Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 322.00 - Rates for Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment › Section 322.06 - Allowable Fees and Rate Schedule

Current through Register 1525, July 5, 2024
Code
Rate
Description
Medical and Surgical Supplies
							 A4000-A9999
Injection Supplies
A4206
0.22
Syringe with needle, sterile 1cc, each
A4207
0.43
Syringe with needle, sterile 2cc, each
A4208
0.28
Syringe with needle, sterile 3cc, each
A4209
0.45
Syringe with needle, sterile 5cc or greater,
							 each
A4210
AAC+20%
Needle-free injection device, each
A4210TW
4.98
Needle-free injection device, each (for use for
							 billing nasal adaptor/mucosacal atomization device/nasal adaptor purchased as
							 part of nasal naloxone rescue kit, each, two maximum per kit)
A4211
AAC+20%
Supplies for self-administered injections
A4212
0.13
Non-coring needle or stylet with or without
							 catheter
A4213
0.76
Syringe, sterile, 20 cc or greater, each
A4215KX
0.23
Needle, sterile, any size, each (specific required
							 documentation on file, member treated with insulin)
A4215NU
0.10
Needle, sterile, any size, each
A4216
0.42
Sterile water, saline and/or dextrose diluent/flush,
							 10 ml
A4217AU
2.51
Sterile water/saline 500 ml (items furnished in
							 conjunction with urological, ostomy, or tracheostomy supplies)
A4217NU
2.51
Sterile water/saline 500 ml
A4218
AAC+20%
Sterile saline or water, metered dose dispenser, 10
							 ml
A4220
AAC+20%
Refill kit for implantable infusion pump
A4221
18.88
Supplies for maintenance of non-insulin drug infusion
							 catheter, per week (list drug separately)
A4222
37.60I
nfusion supplies for external drug infusion pump, per
							 cassette or bag (list drug separately)
A4223
AAC+20%
Infusion supplies not used with external infusion
							 pump, per cassette or bag (list drugs separately)
A4224
16.49
Supplies for maintenance of insulin infusion
							 catheter, per week
A4225
2.21
Supplies for external insulin infusion pump, syringe
							 type cartridge, sterile, each
A4226
I.C.
Supplies for maintenance of insulin infusion pump
							 with dosage rate adjustment using therapeutic continuous glucose sensing, per
							 week
Batteries
A4233NU
0.58
Replacement battery, alkaline (other than j cell),
							 for use with medically necessary home blood glucose monitor owned by patient,
							 each
A4233NUKL
0.77
Replacement battery, alkaline (other than j cell),
							 for use with medically necessary home blood glucose monitor owned by patient,
							 each (DMEPOS item delivered via mail)
A4234NU
2.50
Replacement battery, alkaline, j cell, for use with
							 medically necessary home blood glucose monitor owned by patient,
							 each
A4234NUKL
3.47
Replacement battery, alkaline, j cell, for use with
							 medically necessary home blood glucose monitor owned by patient,
							 each
A4235NU
1.06
Replacement battery, lithium, for use with medically
							 necessary home blood glucose monitor owned by patient, each
A4235NUKL
2.23
Replacement battery, lithium, for use with medically
							 necessary home blood glucose monitor owned by patient, each
A4236NU
1.19
Replacement battery, silver oxide, for use with
							 medically necessary home blood glucose monitor owned by patient,
							 each
A4236NUKL
1.60
Replacement battery, silver oxide, for use with
							 medically necessary home blood glucose monitor owned by patient,
							 each
Other Supplies
A4244
1.27
Alcohol or peroxide, per pint
A4245
3.61
Alcohol wipes, per box
A4246
4.73
Betadine or phisohex solution, per pint
A4247
3.56
Betadine or iodine swabs/wipes, per box
A4248
AAC+20%
Chlorhexidine containing antiseptic, 1 ml
A4250
18.88
Urine test or reagent strips or tablets (100 tablets
							 or strips)
A4253NU
8.32
Blood glucose test or reagent strips for home blood
							 glucose monitor, per 50 strips
A4253NUKL
8.32
Blood glucose test or reagent strips for home blood
							 glucose monitor, per 50 strips (DMEPOS item delivered
via
mail)
A4255
4.32
Platforms for home blood glucose monitor, 50 per
							 box
A4256
4.00
Normal, low and high calibrator solution /
							 chips
A4256KL
10.90
Normal, low and high calibrator solution / chips
							 (DMEPOS delivered via mail)
A4257
14.10
Replacement lens shield cartridge for use with laser
							 skin piercing device, each
A4258
2.52
Spring-powered device for lancet, each
A4258KL
17.20
Spring-powered device for lancet, each (DMEPOS
							 delivered via mail)
A4259
1.65
Lancets, per box of 100
A4259KL
10.31
Lancets, per box of 100 (DMEPOS delivered via
							 mail)
A4264
AAC+20%
Permanent implantable contraceptive intratubal
							 occlusion device(s) and delivery system
A4265
3.20
Paraffin, per pound
A4281
19.18
Tubing for breast pump, replacement
A4282
28.35
Adapter for breast pump, replacement
A4283
1.00
Cap for breast pump bottle, replacement
A4284
18.45
Breast shield and splash protector for use with
							 breast pump, replacement
A4285
7.73
Polycarbonate bottle for use with breast pump,
							 replacement
A4286
AAC+20%
Locking ring for breast pump, replacement
Vascular Catheters and Drug Delivery
							 Systems
A4305
AAC+20%
Disposable drug delivery system, flow rate of 50 ml
							 or greater per hour
A4306
AAC+20%
Disposable drug delivery system, flow rate of less
							 than 50 ml per hour
Incontinence Appliances and Care Supplies
A4310
7.26
Insertion tray without drainage bag and without
							 catheter (accessories only)
A4311
13.13
Insertion tray without drainage bag with indwelling
							 catheter, Foley type, two-way latex with coating (teflon, silicone, silicone
							 elastomer or hydrophilic,
etc
.)
A4312
14.41
Insertion tray without drainage bag with indwelling
							 catheter, Foley type, two-way, all silicone
A4313
14.80
Insertion tray without drainage bag with indwelling
							 catheter, Foley type, three-way, for continuous irrigation
A4314
20.20
Insertion tray with drainage bag with indwelling
							 catheter, Foley type, two-way latex with coating (teflon, silicone, silicone
							 elastomer or hydrophilic, etc.)
