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FOR BREAST PROTH F 00004.68 07012024 99999999 1 A4287 DISP COL STO BAG BREAST MILK M 00000.00 01012024 99999999 1 A4310 INSERTION TRAY W/O DRAINAGE BAG AND W/O F 00007.80 07012024 99999999 1 A4311 INSERTION TRAY W/O DRAINAGE BAD W/INDWEL F 00012.76 07012024 99999999 1 A4312 INSERTION TRAY WITHOUT DRAINAGE BAG W/IN F 00018.32 07012024 99999999 1 A4313 INSERTION TRAY W/O BAG W/INDWELLING CATH F 00017.69 07012024 99999999 1 A4314 INSERTION TRAY WITH/DRAINAGE BAG W/INDWE F 00024.16 07012024 99999999 1 A4315 INSERTION TRAY W/BAG, W/INDWELL CATH F 00025.19 07012024 99999999 1 A4316 INSERTION TRAY W/BAG W/CATH,FOLEY F 00027.13 07012024 99999999 1 A4320 IRRIGATION TRAY WITH BULB OR PISTON SYRI F 00004.92 07012024 99999999 1 A4321 THERAPUETIC AGENT FOR CATH IRRIGATION F 00009.84 07012024 99999999 1 A4322 IRRIGATION SYRINGE, BULB OR PISTON,EACH F 00003.28 07012024 99999999 1 A4326 MALE EXTERNAL CATHETER SPECIALTY F 00009.06 07012024 99999999 1 A4327 FEMALE EXTERNAL URINARY COLLECTION DEVIC F 00042.64 07012024 99999999 1 A4328 FEMALE EXTERNAL URINARY COLLECTION POUCH F 00009.97 07012024 99999999 1 A4330 PERIANAL FECAL COLLECTION POUCH EACH F 00006.83 07012024 99999999 1 A4331 EXT. 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POUCH URINARY W/O FACEPLATE RUBBER F 00026.93 07012024 99999999 1 A4384 OSTOMY FACEPLATE EQUIL. SILICONE RING F 00009.19 07012024 99999999 1 A4385 OST. SKIN BARRIER,4X4 EXT. WEAR EACH F 00004.86 07012024 99999999 1 A4387 OST. POUCH,W/STANDARD WEAR BARRIER F 00002.50 07012024 99999999 1 A4388 OST. POUCH W/EXT WEAR BARRIER ATTACHED F 00004.16 07012024 99999999 1 A4389 OST. POUCH,W/STANDARD WEAR BARRIER F 00005.93 07012024 99999999 1 A4390 OSTOMY POUCH,DRAINABLE,W/EXT WEAR, EACH F 00009.17 07012024 99999999 1 A4391 OST. POUCH URINARY W/EXT WEAR BARRIER F 00006.75 07012024 99999999 1 A4392 OST. POUCH URINARY W/STAND. WEAR BARRIER F 00006.35 07012024 99999999 1 A4393 OST. POUCH,URINARY,W/EXT WEAR BARRIER F 00008.76 07012024 99999999 1 A4394 OST. 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OWNED VENT F 00035.41 07012024 99999999 1 A4613 BATTERY CHARGER,REPLACEMENT FOR PT. VENT F 00137.76 07012024 99999999 1 A4614 PEAK EXP. FLOW METER, HAND HELD F 00026.52 07012024 99999999 1 A4615 CANNULA, NASAL F 00000.80 07012024 99999999 1 A4616 TUBING, OXYGEN, PER FOOT F 00000.07 07012024 99999999 1 A4617 MOUTHPIECE, EACH F 00003.37 07012024 99999999 1 A4618 BREATHING CIRCUITS F 00004.12 07012024 99999999 1 A4619 FACE TENT F 00001.22 07012024 99999999 1 A4620 VARIABLE CONCENTRATION MASK F 00000.70 07012024 99999999 1 A4623 TRACHEOSTOMY INNER CANNULA F 00005.30 07012024 99999999 1 A4624 TRACHEAL SUCTION CATHETER, ANY TYPE, EAC F 00002.05 07012024 99999999 1 A4625 TRACH CARE KIT FOR NEW TRACHEOSTOMY F 00005.62 07012024 99999999 1 A4626 TRACHEOSTOMY CLEANING BRUSH, EACH F 00003.05 07012024 99999999 1 A4627 SPACER, BAG OR RESERVOIR, W W/O MASK FOR F 00029.79 07012024 99999999 1 A4628 OROPHARYNGEAL SUCTION CATH F 00003.75 07012024 99999999 1 A4629 TRACHEOSTOMY CARE KIT FOR ESTABLISHED TR F 00004.27 07012024 99999999 1 A4630 REPLACEMENT BATTERIES FOR TENS UNITS OWN F 00005.08 07012024 99999999 1 A4635 UNDERARM PAD, CRUTCH, REPLACEMENT, EACH F 00002.39 07012024 99999999 1 A4636 REPLACEMENT, HANDGRIP, CANE, CRUTCH, WAL F 00002.39 07012024 99999999 1 A4637 REPLACEMENT, TIP CANE, CRUTCH, WALKER, E F 00001.96 07012024 99999999 1 A4640 REPLACEMENT PAD FOR ALT.PRESS PAD F 00060.49 07012024 99999999 1 A4649 MEDICAL OR SURGICAL SUPPLIES NOT ELSEWHE M 00000.00 09012018 99999999 1 A4660 SPHYGMOMANOMETER/BLOOD PRESS. 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DIAL >5999CC M 00000.00 06112012 99999999 1 A4728 DIALYSATE SOLUTION,NON DEX, 500 ML M 00000.00 06112012 99999999 1 A4736 TOPICAL ANESTHETIC FOR DIALYSIS PER GRAM M 00000.00 06112012 99999999 1 A4737 INJECTABLE ANESTHETIC FOR DIALYSIS /10ML M 00000.00 06112012 99999999 1 A4766 DIAL. CONC. SOL ADD.FOR PERIT./10ML M 00000.00 06112012 99999999 1 A4860 DISPOSABLE CATH CAPS/PERITONEAL DIALYISI M 00000.00 06112012 99999999 1 A4911 DRAIN BAG/BOTTLE FOR DIALYSIS EACH M 00000.00 06112012 99999999 1 A4927 GLOVES, NON STERILE, PER 100 F 00007.22 07012024 99999999 1 A4928 SURGICAL MASK FOR DIALYSIS PER 20 F 00002.97 07012024 99999999 1 A4929 TOURNIQUET FOR DIALYSIS,EACH M 00000.00 06112012 99999999 1 A4931 ORAL THERMOMETER F 00002.95 07012024 99999999 1 A4932 RECTAL THERMOMETER, REUSABLE, ANY TYPE, F 00002.95 07012024 99999999 1 A5051 POUCH, CLOSED, WITH BARRIER ATTACHED (1 F 00002.30 07012024 99999999 1 A5052 POUCH, CLOSED, WITHOUT BARRIER ATTACHED F 00001.66 07012024 99999999 1 A5053 POUCH, CLOSED FOR USE ON FACEPLATE F 00001.66 07012024 99999999 1 A5054 POUCH, URINARY, WITH FACEPLATE ATTACHED, F 00002.01 07012024 99999999 1 A5055 STOMA CAP, EACH F 00001.61 07012024 99999999 1 A5056 OSTOMY POUCH, DRAINABLE,FILTER,EACH F 00004.82 07012024 99999999 1 A5057 OSTOMY POUCH, DRAINABLE,CONVEXITY,EACH F 00009.93 07012024 99999999 1 A5061 POUCH, DRAINABLE, WITH BARRIER ATTACHED F 00003.50 07012024 99999999 1 A5062 POUCH, DRAINABLE, WITHOUT BARRIER ATTACH F 00002.32 07012024 99999999 1 A5063 POUCH, DRAINABLE, FOR USE ON BARRIER W/F F 00002.98 07012024 99999999 1 A5071 POUCH, URINARY, WITH BARRIER ATTACHED (1 F 00004.62 07012024 99999999 1 A5072 POUCH, URINARY, WITHOUT BARRIER ATTACHED F 00003.59 07012024 99999999 1 A5073 POUCH, URINARY, FOR USE ON BARRIER WITH F 00003.13 07012024 99999999 1 A5081 CONTINENT DEVICE,PLUG FOR STOMA F 00003.14 07012024 99999999 1 A5082 CONTINENT DEVICE, CATHETER FOR STOMA F 00009.65 07012024 99999999 1 A5093 OSTOMY, ACCESSORY, CONVEX, INSERT F 00001.85 07012024 99999999 1 A5102 BEDSIDE DRAIN BOTTLE,W/WO TUBING, EACH F 00021.42 07012024 99999999 1 A5105 URINARY SUSPENSORY,W/LEG BAG,W/WO TUBE F 00038.94 07012024 99999999 1 A5112 URINARY LEG BAG LATEX, EACH F 00033.98 07012024 99999999 1 A5113 LEG STRAP,LATEX,REPLACEMENT, PER SET F 00004.49 07012024 99999999 1 A5114 LEG STRAP,FOAM/FABRIC,REPLACE. PER SET F 00007.24 07012024 99999999 1 A5120 SKIN BARRIER, WIPE OR SWAB F 00000.21 07012024 99999999 1 A5121 SKIN BARRIER, SOLID, 6 X 6 OR EQUIVALENT F 00007.70 07012024 99999999 1 A5122 SKIN BARRIER, SOLID, 8 X 8 OR EQUIVALENT F 00013.42 07012024 99999999 1 A5126 ADHESIVE, DISK OR FOAM PAD F 00001.23 07012024 99999999 1 A5131 APPLIANCE CLEANER, INCONTINENCE PER 16OZ F 00012.87 07012024 99999999 1 A5200 PERCUTANEOUS CATH/TUBE ANCHORING DEVICE F 00010.78 07012024 99999999 1 A5500 DIAB SHOE FOR DENSITY INSERT F 00061.76 07012025 99999999 1 A5501 DIAB CUSTOM MOLDED SHOE, PER SHOE F 00185.26 07012025 99999999 1 A5503 DIAB ROLLAR/RIGID ROCKER BOTTOM MODIFIC F 00027.48 07012025 99999999 1 A5504 DIABETIC WEDGE INSERT MOD, PER SHOE F 00027.48 07012025 99999999 1 A5505 DIABETIC METATARSAL BAR MOD, PER SHOE F 00026.47 07012024 99999999 1 A5506 DIABETIC OFFSET HEEL MOD, PER SHOE F 00027.48 07012025 99999999 1 A5507 DIABETIC SHOE MODIF, NOS, PER SHOE F 00027.48 07012025 99999999 1 A5512 MULTI DEN INSERT DIRECT FORM F 00025.20 07012025 99999999 1 A5513 MULTI DEN INSERT CUSTOM MOLD F 00037.60 07012025 99999999 1 A5514 For diabetics only, multiple density ins F 00044.98 07012025 99999999 1 A6010 COLLAGEN BASED WOUND DRY FILLER PER GM F 00031.62 07012024 99999999 1 A6011 COLLAGEN BASED WOUND FILLER, GEL/PASTE F 00002.35 07012024 99999999 1 A6021 COLLAGEN PAD, 16 SQ. INCH OR LESS, EA F 00021.07 07012024 99999999 1 A6022 COLLAGEN PAD, >16 SQ INCH BUT <48SQ.IN F 00020.08 07012024 99999999 1 A6023 COLLAGEN PAD MORE THAN 48SQ. INCH EACH F 00181.80 07012024 99999999 1 A6024 COLLAGEN DRSG WOUND FILLER, PER 6 IN. F 00005.90 07012024 99999999 1 A6025 SILICONE GEL SHEET, EACH M 00000.00 06112012 99999999 1 A6154 WOUND POUCH, EACH F 00013.71 07012024 99999999 1 A6196 ALGINATE DRESS.WOUND COVER,<16 SQ.INCH F 00007.01 07012024 99999999 1 A6197 ALGINATE DRESS.>16SQ INCH AND <48SQ.IN F 00015.71 07012024 99999999 1 A6198 ALGINATE DRESS, >48 SQ. INCHES EACH M 00000.00 09012018 99999999 1 A6199 ALGINATE DRESS.WOUND FILLER,PER 6IN. F 00005.04 07012024 99999999 1 A6203 COMPOSITE DRESS,<16SQ INCH W/BORDER EA F 00003.18 07012024 99999999 1 A6204 COMPOSIT DRESS. PAD SIZE>16 SQ<48SQ IN F 00005.94 07012024 99999999 1 A6205 COMPOSITE DRESS, >48SQ INCH W/BORDR EA M 00000.00 06112012 99999999 1 A6206 CONTACT LAYER,16SQ INCHES OR LESS,EACH M 00000.00 06112012 99999999 1 A6207 CONTACT LAYER,>16SQ INCH,<48SQ INCH,EA F 00007.00 07012024 99999999 1 A6208 CONTACT LAYER, >48SQ INCHES EACH M 00000.00 06112012 99999999 1 A6209 FOAM DRESS.< F 00007.15 07012024 99999999 1 A6210 FOAM DRESS>16SQ IN< F 00019.02 07012024 99999999 1 A6211 FOAM DRESS.>48SQ IN,W/OUT BORDER,EA F 00028.05 07012024 99999999 1 A6212 FOAM DRESS.<16SQ INCH,W/BORDER EACH F 00009.27 07012024 99999999 1 A6213 FOAM DRESS.>16SQ IN<48SQ IN W/BORDER M 00000.00 06112012 99999999 1 A6214 FOAM DRESS,>48SQ INCH,W/BORDER EACH F 00009.83 07012024 99999999 1 A6215 FOAM DRESS,WOUND FILLER PER GRAM M 00000.00 06112012 99999999 1 A6216 GAUZE,NON-IMPREG.<16SQ IN. W/OUT BORDER F 00000.05 07012024 99999999 1 A6217 GAUZE,NON-IMPREG.>16SQ IN,<48SQ IN. M 00000.00 06112012 99999999 1 A6218 GAUZE, NON-IMPREG,>48SQ IN, W/OUT BORDER M 00000.00 06112012 99999999 1 A6219 GAUZE,NON-IMPREG,<16 SQ IN, W/BORDER F 00000.90 07012024 99999999 1 A6220 GAUZE,NON-IMPREG, >16SQ IN,<48SQ INCH F 00002.46 07012024 99999999 1 A6221 GAUZE,NON-IMPREG,>48SQ IN W/BORDER M 00000.00 06112012 99999999 1 A6222 GAUZE, IMPREGNATED <16SQ IN W/O BORDER F 00002.03 07012024 99999999 1 A6223 GAUZE IMPREG>16SQ IN<48 SQ IN WO BORDR F 00002.30 07012024 99999999 1 A6224 GAUZE, IMPREG. >48SQ IN W/OUT BORDER F 00003.45 07012024 99999999 1 A6228 GAUZE IMPREG,W/WATER OR NACL<16SQ INCH M 00000.00 06112012 99999999 1 A6229 GAUZE, IMPREG,W/H2O OR NACL,>16SQ INCH F 00003.45 07012024 99999999 1 A6230 GAUZE,IMPREG W/H20 OR NACL,>48SQ INCH M 00000.00 06112012 99999999 1 A6231 GAUZE, IMPREG,HYDROGEL <16SQ IN F 00004.47 07012024 99999999 1 A6232 GAUZE, IMPREG HYDROGEL 16SQ IN<48SQ F 00006.58 07012024 99999999 1 A6233 GAUZE, IMPREG,HYDROGEL >48 SQ INCHES F 00018.33 07012024 99999999 1 A6234 HYDROCOLL. DRESS<16 SQ IN,W/O BORDER F 00006.25 07012024 99999999 1 A6235 HYDROCOLL. DRESS,>16 BUT<48 SQ INCH F 00016.08 07012024 99999999 1 A6236 HYDROCOLL,DRESS, >48SQ IN W/OUT BORDER F 00026.03 07012024 99999999 1 A6237 HYDROCOLL,DRESS,<16 SQ IN W/BORDER F 00007.55 07012024 99999999 1 A6238 HYDROCOLL,DRESS, >16,<48SQ IN W/BORDER F 00021.76 07012024 99999999 1 A6239 HYDROCOLL,DRESS,>48SQ INCH W/BORDER M 00000.00 06112012 99999999 1 A6240 HYDROCOLL,DRESS, WOUND FILLER PASTE F 00011.69 07012024 99999999 1 A6241 HYDROCOLL, DRESS, WND FILLER, DRY FORM F 00002.45 07012024 99999999 1 A6242 HYDROGEL DRESS,<16 SQ INCH W/O BORDER F 00005.80 07012024 99999999 1 A6243 HYDROGEL DRESS,>16SQ INCH,<48 SQ INCH F 00011.76 07012024 99999999 1 A6244 HYDROGEL DRESS, >48 SQ INCH W/O BORDER F 00037.51 07012024 99999999 1 A6245 HYDROGEL,DRESS,<16SQ IN W/BORDER F 00006.93 07012024 99999999 1 A6246 HYDROGEL,DRESS,>16 SQ<48SQ IN W/BORDR F 00009.48 07012024 99999999 1 A6247 HYDROGEL DRESS, >48SQ IN W/BORDER F 00022.71 07012024 99999999 1 A6248 HYDROGEL,WOUND FILLER, GEL/FLUID OUNCE F 00015.52 07012024 99999999 1 A6250 SKIN SEALANTS,PROTECTANTS,MOISTURIZERS M 00000.00 06112012 99999999 1 A6251 SPECIALTY ABSORB. DRESS.<16SQ IN F 00001.90 07012024 99999999 1 A6252 SPECIALTY ABSORB. DRESS,>16,<48 SQ IN F 00003.10 07012024 99999999 1 A6253 SPECIALTY ABSORB. DRESS,>48 SQ INCHES F 00006.06 07012024 99999999 1 A6254 SPECIALTY ABSORB. DRESS <16 SQ INCHES F 00001.16 07012024 99999999 1 A6255 SPECIALTY ABSORB. DRESS>16, <48SQ IN F 00002.88 07012024 99999999 1 A6256 SPECIALTY DRESS, >48SQUARE INCHES M 00000.00 06112012 99999999 1 A6257 TRANSPARENT FILM,16 SQ IN OR LESS F 00001.46 07012024 99999999 1 A6258 TRANSPARENT FILM, 16 - 48 INCHES, EACH F 00004.11 07012024 99999999 1 A6259 TRANSARENT FILM, MORE THAN 48SQ INCH F 00010.45 07012024 99999999 1 A6260 WOUND CLEANSERS, ANY TYPE, ANY SIZE M 00000.00 06112012 99999999 1 A6261 WOUND FILLER GEL/PASTE, PER OZ, NOS M 00000.00 06112012 99999999 1 A6262 WOUND FILLER, DRY FORM, PER GM, NOS M 00000.00 06112012 99999999 1 A6266 GAUZE, IMPREG OTHER THAN WATER, PER YD F 00001.83 07012024 99999999 1 A6402 GAUZE,NON-IMPREG,STERILE <16SQ INCHES F 00000.11 07012024 99999999 1 A6403 GAUZE, NON-IMPREG,STERILE,>16,<48SQ INCH F 00000.40 07012024 99999999 1 A6404 GAUZE, NON-IMPREG,STERILE,>48 SQ INCHES M 00000.00 06112012 99999999 1 A6407 PACKING STRIPS,NON-IMPREG, <2IN PER YD F 00001.87 07012024 99999999 1 A6410 EYE PAD, STERILE EACH F 00000.39 07012024 99999999 1 A6411 EYE PAD NON-STERILE,EACH F 00000.26 07012024 99999999 1 A6441 PADDING BANDAGE,NON-ELAST,NON WOVEN;YARD F 00000.68 07012024 99999999 1 A6442 CONFORMING BANDAGE;NS,-3"WIDE;PER YARD F 00000.18 07012024 99999999 1 A6443 CORFORMING BANDAGE;NS,+3" WIDE;PER YARD F 00000.29 07012024 99999999 1 A6444 CONFORMING BANDAGE,WIDTH + 5 IN.,PER YD F 00000.58 07012024 99999999 1 A6445 CONFORMING BANDAGE; STERILE,-3" WIDE;YD. F 00000.32 07012024 99999999 1 A6446 CONFORMING BANDAGE,STERILE+3" WIDE;YARD F 00000.41 07012024 99999999 1 A6447 CONFORMING BANDAGE,STERILE,5" OR +/YARD F 00000.68 07012024 99999999 1 A6448 LIGHT COMPRESSION BANDAGE, LESS 3"/YARD F 00001.20 07012024 99999999 1 A6449 LIGHT COMPRESSION BANDAGE, ELASTIC/YARD F 00001.80 07012024 99999999 1 A6450 LIGHT COMPRESSION BANDAGE +5" WIDTH/YD F 00002.30 07012024 99999999 1 A6451 MODERATE COMPRESSION, ELASTIC/YARD F 00002.30 07012024 99999999 1 A6452 HIGH COMPRESSION BANDAGE; PER YARD F 00006.10 07012024 99999999 1 A6453 SELF-ADHERENT BANDAGE,- 3" WIDE/YARD F 00000.63 07012024 99999999 1 A6454 SELF-ADHERENT BANDAGE, ELAST,+5"/YARD F 00000.78 07012024 99999999 1 A6455 SELF-ADHERRENT BANDAGE + 3" WIDTH/YARD F 00001.43 07012024 99999999 1 A6456 ZINC PASTE BANDAGE; PER YARD F 00001.32 07012024 99999999 1 A6457 TUBULAR DRESSING F 00001.50 07012024 99999999 1 A6501 COMPRESSION BURN GARMENT BODY SUIT M 00000.00 06112012 99999999 1 A6502 COMPRESSION BURN GARMENT CHIN STRAP M 00000.00 06112012 99999999 1 A6503 COMPRESSION BURN GARMENT,FACIAL HOOD M 00000.00 06112012 99999999 1 A6504 COMPRESSION BURN GARMENT,GLOVE TO WRIST M 00000.00 06112012 99999999 1 A6505 COMPRESSION BURN GARMENT GLOVE TO ELBOW M 00000.00 06112012 99999999 1 A6506 COMPRESSION BURN GARMENT,GLOVE TO AXILLA M 00000.00 06112012 99999999 1 A6507 COMPRESSION BURN GARMENT FOOT TO KNEE M 00000.00 06112012 99999999 1 A6508 COMPRESSION BURN GARMENT FOOT/THIGH M 00000.00 06112012 99999999 1 A6509 COMPRESSION BURN GARMENT VEST M 00000.00 06112012 99999999 1 A6510 COMPRESSION BURN GARMENT,LEOTARD M 00000.00 06112012 99999999 1 A6511 COMPRESSION BURN GARMENT, PANTY M 00000.00 06112012 99999999 1 A6512 COMPRESSION BURN GARMENT,UNCLASSIFIED M 00000.00 06112012 99999999 1 A6513 COMPRESS BURN MASK FACE/NECK F 00030.50 07012024 99999999 1 A6520 G COM GARMNT GLOVE NGHTTIME F 00116.36 07012024 99999999 1 A6521 G COM GARMNT GLOVE NGHT CUST F 00461.68 07012024 99999999 1 A6522 G COM GARMENT ARM NIGHTTIME F 00282.72 07012024 99999999 1 A6523 G COM GARMENT ARM NGHT CUSTM F 00670.80 07012024 99999999 1 A6524 G COM GARMNT LWR LEG/FT NGHT F 00352.73 07012024 99999999 1 A6525 G COM GARM LWRLEG/FT NGT CUS F 00712.10 07012024 99999999 1 A6526 G COM GARMT FULL LEG/FT NGHT F 00637.71 07012024 99999999 1 A6527 G GARMT FULL LEG/FT NGHT CUS F 01172.68 07012024 99999999 1 A6528 G COM GARMENT BRA NIGHTTIME F 00613.20 07012024 99999999 1 A6529 G COM GARMT BRA NIGHT CUSTM F 00968.96 07012024 99999999 1 A6530 COMPRESSION STOCKING BK18-30 F 00031.66 07012025 99999999 1 A6531 COMPRESS STKING BK30-40 SURG F 00030.50 07012024 99999999 1 A6532 COMPRESS STKING BK40-50 SURG F 00042.34 07012024 99999999 1 A6533 GC STOCKING THIGHLNGTH 18-30 F 00043.95 07012025 99999999 1 A6534 GC STOCKING THIGHLNGTH 30-40 F 00042.34 07012024 99999999 1 A6535 GC STOCKING THIGHLNGTH 40-50 F 00042.34 07012024 99999999 1 A6536 GC STOCKING FULL LNGTH 18-30 F 00042.34 07012024 99999999 1 A6537 GC STOCKING FULL LNGTH 30-40 F 00042.34 07012024 99999999 1 A6538 GC STOCKING FULL LNGTH 40-50 F 00042.34 07012024 99999999 1 A6539 GC STOCKING WAISTLNGTH 18-30 F 00042.34 07012024 99999999 1 A6540 GC STOCKING WAISTLNGTH 30-40 F 00042.34 07012024 99999999 1 A6541 GC STOCKING WAISTLNGTH 40-50 F 00042.34 07012024 99999999 1 A6544 GC STOCKING GARTER BELT F 00042.34 07012024 99999999 1 A6545 GRAD COM NON-ELASTIC BK SURG F 00116.28 07012025 99999999 1 A6549 GRAD COM GARM NOC DAY USE M 00000.00 06112012 99999999 1 A6550 DRESSING FOR NEG. PRESSURE; EACH F 00026.29 07012024 99999999 1 A6552 GRAD COM STOCKING BK 30-40 F 00053.35 07012024 99999999 1 A6553 G COM STCKING BK 30-40 CUSTM F 00208.31 07012024 99999999 1 A6554 GRAD COM STOCKING BK 40+ F 00073.35 07012024 99999999 1 A6555 G COM STCKING BK 40+ CUSTM F 00208.31 07012024 99999999 1 A6556 G COM STCKING THGH18-30 CUST F 00285.47 07012024 99999999 1 A6557 G COM STCKING THGH30-40 CUST F 00285.47 07012024 99999999 1 A6558 G COM STCKING THGH 40+ CUST F 00294.60 07012024 99999999 1 A6559 G STCKNG FULL/CHAP18-30 CUST M 00000.00 01012024 99999999 1 A6560 G STCKNG FULL/CHAP30-40 CUST M 00000.00 01012024 99999999 1 A6561 G STOCKNG FULL/CHAP 40+ CUST M 00000.00 01012024 99999999 1 A6562 G COM STCKNG WAIST18-30 CUST F 00934.28 07012024 99999999 1 A6563 G COM STCKNG WAIST30-40 CUST F 00934.28 07012024 99999999 1 A6564 G COM STCKNG WAIST 40+ CUST F 01006.43 07012024 99999999 1 A6565 GRAD COMP GAUNTLET CUSTOM F 00161.43 07012024 99999999 1 A6566 GRAD COM GARMENT NECK/HEAD F 00234.41 07012024 99999999 1 A6567 G COM GARMENT NECK/HEAD CUST F 00736.50 07012024 99999999 1 A6568 G COM GARMENT TORSO/SHLDR F 00152.98 07012024 99999999 1 A6569 G COM GARMNT TORSO/SHDR CUST F 00871.14 07012024 99999999 1 A6570 GRAD COM GARMENT GENITAL F 00104.23 07012024 99999999 1 A6571 G COM GARMENT GENITAL CUSTM F 00626.47 07012024 99999999 1 A6572 GRAD COM GARMENT TOE CAPS F 00096.72 07012024 99999999 1 A6573 GRAD COM GARMNT TOE CAP CUST F 00229.51 07012024 99999999 1 A6574 CUSTOM GRADIENT SLEEV/GLOV F 00292.60 07012024 99999999 1 A6575 GRADIENT COMP SLEEV/GLOV F 00094.82 07012024 99999999 1 A6576 CUSTOM GRAD COM SLEEVE MED F 00179.58 07012024 99999999 1 A6577 CUSTOM GRAD CM SLEEVE HEAVY F 00148.63 07012024 99999999 1 A6578 GRADIENT COMP SLEEVE F 00073.20 07012024 99999999 1 A6579 CUSTOM GRAD COM GLOVE MED F 00288.25 07012024 99999999 1 A6580 CUSTOM GRAD COM GLOVE HEAVY F 00286.13 07012024 99999999 1 A6581 GRADIENT COMP GLOVE F 00067.16 07012024 99999999 1 A6582 GRADIENT COMP GAUNTLET F 00044.80 07012024 99999999 1 A6583 GRAD COM WRAP W STRAPS BK F 00147.34 07012024 99999999 1 A6584 GRAD COM WRAP W STRAPS M 00000.00 01012024 99999999 1 A6585 GRAD COM WRAP W STRAPS AK F 00174.46 07012024 99999999 1 A6586 GRAD COM WRAP W STRAPS LEG F 00513.98 07012024 99999999 1 A6587 GRAD COM WRAP W STRAPS FOOT F 00067.32 07012024 99999999 1 A6588 GRAD COM WRAP W STRAPS ARM F 00224.40 07012024 99999999 1 A6589 GRAD COM WRAP W STRAPS BRA F 00088.59 07012024 99999999 1 A6590 Urinary cath disp suc pump F 00409.90 12012025 99999999 1 A6591 Urinary cath suc pump F 00083.27 12012025 99999999 1 A6593 GRAD COM ACCESSORY GMT_WRAP M 00000.00 01012024 99999999 1 A6594 G COMP BANDGE LINER LWR EXTR F 00032.26 07012024 99999999 1 A6595 G COMP BANDGE LINER UPR EXTR F 00031.72 07012024 99999999 1 A6596 G COMP BANDGE CONFORM GAUZE F 00000.16 07012024 99999999 1 A6597 G COMP BANDAGE LONG STRETCH F 00001.43 07012024 99999999 1 A6598 G COMP BANDAGE MED STRETCH F 00000.69 07012024 99999999 1 A6599 G COMP BANDAGE SHORT STRETCH F 00001.57 07012024 99999999 1 A6600 G COM BANDGE HGH DN FOAM SHT F 00002.82 07012024 99999999 1 A6601 G COM BANDGE HGH DN FOAM PAD F 00003.17 07012024 99999999 1 A6602 G COM BANDGE HGH DN FOAMROLL F 00004.63 07012024 99999999 1 A6603 G COM BANDGE LOW DN FOAMCHNL F 00002.17 07012024 99999999 1 A6604 G COM BANDGE LOW DN FOAM FLT F 00001.27 07012024 99999999 1 A6605 G COM BANDAGE PADDED FOAM F 00001.45 07012024 99999999 1 A6606 G COM BANDAGE PADDED TEXTILE F 00004.30 07012024 99999999 1 A6607 G COM BANDAGE TUB PROTCT LYR F 00001.14 07012024 99999999 1 A6608 G COM BANDAGE TUB PROTCT PAD F 00004.79 07012024 99999999 1 A6609 G COMPRESSION BANDAGING M 00000.00 01012024 99999999 1 A6610 G COM STCKING BK 18-30 CUSTM F 00208.31 07012024 99999999 1 A7000 CANNISTER,DISPOSABLE,USED W/SUCTION PUMP F 00008.83 07012024 99999999 R A7001 CANNISTER,NON-DISPOSABLE USED W/SUCTION F 00032.58 RR 07012024 99999999 1 A7002 TUBING, USED WITH SUCTION PUMP F 00003.66 07012024 99999999 1 A7003 ADMINISTRATION SET,W/SMALL VOL NEBULIZER F 00002.61 07012024 99999999 1 A7004 SMALL VOL. PNEUMATIC NEB. DISPOSABLE F 00001.72 07012024 99999999 1 A7005 ADM. SET W/SMALL VOL NEB,NON-DISPOSABLE F 00029.45 07012024 99999999 1 A7006 ADMIN. SET W/SM VOL FILTERED NEB F 00009.10 07012024 99999999 1 A7007 LARGE VOL,NEB,DISP, UNFILLED USE W/COMPR F 00004.41 07012024 99999999 1 A7008 LARGE VOL NEB,DISPOSABLE USE W/COMPRESS F 00010.51 07012024 99999999 1 A7009 RESERVOIR BOTTLE, NON-DISPOSABLE F 00040.17 07012024 99999999 1 A7010 CORRUGATED TUBING, DISPOS. USE W/NEB F 00022.53 07012024 99999999 1 A7012 WATER COLLECT. DEVICE USE Q/LRG NEB. F 00003.62 07012024 99999999 1 A7013 FILTER,DISPOSABLE,W/AEROSOL COMPRESSOR F 00000.78 07012024 99999999 1 A7014 FILTER,NON-DISPOS,USE W/AEROSOL COMPRESS F 00004.28 07012024 99999999 1 A7015 AEROSOL MASK, USED WITH DME NEBULIZER F 00001.79 07012024 99999999 1 A7016 DOME AND MOUTHPIECE, USED W/SM VOL NEB F 00006.91 07012024 99999999 1 A7017 NEBULIZER, DURABLE, NOT USED WITH OXYGEN F 00128.06 07012024 99999999 R A7017 NEBULIZER,DURABLE NOT USED WITH OXYGEN F 00012.80 RR 