Appendix E Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Note: Listing of a payment amount does not guarantee payment Effective October 20, 2012 HCPCS Maximum Payment A4216 $0.44 A4217 $3.62 A4221 $25.68 A4222 $50.95 A4233 $0.92 A4234 $4.19 A4235 $2.71 A4236 $1.93 A4253 $42.62 A4255 $4.75 A4256 $13.20 A4257 $14.71 A4258 $20.48 A4259 $13.91 A4265 $3.92 A4280 $5.98 A4310 $7.57 A4311 $14.54 A4312 $17.68 A4313 $18.17 A4314 $24.80 A4315 $25.87 A4316 $27.85 A4320 $6.14 A4322 $3.17 A4326 $11.96 A4327 $51.47 A4328 $11.40 A4330 $7.99 A4331 $3.67 A4332 $0.14 A4333 $2.55 A4334 $5.68 A4336 $1.66 A4338 $14.14 A4340 $36.63 A4344 $18.47 A4346 $22.60 A4349 $2.33 A4351 $2.09 A4352 $7.40 A4353 $8.08 A4354 $11.58