florida medicaid dme fee schedule 2026

Florida Medicaid DME Fee Schedule 2026: Rates, Billing Rules, and Authorization

Florida Medicaid’s 2026 DME fee schedule, effective July 1, 2026, outlines reimbursement rates, HCPCS codes, rental rules, service limits, and prior authorization requirements for durable medical equipment and medical supplies. Use this guide to check applicable fees and billing requirements before submitting claims and help reduce avoidable denials.

How to Use the 2026 Florida Medicaid DME Fee Schedule

Before billing, verify the HCPCS code, maximum fee, coverage requirements, service limits, rental or purchase rules, and prior authorization requirements.

Example Florida Medicaid DME Rates

HCPCS code	Equipment	Maximum fee
E0570	Nebulizer	$114.49
E0143	Folding walker	$92.54
E0260	Semi-electric hospital bed	$1,150.10
K0001	Standard manual wheelchair	$380.16

Understanding Fee Schedule Columns

The schedule identifies HCPCS codes, age ranges, maximum fees, rental requirements, billing units, and limits. It also flags items requiring prior authorization (PA), manual pricing (MP), or review by report (BR). Bundled codes (BC) indicate supplies included in rental reimbursement.

What DME Providers Should Check Before Billing

Confirm the HCPCS code and recipient’s age range.
Verify reimbursement rates and rental or purchase requirements.
Check unit limits and replacement frequencies.
Identify authorization, manual pricing, and medical review requirements.
Avoid separately billing supplies included in bundled rental payments.

Florida Medicaid DME Provider Fee Schedule 2026

Accurate billing requires correct coding, medical necessity documentation, and compliance with applicable authorization and service limits. Review the official Florida Medicaid Provider Fee Schedules for current, code-specific requirements.

Column	Field	Definition
A	HCPCS Code	Identifies the Healthcare Common Procedure Coding System (HCPCS) code associated with the service or item.
B	Age Range	Specifies the recipient age range covered for the procedure code.
C	Orthopedic Specialty (OS)	Codes marked OS are reimbursable to physicians with an orthopedic specialty and DME providers. Codes without OS are reimbursable only to DME providers.
D	Maximum Fee	Lists the maximum Medicaid reimbursement for the DME item, medical supply, orthotic, or prosthetic device. Unless otherwise specified, the rate applies per unilateral item, single item, or unit. Ostomy supply rates generally apply per stoma or fistula unless otherwise specified. A rate of $0.00 indicates a non-classified code that requires prior authorization or a By Report claim, as indicated in the schedule.
E	Rental Only (RO)	Indicates that the equipment remains the provider’s property and is reimbursed through a monthly rental fee during the authorized medically necessary period.
F	Rental Amount	Specifies the monthly reimbursement amount for rental-only and rent-to-purchase items.
G	Daily Rental (DR)	Indicates that rental reimbursement is calculated daily rather than monthly.
H	Units	Specifies the number of units that may be billed for dates of service within the same month. Providers may bill up to a one-month supply on a single billing date, based on the recipient’s medical need.
I	Manually Priced (MP)	Indicates that reimbursement must be negotiated between the provider and the Agency’s contracted Quality Improvement Organization (QIO).
J	Bundled Code (BC)	Indicates that rental reimbursement includes the supplies required to operate the equipment throughout the rental period. These supplies cannot be billed separately and must be replaced when necessary.
K	By Report (BR)	Identifies a non-classified procedure code requiring medical review for approval and appropriate pricing.
L	Prior Authorization (PA)	Identifies services requiring authorization from the Agency’s fee-for-service QIO vendor before the service is performed. This includes requests to exceed limits or request services not listed on the fee schedule, such as E1399.
M	Time-Limited Rate	Identifies codes assigned a temporary reimbursement rate because of specific circumstances, such as a state of emergency or supply shortage.
N	Limit	Specifies the maximum limit applicable to the procedure code.

Ostomy, wound care & diabetic

A4206–A4216: Ostomy, Wound Care, and Diabetic Supplies

Code	Age	Maximum Rate ($)	Daily Rental ($)	Rental Amount ($)	Rental Units	Time Limit
A4206	0–999	0.31	—	—	60	720 per year
A4207	0–999	0.31	—	—	60	720 per year
A4208	0–999	0.31	—	—	60	720 per year
A4209	0–999	0.31	—	—	60	720 per year
A4213	0–999	2.08	—	—	31	372 per year
A4215	0–999	0.20	—	—	100	1,200 per year
A4216	0–999	0.36	—	—	150	150 per month

A4217–A4223: Infusion and Medical Supplies

Code	Age	Maximum Rate ($)	Daily Rental ($)	Rental Amount ($)	Rental Units	Time Limit
A4217	0–20	2.61	—	—	1	31 units per month
A4221	0–20	18.58	—	—	1	52 per year
A4222	0–20	36.90	—	—	7	Up to 365 per year, based on medical necessity
A4223	0–999	36.90	—	—	1	52 per year

A4230–A4250: Diabetic Testing Supplies

Code	Age	Maximum Rate ($)	Daily Rental ($)	Rental Amount ($)	Rental Units	Time Limit
A4230	0–999	166.87	—	—	1	12 boxes per year
A4231	0–999	93.48	—	—	1	12 boxes per year
A4232	0–999	62.06	—	—	1	12 boxes per year
A4244	0–999	0.84	—	—	12	144 per year
A4245	0–999	2.08	—	—	2	24 per year
A4246	0–20	5.20	—	—	3	36 per year
A4247	0–999	7.81	—	—	2	2 boxes per month
A4250	0–999	10.62	—	—	2	2 boxes per month

A4265–A4346: Catheters and Urinary Supplies

Code	Age	Maximum Rate ($)	Daily Rental ($)	Rental Amount ($)	Rental Units	Time Limit
A4265	0–20	4.16	—	—	6	72 per year
A4280	0–999	4.03	—	—	5	5 per month
A4310	0–20	4.32	—	—	2	24 per year
A4311	0–999	4.79	—	—	3	36 per year
A4312	0–999	16.96	—	—	3	36 per year
A4313	0–999	11.15	—	—	3	36 per year
A4314	0–20	11.45	—	—	2	24 per year
A4315	0–20	11.45	—	—	2	24 per year
A4316	0–20	11.45	—	—	2	24 per year
A4320	0–20	5.26	—	—	31	372 per year
A4322	0–20	2.31	—	—	12	144 per year
A4326	0–20	8.95	—	—	31	372 per year
A4327	0–20	17.28	—	—	1	1 per year
A4328	0–20	5.37	—	—	2	24 per year
A4330	0–20	5.57	—	—	31	372 per year
A4331	0–999	1.80	—	—	31	372 per year
A4332	0–999	0.11	—	—	200	200 per month
A4333	0–999	2.61	—	—	31	31 per month
A4338	0–20	6.61	—	—	3	36 per year
A4340	0–20	7.18	—	—	3	36 per year
A4344	0–20	5.73	—	—	3	36 per year
A4346	0–20	9.37	—	—	3	36 per year

A4349–A4395: Ostomy and Wound Care Supplies

Code	Age	Maximum Rate ($)	Daily Rental ($)	Rental Amount ($)	Rental Units	Time Limit
A4349	0–999	1.78	—	—	35	35 per month
A4351	0–999	1.72	—	—	186	186 per month
A4352	0–999	1.97	—	—	186	186 per month
A4353	0–999	5.72	—	—	186	186 per month
A4354	0–20	4.16	—	—	3	36 per year
A4355	0–20	2.70	—	—	4	48 per year
A4356	0–20	37.47	—	—	1	1 per year
A4357	0–999	8.33	—	—	2	24 per year
A4358	0–999	3.65	—	—	5	60 per year
A4361	0–999	18.80	—	—	1	12 per year
A4362	0–999	3.12	—	—	20	240 per year
A4363	0–999	4.45	—	—	12	144 per year
A4364	0–999	2.29	—	—	4	48 per year
A4367	0–999	6.02	—	—	1	12 per year
A4368	0–999	0.21	—	—	200	200 per month
A4369	0–999	1.97	—	—	12	144 per year
A4371	0–999	2.98	—	—	12	144 per year
A4372	0–999	3.41	—	—	20	240 per year
A4373	0–999	5.14	—	—	31	372 per year
A4375	0–999	14.06	—	—	10	10 per month
A4376	0–999	38.95	—	—	10	10 per month
A4377	0–999	3.51	—	—	10	10 per month
A4378	0–999	25.17	—	—	10	10 per month
A4379	0–999	12.30	—	—	10	10 per month
A4380	0–999	30.56	—	—	20	240 per year
A4381	0–999	3.78	—	—	10	10 per month
A4382	0–999	20.15	—	—	10	10 per month
A4383	0–999	23.08	—	—	10	10 per month
A4384	0–999	7.88	—	—	10	10 per month
A4385	0–999	4.16	—	—	10	10 per month
A4387	0–999	3.28	—	—	10	10 per month
A4388	0–999	3.56	—	—	10	10 per month
A4389	0–999	5.09	—	—	10	10 per month
A4390	0–999	7.87	—	—	10	10 per month
A4391	0–999	5.78	—	—	10	10 per month
A4392	0–999	5.44	—	—	10	10 per month
A4393	0–999	7.51	—	—	10	10 per month
A4394	0–999	2.10	—	—	10	10 per month
A4395	0–999	0.04	—	—	31	31 per month

A4396–A4456: Wound Dressings and Related Supplies

Code	Age	Maximum Rate ($)	Daily Rental ($)	Rental Amount ($)	Rental Units	Time Limit
A4396	0–999	33.14	—	—	2	2 per month
A4398	0–999	24.98	—	—	2	24 per year
A4399	0–999	6.24	—	—	1	2 per year
A4400	0–999	34.01	—	—	1	6 per year
A4402	0–999	1.45	—	—	4	48 per year
A4404	0–999	1.38	—	—	31	372 per year
A4405	0–999	2.34	—	—	12	144 per year
A4406	0–999	3.94	—	—	12	144 per year
A4407	0–999	6.02	—	—	31	372 per year
A4408	0–999	6.78	—	—	31	372 per year
A4409	0–999	4.27	—	—	31	372 per year
A4410	0–999	6.20	—	—	31	372 per year
A4411	0–999	5.63	—	—	31	372 per year
A4412	0–999	3.22	—	—	31	31 per month
A4413	0–999	3.78	—	—	10	10 per month
A4414	0–999	3.38	—	—	31	372 per year
A4415	0–999	4.12	—	—	31	372 per year
A4416	0–999	1.89	—	—	31	31 per month
A4417	0–999	2.55	—	—	31	31 per month
A4418	0–999	1.24	—	—	31	31 per month
A4420	0–999	1.37	—	—	31	31 per month
A4421	0–999	MP	—	—	1	12 per year; PA
A4423	0–999	1.37	—	—	31	31 per month
A4424	0–999	3.26	—	—	31	31 per month
A4425	0–999	2.46	—	—	31	372 per year
A4426	0–999	1.62	—	—	31	372 per year
A4427	0–999	2.03	—	—	31	372 per year
A4428	0–999	4.47	—	—	31	372 per year
A4429	0–999	5.17	—	—	31	372 per year
A4430	0–999	5.86	—	—	31	372 per year
A4431	0–999	3.49	—	—	31	31 per month
A4432	0–999	2.47	—	—	31	31 per month
A4433	0–999	2.30	—	—	31	31 per month
A4434	0–999	2.59	—	—	31	372 per year
A4436	0–999	12.98	—	—	1	1 per month
A4437	0–999	12.98	—	—	1	1 per month
A4450	0–999	0.32	—	—	200	2,400 per year
A4452	0–999	0.43	—	—	200	2,400 per year
A4455	0–999	1.24	—	—	4	48 per year
A4456	0–999	0.18	—	—	100	100 per month

A4554–A5200: Medical and Diabetic Supplies

Code	Age	Maximum Rate ($)	Daily Rental ($)	Rental Amount ($)	Rental Units	Time Limit
A4554	0–20	0.36	—	—	150	1,800 per year
A4561	0–999	14.44	—	—	10	10 per month
A4562	0–999	39.12	—	—	10	10 per month
A4640	0–20	36.43	—	—	1	1 per year
A4927	0–999	6.17	—	—	4	48 per year; TL
A4930	0–999	1.29	—	—	100	1,200 per year; TL
A5051	0–999	1.78	—	—	31	372 per year
A5052	0–999	1.36	—	—	31	372 per year
A5053	0–999	1.37	—	—	31	372 per year
A5054	0–999	1.37	—	—	31	372 per year
A5055	0–999	1.30	—	—	31	31 per month
A5056	0–999	6.14	—	—	1	10 per month
A5057	0–999	12.61	—	—	1	10 per month
A5061	0–999	2.34	—	—	31	372 per year
A5062	0–999	2.03	—	—	31	372 per year
A5063	0–999	2.03	—	—	31	372 per year
A5071	0–999	3.03	—	—	31	372 per year
A5072	0–999	2.46	—	—	31	372 per year
A5073	0–999	2.24	—	—	31	372 per year
A5081	0–999	2.69	—	—	1	6 per year
A5082	0–999	8.27	—	—	1	6 per year
A5093	0–999	1.66	—	—	10	120 per year
A5102	0–20	7.18	—	—	1	2 per year
A5105	0–20	15.45	—	—	1	2 per year
A5112	0–999	28.35	—	—	1	12 per year
A5113	0–20	4.81	—	—	1	4 per year
A5114	0–20	5.93	—	—	1	4 per year
A5120	0–999	0.18	—	—	50	600 per year
A5121	0–999	5.19	—	—	10	120 per year
A5122	0–999	10.53	—	—	10	120 per year
A5126	0–20	0.68	—	—	20	240 per year
A5131	0–999	11.03	—	—	3	3 per month
A5200	0–20	9.25	—	—	3	3 per month