07012024 99999999 1 A7018 WATER, DISTILLED, 1000ML F 00000.36 07012024 99999999 1 A7020 INTERFACE FOR COUGH STIMULATING DEVICE F 00019.03 07012024 99999999 1 A7025 HIGH FREQUENCY CHEST OCCILATION VEST F 00057.20 07012024 99999999 1 A7026 HIGH FREQ.OCILL.DEVICE SYSTEM HOSE F 00029.69 07012024 99999999 1 A7027 COMBO ORAL/NASAL MASK,USED WITH CPAP,EA F 00181.54 07012024 99999999 1 A7028 REPLC ORAL CUSHION,ORAL/NASAL MASK,EA F 00048.22 07012024 99999999 1 A7029 RPLC NASAL PILLOW, ORAL/NASAL MASK,PR F 00019.70 07012024 99999999 1 A7030 FULL MASK USED WITH POSITIVE AIRWAY DEV. F 00181.26 07012024 99999999 1 A7031 FACE MASK INTERFACE REPLACEMENT F 00067.04 07012024 99999999 1 A7032 CUSHION FOR USE ON NASAL MASK INTERFACE F 00023.52 07012024 99999999 1 A7033 PILLOW FOR USE ON NASAL CANNULA TYPE F 00023.52 07012024 99999999 1 A7034 NASAL INTERFACE USED WITH AIRWAY DEVICE F 00076.78 07012024 99999999 1 A7035 HEADGEAR USED WITH AIRWAY DEVICE F 00038.18 07012024 99999999 1 A7036 CHINSTRAP USED WITH AIRWAY DEVICE F 00017.40 07012024 99999999 1 A7037 TUBING USED WITH AIRWAY PRESSURE DEVICE F 00005.18 07012024 99999999 1 A7038 FILTER DISPOSABLE,USED WITH AIRWAY DEVIC F 00005.18 07012024 99999999 1 A7039 FILTER,NON-DISP.USED WITH AIRWAY DEVICE F 00014.72 07012024 99999999 1 A7044 ORAL INTERFACE WITH PRESSURE DEVICE F 00116.18 07012024 99999999 1 A7045 EXHALATION PORT W/W/O SWIVEL USED W ACCE F 00018.70 07012024 99999999 1 A7046 WATER CHAMBER/HUMIDIFIER/REPLACE;EACH F 00018.74 07012024 99999999 1 A7047 Oral interface used with respiratory suc F 00127.42 07012024 99999999 1 A7048 VACUUM DRAINAGE COLLECTION UNIT AND TUBI F 00045.03 07012024 99999999 1 A7501 TRACHEOSTOMA VALVE, INCLUDING DIAPHRAGM F 00100.33 07012024 99999999 1 A7502 REPLAC. DIAPHRAGM/FACEPLATE,TRACH VALVE F 00047.70 07012024 99999999 1 A7503 FILTER HOLDER/CAP,REUSABLE FOR TRACHSTOM F 00010.82 07012024 99999999 1 A7504 FILTER FOR TRACHEOSTOMA F 00000.64 07012024 99999999 1 A7505 HOUSING, REUSABLE FOR TRACHEOSTOMA VALVE F 00004.47 07012024 99999999 1 A7506 ADHESIVE DISC FOR TRACHEOSTOMA VALVE F 00000.31 07012024 99999999 1 A7507 FILTER HOLDER AND FILTER FOR TRACHEOSTOM F 00002.37 07012024 99999999 1 A7508 HOUSING W/ADHESIVE FOR TRACHEOSTOMA F 00002.74 07012024 99999999 1 A7509 FILTER HOLDER AND FILTER HOUSING F 00001.34 07012024 99999999 1 A7520 TRACHEOSTOMY/LARYN TUBE,NON CUFF;EACH F 00050.95 07012024 99999999 1 A7521 TRACHEOSTOMY/LARYN TUBE, CUFFED,EACH F 00048.57 07012024 99999999 1 A7522 TRACHEOSTOMY/LARYN TUBE,STAIN. STEEL; EA F 00046.62 07012024 99999999 1 A7524 TRACHEOSTOMA STENT/STUD BUTTON;EACH F 00047.70 07012024 99999999 1 A7525 TRACHEOSTOMY MASK; EACH F 00002.30 07012024 99999999 1 A7526 TRACHEOSTOMY TUBE COLLAR/HOLDER;EACH F 00003.48 07012024 99999999 1 A7527 TRACH/LARYNGECTOMY TUBE PLUG/STOP,EACH F 00003.58 07012024 99999999 1 A8000 SOFT PROTECT HELMET PREFAB F 00152.87 07012025 99999999 1 A8001 HARD PROTECT HELMET PREFAB F 00152.87 07012025 99999999 1 A8002 SOFT PROTECT HELMET CUSTOM M 00000.00 07012021 99999999 1 A8003 HARD PROTECT HELMET CUSTOM M 00000.00 07012021 99999999 1 A8004 REPL SOFT INTERFACE, HELMET M 00000.00 07012021 99999999 1 A9152 SINGLE VITAMIN/MINERAL/TRACE ELEMENT M 00000.00 06112012 99999999 1 A9153 MULTIPLE VITAMINS M 00000.00 06112012 99999999 1 A9274 EXT AMB INSULIN DELIV SYS, DISP, EACH M 00000.00 10012022 99999999 1 A9276 Disposable sensor, cgm sys M 00000.00 11012020 99999999 1 A9277 External transmitter, cgm M 00000.00 01012020 99999999 1 A9278 External receiver, cgm sys M 00000.00 01012020 99999999 1 A9279 MONITORING FEATURE/DEVICE NOC M 00000.00 01012024 99999999 1 A9280 ALERT/ALARM DEVICE,NOS M 00000.00 06112012 99999999 R A9280 ALERT/ALARM DEVICE,NOS M 00000.00 RR 06112012 99999999 1 A9283 FT PRESS OFF LOAD/SUPPORT DEVIE, ANY,EA F 01295.82 07012025 99999999 1 A9900 MISC. DME SUPPLY OF ANOTHER HCPCS CODE M 00000.00 06112012 99999999 1 A9999 MISCELLANEOUS DME SUPPLY OR ACCESSORY NO M 00000.00 01012004 99999999 1 B4034 ENTERAL FEEDING SUPPLY KIT;SYRINGE FED F 00005.47 07012024 99999999 1 B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED F 00010.29 07012024 99999999 1 B4036 ENTERAL FEEDING SUPPLY KIT;GRAVITY FED F 00007.13 07012024 99999999 1 B4081 NASOGASTRIC TUBING WITH STYLET F 00027.83 07012024 99999999 1 B4082 NASOGASTRIC TUBING WITHOUT STYLET (EACH) F 00015.36 07012024 99999999 1 B4083 STOMACH TUBE- LEVINE TYPE F 00002.27 07012024 99999999 1 B4087 GAST/JEJUN TUBE, STAND,ANY MAT/TYPE, EA F 00037.19 07012024 99999999 1 B4088 GAST/J TUBE, LOW PROF,ANY MAT/TYPE, EA F 00193.96 07012024 99999999 1 B4100 FOOD THICKENER, ADMINISTERED ORALLY M 00000.00 06112012 99999999 1 B4102 ENTERAL FORMULA M 00000.00 10012023 99999999 1 B4103 ENTERAL FORMULA F 00005.00 07012024 99999999 1 B4104 ADDITIVE FOR FORMULA M 00000.00 10012023 99999999 1 B4105 In-line cartridge containing digestive e F 00130.83 07012024 99999999 1 B4148 Enteral feeding supply kit; elastomeric M 00000.00 10012023 99999999 1 B4149 ENTERAL FORMULA F 00001.60 07012024 99999999 1 B4150 ENTERAL FORMULAE; CATEGORY I: INTACT PRO F 00000.65 07012024 99999999 1 B4152 ENTERAL FORMULAE; CATEGORY II: INTACT PR F 00000.54 07012024 99999999 1 B4153 ENTERAL FORMULAE; CATEGORY III: HYDROLIZ F 00001.93 07012024 99999999 1 B4154 ENTERAL FORMULAE; CATEGORY IV: DEFINED F F 00001.16 07012024 99999999 1 B4155 ENTERAL FORMULAE; CATEGORY V: MODULAR CO F 00001.04 07012024 99999999 1 B4157 ENTERAL FORMULA W PROTEINS,FATS,CARBS,VI M 00000.00 10012023 99999999 1 B4158 ENTERAL FORM FOR PEDS, PROTEINS,FATS,CAR M 00000.00 10012023 99999999 1 B4159 ENTERAL FORM, PED,SOY BASED,PROTEINS,FAT M 00000.00 10012023 99999999 1 B4160 ENTERAL FORM,PED INCLUDES PROT,FATS,CARB M 00000.00 10012023 99999999 1 B4161 ENT FORM,PED, HYDROLYZED/AMINO ACIDS & P M 00000.00 10012023 99999999 1 B4162 ENT FORM,SPECIAL METABOLIC NEEDS FOR INH M 00000.00 10012023 99999999 1 B4164 PNS;50% DEXTROSE SOLUTION 500ML F 00013.89 07012024 99999999 1 B4168 PNS; AMINO ACID 3.5% 500ML F 00038.58 07012024 99999999 1 B4172 PNS; AMINO ACID 5.5% THRU 7% 500 ML F 00030.60 07012024 99999999 1 B4176 PNS; AMINO ACID GREATER THAN 7% 500 ML F 00078.71 07012024 99999999 1 B4178 PNS; AMINO ACID GREATER THAN 8.5, 500 ML F 00078.71 07012024 99999999 1 B4180 PARENTL NUTRIN SOLN CARBOHYDRATES,ANY ST F 00031.19 07012024 99999999 1 B4185 PARENTERAL SOL 10 GM LIPIDS F 00011.80 07012024 99999999 1 B4187 Omegaven, 10 grams lipids F 00013.06 07012024 99999999 1 B4189 PNS; COMPOUNDED AMINOACID/CARBOHYD 10-51 F 00055.02 07012024 99999999 1 B4193 PNS; COMPOUNDED AMINO ACID/CARBOHYD. 52- F 00068.58 07012024 99999999 1 B4197 PNS; COMPOUNDED AMINO ACID/CARBOHYD. 74 F 00080.58 07012024 99999999 1 B4199 PNS;COMPOUNDED AMINO ACID/CARBOHYD, OVER F 00091.93 07012024 99999999 1 B4220 PARENTERAL NUTRITION SUPPLY KIT; PREMIX, F 00010.65 07012024 99999999 1 B4224 PARENTRAL NUTRITION SUPPLY KIT FOR 1 MON F 00643.00 07012024 99999999 1 B5000 PARENTERAL NUTRITION SOLUTION: COMPOUNDE F 00015.82 07012024 99999999 1 B5100 PARENTERAL NUTRITION SOLUTION: COMPOUNDE F 00006.18 07012024 99999999 1 B5200 PARENTERAL NUTRITION SOLUTION: COMPOUNDE M 00000.00 06012023 99999999 1 B9002 ENTERAL NUTRITION INFUSION PUMP W/ALARM- F 01145.59 07012024 99999999 R B9002 ENTERAL NUTRITION INFUSION PUMP W/ALARM- F 00114.57 RR 07012024 99999999 R B9004 PARENTERAL NUTRITION INFUSION PUMP,PORTA F 00335.79 RR 07012024 99999999 1 B9998 NOC FOR ENTERNAL SUPPLIES M 00000.00 10012007 99999999 1 B9999 PARENTERAL SUPPLIES NOT OTHERWISE CLASSI M 00000.00 07011985 99999999 1 E0100 CANE OF ANY MATERIAL ADJ OR FIXED W/TIP F 00020.11 07012024 99999999 1 E0105 CANE QUAD 3/PRONGED, ANY MATERIAL, ADJ O F 00043.72 07012024 99999999 1 E0110 CRUTCHES FOREARM ANY MATERIA. ADJ OR FIX F 00074.06 07012024 99999999 1 E0111 CRUTCH FOREARM, INCLUDES CRUTCHES OF VAR F 00037.04 07012024 99999999 1 E0112 CRUTCHES UNDERARM WOOD ADJ OR FIXED W/PA F 00022.05 07012024 99999999 1 E0113 CRUTCH UNDERARM, WOOD ADJUSTABLE OR FIXE F 00018.63 07012024 99999999 1 E0114 CRUTCHES,UNDERARM ALUM ADJ OR FIXED(PR) F 00041.24 07012024 99999999 1 E0116 CRUTCH, UNDERARM F 00022.52 07012024 99999999 1 E0117 CRUTCH UNDERARM,ARTICULATING F 00192.91 07012024 99999999 1 E0118 CRUTCH SUBSTITUTE,LOWER LEG,W/WO WHEELS, F 00335.46 07012024 99999999 R E0118 CRUTCH SUBSTITUTE,LOWER LEG,W/WO WHEELS, F 00033.55 RR 07012024 99999999 1 E0130 WALKER, RIGID (PICKUP), ADJUSTABLE OR FI F 00064.99 07012024 99999999 1 E0135 WALKER, FOLDING (PICKUP), ADJUSTABLE OR F 00074.44 07012024 99999999 1 E0140 WALKER W TRUNK SUPPORT,ADJ/FIXED HEIGHT F 00346.61 07012024 99999999 R E0140 WALKER, WHEELED, WITH OR WITHOUT SEAT F 00034.66 RR 07012024 99999999 1 E0141 WALKER WHEELED, WITHOUT SEAT F 00093.62 07012024 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E0157 CRUTCH ATTACHMENT, WALKER, EACH F 00066.91 07012024 99999999 1 E0158 LEG EXTENSIONS FOR A WALKER F 00021.66 07012024 99999999 1 E0159 BRAKE ATTACHMENT FOR WHEELED WALKER F 00017.07 07012024 99999999 1 E0160 SITZ BATH, PORTABLE, FITS OVER COMMODE S F 00027.57 07012024 99999999 1 E0161 SITZ BATH, PORTABLE, FITS OVER COMMODE S F 00021.30 07012024 99999999 1 E0162 SITZ BATH CHAIR F 00128.19 07012024 99999999 1 E0163 COMMODE CHAIR, STATIONARY, WITH FIXED AR F 00102.22 07012024 99999999 1 E0165 COMMODE CHAIR, STATIONARY, WITH DETACHAB F 00186.26 07012024 99999999 R E0165 COMMODE CHAIR,STATIONARY, W DETACH ARMS F 00018.62 RR 07012024 99999999 1 E0167 PAIL OR PAN FOR USE WITH COMMODE CHAIR F 00011.12 07012024 99999999 1 E0168 EXTRA WIDE COMMODE, W OR WO ARMS F 00152.72 07012024 99999999 R E0168 EXTRA WIDE COMMODE W OR W/O ARMS F 00015.28 RR 07012024 99999999 1 E0170 COMMODE CHAIR ELECTRIC F 00505.93 07012024 99999999 1 E0171 COMMODE CHAIR NON-ELECTRIC F 00505.93 07012024 99999999 1 E0172 SEAT LIFT MECHANISM TOILET F 00505.93 07012024 99999999 1 E0175 FOOT REST, FOR USE WITH COMMODE CHAIR, E F 00063.27 07012024 99999999 1 E0181 PRESSURE PAD, ALTERNATING WITH PUMP, HEA F 00230.05 07012024 99999999 R E0181 PRESSURE PAD,ALTERNATING WITH PUMP,HEAVY F 00023.00 RR 07012024 99999999 R E0182 PUMP FOR ALTERNATING PRESSURE PAD F 00026.22 RR 07012024 99999999 1 E0182 PUMP FOR ALTERNATING PRESSURE PAD F 00262.34 07012024 99999999 1 E0184 DRY PRESSURE MATTRESS F 00161.70 07012024 99999999 1 E0185 GEL PRESSURE PAD FOR MATTRESS F 00283.85 07012024 99999999 1 E0186 AIR PRESSURE MATTRESS F 00062.74 07012024 99999999 1 E0187 WATER PRESSURE MATTRESS F 00392.43 07012024 99999999 1 E0188 SYNTHETIC SHEEPSKIN PAD FOR WHEELCHAIR, F 00025.72 07012024 99999999 1 E0189 LAMBSWOOL SHEEPSKIN PAD, ANY SIZE, PURCH F 00049.24 07012024 99999999 1 E0190 POSITIONING CUSHION/PILLOW/WEDGE/ANY M 00000.00 09012018 99999999 1 E0191 HEEL OR ELBOW PROTECTOR, EACH F 00008.12 07012024 99999999 R E0193 POWERED AIR FLOTATION BED (LOW AIR LOSS) F 00863.16 RR 07012024 99999999 R E0196 GEL PRESSURE MATTRESS F 00030.78 RR 07012024 99999999 1 E0196 GEL PRESSURE MATTRESS F 00307.84 07012024 99999999 1 E0197 AIR PRESSURE PAD FOR MATTRESS F 00224.22 07012024 99999999 R E0197 AIR PRESSURE PAD FOR MATTRESS F 00022.42 RR 07012024 99999999 R E0198 WATER PRESSURE PAD FOR MATTRESS F 00019.04 RR 07012024 99999999 1 E0198 WATER PRESSURE PAD FOR MATTRESS F 00190.52 07012024 99999999 1 E0199 DRY PRESSURE PAD FOR MATTRESS F 00030.61 07012024 99999999 1 E0200 HEAT LAMP, W/O STAND, W/BULB OR INFRARED F 00069.36 07012024 99999999 R E0202 PHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOT F 00069.80 RR 07012024 99999999 R E0205 HEAT LAMP WITH STAND INCLUDES BULB OR IN F 00017.05 RR 07012024 99999999 1 E0205 HEATLAMP, WITH STAND, INCLUDES BULB, OR F 00170.67 07012024 99999999 1 E0210 ELECTRIC HEAT PAD, STANDARD F 00025.71 07012024 99999999 1 E0215 ELECTREC HEAT PAD, MOIST F 00067.69 07012024 99999999 1 E0217 WATER CIRCULATING HEAT PAD W/PUMP F 00474.31 07012024 99999999 1 E0221 INFRARED HEATING PAID SYSTEM F 02171.58 07012024 99999999 R E0221 INFRARED HEATING PAD SYSTEM F 00217.15 RR 07012024 99999999 R E0235 PARAFIN BATH UNIT,PORTABLE F 00016.20 RR 07012024 99999999 1 E0235 PARAFIN BATH UNIT, PORTABLE F 00162.06 07012024 99999999 1 E0240 BATH/SHOWER CHAIR, W/WO WHEELS,ANY SIZE M 00000.00 09012013 99999999 R E0240 BATH/SHOWER CHAIR, W/WO WHEELS, ANY SIZE M 00000.00 RR 06112012 99999999 1 E0245 TUB STOOL OR BENCH M 00000.00 09012013 99999999 1 E0247 TRANSFER BENCH FOR TUB/TOILET, W/WO OPEN M 00000.00 09012013 99999999 1 E0248 TRANSFER BENCH, HVY DUTY, TUB OR STOOL M 00000.00 09012013 99999999 1 E0250 HOSPITAL BED, WITH SIDE RAILS, FIXED HEI F 00852.59 07012024 99999999 R E0250 HOSPITAL BED, WITH SIDE RAILS, FIXED HEI F 00085.26 RR 07012024 99999999 R E0255 HOSP. BED W/SIDE RAILS VARIABLE HGHT. HI F 00102.46 RR 07012024 99999999 1 E0255 HOSP.BED W/SIDE RAILS VARIABLE HGT. HI-L F 01024.61 07012024 99999999 1 E0256 HOSPITAL BED,VAR.HT,HI-LO W/SIDE RAILS F 00796.29 07012024 99999999 R E0256 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, W/ F 00079.63 RR 07012024 99999999 R E0260 HOSP. BED W/SIDE RAILS SEMI-ELEC HEAD/FO F 00122.50 RR 07012024 99999999 1 E0260 HOSP. BED W/SIDE RAILS SEMI ELEC HEAD/FO F 01225.15 07012024 99999999 1 E0261 HOSPITAL BED, SEMI-ELECTRIC, W/SIDE RAIL F 01308.33 07012024 99999999 R E0261 HOSPITAL BED, SEMI-ELECTRIC, W/SIDE RAIL F 00130.82 RR 07012024 99999999 R E0265 HOSP.BED TOTAL ELEC HEAD,FT. AND HGT. AD F 00174.32 RR 07012024 99999999 1 E0265 HOSP.BED TOTAL ELEC. HEAD,FT. AND HGT. A F 01743.24 07012024 99999999 1 E0266 HOSP.BED W/SIDE RAILS TOTAL ELEC HD/FT/H F 01537.59 07012024 99999999 R E0266 HOSP.BED W/SIDE RAILS TOTAL ELEC HD/FT/H F 00153.75 RR 07012024 99999999 1 E0270 HOSPITAL BED, INSTITUTIONAL TYPE INCLUDE M 00000.00 09012018 99999999 1 E0271 MATTRESS, INNERSPRING F 00187.55 07012024 99999999 1 E0272 MATTRESS, FOAM RUBBER F 00112.46 07012024 99999999 1 E0276 BED PAN, STANDARD OR FRACTURE, METAL OR F 00010.47 07012024 99999999 R E0277 POWERED PRESSURE-REDUCING MATTRESS F 00675.93 RR 07012024 99999999 1 E0280 BED, CRADLE, ANY TYPE (PURCHASE ONLY) F 00036.45 07012024 99999999 1 E0290 HOSPITAL BED, FIXED HEIGHT, W/O SIDE RAI F 00651.84 07012024 99999999 R E0290 HOSPITAL BED, FIXED HEIGHT, W/O SIDE RAI F 00065.18 RR 07012024 99999999 R E0291 HOSPITAL BED, FIXED HEIGHT, W/O SIDE RAI F 00043.19 RR 07012024 99999999 1 E0291 HOSPITAL BED, FIXED HEIGHT, W/O SIDE RAI F 00431.92 07012024 99999999 1 E0292 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, W/ F 00732.99 07012024 99999999 R E0292 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, W/ F 00073.30 RR 07012024 99999999 R E0293 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, W/ F 00062.36 RR 07012024 99999999 1 E0293 HOSPITAL BED, VARIABLE HEIGHT, HI-LO W/O F 00623.70 07012024 99999999 1 E0294 HOSPITAL BED, SEMI-ELECTRIC, W/O SIDERAI F 01139.48 07012024 99999999 R E0294 HOSPITAL BED, SEMI-ELECTRIC, W/O SIDE RA F 00113.95 RR 07012024 99999999 R E0295 HOSPITAL BED, SEMI-ELECTRIC, W/O SIDE RA F 00111.06 RR 07012024 99999999 1 E0295 HOSPITAL BED, SEMI-ELECTRIC, W/O SIDE RA F 01110.66 07012024 99999999 1 E0296 HOSPITAL BED, TOTAL ELECTRIC, W/O SIDE R F 01432.06 07012024 99999999 R E0296 HOSPITAL BED, TOTAL ELECTRIC, W/O SIDE R F 00143.20 RR 07012024 99999999 R E0297 HOSPITAL BED, TOTAL ELECTRIC, W/O SIDE R F 00122.67 RR 07012024 99999999 1 E0297 HOSPITAL BED, TOTAL ELECTRIC, W/O SIDE R F 01226.89 07012024 99999999 1 E0300 PRDIATRIC CRIB, HOSP GRADE,FULLY ENCLOSE F 02727.39 07012024 99999999 R E0300 PEDIATRIC CRIB FULLY ENCLOSED F 00272.74 RR 07012024 99999999 R E0301 HOSPITAL BED,WEIGHT CAPACITY +350 LBS. F 00260.13 RR 07012024 99999999 1 E0301 HOSPITAL BED,WEIGHT CAPACITY +350 LBS. F 02601.34 07012024 99999999 1 E0302 HOSPITAL BED, WEIGHT CAPACITY + 600 LBS. F 05241.10 07012024 99999999 R E0302 HOSPITAL BED,WEIGHT CAPACITY +600 LBS. F 00397.09 RR 07012024 99999999 R E0303 HOSPITAL BED,CAP. +350,WITH MATTRESS F 00289.25 RR 07012024 99999999 1 E0303 HOSPITAL BED,CAP. +350,WITH MATTRESS F 03044.78 07012024 99999999 1 E0304 HOSPITAL BED,WT CAP. + 600 LBS/MATTRESS F 05414.27 07012024 99999999 R E0304 HOSPITAL BED,WT CAP. +600 LBS/MATTRESS F 00740.51 RR 07012024 99999999 1 E0305 BED SIDE RAILS, HALF LENGTH F 00016.98 07012024 99999999 1 E0310 BED SIDE RAILS, FULL LENGTH F 00159.68 07012024 99999999 1 E0325 URINAL, MALE, ANY MATERIAL F 00007.95 07012024 99999999 1 E0326 URINAL, FEMALE, ANY MATERIAL F 00008.29 07012024 99999999 1 E0328 HOSP BED,PED,MANUAL,FULL ENCLOS W/MAT M 00000.00 09012018 99999999 R E0328 HOSP BED,PED,MANUAL,FULL ENCLOS W/MAT M 00000.00 RR 06112012 99999999 R E0329 HOSP BED,PED,ELECT/SEMI,FULL ENCL W/MAT M 00000.00 RR 06112012 99999999 1 E0329 HOSP BED,PED,ELECT/SEMI,FULL ENCL W/MAT M 00000.00 09012018 99999999 1 E0371 NON-POWERED PRESS.RED. OVERLAY FOR MATT. F 04246.45 07012024 99999999 R E0371 NON-POWERED,PRESS,RED.OVERLAY MATTRESS F 00424.64 RR 07012024 99999999 R E0372 POWERED AIR OVERLAY FOR MATT.STANDARD F 00515.28 RR 07012024 99999999 1 E0372 POWERED AIR OVERLAY FOR MATTRESS, F 05152.43 07012024 99999999 1 E0373 NON-POWERED PRESS,RED. MATTRESS F 05870.49 07012024 99999999 R E0373 NON-POWERED PRESSURE RED. MATTRESS F 00587.05 RR 07012024 99999999 R E0424 STAT. COMP. GAS OXYGEN, RENTAL F 00181.71 RR 07012024 99999999 R E0431 PORT. GAS OXYGEN, RENTAL;AND SUPPLIES F 00030.55 RR 07012024 99999999 R E0433 PORT. LIQ. O2 SYSTEM, RENTAL; HOME F 00049.76 RR 07012024 99999999 R E0434 PORT LIQUID OXYGEN SYSTEM RENTAL F 00030.55 RR 07012024 99999999 R E0439 STAT. LIQUID OXYGEN SYSTEM, RENTAL F 00181.71 RR 07012024 99999999 1 E0441 OXYGEN CONTENTS, GASEOUS, MONTHLY SUPPLY F 00077.79 07012024 99999999 1 E0442 OXYGEN CONTENTS, LIQUID, PER MONTH F 00077.79 07012024 99999999 1 E0443 PORTABLE OXYGEN CONTENTS, GASEOUS,/MONTH F 00021.37 07012024 99999999 1 E0444 PORTABLE OXYGEN CONTENTS, LIQUID,/MONTH F 00021.37 07012024 99999999 R E0445 OXIMETER F 00298.36 RR 07012024 99999999 1 E0447 Portable oxygen contents, liquid, 1 mont F 00006.71 07012024 99999999 R E0465 HOME VENTILATOR; ANY TYPE; USED WITH INV F 00965.62 RR 07012024 99999999 R E0466 HOME VENTILATOR; ANY TYPE; USED WITH NON F 00965.62 RR 07012024 99999999 R E0468 Home vent dual fnct incl all M 00000.00 RR 04012024 99999999 R E0470 RESPIRATORY ASSIST DEVICE W/O BACK-UP F 00245.15 RR 07012024 99999999 R E0471 RESPIRATORY ASSIST DEVICE W BACK-UP F 00521.49 RR 07012024 99999999 1 E0471 RESPIRATORY ASSIST DEVICE W BACK-UP F 03075.08 07012024 99999999 R E0472 RESPIRATORY ASSIST USED W INVASIVE INTER F 00521.49 RR 07012024 99999999 1 E0480 PERCUSSOR, ELECTRIC OR PNEUMATIC, HOME M F 00306.12 07012024 99999999 R E0481 INTRAPULMONARY PERCUSSIVE DEVICE(IPV) M 00000.00 RR 06112012 99999999 R E0482 COUGH STIMULATING DEVICE, F 00307.38 RR 07012024 99999999 R E0483 HIGH FREQUENCY CHEST WALL OSCILLATION SY F 01185.19 RR 07012024 99999999 1 E0483 HIGH FREQUENCY CHEST WALL OSCILLATION SY F 13979.47 07012024 99999999 1 E0484 OSCILLATORY POSITIVE EXPIRATORY DEVICE F 00041.17 07012024 99999999 1 E0500 IPPB MACHINES ALL TYPES WITH BUILT-IN NE F 00684.04 07012024 99999999 R E0500 IPPB MACHINES, ALL TYPES, WITH BUILT-IN F 00068.40 RR 07012024 99999999 R E0550 HUMIDIFIER, DURABLE FOR EXTENSIVE SUPPLE F 00017.86 RR 07012024 99999999 1 E0550 HUMIDIFIER, DURABLE FOR EXTENSIVE SUPPLE F 00178.67 07012024 99999999 1 E0555 HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVAB F 00004.13 07012024 99999999 1 E0560 HUMIDIFIER, DURABLE DURING IPPB OR O2 DE F 00149.46 07012024 99999999 R E0560 HUMIDIFIER, DURABLE USED DURING IPPB OR F 00014.94 RR 07012024 99999999 1 E0561 HUMIDIFIER,NON-HEATED W PAP DEVICE F 00102.23 07012024 99999999 1 E0562 HUMIDIFIER,HEATED,USE W PAP DEVICE F 00287.77 07012024 99999999 R E0562 HUMIDIFIER,HEATED,USE W PAP DEVICE F 00028.78 RR 07012024 99999999 R E0565 COMPRESSOR,AIR POWER SOURCE F 00061.73 RR 07012024 99999999 1 E0565 COMPRESSOR, AIR POWER SOURCE F 00617.34 07012024 99999999 1 E0570 NEBULIZER WITH COMPRESSOR F 00179.48 07012024 99999999 R E0570 NEBULIZER WITH COMPRESSOR F 00017.95 RR 07012024 99999999 R E0572 AEROSOL COMP,ADJ. PRESS, FOR INTERM. USE F 00036.52 RR 07012024 99999999 R E0574 ULTRASONIC GEN, W/SM VOL NEBULIZER F 00038.58 RR 07012024 99999999 1 E0574 ULTRASONIC GEN,W/SM VOL NEBULIZER F 00385.82 07012024 99999999 1 E0575 NEBULIZER, SELF-CONTAINED ULTRASONIC F 00763.23 07012024 99999999 R E0575 NEBULIZER, SELF-CONTAINED ULTRASONIC F 00076.32 RR 07012024 99999999 R E0580 NEBULIZER,DURABLE,GLASS OR AUTOCLAVABLE F 00012.80 RR 07012024 99999999 1 E0580 NEBULIZER, DURABLE, GLASS OR AUTOCLAVABL F 00128.06 07012024 99999999 1 E0585 MEBULIZER WITH COMPRESSOR AND HEATER F 00279.16 07012024 99999999 R E0585 NEBULIZER, WITH COMPRESSOR AND HEATER F 00027.90 RR 07012024 99999999 R E0600 RESPIRATORY SUCTION PUMP,PORT OR STATION F 00033.74 RR 07012024 99999999 1 E0600 RESPIRATORY SUCTION PUMP,PORT OR STATION F 00337.34 07012024 99999999 1 E0601 NASAL CONTINOUS AIRWAY PRESSURE (CPAP) D F 01073.38 07012024 99999999 R E0601 NASAL CONTINOUS AIRWAY PRESSURE (CPAP) D F 00107.34 RR 07012024 99999999 1 E0605 VAPORIZER, ROOM TYPE, HOT OR COLD (PURCH F 00022.49 07012024 99999999 1 E0607 HOME BLOOD GLUCOSE MONITOR (PURCHASE ONL F 00061.92 07012024 99999999 1 E0617 EXTERNAL DEFIBRILLATOR WITH ANALYSIS F 03997.82 07012024 99999999 R E0617 EXTERNAL DEFIBRILLATOR WITH ANALYSIS F 00338.95 RR 07012024 99999999 R E0618 APNEA MONITOR,W/O RECORDING DEVICE F 00305.88 RR 07012024 99999999 R E0619 APNEA MONITOR WITH RECORDING FEATURE F 00305.88 RR 07012024 99999999 1 E0621 SLING OR SEAT PT LIFT CANVAS OR NYLON (E F 00075.63 07012024 99999999 1 E0627 SEAT LIFT MECHANISM INCORPORATED INTO CO F 00745.89 07012024 99999999 R E0627 SEAT LIFT MECHANISM INCORPORATED INTO CO F 00036.82 RR 07012024 