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2013 Blue Advantage HMOSM Durable Medical Equipment Fee
2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule This schedule is not a guaranty of payment. Variances in reimbursement may occur due to rounding calculations. Services represented are subject to provisions of the health plan including, but not limited to, membership eligibility, premium payment, claim payment logic, provider contract terms and conditions, applicable medical policy and benefits, limitations and exclusions. Maximum allowables and components of rates such as modifiers or conversion factors, and applicable rules such as bundling, may change from time to time subject to notice requirements of applicable law and regulation and the prevailing provider agreement. Values reflect the component of a code related to the place of treatment. CPT codes are copyright American Medical Association. All Rights Reserved. BCBSTX - HCSC Confidential and Proprietary. Procedure A4206 A4206 A4206 A4207 A4207 A4207 A4208 A4208 A4208 A4209 A4209 A4209 A4210 A4210 A4210 A4211 A4211 A4211 A4212 A4212 A4212 A4213 A4213 A4213 A4215 A4215 A4215 A4218 A4218 A4218 A4220 A4220 A4220 A4221 A4221 A4221 A4222 A4222 A4222 A4223 A4223 A4223 A4230 A4230 A4230 A4231 Modifier NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR Maximum Allowable $0.31 $0.31 $0.03 $1.00 $1.00 $0.10 $0.13 $0.13 $0.01 $0.25 $0.25 $0.03 $249.90 $249.90 $24.99 $12.68 $12.68 $1.27 $7.25 $7.25 $0.73 $0.55 $0.55 $0.06 $0.17 $0.17 $0.02 $3.13 $3.13 $0.31 $47.50 $47.50 $4.75 $15.32 $15.32 $1.53 $30.41 $30.41 $3.04 $45.88 $45.88 $4.59 $12.00 $12.00 $1.20 $7.46 Effective Date End Date Procedure Modifier A4231 A4231 A4232 A4232 A4232 A4233 A4233 A4233 A4234 A4234 A4234 A4235 A4235 A4235 A4236 A4236 A4236 A4244 A4244 A4244 A4245 A4245 A4245 A4246 A4246 A4246 A4247 A4247 A4247 A4250 A4250 A4250 A4252 A4252 A4252 A4253 A4253 A4253 A4255 A4255 A4255 A4256 A4256 A4256 A4257 A4257 NU RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $7.46 $0.75 $3.91 $3.91 $0.39 $0.54 $0.54 $0.05 $2.46 $2.46 $0.25 $1.59 $1.59 $0.16 $1.13 $1.13 $0.11 $1.23 $1.23 $0.12 $1.41 $1.41 $0.14 $3.88 $3.88 $0.39 $4.06 $4.06 $0.41 $41.16 $41.16 $4.12 $3.49 $3.49 $0.35 $23.38 $23.38 $2.34 $2.65 $2.65 $0.27 $7.74 $7.74 $0.77 $8.63 $8.63 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Page 1 of 58 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A4257 A4258 A4258 A4258 A4259 A4259 A4259 A4261 A4261 A4261 A4262 A4262 A4262 A4263 A4263 A4263 A4264 A4264 A4264 A4265 A4265 A4265 A4266 A4266 A4266 A4267 A4267 A4267 A4268 A4268 A4268 A4269 A4269 A4269 A4270 A4270 A4270 A4280 A4280 A4280 A4281 A4281 A4281 A4282 A4282 A4282 A4283 A4283 A4283 A4284 A4284 A4284 A4285 A4285 A4285 A4286 A4286 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.86 $12.21 $12.21 $1.22 $8.16 $8.16 $0.82 $81.00 $81.00 $8.10 $21.80 $21.80 $2.18 $8.85 $8.85 $0.88 $871.49 $871.49 $87.15 $2.30 $2.30 $0.23 $81.00 $81.00 $8.10 $0.08 $0.08 $0.01 $2.00 $2.00 $0.20 $10.19 $10.19 $1.02 $20.24 $20.24 $2.02 $3.60 $3.60 $0.36 $12.98 $12.98 $1.30 $10.00 $10.00 $1.00 $0.42 $0.42 $0.04 $20.00 $20.00 $2.00 $2.00 $2.00 $0.20 $1.94 $1.94 Effective Date End Date Procedure Modifier A4286 A4290 A4290 A4290 A4300 A4300 A4300 A4301 A4301 A4301 A4305 A4305 A4305 A4306 A4306 A4306 A4310 A4310 A4310 A4311 A4311 A4311 A4312 A4312 A4312 A4313 A4313 A4313 A4314 A4314 A4314 A4315 A4315 A4315 A4316 A4316 A4316 A4320 A4320 A4320 A4321 A4321 A4321 A4322 A4322 A4322 A4326 A4326 A4326 A4327 A4327 A4327 A4328 A4328 A4328 A4330 A4330 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 2 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.19 $107.06 $107.06 $10.71 $8.85 $8.85 $0.88 $36.00 $36.00 $3.60 $36.24 $36.24 $3.62 $36.24 $36.24 $3.62 $4.44 $4.44 $0.44 $8.71 $8.71 $0.87 $12.20 $12.20 $1.22 $12.54 $12.54 $1.25 $17.11 $17.11 $1.71 $17.39 $17.39 $1.74 $19.22 $19.22 $1.92 $3.06 $3.06 $0.31 $6.75 $6.75 $0.68 $1.91 $1.91 $0.19 $7.30 $7.30 $0.73 $30.19 $30.19 $3.02 $6.01 $6.01 $0.60 $4.79 $4.79 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A4330 A4331 A4331 A4331 A4332 A4332 A4332 A4333 A4333 A4333 A4334 A4334 A4334 A4335 A4335 A4335 A4336 A4336 A4336 A4338 A4338 A4338 A4340 A4340 A4340 A4344 A4344 A4344 A4346 A4346 A4346 A4349 A4349 A4349 A4351 A4351 A4351 A4352 A4352 A4352 A4353 A4353 A4353 A4354 A4354 A4354 A4355 A4355 A4355 A4356 A4356 A4356 A4357 A4357 A4357 A4358 A4358 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.48 $2.15 $2.15 $0.22 $0.08 $0.08 $0.01 $1.49 $1.49 $0.15 $3.33 $3.33 $0.33 $12.00 $12.00 $1.20 $0.98 $0.98 $0.10 $8.30 $8.30 $0.83 $21.49 $21.49 $2.15 $9.21 $9.21 $0.92 $11.26 $11.26 $1.13 $1.37 $1.37 $0.14 $1.23 $1.23 $0.12 $4.33 $4.33 $0.43 $4.73 $4.73 $0.47 $7.99 $7.99 $0.80 $6.03 $6.03 $0.60 $26.25 $26.25 $2.62 $5.58 $5.58 $0.56 $3.81 $3.81 Effective Date End Date Procedure Modifier A4358 A4360 A4360 A4360 A4361 A4361 A4361 A4362 A4362 A4362 A4363 A4363 A4363 A4364 A4364 A4364 A4366 A4366 A4366 A4367 A4367 A4367 A4368 A4368 A4368 A4369 A4369 A4369 A4371 A4371 A4371 A4372 A4372 A4372 A4373 A4373 A4373 A4375 A4375 A4375 A4376 A4376 A4376 A4377 A4377 A4377 A4378 A4378 A4378 A4379 A4379 A4379 A4380 A4380 A4380 A4381 A4381 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 3 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.38 $0.28 $0.28 $0.03 $12.43 $12.43 $1.24 $2.17 $2.17 $0.22 $1.60 $1.60 $0.16 $1.83 $1.83 $0.18 $0.88 $0.88 $0.09 $4.61 $4.61 $0.46 $0.18 $0.18 $0.02 $1.64 $1.64 $0.16 $2.47 $2.47 $0.25 $2.84 $2.84 $0.28 $4.25 $4.25 $0.42 $11.62 $11.62 $1.16 $32.20 $32.20 $3.22 $2.90 $2.90 $0.29 $20.81 $20.81 $2.08 $10.16 $10.16 $1.02 $25.26 $25.26 $2.53 $3.12 $3.12 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A4381 A4382 A4382 A4382 A4383 A4383 A4383 A4384 A4384 A4384 A4385 A4385 A4385 A4387 A4387 A4387 A4388 A4388 A4388 A4389 A4389 A4389 A4390 A4390 A4390 A4391 A4391 A4391 A4392 A4392 A4392 A4393 A4393 A4393 A4394 A4394 A4394 A4395 A4395 A4395 A4396 A4396 A4396 A4397 A4397 A4397 A4398 A4398 A4398 A4399 A4399 A4399 A4400 A4400 A4400 A4402 A4402 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.31 $16.66 $16.66 $1.67 $19.08 $19.08 $1.91 $6.51 $6.51 $0.65 $3.45 $3.45 $0.35 $4.00 $4.00 $0.40 $2.95 $2.95 $0.30 $4.21 $4.21 $0.42 $6.50 $6.50 $0.65 $4.78 $4.78 $0.48 $5.54 $5.54 $0.55 $6.12 $6.12 $0.61 $1.75 $1.75 $0.18 $0.03 $0.03 $0.01 $27.39 $27.39 $2.74 $3.24 $3.24 $0.32 $8.12 $8.12 $0.81 $7.05 $7.05 $0.70 $33.07 $33.07 $3.31 $1.08 $1.08 Effective Date End Date Procedure Modifier A4402 A4404 A4404 A4404 A4405 A4405 A4405 A4406 A4406 A4406 A4407 A4407 A4407 A4408 A4408 A4408 A4409 A4409 A4409 A4410 A4410 A4410 A4411 A4411 A4411 A4412 A4412 A4412 A4413 A4413 A4413 A4414 A4414 A4414 A4415 A4415 A4415 A4416 A4416 A4416 A4417 A4417 A4417 A4418 A4418 A4418 A4419 A4419 A4419 A4420 A4420 A4420 A4422 A4422 A4422 A4423 A4423 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 4 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.11 $1.14 $1.14 $0.11 $2.31 $2.31 $0.23 $3.88 $3.88 $0.39 $5.93 $5.93 $0.59 $6.68 $6.68 $0.67 $4.21 $4.21 $0.42 $6.12 $6.12 $0.61 $3.45 $3.45 $0.35 $1.83 $1.83 $0.18 $3.72 $3.72 $0.37 $3.33 $3.33 $0.33 $4.06 $4.06 $0.41 $1.86 $1.86 $0.19 $2.52 $2.52 $0.25 $1.23 $1.23 $0.12 $1.18 $1.18 $0.12 $5.62 $5.62 $0.56 $0.08 $0.08 $0.01 $1.26 $1.26 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A4423 A4424 A4424 A4424 A4425 A4425 A4425 A4426 A4426 A4426 A4427 A4427 A4427 A4428 A4428 A4428 A4429 A4429 A4429 A4430 A4430 A4430 A4431 A4431 A4431 A4432 A4432 A4432 A4433 A4433 A4433 A4434 A4434 A4434 A4435 A4435 A4435 A4450 A4450 A4450 A4452 A4452 A4452 A4455 A4455 A4455 A4456 A4456 A4456 A4458 A4458 A4458 A4461 A4461 A4461 A4463 A4463 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.13 $3.22 $3.22 $0.32 $2.43 $2.43 $0.24 $1.85 $1.85 $0.19 $1.88 $1.88 $0.19 $4.40 $4.40 $0.44 $5.58 $5.58 $0.56 $5.76 $5.76 $0.58 $4.21 $4.21 $0.42 $2.43 $2.43 $0.24 $2.26 $2.26 $0.23 $2.55 $2.55 $0.25 3.94 3.94 0.39 $0.08 $0.08 $0.01 $0.27 $0.27 $0.03 $0.83 $0.83 $0.08 $0.17 $0.17 $0.02 $8.15 $8.15 $0.82 $2.22 $2.22 $0.22 $9.02 $9.02 Effective Date End Date Procedure Modifier A4463 A4465 A4465 A4465 A4466 A4466 A4466 A4470 A4470 A4470 A4480 A4480 A4480 A4481 A4481 A4481 A4483 A4483 A4483 A4490 A4490 A4490 A4495 A4495 A4495 A4500 A4500 A4500 A4510 A4510 A4510 A4520 A4520 A4520 A4550 A4550 A4550 A4554 A4554 A4554 A4556 A4556 A4556 A4557 A4557 A4557 A4558 A4558 A4558 A4559 A4559 A4559 A4561 A4561 A4561 A4562 A4562 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 5 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.90 $30.17 $30.17 $3.02 $26.69 $26.69 $2.67 $1.81 $1.81 $0.18 $12.14 $12.14 $1.21 $0.25 $0.25 $0.03 $1.00 $1.00 $0.10 $17.13 $17.13 $1.71 $14.67 $14.67 $1.47 $1.50 $1.50 $0.15 $6.67 $6.67 $0.67 $1.08 $1.08 $0.11 $8.85 $8.85 $0.88 $6.03 $6.03 $0.60 $8.22 $8.22 $0.82 $14.28 $14.28 $1.43 $3.13 $3.13 $0.31 $0.07 $0.07 $0.01 $13.93 $13.93 $1.39 $34.64 $34.64 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A4562 A4565 A4565 A4565 A4570 A4570 A4570 A4580 A4580 A4580 A4590 A4590 A4590 A4595 A4595 A4595 A4600 A4600 A4600 A4601 A4601 A4601 A4604 A4604 A4604 A4605 A4605 A4605 A4606 A4606 A4606 A4608 A4608 A4608 A4611 A4611 A4611 A4612 A4612 A4612 A4613 A4613 A4613 A4614 A4614 A4614 A4615 A4615 A4615 A4616 A4616 A4616 A4617 A4617 A4617 A4618 A4618 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $3.46 $12.00 $12.00 $1.20 $30.00 $30.00 $3.00 $40.00 $40.00 $4.00 $250.00 $250.00 $25.00 $19.50 $19.50 $1.95 $4.17 $4.17 $0.42 $4.17 $4.17 $0.42 $38.97 $38.97 $3.90 $11.09 $11.09 $1.11 $11.21 $11.21 $1.12 $33.92 $33.92 $3.39 $132.94 $132.94 $13.78 $54.09 $54.09 $5.51 $82.95 $82.95 $8.30 $16.10 $16.10 $1.61 $0.49 $0.49 $0.05 $0.04 $0.04 $0.01 $2.10 $2.10 $0.21 $5.11 $5.11 Effective Date End Date Procedure Modifier A4618 A4619 A4619 A4619 A4620 A4620 A4620 A4623 A4623 A4623 A4624 A4624 A4624 A4625 A4625 A4625 A4626 A4626 A4626 A4627 A4627 A4627 A4628 A4628 A4628 A4629 A4629 A4629 A4630 A4630 A4630 A4633 A4633 A4633 A4634 A4634 A4634 A4635 A4635 A4635 A4636 A4636 A4636 A4637 A4637 A4637 A4638 A4638 A4638 A4639 A4639 A4639 A4640 A4640 A4640 A4648 A4648 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 6 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.59 $1.25 $1.25 $0.13 $0.40 $0.40 $0.04 $3.78 $3.78 $0.38 $1.78 $1.78 $0.18 $4.69 $4.69 $0.47 $1.84 $1.84 $0.18 $22.50 $22.50 $2.25 $2.48 $2.48 $0.25 $3.14 $3.14 $0.31 $4.23 $4.23 $0.42 $27.77 $27.77 $2.78 $2.00 $2.00 $0.20 $2.95 $2.95 $0.43 $2.43 $2.43 $0.25 $1.27 $1.27 $0.18 $6.38 $6.38 $0.64 $194.36 $194.36 $19.44 $36.42 $36.42 $3.70 $141.46 $141.46 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A4648 A4650 A4650 A4650 A4651 A4651 A4651 A4652 A4652 A4652 A4653 A4653 A4653 A4657 A4657 A4657 A4660 A4660 A4660 A4663 A4663 A4663 A4670 A4670 A4670 A4671 A4671 A4671 A4672 A4672 A4672 A4673 A4673 A4673 A4674 A4674 A4674 A4680 A4680 A4680 A4690 A4690 A4690 A4714 A4714 A4714 A4719 A4719 A4719 A4730 A4730 A4730 A4740 A4740 A4740 A4750 A4750 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $14.15 $39.82 $39.82 $3.98 $22.50 $22.50 $2.25 $9.00 $9.00 $0.90 $5.67 $5.67 $0.57 $6.07 $6.07 $0.61 $10.00 $10.00 $1.00 $28.00 $28.00 $2.80 $40.00 $40.00 $4.00 $50.00 $50.00 $5.00 $10.98 $10.98 $1.10 $10.98 $10.98 $1.10 $5.00 $5.00 $0.50 $18.12 $18.12 $1.81 $18.12 $18.12 $1.81 $66.00 $66.00 $6.60 $12.00 $12.00 $1.20 $18.12 $18.12 $1.81 $18.12 $18.12 $1.81 $7.00 $7.00 Effective Date End Date Procedure Modifier A4750 A4755 A4755 A4755 A4760 A4760 A4760 A4765 A4765 A4765 A4770 A4770 A4770 A4772 A4772 A4772 A4773 A4773 A4773 A4860 A4860 A4860 A4927 A4927 A4927 A4928 A4928 A4928 A4930 A4930 A4930 A4931 A4931 A4931 A4932 A4932 A4932 A5051 A5051 A5051 A5052 A5052 A5052 A5053 A5053 A5053 A5054 A5054 A5054 A5055 A5055 A5055 A5056 A5056 A5056 A5057 A5057 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 7 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.70 $18.12 $18.12 $1.81 $18.12 $18.12 $1.81 $18.12 $18.12 $1.81 $30.00 $30.00 $3.00 $72.00 $72.00 $7.20 $12.50 $12.50 $1.25 $8.00 $8.00 $0.80 $10.00 $10.00 $1.00 $2.18 $2.18 $0.22 $1.00 $1.00 $0.10 $6.00 $6.00 $0.60 $6.00 $6.00 $0.60 $1.40 $1.40 $0.14 $1.01 $1.01 $0.10 $1.11 $1.11 $0.11 $1.22 $1.22 $0.12 $0.95 $0.95 $0.09 $3.16 $3.16 $0.32 $6.50 $6.50 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A5057 A5061 A5061 A5061 A5062 A5062 A5062 A5063 A5063 A5063 A5071 A5071 A5071 A5072 A5072 A5072 A5073 A5073 A5073 A5081 A5081 A5081 A5082 A5082 A5082 A5083 A5083 A5083 A5093 A5093 A5093 A5102 A5102 A5102 A5105 A5105 A5105 A5112 A5112 A5112 A5113 A5113 A5113 A5114 A5114 A5114 A5120 A5120 A5120 A5121 A5121 A5121 A5122 A5122 A5122 A5126 A5126 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.65 $2.39 $2.39 $0.24 $1.41 $1.41 $0.14 $1.83 $1.83 $0.18 $4.06 $4.06 $0.41 $2.32 $2.32 $0.23 $2.15 $2.15 $0.22 $1.90 $1.90 $0.19 $8.05 $8.05 $0.80 $0.43 $0.43 $0.04 $1.32 $1.32 $0.13 $15.17 $15.17 $1.52 $27.59 $27.59 $2.76 $19.91 $19.91 $1.99 $2.71 $2.71 $0.27 $6.05 $6.05 $0.61 $0.17 $0.17 $0.02 $4.83 $4.83 $0.48 $7.39 $7.39 $0.74 $0.89 $0.89 Effective Date End Date Procedure Modifier A5126 A5131 A5131 A5131 A5200 A5200 A5200 A5500 A5500 A5500 A5501 A5501 A5501 A5503 A5503 A5503 A5504 A5504 A5504 A5505 A5505 A5505 A5506 A5506 A5506 A5507 A5507 A5507 A5508 A5508 A5508 A5510 A5510 A5510 A5512 A5512 A5512 A5513 A5513 A5513 A6000 A6000 A6000 A6010 A6010 A6010 A6011 A6011 A6011 A6021 A6021 A6021 A6022 A6022 A6022 A6023 A6023 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 8 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.09 $10.73 $10.73 $1.07 $7.64 $7.64 $0.76 $43.02 $43.02 $4.30 $129.06 $129.06 $12.91 $21.12 $21.12 $2.11 $21.12 $21.12 $2.11 $21.12 $21.12 $2.11 $21.12 $21.12 $2.11 $21.12 $21.12 $2.11 $37.00 $37.00 $3.70 $77.70 $77.70 $7.77 $17.55 $17.55 $1.76 $26.20 $26.20 $2.62 $8.51 $8.51 $0.85 $20.95 $20.95 $2.10 $1.54 $1.54 $0.15 $14.23 $14.23 $1.42 $14.23 $14.23 $1.42 $128.78 $128.78 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A6023 A6024 A6024 A6024 A6025 A6025 A6025 A6154 A6154 A6154 A6196 A6196 A6196 A6197 A6197 A6197 A6199 A6199 A6199 A6203 A6203 A6203 A6204 A6204 A6204 A6205 A6205 A6205 A6206 A6206 A6206 A6207 A6207 A6207 A6208 A6208 A6208 A6209 A6209 A6209 A6210 A6210 A6210 A6211 A6211 A6211 A6212 A6212 A6212 A6213 A6213 A6213 A6214 A6214 A6214 A6215 A6215 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $12.88 $4.19 $4.19 $0.42 $22.05 $22.05 $2.21 $9.43 $9.43 $0.94 $4.98 $4.98 $0.50 $11.12 $11.12 $1.11 $3.57 $3.57 $0.36 $2.27 $2.27 $0.23 $4.21 $4.21 $0.42 $12.68 $12.68 $1.27 $1.00 $1.00 $0.10 $4.96 $4.96 $0.50 $8.00 $8.00 $0.80 $5.06 $5.06 $0.51 $13.48 $13.48 $1.35 $19.88 $19.88 $1.99 $6.56 $6.56 $0.66 $13.00 $13.00 $1.30 $6.96 $6.96 $0.70 $12.00 $12.00 Effective Date End Date Procedure Modifier A6215 A6216 A6216 A6216 A6217 A6217 A6217 A6218 A6218 A6218 A6219 A6219 A6219 A6220 A6220 A6220 A6221 A6221 A6221 A6222 A6222 A6222 A6223 A6223 A6223 A6224 A6224 A6224 A6228 A6228 A6228 A6229 A6229 A6229 A6230 A6230 A6230 A6231 A6231 A6231 A6232 A6232 A6232 A6233 A6233 A6233 A6234 A6234 A6234 A6235 A6235 A6235 A6236 A6236 A6236 A6237 A6237 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 9 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $1.20 $0.03 $0.03 $0.01 $10.95 $10.95 $1.10 $1.00 $1.00 $0.10 $0.64 $0.64 $0.06 $1.75 $1.75 $0.18 $3.00 $3.00 $0.30 $1.44 $1.44 $0.14 $1.64 $1.64 $0.16 $2.44 $2.44 $0.24 $3.00 $3.00 $0.30 $2.44 $2.44 $0.24 $3.00 $3.00 $0.30 $3.16 $3.16 $0.32 $4.65 $4.65 $0.46 $12.98 $12.98 $1.30 $4.42 $4.42 $0.44 $11.38 $11.38 $1.14 $18.44 $18.44 $1.84 $5.36 $5.36 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A6237 A6238 A6238 A6238 A6239 A6239 A6239 A6240 A6240 A6240 A6241 A6241 A6241 A6242 A6242 A6242 A6243 A6243 A6243 A6244 A6244 A6244 A6245 A6245 A6245 A6246 A6246 A6246 A6247 A6247 A6247 A6248 A6248 A6248 A6250 A6250 A6250 A6251 A6251 A6251 A6252 A6252 A6252 A6253 A6253 A6253 A6254 A6254 A6254 A6255 A6255 A6255 A6256 A6256 A6256 A6257 A6257 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.54 $15.42 $15.42 $1.54 $23.00 $23.00 $2.30 $8.28 $8.28 $0.83 $1.74 $1.74 $0.17 $4.10 $4.10 $0.41 $8.33 $8.33 $0.83 $26.58 $26.58 $2.66 $4.91 $4.91 $0.49 $6.72 $6.72 $0.67 $16.10 $16.10 $1.61 $10.99 $10.99 $1.10 $2.00 $2.00 $0.20 $1.35 $1.35 $0.13 $2.20 $2.20 $0.22 $4.29 $4.29 $0.43 $0.82 $0.82 $0.08 $2.05 $2.05 $0.21 $5.00 $5.00 $0.50 $1.04 $1.04 Effective Date End Date Procedure Modifier A6257 A6258 A6258 A6258 A6259 A6259 A6259 A6260 A6260 A6260 A6266 A6266 A6266 A6402 A6402 A6402 A6403 A6403 A6403 A6404 A6404 A6404 A6407 A6407 A6407 A6410 A6410 A6410 A6411 A6411 A6411 A6412 A6412 A6412 A6413 A6413 A6413 A6441 A6441 A6441 A6442 A6442 A6442 A6443 A6443 A6443 A6444 A6444 A6444 A6445 A6445 A6445 A6446 A6446 A6446 A6447 A6447 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 10 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.10 $2.92 $2.92 $0.29 $7.41 $7.41 $0.74 $0.03 $0.03 $0.01 $1.30 $1.30 $0.13 $0.08 $0.08 $0.01 $0.29 $0.29 $0.03 $1.00 $1.00 $0.10 $1.27 $1.27 $0.13 $0.26 $0.26 $0.03 $1.00 $1.00 $0.10 $0.08 $0.08 $0.01 $2.43 $2.43 $0.24 $0.45 $0.45 $0.05 $0.11 $0.11 $0.01 $0.20 $0.20 $0.02 $0.38 $0.38 $0.04 $0.22 $0.22 $0.02 $0.28 $0.28 $0.03 $0.45 $0.45 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A6447 A6448 A6448 A6448 A6449 A6449 A6449 A6450 A6450 A6450 A6451 A6451 A6451 A6452 A6452 A6452 A6453 A6453 A6453 A6454 A6454 A6454 A6455 A6455 A6455 A6456 A6456 A6456 A6457 A6457 A6457 A6501 A6501 A6501 A6502 A6502 A6502 A6503 A6503 A6503 A6504 A6504 A6504 A6505 A6505 A6505 A6506 A6506 A6506 A6507 A6507 A6507 A6508 A6508 A6508 A6513 A6513 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.05 $0.79 $0.79 $0.08 $1.18 $1.18 $0.12 $8.94 $8.94 $0.89 $8.94 $8.94 $0.89 $4.00 $4.00 $0.40 $0.42 $0.42 $0.04 $0.52 $0.52 $0.05 $0.95 $0.95 $0.09 $0.86 $0.86 $0.09 $0.77 $0.77 $0.08 $1,449.40 $1,449.40 $144.94 $17.70 $17.70 $1.77 $1.40 $1.40 $0.14 $167.54 $167.54 $16.75 $52.98 $52.98 $5.30 $1,397.86 $1,397.86 $139.79 $2,593.12 $2,593.12 $259.31 $2,515.86 $2,515.86 $251.59 $1.40 $1.40 Effective Date End Date Procedure Modifier A6513 A6530 A6530 A6530 A6531 A6531 A6531 A6532 A6532 A6532 A6533 A6533 A6533 A6534 A6534 A6534 A6535 A6535 A6535 A6536 A6536 A6536 A6537 A6537 A6537 A6539 A6539 A6539 A6540 A6540 A6540 A6541 A6541 A6541 A6545 A6545 A6545 A6549 A6549 A6549 A6550 A6550 A6550 A7000 A7000 A7000 A7001 A7001 A7001 A7002 A7002 A7002 A7003 A7003 A7003 A7004 A7004 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 11 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.14 $47.50 $47.50 $4.75 $29.28 $29.28 $2.93 $41.25 $41.25 $4.13 $55.00 $55.00 $5.50 $44.13 $44.13 $4.41 $150.27 $150.27 $15.03 $7.50 $7.50 $0.75 $40.50 $40.50 $4.05 $31.62 $31.62 $3.16 $72.39 $72.39 $7.24 $42.50 $42.50 $4.25 $57.65 $57.65 $5.76 $59.74 $59.74 $5.97 $16.00 $16.00 $1.60 $6.16 $6.16 $0.62 $19.03 $19.03 $1.90 $2.21 $2.21 $0.22 $1.76 $1.76 $0.18 $1.04 $1.04 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A7004 A7005 A7005 A7005 A7006 A7006 A7006 A7007 A7007 A7007 A7008 A7008 A7008 A7009 A7009 A7009 A7010 A7010 A7010 A7011 A7011 A7011 A7012 A7012 A7012 A7013 A7013 A7013 A7014 A7014 A7014 A7015 A7015 A7015 A7016 A7016 A7016 A7017 A7017 A7017 A7018 A7018 A7018 A7020 A7020 A7020 A7025 A7025 A7025 A7026 A7026 A7026 A7027 A7027 A7027 A7028 A7028 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.10 $17.73 $17.73 $1.77 $6.41 $6.41 $0.64 $2.82 $2.82 $0.28 $6.33 $6.33 $0.63 $26.42 $26.42 $2.64 $13.57 $13.57 $1.36 $22.00 $22.00 $2.20 $2.44 $2.44 $0.24 $0.48 $0.48 $0.05 $2.94 $2.94 $0.29 $1.27 $1.27 $0.13 $4.41 $4.41 $0.44 $90.70 $90.70 $9.07 $0.22 $0.22 $0.02 $9.44 $9.44 $0.94 $294.32 $294.32 $29.43 $19.45 $19.45 $1.95 $121.37 $121.37 $12.14 $33.53 $33.53 Effective Date End Date Procedure Modifier A7028 A7029 A7029 A7029 A7030 A7030 A7030 A7031 A7031 A7031 A7032 A7032 A7032 A7033 A7033 A7033 A7034 A7034 A7034 A7035 A7035 A7035 A7036 A7036 A7036 A7037 A7037 A7037 A7038 A7038 A7038 A7039 A7039 A7039 A7040 A7040 A7040 A7041 A7041 A7041 A7042 A7042 A7042 A7043 A7043 A7043 A7044 A7044 A7044 A7045 A7045 A7045 A7046 A7046 A7046 A7501 A7501 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 12 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $3.35 $13.70 $13.70 $1.37 $110.02 $110.02 $11.00 $40.69 $40.69 $4.07 $23.64 $23.64 $2.36 $16.57 $16.57 $1.66 $68.61 $68.61 $6.86 $20.23 $20.23 $2.02 $9.02 $9.02 $0.90 $22.36 $22.36 $2.24 $2.99 $2.99 $0.30 $7.60 $7.60 $0.76 $27.52 $27.52 $2.75 $51.72 $51.72 $5.17 $117.40 $117.40 $11.74 $19.57 $19.57 $1.96 $70.52 $70.52 $7.05 $11.35 $11.35 $1.13 $11.38 $11.38 $1.14 $71.07 $71.07 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier A7501 A7502 A7502 A7502 A7503 A7503 A7503 A7504 A7504 A7504 A7505 A7505 A7505 A7506 A7506 A7506 A7507 A7507 A7507 A7508 A7508 A7508 A7509 A7509 A7509 A7520 A7520 A7520 A7521 A7521 A7521 A7522 A7522 A7522 A7523 A7523 A7523 A7524 A7524 A7524 A7525 A7525 A7525 A7526 A7526 A7526 A7527 A7527 A7527 A8000 A8000 A8000 A8001 A8001 A8001 A8002 A8002 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $7.11 $33.78 $33.78 $3.38 $7.67 $7.67 $0.77 $0.45 $0.45 $0.05 $3.17 $3.17 $0.32 $0.23 $0.23 $0.02 $1.68 $1.68 $0.17 $1.94 $1.94 $0.19 $0.96 $0.96 $0.10 $32.13 $32.13 $3.21 $31.83 $31.83 $3.18 $30.56 $30.56 $3.06 $8.67 $8.67 $0.87 $52.38 $52.38 $5.24 $1.40 $1.40 $0.14 $2.28 $2.28 $0.23 $2.43 $2.43 $0.24 $103.77 $103.77 $10.38 $103.77 $103.77 $10.38 $4.17 $4.17 Effective Date End Date Procedure Modifier A8002 A8003 A8003 A8003 A8004 A8004 A8004 A9270 A9270 A9270 A9274 A9274 A9274 A9275 A9275 A9275 A9276 A9276 A9276 A9281 A9281 A9281 A9282 A9282 A9282 A9283 A9283 A9283 A9284 A9284 A9284 A9300 A9300 A9300 A9584 A9584 A9584 A9901 A9901 A9901 B4034 B4034 B4034 B4035 B4035 B4035 B4036 B4036 B4036 B4081 B4081 B4081 B4082 B4082 B4082 B4083 B4083 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 13 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.42 $4.17 $4.17 $0.42 $4.17 $4.17 $0.42 $70.00 $70.00 $7.00 $41.24 $41.24 $4.12 $66.82 $66.82 $6.68 $5.84 $5.84 $0.58 $17.50 $17.50 $1.75 $50.00 $50.00 $5.00 $66.99 $66.99 $6.70 $11.85 $11.85 $1.19 $5.82 $5.82 $0.58 $2,160.00 $2,160.00 $216.00 $25.95 $25.95 $2.60 $6.06 $6.06 $0.61 $11.56 $11.56 $1.16 $7.94 $7.94 $0.79 $21.44 $21.44 $2.14 $15.94 $15.94 $1.59 $2.45 $2.45 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier B4083 B4087 B4087 B4087 B4088 B4088 B4088 B4100 B4100 B4100 B4102 B4102 B4102 B4103 B4103 B4103 B4104 B4104 B4104 B4149 B4149 B4149 B4150 B4150 B4150 B4152 B4152 B4152 B4153 B4153 B4153 B4154 B4154 B4154 B4155 B4155 B4155 B4157 B4157 B4157 B4158 B4158 B4158 B4159 B4159 B4159 B4160 B4160 B4160 B4161 B4161 B4161 B4162 B4162 B4162 B4164 B4164 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.25 $35.39 $35.39 $3.54 $35.39 $35.39 $3.54 $0.56 $0.56 $0.06 $2.65 $2.65 $0.27 $2.94 $2.94 $0.29 $0.02 $0.02 $0.01 $1.56 $1.56 $0.16 $0.67 $0.67 $0.07 $0.55 $0.55 $0.06 $1.89 $1.89 $0.19 $1.21 $1.21 $0.12 $0.94 $0.94 $0.09 $3.26 $3.26 $0.33 $1.44 $1.44 $0.14 $1.11 $1.11 $0.11 $0.85 $0.85 $0.09 $2.24 $2.24 $0.22 $2.76 $2.76 $0.28 $18.95 $18.95 Effective Date End Date Procedure Modifier B4164 B4168 B4168 B4168 B4172 B4172 B4172 B4176 B4176 B4176 B4178 B4178 B4178 B4180 B4180 B4180 B4189 B4189 B4189 B4193 B4193 B4193 B4197 B4197 B4197 B4199 B4199 B4199 B4216 B4216 B4216 B4220 B4220 B4220 B4222 B4222 B4222 B4224 B4224 B4224 B5000 B5000 B5000 B5100 B5100 B5100 B5200 B5200 B5200 B9000 B9000 B9000 B9002 B9002 B9002 B9004 B9004 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 14 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $1.90 $27.63 $27.63 $2.76 $192.07 $192.07 $19.21 $53.46 $53.46 $5.35 $64.18 $64.18 $6.42 $27.20 $27.20 $2.72 $198.26 $198.26 $19.83 $256.19 $256.19 $25.62 $311.90 $311.90 $31.19 $356.40 $356.40 $35.64 $8.61 $8.61 $0.86 $8.93 $8.93 $0.89 $11.01 $11.01 $1.10 $27.89 $27.89 $2.79 $13.26 $13.26 $1.33 $5.18 $5.18 $0.52 $0.11 $0.11 $0.01 $1,216.05 $1,216.05 $111.74 $1,216.05 $1,216.05 $117.77 $2,814.32 $2,814.32 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier B9004 B9006 B9006 B9006 E0100 E0100 E0100 E0105 E0105 E0105 E0110 E0110 E0110 E0111 E0111 E0111 E0112 E0112 E0112 E0113 E0113 E0113 E0114 E0114 E0114 E0116 E0116 E0116 E0117 E0117 E0117 E0118 E0118 E0118 E0130 E0130 E0130 E0135 E0135 E0135 E0140 E0140 E0140 E0141 E0141 E0141 E0143 E0143 E0143 E0144 E0144 E0144 E0147 E0147 E0147 E0148 E0148 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $445.52 $2,814.32 $2,814.32 $445.52 $13.26 $13.26 $3.41 $32.30 $32.30 $5.09 $48.30 $48.30 $9.19 $30.63 $30.63 $4.84 $25.04 $25.04 $5.71 $12.39 $12.39 $2.96 $27.86 $27.86 $4.93 $15.96 $15.96 $3.11 $130.41 $130.41 $13.03 $70.84 $70.84 $7.08 $38.07 $38.07 $8.33 $48.90 $48.90 $8.55 $210.38 $210.38 $21.04 $61.91 $61.91 $11.09 $67.54 $67.54 $10.70 $185.74 $185.74 $18.58 $335.25 $335.25 $33.53 $74.11 $74.11 Effective Date End Date Procedure Modifier E0148 E0149 E0149 E0149 E0153 E0153 E0153 E0154 E0154 E0154 E0155 E0155 E0155 E0156 E0156 E0156 E0157 E0157 E0157 E0158 E0158 E0158 E0159 E0159 E0159 E0160 E0160 E0160 E0161 E0161 E0161 E0162 E0162 E0162 E0163 E0163 E0163 E0165 E0165 E0165 E0167 E0167 E0167 E0168 E0168 E0168 E0170 E0170 E0170 E0171 E0171 E0171 E0172 E0172 E0172 E0175 E0175 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 15 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $7.42 $130.18 $130.18 $13.02 $46.95 $46.95 $5.30 $41.13 $41.13 $5.00 $18.40 $18.40 $2.24 $13.10 $13.10 $1.68 $40.62 $40.62 $4.46 $18.08 $18.08 $2.07 $10.42 $10.42 $1.05 $19.01 $19.01 $2.49 $15.08 $15.08 $2.05 $83.81 $83.81 $8.79 $74.63 $74.63 $16.52 $125.75 $125.75 $12.57 $8.08 $8.08 $0.81 $102.13 $102.13 $10.21 $1,087.63 $1,087.63 $108.76 $195.74 $195.74 $19.57 $311.40 $311.40 $31.14 $44.82 $44.82 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier Maximum Allowable E0175 E0181 E0181 E0181 E0182 E0182 E0182 E0184 E0184 E0184 E0185 E0185 E0185 E0186 E0186 E0186 E0187 E0187 E0187 E0188 E0188 E0188 E0189 E0189 E0189 E0190 E0190 E0190 E0191 