Durable Medical Equipment, Prosthetics, Orthotics, and ... · PDF fileDurable Medical...

Durable Medical Equipment,

Prosthetics, Orthotics, and Supplies

(DMEPOS)

Revised 2014 Fee Schedule

HCPCS Mod Description JURIS CATG Ceiling Floor

A4604 NU Tubing with heating element D IN $62,96 $53,52

A4619 NU Face tent D IN $2,03 $1,73

A7003 NU Nebulizer administration set D IN $3,00 $2,55

A7004 NU Disposable nebulizer sml vol D IN $1,98 $1,68

A7005 NU Nondisposable nebulizer set D IN $33,71 $28,65

A7006 NU Filtered nebulizer admin set D IN $10,43 $8,87

A7007 NU Lg vol nebulizer disposable D IN $5,05 $4,29

A7010 NU Disposable corrugated tubing D IN $25,80 $21,93

A7012 NU Nebulizer water collec devic D IN $4,14 $3,52

A7013 NU Disposable compressor filter D IN $0,91 $0,77

A7014 NU Compressor nondispos filter D IN $4,91 $4,17

A7015 NU Aerosol mask used w nebulize D IN $2,06 $1,75

A7017 NU Nebulizer not used w oxygen D IN $146,57 $124,58

A7017 RR Nebulizer not used w oxygen D IN $14,67 $12,47

A7017 UE Nebulizer not used w oxygen D IN $109,92 $93,43

A7018 Water distilled w/nebulizer D SU $0,41 $0,35

A7020 NU Interface, cough stim device D IN $15,83 $13,46

A7025 NU Replace chest compress vest D IN $475,63 $404,29

A7026 NU Replace chst cmprss sys hose D IN $31,44 $26,72

A7027 NU Combination oral/nasal mask D IN $203,97 $173,37

A7028 NU Repl oral cushion combo mask D IN $54,19 $46,06

A7029 NU Repl nasal pillow comb mask D IN $22,13 $18,81

A7030 NU Cpap full face mask D IN $177,80 $151,13

A7031 NU Replacement facemask interfa D IN $65,76 $55,90

A7032 NU Replacement nasal cushion D IN $38,20 $32,47

A7033 NU Replacement nasal pillows D IN $26,78 $22,76

A7034 NU Nasal application device D IN $110,87 $94,24

A7035 NU Pos airway press headgear D IN $37,45 $31,83

A7036 NU Pos airway press chinstrap D IN $17,14 $14,57

A7037 NU Pos airway pressure tubing D IN $38,65 $32,85

A7038 NU Pos airway pressure filter D IN $5,09 $4,33

A7039 NU Filter, non disposable w pap D IN $14,44 $12,27

A7044 NU Pap oral interface D IN $113,96 $96,87

A7045 NU Repl exhalation port for pap D IN $18,34 $15,59

A7045 RR Repl exhalation port for pap D IN $1,83 $1,56

A7045 UE Repl exhalation port for pap D IN $13,77 $11,70

A7046 NU Repl water chamber, pap dev D IN $18,38 $15,62

E0424 RR Stationary compressed gas 02 D OX $0,00 $0,00

E0431 RR Portable gaseous 02 D OX $0,00 $0,00

E0433 RR Portable liquid oxygen sys D OX $0,00 $0,00

E0434 RR Portable liquid 02 D OX $0,00 $0,00

E0439 RR Stationary liquid 02 D OX $0,00 $0,00

E0441 Stationary o2 contents, gas D OX $0,00 $0,00

E0442 Stationary o2 contents, liq D OX $0,00 $0,00

