Kevin Orthopedic _ AFO By State Fee Schedule
 Share
The version of the browser you are using is no longer supported. Please upgrade to a supported browser.Dismiss

View only
 
 
 
ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAFAGAHAIAJAKALAMANAOAPAQARASATAUAVAWAXAYAZBABBBCBDBEBFBGBHBIBJBKBLBMBNBOBPBQBRBSBTBUBVBWBXBYBZCACBCCCDCECFCGCHCICJCKCLCMCNCOCPCQCRCSCTCUCV
1
AFO Product DMEPOS By State Fee Schedule January 2020 Fee Schedule
2
HCPCSDescriptionCeilingFloor
CA MEDI-CAL
AL (NR)
AL (R)
AR (NR)
AR (R)
AZ (NR)
AZ (R)
CA (NR)
CA (R)
CO (NR)
CO (R)
CT (NR)
CT (R)
DC (NR)
DC (R)
DE (NR)
DE (R)
FL (NR)
FL (R)
GA (NR)
GA (R)
IA (NR)
IA (R)
ID (NR)
ID (R)
IL (NR)
IL (R)
IN (NR)
IN (R)
KS (NR)
KS (R)
KY (NR)
KY (R)
LA (NR)
LA (R)
MA (NR)
MA (R)
MD (NR)
MD (R)
ME (NR)
ME (R)
MI (NR)
MI (R)
MN (NR)
MN (R)
MO (NR)
MO (R)
MS (NR)
MS (R)
MT (NR)
MT (R)
NC (NR)
NC (R)
ND (NR)
ND (R)
NE (NR)
NE (R)
NH (NR)
NH (R)
NJ (NR)
NJ (R)
NM (NR)
NM (R)
NV (NR)
NV (R)
NY (NR)
NY (R)
OH (NR)
OH (R)
OK (NR)
OK (R)
OR (NR)
OR (R)
PA (NR)
PA (R)
RI (NR)
RI (R)
SC (NR)
SC (R)
SD (NR)
SD (R)
TN (NR)
TN (R)
TX (NR)
TX (R)
UT (NR)
UT (R)
VA (NR)
VA (R)
VT (NR)
VT (R)
WA (NR)
WA (R)
WI (NR)
3
XTERN
4
L1951Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment1002.14751.61527.93845.920.00845.840.000.000.00821.190.00850.590.00821.190.00821.190.00821.190.00845.920.00845.920.00837.220.00821.190.00841.340.00841.340.00837.220.00845.920.00845.840.00821.190.00821.190.00821.190.00841.340.00841.340.00837.220.00838.370.00850.590.00845.920.00850.590.00837.220.00821.190.00821.190.00845.840.00821.190.00821.190.00841.340.00845.840.00821.190.00821.190.00821.190.00845.920.00850.590.00845.920.00845.840.00850.590.00821.190.00821.190.00821.190.00841.34
5
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
6
Total HCPCS1110.60832.96597.66927.270.00927.190.00108.460.00929.650.00959.050.00929.210.00902.540.00902.540.00927.270.00927.270.00918.570.00902.540.00922.690.00922.690.00918.570.00927.270.00927.190.00929.210.00902.540.00929.210.00922.690.00922.690.00918.570.00919.720.00959.050.00927.270.00959.050.00918.570.00929.210.00914.610.00927.190.00929.650.00914.610.00922.690.00927.190.00902.540.00902.540.00929.210.00927.270.00959.050.00927.270.00927.190.00959.050.00902.540.00929.210.00902.540.00922.69
7
8
A200
Tamarack Free
Motion
9
L1970Ankle foot orthosis, plastic with ankle joint, custom fabricated888.74666.55449.2839.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.080.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.73
10
L2275Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined156.65117.4872.37122.410.00122.400.00146.510.00146.510.00139.540.00123.330.00121.950.00121.950.00122.410.00122.410.00149.360.00146.510.00130.590.00130.590.00149.360.00122.410.00122.400.00123.330.00121.950.00123.330.00130.590.00130.590.00149.360.00122.410.00139.540.00122.410.00139.540.00149.360.00123.330.00118.070.00122.400.00146.510.00118.070.00130.590.00122.400.00146.510.00121.950.00123.330.00122.410.00139.540.00122.410.00122.400.00139.540.00121.950.00123.330.00146.510.00130.59
11
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
12
Total HCPCS1153.85865.38591.38243.490.00243.480.00294.030.00294.030.00287.730.00271.080.00243.030.00243.030.00243.490.00243.490.00269.770.00266.920.00251.670.00251.670.00269.770.00243.490.00243.480.00271.080.00243.030.00271.080.00251.670.00251.670.00270.440.00243.490.00287.080.00243.490.00287.060.00269.770.00271.080.00251.220.00243.480.00294.030.00251.220.00251.670.00243.480.00266.920.00243.030.00271.080.00243.490.00287.060.00243.490.00243.480.00287.730.00243.030.00271.080.00267.590.00251.67
