dme fee schedule for items supplied to rural and non … · a7007 lg vol nebulizer disposable u1 $...
TRANSCRIPT
HCPCS Description Modifier 1 Modifier 2 Modifier 3NM Rural
Rate
A4557 Lead wires, pair U1 17.30$
A4595 Tens suppl 2 lead per month U1 21.69$
A4604 Tubing with heating element U1 54.05$
A4640 Alternating pressure pad U1 63.93$
A6550 Neg pres wound ther drsg set U1 26.62$
A7000 Disposable canister for pump U1 9.10$
DME FEE SCHEDULE FOR ITEMS SUPPLIED TO RURAL AND NON CONTIGUOUS AREAS
NEW MEXICO FEE FOR SERVICE PROGRAM - EFFECTIVE JUNE 1, 2018
FOLLOWING MEDICARE DEFINITIONS, THE FOLLOWING LOCATIONS ARE CONSIDERED RURAL OR NON-
CONTIGUOUS BY MEDICARE. MEDICAID FOLLOWS THE MEDICARE DETERMINATION.
ALAMOGORDO, ARTESIA, CARLSBAD, CLAYTON, CLOVIS, DEMING , ESPANOLA, GALLUP, GRANTS, HOBBS, LAS
VEGAS, LOVINGTON, PORTALES, RATON, ROSWELL, RUIDOSO, SILVER CITY, SOCORRO, T OR C, TAOS, ZUNI
For a complete list of zip codes that are considered rural or non-contiguous, see the bottom of the fee
schedule chart
IN ORDER TO RECEIVE THE RURAL RATE, THE RURAL PROVIDER MUST USE THE U1 MODIFIER ON THE CLAIM
LINE IN ADDITION TO ANY OTHER RELEVANT MODIFIERS SUCH AS THE RR FOR RENTAL AND THE NU FOR
NEW EQUIPMENT.
WHEN TO BILL A RURAL RATE: The modifier U1, rural, may be used when the item is furnished in a rural area.
For example, if a resident of Artesia receives an item from a provider in Artesia, since Artesia is a rural area,
the provider could bill the U1 modifier for increased payment.
Note that the fee schedule for non rural DME rates are found on this same web page, under HCPCS Codes.
USE OF THE KE MODIFIER:
The KE modifier can be used under the same circumstances that you would use the KE modifier on a Medicare
claim. Medicaid follows Medicare rules. Note that the KE modifier can only be used if the item was furnish in
a rural or non-contiguous area.
Under Medicare, in cases where accessories included in the 2008 Competitive Bidding Programs (CBPs) are
furnished for use with base equipment that was not included in the 2008 CBP, the KE modifier can be used.
For further information on the precise application of the KE modifier, please follow the instructions of your
Durable Medical Equipment Administrative Contractor (DME MAC).
1
A7000 Disposable canister for pump U1 KE 9.48$
A7003 Nebulizer administration set U1 2.35$
A7004 Disposable nebulizer sml vol U1 1.54$
A7005 Nondisposable nebulizer set U1 21.12$
A7006 Filtered nebulizer admin set U1 9.25$
A7007 Lg vol nebulizer disposable U1 4.17$
A7010 Disposable corrugated tubing U1 19.54$
A7012 Nebulizer water collec devic U1 3.64$
A7013 Disposable compressor filter U1 0.70$
A7014 Compressor nondispos filter U1 4.27$
A7015 Aerosol mask used w nebulize U1 1.74$
A7017 Nebulizer not used w oxygen U1 137.88$
A7018 Water distilled w/nebulizer U1 0.36$
A7027 Combination oral/nasal mask U1 169.91$
A7028 Repl oral cushion combo mask U1 46.11$
A7029 Repl nasal pillow comb mask U1 19.74$
A7030 Cpap full face mask U1 139.91$
A7031 Replacement facemask interfa U1 52.25$
A7032 Replacement nasal cushion U1 29.95$
A7033 Replacement nasal pillows U1 22.21$
A7034 Nasal application device U1 87.34$
A7035 Pos airway press headgear U1 27.76$
A7036 Pos airway press chinstrap U1 13.33$
A7037 Pos airway pressure tubing U1 26.12$
A7038 Pos airway pressure filter U1 3.76$