E0443 Portable 02 contents, gas D OX $0,00 $0,00

E0444 Portable 02 contents, liquid D OX $0,00 $0,00

E0450 RR Vol control vent invasiv int D FS $1.043,81 $887,24

E0460 RR Neg press vent portabl/statn D FS $802,19 $681,86

E0461 RR Vol control vent noninv int D FS $1.043,81 $887,24

E0463 RR Press supp vent invasive int D FS $1.537,95 $1.307,26

E0464 RR Press supp vent noninv int D FS $1.537,95 $1.307,26

E0470 RR Rad w/o backup non-inv intfc D CR $241,85 $205,57

E0471 RR Rad w/backup non inv intrfc D CR $605,26 $514,47

E0472 RR Rad w backup invasive intrfc D CR $605,26 $514,47

E0482 RR Cough stimulating device D CR $470,26 $399,72

E0485 NU Oral device/appliance prefab D IN $0,00 $0,00

E0485 RR Oral device/appliance prefab D IN $0,00 $0,00

E0485 UE Oral device/appliance prefab D IN $0,00 $0,00

E0486 NU Oral device/appliance cusfab D IN $0,00 $0,00

E0486 RR Oral device/appliance cusfab D IN $0,00 $0,00

E0486 UE Oral device/appliance cusfab D IN $0,00 $0,00

E0561 NU Humidifier nonheated w pap D IN $100,85 $85,72

E0561 RR Humidifier nonheated w pap D IN $10,07 $8,56

E0561 UE Humidifier nonheated w pap D IN $75,63 $64,29

E0562 NU Humidifier heated used w pap D IN $283,91 $241,32

E0562 RR Humidifier heated used w pap D IN $28,37 $24,11

E0562 UE Humidifier heated used w pap D IN $212,93 $180,99

E0565 RR Compressor air power source D CR $66,72 $56,71

E0570 RR Nebulizer with compression D CR $0,00 $0,00

E0572 RR Aerosol compressor adjust pr D CR $41,65 $35,40

E0580 NU Nebulizer for use w/ regulat D IN $126,34 $107,39

E0580 RR Nebulizer for use w/ regulat D IN $12,64 $10,74

E0580 UE Nebulizer for use w/ regulat D IN $94,74 $80,53

E0585 RR Nebulizer w/ compressor & he D CR $38,34 $32,59

E0601 RR Cont airway pressure device D CR $105,29 $89,50

E1372 NU Oxy suppl heater for nebuliz D IN $178,28 $151,54

E1372 RR Oxy suppl heater for nebuliz D IN $25,91 $22,02

E1372 UE Oxy suppl heater for nebuliz D IN $131,97 $112,17

E1390 RR Oxygen concentrator D OX $0,00 $0,00

E1391 RR Oxygen concentrator, dual D OX $0,00 $0,00

E1392 RR Portable oxygen concentrator D OX $0,00 $0,00

K0738 RR Portable gas oxygen system D OX $0,00 $0,00

AL AR AZ CA CO CT DC DE FL

$62,96 $62,96 $62,96 $62,96 $62,96 $62,96 $62,96 $62,96 $62,96

$2,03 $2,03 $2,03 $2,03 $2,03 $2,03 $2,03 $2,03 $2,03

$3,00 $3,00 $3,00 $3,00 $3,00 $3,00 $2,55 $2,99 $2,85

$1,68 $1,68 $1,98 $1,98 $1,68 $1,70 $1,98 $1,68 $1,68

$28,65 $28,65 $33,71 $33,71 $28,65 $32,05 $33,71 $30,39 $28,65

$10,43 $10,43 $10,43 $10,43 $10,43 $9,36 $10,43 $8,90 $10,36

$4,86 $4,82 $5,05 $5,05 $4,84 $4,60 $5,05 $4,34 $4,56

