DME-ORTHOTIC-PROSTHETIC FEE SCHEDULE Effective 07 ......2020/07/01  · DME-ORTHOTIC-PROSTHETIC FEE SCHEDULE Effective 07/01/2020 Print Date 7/7/20 Price does not include cutbacks,

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

ANY TYPE0 999 07/01/2020 12/31/9999 1 2.67

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

0 999 07/01/2020 12/31/9999 1 801.39

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

0 999 07/01/2020 12/31/9999 1 80.14

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

0 999 07/01/2020 12/31/9999 1 400.70

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

0 999 07/01/2020 12/31/9999 1 8.12

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

0 999 07/01/2020 12/31/9999 1 2,435.12

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

0 999 07/01/2020 12/31/9999 1 243.51

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

0 999 07/01/2020 12/31/9999 1 1,217.56

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

0 999 07/01/2020 12/31/9999 1 8.12

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

0 999 07/01/2020 12/31/9999 1 2,435.12

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

0 999 07/01/2020 12/31/9999 1 243.51

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

0 999 07/01/2020 12/31/9999 1 1,217.56

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

0 999 07/01/2020 12/31/9999 1 16.66

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

0 999 07/01/2020 12/31/9999 1 45.65

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

0 999 07/01/2020 12/31/9999 1 68.35

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

0 999 07/01/2020 12/31/9999 2 42.06

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

0 999 07/01/2020 12/31/9999 1 34.39

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

0 999 07/01/2020 12/31/9999 2 19.65

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

0 999 07/01/2020 12/31/9999 1 43.86

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

0 999 07/01/2020 12/31/9999 2 24.46

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

0 20 07/01/2020 12/31/9999 2 179.04

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

0 999 07/01/2020 12/31/9999 1 43.70

DME-ORTHOTIC-PROSTHETIC FEE SCHEDULE Effective 07/01/2020Print Date 7/7/20Price does not include cutbacks, assessment fees, etc. Payment is not guaranteed.

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0135 NU-Fee on File Yes WALKER, FOLDING (PICKUP),

ADJUSTABLE OR FIXED HEIGHT0 999 07/01/2020 12/31/9999 1 48.29

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

0 999 07/01/2020 12/31/9999 1 66.73

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

0 999 07/01/2020 12/31/9999 1 64.44

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

0 999 07/01/2020 12/31/9999 1 1.36

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

0 999 07/01/2020 12/31/9999 1 407.02

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

0 999 07/01/2020 12/31/9999 1 40.70

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

0 999 07/01/2020 12/31/9999 1 203.51

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

0 999 07/01/2020 12/31/9999 1 0.29

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

0 999 07/01/2020 12/31/9999 1 86.73

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

0 999 07/01/2020 12/31/9999 1 8.67

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

0 999 07/01/2020 12/31/9999 1 43.36

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

0 999 07/01/2020 12/31/9999 1 0.47

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

0 999 07/01/2020 12/31/9999 1 140.24

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

0 999 07/01/2020 12/31/9999 1 14.02

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

0 999 07/01/2020 12/31/9999 1 70.12

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

3 20 07/01/2020 12/31/9999 2 64.50

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

0 999 07/01/2020 12/31/9999 2 49.46

E0155 NU-Fee on File Yes WHEEL ATTACHMENT, RIGID PICK-UP WALKER, PER PAIR SEAT ATTACHMENT, WALKER

0 999 07/01/2020 12/31/9999 1 19.79

E0156 NU-Fee on File Yes SEAT ATTACHMENT, WALKER 0 999 07/01/2020 12/31/9999 1 17.40E0157 NU-Fee on File Yes CRUTCH ATTACHMENT, WALKER, EACH 0 999 07/01/2020 12/31/9999 2 52.18E0158 NU-Fee on File Yes LEG EXTENSIONS FOR WALKER, PER

SET OF FOUR (4)0 999 07/01/2020 12/31/9999 1 20.32

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

0 999 07/01/2020 12/31/9999 2 13.51

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

0 999 07/01/2020 12/31/9999 1 69.14

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

0 999 07/01/2020 12/31/9999 1 0.42

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

0 999 07/01/2020 12/31/9999 1 126.48

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0165 RR-Fee on File Yes COMMODE CHAIR, MOBILE OR

STATIONARY, WITH DETACHABLE ARMS0 999 07/01/2020 12/31/9999 1 12.65

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

0 999 07/01/2020 12/31/9999 1 63.24

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

0 999 07/01/2020 12/31/9999 1 10.27

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

0 999 07/01/2020 12/31/9999 1 0.40

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

0 999 07/01/2020 12/31/9999 1 120.87

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

0 999 07/01/2020 12/31/9999 1 12.09

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

0 999 07/01/2020 12/31/9999 1 60.44

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

0 999 07/01/2020 12/31/9999 1 0.63

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

0 999 07/01/2020 12/31/9999 1 188.48

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

0 999 07/01/2020 12/31/9999 1 18.85

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

0 999 07/01/2020 12/31/9999 1 94.24

E0184 NU-Fee on File Yes DRY PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 160.23E0185 KR-Fee on File Yes GEL OR GEL LIKE PRESSURE PAD FOR

MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2020 12/31/9999 1 0.67

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

0 999 07/01/2020 12/31/9999 1 199.81

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

0 999 07/01/2020 12/31/9999 1 19.98

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

0 999 07/01/2020 12/31/9999 1 99.90

E0186 KR-Fee on File Yes AIR PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 0.53E0186 NU-Fee on File Yes AIR PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 160.32E0186 RR-Fee on File Yes AIR PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 16.03E0186 UE-Fee on File Yes AIR PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 80.16E0187 KR-Fee on File Yes WATER PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 0.61E0187 NU-Fee on File Yes WATER PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 183.36E0187 RR-Fee on File Yes WATER PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 18.34E0187 UE-Fee on File Yes WATER PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 91.68E0188 NU-Fee on File Yes SYNTHETIC SHEEPSKIN PAD 0 20 07/01/2020 12/31/9999 1 22.97E0189 NU-Fee on File Yes LAMBSWOOL SHEEPSKIN PAD, ANY SIZE 0 20 07/01/2020 12/31/9999 1 41.06

E0191 NU-Fee on File Yes HEEL OR ELBOW PROTECTOR, EACH 0 999 07/01/2020 12/31/9999 4 8.93E0194 KR-Fee on File Yes AIR FLUIDIZED BED 0 20 07/01/2020 12/31/9999 1 100.82

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0194 RR-Fee on File Yes AIR FLUIDIZED BED 0 20 07/01/2020 12/31/9999 1 3,024.55E0196 KR-Fee on File Yes GEL PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 0.86E0196 NU-Fee on File Yes GEL PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 256.64E0196 RR-Fee on File Yes GEL PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 25.66E0196 UE-Fee on File Yes GEL PRESSURE MATTRESS 0 999 07/01/2020 12/31/9999 1 128.32E0197 KR-Fee on File Yes AIR PRESSURE PAD FOR MATTRESS,

STANDARD MATTRESS LENGTH AND WIDTH

0 999 07/01/2020 12/31/9999 1 0.66

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

0 999 07/01/2020 12/31/9999 1 199.44

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

0 999 07/01/2020 12/31/9999 1 19.94

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

0 999 07/01/2020 12/31/9999 1 99.72

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

0 999 07/01/2020 12/31/9999 1 0.58

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

0 999 07/01/2020 12/31/9999 1 175.04

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

0 999 07/01/2020 12/31/9999 1 17.50

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

0 999 07/01/2020 12/31/9999 1 87.52

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

0 999 07/01/2020 12/31/9999 1 25.33

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

0 20 07/01/2020 12/31/9999 1 0.21

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

0 20 07/01/2020 12/31/9999 1 6.26

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

0 1 07/01/2020 12/31/9999 1 1.94

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

0 20 07/01/2020 12/31/9999 1 0.51

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

0 20 07/01/2020 12/31/9999 1 15.33

E0210 NU-Fee on File Yes ELECTRIC HEAT PAD, STANDARD 0 999 07/01/2020 12/31/9999 1 26.00E0215 NU-Fee on File Yes ELECTRIC HEAT PAD, MOIST 0 999 07/01/2020 12/31/9999 1 55.97E0217 KR-Fee on File Yes WATER CIRCULATING HEAT PAD WITH

PUMP0 20 07/01/2020 12/31/9999 1 1.53

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

0 20 07/01/2020 12/31/9999 1 458.90

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

0 20 07/01/2020 12/31/9999 1 45.89

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

0 20 07/01/2020 12/31/9999 1 229.45

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

0 999 07/01/2020 12/31/9999 1 0.53

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0235 NU-Fee on File Yes PARAFFIN BATH UNIT, PORTABLE (SEE

MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)

0 999 07/01/2020 12/31/9999 1 160.32

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

0 999 07/01/2020 12/31/9999 1 16.03

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

0 999 07/01/2020 12/31/9999 1 80.16

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

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

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

ANY TYPE SIDE RAILS, WITH MATTRESS0 999 07/01/2020 12/31/9999 1 1.99

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

0 999 07/01/2020 12/31/9999 1 596.40

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

0 999 07/01/2020 12/31/9999 1 59.64

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

0 999 07/01/2020 12/31/9999 1 298.20

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

0 999 07/01/2020 12/31/9999 1 1.81

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

0 999 07/01/2020 12/31/9999 1 542.24

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

0 999 07/01/2020 12/31/9999 1 54.22

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

0 999 07/01/2020 12/31/9999 1 271.12

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

0 999 07/01/2020 12/31/9999 1 2.22

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

0 999 07/01/2020 12/31/9999 1 665.52

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

0 999 07/01/2020 12/31/9999 1 66.55

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

0 999 07/01/2020 12/31/9999 1 332.76

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

0 999 07/01/2020 12/31/9999 1 1.81

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

0 999 07/01/2020 12/31/9999 1 541.60

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

0 999 07/01/2020 12/31/9999 1 54.16

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

0 999 07/01/2020 12/31/9999 1 270.80

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

0 999 07/01/2020 12/31/9999 1 2.76

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

0 999 07/01/2020 12/31/9999 1 828.40

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

0 999 07/01/2020 12/31/9999 1 82.84

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0260 UE-Fee on File Yes HOSPITAL BED, SEMI-ELECTRIC (HEAD

AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS WITH MATTRESS

0 999 07/01/2020 12/31/9999 1 414.20

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

0 999 07/01/2020 12/31/9999 1 2.44

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

0 999 07/01/2020 12/31/9999 1 731.76

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

0 999 07/01/2020 12/31/9999 1 73.18

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

0 999 07/01/2020 12/31/9999 1 365.88

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

0 999 07/01/2020 12/31/9999 1 4.43

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

0 999 07/01/2020 12/31/9999 1 1,329.12

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

0 999 07/01/2020 12/31/9999 1 132.91

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

0 999 07/01/2020 12/31/9999 1 664.56

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

0 999 07/01/2020 12/31/9999 1 3.71

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

0 999 07/01/2020 12/31/9999 1 1,112.72

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

0 999 07/01/2020 12/31/9999 1 111.27

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

0 999 07/01/2020 12/31/9999 1 556.36

E0271 NU-Fee on File Yes MATTRESS, INNERSPRING 0 999 07/01/2020 12/31/9999 1 129.21E0272 NU-Fee on File Yes MATTRESS, FOAM RUBBER 0 999 07/01/2020 12/31/9999 1 129.72E0273 NU-Fee on File Yes BED BOARD 0 20 10/01/1998 12/31/9999 1 59.36E0274 KR-Fee on File Yes OVERBED TABLE 0 20 10/01/1998 12/31/9999 1 0.34E0274 NU-Fee on File Yes OVERBED TABLE 0 20 10/01/1998 12/31/9999 1 101.36E0274 RR-Fee on File Yes OVERBED TABLE 0 20 10/01/1998 12/31/9999 1 10.14E0274 UE-Fee on File Yes OVERBED TABLE 0 20 10/01/1998 12/31/9999 1 50.68E0275 NU-Fee on File Yes BED PAN, STANDARD, METAL OR

PLASTIC0 999 07/01/2020 12/31/9999 1 13.17

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

0 999 07/01/2020 12/31/9999 1 11.38

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

0 999 07/01/2020 12/31/9999 1 12.17

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

0 999 07/01/2020 12/31/9999 1 3,652.24

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

0 999 07/01/2020 12/31/9999 1 365.22

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0277 UE-Fee on File Yes POWERED PRESSURE REDUCING AIR

MATTRESS0 999 07/01/2020 12/31/9999 1 1,826.12

E0280 KR-Fee on File Yes BED, CRADLE, ANY TYPE 0 20 07/01/2020 12/31/9999 1 0.09E0280 NU-Fee on File Yes BED, CRADLE, ANY TYPE 0 20 07/01/2020 12/31/9999 1 26.02E0280 RR-Fee on File Yes BED, CRADLE, ANY TYPE 0 20 07/01/2020 12/31/9999 1 2.60E0280 UE-Fee on File Yes BED, CRADLE, ANY TYPE 0 20 07/01/2020 12/31/9999 1 13.01E0290 KR-Fee on File Yes HOSPITAL BED, FIXED HEIGHT, WEIGHT,

WITHOUT SIDE RAILS, WITH MATTRESS0 999 07/01/2020 12/31/9999 1 1.67

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

0 999 07/01/2020 12/31/9999 1 501.68

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

0 999 07/01/2020 12/31/9999 1 50.17

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

0 999 07/01/2020 12/31/9999 1 250.84

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

0 999 07/01/2020 12/31/9999 1 1.34

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

0 999 07/01/2020 12/31/9999 1 402.08

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

0 999 07/01/2020 12/31/9999 1 40.21

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

0 999 07/01/2020 12/31/9999 1 201.04

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

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

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

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

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

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

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

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

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

0 999 07/01/2020 12/31/9999 1 16.35

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

0 999 07/01/2020 12/31/9999 1 4,905.60

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

0 999 07/01/2020 12/31/9999 1 490.56

828.88E0301 UE-Fee on File Yes HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS BUT

0 999 07/01/2020 12/31/9999 1

1,657.76

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

0 999 07/01/2020 12/31/9999 1 165.78

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

0 999 07/01/2020 12/31/9999 1

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

0 999 07/01/2020 12/31/9999 1 5.53

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0302 UE-Fee on File Yes HOSPITAL BED, EXTRA HEAVY DUTY,

EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS

0 999 07/01/2020 12/31/9999 1 2,452.80

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

0 999 07/01/2020 12/31/9999 1 17.28

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

0 999 07/01/2020 12/31/9999 1 5,182.88

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

0 999 07/01/2020 12/31/9999 1 518.29

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

0 999 07/01/2020 12/31/9999 1 2,591.44

E0305 KR-Fee on File Yes BED SIDE RAILS, HALF LENGTH 0 999 07/01/2020 12/31/9999 2 0.39E0305 NU-Fee on File Yes BED SIDE RAILS, HALF LENGTH 0 999 07/01/2020 12/31/9999 2 117.92E0305 RR-Fee on File Yes BED SIDE RAILS, HALF LENGTH 0 999 07/01/2020 12/31/9999 2 11.79E0305 UE-Fee on File Yes BED SIDE RAILS, HALF LENGTH 0 999 07/01/2020 12/31/9999 2 58.96E0310 KR-Fee on File Yes BED SIDE RAILS, FULL LENGTH 0 999 07/01/2020 12/31/9999 2 0.40E0310 NU-Fee on File Yes BED SIDE RAILS, FULL LENGTH 0 999 07/01/2020 12/31/9999 2 118.63E0310 RR-Fee on File Yes BED SIDE RAILS, FULL LENGTH 0 999 07/01/2020 12/31/9999 2 11.86E0310 UE-Fee on File Yes BED SIDE RAILS, FULL LENGTH 0 999 07/01/2020 12/31/9999 2 59.32E0325 NU-Fee on File Yes URINAL; MALE, JUG-TYPE, ANY

MATERIAL0 999 07/01/2020 12/31/9999 1 8.66

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

0 999 07/01/2020 12/31/9999 1 9.11

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

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

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

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

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

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

900.24E0303 UE-Fee on File Yes HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS BUT

0 999 07/01/2020 12/31/9999 1

1,800.48

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

0 999 07/01/2020 12/31/9999 1 180.05

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

0 999 07/01/2020 12/31/9999 1

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

0 999 07/01/2020 12/31/9999 1 6.00

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

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

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

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

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

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

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

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

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

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

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

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

0 20 07/01/2020 12/31/9999 1 8.10

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

0 20 07/01/2020 12/31/9999 1 2,429.12

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

0 20 07/01/2020 12/31/9999 1 242.91

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

0 20 07/01/2020 12/31/9999 1 1,214.56

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

0 999 07/01/2020 12/31/9999 1 9.23

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

0 999 07/01/2020 12/31/9999 1 2,770.48

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

0 999 07/01/2020 12/31/9999 1 277.05

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

0 999 07/01/2020 12/31/9999 1 1,385.24

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

0 20 07/01/2020 12/31/9999 1 10.17

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

0 20 07/01/2020 12/31/9999 1 305.21

E0424 KR-Fee on File Yes STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM RENTAL INCLUDES

0 999 07/01/2020 12/31/9999 1 3.65

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

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

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

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

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

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

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

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

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

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

0 999 07/01/2020 12/31/9999 1 0.65

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

0 999 07/01/2020 12/31/9999 1 19.52

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

0 999 07/01/2020 12/31/9999 1 3.65

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

0 999 07/01/2020 12/31/9999 1 109.42

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

0 999 07/01/2020 12/31/9999 1 52.14

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

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

35.97

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

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

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

0 999 07/01/2020 12/31/9999 1

35.97

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

0 999 07/01/2020 12/31/9999 1 1.20

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

0 999 07/01/2020 12/31/9999 1

109.42

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

0 999 07/01/2020 12/31/9999 1 1.20

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

0 999 07/01/2020 12/31/9999 1

OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER CONTENTS REGULATOR

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0442 NU-Fee on File Yes STATIONARY OXYGEN CONTENTS,

LIQUID, 1 MONTH'S SUPPLY = 1 UNIT0 999 07/01/2020 12/31/9999 1 52.14

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

0 999 07/01/2020 12/31/9999 1 50.06

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

0 999 07/01/2020 12/31/9999 1 50.06

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

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

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

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

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

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

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

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

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

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

0 999 07/01/2020 12/31/9999 2 25.14

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

0 999 07/01/2020 12/31/9999 2 754.06

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

0 999 07/01/2020 12/31/9999 2 25.14

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

0 999 07/01/2020 12/31/9999 2 754.06

4,076.88

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

0 999 07/01/2020 12/31/9999 1 407.69

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

0 999 07/01/2020 12/31/9999 1

349.31

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

0 999 07/01/2020 12/31/9999 1 13.59

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

0 999 07/01/2020 12/31/9999 1

11.64

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

0 999 07/01/2020 12/31/9999 1 3,493.12

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

0 999 07/01/2020 12/31/9999 1

1,402.32

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

0 999 07/01/2020 12/31/9999 1 140.23

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

0 999 07/01/2020 12/31/9999 1

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

0 999 07/01/2020 12/31/9999 1 4.67

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0480 KR-Fee on File Yes PERCUSSOR, ELECTRIC OR PNEUMATIC;

HOME MODEL0 20 07/01/2020 12/31/9999 1 1.16

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

0 20 07/01/2020 12/31/9999 1 347.20

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

0 20 07/01/2020 12/31/9999 1 34.72

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

0 20 07/01/2020 12/31/9999 1 173.60

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

0 999 07/01/2020 12/31/9999 1 11.94

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

0 999 07/01/2020 12/31/9999 1 3,581.36

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

0 999 07/01/2020 12/31/9999 1 358.14

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

0 999 07/01/2020 12/31/9999 1 1,790.68

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

0 999 07/01/2020 12/31/9999 1 9,880.72

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

0 999 07/01/2020 12/31/9999 1 988.07

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

0 999 07/01/2020 12/31/9999 1 34.33

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

0 999 07/01/2020 12/31/9999 1 2.89

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

0 999 07/01/2020 12/31/9999 1 867.04

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

0 999 07/01/2020 12/31/9999 1 86.70

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

0 999 07/01/2020 12/31/9999 1 433.52

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

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

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

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

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

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

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

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

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0561 KR-Fee on File Yes HUMIDIFIER, NON-HEATED, USED WITH

POSITIVE AIRWAY PRESSURE DEVICE0 999 07/01/2020 12/31/9999 1 0.25

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

0 999 07/01/2020 12/31/9999 1 74.52

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

0 999 07/01/2020 12/31/9999 1 7.45

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

0 999 07/01/2020 12/31/9999 1 37.26

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

0 999 07/01/2020 12/31/9999 1 0.60

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

0 999 07/01/2020 12/31/9999 1 181.14

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

0 999 07/01/2020 12/31/9999 1 18.11

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

0 999 07/01/2020 12/31/9999 1 90.57

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

0 999 07/01/2020 12/31/9999 1 1.41

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

0 999 07/01/2020 12/31/9999 1 424.24

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

0 999 07/01/2020 12/31/9999 1 42.42

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

0 999 07/01/2020 12/31/9999 1 212.12

E0570 KR-Fee on File Yes NEBULIZER, WITH COMPRESSOR 0 999 07/01/2020 12/31/9999 1 0.33E0570 NU-Fee on File Yes NEBULIZER, WITH COMPRESSOR 0 999 07/01/2020 12/31/9999 1 99.92E0570 RR-Fee on File Yes NEBULIZER, WITH COMPRESSOR 0 999 07/01/2020 12/31/9999 1 9.99E0570 UE-Fee on File Yes NEBULIZER, WITH COMPRESSOR 0 999 07/01/2020 12/31/9999 1 49.96E0575 KR-Fee on File Yes NEBULIZER, ULTRASONIC, LARGE

VOLUME0 999 07/01/2020 12/31/9999 1 2.71

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

0 999 07/01/2020 12/31/9999 1 812.00

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

0 999 07/01/2020 12/31/9999 1 81.20

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

0 999 07/01/2020 12/31/9999 1 406.00

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

0 999 07/01/2020 12/31/9999 1 0.36

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

0 999 07/01/2020 12/31/9999 1 106.68

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

0 999 07/01/2020 12/31/9999 1 10.67

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

0 999 07/01/2020 12/31/9999 1 53.34

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

0 999 07/01/2020 12/31/9999 1 0.87

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0585 NU-Fee on File Yes NEBULIZER WITH COMPRESSOR AND

HEATER0 999 07/01/2020 12/31/9999 1 262.00

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

0 999 07/01/2020 12/31/9999 1 26.20

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

0 999 07/01/2020 12/31/9999 1 131.00

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

0 999 07/01/2020 12/31/9999 1 1.21

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

0 999 07/01/2020 12/31/9999 1 361.68

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

0 999 07/01/2020 12/31/9999 1 36.17

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

0 999 07/01/2020 12/31/9999 1 180.84

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

0 999 07/01/2020 12/31/9999 1 1.94

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

0 999 07/01/2020 12/31/9999 1 582.32

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

0 999 07/01/2020 12/31/9999 1 58.23

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

0 999 07/01/2020 12/31/9999 1 291.16

E0602 KR-Fee on File Yes BREAST PUMP, MANUAL, ANY TYPE 0 999 07/01/2020 12/31/9999 1 0.09E0602 NU-Fee on File Yes BREAST PUMP, MANUAL, ANY TYPE 0 999 07/01/2020 12/31/9999 1 27.43E0602 RR-Fee on File Yes BREAST PUMP, MANUAL, ANY TYPE 0 999 07/01/2020 12/31/9999 1 2.74E0603 KR-Fee on File Yes BREAST PUMP, ELECTRIC (AC AND/OR

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

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

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

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

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

E0605 KR-Fee on File Yes VAPORIZER, ROOM TYPE 0 999 07/01/2020 12/31/9999 1 0.08E0605 NU-Fee on File Yes VAPORIZER, ROOM TYPE 0 999 07/01/2020 12/31/9999 1 24.55E0605 RR-Fee on File Yes VAPORIZER, ROOM TYPE 0 999 07/01/2020 12/31/9999 1 2.46E0606 KR-Fee on File Yes POSTURAL DRAINAGE BOARD 0 999 07/01/2020 12/31/9999 1 0.71E0606 NU-Fee on File Yes POSTURAL DRAINAGE BOARD 0 999 07/01/2020 12/31/9999 1 213.36E0606 RR-Fee on File Yes POSTURAL DRAINAGE BOARD 0 999 07/01/2020 12/31/9999 1 21.34E0606 UE-Fee on File Yes POSTURAL DRAINAGE BOARD 0 999 07/01/2020 12/31/9999 1 106.68E0607 NU-Fee on File No HOME BLOOD GLUCOSE MONITOR 0 999 07/01/2020 12/31/9999 1 62.10E0607 UE-Fee on File No HOME BLOOD GLUCOSE MONITOR 0 999 07/01/2020 12/31/9999 1 31.05E0610 KR-Fee on File Yes PACEMAKER MONITOR, SELF

CONTAINED, CHECKS BATTERY DEPLETION INCLUDES AUDIBLE AND VISIBLE CHECK SYSTEMS

0 999 07/01/2020 12/31/9999 1 0.74

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

0 999 07/01/2020 12/31/9999 1 221.06

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

0 999 07/01/2020 12/31/9999 1 22.11

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0610 UE-Fee on File Yes PACEMAKER MONITOR, SELF