99999999 R E0630 PATIENT LIFT, HYDRAULIC, WITH SEAT OR SL F 00113.16 RR 07012024 99999999 1 E0630 PATIENT LIFT, HYDRAULIC, WITH SEAT OR SL F 01131.69 07012024 99999999 1 E0635 PATIENT LIFT, ELECTRIC WITH SEAT OR SLIN F 01321.52 07012024 99999999 1 E0637 COMB SIT/STAND W SEAT LIFT,W/WO WHEELS F 02173.62 07012024 99999999 R E0637 COMB SIT/STAND W SEAT LIFT,W/WO WHEELS F 00217.37 RR 07012024 99999999 R E0638 STANDING FRAME,ANY SIZE,W/WO WHEELS F 00088.14 RR 07012024 99999999 1 E0638 STANDING FRAME,ANY SIZE,W/WO WHEELS F 00881.41 07012024 99999999 1 E0639 PT LIFT,MOVEABLE W DISASSEM & REASSEMBLY F 01352.56 07012024 99999999 1 E0640 PT LIFT,FIX SYS,ALL COMP/ACCESSORIES F 01352.56 07012024 99999999 1 E0641 MULTI-POSITION STND FRAM SYS F 02173.62 07012024 99999999 R E0641 MULTI-POSITION STND FRAM SYS F 00217.35 RR 07012024 99999999 R E0642 DYNAMIC STANDING FRAME F 00217.35 RR 07012024 99999999 1 E0642 DYNAMIC STANDING FRAME F 02173.62 07012024 99999999 1 E0650 PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME F 00706.12 07012024 99999999 R E0650 PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME F 00070.61 RR 07012024 99999999 R E0651 PNEUMATIC COMP.,SEGMENTAL FOR HOME F 00066.02 RR 07012024 99999999 1 E0651 PNEUMATIC COMP.,SEGMENTAL FOR HOME F 00660.06 07012024 99999999 1 E0652 PNEUMATIC COMP. W/CALIBRATED PRESS,HOME F 05064.94 07012024 99999999 R E0652 PNEUMATIC COMP. W/CALIBRATED PRESS,HOME F 00506.49 RR 07012024 99999999 1 E0655 PNEUMATIC APPLIANCE FOR USE WITH PNEUMAT F 00064.09 07012024 99999999 1 E0656 SEGMENTAL PNEUMATIC APPLIANCE, TRUNK F 00583.99 07012024 99999999 1 E0657 SEGMENTAL PNEUMATIC APPLIANCE, CHEST F 00548.63 07012024 99999999 1 E0660 PNEUMATIC APPLIANCE FOR USE WITH PNEUMAT F 00099.50 07012024 99999999 1 E0665 PNEUMATIC APPLIANCE FOR USE WITH PNEUMAT F 00092.75 07012024 99999999 1 E0666 PNEUMATIC APPLIANCE FOR USE WITH PNEUMAT F 00089.94 07012024 99999999 1 E0667 SEGMENTAL PNEU. APPL.FULL LEG F 00262.94 07012024 99999999 1 E0668 SEGMENTAL PNEU.APPL. FULL ARM F 00358.84 07012024 99999999 1 E0669 SEGMENTAL PNEU. APPL. HALF LEG F 00175.12 07012024 99999999 1 E0670 Segmental pneumatic appliance for use w/ F 01404.99 07012024 99999999 1 E0671 SEGMENTAL GRAD. PRESS,APPL,FULL LEG F 00396.81 07012024 99999999 1 E0672 SEGMENTAL GRAD. PRESS.APPL, FULL ARM F 00308.33 07012024 99999999 1 E0673 SEGMENTAL GRAD. PRESS. APPL, HALF LEG F 00256.21 07012024 99999999 R E0675 PNEUMATIC COMPRESSION DEVICE,HI-PRESSURE F 00322.51 RR 07012024 99999999 1 E0676 INTER LIMB COMPRESS DEV NOS M 00000.00 09012018 99999999 1 E0677 Non pneum seq comp trunk F 00075.66 12012025 99999999 R E0677 Non pneum seq comp trunk F 00007.57 RR 12012025 99999999 1 E0700 SAFETY EQUIPMENT (E.G., BELT, HARNESS, O M 00000.00 11012023 99999999 1 E0705 TRANSFER BOARD OR DEVICE F 00045.97 07012024 99999999 1 E0711 Ue enclosure restr rom M 00000.00 04012023 99999999 1 E0720 TENS, TWO LEAD, LOCALIZED STIMULATION F 00334.57 07012024 99999999 R E0720 TENS, TWO LEAD, LOCALIZED STIMULATION F 00033.45 RR 07012024 99999999 R E0730 TENS, FOUR LEAD, LARGER AREA/MULTIPLE NE F 00039.36 RR 07012024 99999999 1 E0730 TENS, FOUR LEAD, LARGER AREA/MULTIPLE NE F 00393.62 07012024 99999999 1 E0740 INCONTINENCE TRMT SYSTEM, PELVIC FLOOR S F 00503.89 07012024 99999999 R E0740 INCONTINENCE TRMT SYSTEM, PELVIC FLOOR S F 00050.39 RR 07012024 99999999 R E0745 NEUROMUSCULAR STIMULATOR, ELECTRONIC SHO F 00072.62 RR 07012024 99999999 1 E0747 OSTEOGENESIS STIMULATOR (NON-INVASIVE) F 03816.55 07012024 99999999 1 E0748 OSTEOGENESIS STIMULATOR, NONINVASIVE, SP F 03816.55 07012024 99999999 1 E0749 OSTEOGENESIS STIMULATOR (SURGICALLY IMPL F 02666.70 07012024 99999999 1 E0760 OSTEOGENESIS STIM. LOW INTEN. ULTRASOUND F 02992.16 07012024 99999999 R E0760 OSTEOGENSIS STIM.,ULTRASOUND F 00299.20 RR 07012024 99999999 1 E0762 TRANS ELEC JT STIM DEV SYS F 00108.57 07012024 99999999 1 E0764 FUNCTIONAL NEUROMUSCULARSTIM F 00334.57 07012024 99999999 1 E0770 FUNCTIONAL ELECTRICAL STIMULATOR, NOS M 00000.00 09012018 99999999 1 E0776 IV POLE, PURCHASE F 00110.00 07012024 99999999 R E0776 IV POLE (RENTAL) F 00010.99 RR 07012024 99999999 R E0779 AMBULATORY INFUSION PUMP >8HR/DAY RENTAL F 00006.68 RR 07012024 99999999 R E0780 AMBULATORY INFUSION PUMP RENTAL <8HR/DAY F 00006.68 RR 07012024 99999999 R E0781 AMBULATORY INFUSION PUMP F 00009.90 RR 07012024 99999999 R E0784 EXTERNAL AMBULATORY INFUSION PUMP RENTAL F 00412.43 RR 07012024 99999999 1 E0784 EXTERNAL AMBULATORY INFUSION PUMP, INSUL F 04124.36 07012024 99999999 1 E0787 EXTERNAL AMBULATORY INFUSION PUMP, INSUL M 00000.00 07012020 99999999 1 E0840 TRACTION FRAME, ATTACHED TO HEADBOARD, S F 00035.76 07012024 99999999 1 E0849 TRACT.EQUIP,CERV,FREE STANDING F 00516.29 07012024 99999999 R E0849 TRACT.EQUIP.CERVIC.FREE STANDING F 00051.63 RR 07012024 99999999 1 E0850 TRACTION STAND, FREE STANDING, SIMPLE CE F 00084.36 07012024 99999999 1 E0855 CERVICAL TRACTION EQUIP. W/OUT ADD.STAND F 00472.17 07012024 99999999 1 E0860 TRACTION EQUIPMENT, OVERDOOR, CERVICAL F 00030.34 07012024 99999999 1 E0870 TRACTION FRAME, ATTACHED TO FOOTBOARD, S F 00067.46 07012024 99999999 1 E0880 TRACTION STAND, FREE STANDING, SIMPLE EX F 00107.95 07012024 99999999 1 E0890 TRACTION FRAME, ATTACHED TO FOOTBOARD, S F 00067.46 07012024 99999999 1 E0900 TRACTION STAND, FREE STANDING, SIMPLE PE F 00107.49 07012024 99999999 1 E0910 TRAPEZE BARS AKA PT. HELPER,ATTACHED TO F 00156.11 07012024 99999999 R E0910 TRAPEZE BARS AKA PT. HELPER, ATTACHED TO F 00015.61 RR 07012024 99999999 R E0911 HD TRAPEZE BAR ATTACH TO BED W/GRAB BAR F 00047.89 RR 07012024 99999999 1 E0911 HD TRAPEZE BAR ATTACH TO BED F 00478.89 07012024 99999999 1 E0912 HD TRAPEZE BAR FREE STANDING F 01100.00 07012024 99999999 R E0912 HD TRAPEZE BAR FREE STANDING F 00110.00 RR 07012024 99999999 1 E0920 FRACTURE FRAME, ATTACHED TO BED, INCLUDE F 00259.74 07012024 99999999 R E0935 PASSIVE MOTION EXCERCISE DEVICE F 00021.54 RR 07012024 99999999 R E0936 CPM DEVICE, OTHER THAN KNEE M 00000.00 RR 06112012 99999999 R E0940 TRAPEZE BAR, FREE STANDING, COMPLETE WIT F 00027.95 RR 07012024 99999999 1 E0940 TRAPEZE BAR, FREE STANDING, COMPLETE WIT F 00279.57 07012024 99999999 1 E0942 TRACTION ACCESS: CERVICAL, HEAD HARNESS/ F 00018.39 07012024 99999999 1 E0944 TRACTION ACCESS: PELVIC BELT/HARNESS/BOO F 00036.14 07012024 99999999 1 E0945 TRACTION ACCESS: EXTREMITY BELT/HARNESS F 00033.74 07012024 99999999 1 E0950 WHEELCHAIR TRAY F 00084.42 07012024 99999999 1 E0951 WHEELCHAIR ATTACH: HEEL LOOP (EACH), PUR F 00017.99 07012024 99999999 1 E0952 WHEELCHAIR ATTACH: TOE LOOP (EACH) F 00017.99 07012024 99999999 1 E0953 WHEELCHAIR ATTACH: PNEUMATIC TIRE (EACH, F 00074.02 07012024 99999999 R E0953 WHEELCHAIR ACCESSORY, LATERAL THIGH OR K F 00007.40 RR 07012024 99999999 R E0954 WHEELCHAIR ACCESSORY, FOOT BOX, ANY TYPE F 00004.93 RR 07012024 99999999 1 E0954 SEMI-PNEUMATIC CASTER, EACH F 00049.33 07012024 99999999 1 E0955 WHEELCHAIR ACCESSORY,HEADREST,CUSHIONED F 00194.25 07012024 99999999 R E0955 WHEELCHAIR ACCESSORY,HEADREST,CUSHIONED F 00019.42 RR 07012024 99999999 1 E0956 WHEELCHAIR ACCESSORY,LATERAL TRUNK/HIP F 00094.71 07012024 99999999 1 E0957 WHEELCHAIR ACCESSORY,MEDIAL THIGH SUPPOR F 00132.54 07012024 99999999 1 E0958 WHEELCHAIR ATTACHMENT TO CONVERT ANY WHE F 00416.86 07012024 99999999 1 E0959 AMPUTEE ADAPTER (DEVICE USED TO COMPENSA F 00049.28 07012024 99999999 1 E0960 WHEELCHAIR ACCESSORY,SHOULDER HARNESS/ST F 00087.42 07012024 99999999 1 E0961 WHEELCHAIR ATTACH: BRAKE EXTENSION, PURC F 00022.11 07012024 99999999 1 E0966 WHEELCHAIR ATTACH: HOOK-ON HEADREST EXTE F 00068.18 07012024 99999999 1 E0967 WHEELCHAIR HAND RIMS WITH 8 VERTICAL RUB F 00072.01 07012024 99999999 1 E0968 COMMODE SEAT, WHEELCHAIR F 00017.12 07012024 99999999 1 E0969 NARROWING DEVICE, WHEELCHAIR F 00149.65 07012024 99999999 1 E0971 MANUAL WHEELCHAIR ACCESSORY F 00048.41 07012024 99999999 R E0971 MANUAL WHEELCHAIR ACCESSORY F 00004.84 RR 07012024 99999999 1 E0973 ADJUSTABLE HEIGHT DETACHABLE ARMS, DESK F 00109.84 07012024 99999999 1 E0974 GRADE-AID (DEVICE TO PREVENT ROLLING B F 00068.77 07012024 99999999 1 E0978 BELT, SAFETY W/AIRPLAINE BUCKLE, WHEELCH F 00034.85 07012024 99999999 R E0978 BELT, SAFETY W/AIRPLANE BUCKLE, WHEELCH F 00003.49 RR 07012024 99999999 1 E0980 SAFETY VEST, WHEELCHAIR F 00036.85 07012024 99999999 1 E0981 WHEELCHAIR ACCESSORY,SEAT UPHOL REPLACE F 00045.31 07012024 99999999 1 E0982 WHEELCHAIR ACCESSORY, BACK UPHOL REPLACE F 00047.08 07012024 99999999 1 E0983 MANUAL WC ACCESS,POWER ADD-ON,CONVERT F 02387.80 07012024 99999999 1 E0984 MANUAL WC ACCESS,POWER ADD-ON TO CONVERT F 01825.25 07012024 99999999 1 E0986 MAN W/C POWR ASSIST SYST F 06396.28 07012024 99999999 1 E0988 MANUAL W/C ACCESSORY, LEVER-ACTIVATED F 00309.86 07012024 99999999 1 E0990 WHEELCHAIR ASSESS.ELEVATING LEG REST F 00095.36 07012024 99999999 R E0990 WHEELCHAIR ACCESS. ELEVATING LEG REST F 00009.54 RR 07012024 99999999 1 E0992 SOLID SEAT INSERT F 00090.89 07012024 99999999 1 E0994 ARM REST,EACH F 00014.33 07012024 99999999 1 E0995 CALF REST, EACH F 00029.04 07012024 99999999 1 E1002 WHEELCHAIR ACCESS,POWER SEAT,TILT ONLY F 04222.08 07012024 99999999 R E1002 WHEELCHAIR ACCESS,POWER SEAT,TILT ONLY M 00000.00 RR 06112012 99999999 1 E1003 WHEELCHAIR ACCESS, RECLINE W/O SHEAR RED F 04941.87 07012024 99999999 1 E1004 WC ACCESS,POWER SEAT,RECLINE W MECH SHEA F 04877.02 07012024 99999999 1 E1005 WC ACCESS,POWER SEAT,RECLINE,POWER SHEAR F 05942.00 07012024 99999999 1 E1006 WC ACCESS,COMB TILT/RECLINE W/O SHEAR RE F 07316.24 07012024 99999999 1 E1007 WC ACCESS COMB TILT/RECLINE W MECH SHEAR F 09093.98 07012024 99999999 1 E1008 WC ACCESS COMB TILT/RECLINE W POWER SHEA F 09327.97 07012024 99999999 1 E1009 WHEELCHAIR,MECH.ELEV.LEG SYSTEM M 00000.00 07012021 99999999 1 E1010 WHEELCHAIR,POWER LEG ELEVATION SYSTEM F 02306.48 07012024 99999999 1 E1011 MOD.TO PED.WHEELCHAIR,WIDTH GROWTH M 00000.00 07012021 99999999 1 E1012 W/C ACCESSORY, ADDITION TO POWER SEATING F 01267.66 07012024 99999999 1 E1014 RECLINING BACK, ADDITION TO PED.WC F 00365.73 07012024 99999999 1 E1015 SHOCK ABSORBER FOR MANUAL CHAIR, EACH F 00111.65 07012024 99999999 1 E1016 SHOCK ABSORBER FOR POWER CHAIR F 00127.80 07012024 99999999 1 E1020 RESIDUAL LIMB SUPPORT NON-COUNTOURED F 00233.88 07012024 99999999 1 E1028 W/C MANUAL SWINGAWAY F 00198.46 07012024 99999999 R E1028 W/C MANUAL SWINGAWAY F 00019.85 RR 09012025 99999999 1 E1029 WHEELCHAIR VENTILATOR TRAY FIXED F 00381.59 07012024 99999999 1 E1030 WHEELCHAIR VENT.TRAY GIMBALED F 01203.28 07012024 99999999 1 E1031 ROLLABOUT CHAIR, ANY TYPE W/CASTERS 5 IN F 00321.81 07012024 99999999 R E1031 ROLLABOUT CHAIR, ANY TYPE, W/CASTERS 5 I F 00032.15 RR 07012024 99999999 1 E1036 PT TRANSFER SYS, X-WD, PT WT. 300 OR > F 09726.27 07012024 99999999 1 E1037 TRANSPORT CHAIR,PEDIATRIC SIZE F 01120.29 07012024 99999999 R E1037 PEDIATRIC TRANSPORT CHAIR F 00106.42 RR 07012024 99999999 R E1038 ADULT TRANSPORT CHAIR F 00020.10 RR 07012024 99999999 1 E1038 TRANSPORT CHAIR,ADULT SIZE F 00200.98 07012024 99999999 1 E1039 TRANSPORT CHAIR,ADULT,PT WT. 250 OR + F 00226.86 07012024 99999999 1 E1161 MANUAL ADULT TILT IN SPACE W/C F 02363.06 07012024 99999999 R E1161 ADULT MANUAL TILT IN SPACE W/C F 00236.30 RR 07012024 99999999 1 E1225 SEMI-RECLINING BACK FOR CUSTOMIZED WHEEL F 00327.01 07012024 99999999 1 E1226 FULL RECLINING BACK FOR CUSTOMIZED WHEEL F 00521.30 07012024 99999999 R E1226 FULL RECLINING BACK FOR CUSTOMIZED WHEEL F 00052.14 RR 07012024 99999999 1 E1227 SPECIAL HEIGHT ARMS FOR WHEELCHAIR F 00265.12 07012024 99999999 1 E1228 SPECIAL BACK HEIGHT FOR WHEELCHAIR F 00064.99 07012024 99999999 1 E1229 WC, PED SIZE,NOS M 00000.00 09012018 99999999 R E1229 WHEELCHAIR,PED.NOT OTHEWISE CLASSIFIED M 00000.00 RR 06112012 99999999 R E1231 WHEELCHAIR,PEDIATRIC,TILT IN SPACE M 00000.00 RR 06112012 99999999 1 E1231 WHEELCHAIR PEDIATRIC TILT IN SPACE M 00000.00 07012021 99999999 1 E1232 WHEELCHAIR,PED.TILT IN SPACE FOLDING F 02141.96 07012024 99999999 R E1232 WHEELCHAIR,PED.TILT IN SPACE,FOLDING F 00214.19 RR 07012024 99999999 R E1233 WHEELCHAIR,PED.TILT IN SPACE W/OUT SEAT F 00221.93 RR 07012024 99999999 1 E1233 WHEELCHAIR,PED.TILT IN SPACE,W/OUT SEAT F 02219.30 07012024 99999999 1 E1234 WHEELCHAIR,PED.TILT IN SPACE,W/OUT SEAT F 01932.23 07012024 99999999 R E1234 WHEELCHAIR,PED.TILT IN SPACE W/OUT SEAT F 00193.22 RR 07012024 99999999 R E1235 WHEELCHAIR,PED.REGID,ADJ.W/SEATING F 00186.06 RR 07012024 99999999 1 E1235 WHEELCHAIR,PED.RIGID,ADJUST.W/SEATING F 01860.57 07012024 99999999 1 E1236 WHEELCHAIR,PED.FOLDING,ADJUST,W/SEAT F 01641.35 07012024 99999999 R E1236 WHEELCHAIR,PED.FOLDING AJUSTABLE,W/SEAT F 00164.13 RR 07012024 99999999 R E1237 WHEELCHAIR,PED.RIGID,ADJUST.W/OUT SEAT F 00165.56 RR 07012024 99999999 1 E1237 WHEELCHAIR,PED.RIGID, W/OUT SEATING F 01655.70 07012024 99999999 1 E1238 WHEELCHAIR PED.SIZE,FOLD.ADJ.W/OUT SEAT F 01726.52 07012024 99999999 R E1238 WHEELCHAIR,PED.SIZE,FOLD.,ADJ.W/OUT SEAT F 00172.65 RR 07012024 99999999 R E1239 POWER WC,PEDIATRIC, NOT OTHERWISE SPECIF M 00000.00 RR 06112012 99999999 1 E1296 SPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOO F 00469.75 07012024 99999999 1 E1297 SPECIAL WHEELCHAIR SEAT DEPTH BY UPHOLST F 00099.94 07012024 99999999 1 E1298 SPECIAL WHEELCHAIR SEAT DEPTH AND/OR WID F 00472.30 07012024 99999999 1 E1310 WHIRLPOOL, NON-PORTABLE (BUILT-IN TYPE) F 02400.13 07012024 99999999 1 E1352 TUBING, UNSPECIFIED LENGTH M 00000.00 01012014 99999999 R E1352 Oxygen accessory, flow regulator capable M 00000.00 RR 09012018 99999999 1 E1353 REGULATOR WITH OR WITHOUT HUMIDIFIER - F 00031.58 07012024 99999999 1 E1355 OXYGEN ACCESSORY:RACK OR STAND (LG OR SM F 00023.78 07012024 99999999 R E1390 OXYGEN CONCENTRATOR F 00185.26 RR 07012024 99999999 R E1399 DURABLE MEDICAL EQUIPMENT, NOT OTHERWISE M 00000.00 RR 06112012 99999999 1 E1399 DURABLE MEDICAL EQUIPMENT, NOT OTHERWISE M 00000.00 06112012 99999999 1 E1500 CENTRIFUGE, FOR DIALYSIS M 00000.00 09012018 99999999 1 E1510 KIDNEY DIALYSATE DELIVERY SYST. KIDNEY M M 00000.00 09012018 99999999 R E1510 KIDNEY, DIALYSATE DELIVERY SYST. KIDNEY M 00000.00 RR 06112012 99999999 R E1520 HEPARIN INFUSION PUMP FOR DIALYSIS F 00038.11 RR 07012024 99999999 R E1530 AIR BUBBLE DETECTOR FOR DIALYSIS M 00000.00 RR 06112012 99999999 R E1540 PRESSURE ALARM FOR DIALYSIS M 00000.00 RR 06112012 99999999 R E1550 BATH CONDUCTIVITY METER FOR DIALYSIS M 00000.00 RR 06112012 99999999 R E1560 BLOOD LEAK DETECTOR FOR DIALYSIS M 00000.00 RR 06112012 99999999 R E1590 HEMODIALYSIS MACHINE UNIT OR CYCLER M 00000.00 RR 06112012 99999999 1 E1590 HEMODIALYSIS MACHINE UNIT OR CYCLER M 00000.00 09012018 99999999 1 E1592 AUTOMATIC INTERMITTENT PERITIONEAL DIALY F 09378.01 07012024 99999999 R E1592 AUTOMATIC INTERMITTENT PERITIONEAL DIALY F 00890.92 RR 07012024 99999999 R E1594 CYCLER DIALYSIS MACHINE/MO. F 00309.78 RR 07012024 99999999 R E1610 REVERSE OSMOSIS WATER PURIFICATION SYSTE M 00000.00 RR 06112012 99999999 R E1615 DEIONIZER WATER PURIFICATION SYSTEM M 00000.00 RR 06112012 99999999 R E1625 WATER SOFTENING SYSTEM M 00000.00 RR 06112012 99999999 1 E1625 WATER SOFTENING SYSTEM M 00000.00 09012018 99999999 1 E1629 Tablo hemodialysis system for the billab M 00000.00 01012022 99999999 1 E1630 RECIPROCATING, PERITONEAL DIALYSIS SYSTE M 00000.00 09012018 99999999 R E1630 RECIPROCATINS PERITONEAL DIALYSIS SYSTEM M 00000.00 RR 06112012 99999999 1 E1634 PERITONEAL DIALYSIS CLAMPS M 00000.00 06112012 99999999 1 E1637 HEMOSTATS FOR DIALYSIS, EACH M 00000.00 09012018 99999999 1 E1639 SCALE FOR DIALYSIS EACH M 00000.00 09012018 99999999 1 E1699 DIALYSIS EQUIPMENT, UNSPECIFIED, BY REPO M 00000.00 09012018 99999999 R E1699 DIALYSIS EQUIPMENT, UNSPECIFIED, BY REPO M 00000.00 RR 06112012 99999999 1 E1700 JAW MOTION REHABILITATION SYSTEM F 00329.25 07012024 99999999 1 E1701 REPLAC.CUSIONS FOR JAW MOTION SYSTEM F 00010.33 07012024 99999999 1 E1702 MEASURING SCALES FOR JAW MOTION SYSTEM F 00021.97 07012024 99999999 R E1800 DYNAMIC ADJ. ELBOW EXT/FLEX DEVICE F 00118.05 RR 07012024 99999999 R E1801 SPS/PASS ELBOW DEVICE F 00124.31 RR 07012024 99999999 R E1802 DYNAMIC ADJ.FOREARM PRONATION/SUPINATION F 00314.93 RR 07012024 99999999 R E1805 DYNAMIC ADJUSTABLE WRIST EXTENSION/FLEX F 00121.75 RR 07012024 99999999 R E1806 STATIC PROG STRETCH WRIST EXT/FLEX DEVIC F 00102.06 RR 07012024 99999999 R E1810 DYNAMIC ADJUSTABLE KNEE EXT/FLEX DEVICE F 00120.05 RR 07012024 99999999 R E1811 SPS/PASS KNEE DEVICE F 00129.24 RR 07012024 99999999 R E1812 KNEE EXT/FLEX W ACT RES CTRL F 00087.01 RR 07012024 99999999 R E1815 DYNAMIC ADJUSTABLE ANKLE EXT/FLEX DEVICE F 00127.85 RR 07012024 99999999 R E1816 SPS/PASS ANKLE DEVICE F 00137.85 RR 07012024 99999999 R E1818 SPS/PASS FOREARM DEVICE F 00134.04 RR 07012024 99999999 1 E1820 SOFT INTERFACE MAT. FOR EXT/FLEX DEVICE F 00074.30 07012024 99999999 1 E1821 REPLACEMENT SOFT INTERFACE MATERIAL/CUFF F 00101.42 07012024 99999999 R E1825 DYNAMIC ADJ.FINGER EXT/FLEX DEVICE F 00121.75 RR 07012024 99999999 R E1830 DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION F 00109.10 RR 07012024 99999999 1 E1831 STATIC PROGRESSIVE STRETCH TOE DEVICE F 00868.68 07012024 99999999 R E1840 DYNAMIC ADJ. SHOULDER FLEXION DEVICE F 00372.50 RR 07012024 99999999 R E1841 SPS/PASS SHOULDER DEVICE F 00472.65 RR 07012024 99999999 1 E1902 COMMUNICATION BOARD,NON-ELECTRIC M 00000.00 09012018 99999999 R E2000 GASTRIC SUCTION PUMP HOME MODEL F 00053.26 RR 07012024 99999999 1 E2100 BLOOD GLUCOSE MONITOR W/VOICE SYNTHESIZE F 00596.10 07012024 99999999 1 E2101 BLOOD GLUCOSE MONITOR W/BLOOD SAMPLE F 00247.93 07012024 99999999 R E2102 ADJU CGM RECEIVER/MONITOR M 00000.00 RR 04012022 99999999 R E2103 Non-adju cgm receiver/mon F 00027.37 RR 07012024 99999999 1 E2103 Non-adju cgm receiver/mon F 00273.63 07012024 99999999 1 E2201 MANUAL WC NON-STAND SEAT WIDTH 20-24 INC F 00385.26 07012024 99999999 1 E2202 MANUAL WC NON-STAND WIDTH 24-27INCHES F 00489.34 07012024 99999999 1 E2203 MANUAL WC NON-STAND SEAT DEPTH 20-22 INC F 00494.67 07012024 99999999 1 E2204 MANUAL WC,NON-STAND SEAT DEPTH 22-25 INC F 00839.91 07012024 99999999 1 E2205 HANDRIM W/OUT PROJECTIONS REPLACEMENT F 00032.14 07012024 99999999 1 E2206 WHEEL LOCK ASSEMBLY,COMPLETE EACH F 00044.60 07012024 99999999 1 E2207 CRUTCH AND CANE HOLDER F 00040.73 07012024 99999999 1 E2208 CYLINDER TANK CARRIER F 00111.60 07012024 99999999 1 E2209 ARM TROUGH EACH F 00101.26 07012024 99999999 1 E2210 WHEELCHAIR BEARINGS F 00006.26 07012024 99999999 1 E2211 PNEUMATIC PROPULSION TIRE F 00038.77 07012024 99999999 1 E2212 PNEUMATIC PROP TIRE TUBE F 00006.44 07012024 99999999 1 E2213 PNEUMATIC PROP TIRE INSERT M 00000.00 07012021 99999999 1 E2214 PNEUMATIC CASTER TIRE EACH F 00040.14 07012024 99999999 1 E2215 PNEUMATIC CASTER TIRE TUBE F 00010.53 07012024 99999999 1 E2216 FOAM FILLED PROPULSION TIRE F 00028.54 07012024 99999999 1 E2217 FOAM FILLED CASTER TIRE EACH F 00026.30 07012024 99999999 1 E2218 FOAM PROPULSION TIRE EACH F 00028.54 07012024 99999999 1 E2219 FOAM CASTER TIRE ANY SIZE EA F 00026.30 07012024 99999999 1 E2220 SOLID PROPULSION TIRE EACH F 00028.54 07012024 99999999 1 E2221 SOLID CASTER TIRE EACH F 00026.30 07012024 99999999 1 E2222 SOLID CASTER INTEGRATED WHL F 00023.48 07012024 99999999 1 E2224 PROPULSION WHL EXCLUDES TIRE F 00096.69 07012024 99999999 1 E2225 CASTER WHEEL EXCLUDES TIRE F 00019.40 07012024 99999999 1 E2226 CASTER FORK REPLACEMENT ONLY F 00042.30 07012024 99999999 1 E2230 MANUAL STANDING SYSTEM FOR MANUAL W/C M 00000.00 09012018 99999999 1 E2231 MANUAL W/C SOLID SEAT SUPPORT BASE F 00155.50 07012024 99999999 1 E2291 BACK,PLANER,FOR PED WC,INCLUDE HARDWARE M 00000.00 06112012 99999999 1 E2292 SEAT,PLANAR,FOR PED WC, INCLUDING HARDWA M 00000.00 06112012 99999999 1 E2293 BACK,CONTOURED,FOR PED WC INCL.HARDWARE M 00000.00 06112012 99999999 1 E2294 SEAT,CONTOURED PED WC INCLUD HARDWARE M 00000.00 06112012 99999999 1 E2295 PED MANUAL W/C DYNAMIC SEATINGFRAME M 00000.00 01012014 99999999 1 E2298 Pwr seat elev sys for crt F 00193.23 12012025 99999999 1 E2310 POWER WC ELECT.CONN.SEAT MOTOR F 01208.41 07012024 99999999 1 E2311 POWER WC,ELECT.CONN.TO 2+ SEAT MOTORS F 02446.47 07012024 99999999 1 E2312 POWER WC HAND OR CHIN CONTROL INTERFACE, F 02104.28 07012024 99999999 1 E2313 PWC ACCES,HARNESS FOR EXPAND CONTROL,EA F 00324.06 07012024 99999999 1 E2321 POWER WC HAND CONT. REMOTE JOYSTICK F 01582.89 07012024 99999999 1 E2322 POWER WC, HAND CONTROL INTERFACE F 01456.35 07012024 99999999 1 E2323 POWER WC SPECIALTY JOYSTICK,PREFAB F 00066.46 07012024 99999999 1 E2324 POWER WC,CHIN CUP FOR CHIN INTERFACE F 00042.10 07012024 99999999 1 E2325 POWER WC,SIP AND PUFF INTERFACE F 01390.74 07012024 99999999 1 E2326 POWER WC, BREATH TUBE FOR SIP AND PUFF F 00330.03 07012024 99999999 1 E2327 POWER WC HEAD CONT.INTERFACE MECHANICAL F 02381.35 07012024 99999999 1 E2328 POWER WC HEAD/EXTREM. CONTROL INTERFACE F 04003.77 07012024 99999999 1 E2329 POWER WC,HEAD INTERFACE,HEAD ARRAY F 01786.75 07012024 99999999 1 E2330 POWER WC HEAD CONTROL INTERFACE,HEAD ARR F 03441.99 07012024 99999999 1 E2331 POWER WC ATTEND CONTROL M 00000.00 01012014 99999999 1 E2340 POWER WC,NONSTAND SEAT WIDTH 20-23 INCHE F 00324.46 07012024 99999999 1 E2341 POWER WC.NON-STAND SEAT WIDTH 24-27INCHE F 00478.07 07012024 99999999 1 E2342 POWER WC NON-STAND.SEAT DEPTH 20-21INCHE F 00462.64 07012024 99999999 1 E2343 POWER WC,NON-STAND SEAT DEPTH 22-25INCHE F 00267.72 07012024 99999999 1 E2358 POWER W/C ACCESSORY, GRP 34 NON-SEALED M 00000.00 06112012 99999999 1 E2359 POWER W/C ACCESSORY, GROUP 34 SEALED F 00180.25 07012024 99999999 1 E2360 POWER WC, 22NF NON-SEAL LEAD BATTERY F 00093.80 07012024 99999999 1 E2361 POWER WC.22NF SEALED LEAD BATTERY F 00131.79 07012024 99999999 1 E2362 POWER WC GROUP 24 NON-SEAL LEAD BATTERY F 00100.83 07012024 99999999 1 E2363 POWER WC GROUP 24 SEALED LEAD ACID BATTE F 00175.74 07012024 99999999 1 E2364 POWER WC U-1 NONSEALED BATTERY F 00116.08 07012024 99999999 1 E2365 POWER WC U-1 BATTERY F 00132.90 07012024 99999999 1 E2366 POWER WC BATTERY CHARGER SINGLE MODE F 00317.61 07012024 99999999 1 E2367 POWER WC BATTERY CHARGER DUAL MODE F 00420.14 07012024 99999999 1 E2368 POWER WC COMPONENT,MOTOR,REPLAC ONLY F 00517.42 07012024 99999999 1 E2369 POWER WC COMPONENT,GEAR BOX,REPLAC ONLY F 00450.68 07012024 99999999 1 E2370 POWER WC COMPONENT,MOTOR AND GEAR BOX F 00804.14 07012024 99999999 1 E2371 GR27 SEALED LEADACID BATTERY F 00220.35 07012024 99999999 1 E2372 GR27 NON-SEALED LEADACID F 00112.24 07012024 99999999 1 E2373 HAND/CHIN CTRL SPEC JOYSTICK F 00900.68 07012024 99999999 1 E2374 HAND/CHIN CTRL STD JOYSTICK F 00569.64 07012024 99999999 1 E2375 NON-EXPANDABLE CONTROLLER F 00754.00 07012024 99999999 1 E2376 EXPANDABLE CONTROLLER, REPL F 01415.29 07012024 99999999 1 E2377 EXPANDABLE CONTROLLER, INITIAL F 00524.26 07012024 99999999 1 E2378 Power wheelchair component, actuator, re F 00644.43 07012024 99999999 1 E2381 PNEUM DRIVE WHEEL TIRE F 00066.35 07012024 99999999 1 E2382 TUBE, PNEUM WHEEL DRIVE TIRE F 00020.77 07012024 99999999 1 E2383 INSERT, PNEUM WHEEL DRIVE F 00138.85 07012024 99999999 1 E2384 PNEUMATIC CASTER TIRE F 00069.96 07012024 99999999 1 E2385 TUBE, PNEUMATIC CASTER TIRE F 00049.84 07012024 99999999 1 E2386 FOAM FILLED DRIVE WHEEL TIRE F 00116.61 07012024 99999999 1 E2387 FOAM FILLED CASTER TIRE F 00054.51 07012024 99999999 1 E2388 FOAM DRIVE WHEEL TIRE F 00054.23 07012024 99999999 1 E2389 FOAM CASTER TIRE F 00030.31 07012024 99999999 1 E2390 SOLID DRIVE WHEEL TIRE F 00046.92 07012024 99999999 1 E2391 SOLID CASTER TIRE F 00019.16 07012024 99999999 1 E2392 SOLID CASTER TIRE, INTEGRATE F 00047.15 07012024 99999999 1 E2394 DRIVE WHEEL EXCLUDES TIRE F 00064.75 07012024 99999999 1 E2395 CASTER WHEEL EXCLUDES TIRE F 00050.07 07012024 99999999 1 E2396 CASTER FORK F 00056.61 07012024 99999999 1 E2398 Wheelchair accessory, dynamic positionin F 00150.18 12012025 99999999 R E2402 NEGATIVE WOUND THERAPY PUMP F 00053.53 RR 07012024 99999999 R E2500 SPEECH DEV.PRE-RECORDED MESS.