Kevin Orthopedic _ AFO By State Fee Schedule
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1
AFO Product DMEPOS By State Fee Schedule January 2019 Fee Schedule
2
HCPCSDescriptionCeilingFloor
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)
WI (R)
3
XTERN
4
L1951
Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment
993.21744.90838.370.00838.300.00813.870.00813.870.00843.000.00813.870.00813.870.00813.870.00838.370.00838.370.00829.750.00813.870.00833.840.00833.840.00829.750.00838.370.00838.300.00813.870.00813.870.00813.870.00833.840.00833.840.00829.750.00838.370.00843.000.00838.370.00843.000.00829.750.00813.870.00813.870.00838.300.00813.870.00813.870.00833.840.00838.300.00813.870.00813.870.00813.870.00838.370.00843.000.00838.370.00838.300.00843.000.00813.870.00813.870.00813.870.00833.840.00
5
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
6
Total HCPCS1100.71825.52918.990.00918.920.00921.370.00921.370.00950.500.00920.930.00894.490.00894.490.00918.990.00918.990.00910.370.00894.490.00914.460.00914.460.00910.370.00918.990.00918.920.00920.930.00894.490.00920.930.00914.460.00914.460.00910.370.00918.990.00950.500.00918.990.00950.500.00910.370.00920.930.00906.460.00918.920.00921.370.00906.460.00914.460.00918.920.00894.490.00894.490.00920.930.00918.990.00950.500.00918.990.00918.920.00950.500.00894.490.00920.930.00894.490.00914.460.00
7
8
A200
Tamarack Free
Motion
9
L1970
Ankle foot orthosis, plastic with ankle joint, custom fabricated
880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
10
L2275
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
11
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
12
Total HCPCS1143.56857.67963.060.00862.540.00970.140.00970.140.00939.810.001110.100.00862.090.00862.090.00963.060.00963.060.001018.260.00912.550.00897.260.00897.260.001018.260.00963.060.00862.540.001110.100.00862.090.001110.100.00897.260.00897.260.001018.260.00963.060.00939.810.00963.060.00939.810.001018.260.001110.100.001085.790.00862.540.00970.140.001085.790.00897.260.00862.540.00912.550.00862.090.001110.100.00963.060.00939.810.00963.060.00862.540.00939.810.00862.090.001110.100.00912.550.00897.260.00
13
14
A200L
Tamarack
Free Motion Calf
Lacer
15
L1970
Ankle foot orthosis, plastic with ankle joint, custom fabricated
880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
16
L2275
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
17
L2330
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.
486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
18
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
19
Total HCPCS1327.600.001248.900.001456.190.001456.190.001341.600.001518.040.001261.940.001261.940.001327.600.001327.600.001404.610.001343.840.001261.800.001261.800.001404.610.001327.600.001248.900.001518.040.001261.940.001518.040.001261.800.001261.800.001404.610.001327.600.001341.600.001327.600.001341.600.001404.610.001518.040.001571.840.001248.900.001456.190.001571.840.001261.800.001248.900.001343.840.001261.940.001518.040.001327.600.001341.600.001327.600.001248.900.001341.600.001261.940.001518.040.001343.840.001261.800.00
20
21
A250
Overlap Free
Motion
22
L1970
Ankle foot orthosis, plastic with ankle joint, custom fabricated
880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
23
L2275
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
24
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
25
Total HCPCS1143.56857.67963.060.00862.540.00970.140.00970.140.00939.810.001110.100.00862.090.00862.090.00963.060.00963.060.001018.260.00912.550.00897.260.00897.260.001018.260.00963.060.00862.540.001110.100.00862.090.001110.100.00897.260.00897.260.001018.260.00963.060.00939.810.00963.060.00939.810.001018.260.001110.100.001085.790.00862.540.00970.140.001085.790.00897.260.00862.540.00912.550.00862.090.001110.100.00963.060.00939.810.00963.060.00862.540.00939.810.00862.090.001110.100.00912.550.00897.260.00
26
27
A300
Tamarack
Dorsi-Assist
28
L1970
Ankle foot orthosis, plastic with ankle joint, custom fabricated
880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
29
L2275
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
30
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
31
L2210
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint.