A6022–A6457: Wound Care and Related Medical Supplies

Code	Age	Maximum Rate ($)	Daily Rental ($)	Rental Amount ($)	Rental Units	Time Limit
A6022	0–999	17.21	—	—	31	31 per month
A6023	0–999	155.81	—	—	15	15 per month
A6024	0–999	5.06	—	—	31	31 per month
A6154	0–20	11.42	—	—	15	15 per month
A6196	0–20	6.02	—	—	31	31 per month
A6197	0–20	13.41	—	—	31	31 per month
A6199	0–20	4.33	—	—	31	31 per month
A6203	0–20	2.75	—	—	31	31 per month
A6204	0–20	5.11	—	—	31	31 per month
A6207	0–20	6.01	—	—	31	31 per month
A6209	0–20	6.14	—	—	31	31 per month
A6210	0–20	16.31	—	—	31	31 per month
A6211	0–20	24.04	—	—	31	31 per month
A6212	0–20	7.94	—	—	31	31 per month
A6214	0–20	8.43	—	—	31	31 per month
A6216	0–20	0.04	—	—	200	200 per month
A6219	0–20	0.78	—	—	62	62 per month
A6220	0–20	2.11	—	—	62	62 per month
A6222	0–20	1.75	—	—	31	31 per month
A6223	0–20	1.97	—	—	31	31 per month
A6224	0–20	2.96	—	—	31	31 per month
A6229	0–20	2.95	—	—	31	31 per month
A6231	0–999	3.82	—	—	31	31 per month
A6232	0–999	5.64	—	—	31	31 per month
A6233	0–999	15.71	—	—	31	31 per month
A6234	0–20	5.37	—	—	31	31 per month
A6235	0–20	13.78	—	—	31	31 per month
A6236	0–20	22.32	—	—	31	31 per month
A6237	0–20	6.48	—	—	31	31 per month
A6238	0–20	18.67	—	—	31	31 per month
A6240	0–20	10.03	—	—	31	31 per month
A6241	0–20	2.10	—	—	31	31 per month
A6242	0–20	4.97	—	—	31	31 per month
A6243	0–20	10.09	—	—	31	31 per month
A6244	0–20	32.14	—	—	31	31 per month
A6245	0–20	5.96	—	—	31	31 per month
A6246	0–20	8.10	—	—	31	31 per month
A6247	0–20	19.47	—	—	31	31 per month
A6248	0–20	13.31	—	—	15	15 per month
A6251	0–20	1.63	—	—	31	31 per month
A6252	0–20	2.66	—	—	31	31 per month
A6253	0–20	5.19	—	—	31	31 per month
A6254	0–20	0.97	—	—	31	31 per month
A6255	0–20	2.49	—	—	31	31 per month
A6257	0–999	1.23	—	—	31	31 per month
A6258	0–20	3.52	—	—	31	31 per month
A6259	0–20	8.96	—	—	31	31 per month
A6266	0–20	1.56	—	—	31	31 per month
A6402	0–20	0.11	—	—	200	200 per month
A6403	0–20	0.35	—	—	200	200 per month
A6441	0–20	0.43	—	—	31	31 per month
A6443	0–20	0.43	—	—	31	31 per month
A6444	0–20	0.43	—	—	31	31 per month
A6446	0–20	0.43	—	—	31	31 per month
A6447	0–20	0.43	—	—	31	31 per month
A6449	0–20	0.54	—	—	31	31 per month
A6450	0–20	0.54	—	—	31	31 per month
A6451	0–20	0.54	—	—	31	31 per month
A6452	0–20	0.54	—	—	31	31 per month
A6454	0–20	0.54	—	—	31	31 per month
A6456	0–20	9.76	—	—	31	31 per month
A6457	0–999	0.98	—	—	2	2 every 6 months

A9276–A9900: Diabetic Monitoring and Miscellaneous Supplies

Code	Age	Maximum Rate ($)	Daily Rental ($)	Rental Amount ($)	Rental Units	Time Limit
A9276	0–20	428.34	—	—	1 (per box)	1 per month; PA
A9277	0–20	685.86	—	—	1	2 per year; PA
A9278	0–20	600.02	—	—	1	1 per year; PA
A9900	0–999	MP	—	—	1	Medical necessity; PA

T4521–T4535: Incontinence Supplies

Code	Age	Maximum Fee ($)	Rental Amount ($)	Rental Units	Time Limit
T4521*	4–999	0.68	200	Up to 200 per month	—
T4522*	4–999	0.74	200	Up to 200 per month	—
T4523*	4–999	0.86	200	Up to 200 per month	—
T4524*	4–999	0.97	200	Up to 200 per month	—
T4525*	4–999	0.84	200	Up to 200 per month	—
T4526*	4–999	0.91	200	Up to 200 per month	—
T4527*	4–999	1.01	200	Up to 200 per month	—
T4528*	4–999	1.09	200	Up to 200 per month	—
T4529*	4–999	0.57	200	Up to 200 per month	—
T4530*	4–999	0.62	200	Up to 200 per month	—
T4531*	4–999	0.74	200	Up to 200 per month	—
T4532*	4–999	0.80	200	Up to 200 per month	—
T4533*	4–999	0.70	200	Up to 200 per month	—
T4534*	4–999	0.90	200	Up to 200 per month	—
T4535*	4–999	0.47	200	Up to 200 per month	—

T4543–T4544: Incontinence Supplies

Code	Age	Maximum Fee ($)	Rental Amount ($)	Rental Units	Time Limit
T4543*	4–999	1.63	200	Up to 200 per month	—
T4544*	4–999	1.63	200	Up to 200 per month	—

Durable Medical Equipment

Code	Age	Maximum Rate ($)	Daily Rental ($)	Rental Amount ($)	Rental Units	Time Limit
E0160	0–999	10.41	—	—	1	1 per 8 years
E0161	0–999	26.02	—	—	1	1 per 8 years
E0163	0–999	77.02	—	—	1	1 per 8 years
E0165	0–999	77.55	—	—	1	1 per 3 years
E0167	0–999	7.81	—	—	1	1 per year
E0168	0–999	123.93	—	—	1	1 per 3 years
E0171	0–999	24.83	—	—	1	1 per 3 years
E0181	0–20	161.38	16.14	—	1	1 per 3 years
E0184	0–20	296.68	29.67	—	1	1 per 3 years
E0185	0–999	130.10	—	—	1	1 per 2 years
E0186	0–20	197.75	—	—	1	1 per 3 years
E0187	0–20	197.75	—	—	1	1 per 3 years
E0189	0–20	83.26	—	—	1	1 per 2 years
E0190	0–20	28.32	—	—	1	1 per 3 years
E0191	0–20	7.29	—	—	2	4 per year
E0196	0–20	197.75	—	—	1	1 per 3 years
E0197	0–999	130.10	—	—	1	1 per 2 years
E0198	0–999	130.10	—	—	1	1 per 2 years
E0199	0–999	23.94	—	—	1	1 per 2 years
E0215	0–20	17.69	—	—	1	1 per lifetime
E0217	0–20	345.53	—	—	1	1 per 5 years
E0235	0–20	124.90	12.49	—	1	1 per 8 years
E0244	0–999	31.22	—	—	1	1 per 8 years
E0245	0–999	37.56	—	—	1	1 per 8 years
E0246	0–999	15.61	—	—	1	1 per 8 years
E0249	0–20	27.59	—	—	1	1 per year
E0275	0–999	8.33	—	—	1	1 per 4 years
E0276	0–999	9.89	—	—	1	1 per 4 years
E0325	0–999	6.77	—	—	1	1 per 4 years
E0326	0–999	9.37	—	—	1	1 per 4 years
E0784	0–999	MP	—	—	1	Medical necessity; PA
E0968	0–999	15.31	—	—	1	2 per 4 years

Nutritional

Code	Age	Maximum Fee ($)	Rental Amount	Rental Units	Time Limit
B4034	0–999	5.03	31	31 per month
B4035	0–20	9.23	31	31 per month
B4036	0–999	6.55	31	31 per month
B4081	0–20	15.61	8	96 per year
B4082	0–20	12.49	8	96 per year
B4083	0–20	1.57	15	180 per year
B4087	0–999	15.61	2	24 per year
B4088	0–999	123.40	1	6 per year
B4149	0–20	1.63	930	930 per month
B4150	0–999	0.67	930	930 per month
B4150SC	0–999	0.67	930	930 per month
B4152	0–999	0.54	930	930 per month
B4152SC	0–999	0.54	930	930 per month
B4153	0–999	2.19	930	930 per month
B4153SC	0–999	2.19	930	930 per month
B4154	0–999	0.97	930	930 per month
B4154SC	0–999	0.97	930	930 per month
B4155	0–999	0.79	930	930 per month
B4155SC	0–999	0.79	930	930 per month
B4157	0–999	BR	930	BR	930 per month
B4157SC	0–999	BR	930	BR	930 per month
B4160	0–20	0.84	930	930 per month
B4160SC	0–20	0.84	930	930 per month
B4161	0–20	BR	930	BR	930 per month
B4161SC	0–20	BR	930	BR	930 per month
B4162	0–20	BR	930	BR	930 per month
B4162SC	0–20	BR	930	BR	930 per month
B9002	0–20	88.47	RO	1	Medical necessity
B9004	0–20	88.47	RO	1	Medical necessity
B9998	0–20	MP	10	120 per year	PA
E0776	0–20	114.49	11.45	1 per 8 years
E0779	0–20	12.60	RO	1	Medical necessity
E0780	0–20	8.49	RO	1	Medical necessity

Durable Medical Equipment (Rental)

Code	Age	Maximum Fee ($)	Rental Only	Rental Amount	Daily Rental Units	Bundled Code	Time Limit
E0781	0–20	10.10	RO	RO	DR	1	Medical necessity
E0791	0–20	6.24	RO	RO	DR	1	Medical necessity

Accessibility

Canes, Crutches, and Walkers

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
A4635	0–999	1.92	—	2	—	2 per year
A4636	0–999	1.77	—	2	—	2 per year
A4637	0–999	1.30	—	4	—	4 per year
E0100	0–999	16.65	—	1	—	1 per year
E0105	0–999	39.04	—	1	—	1 per 3 years
E0110	0–999	63.71	—	1	—	1 per 2 years
E0111	0–999	39.68	—	1	—	1 per 2 years
E0112	0–999	22.90	—	1	—	1 per 2 years
E0113	0–999	11.45	—	1	—	1 per 2 years
E0114	0–999	26.02	—	1	—	1 per 2 years
E0116	0–999	13.02	—	1	—	1 per 2 years
E0130	0–999	57.24	—	1	—	1 per 3 years
E0135	0–999	57.24	—	1	—	1 per 3 years
E0141	0–999	87.43	—	1	—	1 per 3 years
E0143	0–999	92.54	—	1	—	1 per 3 years
E0147	0–999	472.04	—	1	—	1 per 3 years
E0148	0–999	104.34	—	1	—	1 per 3 years
E0149	0–999	183.29	—	1	—	1 per 3 years
E0153	0–999	36.95	—	2	—	2 per 3 years
E0154	0–999	43.20	—	2	—	2 per 3 years
E0155	0–999	29.73	—	1	—	1 per 3 years
E0156	0–999	18.39	—	1	—	1 per 3 years
E0157	0–999	42.67	—	1	—	1 per 3 years
E0158	0–999	18.22	—	4	—	4 per 3 years
E0159	0–999	14.64	—	1	—	2 per 2 years

Hospital Beds and Related Equipment

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
E0250	0–999	853.46	85.35	1	PA	1 per 8 years
E0255	0–999	915.91	91.59	1	PA	1 per 8 years
E0260	0–20	1,150.10	—	1	—	1 per 8 years
E0265	0–20	1,441.52	—	1	—	1 per 8 years
E0271	0–999	130.10	—	1	—	1 per 4 years
E0272	0–999	130.10	—	1	—	1 per 4 years
E0303	0–999	2,590.33	259.03	1	PA	1 per 8 years
E0305	0–20	113.45	—	1	—	1 per 8 years
E0310	0–20	113.45	—	1	—	1 per 8 years
E0315	0–20	88.47	—	1	—	1 per 8 years
E0316	0–20	3,755.50	—	1	PA	1 per 5 years
E0370	0–20	21.37	—	1	—	2 per 2 years

Patient Lifts and Transfer Equipment

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
E0621	0–999	62.45	—	1	—	1 per 4 years
E0630	0–999	713.01	71.30	1	PA	1 per 8 years
E0635	0–999	713.01	71.30	1	PA	1 per 8 years
E0705	0–999	43.72	—	1	—	3 per lifetime

Traction Equipment

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
E0840	0–20	67.65	—	1	—	1 per lifetime
E0850	0–20	79.10	—	1	—	1 per lifetime
E0860	0–999	26.55	—	1	—	1 per lifetime
E0870	0–20	67.65	—	1	—	1 per lifetime
E0880	0–20	75.98	—	1	—	1 per lifetime
E0890	0–20	47.88	—	1	—	1 per lifetime
E0900	0–20	83.26	—	1	—	1 per lifetime

Respiratory and Airway Equipment

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
E0910	0–999	161.38	16.14	1	—	1 per 8 years
E0920	0–20	379.95	37.99	1	—	1 per lifetime
E0930	0–20	379.95	37.99	1	—	1 per lifetime
E0935	0–20	RO	RO	DR	—	21 days per medical event
E0940	0–999	286.28	28.63	1	—	1 per 8 years
E0942	0–20	16.65	—	1	—	1 per medical event
E0944	0–20	13.02	—	1	—	1 per medical event
E0945	0–20	16.14	—	1	—	1 per medical event
E0947	0–20	233.70	23.37	1	—	1 per medical event
E0948	0–20	224.79	22.48	1	—	1 per medical event

