| HCPCS | MOD1 | MOD2 | Ceiling | Floor | CT | DE | MA | ME | NH | NJ | NY | PA | RI | VT |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| A5500 | $71.23 | $53.42 | $59.36 | $59.36 | $59.36 | $59.36 | $59.36 | $59.36 | $59.36 | $59.36 | $59.36 | $59.36 | ||
| A5501 | $213.65 | $160.24 | $178.04 | $178.04 | $178.04 | $178.04 | $178.04 | $178.04 | $178.04 | $178.04 | $178.04 | $178.04 | ||
| A5503 | $31.68 | $23.76 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | ||
| A5504 | $31.68 | $23.76 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | ||
| A5505 | $31.68 | $23.76 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | ||
| A5506 | $31.68 | $23.76 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | ||
| A5507 | $31.68 | $23.76 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | $26.40 | ||
| A5512 | $29.06 | $21.80 | $24.22 | $24.22 | $24.22 | $24.22 | $24.22 | $24.22 | $24.22 | $24.22 | $24.22 | $24.22 | ||
| A5513 | $43.37 | $32.53 | $36.14 | $36.14 | $36.14 | $36.14 | $36.14 | $36.14 | $36.14 | $36.14 | $36.14 | $36.14 |