<8 MINUTES F 00038.03 RR 07012024 99999999 1 E2500 SPEECH DEV.PRE-RECORDED MESS.<8 MINUTES F 00380.28 07012024 99999999 1 E2502 SPEECH DEV.PRE-RECORDED MESS. >8 BUT <20 F 01198.83 07012024 99999999 R E2502 SPEECH DEV.PRE-RECORDED MESS. >8 BUT <20 F 00119.88 RR 07012024 99999999 R E2504 SPEECH DEVICE PRE-RECORD.20-40 MINUTES F 00158.01 RR 07012024 99999999 1 E2504 SPEECH DEV.PRE-RECORDED MESSAGES >20<40 F 01579.99 07012024 99999999 1 E2506 SPEECH DEVICE PRE-RECORDED MESSAGES>40MI F 02316.74 07012024 99999999 R E2506 SPEECH DEVICE PRE-RECORDED MESS,>40 MIN F 00231.77 RR 07012024 99999999 R E2508 SPEECH DEVICE, MESSAGE FORM. BY SPELLING F 00358.25 RR 07012024 99999999 1 E2508 SPEECH DEVICE MESSAGE FORM BY SPELLING F 03582.46 07012024 99999999 1 E2510 SPEECH DEVICE MULT. METHODS SPEECH FORM F 07979.94 07012024 99999999 R E2510 SPEECH DEVICE,MULT.MESSAGE FORMULATION F 00797.99 RR 07012024 99999999 R E2511 SPEECH GENERATING SOFTWARE PROGRAM M 00000.00 RR 06112012 99999999 1 E2511 SPEECH GENERATING SOFTWARE PROGRAM M 00000.00 07012021 99999999 1 E2512 ASSESS.SPEECH GEN.DEVICE MOUNTING M 00000.00 07012021 99999999 R E2512 ASSESS.SPEECH GEN.DEVICE MOUNTING M 00000.00 RR 06112012 99999999 R E2599 ASSESS.FOR SPEECH GENER.DEVICE M 00000.00 RR 06012022 99999999 1 E2599 ASSESS.FOR SPEECH GEN.DEVICE M 00000.00 06012022 99999999 1 E2601 GENERAL USE WC CUSHION,<22INCHES ANY DEP F 00058.76 07012024 99999999 1 E2602 GENERAL USE CUSHION >22INCHES ANY DEPTH F 00114.72 07012024 99999999 1 E2603 SKIN PROTECT.CUSHION <22INCHES,ANY DEPTH F 00145.65 07012024 99999999 1 E2604 SKIN PROTECTION CUSHION >22INCHES ANY DE F 00181.04 07012024 99999999 1 E2605 POSIT.CUSHION <22 INCHES ANY DEPTH F 00258.64 07012024 99999999 1 E2606 POSIT.CUSHION >22INCHES ANY DEPTH F 00403.50 07012024 99999999 1 E2607 SKIN PROT.AND POSIT.SEAT CUSH.<22ANY DEP F 00278.50 07012024 99999999 1 E2608 SKIN PROTECT AND POSIT CUSHION >22 ANY F 00334.46 07012024 99999999 1 E2609 CUSTOM FAB.WC SEAT ANY SIZE F 00800.27 07012024 99999999 1 E2611 GENERAL USE BACK CUSHION,<22INCH ANY HEI F 00300.13 07012024 99999999 1 E2612 GENERAL WC/BACK CUSHION >22" ANY HEIGHT F 00406.00 07012024 99999999 1 E2613 POSTIONING WC BACK CUSHION<22"ANY HEIGHT F 00377.66 07012024 99999999 1 E2614 POSITIONING WC BACK CUSH.POST,>22" F 00522.65 07012024 99999999 1 E2615 POSIT WC/BACK CUSH,POST-LAT <22" F 00434.61 07012024 99999999 1 E2616 POSIT WC/BACK CUSH,POST-LAT >22" F 00584.76 07012024 99999999 1 E2617 CUSTOM FAB,W/C BACK CUSH,ANY SIZE F 00793.04 07012024 99999999 1 E2619 REPLAC COVER FOR WC SEAT CUSHION F 00049.31 07012024 99999999 1 E2620 POSIT.SEAT BACK CUSHION,PLANER W/LATER F 00526.25 07012024 99999999 1 E2621 POSIT.BACK CUSHION,PLANAR W/LAT >22" F 00548.60 07012024 99999999 1 E2622 SKIN PROTECTION W/C SEAT CUSHION F 00288.80 07012024 99999999 1 E2623 SKIN PROTECTION W/C SEAT CUSHION F 00367.48 07012024 99999999 1 E2624 SKIN PROTECT & POSITION W/C SEAT CUSH F 00291.17 07012024 99999999 1 E2625 SKIN PROTECT & POSITION W/C SEAT CUSH F 00368.61 07012024 99999999 1 E2626 WHEELCHAIR ACCESSORY, SHOULDER ELBOW F 00642.93 07012024 99999999 1 E2627 WHEELCHAIR ACCESSORY, SHOULDER ELBOW F 01025.93 07012024 99999999 1 E2628 WHEELCHAIR ACCESSORY, SHOULDER ELBOW F 00772.87 07012024 99999999 1 E2629 WHEELCHAIR ACCESSORY, SHOULDER ELBOW F 00954.98 07012024 99999999 1 E2630 WHEELCHAIR ACCESSORY, SHOULDER ELBOW F 00683.95 07012024 99999999 1 E2631 W/C ACCESSORY, MOBILE ARM SUPPORT F 00273.59 07012024 99999999 1 E2632 W/C ACCESSORY, MOBILE ARM SUPPORT F 00161.41 07012024 99999999 1 E2633 W/C ACCESSORY, MOBILE ARM SUPPORT F 00147.55 07012024 99999999 1 E8000 GAIT TRAINER, PED,POS SUPPORT,ALL ACCESS M 00000.00 09012018 99999999 R E8000 GAIT TRAINER, PED SIZE, POST.SUPPORT,INC M 00000.00 RR 06112012 99999999 R E8001 GAIT TRAINER,PED,UPRIGHT SUPPORT M 00000.00 RR 06112012 99999999 1 E8001 GAIT TRAINER,PED,UPRIGHT SUPPORT M 00000.00 09012018 99999999 1 E8002 GAIT TRAINER,PED,ANTERIOR SUPPORT M 00000.00 09012018 99999999 R E8002 GAIT TRAINER,PED,ANTERIOR SUPPORT M 00000.00 RR 06112012 99999999 1 G0248 HOME INR MONITOR DEMO F 00124.65 07012024 99999999 1 G0249 TEST MATERIALS FOR HOME INR MONITOR F 00102.99 07012024 99999999 1 G0310 IMMUNIZATION COUNSELING F 00014.67 07012024 99999999 1 G0311 IMMUNIZATION COUNSELING F 00029.35 07012024 99999999 1 G0312 IMMUNIZATION COUNSELING F 00014.67 07012024 99999999 1 G0313 IMMUNIZATION COUNSELING F 00029.35 07012024 99999999 1 G0314 IMMUNIZATION COUNSELING F 00029.35 07012024 99999999 1 G0315 IMMUNIZATION COUNSELING F 00014.67 07012024 99999999 1 G0532 Take home supp nasal spray M 00000.00 01012025 99999999 1 G0533 Buprenorphone inj weekly M 00000.00 01012025 99999999 1 G1028 Take-home supply of nasal naloxone; 2-pa M 00000.00 01012022 99999999 1 G2215 HOME SUPPLY NASAL NALOXONE M 00000.00 01012021 99999999 1 J0013 ESKETAMINE, NASAL SPRAY, 1 MG F 00013.97 01012026 99999999 1 J0121 Injection, omadacycline, 1 mg F 00004.30 03012024 99999999 1 J0122 Injection, eravacycline, 1 mg F 00001.00 11012023 99999999 1 J0129 INJECTION, ABATACEPT, 10 MG F 00055.91 05012024 99999999 1 J0131 Inj, acetaminophen (nos) F 00000.11 03012024 99999999 1 J0132 ACETYLCYSTEINE INJECTION F 00001.69 03012024 99999999 1 J0133 ACYCLOVIR INJECTION F 00000.14 05012024 99999999 1 J0134 Inj acetaminophen -fresenius F 00000.12 11012023 99999999 1 J0136 Inj, acetaminophen (b braun) F 00000.10 11012023 99999999 1 J0137 Injection, acetaminophen not therapeutic F 00000.12 03012024 99999999 1 J0174 INJECTION, LECANEMAB-IRMB, 1MG M 00000.00 05012024 99999999 1 J0175 Inj, donanemab-azbt, 2 mg M 00000.00 07022024 99999999 1 J0180 INJECTION,AGALIDASE BETA 1MG F 00209.40 05012024 99999999 1 J0185 Injection, aprepitant, 1 mg F 00003.27 05012024 99999999 1 J0218 Inj olipudase alfa-rpcp 1mg F 00361.67 05012024 99999999 1 J0219 INJECTION, AVALGLUCOSIDASE ALFA-NGPT, 4 F 00072.95 05012024 99999999 1 J0221 INJ, ALGLUCOSIDASE ALFA, 10 MG F 00189.66 05012024 99999999 1 J0222 Injection, patisiran, 0.1 mg F 00099.10 05012024 99999999 1 J0223 INJECTION, GIVOSIRAN, 0.5 MG F 00110.86 05012024 99999999 1 J0224 Injection, lumasiran, 0.5 mg F 00312.68 05012024 99999999 1 J0225 Inj, vutrisiran, 1 mg F 04835.15 05012024 99999999 1 J0256 INJECTION, ALPHA 1 PROTEINASE INHIB F 00005.23 05012024 99999999 1 J0257 INJ, ALPHA 1 PROTEINASE INHIB, 10 MG F 00006.25 05012024 99999999 1 J0278 AMIKACIN SULFATE INJECTION F 00001.62 03012024 99999999 1 J0285 AMPHOTERICIN B INJECTION, 50 MG F 00044.26 11012023 99999999 1 J0287 INJECTION,AMPHOTERICIN B LIPID,10MG F 00010.63 03012024 99999999 1 J0289 INJ.AMPHOTERICIN B,LIPOSOME, 10MG F 00051.60 03012024 99999999 1 J0290 AMPICILLIN INJECTION, UP TO 500 MG F 00002.40 03012024 99999999 1 J0291 Injection, plazomicin, 5 mg F 00003.50 05012024 99999999 1 J0295 AMPICILLIN SODIUM/SULBACTAM SODIUM INJEC F 00005.06 03012024 99999999 1 J0348 ANADULAFUNGIN INJECTION 1MG F 00001.93 05012024 99999999 1 J0456 INJECTION, AZITHROMYCIN,500MG F 00004.15 03012024 99999999 1 J0457 Injection, aztreonam, 100 mg F 00003.01 05012024 99999999 1 J0475 BACLOFEN INJECTION, 10 MG F 00157.76 05012024 99999999 1 J0485 Injection, belatacept, 1 mg F 00003.93 05012024 99999999 1 J0490 INJECTION, BELIMUMAB, 10 MG F 00051.75 05012024 99999999 1 J0517 Injection, benralizumab, 1 mg F 00186.07 05012024 99999999 1 J0558 PCN G BENZATHINE & PROCAINE, 100,000 U F 00016.96 03012024 99999999 1 J0561 INJ, PCN G BENZATHINE, 100,000 UNITS F 00021.28 03012024 99999999 1 J0577 Inj, brixadi, 7 days or less M 00000.00 04012024 99999999 1 J0578 Inj,brixadi, more than 7 day M 00000.00 04012024 99999999 1 J0584 Injection, burosumab-twza 1 mg F 00429.38 05012024 99999999 1 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT F 00006.42 07012023 99999999 1 J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS F 00008.70 07012023 99999999 1 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT F 00012.61 07012023 99999999 1 J0588 INJECTION, INCOBOTULINUMTOXINA, 1 UNIT F 00005.27 07012023 99999999 1 J0597 INJ,C-1 ESTERASE INHIB, BERINERT, 10 U F 00073.34 05012024 99999999 1 J0598 INJ,C1 ESTERASE INHIBITOR, 10 UNITS F 00061.06 05012024 99999999 1 J0599 Injection, c-1 esterase inhibitor (human F 00010.72 05012024 99999999 1 J0637 INJECTION CASPOFUNGIN ACETATE, 5MG F 00009.92 05012024 99999999 1 J0638 INJECTION, CANAKINUMAB, 1 MG F 00120.29 05012024 99999999 1 J0687 INJ CEFAZOLIN (WG CRIT CARE) M 00000.00 07012024 99999999 1 J0688 INJ CEFAZOLIN SODIUM, HIKMA F 00001.49 01012024 99999999 1 J0689 Inj cefazolin sodium, baxter F 00002.51 11012023 99999999 1 J0690 INJ. CEFAZOLIN SODIUM 500 MG F 00002.03 03012024 99999999 1 J0691 INJECTION, LEFAMULIN, 1 MG F 00000.69 11012023 99999999 1 J0692 INJECTION,CEFEPIME HCL, 500 MG F 00002.89 03012024 99999999 1 J0694 INJECTION, CEFOXITIN SODIUM, 1 GRAM F 00007.08 03012024 99999999 1 J0696 ROCEPHIN INJECTION - CEFTRIAXONE SODIUM, F 00001.01 03012024 99999999 1 J0697 STERILE CEFUROXIME SODIUM, ZINACOF, INJE F 00003.03 11012023 99999999 1 J0698 CEFOTAXIME SODIUM INJECTION, PER GM F 00009.93 05012024 99999999 1 J0712 INJECTION, CEFTAROLINE FOSAMIL, 10 MG F 00005.92 03012024 99999999 1 J0713 CEFTAZIDIME INJECTION, PER 500 MG (FORTA F 00002.16 03012024 99999999 1 J0717 Injection, certolizumab pegol, 1 mg F 00013.67 05012024 99999999 1 J0720 CHLORMYCETIN SODIUM SUCCINATE INJECTION, F 00049.27 05012024 99999999 1 J0736 Injection, clindamycin phosphate, 300 mg F 00001.20 03012024 99999999 1 J0737 Injection, clindamycin phosphate, not eq F 00004.41 03012024 99999999 1 J0739 Injection, cabotegravir, 1 mg F 00006.43 07012024 99999999 1 J0741 Injection, cabotegravir and rilpivirine, F 00021.71 07012024 99999999 1 J0742 INJECTION, IMIPENEM 4 MG, CILASTATIN 4 M F 00002.41 03012024 99999999 1 J0743 CILASTATIN SODIUM INJECTION, IMIPENEM, P F 00010.88 03012024 99999999 1 J0744 INJECTION CIPROFLOXACIN FOR IV,PER 200MG F 00003.04 03012024 99999999 1 J0750 HIV PREP, FTC/TDF 200/300MG F 00001.22 01012024 99999999 1 J0751 HIV PREP, FTC/TAF 200/25MG F 00072.89 01012024 99999999 1 J0770 COLY-MYCIN M INJECTION, UP TO 150 MG F 00028.35 05012024 99999999 1 J0780 COMPAZINE INJECTION, UP TO 10 MG F 00007.60 05012024 99999999 1 J0791 INJECTION, CRIZANLIZUMAB-TMCA, 5 MG F 00124.22 05012024 99999999 1 J0799 HIV PREP, FDA APPROVED, NOC M 00000.00 01012024 99999999 1 J0850 CYTOMEGALOVIRUS IMMUNE GLOBULIN IV F 01779.34 05012024 99999999 1 J0872 DAPTOMYCIN (XELLIA) UNREFRIG M 00000.00 07012024 99999999 1 J0873 INJ, DAPTOMYCIN (XELLIA) F 00000.14 01012024 99999999 1 J0874 Injection, daptomycin, not therapeutical F 00000.08 05012024 99999999 1 J0877 Inj, daptomycin (hospira) F 00000.15 11012023 99999999 1 J0878 INJ. DAPTOMYCIN 1 MG F 00000.12 03012024 99999999 1 J0895 DEFEROXAMINE MESYLATE INJECTION 500MG F 00013.12 05012024 99999999 1 J0897 INJECTION, DENOSUMAB, 1 MG F 00027.42 05012024 99999999 1 J1100 INJECTION DEXAMETHOSONE SOD. PHOS 1MG F 00000.19 05012024 99999999 1 J1171 Inj, hydromorphone, 0.1 mg M 00000.00 10012024 99999999 1 J1200 DIPHENHYDRAMINE HCL, BENA INJECTION, UP F 00001.42 05012024 99999999 1 J1205 DIAURIL, DIACHLOR INJECTION PER500MG F 00083.03 05012024 99999999 1 J1230 DOLOPHINE HCL, METHADONE HCL INJECTION, F 00021.65 05012024 99999999 1 J1250 DOBUTAMINE PER 250 MG F 00007.02 05012024 99999999 1 J1265 DOPAMINE INJECTION F 00000.59 05012024 99999999 1 J1299 Inj, eculizumab, 2 mg M 00000.00 04012025 99999999 1 J1301 Injection, edaravone, 1 mg F 00021.06 05012024 99999999 1 J1303 Injection, ravulizumab-cwvz, 10 mg F 00216.20 05012024 99999999 1 J1305 Injection, evinacumab-dgnb, 5mg F 00171.16 05012024 99999999 1 J1325 EPOPROSTERNOL INJECTION, 0.5MG F 00018.93 05012024 99999999 1 J1335 INJECTION,ERTAPENEM SODIUM,500MG F 00050.64 03012024 99999999 1 J1364 ERYTHROMYCIN LACTOBIONATE INJECTION, PER F 00085.62 03012024 99999999 1 J1426 Injection, casimersen, 10 mg F 00162.05 06012023 99999999 1 J1427 Injection, viltolarsen, 10 mg F 00057.12 06012023 99999999 1 J1428 Injection, eteplirsen, 10 mg F 00162.05 05012022 99999999 1 J1429 INJECTION, GOLODIRSEN, 10 MG F 00162.05 03012022 99999999 1 J1450 INJECTION, FLUCONAZOLE, 200MG F 00007.60 05012024 99999999 1 J1453 INJ. FOSAPREPITANT 1 MG F 00000.56 05012024 99999999 1 J1455 FOSCARNET SODIUM INJECTION, PER 1000 MG F 00079.80 05012024 99999999 1 J1458 GALSULFASE INJECTION F 00453.33 05012024 99999999 1 J1459 IMM GLOB INJ, IV,NON-LYOPHYLIZD, 500MG F 00086.50 03012024 99999999 1 J1460 INJECTION, GAMMA GOLBULIN 1 CC F 00048.15 03012024 99999999 1 J1551 INJECTION, IMMUNE GLOBULIN (CUTAQUIG), 1 F 00019.98 11012023 99999999 1 J1552 Inj, alyglo, 500 mg M 00000.00 01012025 99999999 1 J1554 Injection, immune globulin (asceniv), 50 F 00469.53 03012024 99999999 1 J1555 Injection, immune globulin (cuvitru), 10 F 00021.45 03012024 99999999 1 J1556 Injection, immune globulin (bivigam), 50 F 00071.82 03012024 99999999 1 J1557 INJ,IMMUNE GLOBULIN,IV,NON-LYOPHILIZED F 00104.03 03012024 99999999 1 J1558 INJECTION, IMMUNE GLOBULIN (XEMBIFY), 10 F 00017.84 03012024 99999999 1 J1559 INJ, IMMUNE GLOBULIN (HIZENTRA),100 MG F 00021.73 03012024 99999999 1 J1561 INJ, GLOBULIN, IV, NONLYOPHIL, 500MG F 00069.24 03012024 99999999 1 J1566 IMMUNE GLOBULIN, POWDER F 00109.20 03012024 99999999 1 J1568 INJ, OCTAGAM, IV, NONLYPHIL, 500MG F 00098.37 03012024 99999999 1 J1569 INF, GAMMAGARD, IV, NONLYPHIL, 500MG F 00081.76 03012024 99999999 1 J1570 INJ. GANCICLOVIR SODIUM 500 MG F 00072.92 02012023 99999999 1 J1572 INJ, FLEBOGAMMA, IV, NONLYPHIL, 500MG F 00053.62 03012024 99999999 1 J1573 INJ, HEP B IMMUNE GLOBULIN, IV, 0.5ML F 00090.13 05012024 99999999 1 J1575 INJECTION; IMMUNE GLOBULIN/HYALURONIDASE F 00023.62 03012024 99999999 1 J1576 Injection, immune globulin, intravenous, F 00103.71 03012024 99999999 1 J1580 GARAMYCIN, GENTAMICIN INJECTION, UP TO F 00002.81 05012024 99999999 1 J1602 Injection, golimumab, 1 mg, for intraven F 00040.50 05012024 99999999 1 J1626 INJECTION, GRANISETRON HCL 100 MCG F 00000.91 05012024 99999999 1 J1627 Injection, granisetron, extended-release F 00007.44 05012024 99999999 1 J1642 HEPARIN SODIUM INJECTION, PER 10 UNITS F 00000.34 03012024 99999999 1 J1643 Inj heparin, pfizer, 1000u F 00000.34 05012024 99999999 1 J1644 INJ HEPARIN SODIUM PER 1000U F 00000.42 05012024 99999999 1 J1720 HYDROCORTISONE AS SODIUM SUCCINATE INJEC F 00014.57 05012024 99999999 1 J1740 IBANDRONATE SODIUM INJECTION F 00081.02 05012024 99999999 1 J1743 INJECTION, IDURSULFASE, 1MG F 00529.33 05012022 99999999 1 J1744 Injection, icatibant, 1 mg F 00102.97 05012024 99999999 1 J1745 INFLIXIMAB INJECTION, 10 MG F 00048.11 05012024 99999999 1 J1746 Injection, ibalizumab-uiyk, 10 mg F 00072.49 05012024 99999999 1 J1748 INJ, ZYMFENTRA, 10 MG M 00000.00 07012024 99999999 1 J1786 INJECTION, IMIGLUCERASE, 10 UNITS F 00043.47 05012024 99999999 1 J1809 Inj, fosdenopterin, 0.1mg M 00000.00 10012025 99999999 1 J1811 Insulin for administration through DME p M 00000.00 07012023 99999999 1 J1812 Insulin (fiasp), per 5 units F 00001.47 03012024 99999999 1 J1813 Insulin for administration through DME p M 00000.00 07012023 99999999 1 J1814 Insulin (lyumjev), per 5 units F 00001.39 03012024 99999999 1 J1823 INJECTION, INEBILIZUMAB-CDON, 1 MG F 00452.43 05012024 99999999 1 J1833 INJECTION; ISAVUCONAZONIUM; 1 MG F 00001.00 05012024 99999999 1 J1836 Injection, metronidazole, 10 mg F 00000.04 05012024 99999999 1 J1885 KETOROLAC TROMETHAMINE, PER 15 MG (TORAD F 00001.50 05012024 99999999 1 J1931 INJECTION,LARONIDASE 0.1MG F 00035.95 05012024 99999999 1 J1941 Injection, furosemide (furoscix), 20 mg F 00208.13 03012024 99999999 1 J1950 LEUPROLIDE ACETATE (LUPRON) INJECTION PE F 01737.30 07012024 99999999 1 J1956 LEVOFLAXICIN INJECTION, 250 MG F 00008.61 05012024 99999999 1 J2020 INJ. LINEZOLID 200 MG F 00011.14 05012024 99999999 1 J2175 MEPERDINE, DEMEROL HCL, PER 100MG F 00002.94 05012024 99999999 1 J2182 INJECTION; MEPOLIZUMAB; 1 MG F 00034.05 05012024 99999999 1 J2183 INJ MEROPENEM (WG CRIT CARE) M 00000.00 07012024 99999999 1 J2184 Inj, meropenem (b. braun) F 00004.15 03012024 99999999 1 J2185 INJ. MEROPENEM 100 MG F 00001.22 03012024 99999999 1 J2186 INJECTION, MEROPENEM AND VABORBACTAM F 00002.19 03012024 99999999 1 J2246 INJ, MICAFUNGIN (BAXTER) M 00000.00 07012024 99999999 1 J2247 Inj, micafungin (par pharm) F 00001.52 05012024 99999999 1 J2248 INJ. MICAFUNGIN SODIUM 1 MG F 00001.89 05012024 99999999 1 J2260 MILRINONE LACTATE INJECTION, PER 5 ML F 00002.13 05012024 99999999 1 J2265 INJ, MINOCYCLINE HYDROCHLORIDE,1 MG F 00002.42 03012024 99999999 1 J2267 INJ, MIRIKIZUMAB-MRKZ, 1 MG M 00000.00 07012024 99999999 1 J2270 INJ. MORPHINE SULFATE, UP TO 10 MG F 00002.58 05012024 99999999 1 J2272 Inj, morphine (fresenius) F 00003.09 05012024 99999999 1 J2280 INJ. MOXIFLOXACIN 100 MG F 00011.62 03012024 99999999 1 J2327 Inj risankizumab-rzaa 1 mg F 00016.04 05012024 99999999 1 J2350 INJECTION, OCRELIZUMAB, 1 MG F 00063.38 05012024 99999999 1 J2351 Inj ocrelizumab 1 mg hya-ocsq M 00000.00 04012025 99999999 1 J2356 Injection, tezepelumab-ekko, 1 mg F 00018.55 05012024 99999999 1 J2357 INJECTION,OMALIZUMAB 5MG F 00044.11 05012024 99999999 1 J2360 NORFLEX INJECTION, UP TO 60 MG F 00015.80 05012024 99999999 1 J2405 ONDANSETRON HCL INJECTION, PER 1 MG F 00000.19 05012024 99999999 1 J2430 PAMIDRONATE DISODIUM INJECTION, PER 30 M F 00020.77 05012024 99999999 1 J2468 INJ, PALONOSETRON (AVYXA) M 00000.00 07012024 99999999 1 J2469 INJECTION,PALONOSETRON HCL,25MCG F 00004.41 05012024 99999999 1 J2508 PEGUNIGALSIDASE ALFA-IWXJ F 00209.40 01012024 99999999 1 J2540 INJECTION, PFIZERPEN, UP TO 600,000 F 00001.54 11012023 99999999 1 J2543 PIPERACILLIN SODIUM 1.125 GRAMS F 00002.79 03012024 99999999 1 J2550 PHENERGAN INJECTION, UP TO 50 MG F 00003.75 05012024 99999999 1 J2700 PROSTAPHLIN INJECTION, UP TO 250 MG F 00002.95 05012024 99999999 1 J2765 REGLAN/METOCLOPRAMIDE HCL INJECTION, UP F 00002.23 05012024 99999999 1 J2786 INJECTION; RESLIZUMAB; 1 MG F 00010.63 05012024 99999999 1 J2800 ROBAXIN, METHOCARBAMOL, INJECTION UP TO F 00010.13 05012024 99999999 1 J2840 INJECTION, SEBELIPASE ALFA, 1 MG F 00517.03 05012024 99999999 1 J3000 STREPTOMYCIN INJECTION, UP TO 1 GM F 00079.13 05012024 99999999 1 J3010 INJECTION, FENATYL CITRATE, 0.1MG F 00001.38 05012024 99999999 1 J3032 INJECTION, EPTINEZUMAB-JJMR, 1 MG F 00017.30 05012024 99999999 1 J3060 INJECTION, TALIGLUCERACE ALFA, 10 UNITS F 00044.19 05012024 99999999 1 J3090 INJECTION, TEDIZOLID PHOSPHATE, 1 MG F 00001.77 05012024 99999999 1 J3095 INJECTION, TELEVANCIN, 10 MG F 00008.37 05012024 99999999 1 J3111 Injection, romosozumab-aqqg, 1 mg F 00011.18 05012024 99999999 1 J3241 INJECTION, TEPROTUMUMAB-TRBW, 10 MG F 00322.48 05012024 99999999 1 J3243 INJ. TIGECYCLINE 1 MG F 00002.03 05012024 99999999 1 J3244 Inj. tigecycline (accord) F 00002.53 05012024 99999999 1 J3245 INJECTION, TILDRAKIZUMAB, 1 MG F 00166.27 05012024 99999999 1 J3250 TIGAN INJECTION, UP TO 200 MG F 00050.85 05012024 99999999 1 J3260 TOBRAMYCIN SULFATE, NEBCIN INJECTION, U F 00002.01 11012023 99999999 1 J3262 INJECTION, TOCILIZUMAB, 1 MG F 00006.73 05012024 99999999 1 J3285 TREPROSTINIL INJECTION F 00060.85 05012024 99999999 1 J3358 Ustekinumab, for intravenous injection, F 00015.02 05012024 99999999 1 J3376 INJ VANCOMYCIN (HIKMA) 10MG M 00000.00 01012026 99999999 1 J3380 INJ VEDOLIZUMAB IV 1 MG F 00027.60 