$21,93 $21,93 $25,80 $25,80 $21,93 $25,80 $25,80 $25,50 $21,93

$4,14 $4,14 $4,14 $4,14 $4,14 $4,13 $3,52 $3,92 $3,94

$0,77 $0,77 $0,91 $0,91 $0,77 $0,86 $0,91 $0,83 $0,77

$4,91 $4,91 $4,91 $4,91 $4,91 $4,68 $4,91 $4,41 $4,75

$2,06 $2,06 $2,06 $2,06 $2,06 $1,90 $1,79 $1,80 $2,06

$146,57 $146,57 $146,57 $146,57 $146,57 $146,57 $146,57 $146,57 $146,57

$14,67 $14,67 $14,67 $14,67 $14,67 $14,67 $14,67 $14,67 $14,67

$109,92 $109,92 $109,92 $109,92 $109,92 $109,92 $109,92 $109,92 $109,92

$0,35 $0,35 $0,41 $0,41 $0,35 $0,41 $0,41 $0,41 $0,35

$15,83 $15,83 $15,25 $15,83 $15,83 $15,25 $15,83 $15,25 $15,25

$475,63 $475,63 $475,63 $475,63 $475,63 $475,63 $475,63 $475,63 $475,63

$31,44 $31,44 $31,44 $31,44 $31,44 $31,44 $31,44 $31,44 $31,44

$203,97 $203,97 $196,13 $203,97 $203,97 $196,13 $203,97 $196,13 $196,13

$54,19 $54,19 $54,19 $54,19 $54,19 $54,19 $54,19 $54,19 $54,19

$22,13 $22,13 $22,13 $22,13 $22,13 $22,13 $22,13 $22,13 $22,13

$177,80 $177,80 $177,80 $177,80 $177,80 $177,80 $177,80 $177,80 $177,80

$65,76 $65,76 $65,76 $65,76 $65,76 $65,76 $65,76 $65,76 $65,76

$38,20 $38,20 $38,20 $38,20 $38,20 $38,20 $38,20 $38,20 $38,20

$26,78 $26,78 $26,78 $26,78 $26,78 $26,78 $26,78 $26,78 $26,78

$110,87 $110,87 $110,87 $110,87 $110,87 $110,87 $110,87 $110,87 $110,87

$34,99 $34,67 $37,45 $37,45 $34,81 $35,18 $37,45 $33,39 $32,69

$14,98 $14,84 $17,14 $17,14 $14,93 $17,14 $14,57 $17,14 $14,57

$38,65 $38,29 $38,65 $38,65 $38,48 $38,65 $38,52 $36,96 $36,13

$5,09 $5,09 $5,09 $5,09 $5,09 $4,33 $4,33 $4,33 $4,84

$12,27 $12,27 $14,44 $14,44 $12,27 $14,44 $13,18 $14,44 $12,27

$113,96 $113,96 $113,96 $113,96 $113,96 $113,96 $113,96 $113,96 $113,96

$18,34 $18,34 $18,34 $18,34 $18,34 $18,34 $18,34 $18,34 $18,34

$1,83 $1,83 $1,83 $1,83 $1,83 $1,83 $1,83 $1,83 $1,83

$13,77 $13,77 $13,77 $13,77 $13,77 $13,77 $13,77 $13,77 $13,77

$18,38 $18,38 $18,38 $18,38 $18,38 $18,38 $18,38 $18,38 $18,38

$178,24 $178,24 $178,24 $178,24 $178,24 $178,24 $178,24 $178,24 $178,24

$29,97 $29,97 $29,97 $29,97 $29,97 $29,97 $29,97 $29,97 $29,97

$51,63 $51,63 $51,63 $51,63 $51,63 $51,63 $51,63 $51,63 $51,63

$29,97 $29,97 $29,97 $29,97 $29,97 $29,97 $29,97 $29,97 $29,97

$178,24 $178,24 $178,24 $178,24 $178,24 $178,24 $178,24 $178,24 $178,24

$77,45 $77,45 $77,45 $77,45 $77,45 $77,45 $77,45 $77,45 $77,45

$887,24 $1.018,94 $1.043,81 $887,24 $887,24 $1.043,81 $939,88 $1.043,81 $1.043,81

$759,12 $802,19 $681,86 $713,68 $802,19 $802,19 $681,86 $681,86 $802,19

$887,24 $1.018,94 $1.043,81 $887,24 $887,24 $1.043,81 $939,88 $1.043,81 $1.043,81

$1.537,95 $1.537,95 $1.537,95 $1.537,95 $1.537,95 $1.537,95 $1.537,95 $1.537,95 $1.537,95