Wheelchair Accessories and Positioning Components

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
E0950	0–999	72.34	—	1	—	2 per 4 years
E0951	0–999	20.41	—	2	—	2 per year
E0952	0–999	15.43	—	2	—	2 per year
E0955	0–999	173.55	—	1	PA	1 per 3 years
E0956	0–999	84.62	—	6	PA	6 per 3 years
E0957	0–999	118.39	—	1	PA	1 per 3 years
E0958	0–999	332.42	—	1	—	1 per 4 years
E0959	0–999	61.54	—	2	—	2 per 5 years
E0960	0–999	84.90	—	1	PA	1 per 3 years
E0961	0–999	41.42	—	2	—	2 per 4 years
E0966	0–999	57.32	—	1	—	1 per 5 years
E0967	0–999	57.54	—	2	—	2 per 4 years
E0969	0–999	133.79	—	1	—	2 per 4 years
E0971	0–999	51.65	—	2	—	2 per 4 years
E0973	0–999	80.01	—	2	—	2 per 4 years
E0974	0–999	109.12	—	1	—	2 per 4 years
E0978	0–999	31.81	—	1	—	1 per medical event
E0980	0–999	24.01	—	1	—	2 per 4 years
E0981	0–999	41.32	—	1	—	2 per 4 years
E0982	0–999	47.59	—	1	—	1 per 5 years
E0983	0–999	2,387.47	—	1	PA	1 per 5 years
E0984	0–999	1,564.32	—	1	PA	1 per 5 years
E0986	0–999	5,219.33	—	1	PA	1 per 5 years
E0990	0–999	96.15	—	2	—	2 per 4 years
E0992	0–999	74.53	—	1	—	1 per 5 years
E0994	0–999	15.05	—	2	—	2 per 4 years
E0995	0–999	21.16	—	2	—	2 per 4 years
E1015	0–999	98.46	—	2	PA	2 per 3 years
E1016	0–999	112.71	—	2	PA	2 per 3 years
E1020	0–999	208.93	—	1	PA	1 per 4 years
E1028	0–999	177.39	—	6	PA	6 per 5 years
E1029	0–999	317.21	—	1	PA	1 per 4 years
E1030	0–20	1,000.26	—	1	PA	1 per 4 years
E1031	0–999	366.64	36.66	1	—	1 per 5 years

Power Wheelchairs and Mobility Equipment

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
E1050	0–999	739.30	73.93	1	—	1 per 5 years
E1060	0–999	915.27	91.53	1	—	1 per 5 years
E1070	0–999	795.20	79.52	1	—	1 per 5 years
E1083	0–999	571.69	57.17	1	—	1 per 5 years
E1084	0–20	712.26	71.23	1	—	1 per 5 years
E1085	0–999	525.66	52.57	1	—	1 per 5 years
E1087	0–999	918.49	91.85	1	—	1 per 5 years
E1088	0–999	1,095.21	109.52	1	—	1 per 5 years
E1092	0–999	932.97	93.30	1	—	1 per 5 years
E1093	0–999	932.97	93.30	1	—	1 per 5 years
E1100	0–999	753.78	75.38	1	—	1 per 5 years
E1110	0–999	738.01	73.80	1	—	1 per 5 years
E1150	0–999	592.30	59.23	1	—	1 per 5 years
E1160	0–999	457.63	45.76	1	—	1 per 5 years
E1170	0–999	648.41	64.84	1	—	1 per 5 years
E1171	0–999	582.00	58.20	1	—	1 per 5 years
E1172	0–999	711.08	71.11	1	—	1 per 5 years
E1180	0–999	735.65	73.56	1	—	1 per 5 years
E1190	0–999	849.92	84.99	1	—	1 per 5 years
E1195	0–999	912.05	91.21	1	—	1 per 5 years
E1200	0–999	631.68	63.17	1	—	1 per 5 years
E1221	0–999	344.86	34.49	1	—	1 per 5 years
E1222	0–999	492.08	49.21	1	—	1 per 5 years
E1223	0–999	537.36	53.74	1	—	1 per 5 years
E1224	0–999	589.18	58.92	1	—	1 per 5 years
E1225	0–999	328.12	32.81	1	—	1 per 5 years
E1226	0–999	379.73	—	1	—	1 per 5 years
E1227	0–999	237.03	—	1	—	1 per 5 years
E1228	0–999	20.35	—	1	—	1 per 5 years
E1231	0–999	2,031.05	—	1	PA	1 per 5 years
E1232	0–999	1,835.61	—	1	PA	1 per 5 years
E1233	0–999	1,901.98	—	1	PA	1 per 5 years
E1234	0–999	1,655.81	—	1	PA	1 per 5 years
E1235	0–999	1,594.41	—	1	PA	1 per 5 years
E1236	0–999	1,406.68	—	1	PA	1 per 5 years
E1237	0–999	1,418.98	—	1	PA	1 per 5 years
E1238	0–999	1,479.50	—	1	PA	1 per 5 years
E1240	0–999	747.88	74.79	1	—	1 per 5 years
E1270	0–999	573.20	57.32	1	—	1 per 5 years
E1280	0–999	953.04	95.30	1	—	1 per 5 years
E1295	0–999	881.90	88.19	1	—	1 per 5 years
E1296	0–999	419.96	—	1	—	1 per 5 years
E1297	0–999	89.35	—	1	—	1 per 5 years
E1298	0–999	321.14	—	1	—	1 per 5 years

Durable Medical Equipment Accessories and Supplies

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
E2205	0–999	28.04	—	1	—	2 per 4 years
E2206	0–999	33.31	—	2	—	2 per 4 years
E2207	0–999	37.21	—	1	—	1 per 5 years
E2208	0–999	101.96	—	1	—	1 per 5 years
E2209	0–999	92.36	—	2	—	2 per 4 years
E2210	0–999	5.62	—	12	—	12 per 4 years
E2211	0–999	35.11	—	2	—	2 per 2 years
E2212	0–999	5.04	—	2	—	2 per 2 years
E2213	0–999	26.10	—	2	—	2 per 2 years
E2214	0–999	26.27	—	2	—	2 per 2 years
E2215	0–999	8.24	—	2	—	2 per 2 years
E2217	0–999	29.12	—	2	—	2 per 2 years
E2219	0–999	30.53	—	2	—	2 per 2 years
E2220	0–999	24.48	—	2	—	2 per 2 years
E2221	0–999	21.93	—	2	—	2 per 2 years
E2224	0–999	84.17	—	2	—	2 per 2 years

Wheelchair and Mobility Equipment Components

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
E2322	0–999	1,210.64	—	1	PA	1 per 5 years
E2323	0–999	59.36	—	1	—	1 per 5 years
E2324	0–999	37.61	—	1	—	1 per 5 years
E2325	0–999	1,156.11	—	1	PA	1 per 5 years
E2326	0–999	297.98	—	1	—	1 per 5 years
E2327	0–999	2,242.46	—	1	PA	1 per 5 years
E2328	0–999	4,253.64	—	1	PA	1 per 5 years
E2329	0–999	1,516.04	—	1	PA	1 per 5 years
E2330	0–999	2,937.52	—	1	PA	1 per 5 years

Wheelchair Seating and Positioning Components

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
E2360	0–999	91.99	—	2	—	4 per 3 years
E2361	0–999	114.19	—	2	—	4 per 3 years
E2362	0–999	75.39	—	2	—	4 per 3 years
E2363	0–999	152.30	—	2	—	4 per 3 years
E2364	0–999	91.98	—	2	—	4 per 3 years
E2365	0–999	91.84	—	2	—	4 per 3 years
E2366	0–999	215.84	—	1	—	1 per 5 years
E2367	0–999	343.12	—	1	—	1 per lifetime
E2368	0–999	443.42	—	2	PA	2 per 5 years
E2369	0–999	386.23	—	2	PA	2 per 5 years
E2370	0–999	689.16	—	2	PA	2 per 5 years
E2373	0–999	880.63	—	1	PA	1 per 5 years
E2374	0–999	458.41	—	1	PA	1 per 5 years
E2381	0–999	62.37	—	2	—	2 per 4 years
E2382	0–999	17.01	—	2	—	2 per 4 years
E2383	0–999	124.36	—	2	—	2 per 4 years
E2384	0–999	40.53	—	2	—	2 per 4 years
E2385	0–999	40.53	—	2	—	2 per 4 years
E2386	0–999	62.37	—	2	—	2 per 4 years
E2387	0–999	66.25	—	2	—	2 per 4 years
E2388	0–999	62.37	—	2	—	2 per 4 years
E2389	0–999	66.25	—	2	—	2 per 4 years
E2390	0–999	62.37	—	2	—	2 per 4 years
E2391	0–999	66.25	—	2	—	2 per 4 years
E2394	0–999	65.88	—	2	—	2 per 4 years
E2395	0–999	32.69	—	2	—	2 per 4 years
E2396	0–999	48.29	—	2	—	2 per 4 years

Respiratory and Therapeutic Equipment

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
E2601	0–999	76.10	—	1	PA	1 per 3 years
E2602	0–999	138.95	—	1	PA	1 per 3 years
E2603	0–999	200.04	—	1	PA	1 per 3 years
E2604	0–999	271.04	—	1	PA	1 per 3 years
E2605	0–999	276.14	—	1	PA	1 per 3 years
E2606	0–999	374.32	—	1	PA	1 per 3 years
E2607	0–999	253.74	—	1	PA	1 per 3 years
E2608	0–999	303.87	—	1	PA	1 per 3 years
E2611	0–999	268.12	—	1	PA	1 per 3 years
E2612	0–999	362.71	—	1	PA	1 per 3 years
E2613	0–999	337.38	—	1	PA	1 per 3 years
E2614	0–999	466.91	—	1	PA	1 per 3 years
E2615	0–999	388.27	—	1	PA	1 per 3 years
E2616	0–999	522.40	—	1	PA	1 per 3 years
E2619	0–999	52.63	—	1	—	1 per 3 years
E2620	0–999	470.15	—	1	PA	1 per 3 years
E2621	0–999	493.38	—	1	PA	1 per 3 years

Manual Wheelchairs and Accessories

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
K0001	0–999	380.16	38.02	1	—	1 per 5 years
K0002	0–999	569.44	56.94	1	—	1 per 5 years
K0003	0–999	623.52	62.35	1	—	1 per 5 years
K0004	0–999	930.08	93.01	1	—	1 per 5 years
K0005	0–999	1,513.68	—	1	—	1 per 5 years
K0006	0–999	872.78	87.28	1	—	1 per 5 years
K0007	0–999	1,356.16	135.62	1	—	1 per 5 years
K0008	0–999	MP	—	1	PA	1 per 5 years
K0009	0–999	MP	—	1	PA	1 per 5 years
K0010	0–999	2,964.70	296.47	1	PA	1 per 5 years
K0012	0–999	2,435.07	243.51	1	PA	1 per 5 years
K0013	0–999	MP	—	1	PA	1 per 5 years
K0014	0–999	MP	—	1	PA	1 per 5 years
K0015	0–999	148.77	—	2	—	2 per 5 years
K0017	0–999	41.85	—	2	—	2 per 5 years
K0018	0–999	23.37	—	2	—	2 per 5 years
K0019	0–999	13.38	—	2	—	2 per 5 years
K0020	0–999	38.04	—	1	—	2 per 4 years
K0037	0–999	39.43	—	2	—	2 per 4 years
K0038	0–999	19.86	—	2	—	2 per 4 years
K0039	0–999	44.11	—	2	—	2 per 4 years
K0040	0–999	61.14	—	2	—	2 per 2 years
K0041	0–999	43.33	—	2	—	2 per 2 years
K0042	0–999	29.82	—	2	—	2 per 2 years
K0043	0–999	15.99	—	2	—	2 per 2 years
K0044	0–999	13.92	—	2	—	2 per 2 years
K0045	0–999	46.14	—	2	—	2 per 2 years
K0046	0–999	15.99	—	2	—	2 per 4 years
K0047	0–999	62.62	—	2	—	2 per 4 years
K0050	0–999	26.61	—	2	—	2 per 4 years
K0051	0–999	43.07	—	2	—	2 per 4 years
K0052	0–999	75.69	—	2	—	2 per 4 years
K0053	0–999	83.52	—	2	—	2 per 4 years
K0056	0–999	77.95	—	1	—	1 per 4 years
K0065	0–999	36.41	—	2	—	1 per 4 years
K0069	0–999	81.81	—	2	—	1 per 4 years
K0070	0–999	149.97	—	2	—	1 per 4 years
K0071	0–999	89.45	—	2	—	1 per 4 years
K0072	0–999	53.84	—	2	—	1 per 4 years
K0073	0–999	27.40	—	2	—	1 per 4 years
K0077	0–999	48.18	—	2	—	1 per 4 years

Wheelchair Cushions and Positioning Accessories

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
K0098	0–999	21.62	—	1	—	2 per 4 years
K0105	0–999	81.41	—	2	—	1 per 5 years
K0108	0–999	MP	—	1	PA	Medical necessity
K0195	0–999	161.59	16.16	1	—	2 per 4 years

Power Mobility Devices and Scooters

Code	Age	Maximum Fee	Rental Fee	Rental Units	Prior Authorization	Time Limit
K0800	0–999	1,027.29	102.73	1	PA	1 per 5 years
K0801	0–999	1,656.28	165.63	1	PA	1 per 5 years
K0802	0–999	1,874.42	187.44	1	PA	1 per 5 years
K0822	0–999	3,969.78	396.98	1	PA	1 per 5 years
K0823	0–999	3,969.78	396.98	1	PA	1 per 5 years
K0824	0–999	5,772.63	577.26	1	PA	1 per 5 years
K0825	0–999	5,284.85	528.48	1	PA	1 per 5 years
K0826	0–999	7,473.45	747.34	1	PA	1 per 5 years
K0827	0–999	6,354.63	635.46	1	PA	1 per 5 years
K0900	0–999	MP	—	1	PA	Per medical event

Respiratory

Respiratory Supplies and Tracheostomy Equipment

Code	Age	Updated Fee	Rental Only	Rental Fee	Rental Units	Bundled Code	Prior Authorization	Time Limit
A4605	0–999	2.31	—	—	7	—	—	372 per year
A4608	0–999	50.07	—	—	5	—	—	5 per month
A4611	0–999	119.69	—	—	1	—	—	Medical necessity
A4612	0–999	44.24	—	—	1	—	—	Medical necessity
A4613	0–999	100.96	—	—	1	—	—	Medical necessity
A4614	0–999	19.46	—	—	1	—	—	1 per year
A4616	0–999	0.23	—	—	25	—	—	300 per year
A4618	0–999	6.19	—	—	1	—	—	Medical necessity
A4623	0–999	6.71	—	—	5	—	—	60 per year
A4624	0–999	2.31	—	—	250	—	—	3000 per year
A4625	0–999	7.09	—	—	14	—	—	14 per medical event
A4626	0–999	1.57	—	—	1	—	—	12 per year
A4627	0–999	29.51	—	—	1	—	—	1 per year
A4629	0–999	3.69	—	—	31	—	—	31 per month
A4481	0–999	0.30	—	—	31	—	—	31 per month

