msm 1300 - nevadadhcfp.nv.gov/uploadedfiles/dhcfpnvgov/content/...may 01, 2015 · a4230 infus...

Updated: May 1, 2015

Note:

MSM 1300

Proc Code Description Mod Rate

A4206 1 CC STERILE SYRINGE&NEEDLE 0.39

A4208 3 CC STERILE SYRINGE&NEEDLE 0.39

A4209 5+ CC STERILE SYRINGE&NEEDLE 0.40

A4213 20+ CC SYRINGE ONLY 0.78

A4221 MAINT DRUG INFUS CATH PER WK 22.10

A4222 INFUSION SUPPLIES WITH PUMP 43.86

A4223 INFUSION SUPPLIES W/O PUMP 43.86

A4230 INFUS INSULIN PUMP NON NEEDL 10.00

A4231 INFUSION INSULIN PUMP NEEDLE 5.06

A4232 SYRINGE W/NEEDLE INSULIN 3CC 2.59

A4244 ALCOHOL OR PEROXIDE PER PINT 0.78

A4245 ALCOHOL WIPES PER BOX 2.35

A4246 BETADINE/PHISOHEX SOLUTION 2.75

A4253 BLOOD GLUCOSE/REAGENT STRIPS NU 33.52

A4255 GLUCOSE MONITOR PLATFORMS 4.08

A4256 CALIBRATOR SOLUTION/CHIPS 9.65

A4257 REPLACE LENSSHIELD CARTRIDGE 12.66

A4258 LANCET DEVICE EACH 17.63

A4259 LANCETS PER BOX 12.65

A4265 PARAFFIN 3.37

A4280 BRST PRSTHS ADHSV ATTCHMNT 4.81

A4305 DRUG DELIVERY SYSTEM >=50 ML 13.32

A4306 DRUG DELIVERY SYSTEM <=50 ML 18.41

CPT codes, descriptions and other data only are copyright © 2008 American Medical Association. All rights

reserved. Applicable FARS/DFARS apply. CPT is a registered trademark ® of the American Medical

Association.

Reimbursement Rates

The information contained in the schedule is made available to provide information and is not

a guarantee by the State or the Department or its employees as to the present accuracy of the

information contained herein. For example, coverage as well as an actual rate may have been

revised or updated and may no longer be the same as posted on the website.

Procedure codes with a rate of $0.00 are reimbursed at 62% of Usual and Customary charges unless

noted otherwise in Nevada Medicaid policy.

Provider Type 33, Durable Medical Equipment, Prosthetics, Orthotics & Supplies

Providers must use the appropriate HCPCS code. For medically necessary DMEPOS items that do

not appear on this list please refer to Medicaid Services Manual, Chapter 1300, see link below.