13
14
A200L
Tamarack
Free Motion Calf
Lacer
15
L1970Ankle foot orthosis, plastic with ankle joint, custom fabricated888.74666.55449.2839.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.080.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.73
16
L2275Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined156.65117.4872.37122.410.00122.400.00146.510.00146.510.00139.540.00123.330.00121.950.00121.950.00122.410.00122.410.00149.360.00146.510.00130.590.00130.590.00149.360.00122.410.00122.400.00123.330.00121.950.00123.330.00130.590.00130.590.00149.360.00122.410.00139.540.00122.410.00139.540.00149.360.00123.330.00118.070.00122.400.00146.510.00118.070.00130.590.00122.400.00146.510.00121.950.00123.330.00122.410.00139.540.00122.410.00122.400.00139.540.00121.950.00123.330.00146.510.00130.59
17
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.490.43367.82206.53367.820.00389.840.00490.430.00490.430.00405.410.00411.610.00403.450.00403.450.00367.820.00367.820.00389.830.00435.170.00367.820.00367.820.00389.830.00367.820.00389.840.00411.610.00403.450.00411.610.00367.820.00367.820.00389.830.00367.820.00405.410.00367.820.00405.410.00389.830.00411.610.00490.430.00389.840.00490.430.00490.430.00367.820.00389.840.00435.170.00403.450.00411.610.00367.820.00405.410.00367.820.00389.840.00405.410.00403.450.00411.610.00435.170.00367.82
18
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
19
Total HCPCS797.91611.310.00633.320.00784.460.00784.460.00693.140.00682.690.00646.480.00646.480.00611.310.00611.310.00659.600.00702.090.00619.490.00619.490.00659.600.00611.310.00633.320.00682.690.00646.480.00682.690.00619.490.00619.490.00660.270.00611.310.00692.490.00611.310.00692.470.00659.600.00682.690.00741.650.00633.320.00784.460.00741.650.00619.490.00633.320.00702.090.00646.480.00682.690.00611.310.00692.470.00611.310.00633.320.00693.140.00646.480.00682.690.00702.760.00619.49
20
21
A250
Overlap Free
Motion
22
L1970Ankle foot orthosis, plastic with ankle joint, custom fabricated888.74666.55449.2839.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.080.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.73
23
L2275Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined156.65117.4872.37122.410.00122.400.00146.510.00146.510.00139.540.00123.330.00121.950.00121.950.00122.410.00122.410.00149.360.00146.510.00130.590.00130.590.00149.360.00122.410.00122.400.00123.330.00121.950.00123.330.00130.590.00130.590.00149.360.00122.410.00139.540.00122.410.00139.540.00149.360.00123.330.00118.070.00122.400.00146.510.00118.070.00130.590.00122.400.00146.510.00121.950.00123.330.00122.410.00139.540.00122.410.00122.400.00139.540.00121.950.00123.330.00146.510.00130.59
24
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
25
Total HCPCS1153.85865.38591.38243.490.00243.480.00294.030.00294.030.00287.730.00271.080.00243.030.00243.030.00243.490.00243.490.00269.770.00266.920.00251.670.00251.670.00269.770.00243.490.00243.480.00271.080.00243.030.00271.080.00251.670.00251.670.00270.440.00243.490.00287.080.00243.490.00287.060.00269.770.00271.080.00251.220.00243.480.00294.030.00251.220.00251.670.00243.480.00266.920.00243.030.00271.080.00243.490.00287.060.00243.490.00243.480.00287.730.00243.030.00271.080.00267.590.00251.67
26
27
A300
Tamarack
Dorsi-Assist
28
L1970Ankle foot orthosis, plastic with ankle joint, custom fabricated888.74666.55449.2839.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.080.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.73
29
