AFO Product DMEPOS By State Fee Schedule 2022

AFO Product DMEPOS By State Fee Schedule 2022

TurboMed XTERN

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

XTERN

L1951 - Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment

1055.35

791.51

5.3096%

5.3086%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section.

114.22

85.67

5.3107%

5.3104%

Total HCPCS

1169.57

877.18

5.3097%

5.3088%

Tamarack Free Motion

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

A200

L1970 - Ankle foot orthosis, plastic with ankle joint, custom fabricated

935.93

701.95

5.3098%

5.3109%

L2275 - Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

164.96

123.72

5.3048%

5.3115%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

Total HCPCS

1215.11

911.34

5.3092%

5.3110%

Tamarack Free Motion Calf Lacer

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

A200L

L1970 - Ankle foot orthosis, plastic with ankle joint, custom fabricated

935.93

701.95

5.3098%

5.3109%

L2275 - Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

164.96

123.72

5.3048%

5.3115%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

Total HCPCS

1731.58

1298.69

5.3093%

5.3106%

Overlap Free Motion

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

A250

L1970 - Ankle foot orthosis, plastic with ankle joint, custom fabricated

935.93

701.95

5.3098%

5.3109%

L2275 - Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

164.96

123.72

5.3048%

5.3115%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

Total HCPCS

1215.11

911.34

5.3092%

5.3110%

Tamarack Dorsi-Assist

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

A300

L1970 - Ankle foot orthosis, plastic with ankle joint, custom fabricated

935.93

701.95

5.3098%

5.3109%

L2275 - Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

164.96

123.72

5.3048%

5.3115%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2210 - Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