1/62

http://dhcfp.nv.gov/MSM/CH1300/Ch 1300 11-14-13.pdf


A4310 INSERT TRAY W/O BAG/CATH 7.67

A4311 CATHETER W/O BAG 2-WAY LATEX 14.74

A4312 CATH W/O BAG 2-WAY SILICONE 17.91

A4313 CATHETER W/BAG 3-WAY 18.39

A4314 CATH W/DRAINAGE 2-WAY LATEX 21.35

A4315 CATH W/DRAINAGE 2-WAY SILCNE 26.21

A4316 CATH W/DRAINAGE 3-WAY 28.20

A4320 IRRIGATION TRAY 5.29

A4322 IRRIGATION SYRINGE 3.02

A4326 MALE EXTERNAL CATHETER 10.71

A4327 FEM URINARY COLLECT DEV CUP 41.97

A4328 FEM URINARY COLLECT POUCH 10.38

A4330 STOOL COLLECTION POUCH 7.10

A4331 EXTENSION DRAINAGE TUBING 3.16

A4332 LUBE STERILE PACKET 0.12

A4333 URINARY CATH ANCHOR DEVICE 2.18

A4334 URINARY CATH LEG STRAP 4.90

A4336 URETHRAL INSERT -

A4338 INDWELLING CATHETER LATEX 12.17

A4340 INDWELLING CATHETER SPECIAL 26.80

A4344 CATH INDW FOLEY 2 WAY SILICN 15.91

A4346 CATH INDW FOLEY 3 WAY 19.12

A4349 DISPOSABLE MALE EXTERNAL CAT 2.01

A4351 STRAIGHT TIP URINE CATHETER 1.80

A4352 COUDE TIP URINARY CATHETER 6.38

A4353 INTERMITTENT URINARY CATH 6.95

A4354 CATH INSERTION TRAY W/BAG 11.72

A4355 BLADDER IRRIGATION TUBING 7.80

A4356 EXT URETH CLMP OR COMPR DVC 39.05

A4357 BEDSIDE DRAINAGE BAG 9.63

A4358 URINARY LEG OR ABDOMEN BAG 6.58

A4360 DISPOSABLE EXT URETHRAL DEV 0.45

A4361 OSTOMY FACE PLATE 18.24

A4362 SOLID SKIN BARRIER 3.44

A4363 OSTOMY CLAMP, REPLACEMENT 2.18

A4364 ADHESIVE, LIQUID OR EQUAL 2.91

A4366 OSTOMY VENT 1.29

A4367 OSTOMY BELT 7.30

A4368 OSTOMY FILTER 0.26

A4369 SKIN BARRIER LIQUID PER OZ 2.05

A4371 SKIN BARRIER POWDER PER OZ 3.57

A4372 SKIN BARRIER SOLID 4X4 EQUIV 4.15

A4373 SKIN BARRIER WITH FLANGE 6.24

A4375 DRAINABLE PLASTIC PCH W FCPL 17.06

A4376 DRAINABLE RUBBER PCH W FCPLT 47.25

2/62


A4377 DRAINABLE PLSTIC PCH W/O FP 4.26

A4378 DRAINABLE RUBBER PCH W/O FP 30.53

A4379 URINARY PLASTIC POUCH W FCPL 14.91

A4380 URINARY RUBBER POUCH W FCPLT 37.07

A4381 URINARY PLASTIC POUCH W/O FP 4.58

A4382 URINARY HVY PLSTC PCH W/O FP 24.45

A4383 URINARY RUBBER POUCH W/O FP 27.99

A4384 OSTOMY FACEPLT/SILICONE RING 9.55

A4385 OST SKN BARRIER SLD EXT WEAR 5.06

A4387 OST CLSD POUCH W ATT ST BARR -

A4388 DRAINABLE PCH W EX WEAR BARR 4.33

A4389 DRAINABLE PCH W ST WEAR BARR 6.18

A4390 DRAINABLE PCH EX WEAR CONVEX 9.54

A4391 URINARY POUCH W EX WEAR BARR 7.02

A4392 URINARY POUCH W ST WEAR BARR 8.12

A4393 URINE PCH W EX WEAR BAR CONV 8.98

A4394 OSTOMY POUCH LIQ DEODORANT 2.56

A4395 OSTOMY POUCH SOLID DEODORANT 0.05

A4396 PERISTOMAL HERNIA SUPPRT BLT 40.20

A4397 IRRIGATION SUPPLY SLEEVE 4.04

A4398 OSTOMY IRRIGATION BAG 13.71

A4399 OSTOMY IRRIG CONE/CATH W BRS 12.17

A4400 OSTOMY IRRIGATION SET 48.53

A4402 LUBRICANT PER OUNCE 1.59

A4404 OSTOMY RING EACH 1.62

A4405 NONPECTIN BASED OSTOMY PASTE 3.38

A4406 PECTIN BASED OSTOMY PASTE 5.70

A4407 EXT WEAR OST SKN BARR <=4SQ� 8.70

A4408 EXT WEAR OST SKN BARR >4SQ� 9.80

A4409 OST SKN BARR CONVEX <=4 SQ I 6.18

A4410 OST SKN BARR EXTND >4 SQ 8.98

A4411 OST SKN BARR EXTND =4SQ 5.06

A4412 OST POUCH DRAIN HIGH OUTPUT 2.68

A4413 2 PC DRAINABLE OST POUCH 5.46

A4414 OST SKNBAR W/O CONV<=4 SQ IN 4.90

A4415 OST SKN BARR W/O CONV >4 SQI 5.96

A4416 OST PCH CLSD W BARRIER/FILTR 2.73

A4417 OST PCH W BAR/BLTINCONV/FLTR 3.69

A4418 OST PCH CLSD W/O BAR W FILTR 1.80

A4419 OST PCH FOR BAR W FLANGE/FLT 1.73

A4420 OST PCH CLSD FOR BAR W LK FL -

A4422 OST POUCH ABSORBENT MATERIAL 0.12

A4423 OST PCH FOR BAR W LK FL/FLTR 1.85

A4424 OST PCH DRAIN W BAR & FILTER 4.72

A4425 OST PCH DRAIN FOR BARRIER FL 3.55

3/62


A4426 OST PCH DRAIN 2 PIECE SYSTEM 2.71

A4427 OST PCH DRAIN/BARR LK FLNG/F 2.76

A4428 URINE OST POUCH W FAUCET/TAP 6.46

A4429 URINE OST POUCH W BLTINCONV 8.19

A4430 OST URINE PCH W B/BLTIN CONV 8.46

A4431 OST PCH URINE W BARRIER/TAPV 6.18

A4432 OS PCH URINE W BAR/FANGE/TAP 3.56

A4433 URINE OST PCH BAR W LOCK FLN 3.32

A4434 OST PCH URINE W LOCK FLNG/FT 3.73

A4435 1pc ost pch drain hgh output 6.26

A4450 NON-WATERPROOF TAPE 0.09

A4452 WATERPROOF TAPE 0.36

A4455 ADHESIVE REMOVER PER OUNCE 1.21

A4456 ADHESIVE REMOVER, WIPES 0.26

A4461 SURGICL DRESS HOLD NON-REUSE 3.27

A4463 SURGICAL DRESS HOLDER REUSE 13.88

A4481 TRACHEOSTOMA FILTER 0.38

A4483 MOISTURE EXCHANGER -

A4490 ABOVE KNEE SURGICAL STOCKING 5.89

A4495 THIGH LENGTH SURG STOCKING 5.89

A4500 BELOW KNEE SURGICAL STOCKING 4.32

A4510 FULL LENGTH SURG STOCKING 10.60

A4556 ELECTRODES, PAIR 12.06

A4557 LEAD WIRES, PAIR 17.81

A4565 SLINGS 6.28

A4595 TENS SUPPL 2 LEAD PER MONTH 28.15

A4601 LITH ION NON PROSTH RECHARGE -

A4604 TUBING WITH HEATING ELEMENT NU 66.34

A4605 TRACH SUCTION CATH CLOSE SYS NU 16.29

A4608 TRANSTRACHEAL OXYGEN CATH 57.74

A4611 HEAVY DUTY BATTERY UE 124.36

A4611 HEAVY DUTY BATTERY RR 20.23

A4611 HEAVY DUTY BATTERY NU 165.81

A4612 BATTERY CABLES UE 60.52

A4612 BATTERY CABLES RR 8.08

A4612 BATTERY CABLES NU 79.37

A4613 BATTERY CHARGER UE 103.56

A4613 BATTERY CHARGER RR 14.33

A4613 BATTERY CHARGER NU 143.20

A4614 HAND-HELD PEFR METER 23.61

A4618 BREATHING CIRCUITS UE 5.63

A4618 BREATHING CIRCUITS RR 1.01

A4618 BREATHING CIRCUITS NU 7.51

A4619 FACE TENT 1.20

A4620 VARIABLE CONCENTRATION MASK 2.35

4/62


A4623 TRACHEOSTOMY INNER CANNULA 5.53

A4624 TRACHEAL SUCTION TUBE NU 2.61

A4625 TRACH CARE KIT FOR NEW TRACH 6.53

A4626 TRACHEOSTOMY CLEANING BRUSH 2.76

A4627 SPACER BAG/RESERVOIR 14.91

A4628 OROPHARYNGEAL SUCTION CATH NU 3.62

A4629 TRACHEOSTOMY CARE KIT 4.58

A4630 REPL BAT T.E.N.S. OWN BY PT NU 6.15

A4633 UVL REPLACEMENT BULB NU 40.75

A4635 UNDERARM CRUTCH PAD UE 2.86

A4635 UNDERARM CRUTCH PAD RR 0.69

A4635 UNDERARM CRUTCH PAD NU 4.32

A4636 HANDGRIP FOR CANE ETC UE 2.59

A4636 HANDGRIP FOR CANE ETC RR 0.43

A4636 HANDGRIP FOR CANE ETC NU 3.55

A4637 REPL TIP CANE/CRUTCH/WALKER UE 1.36

A4637 REPL TIP CANE/CRUTCH/WALKER RR 0.30

A4637 REPL TIP CANE/CRUTCH/WALKER NU 1.80

A4638 REPL BATT PULSE GEN SYS -

A4639 INFRARED HT SYS REPLCMNT PAD NU 285.20

A4640 ALTERNATING PRESSURE PAD UE 37.86

A4640 ALTERNATING PRESSURE PAD RR 6.40

A4640 ALTERNATING PRESSURE PAD NU 53.44

A4660 SPHYG/BP APP W CUFF AND STET 49.65

A4670 AUTOMATIC BP MONITOR, DIAL 49.65

A5051 POUCH CLSD W BARR ATTACHED 2.06

A5052 CLSD OSTOMY POUCH W/O BARR 1.48

A5053 CLSD OSTOMY POUCH FACEPLATE 1.47

A5054 CLSD OSTOMY POUCH W/FLANGE 1.78

A5055 STOMA CAP 1.43

A5056 1 pc ost pouch w filter 4.97

A5057 1 pc ost pou w built-in conv 10.24

A5061 POUCH DRAINABLE W BARRIER AT 3.50

A5062 DRNBLE OSTOMY POUCH W/O BARR 2.08

A5063 DRAIN OSTOMY POUCH W/FLANGE 2.15

A5071 URINARY POUCH W/BARRIER 5.97

A5072 URINARY POUCH W/O BARRIER 3.41

A5073 URINARY POUCH ON BARR W/FLNG 3.16

A5081 STOMA PLUG OR SEAL, ANY TYPE 2.79

A5082 CONTINENT STOMA CATHETER 10.04

A5083 Stoma absorptive cover -

A5093 OSTOMY ACCESSORY CONVEX INSE 1.94

A5102 BEDSIDE DRAIN BTL W/WO TUBE 20.55

A5105 URINARY SUSPENSORY 40.47

A5112 URINARY LEG BAG 34.38

5/62


A5113 LATEX LEG STRAP 4.67

A5114 FOAM/FABRIC LEG STRAP 8.88

A5120 SKIN BARRIER, WIPE OR SWAB AV 0.20

A5120 SKIN BARRIER, WIPE OR SWAB AU 0.20

A5120 SKIN BARRIER, WIPE OR SWAB 0.20

A5121 SOLID SKIN BARRIER 6X6 6.67

A5122 SOLID SKIN BARRIER 8X8 12.76

A5126 DISK/FOAM PAD +OR- ADHESIVE 1.31

A5131 APPLIANCE CLEANER 13.66

A5200 PERCUTANEOUS CATHETER ANCHOR 11.21

A5500 DIAB SHOE FOR DENSITY INSERT 58.94

A5501 DIABETIC CUSTOM MOLDED SHOE 176.79

A5503 DIABETIC SHOE W/ROLLER/ROCKR 26.22

A5504 DIABETIC SHOE WITH WEDGE 26.22

A5505 DIAB SHOE W/METATARSAL BAR 26.22

A5506 DIABETIC SHOE W/OFF SET HEEL 26.22

A5507 MODIFICATION DIABETIC SHOE 26.22

A5512 MULTI DEN INSERT DIRECT FORM 24.05

A5513 MULTI DEN INSERT CUSTOM MOLD 35.89

A6010 COLLAGEN BASED WOUND FILLER 30.74

A6011 COLLAGEN GEL/PASTE WOUND FIL 2.26

A6021 COLLAGEN DRESSING <=16 SQ IN 20.87

A6022 COLLAGEN DRSG>16<=48 SQ IN 20.87

A6023 COLLAGEN DRESSING >48 SQ IN 188.97

A6024 COLLAGEN DSG WOUND FILLER 6.15

A6025 SILICONE GEL SHEET, EACH 21.56

A6154 WOUND POUCH EACH 14.26

A6196 ALGINATE DRESSING <=16 SQ IN 7.30

A6197 ALGINATE DRSG >16 <=48 SQ IN 16.32

A6199 ALGINATE DRSG WOUND FILLER 5.25

A6203 COMPOSITE DRSG <= 16 SQ IN 3.33

A6204 COMPOSITE DRSG >16<=48 SQ IN 6.19

A6207 CONTACT LAYER >16<= 48 SQ IN 7.29

A6209 FOAM DRSG <=16 SQ IN W/O BDR 7.43

A6210 FOAM DRG >16<=48 SQ IN W/O B 19.78

A6211 FOAM DRG > 48 SQ IN W/O BRDR 29.16

A6212 FOAM DRG <=16 SQ IN W/BORDER 9.63

A6214 FOAM DRG > 48 SQ IN W/BORDER 10.22

A6216 NON-STERILE GAUZE<=16 SQ IN 0.05

A6219 GAUZE <= 16 SQ IN W/BORDER 0.94

A6220 GAUZE >16 <=48 SQ IN W/BORDR 2.56

A6222 GAUZE <=16 IN NO W/SAL W/O B 2.12

A6223 GAUZE >16<=48 NO W/SAL W/O B 2.40

A6224 GAUZE > 48 IN NO W/SAL W/O B 3.58

A6229 GAUZE >16<=48 SQ IN WATR/SAL 3.58

6/62


A6231 HYDROGEL DSG<=16 SQ IN 4.65

A6232 HYDROGEL DSG>16<=48 SQ IN 6.83

A6233 HYDROGEL DRESSING >48 SQ IN 19.06

A6234 HYDROCOLLD DRG <=16 W/O BDR 6.49

A6235 HYDROCOLLD DRG >16<=48 W/O B 16.70

A6236 HYDROCOLLD DRG > 48 IN W/O B 27.06

A6237 HYDROCOLLD DRG <=16 IN W/BDR 7.85

A6238 HYDROCOLLD DRG >16<=48 W/BDR 22.63

A6240 HYDROCOLLD DRG FILLER PASTE 12.15

A6241 HYDROCOLLOID DRG FILLER DRY 2.55

A6242 HYDROGEL DRG <=16 IN W/O BDR 6.03

A6243 HYDROGEL DRG >16<=48 W/O BDR 12.22

A6244 HYDROGEL DRG >48 IN W/O BDR 39.01

A6245 HYDROGEL DRG <= 16 IN W/BDR 7.22

A6246 HYDROGEL DRG >16<=48 IN W/B 9.85

A6247 HYDROGEL DRG > 48 SQ IN W/B 23.61

A6248 HYDROGEL DRSG GEL FILLER 16.13

A6251 ABSORPT DRG <=16 SQ IN W/O B 1.98

A6252 ABSORPT DRG >16 <=48 W/O BDR 3.23

A6253 ABSORPT DRG > 48 SQ IN W/O B 6.30

A6254 ABSORPT DRG <=16 SQ IN W/BDR 1.20

A6255 ABSORPT DRG >16<=48 IN W/BDR 3.01

A6257 TRANSPARENT FILM <= 16 SQ IN 1.52

A6258 TRANSPARENT FILM >16<=48 IN 4.27

A6259 TRANSPARENT FILM > 48 SQ IN 10.86

A6261 WOUND FILLER GEL/PASTE /OZ 3.54

A6266 IMPREG GAUZE NO H20/SAL/YARD 1.91

A6402 STERILE GAUZE <= 16 SQ IN 0.12

A6403 STERILE GAUZE>16 <= 48 SQ IN 0.43

A6407 PACKING STRIPS, NON-IMPREG 1.87

A6410 STERILE EYE PAD 0.39

A6441 PAD BAND W>=3� <5�/YD 0.67

A6442 CONFORM BAND N/S W<3�/YD 0.17

A6443 CONFORM BAND N/S W>=3�<5�/YD 0.29

A6444 CONFORM BAND N/S W>=5�/YD 0.56

A6445 CONFORM BAND S W <3�/YD 0.32

A6446 CONFORM BAND S W>=3� <5�/YD 0.41

A6447 CONFORM BAND S W >=5�/YD 0.67

A6448 LT COMPRES BAND <3�/YD 1.15

A6449 LT COMPRES BAND >=3� <5�/YD 1.74

A6450 LT COMPRES BAND >=5�/YD -

A6451 MOD COMPRES BAND W>=3�<5�/YD -

A6452 HIGH COMPRES BAND W>=3�<5�YD 5.87

A6453 SELF-ADHER BAND W <3�/YD 0.61

A6454 SELF-ADHER BAND W>=3� <5�/YD 0.76

7/62


A6455 SELF-ADHER BAND >=5�/YD 1.38

A6456 ZINC PASTE BAND W >=3> �� 1.27

A6457 TUBULAR DRESSING 1.13

A6501 COMPRES BURNGARMENT BODYSUIT -

A6501 COMPRES BURNGARMENT BODYSUIT -

A6502 COMPRES BURNGARMENT CHINSTRP -

A6502 COMPRES BURNGARMENT CHINSTRP -

A6503 COMPRES BURNGARMENT FACEHOOD -

A6503 COMPRES BURNGARMENT FACEHOOD -

A6504 CMPRSBURNGARMENT GLOVE-WRIST -

A6504 CMPRSBURNGARMENT GLOVE-WRIST -

A6505 CMPRSBURNGARMENT GLOVE-ELBOW -

A6505 CMPRSBURNGARMENT GLOVE-ELBOW -

A6506 CMPRSBURNGRMNT GLOVE-AXILLA -

A6506 CMPRSBURNGRMNT GLOVE-AXILLA -

A6507 CMPRS BURNGARMENT FOOT-KNEE -

A6507 CMPRS BURNGARMENT FOOT-KNEE -

A6508 CMPRS BURNGARMENT FOOT-THIGH -

A6508 CMPRS BURNGARMENT FOOT-THIGH -

A6509 COMPRES BURN GARMENT JACKET -

A6509 COMPRES BURN GARMENT JACKET -

A6510 COMPRES BURN GARMENT LEOTARD -

A6510 COMPRES BURN GARMENT LEOTARD -

A6511 COMPRES BURN GARMENT PANTY -

A6511 COMPRES BURN GARMENT PANTY -

A6512 COMPRES BURN GARMENT, NOC -

A6512 COMPRES BURN GARMENT, NOC -

A6513 COMPRESS BURN MASK FACE/NECK -

A6530 COMPRESSION STOCKING BK18-30 24.83



A6533 GC STOCKING THIGHLNGTH 18-30 29.79



A6536 GC STOCKING FULL LNGTH 18-30 39.72



A6539 GC STOCKING WAISTLNGTH 18-30 79.44



A6544 GC STOCKING GARTER BELT 13.90

A6545 GRAD COMP NON-ELASTIC BK -

A6549 G COMPRESSION STOCKING -

A6550 NEG PRES WOUND THER DRSG SET 27.23

8/62


A7000 DISPOSABLE CANISTER FOR PUMP NU 9.47

A7001 NONDISPOSABLE PUMP CANISTER NU 32.85

A7002 TUBING USED W SUCTION PUMP NU 3.80

A7003 NEBULIZER ADMINISTRATION SET NU 2.72

A7004 DISPOSABLE NEBULIZER SML VOL NU 1.79

A7005 NONDISPOSABLE NEBULIZER SET NU 30.61

A7006 FILTERED NEBULIZER ADMIN SET NU 9.47

A7007 LG VOL NEBULIZER DISPOSABLE NU 4.58

A7008 DISPOSABLE NEBULIZER PREFILL NU 10.92

A7009 NEBULIZER RESERVOIR BOTTLE NU 41.75

A7010 DISPOSABLE CORRUGATED TUBING NU 23.42

A7012 NEBULIZER WATER COLLEC DEVIC NU 3.75

A7013 DISPOSABLE COMPRESSOR FILTER NU 0.82

A7014 COMPRESSOR NONDISPOS FILTER NU 4.46

A7015 AEROSOL MASK USED W NEBULIZE NU 1.87

A7016 NEBULIZER DOME & MOUTHPIECE NU 7.20

A7017 NEBULIZER NOT USED W OXYGEN UE 99.82

A7017 NEBULIZER NOT USED W OXYGEN RR 13.31

A7017 NEBULIZER NOT USED W OXYGEN NU 133.10

A7018 WATER DISTILLED W/NEBULIZER 0.38

A7020 INTERFACE, COUGH STIM DEVICE INTER UE -

A7020 INTERFACE, COUGH STIM DEVICE INTER UE -

A7020 INTERFACE, COUGH STIM DEVICE INTER RR -

A7020 INTERFACE, COUGH STIM DEVICE INTER RR -

A7020 INTERFACE, COUGH STIM DEVICE INTER NU -

A7020 INTERFACE, COUGH STIM DEVICE INTER NU -

A7020 INTERFACE, COUGH STIM DEVICE INTER 2.75

A7020 INTERFACE, COUGH STIM DEVICE INTER 2.75

A7025 REPLACE CHEST COMPRESS VEST NU 431.90

A7026 REPLACE CHST CMPRSS SYS HOSE NU 28.55

A7027 Combination oral/nasal mask NU 178.09

A7028 Repl oral cushion combo mask NU 49.19

A7029 Repl nasal pillow comb mask NU 20.10

A7030 CPAP FULL FACE MASK NU 187.32

A7031 REPLACEMENT FACEMASK INTERFA NU 69.28

A7032 REPLACEMENT NASAL CUSHION NU 40.25

A7033 REPLACEMENT NASAL PILLOWS NU 28.21

A7034 NASAL APPLICATION DEVICE NU 116.82

A7035 POS AIRWAY PRESS HEADGEAR NU 39.47

A7036 POS AIRWAY PRESS CHINSTRAP NU 18.07

A7037 POS AIRWAY PRESSURE TUBING NU 40.73

A7038 POS AIRWAY PRESSURE FILTER NU 5.35

A7039 FILTER, NON DISPOSABLE W PAP NU 15.22

A7040 ONE WAY CHEST DRAIN VALVE 36.60

A7041 WATER SEAL DRAIN CONTAINER 68.78

9/62


A7044 PAP ORAL INTERFACE NU 120.06

A7045 REPL EXHALATION PORT FOR PAP UE 14.50

A7045 REPL EXHALATION PORT FOR PAP RR 1.94

A7045 REPL EXHALATION PORT FOR PAP NU 19.33

A7046 REPL WATER CHAMBER, PAP DEV 19.37

A7047 Resp suction oral interface NU 132.22

A7501 TRACHEOSTOMA VALVE W DIAPHRA 104.29

A7502 REPLACEMENT DIAPHRAGM/FPLATE 49.56

A7503 HMES FILTER HOLDER OR CAP 11.25

A7504 TRACHEOSTOMA HMES FILTER 0.67

A7505 HMES OR TRACH VALVE HOUSING 4.65

A7506 HMES/TRACHVALVE ADHESIVEDISK 0.33

A7507 INTEGRATED FILTER & HOLDER 2.47

A7508 HOUSING & INTEGRATED ADHESIV 2.85

A7509 HEAT & MOISTURE EXCHANGE SYS 1.40

A7520 TRACH/LARYN TUBE NON-CUFFED 47.15

A7521 TRACH/LARYN TUBE CUFFED 46.72

A7522 TRACH/LARYN TUBE STAINLESS 44.84

A7524 TRACHEOSTOMA STENT/STUD/BTTN 76.86

A7525 TRACHEOSTOMY MASK 2.06

A7526 TRACHEOSTOMY TUBE COLLAR 3.35

A7527 TRACH/LARYN TUBE PLUG/STOP 3.55

A8000 SOFT PROTECT HELMET PREFAB UE 114.22

A8000 SOFT PROTECT HELMET PREFAB RR 15.22

A8000 SOFT PROTECT HELMET PREFAB NU 152.28

A8001 HARD PROTECT HELMET PREFAB UE 114.22

A8001 HARD PROTECT HELMET PREFAB RR 15.22

A8001 HARD PROTECT HELMET PREFAB NU 152.28

A8002 SOFT PROTECT HELMET CUSTOM UE -

A8002 SOFT PROTECT HELMET CUSTOM RR -

A8002 SOFT PROTECT HELMET CUSTOM NU -

A8003 HARD PROTECT HELMET CUSTOM UE -

A8003 HARD PROTECT HELMET CUSTOM RR -

A8003 HARD PROTECT HELMET CUSTOM NU -

A8004 REPL SOFT INTERFACE HELMET UE -

A8004 REPL SOFT INTERFACE HELMET RR -

A8004 REPL SOFT INTERFACE HELMET NU -

A9900 SUPPLY/ACCESSORY/SERVICE -

A9999 DME SUPPLY OR ACCESSORY, NOS -

B4034 ENTER FEED SUPKIT SYR BY DAY 5.62

B4035 ENTERAL FEED SUPP PUMP PER D 10.71

B4036 ENTERAL FEED SUP KIT GRAV BY 7.34

B4081 ENTERAL NG TUBING W/ STYLET 19.86

B4082 ENTERAL NG TUBING W/O STYLET 14.79

B4083 ENTERAL STOMACH TUBE LEVINE 2.25

10/62


B4087 Gastro/jejuno tube std 37.95

B4088 Gastro/jejuno tube low-pro BA 112.01

B4102 EF ADULT FLUIDS AND ELECTRO -

B4103 EF PED FLUID AND ELECTROLYTE -

B4104 ADDITIVE FOR ENTERAL FORMULA 2.13

B4149 EF BLENDERIZED FOODS 1.52

B4150 EF COMPLET W/INTACT NUTRIENT 0.62

B4152 EF CALORIE DENSE>/=1.5KCAL 0.52

B4153 EF HYDROLYZED/AMINO ACIDS 1.85

B4154 EF SPEC METABOLIC NONINHERIT 1.14

B4155 EF INCOMPLETE/MODULAR 0.87

B4157 EF SPECIAL METABOLIC INHERIT 6.96

B4158 EF PED COMPLETE INTACT NUT 1.36

B4159 EF PED COMPLETE SOY BASED 1.62

B4160 EF PED CALORIC DENSE>/=0.7KC 1.50

B4161 EF PED HYDROLYZED/AMINO ACID 3.25

B4162 EF PED SPECMETABOLIC INHERIT -

B4164 PARENTERAL 50% DEXTROSE SOLU 15.14

B4168 PARENTERAL SOL AMINO ACID 3. 22.04

B4176 PARENTERAL SOL AMINO ACID 7- 42.68

B4178 PARENTERAL SOL AMINO ACID > 51.24

B4180 PARENTERAL SOL CARB > 50% 21.70

B4189 PARENTERAL SOL AMINO ACID & 158.27

B4193 PARENTERAL SOL 52-73 GM PROT 204.53

B4197 PARENTERAL SOL 74-100 GM PRO 248.99

B4199 PARENTERAL SOL > 100GM PROTE 284.53

B4216 PARENTERAL NUTRITION ADDITIV 6.88

B4220 PARENTERAL SUPPLY KIT PREMIX 7.13

B4222 PARENTERAL SUPPLY KIT HOMEMI 8.79

B4224 PARENTERAL ADMINISTRATION KI 22.27

B5000 PARENTERAL SOL RENAL-AMIROSY 10.59

B5100 PARENTERAL SOL HEPATIC-FREAM 4.14

B9000 ENTER INFUSION PUMP W/O ALRM UE 844.77

B9000 ENTER INFUSION PUMP W/O ALRM RR 103.50

B9000 ENTER INFUSION PUMP W/O ALRM NU 1,126.37

B9002 ENTERAL INFUSION PUMP W/ ALA UE 844.77

B9002 ENTERAL INFUSION PUMP W/ ALA RR 109.09

B9002 ENTERAL INFUSION PUMP W/ ALA NU 1,126.37

B9004 PARENTERAL INFUS PUMP PORTAB UE 1,685.09

B9004 PARENTERAL INFUS PUMP PORTAB RR 355.69

B9004 PARENTERAL INFUS PUMP PORTAB NU 2,246.79

B9006 PARENTERAL INFUS PUMP STATIO UE 1,685.09

B9006 PARENTERAL INFUS PUMP STATIO RR 355.69

B9006 PARENTERAL INFUS PUMP STATIO NU 2,246.79

B9998 ENTERAL SUPP NOT OTHERWISE C -

11/62


E0100 CANE ADJUST/FIXED WITH TIP UE 16.68

E0100 CANE ADJUST/FIXED WITH TIP RR 5.90

E0100 CANE ADJUST/FIXED WITH TIP NU 20.92

E0105 CANE ADJUST/FIXED QUAD/3 PRO UE 37.59

E0105 CANE ADJUST/FIXED QUAD/3 PRO RR 8.80

E0105 CANE ADJUST/FIXED QUAD/3 PRO NU 48.77

E0110 CRUTCH FOREARM PAIR UE 49.10

E0110 CRUTCH FOREARM PAIR RR 15.88

E0110 CRUTCH FOREARM PAIR NU 65.49

E0111 CRUTCH FOREARM EACH UE 34.70

E0111 CRUTCH FOREARM EACH RR 8.37

E0111 CRUTCH FOREARM EACH NU 44.95

E0112 CRUTCH UNDERARM PAIR WOOD UE 24.68

E0112 CRUTCH UNDERARM PAIR WOOD RR 9.86

E0112 CRUTCH UNDERARM PAIR WOOD NU 32.88

E0113 CRUTCH UNDERARM EACH WOOD UE 13.39

E0113 CRUTCH UNDERARM EACH WOOD RR 5.11

E0113 CRUTCH UNDERARM EACH WOOD NU 17.83

E0114 CRUTCH UNDERARM PAIR NO WOOD UE 30.11

E0114 CRUTCH UNDERARM PAIR NO WOOD RR 8.51

E0114 CRUTCH UNDERARM PAIR NO WOOD NU 39.83