L2275Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined156.65117.4872.37122.410.00122.400.00146.510.00146.510.00139.540.00123.330.00121.950.00121.950.00122.410.00122.410.00149.360.00146.510.00130.590.00130.590.00149.360.00122.410.00122.400.00123.330.00121.950.00123.330.00130.590.00130.590.00149.360.00122.410.00139.540.00122.410.00139.540.00149.360.00123.330.00118.070.00122.400.00146.510.00118.070.00130.590.00122.400.00146.510.00121.950.00123.330.00122.410.00139.540.00122.410.00122.400.00139.540.00121.950.00123.330.00146.510.00130.59
30
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
31
L2210Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint.83.9662.9730.8072.260.0062.970.0083.960.0083.960.0083.960.0062.970.0064.470.0064.470.0072.260.0072.260.0062.970.0066.010.0062.970.0062.970.0062.970.0072.260.0062.970.0062.970.0064.470.0062.970.0062.970.0062.970.0062.970.0072.260.0083.960.0072.260.0083.960.0062.970.0062.970.0068.810.0062.970.0083.960.0068.810.0062.970.0062.970.0066.010.0064.470.0062.970.0072.260.0083.960.0072.260.0062.970.0083.960.0064.470.0062.970.0066.010.0062.97
32
L2210Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint.83.9662.9730.8072.260.0062.970.0083.960.0083.960.0083.960.0062.970.0064.470.0064.470.0072.260.0072.260.0062.970.0066.010.0062.970.0062.970.0062.970.0072.260.0062.970.0062.970.0064.470.0062.970.0062.970.0062.970.0062.970.0072.260.0083.960.0072.260.0083.960.0062.970.0062.970.0068.810.0062.970.0083.960.0068.810.0062.970.0062.970.0066.010.0064.470.0062.970.0072.260.0083.960.0072.260.0062.970.0083.960.0064.470.0062.970.0066.010.0062.97
33
Total HCPCS1321.77991.32652.98388.010.00369.420.00461.950.00461.950.00455.650.00397.020.00371.970.00371.970.00388.010.00388.010.00395.710.00398.940.00377.610.00377.610.00395.710.00388.010.00369.420.00397.020.00371.970.00397.020.00377.610.00377.610.00396.380.00388.010.00455.000.00388.010.00454.980.00395.710.00397.020.00388.840.00369.420.00461.950.00388.840.00377.610.00369.420.00398.940.00371.970.00397.020.00388.010.00454.980.00388.010.00369.420.00455.650.00371.970.00397.020.00399.610.00377.61
34
35
G50Cabbie
36
L1907Ankle foot orthosis, plastic or other material, custom fabricated.671.44503,58353.71566.770.00566.730.00550.200.00550.200.00569.890.00550.200.00550.200.00550.200.00566.770.00566.770.00560.910.00550.200.00563.730.00563.730.00560.910.00566.770.00566.730.00550.200.00550.200.00550.200.00563.730.00563.730.00560.910.00566.770.00569.890.00566.770.00569.890.00560.910.00550.200.00550.200.00566.730.00550.200.00550.200.00563.730.00566.730.00550.200.00550.200.00550.200.00566.770.00569.890.00566.770.00566.730.00569.890.00550.200.00550.200.00550.200.00563.73
37
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.490.43367,82206.52367.820.00389.840.00490.430.00490.430.00405.410.00411.610.00403.450.00403.450.00367.820.00367.820.00389.830.00435.170.00367.820.00367.820.00389.830.00367.820.00389.840.00411.610.00403.450.00411.610.00367.820.00367.820.00389.830.00367.820.00405.410.00367.820.00405.410.00389.830.00411.610.00490.430.00389.840.00490.430.00490.430.00367.820.00389.840.00435.170.00403.450.00411.610.00367.820.00405.410.00367.820.00389.840.00405.410.00403.450.00411.610.00435.170.00367.82
38
Total HCPCS1161.870.00560.23934.590.00956.570.001040.630.001040.630.00975.300.00961.810.00953.650.00953.650.00934.590.00934.590.00950.740.00985.370.00931.550.00931.550.00950.740.00934.590.00956.570.00961.810.00953.650.00961.810.00931.550.00931.550.00950.740.00934.590.00975.300.00934.590.00975.300.00950.740.00961.810.001040.630.00956.570.001040.630.001040.630.00931.550.00956.570.00985.370.00953.650.00961.810.00934.590.00975.300.00934.590.00956.570.00975.300.00953.650.00961.810.00985.370.00931.55