83.2162.4171.620.0062.410.0083.210.0083.210.0083.210.0062.410.0063.890.0063.890.0071.620.0071.620.0062.410.0065.420.0062.410.0062.410.0062.410.0071.620.0062.410.0062.410.0063.890.0062.410.0062.410.0062.410.0062.410.0071.620.0083.210.0071.620.0083.210.0062.410.0062.410.0068.200.0062.410.0083.210.0068.200.0062.410.0062.410.0065.420.0063.890.0062.410.0071.620.0083.210.0071.620.0062.410.0083.210.0063.890.0062.410.0065.420.0062.410.00
32
L2210
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint.
83.2162.4171.620.0062.410.0083.210.0083.210.0083.210.0062.410.0063.890.0063.890.0071.620.0071.620.0062.410.0065.420.0062.410.0062.410.0062.410.0071.620.0062.410.0062.410.0063.890.0062.410.0062.410.0062.410.0062.410.0071.620.0083.210.0071.620.0083.210.0062.410.0062.410.0068.200.0062.410.0083.210.0068.200.0062.410.0062.410.0065.420.0063.890.0062.410.0071.620.0083.210.0071.620.0062.410.0083.210.0063.890.0062.410.0065.420.0062.410.00
33
Total HCPCS1309.98982.491106.300.00987.360.001136.560.001136.560.001106.230.001234.920.00989.870.00989.870.001106.300.001106.300.001143.080.001043.390.001022.080.001022.080.001143.080.001106.300.00987.360.001234.920.00989.870.001234.920.001022.080.001022.080.001143.080.001106.300.001106.230.001106.300.001106.230.001143.080.001234.920.001222.190.00987.360.001136.560.001222.190.001022.080.00987.360.001043.390.00989.870.001234.920.001106.300.001106.230.001106.300.00987.360.001106.230.00989.870.001234.920.001043.390.001022.080.00
34
35
G100Short
36
L1940
Ankle foot orthosis, plastic or other material, custom fabricated.
612.17459.13496.320.00470.100.00612.170.00612.170.00459.130.00612.170.00459.130.00459.130.00496.320.00496.320.00502.780.00493.220.00483.510.00483.510.00502.780.00496.320.00470.100.00612.170.00459.130.00612.170.00483.510.00483.510.00502.780.00496.320.00459.130.00496.320.00459.130.00502.780.00612.170.00582.790.00470.100.00612.170.00582.790.00483.510.00470.100.00493.220.00459.130.00612.170.00496.320.00459.130.00496.320.00470.100.00459.130.00459.130.00612.170.00493.220.00483.510.00
37
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
38
L2330
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.
486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
39
Total HCPCS1205.72904.29941.480.00937.080.001205.720.001205.720.00968.420.001127.170.00939.600.00939.600.00941.480.00941.480.00969.750.001005.130.00928.670.00928.670.00969.750.00941.480.00937.080.001127.170.00939.600.001127.170.00928.670.00928.670.00969.750.00941.480.00968.420.00941.480.00968.420.00969.750.001127.170.001161.430.00937.080.001205.720.001161.430.00928.670.00937.080.001005.130.00939.600.001127.170.00941.480.00968.420.00941.480.00937.080.00968.420.00939.600.001127.170.001005.130.00928.670.00
40
41
G120Standard
42
L1940
Ankle foot orthosis, plastic or other material, custom fabricated.
612.17459.13496.320.00470.100.00612.170.00612.170.00459.130.00612.170.00459.130.00459.130.00496.320.00496.320.00502.780.00493.220.00483.510.00483.510.00502.780.00496.320.00470.100.00612.170.00459.130.00612.170.00483.510.00483.510.00502.780.00496.320.00459.130.00496.320.00459.130.00502.780.00612.170.00582.790.00470.100.00612.170.00582.790.00483.510.00470.100.00493.220.00459.130.00612.170.00496.320.00459.130.00496.320.00470.100.00459.130.00459.130.00612.170.00493.220.00483.510.00
43
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
44
L2330
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.