E0116 CRUTCH UNDERARM EACH NO WOOD UE 17.63

E0116 CRUTCH UNDERARM EACH NO WOOD RR 5.36

E0116 CRUTCH UNDERARM EACH NO WOOD NU 23.41

E0117 UNDERARM SPRINGASSIST CRUTCH UE 143.54

E0117 UNDERARM SPRINGASSIST CRUTCH RR 19.13

E0117 UNDERARM SPRINGASSIST CRUTCH NU 191.36

E0118 CRUTCH SUBSTITUTE RR 33.17

E0118 CRUTCH SUBSTITUTE RR 33.17

E0118 CRUTCH SUBSTITUTE NU 331.66

E0118 CRUTCH SUBSTITUTE NU 331.66

E0130 WALKER RIGID ADJUST/FIXED HT UE 54.35

E0130 WALKER RIGID ADJUST/FIXED HT RR 16.70

E0130 WALKER RIGID ADJUST/FIXED HT NU 69.74

E0135 WALKER FOLDING ADJUST/FIXED UE 63.87

E0135 WALKER FOLDING ADJUST/FIXED RR 17.14

E0135 WALKER FOLDING ADJUST/FIXED NU 83.25

E0140 WALKER W TRUNK SUPPORT UE 268.65

E0140 WALKER W TRUNK SUPPORT RR 35.83

E0140 WALKER W TRUNK SUPPORT NU 358.19

E0141 RIGID WHEELED WALKER ADJ/FIX UE 85.47

E0141 RIGID WHEELED WALKER ADJ/FIX RR 22.20

E0141 RIGID WHEELED WALKER ADJ/FIX NU 113.94

E0143 WALKER FOLDING WHEELED W/O S UE 89.35

E0143 WALKER FOLDING WHEELED W/O S RR 21.44

12/62


E0143 WALKER FOLDING WHEELED W/O S NU 119.39

E0144 ENCLOSED WALKER W REAR SEAT UE 237.16

E0144 ENCLOSED WALKER W REAR SEAT RR 31.64

E0144 ENCLOSED WALKER W REAR SEAT NU 316.22

E0148 HEAVYDUTY WALKER NO WHEELS UE 94.61

E0148 HEAVYDUTY WALKER NO WHEELS RR 12.63

E0148 HEAVYDUTY WALKER NO WHEELS NU 126.16

E0149 HEAVY DUTY WHEELED WALKER UE 166.22

E0149 HEAVY DUTY WHEELED WALKER RR 22.16

E0149 HEAVY DUTY WHEELED WALKER NU 221.64

E0153 FOREARM CRUTCH PLATFORM ATTA UE 51.67

E0153 FOREARM CRUTCH PLATFORM ATTA RR 7.79

E0153 FOREARM CRUTCH PLATFORM ATTA NU 68.89

E0154 WALKER PLATFORM ATTACHMENT UE 53.20

E0154 WALKER PLATFORM ATTACHMENT RR 8.50

E0154 WALKER PLATFORM ATTACHMENT NU 70.02

E0155 WALKER WHEEL ATTACHMENT,PAIR UE 20.30

E0155 WALKER WHEEL ATTACHMENT,PAIR RR 3.82

E0155 WALKER WHEEL ATTACHMENT,PAIR NU 26.64

E0156 WALKER SEAT ATTACHMENT UE 19.67

E0156 WALKER SEAT ATTACHMENT RR 3.36

E0156 WALKER SEAT ATTACHMENT NU 26.23

E0157 WALKER CRUTCH ATTACHMENT UE 61.02

E0157 WALKER CRUTCH ATTACHMENT RR 8.93

E0157 WALKER CRUTCH ATTACHMENT NU 81.35

E0158 WALKER LEG EXTENDERS SET OF4 UE 20.51

E0158 WALKER LEG EXTENDERS SET OF4 RR 3.53

E0158 WALKER LEG EXTENDERS SET OF4 NU 27.16

E0159 BRAKE FOR WHEELED WALKER UE 13.31

E0159 BRAKE FOR WHEELED WALKER RR 1.79

E0159 BRAKE FOR WHEELED WALKER NU 17.74

E0160 SITZ TYPE BATH OR EQUIPMENT UE 20.90

E0160 SITZ TYPE BATH OR EQUIPMENT RR 3.65

E0160 SITZ TYPE BATH OR EQUIPMENT NU 27.90

E0161 SITZ BATH/EQUIPMENT W/FAUCET UE 16.57

E0161 SITZ BATH/EQUIPMENT W/FAUCET RR 3.55

E0161 SITZ BATH/EQUIPMENT W/FAUCET NU 22.14

E0162 SITZ BATH CHAIR UE 95.38

E0162 SITZ BATH CHAIR RR 12.91

E0162 SITZ BATH CHAIR NU 122.98

E0163 COMMODE CHAIR WITH FIXED ARM UE 81.94

E0163 COMMODE CHAIR WITH FIXED ARM RR 24.26

E0163 COMMODE CHAIR WITH FIXED ARM NU 109.26

E0165 COMMODE CHAIR WITH DETACHARM UE 136.37

E0165 COMMODE CHAIR WITH DETACHARM RR 18.18

13/62


E0165 COMMODE CHAIR WITH DETACHARM NU 181.82

E0167 COMMODE CHAIR PAIL OR PAN UE 8.98

E0167 COMMODE CHAIR PAIL OR PAN RR 1.25

E0167 COMMODE CHAIR PAIL OR PAN NU 11.92

E0168 HEAVYDUTY/WIDE COMMODE CHAIR UE 112.39

E0168 HEAVYDUTY/WIDE COMMODE CHAIR RR 14.98

E0168 HEAVYDUTY/WIDE COMMODE CHAIR NU 149.86

E0175 COMMODE CHAIR FOOT REST UE 41.14

E0175 COMMODE CHAIR FOOT REST RR 5.59

E0175 COMMODE CHAIR FOOT REST NU 55.91

E0181 PRESS PAD ALTERNATING W/ PUM RR 22.72

E0181 PRESS PAD ALTERNATING W/ PUM NU 227.20

E0181 PRESS PAD ALTERNATING W/ PUM MS 22.72

E0182 REPLACE PUMP, ALT PRESS PAD RR 26.00

E0182 REPLACE PUMP, ALT PRESS PAD NU 259.97

E0182 REPLACE PUMP, ALT PRESS PAD MS 26.00

E0184 DRY PRESSURE MATTRESS UE 126.03

E0184 DRY PRESSURE MATTRESS RR 20.73

E0184 DRY PRESSURE MATTRESS NU 164.34

E0185 GEL PRESSURE MATTRESS PAD UE 207.20

E0185 GEL PRESSURE MATTRESS PAD RR 37.93

E0185 GEL PRESSURE MATTRESS PAD NU 269.98

E0186 AIR PRESSURE MATTRESS RR 20.16

E0186 AIR PRESSURE MATTRESS NU 201.58

E0186 AIR PRESSURE MATTRESS MS 20.16

E0187 WATER PRESSURE MATTRESS RR 23.05

E0187 WATER PRESSURE MATTRESS NU 230.48

E0187 WATER PRESSURE MATTRESS MS 23.05

E0188 SYNTHETIC SHEEPSKIN PAD UE 19.71

E0188 SYNTHETIC SHEEPSKIN PAD RR 3.08

E0188 SYNTHETIC SHEEPSKIN PAD NU 26.24

E0189 LAMBSWOOL SHEEPSKIN PAD UE 38.71

E0189 LAMBSWOOL SHEEPSKIN PAD RR 5.59

E0189 LAMBSWOOL SHEEPSKIN PAD NU 51.60

E0191 PROTECTOR HEEL OR ELBOW UE 6.30

E0191 PROTECTOR HEEL OR ELBOW RR 1.01

E0191 PROTECTOR HEEL OR ELBOW NU 8.43

E0193 POWERED AIR FLOTATION BED RR 862.42

E0193 POWERED AIR FLOTATION BED MS 862.42

E0194 AIR FLUIDIZED BED RR 3,231.56

E0194 AIR FLUIDIZED BED MS 3,231.56

E0196 GEL PRESSURE MATTRESS RR 27.43

E0196 GEL PRESSURE MATTRESS NU 274.27

E0196 GEL PRESSURE MATTRESS MS 27.43

E0197 AIR PRESSURE PAD FOR MATTRES UE 164.28

14/62


E0197 AIR PRESSURE PAD FOR MATTRES RR 25.80

E0197 AIR PRESSURE PAD FOR MATTRES NU 217.65

E0198 WATER PRESSURE PAD FOR MATTR UE 163.24

E0198 WATER PRESSURE PAD FOR MATTR RR 21.76

E0198 WATER PRESSURE PAD FOR MATTR NU 217.65

E0199 DRY PRESSURE PAD FOR MATTRES UE 23.87

E0199 DRY PRESSURE PAD FOR MATTRES RR 3.17

E0199 DRY PRESSURE PAD FOR MATTRES NU 31.83

E0200 HEAT LAMP WITHOUT STAND UE 50.22

E0200 HEAT LAMP WITHOUT STAND RR 10.68

E0200 HEAT LAMP WITHOUT STAND NU 66.92

E0202 PHOTOTHERAPY LIGHT W/ PHOTOM RR 53.38

E0202 PHOTOTHERAPY LIGHT W/ PHOTOM MS 53.38

E0205 HEAT LAMP WITH STAND UE 122.84

E0205 HEAT LAMP WITH STAND RR 18.01

E0205 HEAT LAMP WITH STAND NU 163.80

E0210 ELECTRIC HEAT PAD STANDARD UE 20.66

E0210 ELECTRIC HEAT PAD STANDARD RR 3.05

E0210 ELECTRIC HEAT PAD STANDARD NU 27.55

E0215 ELECTRIC HEAT PAD MOIST UE 47.75

E0215 ELECTRIC HEAT PAD MOIST RR 7.36

E0215 ELECTRIC HEAT PAD MOIST NU 63.68

E0217 WATER CIRC HEAT PAD W PUMP UE 369.71

E0217 WATER CIRC HEAT PAD W PUMP RR 54.89

E0217 WATER CIRC HEAT PAD W PUMP NU 492.99

E0221 INFRARED HEATING PAD SYSTEM UE 1,574.00

E0221 INFRARED HEATING PAD SYSTEM RR 209.86

E0221 INFRARED HEATING PAD SYSTEM NU 2,098.67

E0225 HYDROCOLLATOR UNIT UE 289.44

E0225 HYDROCOLLATOR UNIT RR 38.04

E0225 HYDROCOLLATOR UNIT NU 385.93

E0235 PARAFFIN BATH UNIT PORTABLE RR 17.14

E0236 PUMP FOR WATER CIRCULATING P RR 42.24

E0239 HYDROCOLLATOR UNIT PORTABLE UE 335.03

E0239 HYDROCOLLATOR UNIT PORTABLE RR 44.68

E0239 HYDROCOLLATOR UNIT PORTABLE NU 446.68

E0240 BATH/SHOWER CHAIR NU 44.69

E0241 BATH TUB WALL RAIL NU 19.86

E0241 BATH TUB WALL RAIL NU 19.86

E0242 BATH TUB RAIL FLOOR NU 19.86

E0242 BATH TUB RAIL FLOOR NU 19.86

E0243 TOILET RAIL NU 19.86

E0243 TOILET RAIL NU 19.86

E0244 TOILET SEAT RAISED 44.69

E0244 TOILET SEAT RAISED 44.69

15/62


E0245 TUB STOOL OR BENCH NU 79.44

E0245 TUB STOOL OR BENCH NU 79.44

E0246 TRANSFER TUB RAIL ATTACHMENT NU 19.86

E0246 TRANSFER TUB RAIL ATTACHMENT NU 19.86

E0247 TRANS BENCH W/WO COMM OPEN 79.44

E0248 HDTRANS BENCH W/WO COMM OPEN 99.30

E0249 PAD WATER CIRCULATING HEAT U UE 63.06

E0249 PAD WATER CIRCULATING HEAT U RR 9.24

E0249 PAD WATER CIRCULATING HEAT U NU 84.07

E0250 HOSP BED FIXED HT W/ MATTRES RR 97.08

E0250 HOSP BED FIXED HT W/ MATTRES NU 582.45

E0250 HOSP BED FIXED HT W/ MATTRES MS 97.08

E0251 HOSP BED FIXD HT W/O MATTRES RR 73.56

E0251 HOSP BED FIXD HT W/O MATTRES NU 441.37

E0251 HOSP BED FIXD HT W/O MATTRES MS 73.56

E0255 HOSPITAL BED VAR HT W/ MATTR RR 116.66

E0255 HOSPITAL BED VAR HT W/ MATTR NU 699.95

E0255 HOSPITAL BED VAR HT W/ MATTR MS 116.66

E0256 HOSPITAL BED VAR HT W/O MATT RR 82.77

E0256 HOSPITAL BED VAR HT W/O MATT NU 496.60

E0256 HOSPITAL BED VAR HT W/O MATT MS 82.77

E0260 HOSP BED SEMI-ELECTR W/ MATT RR 166.75

E0260 HOSP BED SEMI-ELECTR W/ MATT NU 1,000.53

E0260 HOSP BED SEMI-ELECTR W/ MATT MS 166.75

E0261 HOSP BED SEMI-ELECTR W/O MAT RR 135.98

E0261 HOSP BED SEMI-ELECTR W/O MAT NU 815.89

E0261 HOSP BED SEMI-ELECTR W/O MAT MS 135.98

E0265 HOSP BED TOTAL ELECTR W/ MAT RR 168.71

E0265 HOSP BED TOTAL ELECTR W/ MAT NU 1,012.26

E0265 HOSP BED TOTAL ELECTR W/ MAT MS 168.71

E0266 HOSP BED TOTAL ELEC W/O MATT RR 176.35

E0266 HOSP BED TOTAL ELEC W/O MATT NU 1,058.08

E0266 HOSP BED TOTAL ELEC W/O MATT MS 176.35

E0271 MATTRESS INNERSPRING UE 172.25

E0271 MATTRESS INNERSPRING RR 22.90

E0271 MATTRESS INNERSPRING NU 220.49

E0272 MATTRESS FOAM RUBBER UE 149.99

E0272 MATTRESS FOAM RUBBER RR 20.98

E0272 MATTRESS FOAM RUBBER NU 200.95

E0275 BED PAN STANDARD UE 9.96

E0275 BED PAN STANDARD RR 1.59

E0275 BED PAN STANDARD NU 13.26

E0276 BED PAN FRACTURE UE 8.88

E0276 BED PAN FRACTURE RR 1.56

E0276 BED PAN FRACTURE NU 11.23

16/62


E0277 POWERED PRES-REDU AIR MATTRS RR 640.94

E0277 POWERED PRES-REDU AIR MATTRS NU 3,845.65

E0277 POWERED PRES-REDU AIR MATTRS MS 640.94

E0280 BED CRADLE UE 24.18

E0280 BED CRADLE RR 4.08

E0280 BED CRADLE NU 32.25

E0290 HOSP BED FX HT W/O RAILS W/M RR 74.22

E0290 HOSP BED FX HT W/O RAILS W/M NU 445.30

E0290 HOSP BED FX HT W/O RAILS W/M MS 74.22

E0291 HOSP BED FX HT W/O RAIL W/O RR 53.92

E0291 HOSP BED FX HT W/O RAIL W/O NU 323.52

E0291 HOSP BED FX HT W/O RAIL W/O MS 53.92

E0292 HOSP BED VAR HT W/O RAIL W/O RR 83.45

E0292 HOSP BED VAR HT W/O RAIL W/O NU 500.71

E0292 HOSP BED VAR HT W/O RAIL W/O MS 83.45

E0293 HOSP BED VAR HT W/O RAIL W/ RR 71.01

E0293 HOSP BED VAR HT W/O RAIL W/ NU 426.06

E0293 HOSP BED VAR HT W/O RAIL W/ MS 71.01

E0294 HOSP BED SEMI-ELECT W/ MATTR RR 129.74

E0294 HOSP BED SEMI-ELECT W/ MATTR NU 778.41

E0294 HOSP BED SEMI-ELECT W/ MATTR MS 129.74

E0295 HOSP BED SEMI-ELECT W/O MATT RR 126.46

E0295 HOSP BED SEMI-ELECT W/O MATT NU 758.75

E0295 HOSP BED SEMI-ELECT W/O MATT MS 126.46

E0296 HOSP BED TOTAL ELECT W/ MATT RR 138.59

E0296 HOSP BED TOTAL ELECT W/ MATT NU 831.56

E0296 HOSP BED TOTAL ELECT W/ MATT MS 138.59

E0297 HOSP BED TOTAL ELECT W/O MAT RR 139.69

E0297 HOSP BED TOTAL ELECT W/O MAT NU 838.11

E0297 HOSP BED TOTAL ELECT W/O MAT MS 139.69

E0300 ENCLOSED PED CRIB HOSP GRADE UE 2,114.06

E0300 ENCLOSED PED CRIB HOSP GRADE RR 281.87

E0300 ENCLOSED PED CRIB HOSP GRADE NU 2,818.75

E0301 HD HOSP BED, 350-600 LBS RR 254.51

E0301 HD HOSP BED, 350-600 LBS MS 254.51

E0302 EX HD HOSP BED > 600 LBS RR 710.43

E0302 EX HD HOSP BED > 600 LBS MS 710.43

E0303 HOSP BED HVY DTY XTRA WIDE RR 287.49

E0303 HOSP BED HVY DTY XTRA WIDE MS 287.49

E0304 HOSP BED XTRA HVY DTY X WIDE RR 765.28

E0304 HOSP BED XTRA HVY DTY X WIDE MS 765.28

E0305 RAILS BED SIDE HALF LENGTH RR 17.67

E0305 RAILS BED SIDE HALF LENGTH NU 105.99

E0305 RAILS BED SIDE HALF LENGTH MS 17.67

E0310 RAILS BED SIDE FULL LENGTH UE 145.88

17/62


E0310 RAILS BED SIDE FULL LENGTH RR 20.94

E0310 RAILS BED SIDE FULL LENGTH NU 192.78

E0316 BED SAFETY ENCLOSURE RR 184.70

E0316 BED SAFETY ENCLOSURE NU 1,108.19

E0316 BED SAFETY ENCLOSURE MS 184.70

E0325 URINAL MALE JUG-TYPE UE 5.65

E0325 URINAL MALE JUG-TYPE RR 1.50

E0325 URINAL MALE JUG-TYPE NU 8.53

E0326 URINAL FEMALE JUG-TYPE UE 6.64

E0326 URINAL FEMALE JUG-TYPE RR 1.18

E0326 URINAL FEMALE JUG-TYPE NU 8.87

E0328 Ped hospital bed manual -

E0329 Ped hospital bed semi/elect -

E0371 NONPOWER MATTRESS OVERLAY RR 419.53

E0371 NONPOWER MATTRESS OVERLAY NU 2,517.20

E0371 NONPOWER MATTRESS OVERLAY MS 419.53

E0372 POWERED AIR MATTRESS OVERLAY RR 509.05

E0372 POWERED AIR MATTRESS OVERLAY NU 3,054.31

E0372 POWERED AIR MATTRESS OVERLAY MS 509.05

E0373 NONPOWERED PRESSURE MATTRESS RR 583.15

E0373 NONPOWERED PRESSURE MATTRESS NU 3,498.90

E0373 NONPOWERED PRESSURE MATTRESS MS 583.15

E0424 STATIONARY COMPRESSED GAS 02 RR 171.96

E0430 OXYGEN SYSTEM GAS PORTABLE NU 214.31

E0431 PORTABLE GASEOUS 02 RR 35.72

E0434 PORTABLE LIQUID 02 RR 35.72

E0439 STATIONARY LIQUID 02 RR 171.96

E0441 STATIONARY O2 CONTENTS, GAS 76.91

E0442 STATIONARY O2 CONTENTS, LIQ 161.84

E0443 PORTABLE 02 CONTENTS, GAS 76.91

E0444 PORTABLE 02 CONTENTS, LIQUID 76.91

E0445 OXIMETER NON-INVASIVE RR 19.81

E0450 VOL CONTROL VENT INVASIV INT RR 947.84

E0457 CHEST SHELL UE 457.62

E0457 CHEST SHELL RR 61.02

E0457 CHEST SHELL NU 610.21

E0459 CHEST WRAP RR 50.53

E0459 CHEST WRAP NU 505.34

E0459 CHEST WRAP MS 50.53

E0460 NEG PRESS VENT PORTABL/STATN RR 619.17

E0461 VOL CONTROL VENT NONINV INT RR 995.04

E0462 ROCKING BED W/ OR W/O SIDE R RR 289.36

E0462 ROCKING BED W/ OR W/O SIDE R NU 1,736.16

E0462 ROCKING BED W/ OR W/O SIDE R MS 289.36

E0463 PRESS SUPP VENT INVASIVE INT RR 1,466.36

18/62


E0464 PRESS SUPP VENT NONINV INT RR 1,466.36

E0470 RAD W/O BACKUP NON-INV INTFC RR 216.58

E0470 RAD W/O BACKUP NON-INV INTFC NU 2,165.83

E0470 RAD W/O BACKUP NON-INV INTFC MS 216.58

E0471 RAD W/BACKUP NON INV INTRFC RR 637.67

E0471 RAD W/BACKUP NON INV INTRFC MS 637.67

E0472 RAD W BACKUP INVASIVE INTRFC RR 637.67

E0472 RAD W BACKUP INVASIVE INTRFC MS 637.67

E0480 PERCUSSOR ELECT/PNEUM HOME M RR 43.63

E0480 PERCUSSOR ELECT/PNEUM HOME M NU 436.32

E0480 PERCUSSOR ELECT/PNEUM HOME M MS 43.63

E0482 COUGH STIMULATING DEVICE RR 405.90

E0482 COUGH STIMULATING DEVICE NU 4,058.99

E0482 COUGH STIMULATING DEVICE MS 405.90

E0483 CHEST COMPRESSION GEN SYSTEM RR 1,055.69

E0483 CHEST COMPRESSION GEN SYSTEM NU 10,556.88

E0483 CHEST COMPRESSION GEN SYSTEM MS 1,055.69

E0484 NON-ELEC OSCILLATORY PEP DVC UE 27.51

E0484 NON-ELEC OSCILLATORY PEP DVC RR 3.66

E0484 NON-ELEC OSCILLATORY PEP DVC NU 36.66

E0500 IPPB ALL TYPES RR 107.43

E0550 HUMIDIF EXTENS SUPPLE W IPPB RR 49.78

E0550 HUMIDIF EXTENS SUPPLE W IPPB NU 497.79

E0550 HUMIDIF EXTENS SUPPLE W IPPB MS 49.78

E0560 HUMIDIFIER SUPPLEMENTAL W/ I UE 127.74

E0560 HUMIDIFIER SUPPLEMENTAL W/ I RR 19.96

E0560 HUMIDIFIER SUPPLEMENTAL W/ I NU 170.32

E0561 HUMIDIFIER NONHEATED W PAP UE 79.68

E0561 HUMIDIFIER NONHEATED W PAP RR 10.62

E0561 HUMIDIFIER NONHEATED W PAP NU 106.25

E0562 HUMIDIFIER HEATED USED W PAP UE 224.33

E0562 HUMIDIFIER HEATED USED W PAP RR 29.90

E0562 HUMIDIFIER HEATED USED W PAP NU 299.11

E0565 COMPRESSOR AIR POWER SOURCE RR 51.50

E0565 COMPRESSOR AIR POWER SOURCE NU 514.97

E0565 COMPRESSOR AIR POWER SOURCE MS 51.50

E0570 NEBULIZER WITH COMPRESSION RR 16.65

E0570 NEBULIZER WITH COMPRESSION NU 166.53

E0570 NEBULIZER WITH COMPRESSION MS 16.65

E0572 AEROSOL COMPRESSOR ADJUST PR RR 36.17

E0572 AEROSOL COMPRESSOR ADJUST PR NU 361.65

E0572 AEROSOL COMPRESSOR ADJUST PR MS 36.17

E0574 ULTRASONIC GENERATOR W SVNEB RR 38.23

E0575 NEBULIZER ULTRASONIC RR 95.98

E0580 NEBULIZER FOR USE W/ REGULAT UE 99.82

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E0580 NEBULIZER FOR USE W/ REGULAT RR 13.31

E0580 NEBULIZER FOR USE W/ REGULAT NU 133.10

E0585 NEBULIZER W/ COMPRESSOR & HE RR 29.60

E0585 NEBULIZER W/ COMPRESSOR & HE NU 296.01

E0585 NEBULIZER W/ COMPRESSOR & HE MS 29.60

E0600 SUCTION PUMP PORTAB HOM MODL RR 43.03

E0600 SUCTION PUMP PORTAB HOM MODL NU 323.19

E0600 SUCTION PUMP PORTAB HOM MODL MS 43.03

E0601 CONT AIRWAY PRESSURE DEVICE RR 110.93

E0601 CONT AIRWAY PRESSURE DEVICE NU 1,109.28

E0601 CONT AIRWAY PRESSURE DEVICE MS 110.93

E0605 VAPORIZER ROOM TYPE UE 18.68

E0605 VAPORIZER ROOM TYPE RR 3.05

E0605 VAPORIZER ROOM TYPE NU 24.88

E0606 DRAINAGE BOARD POSTURAL RR 22.78

E0606 DRAINAGE BOARD POSTURAL NU 227.79

E0606 DRAINAGE BOARD POSTURAL MS 22.78

E0607 BLOOD GLUCOSE MONITOR HOME UE 49.75

E0607 BLOOD GLUCOSE MONITOR HOME RR 6.63

E0607 BLOOD GLUCOSE MONITOR HOME NU 66.35

E0610 PACEMAKER MONITR AUDIBLE/VIS UE 177.17

E0610 PACEMAKER MONITR AUDIBLE/VIS RR 24.91

E0610 PACEMAKER MONITR AUDIBLE/VIS NU 236.19

E0615 PACEMAKER MONITR DIGITAL/VIS UE 353.05

E0615 PACEMAKER MONITR DIGITAL/VIS RR 49.38

E0615 PACEMAKER MONITR DIGITAL/VIS NU 470.73

E0617 AUTOMATIC EXT DEFIBRILLATOR RR 301.92

E0618 APNEA MONITOR RR 277.29

E0618 APNEA MONITOR MS 277.29

E0619 APNEA MONITOR W RECORDER RR 277.29

E0620 CAP BLD SKIN PIERCING LASER UE 651.20

E0620 CAP BLD SKIN PIERCING LASER RR 86.82

E0620 CAP BLD SKIN PIERCING LASER NU 868.27

E0621 PATIENT LIFT SLING OR SEAT UE 71.85

E0621 PATIENT LIFT SLING OR SEAT RR 9.19

E0621 PATIENT LIFT SLING OR SEAT NU 95.32

E0627 SEAT LIFT INCORP LIFT-CHAIR UE 246.27

E0627 SEAT LIFT INCORP LIFT-CHAIR RR 32.85

E0627 SEAT LIFT INCORP LIFT-CHAIR NU 328.40

E0628 SEAT LIFT FOR PT FURN-ELECTR UE 246.27

E0628 SEAT LIFT FOR PT FURN-ELECTR RR 32.85

E0628 SEAT LIFT FOR PT FURN-ELECTR NU 328.40

E0629 SEAT LIFT FOR PT FURN-NON-EL UE 246.27

E0629 SEAT LIFT FOR PT FURN-NON-EL RR 32.85

E0629 SEAT LIFT FOR PT FURN-NON-EL NU 328.40

20/62


E0630 PATIENT LIFT HYDRAULIC RR 101.18

E0630 PATIENT LIFT HYDRAULIC NU 607.06

E0630 PATIENT LIFT HYDRAULIC MS 101.18

E0635 PATIENT LIFT ELECTRIC RR 121.50

E0635 PATIENT LIFT ELECTRIC NU 729.02

E0635 PATIENT LIFT ELECTRIC MS 121.50

E0636 PT SUPPORT & POSITIONING SYS RR 1,047.18

E0637 COMBINATION SIT TO STAND SYS UE 1,567.67

E0637 COMBINATION SIT TO STAND SYS RR 209.04

E0637 COMBINATION SIT TO STAND SYS NU 2,090.24

E0638 STANDING FRAME SYS UE 635.70

E0638 STANDING FRAME SYS RR 84.76

E0638 STANDING FRAME SYS NU 847.60

E0639 MOVEABLE PATIENT LIFT SYSTEM -

E0640 FIXED PATIENT LIFT SYSTEM -

E0650 PNEUMA COMPRESOR NON-SEGMENT UE 536.38

E0650 PNEUMA COMPRESOR NON-SEGMENT RR 86.04

E0650 PNEUMA COMPRESOR NON-SEGMENT NU 715.18

E0651 PNEUM COMPRESSOR SEGMENTAL UE 675.60

E0651 PNEUM COMPRESSOR SEGMENTAL RR 90.08

E0651 PNEUM COMPRESSOR SEGMENTAL NU 900.79

E0652 PNEUM COMPRES W/CAL PRESSURE UE 3,944.72

E0652 PNEUM COMPRES W/CAL PRESSURE RR 520.28

E0652 PNEUM COMPRES W/CAL PRESSURE NU 5,264.34

E0655 PNEUMATIC APPLIANCE HALF ARM UE 80.48

E0655 PNEUMATIC APPLIANCE HALF ARM RR 12.59

E0655 PNEUMATIC APPLIANCE HALF ARM NU 107.16

E0656 SEGMENTAL PNEUMATIC TRUNK UE -

E0656 SEGMENTAL PNEUMATIC TRUNK RR -

E0656 SEGMENTAL PNEUMATIC TRUNK NU -

E0657 SEGMENTAL PNEUMATIC CHEST UE -

E0657 SEGMENTAL PNEUMATIC CHEST RR -

E0657 SEGMENTAL PNEUMATIC CHEST NU -

E0660 PNEUMATIC APPLIANCE FULL LEG UE 118.91

E0660 PNEUMATIC APPLIANCE FULL LEG RR 16.51

E0660 PNEUMATIC APPLIANCE FULL LEG NU 158.54

E0665 PNEUMATIC APPLIANCE FULL ARM UE 102.04

E0665 PNEUMATIC APPLIANCE FULL ARM RR 13.97

E0665 PNEUMATIC APPLIANCE FULL ARM NU 136.03

E0666 PNEUMATIC APPLIANCE HALF LEG UE 102.86

E0666 PNEUMATIC APPLIANCE HALF LEG RR 14.13

E0666 PNEUMATIC APPLIANCE HALF LEG NU 137.11

E0667 SEG PNEUMATIC APPL FULL LEG UE 241.13

E0667 SEG PNEUMATIC APPL FULL LEG RR 36.30

E0667 SEG PNEUMATIC APPL FULL LEG NU 321.50

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E0668 SEG PNEUMATIC APPL FULL ARM UE 329.10

