L1620
Prosthetics & Orthotics
53 States
Hip orthosis, abduction control of hip joints, flexible, (pavlik harness), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
Short Desc
Ho flex pavlik harns pre cst
Coverage determined by local carrier discretion.
Added Date
1982-01-01
Effective From
2014-01-01
National Floor
$153.96
National Ceiling
$205.28
Fee Schedule Rates
Effective Jan 2026Official Medicare DMEPOS pricing for 2026.
| State | Modifier | Non-Rural | Rural |
|---|---|---|---|
|
AK
|
Base Rate |
$192.23
|
Same |
|
AL
|
Base Rate |
$166.13
|
Same |
|
AR
|
Base Rate |
$153.96
|
Same |
|
AZ
|
Base Rate |
$190.90
|
Same |
|
CA
|
Base Rate |
$190.90
|
Same |
|
CO
|
Base Rate |
$153.96
|
Same |
|
CT
|
Base Rate |
$181.13
|
Same |
|
DC
|
Base Rate |
$185.07
|
Same |
|
DE
|
Base Rate |
$185.07
|
Same |
|
FL
|
Base Rate |
$166.13
|
Same |
|
GA
|
Base Rate |
$166.13
|
Same |
|
HI
|
Base Rate |
$205.58
|
Same |
|
IA
|
Base Rate |
$158.92
|
Same |
|
ID
|
Base Rate |
$162.21
|
Same |
|
IL
|
Base Rate |
$193.10
|
Same |
|
IN
|
Base Rate |
$193.10
|
Same |
|
KS
|
Base Rate |
$158.92
|
Same |
|
KY
|
Base Rate |
$166.13
|
Same |
|
LA
|
Base Rate |
$153.96
|
Same |
|
MA
|
Base Rate |
$181.13
|
Same |
|
MD
|
Base Rate |
$185.07
|
Same |
|
ME
|
Base Rate |
$181.13
|
Same |
|
MI
|
Base Rate |
$193.10
|
Same |
|
MN
|
Base Rate |
$193.10
|
Same |
|
MO
|
Base Rate |
$158.92
|
Same |
|
MS
|
Base Rate |
$166.13
|
Same |
|
MT
|
Base Rate |
$153.96
|
Same |
|
NC
|
Base Rate |
$166.13
|
Same |
|
ND
|
Base Rate |
$153.96
|
Same |
|
NE
|
Base Rate |
$158.92
|
Same |
|
NH
|
Base Rate |
$181.13
|
Same |
|
NJ
|
Base Rate |
$170.36
|
Same |
|
NM
|
Base Rate |
$153.96
|
Same |
|
NV
|
Base Rate |
$190.90
|
Same |
|
NY
|
Base Rate |
$170.36
|
Same |
|
OH
|
Base Rate |
$193.10
|
Same |
|
OK
|
Base Rate |
$153.96
|
Same |
|
OR
|
Base Rate |
$162.21
|
Same |
|
PA
|
Base Rate |
$185.07
|
Same |
|
PR
|
Base Rate |
$158.72
|
Same |
|
RI
|
Base Rate |
$181.13
|
Same |
|
SC
|
Base Rate |
$166.13
|
Same |
|
SD
|
Base Rate |
$153.96
|
Same |
|
TN
|
Base Rate |
$166.13
|
Same |
|
TX
|
Base Rate |
$153.96
|
Same |
|
UT
|
Base Rate |
$153.96
|
Same |
|
VA
|
Base Rate |
$185.07
|
Same |
|
VI
|
Base Rate |
$170.36
|
Same |
|
VT
|
Base Rate |
$181.13
|
Same |
|
WA
|
Base Rate |
$162.21
|
Same |
|
WI
|
Base Rate |
$193.10
|
Same |
|
WV
|
Base Rate |
$185.07
|
Same |
|
WY
|
Base Rate |
$153.96
|
Same |