A4315
21.07
Insertion tray with drainage bag with indwelling
							 catheter, Foley type, two-way, all silicone
A4316
26.68
Insertion tray with drainage bag with indwelling
							 catheter, Foley type, three-way, for continuous irrigation
A4320
5.02
Irrigation tray with bulb or piston syringe, any
							 purpose
A4321
AAC+20%
Therapeutic agent for urinary catheter
							 irrigation
A4322
2.86
Irrigation syringe, bulb or piston, each
A4326
9.74
Male external catheter with integral collection
							 chamber, any type, each
A4327
39.71
Female external urinary collection device; metal cup,
							 each
A4328
8.34
Female external urinary collection device; pouch,
							 each
A4330
6.72
Perianal fecal collection pouch with adhesive,
							 each
A4331
2.99
Extension drainage tubing, any type, any length, with
							 connector/adaptor, for use with urinary leg bag or urostomy pouch,
							 each
A4332
0.11
Lubricant, individual sterile packet,
							 each
A4333
2.07
Urinary catheter anchoring device, adhesive skin
							 attachment, each
A4334
4.62
Urinary catheter anchoring device, leg strap,
							 each
A4335
AAC+20%
Incontinence supply; miscellaneous
A4336
1.35
Incontinence supply, urethral insert, any type,
							 each
A4337
AAC+20%
Incontinence supply, rectal insert, any type,
							 each
A4338
11.53
Indwelling catheter; foley type, two-way latex with
							 coating (teflon, silicone, silicone elastomer, or hydrophilic,
etc
.), each
A4340
29.84
Indwelling catheter; specialty type,
eg
; coude, mushroom, wing,
etc
.),
							 each
A4344
14.27
Indwelling catheter, foley type, two-way, all
							 silicone, each
A4346
18.40
Indwelling catheter; foley type, three way for
							 continuous irrigation, each
A4349
1.90
Male external catheter, with or without adhesive,
							 disposable, each
A4351
1.71
Intermittent urinary catheter; straight tip, with or
							 without coating (teflon, silicone, silicone elastomer, or hydrophilic,
etc
.), each
A4352
6.04
Intermittent urinary catheter; coude (curved) tip,
							 with or without coating (teflon, silicone, silicone elastomeric, or
							 hydrophilic, etc.), each
A4353
6.57
Intermittent urinary catheter, with insertion
							 supplies
A4354
11.09
Insertion tray with drainage bag but without
							 catheter
A4355
7.12
Irrigation tubing set for continuous bladder
							 irrigation through a three-way indwelling foley catheter, each
A4356
36.44
External urethral clamp or compression device (not to
							 be used for catheter clamp), each
A4357
7.75
Bedside drainage bag, day or night, with or without
							 anti-reflux device, with or without tube, each
A4358 each
6.23
Urinary drainage bag, leg or abdomen, vinyl, with or
							 without tube, with straps, each
A4360
0.39
Disposable external urethral clamp or compression
							 device, with pad and/or pouch, each
Ostomy Supplies
A4361
16.75
Ostomy faceplate, each
A4362
2.77
Skin barrier; solid, 4 x 4 or equivalent;
							 each
A4363
2.23
Ostomy clamp, any type, replacement only,
							 each
A4364
2.71
Adhesive, liquid or equal, any type, per
							 oz
A4366
1.22
Ostomy vent, any type, each
A4367
6.22
Ostomy belt, each
A4368
0.24
Ostomy filter, any type, each
A4369
2.28
Ostomy skin barrier, liquid (spray, brush, etc), per
							 oz
A4371
3.43
Ostomy skin barrier, powder, per oz
A4372
3.94
Ostomy skin barrier, solid 4x4 or equivalent,
							 standard wear, with built-in convexity, each
A4373
5.89
Ostomy skin barrier, with flange (solid, flexible or
							 accordion), with built-in convexity, any size, each
A4375
16.14
Ostomy pouch, drainable, with faceplate attached,
							 plastic, each
A4376
44.72
Ostomy pouch, drainable, with faceplate attached,
							 rubber, each
A4377
4.04
Ostomy pouch, drainable, for use on faceplate,
							 plastic, each
A4378
28.88
Ostomy pouch, drainable, for use on faceplate,
							 rubber, each
A4379
14.11
Ostomy pouch, urinary, with faceplate attached,
							 plastic, each
A4380
35.07
Ostomy pouch, urinary, with faceplate attached,
							 rubber, each
A4381
4.34
Ostomy pouch, urinary, for use on faceplate, plastic,
							 each
A4382
23.13
Ostomy pouch, urinary, for use on faceplate, heavy
							 plastic, each
A4383
26.49
Ostomy pouch, urinary, for use on faceplate, rubber,
							 each
A4384
9.04
Ostomy faceplate equivalent, silicone ring,
							 each
A4385
4.79
Ostomy skin barrier, solid 4 x 4 or equivalent,
							 extended wear, without built-in convexity, each
A4387
2.11
Ostomy pouch, closed, with barrier attached, with
							 built-in convexity (one piece), each
A4388
4.11
Ostomy pouch, drainable, with extended wear barrier
							 attached, (one piece), each
A4389
5.84
Ostomy pouch, drainable, with barrier attached, with
							 built-in convexity (one piece), each
A4390
9.03
Ostomy pouch, drainable, with extended wear barrier
							 attached, with built-in convexity (one piece), each
A4391
6.65
Ostomy pouch, urinary, with extended wear barrier
							 attached (one piece), each
A4392
7.68
Ostomy pouch, urinary, with standard wear barrier
							 attached, with built-in convexity (one piece), each
A4393
8.50
Ostomy pouch, urinary, with extended wear barrier
							 attached, with built-in convexity (one piece), each
A4394
2.43
Ostomy deodorant, with or without lubricant, for use
							 in ostomy pouch, liquid, per fluid ounce
A4395
0.04
Ostomy deodorant for use in ostomy pouch, solid, per
							 tablet
A4396
38.04
Ostomy belt with peristomal hernia
							 support
A4398
12.75
Ostomy irrigation supply; bag, each
A4399
11.53
Ostomy irrigation supply; cone/catheter,with or
							 without brush
A4400
45.92
Ostomy irrigation set
A4402
1.28
Lubricant, per ounce
A4404
1.58
Ostomy ring, each
A4405
3.20
Ostomy skin barrier, non-pectin based, paste, per
							 ounce
A4406
5.38
Ostomy skin barrier, pectin-based, paste, per
							 ounce
A4407
8.23
Ostomy skin barrier, with flange (solid, flexible, or
							 accordion), extended wear, with built-in convexity, 4 x 4 inches or smaller,
							 each
A4408
9.27
Ostomy skin barrier, with flange (solid, flexible or
							 accordion), extended wear, with built-in convexity, larger than 4 x 4 inches,
							 each
A4409
5.84
Ostomy skin barrier, with flange (solid, flexible or
							 accordion), extended wear, without built-in convexity, 4 x 4 inches or smaller,
							 each
A4410
8.50
Ostomy skin barrier, with flange (solid, flexible or
							 accordion), extended wear, without built-in convexity, larger than 4 x 4
							 inches, each
A4411
4.79
Ostomy skin barrier, solid 4x4 or equivalent,
							 extended wear, with built-in convexity, each
A4412
2.54
Ostomy pouch, drainable, high output, for use on a
							 barrier with flange (two piece system), without filter, each
A4413
5.18
Ostomy pouch, drainable, high output, for use on a
							 barrier with flange (two piece system), with filter, each
A4414
4.62
Ostomy skin barrier, with flange (solid, flexible or
							 accordion), without built-in convexity, 4 x 4 inches or smaller,
							 each
A4415
5.63
Ostomy skin barrier, with flange (solid, flexible or
							 accordion), without built-in convexity, larger than 4 x 4 inches,
							 each
A4416
2.59
Ostomy pouch, closed, with barrier attached, with
							 filter (one piece), each
A4417
3.49
Ostomy pouch, closed, with barrier attached, with
							 built-in convexity, with filter (one piece), each
A4418
1.71
Ostomy pouch, closed; without barrier attached, with
							 filter (one piece), each
A4419
1.63
Ostomy pouch, closed; for use on barrier with
							 non-locking flange, with filter (two piece), each
A4420
AAC+20%
Ostomy pouch, closed, for use on barrier with locking
							 flange (two piece), each
A4421
AAC+20%
Ostomy supply; miscellaneous
A4422
0.11
Ostomy absorbent material (sheet/pad/crystal packet)
							 for use in ostomy pouch to thicken liquid stomal output, each
A4423
1.75
Ostomy pouch, closed; for use on barrier with locking
							 flange, with filter (two piece), each
A4424
4.47
Ostomy pouch, drainable, with barrier attached, with
							 filter (one piece), each
A4425
3.37
Ostomy pouch, drainable; for use on barrier with
							 non-locking flange, with filter (two piece system), each
A4426
2.57
Ostomy pouch, drainable; for use on barrier with
							 locking flange (two piece system), each
A4427
2.62
Ostomy pouch, drainable; for use on barrier with
							 locking flange, with filter (two piece system), each
A4428
6.12
Ostomy pouch, urinary, with extended wear barrier
							 attached, with faucet-type tap with valve (one piece), each
A4429
7.75
Ostomy pouch, urinary, with barrier attached, with
							 built-in convexity, with faucet-type tap with valve (one piece),
							 each
A4430
8.00
Ostomy pouch, urinary, with extended wear barrier
							 attached, with built-in convexity, with faucet-type tap with valve (one piece),
							 each
A4431
5.84
Ostomy pouch, urinary; with barrier attached, with
							 faucet-type tap with valve (one piece), each
A4432
3.37
Ostomy pouch, urinary; for use on barrier with
							 non-locking flange, with faucet-type tap with valve (two piece),
							 each
A4433
3.15
Ostomy pouch, urinary; for use on barrier with
							 locking flange (two piece), each
A4434
3.53
Ostomy pouch, urinary; for use on barrier with
							 locking flange, with faucet-type tap with valve (two piece), each
A4435
5.42
Ostomy pouch, drainable, high output, with extended
							 wear barrier (one-piece system), with or without filter, each
A4436
16.95
Irrigation supply: sleeve, reusable, per
							 month
A4437
16.95
Irrigation supply: sleeve disposable, per
							 month
Miscellaneous Supplies
A4450AU
0.08
Tape, non-waterproof, per 18 square
							 inches
A4450AV
0.08
Tape, non-waterproof, per 18 square
							 inches
A4450AW
0.10
Tape, non-waterproof, per 18 square
							 inches
A4452AU
0.34
Tape, waterproof, per 18 square inches
A4452AV
0.34
Tape, waterproof, per 18 square inches
A4452AW
0.37
Tape, waterproof, per 18 square inches
A4455
1.34
Adhesive remover or solvent (for tape, cement or
							 other adhesive), per ounce
A4456
0.23
Adhesive remover, wipes, any type, each
A4458
AAC+20%
Enema bag with tubing, reusable
A4459
AAC+20%
Manual pump-operated enema system, includes balloon,
							 catheter and all accessories, reusable, any type
A4461
3.09
Surgical dressing holder, non-reusable,
							 each
A4463
12.51
Surgical dressing holder, reusable, each
A4465
11.52
Non-elastic binder for extremity
A4467
AAC+20%
Belt, strap, sleeve, garment, or covering, any
							 type
A4470
AAC+20%
Gravlee jet washer
A4480
AAC+20%
Vabra aspirator
A4481
0.35
Tracheostoma filter, any type, any size,
							 each
A4483
69.60
Moisture exchanger, disposable, for use with invasive
							 mechanical ventilation
A4490
7.26
Surgical stockings above knee length,
							 each
A4495
28.85
Surgical stockings thigh length, each
A4500
8.22
Surgical stockings below knee length,
							 each
A4510
11.61
Surgical stockings full length, each
A4520
AAC+20%
Incontinence garment, any type
							 (
e.g.