39
0.000.00ž
40
G100Short
41
L1940Ankle foot orthosis, plastic or other material, custom fabricated.617.68463.26347.88500.790.00474.330.00617.680.00617.680.00463.260.00617.680.00463.260.00463.260.00500.790.00500.790.00507.310.00497.660.00487.860.00487.860.00507.310.00500.790.00474.330.00617.680.00463.260.00617.680.00487.860.00487.860.00507.310.00500.790.00463.260.00500.790.00463.260.00507.310.00617.680.00588.040.00474.330.00617.680.00588.040.00487.860.00474.330.00497.660.00463.260.00617.680.00500.790.00463.260.00500.790.00474.330.00463.260.00463.260.00617.680.00497.660.00487.86
42
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
43
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.490.43367.82206.53367.820.00389.840.00490.430.00490.430.00405.410.00411.610.00403.450.00403.450.00367.820.00367.820.00389.830.00435.170.00367.820.00367.820.00389.830.00367.820.00389.840.00411.610.00403.450.00411.610.00367.820.00367.820.00389.830.00367.820.00405.410.00367.820.00405.410.00389.830.00411.610.00490.430.00389.840.00490.430.00490.430.00367.820.00389.840.00435.170.00403.450.00411.610.00367.820.00405.410.00367.820.00389.840.00405.410.00403.450.00411.610.00435.170.00367.82
44
Total HCPCS1216.57912.43624.14949.960.00945.520.001216.570.001216.570.00977.130.001137.310.00948.060.00948.060.00949.960.00949.960.00978.490.001014.180.00937.030.00937.030.00978.490.00949.960.00945.520.001137.310.00948.060.001137.310.00937.030.00937.030.00978.490.00949.960.00977.130.00949.960.00977.130.00978.490.001137.310.001171.890.00945.520.001216.570.001171.890.00937.030.00945.520.001014.180.00948.060.001137.310.00949.960.00977.130.00949.960.00945.520.00977.130.00948.060.001137.310.001014.180.00937.03
45
46
G120Standard
47
L1940Ankle foot orthosis, plastic or other material, custom fabricated.617.68463.26347.88500.790.00474.330.00617.680.00617.680.00463.260.00617.680.00463.260.00463.260.00500.790.00500.790.00507.310.00497.660.00487.860.00487.860.00507.310.00500.790.00474.330.00617.680.00463.260.00617.680.00487.860.00487.860.00507.310.00500.790.00463.260.00500.790.00463.260.00507.310.00617.680.00588.040.00474.330.00617.680.00588.040.00487.860.00474.330.00497.660.00463.260.00617.680.00500.790.00463.260.00500.790.00474.330.00463.260.00463.260.00617.680.00497.660.00487.86
48
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
49
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.490.43367.82206.53367.820.00389.840.00490.430.00490.430.00405.410.00411.610.00403.450.00403.450.00367.820.00367.820.00389.830.00435.170.00367.820.00367.820.00389.830.00367.820.00389.840.00411.610.00403.450.00411.610.00367.820.00367.820.00389.830.00367.820.00405.410.00367.820.00405.410.00389.830.00411.610.00490.430.00389.840.00490.430.00490.430.00367.820.00389.840.00435.170.00403.450.00411.610.00367.820.00405.410.00367.820.00389.840.00405.410.00403.450.00411.610.00435.170.00367.82
50
Total HCPCS1216.57912.43624.14949.960.00945.520.001216.570.001216.570.00977.130.001137.310.00948.060.00948.060.00949.960.00949.960.00978.490.001014.180.00937.030.00937.030.00978.490.00949.960.00945.520.001137.310.00948.060.001137.310.00937.030.00937.030.00978.490.00949.960.00977.130.00949.960.00977.130.00978.490.001137.310.001171.890.00945.520.001216.570.001171.890.00937.030.00945.520.001014.180.00948.060.001137.310.00949.960.00977.130.00949.960.00945.520.00977.130.00948.060.001137.310.001014.180.00937.03
51
52
G140Tall
53