CONTAINED, CHECKS BATTERY DEPLETION INCLUDES AUDIBLE AND VISIBLE CHECK SYSTEMS

0 999 07/01/2020 12/31/9999 1 110.53

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

0 999 07/01/2020 12/31/9999 1 1.48

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

0 999 07/01/2020 12/31/9999 1 444.99

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

0 999 07/01/2020 12/31/9999 1 44.50

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

0 999 07/01/2020 12/31/9999 1 222.50

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

0 999 07/01/2020 12/31/9999 1 8.69

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

0 999 07/01/2020 12/31/9999 1 2,605.76

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

0 999 07/01/2020 12/31/9999 1 260.58

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

0 999 07/01/2020 12/31/9999 1 1,302.88

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

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

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

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

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

0 999 10/01/2003 12/31/9999 1 224.62

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

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

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

0 999 07/01/2020 12/31/9999 1 0.89

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

0 999 07/01/2020 12/31/9999 1 267.54

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

0 999 07/01/2020 12/31/9999 1 26.75

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

0 999 07/01/2020 12/31/9999 1 133.77

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

0 999 07/01/2020 12/31/9999 1 2.19

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

0 999 07/01/2020 12/31/9999 1 657.36

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

0 999 07/01/2020 12/31/9999 1 65.74

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0630 UE-Fee on File Yes PATIENT LIFT, HYDRAULIC OR

MECHANICAL, INCLUDES ANY SEAT, SLING, STRAP(S) OR PAD(S)

0 999 07/01/2020 12/31/9999 1 328.68

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

0 999 07/01/2020 12/31/9999 1 3.59

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

0 999 07/01/2020 12/31/9999 1 1,077.44

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

0 999 07/01/2020 12/31/9999 1 107.74

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

0 999 07/01/2020 12/31/9999 1 538.72

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0642 NU-Fee on File Yes STANDING FRAME/TABLE SYSTEM,

MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC

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

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

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

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

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

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

0 20 07/01/2020 12/31/9999 1 1.90

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

0 20 07/01/2020 12/31/9999 1 568.95

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

0 20 07/01/2020 12/31/9999 1 56.90

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

0 20 07/01/2020 12/31/9999 1 284.48

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

0 999 07/01/2020 12/31/9999 1 2.85

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

0 999 07/01/2020 12/31/9999 1 853.57

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

0 999 07/01/2020 12/31/9999 1 85.36

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

0 999 07/01/2020 12/31/9999 1 426.78

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

0 999 07/01/2020 12/31/9999 1 13.96

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

0 999 07/01/2020 12/31/9999 1 4,188.06

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

0 999 07/01/2020 12/31/9999 1 418.81

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

0 999 07/01/2020 12/31/9999 1 2,094.03

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

0 20 07/01/2020 12/31/9999 2 0.28

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

0 20 07/01/2020 12/31/9999 2 85.26

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

0 20 07/01/2020 12/31/9999 2 8.53

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

0 20 07/01/2020 12/31/9999 2 42.63

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

0 20 07/01/2020 12/31/9999 2 0.49

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0660 NU-Fee on File Yes NON-SEGMENTAL PNEUMATIC

APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG

0 20 07/01/2020 12/31/9999 2 148.48

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

0 20 07/01/2020 12/31/9999 2 14.85

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

0 20 07/01/2020 12/31/9999 2 74.24

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

0 20 07/01/2020 12/31/9999 2 0.36

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

0 20 07/01/2020 12/31/9999 2 108.23

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

0 20 07/01/2020 12/31/9999 2 10.82

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

0 20 07/01/2020 12/31/9999 2 54.12

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

0 20 07/01/2020 12/31/9999 2 0.36

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

0 20 07/01/2020 12/31/9999 2 109.10

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

0 20 07/01/2020 12/31/9999 2 10.91

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

0 20 07/01/2020 12/31/9999 2 54.55

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

0 999 07/01/2020 12/31/9999 2 0.85

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

0 999 07/01/2020 12/31/9999 2 255.78

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

0 999 07/01/2020 12/31/9999 2 25.58

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

0 999 07/01/2020 12/31/9999 2 127.89

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

0 999 07/01/2020 12/31/9999 2 1.16

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

0 999 07/01/2020 12/31/9999 2 349.08

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

0 999 07/01/2020 12/31/9999 2 34.91

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

0 999 07/01/2020 12/31/9999 2 174.54

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

FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG

0 999 07/01/2020 12/31/9999 2 0.57

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

0 999 07/01/2020 12/31/9999 2 170.38

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

0 999 07/01/2020 12/31/9999 2 17.04

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

0 999 07/01/2020 12/31/9999 2 85.19

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

0 20 07/01/2020 12/31/9999 1 3.43

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

0 20 07/01/2020 12/31/9999 1 1,030.00

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

0 20 07/01/2020 12/31/9999 1 103.00

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

0 20 07/01/2020 12/31/9999 1 515.00

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

0 20 07/01/2020 12/31/9999 2 1.29

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

0 20 07/01/2020 12/31/9999 2 386.02

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

0 20 07/01/2020 12/31/9999 2 38.60

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

0 20 07/01/2020 12/31/9999 2 193.01

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

0 20 07/01/2020 12/31/9999 2 1.00

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

0 20 07/01/2020 12/31/9999 2 299.93

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

0 20 07/01/2020 12/31/9999 2 29.99

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

0 20 07/01/2020 12/31/9999 2 149.96

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

0 20 07/01/2020 12/31/9999 2 0.83

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

0 20 07/01/2020 12/31/9999 2 249.23

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

0 20 07/01/2020 12/31/9999 2 24.92

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

0 20 07/01/2020 12/31/9999 2 124.62

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

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

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

0 20 07/01/2020 12/31/9999 1 2.78

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0691 NU-Fee on File Yes ULTRAVIOLET LIGHT THERAPY SYSTEM,

INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESS

0 20 07/01/2020 12/31/9999 1 835.14

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

0 20 07/01/2020 12/31/9999 1 83.51

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

0 20 07/01/2020 12/31/9999 1 417.57

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

0 20 07/01/2020 12/31/9999 1 3.50

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

0 20 07/01/2020 12/31/9999 1 1,048.71

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

0 20 07/01/2020 12/31/9999 1 104.87

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

0 20 07/01/2020 12/31/9999 1 524.36

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

0 20 07/01/2020 12/31/9999 1 4.31

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

0 20 07/01/2020 12/31/9999 1 1,292.76

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

0 20 07/01/2020 12/31/9999 1 129.28

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

0 20 07/01/2020 12/31/9999 1 646.38

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

0 20 07/01/2020 12/31/9999 1 13.72

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

0 20 07/01/2020 12/31/9999 1 4,114.74

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

0 20 07/01/2020 12/31/9999 1 411.47

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

0 20 07/01/2020 12/31/9999 1 2,057.37

E0705 NU-Fee on File Yes TRANSFER DEVICE, ANY TYPE, EACH 0 999 07/01/2020 12/31/9999 1 45.66

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0720 KR-Fee on File Yes TRANSCUTANEOUS ELECTRICAL NERVE

STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED STIMULATION

0 999 07/01/2020 12/31/9999 1 0.67

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

0 999 07/01/2020 12/31/9999 1 199.82

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

0 999 07/01/2020 12/31/9999 1 19.98

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

0 999 07/01/2020 12/31/9999 1 99.91

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

0 999 07/01/2020 12/31/9999 1 0.67

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

0 999 07/01/2020 12/31/9999 1 201.50

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

0 999 07/01/2020 12/31/9999 1 20.15

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

0 999 07/01/2020 12/31/9999 1 100.75

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

0 999 07/01/2020 12/31/9999 1 0.67

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

0 999 07/01/2020 12/31/9999 1 202.08

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

0 999 07/01/2020 12/31/9999 1 20.21

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

0 999 07/01/2020 12/31/9999 1 101.04

E0744 KR-Fee on File Yes NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS

0 20 07/01/2020 12/31/9999 1 2.41

E0744 RR-Fee on File Yes NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS

0 20 07/01/2020 12/31/9999 1 72.34

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

0 999 07/01/2020 12/31/9999 1 2.36

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

0 999 07/01/2020 12/31/9999 1 70.72

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

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

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

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

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

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

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

0 999 10/01/1998 12/31/9999 1 148.13

E0747 KR-Fee on File Yes OSTEOGENISIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINAL APPLICATIONS

0 20 07/01/2020 12/31/9999 1 12.13

E0747 RR-Fee on File Yes OSTEOGENISIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINAL APPLICATIONS

0 20 07/01/2020 12/31/9999 1 363.96

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0748 KR-Fee on File Yes OSTEGENESIS STIMULATOR,

ELECTRICAL, NON INVASIVE, SPINAL APPLICATIONS

0 20 07/01/2020 12/31/9999 1 12.05

E0748 NU-Fee on File Yes OSTEGENESIS STIMULATOR, ELECTRICAL, NON INVASIVE, SPINAL APPLICATIONS

0 20 07/01/2020 12/31/9999 1 3,616.00

E0748 RR-Fee on File Yes OSTEGENESIS STIMULATOR, ELECTRICAL, NON INVASIVE, SPINAL APPLICATIONS

0 20 07/01/2020 12/31/9999 1 361.60

E0748 UE-Fee on File Yes OSTEGENESIS STIMULATOR, ELECTRICAL, NON INVASIVE, SPINAL APPLICATIONS

0 20 07/01/2020 12/31/9999 1 1,808.00

E0755 NU-Fee on File Yes ELECTRONIC SALIVARY REFLEX STIMULATOR (INTRAORAL / NONINVASIVE)

0 20 10/01/1998 12/31/9999 1 31.96

E0755 UE-Fee on File Yes ELECTRONIC SALIVARY REFLEX STIMULATOR (INTRAORAL / NONINVASIVE)

0 20 10/01/1998 12/31/9999 1 15.98

E0760 KR-Fee on File Yes OSTOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON INVASIVE

0 999 07/01/2020 12/31/9999 1 10.02

E0760 RR-Fee on File Yes OSTOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON INVASIVE

0 999 07/01/2020 12/31/9999 1 300.48

E0762 KR-Fee on File Yes TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES

0 20 07/01/2020 12/31/9999 1 3.41

E0762 NU-Fee on File Yes TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES

0 20 07/01/2020 12/31/9999 1 1,021.92

E0762 RR-Fee on File Yes TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES

0 20 07/01/2020 12/31/9999 1 102.19

E0762 UE-Fee on File Yes TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES

0 20 07/01/2020 12/31/9999 1 510.96

E0770 KR-Priced by PA Yes FUNCTIONAL ELECTRICAL STIMULATOR, TRANSCUTANEOUS STIMULATION OF NERVE AND/OR MUSCLE GROUPS, ANY TYPE, COMPLETE SYSTEM, NOS

0 20 01/01/2009 12/31/9999 1 0.00

E0770 RR-Priced by PA Yes FUNCTIONAL ELECTRICAL STIMULATOR, TRANSCUTANEOUS STIMULATION OF NERVE AND/OR MUSCLE GROUPS, ANY TYPE, COMPLETE SYSTEM, NOS

0 20 01/01/2009 12/31/9999 1 0.00

E0776 KR-Fee on File Yes IV POLE 0 999 07/01/2020 12/31/9999 1 0.42E0776 NU-Fee on File Yes IV POLE 0 999 07/01/2020 12/31/9999 1 125.05E0776 RR-Fee on File Yes IV POLE 0 999 07/01/2020 12/31/9999 1 12.50E0776 UE-Fee on File Yes IV POLE 0 999 07/01/2020 12/31/9999 1 62.52E0781 KR-Fee on File Yes AMBULATORY INFUSION PUMP, SINGLE

OR MULTIPLE CHANNELS, ELECTRIC OR BATTERY OPERATED, WITH ADMINISTRATIVE EQUIPMENT WORN BY PATIENT

0 999 07/01/2020 12/31/9999 1 6.98

E0781 RR-Fee on File Yes AMBULATORY INFUSION PUMP, SINGLE OR MULTIPLE CHANNELS, ELECTRIC OR BATTERY OPERATED, WITH ADMINISTRATIVE EQUIPMENT WORN BY PATIENT

0 999 07/01/2020 12/31/9999 1 209.54

E0784 KR-Fee on File Yes EXTERNAL AMBULATORY INFUSION PUMP, INSULIN

0 999 07/01/2020 12/31/9999 1 12.39

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0784 NU-Fee on File Yes EXTERNAL AMBULATORY INFUSION

PUMP, INSULIN0 999 07/01/2020 12/31/9999 1 3,717.04

E0784 RR-Fee on File Yes EXTERNAL AMBULATORY INFUSION PUMP, INSULIN

0 999 07/01/2020 12/31/9999 1 371.70

E0784 UE-Fee on File Yes EXTERNAL AMBULATORY INFUSION PUMP, INSULIN

0 999 07/01/2020 12/31/9999 1 1,858.52

E0791 KR-Fee on File Yes PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTICHANNEL

0 999 07/01/2020 12/31/9999 1 8.07

E0791 NU-Fee on File Yes PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTICHANNEL

0 999 07/01/2020 12/31/9999 1 2,419.52

E0791 RR-Fee on File Yes PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTICHANNEL

0 999 07/01/2020 12/31/9999 1 241.95

E0791 UE-Fee on File Yes PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTICHANNEL

0 999 07/01/2020 12/31/9999 1 1,209.76

E0840 KR-Fee on File Yes TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION

0 999 07/01/2020 12/31/9999 1 0.23

E0840 NU-Fee on File Yes TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION

0 999 07/01/2020 12/31/9999 1 68.10

E0840 RR-Fee on File Yes TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION

0 999 07/01/2020 12/31/9999 1 6.81

E0840 UE-Fee on File Yes TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION

0 999 07/01/2020 12/31/9999 1 34.05

E0849 KR-Fee on File Yes TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE

0 999 07/01/2020 12/31/9999 1 1.60

E0849 NU-Fee on File Yes TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE

0 999 07/01/2020 12/31/9999 1 478.96

E0849 RR-Fee on File Yes TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE

0 999 07/01/2020 12/31/9999 1 47.90

E0849 UE-Fee on File Yes TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE

0 999 07/01/2020 12/31/9999 1 239.48

E0850 KR-Fee on File Yes TRACTION STAND, FREESTANDING, CERVICAL TRACTION

0 999 07/01/2020 12/31/9999 1 0.33

E0850 NU-Fee on File Yes TRACTION STAND, FREESTANDING, CERVICAL TRACTION

0 999 07/01/2020 12/31/9999 1 97.63

E0850 RR-Fee on File Yes TRACTION STAND, FREESTANDING, CERVICAL TRACTION

0 999 07/01/2020 12/31/9999 1 9.76

E0850 UE-Fee on File Yes TRACTION STAND, FREESTANDING, CERVICAL TRACTION

0 999 07/01/2020 12/31/9999 1 48.82

E0855 KR-Fee on File Yes CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME

0 999 07/01/2020 12/31/9999 1 1.56

E0855 NU-Fee on File Yes CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME

0 999 07/01/2020 12/31/9999 1 467.12

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0855 RR-Fee on File Yes CERVICAL TRACTION EQUIPMENT NOT

REQUIRING ADDITIONAL STAND OR FRAME

0 999 07/01/2020 12/31/9999 1 46.71

E0855 UE-Fee on File Yes CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME

0 999 07/01/2020 12/31/9999 1 233.56

E0856 KR-Fee on File Yes CERVICAL TRACTION DEVICE WITH INFLATABLE AIR BLADDER(S)

0 999 07/01/2020 12/31/9999 1 0.48

E0856 NU-Fee on File Yes CERVICAL TRACTION DEVICE WITH INFLATABLE AIR BLADDER(S)

0 999 07/01/2020 12/31/9999 1 143.04

E0856 RR-Fee on File Yes CERVICAL TRACTION DEVICE WITH INFLATABLE AIR BLADDER(S)

0 999 07/01/2020 12/31/9999 1 14.30

E0856 UE-Fee on File Yes CERVICAL TRACTION DEVICE WITH INFLATABLE AIR BLADDER(S)

0 999 07/01/2020 12/31/9999 1 71.52

E0860 KR-Fee on File Yes TRACTION EQUIPMENT, OVERDOOR, CERVICAL

0 999 07/01/2020 12/31/9999 1 0.12

E0860 NU-Fee on File Yes TRACTION EQUIPMENT, OVERDOOR, CERVICAL

0 999 07/01/2020 12/31/9999 1 35.82

E0860 RR-Fee on File Yes TRACTION EQUIPMENT, OVERDOOR, CERVICAL

0 999 07/01/2020 12/31/9999 1 3.58

E0860 UE-Fee on File Yes TRACTION EQUIPMENT, OVERDOOR, CERVICAL

0 999 07/01/2020 12/31/9999 1 17.91

E0870 KR-Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE EXTREMITY (E.G., BUCK'S)

0 20 07/01/2020 12/31/9999 1 0.31

E0870 NU-Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE EXTREMITY (E.G., BUCK'S)

0 20 07/01/2020 12/31/9999 1 91.89

E0870 RR-Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE EXTREMITY (E.G., BUCK'S)

0 20 07/01/2020 12/31/9999 1 9.19

E0870 UE-Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE EXTREMITY (E.G., BUCK'S)

0 20 07/01/2020 12/31/9999 1 45.94

E0880 KR-Fee on File Yes TRACTION STAND, FREESTANDING, EXTREMITY TRACTION (E.G., BUCK'S)

0 20 07/01/2020 12/31/9999 1 0.33

E0880 NU-Fee on File Yes TRACTION STAND, FREESTANDING, EXTREMITY TRACTION (E.G., BUCK'S)

0 20 07/01/2020 12/31/9999 1 99.18

E0880 RR-Fee on File Yes TRACTION STAND, FREESTANDING, EXTREMITY TRACTION (E.G., BUCK'S)

0 20 07/01/2020 12/31/9999 1 9.92

E0880 UE-Fee on File Yes TRACTION STAND, FREESTANDING, EXTREMITY TRACTION (E.G., BUCK'S)

0 20 07/01/2020 12/31/9999 1 49.59

E0890 KR-Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTION

0 999 07/01/2020 12/31/9999 1 0.32

E0890 NU-Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTION

0 999 07/01/2020 12/31/9999 1 95.11

E0890 RR-Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTION

0 999 07/01/2020 12/31/9999 1 9.51

E0890 UE-Fee on File Yes TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTION

0 999 07/01/2020 12/31/9999 1 47.56

E0900 KR-Fee on File Yes TRACTION STAND, FREE STANDING, PELVIC TRACTION, (E.G., BUCK'S)

0 999 07/01/2020 12/31/9999 1 0.34

E0900 NU-Fee on File Yes TRACTION STAND, FREE STANDING, PELVIC TRACTION, (E.G., BUCK'S)

0 999 07/01/2020 12/31/9999 1 101.22

E0900 RR-Fee on File Yes TRACTION STAND, FREE STANDING, PELVIC TRACTION, (E.G., BUCK'S)

0 999 07/01/2020 12/31/9999 1 10.12

E0900 UE-Fee on File Yes TRACTION STAND, FREE STANDING, PELVIC TRACTION, (E.G., BUCK'S)

0 999 07/01/2020 12/31/9999 1 50.61

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0910 KR-Fee on File Yes TRAPEZE BARS, ALSO KNOWN AS

PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 0.40

E0910 NU-Fee on File Yes TRAPEZE BARS, ALSO KNOWN AS PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 118.72

E0910 RR-Fee on File Yes TRAPEZE BARS, ALSO KNOWN AS PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 11.87

E0910 UE-Fee on File Yes TRAPEZE BARS, ALSO KNOWN AS PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 59.36

E0911 KR-Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 1.27

E0911 NU-Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 382.08

E0911 RR-Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 38.21

E0911 UE-Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED, WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 191.04

E0912 KR-Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREESTANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 2.71

E0912 NU-Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREESTANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 812.56

E0912 RR-Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREESTANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 81.26

E0912 UE-Fee on File Yes TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREESTANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 406.28

E0940 KR-Fee on File Yes TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 0.70

E0940 NU-Fee on File Yes TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 209.52

E0940 RR-Fee on File Yes TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 20.95

E0940 UE-Fee on File Yes TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR

0 999 07/01/2020 12/31/9999 1 104.76

E0941 KR-Fee on File Yes GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE

0 20 07/01/2020 12/31/9999 1 1.14

E0941 NU-Fee on File Yes GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE

0 20 07/01/2020 12/31/9999 1 342.88

E0941 RR-Fee on File Yes GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE

0 20 07/01/2020 12/31/9999 1 34.29

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0941 UE-Fee on File Yes GRAVITY ASSISTED TRACTION DEVICE,

ANY TYPE0 20 07/01/2020 12/31/9999 1 171.44

E0950 NU-Fee on File Yes WHEELCHAIR ACCESSORY, TRAY, EACH 0 999 07/01/2020 12/31/9999 1 74.15E0950 UE-Fee on File Yes WHEELCHAIR ACCESSORY, TRAY, EACH 0 999 07/01/2020 12/31/9999 1 37.08E0951 NU-Fee on File Yes HEEL LOOP/HOLDER, ANY TYPE, WITH

OR WITHOUT ANKLE STRAP, EACH0 999 07/01/2020 12/31/9999 2 12.07

E0951 UE-Fee on File Yes HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH

0 999 07/01/2020 12/31/9999 2 6.04

E0952 NU-Fee on File Yes TOE LOOP/HOLDER, ANY TYPE, EACH 0 20 07/01/2020 12/31/9999 2 14.13E0952 UE-Fee on File Yes TOE LOOP/HOLDER, ANY TYPE, EACH 0 20 07/01/2020 12/31/9999 2 7.06E0958 NU-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY,

ONE-ARM DRIVE ATTACHMENT, EACH0 20 07/01/2020 12/31/9999 1 360.56

E0958 UE-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH

0 20 07/01/2020 12/31/9999 1 180.28

E0959 NU-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH

0 20 07/01/2020 12/31/9999 2 39.07

E0959 UE-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH

0 20 07/01/2020 12/31/9999 2 19.54

E0961 NU-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH

0 20 07/01/2020 12/31/9999 2 20.50

E0961 UE-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH

0 20 07/01/2020 12/31/9999 2 10.25

E0966 NU-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH

0 20 07/01/2020 12/31/9999 1 56.38

E0966 UE-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH

0 20 07/01/2020 12/31/9999 1 28.19

E0967 NU-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, REPLACEMENT ONLY, EACH

0 20 07/01/2020 12/31/9999 2 61.04

E0967 UE-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, REPLACEMENT ONLY, EACH

0 20 07/01/2020 12/31/9999 2 30.52

E0968 NU-Fee on File Yes COMMODE SEAT, WHEELCHAIR 0 20 07/01/2020 12/31/9999 1 166.56E0968 UE-Fee on File Yes COMMODE SEAT, WHEELCHAIR 0 20 07/01/2020 12/31/9999 1 83.28E0969 NU-Fee on File Yes NARROWING DEVICE, WHEELCHAIR 0 20 07/01/2020 12/31/9999 1 145.57E0969 UE-Fee on File Yes NARROWING DEVICE, WHEELCHAIR 0 20 07/01/2020 12/31/9999 1 72.78E0970 NU-Fee on File Yes NO. 2 FOOTPLATES, EXCEPT FOR

ELEVATING LEG REST0 20 10/01/1998 12/31/9999 1 31.24

E0970 UE-Fee on File Yes NO. 2 FOOTPLATES, EXCEPT FOR ELEVATING LEG REST

0 20 10/01/1998 12/31/9999 1 15.62

E0971 NU-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH

0 999 07/01/2020 12/31/9999 2 33.06

E0971 UE-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH

0 999 07/01/2020 12/31/9999 2 16.53

E0973 NU-Fee on File Yes WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH

0 999 07/01/2020 12/31/9999 2 61.94

E0973 UE-Fee on File Yes WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH

0 999 07/01/2020 12/31/9999 2 30.97

E0974 NU-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH

0 20 07/01/2020 12/31/9999 2 67.78

E0974 UE-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH

0 20 07/01/2020 12/31/9999 2 33.89

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE0978 NU-Fee on File Yes WHEELCHAIR ACCESSORY,

POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH

0 999 07/01/2020 12/31/9999 1 27.55

E0978 UE-Fee on File Yes WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH

0 999 07/01/2020 12/31/9999 1 13.78

E0980 NU-Fee on File Yes SAFETY VEST, WHEELCHAIR 0 20 07/01/2020 12/31/9999 1 30.28E0980 UE-Fee on File Yes SAFETY VEST, WHEELCHAIR 0 20 07/01/2020 12/31/9999 1 15.14E0990 NU-Fee on File Yes WHEELCHAIR ACCESSORY, ELEVATING

LEG REST, COMPLETE ASSEMBLY, EACH0 999 07/01/2020 12/31/9999 2 69.95

E0990 UE-Fee on File Yes WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH

0 999 07/01/2020 12/31/9999 2 34.98

E0992 NU-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT

0 20 07/01/2020 12/31/9999 1 77.77

E0992 UE-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT

0 20 07/01/2020 12/31/9999 1 38.88

E0994 NU-Fee on File Yes ARM REST, EACH 0 20 07/01/2020 12/31/9999 2 13.93E0994 UE-Fee on File Yes ARM REST, EACH 0 20 07/01/2020 12/31/9999 2 6.96E0995 NU-Fee on File Yes WHEELCHAIR ACCESSORY, CALF