, brief, diaper), each
A4550
1.52
Surgical trays
A4553
AAC+20%
Non-disposable underpads, all sizes
A4554
0.29
Disposable underpads, all sizes,
							 (
e.g.
, Chux's)
A4555
AAC+20%
Electrode/transducer for use with electrical
							 stimulation device used for cancer treatment, replacement only
A4556
9.71
Electrodes, (
e.g.
, apnea monitor),
							 per pair
A4557
16.65
Lead wires, (
e.g.
, apnea monitor),
							 per pair
A4558
4.36
Conductive gel or paste, for use with electrical
							 device (
e.g.
, TENS, NMES), per oz
A4559
0.09
Coupling gel or paste, for use with ultrasound
							 device, per oz
A4561
18.75
Pessary, rubber, any type
A4562
46.68
Pessary, non rubber, any type
A4565
7.23
Slings
A4566
AAC+20%
Shoulder sling or vest design, abduction restrainer,
							 with or without swathe control, prefabricated, includes fitting and
							 adjustment
A4570
AAC+20%
Splint
A4575
AAC+20%
Topical hyperbaric oxygen chamber,
							 disposable
A4580
AAC+20%
Cast supplies (
e.g.
plaster)
A4590
AAC+20%
Special casting material (
e.g.
fiberglass)
A4595
20.65
Electrical stimulator supplies, two lead, per month,
							 (
e.g.
TENS, NMES)
A4600
AAC+20%
Sleeve for intermittent limb compression device,
							 replacement only, each
A4601
AAC+20%
Lithium ion battery, rechargeable, for non-prosthetic
							 use, replacement
A4602
3.49
Replacement battery for external infusion pump owned
							 by patient, lithium, 1.5 volt, each
A4604NU
46.16
Tubing with integrated heating element for use with
							 positive airway pressure device
A4605NU
15.41
Tracheal suction catheter, closed system,
							 each
A4606
AAC+20%
Oxygen probe for use with oximeter device,
							 replacement
A4608
47.10
Transtracheal oxygen catheter, each
Supplies for Oxygen and Related Respiratory
							 Equipment
A4611NU
175.33
Battery, heavy duty; replacement for patient owned
							 ventilator (new equipment)
A4611RR
18.18
Battery, heavy duty; replacement for patient owned
							 ventilator (rental)
A4611UE
131.50
Battery, heavy duty; replacement for patient owned
							 ventilator (used durable medical equipment)
A4612NU
71.34
Battery cables; replacement for patient-owned
							 ventilator (new equipment)
A4612RR
7.27
Battery cables; replacement for patient-owned
							 ventilator (rental)
A4612UE
54.40
Battery cables; replacement for patient-owned
							 ventilator (used durable medical equipment)
A4613NU
109.40
Battery charger; replacement for patient-owned
							 ventilator (new equipment)
A4613RR
10.95
Battery charger; replacement for patient-owned
							 ventilator (rental)
A4613UE
79.12
Battery charger; replacement for patient-owned
							 ventilator (used durable medical equipment)
A4614
22.35
Peak expiratory flow rate meter, hand
							 held
A4615
0.68
Cannula, nasal
A4616
0.06
Tubing (oxygen), per foot
A4617
2.92
Mouth piece
A4618NU
8.36
Breathing circuits
A4618RR
0.97
Breathing circuits
A4618UE
6.26
Breathing circuits
A4619NU
1.68
Face tent
A4620
0.56
Variable concentration mask
A4623
6.15
Tracheostomy, inner cannula
A4623UA
AAC+30%
Tracheostomy, inner cannula (customized nonstandard
							 size for adults for MassHealth members only)
A4623UC
AAC+30%
Tracheostomy, inner cannula (customized nonstandard
							 size for children for MassHealth members only)
A4624NU
2.10
Tracheal suction catheter, any type other than closed
							 system, each
A4625
5.53
Tracheostomy care kit for new
							 tracheostomy
A4626
3.00
Tracheostomy cleaning brush, each
A4627
13.28
Spacer, bag or reservoir, with or without mask, for
							 use with metered dose inhaler
A4628NU
3.51
Oropharyngeal suction catheter, each
A4629
4.36
Tracheostomy care kit for established
							 tracheostomy
Supplies for Other Durable Medical
							 Equipment
A4630NU
5.87
Replacement batteries, medically necessary,
							 transcutaneous electrical stimulator, owned by patient
A4633NU
38.56
Replacement bulb/lamp for ultraviolet light therapy
							 system, each
A4634
AAC+20%
Replacement bulb for therapeutic light box, tabletop
							 model
A4635NU
4.81
Underarm pad, crutch, replacement, each (new
							 equipment)
A4635RR
0.65
Underarm pad, crutch, replacement, each
							 (rental)
A4635UE
3.20
Underarm pad, crutch, replacement, each (used durable
							 medical equipment)
A4636NU
2.95
Replacement, handgrip, cane, crutch, or walker, each
							 (new equipment)
A4636RR
0.30
Replacement, handgrip, cane, crutch, or walker, each
							 (rental)
A4636UE
2.18
Replacement, handgrip, cane, crutch, or walker, each
							 (used durable medical equipment)
A4637NU
1.56
Replacement, tip, cane, crutch, walker, each (new
							 equipment)
A4637RR
0.19
Replacement, tip, cane, crutch, walker, each
							 (rental)
A4637UE
1.17
Replacement, tip, cane, crutch, walker, each (used
							 durable medical equipment)
A4638NU
AAC+20%
Replacement battery for patient-owned ear pulse
							 generator, each (new equipment)
A4638RR
I.C.
Replacement battery for patient-owned ear pulse
							 generator, each (rental)
A4638UE
I.C.