L1940Ankle foot orthosis, plastic or other material, custom fabricated.617.68463.26347.88500.790.00474.330.00617.680.00617.680.00463.260.00617.680.00463.260.00463.260.00500.790.00500.790.00507.310.00497.660.00487.860.00487.860.00507.310.00500.790.00474.330.00617.680.00463.260.00617.680.00487.860.00487.860.00507.310.00500.790.00463.260.00500.790.00463.260.00507.310.00617.680.00588.040.00474.330.00617.680.00588.040.00487.860.00474.330.00497.660.00463.260.00617.680.00500.790.00463.260.00500.790.00474.330.00463.260.00463.260.00617.680.00497.660.00487.86
54
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
55
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.490.43367.82206.53367.820.00389.840.00490.430.00490.430.00405.410.00411.610.00403.450.00403.450.00367.820.00367.820.00389.830.00435.170.00367.820.00367.820.00389.830.00367.820.00389.840.00411.610.00403.450.00411.610.00367.820.00367.820.00389.830.00367.820.00405.410.00367.820.00405.410.00389.830.00411.610.00490.430.00389.840.00490.430.00490.430.00367.820.00389.840.00435.170.00403.450.00411.610.00367.820.00405.410.00367.820.00389.840.00405.410.00403.450.00411.610.00435.170.00367.82
56
Total HCPCS1216.57912.43624.14949.960.00945.520.001216.570.001216.570.00977.130.001137.310.00948.060.00948.060.00949.960.00949.960.00978.490.001014.180.00937.030.00937.030.00978.490.00949.960.00945.520.001137.310.00948.060.001137.310.00937.030.00937.030.00978.490.00949.960.00977.130.00949.960.00977.130.00978.490.001137.310.001171.890.00945.520.001216.570.001171.890.00937.030.00945.520.001014.180.00948.060.001137.310.00949.960.00977.130.00949.960.00945.520.00977.130.00948.060.001137.310.001014.180.00937.03
57
58
G200
Tamarack
Free Motion
59
L1970Ankle foot orthosis, plastic with ankle joint, custom fabricated888.74666.55449.2839.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.080.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.73
60
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
61
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.490.43367.82206.53367.820.00389.840.00490.430.00490.430.00405.410.00411.610.00403.450.00403.450.00367.820.00367.820.00389.830.00435.170.00367.820.00367.820.00389.830.00367.820.00389.840.00411.610.00403.450.00411.610.00367.820.00367.820.00389.830.00367.820.00405.410.00367.820.00405.410.00389.830.00411.610.00490.430.00389.840.00490.430.00490.430.00367.820.00389.840.00435.170.00403.450.00411.610.00367.820.00405.410.00367.820.00389.840.00405.410.00403.450.00411.610.00435.170.00367.82
62
Total HCPCS1487.631115.72725.54488.900.00510.920.00637.950.00637.950.00553.600.00559.360.00524.530.00524.530.00488.900.00488.900.00510.240.00555.580.00488.900.00488.900.00510.240.00488.900.00510.920.00559.360.00524.530.00559.360.00488.900.00488.900.00510.910.00488.900.00552.950.00488.900.00552.930.00510.240.00559.360.00623.580.00510.920.00637.950.00623.580.00488.900.00510.920.00555.580.00524.530.00559.360.00488.900.00552.930.00488.900.00510.920.00553.600.00524.530.00559.360.00556.250.00488.90
63
64
G250
Overlapping
Articulating Gauntlet
65
L1970Ankle foot orthosis, plastic with ankle joint, custom fabricated888.74666.55449.2839.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.080.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.73
66
L2275Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined156.65117.4872.37122.410.00122.400.00146.510.00146.510.00139.540.00123.330.00121.950.00121.950.00122.410.00122.410.00149.360.00146.510.00130.590.00130.590.00149.360.00122.410.00122.400.00123.330.00121.950.00123.330.00130.590.00130.590.00149.360.00122.410.00139.540.00122.410.00139.540.00149.360.00123.330.00118.070.00122.400.00146.510.00118.070.00130.590.00122.400.00146.510.00121.950.00123.330.00122.410.00139.540.00122.410.00122.400.00139.540.00121.950.00123.330.00146.510.00130.59
