social services blanket code*-hcpcs code billing table...sa878 dme: hospital beds and supplies e0304...

Social Services Blanket Code*-HCPCS code billing table

DSHS

"Blanket

code"

number* DSHS Blanket code name

HCPCS

code Modifier Code short description Modifier description

SA875 DME: Bathroom aids, toileting, and

supplies

E0160 RR Sitz type bath or equipment Rental


supplies

E0160 UE Sitz type bath or equipment Used DME


supplies

E0160 NU Sitz type bath or equipment New Equipment


supplies

E0161 RR Sitz bath/equipment w/faucet Rental


supplies

E0161 UE Sitz bath/equipment w/faucet Used DME


supplies

E0161 NU Sitz bath/equipment w/faucet New Equipment


supplies

E0162 RR Sitz bath chair Rental


supplies

E0162 UE Sitz bath chair Used DME


supplies

E0162 NU Sitz bath chair New Equipment


supplies

E0163 RR Commode chair with fixed arm Rental


supplies

E0167 RR Commode chair pail or pan Rental


supplies

E0167 UE Commode chair electric Used DME


supplies

E0170 RR Commode chair electric Rental


supplies

E0171 RR Commode chair non-electric Rental


supplies

E0172 - Seat lift mechanism toilet N/A


supplies

E0175 - Commode chair foot rest N/A


supplies

E0275 - Bed pan standard N/A


supplies

E0276 - Bed pan fracture N/A

* The blanket code number will appear on the authorization letter you get from DSHS.

1


supplies

E0325 - Urinal male jug-type N/A


supplies

E0326 - Urinal female jug-type N/A


supplies

E1310 RR Whirlpool non-portable Rental


supplies

E1310 UE Whirlpool non-portable Used DME


supplies

E1310 NU Whirlpool non-portable New Equipment

SA876 DME: Communication devices and

supplies

E2500 - SGD digitized pre-rec <=8min N/A


supplies

E2502 - SGD prerec msg >8min

<=20min

N/A


supplies

E2504 - SGD prerec msg>20min

<=40min

N/A


supplies

E2506 - SGD prerec msg > 40 min N/A


supplies

E2508 - SGD spelling phys contact N/A


supplies

E2510 - SGD w multi methods

msg/accs

N/A


supplies

E2511 RR SGD sftwre prgrm for PC/PDA Rental


supplies

E2511 UE SGD sftwre prgrm for PC/PDA Used DME


supplies

E2511 NU SGD sftwre prgrm for PC/PDA New Equipment


supplies

E2512 - SGD accessory, mounting sys N/A


supplies

E2599 - SGD accessory noc N/A

SA877 DME: Diabetic equipment and supplies A4230 - Infus insulin pump non needl N/A

SA877 DME: Diabetic equipment and supplies A4231 - Infusion insulin pump needle N/A

SA877 DME: Diabetic equipment and supplies A4232 - Syringe w/needle insulin 3cc N/A

SA877 DME: Diabetic equipment and supplies A4233 - Alkalin batt for glucose mon N/A

SA877 DME: Diabetic equipment and supplies A4234 - J-cell batt for glucose mon N/A

SA877 DME: Diabetic equipment and supplies A4235 - Lithium batt for glucose mon N/A

SA877 DME: Diabetic equipment and supplies A4236 - Silvr oxide batt glucose mon N/A

SA877 DME: Diabetic equipment and supplies A4245 - Lithium batt for glucose mon N/A

2

SA877 DME: Diabetic equipment and supplies A4253 KX Blood glucose/reagent strips Documentation on file

SA877 DME: Diabetic equipment and supplies A4253 KS Blood glucose/reagent strips Documentation on file

SA877 DME: Diabetic equipment and supplies A4255 - Glucose monitor platforms N/A

SA877 DME: Diabetic equipment and supplies A5500 - Diab shoe for density insert N/A

SA877 DME: Diabetic equipment and supplies A5501 - Diabetic custom molded shoe N/A

SA877 DME: Diabetic equipment and supplies A5503 - Diabetic shoe w/roller/rockr N/A

SA877 DME: Diabetic equipment and supplies A5504 - Diabetic shoe with wedge N/A

SA877 DME: Diabetic equipment and supplies A5505 - Diab shoe w/metatarsal bar N/A

SA877 DME: Diabetic equipment and supplies A5506 - Diabetic shoe w/off set heel N/A

SA877 DME: Diabetic equipment and supplies A5507 - Modification diabetic shoe N/A

SA877 DME: Diabetic equipment and supplies A5508 - Diabetic deluxe shoe N/A

SA877 DME: Diabetic equipment and supplies A5510 - Compression form shoe insert N/A

SA877 DME: Diabetic equipment and supplies A5512 - Multi den insert direct form N/A

SA877 DME: Diabetic equipment and supplies A5513 - Multi den insert custom mold N/A

SA877 DME: Diabetic equipment and supplies E0607 - Blood glucose monitor home N/A

SA877 DME: Diabetic equipment and supplies E2100 - Bld glucose monitor w voice N/A

SA877 DME: Diabetic equipment and supplies E2101 RR Bld glucose monitor w lance Rental

SA877 DME: Diabetic equipment and supplies E2101 UE Bld glucose monitor w lance Used DME

SA877 DME: Diabetic equipment and supplies E2101 NU Bld glucose monitor w lance New equipment

SA877 DME: Diabetic equipment and supplies A4252 - Blood ketone test or strip N/A

SA877 DME: Diabetic equipment and supplies A6531 - Compression stocking BK30-

40

N/A

SA877 DME: Diabetic equipment and supplies A6545 - Grad comp non-elastic BK N/A

SA878 DME: Hospital beds and supplies E0250 RR Hosp bed fixed ht w/ mattres Rental

SA878 DME: Hospital beds and supplies E0251 RR Hosp bed fixd ht w/o mattres Rental

SA878 DME: Hospital beds and supplies E0255 RR Hospital bed var ht w/ mattr Rental

SA878 DME: Hospital beds and supplies E0256 RR Hospital bed var ht w/o matt Rental

SA878 DME: Hospital beds and supplies E0260 RR Hosp bed semi-electr w/ matt Rental

SA878 DME: Hospital beds and supplies E0261 RR Hosp bed semi-electr w/o mat Rental

SA878 DME: Hospital beds and supplies E0265 RR Hosp bed total electr w/ mat Rental

SA878 DME: Hospital beds and supplies E0266 RR Hosp bed total elec w/o matt Rental

SA878 DME: Hospital beds and supplies E0270 - Hospital bed institutional t N/A

3

SA878 DME: Hospital beds and supplies E0271 NU Mattress innerspring New Equipment

SA878 DME: Hospital beds and supplies E0272 - Mattress foam rubber N/A

SA878 DME: Hospital beds and supplies E0277 RR Powered pres-redu air mattrs Rental

SA878 DME: Hospital beds and supplies E0277 NU Powered pres-redu air mattrs New Equipment

SA878 DME: Hospital beds and supplies E0280 RR Bed cradle Rental

SA878 DME: Hospital beds and supplies E0280 UE Bed cradle Used DME

SA878 DME: Hospital beds and supplies E0280 NU Bed cradle New Equipment

SA878 DME: Hospital beds and supplies E0290 RR Hosp bed fx ht w/o rails w/m Rental

SA878 DME: Hospital beds and supplies E0291 RR Hosp bed fx ht w/o rail w/o Rental

SA878 DME: Hospital beds and supplies E0292 RR Hosp bed var ht w/o rail w/o Rental

SA878 DME: Hospital beds and supplies E0292 NU Hosp bed var ht w/o rail w/o New equipment

SA878 DME: Hospital beds and supplies E0293 RR Hosp bed var ht w/o rail w/ Rental

SA878 DME: Hospital beds and supplies E0293 NU Hosp bed var ht w/o rail w/ New equipment

SA878 DME: Hospital beds and supplies E0294 RR Hosp bed semi-elect w/ mattr Rental

SA878 DME: Hospital beds and supplies E0294 NU Hosp bed semi-elect w/ mattr New equipment

SA878 DME: Hospital beds and supplies E0295 RR Hosp bed semi-elect w/o matt Rental

SA878 DME: Hospital beds and supplies E0295 NU Hosp bed semi-elect w/o matt New equipment

SA878 DME: Hospital beds and supplies E0296 RR Hosp bed total elect w/ matt Rental

SA878 DME: Hospital beds and supplies E0296 NU Hosp bed total elect w/ matt New equipment

SA878 DME: Hospital beds and supplies E0297 RR Hosp bed total elect w/o mat Rental

SA878 DME: Hospital beds and supplies E0297 NU Hosp bed total elect w/o mat New equipment

SA878 DME: Hospital beds and supplies E0300 RR Enclosed ped crib hosp grade Rental

SA878 DME: Hospital beds and supplies E0300 NU Enclosed ped crib hosp grade New equipment

SA878 DME: Hospital beds and supplies E0301 RR HD hosp bed, 350-600 lbs Rental

SA878 DME: Hospital beds and supplies E0302 RR Ex hd hosp bed > 600 lbs Rental

SA878 DME: Hospital beds and supplies E0303 RR Hosp bed hvy dty xtra wide Rental

SA878 DME: Hospital beds and supplies E0303 NU Hosp bed hvy dty xtra wide New equipment

SA878 DME: Hospital beds and supplies E0304 RR Hosp bed xtra hvy dty x wide Rental

SA878 DME: Hospital beds and supplies E0304 NU Hosp bed xtra hvy dty x wide New equipment

SA878 DME: Hospital beds and supplies E0305 RR Rails bed side half length Rental

SA878 DME: Hospital beds and supplies E0305 NU Rails bed side half length New equipment

SA878 DME: Hospital beds and supplies E0310 RR Rails bed side full length Rental

4

SA878 DME: Hospital beds and supplies E0310 NU Rails bed side full length New Equipment

SA878 DME: Hospital beds and supplies E0316 - Bed safety enclosure N/A

SA878 DME: Hospital beds and supplies E0328 - Ped hospital bed, manual N/A

SA878 DME: Hospital beds and supplies E0329 - Ped hospital bed semi/elect N/A

SA878 DME: Hospital beds and supplies E0350 - Control unit bowel system N/A

SA878 DME: Hospital beds and supplies E0352 - Disposable pack w/bowel syst N/A

SA878 DME: Hospital beds and supplies E0371 RR Nonpower mattress overlay Rental

SA878 DME: Hospital beds and supplies E0371 NU Nonpower mattress overlay New Equipment

SA878 DME: Hospital beds and supplies E0372 RR Powered air mattress overlay Rental

SA878 DME: Hospital beds and supplies E0372 NU Powered air mattress overlay New Equipment