A7039 Filter, non disposable w pap U1 9.61$
A7044 Pap oral interface U1 103.68$
A7045 Repl exhalation port for pap U1 15.99$
A7046 Repl water chamber, pap dev U1 16.69$
B4034 Enter feed supkit syr by day U1 4.85$
B4035 Enteral feed supp pump per d U1 8.95$
B4036 Enteral feed sup kit grav by U1 6.45$
B4081 Enteral ng tubing w/ stylet U1 19.64$
B4082 Enteral stomach tube levine U1 14.37$
B4083 Gastro/jejuno tube, std U1 2.18$
B4087 Gastro/jejuno tube, low-pro U1 33.24$
B4088 Ef blenderized foods U1 35.73$
B4149 Ef complet w/intact nutrient U1 1.37$
B4150 Ef calorie dense>/=1.5kcal U1 0.56$
B4152 Ef hydrolyzed/amino acids U1 0.46$
B4153 Ef spec metabolic noninherit U1 1.65$
B4154 Ef incomplete/modular U1 0.99$
B4155 Parenteral 50% dextrose solu U1 0.89$
B9002 Enter nutr inf pump any type U1 975.80$
B9002 Enter nutr inf pump any type U1 RR 95.57$
E0130 Walker rigid adjust/fixed ht U1 58.31$
E0130 Walker rigid adjust/fixed ht U1 RR 9.36$
2
E0135 Walker folding adjust/fixed U1 64.95$
E0135 Walker folding adjust/fixed U1 RR 9.54$
E0140 Walker w trunk support U1 RR 32.45$
E0141 Rigid wheeled walker adj/fix U1 79.86$
E0141 Rigid wheeled walker adj/fix U1 RR 11.76$
E0143 Walker folding wheeled w/o s U1 83.61$
E0143 Walker folding wheeled w/o s U1 RR 11.43$
E0147 Walker variable wheel resist U1 490.19$
E0147 Walker variable wheel resist U1 RR 49.02$
E0148 Heavyduty walker no wheels U1 105.72$
E0148 Heavyduty walker no wheels U1 RR 10.58$
E0149 Heavy duty wheeled walker U1 RR 17.08$
E0154 Walker platform attachment U1 60.31$
E0154 Walker platform attachment U1 RR 6.76$
E0155 Walker wheel attachment,pair U1 26.43$
E0155 Walker wheel attachment,pair U1 RR 2.78$
E0156 Walker seat attachment U1 21.21$
E0156 Walker seat attachment U1 RR 2.28$
E0157 Walker crutch attachment U1 69.63$
E0157 Walker crutch attachment U1 RR 7.35$
E0158 Walker leg extenders set of4 U1 27.13$
E0158 Walker leg extenders set of4 U1 RR 2.86$
E0159 Brake for wheeled walker U1 16.49$
E0159 Brake for wheeled walker U1 RR 1.68$
E0160 Sitz type bath or equipment U1 31.21$
E0160 Sitz type bath or equipment U1 RR 3.62$
E0161 Sitz bath/equipment w/faucet U1 25.09$
E0161 Sitz bath/equipment w/faucet U1 RR 3.03$
E0163 Commode chair with fixed arm U1 90.21$
E0163 Commode chair with fixed arm U1 RR 14.50$
E0167 Commode chair pail or pan U1 12.53$
E0168 Heavyduty/wide commode chair U1 147.35$
E0168 Heavyduty/wide commode chair U1 RR 14.78$
E0170 Commode chair electric U1 RR 177.52$
E0171 Commode chair non-electric U1 RR 32.55$
E0181 Press pad alternating w/ pum U1 RR 22.96$
E0182 Replace pump, alt press pad U1 RR 25.24$
E0184 Dry pressure mattress U1 178.95$
E0184 Dry pressure mattress U1 RR 20.33$
E0185 Gel pressure mattress pad U1 270.39$
E0185 Gel pressure mattress pad U1 RR 33.23$
E0186 Air pressure mattress U1 RR 19.42$
E0187 Water pressure mattress U1 RR 22.21$
E0188 Synthetic sheepskin pad U1 25.29$
E0189 Lambswool sheepskin pad U1 55.78$
E0193 Powered air flotation bed U1 RR 757.88$
E0196 Gel pressure mattress U1 RR 33.11$
3
E0199 Dry pressure pad for mattres U1 33.19$
E0250 Hosp bed fixed ht w/ mattres U1 RR 74.09$
E0251 Hosp bed fixd ht w/o mattres U1 RR 61.03$
E0255 Hospital bed var ht w/ mattr U1 RR 84.51$
E0256 Hospital bed var ht w/o matt U1 RR 72.15$
E0260 Hosp bed semi-electr w/ matt U1 RR 100.83$
E0261 Hosp bed semi-electr w/o mat U1 RR 93.33$