486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
45
Total HCPCS1205.72904.29941.480.00937.080.001205.720.001205.720.00968.420.001127.170.00939.600.00939.600.00941.480.00941.480.00969.750.001005.130.00928.670.00928.670.00969.750.00941.480.00937.080.001127.170.00939.600.001127.170.00928.670.00928.670.00969.750.00941.480.00968.420.00941.480.00968.420.00969.750.001127.170.001161.430.00937.080.001205.720.001161.430.00928.670.00937.080.001005.130.00939.600.001127.170.00941.480.00968.420.00941.480.00937.080.00968.420.00939.600.001127.170.001005.130.00928.670.00
46
47
G140Tall
48
L1940
Ankle foot orthosis, plastic or other material, custom fabricated.
612.17459.13496.320.00470.100.00612.170.00612.170.00459.130.00612.170.00459.130.00459.130.00496.320.00496.320.00502.780.00493.220.00483.510.00483.510.00502.780.00496.320.00470.100.00612.170.00459.130.00612.170.00483.510.00483.510.00502.780.00496.320.00459.130.00496.320.00459.130.00502.780.00612.170.00582.790.00470.100.00612.170.00582.790.00483.510.00470.100.00493.220.00459.130.00612.170.00496.320.00459.130.00496.320.00470.100.00459.130.00459.130.00612.170.00493.220.00483.510.00
49
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
50
L2330
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.
486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
51
Total HCPCS1205.72904.29941.480.00937.080.001205.720.001205.720.00968.420.001127.170.00939.600.00939.600.00941.480.00941.480.00969.750.001005.130.00928.670.00928.670.00969.750.00941.480.00937.080.001127.170.00939.600.001127.170.00928.670.00928.670.00969.750.00941.480.00968.420.00941.480.00968.420.00969.750.001127.170.001161.430.00937.080.001205.720.001161.430.00928.670.00937.080.001005.130.00939.600.001127.170.00941.480.00968.420.00941.480.00937.080.00968.420.00939.600.001127.170.001005.130.00928.670.00
52
53
G200
Tamarack
Free Motion
54
L1970
Ankle foot orthosis, plastic with ankle joint, custom fabricated
880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
55
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
56
L2330
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.
486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
57
Total HCPCS1474.361105.771206.280.001127.590.001310.990.001310.990.001203.300.001395.810.001141.080.001141.080.001206.280.001206.280.001256.580.001198.640.001132.370.001132.370.001256.580.001206.280.001127.590.001395.810.001141.080.001395.810.001132.370.001132.370.001256.580.001206.280.001203.300.001206.280.001203.300.001256.580.001395.810.001454.820.001127.590.001310.990.001454.820.001132.370.001127.590.001198.640.001141.080.001395.810.001206.280.001203.300.001206.280.001127.590.001203.300.001141.080.001395.810.001198.640.001132.370.00
58
59
G250
Overlapping
Articulating Gauntlet
60
L1970
Ankle foot orthosis, plastic with ankle joint, custom fabricated
880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
61
L2275
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
62
L2330
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.
486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
63
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
64
Total HCPCS1629.611222.211327.600.001248.900.001456.190.001456.190.001341.600.001518.040.001261.940.001261.940.001327.600.001327.600.001404.610.001343.840.001261.800.001261.800.001404.610.001327.600.001248.900.001518.040.001261.940.001518.040.001261.800.001261.800.001404.610.001327.600.001341.600.001327.600.001341.600.001404.610.001518.040.001571.840.001248.900.001456.190.001571.840.001261.800.001248.900.001343.840.001261.940.001518.040.001327.600.001341.600.001327.600.001248.900.001341.600.001261.940.001518.040.001343.840.001261.800.00
65
66
G300
Tamarack
Dorsi-Assist
67
L1970
Ankle foot orthosis, plastic with ankle joint, custom fabricated
880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
68
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
69
L2330
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.