REST/PAD, REPLACEMENT ONLY, EACH0 20 07/01/2020 12/31/9999 2 20.70

E0995 UE-Fee on File Yes WHEELCHAIR ACCESSORY, CALF REST/PAD, REPLACEMENT ONLY, EACH

0 20 07/01/2020 12/31/9999 2 10.35

E1012 KR-Fee on File Yes WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH

0 20 07/01/2020 12/31/9999 1 3.00

E1012 NU-Fee on File Yes WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH

0 20 07/01/2020 12/31/9999 1 899.76

E1012 RR-Fee on File Yes WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH

0 20 07/01/2020 12/31/9999 1 89.98

E1012 UE-Fee on File Yes WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH

0 20 07/01/2020 12/31/9999 1 449.88

E1020 NU-Fee on File Yes RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE

0 20 07/01/2020 12/31/9999 2 174.08

E1020 UE-Fee on File Yes RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE

0 20 07/01/2020 12/31/9999 2 87.04

E1031 KR-Fee on File Yes ROLL ABOUT CHAIR, ANY AND ALL TYPES WITH CUSTORS 5 INCHES OR GREATER

0 20 07/01/2020 12/31/9999 1 1.27

E1031 NU-Fee on File Yes ROLL ABOUT CHAIR, ANY AND ALL TYPES WITH CUSTORS 5 INCHES OR GREATER

0 20 07/01/2020 12/31/9999 1 382.32

E1031 RR-Fee on File Yes ROLL ABOUT CHAIR, ANY AND ALL TYPES WITH CUSTORS 5 INCHES OR GREATER

0 20 07/01/2020 12/31/9999 1 38.23

E1031 UE-Fee on File Yes ROLL ABOUT CHAIR, ANY AND ALL TYPES WITH CUSTORS 5 INCHES OR GREATER

0 20 07/01/2020 12/31/9999 1 191.16

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1037 KR-Fee on File Yes TRANSPORT CHAIR, PEDIATRIC SIZE 0 999 07/01/2020 12/31/9999 1 3.21E1037 NU-Fee on File Yes TRANSPORT CHAIR, PEDIATRIC SIZE 0 999 07/01/2020 12/31/9999 1 962.16E1037 RR-Fee on File Yes TRANSPORT CHAIR, PEDIATRIC SIZE 0 999 07/01/2020 12/31/9999 1 96.22E1037 UE-Fee on File Yes TRANSPORT CHAIR, PEDIATRIC SIZE 0 999 07/01/2020 12/31/9999 1 481.08E1038 KR-Fee on File Yes TRANSPORT CHAIR, ADULT SIZE,

PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

0 999 07/01/2020 12/31/9999 1 0.49

E1038 NU-Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

0 999 07/01/2020 12/31/9999 1 146.40

E1038 RR-Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

0 999 07/01/2020 12/31/9999 1 14.64

E1038 UE-Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

0 999 07/01/2020 12/31/9999 1 73.20

E1039 KR-Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS

0 999 07/01/2020 12/31/9999 1 1.00

E1039 NU-Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS

0 999 07/01/2020 12/31/9999 1 299.68

E1039 RR-Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS

0 999 07/01/2020 12/31/9999 1 29.97

E1039 UE-Fee on File Yes TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS

0 999 07/01/2020 12/31/9999 1 149.84

E1050 KR-Fee on File Yes FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 2.68

E1050 NU-Fee on File Yes FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 804.56

E1050 RR-Fee on File Yes FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 80.46

E1050 UE-Fee on File Yes FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 402.28

E1060 KR-Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 3.32

E1060 NU-Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 995.84

E1060 RR-Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 99.58

E1060 UE-Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 497.92

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1070 KR-Fee on File Yes FULLY-RECLINING WHEELCHAIR,

DETACHABLE ARMS (DESK OR FULL LENGTH) SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 2.88

E1070 NU-Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 865.36

E1070 RR-Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 86.54

E1070 UE-Fee on File Yes FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 432.68

E1083 KR-Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 2.07

E1083 NU-Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 622.08

E1083 RR-Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 62.21

E1083 UE-Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 311.04

E1084 KR-Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 2.58

E1084 NU-Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 774.96

E1084 RR-Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 77.50

E1084 UE-Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 387.48

E1085 NU-Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 471.32

E1085 UE-Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 235.66

E1085 KR-Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 1.57

E1085 RR-Fee on File Yes HEMI WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 47.13

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1086 NU-Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS

DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 572.38

E1086 KR-Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 1.91

E1086 RR-Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 57.24

E1086 UE-Fee on File Yes HEMI WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 286.21

E1087 KR-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY, DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 3.33

E1087 NU-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY, DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 999.60

E1087 RR-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY, DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 99.96

E1087 UE-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY, DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 499.80

E1088 KR-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH SWING-AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 3.97

E1088 NU-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH SWING-AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 1,191.12

E1088 RR-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH SWING-AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 119.11

E1088 UE-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH SWING-AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 595.56

E1089 NU-Fee on File Yes HIGH STRENGTH WHEELCHAIR, FIXED LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 818.58

E1089 UE-Fee on File Yes HIGH STRENGTH WHEELCHAIR, FIXED LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 409.29

E1089 KR-Fee on File Yes HIGH STRENGTH WHEELCHAIR, FIXED LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 2.73

E1089 RR-Fee on File Yes HIGH STRENGTH WHEELCHAIR, FIXED LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 10/01/1998 12/31/9999 1 81.86

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1090 KR-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT

WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWINGAWAY, DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 3.09

E1090 NU-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWINGAWAY, DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 927.36

E1090 RR-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWINGAWAY, DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 92.74

E1090 UE-Fee on File Yes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWINGAWAY, DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 463.68

E1092 KR-Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 3.90

E1092 NU-Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 1,168.96

E1092 RR-Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 116.90

E1092 UE-Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 584.48

E1093 KR-Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 3.34

E1093 NU-Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 1,002.16

E1093 RR-Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 100.22

E1093 UE-Fee on File Yes WIDE HEAVY DUTY WHEELCHAIR; DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING-AWAY, DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 501.08

E1100 KR-Fee on File Yes SEMI-RECLINING WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 2.73

E1100 NU-Fee on File Yes SEMI-RECLINING WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 820.00

E1100 RR-Fee on File Yes SEMI-RECLINING WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 82.00

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1100 UE-Fee on File Yes SEMI-RECLINING WHEELCHAIR; FIXED

FULL LENGTH ARMS, SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 410.00

E1110 KR-Fee on File Yes SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 2.68

E1110 NU-Fee on File Yes SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 803.04

E1110 RR-Fee on File Yes SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 80.30

E1110 UE-Fee on File Yes SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 401.52

E1130 KR-Fee on File Yes STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 1.06

E1130 NU-Fee on File Yes STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 318.02

E1130 RR-Fee on File Yes STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 31.80

E1130 UE-Fee on File Yes STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 159.01

E1140 KR-Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 1.63

E1140 NU-Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 489.22

E1140 RR-Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 48.92

E1140 UE-Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 244.61

E1150 KR-Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 2.15

E1150 NU-Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 644.40

E1150 RR-Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 64.44

E1150 UE-Fee on File Yes WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 322.20

E1160 KR-Fee on File Yes WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 1.65

E1160 NU-Fee on File Yes WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 493.84

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1160 RR-Fee on File Yes WHEELCHAIR, FIXED FULL LENGTH

ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 49.38

E1160 UE-Fee on File Yes WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 246.92

E1161 KR-Fee on File Yes MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE

0 999 07/01/2020 12/31/9999 1 7.33

E1161 NU-Fee on File Yes MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE

0 999 07/01/2020 12/31/9999 1 2,198.96

E1161 RR-Fee on File Yes MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE

0 999 07/01/2020 12/31/9999 1 219.90

E1161 UE-Fee on File Yes MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE

0 999 07/01/2020 12/31/9999 1 1,099.48

E1170 KR-Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESETS

0 999 07/01/2020 12/31/9999 1 2.35

E1170 NU-Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESETS

0 999 07/01/2020 12/31/9999 1 705.60

E1170 RR-Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESETS

0 999 07/01/2020 12/31/9999 1 70.56

E1170 UE-Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESETS

0 999 07/01/2020 12/31/9999 1 352.80

E1171 KR-Fee on File Yes AMPUTEE, WHEELCHAIR, FIXED FULL LENGTH ARMS WITHOUT FOOT RESTS OR LEG RESTS

0 999 07/01/2020 12/31/9999 1 2.11

E1171 NU-Fee on File Yes AMPUTEE, WHEELCHAIR, FIXED FULL LENGTH ARMS WITHOUT FOOT RESTS OR LEG RESTS

0 999 07/01/2020 12/31/9999 1 633.12

E1171 RR-Fee on File Yes AMPUTEE, WHEELCHAIR, FIXED FULL LENGTH ARMS WITHOUT FOOT RESTS OR LEG RESTS

0 999 07/01/2020 12/31/9999 1 63.31

E1171 UE-Fee on File Yes AMPUTEE, WHEELCHAIR, FIXED FULL LENGTH ARMS WITHOUT FOOT RESTS OR LEG RESTS

0 999 07/01/2020 12/31/9999 1 316.56

E1172 KR-Fee on File Yes AMPUTEE, WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH WITHOUT FOOTRESTS OR LEGRESTS

0 999 07/01/2020 12/31/9999 1 2.58

E1172 NU-Fee on File Yes AMPUTEE, WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH WITHOUT FOOTRESTS OR LEGRESTS

0 999 07/01/2020 12/31/9999 1 774.00

E1172 RR-Fee on File Yes AMPUTEE, WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH WITHOUT FOOTRESTS OR LEGRESTS

0 999 07/01/2020 12/31/9999 1 77.40

E1172 UE-Fee on File Yes AMPUTEE, WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH WITHOUT FOOTRESTS OR LEGRESTS

0 999 07/01/2020 12/31/9999 1 387.00

E1180 KR-Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 2.67

E1180 NU-Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 800.48

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1180 RR-Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE

ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 80.05

E1180 UE-Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 400.24

E1190 KR-Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 3.08

E1190 NU-Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 924.88

E1190 RR-Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 92.49

E1190 UE-Fee on File Yes AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 462.44

E1195 KR-Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 3.31

E1195 NU-Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 992.40

E1195 RR-Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 99.24

E1195 UE-Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 496.20

E1200 KR-Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 2.29

E1200 NU-Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 687.36

E1200 RR-Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 68.74

E1200 UE-Fee on File Yes AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 07/01/2020 12/31/9999 1 343.68

E1220 NU-Priced by PA Yes WHEELCHAIR; SPECIALLY SIZE OR CONTRUCTED (INDICATE BRAND NAME, MODEL NUMBER, IF ANY, AND JUSTIFCATION)

0 999 10/01/1998 12/31/9999 1 0.00

E1221 KR-Fee on File Yes WHEELCHAIR WITH FIXED ARM, FOOTRESTS

0 999 07/01/2020 12/31/9999 1 1.47

E1221 NU-Fee on File Yes WHEELCHAIR WITH FIXED ARM, FOOTRESTS

0 999 07/01/2020 12/31/9999 1 441.60

E1221 RR-Fee on File Yes WHEELCHAIR WITH FIXED ARM, FOOTRESTS

0 999 07/01/2020 12/31/9999 1 44.16

E1221 UE-Fee on File Yes WHEELCHAIR WITH FIXED ARM, FOOTRESTS

0 999 07/01/2020 12/31/9999 1 220.80

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1222 KR-Fee on File Yes WHEELCHAIR WITH FIXED ARM,

ELEVATING LEGRESTS0 999 07/01/2020 12/31/9999 1 2.10

E1222 NU-Fee on File Yes WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 629.92

E1222 RR-Fee on File Yes WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 62.99

E1222 UE-Fee on File Yes WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 314.96

E1223 KR-Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS

0 999 07/01/2020 12/31/9999 1 2.29

E1223 NU-Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS

0 999 07/01/2020 12/31/9999 1 687.92

E1223 RR-Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS

0 999 07/01/2020 12/31/9999 1 68.79

E1223 UE-Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS

0 999 07/01/2020 12/31/9999 1 343.96

E1224 KR-Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 2.51

E1224 NU-Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 754.16

E1224 RR-Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 75.42

E1224 UE-Fee on File Yes WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 377.08

E1225 KR-Fee on File Yes WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH

0 999 07/01/2020 12/31/9999 1 1.17

E1225 NU-Fee on File Yes WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH

0 999 07/01/2020 12/31/9999 1 349.52

E1225 RR-Fee on File Yes WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH

0 999 07/01/2020 12/31/9999 1 34.95

E1225 UE-Fee on File Yes WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH

0 999 07/01/2020 12/31/9999 1 174.76

E1226 KR-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, FULLY RECLINING BACK (RECLINE GREATER THAN 80 DEGREES), EACH

0 999 07/01/2020 12/31/9999 1 1.38

E1226 NU-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, FULLY RECLINING BACK (RECLINE GREATER THAN 80 DEGREES), EACH

0 999 07/01/2020 12/31/9999 1 415.27

E1226 RR-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, FULLY RECLINING BACK (RECLINE GREATER THAN 80 DEGREES), EACH

0 999 07/01/2020 12/31/9999 1 41.53

E1226 UE-Fee on File Yes MANUAL WHEELCHAIR ACCESSORY, FULLY RECLINING BACK (RECLINE GREATER THAN 80 DEGREES), EACH

0 999 07/01/2020 12/31/9999 1 207.64

E1227 NU-Fee on File Yes SPECIAL HEIGHT ARMS FOR WHEELCHAIR

0 999 07/01/2020 12/31/9999 1 257.91

E1228 NU-Fee on File Yes SPECIAL BACK HEIGHT FOR WHEELCHAIR

0 999 07/01/2020 12/31/9999 1 221.44

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1230 NU-Fee on File Yes POWER OPERATED VEHICLE (THREE OR

FOUR WHEEL NONHIGHWAY) SPECIFY BRAND NAME AND MODEL NUMBER

0 20 07/01/2020 12/31/9999 1 1,786.79

E1230 UE-Fee on File Yes POWER OPERATED VEHICLE (THREE OR FOUR WHEEL NONHIGHWAY) SPECIFY BRAND NAME AND MODEL NUMBER

0 20 07/01/2020 12/31/9999 1 893.40

E1232 KR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEA

0 20 07/01/2020 12/31/9999 1 6.63

E1232 NU-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEA

0 20 07/01/2020 12/31/9999 1 1,987.60

E1232 RR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEA

0 20 07/01/2020 12/31/9999 1 198.76

E1232 UE-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEA

0 20 07/01/2020 12/31/9999 1 993.80

E1233 KR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SE

0 20 07/01/2020 12/31/9999 1 6.86

E1233 NU-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SE

0 20 07/01/2020 12/31/9999 1 2,059.28

E1233 RR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SE

0 20 07/01/2020 12/31/9999 1 205.93

E1233 UE-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SE

0 20 07/01/2020 12/31/9999 1 1,029.64

E1234 KR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT

0 20 07/01/2020 12/31/9999 1 5.98

E1234 NU-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT

0 20 07/01/2020 12/31/9999 1 1,792.80

E1234 RR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT

0 20 07/01/2020 12/31/9999 1 179.28

E1234 UE-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT

0 20 07/01/2020 12/31/9999 1 896.40

E1235 KR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 5.75

E1235 NU-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 1,726.40

E1235 RR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 172.64

E1235 UE-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 863.20

E1236 KR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING

0 20 07/01/2020 12/31/9999 1 5.08

E1236 NU-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING

0 20 07/01/2020 12/31/9999 1 1,523.04

E1236 RR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING

0 20 07/01/2020 12/31/9999 1 152.30

E1236 UE-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING

0 20 07/01/2020 12/31/9999 1 761.52

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1237 KR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID,

ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 5.12

E1237 NU-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 1,536.32

E1237 RR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 153.63

E1237 UE-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 768.16

E1238 KR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 5.08

E1238 NU-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 1,523.04

E1238 RR-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 152.30

E1238 UE-Fee on File Yes WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM

0 20 07/01/2020 12/31/9999 1 761.52

E1240 KR-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 2.71

E1240 NU-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 813.92

E1240 RR-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 81.39

E1240 UE-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 406.96

E1250 KR-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 2 1.73

E1250 NU-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 517.61

E1250 RR-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 51.76

E1250 UE-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 258.80

E1260 KR-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 2.12

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1260 NU-Fee on File Yes LIGHTWEIGHT WHEELCHAIR,

DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 634.79

E1260 RR-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 63.48

E1260 UE-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 317.39

E1270 KR-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 2.08

E1270 NU-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 623.60

E1270 RR-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 62.36

E1270 UE-Fee on File Yes LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 311.80

E1280 KR-Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 3.46

E1280 NU-Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 1,036.96

E1280 RR-Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 103.70

E1280 UE-Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS

0 999 07/01/2020 12/31/9999 1 518.48

E1285 KR-Fee on File Yes HEAVY DUTY WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 2.74

E1285 NU-Fee on File Yes HEAVY DUTY WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 821.35

E1285 RR-Fee on File Yes HEAVY DUTY WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 82.14

E1285 UE-Fee on File Yes HEAVY DUTY WHEELCHAIR; FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 410.68

E1290 KR-Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 2.84

E1290 NU-Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 852.26

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1290 RR-Fee on File Yes HEAVY DUTY WHEELCHAIR,

DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 85.23

E1290 UE-Fee on File Yes HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE FOOTRESTS

0 999 05/01/1999 12/31/9999 1 426.13

E1295 KR-Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEG RESTS

0 999 07/01/2020 12/31/9999 1 3.20

E1295 NU-Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEG RESTS

0 999 07/01/2020 12/31/9999 1 959.52

E1295 RR-Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEG RESTS

0 999 07/01/2020 12/31/9999 1 95.95

E1295 UE-Fee on File Yes HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEG RESTS

0 999 07/01/2020 12/31/9999 1 479.76

E1296 KR-Fee on File Yes SPECIAL WHEELCHAIR; SEAT HEIGHT FROM FLOOR

0 999 07/01/2020 12/31/9999 1 1.52

E1296 NU-Fee on File Yes SPECIAL WHEELCHAIR; SEAT HEIGHT FROM FLOOR

0 999 07/01/2020 12/31/9999 1 456.94

E1296 RR-Fee on File Yes SPECIAL WHEELCHAIR; SEAT HEIGHT FROM FLOOR

0 999 07/01/2020 12/31/9999 1 45.69

E1296 UE-Fee on File Yes SPECIAL WHEELCHAIR; SEAT HEIGHT FROM FLOOR

0 999 07/01/2020 12/31/9999 1 228.47

E1297 KR-Fee on File Yes SPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERY

0 999 07/01/2020 12/31/9999 1 0.32

E1297 NU-Fee on File Yes SPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERY

0 999 07/01/2020 12/31/9999 1 97.22

E1297 RR-Fee on File Yes SPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERY

0 999 07/01/2020 12/31/9999 1 9.72

E1297 UE-Fee on File Yes SPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERY

0 999 07/01/2020 12/31/9999 1 48.61

E1298 KR-Fee on File Yes SPECIAL WHEELCHAIR; SEAT DEPTH AND/OR WIDTH BY CONSTRUCTION

0 999 07/01/2020 12/31/9999 1 1.31

E1298 NU-Fee on File Yes SPECIAL WHEELCHAIR; SEAT DEPTH AND/OR WIDTH BY CONSTRUCTION

0 999 07/01/2020 12/31/9999 1 393.75

E1298 RR-Fee on File Yes SPECIAL WHEELCHAIR; SEAT DEPTH AND/OR WIDTH BY CONSTRUCTION

0 999 07/01/2020 12/31/9999 1 39.38

E1298 UE-Fee on File Yes SPECIAL WHEELCHAIR; SEAT DEPTH AND/OR WIDTH BY CONSTRUCTION

0 999 07/01/2020 12/31/9999 1 196.88

E1300 KR-Fee on File Yes WHIRLPOOL, PORTABLE (OVERTUB TYPE)

0 20 10/01/1998 12/31/9999 1 0.20

E1300 NU-Fee on File Yes WHIRLPOOL, PORTABLE (OVERTUB TYPE)

0 20 10/01/1998 12/31/9999 1 59.25

E1300 RR-Fee on File Yes WHIRLPOOL, PORTABLE (OVERTUB TYPE)

0 20 10/01/1998 12/31/9999 1 5.93

E1300 UE-Fee on File Yes WHIRLPOOL, PORTABLE (OVERTUB TYPE)

0 20 10/01/1998 12/31/9999 1 29.63

E1390 KR-Fee on File Yes OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE

0 999 07/01/2020 12/31/9999 1 3.65

E1390 RR-Fee on File Yes OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE

0 999 07/01/2020 12/31/9999 1 109.42

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1391 KR-Fee on File Yes OXYGEN CONCENTRATOR 0 999 07/01/2020 12/31/9999 1 3.65E1391 RR-Fee on File Yes OXYGEN CONCENTRATOR 0 999 07/01/2020 12/31/9999 1 109.42E1392 KR-Fee on File Yes PORTABLE OXYGEN CONCENTRATOR,

RENTAL0 999 07/01/2020 12/31/9999 1 1.20

E1392 RR-Fee on File Yes PORTABLE OXYGEN CONCENTRATOR, RENTAL

0 999 07/01/2020 12/31/9999 1 35.97

E1399 KR-Priced by PA Yes DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

0 999 01/01/1983 12/31/9999 1 0.00

E1399 NU-Priced by PA Yes DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

0 999 01/01/1983 12/31/9999 1 0.00

E1399 RR-Priced by PA Yes DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

0 999 01/01/1983 12/31/9999 1 0.00

E1399 UE-Priced by PA Yes DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

0 999 01/01/1983 12/31/9999 1 0.00

E1405 KR-Fee on File Yes OXYGEN AND WATER VAPOR ENRICHING SYSTEM, WITH HEATED DELIVERY

0 999 07/01/2020 12/31/9999 1 4.53

E1405 RR-Fee on File Yes OXYGEN AND WATER VAPOR ENRICHING SYSTEM, WITH HEATED DELIVERY

0 999 07/01/2020 12/31/9999 1 135.82

E1406 KR-Fee on File Yes OXYGEN AND WATER VAPOR ENRICHING SYSTEM, WITHOUT HEATED DELIVERY

0 999 07/01/2020 12/31/9999 1 3.99

E1406 RR-Fee on File Yes OXYGEN AND WATER VAPOR ENRICHING SYSTEM, WITHOUT HEATED DELIVERY

0 999 07/01/2020 12/31/9999 1 119.62

E1700 NU-Fee on File Yes JAW MOTION REHABILITATION SYSTEM 0 20 07/01/2020 12/31/9999 1 320.56E1700 UE-Fee on File Yes JAW MOTION REHABILITATION SYSTEM 0 20 07/01/2020 12/31/9999 1 160.28E1701 NU-Fee on File Yes REPLACEMENT CUSHIONS FOR JAW

MOTION REHABILITATION SYSTEM, PKG OF 6

0 20 07/01/2020 12/31/9999 3 8.37

E1702 NU-Fee on File Yes REPLACEMENT MEASURING SCALES FOR JAW MOTION REHABILITATION SYSTEM, PKG OF 200

0 20 07/01/2020 12/31/9999 1 17.82

E1800 KR-Fee on File Yes DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 3.23

E1800 NU-Fee on File Yes DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 967.76

E1800 RR-Fee on File Yes DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 96.78

E1800 UE-Fee on File Yes DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 483.88

E1801 KR-Fee on File Yes STATIC PROGRESSIVE STRETCH ELBOW DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 3.58

E1801 NU-Fee on File Yes STATIC PROGRESSIVE STRETCH ELBOW DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 1,074.48

E1801 RR-Fee on File Yes STATIC PROGRESSIVE STRETCH ELBOW DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 107.45

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1801 UE-Fee on File Yes STATIC PROGRESSIVE STRETCH ELBOW

DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 537.24

E1805 KR-Fee on File Yes DYNAMIC ADJUSTABLE WRIST EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 3.33

E1805 NU-Fee on File Yes DYNAMIC ADJUSTABLE WRIST EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 998.16

E1805 RR-Fee on File Yes DYNAMIC ADJUSTABLE WRIST EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 99.82

E1805 UE-Fee on File Yes DYNAMIC ADJUSTABLE WRIST EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 499.08

E1806 KR-Fee on File Yes STATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEX AND/OR EXT W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 2.94

E1806 NU-Fee on File Yes STATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEX AND/OR EXT W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 881.76

E1806 RR-Fee on File Yes STATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEX AND/OR EXT W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 88.18

E1806 UE-Fee on File Yes STATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEX AND/OR EXT W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 440.88

E1810 KR-Fee on File Yes DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 3.28

E1810 NU-Fee on File Yes DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 984.24

E1810 RR-Fee on File Yes DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 98.42

E1810 UE-Fee on File Yes DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 492.12

E1811 KR-Fee on File Yes STATIC PROGRESSIVE STRETCH KNEE DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 3.72

E1811 NU-Fee on File Yes STATIC PROGRESSIVE STRETCH KNEE DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 1,117.12

E1811 RR-Fee on File Yes STATIC PROGRESSIVE STRETCH KNEE DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 111.71

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1811 UE-Fee on File Yes STATIC PROGRESSIVE STRETCH KNEE

DEVICE, EXT AND/OR FLEX, W/WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 558.56

E1812 KR-Fee on File Yes DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROL

0 20 07/01/2020 12/31/9999 2 2.66

E1812 NU-Fee on File Yes DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROL

0 20 07/01/2020 12/31/9999 2 799.20

E1812 RR-Fee on File Yes DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROL

0 20 07/01/2020 12/31/9999 2 79.92

E1812 UE-Fee on File Yes DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROL

0 20 07/01/2020 12/31/9999 2 399.60

E1815 KR-Fee on File Yes DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 3.33

E1815 NU-Fee on File Yes DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 998.16

E1815 RR-Fee on File Yes DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 99.82

E1815 UE-Fee on File Yes DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 499.08

E1816 KR-Fee on File Yes STATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEX AND/OR EXT, W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 3.78

E1816 NU-Fee on File Yes STATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEX AND/OR EXT, W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 1,134.32

E1816 RR-Fee on File Yes STATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEX AND/OR EXT, W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 113.43

E1816 UE-Fee on File Yes STATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEX AND/OR EXT, W/ WO RANGE OF MOTION ADJ, INCL ALL COMPONENTS AND ACCESSORIES

