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10/14/2016 1 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
Provider Type:
TOS:
TOS Desc:
Proc Code:
Mod 1:
Mod 2:
Client Age
Frm:
Thru:
Client Age
Units:
Non-
facility/Facility
Total
RVUs/Base
Units:Conversion
Factor:
Medicaid Fee:
Fee Effect
Date:
Adjust %:
Adjusted Fee
for Report
Date:
Note Codes:
Last Pricing
Review Date:
1 2 3 1 2 3
AUDIOLOGIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES L7368 0 999 Years 0.00 $0.0000 $409.27 5/1/2003 0.00 $409.27 10/1/2016
AUDIOLOGIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES L8615 1 999 Years 0.00 $0.0000 $365.74 2/1/2006 0.00 $365.74 10/1/2016
AUDIOLOGIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES L8616 1 999 Years 0.00 $0.0000 $85.19 2/1/2006 0.00 $85.19 10/1/2016
AUDIOLOGIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES L8617 1 999 Years 0.00 $0.0000 $74.40 2/1/2006 0.00 $74.40 10/1/2016
AUDIOLOGIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES L8618 1 999 Years 0.00 $0.0000 $21.25 2/1/2006 0.00 $21.25 10/1/2016
DMEPOS - TOS 9, E, J, L, AND R
Texas Medicaid Fee Schedule Information
Field Descriptions
Classification assigned during provider enrollment and used to determine payable services
One-character type-of-service (TOS) code assigned to each procedure code for system administration.
Non-Facility pricing is for services that are rendered in places of service other than an inpatient hospital or an outpatient hospital. Facility pricing is for services that are rendered in an inpatient hospital (place of service [POS] 3), or an outpatient hospital or ambulatory surgical center (POS 5).
The current relative value units (RVUs) for the procedure code, if the fee is a resource-based fee (RBF). The payable amount for RBFs is calculated by multiplying the total RVUs by the applicable conversion factor. For Anesthesia services only, this column shows the base units instead; and
payment is based on the sum of the base units plus actual face-to-face time units multiplied by the applicable conversion factor.
Description of the TOS.
The five-digit code for services and items defined in Current Procedure Terminology or the Healthcare Common Procedure Coding System.
1st Modifier, if required for pricing determination.
2nd Modifier, if required for pricing determination.
The “from age” is the beginning of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first row (0-999) is actually 0-20
years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the Texas Medicaid Provider Procedures Manual (TMPPM) for the exact age limitations.
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
This fee schedule is intended to be used by a variety of provider types and provider specialties. Some procedure codes might not apply to every provider type and provider specialty designated to use the fee schedule. For detailed benefits and limitations, providers should refer to the current year’s Texas Medicaid
Provider Procedures Manual and relevant issues of the Texas Medicaid Bulletin.
TOS TOS DescProc
Code
Provider
Type
The Texas Medicaid conversion factor that is applicable for determining the amount payable when the rate is calculated by base units for anesthesia services or RVUs for other services.
The Medicaid allowed amount.
Medicaid rates are reviewed every two years or as necessary. This column shows the date on which the most recent review was conducted.
Note code indicator. Providers should review each note code to identify specific payment explanation or limitation. See Note Codes worksheet for applicable payment explanation or limitation.
A percentage reduction has been applied to the allowed fee for this service. This column does not show reductions that may have been applied using other criteria that include but are not limited to place of service, client type program, or provider specialty. Additional information about rate
changes is available on the TMHP website at www.tmhp.com.
The effective date of service for which the fee is payable.
A percentage reduction has been applied to the allowed fee for this service. This column shows the percent by which the fee was adjusted. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.
The “through age” is the end of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first row (0-999) is actually 0-20 years
of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the TMPPM for exact age limitations.
Medicaid rates are based on the client’s age in days, months or years.
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
AUDIOLOGIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES L8619 1 999 Years 0.00 $0.0000 $6,663.57 2/1/2006 0.00 $6,663.57 10/1/2016
AUDIOLOGIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES L8627 1 999 Years 0.00 $0.0000 $6,366.34 1/1/2010 0.00 $6,366.34 10/1/2016
AUDIOLOGIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES L8628 1 999 Years 0.00 $0.0000 $1,128.30 1/1/2010 0.00 $1,128.30 10/1/2016
AUDIOLOGIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES L8629 1 999 Years 0.00 $0.0000 $167.07 10/1/2012 0.00 $167.07 10/1/2016
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES A5500 0 20 Years 0.00 $0.0000 $66.76 7/1/2011 -8.00 $61.42 6 1/1/2015
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES A5501 0 20 Years 0.00 $0.0000 $200.25 7/1/2011 -8.00 $184.23 6 1/1/2015
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES A5503 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES A5504 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES A5505 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES A5506 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES A5507 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 0 999 Years 0.00 $0.0000 $0.00 1/1/2010 $0.00 5 1/1/2016
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES E0350 0 20 Years 0.00 $0.0000 $0.00 4/1/1995 $0.00 5 6 4/1/2015
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES E0352 0 20 Years 0.00 $0.0000 $56.25 4/1/2013 0.00 $56.25 6 4/1/2015
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES L8507 0 20 Years 0.00 $0.0000 $38.20 7/1/2010 0.00 $38.20 6 0.00 $0.0000 $38.20 7/1/2010 0.00 $38.20 6 10/1/2016
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES L8509 0 20 Years 0.00 $0.0000 $99.60 7/1/2010 0.00 $99.60 6 0.00 $0.0000 $99.60 7/1/2010 0.00 $99.60 6 10/1/2016
CCP
PROVIDER 9
OTHER MEDICAL
ITEMS OR
SERVICES L8510 0 20 Years 0.00 $0.0000 $230.48 7/1/2010 0.00 $230.48 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES A4570 0 999 Years 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 1/1/2015
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES A4690 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L2270 0 20 Years 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L7368 0 999 Years 0.00 $0.0000 $409.27 5/1/2003 0.00 $409.27 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L8603 0 999 Years 0.00 $0.0000 $394.97 4/1/2010 0.00 $394.97 0.00 $0.0000 $394.97 4/1/2010 0.00 $394.97 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L8604 0 999 Years 0.00 $0.0000 $198.49 7/1/2010 0.00 $198.49 0.00 $0.0000 $198.49 7/1/2010 0.00 $198.49 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L8606 0 999 Years 0.00 $0.0000 $198.49 4/1/2010 0.00 $198.49 0.00 $0.0000 $198.49 4/1/2010 0.00 $198.49 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L8615 1 999 Years 0.00 $0.0000 $365.74 2/1/2006 0.00 $365.74 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L8616 1 999 Years 0.00 $0.0000 $85.19 2/1/2006 0.00 $85.19 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L8617 1 999 Years 0.00 $0.0000 $74.40 2/1/2006 0.00 $74.40 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L8618 1 999 Years 0.00 $0.0000 $21.25 2/1/2006 0.00 $21.25 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L8619 1 999 Years 0.00 $0.0000 $6,663.57 2/1/2006 0.00 $6,663.57 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L8627 1 999 Years 0.00 $0.0000 $6,366.34 1/1/2010 0.00 $6,366.34 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L8628 1 999 Years 0.00 $0.0000 $1,128.30 1/1/2010 0.00 $1,128.30 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES L8629 1 999 Years 0.00 $0.0000 $167.07 10/1/2012 0.00 $167.07 10/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES V2623 0 20 Years 0.00 $0.0000 $1,141.18 1/1/2016 0.00 $1,141.18 6 1/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES V2624 0 20 Years 0.00 $0.0000 $34.51 7/1/2014 0.00 $34.51 6 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES V2625 0 20 Years 0.00 $0.0000 $165.76 7/1/2014 0.00 $165.76 6 7/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES V2626 0 20 Years 0.00 $0.0000 $114.95 7/1/2014 0.00 $114.95 6 7/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES V2627 0 20 Years 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 7/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES V2628 0 20 Years 0.00 $0.0000 $162.80 7/1/2014 0.00 $162.80 6 7/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES V2630 0 999 Years 0.00 $0.0000 $73.60 7/1/2014 0.00 $73.60 7/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES V2631 0 999 Years 0.00 $0.0000 $0.00 7/1/2010 -8.00 $0.00 5 6 7/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES V2632 0 999 Years 0.00 $0.0000 $124.20 7/1/2014 0.00 $124.20 6 7/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES V2799 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 7/1/2016
HEARING AID 9
OTHER MEDICAL
ITEMS OR
SERVICES L7368 0 999 Years 0.00 $0.0000 $409.27 5/1/2003 0.00 $409.27 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4206 0 999 Years 0.00 $0.0000 $0.25 7/1/2011 0.00 $0.25 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4207 0 999 Years 0.00 $0.0000 $0.29 7/1/2011 0.00 $0.29 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4208 0 999 Years 0.00 $0.0000 $0.35 1/1/2015 0.00 $0.35 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4209 0 999 Years 0.00 $0.0000 $0.40 7/1/2011 0.00 $0.40 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4211 U4 0 999 Years 0.00 $0.0000 $1.80 7/1/2011 0.00 $1.80 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4212 0 999 Years 0.00 $0.0000 $22.00 1/1/2015 0.00 $22.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4213 0 999 Years 0.00 $0.0000 $0.48 7/1/2011 0.00 $0.48 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4215 0 999 Years 0.00 $0.0000 $0.20 7/1/2011 0.00 $0.20 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4216 0 999 Years 0.00 $0.0000 $0.39 3/1/2008 0.00 $0.39 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4217 0 999 Years 0.00 $0.0000 $3.13 3/1/2008 0.00 $3.13 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4220 0 999 Years 0.00 $0.0000 $50.00 7/1/2011 0.00 $50.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4222 0 999 Years 0.00 $0.0000 $24.58 1/1/2015 0.00 $24.58 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4230 0 999 Years 0.00 $0.0000 $12.00 1/1/2015 0.00 $12.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4231 0 999 Years 0.00 $0.0000 $7.40 7/1/2011 0.00 $7.40 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4232 0 999 Years 0.00 $0.0000 $2.53 7/1/2011 0.00 $2.53 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4233 0 999 Years 0.00 $0.0000 $0.77 1/1/2015 0.00 $0.77 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4234 0 999 Years 0.00 $0.0000 $3.51 1/1/2015 0.00 $3.51 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4235 0 999 Years 0.00 $0.0000 $2.26 1/1/2015 0.00 $2.26 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4236 0 999 Years 0.00 $0.0000 $1.62 1/1/2015 0.00 $1.62 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4244 0 999 Years 0.00 $0.0000 $1.78 1/1/2015 0.00 $1.78 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4245 0 999 Years 0.00 $0.0000 $2.06 7/1/2011 0.00 $2.06 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4246 0 999 Years 0.00 $0.0000 $8.00 1/1/2015 0.00 $8.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4247 0 999 Years 0.00 $0.0000 $6.90 1/1/2015 0.00 $6.90 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4248 0 999 Years 0.00 $0.0000 $0.29 4/1/2010 0.00 $0.29 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4250 0 999 Years 0.00 $0.0000 $13.45 7/1/1997 0.00 $13.45 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4252 0 999 Years 0.00 $0.0000 $4.80 7/1/2011 0.00 $4.80 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4253 0 999 Years 0.00 $0.0000 $28.28 7/1/2013 0.00 $28.28 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4256 0 999 Years 0.00 $0.0000 $9.20 1/1/2015 0.00 $9.20 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4258 0 999 Years 0.00 $0.0000 $14.65 1/1/2015 0.00 $14.65 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4259 0 999 Years 0.00 $0.0000 $11.10 7/1/2013 0.00 $11.10 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4263 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4265 0 999 Years 0.00 $0.0000 $3.23 5/7/1999 0.00 $3.23 0.00 $0.0000 $3.23 5/7/1999 0.00 $3.23 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4280 0 999 Years 0.00 $0.0000 $4.71 2/1/2000 0.00 $4.71 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4281 0 999 Years 0.00 $0.0000 $3.58 1/1/2015 0.00 $3.58 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4282 0 999 Years 0.00 $0.0000 $0.48 1/1/2015 0.00 $0.48 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4283 0 999 Years 0.00 $0.0000 $0.53 1/1/2015 0.00 $0.53 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4284 0 999 Years 0.00 $0.0000 $6.99 1/1/2015 0.00 $6.99 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4285 0 999 Years 0.00 $0.0000 $2.21 1/1/2015 0.00 $2.21 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4286 0 999 Years 0.00 $0.0000 $0.44 1/1/2015 0.00 $0.44 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4290 0 999 Years 0.00 $0.0000 $377.20 1/1/2015 0.00 $377.20 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4300 0 999 Years 0.00 $0.0000 $8.56 1/1/2015 0.00 $8.56 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4301 0 999 Years 0.00 $0.0000 $32.20 1/1/2015 0.00 $32.20 0.00 $0.0000 $32.20 1/1/2015 0.00 $32.20 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 7
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4305 0 999 Years 0.00 $0.0000 $20.93 7/1/2011 0.00 $20.93 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4306 0 999 Years 0.00 $0.0000 $18.33 7/1/2011 0.00 $18.33 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4310 0 999 Years 0.00 $0.0000 $5.47 7/1/1997 0.00 $5.47 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4311 0 999 Years 0.00 $0.0000 $10.72 7/1/1997 0.00 $10.72 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4312 0 999 Years 0.00 $0.0000 $14.65 7/1/1997 0.00 $14.65 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4313 0 999 Years 0.00 $0.0000 $17.01 7/1/1997 0.00 $17.01 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4314 0 999 Years 0.00 $0.0000 $20.64 7/1/1997 0.00 $20.64 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4315 0 999 Years 0.00 $0.0000 $20.64 7/1/1997 0.00 $20.64 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4316 0 999 Years 0.00 $0.0000 $23.01 7/1/1997 0.00 $23.01 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4320 0 999 Years 0.00 $0.0000 $3.65 7/1/1997 0.00 $3.65 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4321 0 999 Years 0.00 $0.0000 $8.28 1/1/2015 0.00 $8.28 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4322 0 999 Years 0.00 $0.0000 $2.35 7/1/1997 0.00 $2.35 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4326 0 999 Years 0.00 $0.0000 $10.79 3/1/2008 0.00 $10.79 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4327 0 999 Years 0.00 $0.0000 $38.54 7/1/1997 0.00 $38.54 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4328 0 999 Years 0.00 $0.0000 $6.83 7/1/1997 0.00 $6.83 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4330 0 999 Years 0.00 $0.0000 $5.65 7/1/1997 0.00 $5.65 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4331 0 999 Years 0.00 $0.0000 $2.50 4/1/2011 0.00 $2.50 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 8
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4332 0 999 Years 0.00 $0.0000 $0.10 4/1/2011 0.00 $0.10 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4333 0 999 Years 0.00 $0.0000 $1.73 4/1/2011 0.00 $1.73 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4334 0 999 Years 0.00 $0.0000 $3.88 4/1/2011 0.00 $3.88 1/1/2015
HOME
HEALTH DME 1
MEDICAL
SERVICES A4335 0 999 Years 0.00 $0.0000 $3.09 7/1/2011 -8.00 $2.84 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4335 0 999 Years 0.00 $0.0000 $0.00 7/1/2011 -8.00 $0.00 5 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4335 U9 0 999 Years 0.00 $0.0000 $3.09 7/1/2011 -8.00 $2.84 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4338 0 999 Years 0.00 $0.0000 $10.44 7/1/1997 0.00 $10.44 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4340 0 999 Years 0.00 $0.0000 $17.36 1/1/2015 0.00 $17.36 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4344 0 999 Years 0.00 $0.0000 $10.66 7/1/1997 0.00 $10.66 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4346 0 999 Years 0.00 $0.0000 $13.27 7/1/1997 0.00 $13.27 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4349 0 999 Years 0.00 $0.0000 $1.80 1/1/2005 0.00 $1.80 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4351 0 999 Years 0.00 $0.0000 $1.81 3/1/2008 0.00 $1.81 7/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4351 SC 0 999 Years 0.00 $0.0000 $3.65 7/1/2015 0.00 $3.65 7/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4352 0 999 Years 0.00 $0.0000 $5.07 7/1/1997 0.00 $5.07 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4353 0 999 Years 0.00 $0.0000 $6.66 7/1/1997 0.00 $6.66 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4354 0 999 Years 0.00 $0.0000 $10.06 7/1/1997 0.00 $10.06 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4355 0 999 Years 0.00 $0.0000 $7.94 7/1/1997 0.00 $7.94 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 9
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4356 0 999 Years 0.00 $0.0000 $30.40 7/1/1997 0.00 $30.40 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4357 0 999 Years 0.00 $0.0000 $7.65 7/1/1997 0.00 $7.65 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4358 0 999 Years 0.00 $0.0000 $6.43 3/1/2012 0.00 $6.43 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4360 0 999 Years 0.00 $0.0000 $0.43 1/1/2010 0.00 $0.43 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4361 0 999 Years 0.00 $0.0000 $18.37 3/1/2008 0.00 $18.37 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4362 0 999 Years 0.00 $0.0000 $2.64 7/1/1997 0.00 $2.64 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4363 0 999 Years 0.00 $0.0000 $2.17 3/1/2012 0.00 $2.17 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4364 0 999 Years 0.00 $0.0000 $2.84 3/1/2012 0.00 $2.84 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4366 0 999 Years 0.00 $0.0000 $1.03 4/1/2011 0.00 $1.03 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4367 0 999 Years 0.00 $0.0000 $7.15 3/1/2012 0.00 $7.15 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4368 0 999 Years 0.00 $0.0000 $0.25 7/1/1997 0.00 $0.25 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4369 0 999 Years 0.00 $0.0000 $2.30 2/1/2000 0.00 $2.30 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4371 0 999 Years 0.00 $0.0000 $3.83 3/1/2012 0.00 $3.83 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4372 0 999 Years 0.00 $0.0000 $3.98 2/1/2000 0.00 $3.98 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4373 0 999 Years 0.00 $0.0000 $5.99 2/1/2000 0.00 $5.99 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4375 0 999 Years 0.00 $0.0000 $16.38 2/1/2000 0.00 $16.38 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4376 0 999 Years 0.00 $0.0000 $45.38 2/1/2000 0.00 $45.38 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 10
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4377 0 999 Years 0.00 $0.0000 $4.09 2/1/2000 0.00 $4.09 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4378 0 999 Years 0.00 $0.0000 $29.33 2/1/2000 0.00 $29.33 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4379 0 999 Years 0.00 $0.0000 $14.33 2/1/2000 0.00 $14.33 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4380 0 999 Years 0.00 $0.0000 $35.60 2/1/2000 0.00 $35.60 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4381 0 999 Years 0.00 $0.0000 $4.40 2/1/2000 0.00 $4.40 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4382 0 999 Years 0.00 $0.0000 $23.48 2/1/2000 0.00 $23.48 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4383 0 999 Years 0.00 $0.0000 $26.89 2/1/2000 0.00 $26.89 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4384 0 999 Years 0.00 $0.0000 $9.18 2/1/2000 0.00 $9.18 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4385 0 999 Years 0.00 $0.0000 $5.25 3/1/2012 0.00 $5.25 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4387 0 999 Years 0.00 $0.0000 $2.45 1/1/2015 0.00 $2.45 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4388 0 999 Years 0.00 $0.0000 $4.58 3/1/2012 0.00 $4.58 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4389 0 999 Years 0.00 $0.0000 $5.93 2/1/2000 0.00 $5.93 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4390 0 999 Years 0.00 $0.0000 $9.17 2/1/2000 0.00 $9.17 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4391 0 999 Years 0.00 $0.0000 $6.74 2/1/2000 0.00 $6.74 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4392 0 999 Years 0.00 $0.0000 $6.34 2/1/2000 0.00 $6.34 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4393 0 999 Years 0.00 $0.0000 $8.75 2/1/2000 0.00 $8.75 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4394 0 999 Years 0.00 $0.0000 $2.50 3/1/2012 0.00 $2.50 1/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 11
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4395 0 999 Years 0.00 $0.0000 $0.05 2/1/2000 0.00 $0.05 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4396 0 999 Years 0.00 $0.0000 $38.61 4/1/2001 0.00 $38.61 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4397 0 999 Years 0.00 $0.0000 $4.41 7/1/1997 0.00 $4.41 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4398 0 999 Years 0.00 $0.0000 $10.84 7/1/1997 0.00 $10.84 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4399 0 999 Years 0.00 $0.0000 $8.18 7/1/1997 0.00 $8.18 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4400 0 999 Years 0.00 $0.0000 $46.88 7/1/1997 0.00 $46.88 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4402 0 999 Years 0.00 $0.0000 $1.52 5/1/2003 0.00 $1.52 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4404 0 999 Years 0.00 $0.0000 $1.55 7/1/1997 0.00 $1.55 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4405 0 999 Years 0.00 $0.0000 $3.35 3/1/2012 0.00 $3.35 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4406 0 999 Years 0.00 $0.0000 $6.02 3/1/2012 0.00 $6.02 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4407 0 999 Years 0.00 $0.0000 $9.19 3/1/2012 0.00 $9.19 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4408 0 999 Years 0.00 $0.0000 $9.87 5/1/2003 0.00 $9.87 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4409 0 999 Years 0.00 $0.0000 $6.52 3/1/2012 0.00 $6.52 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4410 0 999 Years 0.00 $0.0000 $9.04 3/1/2012 0.00 $9.04 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4411 0 999 Years 0.00 $0.0000 $3.72 1/1/2006 0.00 $3.72 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4412 0 999 Years 0.00 $0.0000 $2.84 7/1/2011 0.00 $2.84 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4413 0 999 Years 0.00 $0.0000 $5.50 5/1/2003 0.00 $5.50 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 12
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4414 0 999 Years 0.00 $0.0000 $5.17 3/1/2012 0.00 $5.17 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4415 0 999 Years 0.00 $0.0000 $6.29 3/1/2012 0.00 $6.29 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4416 0 999 Years 0.00 $0.0000 $2.17 4/1/2011 0.00 $2.17 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4417 0 999 Years 0.00 $0.0000 $2.93 4/1/2011 0.00 $2.93 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4418 0 999 Years 0.00 $0.0000 $1.81 5/1/2005 0.00 $1.81 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4419 0 999 Years 0.00 $0.0000 $1.37 4/1/2011 0.00 $1.37 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4420 0 999 Years 0.00 $0.0000 $2.41 7/1/2011 0.00 $2.41 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4421 0 999 Years 0.00 $0.0000 $23.00 1/1/2015 0.00 $23.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4422 0 999 Years 0.00 $0.0000 $0.12 5/1/2003 0.00 $0.12 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4423 0 999 Years 0.00 $0.0000 $1.46 4/1/2011 0.00 $1.46 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4424 0 999 Years 0.00 $0.0000 $3.74 4/1/2011 0.00 $3.74 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4425 0 999 Years 0.00 $0.0000 $2.82 4/1/2011 0.00 $2.82 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4426 0 999 Years 0.00 $0.0000 $2.15 4/1/2011 0.00 $2.15 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4427 0 999 Years 0.00 $0.0000 $2.19 4/1/2011 0.00 $2.19 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4428 0 999 Years 0.00 $0.0000 $6.83 3/1/2012 0.00 $6.83 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4429 0 999 Years 0.00 $0.0000 $6.49 4/1/2011 0.00 $6.49 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4430 0 999 Years 0.00 $0.0000 $6.70 4/1/2011 0.00 $6.70 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 13
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4431 0 999 Years 0.00 $0.0000 $4.89 4/1/2011 0.00 $4.89 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4432 0 999 Years 0.00 $0.0000 $2.83 4/1/2011 0.00 $2.83 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4433 0 999 Years 0.00 $0.0000 $2.63 4/1/2011 0.00 $2.63 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4434 0 999 Years 0.00 $0.0000 $2.96 4/1/2011 0.00 $2.96 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4450 0 999 Years 0.00 $0.0000 $0.09 5/1/2003 0.00 $0.09 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4452 0 999 Years 0.00 $0.0000 $0.36 5/1/2003 0.00 $0.36 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4455 0 999 Years 0.00 $0.0000 $1.22 3/1/2008 0.00 $1.22 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4456 0 999 Years 0.00 $0.0000 $0.26 1/1/2010 0.00 $0.26 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4461 0 999 Years 0.00 $0.0000 $3.29 1/1/2007 0.00 $3.29 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4465 0 999 Years 0.00 $0.0000 $20.00 7/1/2011 0.00 $20.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4466 0 999 Years 0.00 $0.0000 $54.00 7/1/2011 0.00 $54.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4481 0 999 Years 0.00 $0.0000 $0.37 5/1/2003 0.00 $0.37 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4483 0 999 Years 0.00 $0.0000 $5.23 1/1/2015 0.00 $5.23 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4490 0 999 Years 0.00 $0.0000 $17.80 7/1/2011 0.00 $17.80 0.00 $0.0000 $17.80 7/1/2011 0.00 $17.80 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4495 0 999 Years 0.00 $0.0000 $21.00 7/1/2011 0.00 $21.00 0.00 $0.0000 $21.00 7/1/2011 0.00 $21.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4500 0 999 Years 0.00 $0.0000 $12.00 7/1/2011 0.00 $12.00 0.00 $0.0000 $12.00 7/1/2011 0.00 $12.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4510 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 14
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4554 0 999 Years 0.00 $0.0000 $0.41 7/7/2000 -8.00 $0.38 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4556 0 999 Years 0.00 $0.0000 $12.14 3/1/2008 0.00 $12.14 6 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4557 0 999 Years 0.00 $0.0000 $21.10 3/1/2008 0.00 $21.10 6 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4558 0 999 Years 0.00 $0.0000 $2.54 1/1/2015 0.00 $2.54 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4561 0 999 Years 0.00 $0.0000 $19.00 4/1/2001 0.00 $19.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4562 0 999 Years 0.00 $0.0000 $47.26 4/1/2001 0.00 $47.26 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4565 0 999 Years 0.00 $0.0000 $8.41 1/1/2015 0.00 $8.41 0.00 $0.0000 $8.41 1/1/2015 0.00 $8.41 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4566 0 999 Years 0.00 $0.0000 $100.32 1/1/2015 0.00 $100.32 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4570 0 999 Years 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4595 0 999 Years 0.00 $0.0000 $26.73 1/1/2008 0.00 $26.73 6 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4600 0 999 Years 0.00 $0.0000 $37.24 1/1/2015 0.00 $37.24 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4601 0 999 Years 0.00 $0.0000 $2.05 1/1/2015 0.00 $2.05 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4605 0 999 Years 0.00 $0.0000 $16.40 1/1/2005 0.00 $16.40 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4606 0 999 Years 0.00 $0.0000 $36.90 7/1/2011 0.00 $36.90 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4611 0 999 Years 0.00 $0.0000 $133.64 7/1/1997 0.00 $133.64 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4612 0 999 Years 0.00 $0.0000 $47.52 7/1/1997 0.00 $47.52 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4613 0 999 Years 0.00 $0.0000 $99.43 7/1/1997 0.00 $99.43 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 15
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4614 0 999 Years 0.00 $0.0000 $22.68 3/1/1999 0.00 $22.68 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4615 0 999 Years 0.00 $0.0000 $0.75 7/1/2011 0.00 $0.75 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4616 0 999 Years 0.00 $0.0000 $0.07 7/1/2011 0.00 $0.07 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4617 0 999 Years 0.00 $0.0000 $3.25 7/1/2011 0.00 $3.25 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4618 0 999 Years 0.00 $0.0000 $4.13 1/1/2015 0.00 $4.13 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4619 0 999 Years 0.00 $0.0000 $1.21 2/1/2008 0.00 $1.21 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4620 0 999 Years 0.00 $0.0000 $0.62 7/1/2011 0.00 $0.62 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4623 0 999 Years 0.00 $0.0000 $5.28 7/1/1997 0.00 $5.28 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4624 0 999 Years 0.00 $0.0000 $2.38 7/1/1997 0.00 $2.38 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4627 0 999 Years 0.00 $0.0000 $30.00 7/1/2011 0.00 $30.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4628 0 999 Years 0.00 $0.0000 $3.65 10/18/2002 0.00 $3.65 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4629 0 999 Years 0.00 $0.0000 $4.30 5/1/2003 0.00 $4.30 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4636 0 999 Years 0.00 $0.0000 $2.13 1/1/2003 0.00 $2.13 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4637 0 999 Years 0.00 $0.0000 $1.35 7/1/1997 0.00 $1.35 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4640 0 999 Years 0.00 $0.0000 $29.43 1/1/2015 0.00 $29.43 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4660 0 999 Years 0.00 $0.0000 $31.25 7/1/2011 0.00 $31.25 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4663 0 999 Years 0.00 $0.0000 $32.00 7/1/2011 0.00 $32.00 0.00 $0.0000 $32.00 7/1/2011 0.00 $32.00 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 16
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4670 0 999 Years 0.00 $0.0000 $66.09 7/1/2011 0.00 $66.09 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4690 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4750 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4755 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4774 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4860 0 999 Years 0.00 $0.0000 $4.73 1/1/2015 0.00 $4.73 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4918 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4927 0 999 Years 0.00 $0.0000 $7.97 1/1/2015 0.00 $7.97 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4930 0 999 Years 0.00 $0.0000 $0.77 7/1/2011 0.00 $0.77 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4931 0 999 Years 0.00 $0.0000 $11.46 7/1/2011 0.00 $11.46 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A4932 0 999 Years 0.00 $0.0000 $7.00 5/1/2003 0.00 $7.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5051 0 999 Years 0.00 $0.0000 $1.80 7/1/1997 0.00 $1.80 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5052 0 999 Years 0.00 $0.0000 $1.31 7/1/1997 0.00 $1.31 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5053 0 999 Years 0.00 $0.0000 $1.36 7/1/1997 0.00 $1.36 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5054 0 999 Years 0.00 $0.0000 $1.90 3/1/2012 0.00 $1.90 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5055 0 999 Years 0.00 $0.0000 $1.12 7/1/1997 0.00 $1.12 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5056 0 999 Years 0.00 $0.0000 $3.76 1/1/2012 0.00 $3.76 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 17
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DMEPOS - TOS 9, E, J, L, AND R
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5057 0 999 Years 0.00 $0.0000 $7.74 1/1/2012 0.00 $7.74 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5061 0 999 Years 0.00 $0.0000 $4.27 3/1/2012 0.00 $4.27 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5062 0 999 Years 0.00 $0.0000 $2.09 3/1/2008 0.00 $2.09 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5063 0 999 Years 0.00 $0.0000 $3.15 3/1/2012 0.00 $3.15 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5071 0 999 Years 0.00 $0.0000 $4.95 7/1/1997 0.00 $4.95 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5072 0 999 Years 0.00 $0.0000 $3.60 7/1/2011 0.00 $3.60 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5073 0 999 Years 0.00 $0.0000 $3.34 3/1/2012 0.00 $3.34 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5081 0 999 Years 0.00 $0.0000 $2.14 7/1/1997 0.00 $2.14 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5082 0 999 Years 0.00 $0.0000 $9.66 7/1/1997 0.00 $9.66 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5083 0 999 Years 0.00 $0.0000 $0.63 1/1/2009 0.00 $0.63 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5093 0 999 Years 0.00 $0.0000 $1.58 7/1/1997 0.00 $1.58 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5102 0 999 Years 0.00 $0.0000 $23.52 3/1/2012 0.00 $23.52 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5105 0 999 Years 0.00 $0.0000 $34.23 7/1/1997 0.00 $34.23 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5112 0 999 Years 0.00 $0.0000 $30.86 3/1/2012 0.00 $30.86 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5113 0 999 Years 0.00 $0.0000 $3.55 7/1/1997 0.00 $3.55 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5114 0 999 Years 0.00 $0.0000 $8.94 3/1/2008 0.00 $8.94 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5120 0 999 Years 0.00 $0.0000 $0.26 3/1/2012 0.00 $0.26 1/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 18
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DMEPOS - TOS 9, E, J, L, AND R
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5121 0 999 Years 0.00 $0.0000 $5.88 7/1/1997 0.00 $5.88 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5122 0 999 Years 0.00 $0.0000 $8.78 7/1/1997 0.00 $8.78 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5126 0 999 Years 0.00 $0.0000 $1.32 3/1/2008 0.00 $1.32 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5131 0 999 Years 0.00 $0.0000 $13.81 7/1/1997 -8.00 $12.71 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A5200 0 999 Years 0.00 $0.0000 $10.77 3/1/1999 0.00 $10.77 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6010 0 999 Years 0.00 $0.0000 $32.51 7/1/2011 0.00 $32.51 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6011 0 999 Years 0.00 $0.0000 $2.39 7/1/2011 0.00 $2.39 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6021 0 999 Years 0.00 $0.0000 $20.79 4/1/2001 0.00 $20.79 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6022 0 999 Years 0.00 $0.0000 $20.79 4/1/2001 0.00 $20.79 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6023 0 999 Years 0.00 $0.0000 $188.23 4/1/2001 0.00 $188.23 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6024 0 999 Years 0.00 $0.0000 $6.12 4/1/2001 0.00 $6.12 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6025 0 999 Years 0.00 $0.0000 $13.80 1/1/2015 0.00 $13.80 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6154 0 999 Years 0.00 $0.0000 $13.29 7/1/1997 0.00 $13.29 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6196 0 999 Years 0.00 $0.0000 $7.01 7/1/1997 0.00 $7.01 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6197 0 999 Years 0.00 $0.0000 $15.68 7/1/1997 0.00 $15.68 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6198 0 999 Years 0.00 $0.0000 $14.27 7/1/2011 0.00 $14.27 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6199 0 999 Years 0.00 $0.0000 $5.04 7/1/1997 0.00 $5.04 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 19
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6203 0 999 Years 0.00 $0.0000 $3.19 7/1/1997 0.00 $3.19 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6204 0 999 Years 0.00 $0.0000 $5.94 7/1/1997 0.00 $5.94 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6205 0 999 Years 0.00 $0.0000 $6.46 7/1/2011 0.00 $6.46 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6206 0 999 Years 0.00 $0.0000 $4.25 7/1/2011 0.00 $4.25 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6207 0 999 Years 0.00 $0.0000 $7.00 7/1/1997 0.00 $7.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6208 0 999 Years 0.00 $0.0000 $66.61 1/1/2015 0.00 $66.61 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6209 0 999 Years 0.00 $0.0000 $7.14 7/1/1997 0.00 $7.14 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6210 0 999 Years 0.00 $0.0000 $19.00 7/1/1997 0.00 $19.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6211 0 999 Years 0.00 $0.0000 $28.01 7/1/1997 0.00 $28.01 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6212 0 999 Years 0.00 $0.0000 $9.25 7/1/1997 0.00 $9.25 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6213 0 999 Years 0.00 $0.0000 $11.96 1/1/2015 0.00 $11.96 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6214 0 999 Years 0.00 $0.0000 $9.82 7/1/1997 0.00 $9.82 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6215 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6216 0 999 Years 0.00 $0.0000 $0.05 7/1/1997 0.00 $0.05 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6217 0 999 Years 0.00 $0.0000 $0.15 7/1/2011 0.00 $0.15 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6218 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6219 0 999 Years 0.00 $0.0000 $0.91 7/1/1997 0.00 $0.91 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 20
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6220 0 999 Years 0.00 $0.0000 $2.46 7/1/1997 0.00 $2.46 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6221 0 999 Years 0.00 $0.0000 $4.60 1/1/2015 0.00 $4.60 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6222 0 999 Years 0.00 $0.0000 $2.03 7/1/1997 0.00 $2.03 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6223 0 999 Years 0.00 $0.0000 $2.30 7/1/1997 0.00 $2.30 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6224 0 999 Years 0.00 $0.0000 $3.44 7/1/1997 0.00 $3.44 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6228 0 999 Years 0.00 $0.0000 $1.70 1/1/2015 0.00 $1.70 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6229 0 999 Years 0.00 $0.0000 $3.44 7/1/1997 0.00 $3.44 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6230 0 999 Years 0.00 $0.0000 $1.70 1/1/2015 0.00 $1.70 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6231 0 999 Years 0.00 $0.0000 $4.61 4/1/2001 0.00 $4.61 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6232 0 999 Years 0.00 $0.0000 $6.81 4/1/2001 0.00 $6.81 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6233 0 999 Years 0.00 $0.0000 $18.98 4/1/2001 0.00 $18.98 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6234 0 999 Years 0.00 $0.0000 $6.24 7/1/1997 0.00 $6.24 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6235 0 999 Years 0.00 $0.0000 $16.05 7/1/1997 0.00 $16.05 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6236 0 999 Years 0.00 $0.0000 $25.99 7/1/1997 0.00 $25.99 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6237 0 999 Years 0.00 $0.0000 $7.54 7/1/1997 0.00 $7.54 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6238 0 999 Years 0.00 $0.0000 $21.74 7/1/1997 0.00 $21.74 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6239 0 999 Years 0.00 $0.0000 $13.27 7/1/2011 0.00 $13.27 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 21
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6240 0 999 Years 0.00 $0.0000 $11.68 7/1/1997 0.00 $11.68 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6241 0 999 Years 0.00 $0.0000 $2.45 7/1/1997 0.00 $2.45 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6242 0 999 Years 0.00 $0.0000 $5.79 7/1/1997 0.00 $5.79 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6243 0 999 Years 0.00 $0.0000 $11.75 7/1/1997 0.00 $11.75 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6244 0 999 Years 0.00 $0.0000 $37.46 7/1/1997 0.00 $37.46 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6245 0 999 Years 0.00 $0.0000 $6.93 7/1/1997 0.00 $6.93 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6246 0 999 Years 0.00 $0.0000 $9.46 7/1/1997 0.00 $9.46 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6247 0 999 Years 0.00 $0.0000 $22.68 7/1/1997 0.00 $22.68 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6248 0 999 Years 0.00 $0.0000 $15.49 7/1/1997 0.00 $15.49 1/1/2015
HOME
HEALTH DME 1
MEDICAL
SERVICES A6250 0 999 Years 0.00 $0.0000 $5.16 1/1/2012 0.00 $5.16 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6250 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6250 UA 0 999 Years 0.00 $0.0000 $5.16 1/1/2012 0.00 $5.16 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6251 0 999 Years 0.00 $0.0000 $1.90 7/1/1997 0.00 $1.90 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6252 0 999 Years 0.00 $0.0000 $3.10 7/1/1997 0.00 $3.10 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6253 0 999 Years 0.00 $0.0000 $6.05 7/1/1997 0.00 $6.05 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6254 0 999 Years 0.00 $0.0000 $1.16 7/1/1997 0.00 $1.16 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6255 0 999 Years 0.00 $0.0000 $2.89 7/1/1997 0.00 $2.89 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 22
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6256 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6257 0 999 Years 0.00 $0.0000 $1.46 7/1/1997 0.00 $1.46 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6258 0 999 Years 0.00 $0.0000 $4.10 7/1/1997 0.00 $4.10 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6259 0 999 Years 0.00 $0.0000 $10.43 7/1/1997 0.00 $10.43 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6260 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6261 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6262 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6266 0 999 Years 0.00 $0.0000 $1.83 7/1/1997 0.00 $1.83 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6402 0 999 Years 0.00 $0.0000 $0.12 7/1/1997 0.00 $0.12 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6403 0 999 Years 0.00 $0.0000 $0.41 7/1/1997 0.00 $0.41 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6404 0 999 Years 0.00 $0.0000 $0.56 7/1/2011 0.00 $0.56 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6407 0 999 Years 0.00 $0.0000 $1.88 7/1/2004 0.00 $1.88 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6410 0 999 Years 0.00 $0.0000 $0.34 5/1/2003 0.00 $0.34 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6411 0 999 Years 0.00 $0.0000 $0.31 7/1/2011 0.00 $0.31 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6412 0 999 Years 0.00 $0.0000 $0.40 7/1/2011 0.00 $0.40 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6441 0 999 Years 0.00 $0.0000 $0.67 7/1/2004 0.00 $0.67 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6442 0 999 Years 0.00 $0.0000 $0.17 7/1/2004 0.00 $0.17 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 23
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6443 0 999 Years 0.00 $0.0000 $0.29 7/1/2004 0.00 $0.29 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6444 0 999 Years 0.00 $0.0000 $0.56 7/1/2004 0.00 $0.56 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6445 0 999 Years 0.00 $0.0000 $0.32 7/1/2004 0.00 $0.32 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6446 0 999 Years 0.00 $0.0000 $0.41 7/1/2004 0.00 $0.41 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6447 0 999 Years 0.00 $0.0000 $0.67 7/1/2004 0.00 $0.67 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6448 0 999 Years 0.00 $0.0000 $1.16 7/1/2004 0.00 $1.16 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6449 0 999 Years 0.00 $0.0000 $1.75 7/1/2004 0.00 $1.75 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6450 0 999 Years 0.00 $0.0000 $5.52 1/1/2015 0.00 $5.52 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6451 0 999 Years 0.00 $0.0000 $3.65 1/1/2015 0.00 $3.65 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6452 0 999 Years 0.00 $0.0000 $4.72 7/1/2004 0.00 $4.72 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6453 0 999 Years 0.00 $0.0000 $0.61 7/1/2004 0.00 $0.61 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6454 0 999 Years 0.00 $0.0000 $0.70 7/1/2004 0.00 $0.70 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6455 0 999 Years 0.00 $0.0000 $0.77 1/1/2015 0.00 $0.77 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6456 0 999 Years 0.00 $0.0000 $1.14 7/1/2004 0.00 $1.14 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6457 0 999 Years 0.00 $0.0000 $1.14 1/1/2006 0.00 $1.14 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6501 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6502 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 24
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6503 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6504 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6505 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6506 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6507 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6508 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6509 0 999 Years 0.00 $0.0000 $0.00 7/1/2011 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6510 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6511 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6512 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6513 0 999 Years 0.00 $0.0000 $0.00 1/1/2006 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6530 0 999 Years 0.00 $0.0000 $37.54 1/1/2015 0.00 $37.54 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6531 0 999 Years 0.00 $0.0000 $43.27 1/1/2006 0.00 $43.27 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6532 0 999 Years 0.00 $0.0000 $60.96 1/1/2006 0.00 $60.96 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6533 0 999 Years 0.00 $0.0000 $49.00 1/1/2015 0.00 $49.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6534 0 999 Years 0.00 $0.0000 $57.96 1/1/2015 0.00 $57.96 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6535 0 999 Years 0.00 $0.0000 $82.80 1/1/2015 0.00 $82.80 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 25
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6536 0 999 Years 0.00 $0.0000 $55.20 1/1/2015 0.00 $55.20 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6537 0 999 Years 0.00 $0.0000 $69.00 1/1/2015 0.00 $69.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6538 0 999 Years 0.00 $0.0000 $82.80 1/1/2015 0.00 $82.80 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6539 0 999 Years 0.00 $0.0000 $75.82 1/1/2015 0.00 $75.82 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6540 0 999 Years 0.00 $0.0000 $86.78 1/1/2015 0.00 $86.78 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6541 0 999 Years 0.00 $0.0000 $112.70 1/1/2015 0.00 $112.70 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6544 0 999 Years 0.00 $0.0000 $38.12 1/1/2015 0.00 $38.12 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6545 AW 0 999 Years 0.00 $0.0000 $65.84 1/1/2015 0.00 $65.84 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6549 0 999 Years 0.00 $0.0000 $0.00 1/1/2006 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A6550 0 999 Years 0.00 $0.0000 $24.82 7/1/2011 0.00 $24.82 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7000 0 999 Years 0.00 $0.0000 $8.24 7/1/2011 0.00 $8.24 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7002 0 999 Years 0.00 $0.0000 $3.10 2/1/2000 0.00 $3.10 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7003 0 999 Years 0.00 $0.0000 $2.48 2/1/2000 0.00 $2.48 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7004 0 999 Years 0.00 $0.0000 $1.46 2/1/2000 0.00 $1.46 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7005 0 999 Years 0.00 $0.0000 $26.21 2/1/2008 -8.00 $24.11 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7006 0 999 Years 0.00 $0.0000 $9.05 2/1/2000 0.00 $9.05 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7007 0 999 Years 0.00 $0.0000 $3.96 2/1/2000 0.00 $3.96 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 26
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7009 0 999 Years 0.00 $0.0000 $37.24 2/1/2000 0.00 $37.24 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7010 0 999 Years 0.00 $0.0000 $20.05 2/1/2008 0.00 $20.05 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7012 0 999 Years 0.00 $0.0000 $3.60 2/1/2008 0.00 $3.60 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7013 0 999 Years 0.00 $0.0000 $0.67 2/1/2000 0.00 $0.67 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7014 0 999 Years 0.00 $0.0000 $4.13 2/1/2000 0.00 $4.13 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7015 0 999 Years 0.00 $0.0000 $1.79 2/1/2000 0.00 $1.79 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7016 0 999 Years 0.00 $0.0000 $6.22 2/1/2000 0.00 $6.22 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7017 0 999 Years 0.00 $0.0000 $134.04 2/1/2008 0.00 $134.04 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7018 0 999 Years 0.00 $0.0000 $0.31 4/1/2001 0.00 $0.31 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7026 0 999 Years 0.00 $0.0000 $30.19 7/1/2011 0.00 $30.19 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7027 0 999 Years 0.00 $0.0000 $179.35 1/1/2008 0.00 $179.35 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7028 0 999 Years 0.00 $0.0000 $49.54 1/1/2008 0.00 $49.54 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7029 0 999 Years 0.00 $0.0000 $20.24 1/1/2008 0.00 $20.24 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7030 0 999 Years 0.00 $0.0000 $170.72 7/1/2011 0.00 $170.72 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7031 0 999 Years 0.00 $0.0000 $63.14 7/1/2011 0.00 $63.14 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7032 0 999 Years 0.00 $0.0000 $36.68 7/1/2011 0.00 $36.68 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7033 0 999 Years 0.00 $0.0000 $25.71 7/1/2011 0.00 $25.71 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 27
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7034 0 999 Years 0.00 $0.0000 $55.44 1/1/2015 0.00 $55.44 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7035 0 999 Years 0.00 $0.0000 $27.00 5/1/2003 0.00 $27.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7037 0 999 Years 0.00 $0.0000 $18.07 1/1/2015 0.00 $18.07 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7038 0 999 Years 0.00 $0.0000 $4.50 5/1/2003 0.00 $4.50 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7039 0 999 Years 0.00 $0.0000 $11.79 7/1/2011 0.00 $11.79 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7046 0 20 Years 0.00 $0.0000 $17.66 7/1/2011 0.00 $17.66 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7520 0 999 Years 0.00 $0.0000 $45.01 7/1/2004 0.00 $45.01 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7520 TF 0 999 Years 0.00 $0.0000 $104.86 1/1/2015 0.00 $104.86 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7520 TG 0 999 Years 0.00 $0.0000 $0.00 7/1/2004 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7521 0 999 Years 0.00 $0.0000 $45.01 7/1/2004 0.00 $45.01 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7521 TF 0 999 Years 0.00 $0.0000 $104.86 1/1/2015 0.00 $104.86 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7521 TG 0 999 Years 0.00 $0.0000 $0.00 7/1/2004 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7522 0 999 Years 0.00 $0.0000 $45.01 7/1/2004 0.00 $45.01 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7523 0 999 Years 0.00 $0.0000 $11.78 7/1/2011 0.00 $11.78 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7525 0 999 Years 0.00 $0.0000 $1.40 7/1/2004 0.00 $1.40 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A7526 0 999 Years 0.00 $0.0000 $1.85 1/1/2015 0.00 $1.85 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A8000 0 999 Years 0.00 $0.0000 $153.35 1/1/2007 0.00 $153.35 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 28
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A8001 0 999 Years 0.00 $0.0000 $153.35 1/1/2007 0.00 $153.35 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A8002 0 20 Years 0.00 $0.0000 $354.58 1/1/2015 0.00 $354.58 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A8003 0 20 Years 0.00 $0.0000 $537.05 1/1/2015 0.00 $537.05 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A8004 0 999 Years 0.00 $0.0000 $90.00 7/1/2011 0.00 $90.00 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A9272 0 999 Years 0.00 $0.0000 $265.91 1/1/2015 0.00 $265.91 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A9273 0 999 Years 0.00 $0.0000 $0.00 1/1/2011 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A9274 0 20 Years 0.00 $0.0000 $43.50 7/1/2011 0.00 $43.50 6 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A9275 0 999 Years 0.00 $0.0000 $28.28 7/1/2013 0.00 $28.28 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A9284 0 999 Years 0.00 $0.0000 $12.49 1/1/2009 0.00 $12.49 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES A9900 0 999 Years 0.00 $0.0000 $0.00 2/1/2000 $0.00 5 8/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4034 0 999 Years 0.00 $0.0000 $6.11 1/1/2014 0.00 $6.11 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4035 0 999 Years 0.00 $0.0000 $11.65 1/1/2014 0.00 $11.65 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4036 0 999 Years 0.00 $0.0000 $8.00 1/1/2014 0.00 $8.00 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4081 0 999 Years 0.00 $0.0000 $21.61 1/1/2014 0.00 $21.61 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4082 0 999 Years 0.00 $0.0000 $16.07 1/1/2014 0.00 $16.07 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4083 0 999 Years 0.00 $0.0000 $2.47 1/1/2014 0.00 $2.47 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4087 0 999 Years 0.00 $0.0000 $35.67 1/1/2014 0.00 $35.67 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 29
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4088 0 999 Years 0.00 $0.0000 $35.67 1/1/2014 0.00 $35.67 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4100 0 999 Years 0.00 $0.0000 $0.72 1/1/2016 0.00 $0.72 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4103 0 20 Years 0.00 $0.0000 $3.23 1/1/2016 0.00 $3.23 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4104 0 999 Years 0.00 $0.0000 $0.00 10/1/2010 -8.00 $0.00 5 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4149 0 999 Years 0.00 $0.0000 $1.57 1/1/2014 0.00 $1.57 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4150 0 999 Years 0.00 $0.0000 $1.05 1/1/2016 0.00 $1.05 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4152 0 999 Years 0.00 $0.0000 $0.93 1/1/2016 0.00 $0.93 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4153 0 999 Years 0.00 $0.0000 $4.23 1/1/2016 0.00 $4.23 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4154 0 999 Years 0.00 $0.0000 $2.78 1/1/2016 0.00 $2.78 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4155 0 999 Years 0.00 $0.0000 $6.18 1/1/2016 0.00 $6.18 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4157 0 999 Years 0.00 $0.0000 $5.95 1/1/2016 0.00 $5.95 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4164 0 999 Years 0.00 $0.0000 $19.10 1/1/2014 0.00 $19.10 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4168 0 999 Years 0.00 $0.0000 $27.85 1/1/2014 0.00 $27.85 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4172 0 999 Years 0.00 $0.0000 $28.06 1/1/2014 0.00 $28.06 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4176 0 999 Years 0.00 $0.0000 $53.89 1/1/2014 0.00 $53.89 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4178 0 999 Years 0.00 $0.0000 $64.69 1/1/2014 0.00 $64.69 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4180 0 999 Years 0.00 $0.0000 $27.42 1/1/2014 0.00 $27.42 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 30
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4185 0 999 Years 0.00 $0.0000 $12.63 1/1/2014 0.00 $12.63 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4189 0 999 Years 0.00 $0.0000 $199.85 1/1/2014 0.00 $199.85 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4193 0 999 Years 0.00 $0.0000 $258.24 1/1/2014 0.00 $258.24 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4197 0 999 Years 0.00 $0.0000 $314.40 1/1/2014 0.00 $314.40 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4199 0 999 Years 0.00 $0.0000 $359.25 1/1/2014 0.00 $359.25 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4216 0 999 Years 0.00 $0.0000 $8.68 1/1/2014 0.00 $8.68 6 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4220 0 999 Years 0.00 $0.0000 $9.00 1/1/2014 0.00 $9.00 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4222 0 999 Years 0.00 $0.0000 $11.10 1/1/2014 0.00 $11.10 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B4224 0 999 Years 0.00 $0.0000 $28.11 1/1/2014 0.00 $28.11 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B5000 0 999 Years 0.00 $0.0000 $13.37 1/1/2014 0.00 $13.37 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B5100 0 999 Years 0.00 $0.0000 $5.22 1/1/2014 0.00 $5.22 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B5200 0 999 Years 0.00 $0.0000 $3.04 1/1/2016 0.00 $3.04 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 0 999 Years 0.00 $0.0000 $0.00 1/1/2010 $0.00 5 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 U1 0 999 Years 0.00 $0.0000 $6.34 1/1/2016 0.00 $6.34 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 U2 0 999 Years 0.00 $0.0000 $138.00 1/1/2014 0.00 $138.00 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 U3 0 999 Years 0.00 $0.0000 $20.70 1/1/2016 0.00 $20.70 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 U4 0 999 Years 0.00 $0.0000 $28.98 1/1/2016 0.00 $28.98 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 31
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 U5 0 999 Years 0.00 $0.0000 $2.76 1/1/2014 0.00 $2.76 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES B9999 0 999 Years 0.00 $0.0000 $0.00 10/1/2010 -8.00 $0.00 5 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES C1883 0 999 Years 0.00 $0.0000 $733.90 7/1/2015 0.00 $733.90 7/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES C1897 0 999 Years 0.00 $0.0000 $1,336.60 7/1/2015 0.00 $1,336.60 7/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES K0552 0 999 Years 0.00 $0.0000 $2.74 4/1/2010 -8.00 $2.52 11/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES K0601 0 999 Years 0.00 $0.0000 $1.16 4/1/2010 -8.00 $1.07 11/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES K0602 0 999 Years 0.00 $0.0000 $6.67 10/1/2011 -8.00 $6.14 11/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES K0603 0 999 Years 0.00 $0.0000 $0.60 4/1/2010 -8.00 $0.55 11/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES K0604 0 999 Years 0.00 $0.0000 $6.38 10/1/2011 -8.00 $5.87 11/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES K0605 0 999 Years 0.00 $0.0000 $15.31 10/1/2011 -8.00 $14.09 11/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES K0607 U1 1 20 Years 0.00 $0.0000 $152.80 10/1/2011 -8.00 $140.58 6 11/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES K0609 U2 1 20 Years 0.00 $0.0000 $704.78 1/1/2011 -8.00 $648.40 6 11/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES K0739 0 999 Years 0.00 $0.0000 $13.08 3/1/2012 0.00 $13.08 11/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L7368 0 999 Years 0.00 $0.0000 $409.27 5/1/2003 0.00 $409.27 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8000 0 999 Years 0.00 $0.0000 $23.92 6/1/2010 0.00 $23.92 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8001 0 999 Years 0.00 $0.0000 $114.39 7/1/2010 0.00 $114.39 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8002 0 999 Years 0.00 $0.0000 $150.48 7/1/2010 0.00 $150.48 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8010 0 999 Years 0.00 $0.0000 $59.52 10/1/2016 0.00 $59.52 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8015 0 999 Years 0.00 $0.0000 $45.45 6/1/2010 0.00 $45.45 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8020 0 999 Years 0.00 $0.0000 $140.20 6/1/2010 0.00 $140.20 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8030 0 999 Years 0.00 $0.0000 $233.93 6/1/2010 0.00 $233.93 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8031 0 999 Years 0.00 $0.0000 $307.79 10/1/2012 0.00 $307.79 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8032 0 999 Years 0.00 $0.0000 $20.09 1/1/2010 0.00 $20.09 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8035 0 999 Years 0.00 $0.0000 $2,777.90 6/1/2010 0.00 $2,777.90 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8039 0 999 Years 0.00 $0.0000 $0.00 6/1/2010 $0.00 5 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8499 0 999 Years 0.00 $0.0000 $0.00 1/1/2009 $0.00 5 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8499 RB 0 999 Years 0.00 $0.0000 $0.00 1/1/2009 $0.00 5 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8501 0 999 Years 0.00 $0.0000 $71.46 5/1/2003 0.00 $71.46 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8615 1 999 Years 0.00 $0.0000 $365.74 2/1/2006 0.00 $365.74 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8616 1 999 Years 0.00 $0.0000 $85.19 2/1/2006 0.00 $85.19 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8617 1 999 Years 0.00 $0.0000 $74.40 2/1/2006 0.00 $74.40 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8618 1 999 Years 0.00 $0.0000 $21.25 2/1/2006 0.00 $21.25 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8619 1 999 Years 0.00 $0.0000 $6,663.57 2/1/2006 0.00 $6,663.57 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8621 1 999 Years 0.00 $0.0000 $0.50 2/1/2006 0.00 $0.50 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 33
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8622 1 999 Years 0.00 $0.0000 $0.27 2/1/2006 0.00 $0.27 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8623 1 999 Years 0.00 $0.0000 $52.45 12/2/2008 0.00 $52.45 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8624 1 999 Years 0.00 $0.0000 $140.05 12/2/2008 0.00 $140.05 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8627 1 999 Years 0.00 $0.0000 $6,366.34 1/1/2010 0.00 $6,366.34 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8628 1 999 Years 0.00 $0.0000 $1,128.30 1/1/2010 0.00 $1,128.30 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8629 1 999 Years 0.00 $0.0000 $167.07 10/1/2012 0.00 $167.07 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8680 0 999 Years 0.00 $0.0000 $272.16 10/1/2014 0.00 $272.16 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES L8680 TG 0 999 Years 0.00 $0.0000 $4,646.94 10/1/2011 0.00 $4,646.94 10/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES Q0506 0 999 Years 0.00 $0.0000 $787.21 1/1/2016 0.00 $787.21 1/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S1015 0 999 Years 0.00 $0.0000 $10.50 1/1/2010 0.00 $10.50 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8101 0 999 Years 0.00 $0.0000 $30.34 4/1/2015 0.00 $30.34 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8415 10 55 Years 0.00 $0.0000 $56.25 7/1/2015 0.00 $56.25 6 7/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8420 0 20 Years 0.00 $0.0000 $335.86 4/1/2015 0.00 $335.86 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8421 0 20 Years 0.00 $0.0000 $109.88 4/1/2015 0.00 $109.88 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8422 0 20 Years 0.00 $0.0000 $293.50 4/1/2015 0.00 $293.50 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8423 0 20 Years 0.00 $0.0000 $210.80 4/1/2015 0.00 $210.80 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8424 0 20 Years 0.00 $0.0000 $62.24 4/1/2015 0.00 $62.24 6 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8425 0 20 Years 0.00 $0.0000 $138.18 4/1/2015 0.00 $138.18 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8426 0 20 Years 0.00 $0.0000 $142.68 4/1/2015 0.00 $142.68 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8427 0 20 Years 0.00 $0.0000 $46.90 4/1/2015 0.00 $46.90 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8428 0 20 Years 0.00 $0.0000 $72.70 4/1/2015 0.00 $72.70 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8429 0 20 Years 0.00 $0.0000 $16.40 4/1/2015 0.00 $16.40 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8450 1 20 Years 0.00 $0.0000 $6.56 4/1/2015 0.00 $6.56 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8451 1 20 Years 0.00 $0.0000 $20.00 4/1/2015 0.00 $20.00 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES S8452 1 20 Years 0.00 $0.0000 $18.04 4/1/2015 0.00 $18.04 6 4/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T1999 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4521 0 999 Years 0.00 $0.0000 $0.58 1/1/2005 -8.00 $0.53 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4522 0 999 Years 0.00 $0.0000 $0.61 1/1/2005 -8.00 $0.56 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4523 0 999 Years 0.00 $0.0000 $0.65 1/1/2005 -8.00 $0.60 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4524 0 999 Years 0.00 $0.0000 $0.75 3/1/2012 0.00 $0.75 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4525 0 999 Years 0.00 $0.0000 $0.58 1/1/2005 -8.00 $0.53 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4526 0 999 Years 0.00 $0.0000 $0.68 1/1/2005 -8.00 $0.63 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4527 0 999 Years 0.00 $0.0000 $0.83 1/1/2005 -8.00 $0.76 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4528 0 999 Years 0.00 $0.0000 $0.92 3/1/2012 0.00 $0.92 1/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4528 U1 0 999 Years 0.00 $0.0000 $1.50 7/1/2013 0.00 $1.50 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4529 0 999 Years 0.00 $0.0000 $0.30 1/1/2005 -8.00 $0.28 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4530 0 999 Years 0.00 $0.0000 $0.52 1/1/2005 -8.00 $0.48 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4531 0 999 Years 0.00 $0.0000 $0.63 1/1/2005 -8.00 $0.58 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4532 0 999 Years 0.00 $0.0000 $0.84 1/1/2005 -8.00 $0.77 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4533 0 999 Years 0.00 $0.0000 $0.58 1/1/2005 -8.00 $0.53 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4534 0 999 Years 0.00 $0.0000 $0.62 3/1/2012 0.00 $0.62 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4535 0 999 Years 0.00 $0.0000 $0.29 1/1/2005 -8.00 $0.27 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES T4543 0 999 Years 0.00 $0.0000 $0.94 3/1/2012 0.00 $0.94 1/1/2013
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES V2799 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 7/1/2016
HOME
HEALTH DME 9
OTHER MEDICAL
ITEMS OR
SERVICES V5336 1 999 Years 0.00 $0.0000 $0.00 4/1/2010 $0.00 5 7/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4206 0 999 Years 0.00 $0.0000 $0.25 7/1/2011 0.00 $0.25 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4207 0 999 Years 0.00 $0.0000 $0.29 7/1/2011 0.00 $0.29 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4208 0 999 Years 0.00 $0.0000 $0.35 1/1/2015 0.00 $0.35 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4209 0 999 Years 0.00 $0.0000 $0.40 7/1/2011 0.00 $0.40 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4211 U4 0 999 Years 0.00 $0.0000 $1.80 7/1/2011 0.00 $1.80 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4212 0 999 Years 0.00 $0.0000 $22.00 1/1/2015 0.00 $22.00 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 36
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4213 0 999 Years 0.00 $0.0000 $0.48 7/1/2011 0.00 $0.48 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4215 0 999 Years 0.00 $0.0000 $0.20 7/1/2011 0.00 $0.20 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4216 0 999 Years 0.00 $0.0000 $0.39 3/1/2008 0.00 $0.39 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4217 0 999 Years 0.00 $0.0000 $3.13 3/1/2008 0.00 $3.13 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4220 0 999 Years 0.00 $0.0000 $50.00 7/1/2011 0.00 $50.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4222 0 999 Years 0.00 $0.0000 $24.58 1/1/2015 0.00 $24.58 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4230 0 999 Years 0.00 $0.0000 $12.00 1/1/2015 0.00 $12.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4231 0 999 Years 0.00 $0.0000 $7.40 7/1/2011 0.00 $7.40 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4232 0 999 Years 0.00 $0.0000 $2.53 7/1/2011 0.00 $2.53 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4233 0 999 Years 0.00 $0.0000 $0.77 1/1/2015 0.00 $0.77 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4234 0 999 Years 0.00 $0.0000 $3.51 1/1/2015 0.00 $3.51 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4235 0 999 Years 0.00 $0.0000 $2.26 1/1/2015 0.00 $2.26 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4236 0 999 Years 0.00 $0.0000 $1.62 1/1/2015 0.00 $1.62 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4244 0 999 Years 0.00 $0.0000 $1.78 1/1/2015 0.00 $1.78 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4245 0 999 Years 0.00 $0.0000 $2.06 7/1/2011 0.00 $2.06 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4246 0 999 Years 0.00 $0.0000 $8.00 1/1/2015 0.00 $8.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4247 0 999 Years 0.00 $0.0000 $6.90 1/1/2015 0.00 $6.90 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 37
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4248 0 999 Years 0.00 $0.0000 $0.29 4/1/2010 0.00 $0.29 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4250 0 999 Years 0.00 $0.0000 $13.45 7/1/1997 0.00 $13.45 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4252 0 999 Years 0.00 $0.0000 $4.80 7/1/2011 0.00 $4.80 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4253 0 999 Years 0.00 $0.0000 $28.28 7/1/2013 0.00 $28.28 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4256 0 999 Years 0.00 $0.0000 $9.20 1/1/2015 0.00 $9.20 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4258 0 999 Years 0.00 $0.0000 $14.65 1/1/2015 0.00 $14.65 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4259 0 999 Years 0.00 $0.0000 $11.10 7/1/2013 0.00 $11.10 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4263 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4265 0 999 Years 0.00 $0.0000 $3.23 5/7/1999 0.00 $3.23 0.00 $0.0000 $3.23 5/7/1999 0.00 $3.23 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4280 0 999 Years 0.00 $0.0000 $4.71 2/1/2000 0.00 $4.71 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4281 0 999 Years 0.00 $0.0000 $3.58 1/1/2015 0.00 $3.58 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4282 0 999 Years 0.00 $0.0000 $0.48 1/1/2015 0.00 $0.48 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4283 0 999 Years 0.00 $0.0000 $0.53 1/1/2015 0.00 $0.53 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4284 0 999 Years 0.00 $0.0000 $6.99 1/1/2015 0.00 $6.99 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4285 0 999 Years 0.00 $0.0000 $2.21 1/1/2015 0.00 $2.21 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4286 0 999 Years 0.00 $0.0000 $0.44 1/1/2015 0.00 $0.44 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4290 0 999 Years 0.00 $0.0000 $377.20 1/1/2015 0.00 $377.20 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4300 0 999 Years 0.00 $0.0000 $8.56 1/1/2015 0.00 $8.56 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4301 0 999 Years 0.00 $0.0000 $32.20 1/1/2015 0.00 $32.20 0.00 $0.0000 $32.20 1/1/2015 0.00 $32.20 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4305 0 999 Years 0.00 $0.0000 $20.93 7/1/2011 0.00 $20.93 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4306 0 999 Years 0.00 $0.0000 $18.33 7/1/2011 0.00 $18.33 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4310 0 999 Years 0.00 $0.0000 $5.47 7/1/1997 0.00 $5.47 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4311 0 999 Years 0.00 $0.0000 $10.72 7/1/1997 0.00 $10.72 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4312 0 999 Years 0.00 $0.0000 $14.65 7/1/1997 0.00 $14.65 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4313 0 999 Years 0.00 $0.0000 $17.01 7/1/1997 0.00 $17.01 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4314 0 999 Years 0.00 $0.0000 $20.64 7/1/1997 0.00 $20.64 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4315 0 999 Years 0.00 $0.0000 $20.64 7/1/1997 0.00 $20.64 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4316 0 999 Years 0.00 $0.0000 $23.01 7/1/1997 0.00 $23.01 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4320 0 999 Years 0.00 $0.0000 $3.65 7/1/1997 0.00 $3.65 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4321 0 999 Years 0.00 $0.0000 $8.28 1/1/2015 0.00 $8.28 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4322 0 999 Years 0.00 $0.0000 $2.35 7/1/1997 0.00 $2.35 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4326 0 999 Years 0.00 $0.0000 $10.79 3/1/2008 0.00 $10.79 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4327 0 999 Years 0.00 $0.0000 $38.54 7/1/1997 0.00 $38.54 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4328 0 999 Years 0.00 $0.0000 $6.83 7/1/1997 0.00 $6.83 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 39
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4330 0 999 Years 0.00 $0.0000 $5.65 7/1/1997 0.00 $5.65 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4331 0 999 Years 0.00 $0.0000 $2.50 4/1/2011 0.00 $2.50 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4332 0 999 Years 0.00 $0.0000 $0.10 4/1/2011 0.00 $0.10 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4333 0 999 Years 0.00 $0.0000 $1.73 4/1/2011 0.00 $1.73 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4334 0 999 Years 0.00 $0.0000 $3.88 4/1/2011 0.00 $3.88 1/1/2015
