| HCPCS | MOD1 | MOD2 | Ceiling | Floor | CT | DE | MA | ME | NH | NJ | NY | PA | RI | VT |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| A4608 | $58.15 | $49.43 | $58.15 | $58.15 | $58.15 | $58.15 | $58.15 | $58.15 | $58.15 | $58.15 | $58.15 | $58.15 | ||
| A4619 | $1.21 | $1.03 | $1.21 | $1.21 | $1.21 | $1.21 | $1.21 | $1.21 | $1.21 | $1.21 | $1.21 | $1.21 | ||
| E0424 | RR | $0.00 | $0.00 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $194.48 | $200.39 | |
| E0431 | RR | $0.00 | $0.00 | $32.08 | $32.07 | $32.07 | $32.07 | $32.07 | $32.07 | $32.07 | $32.07 | $32.08 | $32.07 | |
| E0434 | RR | $0.00 | $0.00 | $32.08 | $32.07 | $32.07 | $32.07 | $32.07 | $32.07 | $32.07 | $32.07 | $32.08 | $32.07 | |
| E0439 | RR | $0.00 | $0.00 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $194.48 | $200.39 | |
| E0441 | $162.98 | $138.53 | $162.98 | $162.98 | $162.98 | $162.98 | $162.98 | $162.98 | $162.98 | $161.77 | $162.98 | $162.98 | ||
| E0442 | $162.98 | $138.53 | $162.98 | $162.98 | $162.98 | $162.98 | $162.98 | $162.98 | $162.98 | $161.77 | $162.98 | $162.98 | ||
| E0443 | $21.41 | $18.20 | $21.41 | $18.20 | $21.41 | $21.41 | $21.41 | $21.41 | $21.41 | $21.34 | $21.41 | $21.41 | ||
| E0444 | $21.41 | $18.20 | $21.41 | $18.20 | $21.41 | $21.41 | $21.41 | $21.41 | $21.41 | $21.34 | $21.41 | $21.41 | ||
| E1390 | RR | $0.00 | $0.00 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $194.48 | $200.39 | |
| E1391 | RR | $0.00 | $0.00 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $200.41 | $194.48 | $200.39 | |
| E1392 | RR | $0.00 | $0.00 | $32.08 | $32.07 | $32.07 | $32.07 | $32.07 | $32.07 | $32.07 | $32.07 | $32.08 | $32.07 | |
| E1405 | RR | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |
| E1406 | RR | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |