Standard (Power and Manual) Wheelchairs, Scooters, and Related...

1890
Standard (Power and Manual) Wheelchairs, Scooters, and Related Accessories Akron, OH 4 Albany-Schenectady-Troy, NY 22 Albuquerque, NM 41 Allentown-Bethlehem-Easton, PA-NJ 60 Asheville, NC 79 Atlanta-Sandy Springs-Marietta, GA 98 Augusta-Richmond County, GA-SC 117 Austin-Round Rock-San Marcos, TX 136 Bakersfield-Delano, CA 154 Baltimore-Towson, MD 173 Baton Rouge, LA 192 Beaumont-Port Arthur, TX 211 Birmingham-Hoover, AL 230 Boise City-Nampa, ID 249 Boston-Cambridge-Quincy, MA-NH 268 Bridgeport-Stamford-Norwalk, CT 287 Bronx-Manhattan, NY CBA 305 Buffalo-Niagara Falls, NY 324 Cape Coral-Fort Myers, FL 343 Central-Chicago Metro CBA 362 Charleston-North Charleston-Summerville, SC 381 Chattanooga, TN-GA 400 Colorado Springs, CO 419 Columbia, SC 437 Columbus, OH 456 Dayton, OH 475 Deltona-Daytona Beach-Ormond Beach, FL 494 Denver-Aurora-Broomfield, CO 513 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program Round 2 Single Payment Amounts

Transcript of Standard (Power and Manual) Wheelchairs, Scooters, and Related...

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related Accessories

    Akron, OH 4Albany-Schenectady-Troy, NY 22Albuquerque, NM 41Allentown-Bethlehem-Easton, PA-NJ 60Asheville, NC 79Atlanta-Sandy Springs-Marietta, GA 98Augusta-Richmond County, GA-SC 117Austin-Round Rock-San Marcos, TX 136Bakersfield-Delano, CA 154Baltimore-Towson, MD 173Baton Rouge, LA 192Beaumont-Port Arthur, TX 211Birmingham-Hoover, AL 230Boise City-Nampa, ID 249Boston-Cambridge-Quincy, MA-NH 268Bridgeport-Stamford-Norwalk, CT 287Bronx-Manhattan, NY CBA 305Buffalo-Niagara Falls, NY 324Cape Coral-Fort Myers, FL 343Central-Chicago Metro CBA 362Charleston-North Charleston-Summerville, SC 381Chattanooga, TN-GA 400Colorado Springs, CO 419Columbia, SC 437Columbus, OH 456Dayton, OH 475Deltona-Daytona Beach-Ormond Beach, FL 494Denver-Aurora-Broomfield, CO 513

    Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)Competitive Bidding Program Round 2

    Single Payment Amounts

  • DMEPOS Competitive Bidding Program Round 2 – Effective July 01, 2013 Page 2 of 1890

    Detroit-Warren-Livonia, MI 532El Paso, TX 551Flint, MI 570Fresno, CA 588Grand Rapids-Wyoming, MI 607Greensboro-High Point, NC 626Greenville-Mauldin-Easley, SC 645Hartford-West Hartford-East Hartford, CT 664Honolulu, HI 683Houston-Sugar Land-Baytown, TX 702Huntington-Ashland, WV-KY-OH 720Indiana-Chicago Metro 739Indianapolis-Carmel, IN 758Jackson, MS 777Jacksonville, FL 796Knoxville, TN 815Lakeland-Winter Haven, FL 834Las Vegas-Paradise, NV 853Little Rock-North Little Rock-Conway, AR 871Los Angeles County CBA 890Louisville/Jefferson County, KY-IN 909McAllen-Edinburg-Mission, TX 928Memphis, TN-MS-AR 947Milwaukee-Waukesha-West Allis, WI 966Minneapolis-St. Paul-Bloomington, MN-WI 985Nashville-Davidson--Murfreesboro--Franklin, TN 1003Nassau-Brooklyn-Queens-Richmond County Metro CBA 1022New Haven-Milford, CT 1041New Orleans-Metairie-Kenner, LA 1060North East NY CBA Metro 1079North Port-Bradenton-Sarasota, FL 1098Northern NJ Metro CBA 1117Northern-Chicago Metro CBA 1136Ocala, FL 1154Oklahoma City, OK 1173Omaha-Council Bluffs, NE-IA 1192Orange County CBA 1211Oxnard-Thousand Oaks-Ventura, CA 1230Palm Bay-Melbourne-Titusville, FL 1249

  • DMEPOS Competitive Bidding Program Round 2 SPA – Effective July 01, 2013 Page 3 of 1890

    Philadelphia-Camden-Wilmington, PA-NJ-DE-MD 1268Phoenix-Mesa-Glendale, AZ 1286Portland-Vancouver-Hillsboro, OR-WA 1305Poughkeepsie-Newburgh-Middletown, NY 1324Providence-New Bedford-Fall River, RI-MA 1343Raleigh-Cary, NC 1362Richmond, VA 1381Rochester, NY 1400Sacramento--Arden-Arcade--Roseville, CA 1419Salt Lake City, UT 1437San Antonio-New Braunfels, TX 1456San Diego-Carlsbad-San Marcos, CA 1475San Francisco-Oakland-Fremont, CA 1494San Jose-Sunnyvale-Santa Clara, CA 1513Scranton--Wilkes-Barre, PA 1532Seattle-Tacoma-Bellevue, WA 1551South-West-Chicago-Metro CBA 1569Southern NY Metro CBA 1588Springfield, MA 1607St. Louis, MO-IL 1626Stockton, CA 1645Suffolk County CBA 1664Syracuse, NY 1683Tampa-St. Petersburg-Clearwater, FL 1702Toledo, OH 1720Tucson, AZ 1739Tulsa, OK 1758Virginia Beach-Norfolk-Newport News, VA-NC 1777Visalia-Porterville, CA 1796Washington-Arlington-Alexandria, DC-VA-MD-WV 1815Wichita, KS 1834Worcester, MA 1852Youngstown-Warren-Boardman, OH-PA 1871

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Akron, OH E0950 WHEELCHAIR ACCESSORY, TRAY, EACH NU $73.08

    Akron, OH E0950 WHEELCHAIR ACCESSORY, TRAY, EACH RR $7.31

    Akron, OH E0950 WHEELCHAIR ACCESSORY, TRAY, EACH UE $54.81

    Akron, OH E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH NU $12.11

    Akron, OH E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH RR $1.21

    Akron, OH E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH UE $9.08

    WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING Akron, OH E0955 HARDWARE, EACH NU $135.42

    WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING Akron, OH E0955 HARDWARE, EACH RR $13.54

    WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING Akron, OH E0955 HARDWARE, EACH UE $101.57

    WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED Akron, OH E0956 MOUNTING HARDWARE, EACH NU $79.70

    WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED Akron, OH E0956 MOUNTING HARDWARE, EACH RR $7.97

    WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED Akron, OH E0956 MOUNTING HARDWARE, EACH UE $59.78

    WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING Akron, OH E0957 HARDWARE, EACH NU $116.21

    WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING Akron, OH E0957 HARDWARE, EACH RR $11.62

    WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING Akron, OH E0957 HARDWARE, EACH UE $87.16

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 4 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY Akron, OH E0960 TYPE MOUNTING HARDWARE NU $78.42

    WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY Akron, OH E0960 TYPE MOUNTING HARDWARE RR $7.84

    WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY Akron, OH E0960 TYPE MOUNTING HARDWARE UE $58.82

    Akron, OH E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH NU $18.16

    Akron, OH E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH RR $1.82

    Akron, OH E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH UE $13.62

    Akron, OH E0971 MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH NU $33.19

    Akron, OH E0971 MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH RR $3.32

    Akron, OH E0971 MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH UE $24.89

    WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE Akron, OH E0973 ASSEMBLY, EACH NU $49.98

    WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE Akron, OH E0973 ASSEMBLY, EACH RR $5.00

    WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE Akron, OH E0973 ASSEMBLY, EACH UE $37.49

    Akron, OH E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH NU $25.14

    Akron, OH E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH RR $2.51

    Akron, OH E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH UE $18.86

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 5 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Akron, OH E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH NU $63.44

    Akron, OH E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH RR $6.34

    Akron, OH E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH UE $47.58

    Akron, OH E0992 MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT NU $68.08

    Akron, OH E0992 MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT RR $6.81

    Akron, OH E0992 MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT UE $51.06

    Akron, OH E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH NU $109.20

    Akron, OH E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH RR $10.92

    Akron, OH E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH UE $81.90

    Akron, OH E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE NU $190.84

    Akron, OH E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE RR $19.08

    Akron, OH E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE UE $143.13

    WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING Akron, OH E1028 HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY NU $124.38

    WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING Akron, OH E1028 HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY RR $12.44

    WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING Akron, OH E1028 HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY UE $93.29

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 6 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Akron, OH E1031 ROLLABOUT CHAIR, ANY AND ALL TYPES WITH CASTORS 5" OR GREATER RR $42.45

    TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 Akron, OH E1038 POUNDS RR $12.92

    WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 Akron, OH E1225 DEGREES, BUT LESS THAN 80 DEGREES), EACH RR $36.25

    WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80 Akron, OH E1226 DEGREES), EACH NU $332.05

    WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80 Akron, OH E1226 DEGREES), EACH RR $33.21

    WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80 Akron, OH E1226 DEGREES), EACH UE $249.04

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR Akron, OH E2201 EQUAL TO 20 INCHES AND LESS THAN 24 INCHES NU $314.33

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR Akron, OH E2201 EQUAL TO 20 INCHES AND LESS THAN 24 INCHES RR $31.43

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR Akron, OH E2201 EQUAL TO 20 INCHES AND LESS THAN 24 INCHES UE $235.75

    Akron, OH E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES NU $378.00

    Akron, OH E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES RR $37.80

    Akron, OH E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES UE $283.50

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN Akron, OH E2203 22 INCHES NU $423.84

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN Akron, OH E2203 22 INCHES RR $42.38

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN Akron, OH E2203 22 INCHES UE $317.88

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 7 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Akron, OH E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES NU $655.00

    Akron, OH E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES RR $65.50

    Akron, OH E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES UE $491.25

    Akron, OH E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH NU $33.23

    Akron, OH E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH RR $3.32

    Akron, OH E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH UE $24.92

    Akron, OH E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH NU $83.96

    Akron, OH E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH RR $8.40

    Akron, OH E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH UE $62.97

    Akron, OH E2209 ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH NU $87.80

    Akron, OH E2209 ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH RR $8.78

    Akron, OH E2209 ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH UE $65.85

    Akron, OH E2210 WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH NU $5.02

    Akron, OH E2210 WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH RR $0.50

    Akron, OH E2210 WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH UE $3.77

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 8 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Akron, OH E2211 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH NU $31.95

    Akron, OH E2211 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH RR $3.20

    Akron, OH E2211 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH UE $23.96

    MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE Akron, OH E2213 (REMOVABLE), ANY TYPE, ANY SIZE, EACH NU $27.21

    MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE Akron, OH E2213 (REMOVABLE), ANY TYPE, ANY SIZE, EACH RR $2.72

    MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE Akron, OH E2213 (REMOVABLE), ANY TYPE, ANY SIZE, EACH UE $20.41

    MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), Akron, OH E2231 INCLUDES ANY TYPE MOUNTING HARDWARE NU $136.00

    MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), Akron, OH E2231 INCLUDES ANY TYPE MOUNTING HARDWARE RR $13.60

    MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), Akron, OH E2231 INCLUDES ANY TYPE MOUNTING HARDWARE UE $102.00

    Akron, OH E2360 POWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID BATTERY, EACH NU $95.00

    Akron, OH E2360 POWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID BATTERY, EACH RR $9.50

    Akron, OH E2360 POWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID BATTERY, EACH UE $71.25

    POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E. G. GEL Akron, OH E2361 CELL, ABSORBED GLASSMAT) NU $104.65

    POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E. G. GEL Akron, OH E2361 CELL, ABSORBED GLASSMAT) RR $10.47

    POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E. G. GEL Akron, OH E2361 CELL, ABSORBED GLASSMAT) UE $78.49

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 9 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Akron, OH E2362 POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH NU $82.00

    Akron, OH E2362 POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH RR $8.20

    Akron, OH E2362 POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH UE $61.50

    POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E. G. GEL Akron, OH E2363 CELL, ABSORBED GLASSMAT) NU $130.20

    POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E. G. GEL Akron, OH E2363 CELL, ABSORBED GLASSMAT) RR $13.02

    POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E. G. GEL Akron, OH E2363 CELL, ABSORBED GLASSMAT) UE $97.65

    Akron, OH E2364 POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH NU $92.25

    Akron, OH E2364 POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH RR $9.23

    Akron, OH E2364 POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH UE $69.19

    POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E. G. GEL CELL, Akron, OH E2365 ABSORBED GLASSMAT) NU $70.48

    POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E. G. GEL CELL, Akron, OH E2365 ABSORBED GLASSMAT) RR $7.05

    POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E. G. GEL CELL, Akron, OH E2365 ABSORBED GLASSMAT) UE $52.86

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY Akron, OH E2366 ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH NU $145.82

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY Akron, OH E2366 ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH RR $14.58

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY Akron, OH E2366 ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH UE $109.37

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 10 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER Akron, OH E2367 BATTERY TYPE, SEALED OR NON-SEALED, EACH NU $289.02

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER Akron, OH E2367 BATTERY TYPE, SEALED OR NON-SEALED, EACH RR $28.90

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER Akron, OH E2367 BATTERY TYPE, SEALED OR NON-SEALED, EACH UE $216.77

