Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

Competitive Bidding Program Round 2

Single Payment Amounts

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

Akron, OH 4 Albany-Schenectady-Troy, NY 21 Albuquerque, NM 38 Allentown-Bethlehem-Easton, PA-NJ

Deltona-Daytona Beach-Ormond Beach, FL

55

Asheville, NC 72 Atlanta-Sandy Springs-Marietta, GA 89 Augusta-Richmond County, GA-SC 106 Austin-Round Rock-San Marcos, TX 123 Bakersfield-Delano, CA 140 Baltimore-Towson, MD 157 Baton Rouge, LA 174 Beaumont-Port Arthur, TX 191 Birmingham-Hoover, AL 208 Boise City-Nampa, ID 225 Boston-Cambridge-Quincy, MA-NH 242 Bridgeport-Stamford-Norwalk, CT 259 Bronx-Manhattan NY CBA 276

Buffalo-Niagara Falls, NY 293 Cape Coral-Fort Myers, FL 310 Central-Chicago Metro CBA 327 Charleston-North Charleston-Summerville, SC 344

Chattanooga, TN-GA 361 Colorado Springs, CO 378

Columbia, SC 395 Columbus, OH 412 Dayton, OH 429

446 Denver-Aurora-Broomfield, CO 463

Detroit-Warren-Livonia, MI 480 El Paso, TX 497 Flint, MI 514 Fresno, CA 531 Grand Rapids-Wyoming, MI 548 Greensboro-High Point, NC 565 Greenville-Mauldin-Easley, SC 582

Hartford-West Hartford-East Hartford, CT 599 Honolulu, HI 616 Houston-Sugar Land-Baytown, TX 633 Huntington-Ashland, WV-KY-OH 650 Indiana-Chicago Metro 667 Indianapolis-Carmel, IN 684

Jackson, MS 701 Jacksonville, FL 718 Knoxville, TN 735 Lakeland-Winter Haven, FL 752 Las Vegas-Paradise, NV 769 Little Rock-North Little Rock-Conway, AR 786 Los Angeles County CBA 803 Louisville/Jefferson County, KY-IN 820 McAllen-Edinburg-Mission, TX 837 Memphis, TN-MS-AR 854 Milwaukee-Waukesha-West Allis, WI 871

Minneapolis-St. Paul-Bloomington, MN-WI 888 Nashville-Davidson--Murfreesboro--Franklin, TN 905

Nassau-Brooklyn-Queens-Richmond County Metro CBA 922 New Haven-Milford, CT 939 New Orleans-Metairie-Kenner, LA 956

North East NY CBA Metro 973 North Port-Bradenton-Sarasota, FL 990 Northern NJ Metro CBA 1007 Northern-Chicago Metro CBA 1024 Ocala, FL 1041 Oklahoma City, OK 1058 Omaha-Council Bluffs, NE-IA 1075 Orange County CBA 1092 Oxnard-Thousand Oaks-Ventura, CA 1109 Palm Bay-Melbourne-Titusville, FL 1126

DMEPOS Competitive Bidding Program Round 2 SPA Effective July 01, 2013 Page 2 of 1703

Philadelphia-Camden-Wilmington, PA-NJ-DE-MD 1143 Phoenix-Mesa-Glendale, AZ 1160 Portland-Vancouver-Hillsboro, OR-WA 1177

Poughkeepsie-Newburgh-Middletown, NY 1194 Providence-New Bedford-Fall River, RI-MA 1211 Raleigh-Cary, NC 1228 Richmond, VA 1245 Rochester, NY 1262 Sacramento--Arden-Arcade--Roseville, CA 1279 Salt Lake City, UT 1296 San Antonio-New Braunfels, TX 1313 San Diego-Carlsbad-San Marcos, CA 1330 San Francisco-Oakland-Fremont, CA 1347 San Jose-Sunnyvale-Santa Clara, CA 1364 Scranton--Wilkes-Barre, PA 1381 Seattle-Tacoma-Bellevue, WA 1398 South-West-Chicago-Metro CBA 1415 Southern NY Metro CBA 1432

Springfield, MA 1449 St. Louis, MO-IL 1466 Stockton, CA 1483 Suffolk County CBA 1500 Syracuse, NY 1517 Tampa-St. Petersburg-Clearwater, FL 1534 Toledo, OH 1551 Tucson, AZ 1568 Tulsa, OK 1585 Virginia Beach-Norfolk-Newport News, VA-NC 1602 Visalia-Porterville, CA 1619

Washington-Arlington-Alexandria, DC-VA-MD-WV 1636 Wichita, KS 1653 Worcester, MA 1670 Youngstown-Warren-Boardman, OH-PA 1687

DMEPOS Competitive Bidding Program Round 2 SPA Effective July 01, 2013 Page 3 of 1703

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

CBA Name HCPCS 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

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

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

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

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

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

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

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

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

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

DMEPOS Competitive Bidding Program Round 2 SPA - Effective July 01, 2013 Page 4 of 1703

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

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

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

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

Akron, OH E0960 WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY 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

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

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

Akron, OH E0973 WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE 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 1703

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

CBA Name HCPCS 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

Akron, OH E1028

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

Akron, OH E1028

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

Akron, OH E1028

WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING 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 1703

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

CBA Name HCPCS 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

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

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

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

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