E0668 SEG PNEUMATIC APPL FULL ARM RR 43.30

E0668 SEG PNEUMATIC APPL FULL ARM NU 438.79

E0669 SEG PNEUMATIC APPLI HALF LEG UE 136.55

E0669 SEG PNEUMATIC APPLI HALF LEG RR 18.21

E0669 SEG PNEUMATIC APPLI HALF LEG NU 182.03

E0670 Seg pneum int legs/trunk UE 1,020.72

E0670 Seg pneum int legs/trunk RR 144.68

E0670 Seg pneum int legs/trunk NU 1,351.50

E0671 PRESSURE PNEUM APPL FULL LEG UE 309.32

E0671 PRESSURE PNEUM APPL FULL LEG RR 41.25

E0671 PRESSURE PNEUM APPL FULL LEG NU 412.44

E0672 PRESSURE PNEUM APPL FULL ARM UE 240.37

E0672 PRESSURE PNEUM APPL FULL ARM RR 32.05

E0672 PRESSURE PNEUM APPL FULL ARM NU 320.47

E0673 PRESSURE PNEUM APPL HALF LEG UE 199.74

E0673 PRESSURE PNEUM APPL HALF LEG RR 26.63

E0673 PRESSURE PNEUM APPL HALF LEG NU 266.29

E0675 PNEUMATIC COMPRESSION DEVICE RR 319.74

E0675 PNEUMATIC COMPRESSION DEVICE MS 319.74

E0693 UVL SYS PANEL 6 FT UE 1,035.94

E0693 UVL SYS PANEL 6 FT RR 138.13

E0693 UVL SYS PANEL 6 FT NU 1,381.24

E0694 UVL MD CABINET SYS 6 FT UE 3,297.29

E0694 UVL MD CABINET SYS 6 FT RR 439.63

E0694 UVL MD CABINET SYS 6 FT NU 4,396.35

E0700 SAFETY EQUIPMENT NU -

E0705 TRANSFER DEVICE NU 54.73

E0720 TENS TWO LEAD NU 350.93

E0730 TENS FOUR LEAD NU 350.93

E0731 CONDUCTIVE GARMENT FOR TENS/ NU 354.19

E0740 INCONTINENCE TREATMENT SYSTM UE 389.43

E0740 INCONTINENCE TREATMENT SYSTM RR 51.92

E0740 INCONTINENCE TREATMENT SYSTM NU 519.21

E0744 NEUROMUSCULAR STIM FOR SCOLI RR 90.93

E0745 NEUROMUSCULAR STIM FOR SHOCK RR 82.75

E0747 ELEC OSTEOGEN STIM NOT SPINE UE 2,602.31

E0747 ELEC OSTEOGEN STIM NOT SPINE RR 348.06

E0747 ELEC OSTEOGEN STIM NOT SPINE NU 3,502.52

E0748 ELEC OSTEOGEN STIM SPINAL UE 2,609.88

E0748 ELEC OSTEOGEN STIM SPINAL RR 347.98

E0748 ELEC OSTEOGEN STIM SPINAL NU 3,479.82

E0760 OSTEOGEN ULTRASOUND STIMLTOR UE 2,168.75

E0760 OSTEOGEN ULTRASOUND STIMLTOR RR 289.17

E0760 OSTEOGEN ULTRASOUND STIMLTOR NU 2,891.67

22/62


E0765 NERVE STIMULATOR FOR TX N&V UE 62.68

E0765 NERVE STIMULATOR FOR TX N&V RR 8.37

E0765 NERVE STIMULATOR FOR TX N&V NU 83.54

E0776 IV POLE RR 9.36

E0776 IV POLE NU 93.67

E0779 AMB INFUSION PUMP MECHANICAL NU 249.97

E0780 MECH AMB INFUSION PUMP <8HRS NU 10.30

E0781 EXTERNAL AMBULATORY INFUS PU RR 249.97

E0781 EXTERNAL AMBULATORY INFUS PU NU 2,499.68

E0781 EXTERNAL AMBULATORY INFUS PU MS 249.97

E0784 EXT AMB INFUSN PUMP INSULIN RR 414.57

E0784 EXT AMB INFUSN PUMP INSULIN NU 4,145.68

E0784 EXT AMB INFUSN PUMP INSULIN MS 414.57

E0791 PARENTERAL INFUSION PUMP STA RR 313.99

E0791 PARENTERAL INFUSION PUMP STA NU 3,139.87

E0791 PARENTERAL INFUSION PUMP STA MS 313.99

E0840 TRACT FRAME ATTACH HEADBOARD UE 54.55

E0840 TRACT FRAME ATTACH HEADBOARD RR 13.77

E0840 TRACT FRAME ATTACH HEADBOARD NU 72.77

E0850 TRACTION STAND FREE STANDING UE 66.51

E0850 TRACTION STAND FREE STANDING RR 14.33

E0850 TRACTION STAND FREE STANDING NU 88.67

E0855 CERVICAL TRACTION EQUIPMENT UE 368.06

E0855 CERVICAL TRACTION EQUIPMENT RR 49.09

E0855 CERVICAL TRACTION EQUIPMENT NU 490.76

E0860 TRACT EQUIP CERVICAL TRACT UE 29.30

E0860 TRACT EQUIP CERVICAL TRACT RR 6.46

E0860 TRACT EQUIP CERVICAL TRACT NU 38.26

E0870 TRACT FRAME ATTACH FOOTBOARD UE 86.64

E0870 TRACT FRAME ATTACH FOOTBOARD RR 13.31

E0870 TRACT FRAME ATTACH FOOTBOARD NU 115.50

E0880 TRAC STAND FREE STAND EXTREM UE 92.67

E0880 TRAC STAND FREE STAND EXTREM RR 19.57

E0880 TRAC STAND FREE STAND EXTREM NU 123.53

E0890 TRACTION FRAME ATTACH PELVIC UE 81.86

E0890 TRACTION FRAME ATTACH PELVIC RR 32.60

E0890 TRACTION FRAME ATTACH PELVIC NU 101.63

E0900 TRAC STAND FREE STAND PELVIC UE 81.13

E0900 TRAC STAND FREE STAND PELVIC RR 27.43

E0900 TRAC STAND FREE STAND PELVIC NU 108.14

E0910 TRAPEZE BAR ATTACHED TO BED RR 19.86

E0910 TRAPEZE BAR ATTACHED TO BED NU 198.60

E0910 TRAPEZE BAR ATTACHED TO BED MS 19.86

E0911 HD TRAPEZE BAR ATTACH TO BED RR 49.50

E0912 HD TRAPEZE BAR FREE STANDING RR 113.67

23/62


E0920 FRACTURE FRAME ATTACHED TO B RR 45.82

E0930 FRACTURE FRAME FREE STANDING RR 45.37

E0935 CONT PAS MOTION EXERCISE DEV RR 19.18

E0936 CPM DEVICE OTHER THAN KNEE -

E0940 TRAPEZE BAR FREE STANDING RR 34.53

E0940 TRAPEZE BAR FREE STANDING NU 345.27

E0940 TRAPEZE BAR FREE STANDING MS 34.53

E0941 GRAVITY ASSISTED TRACTION DE RR 43.11

E0942 CERVICAL HEAD HARNESS/HALTER UE 12.56

E0942 CERVICAL HEAD HARNESS/HALTER RR 2.32

E0942 CERVICAL HEAD HARNESS/HALTER NU 16.75

E0944 PELVIC BELT/HARNESS/BOOT UE 29.87

E0944 PELVIC BELT/HARNESS/BOOT RR 4.57

E0944 PELVIC BELT/HARNESS/BOOT NU 39.81

E0945 BELT/HARNESS EXTREMITY UE 29.87

E0945 BELT/HARNESS EXTREMITY RR 4.41

E0945 BELT/HARNESS EXTREMITY NU 39.81

E0946 FRACTURE FRAME DUAL W CROSS RR 58.75

E0947 FRACTURE FRAME ATTACHMNTS PE UE 451.66

E0947 FRACTURE FRAME ATTACHMNTS PE RR 62.45

E0947 FRACTURE FRAME ATTACHMNTS PE NU 602.21

E0948 FRACTURE FRAME ATTACHMNTS CE UE 410.80

E0948 FRACTURE FRAME ATTACHMNTS CE RR 58.23

E0948 FRACTURE FRAME ATTACHMNTS CE NU 582.48

E0951 LOOP HEEL UE 14.03

E0951 LOOP HEEL RR 1.94

E0951 LOOP HEEL NU 18.70

E0955 CUSHIONED HEADREST UE 150.57

E0955 CUSHIONED HEADREST RR 20.09

E0955 CUSHIONED HEADREST NU 200.76

E0956 W/C LATERAL TRUNK/HIP SUPPOR UE 73.41

E0956 W/C LATERAL TRUNK/HIP SUPPOR RR 9.80

E0956 W/C LATERAL TRUNK/HIP SUPPOR NU 97.87

E0957 W/C MEDIAL THIGH SUPPORT UE 102.73

E0957 W/C MEDIAL THIGH SUPPORT RR 13.69

E0957 W/C MEDIAL THIGH SUPPORT NU 136.96

E0958 WHLCHR ATT- CONV 1 ARM DRIVE RR 43.32

E0958 WHLCHR ATT- CONV 1 ARM DRIVE MS 43.32

E0960 W/C SHOULDER HARNESS/STRAPS UE 67.76

E0960 W/C SHOULDER HARNESS/STRAPS RR 9.04

E0960 W/C SHOULDER HARNESS/STRAPS NU 90.34

E0967 MANUAL WC HAND RIM W PROJECT UE 98.44

E0967 MANUAL WC HAND RIM W PROJECT RR 13.47

E0967 MANUAL WC HAND RIM W PROJECT NU 131.21

E0968 WHEELCHAIR COMMODE SEAT RR 17.78

24/62


E0968 WHEELCHAIR COMMODE SEAT MS 17.78

E0969 WHEELCHAIR NARROWING DEVICE UE 116.66

E0969 WHEELCHAIR NARROWING DEVICE RR 15.40

E0969 WHEELCHAIR NARROWING DEVICE NU 155.53

E0971 WHEELCHAIR ANTI-TIPPING DEVI UE 41.62

E0971 WHEELCHAIR ANTI-TIPPING DEVI RR 7.41

E0971 WHEELCHAIR ANTI-TIPPING DEVI NU 55.50

E0973 W/CH ACCESS DET ADJ ARMREST UE 85.63

E0973 W/CH ACCESS DET ADJ ARMREST RR 10.87

E0973 W/CH ACCESS DET ADJ ARMREST NU 114.17

E0978 W/C ACC,SAF BELT PELV STRAP UE 30.80

E0978 W/C ACC,SAF BELT PELV STRAP RR 4.25

E0978 W/C ACC,SAF BELT PELV STRAP NU 41.07

E0980 WHEELCHAIR SAFETY VEST UE 20.81

E0980 WHEELCHAIR SAFETY VEST RR 3.28

E0980 WHEELCHAIR SAFETY VEST NU 27.90

E0981 SEAT UPHOLSTERY, REPLACEMENT UE 33.88

E0981 SEAT UPHOLSTERY, REPLACEMENT RR 4.77

E0981 SEAT UPHOLSTERY, REPLACEMENT NU 45.19

E0982 BACK UPHOLSTERY, REPLACEMENT UE 32.61

E0982 BACK UPHOLSTERY, REPLACEMENT RR 5.11

E0982 BACK UPHOLSTERY, REPLACEMENT NU 43.49

E0983 ADD PWR JOYSTICK RR 236.38

E0983 ADD PWR JOYSTICK MS 236.38

E0984 ADD PWR TILLER UE 1,407.49

E0984 ADD PWR TILLER RR 176.35

E0984 ADD PWR TILLER NU 1,876.69

E0985 W/C SEAT LIFT MECHANISM UE 151.06

E0985 W/C SEAT LIFT MECHANISM RR 20.16

E0985 W/C SEAT LIFT MECHANISM NU 201.43

E0986 MAN W/C PUSH-RIM POWR SYSTEM UE 3,622.66

E0986 MAN W/C PUSH-RIM POWR SYSTEM RR 483.02

E0986 MAN W/C PUSH-RIM POWR SYSTEM NU 4,830.19

E0988 Lever-activated wheel drive -

E0992 WHEELCHAIR SOLID SEAT INSERT RR 9.19

E0992 WHEELCHAIR SOLID SEAT INSERT NU 94.48

E0994 WHEELCHAIR ARM REST UE 13.14

E0994 WHEELCHAIR ARM REST RR 1.77

E0994 WHEELCHAIR ARM REST NU 17.51

E0995 WHEELCHAIR CALF REST UE 22.62

E0995 WHEELCHAIR CALF REST RR 3.03

E0995 WHEELCHAIR CALF REST NU 30.19

E1002 PWR SEAT TILT UE 3,063.17

E1002 PWR SEAT TILT RR 408.44

E1002 PWR SEAT TILT NU 4,084.23

25/62


E1003 PWR SEAT RECLINE UE 3,270.43

E1003 PWR SEAT RECLINE RR 436.07

E1003 PWR SEAT RECLINE NU 4,360.56

E1004 PWR SEAT RECLINE MECH UE 3,626.21

E1004 PWR SEAT RECLINE MECH RR 483.49

E1004 PWR SEAT RECLINE MECH NU 4,834.97

E1005 PWR SEAT RECLINE PWR UE 3,925.11

E1005 PWR SEAT RECLINE PWR RR 523.34

E1005 PWR SEAT RECLINE PWR NU 5,233.47

E1006 PWR SEAT COMBO W/O SHEAR UE 4,807.89

E1006 PWR SEAT COMBO W/O SHEAR RR 641.03

E1006 PWR SEAT COMBO W/O SHEAR NU 6,410.51

E1007 PWR SEAT COMBO W/SHEAR UE 6,510.05

E1007 PWR SEAT COMBO W/SHEAR RR 868.01

E1007 PWR SEAT COMBO W/SHEAR NU 8,680.08

E1008 PWR SEAT COMBO PWR SHEAR UE 6,510.65

E1008 PWR SEAT COMBO PWR SHEAR RR 868.08

E1008 PWR SEAT COMBO PWR SHEAR NU 8,680.86

E1009 ADD MECH LEG ELEVATION UE -

E1009 ADD MECH LEG ELEVATION RR -

E1009 ADD MECH LEG ELEVATION NU -

E1010 ADD PWR LEG ELEVATION UE 857.47

E1010 ADD PWR LEG ELEVATION RR 114.32

E1010 ADD PWR LEG ELEVATION NU 1,143.30

E1014 RECLINING BACK ADD PED W/C UE 271.93

E1014 RECLINING BACK ADD PED W/C RR 36.26

E1014 RECLINING BACK ADD PED W/C NU 362.58

E1015 SHOCK ABSORBER FOR MAN W/C UE 85.42

E1015 SHOCK ABSORBER FOR MAN W/C RR 11.38

E1015 SHOCK ABSORBER FOR MAN W/C NU 113.90

E1016 SHOCK ABSORBER FOR POWER W/C UE 97.79

E1016 SHOCK ABSORBER FOR POWER W/C RR 13.05

E1016 SHOCK ABSORBER FOR POWER W/C NU 130.39

E1020 RESIDUAL LIMB SUPPORT SYSTEM UE 181.27

E1020 RESIDUAL LIMB SUPPORT SYSTEM RR 24.15

E1020 RESIDUAL LIMB SUPPORT SYSTEM NU 241.71

E1028 W/C MANUAL SWINGAWAY UE 153.81

E1028 W/C MANUAL SWINGAWAY RR 20.51

E1028 W/C MANUAL SWINGAWAY NU 205.09

E1029 W/C VENT TRAY FIXED UE 275.21

E1029 W/C VENT TRAY FIXED RR 36.69

E1029 W/C VENT TRAY FIXED NU 366.95

E1030 W/C VENT TRAY GIMBALED RR 115.71

E1030 W/C VENT TRAY GIMBALED NU 1,157.11

E1031 ROLLABOUT CHAIR WITH CASTERS RR 50.16

26/62


E1031 ROLLABOUT CHAIR WITH CASTERS NU 501.56

E1035 PATIENT TRANSFER SYSTEM <300 RR 608.91

E1035 PATIENT TRANSFER SYSTEM <300 NU 6,089.08

E1037 TRANSPORT CHAIR, PED SIZE RR 107.73

E1037 TRANSPORT CHAIR, PED SIZE NU 1,077.31

E1038 TRANSPORT CHAIR PT WT<=300LB RR 39.73

E1038 TRANSPORT CHAIR PT WT<=300LB NU 397.30

E1039 TRANSPORT CHAIR PT WT >300LB RR 22.49

E1050 WHELCHR FXD FULL LENGTH ARMS RR 101.13

E1060 WHEELCHAIR DETACHABLE ARMS RR 125.19

E1070 WHEELCHAIR DETACHABLE FOOT R RR 92.68

E1083 HEMI-WHEELCHAIR FIXED ARMS RR 72.61

E1084 HEMI-WHEELCHAIR DETACHABLE A RR 97.41

E1087 WHEELCHAIR LIGHTWT FIXED ARM RR 106.78

E1088 WHEELCHAIR LIGHTWEIGHT DET A RR 149.71

E1092 WHEELCHAIR WIDE W/ LEG RESTS RR 127.61

E1093 WHEELCHAIR WIDE W/ FOOT REST RR 109.75

E1100 WHCHR S-RECL FXD ARM LEG RES RR 97.14

E1110 WHEELCHAIR SEMI-RECL DETACH RR 97.14

E1150 WHEELCHAIR STANDARD W/ LEG R RR 81.01

E1160 WHEELCHAIR FIXED ARMS RR 62.06

E1161 MANUAL ADULT WC W TILTINSPAC RR 234.27

E1161 MANUAL ADULT WC W TILTINSPAC NU 2,349.53

E1170 WHLCHR AMPU FXD ARM LEG REST RR 88.68

E1171 WHEELCHAIR AMPUTEE W/O LEG R RR 79.59

E1172 WHEELCHAIR AMPUTEE DETACH AR RR 95.00

E1180 WHEELCHAIR AMPUTEE W/ FOOT R RR 100.63

E1190 WHEELCHAIR AMPUTEE W/ LEG RE RR 98.81

E1195 WHEELCHAIR AMPUTEE HEAVY DUT RR 124.75

E1200 WHEELCHAIR AMPUTEE FIXED ARM RR 86.40

E1221 WHEELCHAIR SPEC SIZE W FOOT RR 47.18

E1222 WHEELCHAIR SPEC SIZE W/ LEG RR 67.32

E1223 WHEELCHAIR SPEC SIZE W FOOT RR 73.50

E1224 WHEELCHAIR SPEC SIZE W/ LEG RR 80.58

E1225 MANUAL SEMI-RECLINING BACK RR 44.88

E1226 MANUAL FULLY RECLINING BACK UE 365.12

E1226 MANUAL FULLY RECLINING BACK RR 48.70

E1226 MANUAL FULLY RECLINING BACK NU 486.82

E1227 WHEELCHAIR SPEC SZ SPEC HT A UE 175.69

E1227 WHEELCHAIR SPEC SZ SPEC HT A RR 23.42

E1227 WHEELCHAIR SPEC SZ SPEC HT A NU 234.23

E1228 WHEELCHAIR SPEC SZ SPEC HT B RR 27.82

E1229 PEDIATRIC WHEELCHAIR NOS -

E1230 POWER OPERATED VEHICLE UE 1,776.29

E1230 POWER OPERATED VEHICLE RR 220.89

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E1230 POWER OPERATED VEHICLE NU 2,245.96

E1232 FOLDING PED WC TILT-IN-SPACE RR 211.93

E1232 FOLDING PED WC TILT-IN-SPACE NU 2,119.26

E1233 RIG PED WC TLTNSPC W/O SEAT RR 219.30

E1233 RIG PED WC TLTNSPC W/O SEAT NU 2,193.04

E1234 FLD PED WC TLTNSPC W/O SEAT RR 190.97

E1234 FLD PED WC TLTNSPC W/O SEAT NU 1,909.74

E1235 RIGID PED WC ADJUSTABLE RR 183.89

E1235 RIGID PED WC ADJUSTABLE NU 1,838.94

E1236 FOLDING PED WC ADJUSTABLE RR 162.20

E1236 FOLDING PED WC ADJUSTABLE NU 1,621.97

E1237 RGD PED WC ADJSTABL W/O SEAT RR 163.66

E1237 RGD PED WC ADJSTABL W/O SEAT NU 1,636.56

E1238 FLD PED WC ADJSTABL W/O SEAT RR 170.66

E1238 FLD PED WC ADJSTABL W/O SEAT NU 1,706.57

E1239 PED POWER WHEELCHAIR NOS -

E1240 WHCHR LITWT DET ARM LEG REST RR 91.39

E1270 WHEELCHAIR LIGHTWEIGHT LEG R RR 75.56

E1280 WHCHR H-DUTY DET ARM LEG RES RR 130.34

E1295 WHEELCHAIR HEAVY DUTY FIXED RR 120.62

E1296 WHEELCHAIR SPECIAL SEAT HEIG UE 311.25

E1296 WHEELCHAIR SPECIAL SEAT HEIG RR 42.15

E1296 WHEELCHAIR SPECIAL SEAT HEIG NU 414.99

E1297 WHEELCHAIR SPECIAL SEAT DEPT UE 77.90

E1297 WHEELCHAIR SPECIAL SEAT DEPT RR 11.54

E1297 WHEELCHAIR SPECIAL SEAT DEPT NU 103.88

E1298 WHEELCHAIR SPEC SEAT DEPTH/W UE 315.51

E1298 WHEELCHAIR SPEC SEAT DEPTH/W RR 43.05

E1298 WHEELCHAIR SPEC SEAT DEPTH/W NU 420.68

E1310 WHIRLPOOL NON-PORTABLE UE 1,359.39

E1310 WHIRLPOOL NON-PORTABLE RR 181.24

E1310 WHIRLPOOL NON-PORTABLE NU 1,812.51

E1372 OXY SUPPL HEATER FOR NEBULIZ UE 101.86

E1372 OXY SUPPL HEATER FOR NEBULIZ RR 20.00

E1372 OXY SUPPL HEATER FOR NEBULIZ NU 137.61

E1390 OXYGEN CONCENTRATOR RR 171.96

E1391 OXYGEN CONCENTRATOR, DUAL RR 171.96

E1392 PORTABLE OXYGEN CONCENTRATOR RR 31.85

E1399 DURABLE MEDICAL EQUIPMENT MI -

E1405 O2/WATER VAPOR ENRICH W/HEAT RR 256.80

E1406 O2/WATER VAPOR ENRICH W/O HE RR 243.85

E1700 JAW MOTION REHAB SYSTEM UE 256.82

E1700 JAW MOTION REHAB SYSTEM RR 33.58

E1700 JAW MOTION REHAB SYSTEM NU 342.43

E1701 REPL CUSHIONS FOR JAW MOTION 10.54

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E1702 REPL MEASR SCALES JAW MOTION 22.41

E1800 ADJUST ELBOW EXT/FLEX DEVICE RR 121.64

E1801 SPS ELBOW DEVICE RR 121.77

E1802 ADJST FOREARM PRO/SUP DEVICE RR 324.51

E1805 ADJUST WRIST EXT/FLEX DEVICE RR 125.46

E1806 SPS WRIST DEVICE RR 99.97

E1810 ADJUST KNEE EXT/FLEX DEVICE RR 123.71

E1811 SPS KNEE DEVICE RR 126.60

E1812 KNEE EXT/FLEX W ACT RES CTRL RR 85.39

E1815 ADJUST ANKLE EXT/FLEX DEVICE RR 125.46

E1816 SPS ANKLE DEVICE RR 128.58

E1818 SPS FOREARM DEVICE RR 131.24

E1820 SOFT INTERFACE MATERIAL UE 57.43

E1820 SOFT INTERFACE MATERIAL RR 7.67

E1820 SOFT INTERFACE MATERIAL NU 76.57

E1821 REPLACEMENT INTERFACE SPSD UE 78.40

E1821 REPLACEMENT INTERFACE SPSD RR 10.44

E1821 REPLACEMENT INTERFACE SPSD NU 104.51

E1825 ADJUST FINGER EXT/FLEX DEVC RR 125.46

E1830 ADJUST TOE EXT/FLEX DEVICE RR 125.46

E1831 STATIC STR TOE DEV EXT/FLEX STATI RR -

E1840 ADJ SHOULDER EXT/FLEX DEVICE RR 372.55

E1902 AAC NON-ELECTRONIC BOARD -

E2000 GASTRIC SUCTION PUMP HME MDL RR 48.91

E2000 GASTRIC SUCTION PUMP HME MDL NU 489.05

E2100 BLD GLUCOSE MONITOR W VOICE UE 479.02

E2100 BLD GLUCOSE MONITOR W VOICE RR 63.87

E2100 BLD GLUCOSE MONITOR W VOICE NU 638.69

E2101 BLD GLUCOSE MONITOR W LANCE UE 140.43

E2101 BLD GLUCOSE MONITOR W LANCE RR 18.73

E2101 BLD GLUCOSE MONITOR W LANCE NU 187.24

E2201 MAN W/CH ACC SEAT W>=20�<24� UE 277.87

E2201 MAN W/CH ACC SEAT W>=20�<24� RR 37.05

E2201 MAN W/CH ACC SEAT W>=20�<24� NU 370.49

E2202 SEAT WIDTH 24-27 IN UE 353.01

E2202 SEAT WIDTH 24-27 IN RR 47.07

E2202 SEAT WIDTH 24-27 IN NU 470.66

E2203 FRAME DEPTH LESS THAN 22 IN UE 356.77

E2203 FRAME DEPTH LESS THAN 22 IN RR 47.55

E2203 FRAME DEPTH LESS THAN 22 IN NU 475.70

E2204 FRAME DEPTH 22 TO 25 IN UE 605.78

E2204 FRAME DEPTH 22 TO 25 IN RR 80.78

E2204 FRAME DEPTH 22 TO 25 IN NU 807.71

E2205 MANUAL WC ACCESSORY, HANDRIM UE 23.93

E2205 MANUAL WC ACCESSORY, HANDRIM RR 3.17

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E2205 MANUAL WC ACCESSORY, HANDRIM NU 31.88

E2206 COMPLETE WHEEL LOCK ASSEMBLY UE 29.80

E2206 COMPLETE WHEEL LOCK ASSEMBLY RR 3.96

E2206 COMPLETE WHEEL LOCK ASSEMBLY NU 39.73

E2207 CRUTCH AND CANE HOLDER UE 31.75

E2207 CRUTCH AND CANE HOLDER RR 4.24

E2207 CRUTCH AND CANE HOLDER NU 42.32

E2208 CYLINDER TANK CARRIER UE 86.98

E2208 CYLINDER TANK CARRIER RR 11.60

E2208 CYLINDER TANK CARRIER NU 115.39

E2209 ARM TROUGH EACH UE 78.49

E2209 ARM TROUGH EACH RR 10.45

E2209 ARM TROUGH EACH NU 104.65

E2210 WHEELCHAIR BEARINGS UE 4.89

E2210 WHEELCHAIR BEARINGS RR 0.66

E2210 WHEELCHAIR BEARINGS NU 6.50

E2211 PNEUMATIC PROPULSION TIRE UE 24.74

E2211 PNEUMATIC PROPULSION TIRE RR 3.98

E2211 PNEUMATIC PROPULSION TIRE NU 34.53

E2212 PNEUMATIC PROP TIRE TUBE UE 4.31

E2212 PNEUMATIC PROP TIRE TUBE RR 0.61

E2212 PNEUMATIC PROP TIRE TUBE NU 5.74

E2213 PNEUMATIC PROP TIRE INSERT UE 22.25

E2213 PNEUMATIC PROP TIRE INSERT RR 2.99

E2213 PNEUMATIC PROP TIRE INSERT NU 29.70

E2214 PNEUMATIC CASTER TIRE EACH UE 22.94

E2214 PNEUMATIC CASTER TIRE EACH RR 3.93

E2214 PNEUMATIC CASTER TIRE EACH NU 30.60

E2215 PNEUMATIC CASTER TIRE TUBE UE 7.03

E2215 PNEUMATIC CASTER TIRE TUBE RR 0.93

E2215 PNEUMATIC CASTER TIRE TUBE NU 9.38

E2216 FOAM FILLED PROPULSION TIRE UE 21.17

E2216 FOAM FILLED PROPULSION TIRE RR 2.82

E2216 FOAM FILLED PROPULSION TIRE NU 28.22

E2217 FOAM FILLED CASTER TIRE EACH UE -

E2217 FOAM FILLED CASTER TIRE EACH RR -

E2217 FOAM FILLED CASTER TIRE EACH NU -

E2218 FOAM PROPULSION TIRE EACH UE 12.47

E2218 FOAM PROPULSION TIRE EACH RR 1.66

E2218 FOAM PROPULSION TIRE EACH NU 16.62

E2219 FOAM CASTER TIRE ANY SIZE EA UE 26.49

E2219 FOAM CASTER TIRE ANY SIZE EA RR 4.69

E2219 FOAM CASTER TIRE ANY SIZE EA NU 35.32

E2220 SOLID PROPULSION TIRE EACH UE 21.66

E2220 SOLID PROPULSION TIRE EACH RR 2.73

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E2220 SOLID PROPULSION TIRE EACH NU 28.32

E2221 SOLID CASTER TIRE EACH UE 18.73

E2221 SOLID CASTER TIRE EACH RR 2.47

E2221 SOLID CASTER TIRE EACH NU 24.94

E2222 SOLID CASTER INTEGRATED WHL UE 15.70

E2222 SOLID CASTER INTEGRATED WHL RR 2.08

E2222 SOLID CASTER INTEGRATED WHL NU 20.88

E2224 PROPULSION WHL EXCLUDES TIRE UE 62.08

E2224 PROPULSION WHL EXCLUDES TIRE RR 10.22

E2224 PROPULSION WHL EXCLUDES TIRE NU 83.26

E2225 CASTER WHEEL EXCLUDES TIRE UE 12.95

E2225 CASTER WHEEL EXCLUDES TIRE RR 1.70

E2225 CASTER WHEEL EXCLUDES TIRE NU 17.28

E2226 CASTER FORK REPLACEMENT ONLY UE 28.26

E2226 CASTER FORK REPLACEMENT ONLY RR 3.76

E2226 CASTER FORK REPLACEMENT ONLY NU 37.67

E2227 GEAR REDUCTION DRIVE WHEEL UE -

E2227 GEAR REDUCTION DRIVE WHEEL RR -

E2227 GEAR REDUCTION DRIVE WHEEL NU -

E2228 Mwc acc wheelchair brake UE -

E2228 Mwc acc wheelchair brake RR -

E2228 Mwc acc wheelchair brake NU -

E2231 SOLID SEAT SUPPORT BASE UE 120.16

E2231 SOLID SEAT SUPPORT BASE RR 16.03

E2231 SOLID SEAT SUPPORT BASE NU 160.23

E2291 PLANAR BACK FOR PED SIZE WC UE 127.01

E2291 PLANAR BACK FOR PED SIZE WC RR 16.94

E2291 PLANAR BACK FOR PED SIZE WC NU 169.36

E2292 PLANAR SEAT FOR PED SIZE WC UE 127.01

E2292 PLANAR SEAT FOR PED SIZE WC RR 16.94

E2292 PLANAR SEAT FOR PED SIZE WC NU 169.36

E2293 CONTOUR BACK FOR PED SIZE WC UE 169.36

E2293 CONTOUR BACK FOR PED SIZE WC RR 22.58

E2293 CONTOUR BACK FOR PED SIZE WC NU 225.81

E2294 CONTOUR SEAT FOR PED SIZE WC UE 169.36

E2294 CONTOUR SEAT FOR PED SIZE WC RR 22.58

E2294 CONTOUR SEAT FOR PED SIZE WC NU 225.81

E2295 PED DYNAMIC SEATING FRAME -

E2310 ELECTRO CONNECT BTW CONTROL UE 871.54

E2310 ELECTRO CONNECT BTW CONTROL RR 116.20

E2310 ELECTRO CONNECT BTW CONTROL NU 1,162.05

E2311 ELECTRO CONNECT BTW 2 SYS UE 1,764.46

E2311 ELECTRO CONNECT BTW 2 SYS RR 235.27

E2311 ELECTRO CONNECT BTW 2 SYS NU 2,352.62

E2312 MINI-PROP REMOTE JOYSTICK UE 1,444.18

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E2312 MINI-PROP REMOTE JOYSTICK RR 192.56