05012024 99999999 1 J3385 INJ, VELAGLUCERASE ALFA, 100 UNITS F 00369.89 05012024 99999999 1 J3397 Injection, vestronidase alfa-vjbk, 1 mg F 00259.28 05012024 99999999 1 J3401 VYJUVEK 5X10^9PFU/ML, 0.1 ML F 00982.42 01012024 99999999 1 J3415 INJECTION PYRIDOXINE HCL,100MG F 00019.30 05012024 99999999 1 J3420 VITAMIN B - 12 INJECTION, UP TO 1000 MCG F 00003.58 05012024 99999999 1 J3424 Inj hydroxocobalamin iv 25mg M 00000.00 04012024 99999999 1 J3425 HYDROXOCOBALAMIN IM 10MCG F 00000.01 01012024 99999999 1 J3465 INJECTION VORICONAZOLE 10MG F 00003.04 05012024 99999999 1 J3475 MAGNESIUM SULFATE INJECTION, PER 500 MG F 00000.51 05012024 99999999 1 J3480 POTASIUM CHLORIDE INJECTION, PER 2MEQ F 00000.37 05012024 99999999 1 J3489 Injection, zoledronic acid, 1 mg F 00021.27 05012024 99999999 1 J7030 INFUSION, NORMAL SALINE SOLUTION 1 F 00005.32 05012024 99999999 1 J7040 INFUSION, NORMAL SALINE SOLUTION, F 00004.27 05012024 99999999 1 J7042 5% DEXTROSE/NORMAL SALINE (500 ML F 00002.66 05012024 99999999 1 J7050 INFUSION, NORMAL SALINE SOLUTION, 2 F 00004.00 05012024 99999999 1 J7060 5% DEXTROSE/WATER (500 ML F 00004.17 05012024 99999999 1 J7070 INFUSION, D5W, 1000 CC F 00005.23 05012024 99999999 1 J7120 RINGERS INJECTION, UP TO 1000 CC F 00009.47 05012024 99999999 1 J7121 5% DEXTROSE IN LACTATED RINGERS INFUSION F 00007.83 05012024 99999999 1 J7131 HYPERTONIC SALINE SOLUTION, 1 ML F 00000.12 03012024 99999999 1 J7170 INJECTION, EMICIZUMAB-KXWH, 0.5 MG F 00054.90 03012024 99999999 1 J7214 Injection, factor viii/von willebrand fa F 00005.17 03012024 99999999 1 J7294 Segesterone acetate and ethinyl estradio F 02334.79 03012024 99999999 1 J7295 Ethinyl estradiol and etonogestrel 0.015 F 00140.00 03012024 99999999 1 J7340 CARBIDOPA 5 MG/LEVODOPA 20 MG ENTERAL SU F 00221.10 05012024 99999999 1 J7356 INJ FOSCARB/FOSLEVODOPA 5 MG M 00000.00 07012025 99999999 1 J7528 MYCOPHEN MOFETIL FOR SUSP M 00000.00 01012026 99999999 1 J7611 ALBUTEROL,INHALTN SOLN,NON-COMPND,1 MG F 00000.61 03012024 99999999 1 J7612 LEVALBUTEROL,INHAL SOLN, NON-COM,0.5MG F 00002.17 07012021 99999999 1 J7613 ALBUTEROL,INHAL SOLN,NON-COMPND, 1 MG F 00000.10 03012024 99999999 1 J7614 LEVALBUTEROL, INHAL, UNIT DOSE 0.5 MG F 00001.13 03012024 99999999 1 J7620 ALBUTEROL NON-COMPOUNDED F 00000.41 03012024 99999999 1 J7659 ISOPROTERENOL HCL INHAL SOL/DME UNIT/MG F 00000.57 07012013 99999999 1 J7677 Revefenacin inhalation solution, FDA-app F 00000.25 03012024 99999999 1 J7686 TREPROSTINIL, INH SOLN, 1.74 MG F 00720.88 05012024 99999999 1 J8499 PRESCRIPTION DRUG, ORAL, NOS M 00000.00 09012018 99999999 1 J9000 DOXORUBICIN HCL INJECTION, 10 MG F 00007.09 05012024 99999999 1 J9038 Inj axatilimab-csfr 0.1 mg M 00000.00 04012025 99999999 1 J9039 INJECTION; BLINATUMOMAB; 1 MICROGRAM F 00141.80 05012024 99999999 1 J9040 BLEOMYCIN SULFATE INJECTION, 15 UNITS F 00039.71 05012024 99999999 1 J9065 CLADRIBINE INJECTION, PER 1 MG F 00035.45 05012024 99999999 1 J9100 CYTARABINE INJECTION, 100MG F 00000.98 05012024 99999999 1 J9190 FLUOROURACIL INJECTION, 500MG F 00005.81 05012024 99999999 1 J9255 INJ, METHOTREXATE (ACCORD) M 00000.00 01012024 99999999 1 J9256 INJ, NIPOCALIMAB-AAHU, 3 MG M 00000.00 01012026 99999999 1 J9332 Injection, efgartigimod alfa-fcab, 2mg F 00030.73 05012024 99999999 1 J9334 INJ EFGART-ALFA 2MG HYA-QVFC F 00031.69 05012024 99999999 1 J9360 VINBLASTINE SULFATE, INJ, 1MG F 00005.44 05012024 99999999 1 J9370 VINCRISTINE SULFATE, ONCOVIN, 1MG/1 ML F 00011.71 05012024 99999999 1 K0001 STANDARD WHEELCHAIR F 00521.85 07012024 99999999 R K0001 STANDARD WHEELCHAIR F 00052.19 RR 07012024 99999999 R K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR F 00074.27 RR 07012024 99999999 1 K0002 STANDARD HEMI WHEELCHAIR F 00781.77 07012024 99999999 1 K0003 LIGHTWEIGHT WHEELCHAIR F 00855.85 07012024 99999999 R K0003 LIGHTWEIGHT WHEELCHAIR F 00089.30 RR 07012024 99999999 R K0004 HIGH STRENGTH, LIGHT-WEIGHT WHEELCHAIR F 00121.30 RR 07012024 99999999 1 K0004 LIGHTWEIGHT WHEELCHAIR -HIGH STRENGTH F 01276.79 07012024 99999999 1 K0005 ULTRALIGHTWEIGHT WHEELCHAIR F 01839.44 07012024 99999999 R K0005 ULTRALIGHTWEIGHT WHEELCHAIR F 00183.94 RR 07012024 99999999 R K0006 HEAVY-DUTY WHEELCHAIR F 00112.79 RR 07012024 99999999 1 K0006 HEAVY-DUTY WHEELCHAIR F 01187.21 07012024 99999999 1 K0007 EXTRA HEAVY-DUTY WHEELCHAIR F 01705.39 07012024 99999999 R K0007 EXTRA HEAVY-DUTY WHEELCHAIR F 00162.01 RR 07012024 99999999 1 K0008 CUSTOM MANUAL WHEELCHAIR/BASE M 00000.00 01012014 99999999 1 K0009 OTHER MANUAL WHEELCHAIR/BASE F 00977.58 07012024 99999999 R K0009 OTHER MANUAL WHEELCHAIR/BASE M 00000.00 RR 06112012 99999999 1 K0013 CUSTOM MOTORIZED/POWER WHEELCHAIR BASE M 00000.00 01012014 99999999 1 K0015 DETACHABLE, NONADJUSTABLE HEIGHT ARMREST F 00171.69 07012024 99999999 1 K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, B F 00048.28 07012024 99999999 1 K0018 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, U F 00026.99 07012024 99999999 1 K0019 ARM PAD, EACH F 00016.55 07012024 99999999 1 K0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR F 00043.89 07012024 99999999 1 K0037 HIGH MOUNT FLIP-UP FOOTREST, EACH F 00045.71 07012024 99999999 1 K0038 LEG STRAP, EACH F 00022.92 07012024 99999999 1 K0039 LEG STRAP, H STYLE, EACH F 00050.91 07012024 99999999 1 K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH F 00070.54 07012024 99999999 1 K0041 LARGE SIZE FOOTPLATE, EACH F 00050.03 07012024 99999999 1 K0042 STANDARD SIZE FOOTPLATE, EACH F 00029.76 07012024 99999999 1 K0043 FOOTREST, LOWER EXTENSION TUBE, EACH F 00018.45 07012024 99999999 1 K0044 FOOTREST, UPPER HANGER BRACKET F 00015.73 07012024 99999999 1 K0045 FOOTREST, COMPLETE ASSEMBLY F 00046.24 07012024 99999999 1 K0046 ELEVATING LEGREST, LOWER EXTENSION TUBE, F 00018.45 07012024 99999999 1 K0047 ELEVATING LEGREST, UPPER HANGER BRACKET, F 00072.24 07012024 99999999 1 K0050 RATCHET ASSEMBLY F 00030.70 07012024 99999999 1 K0051 CAM RELEASE ASSEMBLY, FOORTREST OR LEGRE F 00047.91 07012024 99999999 1 K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH F 00087.34 07012024 99999999 1 K0053 ELEVATING FOOTREST, ARTICULATING, EACH F 00096.39 07012024 99999999 1 K0056 SEAT HEIGHT LESS THAN 17 INCHES OR LESS F 00104.23 07012024 99999999 1 K0065 SPOKE PROTECTORS F 00040.51 07012024 99999999 1 K0069 REAR WHEEL ASSEMBLY, COMPLETE, W/SOLID T F 00109.50 07012024 99999999 1 K0070 REAR WHEEL ASSEMBLY, COMPL W/PNEUMATIC T F 00200.79 07012024 99999999 1 K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITH PN F 00119.73 07012024 99999999 1 K0072 FRONT CASTER ASSEMBLY, COMPLETE, W/SEMIP F 00043.40 07012024 99999999 1 K0073 CASTER PIN LOCK, EACH F 00036.69 07012024 99999999 1 K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SO F 00057.59 07012024 99999999 1 K0105 IV HANGER, EACH F 00093.39 07012024 99999999 1 K0108 OTHER ACCESSORIES/WHEELCHAIR M 00000.00 12012000 99999999 1 K0195 ELEVATING LEG RESTS,PAIR F 00020.14 07012024 99999999 R K0455 INFUSION PUMP FOR EPOPROSTENOL F 00253.04 RR 07012024 99999999 1 K0462 TEMPORARY REPLACEMENT FOR PT. OWNED M 00000.00 09012018 99999999 1 K0552 SUPPLIES FOR EXTERNAL INFUSION PUMP, F 00002.59 07012024 99999999 1 K0606 AUTOMATED EXTERNAL DIFIBRILLATOR F 24268.63 07012024 99999999 1 K0607 REPLA.BATTERY FOR EXT.DIFIBRILLATOR F 00242.51 07012024 99999999 1 K0608 REPLAC. GARMENT FOR EXT. DIFIBRILLATOR F 00129.69 07012024 99999999 1 K0672 ADD TO LOWER EXTREM ORTHOSIS,REPLC,EA F 00076.42 07012025 99999999 1 K0730 CTRL DOSE INH DRUG DELIV SYS F 02266.83 07012024 99999999 1 K0733 POWER WC, 12 TO 24 AMP LEAD ACID BATT F 00029.03 07012024 99999999 R K0738 PORT. GASEOUS O2 SYSTEM, HOME COMPRESSOR F 00047.26 RR 07012024 99999999 1 K0739 REPAIR OR MAINT. FOR DME PER 15 MIN F 00009.83 07012024 99999999 1 K0800 POV, GRP1, UP TO 300LBS F 01242.22 07012024 99999999 R K0800 POV, GRP1, UP TO 300LBS F 00124.22 RR 07012024 99999999 R K0801 POV, GRP1 HEAVY DUTY, 301-450LBS F 00200.23 RR 07012024 99999999 1 K0801 POV, GRP1 HEAVY DUTY, 301-450LBS F 02002.33 07012024 99999999 1 K0802 POV, GRP1 VERY HEAVY DUTY, 451-600 F 02266.28 07012024 99999999 R K0802 POV, GRP1 VERY HEAVY DUTY, 451-600 F 00226.63 RR 07012024 99999999 R K0806 POV, GRP2, UP TO 300LBS F 00150.27 RR 07012024 99999999 1 K0806 POV, GRP2, UP TO 300LBS F 01502.65 07012024 99999999 1 K0807 POV, GRP2 HEAVY DUTY, 301-450LBS F 02280.14 07012024 99999999 R K0807 POV, GRP2 HEAVY DUTY, 301-450LBS F 00228.01 RR 07012024 99999999 R K0808 POV, GRP2 VERY HEAVY DUTY, 451-600LBS F 00352.79 RR 07012024 99999999 1 K0808 POV, GRP2 VERY HEAVY DUTY, 451-600LBS F 03527.88 07012024 99999999 1 K0812 POV, NOT OTHERWISE CLASSIFIED M 00000.00 06112012 99999999 R K0812 POV, NOT OTHERWISE CLASSIFIED M 00000.00 RR 06112012 99999999 R K0813 PWC, GRP1, PORTABLE, UP TO 300LBS F 00233.78 RR 07012013 99999999 1 K0813 PWC, GRP1, PORTABLE, UP TO 300LBS F 02348.07 07012024 99999999 1 K0814 PWC, GRP1, PORTABLE, UP TO 300LBS F 03005.48 07012024 99999999 R K0814 PWC, GRP1, PORTABLE, UP TO 300LBS F 00299.24 RR 07012013 99999999 R K0815 PWC, GRP1, UP TO 300LBS F 00340.76 RR 07012013 99999999 1 K0815 PWC, GRP1, UP TO 300LBS F 03422.55 07012024 99999999 1 K0816 PWC, GRP1, UP TO 300LBS F 03277.62 07012024 99999999 R K0816 PWC, GRP1, UP TO 300LBS F 00326.33 RR 07012013 99999999 R K0820 PWC, GRP2, PORTABLE, UP TO 300LBS F 00250.79 RR 07012024 99999999 1 K0820 PWC, GRP2, PORTABLE, UP TO 300LBS F 02507.91 07012024 99999999 1 K0821 PWC, GRP2, PORTABLE, UP TO 300LBS F 03219.51 07012024 99999999 R K0821 PWC, GRP2, PORTABLE, UP TO 300LBS F 00321.95 RR 07012024 99999999 R K0822 PWC, GRP2, UP TO 300LBS F 00390.12 RR 07012024 99999999 1 K0822 PWC, GRP2, UP TO 300LBS F 03901.23 07012024 99999999 1 K0823 PWC, GRP2, UP TO 300LBS F 03916.42 07012024 99999999 R K0823 PWC, GRP2, UP TO 300LBS F 00391.64 RR 07012024 99999999 R K0824 PWC, GRP2 HEAVY DUTY, 301-450LBS F 00471.35 RR 07012024 99999999 1 K0824 PWC, GRP2 HEAVY DUTY, 301-450LBS F 04713.59 07012024 99999999 1 K0825 PWC, GRP2 HEAVY DUTY, 301-450LBS F 04116.84 07012024 99999999 R K0825 PWC, GRP2 HEAVY DUTY, 451-600LBS F 00411.68 RR 07012024 99999999 R K0826 PWC, GRP2 VERY HEAVY DUTY, 451-600LBS F 00610.21 RR 07012024 99999999 1 K0826 PWC, GRP2 VERY HEAVY DUTY, 451-600LBS F 06102.15 07012024 99999999 1 K0827 PWC, GRP2 VERY HEAVY DUTY, 451-600LBS F 04681.07 07012024 99999999 R K0827 PWC, GRP2 VERY HEAVY DUTY, 451-600LBS F 00468.10 RR 07012024 99999999 R K0828 PWC, GRP2 X-HEAVY DUTY, 601LBS &UP F 00672.39 RR 07012024 99999999 1 K0828 PWC, GRP2 X-HEAVY DUTY, 601LBS &UP F 06724.02 07012024 99999999 1 K0829 PWC, GRP2 X-HEAVY DUTY, 601LBS &UP F 05851.52 07012024 99999999 R K0829 PWC, GRP2 X-HEAVY DUTY, 601LBS &UP F 00585.14 RR 07012024 99999999 R K0830 PWC, GRP2, SEAT ELEV, UP TO 300LBS F 00380.96 RR 07012024 99999999 1 K0830 PWC, GRP2, SEAT ELEV, UP TO 300LBS F 03809.74 07012024 99999999 1 K0831 PWC, GRP2, SEAT ELEV, UP TO 300LBS F 03809.74 07012024 99999999 R K0831 PWC, GRP2, SEAT ELEV, UP TO 300LBS F 00380.96 RR 07012024 99999999 R K0835 PWC, GRP2, UP TO 300LBS F 00402.20 RR 07012024 99999999 1 K0835 PWC, GRP2, UP TO 300LBS F 04022.12 07012024 99999999 1 K0836 PWC, GRP2, UP TO 300LBS F 04095.33 07012024 99999999 R K0836 PWC, GRP2, UP TO 300LBS F 00409.53 RR 07012024 99999999 R K0837 PWC, GRP2 HEAVY DUTY, 301-450LBS F 00471.35 RR 07012024 99999999 1 K0837 PWC, GRP2 HEAVY DUTY, 301-450LBS F 04713.59 07012024 99999999 1 K0838 PWC, GRP2 HEAVY DUTY, 301-450LBS F 04255.63 07012024 99999999 R K0838 PWC, GRP2 HEAVY DUTY, 301-450LBS F 00425.56 RR 07012024 99999999 R K0839 PWC, GRP2 VERY HEAVY DUTY, 451-600LBS F 00610.21 RR 07012024 99999999 1 K0839 PWC, GRP2 VERY HEAVY DUTY, 451-600LBS F 06102.15 07012024 99999999 1 K0840 PWC, GRP2 X-HEAVY DUTY, 601LBS &UP F 09245.07 07012024 99999999 R K0840 PWC, GRP2 X-HEAVY DUTY, 601LBS &UP F 00924.50 RR 07012024 99999999 R K0841 PWC, GRP2, UP TO 300LBS F 00420.34 RR 07012024 99999999 1 K0841 PWC, GRP2, UP TO 300LBS F 04203.46 07012024 99999999 1 K0842 PWC, GRP2, UP TO 300LBS F 04203.46 07012024 99999999 R K0842 PWC, GRP2, UP TO 300LBS F 00420.34 RR 07012024 99999999 R K0843 PWC, GRP2 HEAVY DUTY, 301-450LBS F 00506.09 RR 07012024 99999999 1 K0843 PWC, GRP2 HEAVY DUTY, 301-450LBS F 05060.98 07012024 99999999 1 K0848 PWC, GRP3, UP TO 300LBS F 05288.73 07012024 99999999 R K0848 PWC, GRP3, UP TO 300LBS F 00528.87 RR 07012024 99999999 R K0849 PWC, GRP3, UP TO 300LBS F 00494.52 RR 07012024 99999999 1 K0849 PWC, GRP3, UP TO 300LBS F 04945.24 07012024 99999999 1 K0850 PWC, GRP3 HEAVY DUTY, 301-450LBS F 05976.21 07012024 99999999 R K0850 PWC, GRP3 HEAVY DUTY, 301-450LBS F 00597.62 RR 07012024 99999999 R K0851 PWC, GRP3 HEAVY DUTY, 301-450LBS F 00558.83 RR 07012024 99999999 1 K0851 PWC, GRP3 HEAVY DUTY, 301-450LBS F 05588.32 07012024 99999999 1 K0852 PWC, GRP 3 VERY HEAVY DUTY, 451-600LBS F 06893.77 07012024 99999999 R K0852 PWC, GRP 3 VERY HEAVY DUTY, 451-600LBS F 00689.37 RR 07012024 99999999 R K0853 PWC, GRP3 VERY HEAVY DUTY, 451-600LBS F 00705.08 RR 07012013 99999999 1 K0853 PWC, GRP3 VERY HEAVY DUTY, 451-600LBS F 07081.62 07012024 99999999 1 K0854 PWC, GRP3 X-HEAVY DUTY, 601LBS &UP F 09381.63 07012024 99999999 R K0854 PWC, GRP3 X-HEAVY DUTY, 601LBS &UP F 00938.16 RR 07012024 99999999 R K0855 PWC, GRP3 X-HEAVY DUTY, 601LBS &UP F 00886.23 RR 07012024 99999999 1 K0855 PWC, GRP3 X-HEAVY DUTY, 601LBS &UP F 08862.35 07012024 99999999 1 K0856 PWC, GRP3, UP TO 300LBS F 05521.07 07012024 99999999 R K0856 PWC, GRP3, UP TO 300LBS F 00552.11 RR 07012024 99999999 R K0857 PWC, GRP3, UP TO 300LBS F 00563.18 RR 07012024 99999999 1 K0857 PWC, GRP3, UP TO 300LBS F 05631.74 07012024 99999999 1 K0858 PWC, GRP3 HEAVY DUTY, 301-450LBS F 06849.97 07012024 99999999 R K0858 PWC, GRP3 HEAVY DUTY, 301-450LBS F 00685.00 RR 07012024 99999999 R K0859 PWC, GRP3 HEAVY DUTY, 301-450LBS F 00636.38 RR 07012024 99999999 1 K0859 PWC, GRP3 HEAVY DUTY, 301-450LBS F 06363.79 07012024 99999999 1 K0860 PWC, GRP3 VERY HEAVY DUTY, 451-600LBS F 09786.05 07012024 99999999 R K0860 PWC, GRP3 VERY HEAVY DUTY, 451-600LBS F 00978.60 RR 07012024 99999999 R K0861 PWC, GRP3, UP TO 300LBS F 00552.99 RR 07012024 99999999 1 K0861 PWC, GRP3, UP TO 300LBS F 05529.93 07012024 99999999 1 K0862 PWC, GRP3 HEAVY DUTY, 301-450LBS F 06849.97 07012024 99999999 R K0862 PWC, GRP3 HEAVY DUTY, 301-450LBS F 00685.00 RR 07012024 99999999 R K0863 PWC, GRP3 VERY HEAVY DUTY, 451-600LBS F 00978.60 RR 07012024 99999999 1 K0863 PWC, GRP3 VERY HEAVY DUTY, 451-600LBS F 09786.05 07012024 99999999 1 K0864 PWC, GRP3 X-HEAVY DUTY, 601LBS &UP F 12232.44 07012024 99999999 R K0864 PWC, GRP3 X-HEAVY DUTY, 601LBS &UP F 01223.23 RR 07012024 99999999 R K0868 PWC, GRP4, UP TO 300LBS F 00443.58 RR 07012024 99999999 1 K0868 PWC, GRP4, UP TO 300LBS F 04435.79 07012024 99999999 1 K0869 PWC, GRP4, UP TO 300LBS F 04435.79 07012024 99999999 R K0869 PWC, GRP4, UP TO 300LBS F 00443.58 RR 07012024 99999999 R K0870 PWC, GRP4 HEAVY DUTY, 301-450LBS M 00000.00 RR 06112012 99999999 1 K0870 PWC, GRP4 HEAVY DUTY, 301-450LBS M 00000.00 06112012 99999999 1 K0871 PWC, GRP4 VERY HEAVY DUTY, 451-600LBS M 00000.00 06112012 99999999 R K0871 PWC, GRP4 VERY HEAVY DUTY, 451-600LBS M 00000.00 RR 06112012 99999999 R K0877 PWC, GRP4, UP TO 300LBS M 00000.00 RR 06112012 99999999 1 K0877 PWC, GRP4, UP TO 300LBS M 00000.00 06112012 99999999 1 K0878 PWC, GRP4, UP TO 300LBS M 00000.00 06112012 99999999 R K0878 PWC, GRP4, UP TO 300LBS M 00000.00 RR 06112012 99999999 R K0879 PWC, GRP4 HEAVY DUTY, 301-450LBS M 00000.00 RR 06112012 99999999 1 K0879 PWC, GRP4 HEAVY DUTY, 301-450LBS M 00000.00 06112012 99999999 1 K0880 PWC, GRP4 VERY HEAVY DUTY, 451-600LBS M 00000.00 06112012 99999999 R K0880 PWC, GRP4 VERY HEAVY DUTY, 451-600LBS M 00000.00 RR 06112012 99999999 R K0884 PWC, GRP4, UP TO 300LBS F 00594.78 RR 07012024 99999999 1 K0884 PWC, GRP4, UP TO 300LBS F 05947.88 07012024 99999999 1 K0885 PWC, GRP4, UP TO 300LBS F 05877.99 07012024 99999999 R K0885 PWC, GRP4, UP TO 300LBS F 00587.79 RR 07012024 99999999 R K0886 PWC, GRP4 HEAVY DUTY, 301-450LBS F 00542.88 RR 07012024 99999999 1 K0886 PWC, GRP4 HEAVY DUTY, 301-450LBS F 05428.80 07012024 99999999 1 K0890 PWC, GRP5 PEDIATRIC, UP TO 125LBS M 00000.00 06112012 99999999 R K0890 PWC, GRP5 PEDIATRIC, UP TO 125LBS M 00000.00 RR 06112012 99999999 R K0891 PWC, GRP5 PEDIATRIC, UP TO 125LBS M 00000.00 RR 06112012 99999999 1 K0891 PWC, GRP5 PEDIATRIC, UP TO 125LBS M 00000.00 06112012 99999999 1 K0898 POWER WHEELCHAIR, NOC M 00000.00 06112012 99999999 R K0898 POWER WHEELCHAIR, NOC M 00000.00 RR 06112012 99999999 1 K0900 CUSTOM DME, OTHER THAN WHEELCHAIR M 00000.00 07012013 99999999 1 K1035 Mol diag reader self-admn M 00000.00 04012023 99999999 1 L0112 CRANIAL CERVICAL ORTHOSIS,CUSTOM F 01157.41 07012024 99999999 1 L0113 CRANIAL CX ORTHOS,W/WO JT/INTRF PREFAB F 00321.76 07012024 99999999 1 L0120 CERVICAL FLEXIBLE, NON-ADJUSTABLE (FOAM F 00025.37 07012025 99999999 1 L0130 CERVICAL, FLEXIBLE, THERMOPLASTIC COLLAR F 00055.55 07012024 99999999 1 L0140 CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTI F 00023.61 07012024 99999999 1 L0150 CERVICAL, SEMI RIGID ADJUSTABLE MOLDED C F 00050.00 07012024 99999999 1 L0160 CERVICAL, SEMI-RIGID, WIRE FRAME OCCIPIT F 00099.21 07012025 99999999 1 L0170 CERVICAL, COLLAR, MOLDED TO PATIENT MODE F 00415.21 07012025 99999999 1 L0172 CERVICAL COLLAR, SEMI-RIGID THERMOPLASTI F 00094.58 07012025 99999999 1 L0174 CERVICAL COLLAR, SEMI RIGID, TWO PIECE F 00216.42 07012025 99999999 1 L0180 CERVICAL, MULTIPLE POST COLLAR OCCIPITAL F 00169.76 07012025 99999999 1 L0190 CERVICAL, MULTIPLE POST COLLAR, OCCIPITA F 00362.35 07012024 99999999 1 L0200 CERVICAL, MULTIPLE POST COLLAR, OCCIPITA F 00323.10 07012025 99999999 1 L0220 THORACIC, RIB BELT, CUSTOM FABRICATED F 00050.00 07012024 99999999 1 L0450 TLSO,FLEX.UPPER TRUNK/THORACIC PREFAB F 00152.08 07012024 99999999 1 L0452 TLSO,FLEX.TRUNK/UPPER THORACIC,CUSTOM M 00000.00 09012018 99999999 1 L0454 TLSO,FLEX.TRUNK/SAGGITAL CONTROL,PREFAB F 00286.91 07012024 99999999 1 L0455 TLSO,flexible,provide trunk support,exte F 00325.57 07012025 99999999 1 L0456 TLSO FLEX.TRUNK SUPP.THORACIC REGION F 00854.00 07012025 99999999 1 L0457 TLSO,flexible,provide trunk support,thor F 00933.59 07012025 99999999 1 L0458 TLSO,TRIPLANER CONTROL,MOD.SEG.SPINAL F 00737.75 07012024 99999999 1 L0460 TLSO TRIPLANER CONTROL,SCAPULAR TO STERN F 00861.93 07012025 99999999 1 L0462 TLSO,TRIPLAN,3PLASTIC SHELLS POST/ANT F 00323.78 07012024 99999999 1 L0464 TLSO,TRIPLAN.CONT.4 RIGID SHELLS F 01276.31 07012025 99999999 1 L0466 TLSO,SAGITTAL CONT.RIGID FRAME F 00303.37 07012024 99999999 1 L0467 TLSO,sagital control,rigid posterior fra F 00344.22 07012025 99999999 1 L0468 TLSO,SAGITAL/CORONAL CONT.RIGID FRAME F 00385.29 07012024 99999999 1 L0469 TLSO,sagital-coronal control,rigid poste F 00421.20 07012024 99999999 1 L0470 TLSO,TRIPLAN.CONT.RIGID POST. FRAME F 00551.57 07012025 99999999 1 L0472 TLSO,TRIPLANER CONT.HYPEREXTENSION FRAME F 00347.57 07012025 99999999 1 L0480 TLSO,TRIPLANAR CONT.1RIGID SHELL F 01433.50 07012024 99999999 1 L0482 TLSO,TRIPLAN.CONT.SHELL W/LINER F 01392.56 07012025 99999999 1 L0484 TLSO,TRIPL.CONT.2 PIECE SHELL,W/OUT LINE F 01425.87 07012025 99999999 1 L0486 TLSO,TRIPLAN.CONT.2 SHELLS W/LINER F 01495.58 07012025 99999999 1 L0488 TLSO,TRIPLAN.CONT.1 SHELL W/LINER F 00830.38 07012024 99999999 1 L0490 TLSO,SAG.CORON.CONT.1 PIECE SHELL F 00233.99 07012024 99999999 1 L0491 TLSO 2 PIECE RIGID SHELL F 00233.99 07012024 99999999 1 L0492 TLSO 3 PIECE RIGID SHELL F 00233.99 07012024 99999999 1 L0621 SIO FLEX PELVISACRAL PREFAB F 00094.32 07012025 99999999 1 L0622 SIO FLEX PELVISACRAL CUSTOM F 00232.97 07012024 99999999 1 L0623 SIO PANEL PREFAB F 00122.48 07012024 99999999 1 L0624 SIO PANEL CUSTOM M 00000.00 09012018 99999999 1 L0625 LO FLEXIBL L1-BELOW L5 PRE F 00045.90 07012025 99999999 1 L0626 LO SAG STAYS/PANELS PRE-FAB F 00065.37 07012025 99999999 1 L0627 LO SAGITT RIGID PANEL PREFAB F 00342.66 07012025 99999999 1 L0628 LO FLEX W/O RIGID STAYS PRE F 00069.93 07012025 99999999 1 L0629 LSO FLEX W/RIGID STAYS CUST F 01059.27 07012024 99999999 1 L0630 LSO POST RIGID PANEL PRE F 00135.05 07012025 99999999 1 L0631 LSO SAG-CORO RIGID FRAME PRE F 00855.80 07012025 99999999 1 L0632 LSO SAG RIGID FRAME CUST M 00000.00 09012018 99999999 1 L0633 LSO FLEXION CONTROL PREFAB F 00230.30 07012024 99999999 1 L0634 LSO FLEXION CONTROL CUSTOM M 00000.00 09012018 99999999 1 L0635 LSO SAGIT RIGID PANEL PREFAB F 00807.75 07012024 99999999 1 L0636 LSO SAGITTAL RIGID PANEL CUS F 01328.65 07012024 99999999 1 L0637 LSO SAG-CORONAL PANEL PREFAB F 00992.90 07012025 99999999 1 L0638 LSO SAG-CORONAL PANEL CUSTOM F 01098.65 07012025 99999999 1 L0639 LSO S/C SHELL/PANEL PREFAB F 00956.55 07012024 99999999 1 L0640 LSO S/C SHELL/PANEL CUSTOM F 00872.31 07012025 99999999 1 L0641 Lumbar orthosis, sagittal control, with F 00070.49 07012024 99999999 1 L0642 Lumbar orthosis, sagittal control, with F 00385.83 07012025 99999999 1 L0643 Lumbar-sacral orthosis,sagittal control, F 00146.43 07012024 99999999 1 L0648 Lumbar-sacral orthosis,sagittal control, F 00963.64 07012025 99999999 1 L0649 Lumbar-sacral orthosis,sagittal-coronal F 00259.30 07012024 99999999 1 L0650 Lumbar-sacral orthosis,sagittal-coronal F 01118.01 07012025 99999999 1 L0651 Lumbar-sacral orthosis, sagittal-coronal F 01118.01 07012025 99999999 1 L0700 CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSIS F 01457.82 07012025 99999999 1 L0710 CTLSO, ANTERIOR-POSTERIOR-LATERAL-CONTRO F 01556.40 07012025 99999999 1 L0810 HALO, CERVICAL INTO JACKET VEST F 02328.43 07012025 99999999 1 L0820 HALO CERVICAL INTO BODY JACKET F 01793.66 07012024 99999999 1 L0830 HALO INTO MILWAUKEE TYPE ORTHOSIS F 02640.98 07012024 