Replacement battery for patient-owned ear pulse
							 generator, each (used durable medical equipment)
A4639KH
27.00
Replacement pad for infrared heating pad system, each
							 (capped rental)
A4639KI
27.00
Replacement pad for infrared heating pad system, each
							 (capped rental)
A4639KJ
20.25
Replacement pad for infrared heating pad system, each
							 (capped rental)
A4639NU
269.96
Replacement pad for infrared heating pad system, each
							 (new equipment)
A4639UE
202.47
Replacement pad for infrared heating pad system, each
							 (used durable medical equipment)
A4640NU
50.46
Replacement pad for use with medically necessary
							 alternating pressure pad owned by patient (new equipment)
A4640RR
5.10
Replacement pad for use with medically necessary
							 alternating pressure pad owned by patient (rental)
A4640UE
36.61
Replacement pad for use with medically necessary
							 alternating pressure pad owned by patient (used durable medical
							 equipment)
A4649
AAC+20%
Surgical supplies, miscellaneous
Dialysis Supplies
A4651
AAC+20%
Calibrated microcapillary tube, each
A4652
AAC+20%
Microcapillary tube sealant
A4653
AAC+20%
Peritoneal dialysis catheter anchoring device, belt,
							 each
A4657
AAC+20%
Syringe, with or without needle, each
A4660
44.52
Sphygmomanometer/blood pressure apparatus with cuff
							 and stethoscope
A4663
30.08
Blood pressure cuff only
A4670
63.57
Automatic blood pressure monitor
A4671
AAC+20%
Disposable cycler set used with cycler dialysis
							 machine, each
A4672
AAC+20%
Drainage extension line, sterile, for dialysis,
							 each
A4673
AAC+20%
Extension line with easy lock connectors, used with
							 dialysis
A4674
AAC+20%
Chemicals/antiseptics solution used to
							 clean/sterilize dialysis equipment, per 8 oz
A4680
AAC+20%
Activated carbon filter for hemodialysis,
							 each
A4690
AAC+20%
Dialyzer (artificial kidneys), all types, all sizes,
							 for hemodialysis, each
A4706
AAC+20%
Bicarbonate concentrate, solution, for hemodialysis,
							 per gallon
A4707
AAC+20%
Bicarbonate concentrate, powder, for hemodialysis,
							 per packet
A4708
AAC+20%
Acetate concentrate solution, for hemodialysis, per
							 gallon
A4709
AAC+20%
Acid concentrate, solution, for hemodialysis, per
							 gallon
A4714
AAC+20%
Treated water (deionized, distilled, or reverse
							 osmosis) for peritoneal dialysis, per gallon
A4719
AAC+20%
Y set tubing for peritoneal dialysis
A4720
AAC+20%
Dialysate solution, any concentration of dextrose,
							 fluid volume greater than 249cc, but less than or equal to 999cc, for
							 peritoneal dialysis
A4721
AAC+20%
Dialysate solution, any concentration of dextrose,
							 fluid volume greater than 999cc but less than or equal to 1999cc, for
							 peritoneal dialysis
A4722
AAC+20%
Dialysate solution, any concentration of dextrose,
							 fluid volume greater than 1999cc but less than or equal to 2999cc, for
							 peritoneal dialysis
A4723
AAC+20%
Dialysate solution, any concentration of dextrose,
							 fluid volume greater than 2999cc but less than or equal to 3999cc, for
							 peritoneal dialysis
A4724
AAC+20%
Dialysate solution, any concentration of dextrose,
							 fluid volume greater than 3999cc but less than or equal to 4999cc, for
							 peritoneal dialysis
A4725
AAC+20%
Dialysate solution, any concentration of dextrose,
							 fluid volume greater than 4999cc but less than or equal to 5999cc, for
							 peritoneal dialysis
A4726
AAC+20%
Dialysate solution, any concentration of dextrose,
							 fluid volume greater than 5999cc, for peritoneal dialysis
A4728
AAC+20%
Dialysate solution, non-dextrose containing, 500
							 ml
A4730
AAC+20%
Fistula cannulation set for hemodialysis,
							 each
A4736
AAC+20%
Topical anesthetic, for dialysis, per
							 gram
A4737
AAC+20%
Injectable anesthetic, for dialysis, per 10
							 ml
A4740
AAC+20%
Shunt accessory, for hemodialysis, any type,
							 each
A4750
AAC+20%
Blood tubing, arterial or venous, for hemodialysis,
							 each
A4755
AAC+20%
Blood tubing, arterial and venous combined, for
							 hemodialysis, each
A4760
AAC+20%
Dialysate solution test kit, for peritoneal dialysis,
							 any type, each
A4765
AAC+20%
Dialysate concentrate, powder, additive for
							 peritoneal dialysis, per packet
A4766
AAC+20%
Dialysate concentrate, solution, additive for
							 peritoneal dialysis, per 10 ml
A4770
AAC+20%
Blood collection tube, vacuum, for dialysis, per
							 50
A4771
AAC+20%
Serum clotting time tube, for dialysis, per
							 50
A4773
AAC+20%
Occult blood test strips, for dialysis, per
							 50
A4774
AAC+20%
Ammonia test strips, for dialysis, per 50
A4802
AAC+20%
Protamine sulfate, for hemodialysis, per 50
							 mg
A4860
AAC+20%
Disposable catheter tips for peritoneal dialysis, per
							 10
A4870
AAC+20%
Plumbing and/or electrical work for home hemodialysis
							 equipment
A4890
AAC+20%
Contracts, repair and maintenance, for hemodialysis
							 equipment
A4911
AAC+20%
Drain bag/bottle, for dialysis, each
A4913
AAC+20%
Miscellaneous dialysis supplies, not otherwise
							 specified
A4918
AAC+20%
Venous pressure clamp, for hemodialysis,
							 each
A4927
7.89
Gloves, non-sterile, per 100
A4930
0.36
Gloves, sterile, per pair
A4931
AAC+20%
Oral thermometer, reusable, any type,
							 each
A4932
AAC+20%
Rectal thermometer, reusable, any type,
							 each
Ostomy Pouches and Supplies
A5051
1.94
Ostomy pouch, closed; with barrier attached (one
							 piece), each
A5052
1.39
Ostomy pouch, closed; without barrier attached (one
							 piece), each
A5053
1.39
Ostomy pouch, closed; for use on faceplate,
							 each
A5054
1.69
Ostomy pouch, closed; for use on barrier with flange
							 (two piece), each
A5055
1.35
Stoma cap
A5056
4.39
Ostomy pouch, drainable, with extended wear barrier
							 attached, with filter, (one piece), each
A5057
9.03
Ostomy pouch, drainable, with extended wear barrier
							 attached, with built in convexity, with filter, (one piece), each
A5061
3.32
Ostomy pouch, drainable; with barrier attached, (one
							 piece), each
A5062
2.09
Ostomy pouch, drainable; without barrier attached
							 (one piece), each
A5063
2.54
Ostomy pouch, drainable; for use on barrier with
							 flange (two piece system), each
A5071
5.64
Ostomy pouch, urinary; with barrier attached (one
							 piece), each
A5072
3.32
Ostomy pouch, urinary; without barrier attached (one
							 piece), each
A5073
2.99
Ostomy pouch, urinary; for use on barrier with flange
							 (two piece), each
A5081
3.11
Stoma plug or seal, any type
A5082
11.18
Continent device; catheter for continent
							 stoma
A5083
0.60
Continent device, stoma absorptive cover for
							 continent stoma
A5093
1.84
Ostomy accessory; convex insert
Incontinence Supplies
A5102
21.06
Bedside drainage bottle with or without tubing, rigid
							 or expandable, each
A5105
32.56
Urinary suspensory; with or without leg bag, with or
							 without tube, each
A5112
28.13
Urinary drainage bag, leg or abdomen, latex, with or
							 without tube, with straps, each
A5113
4.20
Leg strap; latex, replacement only, per
							 set
A5114
7.16
Leg strap; foam or fabric, replacement only, per
							 set
A5120AU
0.23
Skin barrier, wipes or swabs, each
A5120AV
0.26
Skin barrier, wipes or swabs, each
A5121
6.94
Skin barrier; solid, 6 x 6 or equivalent,
							 each
A5122
10.26
Skin barrier; solid, 8 x 8 or equivalent,
							 each
A5126
1.23
Adhesive or non-adhesive; disk or foam
							 pad
A5131
14.90
Appliance cleaner, incontinence and ostomy
							 appliances, per 16 oz.