0 20 07/01/2020 12/31/9999 2 567.16

E1818 KR-Fee on File Yes STATIC PROGRESSIVE STRETCH FOREARM PRONATION / SUPINATION DEVICE, W/WO RANGE OF MOTION ADJ, INCL ALL COMP AND ACCS

0 20 07/01/2020 12/31/9999 2 3.86

E1818 NU-Fee on File Yes STATIC PROGRESSIVE STRETCH FOREARM PRONATION / SUPINATION DEVICE, W/WO RANGE OF MOTION ADJ, INCL ALL COMP AND ACCS

0 20 07/01/2020 12/31/9999 2 1,158.40

E1818 RR-Fee on File Yes STATIC PROGRESSIVE STRETCH FOREARM PRONATION / SUPINATION DEVICE, W/WO RANGE OF MOTION ADJ, INCL ALL COMP AND ACCS

0 20 07/01/2020 12/31/9999 2 115.84

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE1818 UE-Fee on File Yes STATIC PROGRESSIVE STRETCH

FOREARM PRONATION / SUPINATION DEVICE, W/WO RANGE OF MOTION ADJ, INCL ALL COMP AND ACCS

0 20 07/01/2020 12/31/9999 2 579.20

E1820 KR-Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE

0 20 07/01/2020 12/31/9999 2 0.25

E1820 NU-Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE

0 20 07/01/2020 12/31/9999 2 75.98

E1820 RR-Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE

0 20 07/01/2020 12/31/9999 2 7.60

E1820 UE-Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE

0 20 07/01/2020 12/31/9999 2 37.99

E1821 KR-Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH DEVICE

0 20 07/01/2020 12/31/9999 1 0.33

E1821 NU-Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH DEVICE

0 20 07/01/2020 12/31/9999 1 97.81

E1821 RR-Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH DEVICE

0 20 07/01/2020 12/31/9999 1 9.78

E1821 UE-Fee on File Yes REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH DEVICE

0 20 07/01/2020 12/31/9999 1 48.90

E1825 KR-Fee on File Yes DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 3 3.33

E1825 NU-Fee on File Yes DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 3 998.16

E1825 RR-Fee on File Yes DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 3 99.82

E1825 UE-Fee on File Yes DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 3 499.08

E1830 KR-Fee on File Yes DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 3.33

E1830 NU-Fee on File Yes DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 998.16

E1830 RR-Fee on File Yes DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 99.82

E1830 UE-Fee on File Yes DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 2 499.08

E2000 KR-Fee on File Yes GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC

0 20 07/01/2020 12/31/9999 1 1.44

E2000 NU-Fee on File Yes GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC

0 20 07/01/2020 12/31/9999 1 431.52

E2000 RR-Fee on File Yes GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC

0 20 07/01/2020 12/31/9999 1 43.15

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE2000 UE-Fee on File Yes GASTRIC SUCTION PUMP, HOME MODEL,

PORTABLE OR STATIONARY, ELECTRIC0 20 07/01/2020 12/31/9999 1 215.76

E2100 KR-Fee on File Yes BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER

0 20 07/01/2020 12/31/9999 1 1.99

E2100 NU-Fee on File Yes BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER

0 20 07/01/2020 12/31/9999 1 597.77

E2100 RR-Fee on File Yes BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER

0 20 07/01/2020 12/31/9999 1 59.78

E2100 UE-Fee on File Yes BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER

0 20 07/01/2020 12/31/9999 1 298.88

E2208 NU-Fee on File Yes WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH

0 999 07/01/2020 12/31/9999 1 80.06

E2359 NU-Fee on File Yes POWER WHEELCHAIR ACCESSORY, GROUP 34 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT)

0 999 07/01/2020 12/31/9999 2 151.86

E2361 NU-Fee on File Yes POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E.G. GEL CELL, ABSORBED GLASSMAT)

0 999 07/01/2020 12/31/9999 2 104.78

E2363 NU-Fee on File Yes POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT)

0 999 07/01/2020 12/31/9999 2 136.34

E2365 NU-Fee on File Yes POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT)

0 999 07/01/2020 12/31/9999 2 77.54

E2366 NU-Fee on File Yes POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH

0 999 07/01/2020 12/31/9999 1 172.10

E2371 NU-Fee on File Yes POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E.G. GEL CELL, ABSORBED GLASSMAT), EACH

0 999 07/01/2020 12/31/9999 2 119.74

E2397 NU-Fee on File Yes POWER WHEELCHAIR ACCESSORY, LITHIUM-BASED BATTERY, EACH

0 999 07/01/2020 12/31/9999 1 381.42

E2402 KR-Fee on File Yes NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE

0 999 07/01/2020 12/31/9999 1 32.44

E2402 NU-Fee on File Yes NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE

0 999 07/01/2020 12/31/9999 1 9,732.48

E2402 RR-Fee on File Yes NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE

0 999 07/01/2020 12/31/9999 1 973.25

E2500 NU-Fee on File Yes SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, LESS THAN OR EQUAL TO 8 MINUTES RECORDING TIME

0 999 07/01/2020 12/31/9999 1 363.43

E2502 NU-Fee on File Yes SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 8 MINUTES BUT LESS THAN OR EQUAL TO 20 MINUTES RECORDING TIME

0 999 07/01/2020 12/31/9999 1 1,111.35

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE2504 NU-Fee on File Yes SPEECH GENERATING DEVICE,

DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 20 MINUTES BUT LESS THAN OR EQUAL TO 40 MINUTES RECORDING TIME

0 999 07/01/2020 12/31/9999 1 1,466.04

E2506 NU-Fee on File Yes SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 40 MINUTES RECORDING TIME

0 999 07/01/2020 12/31/9999 1 2,149.65

E2508 NU-Fee on File Yes SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, REQUIRING MESSAGE FORMULATION BY SPELLING AND ACCESS BY PHYSICAL CONTACT WITH THE DEVICE

0 999 07/01/2020 12/31/9999 1 3,324.07

E2510 NU-Fee on File Yes SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, PERMITTING MULTIPLE METHODS OF MESSAGE FORMULATION AND MULTIPLE METHODS OF DEVICE ACCESS

0 999 07/01/2020 12/31/9999 1 6,290.37

E2511 NU-Priced by PA Yes SPEECH GENERATING SOFTWARE PROGRAM, FOR PERSONAL COMPUTER OR PERSONAL DIGITAL ASSISTANT

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

E2512 NU-Priced by PA Yes ACCESSORY FOR SPEECH GENERATING DEVICE, MOUNTING SYSTEM

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

E2599 NU-Priced by PA Yes ACCESSORY FOR SPEECH GENERATING DEVICE, NOT OTHERWISE CLASSIFIED

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

E2601 NU-Fee on File Yes GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 41.04

E2602 NU-Fee on File Yes GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 83.50

E2603 NU-Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 104.44

E2604 NU-Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 137.39

E2605 NU-Fee on File Yes POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 197.05

E2606 NU-Fee on File Yes POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 311.29

E2607 NU-Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 202.50

E2608 NU-Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 248.27

E2609 NU-Priced by PA Yes CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE

0 999 01/01/2005 12/31/9999 1 0.00

E2610 NU-Priced by PA Yes WHEELCHAIR SEAT CUSHION, POWERED

0 999 01/01/2005 12/31/9999 1 0.00E2611 NU-Fee on File Yes GENERAL USE WHEELCHAIR BACK

CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 07/01/2020 12/31/9999 1 191.61

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE2612 NU-Fee on File Yes GENERAL USE WHEELCHAIR BACK

CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 07/01/2020 12/31/9999 1 299.02

E2613 NU-Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 07/01/2020 12/31/9999 1 288.76

E2614 NU-Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 07/01/2020 12/31/9999 1 411.65

E2615 NU-Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 07/01/2020 12/31/9999 1 330.98

E2616 NU-Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 07/01/2020 12/31/9999 1 445.54

E2617 NU-Priced by PA Yes CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE MOUNTING HARDWARE

0 999 01/01/2005 12/31/9999 1 0.00

E2619 NU-Fee on File Yes REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACH

0 999 07/01/2020 12/31/9999 2 40.00

E2622 KR-Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 0.85

E2622 NU-Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 256.14

E2622 RR-Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 25.61

E2622 UE-Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 128.07

E2623 KR-Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 1.08

E2623 NU-Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 324.94

E2623 RR-Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 32.49

E2623 UE-Fee on File Yes SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 162.47

379.94

E2621 NU-Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS WIDTH 22 INCHES OR

0 999 07/01/2020 12/31/9999 1 420.42

E2620 NU-Fee on File Yes POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS WIDTH LESS THAN 22

0 999 07/01/2020 12/31/9999 1

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE2624 KR-Fee on File Yes SKIN PROTECTION AND POSITIONING

WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 0.86

E2624 NU-Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 259.22

E2624 RR-Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 25.92

E2624 UE-Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 129.61

E2625 KR-Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 1.08

E2625 NU-Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 324.60

E2625 RR-Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 32.46

E2625 UE-Fee on File Yes SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

0 999 07/01/2020 12/31/9999 1 162.30

E8000 KR-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8000 NU-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8000 RR-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8000 UE-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8001 KR-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8001 NU-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8001 RR-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8001 UE-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeE8002 KR-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE,

ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8002 NU-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8002 RR-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

E8002 UE-Priced by PA Yes GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

0 20 01/01/2005 12/31/9999 1 0.00

K0005 KR-Fee on File Yes ULTRALIGHTWEIGHT WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 5.73K0005 NU-Fee on File Yes ULTRALIGHTWEIGHT WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 1,718.24K0005 RR-Fee on File Yes ULTRALIGHTWEIGHT WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 171.82K0005 UE-Fee on File Yes ULTRALIGHTWEIGHT WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 859.12K0006 KR-Fee on File Yes HEAVY DUTY WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 2.56K0006 NU-Fee on File Yes HEAVY DUTY WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 768.32K0006 RR-Fee on File Yes HEAVY DUTY WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 76.83K0006 UE-Fee on File Yes HEAVY DUTY WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 384.16K0007 KR-Fee on File Yes EXTRA HEAVY DUTY WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 3.79K0007 NU-Fee on File Yes EXTRA HEAVY DUTY WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 1,136.80K0007 RR-Fee on File Yes EXTRA HEAVY DUTY WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 113.68K0007 UE-Fee on File Yes EXTRA HEAVY DUTY WHEELCHAIR 0 999 07/01/2020 12/31/9999 1 568.40K0010 KR-Fee on File Yes STANDARD - WEIGHT FRAME

MOTORIZED/POWER WHEELCHAIR0 999 07/01/2020 12/31/9999 1 11.22

K0010 NU-Fee on File Yes STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR

0 999 07/01/2020 12/31/9999 1 3,365.28

K0010 RR-Fee on File Yes STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR

0 999 07/01/2020 12/31/9999 1 336.53

K0010 UE-Fee on File Yes STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR

0 999 07/01/2020 12/31/9999 1 1,682.64

K0037 NU-Fee on File Yes HIGH MOUNT FLIP-UP FOOTREST, EACH 0 20 07/01/2020 12/31/9999 2 32.79K0038 NU-Fee on File Yes LEG STRAP, EACH 0 20 07/01/2020 12/31/9999 2 19.08K0039 NU-Fee on File Yes LEG STRAP, H STYLE, EACH 0 20 07/01/2020 12/31/9999 2 41.67K0040 NU-Fee on File Yes ADJUSTABLE ANGLE FOOTPLATE, EACH 0 20 07/01/2020 12/31/9999 2 52.22K0041 NU-Fee on File Yes LARGE SIZE FOOTPLATE, EACH 0 20 07/01/2020 12/31/9999 2 40.39K0043 NU-Fee on File Yes FOOTREST, LOWER EXTENSION TUBE,

REPLACEMENT ONLY, EACH0 20 07/01/2020 12/31/9999 2 15.43

K0105 NU-Fee on File Yes IV HANGER, EACH 0 20 07/01/2020 12/31/9999 1 88.59K0554 KR-Fee on File No RECEIVER (MONITOR), DEDICATED, FOR

USE WITH THERAPEUTIC GLUCOSE CONTINUOUS MONITOR SYSTEM

0 999 07/01/2020 12/31/9999 1 0.65

K0554 NU-Fee on File No RECEIVER (MONITOR), DEDICATED, FOR USE WITH THERAPEUTIC GLUCOSE CONTINUOUS MONITOR SYSTEM

0 999 07/01/2020 12/31/9999 1 196.47

K0554 RR-Fee on File No RECEIVER (MONITOR), DEDICATED, FOR USE WITH THERAPEUTIC GLUCOSE CONTINUOUS MONITOR SYSTEM

0 999 07/01/2020 12/31/9999 1 19.65

K0603 NU-Fee on File No Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each

0 999 07/01/2020 12/31/9999 2 0.52

K0606 NU-Fee on File Yes Automatic external defibrillator, with integrated electrocardiogram analysis, garment type

0 999 07/01/2020 12/31/9999 1 23,404.80

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeK0606 RR-Fee on File Yes Automatic external defibrillator, with

integrated electrocardiogram analysis, garment type

0 999 07/01/2020 12/31/9999 1 2,340.48

K0672 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, REMOVABLE SOFT INTERFACE, ALL COMPONENTS, REPLACEMENT ONLY , EACH

0 20 07/01/2020 12/31/9999 4 68.33

K0733 NU-Fee on File Yes POWER WHEELCHAIR ACCESSORY 12 TO 24 AMP HR SEALED LEAD ACID BATTERY EA

0 999 07/01/2020 12/31/9999 2 24.20

L0120 NU-Fee on File Yes CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)

0 20 07/01/2020 12/31/9999 1 22.54

L0130 NU-Fee on File Yes CERVICAL, FLEXIBLE, THERMOPLASTIC COLLAR, MOLDED TO PATIENT

0 20 07/01/2020 12/31/9999 1 163.02

L0140 NU-Fee on File Yes CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTIC COLLAR)

0 20 07/01/2020 12/31/9999 1 56.26

L0150 NU-Fee on File Yes CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDED CHIN CUP (PLASTIC COLLAR)

0 20 07/01/2020 12/31/9999 1 93.81

L0160 NU-Fee on File Yes CERVICAL, SEMI-RIGID, WIRE FRAME OCCIPITAL/MANDIBULAR SUPPORT, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 1 133.56

L0170 NU-Fee on File Yes CERVICAL, COLLAR, MOLDED TO PATIENT MODEL

0 20 07/01/2020 12/31/9999 1 565.18

L0172 NU-Fee on File Yes CERVICAL, COLLAR, SEMI-RIGID THERMOPLASTIC FOAM, TWO-PIECE, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 1 114.59

L0174 NU-Fee on File Yes CERVICAL, COLLAR, SEMI-RIGID, THERMOPLASTIC FOAM, TWO PIECE WITH THORACIC EXTENSION, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 1 205.86

L0180 NU-Fee on File Yes CERVICAL,MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLE

0 20 07/01/2020 12/31/9999 1 279.97

L0190 NU-Fee on File Yes CERVICAL,MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS,

0 20 07/01/2020 12/31/9999 1 421.46

L0200 NU-Fee on File Yes CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABL

0 20 07/01/2020 12/31/9999 1 386.99

L0220 NU-Fee on File Yes THORACIC, RIB BELT, CUSTOM FABRICATED

0 20 07/01/2020 12/31/9999 1 91.78

L0452 NU-Priced by PA Yes TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES

0 20 10/01/2003 12/31/9999 1 0.00

L0454 NU-Fee on File Yes TLSO FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM SACROCOCCYGEAL JUNCT

0 20 07/01/2020 12/31/9999 1 279.46

279.46L0455 NU-Fee on File Yes TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM SACROCOCCYGEAL JUNCTION TO

0 20 07/01/2020 12/31/9999 1

1,127.81

L0450 NU-Fee on File Yes TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES INTRACAVITARY PRESSURE

0 20 07/01/2020 12/31/9999 1 151.52

L0112 NU-Fee on File Yes CRANIAL CERVICAL ORTHOSIS, CONGENITAL TORTICOLLIS TYPE, WITH OR WITHOUT SOFT INTERFACE

0 20 07/01/2020 12/31/9999 1

1.20

K0738 RR-Fee on File Yes PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; HOME COMPRESSOR USED TO FILL PORTABLE OXYGEN CYLINDERS

0 999 07/01/2020 12/31/9999 1 35.97

K0738 KR-Fee on File Yes PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; HOME COMPRESSOR USED TO FILL PORTABLE OXYGEN CYLINDERS

0 999 07/01/2020 12/31/9999 1

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

L0456 NU-Fee on File Yes TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC REGION, RIGID POSTERIOR

0 20 07/01/2020 12/31/9999 1 801.43

L0458 NU-Fee on File Yes TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLAS

0 20 07/01/2020 12/31/9999 1 718.64

L0460 NU-Fee on File Yes TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLAS

0 20 07/01/2020 12/31/9999 1 808.90

L0462 NU-Fee on File Yes TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PL

0 20 07/01/2020 12/31/9999 1 1,006.12

L0464 NU-Fee on File Yes TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, FOUR RIGID PLA

0 20 07/01/2020 12/31/9999 1 1,197.76

L0466 NU-Fee on File Yes TLSO, SAGITTAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR

0 20 07/01/2020 12/31/9999 1 307.99

L0468 NU-Fee on File Yes TLSO, SAGITTAL-CORONAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT

0 20 07/01/2020 12/31/9999 1 386.16

L0470 NU-Fee on File Yes TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIO

0 20 07/01/2020 12/31/9999 1 549.76

L0472 NU-Fee on File Yes TLSO, TRIPLANAR CONTROL, HYPEREXTENSION, RIGID ANTERIOR AND LATERAL FRAM

0 20 07/01/2020 12/31/9999 1 345.09

L0480 NU-Fee on File Yes TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE

0 20 07/01/2020 12/31/9999 1 1,067.09

L0482 NU-Fee on File Yes TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE

0 20 07/01/2020 12/31/9999 1 1,223.28

L0484 NU-Fee on File Yes TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE

0 20 07/01/2020 12/31/9999 1 1,426.31

L0486 NU-Fee on File Yes TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITH INTERFACE

0 20 07/01/2020 12/31/9999 1 1,412.94

L0488 NU-Fee on File Yes TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE

0 20 07/01/2020 12/31/9999 1 808.90

L0490 NU-Fee on File Yes TLSO, SAGITTAL-CORONAL CONTROL, ONE PIECE RIGID PLASTIC SHELL, WITH OVER

0 20 07/01/2020 12/31/9999 1 227.94

L0491 NU-Fee on File Yes TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC SHELLS

0 20 07/01/2020 12/31/9999 1 618.83

L0492 NU-Fee on File Yes TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PLASTIC SHELLS

0 20 07/01/2020 12/31/9999 1 401.06

307.99

L0469 NU-Fee on File Yes TLSO, SAGITTAL-CORONAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON WITH STRAPS, CLOSURES AND PADDING, EXTENDS

0 20 07/01/2020 12/31/9999 1 386.16

L0467 NU-Fee on File Yes TLSO, SAGITTAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON WITH STRAPS

0 20 07/01/2020 12/31/9999 1

L0457 NU-Fee on File Yes TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC REGION, RIGID POSTERIOR PANEL AND SOFT ANTERIOR APRON, EXTENDS FROM THE

0 20 07/01/2020 12/31/9999 1 801.43

SACROCOCCYGEAL JUNCTION TO ABOVE T-9 VERTEBRA, RESTRICTS

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL0621 NU-Fee on File Yes SACROILIAC ORTHOSIS, FLEXIBLE,

PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION ABOUT THE SACROILIAC JOINT

0 20 07/01/2020 12/31/9999 1 71.86

L0622 NU-Fee on File Yes SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION ABOUT THE SACROILIAC JOINT

0 20 07/01/2020 12/31/9999 1 194.83

L0631 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,

0 20 07/01/2020 12/31/9999 1 827.22

L0633 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PANEL(S)

0 20 07/01/2020 12/31/9999 1 231.07

L0634 NU-Priced by PA Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PANEL(S)

0 20 01/01/2006 12/31/9999 1 0.00

L0635 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION,RIGID POSTERIOR FRAME/PANEL(S)

0 20 07/01/2020 12/31/9999 1 856.86

L0638 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANELS

0 20 07/01/2020 12/31/9999 1 1,062.78

L0639 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S)

0 20 07/01/2020 12/31/9999 1 1,096.98

L0640 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S)

0 20 07/01/2020 12/31/9999 1 843.19

1,096.98L0637 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR

0 20 07/01/2020 12/31/9999 1

0.00

L0636 NU-Fee on File Yes LUMBAR SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGID POSTERIOR FRAME/PANELS

0 20 07/01/2020 12/31/9999 1 1,264.35

L0632 NU-Priced by PA Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS POSTERIOR

0 20 01/01/2006 12/31/9999 1

0.00

L0630 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S) POSTERIOR EXTENDS FROM

0 20 07/01/2020 12/31/9999 1 130.48

L0629 NU-Priced by PA Yes LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR EXTENDS FROM

0 20 01/01/2006 12/31/9999 1

331.24

L0628 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR EXTENDS FROM

0 20 07/01/2020 12/31/9999 1 67.58

L0627 NU-Fee on File Yes LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS POSTERIOR

0 20 07/01/2020 12/31/9999 1

44.42

L0626 NU-Fee on File Yes LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S) POSTEROR EXTENDS FROM L-

0 20 07/01/2020 12/31/9999 1 62.82

L0625 NU-Fee on File Yes LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMBAR SUPPORT, POSTERIOR EXTENDS FOM L-1 TO

0 20 07/01/2020 12/31/9999 1

0.00

L0624 NU-Priced by PA Yes SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID PANELS PLACED OVER

0 20 01/01/2006 12/31/9999 1 0.00

L0623 NU-Priced by PA Yes SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID PANELS OVER THE

0 20 01/01/2006 12/31/9999 1

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

L0700 NU-Fee on File Yes CTLSO,ANTERIOR-POSTERIOR-LATERALCONTROL,MOULDEDTOPATIENTMODEL

0 20 07/01/2020 12/31/9999 1 1,734.90

L0710 NU-Fee on File Yes CTLSO, ANTERIOR-POSTERIOR-LATERAL-CONTROL, MOLDED TO PATIEN MODED, WITH

0 20 07/01/2020 12/31/9999 1 1,893.76

L0810 NU-Fee on File Yes HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO JACKET VEST

0 20 07/01/2020 12/31/9999 1 2,011.85

L0820 NU-Fee on File Yes HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO PLASTER BODY

0 20 07/01/2020 12/31/9999 1 1,627.50

L0830 NU-Fee on File Yes HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE

0 20 07/01/2020 12/31/9999 1 2,349.93

L0859 NU-Fee on File Yes ADDITION TO HALO PROCEDURE, MAGNETIC RESONANCE IMAGE COMPATIBLE SYSTEMS,RINGS AND PINS, ANY MATERIAL

0 20 07/01/2020 12/31/9999 1 912.94

L0861 NU-Fee on File Yes ADDITION TO HALO PROCEDURE, REPLACEMENT LINER/INTERFACE MATERIAL

0 20 07/01/2020 12/31/9999 1 173.69

L0970 NU-Fee on File Yes TLSO, CORSET FRONT 0 20 07/01/2020 12/31/9999 1 85.65L0972 NU-Fee on File Yes LSO, CORSET FRONT 0 20 07/01/2020 12/31/9999 1 87.55L0974 NU-Fee on File Yes TLSO, FULL CORSET 0 20 07/01/2020 12/31/9999 1 178.89L0976 NU-Fee on File Yes LSO, FULL CORSET 0 20 07/01/2020 12/31/9999 1 159.78L0978 NU-Fee on File Yes AXILLARY CRUTCH EXTENSION 0 20 07/01/2020 12/31/9999 2 144.26L0980 NU-Fee on File Yes PERONEAL STRAPS, PREFABRICATED,

OFF-THE-SHELF, PAIR0 20 07/01/2020 12/31/9999 1 13.09

L0982 NU-Fee on File Yes STOCKING SUPPORTER GRIPS, PREFABRICATED, OFF-THE-SHELF, SET OF FOUR (4)

0 20 07/01/2020 12/31/9999 1 14.26

L0984 NU-Fee on File Yes PROTECTIVE BODY SOCK, PREFABRICATED, OFF-THE-SHELF, EACH

0 20 07/01/2020 12/31/9999 3 45.50

L1000 NU-Fee on File Yes CTLSO (MILWAUKEE), INCLUSIVE OF FURNISHING INITIAL ORHTOSIS, INCLUDING M

0 20 07/01/2020 12/31/9999 1 1,521.43

1,096.98

L0651 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL

0 20 07/01/2020 12/31/9999 1 1,096.98

L0650 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANEL(S), POSTERIOR EXTENDS

0 20 07/01/2020 12/31/9999 1

827.22

L0649 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PANEL(S), POSTERIOR EXTENDS FROM

0 20 07/01/2020 12/31/9999 1 231.07

L0648 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL

0 20 07/01/2020 12/31/9999 1

331.24

L0643 NU-Fee on File Yes LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9

0 20 07/01/2020 12/31/9999 1 130.48

L0642 NU-Fee on File Yes LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM L-1 TO BELOW L-5

0 20 07/01/2020 12/31/9999 1

L0641 NU-Fee on File Yes LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES

0 20 07/01/2020 12/31/9999 1 62.82

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL1001 NU-Priced by PA Yes CERVICAL THORACIC LUMBAR SACRAL

ORTHOSIS, IMMOBILIZER, INFANT SIZE,0 20 01/01/2007 12/31/9999 1 0.00

L1010 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, AXILLA SLING

0 20 07/01/2020 12/31/9999 2 61.27

L1020 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD

0 20 07/01/2020 12/31/9999 2 83.71

L1025 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD, FLOATING

0 20 07/01/2020 12/31/9999 1 95.14

L1030 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLOSIS ORHTOSIS, LUMBAR BOLSTER PAD