SA878 DME: Hospital beds and supplies E0373 RR Nonpowered pressure

mattress

Rental

SA878 DME: Hospital beds and supplies E0373 NU Nonpowered pressure

mattress

New Equipment

SA879 DME: Miscellaneous A4206 - 1 CC sterile syringe&needle N/A



SA879 DME: Miscellaneous A4209 - 5+ CC sterile syringe&needle N/A

SA879 DME: Miscellaneous A4210 - Nonneedle injection device N/A

SA879 DME: Miscellaneous A4211 - Supp for self-adm injections N/A

SA879 DME: Miscellaneous A4215 - Sterile needle N/A

SA879 DME: Miscellaneous A4216 - Sterile water/saline, 10 ml N/A

SA879 DME: Miscellaneous A4217 - Sterile water/saline, 500 ml N/A

SA879 DME: Miscellaneous A4220 - Infusion pump refill kit N/A

SA879 DME: Miscellaneous A4221 - Maint drug infus cath per wk N/A

SA879 DME: Miscellaneous A4222 - Infusion supplies with pump N/A

SA879 DME: Miscellaneous A4223 - Infusion supplies w/o pump N/A

SA879 DME: Miscellaneous A4244 - Alcohol or peroxide per pint N/A

SA879 DME: Miscellaneous A4247 - Betadine/iodine swabs/wipes N/A

SA879 DME: Miscellaneous A4248 - Chlorhexidine antisept N/A

SA879 DME: Miscellaneous A4250 - Urine reagent strips/tablets N/A

SA879 DME: Miscellaneous A4256 - Calibrator solution/chips N/A

SA879 DME: Miscellaneous A4258 - Lancet device each N/A

5

SA879 DME: Miscellaneous A4259 KX Lancets per box Documentation on File

SA879 DME: Miscellaneous A4259 KS Lancets per box Documentation on File

SA879 DME: Miscellaneous A4280 - Brst prsths adhsv attchmnt N/A

SA879 DME: Miscellaneous A4435 - 1pc ost pch drain hgh output N/A

SA879 DME: Miscellaneous A4458 - Reusable enema bag N/A

SA879 DME: Miscellaneous A4461 - Surgicl dress hold non-reuse N/A

SA879 DME: Miscellaneous A4463 - Surgical dress holder reuse N/A

SA879 DME: Miscellaneous A4465 - Non-elastic extremity binder N/A

SA879 DME: Miscellaneous A4466 - Elastic garment/covering N/A

SA879 DME: Miscellaneous A4490 - Above knee surgical stocking N/A

SA879 DME: Miscellaneous A4520 - Incontinence garment anytype N/A

SA879 DME: Miscellaneous A4554 - Disposable underpads N/A

SA879 DME: Miscellaneous A4556 NU Electrodes, pair New Equipment

SA879 DME: Miscellaneous A4561 - Pessary rubber, any type N/A

SA879 DME: Miscellaneous A4562 - Pessary, non rubber,any type N/A

SA879 DME: Miscellaneous A4565 - Slings N/A

SA879 DME: Miscellaneous A4566 - Should sling/vest/abrestrain N/A

SA879 DME: Miscellaneous A4570 - Splint N/A

SA879 DME: Miscellaneous A4605 NU Trach suction cath close sys New Equipment

SA879 DME: Miscellaneous A4606 NU Oxygen probe used w

oximeter

New Equipment

SA879 DME: Miscellaneous A4640 RA Alternating pressure pad Replacement of a

DME Item

SA879 DME: Miscellaneous A4649 - Surgical supplies N/A

SA879 DME: Miscellaneous A4927 - Non-sterile gloves N/A

SA879 DME: Miscellaneous A4930 - Sterile, gloves per pair N/A

SA879 DME: Miscellaneous E0181 RR Press pad alternating w/ pum Rental

SA879 DME: Miscellaneous E0181 NU Press pad alternating w/ pum New Equipment

SA879 DME: Miscellaneous E0182 - Replace pump, alt press pad N/A

SA879 DME: Miscellaneous E0184 - Dry pressure mattress N/A

6

SA879 DME: Miscellaneous E0185 RR Gel pressure mattress pad Rental

SA879 DME: Miscellaneous E0185 NU Gel pressure mattress pad New Equipment

SA879 DME: Miscellaneous E0186 RR Air pressure mattress Rental

SA879 DME: Miscellaneous E0186 NU Air pressure mattress New Equipment

SA879 DME: Miscellaneous E0188 - Synthetic sheepskin pad N/A

SA879 DME: Miscellaneous E0189 - Lambswool sheepskin pad N/A

SA879 DME: Miscellaneous E0190 - Positioning cushion N/A

SA879 DME: Miscellaneous E0191 - Protector heel or elbow N/A

SA879 DME: Miscellaneous E0193 RR Powered air flotation bed Rental

SA879 DME: Miscellaneous E0194 RR Air fluidized bed Rental

SA879 DME: Miscellaneous E0194 NU Air fluidized bed New Equipment

SA879 DME: Miscellaneous E0196 - Gel pressure mattress N/A

SA879 DME: Miscellaneous E0197 RR Air pressure pad for mattres Rental

SA879 DME: Miscellaneous E0197 NU Air pressure pad for mattres New Equipment

SA879 DME: Miscellaneous E0198 - Water pressure pad for mattr N/A

SA879 DME: Miscellaneous E0199 - Dry pressure pad for mattres N/A

SA879 DME: Miscellaneous E0225 RR Hydrocollator unit Rental

SA879 DME: Miscellaneous E0225 UE Hydrocollator unit Used DME

SA879 DME: Miscellaneous E0225 NU Hydrocollator unit New Equipment

SA879 DME: Miscellaneous E0230 - Ice cap or collar N/A

SA879 DME: Miscellaneous E0232 - Warming card for NWT N/A

SA879 DME: Miscellaneous E0235 RR Paraffin bath unit portable Rental

SA879 DME: Miscellaneous E0236 RR Pump for water circulating p Rental

SA879 DME: Miscellaneous E0236 UE Pump for water circulating p Used DME

SA879 DME: Miscellaneous E0236 NU Pump for water circulating p New Equipment

SA879 DME: Miscellaneous E0239 RR Hydrocollator unit portable Rental

SA879 DME: Miscellaneous E0239 UE Hydrocollator unit portable Used DME

SA879 DME: Miscellaneous E0239 NU Hydrocollator unit portable New Equipment

SA879 DME: Miscellaneous E0600 RR Suction pump portab hom

modl

Rental

SA879 DME: Miscellaneous E0600 TW Suction pump portab hom

modl

Rental (DME)/Back-up

Equipment

SA879 DME: Miscellaneous E0601 RR Cont airway pressure device Rental

SA879 DME: Miscellaneous E0601 NU Cont airway pressure device New Equipment

7

SA879 DME: Miscellaneous E0601 RA Cont airway pressure device Replacement of a

DME Item

SA879 DME: Miscellaneous E0618 RR Apnea monitor Rental

SA879 DME: Miscellaneous E0619 RR Apnea monitor w recorder Rental

SA879 DME: Miscellaneous E0621 - Patient lift sling or seat N/A

SA879 DME: Miscellaneous E0627 RR Seat lift incorp lift-chair Rental

SA879 DME: Miscellaneous E0627 UE Seat lift incorp lift-chair Used DME

SA879 DME: Miscellaneous E0627 NU Seat lift incorp lift-chair New Equipment

SA879 DME: Miscellaneous E0628 RR Seat lift for pt furn-electr Rental

SA879 DME: Miscellaneous E0628 UE Seat lift for pt furn-electr Used DME

SA879 DME: Miscellaneous E0628 NU Seat lift for pt furn-electr New Equipment

SA879 DME: Miscellaneous E0629 RR Seat lift for pt furn-non-el Rental

SA879 DME: Miscellaneous E0629 UE Seat lift for pt furn-non-el Used DME

SA879 DME: Miscellaneous E0629 NU Seat lift for pt furn-non-el New Equipment

SA879 DME: Miscellaneous E0630 RR Patient lift hydraulic Rental

SA879 DME: Miscellaneous E0630 NU Patient lift hydraulic New Equipment

SA879 DME: Miscellaneous E0635 RR Patient lift electric Rental

SA879 DME: Miscellaneous E0635 NU Patient lift electric New Equipment

SA879 DME: Miscellaneous E0636 RR PT support & positioning sys Rental

SA879 DME: Miscellaneous E0637 RR Combination sit to stand sys Rental

SA879 DME: Miscellaneous E0637 NU Combination sit to stand sys New Equipment

SA879 DME: Miscellaneous E0638 NU Standing frame system, one

position (e.g. upright, supine

or prone stander), any size

including pediatric, with or

without wheels

New Equipment

SA879 DME: Miscellaneous E0639 - Moveable patient lift system N/A

SA879 DME: Miscellaneous E0640 - Fixed patient lift system N/A

SA879 DME: Miscellaneous E0641 - Multi-position stnd fram sys N/A

SA879 DME: Miscellaneous E0642 - Dynamic standing frame N/A

SA879 DME: Miscellaneous E0650 RR Pneuma compresor non-

segment

Rental

SA879 DME: Miscellaneous E0650 NU Pneuma compresor non-

segment

New Equipment

8

SA879 DME: Miscellaneous E0651 RR Pneum compressor

segmental

Rental

SA879 DME: Miscellaneous E0651 UE Pneum compressor

segmental

Used DME

SA879 DME: Miscellaneous E0651 NU Pneum compressor

segmental

New Equipment

SA879 DME: Miscellaneous E0652 RR Pneum compres w/cal

pressure

Rental

SA879 DME: Miscellaneous E0652 UE Pneum compres w/cal

pressure

Used DME

SA879 DME: Miscellaneous E0652 NU Pneum compres w/cal

pressure

New Equipment

SA879 DME: Miscellaneous E0655 - Pneumatic appliance half arm N/A

SA879 DME: Miscellaneous E0656 RR Segmental pneumatic trunk Rental

SA879 DME: Miscellaneous E0656 UE Segmental pneumatic trunk Used DME

SA879 DME: Miscellaneous E0656 NU Segmental pneumatic trunk New Equipment

SA879 DME: Miscellaneous E0657 RR Segmental pneumatic chest Rental

SA879 DME: Miscellaneous E0657 UE Segmental pneumatic chest Used DME

SA879 DME: Miscellaneous E0657 NU Segmental pneumatic chest New Equipment

SA879 DME: Miscellaneous E0660 - Pneumatic appliance full leg N/A

SA879 DME: Miscellaneous E0665 - Pneumatic appliance full arm N/A

SA879 DME: Miscellaneous E0666 - Pneumatic appliance half leg N/A

SA879 DME: Miscellaneous E0667 RR Seg pneumatic appl full leg Rental

SA879 DME: Miscellaneous E0667 UE Seg pneumatic appl full leg Used DME

SA879 DME: Miscellaneous E0667 NU Seg pneumatic appl full leg New Equipment

SA879 DME: Miscellaneous E0668 RR Seg pneumatic appl full arm Rental

SA879 DME: Miscellaneous E0668 UE Seg pneumatic appl full arm Used DME

SA879 DME: Miscellaneous E0668 NU Seg pneumatic appl full arm New Equipment

SA879 DME: Miscellaneous E0669 RR Seg pneumatic appli half leg Rental

SA879 DME: Miscellaneous E0669 UE Seg pneumatic appli half leg Used DME

SA879 DME: Miscellaneous E0669 NU Seg pneumatic appli half leg New Equipment

SA879 DME: Miscellaneous E0671 RR Pressure pneum appl full leg Rental

SA879 DME: Miscellaneous E0671 UE Pressure pneum appl full leg Used DME

SA879 DME: Miscellaneous E0671 NU Pressure pneum appl full leg New Equipment

SA879 DME: Miscellaneous E0672 RR Pressure pneum appl full arm Rental

SA879 DME: Miscellaneous E0672 UE Pressure pneum appl full arm Used DME

9

SA879 DME: Miscellaneous E0672 NU Pressure pneum appl full arm New Equipment

SA879 DME: Miscellaneous E0673 RR Pressure pneum appl half leg Rental

SA879 DME: Miscellaneous E0673 UE Pressure pneum appl half leg Used DME

SA879 DME: Miscellaneous E0673 NU Pressure pneum appl half leg New Equipment

SA879 DME: Miscellaneous E0675 RR Pneumatic compression

device

Rental

SA879 DME: Miscellaneous E0691 RR Uvl pnl 2 sq ft or less Rental

SA879 DME: Miscellaneous E0691 UE Uvl pnl 2 sq ft or less Used DME

SA879 DME: Miscellaneous E0691 NU Uvl pnl 2 sq ft or less New Equipment

SA879 DME: Miscellaneous E0692 RR Uvl sys panel 4 ft Rental

SA879 DME: Miscellaneous E0692 UE Uvl sys panel 4 ft Used DME

SA879 DME: Miscellaneous E0692 NU Uvl sys panel 4 ft New Equipment

SA879 DME: Miscellaneous E0693 RR Uvl sys panel 6 ft Rental

SA879 DME: Miscellaneous E0693 UE Uvl sys panel 6 ft Used DME

SA879 DME: Miscellaneous E0693 NU Uvl sys panel 6 ft New Equipment

SA879 DME: Miscellaneous E0694 RR Uvl md cabinet sys 6 ft Rental

SA879 DME: Miscellaneous E0694 UE Uvl md cabinet sys 6 ft Used DME

SA879 DME: Miscellaneous E0694 NU Uvl md cabinet sys 6 ft New Equipment

SA879 DME: Miscellaneous E0700 - Safety equipment N/A

SA879 DME: Miscellaneous E0705 - Transfer device N/A

SA879 DME: Miscellaneous E0720 NU Tens two lead New Equipment

SA879 DME: Miscellaneous E0731 NU Conductive garment for tens/ New Equipment

SA879 DME: Miscellaneous E0740 NU Incontinence treatment systm New Equipment

SA879 DME: Miscellaneous E0740 RR Incontinence treatment systm Rental

SA879 DME: Miscellaneous E0744 RR Neuromuscular stim for scoli Rental

SA879 DME: Miscellaneous E0747 - Elec osteogen stim not spine N/A

SA879 DME: Miscellaneous E0748 - Elec osteogen stim spinal N/A

SA879 DME: Miscellaneous E0749 RR Elec osteogen stim implanted Rental

SA879 DME: Miscellaneous E0760 - Osteogen ultrasound stimltor N/A

SA879 DME: Miscellaneous E0762 RR Trans elec jt stim dev sys Rental

SA879 DME: Miscellaneous E0762 UE Trans elec jt stim dev sys Used DME

SA879 DME: Miscellaneous E0762 NU Trans elec jt stim dev sys New Equipment

SA879 DME: Miscellaneous E0765 RR Nerve stimulator for tx n&v Rental

SA879 DME: Miscellaneous E0765 UE Nerve stimulator for tx n&v Used DME

SA879 DME: Miscellaneous E0765 NU Nerve stimulator for tx n&v New Equipment

10

SA879 DME: Miscellaneous E0776 NU Iv pole New Equipment

SA879 DME: Miscellaneous E0776 RR Iv pole Rental

SA879 DME: Miscellaneous E0779 RR Amb infusion pump

mechanical

Rental

SA879 DME: Miscellaneous E0779 NU Amb infusion pump

mechanical

New Equipment

SA879 DME: Miscellaneous E0780 NU Mech amb infusion pump

<8hrs

New Equipment

SA879 DME: Miscellaneous E0781 RR External ambulatory infus pu Rental

SA879 DME: Miscellaneous E0781 NU External ambulatory infus pu New Equipment

SA879 DME: Miscellaneous E0784 RR Ext amb infusn pump insulin Rental

SA879 DME: Miscellaneous E0791 NU Parenteral infusion pump sta New Equipment

SA879 DME: Miscellaneous E0791 RR Parenteral infusion pump sta Rental

SA879 DME: Miscellaneous E0830 - Ambulatory traction device N/A

SA879 DME: Miscellaneous E0840 - Tract frame attach headboard N/A

SA879 DME: Miscellaneous E0849 RR Cervical pneum trac equip Rental

SA879 DME: Miscellaneous E0849 UE Cervical pneum trac equip Used DME

SA879 DME: Miscellaneous E0849 NU Cervical pneum trac equip New Equipment

SA879 DME: Miscellaneous E0850 - Traction stand free standing N/A

SA879 DME: Miscellaneous E0855 RR Cervical traction equipment Rental

SA879 DME: Miscellaneous E0855 UE Cervical traction equipment Used DME

SA879 DME: Miscellaneous E0855 NU Cervical traction equipment New Equipment

SA879 DME: Miscellaneous E0856 RR Cervic collar w air bladder Rental

SA879 DME: Miscellaneous E0856 UE Cervic collar w air bladder Used DME

SA879 DME: Miscellaneous E0856 NU Cervic collar w air bladder New Equipment

SA879 DME: Miscellaneous E0860 - Tract equip cervical tract N/A

SA879 DME: Miscellaneous E0870 - Tract frame attach footboard N/A

SA879 DME: Miscellaneous E0880 - Trac stand free stand extrem N/A

SA879 DME: Miscellaneous E0890 - Traction frame attach pelvic N/A

SA879 DME: Miscellaneous E0900 - Trac stand free stand pelvic N/A

SA879 DME: Miscellaneous E0910 RR Trapeze bar attached to bed Rental

SA879 DME: Miscellaneous E0910 NU Trapeze bar attached to bed New Equipment

SA879 DME: Miscellaneous E0911 RR HD trapeze bar attach to bed Rental

SA879 DME: Miscellaneous E0911 NU HD trapeze bar attach to bed New Equipment

SA879 DME: Miscellaneous E0912 RR HD trapeze bar free standing Rental

11

SA879 DME: Miscellaneous E0912 NU HD trapeze bar free standing New Equipment

SA879 DME: Miscellaneous E0920 RR Fracture frame attached to b Rental

SA879 DME: Miscellaneous E0920 NU Fracture frame attached to b New Equipment

SA879 DME: Miscellaneous E0930 RR Fracture frame free standing Rental

SA879 DME: Miscellaneous E0930 NU Fracture frame free standing New Equipment

SA879 DME: Miscellaneous E0935 RR Cont pas motion exercise dev Rental

SA879 DME: Miscellaneous E0936 RR CPM device, other than knee Rental

SA879 DME: Miscellaneous E0940 RR Trapeze bar free standing Rental

SA879 DME: Miscellaneous E0940 NU Trapeze bar free standing New Equipment

SA879 DME: Miscellaneous E0941 RR Gravity assisted traction de Rental

SA879 DME: Miscellaneous E0941 NU Gravity assisted traction de New Equipment

SA879 DME: Miscellaneous E0942 - Cervical head harness/halter N/A

SA879 DME: Miscellaneous E0944 - Pelvic belt/harness/boot N/A

SA879 DME: Miscellaneous E0945 - Belt/harness extremity N/A

SA879 DME: Miscellaneous E0946 RR Fracture frame dual w cross Rental

SA879 DME: Miscellaneous E0946 NU Fracture frame dual w cross New Equipment

SA879 DME: Miscellaneous E0947 - Fracture frame attachmnts pe N/A

SA879 DME: Miscellaneous E0948 - Fracture frame attachmnts ce N/A

SA879 DME: Miscellaneous E1031 NU Rollabout chair with casters New Equipment

SA879 DME: Miscellaneous E1037 RR Transport chair, ped size Rental

SA879 DME: Miscellaneous E1038 RR Transport chair pt wt<=300lb Rental

SA879 DME: Miscellaneous E1039 RR Transport chair pt wt >300lb Rental

SA879 DME: Miscellaneous E1399 - Durable medical equipment

miscellaneous

N/A

SA879 DME: Miscellaneous E1399 RR Durable medical equipment

miscellaneous

Rental

SA879 DME: Miscellaneous E1399 NU Durable medical equipment

miscellaneous

New Equipment

SA879 DME: Miscellaneous E2000 RR Gastric suction pump hme mdl Rental

SA879 DME: Miscellaneous E2402 RR Neg press wound therapy

pump

Rental

SA879 DME: Miscellaneous S1040 - Cranial remolding orthosis N/A

SA879 DME: Miscellaneous S8431 - Compression bandage, roll N/A

12

SA879 DME: Miscellaneous T5001 RR Positioning seat for persons

with special orthopedic needs

Rental

SA879 DME: Miscellaneous T5001 NU Positioning seat for persons

with special orthopedic needs

New Equipment

SA879 DME: Miscellaneous A4246 - Betadine/phisohex solution N/A

SA879 DME: Nutrition equipment and supplies A9276 - Disposable sensor, CGM sys N/A

SA879 DME: Nutrition equipment and supplies A9277 - External transmitter, CGM N/A

SA879 DME: Nutrition equipment and supplies A9278 - External receiver, CGM sys N/A

SA879 DME: Miscellaneous A4213 - 20+ CC syringe only N/A

SA879 DME: Miscellaneous A4265 - Paraffin N/A

SA879 DME: Miscellaneous A4281 - Replacement breastpump

tube

N/A

SA879 DME: Miscellaneous A4282 - Replacement breastpump

adpt

N/A

SA879 DME: Miscellaneous A4283 - Replacement breastpump cap N/A

SA879 DME: Miscellaneous A4284 - Replcmnt breast pump shield N/A

SA879 DME: Miscellaneous A4285 - Replcmnt breast pump bottle N/A

SA879 DME: Miscellaneous A4286 - Replcmnt breastpump lok ring N/A

SA879 DME: Miscellaneous A4290 - Sacral nerve stim test lead N/A

SA879 DME: Miscellaneous A4495 - Thigh length surg stocking N/A

SA879 DME: Miscellaneous A4500 - Below knee surgical stocking N/A

SA879 DME: Miscellaneous A4510 - Full length surg stocking N/A

SA879 DME: Miscellaneous A4559 - Coupling gel or paste N/A

SA879 DME: Miscellaneous A4595 - TENS suppl 2 lead per month N/A

SA879 DME: Miscellaneous A4600 - Sleeve, inter limb comp dev N/A

SA879 DME: Miscellaneous A4630 - Repl bat t.e.n.s. own by pt N/A

SA879 DME: Miscellaneous A4633 - Uvl replacement bulb N/A

SA879 DME: Miscellaneous A4634 - Replacement bulb th lightbox N/A

SA879 DME: Miscellaneous A4639 - Infrared ht sys replcmnt pad N/A

SA879 DME: Miscellaneous A4928 - Surgical mask N/A

SA879 DME: Miscellaneous A4931 - Reusable oral thermometer N/A

SA879 DME: Miscellaneous A4932 - Reusable rectal thermometer N/A

SA879 DME: Miscellaneous A6530 - Compression stocking BK18-

30

N/A

SA879 DME: Miscellaneous A6532 - Compression stocking BK40-

50

N/A

13

SA879 DME: Miscellaneous A6533 - Gc stocking thighlngth 18-30 N/A



SA879 DME: Miscellaneous A6536 - Gc stocking full lngth 18-30 N/A



SA879 DME: Miscellaneous A6539 - Gc stocking waistlngth 18-30 N/A



SA879 DME: Miscellaneous A6544 - Gc stocking garter belt N/A

SA879 DME: Miscellaneous A9180 - Lice treatment, topical N/A

SA879 DME: Miscellaneous T5999 - Supply, nos N/A

SA879 DME: Miscellaneous A4556 - Electrodes, pair N/A

SA879 DME: Miscellaneous A4557 - Lead wires, pair N/A

SA879 DME: Miscellaneous A4558 - Conductive gel or paste N/A

SA880 DME: Mobility aids and supplies A4635 - Underarm crutch pad N/A

SA880 DME: Mobility aids and supplies A4636 - Handgrip for cane etc N/A

SA880 DME: Mobility aids and supplies A4637 - Repl tip cane/crutch/walker N/A

SA880 DME: Mobility aids and supplies E0100 - Cane adjust/fixed with tip N/A

SA880 DME: Mobility aids and supplies E0105 - Cane adjust/fixed quad/3 pro N/A

SA880 DME: Mobility aids and supplies E0110 - Crutch forearm pair N/A

SA880 DME: Mobility aids and supplies E0111 - Crutch forearm each N/A

SA880 DME: Mobility aids and supplies E0112 - Crutch underarm pair wood N/A

SA880 DME: Mobility aids and supplies E0113 - Crutch underarm each wood N/A

SA880 DME: Mobility aids and supplies E0114 - Crutch underarm pair no wood N/A

SA880 DME: Mobility aids and supplies E0116 - Crutch underarm each no

wood

N/A

SA880 DME: Mobility aids and supplies E0117 - Underarm springassist crutch N/A

SA880 DME: Mobility aids and supplies E0118 - Crutch substitute N/A

SA880 DME: Mobility aids and supplies E0130 - Walker rigid adjust/fixed ht N/A

SA880 DME: Mobility aids and supplies E0135 - Walker folding adjust/fixed N/A

SA880 DME: Mobility aids and supplies E0140 - Walker w trunk support N/A

SA880 DME: Mobility aids and supplies E0141 - Rigid wheeled walker adj/fix N/A

14

SA880 DME: Mobility aids and supplies E0143 - Walker folding wheeled w/o s N/A

SA880 DME: Mobility aids and supplies E0144 - Enclosed walker w rear seat N/A

SA880 DME: Mobility aids and supplies E0147 - Walker variable wheel resist N/A

SA880 DME: Mobility aids and supplies E0148 - Heavyduty walker no wheels N/A

SA880 DME: Mobility aids and supplies E0149 - Heavy duty wheeled walker N/A

SA880 DME: Mobility aids and supplies E0153 - Forearm crutch platform atta N/A

SA880 DME: Mobility aids and supplies E0154 - Walker platform attachment N/A

SA880 DME: Mobility aids and supplies E0155 - Walker wheel attachment,pair N/A

SA880 DME: Mobility aids and supplies E0156 - Walker seat attachment N/A

SA880 DME: Mobility aids and supplies E0157 - Walker crutch attachment N/A

SA880 DME: Mobility aids and supplies E0158 - Walker leg extenders set of4 N/A

SA880 DME: Mobility aids and supplies E0159 - Brake for wheeled walker N/A

SA880 DME: Mobility aids and supplies E1800 RR Adjust elbow ext/flex device Rental

SA880 DME: Mobility aids and supplies E1801 RR SPS elbow device Rental

SA880 DME: Mobility aids and supplies E1802 RR Adjst forearm pro/sup device Rental

SA880 DME: Mobility aids and supplies E1805 RR Adjust wrist ext/flex device Rental

SA880 DME: Mobility aids and supplies E1806 RR SPS wrist device Rental

SA880 DME: Mobility aids and supplies E1810 RR Adjust knee ext/flex device Rental

SA880 DME: Mobility aids and supplies E1811 RR SPS knee device Rental

SA880 DME: Mobility aids and supplies E1815 RR Adjust ankle ext/flex device Rental

SA880 DME: Mobility aids and supplies E1816 RR SPS ankle device Rental

SA880 DME: Mobility aids and supplies E1818 RR SPS forearm device Rental

SA880 DME: Mobility aids and supplies E1820 RR Soft interface material Rental

SA880 DME: Mobility aids and supplies E1820 UE Soft interface material Used DME

SA880 DME: Mobility aids and supplies E1820 NU Soft interface material New Equipment

SA880 DME: Mobility aids and supplies E1821 RR Replacement interface SPSD Rental

SA880 DME: Mobility aids and supplies E1821 UE Replacement interface SPSD Used DME

SA880 DME: Mobility aids and supplies E1821 NU Replacement interface SPSD New Equipment

SA880 DME: Mobility aids and supplies E1825 RR Adjust finger ext/flex devc Rental

SA880 DME: Mobility aids and supplies E1830 RR Adjust toe ext/flex device Rental

SA880 DME: Mobility aids and supplies E1840 RR Adj shoulder ext/flex device Rental

SA880 DME: Mobility aids and supplies E1902 - AAC non-electronic board N/A

SA880 DME: Mobility aids and supplies E8000 - Posterior gait trainer N/A

SA880 DME: Mobility aids and supplies E8001 - Upright gait trainer N/A

15

SA880 DME: Mobility aids and supplies E8002 - Anterior gait trainer N/A

SA881 DME: Nutrition equipment and supplies B4164 - Parenteral 50% dextrose solu N/A

SA881 DME: Nutrition equipment and supplies B5000 - Parenteral sol renal-amirosy N/A

SA881 DME: Nutrition equipment and supplies B5100 - Parenteral sol hepatic-fream N/A

SA881 DME: Nutrition equipment and supplies B5200 - Parenteral sol stres-brnch c N/A

SA881 DME: Nutrition equipment and supplies B9004 NU Parenteral infus pump portab New Equipment

SA881 DME: Nutrition equipment and supplies B9004 RR Parenteral infus pump portab Rental

SA881 DME: Nutrition equipment and supplies B9006 NU Parenteral infus pump statio New Equipment

SA881 DME: Nutrition equipment and supplies B9006 RR Parenteral infus pump statio Rental

SA881 DME: Nutrition equipment and supplies B9999 - Parenteral supp not othrws c N/A

SA881 DME: Nutrition equipment and supplies B4168 - Parenteral sol amino acid 3. N/A

SA881 DME: Nutrition equipment and supplies B4172 - Parenteral sol amino acid 5. N/A

SA881 DME: Nutrition equipment and supplies B4176 - Parenteral sol amino acid 7- N/A

SA881 DME: Nutrition equipment and supplies B4178 - Parenteral sol amino acid > N/A

SA881 DME: Nutrition equipment and supplies B4180 - Parenteral sol carb > 50% N/A

SA881 DME: Nutrition equipment and supplies B4185 - Parenteral sol 10 gm lipids N/A

SA881 DME: Nutrition equipment and supplies B4189 - Parenteral sol amino acid & N/A

SA881 DME: Nutrition equipment and supplies B4193 - Parenteral sol 52-73 gm prot N/A

SA881 DME: Nutrition equipment and supplies B4197 - Parenteral sol 74-100 gm pro N/A

SA881 DME: Nutrition equipment and supplies B4199 - Parenteral sol > 100gm prote N/A

SA881 DME: Nutrition equipment and supplies B4216 - Parenteral nutrition additiv N/A

SA881 DME: Nutrition equipment and supplies B4220 - Parenteral supply kit premix N/A