99999999 1 L0859 MRI COMPATIBLE SYSTEM F 01030.69 07012025 99999999 1 L0861 HALO, REPLACE LINER/INTERFACE F 00194.05 07012025 99999999 1 L0970 TLSO, CORSET FRONT F 00055.55 07012024 99999999 1 L0972 LOS, CORSET FRONT F 00055.55 07012024 99999999 1 L0974 TLSO, FULL CORSET F 00124.55 07012025 99999999 1 L0976 LSO, FULL CORSET F 00123.96 07012025 99999999 1 L0978 AXILLARY CRUTCH EXTENSION F 00138.89 07012024 99999999 1 L0980 PERITONEAL STRAPS, PAIR F 00005.55 07012024 99999999 1 L0982 STOCKINGS SUPPORTER GRIPS, SET OF FOUR ( F 00008.34 07012024 99999999 1 L0984 PROTECTIVE BODY SOCK F 00051.88 07012025 99999999 1 L0999 ADDITION TO SPINAL ORTHOSIS NOT SPECIFIE M 00000.00 09012018 99999999 1 L1000 CERVICAL-THORACIC-LUMBAR-SACRAL (CTLSO) F 01231.05 07012025 99999999 1 L1001 CTLSO INFANT IMMOBILIZER M 00000.00 09012018 99999999 1 L1005 TENSION BASED SCIOLOSIS ORTH & ACC PADS F 02748.27 07012025 99999999 1 L1006 Scoliosis orth sag/ cor M 00000.00 10012024 99999999 1 L1010 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, F 00014.44 07012024 99999999 1 L1020 ADD TO CTLSO - KYPHOSIS PAD F 00036.92 07012025 99999999 1 L1025 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS F 00089.41 07012024 99999999 1 L1030 ADD TO CTLSO- LUMBAR BOLSTER PAD F 00036.92 07012025 99999999 1 L1040 ADD TO CTLSO - LUMBAR OR LUMBAR RIB PAD F 00040.22 07012025 99999999 1 L1050 ADD TO CTLSO - STERNAL PAD F 00039.21 07012025 99999999 1 L1060 ADD TO CTLSO - THORACIC PAD F 00041.12 07012025 99999999 1 L1070 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS F 00014.44 07012024 99999999 1 L1080 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSES F 00011.10 07012024 99999999 1 L1085 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS F 00110.36 07012024 99999999 1 L1090 ADDITIONS TO CTLSO - LUMBAR SLING F 00019.82 07012024 99999999 1 L1100 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS F 00100.45 07012024 99999999 1 L1110 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSES F 00200.00 07012024 99999999 1 L1120 ADD TO CTLSO OR SIO COVERS FOR UPRIGHT E F 00010.08 07012024 99999999 1 L1200 THORACIC-LUMBAR-SACAL-ORTHOSES (TLSO), I F 01107.21 07012025 99999999 1 L1210 ADDITION TO TLSO, LOW PROFILE, LATERAL T F 00063.44 07012025 99999999 1 L1220 ADDITIONS TO TLSO, (LOW PROFILE) ANTERIO F 00063.44 07012025 99999999 1 L1230 ADDITION TO TLSO, (LOW PROFILE) MILWAUKE F 00302.23 07012024 99999999 1 L1240 ADDITION TO TLSO, LOW PROFILE,LUMBAR PAD F 00057.79 07012025 99999999 1 L1250 ADDITION TO TLSO, ANTERIOR ASIS PAD F 00053.78 07012025 99999999 1 L1260 ADDITION TO TSLO, ANTERIOR DEROTATION F 00056.32 07012025 99999999 1 L1270 ADDITION TO TLSO, ABDOMINAL PAD F 00055.55 07012024 99999999 1 L1280 ADDITION TO TLSO, RIB GUSSET EACH F 00061.85 07012024 99999999 1 L1290 ADDITION TO TLSO, LATERAL TROCHANTERI F 00058.50 07012025 99999999 1 L1300 OTHER SCOLIOSIS PROCEDURES BODY JACKET M F 01107.21 07012025 99999999 1 L1310 OTHER SCOLIOSIS PROC POST - OP BODY JACK F 01097.79 07012024 99999999 1 L1499 UNLISTED PROCEDURE FOR SPINAL ORTHOSIS M 00000.00 09012018 99999999 R L1500 THORACIC-HIP-KNEE-ANKLE MOBILITY FRAME F 00158.96 RR 07012024 99999999 R L1520 THKAO, SWIVAL WALKER F 00186.54 RR 07012024 99999999 1 L1600 HIP ORTHOSES (HO) ABDUCTION CONTROL OF H F 00100.16 07012024 99999999 1 L1610 HO, ABDUCTION CONTROL OF HIP JOINTS, FLE F 00040.18 07012024 99999999 1 L1620 HO, ABDUCTION CONTROL OF HIP JOINTS, FLE F 00111.54 07012025 99999999 1 L1630 HO, ABDUCTION CONTROL OF HIP JOINTS, SEM F 00128.09 07012024 99999999 1 L1640 HO, ABDUCTION CONTROL OF HIP JOINTS, STA F 00271.11 07012024 99999999 1 L1650 HO, ABDUCTION CONTROL OF HIP JOINTS, STA F 00189.55 07012024 99999999 1 L1652 HO BI THIGHCUFFS W SPRDR BAR F 00294.89 07012024 99999999 1 L1660 HO, ABDUCTION CONTROL OF HIP JOINTS, STA F 00138.07 07012025 99999999 1 L1680 HO, ABDUCTION CONTROL OF HIP JOINTS DYNA F 00960.01 07012024 99999999 1 L1681 Hip orthosis, bilateral hip joints and t F 01925.87 12012025 99999999 1 L1685 HO, ABDUCT CONTROL OF HIP JT,POST OP,CUS F 00821.36 07012024 99999999 1 L1686 HO,ABDUCT CONTROL OF HIP JT,POST OP,CUST F 00735.98 07012025 99999999 1 L1690 COMBINATION, BILATERAL LUMBO SACRAL F 01660.42 07012025 99999999 1 L1700 LEGG PERTHES ORTHOSIS, TORONTO TYPE F 00983.89 07012024 99999999 1 L1710 LEGG PERTHES ORTHOSIS, NEWINGTON TYPE F 00800.00 07012024 99999999 1 L1720 LEGG PERTHES ORTHOSIS, TRILATERAL, (TACH F 00801.74 07012024 99999999 1 L1730 LEGG PERTHES ORTHOSIS, SCOTTISH RITE TYP F 00833.98 07012024 99999999 1 L1755 LEGG PERTHES ORTHOSIS F 01161.64 07012024 99999999 1 L1810 KNEE ORTHOSIS, ELASTIC WITH JOINTS F 00080.76 07012025 99999999 1 L1812 Knee orthosis, elastic with joints, pref F 00088.28 07012025 99999999 1 L1820 KO ELAS W/ CONDYLE PADS & JO F 00088.80 07012025 99999999 1 L1830 KO, IMMOBILIZER; CANVAS LONGITUDINAL F 00073.52 07012025 99999999 1 L1831 KNEE ORTH.LOCKING JOINT PREFABRICATED F 00252.72 07012025 99999999 1 L1832 KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS F 00490.53 07012025 99999999 1 L1833 Knee orthosis, adjustable knee joints,po F 00536.25 07012025 99999999 1 L1834 KO, WITHOUT KNEE JOINT, RIGID, MOLDED F 00797.00 07012024 99999999 1 L1836 KNEE ORTH.RIGID,W/OUT JOINT,W/LINER F 00114.56 07012025 99999999 1 L1840 KO, DEROTAT FAB TO PT MDL LENNOX HILL OR F 00895.55 07012024 99999999 1 L1843 KNEE ORTHOSIS, SINGLE UPRIGHT F 00770.46 07012025 99999999 1 L1844 KNEE ORTHOSIS, SINGLE UPRIGHT F 01985.65 07012025 99999999 1 L1845 KNEE ORTHOSIS, DOUBLE UPRIGHT F 00659.48 07012025 99999999 1 L1846 KNEE ORTHOSIS, DOUBLE UPRIGHT F 01102.39 07012025 99999999 1 L1847 KNEE ORTHOSIS, DOUBLE UPRIGHT ADJUSTABLE F 00475.78 07012024 99999999 1 L1848 Knee orthosis double upright w/ adjustab F 00520.12 07012024 99999999 1 L1850 KO, SWEDISH TYPE F 00240.71 07012025 99999999 1 L1851 KNEE ORTHOSIS; SINGLE UPRIGHT; THIGH AND F 00857.43 07012025 99999999 1 L1852 KNEE ORTHOSIS; DOUBLE UPRIGHT; THIGH AND F 00733.93 07012025 99999999 1 L1860 KO, MODIFICATION OF SRIPIACONDYLAR PROST F 01296.16 07012024 99999999 1 L1900 AFO, SPRING WIRE, DORSIFLEXICON ASSIST C F 00133.33 07012024 99999999 1 L1902 AFO, ANKEL GAUNTLET F 00067.96 07012025 99999999 1 L1904 AFO, MOLDED ANKLE GAUNTLET F 00338.95 07012024 99999999 1 L1906 AFO, MULTIGAMENTUS ANKLE SUPPORT F 00097.04 07012025 99999999 1 L1907 AFO SUPRAMALLEOLAR W/STRAPS CUSTOM F 00483.13 07012025 99999999 1 L1910 AFO, POSTERIOR, SINGLE BAR, CLASP ATTACH F 00207.87 07012024 99999999 1 L1920 AFO, SINGLE UPRIGHT WITH STATIC OR ADJUS F 00234.38 07012024 99999999 1 L1930 AFO, PLASTIC OR OTHER,PREFABRICATED F 00223.07 07012025 99999999 1 L1932 AFO RIG ANT TIB TCF/ F 00743.24 07012025 99999999 1 L1940 AFO, PLASTIC OR OTHER,CUSTOM MADE F 00388.19 07012025 99999999 1 L1945 AFO,MOLD TO PAT. MODEL,PLASTIC,RIGID ANT F 00663.52 07012025 99999999 1 L1950 AFO, SPIRAL, MOLDED TO PATIENT MODEL (IR F 00557.90 07012025 99999999 1 L1951 AFO SPIRAL PREFAB CUSTOM F 00721.13 07012025 99999999 1 L1960 AFO, POSTERIOR SOLID ANKLE, MOLDED TO PA F 00517.17 07012025 99999999 1 L1970 AFO, PLASTIC MOLDED TO PATIENT MODEL, WI F 00609.61 07012025 99999999 1 L1971 AFO W/ANKLE JOINT, PREFAB F 00402.45 07012025 99999999 1 L1980 AFO,SINGL UPRIGHT FREE PLANT DORSIFLEX S F 00268.19 07012024 99999999 1 L1990 AFO DOUBL UPRIGHT FREE PLANTAR DORSIFLEX F 00368.82 07012025 99999999 1 L2000 KAFO SINGLE UPRIGHT FREE KNE/ANKLE SOL S F 00680.01 07012024 99999999 1 L2005 KAF ORTH ANY MATERIAL,CUSTOM F 02998.18 07012025 99999999 1 L2010 KAFO,SINGLE UPRIGHT,FREE KNE/ANKLE SOL S F 00641.93 07012024 99999999 1 L2020 KAFO SINGLE UPRIGHT FREE ANKLE F 00812.55 07012025 99999999 1 L2030 KAFO, DOUBLE UPRIGHT, FREE KNEE, FREE AN F 00744.99 07012024 99999999 1 L2034 KAFO PLA SIN UP W/WO K/A CUS F 00070.36 07012025 99999999 1 L2035 KAFO, FULL PLASTIC, STATIC/PEDIAT.SIZE F 00143.28 07012024 99999999 1 L2036 KAFO,FULL PLASTIC,MOLDED TO PATIENT MODE F 01380.76 07012025 99999999 1 L2037 KAFO,FULL PLASTIC,SINGLE UPRIGHT,FREE KN F 01193.87 07012025 99999999 1 L2038 KAFO, FULL PLASTIC,SINGLE UPRIGHT F 01025.16 07012024 99999999 1 L2040 HIP-KNEE-ANKLE-FOOT, ORTHISES TORSION CO F 00070.36 07012025 99999999 1 L2050 HKAFO, TORSION CONTROL, BILATERAL TORSIO F 00331.49 07012025 99999999 1 L2060 HKAFO, TORSION CONTROL, BILATERAL TORSIO F 00403.01 07012024 99999999 1 L2070 HKAFO, TORSION CONTROL, UNILATERAL ROTAT F 00058.81 07012025 99999999 1 L2080 3.AFO, TORSION CONTROL, UNILATERAL, TORS F 00212.50 07012024 99999999 1 L2090 HKAFO, TORSION CONTROL, UNILATERAL TORSI F 00253.32 07012024 99999999 1 L2106 AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE F 00487.53 07012024 99999999 1 L2108 AFO, FRACT ORTH, TIBIAL FRACT CAST ORTHO F 00650.35 07012025 99999999 1 L2112 AFO, FRACTURE ORTHOSIS, TIBIAL SOFT F 00362.65 07012024 99999999 1 L2114 AFO, FRACTURE ORTHOSIS,TIBIAL,SEMI RIGID F 00476.63 07012024 99999999 1 L2116 AFO, FRACTURE ORTHOSIS, TIBIAL RIGID F 00608.05 07012025 99999999 1 L2126 KAFO, FRACTURE ORTHOSIS, FEMORAL, MOLDED F 00858.61 07012024 99999999 1 L2128 KAFO,FRACTURE ORTHOSIS,FEMO FRACT CAST O F 01193.28 07012025 99999999 1 L2132 KAFO,FRACTURE ORTHOSIS,FEMORAL,SOFT F 00626.00 07012024 99999999 1 L2134 KAFO,FRACTURE ORTHOSIS,FEMORAL,SEMI RIGI F 00751.79 07012024 99999999 1 L2136 KAFO,FRACTURE ORTHOSIS,FEMORAL,RIGID F 00963.39 07012025 99999999 1 L2180 PLASTIC SHOE INSERT WITH ANKLE JOINTS F 00073.81 07012025 99999999 1 L2182 DROP LOCK KNEE JOINT F 00076.51 07012025 99999999 1 L2184 ADDITION TO LOWER EXTREMITY,LIMITED F 00088.82 07012024 99999999 1 L2186 ADJUSTABLE MOTION KNEE JOINT (LERMAN TYP F 00046.12 07012025 99999999 1 L2188 ADDITION TO LOWER EXTREMITY QUADRILATERA F 00214.76 07012024 99999999 1 L2190 WAIST BELT F 00061.89 07012024 99999999 1 L2192 HIP JOINT,PELVIC BAND,THIGH FLANGE, AND F 00314.33 07012025 99999999 1 L2200 ADD-LWR EXTRM ORTHO-LTD ANKLE MOTION EAC F 00033.09 07012025 99999999 1 L2210 ADD-LWR EXTRM ORTHO-DORSIFLEX ASSIST PLA F 00036.92 07012025 99999999 1 L2220 ADD-LWR EXTRM ORTHO DORSIFLEX PLANT FLEX F 00043.81 07012025 99999999 1 L2230 ADD-LWR EXTREM ORTHO SPLIT FLAT CALIP ST F 00043.81 07012025 99999999 1 L2232 ADD LOWER EXT ORTH,ROCKER BOTTOM CUSTOM F 00083.78 07012025 99999999 1 L2240 ADD-LWR EXTREM ORTHO ROUND CALIPAR AND P F 00041.11 07012024 99999999 1 L2250 ADD-LWR EXTREM ORTHO FOOT PLATE MLD TO P F 00244.50 07012025 99999999 1 L2260 ADD-LWR EXTREM ORTHO REINFORCE SOLID STI F 00056.52 07012025 99999999 1 L2265 ADD. TO LOWER EXTREMITY, LONG TONGUE F 00089.45 07012025 99999999 1 L2270 ADDITIONS TO LOWER EXTREMITY, VARUS/VALG F 00037.38 07012025 99999999 1 L2275 ADD TO LOW EXTREMITY,VARUS/VULGUS CORR,P F 00114.27 07012025 99999999 1 L2280 ADD-LWR EXTREM ORTHO MOLDED INNER BOOT F 00293.67 07012025 99999999 1 L2300 ADD-LWR EXTREM ORTHO ABDUCTION BAR JOINT F 00110.73 07012025 99999999 1 L2310 ADD-LWR EXTREM ORTHO ABDUCTION BAR STRAI F 00044.43 07012024 99999999 1 L2320 ADD-LWR EXTREM ORTHO NON MOLDED LACER F 00039.99 07012024 99999999 1 L2330 ADD-LWR EXTREM ORTHO LACER MOLDED TO PT F 00119.37 07012025 99999999 1 L2335 ADD. TO LOWER EXTREMITY,ANTERIOR BAND F 00217.19 07012024 99999999 1 L2340 ADD-LWR EXTREM ORTHO PRE TIB SHELL MOLDE F 00293.67 07012025 99999999 1 L2350 ADD-LWR EXTREM ORTHO BK SOCKET MOLDED TO F 00678.38 07012025 99999999 1 L2360 ADD-LWR EXTREM ORTHO EXTENDED STEEL SHAN F 00020.76 07012025 99999999 1 L2370 ADD. TO LOWER EXTREMITY,PATTEN BOTTOM F 00245.41 07012024 99999999 1 L2375 ADD. TO LOWER EXTREMITY, TORSION CONTROL F 00087.38 07012024 99999999 1 L2380 TORSION CONTROL,STRAIGHT KNEE JOINT,EACH F 00029.40 07012025 99999999 1 L2385 STRAIGHT KNEE JOINT,HEAVY DUTY,EACH JOIN F 00044.29 07012025 99999999 1 L2387 ADD LE POLY KNEE CUSTOM KAFO F 00044.29 07012025 99999999 1 L2390 ADD:OFFSET KNEE JOINT,EACH JOINT F 00076.17 07012025 99999999 1 L2395 OFFSET KNEE JOINT,HEAVY DUTY,EACH JOINT F 00011.83 07012025 99999999 1 L2397 ADD. TO LOWER EXTREMITY SUSPENSION F 00100.29 07012025 99999999 1 L2405 ADDITION TO KNEE JOINT,DROP LOCK,EACH JO F 00035.42 07012025 99999999 1 L2415 ADD TO KNEE JOINT,CAM LOCK,EACH JOINT F 00044.29 07012025 99999999 1 L2425 DISC OR DIAL LOCK FOR ADJ KNEE FLEXION,E F 00130.61 07012025 99999999 1 L2430 ADD-LWR EXTREM ORTHO STRGHT KNEE JNT POL F 00077.32 07012025 99999999 1 L2492 ADD TO KNEE JOINT,LIFT LOOP OR DROP LOCK F 00039.21 07012025 99999999 1 L2500 ADD-LWR EXTREM ORTHO THIGH/WGT BEARING,G F 00147.50 07012024 99999999 1 L2510 ADD-LWR EXTREM ORTHO THIGH WGT BEARING Q F 00386.96 07012025 99999999 1 L2520 ADD-LWR EXTREM ORTHO THIGH WGT BEARING Q F 00318.11 07012024 99999999 1 L2525 ADD TO LOW EXTREM,THIGH/WEIGHT BEARING,I F 00957.20 07012025 99999999 1 L2526 ADD TO LOW EXTREM,THIGH/WEIGHT BEARING,C F 00490.93 07012025 99999999 1 L2530 ADD-LWR EXTREM ORTHO THIGH WGT BEARING L F 00121.54 07012024 99999999 1 L2540 ADD-LWR EXTREM ORTHO THIGH WGT BEARING L F 00163.74 07012024 99999999 1 L2550 ADD-LWR EXTREM ORTHO THIGH WGT BEARING H F 00058.81 07012025 99999999 1 L2570 ADD-LWR EXTREM ORTHO GLUTEAL/ISHIAL WGT F 00392.79 07012025 99999999 1 L2580 ADD-LWR EXTREM ORTHO GLUTEAL/ISHIAL WGT F 00065.17 07012024 99999999 1 L2600 ADD-LWR EXTREM ORTHO PELVIC CNTRL HIP JN F 00099.19 07012025 99999999 1 L2610 PELVIC CONTROL, HIP JOINT, CLEIVS OR THR F 00168.99 07012025 99999999 1 L2620 ADD-LWR EXTREM ORTHO PELVIC CNTR HIP JNT F 00234.94 07012025 99999999 1 L2622 ADD. TO LOWER EXTREMITY, PELVIC CONTROL F 00239.98 07012025 99999999 1 L2624 PELVIC C0NTROL,HIP JNT,ADJ FLEX,EXTEN AB F 00271.82 07012025 99999999 1 L2627 ADD TO LOW EXTREM,PLASTIC,MOLD TO PAT,RE F 01228.73 07012025 99999999 1 L2628 ADD TO LOW EXTREM,METAL FRAME,RECIPROCAT F 01156.93 07012024 99999999 1 L2630 ADD-LWR EXTREM PELVIC CNTRL HIP JNT BAND F 00137.55 07012025 99999999 1 L2640 ADD-LWR EXTREM ORTHO PELVIC CNTRL HIP JN F 00197.13 07012025 99999999 1 L2650 ADD-LWR EXTREM ORTHO PELVIC/THORACIC CNT F 00102.29 07012024 99999999 1 L2660 ADD-LWR EXTREM ORTHO THORACIC CONTROL TH F 00066.67 07012024 99999999 1 L2670 ADD-LWR EXTREM ORTHO THORACIC CONTROL PA F 00101.31 07012024 99999999 1 L2680 ADD-LWR EXTREM ORTHO THORACIC CNTR LATER F 00091.32 07012025 99999999 1 L2750 ADDITION TO LOWER EXTREMITY ORTHOSES, PL F 00068.23 07012025 99999999 1 L2755 ADDITION TO LOWER EXTREM ORTHOSIS F 00103.48 07012025 99999999 1 L2760 ADD-LWR EXTREM ORTHO EXTENSION PER EXTEN F 00017.29 07012025 99999999 1 L2768 ORTHOTIC SIDE BAR DISCONNECT DEVICE/BAR F 00110.69 07012025 99999999 1 L2780 ADDITIONS TO LOWER EXTREMITY NON-CORROSI F 00050.02 07012025 99999999 1 L2785 ADD. TO LOWER EXTREMITY,DROP LOCK RETAIN F 00025.16 07012025 99999999 1 L2795 ADD. TO LOWER EXTREMITY, KNEE CONTROL F 00063.25 07012025 99999999 1 L2800 ADD. TO LOWER EXTREMITY, KNEE CONTROL F 00079.39 07012025 99999999 1 L2810 KNEE CONTROL,CONDYLAR PAD F 00042.38 07012025 99999999 1 L2820 SOFT INTERFACE FOR MOLDED PLASTIC,BELOW F 00046.71 07012025 99999999 1 L2830 SOFT INTERFACE FOR MOLDED PLASTIC,ABOVE F 00067.31 07012025 99999999 1 L2840 ADD. TO LOWER EXTREMITY, TIBIAL SOCK F 00033.63 07012025 99999999 1 L2850 ADDITION TO LOWER EXTREMITY ORTHOSIS, FE F 00061.01 07012025 99999999 1 L2861 ADD TO LE JT, KNEE/ANKL, ORTHOTICS, EA M 00000.00 09012022 99999999 1 L2999 UNLISTED PROCEDURES FOR LOWER EXTREMITY M 00000.00 09012018 99999999 1 L3000 FOOT, INSERT, REMOVABLE, MOLDED TO PATIE F 00197.56 07012025 99999999 1 L3001 FOOT, INSERT, REMOVABLE, MOLDED TO PATIE F 00082.14 07012025 99999999 1 L3002 FOOT, INSERT, REMOVABLE, MOLDED TO PATIE F 00087.37 07012025 99999999 1 L3003 FOOT, INSERT, REMOVABLE, MOLDED TO PATIE F 00149.59 07012025 99999999 1 L3010 FOOT, INSERT, REMOVABLE, MOLDED TO PATIE F 00082.14 07012025 99999999 1 L3020 FOOT, INSERT, REMOVABLE, MOLDED TO PATIE F 00082.14 07012025 99999999 1 L3030 FOOT, INSERT, REMOVABLE FORMED T0 PATIEN F 00075.77 07012025 99999999 1 L3031 FOOT INSERT,REMOV.ADD.TO LOW.EXTREMITY F 00143.44 07012025 99999999 1 L3040 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED F 00046.75 07012025 99999999 1 L3050 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED F 00046.75 07012025 99999999 1 L3060 FOOT, ANKLE SUPPORT, REMOVABLE, PREMOLDE F 00043.99 07012025 99999999 1 L3070 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACH F 00023.63 07012024 99999999 1 L3080 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACH F 00017.73 07012024 99999999 1 L3090 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACH F 00035.45 07012024 99999999 1 L3100 HALLUS-VALGUS NIGHT DYNAMIC SPLINT F 00036.80 07012025 99999999 1 L3140 FOOT, ABDUCTION ROTATION BARS (DENNIS BR F 00048.47 07012024 99999999 1 L3150 FOOT, ABDUCTION ROTATION BARS (DENNIS BR F 00050.31 07012025 99999999 1 L3160 FOOT, TORQUE HEELS ON ORTHOPEDIC SHOE M 00000.00 09012018 99999999 1 L3170 FOOT, PLASTIC, SILICONE OR EQUAL, F 00014.44 07012024 99999999 1 L3204 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR F 00049.41 07012025 99999999 1 L3209 SURGICAL BOOT, EACH, CHILD F 00011.81 07012024 99999999 1 L3211 SURGICAL BOOT, EACH, JUNIOR F 00012.19 07012024 99999999 1 L3215 ORTHOPEDIC FOOTWEAR, LADIES SHOES, OXFOR F 00057.66 07012025 99999999 1 L3216 ORTHOPEDIC FOOTWEAR, LADIES SHOES, DEPTH F 00057.66 07012025 99999999 1 L3217 ORTHOPEDIC FOOTWEAR, LADIES SHOES, HIGHT F 00057.66 07012025 99999999 1 L3219 ORTHOPEDIC FOOTWEAR, MENS SHOES, OXFORD F 00059.90 07012025 99999999 1 L3221 ORTHOPEDIC FOOTWEAR, MENS SHOES, DEPTH F 00074.74 07012025 99999999 1 L3222 ORTHOPEDIC FOOTWEAR, MENS SHOES, HIGHTOP F 00074.74 07012025 99999999 1 L3224 ORTHOPEDIC FOOTWARE, WOMANS SHOES OXFORD F 00053.49 07012025 99999999 1 L3225 ORTHOPEDIC FOOTWARE, MANS SHOE,OXFORD F 00062.22 07012025 99999999 1 L3230 ORTHOPEDIC FOOTWEAR, CUSTOM SHOES, DEPTH F 00236.97 07012025 99999999 1 L3250 ORTHO FTWR CUSTOM MOLDED REMOVE INNER MO F 00236.97 07012025 99999999 1 L3254 NON-STANDARD SIZE OR WIDTH M 00000.00 06112012 99999999 1 L3255 NON-STANDARD SIZE OR LENGTH(SHOE) M 00000.00 06112012 99999999 1 L3257 ORTHOPEDIC FOOTWARE, SPLIT SIZE F 00201.84 07012025 99999999 1 L3260 AMBULATORY SURGICAL BOOT, EACH, ADULT F 00018.82 07012025 99999999 1 L3265 PLASTAZOTE SANDAL-ADULT (EACH) F 00046.89 07012024 99999999 1 L3330 LIFTS, ELEVATION, METAL EXTENSION, SKATE F 00468.00 07012024 99999999 1 L3340 HEEL WEDGE, EACH F 00019.01 07012024 99999999 1 L3350 HEEL WEDGE F 00022.42 07012025 99999999 1 L3400 METATARSAL BAR WEDGE, ROCKER F 00022.42 07012025 99999999 1 L3410 METATARSAL BAR WEDGE, BETWEEN SOLE F 00022.42 07012025 99999999 1 L3455 HEEL, NEW LEATHER, STANDARD/ORTHPED SHOE F 00033.65 07012024 99999999 1 L3460 HEEL, NEW RUBBER, STANDARD ON ORTH SHOE F 00028.38 07012024 99999999 1 L3480 HEEL, PAD AND DEPRESSION FOR SPUR F 00018.52 07012024 99999999 1 L3485 HEEL, PAD, REMOVABLE FOR SPUR F 00018.52 07012024 99999999 1 L3500 ORTHOPEDIC SHOE ADDITION, INSOL, LEATHER F 00024.18 07012024 99999999 1 L3510 ORTHOPEDIC SHOE ADDITION,INSOLE, RUBBER F 00024.18 07012024 99999999 1 L3520 ORTHOPEDIC SHOE ADDITION, INSOLE, FELT F 00026.29 07012024 99999999 1 L3530 MISCELLANEOUS SHOE ADDITIONS, SOLE, HALF F 00011.48 07012025 99999999 1 L3540 MISCELLANEOUS SHOE ADDITIONS, SOLE, FULL F 00018.40 07012025 99999999 1 L3550 MISCELLANEOUS SHOE ADDITIONS, TOE TAP, S F 00007.67 07012025 99999999 1 L3560 MISCELLANEOUS SHOE ADDITIONS, TOE TAP, H F 00018.93 07012024 99999999 1 L3570 MISCELLANEOUS SHOE ADDITIONS, SPECIAL EX F 00070.47 07012024 99999999 1 L3595 MISCELLANEOUS SHOE ADDITIONS MARCH BAR F 00034.68 07012024 99999999 1 L3600 TRANSFER OF ORTHO FROM 1 SHOE TO OTHER,C F 00037.19 07012025 99999999 1 L3610 TRANSFER OF ORTHOSIS FROM 1 SHOE TO OTHE F 00099.56 07012025 99999999 1 L3620 TRANSFER OF ORTHOSIS FROM 1 SHOE TO OTHE F 00037.19 07012025 99999999 1 L3630 TRANSFER OF ORTHOSIS FROM 1 SHOE TO OTHE F 00099.56 07012025 99999999 1 L3640 TRANSFERS OF AN ORTHOSIS FROM ONE SHOE T F 00023.68 07012024 99999999 1 L3649 SHOE INSERTS OR MODIFICATIONS N.O.C. M 00000.00 09012018 99999999 1 L3650 SHOULDER ORTHOSIS (SO) FIGURE OF "8" DES F 00055.56 07012025 99999999 1 L3660 SO, FIGURE OF "8" DESIGN ABDUCTION RESTR F 00097.90 07012024 99999999 1 L3670 SO, ACROMIO/CLAVICULAR (CANVAS AND WEBBI F 00119.04 07012025 99999999 1 L3671 SHOULDER ORTHOSIS,JNT DESIGN,W/O JNTS F 00055.56 07012025 99999999 1 L3674 SHOULDER ORTHOSIS, ABD POSITIONING F 00933.17 07012024 99999999 1 L3675 SO, VEST TYPE, CANVAS F 00137.13 07012025 99999999 1 L3677 SHOULDER ORTHOSIS,JNT DESIGN,W/O JNTS M 00000.00 09012018 99999999 1 L3678 Shoulder orthosis, shoulder joint design M 00000.00 09012018 99999999 1 L3702 EO W/O JOINTS CF F 00065.47 07012024 99999999 1 L3710 EO, ELASTIC WITH METAL JOINTS DOUBLE UPR F 00097.59 07012025 99999999 1 L3720 EO, DOUBLE UPRIGHT WITH FOREARM/ARM CUFF F 00466.32 07012025 99999999 1 L3730 EO, DOUBLE UPWRIGHT WITH FOREARM/ARM CUF F 00702.22 07012024 99999999 1 L3740 EO, DOUBLE UPRIGHT WITH FOREARM/ARM CUFF F 00744.89 07012024 99999999 1 L3760 ELBOW ORTHOSIS, W ADJ LOCKING JOINT F 00390.81 07012025 99999999 1 L3761 Elbow orthosis (eo), with adjustable pos F 00439.72 07012025 99999999 1 L3762 ELBOW ORTH.RIGID,W/OUT JOINTS PREFAB. F 00084.10 07012025 99999999 1 L3763 EWHO RIGID W/O JNTS CF F 00067.96 07012025 99999999 1 L3764 EWHO W/JOINT(S) CF F 00065.47 07012024 99999999 1 L3765 EWHFO RIGID W/O JNTS CF F 00065.47 07012024 99999999 1 L3766 EWHFO W/JOINT(S) CF F 00065.47 07012024 99999999 1 L3806 WHFO W/JOINT(S) CUSTOM FAB F 00341.87 07012024 99999999 1 L3807 WHFO, W/OUT JOINT PREFABRICATED F 00195.38 07012025 99999999 1 L3808 WHFO, RIGID W/O JOINTS F 00268.41 07012025 99999999 1 L3809 Wrist hand finger orthosis, without join F 00213.59 07012025 99999999 1 L3900 WHFO, DYNAMIC FLEXOR HINGE; RECIPROCAL