0 20 07/01/2020 12/31/9999 1 63.56

L1040 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS, LUMBAR OR LUMBAR RIB PAD

0 20 07/01/2020 12/31/9999 1 76.50

L1050 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, STERNAL PAD

0 20 07/01/2020 12/31/9999 1 66.23

L1060 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, THORACIC PAD

0 20 07/01/2020 12/31/9999 1 74.71

L1070 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, TRAPEZIUS SLING

0 20 07/01/2020 12/31/9999 2 76.40

L1080 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER

0 20 07/01/2020 12/31/9999 2 52.94

L1085 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSOS ORTHOSIS,OUTRIGGER,BILATERAL WITH VERTICA

0 20 07/01/2020 12/31/9999 1 147.06

L1090 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR SLING

0 20 07/01/2020 12/31/9999 1 68.69

L1100 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE,

0 20 07/01/2020 12/31/9999 2 121.26

L1110 NU-Fee on File Yes ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RIGN FLANGE,

0 20 07/01/2020 12/31/9999 2 205.38

L1120 NU-Fee on File Yes ADDITION TO CTLSO, SCOLIOSIS, ORTHOSIS, COVER FOR UPRIGHT, EACH

0 20 07/01/2020 12/31/9999 3 32.71

L1200 NU-Fee on File Yes TLSO, INCLUSIVE OF FURNISHING ORTHOSIS ONLY

0 20 07/01/2020 12/31/9999 1 1,302.34

L1210 NU-Fee on File Yes ADDITION TO TLSO, (LOW PROFILE), LATERAL THORACIC EXTENSION

0 20 07/01/2020 12/31/9999 2 196.09

L1220 NU-Fee on File Yes ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC EXTENSION

0 20 07/01/2020 12/31/9999 1 166.02

L1230 NU-Fee on File Yes ADDITION TO TLSO, (LOW PROFILE), MILWAUKEE TYPE SUPERSTRUCTURE

0 20 07/01/2020 12/31/9999 1 425.99

L1240 NU-Fee on File Yes ADDITION TO TLSO (LOW PROFILE) LUMBAR DEROTATION PAD

0 20 07/01/2020 12/31/9999 1 73.31

L1250 NU-Fee on File Yes ADDITION TO TLSO (LOW PROFILE), ANTERIOR ASIS PAD

0 20 07/01/2020 12/31/9999 2 72.19

L1260 NU-Fee on File Yes ADDITION TO TLSO (LOW PROFILE, ANTERIOR THORACIC DEROTATION PAD

0 20 07/01/2020 12/31/9999 1 74.19

L1270 NU-Fee on File Yes ADDITION TO TLSO (LOW PROFILE), ABDOMINAL PAD

0 20 07/01/2020 12/31/9999 3 74.10

L1280 NU-Fee on File Yes ADDITION TO TLSO (LOW PROFILE), RIB GUSSET (ELASTIC), EACH

0 20 07/01/2020 12/31/9999 2 66.05

L1290 NU-Fee on File Yes ADDITION TO TLSO (LOW PROFILE), LATERAL TROCHANTERIC PAD

0 20 07/01/2020 12/31/9999 2 74.88

L1300 NU-Fee on File Yes OTHER SCOLIOSIS PROCEDURE, BODY JACKET MOLDED TO PATIENT

0 20 07/01/2020 12/31/9999 1 1,251.81

L1310 NU-Fee on File Yes OTHER SCOLIOSIS PROCEDURE, POST-OPERATIVE BODY JACKET

0 20 07/01/2020 12/31/9999 1 1,288.10

L1499 NU-Priced by PA Yes SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED SPINAL ORTHOSIS, NOT OTHERWISE

0 20 05/01/2004 12/31/9999 1 0.00

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL1600 NU-Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL

OF HIP JOINTS, FLEXIBLE, FREJKA TYPE WIT

0 20 07/01/2020 12/31/9999 1 96.57

L1610 NU-Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (FREJKA COVER O

0 20 07/01/2020 12/31/9999 1 32.90

L1620 NU-Fee on File Yes HO, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (PAVLIK HARNESS), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 1 108.34

L1630 NU-Fee on File Yes HO, ABDUCTION CONTROL OF HIP JOINTS, SEMI-FLEXIBLE (VON ROSEN TYPE), CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 1 129.28

L1640 NU-Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PELVIC BAND OR SP

0 20 07/01/2020 12/31/9999 1 345.79

L1650 NU-Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, ADJUSTABLE, (ILFL

0 20 07/01/2020 12/31/9999 1 183.38

L1652 NU-Fee on File Yes HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH ADJUSTABLE ABDUCTOR SPREADER BA

0 20 07/01/2020 12/31/9999 1 287.25

L1660 NU-Fee on File Yes HO, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PLASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 1 128.25

L1680 NU-Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, DYNAMIC, PELVIC CONTROL,

0 20 07/01/2020 12/31/9999 1 1,054.38

L1685 NU-Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTIO

0 20 07/01/2020 12/31/9999 1 1,112.55

L1686 NU-Fee on File Yes HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTIO

0 20 07/01/2020 12/31/9999 1 746.37

L1690 NU-Fee on File Yes COMBINATION, BILATERAL, LUMBO-SACRAL, HIP, FEMUR ORTHOSIS PROVIDING ADDU

0 20 07/01/2020 12/31/9999 1 1,558.22

L1700 NU-Fee on File Yes LEGG PERTHES ORTHOSIS, (TORONTO TYPE), CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 1 1,296.34

L1710 NU-Fee on File Yes LEGG PERTHES ORTHOSIS, (NEWINGTON TYPE), CUSTOM

0 20 07/01/2020 12/31/9999 1 1,523.77

L1720 NU-Fee on File Yes LEGG PERTHES ORTHOSIS, TRILATERAL, (TACHDIJAN TYPE), CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 1,125.61

L1730 NU-Fee on File Yes LEGG PERTHES ORTHOSIS, (SCOTTISH RITE TYPE), CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 1 849.24

L1755 NU-Fee on File Yes LEGG PERTHES ORTHOSIS, (PATTEN BOTTOM TYPE), CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 1,236.10

L1810 NU-Fee on File Yes KO, ELASTIC WITH JOINTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 97.56

L1812 NU-Fee on File Yes KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 97.56

L1820 NU-Fee on File Yes KO, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 97.17

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL1830 NU-Fee on File Yes KNEE ORTHOSIS, IMMOBILIZER, CANVAS

LONGITUDINAL, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 81.28

L1831 NU-Fee on File Yes KNEE ORTHOSIS, LOCKING KNEE JOINT(S), POSITIONAL ORTHOSIS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 237.14

L1832 NU-Fee on File Yes KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 607.47

L1833 NU-Fee on File Yes KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, OFF-THE SHELF

0 20 07/01/2020 12/31/9999 2 607.47

L1834 NU-Fee on File Yes KO, WITHOUT KNEE JOINT, RIGID, CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 714.69

L1836 NU-Fee on File Yes KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 107.51

L1840 NU-Fee on File Yes KNEE ORTHOSIS, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, C

0 20 07/01/2020 12/31/9999 2 751.26

L1844 NU-Fee on File Yes KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND

0 20 07/01/2020 12/31/9999 2 1,252.81

L1845 NU-Fee on File Yes KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND

0 20 07/01/2020 12/31/9999 2 754.75

L1846 NU-Fee on File Yes KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND

0 20 07/01/2020 12/31/9999 2 957.66

L1847 NU-Fee on File Yes KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH INFLATABLE AIR

0 20 07/01/2020 12/31/9999 2 463.49

L1848 NU-Fee on File Yes KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH INFLATABLE AIR SUPPORT CHAMBER(S), PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 463.49

L1850 NU-Fee on File Yes KNEE ORTHOSIS, SWEDISH TYPE, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 215.70

L1860 NU-Fee on File Yes KO, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET, CUSTOM-FABRICATED (SK)

0 20 07/01/2020 12/31/9999 2 836.64

75.48L1852 RR-Fee on File Yes KNEE ORTHOSIS (KO), DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION

0 20 07/01/2020 12/31/9999 2

72.30

L1852 NU-Fee on File Yes KNEE ORTHOSIS (KO), DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION

0 20 07/01/2020 12/31/9999 2 754.75

L1851 RR-Fee on File Yes KNEE ORTHOSIS (KO), SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT

0 20 07/01/2020 12/31/9999 2

723.01

L1851 NU-Fee on File Yes KNEE ORTHOSIS (KO), SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT

0 20 07/01/2020 12/31/9999 2 723.01

L1843 NU-Fee on File Yes KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT

0 20 07/01/2020 12/31/9999 2

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL1900 NU-Fee on File Yes AFO, SPRING WIRE, DORSIFLEXION

ASSIST CALF BAND, CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 226.66

L1902 NU-Fee on File Yes ANKLE ORTHOSIS ANKLE GUANTLET OR SIMILAR WITH OR WITHOUT JOINTS PREFABRICATED OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 61.56

L1904 NU-Fee on File Yes ANKLE ORTHOSIS ANKLE GUANTLET OR SIMILAR WITH OR WITHOUT JOINTS CUSTOM FABRICATED

0 20 07/01/2020 12/31/9999 2 352.39

L1906 NU-Fee on File Yes ANKLE FOOT ORTHOSIS, MULTILIGAMENTOUS ANKLE SUPPORT, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 102.98

L1907 NU-Fee on File Yes ANKLE ORTHOSIS, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM FABRICATED

0 20 07/01/2020 12/31/9999 2 453.42

L1910 NU-Fee on File Yes AFO, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 200.41

L1920 NU-Fee on File Yes ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHEL

0 20 07/01/2020 12/31/9999 2 261.98

L1930 NU-Fee on File Yes AFO, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 177.28

L1932 NU-Fee on File Yes AFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 719.06

L1940 NU-Fee on File Yes AFO, PLASTIC OR OTHER MATERIAL, CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 400.63

L1945 NU-Fee on File Yes ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACT

0 20 07/01/2020 12/31/9999 2 735.71

L1950 NU-Fee on File Yes ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC, CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 558.18

L1951 NU-Fee on File Yes ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 676.74

L1960 NU-Fee on File Yes AFO, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 415.38

L1970 NU-Fee on File Yes AFO, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 614.38

L1971 NU-Fee on File Yes ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 377.70

L1980 NU-Fee on File Yes ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STI

0 20 07/01/2020 12/31/9999 2 275.03

L1990 NU-Fee on File Yes ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STI

0 20 07/01/2020 12/31/9999 2 353.38

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL2000 NU-Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, SINGLE

UPRIGHT, FREE KNEE, FREE ANKLE, SOLID S

0 20 07/01/2020 12/31/9999 2 760.10

L2010 NU-Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THI

0 20 07/01/2020 12/31/9999 2 692.90

L2020 NU-Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THI

0 20 07/01/2020 12/31/9999 2 875.02

L2030 NU-Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THI

0 20 07/01/2020 12/31/9999 2 759.17

L2035 NU-Fee on File Yes KAFO, FULL PLASTIC, STATIC, (PEDIATRIC SIZE), WITHOUT FREE MOTION ANKLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 139.59

L2036 NU-Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLE UPRIGHT, WITH OR WITHOUT FREE

0 20 07/01/2020 12/31/9999 2 1,390.36

L2037 NU-Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE

0 20 07/01/2020 12/31/9999 2 1,281.30

L2038 NU-Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, WITH OR WITHOUT FREE MOTION KNEE,

0 20 07/01/2020 12/31/9999 2 1,071.43

L2040 NU-Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL ROTATION STRAPS

0 20 07/01/2020 12/31/9999 1 136.86

L2050 NU-Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES,

0 20 07/01/2020 12/31/9999 1 364.46

L2060 NU-Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES,

0 20 07/01/2020 12/31/9999 1 467.78

L2070 NU-Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL ROTATION STRAP

0 20 07/01/2020 12/31/9999 1 134.38

L2080 NU-Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE,

0 20 07/01/2020 12/31/9999 1 286.58

L2090 NU-Fee on File Yes HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE,

0 20 07/01/2020 12/31/9999 1 353.22

L2106 NU-Fee on File Yes ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS,

0 20 07/01/2020 12/31/9999 2 509.53

L2108 NU-Fee on File Yes AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 800.69

L2112 NU-Fee on File Yes AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 380.18

1,654.56L2034 NU-Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE MEDIAL

0 20 07/01/2020 12/31/9999 2

L2005 NU-Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT STANCE CONTROL

0 20 07/01/2020 12/31/9999 2 3,301.96

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL2114 NU-Fee on File Yes AFO, FRACTURE ORTHOSIS, TIBIAL

FRACTURE ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 434.97

L2116 NU-Fee on File Yes AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 573.08

L2126 NU-Fee on File Yes KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHO

0 20 07/01/2020 12/31/9999 2 1,019.67

L2128 NU-Fee on File Yes KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 1,285.01

L2132 NU-Fee on File Yes KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 604.52

L2134 NU-Fee on File Yes KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 724.79

L2136 NU-Fee on File Yes KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 886.23

L2180 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC SHOE INSERT WITH

0 20 07/01/2020 12/31/9999 2 87.76

L2182 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROP LOCK KNEE JOINT

0 20 07/01/2020 12/31/9999 4 68.69

L2184 NU-Fee on File Yes ADDITION TO LOWE EXTREMITY FRACTURE ORTHOSIS, LIMITED MOTION KNEE JOINT

0 20 07/01/2020 12/31/9999 4 123.78

L2186 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, ADJUSTABLE MOTION KNEE JO

0 20 07/01/2020 12/31/9999 4 137.16

L2188 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE OTHOSIS, QUADRILATERAL BRIM

0 20 07/01/2020 12/31/9999 2 299.25

L2190 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, WAIST BELT

0 20 07/01/2020 12/31/9999 2 77.73

L2192 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIP JOINT, PELVIC BAND,

0 20 07/01/2020 12/31/9999 2 267.20

L2200 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINT

0 20 07/01/2020 12/31/9999 4 35.63

L2210 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST

0 20 07/01/2020 12/31/9999 4 57.81

L2220 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR FLEXION ASSIST/RES

0 20 07/01/2020 12/31/9999 4 66.38

L2230 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRUPS

0 20 07/01/2020 12/31/9999 2 57.50

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL2232 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY

ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOT ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2020 12/31/9999 2 77.86

L2240 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ROUND CALIPER AND PLATE ATTACHMENT

0 20 07/01/2020 12/31/9999 2 62.68

L2250 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, FOOT PLATE, MOLDED TO PATIENT

0 20 07/01/2020 12/31/9999 2 266.28

L2260 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, REINFORCED SOLID STIRRUP(SCOTT-CRAIG TYPE)

0 20 07/01/2020 12/31/9999 2 150.22

L2265 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRUP

0 20 07/01/2020 12/31/9999 2 88.26

L2270 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION

0 20 07/01/2020 12/31/9999 2 40.25

L2275 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATI

0 20 07/01/2020 12/31/9999 2 97.93

L2280 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, MOLDED INNER BOOT

0 20 07/01/2020 12/31/9999 2 363.78

L2300 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ABDUCTION BAR (BILATERAL HIP

0 20 07/01/2020 12/31/9999 1 205.35

L2310 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHT

0 20 07/01/2020 12/31/9999 1 92.19

L2320 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2020 12/31/9999 2 154.19

L2330 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2020 12/31/9999 2 294.26

L2335 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ANTERIOR SWING BAND

0 20 07/01/2020 12/31/9999 2 173.10

L2340 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL

0 20 07/01/2020 12/31/9999 2 408.48

L2350 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOCKET, MOLDED

0 20 07/01/2020 12/31/9999 2 667.74

L2360 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANK

0 20 07/01/2020 12/31/9999 2 38.78

L2370 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PATTEN BOTTOM

0 20 07/01/2020 12/31/9999 2 192.37

L2375 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOINT AND HALF SOLID

0 20 07/01/2020 12/31/9999 2 84.67

L2380 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT KNEE JOINT, EACH

0 20 07/01/2020 12/31/9999 2 92.26

L2385 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT

0 20 07/01/2020 12/31/9999 4 100.38

L2387 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS, EACH JOINT

0 20 07/01/2020 12/31/9999 4 136.22

L2390 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINT

0 20 07/01/2020 12/31/9999 4 82.03

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL2395 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,

OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT

0 20 07/01/2020 12/31/9999 4 125.25

L2397 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE

0 20 07/01/2020 12/31/9999 4 87.83

L2405 NU-Fee on File Yes ADDITION TO KNEE JOINT, DROP LOCK, EACH

0 20 07/01/2020 12/31/9999 4 70.26

L2415 NU-Fee on File Yes ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM ( BAIL, CABLE, OR EQUAL), ANY MATERIAL, EACH JOINT

0 20 07/01/2020 12/31/9999 4 97.90

L2425 NU-Fee on File Yes ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION,

0 20 07/01/2020 12/31/9999 4 115.50

L2430 NU-Fee on File Yes ADDITIONS TO KNEE JNTM RATCHET LOCK FOR ACT AND PROG KNEE EXT, EACH JNT

0 20 07/01/2020 12/31/9999 4 115.50

L2492 NU-Fee on File Yes ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING

0 20 07/01/2020 12/31/9999 4 76.42

L2500 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIAL WEIGHT BEARING, RING

0 20 07/01/2020 12/31/9999 2 236.42

L2510 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI-

0 20 07/01/2020 12/31/9999 2 632.98

L2520 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI-

0 20 07/01/2020 12/31/9999 2 345.23

L2525 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,ISCHIAL CONTAINMENT/NAR

0 20 07/01/2020 12/31/9999 2 1,184.41

L2526 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,ISCHIAL CONTAINMENT/NAR

0 20 07/01/2020 12/31/9999 2 638.41

L2530 NU-Fee on File Yes ADDITION TO LOWR EXTREMITY, THIGH-WEIGHT BEARING, LACER

0 20 07/01/2020 12/31/9999 2 176.07

L2540 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LACER,

0 20 07/01/2020 12/31/9999 2 316.83

L2550 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, HIGH

0 20 07/01/2020 12/31/9999 2 215.23

L2570 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE TWO

0 20 07/01/2020 12/31/9999 2 475.92

L2580 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PELVIC SLING

0 20 07/01/2020 12/31/9999 2 451.14

L2600 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT,

0 20 07/01/2020 12/31/9999 2 153.91

L2610 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT,

0 20 07/01/2020 12/31/9999 2 181.99

L2620 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT,

0 20 07/01/2020 12/31/9999 2 200.37

L2622 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT,ADJUSTABLE FLEXIO

0 20 07/01/2020 12/31/9999 2 229.81

L2624 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL,HIP JOINT,ADJUSTABLE FLEXION

0 20 07/01/2020 12/31/9999 2 312.42

L2627 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,PLASTIC,MOLDED TO PATIENT MOD

0 20 07/01/2020 12/31/9999 1 1,287.14

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL2628 NU-Fee on File Yes ADDITION TO LOWER

EXTREMITY,PELVIC CONTROL,METAL FRAME,RECIPROCATING HIP

0 20 07/01/2020 12/31/9999 1 1,511.98

L2630 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND ADN BELT,

0 20 07/01/2020 12/31/9999 1 185.57

L2640 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND BELT,

0 20 07/01/2020 12/31/9999 1 251.84

L2650 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, PELVIC AND THORACIC CONTROL,

0 20 07/01/2020 12/31/9999 2 89.93

L2660 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, THORACUC CONTROL, THORACIC BAND

0 20 07/01/2020 12/31/9999 1 139.67

L2670 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, THORACIC CONTROL,

0 20 07/01/2020 12/31/9999 2 127.83

L2680 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, THORACIC CONTROL,

0 20 07/01/2020 12/31/9999 2 117.27

L2750 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OF NICKEL, PER BAR

0 20 07/01/2020 12/31/9999 8 62.64

L2760 NU-Fee on File Yes ADDITION TO LOWER EXTREMTY ORTHOSIS, EXTENSION, PER

0 20 07/01/2020 12/31/9999 8 45.54

L2780 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, NON-CORROSIVE FINISH, PER BAR

0 20 07/01/2020 12/31/9999 8 53.86

L2785 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER,

0 20 07/01/2020 12/31/9999 4 31.66

L2795 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FULL KNEECAP

0 20 07/01/2020 12/31/9999 2 63.68

L2800 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL OR LATERAL PULL, FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2020 12/31/9999 2 79.94

L2810 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PAD

0 20 07/01/2020 12/31/9999 4 58.53

L2820 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS,SOFT INTERFACE FOR MOLDED PLASTIC

0 20 07/01/2020 12/31/9999 2 65.08

L2830 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS,SOFT INTERFACE FOR MOLDED PLASTIC

0 20 07/01/2020 12/31/9999 2 73.18

L2840 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS,TIBIAL LENGTH SOCK, FRACTURE

0 20 07/01/2020 12/31/9999 4 40.85

L2850 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS,FEMORAL LENGTH SOCK,FRACTURE OR EQU

0 20 07/01/2020 12/31/9999 4 46.40

L2861 NU-Priced by PA Yes ADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, EACH

0 20 01/01/2010 12/31/9999 2 0.00

L2999 NU-Priced by PA Yes LOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIED LOWER EXTREMITY ORTHOS

0 20 05/01/2004 12/31/9999 2 0.00

L2755 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL ALL HYBRID

0 20 07/01/2020 12/31/9999 8 105.31

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL3000 NU-Fee on File Yes FOOT, INSERT, REMOVABLE, MOLDED

TO PATIENT MODEL, 'UCB' TYPE, BERKELEY S

0 20 07/01/2020 12/31/9999 2 253.14

L3001 NU-Fee on File Yes FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SPENCO, EACH

0 20 07/01/2020 12/31/9999 2 106.57

L3002 NU-Fee on File Yes FOOT, INSERT. REMOVABLE, MOLDED TO PATIENT MODEL, PLASTAZOTE OR EQUAL, E

0 20 07/01/2020 12/31/9999 2 130.14

L3003 NU-Fee on File Yes FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SILICON GEL, EACH

0 20 07/01/2020 12/31/9999 2 140.40

L3010 NU-Fee on File Yes FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL ARCH SUPP

0 20 07/01/2020 12/31/9999 2 140.40

L3020 NU-Fee on File Yes FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL/METATARS

0 20 07/01/2020 12/31/9999 2 159.87

L3030 NU-Fee on File Yes FOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT, EACH

0 20 07/01/2020 12/31/9999 2 61.50

L3040 NU-Fee on File Yes FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL, EACH

0 20 07/01/2020 12/31/9999 2 37.93

L3050 NU-Fee on File Yes FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, METATARSAL, EACH

0 20 07/01/2020 12/31/9999 2 37.93

L3060 NU-Fee on File Yes FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL/METATARSAL, EACH

0 20 07/01/2020 12/31/9999 2 59.43

L3070 NU-Fee on File Yes FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL, EACH

0 20 07/01/2020 12/31/9999 2 25.62

L3080 NU-Fee on File Yes FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, METATARSAL, EACH

0 20 07/01/2020 12/31/9999 2 25.62

L3090 NU-Fee on File Yes FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL/METATAR

0 20 07/01/2020 12/31/9999 2 32.80

L3100 NU-Fee on File Yes HALLUS-VALGUS NIGHT DYNAMIC SPLINT, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 34.82

L3140 NU-Fee on File Yes FOOT, ABDUCTION ROTATION BAR, INCLUDING SHOES

0 20 07/01/2020 12/31/9999 1 71.75

L3150 NU-Fee on File Yes FOOT, ABDUCTION ROTATION BAR, WITHOUT SHOES

0 20 07/01/2020 12/31/9999 1 65.60

L3160 NU-Priced by PA Yes FOOT, ADJUSTABLE SHOE-STYLED POSITIONING DEVICE

0 20 05/01/1999 12/31/9999 2 0.00

L3170 NU-Fee on File Yes FOOT, PLASTIC, SILICONE OR EQUAL, HEEL STABILIZER, PRAFABRICATED, OFF-THE-SHELF, EACH

0 20 07/01/2020 12/31/9999 2 41.00

L3201 NU-Fee on File Yes ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, INFANT

0 20 10/01/1998 12/31/9999 2 23.00

L3202 NU-Fee on File Yes ORTHOPEDIC SHOE/ OXFORD WITH SUPINATOR OR PRONATOR, CHILD

0 20 10/01/1998 12/31/9999 2 25.00

L3203 NU-Fee on File Yes ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, JUNIOR

0 20 10/01/1998 12/31/9999 2 28.00

L3204 NU-Fee on File Yes ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, INFANT

0 20 10/01/1998 12/31/9999 2 24.00

L3206 NU-Fee on File Yes ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, CHILD

0 20 10/01/1998 12/31/9999 2 25.00

98.68L3031 NU-Fee on File Yes FOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY ORTHOSIS HIGH STRENGTH

0 20 07/01/2020 12/31/9999 2

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL3207 NU-Fee on File Yes ORTHOPEDIC SHOE, HIGHTOP WIT

SUPINATOR OR PRONATOR, JUNIOR0 20 10/01/1998 12/31/9999 2 27.00

L3208 NU-Fee on File Yes SURGICAL BOOT, EACH, INFANT 0 20 10/01/1998 12/31/9999 2 21.00L3209 NU-Fee on File Yes SURGICAL BOOT, EACH, CHILD 0 20 10/01/1998 12/31/9999 2 23.00L3211 NU-Fee on File Yes SURGICAL BOOT, EACH, JUNIOR 0 20 10/01/1998 12/31/9999 8 26.00L3212 NU-Fee on File Yes BENESCH BOOT, PAIR, INFANT 0 20 10/01/1998 12/31/9999 1 59.00L3213 NU-Fee on File Yes BENESCH BOOT, PAIR, CHILD 0 20 10/01/1998 12/31/9999 1 62.00L3214 NU-Fee on File Yes BENESCH BOOT, PAIR, JUNIOR 0 20 10/01/1998 12/31/9999 1 68.00L3215 NU-Fee on File Yes ORTHOPEDIC FOOTWEAR, LADIES