SA881 DME: Nutrition equipment and supplies B4222 - Parenteral supply kit homemi N/A

SA881 DME: Nutrition equipment and supplies B4224 - Parenteral administration ki N/A

SA882 DME: Orthotic equipment and supplies L0112 - Cranial cervical orthosis N/A

SA882 DME: Orthotic equipment and supplies L0113 - Cranial cervical torticollis N/A

SA882 DME: Orthotic equipment and supplies L0120 - Cerv flexible non-adjustable N/A

SA882 DME: Orthotic equipment and supplies L0130 - Flex thermoplastic collar mo N/A

SA882 DME: Orthotic equipment and supplies L0140 - Cervical semi-rigid adjustab N/A

SA882 DME: Orthotic equipment and supplies L0150 - Cerv semi-rig adj molded chn N/A

SA882 DME: Orthotic equipment and supplies L0160 - Cerv semi-rig wire occ/mand N/A

SA882 DME: Orthotic equipment and supplies L0170 - Cervical collar molded to pt N/A

SA882 DME: Orthotic equipment and supplies L0172 - Cerv col thermplas foam 2 pi N/A

SA882 DME: Orthotic equipment and supplies L0174 - Cerv col foam 2 piece w thor N/A

16

SA882 DME: Orthotic equipment and supplies L0180 - Cer post col occ/man sup adj N/A

SA882 DME: Orthotic equipment and supplies L0190 - Cerv collar supp adj cerv ba N/A

SA882 DME: Orthotic equipment and supplies L0200 - Cerv col supp adj bar & thor N/A

SA882 DME: Orthotic equipment and supplies L0220 - Thor rib belt custom fabrica N/A

SA882 DME: Orthotic equipment and supplies L0430 - Dewall posture protector N/A

SA882 DME: Orthotic equipment and supplies L0450 - TLSO flex prefab thoracic N/A

SA882 DME: Orthotic equipment and supplies L0452 - tlso flex custom fab thoraci N/A

SA882 DME: Orthotic equipment and supplies L0454 - TLSO flex prefab sacrococ-T9 N/A

SA882 DME: Orthotic equipment and supplies L0456 - TLSO flex prefab N/A

SA882 DME: Orthotic equipment and supplies L0458 - TLSO 2Mod symphis-xipho

pre

N/A

SA882 DME: Orthotic equipment and supplies L0460 - TLSO2Mod symphysis-stern

pre

N/A

SA882 DME: Orthotic equipment and supplies L0462 - TLSO 3Mod sacro-scap pre N/A

SA882 DME: Orthotic equipment and supplies L0464 - TLSO 4Mod sacro-scap pre N/A

SA882 DME: Orthotic equipment and supplies L0466 - TLSO rigid frame pre soft ap N/A

SA882 DME: Orthotic equipment and supplies L0468 - TLSO rigid frame prefab pelv N/A

SA882 DME: Orthotic equipment and supplies L0470 - TLSO rigid frame pre subclav N/A

SA882 DME: Orthotic equipment and supplies L0472 - TLSO rigid frame hyperex pre N/A

SA882 DME: Orthotic equipment and supplies L0474 - TLSO, Triplanar control, regid

posterior

N/A

SA882 DME: Orthotic equipment and supplies L0480 - TLSO rigid plastic custom fa N/A

SA882 DME: Orthotic equipment and supplies L0482 - TLSO rigid lined custom fab N/A

SA882 DME: Orthotic equipment and supplies L0484 - TLSO rigid plastic cust fab N/A

SA882 DME: Orthotic equipment and supplies L0486 - TLSO rigidlined cust fab two N/A

SA882 DME: Orthotic equipment and supplies L0488 - TLSO rigid lined pre one pie N/A

SA882 DME: Orthotic equipment and supplies L0490 - TLSO rigid plastic pre one N/A

SA882 DME: Orthotic equipment and supplies L0491 - TLSO 2 piece rigid shell N/A

SA882 DME: Orthotic equipment and supplies L0492 - TLSO 3 piece rigid shell N/A

SA882 DME: Orthotic equipment and supplies L0621 - SIO flex pelvisacral prefab N/A

SA882 DME: Orthotic equipment and supplies L0622 - SIO flex pelvisacral custom N/A

SA882 DME: Orthotic equipment and supplies L0623 - SIO panel prefab N/A

SA882 DME: Orthotic equipment and supplies L0624 - SIO panel custom N/A

SA882 DME: Orthotic equipment and supplies L0625 - LO flexibl L1-below L5 pre N/A

SA882 DME: Orthotic equipment and supplies L0626 - LO sag stays/panels pre-fab N/A

17

SA882 DME: Orthotic equipment and supplies L0627 - LO sagitt rigid panel prefab N/A

SA882 DME: Orthotic equipment and supplies L0628 - LO flex w/o rigid stays pre N/A

SA882 DME: Orthotic equipment and supplies L0629 - LSO flex w/rigid stays cust N/A

SA882 DME: Orthotic equipment and supplies L0630 - LSO post rigid panel pre N/A

SA882 DME: Orthotic equipment and supplies L0631 - LSO sag-coro rigid frame pre N/A

SA882 DME: Orthotic equipment and supplies L0632 - LSO sag rigid frame cust N/A

SA882 DME: Orthotic equipment and supplies L0633 - LSO flexion control prefab N/A

SA882 DME: Orthotic equipment and supplies L0634 - LSO flexion control custom N/A

SA882 DME: Orthotic equipment and supplies L0635 - LSO sagit rigid panel prefab N/A

SA882 DME: Orthotic equipment and supplies L0636 - LSO sagittal rigid panel cus N/A

SA882 DME: Orthotic equipment and supplies L0637 - LSO sag-coronal panel prefab N/A

SA882 DME: Orthotic equipment and supplies L0638 - LSO sag-coronal panel

custom

N/A

SA882 DME: Orthotic equipment and supplies L0639 - LSO s/c shell/panel prefab N/A

SA882 DME: Orthotic equipment and supplies L0640 - LSO s/c shell/panel custom N/A

SA882 DME: Orthotic equipment and supplies L0700 - Ctlso a-p-l control molded N/A

SA882 DME: Orthotic equipment and supplies L0710 - Ctlso a-p-l control w/ inter N/A

SA882 DME: Orthotic equipment and supplies L0810 - Halo cervical into jckt vest N/A

SA882 DME: Orthotic equipment and supplies L0820 - Halo cervical into body jack N/A

SA882 DME: Orthotic equipment and supplies L0830 - Halo cerv into milwaukee typ N/A

SA882 DME: Orthotic equipment and supplies L0859 - MRI compatible system N/A

SA882 DME: Orthotic equipment and supplies L0861 - Halo repl liner/interface N/A

SA882 DME: Orthotic equipment and supplies L0970 - Tlso corset front N/A

SA882 DME: Orthotic equipment and supplies L0972 - Lso corset front N/A

SA882 DME: Orthotic equipment and supplies L0974 - Tlso full corset N/A

SA882 DME: Orthotic equipment and supplies L0976 - Lso full corset N/A

SA882 DME: Orthotic equipment and supplies L0978 - Axillary crutch extension N/A

SA882 DME: Orthotic equipment and supplies L0980 - Peroneal straps pair N/A

SA882 DME: Orthotic equipment and supplies L0982 - Stocking supp grips set of f N/A

SA882 DME: Orthotic equipment and supplies L0984 - Protective body sock each N/A

SA882 DME: Orthotic equipment and supplies L0999 - Add to spinal orthosis NOS N/A

SA882 DME: Orthotic equipment and supplies L1000 - Ctlso milwauke initial model N/A

SA882 DME: Orthotic equipment and supplies L1001 - CTLSO infant immobilizer N/A

SA882 DME: Orthotic equipment and supplies L1005 - Tension based scoliosis orth N/A

18

SA882 DME: Orthotic equipment and supplies L1010 - Ctlso axilla sling N/A

SA882 DME: Orthotic equipment and supplies L1020 - Kyphosis pad N/A

SA882 DME: Orthotic equipment and supplies L1025 - Kyphosis pad floating N/A

SA882 DME: Orthotic equipment and supplies L1030 - Lumbar bolster pad N/A

SA882 DME: Orthotic equipment and supplies L1040 - Lumbar or lumbar rib pad N/A

SA882 DME: Orthotic equipment and supplies L1050 - Sternal pad N/A

SA882 DME: Orthotic equipment and supplies L1060 - Thoracic pad N/A

SA882 DME: Orthotic equipment and supplies L1070 - Trapezius sling N/A

SA882 DME: Orthotic equipment and supplies L1080 - Outrigger N/A

SA882 DME: Orthotic equipment and supplies L1085 - Outrigger bil w/ vert extens N/A

SA882 DME: Orthotic equipment and supplies L1090 - Lumbar sling N/A

SA882 DME: Orthotic equipment and supplies L1100 - Ring flange plastic/leather N/A

SA882 DME: Orthotic equipment and supplies L1110 - Ring flange plas/leather mol N/A

SA882 DME: Orthotic equipment and supplies L1120 - Covers for upright each N/A

SA882 DME: Orthotic equipment and supplies L1200 - Furnsh initial orthosis only N/A

SA882 DME: Orthotic equipment and supplies L1210 - Lateral thoracic extension N/A

SA882 DME: Orthotic equipment and supplies L1220 - Anterior thoracic extension N/A

SA882 DME: Orthotic equipment and supplies L1230 - Milwaukee type superstructur N/A

SA882 DME: Orthotic equipment and supplies L1240 - Lumbar derotation pad N/A

SA882 DME: Orthotic equipment and supplies L1250 - Anterior asis pad N/A

SA882 DME: Orthotic equipment and supplies L1260 - Anterior thoracic derotation N/A

SA882 DME: Orthotic equipment and supplies L1270 - Abdominal pad N/A

SA882 DME: Orthotic equipment and supplies L1280 - Rib gusset (elastic) each N/A

SA882 DME: Orthotic equipment and supplies L1290 - Lateral trochanteric pad N/A

SA882 DME: Orthotic equipment and supplies L1300 - Body jacket mold to patient N/A

SA882 DME: Orthotic equipment and supplies L1310 - Post-operative body jacket N/A

SA882 DME: Orthotic equipment and supplies L1499 - Spinal orthosis NOS N/A

SA882 DME: Orthotic equipment and supplies L1500 - Thkao mobility frame N/A

SA882 DME: Orthotic equipment and supplies L1510 - Thkao standing frame N/A

SA882 DME: Orthotic equipment and supplies L1520 - Thkao swivel walker N/A

SA882 DME: Orthotic equipment and supplies L1600 - Abduct hip flex frejka w cvr N/A

SA882 DME: Orthotic equipment and supplies L1610 - Abduct hip flex frejka covr N/A

SA882 DME: Orthotic equipment and supplies L1620 - Abduct hip flex pavlik harne N/A

SA882 DME: Orthotic equipment and supplies L1630 - Abduct control hip semi-flex N/A

19

SA882 DME: Orthotic equipment and supplies L1640 - Pelv band/spread bar thigh c N/A

SA882 DME: Orthotic equipment and supplies L1650 - HO abduction hip adjustable N/A

SA882 DME: Orthotic equipment and supplies L1652 - HO bi thighcuffs w sprdr bar N/A

SA882 DME: Orthotic equipment and supplies L1660 - HO abduction static plastic N/A

SA882 DME: Orthotic equipment and supplies L1680 - Pelvic & hip control thigh c N/A

SA882 DME: Orthotic equipment and supplies L1685 - Post-op hip abduct custom fa N/A

SA882 DME: Orthotic equipment and supplies L1686 - HO post-op hip abduction N/A

SA882 DME: Orthotic equipment and supplies L1690 - Combination bilateral HO N/A

SA882 DME: Orthotic equipment and supplies L1700 - Leg perthes orth toronto typ N/A

SA882 DME: Orthotic equipment and supplies L1710 - Legg perthes orth newington N/A

SA882 DME: Orthotic equipment and supplies L1720 - Legg perthes orthosis trilat N/A

SA882 DME: Orthotic equipment and supplies L1730 - Legg perthes orth scottish r N/A

SA882 DME: Orthotic equipment and supplies L1755 - Legg perthes patten bottom t N/A

SA882 DME: Orthotic equipment and supplies L1810 - Ko elastic with joints N/A

SA882 DME: Orthotic equipment and supplies L1820 - Ko elas w/ condyle pads & jo N/A

SA882 DME: Orthotic equipment and supplies L1830 - Ko immobilizer canvas longit N/A

SA882 DME: Orthotic equipment and supplies L1831 - Knee orth pos locking joint N/A

SA882 DME: Orthotic equipment and supplies L1832 - KO adj jnt pos rigid support N/A

SA882 DME: Orthotic equipment and supplies L1834 - Ko w/0 joint rigid molded to N/A

SA882 DME: Orthotic equipment and supplies L1836 - Rigid KO wo joints N/A

SA882 DME: Orthotic equipment and supplies L1840 - Ko derot ant cruciate custom N/A

SA882 DME: Orthotic equipment and supplies L1843 - KO single upright custom fit N/A

SA882 DME: Orthotic equipment and supplies L1844 - Ko w/adj jt rot cntrl molded N/A

SA882 DME: Orthotic equipment and supplies L1845 - Ko w/ adj flex/ext rotat cus N/A

SA882 DME: Orthotic equipment and supplies L1846 - Ko w adj flex/ext rotat mold N/A

SA882 DME: Orthotic equipment and supplies L1847 - KO adjustable w air chambers N/A

SA882 DME: Orthotic equipment and supplies L1850 - Ko swedish type N/A

SA882 DME: Orthotic equipment and supplies L1860 - Ko supracondylar socket mold N/A

SA882 DME: Orthotic equipment and supplies L1900 - Afo sprng wir drsflx calf bd N/A

SA882 DME: Orthotic equipment and supplies L1902 - Afo ankle gauntlet N/A

SA882 DME: Orthotic equipment and supplies L1904 - Afo molded ankle gauntlet N/A

SA882 DME: Orthotic equipment and supplies L1906 - Afo multiligamentus ankle su N/A

SA882 DME: Orthotic equipment and supplies L1907 - AFO supramalleolar custom N/A

20

SA882 DME: Orthotic equipment and supplies L1910 - Afo sing bar clasp attach sh N/A

SA882 DME: Orthotic equipment and supplies L1920 - Afo sing upright w/ adjust s N/A

SA882 DME: Orthotic equipment and supplies L1930 - Afo plastic N/A

SA882 DME: Orthotic equipment and supplies L1932 - Afo rig ant tib prefab TCF/= N/A

SA882 DME: Orthotic equipment and supplies L1940 - Afo molded to patient plasti N/A

SA882 DME: Orthotic equipment and supplies L1945 - Afo molded plas rig ant tib N/A

SA882 DME: Orthotic equipment and supplies L1950 - Afo spiral molded to pt plas N/A

SA882 DME: Orthotic equipment and supplies L1951 - AFO spiral prefabricated N/A

SA882 DME: Orthotic equipment and supplies L1960 - Afo pos solid ank plastic mo N/A

SA882 DME: Orthotic equipment and supplies L1970 - Afo plastic molded w/ankle j N/A

SA882 DME: Orthotic equipment and supplies L1971 - AFO w/ankle joint, prefab N/A

SA882 DME: Orthotic equipment and supplies L1980 - Afo sing solid stirrup calf N/A

SA882 DME: Orthotic equipment and supplies L1990 - Afo doub solid stirrup calf N/A

SA882 DME: Orthotic equipment and supplies L2000 - Kafo sing fre stirr thi/calf N/A

SA882 DME: Orthotic equipment and supplies L2005 - KAFO sng/dbl mechanical act N/A

SA882 DME: Orthotic equipment and supplies L2010 - Kafo sng solid stirrup w/o j N/A

SA882 DME: Orthotic equipment and supplies L2020 - Kafo dbl solid stirrup band/ N/A

SA882 DME: Orthotic equipment and supplies L2030 - Kafo dbl solid stirrup w/o j N/A

SA882 DME: Orthotic equipment and supplies L2034 - KAFO pla sin up w/wo k/a cus N/A

SA882 DME: Orthotic equipment and supplies L2035 - KAFO plastic pediatric size N/A

SA882 DME: Orthotic equipment and supplies L2036 - Kafo plas doub free knee mol N/A

SA882 DME: Orthotic equipment and supplies L2037 - Kafo plas sing free knee mol N/A

SA882 DME: Orthotic equipment and supplies L2038 - Kafo w/o joint multi-axis an N/A

SA882 DME: Orthotic equipment and supplies L2040 - Hkafo torsion bil rot straps N/A

SA882 DME: Orthotic equipment and supplies L2050 - Hkafo torsion cable hip pelv N/A

SA882 DME: Orthotic equipment and supplies L2060 - Hkafo torsion ball bearing j N/A

SA882 DME: Orthotic equipment and supplies L2070 - Hkafo torsion unilat rot str N/A

SA882 DME: Orthotic equipment and supplies L2080 - Hkafo unilat torsion cable N/A

SA882 DME: Orthotic equipment and supplies L2090 - Hkafo unilat torsion ball br N/A

SA882 DME: Orthotic equipment and supplies L2106 - Afo tib fx cast plaster mold N/A

SA882 DME: Orthotic equipment and supplies L2108 - Afo tib fx cast molded to pt N/A

SA882 DME: Orthotic equipment and supplies L2112 - Afo tibial fracture soft N/A

SA882 DME: Orthotic equipment and supplies L2114 - Afo tib fx semi-rigid N/A

21

SA882 DME: Orthotic equipment and supplies L2116 - Afo tibial fracture rigid N/A

SA882 DME: Orthotic equipment and supplies L2126 - Kafo fem fx cast thermoplas N/A

SA882 DME: Orthotic equipment and supplies L2128 - Kafo fem fx cast molded to p N/A

SA882 DME: Orthotic equipment and supplies L2132 - Kafo femoral fx cast soft N/A

SA882 DME: Orthotic equipment and supplies L2134 - Kafo fem fx cast semi-rigid N/A

SA882 DME: Orthotic equipment and supplies L2136 - Kafo femoral fx cast rigid N/A

SA882 DME: Orthotic equipment and supplies L2180 - Plas shoe insert w ank joint N/A

SA882 DME: Orthotic equipment and supplies L2182 - Drop lock knee N/A

SA882 DME: Orthotic equipment and supplies L2184 - Limited motion knee joint N/A

SA882 DME: Orthotic equipment and supplies L2186 - Adj motion knee jnt lerman t N/A

SA882 DME: Orthotic equipment and supplies L2188 - Quadrilateral brim N/A

SA882 DME: Orthotic equipment and supplies L2190 - Waist belt N/A

SA882 DME: Orthotic equipment and supplies L2192 - Pelvic band & belt thigh fla N/A

SA882 DME: Orthotic equipment and supplies L2200 - Limited ankle motion ea jnt N/A

SA882 DME: Orthotic equipment and supplies L2210 - Dorsiflexion assist each joi N/A

SA882 DME: Orthotic equipment and supplies L2220 - Dorsi & plantar flex ass/res N/A

SA882 DME: Orthotic equipment and supplies L2230 - Split flat caliper stirr & p N/A

SA882 DME: Orthotic equipment and supplies L2232 - Rocker bottom, contact AFO N/A

SA882 DME: Orthotic equipment and supplies L2240 - Round caliper and plate atta N/A

SA882 DME: Orthotic equipment and supplies L2250 - Foot plate molded stirrup at N/A

SA882 DME: Orthotic equipment and supplies L2260 - Reinforced solid stirrup N/A

SA882 DME: Orthotic equipment and supplies L2265 - Long tongue stirrup N/A

SA882 DME: Orthotic equipment and supplies L2270 - Varus/valgus strap padded/li N/A

SA882 DME: Orthotic equipment and supplies L2275 - Plastic mod low ext pad/line N/A

SA882 DME: Orthotic equipment and supplies L2280 - Molded inner boot N/A

SA882 DME: Orthotic equipment and supplies L2300 - Abduction bar jointed adjust N/A

SA882 DME: Orthotic equipment and supplies L2310 - Abduction bar-straight N/A

SA882 DME: Orthotic equipment and supplies L2320 - Non-molded lacer N/A

SA882 DME: Orthotic equipment and supplies L2330 - Lacer molded to patient mode N/A

SA882 DME: Orthotic equipment and supplies L2335 - Anterior swing band N/A

SA882 DME: Orthotic equipment and supplies L2340 - Pre-tibial shell molded to p N/A