67
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.490.43367.82206.53367.820.00389.840.00490.430.00490.430.00405.410.00411.610.00403.450.00403.450.00367.820.00367.820.00389.830.00435.170.00367.820.00367.820.00389.830.00367.820.00389.840.00411.610.00403.450.00411.610.00367.820.00367.820.00389.830.00367.820.00405.410.00367.820.00405.410.00389.830.00411.610.00490.430.00389.840.00490.430.00490.430.00367.820.00389.840.00435.170.00403.450.00411.610.00367.820.00405.410.00367.820.00389.840.00405.410.00403.450.00411.610.00435.170.00367.82
68
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
69
Total HCPCS1644.281233.20797.91611.310.00633.320.00784.460.00784.460.00693.140.00682.690.00646.480.00646.480.00611.310.00611.310.00659.600.00702.090.00619.490.00619.490.00659.600.00611.310.00633.320.00682.690.00646.480.00682.690.00619.490.00619.490.00660.270.00611.310.00692.490.00611.310.00692.470.00659.600.00682.690.00741.650.00633.320.00784.460.00741.650.00619.490.00633.320.00702.090.00646.480.00682.690.00611.310.00692.470.00611.310.00633.320.00693.140.00646.480.00682.690.00702.760.00619.49
70
71
G300
Tamarack
Dorsi-Assist
72
L1970Ankle foot orthosis, plastic with ankle joint, custom fabricated888.74666.55449.2839.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.060.0039.060.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.080.0039.730.0039.060.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.060.0039.730.0039.730.0039.730.0039.730.0039.730.0039.730.0039.73
73
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
74
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.490.43367.82206.53367.820.00389.840.00490.430.00490.430.00405.410.00411.610.00403.450.00403.450.00367.820.00367.820.00389.830.00435.170.00367.820.00367.820.00389.830.00367.820.00389.840.00411.610.00403.450.00411.610.00367.820.00367.820.00389.830.00367.820.00405.410.00367.820.00405.410.00389.830.00411.610.00490.430.00389.840.00490.430.00490.430.00367.820.00389.840.00435.170.00403.450.00411.610.00367.820.00405.410.00367.820.00389.840.00405.410.00403.450.00411.610.00435.170.00367.82
75
L2210Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint83.9662.9730.8072.260.0062.970.0083.960.0083.960.0083.960.0062.970.0064.470.0064.470.0072.260.0072.260.0062.970.0066.010.0062.970.0062.970.0062.970.0072.260.0062.970.0062.970.0064.470.0062.970.0062.970.0062.970.0062.970.0072.260.0083.960.0072.260.0083.960.0062.970.0062.970.0068.810.0062.970.0083.960.0068.810.0062.970.0062.970.0066.010.0064.470.0062.970.0072.260.0083.960.0072.260.0062.970.0083.960.0064.470.0062.970.0066.010.0062.97
76
L2210Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint83.9662.9730.8072.260.0062.970.0083.960.0083.960.0083.960.0062.970.0064.470.0064.470.0072.260.0072.260.0062.970.0066.010.0062.970.0062.970.0062.970.0072.260.0062.970.0062.970.0064.470.0062.970.0062.970.0062.970.0062.970.0072.260.0083.960.0072.260.0083.960.0062.970.0062.970.0068.810.0062.970.0083.960.0068.810.0062.970.0062.970.0066.010.0064.470.0062.970.0072.260.0083.960.0072.260.0062.970.0083.960.0064.470.0062.970.0066.010.0062.97
77
Total HCPCS1655.551241.66787.14633.420.00636.860.00805.870.00805.870.00721.520.00685.300.00653.470.00653.470.00633.420.00633.420.00636.180.00687.600.00614.840.00614.840.00636.180.00633.420.00636.860.00685.300.00653.470.00685.300.00614.840.00614.840.00636.850.00633.420.00720.870.00633.420.00720.850.00636.180.00685.300.00761.200.00636.860.00805.870.00761.200.00614.840.00636.860.00687.600.00653.470.00685.300.00633.420.00720.850.00633.420.00636.860.00721.520.00653.470.00685.300.00688.270.00614.84