SHOE, OXFORD, EACH0 20 10/01/1998 12/31/9999 1 63.15

L3217 NU-Fee on File Yes ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTOP, DEPTH INLAY, EACH

0 20 05/01/1999 12/31/9999 1 86.16

L3219 NU-Fee on File Yes ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACH

0 20 10/01/1998 12/31/9999 1 72.64

L3222 NU-Fee on File Yes ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, DEPTH INLAY, EACH

0 20 05/01/1999 12/31/9999 1 104.30

L3224 NU-Fee on File Yes ORTHOPEDIC FOOTWEAR WOMAN'S SHOE, OXFORD, INTEGRAL PART OF BRACE

0 20 07/01/2020 12/31/9999 2 44.07

L3225 NU-Fee on File Yes ORTHOPEDIC FOOTWEAR, MAN'S SHOE OXFORD, INTEGRAL PAR OF BRACE

0 20 07/01/2020 12/31/9999 2 50.70

L3230 NU-Fee on File Yes ORTHOPEDIC FOOTWEAR, CUSTOM SHOE, DEPTH INLAY, EACH

0 20 05/01/1999 12/31/9999 1 249.00

L3250 NU-Fee on File Yes ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, REMOVABLE INNER MOLD, PROSTHETI

0 20 10/01/1998 12/31/9999 2 190.98

L3251 NU-Fee on File Yes FOOT, SHOE MOLDED TO PATIENT MODEL, SILICONE SHOE, EACH

0 20 05/01/1999 12/31/9999 2 261.18

L3252 NU-Fee on File Yes FOOT, SHOE MOLDED TO PATIENT MODEL, PLASTAZOTE (OR SIMILAR), CUSTOM FABR

0 20 05/01/1999 12/31/9999 2 169.77

L3253 NU-Fee on File Yes FOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR) CUSTOM FITTED, EACH

0 20 05/01/1999 12/31/9999 2 80.71

L3300 NU-Fee on File Yes LIFT, ELEVATION, HEEL, TAPERED TO METATARSALS, PER INCH LIFT, ELEVATION,

0 20 07/01/2020 12/31/9999 4 42.01

L3310 NU-Fee on File Yes LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE, PER INCH LIFT, ELEVATION, HEEL

0 20 07/01/2020 12/31/9999 4 65.60

L3320 NU-Fee on File Yes LIFT, ELEVATION, HEEL AND SOLE, CORK, PER INCH LIFT, ELEVATION, HEEL AND

0 20 07/01/2005 12/31/9999 4 58.78

L3330 NU-Fee on File Yes LIFT, ELEVATION, METAL EXTENSION (SKATE) LIFT, ELEVATION, METAL EXTENSIO

0 20 07/01/2020 12/31/9999 2 456.02

L3332 NU-Fee on File Yes LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO ONE-HALF INCH

0 20 07/01/2020 12/31/9999 2 59.43

L3334 NU-Fee on File Yes LIFT, ELEVATION, HEEL, PER INCH LIFT, ELEVATION, HEEL, PER INCH

0 20 07/01/2020 12/31/9999 4 30.74

L3340 NU-Fee on File Yes HEEL WEDGE, SACH HEEL WEDGE, SACH

0 20 07/01/2020 12/31/9999 2 68.68L3350 NU-Fee on File Yes HEEL WEDGE HEEL WEDGE 0 20 07/01/2020 12/31/9999 2 18.42L3360 NU-Fee on File Yes SOLE WEDGE, OUTSIDE SOLE SOLE

WEDGE, OUTSIDE SOLE0 20 07/01/2020 12/31/9999 2 28.70

L3370 NU-Fee on File Yes SOLE WEDGE, BETWEEN SOLE SOLE WEDGE, BETWEEN SOLE

0 20 07/01/2020 12/31/9999 2 39.98

L3380 NU-Fee on File Yes CLUBFOOT WEDGE CLUBFOOT WEDGE 0 20 07/01/2020 12/31/9999 2 39.98L3390 NU-Fee on File Yes OUTFLARE WEDGE OUTFLARE WEDGE 0 20 07/01/2020 12/31/9999 2 39.98

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL3400 NU-Fee on File Yes METATARSAL BAR WEDGE, ROCKER

METATARSAL BAR WEDGE, ROCKER0 20 07/01/2020 12/31/9999 2 32.80

L3410 NU-Fee on File Yes METATARSAL BAR WEDGE, BETWEEN SOLE METATARSAL BAR WEDGE, BETWEEN SOLE

0 20 07/01/2020 12/31/9999 2 74.82

L3420 NU-Fee on File Yes FULL SOLE AND HEEL WEDGE, BETWEEN SOLE FULL SOLE AND HEEL WEDGE, BETWEEN

0 20 07/01/2020 12/31/9999 2 44.06

L3430 NU-Fee on File Yes HEEL, COUNTER, PLASTIC REINFORCED 0 20 07/01/2020 12/31/9999 2 129.13L3440 NU-Fee on File Yes HEEL, COUNTERR, LEATHER

REINFORCED HEEL, COUNTER, LEATHER REINFORCED

0 20 07/01/2020 12/31/9999 2 61.50

L3450 NU-Fee on File Yes HEEL, SACH CUSHION TYPE HEEL, SACH CUSHION TYPE

0 20 07/01/2020 12/31/9999 2 85.04

L3455 NU-Fee on File Yes HEEL, NEW LEATHER, STANDARD HEEL, NEW LEATHER, STANDARD

0 20 07/01/2020 12/31/9999 2 32.80

L3460 NU-Fee on File Yes HEEL, NEW RUBBER, STANDARD HEEL, NEW RUBBER, STANDARD

0 20 07/01/2020 12/31/9999 2 27.66

L3465 NU-Fee on File Yes HEEL, THOMAS WITH WEDGE HEEL, THOMAS WITH WEDGE

0 20 07/01/2020 12/31/9999 2 47.14

L3470 NU-Fee on File Yes HEEL, THOMAS EXTENDED TO BALL HEEL, THOMAS EXTENDED TO BALL

0 20 07/01/2020 12/31/9999 2 50.20

L3480 NU-Fee on File Yes HEEL, PAD AND DEPRESSION FOR SPUR HEEL, PAD AND DEPRESSION FOR SPUR

0 20 07/01/2020 12/31/9999 2 50.20

L3485 NU-Fee on File Yes HEEL, PAD, REMOVABLE FOR SPUR HEEL, PAD, REMOVABLE FOR SPUR

0 20 07/01/2005 12/31/9999 2 18.62

L3500 NU-Fee on File Yes ORTHOPEDIC SHOE ADDITION, INSOLE, LEATHER ORTHOPEDIC SHOE ADDITION, INSO

0 20 07/01/2020 12/31/9999 2 23.59

L3510 NU-Fee on File Yes ORTHOPEDIC SHOE ADDITION, INSOLE, RUBBER ORTHOPEDIC SHOE ADDITION, INSOL

0 20 07/01/2020 12/31/9999 2 23.59

L3520 NU-Fee on File Yes ORTHOPEDIC SHOE ADDITION, INSOLE, FELT COVERED WITH LEATHER ORTHOPEDIC S

0 20 07/01/2020 12/31/9999 2 25.62

L3530 NU-Fee on File Yes ORTHOPEDIC SHOE ADDITION, SOLE, HALF ORTHOPEDIC SHOE ADDITION, SOLE, HAL

0 20 07/01/2020 12/31/9999 2 25.62

L3540 NU-Fee on File Yes ORTHOPEDIC SHOE ADDITION, SOLE, FULL ORTHOPEDIC SHOE ADDITION, SOLE, FUL

0 20 07/01/2020 12/31/9999 2 41.00

L3550 NU-Fee on File Yes ORTHOPEDIC SHOE ADDITION, TOE TAP STANDARD ORTHOPEDIC SHOE ADDITION, TOE

0 20 07/01/2020 12/31/9999 2 7.18

L3560 NU-Fee on File Yes ORTHOPEDIC SHOE ADDITION, TOE TAP, HORSESHOE ORTHOPEDIC SHOE ADDITION, T

0 20 07/01/2020 12/31/9999 2 18.42

L3570 NU-Fee on File Yes ORTHOPEDIC SHOE ADDITION, SPECIAL EXTENSION TO INSTEP (LEATHER WITH EYEL

0 20 07/01/2020 12/31/9999 2 68.68

L3580 NU-Fee on File Yes ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP TO VELCRO CLOSURE ORTHOPEDIC SH

0 20 07/01/2020 12/31/9999 2 52.26

L3590 NU-Fee on File Yes ORTHOPEDIC SHOE ADDITION, CONVERT FIRM SHOE COUNTER TO SOFT COUNTER ORTH

0 20 07/01/2020 12/31/9999 2 43.05

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL3595 NU-Fee on File Yes ORTHOPEDIC SHOE ADDITION, MARCH

BAR ORTHOPEDIC SHOE ADDITION, MARCH BAR

0 20 07/01/2020 12/31/9999 2 33.82

L3600 NU-Fee on File Yes TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, EXISTI

0 20 07/01/2020 12/31/9999 2 61.50

L3650 NU-Fee on File Yes SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE SHELF

0 20 07/01/2020 12/31/9999 1 43.90

L3671 NU-Fee on File Yes SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 1 660.78

L3678 NU-Priced by PA Yes SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, OFF-THE-SHELF

0 20 01/01/2014 12/31/9999 2 0.00

L3702 NU-Fee on File Yes ELBOW ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 211.76

L3710 NU-Fee on File Yes ELBOW ORTHOSIS, ELASTIC WITH METAL JOINTS, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 106.33

L3720 NU-Fee on File Yes EO, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, FREE MOTION, CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 530.46

L3730 NU-Fee on File Yes EO, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, EXTENSION/ FLEXION ASSIST, CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 698.28

L3740 NU-Fee on File Yes ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, ADJUSTABLE POSITI

0 20 07/01/2020 12/31/9999 2 784.76

L3762 NU-Fee on File Yes ELBOW ORTHOSIS, RIGID, WITHOUT JOINTS, INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 78.86

L3763 NU-Fee on File Yes ELBOW WRIST HAND ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 582.24

L3765 NU-Fee on File Yes ELBOW WRIST HAND FINGER ORTHOSIS, RIGID, WITHOUT JOINTS,MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTINGAND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 940.33

333.11

L3807 NU-Fee on File Yes WRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S) PREFABRICATED

0 20 07/01/2020 12/31/9999 2 183.38

L3806 NU-Fee on File Yes WRIST HAND FINGER ORTHOSIS, INCL ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES ELASTIC

0 20 07/01/2020 12/31/9999 2

580.66

L3766 NU-Fee on File Yes ELBOW WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS ELASTIC BANDS

0 20 07/01/2020 12/31/9999 2 995.74

L3764 NU-Fee on File Yes ELBOW WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS ELASTIC BANDS

0 20 07/01/2020 12/31/9999 2

L3674 NU-Fee on File Yes SHOULDER ORTHOSIS, ABDUCTION POSITIONING, THORACIC CMPONNT & SUPPORT BAR WITH OR W/O

0 20 07/01/2020 12/31/9999 1 866.85

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

L3808 NU-Fee on File Yes WRIST HAND FINGER ORTHOSIS, RIGID WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE

0 20 07/01/2020 12/31/9999 2 244.94

L3809 NU-Fee on File Yes WRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED, OFF-THE-SHELF, ANY TYPE

0 20 07/01/2020 12/31/9999 2 183.38

L3891 NU-Priced by PA Yes ADDITION TO UPPER EXTREMITY JOINT, WRIST OR ELBOW, CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, EACH

0 20 01/01/2010 12/31/9999 2 0.00

L3900 NU-Fee on File Yes WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTEN

0 20 07/01/2020 12/31/9999 2 1,145.62

L3901 NU-Fee on File Yes WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTEN

0 20 07/01/2020 12/31/9999 2 1,284.54

L3904 NU-Fee on File Yes WHFO, EXTERNAL POWERED, ELECTRIC, CUSTOM-FABRICATED

0 20 07/01/2020 12/31/9999 2 2,614.96

L3906 NU-Fee on File Yes WRIST HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM

0 20 07/01/2020 12/31/9999 2 309.37

L3908 NU-Fee on File Yes WRIST HAND ORTHOSIS, WRIST EXTENSION CONTROL COCK-UP, NON MOLDED, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 43.94

L3912 NU-Fee on File Yes HAND FINGER ORTHOSIS (HFO), FLEXION GLOVE WITH ELASTIC FINGER CONTROL, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 70.48

L3913 NU-Fee on File Yes HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 198.62

L3916 NU-Fee on File Yes WHO NONTORSION JNTS PRE OTS 0 20 07/01/2020 12/31/9999 2 389.84

L3918 NU-Fee on File Yes METACARP FX ORTHOSIS PRE OTS 0 20 07/01/2020 12/31/9999 2 77.47L3919 NU-Fee on File Yes HAND ORTHOSIS, WITHOUT JOINTS, MAY

INCLUDE SOFT INTERFACE, STRAPS,CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 198.62

L3924 NU-Fee on File Yes HFO WITHOUT JOINTS PRE OTS 0 20 07/01/2020 12/31/9999 2 63.78

25.66

L3929 NU-Fee on File Yes HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S)

0 20 07/01/2020 12/31/9999 2 61.74

L3927 NU-Fee on File Yes FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP) WITHOUT

0 20 07/01/2020 12/31/9999 4

63.78

L3925 NU-Fee on File Yes FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP) NON TORSION

0 20 07/01/2020 12/31/9999 4 38.74

L3923 NU-Fee on File Yes HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS PREFABRICATED ITEM THAT

0 20 07/01/2020 12/31/9999 2

77.47

L3921 NU-Fee on File Yes HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS TURNBUCKLES MAY

0 20 07/01/2020 12/31/9999 2 235.54

L3917 NU-Fee on File Yes HAND ORTHOSIS, METACARPAL FRACTURE ORTHOSIS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT

0 20 07/01/2020 12/31/9999 2

727.26

L3915 NU-Fee on File Yes WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), ELASTIC BANDS TURNBUCKLES MAY

0 20 07/01/2020 12/31/9999 2 389.84

L3905 NU-Fee on File Yes WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS TURNBUCKLES MAY

0 20 07/01/2020 12/31/9999 2

WITHOUT JOINT(S), PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT

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

L3930 NU-Fee on File Yes HFO NONTORSION JNTS PRE OTS 0 20 07/01/2020 12/31/9999 2 61.74

L3933 NU-Fee on File Yes FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 3 156.47

L3935 NU-Fee on File Yes FINGER ORTHOSIS, NONTORSION JOINT, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 3 162.03

L3956 NU-Priced by PA Yes ADDITION OF JOINT TO UPPER EXTREMITY ORTHOSIS, ANY MATERIAL; PER JOINT

0 20 05/01/1999 12/31/9999 1 0.00

L3960 NU-Fee on File Yes SEWHO, ABDUCTION POSITIONING, AIRPLANE DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 1 604.48

L3962 NU-Fee on File Yes SEWHO, ABDUCTION POSITIONING, ERBS PALSEY DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 1 629.40

L3980 NU-Fee on File Yes UPPER EXTREMITY FRACTURE ORTHOSIS, HUMERAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 226.70

L3982 NU-Fee on File Yes UPPER EXTREMITY FRACTURE ORTHOSIS, RADIUS/ULNAR, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 280.08

L3984 NU-Fee on File Yes UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 298.97

L3995 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY ORTHOSIS,SOCK,FRACTURE OR EQUAL,EACH

0 20 07/01/2020 12/31/9999 2 25.09

L3999 NU-Priced by PA Yes UPPER LIMB ORTHOSIS, NOT OTHERWISE SPECIFIED UPPER LIMB ORHTOSIS, NOT OT

0 20 05/01/2004 12/31/9999 2 0.00

1,454.70

L3981 NU-Fee on File Yes UPPER EXTREMITY FRACTURE ORTHOSIS, HUMERAL, PREFABBRICATED INCLUDES

0 20 07/01/2020 12/31/9999 2 738.16

L3978 NU-Fee on File Yes SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN) THORACIC

0 20 07/01/2020 12/31/9999 1

1,232.11

L3977 NU-Fee on File Yes SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION

0 20 07/01/2020 12/31/9999 1 1,380.83

L3976 NU-Fee on File Yes SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN) THORACIC

0 20 07/01/2020 12/31/9999 1

1,454.70

L3975 NU-Fee on File Yes SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUTJOINTS MAY INCLUDE SOFT

0 20 07/01/2020 12/31/9999 1 1,232.11

L3973 NU-Fee on File Yes SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN) THORACIC

0 20 07/01/2020 12/31/9999 1

1,454.70

L3971 NU-Fee on File Yes SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION

0 20 07/01/2020 12/31/9999 1 1,380.83

L3967 NU-Fee on File Yes SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN) THORACIC

0 20 07/01/2020 12/31/9999 1

149.35

L3961 NU-Fee on File Yes SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN WITHOUT JOINTS MAY INCLUDE

0 20 07/01/2020 12/31/9999 1 1,232.11

L3931 NU-Fee on File Yes WRIST HAND FINGER ORTHOSIS, INCL ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES ELASTIC

0 20 07/01/2020 12/31/9999 2

ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES ELASTIC

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL4000 NU-Fee on File Yes REPLACE GIRDLE FOR SPINAL

ORTHOSIS (CTLSO OR SO)0 20 07/01/2020 12/31/9999 1 977.61

L4002 NU-Priced by PA Yes REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE

0 20 01/01/2005 12/31/9999 2 0.00

L4010 NU-Fee on File Yes REPLACE TRILATERAL SOCKET BRIM 0 20 07/01/2020 12/31/9999 2 550.14L4020 NU-Fee on File Yes REPLACE QUADRILATERAL SOCKET

BRIM, MOLDED TO PATIENT MODEL0 20 07/01/2020 12/31/9999 2 687.17

L4030 NU-Fee on File Yes REPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTED

0 20 07/01/2020 12/31/9999 2 378.35

L4040 NU-Fee on File Yes REPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2020 12/31/9999 2 305.90

L4045 NU-Fee on File Yes REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2020 12/31/9999 2 245.82

L4050 NU-Fee on File Yes REPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2020 12/31/9999 2 309.38

L4055 NU-Fee on File Yes REPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

0 20 07/01/2020 12/31/9999 2 200.34

L4060 NU-Fee on File Yes REPLACE HIGH ROLL CUFF 0 20 07/01/2020 12/31/9999 2 238.16L4070 NU-Fee on File Yes REPLACE PROXIMAL AND DISTAL

UPRIGHT FOR KAFO0 20 07/01/2020 12/31/9999 2 227.21

L4080 NU-Fee on File Yes REPLACE METAL BANDS KAFO, PROXIMAL THIGH

0 20 07/01/2020 12/31/9999 2 80.10

L4090 NU-Fee on File Yes REPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGH

0 20 07/01/2020 12/31/9999 4 70.90

L4100 NU-Fee on File Yes REPLACE LEATHER CUFF KAFO, PROXIMAL THIGH

0 20 07/01/2020 12/31/9999 2 79.97

L4110 NU-Fee on File Yes REPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGH

0 20 07/01/2020 12/31/9999 4 63.55

L4130 NU-Fee on File Yes REPLACE PRETIBIAL SHELL 0 20 07/01/2020 12/31/9999 2 437.38L4350 NU-Fee on File Yes ANKLE CONTROL ORTHOSIS, STIRRUP

STYLE, RIGID, INCLUDES ANY TYPE INTERFACE (E.G., PNEUMATIC, GEL), PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 78.80

L4361 NU-Fee on File Yes WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 220.46

L4370 NU-Fee on File Yes PNEUMATIC FULL LEG SPLINT, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 141.47

L4387 NU-Fee on File Yes WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 127.75

L4392 NU-Fee on File Yes REPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO

0 20 07/01/2020 12/31/9999 2 18.98

L4394 NU-Fee on File Yes REPALCE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT

0 20 07/01/2020 12/31/9999 2 13.85

135.26L4397 NU-Fee on File Yes STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL ADJUSTABLE FOR FIT FOR

0 20 07/01/2020 12/31/9999 2

220.46

L4396 NU-Fee on File Yes STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL ADJUSTABLE FOR FIT FOR

0 20 07/01/2020 12/31/9999 2 135.26

L4360 NU-Fee on File Yes WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE

0 20 07/01/2020 12/31/9999 2

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL4398 NU-Fee on File Yes FOOT DROP SPLINT, RECUMBENT

POSITIONING DEVICE, PREFABRICATED, OFF-THE-SHELF

0 20 07/01/2020 12/31/9999 2 62.24

L5000 NU-Fee on File Yes PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLER

0 20 07/01/2020 12/31/9999 2 422.52

L5010 NU-Fee on File Yes PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGHT, WITH TOE FILLER

0 20 07/01/2020 12/31/9999 2 1,020.49

L5020 NU-Fee on File Yes PARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBERCLE HEIGHT WITH TOE FILLER

0 20 07/01/2020 12/31/9999 2 1,733.01

L5050 NU-Fee on File Yes SYMES PROSTHESIS PLASTVAPC WITH PTB WEIGHT BEARING

0 20 07/01/2020 12/31/9999 2 1,917.02

L5060 NU-Fee on File Yes ANKLE, SYMES, METAL FRAME, MOLDED LEATHER SOCKET,

0 20 07/01/2020 12/31/9999 2 2,205.14

L5100 NU-Fee on File Yes PATELLAR TENDON BEARING (P T B ) CUFF

0 20 07/01/2020 12/31/9999 2 1,921.26

L5105 NU-Fee on File Yes BELOW KNEE, PLASTIC SOCKET, JOINTS AND THIGH LACER, SACH FOOT

0 20 07/01/2020 12/31/9999 2 2,773.55

L5150 NU-Fee on File Yes KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL

0 20 07/01/2020 12/31/9999 2 2,803.67

L5160 NU-Fee on File Yes KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, BENT KNEE

0 20 07/01/2020 12/31/9999 2 3,049.50

L5200 NU-Fee on File Yes QUAD SOCKET OPEN END, CONSTANT FRIC KNEE SACH FOOT WOOD, PLASTIC

0 20 07/01/2020 12/31/9999 2 2,920.33

L5210 NU-Fee on File Yes ABOVE KNEE, SHORT PROTHESIS, NO KNEE JOINT ("STUBBIES") , WITH

0 20 07/01/2020 12/31/9999 2 1,937.34

L5220 NU-Fee on File Yes ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ("STUBBIES"), WITH

0 20 07/01/2020 12/31/9999 2 2,202.14

L5230 NU-Fee on File Yes ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL DEFICIENCY, CONSTANT

0 20 07/01/2020 12/31/9999 2 3,037.18

L5250 NU-Fee on File Yes HIP DISARTICULATION PROTHESIS CANADIAN

0 20 07/01/2020 12/31/9999 2 4,142.46

L5270 NU-Fee on File Yes HIP DISARTICULATION PROTHESIS TILT TABLE TYPE

0 20 07/01/2020 12/31/9999 2 4,124.07

L5280 NU-Fee on File Yes HEMIPELVECTOMY, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE

0 20 07/01/2020 12/31/9999 2 4,092.50

L5301 NU-Fee on File Yes BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM

0 20 07/01/2020 12/31/9999 2 2,196.13

L5312 NU-Fee on File Yes KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, SINGLE AXIS KNEE, PYLON, SACH FOOT, ENDOSKELETAL SYSTEM

0 20 07/01/2020 12/31/9999 2 3,143.60

L5321 NU-Fee on File Yes ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SIN

0 20 07/01/2020 12/31/9999 2 3,183.34

L5331 NU-Fee on File Yes HIP DISARTICULATION, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM,

0 20 07/01/2020 12/31/9999 2 4,056.21

L5341 NU-Fee on File Yes HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP J

0 20 07/01/2020 12/31/9999 2 4,222.54

L5500 NU-Fee on File Yes INITIAL, BELOW KNEE "PTB" TYPE SOCKET, "USMC" OR EQUAL PYLON, NO COVER,

0 20 07/01/2020 12/31/9999 2 1,025.38

L5505 NU-Fee on File Yes INITIAL, ABOVE KNEE-KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, `USMC`

0 20 07/01/2020 12/31/9999 2 1,418.14

L4631 NU-Fee on File Yes ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM ANTERIOR TIBIAL

0 20 07/01/2020 12/31/9999 2 1,202.50

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5510 NU-Fee on File Yes PREPARATORY, BELOW KNEE "PTB"

TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON,

0 20 07/01/2020 12/31/9999 2 1,162.34

L5520 NU-Fee on File Yes PREPARATORY, BELOW KNEE "PTB" TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON,

0 20 07/01/2020 12/31/9999 2 1,148.12

L5530 NU-Fee on File Yes PREPARATORY, BELOW KNEE "PTB" TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON,

0 20 07/01/2020 12/31/9999 2 1,379.00

L5535 NU-Fee on File Yes PREPARATORY,BELOW KNEE "PTB" TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, N

0 20 07/01/2020 12/31/9999 2 1,353.90

L5540 NU-Fee on File Yes PREPARATORY, BELOW KNEE "PTB" TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON C

0 20 07/01/2020 12/31/9999 2 1,445.04

L5560 NU-Fee on File Yes PREPARATORY, ABOVE KNEE- KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, "US

0 20 07/01/2020 12/31/9999 2 1,551.72

L5570 NU-Fee on File Yes PREPARATORY, ABOVE KNEE-KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, (NON