SA882 DME: Orthotic equipment and supplies L2350 - Prosthetic type socket molde N/A

SA882 DME: Orthotic equipment and supplies L2360 - Extended steel shank N/A

SA882 DME: Orthotic equipment and supplies L2370 - Patten bottom N/A

22

SA882 DME: Orthotic equipment and supplies L2375 - Torsion ank & half solid sti N/A

SA882 DME: Orthotic equipment and supplies L2380 - Torsion straight knee joint N/A

SA882 DME: Orthotic equipment and supplies L2385 - Straight knee joint heavy du N/A

SA882 DME: Orthotic equipment and supplies L2387 - Add LE poly knee custom

KAFO

N/A

SA882 DME: Orthotic equipment and supplies L2390 - Offset knee joint each N/A

SA882 DME: Orthotic equipment and supplies L2395 - Offset knee joint heavy duty N/A

SA882 DME: Orthotic equipment and supplies L2397 - Suspension sleeve lower ext N/A

SA882 DME: Orthotic equipment and supplies L2405 - Knee joint drop lock ea jnt N/A

SA882 DME: Orthotic equipment and supplies L2415 - Knee joint cam lock each joi N/A

SA882 DME: Orthotic equipment and supplies L2425 - Knee disc/dial lock/adj flex N/A

SA882 DME: Orthotic equipment and supplies L2430 - Knee jnt ratchet lock ea jnt N/A

SA882 DME: Orthotic equipment and supplies L2492 - Knee lift loop drop lock rin N/A

SA882 DME: Orthotic equipment and supplies L2500 - Thi/glut/ischia wgt bearing N/A

SA882 DME: Orthotic equipment and supplies L2510 - Th/wght bear quad-lat brim m N/A

SA882 DME: Orthotic equipment and supplies L2520 - Th/wght bear quad-lat brim c N/A

SA882 DME: Orthotic equipment and supplies L2525 - Th/wght bear nar m-l brim mo N/A

SA882 DME: Orthotic equipment and supplies L2526 - Th/wght bear nar m-l brim cu N/A

SA882 DME: Orthotic equipment and supplies L2530 - Thigh/wght bear lacer non-mo N/A

SA882 DME: Orthotic equipment and supplies L2540 - Thigh/wght bear lacer molded N/A

SA882 DME: Orthotic equipment and supplies L2550 - Thigh/wght bear high roll cu N/A

SA882 DME: Orthotic equipment and supplies L2570 - Hip clevis type 2 posit jnt N/A

SA882 DME: Orthotic equipment and supplies L2580 - Pelvic control pelvic sling N/A

SA882 DME: Orthotic equipment and supplies L2600 - Hip clevis/thrust bearing fr N/A

SA882 DME: Orthotic equipment and supplies L2610 - Hip clevis/thrust bearing lo N/A

SA882 DME: Orthotic equipment and supplies L2620 - Pelvic control hip heavy dut N/A

SA882 DME: Orthotic equipment and supplies L2622 - Hip joint adjustable flexion N/A

SA882 DME: Orthotic equipment and supplies L2624 - Hip adj flex ext abduct cont N/A

SA882 DME: Orthotic equipment and supplies L2627 - Plastic mold recipro hip & c N/A

SA882 DME: Orthotic equipment and supplies L2628 - Metal frame recipro hip & ca N/A

SA882 DME: Orthotic equipment and supplies L2630 - Pelvic control band & belt u N/A

SA882 DME: Orthotic equipment and supplies L2640 - Pelvic control band & belt b N/A

SA882 DME: Orthotic equipment and supplies L2650 - Pelv & thor control gluteal N/A

23

SA882 DME: Orthotic equipment and supplies L2660 - Thoracic control thoracic ba N/A

SA882 DME: Orthotic equipment and supplies L2670 - Thorac cont paraspinal uprig N/A

SA882 DME: Orthotic equipment and supplies L2680 - Thorac cont lat support upri N/A

SA882 DME: Orthotic equipment and supplies L2750 - Plating chrome/nickel pr bar N/A

SA882 DME: Orthotic equipment and supplies L2755 - Carbon graphite lamination N/A

SA882 DME: Orthotic equipment and supplies L2760 - Extension per extension per N/A

SA882 DME: Orthotic equipment and supplies L2768 - Ortho sidebar disconnect N/A

SA882 DME: Orthotic equipment and supplies L2780 - Non-corrosive finish N/A

SA882 DME: Orthotic equipment and supplies L2785 - Drop lock retainer each N/A

SA882 DME: Orthotic equipment and supplies L2795 - Knee control full kneecap N/A

SA882 DME: Orthotic equipment and supplies L2800 - Knee cap medial or lateral p N/A

SA882 DME: Orthotic equipment and supplies L2810 - Knee control condylar pad N/A

SA882 DME: Orthotic equipment and supplies L2820 - Soft interface below knee se N/A

SA882 DME: Orthotic equipment and supplies L2830 - Soft interface above knee se N/A

SA882 DME: Orthotic equipment and supplies L2840 - Tibial length sock fx or equ N/A

SA882 DME: Orthotic equipment and supplies L2850 - Femoral lgth sock fx or equa N/A

SA882 DME: Orthotic equipment and supplies L2861 - Torsion mechanism

knee/ankle

N/A

SA882 DME: Orthotic equipment and supplies L2999 - Lower extremity orthosis NOS N/A

SA882 DME: Orthotic equipment and supplies L3000 - Ft insert ucb berkeley shell N/A

SA882 DME: Orthotic equipment and supplies L3001 - Foot insert remov molded spe N/A

SA882 DME: Orthotic equipment and supplies L3002 - Foot insert plastazote or eq N/A

SA882 DME: Orthotic equipment and supplies L3003 - Foot insert silicone gel eac N/A

SA882 DME: Orthotic equipment and supplies L3010 - Foot longitudinal arch suppo N/A

SA882 DME: Orthotic equipment and supplies L3020 - Foot longitud/metatarsal sup N/A

SA882 DME: Orthotic equipment and supplies L3030 - Foot arch support remov prem N/A

SA882 DME: Orthotic equipment and supplies L3031 - Foot lamin/prepreg composite N/A

SA882 DME: Orthotic equipment and supplies L3040 - Ft arch suprt premold longit N/A

SA882 DME: Orthotic equipment and supplies L3050 - Foot arch supp premold metat N/A

SA882 DME: Orthotic equipment and supplies L3060 - Foot arch supp longitud/meta N/A

SA882 DME: Orthotic equipment and supplies L3070 - Arch suprt att to sho longit N/A

SA882 DME: Orthotic equipment and supplies L3080 - Arch supp att to shoe metata N/A

24

SA882 DME: Orthotic equipment and supplies L3090 - Arch supp att to shoe long/m N/A

SA882 DME: Orthotic equipment and supplies L3100 - Hallus-valgus nght dynamic s N/A

SA882 DME: Orthotic equipment and supplies L3140 - Abduction rotation bar shoe N/A

SA882 DME: Orthotic equipment and supplies L3150 - Abduct rotation bar w/o shoe N/A

SA882 DME: Orthotic equipment and supplies L3160 - Shoe styled positioning dev N/A

SA882 DME: Orthotic equipment and supplies L3170 - Foot plastic heel stabilizer N/A

SA882 DME: Orthotic equipment and supplies L3201 - Oxford w supinat/pronat inf N/A

SA882 DME: Orthotic equipment and supplies L3202 - Oxford w/ supinat/pronator c N/A

SA882 DME: Orthotic equipment and supplies L3203 - Oxford w/ supinator/pronator N/A

SA882 DME: Orthotic equipment and supplies L3204 - Hightop w/ supp/pronator inf N/A

SA882 DME: Orthotic equipment and supplies L3206 - Hightop w/ supp/pronator chi N/A

SA882 DME: Orthotic equipment and supplies L3207 - Hightop w/ supp/pronator jun N/A

SA882 DME: Orthotic equipment and supplies L3208 - Surgical boot each infant N/A

SA882 DME: Orthotic equipment and supplies L3209 - Surgical boot each child N/A

SA882 DME: Orthotic equipment and supplies L3211 - Surgical boot each junior N/A

SA882 DME: Orthotic equipment and supplies L3212 - Benesch boot pair infant N/A

SA882 DME: Orthotic equipment and supplies L3213 - Benesch boot pair child N/A

SA882 DME: Orthotic equipment and supplies L3214 - Benesch boot pair junior N/A

SA882 DME: Orthotic equipment and supplies L3215 - Orthopedic ftwear ladies oxf N/A

SA882 DME: Orthotic equipment and supplies L3216 - Orthoped ladies shoes dpth i N/A

SA882 DME: Orthotic equipment and supplies L3217 - Ladies shoes hightop depth i N/A

SA882 DME: Orthotic equipment and supplies L3219 - Orthopedic mens shoes

oxford

N/A

SA882 DME: Orthotic equipment and supplies L3221 - Orthopedic mens shoes dpth i N/A

SA882 DME: Orthotic equipment and supplies L3222 - Mens shoes hightop depth inl N/A

SA882 DME: Orthotic equipment and supplies L3224 - Woman's shoe oxford brace N/A

SA882 DME: Orthotic equipment and supplies L3225 - Man's shoe oxford brace N/A

SA882 DME: Orthotic equipment and supplies L3230 - Custom shoes depth inlay N/A

SA882 DME: Orthotic equipment and supplies L3250 - Custom mold shoe remov

prost

N/A

SA882 DME: Orthotic equipment and supplies L3251 - Shoe molded to pt silicone s N/A

SA882 DME: Orthotic equipment and supplies L3252 - Shoe molded plastazote cust N/A

SA882 DME: Orthotic equipment and supplies L3253 - Shoe molded plastazote cust N/A

SA882 DME: Orthotic equipment and supplies L3254 - Orth foot non-stndard size/w N/A

25

SA882 DME: Orthotic equipment and supplies L3255 - Orth foot non-standard size/ N/A

SA882 DME: Orthotic equipment and supplies L3257 - Orth foot add charge split s N/A

SA882 DME: Orthotic equipment and supplies L3260 - Ambulatory surgical boot eac N/A

SA882 DME: Orthotic equipment and supplies L3265 - Plastazote sandal each N/A

SA882 DME: Orthotic equipment and supplies L3300 - Sho lift taper to metatarsal N/A

SA882 DME: Orthotic equipment and supplies L3310 - Shoe lift elev heel/sole neo N/A

SA882 DME: Orthotic equipment and supplies L3320 - Shoe lift elev heel/sole cor N/A

SA882 DME: Orthotic equipment and supplies L3330 - Lifts elevation metal extens N/A

SA882 DME: Orthotic equipment and supplies L3332 - Shoe lifts tapered to one-ha N/A

SA882 DME: Orthotic equipment and supplies L3334 - Shoe lifts elevation heel /i N/A

SA882 DME: Orthotic equipment and supplies L3340 - Shoe wedge sach N/A

SA882 DME: Orthotic equipment and supplies L3350 - Shoe heel wedge N/A

SA882 DME: Orthotic equipment and supplies L3360 - Shoe sole wedge outside sole N/A

SA882 DME: Orthotic equipment and supplies L3370 - Shoe sole wedge between

sole

N/A

SA882 DME: Orthotic equipment and supplies L3380 - Shoe clubfoot wedge N/A

SA882 DME: Orthotic equipment and supplies L3390 - Shoe outflare wedge N/A

SA882 DME: Orthotic equipment and supplies L3400 - Shoe metatarsal bar wedge ro N/A

SA882 DME: Orthotic equipment and supplies L3410 - Shoe metatarsal bar between N/A

SA882 DME: Orthotic equipment and supplies L3420 - Full sole/heel wedge btween N/A

SA882 DME: Orthotic equipment and supplies L3430 - Sho heel count plast reinfor N/A

SA882 DME: Orthotic equipment and supplies L3440 - Heel leather reinforced N/A

SA882 DME: Orthotic equipment and supplies L3450 - Shoe heel sach cushion type N/A

SA882 DME: Orthotic equipment and supplies L3455 - Shoe heel new leather standa N/A

SA882 DME: Orthotic equipment and supplies L3460 - Shoe heel new rubber standar N/A

SA882 DME: Orthotic equipment and supplies L3465 - Shoe heel thomas with wedge N/A

SA882 DME: Orthotic equipment and supplies L3470 - Shoe heel thomas extend to b N/A

SA882 DME: Orthotic equipment and supplies L3480 - Shoe heel pad & depress for N/A

SA882 DME: Orthotic equipment and supplies L3485 - Shoe heel pad removable for N/A

SA882 DME: Orthotic equipment and supplies L3500 - Ortho shoe add leather insol N/A

SA882 DME: Orthotic equipment and supplies L3510 - Orthopedic shoe add rub insl N/A

SA882 DME: Orthotic equipment and supplies L3520 - O shoe add felt w leath insl N/A

26

SA882 DME: Orthotic equipment and supplies L3530 - Ortho shoe add half sole N/A

SA882 DME: Orthotic equipment and supplies L3540 - Ortho shoe add full sole N/A

SA882 DME: Orthotic equipment and supplies L3550 - O shoe add standard toe tap N/A

SA882 DME: Orthotic equipment and supplies L3560 - O shoe add horseshoe toe tap N/A

SA882 DME: Orthotic equipment and supplies L3570 - O shoe add instep extension N/A

SA882 DME: Orthotic equipment and supplies L3580 - O shoe add instep velcro clo N/A

SA882 DME: Orthotic equipment and supplies L3590 - O shoe convert to sof counte N/A

SA882 DME: Orthotic equipment and supplies L3595 - Ortho shoe add march bar N/A

SA882 DME: Orthotic equipment and supplies L3600 - Trans shoe calip plate exist N/A

SA882 DME: Orthotic equipment and supplies L3610 - Trans shoe caliper plate new N/A

SA882 DME: Orthotic equipment and supplies L3620 - Trans shoe solid stirrup exi N/A

SA882 DME: Orthotic equipment and supplies L3630 - Trans shoe solid stirrup new N/A

SA882 DME: Orthotic equipment and supplies L3640 - Shoe dennis browne splint bo N/A

SA882 DME: Orthotic equipment and supplies L3649 - Orthopedic shoe modifica

NOS

N/A

SA882 DME: Orthotic equipment and supplies L3650 - Shlder fig 8 abduct restrain N/A

SA882 DME: Orthotic equipment and supplies L3660 - Abduct restrainer canvas&web N/A

SA882 DME: Orthotic equipment and supplies L3670 - Acromio/clavicular canvas&we N/A

SA882 DME: Orthotic equipment and supplies L3671 - SO cap design w/o jnts CF N/A

SA882 DME: Orthotic equipment and supplies L3672 - SO airplane w/o jnts CF N/A

SA882 DME: Orthotic equipment and supplies L3673 - SO airplane w/joint CF N/A

SA882 DME: Orthotic equipment and supplies L3675 - Canvas vest SO N/A

SA882 DME: Orthotic equipment and supplies L3677 - SO hard plastic stabilizer N/A

SA882 DME: Orthotic equipment and supplies L3702 - EO w/o joints CF N/A

SA882 DME: Orthotic equipment and supplies L3710 - Elbow elastic with metal joi N/A

SA882 DME: Orthotic equipment and supplies L3720 - Forearm/arm cuffs free motio N/A

SA882 DME: Orthotic equipment and supplies L3730 - Forearm/arm cuffs ext/flex a N/A

SA882 DME: Orthotic equipment and supplies L3740 - Cuffs adj lock w/ active con N/A

SA882 DME: Orthotic equipment and supplies L3760 - EO withjoint, Prefabricated N/A

SA882 DME: Orthotic equipment and supplies L3762 - Rigid EO wo joints N/A

SA882 DME: Orthotic equipment and supplies L3763 - EWHO rigid w/o jnts CF N/A

SA882 DME: Orthotic equipment and supplies L3764 - EWHO w/joint(s) CF N/A

SA882 DME: Orthotic equipment and supplies L3765 - EWHFO rigid w/o jnts CF N/A

27

SA882 DME: Orthotic equipment and supplies L3766 - EWHFO w/joint(s) CF N/A

SA882 DME: Orthotic equipment and supplies L3806 - WHFO w/joint(s) custom fab N/A

SA882 DME: Orthotic equipment and supplies L3807 - WHFO,no joint, prefabricated N/A

SA882 DME: Orthotic equipment and supplies L3808 - WHFO, rigid w/o joints N/A

SA882 DME: Orthotic equipment and supplies L3891 - Torsion mechanism wrist/elbo N/A

SA882 DME: Orthotic equipment and supplies L3900 - Hinge extension/flex wrist/f N/A

SA882 DME: Orthotic equipment and supplies L3901 - Hinge ext/flex wrist finger N/A

SA882 DME: Orthotic equipment and supplies L3904 - Whfo electric custom fitted N/A

SA882 DME: Orthotic equipment and supplies L3905 - WHO w/nontorsion jnt(s) CF N/A

SA882 DME: Orthotic equipment and supplies L3906 - WHO w/o joints CF N/A

SA882 DME: Orthotic equipment and supplies L3908 - Wrist cock-up non-molded N/A

SA882 DME: Orthotic equipment and supplies L3912 - Flex glove w/elastic finger N/A

SA882 DME: Orthotic equipment and supplies L3913 - HFO w/o joints CF N/A

SA882 DME: Orthotic equipment and supplies L3915 - WHO w nontor jnt(s) prefab N/A

SA882 DME: Orthotic equipment and supplies L3917 - Prefab metacarpl fx orthosis N/A

SA882 DME: Orthotic equipment and supplies L3919 - HO w/o joints CF N/A

SA882 DME: Orthotic equipment and supplies L3921 - HFO w/joint(s) CF N/A

SA882 DME: Orthotic equipment and supplies L3923 - HFO w/o joints PF N/A

SA882 DME: Orthotic equipment and supplies L3925 - FO pip/dip with joint/spring N/A

SA882 DME: Orthotic equipment and supplies L3927 - FO pip/dip w/o joint/spring N/A

SA882 DME: Orthotic equipment and supplies L3929 - HFO nontorsion joint, prefab N/A

SA882 DME: Orthotic equipment and supplies L3931 - WHFO nontorsion joint prefab N/A

SA882 DME: Orthotic equipment and supplies L3933 - FO w/o joints CF N/A

SA882 DME: Orthotic equipment and supplies L3935 - FO nontorsion joint CF N/A

SA882 DME: Orthotic equipment and supplies L3956 - Add joint upper ext orthosis N/A

SA882 DME: Orthotic equipment and supplies L3960 - Sewho airplan desig abdu pos N/A

SA882 DME: Orthotic equipment and supplies L3961 - SEWHO cap design w/o jnts

CF

N/A

SA882 DME: Orthotic equipment and supplies L3962 - Sewho erbs palsey design

abd

N/A

SA882 DME: Orthotic equipment and supplies L3964 RR Seo mobile arm sup att to wc Rental

SA882 DME: Orthotic equipment and supplies L3964 UE Seo mobile arm sup att to wc Used DME

SA882 DME: Orthotic equipment and supplies L3964 NU Seo mobile arm sup att to wc New Equipment

28

SA882 DME: Orthotic equipment and supplies L3965 RR Arm supp att to wc rancho ty Rental

SA882 DME: Orthotic equipment and supplies L3965 UE Arm supp att to wc rancho ty Used DME

SA882 DME: Orthotic equipment and supplies L3965 NU Arm supp att to wc rancho ty New Equipment

SA882 DME: Orthotic equipment and supplies L3966 RR Mobile arm supports reclinin Rental

SA882 DME: Orthotic equipment and supplies L3966 UE Mobile arm supports reclinin Used DME

SA882 DME: Orthotic equipment and supplies L3966 NU Mobile arm supports reclinin New Equipment

SA882 DME: Orthotic equipment and supplies L3967 - SEWHO airplane w/o jnts CF N/A

SA882 DME: Orthotic equipment and supplies L3968 RR Friction dampening arm supp Rental

SA882 DME: Orthotic equipment and supplies L3968 UE Friction dampening arm supp Used DME

SA882 DME: Orthotic equipment and supplies L3968 NU Friction dampening arm supp New Equipment

SA882 DME: Orthotic equipment and supplies L3969 - Monosuspension arm/hand

supp

N/A

SA882 DME: Orthotic equipment and supplies L3970 - Elevat proximal arm support N/A

SA882 DME: Orthotic equipment and supplies L3971 - SEWHO cap design w/jnt(s)

CF

N/A

SA882 DME: Orthotic equipment and supplies L3972 - Offset/lat rocker arm w/ ela N/A

