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%