0 20 07/01/2020 12/31/9999 2 1,613.24

L5580 NU-Fee on File Yes PREPRATORY, ABOVE KNEE-KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, (NON-

0 20 07/01/2020 12/31/9999 2 1,883.35

L5585 NU-Fee on File Yes PREPARATORY,ABOVE KNEE-KNEE DISARTICULATION,ISCHIAL LEVEL SOCKET,(NON-AL

0 20 07/01/2020 12/31/9999 2 2,317.77

L5590 NU-Fee on File Yes PREPARATORY, ABOVE KNEE-KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, (NON-

0 20 07/01/2020 12/31/9999 2 1,919.26

L5595 NU-Fee on File Yes PREPARATORY,HIP DISARTICULATION-HEMIPELVECTOMY,PYLON,NO COVER, SACH FOOT

0 20 07/01/2020 12/31/9999 2 3,390.63

L5600 NU-Fee on File Yes PREPARATORY,HIP DISARTICULATION-HEMIPELVECTOMY,PLYON,NO COVER,SACH FOOT

0 20 07/01/2020 12/31/9999 2 3,644.78

L5610 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, HYDRACADENCE SYSTEM

0 20 07/01/2020 12/31/9999 2 1,652.96

L5611 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, "ENDOSKELETAL SYSTEM" ABOVE KNEE-KNEE DISAR

0 20 07/01/2020 12/31/9999 2 1,286.34

L5613 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,"ENDOSKELETAL SYSTEM," ABOVE KNEE-KNEE DISAR

0 20 07/01/2020 12/31/9999 2 2,011.14

L5614 NU-Fee on File Yes ADDITIONS TO LOWER EXTREMITY, "ENDOSKELETAL SYSTEM," ABOVE KNEE, KNEE DI

0 20 07/01/2020 12/31/9999 2 1,362.41

L5616 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, "ENDOSKELETAL SYSTEM" ABOVE KNEE, UNIVERSAL

0 20 07/01/2020 12/31/9999 2 1,086.81

L5617 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, QUICK CHANGE SELF-ALIGNING UNIT, ABOVE OR B

0 20 07/01/2020 12/31/9999 2 451.73

L5618 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST SOCKET, SYMES

0 20 07/01/2020 12/31/9999 4 238.98

L5620 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEE

0 20 07/01/2020 12/31/9999 4 221.96

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5622 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST

SOCKET, KNEE DISARTICULATION0 20 07/01/2020 12/31/9999 4 289.43

L5624 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEE

0 20 07/01/2020 12/31/9999 4 290.26

L5626 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST SOCKET, HIP DISARTICULATION

0 20 07/01/2020 12/31/9999 4 380.66

L5628 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVECTOMY

0 20 07/01/2020 12/31/9999 2 407.02

L5629 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,BELOW KNEE,ACRYLIC

0 20 07/01/2020 12/31/9999 2 253.73

L5630 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, SYMES TYPE, EXPANDABLE WALL

0 20 07/01/2020 12/31/9999 2 358.31

L5631 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,ABOVE KNEE OR KNEE DISARTICULATION

0 20 07/01/2020 12/31/9999 2 350.79

L5632 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, SYMES TYPE, "PTB" BRIM DESIGN SOCKET

0 20 07/01/2020 12/31/9999 2 195.78

L5634 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPENING

0 20 07/01/2020 12/31/9999 2 242.86

L5636 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, SYMES TYPE, MEDIAL OPENING SOCKET

0 20 07/01/2020 12/31/9999 2 203.42

L5637 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,BELOW KNEE, TOTAL

0 20 07/01/2020 12/31/9999 2 230.64

L5638 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, LEATHER SOCKET

0 20 07/01/2020 12/31/9999 2 401.78

L5639 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,BELOW KNEE,WOOD

0 20 07/01/2020 12/31/9999 2 895.13

L5640 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, LEATHER SOCKET

0 20 07/01/2020 12/31/9999 2 510.51

L5642 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE, LEATHER SOCKET

0 20 07/01/2020 12/31/9999 2 494.65

L5643 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,HIP DISARTICULATION,FLEXIBLE INNER SOCKET,EX

0 20 07/01/2020 12/31/9999 2 1,242.64

L5644 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKET

0 20 07/01/2020 12/31/9999 2 471.56

L5645 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,BELOW KNEE,FLEXIBLE INNER SOCKET,EXTERNAL FR

0 20 07/01/2020 12/31/9999 2 637.02

L5646 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET

0 20 07/01/2020 12/31/9999 2 437.44

L5647 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,BELOW KNEE SUCTION

0 20 07/01/2020 12/31/9999 2 635.08

L5648 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET

0 20 07/01/2020 12/31/9999 2 525.64

L5649 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M-L SOCKET

0 20 07/01/2020 12/31/9999 2 1,904.68

L5650 NU-Fee on File Yes ADDITIONS TO LOWER EXTREMITY, TOTAL CONTACT, ABOVE KNEE OR KNEE DISARTIC

0 20 07/01/2020 12/31/9999 2 389.76

L5651 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,ABOVE KNEE,FLEXIBLE INNER SOCKET,EXTERNAL FR

0 20 07/01/2020 12/31/9999 2 958.79

L5652 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, SUCTION SUSPENSION, ABOVE KNEE

0 20 07/01/2020 12/31/9999 2 348.08

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5653 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, KNEE

DISARTICULATION, EXPANDABLE0 20 07/01/2020 12/31/9999 2 464.66

L5654 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, SOCKET INSERT, SYMES, (KEMBLO,

0 20 07/01/2020 12/31/9999 2 264.78

L5655 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, SOCKET INSERT, BELOW KNEE

0 20 07/01/2020 12/31/9999 2 224.38

L5656 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, SOCKET INSERT, KNEE DISARTICULATION (KEMBL

0 20 07/01/2020 12/31/9999 2 301.01

L5658 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, SOCKET INSERT, ABOVE KNEE

0 20 07/01/2020 12/31/9999 2 290.29

L5661 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY,SOCKET INSERT,MULTI-DUROMETER SYMES

0 20 07/01/2020 12/31/9999 2 485.86

L5665 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER, BELOW KNEE

0 20 07/01/2020 12/31/9999 2 408.79

L5666 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, CUFF SUSPENSION

0 20 07/01/2020 12/31/9999 2 55.89

L5668 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED DISTAL

0 20 07/01/2020 12/31/9999 2 90.14

L5670 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED SUPRACONDYLAR

0 20 07/01/2020 12/31/9999 2 216.64

L5671 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE / ABOVE KNEE SUSPENSION LOCKING

0 20 07/01/2020 12/31/9999 2 459.09

L5672 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, REMOVABLE MEDIAL

0 20 07/01/2020 12/31/9999 2 238.06

L5676 NU-Fee on File Yes ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, SINGLE AXIS, PAIR

0 20 07/01/2020 12/31/9999 2 289.31

L5677 NU-Fee on File Yes ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, POLYCENTRIC, PAIR

0 20 07/01/2020 12/31/9999 2 393.65

L5678 NU-Fee on File Yes ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, JOINT COVERS, PAIR

0 20 07/01/2020 12/31/9999 2 31.70

L5680 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, NON-

0 20 07/01/2020 12/31/9999 2 264.62

L5681 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE

0 20 07/01/2020 12/31/9999 2 1,062.02

L5682 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER,

0 20 07/01/2020 12/31/9999 2 499.30

L5683 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE

0 20 07/01/2020 12/31/9999 2 1,062.02

L5684 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, FORK STRAP

0 20 07/01/2020 12/31/9999 2 38.42

567.70

L5679 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR

0 20 07/01/2020 12/31/9999 4 473.06

L5673 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR

0 20 07/01/2020 12/31/9999 4

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5685 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY

PROSTHESIS, BELOW KNEE, SUSPENSION/SEALING SLEEVE, WITH OR WITHOUT VALVE, ANY MATERIAL, EACH

0 20 07/01/2020 12/31/9999 4 103.41

L5686 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, BACK CHECK (EXTENS-

0 20 07/01/2020 12/31/9999 2 40.78

L5688 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, WEBBING

0 20 07/01/2020 12/31/9999 2 48.77

L5690 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, PADDED

0 20 07/01/2020 12/31/9999 2 78.13

L5692 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT,

0 20 07/01/2020 12/31/9999 2 106.09

L5694 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, PADDED AND

0 20 07/01/2020 12/31/9999 2 144.84

L5695 NU-Fee on File Yes ADDITION ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL, SLEEVE

0 20 07/01/2020 12/31/9999 2 133.70

L5696 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULAT-

0 20 07/01/2020 12/31/9999 2 147.72

L5697 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULAT-

0 20 07/01/2020 12/31/9999 2 64.09

L5698 NU-Fee on File Yes ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULAT-

0 20 07/01/2020 12/31/9999 2 104.81

L5699 NU-Fee on File Yes ALL LOWER EXTREMITY PROTHESES, SHOULDER HARNESS

0 20 07/01/2020 12/31/9999 2 188.81

L5700 NU-Fee on File Yes REPLACEMENT, SOCKET, BELOW KNEE, MOLDED TO PATIENT MODEL

0 20 07/01/2020 12/31/9999 2 2,287.52

L5701 NU-Fee on File Yes REPLACEMENT,SOCKET,ABOVE KNEE/KNEE DISARTICULATION, INCLUDING ATTACHMENT

0 20 07/01/2020 12/31/9999 2 2,747.14

L5702 NU-Fee on File Yes REPLACEMENT,SOCKET HIP DISARTICULATION,INCLUDING HIP JOINT,MOLDED TO PAT

0 20 07/01/2020 12/31/9999 2 3,475.53

L5703 NU-Fee on File Yes ANKLE, SYMES, MOLDED TO PATIENT MODEL, SOCKET WITHOUT SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY

0 20 07/01/2020 12/31/9999 2 1,798.62

L5704 NU-Fee on File Yes CUSTOM SHAPED PROTECTIVE COVER, BELOW KNEE

0 20 07/01/2020 12/31/9999 2 427.94

L5705 NU-Fee on File Yes CUSTOM SHAPED PROTECTIVE COVER, ABOVE KNEE

0 20 07/01/2020 12/31/9999 2 764.67

L5706 NU-Fee on File Yes CUSTOM SHAPED PROTECTIVE COVER, KNEE DISARTICULATION

0 20 07/01/2020 12/31/9999 2 749.57

L5707 NU-Fee on File Yes CUSTOM SHAPED PROTECTIVE COVER, HIP DISARTICULATION

0 20 07/01/2020 12/31/9999 2 988.18

L5710 NU-Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK

0 20 07/01/2020 12/31/9999 2 298.58

L5711 NU-Fee on File Yes ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL LOCK,ULTA-LIGH

0 20 07/01/2020 12/31/9999 2 417.30

L5712 NU-Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND

0 20 07/01/2020 12/31/9999 2 349.66

L5714 NU-Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, VARIABLE FRICTION

0 20 07/01/2020 12/31/9999 2 359.14

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5716 NU-Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN

SYSTEM, POLYCENTRIC, MECHANICAL STANCE

0 20 07/01/2020 12/31/9999 2 581.89

L5718 NU-Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING AN

0 20 07/01/2020 12/31/9999 2 727.30

L5722 NU-Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING,

0 20 07/01/2020 12/31/9999 2 768.37

L5724 NU-Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE

0 20 07/01/2020 12/31/9999 2 1,205.09

L5726 NU-Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, EXTERNAL JOINTS FL

0 20 07/01/2020 12/31/9999 2 1,388.84

L5728 NU-Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND ST

0 20 07/01/2020 12/31/9999 2 1,899.75

L5780 NU-Fee on File Yes ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/HYDRA PN

0 20 07/01/2020 12/31/9999 2 914.08

L5781 NU-Fee on File Yes ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MAN

0 20 07/01/2020 12/31/9999 2 3,230.44

L5782 NU-Fee on File Yes ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MAN

0 20 07/01/2020 12/31/9999 2 3,405.62

L5785 NU-Fee on File Yes ADDITION,EXOSKELETAL SYSTEM,BELOW KNEE,ULTRA-LIGHT MATERIAL (TITANIUM,CA

0 20 07/01/2020 12/31/9999 2 513.82

L5790 NU-Fee on File Yes ADDITION,EXOSKELETAL SYSTEM,ABOVE KNEE,ULTRA-LIGHT MATERIAL (TITANIUM,CA

0 20 07/01/2020 12/31/9999 2 574.06

L5795 NU-Fee on File Yes ADDITION,EXOSKELETAL SYSTEM,HIP DISARTICULATION,ULTRA-LIGHT MATERIAL(TIT

0 20 07/01/2020 12/31/9999 2 1,142.95

L5810 NU-Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, MANUAL LOCK

0 20 07/01/2020 12/31/9999 2 388.70

L5811 NU-Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL LOCK,ULTRA-LIG

0 20 07/01/2020 12/31/9999 2 582.27

L5812 NU-Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FRICTION SWING AND ST

0 20 07/01/2020 12/31/9999 2 451.33

L5814 NU-Fee on File Yes ADD. ENDOSKTL KNEE-SHIN SYST, POLY HYDRAUL,SWG PHASE CNTRL MECH PHS LOCK

0 20 07/01/2020 12/31/9999 2 2,998.48

L5816 NU-Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC,MECHANICAL STANCE PHA

0 20 07/01/2020 12/31/9999 2 683.08

L5818 NU-Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC,FRICTION SWING,AND ST

0 20 07/01/2020 12/31/9999 2 766.70

L5822 NU-Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,PNEUMATIC SWING,FRICT

0 20 07/01/2020 12/31/9999 2 1,359.57

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5824 NU-Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN

SYSTEM,SINGLE AXIS,FLUID SWING PHASE CON

0 20 07/01/2020 12/31/9999 2 1,224.37

L5826 NU-Fee on File Yes ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, HYDRAULIC SWING PH

0 20 07/01/2020 12/31/9999 2 2,521.33

L5828 NU-Fee on File Yes ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID SWING AND STANC

0 20 07/01/2020 12/31/9999 2 2,254.58

L5830 NU-Fee on File Yes ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/ SWING P

0 20 07/01/2020 12/31/9999 2 1,514.96

L5840 NU-Fee on File Yes ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, 4-BAR LINKAGE OR MULTIAXIAL, PN

0 20 07/01/2020 12/31/9999 2 2,801.17

L5845 NU-Fee on File Yes ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION FEATURE, ADJUST

0 20 07/01/2020 12/31/9999 2 1,447.14

L5848 NU-Fee on File Yes ADDITION TO ENDOSKELETAL KNEE-SHIN SYSTEM, FLUID STANCE EXTENSION, DAMPENING FEATURE, WITH OR WITHOUT ADJUSTABILITY

0 20 07/01/2020 12/31/9999 2 868.17

L5850 NU-Fee on File Yes ADDITION,ENDOSKELETAL SYSTEM,ABOVE KNEE OR HIP DISARTICULATION,KNEE EXTE

0 20 07/01/2020 12/31/9999 2 102.14

L5855 NU-Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, MECHANICAL HIP EXTEN

0 20 07/01/2020 12/31/9999 2 274.44

L5910 NU-Fee on File Yes ADDITION,ENDOSKELETAL SYSTEM,BELOW KNEE,ALIGNABLE SYSTEM

0 20 07/01/2020 12/31/9999 2 289.15

L5920 NU-Fee on File Yes ADDITION,ENDOSKELETAL SYSTEM,ABOVE KNEE OR HIP DISARTICULATION,ALIGNABLE

0 20 07/01/2020 12/31/9999 2 423.62

L5925 NU-Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE DISARTICULATION OR HIP

0 20 07/01/2020 12/31/9999 2 357.68

L5930 NU-Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAME

0 20 07/01/2020 12/31/9999 2 2,717.53

L5940 NU-Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIU

0 20 07/01/2020 12/31/9999 2 400.48

L5950 NU-Fee on File Yes ADDITION,ENDOSKELETAL SYSTEM,ABOVE KNEE,ULTRA-LIGHT MATERIAL(TITANIUM,CA

0 20 07/01/2020 12/31/9999 2 626.17

L5960 NU-Fee on File Yes ADDITION,ENDOSKELETAL SYSTEM,HIP DISARTICULATION,ULTRA-LIGHT MATERIAL(TI

0 20 07/01/2020 12/31/9999 2 769.67

L5962 NU-Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, FLEXIBLE PROCTECTIVE OUTER SU

0 20 07/01/2020 12/31/9999 2 506.53

L5964 NU-Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, FLEXIBLE PROTECTIVE OUTER SUR

0 20 07/01/2020 12/31/9999 2 747.70

3,670.12L5961 NU-Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, POLYCENTRIC HIP JOINT, PNEUMATIC OR HYDRAULIC CONTROL ROTATION

0 20 07/01/2020 12/31/9999 1

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL5966 NU-Fee on File Yes ADDITION, ENDOSKELETAL SYSTEM, HIP

DISARTICULATION, FLEXIBLE PROTECTIVE

0 20 07/01/2020 12/31/9999 2 952.76

L5968 NU-Fee on File Yes ADDITION TO LOWER LIMB PROSTHESIS, MULTIAXIAL ANKLE WITH SWING PHASE ACT

0 20 07/01/2020 12/31/9999 2 2,933.94

L5969 NU-Fee on File Yes ADDITION, ENDOSKELETAL ANKLE-FOOT OR ANKLE SYSTEM, POWER ASSIST, INCLUDES ANY TYPE MOTOR(S)

0 20 01/01/2014 12/31/9999 2 11,026.77

L5970 NU-Fee on File Yes ALL LOWER EXTREMITY PROTHESE, FOOT, EXTERNAL KEEL, SACH FOOT

0 20 07/01/2020 12/31/9999 2 162.14

L5971 NU-Fee on File Yes ALL LOWER EXTREMITY PROSTHESIS, SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY

0 20 07/01/2020 12/31/9999 2 162.14

L5972 NU-Fee on File Yes ALL LOWER EXTREMITY PROSTHESES, FOOT, FLEXIBLE KEEL

0 20 07/01/2020 12/31/9999 2 302.87

L5974 NU-Fee on File Yes ALL LOWER EXTREMITY PROTHESES, FOOT, SINGLE AXIS ANKLE/FOOT

0 20 07/01/2020 12/31/9999 2 186.05

L5975 NU-Fee on File Yes ALL LOWER EXTREMITY PROSTHESIS, COMBINATION SINGLE AXIS ANKLE AND FLEXIB

0 20 07/01/2020 12/31/9999 2 374.31

L5976 NU-Fee on File Yes ALL LOWER EXTREMITY PROTHESES, ENERGY STORING FOOT

0 20 07/01/2020 12/31/9999 2 447.11

L5978 NU-Fee on File Yes ALL LOWER EXTREMITY PROTHESES, FOOT, MULTIAXIAL ANKLE/FOOT

0 20 07/01/2020 12/31/9999 2 232.99

L5979 NU-Fee on File Yes ALL LOWER EXTREMITY PROSTHESIS, MULTI-AXIAL ANKLE, DYNAMIC RESPONSE FOOT

0 20 07/01/2020 12/31/9999 2 1,821.72

L5980 NU-Fee on File Yes ALL LOWER EXTREMITY PROTHESES, FLEX FOOT SYSTEM

0 20 07/01/2020 12/31/9999 2 2,960.17

L5981 NU-Fee on File Yes ALL LOWER EXTREMITY PROTHESES, FLEX-WALK SYSTEM OR EQUAL

0 20 07/01/2020 12/31/9999 2 2,391.42

L5982 NU-Fee on File Yes ALL EXOSKELETAL LOWER EXTREMITY PROTHESES, AXIAL ROTATION UNIT

0 20 07/01/2020 12/31/9999 2 461.55

L5984 NU-Fee on File Yes ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESIS, AXIAL ROTATION UNIT, WITH OR WITHOUT ADJUSTABILITY

0 20 07/01/2020 12/31/9999 2 454.82

L5985 NU-Fee on File Yes ALL ENDOSKELETAL LOWER EXTREMITY PROTHESES, SYNAMIC PROTHETIC PYLON

0 20 07/01/2020 12/31/9999 2 227.98

L5986 NU-Fee on File Yes ALL LOWER EXTREMITY PROTHESES, MULTI-AXIAL ROTATION UNIT

0 20 07/01/2020 12/31/9999 2 505.92

L5987 NU-Fee on File Yes ALL LOWER EXTREMITY PROTHESES, SHANK FOOT SYSTEM WITH VERTICAL LOADING

0 20 07/01/2020 12/31/9999 2 5,808.03

L5988 NU-Fee on File Yes ADDITION TO LOWER LIMB PROSTHESIS, VERTICAL SHOCK REDUCING PYLON FEATURE

0 20 07/01/2020 12/31/9999 2 1,612.88

L5999 NU-Priced by PA Yes LOWER EXTREMITY PROTHESIS, NOT OTHERWWISE SPECIFIED LOWER EXTREMITY PROS

0 20 05/01/2004 12/31/9999 2 0.00

L6000 NU-Fee on File Yes PARTIAL HAND, THUMB REMAINING 0 20 07/01/2020 12/31/9999 2 1,060.81L6010 NU-Fee on File Yes PARTIAL HAND, LITTLE AND/OR RING

FINGER REMAINING0 20 07/01/2020 12/31/9999 2 1,180.50

L6020 NU-Fee on File Yes PARTIAL HAND, NO FINGER REMAINING 0 20 07/01/2020 12/31/9999 2 1,100.63L6050 NU-Fee on File Yes WRIST DISARTICULATION, MOLDED

SOCKET, FLEXIBLE ELBOW HINGES,0 20 07/01/2020 12/31/9999 2 1,516.62

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL6055 NU-Fee on File Yes WRIST DISARTICULATION,MOLDED

SOCKET WITH EXPANDABLE INTERFACE,FLEXIBLE E

0 20 07/01/2020 12/31/9999 2 2,113.78

L6100 NU-Fee on File Yes BELOW ELBOW PROTHESIS PLASTIC DOUBLE WALL

0 20 07/01/2020 12/31/9999 2 1,536.58

L6110 NU-Fee on File Yes BELOW ELBOW PROTHES-MUNSTER 0 20 07/01/2020 12/31/9999 2 1,629.79L6120 NU-Fee on File Yes BELOW ELBOW, MOLDED DOUBLE WALL

SPLIT SOCKET, STEP-UP HINGES,0 20 07/01/2020 12/31/9999 2 1,899.30

L6130 NU-Fee on File Yes BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STUMP ACTIVATED

0 20 07/01/2020 12/31/9999 2 2,066.78

L6200 NU-Fee on File Yes ELBOW DISARTICULATION PROTHESIS 0 20 07/01/2020 12/31/9999 2 2,178.06L6205 NU-Fee on File Yes ELBOW DISARTICULATION, MOLDED

SOCKET WITH EXPANDABLE INTERFACE, OUTSIDE

0 20 07/01/2020 12/31/9999 2 2,907.36

L6250 NU-Fee on File Yes ABOVE ELBOW PROTHESIS PLASTIC DOUBLE WALL

0 20 07/01/2020 12/31/9999 2 2,282.10

L6300 NU-Fee on File Yes SHOULDER DISARTICULATION PROTHESIS

0 20 07/01/2020 12/31/9999 2 2,974.48

L6310 NU-Fee on File Yes SHOULDER DISARTICULATION, PASSIVE RESTORATION (COMPLETE PROS-

0 20 07/01/2020 12/31/9999 2 2,568.34

L6320 NU-Fee on File Yes SHOULDER DISARTICULATION, PASSIVE RESTORATION (SHOULDER CAP

0 20 07/01/2020 12/31/9999 2 1,403.02

L6350 NU-Fee on File Yes INTERSCAPULAR THORACIC, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTIO

0 20 07/01/2020 12/31/9999 2 3,127.21

L6360 NU-Fee on File Yes INTERSCAPULAR THORACIC, PASSIVE RESTORATION (COMPLETE PROS-

0 20 07/01/2020 12/31/9999 2 2,812.43

L6370 NU-Fee on File Yes INTERSCAPULAR THORACIC, PASSIVE RESTORATION (SHOULDER CAP ONLY)

0 20 07/01/2020 12/31/9999 2 1,682.86

L6400 NU-Fee on File Yes BELOW ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING

0 20 07/01/2020 12/31/9999 2 1,852.57

L6450 NU-Fee on File Yes ELBOW DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM,

0 20 07/01/2020 12/31/9999 2 2,474.98

L6500 NU-Fee on File Yes ABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING

0 20 07/01/2020 12/31/9999 2 2,589.34

L6550 NU-Fee on File Yes SHOULDER DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING

0 20 07/01/2020 12/31/9999 2 3,112.43

L6570 NU-Fee on File Yes INTERSCAPULAR THORACIC, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SO

0 20 07/01/2020 12/31/9999 2 3,494.42

L6580 NU-Fee on File Yes PREPARATORY,WRIST DISARTICULATION OR BELOW ELBOW,SINGLE WALL PLASTIC SOC

0 20 07/01/2020 12/31/9999 2 1,334.10

L6582 NU-Fee on File Yes PREPARATORY,WRIST DISARTICULATION OR BELOW ELBOW,SINGLE WALL SOCKET,FRIC

0 20 07/01/2020 12/31/9999 2 1,208.34

L6584 NU-Fee on File Yes PREPARATORY,ELBOW DISARTICULATION OR ABOVE ELBOW,SINGLE WALL PLASTIC SOC

0 20 07/01/2020 12/31/9999 2 1,894.98

L6586 NU-Fee on File Yes PREPARATORY,ELBOW DISARTICULATION OR ABOVE ELBOW,SINGLE WALL SOCKET,FRIC

0 20 07/01/2020 12/31/9999 2 1,773.40

L6588 NU-Fee on File Yes PREPARATORY,SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC,SINGLE WA