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES A4335 0 999 Years 0.00 $0.0000 $3.09 7/1/2011 -8.00 $2.84 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4335 0 999 Years 0.00 $0.0000 $0.00 7/1/2011 -8.00 $0.00 5 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4335 U9 0 999 Years 0.00 $0.0000 $3.09 7/1/2011 -8.00 $2.84 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4338 0 999 Years 0.00 $0.0000 $10.44 7/1/1997 0.00 $10.44 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4340 0 999 Years 0.00 $0.0000 $17.36 1/1/2015 0.00 $17.36 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4344 0 999 Years 0.00 $0.0000 $10.66 7/1/1997 0.00 $10.66 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4346 0 999 Years 0.00 $0.0000 $13.27 7/1/1997 0.00 $13.27 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4349 0 999 Years 0.00 $0.0000 $1.80 1/1/2005 0.00 $1.80 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4351 0 999 Years 0.00 $0.0000 $1.81 3/1/2008 0.00 $1.81 7/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4351 SC 0 999 Years 0.00 $0.0000 $3.65 7/1/2015 0.00 $3.65 7/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4352 0 999 Years 0.00 $0.0000 $5.07 7/1/1997 0.00 $5.07 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4353 0 999 Years 0.00 $0.0000 $6.66 7/1/1997 0.00 $6.66 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4354 0 999 Years 0.00 $0.0000 $10.06 7/1/1997 0.00 $10.06 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4355 0 999 Years 0.00 $0.0000 $7.94 7/1/1997 0.00 $7.94 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4356 0 999 Years 0.00 $0.0000 $30.40 7/1/1997 0.00 $30.40 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4357 0 999 Years 0.00 $0.0000 $7.65 7/1/1997 0.00 $7.65 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4358 0 999 Years 0.00 $0.0000 $6.43 3/1/2012 0.00 $6.43 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4360 0 999 Years 0.00 $0.0000 $0.43 1/1/2010 0.00 $0.43 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4361 0 999 Years 0.00 $0.0000 $18.37 3/1/2008 0.00 $18.37 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4362 0 999 Years 0.00 $0.0000 $2.64 7/1/1997 0.00 $2.64 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4363 0 999 Years 0.00 $0.0000 $2.17 3/1/2012 0.00 $2.17 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4364 0 999 Years 0.00 $0.0000 $2.84 3/1/2012 0.00 $2.84 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4366 0 999 Years 0.00 $0.0000 $1.03 4/1/2011 0.00 $1.03 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4367 0 999 Years 0.00 $0.0000 $7.15 3/1/2012 0.00 $7.15 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4368 0 999 Years 0.00 $0.0000 $0.25 7/1/1997 0.00 $0.25 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4369 0 999 Years 0.00 $0.0000 $2.30 2/1/2000 0.00 $2.30 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4371 0 999 Years 0.00 $0.0000 $3.83 3/1/2012 0.00 $3.83 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4372 0 999 Years 0.00 $0.0000 $3.98 2/1/2000 0.00 $3.98 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4373 0 999 Years 0.00 $0.0000 $5.99 2/1/2000 0.00 $5.99 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4375 0 999 Years 0.00 $0.0000 $16.38 2/1/2000 0.00 $16.38 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4376 0 999 Years 0.00 $0.0000 $45.38 2/1/2000 0.00 $45.38 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4377 0 999 Years 0.00 $0.0000 $4.09 2/1/2000 0.00 $4.09 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4378 0 999 Years 0.00 $0.0000 $29.33 2/1/2000 0.00 $29.33 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4379 0 999 Years 0.00 $0.0000 $14.33 2/1/2000 0.00 $14.33 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4380 0 999 Years 0.00 $0.0000 $35.60 2/1/2000 0.00 $35.60 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4381 0 999 Years 0.00 $0.0000 $4.40 2/1/2000 0.00 $4.40 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4382 0 999 Years 0.00 $0.0000 $23.48 2/1/2000 0.00 $23.48 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4383 0 999 Years 0.00 $0.0000 $26.89 2/1/2000 0.00 $26.89 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4384 0 999 Years 0.00 $0.0000 $9.18 2/1/2000 0.00 $9.18 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4385 0 999 Years 0.00 $0.0000 $5.25 3/1/2012 0.00 $5.25 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4387 0 999 Years 0.00 $0.0000 $2.45 1/1/2015 0.00 $2.45 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4388 0 999 Years 0.00 $0.0000 $4.58 3/1/2012 0.00 $4.58 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4389 0 999 Years 0.00 $0.0000 $5.93 2/1/2000 0.00 $5.93 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4390 0 999 Years 0.00 $0.0000 $9.17 2/1/2000 0.00 $9.17 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4391 0 999 Years 0.00 $0.0000 $6.74 2/1/2000 0.00 $6.74 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4392 0 999 Years 0.00 $0.0000 $6.34 2/1/2000 0.00 $6.34 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4393 0 999 Years 0.00 $0.0000 $8.75 2/1/2000 0.00 $8.75 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4394 0 999 Years 0.00 $0.0000 $2.50 3/1/2012 0.00 $2.50 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4395 0 999 Years 0.00 $0.0000 $0.05 2/1/2000 0.00 $0.05 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4396 0 999 Years 0.00 $0.0000 $38.61 4/1/2001 0.00 $38.61 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4397 0 999 Years 0.00 $0.0000 $4.41 7/1/1997 0.00 $4.41 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4398 0 999 Years 0.00 $0.0000 $10.84 7/1/1997 0.00 $10.84 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4399 0 999 Years 0.00 $0.0000 $8.18 7/1/1997 0.00 $8.18 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4400 0 999 Years 0.00 $0.0000 $46.88 7/1/1997 0.00 $46.88 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4402 0 999 Years 0.00 $0.0000 $1.52 5/1/2003 0.00 $1.52 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4404 0 999 Years 0.00 $0.0000 $1.55 7/1/1997 0.00 $1.55 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4405 0 999 Years 0.00 $0.0000 $3.35 3/1/2012 0.00 $3.35 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4406 0 999 Years 0.00 $0.0000 $6.02 3/1/2012 0.00 $6.02 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4407 0 999 Years 0.00 $0.0000 $9.19 3/1/2012 0.00 $9.19 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4408 0 999 Years 0.00 $0.0000 $9.87 5/1/2003 0.00 $9.87 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4409 0 999 Years 0.00 $0.0000 $6.52 3/1/2012 0.00 $6.52 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4410 0 999 Years 0.00 $0.0000 $9.04 3/1/2012 0.00 $9.04 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4411 0 999 Years 0.00 $0.0000 $3.72 1/1/2006 0.00 $3.72 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4412 0 999 Years 0.00 $0.0000 $2.84 7/1/2011 0.00 $2.84 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4413 0 999 Years 0.00 $0.0000 $5.50 5/1/2003 0.00 $5.50 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4414 0 999 Years 0.00 $0.0000 $5.17 3/1/2012 0.00 $5.17 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4415 0 999 Years 0.00 $0.0000 $6.29 3/1/2012 0.00 $6.29 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4416 0 999 Years 0.00 $0.0000 $2.17 4/1/2011 0.00 $2.17 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4417 0 999 Years 0.00 $0.0000 $2.93 4/1/2011 0.00 $2.93 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4418 0 999 Years 0.00 $0.0000 $1.81 5/1/2005 0.00 $1.81 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4419 0 999 Years 0.00 $0.0000 $1.37 4/1/2011 0.00 $1.37 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4420 0 999 Years 0.00 $0.0000 $2.41 7/1/2011 0.00 $2.41 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4421 0 999 Years 0.00 $0.0000 $23.00 1/1/2015 0.00 $23.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4422 0 999 Years 0.00 $0.0000 $0.12 5/1/2003 0.00 $0.12 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4423 0 999 Years 0.00 $0.0000 $1.46 4/1/2011 0.00 $1.46 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4424 0 999 Years 0.00 $0.0000 $3.74 4/1/2011 0.00 $3.74 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4425 0 999 Years 0.00 $0.0000 $2.82 4/1/2011 0.00 $2.82 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4426 0 999 Years 0.00 $0.0000 $2.15 4/1/2011 0.00 $2.15 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4427 0 999 Years 0.00 $0.0000 $2.19 4/1/2011 0.00 $2.19 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4428 0 999 Years 0.00 $0.0000 $6.83 3/1/2012 0.00 $6.83 1/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4429 0 999 Years 0.00 $0.0000 $6.49 4/1/2011 0.00 $6.49 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4430 0 999 Years 0.00 $0.0000 $6.70 4/1/2011 0.00 $6.70 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4431 0 999 Years 0.00 $0.0000 $4.89 4/1/2011 0.00 $4.89 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4432 0 999 Years 0.00 $0.0000 $2.83 4/1/2011 0.00 $2.83 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4433 0 999 Years 0.00 $0.0000 $2.63 4/1/2011 0.00 $2.63 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4434 0 999 Years 0.00 $0.0000 $2.96 4/1/2011 0.00 $2.96 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4450 0 999 Years 0.00 $0.0000 $0.09 5/1/2003 0.00 $0.09 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4452 0 999 Years 0.00 $0.0000 $0.36 5/1/2003 0.00 $0.36 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4455 0 999 Years 0.00 $0.0000 $1.22 3/1/2008 0.00 $1.22 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4456 0 999 Years 0.00 $0.0000 $0.26 1/1/2010 0.00 $0.26 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4461 0 999 Years 0.00 $0.0000 $3.29 1/1/2007 0.00 $3.29 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4465 0 999 Years 0.00 $0.0000 $20.00 7/1/2011 0.00 $20.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4466 0 999 Years 0.00 $0.0000 $54.00 7/1/2011 0.00 $54.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4481 0 999 Years 0.00 $0.0000 $0.37 5/1/2003 0.00 $0.37 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4483 0 999 Years 0.00 $0.0000 $5.23 1/1/2015 0.00 $5.23 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4490 0 999 Years 0.00 $0.0000 $17.80 7/1/2011 0.00 $17.80 0.00 $0.0000 $17.80 7/1/2011 0.00 $17.80 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4495 0 999 Years 0.00 $0.0000 $21.00 7/1/2011 0.00 $21.00 0.00 $0.0000 $21.00 7/1/2011 0.00 $21.00 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4500 0 999 Years 0.00 $0.0000 $12.00 7/1/2011 0.00 $12.00 0.00 $0.0000 $12.00 7/1/2011 0.00 $12.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4510 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4554 0 999 Years 0.00 $0.0000 $0.41 7/7/2000 -8.00 $0.38 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4556 0 999 Years 0.00 $0.0000 $12.14 3/1/2008 0.00 $12.14 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4557 0 999 Years 0.00 $0.0000 $21.10 3/1/2008 0.00 $21.10 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4558 0 999 Years 0.00 $0.0000 $2.54 1/1/2015 0.00 $2.54 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4561 0 999 Years 0.00 $0.0000 $19.00 4/1/2001 0.00 $19.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4562 0 999 Years 0.00 $0.0000 $47.26 4/1/2001 0.00 $47.26 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4565 0 999 Years 0.00 $0.0000 $8.41 1/1/2015 0.00 $8.41 0.00 $0.0000 $8.41 1/1/2015 0.00 $8.41 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4566 0 999 Years 0.00 $0.0000 $100.32 1/1/2015 0.00 $100.32 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4570 0 999 Years 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4595 0 999 Years 0.00 $0.0000 $26.73 1/1/2008 0.00 $26.73 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4600 0 999 Years 0.00 $0.0000 $37.24 1/1/2015 0.00 $37.24 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4601 0 999 Years 0.00 $0.0000 $2.05 1/1/2015 0.00 $2.05 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4605 0 999 Years 0.00 $0.0000 $16.40 1/1/2005 0.00 $16.40 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4606 0 999 Years 0.00 $0.0000 $36.90 7/1/2011 0.00 $36.90 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4611 0 999 Years 0.00 $0.0000 $133.64 7/1/1997 0.00 $133.64 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4612 0 999 Years 0.00 $0.0000 $47.52 7/1/1997 0.00 $47.52 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4613 0 999 Years 0.00 $0.0000 $99.43 7/1/1997 0.00 $99.43 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4614 0 999 Years 0.00 $0.0000 $22.68 3/1/1999 0.00 $22.68 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4615 0 999 Years 0.00 $0.0000 $0.75 7/1/2011 0.00 $0.75 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4616 0 999 Years 0.00 $0.0000 $0.07 7/1/2011 0.00 $0.07 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4617 0 999 Years 0.00 $0.0000 $3.25 7/1/2011 0.00 $3.25 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4618 0 999 Years 0.00 $0.0000 $4.13 1/1/2015 0.00 $4.13 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4619 0 999 Years 0.00 $0.0000 $1.21 2/1/2008 0.00 $1.21 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4620 0 999 Years 0.00 $0.0000 $0.62 7/1/2011 0.00 $0.62 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4623 0 999 Years 0.00 $0.0000 $5.28 7/1/1997 0.00 $5.28 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4624 0 999 Years 0.00 $0.0000 $2.38 7/1/1997 0.00 $2.38 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4627 0 999 Years 0.00 $0.0000 $30.00 7/1/2011 0.00 $30.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4628 0 999 Years 0.00 $0.0000 $3.65 10/18/2002 0.00 $3.65 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4629 0 999 Years 0.00 $0.0000 $4.30 5/1/2003 0.00 $4.30 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4630 0 20 Years 0.00 $0.0000 $6.56 7/1/2011 0.00 $6.56 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4635 0 999 Years 0.00 $0.0000 $2.58 1/1/2003 0.00 $2.58 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4636 0 999 Years 0.00 $0.0000 $2.13 1/1/2003 0.00 $2.13 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4637 0 999 Years 0.00 $0.0000 $1.35 7/1/1997 0.00 $1.35 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4640 0 999 Years 0.00 $0.0000 $29.43 1/1/2015 0.00 $29.43 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4651 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4652 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4657 0 20 Years 0.00 $0.0000 $0.70 7/1/2011 0.00 $0.70 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4660 0 999 Years 0.00 $0.0000 $31.25 7/1/2011 0.00 $31.25 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4663 0 999 Years 0.00 $0.0000 $32.00 7/1/2011 0.00 $32.00 0.00 $0.0000 $32.00 7/1/2011 0.00 $32.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4670 0 999 Years 0.00 $0.0000 $66.09 7/1/2011 0.00 $66.09 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4680 0 20 Years 0.00 $0.0000 $140.57 7/1/2011 0.00 $140.57 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4690 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4706 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4707 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4708 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4709 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4714 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4719 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4720 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4721 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4722 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4723 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4724 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4725 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4726 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4730 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4736 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4737 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4740 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4750 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4755 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4760 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4765 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4766 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4772 0 20 Years 0.00 $0.0000 $30.99 7/1/2011 0.00 $30.99 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4773 0 20 Years 0.00 $0.0000 $21.12 6/1/2002 0.00 $21.12 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4774 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4802 0 20 Years 0.00 $0.0000 $0.00 6/1/2002 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4860 0 999 Years 0.00 $0.0000 $4.73 1/1/2015 0.00 $4.73 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4911 0 20 Years 0.00 $0.0000 $10.40 1/1/2015 0.00 $10.40 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4913 0 999 Years 0.00 $0.0000 $0.00 1/1/1982 $0.00 5 6 0.00 $0.0000 $0.00 1/1/1982 $0.00 5 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4918 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4927 0 999 Years 0.00 $0.0000 $7.97 1/1/2015 0.00 $7.97 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4928 0 20 Years 0.00 $0.0000 $24.16 1/1/2015 0.00 $24.16 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4929 0 20 Years 0.00 $0.0000 $1.24 7/1/2011 0.00 $1.24 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4930 0 999 Years 0.00 $0.0000 $0.77 7/1/2011 0.00 $0.77 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4931 0 999 Years 0.00 $0.0000 $11.46 7/1/2011 0.00 $11.46 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4932 0 999 Years 0.00 $0.0000 $7.00 5/1/2003 0.00 $7.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5051 0 999 Years 0.00 $0.0000 $1.80 7/1/1997 0.00 $1.80 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5052 0 999 Years 0.00 $0.0000 $1.31 7/1/1997 0.00 $1.31 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5053 0 999 Years 0.00 $0.0000 $1.36 7/1/1997 0.00 $1.36 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5054 0 999 Years 0.00 $0.0000 $1.90 3/1/2012 0.00 $1.90 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5055 0 999 Years 0.00 $0.0000 $1.12 7/1/1997 0.00 $1.12 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5056 0 999 Years 0.00 $0.0000 $3.76 1/1/2012 0.00 $3.76 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5057 0 999 Years 0.00 $0.0000 $7.74 1/1/2012 0.00 $7.74 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5061 0 999 Years 0.00 $0.0000 $4.27 3/1/2012 0.00 $4.27 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5062 0 999 Years 0.00 $0.0000 $2.09 3/1/2008 0.00 $2.09 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5063 0 999 Years 0.00 $0.0000 $3.15 3/1/2012 0.00 $3.15 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5071 0 999 Years 0.00 $0.0000 $4.95 7/1/1997 0.00 $4.95 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5072 0 999 Years 0.00 $0.0000 $3.60 7/1/2011 0.00 $3.60 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5073 0 999 Years 0.00 $0.0000 $3.34 3/1/2012 0.00 $3.34 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5081 0 999 Years 0.00 $0.0000 $2.14 7/1/1997 0.00 $2.14 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5082 0 999 Years 0.00 $0.0000 $9.66 7/1/1997 0.00 $9.66 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5083 0 999 Years 0.00 $0.0000 $0.63 1/1/2009 0.00 $0.63 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5093 0 999 Years 0.00 $0.0000 $1.58 7/1/1997 0.00 $1.58 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5102 0 999 Years 0.00 $0.0000 $23.52 3/1/2012 0.00 $23.52 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5105 0 999 Years 0.00 $0.0000 $34.23 7/1/1997 0.00 $34.23 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5112 0 999 Years 0.00 $0.0000 $30.86 3/1/2012 0.00 $30.86 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5113 0 999 Years 0.00 $0.0000 $3.55 7/1/1997 0.00 $3.55 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5114 0 999 Years 0.00 $0.0000 $8.94 3/1/2008 0.00 $8.94 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5120 0 999 Years 0.00 $0.0000 $0.26 3/1/2012 0.00 $0.26 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5121 0 999 Years 0.00 $0.0000 $5.88 7/1/1997 0.00 $5.88 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5122 0 999 Years 0.00 $0.0000 $8.78 7/1/1997 0.00 $8.78 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5126 0 999 Years 0.00 $0.0000 $1.32 3/1/2008 0.00 $1.32 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5131 0 999 Years 0.00 $0.0000 $13.81 7/1/1997 -8.00 $12.71 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5200 0 999 Years 0.00 $0.0000 $10.77 3/1/1999 0.00 $10.77 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5500 0 20 Years 0.00 $0.0000 $66.76 7/1/2011 -8.00 $61.42 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5501 0 20 Years 0.00 $0.0000 $200.25 7/1/2011 -8.00 $184.23 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5503 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5504 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5505 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5506 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A5507 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6010 0 999 Years 0.00 $0.0000 $32.51 7/1/2011 0.00 $32.51 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6011 0 999 Years 0.00 $0.0000 $2.39 7/1/2011 0.00 $2.39 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6021 0 999 Years 0.00 $0.0000 $20.79 4/1/2001 0.00 $20.79 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6022 0 999 Years 0.00 $0.0000 $20.79 4/1/2001 0.00 $20.79 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6023 0 999 Years 0.00 $0.0000 $188.23 4/1/2001 0.00 $188.23 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6024 0 999 Years 0.00 $0.0000 $6.12 4/1/2001 0.00 $6.12 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6025 0 999 Years 0.00 $0.0000 $13.80 1/1/2015 0.00 $13.80 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6154 0 999 Years 0.00 $0.0000 $13.29 7/1/1997 0.00 $13.29 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6196 0 999 Years 0.00 $0.0000 $7.01 7/1/1997 0.00 $7.01 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6197 0 999 Years 0.00 $0.0000 $15.68 7/1/1997 0.00 $15.68 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6198 0 999 Years 0.00 $0.0000 $14.27 7/1/2011 0.00 $14.27 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6199 0 999 Years 0.00 $0.0000 $5.04 7/1/1997 0.00 $5.04 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6203 0 999 Years 0.00 $0.0000 $3.19 7/1/1997 0.00 $3.19 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6204 0 999 Years 0.00 $0.0000 $5.94 7/1/1997 0.00 $5.94 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6205 0 999 Years 0.00 $0.0000 $6.46 7/1/2011 0.00 $6.46 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6206 0 999 Years 0.00 $0.0000 $4.25 7/1/2011 0.00 $4.25 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6207 0 999 Years 0.00 $0.0000 $7.00 7/1/1997 0.00 $7.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6208 0 999 Years 0.00 $0.0000 $66.61 1/1/2015 0.00 $66.61 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6209 0 999 Years 0.00 $0.0000 $7.14 7/1/1997 0.00 $7.14 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6210 0 999 Years 0.00 $0.0000 $19.00 7/1/1997 0.00 $19.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6211 0 999 Years 0.00 $0.0000 $28.01 7/1/1997 0.00 $28.01 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6212 0 999 Years 0.00 $0.0000 $9.25 7/1/1997 0.00 $9.25 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6213 0 999 Years 0.00 $0.0000 $11.96 1/1/2015 0.00 $11.96 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6214 0 999 Years 0.00 $0.0000 $9.82 7/1/1997 0.00 $9.82 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6215 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6216 0 999 Years 0.00 $0.0000 $0.05 7/1/1997 0.00 $0.05 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6217 0 999 Years 0.00 $0.0000 $0.15 7/1/2011 0.00 $0.15 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6218 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6219 0 999 Years 0.00 $0.0000 $0.91 7/1/1997 0.00 $0.91 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6220 0 999 Years 0.00 $0.0000 $2.46 7/1/1997 0.00 $2.46 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6221 0 999 Years 0.00 $0.0000 $4.60 1/1/2015 0.00 $4.60 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6222 0 999 Years 0.00 $0.0000 $2.03 7/1/1997 0.00 $2.03 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6223 0 999 Years 0.00 $0.0000 $2.30 7/1/1997 0.00 $2.30 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6224 0 999 Years 0.00 $0.0000 $3.44 7/1/1997 0.00 $3.44 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6228 0 999 Years 0.00 $0.0000 $1.70 1/1/2015 0.00 $1.70 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6229 0 999 Years 0.00 $0.0000 $3.44 7/1/1997 0.00 $3.44 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6230 0 999 Years 0.00 $0.0000 $1.70 1/1/2015 0.00 $1.70 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6231 0 999 Years 0.00 $0.0000 $4.61 4/1/2001 0.00 $4.61 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6232 0 999 Years 0.00 $0.0000 $6.81 4/1/2001 0.00 $6.81 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6233 0 999 Years 0.00 $0.0000 $18.98 4/1/2001 0.00 $18.98 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6234 0 999 Years 0.00 $0.0000 $6.24 7/1/1997 0.00 $6.24 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6235 0 999 Years 0.00 $0.0000 $16.05 7/1/1997 0.00 $16.05 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6236 0 999 Years 0.00 $0.0000 $25.99 7/1/1997 0.00 $25.99 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6237 0 999 Years 0.00 $0.0000 $7.54 7/1/1997 0.00 $7.54 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6238 0 999 Years 0.00 $0.0000 $21.74 7/1/1997 0.00 $21.74 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6239 0 999 Years 0.00 $0.0000 $13.27 7/1/2011 0.00 $13.27 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6240 0 999 Years 0.00 $0.0000 $11.68 7/1/1997 0.00 $11.68 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6241 0 999 Years 0.00 $0.0000 $2.45 7/1/1997 0.00 $2.45 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6242 0 999 Years 0.00 $0.0000 $5.79 7/1/1997 0.00 $5.79 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6243 0 999 Years 0.00 $0.0000 $11.75 7/1/1997 0.00 $11.75 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6244 0 999 Years 0.00 $0.0000 $37.46 7/1/1997 0.00 $37.46 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6245 0 999 Years 0.00 $0.0000 $6.93 7/1/1997 0.00 $6.93 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6246 0 999 Years 0.00 $0.0000 $9.46 7/1/1997 0.00 $9.46 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6247 0 999 Years 0.00 $0.0000 $22.68 7/1/1997 0.00 $22.68 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6248 0 999 Years 0.00 $0.0000 $15.49 7/1/1997 0.00 $15.49 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES A6250 0 999 Years 0.00 $0.0000 $5.16 1/1/2012 0.00 $5.16 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6250 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6250 UA 0 999 Years 0.00 $0.0000 $5.16 1/1/2012 0.00 $5.16 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6251 0 999 Years 0.00 $0.0000 $1.90 7/1/1997 0.00 $1.90 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6252 0 999 Years 0.00 $0.0000 $3.10 7/1/1997 0.00 $3.10 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6253 0 999 Years 0.00 $0.0000 $6.05 7/1/1997 0.00 $6.05 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6254 0 999 Years 0.00 $0.0000 $1.16 7/1/1997 0.00 $1.16 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6255 0 999 Years 0.00 $0.0000 $2.89 7/1/1997 0.00 $2.89 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6256 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6257 0 999 Years 0.00 $0.0000 $1.46 7/1/1997 0.00 $1.46 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6258 0 999 Years 0.00 $0.0000 $4.10 7/1/1997 0.00 $4.10 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6259 0 999 Years 0.00 $0.0000 $10.43 7/1/1997 0.00 $10.43 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6260 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6261 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6262 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6266 0 999 Years 0.00 $0.0000 $1.83 7/1/1997 0.00 $1.83 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6402 0 999 Years 0.00 $0.0000 $0.12 7/1/1997 0.00 $0.12 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6403 0 999 Years 0.00 $0.0000 $0.41 7/1/1997 0.00 $0.41 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6404 0 999 Years 0.00 $0.0000 $0.56 7/1/2011 0.00 $0.56 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6407 0 999 Years 0.00 $0.0000 $1.88 7/1/2004 0.00 $1.88 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6410 0 999 Years 0.00 $0.0000 $0.34 5/1/2003 0.00 $0.34 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6411 0 999 Years 0.00 $0.0000 $0.31 7/1/2011 0.00 $0.31 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6412 0 999 Years 0.00 $0.0000 $0.40 7/1/2011 0.00 $0.40 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6441 0 999 Years 0.00 $0.0000 $0.67 7/1/2004 0.00 $0.67 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6442 0 999 Years 0.00 $0.0000 $0.17 7/1/2004 0.00 $0.17 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6443 0 999 Years 0.00 $0.0000 $0.29 7/1/2004 0.00 $0.29 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6444 0 999 Years 0.00 $0.0000 $0.56 7/1/2004 0.00 $0.56 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6445 0 999 Years 0.00 $0.0000 $0.32 7/1/2004 0.00 $0.32 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6446 0 999 Years 0.00 $0.0000 $0.41 7/1/2004 0.00 $0.41 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6447 0 999 Years 0.00 $0.0000 $0.67 7/1/2004 0.00 $0.67 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6448 0 999 Years 0.00 $0.0000 $1.16 7/1/2004 0.00 $1.16 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6449 0 999 Years 0.00 $0.0000 $1.75 7/1/2004 0.00 $1.75 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6450 0 999 Years 0.00 $0.0000 $5.52 1/1/2015 0.00 $5.52 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6451 0 999 Years 0.00 $0.0000 $3.65 1/1/2015 0.00 $3.65 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6452 0 999 Years 0.00 $0.0000 $4.72 7/1/2004 0.00 $4.72 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6453 0 999 Years 0.00 $0.0000 $0.61 7/1/2004 0.00 $0.61 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6454 0 999 Years 0.00 $0.0000 $0.70 7/1/2004 0.00 $0.70 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6455 0 999 Years 0.00 $0.0000 $0.77 1/1/2015 0.00 $0.77 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6456 0 999 Years 0.00 $0.0000 $1.14 7/1/2004 0.00 $1.14 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6457 0 999 Years 0.00 $0.0000 $1.14 1/1/2006 0.00 $1.14 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6501 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6502 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6503 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6504 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6505 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6506 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6507 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6508 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6509 0 999 Years 0.00 $0.0000 $0.00 7/1/2011 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6510 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6511 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6512 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6513 0 999 Years 0.00 $0.0000 $0.00 1/1/2006 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6530 0 999 Years 0.00 $0.0000 $37.54 1/1/2015 0.00 $37.54 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6531 0 999 Years 0.00 $0.0000 $43.27 1/1/2006 0.00 $43.27 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6532 0 999 Years 0.00 $0.0000 $60.96 1/1/2006 0.00 $60.96 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6533 0 999 Years 0.00 $0.0000 $49.00 1/1/2015 0.00 $49.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6534 0 999 Years 0.00 $0.0000 $57.96 1/1/2015 0.00 $57.96 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6535 0 999 Years 0.00 $0.0000 $82.80 1/1/2015 0.00 $82.80 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6536 0 999 Years 0.00 $0.0000 $55.20 1/1/2015 0.00 $55.20 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6537 0 999 Years 0.00 $0.0000 $69.00 1/1/2015 0.00 $69.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6538 0 999 Years 0.00 $0.0000 $82.80 1/1/2015 0.00 $82.80 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6539 0 999 Years 0.00 $0.0000 $75.82 1/1/2015 0.00 $75.82 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6540 0 999 Years 0.00 $0.0000 $86.78 1/1/2015 0.00 $86.78 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6541 0 999 Years 0.00 $0.0000 $112.70 1/1/2015 0.00 $112.70 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6544 0 999 Years 0.00 $0.0000 $38.12 1/1/2015 0.00 $38.12 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6545 AW 0 999 Years 0.00 $0.0000 $65.84 1/1/2015 0.00 $65.84 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6549 0 999 Years 0.00 $0.0000 $0.00 1/1/2006 $0.00 5 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A6550 0 999 Years 0.00 $0.0000 $24.82 7/1/2011 0.00 $24.82 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7000 0 999 Years 0.00 $0.0000 $8.24 7/1/2011 0.00 $8.24 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7002 0 999 Years 0.00 $0.0000 $3.10 2/1/2000 0.00 $3.10 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7003 0 999 Years 0.00 $0.0000 $2.48 2/1/2000 0.00 $2.48 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7004 0 999 Years 0.00 $0.0000 $1.46 2/1/2000 0.00 $1.46 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7005 0 999 Years 0.00 $0.0000 $26.21 2/1/2008 -8.00 $24.11 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7006 0 999 Years 0.00 $0.0000 $9.05 2/1/2000 0.00 $9.05 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7007 0 999 Years 0.00 $0.0000 $3.96 2/1/2000 0.00 $3.96 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7009 0 999 Years 0.00 $0.0000 $37.24 2/1/2000 0.00 $37.24 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7010 0 999 Years 0.00 $0.0000 $20.05 2/1/2008 0.00 $20.05 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7012 0 999 Years 0.00 $0.0000 $3.60 2/1/2008 0.00 $3.60 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7013 0 999 Years 0.00 $0.0000 $0.67 2/1/2000 0.00 $0.67 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7014 0 999 Years 0.00 $0.0000 $4.13 2/1/2000 0.00 $4.13 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7015 0 999 Years 0.00 $0.0000 $1.79 2/1/2000 0.00 $1.79 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7016 0 999 Years 0.00 $0.0000 $6.22 2/1/2000 0.00 $6.22 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7017 0 999 Years 0.00 $0.0000 $134.04 2/1/2008 0.00 $134.04 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7018 0 999 Years 0.00 $0.0000 $0.31 4/1/2001 0.00 $0.31 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7026 0 999 Years 0.00 $0.0000 $30.19 7/1/2011 0.00 $30.19 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7027 0 999 Years 0.00 $0.0000 $179.35 1/1/2008 0.00 $179.35 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7028 0 999 Years 0.00 $0.0000 $49.54 1/1/2008 0.00 $49.54 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7029 0 999 Years 0.00 $0.0000 $20.24 1/1/2008 0.00 $20.24 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7030 0 999 Years 0.00 $0.0000 $170.72 7/1/2011 0.00 $170.72 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7031 0 999 Years 0.00 $0.0000 $63.14 7/1/2011 0.00 $63.14 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7032 0 999 Years 0.00 $0.0000 $36.68 7/1/2011 0.00 $36.68 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7033 0 999 Years 0.00 $0.0000 $25.71 7/1/2011 0.00 $25.71 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7034 0 999 Years 0.00 $0.0000 $55.44 1/1/2015 0.00 $55.44 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7035 0 999 Years 0.00 $0.0000 $27.00 5/1/2003 0.00 $27.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7037 0 999 Years 0.00 $0.0000 $18.07 1/1/2015 0.00 $18.07 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7038 0 999 Years 0.00 $0.0000 $4.50 5/1/2003 0.00 $4.50 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7039 0 999 Years 0.00 $0.0000 $11.79 7/1/2011 0.00 $11.79 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7046 0 20 Years 0.00 $0.0000 $17.66 7/1/2011 0.00 $17.66 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7520 0 999 Years 0.00 $0.0000 $45.01 7/1/2004 0.00 $45.01 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7520 TF 0 999 Years 0.00 $0.0000 $104.86 1/1/2015 0.00 $104.86 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7520 TG 0 999 Years 0.00 $0.0000 $0.00 7/1/2004 $0.00 5 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7521 0 999 Years 0.00 $0.0000 $45.01 7/1/2004 0.00 $45.01 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7521 TF 0 999 Years 0.00 $0.0000 $104.86 1/1/2015 0.00 $104.86 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7521 TG 0 999 Years 0.00 $0.0000 $0.00 7/1/2004 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7522 0 999 Years 0.00 $0.0000 $45.01 7/1/2004 0.00 $45.01 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7523 0 999 Years 0.00 $0.0000 $11.78 7/1/2011 0.00 $11.78 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7525 0 999 Years 0.00 $0.0000 $1.40 7/1/2004 0.00 $1.40 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A7526 0 999 Years 0.00 $0.0000 $1.85 1/1/2015 0.00 $1.85 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A8000 0 999 Years 0.00 $0.0000 $153.35 1/1/2007 0.00 $153.35 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A8001 0 999 Years 0.00 $0.0000 $153.35 1/1/2007 0.00 $153.35 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A8002 0 20 Years 0.00 $0.0000 $354.58 1/1/2015 0.00 $354.58 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A8003 0 20 Years 0.00 $0.0000 $537.05 1/1/2015 0.00 $537.05 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A8004 0 999 Years 0.00 $0.0000 $90.00 7/1/2011 0.00 $90.00 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A9272 0 999 Years 0.00 $0.0000 $265.91 1/1/2015 0.00 $265.91 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A9273 0 999 Years 0.00 $0.0000 $0.00 1/1/2011 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A9274 0 20 Years 0.00 $0.0000 $43.50 7/1/2011 0.00 $43.50 6 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A9275 0 999 Years 0.00 $0.0000 $28.28 7/1/2013 0.00 $28.28 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A9284 0 999 Years 0.00 $0.0000 $12.49 1/1/2009 0.00 $12.49 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES A9900 0 999 Years 0.00 $0.0000 $0.00 2/1/2000 $0.00 5 8/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4034 0 999 Years 0.00 $0.0000 $6.11 1/1/2014 0.00 $6.11 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4035 0 999 Years 0.00 $0.0000 $11.65 1/1/2014 0.00 $11.65 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4036 0 999 Years 0.00 $0.0000 $8.00 1/1/2014 0.00 $8.00 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4081 0 999 Years 0.00 $0.0000 $21.61 1/1/2014 0.00 $21.61 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4082 0 999 Years 0.00 $0.0000 $16.07 1/1/2014 0.00 $16.07 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4083 0 999 Years 0.00 $0.0000 $2.47 1/1/2014 0.00 $2.47 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4087 0 999 Years 0.00 $0.0000 $35.67 1/1/2014 0.00 $35.67 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4088 0 999 Years 0.00 $0.0000 $35.67 1/1/2014 0.00 $35.67 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4100 0 999 Years 0.00 $0.0000 $0.72 1/1/2016 0.00 $0.72 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4103 0 20 Years 0.00 $0.0000 $3.23 1/1/2016 0.00 $3.23 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4104 0 999 Years 0.00 $0.0000 $0.00 10/1/2010 -8.00 $0.00 5 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4149 0 999 Years 0.00 $0.0000 $1.57 1/1/2014 0.00 $1.57 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4150 0 999 Years 0.00 $0.0000 $1.05 1/1/2016 0.00 $1.05 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4152 0 999 Years 0.00 $0.0000 $0.93 1/1/2016 0.00 $0.93 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4153 0 999 Years 0.00 $0.0000 $4.23 1/1/2016 0.00 $4.23 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4154 0 999 Years 0.00 $0.0000 $2.78 1/1/2016 0.00 $2.78 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4155 0 999 Years 0.00 $0.0000 $6.18 1/1/2016 0.00 $6.18 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4157 0 999 Years 0.00 $0.0000 $5.95 1/1/2016 0.00 $5.95 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4158 0 20 Years 0.00 $0.0000 $1.30 1/1/2016 0.00 $1.30 6 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4159 0 20 Years 0.00 $0.0000 $1.27 1/1/2016 0.00 $1.27 6 1/1/2014
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4160 0 20 Years 0.00 $0.0000 $1.11 1/1/2014 0.00 $1.11 6 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4161 0 20 Years 0.00 $0.0000 $2.93 1/1/2014 0.00 $2.93 6 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4162 0 20 Years 0.00 $0.0000 $8.82 3/1/2012 0.00 $8.82 6 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4164 0 999 Years 0.00 $0.0000 $19.10 1/1/2014 0.00 $19.10 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4168 0 999 Years 0.00 $0.0000 $27.85 1/1/2014 0.00 $27.85 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4172 0 999 Years 0.00 $0.0000 $28.06 1/1/2014 0.00 $28.06 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4176 0 999 Years 0.00 $0.0000 $53.89 1/1/2014 0.00 $53.89 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4178 0 999 Years 0.00 $0.0000 $64.69 1/1/2014 0.00 $64.69 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4180 0 999 Years 0.00 $0.0000 $27.42 1/1/2014 0.00 $27.42 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4185 0 999 Years 0.00 $0.0000 $12.63 1/1/2014 0.00 $12.63 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4189 0 999 Years 0.00 $0.0000 $199.85 1/1/2014 0.00 $199.85 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4193 0 999 Years 0.00 $0.0000 $258.24 1/1/2014 0.00 $258.24 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4197 0 999 Years 0.00 $0.0000 $314.40 1/1/2014 0.00 $314.40 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4199 0 999 Years 0.00 $0.0000 $359.25 1/1/2014 0.00 $359.25 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4216 0 999 Years 0.00 $0.0000 $8.68 1/1/2014 0.00 $8.68 6 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4220 0 999 Years 0.00 $0.0000 $9.00 1/1/2014 0.00 $9.00 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4222 0 999 Years 0.00 $0.0000 $11.10 1/1/2014 0.00 $11.10 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B4224 0 999 Years 0.00 $0.0000 $28.11 1/1/2014 0.00 $28.11 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B5000 0 999 Years 0.00 $0.0000 $13.37 1/1/2014 0.00 $13.37 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B5100 0 999 Years 0.00 $0.0000 $5.22 1/1/2014 0.00 $5.22 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B5200 0 999 Years 0.00 $0.0000 $3.04 1/1/2016 0.00 $3.04 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 0 999 Years 0.00 $0.0000 $0.00 1/1/2010 $0.00 5 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 U1 0 999 Years 0.00 $0.0000 $6.34 1/1/2016 0.00 $6.34 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 U2 0 999 Years 0.00 $0.0000 $138.00 1/1/2014 0.00 $138.00 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 U3 0 999 Years 0.00 $0.0000 $20.70 1/1/2016 0.00 $20.70 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 U4 0 999 Years 0.00 $0.0000 $28.98 1/1/2016 0.00 $28.98 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B9998 U5 0 999 Years 0.00 $0.0000 $2.76 1/1/2014 0.00 $2.76 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES B9999 0 999 Years 0.00 $0.0000 $0.00 10/1/2010 -8.00 $0.00 5 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES C1883 0 999 Years 0.00 $0.0000 $733.90 7/1/2015 0.00 $733.90 7/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES C1897 0 999 Years 0.00 $0.0000 $1,336.60 7/1/2015 0.00 $1,336.60 7/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES E0350 0 20 Years 0.00 $0.0000 $0.00 4/1/1995 $0.00 5 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES E0352 0 20 Years 0.00 $0.0000 $56.25 4/1/2013 0.00 $56.25 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES K0552 0 999 Years 0.00 $0.0000 $2.74 4/1/2010 -8.00 $2.52 11/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES K0601 0 999 Years 0.00 $0.0000 $1.16 4/1/2010 -8.00 $1.07 11/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES K0602 0 999 Years 0.00 $0.0000 $6.67 10/1/2011 -8.00 $6.14 11/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES K0603 0 999 Years 0.00 $0.0000 $0.60 4/1/2010 -8.00 $0.55 11/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES K0604 0 999 Years 0.00 $0.0000 $6.38 10/1/2011 -8.00 $5.87 11/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES K0605 0 999 Years 0.00 $0.0000 $15.31 10/1/2011 -8.00 $14.09 11/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES K0607 U1 1 20 Years 0.00 $0.0000 $152.80 10/1/2011 -8.00 $140.58 6 11/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES K0609 U2 1 20 Years 0.00 $0.0000 $704.78 1/1/2011 -8.00 $648.40 6 11/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES K0672 0 20 Years 0.00 $0.0000 $70.02 4/1/2008 -8.00 $64.42 0.00 $0.0000 $70.02 4/1/2008 -8.00 $64.42 11/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES K0739 0 999 Years 0.00 $0.0000 $13.08 3/1/2012 0.00 $13.08 11/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0112 0 20 Years 0.00 $0.0000 $1,132.77 5/1/2005 0.00 $1,132.77 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0113 0 20 Years 0.00 $0.0000 $259.61 7/1/2010 0.00 $259.61 0.00 $0.0000 $259.61 7/1/2010 0.00 $259.61 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0120 0 20 Years 0.00 $0.0000 $16.23 2/1/1993 0.00 $16.23 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0130 0 20 Years 0.00 $0.0000 $101.68 2/1/1993 0.00 $101.68 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0140 0 20 Years 0.00 $0.0000 $45.96 4/1/1992 0.00 $45.96 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0150 0 20 Years 0.00 $0.0000 $66.89 2/1/1993 0.00 $66.89 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0160 0 20 Years 0.00 $0.0000 $133.23 2/1/1993 0.00 $133.23 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0170 0 20 Years 0.00 $0.0000 $432.04 4/1/1992 0.00 $432.04 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0172 0 20 Years 0.00 $0.0000 $88.56 4/1/1992 0.00 $88.56 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0174 0 20 Years 0.00 $0.0000 $159.67 4/1/1992 0.00 $159.67 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0180 0 20 Years 0.00 $0.0000 $253.21 4/1/1992 0.00 $253.21 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0190 0 20 Years 0.00 $0.0000 $325.78 4/1/1992 0.00 $325.78 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0200 0 20 Years 0.00 $0.0000 $374.83 4/1/1992 0.00 $374.83 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0220 0 20 Years 0.00 $0.0000 $103.23 2/1/1993 0.00 $103.23 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0450 0 20 Years 0.00 $0.0000 $130.83 6/1/2003 0.00 $130.83 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0452 0 20 Years 0.00 $0.0000 $263.81 6/1/2003 0.00 $263.81 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0454 0 20 Years 0.00 $0.0000 $275.12 6/1/2003 0.00 $275.12 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0456 0 20 Years 0.00 $0.0000 $476.61 10/1/2016 0.00 $476.61 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0458 0 20 Years 0.00 $0.0000 $661.15 6/1/2003 0.00 $661.15 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0460 0 20 Years 0.00 $0.0000 $661.15 6/1/2003 0.00 $661.15 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0462 0 20 Years 0.00 $0.0000 $661.15 5/1/2003 0.00 $661.15 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0464 0 20 Years 0.00 $0.0000 $712.30 10/1/2016 0.00 $712.30 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0466 0 20 Years 0.00 $0.0000 $322.23 5/1/2003 0.00 $322.23 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0468 0 20 Years 0.00 $0.0000 $373.07 5/1/2003 0.00 $373.07 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0470 0 20 Years 0.00 $0.0000 $479.92 5/1/2003 0.00 $479.92 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0472 0 20 Years 0.00 $0.0000 $335.00 6/1/2003 0.00 $335.00 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0480 0 20 Years 0.00 $0.0000 $1,154.28 6/1/2003 0.00 $1,154.28 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0482 0 20 Years 0.00 $0.0000 $1,167.31 6/1/2003 0.00 $1,167.31 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0484 0 20 Years 0.00 $0.0000 $1,337.75 6/1/2003 0.00 $1,337.75 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0486 0 20 Years 0.00 $0.0000 $1,443.52 6/1/2003 0.00 $1,443.52 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0488 0 20 Years 0.00 $0.0000 $913.78 7/1/2010 0.00 $913.78 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0490 0 20 Years 0.00 $0.0000 $257.49 7/1/2010 0.00 $257.49 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0491 0 20 Years 0.00 $0.0000 $621.58 1/1/2006 0.00 $621.58 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0492 0 20 Years 0.00 $0.0000 $402.85 1/1/2006 0.00 $402.85 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0621 0 20 Years 0.00 $0.0000 $75.19 1/1/2006 0.00 $75.19 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0622 0 20 Years 0.00 $0.0000 $194.97 1/1/2006 0.00 $194.97 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0623 0 20 Years 0.00 $0.0000 $197.00 7/1/2010 0.00 $197.00 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0624 0 20 Years 0.00 $0.0000 $0.00 1/1/2006 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0625 0 20 Years 0.00 $0.0000 $44.59 1/1/2006 0.00 $44.59 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0626 0 20 Years 0.00 $0.0000 $63.09 1/1/2006 0.00 $63.09 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0627 0 20 Years 0.00 $0.0000 $332.68 1/1/2006 0.00 $332.68 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0628 0 20 Years 0.00 $0.0000 $67.89 1/1/2006 0.00 $67.89 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0629 0 20 Years 0.00 $0.0000 $172.21 10/1/2012 0.00 $172.21 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0630 0 20 Years 0.00 $0.0000 $131.06 1/1/2006 0.00 $131.06 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0631 0 20 Years 0.00 $0.0000 $830.85 1/1/2006 0.00 $830.85 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0632 0 20 Years 0.00 $0.0000 $648.98 7/1/2010 0.00 $648.98 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0633 0 20 Years 0.00 $0.0000 $232.08 1/1/2006 0.00 $232.08 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0634 0 20 Years 0.00 $0.0000 $368.90 10/1/2014 0.00 $368.90 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0635 0 20 Years 0.00 $0.0000 $800.80 1/1/2006 0.00 $800.80 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0636 0 20 Years 0.00 $0.0000 $1,085.59 1/1/2006 0.00 $1,085.59 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0637 0 20 Years 0.00 $0.0000 $844.89 1/1/2006 0.00 $844.89 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0638 0 20 Years 0.00 $0.0000 $1,067.44 1/1/2006 0.00 $1,067.44 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0639 0 20 Years 0.00 $0.0000 $648.94 1/1/2006 0.00 $648.94 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0640 0 20 Years 0.00 $0.0000 $846.86 1/1/2006 0.00 $846.86 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0700 0 20 Years 0.00 $0.0000 $1,267.31 4/1/1992 0.00 $1,267.31 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0710 0 20 Years 0.00 $0.0000 $1,374.07 4/1/1992 0.00 $1,374.07 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0810 0 20 Years 0.00 $0.0000 $1,708.01 4/1/1992 0.00 $1,708.01 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0820 0 20 Years 0.00 $0.0000 $1,446.90 4/1/1992 0.00 $1,446.90 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0830 0 20 Years 0.00 $0.0000 $2,198.97 4/1/1992 0.00 $2,198.97 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0859 0 20 Years 0.00 $0.0000 $1,138.35 1/1/2006 0.00 $1,138.35 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0861 0 20 Years 0.00 $0.0000 $174.46 5/1/2005 0.00 $174.46 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0970 0 20 Years 0.00 $0.0000 $100.52 2/1/1993 0.00 $100.52 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0972 0 20 Years 0.00 $0.0000 $91.26 4/1/1992 0.00 $91.26 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0974 0 20 Years 0.00 $0.0000 $123.12 4/1/1992 0.00 $123.12 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0976 0 20 Years 0.00 $0.0000 $124.91 4/1/1992 0.00 $124.91 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0978 0 20 Years 0.00 $0.0000 $125.35 4/1/1992 0.00 $125.35 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0980 0 20 Years 0.00 $0.0000 $15.12 2/1/1993 0.00 $15.12 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0982 0 20 Years 0.00 $0.0000 $18.38 7/1/2010 0.00 $18.38 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0984 0 20 Years 0.00 $0.0000 $39.55 4/1/1994 0.00 $39.55 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L0999 0 20 Years 0.00 $0.0000 $0.00 3/1/1998 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1000 0 20 Years 0.00 $0.0000 $1,401.85 4/1/1992 0.00 $1,401.85 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1001 0 20 Years 0.00 $0.0000 $0.00 7/1/2010 $0.00 5 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1005 0 20 Years 0.00 $0.0000 $2,913.48 7/1/2010 0.00 $2,913.48 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1010 0 20 Years 0.00 $0.0000 $48.92 4/1/1992 0.00 $48.92 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1020 0 20 Years 0.00 $0.0000 $70.61 4/1/1992 0.00 $70.61 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1025 0 20 Years 0.00 $0.0000 $75.04 2/1/1993 0.00 $75.04 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1030 0 20 Years 0.00 $0.0000 $54.07 2/1/1993 0.00 $54.07 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1040 0 20 Years 0.00 $0.0000 $53.81 4/1/1992 0.00 $53.81 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1050 0 20 Years 0.00 $0.0000 $70.25 4/1/1992 0.00 $70.25 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1060 0 20 Years 0.00 $0.0000 $64.37 4/1/1992 0.00 $64.37 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1070 0 20 Years 0.00 $0.0000 $63.21 4/1/1992 0.00 $63.21 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1080 0 20 Years 0.00 $0.0000 $36.59 4/1/1992 0.00 $36.59 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1085 0 20 Years 0.00 $0.0000 $115.21 4/1/1992 0.00 $115.21 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1090 0 20 Years 0.00 $0.0000 $63.31 4/1/1992 0.00 $63.31 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1100 0 20 Years 0.00 $0.0000 $113.45 4/1/1992 0.00 $113.45 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1110 0 20 Years 0.00 $0.0000 $160.05 4/1/1992 0.00 $160.05 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1120 0 20 Years 0.00 $0.0000 $29.34 4/1/1992 0.00 $29.34 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1200 0 20 Years 0.00 $0.0000 $1,093.40 4/1/1992 0.00 $1,093.40 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1210 0 20 Years 0.00 $0.0000 $187.16 4/1/1992 0.00 $187.16 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1220 0 20 Years 0.00 $0.0000 $153.62 4/1/1992 0.00 $153.62 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1230 0 20 Years 0.00 $0.0000 $356.44 4/1/1992 0.00 $356.44 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1240 0 20 Years 0.00 $0.0000 $54.17 4/1/1992 0.00 $54.17 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1250 0 20 Years 0.00 $0.0000 $52.80 4/1/1992 0.00 $52.80 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1260 0 20 Years 0.00 $0.0000 $54.01 4/1/1992 0.00 $54.01 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1270 0 20 Years 0.00 $0.0000 $54.76 4/1/1992 0.00 $54.76 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1280 0 20 Years 0.00 $0.0000 $54.52 4/1/1992 0.00 $54.52 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1290 0 20 Years 0.00 $0.0000 $46.56 4/1/1992 0.00 $46.56 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1300 0 20 Years 0.00 $0.0000 $1,263.59 4/1/1992 0.00 $1,263.59 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1310 0 20 Years 0.00 $0.0000 $1,169.90 4/1/1992 0.00 $1,169.90 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1499 0 20 Years 0.00 $0.0000 $0.00 4/1/1992 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1600 0 20 Years 0.00 $0.0000 $108.27 2/1/1993 0.00 $108.27 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1610 0 20 Years 0.00 $0.0000 $27.71 4/1/1992 0.00 $27.71 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1620 0 20 Years 0.00 $0.0000 $81.01 4/1/1992 0.00 $81.01 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1630 0 20 Years 0.00 $0.0000 $102.31 2/1/1993 0.00 $102.31 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1640 0 20 Years 0.00 $0.0000 $350.48 4/1/1992 0.00 $350.48 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1650 0 20 Years 0.00 $0.0000 $141.06 2/1/1993 0.00 $141.06 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1652 0 20 Years 0.00 $0.0000 $288.51 6/1/2003 0.00 $288.51 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1660 0 20 Years 0.00 $0.0000 $143.87 2/1/1993 0.00 $143.87 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1680 0 20 Years 0.00 $0.0000 $965.59 4/1/1992 0.00 $965.59 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1685 0 20 Years 0.00 $0.0000 $798.83 4/1/1992 0.00 $798.83 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1686 0 20 Years 0.00 $0.0000 $545.87 4/1/1992 0.00 $545.87 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1690 0 20 Years 0.00 $0.0000 $1,463.38 3/1/1999 0.00 $1,463.38 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1700 0 20 Years 0.00 $0.0000 $1,089.85 4/1/1992 0.00 $1,089.85 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1710 0 20 Years 0.00 $0.0000 $1,414.76 4/1/1992 0.00 $1,414.76 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1720 0 20 Years 0.00 $0.0000 $1,086.70 4/1/1992 0.00 $1,086.70 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1730 0 20 Years 0.00 $0.0000 $788.98 4/1/1992 0.00 $788.98 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1755 0 20 Years 0.00 $0.0000 $1,057.74 4/1/1992 0.00 $1,057.74 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1810 0 20 Years 0.00 $0.0000 $72.68 4/1/1992 0.00 $72.68 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1820 0 20 Years 0.00 $0.0000 $93.43 4/1/1992 0.00 $93.43 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1830 0 20 Years 0.00 $0.0000 $53.08 2/1/1993 0.00 $53.08 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1831 0 20 Years 0.00 $0.0000 $238.21 5/1/2005 0.00 $238.21 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1832 0 20 Years 0.00 $0.0000 $359.45 2/1/1993 0.00 $359.45 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1834 0 20 Years 0.00 $0.0000 $458.24 2/1/1993 0.00 $458.24 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1836 0 20 Years 0.00 $0.0000 $107.98 6/1/2003 0.00 $107.98 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1840 0 20 Years 0.00 $0.0000 $651.36 4/1/1992 0.00 $651.36 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1843 0 20 Years 0.00 $0.0000 $637.97 4/1/2015 0.00 $637.97 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1844 0 20 Years 0.00 $0.0000 $1,103.63 4/1/2015 0.00 $1,103.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1845 0 20 Years 0.00 $0.0000 $619.42 4/1/2015 0.00 $619.42 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1846 0 20 Years 0.00 $0.0000 $776.22 4/1/2015 0.00 $776.22 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1847 0 20 Years 0.00 $0.0000 $435.27 3/1/1999 0.00 $435.27 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1850 0 20 Years 0.00 $0.0000 $206.43 4/1/1992 0.00 $206.43 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1860 0 20 Years 0.00 $0.0000 $706.05 4/1/1992 0.00 $706.05 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1900 0 20 Years 0.00 $0.0000 $207.61 4/1/1992 0.00 $207.61 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1902 0 20 Years 0.00 $0.0000 $64.87 4/1/1992 0.00 $64.87 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1904 0 20 Years 0.00 $0.0000 $295.75 4/1/1992 0.00 $295.75 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1906 0 20 Years 0.00 $0.0000 $75.16 4/1/1992 0.00 $75.16 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1907 0 20 Years 0.00 $0.0000 $445.42 5/1/2005 0.00 $445.42 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1910 0 20 Years 0.00 $0.0000 $173.59 4/1/1992 0.00 $173.59 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1920 0 20 Years 0.00 $0.0000 $234.41 4/1/1992 0.00 $234.41 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1930 0 20 Years 0.00 $0.0000 $190.95 4/1/1992 0.00 $190.95 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1932 0 20 Years 0.00 $0.0000 $812.30 7/1/2010 0.00 $812.30 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1940 0 20 Years 0.00 $0.0000 $316.47 4/1/1992 0.00 $316.47 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1945 0 20 Years 0.00 $0.0000 $545.70 2/1/1993 0.00 $545.70 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1950 0 20 Years 0.00 $0.0000 $469.11 2/1/1993 0.00 $469.11 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1951 0 20 Years 0.00 $0.0000 $679.71 5/1/2005 0.00 $679.71 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1960 0 20 Years 0.00 $0.0000 $362.49 4/1/1992 0.00 $362.49 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1970 0 20 Years 0.00 $0.0000 $427.73 2/1/1993 0.00 $427.73 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1971 0 20 Years 0.00 $0.0000 $379.96 5/1/2005 0.00 $379.96 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1980 0 20 Years 0.00 $0.0000 $233.80 4/1/1992 0.00 $233.80 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L1990 0 20 Years 0.00 $0.0000 $306.84 4/1/1992 0.00 $306.84 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2000 0 20 Years 0.00 $0.0000 $652.40 4/1/1992 0.00 $652.40 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2005 0 20 Years 0.00 $0.0000 $3,730.06 7/1/2010 0.00 $3,730.06 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2010 0 20 Years 0.00 $0.0000 $623.27 4/1/1992 0.00 $623.27 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2020 0 20 Years 0.00 $0.0000 $746.78 4/1/1992 0.00 $746.78 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2030 0 20 Years 0.00 $0.0000 $657.28 4/1/1992 0.00 $657.28 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2034 0 20 Years 0.00 $0.0000 $1,006.31 10/1/2016 0.00 $1,006.31 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2035 0 20 Years 0.00 $0.0000 $157.70 7/1/2010 0.00 $157.70 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2036 0 20 Years 0.00 $0.0000 $1,168.65 4/1/1992 0.00 $1,168.65 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2037 0 20 Years 0.00 $0.0000 $997.41 2/1/1993 0.00 $997.41 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2038 0 20 Years 0.00 $0.0000 $861.39 2/1/1993 0.00 $861.39 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2040 0 20 Years 0.00 $0.0000 $102.63 4/1/1992 0.00 $102.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2050 0 20 Years 0.00 $0.0000 $359.39 4/1/1992 0.00 $359.39 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2060 0 20 Years 0.00 $0.0000 $410.81 4/1/1992 0.00 $410.81 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2070 0 20 Years 0.00 $0.0000 $85.68 4/1/1992 0.00 $85.68 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2080 0 20 Years 0.00 $0.0000 $224.80 4/1/1992 0.00 $224.80 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2090 0 20 Years 0.00 $0.0000 $278.67 4/1/1992 0.00 $278.67 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2106 0 20 Years 0.00 $0.0000 $493.86 4/1/1992 0.00 $493.86 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2108 0 20 Years 0.00 $0.0000 $718.65 4/1/1992 0.00 $718.65 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2112 0 20 Years 0.00 $0.0000 $358.72 4/1/1992 0.00 $358.72 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2114 0 20 Years 0.00 $0.0000 $423.09 4/1/1992 0.00 $423.09 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2116 0 20 Years 0.00 $0.0000 $483.40 4/1/1992 0.00 $483.40 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2126 0 20 Years 0.00 $0.0000 $810.38 4/1/1992 0.00 $810.38 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2128 0 20 Years 0.00 $0.0000 $1,067.39 4/1/1992 0.00 $1,067.39 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2132 0 20 Years 0.00 $0.0000 $554.14 4/1/1992 0.00 $554.14 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2134 0 20 Years 0.00 $0.0000 $704.90 4/1/1992 0.00 $704.90 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2136 0 20 Years 0.00 $0.0000 $807.30 4/1/1992 0.00 $807.30 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2180 0 20 Years 0.00 $0.0000 $72.02 2/1/1993 0.00 $72.02 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2182 0 20 Years 0.00 $0.0000 $65.92 4/1/1992 0.00 $65.92 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2184 0 20 Years 0.00 $0.0000 $83.29 4/1/1992 0.00 $83.29 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2186 0 20 Years 0.00 $0.0000 $90.84 2/1/1993 0.00 $90.84 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2188 0 20 Years 0.00 $0.0000 $223.40 4/1/1992 0.00 $223.40 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2190 0 20 Years 0.00 $0.0000 $59.72 4/1/1992 0.00 $59.72 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2192 0 20 Years 0.00 $0.0000 $248.54 4/1/1992 0.00 $248.54 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2200 0 20 Years 0.00 $0.0000 $42.89 2/1/1993 0.00 $42.89 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2210 0 20 Years 0.00 $0.0000 $39.01 2/1/1993 0.00 $39.01 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2220 0 20 Years 0.00 $0.0000 $54.26 4/1/1992 0.00 $54.26 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2230 0 20 Years 0.00 $0.0000 $51.39 4/1/1992 0.00 $51.39 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2232 0 20 Years 0.00 $0.0000 $87.95 7/1/2010 0.00 $87.95 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2240 0 20 Years 0.00 $0.0000 $54.17 4/1/1992 0.00 $54.17 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2250 0 20 Years 0.00 $0.0000 $214.36 2/1/1993 0.00 $214.36 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2260 0 20 Years 0.00 $0.0000 $131.16 4/1/1992 0.00 $131.16 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2265 0 20 Years 0.00 $0.0000 $81.13 4/1/1992 0.00 $81.13 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2270 0 20 Years 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2275 0 20 Years 0.00 $0.0000 $85.14 4/1/1994 0.00 $85.14 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2280 0 20 Years 0.00 $0.0000 $283.17 4/1/1992 0.00 $283.17 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2300 0 20 Years 0.00 $0.0000 $239.35 2/1/1993 0.00 $239.35 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2310 0 20 Years 0.00 $0.0000 $103.81 2/1/1993 0.00 $103.81 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2320 0 20 Years 0.00 $0.0000 $139.77 4/1/1992 0.00 $139.77 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2330 0 20 Years 0.00 $0.0000 $284.59 4/1/1992 0.00 $284.59 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2335 0 20 Years 0.00 $0.0000 $137.32 2/1/1993 0.00 $137.32 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2340 0 20 Years 0.00 $0.0000 $374.49 4/1/1992 0.00 $374.49 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2350 0 20 Years 0.00 $0.0000 $601.46 4/1/1992 0.00 $601.46 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2360 0 20 Years 0.00 $0.0000 $43.78 4/1/1992 0.00 $43.78 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2370 0 20 Years 0.00 $0.0000 $171.90 4/1/1992 0.00 $171.90 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2375 0 20 Years 0.00 $0.0000 $96.10 4/1/1992 0.00 $96.10 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2380 0 20 Years 0.00 $0.0000 $104.33 2/1/1993 0.00 $104.33 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2385 0 20 Years 0.00 $0.0000 $87.90 4/1/1992 0.00 $87.90 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2387 0 20 Years 0.00 $0.0000 $87.90 1/1/2006 0.00 $87.90 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2390 0 20 Years 0.00 $0.0000 $65.06 2/1/1993 0.00 $65.06 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2395 0 20 Years 0.00 $0.0000 $122.70 4/1/1992 0.00 $122.70 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2397 0 20 Years 0.00 $0.0000 $99.23 1/1/2010 0.00 $99.23 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2405 0 20 Years 0.00 $0.0000 $66.64 9/1/2000 0.00 $66.64 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2415 0 20 Years 0.00 $0.0000 $92.84 10/1/2000 0.00 $92.84 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2425 0 20 Years 0.00 $0.0000 $109.55 10/1/2000 0.00 $109.55 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2430 0 20 Years 0.00 $0.0000 $109.55 9/1/2000 0.00 $109.55 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2492 0 20 Years 0.00 $0.0000 $73.30 4/1/1992 0.00 $73.30 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2500 0 20 Years 0.00 $0.0000 $242.91 4/1/1992 0.00 $242.91 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2510 0 20 Years 0.00 $0.0000 $491.32 4/1/1992 0.00 $491.32 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2520 0 20 Years 0.00 $0.0000 $331.94 4/1/1992 0.00 $331.94 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2525 0 20 Years 0.00 $0.0000 $750.58 2/1/1993 0.00 $750.58 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2526 0 20 Years 0.00 $0.0000 $414.12 2/1/1993 0.00 $414.12 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2530 0 20 Years 0.00 $0.0000 $151.28 4/1/1992 0.00 $151.28 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2540 0 20 Years 0.00 $0.0000 $283.40 4/1/1992 0.00 $283.40 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2550 0 20 Years 0.00 $0.0000 $180.22 2/1/1993 0.00 $180.22 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2570 0 20 Years 0.00 $0.0000 $415.75 2/1/1993 0.00 $415.75 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2580 0 20 Years 0.00 $0.0000 $305.28 4/1/1992 0.00 $305.28 6 10/1/2016
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2600 0 20 Years 0.00 $0.0000 $176.50 2/1/1993 0.00 $176.50 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2610 0 20 Years 0.00 $0.0000 $214.62 2/1/1993 0.00 $214.62 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2620 0 20 Years 0.00 $0.0000 $193.04 4/1/1992 0.00 $193.04 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2622 0 20 Years 0.00 $0.0000 $264.02 4/1/1992 0.00 $264.02 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2624 0 20 Years 0.00 $0.0000 $221.86 4/1/1992 0.00 $221.86 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2627 0 20 Years 0.00 $0.0000 $1,066.19 2/1/1993 0.00 $1,066.19 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2628 0 20 Years 0.00 $0.0000 $1,003.25 2/1/1993 0.00 $1,003.25 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2630 0 20 Years 0.00 $0.0000 $169.58 4/1/1992 0.00 $169.58 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2640 0 20 Years 0.00 $0.0000 $222.48 4/1/1992 0.00 $222.48 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2650 0 20 Years 0.00 $0.0000 $89.92 4/1/1992 0.00 $89.92 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2660 0 20 Years 0.00 $0.0000 $153.81 2/1/1993 0.00 $153.81 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2670 0 20 Years 0.00 $0.0000 $145.46 2/1/1993 0.00 $145.46 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2680 0 20 Years 0.00 $0.0000 $134.83 2/1/1993 0.00 $134.83 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2750 0 20 Years 0.00 $0.0000 $70.61 2/1/1993 0.00 $70.61 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2755 0 20 Years 0.00 $0.0000 $96.94 2/1/1997 0.00 $96.94 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2760 0 20 Years 0.00 $0.0000 $53.36 4/1/1992 0.00 $53.36 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2768 0 20 Years 0.00 $0.0000 $118.60 7/1/2010 0.00 $118.60 6 10/1/2016
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2780 0 20 Years 0.00 $0.0000 $39.61 2/1/1993 0.00 $39.61 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2785 0 20 Years 0.00 $0.0000 $19.13 2/1/1993 0.00 $19.13 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2795 0 20 Years 0.00 $0.0000 $67.38 4/1/1992 0.00 $67.38 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2800 0 20 Years 0.00 $0.0000 $70.61 4/1/1992 0.00 $70.61 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2810 0 20 Years 0.00 $0.0000 $54.70 4/1/1992 0.00 $54.70 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2820 0 20 Years 0.00 $0.0000 $52.60 2/1/1993 0.00 $52.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2830 0 20 Years 0.00 $0.0000 $57.67 2/1/1993 0.00 $57.67 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2840 0 20 Years 0.00 $0.0000 $36.79 2/1/1993 0.00 $36.79 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2850 0 20 Years 0.00 $0.0000 $46.09 4/1/1992 0.00 $46.09 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2861 0 20 Years 0.00 $0.0000 $290.28 10/1/2016 0.00 $290.28 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2999 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3000 0 20 Years 0.00 $0.0000 $150.54 10/1/2016 0.00 $150.54 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3001 0 20 Years 0.00 $0.0000 $63.38 10/1/2016 0.00 $63.38 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3002 0 20 Years 0.00 $0.0000 $77.39 10/1/2016 0.00 $77.39 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3003 0 20 Years 0.00 $0.0000 $83.50 10/1/2016 0.00 $83.50 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3010 0 20 Years 0.00 $0.0000 $83.50 10/1/2016 0.00 $83.50 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3020 0 20 Years 0.00 $0.0000 $95.07 10/1/2016 0.00 $95.07 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3030 0 20 Years 0.00 $0.0000 $57.56 4/1/1990 0.00 $57.56 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3031 0 20 Years 0.00 $0.0000 $116.10 10/1/2014 0.00 $116.10 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3040 0 20 Years 0.00 $0.0000 $31.05 4/1/1990 0.00 $31.05 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3050 0 20 Years 0.00 $0.0000 $37.42 4/1/1990 0.00 $37.42 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3060 0 20 Years 0.00 $0.0000 $35.81 4/1/1990 0.00 $35.81 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3070 0 20 Years 0.00 $0.0000 $15.24 10/1/2016 0.00 $15.24 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3080 0 20 Years 0.00 $0.0000 $15.24 10/1/2016 0.00 $15.24 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3090 0 20 Years 0.00 $0.0000 $19.51 10/1/2016 0.00 $19.51 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3100 0 20 Years 0.00 $0.0000 $30.30 4/1/1990 0.00 $30.30 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3140 0 20 Years 0.00 $0.0000 $63.58 4/1/1992 0.00 $63.58 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3150 0 20 Years 0.00 $0.0000 $65.77 10/16/2003 0.00 $65.77 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3160 0 20 Years 0.00 $0.0000 $93.84 10/1/2016 0.00 $93.84 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3170 0 20 Years 0.00 $0.0000 $24.38 10/1/2016 0.00 $24.38 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3201 0 20 Years 0.00 $0.0000 $40.81 10/1/2016 0.00 $40.81 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3202 0 20 Years 0.00 $0.0000 $42.50 10/1/2016 0.00 $42.50 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3203 0 20 Years 0.00 $0.0000 $58.52 10/1/2012 0.00 $58.52 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3204 0 20 Years 0.00 $0.0000 $42.50 10/1/2016 0.00 $42.50 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3206 0 20 Years 0.00 $0.0000 $49.29 10/1/2016 0.00 $49.29 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3207 0 20 Years 0.00 $0.0000 $52.74 10/1/2016 0.00 $52.74 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3208 0 20 Years 0.00 $0.0000 $32.05 10/1/2016 0.00 $32.05 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3209 0 20 Years 0.00 $0.0000 $39.55 10/1/2016 0.00 $39.55 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3211 0 20 Years 0.00 $0.0000 $45.08 10/1/2016 0.00 $45.08 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3212 0 20 Years 0.00 $0.0000 $54.26 10/1/2012 0.00 $54.26 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3213 0 20 Years 0.00 $0.0000 $54.53 10/1/2016 0.00 $54.53 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3214 0 20 Years 0.00 $0.0000 $57.20 10/1/2016 0.00 $57.20 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3215 0 20 Years 0.00 $0.0000 $74.97 7/1/2010 0.00 $74.97 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3216 0 20 Years 0.00 $0.0000 $80.71 10/1/2016 0.00 $80.71 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3217 0 20 Years 0.00 $0.0000 $92.17 10/1/2016 0.00 $92.17 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3219 0 20 Years 0.00 $0.0000 $82.45 10/1/2016 0.00 $82.45 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3221 0 20 Years 0.00 $0.0000 $85.03 10/1/2016 0.00 $85.03 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3222 0 20 Years 0.00 $0.0000 $93.75 10/1/2016 0.00 $93.75 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3224 0 20 Years 0.00 $0.0000 $49.79 7/1/2010 0.00 $49.79 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3225 0 20 Years 0.00 $0.0000 $58.37 7/1/2010 0.00 $58.37 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3230 0 20 Years 0.00 $0.0000 $175.32 10/1/2016 0.00 $175.32 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3250 0 20 Years 0.00 $0.0000 $237.39 10/1/2016 0.00 $237.39 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3251 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3252 0 20 Years 0.00 $0.0000 $137.94 10/1/2014 0.00 $137.94 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3253 0 20 Years 0.00 $0.0000 $68.02 10/1/2016 0.00 $68.02 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3254 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3255 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3257 0 20 Years 0.00 $0.0000 $38.01 10/1/2016 0.00 $38.01 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3260 0 20 Years 0.00 $0.0000 $37.50 10/1/2016 0.00 $37.50 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3265 0 20 Years 0.00 $0.0000 $28.99 10/1/2012 0.00 $28.99 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3300 0 20 Years 0.00 $0.0000 $24.99 10/1/2016 0.00 $24.99 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3310 0 20 Years 0.00 $0.0000 $39.01 10/1/2016 0.00 $39.01 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3320 0 20 Years 0.00 $0.0000 $76.98 10/1/2014 0.00 $76.98 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3330 0 20 Years 0.00 $0.0000 $271.21 10/1/2016 0.00 $271.21 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3332 0 20 Years 0.00 $0.0000 $35.35 10/1/2016 0.00 $35.35 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3334 0 20 Years 0.00 $0.0000 $19.58 4/1/1990 0.00 $19.58 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3340 0 20 Years 0.00 $0.0000 $40.83 10/1/2016 0.00 $40.83 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3350 0 20 Years 0.00 $0.0000 $11.04 4/1/1990 0.00 $11.04 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3360 0 20 Years 0.00 $0.0000 $17.07 10/1/2016 0.00 $17.07 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3370 0 20 Years 0.00 $0.0000 $23.77 10/1/2016 0.00 $23.77 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3380 0 20 Years 0.00 $0.0000 $23.77 10/1/2016 0.00 $23.77 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3390 0 20 Years 0.00 $0.0000 $23.77 10/1/2016 0.00 $23.77 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3400 0 20 Years 0.00 $0.0000 $27.13 4/1/1992 0.00 $27.13 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3410 0 20 Years 0.00 $0.0000 $44.51 10/1/2016 0.00 $44.51 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3420 0 20 Years 0.00 $0.0000 $49.33 4/1/1992 0.00 $49.33 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3430 0 20 Years 0.00 $0.0000 $76.79 10/1/2016 0.00 $76.79 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3440 0 20 Years 0.00 $0.0000 $36.58 10/1/2016 0.00 $36.58 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3450 0 20 Years 0.00 $0.0000 $50.58 10/1/2016 0.00 $50.58 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3455 0 20 Years 0.00 $0.0000 $19.51 10/1/2016 0.00 $19.51 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3460 0 20 Years 0.00 $0.0000 $16.45 10/1/2016 0.00 $16.45 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3465 0 20 Years 0.00 $0.0000 $28.04 10/1/2016 0.00 $28.04 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3470 0 20 Years 0.00 $0.0000 $29.86 10/1/2016 0.00 $29.86 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3480 0 20 Years 0.00 $0.0000 $29.86 10/1/2016 0.00 $29.86 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3485 0 20 Years 0.00 $0.0000 $24.45 10/1/2016 0.00 $24.45 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3500 0 20 Years 0.00 $0.0000 $14.03 10/1/2016 0.00 $14.03 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3510 0 20 Years 0.00 $0.0000 $14.03 10/1/2016 0.00 $14.03 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3520 0 20 Years 0.00 $0.0000 $22.75 4/1/1990 0.00 $22.75 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3530 0 20 Years 0.00 $0.0000 $21.60 4/1/1990 0.00 $21.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3540 0 20 Years 0.00 $0.0000 $28.80 4/1/1990 0.00 $28.80 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3550 0 20 Years 0.00 $0.0000 $4.28 10/1/2016 0.00 $4.28 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3560 0 20 Years 0.00 $0.0000 $10.96 10/1/2016 0.00 $10.96 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3570 0 20 Years 0.00 $0.0000 $40.83 10/1/2016 0.00 $40.83 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3580 0 20 Years 0.00 $0.0000 $31.08 10/1/2016 0.00 $31.08 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3590 0 20 Years 0.00 $0.0000 $25.60 10/1/2016 0.00 $25.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3595 0 20 Years 0.00 $0.0000 $38.19 7/1/2010 0.00 $38.19 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3600 0 20 Years 0.00 $0.0000 $42.36 10/1/2016 0.00 $42.36 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3610 0 20 Years 0.00 $0.0000 $65.56 10/1/2016 0.00 $65.56 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3620 0 20 Years 0.00 $0.0000 $45.38 10/1/2016 0.00 $45.38 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3630 0 20 Years 0.00 $0.0000 $84.15 10/1/2016 0.00 $84.15 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3640 0 20 Years 0.00 $0.0000 $33.72 10/1/2016 0.00 $33.72 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3649 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3650 0 20 Years 0.00 $0.0000 $35.92 2/1/1993 0.00 $35.92 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3660 0 20 Years 0.00 $0.0000 $64.20 2/1/1993 0.00 $64.20 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3670 0 20 Years 0.00 $0.0000 $71.27 4/1/1992 0.00 $71.27 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3671 0 20 Years 0.00 $0.0000 $392.97 10/1/2016 0.00 $392.97 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3674 0 20 Years 0.00 $0.0000 $758.81 1/1/2011 0.00 $758.81 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3675 0 20 Years 0.00 $0.0000 $120.86 3/1/1999 0.00 $120.86 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3677 0 20 Years 0.00 $0.0000 $158.05 10/1/2012 0.00 $158.05 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3702 0 20 Years 0.00 $0.0000 $125.94 10/1/2016 0.00 $125.94 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3710 0 20 Years 0.00 $0.0000 $92.68 4/1/1992 0.00 $92.68 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3720 0 20 Years 0.00 $0.0000 $481.91 4/1/1992 0.00 $481.91 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3730 0 20 Years 0.00 $0.0000 $755.94 4/1/1992 0.00 $755.94 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3740 0 20 Years 0.00 $0.0000 $960.24 4/1/1992 0.00 $960.24 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3760 0 20 Years 0.00 $0.0000 $364.35 4/1/2001 0.00 $364.35 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3762 0 20 Years 0.00 $0.0000 $79.21 6/1/2003 0.00 $79.21 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3763 0 20 Years 0.00 $0.0000 $305.34 10/1/2016 0.00 $305.34 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3764 0 20 Years 0.00 $0.0000 $364.35 1/1/2006 0.00 $364.35 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3765 0 20 Years 0.00 $0.0000 $559.21 10/1/2016 0.00 $559.21 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3766 0 20 Years 0.00 $0.0000 $833.68 1/1/2006 0.00 $833.68 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3806 0 20 Years 0.00 $0.0000 $348.98 1/1/2007 0.00 $348.98 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3807 0 20 Years 0.00 $0.0000 $207.15 7/1/2010 0.00 $207.15 6 0.00 $0.0000 $207.15 7/1/2010 0.00 $207.15 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3808 0 20 Years 0.00 $0.0000 $216.81 1/1/2007 0.00 $216.81 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3891 0 20 Years 0.00 $0.0000 $256.13 10/1/2016 0.00 $256.13 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3900 0 20 Years 0.00 $0.0000 $833.68 4/1/1992 0.00 $833.68 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3901 0 20 Years 0.00 $0.0000 $979.40 4/1/1992 0.00 $979.40 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3904 0 20 Years 0.00 $0.0000 $1,715.16 2/1/1993 0.00 $1,715.16 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3905 0 20 Years 0.00 $0.0000 $821.55 7/1/2010 0.00 $821.55 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3906 0 20 Years 0.00 $0.0000 $247.71 4/1/1992 0.00 $247.71 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3908 0 20 Years 0.00 $0.0000 $38.25 4/1/1992 0.00 $38.25 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3912 0 20 Years 0.00 $0.0000 $73.60 4/1/1992 0.00 $73.