Suction Equipment and Related Supplies

Code	Age	Updated Fee	Rental Only	Rental Fee	Rental Units	Bundled Code	Prior Authorization	Time Limit
A7000	0–999	7.45	—	—	1	—	—	4 per year
A7001	0–999	23.02	—	—	1	—	—	1 per 2 years
A7002	0–999	2.66	—	—	1	—	—	12 per year
A7003	0–999	4.16	—	—	3	—	—	36 per year
A7004	0–999	1.24	—	—	3	—	—	36 per year
A7005	0–999	21.45	—	—	1	—	—	2 per year
A7006	0–999	7.77	—	—	3	—	—	36 per year
A7007	0–999	4.16	—	—	3	—	—	36 per year
A7008	0–999	7.65	—	—	3	—	—	36 per year
A7009	0–999	31.96	—	—	1	—	—	1 per year
A7010	0–999	16.42	—	—	1	—	—	12 per year
A7012	0–999	2.94	—	—	1	—	—	12 per year
A7013	0–999	0.57	—	—	31	—	—	372 per year
A7014	0–999	3.54	—	—	1	—	—	12 per year
A7015	0–999	1.53	—	—	1	—	—	12 per year
A7016	0–999	5.33	—	—	1	—	—	12 per year
A7017	0–999	109.75	—	—	1	—	—	1 per year
A7020	0–999	19.89	—	—	1	—	—	1 per month

Tracheostomy Supplies and Accessories

Code	Age	Updated Fee	Rental Only	Rental Fee	Rental Units	Bundled Code	Prior Authorization	Time Limit
A7501	0–999	85.99	—	—	1	—	—	1 per month
A7502	0–999	40.87	—	—	1	—	—	1 per month
A7503	0–999	9.28	—	—	1	—	—	4 per year
A7504	0–999	0.55	—	—	31	—	—	372 per year
A7505	0–999	3.83	—	—	1	—	—	12 per year
A7506	0–999	0.28	—	—	31	—	—	31 per month
A7507	0–999	2.04	—	—	1	—	—	4 per year
A7508	0–999	2.35	—	—	31	—	—	31 per month
A7520	0–999	56.20	—	—	1	—	—	Medical necessity
A7521	0–999	56.20	—	—	1	—	—	Medical necessity
A7522	0–999	56.20	—	—	1	—	—	Medical necessity
A7525	0–999	1.27	—	—	4	—	—	4 per month
A7526	0–999	1.27	—	—	14	—	—	14 per month

Oxygen Equipment and Oxygen Supplies

Code	Age	Updated Fee	Rental Only	Rental Fee	Rental Units	Bundled Code	Prior Authorization	Time Limit
E0424	0–999	RO	RO	228.98	1	—	—	1 per month
E0431	0–999	RO	RO	41.34	1	—	—	1 per month
E0434	0–999	RO	RO	41.34	1	—	—	1 per month
E0439	0–999	RO	RO	228.98	1	—	—	1 per month
E0441	0–999	RO	RO	135.31	1	—	—	1 per month
E0442	0–999	RO	RO	135.31	1	—	—	1 per month
E0443	0–999	RO	RO	20.94	1	—	—	1 per month
E0444	0–999	RO	RO	20.94	1	—	—	1 per month
E0445	0–20	RO	RO	101.94	1	—	—	Medical necessity

Respiratory Support and Airway Clearance Equipment

Code	Age	Updated Fee	Rental Only	Rental Fee	Rental Units	Bundled Code	Prior Authorization	Time Limit
E0457	0–999	RO	RO	39.55	1	—	—	Medical necessity
E0459	0–999	365.36	—	36.54	1	—	—	Medical necessity
E0465	0–999	RO	RO	811.83	1	BC	—	Medical necessity
E0466	0–999	RO	RO	811.83	1	BC	—	Medical necessity
E0468	0–999	835.15	—	83.52	1	—	—	Medical necessity
E0470	0–999	RO	RO	190.73	1	BC	—	1 per month
E0471	0–999	RO	RO	446.92	1	BC	—	1 per month
E0472	0–999	RO	RO	446.92	1	BC	—	1 per month
E0480	0–999	400.77	—	40.08	1	—	—	1 per 4 years
E0482	0–999	5,674.02	—	—	1	—	PA	Medical necessity
E0483	0–999	11,455.62	—	—	1	—	PA	Medical necessity
E0485	0–999	MP	—	—	1	—	PA	1 per year

Humidifiers, Nebulizers, and Respiratory Therapy Equipment

Code	Age	Updated Fee	Rental Only	Rental Fee	Rental Units	Bundled Code	Prior Authorization	Time Limit
E0500	0–999	RO	RO	95.24	1	BC	—	Medical necessity
E0550	0–999	RO	RO	52.04	1	—	—	Medical necessity
E0555	0–999	33.83	—	—	1	—	—	1 per 2 years
E0560	0–999	RO	RO	15.61	1	—	—	Medical necessity
E0561	0–999	RO	RO	9.38	1	—	—	1 per month
E0562	0–999	RO	RO	9.38	1	—	—	1 per month
E0565	0–999	RO	RO	31.22	1	—	—	Medical necessity
E0570	0–999	114.49	—	—	1	—	—	1 per 2 years
E0572	0–999	RO	RO	28.80	1	—	—	1 per month
E0574	0–999	RO	RO	30.43	1	—	—	1 per month
E0585	0–999	161.38	—	16.14	1	—	—	1 per 2 years

Suction Machines and Positive Airway Pressure Equipment

Code	Age	Updated Fee	Rental Only	Rental Fee	Rental Units	Bundled Code	Prior Authorization	Time Limit
E0600	0–999	326.08	—	32.61	1	—	—	1 per 2 years
E0601	0–999	RO	RO	85.87	1	BC	—	Medical necessity
E0605	0–999	20.30	—	—	1	—	—	1 per 4 years
E0606	0–999	171.79	—	17.18	1	—	—	1 per 8 years

Respiratory Monitoring and Related Equipment

Code	Age	Updated Fee	Rental Only	Rental Fee	Rental Units	Bundled Code	Prior Authorization	Time Limit
E0618	0–20	RO	RO	6.60	DR	1	BC	Medical necessity
E0619	0–20	RO	RO	6.60	DR	1	BC	Medical necessity

Oxygen Concentrators and Portable Oxygen Equipment

Code	Age	Updated Fee	Rental Only	Rental Fee	Rental Units	Bundled Code	Prior Authorization	Time Limit
E1390	0–999	RO	RO	182.93	1	—	—	1 per month
E1392	0–999	RO	RO	27.52	1	—	—	1 per month

Respiratory Medication Delivery and Related Supplies

Code	Age	Updated Fee	Rental Only	Rental Fee	Rental Units	Bundled Code	Prior Authorization	Time Limit
Q4074	0–999	26.70	—	—	5	—	—	155 per month

Orthotic & Specialized Equipment

Orthotic / Medical Equipment

Code	Age	Maximum Fee	Rental Only	Rental Fee	Rental Units	Manual Pricing / Bundled Code	Prior Authorization	Time Limit
A6530	0–999	$33.31			2			8 stockings per year
A6531	0–999	$37.14			2			8 stockings per year
A6532	0–999	$65.41			2			8 stockings per year
A6533	0–999	$43.71			2			8 stockings per year
A6534	0–999	$43.71			2			8 stockings per year
A6535	0–999	$43.71			2			8 stockings per year
A6536	0–999	$119.69			2			Per year
A6537	0–999	$119.69			2			Per year
A6538	0–999	$119.69			2			Per year
A6539	0–999	$119.69			2			Per year
A6540	0–999	$119.69			2			Per year
A6541	0–999	$119.69			2			Per year
A8000	0–999	$92.83			1			1 per year
A8001	0–999	$92.83			1			1 per year
A8002	0–999	$265.41			1			Medical necessity
A8003	0–999	$265.41			1			Medical necessity
E0202	0–20	$45.80	RO	RO	1	DR		1 per medical event (up to 5 days)
E0205	0–20	$41.63			1			1 per lifetime
E0603	0–999	$133.05			1		PA	1 per 5 years
E0604	0–999	$62.31	RO	RO		BC	PA	3 months max
E0650	0–20	$520.41		$52.04	1			1 per 8 years
E0651	0–20	$1,010.66		$101.07	1			1 per 8 years
E0652	0–20	$3,959.26		$395.93	1			1 per 8 years
E0655	0–20	$79.10			1			2 per year
E0660	0–20	$72.86			1			2 per year
E0665	0–20	$72.86			1			2 per year
E0666	0–20	$108.77			1			2 per year
E0667	0–20	$424.65			1			2 per year
E0668	0–20	$424.65			1			2 per year
E0744	0–20	$869.13		$86.91	1			Medical necessity
E0745	0–20	$770.20		$77.02	1			Medical necessity
E0747	0–999	$265.41	RO	RO	1			Maximum 6 months rental
E1399	0–999		MP		1	MP	PA	Medical necessity
E1902	0–999		MP		1	MP	PA	1 per 5 years

Specialized Equipment

Code	Age	Maximum Fee	Rental Only	Rental Units	Manual Pricing / Bundled Code	Prior Authorization	Time Limit
E2000	0–999	$24.46		1			1 per 2 years
E2500	0–999	$360.56		1		PA	1 per 5 years
E2502	0–999	$1,102.55		1		PA	1 per 5 years
E2504	0–999	$1,454.42		1		PA	1 per 5 years
E2506	0–999	$2,132.62		1		PA	1 per 5 years
E2508	0–999	$3,297.74		1		PA	1 per 5 years
E2510	0–999	$6,240.51		1		PA	1 per 5 years
E2511	0–999		MP	1	MP	PA	1 per 5 years
E2512	0–999		MP	1	MP	PA	1 per 5 years
E2599	0–999		MP	1	MP	PA	1 per 5 years
K0739	0–999	$10.73		16			$160.00 per year
S1040	0–20	$3,219.00		1		PA	Medical necessity
V5336	0–999		MP	1	MP	PA	Medical necessity

Orthotic and Prosthetic Devices Fee Schedule

Medical/Surgical Supplies

Code	Age	Orthopedic Specialty	Maximum Fee / Marker	Remaining Schedule Values (as supplied)
A4565	0-20		5.73	1 1 PER MEDICAL EVENT
A4570	0-20		11.45	1 1 PER MEDICAL EVENT

Therapeutic Footwear & Inserts

Code	Age	Maximum Fee / Marker	Remaining Schedule Values (as supplied)
A5500	0-999	54.08	2 2 PER MEDICAL EVENT
A5501	0-999	162.24	2 2 PER MEDICAL EVENT
A5503	0-999	27.47	2 2 PER FOOT PER YEAR
A5504	0-999	27.47	2 2 PER FOOT PER YEAR
A5505	0-999	27.47	2 2 PER FOOT PER YEAR
A5506	0-999	27.47	2 2 PER FOOT PER YEAR
A5507	0-999	28.79	2 2 PER FOOT PER YEAR
A5512	0-999	20.78	2 2 PER FOOT PER YEAR
A5513	0-999	31.02	2 2 PER FOOT PER YEAR

Durable Medical Equipment (DME)

Code	Age	Maximum Fee / Marker	Remaining Schedule Values (as supplied)
E1800	0-20	78.87	2 2 PER 2 YEARS
E1801	0-999	78.87	1 2 PER 2 YEARS
E1805	0-999	81.01	2 2 PER 2 YEARS
E1806	0-999	78.87	1 2 PER 2 YEARS
E1810	0-999	78.87	1 2 PER 2 YEARS
E1811	0-999	78.87	1 2 PER 2 YEARS
E1815	0-20	81.01	2 2 PER 2 YEARS
E1816	0-999	78.87	1 2 PER 2 YEARS
E1818	0-999	78.87	1 2 PER 2 YEARS
E1820	0-20	6.5	8 8 PER YEAR
E1821	0-999	6.5	8 8 PER YEAR
E1825	0-20	81.01	2 2 PER 2 YEARS
E1830	0-20	81.01	2 2 PER 2 YEARS
E1840	0-999	78.87	2 2 PER 2 YEARS