E0271 Mattress innerspring U1 173.66$
E0271 Mattress innerspring U1 RR 17.79$
E0272 Mattress foam rubber U1 172.99$
E0272 Mattress foam rubber U1 RR 17.74$
E0275 Bed pan standard U1 16.07$
E0276 Bed pan fracture U1 13.89$
E0277 Powered pres-redu air mattrs U1 RR 428.28$
E0280 Bed cradle U1 31.51$
E0280 Bed cradle U1 RR 3.37$
E0290 Hosp bed fx ht w/o rails w/m U1 RR 61.23$
E0291 Hosp bed fx ht w/o rail w/o U1 RR 44.78$
E0292 Hosp bed var ht no sr w/matt U1 RR 72.86$
E0293 Hosp bed var ht no sr no mat U1 RR 64.50$
E0294 Hosp bed semi-elect w/ mattr U1 RR 94.73$
E0295 Hosp bed semi-elect w/o matt U1 RR 85.37$
E0301 Hd hosp bed, 350-600 lbs U1 RR 199.68$
E0302 Ex hd hosp bed > 600 lbs U1 RR 598.00$
E0303 Hosp bed hvy dty xtra wide U1 RR 217.00$
E0304 Hosp bed xtra hvy dty x wide U1 RR 631.69$
E0305 Rails bed side half length U1 RR 14.37$
E0310 Rails bed side full length U1 153.83$
E0310 Rails bed side full length U1 RR 15.40$
E0325 Urinal male jug-type U1 10.56$
E0326 Urinal female jug-type U1 10.04$
E0371 Nonpower mattress overlay U1 RR 293.16$
E0372 Powered air mattress overlay U1 RR 333.94$
E0373 Nonpowered pressure mattress U1 RR 367.60$
E0424 Stationary compressed gas 02 U1 RR 121.46$
E0431 Portable gaseous 02 U1 RR 24.94$
E0433 Portable liquid oxygen sys U1 RR 46.77$
E0434 Portable liquid 02 U1 RR 24.94$
E0439 Stationary liquid 02 U1 RR 121.46$
E0441 Stationary o2 contents, gas U1 67.71$
E0442 Stationary o2 contents, liq U1 67.98$
E0443 Portable 02 contents, gas U1 65.03$
E0444 Portable 02 contents, liquid U1 65.03$
E0470 Rad w/o backup non-inv intfc U1 RR 177.82$
E0471 Rad w/backup non inv intrfc U1 RR 409.29$
E0472 Rad w backup invasive intrfc U1 RR 481.11$
E0561 Humidifier nonheated w pap U1 90.85$
4
E0561 Humidifier nonheated w pap U1 RR 9.08$
E0562 Humidifier heated used w pap U1 220.52$
E0562 Humidifier heated used w pap U1 RR 22.04$
E0565 Compressor air power source U1 RR 56.88$
E0570 Nebulizer with compression U1 RR 12.15$
E0572 Aerosol compressor adjust pr U1 RR 34.44$
E0585 Nebulizer w/ compressor & he U1 RR 32.27$
E0601 Cont airway pressure device U1 RR 76.38$
E0621 Patient lift sling or seat U1 98.64$
E0621 Patient lift sling or seat U1 RR 9.66$
E0627 Seat lift mech, electric any U1 326.19$
E0627 Seat lift mech, electric any U1 RR 32.62$
E0629 Seat lift mech, non-electric U1 324.61$
E0629 Seat lift mech, non-electric U1 RR 32.46$
E0630 Patient lift hydraulic U1 RR 83.70$
E0635 Patient lift electric U1 RR 131.46$
E0636 Pt support & positioning sys U1 RR 1,120.45$
E0705 Transfer device U1 55.68$
E0776 Iv pole U1 80.67$
E0776 Iv pole U1 KE 85.70$
E0705 Transfer device U1 RR 5.62$
E0776 Iv pole U1 RR KE 17.98$
E0720 Tens two lead U1 242.53$
E0730 Tens four lead U1 244.58$
E0731 Conductive garment for tens/ U1 245.42$
E0910 Trapeze bar attached to bed U1 RR 14.16$
E0911 Hd trapeze bar attach to bed U1 RR 46.62$
E0912 Hd trapeze bar free standing U1 RR 99.09$
E0940 Trapeze bar free standing U1 RR 25.59$
E0950 Tray U1 90.42$
E0950 Tray U1 KE 94.81$
E0950 Tray U1 RR KE 9.49$
E0950 Tray U1 RR 9.06$
E0951 Loop heel U1 16.10$
E0951 Loop heel U1 KE 16.58$
E0951 Loop heel U1 RR KE 1.70$
E0951 Loop heel U1 RR 1.64$
E0953 W/c lateral thigh/knee sup U1 87.97$
E0953 W/c lateral thigh/knee sup U1 RR 8.80$
E0955 Cushioned headrest U1 RR KE 18.22$
E0955 Cushioned headrest U1 RR 17.43$