486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
70
L2210
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint
83.2162.4171.620.0062.410.0083.210.0083.210.0083.210.0062.410.0063.890.0063.890.0071.620.0071.620.0062.410.0065.420.0062.410.0062.410.0062.410.0071.620.0062.410.0062.410.0063.890.0062.410.0062.410.0062.410.0062.410.0071.620.0083.210.0071.620.0083.210.0062.410.0062.410.0068.200.0062.410.0083.210.0068.200.0062.410.0062.410.0065.420.0063.890.0062.410.0071.620.0083.210.0071.620.0062.410.0083.210.0063.890.0062.410.0065.420.0062.410.00
71
L2210
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint
83.2162.4171.620.0062.410.0083.210.0083.210.0083.210.0062.410.0063.890.0063.890.0071.620.0071.620.0062.410.0065.420.0062.410.0062.410.0062.410.0071.620.0062.410.0062.410.0063.890.0062.410.0062.410.0062.410.0062.410.0071.620.0083.210.0071.620.0083.210.0062.410.0062.410.0068.200.0062.410.0083.210.0068.200.0062.410.0062.410.0065.420.0063.890.0062.410.0071.620.0083.210.0071.620.0062.410.0083.210.0063.890.0062.410.0065.420.0062.410.00
72
Total HCPCS1640.781230.591349.520.001252.410.001477.410.001477.410.001369.720.001520.630.001268.860.001268.860.001349.520.001349.520.001381.400.001329.480.001257.190.001257.190.001381.400.001349.520.001252.410.001520.630.001268.860.001520.630.001257.190.001257.190.001381.400.001349.520.001369.720.001349.520.001369.720.001381.400.001520.630.001591.220.001252.410.001477.410.001591.220.001257.190.001252.410.001329.480.001268.860.001520.630.001349.520.001369.720.001349.520.001252.410.001369.720.001268.860.001520.630.001329.480.001257.190.00
73
74
G600
Leather Partial
Foot
75
L1960
Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated
686.13514.59514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00548.940.00548.940.00514.590.00514.590.00514.590.00514.590.00615.470.00615.470.00514.590.00514.590.00514.590.00686.130.00548.940.00686.130.00615.470.00615.470.00514.590.00514.590.00514.590.00514.590.00514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00686.130.00615.470.00514.590.00514.590.00548.940.00686.130.00514.590.00514.590.00514.590.00514.590.00514.590.00548.940.00686.130.00514.590.00615.470.00
76
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
77
L2330
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.
486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
78
L5000Partial foot, shoe insert with longitudinal arch, toe filler666.32499.74523.440.00666.320.00594.400.00594.400.00499.740.00499.740.00551.270.00551.270.00523.440.00523.440.00522.050.00499.740.00570.140.00570.140.00522.050.00523.440.00666.320.00499.740.00551.270.00499.740.00570.140.00570.140.00522.050.00523.440.00499.740.00523.440.00499.740.00522.050.00499.740.00499.740.00666.320.00594.400.00499.740.00570.140.00666.320.00499.740.00551.270.00499.740.00523.440.00499.740.00523.440.00666.320.00499.740.00551.270.00499.740.00499.740.00570.140.00
79
Total HCPCS1946.001459.491483.190.001647.890.001874.080.001874.080.001523.620.001700.870.001580.680.001580.680.001483.190.001483.190.001503.610.001526.240.001630.770.001630.770.001503.610.001483.190.001647.890.001700.870.001580.680.001700.870.001630.770.001630.770.001503.610.001483.190.001523.620.001483.190.001523.620.001503.610.001700.870.001764.510.001647.890.001874.080.001764.510.001630.770.001647.890.001526.240.001580.680.001700.870.001483.190.001523.620.001483.190.001647.890.001523.620.001580.680.001700.870.001526.240.001630.770.00
80
81
G800Balance Brace
82
L1940
Ankle foot orthosis, plastic or other material, custom fabricated.
612.17459.13496.320.00470.100.00612.170.00612.170.00459.130.00612.170.00459.130.00459.130.00496.320.00496.320.00502.780.00493.220.00483.510.00483.510.00502.780.00496.320.00470.100.00612.170.00459.130.00612.170.00483.510.00483.510.00502.780.00496.320.00459.130.00496.320.00459.130.00502.780.00612.170.00582.790.00470.100.00612.170.00582.790.00483.510.00470.100.00493.220.00459.130.00612.170.00496.320.00459.130.00496.320.00470.100.00459.130.00459.130.00612.170.00493.220.00483.510.00
83
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
84
L2330
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only.