W F 00734.86 07012025 99999999 1 L3901 WHFO, DYMANIC FLEXOR HINGE, RECIPROCAL W F 01131.69 07012024 99999999 1 L3904 WHFO, EXTERNAL POWERED, ELECTRIC F 02040.48 07012024 99999999 1 L3905 WHO W/NONTORSION JNT(S) CF F 00087.89 07012025 99999999 1 L3906 WHO, WITHOUT JOINTS F 00157.00 07012025 99999999 1 L3908 WHFO, WRIST EXTENSION CONTROL (COCK-UP), F 00048.08 07012025 99999999 1 L3912 WHFO, FLEXION GLOVE WITH ELASTIC FINGER F 00089.23 07012024 99999999 1 L3913 HFO W/O JOINTS CF F 00087.89 07012025 99999999 1 L3915 WHO W NONTOR JNT(S) PREFAB F 00400.07 07012024 99999999 1 L3916 WHFO, WRIST EXTENSIONS (COCK-UP), WITH O F 00437.50 07012024 99999999 1 L3917 HAND ORTH.FRACT.ORTH,PREFABRICATED F 00079.51 07012024 99999999 1 L3918 WHFO, KNUCKLE BENDER F 00086.91 07012024 99999999 1 L3919 HO W/O JOINTS CF F 00084.67 07012024 99999999 1 L3921 HFO W/JOINT(S) CF F 00084.67 07012024 99999999 1 L3923 HAND FINGER ORTHOSIS, W/O JOINT F 00030.41 07012025 99999999 1 L3924 WHFO, OPPENHEIMER F 00076.66 07012025 99999999 1 L3925 FO,PIP/DIP,NON TORSN JOINT/SPRING PREFB F 00048.80 07012024 99999999 1 L3929 HFO, > F 00077.39 07012024 99999999 1 L3930 WHFO, FINGER EXTENSION, WITH WRIST SUPPO F 00083.78 07012024 99999999 1 L3931 WHFO, > F 00178.65 07012025 99999999 1 L3933 FO W/O JOINTS CF F 00087.89 07012025 99999999 1 L3935 FO NONTORSION JOINT CF F 00084.67 07012024 99999999 1 L3956 ADD. OF JOINT TO UPPER EXTREMITY M 00000.00 09012018 99999999 1 L3960 SEWHO, ABDUCTION POSITIONINGS, AIRPLANE F 00612.68 07012024 99999999 1 L3961 SEWHO CAP DESIGN W/O JNTS CF F 00612.68 07012024 99999999 1 L3962 SEWHO, ABDUCTION POSITIONING, ERBS PALSE F 00636.99 07012024 99999999 R L3964 SEO,MOBILE ARM SUPPORT ATTACH TO WHEELCH F 00064.12 RR 07012024 99999999 R L3965 SEO,MOBILE ARM SUPPORT, RANCHO TYPE F 00102.35 RR 07012024 99999999 R L3966 SEO,MOBILE ARM SUPPORT,BALANCED, RECLINI F 00077.11 RR 07012024 99999999 1 L3967 SEWHO AIRPLANE W/O JNTS CF F 00612.68 07012024 99999999 R L3968 SEO,MOBILE FRICTION ARM SUPPORT ATTACH F 00095.27 RR 07012024 99999999 R L3969 SEO,MOBILE ARM SUPPORT,MONOSUSPENSION F 00068.23 RR 07012024 99999999 1 L3971 SEWHO CAP DESIGN W/JNT(S) CF F 00612.68 07012024 99999999 1 L3973 SEWHO AIRPLANE W/JNT(S) CF F 00612.68 07012024 99999999 1 L3975 SEWHFO CAP DESIGN W/O JNT CF F 00612.68 07012024 99999999 1 L3976 SEWHFO AIRPLANE W/O JNTS CF F 00612.68 07012024 99999999 1 L3977 SEWHFO CAP DESGN W/JNT(S) CF F 00612.68 07012024 99999999 1 L3978 SEWHFO AIRPLANE W/JNT(S) CF F 00612.68 07012024 99999999 1 L3980 UPPER EXTREMITY FRACTURE ORTHOSIS, HUMER F 00290.68 07012025 99999999 1 L3981 UPPER EXTREMITY FRACTURE ORTHOSIS; HUMER F 01072.91 07012025 99999999 1 L3982 UPPER EXTREMITY FRACTURE ORTHOSIS, RADIU F 00307.08 07012025 99999999 1 L3984 UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST F 00327.06 07012025 99999999 1 L3995 ADD. TO UPPER EXTREMITY ORTHOSIS, SOCK F 00023.82 07012025 99999999 1 L3999 UNLISTED PROCEDURES FOR UPPER LIMB ORTHO M 00000.00 09012018 99999999 1 L4000 REPLACE GIRDLE - FOR SPINAL ORTHOSIS F 00849.87 07012024 99999999 1 L4002 REPLAC.STRAP,ANY ORTHO.ANY TYPE M 00000.00 09012018 99999999 1 L4010 REPLACE TRI LATERAL SOCKET BRIM F 00528.90 07012024 99999999 1 L4020 REPLACE QUAD LATERAL SOCKET BRIM MOLDED F 00528.90 07012024 99999999 1 L4030 REPLACE QUAD LATERAL SOCKET BRIM CUSTOM F 00336.66 07012024 99999999 1 L4040 REPLACE MOLDED THIGH LACER F 00163.74 07012024 99999999 1 L4045 REPLACE NONMOLDED THIGH LACER F 00253.25 07012024 99999999 1 L4050 REPLACE MOLDED CALF LACER F 00115.00 07012024 99999999 1 L4055 REPLACE NONMOLDED CALF LACER F 00204.94 07012024 99999999 1 L4060 REPLACE HI ROLL CUFF F 00214.49 07012024 99999999 1 L4070 REPLACE PROXIMAL/DISTAL UPRIGHT FOR KAFO F 00147.11 07012024 99999999 1 L4080 REPLACE METAL BANDS KAFO, PROXIMAL THIGH F 00027.62 07012025 99999999 1 L4090 REPLACE METAL BANDS KAFO/AFO CALF OR DIS F 00030.16 07012024 99999999 1 L4100 REPLACE LEATHER CUFF KAFO, PROXIMAL THIG F 00051.32 07012025 99999999 1 L4110 REPLACE LEATHER CUFF KAFO/AFO CALF OR DI F 00049.44 07012024 99999999 1 L4130 REPLACE PRETIBIAL SHELL F 00257.78 07012024 99999999 1 L4205 REPAIR OF ORTHOTIC DEVICE, LABOR PER 15 F 00017.36 07012025 99999999 1 L4210 REPAIR OF ORTHOTIC DEVICE, REPAIR OR REP M 00000.00 09012018 99999999 1 L4350 PNEUMATIC ANKLE CONTROL SPLINT F 00069.48 07012024 99999999 1 L4360 PNEUMATIC/VAC WALKING BOOT, PREFAB F 00223.40 07012025 99999999 1 L4361 Walking boot,pneumatic and/or vacuum,wit F 00244.22 07012025 99999999 1 L4370 PNEUMATIC FULL LEG SPLINT F 00146.74 07012024 99999999 1 L4386 NON-PNUEM.WALKING SPLINT PREFABRICATED F 00136.14 07012025 99999999 1 L4387 Walking boot non-pneumatic,with or witho F 00148.84 07012025 99999999 1 L4392 REPLACE INTERFACE MATERIAL, AFO F 00017.32 07012024 99999999 1 L4394 REPLACE INTERFACE MATERIAL, FOOT DROP F 00012.63 07012024 99999999 1 L4396 STATIC AFO FOR POSITIONING,PRESSURE F 00138.97 07012025 99999999 1 L4397 Static or dynamic ankle foot orthosis,in F 00151.92 07012025 99999999 1 L4398 FOOT DROP SPLINT, RECUMBANT POSITIONING F 00063.96 07012025 99999999 1 L4631 ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE F 01295.82 07012025 99999999 1 L5000 PARTIAL FOOT, SHOE INSET WITH LONGITUDIN F 00391.29 07012025 99999999 1 L5010 PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGH F 00980.34 07012025 99999999 1 L5020 PARTIAL FOOT MOLDED SOCKET TIBIAL TUBUCL F 01010.23 07012025 99999999 1 L5050 ANKLE, SYMES, MOLDED SOCKET SACH FOOT F 01667.11 07012025 99999999 1 L5060 ANKLE, SYMES, METAL FRAME, MOLDED LEATHE F 01944.46 07012024 99999999 1 L5100 BELOW KNEE, MOLDED SOCKET, SHIN SACH FOO F 02011.32 07012025 99999999 1 L5105 BELOW KNEE,PLASIC SOCKET,JT AND THIGH LA F 02737.72 07012024 99999999 1 L5150 KNEE DISARTICULATION (OR THROUGH KNEE), F 02572.05 07012024 99999999 1 L5160 KNEE DISARTICULATION (OR THROUGH KNEE), F 02777.81 07012024 99999999 1 L5200 ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS C F 02693.45 07012025 99999999 1 L5210 ABOVE KNEE, SHORT PROSTHESIS NO KNEE JOI F 01601.87 07012025 99999999 1 L5220 ABOVE KNEE, SHORT PROSTESIS NO KNEE JOIN F 01722.24 07012024 99999999 1 L5230 ABOVE KNEE FOR PROXIMAL FEMORAL FOCAL DE F 02572.05 07012024 99999999 1 L5250 HIP DISARTICULATION CAUAKIAN TYPE MOLDED F 03600.87 07012024 99999999 1 L5270 HIP DISARTUCULATION TILT TABLE TYPE MOLD F 03395.11 07012024 99999999 1 L5280 HEMIPELVIC CANADIAN TYPE MOLDED SOCKET H F 03806.64 07012024 99999999 1 L5301 BK,MOLDED SOCKET,SHIN,SACHFOOT F 02211.99 07012025 99999999 1 L5312 KNEE DISARTICULATION,ENDOSKELETL SYSTM F 03614.22 07012025 99999999 1 L5321 AK,MOLDED SOCKET,OPEN END,SACH FOOT F 02794.48 07012025 99999999 1 L5331 HIP DISART.CANADIAN TYPE, MOLDED SOCKET F 04723.88 07012025 99999999 1 L5341 HEMIPELVECTOMY,CANADIAN TYPE,MOLDED SOCK F 04651.70 07012024 99999999 1 L5400 IMMEDIATE POST SURGICAL OR EARLY FITTING F 01120.98 07012024 99999999 1 L5410 IMMEDIATE POST SURGICAL OR EARLY FITTING F 00416.68 07012024 99999999 1 L5420 IMMEDIATE POST SURGICAL OR EARLY FITTING F 01510.24 07012024 99999999 1 L5430 IMMEDIATE POST SURGICAL OR EARLY FITTING F 00494.66 07012024 99999999 1 L5450 IMMEDIATE POST SURGICAL OR EARLY FITTING F 00216.82 07012025 99999999 1 L5460 IMMEDIATE POST SURGICAL OR EARLY FITTING F 00340.48 07012025 99999999 1 L5500 PREPARATORY BELOW KNEE, (PTB) (TYPE) SOC F 00823.06 07012024 99999999 1 L5505 PREPARATORY ABOVE KNEE DISARTICULATION I F 01448.95 07012024 99999999 1 L5510 PREPARATORY BELOW KNEE (PTB" TYPE) SOCKE F 01271.23 07012024 99999999 1 L5520 PREPARATORY BELOW KNEE (PTB" TYPE) SOCKE F 01291.26 07012024 99999999 1 L5530 PREPARATORY BELOW KNEE (PTB" TYPE) SOCKE F 01404.80 07012025 99999999 1 L5535 PREPARATORY BELOW KNEE TYPE SOCKET F 01614.42 07012025 99999999 1 L5540 PREPARATORY BELOW KNEE (PTB" TYPE) SOCKE F 01724.07 07012025 99999999 1 L5560 PREPARATORY ABOVE KNEE DISARTICULATION ( F 01597.57 07012024 99999999 1 L5570 PREPARATORY ABOVE KNEE DISARTICULATION ( F 01767.07 07012024 99999999 1 L5580 PREPARATORY ABOVE KNEE DISARTICULATION ( F 01991.05 07012025 99999999 1 L5585 PREP,AK,KNEE DISARTIC,ISCHIAL LEVEL SOCK F 01985.96 07012024 99999999 1 L5590 PREPARATORY ABOVE KNEE DISARTICULATION ( F 01646.10 07012024 99999999 1 L5595 PREPARATORY HIP DISARTICULATION F 03075.90 07012024 99999999 1 L5600 PREP. HIP DISARTICULATION LAMINATED SOCK F 03428.06 07012024 99999999 1 L5610 ADDITIONS TO LOWER EXTREMITY, ABOVE KNEE F 01971.70 07012024 99999999 1 L5611 ADD. TO LOWER EXTREMITY, ABOVE KNEE F 01455.09 07012025 99999999 1 L5613 ADDITON TO LOWER EXTREMTIY F 02365.88 07012025 99999999 1 L5614 ADD. TO LO EXTRM PROS - LAWRENCE POLYCEN F 01281.24 07012024 99999999 1 L5616 ADD. TO LO EXTRM PROS - UNIVERSAL MULTIP F 01026.69 07012024 99999999 1 L5617 ADDITION TO LOWER EXTREMITY, QUICK-CHANG F 00427.20 07012025 99999999 1 L5618 ADD. TO LO EXTRM PROS - TEST SOCKET SYME F 00227.11 07012025 99999999 1 L5620 ADD. TO LO EXTRM PROS - TEST SOCKET BELO F 00216.15 07012025 99999999 1 L5622 ADD. TO LO EXTRM PROS - TEST SOCKET KNEE F 00115.32 07012025 99999999 1 L5624 ADD. TO LO EXTRM PROS - TEST SOCKET ABOV F 00277.62 07012025 99999999 1 L5626 ADD. TO LO EXTRM PROS - TEST OSCKET HIP F 00155.70 07012025 99999999 1 L5628 ADD. TO LO EXTRM PROS - TEST HEMIPELVECT F 00150.00 07012024 99999999 1 L5629 ADDITION TO LOWER EXTREMITY,BELOW KNEE,A F 00242.68 07012025 99999999 1 L5630 ADD. TO LO EXTRM PROS - SYMES TYPE EXPAN F 00366.21 07012024 99999999 1 L5631 ADD TO LOW EXTREM,ABOVE KNEE/KNEE DISART F 00335.50 07012025 99999999 1 L5632 ADDITIONS TO LOWER EXTREMITY, SYMES TYPE F 00073.81 07012025 99999999 1 L5634 ADD. TO LO EXTRM PROS - SYMES TYPE POST. F 00073.81 07012025 99999999 1 L5636 ADD. TO LO EXTRM PROS - SYMES TYPE MEDIA F 00138.40 07012025 99999999 1 L5637 ADDITION TO LOWER EXTREMITY,BELOW KNEE,T F 00220.59 07012025 99999999 1 L5638 ADD. TO LO EXTRM PROS - BELOW KNEE LEATH F 00092.27 07012025 99999999 1 L5639 ADD. TO LOWER EXTREMTIY,BELOW THE KNEE F 00856.48 07012024 99999999 1 L5640 ADD. TO LO EXTRM PROS- KNEE DISART LEATH F 00223.32 07012024 99999999 1 L5642 ADD. TO LO EXTRM PROS - ABOVE KNEE LEATH F 00111.10 07012024 99999999 1 L5643 HIP DISARTICULATION,FLEXIBLE INNER SOCKE F 00432.50 07012025 99999999 1 L5644 ADD. TO LO EXTRM PROS - ABOVE KNEE WOOD F 00150.00 07012024 99999999 1 L5645 BELOW KNEE,FLEXIBLE INNER SOCKET,EXTERNA F 00274.49 07012025 99999999 1 L5646 ADD. TO LO EXTRM PROS - BELOW KNEE AIR C F 00110.73 07012025 99999999 1 L5647 ADD TO LO EXTRM-BELOW KNEE SUCTION SOCKE F 00809.93 07012025 99999999 1 L5648 ADDITIONS TO LOWER EXTREMITY, ABOVE KNEE F 00311.12 07012024 99999999 1 L5649 ADD TO LOW EXTREM,ISCHIAL CONTAINMENT/NA F 01453.91 07012025 99999999 1 L5650 ADD TO LO EXTRM PROS-TOTAL CONTACT AK OR F 00372.79 07012025 99999999 1 L5651 ADD TO LO EXTRM-AK,FLEXIBLE INNER SOCKET F 00548.89 07012025 99999999 1 L5652 ADD. TO LO EXTRM PROS-SUCTION SUSP AK OR F 00332.95 07012025 99999999 1 L5653 ADD. TO LO EXTRM PROS - KNEE DISART EXPA F 00071.11 07012024 99999999 1 L5654 ADD. TO LO EXTRM PROS-SOCKET INSERT SYME F 00185.69 07012025 99999999 1 L5655 ADD. TO LO EXTRM PROS-SOCKET INSERT KEMB F 00202.54 07012025 99999999 1 L5656 ADD. TO LO EXTRM PROS-SOCKET INSRT KNEE F 00071.11 07012024 99999999 1 L5658 ADD. TO LO EXTRM PROS-SOCKET INSERT AK K F 00334.27 07012025 99999999 1 L5661 ADD. TO LOWER EXTREMTIY, SOCKET INSERT F 00541.28 07012025 99999999 1 L5665 ADD. TO LOWERE EXTREMTIY, SOCKET, GEL F 00534.99 07012025 99999999 1 L5666 ADD TO LO EXTRM PROS- BK CUFF SUSPENSION F 00057.01 07012025 99999999 1 L5668 ADD TO LO EXTRM PROS-BK MOLDED DISTAL CU F 00092.64 07012025 99999999 1 L5670 ADD TO LO EXTRM PROS-BK MOLDED SUPRA CON F 00207.20 07012025 99999999 1 L5671 ADD TO LOWER EXT.BK/AK SUSP LOCK F 00563.88 07012025 99999999 1 L5672 ADD TO LO EXTRM PROS-BK REMOVABLE MEDIAL F 00235.43 07012025 99999999 1 L5673 ADD.LOWER EXT.BKN,AKN PREFAB.SOCKET INSE F 00643.91 07012025 99999999 1 L5676 ADD TO LO EXTRM PROS-BK KNEE JNTS (PAIR) F 00073.81 07012025 99999999 1 L5677 ADD TO LO EXT PROS,BELOW KNEE,KNEE JOINT F 00159.16 07012025 99999999 1 L5678 ADD TO LO EXTRM PROS-BK JNT COVERS (PAIR F 00029.99 07012024 99999999 1 L5679 ADD.LOWER EXTBKN/AKN SOCKET PREFABRIC F 00536.47 07012025 99999999 1 L5680 ADD TO LO EXTRM PROS-BK THIGH LACER NON F 00167.22 07012025 99999999 1 L5681 ADD.LOWER EXT.BKN/AKN CUSTOM SOCKET INSE F 01131.66 07012025 99999999 1 L5682 ADD TO LO EXTRM PROS-BK THIGH LACER GLUT F 00384.05 07012025 99999999 1 L5683 ADD.LOWER EXT.BKN/AKN,CUSTOM INSERT F 01131.66 07012025 99999999 1 L5684 ADD TO LO EXTRM PROS-BK FORK STRAP F 00040.68 07012025 99999999 1 L5685 ADD TO LOWER EXT PROTH BELOW KNEE,SUSP F 00110.16 07012025 99999999 1 L5686 ADD TO LO EXTRM PROS-BK BACK CHECK (EXTE F 00014.44 07012024 99999999 1 L5688 ADD TO LO EXTRM PROS-BK WAIST BELT WEBBI F 00054.16 07012025 99999999 1 L5690 ADD TO LO EXTRM PROS-BK WAIST BELT PAD/L F 00062.29 07012025 99999999 1 L5692 ADD TO LO EXTRM PROS-AK PELVIC CONTROL B F 00066.67 07012024 99999999 1 L5694 ADD TO LO EXTRM PROS-AK PELVIC CONTROL B F 00100.33 07012025 99999999 1 L5695 ADD. TO LOWER EXTREM,A/K PELVIC CONTROL F 00129.30 07012025 99999999 1 L5696 ADD TO LO EXTRM PROS-AK OR KNEE DISART P F 00044.43 07012024 99999999 1 L5697 ADD TO LO EXTRM PROS-AK OR KNEE DISART P F 00031.11 07012024 99999999 1 L5698 ADD TO LO EXTRM PROS-AK OR KNEE DISART S F 00072.66 07012025 99999999 1 L5699 ADD TO LO EXTRM PROS-SHOULDER HARNESS F 00089.97 07012024 99999999 1 L5700 REPLACEMENT, SOCKET, BELOW KNEE, MOLDED F 02498.52 07012025 99999999 1 L5701 REPLACE,SOCKET,ABOVE KNEE,WITH ATTACH PL F 03027.86 07012025 99999999 1 L5702 REPLACEMENT, SOCKET, HIP DISARTICUL. INC F 04279.91 07012025 99999999 1 L5703 SYMES ANKLE W/O (SACH) FOOT F 02091.25 07012025 99999999 1 L5704 CUSTOM SHAPED PROTECTIVE CO F 00460.93 07012025 99999999 1 L5705 CUSTOM COVER, ABOVE KNEE F 00803.70 07012025 99999999 1 L5706 CUSTOMY SHAPED PROTECTIVE COVER F 00749.99 07012025 99999999 1 L5707 CUSTOM SHAPED PROTECTIVE COVER HIP F 01027.12 07012024 99999999 1 L5710 ADDITIONS KNEE-SHIN SYSTEM SINGLE AXIS, F 00142.22 07012024 99999999 1 L5711 ADD. EXOSKELETAL KNEE-SHIN SINGLE AXIS F 00437.36 07012024 99999999 1 L5712 ADDITIONS KNEE-SHIN SYSTEM SINGLE AXIS F F 00111.10 07012024 99999999 1 L5714 ADDITIONS KNEE-SHIN SYSTEM SINGLE AXIS V F 00053.33 07012024 99999999 1 L5716 ADDITIONS KNEE-SHIN SYSTEM POLYCENTRIC M F 00601.89 07012024 99999999 1 L5718 ADDITIONS KNEE-SHIN SYSTEM POLYCENTRIC F F 00411.52 07012024 99999999 1 L5722 ADDITIONS KNEE-SHIN SYSTEM SINGLE AXIS P F 00511.11 07012024 99999999 1 L5724 ADDITIONS KNEE-SHIN SYSTEM SINGLE SINGLE F 00853.35 07012024 99999999 1 L5726 ADDITIONS, KNEE-SHIN SYSTEM, SINGLE AXIS F 01447.91 07012024 99999999 1 L5728 ADDITIONS, KNEE-SHIN SYSTEM, SINGLE AXIS F 01697.56 07012024 99999999 1 L5780 ADDITIONS, KNEE-SHIN SYSTEM, SINGLE AXIS F 01090.33 07012024 99999999 1 L5781 ADD.LOWER EXT.VACUME PUMP F 03441.25 07012025 99999999 1 L5782 ADD.TO LOWER EXT,VAUME PUMP,HEAVY DUTY F 03627.87 07012025 99999999 1 L5785 ADD,EXOSKELETAL SYS,BELOW KNEE,LIGHT MAT F 00396.74 07012025 99999999 1 L5790 ADD,EXOSKELETAL SYS,ABOVE KNEE,LIGHT MAT F 00564.15 07012025 99999999 1 L5795 ADD,EXOSKELETAL SYS,HIP DISARTICULATION, F 00789.89 07012024 99999999 1 L5810 ADD. ENDOSKELETAL KNEE-SHIN SYSTEM SINGL F 00386.04 07012025 99999999 1 L5811 ADD. ENDOSKEL KNEE-SHIN, ULTRA LIGHT F 00607.95 07012025 99999999 1 L5812 ADD,ENDOSKELETAL KNEE-SHIN SYS,SINGLE AX F 00463.25 07012025 99999999 1 L5814 ADD. ENDOSKEL KNEE SHIN, POLYCENTRIC F 02947.45 07012025 99999999 1 L5816 ADD. ENDOSKEL KNEE-SHIN MECHANICAL LOCK F 00649.65 07012024 99999999 1 L5818 ADD. ENDOSKEL KNEE-SHIN FRICTION SWING F 00865.77 07012024 99999999 1 L5822 ADD., ENDOSKELETAL,KNEE-SHIN PNEUMATIC F 01291.83 07012024 99999999 1 L5824 ADD. ENDO. KNEE-SHIN,FLUID SWING F 01252.47 07012025 99999999 1 L5826 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM F 02127.54 07012025 99999999 1 L5828 ADD,ENDOSKELETAL KNEE-SHIN,SINGLE AXIS,S F 02394.81 07012025 99999999 1 L5830 ADD. ENDO KNEE SHIN, PNEUMATIC SWING F 01575.33 07012024 99999999 1 L5840 ADD. ENDO KNEE-SHIN 4-BAR LINKAGE F 03240.27 07012025 99999999 1 L5841 Addition endoskletl knee-shi F 02879.02 12012025 99999999 1 L5845 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, F 01783.25 07012025 99999999 1 L5848 ADD.TO ENDOSKEL.KNEE-SHIN SYSTEM F 00897.39 07012025 99999999 1 L5850 ADD. ENDO KNEE-SHIN AK OR HIP DISART F 00100.73 07012025 99999999 1 L5855 ADD. ENDO. HIP DISARTICULATION F 00312.36 07012024 99999999 1 L5856 ADD.LOWER EXT PROST.ENDOSKEL,SYSTEM F 20641.74 07012025 99999999 1 L5857 ADD.LOWER EXT,PROST.SWING PHASE,ANY TYPE F 07053.38 07012024 99999999 1 L5858 STANCE PHASE ONLY F 15399.24 07012024 99999999 1 L5859 Addition to lower extremity prosthesis, F 17026.80 07012025 99999999 1 L5910 ADD,ENDOSKELETAL SYS, BELOW KNEE,ALIGNAB F 00276.56 07012025 99999999 1 L5920 ADD,ENDOSKELETAL SYS,ABOVE KNEE OR HIP D F 00405.16 07012025 99999999 1 L5925 ADDITION,ENDOSKEL,ABOVE KNEE,DISARTIC OR F 00350.12 07012025 99999999 1 L5926 ENDOSKEL POSIT ROTAT UNIT F 00790.52 07012025 99999999 1 L5930 ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTI F 02569.93 07012025 99999999 1 L5940 ADD,ENDOSKEL SYS,BELOW KNEE,LIGHT MATERI F 00508.03 07012025 99999999 1 L5950 ADD,ENDOSKEL SYS,ABOVE KNEE, LIGHT MATER F 00638.25 07012025 99999999 1 L5960 ADD,ENDOSKEL SYS,HIP DISARTICULATION,LIG F 00816.30 07012025 99999999 1 L5961 ADDITION, ENDOSKELETAL SYSTEM F 05513.47 07012024 99999999 1 L5962 ADDITION, ENDOSKELETAL SYS., BELOW KNEE F 00617.12 07012025 99999999 1 L5964 ADDITION, ENDOSKELETAL SYS., ABOVE KNEE F 00905.77 07012025 99999999 1 L5966 ADDITION, ENDOSKELETAL SYS., HIP F 01131.29 07012024 99999999 1 L5968 ADDITION TO LOWER LIMB PROTHESIS, F 02863.94 07012025 99999999 1 L5969 Addition, endoskeletal ankle-foot or ank F 13146.65 07012024 99999999 1 L5970 ALL LOWER EXTREMITY PROSTHESES, FOOT, F 00165.09 07012025 99999999 1 L5971 SACH FOOT, REPLACEMENT F 00165.09 07012025 99999999 1 L5972 ALL LOWER EXTREMITY PROSTHESES, FLEXIBLE F 00307.19 07012025 99999999 1 L5973 ANKLE FT SYS,DORSIFLEX&/OR PLANTR FLEX F 15875.37 07012025 99999999 1 L5974 ALL LOWER EXTREMITY PROSTHESIS, FOOT F 00172.78 07012025 99999999 1 L5975 ALL LOWER EXTR. PROSTHESIS, COMBINATION F 00351.98 07012024 99999999 1 L5976 ALL LOWER EXTR. PROSTHESES, ENERGY F 00496.72 07012025 99999999 1 L5978 ALL LOWER EXTR. PROSTHESES, FOOT, MULTI- F 00295.17 07012024 99999999 1 L5979 ALL LOWER EXTR. PROSTHESES, DYNAMIC F 02395.63 07012025 99999999 1 L5980 ALL LOWER EXTREMITY PROSTHESES,FLEX-FOOT F 03151.16 07012025 99999999 1 L5981 ALL LOWER EXTR. PROSTHESES, FLEX-WALK F 02629.68 07012025 99999999 1 L5982 ALL EXOSKELETAL LOWER EXTREMITY PROS. F 00511.06 07012024 99999999 1 L5984 ALL ENDOSKELETAL LOWER EXTREMITY PROS. F 00525.64 07012025 99999999 1 L5985 ALL ENDOSKELETAL LOWER EXTR. PROS., DYNA F 00222.32 07012025 99999999 1 L5986 ALL LOWER EXTR. PROS., MULTI-AXIAL ROTAT F 00562.51 07012025 99999999 1 L5987 ALL LOWER EXTREMITY PROSTHESES, SHANK F 06187.07 07012025 99999999 1 L5988 ADDITION TO LOWER LIMB PROTHESIS, VERTIC F 01574.41 07012025 99999999 1 L5990 ADD TO LOWER EXT. USER ADJ.HEEL HEIGHT F 01543.85 07012025 99999999 1 L5999 UNLISTED PROCEDURES FOR LOWER EXTREMITY M 00000.00 09012018 99999999 1 L6000 PARTIAL HAND, THUMB REMAINING F 00888.90 07012024 99999999 1 L6010 PARTIAL HAND,LITTLE&OR RING FINGER F 00888.90 07012024 99999999 1 L6020 PARTIAL HAND, NO FINGER REMAINING F 00922.68 07012025 99999999 1 L6026 TRANSCARPAL/METACARPAL OR PARTIAL HAND D F 05317.65 07012024 99999999 1 L6050 WRIST DISARTICULATION, MOLDED SOCKET, FL F 01281.49 07012025 99999999 1 L6055 WRIST DISARTICULATION, EXPANDABLE INTERF F 02114.42 07012024 99999999 1 L6100 BELOW-ELBOW MOLDED SOCKET FLEXIBLE ELBOW F 01388.28 07012025 99999999 1 L6110 BELOW ELBOW MOLDED SOCKET (MUENSTER OR N F 01495.08 07012025 99999999 1 L6120 BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SO F 01543.23 07012024 99999999 1 L6130 BELOW ELBOW MOLDED DOUBLE WALL SPLIT SOC F 01749.01 07012024 99999999 1 L6200 ELBOW DISARTICULATION, MOLDED SOCKET, OU F 02057.63 07012024 99999999 1 L6205 ELBOW DISARTICULATION, WITH EXPANDABLE F 02837.80 07012024 99999999 1 L6250 ABOVE ELBOW, MOLDED DOUBLE WALL SOCKET, F 02029.02 07012025 99999999 1 L6300 SHOULDER DISARTICULATION, MOLDED SOCKET, F 02572.05 07012024 99999999 1 L6310 SHOULDER DISARTICULATION PASSIVE RESTORA F 02160.52 07012024 99999999 1 L6320 SHOULDER DISARTICULATION PASSIVE RESTORA F 00925.94 07012024 99999999 1 L6350 INTERSCAPULAR THORACIC, MOLDED SOCKET, S F 02057.63 07012024 99999999 1 L6360 INTERSACPULAR THORACIC PASSIVE RESTORATI F 01954.74 07012024 99999999 1 L6370 INTERSCAPULAR THORACIC PASSIVE RESTORATI F 00925.94 07012024 99999999 1 L6380 IMMEDIATE POSTSUGICAL OR EARLY FITTING, F 01060.14 07012024 99999999 1 L6382 IMMED POST SURG/EARLY FIT APLIC INIT RIG F 01245.79 07012024 99999999 1 L6384 IMMED. POSTSURGICAL OR EARLY FITTING, SH F 01578.91 07012024 99999999 1 L6386 IMMED. POSTSURGICAL OR EARLY FITTING, EA F 00346.36 07012024 99999999 1 L6388 IMMED. POSTSURGICAL OR EARLY FITTING, AP F 00358.90 07012024 99999999 1 L6400 BELOW ELBOW MOLDED SOCKET ENPLOSKELETAL F 01028.83 07012024 99999999 1 L6450 ELBOW DISARTICULATION MOLDED SOCKET ENDO F 01440.35 07012024 99999999 1 L6500 ABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL F 01543.23 07012024 99999999 1 L6550 SHOULDER DISARTICULATION MOLDED SOCKET E F 01851.88 07012024 99999999 1 L6570 INTERSCAPULAR THORACIC MOLDED SOCKET END F 01543.23 07012024 99999999 1 L6580 PREPARATORY, WRIST DISARTICULATION OR BE F 01275.99 07012024 99999999 