E0956 W/c lateral trunk/hip suppor U1 87.97$
E0956 W/c lateral trunk/hip suppor U1 KE 92.04$
E0956 W/c lateral trunk/hip suppor U1 RR KE 9.21$
E0956 W/c lateral trunk/hip suppor U1 RR 8.80$
E0957 W/c medial thigh support U1 130.08$
E0957 W/c medial thigh support U1 KE 136.32$
5
E0957 W/c medial thigh support U1 RR KE 13.64$
E0957 W/c medial thigh support U1 RR 13.01$
E0958 Whlchr att- conv 1 arm drive U1 RR 44.07$
E0959 Amputee adapter U1 48.14$
E0959 Amputee adapter U1 RR 4.83$
E0960 W/c shoulder harness/straps U1 82.21$
E0960 W/c shoulder harness/straps U1 KE 86.03$
E0960 W/c shoulder harness/straps U1 RR KE 8.61$
E0960 W/c shoulder harness/straps U1 RR 8.23$
E0961 Wheelchair brake extension U1 24.99$
E0966 Wheelchair head rest extensi U1 77.41$
E0967 Man wc rim/projection rep ea U1 73.92$
E0967 Man wc rim/projection rep ea U1 RR 7.40$
E0971 Wheelchair anti-tipping devi U1 40.29$
E0971 Wheelchair anti-tipping devi U1 RR 4.04$
E0973 W/ch access det adj armrest U1 75.45$
E0973 W/ch access det adj armrest U1 KE 79.29$
E0973 W/ch access det adj armrest U1 RR KE 7.67$
E0973 W/ch access det adj armrest U1 RR 7.32$
E0974 W/ch access anti-rollback U1 82.69$
E0974 W/ch access anti-rollback U1 RR 8.54$
E0978 W/c acc,saf belt pelv strap U1 30.45$
E0978 W/c acc,saf belt pelv strap U1 KE 31.25$
E0978 W/c acc,saf belt pelv strap U1 RR KE 3.14$
E0978 W/c acc,saf belt pelv strap U1 RR 3.05$
E0985 W/c seat lift mechanism U1 RR 22.74$
E0990 Wheelchair elevating leg res U1 93.36$
E0990 Wheelchair elevating leg res U1 KE 97.24$
E0990 Wheelchair elevating leg res U1 RR KE 9.72$
E0990 Wheelchair elevating leg res U1 RR 9.33$
E0992 Wheelchair solid seat insert U1 93.27$
E0992 Wheelchair solid seat insert U1 RR 9.33$
E1015 Shock absorber for man w/c U1 127.10$
E1016 Shock absorber for power w/c U1 122.41$
E1016 Shock absorber for power w/c U1 KE 127.27$
E1016 Shock absorber for power w/c U1 RR KE 12.74$
E1016 Shock absorber for power w/c U1 RR 12.25$
E1020 Residual limb support system U1 RR KE 22.33$
E1020 Residual limb support system U1 RR 21.23$
E1028 W/c manual swingaway U1 RR KE 17.75$
E1028 W/c manual swingaway U1 RR 17.08$
E1031 Rollabout chair with casters U1 RR 46.65$
E1036 Patient transfer system >300 U1 RR 934.77$
E1037 Transport chair, ped size U1 RR 117.40$
E1038 Transport chair pt wt<=300lb U1 RR 17.85$
E1039 Transport chair pt wt >300lb U1 RR 36.56$
E1225 Manual semi-reclining back U1 RR 43.91$
6
E1226 Manual fully reclining back U1 506.01$
E1226 Manual fully reclining back U1 RR 51.50$
E1372 Oxy suppl heater for nebuliz U1 149.38$
E1372 Oxy suppl heater for nebuliz U1 RR 17.94$
E1390 Oxygen concentrator U1 RR 121.46$
E1391 Oxygen concentrator, dual U1 RR 121.46$
E1392 Portable oxygen concentrator U1 RR 46.77$
E1405 O2/water vapor enrich w/heat U1 RR 151.77$
E1406 O2/water vapor enrich w/o he U1 RR 127.58$
E2201 Man w/ch acc seat w>=20"<24" U1 370.85$
E2201 Man w/ch acc seat w>=20"<24" U1 RR 37.08$
E2202 Seat width 24-27 in U1 501.12$
E2202 Seat width 24-27 in U1 RR 50.11$
E2203 Frame depth less than 22 in U1 488.84$
E2203 Frame depth less than 22 in U1 RR 48.88$
E2204 Frame depth 22 to 25 in U1 841.44$
E2204 Frame depth 22 to 25 in U1 RR 84.15$
E2205 Manual wc accessory, handrim U1 36.52$
E2205 Manual wc accessory, handrim U1 RR 3.64$
E2206 Man wc whl lock comp repl ea U1 42.78$