A5200
10.63
Percutaneous catheter/tube anchoring device, adhesive
							 skin attachment
Dressings
A6000
AAC+20%
Non-contact wound warming wound cover for use with
							 the non-contact wound warming device and warming card
A6010
29.10
Collagen based wound filler, dry form, sterile, per
							 gram of collagen
A6011
2.14
Collagen based wound filler, gel/paste, per gram of
							 collagen
A6021
19.75
Collagen dressing, sterile, size 16 sq. in. or less,
							 each
A6022
19.75
Collagen dressing, sterile, size more than 16 sq. in.
							 but less than or equal to 48 sq. in., each
A6023
178.83
Collagen dressing, sterile, size more than 48 sq.
							 in., each
A6024
5.81
Collagen dressing wound filler, sterile, per 6
							 inches
A6025
AAC+20%
Gel sheet for dermal or epidermal application,
							 (
e.g.
, silicone, hydrogel, other), each
A6154
13.52
Wound pouch, each
A6196
6.91
Alginate or other fiber gelling dressing, wound
							 cover, sterile, pad size 16 sq. in. or less, each dressing
A6197
15.44
Alginate or other fiber gelling dressing, wound
							 cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq.
							 in., each dressing
A6198
AAC+20%
Alginate or other fiber gelling dressing, wound
							 cover, sterile, pad size more than 48 sq. in., each dressing
A6199
4.97
Alginate or other fiber gelling dressing, wound
							 filler, sterile, per 6 inches
A6203
3.16
Composite dressing, sterile, pad size 16 sq. in. or
							 less, with any size adhesive border, each dressing
A6204
5.85
Composite dressing, sterile, pad size more than 16
							 sq. in. but less than or equal to 48 sq. in., with any size adhesive border,
							 each dressing
A6205
14.64
Composite dressing, sterile, pad size more than 48
							 sq. in., with any size adhesive border, each dressing
A6206
AAC+20%
Contact layer, sterile, 16 sq. in. or less, each
							 dressing
A6207
6.89
Contact layer, sterile, more than 16 sq. in. but less
							 than or equal to 48 sq. in., each dressing
A6208
AAC+20%
Contact layer, sterile, more than 48 sq. in., each
							 dressing
A6209
7.02
Foam dressing, wound cover, sterile, pad size 16 sq.
							 in. or less, without adhesive border, each dressing
A6210
18.73
Foam dressing, wound cover, sterile, pad size more
							 than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border,
							 each dressing
A6211
27.60
Foam dressing, wound cover, sterile, pad size more
							 than 48 sq. in., without adhesive border, each dressing
A6212
9.12
Foam dressing, wound cover, sterile, pad size 16 sq.
							 in. or less, with any size adhesive border, each dressing
A6213
9.25
Foam dressing, wound cover, sterile, pad size more
							 than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive
							 border, each dressing
A6214
9.66
Foam dressing, wound cover, sterile, pad size more
							 than 48 sq. in., with any size adhesive border, each dressing
A6215
AAC+20%
Foam dressing, wound filler, sterile, per
							 gram
A6216
0.04
Gauze, non-impregnated, non-sterile, pad size 16 sq.
							 in. or less, without adhesive border, each dressing
A6217
0.18
Gauze, non-impregnated, non-sterile, pad size more
							 than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border,
							 each dressing
A6218
0.57
Gauze, non-impregnated, non-sterile, pad size more
							 than 48 sq. in., without adhesive border, each dressing
A6219
0.90
Gauze, non-impregnated, sterile, pad size 16 sq. in.
							 or less, with any size adhesive border, each dressing
A6220
2.43
Gauze, non-impregnated, sterile, pad size more than
							 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border,
							 each dressing
A6221
AAC+20%
Gauze, non-impregnated, sterile, pad size more than
							 48 sq. in., with any size adhesive border, each dressing
A6222
2.00
Gauze, impregnated with other than water, normal
							 saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive
							 border, each dressing
A6223
2.28
Gauze, impregnated with other than water, normal
							 saline, or hydrogel, sterile, pad size more than 16 square inches, but less
							 than or equal to 48 square inches, without adhesive border, each
							 dressing
A6224
3.39
Gauze, impregnated with other than water, normal
							 saline, or hydrogel, sterile, pad size more than 48 square inches, without
							 adhesive border, each dressing
A6228
AAC+20%
Gauze, impregnated, water or normal saline, sterile,
							 pad size 16 sq. in. or less, without adhesive border, each dressing
A6229
3.39
Gauze, impregnated, water or normal saline, sterile,
							 pad size more tha 16 sq. in. but less than or equal to 48 sq. in., without
							 adhesive border, each dressing
A6230
AAC+20%
Gauze, impregnated, water or normal saline, sterile,
							 pad size more than 48 sq. in., without adhesive border, each
							 dressing
A6231
4.39
Gauze, impregnated, hydrogel, for direct wound
							 contact, sterile, pad size 16 sq. in. or less, each dressing
A6232
6.45
Gauze, impregnated, hydrogel, for direct wound
							 contact, sterile, pad size greater than 16 sq. in., but less than or equal to
							 48 sq. in., each dressing
A6233
18.02
Gauze, impregnated, hydrogel for direct wound
							 contact, sterile, pad size more than 48 sq. in., each dressing
A6234
6.15
Hydrocolloid dressing, wound cover, sterile, pad size
							 16 sq. in. or less, without adhesive border, each dressing
A6235
15.80
Hydrocolloid dressing, wound cover, sterile, pad size
							 more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive
							 border, each dressing
A6236
25.61
Hydrocolloid dressing, wound cover, sterile, pad size
							 more than 48 sq. in., without adhesive border, each dressing
A6237
7.44
Hydrocolloid dressing, wound cover, sterile, pad size
							 16 sq. in. or less, with any size adhesive border, each dressing
A6238
21.42
Hydrocolloid dressing, wound cover, sterile, pad size
							 more than 16 sq. in. but less than or equal to 48 sq. in., with any size
							 adhesive border, each dressing
A6239
20.53
Hydrocolloid dressing, wound cover, sterile, pad size
							 more than 48 sq. in., with any size adhesive border, each dressing
A6240
11.51
Hydrocolloid dressing, wound filler, paste, sterile,
							 per fluid ounce
A6241
2.41
Hydrocolloid dressing, wound filler, dry form,
							 sterile, per gram
A6242
5.70
Hydrogel dressing, wound cover, sterile, pad size 16
							 sq. in. or less, without adhesive border, each dressing
A6243
11.58
Hydrogel dressing, wound cover, sterile, pad size
							 more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive
							 border, each dressing
A6244
36.92
Hydrogel dressing, wound cover, sterile, pad size
							 more than 48 sq. in., without adhesive border, each dressing
A6245
6.83
Hydrogel dressing, wound cover, sterile, pad size 16
							 sq. in. or less, with any size adhesive border, each dressing
A6246
9.33
Hydrogel dressing, wound cover, sterile, pad size
							 more than 16 sq. in. but less than or equal to 48 sq. in., with any size
							 adhesive border, each dressing
A6247
22.35
Hydrogel dressing, wound cover, sterile, pad size
							 more than 48 sq. in., with any size adhesive border, each dressing
A6248
15.27
Hydrogel dressing, wound filler, gel, per fluid
							 ounce
A6250
9.21
Skin sealants, protectants, moisturizers, ointments,
							 any type, any size
A6251
1.87
Specialty absorptive dressing, wound cover, sterile,
							 pad size 16 sq. in. or less, without adhesive border, each dressing
A6252
3.06
Specialty absorptive dressing, wound cover, sterile,
							 pad size more than 16 sq. in. but less than or equal to 48 sq. in., without
							 adhesive border, each dressing
A6253
5.95
Specialty absorptive dressing, wound cover, sterile,
							 pad size more than 48 sq. in., without adhesive border, each
							 dressing
A6254
5.95
Specialty absorptive dressing, wound cover, sterile,
							 pad size 16 sq. in. or less, with any size adhesive border, each
							 dressing
A6255
1.13
Specialty absorptive dressing, wound cover, sterile,
							 pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any
							 size adhesive border, each dressing
A6256
1.38
Specialty absorptive dressing, wound cover, sterile,
							 pad size more than 48 sq. in., with any size adhesive border, each
							 dressing
A6257
1.45
Transparent film, sterile, 16 sq. in. or less, each
							 dressing
A6258
4.05
Transparent film, sterile, more than 16 sq. in. but
							 less than or equal to 48 sq. in., each dressing
A6259
10.29
Transparent film, sterile, more than 48 sq. in., each
							 dressing
A6260
11.23
Wound cleansers, any type, any size
A6261
AAC+20%
Wound filler, gel/paste, per fluid ounce, not
							 otherwise specified
A6262
0.97
Wound filler, dry form, per gram, not otherwise
							 specified
A6266
1.81
Gauze, impregnated, other than water, normal saline,
							 or zinc paste, sterile, any width, per linear yard
A6402
0.11
Gauze, non-impregnated, sterile, pad size 16 sq. in.
							 or less, without adhesive border, each dressing
A6403
0.40
Gauze, non-impregnated, sterile, pad size more than
							 16 sq. in. less than or equal to 48 sq. in., without adhesive border, each
							 dressing
A6404
0.64
Gauze, non-impregnated, sterile, pad size more than
							 48 sq. in., without adhesive border, each dressing
A6407
1.77
Packing strips, non-impregnated, sterile, up to 2
							 inch in width, per linear yard
A6410
0.37
Eye pad, sterile, each
A6411
AAC+20%
Eye pad, non-sterile, each
A6412
AAC+20%
Eye patch, occlusive, each
A6413
AAC+20%
Adhesive bandage, first-aid type, any size,
							 each
A6441
0.64
Padding bandage, non-elastic, non-woven/non-knitted,
							 width greater than or equal to three inches and less than five inches, per
							 yard
A6442
0.15
Conforming bandage, non-elastic, knitted/woven,
							 non-sterile, width less than three inches, per yard
A6443
0.26
Conforming bandage, non-elastic, knitted/woven,
							 non-sterile, width greater than or equal to three inches and less than five
							 inches, per yard
A6444
0.53
Conforming bandage, non-elastic, knitted/woven,
							 non-sterile, width greater than five inches, per yard
A6445
0.31
Conforming bandage, non-elastic, knitted/woven,
							 sterile, width less than three inches, per yard
A6446
0.38
Conforming bandage, non-elastic, knitted/woven,
							 sterile, width greater than or equal to three inches and less than five inches,
							 per yard
A6447
0.64
Conforming bandage, non-elastic, knitted/woven,
							 sterile, width greater than or equal to five inches, per yard
A6448
1.09
Light compression bandage, elastic, knitted/woven,
							 width less than three inches, per yard
A6449
1.65
Light compression bandage, elastic, knitted/woven,
							 width greater than or equal to three inches and less than five inches, per
							 yard
A6450
AAC+20%
Light compression bandage, elastic, knitted/woven,
							 width greater than or equal to five inches, per yard
A6451
AAC+20%
Moderate compression bandage, elastic, knitted/woven,
							 load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width
							 greater than or equal to three inches or less than five inches, per
							 yard
A6452
5.55
High compression bandage, elastic, knitted/woven,
							 load resistance greater than or equal to 1.35 foot pounds at 50% maximum
							 stretch, width greater than or equal to three inches or less than five inches,
							 per yard
A6453
0.59
Self-adherent bandage, elastic,
							 non-knitted/non-woven, less than three inches, per yard
A6454
0.73
Self-adherent bandage, elastic,
							 non-knitted/non-woven, width greater than or equal to three inches and less
							 than five inches, per yard
A6455
1.31
Self-adherent bandage, elastic,
							 non-knitted/non-woven, width greater than or equal to five inches, per
							 yard
A6456
1.19
Zinc paste impregnated bandage, non-elastic,
							 knitted/woven, width greater than or equal to three inches and less than five
							 inches, per yard
A6457
1.07
Tubular dressing with or without elastic, any width,
							 per linear yard
A6460
AAC+20%
Synthetic resorbable wound dressing, sterile, pad
							 size 16 sq. in. or less, without adhesive border, each dressing
A6461
AAC+20%
Synthetic resorbable wound dressing, sterile, pad
							 size more than 16 sq. in. but less than or equal to 48 sq. in., without
							 adhesive border, each dressing
Compression Garments
A6501
AAC+20%
Compression burn garment, bodysuit (head to foot),
							 custom fabricated
A6502
AAC+20%
Compression burn garment, chin strap, custom
							 fabricated
A6503
AAC+20%
Compression burn garment, facial hood, custom
							 fabricated
A6504
AAC+20%
Compression burn garment, glove to wrist, custom
							 fabricated
A6505
AAC+20%
Compression burn garment, glove to elbow, custom
							 fabricated
A6506
AAC+20%
Compression burn garment, glove to axilla, custom
							 fabricated
A6507
AAC+20%
Compression burn garment, foot to knee length, custom
							 fabricated
A6508
AAC+20%
Compression burn garment, foot to thigh length,
							 custom fabricated
A6509
AAC+20%
Compression burn garment, upper trunk to waist
							 including arm openings (vest), custom fabricated
A6510
AAC+20%
Compression burn garment, trunk, including arms down
							 to leg openings (leotard), custom fabricated
A6511
AAC+20%
Compression burn garment, lower trunk including leg
							 openings (panty), custom fabricated
A6512
AAC+20%
Compression burn garment, not otherwise
							 classified
A6513
AAC+20%
Compression burn mask, face/neck
A6550
21.28
Wound care set, for negative pressure wound therapy
							 electrical pump, includes all supplies and accessories
Respiratory Supplies
A7000NU
6.73
Canister, disposable, used with suction pump, each
							 (new equipment)
A7001NU
29.42
Canister, non-disposable, used with suction pump,
							 each
A7002NU
3.41
Tubing, used with suction pump, each
A7003NU
2.13
Administration set, with small volume nonfiltered
							 pneumatic nebulizer, disposable
A7004NU
1.32
Small volume nonfiltered pneumatic nebulizer,
							 disposable
A7005NU
22.88
Administration set, with small volume nonfiltered
							 pneumatic nebulizer, non-disposable
A7006NU
8.02
Administration set, with small volume filtered
							 pneumatic nebulizer
A7007NU
3.85
Large volume nebulizer, disposable, unfilled, used
							 with aerosol compressor
A7008NU
10.34
Large volume nebulizer, disposable, prefilled, used
							 with aerosol compressor
A7009NU
37.38
Reservoir bottle, non-disposable, used with large
							 volume ultrasonic nebulizer
A7010NU
19.69
Corrugated tubing, disposable, used with large volume
							 nebulizer, 100 feet
A7012NU
3.30
Water collection device, used with large volume
							 nebulizer
A7013NU
0.67
Filter, disposable, used with aerosol compressor or
							 ultrasonic generator
A7014NU
3.80
Filter, nondisposable, used with aerosol compressor
							 or ultrasonic generator
A7015NU
1.56
Aerosol mask, used with DME nebulizer
A7016NU
6.43
Dome and mouthpiece, used with small volume
							 ultrasonic nebulizer
A7017NU
125.19
Nebulizer, durable, glass or autoclavable plastic,
							 bottle type, not used with oxygen (new equipment)
A7017RR
12.52
Nebulizer, durable, glass or autoclavable plastic,
							 bottle type, not used with oxygen (rental)
A7017UE
93.89
Nebulizer, durable, glass or autoclavable plastic,
							 bottle type, not used with oxygen (used durable medical equipment)
A7018
0.33
Water, distilled, used with large volume nebulizer,
							 1000 ml
A7020
13.11
Interface for cough stimulating device, includes all
							 components, replacement only
A7025KH
40.88
High frequency chest wall oscillation system vest,
							 replacement for use with patient owned equipment, each (capped
							 rental)
A7025KI
40.88
High frequency chest wall oscillation system vest,
							 replacement for use with patient owned equipment, each (capped
							 rental)
A7025KJ
30.66
High frequency chest wall oscillation system vest,
							 replacement for use with patient owned equipment, each (capped
							 rental)
A7025NU
408.77
High frequency chest wall oscillation system vest,
							 replacement for use with patient owned equipment, each (new
							 equipment)
A7025UE
306.58
High frequency chest wall oscillation system vest,