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3913 0 20 Years 0.00 $0.0000 $184.18 1/1/2006 0.00 $184.18 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3915 0 20 Years 0.00 $0.0000 $408.38 1/1/2007 0.00 $408.38 0.00 $0.0000 $408.38 1/1/2007 0.00 $408.38 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3917 0 20 Years 0.00 $0.0000 $77.79 5/1/2005 0.00 $77.79 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3919 0 20 Years 0.00 $0.0000 $184.18 1/1/2006 0.00 $184.18 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3921 0 20 Years 0.00 $0.0000 $184.18 1/1/2006 0.00 $184.18 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3923 0 20 Years 0.00 $0.0000 $37.94 10/1/2016 0.00 $37.94 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3925 0 20 Years 0.00 $0.0000 $32.68 1/1/2008 0.00 $32.68 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3927 0 20 Years 0.00 $0.0000 $28.99 7/1/2010 0.00 $28.99 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3929 0 20 Years 0.00 $0.0000 $64.25 1/1/2008 0.00 $64.25 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3931 0 20 Years 0.00 $0.0000 $118.54 1/1/2008 0.00 $118.54 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3933 0 20 Years 0.00 $0.0000 $93.06 10/1/2016 0.00 $93.06 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3935 0 20 Years 0.00 $0.0000 $96.37 10/1/2016 0.00 $96.37 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3956 0 20 Years 0.00 $0.0000 $120.00 10/1/2012 0.00 $120.00 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3960 0 20 Years 0.00 $0.0000 $580.17 4/1/1992 0.00 $580.17 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3961 0 20 Years 0.00 $0.0000 $732.73 10/1/2016 0.00 $732.73 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3962 0 20 Years 0.00 $0.0000 $417.08 4/1/1992 0.00 $417.08 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3967 0 20 Years 0.00 $0.0000 $865.12 10/1/2016 0.00 $865.12 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3971 0 20 Years 0.00 $0.0000 $959.63 1/1/2006 0.00 $959.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3973 0 20 Years 0.00 $0.0000 $959.63 1/1/2006 0.00 $959.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3975 0 20 Years 0.00 $0.0000 $732.73 10/1/2016 0.00 $732.73 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3976 0 20 Years 0.00 $0.0000 $732.73 10/1/2016 0.00 $732.73 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3977 0 20 Years 0.00 $0.0000 $959.63 1/1/2006 0.00 $959.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3978 0 20 Years 0.00 $0.0000 $959.63 1/1/2006 0.00 $959.63 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3980 0 20 Years 0.00 $0.0000 $241.80 4/1/1992 0.00 $241.80 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3982 0 20 Years 0.00 $0.0000 $244.05 4/1/1992 0.00 $244.05 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3984 0 20 Years 0.00 $0.0000 $219.92 4/1/1992 0.00 $219.92 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3995 0 20 Years 0.00 $0.0000 $35.33 7/1/2010 0.00 $35.33 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L3999 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4000 0 20 Years 0.00 $0.0000 $761.56 10/1/2016 0.00 $761.56 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4002 0 20 Years 0.00 $0.0000 $21.25 10/1/2016 0.00 $21.25 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4010 0 20 Years 0.00 $0.0000 $427.04 10/1/2016 0.00 $427.04 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4020 0 20 Years 0.00 $0.0000 $483.00 10/1/2016 0.00 $483.00 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4030 0 20 Years 0.00 $0.0000 $293.52 10/1/2016 0.00 $293.52 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4040 0 20 Years 0.00 $0.0000 $191.30 10/1/2016 0.00 $191.30 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4045 0 20 Years 0.00 $0.0000 $146.21 10/1/2016 0.00 $146.21 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4050 0 20 Years 0.00 $0.0000 $184.01 10/1/2016 0.00 $184.01 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4055 0 20 Years 0.00 $0.0000 $121.38 10/1/2016 0.00 $121.38 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4060 0 20 Years 0.00 $0.0000 $195.60 2/1/1993 0.00 $195.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4070 0 20 Years 0.00 $0.0000 $224.97 10/1/2016 0.00 $224.97 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4080 0 20 Years 0.00 $0.0000 $56.89 10/1/2016 0.00 $56.89 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4090 0 20 Years 0.00 $0.0000 $69.75 10/1/2016 0.00 $69.75 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4100 0 20 Years 0.00 $0.0000 $69.40 4/1/1992 0.00 $69.40 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4110 0 20 Years 0.00 $0.0000 $54.60 10/1/2016 0.00 $54.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4130 0 20 Years 0.00 $0.0000 $378.33 4/1/1992 0.00 $378.33 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4205 0 20 Years 0.00 $0.0000 $28.00 7/1/2014 0.00 $28.00 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4210 0 20 Years 0.00 $0.0000 $59.00 10/1/2012 0.00 $59.00 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4350 0 20 Years 0.00 $0.0000 $53.78 2/1/1993 0.00 $53.78 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4360 0 20 Years 0.00 $0.0000 $162.84 2/1/1993 0.00 $162.84 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4370 0 20 Years 0.00 $0.0000 $113.23 2/1/1993 0.00 $113.23 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4386 0 20 Years 0.00 $0.0000 $128.33 6/1/2003 0.00 $128.33 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4392 0 20 Years 0.00 $0.0000 $17.46 2/1/1997 0.00 $17.46 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4394 0 20 Years 0.00 $0.0000 $14.45 10/1/2016 0.00 $14.45 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4396 0 20 Years 0.00 $0.0000 $124.50 2/1/1997 0.00 $124.50 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4398 0 20 Years 0.00 $0.0000 $57.31 2/1/1997 0.00 $57.31 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L4631 0 20 Years 0.00 $0.0000 $1,377.40 10/1/2012 0.00 $1,377.40 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5000 0 20 Years 0.00 $0.0000 $456.50 4/1/1992 0.00 $456.50 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5010 0 20 Years 0.00 $0.0000 $1,030.91 4/1/1992 0.00 $1,030.91 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5020 0 20 Years 0.00 $0.0000 $1,453.68 4/1/1992 0.00 $1,453.68 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5050 0 20 Years 0.00 $0.0000 $1,834.75 4/1/1992 0.00 $1,834.75 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5060 0 20 Years 0.00 $0.0000 $2,203.30 4/1/1992 0.00 $2,203.30 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5100 0 20 Years 0.00 $0.0000 $2,041.52 4/1/1992 0.00 $2,041.52 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5105 0 20 Years 0.00 $0.0000 $2,399.36 4/1/1992 0.00 $2,399.36 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5150 0 20 Years 0.00 $0.0000 $2,753.18 4/1/1992 0.00 $2,753.18 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5160 0 20 Years 0.00 $0.0000 $2,864.71 4/1/1992 0.00 $2,864.71 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5200 0 20 Years 0.00 $0.0000 $2,652.11 4/1/1992 0.00 $2,652.11 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5210 0 20 Years 0.00 $0.0000 $1,753.37 4/1/1992 0.00 $1,753.37 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5220 0 20 Years 0.00 $0.0000 $2,204.80 4/1/1992 0.00 $2,204.80 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5230 0 20 Years 0.00 $0.0000 $2,588.51 4/1/1992 0.00 $2,588.51 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5250 0 20 Years 0.00 $0.0000 $3,804.80 4/1/1992 0.00 $3,804.80 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5270 0 20 Years 0.00 $0.0000 $3,569.42 4/1/1992 0.00 $3,569.42 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5280 0 20 Years 0.00 $0.0000 $3,904.83 4/1/1992 0.00 $3,904.83 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5301 0 20 Years 0.00 $0.0000 $2,487.62 7/1/2010 0.00 $2,487.62 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5312 0 20 Years 0.00 $0.0000 $2,547.39 1/1/2012 0.00 $2,547.39 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5321 0 20 Years 0.00 $0.0000 $3,470.57 7/1/2010 0.00 $3,470.57 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5331 0 20 Years 0.00 $0.0000 $5,224.82 7/1/2010 0.00 $5,224.82 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5341 0 20 Years 0.00 $0.0000 $5,452.42 7/1/2010 0.00 $5,452.42 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5400 0 20 Years 0.00 $0.0000 $867.54 4/1/1992 0.00 $867.54 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5410 0 20 Years 0.00 $0.0000 $383.92 2/1/1993 0.00 $383.92 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5420 0 20 Years 0.00 $0.0000 $1,182.14 4/1/1992 0.00 $1,182.14 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5430 0 20 Years 0.00 $0.0000 $470.73 2/1/1993 0.00 $470.73 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5450 0 20 Years 0.00 $0.0000 $369.17 4/1/1992 0.00 $369.17 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5460 0 20 Years 0.00 $0.0000 $484.07 2/1/1993 0.00 $484.07 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5500 0 20 Years 0.00 $0.0000 $933.65 4/1/1992 0.00 $933.65 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5505 0 20 Years 0.00 $0.0000 $1,602.55 4/1/1992 0.00 $1,602.55 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5510 0 20 Years 0.00 $0.0000 $988.76 4/1/1992 0.00 $988.76 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5520 0 20 Years 0.00 $0.0000 $1,359.06 2/1/1993 0.00 $1,359.06 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5530 0 20 Years 0.00 $0.0000 $1,373.87 4/1/1992 0.00 $1,373.87 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5535 0 20 Years 0.00 $0.0000 $1,365.25 4/1/1992 0.00 $1,365.25 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5540 0 20 Years 0.00 $0.0000 $1,481.57 4/1/1992 0.00 $1,481.57 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5560 0 20 Years 0.00 $0.0000 $1,824.08 2/1/1993 0.00 $1,824.08 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5570 0 20 Years 0.00 $0.0000 $1,675.91 4/1/1992 0.00 $1,675.91 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5580 0 20 Years 0.00 $0.0000 $1,932.25 4/1/1992 0.00 $1,932.25 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5585 0 20 Years 0.00 $0.0000 $1,861.41 4/1/1992 0.00 $1,861.41 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5590 0 20 Years 0.00 $0.0000 $1,921.37 4/1/1992 0.00 $1,921.37 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5595 0 20 Years 0.00 $0.0000 $2,614.81 2/1/1993 0.00 $2,614.81 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5600 0 20 Years 0.00 $0.0000 $2,920.67 2/1/1993 0.00 $2,920.67 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5610 0 20 Years 0.00 $0.0000 $1,590.05 1/1/2004 0.00 $1,590.05 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5611 0 20 Years 0.00 $0.0000 $1,037.38 4/1/1992 0.00 $1,037.38 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5613 0 20 Years 0.00 $0.0000 $1,654.72 4/1/1992 0.00 $1,654.72 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5614 0 20 Years 0.00 $0.0000 $1,539.04 7/1/2010 0.00 $1,539.04 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5616 0 20 Years 0.00 $0.0000 $1,260.48 2/1/1993 0.00 $1,260.48 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5617 0 20 Years 0.00 $0.0000 $404.55 2/1/1996 0.00 $404.55 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5618 0 20 Years 0.00 $0.0000 $214.55 4/1/1992 0.00 $214.55 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5620 0 20 Years 0.00 $0.0000 $256.89 2/1/1993 0.00 $256.89 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5622 0 20 Years 0.00 $0.0000 $336.07 2/1/1993 0.00 $336.07 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5624 0 20 Years 0.00 $0.0000 $335.28 2/1/1993 0.00 $335.28 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5626 0 20 Years 0.00 $0.0000 $361.14 4/1/1992 0.00 $361.14 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5628 0 20 Years 0.00 $0.0000 $409.35 4/1/1992 0.00 $409.35 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5629 0 20 Years 0.00 $0.0000 $288.62 2/1/1993 0.00 $288.62 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5630 0 20 Years 0.00 $0.0000 $314.35 4/1/1992 0.00 $314.35 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5631 0 20 Years 0.00 $0.0000 $401.22 2/1/1993 0.00 $401.22 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5632 0 20 Years 0.00 $0.0000 $136.66 2/1/1993 0.00 $136.66 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5634 0 20 Years 0.00 $0.0000 $193.96 2/1/1993 0.00 $193.96 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5636 0 20 Years 0.00 $0.0000 $166.63 4/1/1992 0.00 $166.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5637 0 20 Years 0.00 $0.0000 $273.73 2/1/1993 0.00 $273.73 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5638 0 20 Years 0.00 $0.0000 $324.82 4/1/1992 0.00 $324.82 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5639 0 20 Years 0.00 $0.0000 $780.06 2/1/1993 0.00 $780.06 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5640 0 20 Years 0.00 $0.0000 $408.23 2/1/1993 0.00 $408.23 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5642 0 20 Years 0.00 $0.0000 $395.66 2/1/1993 0.00 $395.66 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5643 0 20 Years 0.00 $0.0000 $1,020.37 4/1/1992 0.00 $1,020.37 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5644 0 20 Years 0.00 $0.0000 $557.05 4/1/1992 0.00 $557.05 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5645 0 20 Years 0.00 $0.0000 $491.45 4/1/1992 0.00 $491.45 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5646 0 20 Years 0.00 $0.0000 $523.55 4/1/1992 0.00 $523.55 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5647 0 20 Years 0.00 $0.0000 $497.66 2/1/1993 0.00 $497.66 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5648 0 20 Years 0.00 $0.0000 $592.57 4/1/1992 0.00 $592.57 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5649 0 20 Years 0.00 $0.0000 $1,631.89 4/1/1992 0.00 $1,631.89 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5650 0 20 Years 0.00 $0.0000 $451.75 4/1/1992 0.00 $451.75 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5651 0 20 Years 0.00 $0.0000 $938.37 4/1/1992 0.00 $938.37 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5652 0 20 Years 0.00 $0.0000 $380.62 4/1/1992 0.00 $380.62 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5653 0 20 Years 0.00 $0.0000 $395.63 4/1/1992 0.00 $395.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5654 0 20 Years 0.00 $0.0000 $279.67 4/1/1992 0.00 $279.67 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5655 0 20 Years 0.00 $0.0000 $245.87 2/1/1993 0.00 $245.87 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5656 0 20 Years 0.00 $0.0000 $252.74 4/1/1992 0.00 $252.74 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5658 0 20 Years 0.00 $0.0000 $233.37 4/1/1992 0.00 $233.37 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5661 0 20 Years 0.00 $0.0000 $383.31 4/1/1992 0.00 $383.31 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5665 0 20 Years 0.00 $0.0000 $332.22 4/1/1992 0.00 $332.22 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5666 0 20 Years 0.00 $0.0000 $62.90 2/1/1993 0.00 $62.90 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5668 0 20 Years 0.00 $0.0000 $90.46 2/1/1993 0.00 $90.46 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5670 0 20 Years 0.00 $0.0000 $250.47 2/1/1993 0.00 $250.47 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5671 0 20 Years 0.00 $0.0000 $518.60 7/1/2010 0.00 $518.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5672 0 20 Years 0.00 $0.0000 $195.10 2/1/1993 0.00 $195.10 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5673 0 20 Years 0.00 $0.0000 $587.53 7/1/2004 0.00 $587.53 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5676 0 20 Years 0.00 $0.0000 $328.32 2/1/1993 0.00 $328.32 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5677 0 20 Years 0.00 $0.0000 $462.39 2/1/1993 0.00 $462.39 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5678 0 20 Years 0.00 $0.0000 $35.56 2/1/1993 0.00 $35.56 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5679 0 20 Years 0.00 $0.0000 $489.59 7/1/2004 0.00 $489.59 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5680 0 20 Years 0.00 $0.0000 $224.64 4/1/1992 0.00 $224.64 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5681 0 20 Years 0.00 $0.0000 $1,066.68 7/1/2004 0.00 $1,066.68 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5682 0 20 Years 0.00 $0.0000 $415.03 4/1/1992 0.00 $415.03 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5683 0 20 Years 0.00 $0.0000 $1,066.68 7/1/2004 0.00 $1,066.68 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5684 0 20 Years 0.00 $0.0000 $37.99 4/1/1992 0.00 $37.99 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5685 0 20 Years 0.00 $0.0000 $77.40 1/1/2005 0.00 $77.40 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5686 0 20 Years 0.00 $0.0000 $38.61 4/1/1992 0.00 $38.61 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5688 0 20 Years 0.00 $0.0000 $58.12 2/1/1993 0.00 $58.12 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5690 0 20 Years 0.00 $0.0000 $77.77 4/1/1992 0.00 $77.77 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5692 0 20 Years 0.00 $0.0000 $124.39 2/1/1993 0.00 $124.39 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5694 0 20 Years 0.00 $0.0000 $169.28 2/1/1993 0.00 $169.28 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5695 0 20 Years 0.00 $0.0000 $151.25 2/1/1993 0.00 $151.25 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5696 0 20 Years 0.00 $0.0000 $166.43 4/1/1992 0.00 $166.43 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5697 0 20 Years 0.00 $0.0000 $52.36 4/1/1992 0.00 $52.36 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5698 0 20 Years 0.00 $0.0000 $85.11 4/1/1992 0.00 $85.11 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5699 0 20 Years 0.00 $0.0000 $116.45 2/1/1993 0.00 $116.45 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5700 0 20 Years 0.00 $0.0000 $1,988.95 4/1/1994 0.00 $1,988.95 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5701 0 20 Years 0.00 $0.0000 $2,388.59 4/1/1994 0.00 $2,388.59 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5702 0 20 Years 0.00 $0.0000 $3,021.91 4/1/1994 0.00 $3,021.91 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5703 0 20 Years 0.00 $0.0000 $1,988.95 1/1/2006 0.00 $1,988.95 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5704 0 20 Years 0.00 $0.0000 $372.09 4/1/1994 0.00 $372.09 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5705 0 20 Years 0.00 $0.0000 $664.84 4/1/1994 0.00 $664.84 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5706 0 20 Years 0.00 $0.0000 $651.74 4/1/1994 0.00 $651.74 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5707 0 20 Years 0.00 $0.0000 $859.23 4/1/1994 0.00 $859.23 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5710 0 20 Years 0.00 $0.0000 $289.90 4/1/1992 0.00 $289.90 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5711 0 20 Years 0.00 $0.0000 $370.82 4/1/1992 0.00 $370.82 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5712 0 20 Years 0.00 $0.0000 $376.43 4/1/1992 0.00 $376.43 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5714 0 20 Years 0.00 $0.0000 $300.27 4/1/1992 0.00 $300.27 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5716 0 20 Years 0.00 $0.0000 $519.58 4/1/1992 0.00 $519.58 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5718 0 20 Years 0.00 $0.0000 $613.21 4/1/1992 0.00 $613.21 6 10/1/2016
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5722 0 20 Years 0.00 $0.0000 $584.63 2/1/1993 0.00 $584.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5724 0 20 Years 0.00 $0.0000 $1,448.26 4/1/1992 0.00 $1,448.26 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5726 0 20 Years 0.00 $0.0000 $1,656.45 4/1/1992 0.00 $1,656.45 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5728 0 20 Years 0.00 $0.0000 $1,652.69 4/1/1992 0.00 $1,652.69 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5780 0 20 Years 0.00 $0.0000 $820.29 4/1/1992 0.00 $820.29 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5785 0 20 Years 0.00 $0.0000 $372.37 4/1/1992 0.00 $372.37 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5790 0 20 Years 0.00 $0.0000 $667.39 2/1/1993 0.00 $667.39 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5795 0 20 Years 0.00 $0.0000 $946.60 2/1/1993 0.00 $946.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5810 0 20 Years 0.00 $0.0000 $359.77 4/1/1992 0.00 $359.77 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5811 0 20 Years 0.00 $0.0000 $525.35 4/1/1992 0.00 $525.35 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5812 0 20 Years 0.00 $0.0000 $385.99 4/1/1992 0.00 $385.99 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5814 0 20 Years 0.00 $0.0000 $3,387.27 7/1/2010 0.00 $3,387.27 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5816 0 20 Years 0.00 $0.0000 $631.91 4/1/1992 0.00 $631.91 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5818 0 20 Years 0.00 $0.0000 $641.93 4/1/1992 0.00 $641.93 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5822 0 20 Years 0.00 $0.0000 $1,028.34 4/1/1992 0.00 $1,028.34 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5824 0 20 Years 0.00 $0.0000 $1,225.63 4/1/1992 0.00 $1,225.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5826 0 20 Years 0.00 $0.0000 $2,848.26 7/1/2010 0.00 $2,848.26 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5828 0 20 Years 0.00 $0.0000 $1,993.68 4/1/1992 0.00 $1,993.68 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5830 0 20 Years 0.00 $0.0000 $1,370.31 4/1/1992 0.00 $1,370.31 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5840 0 20 Years 0.00 $0.0000 $1,676.92 4/1/1994 0.00 $1,676.92 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5845 0 20 Years 0.00 $0.0000 $1,634.75 7/1/2010 0.00 $1,634.75 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5848 0 20 Years 0.00 $0.0000 $871.99 6/1/2003 0.00 $871.99 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5850 0 20 Years 0.00 $0.0000 $101.67 4/1/1992 0.00 $101.67 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5855 0 20 Years 0.00 $0.0000 $238.62 4/1/1994 0.00 $238.62 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5856 0 20 Years 0.00 $0.0000 $21,894.75 7/1/2010 0.00 ####### 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5857 0 20 Years 0.00 $0.0000 $7,769.10 7/1/2010 0.00 $7,769.10 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5858 0 20 Years 0.00 $0.0000 $8,923.46 10/1/2016 0.00 $8,923.46 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5910 0 20 Years 0.00 $0.0000 $323.90 2/1/1993 0.00 $323.90 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5920 0 20 Years 0.00 $0.0000 $472.81 2/1/1993 0.00 $472.81 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5925 0 20 Years 0.00 $0.0000 $404.10 1/1/2010 0.00 $404.10 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5930 0 20 Years 0.00 $0.0000 $2,433.73 2/1/1996 0.00 $2,433.73 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5940 0 20 Years 0.00 $0.0000 $420.12 4/1/1992 0.00 $420.12 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5950 0 20 Years 0.00 $0.0000 $713.94 2/1/1993 0.00 $713.94 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5960 0 20 Years 0.00 $0.0000 $931.97 2/1/1993 0.00 $931.97 6 10/1/2016
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5961 0 20 Years 0.00 $0.0000 $4,399.48 10/1/2012 0.00 $4,399.48 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5962 0 20 Years 0.00 $0.0000 $572.22 1/1/2010 0.00 $572.22 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5964 0 20 Years 0.00 $0.0000 $844.74 1/1/2010 0.00 $844.74 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5966 0 20 Years 0.00 $0.0000 $931.97 1/1/2010 0.00 $931.97 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5968 0 20 Years 0.00 $0.0000 $2,755.37 3/1/1999 0.00 $2,755.37 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5970 0 20 Years 0.00 $0.0000 $164.11 4/1/1992 0.00 $164.11 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5971 0 20 Years 0.00 $0.0000 $205.31 7/1/2010 0.00 $205.31 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5972 0 20 Years 0.00 $0.0000 $386.47 7/1/2010 0.00 $386.47 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5973 0 20 Years 0.00 $0.0000 $15,691.70 1/1/2010 0.00 ####### 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5974 0 20 Years 0.00 $0.0000 $193.89 4/1/1992 0.00 $193.89 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5975 0 20 Years 0.00 $0.0000 $351.52 3/1/1999 0.00 $351.52 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5976 0 20 Years 0.00 $0.0000 $350.00 4/1/1990 0.00 $350.00 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5978 0 20 Years 0.00 $0.0000 $252.72 4/1/1992 0.00 $252.72 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5979 0 20 Years 0.00 $0.0000 $1,584.09 4/1/1994 0.00 $1,584.09 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5980 0 20 Years 0.00 $0.0000 $2,500.00 4/1/1990 0.00 $2,500.00 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5981 0 20 Years 0.00 $0.0000 $2,500.00 1/1/2010 0.00 $2,500.00 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5982 0 20 Years 0.00 $0.0000 $392.46 4/1/1992 0.00 $392.46 6 10/1/2016
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Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5984 0 20 Years 0.00 $0.0000 $428.19 4/1/1992 0.00 $428.19 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5985 0 20 Years 0.00 $0.0000 $204.17 2/1/1996 0.00 $204.17 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5986 0 20 Years 0.00 $0.0000 $420.19 4/1/1992 0.00 $420.19 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5987 0 20 Years 0.00 $0.0000 $5,347.10 2/1/1997 0.00 $5,347.10 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5988 0 20 Years 0.00 $0.0000 $1,514.73 3/1/1999 0.00 $1,514.73 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5990 0 20 Years 0.00 $0.0000 $1,654.66 7/1/2010 0.00 $1,654.66 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L5999 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6000 0 20 Years 0.00 $0.0000 $972.86 4/1/1992 0.00 $972.86 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6010 0 20 Years 0.00 $0.0000 $1,016.34 4/1/1992 0.00 $1,016.34 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6020 0 20 Years 0.00 $0.0000 $982.86 4/1/1992 0.00 $982.86 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6050 0 20 Years 0.00 $0.0000 $1,560.05 4/1/1992 0.00 $1,560.05 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6055 0 20 Years 0.00 $0.0000 $1,875.19 4/1/1992 0.00 $1,875.19 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6100 0 20 Years 0.00 $0.0000 $1,673.07 4/1/1992 0.00 $1,673.07 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6110 0 20 Years 0.00 $0.0000 $1,706.62 4/1/1992 0.00 $1,706.62 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6120 0 20 Years 0.00 $0.0000 $1,937.07 4/1/1992 0.00 $1,937.07 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6130 0 20 Years 0.00 $0.0000 $1,749.29 4/1/1992 0.00 $1,749.29 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6200 0 20 Years 0.00 $0.0000 $2,157.71 4/1/1992 0.00 $2,157.71 6 10/1/2016
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Mod
2
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Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6205 0 20 Years 0.00 $0.0000 $2,362.09 4/1/1992 0.00 $2,362.09 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6250 0 20 Years 0.00 $0.0000 $2,262.60 4/1/1992 0.00 $2,262.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6300 0 20 Years 0.00 $0.0000 $2,607.09 4/1/1992 0.00 $2,607.09 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6310 0 20 Years 0.00 $0.0000 $2,162.15 4/1/1992 0.00 $2,162.15 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6320 0 20 Years 0.00 $0.0000 $1,357.49 4/1/1992 0.00 $1,357.49 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6350 0 20 Years 0.00 $0.0000 $2,554.34 2/1/1993 0.00 $2,554.34 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6360 0 20 Years 0.00 $0.0000 $2,275.13 4/1/1992 0.00 $2,275.13 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6370 0 20 Years 0.00 $0.0000 $1,673.51 4/1/1992 0.00 $1,673.51 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6380 0 20 Years 0.00 $0.0000 $884.50 4/1/1992 0.00 $884.50 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6382 0 20 Years 0.00 $0.0000 $1,060.87 4/1/1992 0.00 $1,060.87 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6384 0 20 Years 0.00 $0.0000 $1,363.57 4/1/1992 0.00 $1,363.57 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6386 0 20 Years 0.00 $0.0000 $294.89 4/1/1992 0.00 $294.89 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6388 0 20 Years 0.00 $0.0000 $343.73 4/1/1992 0.00 $343.73 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6400 0 20 Years 0.00 $0.0000 $1,631.25 4/1/1992 0.00 $1,631.25 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6450 0 20 Years 0.00 $0.0000 $1,993.94 4/1/1992 0.00 $1,993.94 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6500 0 20 Years 0.00 $0.0000 $2,053.82 4/1/1992 0.00 $2,053.82 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6550 0 20 Years 0.00 $0.0000 $2,487.09 4/1/1992 0.00 $2,487.09 6 10/1/2016
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6570 0 20 Years 0.00 $0.0000 $2,802.70 4/1/1992 0.00 $2,802.70 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6580 0 20 Years 0.00 $0.0000 $1,099.39 4/1/1992 0.00 $1,099.39 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6582 0 20 Years 0.00 $0.0000 $999.28 4/1/1992 0.00 $999.28 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6584 0 20 Years 0.00 $0.0000 $1,532.85 4/1/1992 0.00 $1,532.85 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6586 0 20 Years 0.00 $0.0000 $1,447.11 4/1/1992 0.00 $1,447.11 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6588 0 20 Years 0.00 $0.0000 $2,076.56 4/1/1992 0.00 $2,076.56 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6590 0 20 Years 0.00 $0.0000 $1,987.15 4/1/1992 0.00 $1,987.15 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6600 0 20 Years 0.00 $0.0000 $176.15 2/1/1993 0.00 $176.15 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6605 0 20 Years 0.00 $0.0000 $170.62 4/1/1992 0.00 $170.62 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6610 0 20 Years 0.00 $0.0000 $142.80 4/1/1992 0.00 $142.80 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6611 0 20 Years 0.00 $0.0000 $375.52 7/1/2010 0.00 $375.52 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6615 0 20 Years 0.00 $0.0000 $127.83 4/1/1992 0.00 $127.83 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6616 0 20 Years 0.00 $0.0000 $59.41 2/1/1993 0.00 $59.41 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6620 0 20 Years 0.00 $0.0000 $212.21 4/1/1992 0.00 $212.21 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6621 0 20 Years 0.00 $0.0000 $1,098.22 10/1/2016 0.00 $1,098.22 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6623 0 20 Years 0.00 $0.0000 $474.77 4/1/1992 0.00 $474.77 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6624 0 20 Years 0.00 $0.0000 $3,185.32 1/1/2007 0.00 $3,185.32 10/1/2016
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6625 0 20 Years 0.00 $0.0000 $468.62 2/1/1993 0.00 $468.62 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6628 0 20 Years 0.00 $0.0000 $366.57 4/1/1992 0.00 $366.57 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6629 0 20 Years 0.00 $0.0000 $108.88 4/1/1992 0.00 $108.88 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6630 0 20 Years 0.00 $0.0000 $160.41 4/1/1992 0.00 $160.41 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6632 0 20 Years 0.00 $0.0000 $41.63 2/1/1993 0.00 $41.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6635 0 20 Years 0.00 $0.0000 $147.94 4/1/1992 0.00 $147.94 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6637 0 20 Years 0.00 $0.0000 $296.18 4/1/1992 0.00 $296.18 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6638 0 20 Years 0.00 $0.0000 $2,027.88 6/1/2003 0.00 $2,027.88 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6640 0 20 Years 0.00 $0.0000 $257.70 2/1/1993 0.00 $257.70 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6641 0 20 Years 0.00 $0.0000 $128.66 4/1/1992 0.00 $128.66 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6642 0 20 Years 0.00 $0.0000 $165.34 4/1/1992 0.00 $165.34 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6645 0 20 Years 0.00 $0.0000 $296.78 2/1/1993 0.00 $296.78 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6646 0 20 Years 0.00 $0.0000 $2,557.62 6/1/2003 0.00 $2,557.62 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6647 0 20 Years 0.00 $0.0000 $421.06 6/1/2003 0.00 $421.06 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6648 0 20 Years 0.00 $0.0000 $2,637.84 6/1/2003 0.00 $2,637.84 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6650 0 20 Years 0.00 $0.0000 $314.50 2/1/1993 0.00 $314.50 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6655 0 20 Years 0.00 $0.0000 $68.90 4/1/1992 0.00 $68.90 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6660 0 20 Years 0.00 $0.0000 $70.50 4/1/1992 0.00 $70.50 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6665 0 20 Years 0.00 $0.0000 $41.60 2/1/1993 0.00 $41.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6670 0 20 Years 0.00 $0.0000 $43.61 2/1/1993 0.00 $43.61 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6672 0 20 Years 0.00 $0.0000 $111.91 4/1/1992 0.00 $111.91 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6675 0 20 Years 0.00 $0.0000 $88.97 4/1/1992 0.00 $88.97 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6676 0 20 Years 0.00 $0.0000 $83.66 4/1/1992 0.00 $83.66 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6677 0 20 Years 0.00 $0.0000 $142.44 10/1/2016 0.00 $142.44 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6680 0 20 Years 0.00 $0.0000 $214.42 2/1/1993 0.00 $214.42 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6682 0 20 Years 0.00 $0.0000 $204.24 4/1/1992 0.00 $204.24 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6684 0 20 Years 0.00 $0.0000 $225.51 4/1/1992 0.00 $225.51 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6686 0 20 Years 0.00 $0.0000 $388.52 4/1/1992 0.00 $388.52 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6687 0 20 Years 0.00 $0.0000 $358.09 2/1/1993 0.00 $358.09 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6688 0 20 Years 0.00 $0.0000 $394.75 4/1/1992 0.00 $394.75 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6689 0 20 Years 0.00 $0.0000 $473.35 4/1/1992 0.00 $473.35 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6690 0 20 Years 0.00 $0.0000 $489.36 4/1/1992 0.00 $489.36 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6691 0 20 Years 0.00 $0.0000 $219.63 4/1/1992 0.00 $219.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6692 0 20 Years 0.00 $0.0000 $466.60 4/1/1992 0.00 $466.60 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6693 0 20 Years 0.00 $0.0000 $2,152.63 3/1/1999 0.00 $2,152.63 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6694 0 20 Years 0.00 $0.0000 $660.81 7/1/2010 0.00 $660.81 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6695 0 20 Years 0.00 $0.0000 $550.65 7/1/2010 0.00 $550.65 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6696 0 20 Years 0.00 $0.0000 $1,199.72 7/1/2010 0.00 $1,199.72 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6697 0 20 Years 0.00 $0.0000 $1,199.72 7/1/2010 0.00 $1,199.72 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6698 0 20 Years 0.00 $0.0000 $518.60 7/1/2010 0.00 $518.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6703 0 20 Years 0.00 $0.0000 $276.63 1/1/2007 0.00 $276.63 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6704 0 20 Years 0.00 $0.0000 $648.73 1/1/2007 0.00 $648.73 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6706 0 20 Years 0.00 $0.0000 $336.56 1/1/2007 0.00 $336.56 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6707 0 20 Years 0.00 $0.0000 $1,197.57 1/1/2007 0.00 $1,197.57 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6708 0 20 Years 0.00 $0.0000 $804.87 1/1/2007 0.00 $804.87 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6709 0 20 Years 0.00 $0.0000 $1,180.90 1/1/2007 0.00 $1,180.90 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6711 0 20 Years 0.00 $0.0000 $583.99 1/1/2009 0.00 $583.99 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6712 0 20 Years 0.00 $0.0000 $1,075.26 1/1/2009 0.00 $1,075.26 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6713 0 20 Years 0.00 $0.0000 $1,357.07 1/1/2009 0.00 $1,357.07 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6714 0 20 Years 0.00 $0.0000 $1,149.43 1/1/2009 0.00 $1,149.43 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6715 0 20 Years 0.00 $0.0000 $2,998.93 10/1/2014 0.00 $2,998.93 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6721 0 20 Years 0.00 $0.0000 $2,042.98 1/1/2009 0.00 $2,042.98 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6722 0 20 Years 0.00 $0.0000 $1,761.19 1/1/2009 0.00 $1,761.19 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6805 0 20 Years 0.00 $0.0000 $285.58 4/1/1992 0.00 $285.58 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6810 0 20 Years 0.00 $0.0000 $144.51 4/1/1992 0.00 $144.51 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6880 0 20 Years 0.00 $0.0000 $0.00 1/1/2012 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6881 0 20 Years 0.00 $0.0000 $3,728.72 7/1/2010 0.00 $3,728.72 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6882 0 20 Years 0.00 $0.0000 $2,828.42 7/1/2010 0.00 $2,828.42 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6883 0 20 Years 0.00 $0.0000 $1,683.10 7/1/2010 0.00 $1,683.10 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6884 0 20 Years 0.00 $0.0000 $2,525.99 7/1/2010 0.00 $2,525.99 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6885 0 20 Years 0.00 $0.0000 $2,873.00 7/1/2010 0.00 $2,873.00 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6890 0 20 Years 0.00 $0.0000 $116.22 4/1/1992 0.00 $116.22 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6895 0 20 Years 0.00 $0.0000 $348.92 4/1/1992 0.00 $348.92 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6900 0 20 Years 0.00 $0.0000 $1,018.70 4/1/1992 0.00 $1,018.70 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6905 0 20 Years 0.00 $0.0000 $935.52 2/1/1993 0.00 $935.52 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6910 0 20 Years 0.00 $0.0000 $981.37 4/1/1992 0.00 $981.37 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6915 0 20 Years 0.00 $0.0000 $402.34 2/1/1993 0.00 $402.34 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6920 0 20 Years 0.00 $0.0000 $6,609.86 7/1/2010 0.00 $6,609.86 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6925 0 20 Years 0.00 $0.0000 $6,979.44 7/1/2010 0.00 $6,979.44 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6930 0 20 Years 0.00 $0.0000 $7,096.46 7/1/2010 0.00 $7,096.46 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6935 0 20 Years 0.00 $0.0000 $7,806.03 7/1/2010 0.00 $7,806.03 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6940 0 20 Years 0.00 $0.0000 $8,869.04 7/1/2010 0.00 $8,869.04 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6945 0 20 Years 0.00 $0.0000 $10,032.95 7/1/2010 0.00 ####### 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6950 0 20 Years 0.00 $0.0000 $9,429.49 7/1/2010 0.00 $9,429.49 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6955 0 20 Years 0.00 $0.0000 $11,832.69 7/1/2010 0.00 ####### 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6960 0 20 Years 0.00 $0.0000 $11,667.63 7/1/2010 0.00 ####### 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6965 0 20 Years 0.00 $0.0000 $17,044.73 7/1/2010 0.00 ####### 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6970 0 20 Years 0.00 $0.0000 $17,324.81 7/1/2010 0.00 ####### 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L6975 0 20 Years 0.00 $0.0000 $17,417.80 7/1/2010 0.00 ####### 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7007 0 20 Years 0.00 $0.0000 $3,837.72 1/1/2007 0.00 $3,837.72 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7008 0 20 Years 0.00 $0.0000 $6,513.41 7/1/2010 0.00 $6,513.41 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7009 0 20 Years 0.00 $0.0000 $4,222.48 7/1/2010 0.00 $4,222.48 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7040 0 20 Years 0.00 $0.0000 $3,390.49 7/1/2010 0.00 $3,390.49 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7045 0 20 Years 0.00 $0.0000 $1,943.89 7/1/2010 0.00 $1,943.89 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7170 0 20 Years 0.00 $0.0000 $7,051.76 7/1/2010 0.00 $7,051.76 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7180 0 20 Years 0.00 $0.0000 $36,843.81 7/1/2010 0.00 ####### 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7181 0 20 Years 0.00 $0.0000 $36,544.45 7/1/2010 0.00 ####### 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7185 0 20 Years 0.00 $0.0000 $7,140.85 7/1/2010 0.00 $7,140.85 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7186 0 20 Years 0.00 $0.0000 $10,305.99 7/1/2010 0.00 ####### 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7190 0 20 Years 0.00 $0.0000 $9,085.38 7/1/2010 0.00 $9,085.38 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7191 0 20 Years 0.00 $0.0000 $10,954.94 7/1/2010 0.00 ####### 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7360 0 20 Years 0.00 $0.0000 $217.02 7/1/2010 0.00 $217.02 6 0.00 $0.0000 $217.02 7/1/2010 0.00 $217.02 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7362 0 20 Years 0.00 $0.0000 $261.22 7/1/2010 0.00 $261.22 6 0.00 $0.0000 $261.22 7/1/2010 0.00 $261.22 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7364 0 20 Years 0.00 $0.0000 $475.85 7/1/2010 0.00 $475.85 6 0.00 $0.0000 $475.85 7/1/2010 0.00 $475.85 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7366 0 20 Years 0.00 $0.0000 $645.54 7/1/2010 0.00 $645.54 6 0.00 $0.0000 $645.54 7/1/2010 0.00 $645.54 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7367 0 20 Years 0.00 $0.0000 $315.70 5/1/2003 0.00 $315.70 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7368 0 999 Years 0.00 $0.0000 $409.27 5/1/2003 0.00 $409.27 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7400 0 20 Years 0.00 $0.0000 $279.53 7/1/2010 0.00 $279.53 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7401 0 20 Years 0.00 $0.0000 $312.93 7/1/2010 0.00 $312.93 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7402 0 20 Years 0.00 $0.0000 $337.94 7/1/2010 0.00 $337.94 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7403 0 20 Years 0.00 $0.0000 $335.88 7/1/2010 0.00 $335.88 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7404 0 20 Years 0.00 $0.0000 $506.92 7/1/2010 0.00 $506.92 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7405 0 20 Years 0.00 $0.0000 $662.98 7/1/2010 0.00 $662.98 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7499 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7510 0 20 Years 0.00 $0.0000 $30.45 10/1/2016 0.00 $30.45 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7520 0 20 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7600 0 20 Years 0.00 $0.0000 $66.30 10/1/2016 0.00 $66.30 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8000 0 999 Years 0.00 $0.0000 $23.92 6/1/2010 0.00 $23.92 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8001 0 999 Years 0.00 $0.0000 $114.39 7/1/2010 0.00 $114.39 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8002 0 999 Years 0.00 $0.0000 $150.48 7/1/2010 0.00 $150.48 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8010 0 999 Years 0.00 $0.0000 $59.52 10/1/2016 0.00 $59.52 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8015 0 999 Years 0.00 $0.0000 $45.45 6/1/2010 0.00 $45.45 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8020 0 999 Years 0.00 $0.0000 $140.20 6/1/2010 0.00 $140.20 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8030 0 999 Years 0.00 $0.0000 $233.93 6/1/2010 0.00 $233.93 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8031 0 999 Years 0.00 $0.0000 $307.79 10/1/2012 0.00 $307.79 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8032 0 999 Years 0.00 $0.0000 $20.09 1/1/2010 0.00 $20.09 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8035 0 999 Years 0.00 $0.0000 $2,777.90 6/1/2010 0.00 $2,777.90 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8039 0 999 Years 0.00 $0.0000 $0.00 6/1/2010 $0.00 5 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8040 0 20 Years 0.00 $0.0000 $1,873.58 10/1/2016 0.00 $1,873.58 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8041 0 20 Years 0.00 $0.0000 $2,258.29 10/1/2016 0.00 $2,258.29 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8042 0 20 Years 0.00 $0.0000 $2,589.19 4/1/2001 0.00 $2,589.19 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8043 0 20 Years 0.00 $0.0000 $2,899.88 4/1/2001 0.00 $2,899.88 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8044 0 20 Years 0.00 $0.0000 $3,210.59 4/1/2001 0.00 $3,210.59 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8045 0 20 Years 0.00 $0.0000 $2,010.46 4/1/2001 0.00 $2,010.46 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8046 0 20 Years 0.00 $0.0000 $2,071.34 4/1/2001 0.00 $2,071.34 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8047 0 20 Years 0.00 $0.0000 $1,061.57 4/1/2001 0.00 $1,061.57 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8300 0 20 Years 0.00 $0.0000 $54.64 2/1/1993 0.00 $54.64 6 0.00 $0.0000 $54.64 2/1/1993 0.00 $54.64 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8310 0 20 Years 0.00 $0.0000 $87.22 2/1/1993 0.00 $87.22 6 0.00 $0.0000 $87.22 2/1/1993 0.00 $87.22 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8320 0 20 Years 0.00 $0.0000 $39.08 4/1/1992 0.00 $39.08 6 0.00 $0.0000 $39.08 4/1/1992 0.00 $39.08 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8330 0 20 Years 0.00 $0.0000 $44.51 4/1/1992 0.00 $44.51 6 0.00 $0.0000 $44.51 4/1/1992 0.00 $44.51 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8400 0 20 Years 0.00 $0.0000 $10.45 4/1/1992 0.00 $10.45 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8410 0 20 Years 0.00 $0.0000 $14.86 4/1/1992 0.00 $14.86 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8415 0 20 Years 0.00 $0.0000 $15.72 4/1/1992 0.00 $15.72 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8417 0 20 Years 0.00 $0.0000 $55.89 2/1/1997 0.00 $55.89 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8420 0 20 Years 0.00 $0.0000 $14.48 7/1/1997 0.00 $14.48 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8430 0 20 Years 0.00 $0.0000 $16.00 7/1/1997 0.00 $16.00 10/1/2016
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8435 0 20 Years 0.00 $0.0000 $15.62 7/1/1997 0.00 $15.62 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8440 0 20 Years 0.00 $0.0000 $30.38 4/1/1992 0.00 $30.38 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8460 0 20 Years 0.00 $0.0000 $59.16 4/1/1992 0.00 $59.16 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8465 0 20 Years 0.00 $0.0000 $37.20 4/1/1992 0.00 $37.20 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8470 0 20 Years 0.00 $0.0000 $4.98 7/1/1997 0.00 $4.98 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8480 0 20 Years 0.00 $0.0000 $6.96 7/1/1997 0.00 $6.96 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8485 0 20 Years 0.00 $0.0000 $7.72 7/1/1997 0.00 $7.72 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8499 0 999 Years 0.00 $0.0000 $0.00 1/1/2009 $0.00 5 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8499 RB 0 999 Years 0.00 $0.0000 $0.00 1/1/2009 $0.00 5 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8500 0 20 Years 0.00 $0.0000 $523.50 4/1/1992 0.00 $523.50 6 0.00 $0.0000 $523.50 4/1/1992 0.00 $523.50 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8501 0 999 Years 0.00 $0.0000 $71.46 5/1/2003 0.00 $71.46 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8507 0 20 Years 0.00 $0.0000 $38.20 7/1/2010 0.00 $38.20 6 0.00 $0.0000 $38.20 7/1/2010 0.00 $38.20 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8509 0 20 Years 0.00 $0.0000 $99.60 7/1/2010 0.00 $99.60 6 0.00 $0.0000 $99.60 7/1/2010 0.00 $99.60 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8510 0 20 Years 0.00 $0.0000 $230.48 7/1/2010 0.00 $230.48 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8610 0 20 Years 0.00 $0.0000 $598.36 7/1/2010 0.00 $598.36 6 0.00 $0.0000 $598.36 7/1/2010 0.00 $598.36 6 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8615 1 999 Years 0.00 $0.0000 $365.74 2/1/2006 0.00 $365.74 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8616 1 999 Years 0.00 $0.0000 $85.19 2/1/2006 0.00 $85.19 10/1/2016
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8617 1 999 Years 0.00 $0.0000 $74.40 2/1/2006 0.00 $74.40 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8618 1 999 Years 0.00 $0.0000 $21.25 2/1/2006 0.00 $21.25 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8619 1 999 Years 0.00 $0.0000 $6,663.57 2/1/2006 0.00 $6,663.57 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8621 1 999 Years 0.00 $0.0000 $0.50 2/1/2006 0.00 $0.50 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8622 1 999 Years 0.00 $0.0000 $0.27 2/1/2006 0.00 $0.27 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8623 1 999 Years 0.00 $0.0000 $52.45 12/2/2008 0.00 $52.45 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8624 1 999 Years 0.00 $0.0000 $140.05 12/2/2008 0.00 $140.05 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8627 1 999 Years 0.00 $0.0000 $6,366.34 1/1/2010 0.00 $6,366.34 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8628 1 999 Years 0.00 $0.0000 $1,128.30 1/1/2010 0.00 $1,128.30 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8629 1 999 Years 0.00 $0.0000 $167.07 10/1/2012 0.00 $167.07 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8680 0 999 Years 0.00 $0.0000 $272.16 10/1/2014 0.00 $272.16 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8680 TG 0 999 Years 0.00 $0.0000 $4,646.94 10/1/2011 0.00 $4,646.94 10/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES Q0506 0 999 Years 0.00 $0.0000 $787.21 1/1/2016 0.00 $787.21 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S1015 0 999 Years 0.00 $0.0000 $10.50 1/1/2010 0.00 $10.50 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S1040 3 18 Months 0.00 $0.0000 $2,418.18 1/1/2010 0.00 $2,418.18 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8101 0 999 Years 0.00 $0.0000 $30.34 4/1/2015 0.00 $30.34 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8265 0 20 Years 0.00 $0.0000 $49.08 4/1/2015 0.00 $49.08 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8415 10 55 Years 0.00 $0.0000 $56.25 7/1/2015 0.00 $56.25 6 7/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8420 0 20 Years 0.00 $0.0000 $335.86 4/1/2015 0.00 $335.86 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8421 0 20 Years 0.00 $0.0000 $109.88 4/1/2015 0.00 $109.88 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8422 0 20 Years 0.00 $0.0000 $293.50 4/1/2015 0.00 $293.50 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8423 0 20 Years 0.00 $0.0000 $210.80 4/1/2015 0.00 $210.80 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8424 0 20 Years 0.00 $0.0000 $62.24 4/1/2015 0.00 $62.24 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8425 0 20 Years 0.00 $0.0000 $138.18 4/1/2015 0.00 $138.18 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8426 0 20 Years 0.00 $0.0000 $142.68 4/1/2015 0.00 $142.68 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8427 0 20 Years 0.00 $0.0000 $46.90 4/1/2015 0.00 $46.90 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8428 0 20 Years 0.00 $0.0000 $72.70 4/1/2015 0.00 $72.70 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8429 0 20 Years 0.00 $0.0000 $16.40 4/1/2015 0.00 $16.40 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8450 1 20 Years 0.00 $0.0000 $6.56 4/1/2015 0.00 $6.56 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8451 1 20 Years 0.00 $0.0000 $20.00 4/1/2015 0.00 $20.00 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES S8452 1 20 Years 0.00 $0.0000 $18.04 4/1/2015 0.00 $18.04 6 4/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T1999 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2015
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4521 0 999 Years 0.00 $0.0000 $0.58 1/1/2005 -8.00 $0.53 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4522 0 999 Years 0.00 $0.0000 $0.61 1/1/2005 -8.00 $0.56 1/1/2013
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4523 0 999 Years 0.00 $0.0000 $0.65 1/1/2005 -8.00 $0.60 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4524 0 999 Years 0.00 $0.0000 $0.75 3/1/2012 0.00 $0.75 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4525 0 999 Years 0.00 $0.0000 $0.58 1/1/2005 -8.00 $0.53 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4526 0 999 Years 0.00 $0.0000 $0.68 1/1/2005 -8.00 $0.63 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4527 0 999 Years 0.00 $0.0000 $0.83 1/1/2005 -8.00 $0.76 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4528 0 999 Years 0.00 $0.0000 $0.92 3/1/2012 0.00 $0.92 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4528 U1 0 999 Years 0.00 $0.0000 $1.50 7/1/2013 0.00 $1.50 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4529 0 999 Years 0.00 $0.0000 $0.30 1/1/2005 -8.00 $0.28 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4530 0 999 Years 0.00 $0.0000 $0.52 1/1/2005 -8.00 $0.48 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4531 0 999 Years 0.00 $0.0000 $0.63 1/1/2005 -8.00 $0.58 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4532 0 999 Years 0.00 $0.0000 $0.84 1/1/2005 -8.00 $0.77 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4533 0 999 Years 0.00 $0.0000 $0.58 1/1/2005 -8.00 $0.53 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4534 0 999 Years 0.00 $0.0000 $0.62 3/1/2012 0.00 $0.62 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4535 0 999 Years 0.00 $0.0000 $0.29 1/1/2005 -8.00 $0.27 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES T4543 0 999 Years 0.00 $0.0000 $0.94 3/1/2012 0.00 $0.94 1/1/2013
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2623 0 20 Years 0.00 $0.0000 $1,141.18 1/1/2016 0.00 $1,141.18 6 1/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2624 0 20 Years 0.00 $0.0000 $34.51 7/1/2014 0.00 $34.51 6 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2625 0 20 Years 0.00 $0.0000 $165.76 7/1/2014 0.00 $165.76 6 7/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2626 0 20 Years 0.00 $0.0000 $114.95 7/1/2014 0.00 $114.95 6 7/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2628 0 20 Years 0.00 $0.0000 $162.80 7/1/2014 0.00 $162.80 6 7/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2799 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 7/1/2016
MEDICAL
SUPPLIER
(DME) 9
OTHER MEDICAL
ITEMS OR
SERVICES V5336 1 999 Years 0.00 $0.0000 $0.00 4/1/2010 $0.00 5 7/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4206 0 999 Years 0.00 $0.0000 $0.25 7/1/2011 0.00 $0.25 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4207 0 999 Years 0.00 $0.0000 $0.29 7/1/2011 0.00 $0.29 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4208 0 999 Years 0.00 $0.0000 $0.35 1/1/2015 0.00 $0.35 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4209 0 999 Years 0.00 $0.0000 $0.40 7/1/2011 0.00 $0.40 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4215 0 999 Years 0.00 $0.0000 $0.20 7/1/2011 0.00 $0.20 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4220 0 999 Years 0.00 $0.0000 $50.00 7/1/2011 0.00 $50.00 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4245 0 999 Years 0.00 $0.0000 $2.06 7/1/2011 0.00 $2.06 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4263 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4265 0 999 Years 0.00 $0.0000 $3.23 5/7/1999 0.00 $3.23 0.00 $0.0000 $3.23 5/7/1999 0.00 $3.23 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4300 0 999 Years 0.00 $0.0000 $8.56 1/1/2015 0.00 $8.56 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4490 0 999 Years 0.00 $0.0000 $17.80 7/1/2011 0.00 $17.80 0.00 $0.0000 $17.80 7/1/2011 0.00 $17.80 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4495 0 999 Years 0.00 $0.0000 $21.00 7/1/2011 0.00 $21.00 0.00 $0.0000 $21.00 7/1/2011 0.00 $21.00 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4500 0 999 Years 0.00 $0.0000 $12.00 7/1/2011 0.00 $12.00 0.00 $0.0000 $12.00 7/1/2011 0.00 $12.00 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4510 0 999 Years 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 0.00 $0.0000 $0.00 7/1/1997 $0.00 5 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4558 0 999 Years 0.00 $0.0000 $2.54 1/1/2015 0.00 $2.54 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4565 0 999 Years 0.00 $0.0000 $8.41 1/1/2015 0.00 $8.41 0.00 $0.0000 $8.41 1/1/2015 0.00 $8.41 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4570 0 999 Years 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4630 0 20 Years 0.00 $0.0000 $6.56 7/1/2011 0.00 $6.56 6 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4640 0 999 Years 0.00 $0.0000 $29.43 1/1/2015 0.00 $29.43 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4660 0 999 Years 0.00 $0.0000 $31.25 7/1/2011 0.00 $31.25 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4663 0 999 Years 0.00 $0.0000 $32.00 7/1/2011 0.00 $32.00 0.00 $0.0000 $32.00 7/1/2011 0.00 $32.00 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4670 0 999 Years 0.00 $0.0000 $66.09 7/1/2011 0.00 $66.09 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4680 0 20 Years 0.00 $0.0000 $140.57 7/1/2011 0.00 $140.57 6 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4714 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4730 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4740 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4750 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4755 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4760 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4765 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4774 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4860 0 999 Years 0.00 $0.0000 $4.73 1/1/2015 0.00 $4.73 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4913 0 999 Years 0.00 $0.0000 $0.00 1/1/1982 $0.00 5 6 0.00 $0.0000 $0.00 1/1/1982 $0.00 5 6 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES A4918 0 999 Years 0.00 $0.0000 $0.00 12/1/2007 $0.00 5 1/1/2015
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4034 0 999 Years 0.00 $0.0000 $6.11 1/1/2014 0.00 $6.11 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4036 0 999 Years 0.00 $0.0000 $8.00 1/1/2014 0.00 $8.00 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4081 0 999 Years 0.00 $0.0000 $21.61 1/1/2014 0.00 $21.61 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4082 0 999 Years 0.00 $0.0000 $16.07 1/1/2014 0.00 $16.07 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4083 0 999 Years 0.00 $0.0000 $2.47 1/1/2014 0.00 $2.47 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4164 0 999 Years 0.00 $0.0000 $19.10 1/1/2014 0.00 $19.10 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4168 0 999 Years 0.00 $0.0000 $27.85 1/1/2014 0.00 $27.85 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4172 0 999 Years 0.00 $0.0000 $28.06 1/1/2014 0.00 $28.06 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4176 0 999 Years 0.00 $0.0000 $53.89 1/1/2014 0.00 $53.89 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4178 0 999 Years 0.00 $0.0000 $64.69 1/1/2014 0.00 $64.69 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4180 0 999 Years 0.00 $0.0000 $27.42 1/1/2014 0.00 $27.42 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4185 0 999 Years 0.00 $0.0000 $12.63 1/1/2014 0.00 $12.63 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4189 0 999 Years 0.00 $0.0000 $199.85 1/1/2014 0.00 $199.85 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4193 0 999 Years 0.00 $0.0000 $258.24 1/1/2014 0.00 $258.24 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4197 0 999 Years 0.00 $0.0000 $314.40 1/1/2014 0.00 $314.40 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4199 0 999 Years 0.00 $0.0000 $359.25 1/1/2014 0.00 $359.25 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4216 0 999 Years 0.00 $0.0000 $8.68 1/1/2014 0.00 $8.68 6 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4220 0 999 Years 0.00 $0.0000 $9.00 1/1/2014 0.00 $9.00 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4222 0 999 Years 0.00 $0.0000 $11.10 1/1/2014 0.00 $11.10 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B4224 0 999 Years 0.00 $0.0000 $28.11 1/1/2014 0.00 $28.11 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B5000 0 999 Years 0.00 $0.0000 $13.37 1/1/2014 0.00 $13.37 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B5100 0 999 Years 0.00 $0.0000 $5.22 1/1/2014 0.00 $5.22 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B5200 0 999 Years 0.00 $0.0000 $3.04 1/1/2016 0.00 $3.04 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES B9999 0 999 Years 0.00 $0.0000 $0.00 10/1/2010 -8.00 $0.00 5 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES L2270 0 20 Years 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 10/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES V2623 0 20 Years 0.00 $0.0000 $1,141.18 1/1/2016 0.00 $1,141.18 6 1/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES V2624 0 20 Years 0.00 $0.0000 $34.51 7/1/2014 0.00 $34.51 6 7/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES V2625 0 20 Years 0.00 $0.0000 $165.76 7/1/2014 0.00 $165.76 6 7/1/2016
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES V2626 0 20 Years 0.00 $0.0000 $114.95 7/1/2014 0.00 $114.95 6 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MEDICAL
SUPPLY
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES V2628 0 20 Years 0.00 $0.0000 $162.80 7/1/2014 0.00 $162.80 6 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES V2623 0 20 Years 0.00 $0.0000 $1,141.18 1/1/2016 0.00 $1,141.18 6 1/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES V2624 0 20 Years 0.00 $0.0000 $34.51 7/1/2014 0.00 $34.51 6 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES V2625 0 20 Years 0.00 $0.0000 $165.76 7/1/2014 0.00 $165.76 6 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES V2626 0 20 Years 0.00 $0.0000 $114.95 7/1/2014 0.00 $114.95 6 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES V2627 0 20 Years 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY 9
OTHER MEDICAL
ITEMS OR
SERVICES V2628 0 20 Years 0.00 $0.0000 $162.80 7/1/2014 0.00 $162.80 6 7/1/2016
OPTOMETRIC
GROUP 9
OTHER MEDICAL
ITEMS OR
SERVICES V2623 0 20 Years 0.00 $0.0000 $1,141.18 1/1/2016 0.00 $1,141.18 6 1/1/2016
OPTOMETRIC
GROUP 9
OTHER MEDICAL
ITEMS OR
SERVICES V2624 0 20 Years 0.00 $0.0000 $34.51 7/1/2014 0.00 $34.51 6 7/1/2016
OPTOMETRIC
GROUP 9
OTHER MEDICAL
ITEMS OR
SERVICES V2625 0 20 Years 0.00 $0.0000 $165.76 7/1/2014 0.00 $165.76 6 7/1/2016
OPTOMETRIC
GROUP 9
OTHER MEDICAL
ITEMS OR
SERVICES V2626 0 20 Years 0.00 $0.0000 $114.95 7/1/2014 0.00 $114.95 6 7/1/2016
OPTOMETRIC
GROUP 9
OTHER MEDICAL
ITEMS OR
SERVICES V2627 0 20 Years 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 7/1/2016
OPTOMETRIC
GROUP 9
OTHER MEDICAL
ITEMS OR
SERVICES V2628 0 20 Years 0.00 $0.0000 $162.80 7/1/2014 0.00 $162.80 6 7/1/2016
OPTOMETRIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES V2623 0 20 Years 0.00 $0.0000 $1,141.18 1/1/2016 0.00 $1,141.18 6 1/1/2016
OPTOMETRIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES V2624 0 20 Years 0.00 $0.0000 $34.51 7/1/2014 0.00 $34.51 6 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
OPTOMETRIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES V2625 0 20 Years 0.00 $0.0000 $165.76 7/1/2014 0.00 $165.76 6 7/1/2016
OPTOMETRIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES V2626 0 20 Years 0.00 $0.0000 $114.95 7/1/2014 0.00 $114.95 6 7/1/2016
OPTOMETRIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES V2627 0 20 Years 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 7/1/2016
OPTOMETRIS
T 9
OTHER MEDICAL
ITEMS OR
SERVICES V2628 0 20 Years 0.00 $0.0000 $162.80 7/1/2014 0.00 $162.80 6 7/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0112 0 20 Years 0.00 $0.0000 $1,132.77 5/1/2005 0.00 $1,132.77 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0120 0 20 Years 0.00 $0.0000 $16.23 2/1/1993 0.00 $16.23 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0130 0 20 Years 0.00 $0.0000 $101.68 2/1/1993 0.00 $101.68 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0140 0 20 Years 0.00 $0.0000 $45.96 4/1/1992 0.00 $45.96 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0150 0 20 Years 0.00 $0.0000 $66.89 2/1/1993 0.00 $66.89 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0160 0 20 Years 0.00 $0.0000 $133.23 2/1/1993 0.00 $133.23 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0170 0 20 Years 0.00 $0.0000 $432.04 4/1/1992 0.00 $432.04 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0172 0 20 Years 0.00 $0.0000 $88.56 4/1/1992 0.00 $88.56 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0174 0 20 Years 0.00 $0.0000 $159.67 4/1/1992 0.00 $159.67 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0180 0 20 Years 0.00 $0.0000 $253.21 4/1/1992 0.00 $253.21 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0190 0 20 Years 0.00 $0.0000 $325.78 4/1/1992 0.00 $325.78 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0200 0 20 Years 0.00 $0.0000 $374.83 4/1/1992 0.00 $374.83 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0220 0 20 Years 0.00 $0.0000 $103.23 2/1/1993 0.00 $103.23 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0450 0 20 Years 0.00 $0.0000 $130.83 6/1/2003 0.00 $130.83 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0452 0 20 Years 0.00 $0.0000 $263.81 6/1/2003 0.00 $263.81 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0454 0 20 Years 0.00 $0.0000 $275.12 6/1/2003 0.00 $275.12 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0456 0 20 Years 0.00 $0.0000 $476.61 10/1/2016 0.00 $476.61 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0458 0 20 Years 0.00 $0.0000 $661.15 6/1/2003 0.00 $661.15 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0460 0 20 Years 0.00 $0.0000 $661.15 6/1/2003 0.00 $661.15 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0462 0 20 Years 0.00 $0.0000 $661.15 5/1/2003 0.00 $661.15 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0464 0 20 Years 0.00 $0.0000 $712.30 10/1/2016 0.00 $712.30 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0466 0 20 Years 0.00 $0.0000 $322.23 5/1/2003 0.00 $322.23 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0468 0 20 Years 0.00 $0.0000 $373.07 5/1/2003 0.00 $373.07 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0470 0 20 Years 0.00 $0.0000 $479.92 5/1/2003 0.00 $479.92 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0472 0 20 Years 0.00 $0.0000 $335.00 6/1/2003 0.00 $335.00 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0480 0 20 Years 0.00 $0.0000 $1,154.28 6/1/2003 0.00 $1,154.28 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0482 0 20 Years 0.00 $0.0000 $1,167.31 6/1/2003 0.00 $1,167.31 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0484 0 20 Years 0.00 $0.0000 $1,337.75 6/1/2003 0.00 $1,337.75 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0486 0 20 Years 0.00 $0.0000 $1,443.52 6/1/2003 0.00 $1,443.52 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0488 0 20 Years 0.00 $0.0000 $913.78 7/1/2010 0.00 $913.78 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0490 0 20 Years 0.00 $0.0000 $257.49 7/1/2010 0.00 $257.49 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0491 0 20 Years 0.00 $0.0000 $621.58 1/1/2006 0.00 $621.58 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0492 0 20 Years 0.00 $0.0000 $402.85 1/1/2006 0.00 $402.85 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0621 0 20 Years 0.00 $0.0000 $75.19 1/1/2006 0.00 $75.19 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0622 0 20 Years 0.00 $0.0000 $194.97 1/1/2006 0.00 $194.97 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0623 0 20 Years 0.00 $0.0000 $197.00 7/1/2010 0.00 $197.00 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0624 0 20 Years 0.00 $0.0000 $0.00 1/1/2006 $0.00 5 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0625 0 20 Years 0.00 $0.0000 $44.59 1/1/2006 0.00 $44.59 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0626 0 20 Years 0.00 $0.0000 $63.09 1/1/2006 0.00 $63.09 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0627 0 20 Years 0.00 $0.0000 $332.68 1/1/2006 0.00 $332.68 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0628 0 20 Years 0.00 $0.0000 $67.89 1/1/2006 0.00 $67.89 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0629 0 20 Years 0.00 $0.0000 $172.21 10/1/2012 0.00 $172.21 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0630 0 20 Years 0.00 $0.0000 $131.06 1/1/2006 0.00 $131.06 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0631 0 20 Years 0.00 $0.0000 $830.85 1/1/2006 0.00 $830.85 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0632 0 20 Years 0.00 $0.0000 $648.98 7/1/2010 0.00 $648.98 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0633 0 20 Years 0.00 $0.0000 $232.08 1/1/2006 0.00 $232.08 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0634 0 20 Years 0.00 $0.0000 $368.90 10/1/2014 0.00 $368.90 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0635 0 20 Years 0.00 $0.0000 $800.80 1/1/2006 0.00 $800.80 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0636 0 20 Years 0.00 $0.0000 $1,085.59 1/1/2006 0.00 $1,085.59 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0637 0 20 Years 0.00 $0.0000 $844.89 1/1/2006 0.00 $844.89 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0638 0 20 Years 0.00 $0.0000 $1,067.44 1/1/2006 0.00 $1,067.44 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0639 0 20 Years 0.00 $0.0000 $648.94 1/1/2006 0.00 $648.94 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0640 0 20 Years 0.00 $0.0000 $846.86 1/1/2006 0.00 $846.86 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0700 0 20 Years 0.00 $0.0000 $1,267.31 4/1/1992 0.00 $1,267.31 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0710 0 20 Years 0.00 $0.0000 $1,374.07 4/1/1992 0.00 $1,374.07 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0810 0 20 Years 0.00 $0.0000 $1,708.01 4/1/1992 0.00 $1,708.01 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0820 0 20 Years 0.00 $0.0000 $1,446.90 4/1/1992 0.00 $1,446.90 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0830 0 20 Years 0.00 $0.0000 $2,198.97 4/1/1992 0.00 $2,198.97 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0859 0 20 Years 0.00 $0.0000 $1,138.35 1/1/2006 0.00 $1,138.35 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0861 0 20 Years 0.00 $0.0000 $174.46 5/1/2005 0.00 $174.46 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0970 0 20 Years 0.00 $0.0000 $100.52 2/1/1993 0.00 $100.52 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0972 0 20 Years 0.00 $0.0000 $91.26 4/1/1992 0.00 $91.26 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0974 0 20 Years 0.00 $0.0000 $123.12 4/1/1992 0.00 $123.12 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0976 0 20 Years 0.00 $0.0000 $124.91 4/1/1992 0.00 $124.91 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0978 0 20 Years 0.00 $0.0000 $125.35 4/1/1992 0.00 $125.35 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0980 0 20 Years 0.00 $0.0000 $15.12 2/1/1993 0.00 $15.12 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0982 0 20 Years 0.00 $0.0000 $18.38 7/1/2010 0.00 $18.38 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0984 0 20 Years 0.00 $0.0000 $39.55 4/1/1994 0.00 $39.55 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L0999 0 20 Years 0.00 $0.0000 $0.00 3/1/1998 $0.00 5 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1000 0 20 Years 0.00 $0.0000 $1,401.85 4/1/1992 0.00 $1,401.85 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1001 0 20 Years 0.00 $0.0000 $0.00 7/1/2010 $0.00 5 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1005 0 20 Years 0.00 $0.0000 $2,913.48 7/1/2010 0.00 $2,913.48 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1010 0 20 Years 0.00 $0.0000 $48.92 4/1/1992 0.00 $48.92 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1020 0 20 Years 0.00 $0.0000 $70.61 4/1/1992 0.00 $70.61 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1025 0 20 Years 0.00 $0.0000 $75.04 2/1/1993 0.00 $75.04 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1030 0 20 Years 0.00 $0.0000 $54.07 2/1/1993 0.00 $54.07 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1040 0 20 Years 0.00 $0.0000 $53.81 4/1/1992 0.00 $53.81 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1050 0 20 Years 0.00 $0.0000 $70.25 4/1/1992 0.00 $70.25 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1060 0 20 Years 0.00 $0.0000 $64.37 4/1/1992 0.00 $64.37 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1070 0 20 Years 0.00 $0.0000 $63.21 4/1/1992 0.00 $63.21 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1080 0 20 Years 0.00 $0.0000 $36.59 4/1/1992 0.00 $36.59 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1085 0 20 Years 0.00 $0.0000 $115.21 4/1/1992 0.00 $115.21 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1090 0 20 Years 0.00 $0.0000 $63.31 4/1/1992 0.00 $63.31 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1100 0 20 Years 0.00 $0.0000 $113.45 4/1/1992 0.00 $113.45 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1110 0 20 Years 0.00 $0.0000 $160.05 4/1/1992 0.00 $160.05 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1120 0 20 Years 0.00 $0.0000 $29.34 4/1/1992 0.00 $29.34 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1200 0 20 Years 0.00 $0.0000 $1,093.40 4/1/1992 0.00 $1,093.40 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1210 0 20 Years 0.00 $0.0000 $187.16 4/1/1992 0.00 $187.16 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1220 0 20 Years 0.00 $0.0000 $153.62 4/1/1992 0.00 $153.62 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1230 0 20 Years 0.00 $0.0000 $356.44 4/1/1992 0.00 $356.44 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1240 0 20 Years 0.00 $0.0000 $54.17 4/1/1992 0.00 $54.17 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1250 0 20 Years 0.00 $0.0000 $52.80 4/1/1992 0.00 $52.80 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1260 0 20 Years 0.00 $0.0000 $54.01 4/1/1992 0.00 $54.01 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1270 0 20 Years 0.00 $0.0000 $54.76 4/1/1992 0.00 $54.76 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1280 0 20 Years 0.00 $0.0000 $54.52 4/1/1992 0.00 $54.52 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1290 0 20 Years 0.00 $0.0000 $46.56 4/1/1992 0.00 $46.56 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1300 0 20 Years 0.00 $0.0000 $1,263.59 4/1/1992 0.00 $1,263.59 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1310 0 20 Years 0.00 $0.0000 $1,169.90 4/1/1992 0.00 $1,169.90 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1499 0 20 Years 0.00 $0.0000 $0.00 4/1/1992 $0.00 5 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1600 0 20 Years 0.00 $0.0000 $108.27 2/1/1993 0.00 $108.27 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1610 0 20 Years 0.00 $0.0000 $27.71 4/1/1992 0.00 $27.71 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1620 0 20 Years 0.00 $0.0000 $81.01 4/1/1992 0.00 $81.01 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1630 0 20 Years 0.00 $0.0000 $102.31 2/1/1993 0.00 $102.31 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1640 0 20 Years 0.00 $0.0000 $350.48 4/1/1992 0.00 $350.48 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1650 0 20 Years 0.00 $0.0000 $141.06 2/1/1993 0.00 $141.06 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1652 0 20 Years 0.00 $0.0000 $288.51 6/1/2003 0.00 $288.51 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1660 0 20 Years 0.00 $0.0000 $143.87 2/1/1993 0.00 $143.87 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1680 0 20 Years 0.00 $0.0000 $965.59 4/1/1992 0.00 $965.59 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1685 0 20 Years 0.00 $0.0000 $798.83 4/1/1992 0.00 $798.83 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1686 0 20 Years 0.00 $0.0000 $545.87 4/1/1992 0.00 $545.87 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1690 0 20 Years 0.00 $0.0000 $1,463.38 3/1/1999 0.00 $1,463.38 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1700 0 20 Years 0.00 $0.0000 $1,089.85 4/1/1992 0.00 $1,089.85 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1710 0 20 Years 0.00 $0.0000 $1,414.76 4/1/1992 0.00 $1,414.76 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1720 0 20 Years 0.00 $0.0000 $1,086.70 4/1/1992 0.00 $1,086.70 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1730 0 20 Years 0.00 $0.0000 $788.98 4/1/1992 0.00 $788.98 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1755 0 20 Years 0.00 $0.0000 $1,057.74 4/1/1992 0.00 $1,057.74 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1810 0 20 Years 0.00 $0.0000 $72.68 4/1/1992 0.00 $72.68 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1820 0 20 Years 0.00 $0.0000 $93.43 4/1/1992 0.00 $93.43 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1830 0 20 Years 0.00 $0.0000 $53.08 2/1/1993 0.00 $53.08 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1831 0 20 Years 0.00 $0.0000 $238.21 5/1/2005 0.00 $238.21 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1832 0 20 Years 0.00 $0.0000 $359.45 2/1/1993 0.00 $359.45 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1834 0 20 Years 0.00 $0.0000 $458.24 2/1/1993 0.00 $458.24 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1836 0 20 Years 0.00 $0.0000 $107.98 6/1/2003 0.00 $107.98 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1840 0 20 Years 0.00 $0.0000 $651.36 4/1/1992 0.00 $651.36 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1843 0 20 Years 0.00 $0.0000 $637.97 4/1/2015 0.00 $637.97 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1844 0 20 Years 0.00 $0.0000 $1,103.63 4/1/2015 0.00 $1,103.63 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1845 0 20 Years 0.00 $0.0000 $619.42 4/1/2015 0.00 $619.42 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1846 0 20 Years 0.00 $0.0000 $776.22 4/1/2015 0.00 $776.22 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1847 0 20 Years 0.00 $0.0000 $435.27 3/1/1999 0.00 $435.27 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1850 0 20 Years 0.00 $0.0000 $206.43 4/1/1992 0.00 $206.43 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1860 0 20 Years 0.00 $0.0000 $706.05 4/1/1992 0.00 $706.05 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1900 0 20 Years 0.00 $0.0000 $207.61 4/1/1992 0.00 $207.61 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1902 0 20 Years 0.00 $0.0000 $64.87 4/1/1992 0.00 $64.87 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1904 0 20 Years 0.00 $0.0000 $295.75 4/1/1992 0.00 $295.75 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1906 0 20 Years 0.00 $0.0000 $75.16 4/1/1992 0.00 $75.16 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1907 0 20 Years 0.00 $0.0000 $445.42 5/1/2005 0.00 $445.42 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1910 0 20 Years 0.00 $0.0000 $173.59 4/1/1992 0.00 $173.59 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1920 0 20 Years 0.00 $0.0000 $234.41 4/1/1992 0.00 $234.41 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1930 0 20 Years 0.00 $0.0000 $190.95 4/1/1992 0.00 $190.95 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1932 0 20 Years 0.00 $0.0000 $812.30 7/1/2010 0.00 $812.30 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1940 0 20 Years 0.00 $0.0000 $316.47 4/1/1992 0.00 $316.47 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1945 0 20 Years 0.00 $0.0000 $545.70 2/1/1993 0.00 $545.70 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1950 0 20 Years 0.00 $0.0000 $469.11 2/1/1993 0.00 $469.11 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1951 0 20 Years 0.00 $0.0000 $679.71 5/1/2005 0.00 $679.71 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1960 0 20 Years 0.00 $0.0000 $362.49 4/1/1992 0.00 $362.49 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1970 0 20 Years 0.00 $0.0000 $427.73 2/1/1993 0.00 $427.73 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1971 0 20 Years 0.00 $0.0000 $379.96 5/1/2005 0.00 $379.96 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1980 0 20 Years 0.00 $0.0000 $233.80 4/1/1992 0.00 $233.80 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L1990 0 20 Years 0.00 $0.0000 $306.84 4/1/1992 0.00 $306.84 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2000 0 20 Years 0.00 $0.0000 $652.40 4/1/1992 0.00 $652.40 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2005 0 20 Years 0.00 $0.0000 $3,730.06 7/1/2010 0.00 $3,730.06 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2010 0 20 Years 0.00 $0.0000 $623.27 4/1/1992 0.00 $623.27 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2020 0 20 Years 0.00 $0.0000 $746.78 4/1/1992 0.00 $746.78 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2030 0 20 Years 0.00 $0.0000 $657.28 4/1/1992 0.00 $657.28 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2034 0 20 Years 0.00 $0.0000 $1,006.31 10/1/2016 0.00 $1,006.31 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2035 0 20 Years 0.00 $0.0000 $157.70 