88.41

66.31

5.3001%

5.3041%

L2210 - Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

88.41

66.31

5.3001%

5.3041%

Total HCPCS

1391.93

1043.96

5.3080%

5.3101%

Cabbie

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

G50

L1907 - Ankle foot orthosis, plastic or other material, custom fabricated

707.10

530.32

5.3110%

5.3100%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

Total HCPCS

1223.57

917.67

5.3104%

5.3098%

Short

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

G100

L1940 - Ankle foot orthosis, plastic or other material, custom fabricated

650.48

487.86

5.3102%

5.3102%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

Total HCPCS

1281.17

960.88

5.3100%

5.3100%

Standard

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

G120

L1940 - Ankle foot orthosis, plastic or other material, custom fabricated

650.48

487.86

5.3102%

5.3102%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

Total HCPCS

1281.17

960.88

5.3100%

5.3100%

Tall

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

G140

L1940 - Ankle foot orthosis, plastic or other material, custom fabricated

650.48

487.86

5.3102%

5.3102%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

Total HCPCS

1281.17

960.88

5.3100%

5.3100%

Tamarack Free Motion

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

G200

L1970 - Ankle foot orthosis, plastic with ankle joint, custom fabricated

935.93

701.95

5.3098%

5.3109%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

Total HCPCS

1566.62

1174.97

5.3098%

5.3105%

Overlapping Articulating Gauntlet

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

G250

L1970 - Ankle foot orthosis, plastic with ankle joint, custom fabricated

935.93

701.95

5.3098%

5.3109%

L2275 - Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

164.96

123.72

5.3048%

5.3115%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

Total HCPCS

1731.58

1298.69

5.3093%

5.3106%

Tamarack Dorsi-Assist

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

G300

L1970 - Ankle foot orthosis, plastic with ankle joint, custom fabricated

935.93

701.95

5.3098%

5.3109%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

L2210 - Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

88.41

66.31

5.3001%

5.3041%

L2210 - Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

88.41

66.31

5.3001%

5.3041%

Total HCPCS

1743.44

1307.59

5.3093%

5.3106%

Leather Partial Foot

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

G600

L1960 - Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated

729.06

546.80

5.3098%

5.3098%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

L5000 - Partial foot, shoe insert with longitudinal arch, toe filler

708.02

531.01

5.3115%

5.3090%

Total HCPCS

2067.77

1550.83

5.3104%

5.3095%

Balance Brace

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

G800

L1940 - Ankle foot orthosis, plastic or other material, custom fabricated

650.48

487.86

5.3102%

5.3102%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

Total HCPCS

1281.17

960.88

5.3100%

5.3100%

Leaf Spring

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

T100

L1960 - Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated

729.06

546.80

5.3098%

5.3098%

L2275 - Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

164.96

123.72

5.3048%

5.3115%

Total HCPCS

894.02

670.52

5.3089%

5.3101%

Solid Ankle

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

T150

L1960 - Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated

729.06

546.80

5.3098%

5.3098%

L2275 - Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

164.96

123.72

5.3048%

5.3115%

Total HCPCS

894.02

670.52

5.3089%

5.3101%

Tamarack Dorsi-Assist

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

T300

L1970 - Ankle foot orthosis, plastic with ankle joint, custom fabricated

935.93

701.95

5.3098%

5.3109%

L2275 - Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

164.96

123.72

5.3048%

5.3115%

L2210 - Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

88.41

66.31

5.3001%

5.3041%

L2210 - Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

88.41

66.31

5.3001%

5.3041%

Total HCPCS

1277.71

958.29

5.3078%

5.3101%

Traditional CROW

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

C100

L4631 - Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated

1938.05

1453.53

5.3105%

5.3099%

Total HCPCS

1938.05

1453.53

5.3105%

5.3099%

Tundra Boot

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

C200

L1960 - Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated

729.06

546.80

5.3098%

5.3098%

L1940 - Ankle foot orthosis, plastic or other material, custom fabricated

650.48

487.86

5.3102%

5.3102%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2280 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

595.59

446.69

5.3116%

5.3117%

L2232 - Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only

122.98

92.23

5.3091%

5.2974%

L3400 - Metatarsal bar wedge, rocker

51.15

38.36

5.3119%

5.2978%

Total HCPCS

2779.95

2084.96

5.3103%

5.3095%

Tundra Sandal

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

C250

L1960 - Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated

729.06

546.80

5.3098%

5.3098%

L1940 - Ankle foot orthosis, plastic or other material, custom fabricated

650.48

487.86

5.3102%

5.3102%

L2330 - Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

516.47

387.35

5.3096%

5.3097%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2280 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

595.59

446.69

5.3116%

5.3117%

L2232 - Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only

122.98

92.23

5.3091%

5.2974%

L3400 - Metatarsal bar wedge, rocker

51.15

38.36

5.3119%

5.2978%

Total HCPCS

2779.95

2084.96

5.3103%

5.3095%

Dorsiflex Posterior

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

D100

L1945 - Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom fabricated

1217.57

913.18

5.3106%

5.3106%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2755 - Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only

164.19

123.14

5.3108%

5.3109%

L2755 - Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only

164.19

123.14

5.3108%

5.3109%

Total HCPCS

1660.17

1245.13

5.3107%

5.3107%

Dorsiflex Anterior

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

D110

L1945 - Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom fabricated

1217.57

913.18

5.3106%

5.3106%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2755 - Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only

164.19

123.14

5.3108%

5.3109%

L2755 - Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only

164.19

123.14

5.3108%

5.3109%

Total HCPCS

1660.17

1245.13

5.3107%

5.3107%

 

HCPCS

CEILING

FLOOR

CEILING % CHANGE

FLOOR % CHANGE

ADDITIONAL
CODES

L2270 - Addition to lower extremity, varus/valgus correction ('t') strap, padded/lined or malleolus pad

70.64

52.98

5.3071%

5.3071%

L2275 - Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

164.96

123.72

5.3048%

5.3115%

L2820 - Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

114.22

85.67

5.3107%

5.3104%

L2350 - Addition to lower extremity, prosthetic type, (bk) socket, molded to patient model, (used for 'ptb' 'afo' orthoses)

1172.01

879.01

5.3104%

5.3110%

AFO Product DMEPOS By State Fee Schedule 2022