486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
85
Total HCPCS1205.72904.29941.480.00937.080.001205.720.001205.720.00968.420.001127.170.00939.600.00939.600.00941.480.00941.480.00969.750.001005.130.00928.670.00928.670.00969.750.00941.480.00937.080.001127.170.00939.600.001127.170.00928.670.00928.670.00969.750.00941.480.00968.420.00941.480.00968.420.00969.750.001127.170.001161.430.00937.080.001205.720.001161.430.00928.670.00937.080.001005.130.00939.600.001127.170.00941.480.00968.420.00941.480.00937.080.00968.420.00939.600.001127.170.001005.130.00928.670.00
86
87
T100Leaf Spring
88
L1960
Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated
686.13514.59514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00548.940.00548.940.00514.590.00514.590.00514.590.00514.590.00615.470.00615.470.00514.590.00514.590.00514.590.00686.130.00548.940.00686.130.00615.470.00615.470.00514.590.00514.590.00514.590.00514.590.00514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00686.130.00615.470.00514.590.00514.590.00548.940.00686.130.00514.590.00514.590.00514.590.00514.590.00514.590.00548.940.00686.130.00514.590.00615.470.00
89
L2275
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
90
Total HCPCS841.38631.03635.910.00635.900.00831.330.00831.330.00652.890.00808.360.00669.800.00669.800.00635.910.00635.910.00662.620.00659.790.00744.900.00744.900.00662.620.00635.910.00635.900.00808.360.00669.800.00808.360.00744.900.00744.900.00662.620.00635.910.00652.890.00635.910.00652.890.00662.620.00808.360.00803.150.00635.900.00831.330.00803.150.00744.900.00635.900.00659.790.00669.800.00808.360.00635.910.00652.890.00635.910.00635.900.00652.890.00669.800.00808.360.00659.790.00744.900.00
91
92
T150Solid Ankle
93
L1960
Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated
686.13514.59514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00548.940.00548.940.00514.590.00514.590.00514.590.00514.590.00615.470.00615.470.00514.590.00514.590.00514.590.00686.130.00548.940.00686.130.00615.470.00615.470.00514.590.00514.590.00514.590.00514.590.00514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00686.130.00615.470.00514.590.00514.590.00548.940.00686.130.00514.590.00514.590.00514.590.00514.590.00514.590.00548.940.00686.130.00514.590.00615.470.00
94
L2275
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
95
Total HCPCS841.38631.03635.910.00635.900.00831.330.00831.330.00652.890.00808.360.00669.800.00669.800.00635.910.00635.910.00662.620.00659.790.00744.900.00744.900.00662.620.00635.910.00635.900.00808.360.00669.800.00808.360.00744.900.00744.900.00662.620.00635.910.00652.890.00635.910.00652.890.00662.620.00808.360.00803.150.00635.900.00831.330.00803.150.00744.900.00635.900.00659.790.00669.800.00808.360.00635.910.00652.890.00635.910.00635.900.00652.890.00669.800.00808.360.00659.790.00744.900.00
96
97
T200
Tamarack Free
Motion
98
L1970
Ankle foot orthosis, plastic with ankle joint, custom fabricated
880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
99
L2275
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
100
Total HCPCS1036.06777.05882.440.00781.920.00862.640.00862.640.00832.310.001003.040.00781.470.00781.470.00882.440.00882.440.00937.640.00831.930.00816.640.00816.640.00937.640.00882.440.00781.920.001003.040.00781.470.001003.040.00816.640.00816.640.00937.640.00882.440.00832.310.00882.440.00832.310.00937.640.001003.040.00993.200.00781.920.00862.640.00993.200.00816.640.00781.920.00831.930.00781.470.001003.040.00882.440.00832.310.00882.440.00781.920.00832.310.00781.470.001003.040.00831.930.00816.640.00
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