Orthotics, Prosthetics & Related Devices

Code	Age	Orthopedic Specialty	Maximum Fee / Marker	Remaining Schedule Values (as supplied)
L0120	0-999	OS	13.02	1 2 PER MEDICAL EVENT
L0130	0-999		52.04	1 1 PER MEDICAL EVENT
L0140	0-999		41.63	1 1 PER YEAR
L0150	0-999		57.24	1 1 PER MEDICAL EVENT
L0160	0-999		93.67	1 1 PER MEDICAL EVENT
L0170	0-999		374.4	1 1 PER MEDICAL EVENT
L0172	0-999		46.32	1 2 PER MEDICAL EVENT
L0174	0-999		56.2	1 1 PER YEAR
L0180	0-999		193.59	1 1 PER MEDICAL EVENT
L0190	0-999		301.83	1 1 PER MEDICAL EVENT
L0200	0-999		212.33	1 1 PER MEDICAL EVENT
L0220	0-999		62.45	1 1 PER YEAR
L0450	0-999		130.65	1 1 PER MEDICAL EVENT
L0452	0-999		244.14	1 1 PER MEDICAL EVENT
L0454	0-999		236.17	1 1 PER MEDICAL EVENT
L0455	0-999		187.9	1 1 PER MEDICAL EVENT
L0456	0-999		236.17	1 1 PER MEDICAL EVENT
L0457	0-999		187.89	1 1 PER MEDICAL EVENT
L0458	0-999		586.18	1 1 PER MEDICAL EVENT
L0460	0-999		586.18	1 1 PER MEDICAL EVENT
L0462	0-999		586.18	1 1 PER MEDICAL EVENT
L0464	0-999		586.18	1 1 PER MEDICAL EVENT
L0466	0-999		265.57	1 1 PER MEDICAL EVENT
L0467	0-999		213.85	1 1 PER MEDICAL EVENT
L0468	0-999		332.95	1 1 PER MEDICAL EVENT
L0470	0-999		474.04	1 1 PER MEDICAL EVENT
L0472	0-999		297.54	1 1 PER MEDICAL EVENT
L0480	0-999		920.1	1 1 PER MEDICAL EVENT
L0482	0-999		1054.77	1 1 PER MEDICAL EVENT
L0484	0-999		1229.38	1 1 PER MEDICAL EVENT
L0486	0-999		1218.31	1 1 PER MEDICAL EVENT
L0488	0-999		244.14	1 1 PER MEDICAL EVENT
L0490	0-999		788.18	1 1 PER MEDICAL EVENT
L0491	0-999		533.59	1 1 PER 2 YEARS
L0621	0-999		77.44	1 1 PER 2 YEARS
L0622	0-999		209.99	1 1 PER 2 YEARS
L0623	0-999		36.48	1 1 PER 2 YEARS
L0624	0-999		259.32	1 1 PER 2 YEARS
L0625	0-999		47.86	1 1 PER 2 YEARS
L0626	0-999		67.71	1 1 PER 2 YEARS
L0627	0-999		357.01	1 1 PER 2 YEARS
L0628	0-999		72.85	1 1 PER 2 YEARS
L0629	0-999		186.3	1 MEDICAL NECESSITY
L0630	0-999		140.64	1 2 PER LIFETIME
L0631	0-999		891.58	1 2 PER LIFETIME
L0641	0-999		53.86	1 1 PER 2 YEARS
L0642	0-999	OS	284.08	1 1 PER 2 YEARS
L0648	0-999		709.46	1 2 PER LIFETIME
L0700	0-999		1509.17	1 1 PER MEDICAL EVENT
L0710	0-999		1665.3	1 1 PER MEDICAL EVENT
L0810	0-999		1665.3	1 1 PER MEDICAL EVENT
L0820	0-999		1248.97	1 1 PER MEDICAL EVENT
L0830	0-999		1639.28	1 1 PER MEDICAL EVENT
L0859	0-999		983.97	2 2 EVERY 2 YEARS
L0970	0-999		54.65	1 1 PER 2 YEARS
L0972	0-999		52.04	1 1 PER 2 YEARS
L0974	0-999		119.69	1 1 PER 2 YEARS
L0976	0-999		120.73	1 1 PER 2 YEARS
L0978	0-999		72.86	1 1 PER 2 YEARS
L0980	0-999		4.16	1 2 PER YEAR
L0984	0-999		36.31	2 2 PER YEAR
L0999	0-999		MP	1 MP PA MEDICAL NECESSITY
L1000	0-999		1005.42	1 1 PER YEAR
L1005	0-999		64.38	1 1 PER 2 YEARS
L1010	0-999		36.43	1 1 PER YEAR
L1020	0-999		64.02	2 2 PER YEAR
L1025	0-999		84.31	1 1 PER YEAR
L1030	0-999		63.49	2 2 PER YEAR
L1040	0-999		72.86	2 2 PER YEAR
L1050	0-999		42.67	1 1 PER YEAR
L1060	0-999		48.92	2 2 PER YEAR
L1070	0-999		36.43	2 2 PER YEAR
L1080	0-999		46.84	2 2 PER YEAR
L1085	0-999		71.82	1 1 PER YEAR
L1090	0-999		46.84	2 2 PER YEAR
L1100	0-999		78.06	1 1 PER YEAR
L1110	0-999		130.1	1 1 PER YEAR
L1120	0-999		22.9	6 6 PER YEAR
L1200	0-999		728.57	1 1 PER YEAR
L1210	0-999		48.92	2 2 PER YEAR
L1220	0-999		48.92	1 1 PER YEAR
L1230	0-999		286.22	1 1 PER 2 YEARS
L1240	0-999		52.04	2 2 PER YEAR
L1250	0-999		32.27	2 2 PER YEAR
L1260	0-999		62.45	2 2 PER YEAR
L1270	0-999		54.12	2 2 PER YEAR
L1280	0-999		49.96	2 2 PER YEAR
L1290	0-999		46.84	2 2 PER YEAR
L1300	0-999		780.61	1 1 PER YEAR
L1310	0-999		832.65	1 1 PER MEDICAL EVENT
L1499	0-999		MP	1 MP PA MEDICAL NECESSITY
L1600	0-999		57.24	1 1 PER LIFETIME
L1620	0-999	OS	46.84	1 1 PER 5 YEARS
L1630	0-999		57.24	1 1 PER LIFETIME
L1640	0-999		124.9	1 1 PER 5 YEARS
L1650	0-999		124.9	1 1 PER LIFETIME
L1652	0-999		198.14	1 1 PER MEDICAL EVENT
L1660	0-999	OS	31.22	1 1 PER 5 YEARS
L1680	0-999		494.38	1 1 PER MEDICAL EVENT
L1685	0-999		879.48	1 1 PER MEDICAL EVENT
L1686	0-999		608.87	1 1 PER MEDICAL EVENT
L1690	0-999		1256.29	2 2 PER MEDICAL EVENT
L1700	0-999		970.03	1 1 PER MEDICAL EVENT
L1710	0-999		598.47	1 1 PER MEDICAL EVENT
L1720	0-999		895.1	1 1 PER MEDICAL EVENT
L1730	0-999		598.47	1 1 PER MEDICAL EVENT
L1755	0-999		785.81	1 1 PER MEDICAL EVENT
L1810	0-999	OS	84.83	2 2 PER YEAR
L1812	0-999	OS	63.4	2 2 PER YEAR
L1820	0-999	OS	62.45	2 2 PER YEAR
L1830	0-999	OS	52.04	2 2 PER YEAR
L1832	0-999	OS	600.15	2 2 PER 2 YEARS
L1833	0-999	OS	461.15	2 2 PER 2 YEARS
L1834	0-999		676.53	2 2 PER YEAR
L1836	0-999	OS	74.17	2 2 PER YEAR
L1840	0-999		624.49	2 2 PER YEAR
L1843	0-999	OS	347.35	2 2 PER 2 YEARS
L1844	0-999		614.08	2 2 PER 2 YEARS
L1845	0-999	OS	614.08	2 2 PER 2 YEARS
L1846	0-999		619.28	2 2 PER YEAR
L1847	0-999	OS	373.67	2 2 PER MEDICAL EVENT
L1850	0-999	OS	144.67	2 2 PER 2 YEARS
L1851	0-999		286.52	2 2 PER 2 YEARS
L1852	0-999	OS	476.14	2 2 PER 2 YEARS
L1860	0-999		520.41	2 2 PER 2 YEARS
L1900	0-999		202.96	2 2 PER 2 YEARS
L1902	0-999	OS	42.16	2 2 PER YEAR
L1904	0-999		237.83	2 2 PER YEAR
L1906	0-999	OS	90.04	2 2 PER MEDICAL EVENT
L1910	0-999	OS	147.8	2 2 PER 2 YEARS
L1920	0-999		135.31	2 2 PER YEAR
L1930	0-999	OS	84.83	2 2 PER YEAR
L1932	0-999		832.61	2 2 PER YEAR
L1940	0-999		281.02	2 2 PER YEAR
L1945	0-999		676.53	2 2 PER YEAR
L1950	0-999		231.06	2 2 PER YEAR
L1951	0-999		806.1	2 2 PER YEAR
L1960	0-999		269.57	2 2 PER YEAR
L1970	0-999		390.3	2 2 PER YEAR
L1980	0-999		130.1	2 2 PER 2 YEARS
L1990	0-999		239.39	2 2 PER 2 YEARS
L2000	0-999		302.88	2 2 PER 2 YEARS
L2010	0-999		255	2 2 PER 2 YEARS
L2020	0-999		495.43	2 2 PER YEAR
L2030	0-999		317.45	2 2 PER 2 YEARS
L2034	0-999	OS	1326.23	1 2 PER 2 YEARS
L2036	0-999		1124.07	2 2 PER YEAR
L2037	0-999		1144.89	2 2 PER 2 YEARS
L2038	0-999		624.49	2 2 PER YEAR
L2040	0-999		104.08	1 1 PER YEAR
L2050	0-999		249.79	1 1 PER YEAR
L2060	0-999		312.24	1 1 PER YEAR
L2070	0-999		64.53	1 1 PER YEAR
L2080	0-999		202.96	1 1 PER YEAR
L2090	0-999		281.97	2 2 PER 2 YEARS
L2106	0-999		245.63	2 2 PER MEDICAL EVENT
L2108	0-999		642.18	2 2 PER MEDICAL EVENT
L2112	0-999	OS	355.96	2 2 PER MEDICAL EVENT
L2114	0-999	OS	499.59	2 2 PER MEDICAL EVENT
L2116	0-999	OS	499.59	2 2 PER MEDICAL EVENT
L2126	0-999		833.17	2 2 PER MEDICAL EVENT
L2128	0-999		1047.58	2 2 PER MEDICAL EVENT
L2132	0-999	OS	523.53	2 2 PER MEDICAL EVENT
L2134	0-999		523.53	2 2 PER MEDICAL EVENT
L2136	0-999		714	2 2 PER MEDICAL EVENT
L2180	0-999		46.84	2 2 PER MEDICAL EVENT
L2182	0-999		44.16	2 2 PER MEDICAL EVENT
L2184	0-999		79.52	2 2 PER MEDICAL EVENT
L2186	0-999		46.84	2 2 PER MEDICAL EVENT
L2188	0-999		309.12	2 2 PER MEDICAL EVENT
L2190	0-999		51.53	2 2 PER MEDICAL EVENT
L2192	0-999		161.33	1 1 PER MEDICAL EVENT
L2200	0-999		22.44	4 2 PER INDIVIDUAL ORTHOSIS
L2210	0-999		46.84	4 2 PER INDIVIDUAL ORTHOSIS
L2220	0-999		60.37	4 2 PER INDIVIDUAL ORTHOSIS
L2230	0-999		33.31	2 2 PER ORTHOSIS
L2240	0-999		33.31	2 2 PER ORTHOSIS
L2250	0-999		192.55	2 2 PER ORTHOSIS
L2260	0-999		72.86	2 2 PER ORTHOSIS
L2265	0-999		20.82	2 2 PER ORTHOSIS
L2270	0-999		33.31	4 1 PER ORTHOSIS
L2275	0-999		78.17	4 Only 2 PER ORTHOSIS
L2280	0-999		260.2	2 2 PER 3 YEARS
L2300	0-999		78.06	1 1 PER 2 YEARS
L2310	0-999		46.84	1 1 PER 2 YEARS
L2320	0-999		72.86	2 2 PER ORTHOSIS
L2330	0-999		173.82	2 2 PER ORTHOSIS
L2335	0-999		118.65	2 2 PER ORTHOSIS
L2340	0-999		311.2	2 2 PER ORTHOSIS
L2350	0-999		390.3	4 2 PER INDIVIDUAL ORTHOSIS
L2360	0-999		31.22	4 4 PER YEAR
L2370	0-999		70.78	4 2 PER INDIVIDUAL ORTHOSIS
L2375	0-999		46.84	4 4 PER ORTHOSIS
L2380	0-999		46.84	4 4 PER ORTHOSIS
L2385	0-999		23.42	4 4 PER ORTHOSIS
L2390	0-999		45.28	4 4 PER ORTHOSIS
L2395	0-999		78.82	4 4 PER ORTHOSIS
L2397	0-999		70.11	2 4 PER ORTHOSIS
L2405	0-999		22.9	4 4 PER ORTHOSIS
L2415	0-999		152.48	4 4 PER ORTHOSIS
L2425	0-999		112.41	4 4 PER ORTHOSIS
L2430	0-999		62.56	4 2 PER ORTHOSIS
L2492	0-999		20.82	4 2 PER ORTHOSIS
L2500	0-999		106.16	2 1 PER INDIVIDUAL ORTHOSIS
L2510	0-999		359.08	2 1 PER ORTHOSIS
L2520	0-999		187.35	2 1 PER ORTHOSIS
L2525	0-999		676.53	2 1 PER ORTHOSIS
L2526	0-999		468.36	2 1 PER ORTHOSIS
L2530	0-999		93.67	2 1 PER ORTHOSIS
L2540	0-999		173.82	2 1 PER ORTHOSIS
L2550	0-999		121.77	2 1 PER ORTHOSIS
L2570	0-999		98.88	2 1 PER ORTHOSIS
L2580	0-999		381.98	1 1 PER 2 YEARS
L2600	0-999		88.47	2 2 PER ORTHOSIS
L2610	0-999		114.75	2 2 PER ORTHOSIS
L2620	0-999		126.5	2 1 PER ORTHOSIS
L2622	0-999		90.04	2 2 PER ORTHOSIS
L2624	0-999		285.71	2 1 PER ORTHOSIS
L2627	0-999		714	1 1 PER 2 YEARS
L2628	0-999		1092.85	1 1 PER YEAR
L2630	0-999		88.47	1 1 PER ORTHOSIS
L2640	0-999		130.1	1 1 PER YEAR
L2650	0-999		52.04	1 2 PER YEAR
L2660	0-999		93.67	1 1 PER 2 YEARS
L2670	0-999		72.86	1 1 PER 2 YEARS
L2680	0-999		62.45	2 2 PER YEAR
L2750	0-999		50	2 4 PER ORTHOSIS
L2755	0-999		83.16	2 1 PER ORTHOSIS
L2760	0-999		29.14	8 4 PER ORTHOSIS
L2768	0-999		16.1	2 2 PER 2 YEARS
L2780	0-999		42.98	4 4 PER ORTHOSIS
L2785	0-999		22.9	4 2 PER KAFO
L2795	0-999		38.51	2 1 PER KAFO
L2800	0-999		52.57	2 1 PER KAFO
L2810	0-999		51.53	2 2 PER KAFO
L2820	0-999		32.79	2 1 PER KAFO
L2830	0-999		32.79	2 1 PER KAFO
L2840	0-999		40.34	2 2 PER MEDICAL EVENT