    Akron, OH E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY NU $399.54

    Akron, OH E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY RR $39.95

    Akron, OH E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY UE $299.66

    Akron, OH E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY NU $368.65

    Akron, OH E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY RR $36.87

    Akron, OH E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY UE $276.49

    POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX Akron, OH E2370 COMBINATION, REPLACEMENT ONLY NU $534.64

    POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX Akron, OH E2370 COMBINATION, REPLACEMENT ONLY RR $53.46

    POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX Akron, OH E2370 COMBINATION, REPLACEMENT ONLY UE $400.98

    POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E. G. GEL CELL, Akron, OH E2371 ABSORBED GLASSMAT), EACH NU $123.20

    POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E. G. GEL CELL, Akron, OH E2371 ABSORBED GLASSMAT), EACH RR $12.32

    POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E. G. GEL CELL, Akron, OH E2371 ABSORBED GLASSMAT), EACH UE $92.40

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 11 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, Akron, OH E2381 REPLACEMENT ONLY, EACH NU $59.68

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, Akron, OH E2381 REPLACEMENT ONLY, EACH RR $5.97

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, Akron, OH E2381 REPLACEMENT ONLY, EACH UE $44.76

    POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE Akron, OH E2383 (REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH NU $111.10

    POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE Akron, OH E2383 (REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH RR $11.11

    POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE Akron, OH E2383 (REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH UE $83.33

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT Akron, OH E2384 ONLY, EACH NU $61.00

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT Akron, OH E2384 ONLY, EACH RR $6.10

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT Akron, OH E2384 ONLY, EACH UE $45.75

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, Akron, OH E2386 REPLACEMENT ONLY, EACH NU $105.44

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, Akron, OH E2386 REPLACEMENT ONLY, EACH RR $10.54

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, Akron, OH E2386 REPLACEMENT ONLY, EACH UE $79.08

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT Akron, OH E2387 ONLY, EACH NU $51.15

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT Akron, OH E2387 ONLY, EACH RR $5.12

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT Akron, OH E2387 ONLY, EACH UE $38.36

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 12 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), Akron, OH E2391 ANY SIZE, REPLACEMENT ONLY, EACH NU $15.90

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), Akron, OH E2391 ANY SIZE, REPLACEMENT ONLY, EACH RR $1.59

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), Akron, OH E2391 ANY SIZE, REPLACEMENT ONLY, EACH UE $11.93

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH Akron, OH E2392 INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH NU $44.20

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH Akron, OH E2392 INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH RR $4.42

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH Akron, OH E2392 INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH UE $33.15

    POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT Akron, OH E2394 ONLY, EACH NU $60.91

    POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT Akron, OH E2394 ONLY, EACH RR $6.09

    POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT Akron, OH E2394 ONLY, EACH UE $45.68

    POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, Akron, OH E2395 REPLACEMENT ONLY, EACH NU $41.01

    POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, Akron, OH E2395 REPLACEMENT ONLY, EACH RR $4.10

    POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, Akron, OH E2395 REPLACEMENT ONLY, EACH UE $30.76

    Akron, OH E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH NU $44.22

    Akron, OH E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH RR $4.42

    Akron, OH E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH UE $33.17

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 13 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Akron, OH E2601 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH NU $38.45

    Akron, OH E2601 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH RR $3.85

    Akron, OH E2601 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH UE $28.84

    Akron, OH E2602 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH NU $87.77

    Akron, OH E2602 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH RR $8.78

    Akron, OH E2602 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH UE $65.83

    Akron, OH E2603 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH NU $114.04

    Akron, OH E2603 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH RR $11.40

    Akron, OH E2603 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH UE $85.53

    Akron, OH E2604 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH NU $145.36

    Akron, OH E2604 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH RR $14.54

    Akron, OH E2604 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH UE $109.02

    Akron, OH E2605 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH NU $199.98

    Akron, OH E2605 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH RR $20.00

    Akron, OH E2605 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH UE $149.99

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 14 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Akron, OH E2606 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH NU $331.62

    Akron, OH E2606 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH RR $33.16

    Akron, OH E2606 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH UE $248.72

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 Akron, OH E2607 INCHES, ANY DEPTH NU $212.44

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 Akron, OH E2607 INCHES, ANY DEPTH RR $21.24

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 Akron, OH E2607 INCHES, ANY DEPTH UE $159.33

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR Akron, OH E2608 GREATER, ANY DEPTH NU $270.04

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR Akron, OH E2608 GREATER, ANY DEPTH RR $27.00

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR Akron, OH E2608 GREATER, ANY DEPTH UE $202.53

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, Akron, OH E2611 INCLUDING ANY TYPE MOUNTING HARDWARE NU $158.63

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, Akron, OH E2611 INCLUDING ANY TYPE MOUNTING HARDWARE RR $15.86

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, Akron, OH E2611 INCLUDING ANY TYPE MOUNTING HARDWARE UE $118.97

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, Akron, OH E2612 INCLUDING ANY TYPE MOUNTING HARDWARE NU $321.50

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, Akron, OH E2612 INCLUDING ANY TYPE MOUNTING HARDWARE RR $32.15

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, Akron, OH E2612 INCLUDING ANY TYPE MOUNTING HARDWARE UE $241.13

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 15 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY Akron, OH E2613 HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $303.78

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY Akron, OH E2613 HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $30.38

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY Akron, OH E2613 HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $227.84

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, Akron, OH E2614 ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $446.55

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, Akron, OH E2614 ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $44.66

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, Akron, OH E2614 ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $334.91

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 Akron, OH E2615 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $369.66

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 Akron, OH E2615 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $36.97

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 Akron, OH E2615 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $277.25

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR Akron, OH E2616 GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $495.09

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR Akron, OH E2616 GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $49.51

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR Akron, OH E2616 GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $371.32

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Akron, OH E2620 LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $417.56

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Akron, OH E2620 LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $41.76

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Akron, OH E2620 LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $313.17

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 16 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Akron, OH E2621 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $456.45

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Akron, OH E2621 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $45.65

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Akron, OH E2621 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $342.34

    Akron, OH K0001 STANDARD WHEELCHAIR RR $23.57

    Akron, OH K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR RR $35.82

    Akron, OH K0003 LIGHTWEIGHT WHEELCHAIR RR $37.75

    Akron, OH K0004 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR RR $47.82

    Akron, OH K0006 HEAVY DUTY WHEELCHAIR RR $67.83

    Akron, OH K0007 EXTRA HEAVY DUTY WHEELCHAIR RR $102.72

    Akron, OH K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH NU $137.10

    Akron, OH K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH RR $13.71

    Akron, OH K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH UE $102.83

    Akron, OH K0019 ARM PAD, EACH NU $10.00

    Akron, OH K0019 ARM PAD, EACH RR $1.00

    Akron, OH K0019 ARM PAD, EACH UE $7.50

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 17 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Akron, OH K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH NU $56.50