$222,49 $241,85 $205,57 $232,16 $241,85 $226,00 $205,57 $205,57 $219,55

$514,47 $514,47 $605,26 $605,26 $529,26 $605,26 $514,47 $514,47 $514,47

$460,46 $470,26 $436,45 $447,98 $470,26 $470,26 $470,26 $459,00 $430,45

$0,00 $0,00 $0,00 $0,00 $0,00 $0,00 $0,00 $0,00 $0,00

$100,85 $100,85 $100,85 $100,85 $100,85 $100,85 $100,85 $100,85 $100,85

$10,07 $10,07 $10,07 $10,07 $10,07 $10,07 $10,07 $10,07 $10,07

$75,63 $75,63 $75,63 $75,63 $75,63 $75,63 $75,63 $75,63 $75,63

$283,91 $283,91 $283,91 $283,91 $283,91 $283,91 $283,91 $283,91 $283,91

$28,37 $28,37 $28,37 $28,37 $28,37 $28,37 $28,37 $28,37 $28,37

$212,93 $212,93 $212,93 $212,93 $212,93 $212,93 $212,93 $212,93 $212,93

$56,71 $56,71 $56,71 $66,72 $56,71 $66,72 $56,71 $56,71 $56,71

$17,62 $17,62 $17,62 $17,61 $17,62 $17,61 $17,61 $17,61 $17,61

$40,99 $41,65 $38,86 $39,92 $41,65 $41,65 $41,65 $40,87 $38,34

$126,34 $126,34 $126,34 $126,34 $126,34 $126,34 $126,34 $126,34 $126,34

$12,64 $12,64 $12,64 $12,64 $12,64 $12,64 $12,64 $12,64 $12,64

$94,74 $94,74 $94,74 $94,74 $94,74 $94,74 $94,74 $94,74 $94,74

$32,59 $38,34 $32,59 $38,34 $38,34 $38,34 $38,34 $38,34 $37,00

$105,29 $89,50 $105,29 $99,20 $92,32 $96,37 $101,65 $98,11 $89,50

$151,54 $178,28 $151,54 $151,54 $178,28 $178,28 $178,28 $178,28 $151,54

$22,02 $25,91 $22,02 $25,91 $25,91 $25,91 $25,91 $25,91 $22,02

$112,17 $131,97 $112,17 $112,17 $131,97 $131,97 $131,97 $131,97 $112,17

$178,24 $178,24 $178,24 $178,24 $178,24 $178,24 $178,24 $178,24 $178,24

$51,63 $51,63 $51,63 $51,63 $51,63 $51,63 $51,63 $51,63 $51,63

GA IA ID IL IN KS KY LA MA

$62,96 $62,96 $62,96 $62,96 $62,96 $62,96 $62,96 $62,96 $62,96

$2,03 $2,03 $2,03 $2,03 $2,03 $2,03 $2,03 $2,03 $2,03

$2,96 $3,00 $3,00 $2,55 $2,61 $3,00 $2,98 $3,00 $3,00

$1,68 $1,98 $1,98 $1,98 $1,98 $1,98 $1,68 $1,68 $1,70

$28,65 $33,71 $33,71 $33,71 $33,71 $33,71 $28,65 $28,65 $31,94

$10,43 $10,43 $10,43 $10,43 $10,43 $10,43 $10,43 $10,43 $9,34

$4,73 $5,05 $5,05 $5,05 $5,05 $5,05 $4,77 $4,96 $4,59

$21,93 $25,80 $25,80 $25,80 $25,80 $25,80 $21,93 $21,93 $25,80

$4,10 $4,14 $4,14 $3,52 $3,54 $4,14 $4,14 $4,14 $4,11

$0,77 $0,91 $0,91 $0,91 $0,91 $0,91 $0,77 $0,77 $0,86

$4,91 $4,91 $4,91 $4,91 $4,91 $4,91 $4,91 $4,91 $4,65

$2,06 $2,06 $2,06 $1,79 $1,87 $2,06 $2,06 $2,06 $1,88

$146,57 $146,57 $146,57 $146,57 $146,57 $146,57 $146,57 $146,57 $146,57

$14,67 $14,67 $14,67 $14,67 $14,67 $14,67 $14,67 $14,67 $14,67

$109,92 $109,92 $109,92 $109,92 $109,92 $109,92 $109,92 $109,92 $109,92

$0,35 $0,41 $0,41 $0,41 $0,41 $0,41 $0,35 $0,35 $0,41

$15,83 $15,83 $15,25 $15,83 $15,83 $15,25 $15,83 $15,83 $15,25

$475,63 $475,63 $475,63 $475,63 $475,63 $475,63 $475,63 $475,63 $475,63

$31,44 $31,44 $31,44 $31,44 $31,44 $31,44 $31,44 $31,44 $31,44

$203,97 $203,97 $196,13 $203,97 $203,97 $196,13 $203,97 $203,97 $196,13

$54,19 $54,19 $54,19 $54,19 $54,19 $54,19 $54,19 $54,19 $54,19

$22,13 $22,13 $22,13 $22,13 $22,13 $22,13 $22,13 $22,13 $22,13

$177,80 $177,80 $177,80 $177,80 $177,80 $177,80 $177,80 $177,80 $177,80

$65,76 $65,76 $65,76 $65,76 $65,76 $65,76 $65,76 $65,76 $65,76

$38,20 $38,20 $38,20 $38,20 $38,20 $38,20 $38,20 $38,20 $38,20

$26,78 $26,78 $26,78 $26,78 $26,78 $26,78 $26,78 $26,78 $26,78

$110,87 $110,87 $110,87 $110,87 $110,87 $110,87 $110,87 $110,87 $110,87

$34,02 $37,45 $37,45 $37,45 $37,45 $37,45 $34,34 $35,64 $35,04

$14,57 $17,14 $17,14 $14,57 $14,62 $17,14 $14,70 $15,26 $17,14

$37,59 $38,65 $38,65 $38,52 $38,65 $38,65 $37,94 $38,65 $38,65

$5,04 $5,09 $5,09 $4,33 $4,33 $5,09 $5,09 $5,09 $4,33

$12,27 $14,44 $14,44 $13,18 $13,87 $14,44 $12,27 $12,35 $14,44