SA882 DME: Orthotic equipment and supplies L3973 - SEWHO airplane w/jnt(s) CF N/A

SA882 DME: Orthotic equipment and supplies L3974 - Mobile arm support supinator N/A

SA882 DME: Orthotic equipment and supplies L3975 - SEWHFO cap design w/o jnt

CF

N/A

SA882 DME: Orthotic equipment and supplies L3976 - SEWHFO airplane w/o jnts CF N/A

SA882 DME: Orthotic equipment and supplies L3977 - SEWHFO cap desgn w/jnt(s)

CF

N/A

SA882 DME: Orthotic equipment and supplies L3978 - SEWHFO airplane w/jnt(s) CF N/A

SA882 DME: Orthotic equipment and supplies L3980 - Upp ext fx orthosis humeral N/A

SA882 DME: Orthotic equipment and supplies L3982 - Upper ext fx orthosis rad/ul N/A

SA882 DME: Orthotic equipment and supplies L3984 - Upper ext fx orthosis wrist N/A

SA882 DME: Orthotic equipment and supplies L3995 - Sock fracture or equal each N/A

SA882 DME: Orthotic equipment and supplies L3999 - Upper limb orthosis NOS N/A

SA882 DME: Orthotic equipment and supplies L4000 - Repl girdle milwaukee orth N/A

SA882 DME: Orthotic equipment and supplies L4002 - Replace strap, any orthosis N/A

SA882 DME: Orthotic equipment and supplies L4010 - Replace trilateral socket br N/A

SA882 DME: Orthotic equipment and supplies L4020 - Replace quadlat socket brim N/A

SA882 DME: Orthotic equipment and supplies L4030 - Replace socket brim cust fit N/A

SA882 DME: Orthotic equipment and supplies L4040 - Replace molded thigh lacer N/A

29

SA882 DME: Orthotic equipment and supplies L4045 - Replace non-molded thigh lac N/A

SA882 DME: Orthotic equipment and supplies L4050 - Replace molded calf lacer N/A

SA882 DME: Orthotic equipment and supplies L4055 - Replace non-molded calf lace N/A

SA882 DME: Orthotic equipment and supplies L4060 - Replace high roll cuff N/A

SA882 DME: Orthotic equipment and supplies L4070 - Replace prox & dist upright N/A

SA882 DME: Orthotic equipment and supplies L4080 - Repl met band kafo-afo prox N/A

SA882 DME: Orthotic equipment and supplies L4090 - Repl met band kafo-afo calf/ N/A

SA882 DME: Orthotic equipment and supplies L4100 - Repl leath cuff kafo prox th N/A

SA882 DME: Orthotic equipment and supplies L4110 - Repl leath cuff kafo-afo cal N/A

SA882 DME: Orthotic equipment and supplies L4130 - Replace pretibial shell N/A

SA882 DME: Orthotic equipment and supplies L4205 - Ortho dvc repair per 15 min N/A

SA882 DME: Orthotic equipment and supplies L4210 - Orth dev repair/repl minor p N/A

SA882 DME: Orthotic equipment and supplies L4350 - Ankle control orthosi prefab N/A

SA882 DME: Orthotic equipment and supplies L4360 - Pneumati walking boot prefab N/A

SA882 DME: Orthotic equipment and supplies L4370 - Pneumatic full leg splint N/A

SA882 DME: Orthotic equipment and supplies L4380 - Pneumatic knee splint N/A

SA882 DME: Orthotic equipment and supplies L4386 - Non-pneum walk boot prefab N/A

SA882 DME: Orthotic equipment and supplies L4392 - Replace AFO soft interface N/A

SA882 DME: Orthotic equipment and supplies L4394 - Replace foot drop spint N/A

SA882 DME: Orthotic equipment and supplies L4396 - Static AFO N/A

SA882 DME: Orthotic equipment and supplies L4398 - Foot drop splint recumbent N/A

SA882 DME: Orthotic equipment and supplies A9283 - Foot press off load supp dev N/A

SA882 DME: Orthotic equipment and supplies A4280 - Brst prsths adhsv attchmnt N/A