E0191 E0191 E0193 E0193 E0193 E0194 E0194 E0194 E0196 E0196 E0196 E0197 E0197 E0197 E0198 E0198 E0198 E0199 E0199 E0199 E0200 E0200 E0200 E0202 E0202 E0202 E0203 E0203 RR $4.48 $176.34 $176.34 $17.63 $150.57 $150.57 $15.06 $112.00 $112.00 $16.63 $216.44 $216.44 $30.41 $137.40 $137.40 $13.74 $157.06 $157.06 $15.71 $15.20 $15.20 $1.79 $35.17 $35.17 $3.81 $56.76 $56.76 $5.68 $6.34 $6.34 $0.63 $5,269.38 $5,269.38 $526.94 $20,069.09 $20,069.09 $2,006.91 $219.87 $219.87 $21.99 $127.46 $127.46 $17.58 $127.46 $127.46 $13.20 $21.12 $21.12 $2.11 $53.65 $53.65 $7.28 $423.68 $423.68 $42.37 $223.17 $223.17 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Effective Date End Date Procedure Modifier E0203 E0205 E0205 E0205 E0210 E0210 E0210 E0215 E0215 E0215 E0217 E0217 E0217 E0218 E0218 E0218 E0221 E0221 E0221 E0225 E0225 E0225 E0235 E0235 E0235 E0236 E0236 E0236 E0239 E0239 E0239 E0240 E0240 E0240 E0241 E0241 E0241 E0242 E0242 E0242 E0243 E0243 E0243 E0245 E0245 E0245 E0246 E0246 E0246 E0247 E0247 E0247 E0248 E0248 E0248 E0249 E0249 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 16 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $22.32 $131.32 $131.32 $14.45 $18.77 $18.77 $1.77 $47.94 $47.94 $5.01 $335.96 $335.96 $37.40 $290.00 $290.00 $29.00 $2,157.84 $2,157.84 $215.78 $262.99 $262.99 $25.92 $116.74 $116.74 $11.67 $299.38 $299.38 $29.94 $304.40 $304.40 $30.44 $126.45 $126.45 $12.65 $32.00 $32.00 $3.20 $18.12 $18.12 $1.81 $40.00 $40.00 $4.00 $39.00 $39.00 $3.90 $18.12 $18.12 $1.81 $47.84 $47.84 $4.78 $47.84 $47.84 $4.78 $67.40 $67.40 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier E0249 E0250 E0250 E0250 E0251 E0251 E0251 E0255 E0255 E0255 E0256 E0256 E0256 E0260 E0260 E0260 E0261 E0261 E0261 E0265 E0265 E0265 E0266 E0266 E0266 E0270 E0270 E0270 E0271 E0271 E0271 E0272 E0272 E0272 E0273 E0273 E0273 E0274 E0274 E0274 E0275 E0275 E0275 E0276 E0276 E0276 E0277 E0277 E0277 E0280 E0280 E0280 E0290 E0290 E0290 E0291 E0291 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $7.42 $570.15 $570.15 $57.02 $432.05 $432.05 $43.21 $685.19 $685.19 $68.52 $486.11 $486.11 $48.61 $819.25 $819.25 $81.93 $798.71 $798.71 $79.87 $1,165.82 $1,165.82 $116.58 $1,035.78 $1,035.78 $103.58 $18.12 $18.12 $1.81 $120.07 $120.07 $12.01 $107.91 $107.91 $10.79 $18.12 $18.12 $1.81 $15.00 $15.00 $1.50 $10.36 $10.36 $1.08 $9.01 $9.01 $1.06 $4,102.94 $4,102.94 $410.29 $22.28 $22.28 $2.40 $435.90 $435.90 $43.59 $316.70 $316.70 Effective Date End Date Procedure Modifier E0291 E0292 E0292 E0292 E0293 E0293 E0293 E0294 E0294 E0294 E0295 E0295 E0295 E0296 E0296 E0296 E0297 E0297 E0297 E0300 E0300 E0300 E0301 E0301 E0301 E0302 E0302 E0302 E0303 E0303 E0303 E0304 E0304 E0304 E0305 E0305 E0305 E0310 E0310 E0310 E0316 E0316 E0316 E0325 E0325 E0325 E0326 E0326 E0326 E0350 E0350 E0350 E0370 E0370 E0370 E0371 E0371 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 17 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $31.67 $490.14 $490.14 $49.01 $417.12 $417.12 $41.71 $761.99 $761.99 $76.20 $742.71 $742.71 $74.27 $957.66 $957.66 $95.77 $820.45 $820.45 $82.04 $1,655.62 $1,655.62 $165.56 $1,578.97 $1,578.97 $157.90 $4,172.74 $4,172.74 $417.27 $1,772.95 $1,772.95 $177.29 $4,494.92 $4,494.92 $449.49 $103.76 $103.76 $10.38 $106.39 $106.39 $13.07 $1,125.50 $1,125.50 $112.55 $6.84 $6.84 $1.03 $7.11 $7.11 $0.81 $47.50 $47.50 $4.75 $29.00 $29.00 $2.90 $2,592.39 $2,592.39 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier E0371 E0372 E0372 E0372 E0373 E0373 E0373 E0424 E0424 E0424 E0425 E0425 E0425 E0430 E0430 E0430 E0431 E0431 E0431 E0433 E0433 E0433 E0434 E0434 E0434 E0435 E0435 E0435 E0439 E0439 E0439 E0440 E0440 E0440 E0441 E0441 E0441 E0442 E0442 E0442 E0443 E0443 E0443 E0444 E0444 E0444 E0445 E0445 E0445 E0450 E0450 E0450 E0455 E0455 E0455 E0457 E0457 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $259.24 $3,145.65 $3,145.65 $314.57 $3,583.88 $3,583.88 $358.39 $1,109.18 $1,109.18 $110.92 $641.45 $641.45 $64.15 $245.00 $245.00 $24.50 $185.41 $185.41 $18.54 $325.27 $325.27 $32.53 $185.41 $185.41 $18.54 $2,951.75 $2,951.75 $295.18 $1,109.18 $1,109.18 $110.92 $3,228.98 $3,228.98 $322.90 $48.79 $48.79 $4.88 $48.79 $48.79 $4.88 $48.79 $48.79 $4.88 $48.79 $48.79 $4.88 $100.00 $100.00 $10.00 $6,459.26 $6,459.26 $645.93 $2,415.40 $2,415.40 $241.54 $415.84 $415.84 Effective Date End Date Procedure Modifier E0457 E0459 E0459 E0459 E0460 E0460 E0460 E0461 E0461 E0461 E0462 E0462 E0462 E0463 E0463 E0463 E0464 E0464 E0464 E0470 E0470 E0470 E0471 E0471 E0471 E0472 E0472 E0472 E0480 E0480 E0480 E0481 E0481 E0481 E0482 E0482 E0482 E0483 E0483 E0483 E0484 E0484 E0484 E0485 E0485 E0485 E0486 E0486 E0486 E0500 E0500 E0500 E0550 E0550 E0550 E0555 E0555 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 18 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $41.59 $292.70 $292.70 $29.27 $4,964.09 $4,964.09 $496.41 $6,459.26 $6,459.26 $645.93 $1,971.90 $1,971.90 $197.19 $9,516.97 $9,516.97 $951.70 $9,516.97 $9,516.97 $951.70 $1,496.63 $1,496.63 $149.66 $3,183.58 $3,183.58 $318.36 $3,183.58 $3,183.58 $318.36 $297.36 $297.36 $29.74 $6,138.30 $6,138.30 $613.83 $2,909.97 $2,909.97 $291.00 $7,194.16 $7,194.16 $719.42 $24.99 $24.99 $2.49 $117.75 $117.75 $11.78 $926.74 $926.74 $92.67 $742.77 $742.77 $74.28 $339.26 $339.26 $33.93 $33.00 $33.00 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier E0555 E0560 E0560 E0560 E0561 E0561 E0561 E0562 E0562 E0562 E0565 E0565 E0565 E0570 E0570 E0570 E0572 E0572 E0572 E0574 E0574 E0574 E0575 E0575 E0575 E0580 E0580 E0580 E0585 E0585 E0585 E0600 E0600 E0600 E0601 E0601 E0601 E0602 E0602 E0602 E0603 E0603 E0603 E0604 E0604 E0604 E0605 E0605 E0605 E0606 E0606 E0606 E0607 E0607 E0607 E0610 E0610 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $3.30 $100.04 $100.04 $10.81 $62.41 $62.41 $6.23 $175.69 $175.69 $17.56 $412.90 $412.90 $41.29 $108.99 $108.99 $10.90 $257.73 $257.73 $25.77 $272.41 $272.41 $27.24 $695.52 $695.52 $69.55 $78.18 $78.18 $7.82 $237.26 $237.26 $23.73 $309.83 $309.83 $30.98 $599.51 $599.51 $59.95 $19.98 $19.98 $2.00 $33.79 $33.79 $3.38 $33.79 $33.79 $3.38 $17.89 $17.89 $2.08 $136.21 $136.21 $13.62 $45.22 $45.22 $4.52 $160.96 $160.96 Effective Date End Date Procedure Modifier E0610 E0615 E0615 E0615 E0616 E0616 E0616 E0617 E0617 E0617 E0618 E0618 E0618 E0619 E0619 E0619 E0620 E0620 E0620 E0621 E0621 E0621 E0625 E0625 E0625 E0627 E0627 E0627 E0628 E0628 E0628 E0629 E0629 E0629 E0630 E0630 E0630 E0635 E0635 E0635 E0636 E0636 E0636 E0637 E0637 E0637 E0638 E0638 E0638 E0639 E0639 E0639 E0640 E0640 E0640 E0641 E0641 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 19 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $16.97 $324.02 $324.02 $39.59 $525.00 $525.00 $52.50 $2,284.38 $2,284.38 $228.44 $1,612.61 $1,612.61 $161.26 $3,288.60 $3,288.60 $328.86 $591.70 $591.70 $59.16 $64.96 $64.96 $6.26 $978.48 $978.48 $97.85 $223.80 $223.80 $22.35 $223.80 $223.80 $22.35 $223.79 $223.79 $22.35 $689.41 $689.41 $68.94 $828.01 $828.01 $82.80 $7,136.20 $7,136.20 $713.62 $2,104.97 $2,104.97 $210.50 $129.72 $129.72 $12.97 $978.48 $978.48 $97.85 $978.48 $978.48 $97.85 $129.72 $129.72 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier E0641 E0642 E0642 E0642 E0650 E0650 E0650 E0651 E0651 E0651 E0652 E0652 E0652 E0655 E0655 E0655 E0656 E0656 E0656 E0657 E0657 E0657 E0660 E0660 E0660 E0665 E0665 E0665 E0666 E0666 E0666 E0667 E0667 E0667 E0668 E0668 E0668 E0669 E0669 E0669 E0670 E0670 E0670 E0671 E0671 E0671 E0672 E0672 E0672 E0673 E0673 E0673 E0675 E0675 E0675 E0691 E0691 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $12.97 $129.72 $129.72 $12.97 $472.98 $472.98 $54.44 $621.50 $621.50 $62.15 $3,587.48 $3,587.48 $354.56 $70.75 $70.75 $7.30 $390.93 $390.93 $39.05 $367.27 $367.27 $36.66 $108.10 $108.10 $11.00 $92.70 $92.70 $9.34 $93.44 $93.44 $9.59 $219.10 $219.10 $24.74 $299.02 $299.02 $29.51 $117.78 $117.78 $11.78 857.45 857.45 91.79 $281.07 $281.07 $28.12 $218.39 $218.39 $21.84 $181.47 $181.47 $18.15 $2,602.28 $2,602.28 $260.23 $608.08 $608.08 Effective Date End Date Procedure Modifier E0691 E0692 E0692 E0692 E0693 E0693 E0693 E0694 E0694 E0694 E0700 E0700 E0700 E0705 E0705 E0705 E0710 E0710 E0710 E0720 E0720 E0720 E0730 E0730 E0730 E0731 E0731 E0731 E0740 E0740 E0740 E0744 E0744 E0744 E0745 E0745 E0745 E0746 E0746 E0746 E0747 E0747 E0747 E0748 E0748 E0748 E0749 E0749 E0749 E0760 E0760 E0760 E0761 E0761 E0761 E0762 E0762 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 20 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $60.81 $763.57 $763.57 $76.35 $941.28 $941.28 $94.13 $2,995.98 $2,995.98 $299.60 $45.00 $45.00 $4.50 $31.71 $31.71 $3.23 $168.60 $168.60 $16.86 $236.67 $236.67 $23.67 $242.10 $242.10 $24.21 $205.17 $205.17 $20.52 $353.82 $353.82 $35.39 $526.74 $526.74 $52.67 $605.75 $605.75 $60.57 $25.00 $25.00 $2.50 $2,650.00 $2,650.00 $263.34 $2,632.83 $2,632.83 $263.28 $1,924.34 $1,924.34 $192.43 $2,187.84 $2,187.84 $218.79 $3,348.86 $3,348.86 $334.89 $632.46 $632.46 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier E0762 E0764 E0764 E0764 E0765 E0765 E0765 E0776 E0776 E0776 E0779 E0779 E0779 E0780 E0780 E0780 E0781 E0781 E0781 E0782 E0782 E0782 E0783 E0783 E0783 E0784 E0784 E0784 E0785 E0785 E0785 E0786 E0786 E0786 E0791 E0791 E0791 E0830 E0830 E0830 E0840 E0840 E0840 E0849 E0849 E0849 E0850 E0850 E0850 E0855 E0855 E0855 E0856 E0856 E0856 E0860 E0860 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $63.25 $7,488.90 $7,488.90 $748.88 $56.93 $56.93 $5.70 $82.34 $82.34 $10.73 $113.21 $113.21 $11.32 $7.02 $7.02 $0.70 $1,792.35 $1,792.35 $179.24 $2,591.83 $2,591.83 $259.17 $5,502.14 $5,502.14 $550.24 $2,825.11 $2,825.11 $282.51 $319.74 $319.74 $31.97 $5,208.96 $5,208.96 $520.90 $2,139.73 $2,139.73 $213.97 $17.50 $17.50 $1.75 $42.15 $42.15 $10.38 $348.71 $348.71 $34.87 $71.09 $71.09 $8.30 $334.44 $334.44 $33.45 $104.23 $104.23 $10.41 $22.16 $22.16 Effective Date End Date Procedure Modifier E0860 E0870 E0870 E0870 E0880 E0880 E0880 E0890 E0890 E0890 E0900 E0900 E0900 E0910 E0910 E0910 E0911 E0911 E0911 E0912 E0912 E0912 E0920 E0920 E0920 E0930 E0930 E0930 E0935 E0935 E0935 E0936 E0936 E0936 E0940 E0940 E0940 E0941 E0941 E0941 E0942 E0942 E0942 E0944 E0944 E0944 E0945 E0945 E0945 E0946 E0946 E0946 E0947 E0947 E0947 E0948 E0948 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 21 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $3.74 $78.71 $78.71 $9.07 $75.29 $75.29 $11.34 $81.48 $81.48 $18.89 $79.81 $79.81 $15.89 $116.61 $116.61 $11.66 $290.68 $290.68 $29.07 $667.67 $667.67 $66.77 $312.23 $312.23 $31.22 $309.14 $309.14 $30.91 $4,614.00 $4,614.00 $15.38 $6,138.00 $6,138.00 $20.46 $202.80 $202.80 $20.28 $293.71 $293.71 $29.37 $13.43 $13.43 $1.59 $26.38 $26.38 $2.65 $25.50 $25.50 $2.55 $340.33 $340.33 $34.03 $348.83 $348.83 $36.17 $337.40 $337.40 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier E0948 E0950 E0950 E0950 E0951 E0951 E0951 E0952 E0952 E0952 E0955 E0955 E0955 E0956 E0956 E0956 E0957 E0957 E0957 E0958 E0958 E0958 E0959 E0959 E0959 E0960 E0960 E0960 E0961 E0961 E0961 E0966 E0966 E0966 E0967 E0967 E0967 E0968 E0968 E0968 E0969 E0969 E0969 E0970 E0970 E0970 E0971 E0971 E0971 E0973 E0973 E0973 E0974 E0974 E0974 E0978 E0978 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $33.73 $70.35 $70.35 $7.04 $10.92 $10.92 $1.13 $11.40 $11.40 $1.14 $136.82 $136.82 $13.69 $66.71 $66.71 $6.68 $93.34 $93.34 $9.34 $270.02 $270.02 $27.00 $29.26 $29.26 $2.94 $61.56 $61.56 $6.16 $19.08 $19.08 $2.10 $48.30 $48.30 $4.76 $44.43 $44.43 $4.44 $121.34 $121.34 $12.13 $96.45 $96.45 $9.66 $132.00 $132.00 $13.20 $29.36 $29.36 $2.94 $66.13 $66.13 $6.30 $53.06 $53.06 $5.63 $28.04 $28.04 Effective Date End Date Procedure Modifier E0978 E0980 E0980 E0980 E0981 E0981 E0981 E0982 E0982 E0982 E0983 E0983 E0983 E0984 E0984 E0984 E0985 E0985 E0985 E0986 E0986 E0986 E0988 E0988 E0988 E0990 E0990 E0990 E0992 E0992 E0992 E0994 E0994 E0994 E0995 E0995 E0995 E1002 E1002 E1002 E1003 E1003 E1003 E1004 E1004 E1004 E1005 E1005 E1005 E1006 E1006 E1006 E1007 E1007 E1007 E1008 E1008 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 22 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $2.81 $20.95 $20.95 $2.09 $27.12 $27.12 $2.76 $34.88 $34.88 $3.48 $1,691.30 $1,691.30 $169.13 $1,292.89 $1,292.89 $120.17 $137.27 $137.27 $13.74 $3,291.62 $3,291.62 $329.17 $1,947.77 $1,947.77 $194.78 $75.96 $75.96 $7.60 $54.73 $54.73 $5.32 $10.14 $10.14 $1.02 $17.49 $17.49 $1.76 $2,742.80 $2,742.80 $274.28 $2,971.59 $2,971.59 $297.17 $3,294.88 $3,294.88 $329.49 $3,566.45 $3,566.45 $356.64 $4,368.56 $4,368.56 $436.84 $5,915.20 $5,915.20 $591.53 $5,915.73 $5,915.73 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier E1008 E1009 E1009 E1009 E1010 E1010 E1010 E1014 E1014 E1014 E1015 E1015 E1015 E1016 E1016 E1016 E1017 E1017 E1017 E1018 E1018 E1018 E1020 E1020 E1020 E1028 E1028 E1028 E1029 E1029 E1029 E1030 E1030 E1030 E1031 E1031 E1031 E1035 E1035 E1035 E1036 E1036 E1036 E1037 E1037 E1037 E1038 E1038 E1038 E1039 E1039 E1039 E1050 E1050 E1050 E1060 E1060 