    Akron, OH K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH RR $5.65

    Akron, OH K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH UE $42.38

    Akron, OH K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH NU $75.00

    Akron, OH K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH RR $7.50

    Akron, OH K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH UE $56.25

    Akron, OH K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH NU $85.00

    Akron, OH K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH RR $8.50

    Akron, OH K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH UE $63.75

    SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, Akron, OH K0056 LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR NU $85.44

    SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, Akron, OH K0056 LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR RR $8.54

    SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, Akron, OH K0056 LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR UE $64.08

    Akron, OH K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, EACH NU $88.50

    Akron, OH K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, EACH RR $8.85

    Akron, OH K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, EACH UE $66.38

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 18 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Akron, OH K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, EACH NU $160.00

    Akron, OH K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, EACH RR $16.00

    Akron, OH K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, EACH UE $120.00

    Akron, OH K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH NU $51.50

    Akron, OH K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH RR $5.15

    Akron, OH K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH UE $38.63

    Akron, OH K0195 ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE) RR $10.52

    POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND Akron, OH K0800 INCLUDING 300 POUNDS NU $826.78

    POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND Akron, OH K0800 INCLUDING 300 POUNDS RR $82.68

    POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND Akron, OH K0800 INCLUDING 300 POUNDS UE $620.09

    POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 Akron, OH K0801 POUNDS NU $1,532.00

    POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 Akron, OH K0801 POUNDS RR $153.20

    POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 Akron, OH K0801 POUNDS UE $1,149.00

    POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 Akron, OH K0802 TO 600 POUNDS NU $1,943.14

    POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 Akron, OH K0802 TO 600 POUNDS RR $194.31

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 19 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 Akron, OH K0802 TO 600 POUNDS UE $1,457.36

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, Akron, OH K0813 PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS NU $1,921.50

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, Akron, OH K0813 PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS RR $288.23

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, Akron, OH K0813 PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,441.13

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Akron, OH K0814 CAPACITY UP TO AND INCLUDING 300 POUNDS NU $2,243.50

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Akron, OH K0814 CAPACITY UP TO AND INCLUDING 300 POUNDS RR $336.53

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Akron, OH K0814 CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,682.63

    POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT Akron, OH K0815 CAPACITY UP TO AND INCLUDING 300 POUNDS NU $2,552.00

    POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT Akron, OH K0815 CAPACITY UP TO AND INCLUDING 300 POUNDS RR $382.80

    POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT Akron, OH K0815 CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,914.00

    POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Akron, OH K0816 UP TO AND INCLUDING 300 POUNDS NU $2,497.00

    POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Akron, OH K0816 UP TO AND INCLUDING 300 POUNDS RR $374.55

    POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Akron, OH K0816 UP TO AND INCLUDING 300 POUNDS UE $1,872.75

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT Akron, OH K0820 WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS NU $1,991.70

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT Akron, OH K0820 WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS RR $298.76

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 20 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT Akron, OH K0820 WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,493.78

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Akron, OH K0821 CAPACITY UP TO AND INCLUDING 300 POUNDS NU $2,582.05

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Akron, OH K0821 CAPACITY UP TO AND INCLUDING 300 POUNDS RR $387.31

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Akron, OH K0821 CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,936.54

    POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Akron, OH K0822 CAPACITY UP TO AND INCLUDING 300 POUNDS NU $1,947.50

    POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Akron, OH K0822 CAPACITY UP TO AND INCLUDING 300 POUNDS RR $292.13

    POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Akron, OH K0822 CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,460.63

    POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Akron, OH K0823 UP TO AND INCLUDING 300 POUNDS NU $1,800.00

    POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Akron, OH K0823 UP TO AND INCLUDING 300 POUNDS RR $270.00

    POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Akron, OH K0823 UP TO AND INCLUDING 300 POUNDS UE $1,350.00

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Akron, OH K0824 CAPACITY 301 TO 450 POUNDS NU $2,903.12

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Akron, OH K0824 CAPACITY 301 TO 450 POUNDS RR $435.47

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Akron, OH K0824 CAPACITY 301 TO 450 POUNDS UE $2,177.34

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Akron, OH K0825 301 TO 450 POUNDS NU $2,330.63

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Akron, OH K0825 301 TO 450 POUNDS RR $349.59

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 21 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Akron, OH K0825 301 TO 450 POUNDS UE $1,747.97

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Akron, OH K0826 WEIGHT CAPACITY 451 TO 600 POUNDS NU $5,200.00

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Akron, OH K0826 WEIGHT CAPACITY 451 TO 600 POUNDS RR $780.00

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Akron, OH K0826 WEIGHT CAPACITY 451 TO 600 POUNDS UE $3,900.00

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT Akron, OH K0827 CAPACITY 451 TO 600 POUNDS NU $4,171.50

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT Akron, OH K0827 CAPACITY 451 TO 600 POUNDS RR $625.73

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT Akron, OH K0827 CAPACITY 451 TO 600 POUNDS UE $3,128.63

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Akron, OH K0828 WEIGHT CAPACITY 601 POUNDS OR MORE NU $5,300.00

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Akron, OH K0828 WEIGHT CAPACITY 601 POUNDS OR MORE RR $795.00

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Akron, OH K0828 WEIGHT CAPACITY 601 POUNDS OR MORE UE $3,975.00

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT 601 Akron, OH K0829 POUNDS OR MORE NU $5,054.78

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT 601 Akron, OH K0829 POUNDS OR MORE RR $758.22

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT 601 Akron, OH K0829 POUNDS OR MORE UE $3,791.09

    Albany-Schenectady-Troy, NY E0950 WHEELCHAIR ACCESSORY, TRAY, EACH NU $75.00

    Albany-Schenectady-Troy, NY E0950 WHEELCHAIR ACCESSORY, TRAY, EACH RR $7.50

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 22 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Albany-Schenectady-Troy, NY E0950 WHEELCHAIR ACCESSORY, TRAY, EACH UE $56.25

    Albany-Schenectady-Troy, NY E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH NU $13.00

    Albany-Schenectady-Troy, NY E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH RR $1.30

    Albany-Schenectady-Troy, NY E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH UE $9.75

    WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING Albany-Schenectady-Troy, NY E0955 HARDWARE, EACH NU $138.84

    WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING Albany-Schenectady-Troy, NY E0955 HARDWARE, EACH RR $13.88

    WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING Albany-Schenectady-Troy, NY E0955 HARDWARE, EACH UE $104.13

    WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED Albany-Schenectady-Troy, NY E0956 MOUNTING HARDWARE, EACH NU $77.76

    WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED Albany-Schenectady-Troy, NY E0956 MOUNTING HARDWARE, EACH RR $7.78

    WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED Albany-Schenectady-Troy, NY E0956 MOUNTING HARDWARE, EACH UE $58.32

    WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING Albany-Schenectady-Troy, NY E0957 HARDWARE, EACH NU $112.61

    WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING Albany-Schenectady-Troy, NY E0957 HARDWARE, EACH RR $11.26

    WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING Albany-Schenectady-Troy, NY E0957 HARDWARE, EACH UE $84.46

    WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY Albany-Schenectady-Troy, NY E0960 TYPE MOUNTING HARDWARE NU $70.81

    WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY Albany-Schenectady-Troy, NY E0960 TYPE MOUNTING HARDWARE RR $7.08

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 23 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY Albany-Schenectady-Troy, NY E0960 TYPE MOUNTING HARDWARE UE $53.11

    Albany-Schenectady-Troy, NY E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH NU $17.38

    Albany-Schenectady-Troy, NY E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH RR $1.74

    Albany-Schenectady-Troy, NY E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH UE $13.04

    Albany-Schenectady-Troy, NY E0971 MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH NU $26.92

    Albany-Schenectady-Troy, NY E0971 MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH RR $2.69

    Albany-Schenectady-Troy, NY E0971 MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH UE $20.19

    WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE Albany-Schenectady-Troy, NY E0973 ASSEMBLY, EACH NU $43.66

    WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE Albany-Schenectady-Troy, NY E0973 ASSEMBLY, EACH RR $4.37

    WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE Albany-Schenectady-Troy, NY E0973 ASSEMBLY, EACH UE $32.75

    Albany-Schenectady-Troy, NY E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH NU $24.30

    Albany-Schenectady-Troy, NY E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH RR $2.43

    Albany-Schenectady-Troy, NY E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH UE $18.23

    Albany-Schenectady-Troy, NY E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH NU $64.02

    Albany-Schenectady-Troy, NY E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH RR $6.40

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 24 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Albany-Schenectady-Troy, NY E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH UE $48.02

    Albany-Schenectady-Troy, NY E0992 MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT NU $77.63

    Albany-Schenectady-Troy, NY E0992 MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT RR $7.76

    Albany-Schenectady-Troy, NY E0992 MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT UE $58.22

    Albany-Schenectady-Troy, NY E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH NU $95.22

    Albany-Schenectady-Troy, NY E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH RR $9.52

    Albany-Schenectady-Troy, NY E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH UE $71.42

    Albany-Schenectady-Troy, NY E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE NU $193.00

    Albany-Schenectady-Troy, NY E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE RR $19.30

    Albany-Schenectady-Troy, NY E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE UE $144.75

    WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING Albany-Schenectady-Troy, NY E1028 HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY NU $124.38

    WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING Albany-Schenectady-Troy, NY E1028 HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY RR $12.44

    WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING Albany-Schenectady-Troy, NY E1028 HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY UE $93.29

    Albany-Schenectady-Troy, NY E1031 ROLLABOUT CHAIR, ANY AND ALL TYPES WITH CASTORS 5" OR GREATER RR $43.06

    TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 Albany-Schenectady-Troy, NY E1038 POUNDS RR $15.08

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 25 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 Albany-Schenectady-Troy, NY E1225 DEGREES, BUT LESS THAN 80 DEGREES), EACH RR $35.00

    WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80 Albany-Schenectady-Troy, NY E1226 DEGREES), EACH NU $343.22

    WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80 Albany-Schenectady-Troy, NY E1226 DEGREES), EACH RR $34.32

    WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80 Albany-Schenectady-Troy, NY E1226 DEGREES), EACH UE $257.42

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR Albany-Schenectady-Troy, NY E2201 EQUAL TO 20 INCHES AND LESS THAN 24 INCHES NU $295.09

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR Albany-Schenectady-Troy, NY E2201 EQUAL TO 20 INCHES AND LESS THAN 24 INCHES RR $29.51

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR Albany-Schenectady-Troy, NY E2201 EQUAL TO 20 INCHES AND LESS THAN 24 INCHES UE $221.32

    Albany-Schenectady-Troy, NY E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES NU $412.50

    Albany-Schenectady-Troy, NY E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES RR $41.25

    Albany-Schenectady-Troy, NY E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES UE $309.38

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN Albany-Schenectady-Troy, NY E2203 22 INCHES NU $415.00

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN Albany-Schenectady-Troy, NY E2203 22 INCHES RR $41.50

    MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN Albany-Schenectady-Troy, NY E2203 22 INCHES UE $311.25

    Albany-Schenectady-Troy, NY E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES NU $699.50

    Albany-Schenectady-Troy, NY E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES RR $69.95

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 26 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Albany-Schenectady-Troy, NY E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES UE $524.63

    Albany-Schenectady-Troy, NY E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH NU $35.50

    Albany-Schenectady-Troy, NY E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH RR $3.55

    Albany-Schenectady-Troy, NY E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH UE $26.63

    Albany-Schenectady-Troy, NY E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH NU $76.36

    Albany-Schenectady-Troy, NY E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH RR $7.64

    Albany-Schenectady-Troy, NY E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH UE $57.27

    Albany-Schenectady-Troy, NY E2209 ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH NU $81.70

    Albany-Schenectady-Troy, NY E2209 ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH RR $8.17

    Albany-Schenectady-Troy, NY E2209 ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH UE $61.28

    Albany-Schenectady-Troy, NY E2210 WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH NU $5.00

    Albany-Schenectady-Troy, NY E2210 WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH RR $0.50

    Albany-Schenectady-Troy, NY E2210 WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH UE $3.75

    Albany-Schenectady-Troy, NY E2211 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH NU $30.50

    Albany-Schenectady-Troy, NY E2211 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH RR $3.05

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 27 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Albany-Schenectady-Troy, NY E2211 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH UE $22.88

    MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE Albany-Schenectady-Troy, NY E2213 (REMOVABLE), ANY TYPE, ANY SIZE, EACH NU $28.00

    MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE Albany-Schenectady-Troy, NY E2213 (REMOVABLE), ANY TYPE, ANY SIZE, EACH RR $2.80

    MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE Albany-Schenectady-Troy, NY E2213 (REMOVABLE), ANY TYPE, ANY SIZE, EACH UE $21.00

    MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), Albany-Schenectady-Troy, NY E2231 INCLUDES ANY TYPE MOUNTING HARDWARE NU $138.50

    MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), Albany-Schenectady-Troy, NY E2231 INCLUDES ANY TYPE MOUNTING HARDWARE RR $13.85

    MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), Albany-Schenectady-Troy, NY E2231 INCLUDES ANY TYPE MOUNTING HARDWARE UE $103.88

    Albany-Schenectady-Troy, NY E2360 POWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID BATTERY, EACH NU $97.50

    Albany-Schenectady-Troy, NY E2360 POWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID BATTERY, EACH RR $9.75

    Albany-Schenectady-Troy, NY E2360 POWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID BATTERY, EACH UE $73.13

    POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E. G. GEL Albany-Schenectady-Troy, NY E2361 CELL, ABSORBED GLASSMAT) NU $104.65

    POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E. G. GEL Albany-Schenectady-Troy, NY E2361 CELL, ABSORBED GLASSMAT) RR $10.47

    POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E. G. GEL Albany-Schenectady-Troy, NY E2361 CELL, ABSORBED GLASSMAT) UE $78.49

    Albany-Schenectady-Troy, NY E2362 POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH NU $87.50

    Albany-Schenectady-Troy, NY E2362 POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH RR $8.75

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 28 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Albany-Schenectady-Troy, NY E2362 POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH UE $65.63

    POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E. G. GEL Albany-Schenectady-Troy, NY E2363 CELL, ABSORBED GLASSMAT) NU $129.00

    POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E. G. GEL Albany-Schenectady-Troy, NY E2363 CELL, ABSORBED GLASSMAT) RR $12.90

    POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E. G. GEL Albany-Schenectady-Troy, NY E2363 CELL, ABSORBED GLASSMAT) UE $96.75

    Albany-Schenectady-Troy, NY E2364 POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH NU $100.00

    Albany-Schenectady-Troy, NY E2364 POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH RR $10.00

    Albany-Schenectady-Troy, NY E2364 POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH UE $75.00

    POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E. G. GEL CELL, Albany-Schenectady-Troy, NY E2365 ABSORBED GLASSMAT) NU $67.30

    POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E. G. GEL CELL, Albany-Schenectady-Troy, NY E2365 ABSORBED GLASSMAT) RR $6.73

    POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E. G. GEL CELL, Albany-Schenectady-Troy, NY E2365 ABSORBED GLASSMAT) UE $50.48

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY Albany-Schenectady-Troy, NY E2366 ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH NU $142.66

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY Albany-Schenectady-Troy, NY E2366 ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH RR $14.27

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY Albany-Schenectady-Troy, NY E2366 ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH UE $107.00

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER Albany-Schenectady-Troy, NY E2367 BATTERY TYPE, SEALED OR NON-SEALED, EACH NU $312.50

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER Albany-Schenectady-Troy, NY E2367 BATTERY TYPE, SEALED OR NON-SEALED, EACH RR $31.25

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 29 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER Albany-Schenectady-Troy, NY E2367 BATTERY TYPE, SEALED OR NON-SEALED, EACH UE $234.38

    Albany-Schenectady-Troy, NY E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY NU $379.00

    Albany-Schenectady-Troy, NY E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY RR $37.90

    Albany-Schenectady-Troy, NY E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY UE $284.25

    Albany-Schenectady-Troy, NY E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY NU $334.00

    Albany-Schenectady-Troy, NY E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY RR $33.40

    Albany-Schenectady-Troy, NY E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY UE $250.50

    POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX Albany-Schenectady-Troy, NY E2370 COMBINATION, REPLACEMENT ONLY NU $515.21

    POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX Albany-Schenectady-Troy, NY E2370 COMBINATION, REPLACEMENT ONLY RR $51.52

    POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX Albany-Schenectady-Troy, NY E2370 COMBINATION, REPLACEMENT ONLY UE $386.41

    POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E. G. GEL CELL, Albany-Schenectady-Troy, NY E2371 ABSORBED GLASSMAT), EACH NU $124.50

    POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E. G. GEL CELL, Albany-Schenectady-Troy, NY E2371 ABSORBED GLASSMAT), EACH RR $12.45

    POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E. G. GEL CELL, Albany-Schenectady-Troy, NY E2371 ABSORBED GLASSMAT), EACH UE $93.38

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, Albany-Schenectady-Troy, NY E2381 REPLACEMENT ONLY, EACH NU $55.99

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, Albany-Schenectady-Troy, NY E2381 REPLACEMENT ONLY, EACH RR $5.60

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 30 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, Albany-Schenectady-Troy, NY E2381 REPLACEMENT ONLY, EACH UE $41.99

    POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE Albany-Schenectady-Troy, NY E2383 (REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH NU $117.28

    POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE Albany-Schenectady-Troy, NY E2383 (REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH RR $11.73

    POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE Albany-Schenectady-Troy, NY E2383 (REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH UE $87.96

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT Albany-Schenectady-Troy, NY E2384 ONLY, EACH NU $57.95

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT Albany-Schenectady-Troy, NY E2384 ONLY, EACH RR $5.80

    POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT Albany-Schenectady-Troy, NY E2384 ONLY, EACH UE $43.46

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, Albany-Schenectady-Troy, NY E2386 REPLACEMENT ONLY, EACH NU $103.50

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, Albany-Schenectady-Troy, NY E2386 REPLACEMENT ONLY, EACH RR $10.35

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, Albany-Schenectady-Troy, NY E2386 REPLACEMENT ONLY, EACH UE $77.63

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT Albany-Schenectady-Troy, NY E2387 ONLY, EACH NU $46.76

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT Albany-Schenectady-Troy, NY E2387 ONLY, EACH RR $4.68

    POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT Albany-Schenectady-Troy, NY E2387 ONLY, EACH UE $35.07

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), Albany-Schenectady-Troy, NY E2391 ANY SIZE, REPLACEMENT ONLY, EACH NU $15.00

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), Albany-Schenectady-Troy, NY E2391 ANY SIZE, REPLACEMENT ONLY, EACH RR $1.50

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 31 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), Albany-Schenectady-Troy, NY E2391 ANY SIZE, REPLACEMENT ONLY, EACH UE $11.25

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH Albany-Schenectady-Troy, NY E2392 INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH NU $37.58

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH Albany-Schenectady-Troy, NY E2392 INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH RR $3.76

    POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH Albany-Schenectady-Troy, NY E2392 INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH UE $28.19

    POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT Albany-Schenectady-Troy, NY E2394 ONLY, EACH NU $55.24

    POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT Albany-Schenectady-Troy, NY E2394 ONLY, EACH RR $5.52

    POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT Albany-Schenectady-Troy, NY E2394 ONLY, EACH UE $41.43

    POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, Albany-Schenectady-Troy, NY E2395 REPLACEMENT ONLY, EACH NU $43.32

    POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, Albany-Schenectady-Troy, NY E2395 REPLACEMENT ONLY, EACH RR $4.33

    POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, Albany-Schenectady-Troy, NY E2395 REPLACEMENT ONLY, EACH UE $32.49

    Albany-Schenectady-Troy, NY E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH NU $46.50

    Albany-Schenectady-Troy, NY E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH RR $4.65

    Albany-Schenectady-Troy, NY E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH UE $34.88

    Albany-Schenectady-Troy, NY E2601 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH NU $33.72

    Albany-Schenectady-Troy, NY E2601 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH RR $3.37

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 32 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Albany-Schenectady-Troy, NY E2601 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH UE $25.29