SA883 DME: Ostomy care A4361 - Ostomy face plate N/A

SA883 DME: Ostomy care A4362 - Solid skin barrier N/A

SA883 DME: Ostomy care A4363 - Ostomy clamp, replacement N/A

SA883 DME: Ostomy care A4366 - Ostomy vent N/A

SA883 DME: Ostomy care A4367 - Ostomy belt N/A

SA883 DME: Ostomy care A4368 - Ostomy filter N/A

SA883 DME: Ostomy care A4369 - Skin barrier liquid per oz N/A

SA883 DME: Ostomy care A4371 - Skin barrier powder per oz N/A

SA883 DME: Ostomy care A4372 - Skin barrier solid 4x4 equiv N/A

SA883 DME: Ostomy care A4373 - Skin barrier with flange N/A

30

SA883 DME: Ostomy care A4375 - Drainable plastic pch w fcpl N/A

SA883 DME: Ostomy care A4376 - Drainable rubber pch w fcplt N/A

SA883 DME: Ostomy care A4377 - Drainable plstic pch w/o fp N/A

SA883 DME: Ostomy care A4378 - Drainable rubber pch w/o fp N/A

SA883 DME: Ostomy care A4379 - Urinary plastic pouch w fcpl N/A

SA883 DME: Ostomy care A4380 - Urinary rubber pouch w fcplt N/A

SA883 DME: Ostomy care A4381 - Urinary plastic pouch w/o fp N/A

SA883 DME: Ostomy care A4382 - Urinary hvy plstc pch w/o fp N/A

SA883 DME: Ostomy care A4383 - Urinary rubber pouch w/o fp N/A

SA883 DME: Ostomy care A4384 - Ostomy faceplt/silicone ring N/A

SA883 DME: Ostomy care A4385 - Ost skn barrier sld ext wear N/A

SA883 DME: Ostomy care A4387 - Ost clsd pouch w att st barr N/A

SA883 DME: Ostomy care A4388 - Drainable pch w ex wear barr N/A

SA883 DME: Ostomy care A4389 - Drainable pch w st wear barr N/A

SA883 DME: Ostomy care A4390 - Drainable pch ex wear convex N/A

SA883 DME: Ostomy care A4391 - Urinary pouch w ex wear barr N/A

SA883 DME: Ostomy care A4392 - Urinary pouch w st wear barr N/A

SA883 DME: Ostomy care A4393 - Urine pch w ex wear bar conv N/A

SA883 DME: Ostomy care A4394 - Ostomy pouch liq deodorant N/A

SA883 DME: Ostomy care A4395 - Ostomy pouch solid

deodorant

N/A

SA883 DME: Ostomy care A4396 - Peristomal hernia supprt blt N/A

SA883 DME: Ostomy care A4397 - Irrigation supply sleeve N/A

SA883 DME: Ostomy care A4398 - Ostomy irrigation bag N/A

SA883 DME: Ostomy care A4399 - Ostomy irrig cone/cath w brs N/A

SA883 DME: Ostomy care A4400 - Ostomy irrigation set N/A

SA883 DME: Ostomy care A4402 - Lubricant per ounce N/A

SA883 DME: Ostomy care A4404 - Ostomy ring each N/A

SA883 DME: Ostomy care A4405 - Nonpectin based ostomy

paste

N/A

SA883 DME: Ostomy care A4406 - Pectin based ostomy paste N/A

SA883 DME: Ostomy care A4407 - Ext wear ost skn barr <=4sqo N/A

SA883 DME: Ostomy care A4408 - Ext wear ost skn barr >4sqo N/A

SA883 DME: Ostomy care A4409 - Ost skn barr convex <=4 sq i N/A

31

SA883 DME: Ostomy care A4410 - Ost skn barr extnd >4 sq N/A

SA883 DME: Ostomy care A4411 - Ost skn barr extnd =4sq N/A

SA883 DME: Ostomy care A4412 - Ost pouch drain high output N/A

SA883 DME: Ostomy care A4413 - 2 pc drainable ost pouch N/A

SA883 DME: Ostomy care A4414 - Ost sknbar w/o conv<=4 sq in N/A

SA883 DME: Ostomy care A4415 - Ost skn barr w/o conv >4 sqi N/A

SA883 DME: Ostomy care A4416 - Ost pch clsd w barrier/filtr N/A

SA883 DME: Ostomy care A4417 - Ost pch w bar/bltinconv/fltr N/A

SA883 DME: Ostomy care A4418 - Ost pch clsd w/o bar w filtr N/A

SA883 DME: Ostomy care A4419 - Ost pch for bar w flange/flt N/A

SA883 DME: Ostomy care A4420 - Ost pch clsd for bar w lk fl N/A

SA883 DME: Ostomy care A4421 - Ostomy supply misc N/A

SA883 DME: Ostomy care A4422 - Ost pouch absorbent material N/A

SA883 DME: Ostomy care A4423 - Ost pch for bar w lk fl/fltr N/A

SA883 DME: Ostomy care A4424 - Ost pch drain w bar & filter N/A

SA883 DME: Ostomy care A4425 - Ost pch drain for barrier fl N/A

SA883 DME: Ostomy care A4426 - Ost pch drain 2 piece system N/A

SA883 DME: Ostomy care A4427 - Ost pch drain/barr lk flng/f N/A

SA883 DME: Ostomy care A4428 - Urine ost pouch w faucet/tap N/A

SA883 DME: Ostomy care A4429 - Urine ost pouch w bltinconv N/A

SA883 DME: Ostomy care A4430 - Ost urine pch w b/bltin conv N/A

SA883 DME: Ostomy care A4431 - Ost pch urine w barrier/tapv N/A

SA883 DME: Ostomy care A4432 - Os pch urine w bar/fange/tap N/A

SA883 DME: Ostomy care A4433 - Urine ost pch bar w lock fln N/A

SA883 DME: Ostomy care A4434 - Ost pch urine w lock flng/ft N/A

SA883 DME: Ostomy care A5051 - Pouch clsd w barr attached N/A

SA883 DME: Ostomy care A5052 - Clsd ostomy pouch w/o barr N/A

SA883 DME: Ostomy care A5053 - Clsd ostomy pouch faceplate N/A

SA883 DME: Ostomy care A5054 - Clsd ostomy pouch w/flange N/A

SA883 DME: Ostomy care A5055 - Stoma cap N/A

SA883 DME: Ostomy care A5061 - Pouch drainable w barrier at N/A

SA883 DME: Ostomy care A5062 - Drnble ostomy pouch w/o barr N/A

32

SA883 DME: Ostomy care A5063 - Drain ostomy pouch w/flange N/A

SA883 DME: Ostomy care A5071 - Urinary pouch w/barrier N/A

SA883 DME: Ostomy care A5072 - Urinary pouch w/o barrier N/A

SA883 DME: Ostomy care A5073 - Urinary pouch on barr w/flng N/A

SA883 DME: Ostomy care A5081 - Continent stoma plug N/A

SA883 DME: Ostomy care A5082 - Continent stoma catheter N/A

SA883 DME: Ostomy care A5083 - Stoma absorptive cover N/A

SA883 DME: Ostomy care A5093 - Ostomy accessory convex

inse

N/A

SA884 DME: Respiratory equipment and

supplies

K0740 - Repair/svc oxygen equipment N/A


supplies

A4611 NU Heavy duty battery New Equipment


supplies

A4612 NU Battery cables New Equipment


supplies

A4614 NU Hand-held PEFR meter New Equipment


supplies

A4615 NU Cannula nasal New Equipment


supplies

A4616 NU Tubing (oxygen) per foot New Equipment


supplies

A4618 NU Breathing circuits New Equipment


supplies

A4619 NU Face tent New Equipment


supplies

A4620 NU Variable concentration mask New Equipment


supplies

A4623 NU Tracheostomy inner cannula New Equipment


supplies

A4624 NU Tracheal suction tube New Equipment


supplies

A4625 NU Trach care kit for new trach New Equipment


supplies

A4627 NU Spacer bag/reservoir New Equipment


supplies

A4628 NU Oropharyngeal suction cath New Equipment


supplies

A4629 NU Tracheostomy care kit New Equipment


supplies

A7000 - Disposable canister for pump N/A

33


supplies

A7000 NU Disposable canister for pump New Equipment


supplies

A7000 TW Disposable canister for pump New Equipment/ Back-

up Equipment


supplies

A7001 NU Nondisposable pump canister New Equipment


supplies

A7002 NU Tubing used w suction pump New Equipment


supplies

A7003 NU Nebulizer administration set New Equipment/ Back-

up Equipment


supplies

A7003 TW Nebulizer administration set New Equipment/ Back-

up Equipment


supplies

A7004 NU Disposable nebulizer sml vol New Equipment


supplies

A7005 NU Nondisposable nebulizer set New Equipment


supplies

A7006 NU Filtered nebulizer admin set New Equipment


supplies

A7007 NU Lg vol nebulizer disposable New Equipment


supplies

A7008 NU Disposable nebulizer prefill New Equipment


supplies

A7009 NU Nebulizer reservoir bottle New Equipment


supplies

A7010 NU Disposable corrugated tubing New Equipment


supplies

A7011 NU Nondispos corrugated tubing New Equipment


supplies

A7012 NU Nebulizer water collec devic New Equipment


supplies

A7013 NU Disposable compressor filter New Equipment


supplies

A7014 NU Compressor nondispos filter New Equipment


supplies

A7015 NU Aerosol mask used w nebulize New Equipment

34


supplies

A7016 NU Nebulizer dome & mouthpiece New Equipment


supplies

A7017 RR Nebulizer not used w oxygen Rental


supplies

A7017 UE Nebulizer not used w oxygen Used DME


supplies

A7017 NU Nebulizer not used w oxygen New Equipment


supplies

A7018 NU Water distilled w/nebulizer New Equipment


supplies

A7027 NU Combination oral/nasal mask New Equipment


supplies

A7028 NU Repl oral cushion combo

mask

New Equipment


supplies

A7029 NU Repl nasal pillow comb mask New Equipment


supplies

A7030 NU CPAP full face mask New Equipment


supplies

A7031 NU Replacement facemask interfa New Equipment


supplies

A7032 NU Replacement nasal cushion New Equipment


supplies

A7033 NU Replacement nasal pillows New Equipment


supplies

A7034 NU Nasal application device New Equipment


supplies

A7035 NU Pos airway press headgear New Equipment


supplies

A7036 NU Pos airway press chinstrap New Equipment


supplies

A7037 NU Pos airway pressure tubing New Equipment


supplies

A7038 NU Pos airway pressure filter New Equipment


supplies

A7039 NU Filter, non disposable w pap New Equipment


supplies

A7044 NU PAP oral interface New Equipment


supplies

A7045 RR Repl exhalation port for PAP Rental


supplies

A7046 NU Repl water chamber, PAP dev New Equipment

35


supplies

A7509 NU Heat & moisture exchange sys New Equipment


supplies

A7520 NU Trach/laryn tube non-cuffed New Equipment


supplies

A7521 NU Trach/laryn tube cuffed New Equipment


supplies

A7522 NU Trach/laryn tube stainless New Equipment


supplies

A7525 NU Tracheostomy mask New Equipment


supplies

A7526 NU Tracheostomy tube collar New Equipment


supplies

A8000 - Soft protect helmet prefab N/A


supplies

A8001 - Hard protect helmet prefab N/A


supplies

A8002 - Soft protect helmet custom N/A


supplies

A8003 - Hard protect helmet custom N/A


supplies

A8004 - Repl soft interface, helmet N/A


supplies

E0424 RR Stationary compressed gas 02 Rental


supplies

E0424 MS Stationary compressed gas 03 Six-month

Maintenance and

Servicing Fee


supplies

E0431 RR Portable gaseous 02 Rental


supplies

E0431 MS Portable gaseous 03 Six-month

Maintenance and

Servicing Fee


supplies

E0433 RR Portable liquid oxygen sys Rental


supplies

E0434 RR Portable liquid 02 Rental


supplies

E0434 MS Portable liquid 03 Six-month

Maintenance and

Servicing Fee


supplies

E0439 RR Stationary liquid 02 Rental

36


supplies

E0439 MS Stationary liquid 02 Six-month

Maintenance and

Servicing Fee


supplies

E0441 NU Stationary O2 contents, gas New Equipment


supplies

E0442 NU Stationary O2 contents, liq New Equipment


supplies

E0443 NU Portable 02 contents, gas New Equipment


supplies

E0444 NU Portable 02 contents, liquid New Equipment


supplies

E0445 RR Oximeter non-invasive Rental


supplies

E0450 U2 Vol control vent invasiv int Medicaid Level of

Care 2


supplies

E0450 MS Vol control vent invasiv int Six-month

Maintenance and

Servicing Fee


supplies

E0450 RR Vol control vent invasiv int Rental


supplies

E0460 U2 Neg press vent portabl/statn Medicaid Level of

Care 2


supplies

E0460 MS Neg press vent portabl/statn Six-month

Maintenance and

Servicing Fee


supplies

E0460 RR Neg press vent portabl/statn Rental


supplies

E0461 U2 Vol control vent noninv int Medicaid Level of

Care 2


supplies

E0461 MS Vol control vent noninv int Six-month

Maintenance and

Servicing Fee


supplies

E0461 RR Vol control vent noninv int Rental

37


supplies

E0463 U2 Press supp vent invasive int Medicaid Level of

Care 2


supplies

E0463 MS Press supp vent invasive int Six-month

Maintenance and

Servicing Fee


supplies

E0463 RR Press supp vent invasive int Rental


supplies

E0464 U2 Press supp vent noninv int Medicaid Level of

Care 2


supplies

E0464 MS Press supp vent noninv int Six-month

Maintenance and

Servicing Fee


supplies

E0464 RR Press supp vent noninv int Rental


supplies

E0470 RR RAD w/o backup non-inv intfc Rental


supplies

E0470 NU RAD w/o backup non-inv intfc New Equipment


supplies

E0471 RR RAD w/backup non inv intrfc Rental


supplies

E0472 RR RAD w backup invasive intrfc Rental


supplies

E0480 NU Percussor elect/pneum home

m

New Equipment


supplies

E0482 RR Cough stimulating device Rental


supplies

E0483 RR Chest compression gen

system

Rental


supplies

E0484 RR Non-elec oscillatory pep dvc Rental


supplies

E0484 UE Non-elec oscillatory pep dvc Used DME


supplies

E0484 NU Non-elec oscillatory pep dvc New Equipment


supplies

E0550 RR Humidif extens supple w ippb Rental


supplies

E0560 RR Humidifier supplemental w/ i Rental

38


supplies

E0560 UE Humidifier supplemental w/ i Used DME


supplies

E0560 NU Humidifier supplemental w/ i New Equipment


supplies

E0561 RR Humidifier nonheated w PAP Rental


supplies

E0561 UE Humidifier nonheated w PAP Used DME


supplies

E0561 NU Humidifier nonheated w PAP New Equipment


supplies

E0562 NU Humidifier heated used w PAP New Equipment


supplies

E0565 RR Compressor air power source Rental


supplies

E0570 NU Nebulizer with compression New Equipment


supplies

E0571 RR Aerosol compressor for svneb Rental


supplies

E0572 RR Aerosol compressor adjust pr Rental


supplies

E0574 RR Ultrasonic generator w svneb Rental


supplies

E0575 RR Nebulizer ultrasonic Rental


supplies

E0580 RR Nebulizer for use w/ regulat Rental


supplies

E0580 UE Nebulizer for use w/ regulat Used DME


supplies

E0580 NU Nebulizer for use w/ regulat New Equipment


supplies

E0585 RR Nebulizer w/ compressor & he Rental


supplies

E1372 RR Oxy suppl heater for nebuliz Rental


supplies

E1372 UE Oxy suppl heater for nebuliz Used DME


supplies

E1372 NU Oxy suppl heater for nebuliz New Equipment


supplies

E1390 RR Oxygen concentrator Rental


supplies

E1390 MS Oxygen concentrator Six-month

Maintenance and

Servicing Fee

39


supplies

E1391 RR Oxygen concentrator, dual Rental


supplies

E1392 RR Portable oxygen concentrator Rental


supplies

E1392 MS Portable oxygen concentrator Six-month

Maintenance and

Servicing Fee


supplies

E1405 RR O2/water vapor enrich w/heat Rental


supplies

E1406 RR O2/water vapor enrich w/o he Rental


supplies

S8185 NU Flutter device New Equipment


supplies

S8265 - Haberman feeder N/A


supplies

A7045 UE Repl exhalation port for PAP Used DME


supplies

A7045 NU Repl exhalation port for PAP New Equipment


supplies

A4218 - Sterile saline or water N/A


supplies

A4450 NU Non-waterproof tape New Equipment


supplies

A4452 NU Waterproof tape New Equipment


supplies

A4481 - Tracheostoma filter N/A


supplies

A4483 - Moisture exchanger N/A


supplies

A4558 NU Conductive gel or paste New Equipment


supplies

A4604 NU Tubing with heating element New Equipment


supplies

A4606 RA Oxygen probe used w

oximeter

REPLACEMENT OF A

DME ITEM


supplies

A4608 - Transtracheal oxygen cath N/A


supplies

A4613 NU Battery charger New Equipment


supplies

A4617 NU Mouth piece New Equipment

40


supplies

A4626 - Tracheostomy cleaning brush N/A


supplies

A7008 - Disposable nebulizer prefill N/A


supplies

A7009 - Nebulizer reservoir bottle N/A


supplies

A7016 - Nebulizer dome & mouthpiece N/A


supplies

A7017 - Nebulizer not used w oxygen N/A


supplies

A7020 NU Interface, cough stim device New Equipment


supplies

A7025 NU Replace chest compress vest New Equipment


supplies

A7027 - Combination oral/nasal mask N/A


supplies

A7028 - Repl oral cushion combo

mask

N/A


supplies

A7029 - Repl nasal pillow comb mask N/A


supplies

A7044 - PAP oral interface N/A


supplies

A7045 - Repl exhalation port for PAP N/A


supplies

A7501 - Tracheostoma valve w

diaphra

N/A


supplies

A7502 - Replacement

diaphragm/fplate

N/A


supplies

A7503 - HMES filter holder or cap N/A


supplies

A7504 - Tracheostoma HMES filter N/A


supplies

A7505 - HMES or trach valve housing N/A


supplies

A7506 - HMES/trachvalve

adhesivedisk

N/A


supplies

A7507 - Integrated filter & holder N/A


supplies

A7508 - Housing & Integrated Adhesiv N/A


supplies

A7523 - Tracheostomy shower protect N/A

41


supplies

A7524 - Tracheostoma stent/stud/bttn N/A


supplies

A7527 - Trach/laryn tube plug/stop N/A


supplies

A9284 - Non-electronic spirometer N/A


supplies

E0425 - s system stationary compre N/A


supplies

E0430 - Oxygen system gas portable N/A


supplies

E0433 - Portable liquid oxygen sys N/A


supplies

E0435 - Oxygen system liquid portabl N/A


supplies

E0440 - Oxygen system liquid station N/A


supplies

E0445 NU Oximeter non-invasive New Equipment


supplies

E0445 SC Oximeter non-invasive Medically necessary

service or supply


supplies

E0446 - Topical ox deliver sys, NOS N/A


supplies

E0455 - Oxygen tent excl croup/ped t N/A


supplies

E0457 - Chest shell N/A


supplies

E0459 - Chest wrap N/A


supplies

E0470 RA RAD w/o backup non-inv intfc Replacement of a

DME Item


supplies

E0471 RA RAD w/backup non inv intrfc Replacement of a

DME Item


supplies

E0481 - Intrpulmnry percuss vent sys N/A


supplies

E0484 - Non-elec oscillatory pep dvc N/A


supplies

E0487 - Electronic spirometer N/A


supplies

E0500 RR Ippb all types Rental

42


supplies

E0550 - Humidif extens supple w ippb N/A


supplies

E0555 - Humidifier for use w/ regula N/A


supplies

E0560 - Humidifier supplemental w/ i N/A


supplies

E0561 - Humidifier nonheated w PAP N/A


supplies

E0572 - Aerosol compressor adjust pr N/A


supplies

E0574 - Ultrasonic generator w svneb N/A


supplies

E0575 - Nebulizer ultrasonic N/A


supplies

E0580 - Nebulizer for use w/ regulat N/A


supplies

E0585 - Nebulizer w/ compressor & he N/A


supplies

E0605 - Vaporizer room type N/A


supplies

E0618 - Apnea monitor N/A


supplies

E1352 - O2 flow reg pos inspir press N/A


supplies

E1354 - Wheeled cart, port cyl/conc N/A


supplies

E1355 - Oxygen supplies stand/rack N/A


supplies

E1356 - Batt pack/cart, port conc N/A


supplies

E1357 - Battery charger, port conc N/A


supplies

E1358 - DC power adapter, port conc N/A


supplies

E1372 - Oxy suppl heater for nebuliz N/A


supplies

E1391 - Oxygen concentrator, dual N/A


supplies

E1405 - O2/water vapor enrich w/heat N/A


supplies

E1406 - O2/water vapor enrich w/o he N/A

43


supplies

K0462 RR Temporary replacement

eqpmnt

Rental


supplies

L8501 NU Tracheostomy speaking valve New Equipment


supplies

S8186 - Swivel adaptor N/A


supplies

S8189 - Trach supply noc N/A


supplies

S8210 - Mucus trap N/A


supplies

S8999 - Resuscitation bag N/A

SA885 DME: Urinary/incontinence equipment A4310 - Insert tray w/o bag/cath N/A

SA885 DME: Urinary/incontinence equipment A4311 - Catheter w/o bag 2-way latex N/A

SA885 DME: Urinary/incontinence equipment A4312 - Cath w/o bag 2-way silicone N/A

SA885 DME: Urinary/incontinence equipment A4313 - Catheter w/bag 3-way N/A

SA885 DME: Urinary/incontinence equipment A4314 - Cath w/drainage 2-way latex N/A

SA885 DME: Urinary/incontinence equipment A4315 - Cath w/drainage 2-way silcne N/A

SA885 DME: Urinary/incontinence equipment A4316 - Cath w/drainage 3-way N/A

SA885 DME: Urinary/incontinence equipment A4320 - Irrigation tray N/A

SA885 DME: Urinary/incontinence equipment A4321 - Cath therapeutic irrig agent N/A

SA885 DME: Urinary/incontinence equipment A4322 - Irrigation syringe N/A

SA885 DME: Urinary/incontinence equipment A4326 - Male external catheter N/A

SA885 DME: Urinary/incontinence equipment A4327 - Fem urinary collect dev cup N/A

SA885 DME: Urinary/incontinence equipment A4328 - Fem urinary collect pouch N/A

SA885 DME: Urinary/incontinence equipment A4330 - Stool collection pouch N/A

SA885 DME: Urinary/incontinence equipment A4331 - Extension drainage tubing N/A

SA885 DME: Urinary/incontinence equipment A4332 - Lube sterile packet N/A

SA885 DME: Urinary/incontinence equipment A4333 - Urinary cath anchor device N/A

SA885 DME: Urinary/incontinence equipment A4334 - Urinary cath leg strap N/A

SA885 DME: Urinary/incontinence equipment A4335 - Incontinence supply N/A

SA885 DME: Urinary/incontinence equipment A4336 - Urethral insert N/A

SA885 DME: Urinary/incontinence equipment A4338 - Indwelling catheter latex N/A

SA885 DME: Urinary/incontinence equipment A4340 - Indwelling catheter special N/A

SA885 DME: Urinary/incontinence equipment A4344 - Cath indw foley 2 way silicn N/A

SA885 DME: Urinary/incontinence equipment A4346 - Cath indw foley 3 way N/A

SA885 DME: Urinary/incontinence equipment A4349 - Disposable male external cat N/A

44

SA885 DME: Urinary/incontinence equipment A4351 - Straight tip urine catheter N/A

SA885 DME: Urinary/incontinence equipment A4352 - Coude tip urinary catheter N/A

SA885 DME: Urinary/incontinence equipment A4353 - Intermittent urinary cath N/A

SA885 DME: Urinary/incontinence equipment A4354 - Cath insertion tray w/bag N/A

SA885 DME: Urinary/incontinence equipment A4355 - Bladder irrigation tubing N/A

SA885 DME: Urinary/incontinence equipment A4356 - Ext ureth clmp or compr dvc N/A

SA885 DME: Urinary/incontinence equipment A4357 - Bedside drainage bag N/A

SA885 DME: Urinary/incontinence equipment A4358 - Urinary leg or abdomen bag N/A

SA885 DME: Urinary/incontinence equipment A4360 - Disposable ext urethral dev N/A

SA885 DME: Urinary/incontinence equipment A5102 - Bedside drain btl w/wo tube N/A

SA885 DME: Urinary/incontinence equipment A5105 - Urinary suspensory N/A

SA885 DME: Urinary/incontinence equipment A5112 - Urinary leg bag N/A

SA885 DME: Urinary/incontinence equipment A5113 RA Latex leg strap Replacement of a

DME Item

SA885 DME: Urinary/incontinence equipment A5114 RA Foam/fabric leg strap Replacement of a

DME Item

SA885 DME: Urinary/incontinence equipment A5120 - Skin barrier, wipe or swab N/A

SA885 DME: Urinary/incontinence equipment A5121 - Solid skin barrier 6x6 N/A

SA885 DME: Urinary/incontinence equipment A5122 - Solid skin barrier 8x8 N/A

SA885 DME: Urinary/incontinence equipment A5126 - Disk/foam pad +or- adhesive N/A

SA885 DME: Urinary/incontinence equipment T4521 - Adult sized disposable

incontinence product,

brief/diaper, small, each

N/A



brief/diaper, medium, each

N/A



brief/diaper, large, each

N/A



brief/diaper, xtra-large, each

N/A



protective underwear/pull-on,

small size, each

N/A

45




medium size, each

N/A




large size, each

N/A




extra large size, each

N/A

SA885 DME: Urinary/incontinence equipment T4529 - Pediatric sized disposable


brief/diaper, small/medium

size, each

N/A



brief/diaper, large size, each

N/A




small/medium size, each

N/A




large size, each

N/A

SA885 DME: Urinary/incontinence equipment T4533 - Youth sized disposable


brief/diaper, each

N/A

SA885 DME: Urinary/incontinence equipment T4534 - Youth sized disposable



each

N/A

SA885 DME: Urinary/incontinence equipment T4535 - Disposable liner/ shield/

guard/ pad/ undergarment, for

incontinence, each

N/A

SA885 DME: Urinary/incontinence equipment T4536 RR Incontinence product,


reusable, any size, each

Rental

SA885 DME: Urinary/incontinence equipment T4536 NU Incontinence product,


reusable, any size, each

New Equipment

46


protective underpad, reusable,

bed size, each

New Equipment

SA885 DME: Urinary/incontinence equipment T4537 RR Incontinence product,

protective underpad, reusable,

bed size, each

Rental

SA885 DME: Urinary/incontinence equipment T4538 RR Diaper service, reusable

diaper, each diaper

Rental


diaper/brief, reusable, any

size, each

New Equipment

SA885 DME: Urinary/incontinence equipment T4541 - Incontinence product,

disposable underpad, large,

each

N/A

SA885 DME: Urinary/incontinence equipment T4543 - Disposable incontinence

product, brief/diaper, bariatric,

each

N/A

SA885 DME: Urinary/incontinence equipment T4540 - Reusable underpad chair size N/A

SA885 DME: Urinary/incontinence equipment T4542 - Small disposable underpad N/A

SA885 DME: Urinary/incontinence equipment T4544 - ADLT disp und/pull on abv xl N/A

SA886 DME: Wheelchairs and accessories E0950 - Tray N/A

SA886 DME: Wheelchairs and accessories E0951 - Loop heel N/A

SA886 DME: Wheelchairs and accessories E0952 - Toe loop/holder, each N/A

SA886 DME: Wheelchairs and accessories E0955 - Cushioned headrest N/A

SA886 DME: Wheelchairs and accessories E0956 - W/c lateral trunk/hip suppor N/A

SA886 DME: Wheelchairs and accessories E0957 - W/c medial thigh support N/A

SA886 DME: Wheelchairs and accessories E0958 - Whlchr att- conv 1 arm drive N/A

SA886 DME: Wheelchairs and accessories E0959 - Amputee adapter N/A

SA886 DME: Wheelchairs and accessories E0960 - W/c shoulder harness/straps N/A

SA886 DME: Wheelchairs and accessories E0961 - Wheelchair brake extension N/A

SA886 DME: Wheelchairs and accessories E0966 RR Wheelchair head rest extensi Rental

SA886 DME: Wheelchairs and accessories E0966 UE Wheelchair head rest extensi Used DME

SA886 DME: Wheelchairs and accessories E0966 NU Wheelchair head rest extensi New Equipment

SA886 DME: Wheelchairs and accessories E0967 - Manual wc hand rim w project N/A

SA886 DME: Wheelchairs and accessories E0968 RR Wheelchair commode seat Rental

SA886 DME: Wheelchairs and accessories E0969 RR Wheelchair narrowing device Rental

SA886 DME: Wheelchairs and accessories E0969 UE Wheelchair narrowing device Used DME

47

SA886 DME: Wheelchairs and accessories E0969 NU Wheelchair narrowing device New Equipment

SA886 DME: Wheelchairs and accessories E0970 - Wheelchair no. 2 footplates N/A

SA886 DME: Wheelchairs and accessories E0971 - Wheelchair anti-tipping devi N/A

SA886 DME: Wheelchairs and accessories E0972 - TRANSFER BOARD OR

DEVICE

N/A

SA886 DME: Wheelchairs and accessories E0973 - W/Ch access det adj armrest N/A

SA886 DME: Wheelchairs and accessories E0974 - W/Ch access anti-rollback N/A

SA886 DME: Wheelchairs and accessories E0978 - W/C acc,saf belt pelv strap N/A

SA886 DME: Wheelchairs and accessories E0980 - Wheelchair safety vest N/A

SA886 DME: Wheelchairs and accessories E0981 - Seat upholstery, replacement N/A

SA886 DME: Wheelchairs and accessories E0982 - Back upholstery, replacement N/A

SA886 DME: Wheelchairs and accessories E0983 - Add pwr joystick N/A

SA886 DME: Wheelchairs and accessories E0984 - Add pwr tiller N/A

SA886 DME: Wheelchairs and accessories E0985 - W/c seat lift mechanism N/A

SA886 DME: Wheelchairs and accessories E0986 - Man w/c push-rim pow assist N/A

SA886 DME: Wheelchairs and accessories E0990 - Wheelchair elevating leg res N/A

SA886 DME: Wheelchairs and accessories E0992 - Wheelchair solid seat insert N/A

SA886 DME: Wheelchairs and accessories E0994 - Wheelchair arm rest N/A

SA886 DME: Wheelchairs and accessories E0995 - Wheelchair calf rest N/A

SA886 DME: Wheelchairs and accessories E1002 - Pwr seat tilt N/A

SA886 DME: Wheelchairs and accessories E1003 - Pwr seat recline N/A

SA886 DME: Wheelchairs and accessories E1004 - Pwr seat recline mech N/A

SA886 DME: Wheelchairs and accessories E1005 - Pwr seat recline pwr N/A

SA886 DME: Wheelchairs and accessories E1006 - Pwr seat combo w/o shear N/A

SA886 DME: Wheelchairs and accessories E1007 - Pwr seat combo w/shear N/A

SA886 DME: Wheelchairs and accessories E1008 - Pwr seat combo pwr shear N/A

SA886 DME: Wheelchairs and accessories E1009 - Add mech leg elevation N/A

SA886 DME: Wheelchairs and accessories E1010 - Add pwr leg elevation N/A

SA886 DME: Wheelchairs and accessories E1011 - Ped wc modify width adjustm N/A

SA886 DME: Wheelchairs and accessories E1014 - Reclining back add ped w/c N/A

SA886 DME: Wheelchairs and accessories E1015 - Shock absorber for man w/c N/A

SA886 DME: Wheelchairs and accessories E1016 - Shock absorber for power w/c N/A

SA886 DME: Wheelchairs and accessories E1017 - HD shck absrbr for hd man wc N/A

48

SA886 DME: Wheelchairs and accessories E1018 - HD shck absrber for hd

powwc

N/A

SA886 DME: Wheelchairs and accessories E1020 - Residual limb support system N/A

SA886 DME: Wheelchairs and accessories E1028 - W/c manual swingaway N/A

SA886 DME: Wheelchairs and accessories E1029 - W/c vent tray fixed N/A

SA886 DME: Wheelchairs and accessories E1030 - W/c vent tray gimbaled N/A

SA886 DME: Wheelchairs and accessories E1050 RR Whelchr fxd full length arms Rental

SA886 DME: Wheelchairs and accessories E1060 RR Wheelchair detachable arms Rental

SA886 DME: Wheelchairs and accessories E1065 - Power attachments to convert

any

N/A

SA886 DME: Wheelchairs and accessories E1070 RR Wheelchair detachable foot r Rental

SA886 DME: Wheelchairs and accessories E1083 RR Hemi-wheelchair fixed arms Rental

SA886 DME: Wheelchairs and accessories E1084 RR Hemi-wheelchair detachable a Rental

SA886 DME: Wheelchairs and accessories E1085 - Hemi-wheelchair fixed arms N/A

SA886 DME: Wheelchairs and accessories E1086 - Hemi-wheelchair detachable a N/A

SA886 DME: Wheelchairs and accessories E1087 RR Wheelchair lightwt fixed arm Rental

SA886 DME: Wheelchairs and accessories E1088 RR Wheelchair lightweight det a Rental

SA886 DME: Wheelchairs and accessories E1089 - Wheelchair lightwt fixed arm N/A

SA886 DME: Wheelchairs and accessories E1090 - Wheelchair lightweight det a N/A

SA886 DME: Wheelchairs and accessories E1092 - Wheelchair wide w/ leg rests N/A

SA886 DME: Wheelchairs and accessories E1093 RR Wheelchair wide w/ foot rest Rental

SA886 DME: Wheelchairs and accessories E1100 RR Whchr s-recl fxd arm leg res Rental

SA886 DME: Wheelchairs and accessories E1110 RR Wheelchair semi-recl detach Rental

SA886 DME: Wheelchairs and accessories E1130 - Whlchr stand fxd arm ft rest N/A

SA886 DME: Wheelchairs and accessories E1140 - Wheelchair standard detach a N/A

SA886 DME: Wheelchairs and accessories E1150 RR Wheelchair standard w/ leg r Rental

SA886 DME: Wheelchairs and accessories E1160 RR Wheelchair fixed arms Rental

SA886 DME: Wheelchairs and accessories E1161 NU Manual adult wc w tiltinspac New Equipment

SA886 DME: Wheelchairs and accessories E1170 RR Whlchr ampu fxd arm leg rest Rental

SA886 DME: Wheelchairs and accessories E1171 RR Wheelchair amputee w/o leg r Rental

49

SA886 DME: Wheelchairs and accessories E1172 RR Wheelchair amputee detach

ar

Rental

SA886 DME: Wheelchairs and accessories E1180 RR Wheelchair amputee w/ foot r Rental

SA886 DME: Wheelchairs and accessories E1190 RR Wheelchair amputee w/ leg re Rental

SA886 DME: Wheelchairs and accessories E1195 RR Wheelchair amputee heavy

dut

Rental

SA886 DME: Wheelchairs and accessories E1200 RR Wheelchair amputee fixed

arm

Rental

SA886 DME: Wheelchairs and accessories E1220 - Whlchr special size/constrc N/A

SA886 DME: Wheelchairs and accessories E1221 RR Wheelchair spec size w foot Rental

SA886 DME: Wheelchairs and accessories E1222 RR Wheelchair spec size w/ leg Rental

SA886 DME: Wheelchairs and accessories E1223 RR Wheelchair spec size w foot Rental

SA886 DME: Wheelchairs and accessories E1224 RR Wheelchair spec size w/ leg Rental

SA886 DME: Wheelchairs and accessories E1225 - Manual semi-reclining back N/A

SA886 DME: Wheelchairs and accessories E1226 - Manual fully reclining back N/A

SA886 DME: Wheelchairs and accessories E1227 - Wheelchair spec sz spec ht a N/A

SA886 DME: Wheelchairs and accessories E1228 - Wheelchair spec sz spec ht b N/A

SA886 DME: Wheelchairs and accessories E1229 NU Pediatric wheelchair NOS New Equipment

SA886 DME: Wheelchairs and accessories E1231 NU Rigid ped w/c tilt-in-space New Equipment

SA886 DME: Wheelchairs and accessories E1232 NU Folding ped wc tilt-in-space New Equipment

SA886 DME: Wheelchairs and accessories E1233 NU Rig ped wc tltnspc w/o seat New Equipment