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $591.57 $1,673.37 $1,673.37 $167.34 $774.00 $774.00 $77.40 $247.09 $247.09 $24.71 $77.62 $77.62 $7.76 $88.86 $88.86 $8.90 $33.00 $33.00 $3.30 $33.00 $33.00 $3.30 $164.71 $164.71 $16.46 $139.77 $139.77 $13.97 $250.07 $250.07 $25.00 $788.54 $788.54 $78.86 $341.84 $341.84 $34.18 $4,149.56 $4,149.56 $414.96 $5,817.23 $5,817.23 $581.72 $734.14 $734.14 $73.41 $121.97 $121.97 $12.20 $231.40 $231.40 $23.14 $676.87 $676.87 $67.69 $853.08 $853.08 Effective Date End Date Procedure Modifier E1060 E1070 E1070 E1070 E1083 E1083 E1083 E1084 E1084 E1084 E1085 E1085 E1085 E1086 E1086 E1086 E1087 E1087 E1087 E1088 E1088 E1088 E1089 E1089 E1089 E1090 E1090 E1090 E1092 E1092 E1092 E1093 E1093 E1093 E1100 E1100 E1100 E1110 E1110 E1110 E1130 E1130 E1130 E1140 E1140 E1140 E1150 E1150 E1150 E1160 E1160 E1160 E1161 E1161 E1161 E1170 E1170 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 23 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $85.31 $725.19 $725.19 $72.52 $452.91 $452.91 $45.29 $663.89 $663.89 $66.39 $931.37 $931.37 $93.14 $1,297.39 $1,297.39 $129.74 $856.17 $856.17 $85.62 $1,020.29 $1,020.29 $102.03 $1,978.00 $1,978.00 $197.80 $1,488.00 $1,488.00 $148.80 $869.72 $869.72 $86.97 $747.87 $747.87 $74.79 $702.45 $702.45 $70.25 $687.90 $687.90 $68.79 $500.00 $500.00 $50.00 $550.00 $550.00 $55.00 $552.01 $552.01 $55.20 $422.92 $422.92 $42.29 $1,601.13 $1,601.13 $160.11 $604.42 $604.42 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier E1170 E1171 E1171 E1171 E1172 E1172 E1172 E1180 E1180 E1180 E1190 E1190 E1190 E1195 E1195 E1195 E1200 E1200 E1200 E1221 E1221 E1221 E1222 E1222 E1222 E1223 E1223 E1223 E1224 E1224 E1224 E1225 E1225 E1225 E1226 E1226 E1226 E1227 E1227 E1227 E1228 E1228 E1228 E1230 E1230 E1230 E1231 E1231 E1231 E1232 E1232 E1232 E1233 E1233 E1233 E1234 E1234 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $60.44 $542.43 $542.43 $54.24 $662.89 $662.89 $66.29 $685.76 $685.76 $68.58 $792.23 $792.23 $79.22 $850.12 $850.12 $85.01 $588.80 $588.80 $58.88 $321.55 $321.55 $32.16 $438.54 $438.54 $43.85 $500.85 $500.85 $50.09 $549.11 $549.11 $54.91 $260.00 $260.00 $26.00 $313.86 $313.86 $32.30 $159.62 $159.62 $15.96 $189.63 $189.63 $18.96 $1,412.96 $1,412.96 $150.53 $977.88 $977.88 $97.79 $1,447.05 $1,447.05 $144.71 $1,499.38 $1,499.38 $149.94 $1,305.32 $1,305.32 Effective Date End Date Procedure Modifier E1234 E1235 E1235 E1235 E1236 E1236 E1236 E1237 E1237 E1237 E1238 E1238 E1238 E1240 E1240 E1240 E1250 E1250 E1250 E1260 E1260 E1260 E1270 E1270 E1270 E1280 E1280 E1280 E1285 E1285 E1285 E1290 E1290 E1290 E1295 E1295 E1295 E1296 E1296 E1296 E1297 E1297 E1297 E1298 E1298 E1298 E1300 E1300 E1300 E1310 E1310 E1310 E1353 E1353 E1353 E1355 E1355 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 24 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $130.54 $1,256.92 $1,256.92 $125.70 $1,108.93 $1,108.93 $110.89 $1,118.62 $1,118.62 $111.86 $1,108.93 $1,108.93 $110.89 $697.10 $697.10 $69.71 $750.00 $750.00 $75.00 $1,254.00 $1,254.00 $125.40 $534.24 $534.24 $53.42 $888.17 $888.17 $88.82 $2,069.30 $2,069.30 $206.93 $2,203.39 $2,203.39 $220.34 $821.96 $821.96 $82.20 $282.80 $282.80 $28.73 $60.17 $60.17 $6.68 $243.68 $243.68 $24.94 $200.00 $200.00 $20.00 $1,453.15 $1,453.15 $114.80 $19.17 $19.17 $1.92 $14.44 $14.44 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier Maximum Allowable E1355 E1372 E1372 E1372 E1390 E1390 E1390 E1391 E1391 E1391 E1392 E1392 E1392 E1405 E1405 E1405 E1406 E1406 E1406 E1510 E1510 E1510 E1570 E1570 E1570 E1575 E1575 E1575 E1594 E1594 E1594 E1610 E1610 E1610 E1615 E1615 E1615 E1620 E1620 E1620 E1634 E1634 E1634 E1637 E1637 E1637 E1639 E1639 E1639 E1700 E1700 E1700 E1701 E1701 E1701 E1702 E1702 RR $1.44 $110.32 $110.32 $16.03 $1,109.18 $1,109.18 $110.92 $1,109.18 $1,109.18 $110.92 $325.27 $325.27 $32.53 $1,346.44 $1,346.44 $134.64 $1,218.17 $1,218.17 $121.82 $15,704.60 $15,704.60 $1,570.46 $556.28 $556.28 $55.63 $1.81 $1.81 $0.18 $5,450.00 $5,450.00 $545.00 $4,832.60 $4,832.60 $483.26 $3,360.00 $3,360.00 $336.00 $1,949.71 $1,949.71 $194.97 $5.00 $5.00 $0.50 $5.92 $5.92 $0.59 $28.44 $28.44 $2.84 $198.35 $198.35 $19.45 $6.84 $6.84 $0.68 $12.98 $12.98 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Effective Date End Date Procedure Modifier E1702 E1800 E1800 E1800 E1801 E1801 E1801 E1802 E1802 E1802 E1805 E1805 E1805 E1806 E1806 E1806 E1810 E1810 E1810 E1811 E1811 E1811 E1812 E1812 E1812 E1815 E1815 E1815 E1816 E1816 E1816 E1818 E1818 E1818 E1820 E1820 E1820 E1821 E1821 E1821 E1825 E1825 E1825 E1830 E1830 E1830 E1831 E1831 E1831 E1840 E1840 E1840 E1841 E1841 E1841 E2000 E2000 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 25 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $1.30 $718.96 $718.96 $71.90 $872.93 $872.93 $87.29 $2,211.49 $2,211.49 $221.15 $726.71 $726.71 $72.67 $716.75 $716.75 $71.68 $728.85 $728.85 $72.88 $907.64 $907.64 $90.76 $581.87 $581.87 $58.19 $728.85 $728.85 $72.88 $921.94 $921.94 $92.19 $941.16 $941.16 $94.12 $55.31 $55.31 $5.53 $71.22 $71.22 $7.11 $726.71 $726.71 $72.67 $726.71 $726.71 $72.67 $429.98 $429.98 $43.00 $2,589.80 $2,589.80 $258.98 $3,065.39 $3,065.39 $306.54 $350.72 $350.72 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier E2000 E2100 E2100 E2100 E2101 E2101 E2101 E2120 E2120 E2120 E2201 E2201 E2201 E2202 E2202 E2202 E2203 E2203 E2203 E2204 E2204 E2204 E2205 E2205 E2205 E2206 E2206 E2206 E2207 E2207 E2207 E2208 E2208 E2208 E2209 E2209 E2209 E2210 E2210 E2210 E2211 E2211 E2211 E2212 E2212 E2212 E2213 E2213 E2213 E2214 E2214 E2214 E2215 E2215 E2215 E2216 E2216 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $35.07 $369.95 $369.95 $37.00 $127.60 $127.60 $12.76 $1,918.60 $1,918.60 $191.86 $252.48 $252.48 $25.25 $320.74 $320.74 $32.07 $324.17 $324.17 $32.41 $550.43 $550.43 $55.05 $22.11 $22.11 $2.20 $27.52 $27.52 $2.75 $29.33 $29.33 $2.94 $80.38 $80.38 $8.03 $72.52 $72.52 $7.27 $4.43 $4.43 $0.45 $23.54 $23.54 $2.31 $3.98 $3.98 $0.42 $20.58 $20.58 $2.07 $20.71 $20.71 $2.28 $6.50 $6.50 $0.64 $97.72 $97.72 Effective Date End Date Procedure Modifier Maximum Allowable E2216 E2217 E2217 E2217 E2218 E2218 E2218 E2219 E2219 E2219 E2220 E2220 E2220 E2221 E2221 E2221 E2222 E2222 E2222 E2224 E2224 E2224 E2225 E2225 E2225 E2226 E2226 E2226 E2227 E2227 E2227 E2228 E2228 E2228 E2231 E2231 E2231 E2291 E2291 E2291 E2292 E2292 E2292 E2293 E2293 E2293 E2294 E2294 E2294 E2295 E2295 E2295 E2300 E2300 E2300 E2301 E2301 RR $9.77 $56.53 $56.53 $5.65 $97.72 $97.72 $9.77 $24.07 $24.07 $2.72 $16.41 $16.41 $1.59 $17.29 $17.29 $1.75 $14.25 $14.25 $1.41 $56.40 $56.40 $5.92 $11.77 $11.77 $1.18 $25.68 $25.68 $2.57 $1,217.19 $1,217.19 $121.71 $633.57 $633.57 $63.35 $103.99 $103.99 $10.40 $91.50 $91.50 $9.15 $91.50 $91.50 $9.15 $196.95 $196.95 $19.70 $196.95 $196.95 $19.70 $695.00 $695.00 $69.50 $1,249.30 $1,249.30 $124.93 $10,767.10 $10,767.10 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 26 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier E2301 E2310 E2310 E2310 E2311 E2311 E2311 E2312 E2312 E2312 E2313 E2313 E2313 E2321 E2321 E2321 E2322 E2322 E2322 E2323 E2323 E2323 E2324 E2324 E2324 E2325 E2325 E2325 E2326 E2326 E2326 E2327 E2327 E2327 E2328 E2328 E2328 E2329 E2329 E2329 E2330 E2330 E2330 E2340 E2340 E2340 E2341 E2341 E2341 E2342 E2342 E2342 E2343 E2343 E2343 E2351 E2351 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $1,076.71 $791.90 $791.90 $79.19 $1,603.23 $1,603.23 $160.33 $1,673.60 $1,673.60 $167.37 $208.38 $208.38 $20.85 $1,509.72 $1,509.72 $150.98 $1,598.76 $1,598.76 $159.88 $46.80 $46.80 $4.68 $29.65 $29.65 $2.96 $911.40 $911.40 $91.15 $234.91 $234.91 $23.50 $2,314.83 $2,314.83 $231.48 $3,353.26 $3,353.26 $335.32 $1,195.14 $1,195.14 $119.51 $2,315.72 $2,315.72 $231.56 $242.50 $242.50 $24.26 $363.78 $363.78 $36.38 $303.15 $303.15 $30.32 $485.04 $485.04 $48.49 $472.76 $472.76 Effective Date End Date Procedure Modifier E2351 E2359 E2359 E2359 E2360 E2360 E2360 E2361 E2361 E2361 E2362 E2362 E2362 E2363 E2363 E2363 E2364 E2364 E2364 E2365 E2365 E2365 E2366 E2366 E2366 E2367 E2367 E2367 E2368 E2368 E2368 E2369 E2369 E2369 E2370 E2370 E2370 E2371 E2371 E2371 E2372 E2372 E2372 E2373 E2373 E2373 E2374 E2374 E2374 E2375 E2375 E2375 E2376 E2376 E2376 E2377 E2377 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 27 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $47.29 $113.29 $113.29 $11.33 $73.07 $73.07 $7.31 $94.37 $94.37 $9.44 $62.24 $62.24 $6.22 $125.86 $125.86 $12.59 $73.07 $73.07 $7.31 $75.90 $75.90 $7.59 $178.39 $178.39 $17.89 $283.59 $283.59 $28.37 $349.56 $349.56 $34.97 $304.48 $304.48 $30.45 $543.28 $543.28 $54.33 $102.00 $102.00 $10.20 $186.00 $186.00 $18.60 $705.69 $705.69 $70.58 $361.37 $361.37 $36.13 $579.63 $579.63 $57.96 $908.31 $908.31 $90.83 $328.68 $328.68 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier Maximum Allowable E2377 E2381 E2381 E2381 E2382 E2382 E2382 E2383 E2383 E2383 E2384 E2384 E2384 E2385 E2385 E2385 E2386 E2386 E2386 E2387 E2387 E2387 E2388 E2388 E2388 E2389 E2389 E2389 E2390 E2390 E2390 E2391 E2391 E2391 E2392 E2392 E2392 E2394 E2394 E2394 E2395 E2395 E2395 E2396 E2396 E2396 E2397 E2397 E2397 E2402 E2402 E2402 E2500 E2500 E2500 E2502 E2502 RR $32.86 $51.55 $51.55 $5.16 $14.06 $14.06 $1.40 $102.77 $102.77 $10.28 $54.76 $54.76 $5.49 $33.50 $33.50 $3.35 $101.85 $101.85 $10.18 $43.94 $43.94 $4.40 $34.10 $34.10 $3.41 $18.52 $18.52 $1.86 $28.96 $28.96 $2.90 $13.88 $13.88 $1.39 $36.46 $36.46 $3.65 $51.94 $51.94 $5.20 $36.91 $36.91 $3.69 $38.25 $38.25 $4.10 $280.25 $280.25 $28.02 $10,011.27 $10,011.27 $1,001.13 $264.63 $264.63 $26.47 $809.19 $809.19 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Effective Date End Date Procedure Modifier E2502 E2504 E2504 E2504 E2506 E2506 E2506 E2508 E2508 E2508 E2510 E2510 E2510 E2511 E2511 E2511 E2601 E2601 E2601 E2602 E2602 E2602 E2603 E2603 E2603 E2604 E2604 E2604 E2605 E2605 E2605 E2606 E2606 E2606 E2607 E2607 E2607 E2608 E2608 E2608 E2609 E2609 E2609 E2610 E2610 E2610 E2611 E2611 E2611 E2612 E2612 E2612 E2613 E2613 E2613 E2614 E2614 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 28 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $80.92 $1,067.43 $1,067.43 $106.75 $1,565.18 $1,565.18 $156.51 $2,420.28 $2,420.28 $242.03 $4,580.06 $4,580.06 $458.00 $3,651.72 $3,651.72 $365.17 $41.39 $41.39 $4.15 $80.80 $80.80 $8.08 $102.58 $102.58 $10.26 $127.49 $127.49 $12.74 $182.15 $182.15 $18.23 $284.17 $284.17 $28.43 $196.14 $196.14 $19.62 $235.54 $235.54 $23.55 $799.47 $799.47 $79.95 $88.26 $88.26 $8.83 $211.37 $211.37 $21.14 $285.94 $285.94 $28.59 $265.97 $265.97 $26.60 $368.08 $368.08 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier E2614 E2615 E2615 E2615 E2616 E2616 E2616 E2617 E2617 E2617 E2619 E2619 E2619 E2620 E2620 E2620 E2621 E2621 E2621 E2622 E2622 E2622 E2623 E2623 E2623 E2624 E2624 E2624 E2625 E2625 E2625 E2626 E2626 E2626 E2627 E2627 E2627 E2628 E2628 E2628 E2629 E2629 E2629 E2630 E2630 E2630 E2631 E2631 E2631 E2632 E2632 E2632 E2633 E2633 E2633 E8000 E8000 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $36.81 $306.09 $306.09 $30.61 $411.82 $411.82 $41.18 $791.41 $791.41 $79.14 $34.73 $34.73 $3.47 $370.63 $370.63 $37.06 $388.94 $388.94 $38.89 $224.30 $224.30 $22.43 $285.42 $285.42 $28.55 $226.14 $226.14 $22.61 $286.28 $286.28 $28.63 $390.55 $390.55 $39.06 $670.69 $670.69 $67.09 $445.42 $445.42 $44.54 $596.95 $596.95 $59.69 $447.12 $447.12 $44.71 $178.86 $178.86 $17.89 $113.73 $113.73 $11.37 $96.47 $96.47 $9.66 $1,104.90 $1,104.90 Effective Date End Date Procedure Modifier E8000 E8001 E8001 E8001 E8002 E8002 E8002 K0001 K0001 K0001 K0002 K0002 K0002 K0003 K0003 K0003 K0004 K0004 K0004 K0005 K0005 K0005 K0006 K0006 K0006 K0007 K0007 K0007 K0009 K0009 K0009 K0010 K0010 K0010 K0011 K0011 K0011 K0012 K0012 K0012 K0014 K0014 K0014 K0015 K0015 K0015 K0017 K0017 K0017 K0018 K0018 K0018 K0019 K0019 K0019 K0020 K0020 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 29 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $110.49 $1,104.90 $1,104.90 $110.49 $1,104.90 $1,104.90 $110.49 $360.42 $360.42 $36.04 $553.71 $553.71 $55.37 $606.31 $606.31 $60.63 $904.30 $904.30 $90.43 $1,251.05 $1,251.05 $125.09 $848.67 $848.67 $84.87 $1,207.90 $1,207.90 $120.79 $2,248.38 $2,248.38 $224.84 $2,450.26 $2,450.26 $245.03 $3,848.73 $3,848.73 $384.87 $2,198.76 $2,198.76 $219.88 $2,622.00 $2,622.00 $262.20 $122.96 $122.96 $12.30 $34.59 $34.59 $3.46 $19.32 $19.32 $1.92 $11.06 $11.06 $1.11 $31.44 $31.44 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier K0020 K0037 K0037 K0037 K0038 K0038 K0038 K0039 K0039 K0039 K0040 K0040 K0040 K0041 K0041 K0041 K0042 K0042 K0042 K0043 K0043 K0043 K0044 K0044 K0044 K0045 K0045 K0045 K0046 K0046 K0046 K0047 K0047 K0047 K0050 K0050 K0050 K0051 K0051 K0051 K0052 K0052 K0052 K0053 K0053 K0053 K0056 K0056 K0056 K0065 K0065 K0065 K0069 K0069 K0069 K0070 K0070 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $3.15 $32.59 $32.59 $2.92 $16.41 $16.41 $1.64 $36.46 $36.46 $3.65 $50.53 $50.53 $5.04 $35.81 $35.81 $3.59 $24.65 $24.65 $2.46 $13.22 $13.22 $1.32 $11.26 $11.26 $1.13 $38.32 $38.32 $3.83 $13.22 $13.22 $1.32 $51.75 $51.75 $5.18 $22.00 $22.00 $2.19 $35.60 $35.60 $3.57 $62.55 $62.55 $6.25 $69.03 $69.03 $6.90 $64.35 $64.35 $6.44 $30.08 $30.08 $3.01 $67.62 $67.62 $6.76 $123.95 $123.95 Effective Date End Date Procedure Modifier Maximum Allowable K0070 K0071 K0071 K0071 K0072 K0072 K0072 K0073 K0073 K0073 K0077 K0077 K0077 K0098 K0098 K0098 K0105 K0105 K0105 K0195 K0195 K0195 K0455 K0455 K0455 K0552 K0552 K0552 K0601 K0601 K0601 K0602 K0602 K0602 K0603 K0603 K0603 K0604 K0604 K0604 K0605 K0605 K0605 K0606 K0606 K0606 K0607 K0607 K0607 K0608 K0608 K0608 K0609 K0609 K0609 K0669 K0669 RR $12.40 $73.93 $73.93 $7.40 $44.50 $44.50 $4.45 $22.64 $22.64 $2.28 $39.82 $39.82 $3.98 $17.87 $17.87 $1.80 $67.28 $67.28 $6.72 $142.57 $142.57 $14.26 $1,792.35 $1,792.35 $179.24 $1.77 $1.77 $0.18 $0.75 $0.75 $0.07 $4.30 $4.30 $0.43 $0.38 $0.38 $0.04 $4.11 $4.11 $0.41 $9.88 $9.88 $0.99 $17,041.12 $17,041.12 $1,704.11 $145.92 $145.92 $14.60 $91.07 $91.07 $9.12 $605.62 $605.62 $60.56 $73.55 $73.55 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 30 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier K0669 K0672 K0672 K0672 K0730 K0730 K0730 K0733 K0733 K0733 K0738 K0738 K0738 K0800 K0800 K0800 K0801 K0801 K0801 K0802 K0802 K0802 K0806 K0806 K0806 K0807 K0807 K0807 K0808 K0808 K0808 K0813 K0813 K0813 K0814 K0814 K0814 K0815 K0815 K0815 K0816 K0816 K0816 K0820 K0820 K0820 K0821 K0821 K0821 K0822 K0822 K0822 K0823 K0823 K0823 K0824 K0824 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $7.36 $49.74 $49.74 $4.97 $1,166.64 $1,166.64 $116.66 $20.44 $20.44 $2.06 $325.27 $325.27 $32.53 $754.01 $754.01 $75.40 $1,215.62 $1,215.62 $121.55 $1,375.69 $1,375.69 $137.57 $912.15 $912.15 $91.21 $1,384.08 $1,384.08 $138.41 $2,141.46 $2,141.46 $214.14 $2,110.50 $2,110.50 $211.05 $2,701.69 $2,701.69 $270.17 $3,076.16 $3,076.16 $307.62 $2,946.13 $2,946.13 $294.61 $2,254.33 $2,254.33 $225.43 $2,893.84 $2,893.84 $289.38 $3,497.32 $3,497.32 $349.73 $3,520.38 $3,520.38 $352.04 $4,236.69 $4,236.69 Effective Date End Date Procedure Modifier K0824 K0825 K0825 K0825 K0826 K0826 K0826 K0827 K0827 K0827 K0828 K0828 K0828 K0829 K0829 K0829 K0830 K0830 K0830 K0831 K0831 K0831 K0835 K0835 K0835 K0836 K0836 K0836 K0837 K0837 K0837 K0838 K0838 K0838 K0839 K0839 K0839 K0840 K0840 K0840 K0841 K0841 K0841 K0842 K0842 K0842 K0843 K0843 K0843 K0848 K0848 K0848 K0849 K0849 K0849 K0850 K0850 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 31 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $423.67 $3,878.66 $3,878.66 $387.87 $5,484.97 $5,484.97 $548.50 $4,663.83 $4,663.83 $466.38 $6,043.84 $6,043.84 $604.38 $5,550.05 $5,550.05 $555.00 $3,131.30 $3,131.30 $313.13 $3,131.30 $3,131.30 $313.13 $3,549.74 $3,549.74 $354.97 $3,681.28 $3,681.28 $368.13 $4,236.69 $4,236.69 $423.67 $3,790.14 $3,790.14 $379.01 $5,484.97 $5,484.97 $548.50 $8,309.64 $8,309.64 $830.96 $3,778.30 $3,778.30 $377.83 $3,778.30 $3,778.30 $377.83 $4,548.98 $4,548.98 $454.90 $4,623.13 $4,623.13 $462.31 $4,445.03 $4,445.03 $444.50 $5,362.75 $5,362.75 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier Maximum Allowable K0850 K0851 K0851 K0851 K0852 K0852 K0852 K0853 K0853 K0853 K0854 K0854 K0854 K0855 K0855 K0855 K0856 K0856 K0856 K0857 K0857 K0857 K0858 K0858 K0858 K0859 K0859 K0859 K0860 K0860 K0860 K0861 K0861 K0861 K0862 K0862 K0862 K0863 K0863 K0863 K0864 K0864 K0864 K0868 K0868 K0868 K0869 K0869 K0869 K0870 K0870 K0870 K0871 K0871 K0871 K0877 K0877 RR $536.27 $5,156.24 $5,156.24 $515.62 $6,196.30 $6,196.30 $619.63 $6,365.21 $6,365.21 $636.52 $8,432.42 $8,432.42 $843.24 $7,965.66 $7,965.66 $796.57 $4,962.51 $4,962.51 $496.25 $5,061.92 $5,061.92 $506.19 $6,157.05 $6,157.05 $615.71 $5,871.85 $5,871.85 $587.19 $8,796.06 $8,796.06 $879.61 $6,402.63 $6,402.63 $640.26 $6,157.05 $6,157.05 $615.71 $8,796.06 $8,796.06 $879.61 $10,467.39 $10,467.39 $1,046.74 $3,258.80 $3,258.80 $325.88 $3,258.80 $3,258.80 $325.88 $4,073.50 $4,073.50 $407.35 $4,888.20 $4,888.20 $488.82 $3,258.80 $3,258.80 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Effective Date End Date Procedure Modifier K0877 K0878 K0878 K0878 K0879 K0879 K0879 K0880 K0880 K0880 K0884 K0884 K0884 K0885 K0885 K0885 K0886 K0886 K0886 K0890 K0890 K0890 K0891 K0891 K0891 L0112 L0112 L0112 L0113 L0113 L0113 L0120 L0120 L0120 L0130 L0130 L0130 L0140 L0140 L0140 L0150 L0150 L0150 L0160 L0160 L0160 L0170 L0170 L0170 L0172 L0172 L0172 L0174 L0174 L0174 L0180 L0180 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 32 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $325.88 $3,258.80 $3,258.80 $325.88 $4,073.50 $4,073.50 $407.35 $4,888.20 $4,888.20 $488.82 $3,258.80 $3,258.80 $325.88 $3,258.80 $3,258.80 $325.88 $4,073.50 $4,073.50 $407.35 $3,258.80 $3,258.80 $325.88 $3,258.80 $3,258.80 $325.88 $821.10 $821.10 $82.11 $167.31 $167.31 $16.73 $14.48 $14.48 $1.45 $89.02 $89.02 $8.90 $35.64 $35.64 $3.56 $58.96 $58.96 $5.90 $113.94 $113.94 $11.39 $373.22 $373.22 $37.32 $76.90 $76.90 $7.69 $149.89 $149.89 $14.99 $224.60 $224.60 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L0180 L0190 L0190 L0190 L0200 L0200 L0200 L0220 L0220 L0220 L0430 L0430 L0430 L0450 L0450 L0450 L0452 L0452 L0452 L0454 L0454 L0454 L0456 L0456 L0456 L0458 L0458 L0458 L0460 L0460 L0460 L0462 L0462 L0462 L0464 L0464 L0464 L0466 L0466 L0466 L0468 L0468 L0468 L0470 L0470 L0470 L0472 L0472 L0472 L0480 L0480 L0480 L0482 L0482 L0482 L0484 L0484 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $22.46 $290.84 $290.84 $29.08 $324.97 $324.97 $32.50 $89.10 $89.10 $8.91 $890.66 $890.66 $89.07 $94.83 $94.83 $9.48 $263.81 $263.81 $26.38 $203.46 $203.46 $20.35 $583.47 $583.47 $58.35 $523.21 $523.21 $52.32 $588.91 $588.91 $58.89 $732.48 $732.48 $73.25 $872.02 $872.02 $87.20 $233.57 $233.57 $23.36 $270.42 $270.42 $27.04 $347.87 $347.87 $34.79 $242.82 $242.82 $24.28 $836.68 $836.68 $83.67 $846.13 $846.13 $84.61 $969.67 $969.67 Effective Date End Date Procedure Modifier L0484 L0486 L0486 L0486 L0488 L0488 L0488 L0490 L0490 L0490 L0491 L0491 L0491 L0492 L0492 L0492 L0621 L0621 L0621 L0622 L0622 L0622 L0623 L0623 L0623 L0624 L0624 L0624 L0625 L0625 L0625 L0626 L0626 L0626 L0627 L0627 L0627 L0628 L0628 L0628 L0629 L0629 L0629 L0630 L0630 L0630 L0631 L0631 L0631 L0632 L0632 L0632 L0633 L0633 L0633 L0634 L0634 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 33 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $96.97 $1,046.34 $1,046.34 $104.63 $588.91 $588.91 $58.89 $165.94 $165.94 $16.59 $450.55 $450.55 $45.06 $292.01 $292.01 $29.20 $54.51 $54.51 $5.45 $140.96 $140.96 $14.10 $75.19 $75.19 $7.52 $75.19 $75.19 $7.52 $32.33 $32.33 $3.23 $45.73 $45.73 $4.57 $241.15 $241.15 $24.12 $49.21 $49.21 $4.92 $115.21 $115.21 $11.52 $95.00 $95.00 $9.50 $602.25 $602.25 $60.23 $115.21 $115.21 $11.52 $168.23 $168.23 $16.82 $67.89 $67.89 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L0634 L0635 L0635 L0635 L0636 L0636 L0636 L0637 L0637 L0637 L0638 L0638 L0638 L0639 L0639 L0639 L0640 L0640 L0640 L0700 L0700 L0700 L0710 L0710 L0710 L0810 L0810 L0810 L0820 L0820 L0820 L0830 L0830 L0830 L0859 L0859 L0859 L0861 L0861 L0861 L0970 L0970 L0970 L0972 L0972 L0972 L0974 L0974 L0974 L0976 L0976 L0976 L0978 L0978 L0978 L0980 L0980 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $6.79 $580.46 $580.46 $58.05 $786.89 $786.89 $78.69 $712.73 $712.73 $71.27 $773.73 $773.73 $77.37 $712.73 $712.73 $71.27 $613.85 $613.85 $61.39 $1,119.72 $1,119.72 $111.97 $1,206.22 $1,206.22 $120.62 $1,494.35 $1,494.35 $149.44 $1,260.57 $1,260.57 $126.06 $2,019.74 $2,019.74 $201.97 $886.28 $886.28 $88.63 $126.45 $126.45 $12.64 $79.33 $79.33 $7.93 $72.54 $72.54 $7.25 $109.66 $109.66 $10.97 $102.69 $102.69 $10.27 $107.58 $107.58 $10.76 $12.71 $12.71 Effective Date End Date Procedure Modifier L0980 L0982 L0982 L0982 L0984 L0984 L0984 L1000 L1000 L1000 L1001 L1001 L1001 L1005 L1005 L1005 L1010 L1010 L1010 L1020 L1020 L1020 L1025 L1025 L1025 L1030 L1030 L1030 L1040 L1040 L1040 L1050 L1050 L1050 L1060 L1060 L1060 L1070 L1070 L1070 L1080 L1080 L1080 L1085 L1085 L1085 L1090 L1090 L1090 L1100 L1100 L1100 L1110 L1110 L1110 L1120 L1120 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 34 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $1.27 $11.84 $11.84 $1.18 $33.13 $33.13 $3.31 $1,204.36 $1,204.36 $120.44 $1,390.28 $1,390.28 $139.03 $1,877.66 $1,877.66 $187.77 $43.16 $43.16 $4.32 $59.79 $59.79 $5.98 $68.04 $68.04 $6.80 $46.28 $46.28 $4.63 $48.39 $48.39 $4.84 $58.56 $58.56 $5.86 $56.83 $56.83 $5.68 $55.58 $55.58 $5.56 $31.27 $31.27 $3.13 $94.44 $94.44 $9.44 $55.93 $55.93 $5.59 $96.40 $96.40 $9.64 $140.59 $140.59 $14.06 $25.48 $25.48 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L1120 L1200 L1200 L1200 L1210 L1210 L1210 L1220 L1220 L1220 L1230 L1230 L1230 L1240 L1240 L1240 L1250 L1250 L1250 L1260 L1260 L1260 L1270 L1270 L1270 L1280 L1280 L1280 L1290 L1290 L1290 L1300 L1300 L1300 L1310 L1310 L1310 L1600 L1600 L1600 L1610 L1610 L1610 L1620 L1620 L1620 L1630 L1630 L1630 L1640 L1640 L1640 L1650 L1650 L1650 L1652 L1652 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $2.55 $983.23 $983.23 $98.32 $142.77 $142.77 $14.28 $138.17 $138.17 $13.82 $310.17 $310.17 $31.02 $45.75 $45.75 $4.58 $44.38 $44.38 $4.44 $44.66 $44.66 $4.47 $42.93 $42.93 $4.29 $47.07 $47.07 $4.71 $42.88 $42.88 $4.29 $1,050.60 $1,050.60 $105.06 $1,012.06 $1,012.06 $101.21 $93.75 $93.75 $9.38 $24.83 $24.83 $2.48 $73.11 $73.11 $7.31 $92.46 $92.46 $9.25 $289.93 $289.93 $28.99 $133.14 $133.14 $13.31 $209.13 $209.13 Effective Date End Date Procedure Modifier L1652 L1660 L1660 L1660 L1680 L1680 L1680 L1685 L1685 L1685 L1686 L1686 L1686 L1690 L1690 L1690 L1700 L1700 L1700 L1710 L1710 L1710 L1720 L1720 L1720 L1730 L1730 L1730 L1755 L1755 L1755 L1810 L1810 L1810 L1820 L1820 L1820 L1830 L1830 L1830 L1831 L1831 L1831 L1832 L1832 L1832 L1834 L1834 L1834 L1836 L1836 L1836 L1840 L1840 L1840 L1843 L1843 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 35 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $20.91 $124.51 $124.51 $12.45 $785.93 $785.93 $78.59 $649.03 $649.03 $64.90 $497.73 $497.73 $49.77 $1,134.43 $1,134.43 $113.44 $935.95 $935.95 $93.60 $1,203.55 $1,203.55 $120.35 $892.85 $892.85 $89.28 $706.76 $706.76 $70.68 $863.87 $863.87 $86.39 $58.36 $58.36 $5.84 $78.50 $78.50 $7.85 $47.74 $47.74 $4.77 $172.66 $172.66 $17.27 $331.73 $331.73 $33.17 $423.56 $423.56 $42.36 $78.26 $78.26 $7.83 $616.46 $616.46 $61.65 $526.38 $526.38 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L1843 L1844 L1844 L1844 L1845 L1845 L1845 L1846 L1846 L1846 L1847 L1847 L1847 L1850 L1850 L1850 L1860 L1860 L1860 L1900 L1900 L1900 L1902 L1902 L1902 L1904 L1904 L1904 L1906 L1906 L1906 L1907 L1907 L1907 L1910 L1910 L1910 L1920 L1920 L1920 L1930 L1930 L1930 L1932 L1932 L1932 L1940 L1940 L1940 L1945 L1945 L1945 L1950 L1950 L1950 L1951 L1951 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $52.64 $910.59 $910.59 $91.06 $511.07 $511.07 $51.11 $640.45 $640.45 $64.04 $337.43 $337.43 $33.74 $181.62 $181.62 $18.16 $596.73 $596.73 $59.67 $189.03 $189.03 $18.90 $58.08 $58.08 $5.81 $256.59 $256.59 $25.66 $65.62 $65.62 $6.56 $330.11 $330.11 $33.01 $164.39 $164.39 $16.44 $197.51 $197.51 $19.75 $172.10 $172.10 $17.21 $523.51 $523.51 $52.35 $276.29 $276.29 $27.63 $505.09 $505.09 $50.51 $407.81 $407.81 $40.78 $492.69 $492.69 Effective Date End Date Procedure Modifier L1951 L1960 L1960 L1960 L1970 L1970 L1970 L1971 L1971 L1971 L1980 L1980 L1980 L1990 L1990 L1990 L2000 L2000 L2000 L2005 L2005 L2005 L2010 L2010 L2010 L2020 L2020 L2020 L2030 L2030 L2030 L2034 L2034 L2034 L2035 L2035 L2035 L2036 L2036 L2036 L2037 L2037 L2037 L2038 L2038 L2038 L2040 L2040 L2040 L2050 L2050 L2050 L2060 L2060 L2060 L2070 L2070 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 36 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $49.27 $302.44 $302.44 $30.24 $388.26 $388.26 $38.83 $274.98 $274.98 $27.50 $209.33 $209.33 $20.93 $243.22 $243.22 $24.32 $553.44 $553.44 $55.34 $2,403.93 $2,403.93 $240.39 $540.45 $540.45 $54.04 $637.11 $637.11 $63.71 $558.84 $558.84 $55.88 $1,231.96 $1,231.96 $123.20 $101.63 $101.63 $10.16 $1,063.74 $1,063.74 $106.37 $908.81 $908.81 $90.88 $780.12 $780.12 $78.01 $96.88 $96.88 $9.69 $308.32 $308.32 $30.83 $356.72 $356.72 $35.67 $73.92 $73.92 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L2070 L2080 L2080 L2080 L2090 L2090 L2090 L2106 L2106 L2106 L2108 L2108 L2108 L2112 L2112 L2112 L2114 L2114 L2114 L2116 L2116 L2116 L2126 L2126 L2126 L2128 L2128 L2128 L2132 L2132 L2132 L2134 L2134 L2134 L2136 L2136 L2136 L2180 L2180 L2180 L2182 L2182 L2182 L2184 L2184 L2184 L2186 L2186 L2186 L2188 L2188 L2188 L2190 L2190 L2190 L2192 L2192 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $7.39 $209.70 $209.70 $20.97 $254.14 $254.14 $25.41 $456.59 $456.59 $45.66 $634.33 $634.33 $63.43 $309.07 $309.07 $30.91 $357.78 $357.78 $35.78 $428.63 $428.63 $42.86 $653.38 $653.38 $65.34 $935.62 $935.62 $93.56 $496.55 $496.55 $49.65 $621.04 $621.04 $62.10 $703.12 $703.12 $70.31 $85.20 $85.20 $8.52 $62.60 $62.60 $6.26 $81.33 $81.33 $8.13 $82.15 $82.15 $8.21 $191.14 $191.14 $19.11 $54.63 $54.63 $5.46 $215.21 $215.21 Effective Date End Date Procedure Modifier L2192 L2200 L2200 L2200 L2210 L2210 L2210 L2220 L2220 L2220 L2230 L2230 L2230 L2232 L2232 L2232 L2240 L2240 L2240 L2250 L2250 L2250 L2260 L2260 L2260 L2265 L2265 L2265 L2270 L2270 L2270 L2275 L2275 L2275 L2280 L2280 L2280 L2300 L2300 L2300 L2310 L2310 L2310 L2320 L2320 L2320 L2330 L2330 L2330 L2335 L2335 L2335 L2340 L2340 L2340 L2350 L2350 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 37 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $21.52 $34.59 $34.59 $3.46 $36.68 $36.68 $3.67 $47.67 $47.67 $4.77 $44.06 $44.06 $4.41 $56.68 $56.68 $5.67 $45.63 $45.63 $4.56 $193.88 $193.88 $19.39 $112.88 $112.88 $11.29 $85.67 $85.67 $8.57 $29.30 $29.30 $2.93 $71.29 $71.29 $7.13 $247.07 $247.07 $24.71 $195.88 $195.88 $19.59 $89.50 $89.50 $8.95 $122.48 $122.48 $12.25 $227.08 $227.08 $22.71 $123.95 $123.95 $12.40 $302.40 $302.40 $30.24 $518.08 $518.08 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L2350 L2360 L2360 L2360 L2370 L2370 L2370 L2375 L2375 L2375 L2380 L2380 L2380 L2385 L2385 L2385 L2387 L2387 L2387 L2390 L2390 L2390 L2395 L2395 L2395 L2397 L2397 L2397 L2405 L2405 L2405 L2415 L2415 L2415 L2425 L2425 L2425 L2430 L2430 L2430 L2492 L2492 L2492 L2500 L2500 L2500 L2510 L2510 L2510 L2520 L2520 L2520 L2525 L2525 L2525 L2526 L2526 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $51.81 $37.64 $37.64 $3.76 $160.13 $160.13 $16.01 $82.20 $82.20 $8.22 $89.56 $89.56 $8.96 $94.36 $94.36 $9.44 $90.30 $90.30 $9.03 $59.73 $59.73 $5.97 $113.83 $113.83 $11.38 $63.95 $63.95 $6.40 $51.15 $51.15 $5.11 $71.27 $71.27 $7.13 $84.09 $84.09 $8.41 $84.09 $84.09 $8.41 $62.11 $62.11 $6.21 $200.72 $200.72 $20.07 $455.26 $455.26 $45.53 $287.40 $287.40 $28.74 $665.13 $665.13 $66.51 $373.73 $373.73 Effective Date End Date Procedure Modifier L2526 L2530 L2530 L2530 L2540 L2540 L2540 L2550 L2550 L2550 L2570 L2570 L2570 L2580 L2580 L2580 L2600 L2600 L2600 L2610 L2610 L2610 L2620 L2620 L2620 L2622 L2622 L2622 L2624 L2624 L2624 L2627 L2627 L2627 L2628 L2628 L2628 L2630 L2630 L2630 L2640 L2640 L2640 L2650 L2650 L2650 L2660 L2660 L2660 L2670 L2670 L2670 L2680 L2680 L2680 L2750 L2750 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 38 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $37.37 $129.26 $129.26 $12.93 $245.38 $245.38 $24.54 $156.71 $156.71 $15.67 $346.53 $346.53 $34.65 $253.23 $253.23 $25.32 $149.42 $149.42 $14.94 $176.68 $176.68 $17.67 $170.71 $170.71 $17.07 $223.10 $223.10 $22.31 $194.01 $194.01 $19.40 $935.39 $935.39 $93.54 $914.16 $914.16 $91.42 $159.77 $159.77 $15.98 $210.04 $210.04 $21.00 $78.88 $78.88 $7.89 $122.83 $122.83 $12.28 $124.10 $124.10 $12.41 $113.85 $113.85 $11.38 $59.97 $59.97 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L2750 L2755 L2755 L2755 L2760 L2760 L2760 L2768 L2768 L2768 L2780 L2780 L2780 L2785 L2785 L2785 L2795 L2795 L2795 L2800 L2800 L2800 L2810 L2810 L2810 L2820 L2820 L2820 L2830 L2830 L2830 L2840 L2840 L2840 L2850 L2850 L2850 L3000 L3000 L3000 L3001 L3001 L3001 L3002 L3002 L3002 L3003 L3003 L3003 L3010 L3010 L3010 L3020 L3020 L3020 L3030 L3030 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $6.00 $76.67 $76.67 $7.67 $44.21 $44.21 $4.42 $76.43 $76.43 $7.64 $36.93 $36.93 $3.69 $17.29 $17.29 $1.73 $53.44 $53.44 $5.34 $58.20 $58.20 $5.82 $47.44 $47.44 $4.74 $47.38 $47.38 $4.74 $51.26 $51.26 $5.13 $31.79 $31.79 $3.18 $36.35 $36.35 $3.64 $184.29 $184.29 $18.43 $77.58 $77.58 $7.76 $94.74 $94.74 $9.47 $102.21 $102.21 $10.22 $102.21 $102.21 $10.22 $116.39 $116.39 $11.64 $44.77 $44.77 Effective Date End Date Procedure Modifier L3030 L3031 L3031 L3031 L3040 L3040 L3040 L3050 L3050 L3050 L3060 L3060 L3060 L3070 L3070 L3070 L3080 L3080 L3080 L3090 L3090 L3090 L3100 L3100 L3100 L3140 L3140 L3140 L3150 L3150 L3150 L3160 L3160 L3160 L3170 L3170 L3170 L3201 L3201 L3201 L3202 L3202 L3202 L3209 L3209 L3209 L3211 L3211 L3211 L3214 L3214 L3214 L3215 L3215 L3215 L3216 L3216 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 39 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $4.48 $37.00 $37.00 $3.70 $27.61 $27.61 $2.76 $27.61 $27.61 $2.76 $43.27 $43.27 $4.33 $18.65 $18.65 $1.86 $18.65 $18.65 $1.86 $23.89 $23.89 $2.39 $25.36 $25.36 $2.54 $52.23 $52.23 $5.22 $47.75 $47.75 $4.77 $17.31 $17.31 $1.73 $29.85 $29.85 $2.98 $22.50 $22.50 $2.25 $25.00 $25.00 $2.50 $27.50 $27.50 $2.75 $21.02 $21.02 $2.10 $15.64 $15.64 $1.56 $91.00 $91.00 $9.10 $60.63 $60.63 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L3216 L3217 L3217 L3217 L3219 L3219 L3219 L3221 L3221 L3221 L3222 L3222 L3222 L3224 L3224 L3224 L3225 L3225 L3225 L3230 L3230 L3230 L3250 L3250 L3250 L3251 L3251 L3251 L3252 L3252 L3252 L3253 L3253 L3253 L3254 L3254 L3254 L3257 L3257 L3257 L3260 L3260 L3260 L3265 L3265 L3265 L3300 L3300 L3300 L3310 L3310 L3310 L3320 L3320 L3320 L3330 L3330 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $6.06 $43.75 $43.75 $4.38 $106.00 $106.00 $10.60 $104.17 $104.17 $10.42 $30.00 $30.00 $3.00 $32.09 $32.09 $3.21 $37.62 $37.62 $3.76 $114.94 $114.94 $11.49 $106.49 $106.49 $10.65 $17.25 $17.25 $1.73 $79.63 $79.63 $7.96 $137.80 $137.80 $13.78 $7.09 $7.09 $0.71 $61.22 $61.22 $6.12 $19.19 $19.19 $1.92 $14.57 $14.57 $1.46 $30.59 $30.59 $3.06 $47.75 $47.75 $4.77 $2.00 $2.00 $0.20 $332.02 $332.02 Effective Date End Date Procedure Modifier L3330 L3332 L3332 L3332 L3334 L3334 L3334 L3340 L3340 L3340 L3350 L3350 L3350 L3360 L3360 L3360 L3370 L3370 L3370 L3380 L3380 L3380 L3390 L3390 L3390 L3400 L3400 L3400 L3410 L3410 L3410 L3420 L3420 L3420 L3430 L3430 L3430 L3440 L3440 L3440 L3450 L3450 L3450 L3455 L3455 L3455 L3460 L3460 L3460 L3465 L3465 L3465 L3470 L3470 L3470 L3480 L3480 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 40 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $33.20 $43.27 $43.27 $4.33 $22.38 $22.38 $2.24 $49.99 $49.99 $5.00 $13.42 $13.42 $1.34 $20.89 $20.89 $2.09 $29.09 $29.09 $2.91 $29.09 $29.09 $2.91 $29.09 $29.09 $2.91 $23.89 $23.89 $2.39 $54.49 $54.49 $5.45 $32.07 $32.07 $3.21 $94.01 $94.01 $9.40 $44.77 $44.77 $4.48 $61.92 $61.92 $6.19 $23.89 $23.89 $2.39 $20.13 $20.13 $2.01 $34.32 $34.32 $3.43 $36.55 $36.55 $3.66 $36.55 $36.55 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L3480 L3485 L3485 L3485 L3500 L3500 L3500 L3510 L3510 L3510 L3520 L3520 L3520 L3530 L3530 L3530 L3540 L3540 L3540 L3550 L3550 L3550 L3560 L3560 L3560 L3570 L3570 L3570 L3580 L3580 L3580 L3590 L3590 L3590 L3595 L3595 L3595 L3600 L3600 L3600 L3610 L3610 L3610 L3620 L3620 L3620 L3630 L3630 L3630 L3640 L3640 L3640 L3650 L3650 L3650 L3660 L3660 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $3.66 $18.64 $18.64 $1.86 $17.17 $17.17 $1.72 $17.17 $17.17 $1.72 $18.65 $18.65 $1.86 $18.65 $18.65 $1.86 $29.85 $29.85 $2.98 $5.23 $5.23 $0.52 $13.42 $13.42 $1.34 $49.99 $49.99 $5.00 $38.05 $38.05 $3.81 $31.34 $31.34 $3.13 $24.61 $24.61 $2.46 $44.77 $44.77 $4.48 $58.95 $58.95 $5.89 $44.77 $44.77 $4.48 $58.95 $58.95 $5.89 $25.36 $25.36 $2.54 $34.70 $34.70 $3.47 $54.88 $54.88 Effective Date End Date Procedure Modifier L3660 L3670 L3670 L3670 L3671 L3671 L3671 L3674 L3674 L3674 L3675 L3675 L3675 L3677 L3677 L3677 L3702 L3702 L3702 L3710 L3710 L3710 L3720 L3720 L3720 L3730 L3730 L3730 L3740 L3740 L3740 L3760 L3760 L3760 L3762 L3762 L3762 L3763 L3763 L3763 L3764 L3764 L3764 L3765 L3765 L3765 L3766 L3766 L3766 L3806 L3806 L3806 L3807 L3807 L3807 L3808 L3808 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 41 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $5.49 $62.69 $62.69 $6.27 $481.09 $481.09 $48.11 $631.10 $631.10 $63.11 $93.70 $93.70 $9.37 $141.79 $141.79 $14.18 $154.17 $154.17 $15.42 $79.32 $79.32 $7.93 $405.11 $405.11 $40.51 $592.54 $592.54 $59.25 $760.85 $760.85 $76.09 $267.01 $267.01 $26.70 $57.42 $57.42 $5.74 $373.80 $373.80 $37.38 $406.15 $406.15 $40.61 $684.60 $684.60 $68.46 $724.94 $724.94 $72.49 $242.52 $242.52 $24.25 $133.50 $133.50 $13.35 $178.42 $178.42 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L3808 L3891 L3891 L3891 L3900 L3900 L3900 L3901 L3901 L3901 L3904 L3904 L3904 L3905 L3905 L3905 L3906 L3906 L3906 L3908 L3908 L3908 L3912 L3912 L3912 L3913 L3913 L3913 L3915 L3915 L3915 L3917 L3917 L3917 L3919 L3919 L3919 L3921 L3921 L3921 L3923 L3923 L3923 L3925 L3925 L3925 L3927 L3927 L3927 L3929 L3929 L3929 L3931 L3931 L3931 L3933 L3933 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $17.84 $14.13 $14.13 $1.41 $697.92 $697.92 $69.79 $858.04 $858.04 $85.80 $1,563.60 $1,563.60 $156.36 $529.47 $529.47 $52.95 $210.98 $210.98 $21.10 $31.99 $31.99 $3.20 $66.57 $66.57 $6.66 $144.60 $144.60 $14.46 $283.82 $283.82 $28.38 $56.39 $56.39 $5.64 $144.60 $144.60 $14.46 $171.49 $171.49 $17.15 $46.44 $46.44 $4.64 $28.68 $28.68 $2.87 $18.69 $18.69 $1.87 $49.11 $49.11 $4.91 $109.68 $109.68 $10.97 $113.93 $113.93 Effective Date End Date Procedure Modifier L3933 L3935 L3935 L3935 L3956 L3956 L3956 L3960 L3960 L3960 L3961 L3961 L3961 L3962 L3962 L3962 L3967 L3967 L3967 L3971 L3971 L3971 L3973 L3973 L3973 L3975 L3975 L3975 L3976 L3976 L3976 L3977 L3977 L3977 L3978 L3978 L3978 L3980 L3980 L3980 L3982 L3982 L3982 L3984 L3984 L3984 L3995 L3995 L3995 L4000 L4000 L4000 L4002 L4002 L4002 L4010 L4010 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 42 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $11.39 $117.97 $117.97 $11.80 $42.00 $42.00 $4.20 $478.44 $478.44 $47.84 $897.03 $897.03 $89.70 $383.10 $383.10 $38.31 $1,059.11 $1,059.11 $105.91 $1,005.31 $1,005.31 $100.53 $1,059.11 $1,059.11 $105.91 $897.03 $897.03 $89.70 $897.03 $897.03 $89.70 $1,005.31 $1,005.31 $100.53 $1,059.11 $1,059.11 $105.91 $196.55 $196.55 $19.66 $221.80 $221.80 $22.18 $192.97 $192.97 $19.30 $22.77 $22.77 $2.28 $735.22 $735.22 $73.52 $10.00 $10.00 $1.00 $375.75 $375.75 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L4010 L4020 L4020 L4020 L4030 L4030 L4030 L4040 L4040 L4040 L4045 L4045 L4045 L4050 L4050 L4050 L4055 L4055 L4055 L4060 L4060 L4060 L4070 L4070 L4070 L4080 L4080 L4080 L4090 L4090 L4090 L4100 L4100 L4100 L4110 L4110 L4110 L4130 L4130 L4130 L4205 L4205 L4205 L4210 L4210 L4210 L4350 L4350 L4350 L4360 L4360 L4360 L4370 L4370 L4370 L4386 L4386 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $37.58 $549.48 $549.48 $54.95 $359.33 $359.33 $35.93 $234.20 $234.20 $23.42 $178.98 $178.98 $17.90 $225.26 $225.26 $22.53 $148.59 $148.59 $14.86 $173.40 $173.40 $17.34 $193.30 $193.30 $19.33 $55.19 $55.19 $5.52 $62.34 $62.34 $6.23 $64.01 $64.01 $6.40 $51.20 $51.20 $5.12 $315.50 $315.50 $31.55 $21.55 $21.55 $2.16 $66.00 $66.00 $6.60 $50.16 $50.16 $5.02 $151.08 $151.08 $15.11 $103.01 $103.01 $10.30 $93.02 $93.02 Effective Date End Date Procedure Modifier L4386 L4392 L4392 L4392 L4394 L4394 L4394 L4396 L4396 L4396 L4398 L4398 L4398 L4631 L4631 L4631 L5000 L5000 L5000 L5010 L5010 L5010 L5020 L5020 L5020 L5050 L5050 L5050 L5060 L5060 L5060 L5100 L5100 L5100 L5105 L5105 L5105 L5150 L5150 L5150 L5160 L5160 L5160 L5200 L5200 L5200 L5210 L5210 L5210 L5220 L5220 L5220 L5230 L5230 L5230 L5250 L5250 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 43 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $9.30 $13.82 $13.82 $1.38 $10.09 $10.09 $1.01 $98.47 $98.47 $9.85 $45.32 $45.32 $4.53 $867.76 $867.76 $86.78 $391.61 $391.61 $39.16 $889.21 $889.21 $88.92 $1,335.83 $1,335.83 $133.58 $1,681.60 $1,681.60 $168.16 $1,900.12 $1,900.12 $190.01 $1,652.45 $1,652.45 $165.25 $2,019.44 $2,019.44 $201.94 $2,407.13 $2,407.13 $240.71 $2,532.59 $2,532.59 $253.26 $2,201.01 $2,201.01 $220.10 $1,626.91 $1,626.91 $162.69 $2,043.89 $2,043.89 $204.39 $2,422.58 $2,422.58 $242.26 $3,279.70 $3,279.70 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L5250 L5270 L5270 L5270 L5280 L5280 L5280 L5301 L5301 L5301 L5312 L5312 L5312 L5321 L5321 L5321 L5331 L5331 L5331 L5341 L5341 L5341 L5400 L5400 L5400 L5410 L5410 L5410 L5420 L5420 L5420 L5430 L5430 L5430 L5450 L5450 L5450 L5460 L5460 L5460 L5500 L5500 L5500 L5505 L5505 L5505 L5510 L5510 L5510 L5520 L5520 L5520 L5530 L5530 L5530 L5535 L5535 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $327.97 $3,116.38 $3,116.38 $311.64 $3,392.37 $3,392.37 $339.24 $1,603.21 $1,603.21 $160.32 $2,139.81 $2,139.81 $213.98 $2,236.70 $2,236.70 $223.67 $3,367.27 $3,367.27 $336.73 $3,513.95 $3,513.95 $351.40 $829.04 $829.04 $82.90 $323.84 $323.84 $32.38 $1,061.70 $1,061.70 $106.17 $390.03 $390.03 $39.00 $315.77 $315.77 $31.58 $422.64 $422.64 $42.26 $834.20 $834.20 $83.42 $1,348.11 $1,348.11 $134.81 $991.75 $991.75 $99.18 $1,114.61 $1,114.61 $111.46 $1,151.89 $1,151.89 $115.19 $1,154.14 $1,154.14 Effective Date End Date Procedure Modifier L5535 L5540 L5540 L5540 L5560 L5560 L5560 L5570 L5570 L5570 L5580 L5580 L5580 L5585 L5585 L5585 L5590 L5590 L5590 L5595 L5595 L5595 L5600 L5600 L5600 L5610 L5610 L5610 L5611 L5611 L5611 L5613 L5613 L5613 L5614 L5614 L5614 L5616 L5616 L5616 L5617 L5617 L5617 L5618 L5618 L5618 L5620 L5620 L5620 L5622 L5622 L5622 L5624 L5624 L5624 L5626 L5626 