E2312 MINI-PROP REMOTE JOYSTICK NU 1,925.61

E2313 PWC HARNESS, EXPAND CONTROL UE 229.33

E2313 PWC HARNESS, EXPAND CONTROL RR 30.59

E2313 PWC HARNESS, EXPAND CONTROL NU 305.77

E2321 HAND INTERFACE JOYSTICK UE 1,141.63

E2321 HAND INTERFACE JOYSTICK RR 152.21

E2321 HAND INTERFACE JOYSTICK NU 1,522.17

E2322 MULT MECH SWITCHES UE 1,050.38

E2322 MULT MECH SWITCHES RR 140.04

E2322 MULT MECH SWITCHES NU 1,400.49

E2323 SPECIAL JOYSTICK HANDLE UE 48.14

E2323 SPECIAL JOYSTICK HANDLE RR 6.42

E2323 SPECIAL JOYSTICK HANDLE NU 64.19

E2324 CHIN CUP INTERFACE UE 33.14

E2324 CHIN CUP INTERFACE RR 4.42

E2324 CHIN CUP INTERFACE NU 44.18

E2325 SIP AND PUFF INTERFACE UE 1,003.06

E2325 SIP AND PUFF INTERFACE RR 133.76

E2325 SIP AND PUFF INTERFACE NU 1,337.40

E2326 BREATH TUBE KIT UE 238.04

E2326 BREATH TUBE KIT RR 31.74

E2326 BREATH TUBE KIT NU 317.36

E2327 HEAD CONTROL INTERFACE MECH UE 1,717.47

E2327 HEAD CONTROL INTERFACE MECH RR 229.01

E2327 HEAD CONTROL INTERFACE MECH NU 2,290.00

E2328 HEAD/EXTREMITY CONTROL INTER UE 2,887.65

E2328 HEAD/EXTREMITY CONTROL INTER RR 384.73

E2328 HEAD/EXTREMITY CONTROL INTER NU 3,850.08

E2329 HEAD CONTROL NONPROPORTIONAL UE 1,288.64

E2329 HEAD CONTROL NONPROPORTIONAL RR 171.83

E2329 HEAD CONTROL NONPROPORTIONAL NU 1,718.10

E2330 HEAD CONTROL PROXIMITY SWITC UE 2,482.46

E2330 HEAD CONTROL PROXIMITY SWITC RR 330.99

E2330 HEAD CONTROL PROXIMITY SWITC NU 3,309.94

E2340 W/C WDTH 20-23 IN SEAT FRAME UE 234.02

E2340 W/C WDTH 20-23 IN SEAT FRAME RR 31.20

E2340 W/C WDTH 20-23 IN SEAT FRAME NU 312.02

E2341 W/C WDTH 24-27 IN SEAT FRAME UE 344.80

E2341 W/C WDTH 24-27 IN SEAT FRAME RR 45.98

E2341 W/C WDTH 24-27 IN SEAT FRAME NU 459.73

E2342 W/C DPTH 20-21 IN SEAT FRAME UE 333.68

E2342 W/C DPTH 20-21 IN SEAT FRAME RR 44.49

E2342 W/C DPTH 20-21 IN SEAT FRAME NU 444.89

E2343 W/C DPTH 22-25 IN SEAT FRAME UE 193.08

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E2343 W/C DPTH 22-25 IN SEAT FRAME RR 25.75

E2343 W/C DPTH 22-25 IN SEAT FRAME NU 257.46

E2351 ELECTRONIC SGD INTERFACE UE 520.29

E2351 ELECTRONIC SGD INTERFACE RR 69.39

E2351 ELECTRONIC SGD INTERFACE NU 693.74

E2358 Gr 34 nonsealed leadacid -

E2359 Gr34 sealed leadacid battery -

E2360 22NF NONSEALED LEADACID UE 83.67

E2360 22NF NONSEALED LEADACID RR 11.21

E2360 22NF NONSEALED LEADACID NU 111.55

E2361 22NF SEALED LEADACID BATTERY UE 102.14

E2361 22NF SEALED LEADACID BATTERY RR 13.62

E2361 22NF SEALED LEADACID BATTERY NU 136.19

E2362 GR24 NONSEALED LEADACID UE 67.35

E2362 GR24 NONSEALED LEADACID RR 8.98

E2362 GR24 NONSEALED LEADACID NU 89.81

E2363 GR24 SEALED LEADACID BATTERY UE 136.21

E2363 GR24 SEALED LEADACID BATTERY RR 18.17

E2363 GR24 SEALED LEADACID BATTERY NU 181.61

E2364 U1NONSEALED LEADACID BATTERY UE 83.67

E2364 U1NONSEALED LEADACID BATTERY RR 11.21

E2364 U1NONSEALED LEADACID BATTERY NU 111.55

E2365 U1 SEALED LEADACID BATTERY UE 82.17

E2365 U1 SEALED LEADACID BATTERY RR 10.95

E2365 U1 SEALED LEADACID BATTERY NU 109.54

E2366 BATTERY CHARGER, SINGLE MODE UE 166.88

E2366 BATTERY CHARGER, SINGLE MODE RR 22.31

E2366 BATTERY CHARGER, SINGLE MODE NU 222.51

E2367 BATTERY CHARGER, DUAL MODE UE 312.11

E2367 BATTERY CHARGER, DUAL MODE RR 41.62

E2367 BATTERY CHARGER, DUAL MODE NU 416.15

E2368 PWR WC DRIVEWHEEL MOTOR REPL UE 384.73

E2368 PWR WC DRIVEWHEEL MOTOR REPL RR 51.31

E2368 PWR WC DRIVEWHEEL MOTOR REPL NU 512.95

E2369 PWR WC DRIVEWHEEL GEAR REPL UE 335.09

E2369 PWR WC DRIVEWHEEL GEAR REPL RR 44.69

E2369 PWR WC DRIVEWHEEL GEAR REPL NU 446.79

E2370 PWR WC DR WH MOTOR/GEAR COMB UE 597.91

E2370 PWR WC DR WH MOTOR/GEAR COMB RR 79.73

E2370 PWR WC DR WH MOTOR/GEAR COMB NU 797.22

E2371 GR27 SEALED LEADACID BATTERY UE 112.27

E2371 GR27 SEALED LEADACID BATTERY RR 14.97

E2371 GR27 SEALED LEADACID BATTERY NU 149.68

E2372 GR27 NON-SEALED LEADACID UE -

E2372 GR27 NON-SEALED LEADACID RR -

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E2372 GR27 NON-SEALED LEADACID NU -

E2373 HAND/CHIN CTRL SPEC JOYSTICK UE 503.41

E2373 HAND/CHIN CTRL SPEC JOYSTICK RR 67.14

E2373 HAND/CHIN CTRL SPEC JOYSTICK NU 671.19

E2374 HAND/CHIN CTRL STD JOYSTICK UE 397.73

E2374 HAND/CHIN CTRL STD JOYSTICK RR 53.03

E2374 HAND/CHIN CTRL STD JOYSTICK NU 530.28

E2375 NON-EXPANDABLE CONTROLLER UE 637.90

E2375 NON-EXPANDABLE CONTROLLER RR 85.05

E2375 NON-EXPANDABLE CONTROLLER NU 850.56

E2376 EXPANDABLE CONTROLLER, REPL UE 999.67

E2376 EXPANDABLE CONTROLLER, REPL RR 133.29

E2376 EXPANDABLE CONTROLLER, REPL NU 1,332.87

E2377 EXPANDABLE CONTROLLER, INITL UE 361.75

E2377 EXPANDABLE CONTROLLER, INITL RR 48.22

E2377 EXPANDABLE CONTROLLER, INITL NU 482.31

E2378 PW ACTUATOR REPLACEMENT NU -

E2381 PNEUM DRIVE WHEEL TIRE UE 55.79

E2381 PNEUM DRIVE WHEEL TIRE RR 7.42

E2381 PNEUM DRIVE WHEEL TIRE NU 74.38

E2382 TUBE PNEUM WHEEL DRIVE TIRE UE 15.21

E2382 TUBE PNEUM WHEEL DRIVE TIRE RR 2.01

E2382 TUBE PNEUM WHEEL DRIVE TIRE NU 20.27

E2383 INSERT PNEUM WHEEL DRIVE UE 111.24

E2383 INSERT PNEUM WHEEL DRIVE RR 14.83

E2383 INSERT PNEUM WHEEL DRIVE NU 148.29

E2384 PNEUMATIC CASTER TIRE UE 59.25

E2384 PNEUMATIC CASTER TIRE RR 7.88

E2384 PNEUMATIC CASTER TIRE NU 79.01

E2385 TUBE PNEUMATIC CASTER TIRE UE 36.24

E2385 TUBE PNEUMATIC CASTER TIRE RR 4.82

E2385 TUBE PNEUMATIC CASTER TIRE NU 48.33

E2386 FOAM FILLED DRIVE WHEEL TIRE UE 110.23

E2386 FOAM FILLED DRIVE WHEEL TIRE RR 14.70

E2386 FOAM FILLED DRIVE WHEEL TIRE NU 146.94

E2387 FOAM FILLED CASTER TIRE UE 47.53

E2387 FOAM FILLED CASTER TIRE RR 6.33

E2387 FOAM FILLED CASTER TIRE NU 63.39

E2388 FOAM DRIVE WHEEL TIRE UE 37.54

E2388 FOAM DRIVE WHEEL TIRE RR 5.00

E2388 FOAM DRIVE WHEEL TIRE NU 50.04

E2389 FOAM CASTER TIRE UE 20.37

E2389 FOAM CASTER TIRE RR 2.72

E2389 FOAM CASTER TIRE NU 27.17

E2390 SOLID DRIVE WHEEL TIRE UE 31.85

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E2390 SOLID DRIVE WHEEL TIRE RR 4.25

E2390 SOLID DRIVE WHEEL TIRE NU 42.49

E2391 SOLID CASTER TIRE UE 15.27

E2391 SOLID CASTER TIRE RR 2.04

E2391 SOLID CASTER TIRE NU 20.36

E2392 SOLID CASTER TIRE INTEGRATE UE 40.13

E2392 SOLID CASTER TIRE INTEGRATE RR 5.36

E2392 SOLID CASTER TIRE INTEGRATE NU 53.50

E2394 DRIVE WHEEL EXCLUDES TIRE UE 57.17

E2394 DRIVE WHEEL EXCLUDES TIRE RR 7.64

E2394 DRIVE WHEEL EXCLUDES TIRE NU 76.21

E2395 CASTER WHEEL EXCLUDES TIRE UE 40.64

E2395 CASTER WHEEL EXCLUDES TIRE RR 5.42

E2395 CASTER WHEEL EXCLUDES TIRE NU 54.17

E2396 CASTER FORK UE 42.11

E2396 CASTER FORK RR 7.08

E2396 CASTER FORK NU 56.13

E2397 Pwc acc lith-based battery NU -

E2402 NEG PRESS WOUND THERAPY PUMP RR 1,542.53

E2500 SGD DIGITIZED PRE-REC <=8MIN UE 291.24

E2500 SGD DIGITIZED PRE-REC <=8MIN RR 38.84

E2500 SGD DIGITIZED PRE-REC <=8MIN NU 388.32

E2502 SGD PREREC MSG >8MIN <=20MIN UE 890.58

E2502 SGD PREREC MSG >8MIN <=20MIN RR 118.75

E2502 SGD PREREC MSG >8MIN <=20MIN NU 1,187.43

E2504 SGD PREREC MSG>20MIN <=40MIN UE 1,174.77

E2504 SGD PREREC MSG>20MIN <=40MIN RR 156.66

E2504 SGD PREREC MSG>20MIN <=40MIN NU 1,566.38

E2506 SGD PREREC MSG > 40 MIN UE 1,722.55

E2506 SGD PREREC MSG > 40 MIN RR 229.67

E2506 SGD PREREC MSG > 40 MIN NU 2,296.77

E2508 SGD SPELLING PHYS CONTACT UE 2,663.69

E2508 SGD SPELLING PHYS CONTACT RR 355.17

E2508 SGD SPELLING PHYS CONTACT NU 3,551.57

E2510 SGD W MULTI METHODS MSG/ACCS UE 5,040.65

E2510 SGD W MULTI METHODS MSG/ACCS RR 672.08

E2510 SGD W MULTI METHODS MSG/ACCS NU 6,720.87

E2511 SGD SFTWRE PRGRM FOR PC/PDA -

E2512 SGD ACCESSORY, MOUNTING SYS -

E2599 SGD ACCESSORY NOC -

E2601 GEN W/C CUSHION WDTH < 22 IN UE 66.02

E2601 GEN W/C CUSHION WDTH < 22 IN RR 8.80

E2601 GEN W/C CUSHION WDTH < 22 IN NU 88.03

E2602 GEN W/C CUSHION WDTH >=22 IN UE 120.58

E2602 GEN W/C CUSHION WDTH >=22 IN RR 16.09

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E2602 GEN W/C CUSHION WDTH >=22 IN NU 160.75

E2603 SKIN PROTECT WC CUS WD <22IN UE 166.11

E2603 SKIN PROTECT WC CUS WD <22IN RR 22.15

E2603 SKIN PROTECT WC CUS WD <22IN NU 221.48

E2604 SKIN PROTECT WC CUS WD>=22IN UE 235.17

E2604 SKIN PROTECT WC CUS WD>=22IN RR 31.34

E2604 SKIN PROTECT WC CUS WD>=22IN NU 313.55

E2605 POSITION WC CUSH WDTH <22 IN UE 239.60

E2605 POSITION WC CUSH WDTH <22 IN RR 31.96

E2605 POSITION WC CUSH WDTH <22 IN NU 319.44

E2606 POSITION WC CUSH WDTH>=22 IN UE 324.77

E2606 POSITION WC CUSH WDTH>=22 IN RR 43.30

E2606 POSITION WC CUSH WDTH>=22 IN NU 433.02

E2607 SKIN PRO/POS WC CUS WD <22IN UE 220.15

E2607 SKIN PRO/POS WC CUS WD <22IN RR 29.35

E2607 SKIN PRO/POS WC CUS WD <22IN NU 293.53

E2608 SKIN PRO/POS WC CUS WD>=22IN UE 263.65

E2608 SKIN PRO/POS WC CUS WD>=22IN RR 35.17

E2608 SKIN PRO/POS WC CUS WD>=22IN NU 351.52

E2609 CUSTOM FABRICATE W/C CUSHION UE -

E2609 CUSTOM FABRICATE W/C CUSHION RR -

E2609 CUSTOM FABRICATE W/C CUSHION NU -

E2609 CUSTOM FABRICATE W/C CUSHION -

E2610 POWERED W/C CUSHION -

E2611 GEN USE BACK CUSH WDTH <22IN UE 232.65

E2611 GEN USE BACK CUSH WDTH <22IN RR 31.01

E2611 GEN USE BACK CUSH WDTH <22IN NU 310.16

E2612 GEN USE BACK CUSH WDTH>=22IN UE 314.65

E2612 GEN USE BACK CUSH WDTH>=22IN RR 41.95

E2612 GEN USE BACK CUSH WDTH>=22IN NU 419.58

E2613 POSITION BACK CUSH WD <22IN UE 292.72

E2613 POSITION BACK CUSH WD <22IN RR 39.03

E2613 POSITION BACK CUSH WD <22IN NU 390.29

E2614 POSITION BACK CUSH WD>=22IN UE 405.11

E2614 POSITION BACK CUSH WD>=22IN RR 54.02

E2614 POSITION BACK CUSH WD>=22IN NU 540.12

E2615 POS BACK POST/LAT WDTH <22IN UE 336.86

E2615 POS BACK POST/LAT WDTH <22IN RR 44.92

E2615 POS BACK POST/LAT WDTH <22IN NU 449.15

E2616 POS BACK POST/LAT WDTH>=22IN UE 453.25

E2616 POS BACK POST/LAT WDTH>=22IN RR 60.43

E2616 POS BACK POST/LAT WDTH>=22IN NU 604.32

E2617 CUSTOM FAB W/C BACK CUSHION UE -

E2617 CUSTOM FAB W/C BACK CUSHION RR -

E2617 CUSTOM FAB W/C BACK CUSHION NU -

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E2617 CUSTOM FAB W/C BACK CUSHION -

E2619 REPLACE COVER W/C SEAT CUSH UE 38.24

E2619 REPLACE COVER W/C SEAT CUSH RR 5.09

E2619 REPLACE COVER W/C SEAT CUSH NU 50.96

E2620 WC PLANAR BACK CUSH WD <22IN UE 428.06

E2620 WC PLANAR BACK CUSH WD <22IN RR 57.07

E2620 WC PLANAR BACK CUSH WD <22IN NU 570.74

E2621 WC PLANAR BACK CUSH WD>=22IN UE 407.91

E2621 WC PLANAR BACK CUSH WD>=22IN RR 54.39

E2621 WC PLANAR BACK CUSH WD>=22IN NU 543.87

E2622 ADJ SKIN PRO W/C CUS WD<22IN SKIN UE 223.18

E2622 ADJ SKIN PRO W/C CUS WD<22IN SKIN RR 29.76

E2622 ADJ SKIN PRO W/C CUS WD<22IN SKIN NU 297.57

E2623 ADJ SKIN PRO WC CUS WD>=22IN SKIN UE 283.98

E2623 ADJ SKIN PRO WC CUS WD>=22IN SKIN RR 37.86

E2623 ADJ SKIN PRO WC CUS WD>=22IN SKIN NU 378.65

E2624 ADJ SKIN PRO/POS CUS<22IN SKIN UE 225.02

E2624 ADJ SKIN PRO/POS CUS<22IN SKIN RR 30.00

E2624 ADJ SKIN PRO/POS CUS<22IN SKIN NU 300.03

E2625 ADJ SKIN PRO/POS WC CUS>=22 SKIN UE 284.84

E2625 ADJ SKIN PRO/POS WC CUS>=22 SKIN RR 37.97

E2625 ADJ SKIN PRO/POS WC CUS>=22 SKIN NU 379.81

E2626 Seo mobile arm sup att to wc UE 496.82

E2626 Seo mobile arm sup att to wc RR 66.23

E2626 Seo mobile arm sup att to wc NU 662.48

E2627 Arm supp att to wc rancho ty UE 792.84

E2627 Arm supp att to wc rancho ty RR 105.74

E2627 Arm supp att to wc rancho ty NU 1,057.12

E2628 Mobile arm supports reclinin UE 597.27

E2628 Mobile arm supports reclinin RR 79.63

E2628 Mobile arm supports reclinin NU 796.37

E2629 Friction dampening arm supp UE 755.85

E2629 Friction dampening arm supp RR 100.76

E2629 Friction dampening arm supp NU 1,007.79

E2630 Monosuspension arm/hand supp UE 528.55

E2630 Monosuspension arm/hand supp RR 70.47

E2630 Monosuspension arm/hand supp NU 704.75

E2631 Elevat proximal arm support UE 211.42

E2631 Elevat proximal arm support RR 28.19

E2631 Elevat proximal arm support NU 281.91

E2632 Offset/lat rocker arm w/ela UE 132.13

E2632 Offset/lat rocker arm w/ela RR 17.61

E2632 Offset/lat rocker arm w/ela NU 176.18

E2633 Mobile arm support supinator UE 114.03

E2633 Mobile arm support supinator RR 15.22

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E2633 Mobile arm support supinator NU 152.04