SA886 DME: Wheelchairs and accessories E1234 NU Fld ped wc tltnspc w/o seat New Equipment

SA886 DME: Wheelchairs and accessories E1235 NU Rigid ped wc adjustable New Equipment

SA886 DME: Wheelchairs and accessories E1236 NU Folding ped wc adjustable New Equipment

SA886 DME: Wheelchairs and accessories E1237 NU Rgd ped wc adjstabl w/o seat New Equipment

SA886 DME: Wheelchairs and accessories E1237 RR Rgd ped wc adjstabl w/o seat Rental

SA886 DME: Wheelchairs and accessories E1238 NU Fld ped wc adjstabl w/o seat New Equipment

SA886 DME: Wheelchairs and accessories E1239 NU Ped power wheelchair NOS New Equipment

SA886 DME: Wheelchairs and accessories E1240 RR Whchr litwt det arm leg rest Rental


50

SA886 DME: Wheelchairs and accessories E1260 - Wheelchair lightwt foot rest N/A

SA886 DME: Wheelchairs and accessories E1270 RR Wheelchair lightweight leg r Rental

SA886 DME: Wheelchairs and accessories E1280 RR Whchr h-duty det arm leg res Rental

SA886 DME: Wheelchairs and accessories E1285 - Wheelchair heavy duty fixed N/A

SA886 DME: Wheelchairs and accessories E1290 - Wheelchair hvy duty detach a N/A

SA886 DME: Wheelchairs and accessories E1295 RR Wheelchair heavy duty fixed Rental

SA886 DME: Wheelchairs and accessories E1296 RR Wheelchair special seat heig Rental

SA886 DME: Wheelchairs and accessories E1296 UE Wheelchair special seat heig Used DME

SA886 DME: Wheelchairs and accessories E1296 NU Wheelchair special seat heig New Equipment

SA886 DME: Wheelchairs and accessories E1297 - Wheelchair special seat dept N/A

SA886 DME: Wheelchairs and accessories E1298 - Wheelchair spec seat depth/w N/A

SA886 DME: Wheelchairs and accessories E2201 - Man w/ch acc seat

w>=20o<24o

N/A

SA886 DME: Wheelchairs and accessories E2202 - Seat width 24-27 in N/A

SA886 DME: Wheelchairs and accessories E2203 - Frame depth less than 22 in N/A

SA886 DME: Wheelchairs and accessories E2204 - Frame depth 22 to 25 in N/A

SA886 DME: Wheelchairs and accessories E2205 - Manual wc accessory,

handrim

N/A

SA886 DME: Wheelchairs and accessories E2206 - Complete wheel lock

assembly

N/A

SA886 DME: Wheelchairs and accessories E2207 - Crutch and cane holder N/A

SA886 DME: Wheelchairs and accessories E2208 - Cylinder tank carrier N/A

SA886 DME: Wheelchairs and accessories E2209 - Arm trough each N/A

51

SA886 DME: Wheelchairs and accessories E2210 - Wheelchair bearings N/A

SA886 DME: Wheelchairs and accessories E2211 - Pneumatic propulsion tire N/A

SA886 DME: Wheelchairs and accessories E2212 - Pneumatic prop tire tube N/A

SA886 DME: Wheelchairs and accessories E2213 - Pneumatic prop tire insert N/A

SA886 DME: Wheelchairs and accessories E2214 - Pneumatic caster tire each N/A

SA886 DME: Wheelchairs and accessories E2215 - Pneumatic caster tire tube N/A

SA886 DME: Wheelchairs and accessories E2216 - Foam filled propulsion tire N/A

SA886 DME: Wheelchairs and accessories E2217 - Foam filled caster tire each N/A

SA886 DME: Wheelchairs and accessories E2218 - Foam propulsion tire each N/A

SA886 DME: Wheelchairs and accessories E2219 - Foam caster tire any size ea N/A

SA886 DME: Wheelchairs and accessories E2220 - Solid propulsion tire each N/A

SA886 DME: Wheelchairs and accessories E2221 - Solid caster tire each N/A

SA886 DME: Wheelchairs and accessories E2222 - Solid caster integrated whl N/A

SA886 DME: Wheelchairs and accessories E2224 - Propulsion whl excludes tire N/A

SA886 DME: Wheelchairs and accessories E2225 - Caster wheel excludes tire N/A

SA886 DME: Wheelchairs and accessories E2226 - Caster fork replacement only N/A

SA886 DME: Wheelchairs and accessories E2227 - Gear reduction drive wheel N/A

52

SA886 DME: Wheelchairs and accessories E2228 RR Mwc acc, wheelchair brake Rental

SA886 DME: Wheelchairs and accessories E2228 UE Mwc acc, wheelchair brake Used DME

SA886 DME: Wheelchairs and accessories E2228 NU Mwc acc, wheelchair brake New Equipment

SA886 DME: Wheelchairs and accessories E2230 - Manual standing system N/A

SA886 DME: Wheelchairs and accessories E2231 - Solid seat support base N/A

SA886 DME: Wheelchairs and accessories E2291 - Planar back for ped size wc N/A

SA886 DME: Wheelchairs and accessories E2292 - Planar seat for ped size wc N/A

SA886 DME: Wheelchairs and accessories E2293 - Contour back for ped size wc N/A

SA886 DME: Wheelchairs and accessories E2294 - Contour seat for ped size wc N/A

SA886 DME: Wheelchairs and accessories E2295 - Ped dynamic seating frame N/A

SA886 DME: Wheelchairs and accessories E2300 - Pwr seat elevation sys N/A

SA886 DME: Wheelchairs and accessories E2301 - Pwr standing N/A

SA886 DME: Wheelchairs and accessories E2310 - Electro connect btw control N/A

SA886 DME: Wheelchairs and accessories E2311 - Electro connect btw 2 sys N/A

SA886 DME: Wheelchairs and accessories E2312 - Mini-prop remote joystick N/A

SA886 DME: Wheelchairs and accessories E2313 - PWC harness, expand control N/A

SA886 DME: Wheelchairs and accessories E2321 - Hand interface joystick N/A

SA886 DME: Wheelchairs and accessories E2322 - Mult mech switches N/A

SA886 DME: Wheelchairs and accessories E2323 - Special joystick handle N/A

SA886 DME: Wheelchairs and accessories E2324 - Chin cup interface N/A

SA886 DME: Wheelchairs and accessories E2325 - Sip and puff interface N/A

SA886 DME: Wheelchairs and accessories E2326 - Breath tube kit N/A

SA886 DME: Wheelchairs and accessories E2327 - Head control interface mech N/A

SA886 DME: Wheelchairs and accessories E2328 - Head/extremity control inter N/A

SA886 DME: Wheelchairs and accessories E2329 - Head control nonproportional N/A

SA886 DME: Wheelchairs and accessories E2330 - Head control proximity switc N/A

SA886 DME: Wheelchairs and accessories E2331 - Attendant control N/A

SA886 DME: Wheelchairs and accessories E2340 - W/c wdth 20-23 in seat frame N/A

SA886 DME: Wheelchairs and accessories E2341 - W/c wdth 24-27 in seat frame N/A

SA886 DME: Wheelchairs and accessories E2342 - W/c dpth 20-21 in seat frame N/A

53

SA886 DME: Wheelchairs and accessories E2343 - W/c dpth 22-25 in seat frame N/A

SA886 DME: Wheelchairs and accessories E2351 - Electronic SGD interface N/A

SA886 DME: Wheelchairs and accessories E2360 - 22nf nonsealed leadacid N/A

SA886 DME: Wheelchairs and accessories E2361 - 22nf sealed leadacid battery N/A

SA886 DME: Wheelchairs and accessories E2362 RR Gr24 nonsealed leadacid Rental

SA886 DME: Wheelchairs and accessories E2362 UE Gr24 nonsealed leadacid Used DME

SA886 DME: Wheelchairs and accessories E2362 NU Gr24 nonsealed leadacid New Equipment

SA886 DME: Wheelchairs and accessories E2363 - Gr24 sealed leadacid battery N/A

SA886 DME: Wheelchairs and accessories E2364 RR U1nonsealed leadacid battery Rental

SA886 DME: Wheelchairs and accessories E2364 UE U1nonsealed leadacid battery Used DME

SA886 DME: Wheelchairs and accessories E2364 NU U1nonsealed leadacid battery New Equipment

SA886 DME: Wheelchairs and accessories E2365 - U1 sealed leadacid battery N/A

SA886 DME: Wheelchairs and accessories E2366 - Battery charger, single mode N/A

SA886 DME: Wheelchairs and accessories E2367 - Battery charger, dual mode N/A

SA886 DME: Wheelchairs and accessories E2368 - Power wc motor replacement N/A

SA886 DME: Wheelchairs and accessories E2369 - Pwr wc gear box replacement N/A

SA886 DME: Wheelchairs and accessories E2370 - Pwr wc motor/gear box combo N/A

SA886 DME: Wheelchairs and accessories E2371 - Gr27 sealed leadacid battery N/A

SA886 DME: Wheelchairs and accessories E2372 - Gr27 non-sealed leadacid N/A

SA886 DME: Wheelchairs and accessories E2373 - Hand/chin ctrl spec joystick N/A

SA886 DME: Wheelchairs and accessories E2374 - Hand/chin ctrl std joystick N/A

SA886 DME: Wheelchairs and accessories E2375 - Non-expandable controller N/A

SA886 DME: Wheelchairs and accessories E2376 - Expandable controller, repl N/A

SA886 DME: Wheelchairs and accessories E2377 - Expandable controller, initl N/A

SA886 DME: Wheelchairs and accessories E2378 - Pw actuator replacement N/A

54

SA886 DME: Wheelchairs and accessories E2381 - Pneum drive wheel tire N/A

SA886 DME: Wheelchairs and accessories E2382 - Tube, pneum wheel drive tire N/A

SA886 DME: Wheelchairs and accessories E2383 - Insert, pneum wheel drive N/A

SA886 DME: Wheelchairs and accessories E2384 - Pneumatic caster tire N/A

SA886 DME: Wheelchairs and accessories E2385 - Tube, pneumatic caster tire N/A

SA886 DME: Wheelchairs and accessories E2386 - Foam filled drive wheel tire N/A

SA886 DME: Wheelchairs and accessories E2387 - Foam filled caster tire N/A

SA886 DME: Wheelchairs and accessories E2388 - Foam drive wheel tire N/A

SA886 DME: Wheelchairs and accessories E2389 - Foam caster tire N/A

SA886 DME: Wheelchairs and accessories E2390 - Solid drive wheel tire N/A

SA886 DME: Wheelchairs and accessories E2391 - Solid caster tire N/A

SA886 DME: Wheelchairs and accessories E2392 - Solid caster tire, integrate N/A

SA886 DME: Wheelchairs and accessories E2394 - Drive wheel excludes tire N/A


SA886 DME: Wheelchairs and accessories E2396 - Caster fork N/A

SA886 DME: Wheelchairs and accessories E2397 RR Pwc acc, lith-based battery Rental

SA886 DME: Wheelchairs and accessories E2397 UE Pwc acc, lith-based battery Used DME

SA886 DME: Wheelchairs and accessories E2397 NU Pwc acc, lith-based battery New Equipment

SA886 DME: Wheelchairs and accessories E2601 - Gen w/c cushion wdth < 22 in N/A

SA886 DME: Wheelchairs and accessories E2602 - Gen w/c cushion wdth >=22 in N/A

SA886 DME: Wheelchairs and accessories E2603 - Skin protect wc cus wd <22in N/A

SA886 DME: Wheelchairs and accessories E2604 - Skin protect wc cus wd>=22in N/A

SA886 DME: Wheelchairs and accessories E2605 - Position wc cush wdth <22 in N/A

SA886 DME: Wheelchairs and accessories E2606 - Position wc cush wdth>=22 in N/A

55

SA886 DME: Wheelchairs and accessories E2607 - Skin pro/pos wc cus wd <22in N/A

SA886 DME: Wheelchairs and accessories E2608 - Skin pro/pos wc cus wd>=22in N/A

SA886 DME: Wheelchairs and accessories E2609 - Custom fabricate w/c cushion N/A

SA886 DME: Wheelchairs and accessories E2610 - Powered w/c cushion N/A

SA886 DME: Wheelchairs and accessories E2611 - Gen use back cush wdth

<22in

N/A

SA886 DME: Wheelchairs and accessories E2612 - Gen use back cush

wdth>=22in

N/A

SA886 DME: Wheelchairs and accessories E2613 - Position back cush wd <22in N/A

SA886 DME: Wheelchairs and accessories E2614 - Position back cush wd>=22in N/A

SA886 DME: Wheelchairs and accessories E2615 - Pos back post/lat wdth <22in N/A

SA886 DME: Wheelchairs and accessories E2616 - Pos back post/lat wdth>=22in N/A

SA886 DME: Wheelchairs and accessories E2617 - Custom fab w/c back cushion N/A

SA886 DME: Wheelchairs and accessories E2619 - Replace cover w/c seat cush N/A

SA886 DME: Wheelchairs and accessories E2620 - WC planar back cush wd

<22in

N/A

SA886 DME: Wheelchairs and accessories E2621 - WC planar back cush

wd>=22in

N/A

SA886 DME: Wheelchairs and accessories K0001 RR Standard wheelchair Rental

SA886 DME: Wheelchairs and accessories K0001 NU Standard wheelchair New Equipment

SA886 DME: Wheelchairs and accessories K0002 RR Stnd hemi (low seat) whlchr Rental

56

SA886 DME: Wheelchairs and accessories K0002 NU Stnd hemi (low seat) whlchr New Equipment

SA886 DME: Wheelchairs and accessories K0003 RR Lightweight wheelchair Rental

SA886 DME: Wheelchairs and accessories K0003 NU Lightweight wheelchair New Equipment

SA886 DME: Wheelchairs and accessories K0004 NU High strength ltwt whlchr New Equipment

SA886 DME: Wheelchairs and accessories K0005 NU Ultralightweight wheelchair New Equipment

SA886 DME: Wheelchairs and accessories K0006 RR Heavy duty wheelchair Rental

SA886 DME: Wheelchairs and accessories K0006 NU Heavy duty wheelchair New Equipment

SA886 DME: Wheelchairs and accessories K0007 NU Extra heavy duty wheelchair New Equipment

SA886 DME: Wheelchairs and accessories K0009 NU Other manual wheelchair/base New Equipment

SA886 DME: Wheelchairs and accessories K0010 NU Stnd wt frame power whlchr New Equipment

SA886 DME: Wheelchairs and accessories K0010 RR Stnd wt frame power whlchr Rental

SA886 DME: Wheelchairs and accessories K0011 NU Stnd wt pwr whlchr w control New Equipment

SA886 DME: Wheelchairs and accessories K0011 RR Stnd wt pwr whlchr w control Rental

SA886 DME: Wheelchairs and accessories K0012 NU Stnd wt pwr whlchr w control New Equipment

SA886 DME: Wheelchairs and accessories K0012 RR Stnd wt pwr whlchr w control Rental

SA886 DME: Wheelchairs and accessories K0015 - Detach non-adjus hght armrst N/A

SA886 DME: Wheelchairs and accessories K0017 - Detach adjust armrest base N/A

57

SA886 DME: Wheelchairs and accessories K0018 - Detach adjust armrst upper N/A

SA886 DME: Wheelchairs and accessories K0019 - Arm pad each N/A

SA886 DME: Wheelchairs and accessories K0020 - Fixed adjust armrest pair N/A

SA886 DME: Wheelchairs and accessories K0037 - High mount flip-up footrest N/A

SA886 DME: Wheelchairs and accessories K0038 - Leg strap each N/A

SA886 DME: Wheelchairs and accessories K0039 - Leg strap h style each N/A

SA886 DME: Wheelchairs and accessories K0040 - Adjustable angle footplate N/A

SA886 DME: Wheelchairs and accessories K0041 - Large size footplate each N/A

SA886 DME: Wheelchairs and accessories K0042 - Standard size footplate each N/A

SA886 DME: Wheelchairs and accessories K0043 - Ftrst lower extension tube N/A

SA886 DME: Wheelchairs and accessories K0044 - Ftrst upper hanger bracket N/A

SA886 DME: Wheelchairs and accessories K0045 - Footrest complete assembly N/A

SA886 DME: Wheelchairs and accessories K0046 - Elevat legrst low extension N/A

SA886 DME: Wheelchairs and accessories K0047 - Elevat legrst up hangr brack N/A

SA886 DME: Wheelchairs and accessories K0050 - Ratchet assembly N/A

SA886 DME: Wheelchairs and accessories K0051 - Cam relese assem ftrst/lgrst N/A

SA886 DME: Wheelchairs and accessories K0052 - Swingaway detach footrest N/A

58

SA886 DME: Wheelchairs and accessories K0053 - Elevate footrest articulate N/A

SA886 DME: Wheelchairs and accessories K0056 - Seat ht <17 or >=21 ltwt wc N/A

SA886 DME: Wheelchairs and accessories K0065 - Spoke protectors N/A

SA886 DME: Wheelchairs and accessories K0069 - Rear whl complete solid tire N/A

SA886 DME: Wheelchairs and accessories K0070 - Rear whl compl pneum tire N/A

SA886 DME: Wheelchairs and accessories K0071 - Front castr compl pneum tire N/A

SA886 DME: Wheelchairs and accessories K0072 - Frnt cstr cmpl sem-pneum tir N/A

SA886 DME: Wheelchairs and accessories K0073 - Caster pin lock each N/A

SA886 DME: Wheelchairs and accessories K0077 - Front caster assem complete N/A

SA886 DME: Wheelchairs and accessories K0098 - Drive belt power wheelchair N/A

SA886 DME: Wheelchairs and accessories K0105 - Iv hanger N/A

SA886 DME: Wheelchairs and accessories K0108 - W/c component-accessory

NOS

N/A

SA886 DME: Wheelchairs and accessories K0195 RR Elevating whlchair leg rests Rental

SA886 DME: Wheelchairs and accessories K0601 - Repl batt silver oxide 1.5 v N/A

SA886 DME: Wheelchairs and accessories K0602 - Repl batt silver oxide 3 v N/A

SA886 DME: Wheelchairs and accessories K0603 - Repl batt alkaline 1.5 v N/A

SA886 DME: Wheelchairs and accessories K0604 - Repl batt lithium 3.6 v N/A

SA886 DME: Wheelchairs and accessories K0605 - Repl batt lithium 4.5 v N/A

SA886 DME: Wheelchairs and accessories K0669 - Seat/back cus no sadmerc ver N/A

59

SA886 DME: Wheelchairs and accessories K0672 - Removable soft interface LE N/A

SA886 DME: Wheelchairs and accessories K0733 - 12-24hr sealed lead acid N/A

SA886 DME: Wheelchairs and accessories K0734 - Adj skin pro w/c cus wd<22in N/A

SA886 DME: Wheelchairs and accessories K0735 - Adj skin pro wc cus wd>=22in N/A

SA886 DME: Wheelchairs and accessories K0736 - Adj skin pro/pos wc cus<22in N/A

SA886 DME: Wheelchairs and accessories K0737 - Adj skin pro/pos wc cus>=22o N/A

SA886 DME: Wheelchairs and accessories K0738 RR Portable gas oxygen system Rental

SA886 DME: Wheelchairs and accessories K0738 MS Portable gas oxygen system Six-month