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 44 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $115.41 $1,237.46 $1,237.46 $123.75 $1,488.25 $1,488.25 $148.82 $1,469.39 $1,469.39 $146.94 $1,640.68 $1,640.68 $164.07 $1,646.09 $1,646.09 $164.61 $1,610.57 $1,610.57 $161.06 $2,340.64 $2,340.64 $234.06 $2,584.77 $2,584.77 $258.48 $1,394.88 $1,394.88 $139.49 $936.59 $936.59 $93.66 $1,442.63 $1,442.63 $144.26 $991.87 $991.87 $99.19 $1,052.68 $1,052.68 $105.27 $328.87 $328.87 $32.89 $175.61 $175.61 $17.56 $215.49 $215.49 $21.55 $280.99 $280.99 $28.10 $281.79 $281.79 $28.18 $309.44 $309.44 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L5626 L5628 L5628 L5628 L5629 L5629 L5629 L5630 L5630 L5630 L5631 L5631 L5631 L5632 L5632 L5632 L5634 L5634 L5634 L5636 L5636 L5636 L5637 L5637 L5637 L5638 L5638 L5638 L5639 L5639 L5639 L5640 L5640 L5640 L5642 L5642 L5642 L5643 L5643 L5643 L5644 L5644 L5644 L5645 L5645 L5645 L5646 L5646 L5646 L5647 L5647 L5647 L5648 L5648 L5648 L5649 L5649 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $30.94 $333.96 $333.96 $33.40 $246.32 $246.32 $24.63 $300.69 $300.69 $30.07 $340.55 $340.55 $34.06 $129.07 $129.07 $12.91 $176.83 $176.83 $17.68 $148.12 $148.12 $14.81 $223.91 $223.91 $22.39 $293.43 $293.43 $29.34 $651.75 $651.75 $65.18 $371.71 $371.71 $37.17 $371.45 $371.45 $37.15 $973.11 $973.11 $97.31 $409.59 $409.59 $40.96 $464.76 $464.76 $46.48 $413.44 $413.44 $41.34 $462.41 $462.41 $46.24 $450.97 $450.97 $45.10 $1,412.42 $1,412.42 Effective Date End Date Procedure Modifier L5649 L5650 L5650 L5650 L5651 L5651 L5651 L5652 L5652 L5652 L5653 L5653 L5653 L5654 L5654 L5654 L5655 L5655 L5655 L5656 L5656 L5656 L5658 L5658 L5658 L5661 L5661 L5661 L5665 L5665 L5665 L5666 L5666 L5666 L5668 L5668 L5668 L5670 L5670 L5670 L5671 L5671 L5671 L5672 L5672 L5672 L5673 L5673 L5673 L5676 L5676 L5676 L5677 L5677 L5677 L5678 L5678 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 45 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $141.24 $333.01 $333.01 $33.30 $930.81 $930.81 $93.08 $295.68 $295.68 $29.57 $346.31 $346.31 $34.63 $229.16 $229.16 $22.92 $178.28 $178.28 $17.83 $220.96 $220.96 $22.10 $211.37 $211.37 $21.14 $353.75 $353.75 $35.38 $318.10 $318.10 $31.81 $54.26 $54.26 $5.43 $78.27 $78.27 $7.83 $210.32 $210.32 $21.03 $334.22 $334.22 $33.42 $173.34 $173.34 $17.33 $425.87 $425.87 $42.59 $274.34 $274.34 $27.43 $382.16 $382.16 $38.22 $30.78 $30.78 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L5678 L5679 L5679 L5679 L5680 L5680 L5680 L5681 L5681 L5681 L5682 L5682 L5682 L5683 L5683 L5683 L5684 L5684 L5684 L5685 L5685 L5685 L5686 L5686 L5686 L5688 L5688 L5688 L5690 L5690 L5690 L5692 L5692 L5692 L5694 L5694 L5694 L5695 L5695 L5695 L5696 L5696 L5696 L5697 L5697 L5697 L5698 L5698 L5698 L5699 L5699 L5699 L5700 L5700 L5700 L5701 L5701 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $3.08 $354.88 $354.88 $35.49 $189.75 $189.75 $18.97 $773.19 $773.19 $77.32 $370.92 $370.92 $37.09 $773.19 $773.19 $77.32 $31.29 $31.29 $3.13 $75.28 $75.28 $7.53 $31.41 $31.41 $3.14 $44.64 $44.64 $4.46 $62.72 $62.72 $6.27 $102.99 $102.99 $10.30 $140.61 $140.61 $14.06 $126.40 $126.40 $12.64 $129.03 $129.03 $12.90 $46.66 $46.66 $4.67 $69.57 $69.57 $6.96 $108.39 $108.39 $10.84 $1,665.41 $1,665.41 $166.54 $2,000.04 $2,000.04 Effective Date End Date Procedure Modifier L5701 L5702 L5702 L5702 L5703 L5703 L5703 L5704 L5704 L5704 L5705 L5705 L5705 L5706 L5706 L5706 L5707 L5707 L5707 L5710 L5710 L5710 L5711 L5711 L5711 L5712 L5712 L5712 L5714 L5714 L5714 L5716 L5716 L5716 L5718 L5718 L5718 L5722 L5722 L5722 L5724 L5724 L5724 L5726 L5726 L5726 L5728 L5728 L5728 L5780 L5780 L5780 L5781 L5781 L5781 L5782 L5782 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 46 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $200.00 $2,530.34 $2,530.34 $253.03 $1,549.31 $1,549.31 $154.93 $311.56 $311.56 $31.16 $556.69 $556.69 $55.67 $545.71 $545.71 $54.57 $719.46 $719.46 $71.95 $248.81 $248.81 $24.88 $315.16 $315.16 $31.52 $330.28 $330.28 $33.03 $279.04 $279.04 $27.90 $493.22 $493.22 $49.32 $544.15 $544.15 $54.41 $528.99 $528.99 $52.90 $1,169.92 $1,169.92 $116.99 $1,348.30 $1,348.30 $134.83 $1,440.49 $1,440.49 $144.05 $766.82 $766.82 $76.68 $2,351.90 $2,351.90 $235.19 $2,479.42 $2,479.42 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L5782 L5785 L5785 L5785 L5790 L5790 L5790 L5795 L5795 L5795 L5810 L5810 L5810 L5811 L5811 L5811 L5812 L5812 L5812 L5814 L5814 L5814 L5816 L5816 L5816 L5818 L5818 L5818 L5822 L5822 L5822 L5824 L5824 L5824 L5826 L5826 L5826 L5828 L5828 L5828 L5830 L5830 L5830 L5840 L5840 L5840 L5845 L5845 L5845 L5848 L5848 L5848 L5850 L5850 L5850 L5855 L5855 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $247.94 $336.74 $336.74 $33.67 $557.30 $557.30 $55.73 $832.20 $832.20 $83.22 $312.49 $312.49 $31.25 $462.87 $462.87 $46.29 $350.27 $350.27 $35.03 $2,183.01 $2,183.01 $218.30 $563.42 $563.42 $56.34 $564.93 $564.93 $56.49 $989.91 $989.91 $98.99 $1,061.97 $1,061.97 $106.20 $1,835.63 $1,835.63 $183.56 $1,641.58 $1,641.58 $164.16 $1,210.63 $1,210.63 $121.06 $2,039.36 $2,039.36 $203.94 $1,053.56 $1,053.56 $105.36 $632.07 $632.07 $63.21 $99.16 $99.16 $9.92 $199.80 $199.80 Effective Date End Date Procedure Modifier Maximum Allowable L5855 L5856 L5856 L5856 L5857 L5857 L5857 L5858 L5858 L5858 L5910 L5910 L5910 L5920 L5920 L5920 L5925 L5925 L5925 L5930 L5930 L5930 L5940 L5940 L5940 L5950 L5950 L5950 L5960 L5960 L5960 L5961 L5961 L5961 L5962 L5962 L5962 L5964 L5964 L5964 L5966 L5966 L5966 L5968 L5968 L5968 L5970 L5970 L5970 L5971 L5971 L5971 L5972 L5972 L5972 L5973 L5973 RR $19.98 $14,110.62 $14,110.62 $1,411.06 $5,006.99 $5,006.99 $500.70 $10,924.37 $10,924.37 $1,092.44 $280.72 $280.72 $28.07 $411.25 $411.25 $41.12 $260.43 $260.43 $26.04 $1,978.47 $1,978.47 $197.85 $388.79 $388.79 $38.88 $603.02 $603.02 $60.30 $747.21 $747.21 $74.72 $2,771.67 $2,771.67 $277.17 $368.78 $368.78 $36.88 $544.41 $544.41 $54.44 $693.71 $693.71 $69.37 $2,136.01 $2,136.01 $213.60 $132.31 $132.31 $13.23 $132.31 $132.31 $13.23 $249.07 $249.07 $24.91 $10,112.90 $10,112.90 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 47 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L5973 L5974 L5974 L5974 L5975 L5975 L5975 L5976 L5976 L5976 L5978 L5978 L5978 L5979 L5979 L5979 L5980 L5980 L5980 L5981 L5981 L5981 L5982 L5982 L5982 L5984 L5984 L5984 L5985 L5985 L5985 L5986 L5986 L5986 L5987 L5987 L5987 L5988 L5988 L5988 L5990 L5990 L5990 L6000 L6000 L6000 L6010 L6010 L6010 L6020 L6020 L6020 L6025 L6025 L6025 L6050 L6050 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $1,011.29 $154.09 $154.09 $15.41 $272.52 $272.52 $27.25 $352.86 $352.86 $35.29 $197.84 $197.84 $19.78 $1,326.41 $1,326.41 $132.64 $2,279.76 $2,279.76 $227.98 $1,741.04 $1,741.04 $174.10 $363.85 $363.85 $36.39 $390.82 $390.82 $39.08 $165.97 $165.97 $16.60 $388.87 $388.87 $38.89 $4,228.48 $4,228.48 $422.85 $1,174.24 $1,174.24 $117.42 $1,066.39 $1,066.39 $106.64 $870.08 $870.08 $87.01 $875.39 $875.39 $87.54 $870.75 $870.75 $87.08 $4,703.79 $4,703.79 $470.38 $1,337.67 $1,337.67 Effective Date End Date Procedure Modifier L6050 L6055 L6055 L6055 L6100 L6100 L6100 L6110 L6110 L6110 L6120 L6120 L6120 L6130 L6130 L6130 L6200 L6200 L6200 L6205 L6205 L6205 L6250 L6250 L6250 L6300 L6300 L6300 L6310 L6310 L6310 L6320 L6320 L6320 L6350 L6350 L6350 L6360 L6360 L6360 L6370 L6370 L6370 L6380 L6380 L6380 L6382 L6382 L6382 L6384 L6384 L6384 L6386 L6386 L6386 L6388 L6388 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 48 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $133.77 $1,650.13 $1,650.13 $165.01 $1,372.42 $1,372.42 $137.24 $1,456.85 $1,456.85 $145.68 $1,642.60 $1,642.60 $164.26 $1,522.07 $1,522.07 $152.21 $1,851.88 $1,851.88 $185.19 $2,116.88 $2,116.88 $211.69 $1,920.42 $1,920.42 $192.04 $2,312.57 $2,312.57 $231.26 $1,856.80 $1,856.80 $185.68 $1,117.08 $1,117.08 $111.71 $2,276.95 $2,276.95 $227.69 $1,851.57 $1,851.57 $185.16 $1,290.88 $1,290.88 $129.09 $763.09 $763.09 $76.31 $905.30 $905.30 $90.53 $1,122.26 $1,122.26 $112.23 $259.88 $259.88 $25.99 $290.42 $290.42 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L6388 L6400 L6400 L6400 L6450 L6450 L6450 L6500 L6500 L6500 L6550 L6550 L6550 L6570 L6570 L6570 L6580 L6580 L6580 L6582 L6582 L6582 L6584 L6584 L6584 L6586 L6586 L6586 L6588 L6588 L6588 L6590 L6590 L6590 L6600 L6600 L6600 L6605 L6605 L6605 L6610 L6610 L6610 L6611 L6611 L6611 L6615 L6615 L6615 L6616 L6616 L6616 L6620 L6620 L6620 L6621 L6621 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $29.04 $1,458.05 $1,458.05 $145.80 $1,792.22 $1,792.22 $179.22 $1,808.38 $1,808.38 $180.84 $2,216.68 $2,216.68 $221.67 $2,544.32 $2,544.32 $254.43 $955.24 $955.24 $95.52 $885.89 $885.89 $88.59 $1,294.16 $1,294.16 $129.42 $1,273.31 $1,273.31 $127.33 $1,753.04 $1,753.04 $175.30 $1,719.24 $1,719.24 $171.92 $145.39 $145.39 $14.54 $143.56 $143.56 $14.36 $117.57 $117.57 $11.76 $242.01 $242.01 $24.20 $112.86 $112.86 $11.29 $47.97 $47.97 $4.80 $195.01 $195.01 $19.50 $1,344.47 $1,344.47 Effective Date End Date Procedure Modifier L6621 L6623 L6623 L6623 L6624 L6624 L6624 L6625 L6625 L6625 L6628 L6628 L6628 L6629 L6629 L6629 L6630 L6630 L6630 L6632 L6632 L6632 L6635 L6635 L6635 L6637 L6637 L6637 L6638 L6638 L6638 L6640 L6640 L6640 L6641 L6641 L6641 L6642 L6642 L6642 L6645 L6645 L6645 L6646 L6646 L6646 L6647 L6647 L6647 L6648 L6648 L6648 L6650 L6650 L6650 L6655 L6655 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 49 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $134.45 $391.56 $391.56 $39.16 $2,213.71 $2,213.71 $221.37 $412.23 $412.23 $41.22 $300.07 $300.07 $30.01 $103.18 $103.18 $10.32 $167.04 $167.04 $16.70 $37.77 $37.77 $3.78 $128.61 $128.61 $12.86 $250.61 $250.61 $25.06 $1,469.92 $1,469.92 $146.99 $209.68 $209.68 $20.97 $113.39 $113.39 $11.34 $135.01 $135.01 $13.50 $234.13 $234.13 $23.41 $1,853.90 $1,853.90 $185.39 $305.21 $305.21 $30.52 $1,912.04 $1,912.04 $191.20 $245.84 $245.84 $24.58 $53.83 $53.83 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L6655 L6660 L6660 L6660 L6665 L6665 L6665 L6670 L6670 L6670 L6672 L6672 L6672 L6675 L6675 L6675 L6676 L6676 L6676 L6677 L6677 L6677 L6680 L6680 L6680 L6682 L6682 L6682 L6684 L6684 L6684 L6686 L6686 L6686 L6687 L6687 L6687 L6688 L6688 L6688 L6689 L6689 L6689 L6690 L6690 L6690 L6691 L6691 L6691 L6692 L6692 L6692 L6693 L6693 L6693 L6694 L6694 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $5.38 $60.00 $60.00 $6.00 $35.70 $35.70 $3.57 $37.17 $37.17 $3.72 $103.43 $103.43 $10.34 $72.53 $72.53 $7.25 $76.24 $76.24 $7.62 $174.38 $174.38 $17.44 $179.83 $179.83 $17.98 $176.08 $176.08 $17.61 $202.63 $202.63 $20.26 $376.74 $376.74 $37.67 $335.30 $335.30 $33.53 $396.30 $396.30 $39.63 $414.70 $414.70 $41.47 $449.96 $449.96 $45.00 $200.66 $200.66 $20.07 $413.62 $413.62 $41.36 $1,668.75 $1,668.75 $166.88 $425.87 $425.87 Effective Date End Date Procedure Modifier L6694 L6695 L6695 L6695 L6696 L6696 L6696 L6697 L6697 L6697 L6698 L6698 L6698 L6703 L6703 L6703 L6704 L6704 L6704 L6706 L6706 L6706 L6707 L6707 L6707 L6708 L6708 L6708 L6709 L6709 L6709 L6711 L6711 L6711 L6712 L6712 L6712 L6713 L6713 L6713 L6714 L6714 L6714 L6721 L6721 L6721 L6722 L6722 L6722 L6805 L6805 L6805 L6810 L6810 L6810 L6881 L6881 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 50 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $42.59 $354.88 $354.88 $35.49 $773.19 $773.19 $77.32 $773.19 $773.19 $77.32 $334.22 $334.22 $33.42 $192.25 $192.25 $19.23 $450.85 $450.85 $45.08 $233.90 $233.90 $23.39 $832.27 $832.27 $83.23 $559.36 $559.36 $55.94 $820.69 $820.69 $82.07 $395.19 $395.19 $39.52 $727.62 $727.62 $72.76 $918.33 $918.33 $91.83 $777.82 $777.82 $77.78 $1,382.48 $1,382.48 $138.25 $1,191.80 $1,191.80 $119.18 $247.36 $247.36 $24.74 $144.58 $144.58 $14.46 $2,403.07 $2,403.07 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L6881 L6882 L6882 L6882 L6883 L6883 L6883 L6884 L6884 L6884 L6885 L6885 L6885 L6890 L6890 L6890 L6895 L6895 L6895 L6900 L6900 L6900 L6905 L6905 L6905 L6910 L6910 L6910 L6915 L6915 L6915 L6920 L6920 L6920 L6925 L6925 L6925 L6930 L6930 L6930 L6935 L6935 L6935 L6940 L6940 L6940 L6945 L6945 L6945 L6950 L6950 L6950 L6955 L6955 L6955 L6960 L6960 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $240.31 $1,822.84 $1,822.84 $182.28 $1,084.72 $1,084.72 $108.47 $1,627.93 $1,627.93 $162.79 $1,851.57 $1,851.57 $185.16 $107.16 $107.16 $10.72 $324.59 $324.59 $32.46 $898.80 $898.80 $89.88 $853.49 $853.49 $85.35 $841.04 $841.04 $84.10 $363.91 $363.91 $36.39 $4,259.89 $4,259.89 $425.99 $4,498.07 $4,498.07 $449.81 $4,573.49 $4,573.49 $457.35 $5,030.79 $5,030.79 $503.08 $5,715.87 $5,715.87 $571.59 $6,465.99 $6,465.99 $646.60 $6,077.07 $6,077.07 $607.71 $7,625.87 $7,625.87 $762.59 $7,519.49 $7,519.49 Effective Date End Date Procedure Modifier Maximum Allowable L6960 L6965 L6965 L6965 L6970 L6970 L6970 L6975 L6975 L6975 L7007 L7007 L7007 L7008 L7008 L7008 L7009 L7009 L7009 L7040 L7040 L7040 L7045 L7045 L7045 L7170 L7170 L7170 L7180 L7180 L7180 L7181 L7181 L7181 L7185 L7185 L7185 L7186 L7186 L7186 L7190 L7190 L7190 L7191 