							 replacement for use with patient owned equipment, each (used durable medical
							 equipment)
A7026NU
27.01
High frequency chest wall oscillation system hose,
							 replacement for use with patient owned equipment, each
A7027NU
138.24
Combination oral/nasal mask, used with continuous
							 positive airway pressure device, each
A7028NU
40.71
Oral cushion for combination oral/nasal mask,
							 replacement only, each
A7029NU
16.71
Nasal pillows for combination oral/nasal mask,
							 replacement only, pair
A7030NU
122.43
Full face mask used with positive airway pressure
							 device, each
A7031NU
46.07
Face mask interface, replacement for full face mask,
							 each
A7032NU
26.11
Cushion for use on nasal mask interface, replacement
							 only, each
A7033NU
18.77
Pillow for use on nasal cannula type interface,
							 replacement only, pair
A7034NU
75.89
Nasal interface (mask or cannula type) used with
							 positive airway pressure device, with or without head strap
A7035NU
24.17
Headgear used with positive airway pressure
							 device
A7036NU
12.44
Chinstrap used with positive airway pressure
							 device
A7037NU
23.47
Tubing used with positive airway pressure
							 device
A7038NU
2.90
Filter, disposable, used with positive airway
							 pressure device
A7039NU
9.48
Filter, non disposable, used with positive airway
							 pressure device
A7040
37.09
One way chest drain valve
A7041
69.72
Water seal drainage container and tubing for use with
							 implanted chest tube
A7042
164.90
Implanted pleural catheter, each
A7043
26.13
Vacuum drainage bottle and tubing for use with
							 implanted catheter
A7044NU
84.39
Oral interface used with positive airway pressure
							 device, each
A7045NU
13.43
Exhalation port with or without swivel used with
							 accessories for positive airway devices, replacement only (new
							 equipment)
A7045RR
1.34
Exhalation port with or without swivel used with
							 accessories for positive airway devices, replacement only (rental)
A7045UE
10.08
Exhalation port with or without swivel used with
							 accessories for positive airway devices, replacement only (used durable medical
							 equipment)
A7046NU
13.88
Replacement water chamber for humidifier, used with
							 positive pressure device, each
A7047
113.61
Oral interface used with respiratory suction pump,
							 each
A7048
46.48
Vacuum drainage collection and tubing kit, including
							 all supplies needed for collection unit change, for use with implanted
							 catheter, each
Tracheostomy Supplies
A7501
98.69
Tracheostoma valve, including diaphragm,
							 each
A7502
46.91
Replacement diaphragm/faceplate for tracheostoma
							 valve, each
A7503
10.66
Filter holder or filter cap, reusable, for use in a
							 tracheostoma heat and moisture exchange system, each
A7504
0.64
Filter for use in a tracheostoma heat and moisture
							 exchange system, each
A7505
4.40
Housing, reusable without adhesive, for use in a heat
							 and moisture exchange system and/or with a tracheostoma valve, each
A7506
0.31
Adhesive disc for use in a heat and moisture exchange
							 system and/or with tracheostoma valve, any type each
A7507
2.34
Filter holder and integrated filter without adhesive,
							 for use in a tracheostoma heat and moisture exchange system, each
A7508
2.69
Housing and integrated adhesive, for use in a
							 tracheostoma heat and moisture exchange system and/or with a tracheostoma
							 valve, each
A7509
1.33
Filter holder and integrated filter housing, and
							 adhesive, for use as a tracheostoma heat and moisture exchange system,
							 each
A7520NU
44.62
Tracheostomy/laryngectomy tube, non-cuffed,
							 polyvinyalchloride (PVC), silicone or equal, each
A7520UA
AAC+30%
Tracheostomy/laryngectomy tube, non-cuffed,
							 polyvinyalchloride (PVC), silicone or equal, each (customized nonstandard size
							 for adults for MassHealth members only)
A7520UC
AAC+30%
Tracheostomy/laryngectomy tube, non-cuffed,
							 polyvinyalchloride (PVC), silicone or equal, each (customized nonstandards for
							 children for MassHealth members only)
A7521NU
44.20
Tracheostomy/laryngectomy tube, cuffed,
							 polyvinyalchloride (PVC), silicone or equal, each
A7521UA
AAC+30%
Tracheostomy/laryngectomy tube, cuffed,
							 polyvinyalchloride (PVC), silicone or equal, each (customized nonstandard size
							 for adults for MassHealth members only)
A7521UC
AAC+30%
Tracheostomy/laryngectomy tube, cuffed,
							 polyvinyalchloride (PVC), silicone or equal, each (customized nonstandard size
							 for children for MassHealth members only)
A7522NU
42.44
Tracheostomy/laryngectomy tube, stainless steel
							 [sterilizable and reusable], each
A7522UC
AAC+20%
Tracheostomy/laryngectomy tube, stainless steel
							 [sterilizable and reusable], each (pediatric specialized rehabilitation
							 equipment)
A7523
AAC+20%
Tracheostomy shower protector, each
A7524
72.74
Tracheostoma stent/stud/button, each
A7525
1.94
Tracheostomy mask, each
A7526
3.18
Tracheostomy tube collar/holder, each
A7527
3.37
Tracheostomy/laryngectomy tube plug, each
Protective Helmet
A8000NU
144.11
Helmet, protective, soft, prefabricated, includes all
							 components and accessories (new equipment)
A8000RR
14.41
Helmet, protective, soft, prefabricated, includes all
							 components and accessories (rental)
A8000UE
108.10
Helmet, protective, soft, prefabricated, includes all
							 components and accessories (used durable medical equipment)
A8001NU
144.11
Helmet, protective, hard, prefabricated, includes all
							 components and accessories (new equipment)
A8001RR
14.41
Helmet, protective, hard, prefabricated, includes all
							 components and accessories (rental)
A8001UE
108.10
Helmet, protective, hard, prefabricated, includes all
							 components and accessories (used durable medical equipment)
A8002NU
AAC+30%
Helmet, protective, soft, custom fabricated, includes
							 all components and accessories (new equipment)
A8002RR
I.C.
Helmet, protective, soft, custom fabricated, includes
							 all components and accessories (rental)
A8002UE
I.C.
Helmet, protective, soft, custom fabricated, includes
							 all components and accessories (used durable medical equipment)
A8003NU
AAC+30%
Helmet, protective, hard, custom fabricated, includes
							 all components and accessories (new equipment)
A8003RR
I.C.
Helmet, protective, hard, custom fabricated, includes
							 all components and accessories (rental)
A8003UE
I.C.
Helmet, protective, hard, custom fabricated, includes
							 all components and accessories (used durable medical equipment)
A8004NU
AAC+30%
Soft interface for helmet, replacement only (new
							 equipment)
A8004RR
I.C.
Soft interface for helmet, replacement only
							 (rental)
A8004UE
I.C.
Soft interface for helmet, replacement only (used
							 durable medical equipment)
Other Supplies and Devices
A9272
AAC+20%
Wound suction, disposable, includes dressing, all
							 accessories and components, any type, each
A9273
AAC+20%
Cold or hot fluid bottle, ice cap or collar, heat
							 and/or cold wrap, any type
A9274
AAC+30%
External ambulatory insulin delivery system,
							 disposable, each, includes all supplies and accessories
A9275
AAC+30%
Home glucose disposable monitor, includes test
							 strips
A9276
AAC+30%
Sensor, invasive (
e.g.