E2206 Man wc whl lock comp repl ea U1 RR 4.27$
E2207 Crutch and cane holder U1 48.19$
E2207 Crutch and cane holder U1 RR 4.83$
E2208 Cylinder tank carrier U1 97.57$
E2208 Cylinder tank carrier U1 KE 102.50$
E2208 Cylinder tank carrier U1 RR KE 10.24$
E2208 Cylinder tank carrier U1 RR 9.76$
E2209 Arm trough each U1 95.57$
E2209 Arm trough each U1 KE 98.99$
E2209 Arm trough each U1 RR KE 9.92$
E2209 Arm trough each U1 RR 9.57$
E2210 Wheelchair bearings U1 5.96$
E2210 Wheelchair bearings U1 KE 6.17$
E2210 Wheelchair bearings U1 RR KE 0.62$
E2210 Wheelchair bearings U1 RR 0.60$
E2211 Pneumatic propulsion tire U1 40.76$
E2211 Pneumatic propulsion tire U1 RR 4.03$
E2212 Pneumatic prop tire tube U1 6.56$
E2212 Pneumatic prop tire tube U1 RR 0.68$
E2213 Pneumatic prop tire insert U1 32.61$
E2213 Pneumatic prop tire insert U1 RR 3.27$
E2214 Pneumatic caster tire each U1 37.32$
E2214 Pneumatic caster tire each U1 RR 3.93$
E2215 Pneumatic caster tire tube U1 10.75$
E2215 Pneumatic caster tire tube U1 RR 1.07$
E2219 Foam caster tire any size ea U1 40.03$
E2219 Foam caster tire any size ea U1 RR 4.37$
7
E2220 Solid propuls tire, repl, ea U1 31.26$
E2220 Solid propuls tire, repl, ea U1 RR 3.07$
E2221 Solid caster tire repl, each U1 28.24$
E2221 Solid caster tire repl, each U1 RR 2.84$
E2222 Solid caster integ whl, repl U1 23.44$
E2222 Solid caster integ whl, repl U1 RR 2.33$
E2224 Propulsion whl excl tire rep U1 104.40$
E2224 Propulsion whl excl tire rep U1 RR 10.45$
E2225 Caster wheel excludes tire U1 19.56$
E2225 Caster wheel excludes tire U1 RR 1.96$
E2226 Caster fork replacement only U1 41.83$
E2226 Caster fork replacement only U1 RR 4.18$
E2228 Mwc acc, wheelchair brake U1 RR 102.27$
E2231 Solid seat support base U1 158.93$
E2231 Solid seat support base U1 RR 15.89$
E2359 Gr34 sealed leadacid battery U1 185.27$
E2359 Gr34 sealed leadacid battery U1 RR 18.53$
E2360 22nf nonsealed leadacid U1 118.41$
E2360 22nf nonsealed leadacid U1 RR 11.87$
E2361 22nf sealed leadacid battery U1 127.83$
E2361 22nf sealed leadacid battery U1 KE 131.48$
E2361 22nf sealed leadacid battery U1 RR KE 13.15$
E2361 22nf sealed leadacid battery U1 RR 12.78$
E2362 Gr24 nonsealed leadacid U1 101.99$
E2362 Gr24 nonsealed leadacid U1 RR 10.20$
E2363 Gr24 sealed leadacid battery U1 166.30$
E2363 Gr24 sealed leadacid battery U1 KE 169.83$
E2363 Gr24 sealed leadacid battery U1 RR KE 16.99$
E2363 Gr24 sealed leadacid battery U1 RR 16.63$
E2364 U1nonsealed leadacid battery U1 116.44$
E2364 U1nonsealed leadacid battery U1 RR 11.67$
E2365 U1 sealed leadacid battery U1 94.52$
E2365 U1 sealed leadacid battery U1 KE 97.23$
E2365 U1 sealed leadacid battery U1 RR KE 9.72$
E2365 U1 sealed leadacid battery U1 RR 9.45$
E2366 Battery charger, single mode U1 190.52$
E2366 Battery charger, single mode U1 KE 196.37$
E2366 Battery charger, single mode U1 RR KE 19.67$
E2366 Battery charger, single mode U1 RR 19.08$
E2367 Battery charger, dual mode U1 376.37$
E2367 Battery charger, dual mode U1 KE 392.65$
E2367 Battery charger, dual mode U1 RR KE 39.27$
E2367 Battery charger, dual mode U1 RR 37.64$
E2368 Pwr wc drivewheel motor repl U1 RR KE 48.10$
E2368 Pwr wc drivewheel motor repl U1 RR 46.42$
E2369 Pwr wc drivewheel gear repl U1 RR KE 42.97$
E2369 Pwr wc drivewheel gear repl U1 RR 42.07$
8
E2370 Pwr wc dr wh motor/gear comb U1 RR KE 69.96$