Maintenance and

Servicing Fee

SA886 DME: Wheelchairs and accessories K0800 - POV group 1 std up to 300lbs N/A

SA886 DME: Wheelchairs and accessories K0801 - POV group 1 hd 301-450 lbs N/A

SA886 DME: Wheelchairs and accessories K0802 - POV group 1 vhd 451-600 lbs N/A

SA886 DME: Wheelchairs and accessories K0806 - POV group 2 std up to 300lbs N/A

SA886 DME: Wheelchairs and accessories K0807 - POV group 2 hd 301-450 lbs N/A

SA886 DME: Wheelchairs and accessories K0808 - POV group 2 vhd 451-600 lbs N/A

SA886 DME: Wheelchairs and accessories K0812 - Power operated vehicle NOC N/A

SA886 DME: Wheelchairs and accessories K0813 - PWC gp 1 std port seat/back N/A

SA886 DME: Wheelchairs and accessories K0814 - PWC gp 1 std port cap chair N/A

SA886 DME: Wheelchairs and accessories K0815 - PWC gp 1 std seat/back N/A

SA886 DME: Wheelchairs and accessories K0816 - PWC gp 1 std cap chair N/A

SA886 DME: Wheelchairs and accessories K0820 - PWC gp 2 std port seat/back N/A

60

SA886 DME: Wheelchairs and accessories K0821 - PWC gp 2 std port cap chair N/A



SA886 DME: Wheelchairs and accessories K0824 - PWC gp 2 hd seat/back N/A

SA886 DME: Wheelchairs and accessories K0825 - PWC gp 2 hd cap chair N/A

SA886 DME: Wheelchairs and accessories K0826 - PWC gp 2 vhd seat/back N/A

SA886 DME: Wheelchairs and accessories K0827 - PWC gp vhd cap chair N/A

SA886 DME: Wheelchairs and accessories K0828 - PWC gp 2 xtra hd seat/back N/A

SA886 DME: Wheelchairs and accessories K0829 - PWC gp 2 xtra hd cap chair N/A

SA886 DME: Wheelchairs and accessories K0830 - PWC gp2 std seat elevate s/b N/A

SA886 DME: Wheelchairs and accessories K0831 - PWC gp2 std seat elevate cap N/A

SA886 DME: Wheelchairs and accessories K0835 - PWC gp2 std sing pow opt s/b N/A

SA886 DME: Wheelchairs and accessories K0836 - PWC gp2 std sing pow opt

cap

N/A

SA886 DME: Wheelchairs and accessories K0837 - PWC gp 2 hd sing pow opt s/b N/A

SA886 DME: Wheelchairs and accessories K0838 - PWC gp 2 hd sing pow opt

cap

N/A

SA886 DME: Wheelchairs and accessories K0839 - PWC gp2 vhd sing pow opt

s/b

N/A

SA886 DME: Wheelchairs and accessories K0840 - PWC gp2 xhd sing pow opt

s/b

N/A

SA886 DME: Wheelchairs and accessories K0841 - PWC gp2 std mult pow opt s/b N/A

SA886 DME: Wheelchairs and accessories K0842 - PWC gp2 std mult pow opt

cap

N/A

SA886 DME: Wheelchairs and accessories K0843 - PWC gp2 hd mult pow opt s/b N/A




SA886 DME: Wheelchairs and accessories K0851 - PWC gp 3 hd cap chair N/A


SA886 DME: Wheelchairs and accessories K0853 - PWC gp 3 vhd cap chair N/A

SA886 DME: Wheelchairs and accessories K0854 - PWC gp 3 xhd seat/back N/A

SA886 DME: Wheelchairs and accessories K0855 - PWC gp 3 xhd cap chair N/A

61



cap

N/A

SA886 DME: Wheelchairs and accessories K0858 - PWC gp3 hd sing pow opt s/b N/A

SA886 DME: Wheelchairs and accessories K0859 - PWC gp3 hd sing pow opt cap N/A


s/b

N/A


SA886 DME: Wheelchairs and accessories K0862 - PWC gp3 hd mult pow opt s/b N/A

SA886 DME: Wheelchairs and accessories K0863 - PWC gp3 vhd mult pow opt

s/b

N/A

SA886 DME: Wheelchairs and accessories K0864 RR PWC gp3 xhd mult pow opt

s/b

Rental







cap

N/A

SA886 DME: Wheelchairs and accessories K0879 - PWC gp4 hd sing pow opt s/b N/A


s/b

N/A


SA886 DME: Wheelchairs and accessories K0885 - PWC gp4 std mult pow opt

cap

N/A

SA886 DME: Wheelchairs and accessories K0886 - PWC gp4 hd mult pow s/b N/A

SA886 DME: Wheelchairs and accessories K0890 - PWC gp5 ped sing pow opt

s/b

N/A

SA886 DME: Wheelchairs and accessories K0891 - PWC gp5 ped mult pow opt

s/b

N/A

SA886 DME: Wheelchairs and accessories K0898 - Power wheelchair NOC N/A

62

SA886 DME: Wheelchairs and accessories K0899 - Pow mobil dev no SADMERC N/A

SA886 DME: Wheelchairs and accessories E1037 - Transport chair, ped size N/A

SA886 DME: Wheelchairs and accessories E1038 - Transport chair pt wt<=300lb N/A

SA886 DME: Wheelchairs and accessories E1039 - Transport chair pt wt >300lb N/A

SA886 DME: Wheelchairs and accessories E1050 - Whelchr fxd full length arms N/A

SA886 DME: Wheelchairs and accessories E1060 RR Wheelchair detachable arms Rental

SA886 DME: Wheelchairs and accessories E1070 - Wheelchair detachable foot r N/A









SA886 DME: Wheelchairs and accessories E1092 - Wheelchair wide w/ leg rests N/A

SA886 DME: Wheelchairs and accessories E1093 - Wheelchair wide w/ foot rest N/A

63

SA886 DME: Wheelchairs and accessories E1100 - Whchr s-recl fxd arm leg res N/A

SA886 DME: Wheelchairs and accessories E1110 - Wheelchair semi-recl detach N/A

SA886 DME: Wheelchairs and accessories E1130 - Whlchr stand fxd arm ft rest N/A

SA886 DME: Wheelchairs and accessories E1160 - Wheelchair fixed arms N/A

SA886 DME: Wheelchairs and accessories E1170 - Whlchr ampu fxd arm leg rest N/A

SA886 DME: Wheelchairs and accessories E1171 - Wheelchair amputee w/o leg r N/A

SA886 DME: Wheelchairs and accessories E1172 - Wheelchair amputee detach

ar

N/A

SA886 DME: Wheelchairs and accessories E1180 - Wheelchair amputee w/ foot r N/A

SA886 DME: Wheelchairs and accessories E1190 - Wheelchair amputee w/ leg re N/A

SA886 DME: Wheelchairs and accessories E1195 - Wheelchair amputee heavy

dut

N/A

SA886 DME: Wheelchairs and accessories E1200 - Wheelchair amputee fixed

arm

N/A

SA886 DME: Wheelchairs and accessories E1221 - Wheelchair spec size w foot N/A

SA886 DME: Wheelchairs and accessories E1222 - Wheelchair spec size w/ leg N/A

SA886 DME: Wheelchairs and accessories E1223 - Wheelchair spec size w foot N/A

SA886 DME: Wheelchairs and accessories E1224 - Wheelchair spec size w/ leg N/A

SA886 DME: Wheelchairs and accessories E1240 - Whchr litwt det arm leg rest N/A


64

SA886 DME: Wheelchairs and accessories E1260 - Wheelchair lightwt foot rest N/A

SA886 DME: Wheelchairs and accessories E1270 - Wheelchair lightweight leg r N/A

SA886 DME: Wheelchairs and accessories E1280 - Whchr h-duty det arm leg res N/A


SA886 DME: Wheelchairs and accessories E1290 - Wheelchair hvy duty detach a N/A


SA886 DME: Wheelchairs and accessories E2207 - Crutch and cane holder N/A

SA886 DME: Wheelchairs and accessories E2208 - Cylinder tank carrier N/A

SA886 DME: Wheelchairs and accessories E2210 - Wheelchair bearings N/A

SA886 DME: Wheelchairs and accessories E2211 - Pneumatic propulsion tire N/A

SA886 DME: Wheelchairs and accessories E2212 - Pneumatic prop tire tube N/A

SA886 DME: Wheelchairs and accessories E2213 - Pneumatic prop tire insert N/A

SA886 DME: Wheelchairs and accessories E2214 - Pneumatic caster tire each N/A

SA886 DME: Wheelchairs and accessories E2215 - Pneumatic caster tire tube N/A

SA886 DME: Wheelchairs and accessories E2216 - Foam filled propulsion tire N/A

SA886 DME: Wheelchairs and accessories E2217 - Foam filled caster tire each N/A

SA886 DME: Wheelchairs and accessories E2218 - Foam propulsion tire each N/A

65

SA886 DME: Wheelchairs and accessories E2219 - Foam caster tire any size ea N/A

SA886 DME: Wheelchairs and accessories E2220 - Solid propulsion tire each N/A

SA886 DME: Wheelchairs and accessories E2221 - Solid caster tire each N/A

SA886 DME: Wheelchairs and accessories E2222 - Solid caster integrated whl N/A

SA886 DME: Wheelchairs and accessories E2224 - Propulsion whl excludes tire N/A


SA886 DME: Wheelchairs and accessories E2226 - Caster fork replacement only N/A

SA886 DME: Wheelchairs and accessories E2231 - Solid seat support base N/A

SA886 DME: Wheelchairs and accessories E2291 - Planar back for ped size wc N/A

SA886 DME: Wheelchairs and accessories E2292 - Planar seat for ped size wc N/A

SA886 DME: Wheelchairs and accessories E2293 - Contour back for ped size wc N/A

SA886 DME: Wheelchairs and accessories E2294 - Contour seat for ped size wc N/A

SA886 DME: Wheelchairs and accessories E2601 - Gen w/c cushion wdth < 22 in N/A

SA886 DME: Wheelchairs and accessories E2602 - Gen w/c cushion wdth >=22 in N/A

SA886 DME: Wheelchairs and accessories E2603 - Skin protect wc cus wd <22in N/A

SA886 DME: Wheelchairs and accessories E2604 - Skin protect wc cus wd>=22in N/A

SA886 DME: Wheelchairs and accessories E2605 - Position wc cush wdth <22 in N/A

66

SA886 DME: Wheelchairs and accessories E2606 - Position wc cush wdth>=22 in N/A

SA886 DME: Wheelchairs and accessories E2607 - Skin pro/pos wc cus wd <22in N/A

SA886 DME: Wheelchairs and accessories E2608 - Skin pro/pos wc cus wd>=22in N/A

SA886 DME: Wheelchairs and accessories E2611 - Gen use back cush wdth

<22in

N/A

SA886 DME: Wheelchairs and accessories E2612 - Gen use back cush

wdth>=22in

N/A

SA886 DME: Wheelchairs and accessories E2613 - Position back cush wd <22in N/A

SA886 DME: Wheelchairs and accessories E2614 - Position back cush wd>=22in N/A

SA886 DME: Wheelchairs and accessories E2615 - Pos back post/lat wdth <22in N/A

SA886 DME: Wheelchairs and accessories E2616 - Pos back post/lat wdth>=22in N/A

SA886 DME: Wheelchairs and accessories E2619 - Replace cover w/c seat cush N/A

SA886 DME: Wheelchairs and accessories E2622 - Adj skin pro w/c cus WD<22IN N/A

SA886 DME: Wheelchairs and accessories E2623 - Adj skin pro wc cus

WD>=22IN

N/A

SA886 DME: Wheelchairs and accessories E2624 - Adj skin pro/pos cus<22IN N/A

SA886 DME: Wheelchairs and accessories E2625 - Adj skin pro/pos wc cus>=22 N/A

SA887 DME: Wound care A6010 - Collagen based wound filler N/A

SA887 DME: Wound care A6011 - Collagen gel/paste wound fil N/A

SA887 DME: Wound care A6021 - Collagen dressing <=16 sq in N/A

SA887 DME: Wound care A6022 - Collagen drsg>16<=48 sq in N/A

SA887 DME: Wound care A6023 - Collagen dressing >48 sq in N/A

SA887 DME: Wound care A6024 - Collagen dsg wound filler N/A

67

SA887 DME: Wound care A6025 - Silicone gel sheet, each N/A

SA887 DME: Wound care A6154 - Wound pouch each N/A

SA887 DME: Wound care A6196 - Alginate dressing <=16 sq in N/A

SA887 DME: Wound care A6197 - Alginate drsg >16 <=48 sq in N/A

SA887 DME: Wound care A6198 - alginate dressing > 48 sq in N/A

SA887 DME: Wound care A6199 - Alginate drsg wound filler N/A

SA887 DME: Wound care A6203 - Composite drsg <= 16 sq in N/A

SA887 DME: Wound care A6204 - Composite drsg >16<=48 sq

in

N/A

SA887 DME: Wound care A6205 - Composite drsg > 48 sq in N/A

SA887 DME: Wound care A6206 - Contact layer <= 16 sq in N/A

SA887 DME: Wound care A6207 - Contact layer >16<= 48 sq in N/A

SA887 DME: Wound care A6208 - Contact layer > 48 sq in N/A

SA887 DME: Wound care A6209 - Foam drsg <=16 sq in w/o bdr N/A

SA887 DME: Wound care A6210 - Foam drg >16<=48 sq in w/o

b

N/A

SA887 DME: Wound care A6211 - Foam drg > 48 sq in w/o brdr N/A

SA887 DME: Wound care A6212 - Foam drg <=16 sq in w/border N/A

SA887 DME: Wound care A6213 - Foam drg >16<=48 sq in

w/bdr

N/A

SA887 DME: Wound care A6214 - Foam drg > 48 sq in w/border N/A

SA887 DME: Wound care A6215 - Foam dressing wound filler N/A

SA887 DME: Wound care A6216 - Non-sterile gauze<=16 sq in N/A

SA887 DME: Wound care A6217 - Non-sterile gauze>16<=48 sq N/A

SA887 DME: Wound care A6218 - Non-sterile gauze > 48 sq in N/A

SA887 DME: Wound care A6219 - Gauze <= 16 sq in w/border N/A

SA887 DME: Wound care A6220 - Gauze >16 <=48 sq in w/bordr N/A

SA887 DME: Wound care A6221 - Gauze > 48 sq in w/border N/A

SA887 DME: Wound care A6222 - Gauze <=16 in no w/sal w/o b N/A

SA887 DME: Wound care A6223 - Gauze >16<=48 no w/sal w/o

b

N/A

SA887 DME: Wound care A6224 - Gauze > 48 in no w/sal w/o b N/A

68

SA887 DME: Wound care A6229 - Gauze >16<=48 sq in watr/sal N/A

SA887 DME: Wound care A6230 - Gauze > 48 sq in water/salne N/A

SA887 DME: Wound care A6231 - Hydrogel dsg<=16 sq in N/A

SA887 DME: Wound care A6232 - Hydrogel dsg>16<=48 sq in N/A

SA887 DME: Wound care A6233 - Hydrogel dressing >48 sq in N/A

SA887 DME: Wound care A6234 - Hydrocolld drg <=16 w/o bdr N/A

SA887 DME: Wound care A6235 - Hydrocolld drg >16<=48 w/o b N/A

SA887 DME: Wound care A6236 - Hydrocolld drg > 48 in w/o b N/A

SA887 DME: Wound care A6237 - Hydrocolld drg <=16 in w/bdr N/A

SA887 DME: Wound care A6238 - Hydrocolld drg >16<=48 w/bdr N/A

SA887 DME: Wound care A6240 - Hydrocolld drg filler paste N/A

SA887 DME: Wound care A6241 - Hydrocolloid drg filler dry N/A

SA887 DME: Wound care A6242 - Hydrogel drg <=16 in w/o bdr N/A

SA887 DME: Wound care A6243 - Hydrogel drg >16<=48 w/o bdr N/A

SA887 DME: Wound care A6244 - Hydrogel drg >48 in w/o bdr N/A

SA887 DME: Wound care A6245 - Hydrogel drg <= 16 in w/bdr N/A

SA887 DME: Wound care A6246 - Hydrogel drg >16<=48 in w/b N/A

SA887 DME: Wound care A6247 - Hydrogel drg > 48 sq in w/b N/A

SA887 DME: Wound care A6248 - Hydrogel drsg gel filler N/A

SA887 DME: Wound care A6251 - Absorpt drg <=16 sq in w/o b N/A

SA887 DME: Wound care A6252 - Absorpt drg >16 <=48 w/o bdr N/A

SA887 DME: Wound care A6253 - Absorpt drg > 48 sq in w/o b N/A

SA887 DME: Wound care A6254 - Absorpt drg <=16 sq in w/bdr N/A

SA887 DME: Wound care A6255 - Absorpt drg >16<=48 in w/bdr N/A

SA887 DME: Wound care A6256 - Absorpt drg > 48 sq in w/bdr N/A

SA887 DME: Wound care A6257 - Transparent film <= 16 sq in N/A

SA887 DME: Wound care A6258 - Transparent film >16<=48 in N/A

SA887 DME: Wound care A6259 - Transparent film > 48 sq in N/A

SA887 DME: Wound care A6260 - Wound cleanser any type/size N/A

SA887 DME: Wound care A6261 - Wound filler gel/paste /oz N/A

69

SA887 DME: Wound care A6262 - Wound filler dry form / gram N/A

SA887 DME: Wound care A6266 - Impreg gauze no h20/sal/yard N/A

SA887 DME: Wound care A6402 - Sterile gauze <= 16 sq in N/A

SA887 DME: Wound care A6403 - Sterile gauze>16 <= 48 sq in N/A

SA887 DME: Wound care A6404 - Sterile gauze > 48 sq in N/A

SA887 DME: Wound care A6407 - Packing strips, non-impreg N/A

SA887 DME: Wound care A6410 - Sterile eye pad N/A

SA887 DME: Wound care A6411 - Non-sterile eye pad N/A

SA887 DME: Wound care A6441 - Pad band w>=3o <5o/yd N/A

SA887 DME: Wound care A6442 - Conform band n/s w<3o/yd N/A

SA887 DME: Wound care A6443 - Conform band n/s

w>=3o<5o/yd

N/A

SA887 DME: Wound care A6444 - Conform band n/s w>=5o/yd N/A

SA887 DME: Wound care A6445 - Conform band s w <3o/yd N/A

SA887 DME: Wound care A6446 - Conform band s w>=3o

<5o/yd

N/A

SA887 DME: Wound care A6447 - Conform band s w >=5o/yd N/A

SA887 DME: Wound care A6448 - Lt compres band <3o/yd N/A

SA887 DME: Wound care A6449 - Lt compres band >=3o <5o/yd N/A

SA887 DME: Wound care A6450 - Lt compres band >=5o/yd N/A

SA887 DME: Wound care A6451 - Mod compres band

w>=3o<5o/yd

N/A

SA887 DME: Wound care A6452 - High compres band

w>=3o<5oyd

N/A

SA887 DME: Wound care A6453 - Self-adher band w <3o/yd N/A

SA887 DME: Wound care A6454 - Self-adher band w>=3o

<5o/yd

N/A

SA887 DME: Wound care A6455 - Self-adher band >=5o/yd N/A

SA887 DME: Wound care A6456 - Zinc paste band w

>=3o<5o/yd

N/A

SA887 DME: Wound care A6457 - Tubular dressing N/A

SA887 DME: Wound care A6501 - Compres burngarment

bodysuit

N/A


chinstrp

N/A


facehood

N/A

70

SA887 DME: Wound care A6504 - Cmprsburngarment glove-

wrist

N/A

SA887 DME: Wound care A6505 - Cmprsburngarment glove-

elbow

N/A

SA887 DME: Wound care A6506 - Cmprsburngrmnt glove-axilla N/A

SA887 DME: Wound care A6507 - Cmprs burngarment foot-knee N/A

SA887 DME: Wound care A6508 - Cmprs burngarment foot-thigh N/A

SA887 DME: Wound care A6509 - Compres burn garment jacket N/A

SA887 DME: Wound care A6510 - Compres burn garment

leotard

N/A

SA887 DME: Wound care A6511 - Compres burn garment panty N/A

SA887 DME: Wound care A6512 - Compres burn garment, noc N/A

SA887 DME: Wound care A6513 - Compress burn mask

face/neck

N/A

SA887 DME: Wound care A6550 - Neg pres wound ther drsg set N/A

SA887 DME: Wound care A6549 - G compression stocking N/A

SA887 DME: Wound care A4364 - Adhesive, liquid or equal N/A

SA887 DME: Wound care A4450 - Non-waterproof tape N/A

SA887 DME: Wound care A4452 - Waterproof tape N/A

SA887 DME: Wound care A4455 - Adhesive remover per ounce N/A

SA887 DME: Wound care A4456 - Adhesive remover, wipes N/A

SA887 DME: Ostomy care A5056 - 1 pc ost pouch w filter N/A

SA887 DME: Ostomy care A5057 - 1 pc ost pou w built-in conv N/A

SA887 DME: Wound care A5131 - Appliance cleaner N/A

SA887 DME: Wound care A6000 - Wound warming wound cover N/A

SA887 DME: Wound care A6228 - Gauze <= 16 sq in water/sal N/A

SA887 DME: Wound care A6239 - Hydrocolld drg > 48 in w/bdr N/A

SA887 DME: Wound care A6250 - Skin seal protect moisturizr N/A

SA887 DME: Wound care A6412 - Occlusive eye patch N/A

SA887 DME: Wound care A6413 - Adhesive bandage, first-aid N/A

71

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