0 20 07/01/2020 12/31/9999 2 2,330.20

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL6590 NU-Fee on File Yes PREPARATORY,SHOULDER

DISARTICULATION OR INTERSCAPULAR THORACIC,SINGLE WA

0 20 07/01/2020 12/31/9999 2 2,213.33

L6600 NU-Fee on File Yes UPPER EXTREMITY ADDITIONS, POLYCENTRIC HINGE, PAIR

0 20 07/01/2020 12/31/9999 2 149.76

L6605 NU-Fee on File Yes UPPER EXTREMITY ADDITIONS, SINGLE PIVOT HINGE, PAIR

0 20 07/01/2020 12/31/9999 2 147.87

L6610 NU-Fee on File Yes UPPER EXTREMITY ADDITIONS, FLEXIBLE METAL HINGE, PAIR

0 20 07/01/2020 12/31/9999 2 142.00

L6615 NU-Fee on File Yes UPPER EXTREMITY ADDITION, DISCONNECT LOCKING WRIST UNIT

0 20 07/01/2020 12/31/9999 2 153.01

L6616 NU-Fee on File Yes UPPER EXTREMITY ADDITION, ADDITIONAL DISCONNECT INSERT FOR LOCKING WRIST

0 20 07/01/2020 12/31/9999 2 56.70

L6620 NU-Fee on File Yes UPPER EXTREMITY ADDITION, FLEXION/EXTENSION WRIST UNIT, WITH OR WITHOUT FRICTION

0 20 07/01/2020 12/31/9999 2 244.80

L6621 NU-Fee on File Yes UPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION WRIST WITH ORWITHOUT FRICTION, FOR USE WITH EXTERNAL POWERED TERMINAL DEVICE

0 20 07/01/2020 12/31/9999 2 1,846.68

L6623 NU-Fee on File Yes UPPER EXTREMITY ADDITION,SPRING ASSISTED ROTATIONAL WRIST UNIT WITH LATC

0 20 07/01/2020 12/31/9999 2 682.85

L6625 NU-Fee on File Yes UPPER EXTREMITY ADDITION, ROTATION WRIST UNIT WITH CABLE

0 20 07/01/2020 12/31/9999 2 485.17

L6628 NU-Fee on File Yes UPPER EXTREMITY ADDITION,QUICK DISCONNECT HOOK ADAPTER,OTTO BOCK OR EQUA

0 20 07/01/2020 12/31/9999 2 382.46

L6629 NU-Fee on File Yes UPPER EXTREMITY ADDITION,QUICK DISCONNECT LAMINATION COLLAR WITH COUPLIN

0 20 07/01/2020 12/31/9999 2 116.81

L6630 NU-Fee on File Yes UPPER EXTREMITY ADDITION, STAINLESS STEEL, ANY WRIST

0 20 07/01/2020 12/31/9999 2 172.06

L6632 NU-Fee on File Yes UPPER EXTREMITY ADDITION, LATEX SUSPENSION SLEEVE, EACH

0 20 07/01/2020 12/31/9999 4 59.76

L6635 NU-Fee on File Yes UPPER EXTREMITY ADDITION, LIFT ASSIST FOR ELBOW

0 20 07/01/2020 12/31/9999 2 140.62

L6637 NU-Fee on File Yes UPPER EXTREMITY ADDITION, NUDGE CONTROL ELBOW LOCK

0 20 07/01/2020 12/31/9999 2 299.93

L6640 NU-Fee on File Yes UPPER EXTREMITY ADDITIONS SHOULDER ABDUCTION JOINT, PAIR

0 20 07/01/2020 12/31/9999 2 266.46

L6641 NU-Fee on File Yes UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, PULLEY TYPE

0 20 07/01/2020 12/31/9999 2 128.08

L6642 NU-Fee on File Yes UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, LEVER TYPE

0 20 07/01/2020 12/31/9999 2 173.61

L6645 NU-Fee on File Yes UPPER EXTREMITY ADDITION, SHOULDER FLEXION-ABDUCTION

0 20 07/01/2020 12/31/9999 2 320.45

L6650 NU-Fee on File Yes UPPER EXTREMITY ADDITION, SHOULDER UNIVERSAL JOINT, EACH

0 20 07/01/2020 12/31/9999 2 332.70

L6655 NU-Fee on File Yes UPPER EXTREMITY ADDITION, STANDARD CONTROL CABLE, EXTRA

0 20 07/01/2020 12/31/9999 4 65.38

L6660 NU-Fee on File Yes UPPER EXTREMITY ADDITION, HEAVY DUTY CONTROL CABLE

0 20 07/01/2020 12/31/9999 4 73.28

L6665 NU-Fee on File Yes UPPER EXTREMITY ADDITION, TEFLON, OR EQUAL, CABLE LINING

0 20 07/01/2020 12/31/9999 4 36.77

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL6670 NU-Fee on File Yes UPPER EXTREMITY ADDITION, HOOK TO

HAND, CABLE ADAPTER0 20 07/01/2020 12/31/9999 2 40.66

L6672 NU-Fee on File Yes UPPER EXTREMITY ADDITION, HARNESS, CHEST OR

0 20 07/01/2020 12/31/9999 2 161.34

L6675 NU-Fee on File Yes UPPER EXTREMITY ADDITION, HARNESS, (E.G. FIGURE OF EIGHT TYPE), SINGLE CABLE DESIGN

0 20 07/01/2020 12/31/9999 2 95.88

L6676 NU-Fee on File Yes UPPER EXTREMITY ADDITION, HARNESS, (E.G. FIGURE OF EIGHT TYPE), DUAL CABLE DESIGN

0 20 07/01/2020 12/31/9999 2 110.83

L6677 NU-Fee on File Yes UPPER EXTREMITY ADDITION, HARNESS, TRIPLE CONTROL, SIMULTANEOUS OPERATION OF TERMINAL DEVICE AND ELBOW

0 20 07/01/2020 12/31/9999 2 239.54

L6680 NU-Fee on File Yes UPPER EXTREMITY ADDITION, TEST SOCKET, WRIST DISARTICULAT-

0 20 07/01/2020 12/31/9999 4 185.23

L6682 NU-Fee on File Yes UPPER EXTREMITY ADDITION, TEST SOCKET, ELBOW DISARTICULAT-

0 20 07/01/2020 12/31/9999 4 204.80

L6684 NU-Fee on File Yes UPPER EXTREMITY ADDITION, TEST SOCKET, SHOULDER DIS-

0 20 07/01/2020 12/31/9999 4 278.30

L6686 NU-Fee on File Yes UPPER EXTREMITY ADDITION,SUCTION SOCKET

0 20 07/01/2020 12/31/9999 2 628.45

L6687 NU-Fee on File Yes UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, BELOW ELBOW OR WRIST DISART

0 20 07/01/2020 12/31/9999 2 460.52

L6688 NU-Fee on File Yes UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, ABOVE ELBOW OR ELBOW DISART

0 20 07/01/2020 12/31/9999 2 457.74

L6689 NU-Fee on File Yes UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET,SHOULDER DISARTICULATION

0 20 07/01/2020 12/31/9999 2 548.43

L6690 NU-Fee on File Yes UPPER EXTREMITY ADDITION,FRAME TYPE SOCKET,INTERSCAPULAR-THORACIC

0 20 07/01/2020 12/31/9999 2 597.63

L6691 NU-Fee on File Yes UPPER EXTREMITY ADDITION, REMOVABLE INSERT,EACH

0 20 07/01/2020 12/31/9999 2 276.60

L6692 NU-Fee on File Yes UPPER EXTREMITY ADDITION, SILICONE GEL INSERT OR EQUAL, EACH

0 20 07/01/2020 12/31/9999 2 446.48

L6693 NU-Fee on File Yes UPPER EXTREMITY ADDITION, LOCKING ELBOW, FOREARM COUNTERBALANCE UPPER EX

0 20 07/01/2020 12/31/9999 2 2,292.11

L6696 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE

0 20 07/01/2020 12/31/9999 2 1,062.02

L6698 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, LOCK MECHANISM, EXCLUDES SOCKET INSERT

0 20 07/01/2020 12/31/9999 2 459.09

473.06

L6697 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW CUSTOM FABRICATED SOCKET

0 20 07/01/2020 12/31/9999 2 1,062.02

L6695 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW CUSTOM FABRICATED FROM

0 20 07/01/2020 12/31/9999 2

L6694 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW CUSTOM FABRICATED

0 20 07/01/2020 12/31/9999 2 567.70

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL6703 NU-Fee on File Yes TERMINAL DEVICE, PASSIVE HAND/MITT,

ANY MATERIAL, ANY SIZE0 20 07/01/2020 12/31/9999 2 290.24

L6704 NU-Fee on File Yes TERMINAL DEVICE, SPORT/RECREATIONAL/WORK ATTACHMENT, ANY MATERIAL, ANY SIZE

0 20 07/01/2020 12/31/9999 2 467.56

L6706 NU-Fee on File Yes TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,

0 20 07/01/2020 12/31/9999 2 278.57

L6707 NU-Fee on File Yes TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,

0 20 07/01/2020 12/31/9999 2 1,026.78

L6708 NU-Fee on File Yes TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE

0 20 07/01/2020 12/31/9999 2 671.23

L6709 NU-Fee on File Yes TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE

0 20 07/01/2020 12/31/9999 2 967.27

L6711 NU-Fee on File Yes TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED PEDIATRIC

0 20 07/01/2020 12/31/9999 2 542.80

L6712 NU-Fee on File Yes 'TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED PEDIATRIC

0 20 07/01/2020 12/31/9999 2 999.42

L6713 NU-Fee on File Yes 'TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, PEDIATRIC

0 20 07/01/2020 12/31/9999 2 1,261.34

L6714 NU-Fee on File Yes 'TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, PEDIATRIC

0 20 07/01/2020 12/31/9999 2 1,068.38

L6721 NU-Fee on File Yes 'TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY OPENING, ANY SIZE LINED OR UNLINED

0 20 07/01/2020 12/31/9999 2 1,898.92

L6722 NU-Fee on File Yes 'TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY CLOSING, ANY SIZE LINES OR UNLINED

0 20 07/01/2020 12/31/9999 2 1,637.00

L6805 NU-Fee on File Yes ADDITION TO TERMINAL DEVICE, MODIFIER WRIST UNIT ADDITION TO TERMINAL DEVICE, MODIFIER WRIST UNIT

0 20 07/01/2020 12/31/9999 2 271.64

L6810 NU-Fee on File Yes ADDITION TO TERMINAL DEVICE, PRECISION PINCH DEVICE ADDITION TO TERMINAL DEVICE, PRECISION PINCH DEVICE

0 20 07/01/2020 12/31/9999 2 153.97

L6883 NU-Fee on File Yes REPLACEMENT SOCKET, BELOW ELBOW/WRIST DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER

0 20 07/01/2020 12/31/9999 2 1,266.94

L6884 NU-Fee on File Yes REPLACEMENT SOCKET, ABOVE ELBOW/ELBOW DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER

0 20 07/01/2020 12/31/9999 2 1,880.41

L6885 NU-Fee on File Yes REPLACEMENT SOCKET, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER

0 20 07/01/2020 12/31/9999 2 2,812.43

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL6890 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY

PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

0 20 07/01/2020 12/31/9999 2 135.79

L6895 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY MATERIAL, CUSTOM FABRICATED

0 20 07/01/2020 12/31/9999 2 499.55

L6900 NU-Fee on File Yes HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED),

0 20 07/01/2020 12/31/9999 2 1,425.60

L6905 NU-Fee on File Yes HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED),

0 20 07/01/2020 12/31/9999 2 1,417.50

L6910 NU-Fee on File Yes HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED),

0 20 07/01/2020 12/31/9999 2 1,212.10

L6915 NU-Fee on File Yes HAND RESTORATION (SHADING, AND MEASUREMENTS INCLUDED),

0 20 07/01/2020 12/31/9999 2 611.12

L6920 NU-Fee on File Yes WRIST DISARTICULATION,EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET,REMOVAB

0 20 07/01/2020 12/31/9999 2 5,328.19

L6925 NU-Fee on File Yes WRIST DISARTICULATION,EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET,REMOVAB

0 20 07/01/2020 12/31/9999 2 7,172.67

L6930 NU-Fee on File Yes BELOW ELBOW,EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET,REMOVABLE FOREARM

0 20 07/01/2020 12/31/9999 2 5,361.23

L6935 NU-Fee on File Yes BELOW ELBOW,EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET,REMOVABLE FOREARM

0 20 07/01/2020 12/31/9999 2 7,283.98

L6940 NU-Fee on File Yes ELBOW DISARTICULATION,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE HUMER

0 20 07/01/2020 12/31/9999 2 7,004.80

L6945 NU-Fee on File Yes ELBOW DISARTICULATION,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE HUMER

0 20 07/01/2020 12/31/9999 2 8,559.02

L6950 NU-Fee on File Yes ABOVE ELBOW,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE HUMERAL SHELL

0 20 07/01/2020 12/31/9999 2 7,961.94

L6955 NU-Fee on File Yes ABOVE ELBOW,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE HUMERAL SHELL

0 20 07/01/2020 12/31/9999 2 9,535.51

L6960 NU-Fee on File Yes SHOULDER DISARTICULATION,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE

0 20 07/01/2020 12/31/9999 2 10,801.36

L6965 NU-Fee on File Yes SHOULDER DISARTICULATION,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE

0 20 07/01/2020 12/31/9999 2 11,520.04

L6970 NU-Fee on File Yes INTERSCAPULAR-THORACIC,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE SHOU

0 20 07/01/2020 12/31/9999 2 12,004.07

L6975 NU-Fee on File Yes INTERSCAPULAR-THORACIC,EXTERNAL POWER,MOLDED INNER SOCKET,REMOVABLE SHOU

0 20 07/01/2020 12/31/9999 2 13,128.58

L7040 NU-Fee on File Yes PREHENSILE ACTUATOR, SWITCH CONTROLLED

0 20 07/01/2020 12/31/9999 2 2,250.78

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL7045 NU-Fee on File Yes ELECTRIC HOOK, SWITCH OR

MYOELECTRIC ONTROLLED, PEDIATRIC0 20 07/01/2020 12/31/9999 2 1,290.45

L7170 NU-Fee on File Yes ELECTRONIC ELBOW. HOSMER OR EQUAL, SWITCH CONTROLLED

0 20 07/01/2020 12/31/9999 2 5,941.73

L7180 NU-Fee on File Yes ELECTRONIC ELBOW, MICROPROCESSOR SEQUENTIAL CONTROL OF ELBOW AND TERMINAL DEVICE

0 20 07/01/2020 12/31/9999 2 26,080.87

L7185 NU-Fee on File Yes ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLE

0 20 07/01/2020 12/31/9999 2 5,867.54

L7186 NU-Fee on File Yes ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED

0 20 07/01/2020 12/31/9999 2 7,062.14

L7190 NU-Fee on File Yes ELECTRONIC ELBOW, ADOLESCENT,VARIETY VILLAGE OR EQUAL, MYOELECTRONICALL

0 20 07/01/2020 12/31/9999 2 6,162.91

L7191 NU-Fee on File Yes ELECTRONIC ELBOW,CHILD,VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTR

0 20 07/01/2020 12/31/9999 2 7,379.52

L7259 NU-Fee on File Yes ELECTRONIC WRIST ROTATOR, ANY TYPE

0 20 07/01/2020 12/31/9999 2 2,551.57

L7360 NU-Fee on File Yes SIX VOLT BATTERY, EACH 0 20 07/01/2020 12/31/9999 1 190.50L7362 NU-Fee on File Yes BATTERY CHARGER, SIX VOLT, EACH 0 20 07/01/2020 12/31/9999 1 200.03L7364 NU-Fee on File Yes TWELVE VOLT BATTERY, EACH 0 20 07/01/2020 12/31/9999 1 318.14L7366 NU-Fee on File Yes BATTERY CHARGER, TWELVE VOLT,

EACH0 20 07/01/2020 12/31/9999 1 428.54

L7400 NU-Fee on File Yes DDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL)

0 20 07/01/2020 12/31/9999 2 247.46

L7401 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL)

0 20 07/01/2020 12/31/9999 2 277.03

L7402 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL)

0 20 07/01/2020 12/31/9999 2 299.14

L7403 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ACRYLIC MATERIAL

0 20 07/01/2020 12/31/9999 2 297.34

L7404 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ACRYLIC MATERIAL

0 20 07/01/2020 12/31/9999 2 448.73

L7405 NU-Fee on File Yes ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, ACRYLIC MATERIAL

0 20 07/01/2020 12/31/9999 2 586.89

L7499 NU-Priced by PA Yes UPPER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED UPPER EXTREMITY PROS

0 20 05/01/2004 12/31/9999 2 0.00

L7600 NU-Priced by PA Yes PROSTHETIC DONNING SLEEVE, ANY MATERIAL, EACH

0 20 01/01/2006 12/31/9999 1 0.00

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL8000 NU-Fee on File Yes BREAST PROSTHESES, MASTECTOMY

BRA, WITHOUT INTEGRATED BREAST PROSTHESES FORM, ANY SIZE, ANY TYPE

0 20 07/01/2020 12/31/9999 6 35.11

L8010 NU-Fee on File Yes BREAST PROSTHESIS, MASTECOMY SLEEVE

0 20 05/01/1999 12/31/9999 2 37.52

L8015 NU-Fee on File Yes EXTERNAL BREAST PROSTHESIS GARMENT, WITH MASTECTOMY FORM, POST MASTECTOM

0 20 07/01/2020 12/31/9999 4 48.39

L8020 NU-Fee on File Yes BREAST PROSTHESIS, MASTECTOMY FORM

0 20 07/01/2020 12/31/9999 4 182.02

L8030 NU-Fee on File Yes BREAST PROSTHESIS, SILICONE OR EQUAL, WITHOUT INTEGRAL ADHESIVE

0 20 07/01/2020 12/31/9999 2 263.28

L8035 NU-Fee on File Yes CUSTOM BREAST PROSTHESIS, POST MASTECTOMY, MOLDED TO PATIENT MODEL

0 20 07/01/2020 12/31/9999 2 2,957.91

L8039 NU-Priced by PA Yes BREAST PROSTHESIS, NOT OTHERWISE SPECIFIED

0 20 05/01/2004 12/31/9999 2 0.00

L8300 NU-Fee on File Yes TRUSS, SINGLE WITH STANDARD PAD 0 20 07/01/2020 12/31/9999 1 77.76L8310 NU-Fee on File Yes TRUSS, DOUBLE WITH STANDARD PADS 0 20 07/01/2020 12/31/9999 1 119.56L8320 NU-Fee on File Yes TRUSS, ADDITION TO STANDARD PAD,

WATER PAD0 20 07/01/2020 12/31/9999 2 52.22

L8330 NU-Fee on File Yes TRUSS, ADDITION TO STANDARD PAD, SCROTAL PAD

0 20 07/01/2020 12/31/9999 2 51.76

L8400 NU-Fee on File Yes PROSTHETIC SHEATH, BELOW KNEE, EACH

0 20 07/01/2020 12/31/9999 12 15.14

L8410 NU-Fee on File Yes PROSTHETIC SHEATH, ABOVE KNEE, EACH

0 20 07/01/2020 12/31/9999 12 17.22

L8415 NU-Fee on File Yes PROSTHETIC SHEATH,UPPER LIMB,EACH 0 20 07/01/2020 12/31/9999 6 17.11L8417 NU-Fee on File Yes PROSTHETIC SHEATH/SOCK, INCLUDING

A GEL CUSHION LAYER, BELOW KNEE OR ABO

0 20 07/01/2020 12/31/9999 12 60.71

L8420 NU-Fee on File Yes PROSTHETIC SOCK, MULTIPLE PLY, BELOW KNEE, EACH PROSTHETIC SOCK, MULTIPL

0 20 07/01/2020 12/31/9999 24 20.01

L8430 NU-Fee on File Yes PROSTHETIC SOCK, MULTIPLE PLY, ABOVE KNEE, EACH PROSTHETIC SOCK, MULTIPL

0 20 07/01/2020 12/31/9999 24 22.00

L8435 NU-Fee on File Yes PROSTHETIC SOCK, MULTIPLE PLY, UPPER LIMB, EACH PROSTHETIC SOCK, MULTIP

0 20 07/01/2020 12/31/9999 12 19.74

L8440 NU-Fee on File Yes PROSTHETIC SHRINKER, BELOW KNEE, EACH

0 20 07/01/2020 12/31/9999 4 41.86

L8460 NU-Fee on File Yes PROSTHETIC SHRINKER, ABOVE KNEE, EACH

0 20 07/01/2020 12/31/9999 4 58.26

L8465 NU-Fee on File Yes PROSTHETIC SHRINKER,UPPER LIMB,EACH

0 20 07/01/2020 12/31/9999 4 51.93

L8470 NU-Fee on File Yes PROSTHETIC SOCK, SINGLE PLY, FITTING, BELOW KNEE, EACH PROSTHETIC SOCK,

0 20 07/01/2020 12/31/9999 24 5.33

L8480 NU-Fee on File Yes PROSTHETIC SOCK, SINGLE PLY, FITTING, ABOVE KNEE, EACH PROSTHETIC SOCK,

0 20 07/01/2020 12/31/9999 24 7.35

L8485 NU-Fee on File Yes PROSTHETIC SOCK, SINGLE PLY, FITTING, UPPER LIMB, EACH PROSTHETIC SOCK,

0 20 07/01/2020 12/31/9999 12 8.88

L8500 NU-Fee on File Yes ARTIFICIAL LARYNX, ANY TYPE 0 20 07/01/2020 12/31/9999 1 526.90

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL8501 NU-Fee on File Yes TRACHEOSTOMY SPEAKING VALVE 0 20 07/01/2020 12/31/9999 2 117.02L8615 NU-Fee on File Yes HEADSET/HEADPIECE FOR USE WITH

COCHLEAR IMPLANT DEVICE, REPLACEMENT

0 999 07/01/2020 12/31/9999 2 364.14

L8616 NU-Fee on File Yes MICROPHONE FOR USE WITH COCHLEAR IMPLANT DEVICE,

0 999 07/01/2020 12/31/9999 2 84.82

L8617 NU-Fee on File Yes TRANSMITTING COIL FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT

0 999 07/01/2020 12/31/9999 2 74.10

L8618 NU-Fee on File Yes TRANSMITTER CABLE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT

0 999 07/01/2020 12/31/9999 2 21.17

L8619 NU-Fee on File Yes COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR AND CONTROLLER, INTEGRATED SYSTEM, REPLACEMENT

0 999 07/01/2020 12/31/9999 2 6,556.62

L8619 UE-Fee on File Yes COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR AND CONTROLLER, INTEGRATED SYSTEM, REPLACEMENT

0 999 07/01/2020 12/31/9999 2 3,278.31

L8621 NU-Fee on File Yes ZINC AIR BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT, EACH

0 999 07/01/2020 12/31/9999 300 0.50

L8622 NU-Fee on File Yes ALKALINE BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, ANY SIZE, REPLACEMENT

0 999 07/01/2020 12/31/9999 1 0.26

L8623 NU-Fee on File Yes LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR, OTHER THAN EAR LEVEL, REPLACEMENT, EACH

0 999 07/01/2020 12/31/9999 4 52.22

L8624 NU-Fee on File Yes LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOOR, EAR LEVEL, REPLACEMENT, EACH

0 999 07/01/2020 12/31/9999 4 130.18

L8625 NU-Fee on File Yes EXTERNAL RECHARGING SYSTEM FOR BATTERY FOR USE WITH COCHLEAR IMPLANT OR AUDITORY OSSEOINTEGRATED DEVICE, REPLACEMENT ONLY, EACH

0 999 07/01/2020 12/31/9999 1 152.49

L8627 NU-Fee on File Yes COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR, COMPONENT, REPLACEMENT

0 999 07/01/2020 12/31/9999 1 5,557.84

L8628 NU-Fee on File Yes COCHLEAR IMPLANT, EXTERNAL CONTROLLER COMPONENT, REPLACEMENT

0 999 07/01/2020 12/31/9999 1 998.80

L8629 NU-Fee on File Yes TRANSMITTING COIL AND CABLE, INTEGRATED, FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT

0 999 07/01/2020 12/31/9999 1 144.56

L8679 NU-Fee on File Yes IMPLANTABLE NEUROSTIMULATOR, PULSE GENERATOR, ANY TYPE

0 20 07/01/2020 12/31/9999 1 6,736.76

L8691 NU-Fee on File Yes AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, REPLACEMENT

5 999 07/01/2020 12/31/9999 1 1,390.42

L8693 NU-Fee on File Yes AUDITORY OSSEOINTEGRATED DEVICE ABUTMENT, ANY LENGTH, REPLACEMENT ONLY

5 999 07/01/2020 12/31/9999 2 1,224.24

3,155.65L8692 NU-Fee on File Yes AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, USED WITHOUT OSSEOINTEGRATION BODY

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

Code Code Status PA Description Min Age Max Age Begin Date End Date Max Units FeeL8694 NU-Fee on File Yes AUDITORY OSSEOINTEGRATED DEVICE,

TRANSDUCER/ACTUATOR, REPLACEMENT ONLY, EACH

5 999 07/01/2020 12/31/9999 1 762.48

L9900 NU-Priced by PA Yes ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF A

0 20 05/01/2004 12/31/9999 1 0.00

Q0496 NU-Fee on File Yes BATTERY, OTHER THAN LITHIUM-ION, FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY

0 999 07/01/2020 12/31/9999 1 1,210.44

S8185 NU-Priced by PA Yes FLUTTER DEVICE 0 20 05/01/2006 12/31/9999 1 0.00