E2370 Pwr wc dr wh motor/gear comb U1 RR 66.65$
E2371 Gr27 sealed leadacid battery U1 146.15$
E2371 Gr27 sealed leadacid battery U1 KE 150.14$
E2371 Gr27 sealed leadacid battery U1 RR KE 15.01$
E2371 Gr27 sealed leadacid battery U1 RR 14.62$
E2375 Non-expandable controller U1 RR KE 79.57$
E2375 Non-expandable controller U1 RR 76.84$
E2378 Pw actuator replacement U1 RR 57.36$
E2381 Pneum drive wheel tire U1 68.77$
E2381 Pneum drive wheel tire U1 KE 70.93$
E2381 Pneum drive wheel tire U1 RR KE 7.10$
E2381 Pneum drive wheel tire U1 RR 6.89$
E2383 Insert, pneum wheel drive U1 140.44$
E2383 Insert, pneum wheel drive U1 KE 145.62$
E2383 Insert, pneum wheel drive U1 RR KE 14.56$
E2383 Insert, pneum wheel drive U1 RR 14.04$
E2384 Pneumatic caster tire U1 71.34$
E2384 Pneumatic caster tire U1 KE 73.87$
E2384 Pneumatic caster tire U1 RR KE 7.40$
E2384 Pneumatic caster tire U1 RR 7.14$
E2386 Foam filled drive wheel tire U1 126.54$
E2386 Foam filled drive wheel tire U1 KE 133.01$
E2386 Foam filled drive wheel tire U1 RR KE 13.30$
E2386 Foam filled drive wheel tire U1 RR 12.65$
E2387 Foam filled caster tire U1 58.43$
E2387 Foam filled caster tire U1 KE 60.78$
E2387 Foam filled caster tire U1 RR KE 6.08$
E2387 Foam filled caster tire U1 RR 5.84$
E2391 Solid caster tire U1 19.16$
E2391 Solid caster tire U1 KE 19.74$
E2391 Solid caster tire U1 RR KE 1.97$
E2391 Solid caster tire U1 RR 1.92$
E2392 Solid caster tire, integrate U1 48.18$
E2392 Solid caster tire, integrate U1 KE 49.55$
E2392 Solid caster tire, integrate U1 RR KE 4.97$
E2392 Solid caster tire, integrate U1 RR 4.83$
E2394 Drive wheel excludes tire U1 67.64$
E2394 Drive wheel excludes tire U1 KE 70.59$
E2394 Drive wheel excludes tire U1 RR KE 7.07$
E2394 Drive wheel excludes tire U1 RR 6.77$
E2395 Caster wheel excludes tire U1 49.23$
E2395 Caster wheel excludes tire U1 KE 51.28$
E2395 Caster wheel excludes tire U1 RR KE 5.13$
E2395 Caster wheel excludes tire U1 RR 4.93$
E2396 Caster fork U1 54.80$
E2396 Caster fork U1 KE 55.68$
9
E2396 Caster fork U1 RR KE 5.80$
E2396 Caster fork U1 RR 5.67$
E2397 Pwc acc, lith-based battery U1 465.55$
E2397 Pwc acc, lith-based battery U1 RR 46.56$
E2402 Neg press wound therapy pump U1 RR 1,184.12$
E2601 Gen w/c cushion wdth < 22 in U1 50.02$
E2601 Gen w/c cushion wdth < 22 in U1 KE 52.15$
E2602 Gen w/c cushion wdth >=22 in U1 101.81$
E2602 Gen w/c cushion wdth >=22 in U1 KE 105.53$
E2602 Gen w/c cushion wdth >=22 in U1 RR KE 10.56$
E2602 Gen w/c cushion wdth >=22 in U1 RR 10.19$
E2603 Skin protect wc cus wd <22in U1 127.32$
E2603 Skin protect wc cus wd <22in U1 KE 133.62$
E2603 Skin protect wc cus wd <22in U1 RR KE 13.36$
E2603 Skin protect wc cus wd <22in U1 RR 12.74$
E2604 Skin protect wc cus wd>=22in U1 167.58$
E2604 Skin protect wc cus wd>=22in U1 KE 176.45$
E2604 Skin protect wc cus wd>=22in U1 RR KE 17.63$
E2604 Skin protect wc cus wd>=22in U1 RR 16.76$
E2605 Position wc cush wdth <22 in U1 240.35$
E2605 Position wc cush wdth <22 in U1 KE 250.55$
E2605 Position wc cush wdth <22 in U1 RR KE 25.06$
E2605 Position wc cush wdth <22 in U1 RR 24.04$
E2606 Position wc cush wdth>=22 in U1 379.73$
E2606 Position wc cush wdth>=22 in U1 KE 396.18$
E2606 Position wc cush wdth>=22 in U1 RR KE 39.63$
E2606 Position wc cush wdth>=22 in U1 RR 37.98$
E2607 Skin pro/pos wc cus wd <22in U1 246.89$
E2607 Skin pro/pos wc cus wd <22in U1 KE 259.27$
