9999 1 143.27

L8679 NU - Fee on File Yes IMPLANTABLE NEUROSTIMULATOR, PULSE GENERATOR, ANY TYPE

0 20 07/01/2019 12/31/9999 1 6,676.67

L8691 NU - Fee on File Yes AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, REPLACEMENT

5 999 07/01/2019 12/31/9999 1 1,378.02

L8693 NU - Fee on File Yes AUDITORY OSSEOINTEGRATED DEVICE ABUTMENT, ANY LENGTH, REPLACEMENT ONLY

5 999 07/01/2019 12/31/9999 2 1,213.32

L8694 NU - Fee on File Yes AUDITORY OSSEOINTEGRATED DEVICE, TRANSDUCER/ACTUATOR, REPLACEMENT ONLY, EACH

5 999 07/01/2019 12/31/9999 1 755.68

L9900 NU - Priced by PA Yes ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF A

0 20 05/01/2004 12/31/9999 1 0.00

Q0496 NU - Fee on File Yes BATTERY, OTHER THAN LITHIUM-ION, FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY

0 999 07/01/2019 12/31/9999 1 1,199.64

S8185 NU - Priced by PA Yes FLUTTER DEVICE 0 20 05/01/2006 12/31/9999 1 0.00

3,155.65L8692 NU - Fee on File Yes AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, USED WITHOUT OSSEOINTEGRATION BODY

0 999 04/01/2020 12/31/9999 1

dme-orthotic-prosthetic fee schedule effective … · 01/01/2020 · e0110 nu - fee on file yes...

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