7/1/2010 0.00 $157.70 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2036 0 20 Years 0.00 $0.0000 $1,168.65 4/1/1992 0.00 $1,168.65 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2037 0 20 Years 0.00 $0.0000 $997.41 2/1/1993 0.00 $997.41 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2038 0 20 Years 0.00 $0.0000 $861.39 2/1/1993 0.00 $861.39 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2040 0 20 Years 0.00 $0.0000 $102.63 4/1/1992 0.00 $102.63 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2050 0 20 Years 0.00 $0.0000 $359.39 4/1/1992 0.00 $359.39 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2060 0 20 Years 0.00 $0.0000 $410.81 4/1/1992 0.00 $410.81 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2070 0 20 Years 0.00 $0.0000 $85.68 4/1/1992 0.00 $85.68 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2080 0 20 Years 0.00 $0.0000 $224.80 4/1/1992 0.00 $224.80 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2090 0 20 Years 0.00 $0.0000 $278.67 4/1/1992 0.00 $278.67 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2106 0 20 Years 0.00 $0.0000 $493.86 4/1/1992 0.00 $493.86 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2108 0 20 Years 0.00 $0.0000 $718.65 4/1/1992 0.00 $718.65 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2112 0 20 Years 0.00 $0.0000 $358.72 4/1/1992 0.00 $358.72 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2114 0 20 Years 0.00 $0.0000 $423.09 4/1/1992 0.00 $423.09 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2116 0 20 Years 0.00 $0.0000 $483.40 4/1/1992 0.00 $483.40 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2126 0 20 Years 0.00 $0.0000 $810.38 4/1/1992 0.00 $810.38 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2128 0 20 Years 0.00 $0.0000 $1,067.39 4/1/1992 0.00 $1,067.39 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2132 0 20 Years 0.00 $0.0000 $554.14 4/1/1992 0.00 $554.14 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2134 0 20 Years 0.00 $0.0000 $704.90 4/1/1992 0.00 $704.90 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2136 0 20 Years 0.00 $0.0000 $807.30 4/1/1992 0.00 $807.30 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2180 0 20 Years 0.00 $0.0000 $72.02 2/1/1993 0.00 $72.02 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2182 0 20 Years 0.00 $0.0000 $65.92 4/1/1992 0.00 $65.92 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2184 0 20 Years 0.00 $0.0000 $83.29 4/1/1992 0.00 $83.29 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2186 0 20 Years 0.00 $0.0000 $90.84 2/1/1993 0.00 $90.84 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2188 0 20 Years 0.00 $0.0000 $223.40 4/1/1992 0.00 $223.40 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2190 0 20 Years 0.00 $0.0000 $59.72 4/1/1992 0.00 $59.72 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2192 0 20 Years 0.00 $0.0000 $248.54 4/1/1992 0.00 $248.54 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2200 0 20 Years 0.00 $0.0000 $42.89 2/1/1993 0.00 $42.89 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2210 0 20 Years 0.00 $0.0000 $39.01 2/1/1993 0.00 $39.01 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2220 0 20 Years 0.00 $0.0000 $54.26 4/1/1992 0.00 $54.26 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2230 0 20 Years 0.00 $0.0000 $51.39 4/1/1992 0.00 $51.39 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2232 0 20 Years 0.00 $0.0000 $87.95 7/1/2010 0.00 $87.95 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2240 0 20 Years 0.00 $0.0000 $54.17 4/1/1992 0.00 $54.17 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2250 0 20 Years 0.00 $0.0000 $214.36 2/1/1993 0.00 $214.36 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2260 0 20 Years 0.00 $0.0000 $131.16 4/1/1992 0.00 $131.16 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2265 0 20 Years 0.00 $0.0000 $81.13 4/1/1992 0.00 $81.13 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2270 0 20 Years 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2275 0 20 Years 0.00 $0.0000 $85.14 4/1/1994 0.00 $85.14 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2280 0 20 Years 0.00 $0.0000 $283.17 4/1/1992 0.00 $283.17 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2300 0 20 Years 0.00 $0.0000 $239.35 2/1/1993 0.00 $239.35 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2310 0 20 Years 0.00 $0.0000 $103.81 2/1/1993 0.00 $103.81 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2320 0 20 Years 0.00 $0.0000 $139.77 4/1/1992 0.00 $139.77 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2330 0 20 Years 0.00 $0.0000 $284.59 4/1/1992 0.00 $284.59 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2335 0 20 Years 0.00 $0.0000 $137.32 2/1/1993 0.00 $137.32 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2340 0 20 Years 0.00 $0.0000 $374.49 4/1/1992 0.00 $374.49 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2350 0 20 Years 0.00 $0.0000 $601.46 4/1/1992 0.00 $601.46 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2360 0 20 Years 0.00 $0.0000 $43.78 4/1/1992 0.00 $43.78 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2370 0 20 Years 0.00 $0.0000 $171.90 4/1/1992 0.00 $171.90 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2375 0 20 Years 0.00 $0.0000 $96.10 4/1/1992 0.00 $96.10 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2380 0 20 Years 0.00 $0.0000 $104.33 2/1/1993 0.00 $104.33 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2385 0 20 Years 0.00 $0.0000 $87.90 4/1/1992 0.00 $87.90 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2387 0 20 Years 0.00 $0.0000 $87.90 1/1/2006 0.00 $87.90 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2390 0 20 Years 0.00 $0.0000 $65.06 2/1/1993 0.00 $65.06 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2395 0 20 Years 0.00 $0.0000 $122.70 4/1/1992 0.00 $122.70 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2397 0 20 Years 0.00 $0.0000 $99.23 1/1/2010 0.00 $99.23 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2405 0 20 Years 0.00 $0.0000 $66.64 9/1/2000 0.00 $66.64 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2415 0 20 Years 0.00 $0.0000 $92.84 10/1/2000 0.00 $92.84 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2425 0 20 Years 0.00 $0.0000 $109.55 10/1/2000 0.00 $109.55 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2430 0 20 Years 0.00 $0.0000 $109.55 9/1/2000 0.00 $109.55 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2492 0 20 Years 0.00 $0.0000 $73.30 4/1/1992 0.00 $73.30 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2500 0 20 Years 0.00 $0.0000 $242.91 4/1/1992 0.00 $242.91 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2510 0 20 Years 0.00 $0.0000 $491.32 4/1/1992 0.00 $491.32 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2520 0 20 Years 0.00 $0.0000 $331.94 4/1/1992 0.00 $331.94 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2525 0 20 Years 0.00 $0.0000 $750.58 2/1/1993 0.00 $750.58 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2526 0 20 Years 0.00 $0.0000 $414.12 2/1/1993 0.00 $414.12 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2530 0 20 Years 0.00 $0.0000 $151.28 4/1/1992 0.00 $151.28 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2540 0 20 Years 0.00 $0.0000 $283.40 4/1/1992 0.00 $283.40 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2550 0 20 Years 0.00 $0.0000 $180.22 2/1/1993 0.00 $180.22 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2570 0 20 Years 0.00 $0.0000 $415.75 2/1/1993 0.00 $415.75 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2580 0 20 Years 0.00 $0.0000 $305.28 4/1/1992 0.00 $305.28 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2600 0 20 Years 0.00 $0.0000 $176.50 2/1/1993 0.00 $176.50 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2610 0 20 Years 0.00 $0.0000 $214.62 2/1/1993 0.00 $214.62 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2620 0 20 Years 0.00 $0.0000 $193.04 4/1/1992 0.00 $193.04 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2622 0 20 Years 0.00 $0.0000 $264.02 4/1/1992 0.00 $264.02 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2624 0 20 Years 0.00 $0.0000 $221.86 4/1/1992 0.00 $221.86 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2627 0 20 Years 0.00 $0.0000 $1,066.19 2/1/1993 0.00 $1,066.19 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2628 0 20 Years 0.00 $0.0000 $1,003.25 2/1/1993 0.00 $1,003.25 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2630 0 20 Years 0.00 $0.0000 $169.58 4/1/1992 0.00 $169.58 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2640 0 20 Years 0.00 $0.0000 $222.48 4/1/1992 0.00 $222.48 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2650 0 20 Years 0.00 $0.0000 $89.92 4/1/1992 0.00 $89.92 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2660 0 20 Years 0.00 $0.0000 $153.81 2/1/1993 0.00 $153.81 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2670 0 20 Years 0.00 $0.0000 $145.46 2/1/1993 0.00 $145.46 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2680 0 20 Years 0.00 $0.0000 $134.83 2/1/1993 0.00 $134.83 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2750 0 20 Years 0.00 $0.0000 $70.61 2/1/1993 0.00 $70.61 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2755 0 20 Years 0.00 $0.0000 $96.94 2/1/1997 0.00 $96.94 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2760 0 20 Years 0.00 $0.0000 $53.36 4/1/1992 0.00 $53.36 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2768 0 20 Years 0.00 $0.0000 $118.60 7/1/2010 0.00 $118.60 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2780 0 20 Years 0.00 $0.0000 $39.61 2/1/1993 0.00 $39.61 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2785 0 20 Years 0.00 $0.0000 $19.13 2/1/1993 0.00 $19.13 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2795 0 20 Years 0.00 $0.0000 $67.38 4/1/1992 0.00 $67.38 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2800 0 20 Years 0.00 $0.0000 $70.61 4/1/1992 0.00 $70.61 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2810 0 20 Years 0.00 $0.0000 $54.70 4/1/1992 0.00 $54.70 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2820 0 20 Years 0.00 $0.0000 $52.60 2/1/1993 0.00 $52.60 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2830 0 20 Years 0.00 $0.0000 $57.67 2/1/1993 0.00 $57.67 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2840 0 20 Years 0.00 $0.0000 $36.79 2/1/1993 0.00 $36.79 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2850 0 20 Years 0.00 $0.0000 $46.09 4/1/1992 0.00 $46.09 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2861 0 20 Years 0.00 $0.0000 $290.28 10/1/2016 0.00 $290.28 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L2999 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3000 0 20 Years 0.00 $0.0000 $150.54 10/1/2016 0.00 $150.54 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3001 0 20 Years 0.00 $0.0000 $63.38 10/1/2016 0.00 $63.38 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3002 0 20 Years 0.00 $0.0000 $77.39 10/1/2016 0.00 $77.39 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3003 0 20 Years 0.00 $0.0000 $83.50 10/1/2016 0.00 $83.50 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3010 0 20 Years 0.00 $0.0000 $83.50 10/1/2016 0.00 $83.50 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3020 0 20 Years 0.00 $0.0000 $95.07 10/1/2016 0.00 $95.07 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3030 0 20 Years 0.00 $0.0000 $57.56 4/1/1990 0.00 $57.56 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3031 0 20 Years 0.00 $0.0000 $116.10 10/1/2014 0.00 $116.10 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3040 0 20 Years 0.00 $0.0000 $31.05 4/1/1990 0.00 $31.05 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3050 0 20 Years 0.00 $0.0000 $37.42 4/1/1990 0.00 $37.42 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3060 0 20 Years 0.00 $0.0000 $35.81 4/1/1990 0.00 $35.81 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3070 0 20 Years 0.00 $0.0000 $15.24 10/1/2016 0.00 $15.24 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3080 0 20 Years 0.00 $0.0000 $15.24 10/1/2016 0.00 $15.24 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3090 0 20 Years 0.00 $0.0000 $19.51 10/1/2016 0.00 $19.51 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3100 0 20 Years 0.00 $0.0000 $30.30 4/1/1990 0.00 $30.30 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3140 0 20 Years 0.00 $0.0000 $63.58 4/1/1992 0.00 $63.58 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3150 0 20 Years 0.00 $0.0000 $65.77 10/16/2003 0.00 $65.77 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3160 0 20 Years 0.00 $0.0000 $93.84 10/1/2016 0.00 $93.84 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3170 0 20 Years 0.00 $0.0000 $24.38 10/1/2016 0.00 $24.38 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3201 0 20 Years 0.00 $0.0000 $40.81 10/1/2016 0.00 $40.81 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3202 0 20 Years 0.00 $0.0000 $42.50 10/1/2016 0.00 $42.50 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3203 0 20 Years 0.00 $0.0000 $58.52 10/1/2012 0.00 $58.52 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3204 0 20 Years 0.00 $0.0000 $42.50 10/1/2016 0.00 $42.50 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3206 0 20 Years 0.00 $0.0000 $49.29 10/1/2016 0.00 $49.29 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3207 0 20 Years 0.00 $0.0000 $52.74 10/1/2016 0.00 $52.74 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3208 0 20 Years 0.00 $0.0000 $32.05 10/1/2016 0.00 $32.05 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3209 0 20 Years 0.00 $0.0000 $39.55 10/1/2016 0.00 $39.55 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3211 0 20 Years 0.00 $0.0000 $45.08 10/1/2016 0.00 $45.08 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3212 0 20 Years 0.00 $0.0000 $54.26 10/1/2012 0.00 $54.26 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3213 0 20 Years 0.00 $0.0000 $54.53 10/1/2016 0.00 $54.53 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3214 0 20 Years 0.00 $0.0000 $57.20 10/1/2016 0.00 $57.20 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3215 0 20 Years 0.00 $0.0000 $74.97 7/1/2010 0.00 $74.97 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3216 0 20 Years 0.00 $0.0000 $80.71 10/1/2016 0.00 $80.71 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3217 0 20 Years 0.00 $0.0000 $92.17 10/1/2016 0.00 $92.17 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3219 0 20 Years 0.00 $0.0000 $82.45 10/1/2016 0.00 $82.45 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3221 0 20 Years 0.00 $0.0000 $85.03 10/1/2016 0.00 $85.03 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3222 0 20 Years 0.00 $0.0000 $93.75 10/1/2016 0.00 $93.75 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3224 0 20 Years 0.00 $0.0000 $49.79 7/1/2010 0.00 $49.79 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3225 0 20 Years 0.00 $0.0000 $58.37 7/1/2010 0.00 $58.37 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3230 0 20 Years 0.00 $0.0000 $175.32 10/1/2016 0.00 $175.32 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3250 0 20 Years 0.00 $0.0000 $237.39 10/1/2016 0.00 $237.39 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3251 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3252 0 20 Years 0.00 $0.0000 $137.94 10/1/2014 0.00 $137.94 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3253 0 20 Years 0.00 $0.0000 $68.02 10/1/2016 0.00 $68.02 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3254 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3255 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3257 0 20 Years 0.00 $0.0000 $38.01 10/1/2016 0.00 $38.01 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3260 0 20 Years 0.00 $0.0000 $37.50 10/1/2016 0.00 $37.50 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3265 0 20 Years 0.00 $0.0000 $28.99 10/1/2012 0.00 $28.99 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3300 0 20 Years 0.00 $0.0000 $24.99 10/1/2016 0.00 $24.99 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3310 0 20 Years 0.00 $0.0000 $39.01 10/1/2016 0.00 $39.01 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3320 0 20 Years 0.00 $0.0000 $76.98 10/1/2014 0.00 $76.98 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3330 0 20 Years 0.00 $0.0000 $271.21 10/1/2016 0.00 $271.21 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3332 0 20 Years 0.00 $0.0000 $35.35 10/1/2016 0.00 $35.35 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3334 0 20 Years 0.00 $0.0000 $19.58 4/1/1990 0.00 $19.58 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3340 0 20 Years 0.00 $0.0000 $40.83 10/1/2016 0.00 $40.83 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3350 0 20 Years 0.00 $0.0000 $11.04 4/1/1990 0.00 $11.04 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3360 0 20 Years 0.00 $0.0000 $17.07 10/1/2016 0.00 $17.07 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3370 0 20 Years 0.00 $0.0000 $23.77 10/1/2016 0.00 $23.77 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3380 0 20 Years 0.00 $0.0000 $23.77 10/1/2016 0.00 $23.77 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3390 0 20 Years 0.00 $0.0000 $23.77 10/1/2016 0.00 $23.77 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3400 0 20 Years 0.00 $0.0000 $27.13 4/1/1992 0.00 $27.13 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3410 0 20 Years 0.00 $0.0000 $44.51 10/1/2016 0.00 $44.51 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3420 0 20 Years 0.00 $0.0000 $49.33 4/1/1992 0.00 $49.33 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3430 0 20 Years 0.00 $0.0000 $76.79 10/1/2016 0.00 $76.79 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3440 0 20 Years 0.00 $0.0000 $36.58 10/1/2016 0.00 $36.58 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3450 0 20 Years 0.00 $0.0000 $50.58 10/1/2016 0.00 $50.58 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3455 0 20 Years 0.00 $0.0000 $19.51 10/1/2016 0.00 $19.51 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3460 0 20 Years 0.00 $0.0000 $16.45 10/1/2016 0.00 $16.45 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3465 0 20 Years 0.00 $0.0000 $28.04 10/1/2016 0.00 $28.04 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3470 0 20 Years 0.00 $0.0000 $29.86 10/1/2016 0.00 $29.86 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3480 0 20 Years 0.00 $0.0000 $29.86 10/1/2016 0.00 $29.86 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3485 0 20 Years 0.00 $0.0000 $24.45 10/1/2016 0.00 $24.45 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3500 0 20 Years 0.00 $0.0000 $14.03 10/1/2016 0.00 $14.03 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3510 0 20 Years 0.00 $0.0000 $14.03 10/1/2016 0.00 $14.03 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3520 0 20 Years 0.00 $0.0000 $22.75 4/1/1990 0.00 $22.75 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3530 0 20 Years 0.00 $0.0000 $21.60 4/1/1990 0.00 $21.60 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3540 0 20 Years 0.00 $0.0000 $28.80 4/1/1990 0.00 $28.80 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3550 0 20 Years 0.00 $0.0000 $4.28 10/1/2016 0.00 $4.28 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3560 0 20 Years 0.00 $0.0000 $10.96 10/1/2016 0.00 $10.96 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3570 0 20 Years 0.00 $0.0000 $40.83 10/1/2016 0.00 $40.83 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3580 0 20 Years 0.00 $0.0000 $31.08 10/1/2016 0.00 $31.08 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3590 0 20 Years 0.00 $0.0000 $25.60 10/1/2016 0.00 $25.60 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3595 0 20 Years 0.00 $0.0000 $38.19 7/1/2010 0.00 $38.19 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3600 0 20 Years 0.00 $0.0000 $42.36 10/1/2016 0.00 $42.36 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3610 0 20 Years 0.00 $0.0000 $65.56 10/1/2016 0.00 $65.56 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3620 0 20 Years 0.00 $0.0000 $45.38 10/1/2016 0.00 $45.38 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3630 0 20 Years 0.00 $0.0000 $84.15 10/1/2016 0.00 $84.15 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3640 0 20 Years 0.00 $0.0000 $33.72 10/1/2016 0.00 $33.72 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3649 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3650 0 20 Years 0.00 $0.0000 $35.92 2/1/1993 0.00 $35.92 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3660 0 20 Years 0.00 $0.0000 $64.20 2/1/1993 0.00 $64.20 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3670 0 20 Years 0.00 $0.0000 $71.27 4/1/1992 0.00 $71.27 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3671 0 20 Years 0.00 $0.0000 $392.97 10/1/2016 0.00 $392.97 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3674 0 20 Years 0.00 $0.0000 $758.81 1/1/2011 0.00 $758.81 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3675 0 20 Years 0.00 $0.0000 $120.86 3/1/1999 0.00 $120.86 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3677 0 20 Years 0.00 $0.0000 $158.05 10/1/2012 0.00 $158.05 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3702 0 20 Years 0.00 $0.0000 $125.94 10/1/2016 0.00 $125.94 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3710 0 20 Years 0.00 $0.0000 $92.68 4/1/1992 0.00 $92.68 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3720 0 20 Years 0.00 $0.0000 $481.91 4/1/1992 0.00 $481.91 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3730 0 20 Years 0.00 $0.0000 $755.94 4/1/1992 0.00 $755.94 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3740 0 20 Years 0.00 $0.0000 $960.24 4/1/1992 0.00 $960.24 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3760 0 20 Years 0.00 $0.0000 $364.35 4/1/2001 0.00 $364.35 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3762 0 20 Years 0.00 $0.0000 $79.21 6/1/2003 0.00 $79.21 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3763 0 20 Years 0.00 $0.0000 $305.34 10/1/2016 0.00 $305.34 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3764 0 20 Years 0.00 $0.0000 $364.35 1/1/2006 0.00 $364.35 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3765 0 20 Years 0.00 $0.0000 $559.21 10/1/2016 0.00 $559.21 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3766 0 20 Years 0.00 $0.0000 $833.68 1/1/2006 0.00 $833.68 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3806 0 20 Years 0.00 $0.0000 $348.98 1/1/2007 0.00 $348.98 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3807 0 20 Years 0.00 $0.0000 $207.15 7/1/2010 0.00 $207.15 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3808 0 20 Years 0.00 $0.0000 $216.81 1/1/2007 0.00 $216.81 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3891 0 20 Years 0.00 $0.0000 $256.13 10/1/2016 0.00 $256.13 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3900 0 20 Years 0.00 $0.0000 $833.68 4/1/1992 0.00 $833.68 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3901 0 20 Years 0.00 $0.0000 $979.40 4/1/1992 0.00 $979.40 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3904 0 20 Years 0.00 $0.0000 $1,715.16 2/1/1993 0.00 $1,715.16 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3905 0 20 Years 0.00 $0.0000 $821.55 7/1/2010 0.00 $821.55 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3906 0 20 Years 0.00 $0.0000 $247.71 4/1/1992 0.00 $247.71 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3908 0 20 Years 0.00 $0.0000 $38.25 4/1/1992 0.00 $38.25 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3912 0 20 Years 0.00 $0.0000 $73.60 4/1/1992 0.00 $73.60 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3913 0 20 Years 0.00 $0.0000 $184.18 1/1/2006 0.00 $184.18 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3915 0 20 Years 0.00 $0.0000 $408.38 1/1/2007 0.00 $408.38 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3917 0 20 Years 0.00 $0.0000 $77.79 5/1/2005 0.00 $77.79 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3919 0 20 Years 0.00 $0.0000 $184.18 1/1/2006 0.00 $184.18 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3921 0 20 Years 0.00 $0.0000 $184.18 1/1/2006 0.00 $184.18 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3923 0 20 Years 0.00 $0.0000 $37.94 10/1/2016 0.00 $37.94 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3925 0 20 Years 0.00 $0.0000 $32.68 1/1/2008 0.00 $32.68 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3927 0 20 Years 0.00 $0.0000 $28.99 7/1/2010 0.00 $28.99 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3929 0 20 Years 0.00 $0.0000 $64.25 1/1/2008 0.00 $64.25 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3931 0 20 Years 0.00 $0.0000 $118.54 1/1/2008 0.00 $118.54 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3933 0 20 Years 0.00 $0.0000 $93.06 10/1/2016 0.00 $93.06 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3935 0 20 Years 0.00 $0.0000 $96.37 10/1/2016 0.00 $96.37 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3956 0 20 Years 0.00 $0.0000 $120.00 10/1/2012 0.00 $120.00 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3960 0 20 Years 0.00 $0.0000 $580.17 4/1/1992 0.00 $580.17 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3961 0 20 Years 0.00 $0.0000 $732.73 10/1/2016 0.00 $732.73 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3962 0 20 Years 0.00 $0.0000 $417.08 4/1/1992 0.00 $417.08 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3967 0 20 Years 0.00 $0.0000 $865.12 10/1/2016 0.00 $865.12 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3971 0 20 Years 0.00 $0.0000 $959.63 1/1/2006 0.00 $959.63 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3973 0 20 Years 0.00 $0.0000 $959.63 1/1/2006 0.00 $959.63 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3975 0 20 Years 0.00 $0.0000 $732.73 10/1/2016 0.00 $732.73 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3976 0 20 Years 0.00 $0.0000 $732.73 10/1/2016 0.00 $732.73 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3977 0 20 Years 0.00 $0.0000 $959.63 1/1/2006 0.00 $959.63 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3978 0 20 Years 0.00 $0.0000 $959.63 1/1/2006 0.00 $959.63 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3980 0 20 Years 0.00 $0.0000 $241.80 4/1/1992 0.00 $241.80 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3982 0 20 Years 0.00 $0.0000 $244.05 4/1/1992 0.00 $244.05 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3984 0 20 Years 0.00 $0.0000 $219.92 4/1/1992 0.00 $219.92 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3995 0 20 Years 0.00 $0.0000 $35.33 7/1/2010 0.00 $35.33 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3999 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4000 0 20 Years 0.00 $0.0000 $761.56 10/1/2016 0.00 $761.56 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4002 0 20 Years 0.00 $0.0000 $21.25 10/1/2016 0.00 $21.25 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4010 0 20 Years 0.00 $0.0000 $427.04 10/1/2016 0.00 $427.04 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4020 0 20 Years 0.00 $0.0000 $483.00 10/1/2016 0.00 $483.00 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4030 0 20 Years 0.00 $0.0000 $293.52 10/1/2016 0.00 $293.52 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4040 0 20 Years 0.00 $0.0000 $191.30 10/1/2016 0.00 $191.30 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4045 0 20 Years 0.00 $0.0000 $146.21 10/1/2016 0.00 $146.21 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4050 0 20 Years 0.00 $0.0000 $184.01 10/1/2016 0.00 $184.01 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4055 0 20 Years 0.00 $0.0000 $121.38 10/1/2016 0.00 $121.38 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4060 0 20 Years 0.00 $0.0000 $195.60 2/1/1993 0.00 $195.60 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4070 0 20 Years 0.00 $0.0000 $224.97 10/1/2016 0.00 $224.97 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4080 0 20 Years 0.00 $0.0000 $56.89 10/1/2016 0.00 $56.89 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4090 0 20 Years 0.00 $0.0000 $69.75 10/1/2016 0.00 $69.75 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4100 0 20 Years 0.00 $0.0000 $69.40 4/1/1992 0.00 $69.40 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4110 0 20 Years 0.00 $0.0000 $54.60 10/1/2016 0.00 $54.60 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4130 0 20 Years 0.00 $0.0000 $378.33 4/1/1992 0.00 $378.33 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4205 0 20 Years 0.00 $0.0000 $28.00 7/1/2014 0.00 $28.00 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4210 0 20 Years 0.00 $0.0000 $59.00 10/1/2012 0.00 $59.00 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4350 0 20 Years 0.00 $0.0000 $53.78 2/1/1993 0.00 $53.78 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4360 0 20 Years 0.00 $0.0000 $162.84 2/1/1993 0.00 $162.84 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4370 0 20 Years 0.00 $0.0000 $113.23 2/1/1993 0.00 $113.23 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4386 0 20 Years 0.00 $0.0000 $128.33 6/1/2003 0.00 $128.33 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4392 0 20 Years 0.00 $0.0000 $17.46 2/1/1997 0.00 $17.46 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4394 0 20 Years 0.00 $0.0000 $14.45 10/1/2016 0.00 $14.45 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4396 0 20 Years 0.00 $0.0000 $124.50 2/1/1997 0.00 $124.50 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4398 0 20 Years 0.00 $0.0000 $57.31 2/1/1997 0.00 $57.31 6 10/1/2016
ORTHOTIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L4631 0 20 Years 0.00 $0.0000 $1,377.40 10/1/2012 0.00 $1,377.40 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4570 0 999 Years 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 1/1/2015
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4690 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2270 0 20 Years 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7368 0 999 Years 0.00 $0.0000 $409.27 5/1/2003 0.00 $409.27 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8603 0 999 Years 0.00 $0.0000 $394.97 4/1/2010 0.00 $394.97 0.00 $0.0000 $394.97 4/1/2010 0.00 $394.97 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8604 0 999 Years 0.00 $0.0000 $198.49 7/1/2010 0.00 $198.49 0.00 $0.0000 $198.49 7/1/2010 0.00 $198.49 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8606 0 999 Years 0.00 $0.0000 $198.49 4/1/2010 0.00 $198.49 0.00 $0.0000 $198.49 4/1/2010 0.00 $198.49 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8615 1 999 Years 0.00 $0.0000 $365.74 2/1/2006 0.00 $365.74 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8616 1 999 Years 0.00 $0.0000 $85.19 2/1/2006 0.00 $85.19 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8617 1 999 Years 0.00 $0.0000 $74.40 2/1/2006 0.00 $74.40 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8618 1 999 Years 0.00 $0.0000 $21.25 2/1/2006 0.00 $21.25 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8619 1 999 Years 0.00 $0.0000 $6,663.57 2/1/2006 0.00 $6,663.57 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8627 1 999 Years 0.00 $0.0000 $6,366.34 1/1/2010 0.00 $6,366.34 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8628 1 999 Years 0.00 $0.0000 $1,128.30 1/1/2010 0.00 $1,128.30 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8629 1 999 Years 0.00 $0.0000 $167.07 10/1/2012 0.00 $167.07 10/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2623 0 20 Years 0.00 $0.0000 $1,141.18 1/1/2016 0.00 $1,141.18 6 1/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2624 0 20 Years 0.00 $0.0000 $34.51 7/1/2014 0.00 $34.51 6 7/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2625 0 20 Years 0.00 $0.0000 $165.76 7/1/2014 0.00 $165.76 6 7/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2626 0 20 Years 0.00 $0.0000 $114.95 7/1/2014 0.00 $114.95 6 7/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2627 0 20 Years 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 7/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2628 0 20 Years 0.00 $0.0000 $162.80 7/1/2014 0.00 $162.80 6 7/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2630 0 999 Years 0.00 $0.0000 $73.60 7/1/2014 0.00 $73.60 7/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2631 0 999 Years 0.00 $0.0000 $0.00 7/1/2010 -8.00 $0.00 5 6 7/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2632 0 999 Years 0.00 $0.0000 $124.20 7/1/2014 0.00 $124.20 6 7/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2799 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 7/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4570 0 999 Years 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 1/1/2015
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4690 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2270 0 20 Years 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7368 0 999 Years 0.00 $0.0000 $409.27 5/1/2003 0.00 $409.27 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8603 0 999 Years 0.00 $0.0000 $394.97 4/1/2010 0.00 $394.97 0.00 $0.0000 $394.97 4/1/2010 0.00 $394.97 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8604 0 999 Years 0.00 $0.0000 $198.49 7/1/2010 0.00 $198.49 0.00 $0.0000 $198.49 7/1/2010 0.00 $198.49 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8606 0 999 Years 0.00 $0.0000 $198.49 4/1/2010 0.00 $198.49 0.00 $0.0000 $198.49 4/1/2010 0.00 $198.49 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8615 1 999 Years 0.00 $0.0000 $365.74 2/1/2006 0.00 $365.74 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8616 1 999 Years 0.00 $0.0000 $85.19 2/1/2006 0.00 $85.19 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8617 1 999 Years 0.00 $0.0000 $74.40 2/1/2006 0.00 $74.40 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8618 1 999 Years 0.00 $0.0000 $21.25 2/1/2006 0.00 $21.25 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8619 1 999 Years 0.00 $0.0000 $6,663.57 2/1/2006 0.00 $6,663.57 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8627 1 999 Years 0.00 $0.0000 $6,366.34 1/1/2010 0.00 $6,366.34 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8628 1 999 Years 0.00 $0.0000 $1,128.30 1/1/2010 0.00 $1,128.30 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8629 1 999 Years 0.00 $0.0000 $167.07 10/1/2012 0.00 $167.07 10/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2623 0 20 Years 0.00 $0.0000 $1,141.18 1/1/2016 0.00 $1,141.18 6 1/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2624 0 20 Years 0.00 $0.0000 $34.51 7/1/2014 0.00 $34.51 6 7/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2625 0 20 Years 0.00 $0.0000 $165.76 7/1/2014 0.00 $165.76 6 7/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2626 0 20 Years 0.00 $0.0000 $114.95 7/1/2014 0.00 $114.95 6 7/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2627 0 20 Years 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2628 0 20 Years 0.00 $0.0000 $162.80 7/1/2014 0.00 $162.80 6 7/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2630 0 999 Years 0.00 $0.0000 $73.60 7/1/2014 0.00 $73.60 7/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2631 0 999 Years 0.00 $0.0000 $0.00 7/1/2010 -8.00 $0.00 5 6 7/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2632 0 999 Years 0.00 $0.0000 $124.20 7/1/2014 0.00 $124.20 6 7/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2799 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 9
OTHER MEDICAL
ITEMS OR
SERVICES L8603 0 999 Years 0.00 $0.0000 $363.37 4/1/2010 0.00 $363.37 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 9
OTHER MEDICAL
ITEMS OR
SERVICES L8606 0 999 Years 0.00 $0.0000 $182.61 4/1/2010 0.00 $182.61 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 9
OTHER MEDICAL
ITEMS OR
SERVICES V2627 0 20 Years 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 7/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4570 0 999 Years 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4690 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L2270 0 20 Years 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 0.00 $0.0000 $31.98 2/1/1993 0.00 $31.98 6 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L7368 0 999 Years 0.00 $0.0000 $409.27 5/1/2003 0.00 $409.27 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8603 0 999 Years 0.00 $0.0000 $394.97 4/1/2010 0.00 $394.97 0.00 $0.0000 $394.97 4/1/2010 0.00 $394.97 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8604 0 999 Years 0.00 $0.0000 $198.49 7/1/2010 0.00 $198.49 0.00 $0.0000 $198.49 7/1/2010 0.00 $198.49 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8606 0 999 Years 0.00 $0.0000 $198.49 4/1/2010 0.00 $198.49 0.00 $0.0000 $198.49 4/1/2010 0.00 $198.49 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8615 1 999 Years 0.00 $0.0000 $365.74 2/1/2006 0.00 $365.74 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8616 1 999 Years 0.00 $0.0000 $85.19 2/1/2006 0.00 $85.19 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8617 1 999 Years 0.00 $0.0000 $74.40 2/1/2006 0.00 $74.40 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8618 1 999 Years 0.00 $0.0000 $21.25 2/1/2006 0.00 $21.25 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8619 1 999 Years 0.00 $0.0000 $6,663.57 2/1/2006 0.00 $6,663.57 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8627 1 999 Years 0.00 $0.0000 $6,366.34 1/1/2010 0.00 $6,366.34 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8628 1 999 Years 0.00 $0.0000 $1,128.30 1/1/2010 0.00 $1,128.30 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES L8629 1 999 Years 0.00 $0.0000 $167.07 10/1/2012 0.00 $167.07 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2623 0 20 Years 0.00 $0.0000 $1,141.18 1/1/2016 0.00 $1,141.18 6 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2624 0 20 Years 0.00 $0.0000 $34.51 7/1/2014 0.00 $34.51 6 7/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2625 0 20 Years 0.00 $0.0000 $165.76 7/1/2014 0.00 $165.76 6 7/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2626 0 20 Years 0.00 $0.0000 $114.95 7/1/2014 0.00 $114.95 6 7/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2627 0 20 Years 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 0.00 $0.0000 $625.80 7/1/2014 0.00 $625.80 6 7/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2628 0 20 Years 0.00 $0.0000 $162.80 7/1/2014 0.00 $162.80 6 7/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2630 0 999 Years 0.00 $0.0000 $73.60 7/1/2014 0.00 $73.60 7/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2631 0 999 Years 0.00 $0.0000 $0.00 7/1/2010 -8.00 $0.00 5 6 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2632 0 999 Years 0.00 $0.0000 $124.20 7/1/2014 0.00 $124.20 6 7/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES V2799 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 6 7/1/2016
PODIATRIST 9
OTHER MEDICAL
ITEMS OR
SERVICES A5500 0 20 Years 0.00 $0.0000 $66.76 7/1/2011 -8.00 $61.42 6 1/1/2015
PODIATRIST 9
OTHER MEDICAL
ITEMS OR
SERVICES A5501 0 20 Years 0.00 $0.0000 $200.25 7/1/2011 -8.00 $184.23 6 1/1/2015
PODIATRIST 9
OTHER MEDICAL
ITEMS OR
SERVICES A5503 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
PODIATRIST 9
OTHER MEDICAL
ITEMS OR
SERVICES A5504 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
PODIATRIST 9
OTHER MEDICAL
ITEMS OR
SERVICES A5505 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
PODIATRIST 9
OTHER MEDICAL
ITEMS OR
SERVICES A5506 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
PODIATRIST 9
OTHER MEDICAL
ITEMS OR
SERVICES A5507 0 20 Years 0.00 $0.0000 $29.69 7/1/2011 -8.00 $27.31 6 1/1/2015
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L3250 0 20 Years 0.00 $0.0000 $237.39 10/1/2016 0.00 $237.39 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5000 0 20 Years 0.00 $0.0000 $456.50 4/1/1992 0.00 $456.50 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5010 0 20 Years 0.00 $0.0000 $1,030.91 4/1/1992 0.00 $1,030.91 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5020 0 20 Years 0.00 $0.0000 $1,453.68 4/1/1992 0.00 $1,453.68 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5050 0 20 Years 0.00 $0.0000 $1,834.75 4/1/1992 0.00 $1,834.75 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5060 0 20 Years 0.00 $0.0000 $2,203.30 4/1/1992 0.00 $2,203.30 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5100 0 20 Years 0.00 $0.0000 $2,041.52 4/1/1992 0.00 $2,041.52 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5105 0 20 Years 0.00 $0.0000 $2,399.36 4/1/1992 0.00 $2,399.36 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5150 0 20 Years 0.00 $0.0000 $2,753.18 4/1/1992 0.00 $2,753.18 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5160 0 20 Years 0.00 $0.0000 $2,864.71 4/1/1992 0.00 $2,864.71 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5200 0 20 Years 0.00 $0.0000 $2,652.11 4/1/1992 0.00 $2,652.11 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5210 0 20 Years 0.00 $0.0000 $1,753.37 4/1/1992 0.00 $1,753.37 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5220 0 20 Years 0.00 $0.0000 $2,204.80 4/1/1992 0.00 $2,204.80 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5230 0 20 Years 0.00 $0.0000 $2,588.51 4/1/1992 0.00 $2,588.51 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5250 0 20 Years 0.00 $0.0000 $3,804.80 4/1/1992 0.00 $3,804.80 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5270 0 20 Years 0.00 $0.0000 $3,569.42 4/1/1992 0.00 $3,569.42 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5280 0 20 Years 0.00 $0.0000 $3,904.83 4/1/1992 0.00 $3,904.83 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5301 0 20 Years 0.00 $0.0000 $2,487.62 7/1/2010 0.00 $2,487.62 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5312 0 20 Years 0.00 $0.0000 $2,547.39 1/1/2012 0.00 $2,547.39 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5321 0 20 Years 0.00 $0.0000 $3,470.57 7/1/2010 0.00 $3,470.57 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5331 0 20 Years 0.00 $0.0000 $5,224.82 7/1/2010 0.00 $5,224.82 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5341 0 20 Years 0.00 $0.0000 $5,452.42 7/1/2010 0.00 $5,452.42 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5400 0 20 Years 0.00 $0.0000 $867.54 4/1/1992 0.00 $867.54 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5410 0 20 Years 0.00 $0.0000 $383.92 2/1/1993 0.00 $383.92 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5420 0 20 Years 0.00 $0.0000 $1,182.14 4/1/1992 0.00 $1,182.14 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5430 0 20 Years 0.00 $0.0000 $470.73 2/1/1993 0.00 $470.73 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5450 0 20 Years 0.00 $0.0000 $369.17 4/1/1992 0.00 $369.17 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5460 0 20 Years 0.00 $0.0000 $484.07 2/1/1993 0.00 $484.07 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5500 0 20 Years 0.00 $0.0000 $933.65 4/1/1992 0.00 $933.65 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5505 0 20 Years 0.00 $0.0000 $1,602.55 4/1/1992 0.00 $1,602.55 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5510 0 20 Years 0.00 $0.0000 $988.76 4/1/1992 0.00 $988.76 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5520 0 20 Years 0.00 $0.0000 $1,359.06 2/1/1993 0.00 $1,359.06 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5530 0 20 Years 0.00 $0.0000 $1,373.87 4/1/1992 0.00 $1,373.87 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5535 0 20 Years 0.00 $0.0000 $1,365.25 4/1/1992 0.00 $1,365.25 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5540 0 20 Years 0.00 $0.0000 $1,481.57 4/1/1992 0.00 $1,481.57 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5560 0 20 Years 0.00 $0.0000 $1,824.08 2/1/1993 0.00 $1,824.08 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5570 0 20 Years 0.00 $0.0000 $1,675.91 4/1/1992 0.00 $1,675.91 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5580 0 20 Years 0.00 $0.0000 $1,932.25 4/1/1992 0.00 $1,932.25 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5585 0 20 Years 0.00 $0.0000 $1,861.41 4/1/1992 0.00 $1,861.41 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5590 0 20 Years 0.00 $0.0000 $1,921.37 4/1/1992 0.00 $1,921.37 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5595 0 20 Years 0.00 $0.0000 $2,614.81 2/1/1993 0.00 $2,614.81 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5600 0 20 Years 0.00 $0.0000 $2,920.67 2/1/1993 0.00 $2,920.67 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5610 0 20 Years 0.00 $0.0000 $1,590.05 1/1/2004 0.00 $1,590.05 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5611 0 20 Years 0.00 $0.0000 $1,037.38 4/1/1992 0.00 $1,037.38 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5613 0 20 Years 0.00 $0.0000 $1,654.72 4/1/1992 0.00 $1,654.72 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5614 0 20 Years 0.00 $0.0000 $1,539.04 7/1/2010 0.00 $1,539.04 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5616 0 20 Years 0.00 $0.0000 $1,260.48 2/1/1993 0.00 $1,260.48 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5617 0 20 Years 0.00 $0.0000 $404.55 2/1/1996 0.00 $404.55 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5618 0 20 Years 0.00 $0.0000 $214.55 4/1/1992 0.00 $214.55 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5620 0 20 Years 0.00 $0.0000 $256.89 2/1/1993 0.00 $256.89 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5622 0 20 Years 0.00 $0.0000 $336.07 2/1/1993 0.00 $336.07 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5624 0 20 Years 0.00 $0.0000 $335.28 2/1/1993 0.00 $335.28 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5626 0 20 Years 0.00 $0.0000 $361.14 4/1/1992 0.00 $361.14 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5628 0 20 Years 0.00 $0.0000 $409.35 4/1/1992 0.00 $409.35 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5629 0 20 Years 0.00 $0.0000 $288.62 2/1/1993 0.00 $288.62 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5630 0 20 Years 0.00 $0.0000 $314.35 4/1/1992 0.00 $314.35 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5631 0 20 Years 0.00 $0.0000 $401.22 2/1/1993 0.00 $401.22 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5632 0 20 Years 0.00 $0.0000 $136.66 2/1/1993 0.00 $136.66 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5634 0 20 Years 0.00 $0.0000 $193.96 2/1/1993 0.00 $193.96 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5636 0 20 Years 0.00 $0.0000 $166.63 4/1/1992 0.00 $166.63 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5637 0 20 Years 0.00 $0.0000 $273.73 2/1/1993 0.00 $273.73 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5638 0 20 Years 0.00 $0.0000 $324.82 4/1/1992 0.00 $324.82 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5639 0 20 Years 0.00 $0.0000 $780.06 2/1/1993 0.00 $780.06 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5640 0 20 Years 0.00 $0.0000 $408.23 2/1/1993 0.00 $408.23 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5642 0 20 Years 0.00 $0.0000 $395.66 2/1/1993 0.00 $395.66 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5643 0 20 Years 0.00 $0.0000 $1,020.37 4/1/1992 0.00 $1,020.37 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5644 0 20 Years 0.00 $0.0000 $557.05 4/1/1992 0.00 $557.05 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5645 0 20 Years 0.00 $0.0000 $491.45 4/1/1992 0.00 $491.45 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5646 0 20 Years 0.00 $0.0000 $523.55 4/1/1992 0.00 $523.55 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5647 0 20 Years 0.00 $0.0000 $497.66 2/1/1993 0.00 $497.66 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5648 0 20 Years 0.00 $0.0000 $592.57 4/1/1992 0.00 $592.57 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5649 0 20 Years 0.00 $0.0000 $1,631.89 4/1/1992 0.00 $1,631.89 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5650 0 20 Years 0.00 $0.0000 $451.75 4/1/1992 0.00 $451.75 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5651 0 20 Years 0.00 $0.0000 $938.37 4/1/1992 0.00 $938.37 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5652 0 20 Years 0.00 $0.0000 $380.62 4/1/1992 0.00 $380.62 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5653 0 20 Years 0.00 $0.0000 $395.63 4/1/1992 0.00 $395.63 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5654 0 20 Years 0.00 $0.0000 $279.67 4/1/1992 0.00 $279.67 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5655 0 20 Years 0.00 $0.0000 $245.87 2/1/1993 0.00 $245.87 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5656 0 20 Years 0.00 $0.0000 $252.74 4/1/1992 0.00 $252.74 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5658 0 20 Years 0.00 $0.0000 $233.37 4/1/1992 0.00 $233.37 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5661 0 20 Years 0.00 $0.0000 $383.31 4/1/1992 0.00 $383.31 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5665 0 20 Years 0.00 $0.0000 $332.22 4/1/1992 0.00 $332.22 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5666 0 20 Years 0.00 $0.0000 $62.90 2/1/1993 0.00 $62.90 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5668 0 20 Years 0.00 $0.0000 $90.46 2/1/1993 0.00 $90.46 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5670 0 20 Years 0.00 $0.0000 $250.47 2/1/1993 0.00 $250.47 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5671 0 20 Years 0.00 $0.0000 $518.60 7/1/2010 0.00 $518.60 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5672 0 20 Years 0.00 $0.0000 $195.10 2/1/1993 0.00 $195.10 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5673 0 20 Years 0.00 $0.0000 $587.53 7/1/2004 0.00 $587.53 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5676 0 20 Years 0.00 $0.0000 $328.32 2/1/1993 0.00 $328.32 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5677 0 20 Years 0.00 $0.0000 $462.39 2/1/1993 0.00 $462.39 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5678 0 20 Years 0.00 $0.0000 $35.56 2/1/1993 0.00 $35.56 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5679 0 20 Years 0.00 $0.0000 $489.59 7/1/2004 0.00 $489.59 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5680 0 20 Years 0.00 $0.0000 $224.64 4/1/1992 0.00 $224.64 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5681 0 20 Years 0.00 $0.0000 $1,066.68 7/1/2004 0.00 $1,066.68 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5682 0 20 Years 0.00 $0.0000 $415.03 4/1/1992 0.00 $415.03 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5683 0 20 Years 0.00 $0.0000 $1,066.68 7/1/2004 0.00 $1,066.68 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5684 0 20 Years 0.00 $0.0000 $37.99 4/1/1992 0.00 $37.99 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5685 0 20 Years 0.00 $0.0000 $77.40 1/1/2005 0.00 $77.40 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5686 0 20 Years 0.00 $0.0000 $38.61 4/1/1992 0.00 $38.61 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5688 0 20 Years 0.00 $0.0000 $58.12 2/1/1993 0.00 $58.12 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5690 0 20 Years 0.00 $0.0000 $77.77 4/1/1992 0.00 $77.77 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5692 0 20 Years 0.00 $0.0000 $124.39 2/1/1993 0.00 $124.39 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5694 0 20 Years 0.00 $0.0000 $169.28 2/1/1993 0.00 $169.28 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5695 0 20 Years 0.00 $0.0000 $151.25 2/1/1993 0.00 $151.25 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5696 0 20 Years 0.00 $0.0000 $166.43 4/1/1992 0.00 $166.43 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5697 0 20 Years 0.00 $0.0000 $52.36 4/1/1992 0.00 $52.36 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5698 0 20 Years 0.00 $0.0000 $85.11 4/1/1992 0.00 $85.11 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5699 0 20 Years 0.00 $0.0000 $116.45 2/1/1993 0.00 $116.45 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5700 0 20 Years 0.00 $0.0000 $1,988.95 4/1/1994 0.00 $1,988.95 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5701 0 20 Years 0.00 $0.0000 $2,388.59 4/1/1994 0.00 $2,388.59 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5702 0 20 Years 0.00 $0.0000 $3,021.91 4/1/1994 0.00 $3,021.91 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5703 0 20 Years 0.00 $0.0000 $1,988.95 1/1/2006 0.00 $1,988.95 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5704 0 20 Years 0.00 $0.0000 $372.09 4/1/1994 0.00 $372.09 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5705 0 20 Years 0.00 $0.0000 $664.84 4/1/1994 0.00 $664.84 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5706 0 20 Years 0.00 $0.0000 $651.74 4/1/1994 0.00 $651.74 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5707 0 20 Years 0.00 $0.0000 $859.23 4/1/1994 0.00 $859.23 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5710 0 20 Years 0.00 $0.0000 $289.90 4/1/1992 0.00 $289.90 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5711 0 20 Years 0.00 $0.0000 $370.82 4/1/1992 0.00 $370.82 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5712 0 20 Years 0.00 $0.0000 $376.43 4/1/1992 0.00 $376.43 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5714 0 20 Years 0.00 $0.0000 $300.27 4/1/1992 0.00 $300.27 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5716 0 20 Years 0.00 $0.0000 $519.58 4/1/1992 0.00 $519.58 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5718 0 20 Years 0.00 $0.0000 $613.21 4/1/1992 0.00 $613.21 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5722 0 20 Years 0.00 $0.0000 $584.63 2/1/1993 0.00 $584.63 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5724 0 20 Years 0.00 $0.0000 $1,448.26 4/1/1992 0.00 $1,448.26 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5726 0 20 Years 0.00 $0.0000 $1,656.45 4/1/1992 0.00 $1,656.45 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5728 0 20 Years 0.00 $0.0000 $1,652.69 4/1/1992 0.00 $1,652.69 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5780 0 20 Years 0.00 $0.0000 $820.29 4/1/1992 0.00 $820.29 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5785 0 20 Years 0.00 $0.0000 $372.37 4/1/1992 0.00 $372.37 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5790 0 20 Years 0.00 $0.0000 $667.39 2/1/1993 0.00 $667.39 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5795 0 20 Years 0.00 $0.0000 $946.60 2/1/1993 0.00 $946.60 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5810 0 20 Years 0.00 $0.0000 $359.77 4/1/1992 0.00 $359.77 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5811 0 20 Years 0.00 $0.0000 $525.35 4/1/1992 0.00 $525.35 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5812 0 20 Years 0.00 $0.0000 $385.99 4/1/1992 0.00 $385.99 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5814 0 20 Years 0.00 $0.0000 $3,387.27 7/1/2010 0.00 $3,387.27 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5816 0 20 Years 0.00 $0.0000 $631.91 4/1/1992 0.00 $631.91 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5818 0 20 Years 0.00 $0.0000 $641.93 4/1/1992 0.00 $641.93 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5822 0 20 Years 0.00 $0.0000 $1,028.34 4/1/1992 0.00 $1,028.34 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5824 0 20 Years 0.00 $0.0000 $1,225.63 4/1/1992 0.00 $1,225.63 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5826 0 20 Years 0.00 $0.0000 $2,848.26 7/1/2010 0.00 $2,848.26 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5828 0 20 Years 0.00 $0.0000 $1,993.68 4/1/1992 0.00 $1,993.68 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5830 0 20 Years 0.00 $0.0000 $1,370.31 4/1/1992 0.00 $1,370.31 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5840 0 20 Years 0.00 $0.0000 $1,676.92 4/1/1994 0.00 $1,676.92 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5845 0 20 Years 0.00 $0.0000 $1,634.75 7/1/2010 0.00 $1,634.75 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5848 0 20 Years 0.00 $0.0000 $871.99 6/1/2003 0.00 $871.99 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5850 0 20 Years 0.00 $0.0000 $101.67 4/1/1992 0.00 $101.67 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5855 0 20 Years 0.00 $0.0000 $238.62 4/1/1994 0.00 $238.62 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5856 0 20 Years 0.00 $0.0000 $21,894.75 7/1/2010 0.00 ####### 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5857 0 20 Years 0.00 $0.0000 $7,769.10 7/1/2010 0.00 $7,769.10 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5858 0 20 Years 0.00 $0.0000 $8,923.46 10/1/2016 0.00 $8,923.46 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5910 0 20 Years 0.00 $0.0000 $323.90 2/1/1993 0.00 $323.90 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5920 0 20 Years 0.00 $0.0000 $472.81 2/1/1993 0.00 $472.81 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5925 0 20 Years 0.00 $0.0000 $404.10 1/1/2010 0.00 $404.10 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5930 0 20 Years 0.00 $0.0000 $2,433.73 2/1/1996 0.00 $2,433.73 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5940 0 20 Years 0.00 $0.0000 $420.12 4/1/1992 0.00 $420.12 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5950 0 20 Years 0.00 $0.0000 $713.94 2/1/1993 0.00 $713.94 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5960 0 20 Years 0.00 $0.0000 $931.97 2/1/1993 0.00 $931.97 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5961 0 20 Years 0.00 $0.0000 $4,399.48 10/1/2012 0.00 $4,399.48 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5962 0 20 Years 0.00 $0.0000 $572.22 1/1/2010 0.00 $572.22 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5964 0 20 Years 0.00 $0.0000 $844.74 1/1/2010 0.00 $844.74 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5966 0 20 Years 0.00 $0.0000 $931.97 1/1/2010 0.00 $931.97 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5968 0 20 Years 0.00 $0.0000 $2,755.37 3/1/1999 0.00 $2,755.37 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5970 0 20 Years 0.00 $0.0000 $164.11 4/1/1992 0.00 $164.11 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5971 0 20 Years 0.00 $0.0000 $205.31 7/1/2010 0.00 $205.31 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5972 0 20 Years 0.00 $0.0000 $386.47 7/1/2010 0.00 $386.47 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5973 0 20 Years 0.00 $0.0000 $15,691.70 1/1/2010 0.00 ####### 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5974 0 20 Years 0.00 $0.0000 $193.89 4/1/1992 0.00 $193.89 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5975 0 20 Years 0.00 $0.0000 $351.52 3/1/1999 0.00 $351.52 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5976 0 20 Years 0.00 $0.0000 $350.00 4/1/1990 0.00 $350.00 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5978 0 20 Years 0.00 $0.0000 $252.72 4/1/1992 0.00 $252.72 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5979 0 20 Years 0.00 $0.0000 $1,584.09 4/1/1994 0.00 $1,584.09 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5980 0 20 Years 0.00 $0.0000 $2,500.00 4/1/1990 0.00 $2,500.00 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5981 0 20 Years 0.00 $0.0000 $2,500.00 1/1/2010 0.00 $2,500.00 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5982 0 20 Years 0.00 $0.0000 $392.46 4/1/1992 0.00 $392.46 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5984 0 20 Years 0.00 $0.0000 $428.19 4/1/1992 0.00 $428.19 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5985 0 20 Years 0.00 $0.0000 $204.17 2/1/1996 0.00 $204.17 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5986 0 20 Years 0.00 $0.0000 $420.19 4/1/1992 0.00 $420.19 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5987 0 20 Years 0.00 $0.0000 $5,347.10 2/1/1997 0.00 $5,347.10 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5988 0 20 Years 0.00 $0.0000 $1,514.73 3/1/1999 0.00 $1,514.73 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5990 0 20 Years 0.00 $0.0000 $1,654.66 7/1/2010 0.00 $1,654.66 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L5999 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6000 0 20 Years 0.00 $0.0000 $972.86 4/1/1992 0.00 $972.86 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6010 0 20 Years 0.00 $0.0000 $1,016.34 4/1/1992 0.00 $1,016.34 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6020 0 20 Years 0.00 $0.0000 $982.86 4/1/1992 0.00 $982.86 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6050 0 20 Years 0.00 $0.0000 $1,560.05 4/1/1992 0.00 $1,560.05 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6055 0 20 Years 0.00 $0.0000 $1,875.19 4/1/1992 0.00 $1,875.19 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6100 0 20 Years 0.00 $0.0000 $1,673.07 4/1/1992 0.00 $1,673.07 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6110 0 20 Years 0.00 $0.0000 $1,706.62 4/1/1992 0.00 $1,706.62 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6120 0 20 Years 0.00 $0.0000 $1,937.07 4/1/1992 0.00 $1,937.07 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6130 0 20 Years 0.00 $0.0000 $1,749.29 4/1/1992 0.00 $1,749.29 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6200 0 20 Years 0.00 $0.0000 $2,157.71 4/1/1992 0.00 $2,157.71 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6205 0 20 Years 0.00 $0.0000 $2,362.09 4/1/1992 0.00 $2,362.09 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6250 0 20 Years 0.00 $0.0000 $2,262.60 4/1/1992 0.00 $2,262.60 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6300 0 20 Years 0.00 $0.0000 $2,607.09 4/1/1992 0.00 $2,607.09 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6310 0 20 Years 0.00 $0.0000 $2,162.15 4/1/1992 0.00 $2,162.15 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6320 0 20 Years 0.00 $0.0000 $1,357.49 4/1/1992 0.00 $1,357.49 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6350 0 20 Years 0.00 $0.0000 $2,554.34 2/1/1993 0.00 $2,554.34 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6360 0 20 Years 0.00 $0.0000 $2,275.13 4/1/1992 0.00 $2,275.13 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6370 0 20 Years 0.00 $0.0000 $1,673.51 4/1/1992 0.00 $1,673.51 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6380 0 20 Years 0.00 $0.0000 $884.50 4/1/1992 0.00 $884.50 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6382 0 20 Years 0.00 $0.0000 $1,060.87 4/1/1992 0.00 $1,060.87 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6384 0 20 Years 0.00 $0.0000 $1,363.57 4/1/1992 0.00 $1,363.57 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6386 0 20 Years 0.00 $0.0000 $294.89 4/1/1992 0.00 $294.89 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6388 0 20 Years 0.00 $0.0000 $343.73 4/1/1992 0.00 $343.73 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6400 0 20 Years 0.00 $0.0000 $1,631.25 4/1/1992 0.00 $1,631.25 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6450 0 20 Years 0.00 $0.0000 $1,993.94 4/1/1992 0.00 $1,993.94 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6500 0 20 Years 0.00 $0.0000 $2,053.82 4/1/1992 0.00 $2,053.82 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6550 0 20 Years 0.00 $0.0000 $2,487.09 4/1/1992 0.00 $2,487.09 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6570 0 20 Years 0.00 $0.0000 $2,802.70 4/1/1992 0.00 $2,802.70 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6580 0 20 Years 0.00 $0.0000 $1,099.39 4/1/1992 0.00 $1,099.39 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6582 0 20 Years 0.00 $0.0000 $999.28 4/1/1992 0.00 $999.28 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6584 0 20 Years 0.00 $0.0000 $1,532.85 4/1/1992 0.00 $1,532.85 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6586 0 20 Years 0.00 $0.0000 $1,447.11 4/1/1992 0.00 $1,447.11 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6588 0 20 Years 0.00 $0.0000 $2,076.56 4/1/1992 0.00 $2,076.56 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6590 0 20 Years 0.00 $0.0000 $1,987.15 4/1/1992 0.00 $1,987.15 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6600 0 20 Years 0.00 $0.0000 $176.15 2/1/1993 0.00 $176.15 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6605 0 20 Years 0.00 $0.0000 $170.62 4/1/1992 0.00 $170.62 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6610 0 20 Years 0.00 $0.0000 $142.80 4/1/1992 0.00 $142.80 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6611 0 20 Years 0.00 $0.0000 $375.52 7/1/2010 0.00 $375.52 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6615 0 20 Years 0.00 $0.0000 $127.83 4/1/1992 0.00 $127.83 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6616 0 20 Years 0.00 $0.0000 $59.41 2/1/1993 0.00 $59.41 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6620 0 20 Years 0.00 $0.0000 $212.21 4/1/1992 0.00 $212.21 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6621 0 20 Years 0.00 $0.0000 $1,098.22 10/1/2016 0.00 $1,098.22 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6623 0 20 Years 0.00 $0.0000 $474.77 4/1/1992 0.00 $474.77 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6624 0 20 Years 0.00 $0.0000 $3,185.32 1/1/2007 0.00 $3,185.32 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6625 0 20 Years 0.00 $0.0000 $468.62 2/1/1993 0.00 $468.62 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6628 0 20 Years 0.00 $0.0000 $366.57 4/1/1992 0.00 $366.57 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6629 0 20 Years 0.00 $0.0000 $108.88 4/1/1992 0.00 $108.88 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6630 0 20 Years 0.00 $0.0000 $160.41 4/1/1992 0.00 $160.41 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6632 0 20 Years 0.00 $0.0000 $41.63 2/1/1993 0.00 $41.63 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6635 0 20 Years 0.00 $0.0000 $147.94 4/1/1992 0.00 $147.94 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6637 0 20 Years 0.00 $0.0000 $296.18 4/1/1992 0.00 $296.18 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6638 0 20 Years 0.00 $0.0000 $2,027.88 6/1/2003 0.00 $2,027.88 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6640 0 20 Years 0.00 $0.0000 $257.70 2/1/1993 0.00 $257.70 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6641 0 20 Years 0.00 $0.0000 $128.66 4/1/1992 0.00 $128.66 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6642 0 20 Years 0.00 $0.0000 $165.34 4/1/1992 0.00 $165.34 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6645 0 20 Years 0.00 $0.0000 $296.78 2/1/1993 0.00 $296.78 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6646 0 20 Years 0.00 $0.0000 $2,557.62 6/1/2003 0.00 $2,557.62 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6647 0 20 Years 0.00 $0.0000 $421.06 6/1/2003 0.00 $421.06 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6648 0 20 Years 0.00 $0.0000 $2,637.84 6/1/2003 0.00 $2,637.84 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6650 0 20 Years 0.00 $0.0000 $314.50 2/1/1993 0.00 $314.50 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6655 0 20 Years 0.00 $0.0000 $68.90 4/1/1992 0.00 $68.90 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6660 0 20 Years 0.00 $0.0000 $70.50 4/1/1992 0.00 $70.50 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6665 0 20 Years 0.00 $0.0000 $41.60 2/1/1993 0.00 $41.60 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6670 0 20 Years 0.00 $0.0000 $43.61 2/1/1993 0.00 $43.61 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6672 0 20 Years 0.00 $0.0000 $111.91 4/1/1992 0.00 $111.91 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6675 0 20 Years 0.00 $0.0000 $88.97 4/1/1992 0.00 $88.97 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6676 0 20 Years 0.00 $0.0000 $83.66 4/1/1992 0.00 $83.66 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6677 0 20 Years 0.00 $0.0000 $142.44 10/1/2016 0.00 $142.44 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6680 0 20 Years 0.00 $0.0000 $214.42 2/1/1993 0.00 $214.42 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6682 0 20 Years 0.00 $0.0000 $204.24 4/1/1992 0.00 $204.24 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6684 0 20 Years 0.00 $0.0000 $225.51 4/1/1992 0.00 $225.51 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6686 0 20 Years 0.00 $0.0000 $388.52 4/1/1992 0.00 $388.52 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6687 0 20 Years 0.00 $0.0000 $358.09 2/1/1993 0.00 $358.09 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6688 0 20 Years 0.00 $0.0000 $394.75 4/1/1992 0.00 $394.75 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6689 0 20 Years 0.00 $0.0000 $473.35 4/1/1992 0.00 $473.35 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6690 0 20 Years 0.00 $0.0000 $489.36 4/1/1992 0.00 $489.36 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6691 0 20 Years 0.00 $0.0000 $219.63 4/1/1992 0.00 $219.63 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6692 0 20 Years 0.00 $0.0000 $466.60 4/1/1992 0.00 $466.60 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6693 0 20 Years 0.00 $0.0000 $2,152.63 3/1/1999 0.00 $2,152.63 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6694 0 20 Years 0.00 $0.0000 $660.81 7/1/2010 0.00 $660.81 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6695 0 20 Years 0.00 $0.0000 $550.65 7/1/2010 0.00 $550.65 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6696 0 20 Years 0.00 $0.0000 $1,199.72 7/1/2010 0.00 $1,199.72 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6697 0 20 Years 0.00 $0.0000 $1,199.72 7/1/2010 0.00 $1,199.72 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6698 0 20 Years 0.00 $0.0000 $518.60 7/1/2010 0.00 $518.60 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6703 0 20 Years 0.00 $0.0000 $276.63 1/1/2007 0.00 $276.63 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6704 0 20 Years 0.00 $0.0000 $648.73 1/1/2007 0.00 $648.73 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6706 0 20 Years 0.00 $0.0000 $336.56 1/1/2007 0.00 $336.56 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6707 0 20 Years 0.00 $0.0000 $1,197.57 1/1/2007 0.00 $1,197.57 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6708 0 20 Years 0.00 $0.0000 $804.87 1/1/2007 0.00 $804.87 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6709 0 20 Years 0.00 $0.0000 $1,180.90 1/1/2007 0.00 $1,180.90 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6711 0 20 Years 0.00 $0.0000 $583.99 1/1/2009 0.00 $583.99 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6712 0 20 Years 0.00 $0.0000 $1,075.26 1/1/2009 0.00 $1,075.26 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6713 0 20 Years 0.00 $0.0000 $1,357.07 1/1/2009 0.00 $1,357.07 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6714 0 20 Years 0.00 $0.0000 $1,149.43 1/1/2009 0.00 $1,149.43 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6715 0 20 Years 0.00 $0.0000 $2,998.93 10/1/2014 0.00 $2,998.93 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6721 0 20 Years 0.00 $0.0000 $2,042.98 1/1/2009 0.00 $2,042.98 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6722 0 20 Years 0.00 $0.0000 $1,761.19 1/1/2009 0.00 $1,761.19 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6805 0 20 Years 0.00 $0.0000 $285.58 4/1/1992 0.00 $285.58 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6810 0 20 Years 0.00 $0.0000 $144.51 4/1/1992 0.00 $144.51 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6880 0 20 Years 0.00 $0.0000 $0.00 1/1/2012 $0.00 5 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6881 0 20 Years 0.00 $0.0000 $3,728.72 7/1/2010 0.00 $3,728.72 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6882 0 20 Years 0.00 $0.0000 $2,828.42 7/1/2010 0.00 $2,828.42 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6883 0 20 Years 0.00 $0.0000 $1,683.10 7/1/2010 0.00 $1,683.10 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6884 0 20 Years 0.00 $0.0000 $2,525.99 7/1/2010 0.00 $2,525.99 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6885 0 20 Years 0.00 $0.0000 $2,873.00 7/1/2010 0.00 $2,873.00 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6890 0 20 Years 0.00 $0.0000 $116.22 4/1/1992 0.00 $116.22 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6895 0 20 Years 0.00 $0.0000 $348.92 4/1/1992 0.00 $348.92 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6900 0 20 Years 0.00 $0.0000 $1,018.70 4/1/1992 0.00 $1,018.70 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6905 0 20 Years 0.00 $0.0000 $935.52 2/1/1993 0.00 $935.52 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6910 0 20 Years 0.00 $0.0000 $981.37 4/1/1992 0.00 $981.37 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6915 0 20 Years 0.00 $0.0000 $402.34 2/1/1993 0.00 $402.34 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6920 0 20 Years 0.00 $0.0000 $6,609.86 7/1/2010 0.00 $6,609.86 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6925 0 20 Years 0.00 $0.0000 $6,979.44 7/1/2010 0.00 $6,979.44 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6930 0 20 Years 0.00 $0.0000 $7,096.46 7/1/2010 0.00 $7,096.46 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6935 0 20 Years 0.00 $0.0000 $7,806.03 7/1/2010 0.00 $7,806.03 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6940 0 20 Years 0.00 $0.0000 $8,869.04 7/1/2010 0.00 $8,869.04 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6945 0 20 Years 0.00 $0.0000 $10,032.95 7/1/2010 0.00 ####### 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6950 0 20 Years 0.00 $0.0000 $9,429.49 7/1/2010 0.00 $9,429.49 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6955 0 20 Years 0.00 $0.0000 $11,832.69 7/1/2010 0.00 ####### 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6960 0 20 Years 0.00 $0.0000 $11,667.63 7/1/2010 0.00 ####### 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6965 0 20 Years 0.00 $0.0000 $17,044.73 7/1/2010 0.00 ####### 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6970 0 20 Years 0.00 $0.0000 $17,324.81 7/1/2010 0.00 ####### 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L6975 0 20 Years 0.00 $0.0000 $17,417.80 7/1/2010 0.00 ####### 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7007 0 20 Years 0.00 $0.0000 $3,837.72 1/1/2007 0.00 $3,837.72 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7008 0 20 Years 0.00 $0.0000 $6,513.41 7/1/2010 0.00 $6,513.41 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7009 0 20 Years 0.00 $0.0000 $4,222.48 7/1/2010 0.00 $4,222.48 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7040 0 20 Years 0.00 $0.0000 $3,390.49 7/1/2010 0.00 $3,390.49 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7045 0 20 Years 0.00 $0.0000 $1,943.89 7/1/2010 0.00 $1,943.89 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7170 0 20 Years 0.00 $0.0000 $7,051.76 7/1/2010 0.00 $7,051.76 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7180 0 20 Years 0.00 $0.0000 $36,843.81 7/1/2010 0.00 ####### 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7181 0 20 Years 0.00 $0.0000 $36,544.45 7/1/2010 0.00 ####### 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7185 0 20 Years 0.00 $0.0000 $7,140.85 7/1/2010 0.00 $7,140.85 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7186 0 20 Years 0.00 $0.0000 $10,305.99 7/1/2010 0.00 ####### 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7190 0 20 Years 0.00 $0.0000 $9,085.38 7/1/2010 0.00 $9,085.38 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7191 0 20 Years 0.00 $0.0000 $10,954.94 7/1/2010 0.00 ####### 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7400 0 20 Years 0.00 $0.0000 $279.53 7/1/2010 0.00 $279.53 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7401 0 20 Years 0.00 $0.0000 $312.93 7/1/2010 0.00 $312.93 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7402 0 20 Years 0.00 $0.0000 $337.94 7/1/2010 0.00 $337.94 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7403 0 20 Years 0.00 $0.0000 $335.88 7/1/2010 0.00 $335.88 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7404 0 20 Years 0.00 $0.0000 $506.92 7/1/2010 0.00 $506.92 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7405 0 20 Years 0.00 $0.0000 $662.98 7/1/2010 0.00 $662.98 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7499 0 20 Years 0.00 $0.0000 $0.00 4/1/1990 $0.00 5 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7510 0 20 Years 0.00 $0.0000 $30.45 10/1/2016 0.00 $30.45 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7520 0 20 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L7600 0 20 Years 0.00 $0.0000 $66.30 10/1/2016 0.00 $66.30 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8000 0 999 Years 0.00 $0.0000 $23.92 6/1/2010 0.00 $23.92 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8001 0 999 Years 0.00 $0.0000 $114.39 7/1/2010 0.00 $114.39 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8002 0 999 Years 0.00 $0.0000 $150.48 7/1/2010 0.00 $150.48 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8010 0 999 Years 0.00 $0.0000 $59.52 10/1/2016 0.00 $59.52 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8015 0 999 Years 0.00 $0.0000 $45.45 6/1/2010 0.00 $45.45 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8020 0 999 Years 0.00 $0.0000 $140.20 6/1/2010 0.00 $140.20 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8030 0 999 Years 0.00 $0.0000 $233.93 6/1/2010 0.00 $233.93 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8031 0 999 Years 0.00 $0.0000 $307.79 10/1/2012 0.00 $307.79 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8032 0 999 Years 0.00 $0.0000 $20.09 1/1/2010 0.00 $20.09 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8035 0 999 Years 0.00 $0.0000 $2,777.90 6/1/2010 0.00 $2,777.90 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8039 0 999 Years 0.00 $0.0000 $0.00 6/1/2010 $0.00 5 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8040 0 20 Years 0.00 $0.0000 $1,873.58 10/1/2016 0.00 $1,873.58 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8041 0 20 Years 0.00 $0.0000 $2,258.29 10/1/2016 0.00 $2,258.29 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8042 0 20 Years 0.00 $0.0000 $2,589.19 4/1/2001 0.00 $2,589.19 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8043 0 20 Years 0.00 $0.0000 $2,899.88 4/1/2001 0.00 $2,899.88 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8044 0 20 Years 0.00 $0.0000 $3,210.59 4/1/2001 0.00 $3,210.59 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8045 0 20 Years 0.00 $0.0000 $2,010.46 4/1/2001 0.00 $2,010.46 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8046 0 20 Years 0.00 $0.0000 $2,071.34 4/1/2001 0.00 $2,071.34 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8047 0 20 Years 0.00 $0.0000 $1,061.57 4/1/2001 0.00 $1,061.57 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8400 0 20 Years 0.00 $0.0000 $10.45 4/1/1992 0.00 $10.45 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8410 0 20 Years 0.00 $0.0000 $14.86 4/1/1992 0.00 $14.86 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8415 0 20 Years 0.00 $0.0000 $15.72 4/1/1992 0.00 $15.72 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8417 0 20 Years 0.00 $0.0000 $55.89 2/1/1997 0.00 $55.89 6 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8420 0 20 Years 0.00 $0.0000 $14.48 7/1/1997 0.00 $14.48 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8430 0 20 Years 0.00 $0.0000 $16.00 7/1/1997 0.00 $16.00 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8435 0 20 Years 0.00 $0.0000 $15.62 7/1/1997 0.00 $15.62 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8440 0 20 Years 0.00 $0.0000 $30.38 4/1/1992 0.00 $30.38 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8460 0 20 Years 0.00 $0.0000 $59.16 4/1/1992 0.00 $59.16 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8465 0 20 Years 0.00 $0.0000 $37.20 4/1/1992 0.00 $37.20 6 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8470 0 20 Years 0.00 $0.0000 $4.98 7/1/1997 0.00 $4.98 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8480 0 20 Years 0.00 $0.0000 $6.96 7/1/1997 0.00 $6.96 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8485 0 20 Years 0.00 $0.0000 $7.72 7/1/1997 0.00 $7.72 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8499 0 999 Years 0.00 $0.0000 $0.00 1/1/2009 $0.00 5 10/1/2016
PROSTHETIST 9
OTHER MEDICAL
ITEMS OR
SERVICES L8499 RB 0 999 Years 0.00 $0.0000 $0.00 1/1/2009 $0.00 5 10/1/2016
REHABILITATI
ON CENTERS 9
OTHER MEDICAL
ITEMS OR
SERVICES A4570 0 999 Years 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 0.00 $0.0000 $31.01 7/1/2011 0.00 $31.01 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1 2 3 1 2 3
CCP
PROVIDER E0673 0 999 Years $23.53 4/1/2013 0.00 23.53 4/1/2015
CCP
PROVIDER E1801 0 20 Years $1,327.41 4/1/2013 0.00 $1,327.41 6 4/1/2015 $132.74 4/1/2015 0.00 132.74 4/1/2015
CCP
PROVIDER E1806 0 20 Years $974.37 4/1/2013 0.00 $974.37 6 4/1/2015 $97.44 4/1/2015 0.00 97.44 4/1/2015
CCP
PROVIDER E1811 0 20 Years $1,314.38 4/1/2013 0.00 $1,314.38 6 4/1/2015 $131.44 4/1/2015 0.00 131.44 4/1/2015
CCP
PROVIDER E1816 0 20 Years $1,335.15 4/1/2013 0.00 $1,335.15 6 4/1/2015 $133.52 4/1/2015 0.00 133.52 4/1/2015
CCP
PROVIDER E1818 0 20 Years $1,363.08 4/1/2013 0.00 $1,363.08 6 4/1/2015 $136.31 4/1/2015 0.00 136.31 4/1/2015
CCP
PROVIDER E1821 0 20 Years $108.30 4/1/2013 0.00 $108.30 6 4/1/2015
CLINIC/GRO
UP PRACTICE S0515 0 999 Years $0.00 4/1/2010 $0.00 5 4/1/2015
CLINIC/GRO
UP PRACTICE V2020 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
CLINIC/GRO
UP PRACTICE V2025 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Texas Medicaid Fee Schedule Information
DMEPOS - TOS 9, E, J, L, AND RThis fee schedule is intended to be used by a variety of provider types and provider specialties. Some procedure codes might not apply to every provider type and provider specialty designated to use the fee schedule. For detailed benefits and limitations, providers should refer to the
current year’s Texas Medicaid Provider Procedures Manual and relevant issues of the Texas Medicaid Bulletin.