K0001 STANDARD WHEELCHAIR RR 52.74

K0001 STANDARD WHEELCHAIR NU 316.43

K0002 STND HEMI (LOW SEAT) WHLCHR RR 81.26

K0002 STND HEMI (LOW SEAT) WHLCHR NU 487.54

K0003 LIGHTWEIGHT WHEELCHAIR RR 79.20

K0003 LIGHTWEIGHT WHEELCHAIR NU 475.21

K0004 HIGH STRENGTH LTWT WHLCHR RR 132.70

K0004 HIGH STRENGTH LTWT WHLCHR NU 796.23

K0005 ULTRALIGHTWEIGHT WHEELCHAIR UE 1,353.85

K0005 ULTRALIGHTWEIGHT WHEELCHAIR RR 180.51

K0005 ULTRALIGHTWEIGHT WHEELCHAIR NU 1,805.12

K0006 HEAVY DUTY WHEELCHAIR RR 124.53

K0006 HEAVY DUTY WHEELCHAIR NU 747.19

K0007 EXTRA HEAVY DUTY WHEELCHAIR RR 167.95

K0007 EXTRA HEAVY DUTY WHEELCHAIR NU 1,007.68

K0008 Cstm manual wheelchair/base NU -

K0010 STND WT FRAME POWER WHLCHR RR 423.01

K0010 STND WT FRAME POWER WHLCHR NU 4,230.08

K0011 STND WT PWR WHLCHR W CONTROL RR 499.96

K0011 STND WT PWR WHLCHR W CONTROL NU 4,999.56

K0012 LTWT PORTBL POWER WHLCHR RR 306.68

K0012 LTWT PORTBL POWER WHLCHR NU 3,066.78

K0013 CUSTOM POWER WHLCHR BASE -

K0015 DETACH NON-ADJUS HGHT ARMRST UE 133.07

K0015 DETACH NON-ADJUS HGHT ARMRST RR 17.73

K0015 DETACH NON-ADJUS HGHT ARMRST NU 177.42

K0017 DETACH ADJUST ARMREST BASE UE 37.42

K0017 DETACH ADJUST ARMREST BASE RR 4.99

K0017 DETACH ADJUST ARMREST BASE NU 49.90

K0018 DETACH ADJUST ARMRST UPPER UE 20.91

K0018 DETACH ADJUST ARMRST UPPER RR 2.78

K0018 DETACH ADJUST ARMRST UPPER NU 27.89

K0019 ARM PAD EACH UE 12.84

K0019 ARM PAD EACH RR 1.71

K0019 ARM PAD EACH NU 17.12

K0020 FIXED ADJUST ARMREST PAIR UE 34.02

K0020 FIXED ADJUST ARMREST PAIR RR 4.55

K0020 FIXED ADJUST ARMREST PAIR NU 45.35

K0037 HIGH MOUNT FLIP-UP FOOTREST UE 35.88

K0037 HIGH MOUNT FLIP-UP FOOTREST RR 4.27

K0037 HIGH MOUNT FLIP-UP FOOTREST NU 47.82

K0038 LEG STRAP EACH UE 17.75

K0038 LEG STRAP EACH RR 2.36

K0038 LEG STRAP EACH NU 23.67

38/62


K0039 LEG STRAP H STYLE EACH UE 39.45

K0039 LEG STRAP H STYLE EACH RR 5.28

K0039 LEG STRAP H STYLE EACH NU 52.62

K0040 ADJUSTABLE ANGLE FOOTPLATE UE 54.68

K0040 ADJUSTABLE ANGLE FOOTPLATE RR 7.30

K0040 ADJUSTABLE ANGLE FOOTPLATE NU 72.90

K0041 LARGE SIZE FOOTPLATE EACH UE 38.75

K0041 LARGE SIZE FOOTPLATE EACH RR 5.15

K0041 LARGE SIZE FOOTPLATE EACH NU 51.69

K0042 STANDARD SIZE FOOTPLATE EACH UE 23.06

K0042 STANDARD SIZE FOOTPLATE EACH RR 3.07

K0042 STANDARD SIZE FOOTPLATE EACH NU 30.75

K0043 FTRST LOWER EXTENSION TUBE UE 14.31

K0043 FTRST LOWER EXTENSION TUBE RR 1.91

K0043 FTRST LOWER EXTENSION TUBE NU 19.07

K0044 FTRST UPPER HANGER BRACKET UE 12.16

K0044 FTRST UPPER HANGER BRACKET RR 1.63

K0044 FTRST UPPER HANGER BRACKET NU 16.26

K0045 FOOTREST COMPLETE ASSEMBLY UE 42.17

K0045 FOOTREST COMPLETE ASSEMBLY RR 5.80

K0045 FOOTREST COMPLETE ASSEMBLY NU 56.22

K0046 ELEVAT LEGRST LOW EXTENSION UE 14.31

K0046 ELEVAT LEGRST LOW EXTENSION RR 1.91

K0046 ELEVAT LEGRST LOW EXTENSION NU 19.07

K0047 ELEVAT LEGRST UP HANGR BRACK UE 56.01

K0047 ELEVAT LEGRST UP HANGR BRACK RR 7.47

K0047 ELEVAT LEGRST UP HANGR BRACK NU 74.65

K0050 RATCHET ASSEMBLY UE 23.81

K0050 RATCHET ASSEMBLY RR 3.16

K0050 RATCHET ASSEMBLY NU 31.74

K0051 CAM RELESE ASSEM FTRST/LGRST UE 38.52

K0051 CAM RELESE ASSEM FTRST/LGRST RR 5.12

K0051 CAM RELESE ASSEM FTRST/LGRST NU 51.36

K0052 SWINGAWAY DETACH FOOTREST UE 67.68

K0052 SWINGAWAY DETACH FOOTREST RR 9.04

K0052 SWINGAWAY DETACH FOOTREST NU 90.26

K0053 ELEVATE FOOTREST ARTICULATE UE 74.69

K0053 ELEVATE FOOTREST ARTICULATE RR 9.97

K0053 ELEVATE FOOTREST ARTICULATE NU 99.61

K0056 SEAT HT <17 OR >=21 LTWT WC UE 69.66

K0056 SEAT HT <17 OR >=21 LTWT WC RR 9.29

K0056 SEAT HT <17 OR >=21 LTWT WC NU 92.86

K0065 SPOKE PROTECTORS UE 32.56

K0065 SPOKE PROTECTORS RR 4.33

K0065 SPOKE PROTECTORS NU 43.40

39/62


K0069 REAR WHL COMPLETE SOLID TIRE UE 73.16

K0069 REAR WHL COMPLETE SOLID TIRE RR 9.77

K0069 REAR WHL COMPLETE SOLID TIRE NU 97.54

K0070 REAR WHL COMPL PNEUM TIRE UE 134.14

K0070 REAR WHL COMPL PNEUM TIRE RR 17.89

K0070 REAR WHL COMPL PNEUM TIRE NU 178.85

K0071 FRONT CASTR COMPL PNEUM TIRE UE 80.00

K0071 FRONT CASTR COMPL PNEUM TIRE RR 10.69

K0071 FRONT CASTR COMPL PNEUM TIRE NU 106.66

K0072 FRNT CSTR CMPL SEM-PNEUM TIR UE 45.26

K0072 FRNT CSTR CMPL SEM-PNEUM TIR RR 6.04

K0072 FRNT CSTR CMPL SEM-PNEUM TIR NU 60.33

K0073 CASTER PIN LOCK EACH UE 24.51

K0073 CASTER PIN LOCK EACH RR 3.27

K0073 CASTER PIN LOCK EACH NU 32.67

K0077 FRONT CASTER ASSEM COMPLETE UE 43.08

K0077 FRONT CASTER ASSEM COMPLETE RR 5.74

K0077 FRONT CASTER ASSEM COMPLETE NU 57.44

K0098 DRIVE BELT POWER WHEELCHAIR UE 19.34

K0098 DRIVE BELT POWER WHEELCHAIR RR 2.59

K0098 DRIVE BELT POWER WHEELCHAIR NU 25.78

K0105 IV HANGER UE 72.83

K0105 IV HANGER RR 9.69

K0105 IV HANGER NU 97.08

K0108 W/C COMPONENT-ACCESSORY NOS UE -

K0108 W/C COMPONENT-ACCESSORY NOS RR -

K0108 W/C COMPONENT-ACCESSORY NOS NU -

K0108 W/C COMPONENT-ACCESSORY NOS -

K0195 ELEVATING WHLCHAIR LEG RESTS RR 20.33

K0195 ELEVATING WHLCHAIR LEG RESTS NU 203.27

K0455 PUMP UNINTERRUPTED INFUSION RR 249.97

K0462 TEMPORARY REPLACEMENT EQPMNT -

K0552 SUPPLY/EXT INF PUMP SYR TYPE NU 2.59

K0601 REPL BATT SILVER OXIDE 1.5 V NU 1.09

K0602 REPL BATT SILVER OXIDE 3 V NU 6.32

K0603 REPL BATT ALKALINE 1.5 V NU 0.57

K0604 REPL BATT LITHIUM 3.6 V NU 6.05

K0605 REPL BATT LITHIUM 4.5 V NU 14.50

K0669 SEAT/BACK CUS NO DMEPDAC VER UE 180.04

K0669 SEAT/BACK CUS NO DMEPDAC VER RR 24.00

K0669 SEAT/BACK CUS NO DMEPDAC VER NU 240.05

K0672 REMOVABLE SOFT INTERFACE LE 74.40

K0730 CTRL DOSE INH DRUG DELIV SYS RR 171.19

K0733 12-24HR SEALED LEAD ACID UE 22.51

K0733 12-24HR SEALED LEAD ACID RR 3.02

40/62


K0733 12-24HR SEALED LEAD ACID NU 30.00

K0738 PORTABLE GAS OXYGEN SYSTEM -

K0739 REPAIR/SVC DME NON-OXYGEN E 21.22

K0800 POV GROUP 1 STD UP TO 300LBS UE 962.79

K0800 POV GROUP 1 STD UP TO 300LBS RR 128.38

K0800 POV GROUP 1 STD UP TO 300LBS NU 1,283.72

K0801 POV GROUP 1 HD 301-450 LBS UE 1,552.21

K0801 POV GROUP 1 HD 301-450 LBS RR 206.94

K0801 POV GROUP 1 HD 301-450 LBS NU 2,069.63

K0802 POV GROUP 1 VHD 451-600 LBS UE 1,756.63

K0802 POV GROUP 1 VHD 451-600 LBS RR 234.21

K0802 POV GROUP 1 VHD 451-600 LBS NU 2,342.15

K0815 PWC GP 1 STD SEAT/BACK RR 349.17

K0815 PWC GP 1 STD SEAT/BACK NU 3,491.69

K0816 PWC GP 1 STD CAP CHAIR RR 334.38

K0816 PWC GP 1 STD CAP CHAIR NU 3,343.83





K0824 PWC GP 2 HD SEAT/BACK RR 480.88

K0824 PWC GP 2 HD SEAT/BACK NU 4,808.80

K0825 PWC GP 2 HD CAP CHAIR RR 420.00

K0825 PWC GP 2 HD CAP CHAIR NU 4,199.99

K0826 PWC GP 2 VHD SEAT/BACK RR 622.54

K0826 PWC GP 2 VHD SEAT/BACK NU 6,225.41

K0827 PWC GP VHD CAP CHAIR RR 477.56

K0827 PWC GP VHD CAP CHAIR NU 4,775.63

K0828 PWC GP 2 XTRA HD SEAT/BACK RR 685.98

K0828 PWC GP 2 XTRA HD SEAT/BACK NU 6,859.84

K0829 PWC GP 2 XTRA HD CAP CHAIR RR 596.97

K0829 PWC GP 2 XTRA HD CAP CHAIR NU 5,969.72

K0835 PWC GP2 STD SING POW OPT S/B RR 409.34

K0835 PWC GP2 STD SING POW OPT S/B NU 4,093.44

K0841 PWC GP2 STD MULT POW OPT S/B RR 428.84

K0841 PWC GP2 STD MULT POW OPT S/B NU 4,288.37

K0843 PWC GP2 HD MULT POW OPT S/B RR 516.32

K0843 PWC GP2 HD MULT POW OPT S/B NU 5,163.20





K0850 PWC GP 3 HD SEAT/BACK RR 609.69

K0850 PWC GP 3 HD SEAT/BACK NU 6,096.92

K0851 PWC GP 3 HD CAP CHAIR RR 570.12

41/62


K0851 PWC GP 3 HD CAP CHAIR NU 5,701.21

K0852 PWC GP 3 VHD SEAT/BACK RR 703.30

K0852 PWC GP 3 VHD SEAT/BACK NU 7,033.02

K0853 PWC GP 3 VHD CAP CHAIR RR 722.47

K0853 PWC GP 3 VHD CAP CHAIR NU 7,224.67

K0854 PWC GP 3 XHD SEAT/BACK RR 957.11

K0854 PWC GP 3 XHD SEAT/BACK NU 9,571.13

K0855 PWC GP 3 XHD CAP CHAIR RR 904.14

K0855 PWC GP 3 XHD CAP CHAIR NU 9,041.36

K0856 PWC GP3 STD SING POW OPT S/B RR 563.26

K0856 PWC GP3 STD SING POW OPT S/B NU 5,632.59

K0857 PWC GP3 STD SING POW OPT CAP RR 574.55

K0857 PWC GP3 STD SING POW OPT CAP NU 5,745.50

K0858 PWC GP3 HD SING POW OPT S/B RR 698.83

K0858 PWC GP3 HD SING POW OPT S/B NU 6,988.34

K0859 PWC GP3 HD SING POW OPT CAP RR 649.23

K0859 PWC GP3 HD SING POW OPT CAP NU 6,492.33

K0860 PWC GP3 VHD SING POW OPT S/B RR 998.37

K0860 PWC GP3 VHD SING POW OPT S/B NU 9,983.72

K0861 PWC GP3 STD MULT POW OPT S/B RR 564.16

K0861 PWC GP3 STD MULT POW OPT S/B NU 5,641.63

K0862 PWC GP3 HD MULT POW OPT S/B RR 698.83

K0862 PWC GP3 HD MULT POW OPT S/B NU 6,988.34

K0863 PWC GP3 VHD MULT POW OPT S/B RR 998.37

K0863 PWC GP3 VHD MULT POW OPT S/B NU 9,983.72

K0864 PWC GP3 XHD MULT POW OPT S/B RR 1,247.95

K0864 PWC GP3 XHD MULT POW OPT S/B NU 12,479.53

K0868 PWC GP 4 STD SEAT/BACK RR -

K0868 PWC GP 4 STD SEAT/BACK NU -

K0869 PWC GP 4 STD CAP CHAIR RR -

K0869 PWC GP 4 STD CAP CHAIR NU -

K0870 PWC GP 4 HD SEAT/BACK RR -

K0870 PWC GP 4 HD SEAT/BACK NU -

K0871 PWC GP 4 VHD SEAT/BACK RR -

K0871 PWC GP 4 VHD SEAT/BACK NU -

K0877 PWC GP4 STD SING POW OPT S/B RR -

K0877 PWC GP4 STD SING POW OPT S/B NU -

K0878 PWC GP4 STD SING POW OPT CAP RR -

K0878 PWC GP4 STD SING POW OPT CAP NU -

K0879 PWC GP4 HD SING POW OPT S/B RR -

K0879 PWC GP4 HD SING POW OPT S/B NU -

K0880 PWC GP4 VHD SING POW OPT S/B RR -

K0880 PWC GP4 VHD SING POW OPT S/B NU -

K0884 PWC GP4 STD MULT POW OPT S/B RR -

K0884 PWC GP4 STD MULT POW OPT S/B NU -

42/62


K0885 PWC GP4 STD MULT POW OPT CAP RR -

K0885 PWC GP4 STD MULT POW OPT CAP NU -

K0886 PWC GP4 HD MULT POW S/B RR -

K0886 PWC GP4 HD MULT POW S/B NU -

K0890 PWC GP5 PED SING POW OPT S/B RR 913.31

K0890 PWC GP5 PED SING POW OPT S/B NU 9,133.12

K0891 PWC GP5 PED MULT POW OPT S/B RR 1,209.51

K0891 PWC GP5 PED MULT POW OPT S/B NU 12,095.14

L0112 CRANIAL CERVICAL ORTHOSIS 1,092.07

L0113 CRANIAL CERVICAL TORTICOLLIS -

L0120 CERV FLEX N/ADJ FOAM PRE OTS 26.44

L0130 FLEX THERMOPLASTIC COLLAR MO 132.09

L0140 CERVICAL SEMI-RIGID ADJUSTAB 47.85

L0150 CERV SEMI-RIG ADJ MOLDED CHN 107.70

L0160 CERV SR WIRE OCC/MAN PRE OTS 132.13

L0170 CERVICAL COLLAR MOLDED TO PT 637.31

L0172 CERV COL SR FOAM 2PC PRE OTS 118.98

L0174 CERV SR 2PC THOR EXT PRE OTS 273.79

L0180 CER POST COL OCC/MAN SUP ADJ 354.94

L0190 CERV COLLAR SUPP ADJ CERV BA 493.70

L0200 CERV COL SUPP ADJ BAR & THOR 514.67

L0220 THOR RIB BELT CUSTOM FABRICA 91.54

L0450 TLSO FLEX TRUNK/THOR PRE OTS 173.22

L0452 TLSO FLEX CUSTOM FAB THORACI 328.53

L0454 TLSO TRNK SJ-T9 PRE CST 348.37

L0455 Tlso flex trnk sj-t9 pre ots NU 319.22

L0456 TLSO FLEX TRNK SJ-SS PRE CST 348.37

L0457 Tlso flex trnk sj-ss pre ots NU 915.41

L0458 TLSO 2MOD SYMPHIS-XIPHO PRE 543.30

L0460 TLSO 2 SHL SYMPHYS-STERN CST 543.30

L0462 TLSO 3MOD SACRO-SCAP PRE 543.30

L0464 TLSO 4MOD SACRO-SCAP PRE 543.30

L0466 TLSO R FRAM SOFT ANT PRE CST 372.37

L0467 Tlso r fram soft pre ots NU 439.25

L0468 TLSO RIG FRAM PELVIC PRE CST 451.32

L0469 Tlso rig fram pelvic pre ots NU 532.38

L0470 TLSO RIGID FRAME PRE SUBCLAV 635.42

L0472 TLSO RIGID FRAME HYPEREX PRE 402.99

L0480 TLSO RIGID PLASTIC CUSTOM FA 1,209.27

L0482 TLSO RIGID LINED CUSTOM FAB 1,379.04

L0484 TLSO RIGID PLASTIC CUST FAB 1,551.92

L0486 TLSO RIGIDLINED CUST FAB TWO 1,680.76

L0488 TLSO RIGID LINED PRE ONE PIE 1,203.92

L0490 TLSO RIGID PLASTIC PRE ONE 1,116.56

L0491 TLSO 2 PIECE RIGID SHELL 599.25

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L0492 TLSO 3 PIECE RIGID SHELL 413.51

L0621 SIO FLEX PELVIC/SACR PRE OTS 91.90

L0622 SIO FLEX PELVISACRAL CUSTOM 257.47

L0623 SIO RIG PNL PELV/SAC PRE OTS 56.83

L0624 SIO PANEL CUSTOM -

L0625 LO FLEX L1-BELOW L5 PRE OTS 42.97

L0626 LO SAG RIG PNL STAYS PRE CST 60.82

L0627 LO SAG RI AN/POS PNL PRE CST 320.72

L0628 LSO FLEX NO RI STAYS PRE OTS 65.46

L0629 LSO FLEX W/RIGID STAYS CUST -

L0630 LSO R POST PNL SJ-T9 PRE CST 126.37

L0631 LSO SAG R AN/POS PNL PRE CST 800.99

L0632 LSO SAG RIGID FRAME CUST -

L0633 LSO SC R POS/LAT PNL PRE CST 223.73

L0634 LSO FLEXION CONTROL CUSTOM -

L0635 LSO SAGIT RIGID PANEL PREFAB 953.99

L0636 LSO SAGITTAL RIGID PANEL CUS 1,412.25

L0637 LSO SC R ANT/POS PNL PRE CST 984.58

L0638 LSO SAG-CORONAL PANEL CUSTOM 1,029.10

L0639 LSO S/C SHELL/PANEL PREFAB 943.99

L0640 LSO S/C SHELL/PANEL CUSTOM 816.45

L0641 Lo rig pos pnl l1-l5 pre ots NU 71.73

L0642 Lo sag ri an/pos pnl pre ots NU 378.33

L0643 Lso sag ctr rigi pos pre ots NU 149.07

L0648 Lso sag r an/pos pnl pre ots NU 944.86

L0649 Lso sc r pos/lat pnl pre ots NU 263.92

L0650 Lso sc r ant/pos pnl pre ots NU 1,113.55

L0651 Lso sag-co shell pnl pre ots NU 1,113.55

L0700 CTLSO A-P-L CONTROL MOLDED 2,014.93

L0710 CTLSO A-P-L CONTROL W/ INTER 2,081.51

L0810 HALO CERVICAL INTO JCKT VEST 2,570.77

L0820 HALO CERVICAL INTO BODY JACK 2,026.57

L0830 HALO CERV INTO MILWAUKEE TYP 3,125.28

L0859 MRI COMPATIBLE SYSTEM 910.61

L0861 HALO REPL LINER/INTERFACE 168.17

L0970 TLSO CORSET FRONT 113.91

L0972 LSO CORSET FRONT 102.57

L0974 TLSO FULL CORSET 172.48

L0976 LSO FULL CORSET 121.75

L0978 AXILLARY CRUTCH EXTENSION 191.85

L0980 PERONEAL STRAPS PAIR PRE OTS 13.05

L0982 STOCKING SUP GRIPS 4 PRE OTS 12.94

L0984 PROTECT BODY SOCK EA PRE OTS 51.10

L0999 ADD TO SPINAL ORTHOSIS NOS -

L1000 CTLSO MILWAUKE INITIAL MODEL 2,023.44

44/62


L1001 CTLSO INFANT IMMOBILIZER -

L1005 TENSION BASED SCOLIOSIS ORTH 2,497.33

L1010 CTLSO AXILLA SLING 56.78

L1020 KYPHOSIS PAD 86.14

L1025 KYPHOSIS PAD FLOATING 116.05

L1030 LUMBAR BOLSTER PAD 49.81

L1040 LUMBAR OR LUMBAR RIB PAD 77.75

L1050 STERNAL PAD 82.98

L1060 THORACIC PAD 95.32

L1070 TRAPEZIUS SLING 89.68

L1080 OUTRIGGER 47.70

L1085 OUTRIGGER BIL W/ VERT EXTENS 153.41

L1090 LUMBAR SLING 91.36

L1100 RING FLANGE PLASTIC/LEATHER 158.49

L1110 RING FLANGE PLAS/LEATHER MOL 254.54

L1120 COVERS FOR UPRIGHT EACH 39.58

L1200 FURNSH INITIAL ORTHOSIS ONLY 1,561.57

L1210 LATERAL THORACIC EXTENSION 260.78

L1220 ANTERIOR THORACIC EXTENSION 220.79

L1230 MILWAUKEE TYPE SUPERSTRUCTUR 443.68

L1240 LUMBAR DEROTATION PAD 77.38

L1250 ANTERIOR ASIS PAD 61.38

L1260 ANTERIOR THORACIC DEROTATION 67.13

L1270 ABDOMINAL PAD 77.22

L1280 RIB GUSSET (ELASTIC) EACH 85.97

L1290 LATERAL TROCHANTERIC PAD 78.34

L1300 BODY JACKET MOLD TO PATIENT 1,664.83

L1310 POST-OPERATIVE BODY JACKET 1,564.50

L1499 SPINAL ORTHOSIS NOS -

L1600 HO FLEX FREJKA W/COV PRE CST 122.40

L1610 HO FREJKA COV ONLY PRE CST 43.75

L1620 HO FLEX PAVLIK HARNS PRE CST 124.16

L1630 ABDUCT CONTROL HIP SEMI-FLEX 137.79

L1640 PELV BAND/SPREAD BAR THIGH C 344.91

L1650 HO ABDUCTION HIP ADJUSTABLE 201.94

L1652 HO BI THIGHCUFFS W SPRDR BAR 278.14

L1660 HO ABDUCTION STATIC PLASTIC 127.92

L1680 PELVIC & HIP CONTROL THIGH C 1,214.34

L1685 POST-OP HIP ABDUCT CUSTOM FA 1,185.49

L1686 HO POST-OP HIP ABDUCTION 909.14

L1690 COMBINATION BILATERAL HO 1,508.81

L1700 LEG PERTHES ORTH TORONTO TYP 1,521.99

L1710 LEGG PERTHES ORTH NEWINGTON 1,781.66

L1720 LEGG PERTHES ORTHOSIS TRILAT 1,313.30

L1730 LEGG PERTHES ORTH SCOTTISH R 1,128.00

45/62


L1755 LEGG PERTHES PATTEN BOTTOM T 1,569.90

L1810 KO ELASTIC WITH JOINTS 97.12

L1812 Ko elastic w/joints pre ots NU 114.55

L1820 KO ELAS W/ CONDYLE PADS & JO 118.25

L1830 KO IMMOB CANVAS LONG PRE OTS 87.19

L1831 KNEE ORTH POS LOCKING JOINT 229.64

L1832 KO ADJ JNT POS R SUP PRE CST 542.64

L1833 Ko adj jnt pos r sup pre ots NU 640.13

L1834 KO W/0 JOINT RIGID MOLDED TO 731.24

L1836 KO RIGID W/O JOINTS PRE OTS 104.11

L1840 KO DEROT ANT CRUCIATE CUSTOM 916.40

L1843 KO SINGLE UPRIGHT PRE CST 700.09

L1844 KO W/ADJ JT ROT CNTRL MOLDED 1,584.74

L1845 KO DOUBLE UPRIGHT PRE CST 610.96

L1846 KO W ADJ FLEX/EXT ROTAT MOLD 1,058.14

L1847 KO DBL UPRIGHT W/AIR PRE CST 448.78

L1848 Ko dbl upright w/air pre ots NU 529.39

L1850 KO SWEDISH TYPE PRE OTS 286.88

L1860 KO SUPRACONDYLAR SOCKET MOLD 1,069.46

L1900 AFO SPRNG WIR DRSFLX CALF BD 228.10

L1902 AFO ANKLE GAUNTLET PRE OTS 68.38

L1904 AFO MOLDED ANKLE GAUNTLET 468.68

L1906 AFO MULTILIG ANK SUP PRE OTS 119.86

L1907 AFO SUPRAMALLEOLAR CUSTOM 439.05

L1910 AFO SING BAR CLASP ATTACH SH 266.53

L1920 AFO SING UPRIGHT W/ ADJUST S 272.51

L1930 AFO PLASTIC 235.78

L1932 AFO RIG ANT TIB PREFAB TCF/= 696.27

L1940 AFO MOLDED TO PATIENT PLASTI 492.90

L1945 AFO MOLDED PLAS RIG ANT TIB 922.60

L1950 AFO SPIRAL MOLDED TO PT PLAS 742.35

L1951 AFO SPIRAL PREFABRICATED 655.29

L1960 AFO POS SOLID ANK PLASTIC MO 552.44

L1970 AFO PLASTIC MOLDED W/ANKLE J 577.65

L1971 AFO W/ANKLE JOINT, PREFAB 365.72

L1980 AFO SING SOLID STIRRUP CALF 365.78

L1990 AFO DOUB SOLID STIRRUP CALF 444.26

L2000 KAFO SING FRE STIRR THI/CALF 1,010.88

L2005 KAFO SNG/DBL MECHANICAL ACT 2,808.67

L2010 KAFO SNG SOLID STIRRUP W/O J 921.51

L2020 KAFO DBL SOLID STIRRUP BAND/ 1,163.74

L2030 KAFO DBL SOLID STIRRUP W/O J 1,009.65

L2034 KAFO PLA SIN UP W/WO K/A CUS 1,563.23

L2035 KAFO PLASTIC PEDIATRIC SIZE 135.16

L2036 KAFO PLAS DOUB FREE KNEE MOL 1,658.15

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L2037 KAFO PLAS SING FREE KNEE MOL 1,660.02