E2607 Skin pro/pos wc cus wd <22in U1 RR KE 25.93$
E2607 Skin pro/pos wc cus wd <22in U1 RR 24.69$
E2608 Skin pro/pos wc cus wd>=22in U1 302.76$
E2608 Skin pro/pos wc cus wd>=22in U1 KE 318.77$
E2608 Skin pro/pos wc cus wd>=22in U1 RR KE 31.88$
E2608 Skin pro/pos wc cus wd>=22in U1 RR 30.27$
E2611 Gen use back cush wdth <22in U1 233.32$
E2611 Gen use back cush wdth <22in U1 KE 247.96$
E2611 Gen use back cush wdth <22in U1 RR KE 24.80$
E2611 Gen use back cush wdth <22in U1 RR 23.33$
E2612 Gen use back cush wdth>=22in U1 364.63$
E2612 Gen use back cush wdth>=22in U1 KE 380.35$
E2612 Gen use back cush wdth>=22in U1 RR KE 38.03$
E2612 Gen use back cush wdth>=22in U1 RR 36.46$
E2613 Position back cush wd <22in U1 352.23$
E2613 Position back cush wd <22in U1 KE 366.05$
E2613 Position back cush wd <22in U1 RR KE 36.62$
E2613 Position back cush wd <22in U1 RR 35.23$
10
E2614 Position back cush wd>=22in U1 502.25$
E2614 Position back cush wd>=22in U1 KE 519.62$
E2614 Position back cush wd>=22in U1 RR KE 51.97$
E2614 Position back cush wd>=22in U1 RR 50.23$
E2615 Pos back post/lat wdth <22in U1 403.71$
E2615 Pos back post/lat wdth <22in U1 KE 420.15$
E2615 Pos back post/lat wdth <22in U1 RR KE 42.02$
E2615 Pos back post/lat wdth <22in U1 RR 40.38$
E2616 Pos back post/lat wdth>=22in U1 543.45$
E2616 Pos back post/lat wdth>=22in U1 KE 565.46$
E2616 Pos back post/lat wdth>=22in U1 RR KE 56.55$
E2616 Pos back post/lat wdth>=22in U1 RR 54.34$
E2620 Wc planar back cush wd <22in U1 463.22$
E2620 Wc planar back cush wd <22in U1 KE 489.12$
E2620 Wc planar back cush wd <22in U1 RR KE 48.91$
E2620 Wc planar back cush wd <22in U1 RR 46.32$
E2621 Wc planar back cush wd>=22in U1 512.80$
E2621 Wc planar back cush wd>=22in U1 KE 536.34$
E2621 Wc planar back cush wd>=22in U1 RR KE 53.63$
E2621 Wc planar back cush wd>=22in U1 RR 51.28$
E2626 Seo mobile arm sup att to wc U1 677.74$
E2626 Seo mobile arm sup att to wc U1 RR 67.79$
E2627 Arm supp att to wc rancho ty U1 1,077.91$
E2627 Arm supp att to wc rancho ty U1 RR 107.81$
E2628 Mobile arm supports reclinin U1 728.85$
E2628 Mobile arm supports reclinin U1 RR 72.88$
E2629 Friction dampening arm supp U1 985.42$
E2629 Friction dampening arm supp U1 RR 98.54$
E2630 Monosuspension arm/hand supp U1 716.77$
E2630 Monosuspension arm/hand supp U1 RR 71.68$
E2631 Elevat proximal arm support U1 255.00$
E2631 Elevat proximal arm support U1 RR 25.51$
E2632 Offset/lat rocker arm w/ela U1 160.78$
E2632 Offset/lat rocker arm w/ela U1 RR 16.07$
E2633 Mobile arm support supinator U1 152.56$
E2633 Mobile arm support supinator U1 RR 15.26$
K0001 Standard wheelchair U1 RR 39.28$
K0002 Stnd hemi (low seat) whlchr U1 RR 67.19$
K0003 Lightweight wheelchair U1 RR 68.79$
K0004 High strength ltwt whlchr U1 RR 97.83$
K0006 Heavy duty wheelchair U1 RR 104.16$
K0007 Extra heavy duty wheelchair U1 RR 137.15$
K0015 Detach non-adjus hght armrst U1 RR KE 16.99$
K0019 Arm pad repl, each U1 15.32$
K0019 Arm pad each U1 KE 15.47$
K0040 Adjustable angle footplate U1 63.67$
K0040 Adjustable angle footplate U1 KE 67.06$
11
K0040 Adjustable angle footplate U1 RR KE 6.69$
K0040 Adjustable angle footplate U1 RR 6.36$
K0052 Swingaway detach ftrest repl U1 82.00$
K0052 Swingaway detach footrest U1 KE 85.33$
K0053 Elevate footrest articulate U1 93.73$
K0053 Elevate footrest articulate U1 KE 97.04$