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Medicaid rates are based on the client’s age in days, months or years.
Purchase/Rental
Provider Type: Classification assigned during provider enrollment and used to determine payable services.
Proc Code: The five-digit code for services and items defined in Current Procedure Terminology or the Healthcare Common Procedure Coding System.
Mod 1: 1st Modifier, if required for pricing determination.
Mod 2: 2nd Modifier, if required for pricing determination.
Client Age
Frm: The “from age” is the beginning of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client
age range for the first row (0-999) is actually 0-20 years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the Texas
Medicaid Provider Procedures Manual (TMPPM) for the exact age limitations.
Thru:
Field Descriptions
Purchase
Adjusted Fee for Report Date: A percentage reduction has been applied to the allowed fee for this service. This column does not show reductions that may have been applied using other criteria that include but are not limited to place of service, client type program, or
provider specialty. Additional information about rate changes is available on the TMHP website at www.tmhp.com.
Note Codes: Note code indicator. Providers should review each note code to identify specific payment explanation or limitation. See Note Codes worksheet for applicable payment explanation or limitation.
Last Pricing Review Date: Medicaid rates are reviewed every two years or as necessary. This column shows the date on which the most recent review was conducted.
Fee: The Medicaid allowed amount.
Fee Effect Date: The effective date of service for which the fee is payable.
Adjust%: A percentage reduction has been applied to the allowed fee for this service. This column shows the percent by which the fee was adjusted. Additional information about rate changes is available on the TMHP website at
www.tmhp.com/pages/topics/rates.aspx.
The “through age” is the end of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age
range for the first row (0-999) is actually 0-20 years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the TMPPM
for exact age limitations.
Client Age Units:
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
CLINIC/GRO
UP PRACTICE V2100 0 999 Years $19.94 7/1/2014 0.00 $19.94 7/1/2016
CLINIC/GRO
UP PRACTICE V2101 0 999 Years $23.78 7/1/2014 0.00 $23.78 7/1/2016
CLINIC/GRO
UP PRACTICE V2102 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
CLINIC/GRO
UP PRACTICE V2102 VP 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
CLINIC/GRO
UP PRACTICE V2103 0 999 Years $15.73 7/1/2014 0.00 $15.73 7/1/2016
CLINIC/GRO
UP PRACTICE V2104 0 999 Years $18.59 7/1/2014 0.00 $18.59 7/1/2016
CLINIC/GRO
UP PRACTICE V2105 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
CLINIC/GRO
UP PRACTICE V2105 VP 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
CLINIC/GRO
UP PRACTICE V2106 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
CLINIC/GRO
UP PRACTICE V2106 VP 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
CLINIC/GRO
UP PRACTICE V2107 0 999 Years $23.45 7/1/2014 0.00 $23.45 7/1/2016
CLINIC/GRO
UP PRACTICE V2108 0 999 Years $23.01 7/1/2014 0.00 $23.01 7/1/2016
CLINIC/GRO
UP PRACTICE V2109 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
CLINIC/GRO
UP PRACTICE V2109 VP 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
CLINIC/GRO
UP PRACTICE V2110 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
CLINIC/GRO
UP PRACTICE V2110 VP 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
CLINIC/GRO
UP PRACTICE V2111 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
CLINIC/GRO
UP PRACTICE V2111 VP 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
CLINIC/GRO
UP PRACTICE V2112 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
CLINIC/GRO
UP PRACTICE V2112 VP 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
CLINIC/GRO
UP PRACTICE V2113 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
CLINIC/GRO
UP PRACTICE V2113 VP 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
CLINIC/GRO
UP PRACTICE V2114 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
CLINIC/GRO
UP PRACTICE V2114 VP 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
CLINIC/GRO
UP PRACTICE V2115 0 999 Years $42.62 7/1/2014 0.00 $42.62 7/1/2016
CLINIC/GRO
UP PRACTICE V2118 0 999 Years $33.76 7/1/2014 0.00 $33.76 7/1/2016
CLINIC/GRO
UP PRACTICE V2121 0 999 Years $43.62 7/1/2014 0.00 $43.62 6 7/1/2016
CLINIC/GRO
UP PRACTICE V2200 0 999 Years $25.59 7/1/2014 0.00 $25.59 7/1/2016
CLINIC/GRO
UP PRACTICE V2201 0 999 Years $26.95 7/1/2014 0.00 $26.95 7/1/2016
CLINIC/GRO
UP PRACTICE V2202 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
CLINIC/GRO
UP PRACTICE V2202 VP 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
CLINIC/GRO
UP PRACTICE V2203 0 999 Years $25.13 7/1/2014 0.00 $25.13 7/1/2016
CLINIC/GRO
UP PRACTICE V2204 0 999 Years $25.58 7/1/2014 0.00 $25.58 7/1/2016
CLINIC/GRO
UP PRACTICE V2205 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
CLINIC/GRO
UP PRACTICE V2205 VP 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
CLINIC/GRO
UP PRACTICE V2206 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
CLINIC/GRO
UP PRACTICE V2206 VP 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
CLINIC/GRO
UP PRACTICE V2207 0 999 Years $25.42 7/1/2014 0.00 $25.42 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
CLINIC/GRO
UP PRACTICE V2208 0 999 Years $28.21 7/1/2014 0.00 $28.21 7/1/2016
CLINIC/GRO
UP PRACTICE V2209 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
CLINIC/GRO
UP PRACTICE V2209 VP 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
CLINIC/GRO
UP PRACTICE V2210 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
CLINIC/GRO
UP PRACTICE V2210 VP 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
CLINIC/GRO
UP PRACTICE V2211 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
CLINIC/GRO
UP PRACTICE V2211 VP 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
CLINIC/GRO
UP PRACTICE V2212 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
CLINIC/GRO
UP PRACTICE V2212 VP 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
CLINIC/GRO
UP PRACTICE V2213 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
CLINIC/GRO
UP PRACTICE V2213 VP 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
CLINIC/GRO
UP PRACTICE V2214 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
CLINIC/GRO
UP PRACTICE V2214 VP 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
CLINIC/GRO
UP PRACTICE V2215 0 999 Years $41.26 7/1/2014 0.00 $41.26 7/1/2016
CLINIC/GRO
UP PRACTICE V2218 0 999 Years $43.71 7/1/2014 0.00 $43.71 7/1/2016
CLINIC/GRO
UP PRACTICE V2219 0 999 Years $22.22 7/1/2014 0.00 $22.22 7/1/2016
CLINIC/GRO
UP PRACTICE V2220 0 999 Years $20.34 7/1/2014 0.00 $20.34 7/1/2016
CLINIC/GRO
UP PRACTICE V2221 0 999 Years $43.45 7/1/2014 0.00 $43.45 7/1/2016
CLINIC/GRO
UP PRACTICE V2300 0 999 Years $33.41 7/1/2014 0.00 $33.41 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
CLINIC/GRO
UP PRACTICE V2301 0 999 Years $43.76 7/1/2014 0.00 $43.76 7/1/2016
CLINIC/GRO
UP PRACTICE V2302 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
CLINIC/GRO
UP PRACTICE V2302 VP 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
CLINIC/GRO
UP PRACTICE V2303 0 999 Years $31.75 7/1/2014 0.00 $31.75 7/1/2016
CLINIC/GRO
UP PRACTICE V2304 0 999 Years $31.00 7/1/2014 0.00 $31.00 7/1/2016
CLINIC/GRO
UP PRACTICE V2305 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
CLINIC/GRO
UP PRACTICE V2305 VP 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
CLINIC/GRO
UP PRACTICE V2306 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
CLINIC/GRO
UP PRACTICE V2306 VP 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
CLINIC/GRO
UP PRACTICE V2307 0 999 Years $34.72 7/1/2014 0.00 $34.72 7/1/2016
CLINIC/GRO
UP PRACTICE V2308 0 999 Years $36.12 7/1/2014 0.00 $36.12 7/1/2016
CLINIC/GRO
UP PRACTICE V2309 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
CLINIC/GRO
UP PRACTICE V2309 VP 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
CLINIC/GRO
UP PRACTICE V2310 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
CLINIC/GRO
UP PRACTICE V2310 VP 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
CLINIC/GRO
UP PRACTICE V2311 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
CLINIC/GRO
UP PRACTICE V2311 VP 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
CLINIC/GRO
UP PRACTICE V2312 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
CLINIC/GRO
UP PRACTICE V2312 VP 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
CLINIC/GRO
UP PRACTICE V2313 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
CLINIC/GRO
UP PRACTICE V2313 VP 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
CLINIC/GRO
UP PRACTICE V2314 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
CLINIC/GRO
UP PRACTICE V2314 VP 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
CLINIC/GRO
UP PRACTICE V2315 0 999 Years $54.92 7/1/2014 0.00 $54.92 7/1/2016
CLINIC/GRO
UP PRACTICE V2318 0 999 Years $63.39 7/1/2014 0.00 $63.39 7/1/2016
CLINIC/GRO
UP PRACTICE V2319 0 999 Years $24.22 7/1/2014 0.00 $24.22 7/1/2016
CLINIC/GRO
UP PRACTICE V2320 0 999 Years $30.19 7/1/2014 0.00 $30.19 7/1/2016
CLINIC/GRO
UP PRACTICE V2321 0 20 Years $51.41 7/1/2014 0.00 $51.41 6 7/1/2016
CLINIC/GRO
UP PRACTICE V2410 0 999 Years $45.71 7/1/2014 0.00 $45.71 7/1/2016
CLINIC/GRO
UP PRACTICE V2430 0 999 Years $52.95 7/1/2014 0.00 $52.95 7/1/2016
CLINIC/GRO
UP PRACTICE V2500 0 999 Years $43.91 7/1/2014 0.00 $43.91 7/1/2016
CLINIC/GRO
UP PRACTICE V2501 0 999 Years $53.50 7/1/2014 0.00 $53.50 7/1/2016
CLINIC/GRO
UP PRACTICE V2502 0 999 Years $65.91 7/1/2014 0.00 $65.91 7/1/2016
CLINIC/GRO
UP PRACTICE V2510 0 999 Years $63.40 7/1/2014 0.00 $63.40 7/1/2016
CLINIC/GRO
UP PRACTICE V2511 0 999 Years $82.23 7/1/2014 0.00 $82.23 7/1/2016
CLINIC/GRO
UP PRACTICE V2512 0 999 Years $108.54 7/1/2014 0.00 $108.54 7/1/2016
CLINIC/GRO
UP PRACTICE V2513 0 999 Years $91.12 7/1/2014 0.00 $91.12 7/1/2016
CLINIC/GRO
UP PRACTICE V2520 0 999 Years $54.56 7/1/2014 0.00 $54.56 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
CLINIC/GRO
UP PRACTICE V2521 0 999 Years $83.43 7/1/2014 0.00 $83.43 7/1/2016
CLINIC/GRO
UP PRACTICE V2522 0 999 Years $101.81 7/1/2014 0.00 $101.81 7/1/2016
CLINIC/GRO
UP PRACTICE V2523 0 999 Years $79.53 7/1/2014 0.00 $79.53 7/1/2016
CLINIC/GRO
UP PRACTICE V2530 0 999 Years $122.85 7/1/2014 0.00 $122.85 7/1/2016
CLINIC/GRO
UP PRACTICE V2531 0 999 Years $236.58 7/1/2014 0.00 $236.58 7/1/2016
CLINIC/GRO
UP PRACTICE V2599 0 999 Years $0.00 4/1/2010 -8.00 $0.00 5 7/1/2016
CLINIC/GRO
UP PRACTICE V2700 0 999 Years $22.89 7/1/2014 0.00 $22.89 7/1/2016
CLINIC/GRO
UP PRACTICE V2710 0 999 Years $34.37 7/1/2014 0.00 $34.37 7/1/2016
CLINIC/GRO
UP PRACTICE V2715 0 999 Years $5.67 7/1/2014 0.00 $5.67 7/1/2016
CLINIC/GRO
UP PRACTICE V2718 0 999 Years $14.09 7/1/2014 0.00 $14.09 7/1/2016
CLINIC/GRO
UP PRACTICE V2730 0 999 Years $24.30 7/1/2014 0.00 $24.30 7/1/2016
CLINIC/GRO
UP PRACTICE V2755 0 999 Years $19.15 7/1/2014 0.00 $19.15 7/1/2016
CLINIC/GRO
UP PRACTICE V2770 0 999 Years $9.25 7/1/2014 0.00 $9.25 7/1/2016
CLINIC/GRO
UP PRACTICE V2780 0 999 Years $5.41 7/1/2014 0.00 $5.41 7/1/2016
CLINIC/GRO
UP PRACTICE V2784 0 999 Years $41.25 7/1/2014 0.00 $41.25 7/1/2016
HEARING
AID V5010 0 20 Years $46.80 10/1/2013 0.00 $46.80 7/1/2016
HEARING
AID V5010 21 999 Years $45.00 10/1/2013 0.00 $45.00 7/1/2016
HEARING
AID V5011 0 20 Years $64.45 10/1/2013 0.00 $64.45 7/1/2016
HEARING
AID V5011 21 999 Years $64.45 10/1/2013 0.00 $64.45 7/1/2016
HEARING
AID V5014 0 20 Years $323.13 10/1/2013 0.00 $323.13 7/1/2016
HEARING
AID V5014 21 999 Years $222.38 10/1/2013 0.00 $222.38 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
HEARING
AID V5030 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5030 21 999 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5040 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5040 21 999 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5090 0 20 Years $222.49 10/1/2013 0.00 $222.49 7/1/2016
HEARING
AID V5090 21 999 Years $203.12 10/1/2013 0.00 $203.12 7/1/2016
HEARING
AID V5100 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5110 0 20 Years $229.98 10/1/2012 0.00 $229.98 7/1/2016
HEARING
AID V5160 0 20 Years $321.35 10/1/2013 0.00 $321.35 7/1/2016
HEARING
AID V5170 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5180 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5200 0 20 Years $195.37 10/1/2013 0.00 $195.37 7/1/2016
HEARING
AID V5210 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5220 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5240 0 20 Years $216.20 10/1/2012 0.00 $216.20 7/1/2016
HEARING
AID V5241 0 20 Years $194.69 10/1/2013 0.00 $194.69 7/1/2016
HEARING
AID V5241 21 999 Years $194.00 10/1/2013 0.00 $194.00 7/1/2016
HEARING
AID V5244 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5244 21 999 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5245 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5245 21 999 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5246 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5246 21 999 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5247 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5247 21 999 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5249 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5250 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5251 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
HEARING
AID V5252 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5253 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5254 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5254 21 999 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5255 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5255 21 999 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5256 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5256 21 999 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5257 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5257 21 999 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5258 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5259 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5260 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5261 0 20 Years $0.00 6/1/2013 $0.00 5B 7/1/2016
HEARING
AID V5264 0 20 Years $40.76 10/1/2013 0.00 $40.76 7/1/2016
HEARING
AID V5264 21 999 Years $38.54 10/1/2013 0.00 $38.54 7/1/2016
HEARING
AID V5265 0 20 Years $45.00 10/1/2013 0.00 $45.00 7/1/2016
HEARING
AID V5265 21 999 Years $45.00 10/1/2013 0.00 $45.00 7/1/2016
HEARING
AID V5266 0 20 Years $0.82 10/1/2012 0.00 $0.82 7/1/2016
HEARING
AID V5266 21 999 Years $0.82 10/1/2012 0.00 $0.82 7/1/2016
HEARING
AID V5267 0 20 Years $0.00 9/1/2009 $0.00 5 7/1/2016
HEARING
AID V5275 0 20 Years $24.18 10/1/2012 0.00 $24.18 7/1/2016
HEARING
AID V5275 21 999 Years $24.18 10/1/2012 0.00 $24.18 7/1/2016
HEARING
AID V5298 0 20 Years $0.00 9/1/2009 $0.00 5B 7/1/2016
HOME
HEALTH DME B9000 0 999 Years $1,225.78 1/1/2014 0.00 $1,225.78 1/1/2016 $122.58 1/1/2016 0.00 122.58 1/1/2016
HOME
HEALTH DME B9002 0 999 Years $1,225.78 1/1/2014 0.00 $1,225.78 1/1/2016 $122.58 1/1/2016 0.00 122.58 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME B9004 0 999 Years $2,836.83 1/1/2014 0.00 $2,836.83 1/1/2016 $449.08 1/1/2014 0.00 449.08 1/1/2016
HOME
HEALTH DME B9006 0 999 Years $2,836.83 1/1/2014 0.00 $2,836.83 1/1/2016 $449.08 1/1/2014 0.00 449.08 1/1/2016
HOME
HEALTH DME E0100 0 999 Years $15.27 4/1/2013 0.00 $15.27 4/1/2015
HOME
HEALTH DME E0105 0 999 Years $36.35 4/1/2013 0.00 $36.35 4/1/2015
HOME
HEALTH DME E0110 0 999 Years $54.34 4/1/2013 0.00 $54.34 4/1/2015 $5.43 4/1/2015 0.00 5.43 4/1/2015
HOME
HEALTH DME E0111 0 999 Years $35.87 4/1/2013 0.00 $35.87 4/1/2015 $3.59 4/1/2015 0.00 3.59 4/1/2015
HOME
HEALTH DME E0112 0 999 Years $28.78 4/1/2013 0.00 $28.78 4/1/2015 $2.88 4/1/2015 0.00 2.88 4/1/2015
HOME
HEALTH DME E0113 0 999 Years $16.76 4/1/2013 0.00 $16.76 4/1/2015 $1.68 4/1/2015 0.00 1.68 4/1/2015
HOME
HEALTH DME E0114 0 999 Years $32.30 4/1/2013 0.00 $32.30 4/1/2015 $3.23 4/1/2015 0.00 3.23 4/1/2015
HOME
HEALTH DME E0116 0 999 Years $20.72 4/1/2013 0.00 $20.72 4/1/2015 $2.07 4/1/2015 0.00 2.07 4/1/2015
HOME
HEALTH DME E0130 0 999 Years $54.34 4/1/2013 0.00 $54.34 4/1/2015 $5.43 4/1/2015 0.00 5.43 4/1/2015
HOME
HEALTH DME E0135 0 999 Years $69.81 4/1/2013 0.00 $69.81 4/1/2015 $6.98 4/1/2015 0.00 6.98 4/1/2015
HOME
HEALTH DME E0140 0 999 Years $345.08 4/1/2015 0.00 $345.08 4/1/2015
HOME
HEALTH DME E0141 0 999 Years $88.39 4/1/2013 0.00 $88.39 4/1/2015 $8.84 4/1/2015 0.00 8.84 4/1/2015
HOME
HEALTH DME E0143 0 999 Years $92.22 4/1/2013 0.00 $92.22 4/1/2015 $9.22 4/1/2015 0.00 9.22 4/1/2015
HOME
HEALTH DME E0144 0 999 Years $198.12 4/1/2015 0.00 $198.12 4/1/2015 $19.81 4/1/2015 0.00 19.81 4/1/2015
HOME
HEALTH DME E0147 0 999 Years $478.58 4/1/2013 0.00 $478.58 4/1/2015 $47.86 4/1/2013 0.00 47.86 4/1/2015
HOME
HEALTH DME E0148 0 999 Years $105.78 4/1/2013 0.00 $105.78 4/1/2015 $10.58 4/1/2015 0.00 10.58 4/1/2015
HOME
HEALTH DME E0149 0 999 Years $157.56 4/1/2013 0.00 $157.56 4/1/2015 $15.76 4/1/2013 0.00 15.76 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E0153 0 999 Years $63.52 4/1/2013 0.00 $63.52 4/1/2015
HOME
HEALTH DME E0154 0 999 Years $58.71 4/1/2013 0.00 $58.71 4/1/2015
HOME
HEALTH DME E0155 0 999 Years $25.22 4/1/2013 0.00 $25.22 4/1/2015
HOME
HEALTH DME E0157 0 999 Years $41.94 4/1/2013 0.00 $41.94 4/1/2015
HOME
HEALTH DME E0158 0 999 Years $21.42 4/1/2013 0.00 $21.42 4/1/2015
HOME
HEALTH DME E0159 0 999 Years $14.88 4/1/2013 0.00 $14.88 4/1/2015
HOME
HEALTH DME E0160 0 999 Years $20.81 4/1/2013 0.00 $20.81 4/1/2015
HOME
HEALTH DME E0161 0 999 Years $21.54 4/1/2013 0.00 $21.54 4/1/2015
HOME
HEALTH DME E0162 0 999 Years $119.64 4/1/2013 0.00 $119.64 4/1/2015 $11.96 4/1/2015 0.00 11.96 4/1/2015
HOME
HEALTH DME E0163 0 999 Years $97.06 4/1/2013 0.00 $97.06 4/1/2015
HOME
HEALTH DME E0163 TG 0 999 Years $0.00 10/16/2003 -2.00 $0.00 5 4/1/2015
HOME
HEALTH DME E0165 0 999 Years $171.69 4/1/2013 0.00 $171.69 4/1/2015
HOME
HEALTH DME E0165 TG 0 999 Years $0.00 10/16/2003 -2.00 $0.00 5 4/1/2015
HOME
HEALTH DME E0167 0 999 Years $9.09 4/1/2013 0.00 $9.09 4/1/2015 $0.91 4/1/2013 0.00 0.91 4/1/2015
HOME
HEALTH DME E0168 0 999 Years $132.81 4/1/2013 0.00 $132.81 4/1/2015
HOME
HEALTH DME E0168 TF 0 999 Years $319.26 4/1/2013 0.00 $319.26 4/1/2015
HOME
HEALTH DME E0168 TG 0 999 Years $1,544.22 4/1/2013 0.00 $1,544.22 4/1/2015
HOME
HEALTH DME E0170 0 999 Years $1,653.85 4/1/2013 0.00 $1,653.85 4/1/2015
HOME
HEALTH DME E0171 0 999 Years $297.63 4/1/2013 0.00 $297.63 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HOME
HEALTH DME E0172 0 999 Years $1,806.79 4/1/2013 0.00 $1,806.79 4/1/2015
HOME
HEALTH DME E0175 0 999 Years $51.06 4/1/2013 0.00 $51.06 4/1/2015 $5.11 4/1/2013 0.00 5.11 4/1/2015
HOME
HEALTH DME E0181 0 999 Years $251.71 4/1/2013 0.00 $251.71 4/1/2015 $25.17 4/1/2013 0.00 25.17 4/1/2015
HOME
HEALTH DME E0182 0 999 Years $17.98 4/1/2013 0.00 17.98 4/1/2015
HOME
HEALTH DME E0184 0 999 Years $440.74 4/1/2013 0.00 $440.74 10/1/2013 $22.60 4/1/2013 0.00 22.60 10/1/2013
HOME
HEALTH DME E0185 0 999 Years $280.68 4/1/2013 0.00 $280.68 4/1/2015 $28.07 4/1/2015 0.00 28.07 4/1/2015
HOME
HEALTH DME E0186 0 999 Years $17.81 4/1/2013 0.00 17.81 10/1/2013
HOME
HEALTH DME E0186 0 20 Years $1,778.79 4/1/2013 0.00 $1,778.79 10/1/2013
HOME
HEALTH DME E0187 0 999 Years $224.20 4/1/2013 0.00 $224.20 4/1/2015 $22.42 4/1/2013 0.00 22.42 4/1/2015
HOME
HEALTH DME E0188 0 999 Years $20.67 4/1/2013 0.00 $20.67 4/1/2015
HOME
HEALTH DME E0189 0 999 Years $47.80 4/1/2013 0.00 $47.80 4/1/2015
HOME
HEALTH DME E0190 0 999 Years $47.99 4/1/2013 0.00 $47.99 4/1/2015
HOME
HEALTH DME E0190 UD 0 20 Years $0.00 7/1/2010 $0.00 5 4/1/2015
HOME
HEALTH DME E0191 0 999 Years $7.74 4/1/2013 0.00 $7.74 4/1/2015
HOME
HEALTH DME E0193 0 999 Years $752.22 4/1/2013 0.00 752.22 4/1/2015
HOME
HEALTH DME E0194 0 999 Years $2,258.07 4/1/2013 0.00 2,258.07 4/1/2015
HOME
HEALTH DME E0196 0 999 Years $313.81 4/1/2013 0.00 $313.81 4/1/2015 $31.38 4/1/2013 0.00 31.38 4/1/2015
HOME
HEALTH DME E0197 0 999 Years $173.27 4/1/2013 0.00 $173.27 4/1/2015 $17.33 4/1/2015 0.00 17.33 4/1/2015
HOME
HEALTH DME E0198 0 999 Years $135.92 4/1/2015 0.00 $135.92 4/1/2015 $13.59 4/1/2015 0.00 13.59 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E0199 0 999 Years $30.15 4/1/2013 0.00 $30.15 4/1/2015
HOME
HEALTH DME E0210 0 999 Years $24.09 4/1/2013 0.00 $24.09 4/1/2015
HOME
HEALTH DME E0217 0 999 Years $435.67 4/1/2013 0.00 $435.67 4/1/2015 $43.57 4/1/2013 0.00 43.57 4/1/2015
HOME
HEALTH DME E0218 0 999 Years $360.49 4/1/2013 0.00 $360.49 4/1/2015 $36.05 4/1/2015 0.00 36.05 4/1/2015
HOME
HEALTH DME E0225 0 999 Years $37.01 4/1/2013 0.00 37.01 4/1/2015
HOME
HEALTH DME E0235 0 999 Years $166.70 4/1/2013 0.00 $166.70 4/1/2015 $16.67 4/1/2013 0.00 16.67 4/1/2015
HOME
HEALTH DME E0236 0 999 Years $427.43 4/1/2013 0.00 $427.43 4/1/2015
HOME
HEALTH DME E0240 0 999 Years $83.13 4/1/2013 0.00 $83.13 4/1/2015
HOME
HEALTH DME E0240 TF 0 999 Years $1,434.28 4/1/2013 0.00 $1,434.28 4/1/2015
HOME
HEALTH DME E0240 TG 0 999 Years $1,935.82 4/1/2013 0.00 $1,935.82 4/1/2015
HOME
HEALTH DME E0243 0 999 Years $40.00 4/1/2015 0.00 $40.00 4/1/2015
HOME
HEALTH DME E0244 0 999 Years $28.90 4/1/2013 0.00 $28.90 4/1/2015
HOME
HEALTH DME E0245 0 999 Years $39.00 4/1/2015 0.00 $39.00 4/1/2015
HOME
HEALTH DME E0246 0 999 Years $41.49 4/1/2013 0.00 $41.49 4/1/2015
HOME
HEALTH DME E0247 0 999 Years $88.70 4/1/2013 0.00 $88.70 4/1/2015
HOME
HEALTH DME E0248 0 999 Years $138.62 4/1/2013 0.00 $138.62 4/1/2015
HOME
HEALTH DME E0250 0 999 Years $738.59 4/1/2013 0.00 $738.59 4/1/2015 $73.86 4/1/2013 0.00 73.86 4/1/2015
HOME
HEALTH DME E0255 0 999 Years $930.30 4/1/2013 0.00 $930.30 4/1/2015 $93.03 4/1/2013 0.00 93.03 4/1/2015
HOME
HEALTH DME E0260 0 999 Years $1,118.66 4/1/2013 0.00 $1,118.66 4/1/2015 $111.87 4/1/2013 0.00 111.87 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E0265 0 999 Years $1,772.72 4/1/2013 0.00 $1,772.72 4/1/2015 $177.27 4/1/2013 0.00 177.27 4/1/2015
HOME
HEALTH DME E0271 0 999 Years $148.48 4/1/2013 0.00 $148.48 4/1/2015
HOME
HEALTH DME E0275 0 999 Years $14.85 4/1/2015 0.00 $14.85 4/1/2015
HOME
HEALTH DME E0276 0 999 Years $12.22 4/1/2013 0.00 $12.22 4/1/2015
HOME
HEALTH DME E0277 0 999 Years $506.13 4/1/2013 0.00 506.13 4/1/2015
HOME
HEALTH DME E0280 0 999 Years $30.25 4/1/2013 0.00 $30.25 4/1/2015 $3.03 4/1/2015 0.00 3.03 4/1/2015
HOME
HEALTH DME E0300 0 20 Years $2,838.62 4/1/2013 0.00 $2,838.62 4/1/2015 $283.86 4/1/2015 0.00 283.86 4/1/2015
HOME
HEALTH DME E0303 0 999 Years $4,273.17 4/1/2013 0.00 $4,273.17 10/1/2013 $427.32 4/1/2013 0.00 427.32 10/1/2013
HOME
HEALTH DME E0304 0 999 Years $3,978.56 4/1/2013 0.00 $3,978.56 10/1/2013 $610.28 4/1/2013 0.00 610.28 10/1/2013
HOME
HEALTH DME E0305 0 999 Years $140.88 4/1/2013 0.00 $140.88 4/1/2015
HOME
HEALTH DME E0310 0 999 Years $121.94 4/1/2013 0.00 $121.94 4/1/2015
HOME
HEALTH DME E0315 0 999 Years $150.68 4/1/2013 0.00 $150.68 4/1/2015
HOME
HEALTH DME E0316 0 20 Years $1,865.73 4/1/2013 0.00 $1,865.73 10/1/2013 $168.85 4/1/2013 0.00 168.85 10/1/2013
HOME
HEALTH DME E0325 0 999 Years $11.23 4/1/2015 0.00 $11.23 4/1/2015 $1.12 4/1/2015 0.00 1.12 4/1/2015
HOME
HEALTH DME E0326 0 999 Years $7.81 4/1/2013 0.00 $7.81 4/1/2015
HOME
HEALTH DME E0328 0 20 Years $5,059.53 4/1/2013 0.00 $5,059.53 10/1/2013 $505.95 4/1/2013 0.00 505.95 10/1/2013
HOME
HEALTH DME E0329 0 20 Years $6,746.03 4/1/2013 0.00 $6,746.03 10/1/2013 $674.61 4/1/2013 0.00 674.61 10/1/2013
HOME
HEALTH DME E0370 0 999 Years $21.78 4/1/2013 0.00 $21.78 4/1/2015 $2.18 4/1/2013 0.00 2.18 4/1/2015
HOME
HEALTH DME E0371 0 999 Years $3,519.69 4/1/2013 0.00 $3,519.69 4/1/2015 $351.97 4/1/2013 0.00 351.97 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E0372 0 999 Years $4,270.88 4/1/2013 0.00 $4,270.88 4/1/2015 $427.09 4/1/2013 0.00 427.09 4/1/2015
HOME
HEALTH DME E0373 0 999 Years $4,865.88 4/1/2013 0.00 $4,865.88 4/1/2015 $486.59 4/1/2013 0.00 486.59 4/1/2015
HOME
HEALTH DME E0424 0 999 Years $159.32 4/1/2013 0.00 159.32 4/1/2015
HOME
HEALTH DME E0431 0 999 Years $26.47 4/1/2013 0.00 26.47 4/1/2015
HOME
HEALTH DME E0433 0 999 Years $47.50 4/1/2013 0.00 47.50 4/1/2015
HOME
HEALTH DME E0434 0 999 Years $26.47 4/1/2013 0.00 26.47 4/1/2015
HOME
HEALTH DME E0439 0 999 Years $159.32 4/1/2013 0.00 159.32 4/1/2015
HOME
HEALTH DME E0441 0 999 Years $7.13 4/1/2013 0.00 7.13 4/1/2015
HOME
HEALTH DME E0442 0 999 Years $7.13 4/1/2013 0.00 7.13 4/1/2015
HOME
HEALTH DME E0443 0 999 Years $7.13 4/1/2013 0.00 7.13 4/1/2015
HOME
HEALTH DME E0444 0 999 Years $7.13 4/1/2013 0.00 7.13 4/1/2015
HOME
HEALTH DME E0445 0 20 Years $553.50 2/1/2011 -8.00 $509.22 10/1/2013 $55.35 2/1/2011 -8.00 50.92 10/1/2013
HOME
HEALTH DME E0457 0 999 Years $574.41 4/1/2013 0.00 $574.41 4/1/2015 $57.44 4/1/2013 0.00 57.44 4/1/2015
HOME
HEALTH DME E0459 0 999 Years $445.12 4/1/2013 0.00 $445.12 4/1/2015 $44.51 4/1/2013 0.00 44.51 4/1/2015
HOME
HEALTH DME E0465 0 999 Years $1,059.64 1/1/2016 0.00 1,059.64 1/1/2016
HOME
HEALTH DME E0466 0 999 Years $1,059.64 1/1/2016 0.00 1,059.64 1/1/2016
HOME
HEALTH DME E0470 0 999 Years $2,777.35 4/1/2013 0.00 $2,777.35 4/1/2015 $277.74 4/1/2015 0.00 277.74 4/1/2015
HOME
HEALTH DME E0471 0 999 Years $363.60 4/1/2013 0.00 363.60 4/1/2015
HOME
HEALTH DME E0472 0 999 Years $363.60 4/1/2013 0.00 363.60 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E0480 0 999 Years $359.08 4/1/2013 0.00 $359.08 4/1/2015 $35.91 4/1/2013 0.00 35.91 4/1/2015
HOME
HEALTH DME E0482 0 999 Years $266.76 4/1/2013 0.00 266.76 4/1/2015
HOME
HEALTH DME E0483 0 999 Years $9,253.45 4/1/2013 0.00 $9,253.45 4/1/2015 $925.35 4/1/2013 0.00 925.35 4/1/2015
HOME
HEALTH DME E0500 0 999 Years $95.39 4/1/2013 0.00 95.39 4/1/2015
HOME
HEALTH DME E0550 0 999 Years $427.43 4/1/2013 0.00 $427.43 4/1/2015 $42.74 4/1/2013 0.00 42.74 4/1/2015
HOME
HEALTH DME E0561 0 999 Years $89.09 4/1/2013 0.00 $89.09 4/1/2015 $8.91 4/1/2015 0.00 8.91 4/1/2015
HOME
HEALTH DME E0562 0 999 Years $250.79 4/1/2013 0.00 $250.79 4/1/2015 $25.08 4/1/2015 0.00 25.08 4/1/2015
HOME
HEALTH DME E0565 0 999 Years $589.35 4/1/2013 0.00 $589.35 4/1/2015 $58.94 4/1/2013 0.00 58.94 4/1/2015
HOME
HEALTH DME E0570 0 999 Years $129.63 4/1/2013 0.00 $129.63 4/1/2015
HOME
HEALTH DME E0574 0 999 Years $388.88 4/1/2013 0.00 $388.88 4/1/2015
HOME
HEALTH DME E0575 0 999 Years $992.86 4/1/2013 0.00 $992.86 4/1/2015
HOME
HEALTH DME E0580 0 999 Years $118.88 4/1/2013 0.00 $118.88 4/1/2015 $11.89 4/1/2013 0.00 11.89 4/1/2015
HOME
HEALTH DME E0585 0 999 Years $322.64 4/1/2013 0.00 $322.64 4/1/2015
HOME
HEALTH DME E0600 0 999 Years $442.34 4/1/2013 0.00 $442.34 4/1/2015
HOME
HEALTH DME E0601 0 999 Years $1,112.52 4/1/2013 0.00 $1,112.52 4/1/2015 $85.58 4/1/2013 0.00 85.58 4/1/2015
HOME
HEALTH DME E0602 0 999 Years $16.66 4/1/2013 0.00 $16.66 4/1/2015
HOME
HEALTH DME E0603 0 999 Years $152.88 4/1/2013 0.00 $152.88 4/1/2015
HOME
HEALTH DME E0604 0 999 Years $69.15 4/1/2013 0.00 69.15 4/1/2015
HOME
HEALTH DME E0605 0 999 Years $24.20 4/1/2013 0.00 $24.20 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
HOME
HEALTH DME E0606 0 999 Years $158.15 4/1/2013 0.00 $158.15 4/1/2015
HOME
HEALTH DME E0610 0 999 Years $229.77 4/1/2013 0.00 $229.77 4/1/2015
HOME
HEALTH DME E0615 0 999 Years $450.27 4/1/2013 0.00 $450.27 4/1/2015
HOME
HEALTH DME E0616 0 20 Years $3,033.59 4/1/2013 0.00 $3,033.59 6 4/1/2015
HOME
HEALTH DME E0617 1 20 Years $2,346.51 4/1/2013 0.00 $2,346.51 6 4/1/2015 $234.65 4/1/2013 0.00 234.65 6 4/1/2015
HOME
HEALTH DME E0621 0 999 Years $87.88 4/1/2013 0.00 $87.88 4/1/2015
HOME
HEALTH DME E0625 0 999 Years $463.75 4/1/2013 0.00 $463.75 4/1/2015 $46.38 4/1/2013 0.00 46.38 4/1/2015
HOME
HEALTH DME E0625 U1 0 999 Years $980.71 4/1/2013 0.00 $980.71 4/1/2015
HOME
HEALTH DME E0625 U2 0 999 Years $2,376.36 4/1/2013 0.00 $2,376.36 4/1/2015
HOME
HEALTH DME E0625 U3 0 999 Years $0.00 4/1/2013 $0.00 4/1/2015
HOME
HEALTH DME E0628 0 999 Years $319.48 4/1/2013 0.00 $319.48 4/1/2015
HOME
HEALTH DME E0629 0 999 Years $319.47 4/1/2013 0.00 $319.47 4/1/2015
HOME
HEALTH DME E0630 0 999 Years $984.22 4/1/2013 0.00 $984.22 4/1/2015 $98.42 4/1/2013 0.00 98.42 4/1/2015
HOME
HEALTH DME E0635 0 999 Years $176.55 4/1/2015 0.00 176.55 4/1/2015
HOME
HEALTH DME E0635 0 20 Years $1,765.53 4/1/2015 0.00 $1,765.53 1/1/2016
HOME
HEALTH DME E0635 21 999 Years $1,765.53 4/1/2015 0.00 $1,765.53 1/1/2016
HOME
HEALTH DME E0637 0 999 Years $3,271.83 4/1/2015 0.00 $3,271.83 4/1/2015
HOME
HEALTH DME E0638 UA 0 999 Years $2,302.31 4/1/2015 0.00 $2,302.31 4/1/2015
HOME
HEALTH DME E0638 UB 0 999 Years $2,868.85 4/1/2015 0.00 $2,868.85 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
HOME
HEALTH DME E0641 0 999 Years $2,588.49 4/1/2015 0.00 $2,588.49 4/1/2015
HOME
HEALTH DME E0650 0 999 Years $532.16 4/1/2013 0.00 $532.16 4/1/2015 $53.22 4/1/2015 0.00 53.22 4/1/2015
HOME
HEALTH DME E0651 0 999 Years $887.19 4/1/2013 0.00 $887.19 4/1/2015 $88.72 4/1/2013 0.00 88.72 4/1/2015
HOME
HEALTH DME E0652 0 999 Years $4,170.41 4/1/2013 0.00 $4,170.41 4/1/2015 $417.04 4/1/2015 0.00 417.04 4/1/2015
HOME
HEALTH DME E0655 0 999 Years $84.77 4/1/2013 0.00 $84.77 4/1/2015 $8.48 4/1/2013 0.00 8.48 4/1/2015
HOME
HEALTH DME E0660 0 999 Years $120.92 4/1/2013 0.00 $120.92 4/1/2015 $12.09 4/1/2013 0.00 12.09 4/1/2015
HOME
HEALTH DME E0665 0 999 Years $103.33 4/1/2013 0.00 $103.33 4/1/2015 $10.33 4/1/2013 0.00 10.33 4/1/2015
HOME
HEALTH DME E0666 0 999 Years $98.84 4/1/2013 0.00 $98.84 4/1/2015 $9.88 4/1/2013 0.00 9.88 4/1/2015
HOME
HEALTH DME E0667 0 999 Years $312.76 4/1/2013 0.00 $312.76 4/1/2015 $31.28 4/1/2015 0.00 31.28 4/1/2015
HOME
HEALTH DME E0668 0 999 Years $399.35 4/1/2013 0.00 $399.35 4/1/2015 $39.94 4/1/2013 0.00 39.94 4/1/2015
HOME
HEALTH DME E0669 0 999 Years $152.75 4/1/2013 0.00 $152.75 4/1/2015 $15.28 4/1/2013 0.00 15.28 4/1/2015
HOME
HEALTH DME E0671 0 999 Years $364.48 4/1/2013 0.00 $364.48 4/1/2015 $36.45 4/1/2013 0.00 36.45 4/1/2015
HOME
HEALTH DME E0672 0 999 Years $301.67 4/1/2013 0.00 $301.67 4/1/2015 $30.17 4/1/2013 0.00 30.17 4/1/2015
HOME
HEALTH DME E0673 0 999 Years $235.33 4/1/2013 0.00 $235.33 4/1/2015 $23.53 4/1/2013 0.00 23.53 4/1/2015
HOME
HEALTH DME E0676 0 999 Years $0.00 2/1/2011 $0.00 5 4/1/2015 $0.00 2/1/2011 0.00 5 4/1/2015
HOME
HEALTH DME E0700 0 999 Years $35.00 4/1/2015 0.00 $35.00 4/1/2015
HOME
HEALTH DME E0705 0 999 Years $34.88 4/1/2013 0.00 $34.88 4/1/2015
HOME
HEALTH DME E0710 0 999 Years $31.80 4/1/2013 0.00 $31.80 4/1/2015 $3.18 4/1/2013 0.00 3.18 4/1/2015
HOME
HEALTH DME E0720 0 999 Years $321.77 4/1/2013 0.00 $321.77 4/1/2015 $32.18 4/1/2013 0.00 32.18 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
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Report
Date
Last Pricing
Review Date
Adjust
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Fee Effect
Date
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Type
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Mod
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Purchase
HOME
HEALTH DME E0730 0 999 Years $329.14 4/1/2013 0.00 $329.14 4/1/2015 $32.91 4/1/2015 0.00 32.91 4/1/2015
HOME
HEALTH DME E0731 0 999 Years $278.93 4/1/2013 0.00 $278.93 4/1/2015 $27.89 4/1/2013 0.00 27.89 4/1/2015
HOME
HEALTH DME E0740 0 999 Years $481.04 4/1/2013 0.00 $481.04 4/1/2015
HOME
HEALTH DME E0745 0 999 Years $823.49 4/1/2013 0.00 $823.49 4/1/2015 $82.35 4/1/2013 0.00 82.35 4/1/2015
HOME
HEALTH DME E0747 0 999 Years $3,602.78 4/1/2013 0.00 $3,602.78 4/1/2015
HOME
HEALTH DME E0748 0 999 Years $3,579.44 4/1/2013 0.00 $3,579.44 4/1/2015
HOME
HEALTH DME E0760 0 999 Years $2,974.45 4/1/2013 0.00 $2,974.45 4/1/2015
HOME
HEALTH DME E0762 0 999 Years $915.94 4/1/2013 0.00 $915.94 4/1/2015 $91.59 4/1/2015 0.00 91.59 4/1/2015
HOME
HEALTH DME E0764 0 999 Years $10,845.48 4/1/2013 0.00 $10,845.48 4/1/2015 $1,084.55 4/1/2015 0.00 1,084.55 4/1/2015
HOME
HEALTH DME E0776 0 999 Years $79.62 4/1/2013 0.00 $79.62 4/1/2015 $7.96 4/1/2015 0.00 7.96 4/1/2015
HOME
HEALTH DME E0779 0 999 Years $153.74 4/1/2013 0.00 $153.74 10/1/2013 $15.37 4/1/2013 0.00 15.37 10/1/2013
HOME
HEALTH DME E0780 0 999 Years $9.53 4/1/2013 0.00 $9.53 10/1/2013 $0.95 4/1/2013 0.00 0.95 10/1/2013
HOME
HEALTH DME E0781 0 999 Years $2,106.90 4/1/2013 0.00 $2,106.90 4/1/2015 $210.69 4/1/2013 0.00 210.69 4/1/2015
HOME
HEALTH DME E0782 0 999 Years $3,753.51 4/1/2013 0.00 $3,753.51 4/1/2015
HOME
HEALTH DME E0783 0 999 Years $7,480.40 4/1/2013 0.00 $7,480.40 4/1/2015
HOME
HEALTH DME E0784 0 999 Years $4,032.91 4/1/2013 0.00 $4,032.91 4/1/2015 $403.29 4/1/2013 0.00 403.29 4/1/2015
HOME
HEALTH DME E0784 U1 0 999 Years $724.36 4/1/2015 0.00 $724.36 4/1/2015 $72.44 4/1/2015 0.00 72.44 4/1/2015
HOME
HEALTH DME E0786 0 999 Years $5,571.34 4/1/2013 0.00 $5,571.34 4/1/2015
HOME
HEALTH DME E0791 0 999 Years $3,054.49 4/1/2013 0.00 $3,054.49 4/1/2015 $305.45 4/1/2013 0.00 305.45 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
Date
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HOME
HEALTH DME E0840 0 999 Years $53.11 4/1/2013 0.00 $53.11 4/1/2015 $5.31 4/1/2015 0.00 5.31 4/1/2015
HOME
HEALTH DME E0850 0 999 Years $82.50 4/1/2013 0.00 $82.50 4/1/2015 $8.25 4/1/2015 0.00 8.25 4/1/2015
HOME
HEALTH DME E0855 0 999 Years $461.97 4/1/2013 0.00 $461.97 4/1/2015 $46.20 4/1/2015 0.00 46.20 4/1/2015
HOME
HEALTH DME E0856 0 999 Years $150.95 4/1/2013 0.00 $150.95 4/1/2015
HOME
HEALTH DME E0860 0 999 Years $24.82 4/1/2013 0.00 $24.82 4/1/2015 $2.48 4/1/2015 0.00 2.48 4/1/2015
HOME
HEALTH DME E0880 0 999 Years $89.85 4/1/2013 0.00 $89.85 4/1/2015 $8.99 4/1/2015 0.00 8.99 4/1/2015
HOME
HEALTH DME E0900 0 999 Years $90.45 4/1/2013 0.00 $90.45 4/1/2015 $9.05 4/1/2015 0.00 9.05 4/1/2015
HOME
HEALTH DME E0910 0 999 Years $150.23 4/1/2013 0.00 $150.23 4/1/2015 $15.02 4/1/2013 0.00 15.02 4/1/2015
HOME
HEALTH DME E0911 0 999 Years $415.01 4/1/2013 0.00 $415.01 4/1/2015 $41.50 4/1/2013 0.00 41.50 4/1/2015
HOME
HEALTH DME E0912 0 999 Years $953.12 4/1/2013 0.00 $953.12 4/1/2015 $95.31 4/1/2013 0.00 95.31 4/1/2015
HOME
HEALTH DME E0920 0 999 Years $445.74 4/1/2013 0.00 $445.74 4/1/2015 $44.57 4/1/2013 0.00 44.57 4/1/2015
HOME
HEALTH DME E0930 0 999 Years $441.32 4/1/2013 0.00 $441.32 4/1/2015 $44.13 4/1/2013 0.00 44.13 4/1/2015
HOME
HEALTH DME E0935 0 999 Years $19.81 4/1/2013 0.00 19.81 4/1/2015
HOME
HEALTH DME E0940 0 999 Years $286.78 4/1/2013 0.00 $286.78 4/1/2015 $28.68 4/1/2013 0.00 28.68 4/1/2015
HOME
HEALTH DME E0941 0 999 Years $419.34 4/1/2013 0.00 $419.34 4/1/2015 $41.93 4/1/2013 0.00 41.93 4/1/2015
HOME
HEALTH DME E0942 0 999 Years $18.62 4/1/2013 0.00 $18.62 4/1/2015
HOME
HEALTH DME E0944 0 999 Years $28.90 4/1/2013 0.00 $28.90 4/1/2015
HOME
HEALTH DME E0945 0 999 Years $24.45 4/1/2013 0.00 $24.45 4/1/2015
HOME
HEALTH DME E0946 0 999 Years $372.79 4/1/2013 0.00 $372.79 4/1/2015 $37.28 4/1/2013 0.00 37.28 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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Mod
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Purchase
HOME
HEALTH DME E0950 0 999 Years $171.93 3/1/2012 0.00 $171.93 10/1/2013
HOME
HEALTH DME E0951 0 999 Years $12.05 3/1/2012 0.00 $12.05 10/1/2013
HOME
HEALTH DME E0952 0 999 Years $12.58 3/1/2012 0.00 $12.58 10/1/2013
HOME
HEALTH DME E0955 0 999 Years $182.29 3/1/2012 0.00 $182.29 10/1/2013
HOME
HEALTH DME E0956 0 999 Years $208.84 4/1/2013 0.00 208.84 4/1/2013
HOME
HEALTH DME E0957 0 999 Years $134.51 4/1/2013 0.00 $134.51 10/1/2013
HOME
HEALTH DME E0958 0 999 Years $679.71 4/1/2013 0.00 $679.71 10/1/2013
HOME
HEALTH DME E0959 0 999 Years $35.11 7/1/2013 0.00 $35.11 4/1/2015 $3.51 4/1/2014 0.00 3.51 4/1/2015
HOME
HEALTH DME E0960 0 999 Years $88.72 4/1/2013 0.00 $88.72 10/1/2013
HOME
HEALTH DME E0961 0 999 Years $16.63 3/1/2012 0.00 $16.63 10/1/2013
HOME
HEALTH DME E0967 0 999 Years $53.31 7/1/2013 0.00 $53.31 4/1/2015 $5.33 4/1/2014 0.00 5.33 4/1/2015
HOME
HEALTH DME E0969 0 20 Years $146.66 4/1/2013 0.00 $146.66 4/1/2015
HOME
HEALTH DME E0970 0 999 Years $51.98 3/1/2012 0.00 $51.98 10/1/2013
HOME
HEALTH DME E0971 0 999 Years $53.98 3/1/2012 0.00 $53.98 10/1/2013
HOME
HEALTH DME E0973 0 999 Years $68.33 3/1/2012 0.00 $68.33 10/1/2013
HOME
HEALTH DME E0974 0 999 Years $71.75 3/1/2012 0.00 $71.75 2/1/2011
HOME
HEALTH DME E0978 0 999 Years $35.40 3/1/2012 0.00 $35.40 10/1/2013
HOME
HEALTH DME E0980 0 999 Years $28.79 3/1/2012 0.00 $28.79 10/1/2013
HOME
HEALTH DME E0981 0 999 Years $34.42 3/1/2012 0.00 $34.42 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Report
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Mod
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Purchase
HOME
HEALTH DME E0982 0 999 Years $50.25 3/1/2012 0.00 $50.25 10/1/2013
HOME
HEALTH DME E0990 0 999 Years $124.59 1/1/2016 0.00 $124.59 1/1/2016 $12.46 1/1/2016 0.00 12.46 1/1/2016
HOME
HEALTH DME E0992 0 999 Years $82.82 4/1/2013 0.00 $82.82 10/1/2013
HOME
HEALTH DME E0994 0 999 Years $13.24 3/1/2012 0.00 $13.24 10/1/2013
HOME
HEALTH DME E0995 0 999 Years $22.12 4/1/2013 0.00 $22.12 10/1/2013
HOME
HEALTH DME E1002 0 999 Years $3,661.00 3/1/2012 0.00 $3,661.00 1/1/2016
HOME
HEALTH DME E1003 0 999 Years $4,282.40 3/1/2012 0.00 $4,282.40 1/1/2016
HOME
HEALTH DME E1004 0 999 Years $4,748.30 3/1/2012 0.00 $4,748.30 1/1/2016
HOME
HEALTH DME E1005 0 999 Years $4,781.68 4/1/2013 0.00 $4,781.68 4/1/2015
HOME
HEALTH DME E1006 0 999 Years $6,295.60 4/1/2013 0.00 $6,295.60 1/1/2016
HOME
HEALTH DME E1007 0 999 Years $7,861.02 4/1/2013 0.00 $7,861.02 1/1/2016
HOME
HEALTH DME E1008 0 999 Years $7,881.83 3/1/2012 0.00 $7,881.83 1/1/2016
HOME
HEALTH DME E1009 0 999 Years $0.00 5/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E1010 0 999 Years $1,595.33 3/1/2012 0.00 $1,595.33 1/1/2016
HOME
HEALTH DME E1011 0 999 Years $0.00 5/1/2003 $0.00 5 10/1/2013
HOME
HEALTH DME E1012 0 999 Years $926.15 1/1/2016 0.00 $926.15 1/1/2016
HOME
HEALTH DME E1014 0 999 Years $319.87 3/1/2012 0.00 $319.87 1/1/2016
HOME
HEALTH DME E1015 0 999 Years $117.46 4/1/2013 0.00 $117.46 10/1/2013
HOME
HEALTH DME E1016 0 999 Years $127.15 3/1/2012 0.00 $127.15 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Frm Thru Units FeeFee Effect
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Report
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HEALTH DME E1017 0 999 Years $0.00 4/1/2013 $0.00 5 4/1/2015
HOME
HEALTH DME E1018 0 999 Years $0.00 5/1/2003 $0.00 5 4/1/2015
HOME
HEALTH DME E1020 0 999 Years $223.91 4/1/2013 0.00 $223.91 10/1/2013 $21.47 3/1/2012 0.00 21.47 10/1/2013
HOME
HEALTH DME E1028 0 999 Years $186.22 3/1/2012 0.00 $186.22 10/1/2013
HOME
HEALTH DME E1029 0 999 Years $326.14 3/1/2012 0.00 $326.14 10/1/2013
HOME
HEALTH DME E1031 0 999 Years $41.92 4/1/2013 0.00 41.92 4/1/2015
HOME
HEALTH DME E1035 TF 0 20 Years $0.00 4/1/2013 -2.00 $0.00 5 6 4/1/2015
HOME
HEALTH DME E1035 TG 0 20 Years $0.00 10/16/2003 -2.00 $0.00 5 6 4/1/2015
HOME
HEALTH DME E1050 0 999 Years $721.63 4/1/2015 0.00 $721.63 4/1/2015 $72.16 4/1/2015 0.00 72.16 4/1/2015
HOME
HEALTH DME E1060 0 999 Years $1,069.90 4/1/2013 0.00 $1,069.90 4/1/2015 $106.99 4/1/2013 0.00 106.99 4/1/2015
HOME
HEALTH DME E1070 0 999 Years $842.08 4/1/2013 0.00 $842.08 4/1/2015 $84.21 4/1/2013 0.00 84.21 4/1/2015
HOME
HEALTH DME E1083 0 999 Years $482.89 4/1/2015 0.00 $482.89 4/1/2015 $48.29 4/1/2015 0.00 48.29 4/1/2015
HOME
HEALTH DME E1084 0 999 Years $770.70 4/1/2013 0.00 $770.70 4/1/2015 $77.07 4/1/2013 0.00 77.07 4/1/2015
HOME
HEALTH DME E1085 0 999 Years $861.32 4/1/2013 0.00 $861.32 4/1/2015 $86.13 4/1/2013 0.00 86.13 4/1/2015
HOME
HEALTH DME E1086 0 999 Years $808.59 4/1/2013 0.00 $808.59 4/1/2015 $80.86 4/1/2013 0.00 80.86 4/1/2015
HOME
HEALTH DME E1087 0 999 Years $1,095.19 4/1/2013 0.00 $1,095.19 4/1/2015 $109.52 4/1/2013 0.00 109.52 4/1/2015
HOME
HEALTH DME E1088 0 999 Years $1,147.05 4/1/2013 0.00 $1,147.05 4/1/2015 $114.71 4/1/2013 0.00 114.71 4/1/2015
HOME
HEALTH DME E1089 0 999 Years $1,320.57 4/1/2013 0.00 $1,320.57 4/1/2015 $132.06 4/1/2013 0.00 132.06 4/1/2015
HOME
HEALTH DME E1090 0 999 Years $1,320.57 4/1/2013 0.00 $1,320.57 10/1/2013 $126.90 4/1/2013 -8.00 116.75 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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HOME
HEALTH DME E1092 0 999 Years $1,052.53 4/1/2013 0.00 $1,052.53 4/1/2015 $105.25 4/1/2013 0.00 105.25 4/1/2015
HOME
HEALTH DME E1093 0 999 Years $1,067.66 4/1/2013 0.00 $1,067.66 4/1/2015 $106.77 4/1/2013 0.00 106.77 4/1/2015
HOME
HEALTH DME E1100 0 999 Years $1,002.80 4/1/2013 0.00 $1,002.80 4/1/2015 $100.28 4/1/2013 0.00 100.28 4/1/2015
HOME
HEALTH DME E1110 0 999 Years $982.01 4/1/2013 0.00 $982.01 4/1/2015 $98.20 4/1/2013 0.00 98.20 4/1/2015
HOME
HEALTH DME E1130 0 999 Years $526.33 4/1/2013 0.00 $526.33 4/1/2015 $52.63 4/1/2015 0.00 52.63 4/1/2015
HOME
HEALTH DME E1140 0 999 Years $446.24 4/1/2013 0.00 $446.24 4/1/2015 $44.62 4/1/2013 0.00 44.62 4/1/2015
HOME
HEALTH DME E1150 0 999 Years $588.51 4/1/2015 0.00 $588.51 4/1/2015 $58.85 4/1/2015 0.00 58.85 4/1/2015
HOME
HEALTH DME E1160 0 999 Years $509.31 4/1/2013 0.00 $509.31 4/1/2015 $50.93 4/1/2013 0.00 50.93 4/1/2015
HOME
HEALTH DME E1161 0 999 Years $2,422.78 3/1/2012 0.00 $2,422.78 10/1/2013 $242.27 3/1/2012 0.00 242.27 10/1/2013
HOME
HEALTH DME E1170 0 999 Years $919.04 4/1/2013 0.00 $919.04 4/1/2015 $91.90 4/1/2013 0.00 91.90 4/1/2015
HOME
HEALTH DME E1171 0 999 Years $824.77 4/1/2013 0.00 $824.77 4/1/2015 $82.48 4/1/2013 0.00 82.48 4/1/2015
HOME
HEALTH DME E1172 0 999 Years $779.54 4/1/2013 0.00 $779.54 4/1/2015 $77.95 4/1/2013 0.00 77.95 4/1/2015
HOME
HEALTH DME E1180 0 999 Years $922.56 4/1/2013 0.00 $922.56 4/1/2015 $92.26 4/1/2013 0.00 92.26 4/1/2015
HOME
HEALTH DME E1190 0 999 Years $1,028.84 4/1/2013 0.00 $1,028.84 10/1/2013 $111.83 3/1/2012 0.00 111.83 10/1/2013
HOME
HEALTH DME E1195 0 999 Years $979.89 4/1/2013 0.00 $979.89 10/1/2013 $106.51 3/1/2012 0.00 106.51 10/1/2013
HOME
HEALTH DME E1200 0 999 Years $692.89 4/1/2013 0.00 $692.89 4/1/2015 $69.29 4/1/2013 0.00 69.29 4/1/2015
HOME
HEALTH DME E1220 0 999 Years $0.00 7/1/1997 $0.00 5 10/1/2013
HOME
HEALTH DME E1225 0 999 Years $312.00 7/1/2013 0.00 $312.00 4/1/2015 $31.20 4/1/2014 0.00 31.20 4/1/2015
HOME
HEALTH DME E1226 0 999 Years $376.63 7/1/2013 0.00 $376.63 4/1/2015 $37.66 4/1/2014 0.00 37.66 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HOME
HEALTH DME E1229 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E1230 0 999 Years $1,353.82 4/1/2013 0.00 $1,353.82 10/1/2013 $141.41 3/1/2012 0.00 141.41 10/1/2013
HOME
HEALTH DME E1231 0 999 Years $0.00 1/1/2016 $0.00 1/1/2016 $0.00 1/1/2016 0.00 1/1/2016
HOME
HEALTH DME E1232 0 999 Years $2,189.65 4/1/2013 0.00 $2,189.65 1/1/2016 $218.97 1/1/2016 0.00 218.97 1/1/2016
HOME
HEALTH DME E1233 0 999 Years $2,268.82 3/1/2012 0.00 $2,268.82 1/1/2016 $226.88 3/1/2012 0.00 226.88 1/1/2016
HOME
HEALTH DME E1234 0 999 Years $1,975.17 3/1/2012 0.00 $1,975.17 1/1/2016 $197.52 1/1/2016 0.00 197.52 1/1/2016
HOME
HEALTH DME E1235 0 999 Years $2,680.34 1/1/2016 0.00 $2,680.34 1/1/2016 $190.20 4/1/2013 0.00 190.20 10/1/2013
HOME
HEALTH DME E1236 0 999 Years $2,364.57 1/1/2016 0.00 $2,364.57 1/1/2016 $167.80 3/1/2012 0.00 167.80 10/1/2013
HOME
HEALTH DME E1237 0 999 Years $1,439.40 3/1/2012 0.00 $1,439.40 10/1/2013 $143.94 3/1/2012 0.00 143.94 10/1/2013
HOME
HEALTH DME E1238 0 999 Years $1,599.33 3/1/2012 0.00 $1,599.33 10/1/2013 $159.93 3/1/2012 0.00 159.93 10/1/2013
HOME
HEALTH DME E1239 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E1240 0 999 Years $764.25 4/1/2013 0.00 $764.25 4/1/2015 $76.43 4/1/2015 0.00 76.43 4/1/2015
HOME
HEALTH DME E1250 0 999 Years $885.41 4/1/2013 0.00 $885.41 4/1/2015 $88.54 4/1/2013 0.00 88.54 4/1/2015
HOME
HEALTH DME E1260 0 999 Years $750.67 4/1/2013 0.00 $750.67 4/1/2015 $75.07 4/1/2013 0.00 75.07 4/1/2015
HOME
HEALTH DME E1270 0 999 Years $762.59 4/1/2013 0.00 $762.59 4/1/2015 $76.26 4/1/2013 0.00 76.26 4/1/2015
HOME
HEALTH DME E1280 0 999 Years $1,075.00 4/1/2013 0.00 $1,075.00 4/1/2015 $107.50 4/1/2013 0.00 107.50 4/1/2015
HOME
HEALTH DME E1285 0 999 Years $1,239.33 4/1/2013 0.00 $1,239.33 4/1/2015 $123.93 4/1/2013 0.00 123.93 4/1/2015
HOME
HEALTH DME E1290 0 999 Years $1,034.51 7/1/1997 -8.00 $951.75 10/1/2013 $103.45 2/1/2011 -8.00 95.17 10/1/2013
HOME
HEALTH DME E1295 0 999 Years $1,113.60 7/1/1997 -8.00 $1,024.51 10/1/2013 $102.45 4/1/2013 0.00 102.45 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E1296 0 999 Years $384.49 4/1/2013 0.00 $384.49 4/1/2015
HOME
HEALTH DME E1297 0 999 Years $81.81 4/1/2013 0.00 $81.81 4/1/2015
HOME
HEALTH DME E1298 0 999 Years $331.29 4/1/2013 0.00 $331.29 4/1/2015
HOME
HEALTH DME E1353 0 999 Years $27.37 4/1/2013 0.00 $27.37 4/1/2015
HOME
HEALTH DME E1355 0 999 Years $20.61 4/1/2013 0.00 $20.61 4/1/2015 $2.06 4/1/2013 0.00 2.06 4/1/2015
HOME
HEALTH DME E135F 0 20 Years $0.00 4/1/2013 -2.00 $0.00 5 6 2/1/2011
HOME
HEALTH DME E1372 0 999 Years $149.99 4/1/2013 0.00 $149.99 4/1/2015
HOME
HEALTH DME E1390 0 999 Years $161.05 4/1/2013 0.00 161.05 4/1/2015
HOME
HEALTH DME E1399 0 999 Years $0.00 5/1/2003 $0.00 5 4/1/2015 $0.00 5/1/2003 0.00 5 4/1/2015
HOME
HEALTH DME E1510 0 20 Years $9,928.69 4/1/2013 0.00 $9,928.69 6 4/1/2015 $992.87 4/1/2013 0.00 992.87 6 4/1/2015
HOME
HEALTH DME E1520 0 20 Years $372.70 4/1/2013 0.00 $372.70 6 4/1/2015 $37.27 4/1/2013 0.00 37.27 6 4/1/2015
HOME
HEALTH DME E1530 0 20 Years $536.28 4/1/2013 0.00 $536.28 6 4/1/2015
HOME
HEALTH DME E1540 0 20 Years $22.50 4/1/2013 0.00 $22.50 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
HOME
HEALTH DME E1550 0 20 Years $274.08 4/1/2013 0.00 $274.08 6 4/1/2015 $27.41 4/1/2013 0.00 27.41 6 4/1/2015
HOME
HEALTH DME E1560 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
HOME
HEALTH DME E1570 0 20 Years $556.28 4/1/2015 0.00 $556.28 6 4/1/2015 $55.63 4/1/2015 0.00 55.63 6 4/1/2015
HOME
HEALTH DME E1575 0 20 Years $1.60 4/1/2013 0.00 $1.60 4/1/2015 $0.16 4/1/2009 0.00 0.16 4/1/2015
HOME
HEALTH DME E1580 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
HOME
HEALTH DME E1590 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $284.20 4/1/2013 0.00 284.20 6 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E1592 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
HOME
HEALTH DME E1594 0 20 Years $6,020.48 4/1/2013 0.00 $6,020.48 6 4/1/2015 $602.05 4/1/2013 0.00 602.05 6 4/1/2015
HOME
HEALTH DME E1600 0 20 Years $35.75 4/1/2013 0.00 35.75 6 4/1/2015
HOME
HEALTH DME E1620 0 20 Years $1,719.65 4/1/2013 0.00 $1,719.65 6 4/1/2015 $171.97 4/1/2015 0.00 171.97 6 4/1/2015
HOME
HEALTH DME E1630 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
HOME
HEALTH DME E1632 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
HOME
HEALTH DME E1635 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $616.30 4/1/2013 0.00 616.30 6 4/1/2013
HOME
HEALTH DME E1699 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
HOME
HEALTH DME E1700 0 20 Years $27.77 4/1/2013 0.00 27.77 6 4/1/2015
HOME
HEALTH DME E1701 0 20 Years $1.06 4/1/2013 0.00 1.06 6 4/1/2015
HOME
HEALTH DME E1702 0 20 Years $2.02 4/1/2013 0.00 2.02 6 4/1/2015
HOME
HEALTH DME E1841 0 999 Years $3,678.45 7/1/2013 0.00 $3,678.45 4/1/2015 $367.85 4/1/2015 0.00 367.85 4/1/2015
HOME
HEALTH DME E2100 0 999 Years $312.80 4/1/2013 0.00 $312.80 4/1/2015
HOME
HEALTH DME E2101 0 999 Years $173.48 4/1/2013 0.00 $173.48 10/1/2013
HOME
HEALTH DME E2201 0 999 Years $363.85 3/1/2012 0.00 $363.85 10/1/2013
HOME
HEALTH DME E2202 0 999 Years $462.23 4/1/2013 0.00 $462.23 10/1/2013
HOME
HEALTH DME E2203 0 999 Years $431.91 4/1/2013 0.00 $431.91 10/1/2013
HOME
HEALTH DME E2204 0 999 Years $651.05 3/1/2012 0.00 $651.05 10/1/2013
HOME
HEALTH DME E2205 0 999 Years $33.45 3/1/2012 0.00 $33.45 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E2206 0 999 Years $41.65 3/1/2012 0.00 $41.65 1/1/2016
HOME
HEALTH DME E2207 0 999 Years $42.25 4/1/2013 0.00 $42.25 1/1/2016 $4.23 3/1/2012 0.00 4.23 1/1/2016
HOME
HEALTH DME E2208 0 999 Years $115.83 4/1/2013 0.00 $115.83 10/1/2013 $11.58 3/1/2012 0.00 11.58 10/1/2013
HOME
HEALTH DME E2209 0 999 Years $104.51 3/1/2012 0.00 $104.51 1/1/2016 $10.45 1/1/2016 0.00 10.45 1/1/2016
HOME
HEALTH DME E2210 0 999 Years $6.39 3/1/2012 0.00 $6.39 1/1/2016
HOME
HEALTH DME E2211 0 999 Years $28.51 3/1/2012 0.00 $28.51 10/1/2013
HOME
HEALTH DME E2212 0 999 Years $5.73 3/1/2012 0.00 $5.73 10/1/2013
HOME
HEALTH DME E2213 0 999 Years $28.51 3/1/2012 0.00 $28.51 10/1/2013
HOME
HEALTH DME E2214 0 999 Years $29.84 3/1/2012 0.00 $29.84 10/1/2013
HOME
HEALTH DME E2215 0 999 Years $9.36 3/1/2012 0.00 $9.36 10/1/2013
HOME
HEALTH DME E2216 0 999 Years $0.00 1/1/2016 $0.00 1/1/2016
HOME
HEALTH DME E2217 0 999 Years $0.00 1/1/2016 $0.00 1/1/2016
HOME
HEALTH DME E2218 0 999 Years $43.98 3/1/2012 0.00 $43.98 10/1/2013
HOME
HEALTH DME E2219 0 999 Years $32.07 3/1/2012 0.00 $32.07 10/1/2013
HOME
HEALTH DME E2220 0 999 Years $23.64 3/1/2012 0.00 $23.64 10/1/2013
HOME
HEALTH DME E2221 0 999 Years $24.92 3/1/2012 0.00 $24.92 10/1/2013
HOME
HEALTH DME E2222 0 999 Years $59.18 3/1/2012 0.00 $59.18 10/1/2013
HOME
HEALTH DME E2224 0 999 Years $43.91 3/1/2012 0.00 $43.91 10/1/2013
HOME
HEALTH DME E2225 0 999 Years $39.98 3/1/2012 0.00 $39.98 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E2226 0 999 Years $50.63 3/1/2012 0.00 $50.63 10/1/2013
HOME
HEALTH DME E2227 0 999 Years $1,530.22 3/1/2012 0.00 $1,530.22 1/1/2016
HOME
HEALTH DME E2228 0 999 Years $913.04 3/1/2012 0.00 $913.04 1/1/2016
HOME
HEALTH DME E2291 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2292 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2293 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2294 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2300 0 999 Years $0.00 4/1/2013 $0.00 5 4/1/2015
HOME
HEALTH DME E2310 0 999 Years $1,141.22 3/1/2012 0.00 $1,141.22 1/1/2016
HOME
HEALTH DME E2311 0 999 Years $2,136.07 3/1/2012 0.00 $2,136.07 1/1/2016
HOME
HEALTH DME E2312 0 999 Years $1,891.09 3/1/2012 0.00 $1,891.09 10/1/2013 $189.11 4/1/2013 0.00 189.11 4/1/2013
HOME
HEALTH DME E2312 KC 0 999 Years $2,411.85 3/1/2012 0.00 $2,411.85 10/1/2013 $241.19 4/1/2013 0.00 241.19 4/1/2013
HOME
HEALTH DME E2313 0 999 Years $300.29 4/1/2013 0.00 $300.29 10/1/2013
HOME
HEALTH DME E2321 0 999 Years $1,719.28 3/1/2012 0.00 $1,719.28 10/1/2013
HOME
HEALTH DME E2321 KC 0 999 Years $2,284.45 4/1/2013 0.00 $2,284.45 10/1/2013
HOME
HEALTH DME E2323 0 999 Years $63.04 3/1/2012 0.00 $63.04 10/1/2013
HOME
HEALTH DME E2324 0 999 Years $43.39 3/1/2012 0.00 $43.39 10/1/2013
HOME
HEALTH DME E2325 0 999 Years $1,313.43 4/1/2013 0.00 $1,313.43 10/1/2013
HOME
HEALTH DME E2326 0 999 Years $311.67 3/1/2012 0.00 $311.67 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E2327 0 999 Years $2,248.95 3/1/2012 0.00 $2,248.95 10/1/2013
HOME
HEALTH DME E2328 0 999 Years $3,781.16 3/1/2012 0.00 $3,781.16 10/1/2013
HOME
HEALTH DME E2329 0 999 Years $2,181.89 3/1/2012 0.00 $2,181.89 10/1/2013
HOME
HEALTH DME E2330 0 999 Years $3,250.60 4/1/2013 0.00 $3,250.60 10/1/2013
HOME
HEALTH DME E2340 0 999 Years $306.43 4/1/2013 0.00 $306.43 10/1/2013
HOME
HEALTH DME E2341 0 999 Years $451.49 3/1/2012 0.00 $451.49 10/1/2013
HOME
HEALTH DME E2342 0 999 Years $436.92 3/1/2012 0.00 $436.92 10/1/2013
HOME
HEALTH DME E2343 0 999 Years $733.96 4/1/2013 0.00 $733.96 10/1/2013
HOME
HEALTH DME E2351 0 999 Years $681.30 3/1/2012 0.00 $681.30 10/1/2013
HOME
HEALTH DME E2359 0 999 Years $134.87 4/1/2013 0.00 $134.87 4/1/2015
HOME
HEALTH DME E2361 0 999 Years $151.41 3/1/2012 0.00 $151.41 10/1/2013
HOME
HEALTH DME E2363 0 999 Years $196.79 3/1/2012 0.00 $196.79 10/1/2013
HOME
HEALTH DME E2366 0 999 Years $237.68 3/1/2012 0.00 $237.68 10/1/2013
HOME
HEALTH DME E2368 0 999 Years $455.91 3/1/2012 0.00 $455.91 10/1/2013
HOME
HEALTH DME E2369 0 999 Years $397.10 3/1/2012 0.00 $397.10 10/1/2013
HOME
HEALTH DME E2370 0 999 Years $854.42 3/1/2012 0.00 $854.42 10/1/2013
HOME
HEALTH DME E2371 0 999 Years $167.31 1/1/2016 0.00 $167.31 1/1/2016
HOME
HEALTH DME E2373 0 999 Years $1,179.92 4/1/2013 0.00 $1,179.92 10/1/2013
HOME
HEALTH DME E2373 KC 0 999 Years $1,067.83 3/1/2012 0.00 $1,067.83 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E2374 0 999 Years $520.78 3/1/2012 0.00 $520.78 10/1/2013
HOME
HEALTH DME E2375 0 999 Years $835.33 4/1/2013 0.00 $835.33 10/1/2013
HOME
HEALTH DME E2376 0 999 Years $1,259.56 3/1/2012 0.00 $1,259.56 10/1/2013