78
79
G600
Leather Partial
Foot
80
L1960Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated692.30519.23332.00519.230.00519.230.00692.300.00692.300.00519.230.00692.300.00553.880.00553.880.00519.230.00519.230.00519.230.00519.230.00621.010.00621.010.00519.230.00519.230.00519.230.00692.300.00553.880.00692.300.00621.010.00621.010.00519.230.00519.230.00519.230.00519.230.00519.230.00519.230.00692.300.00692.300.00519.230.00692.300.00692.300.00621.010.00519.230.00519.230.00553.880.00692.300.00519.230.00519.230.00519.230.00519.230.00519.230.00553.880.00692.300.00519.230.00621.01
81
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
82
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.490.43367.82206.53367.820.00389.840.00490.430.00490.430.00405.410.00411.610.00403.450.00403.450.00367.820.00367.820.00389.830.00435.170.00367.820.00367.820.00389.830.00367.820.00389.840.00411.610.00403.450.00411.610.00367.820.00367.820.00389.830.00367.820.00405.410.00367.820.00405.410.00389.830.00411.610.00490.430.00389.840.00490.430.00490.430.00367.820.00389.840.00435.170.00403.450.00411.610.00367.820.00405.410.00367.820.00389.840.00405.410.00403.450.00411.610.00435.170.00367.82
83
L5000Partial foot, shoe insert with longitudinal arch, toe filler672.31504.24195.45528.150.00672.310.00599.750.00599.750.00504.240.00504.240.00556.230.00556.230.00528.150.00528.150.00526.750.00504.240.00575.270.00575.270.00526.750.00528.150.00672.310.00504.240.00556.230.00504.240.00575.270.00575.270.00526.750.00528.150.00504.240.00528.150.00504.240.00526.750.00504.240.00504.240.00672.310.00599.750.00504.240.00575.270.00672.310.00504.240.00556.230.00504.240.00528.150.00504.240.00528.150.00672.310.00504.240.00556.230.00504.240.00504.240.00575.27
84
Total HCPCS1963.501472.64803.711496.550.001662.730.001890.940.001890.940.001537.340.001716.170.001594.910.001594.910.001496.550.001496.550.001517.160.001539.990.001645.450.001645.450.001517.160.001496.550.001662.730.001716.170.001594.910.001716.170.001645.450.001645.450.001517.160.001496.550.001537.340.001496.550.001537.340.001517.160.001716.170.001780.390.001662.730.001890.940.001780.390.001645.450.001662.730.001539.990.001594.910.001716.170.001496.550.001537.340.001496.550.001662.730.001537.340.001594.910.001716.170.001539.990.001645.45
85
86
87
G800Balance Brace
88
L1940Ankle foot orthosis, plastic or other material, custom fabricated.617.68463.26347.88500.790.00474.330.00617.680.00617.680.00463.260.00617.680.00463.260.00463.260.00500.790.00500.790.00507.310.00497.660.00487.860.00487.860.00507.310.00500.790.00474.330.00617.680.00463.260.00617.680.00487.860.00487.860.00507.310.00500.790.00463.260.00500.790.00463.260.00507.310.00617.680.00588.040.00474.330.00617.680.00588.040.00487.860.00474.330.00497.660.00463.260.00617.680.00500.790.00463.260.00500.790.00474.330.00463.260.00463.260.00617.680.00497.660.00487.86
89
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section108.4681.3569.7381.350.0081.350.00108.460.00108.460.00108.460.00108.020.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.020.0081.350.0081.350.0081.350.0081.350.00108.460.0081.350.00108.460.0081.350.00108.020.0093.420.0081.350.00108.460.0093.420.0081.350.0081.350.0081.350.0081.350.00108.020.0081.350.00108.460.0081.350.0081.350.00108.460.0081.350.00108.020.0081.350.0081.35
90