K0056 Seat ht <17 or >=21 ltwt wc U1 102.84$
K0065 Spoke protectors U1 49.55$
K0069 Rr whl compl sol tire rep ea U1 105.81$
K0071 Fr cstr comp pne tire rep ea U1 118.65$
K0072 Fr cstr semi-pne tire rep ea U1 72.53$
K0073 Caster pin lock each U1 38.19$
K0077 Fr cstr asmb sol tire rep ea U1 61.23$
K0098 Drive belt for pwc, repl U1 25.79$
K0098 Drive belt power wheelchair U1 KE 26.66$
K0105 Iv hanger U1 108.11$
K0105 Iv hanger U1 RR 10.81$
K0733 12-24hr sealed lead acid U1 29.30$
K0733 12-24hr sealed lead acid U1 KE 30.48$
K0733 12-24hr sealed lead acid U1 RR KE 3.06$
K0733 12-24hr sealed lead acid U1 RR 2.95$
K0738 Portable gas oxygen system U1 RR 46.77$
K0800 Pov group 1 std up to 300lbs U1 1,068.47$
K0800 Pov group 1 std up to 300lbs U1 RR 106.85$
K0801 Pov group 1 hd 301-450 lbs U1 1,818.18$
K0801 Pov group 1 hd 301-450 lbs U1 RR 181.80$
K0802 Pov group 1 vhd 451-600 lbs U1 2,219.79$
K0802 Pov group 1 vhd 451-600 lbs U1 RR 221.98$
K0813 Pwc gp 1 std port seat/back U1 RR 314.41$
K0814 Pwc gp 1 std port cap chair U1 RR 368.33$
K0815 Pwc gp 1 std seat/back U1 RR 414.33$
K0816 Pwc gp 1 std cap chair U1 RR 391.98$
K0820 Pwc gp 2 std port seat/back U1 RR 330.15$
K0821 Pwc gp 2 std port cap chair U1 RR 387.90$
K0822 Pwc gp 2 std seat/back U1 RR 449.19$
K0823 Pwc gp 2 std cap chair U1 RR 440.11$
K0824 Pwc gp 2 hd seat/back U1 RR 579.44$
K0825 Pwc gp 2 hd cap chair U1 RR 532.98$
K0826 Pwc gp 2 vhd seat/back U1 RR 840.66$
K0827 Pwc gp vhd cap chair U1 RR 723.82$
K0828 Pwc gp 2 xtra hd seat/back U1 RR 979.16$
K0829 Pwc gp 2 xtra hd cap chair U1 RR 923.09$
87005 87511 87577 87831 88121 88321
87006 87512 87578 87832 88122 88323
RURAL AND NON-CONTIGUOUS ZIP CODES FOR USE WITH THE DME FEE SCHEDULE
12
87007 87513 87579 87901 88123 88324
87009 87514 87580 87930 88124 88325
87011 87515 87581 87931 88125 88330
87012 87516 87582 87933 88126 88336
87013 87517 87583 87935 88130 88337
87014 87518 87654 87939 88132 88338
87017 87519 87701 87942 88133 88339
87018 87520 87710 87943 88134 88340
87020 87521 87711 88009 88135 88341
87021 87522 87712 88020 88136 88342
87026 87523 87713 88022 88201 88343
87027 87524 87714 88023 88202 88344
87028 87525 87715 88025 88203 88345
87029 87527 87718 88026 88210 88346
87038 87528 87722 88028 88211 88347
87040 87529 87723 88029 88213 88348
87045 87530 87724 88030 88220 88349
87046 87531 87728 88031 88221 88350
87049 87532 87729 88034 88230 88351
87051 87533 87730 88036 88231 88352
87062 87537 87731 88038 88232 88353
87064 87538 87732 88039 88240 88354
87301 87539 87733 88040 88241 88355
87302 87543 87734 88041 88242 88401
87305 87544 87735 88042 88244 88410
87310 87545 87736 88043 88250 88411
87311 87547 87740 88045 88252 88414
87312 87548 87742 88049 88253 88415
87313 87549 87743 88051 88254 88416
87315 87551 87745 88053 88255 88417
87316 87552 87746 88055 88256 88418
87317 87553 87747 88056 88260 88419
87319 87554 87749 88061 88262 88421
87320 87556 87750 88062 88263 88422
87321 87557 87752 88065 88264 88424
87322 87558 87753 88101 88265 88426
87323 87560 87801 88102 88267 88427
87325 87562 87820 88103 88268 88430
87326 87564 87821 88112 88301 88431
87327 87565 87823 88113 88310 88433
87328 87566 87824 88114 88311 88434
87347 87569 87825 88115 88312 88435
87357 87571 87827 88116 88314 88436
87365 87573 87828 88118 88316 88439
87375 87575 87829 88119 88317
87510 87576 87830 88120 88318
13