HOME
HEALTH DME E2377 0 999 Years $473.66 3/1/2012 0.00 $473.66 10/1/2013
HOME
HEALTH DME E2381 0 999 Years $57.47 3/1/2012 0.00 $57.47 10/1/2013
HOME
HEALTH DME E2382 0 999 Years $20.26 3/1/2012 0.00 $20.26 10/1/2013
HOME
HEALTH DME E2383 0 999 Years $113.88 3/1/2012 0.00 $113.88 10/1/2013
HOME
HEALTH DME E2384 0 999 Years $60.67 3/1/2012 0.00 $60.67 10/1/2013
HOME
HEALTH DME E2385 0 999 Years $48.27 3/1/2012 0.00 $48.27 10/1/2013
HOME
HEALTH DME E2386 0 999 Years $139.34 4/1/2013 0.00 $139.34 4/1/2015
HOME
HEALTH DME E2387 0 999 Years $58.55 3/1/2012 0.00 $58.55 10/1/2013
HOME
HEALTH DME E2388 0 999 Years $49.14 3/1/2012 0.00 $49.14 10/1/2013
HOME
HEALTH DME E2389 0 999 Years $26.68 3/1/2012 0.00 $26.68 10/1/2013
HOME
HEALTH DME E2390 0 999 Years $41.73 3/1/2012 0.00 $41.73 10/1/2013
HOME
HEALTH DME E2391 0 999 Years $19.99 3/1/2012 0.00 $19.99 10/1/2013
HOME
HEALTH DME E2392 0 999 Years $52.54 3/1/2012 0.00 $52.54 10/1/2013
HOME
HEALTH DME E2394 0 999 Years $74.85 3/1/2012 0.00 $74.85 10/1/2013
HOME
HEALTH DME E2395 0 999 Years $53.20 3/1/2012 0.00 $53.20 10/1/2013
HOME
HEALTH DME E2396 0 999 Years $44.74 3/1/2012 0.00 $44.74 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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HEALTH DME E2402 0 999 Years $1,289.32 4/1/2013 0.00 1,289.32 4/1/2015
HOME
HEALTH DME E2500 0 999 Years $344.20 4/1/2013 0.00 $344.20 4/1/2015 $34.42 4/1/2013 0.00 34.42 4/1/2015
HOME
HEALTH DME E2502 0 999 Years $1,155.14 4/1/2013 0.00 $1,155.14 4/1/2015 $115.51 4/1/2015 0.00 115.51 4/1/2015
HOME
HEALTH DME E2504 0 999 Years $1,545.87 4/1/2013 0.00 $1,545.87 4/1/2015 $154.59 4/1/2015 0.00 154.59 4/1/2015
HOME
HEALTH DME E2506 0 999 Years $2,127.92 4/1/2013 0.00 $2,127.92 4/1/2015 $212.79 4/1/2013 0.00 212.79 4/1/2015
HOME
HEALTH DME E2508 0 999 Years $3,290.48 4/1/2013 0.00 $3,290.48 4/1/2015 $329.05 4/1/2015 0.00 329.05 4/1/2015
HOME
HEALTH DME E2510 0 999 Years $6,226.79 4/1/2013 0.00 $6,226.79 4/1/2015 $622.68 4/1/2015 0.00 622.68 4/1/2015
HOME
HEALTH DME E2511 0 999 Years $354.37 4/1/2013 0.00 $354.37 4/1/2015
HOME
HEALTH DME E2512 0 999 Years $0.00 7/1/2004 $0.00 5 4/1/2015 $82.71 4/1/2013 0.00 82.71 4/1/2015
HOME
HEALTH DME E2599 0 999 Years $0.00 7/1/2004 $0.00 5 4/1/2015 $0.00 7/1/2004 0.00 5 4/1/2015
HOME
HEALTH DME E2599 U1 0 999 Years $139.00 4/1/2015 0.00 $139.00 4/1/2015
HOME
HEALTH DME E2601 0 999 Years $53.98 3/1/2012 0.00 $53.98 10/1/2013
HOME
HEALTH DME E2602 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2603 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2604 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2605 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2606 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2607 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2608 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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HOME
HEALTH DME E2609 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2611 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2612 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2613 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2614 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2615 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2616 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2617 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2619 0 999 Years $0.00 1/1/2005 $0.00 5 1/1/2016
HOME
HEALTH DME E2620 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
HOME
HEALTH DME E2621 0 999 Years $507.26 3/1/2012 0.00 $507.26 10/1/2013
HOME
HEALTH DME E2622 0 999 Years $323.25 3/1/2012 0.00 $323.25 10/1/2013
HOME
HEALTH DME E2623 0 999 Years $411.32 3/1/2012 0.00 $411.32 10/1/2013
HOME
HEALTH DME E2624 0 999 Years $325.89 4/1/2013 0.00 $325.89 10/1/2013
HOME
HEALTH DME E2625 0 999 Years $412.58 4/1/2013 0.00 $412.58 4/1/2015
HOME
HEALTH DME E2626 0 20 Years $446.66 4/1/2013 0.00 $446.66 6 4/1/2015
HOME
HEALTH DME E2627 0 20 Years $773.31 4/1/2013 0.00 $773.31 6 4/1/2015
HOME
HEALTH DME E2628 0 20 Years $527.86 4/1/2013 0.00 $527.86 6 4/1/2015
HOME
HEALTH DME E2629 0 20 Years $705.36 4/1/2013 0.00 $705.36 6 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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HOME
HEALTH DME E2630 0 20 Years $513.92 4/1/2013 0.00 $513.92 6 4/1/2015
HOME
HEALTH DME E2631 0 20 Years $204.43 4/1/2013 0.00 $204.43 6 4/1/2015
HOME
HEALTH DME E2632 0 20 Years $172.94 4/1/2013 0.00 $172.94 6 4/1/2015
HOME
HEALTH DME E2633 0 20 Years $138.56 4/1/2013 0.00 $138.56 6 4/1/2015
HOME
HEALTH DME E8001 0 999 Years $0.00 1/1/2005 $0.00 5 4/1/2015 $0.00 1/1/2005 0.00 5 4/1/2015
HOME
HEALTH DME K0001 0 999 Years $432.52 7/1/2013 0.00 $432.52 11/1/2015 $43.25 7/1/2013 0.00 43.25 11/1/2015
HOME
HEALTH DME K0002 0 999 Years $664.42 7/1/2013 0.00 $664.42 11/1/2015 $66.44 7/1/2013 0.00 66.44 11/1/2015
HOME
HEALTH DME K0003 0 999 Years $727.58 7/1/2013 0.00 $727.58 11/1/2015 $72.76 7/1/2013 0.00 72.76 11/1/2015
HOME
HEALTH DME K0004 0 999 Years $1,085.18 7/1/2013 0.00 $1,085.18 11/1/2015 $108.52 7/1/2013 0.00 108.52 11/1/2015
HOME
HEALTH DME K0005 0 999 Years $2,001.69 7/1/2013 0.00 $2,001.69 11/1/2015 $200.15 7/1/2013 0.00 200.15 11/1/2015
HOME
HEALTH DME K0006 0 999 Years $1,018.42 7/1/2013 0.00 $1,018.42 11/1/2015 $101.84 7/1/2013 0.00 101.84 11/1/2015
HOME
HEALTH DME K0007 0 999 Years $1,449.45 7/1/2013 0.00 $1,449.45 11/1/2015 $144.94 7/1/2013 0.00 144.94 11/1/2015
HOME
HEALTH DME K0008 0 20 Years $0.00 4/1/2014 -2.00 $0.00 11/1/2015 $0.00 4/1/2014 -2.00 0.00 11/1/2015
HOME
HEALTH DME K0009 0 999 Years $0.00 7/1/2013 $0.00 5 11/1/2015 $0.00 7/1/2013 0.00 5 11/1/2015
HOME
HEALTH DME K0010 0 999 Years $3,620.90 10/1/2006 -8.00 $3,331.23 11/1/2015 $362.09 10/1/2006 -8.00 333.12 11/1/2015
HOME
HEALTH DME K0011 0 999 Years $5,122.80 10/1/2006 -8.00 $4,712.98 11/1/2015 $512.28 10/1/2006 -8.00 471.30 11/1/2015
HOME
HEALTH DME K0012 0 999 Years $3,343.49 1/1/2006 -8.00 $3,076.01 11/1/2015 $334.35 10/1/2011 -8.00 307.60 11/1/2015
HOME
HEALTH DME K0013 0 20 Years $0.00 4/1/2014 -2.00 $0.00 11/1/2015 $0.00 4/1/2014 -2.00 0.00 11/1/2015
HOME
HEALTH DME K0015 0 999 Years $196.73 7/1/2013 0.00 $196.73 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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HOME
HEALTH DME K0017 0 999 Years $55.35 7/1/2013 0.00 $55.35 11/1/2015
HOME
HEALTH DME K0018 0 999 Years $30.92 7/1/2013 0.00 $30.92 11/1/2015
HOME
HEALTH DME K0019 0 999 Years $17.70 7/1/2013 0.00 $17.70 11/1/2015
HOME
HEALTH DME K0020 0 999 Years $50.30 7/1/2013 0.00 $50.30 11/1/2015
HOME
HEALTH DME K0037 0 999 Years $52.14 7/1/2013 0.00 $52.14 11/1/2015
HOME
HEALTH DME K0038 0 999 Years $26.26 7/1/2013 0.00 $26.26 11/1/2015
HOME
HEALTH DME K0039 0 999 Years $58.33 7/1/2013 0.00 $58.33 11/1/2015
HOME
HEALTH DME K0040 0 999 Years $80.84 7/1/2013 0.00 $80.84 11/1/2015
HOME
HEALTH DME K0041 0 999 Years $57.29 7/1/2013 0.00 $57.29 11/1/2015
HOME
HEALTH DME K0042 0 999 Years $39.44 7/1/2013 0.00 $39.44 11/1/2015
HOME
HEALTH DME K0043 0 999 Years $21.15 7/1/2013 0.00 $21.15 11/1/2015
HOME
HEALTH DME K0044 0 999 Years $18.01 7/1/2013 0.00 $18.01 11/1/2015
HOME
HEALTH DME K0045 0 999 Years $61.31 7/1/2013 0.00 $61.31 11/1/2015
HOME
HEALTH DME K0046 0 999 Years $21.15 7/1/2013 0.00 $21.15 11/1/2015 $2.12 4/1/2014 0.00 2.12 11/1/2015
HOME
HEALTH DME K0047 0 999 Years $82.81 7/1/2013 0.00 $82.81 11/1/2015 $8.28 4/1/2014 0.00 8.28 11/1/2015
HOME
HEALTH DME K0050 0 999 Years $35.20 7/1/2013 0.00 $35.20 11/1/2015
HOME
HEALTH DME K0051 0 999 Years $56.95 7/1/2013 0.00 $56.95 11/1/2015
HOME
HEALTH DME K0052 0 999 Years $100.08 7/1/2013 0.00 $100.08 11/1/2015
HOME
HEALTH DME K0053 0 999 Years $110.45 7/1/2013 0.00 $110.45 11/1/2015 $11.05 4/1/2014 0.00 11.05 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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HOME
HEALTH DME K0056 0 999 Years $77.23 7/1/2013 0.00 $77.23 11/1/2015
HOME
HEALTH DME K0065 0 999 Years $36.10 7/1/2013 0.00 $36.10 11/1/2015 $3.61 4/1/2014 0.00 3.61 11/1/2015
HOME
HEALTH DME K0069 0 999 Years $81.15 7/1/2013 0.00 $81.15 11/1/2015
HOME
HEALTH DME K0070 0 999 Years $148.73 7/1/2013 0.00 $148.73 11/1/2015
HOME
HEALTH DME K0071 0 999 Years $88.72 7/1/2013 0.00 $88.72 11/1/2015
HOME
HEALTH DME K0072 0 999 Years $53.41 7/1/2013 0.00 $53.41 11/1/2015
HOME
HEALTH DME K0073 0 999 Years $27.17 7/1/2013 0.00 $27.17 11/1/2015
HOME
HEALTH DME K0077 0 999 Years $47.79 7/1/2013 0.00 $47.79 11/1/2015
HOME
HEALTH DME K0098 0 999 Years $28.59 7/1/2013 0.00 $28.59 11/1/2015
HOME
HEALTH DME K0105 0 999 Years $80.74 7/1/2013 0.00 $80.74 11/1/2015 $8.07 4/1/2014 0.00 8.07 11/1/2015
HOME
HEALTH DME K0108 0 999 Years $0.00 5/1/2003 $0.00 5 11/1/2015
HOME
HEALTH DME K0195 0 999 Years $147.53 7/1/2013 0.00 $147.53 11/1/2015 $14.75 4/1/2014 0.00 14.75 11/1/2015
HOME
HEALTH DME K0455 0 999 Years $277.83 10/1/2011 -8.00 255.60 11/1/2015
HOME
HEALTH DME K0462 0 999 Years $48.76 3/1/2012 0.00 48.76 11/1/2015
HOME
HEALTH DME K0606 0 999 Years $2,518.27 10/1/2009 -8.00 2,316.81 11/1/2015
HOME
HEALTH DME K0669 0 999 Years $73.55 7/1/2013 0.00 $73.55 11/1/2015
HOME
HEALTH DME K0730 0 999 Years $1,724.02 6/1/2008 -8.00 $1,586.10 11/1/2015
HOME
HEALTH DME K0733 0 999 Years $29.46 3/1/2012 0.00 $29.46 11/1/2015
HOME
HEALTH DME K0738 0 999 Years $0.00 3/1/2012 0.00 5 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Report
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HOME
HEALTH DME K0800 0 999 Years $1,260.71 3/1/2012 0.00 $1,260.71 11/1/2015 $126.08 3/1/2012 0.00 126.08 11/1/2015
HOME
HEALTH DME K0801 0 999 Years $1,989.39 3/1/2012 0.00 $1,989.39 11/1/2015 $198.92 3/1/2012 0.00 198.92 11/1/2015
HOME
HEALTH DME K0802 0 999 Years $2,300.17 3/1/2012 0.00 $2,300.17 11/1/2015 $230.01 3/1/2012 0.00 230.01 11/1/2015
HOME
HEALTH DME K0813 0 999 Years $2,352.57 3/1/2012 0.00 $2,352.57 11/1/2015 $235.26 3/1/2012 0.00 235.26 11/1/2015
HOME
HEALTH DME K0814 0 999 Years $3,011.23 3/1/2012 0.00 $3,011.23 11/1/2015 $301.12 3/1/2012 0.00 301.12 11/1/2015
HOME
HEALTH DME K0815 0 999 Years $3,429.01 3/1/2012 0.00 $3,429.01 11/1/2015 $342.91 3/1/2012 0.00 342.91 11/1/2015
HOME
HEALTH DME K0816 0 999 Years $3,283.99 3/1/2012 0.00 $3,283.99 11/1/2015 $328.39 3/1/2012 0.00 328.39 11/1/2015
HOME
HEALTH DME K0820 0 999 Years $2,512.88 3/1/2012 0.00 $2,512.88 11/1/2015 $251.27 3/1/2012 0.00 251.27 11/1/2015
HOME
HEALTH DME K0821 0 999 Years $3,157.20 3/1/2012 0.00 $3,157.20 11/1/2015 $315.72 3/1/2012 0.00 315.72 11/1/2015
HOME
HEALTH DME K0822 0 999 Years $2,715.89 3/1/2012 0.00 $2,715.89 11/1/2015 $282.17 3/1/2012 0.00 282.17 11/1/2015
HOME
HEALTH DME K0823 0 999 Years $2,703.93 3/1/2012 0.00 $2,703.93 11/1/2015 $272.85 3/1/2012 0.00 272.85 11/1/2015
HOME
HEALTH DME K0824 0 999 Years $4,009.76 3/1/2012 0.00 $4,009.76 11/1/2015 $405.43 3/1/2012 0.00 405.43 11/1/2015
HOME
HEALTH DME K0825 0 999 Years $3,343.50 3/1/2012 0.00 $3,343.50 11/1/2015 $365.82 3/1/2012 0.00 365.82 11/1/2015
HOME
HEALTH DME K0826 0 999 Years $6,143.91 3/1/2012 0.00 $6,143.91 11/1/2015 $611.81 3/1/2012 0.00 611.81 11/1/2015
HOME
HEALTH DME K0827 0 999 Years $5,198.70 3/1/2012 0.00 $5,198.70 11/1/2015 $519.87 3/1/2012 0.00 519.87 11/1/2015
HOME
HEALTH DME K0828 0 999 Years $6,736.87 3/1/2012 0.00 $6,736.87 11/1/2015 $673.68 3/1/2012 0.00 673.68 11/1/2015
HOME
HEALTH DME K0829 0 999 Years $6,186.37 3/1/2012 0.00 $6,186.37 11/1/2015 $618.64 3/1/2012 0.00 618.64 11/1/2015
HOME
HEALTH DME K0835 0 999 Years $4,029.82 3/1/2012 0.00 $4,029.82 11/1/2015 $402.98 3/1/2012 0.00 402.98 11/1/2015
HOME
HEALTH DME K0836 0 999 Years $4,103.15 3/1/2012 0.00 $4,103.15 11/1/2015 $410.32 3/1/2012 0.00 410.32 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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HOME
HEALTH DME K0837 0 999 Years $4,722.60 3/1/2012 0.00 $4,722.60 11/1/2015 $472.26 3/1/2012 0.00 472.26 11/1/2015
HOME
HEALTH DME K0838 0 999 Years $4,263.77 3/1/2012 0.00 $4,263.77 11/1/2015 $426.37 3/1/2012 0.00 426.37 11/1/2015
HOME
HEALTH DME K0839 0 999 Years $6,113.83 3/1/2012 0.00 $6,113.83 11/1/2015 $611.39 3/1/2012 0.00 611.39 11/1/2015
HOME
HEALTH DME K0840 0 999 Years $9,262.75 3/1/2012 0.00 $9,262.75 11/1/2015 $926.27 3/1/2012 0.00 926.27 11/1/2015
HOME
HEALTH DME K0841 0 999 Years $4,211.50 3/1/2012 0.00 $4,211.50 11/1/2015 $421.15 3/1/2012 0.00 421.15 11/1/2015
HOME
HEALTH DME K0842 0 999 Years $4,211.50 3/1/2012 0.00 $4,211.50 11/1/2015 $421.15 3/1/2012 0.00 421.15 11/1/2015
HOME
HEALTH DME K0843 0 999 Years $5,070.65 3/1/2012 0.00 $5,070.65 11/1/2015 $507.06 3/1/2012 0.00 507.06 11/1/2015
HOME
HEALTH DME K0848 0 999 Years $4,948.92 3/1/2012 0.00 $4,948.92 11/1/2015 $529.88 3/1/2012 0.00 529.88 11/1/2015
HOME
HEALTH DME K0849 0 999 Years $4,954.69 3/1/2012 0.00 $4,954.69 11/1/2015 $495.47 3/1/2012 0.00 495.47 11/1/2015
HOME
HEALTH DME K0850 0 999 Years $5,987.63 3/1/2012 0.00 $5,987.63 11/1/2015 $598.76 3/1/2012 0.00 598.76 11/1/2015
HOME
HEALTH DME K0851 0 999 Years $5,599.02 3/1/2012 0.00 $5,599.02 11/1/2015 $559.90 3/1/2012 0.00 559.90 11/1/2015
HOME
HEALTH DME K0852 0 999 Years $6,906.95 3/1/2012 0.00 $6,906.95 11/1/2015 $690.70 3/1/2012 0.00 690.70 11/1/2015
HOME
HEALTH DME K0853 0 999 Years $7,095.16 3/1/2012 0.00 $7,095.16 11/1/2015 $709.52 3/1/2012 0.00 709.52 11/1/2015
HOME
HEALTH DME K0854 0 999 Years $9,399.56 3/1/2012 0.00 $9,399.56 11/1/2015 $939.96 3/1/2012 0.00 939.96 11/1/2015
HOME
HEALTH DME K0855 0 999 Years $8,879.29 3/1/2012 0.00 $8,879.29 11/1/2015 $887.93 3/1/2012 0.00 887.93 11/1/2015
HOME
HEALTH DME K0856 0 999 Years $5,558.85 3/1/2012 0.00 $5,558.85 11/1/2015 $567.23 10/1/2009 -8.00 521.85 11/1/2015
HOME
HEALTH DME K0857 0 999 Years $5,642.51 3/1/2012 0.00 $5,642.51 11/1/2015 $564.25 3/1/2012 0.00 564.25 11/1/2015
HOME
HEALTH DME K0858 0 999 Years $6,863.07 3/1/2012 0.00 $6,863.07 11/1/2015 $686.31 3/1/2012 0.00 686.31 11/1/2015
HOME
HEALTH DME K0859 0 999 Years $6,375.95 3/1/2012 0.00 $6,375.95 11/1/2015 $637.60 3/1/2012 0.00 637.60 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
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Report
Date
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HOME
HEALTH DME K0860 0 999 Years $9,804.76 3/1/2012 0.00 $9,804.76 11/1/2015 $980.48 3/1/2012 0.00 980.48 11/1/2015
HOME
HEALTH DME K0861 0 999 Years $5,226.89 3/1/2012 0.00 $5,226.89 11/1/2015 $543.60 3/1/2012 0.00 543.60 11/1/2015
HOME
HEALTH DME K0862 0 999 Years $6,863.07 3/1/2012 0.00 $6,863.07 11/1/2015 $686.31 3/1/2012 0.00 686.31 11/1/2015
HOME
HEALTH DME K0863 0 999 Years $9,804.76 3/1/2012 0.00 $9,804.76 11/1/2015 $980.48 3/1/2012 0.00 980.48 11/1/2015
HOME
HEALTH DME K0864 0 999 Years $11,667.78 3/1/2012 0.00 $11,667.78 11/1/2015 $1,166.77 3/1/2012 0.00 1,166.77 11/1/2015
HOME
HEALTH DME K0868 0 999 Years $0.00 12/1/2006 $0.00 5 11/1/2015 $0.00 3/1/2012 0.00 5 11/1/2015
HOME
HEALTH DME K0869 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $261.09 3/1/2012 0.00 261.09 11/1/2015
HOME
HEALTH DME K0870 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $0.00 10/1/2009 0.00 5 11/1/2015
HOME
HEALTH DME K0871 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $0.00 10/1/2009 0.00 5 11/1/2015
HOME
HEALTH DME K0877 0 999 Years $0.00 3/1/2012 $0.00 5 11/1/2015 $275.87 3/1/2012 0.00 275.87 11/1/2015
HOME
HEALTH DME K0878 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $0.00 10/1/2009 0.00 5 11/1/2015
HOME
HEALTH DME K0879 0 999 Years $0.00 3/1/2012 $0.00 5 11/1/2015 $529.74 3/1/2012 0.00 529.74 11/1/2015
HOME
HEALTH DME K0880 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $824.92 3/1/2012 0.00 824.92 11/1/2015
HOME
HEALTH DME K0884 0 999 Years $0.00 3/1/2012 $0.00 5 11/1/2015 $0.00 3/1/2012 0.00 5 11/1/2015
HOME
HEALTH DME K0885 0 999 Years $5,889.23 3/1/2012 0.00 $5,889.23 11/1/2015 $588.93 3/1/2012 0.00 588.93 11/1/2015
HOME
HEALTH DME K0886 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $543.92 3/1/2012 0.00 543.92 11/1/2015
HOME
HEALTH DME K0890 0 999 Years $9,197.50 10/1/2009 -8.00 $8,461.70 11/1/2015 $919.75 10/1/2009 -8.00 846.17 11/1/2015
HOME
HEALTH DME K0891 0 999 Years $10,981.85 3/1/2012 0.00 $10,981.85 11/1/2015 $1,218.04 10/1/2009 -8.00 1,120.60 11/1/2015
HOME
HEALTH DME K0898 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $0.00 10/1/2009 0.00 5 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Date
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
Date
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Adjust
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Date
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Type
Rental
Proc
Code
Client Age
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1
Mod
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Purchase
HOME
HEALTH DME K0899 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $0.00 10/1/2009 0.00 5 11/1/2015
HOME
HEALTH DME K0900 0 999 Years $0.00 4/1/2014 -2.00 $0.00 11/1/2015 $0.00 4/1/2014 -2.00 0.00 11/1/2015
HOME
HEALTH DME L8614 1 999 Years $23,380.00 4/1/2015 0.00 $23,380.00 10/1/2016
HOME
HEALTH DME L8681 0 999 Years $926.72 1/1/2008 0.00 $926.72 10/1/2016
HOME
HEALTH DME L8682 0 999 Years $5,178.47 1/1/2008 0.00 $5,178.47 10/1/2016
HOME
HEALTH DME L8683 0 999 Years $4,558.23 1/1/2008 0.00 $4,558.23 10/1/2016
HOME
HEALTH DME L8684 0 999 Years $670.64 1/1/2008 0.00 $670.64 10/1/2016
HOME
HEALTH DME L8685 0 999 Years $11,358.87 1/1/2008 0.00 $11,358.87 10/1/2016
HOME
HEALTH DME L8686 0 999 Years $6,885.47 10/1/2016 0.00 $6,885.47 10/1/2016
HOME
HEALTH DME L8686 TG 0 999 Years $14,968.49 10/1/2016 0.00 $14,968.49 10/1/2016
HOME
HEALTH DME L8687 0 999 Years $14,043.32 10/1/2016 0.00 $14,043.32 10/1/2016
HOME
HEALTH DME L8688 0 999 Years $8,960.75 10/1/2016 0.00 $8,960.75 10/1/2016
HOME
HEALTH DME L8689 0 999 Years $1,498.34 1/1/2008 0.00 $1,498.34 10/1/2016
HOME
HEALTH DME L8690 5 999 Years $4,338.80 7/1/2010 0.00 $4,338.80 10/1/2016
HOME
HEALTH DME L8691 5 999 Years $2,432.05 7/1/2010 0.00 $2,432.05 10/1/2016
HOME
HEALTH DME L8692 5 999 Years $3,321.00 10/1/2012 0.00 $3,321.00 10/1/2016
HOME
HEALTH DME L8693 5 999 Years $1,414.77 10/1/2012 0.00 $1,414.77 10/1/2016
HOME
HEALTH DME L8695 0 999 Years $11.86 10/1/2014 0.00 $11.86 10/1/2016
HOME
HEALTH DME Q0480 0 20 Years $77,927.47 1/1/2016 0.00 $77,927.47 6 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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HOME
HEALTH DME Q0481 0 20 Years $12,572.70 1/1/2016 0.00 $12,572.70 6 1/1/2016
HOME
HEALTH DME Q0482 0 20 Years $3,938.00 1/1/2016 0.00 $3,938.00 6 1/1/2016
HOME
HEALTH DME Q0483 0 20 Years $17,280.81 1/1/2016 0.00 $17,280.81 6 1/1/2016
HOME
HEALTH DME Q0484 0 20 Years $3,355.87 1/1/2016 0.00 $3,355.87 6 1/1/2016
HOME
HEALTH DME Q0485 0 20 Years $324.02 1/1/2016 0.00 $324.02 6 1/1/2016
HOME
HEALTH DME Q0486 0 20 Years $269.66 1/1/2016 0.00 $269.66 6 1/1/2016
HOME
HEALTH DME Q0487 0 20 Years $314.62 1/1/2016 0.00 $314.62 6 1/1/2016
HOME
HEALTH DME Q0488 0 20 Years $12,054.00 1/1/2016 0.00 $12,054.00 6 1/1/2016
HOME
HEALTH DME Q0489 0 20 Years $14,064.31 1/1/2016 0.00 $14,064.31 6 1/1/2016
HOME
HEALTH DME Q0490 0 20 Years $648.04 1/1/2016 0.00 $648.04 6 1/1/2016
HOME
HEALTH DME Q0491 0 20 Years $1,018.76 1/1/2016 0.00 $1,018.76 6 1/1/2016
HOME
HEALTH DME Q0492 0 20 Years $82.09 1/1/2016 0.00 $82.09 6 1/1/2016
HOME
HEALTH DME Q0493 0 20 Years $233.68 1/1/2016 0.00 $233.68 6 1/1/2016
HOME
HEALTH DME Q0494 0 20 Years $197.73 1/1/2016 0.00 $197.73 6 1/1/2016
HOME
HEALTH DME Q0495 0 20 Years $3,614.17 1/1/2016 0.00 $3,614.17 6 1/1/2016
HOME
HEALTH DME Q0496 0 20 Years $1,297.16 1/1/2016 0.00 $1,297.16 6 1/1/2016
HOME
HEALTH DME Q0497 0 20 Years $405.04 1/1/2016 0.00 $405.04 6 1/1/2016
HOME
HEALTH DME Q0498 0 20 Years $473.40 1/1/2016 0.00 $473.40 6 1/1/2016
HOME
HEALTH DME Q0499 0 20 Years $153.82 1/1/2016 0.00 $153.82 6 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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Purchase
HOME
HEALTH DME Q0500 0 20 Years $26.42 1/1/2016 0.00 $26.42 6 1/1/2016
HOME
HEALTH DME Q0501 0 20 Years $441.89 1/1/2016 0.00 $441.89 6 1/1/2016
HOME
HEALTH DME Q0502 0 20 Years $599.24 1/1/2016 0.00 $599.24 6 1/1/2016
HOME
HEALTH DME Q0503 0 20 Years $1,198.54 1/1/2016 0.00 $1,198.54 6 1/1/2016
HOME
HEALTH DME Q0504 0 20 Years $632.41 1/1/2016 0.00 $632.41 6 1/1/2016
HOME
HEALTH DME Q0507 0 999 Years $0.00 7/1/2013 $0.00 5 1/1/2016
HOME
HEALTH DME Q0508 0 999 Years $0.00 7/1/2013 $0.00 5 1/1/2016
HOME
HEALTH DME S8185 0 999 Years $61.50 4/1/2015 0.00 $61.50 4/1/2015
HOME
HEALTH DME S8189 0 999 Years $0.00 5/1/2003 $0.00 5 4/1/2015
HOME
HEALTH DME S8999 0 999 Years $58.26 1/1/2010 0.00 $58.26 4/1/2015
MEDICAL
SUPPLIER
(DME) A9279 U1 0 20 Years $2,104.78 1/1/2015 0.00 $2,104.78 1/1/2015 $210.48 1/1/2015 0.00 210.48 1/1/2015
MEDICAL
SUPPLIER
(DME) B9000 0 999 Years $1,225.78 1/1/2014 0.00 $1,225.78 1/1/2016 $122.58 1/1/2016 0.00 122.58 1/1/2016
MEDICAL
SUPPLIER
(DME) B9002 0 999 Years $1,225.78 1/1/2014 0.00 $1,225.78 1/1/2016 $122.58 1/1/2016 0.00 122.58 1/1/2016
MEDICAL
SUPPLIER
(DME) B9004 0 999 Years $2,836.83 1/1/2014 0.00 $2,836.83 1/1/2016 $449.08 1/1/2014 0.00 449.08 1/1/2016
MEDICAL
SUPPLIER
(DME) B9006 0 999 Years $2,836.83 1/1/2014 0.00 $2,836.83 1/1/2016 $449.08 1/1/2014 0.00 449.08 1/1/2016
MEDICAL
SUPPLIER
(DME) E0100 0 999 Years $15.27 4/1/2013 0.00 $15.27 4/1/2015
MEDICAL
SUPPLIER
(DME) E0105 0 999 Years $36.35 4/1/2013 0.00 $36.35 4/1/2015
MEDICAL
SUPPLIER
(DME) E0110 0 999 Years $54.34 4/1/2013 0.00 $54.34 4/1/2015 $5.43 4/1/2015 0.00 5.43 4/1/2015
MEDICAL
SUPPLIER
(DME) E0111 0 999 Years $35.87 4/1/2013 0.00 $35.87 4/1/2015 $3.59 4/1/2015 0.00 3.59 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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MEDICAL
SUPPLIER
(DME) E0112 0 999 Years $28.78 4/1/2013 0.00 $28.78 4/1/2015 $2.88 4/1/2015 0.00 2.88 4/1/2015
MEDICAL
SUPPLIER
(DME) E0113 0 999 Years $16.76 4/1/2013 0.00 $16.76 4/1/2015 $1.68 4/1/2015 0.00 1.68 4/1/2015
MEDICAL
SUPPLIER
(DME) E0114 0 999 Years $32.30 4/1/2013 0.00 $32.30 4/1/2015 $3.23 4/1/2015 0.00 3.23 4/1/2015
MEDICAL
SUPPLIER
(DME) E0116 0 999 Years $20.72 4/1/2013 0.00 $20.72 4/1/2015 $2.07 4/1/2015 0.00 2.07 4/1/2015
MEDICAL
SUPPLIER
(DME) E0130 0 999 Years $54.34 4/1/2013 0.00 $54.34 4/1/2015 $5.43 4/1/2015 0.00 5.43 4/1/2015
MEDICAL
SUPPLIER
(DME) E0135 0 999 Years $69.81 4/1/2013 0.00 $69.81 4/1/2015 $6.98 4/1/2015 0.00 6.98 4/1/2015
MEDICAL
SUPPLIER
(DME) E0140 0 999 Years $345.08 4/1/2015 0.00 $345.08 4/1/2015
MEDICAL
SUPPLIER
(DME) E0141 0 999 Years $88.39 4/1/2013 0.00 $88.39 4/1/2015 $8.84 4/1/2015 0.00 8.84 4/1/2015
MEDICAL
SUPPLIER
(DME) E0143 0 999 Years $92.22 4/1/2013 0.00 $92.22 4/1/2015 $9.22 4/1/2015 0.00 9.22 4/1/2015
MEDICAL
SUPPLIER
(DME) E0144 0 999 Years $198.12 4/1/2015 0.00 $198.12 4/1/2015 $19.81 4/1/2015 0.00 19.81 4/1/2015
MEDICAL
SUPPLIER
(DME) E0147 0 999 Years $478.58 4/1/2013 0.00 $478.58 4/1/2015 $47.86 4/1/2013 0.00 47.86 4/1/2015
MEDICAL
SUPPLIER
(DME) E0148 0 999 Years $105.78 4/1/2013 0.00 $105.78 4/1/2015 $10.58 4/1/2015 0.00 10.58 4/1/2015
MEDICAL
SUPPLIER
(DME) E0149 0 999 Years $157.56 4/1/2013 0.00 $157.56 4/1/2015 $15.76 4/1/2013 0.00 15.76 4/1/2015
MEDICAL
SUPPLIER
(DME) E0153 0 999 Years $63.52 4/1/2013 0.00 $63.52 4/1/2015
MEDICAL
SUPPLIER
(DME) E0154 0 999 Years $58.71 4/1/2013 0.00 $58.71 4/1/2015
MEDICAL
SUPPLIER
(DME) E0155 0 999 Years $25.22 4/1/2013 0.00 $25.22 4/1/2015
MEDICAL
SUPPLIER
(DME) E0157 0 999 Years $41.94 4/1/2013 0.00 $41.94 4/1/2015
MEDICAL
SUPPLIER
(DME) E0158 0 999 Years $21.42 4/1/2013 0.00 $21.42 4/1/2015
MEDICAL
SUPPLIER
(DME) E0159 0 999 Years $14.88 4/1/2013 0.00 $14.88 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note CodesAdjusted
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Report
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Date
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MEDICAL
SUPPLIER
(DME) E0160 0 999 Years $20.81 4/1/2013 0.00 $20.81 4/1/2015
MEDICAL
SUPPLIER
(DME) E0161 0 999 Years $21.54 4/1/2013 0.00 $21.54 4/1/2015
MEDICAL
SUPPLIER
(DME) E0162 0 999 Years $119.64 4/1/2013 0.00 $119.64 4/1/2015 $11.96 4/1/2015 0.00 11.96 4/1/2015
MEDICAL
SUPPLIER
(DME) E0163 0 999 Years $97.06 4/1/2013 0.00 $97.06 4/1/2015
MEDICAL
SUPPLIER
(DME) E0163 TG 0 999 Years $0.00 10/16/2003 -2.00 $0.00 5 4/1/2015
MEDICAL
SUPPLIER
(DME) E0165 0 999 Years $171.69 4/1/2013 0.00 $171.69 4/1/2015
MEDICAL
SUPPLIER
(DME) E0165 TG 0 999 Years $0.00 10/16/2003 -2.00 $0.00 5 4/1/2015
MEDICAL
SUPPLIER
(DME) E0167 0 999 Years $9.09 4/1/2013 0.00 $9.09 4/1/2015 $0.91 4/1/2013 0.00 0.91 4/1/2015
MEDICAL
SUPPLIER
(DME) E0168 0 999 Years $132.81 4/1/2013 0.00 $132.81 4/1/2015
MEDICAL
SUPPLIER
(DME) E0168 TF 0 999 Years $319.26 4/1/2013 0.00 $319.26 4/1/2015
MEDICAL
SUPPLIER
(DME) E0168 TG 0 999 Years $1,544.22 4/1/2013 0.00 $1,544.22 4/1/2015
MEDICAL
SUPPLIER
(DME) E0170 0 999 Years $1,653.85 4/1/2013 0.00 $1,653.85 4/1/2015
MEDICAL
SUPPLIER
(DME) E0171 0 999 Years $297.63 4/1/2013 0.00 $297.63 4/1/2015
MEDICAL
SUPPLIER
(DME) E0172 0 999 Years $1,806.79 4/1/2013 0.00 $1,806.79 4/1/2015
MEDICAL
SUPPLIER
(DME) E0175 0 999 Years $51.06 4/1/2013 0.00 $51.06 4/1/2015 $5.11 4/1/2013 0.00 5.11 4/1/2015
MEDICAL
SUPPLIER
(DME) E0181 0 999 Years $251.71 4/1/2013 0.00 $251.71 4/1/2015 $25.17 4/1/2013 0.00 25.17 4/1/2015
MEDICAL
SUPPLIER
(DME) E0182 0 999 Years $17.98 4/1/2013 0.00 17.98 4/1/2015
MEDICAL
SUPPLIER
(DME) E0184 0 999 Years $440.74 4/1/2013 0.00 $440.74 10/1/2013 $22.60 4/1/2013 0.00 22.60 10/1/2013
MEDICAL
SUPPLIER
(DME) E0185 0 999 Years $280.68 4/1/2013 0.00 $280.68 4/1/2015 $28.07 4/1/2015 0.00 28.07 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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MEDICAL
SUPPLIER
(DME) E0186 0 999 Years $17.81 4/1/2013 0.00 17.81 10/1/2013
MEDICAL
SUPPLIER
(DME) E0186 0 20 Years $1,778.79 4/1/2013 0.00 $1,778.79 10/1/2013
MEDICAL
SUPPLIER
(DME) E0187 0 999 Years $224.20 4/1/2013 0.00 $224.20 4/1/2015 $22.42 4/1/2013 0.00 22.42 4/1/2015
MEDICAL
SUPPLIER
(DME) E0188 0 999 Years $20.67 4/1/2013 0.00 $20.67 4/1/2015
MEDICAL
SUPPLIER
(DME) E0189 0 999 Years $47.80 4/1/2013 0.00 $47.80 4/1/2015
MEDICAL
SUPPLIER
(DME) E0190 0 999 Years $47.99 4/1/2013 0.00 $47.99 4/1/2015
MEDICAL
SUPPLIER
(DME) E0190 UD 0 20 Years $0.00 7/1/2010 $0.00 5 4/1/2015
MEDICAL
SUPPLIER
(DME) E0191 0 999 Years $7.74 4/1/2013 0.00 $7.74 4/1/2015
MEDICAL
SUPPLIER
(DME) E0193 0 999 Years $752.22 4/1/2013 0.00 752.22 4/1/2015
MEDICAL
SUPPLIER
(DME) E0194 0 999 Years $2,258.07 4/1/2013 0.00 2,258.07 4/1/2015
MEDICAL
SUPPLIER
(DME) E0196 0 999 Years $313.81 4/1/2013 0.00 $313.81 4/1/2015 $31.38 4/1/2013 0.00 31.38 4/1/2015
MEDICAL
SUPPLIER
(DME) E0197 0 999 Years $173.27 4/1/2013 0.00 $173.27 4/1/2015 $17.33 4/1/2015 0.00 17.33 4/1/2015
MEDICAL
SUPPLIER
(DME) E0198 0 999 Years $135.92 4/1/2015 0.00 $135.92 4/1/2015 $13.59 4/1/2015 0.00 13.59 4/1/2015
MEDICAL
SUPPLIER
(DME) E0199 0 999 Years $30.15 4/1/2013 0.00 $30.15 4/1/2015
MEDICAL
SUPPLIER
(DME) E0202 0 20 Years $53.90 4/1/2013 0.00 53.90 4/1/2015
MEDICAL
SUPPLIER
(DME) E0210 0 999 Years $24.09 4/1/2013 0.00 $24.09 4/1/2015
MEDICAL
SUPPLIER
(DME) E0217 0 999 Years $435.67 4/1/2013 0.00 $435.67 4/1/2015 $43.57 4/1/2013 0.00 43.57 4/1/2015
MEDICAL
SUPPLIER
(DME) E0218 0 999 Years $360.49 4/1/2013 0.00 $360.49 4/1/2015 $36.05 4/1/2015 0.00 36.05 4/1/2015
MEDICAL
SUPPLIER
(DME) E0225 0 999 Years $37.01 4/1/2013 0.00 37.01 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
Date
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Date
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MEDICAL
SUPPLIER
(DME) E0235 0 999 Years $166.70 4/1/2013 0.00 $166.70 4/1/2015 $16.67 4/1/2013 0.00 16.67 4/1/2015
MEDICAL
SUPPLIER
(DME) E0236 0 999 Years $427.43 4/1/2013 0.00 $427.43 4/1/2015
MEDICAL
SUPPLIER
(DME) E0240 0 999 Years $83.13 4/1/2013 0.00 $83.13 4/1/2015
MEDICAL
SUPPLIER
(DME) E0240 TF 0 999 Years $1,434.28 4/1/2013 0.00 $1,434.28 4/1/2015
MEDICAL
SUPPLIER
(DME) E0240 TG 0 999 Years $1,935.82 4/1/2013 0.00 $1,935.82 4/1/2015
MEDICAL
SUPPLIER
(DME) E0243 0 999 Years $40.00 4/1/2015 0.00 $40.00 4/1/2015
MEDICAL
SUPPLIER
(DME) E0244 0 999 Years $28.90 4/1/2013 0.00 $28.90 4/1/2015
MEDICAL
SUPPLIER
(DME) E0245 0 999 Years $39.00 4/1/2015 0.00 $39.00 4/1/2015
MEDICAL
SUPPLIER
(DME) E0246 0 999 Years $41.49 4/1/2013 0.00 $41.49 4/1/2015
MEDICAL
SUPPLIER
(DME) E0247 0 999 Years $88.70 4/1/2013 0.00 $88.70 4/1/2015
MEDICAL
SUPPLIER
(DME) E0248 0 999 Years $138.62 4/1/2013 0.00 $138.62 4/1/2015
MEDICAL
SUPPLIER
(DME) E0250 0 999 Years $738.59 4/1/2013 0.00 $738.59 4/1/2015 $73.86 4/1/2013 0.00 73.86 4/1/2015
MEDICAL
SUPPLIER
(DME) E0255 0 999 Years $930.30 4/1/2013 0.00 $930.30 4/1/2015 $93.03 4/1/2013 0.00 93.03 4/1/2015
MEDICAL
SUPPLIER
(DME) E0260 0 999 Years $1,118.66 4/1/2013 0.00 $1,118.66 4/1/2015 $111.87 4/1/2013 0.00 111.87 4/1/2015
MEDICAL
SUPPLIER
(DME) E0265 0 999 Years $1,772.72 4/1/2013 0.00 $1,772.72 4/1/2015 $177.27 4/1/2013 0.00 177.27 4/1/2015
MEDICAL
SUPPLIER
(DME) E0271 0 999 Years $148.48 4/1/2013 0.00 $148.48 4/1/2015
MEDICAL
SUPPLIER
(DME) E0275 0 999 Years $14.85 4/1/2015 0.00 $14.85 4/1/2015
MEDICAL
SUPPLIER
(DME) E0276 0 999 Years $12.22 4/1/2013 0.00 $12.22 4/1/2015
MEDICAL
SUPPLIER
(DME) E0277 0 999 Years $506.13 4/1/2013 0.00 506.13 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Date
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
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Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) E0280 0 999 Years $30.25 4/1/2013 0.00 $30.25 4/1/2015 $3.03 4/1/2015 0.00 3.03 4/1/2015
MEDICAL
SUPPLIER
(DME) E0300 0 20 Years $2,838.62 4/1/2013 0.00 $2,838.62 4/1/2015 $283.86 4/1/2015 0.00 283.86 4/1/2015
MEDICAL
SUPPLIER
(DME) E0303 0 999 Years $4,273.17 4/1/2013 0.00 $4,273.17 10/1/2013 $427.32 4/1/2013 0.00 427.32 10/1/2013
MEDICAL
SUPPLIER
(DME) E0304 0 999 Years $3,978.56 4/1/2013 0.00 $3,978.56 10/1/2013 $610.28 4/1/2013 0.00 610.28 10/1/2013
MEDICAL
SUPPLIER
(DME) E0305 0 999 Years $140.88 4/1/2013 0.00 $140.88 4/1/2015
MEDICAL
SUPPLIER
(DME) E0310 0 999 Years $121.94 4/1/2013 0.00 $121.94 4/1/2015
MEDICAL
SUPPLIER
(DME) E0315 0 999 Years $150.68 4/1/2013 0.00 $150.68 4/1/2015
MEDICAL
SUPPLIER
(DME) E0316 0 20 Years $1,865.73 4/1/2013 0.00 $1,865.73 10/1/2013 $168.85 4/1/2013 0.00 168.85 10/1/2013
MEDICAL
SUPPLIER
(DME) E0325 0 999 Years $11.23 4/1/2015 0.00 $11.23 4/1/2015 $1.12 4/1/2015 0.00 1.12 4/1/2015
MEDICAL
SUPPLIER
(DME) E0326 0 999 Years $7.81 4/1/2013 0.00 $7.81 4/1/2015
MEDICAL
SUPPLIER
(DME) E0328 0 20 Years $5,059.53 4/1/2013 0.00 $5,059.53 10/1/2013 $505.95 4/1/2013 0.00 505.95 10/1/2013
MEDICAL
SUPPLIER
(DME) E0329 0 20 Years $6,746.03 4/1/2013 0.00 $6,746.03 10/1/2013 $674.61 4/1/2013 0.00 674.61 10/1/2013
MEDICAL
SUPPLIER
(DME) E0370 0 999 Years $21.78 4/1/2013 0.00 $21.78 4/1/2015 $2.18 4/1/2013 0.00 2.18 4/1/2015
MEDICAL
SUPPLIER
(DME) E0371 0 999 Years $3,519.69 4/1/2013 0.00 $3,519.69 4/1/2015 $351.97 4/1/2013 0.00 351.97 4/1/2015
MEDICAL
SUPPLIER
(DME) E0372 0 999 Years $4,270.88 4/1/2013 0.00 $4,270.88 4/1/2015 $427.09 4/1/2013 0.00 427.09 4/1/2015
MEDICAL
SUPPLIER
(DME) E0373 0 999 Years $4,865.88 4/1/2013 0.00 $4,865.88 4/1/2015 $486.59 4/1/2013 0.00 486.59 4/1/2015
MEDICAL
SUPPLIER
(DME) E0424 0 999 Years $159.32 4/1/2013 0.00 159.32 4/1/2015
MEDICAL
SUPPLIER
(DME) E0431 0 999 Years $26.47 4/1/2013 0.00 26.47 4/1/2015
MEDICAL
SUPPLIER
(DME) E0433 0 999 Years $47.50 4/1/2013 0.00 47.50 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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MEDICAL
SUPPLIER
(DME) E0434 0 999 Years $26.47 4/1/2013 0.00 26.47 4/1/2015
MEDICAL
SUPPLIER
(DME) E0439 0 999 Years $159.32 4/1/2013 0.00 159.32 4/1/2015
MEDICAL
SUPPLIER
(DME) E0441 0 999 Years $7.13 4/1/2013 0.00 7.13 4/1/2015
MEDICAL
SUPPLIER
(DME) E0442 0 999 Years $7.13 4/1/2013 0.00 7.13 4/1/2015
MEDICAL
SUPPLIER
(DME) E0443 0 999 Years $7.13 4/1/2013 0.00 7.13 4/1/2015
MEDICAL
SUPPLIER
(DME) E0444 0 999 Years $7.13 4/1/2013 0.00 7.13 4/1/2015
MEDICAL
SUPPLIER
(DME) E0445 0 20 Years $553.50 2/1/2011 -8.00 $509.22 10/1/2013 $55.35 2/1/2011 -8.00 50.92 10/1/2013
MEDICAL
SUPPLIER
(DME) E0445 TG 0 20 Years $2,214.00 1/1/2010 -8.00 $2,036.88 6 10/1/2013 $221.40 1/1/2010 -8.00 203.69 6 10/1/2013
MEDICAL
SUPPLIER
(DME) E0457 0 999 Years $574.41 4/1/2013 0.00 $574.41 4/1/2015 $57.44 4/1/2013 0.00 57.44 4/1/2015
MEDICAL
SUPPLIER
(DME) E0459 0 999 Years $445.12 4/1/2013 0.00 $445.12 4/1/2015 $44.51 4/1/2013 0.00 44.51 4/1/2015
MEDICAL
SUPPLIER
(DME) E0465 0 999 Years $1,059.64 1/1/2016 0.00 1,059.64 1/1/2016
MEDICAL
SUPPLIER
(DME) E0466 0 999 Years $1,059.64 1/1/2016 0.00 1,059.64 1/1/2016
MEDICAL
SUPPLIER
(DME) E0470 0 999 Years $2,777.35 4/1/2013 0.00 $2,777.35 4/1/2015 $277.74 4/1/2015 0.00 277.74 4/1/2015
MEDICAL
SUPPLIER
(DME) E0471 0 999 Years $363.60 4/1/2013 0.00 363.60 4/1/2015
MEDICAL
SUPPLIER
(DME) E0472 0 999 Years $363.60 4/1/2013 0.00 363.60 4/1/2015
MEDICAL
SUPPLIER
(DME) E0480 0 999 Years $359.08 4/1/2013 0.00 $359.08 4/1/2015 $35.91 4/1/2013 0.00 35.91 4/1/2015
MEDICAL
SUPPLIER
(DME) E0482 0 999 Years $266.76 4/1/2013 0.00 266.76 4/1/2015
MEDICAL
SUPPLIER
(DME) E0483 0 999 Years $9,253.45 4/1/2013 0.00 $9,253.45 4/1/2015 $925.35 4/1/2013 0.00 925.35 4/1/2015
MEDICAL
SUPPLIER
(DME) E0500 0 999 Years $95.39 4/1/2013 0.00 95.39 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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MEDICAL
SUPPLIER
(DME) E0550 0 999 Years $427.43 4/1/2013 0.00 $427.43 4/1/2015 $42.74 4/1/2013 0.00 42.74 4/1/2015
MEDICAL
SUPPLIER
(DME) E0561 0 999 Years $89.09 4/1/2013 0.00 $89.09 4/1/2015 $8.91 4/1/2015 0.00 8.91 4/1/2015
MEDICAL
SUPPLIER
(DME) E0562 0 999 Years $250.79 4/1/2013 0.00 $250.79 4/1/2015 $25.08 4/1/2015 0.00 25.08 4/1/2015
MEDICAL
SUPPLIER
(DME) E0565 0 999 Years $589.35 4/1/2013 0.00 $589.35 4/1/2015 $58.94 4/1/2013 0.00 58.94 4/1/2015
MEDICAL
SUPPLIER
(DME) E0570 0 999 Years $129.63 4/1/2013 0.00 $129.63 4/1/2015
MEDICAL
SUPPLIER
(DME) E0574 0 999 Years $388.88 4/1/2013 0.00 $388.88 4/1/2015
MEDICAL
SUPPLIER
(DME) E0575 0 999 Years $992.86 4/1/2013 0.00 $992.86 4/1/2015
MEDICAL
SUPPLIER
(DME) E0580 0 999 Years $118.88 4/1/2013 0.00 $118.88 4/1/2015 $11.89 4/1/2013 0.00 11.89 4/1/2015
MEDICAL
SUPPLIER
(DME) E0585 0 999 Years $322.64 4/1/2013 0.00 $322.64 4/1/2015
MEDICAL
SUPPLIER
(DME) E0600 0 999 Years $442.34 4/1/2013 0.00 $442.34 4/1/2015
MEDICAL
SUPPLIER
(DME) E0601 0 999 Years $1,112.52 4/1/2013 0.00 $1,112.52 4/1/2015 $85.58 4/1/2013 0.00 85.58 4/1/2015
MEDICAL
SUPPLIER
(DME) E0602 0 999 Years $16.66 4/1/2013 0.00 $16.66 4/1/2015
MEDICAL
SUPPLIER
(DME) E0603 0 999 Years $152.88 4/1/2013 0.00 $152.88 4/1/2015
MEDICAL
SUPPLIER
(DME) E0604 0 999 Years $69.15 4/1/2013 0.00 69.15 4/1/2015
MEDICAL
SUPPLIER
(DME) E0605 0 999 Years $24.20 4/1/2013 0.00 $24.20 4/1/2015
MEDICAL
SUPPLIER
(DME) E0606 0 999 Years $158.15 4/1/2013 0.00 $158.15 4/1/2015
MEDICAL
SUPPLIER
(DME) E0610 0 999 Years $229.77 4/1/2013 0.00 $229.77 4/1/2015
MEDICAL
SUPPLIER
(DME) E0615 0 999 Years $450.27 4/1/2013 0.00 $450.27 4/1/2015
MEDICAL
SUPPLIER
(DME) E0616 0 20 Years $3,033.59 4/1/2013 0.00 $3,033.59 6 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Report
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MEDICAL
SUPPLIER
(DME) E0617 1 20 Years $2,346.51 4/1/2013 0.00 $2,346.51 6 4/1/2015 $234.65 4/1/2013 0.00 234.65 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E0618 0 20 Years $2,335.34 4/1/2013 0.00 $2,335.34 4/1/2015
MEDICAL
SUPPLIER
(DME) E0619 0 20 Years $2,094.10 4/1/2015 0.00 $2,094.10 4/1/2015 $209.41 4/1/2015 0.00 209.41 4/1/2015
MEDICAL
SUPPLIER
(DME) E0621 0 999 Years $87.88 4/1/2013 0.00 $87.88 4/1/2015
MEDICAL
SUPPLIER
(DME) E0625 0 999 Years $463.75 4/1/2013 0.00 $463.75 4/1/2015 $46.38 4/1/2013 0.00 46.38 4/1/2015
MEDICAL
SUPPLIER
(DME) E0625 U1 0 999 Years $980.71 4/1/2013 0.00 $980.71 4/1/2015
MEDICAL
SUPPLIER
(DME) E0625 U2 0 999 Years $2,376.36 4/1/2013 0.00 $2,376.36 4/1/2015
MEDICAL
SUPPLIER
(DME) E0625 U3 0 999 Years $0.00 4/1/2013 $0.00 4/1/2015
MEDICAL
SUPPLIER
(DME) E0628 0 999 Years $319.48 4/1/2013 0.00 $319.48 4/1/2015
MEDICAL
SUPPLIER
(DME) E0629 0 999 Years $319.47 4/1/2013 0.00 $319.47 4/1/2015
MEDICAL
SUPPLIER
(DME) E0630 0 999 Years $984.22 4/1/2013 0.00 $984.22 4/1/2015 $98.42 4/1/2013 0.00 98.42 4/1/2015
MEDICAL
SUPPLIER
(DME) E0635 0 999 Years $176.55 4/1/2015 0.00 176.55 4/1/2015
MEDICAL
SUPPLIER
(DME) E0635 TG 0 20 Years $0.00 12/1/2008 $0.00 P2 5 1/1/2016
MEDICAL
SUPPLIER
(DME) E0635 TG 21 999 Years $0.00 2/1/2011 $0.00 5 1/1/2016
MEDICAL
SUPPLIER
(DME) E0637 0 999 Years $3,271.83 4/1/2015 0.00 $3,271.83 4/1/2015
MEDICAL
SUPPLIER
(DME) E0638 UA 0 999 Years $2,302.31 4/1/2015 0.00 $2,302.31 4/1/2015
MEDICAL
SUPPLIER
(DME) E0638 UB 0 999 Years $2,868.85 4/1/2015 0.00 $2,868.85 4/1/2015
MEDICAL
SUPPLIER
(DME) E0641 0 999 Years $2,588.49 4/1/2015 0.00 $2,588.49 4/1/2015
MEDICAL
SUPPLIER
(DME) E0642 0 20 Years $3,452.89 4/1/2013 0.00 $3,452.89 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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Date
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Purchase
MEDICAL
SUPPLIER
(DME) E0650 0 999 Years $532.16 4/1/2013 0.00 $532.16 4/1/2015 $53.22 4/1/2015 0.00 53.22 4/1/2015
MEDICAL
SUPPLIER
(DME) E0651 0 999 Years $887.19 4/1/2013 0.00 $887.19 4/1/2015 $88.72 4/1/2013 0.00 88.72 4/1/2015
MEDICAL
SUPPLIER
(DME) E0652 0 999 Years $4,170.41 4/1/2013 0.00 $4,170.41 4/1/2015 $417.04 4/1/2015 0.00 417.04 4/1/2015
MEDICAL
SUPPLIER
(DME) E0655 0 999 Years $84.77 4/1/2013 0.00 $84.77 4/1/2015 $8.48 4/1/2013 0.00 8.48 4/1/2015
MEDICAL
SUPPLIER
(DME) E0660 0 999 Years $120.92 4/1/2013 0.00 $120.92 4/1/2015 $12.09 4/1/2013 0.00 12.09 4/1/2015
MEDICAL
SUPPLIER
(DME) E0665 0 999 Years $103.33 4/1/2013 0.00 $103.33 4/1/2015 $10.33 4/1/2013 0.00 10.33 4/1/2015
MEDICAL
SUPPLIER
(DME) E0666 0 999 Years $98.84 4/1/2013 0.00 $98.84 4/1/2015 $9.88 4/1/2013 0.00 9.88 4/1/2015
MEDICAL
SUPPLIER
(DME) E0667 0 999 Years $312.76 4/1/2013 0.00 $312.76 4/1/2015 $31.28 4/1/2015 0.00 31.28 4/1/2015
MEDICAL
SUPPLIER
(DME) E0668 0 999 Years $399.35 4/1/2013 0.00 $399.35 4/1/2015 $39.94 4/1/2013 0.00 39.94 4/1/2015
MEDICAL
SUPPLIER
(DME) E0669 0 999 Years $152.75 4/1/2013 0.00 $152.75 4/1/2015 $15.28 4/1/2013 0.00 15.28 4/1/2015
MEDICAL
SUPPLIER
(DME) E0671 0 999 Years $364.48 4/1/2013 0.00 $364.48 4/1/2015 $36.45 4/1/2013 0.00 36.45 4/1/2015
MEDICAL
SUPPLIER
(DME) E0672 0 999 Years $301.67 4/1/2013 0.00 $301.67 4/1/2015 $30.17 4/1/2013 0.00 30.17 4/1/2015
MEDICAL
SUPPLIER
(DME) E0673 0 999 Years $235.33 4/1/2013 0.00 $235.33 4/1/2015 $23.53 4/1/2013 0.00 23.53 4/1/2015
MEDICAL
SUPPLIER
(DME) E0676 0 999 Years $0.00 2/1/2011 $0.00 5 4/1/2015 $0.00 2/1/2011 0.00 5 4/1/2015
MEDICAL
SUPPLIER
(DME) E0700 0 999 Years $35.00 4/1/2015 0.00 $35.00 4/1/2015
MEDICAL
SUPPLIER
(DME) E0705 0 999 Years $34.88 4/1/2013 0.00 $34.88 4/1/2015
MEDICAL
SUPPLIER
(DME) E0710 0 999 Years $31.80 4/1/2013 0.00 $31.80 4/1/2015 $3.18 4/1/2013 0.00 3.18 4/1/2015
MEDICAL
SUPPLIER
(DME) E0720 0 999 Years $321.77 4/1/2013 0.00 $321.77 4/1/2015 $32.18 4/1/2013 0.00 32.18 4/1/2015
MEDICAL
SUPPLIER
(DME) E0730 0 999 Years $329.14 4/1/2013 0.00 $329.14 4/1/2015 $32.91 4/1/2015 0.00 32.91 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note CodesAdjusted
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Report
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MEDICAL
SUPPLIER
(DME) E0731 0 999 Years $278.93 4/1/2013 0.00 $278.93 4/1/2015 $27.89 4/1/2013 0.00 27.89 4/1/2015
MEDICAL
SUPPLIER
(DME) E0740 0 999 Years $481.04 4/1/2013 0.00 $481.04 4/1/2015
MEDICAL
SUPPLIER
(DME) E0745 0 999 Years $823.49 4/1/2013 0.00 $823.49 4/1/2015 $82.35 4/1/2013 0.00 82.35 4/1/2015
MEDICAL
SUPPLIER
(DME) E0747 0 999 Years $3,602.78 4/1/2013 0.00 $3,602.78 4/1/2015
MEDICAL
SUPPLIER
(DME) E0748 0 999 Years $3,579.44 4/1/2013 0.00 $3,579.44 4/1/2015
MEDICAL
SUPPLIER
(DME) E0760 0 999 Years $2,974.45 4/1/2013 0.00 $2,974.45 4/1/2015
MEDICAL
SUPPLIER
(DME) E0762 0 999 Years $915.94 4/1/2013 0.00 $915.94 4/1/2015 $91.59 4/1/2015 0.00 91.59 4/1/2015
MEDICAL
SUPPLIER
(DME) E0764 0 999 Years $10,845.48 4/1/2013 0.00 $10,845.48 4/1/2015 $1,084.55 4/1/2015 0.00 1,084.55 4/1/2015
MEDICAL
SUPPLIER
(DME) E0776 0 999 Years $79.62 4/1/2013 0.00 $79.62 4/1/2015 $7.96 4/1/2015 0.00 7.96 4/1/2015
MEDICAL
SUPPLIER
(DME) E0779 0 999 Years $153.74 4/1/2013 0.00 $153.74 10/1/2013 $15.37 4/1/2013 0.00 15.37 10/1/2013
MEDICAL
SUPPLIER
(DME) E0780 0 999 Years $9.53 4/1/2013 0.00 $9.53 10/1/2013 $0.95 4/1/2013 0.00 0.95 10/1/2013
MEDICAL
SUPPLIER
(DME) E0781 0 999 Years $2,106.90 4/1/2013 0.00 $2,106.90 4/1/2015 $210.69 4/1/2013 0.00 210.69 4/1/2015
MEDICAL
SUPPLIER
(DME) E0782 0 999 Years $3,753.51 4/1/2013 0.00 $3,753.51 4/1/2015
MEDICAL
SUPPLIER
(DME) E0783 0 999 Years $7,480.40 4/1/2013 0.00 $7,480.40 4/1/2015
MEDICAL
SUPPLIER
(DME) E0784 0 999 Years $4,032.91 4/1/2013 0.00 $4,032.91 4/1/2015 $403.29 4/1/2013 0.00 403.29 4/1/2015
MEDICAL
SUPPLIER
(DME) E0784 U1 0 999 Years $724.36 4/1/2015 0.00 $724.36 4/1/2015 $72.44 4/1/2015 0.00 72.44 4/1/2015
MEDICAL
SUPPLIER
(DME) E0786 0 999 Years $5,571.34 4/1/2013 0.00 $5,571.34 4/1/2015
MEDICAL
SUPPLIER
(DME) E0791 0 999 Years $3,054.49 4/1/2013 0.00 $3,054.49 4/1/2015 $305.45 4/1/2013 0.00 305.45 4/1/2015
MEDICAL
SUPPLIER
(DME) E0840 0 999 Years $53.11 4/1/2013 0.00 $53.11 4/1/2015 $5.31 4/1/2015 0.00 5.31 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Report
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MEDICAL
SUPPLIER
(DME) E0850 0 999 Years $82.50 4/1/2013 0.00 $82.50 4/1/2015 $8.25 4/1/2015 0.00 8.25 4/1/2015
MEDICAL
SUPPLIER
(DME) E0855 0 999 Years $461.97 4/1/2013 0.00 $461.97 4/1/2015 $46.20 4/1/2015 0.00 46.20 4/1/2015
MEDICAL
SUPPLIER
(DME) E0856 0 999 Years $150.95 4/1/2013 0.00 $150.95 4/1/2015
MEDICAL
SUPPLIER
(DME) E0860 0 999 Years $24.82 4/1/2013 0.00 $24.82 4/1/2015 $2.48 4/1/2015 0.00 2.48 4/1/2015
MEDICAL
SUPPLIER
(DME) E0880 0 999 Years $89.85 4/1/2013 0.00 $89.85 4/1/2015 $8.99 4/1/2015 0.00 8.99 4/1/2015
MEDICAL
SUPPLIER
(DME) E0900 0 999 Years $90.45 4/1/2013 0.00 $90.45 4/1/2015 $9.05 4/1/2015 0.00 9.05 4/1/2015
MEDICAL
SUPPLIER
(DME) E0910 0 999 Years $150.23 4/1/2013 0.00 $150.23 4/1/2015 $15.02 4/1/2013 0.00 15.02 4/1/2015
MEDICAL
SUPPLIER
(DME) E0911 0 999 Years $415.01 4/1/2013 0.00 $415.01 4/1/2015 $41.50 4/1/2013 0.00 41.50 4/1/2015
MEDICAL
SUPPLIER
(DME) E0912 0 999 Years $953.12 4/1/2013 0.00 $953.12 4/1/2015 $95.31 4/1/2013 0.00 95.31 4/1/2015
MEDICAL
SUPPLIER
(DME) E0920 0 999 Years $445.74 4/1/2013 0.00 $445.74 4/1/2015 $44.57 4/1/2013 0.00 44.57 4/1/2015
MEDICAL
SUPPLIER
(DME) E0930 0 999 Years $441.32 4/1/2013 0.00 $441.32 4/1/2015 $44.13 4/1/2013 0.00 44.13 4/1/2015
MEDICAL
SUPPLIER
(DME) E0935 0 999 Years $19.81 4/1/2013 0.00 19.81 4/1/2015
MEDICAL
SUPPLIER
(DME) E0940 0 999 Years $286.78 4/1/2013 0.00 $286.78 4/1/2015 $28.68 4/1/2013 0.00 28.68 4/1/2015
MEDICAL
SUPPLIER
(DME) E0941 0 999 Years $419.34 4/1/2013 0.00 $419.34 4/1/2015 $41.93 4/1/2013 0.00 41.93 4/1/2015
MEDICAL
SUPPLIER
(DME) E0942 0 999 Years $18.62 4/1/2013 0.00 $18.62 4/1/2015
MEDICAL
SUPPLIER
(DME) E0944 0 999 Years $28.90 4/1/2013 0.00 $28.90 4/1/2015
MEDICAL
SUPPLIER
(DME) E0945 0 999 Years $24.45 4/1/2013 0.00 $24.45 4/1/2015
MEDICAL
SUPPLIER
(DME) E0946 0 999 Years $372.79 4/1/2013 0.00 $372.79 4/1/2015 $37.28 4/1/2013 0.00 37.28 4/1/2015
MEDICAL
SUPPLIER
(DME) E0950 0 999 Years $171.93 3/1/2012 0.00 $171.93 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
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%
Fee Effect
Date
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Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) E0951 0 999 Years $12.05 3/1/2012 0.00 $12.05 10/1/2013
MEDICAL
SUPPLIER
(DME) E0952 0 999 Years $12.58 3/1/2012 0.00 $12.58 10/1/2013
MEDICAL
SUPPLIER
(DME) E0955 0 999 Years $182.29 3/1/2012 0.00 $182.29 10/1/2013
MEDICAL
SUPPLIER
(DME) E0956 0 999 Years $208.84 4/1/2013 0.00 208.84 4/1/2013
MEDICAL
SUPPLIER
(DME) E0957 0 999 Years $134.51 4/1/2013 0.00 $134.51 10/1/2013
MEDICAL
SUPPLIER
(DME) E0958 0 999 Years $679.71 4/1/2013 0.00 $679.71 10/1/2013
MEDICAL
SUPPLIER
(DME) E0959 0 999 Years $35.11 7/1/2013 0.00 $35.11 4/1/2015 $3.51 4/1/2014 0.00 3.51 4/1/2015
MEDICAL
SUPPLIER
(DME) E0960 0 999 Years $88.72 4/1/2013 0.00 $88.72 10/1/2013
MEDICAL
SUPPLIER
(DME) E0961 0 999 Years $16.63 3/1/2012 0.00 $16.63 10/1/2013
MEDICAL
SUPPLIER
(DME) E0967 0 999 Years $53.31 7/1/2013 0.00 $53.31 4/1/2015 $5.33 4/1/2014 0.00 5.33 4/1/2015
MEDICAL
SUPPLIER
(DME) E0969 0 20 Years $146.66 4/1/2013 0.00 $146.66 4/1/2015
MEDICAL
SUPPLIER
(DME) E0970 0 999 Years $51.98 3/1/2012 0.00 $51.98 10/1/2013
MEDICAL
SUPPLIER
(DME) E0971 0 999 Years $53.98 3/1/2012 0.00 $53.98 10/1/2013
MEDICAL
SUPPLIER
(DME) E0973 0 999 Years $68.33 3/1/2012 0.00 $68.33 10/1/2013
MEDICAL
SUPPLIER
(DME) E0974 0 999 Years $71.75 3/1/2012 0.00 $71.75 2/1/2011
MEDICAL
SUPPLIER
(DME) E0978 0 999 Years $35.40 3/1/2012 0.00 $35.40 10/1/2013
MEDICAL
SUPPLIER
(DME) E0980 0 999 Years $28.79 3/1/2012 0.00 $28.79 10/1/2013
MEDICAL
SUPPLIER
(DME) E0981 0 999 Years $34.42 3/1/2012 0.00 $34.42 10/1/2013
MEDICAL
SUPPLIER
(DME) E0982 0 999 Years $50.25 3/1/2012 0.00 $50.25 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
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Report
Date
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Date
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MEDICAL
SUPPLIER
(DME) E0990 0 999 Years $124.59 1/1/2016 0.00 $124.59 1/1/2016 $12.46 1/1/2016 0.00 12.46 1/1/2016
MEDICAL
SUPPLIER
(DME) E0992 0 999 Years $82.82 4/1/2013 0.00 $82.82 10/1/2013
MEDICAL
SUPPLIER
(DME) E0994 0 999 Years $13.24 3/1/2012 0.00 $13.24 10/1/2013
MEDICAL
SUPPLIER
(DME) E0995 0 999 Years $22.12 4/1/2013 0.00 $22.12 10/1/2013
MEDICAL
SUPPLIER
(DME) E1002 0 999 Years $3,661.00 3/1/2012 0.00 $3,661.00 1/1/2016
MEDICAL
SUPPLIER
(DME) E1003 0 999 Years $4,282.40 3/1/2012 0.00 $4,282.40 1/1/2016
MEDICAL
SUPPLIER
(DME) E1004 0 999 Years $4,748.30 3/1/2012 0.00 $4,748.30 1/1/2016
MEDICAL
SUPPLIER
(DME) E1005 0 999 Years $4,781.68 4/1/2013 0.00 $4,781.68 4/1/2015
MEDICAL
SUPPLIER
(DME) E1006 0 999 Years $6,295.60 4/1/2013 0.00 $6,295.60 1/1/2016
MEDICAL
SUPPLIER
(DME) E1007 0 999 Years $7,861.02 4/1/2013 0.00 $7,861.02 1/1/2016
MEDICAL
SUPPLIER
(DME) E1008 0 999 Years $7,881.83 3/1/2012 0.00 $7,881.83 1/1/2016
MEDICAL
SUPPLIER
(DME) E1009 0 999 Years $0.00 5/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E1010 0 999 Years $1,595.33 3/1/2012 0.00 $1,595.33 1/1/2016
MEDICAL
SUPPLIER
(DME) E1011 0 999 Years $0.00 5/1/2003 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E1012 0 999 Years $926.15 1/1/2016 0.00 $926.15 1/1/2016
MEDICAL
SUPPLIER
(DME) E1014 0 999 Years $319.87 3/1/2012 0.00 $319.87 1/1/2016
MEDICAL
SUPPLIER
(DME) E1015 0 999 Years $117.46 4/1/2013 0.00 $117.46 10/1/2013
MEDICAL
SUPPLIER
(DME) E1016 0 999 Years $127.15 3/1/2012 0.00 $127.15 10/1/2013
MEDICAL
SUPPLIER
(DME) E1017 0 999 Years $0.00 4/1/2013 $0.00 5 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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MEDICAL
SUPPLIER
(DME) E1018 0 999 Years $0.00 5/1/2003 $0.00 5 4/1/2015
MEDICAL
SUPPLIER
(DME) E1020 0 999 Years $223.91 4/1/2013 0.00 $223.91 10/1/2013 $21.47 3/1/2012 0.00 21.47 10/1/2013
MEDICAL
SUPPLIER
(DME) E1028 0 999 Years $186.22 3/1/2012 0.00 $186.22 10/1/2013
MEDICAL
SUPPLIER
(DME) E1029 0 999 Years $326.14 3/1/2012 0.00 $326.14 10/1/2013
MEDICAL
SUPPLIER
(DME) E1031 0 999 Years $41.92 4/1/2013 0.00 41.92 4/1/2015
MEDICAL
SUPPLIER
(DME) E1035 0 20 Years $4,424.10 4/1/2015 0.00 $4,424.10 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1035 TF 0 20 Years $0.00 4/1/2013 -2.00 $0.00 5 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1035 TG 0 20 Years $0.00 10/16/2003 -2.00 $0.00 5 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1050 0 999 Years $721.63 4/1/2015 0.00 $721.63 4/1/2015 $72.16 4/1/2015 0.00 72.16 4/1/2015
MEDICAL
SUPPLIER
(DME) E1060 0 999 Years $1,069.90 4/1/2013 0.00 $1,069.90 4/1/2015 $106.99 4/1/2013 0.00 106.99 4/1/2015
MEDICAL
SUPPLIER
(DME) E1070 0 999 Years $842.08 4/1/2013 0.00 $842.08 4/1/2015 $84.21 4/1/2013 0.00 84.21 4/1/2015
MEDICAL
SUPPLIER
(DME) E1083 0 999 Years $482.89 4/1/2015 0.00 $482.89 4/1/2015 $48.29 4/1/2015 0.00 48.29 4/1/2015
MEDICAL
SUPPLIER
(DME) E1084 0 999 Years $770.70 4/1/2013 0.00 $770.70 4/1/2015 $77.07 4/1/2013 0.00 77.07 4/1/2015
MEDICAL
SUPPLIER
(DME) E1085 0 999 Years $861.32 4/1/2013 0.00 $861.32 4/1/2015 $86.13 4/1/2013 0.00 86.13 4/1/2015
MEDICAL
SUPPLIER
(DME) E1086 0 999 Years $808.59 4/1/2013 0.00 $808.59 4/1/2015 $80.86 4/1/2013 0.00 80.86 4/1/2015
MEDICAL
SUPPLIER
(DME) E1087 0 999 Years $1,095.19 4/1/2013 0.00 $1,095.19 4/1/2015 $109.52 4/1/2013 0.00 109.52 4/1/2015
MEDICAL
SUPPLIER
(DME) E1088 0 999 Years $1,147.05 4/1/2013 0.00 $1,147.05 4/1/2015 $114.71 4/1/2013 0.00 114.71 4/1/2015
MEDICAL
SUPPLIER
(DME) E1089 0 999 Years $1,320.57 4/1/2013 0.00 $1,320.57 4/1/2015 $132.06 4/1/2013 0.00 132.06 4/1/2015
MEDICAL
SUPPLIER
(DME) E1090 0 999 Years $1,320.57 4/1/2013 0.00 $1,320.57 10/1/2013 $126.90 4/1/2013 -8.00 116.75 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
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Report
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Date
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MEDICAL
SUPPLIER
(DME) E1092 0 999 Years $1,052.53 4/1/2013 0.00 $1,052.53 4/1/2015 $105.25 4/1/2013 0.00 105.25 4/1/2015
MEDICAL
SUPPLIER
(DME) E1093 0 999 Years $1,067.66 4/1/2013 0.00 $1,067.66 4/1/2015 $106.77 4/1/2013 0.00 106.77 4/1/2015
MEDICAL
SUPPLIER
(DME) E1100 0 999 Years $1,002.80 4/1/2013 0.00 $1,002.80 4/1/2015 $100.28 4/1/2013 0.00 100.28 4/1/2015
MEDICAL
SUPPLIER
(DME) E1110 0 999 Years $982.01 4/1/2013 0.00 $982.01 4/1/2015 $98.20 4/1/2013 0.00 98.20 4/1/2015
MEDICAL
SUPPLIER
(DME) E1130 0 999 Years $526.33 4/1/2013 0.00 $526.33 4/1/2015 $52.63 4/1/2015 0.00 52.63 4/1/2015
MEDICAL
SUPPLIER
(DME) E1140 0 999 Years $446.24 4/1/2013 0.00 $446.24 4/1/2015 $44.62 4/1/2013 0.00 44.62 4/1/2015
MEDICAL
SUPPLIER
(DME) E1150 0 999 Years $588.51 4/1/2015 0.00 $588.51 4/1/2015 $58.85 4/1/2015 0.00 58.85 4/1/2015
MEDICAL
SUPPLIER
(DME) E1160 0 999 Years $509.31 4/1/2013 0.00 $509.31 4/1/2015 $50.93 4/1/2013 0.00 50.93 4/1/2015
MEDICAL
SUPPLIER
(DME) E1161 0 999 Years $2,422.78 3/1/2012 0.00 $2,422.78 10/1/2013 $242.27 3/1/2012 0.00 242.27 10/1/2013
MEDICAL
SUPPLIER
(DME) E1170 0 999 Years $919.04 4/1/2013 0.00 $919.04 4/1/2015 $91.90 4/1/2013 0.00 91.90 4/1/2015
MEDICAL
SUPPLIER
(DME) E1171 0 999 Years $824.77 4/1/2013 0.00 $824.77 4/1/2015 $82.48 4/1/2013 0.00 82.48 4/1/2015
MEDICAL
SUPPLIER
(DME) E1172 0 999 Years $779.54 4/1/2013 0.00 $779.54 4/1/2015 $77.95 4/1/2013 0.00 77.95 4/1/2015
MEDICAL
SUPPLIER
(DME) E1180 0 999 Years $922.56 4/1/2013 0.00 $922.56 4/1/2015 $92.26 4/1/2013 0.00 92.26 4/1/2015
MEDICAL
SUPPLIER
(DME) E1190 0 999 Years $1,028.84 4/1/2013 0.00 $1,028.84 10/1/2013 $111.83 3/1/2012 0.00 111.83 10/1/2013
MEDICAL
SUPPLIER
(DME) E1195 0 999 Years $979.89 4/1/2013 0.00 $979.89 10/1/2013 $106.51 3/1/2012 0.00 106.51 10/1/2013
MEDICAL
SUPPLIER
(DME) E1200 0 999 Years $692.89 4/1/2013 0.00 $692.89 4/1/2015 $69.29 4/1/2013 0.00 69.29 4/1/2015
MEDICAL
SUPPLIER
(DME) E1220 0 999 Years $0.00 7/1/1997 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E1225 0 999 Years $312.00 7/1/2013 0.00 $312.00 4/1/2015 $31.20 4/1/2014 0.00 31.20 4/1/2015
MEDICAL
SUPPLIER
(DME) E1226 0 999 Years $376.63 7/1/2013 0.00 $376.63 4/1/2015 $37.66 4/1/2014 0.00 37.66 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
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Report
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Date
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Purchase
MEDICAL
SUPPLIER
(DME) E1229 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E1230 0 999 Years $1,353.82 4/1/2013 0.00 $1,353.82 10/1/2013 $141.41 3/1/2012 0.00 141.41 10/1/2013
MEDICAL
SUPPLIER
(DME) E1231 0 999 Years $0.00 1/1/2016 $0.00 1/1/2016 $0.00 1/1/2016 0.00 1/1/2016
MEDICAL
SUPPLIER
(DME) E1232 0 999 Years $2,189.65 4/1/2013 0.00 $2,189.65 1/1/2016 $218.97 1/1/2016 0.00 218.97 1/1/2016
MEDICAL
SUPPLIER
(DME) E1233 0 999 Years $2,268.82 3/1/2012 0.00 $2,268.82 1/1/2016 $226.88 3/1/2012 0.00 226.88 1/1/2016
MEDICAL
SUPPLIER