L2850	0-999		31.22	2 2 PER MEDICAL EVENT
L2999	0-999	OS	MP	1 MP PA MEDICAL NECESSITY
L3000	0-999		181.1	2 1 PER FOOT PER YEAR
L3001	0-999		31.22	2 2 PER FOOT PER YEAR
L3002	0-999		83.26	2 2 PER FOOT PER YEAR
L3010	0-999		83.26	2 1 PER FOOT PER YEAR
L3020	0-999		83.26	2 1 PER FOOT PER YEAR
L3030	0-999		78.06	2 2 PER FOOT PER YEAR
L3040	0-999		62.45	2 2 PER FOOT PER YEAR
L3050	0-999		62.45	2 2 PER FOOT PER YEAR
L3060	0-999		83.26	2 2 PER FOOT PER YEAR
L3070	0-999		9.37	2 1 PER FOOT PER YEAR
L3080	0-999		4.69	2 1 PER FOOT PER YEAR
L3100	0-999		26.02	2 2 PER YEAR
L3140	0-999		37.99	1 2 PER YEAR
L3150	0-999		30.18	1 2 PER YEAR
L3170	0-999	OS	16.65	2 2 PER FOOT PER YEAR
L3201	0-20		39.04	2 3 PAIR PER YEAR
L3202	0-20		39.04	2 3 PAIR PER YEAR
L3203	0-20		39.04	2 3 PAIR PER YEAR
L3204	0-20		37.47	2 3 PAIR PER YEAR
L3206	0-20		44.75	2 3 PAIR PER YEAR
L3207	0-20		56.2	2 3 PAIR PER YEAR
L3208	0-20	OS	18.73	2 2 PER FOOT PER YEAR
L3209	0-20	OS	18.73	2 2 PER FOOT PER YEAR
L3211	0-20	OS	20.82	2 2 PER FOOT PER YEAR
L3215	0-999		85.35	2 2 PER FOOT PER YEAR
L3216	0-999		85.35	2 2 PER FOOT PER YEAR
L3217	0-999		97.84	2 2 PER FOOT PER YEAR
L3219	0-999		85.35	2 2 PER FOOT PER YEAR
L3221	0-999		74.94	2 2 PER FOOT PER YEAR
L3222	0-999		103.04	2 2 PER FOOT PER YEAR
L3230	0-999		85.35	2 2 PER FOOT PER YEAR
L3251	0-999		229.02	2 2 PER FOOT PER YEAR
L3253	0-999		70.78	2 1 PER FOOT PER YEAR
L3254	0-999		2.14	2 6 PER YEAR
L3255	0-999		3.38	2 6 PER YEAR
L3257	0-999		MP	1 MP PA 3 PER YEAR
L3300	0-999		19.26	3 3 PER YEAR
L3310	0-999		37.99	3 3 PER YEAR
L3320	0-999		115.01	3 3 PER YEAR
L3330	0-999		313.14	3 3 PER YEAR
L3332	0-999		27.59	3 3 PER YEAR
L3334	0-999		18.22	3 3 PER YEAR
L3340	0-999		51.53	2 4 PER YEAR
L3350	0-999		13.53	2 4 PER YEAR
L3360	0-999		20.82	2 4 PER YEAR
L3370	0-999		15.61	2 4 PER YEAR
L3380	0-999		16.65	2 4 PER YEAR
L3390	0-999		24.46	2 4 PER YEAR
L3400	0-999		26.02	2 4 PER YEAR
L3410	0-999		11.97	2 4 PER YEAR
L3420	0-999		20.3	2 4 PER YEAR
L3430	0-999		21.34	2 2 PER YEAR
L3440	0-999		30.18	2 2 PER YEAR
L3450	0-999		27.59	2 2 PER YEAR
L3460	0-999		9.89	2 2 PER YEAR
L3465	0-999		11.97	2 2 PER YEAR
L3470	0-999		15.61	2 2 PER YEAR
L3480	0-999		10.41	2 2 PER FOOT PER YEAR
L3570	0-999		21.86	2 6 PER YEAR
L3580	0-999		36.15	2 2 PER YEAR
L3590	0-999		29.77	2 2 PER YEAR
L3595	0-999		21.86	2 2 PER YEAR
L3600	0-999		35.39	2 3 PER YEAR
L3610	0-999		55.99	2 3 PER YEAR
L3620	0-999		34.35	2 3 PER YEAR
L3630	0-999		55.99	2 3 PER YEAR
L3640	0-999		24.1	1 3 PER YEAR
L3649	0-999		MP	1 MP PA MEDICAL NECESSITY
L3650	0-999	OS	29.14	2 2 PER MEDICAL EVENT
L3660	0-999	OS	46.32	2 2 PER MEDICAL EVENT
L3670	0-999	OS	62.45	2 2 PER MEDICAL EVENT
L3675	0-999	OS	103.76	1 1 PER 2 YEARS
L3677	0-999	OS	155.05	2 2 PER 2 YEARS
L3710	0-999	OS	84.87	2 2 PER YEAR
L3720	0-999		242.51	2 2 PER YEAR
L3730	0-999		403.83	2 2 PER YEAR
L3740	0-999		475.65	2 2 PER YEAR
L3760	0-999	OS	288.18	2 PER MEDICAL EVENT
L3761	0-999	OS	403.07	2 PER MEDICAL EVENT
L3762	0-999	OS	54.4	2 2 PER YEAR
L3763	0-999		234.18	2 2 PER MEDICAL EVENT
L3764	0-999		309.12	2 2 PER MEDICAL EVENT
L3808	0-999		186.12	2 2 PER MEDICAL EVENT
L3809	0-999	OS	139.35	2 2 PER MEDICAL EVENT
L3900	0-999		952.34	2 2 PER YEAR
L3901	0-999		975.76	2 2 PER YEAR
L3904	0-999		2087.41	2 1 PER ORTHOSIS
L3906	0-999		259.16	2 2 PER MEDICAL EVENT
L3908	0-999	OS	18.73	2 4 PER YEAR
L3912	0-999	OS	20.82	2 2 PER 2 YEARS
L3918	0-999		63.46	2 2 PER 2 YEARS
L3923	0-999	OS	23.48	1 PER MEDICAL EVENT
L3924	0-999	OS	23.48	1 PER MEDICAL EVENT
L3925	0-999	OS	35.78	2 2 PER YEAR
L3929	0-999	OS	57.02	2 2 PER YEAR
L3931	0-999	OS	137.93	2 2 PER YEAR
L3960	0-999	OS	317.97	2 2 PER MEDICAL EVENT
L3962	0-999	OS	199.84	2 2 PER 2 YEARS
L3980	0-999	OS	130.1	2 2 PER MEDICAL EVENT
L3982	0-999	OS	234.18	2 2 PER MEDICAL EVENT
L3984	0-999	OS	262.28	2 2 PER MEDICAL EVENT
L3995	0-999	OS	12.49	2 6 PER MEDICAL EVENT
L3999	0-999		MP	2 MP PA MEDICAL NECESSITY
L4000	0-999		676.53	2 2 PER 2 YEARS
L4010	0-999		187.35	2 2 PER LIFETIME
L4020	0-999		359.08	2 2 PER YEAR
L4030	0-999		187.35	2 2 PER YEAR
L4040	0-999		189.43	2 2 PER YEAR
L4045	0-999		189.95	2 2 PER YEAR
L4050	0-999		171.73	2 2 PER YEAR
L4055	0-999		166.01	2 2 PER YEAR
L4060	0-999		220.65	2 2 PER YEAR
L4070	0-999		93.67	4 4 PER YEAR
L4080	0-999		49.37	2 2 PER YEAR
L4090	0-999		44.2	2 2 PER YEAR
L4100	0-999		39.55	2 2 PER YEAR
L4110	0-999		35.39	2 2 PER YEAR
L4130	0-999		311.2	2 2 PER YEAR
L4205	0-999		10.73	16 $160.00 PER YEAR
L4210	0-999		MP	1 MP PA LIMITED TO $160 PER YEAR
L4350	0-999	OS	64.53	2 2 PER MEDICAL EVENT (One per Leg)
L4360	0-999	OS	198.27	2 2 PER MEDICAL EVENT (One per Leg)
L4361	0-999	OS	198.27	2 2 PER MEDICAL EVENT (One per Leg)
L4370	0-999	OS	78.06	2 2 PER MEDICAL EVENT
L4386	0-999	OS	114.9	2 2 PER MEDICAL EVENT (One per Leg)
L4387	0-999	OS	114.9	2 2 PER MEDICAL EVENT (One per Leg)
L4392	0-999		14.97	1 2 PER YEAR
L4394	0-999		10.94	1 2 PER YEAR
L4396	0-999		106.87	2 2 PER YEAR
L4397	0-999		106.87	2 2 PER YEAR
L4398	0-999		49.14	2 2 PER 2 YEARS
L5000	0-999		139.47	2 2 PER PROSTHETIC PER 2 YEARS
L5010	0-999		565.69	2 2 PER PROSTHETIC PER 2 YEARS
L5020	0-999		565.69	2 2 PER PROSTHETIC PER 2 YEARS
L5050	0-999		1488.88	2 2 PER PROSTHETIC PER 2 YEARS
L5060	0-999		1342.64	2 2 PER PROSTHETIC PER 2 YEARS
L5100	0-999		1477.95	2 2 PER PROSTHETIC PER YEAR
L5105	0-999		1845.36	2 2 PER PROSTHETIC PER YEAR
L5150	0-999		2081.62	2 2 PER PROSTHETIC PER YEAR
L5160	0-999		2185.7	2 2 PER PROSTHETIC PER YEAR
L5200	0-999		1838.07	2 2 PER PROSTHETIC PER YEAR
L5210	0-999		1353.05	2 2 PER PROSTHETIC PER YEAR
L5220	0-999		1353.05	2 2 PER PROSTHETIC PER YEAR
L5230	0-999		1873.46	2 2 PER PROSTHETIC PER YEAR
L5250	0-999		3047.49	2 2 PER PROSTHETIC PER YEAR
L5280	0-999		3226.51	2 2 PER PROSTHETIC PER YEAR
L5301	0-999		1563.41	2 2 PER PROSTHETIC PER 2 YEARS
L5312	0-999		3175.07	2 2 PER PROSTHETIC PER 2 YEARS
L5321	0-999		2714.98	2 2 PER PROSTHETIC PER 2 YEARS
L5331	0-999		3459.44	2 2 PER PROSTHETIC PER 2 YEARS
L5341	0-999		3601.29	2 2 PER PROSTHETIC PER 2 YEARS
L5400	0-999		728.57	2 1 PER AMPUTATION
L5410	0-999		218.57	2 1 PER AMPUTATION
L5420	0-999		785.81	2 1 PER AMPUTATION
L5430	0-999		218.57	2 1 PER AMPUTATION
L5450	0-999		244.59	2 1 PER AMPUTATION
L5460	0-999		405.92	2 1 PER AMPUTATION
L5530	0-999		941.93	2 1 PER AMPUTATION
L5535	0-999		780.61	2 1 PER AMPUTATION
L5540	0-999		941.93	2 1 PER AMPUTATION
L5560	0-999		936.73	4 2 PER AMPUTATION
L5580	0-999		1014.79	2 1 PER AMPUTATION
L5585	0-999		861.79	2 1 PER AMPUTATION
L5590	0-999		1145.93	2 1 PER AMPUTATION
L5595	0-999		2227.33	2 1 PER AMPUTATION
L5600	0-999		2477.13	2 1 PER AMPUTATION
L5610	0-999		987.73	2 2 PER PROSTHETIC PER 4 YEARS
L5611	0-999		988.77	2 2 PER PROSTHETIC PER 4 YEARS
L5613	0-999		1821.42	2 2 PER PROSTHETIC PER 4 YEARS
L5616	0-999		520.41	2 2 PER PROSTHETIC PER 4 YEARS
L5617	0-999		346.58	2 2 PER PROSTHETIC PER 3 YEARS
L5618	0-999		182.14	2 2 PER PROSTHETIC PER 2 YEARS
L5620	0-999		156.12	2 2 PER PROSTHETIC PER 2 YEARS
L5622	0-999		182.14	2 2 PER PROSTHETIC PER 2 YEARS
L5624	0-999		174.86	2 2 PER PROSTHETIC PER 2 YEARS
L5626	0-999		182.14	2 2 PER PROSTHETIC PER 2 YEARS
L5628	0-999		182.14	2 2 PER PROSTHETIC PER 2 YEARS
L5629	0-999		130.1	2 1 PER PROSTHESIS
L5630	0-999		260.2	2 2 PER PROSTHETIC PER 4 YEARS
L5631	0-999		208.16	2 2 PER PROSTHETIC PER 4 YEARS
L5632	0-999		128.58	2 2 PER PROSTHETIC PER 4 YEARS
L5634	0-999		78.06	2 2 PER PROSTHETIC PER 4 YEARS
L5636	0-999		127.44	2 2 PER PROSTHETIC PER 4 YEARS
L5637	0-999		130.1	2 2 PER PROSTHETIC PER 4 YEARS
L5638	0-999		182.14	2 2 PER PROSTHETIC PER 4 YEARS
L5639	0-999		604.4	2 1 PER PROSTHESIS
L5640	0-999		398.63	2 2 PER PROSTHETIC PER 4 YEARS
L5642	0-999		398.63	2 2 PER PROSTHETIC PER 4 YEARS
L5643	0-999		428.3	2 2 PER PROSTHETIC PER 4 YEARS
L5644	0-999		104.08	2 2 PER PROSTHETIC PER 4 YEARS
L5645	0-999		142.59	2 2 PER PROSTHETIC PER 4 YEARS
L5646	0-999		226.9	2 2 PER PROSTHETIC PER 4 YEARS
L5647	0-999		285.71	2 2 PER PROSTHETIC PER 4 YEARS
L5648	0-999		226.9	2 2 PER PROSTHETIC PER 2 YEARS
L5649	0-999		1428.52	2 2 PER PROSTHETIC PER 2 YEARS
L5650	0-999		104.08	2 2 PER PROSTHETIC PER 4 YEARS
L5651	0-999		475.65	2 2 PER PROSTHETIC PER 2 YEARS
L5652	0-999		234.18	2 2 PER PROSTHETIC PER 2 YEARS
L5653	0-999		260.2	2 2 PER PROSTHETIC PER 2 YEARS
L5654	0-999		218.57	2 2 PER PROSTHETIC PER YEAR
L5655	0-999		174.86	2 2 PER PROSTHETIC PER YEAR
L5656	0-999		234.18	2 2 PER PROSTHETIC PER YEAR
L5658	0-999		234.18	2 2 PER PROSTHETIC PER YEAR
L5661	0-999		237.3	2 2 PER PROSTHETIC PER YEAR
L5665	0-999		213.37	2 2 PER PROSTHETIC PER YEAR
L5666	0-999		31.22	2 2 PER PROSTHETIC PER YEAR
L5668	0-999		83.26	2 2 PER PROSTHETIC PER YEAR
L5670	0-999		114.49	2 2 PER PROSTHETIC PER 2 YEARS
L5671	0-999		404.16	2 2 PER PROSTHETIC PER 2 YEARS
L5672	0-999		99.92	2 2 PER PROSTHETIC PER 2 YEARS
L5673	0-999		484.17	2 1 PER PROSTHESIS
L5676	0-999		230.02	2 2 PER PROSTHETIC PER 4 YEARS
L5677	0-999		271.14	2 2 PER PROSTHETIC PER 4 YEARS
L5678	0-999		10.41	2 2 PER PROSTHETIC PER 2 YEARS
