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
L1951Afo spiral prefabricated993.21744.90838.370.00838.300.00813.870.00813.870.00843.000.00813.870.00813.870.00813.870.00838.370.00838.370.00829.750.00813.870.00833.840.00833.840.00829.750.00838.370.00838.300.00813.870.00813.870.00813.870.00833.840.00833.840.00829.750.00838.370.00843.000.00838.370.00843.000.00829.750.00813.870.00813.870.00838.300.00813.870.00813.870.00833.840.00838.300.00813.870.00813.870.00813.870.00838.370.00843.000.00838.370.00838.300.00843.000.00813.870.00813.870.00813.870.00833.840.00
5
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
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
L1970Afo plastic molded w/ankle j880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
10
L2275Plastic mod low ext pad/line155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
11
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
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
L1970Afo plastic molded w/ankle j880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
16
L2275Plastic mod low ext pad/line155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
17
L2330Lacer molded to patient mode486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
18
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
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
L1970Afo plastic molded w/ankle j880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
23
L2275Plastic mod low ext pad/line155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
24
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
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
L1970Afo plastic molded w/ankle j880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
29
L2275Plastic mod low ext pad/line155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
30
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
31
L2210Dorsiflexion assist each joi83.2162.4171.620.0062.410.0083.210.0083.210.0083.210.0062.410.0063.890.0063.890.0071.620.0071.620.0062.410.0065.420.0062.410.0062.410.0062.410.0071.620.0062.410.0062.410.0063.890.0062.410.0062.410.0062.410.0062.410.0071.620.0083.210.0071.620.0083.210.0062.410.0062.410.0068.200.0062.410.0083.210.0068.200.0062.410.0062.410.0065.420.0063.890.0062.410.0071.620.0083.210.0071.620.0062.410.0083.210.0063.890.0062.410.0065.420.0062.410.00
32
L2210Dorsiflexion assist each joi83.2162.4171.620.0062.410.0083.210.0083.210.0083.210.0062.410.0063.890.0063.890.0071.620.0071.620.0062.410.0065.420.0062.410.0062.410.0062.410.0071.620.0062.410.0062.410.0063.890.0062.410.0062.410.0062.410.0062.410.0071.620.0083.210.0071.620.0083.210.0062.410.0062.410.0068.200.0062.410.0083.210.0068.200.0062.410.0062.410.0065.420.0063.890.0062.410.0071.620.0083.210.0071.620.0062.410.0083.210.0063.890.0062.410.0065.420.0062.410.00
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
L1940Afo molded to patient plasti612.17459.13496.320.00470.100.00612.170.00612.170.00459.130.00612.170.00459.130.00459.130.00496.320.00496.320.00502.780.00493.220.00483.510.00483.510.00502.780.00496.320.00470.100.00612.170.00459.130.00612.170.00483.510.00483.510.00502.780.00496.320.00459.130.00496.320.00459.130.00502.780.00612.170.00582.790.00470.100.00612.170.00582.790.00483.510.00470.100.00493.220.00459.130.00612.170.00496.320.00459.130.00496.320.00470.100.00459.130.00459.130.00612.170.00493.220.00483.510.00
37
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
38
L2330Lacer molded to patient mode486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
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
L1940Afo molded to patient plasti612.17459.13496.320.00470.100.00612.170.00612.170.00459.130.00612.170.00459.130.00459.130.00496.320.00496.320.00502.780.00493.220.00483.510.00483.510.00502.780.00496.320.00470.100.00612.170.00459.130.00612.170.00483.510.00483.510.00502.780.00496.320.00459.130.00496.320.00459.130.00502.780.00612.170.00582.790.00470.100.00612.170.00582.790.00483.510.00470.100.00493.220.00459.130.00612.170.00496.320.00459.130.00496.320.00470.100.00459.130.00459.130.00612.170.00493.220.00483.510.00
43
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
44
L2330Lacer molded to patient mode486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
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
L1940Afo molded to patient plasti612.17459.13496.320.00470.100.00612.170.00612.170.00459.130.00612.170.00459.130.00459.130.00496.320.00496.320.00502.780.00493.220.00483.510.00483.510.00502.780.00496.320.00470.100.00612.170.00459.130.00612.170.00483.510.00483.510.00502.780.00496.320.00459.130.00496.320.00459.130.00502.780.00612.170.00582.790.00470.100.00612.170.00582.790.00483.510.00470.100.00493.220.00459.130.00612.170.00496.320.00459.130.00496.320.00470.100.00459.130.00459.130.00612.170.00493.220.00483.510.00
49
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
50
L2330Lacer molded to patient mode486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
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
L1970Afo plastic molded w/ankle j880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
55
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
56
L2330Lacer molded to patient mode486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
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
L1970Afo plastic molded w/ankle j880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
61
L2275Plastic mod low ext pad/line155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
62
L2330Lacer molded to patient mode486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
63
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
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
L1970Afo plastic molded w/ankle j880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
68