(DME) E1234 0 999 Years $1,975.17 3/1/2012 0.00 $1,975.17 1/1/2016 $197.52 1/1/2016 0.00 197.52 1/1/2016
MEDICAL
SUPPLIER
(DME) E1235 0 999 Years $2,680.34 1/1/2016 0.00 $2,680.34 1/1/2016 $190.20 4/1/2013 0.00 190.20 10/1/2013
MEDICAL
SUPPLIER
(DME) E1236 0 999 Years $2,364.57 1/1/2016 0.00 $2,364.57 1/1/2016 $167.80 3/1/2012 0.00 167.80 10/1/2013
MEDICAL
SUPPLIER
(DME) E1237 0 999 Years $1,439.40 3/1/2012 0.00 $1,439.40 10/1/2013 $143.94 3/1/2012 0.00 143.94 10/1/2013
MEDICAL
SUPPLIER
(DME) E1238 0 999 Years $1,599.33 3/1/2012 0.00 $1,599.33 10/1/2013 $159.93 3/1/2012 0.00 159.93 10/1/2013
MEDICAL
SUPPLIER
(DME) E1239 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E1240 0 999 Years $764.25 4/1/2013 0.00 $764.25 4/1/2015 $76.43 4/1/2015 0.00 76.43 4/1/2015
MEDICAL
SUPPLIER
(DME) E1250 0 999 Years $885.41 4/1/2013 0.00 $885.41 4/1/2015 $88.54 4/1/2013 0.00 88.54 4/1/2015
MEDICAL
SUPPLIER
(DME) E1260 0 999 Years $750.67 4/1/2013 0.00 $750.67 4/1/2015 $75.07 4/1/2013 0.00 75.07 4/1/2015
MEDICAL
SUPPLIER
(DME) E1270 0 999 Years $762.59 4/1/2013 0.00 $762.59 4/1/2015 $76.26 4/1/2013 0.00 76.26 4/1/2015
MEDICAL
SUPPLIER
(DME) E1280 0 999 Years $1,075.00 4/1/2013 0.00 $1,075.00 4/1/2015 $107.50 4/1/2013 0.00 107.50 4/1/2015
MEDICAL
SUPPLIER
(DME) E1285 0 999 Years $1,239.33 4/1/2013 0.00 $1,239.33 4/1/2015 $123.93 4/1/2013 0.00 123.93 4/1/2015
MEDICAL
SUPPLIER
(DME) E1290 0 999 Years $1,034.51 7/1/1997 -8.00 $951.75 10/1/2013 $103.45 2/1/2011 -8.00 95.17 10/1/2013
MEDICAL
SUPPLIER
(DME) E1295 0 999 Years $1,113.60 7/1/1997 -8.00 $1,024.51 10/1/2013 $102.45 4/1/2013 0.00 102.45 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes
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Note CodesAdjusted
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Report
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Purchase
MEDICAL
SUPPLIER
(DME) E1296 0 999 Years $384.49 4/1/2013 0.00 $384.49 4/1/2015
MEDICAL
SUPPLIER
(DME) E1297 0 999 Years $81.81 4/1/2013 0.00 $81.81 4/1/2015
MEDICAL
SUPPLIER
(DME) E1298 0 999 Years $331.29 4/1/2013 0.00 $331.29 4/1/2015
MEDICAL
SUPPLIER
(DME) E1300 0 20 Years $156.40 4/1/2013 0.00 $156.40 6 4/1/2015 $15.64 4/1/2013 0.00 15.64 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1310 0 20 Years $2,074.39 4/1/2013 0.00 $2,074.39 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1353 0 999 Years $27.37 4/1/2013 0.00 $27.37 4/1/2015
MEDICAL
SUPPLIER
(DME) E1355 0 999 Years $20.61 4/1/2013 0.00 $20.61 4/1/2015 $2.06 4/1/2013 0.00 2.06 4/1/2015
MEDICAL
SUPPLIER
(DME) E135F 0 20 Years $0.00 4/1/2013 -2.00 $0.00 5 6 2/1/2011
MEDICAL
SUPPLIER
(DME) E1372 0 999 Years $149.99 4/1/2013 0.00 $149.99 4/1/2015
MEDICAL
SUPPLIER
(DME) E1390 0 999 Years $161.05 4/1/2013 0.00 161.05 4/1/2015
MEDICAL
SUPPLIER
(DME) E1399 0 999 Years $0.00 5/1/2003 $0.00 5 4/1/2015 $0.00 5/1/2003 0.00 5 4/1/2015
MEDICAL
SUPPLIER
(DME) E1510 0 20 Years $9,928.69 4/1/2013 0.00 $9,928.69 6 4/1/2015 $992.87 4/1/2013 0.00 992.87 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1520 0 20 Years $372.70 4/1/2013 0.00 $372.70 6 4/1/2015 $37.27 4/1/2013 0.00 37.27 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1530 0 20 Years $536.28 4/1/2013 0.00 $536.28 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1540 0 20 Years $22.50 4/1/2013 0.00 $22.50 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1550 0 20 Years $274.08 4/1/2013 0.00 $274.08 6 4/1/2015 $27.41 4/1/2013 0.00 27.41 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1560 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1570 0 20 Years $556.28 4/1/2015 0.00 $556.28 6 4/1/2015 $55.63 4/1/2015 0.00 55.63 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1575 0 20 Years $1.60 4/1/2013 0.00 $1.60 4/1/2015 $0.16 4/1/2009 0.00 0.16 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) E1580 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1590 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $284.20 4/1/2013 0.00 284.20 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1592 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1594 0 20 Years $6,020.48 4/1/2013 0.00 $6,020.48 6 4/1/2015 $602.05 4/1/2013 0.00 602.05 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1600 0 20 Years $35.75 4/1/2013 0.00 35.75 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1620 0 20 Years $1,719.65 4/1/2013 0.00 $1,719.65 6 4/1/2015 $171.97 4/1/2015 0.00 171.97 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1630 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1632 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1635 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $616.30 4/1/2013 0.00 616.30 6 4/1/2013
MEDICAL
SUPPLIER
(DME) E1637 0 20 Years $3.92 4/1/2013 0.00 $3.92 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1639 0 20 Years $252.47 4/1/2015 0.00 $252.47 6 4/1/2015 $25.25 4/1/2015 0.00 25.25 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1699 0 20 Years $0.00 4/1/1990 $0.00 5 6 4/1/2015 $0.00 4/1/1990 0.00 5 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1700 0 20 Years $27.77 4/1/2013 0.00 27.77 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1701 0 20 Years $1.06 4/1/2013 0.00 1.06 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1702 0 20 Years $2.02 4/1/2013 0.00 2.02 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1800 0 20 Years $1,026.35 4/1/2013 0.00 $1,026.35 6 4/1/2015 $102.64 4/1/2013 0.00 102.64 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1801 0 20 Years $1,327.41 4/1/2013 0.00 $1,327.41 6 4/1/2015 $132.74 4/1/2015 0.00 132.74 4/1/2015
MEDICAL
SUPPLIER
(DME) E1802 0 20 Years $3,156.89 4/1/2013 0.00 $3,156.89 6 4/1/2015 $315.69 4/1/2013 0.00 315.69 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1805 0 20 Years $1,037.39 4/1/2013 0.00 $1,037.39 6 4/1/2015 $103.74 4/1/2013 0.00 103.74 6 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) E1806 0 20 Years $974.37 4/1/2013 0.00 $974.37 6 4/1/2015 $97.44 4/1/2015 0.00 97.44 4/1/2015
MEDICAL
SUPPLIER
(DME) E1810 0 20 Years $1,040.43 4/1/2013 0.00 $1,040.43 6 4/1/2015 $104.04 4/1/2013 0.00 104.04 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1811 0 20 Years $1,314.38 4/1/2013 0.00 $1,314.38 6 4/1/2015 $131.44 4/1/2015 0.00 131.44 4/1/2015
MEDICAL
SUPPLIER
(DME) E1812 0 20 Years $842.70 4/1/2013 0.00 $842.70 6 4/1/2015 $84.27 4/1/2013 0.00 84.27 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1815 0 20 Years $1,040.43 4/1/2013 0.00 $1,040.43 6 4/1/2015 $104.04 4/1/2013 0.00 104.04 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1816 0 20 Years $1,335.15 4/1/2013 0.00 $1,335.15 6 4/1/2015 $133.52 4/1/2015 0.00 133.52 4/1/2015
MEDICAL
SUPPLIER
(DME) E1818 0 20 Years $1,363.08 4/1/2013 0.00 $1,363.08 6 4/1/2015 $136.31 4/1/2015 0.00 136.31 4/1/2015
MEDICAL
SUPPLIER
(DME) E1820 0 20 Years $69.78 4/1/2013 0.00 $69.78 6 4/1/2015 $6.98 4/1/2015 0.00 6.98 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1821 0 20 Years $108.30 4/1/2013 0.00 $108.30 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1825 0 20 Years $1,037.39 4/1/2013 0.00 $1,037.39 6 4/1/2015 $103.74 4/1/2013 0.00 103.74 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1830 0 20 Years $1,037.39 4/1/2013 0.00 $1,037.39 6 4/1/2015 $103.74 4/1/2013 0.00 103.74 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1831 0 20 Years $62.79 4/1/2013 0.00 62.79 4/1/2015
MEDICAL
SUPPLIER
(DME) E1840 0 20 Years $3,697.02 4/1/2013 0.00 $3,697.02 6 4/1/2015 $369.70 4/1/2013 0.00 369.70 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E1841 0 999 Years $3,678.45 7/1/2013 0.00 $3,678.45 4/1/2015 $367.85 4/1/2015 0.00 367.85 4/1/2015
MEDICAL
SUPPLIER
(DME) E2100 0 999 Years $312.80 4/1/2013 0.00 $312.80 4/1/2015
MEDICAL
SUPPLIER
(DME) E2101 0 999 Years $173.48 4/1/2013 0.00 $173.48 10/1/2013
MEDICAL
SUPPLIER
(DME) E2201 0 999 Years $363.85 3/1/2012 0.00 $363.85 10/1/2013
MEDICAL
SUPPLIER
(DME) E2202 0 999 Years $462.23 4/1/2013 0.00 $462.23 10/1/2013
MEDICAL
SUPPLIER
(DME) E2203 0 999 Years $431.91 4/1/2013 0.00 $431.91 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Date
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) E2204 0 999 Years $651.05 3/1/2012 0.00 $651.05 10/1/2013
MEDICAL
SUPPLIER
(DME) E2205 0 999 Years $33.45 3/1/2012 0.00 $33.45 1/1/2016
MEDICAL
SUPPLIER
(DME) E2206 0 999 Years $41.65 3/1/2012 0.00 $41.65 1/1/2016
MEDICAL
SUPPLIER
(DME) E2207 0 999 Years $42.25 4/1/2013 0.00 $42.25 1/1/2016 $4.23 3/1/2012 0.00 4.23 1/1/2016
MEDICAL
SUPPLIER
(DME) E2208 0 999 Years $115.83 4/1/2013 0.00 $115.83 10/1/2013 $11.58 3/1/2012 0.00 11.58 10/1/2013
MEDICAL
SUPPLIER
(DME) E2209 0 999 Years $104.51 3/1/2012 0.00 $104.51 1/1/2016 $10.45 1/1/2016 0.00 10.45 1/1/2016
MEDICAL
SUPPLIER
(DME) E2210 0 999 Years $6.39 3/1/2012 0.00 $6.39 1/1/2016
MEDICAL
SUPPLIER
(DME) E2211 0 999 Years $28.51 3/1/2012 0.00 $28.51 10/1/2013
MEDICAL
SUPPLIER
(DME) E2212 0 999 Years $5.73 3/1/2012 0.00 $5.73 10/1/2013
MEDICAL
SUPPLIER
(DME) E2213 0 999 Years $28.51 3/1/2012 0.00 $28.51 10/1/2013
MEDICAL
SUPPLIER
(DME) E2214 0 999 Years $29.84 3/1/2012 0.00 $29.84 10/1/2013
MEDICAL
SUPPLIER
(DME) E2215 0 999 Years $9.36 3/1/2012 0.00 $9.36 10/1/2013
MEDICAL
SUPPLIER
(DME) E2216 0 999 Years $0.00 1/1/2016 $0.00 1/1/2016
MEDICAL
SUPPLIER
(DME) E2217 0 999 Years $0.00 1/1/2016 $0.00 1/1/2016
MEDICAL
SUPPLIER
(DME) E2218 0 999 Years $43.98 3/1/2012 0.00 $43.98 10/1/2013
MEDICAL
SUPPLIER
(DME) E2219 0 999 Years $32.07 3/1/2012 0.00 $32.07 10/1/2013
MEDICAL
SUPPLIER
(DME) E2220 0 999 Years $23.64 3/1/2012 0.00 $23.64 10/1/2013
MEDICAL
SUPPLIER
(DME) E2221 0 999 Years $24.92 3/1/2012 0.00 $24.92 10/1/2013
MEDICAL
SUPPLIER
(DME) E2222 0 999 Years $59.18 3/1/2012 0.00 $59.18 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) E2224 0 999 Years $43.91 3/1/2012 0.00 $43.91 10/1/2013
MEDICAL
SUPPLIER
(DME) E2225 0 999 Years $39.98 3/1/2012 0.00 $39.98 10/1/2013
MEDICAL
SUPPLIER
(DME) E2226 0 999 Years $50.63 3/1/2012 0.00 $50.63 10/1/2013
MEDICAL
SUPPLIER
(DME) E2227 0 999 Years $1,530.22 3/1/2012 0.00 $1,530.22 1/1/2016
MEDICAL
SUPPLIER
(DME) E2228 0 999 Years $913.04 3/1/2012 0.00 $913.04 1/1/2016
MEDICAL
SUPPLIER
(DME) E2291 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2292 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2293 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2294 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2300 0 999 Years $0.00 4/1/2013 $0.00 5 4/1/2015
MEDICAL
SUPPLIER
(DME) E2310 0 999 Years $1,141.22 3/1/2012 0.00 $1,141.22 1/1/2016
MEDICAL
SUPPLIER
(DME) E2311 0 999 Years $2,136.07 3/1/2012 0.00 $2,136.07 1/1/2016
MEDICAL
SUPPLIER
(DME) E2312 0 999 Years $1,891.09 3/1/2012 0.00 $1,891.09 10/1/2013 $189.11 4/1/2013 0.00 189.11 4/1/2013
MEDICAL
SUPPLIER
(DME) E2312 KC 0 999 Years $2,411.85 3/1/2012 0.00 $2,411.85 10/1/2013 $241.19 4/1/2013 0.00 241.19 4/1/2013
MEDICAL
SUPPLIER
(DME) E2313 0 999 Years $300.29 4/1/2013 0.00 $300.29 10/1/2013
MEDICAL
SUPPLIER
(DME) E2321 0 999 Years $1,719.28 3/1/2012 0.00 $1,719.28 10/1/2013
MEDICAL
SUPPLIER
(DME) E2321 KC 0 999 Years $2,284.45 4/1/2013 0.00 $2,284.45 10/1/2013
MEDICAL
SUPPLIER
(DME) E2323 0 999 Years $63.04 3/1/2012 0.00 $63.04 10/1/2013
MEDICAL
SUPPLIER
(DME) E2324 0 999 Years $43.39 3/1/2012 0.00 $43.39 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Date
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) E2325 0 999 Years $1,313.43 4/1/2013 0.00 $1,313.43 10/1/2013
MEDICAL
SUPPLIER
(DME) E2326 0 999 Years $311.67 3/1/2012 0.00 $311.67 10/1/2013
MEDICAL
SUPPLIER
(DME) E2327 0 999 Years $2,248.95 3/1/2012 0.00 $2,248.95 10/1/2013
MEDICAL
SUPPLIER
(DME) E2328 0 999 Years $3,781.16 3/1/2012 0.00 $3,781.16 10/1/2013
MEDICAL
SUPPLIER
(DME) E2329 0 999 Years $2,181.89 3/1/2012 0.00 $2,181.89 10/1/2013
MEDICAL
SUPPLIER
(DME) E2330 0 999 Years $3,250.60 4/1/2013 0.00 $3,250.60 10/1/2013
MEDICAL
SUPPLIER
(DME) E2340 0 999 Years $306.43 4/1/2013 0.00 $306.43 10/1/2013
MEDICAL
SUPPLIER
(DME) E2341 0 999 Years $451.49 3/1/2012 0.00 $451.49 10/1/2013
MEDICAL
SUPPLIER
(DME) E2342 0 999 Years $436.92 3/1/2012 0.00 $436.92 10/1/2013
MEDICAL
SUPPLIER
(DME) E2343 0 999 Years $733.96 4/1/2013 0.00 $733.96 10/1/2013
MEDICAL
SUPPLIER
(DME) E2351 0 999 Years $681.30 3/1/2012 0.00 $681.30 10/1/2013
MEDICAL
SUPPLIER
(DME) E2359 0 999 Years $134.87 4/1/2013 0.00 $134.87 4/1/2015
MEDICAL
SUPPLIER
(DME) E2361 0 999 Years $151.41 3/1/2012 0.00 $151.41 10/1/2013
MEDICAL
SUPPLIER
(DME) E2363 0 999 Years $196.79 3/1/2012 0.00 $196.79 10/1/2013
MEDICAL
SUPPLIER
(DME) E2366 0 999 Years $237.68 3/1/2012 0.00 $237.68 10/1/2013
MEDICAL
SUPPLIER
(DME) E2368 0 999 Years $455.91 3/1/2012 0.00 $455.91 10/1/2013
MEDICAL
SUPPLIER
(DME) E2369 0 999 Years $397.10 3/1/2012 0.00 $397.10 10/1/2013
MEDICAL
SUPPLIER
(DME) E2370 0 999 Years $854.42 3/1/2012 0.00 $854.42 10/1/2013
MEDICAL
SUPPLIER
(DME) E2371 0 999 Years $167.31 1/1/2016 0.00 $167.31 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) E2373 0 999 Years $1,179.92 4/1/2013 0.00 $1,179.92 10/1/2013
MEDICAL
SUPPLIER
(DME) E2373 KC 0 999 Years $1,067.83 3/1/2012 0.00 $1,067.83 10/1/2013
MEDICAL
SUPPLIER
(DME) E2374 0 999 Years $520.78 3/1/2012 0.00 $520.78 10/1/2013
MEDICAL
SUPPLIER
(DME) E2375 0 999 Years $835.33 4/1/2013 0.00 $835.33 10/1/2013
MEDICAL
SUPPLIER
(DME) E2376 0 999 Years $1,259.56 3/1/2012 0.00 $1,259.56 10/1/2013
MEDICAL
SUPPLIER
(DME) E2377 0 999 Years $473.66 3/1/2012 0.00 $473.66 10/1/2013
MEDICAL
SUPPLIER
(DME) E2381 0 999 Years $57.47 3/1/2012 0.00 $57.47 10/1/2013
MEDICAL
SUPPLIER
(DME) E2382 0 999 Years $20.26 3/1/2012 0.00 $20.26 10/1/2013
MEDICAL
SUPPLIER
(DME) E2383 0 999 Years $113.88 3/1/2012 0.00 $113.88 10/1/2013
MEDICAL
SUPPLIER
(DME) E2384 0 999 Years $60.67 3/1/2012 0.00 $60.67 10/1/2013
MEDICAL
SUPPLIER
(DME) E2385 0 999 Years $48.27 3/1/2012 0.00 $48.27 10/1/2013
MEDICAL
SUPPLIER
(DME) E2386 0 999 Years $139.34 4/1/2013 0.00 $139.34 4/1/2015
MEDICAL
SUPPLIER
(DME) E2387 0 999 Years $58.55 3/1/2012 0.00 $58.55 10/1/2013
MEDICAL
SUPPLIER
(DME) E2388 0 999 Years $49.14 3/1/2012 0.00 $49.14 10/1/2013
MEDICAL
SUPPLIER
(DME) E2389 0 999 Years $26.68 3/1/2012 0.00 $26.68 10/1/2013
MEDICAL
SUPPLIER
(DME) E2390 0 999 Years $41.73 3/1/2012 0.00 $41.73 10/1/2013
MEDICAL
SUPPLIER
(DME) E2391 0 999 Years $19.99 3/1/2012 0.00 $19.99 10/1/2013
MEDICAL
SUPPLIER
(DME) E2392 0 999 Years $52.54 3/1/2012 0.00 $52.54 10/1/2013
MEDICAL
SUPPLIER
(DME) E2394 0 999 Years $74.85 3/1/2012 0.00 $74.85 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Date
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
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%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) E2395 0 999 Years $53.20 3/1/2012 0.00 $53.20 10/1/2013
MEDICAL
SUPPLIER
(DME) E2396 0 999 Years $44.74 3/1/2012 0.00 $44.74 10/1/2013
MEDICAL
SUPPLIER
(DME) E2402 0 999 Years $1,289.32 4/1/2013 0.00 1,289.32 4/1/2015
MEDICAL
SUPPLIER
(DME) E2500 0 999 Years $344.20 4/1/2013 0.00 $344.20 4/1/2015 $34.42 4/1/2013 0.00 34.42 4/1/2015
MEDICAL
SUPPLIER
(DME) E2502 0 999 Years $1,155.14 4/1/2013 0.00 $1,155.14 4/1/2015 $115.51 4/1/2015 0.00 115.51 4/1/2015
MEDICAL
SUPPLIER
(DME) E2504 0 999 Years $1,545.87 4/1/2013 0.00 $1,545.87 4/1/2015 $154.59 4/1/2015 0.00 154.59 4/1/2015
MEDICAL
SUPPLIER
(DME) E2506 0 999 Years $2,127.92 4/1/2013 0.00 $2,127.92 4/1/2015 $212.79 4/1/2013 0.00 212.79 4/1/2015
MEDICAL
SUPPLIER
(DME) E2508 0 999 Years $3,290.48 4/1/2013 0.00 $3,290.48 4/1/2015 $329.05 4/1/2015 0.00 329.05 4/1/2015
MEDICAL
SUPPLIER
(DME) E2510 0 999 Years $6,226.79 4/1/2013 0.00 $6,226.79 4/1/2015 $622.68 4/1/2015 0.00 622.68 4/1/2015
MEDICAL
SUPPLIER
(DME) E2511 0 999 Years $354.37 4/1/2013 0.00 $354.37 4/1/2015
MEDICAL
SUPPLIER
(DME) E2512 0 999 Years $0.00 7/1/2004 $0.00 5 4/1/2015 $82.71 4/1/2013 0.00 82.71 4/1/2015
MEDICAL
SUPPLIER
(DME) E2599 0 999 Years $0.00 7/1/2004 $0.00 5 4/1/2015 $0.00 7/1/2004 0.00 5 4/1/2015
MEDICAL
SUPPLIER
(DME) E2599 U1 0 999 Years $139.00 4/1/2015 0.00 $139.00 4/1/2015
MEDICAL
SUPPLIER
(DME) E2601 0 999 Years $53.98 3/1/2012 0.00 $53.98 10/1/2013
MEDICAL
SUPPLIER
(DME) E2602 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2603 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2604 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2605 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2606 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Date
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) E2607 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2608 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2609 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2611 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2612 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2613 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2614 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2615 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2616 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2617 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2619 0 999 Years $0.00 1/1/2005 $0.00 5 1/1/2016
MEDICAL
SUPPLIER
(DME) E2620 0 999 Years $0.00 1/1/2005 $0.00 5 10/1/2013
MEDICAL
SUPPLIER
(DME) E2621 0 999 Years $507.26 3/1/2012 0.00 $507.26 10/1/2013
MEDICAL
SUPPLIER
(DME) E2622 0 999 Years $323.25 3/1/2012 0.00 $323.25 10/1/2013
MEDICAL
SUPPLIER
(DME) E2623 0 999 Years $411.32 3/1/2012 0.00 $411.32 10/1/2013
MEDICAL
SUPPLIER
(DME) E2624 0 999 Years $325.89 4/1/2013 0.00 $325.89 10/1/2013
MEDICAL
SUPPLIER
(DME) E2625 0 999 Years $412.58 4/1/2013 0.00 $412.58 4/1/2015
MEDICAL
SUPPLIER
(DME) E2626 0 20 Years $446.66 4/1/2013 0.00 $446.66 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E2627 0 20 Years $773.31 4/1/2013 0.00 $773.31 6 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) E2628 0 20 Years $527.86 4/1/2013 0.00 $527.86 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E2629 0 20 Years $705.36 4/1/2013 0.00 $705.36 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E2630 0 20 Years $513.92 4/1/2013 0.00 $513.92 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E2631 0 20 Years $204.43 4/1/2013 0.00 $204.43 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E2632 0 20 Years $172.94 4/1/2013 0.00 $172.94 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E2633 0 20 Years $138.56 4/1/2013 0.00 $138.56 6 4/1/2015
MEDICAL
SUPPLIER
(DME) E8001 0 999 Years $0.00 1/1/2005 $0.00 5 4/1/2015 $0.00 1/1/2005 0.00 5 4/1/2015
MEDICAL
SUPPLIER
(DME) K0001 0 999 Years $432.52 7/1/2013 0.00 $432.52 11/1/2015 $43.25 7/1/2013 0.00 43.25 11/1/2015
MEDICAL
SUPPLIER
(DME) K0002 0 999 Years $664.42 7/1/2013 0.00 $664.42 11/1/2015 $66.44 7/1/2013 0.00 66.44 11/1/2015
MEDICAL
SUPPLIER
(DME) K0003 0 999 Years $727.58 7/1/2013 0.00 $727.58 11/1/2015 $72.76 7/1/2013 0.00 72.76 11/1/2015
MEDICAL
SUPPLIER
(DME) K0004 0 999 Years $1,085.18 7/1/2013 0.00 $1,085.18 11/1/2015 $108.52 7/1/2013 0.00 108.52 11/1/2015
MEDICAL
SUPPLIER
(DME) K0005 0 999 Years $2,001.69 7/1/2013 0.00 $2,001.69 11/1/2015 $200.15 7/1/2013 0.00 200.15 11/1/2015
MEDICAL
SUPPLIER
(DME) K0006 0 999 Years $1,018.42 7/1/2013 0.00 $1,018.42 11/1/2015 $101.84 7/1/2013 0.00 101.84 11/1/2015
MEDICAL
SUPPLIER
(DME) K0007 0 999 Years $1,449.45 7/1/2013 0.00 $1,449.45 11/1/2015 $144.94 7/1/2013 0.00 144.94 11/1/2015
MEDICAL
SUPPLIER
(DME) K0008 0 20 Years $0.00 4/1/2014 -2.00 $0.00 11/1/2015 $0.00 4/1/2014 -2.00 0.00 11/1/2015
MEDICAL
SUPPLIER
(DME) K0009 0 999 Years $0.00 7/1/2013 $0.00 5 11/1/2015 $0.00 7/1/2013 0.00 5 11/1/2015
MEDICAL
SUPPLIER
(DME) K0010 0 999 Years $3,620.90 10/1/2006 -8.00 $3,331.23 11/1/2015 $362.09 10/1/2006 -8.00 333.12 11/1/2015
MEDICAL
SUPPLIER
(DME) K0011 0 999 Years $5,122.80 10/1/2006 -8.00 $4,712.98 11/1/2015 $512.28 10/1/2006 -8.00 471.30 11/1/2015
MEDICAL
SUPPLIER
(DME) K0012 0 999 Years $3,343.49 1/1/2006 -8.00 $3,076.01 11/1/2015 $334.35 10/1/2011 -8.00 307.60 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Date
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
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Type
Rental
Proc
Code
Client Age
Mod
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Mod
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Purchase
MEDICAL
SUPPLIER
(DME) K0013 0 20 Years $0.00 4/1/2014 -2.00 $0.00 11/1/2015 $0.00 4/1/2014 -2.00 0.00 11/1/2015
MEDICAL
SUPPLIER
(DME) K0015 0 999 Years $196.73 7/1/2013 0.00 $196.73 11/1/2015
MEDICAL
SUPPLIER
(DME) K0017 0 999 Years $55.35 7/1/2013 0.00 $55.35 11/1/2015
MEDICAL
SUPPLIER
(DME) K0018 0 999 Years $30.92 7/1/2013 0.00 $30.92 11/1/2015
MEDICAL
SUPPLIER
(DME) K0019 0 999 Years $17.70 7/1/2013 0.00 $17.70 11/1/2015
MEDICAL
SUPPLIER
(DME) K0020 0 999 Years $50.30 7/1/2013 0.00 $50.30 11/1/2015
MEDICAL
SUPPLIER
(DME) K0037 0 999 Years $52.14 7/1/2013 0.00 $52.14 11/1/2015
MEDICAL
SUPPLIER
(DME) K0038 0 999 Years $26.26 7/1/2013 0.00 $26.26 11/1/2015
MEDICAL
SUPPLIER
(DME) K0039 0 999 Years $58.33 7/1/2013 0.00 $58.33 11/1/2015
MEDICAL
SUPPLIER
(DME) K0040 0 999 Years $80.84 7/1/2013 0.00 $80.84 11/1/2015
MEDICAL
SUPPLIER
(DME) K0041 0 999 Years $57.29 7/1/2013 0.00 $57.29 11/1/2015
MEDICAL
SUPPLIER
(DME) K0042 0 999 Years $39.44 7/1/2013 0.00 $39.44 11/1/2015
MEDICAL
SUPPLIER
(DME) K0043 0 999 Years $21.15 7/1/2013 0.00 $21.15 11/1/2015
MEDICAL
SUPPLIER
(DME) K0044 0 999 Years $18.01 7/1/2013 0.00 $18.01 11/1/2015
MEDICAL
SUPPLIER
(DME) K0045 0 999 Years $61.31 7/1/2013 0.00 $61.31 11/1/2015
MEDICAL
SUPPLIER
(DME) K0046 0 999 Years $21.15 7/1/2013 0.00 $21.15 11/1/2015 $2.12 4/1/2014 0.00 2.12 11/1/2015
MEDICAL
SUPPLIER
(DME) K0047 0 999 Years $82.81 7/1/2013 0.00 $82.81 11/1/2015 $8.28 4/1/2014 0.00 8.28 11/1/2015
MEDICAL
SUPPLIER
(DME) K0050 0 999 Years $35.20 7/1/2013 0.00 $35.20 11/1/2015
MEDICAL
SUPPLIER
(DME) K0051 0 999 Years $56.95 7/1/2013 0.00 $56.95 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
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Note CodesAdjusted
Fee for
Report
Date
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Date
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Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) K0052 0 999 Years $100.08 7/1/2013 0.00 $100.08 11/1/2015
MEDICAL
SUPPLIER
(DME) K0053 0 999 Years $110.45 7/1/2013 0.00 $110.45 11/1/2015 $11.05 4/1/2014 0.00 11.05 11/1/2015
MEDICAL
SUPPLIER
(DME) K0056 0 999 Years $77.23 7/1/2013 0.00 $77.23 11/1/2015
MEDICAL
SUPPLIER
(DME) K0065 0 999 Years $36.10 7/1/2013 0.00 $36.10 11/1/2015 $3.61 4/1/2014 0.00 3.61 11/1/2015
MEDICAL
SUPPLIER
(DME) K0069 0 999 Years $81.15 7/1/2013 0.00 $81.15 11/1/2015
MEDICAL
SUPPLIER
(DME) K0070 0 999 Years $148.73 7/1/2013 0.00 $148.73 11/1/2015
MEDICAL
SUPPLIER
(DME) K0071 0 999 Years $88.72 7/1/2013 0.00 $88.72 11/1/2015
MEDICAL
SUPPLIER
(DME) K0072 0 999 Years $53.41 7/1/2013 0.00 $53.41 11/1/2015
MEDICAL
SUPPLIER
(DME) K0073 0 999 Years $27.17 7/1/2013 0.00 $27.17 11/1/2015
MEDICAL
SUPPLIER
(DME) K0077 0 999 Years $47.79 7/1/2013 0.00 $47.79 11/1/2015
MEDICAL
SUPPLIER
(DME) K0098 0 999 Years $28.59 7/1/2013 0.00 $28.59 11/1/2015
MEDICAL
SUPPLIER
(DME) K0105 0 999 Years $80.74 7/1/2013 0.00 $80.74 11/1/2015 $8.07 4/1/2014 0.00 8.07 11/1/2015
MEDICAL
SUPPLIER
(DME) K0108 0 999 Years $0.00 5/1/2003 $0.00 5 11/1/2015
MEDICAL
SUPPLIER
(DME) K0195 0 999 Years $147.53 7/1/2013 0.00 $147.53 11/1/2015 $14.75 4/1/2014 0.00 14.75 11/1/2015
MEDICAL
SUPPLIER
(DME) K0455 0 999 Years $277.83 10/1/2011 -8.00 255.60 11/1/2015
MEDICAL
SUPPLIER
(DME) K0462 0 999 Years $48.76 3/1/2012 0.00 48.76 11/1/2015
MEDICAL
SUPPLIER
(DME) K0606 0 999 Years $2,518.27 10/1/2009 -8.00 2,316.81 11/1/2015
MEDICAL
SUPPLIER
(DME) K0669 0 999 Years $73.55 7/1/2013 0.00 $73.55 11/1/2015
MEDICAL
SUPPLIER
(DME) K0730 0 999 Years $1,724.02 6/1/2008 -8.00 $1,586.10 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Date
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) K0733 0 999 Years $29.46 3/1/2012 0.00 $29.46 11/1/2015
MEDICAL
SUPPLIER
(DME) K0738 0 999 Years $0.00 3/1/2012 0.00 5 11/1/2015
MEDICAL
SUPPLIER
(DME) K0800 0 999 Years $1,260.71 3/1/2012 0.00 $1,260.71 11/1/2015 $126.08 3/1/2012 0.00 126.08 11/1/2015
MEDICAL
SUPPLIER
(DME) K0801 0 999 Years $1,989.39 3/1/2012 0.00 $1,989.39 11/1/2015 $198.92 3/1/2012 0.00 198.92 11/1/2015
MEDICAL
SUPPLIER
(DME) K0802 0 999 Years $2,300.17 3/1/2012 0.00 $2,300.17 11/1/2015 $230.01 3/1/2012 0.00 230.01 11/1/2015
MEDICAL
SUPPLIER
(DME) K0813 0 999 Years $2,352.57 3/1/2012 0.00 $2,352.57 11/1/2015 $235.26 3/1/2012 0.00 235.26 11/1/2015
MEDICAL
SUPPLIER
(DME) K0814 0 999 Years $3,011.23 3/1/2012 0.00 $3,011.23 11/1/2015 $301.12 3/1/2012 0.00 301.12 11/1/2015
MEDICAL
SUPPLIER
(DME) K0815 0 999 Years $3,429.01 3/1/2012 0.00 $3,429.01 11/1/2015 $342.91 3/1/2012 0.00 342.91 11/1/2015
MEDICAL
SUPPLIER
(DME) K0816 0 999 Years $3,283.99 3/1/2012 0.00 $3,283.99 11/1/2015 $328.39 3/1/2012 0.00 328.39 11/1/2015
MEDICAL
SUPPLIER
(DME) K0820 0 999 Years $2,512.88 3/1/2012 0.00 $2,512.88 11/1/2015 $251.27 3/1/2012 0.00 251.27 11/1/2015
MEDICAL
SUPPLIER
(DME) K0821 0 999 Years $3,157.20 3/1/2012 0.00 $3,157.20 11/1/2015 $315.72 3/1/2012 0.00 315.72 11/1/2015
MEDICAL
SUPPLIER
(DME) K0822 0 999 Years $2,715.89 3/1/2012 0.00 $2,715.89 11/1/2015 $282.17 3/1/2012 0.00 282.17 11/1/2015
MEDICAL
SUPPLIER
(DME) K0823 0 999 Years $2,703.93 3/1/2012 0.00 $2,703.93 11/1/2015 $272.85 3/1/2012 0.00 272.85 11/1/2015
MEDICAL
SUPPLIER
(DME) K0824 0 999 Years $4,009.76 3/1/2012 0.00 $4,009.76 11/1/2015 $405.43 3/1/2012 0.00 405.43 11/1/2015
MEDICAL
SUPPLIER
(DME) K0825 0 999 Years $3,343.50 3/1/2012 0.00 $3,343.50 11/1/2015 $365.82 3/1/2012 0.00 365.82 11/1/2015
MEDICAL
SUPPLIER
(DME) K0826 0 999 Years $6,143.91 3/1/2012 0.00 $6,143.91 11/1/2015 $611.81 3/1/2012 0.00 611.81 11/1/2015
MEDICAL
SUPPLIER
(DME) K0827 0 999 Years $5,198.70 3/1/2012 0.00 $5,198.70 11/1/2015 $519.87 3/1/2012 0.00 519.87 11/1/2015
MEDICAL
SUPPLIER
(DME) K0828 0 999 Years $6,736.87 3/1/2012 0.00 $6,736.87 11/1/2015 $673.68 3/1/2012 0.00 673.68 11/1/2015
MEDICAL
SUPPLIER
(DME) K0829 0 999 Years $6,186.37 3/1/2012 0.00 $6,186.37 11/1/2015 $618.64 3/1/2012 0.00 618.64 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) K0835 0 999 Years $4,029.82 3/1/2012 0.00 $4,029.82 11/1/2015 $402.98 3/1/2012 0.00 402.98 11/1/2015
MEDICAL
SUPPLIER
(DME) K0836 0 999 Years $4,103.15 3/1/2012 0.00 $4,103.15 11/1/2015 $410.32 3/1/2012 0.00 410.32 11/1/2015
MEDICAL
SUPPLIER
(DME) K0837 0 999 Years $4,722.60 3/1/2012 0.00 $4,722.60 11/1/2015 $472.26 3/1/2012 0.00 472.26 11/1/2015
MEDICAL
SUPPLIER
(DME) K0838 0 999 Years $4,263.77 3/1/2012 0.00 $4,263.77 11/1/2015 $426.37 3/1/2012 0.00 426.37 11/1/2015
MEDICAL
SUPPLIER
(DME) K0839 0 999 Years $6,113.83 3/1/2012 0.00 $6,113.83 11/1/2015 $611.39 3/1/2012 0.00 611.39 11/1/2015
MEDICAL
SUPPLIER
(DME) K0840 0 999 Years $9,262.75 3/1/2012 0.00 $9,262.75 11/1/2015 $926.27 3/1/2012 0.00 926.27 11/1/2015
MEDICAL
SUPPLIER
(DME) K0841 0 999 Years $4,211.50 3/1/2012 0.00 $4,211.50 11/1/2015 $421.15 3/1/2012 0.00 421.15 11/1/2015
MEDICAL
SUPPLIER
(DME) K0842 0 999 Years $4,211.50 3/1/2012 0.00 $4,211.50 11/1/2015 $421.15 3/1/2012 0.00 421.15 11/1/2015
MEDICAL
SUPPLIER
(DME) K0843 0 999 Years $5,070.65 3/1/2012 0.00 $5,070.65 11/1/2015 $507.06 3/1/2012 0.00 507.06 11/1/2015
MEDICAL
SUPPLIER
(DME) K0848 0 999 Years $4,948.92 3/1/2012 0.00 $4,948.92 11/1/2015 $529.88 3/1/2012 0.00 529.88 11/1/2015
MEDICAL
SUPPLIER
(DME) K0849 0 999 Years $4,954.69 3/1/2012 0.00 $4,954.69 11/1/2015 $495.47 3/1/2012 0.00 495.47 11/1/2015
MEDICAL
SUPPLIER
(DME) K0850 0 999 Years $5,987.63 3/1/2012 0.00 $5,987.63 11/1/2015 $598.76 3/1/2012 0.00 598.76 11/1/2015
MEDICAL
SUPPLIER
(DME) K0851 0 999 Years $5,599.02 3/1/2012 0.00 $5,599.02 11/1/2015 $559.90 3/1/2012 0.00 559.90 11/1/2015
MEDICAL
SUPPLIER
(DME) K0852 0 999 Years $6,906.95 3/1/2012 0.00 $6,906.95 11/1/2015 $690.70 3/1/2012 0.00 690.70 11/1/2015
MEDICAL
SUPPLIER
(DME) K0853 0 999 Years $7,095.16 3/1/2012 0.00 $7,095.16 11/1/2015 $709.52 3/1/2012 0.00 709.52 11/1/2015
MEDICAL
SUPPLIER
(DME) K0854 0 999 Years $9,399.56 3/1/2012 0.00 $9,399.56 11/1/2015 $939.96 3/1/2012 0.00 939.96 11/1/2015
MEDICAL
SUPPLIER
(DME) K0855 0 999 Years $8,879.29 3/1/2012 0.00 $8,879.29 11/1/2015 $887.93 3/1/2012 0.00 887.93 11/1/2015
MEDICAL
SUPPLIER
(DME) K0856 0 999 Years $5,558.85 3/1/2012 0.00 $5,558.85 11/1/2015 $567.23 10/1/2009 -8.00 521.85 11/1/2015
MEDICAL
SUPPLIER
(DME) K0857 0 999 Years $5,642.51 3/1/2012 0.00 $5,642.51 11/1/2015 $564.25 3/1/2012 0.00 564.25 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Date
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Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) K0858 0 999 Years $6,863.07 3/1/2012 0.00 $6,863.07 11/1/2015 $686.31 3/1/2012 0.00 686.31 11/1/2015
MEDICAL
SUPPLIER
(DME) K0859 0 999 Years $6,375.95 3/1/2012 0.00 $6,375.95 11/1/2015 $637.60 3/1/2012 0.00 637.60 11/1/2015
MEDICAL
SUPPLIER
(DME) K0860 0 999 Years $9,804.76 3/1/2012 0.00 $9,804.76 11/1/2015 $980.48 3/1/2012 0.00 980.48 11/1/2015
MEDICAL
SUPPLIER
(DME) K0861 0 999 Years $5,226.89 3/1/2012 0.00 $5,226.89 11/1/2015 $543.60 3/1/2012 0.00 543.60 11/1/2015
MEDICAL
SUPPLIER
(DME) K0862 0 999 Years $6,863.07 3/1/2012 0.00 $6,863.07 11/1/2015 $686.31 3/1/2012 0.00 686.31 11/1/2015
MEDICAL
SUPPLIER
(DME) K0863 0 999 Years $9,804.76 3/1/2012 0.00 $9,804.76 11/1/2015 $980.48 3/1/2012 0.00 980.48 11/1/2015
MEDICAL
SUPPLIER
(DME) K0864 0 999 Years $11,667.78 3/1/2012 0.00 $11,667.78 11/1/2015 $1,166.77 3/1/2012 0.00 1,166.77 11/1/2015
MEDICAL
SUPPLIER
(DME) K0868 0 999 Years $0.00 12/1/2006 $0.00 5 11/1/2015 $0.00 3/1/2012 0.00 5 11/1/2015
MEDICAL
SUPPLIER
(DME) K0869 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $261.09 3/1/2012 0.00 261.09 11/1/2015
MEDICAL
SUPPLIER
(DME) K0870 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $0.00 10/1/2009 0.00 5 11/1/2015
MEDICAL
SUPPLIER
(DME) K0871 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $0.00 10/1/2009 0.00 5 11/1/2015
MEDICAL
SUPPLIER
(DME) K0877 0 999 Years $0.00 3/1/2012 $0.00 5 11/1/2015 $275.87 3/1/2012 0.00 275.87 11/1/2015
MEDICAL
SUPPLIER
(DME) K0878 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $0.00 10/1/2009 0.00 5 11/1/2015
MEDICAL
SUPPLIER
(DME) K0879 0 999 Years $0.00 3/1/2012 $0.00 5 11/1/2015 $529.74 3/1/2012 0.00 529.74 11/1/2015
MEDICAL
SUPPLIER
(DME) K0880 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $824.92 3/1/2012 0.00 824.92 11/1/2015
MEDICAL
SUPPLIER
(DME) K0884 0 999 Years $0.00 3/1/2012 $0.00 5 11/1/2015 $0.00 3/1/2012 0.00 5 11/1/2015
MEDICAL
SUPPLIER
(DME) K0885 0 999 Years $5,889.23 3/1/2012 0.00 $5,889.23 11/1/2015 $588.93 3/1/2012 0.00 588.93 11/1/2015
MEDICAL
SUPPLIER
(DME) K0886 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $543.92 3/1/2012 0.00 543.92 11/1/2015
MEDICAL
SUPPLIER
(DME) K0890 0 999 Years $9,197.50 10/1/2009 -8.00 $8,461.70 11/1/2015 $919.75 10/1/2009 -8.00 846.17 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) K0891 0 999 Years $10,981.85 3/1/2012 0.00 $10,981.85 11/1/2015 $1,218.04 10/1/2009 -8.00 1,120.60 11/1/2015
MEDICAL
SUPPLIER
(DME) K0898 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $0.00 10/1/2009 0.00 5 11/1/2015
MEDICAL
SUPPLIER
(DME) K0899 0 999 Years $0.00 10/1/2009 $0.00 5 11/1/2015 $0.00 10/1/2009 0.00 5 11/1/2015
MEDICAL
SUPPLIER
(DME) K0900 0 999 Years $0.00 4/1/2014 -2.00 $0.00 11/1/2015 $0.00 4/1/2014 -2.00 0.00 11/1/2015
MEDICAL
SUPPLIER
(DME) L8614 1 999 Years $23,380.00 4/1/2015 0.00 $23,380.00 10/1/2016
MEDICAL
SUPPLIER
(DME) L8681 0 999 Years $926.72 1/1/2008 0.00 $926.72 10/1/2016
MEDICAL
SUPPLIER
(DME) L8682 0 999 Years $5,178.47 1/1/2008 0.00 $5,178.47 10/1/2016
MEDICAL
SUPPLIER
(DME) L8683 0 999 Years $4,558.23 1/1/2008 0.00 $4,558.23 10/1/2016
MEDICAL
SUPPLIER
(DME) L8684 0 999 Years $670.64 1/1/2008 0.00 $670.64 10/1/2016
MEDICAL
SUPPLIER
(DME) L8685 0 999 Years $11,358.87 1/1/2008 0.00 $11,358.87 10/1/2016
MEDICAL
SUPPLIER
(DME) L8686 0 999 Years $6,885.47 10/1/2016 0.00 $6,885.47 10/1/2016
MEDICAL
SUPPLIER
(DME) L8686 TG 0 999 Years $14,968.49 10/1/2016 0.00 $14,968.49 10/1/2016
MEDICAL
SUPPLIER
(DME) L8687 0 999 Years $14,043.32 10/1/2016 0.00 $14,043.32 10/1/2016
MEDICAL
SUPPLIER
(DME) L8688 0 999 Years $8,960.75 10/1/2016 0.00 $8,960.75 10/1/2016
MEDICAL
SUPPLIER
(DME) L8689 0 999 Years $1,498.34 1/1/2008 0.00 $1,498.34 10/1/2016
MEDICAL
SUPPLIER
(DME) L8690 5 999 Years $4,338.80 7/1/2010 0.00 $4,338.80 10/1/2016
MEDICAL
SUPPLIER
(DME) L8691 5 999 Years $2,432.05 7/1/2010 0.00 $2,432.05 10/1/2016
MEDICAL
SUPPLIER
(DME) L8692 5 999 Years $3,321.00 10/1/2012 0.00 $3,321.00 10/1/2016
MEDICAL
SUPPLIER
(DME) L8693 5 999 Years $1,414.77 10/1/2012 0.00 $1,414.77 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1 2 3 1 2 3
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) L8695 0 999 Years $11.86 10/1/2014 0.00 $11.86 10/1/2016
MEDICAL
SUPPLIER
(DME) Q0480 0 20 Years $77,927.47 1/1/2016 0.00 $77,927.47 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0481 0 20 Years $12,572.70 1/1/2016 0.00 $12,572.70 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0482 0 20 Years $3,938.00 1/1/2016 0.00 $3,938.00 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0483 0 20 Years $17,280.81 1/1/2016 0.00 $17,280.81 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0484 0 20 Years $3,355.87 1/1/2016 0.00 $3,355.87 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0485 0 20 Years $324.02 1/1/2016 0.00 $324.02 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0486 0 20 Years $269.66 1/1/2016 0.00 $269.66 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0487 0 20 Years $314.62 1/1/2016 0.00 $314.62 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0488 0 20 Years $12,054.00 1/1/2016 0.00 $12,054.00 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0489 0 20 Years $14,064.31 1/1/2016 0.00 $14,064.31 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0490 0 20 Years $648.04 1/1/2016 0.00 $648.04 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0491 0 20 Years $1,018.76 1/1/2016 0.00 $1,018.76 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0492 0 20 Years $82.09 1/1/2016 0.00 $82.09 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0493 0 20 Years $233.68 1/1/2016 0.00 $233.68 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0494 0 20 Years $197.73 1/1/2016 0.00 $197.73 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0495 0 20 Years $3,614.17 1/1/2016 0.00 $3,614.17 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0496 0 20 Years $1,297.16 1/1/2016 0.00 $1,297.16 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0497 0 20 Years $405.04 1/1/2016 0.00 $405.04 6 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1 2 3 1 2 3
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLIER
(DME) Q0498 0 20 Years $473.40 1/1/2016 0.00 $473.40 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0499 0 20 Years $153.82 1/1/2016 0.00 $153.82 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0500 0 20 Years $26.42 1/1/2016 0.00 $26.42 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0501 0 20 Years $441.89 1/1/2016 0.00 $441.89 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0502 0 20 Years $599.24 1/1/2016 0.00 $599.24 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0503 0 20 Years $1,198.54 1/1/2016 0.00 $1,198.54 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0504 0 20 Years $632.41 1/1/2016 0.00 $632.41 6 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0507 0 999 Years $0.00 7/1/2013 $0.00 5 1/1/2016
MEDICAL
SUPPLIER
(DME) Q0508 0 999 Years $0.00 7/1/2013 $0.00 5 1/1/2016
MEDICAL
SUPPLIER
(DME) S8185 0 999 Years $61.50 4/1/2015 0.00 $61.50 4/1/2015
MEDICAL
SUPPLIER
(DME) S8189 0 999 Years $0.00 5/1/2003 $0.00 5 4/1/2015
MEDICAL
SUPPLIER
(DME) S8270 5 20 Years $64.31 1/1/2010 0.00 $64.31 4/1/2015
MEDICAL
SUPPLIER
(DME) S8999 0 999 Years $58.26 1/1/2010 0.00 $58.26 4/1/2015
MEDICAL
SUPPLY
COMPANY B9004 0 999 Years $2,836.83 1/1/2014 0.00 $2,836.83 1/1/2016 $449.08 1/1/2014 0.00 449.08 1/1/2016
MEDICAL
SUPPLY
COMPANY B9006 0 999 Years $2,836.83 1/1/2014 0.00 $2,836.83 1/1/2016 $449.08 1/1/2014 0.00 449.08 1/1/2016
MEDICAL
SUPPLY
COMPANY E0162 0 999 Years $119.64 4/1/2013 0.00 $119.64 4/1/2015 $11.96 4/1/2015 0.00 11.96 4/1/2015
MEDICAL
SUPPLY
COMPANY E0181 0 999 Years $251.71 4/1/2013 0.00 $251.71 4/1/2015 $25.17 4/1/2013 0.00 25.17 4/1/2015
MEDICAL
SUPPLY
COMPANY E0182 0 999 Years $17.98 4/1/2013 0.00 17.98 4/1/2015
MEDICAL
SUPPLY
COMPANY E0210 0 999 Years $24.09 4/1/2013 0.00 $24.09 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLY
COMPANY E0225 0 999 Years $37.01 4/1/2013 0.00 37.01 4/1/2015
MEDICAL
SUPPLY
COMPANY E0235 0 999 Years $166.70 4/1/2013 0.00 $166.70 4/1/2015 $16.67 4/1/2013 0.00 16.67 4/1/2015
MEDICAL
SUPPLY
COMPANY E0236 0 999 Years $427.43 4/1/2013 0.00 $427.43 4/1/2015
MEDICAL
SUPPLY
COMPANY E0250 0 999 Years $738.59 4/1/2013 0.00 $738.59 4/1/2015
MEDICAL
SUPPLY
COMPANY E0325 0 999 Years $1.12 4/1/2015 0.00 1.12 4/1/2015
MEDICAL
SUPPLY
COMPANY E0550 0 999 Years $427.43 4/1/2013 0.00 $427.43 4/1/2015 $42.74 4/1/2013 0.00 42.74 4/1/2015
MEDICAL
SUPPLY
COMPANY E0710 0 999 Years $31.80 4/1/2013 0.00 $31.80 4/1/2015 $3.18 4/1/2013 0.00 3.18 4/1/2015
MEDICAL
SUPPLY
COMPANY E0776 0 999 Years $79.62 4/1/2013 0.00 $79.62 4/1/2015 $7.96 4/1/2015 0.00 7.96 4/1/2015
MEDICAL
SUPPLY
COMPANY E0781 0 999 Years $2,106.90 4/1/2013 0.00 $2,106.90 4/1/2015 $210.69 4/1/2013 0.00 210.69 4/1/2015
MEDICAL
SUPPLY
COMPANY E0791 0 999 Years $3,054.49 4/1/2013 0.00 $3,054.49 4/1/2015 $305.45 4/1/2013 0.00 305.45 4/1/2015
MEDICAL
SUPPLY
COMPANY E0840 0 999 Years $53.11 4/1/2013 0.00 $53.11 4/1/2015 $5.31 4/1/2015 0.00 5.31 4/1/2015
MEDICAL
SUPPLY
COMPANY E0850 0 999 Years $82.50 4/1/2013 0.00 $82.50 4/1/2015 $8.25 4/1/2015 0.00 8.25 4/1/2015
MEDICAL
SUPPLY
COMPANY E0855 0 999 Years $461.97 4/1/2013 0.00 $461.97 4/1/2015 $46.20 4/1/2015 0.00 46.20 4/1/2015
MEDICAL
SUPPLY
COMPANY E0860 0 999 Years $24.82 4/1/2013 0.00 $24.82 4/1/2015 $2.48 4/1/2015 0.00 2.48 4/1/2015
MEDICAL
SUPPLY
COMPANY E0880 0 999 Years $89.85 4/1/2013 0.00 $89.85 4/1/2015 $8.99 4/1/2015 0.00 8.99 4/1/2015
MEDICAL
SUPPLY
COMPANY E0900 0 999 Years $90.45 4/1/2013 0.00 $90.45 4/1/2015 $9.05 4/1/2015 0.00 9.05 4/1/2015
MEDICAL
SUPPLY
COMPANY E0930 0 999 Years $441.32 4/1/2013 0.00 $441.32 4/1/2015 $44.13 4/1/2013 0.00 44.13 4/1/2015
MEDICAL
SUPPLY
COMPANY E0935 0 999 Years $19.81 4/1/2013 0.00 19.81 4/1/2015
MEDICAL
SUPPLY
COMPANY E0941 0 999 Years $419.34 4/1/2013 0.00 $419.34 4/1/2015 $41.93 4/1/2013 0.00 41.93 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
MEDICAL
SUPPLY
COMPANY E1031 0 999 Years $41.92 4/1/2013 0.00 41.92 4/1/2015
MEDICAL
SUPPLY
COMPANY E1300 0 20 Years $156.40 4/1/2013 0.00 $156.40 6 4/1/2015 $15.64 4/1/2013 0.00 15.64 6 4/1/2015
MEDICAL
SUPPLY
COMPANY E1310 0 20 Years $2,074.39 4/1/2013 0.00 $2,074.39 6 4/1/2015
MEDICAL
SUPPLY
COMPANY E1635 0 20 Years $616.30 4/1/2013 0.00 616.30 6 4/1/2013
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2020 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2025 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2100 0 999 Years $19.94 7/1/2014 0.00 $19.94 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2101 0 999 Years $23.78 7/1/2014 0.00 $23.78 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2102 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2102 VP 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2103 0 999 Years $15.73 7/1/2014 0.00 $15.73 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2104 0 999 Years $18.59 7/1/2014 0.00 $18.59 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2105 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2105 VP 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2106 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2106 VP 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2107 0 999 Years $23.45 7/1/2014 0.00 $23.45 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2108 0 999 Years $23.01 7/1/2014 0.00 $23.01 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2109 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2109 VP 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2110 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2110 VP 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2111 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2111 VP 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2112 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2112 VP 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2113 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2113 VP 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2114 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2114 VP 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2115 0 999 Years $42.62 7/1/2014 0.00 $42.62 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2118 0 999 Years $33.76 7/1/2014 0.00 $33.76 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2121 0 999 Years $43.62 7/1/2014 0.00 $43.62 6 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2200 0 999 Years $25.59 7/1/2014 0.00 $25.59 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2201 0 999 Years $26.95 7/1/2014 0.00 $26.95 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2202 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2202 VP 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2203 0 999 Years $25.13 7/1/2014 0.00 $25.13 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2204 0 999 Years $25.58 7/1/2014 0.00 $25.58 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2205 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2205 VP 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2206 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2206 VP 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2207 0 999 Years $25.42 7/1/2014 0.00 $25.42 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2208 0 999 Years $28.21 7/1/2014 0.00 $28.21 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2209 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 254
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2209 VP 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2210 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2210 VP 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2211 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2211 VP 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2212 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2212 VP 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2213 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2213 VP 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2214 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2214 VP 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 255
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2215 0 999 Years $41.26 7/1/2014 0.00 $41.26 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2218 0 999 Years $43.71 7/1/2014 0.00 $43.71 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2219 0 999 Years $22.22 7/1/2014 0.00 $22.22 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2220 0 999 Years $20.34 7/1/2014 0.00 $20.34 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2221 0 999 Years $43.45 7/1/2014 0.00 $43.45 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2300 0 999 Years $33.41 7/1/2014 0.00 $33.41 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2301 0 999 Years $43.76 7/1/2014 0.00 $43.76 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2302 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2302 VP 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2303 0 999 Years $31.75 7/1/2014 0.00 $31.75 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2304 0 999 Years $31.00 7/1/2014 0.00 $31.00 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 256
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2305 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2305 VP 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2306 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2306 VP 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2307 0 999 Years $34.72 7/1/2014 0.00 $34.72 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2308 0 999 Years $36.12 7/1/2014 0.00 $36.12 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2309 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2309 VP 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2310 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2310 VP 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2311 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 257
10/14/2016 257 of 299TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2311 VP 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2312 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2312 VP 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2313 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2313 VP 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2314 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2314 VP 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2315 0 999 Years $54.92 7/1/2014 0.00 $54.92 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2318 0 999 Years $63.39 7/1/2014 0.00 $63.39 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2319 0 999 Years $24.22 7/1/2014 0.00 $24.22 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2320 0 999 Years $30.19 7/1/2014 0.00 $30.19 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 258
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2321 0 20 Years $51.41 7/1/2014 0.00 $51.41 6 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2410 0 999 Years $45.71 7/1/2014 0.00 $45.71 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2430 0 999 Years $52.95 7/1/2014 0.00 $52.95 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2500 0 999 Years $43.91 7/1/2014 0.00 $43.91 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2501 0 999 Years $53.50 7/1/2014 0.00 $53.50 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2502 0 999 Years $65.91 7/1/2014 0.00 $65.91 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2510 0 999 Years $63.40 7/1/2014 0.00 $63.40 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2511 0 999 Years $82.23 7/1/2014 0.00 $82.23 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2512 0 999 Years $108.54 7/1/2014 0.00 $108.54 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2513 0 999 Years $91.12 7/1/2014 0.00 $91.12 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2520 0 999 Years $54.56 7/1/2014 0.00 $54.56 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 259
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2521 0 999 Years $83.43 7/1/2014 0.00 $83.43 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2522 0 999 Years $101.81 7/1/2014 0.00 $101.81 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2523 0 999 Years $79.53 7/1/2014 0.00 $79.53 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2530 0 999 Years $122.85 7/1/2014 0.00 $122.85 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2531 0 999 Years $236.58 7/1/2014 0.00 $236.58 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2599 0 999 Years $0.00 4/1/2010 -8.00 $0.00 5 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2700 0 999 Years $22.89 7/1/2014 0.00 $22.89 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2710 0 999 Years $34.37 7/1/2014 0.00 $34.37 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2715 0 999 Years $5.67 7/1/2014 0.00 $5.67 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2718 0 999 Years $14.09 7/1/2014 0.00 $14.09 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2730 0 999 Years $24.30 7/1/2014 0.00 $24.30 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 260
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2755 0 999 Years $19.15 7/1/2014 0.00 $19.15 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2770 0 999 Years $9.25 7/1/2014 0.00 $9.25 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2780 0 999 Years $5.41 7/1/2014 0.00 $5.41 7/1/2016
OPTICIAN OR
DISPENSING
OPTICAL
COMPANY V2784 0 999 Years $41.25 7/1/2014 0.00 $41.25 7/1/2016
OPTOMETRIC
GROUP S0515 0 999 Years $0.00 4/1/2010 $0.00 5 4/1/2015
OPTOMETRIC
GROUP V2020 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
OPTOMETRIC
GROUP V2025 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
OPTOMETRIC
GROUP V2100 0 999 Years $19.94 7/1/2014 0.00 $19.94 7/1/2016
OPTOMETRIC
GROUP V2101 0 999 Years $23.78 7/1/2014 0.00 $23.78 7/1/2016
OPTOMETRIC
GROUP V2102 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
OPTOMETRIC
GROUP V2102 VP 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
OPTOMETRIC
GROUP V2103 0 999 Years $15.73 7/1/2014 0.00 $15.73 7/1/2016
OPTOMETRIC
GROUP V2104 0 999 Years $18.59 7/1/2014 0.00 $18.59 7/1/2016
OPTOMETRIC
GROUP V2105 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
OPTOMETRIC
GROUP V2105 VP 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
OPTOMETRIC
GROUP V2106 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
OPTOMETRIC
GROUP V2106 VP 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
OPTOMETRIC
GROUP V2107 0 999 Years $23.45 7/1/2014 0.00 $23.45 7/1/2016
OPTOMETRIC
GROUP V2108 0 999 Years $23.01 7/1/2014 0.00 $23.01 7/1/2016
OPTOMETRIC
GROUP V2109 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
OPTOMETRIC
GROUP V2109 VP 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
OPTOMETRIC
GROUP V2110 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 261
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTOMETRIC
GROUP V2110 VP 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
OPTOMETRIC
GROUP V2111 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
OPTOMETRIC
GROUP V2111 VP 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
OPTOMETRIC
GROUP V2112 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
OPTOMETRIC
GROUP V2112 VP 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
OPTOMETRIC
GROUP V2113 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
OPTOMETRIC
GROUP V2113 VP 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
OPTOMETRIC
GROUP V2114 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
OPTOMETRIC
GROUP V2114 VP 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
OPTOMETRIC
GROUP V2115 0 999 Years $42.62 7/1/2014 0.00 $42.62 7/1/2016
OPTOMETRIC
GROUP V2118 0 999 Years $33.76 7/1/2014 0.00 $33.76 7/1/2016
OPTOMETRIC
GROUP V2121 0 999 Years $43.62 7/1/2014 0.00 $43.62 6 7/1/2016
OPTOMETRIC
GROUP V2200 0 999 Years $25.59 7/1/2014 0.00 $25.59 7/1/2016
OPTOMETRIC
GROUP V2201 0 999 Years $26.95 7/1/2014 0.00 $26.95 7/1/2016
OPTOMETRIC
GROUP V2202 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
OPTOMETRIC
GROUP V2202 VP 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
OPTOMETRIC
GROUP V2203 0 999 Years $25.13 7/1/2014 0.00 $25.13 7/1/2016
OPTOMETRIC
GROUP V2204 0 999 Years $25.58 7/1/2014 0.00 $25.58 7/1/2016
OPTOMETRIC
GROUP V2205 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
OPTOMETRIC
GROUP V2205 VP 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
OPTOMETRIC
GROUP V2206 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
OPTOMETRIC
GROUP V2206 VP 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
OPTOMETRIC
GROUP V2207 0 999 Years $25.42 7/1/2014 0.00 $25.42 7/1/2016
OPTOMETRIC
GROUP V2208 0 999 Years $28.21 7/1/2014 0.00 $28.21 7/1/2016
OPTOMETRIC
GROUP V2209 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
OPTOMETRIC
GROUP V2209 VP 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
OPTOMETRIC
GROUP V2210 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
OPTOMETRIC
GROUP V2210 VP 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 262
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTOMETRIC
GROUP V2211 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
OPTOMETRIC
GROUP V2211 VP 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
OPTOMETRIC
GROUP V2212 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
OPTOMETRIC
GROUP V2212 VP 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
OPTOMETRIC
GROUP V2213 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
OPTOMETRIC
GROUP V2213 VP 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
OPTOMETRIC
GROUP V2214 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
OPTOMETRIC
GROUP V2214 VP 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
OPTOMETRIC
GROUP V2215 0 999 Years $41.26 7/1/2014 0.00 $41.26 7/1/2016
OPTOMETRIC
GROUP V2218 0 999 Years $43.71 7/1/2014 0.00 $43.71 7/1/2016