    Albany-Schenectady-Troy, NY E2602 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH NU $81.24

    Albany-Schenectady-Troy, NY E2602 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH RR $8.12

    Albany-Schenectady-Troy, NY E2602 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH UE $60.93

    Albany-Schenectady-Troy, NY E2603 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH NU $105.32

    Albany-Schenectady-Troy, NY E2603 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH RR $10.53

    Albany-Schenectady-Troy, NY E2603 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH UE $78.99

    Albany-Schenectady-Troy, NY E2604 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH NU $156.90

    Albany-Schenectady-Troy, NY E2604 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH RR $15.69

    Albany-Schenectady-Troy, NY E2604 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH UE $117.68

    Albany-Schenectady-Troy, NY E2605 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH NU $205.00

    Albany-Schenectady-Troy, NY E2605 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH RR $20.50

    Albany-Schenectady-Troy, NY E2605 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH UE $153.75

    Albany-Schenectady-Troy, NY E2606 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH NU $317.50

    Albany-Schenectady-Troy, NY E2606 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH RR $31.75

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 33 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Albany-Schenectady-Troy, NY E2606 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH UE $238.13

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 Albany-Schenectady-Troy, NY E2607 INCHES, ANY DEPTH NU $214.77

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 Albany-Schenectady-Troy, NY E2607 INCHES, ANY DEPTH RR $21.48

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 Albany-Schenectady-Troy, NY E2607 INCHES, ANY DEPTH UE $161.08

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR Albany-Schenectady-Troy, NY E2608 GREATER, ANY DEPTH NU $245.43

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR Albany-Schenectady-Troy, NY E2608 GREATER, ANY DEPTH RR $24.54

    SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR Albany-Schenectady-Troy, NY E2608 GREATER, ANY DEPTH UE $184.07

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, Albany-Schenectady-Troy, NY E2611 INCLUDING ANY TYPE MOUNTING HARDWARE NU $150.00

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, Albany-Schenectady-Troy, NY E2611 INCLUDING ANY TYPE MOUNTING HARDWARE RR $15.00

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, Albany-Schenectady-Troy, NY E2611 INCLUDING ANY TYPE MOUNTING HARDWARE UE $112.50

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, Albany-Schenectady-Troy, NY E2612 INCLUDING ANY TYPE MOUNTING HARDWARE NU $300.12

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, Albany-Schenectady-Troy, NY E2612 INCLUDING ANY TYPE MOUNTING HARDWARE RR $30.01

    GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, Albany-Schenectady-Troy, NY E2612 INCLUDING ANY TYPE MOUNTING HARDWARE UE $225.09

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY Albany-Schenectady-Troy, NY E2613 HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $290.43

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY Albany-Schenectady-Troy, NY E2613 HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $29.04

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 34 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY Albany-Schenectady-Troy, NY E2613 HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $217.82

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, Albany-Schenectady-Troy, NY E2614 ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $427.50

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, Albany-Schenectady-Troy, NY E2614 ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $42.75

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, Albany-Schenectady-Troy, NY E2614 ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $320.63

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 Albany-Schenectady-Troy, NY E2615 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $353.08

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 Albany-Schenectady-Troy, NY E2615 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $35.31

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 Albany-Schenectady-Troy, NY E2615 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $264.81

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR Albany-Schenectady-Troy, NY E2616 GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $475.50

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR Albany-Schenectady-Troy, NY E2616 GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $47.55

    POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR Albany-Schenectady-Troy, NY E2616 GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $356.63

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Albany-Schenectady-Troy, NY E2620 LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $382.66

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Albany-Schenectady-Troy, NY E2620 LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $38.27

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Albany-Schenectady-Troy, NY E2620 LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $287.00

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Albany-Schenectady-Troy, NY E2621 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE NU $389.50

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Albany-Schenectady-Troy, NY E2621 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE RR $38.95

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 35 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH Albany-Schenectady-Troy, NY E2621 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE UE $292.13

    Albany-Schenectady-Troy, NY K0001 STANDARD WHEELCHAIR RR $23.02

    Albany-Schenectady-Troy, NY K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR RR $44.03

    Albany-Schenectady-Troy, NY K0003 LIGHTWEIGHT WHEELCHAIR RR $35.25

    Albany-Schenectady-Troy, NY K0004 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR RR $43.85

    Albany-Schenectady-Troy, NY K0006 HEAVY DUTY WHEELCHAIR RR $68.49

    Albany-Schenectady-Troy, NY K0007 EXTRA HEAVY DUTY WHEELCHAIR RR $94.23

    Albany-Schenectady-Troy, NY K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH NU $120.10

    Albany-Schenectady-Troy, NY K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH RR $12.01

    Albany-Schenectady-Troy, NY K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH UE $90.08

    Albany-Schenectady-Troy, NY K0019 ARM PAD, EACH NU $11.00

    Albany-Schenectady-Troy, NY K0019 ARM PAD, EACH RR $1.10

    Albany-Schenectady-Troy, NY K0019 ARM PAD, EACH UE $8.25

    Albany-Schenectady-Troy, NY K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH NU $50.69

    Albany-Schenectady-Troy, NY K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH RR $5.07

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 36 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Albany-Schenectady-Troy, NY K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH UE $38.02

    Albany-Schenectady-Troy, NY K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH NU $65.00

    Albany-Schenectady-Troy, NY K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH RR $6.50

    Albany-Schenectady-Troy, NY K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH UE $48.75

    Albany-Schenectady-Troy, NY K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH NU $83.70

    Albany-Schenectady-Troy, NY K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH RR $8.37

    Albany-Schenectady-Troy, NY K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH UE $62.78

    SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, Albany-Schenectady-Troy, NY K0056 LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR NU $83.50

    SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, Albany-Schenectady-Troy, NY K0056 LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR RR $8.35

    SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, Albany-Schenectady-Troy, NY K0056 LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR UE $62.63

    Albany-Schenectady-Troy, NY K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, EACH NU $93.50

    Albany-Schenectady-Troy, NY K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, EACH RR $9.35

    Albany-Schenectady-Troy, NY K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, EACH UE $70.13

    Albany-Schenectady-Troy, NY K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, EACH NU $159.94

    Albany-Schenectady-Troy, NY K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, EACH RR $15.99

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 37 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Albany-Schenectady-Troy, NY K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, EACH UE $119.96

    Albany-Schenectady-Troy, NY K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH NU $52.00

    Albany-Schenectady-Troy, NY K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH RR $5.20

    Albany-Schenectady-Troy, NY K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH UE $39.00

    Albany-Schenectady-Troy, NY K0195 ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE) RR $9.78

    POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND Albany-Schenectady-Troy, NY K0800 INCLUDING 300 POUNDS NU $797.58

    POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND Albany-Schenectady-Troy, NY K0800 INCLUDING 300 POUNDS RR $79.76

    POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND Albany-Schenectady-Troy, NY K0800 INCLUDING 300 POUNDS UE $598.19

    POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 Albany-Schenectady-Troy, NY K0801 POUNDS NU $1,625.00

    POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 Albany-Schenectady-Troy, NY K0801 POUNDS RR $162.50

    POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 Albany-Schenectady-Troy, NY K0801 POUNDS UE $1,218.75

    POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 Albany-Schenectady-Troy, NY K0802 TO 600 POUNDS NU $1,759.00

    POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 Albany-Schenectady-Troy, NY K0802 TO 600 POUNDS RR $175.90

    POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 Albany-Schenectady-Troy, NY K0802 TO 600 POUNDS UE $1,319.25

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, Albany-Schenectady-Troy, NY K0813 PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS NU $1,849.50

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 38 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, Albany-Schenectady-Troy, NY K0813 PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS RR $277.43

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, Albany-Schenectady-Troy, NY K0813 PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,387.13

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0814 CAPACITY UP TO AND INCLUDING 300 POUNDS NU $1,975.00

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0814 CAPACITY UP TO AND INCLUDING 300 POUNDS RR $296.25

    POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0814 CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,481.25

    POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0815 CAPACITY UP TO AND INCLUDING 300 POUNDS NU $2,320.08

    POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0815 CAPACITY UP TO AND INCLUDING 300 POUNDS RR $348.01

    POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0815 CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,740.06

    POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Albany-Schenectady-Troy, NY K0816 UP TO AND INCLUDING 300 POUNDS NU $2,347.00

    POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Albany-Schenectady-Troy, NY K0816 UP TO AND INCLUDING 300 POUNDS RR $352.05

    POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Albany-Schenectady-Troy, NY K0816 UP TO AND INCLUDING 300 POUNDS UE $1,760.25

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT Albany-Schenectady-Troy, NY K0820 WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS NU $1,904.00

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT Albany-Schenectady-Troy, NY K0820 WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS RR $285.60

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT Albany-Schenectady-Troy, NY K0820 WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,428.00

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0821 CAPACITY UP TO AND INCLUDING 300 POUNDS NU $2,128.87

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 39 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0821 CAPACITY UP TO AND INCLUDING 300 POUNDS RR $319.33

    POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0821 CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,596.65

    POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0822 CAPACITY UP TO AND INCLUDING 300 POUNDS NU $2,157.50

    POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0822 CAPACITY UP TO AND INCLUDING 300 POUNDS RR $323.63

    POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0822 CAPACITY UP TO AND INCLUDING 300 POUNDS UE $1,618.13

    POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Albany-Schenectady-Troy, NY K0823 UP TO AND INCLUDING 300 POUNDS NU $1,848.25

    POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Albany-Schenectady-Troy, NY K0823 UP TO AND INCLUDING 300 POUNDS RR $277.24

    POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Albany-Schenectady-Troy, NY K0823 UP TO AND INCLUDING 300 POUNDS UE $1,386.19

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0824 CAPACITY 301 TO 450 POUNDS NU $2,798.38

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0824 CAPACITY 301 TO 450 POUNDS RR $419.76

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0824 CAPACITY 301 TO 450 POUNDS UE $2,098.79

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Albany-Schenectady-Troy, NY K0825 301 TO 450 POUNDS NU $2,406.22

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Albany-Schenectady-Troy, NY K0825 301 TO 450 POUNDS RR $360.93

    POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY Albany-Schenectady-Troy, NY K0825 301 TO 450 POUNDS UE $1,804.67

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Albany-Schenectady-Troy, NY K0826 WEIGHT CAPACITY 451 TO 600 POUNDS NU $4,585.75

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 40 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Albany-Schenectady-Troy, NY K0826 WEIGHT CAPACITY 451 TO 600 POUNDS RR $687.86

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Albany-Schenectady-Troy, NY K0826 WEIGHT CAPACITY 451 TO 600 POUNDS UE $3,439.31

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0827 CAPACITY 451 TO 600 POUNDS NU $3,781.88

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0827 CAPACITY 451 TO 600 POUNDS RR $567.28

    POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT Albany-Schenectady-Troy, NY K0827 CAPACITY 451 TO 600 POUNDS UE $2,836.41

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Albany-Schenectady-Troy, NY K0828 WEIGHT CAPACITY 601 POUNDS OR MORE NU $4,991.42

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Albany-Schenectady-Troy, NY K0828 WEIGHT CAPACITY 601 POUNDS OR MORE RR $748.71

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT Albany-Schenectady-Troy, NY K0828 WEIGHT CAPACITY 601 POUNDS OR MORE UE $3,743.57

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT 601 Albany-Schenectady-Troy, NY K0829 POUNDS OR MORE NU $4,784.50

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT 601 Albany-Schenectady-Troy, NY K0829 POUNDS OR MORE RR $717.68

    POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT 601 Albany-Schenectady-Troy, NY K0829 POUNDS OR MORE UE $3,588.38

    Albuquerque, NM E0950 WHEELCHAIR ACCESSORY, TRAY, EACH NU $77.71

    Albuquerque, NM E0950 WHEELCHAIR ACCESSORY, TRAY, EACH RR $7.77

    Albuquerque, NM E0950 WHEELCHAIR ACCESSORY, TRAY, EACH UE $58.28

    Albuquerque, NM E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH NU $13.00

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 41 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Albuquerque, NM E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH RR $1.30

    Albuquerque, NM E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH UE $9.75

    WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING Albuquerque, NM E0955 HARDWARE, EACH NU $139.40

    WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING Albuquerque, NM E0955 HARDWARE, EACH RR $13.94

    WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING Albuquerque, NM E0955 HARDWARE, EACH UE $104.55

    WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED Albuquerque, NM E0956 MOUNTING HARDWARE, EACH NU $86.70

    WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED Albuquerque, NM E0956 MOUNTING HARDWARE, EACH RR $8.67

    WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED Albuquerque, NM E0956 MOUNTING HARDWARE, EACH UE $65.03

    WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING Albuquerque, NM E0957 HARDWARE, EACH NU $115.22

    WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING Albuquerque, NM E0957 HARDWARE, EACH RR $11.52

    WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING Albuquerque, NM E0957 HARDWARE, EACH UE $86.42

    WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY Albuquerque, NM E0960 TYPE MOUNTING HARDWARE NU $79.50

    WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY Albuquerque, NM E0960 TYPE MOUNTING HARDWARE RR $7.95

    WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY Albuquerque, NM E0960 TYPE MOUNTING HARDWARE UE $59.63

    Albuquerque, NM E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH NU $22.00

    DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 42 of 1890

  • Standard (Power and Manual) Wheelchairs, Scooters, and Related AccessoriesHCPCS

    CBA Name Code HCPCS Code Description Modifier 1 Modifier 2 Modifier 3 SPA

    Albuquerque, NM E0961 MANUAL WHEELCHAIR AC