L7191 L7191 L7260 L7260 L7260 L7261 L7261 L7261 L7360 L7360 L7360 L7362 L7362 RR $751.95 $10,984.90 $10,984.90 $1,098.49 $11,165.41 $11,165.41 $1,116.54 $11,225.33 $11,225.33 $1,122.53 $2,667.10 $2,667.10 $266.71 $4,197.73 $4,197.73 $419.77 $2,721.29 $2,721.29 $272.13 $2,185.09 $2,185.09 $218.51 $1,252.79 $1,252.79 $125.28 $4,544.69 $4,544.69 $454.47 $23,744.91 $23,744.91 $2,374.49 $23,551.98 $23,551.98 $2,355.20 $4,602.10 $4,602.10 $460.21 $6,641.95 $6,641.95 $664.20 $5,855.30 $5,855.30 $585.53 $7,060.19 $7,060.19 $706.02 $1,525.37 $1,525.37 $152.54 $2,441.38 $2,441.38 $244.14 $139.98 $139.98 $14.00 $168.35 $168.35 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 51 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L7362 L7364 L7364 L7364 L7366 L7366 L7366 L7367 L7367 L7367 L7368 L7368 L7368 L7400 L7400 L7400 L7401 L7401 L7401 L7402 L7402 L7402 L7403 L7403 L7403 L7404 L7404 L7404 L7405 L7405 L7405 L7510 L7510 L7510 L7520 L7520 L7520 L7900 L7900 L7900 L8000 L8000 L8000 L8001 L8001 L8001 L8002 L8002 L8002 L8010 L8010 L8010 L8015 L8015 L8015 L8020 L8020 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $16.83 $306.67 $306.67 $30.67 $416.03 $416.03 $41.60 $228.83 $228.83 $22.88 $296.67 $296.67 $29.67 $180.15 $180.15 $18.01 $201.68 $201.68 $20.17 $217.79 $217.79 $21.78 $216.46 $216.46 $21.65 $326.69 $326.69 $32.67 $427.28 $427.28 $42.73 $92.63 $92.63 $9.26 $24.00 $24.00 $2.40 $318.14 $318.14 $31.81 $21.81 $21.81 $2.18 $73.72 $73.72 $7.37 $96.98 $96.98 $9.70 $58.00 $58.00 $5.80 $35.24 $35.24 $3.52 $132.08 $132.08 Effective Date End Date Procedure Modifier L8020 L8030 L8030 L8030 L8031 L8031 L8031 L8032 L8032 L8032 L8035 L8035 L8035 L8039 L8039 L8039 L8040 L8040 L8040 L8041 L8041 L8041 L8042 L8042 L8042 L8043 L8043 L8043 L8044 L8044 L8044 L8045 L8045 L8045 L8046 L8046 L8046 L8047 L8047 L8047 L8300 L8300 L8300 L8310 L8310 L8310 L8320 L8320 L8320 L8330 L8330 L8330 L8400 L8400 L8400 L8410 L8410 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 52 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $13.21 $193.91 $193.91 $19.39 $193.91 $193.91 $19.39 $23.03 $23.03 $2.30 $2,153.47 $2,153.47 $215.35 $154.03 $154.03 $15.40 $1,401.03 $1,401.03 $140.10 $1,688.72 $1,688.72 $168.87 $1,897.43 $1,897.43 $189.74 $2,125.11 $2,125.11 $212.51 $2,352.80 $2,352.80 $235.28 $1,473.32 $1,473.32 $147.33 $1,517.93 $1,517.93 $151.79 $777.94 $777.94 $77.79 $49.03 $49.03 $4.90 $77.42 $77.42 $7.74 $35.74 $35.74 $3.57 $38.27 $38.27 $3.83 $9.15 $9.15 $0.91 $13.39 $13.39 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L8410 L8415 L8415 L8415 L8417 L8417 L8417 L8420 L8420 L8420 L8430 L8430 L8430 L8435 L8435 L8435 L8440 L8440 L8440 L8460 L8460 L8460 L8465 L8465 L8465 L8470 L8470 L8470 L8480 L8480 L8480 L8485 L8485 L8485 L8500 L8500 L8500 L8501 L8501 L8501 L8505 L8505 L8505 L8507 L8507 L8507 L8509 L8509 L8509 L8510 L8510 L8510 L8511 L8511 L8511 L8512 L8512 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $1.34 $13.60 $13.60 $1.36 $44.19 $44.19 $4.42 $12.09 $12.09 $1.21 $13.27 $13.27 $1.33 $14.02 $14.02 $1.40 $25.69 $25.69 $2.57 $44.68 $44.68 $4.47 $31.83 $31.83 $3.18 $4.66 $4.66 $0.47 $6.11 $6.11 $0.61 $6.46 $6.46 $0.65 $451.93 $451.93 $45.19 $70.22 $70.22 $7.02 $68.40 $68.40 $6.84 $24.62 $24.62 $2.46 $64.19 $64.19 $6.42 $148.54 $148.54 $14.85 $42.75 $42.75 $4.28 $1.29 $1.29 Effective Date End Date Procedure Modifier Maximum Allowable L8512 L8513 L8513 L8513 L8514 L8514 L8514 L8515 L8515 L8515 L8600 L8600 L8600 L8603 L8603 L8603 L8605 L8605 L8605 L8606 L8606 L8606 L8609 L8609 L8609 L8610 L8610 L8610 L8612 L8612 L8612 L8613 L8613 L8613 L8614 L8614 L8614 L8615 L8615 L8615 L8616 L8616 L8616 L8617 L8617 L8617 L8618 L8618 L8618 L8619 L8619 L8619 L8621 L8621 L8621 L8622 L8622 RR $0.13 $3.06 $3.06 $0.31 $55.43 $55.43 $5.54 $37.10 $37.10 $3.71 $362.99 $362.99 $36.30 $300.00 $300.00 $30.00 424.36 424.36 42.44 $127.92 $127.92 $12.79 $3,829.76 $3,829.76 $382.98 $385.63 $385.63 $38.56 $372.63 $372.63 $37.26 $174.98 $174.98 $17.50 $11,251.31 $11,251.31 $1,125.13 $265.11 $265.11 $26.51 $61.75 $61.75 $6.17 $53.94 $53.94 $5.39 $15.40 $15.40 $1.54 $4,830.11 $4,830.11 $483.01 $0.36 $0.36 $0.04 $0.20 $0.20 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 53 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier L8622 L8623 L8623 L8623 L8624 L8624 L8624 L8627 L8627 L8627 L8628 L8628 L8628 L8629 L8629 L8629 L8630 L8630 L8630 L8631 L8631 L8631 L8641 L8641 L8641 L8642 L8642 L8642 L8658 L8658 L8658 L8659 L8659 L8659 L8670 L8670 L8670 L8680 L8680 L8680 L8681 L8681 L8681 L8682 L8682 L8682 L8683 L8683 L8683 L8684 L8684 L8684 L8685 L8685 L8685 L8686 L8686 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $0.02 $38.02 $38.02 $3.80 $94.77 $94.77 $9.48 $4,102.94 $4,102.94 $410.29 $727.16 $727.16 $72.72 $105.25 $105.25 $10.53 $195.84 $195.84 $19.58 $1,276.05 $1,276.05 $127.61 $203.48 $203.48 $20.35 $169.21 $169.21 $16.92 $177.42 $177.42 $17.74 $1,134.28 $1,134.28 $113.43 $323.59 $323.59 $32.36 $270.00 $270.00 $27.00 $627.11 $627.11 $62.71 $3,504.26 $3,504.26 $350.43 $3,084.54 $3,084.54 $308.45 $453.82 $453.82 $45.38 $7,686.53 $7,686.53 $768.65 $4,904.61 $4,904.61 Effective Date End Date Procedure Modifier Maximum Allowable L8686 L8687 L8687 L8687 L8688 L8688 L8688 L8689 L8689 L8689 L8690 L8690 L8690 L8691 L8691 L8691 L8693 L8693 L8693 L8695 L8695 L8695 Q0478 Q0478 Q0478 Q0479 Q0479 Q0479 Q0480 Q0480 Q0480 Q0481 Q0481 Q0481 Q0482 Q0482 Q0482 Q0483 Q0483 Q0483 Q0484 Q0484 Q0484 Q0485 Q0485 Q0485 Q0486 Q0486 Q0486 Q0487 Q0487 Q0487 Q0488 Q0488 Q0488 Q0489 Q0489 RR $490.46 $10,003.25 $10,003.25 $1,000.33 $6,382.88 $6,382.88 $638.29 $1,013.93 $1,013.93 $101.39 $2,796.25 $2,796.25 $279.62 $1,567.40 $1,567.40 $156.74 $891.31 $891.31 $89.13 $9.79 $9.79 $0.98 $108.02 $108.02 $10.80 $7,099.27 $7,099.27 $709.93 $52,939.86 $52,939.86 $5,293.99 $8,541.24 $8,541.24 $854.12 $2,675.27 $2,675.27 $267.53 $11,020.92 $11,020.92 $1,102.09 $2,140.22 $2,140.22 $214.02 $206.65 $206.65 $20.66 $171.98 $171.98 $17.20 $200.65 $200.65 $20.06 $40,930.00 $40,930.00 $4,093.00 $9,554.55 $9,554.55 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 54 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier Q0489 Q0490 Q0490 Q0490 Q0491 Q0491 Q0491 Q0492 Q0492 Q0492 Q0493 Q0493 Q0493 Q0494 Q0494 Q0494 Q0495 Q0495 Q0495 Q0496 Q0496 Q0496 Q0497 Q0497 Q0497 Q0498 Q0498 Q0498 Q0499 Q0499 Q0499 Q0500 Q0500 Q0500 Q0501 Q0501 Q0501 Q0502 Q0502 Q0502 Q0503 Q0503 Q0503 Q0504 Q0504 Q0504 Q0506 Q0506 Q0506 Q4001 Q4001 Q4001 Q4002 Q4002 Q4002 Q4003 Q4003 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $955.46 $413.29 $413.29 $41.33 $649.72 $649.72 $64.97 $52.36 $52.36 $5.24 $149.03 $149.03 $14.90 $126.11 $126.11 $12.61 $2,455.28 $2,455.28 $245.53 $881.23 $881.23 $88.12 $275.17 $275.17 $27.52 $301.91 $301.91 $30.19 $98.10 $98.10 $9.81 $17.95 $17.95 $1.79 $300.20 $300.20 $30.02 $382.17 $382.17 $38.22 $764.37 $764.37 $76.44 $403.33 $403.33 $40.33 $502.05 $502.05 $50.20 $48.34 $48.34 $4.83 $182.70 $182.70 $18.27 $34.72 $34.72 Effective Date End Date Procedure Modifier Q4003 Q4004 Q4004 Q4004 Q4005 Q4005 Q4005 Q4006 Q4006 Q4006 Q4007 Q4007 Q4007 Q4008 Q4008 Q4008 Q4009 Q4009 Q4009 Q4010 Q4010 Q4010 Q4011 Q4011 Q4011 Q4012 Q4012 Q4012 Q4013 Q4013 Q4013 Q4014 Q4014 Q4014 Q4015 Q4015 Q4015 Q4016 Q4016 Q4016 Q4017 Q4017 Q4017 Q4018 Q4018 Q4018 Q4019 Q4019 Q4019 Q4020 Q4020 Q4020 Q4021 Q4021 Q4021 Q4022 Q4022 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 55 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $3.47 $120.21 $120.21 $12.02 $12.80 $12.80 $1.28 $28.86 $28.86 $2.89 $6.41 $6.41 $0.64 $14.43 $14.43 $1.44 $8.53 $8.53 $0.85 $19.24 $19.24 $1.92 $4.27 $4.27 $0.43 $9.62 $9.62 $0.96 $15.54 $15.54 $1.55 $26.24 $26.24 $2.62 $7.77 $7.77 $0.78 $13.12 $13.12 $1.31 $8.99 $8.99 $0.90 $14.34 $14.34 $1.43 $4.50 $4.50 $0.45 $7.17 $7.17 $0.72 $6.66 $6.66 $0.67 $12.01 $12.01 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier Q4022 Q4023 Q4023 Q4023 Q4024 Q4024 Q4024 Q4025 Q4025 Q4025 Q4026 Q4026 Q4026 Q4027 Q4027 Q4027 Q4028 Q4028 Q4028 Q4029 Q4029 Q4029 Q4030 Q4030 Q4030 Q4031 Q4031 Q4031 Q4032 Q4032 Q4032 Q4033 Q4033 Q4033 Q4034 Q4034 Q4034 Q4035 Q4035 Q4035 Q4036 Q4036 Q4036 Q4037 Q4037 Q4037 Q4038 Q4038 Q4038 Q4039 Q4039 Q4039 Q4040 Q4040 Q4040 Q4041 Q4041 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $1.20 $3.34 $3.34 $0.33 $6.00 $6.00 $0.60 $37.34 $37.34 $3.73 $116.55 $116.55 $11.66 $18.67 $18.67 $1.87 $58.28 $58.28 $5.83 $28.54 $28.54 $2.85 $75.13 $75.13 $7.51 $14.28 $14.28 $1.43 $37.57 $37.57 $3.76 $26.62 $26.62 $2.66 $66.23 $66.23 $6.62 $13.32 $13.32 $1.33 $33.12 $33.12 $3.31 $16.25 $16.25 $1.63 $40.69 $40.69 $4.07 $8.13 $8.13 $0.81 $20.35 $20.35 $2.04 $19.75 $19.75 Effective Date End Date Procedure Modifier Q4041 Q4042 Q4042 Q4042 Q4043 Q4043 Q4043 Q4044 Q4044 Q4044 Q4045 Q4045 Q4045 Q4046 Q4046 Q4046 Q4047 Q4047 Q4047 Q4048 Q4048 Q4048 Q4049 Q4049 Q4049 Q4132 Q4132 Q4132 Q4133 Q4133 Q4133 S0500 S0500 S0500 S0504 S0504 S0504 S0506 S0506 S0506 S0508 S0508 S0508 S0510 S0510 S0510 S0512 S0512 S0512 S0514 S0514 S0514 S0515 S0515 S0515 S0516 S0516 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 56 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $1.98 $33.71 $33.71 $3.37 $9.87 $9.87 $0.99 $16.86 $16.86 $1.69 $11.47 $11.47 $1.15 $18.45 $18.45 $1.85 $5.73 $5.73 $0.57 $9.23 $9.23 $0.92 $2.09 $2.09 $0.21 176.50 176.50 17.65 176.50 176.50 17.65 $3.03 $3.03 $0.30 $51.32 $51.32 $5.13 $24.88 $24.88 $2.49 $36.00 $36.00 $3.60 $10.70 $10.70 $1.07 $3.50 $3.50 $0.35 $18.00 $18.00 $1.80 $3.69 $3.69 $0.37 $20.00 $20.00 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier Maximum Allowable S0516 S0580 S0580 S0580 S0590 S0590 S0590 S1001 S1001 S1001 S1002 S1002 S1002 S1015 S1015 S1015 S1016 S1016 S1016 S1030 S1030 S1030 S1031 S1031 S1031 S1040 S1040 S1040 S2150 S2150 S2150 S4989 S4989 S4989 S5560 S5560 S5560 S5561 S5561 S5561 S5565 S5565 S5565 S5566 S5566 S5566 S5570 S5570 S5570 S5571 S5571 S5571 S8096 S8096 S8096 S8097 S8097 RR $2.00 $69.20 $69.20 $6.92 $25.91 $25.91 $2.59 $5.77 $5.77 $0.58 $4.74 $4.74 $0.47 $13.85 $13.85 $1.39 $111.57 $111.57 $11.16 $19.50 $19.50 $1.95 $750.00 $750.00 $75.00 $1,706.25 $1,706.25 $170.63 $57,000.00 $57,000.00 $5,700.00 $189.60 $189.60 $18.96 $11.87 $11.87 $1.19 $30.98 $30.98 $3.10 $11.87 $11.87 $1.19 $35.51 $35.51 $3.55 $830.55 $830.55 $83.06 $34.87 $34.87 $3.49 $13.46 $13.46 $1.35 $20.00 $20.00 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Effective Date End Date Procedure Modifier S8097 S8100 S8100 S8100 S8101 S8101 S8101 S8120 S8120 S8120 S8121 S8121 S8121 S8186 S8186 S8186 S8262 S8262 S8262 S8301 S8301 S8301 S8415 S8415 S8415 S8422 S8422 S8422 S8424 S8424 S8424 S8425 S8425 S8425 S8427 S8427 S8427 S8428 S8428 S8428 S8429 S8429 S8429 S8430 S8430 S8430 S8431 S8431 S8431 S8450 S8450 S8450 S8451 S8451 S8451 S8452 S8452 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 Page 57 of 58 NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $2.00 $35.00 $35.00 $3.50 $30.00 $30.00 $3.00 $15.20 $15.20 $1.52 $15.20 $15.20 $1.52 $13.00 $13.00 $1.30 $871.44 $871.44 $87.14 $63.00 $63.00 $6.30 $56.25 $56.25 $5.63 $59.89 $59.89 $5.99 $69.33 $69.33 $6.93 $125.00 $125.00 $12.50 $76.17 $76.17 $7.62 $28.19 $28.19 $2.82 $10.00 $10.00 $1.00 $8.30 $8.30 $0.83 $8.89 $8.89 $0.89 $11.50 $11.50 $1.15 $16.61 $16.61 $1.66 $24.84 $24.84 Effective Date End Date 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 dmerc_2013_v4 2013 Blue Advantage HMOSM Durable Medical Equipment Fee Schedule Procedure Modifier S8452 S8460 S8460 S8460 S8490 S8490 S8490 S8999 S8999 S8999 S9433 S9433 S9433 V5050 V5050 V5050 V5060 V5060 V5060 V5130 V5130 V5130 V5140 V5140 V5140 V5160 V5160 V5160 V5241 V5241 V5241 V5247 V5247 V5247 V5253 V5253 V5253 V5254 V5254 V5254 V5255 V5255 V5255 V5256 V5256 V5256 V5257 V5257 V5257 V5258 V5258 V5258 V5259 V5259 V5259 V5260 V5260 RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU RR NU Maximum Allowable $2.48 $48.61 $48.61 $4.86 $17.60 $17.60 $1.76 $11.85 $11.85 $1.19 $21.33 $21.33 $2.13 $693.67 $693.67 $69.37 $1,734.19 $1,734.19 $173.42 $2,831.85 $2,831.85 $283.19 $2,147.57 $2,147.57 $214.76 $310.26 $310.26 $31.03 $227.03 $227.03 $22.70 $1,767.60 $1,767.60 $176.76 $1,672.98 $1,672.98 $167.30 $2,919.21 $2,919.21 $291.92 $2,008.20 $2,008.20 $200.82 $1,861.54 $1,861.54 $186.15 $2,551.13 $2,551.13 $255.11 $4,028.93 $4,028.93 $402.89 $3,597.20 $3,597.20 $359.72 $2,669.93 $2,669.93 Effective Date End Date Procedure Modifier V5260 V5261 V5261 V5261 V5264 V5264 V5264 V5265 V5265 V5265 V5266 V5266 V5266 V5267 V5267 V5267 V5275 V5275 V5275 RR 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 1/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 Page 58 of 58 NU RR NU RR NU RR NU RR NU RR NU RR Maximum Allowable $266.99 $4,275.97 $4,275.97 $427.60 $71.53 $71.53 $7.15 $32.84 $32.84 $3.28 $1.23 $1.23 $0.12 $400.83 $400.83 $40.08 $51.65 $51.65 $5.17 Effective Date End Date 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 3/1/13 dmerc_2013_v4
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