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
69
L2330Lacer molded to patient mode486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
70
L2210Dorsiflexion assist each joi83.2162.4171.620.0062.410.0083.210.0083.210.0083.210.0062.410.0063.890.0063.890.0071.620.0071.620.0062.410.0065.420.0062.410.0062.410.0062.410.0071.620.0062.410.0062.410.0063.890.0062.410.0062.410.0062.410.0062.410.0071.620.0083.210.0071.620.0083.210.0062.410.0062.410.0068.200.0062.410.0083.210.0068.200.0062.410.0062.410.0065.420.0063.890.0062.410.0071.620.0083.210.0071.620.0062.410.0083.210.0063.890.0062.410.0065.420.0062.410.00
71
L2210Dorsiflexion assist each joi83.2162.4171.620.0062.410.0083.210.0083.210.0083.210.0062.410.0063.890.0063.890.0071.620.0071.620.0062.410.0065.420.0062.410.0062.410.0062.410.0071.620.0062.410.0062.410.0063.890.0062.410.0062.410.0062.410.0062.410.0071.620.0083.210.0071.620.0083.210.0062.410.0062.410.0068.200.0062.410.0083.210.0068.200.0062.410.0062.410.0065.420.0063.890.0062.410.0071.620.0083.210.0071.620.0062.410.0083.210.0063.890.0062.410.0065.420.0062.410.00
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
L1960Afo pos solid ank plastic mo686.13514.59514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00548.940.00548.940.00514.590.00514.590.00514.590.00514.590.00615.470.00615.470.00514.590.00514.590.00514.590.00686.130.00548.940.00686.130.00615.470.00615.470.00514.590.00514.590.00514.590.00514.590.00514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00686.130.00615.470.00514.590.00514.590.00548.940.00686.130.00514.590.00514.590.00514.590.00514.590.00514.590.00548.940.00686.130.00514.590.00615.470.00
76
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
77
L2330Lacer molded to patient mode486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
78
L5000Sho insert w 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
L1940Afo molded to patient plasti612.17459.13496.320.00470.100.00612.170.00612.170.00459.130.00612.170.00459.130.00459.130.00496.320.00496.320.00502.780.00493.220.00483.510.00483.510.00502.780.00496.320.00470.100.00612.170.00459.130.00612.170.00483.510.00483.510.00502.780.00496.320.00459.130.00496.320.00459.130.00502.780.00612.170.00582.790.00470.100.00612.170.00582.790.00483.510.00470.100.00493.220.00459.130.00612.170.00496.320.00459.130.00496.320.00470.100.00459.130.00459.130.00612.170.00493.220.00483.510.00
83
L2820Soft interface below knee se107.5080.6280.620.0080.620.00107.500.00107.500.00107.500.00107.060.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.060.0080.620.0080.620.0080.620.0080.620.00107.500.0080.620.00107.500.0080.620.00107.060.0092.590.0080.620.00107.500.0092.590.0080.620.0080.620.0080.620.0080.620.00107.060.0080.620.00107.500.0080.620.0080.620.00107.500.0080.620.00107.060.0080.620.0080.620.00
84
L2330Lacer molded to patient mode486.05364.54364.540.00386.360.00486.050.00486.050.00401.790.00407.940.00399.850.00399.850.00364.540.00364.540.00386.350.00431.290.00364.540.00364.540.00386.350.00364.540.00386.360.00407.940.00399.850.00407.940.00364.540.00364.540.00386.350.00364.540.00401.790.00364.540.00401.790.00386.350.00407.940.00486.050.00386.360.00486.050.00486.050.00364.540.00386.360.00431.290.00399.850.00407.940.00364.540.00401.790.00364.540.00386.360.00401.790.00399.850.00407.940.00431.290.00364.540.00
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
L1960Afo pos solid ank plastic mo686.13514.59514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00548.940.00548.940.00514.590.00514.590.00514.590.00514.590.00615.470.00615.470.00514.590.00514.590.00514.590.00686.130.00548.940.00686.130.00615.470.00615.470.00514.590.00514.590.00514.590.00514.590.00514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00686.130.00615.470.00514.590.00514.590.00548.940.00686.130.00514.590.00514.590.00514.590.00514.590.00514.590.00548.940.00686.130.00514.590.00615.470.00
89
L2275Plastic mod low ext pad/line155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
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
L1960Afo pos solid ank plastic mo686.13514.59514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00548.940.00548.940.00514.590.00514.590.00514.590.00514.590.00615.470.00615.470.00514.590.00514.590.00514.590.00686.130.00548.940.00686.130.00615.470.00615.470.00514.590.00514.590.00514.590.00514.590.00514.590.00514.590.00686.130.00686.130.00514.590.00686.130.00686.130.00615.470.00514.590.00514.590.00548.940.00686.130.00514.590.00514.590.00514.590.00514.590.00514.590.00548.940.00686.130.00514.590.00615.470.00
94
L2275Plastic mod low ext pad/line155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
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
L1970Afo plastic molded w/ankle j880.81660.61761.120.00660.610.00717.440.00717.440.00694.010.00880.810.00660.610.00660.610.00761.120.00761.120.00789.610.00686.730.00687.210.00687.210.00789.610.00761.120.00660.610.00880.810.00660.610.00880.810.00687.210.00687.210.00789.610.00761.120.00694.010.00761.120.00694.010.00789.610.00880.810.00876.180.00660.610.00717.440.00876.180.00687.210.00660.610.00686.730.00660.610.00880.810.00761.120.00694.010.00761.120.00660.610.00694.010.00660.610.00880.810.00686.730.00687.210.00
99
L2275Plastic mod low ext pad/line155.25116.44121.320.00121.310.00145.200.00145.200.00138.300.00122.230.00120.860.00120.860.00121.320.00121.320.00148.030.00145.200.00129.430.00129.430.00148.030.00121.320.00121.310.00122.230.00120.860.00122.230.00129.430.00129.430.00148.030.00121.320.00138.300.00121.320.00138.300.00148.030.00122.230.00117.020.00121.310.00145.200.00117.020.00129.430.00121.310.00145.200.00120.860.00122.230.00121.320.00138.300.00121.320.00121.310.00138.300.00120.860.00122.230.00145.200.00129.430.00
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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