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.490.43367.82206.53367.820.00389.840.00490.430.00490.430.00405.410.00411.610.00403.450.00403.450.00367.820.00367.820.00389.830.00435.170.00367.820.00367.820.00389.830.00367.820.00389.840.00411.610.00403.450.00411.610.00367.820.00367.820.00389.830.00367.820.00405.410.00367.820.00405.410.00389.830.00411.610.00490.430.00389.840.00490.430.00490.430.00367.820.00389.840.00435.170.00403.450.00411.610.00367.820.00405.410.00367.820.00389.840.00405.410.00403.450.00411.610.00435.170.00367.82
91
Total HCPCS1216.57912.43624.14949.960.00945.520.001216.570.001216.570.00977.130.001137.310.00948.060.00948.060.00949.960.00949.960.00978.490.001014.180.00937.030.00937.030.00978.490.00949.960.00945.520.001137.310.00948.060.001137.310.00937.030.00937.030.00978.490.00949.960.00977.130.00949.960.00977.130.00978.490.001137.310.001171.890.00945.520.001216.570.001171.890.00937.030.00945.520.001014.180.00948.060.001137.310.00949.960.00977.130.00949.960.00945.520.00977.130.00948.060.001137.310.001014.180.00937.03
92
93
T100Leaf Spring
94
L1960Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated692.30519.23332.00519.230.00519.230.00692.300.00692.300.00519.230.00692.300.00553.880.00553.880.00519.230.00519.230.00519.230.00519.230.00621.010.00621.010.00519.230.00519.230.00519.230.00692.300.00553.880.00692.300.00621.010.00621.010.00519.230.00519.230.00519.230.00519.230.00519.230.00519.230.00692.300.00692.300.00519.230.00692.300.00692.300.00621.010.00519.230.00519.230.00553.880.00692.300.00519.230.00519.230.00519.230.00519.230.00519.230.00553.880.00692.300.00519.230.00621.01
95
L2275Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined156.65117.4872.37122.410.00122.400.00146.510.00146.510.00139.540.00123.330.00121.950.00121.950.00122.410.00122.410.00149.360.00146.510.00130.590.00130.590.00149.360.00122.410.00122.400.00123.330.00121.950.00123.330.00130.590.00130.590.00149.360.00122.410.00139.540.00122.410.00139.540.00149.360.00123.330.00118.070.00122.400.00146.510.00118.070.00130.590.00122.400.00146.510.00121.950.00123.330.00122.410.00139.540.00122.410.00122.400.00139.540.00121.950.00123.330.00146.510.00130.59
96
Total HCPCS848.95636.71404.37641.640.00641.630.00838.810.00838.810.00658.770.00815.630.00675.830.00675.830.00641.640.00641.640.00668.590.00665.740.00751.600.00751.600.00668.590.00641.640.00641.630.00815.630.00675.830.00815.630.00751.600.00751.600.00668.590.00641.640.00658.770.00641.640.00658.770.00668.590.00815.630.00810.370.00641.630.00838.810.00810.370.00751.600.00641.630.00665.740.00675.830.00815.630.00641.640.00658.770.00641.640.00641.630.00658.770.00675.830.00815.630.00665.740.00751.60
97
98
T150Solid Ankle
99
L1960Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated692.30519.23332.00519.230.00519.230.00692.300.00692.300.00519.230.00692.300.00553.880.00553.880.00519.230.00519.230.00519.230.00519.230.00621.010.00621.010.00519.230.00519.230.00519.230.00692.300.00553.880.00692.300.00621.010.00621.010.00519.230.00519.230.00519.230.00519.230.00519.230.00519.230.00692.300.00692.300.00519.230.00692.300.00692.300.00621.010.00519.230.00519.230.00553.880.00692.300.00519.230.00519.230.00519.230.00519.230.00519.230.00553.880.00692.300.00519.230.00621.01
100
L2275Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined156.65117.4872.37122.410.00122.400.00146.510.00146.510.00139.540.00123.330.00121.950.00121.950.00122.410.00122.410.00149.360.00146.510.00130.590.00130.590.00149.360.00122.410.00122.400.00123.330.00121.950.00123.330.00130.590.00130.590.00149.360.00122.410.00139.540.00122.410.00139.540.00149.360.00123.330.00118.070.00122.400.00146.510.00118.070.00130.590.00122.400.00146.510.00121.950.00123.330.00122.410.00139.540.00122.410.00122.400.00139.540.00121.950.00123.330.00146.510.00130.59