OPTOMETRIC
GROUP V2219 0 999 Years $22.22 7/1/2014 0.00 $22.22 7/1/2016
OPTOMETRIC
GROUP V2220 0 999 Years $20.34 7/1/2014 0.00 $20.34 7/1/2016
OPTOMETRIC
GROUP V2221 0 999 Years $43.45 7/1/2014 0.00 $43.45 7/1/2016
OPTOMETRIC
GROUP V2300 0 999 Years $33.41 7/1/2014 0.00 $33.41 7/1/2016
OPTOMETRIC
GROUP V2301 0 999 Years $43.76 7/1/2014 0.00 $43.76 7/1/2016
OPTOMETRIC
GROUP V2302 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
OPTOMETRIC
GROUP V2302 VP 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
OPTOMETRIC
GROUP V2303 0 999 Years $31.75 7/1/2014 0.00 $31.75 7/1/2016
OPTOMETRIC
GROUP V2304 0 999 Years $31.00 7/1/2014 0.00 $31.00 7/1/2016
OPTOMETRIC
GROUP V2305 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
OPTOMETRIC
GROUP V2305 VP 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
OPTOMETRIC
GROUP V2306 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
OPTOMETRIC
GROUP V2306 VP 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
OPTOMETRIC
GROUP V2307 0 999 Years $34.72 7/1/2014 0.00 $34.72 7/1/2016
OPTOMETRIC
GROUP V2308 0 999 Years $36.12 7/1/2014 0.00 $36.12 7/1/2016
OPTOMETRIC
GROUP V2309 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
OPTOMETRIC
GROUP V2309 VP 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
OPTOMETRIC
GROUP V2310 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTOMETRIC
GROUP V2310 VP 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
OPTOMETRIC
GROUP V2311 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
OPTOMETRIC
GROUP V2311 VP 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
OPTOMETRIC
GROUP V2312 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
OPTOMETRIC
GROUP V2312 VP 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
OPTOMETRIC
GROUP V2313 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
OPTOMETRIC
GROUP V2313 VP 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
OPTOMETRIC
GROUP V2314 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
OPTOMETRIC
GROUP V2314 VP 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
OPTOMETRIC
GROUP V2315 0 999 Years $54.92 7/1/2014 0.00 $54.92 7/1/2016
OPTOMETRIC
GROUP V2318 0 999 Years $63.39 7/1/2014 0.00 $63.39 7/1/2016
OPTOMETRIC
GROUP V2319 0 999 Years $24.22 7/1/2014 0.00 $24.22 7/1/2016
OPTOMETRIC
GROUP V2320 0 999 Years $30.19 7/1/2014 0.00 $30.19 7/1/2016
OPTOMETRIC
GROUP V2321 0 20 Years $51.41 7/1/2014 0.00 $51.41 6 7/1/2016
OPTOMETRIC
GROUP V2410 0 999 Years $45.71 7/1/2014 0.00 $45.71 7/1/2016
OPTOMETRIC
GROUP V2430 0 999 Years $52.95 7/1/2014 0.00 $52.95 7/1/2016
OPTOMETRIC
GROUP V2500 0 999 Years $43.91 7/1/2014 0.00 $43.91 7/1/2016
OPTOMETRIC
GROUP V2501 0 999 Years $53.50 7/1/2014 0.00 $53.50 7/1/2016
OPTOMETRIC
GROUP V2502 0 999 Years $65.91 7/1/2014 0.00 $65.91 7/1/2016
OPTOMETRIC
GROUP V2510 0 999 Years $63.40 7/1/2014 0.00 $63.40 7/1/2016
OPTOMETRIC
GROUP V2511 0 999 Years $82.23 7/1/2014 0.00 $82.23 7/1/2016
OPTOMETRIC
GROUP V2512 0 999 Years $108.54 7/1/2014 0.00 $108.54 7/1/2016
OPTOMETRIC
GROUP V2513 0 999 Years $91.12 7/1/2014 0.00 $91.12 7/1/2016
OPTOMETRIC
GROUP V2520 0 999 Years $54.56 7/1/2014 0.00 $54.56 7/1/2016
OPTOMETRIC
GROUP V2521 0 999 Years $83.43 7/1/2014 0.00 $83.43 7/1/2016
OPTOMETRIC
GROUP V2522 0 999 Years $101.81 7/1/2014 0.00 $101.81 7/1/2016
OPTOMETRIC
GROUP V2523 0 999 Years $79.53 7/1/2014 0.00 $79.53 7/1/2016
OPTOMETRIC
GROUP V2530 0 999 Years $122.85 7/1/2014 0.00 $122.85 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTOMETRIC
GROUP V2531 0 999 Years $236.58 7/1/2014 0.00 $236.58 7/1/2016
OPTOMETRIC
GROUP V2599 0 999 Years $0.00 4/1/2010 -8.00 $0.00 5 7/1/2016
OPTOMETRIC
GROUP V2700 0 999 Years $22.89 7/1/2014 0.00 $22.89 7/1/2016
OPTOMETRIC
GROUP V2710 0 999 Years $34.37 7/1/2014 0.00 $34.37 7/1/2016
OPTOMETRIC
GROUP V2715 0 999 Years $5.67 7/1/2014 0.00 $5.67 7/1/2016
OPTOMETRIC
GROUP V2718 0 999 Years $14.09 7/1/2014 0.00 $14.09 7/1/2016
OPTOMETRIC
GROUP V2730 0 999 Years $24.30 7/1/2014 0.00 $24.30 7/1/2016
OPTOMETRIC
GROUP V2755 0 999 Years $19.15 7/1/2014 0.00 $19.15 7/1/2016
OPTOMETRIC
GROUP V2770 0 999 Years $9.25 7/1/2014 0.00 $9.25 7/1/2016
OPTOMETRIC
GROUP V2780 0 999 Years $5.41 7/1/2014 0.00 $5.41 7/1/2016
OPTOMETRIC
GROUP V2784 0 999 Years $41.25 7/1/2014 0.00 $41.25 7/1/2016
OPTOMETRIS
T S0515 0 999 Years $0.00 4/1/2010 $0.00 5 4/1/2015
OPTOMETRIS
T V2020 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
OPTOMETRIS
T V2025 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
OPTOMETRIS
T V2100 0 999 Years $19.94 7/1/2014 0.00 $19.94 7/1/2016
OPTOMETRIS
T V2101 0 999 Years $23.78 7/1/2014 0.00 $23.78 7/1/2016
OPTOMETRIS
T V2102 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
OPTOMETRIS
T V2102 VP 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
OPTOMETRIS
T V2103 0 999 Years $15.73 7/1/2014 0.00 $15.73 7/1/2016
OPTOMETRIS
T V2104 0 999 Years $18.59 7/1/2014 0.00 $18.59 7/1/2016
OPTOMETRIS
T V2105 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
OPTOMETRIS
T V2105 VP 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
OPTOMETRIS
T V2106 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
OPTOMETRIS
T V2106 VP 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
OPTOMETRIS
T V2107 0 999 Years $23.45 7/1/2014 0.00 $23.45 7/1/2016
OPTOMETRIS
T V2108 0 999 Years $23.01 7/1/2014 0.00 $23.01 7/1/2016
OPTOMETRIS
T V2109 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
OPTOMETRIS
T V2109 VP 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTOMETRIS
T V2110 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
OPTOMETRIS
T V2110 VP 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
OPTOMETRIS
T V2111 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
OPTOMETRIS
T V2111 VP 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
OPTOMETRIS
T V2112 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
OPTOMETRIS
T V2112 VP 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
OPTOMETRIS
T V2113 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
OPTOMETRIS
T V2113 VP 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
OPTOMETRIS
T V2114 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
OPTOMETRIS
T V2114 VP 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
OPTOMETRIS
T V2115 0 999 Years $42.62 7/1/2014 0.00 $42.62 7/1/2016
OPTOMETRIS
T V2118 0 999 Years $33.76 7/1/2014 0.00 $33.76 7/1/2016
OPTOMETRIS
T V2121 0 999 Years $43.62 7/1/2014 0.00 $43.62 6 7/1/2016
OPTOMETRIS
T V2200 0 999 Years $25.59 7/1/2014 0.00 $25.59 7/1/2016
OPTOMETRIS
T V2201 0 999 Years $26.95 7/1/2014 0.00 $26.95 7/1/2016
OPTOMETRIS
T V2202 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
OPTOMETRIS
T V2202 VP 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
OPTOMETRIS
T V2203 0 999 Years $25.13 7/1/2014 0.00 $25.13 7/1/2016
OPTOMETRIS
T V2204 0 999 Years $25.58 7/1/2014 0.00 $25.58 7/1/2016
OPTOMETRIS
T V2205 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
OPTOMETRIS
T V2205 VP 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
OPTOMETRIS
T V2206 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
OPTOMETRIS
T V2206 VP 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
OPTOMETRIS
T V2207 0 999 Years $25.42 7/1/2014 0.00 $25.42 7/1/2016
OPTOMETRIS
T V2208 0 999 Years $28.21 7/1/2014 0.00 $28.21 7/1/2016
OPTOMETRIS
T V2209 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
OPTOMETRIS
T V2209 VP 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
OPTOMETRIS
T V2210 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTOMETRIS
T V2210 VP 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
OPTOMETRIS
T V2211 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
OPTOMETRIS
T V2211 VP 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
OPTOMETRIS
T V2212 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
OPTOMETRIS
T V2212 VP 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
OPTOMETRIS
T V2213 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
OPTOMETRIS
T V2213 VP 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
OPTOMETRIS
T V2214 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
OPTOMETRIS
T V2214 VP 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
OPTOMETRIS
T V2215 0 999 Years $41.26 7/1/2014 0.00 $41.26 7/1/2016
OPTOMETRIS
T V2218 0 999 Years $43.71 7/1/2014 0.00 $43.71 7/1/2016
OPTOMETRIS
T V2219 0 999 Years $22.22 7/1/2014 0.00 $22.22 7/1/2016
OPTOMETRIS
T V2220 0 999 Years $20.34 7/1/2014 0.00 $20.34 7/1/2016
OPTOMETRIS
T V2221 0 999 Years $43.45 7/1/2014 0.00 $43.45 7/1/2016
OPTOMETRIS
T V2300 0 999 Years $33.41 7/1/2014 0.00 $33.41 7/1/2016
OPTOMETRIS
T V2301 0 999 Years $43.76 7/1/2014 0.00 $43.76 7/1/2016
OPTOMETRIS
T V2302 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
OPTOMETRIS
T V2302 VP 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
OPTOMETRIS
T V2303 0 999 Years $31.75 7/1/2014 0.00 $31.75 7/1/2016
OPTOMETRIS
T V2304 0 999 Years $31.00 7/1/2014 0.00 $31.00 7/1/2016
OPTOMETRIS
T V2305 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
OPTOMETRIS
T V2305 VP 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
OPTOMETRIS
T V2306 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
OPTOMETRIS
T V2306 VP 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
OPTOMETRIS
T V2307 0 999 Years $34.72 7/1/2014 0.00 $34.72 7/1/2016
OPTOMETRIS
T V2308 0 999 Years $36.12 7/1/2014 0.00 $36.12 7/1/2016
OPTOMETRIS
T V2309 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
OPTOMETRIS
T V2309 VP 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTOMETRIS
T V2310 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
OPTOMETRIS
T V2310 VP 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
OPTOMETRIS
T V2311 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
OPTOMETRIS
T V2311 VP 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
OPTOMETRIS
T V2312 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
OPTOMETRIS
T V2312 VP 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
OPTOMETRIS
T V2313 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
OPTOMETRIS
T V2313 VP 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
OPTOMETRIS
T V2314 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
OPTOMETRIS
T V2314 VP 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
OPTOMETRIS
T V2315 0 999 Years $54.92 7/1/2014 0.00 $54.92 7/1/2016
OPTOMETRIS
T V2318 0 999 Years $63.39 7/1/2014 0.00 $63.39 7/1/2016
OPTOMETRIS
T V2319 0 999 Years $24.22 7/1/2014 0.00 $24.22 7/1/2016
OPTOMETRIS
T V2320 0 999 Years $30.19 7/1/2014 0.00 $30.19 7/1/2016
OPTOMETRIS
T V2321 0 20 Years $51.41 7/1/2014 0.00 $51.41 6 7/1/2016
OPTOMETRIS
T V2410 0 999 Years $45.71 7/1/2014 0.00 $45.71 7/1/2016
OPTOMETRIS
T V2430 0 999 Years $52.95 7/1/2014 0.00 $52.95 7/1/2016
OPTOMETRIS
T V2500 0 999 Years $43.91 7/1/2014 0.00 $43.91 7/1/2016
OPTOMETRIS
T V2501 0 999 Years $53.50 7/1/2014 0.00 $53.50 7/1/2016
OPTOMETRIS
T V2502 0 999 Years $65.91 7/1/2014 0.00 $65.91 7/1/2016
OPTOMETRIS
T V2510 0 999 Years $63.40 7/1/2014 0.00 $63.40 7/1/2016
OPTOMETRIS
T V2511 0 999 Years $82.23 7/1/2014 0.00 $82.23 7/1/2016
OPTOMETRIS
T V2512 0 999 Years $108.54 7/1/2014 0.00 $108.54 7/1/2016
OPTOMETRIS
T V2513 0 999 Years $91.12 7/1/2014 0.00 $91.12 7/1/2016
OPTOMETRIS
T V2520 0 999 Years $54.56 7/1/2014 0.00 $54.56 7/1/2016
OPTOMETRIS
T V2521 0 999 Years $83.43 7/1/2014 0.00 $83.43 7/1/2016
OPTOMETRIS
T V2522 0 999 Years $101.81 7/1/2014 0.00 $101.81 7/1/2016
OPTOMETRIS
T V2523 0 999 Years $79.53 7/1/2014 0.00 $79.53 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
OPTOMETRIS
T V2530 0 999 Years $122.85 7/1/2014 0.00 $122.85 7/1/2016
OPTOMETRIS
T V2531 0 999 Years $236.58 7/1/2014 0.00 $236.58 7/1/2016
OPTOMETRIS
T V2599 0 999 Years $0.00 4/1/2010 -8.00 $0.00 5 7/1/2016
OPTOMETRIS
T V2700 0 999 Years $22.89 7/1/2014 0.00 $22.89 7/1/2016
OPTOMETRIS
T V2710 0 999 Years $34.37 7/1/2014 0.00 $34.37 7/1/2016
OPTOMETRIS
T V2715 0 999 Years $5.67 7/1/2014 0.00 $5.67 7/1/2016
OPTOMETRIS
T V2718 0 999 Years $14.09 7/1/2014 0.00 $14.09 7/1/2016
OPTOMETRIS
T V2730 0 999 Years $24.30 7/1/2014 0.00 $24.30 7/1/2016
OPTOMETRIS
T V2755 0 999 Years $19.15 7/1/2014 0.00 $19.15 7/1/2016
OPTOMETRIS
T V2770 0 999 Years $9.25 7/1/2014 0.00 $9.25 7/1/2016
OPTOMETRIS
T V2780 0 999 Years $5.41 7/1/2014 0.00 $5.41 7/1/2016
OPTOMETRIS
T V2784 0 999 Years $41.25 7/1/2014 0.00 $41.25 7/1/2016
PHYSICIAN
(D.O.) S0515 0 999 Years $0.00 4/1/2010 $0.00 5 4/1/2015
PHYSICIAN
(D.O.) V2020 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
PHYSICIAN
(D.O.) V2025 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
PHYSICIAN
(D.O.) V2100 0 999 Years $19.94 7/1/2014 0.00 $19.94 7/1/2016
PHYSICIAN
(D.O.) V2101 0 999 Years $23.78 7/1/2014 0.00 $23.78 7/1/2016
PHYSICIAN
(D.O.) V2102 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
PHYSICIAN
(D.O.) V2102 VP 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
PHYSICIAN
(D.O.) V2103 0 999 Years $15.73 7/1/2014 0.00 $15.73 7/1/2016
PHYSICIAN
(D.O.) V2104 0 999 Years $18.59 7/1/2014 0.00 $18.59 7/1/2016
PHYSICIAN
(D.O.) V2105 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
PHYSICIAN
(D.O.) V2105 VP 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
PHYSICIAN
(D.O.) V2106 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
PHYSICIAN
(D.O.) V2106 VP 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
PHYSICIAN
(D.O.) V2107 0 999 Years $23.45 7/1/2014 0.00 $23.45 7/1/2016
PHYSICIAN
(D.O.) V2108 0 999 Years $23.01 7/1/2014 0.00 $23.01 7/1/2016
PHYSICIAN
(D.O.) V2109 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
(D.O.) V2109 VP 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
PHYSICIAN
(D.O.) V2110 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
PHYSICIAN
(D.O.) V2110 VP 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
PHYSICIAN
(D.O.) V2111 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
PHYSICIAN
(D.O.) V2111 VP 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
PHYSICIAN
(D.O.) V2112 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
PHYSICIAN
(D.O.) V2112 VP 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
PHYSICIAN
(D.O.) V2113 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
PHYSICIAN
(D.O.) V2113 VP 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
PHYSICIAN
(D.O.) V2114 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
PHYSICIAN
(D.O.) V2114 VP 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
PHYSICIAN
(D.O.) V2115 0 999 Years $42.62 7/1/2014 0.00 $42.62 7/1/2016
PHYSICIAN
(D.O.) V2118 0 999 Years $33.76 7/1/2014 0.00 $33.76 7/1/2016
PHYSICIAN
(D.O.) V2121 0 999 Years $43.62 7/1/2014 0.00 $43.62 6 7/1/2016
PHYSICIAN
(D.O.) V2200 0 999 Years $25.59 7/1/2014 0.00 $25.59 7/1/2016
PHYSICIAN
(D.O.) V2201 0 999 Years $26.95 7/1/2014 0.00 $26.95 7/1/2016
PHYSICIAN
(D.O.) V2202 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
PHYSICIAN
(D.O.) V2202 VP 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
PHYSICIAN
(D.O.) V2203 0 999 Years $25.13 7/1/2014 0.00 $25.13 7/1/2016
PHYSICIAN
(D.O.) V2204 0 999 Years $25.58 7/1/2014 0.00 $25.58 7/1/2016
PHYSICIAN
(D.O.) V2205 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
PHYSICIAN
(D.O.) V2205 VP 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
PHYSICIAN
(D.O.) V2206 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
PHYSICIAN
(D.O.) V2206 VP 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
PHYSICIAN
(D.O.) V2207 0 999 Years $25.42 7/1/2014 0.00 $25.42 7/1/2016
PHYSICIAN
(D.O.) V2208 0 999 Years $28.21 7/1/2014 0.00 $28.21 7/1/2016
PHYSICIAN
(D.O.) V2209 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
PHYSICIAN
(D.O.) V2209 VP 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
(D.O.) V2210 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
PHYSICIAN
(D.O.) V2210 VP 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
PHYSICIAN
(D.O.) V2211 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
PHYSICIAN
(D.O.) V2211 VP 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
PHYSICIAN
(D.O.) V2212 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
PHYSICIAN
(D.O.) V2212 VP 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
PHYSICIAN
(D.O.) V2213 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
PHYSICIAN
(D.O.) V2213 VP 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
PHYSICIAN
(D.O.) V2214 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
PHYSICIAN
(D.O.) V2214 VP 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
PHYSICIAN
(D.O.) V2215 0 999 Years $41.26 7/1/2014 0.00 $41.26 7/1/2016
PHYSICIAN
(D.O.) V2218 0 999 Years $43.71 7/1/2014 0.00 $43.71 7/1/2016
PHYSICIAN
(D.O.) V2219 0 999 Years $22.22 7/1/2014 0.00 $22.22 7/1/2016
PHYSICIAN
(D.O.) V2220 0 999 Years $20.34 7/1/2014 0.00 $20.34 7/1/2016
PHYSICIAN
(D.O.) V2221 0 999 Years $43.45 7/1/2014 0.00 $43.45 7/1/2016
PHYSICIAN
(D.O.) V2300 0 999 Years $33.41 7/1/2014 0.00 $33.41 7/1/2016
PHYSICIAN
(D.O.) V2301 0 999 Years $43.76 7/1/2014 0.00 $43.76 7/1/2016
PHYSICIAN
(D.O.) V2302 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
PHYSICIAN
(D.O.) V2302 VP 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
PHYSICIAN
(D.O.) V2303 0 999 Years $31.75 7/1/2014 0.00 $31.75 7/1/2016
PHYSICIAN
(D.O.) V2304 0 999 Years $31.00 7/1/2014 0.00 $31.00 7/1/2016
PHYSICIAN
(D.O.) V2305 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
PHYSICIAN
(D.O.) V2305 VP 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
PHYSICIAN
(D.O.) V2306 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
PHYSICIAN
(D.O.) V2306 VP 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
PHYSICIAN
(D.O.) V2307 0 999 Years $34.72 7/1/2014 0.00 $34.72 7/1/2016
PHYSICIAN
(D.O.) V2308 0 999 Years $36.12 7/1/2014 0.00 $36.12 7/1/2016
PHYSICIAN
(D.O.) V2309 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
(D.O.) V2309 VP 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
PHYSICIAN
(D.O.) V2310 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
PHYSICIAN
(D.O.) V2310 VP 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
PHYSICIAN
(D.O.) V2311 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
PHYSICIAN
(D.O.) V2311 VP 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
PHYSICIAN
(D.O.) V2312 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
PHYSICIAN
(D.O.) V2312 VP 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
PHYSICIAN
(D.O.) V2313 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
PHYSICIAN
(D.O.) V2313 VP 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
PHYSICIAN
(D.O.) V2314 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
PHYSICIAN
(D.O.) V2314 VP 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
PHYSICIAN
(D.O.) V2315 0 999 Years $54.92 7/1/2014 0.00 $54.92 7/1/2016
PHYSICIAN
(D.O.) V2318 0 999 Years $63.39 7/1/2014 0.00 $63.39 7/1/2016
PHYSICIAN
(D.O.) V2319 0 999 Years $24.22 7/1/2014 0.00 $24.22 7/1/2016
PHYSICIAN
(D.O.) V2320 0 999 Years $30.19 7/1/2014 0.00 $30.19 7/1/2016
PHYSICIAN
(D.O.) V2321 0 20 Years $51.41 7/1/2014 0.00 $51.41 6 7/1/2016
PHYSICIAN
(D.O.) V2410 0 999 Years $45.71 7/1/2014 0.00 $45.71 7/1/2016
PHYSICIAN
(D.O.) V2430 0 999 Years $52.95 7/1/2014 0.00 $52.95 7/1/2016
PHYSICIAN
(D.O.) V2500 0 999 Years $43.91 7/1/2014 0.00 $43.91 7/1/2016
PHYSICIAN
(D.O.) V2501 0 999 Years $53.50 7/1/2014 0.00 $53.50 7/1/2016
PHYSICIAN
(D.O.) V2502 0 999 Years $65.91 7/1/2014 0.00 $65.91 7/1/2016
PHYSICIAN
(D.O.) V2510 0 999 Years $63.40 7/1/2014 0.00 $63.40 7/1/2016
PHYSICIAN
(D.O.) V2511 0 999 Years $82.23 7/1/2014 0.00 $82.23 7/1/2016
PHYSICIAN
(D.O.) V2512 0 999 Years $108.54 7/1/2014 0.00 $108.54 7/1/2016
PHYSICIAN
(D.O.) V2513 0 999 Years $91.12 7/1/2014 0.00 $91.12 7/1/2016
PHYSICIAN
(D.O.) V2520 0 999 Years $54.56 7/1/2014 0.00 $54.56 7/1/2016
PHYSICIAN
(D.O.) V2521 0 999 Years $83.43 7/1/2014 0.00 $83.43 7/1/2016
PHYSICIAN
(D.O.) V2522 0 999 Years $101.81 7/1/2014 0.00 $101.81 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
(D.O.) V2523 0 999 Years $79.53 7/1/2014 0.00 $79.53 7/1/2016
PHYSICIAN
(D.O.) V2530 0 999 Years $122.85 7/1/2014 0.00 $122.85 7/1/2016
PHYSICIAN
(D.O.) V2531 0 999 Years $236.58 7/1/2014 0.00 $236.58 7/1/2016
PHYSICIAN
(D.O.) V2599 0 999 Years $0.00 4/1/2010 -8.00 $0.00 5 7/1/2016
PHYSICIAN
(D.O.) V2700 0 999 Years $22.89 7/1/2014 0.00 $22.89 7/1/2016
PHYSICIAN
(D.O.) V2710 0 999 Years $34.37 7/1/2014 0.00 $34.37 7/1/2016
PHYSICIAN
(D.O.) V2715 0 999 Years $5.67 7/1/2014 0.00 $5.67 7/1/2016
PHYSICIAN
(D.O.) V2718 0 999 Years $14.09 7/1/2014 0.00 $14.09 7/1/2016
PHYSICIAN
(D.O.) V2730 0 999 Years $24.30 7/1/2014 0.00 $24.30 7/1/2016
PHYSICIAN
(D.O.) V2755 0 999 Years $19.15 7/1/2014 0.00 $19.15 7/1/2016
PHYSICIAN
(D.O.) V2770 0 999 Years $9.25 7/1/2014 0.00 $9.25 7/1/2016
PHYSICIAN
(D.O.) V2780 0 999 Years $5.41 7/1/2014 0.00 $5.41 7/1/2016
PHYSICIAN
(D.O.) V2784 0 999 Years $41.25 7/1/2014 0.00 $41.25 7/1/2016
PHYSICIAN
(M.D.) S0515 0 999 Years $0.00 4/1/2010 $0.00 5 4/1/2015
PHYSICIAN
(M.D.) V2020 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
PHYSICIAN
(M.D.) V2025 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
PHYSICIAN
(M.D.) V2100 0 999 Years $19.94 7/1/2014 0.00 $19.94 7/1/2016
PHYSICIAN
(M.D.) V2101 0 999 Years $23.78 7/1/2014 0.00 $23.78 7/1/2016
PHYSICIAN
(M.D.) V2102 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
PHYSICIAN
(M.D.) V2102 VP 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
PHYSICIAN
(M.D.) V2103 0 999 Years $15.73 7/1/2014 0.00 $15.73 7/1/2016
PHYSICIAN
(M.D.) V2104 0 999 Years $18.59 7/1/2014 0.00 $18.59 7/1/2016
PHYSICIAN
(M.D.) V2105 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
PHYSICIAN
(M.D.) V2105 VP 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
PHYSICIAN
(M.D.) V2106 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
PHYSICIAN
(M.D.) V2106 VP 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
PHYSICIAN
(M.D.) V2107 0 999 Years $23.45 7/1/2014 0.00 $23.45 7/1/2016
PHYSICIAN
(M.D.) V2108 0 999 Years $23.01 7/1/2014 0.00 $23.01 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
(M.D.) V2109 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
PHYSICIAN
(M.D.) V2109 VP 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
PHYSICIAN
(M.D.) V2110 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
PHYSICIAN
(M.D.) V2110 VP 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
PHYSICIAN
(M.D.) V2111 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
PHYSICIAN
(M.D.) V2111 VP 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
PHYSICIAN
(M.D.) V2112 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
PHYSICIAN
(M.D.) V2112 VP 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
PHYSICIAN
(M.D.) V2113 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
PHYSICIAN
(M.D.) V2113 VP 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
PHYSICIAN
(M.D.) V2114 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
PHYSICIAN
(M.D.) V2114 VP 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
PHYSICIAN
(M.D.) V2115 0 999 Years $42.62 7/1/2014 0.00 $42.62 7/1/2016
PHYSICIAN
(M.D.) V2118 0 999 Years $33.76 7/1/2014 0.00 $33.76 7/1/2016
PHYSICIAN
(M.D.) V2121 0 999 Years $43.62 7/1/2014 0.00 $43.62 6 7/1/2016
PHYSICIAN
(M.D.) V2200 0 999 Years $25.59 7/1/2014 0.00 $25.59 7/1/2016
PHYSICIAN
(M.D.) V2201 0 999 Years $26.95 7/1/2014 0.00 $26.95 7/1/2016
PHYSICIAN
(M.D.) V2202 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
PHYSICIAN
(M.D.) V2202 VP 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
PHYSICIAN
(M.D.) V2203 0 999 Years $25.13 7/1/2014 0.00 $25.13 7/1/2016
PHYSICIAN
(M.D.) V2204 0 999 Years $25.58 7/1/2014 0.00 $25.58 7/1/2016
PHYSICIAN
(M.D.) V2205 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
PHYSICIAN
(M.D.) V2205 VP 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
PHYSICIAN
(M.D.) V2206 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
PHYSICIAN
(M.D.) V2206 VP 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
PHYSICIAN
(M.D.) V2207 0 999 Years $25.42 7/1/2014 0.00 $25.42 7/1/2016
PHYSICIAN
(M.D.) V2208 0 999 Years $28.21 7/1/2014 0.00 $28.21 7/1/2016
PHYSICIAN
(M.D.) V2209 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
(M.D.) V2209 VP 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
PHYSICIAN
(M.D.) V2210 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
PHYSICIAN
(M.D.) V2210 VP 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
PHYSICIAN
(M.D.) V2211 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
PHYSICIAN
(M.D.) V2211 VP 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
PHYSICIAN
(M.D.) V2212 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
PHYSICIAN
(M.D.) V2212 VP 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
PHYSICIAN
(M.D.) V2213 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
PHYSICIAN
(M.D.) V2213 VP 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
PHYSICIAN
(M.D.) V2214 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
PHYSICIAN
(M.D.) V2214 VP 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
PHYSICIAN
(M.D.) V2215 0 999 Years $41.26 7/1/2014 0.00 $41.26 7/1/2016
PHYSICIAN
(M.D.) V2218 0 999 Years $43.71 7/1/2014 0.00 $43.71 7/1/2016
PHYSICIAN
(M.D.) V2219 0 999 Years $22.22 7/1/2014 0.00 $22.22 7/1/2016
PHYSICIAN
(M.D.) V2220 0 999 Years $20.34 7/1/2014 0.00 $20.34 7/1/2016
PHYSICIAN
(M.D.) V2221 0 999 Years $43.45 7/1/2014 0.00 $43.45 7/1/2016
PHYSICIAN
(M.D.) V2300 0 999 Years $33.41 7/1/2014 0.00 $33.41 7/1/2016
PHYSICIAN
(M.D.) V2301 0 999 Years $43.76 7/1/2014 0.00 $43.76 7/1/2016
PHYSICIAN
(M.D.) V2302 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
PHYSICIAN
(M.D.) V2302 VP 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
PHYSICIAN
(M.D.) V2303 0 999 Years $31.75 7/1/2014 0.00 $31.75 7/1/2016
PHYSICIAN
(M.D.) V2304 0 999 Years $31.00 7/1/2014 0.00 $31.00 7/1/2016
PHYSICIAN
(M.D.) V2305 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
PHYSICIAN
(M.D.) V2305 VP 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
PHYSICIAN
(M.D.) V2306 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
PHYSICIAN
(M.D.) V2306 VP 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
PHYSICIAN
(M.D.) V2307 0 999 Years $34.72 7/1/2014 0.00 $34.72 7/1/2016
PHYSICIAN
(M.D.) V2308 0 999 Years $36.12 7/1/2014 0.00 $36.12 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
(M.D.) V2309 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
PHYSICIAN
(M.D.) V2309 VP 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
PHYSICIAN
(M.D.) V2310 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
PHYSICIAN
(M.D.) V2310 VP 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
PHYSICIAN
(M.D.) V2311 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
PHYSICIAN
(M.D.) V2311 VP 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
PHYSICIAN
(M.D.) V2312 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
PHYSICIAN
(M.D.) V2312 VP 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
PHYSICIAN
(M.D.) V2313 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
PHYSICIAN
(M.D.) V2313 VP 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
PHYSICIAN
(M.D.) V2314 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
PHYSICIAN
(M.D.) V2314 VP 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
PHYSICIAN
(M.D.) V2315 0 999 Years $54.92 7/1/2014 0.00 $54.92 7/1/2016
PHYSICIAN
(M.D.) V2318 0 999 Years $63.39 7/1/2014 0.00 $63.39 7/1/2016
PHYSICIAN
(M.D.) V2319 0 999 Years $24.22 7/1/2014 0.00 $24.22 7/1/2016
PHYSICIAN
(M.D.) V2320 0 999 Years $30.19 7/1/2014 0.00 $30.19 7/1/2016
PHYSICIAN
(M.D.) V2321 0 20 Years $51.41 7/1/2014 0.00 $51.41 6 7/1/2016
PHYSICIAN
(M.D.) V2410 0 999 Years $45.71 7/1/2014 0.00 $45.71 7/1/2016
PHYSICIAN
(M.D.) V2430 0 999 Years $52.95 7/1/2014 0.00 $52.95 7/1/2016
PHYSICIAN
(M.D.) V2500 0 999 Years $43.91 7/1/2014 0.00 $43.91 7/1/2016
PHYSICIAN
(M.D.) V2501 0 999 Years $53.50 7/1/2014 0.00 $53.50 7/1/2016
PHYSICIAN
(M.D.) V2502 0 999 Years $65.91 7/1/2014 0.00 $65.91 7/1/2016
PHYSICIAN
(M.D.) V2510 0 999 Years $63.40 7/1/2014 0.00 $63.40 7/1/2016
PHYSICIAN
(M.D.) V2511 0 999 Years $82.23 7/1/2014 0.00 $82.23 7/1/2016
PHYSICIAN
(M.D.) V2512 0 999 Years $108.54 7/1/2014 0.00 $108.54 7/1/2016
PHYSICIAN
(M.D.) V2513 0 999 Years $91.12 7/1/2014 0.00 $91.12 7/1/2016
PHYSICIAN
(M.D.) V2520 0 999 Years $54.56 7/1/2014 0.00 $54.56 7/1/2016
PHYSICIAN
(M.D.) V2521 0 999 Years $83.43 7/1/2014 0.00 $83.43 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
(M.D.) V2522 0 999 Years $101.81 7/1/2014 0.00 $101.81 7/1/2016
PHYSICIAN
(M.D.) V2523 0 999 Years $79.53 7/1/2014 0.00 $79.53 7/1/2016
PHYSICIAN
(M.D.) V2530 0 999 Years $122.85 7/1/2014 0.00 $122.85 7/1/2016
PHYSICIAN
(M.D.) V2531 0 999 Years $236.58 7/1/2014 0.00 $236.58 7/1/2016
PHYSICIAN
(M.D.) V2599 0 999 Years $0.00 4/1/2010 -8.00 $0.00 5 7/1/2016
PHYSICIAN
(M.D.) V2700 0 999 Years $22.89 7/1/2014 0.00 $22.89 7/1/2016
PHYSICIAN
(M.D.) V2710 0 999 Years $34.37 7/1/2014 0.00 $34.37 7/1/2016
PHYSICIAN
(M.D.) V2715 0 999 Years $5.67 7/1/2014 0.00 $5.67 7/1/2016
PHYSICIAN
(M.D.) V2718 0 999 Years $14.09 7/1/2014 0.00 $14.09 7/1/2016
PHYSICIAN
(M.D.) V2730 0 999 Years $24.30 7/1/2014 0.00 $24.30 7/1/2016
PHYSICIAN
(M.D.) V2755 0 999 Years $19.15 7/1/2014 0.00 $19.15 7/1/2016
PHYSICIAN
(M.D.) V2770 0 999 Years $9.25 7/1/2014 0.00 $9.25 7/1/2016
PHYSICIAN
(M.D.) V2780 0 999 Years $5.41 7/1/2014 0.00 $5.41 7/1/2016
PHYSICIAN
(M.D.) V2784 0 999 Years $41.25 7/1/2014 0.00 $41.25 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC S0515 0 999 Years $0.00 4/1/2010 $0.00 5 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2020 0 999 Years $25.70 7/1/2014 0.00 $25.70 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2025 0 999 Years $25.70 7/1/2014 0.00 $25.70 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2100 0 999 Years $18.34 7/1/2014 0.00 $18.34 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2101 0 999 Years $21.88 7/1/2014 0.00 $21.88 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2102 0 999 Years $24.32 7/1/2014 0.00 $24.32 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2102 VP 0 999 Years $24.32 7/1/2014 0.00 $24.32 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2103 0 999 Years $14.47 7/1/2014 0.00 $14.47 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2104 0 999 Years $17.10 7/1/2014 0.00 $17.10 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2105 0 999 Years $16.75 7/1/2014 0.00 $16.75 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2105 VP 0 999 Years $16.75 7/1/2014 0.00 $16.75 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2106 0 999 Years $20.01 7/1/2014 0.00 $20.01 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2106 VP 0 999 Years $20.01 7/1/2014 0.00 $20.01 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2107 0 999 Years $21.57 7/1/2014 0.00 $21.57 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2108 0 999 Years $21.17 7/1/2014 0.00 $21.17 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2109 0 999 Years $20.30 7/1/2014 0.00 $20.30 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2109 VP 0 999 Years $20.30 7/1/2014 0.00 $20.30 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2110 0 999 Years $19.49 7/1/2014 0.00 $19.49 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2110 VP 0 999 Years $19.49 7/1/2014 0.00 $19.49 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2111 0 999 Years $22.83 7/1/2014 0.00 $22.83 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2111 VP 0 999 Years $22.83 7/1/2014 0.00 $22.83 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2112 0 999 Years $29.51 7/1/2014 0.00 $29.51 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2112 VP 0 999 Years $29.51 7/1/2014 0.00 $29.51 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2113 0 999 Years $31.76 7/1/2014 0.00 $31.76 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2113 VP 0 999 Years $31.76 7/1/2014 0.00 $31.76 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2114 0 999 Years $36.03 7/1/2014 0.00 $36.03 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2114 VP 0 999 Years $36.03 7/1/2014 0.00 $36.03 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2115 0 999 Years $39.21 7/1/2014 0.00 $39.21 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2118 0 999 Years $31.06 7/1/2014 0.00 $31.06 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2121 0 999 Years $43.62 7/1/2014 0.00 $43.62 6 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2200 0 999 Years $23.54 7/1/2014 0.00 $23.54 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2201 0 999 Years $24.79 7/1/2014 0.00 $24.79 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2202 0 999 Years $28.17 7/1/2014 0.00 $28.17 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2202 VP 0 999 Years $28.17 7/1/2014 0.00 $28.17 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2203 0 999 Years $23.12 7/1/2014 0.00 $23.12 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2204 0 999 Years $23.53 7/1/2014 0.00 $23.53 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2205 0 999 Years $24.55 7/1/2014 0.00 $24.55 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2205 VP 0 999 Years $24.55 7/1/2014 0.00 $24.55 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2206 0 999 Years $25.10 7/1/2014 0.00 $25.10 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2206 VP 0 999 Years $25.10 7/1/2014 0.00 $25.10 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2207 0 999 Years $23.39 7/1/2014 0.00 $23.39 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2208 0 999 Years $25.95 7/1/2014 0.00 $25.95 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2209 0 999 Years $25.67 7/1/2014 0.00 $25.67 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2209 VP 0 999 Years $25.67 7/1/2014 0.00 $25.67 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2210 0 999 Years $29.35 7/1/2014 0.00 $29.35 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2210 VP 0 999 Years $29.35 7/1/2014 0.00 $29.35 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2211 0 999 Years $29.36 7/1/2014 0.00 $29.36 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2211 VP 0 999 Years $29.36 7/1/2014 0.00 $29.36 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2212 0 999 Years $30.31 7/1/2014 0.00 $30.31 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2212 VP 0 999 Years $30.31 7/1/2014 0.00 $30.31 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2213 0 999 Years $32.39 7/1/2014 0.00 $32.39 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2213 VP 0 999 Years $32.39 7/1/2014 0.00 $32.39 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2214 0 999 Years $33.29 7/1/2014 0.00 $33.29 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2214 VP 0 999 Years $33.29 7/1/2014 0.00 $33.29 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2215 0 999 Years $37.96 7/1/2014 0.00 $37.96 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2218 0 999 Years $40.21 7/1/2014 0.00 $40.21 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2219 0 999 Years $20.44 7/1/2014 0.00 $20.44 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2220 0 999 Years $18.71 7/1/2014 0.00 $18.71 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2221 0 999 Years $39.97 7/1/2014 0.00 $39.97 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2300 0 999 Years $30.74 7/1/2014 0.00 $30.74 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2301 0 999 Years $40.26 7/1/2014 0.00 $40.26 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2302 0 999 Years $40.45 7/1/2014 0.00 $40.45 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2302 VP 0 999 Years $40.45 7/1/2014 0.00 $40.45 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2303 0 999 Years $29.21 7/1/2014 0.00 $29.21 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2304 0 999 Years $28.52 7/1/2014 0.00 $28.52 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2305 0 999 Years $35.42 7/1/2014 0.00 $35.42 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2305 VP 0 999 Years $35.42 7/1/2014 0.00 $35.42 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2306 0 999 Years $42.49 7/1/2014 0.00 $42.49 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2306 VP 0 999 Years $42.49 7/1/2014 0.00 $42.49 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2307 0 999 Years $31.94 7/1/2014 0.00 $31.94 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2308 0 999 Years $33.23 7/1/2014 0.00 $33.23 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2309 0 999 Years $37.17 7/1/2014 0.00 $37.17 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2309 VP 0 999 Years $37.17 7/1/2014 0.00 $37.17 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2310 0 999 Years $36.27 7/1/2014 0.00 $36.27 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2310 VP 0 999 Years $36.27 7/1/2014 0.00 $36.27 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2311 0 999 Years $42.57 7/1/2014 0.00 $42.57 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2311 VP 0 999 Years $42.57 7/1/2014 0.00 $42.57 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2312 0 999 Years $40.25 7/1/2014 0.00 $40.25 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2312 VP 0 999 Years $40.25 7/1/2014 0.00 $40.25 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2313 0 999 Years $42.03 7/1/2014 0.00 $42.03 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2313 VP 0 999 Years $42.03 7/1/2014 0.00 $42.03 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2314 0 999 Years $45.51 7/1/2014 0.00 $45.51 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2314 VP 0 999 Years $45.51 7/1/2014 0.00 $45.51 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2315 0 999 Years $50.53 7/1/2014 0.00 $50.53 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 287
10/14/2016 287 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2318 0 999 Years $58.32 7/1/2014 0.00 $58.32 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2319 0 999 Years $22.28 7/1/2014 0.00 $22.28 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2320 0 999 Years $27.77 7/1/2014 0.00 $27.77 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2321 0 20 Years $51.41 7/1/2014 0.00 $51.41 6 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2410 0 999 Years $42.05 7/1/2014 0.00 $42.05 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2430 0 999 Years $48.71 7/1/2014 0.00 $48.71 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2500 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2501 0 999 Years $49.22 7/1/2014 0.00 $49.22 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 288
10/14/2016 288 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2502 0 999 Years $60.64 7/1/2014 0.00 $60.64 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2510 0 999 Years $58.33 7/1/2014 0.00 $58.33 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2511 0 999 Years $75.65 7/1/2014 0.00 $75.65 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2512 0 999 Years $99.86 7/1/2014 0.00 $99.86 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2513 0 999 Years $83.83 7/1/2014 0.00 $83.83 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2520 0 999 Years $50.20 7/1/2014 0.00 $50.20 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2521 0 999 Years $76.76 7/1/2014 0.00 $76.76 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2522 0 999 Years $93.67 7/1/2014 0.00 $93.67 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 289
10/14/2016 289 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2523 0 999 Years $73.17 7/1/2014 0.00 $73.17 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2530 0 999 Years $113.02 7/1/2014 0.00 $113.02 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2531 0 999 Years $217.65 7/1/2014 0.00 $217.65 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2599 0 999 Years $0.00 4/1/2010 -8.00 $0.00 5 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2700 0 999 Years $21.06 7/1/2014 0.00 $21.06 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2710 0 999 Years $31.62 7/1/2014 0.00 $31.62 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2715 0 999 Years $5.22 7/1/2014 0.00 $5.22 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2718 0 999 Years $12.96 7/1/2014 0.00 $12.96 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 290
10/14/2016 290 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2730 0 999 Years $22.36 7/1/2014 0.00 $22.36 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2755 0 999 Years $17.62 7/1/2014 0.00 $17.62 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2770 0 999 Years $8.51 7/1/2014 0.00 $8.51 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2780 0 999 Years $4.98 7/1/2014 0.00 $4.98 7/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC V2784 0 999 Years $37.95 7/1/2014 0.00 $37.95 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) S0515 0 999 Years $0.00 4/1/2010 $0.00 5 4/1/2015
PHYSICIAN
GROUP
(D.O.S
ONLY) V2020 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2025 0 999 Years $27.93 7/1/2014 0.00 $27.93 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2100 0 999 Years $19.94 7/1/2014 0.00 $19.94 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2101 0 999 Years $23.78 7/1/2014 0.00 $23.78 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 291
10/14/2016 291 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
GROUP
(D.O.S
ONLY) V2102 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2102 VP 0 999 Years $26.43 7/1/2014 0.00 $26.43 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2103 0 999 Years $15.73 7/1/2014 0.00 $15.73 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2104 0 999 Years $18.59 7/1/2014 0.00 $18.59 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2105 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2105 VP 0 999 Years $18.21 7/1/2014 0.00 $18.21 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2106 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2106 VP 0 999 Years $21.75 7/1/2014 0.00 $21.75 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2107 0 999 Years $23.45 7/1/2014 0.00 $23.45 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2108 0 999 Years $23.01 7/1/2014 0.00 $23.01 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2109 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2109 VP 0 999 Years $22.06 7/1/2014 0.00 $22.06 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2110 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2110 VP 0 999 Years $21.19 7/1/2014 0.00 $21.19 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 292
10/14/2016 292 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
GROUP
(D.O.S
ONLY) V2111 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2111 VP 0 999 Years $24.81 7/1/2014 0.00 $24.81 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2112 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2112 VP 0 999 Years $32.08 7/1/2014 0.00 $32.08 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2113 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2113 VP 0 999 Years $34.52 7/1/2014 0.00 $34.52 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2114 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2114 VP 0 999 Years $39.16 7/1/2014 0.00 $39.16 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2115 0 999 Years $42.62 7/1/2014 0.00 $42.62 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2118 0 999 Years $33.76 7/1/2014 0.00 $33.76 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2121 0 999 Years $43.62 7/1/2014 0.00 $43.62 6 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2200 0 999 Years $25.59 7/1/2014 0.00 $25.59 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2201 0 999 Years $26.95 7/1/2014 0.00 $26.95 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2202 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 293
10/14/2016 293 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
GROUP
(D.O.S
ONLY) V2202 VP 0 999 Years $30.62 7/1/2014 0.00 $30.62 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2203 0 999 Years $25.13 7/1/2014 0.00 $25.13 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2204 0 999 Years $25.58 7/1/2014 0.00 $25.58 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2205 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2205 VP 0 999 Years $26.68 7/1/2014 0.00 $26.68 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2206 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2206 VP 0 999 Years $27.28 7/1/2014 0.00 $27.28 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2207 0 999 Years $25.42 7/1/2014 0.00 $25.42 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2208 0 999 Years $28.21 7/1/2014 0.00 $28.21 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2209 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2209 VP 0 999 Years $27.90 7/1/2014 0.00 $27.90 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2210 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2210 VP 0 999 Years $31.90 7/1/2014 0.00 $31.90 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2211 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 294
10/14/2016 294 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
GROUP
(D.O.S
ONLY) V2211 VP 0 999 Years $31.91 7/1/2014 0.00 $31.91 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2212 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2212 VP 0 999 Years $32.95 7/1/2014 0.00 $32.95 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2213 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2213 VP 0 999 Years $35.21 7/1/2014 0.00 $35.21 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2214 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2214 VP 0 999 Years $36.18 7/1/2014 0.00 $36.18 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2215 0 999 Years $41.26 7/1/2014 0.00 $41.26 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2218 0 999 Years $43.71 7/1/2014 0.00 $43.71 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2219 0 999 Years $22.22 7/1/2014 0.00 $22.22 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2220 0 999 Years $20.34 7/1/2014 0.00 $20.34 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2221 0 999 Years $43.45 7/1/2014 0.00 $43.45 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2300 0 999 Years $33.41 7/1/2014 0.00 $33.41 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2301 0 999 Years $43.76 7/1/2014 0.00 $43.76 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 295
10/14/2016 295 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
GROUP
(D.O.S
ONLY) V2302 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2302 VP 0 999 Years $43.97 7/1/2014 0.00 $43.97 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2303 0 999 Years $31.75 7/1/2014 0.00 $31.75 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2304 0 999 Years $31.00 7/1/2014 0.00 $31.00 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2305 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2305 VP 0 999 Years $38.50 7/1/2014 0.00 $38.50 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2306 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2306 VP 0 999 Years $46.19 7/1/2014 0.00 $46.19 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2307 0 999 Years $34.72 7/1/2014 0.00 $34.72 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2308 0 999 Years $36.12 7/1/2014 0.00 $36.12 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2309 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2309 VP 0 999 Years $40.40 7/1/2014 0.00 $40.40 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2310 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2310 VP 0 999 Years $39.42 7/1/2014 0.00 $39.42 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 296
10/14/2016 296 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
GROUP
(D.O.S
ONLY) V2311 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2311 VP 0 999 Years $46.27 7/1/2014 0.00 $46.27 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2312 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2312 VP 0 999 Years $43.75 7/1/2014 0.00 $43.75 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2313 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2313 VP 0 999 Years $45.69 7/1/2014 0.00 $45.69 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2314 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2314 VP 0 999 Years $49.47 7/1/2014 0.00 $49.47 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2315 0 999 Years $54.92 7/1/2014 0.00 $54.92 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2318 0 999 Years $63.39 7/1/2014 0.00 $63.39 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2319 0 999 Years $24.22 7/1/2014 0.00 $24.22 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2320 0 999 Years $30.19 7/1/2014 0.00 $30.19 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2321 0 20 Years $51.41 7/1/2014 0.00 $51.41 6 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2410 0 999 Years $45.71 7/1/2014 0.00 $45.71 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 297
10/14/2016 297 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
GROUP
(D.O.S
ONLY) V2430 0 999 Years $52.95 7/1/2014 0.00 $52.95 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2500 0 999 Years $43.91 7/1/2014 0.00 $43.91 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2501 0 999 Years $53.50 7/1/2014 0.00 $53.50 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2502 0 999 Years $65.91 7/1/2014 0.00 $65.91 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2510 0 999 Years $63.40 7/1/2014 0.00 $63.40 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2511 0 999 Years $82.23 7/1/2014 0.00 $82.23 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2512 0 999 Years $108.54 7/1/2014 0.00 $108.54 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2513 0 999 Years $91.12 7/1/2014 0.00 $91.12 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2520 0 999 Years $54.56 7/1/2014 0.00 $54.56 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2521 0 999 Years $83.43 7/1/2014 0.00 $83.43 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2522 0 999 Years $101.81 7/1/2014 0.00 $101.81 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2523 0 999 Years $79.53 7/1/2014 0.00 $79.53 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2530 0 999 Years $122.85 7/1/2014 0.00 $122.85 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2531 0 999 Years $236.58 7/1/2014 0.00 $236.58 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 298
10/14/2016 298 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
1 2 3 1 2 3
Adjust
%Adjusted Fee
for Report
Date
Last Pricing
Review Date
Note Codes
Frm Thru Units FeeFee Effect
DateFee
Note CodesAdjusted
Fee for
Report
Date
Last Pricing
Review Date
Adjust
%
Fee Effect
Date
Provider
Type
Rental
Proc
Code
Client Age
Mod
1
Mod
2
Purchase
PHYSICIAN
GROUP
(D.O.S
ONLY) V2599 0 999 Years $0.00 4/1/2010 -8.00 $0.00 5 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2700 0 999 Years $22.89 7/1/2014 0.00 $22.89 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2710 0 999 Years $34.37 7/1/2014 0.00 $34.37 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2715 0 999 Years $5.67 7/1/2014 0.00 $5.67 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2718 0 999 Years $14.09 7/1/2014 0.00 $14.09 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2730 0 999 Years $24.30 7/1/2014 0.00 $24.30 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2755 0 999 Years $19.15 7/1/2014 0.00 $19.15 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2770 0 999 Years $9.25 7/1/2014 0.00 $9.25 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2780 0 999 Years $5.41 7/1/2014 0.00 $5.41 7/1/2016
PHYSICIAN
GROUP
(D.O.S
ONLY) V2784 0 999 Years $41.25 7/1/2014 0.00 $41.25 7/1/2016
REHABILITAT
ION
CENTERS E0710 0 999 Years $31.80 4/1/2013 0.00 $31.80 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Page 299
10/14/2016 299 of 299TEXAS MEDICAID FEE SCHEDULE -
DMEPOS - TOS 9, E, J, L, AND R
Note Code(s): 5 - This procedure is manually reviewed to determine pricing.
5B - Procedure suspends for manual pricing and is reimbursed the lesser of the Max Fee, Invoice, or Acquisition Cost
6 - This procedure is payable only through the CCP program.
P2 - Displayed fee reflects reimbursement for the service rendered in the home setting.
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