L2038 KAFO W/O JOINT MULTI-AXIS AN 1,219.87

L2040 HKAFO TORSION BIL ROT STRAPS 132.71

L2050 HKAFO TORSION CABLE HIP PELV 474.76

L2060 HKAFO TORSION BALL BEARING J 578.64

L2070 HKAFO TORSION UNILAT ROT STR 110.82

L2080 HKAFO UNILAT TORSION CABLE 358.47

L2090 HKAFO UNILAT TORSION BALL BR 437.02

L2106 AFO TIB FX CAST PLASTER MOLD 677.63

L2108 AFO TIB FX CAST MOLDED TO PT 984.82

L2112 AFO TIBIAL FRACTURE SOFT 429.02

L2114 AFO TIB FX SEMI-RIGID 578.49

L2116 AFO TIBIAL FRACTURE RIGID 709.52

L2126 KAFO FEM FX CAST THERMOPLAS 1,024.01

L2128 KAFO FEM FX CAST MOLDED TO P 1,608.50

L2132 KAFO FEMORAL FX CAST SOFT 621.41

L2134 KAFO FEM FX CAST SEMI-RIGID 963.93

L2136 KAFO FEMORAL FX CAST RIGID 1,178.64

L2180 PLAS SHOE INSERT W ANK JOINT 116.71

L2182 DROP LOCK KNEE 79.90

L2184 LIMITED MOTION KNEE JOINT 92.60

L2186 ADJ MOTION KNEE JNT LERMAN T 112.54

L2188 QUADRILATERAL BRIM 223.86

L2190 WAIST BELT 65.28

L2192 PELVIC BAND & BELT THIGH FLA 355.36

L2200 LIMITED ANKLE MOTION EA JNT 47.39

L2210 DORSIFLEXION ASSIST EACH JOI 67.00

L2220 DORSI & PLANTAR FLEX ASS/RES 81.61

L2230 SPLIT FLAT CALIPER STIRR & P 76.47

L2232 ROCKER BOTTOM, CONTACT AFO 87.33

L2240 ROUND CALIPER AND PLATE ATTA 83.34

L2250 FOOT PLATE MOLDED STIRRUP AT 354.14

L2260 REINFORCED SOLID STIRRUP 199.79

L2265 LONG TONGUE STIRRUP 117.37

L2270 VARUS/VALGUS STRAP PADDED/LI 53.52

L2275 PLASTIC MOD LOW EXT PAD/LINE 116.91

L2280 MOLDED INNER BOOT 451.30

L2300 ABDUCTION BAR JOINTED ADJUST 268.34

L2310 ABDUCTION BAR-STRAIGHT 122.61

L2320 NON-MOLDED LACER 205.05

L2330 LACER MOLDED TO PATIENT MODE 391.34

L2335 ANTERIOR SWING BAND 226.41

L2340 PRE-TIBIAL SHELL MOLDED TO P 445.44

L2350 PROSTHETIC TYPE SOCKET MOLDE 888.06

L2360 EXTENDED STEEL SHANK 51.00

47/62


L2370 PATTEN BOTTOM 255.85

L2375 TORSION ANK & HALF SOLID STI 112.62

L2380 TORSION STRAIGHT KNEE JOINT 122.70

L2385 STRAIGHT KNEE JOINT HEAVY DU 133.49

L2387 ADD LE POLY KNEE CUSTOM KAFO 164.94

L2390 OFFSET KNEE JOINT EACH 109.09

L2395 OFFSET KNEE JOINT HEAVY DUTY 142.92

L2397 SUSPENSION SLEEVE LOWER EXT 98.78

L2405 KNEE JOINT DROP LOCK EA JNT 68.02

L2415 KNEE JOINT CAM LOCK EACH JOI 94.76

L2425 KNEE DISC/DIAL LOCK/ADJ FLEX 111.85

L2430 KNEE JNT RATCHET LOCK EA JNT 111.85

L2492 KNEE LIFT LOOP DROP LOCK RIN 88.36

L2500 THI/GLUT/ISCHIA WGT BEARING 314.41

L2510 TH/WGHT BEAR QUAD-LAT BRIM M 723.95

L2520 TH/WGHT BEAR QUAD-LAT BRIM C 459.13

L2525 TH/WGHT BEAR NAR M-L BRIM MO 1,134.10

L2526 TH/WGHT BEAR NAR M-L BRIM CU 633.05

L2530 THIGH/WGHT BEAR LACER NON-MO 234.17

L2540 THIGH/WGHT BEAR LACER MOLDED 421.37

L2550 THIGH/WGHT BEAR HIGH ROLL CU 286.24

L2570 HIP CLEVIS TYPE 2 POSIT JNT 474.71

L2580 PELVIC CONTROL PELVIC SLING 462.55

L2600 HIP CLEVIS/THRUST BEARING FR 204.69

L2610 HIP CLEVIS/THRUST BEARING LO 242.03

L2620 PELVIC CONTROL HIP HEAVY DUT 266.48

L2622 HIP JOINT ADJUSTABLE FLEXION 305.64

L2624 HIP ADJ FLEX EXT ABDUCT CONT 330.03

L2627 PLASTIC MOLD RECIPRO HIP & C 1,281.41

L2628 METAL FRAME RECIPRO HIP & CA 1,252.33

L2630 PELVIC CONTROL BAND & BELT U 246.79

L2640 PELVIC CONTROL BAND & BELT B 334.93

L2650 PELV & THOR CONTROL GLUTEAL 99.95

L2660 THORACIC CONTROL THORACIC BA 185.75

L2670 THORAC CONT PARASPINAL UPRIG 152.44

L2680 THORAC CONT LAT SUPPORT UPRI 141.52

L2750 PLATING CHROME/NICKEL PR BAR 62.48

L2755 CARBON GRAPHITE LAMINATION 101.96

L2760 EXTENSION PER EXTENSION PER 60.55

L2768 ORTHO SIDEBAR DISCONNECT 101.66

L2780 NON-CORROSIVE FINISH 67.44

L2785 DROP LOCK RETAINER EACH 31.59

L2795 KNEE CONTROL FULL KNEECAP 84.68

L2800 KNEE CAP MEDIAL OR LATERAL P 106.31

L2810 KNEE CONTROL CONDYLAR PAD 77.84

48/62


L2820 SOFT INTERFACE BELOW KNEE SE 86.55

L2830 SOFT INTERFACE ABOVE KNEE SE 93.64

L2840 TIBIAL LENGTH SOCK FX OR EQU 32.66

L2850 FEMORAL LGTH SOCK FX OR EQUA 55.95

L2999 LOWER EXTREMITY ORTHOSIS NOS -

L3000 FT INSERT UCB BERKELEY SHELL 245.10

L3001 FOOT INSERT REMOV MOLDED SPE 84.41

L3002 FOOT INSERT PLASTAZOTE OR EQ 126.01

L3003 FOOT INSERT SILICONE GEL EAC 135.96

L3010 FOOT LONGITUDINAL ARCH SUPPO 135.96

L3020 FOOT LONGITUD/METATARSAL SUP 154.82

L3030 FOOT ARCH SUPPORT REMOV PREM 59.55

L3040 FT ARCH SUPRT PREMOLD LONGIT 36.71

L3050 FOOT ARCH SUPP PREMOLD METAT 36.71

L3060 FOOT ARCH SUPP LONGITUD/META 57.56

L3070 ARCH SUPRT ATT TO SHO LONGIT 24.79

L3080 ARCH SUPP ATT TO SHOE METATA 24.79

L3090 ARCH SUPP ATT TO SHOE LONG/M 31.77

L3100 HALLUS-VALGUS NT DYN PRE OTS 33.73

L3140 ABDUCTION ROTATION BAR SHOE 32.77

L3150 ABDUCT ROTATION BAR W/O SHOE 32.77

L3160 SHOE STYLED POSITIONING DEV 11.78

L3170 FOOT PLAS HEEL STABI PRE OTS 39.71

L3201 OXFORD W SUPINAT/PRONAT INF 42.20

L3202 OXFORD W/ SUPINAT/PRONATOR C 42.20

L3203 OXFORD W/ SUPINATOR/PRONATOR 42.20

L3204 HIGHTOP W/ SUPP/PRONATOR INF 42.20

L3206 HIGHTOP W/ SUPP/PRONATOR CHI 42.20

L3207 HIGHTOP W/ SUPP/PRONATOR JUN 42.20

L3208 SURGICAL BOOT EACH INFANT 23.55

L3209 SURGICAL BOOT EACH CHILD 33.36

L3211 SURGICAL BOOT EACH JUNIOR 35.72

L3212 BENESCH BOOT PAIR INFANT 49.85

L3213 BENESCH BOOT PAIR CHILD 60.06

L3214 BENESCH BOOT PAIR JUNIOR 63.98

L3215 ORTHOPEDIC FTWEAR LADIES OXF 47.17

L3216 ORTHOPED LADIES SHOES DPTH I 47.17

L3217 LADIES SHOES HIGHTOP DEPTH I 47.17

L3219 ORTHOPEDIC MENS SHOES OXFORD 62.06

L3221 ORTHOPEDIC MENS SHOES DPTH I 62.06

L3222 MENS SHOES HIGHTOP DEPTH INL 62.06

L3224 WOMAN'S SHOE OXFORD BRACE 47.17

L3225 MAN'S SHOE OXFORD BRACE 67.41

L3230 CUSTOM SHOES DEPTH INLAY 156.31

L3250 CUSTOM MOLD SHOE REMOV PROST 276.72

49/62


L3251 SHOE MOLDED TO PT SILICONE S 38.07

L3252 SHOE MOLDED PLASTAZOTE CUST 151.50

L3253 SHOE MOLDED PLASTAZOTE CUST 38.07

L3254 ORTH FOOT NON-STNDARD SIZE/W -

L3255 ORTH FOOT NON-STANDARD SIZE/ -

L3257 ORTH FOOT ADD CHARGE SPLIT S 27.48

L3260 AMBULATORY SURGICAL BOOT EAC 15.31

L3265 PLASTAZOTE SANDAL EACH 16.88

L3300 SHO LIFT TAPER TO METATARSAL 40.68

L3310 SHOE LIFT ELEV HEEL/SOLE NEO 63.51

L3320 SHOE LIFT ELEV HEEL/SOLE COR 102.45

L3330 LIFTS ELEVATION METAL EXTENS 441.59

L3332 SHOE LIFTS TAPERED TO ONE-HA 57.56

L3334 SHOE LIFTS ELEVATION HEEL /I 29.77

L3340 SHOE WEDGE SACH 66.49

L3350 SHOE HEEL WEDGE 17.87

L3360 SHOE SOLE WEDGE OUTSIDE SOLE 27.78

L3370 SHOE SOLE WEDGE BETWEEN SOLE 38.68

L3380 SHOE CLUBFOOT WEDGE 38.68

L3390 SHOE OUTFLARE WEDGE 38.68

L3400 SHOE METATARSAL BAR WEDGE RO 31.77

L3410 SHOE METATARSAL BAR BETWEEN 72.43

L3420 FULL SOLE/HEEL WEDGE BTWEEN 42.67

L3430 SHO HEEL COUNT PLAST REINFOR 125.04

L3440 HEEL LEATHER REINFORCED 59.55

L3450 SHOE HEEL SACH CUSHION TYPE 82.36

L3455 SHOE HEEL NEW LEATHER STANDA 31.77

L3460 SHOE HEEL NEW RUBBER STANDAR 26.78

L3465 SHOE HEEL THOMAS WITH WEDGE 9.93

L3470 SHOE HEEL THOMAS EXTEND TO B 48.62

L3480 SHOE HEEL PAD & DEPRESS FOR 48.62

L3485 SHOE HEEL PAD REMOVABLE FOR 15.31

L3500 ORTHO SHOE ADD LEATHER INSOL 22.82

L3510 ORTHOPEDIC SHOE ADD RUB INSL 22.82

L3520 O SHOE ADD FELT W LEATH INSL 24.79

L3530 ORTHO SHOE ADD HALF SOLE 24.79

L3540 ORTHO SHOE ADD FULL SOLE 39.71

L3550 O SHOE ADD STANDARD TOE TAP 6.93

L3560 O SHOE ADD HORSESHOE TOE TAP 17.87

L3570 O SHOE ADD INSTEP EXTENSION 66.49

L3580 O SHOE ADD INSTEP VELCRO CLO 50.60

L3590 O SHOE CONVERT TO SOF COUNTE 41.68

L3595 ORTHO SHOE ADD MARCH BAR 32.74

L3600 TRANS SHOE CALIP PLATE EXIST 59.55

L3610 TRANS SHOE CALIPER PLATE NEW 78.39

50/62


L3620 TRANS SHOE SOLID STIRRUP EXI 59.55

L3630 TRANS SHOE SOLID STIRRUP NEW 78.39

L3640 SHOE DENNIS BROWNE SPLINT BO 33.73

L3649 ORTHOPEDIC SHOE MODIFICA NOS -

L3650 SO 8 ABD RESTRAINT PRE OTS 57.84

L3660 SO 8 AB RSTR CAN/WEB PRE OTS 88.99

L3670 SO ACRO/CLAV CAN WEB PRE OTS 110.28

L3671 SO CAP DESIGN W/O JNTS CF 639.86

L3674 SO AIRPLANE W/WO JOINT CF SHOUL 943.12

L3675 SO VEST CANVAS/WEB PRE OTS 124.61

L3677 SO HARD PLAS STABILI PRE CST 67.39

L3702 EO W/O JOINTS CF 205.04

L3710 EO ELAS W/METAL JNTS PRE OTS 101.24

L3720 FOREARM/ARM CUFFS FREE MOTIO 637.90

L3730 FOREARM/ARM CUFFS EXT/FLEX A 879.16

L3740 CUFFS ADJ LOCK W/ ACTIVE CON 1,042.32

L3760 EO WITHJOINT, PREFABRICATED 355.12

L3762 EO RIGID W/O JOINTS PRE OTS 76.35

L3763 EWHO RIGID W/O JNTS CF 910.52

L3764 EWHO W/JOINT(S) CF 964.18

L3765 EWHFO RIGID W/O JNTS CF 910.52

L3766 EWHFO W/JOINT(S) CF 964.18

L3806 WHFO W/JOINT(S) CUSTOM FAB 362.79

L3807 WHFO W/O JOINTS PRE CST 177.56

L3808 WHFO RIGID W/O JOINTS 363.23

L3809 Whfo w/o joints pre ots NU -

L3900 HINGE EXTENSION/FLEX WRIST/F 1,158.78

L3901 HINGE EXT/FLEX WRIST FINGER 1,426.35

L3904 WHFO ELECTRIC CUSTOM FITTED 2,856.03

L3905 WHO W/NONTORSION JNT(S) CF 704.23

L3906 WHO W/O JOINTS CF 385.36

L3908 WHO COCK-UP NONMOLDE PRE OTS 58.44

L3912 HFO FLEXION GLOVE PRE OTS 92.49

L3913 HFO W/O JOINTS CF 192.33

L3915 WHO NONTORSION JNTS PRE CST 424.54

L3916 Who nontorsion jnts pre ots NU 445.26

L3916 Who nontorsion jnts pre ots NU 445.26

L3916 Who nontorsion jnts pre ots 115.14

L3916 Who nontorsion jnts pre ots 115.14

L3917 METACARP FX ORTHOSIS PRE CST 75.01

L3918 Metacarp fx orthosis pre ots NU 88.51

L3918 Metacarp fx orthosis pre ots NU 88.51

L3918 Metacarp fx orthosis pre ots 76.97

L3918 Metacarp fx orthosis pre ots 76.97

L3919 HO W/O JOINTS CF 192.33

51/62


L3921 HFO W/JOINT(S) CF 228.10

L3923 HFO WITHOUT JOINTS PRE CST 27.63

L3924 Hfo without joints pre ots NU 75.05

L3924 Hfo without joints pre ots NU 75.05

L3924 Hfo without joints pre ots 97.42

L3924 Hfo without joints pre ots 97.42

L3925 FO PIP DIP JNT/SPRNG PRE OTS 49.96

L3927 FO PIP DIP NO JT SPR PRE OTS -

L3929 HFO NONTORSION JNTS PRE CST 81.66

L3930 Hfo nontorsion jnts pre ots NU 89.93

L3930 Hfo nontorsion jnts pre ots NU 89.93

L3930 Hfo nontorsion jnts pre ots 53.50

L3930 Hfo nontorsion jnts pre ots 53.50

L3931 WHFO nontorsion joint prefab 182.38

L3933 FO W/O JOINTS CF 151.51

L3935 FO NONTORSION JOINT CF 156.87

L3956 ADD JOINT UPPER EXT ORTHOSIS -

L3960 SEWHO AIRPLAN DESIG ABDU POS 716.76

L3961 SEWHO CAP DESIGN W/O JNTS CF 1,193.06

L3962 SEWHO ERBS PALSEY DESIGN ABD 699.75

L3967 SEWHO AIRPLANE W/O JNTS CF 1,584.28

L3971 SEWHO CAP DESIGN W/JNT(S) CF 1,503.85

L3973 SEWHO AIRPLANE W/JNT(S) CF 1,408.60

L3975 SEWHFO CAP DESIGN W/O JNT CF 1,193.06

L3976 SEWHFO AIRPLANE W/O JNTS CF 1,193.06

L3977 SEWHFO CAP DESGN W/JNT(S) CF 1,337.08

L3978 SEWHFO AIRPLANE W/JNT(S) CF 1,408.60

L3980 UP EXT FX ORTHOS HUMERAL NOS 301.50

L3982 UPPER EXT FX ORTHOSIS RAD/UL 364.08

L3984 UPPER EXT FX ORTHOSIS WRIST 335.68

L3995 SOCK FRACTURE OR EQUAL EACH 27.86

L3999 UPPER LIMB ORTHOSIS NOS -

L4000 REPL GIRDLE MILWAUKEE ORTH 1,270.77

L4002 REPLACE STRAP, ANY ORTHOSIS -

L4010 REPLACE TRILATERAL SOCKET BR 668.87

L4020 REPLACE QUADLAT SOCKET BRIM 858.44

L4030 REPLACE SOCKET BRIM CUST FIT 503.19

L4040 REPLACE MOLDED THIGH LACER 406.83

L4045 REPLACE NON-MOLDED THIGH LAC 326.94

L4050 REPLACE MOLDED CALF LACER 411.46

L4055 REPLACE NON-MOLDED CALF LACE 266.43

L4060 REPLACE HIGH ROLL CUFF 316.74

L4070 REPLACE PROX & DIST UPRIGHT 280.48

L4080 REPL MET BAND KAFO-AFO PROX 86.38

L4090 REPL MET BAND KAFO-AFO CALF/ 82.26

52/62


L4100 REPL LEATH CUFF KAFO PROX TH 103.96

L4110 REPL LEATH CUFF KAFO-AFO CAL 84.51

L4130 REPLACE PRETIBIAL SHELL 494.47

L4205 ORTHO DVC REPAIR PER 15 MIN 7.94

L4210 ORTH DEV REPAIR/REPL MINOR P 7.94

L4350 ANKLE CONTROL ORTHO PRE OTS 89.09

L4360 PNEUMAT WALKING BOOT PRE CST 241.47

L4361 Pneuma/vac walk boot pre ots NU 284.85

L4370 PNEUM FULL LEG SPLNT PRE OTS 141.12

L4386 NON-PNEUM WALK BOOT PRE CST 123.71

L4387 Non-pneum walk boot pre ots NU 145.92

L4392 REPLACE AFO SOFT INTERFACE 18.06

L4394 REPLACE FOOT DROP SPINT 13.16

L4396 STATIC OR DYNAMI AFO PRE CST 128.75

L4397 Static or dynami afo pre ots NU 151.86

L4398 FOOT DROP SPLINT PRE OTS 59.27

L4631 AFO, WALK BOOT TYPE, CUS FAB ANKLE 1,650.02

L5000 SHO INSERT W ARCH TOE FILLER 478.58

L5010 MOLD SOCKET ANK HGT W/ TOE F 1,074.43

L5020 TIBIAL TUBERCLE HGT W/ TOE F 2,104.24

L5050 ANK SYMES MOLD SCKT SACH FT 2,120.41

L5060 SYMES MET FR LEATH SOCKET AR 2,932.72

L5100 MOLDED SOCKET SHIN SACH FOOT 2,140.97

L5105 PLAST SOCKET JTS/THGH LACER 3,688.66

L5150 MOLD SCKT EXT KNEE SHIN SACH 3,728.73

L5160 MOLD SOCKET BENT KNEE SHIN S 4,055.67

L5200 KNE SING AXIS FRIC SHIN SACH 3,195.90

L5210 NO KNEE/ANKLE JOINTS W/ FT B 2,357.99

L5220 NO KNEE JOINT WITH ARTIC ALI 2,928.72

L5230 FEM FOCAL DEFIC CONSTANT FRI 4,039.30

L5250 HIP CANAD SING AXI CONS FRIC 5,509.23

L5270 TILT TABLE LOCKING HIP SING 5,460.97

L5280 HEMIPELVECT CANAD SING AXIS 5,406.36

L5301 BK MOLD SOCKET SACH FT ENDO 2,427.53

L5312 "Knee disart SACH ft endo" 3,610.36

L5321 AK OPEN END SACH 3,489.84

L5331 HIP DISART CANADIAN SACH FT 4,637.72

L5341 HEMIPELVECTOMY CANADIAN SACH 5,366.32

L5400 POSTOP DRESS & 1 CAST CHG BK 1,263.64

L5410 POSTOP DSG BK EA ADD CAST CH 332.73

L5420 POSTOP DSG & 1 CAST CHG AK/D 1,613.96

L5430 POSTOP DSG AK EA ADD CAST CH 449.82

L5450 POSTOP APP NON-WGT BEAR DSG 324.44

L5460 POSTOP APP NON-WGT BEAR DSG 434.24

L5500 INIT BK PTB PLASTER DIRECT 1,358.11

53/62


L5505 INIT AK ISCHAL PLSTR DIRECT 1,846.82

L5510 PREP BK PTB PLASTER MOLDED 1,400.95

L5520 PERP BK PTB THERMOPLS DIRECT 1,525.99

L5530 PREP BK PTB THERMOPLS MOLDED 1,833.99

L5535 PREP BK PTB OPEN END SOCKET 1,800.62

L5540 PREP BK PTB LAMINATED SOCKET 1,920.56

L5560 PREP AK ISCHIAL PLAST MOLDED 1,872.12

L5570 PREP AK ISCHIAL DIRECT FORM 2,052.48

L5580 PREP AK ISCHIAL THERMO MOLD 2,491.18

L5585 PREP AK ISCHIAL OPEN END 2,206.24

L5590 PREP AK ISCHIAL LAMINATED 2,552.52

L5595 HIP DISARTIC SACH THERMOPLS 4,275.36

L5600 HIP DISART SACH LAMINAT MOLD 4,721.28

L5610 ABOVE KNEE HYDRACADENCE 1,951.47

L5611 AK 4 BAR LINK W/FRIC SWING 1,578.19

L5613 AK 4 BAR LING W/HYDRAUL SWIG 2,602.17

L5614 4-BAR LINK ABOVE KNEE W/SWNG 1,319.21

L5616 AK UNIV MULTIPLEX SYS FRICT 1,123.83

L5617 AK/BK SELF-ALIGNING UNIT EA 437.42

L5618 TEST SOCKET SYMES 229.96

L5620 TEST SOCKET BELOW KNEE 232.92

L5622 TEST SOCKET KNEE DISARTICULA 301.89

L5624 TEST SOCKET ABOVE KNEE 331.13

L5626 TEST SOCKET HIP DISARTICULAT 434.99

L5628 TEST SOCKET HEMIPELVECTOMY 384.96

L5629 BELOW KNEE ACRYLIC SOCKET 253.09

L5630 SYME TYP EXPANDABL WALL SCKT 438.77

L5631 AK/KNEE DISARTIC ACRYLIC SOC 349.90

L5632 SYMES TYPE PTB BRIM DESIGN S 188.18

L5634 SYMES TYPE POSTER OPENING SO 322.98

L5636 SYMES TYPE MEDIAL OPENING SO 202.91

L5637 BELOW KNEE TOTAL CONTACT 305.54