1 L6582 PREP., WRIST DISART. OR BELOW ELBOW, DIR F 01084.88 07012024 99999999 1 L6584 PREP., ELBOW DISARTICULATION OR ABOVE EL F 01574.41 07012024 99999999 1 L6586 PREP., ELBOW DISART. OR ABOVE, DIRECT FO F 01457.41 07012024 99999999 1 L6588 PREPARATORY, SHOULDER DISARTICULATION OR F 02307.94 07012024 99999999 1 L6590 PREPARATORY, SHOULDER DISART., DIRECT FO F 02036.53 07012024 99999999 1 L6600 UPPER EXTREMITY ADDITIONS POLYCENTRIC HI F 00101.31 07012024 99999999 1 L6605 SINGLE PIVOT HINGE (PAIR) F 00119.04 07012025 99999999 1 L6610 UPPER EXTREMITY ADDITIONS FLEXIBLE METAL F 00121.79 07012025 99999999 1 L6611 ADDITIONAL SWITCH, EXT POWER F 00341.15 07012024 99999999 1 L6615 UPPER EXTREMITY ADDITIONS, DISCONNECT LO F 00065.60 07012025 99999999 1 L6616 UPPER EXTREMITY ADDITION, ADD'L DISCONNE F 00051.07 07012025 99999999 1 L6620 UPPER EXTREMITY ADDITIONS, FLEXION-FRICT F 00143.04 07012024 99999999 1 L6621 FLEX/EXT WRIST W/WO FRICTION F 00148.48 07012025 99999999 1 L6623 SPRING ASSISTED ROTATIONAL WRIST UNIT WI F 00534.31 07012024 99999999 1 L6624 FLEX/EXT/ROTATION WRIST UNIT F 03120.51 07012024 99999999 1 L6625 UPPER EXTREMITY ADDITIONS, ROTATION WRIS F 00391.28 07012024 99999999 1 L6628 UPPER EXTREMITY ADDITION, QUICK DISCONNE F 00446.22 07012024 99999999 1 L6629 UPPER EXTR. ADD., QUICK DISCONNECT LAMIN F 00118.77 07012025 99999999 1 L6630 UPPER EXTREMITY ADDITION, STAINLESS STEE F 00169.70 07012025 99999999 1 L6632 UPPER EXTREMITY ADDITION, LATEX SUSPENSI F 00054.36 07012024 99999999 1 L6635 UPPER EXTREMITY ADDITIONS, LIFT ASSIST F F 00092.80 07012025 99999999 1 L6637 UPPER EXTREMITY ADDITION, NUDGE CONTROL F 00295.35 07012024 99999999 1 L6638 UPP.EXT.ADD.ELECT.LOCK.FOR ELBOW F 02072.06 07012024 99999999 1 L6640 UPPER EXTREMITY ADDITIONS, SHOULDER ABDU F 00190.72 07012024 99999999 1 L6641 UPPER EXTREMITY ADDITION, EXCURSION AMPL F 00148.01 07012024 99999999 1 L6642 UPPER EXTR. ADD., EXCURSION AMP., LEVER F 00202.65 07012024 99999999 1 L6645 UPPER EXTREMITY ADDITIONS, SHOULDER FLEX F 00280.11 07012024 99999999 1 L6646 UPPER EXT.ADD.SHOULDER JOINT,LOCKING F 02613.29 07012024 99999999 1 L6647 UPP.EXT.ADD.SHOULDER LOCK MECHANISM F 00430.23 07012024 99999999 1 L6648 UPP.EXT.ADD.SHOULDER LOCK,EXTERNAL POWER F 02695.24 07012024 99999999 1 L6650 SHOULDER UNIVERSAL JOINT (EACH) F 00198.89 07012024 99999999 1 L6655 UPPER EXTREMITY ADDITIONS STANDARD CONTR F 00046.12 07012025 99999999 1 L6660 UPPER EXTREMITY ADDITIONS HEAVY DUTY CON F 00050.74 07012025 99999999 1 L6665 UPPER EXTREMITY ADDITIONS TELFLON OR EQU F 00016.03 07012025 99999999 1 L6670 UPPER EXTREMITY ADDITIONS HOOK TO HAND C F 00020.76 07012025 99999999 1 L6672 UPPER EXTRM LIMB ADD:HARNESS, CHEST/SHOU F 00073.81 07012025 99999999 1 L6675 UPPER EXTRM ADD:HARNESS FIG 8 SINGLE CON F 00052.59 07012025 99999999 1 L6676 UPPER EXTRM ADD: HARNESS FIG 8 DUAL CONT F 00059.95 07012025 99999999 1 L6677 UE TRIPLE CONTROL HARNESS F 00059.95 07012025 99999999 1 L6680 UPPER EXTRM ADD: TEST SOCKET WRIST DISAR F 00055.36 07012025 99999999 1 L6682 UPPER EXTRM ADD: TEST SOCKET ELBOW DISAR F 00055.36 07012025 99999999 1 L6684 UPPER EXTRM ADD: TEST SOCKET SHOULDER DI F 00053.33 07012024 99999999 1 L6686 UPPER EXTREMITY ADDITION, SUCTION SOCKET F 00464.86 07012025 99999999 1 L6687 UPPER EXTREMITY ADDITION, FRAME TYPE SOC F 00454.20 07012025 99999999 1 L6688 UPPER EXTR. ADD., FRAME TYPE SOCKET, ABO F 00438.72 07012025 99999999 1 L6689 UPPER EXTR. ADD., FRAME TYPE SOCKET, SHO F 00527.56 07012024 99999999 1 L6690 UPPER EXTR. ADD., FRAME TYPE SOCKET, INT F 00553.07 07012024 99999999 1 L6691 UPPER EXTREMITY ADDITION, REMOVABLE INSE F 00323.38 07012025 99999999 1 L6692 SILICON GEL INSERT W/WO LOCK F 00445.59 07012025 99999999 1 L6693 UPPER EXTREMITY ADDITION, LOCKING ELBOW, F 02155.54 07012024 99999999 1 L6694 ADD.UPPER EXT.PROST.ELBOW CUSTOM F 00643.71 07012025 99999999 1 L6695 ADD UPPER EXT PROST.ELBOW,CUSTOM F 00536.41 07012025 99999999 1 L6698 ADD UP-EX PROSTHES LOCK MECH F 00569.89 07012025 99999999 1 L6703 TERM DEV, PASSIVE HAND MITT F 00290.81 07012025 99999999 1 L6704 TERM DEV, SPORT/REC/WORK ATT F 00576.56 07012025 99999999 1 L6706 TERM DEV MECH HOOK VOL OPEN F 00350.80 07012025 99999999 1 L6707 TERM DEV MECH HOOK VOL CLOSE F 01266.40 07012025 99999999 1 L6708 TERM DEV MECH HAND VOL OPEN F 00850.73 07012025 99999999 1 L6709 TERM DEV MECH HAND VOL CLOSE F 01181.36 07012025 99999999 1 L6711 TERM DEVICE, HOOK, MECH, VOL OPEN, PED F 00607.16 07012025 99999999 1 L6712 TERM DEVICE, HOOK, MECH, VOL CLOS, PED F 01076.97 07012024 99999999 1 L6713 TERM DEVICE, HAND, MECH, VOL OPEN, PED F 01359.19 07012024 99999999 1 L6714 TERM DEVICE, HAND, MECH, VOL CLOS, PED F 01151.24 07012024 99999999 1 L6715 TERMINL DEVICE,INITIAL ISSUE OR REPLAC F 03569.32 07012024 99999999 1 L6721 TERM DEVICE, HOOK/HAND, HD,MECH,VOL OP F 02123.99 07012025 99999999 1 L6722 TERM DEV, HOOK/HAND, HD, MECH,VOL CLOS F 01831.03 07012025 99999999 1 L6805 TERMINAL DEVICES, MODIFIER WRIST FLEXION F 00201.84 07012025 99999999 1 L6810 TERMINAL DEVICE,PINCHER TOOL,OTTO BOCK O F 00149.74 07012024 99999999 1 L6880 ELECTRIC HAND, SWITCH OR MYOLELECTRIC F 27327.51 07012025 99999999 1 L6881 AUTOMATIC GRASP FEATURE,ADD.TO LIMB F 03478.99 07012025 99999999 1 L6882 MICROPROCESSOR CONT FEATURE ADD TO LIMB F 02797.69 07012025 99999999 1 L6883 REPLC SOCKT BELOW E/W DISA F 01388.28 07012025 99999999 1 L6884 REPLC SOCKT ABOVE ELBOW DISA F 01337.46 07012024 99999999 1 L6885 REPLC SOCKT SHLDR DIS/INTERC F 01337.46 07012024 99999999 1 L6890 GLOVE FOR ABOVE HANDS, PRODUCTION GLOVE F 00073.33 07012025 99999999 1 L6895 GLOVE FOR ABOVE HANDS, CUSTOM GLOVE F 00284.30 07012025 99999999 1 L6900 HAND RESTORATION (CASTE SHADING AND MEAS F 01498.69 07012024 99999999 1 L6905 HAND RESTORATION (CASTE, SHADING AND MEA F 01190.16 07012024 99999999 1 L6910 HAND RESTORATION (CASTE SHADING AND MEAS F 01446.75 07012024 99999999 1 L6915 HAND RESTORATION (SHADING AND MEASUREMEN F 00628.22 07012024 99999999 1 L6920 WRIST DISARTICULATION, EXTERNAL POWER, F 06215.83 07012024 99999999 1 L6925 WRIST DISARTICULATION, EXT. POWER, MYOEL F 06838.34 07012024 99999999 1 L6930 BELOW ELBOW, EXTERNAL POWER, SELF- F 06166.44 07012024 99999999 1 L6935 BELOW ELBOW, EXT. POWER, SELF-SUSPENDED F 07237.69 07012025 99999999 1 L6940 ELBOW DISARTICULATION, EXTERNAL POWER, F 07280.87 07012024 99999999 1 L6945 ELBOW DISARTICULATION, EXT. POWER, MYOEL F 08450.10 07012024 99999999 1 L6950 ABOVE ELBOW, EXTERNAL POWER, MOLDED INNE F 08255.86 07012024 99999999 1 L6955 ABOVE ELBOW, EXT. POWER, MYOELECTRONIC F 09887.51 07012024 99999999 1 L6960 SHOULDER DISARTRICULATION, EXTERNAL POWE F 10264.74 07012024 99999999 1 L6965 SHOULDER DISARTICULATION, MYOELECTRONIC F 11891.22 07012024 99999999 1 L6970 INTERSCAPULAR-THORACIC EXT. POWER F 12498.16 07012024 99999999 1 L6975 INTERSCAPULAR-THORACIC, MYOELECTRONIC F 14091.06 07012024 99999999 1 L7007 ADULT ELECTRIC HAND F 02956.95 07012025 99999999 1 L7008 PEDIATRIC ELECTRIC HAND F 04571.68 07012024 99999999 1 L7009 ADULT ELECTRIC HOOK F 03017.04 07012025 99999999 1 L7040 PREHENSILE ACTUATOR, HOSMER OR EQUAL F 02194.85 07012024 99999999 1 L7045 ELECTRONIC HOOK, CHILD, MICHIGAN OR EQUA F 01338.10 07012024 99999999 1 L7170 ELECTRONIC ELBOW, HOSMER OR EQUAL F 04854.14 07012024 99999999 1 L7180 ELECTRONIC ELBOW, BOSTON, UTAH OR EQUAL F 29916.12 07012024 99999999 1 L7181 ELECTRONIC ELBOW,MICROPROCESS F 33199.38 07012024 99999999 1 L7185 ELECTRONIC ELBOW, ADOLESCENT, VARIETY F 04915.47 07012024 99999999 1 L7186 ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE F 09018.14 07012024 99999999 1 L7190 ELECTRONIC ELBOW, ADOLESCENT, MYOELECTRO F 06309.61 07012024 99999999 1 L7191 ELECTRONIC ELBOW, CHILD, MYOELECTRONICAL F 08779.66 07012024 99999999 1 L7360 SIX VOLT BATTERY, OTTO BOCK OR EQUAL, EA F 00173.21 07012024 99999999 1 L7362 BATTERY CHARGER, SIX VOLT, OTTO BOCK OR F 00190.06 07012024 99999999 1 L7364 TWELVE VOLT BATTERY, UTAH OR EQUAL, EACH F 00357.34 07012024 99999999 1 L7366 BATTERY CHARGER, TWELVE VOLT, UTAH OR EQ F 00447.48 07012024 99999999 1 L7367 LITHIUM ION BATTERY,REPLACEMENT F 00334.83 07012025 99999999 1 L7368 LITHIUM ION BATTERY CHARGER,REPLACEMNT F 00434.05 07012025 99999999 1 L7400 ADD UE PROST BE/WD, ULTLITE F 00073.33 07012025 99999999 1 L7401 ADD UE PROST A/E ULTLITE MAT F 00295.09 07012025 99999999 1 L7402 ADD UE PROST S/D ULTLITE MAT F 00307.02 07012024 99999999 1 L7403 ADD UE PROST B/E ACRYLIC F 00316.71 07012025 99999999 1 L7404 ADD UE PROST A/E ACRYLIC F 00478.03 07012025 99999999 1 L7405 ADD UE PROST S/D ACRYLIC F 00602.30 07012024 99999999 1 L7499 UNLISTED PROCEDURES FOR UPPER EXTREMITY M 00000.00 09012018 99999999 1 L7510 REPAIR PROSTHETIC DEVICE, REPAIR OR REPL M 00000.00 09012018 99999999 1 L7520 REPAIR PROSTETIC DEVICE, LABOR COMPONENT F 00017.36 07012025 99999999 1 L7600 PROSTHETIC DONNING SLEEVE F 00007.49 07012025 99999999 1 L7700 Gasket or seal, for use with prosthetic F 00126.27 07012025 99999999 1 L8000 BREAST PROSTHESES, MASTECTOMY BRA F 00029.99 07012025 99999999 1 L8001 BREAST PROST.MAST.BRA,WITH FORM UNILATER F 00102.83 07012024 99999999 1 L8002 BREAST PROST.MAST.BRA WITH FORM BILATER F 00135.28 07012024 99999999 1 L8015 EXTERNAL BREAST PROSTHESIS GARMENT, WITH F 00045.50 07012024 99999999 1 L8020 BREAST PROSTHESES, MASTECTOMY FORM F 00170.12 07012024 99999999 1 L8030 BREAST PROSTHESIS, SILICONE OR EQUAL F 00280.80 07012025 99999999 1 L8032 NIPPLE PROSTHESIS,REUSABLE,ANY TYPE,EA F 00044.27 07012024 99999999 1 L8035 CUSTOM BREAST PROSTHESIS, POST MASTECTOM F 02781.66 07012024 99999999 1 L8039 BREAST PROTHESIS, NOT CLASSIFIED M 00000.00 09012018 99999999 1 L8300 TRUSSES, SINGLE WITH STANDARD PAD F 00033.74 07012024 99999999 1 L8310 TRUSSES DOUBLE WITH STANDARD PADS F 00129.20 07012024 99999999 1 L8320 TRUSSES ADDITION TO STANDARD PADS, WATER F 00040.56 07012024 99999999 1 L8330 TRUSSES ADDITION TO STANDARD PADS, SCROT F 00037.44 07012024 99999999 1 L8400 PROSTHETIC SHEATH BELOW KNEE (EACH) F 00007.49 07012025 99999999 1 L8410 PROSTHETIC SHEATH ABOVE KNEE (EACH) F 00007.49 07012025 99999999 1 L8415 PROSTHETIC SHEATH, UPPER LIMB, EACH F 00019.15 07012025 99999999 1 L8417 PROSTHETIC SHEATH/SOCK, INCLUDING A GEL F 00059.27 07012025 99999999 1 L8420 PROSTHETIC SOCK, WOOL, BELOW KNEE, EACH F 00016.44 07012025 99999999 1 L8430 PROSTHETIC SOCK,WOOL,ABOVE KNEE, EACH F 00018.12 07012025 99999999 1 L8435 PROSTHETIC SOCK, MULTIPLE PLY, UPPER LIM F 00018.33 07012025 99999999 1 L8440 PROSTHETIC SHRINKER, BELOW KNEE, EACH F 00028.84 07012025 99999999 1 L8460 PROSTHETIC SHRINKER, ABOVE KNEE, EACH F 00049.40 07012025 99999999 1 L8465 PROSTHETIC SHRINKER, UPPER LIMB, EACH F 00037.01 07012024 99999999 1 L8470 STUMP SOCK SINGLE PLY BELOW KNEE (EACH) F 00001.32 07012025 99999999 1 L8480 STUMP SOCK SINGLE ABOVE KNEE (EACH) F 00001.57 07012025 99999999 1 L8485 PROSTHETIC SOCK, SINGLE PLY, FITTING, UP F 00011.52 07012025 99999999 1 L8499 UNLISTED PROCEDURE FOR MISCELLANEOUS PRO M 00000.00 09012018 99999999 1 L8500 ARTIFICIAL LARYNX, ANY TYPE F 00621.49 07012024 99999999 1 L8501 TRACHEOSTOMY SPEAKING VALVE F 00091.64 07012024 99999999 1 L8505 ART. LARYNX REPLAC. BATTERY ANY TYPE M 00000.00 09012018 99999999 1 L8507 TRACHOE-ESOPH VOICE PROSTHESIS PT.INSERT F 00034.35 07012024 99999999 1 L8509 TRACHEO-ESOPH VOICE PROST,INSERT.BY PROV F 00089.53 07012024 99999999 1 L8510 VOICE AMPLIFIER F 00207.17 07012024 99999999 1 L8511 INSERT FOR TRACHEOESOPH.PROSTHESIS REPLA F 00060.27 07012024 99999999 1 L8512 GELETIN CAPSULES FOR VOICE PROSTHESIS F 00001.78 07012024 99999999 1 L8513 CLEANING DEVICE FOR TRACHEOSOPH DEVICE F 00004.31 07012024 99999999 1 L8514 TRACHEOSOPHAGEAL DILATOR REPLACEMENT F 00078.15 07012024 99999999 1 L8515 GELATIN CAPSULE,APPL DEVICE,FOR VOICE F 00050.75 07012024 99999999 1 L8609 ARTIFICIAL CORNEA F 00621.49 07012024 99999999 1 L8615 HEADSET/HEADPIECE W/COCHLEAR DEVICE F 00377.44 07012024 99999999 1 L8616 MICROPHONE FOR COCH.IMPLANT REPLACE F 00087.89 07012024 99999999 1 L8617 TRANSMITTING COIL FOR COCH.IMPLANT - REP F 00076.77 07012024 99999999 1 L8618 TRANSMITTER CABLE FOR COCH.IMPLANT-REPLA F 00021.96 07012024 99999999 1 L8619 COCHLEAR IMPLANT EXTERNAL SPEECH PROCESS F 09200.28 07012024 99999999 1 L8621 ZINC AIR BATTERY FOR USE WITH COCH.DEVIC F 00000.51 07012024 99999999 1 L8622 ALKALINE BATTERY FOR USE WITH COCH DEVIC F 00000.27 07012024 99999999 1 L8623 LITH ION BATT CID,NON-EARLVL F 00056.29 07012024 99999999 1 L8624 LITH ION BATT CID, EAR LEVEL F 00140.30 07012024 99999999 1 L8625 External recharging system for battery f F 00212.63 09012024 99999999 1 L8627 COCHLEAR IMPL,EXT PROCESSOR,REPLACMENT F 05993.23 07012024 99999999 1 L8628 COCHLEAR IMPL,EXT CONTROLER,REPLACEMNT F 01086.78 07012024 99999999 1 L8629 COIL&CABLE,W/COCHLR IMPLNT DV,REPLCMNT F 00202.46 07012024 99999999 1 L8678 Ext sply implt neurostim F 00018.02 12012025 99999999 1 L8690 AUD OSSEO DEV, INT/EXT COMP F 05378.18 07012024 99999999 1 L8691 AUD OSSEO DEV EXT SND PROCES F 01946.98 07012024 99999999 1 L8692 AUDIO OSSEOINTEGRATD DVC,EXT PROCESSOR M 00000.00 09012018 99999999 1 L8693 AUDITORY OSSEOINTEGRATD DEVICE,REPLACE F 01317.92 07012024 99999999 1 L8694 Auditory osseointegrated device, transdu F 00880.72 07012024 99999999 1 Q0477 Power module patient cable for use with F 00078.44 07012024 99999999 1 Q0478 POWER ADAPTR FOR USE PVAD,VEHICLE TYPE F 00186.25 07012024 99999999 1 Q4001 CAST SUPPLIES, BODY F 00046.95 07012024 99999999 1 Q4002 CAST SUPPLIES, BODY F 00177.39 07012024 99999999 1 Q4003 CAST SUPPLIES, SHOULDER F 00033.38 07012024 99999999 1 Q4004 CAST SUPPLIES, BODY F 00116.71 07012024 99999999 1 Q4005 CAST SUPPLIES, LONG ARM F 00012.43 07012024 99999999 1 Q4006 CAST SUPPLIES, LONG ARM F 00028.00 07012024 99999999 1 Q4007 CAST SUPPLIES, LONG ARM F 00006.22 07012024 99999999 1 Q4008 CAST SUPPLIES, LONG ARM F 00013.99 07012024 99999999 1 Q4009 CAST SUPPLIES, SHORT ARM F 00008.31 07012024 99999999 1 Q4010 CAST SUPPLIES, SHORT ARM F 00018.68 07012024 99999999 1 Q4011 CAST SUPPLIES, SHORT ARM F 00004.14 07012024 99999999 1 Q4012 CAST SUPPLIES, SHORT ARM F 00009.35 07012024 99999999 1 Q4013 CAST SUPPLIES, GAUNTLET CAST F 00015.11 07012024 99999999 1 Q4014 CAST SUPPLIES, GAUNTLET F 00025.47 07012024 99999999 1 Q4015 CAST SUPPLIES, GAUNTLET F 00007.56 07012024 99999999 1 Q4016 CAST SUPPLIES, GAUNTLET F 00012.73 07012024 99999999 1 Q4017 CAST SUPPLIES, LONG ARM F 00008.73 07012024 99999999 1 Q4018 CAST SUPPLIES, LONG ARM F 00013.92 07012024 99999999 1 Q4019 CAST SUPPLIES, LONG ARM F 00004.38 07012024 99999999 1 Q4020 CAST SUPPLIES, LONG ARM F 00006.98 07012024 99999999 1 Q4021 CAST SUPPLIES, SHORT ARM F 00006.47 07012024 99999999 1 Q4022 CAST SUPPLIES, SHORT ARM F 00011.66 07012024 99999999 1 Q4023 CAST SUPPLIES, SHORT ARM F 00003.24 07012024 99999999 1 Q4024 CAST SUPPLIES, LONG ARM F 00005.84 07012024 99999999 1 Q4025 CAST SUPPLIES, HIP SPICA F 00036.24 07012024 99999999 1 Q4026 CAST SUPPLIES, HIP SPICA F 00113.15 07012024 99999999 1 Q4027 CAST SUPPLIES, HIP SPICA F 00018.13 07012024 99999999 1 Q4028 CAST SUPPLIES, HIP SPICA F 00056.61 07012024 99999999 1 Q4029 CAST SUPPLIES, LONG LEG F 00027.72 07012024 99999999 1 Q4030 CAST SUPPLIES, LONG LEG F 00072.96 07012024 99999999 1 Q4031 CAST SUPPLIES, LONG LEG F 00013.85 07012024 99999999 1 Q4032 CAST SUPPLIES, LONG LEG F 00036.48 07012024 99999999 1 Q4033 CAST SUPPLIES, LONG LEG F 00025.85 07012024 99999999 1 Q4034 CAST SUPPLIES, LONG LEG F 00064.29 07012024 99999999 1 Q4035 CAST SUPPLIES, LONG LEG F 00012.93 07012024 99999999 1 Q4036 CAST SUPPLIES, LONG LEG F 00032.16 07012024 99999999 1 Q4037 CAST SUPPLIES, SHORT LEG F 00015.76 07012024 99999999 1 Q4038 CAST SUPPLIES, SHORT LEG F 00039.50 07012024 99999999 1 Q4039 CAST SUPPLIES, SHORT LEG F 00007.90 07012024 99999999 1 Q4040 CAST SUPPLIES, SHORT LEG F 00019.75 07012024 99999999 1 Q4041 CAST SUPPLIES, LONG LEG F 00019.17 07012024 99999999 1 Q4042 CAST SUPPLIES, LONG LEG F 00032.73 07012024 99999999 1 Q4043 CAST SUPPLIES, LONG LEG F 00009.60 07012024 99999999 1 Q4044 CAST SUPPLIES, LONG LEG F 00016.37 07012024 99999999 1 Q4045 CAST SUPPLIES, SHORT LEG F 00011.13 07012024 99999999 1 Q4046 CAST SUPPLIES, SHORT LEG F 00017.91 07012024 99999999 1 Q4047 CAST SUPPLIES, SHORT LEG F 00005.55 07012024 99999999 1 Q4048 CAST SUPPLIES, SHORT LEG F 00008.95 07012024 99999999 1 Q4049 FINGER SPLINT, STATIC F 00002.02 07012024 99999999 1 Q4050 CAST SUPPLIES, UNLISTED M 00000.00 08012017 99999999 1 Q4051 SPLINT SUPPLIES, MISCELLANEOUS M 00000.00 08012017 99999999 1 Q5103 Injection, infliximab-dyyb, biosimilar, F 00095.84 05012024 99999999 1 Q5104 Injection, infliximab-abda, biosimilar, F 00076.31 05012024 99999999 1 Q5121 INJECTION, INFLIXIMAB-AXXQ, BIOSIMILAR, F 00050.64 05012024 99999999 1 Q5133 Inj, tofidence, 1 mg M 00000.00 04012024 99999999 1 Q5135 Inj, tyenne, 1 mg M 00000.00 10012024 99999999 1 Q5136 Inj. denosumab-bbdz, 1 mg M 00000.00 10012024 99999999 1 Q5138 INJ, WEZLANA, IV, 1 MG M 00000.00 07012024 99999999 1 Q5139 Inj, eculizumab-aeeb, 10 mg M 00000.00 01012025 99999999 1 Q5152 Inj, eculizumab-aeeb, 2 mg M 00000.00 04012025 99999999 1 Q5156 Inj, tocilizumab-anoh, 1 mg M 00000.00 10012025 99999999 1 Q5157 Inj, denosumab-bmwo, 1 mg M 00000.00 10012025 99999999 1 Q5158 Inj, denosumab-bnht, 1 mg M 00000.00 10012025 99999999 1 Q9991 Injection, buprenorphine extended-releas F 01945.08 12012025 99999999 1 Q9992 Injection, buprenorphine extended-releas F 01945.08 12012025 99999999 1 S1015 IV TUBING EXTENSION SET M 00000.00 06112012 99999999 1 S5185 MED REMINDER SERV, NON-FACE-TO-FACE M 00000.00 05012022 99999999 1 S5560 INSULIN DELIVERY DEVICE, REUSABLE; 1.5 M M 00000.00 10012015 99999999 1 S5561 INSULIN DELIVERY DEVICE, REUSABLE; 3 ML M 00000.00 10012015 99999999 1 S8100 HOLDING CHAMBER FOR SPACER,W/O MASK F 00029.79 07012024 99999999 1 S8101 HOLDING CHAMBER FOR INHALER W/MASK F 00044.12 07012024 99999999 1 S8185 FLUTTER DEVICE M 00000.00 06012022 99999999 1 S8270 ENURESIS ALARM F 00047.80 07012024 99999999 R S8270 ENURESIS ALARM F 00001.12 RR 07012024 99999999 1 S8420 COMPRESSION SLEEVE&GLOVE COMB, CUSTOM M 00000.00 06112012 99999999 1 S8421 COMPRESSION SLEEVE&GLOVE COMB,READY MADE M 00000.00 06112012 99999999 1 S8422 COMPRESSION SLEEVE, CUSTOM MADE, MED WT M 00000.00 06112012 99999999 1 S8423 COMPRESSION SLEEVE, CUSTOM MADE, HVY WT M 00000.00 06112012 99999999 1 S8424 COMPRESSION SLEEVE, READY MADE M 00000.00 06112012 99999999 1 S8425 COMPRESSION GLOVE, CUSTOM MADE, MED WT M 00000.00 06112012 99999999 1 S8426 COMPRESSION GLOVE, CUSTOM MADE, HVY WT M 00000.00 06112012 99999999 1 S8427 COMPRESSION GLOVE, READY MADE M 00000.00 06112012 99999999 1 S8428 COMPRESSION GAUNTLET, READY MADE M 00000.00 06112012 99999999 1 S8429 GRADIENT PRESSURE EXTERIOR WRAP M 00000.00 06112012 99999999 1 S8430 PADDING FOR COMPRESSION BANDAGE, ROLL M 00000.00 06112012 99999999 1 S8431 COMPRESSION BANDAGE, ROLL M 00000.00 06112012 99999999 1 S8450 SPLINT PREFABRICATED, DIGIT F 00002.13 07012024 99999999 1 S8451 SPLINT,PREFABRICATED,WRIST OR ANKLE F 00354.81 07012024 99999999 1 S8999 RESUSCITATION BAG F 00179.52 07012024 99999999 1 S9434 MODIFIED FOOD SUPP. FOR INBORN ERRORS M 00000.00 06112012 99999999 1 S9435 MEDICAL FOODS FOR INBORN ERROR OF METAB. M 00000.00 09012018 99999999 1 T1013 SIGN LANGUAGE OR ORAL INTERP SERVICES F 00014.39 07012013 99999999 U T1013 TELEPHONIC INTERPRETIVE SERVICES F 00001.63 UC 07012013 99999999 1 T1015 CLINIC VISIT/ENCOUNTER RHC & FQHC F 00000.00 07012024 99999999 1 T1505 ELECTRONIC MED COMPLIANCE MGMT DEVICE M 00000.00 06112012 99999999 R T1505 ELECTRONIC MED COMPLIANCE MGMT DEVICE M 00000.00 RR 06112012 99999999 1 T1999 MISCELLANEOUS THERAPEUTIC ITEMS AND SUPP M 00000.00 06112012 99999999 1 T4521 ADULT BRIEF/DIAPER SMALL F 00000.77 07012024 99999999 1 T4522 ADULT BRIEF/DIAPER MEDIUM F 00000.74 07012024 99999999 1 T4523 ADULT BRIEF/DIAPER LARGE F 00000.95 07012024 99999999 1 T4524 ADULT DIAPER/BRIEF EXTRA LARGE F 00001.12 07012024 99999999 1 T4525 ADULT PULL-ON SMALL F 00000.77 07012024 99999999 1 T4526 ADULT PULL ON, MEDIUM F 00000.74 07012024 99999999 1 T4527 ADULT SIZE PULL ON LARGE F 00000.95 07012024 99999999 1 T4528 ADULT PULL-ON EXTRA LARGE F 00001.12 07012024 99999999 1 T4529 PEDIATRIC SIZE BRIEF/DIAPER SMALL/MEDIUM F 00000.77 07012024 99999999 1 T4530 PEDIATRIC BRIEF/DIAPER LARGE SIZE F 00000.87 07012024 99999999 1 T4531 PEDIATRIC PULL-ON SMALL/MEDIUM F 00000.77 07012024 99999999 1 T4532 PEDIATRIC SIZE PULL-ON LARGE F 00000.87 07012024 99999999 1 T4533 YOUTH SIZE BRIEF/DIAPER F 00000.87 07012024 99999999 1 T4534 YOUTH SIZE PULL-ON,EACH F 00000.87 07012024 99999999 1 T4535 DISP.LINER/SHIELD/GUARD/PAD UNDERGARMENT F 00000.40 07012024 99999999 1 T4537 PROTECTIVE UNDERPAD F 00014.20 07012024 99999999 1 T4540 PROTECTIVE UNDERPAD REUSABLE F 00007.10 07012024 99999999 1 T4543 DISP BARIATRIC BRIEF/DIAPER F 00000.76 07012024 99999999 1 T4544 Adult disposable incontinence product,pr F 00000.76 07012024 99999999 1 T5001 POSITION SEAT FOR VEHICLE M 00000.00 06112012 99999999 1 T5999 SUPPLIES NOT OTHERWISE CLASSIFIED F 00025.11 07012024 99999999 1 V5266 BATTERY FOR USE IN HEARING AID F 00001.80 07012024 99999999 1 V5336 REPAIR/MODIFY AUGMEN DEVICE M 00000.00 07012022 99999999 1 94772 CIRCADIAN RESPIR PATTERN REC F 00130.66 07012024 99999999 1 94772 CIRCADIAN RESPIR PATTERN REC G 00026.13 26 07012024 99999999 1 94772 CIRCADIAN RESPIR PATTERN REC H 00104.54 TC 07012024 99999999 1 99082 UNUSUAL TRAVEL; MILEAGE F 00000.24 07012024 99999999 1 99605 MTMS BY PHARM NP 15 MIN F 00045.65 07012024 99999999 1 99606 MTMS BY PHARM EST 15 MIN F 00020.29 07012024 99999999 1 99607 MTMS BY PHARM ADDL 15 MIN F 00010.14 07012024 99999999