L5679	0-999		403.47	2 2 PER PROSTHETIC PER YEAR
L5680	0-999		197.75	2 2 PER PROSTHETIC PER 4 YEARS
L5681	0-999		858.09	2 1 PER PROSTHESIS
L5682	0-999		208.16	2 2 PER PROSTHETIC PER 4 YEARS
L5684	0-999		15.61	2 2 PER PROSTHETIC PER 4 YEARS
L5685	0-999		48.92	2 6 PER PROSTHETIC PER YEAR
L5686	0-999		10.41	2 2 PER PROSTHETIC PER 2 YEARS
L5688	0-999		37.47	2 2 PER PROSTHETIC PER YEAR
L5690	0-999		54.12	2 2 PER PROSTHETIC PER YEAR
L5692	0-999		46.84	2 2 PER PROSTHETIC PER YEAR
L5694	0-999		87.43	2 2 PER PROSTHETIC PER YEAR
L5695	0-999		96.28	2 4 PER PROSTHETIC PER YEAR
L5696	0-999		98.88	2 2 PER PROSTHETIC PER 2 YEARS
L5697	0-999		52.04	2 2 PER PROSTHETIC PER 2 YEARS
L5698	0-999		78.06	2 2 PER PROSTHETIC PER YEAR
L5699	0-999		41.63	2 2 PER PROSTHETIC PER YEAR
L5700	0-999		1826.02	2 2 PER PROSTHETIC PER 4 YEARS
L5701	0-999		2192.92	2 2 PER PROSTHETIC PER 4 YEARS
L5702	0-999		2774.37	2 2 PER PROSTHETIC PER 4 YEARS
L5704	0-999		341.6	2 2 PER PROSTHETIC PER 4 YEARS
L5705	0-999		610.39	2 2 PER PROSTHETIC PER 4 YEARS
L5706	0-999		598.35	2 2 PER PROSTHETIC PER 4 YEARS
L5707	0-999		788.84	2 2 PER PROSTHETIC PER 4 YEARS
L5710	0-999		104.08	2 2 PER PROSTHETIC PER 4 YEARS
L5711	0-999		94.71	2 2 PER PROSTHETIC PER 4 YEARS
L5712	0-999		260.2	2 2 PER PROSTHETIC PER 4 YEARS
L5714	0-999		225.19	2 2 PER PROSTHETIC PER 4 YEARS
L5716	0-999		260.2	2 2 PER PROSTHETIC PER 4 YEARS
L5718	0-999		428.3	2 2 PER PROSTHETIC PER 4 YEARS
L5722	0-999		528.73	2 2 PER PROSTHETIC PER 4 YEARS
L5724	0-999		698.38	2 2 PER PROSTHETIC PER 4 YEARS
L5726	0-999		690.06	2 2 PER PROSTHETIC PER 4 YEARS
L5728	0-999		1149.05	2 2 PER PROSTHETIC PER 4 YEARS
L5780	0-999		729.66	2 2 PER PROSTHETIC PER 4 YEARS
L5785	0-999		332.54	2 2 PER PROSTHETIC PER 4 YEARS
L5790	0-999		567.13	2 2 PER PROSTHETIC PER 4 YEARS
L5795	0-999		1129.17	2 2 PER PROSTHETIC PER 4 YEARS
L5810	0-999		94.71	2 2 PER PROSTHETIC PER 4 YEARS
L5811	0-999		366.93	2 2 PER PROSTHETIC PER 4 YEARS
L5812	0-999		338.26	2 2 PER PROSTHETIC PER 4 YEARS
L5814	0-999		2360.6	2 2 PER PROSTHETIC PER 2 YEARS
L5816	0-999		237.3	2 2 PER PROSTHETIC PER 4 YEARS
L5818	0-999		427.77	2 2 PER PROSTHETIC PER 4 YEARS
L5822	0-999		483.98	2 2 PER PROSTHETIC PER 4 YEARS
L5824	0-999		651.55	2 2 PER PROSTHETIC PER 4 YEARS
L5828	0-999		1142.81	2 2 PER PROSTHETIC PER 4 YEARS
L5830	0-999		843.06	2 2 PER PROSTHETIC PER 4 YEARS
L5840	0-999		2236.04	2 2 PER PROSTHETIC PER 4 YEARS
L5845	0-999		1143.82	2 2 PER PROSTHETIC PER 3 YEARS
L5850	0-999		46.84	2 2 PER PROSTHETIC PER 4 YEARS
L5855	0-999		219.09	2 2 PER PROSTHETIC PER 4 YEARS
L5910	0-999		94.71	2 2 PER PROSTHETIC PER 4 YEARS
L5920	0-999		189.95	2 2 PER PROSTHETIC PER 4 YEARS
L5940	0-999		365.32	2 2 PER PROSTHETIC PER 2 YEARS
L5950	0-999		618.63	2 2 PER PROSTHETIC PER 2 YEARS
L5960	0-999		1284.36	2 2 PER PROSTHETIC PER 4 YEARS
L5962	0-999		404.33	2 2 PER PROSTHETIC PER 4 YEARS
L5964	0-999		596.87	2 2 PER PROSTHETIC PER 4 YEARS
L5966	0-999		760.54	2 2 PER PROSTHETIC PER 4 YEARS
L5968	0-999		2365.44	2 2 PER PROSTHETIC PER 4 YEARS
L5970	0-999		52.04	2 2 PER PROSTHETIC PER 2 YEARS
L5972	0-999		189.95	2 2 PER PROSTHETIC PER 2 YEARS
L5974	0-999		72.86	2 2 PER PROSTHETIC PER 2 YEARS
L5975	0-999		301.77	2 2 PER PROSTHETIC PER 4 YEARS
L5976	0-999		312.24	2 2 PER PROSTHETIC PER 2 YEARS
L5978	0-999		145.71	2 2 PER PROSTHETIC PER 2 YEARS
L5979	0-999		1454.19	2 2 PER PROSTHETIC PER 2 YEARS
L5980	0-999		2362.97	2 2 PER PROSTHETIC PER 2 YEARS
L5981	0-999		1908.95	2 2 PER PROSTHETIC PER 2 YEARS
L5982	0-999		219.61	2 2 PER PROSTHETIC PER 2 YEARS
L5984	0-999		261.24	2 2 PER PROSTHETIC PER 2 YEARS
L5985	0-999		174.9	2 2 PER PROSTHETIC PER 3 YEARS
L5986	0-999		218.57	2 2 PER PROSTHETIC PER 2 YEARS
L5987	0-999		4587.08	2 2 PER PROSTHETIC PER 2 YEARS
L5988	0-999		1300.35	2 2 PER PROSTHETIC PER 4 YEARS
L5990	0-999		42.33	2 2 PER PROSTHETIC PER 2 YEARS
L5999	0-999		MP	1 MP PA MEDICAL NECESSITY
L6000	0-999		684.85	2 2 PER 4 YEARS
L6010	0-999		684.85	2 2 PER 4 YEARS
L6020	0-999		684.85	2 2 PER 2 YEARS
L6050	0-999		1087.65	2 2 PER 2 YEARS
L6055	0-999		1328.07	2 2 PER 4 YEARS
L6100	0-999		1083.48	2 2 PER 2 YEARS
L6110	0-999		1134.48	2 2 PER 2 YEARS
L6120	0-999		1321.83	2 2 PER 4 YEARS
L6130	0-999		1321.83	2 2 PER 4 YEARS
L6200	0-999		1524.79	2 2 PER 4 YEARS
L6205	0-999		1761.05	2 2 PER 4 YEARS
L6250	0-999		1529.99	2 2 PER 2 YEARS
L6300	0-999		2029.58	2 2 PER 2 YEARS
L6310	0-999		2029.58	2 2 PER 4 YEARS
L6320	0-999		676.53	2 2 PER 4 YEARS
L6350	0-999		2029.58	2 2 PER 2 YEARS
L6360	0-999		2237.74	2 2 PER 4 YEARS
L6370	0-999		676.53	2 2 PER 4 YEARS
L6380	0-999		778.44	2 1 PER ORTHOSIS
L6382	0-999		1171.15	2 1 PER ORTHOSIS
L6384	0-999		1620.14	2 1 PER ORTHOSIS
L6386	0-999		255.93	2 1 PER ORTHOSIS
L6388	0-999		280.18	2 1 PER ORTHOSIS
L6400	0-999		1353.05	2 2 PER 4 YEARS
L6450	0-999		1951.52	2 2 PER 4 YEARS
L6500	0-999		1951.52	2 2 PER 4 YEARS
L6550	0-999		2029.58	2 2 PER 4 YEARS
L6570	0-999		2237.74	2 2 PER 4 YEARS
L6580	0-999		1064.95	2 2 PER 4 YEARS
L6582	0-999		964.55	2 2 PER 4 YEARS
L6584	0-999		1512.5	2 2 PER 4 YEARS
L6586	0-999		1415.61	2 2 PER 4 YEARS
L6588	0-999		2325.11	2 2 PER 4 YEARS
L6590	0-999		1766.81	2 2 PER 4 YEARS
L6600	0-999		57.24	2 2 PER 4 YEARS
L6605	0-999		57.24	2 2 PER 4 YEARS
L6610	0-999		57.24	2 2 PER 4 YEARS
L6615	0-999		137.39	2 2 PER 2 YEARS
L6616	0-999		46.84	2 6 PER 4 YEARS
L6620	0-999		175.9	2 2 PER 2 YEARS
L6624	0-999		1510.37	2 1 PER ORTHOSIS
L6625	0-999		156.12	2 2 PER 4 YEARS
L6628	0-999		305.31	2 2 PER 4 YEARS
L6629	0-999		93.24	2 2 PER 4 YEARS
L6630	0-999		109.61	2 2 PER 2 YEARS
L6632	0-999		32.79	2 12 PER YEAR
L6635	0-999		81.18	2 2 PER 2 YEARS
L6637	0-999		239.43	2 2 PER 4 YEARS
L6640	0-999		168.1	2 2 PER 4 YEARS
L6641	0-999		56.73	2 2 PER 4 YEARS
L6642	0-999		71.82	2 2 PER 4 YEARS
L6645	0-999		253.44	2 2 PER 4 YEARS
L6650	0-999		267.49	2 2 PER 4 YEARS
L6655	0-999		20.82	2 2 PER YEAR
L6660	0-999		26.02	2 2 PER YEAR
L6665	0-999		22.69	2 2 PER YEAR
L6670	0-999		12.49	2 2 PER YEAR
L6672	0-999		41.63	2 2 PER YEAR
L6675	0-999		33.31	2 2 PER YEAR
L6676	0-999		83.26	2 2 PER YEAR
L6680	0-999		72.86	2 2 PER PROSTHESIS
L6682	0-999		83.26	2 2 PER PROSTHESIS
L6684	0-999		88.47	2 2 PER PROSTHESIS
L6686	0-999		332.54	2 2 PER 4 YEARS
L6687	0-999		285.71	2 2 PER 4 YEARS
L6688	0-999		285.71	2 2 PER 4 YEARS
L6689	0-999		427.77	2 2 PER 4 YEARS
L6690	0-999		427.77	2 2 PER 4 YEARS
L6691	0-999		213.89	2 2 PER YEAR
L6692	0-999		390.3	2 2 PER 2 YEARS
L6693	0-999		1847.98	2 2 PER 4 YEARS
L6703	0-999		290.25	2 2 PER 4 YEARS
L6706	0-999		278.57	2 2 PER 4 YEARS
L6707	0-999		1026.79	2 2 PER 4 YEARS
L6708	0-999		671.25	2 2 PER 4 YEARS
L6709	0-999		967.28	2 2 PER 4 YEARS
L6805	0-999		167.57	2 2 PER 4 YEARS
L6810	0-999		87.43	2 2 PER 4 YEARS
L6881	0-999		536.5	2 2 PER 2 YEARS
L6882	0-999		2503.8	1 2 PER 2 YEARS
L6890	0-999		83.79	2 2 PER YEAR
L6900	0-999		565.16	2 2 PER 4 YEARS
L6905	0-999		565.16	2 2 PER 4 YEARS
L6910	0-999		565.16	2 2 PER 4 YEARS
L6915	0-999		296.63	2 2 PER 4 YEARS
L6920	0-999		2706.11	2 2 PER LIFETIME
L6925	0-999		3434.67	2 2 PER LIFETIME
L6930	0-999		2706.11	2 2 PER LIFETIME
L6935	0-999		3434.67	2 2 PER LIFETIME
L6940	0-999		3887.43	2 2 PER LIFETIME
L6945	0-999		4615.99	2 2 PER LIFETIME
L6950	0-999		4492.14	2 2 PER LIFETIME
L6955	0-999		5220.7	2 2 PER LIFETIME
L6960	0-999		6551.9	2 2 PER LIFETIME
L6965	0-999		5823.33	2 2 PER LIFETIME
L6970	0-999		6551.9	2 2 PER LIFETIME
L6975	0-999		7280.47	2 2 PER LIFETIME
L7007	0-999		2831.17	2 2 PER LIFETIME
L7008	0-999		2331.41	2 2 PER LIFETIME
L7009	0-999		2774.8	2 2 PER LIFETIME
L7040	0-999		1057.46	2 2 PER LIFETIME
L7045	0-999		501.67	2 2 PER LIFETIME
L7170	0-999		3664.69	2 2 PER LIFETIME
L7185	0-999		3664.69	2 2 PER LIFETIME
L7186	0-999		6753.82	2 2 PER LIFETIME
L7360	0-999		85.35	2 2 PER 3 YEARS
L7362	0-999		85.35	2 2 PER LIFETIME
L7364	0-999		130.1	2 2 PER 3 YEARS
L7366	0-999		267.49	1 1 PER 3 YEARS
L7499	0-999		MP	2 MP PA MEDICAL NECESSITY
L7520	0-999		MP	1 MP PA MEDICAL NECESSITY
L8000	0-999		28.04	2 2 PER YEAR
L8001	0-999		134.13	2 2 PER 2 YEARS
L8002	0-999		177.05	2 2 PER 2 YEARS
L8010	0-999		39.86	6 6 PER YEAR
L8015	0-999		36.93	2 2 PER 4 YEARS
L8020	0-999		145.31	2 2 PER YEAR
L8030	0-999		157.16	2 2 PER 2 YEARS
L8300	0-999		67.65	1 2 PER YEAR
L8310	0-999		182.14	1 2 PER YEAR
L8400	0-999		6.24	6 72 PER PROSTHETIC PER YEAR
L8410	0-999		6.24	6 72 PER PROSTHETIC PER YEAR
L8415	0-999		9.37	6 72 PER PROSTHETIC PER YEAR
L8417	0-999		47.75	2 6 PER PROSTHETIC PER YEAR
L8420	0-999		13.53	6 72 PER PROSTHETIC PER YEAR
L8430	0-999		14.57	6 72 PER PROSTHETIC PER YEAR
L8435	0-999		13.53	6 72 PER PROSTHETIC PER YEAR
L8440	0-999		31.22	2 4 PER PROSTHETIC PER YEAR
L8460	0-999		46.32	2 4 PER PROSTHETIC PER YEAR
L8465	0-999		37.99	2 4 PER PROSTHETIC PER YEAR
L8470	0-999		2.08	6 72 PER PROSTHETIC PER YEAR
L8480	0-999		2.61	6 72 PER PROSTHETIC PER YEAR
L8485	0-999		7.08	2 72 PER PROSTHETIC PER YEAR
L8499	0-999		MP	1 MP PA MEDICAL NECESSITY
L8500	0-999		420.62	1 1 PER LIFETIME
L8501	0-999		124.9	1 6 PER YEAR
L8507	0-999		124.9	1 1 PER 5 YEARS

Vision/Ocular Prosthetic Devices

Code	Age	Maximum Fee / Marker	Remaining Schedule Values (as supplied)
V2623	0-999	608.87	2 MEDICAL NECESSITY
V2624	0-999	41.63	2 2 PER YEAR
V2625	0-999	260.2	2 1 PER PROSTHESIS
V2626	0-999	166.53	2 1 PER PROSTHESIS
V2627	0-999	967.95	2 MEDICAL NECESSITY
V2628	0-999	223.77	2 MEDICAL NECESSITY

QIO Wheelchair Pricing and Enteral Nutrition Product Lists

QIO pricing note: The supplied guide states that the wheelchair codes and rates below are used by the Agency’s fee-for-service Quality Improvement Organization (QIO) vendor for pricing purposes only. They are not separately available through the DME program; fee-for-service providers are reimbursed for codes submitted with custom wheelchair and wheelchair repair requests.

Category 1: Wheelchair Components, Accessories, and Power Seating

Code	Rate
E0988	$265.39
E1006	$5,130.36
E1007	$6,946.70
E1008	$6,947.32
E1010	$908.97
E1014	$336.67
E1017	$131.54
E1086	$844.02
E1089	$1,273.76
E1090	$1,361.53
E1130	$489.42
E1140	$682.55
E1161	$2,181.61
E1250	$782.54
E1260	$966.67
E1285	$1,270.00
E1290	$1,110.02
E2201	$344.01
E2202	$437.02
E2203	$441.70
E2204	$749.98
E2216	$31.37
E2218	$48.39
E2219	$43.62
E2225	$16.04
E2226	$34.99
E2227	$1,658.46
E2228	$863.26
E2231	$141.70
E2310	$929.99
E2311	$1,882.81
E2312	$1,787.98
E2313	$283.92
E2321	$1,262.86
E2340	$330.42
E2341	$495.67
E2342	$413.05
E2343	$660.89
E2351	$555.20
E2359	$154.37
E2371	$119.79
E2375	$680.71
E2376	$1,066.70
E2392	$42.82

Category 2: Wheelchair Seat Cushions

Code	Rate
E2622	$263.42
E2623	$335.19
E2624	$265.58
E2625	$336.21
E2626	$572.69
E2627	$913.84
E2628	$688.43
E2629	$871.19
E2630	$609.22
E2631	$243.70
E2632	$154.96
E2633	$129.02

Category 3: Power Wheelchair Battery Accessory

Code	Rate
K0733	$24.01

Category 4: Power-Operated Vehicle Bases

Code	Rate
K0806	$1,242.83
K0807	$1,885.86
K0808	$2,917.83

Category 5: Power Wheelchair Bases

Code	Rate
K0813	$2,012.86
K0814	$2,576.85
K0815	$2,933.96
K0816	$2,809.99
K0820	$2,150.11
K0821	$2,760.12
K0828	$5,764.52
K0829	$5,293.48
K0835	$3,385.66
K0836	$3,511.12
K0837	$4,040.86
K0838	$3,614.95
K0839	$5,231.44
K0840	$7,925.55
K0841	$3,603.66
K0842	$3,603.66
K0843	$4,338.71
K0848	$4,409.44
K0849	$4,239.57
K0850	$5,114.87
K0851	$4,917.90
K0852	$5,909.90
K0853	$6,070.99
K0854	$8,042.66
K0855	$7,597.47
K0856	$4,733.13
K0857	$4,827.95
K0858	$5,872.46
K0859	$5,600.44
K0860	$8,389.49
K0861	$6,106.68
K0862	$4,740.70
K0863	$5,872.46
K0864	$8,389.49

Enteral Nutrition Product Listings

Enteral Formula — Manufactured Blenderized Natural-Food Formulas

The source lists the following products under HCPCS code B4149.

Code	Product Name
B4149	Compleat Pediatric
	Compleat Pediatric Reduced Calorie
	Compleat

Enteral Formula — Standard Intact-Nutrient Formulas

The source lists the following products under HCPCS code B4150.

Code	Product Name
B4150	Kate Farms® Pediatric Blended Meals – Banana & Blue
	Kate Farms® Pediatric Blended Meals – Mango & Straw
	Kate Farms® Pediatric Blended Meals – Squash & Carrot
	Boost
	Boost High Protein
	Ensure
	Ensure High Protein
	Fibersource HN
	Isosource
	Isosource HN
	Jevity 1 Cal
	Jevity 1.2 Cal

B4150SC — Listed Formula Products

The product list preserves the B4150SC code exactly as supplied.

Code	Product Name
B4150SC	Kate Farms® Standard 1.0 Chocolate
	Kate Farms® Standard 1.0 Plain
	Kate Farms® Standard 1.0 Vanilla
	Kate Farms® Standard 1.4 Chocolate
	Kate Farms® Standard 1.4 Plain
	Kate Farms® Standard 1.4 Strawberry
	Kate Farms® Standard 1.4 Vanilla

Enteral Formula — Calorically Dense Formulas

The source lists the following products under HCPCS code B4152.

Code	Product Name
B4152	Lipistart
	Nutren 1.0
	Nutren 1.0 Fiber
	Nutren Replete
	Osmolite
	Osmolite 1 Cal
	Osmolite 1.2 Cal
	Promote
	Promote with Fiber
	Replete
	Replete with Fiber

B4152SC — Listed Formula Products

The product list preserves the B4152SC code exactly as supplied.

Code	Product Name
B4152SC	Boost Plus
	Ensure Complete
	Ensure Plus
	Ensure Plus HN
	Isosource 1.5
	Jevity 1.5
	Nutren 1.5
	Nutren 2.0
	Osmolite 1.5 Cal
	Resource 2.0
	Resurgex Plus
	TwoCal HN

Enteral Formula — Hydrolyzed-Protein / Peptide Formulas

The source lists the following products under HCPCS code B4153.

Code	Product Name
B4153	Impact Peptide 1.5
	Impact Glutamine
	Kate Farms® Peptide 1.0 Plain
	Kate Farms® Peptide 1.0 Vanilla
	Kate Farms® Peptide 1.5 Plain
	Kate Farms® Peptide 1.5 Vanilla
	L-Emental
	Peptamen
	Peptamen 1.5
	Peptamen AF
	Peptamen with PreBio1
	Perative

Enteral Nutrition Products and Codes

Code	Product Name
B4154	Tolerex
	Vital 1.0 Cal
	Vital 1.5 Cal
	Vital AF 1.2 Cal
	Vital HN
	Vivonex Plus
	Vivonex RTF
	Vivonex TEN
B4154SC	Glucerna 1.0
	Glucerna 1.2
	Glucerna 1.5
	Glytrol
	Impact
	Impact 1.5
	Impact Advanced Recovery
	Impact with Fiber
	Kate Farms® Glucose Support 1.2 Vanilla
	Kate Farms® Renal Support 1.8 Vanilla
B4155	KetoCal
	KetoCal 3.1
	KetoCal 4.1
	KetoVie
	Nepro
	NovaSource Renal
	Nutren Pulmonary
	NutriHep
	NutriRenal
	Oxepa
	Pulmocare
	Ren/Gen
	Renalcal
	Resource Diabetic
	Suplena
B4155SC	Complex MSD Amino Acid Blend
	Beneprotein
	Duocal
	GlutarAde GA-1 Amino Acid Blend
	Glycosade
	Liquigen
	MCT Oil
	MCT procal
	Microlipid
	OS 2 (Milupa OS 2)
	PhenylAde Amino Acid Blend MTE
	Polycose
	ProMod
	ProPhree
	Proteinex Liquid
	ProViMin
	Ross Carbohydrate Free
	SolCarb
	Acerflex 454g
	Camino pro- MSUD 140ml
	Camino pro- PKU 140ml
	Complex Essential MSD 454g
	Cyclinex – 2 400g
	Glutarex – 2 400g
B4161	HCY 2 454g
	Hominex – 2 400g
	I – Valex – 2 400g
	Ketonex – 2 400g
	MSUD 2 (Milupa) 500g
	MSUD Maxamum 454g
	Periflex Junior 454g
	Phenex – 2 400g
	PhenylAde Essential 454g
	Phenyl-Free 2 454g
	Phenyl-Free 2HP 454g
	Propimex – 2 400g
	Tyrex – 2 400g
	WND 2 400g
	XLEU Maxamum 454g
	XLYS, TRY Maxamum 500g
	XMET Maxamum 454g
	XP Maxamum 500g
B4161SC	Boost Kid Essentials
	Boost Kid Essentials 1.5
	Boost Kid Essentials 1.5 with Fiber
B4157	Kate Farms® Kids Nutrition Chocolate
	Kate Farms® Kids Nutrition Strawberry
	Kate Farms® Kids Nutrition Vanilla
	Kate Farms® Pediatric Standard 1.2 Chocolate
	Kate Farms® Pediatric Standard 1.2 Vanilla
	Kindercal
	Kindercal TF
	Kindercal TF with Fiber
	Kindercal with Fiber
B4157SC	Nutren Junior
	Nutren Junior with Fiber
	PediaSure
	PediaSure 1.5 Cal
	PediaSure 1.5 Cal with Fiber
	PediaSure Enteral
	PediaSure Enteral with Fiber
	PediaSure with Fiber
B4160	Alfamino Infant 400g
	Alfamino Junior 400g
	E028 Splash 237mL
	EleCare (for infants) 400g
	EleCare Junior 400g
	Gerber Extensive HA 400g
	Homactin AA Plus 250ml
	Isovactin AA Plus 250ml
	Kate Farms® Pediatric Peptide 1.0 Strawberry
	Kate Farms® Pediatric Peptide 1.0 Vanilla
	Kate Farms® Pediatric Peptide 1.5 Plain
	Kate Farms® Pediatric Peptide 1.5 Vanilla
B4160SC	Neocate 400g
	Neocate Junior 400g
	Neocate Nutra 400g
	Nutramigen with Enflora LGG 357g
	PediaSure Peptide 1.0 Cal 237mL
	PediaSure Peptide 1.5 Cal 237mL
B4162	Pepdite One+ (Pepdite Junior) 51g
	Peptamen Junior 1.5 250mL
	Peptamen Junior 250mL
	Peptamen Junior Fiber 250mL
	Peptamen Junior Prebio 250mL
	Phenactin AA Plus 250ml
	Portagen 454g
	Pregestimil 24 454g
	Pregestimil 454g
	Promactin AA Plus 250ml
	Puramino Infant
	Puramino Jr Unflavored
	Puramino Jr Vanilla
	Similac Expert Care Alimentum 454g
	Vilactin AA Plus 250mL
	Vivonex Pediatric 250mL
B4162SC	3232A 454g
	Calcilo XD 375g
	Complex JR MSD 400g
	Cyclinex – 1 400g
	GlutarAde Junior GA-1 400g
	Glutarex – 1 400g
	Glytactin RTD 250mL
	Hominex – 1 400g
	I – Valex – 1 400g
	Ketonex – 1 400g
	Milupa HOM 2 500g
	MSUD 1 500g
	MSUD Analog 400g
	OS 1 500g
	Periflex Infant 400g
	Phenex – 1 400g
	PhenylAde60 454g
	Phenyl-Free 1 454g
	PKU 1 500g
	PKU 2 500g
	PKU 3 500g
	Propimex – 1 400g
	Tylactin RTD 15 250ml
	TYR 2 500g
	Tyrex – 1 400g
	TYROS 1 454g
	TYROS 2 454g
	UCD 2 450g
	XLEU Analog 400g
	XLEU Maxamaid 454g
	XLYS, XTrp Analog 400g
	XLYS, XTrp Maxamaid 454g
	XMET Analog 400g
	XMET Maxamaid 454g
	XMTVI Analog 400g
	XMTVI Maxamaid 454g
	XPhe, XTyr Analog 400g
	XPTM Analog 400g

Surgically Implantable Devices

The codes and descriptions below are reimbursable only to hospitals and ambulatory surgical centers enrolled in the Fee-for-Service delivery system.

Code	Modifier	Age	Maximum Fee	Prior Authorization	Limit
E0783		0–999	$9,991.75	PA	Medical necessity
E0786		0–999	$9,392.25	PA	Medical necessity
L8679		0–999	$17,383.00		Medical necessity
	SC	0–999	$8,691.00		Medical necessity

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