L5638 BELOW KNEE LEATHER SOCKET 516.75

L5639 BELOW KNEE WOOD SOCKET 1,190.48

L5640 KNEE DISARTICULAT LEATHER SO 617.86

L5642 ABOVE KNEE LEATHER SOCKET 493.39

L5643 HIP FLEX INNER SOCKET EXT FR 1,239.48

L5644 ABOVE KNEE WOOD SOCKET 470.36

L5645 BK FLEX INNER SOCKET EXT FRA 719.25

L5646 BELOW KNEE CUSHION SOCKET 436.33

L5647 BELOW KNEE SUCTION SOCKET 844.63

L5648 ABOVE KNEE CUSHION SOCKET 524.30

L5649 ISCH CONTAINMT/NARROW M-L SO 1,526.08

L5650 TOT CONTACT AK/KNEE DISART S 518.36

L5651 AK FLEX INNER SOCKET EXT FRA 956.36

54/62


L5652 SUCTION SUSP AK/KNEE DISART 347.19

L5653 KNEE DISART EXPAND WALL SOCK 518.81

L5654 SOCKET INSERT SYMES 324.48

L5655 SOCKET INSERT BELOW KNEE 281.63

L5656 SOCKET INSERT KNEE ARTICULAT 393.88

L5658 SOCKET INSERT ABOVE KNEE 299.77

L5661 MULTI-DUROMETER SYMES 599.00

L5665 MULTI-DUROMETER BELOW KNEE 543.68

L5666 BELOW KNEE CUFF SUSPENSION 74.33

L5668 BK MOLDED DISTAL CUSHION 107.22

L5670 BK MOLDED SUPRACONDYLAR SUSP 288.12

L5671 BK/AK LOCKING MECHANISM 528.15

L5672 BK REMOVABLE MEDIAL BRIM SUS 251.00

L5673 SOCKET INSERT W LOCK MECH 624.07

L5676 BK KNEE JOINTS SINGLE AXIS P 384.77

L5677 BK KNEE JOINTS POLYCENTRIC P 523.53

L5678 BK JOINT COVERS PAIR 42.16

L5679 SOCKET INSERT W/O LOCK MECH 520.00

L5680 BK THIGH LACER NON-MOLDED 253.96

L5681 INTL CUSTM CONG/LATYP INSERT 1,028.34

L5682 BK THIGH LACER GLUT/ISCHIA M 664.05

L5683 INITIAL CUSTOM SOCKET INSERT 1,028.34

L5684 BK FORK STRAP 51.10

L5685 BELOW KNEE SUS/SEAL SLEEVE 100.12

L5686 BK BACK CHECK 49.44

L5688 BK WAIST BELT WEBBING 64.85

L5690 BK WAIST BELT PADDED AND LIN 103.90

L5692 AK PELVIC CONTROL BELT LIGHT 141.09

L5694 AK PELVIC CONTROL BELT PAD/L 192.62

L5695 AK SLEEVE SUSP NEOPRENE/EQUA 173.16

L5696 AK/KNEE DISARTIC PELVIC JOIN 196.46

L5697 AK/KNEE DISARTIC PELVIC BAND 85.24

L5698 AK/KNEE DISARTIC SILESIAN BA 109.25

L5699 SHOULDER HARNESS 197.97

L5700 REPLACE SOCKET BELOW KNEE 2,907.80

L5701 REPLACE SOCKET ABOVE KNEE 3,610.27

L5702 REPLACE SOCKET HIP 4,613.18

L5703 SYMES ANKLE W/O (SACH) FOOT 1,916.99

L5704 CUSTOM SHAPE COVER BK 485.63

L5705 CUSTOM SHAPE COVER AK 797.24

L5706 CUSTOM SHAPE CVR KNEE DISART 790.16

L5707 CUSTOM SHAPE CVR HIP DISART 1,123.26

L5710 KNE-SHIN EXO SNG AXI MNL LOC 381.89

L5711 KNEE-SHIN EXO MNL LOCK ULTRA 554.43

L5712 KNEE-SHIN EXO FRICT SWG & ST 457.52

55/62


L5714 KNEE-SHIN EXO VARIABLE FRICT 397.63

L5716 KNEE-SHIN EXO MECH STANCE PH 773.88

L5718 KNEE-SHIN EXO FRCT SWG & STA 967.27

L5722 KNEE-SHIN PNEUM SWG FRCT EXO 864.08

L5724 KNEE-SHIN EXO FLUID SWING PH 1,535.82

L5726 KNEE-SHIN EXT JNTS FLD SWG E 1,570.62

L5728 KNEE-SHIN FLUID SWG & STANCE 2,526.56

L5780 KNEE-SHIN PNEUM/HYDRA PNEUM 1,215.67

L5781 LOWER LIMB PROS VACUUM PUMP 3,128.03

L5785 EXOSKELETAL BK ULTRALT MATER 437.44

L5790 EXOSKELETAL AK ULTRA-LIGHT M 704.29

L5795 EXOSKEL HIP ULTRA-LIGHT MATE 888.72

L5810 ENDOSKEL KNEE-SHIN MNL LOCK 516.96

L5811 ENDO KNEE-SHIN MNL LCK ULTRA 774.39

L5812 ENDO KNEE-SHIN FRCT SWG & ST 600.23

L5814 ENDO KNEE-SHIN HYDRAL SWG PH 2,903.44

L5816 ENDO KNEE-SHIN POLYC MCH STA 903.00

L5818 ENDO KNEE-SHIN FRCT SWG & ST 1,019.68

L5822 ENDO KNEE-SHIN PNEUM SWG FRC 1,356.11

L5824 ENDO KNEE-SHIN FLUID SWING P 1,628.34

L5826 MINIATURE KNEE JOINT 2,441.43

L5828 ENDO KNEE-SHIN FLUID SWG/STA 2,913.10

L5830 ENDO KNEE-SHIN PNEUM/SWG PHA 2,014.81

L5840 MULTI-AXIAL KNEE/SHIN SYSTEM 3,214.23

L5845 KNEE-SHIN SYS STANCE FLEXION 1,401.23

L5848 KNEE-SHIN SYS HYDRAUL STANCE 840.67

L5850 ENDO AK/HIP KNEE EXTENS ASSI 101.87

L5855 MECH HIP EXTENSION ASSIST 327.92

L5856 ELEC KNEE-SHIN SWING/STANCE 18,767.31

L5857 ELEC KNEE-SHIN SWING ONLY 6,659.36

L5910 ENDO BELOW KNEE ALIGNABLE SY 288.42

L5920 ENDO AK/HIP ALIGNABLE SYSTEM 422.53

L5925 ABOVE KNEE MANUAL LOCK 347.31

L5930 HIGH ACTIVITY KNEE FRAME 2,631.40

L5940 ENDO BK ULTRA-LIGHT MATERIAL 424.55

L5950 ENDO AK ULTRA-LIGHT MATERIAL 619.57

L5960 ENDO HIP ULTRA-LIGHT MATERIA 767.72

L5961 ENDO POLY HIP, PNEU/HYD/ROT ADDIT -

L5962 BELOW KNEE FLEX COVER SYSTEM 624.12

L5964 ABOVE KNEE FLEX COVER SYSTEM 898.47

L5966 HIP FLEXIBLE COVER SYSTEM 1,164.83

L5968 MULTIAXIAL ANKLE W DORSIFLEX 2,840.93

L5970 FOOT EXTERNAL KEEL SACH FOOT 203.47

L5971 SACH FOOT, REPLACEMENT 203.47

L5972 FLEXIBLE KEEL FOOT 374.21

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L5974 FOOT SINGLE AXIS ANKLE/FOOT 247.43

L5975 COMBO ANKLE/FOOT PROSTHESIS 362.43

L5976 ENERGY STORING FOOT 594.64

L5978 FT PROSTH MULTIAXIAL ANKL/FT 309.87

L5979 MULTI-AXIAL ANKLE/FT PROSTH 2,400.41

L5980 FLEX FOOT SYSTEM 3,360.88

L5981 FLEX-WALK SYS LOW EXT PROSTH 2,608.55

L5982 EXOSKELETAL AXIAL ROTATION U 613.84

L5984 ENDOSKELETAL AXIAL ROTATION 604.89

L5985 LWR EXT DYNAMIC PROSTH PYLON 220.76

L5986 MULTI-AXIAL ROTATION UNIT 672.85

L5987 SHANK FT W VERT LOAD PYLON 5,623.93

L5988 VERTICAL SHOCK REDUCING PYLO 1,561.77

L5990 USER ADJUSTABLE HEEL HEIGHT 1,418.31

L5999 LOWR EXTREMITY PROSTHES NOS -

L6000 PART HAND THUMB REM 1,410.81

L6010 PART HAND LITTLE/RING 1,570.00

L6020 PART HAND NO FINGERS 1,463.78

L6050 WRST MLD SCK FLX HNG TRI PAD 2,010.64

L6055 WRST MOLD SOCK W/EXP INTERFA 2,578.55

L6100 ELB MOLD SOCK FLEX HINGE PAD 1,673.21

L6110 ELBOW MOLD SOCK SUSPENSION T 2,166.90

L6120 ELBOW MOLD DOUB SPLT SOC STE 2,460.47

L6130 ELBOW STUMP ACTIVATED LOCK H 2,748.71

L6200 ELBOW MOLD OUTSID LOCK HINGE 2,896.70

L6205 ELBOW MOLDED W/ EXPAND INTER 3,536.00

L6250 ELBOW INTER LOC ELBOW FORARM 2,851.32

L6300 SHLDER DISART INT LOCK ELBOW 3,955.89

L6310 SHOULDER PASSIVE RESTOR COMP 3,222.16

L6320 SHOULDER PASSIVE RESTOR CAP 1,814.56

L6350 THORACIC INTERN LOCK ELBOW 4,127.66

L6360 THORACIC PASSIVE RESTOR COMP 3,382.04

L6370 THORACIC PASSIVE RESTOR CAP 2,156.61

L6380 POSTOP DSG CAST CHG WRST/ELB 1,030.12

L6382 POSTOP DSG CAST CHG ELB DIS/ 1,295.89

L6384 POSTOP DSG CAST CHG SHLDER/T 1,680.40

L6386 POSTOP EA CAST CHG & REALIGN 426.40

L6388 POSTOP APPLICAT RIGID DSG ON 435.34

L6400 BELOW ELBOW PROSTH TISS SHAP 2,463.81

L6450 ELB DISART PROSTH TISS SHAP 3,003.27

L6500 ABOVE ELBOW PROSTH TISS SHAP 2,730.23

L6550 SHLDR DISAR PROSTH TISS SHAP 4,048.93

L6570 SCAP THORAC PROSTH TISS SHAP 4,647.39

L6580 WRIST/ELBOW BOWDEN CABLE MOL 1,423.20

L6582 WRIST/ELBOW BOWDEN CBL DIR F 1,096.02

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L6584 ELBOW FAIR LEAD CABLE MOLDED 1,779.41

L6586 ELBOW FAIR LEAD CABLE DIR FO 1,513.63

L6588 SHDR FAIR LEAD CABLE MOLDED 2,575.12

L6590 SHDR FAIR LEAD CABLE DIRECT 2,262.43

L6600 POLYCENTRIC HINGE PAIR 199.17

L6605 SINGLE PIVOT HINGE PAIR 196.66

L6610 FLEXIBLE METAL HINGE PAIR 176.77

L6615 DISCONNECT LOCKING WRIST UNI 145.90

L6616 DISCONNECT INSERT LOCKING WR 51.66

L6620 FLEXION/EXTENSION WRIST UNIT 304.32

L6621 FLEX/EXT WRIST W/WO FRICTION 1,788.17

L6623 SPRING-ASS ROT WRST W/ LATCH 510.83

L6624 FLEX/EXT/ROTATION WRIST UNIT 3,311.47

L6625 ROTATION WRST W/ CABLE LOCK 564.73

L6628 QUICK DISCONN HOOK ADAPTER O 381.49

L6629 LAMINATION COLLAR W/ COUPLIN 139.45

L6630 STAINLESS STEEL ANY WRIST 171.63

L6632 LATEX SUSPENSION SLEEVE EACH 51.74

L6635 LIFT ASSIST FOR ELBOW 187.01

L6637 NUDGE CONTROL ELBOW LOCK 341.48

L6638 ELEC LOCK ON MANUAL PW ELBOW 1,955.03

L6640 SHOULDER ABDUCTION JOINT PAI 223.07

L6641 EXCURSION AMPLIFIER PULLEY T 159.98

L6642 EXCURSION AMPLIFIER LEVER TY 207.49

L6645 SHOULDER FLEXION-ABDUCTION J 338.96

L6646 MULTIPO LOCKING SHOULDER JNT 2,465.73

L6647 SHOULDER LOCK ACTUATOR 405.93

L6648 EXT PWRD SHLDER LOCK/UNLOCK 2,543.05

L6650 SHOULDER UNIVERSAL JOINT 359.41

L6655 STANDARD CONTROL CABLE EXTRA 79.76

L6660 HEAVY DUTY CONTROL CABLE 97.46

L6665 TEFLON OR EQUAL CABLE LINING 39.49

L6670 HOOK TO HAND CABLE ADAPTER 50.92

L6672 HARNESS CHEST/SHLDER SADDLE 179.04

L6675 HARNESS FIGURE OF 8 SING CON 121.56

L6676 HARNESS FIGURE OF 8 DUAL CON 128.77

L6677 UE TRIPLE CONTROL HARNESS 231.91

L6680 TEST SOCK WRIST DISART/BEL E 246.35

L6682 TEST SOCK ELBW DISART/ABOVE 245.30

L6684 TEST SOCKET SHLDR DISART/THO 370.12

L6686 SUCTION SOCKET 626.85

L6687 FRAME TYP SOCKET BEL ELBOW/W 464.59

L6688 FRAME TYP SOCK ABOVE ELB/DIS 503.29

L6689 FRAME TYP SOCKET SHOULDER DI 573.92

L6690 FRAME TYP SOCK INTERSCAP-THO 664.85

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L6691 REMOVABLE INSERT EACH 365.83

L6692 SILICONE GEL INSERT OR EQUAL 593.79

L6693 LOCKINGELBOW FOREARM CNTRBAL 2,219.48

L6694 ELBOW SOCKET INS USE W/LOCK 624.01

L6695 ELBOW SOCKET INS USE W/O LCK 520.00

L6696 CUS ELBO SKT IN FOR CON/ATYP 1,028.34

L6697 CUS ELBO SKT IN NOT CON/ATYP 1,028.34

L6698 BELOW/ABOVE ELBOW LOCK MECH 528.15

L6703 TERM DEV PASSIVE HAND MITT 298.52

L6704 TERM DEV SPORT/REC/WORK ATT 648.57

L6706 TERM DEV MECH HOOK VOL OPEN 358.46

L6707 TERM DEV MECH HOOK VOL CLOSE 1,368.75

L6708 TERM DEV MECH HAND VOL OPEN 926.35

L6709 TERM DEV MECH HAND VOL CLOSE 1,341.72

L6711 PED TERM DEV, HOOK, VOL OPEN 591.16

L6712 PED TERM DEV, HOOK, VOL CLOS 1,088.43

L6713 PED TERM DEV, HAND, VOL OPEN 1,373.72

L6714 PED TERM DEV, HAND, VOL CLOS 1,163.54

L6715 "Term device multi art digit" -

L6715 "Term device multi art digit" 342.54

L6715 "Term device multi art digit" -

L6715 "Term device multi art digit" 342.54

L6721 HOOK/HAND, HVY DTY, VOL OPEN 2,068.04

L6722 HOOK/HAND, HVY DTY, VOL CLOS 1,782.81

L6805 TERM DEV MODIFIER WRIST UNIT 337.19

L6810 TERM DEV PRECISION PINCH DEV 173.33

L6880 Elec hand ind art digits -

L6880 Elec hand ind art digits 494.41

L6880 Elec hand ind art digits -

L6880 Elec hand ind art digits 494.41

L6881 TERM DEV AUTO GRASP FEATURE 3,196.12

L6882 MICROPROCESSOR CONTROL UPLMB 2,424.40

L6883 REPLC SOCKT BELOW E/W DISA 1,368.94

L6884 REPLC SOCKT ABOVE ELBOW DISA 2,370.50

L6885 REPLC SOCKT SHLDR DIS/INTERC 3,382.04

L6890 PREFAB GLOVE FOR TERM DEVICE 180.60

L6895 CUSTOM GLOVE FOR TERM DEVICE 444.68

L6900 HAND RESTORAT THUMB/1 FINGER 1,597.57

L6905 HAND RESTORATION MULTIPLE FI 1,558.95

L6910 HAND RESTORATION NO FINGERS 1,518.74

L6915 HAND RESTORATION REPLACMNT G 642.99

L6920 WRIST DISARTICUL SWITCH CTRL 5,937.34

L6925 WRIST DISART MYOELECTRONIC C 6,776.18

L6930 BELOW ELBOW SWITCH CONTROL 5,526.16

L6935 BELOW ELBOW MYOELECTRONIC CT 6,418.30

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L6940 ELBOW DISARTICULATION SWITCH 6,994.49

L6945 ELBOW DISART MYOELECTRONIC C 8,128.56

L6950 ABOVE ELBOW SWITCH CONTROL 7,941.71

L6955 ABOVE ELBOW MYOELECTRONIC CT 9,511.28

L6960 SHLDR DISARTIC SWITCH CONTRO 10,176.34

L6965 SHLDR DISARTIC MYOELECTRONIC 11,815.52

L6970 INTERSCAPULAR-THOR SWITCH CT 12,513.54

L6975 INTERSCAP-THOR MYOELECTRONIC 14,796.75

L7040 PREHENSILE ACTUATOR 2,245.06

L7045 PEDIATRIC ELECTRIC HOOK 1,287.18

L7170 ELECTRONIC ELBOW HOSMER SWIT 4,669.43

L7180 ELECTRONIC ELBOW SEQUENTIAL 28,853.49

L7185 ELECTRON ELBOW ADOLESCENT SW 4,767.56

L7186 ELECTRON ELBOW CHILD SWITCH 7,044.19

L7190 ELBOW ADOLESCENT MYOELECTRON 6,244.83

L7191 ELBOW CHILD MYOELECTRONIC CT 7,360.77

L7368 LITHIUM ION BATTERY CHARGER 394.56

L7400 ADD UE PROST BE/WD, ULTLITE 239.60

L7401 ADD UE PROST A/E ULTLITE MAT 268.23

L7402 ADD UE PROST S/D ULTLITE MAT 289.68

L7404 ADD UE PROST A/E ACRYLIC 434.52

L7405 ADD UE PROST S/D ACRYLIC 568.29

L7499 UPPER EXTREMITY PROSTHES NOS -

L7510 PROSTHETIC DEVICE REPAIR REP 7.94

L7520 REPAIR PROSTHESIS PER 15 MIN 7.94

L7600 PROSTHETIC DONNING SLEEVE -

L8000 MASTECTOMY BRA 38.77

L8001 BREAST PROSTHESIS BRA & FORM 98.05

L8002 BRST PRSTH BRA & BILAT FORM 128.97

L8010 MASTECTOMY SLEEVE 34.93

L8015 EXT BREASTPROSTHESIS GARMENT 46.86

L8020 MASTECTOMY FORM 166.47

L8030 BREAST PROSTHES W/O ADHESIVE 304.14

L8031 BREAST PROSTHESIS W ADHESIVE -

L8032 REUSABLE NIPPLE PROSTHESIS -

L8035 CUSTOM BREAST PROSTHESIS 2,864.16

L8039 BREAST PROSTHESIS NOS -

L8300 TRUSS SINGLE W/ STANDARD PAD 89.57

L8310 TRUSS DOUBLE W/ STANDARD PAD 141.41

L8320 TRUSS ADDITION TO STD PAD WA 56.76

L8330 TRUSS ADD TO STD PAD SCROTAL 52.42

L8400 SHEATH BELOW KNEE 16.71

L8410 SHEATH ABOVE KNEE 21.57

L8415 SHEATH UPPER LIMB 19.07

L8417 PROS SHEATH/SOCK W GEL CUSHN 58.79

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L8420 PROSTHETIC SOCK MULTI PLY BK 20.65

L8430 PROSTHETIC SOCK MULTI PLY AK 22.16

L8435 PROS SOCK MULTI PLY UPPER LM 20.57

L8440 SHRINKER BELOW KNEE 44.41

L8460 SHRINKER ABOVE KNEE 70.77

L8465 SHRINKER UPPER LIMB 38.85

L8470 PROS SOCK SINGLE PLY BK 7.09

L8480 PROS SOCK SINGLE PLY AK 8.45

L8485 PROS SOCK SINGLE PLY UPPER L 11.45

L8501 TRACHEOSTOMY SPEAKING VALVE 96.20

L8510 VOICE AMPLIFIER 197.55

L8615 COCH IMPLANT HEADSET REPLACE 367.75

L8616 COCH IMPLANT MICROPHONE REPL 85.66

L8617 COCH IMPLANT TRANS COIL REPL 74.81

L8618 COCH IMPLANT TRAN CABLE REPL 21.38

L8619 COCH IMP EXT PROC/CONTR RPLC 6,743.61

L8621 REPL ZINC AIR BATTERY 0.51

L8622 REPL ALKALINE BATTERY 0.27

L8623 LITH ION BATT CID,NON-EARLVL 50.57

L8624 LITH ION BATT CID, EAR LEVEL 126.07

L8627 CID EXT SPEECH PROCESS REPL 6,442.48

L8628 CID EXT CONTROLLER REPL 1,142.16

L8629 CID TRANSMIT COIL AND CABLE -

L8691 OSSEOINTEGRATED SND PROC RPL 2,086.25

L8692 NON-OSSEOINTEGRATED SND PROC -

L8693 AUD OSSEO DEV, ABUTMENT AUDIT 1,331.93

L9900 O&P SUPPLY/ACCESSORY/SERVICE -

S9349 HIT TOCOLYSIS DIEM 238.32

S9364 HIT TPN TOTAL DIEM 295.91

S9365 HIT TPN 1 LITER DIEM 295.91



S9368 HIT TPN OVER 3L DIEM 322.73

S9435 MEDICAL FOODS FOR INBORN ERR -

T4521 ADULT SIZE BRIEF/DIAPER SM 0.56

T4522 ADULT SIZE BRIEF/DIAPER MED 0.60

T4523 ADULT SIZE BRIEF/DIAPER LG 0.80

T4524 ADULT SIZE BRIEF/DIAPER XL 0.96

T4525 ADULT SIZE PULL-ON SM 0.83

T4526 ADULT SIZE PULL-ON MED 0.83

T4527 ADULT SIZE PULL-ON LG 0.87

T4528 ADULT SIZE PULL-ON XL 1.00

T4529 PED SIZE BRIEF/DIAPER SM/MED 0.43

T4530 PED SIZE BRIEF/DIAPER LG 0.47

T4531 PED SIZE PULL-ON SM/MED 0.54

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T4532 PED SIZE PULL-ON LG 0.54

T4533 YOUTH SIZE BRIEF/DIAPER 0.56

T4534 YOUTH SIZE PULL-ON 0.79

T4535 DISPOSABLE LINER/SHIELD/PAD 0.37

T4536 REUSABLE PULL-ON ANY SIZE -

T4537 REUSABLE UNDERPAD BED SIZE -

T4538 DIAPER SERV REUSABLE DIAPER -

T4539 REUSE DIAPER/BRIEF ANY SIZE -

T4540 REUSABLE UNDERPAD CHAIR SIZE -

T4541 LARGE DISPOSABLE UNDERPAD 0.41

T4542 SMALL DISPOSABLE UNDERPAD 0.41

T4543 ADULT DISP BRIEF/DIAP ABV XL 1.95

V5266 BATTERY FOR HEARING DEVICE 5.96

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