,
							 subcutaneous), disposable, for use with interstitial continuous glucose
							 monitoring system, 1 unit + 1 day supply
A9277
AAC+30%
Transmitter; external, for use with interstitial
							 continuous glucose monitoring system
A9278
AAC+30%
Receiver (monitor); external, for use with
							 interstitial continuous glucose monitoring system
A9279
AAC+30%
Monitoring feature/device, stand-alone or integrated,
							 any type, includes all accessories, components and electronics, not otherwise
							 classified
A9280
AAC+30%
Alarm or alarm device, not otherwise
							 classified
A9281
AAC+20%
Reaching/grabbing device, any type, any length,
							 each
A9282
AAC+20%
Wig, any type, each
A9284
AAC+20%
Spirometer, non-electronic, includes all
							 accessories
A9286
AAC+20%
Hygienic item or device, disposable or
							 non-disposable, any type, each
A9300
AAC+30%
Exercise equipment
A9900
AAC+20%
Miscellaneous DME supply, accessory, and/or service
							 component of another HCPCS code
A9999
AAC+20%
Miscellaneous DME supply or accessory, not otherwise
							 specified
Enteral and Parenteral Therapy
							 B4000-B9999
Enteral Formulae and Enteral Medical
							 Supplies
B4034
4.01
Enteral feeding supply kit; syringe fed, per day,
							 includes but not limited to feeding/flushing syringe, administration set
							 tubing, dressings, tape
B4035
7.57
Enteral feeding supply kit; pump fed, per day,
							 includes but not limited to feeding/flushing syringe, administration set
							 tubing, dressings, tape
B4036
5.34
Enteral feeding supply kit; gravity fed, per day,
							 includes but not limited to feeding/flushing syringe, administration set
							 tubing, dressings, tape
B4081
15.61
Nasogastric tubing with stylet
B4082
11.49
Nasogastric tubing without stylet
B4083
1.78
Stomach tube - Levine type
B4087NU
25.80
Gastrostomy/jejunostomy tube, standard, any material,
							 any type, each
B4087UC
144.00
Gastrostomy/jejunostomy tube, standard, any material,
							 any type, each (mickey tube)
B4088NU
27.96
Gastrostomy/jejunostomy tube, low-profile, any
							 material, any type, each
B4088UC
144.00
Gastrostomy/jejunostomy tube, low-profile, any
							 material, any type, each (mickey tube)
B4100
AAC+25%
Food thickener, administered orally, per
							 ounce
B4102
AAC+25%
Enteral formula, for adults, used to replace fluids
							 and electrolytes (
e.g.
, clear liquids), 500 ML = 1
							 unit
B4103
AAC+25%
Enteral formula, for pediatrics, used to replace
							 fluids and electrolytes (
e.g.
, clear liquids), 500 ML = 1
							 unit
B4104
AAC+25%
Additive for enteral formula (
e.g.
,
							 fiber)
B4105
AAC + 20%
In-Line cartridge containing digestive enzyme(s) for
							 enteral feeding, each
B4149BA
1.11
Enteral formula, manufactured blenderized natural
							 foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins
							 and minerals, may include fiber, administered through an enteral feeding tube,
							 100 calories = 1 unit (item furnished in conjunction with PEN
							 services)
B4149BO
AAC+25%
Enteral formula, manufactured blenderized natural
							 foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins
							 and minerals, may include fiber, administered through an enteral feeding tube,
							 100 calories = 1 unit (orally administered, 1 can = 1 unit)
B4150BA
0.47
Enteral formula, nutritionally complete with intact
							 nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may
							 include fiber, administered through an enteral feeding tube, 100 calories = 1
							 unit (item furnished in conjunction with PEN services)
B4150BO
1.82
Enteral formula, nutritionally complete with intact
							 nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may
							 include fiber, administered through an enteral feeding tube, 100 calories = 1
							 unit (orally administered, 1 can = 1 unit)
B4152BA
0.38
Enteral formula, nutritionally complete, calorically
							 dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes
							 proteins, fats, carbohydrates, vitamins and minerals, may include fiber,
							 administered through an enteral feeding tube, 100 calories = 1 unit (item
							 furnished in conjunction with PEN services)
B4152BO
1.67
Enteral formula, calorically dense (equal to or
							 greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats,
							 carbohydrates, vitamins and minerals, may include fiber, administered through
							 an enteral feeding tube, 100 calories = 1 unit (orally administered, 1 can = 1
							 unit)
B4153BA
1.34
Enteral formula, hydrolyzed nutritionally complete,
							 hydrolyzed proteins (amino acids and peptide chain), includes fats,
							 carbohydrates, vitamins and minerals, may include fiber, administered through
							 an enteral feeding tube, 100 calories = 1 unit (item furnished in conjunction
							 with PEN services)
B4153BO
10.24
Enteral formula,hydrolyzed nutritionally complete,
							 hydrolyzed proteins (amino acids and peptide chain), includes fats,
							 carbohydrates, vitamins and minerals, may include fiber, administered through
							 an enteral feeding tube, 100 calories = 1 unit (orally administered, 1 can = 1
							 unit)
B4154BA
0.84
Enteral formula, nutritionally complete, for special
							 metabolic needs, excludes inherited disease or metabolism, includes altered
							 composition of proteins, fats, carbohydrates, vitamins and/or minerals, may
							 include fiber, administered through an enteral feeding tube, 100 calories = 1
							 unit (item furnished in conjunction with PEN services)
B4154BO
AAC+25%
Enteral formula, nutritionally complete, for special
							 metabolic needs, excludes inherited disease or metabolism, includes altered
							 composition of proteins, fats, carbohydrates, vitamins and/or minerals, may
							 include fiber, administered through an enteral feeding tube, 100 calories = 1
							 unit (orally administered, 1 can = 1 unit)
B4155BA
0.71
Enteral formula, nutritionally incomplete/modular
							 nutrients, includes specific nutrients, carbohydrates (
e.g.
,
							 glucose polymers), proteins/amino acids (
e.g.
, glutamine,
							 arginine), fat (
e.g.
, medium chain tryglycerides) or
							 combination, administered through an enteral feeding tube, 100 calories = 1
							 unit (item furnished in conjunction with PEN services)
B4155BO
AAC+25%
Enteral formula, nutritionally incomplete/modular
							 nutrients, includes specific nutrients, carbohydrates (
e.g.
,
							 glucose polymers), proteins/amino acids (
e.g.
, glutamine,
							 arginine), fat (
e.g.
, medium chain tryglycerides) or
							 combination, administered through an enteral feeding tube, 100 calories = 1
							 unit (orally administered, 1 can = 1 unit)
B4157BA
AAC+25%
Enteral formula, nutritionally complete for special
							 metabolic needs for inherited disease of metabolism, includes proteins, fats,
							 carbohydrates, vitamins and minerals, may include fiber, administered through
							 an enteral feeding tube, 100 calories = 1 unit (item furnished in conjunction
							 with PEN services)
B4157BO
AAC+25%
Enteral formula, nutritionally complete for special
							 metabolic neds for inherited disease of metabolism, includes proteins, fats,
							 carbohydrates, vitamins and minerals, may include fiber, administered through
							 an enteral feeding tube, 100 calories = 1 unit (orally administered, 1 can = 1
							 unit)
B4158BA
AAC+25%
Enteral formula, for pediatrics, nutritionally
							 complete with intact nutrients, includes proteins, fats, carbohydrates,
							 vitamins and minerals, may include fiber and/or iron, administered through an
							 enteral feeding tube, 100 calories = 1 unit (item furnished in conjunction with
							 PEN services)
B4158BO
AAC+25%
Enteral formula, for pediatrics, nutritionally
							 complete with intact nutrients, includes proteins, fats, carbohydrates,
							 vitamins and minerals, may include fiber and/or iron, administered through an
							 enteral feeding tube, 100 calories = 1 unit (orally administered, 1 can = 1
							 unit)
B4159BA
AAC+25%
Enteral formula for pediatrics, nutritionally
							 complete soy based with intact nutrients, includes proteins, fats,
							 carbohydrates, vitamins and minerals, may include fiber and/or iron,
							 administered through an enteral feeding tube, 100 calories = 1 unit
B4159BO
AAC+25%
Enteral formula for pediatrics, nutritionally
							 complete soy based with intact nutrients, includes proteins, fats,
							 carbohydrates, vitamins and minerals, may include fiber and/or iron,
							 administered through an enteral feeding tube, 100 calories = 1 unit (orally
							 administered, 1 can = 1 unit)
B4160BA
AAC+25%
Enteral formula, for pediatrics, nutritionally
							 complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact
							 nutrients, includes proteins, fats, carbohydrates, vitamins and minterals, may
							 include fiber, administered through an enteral feeding tube, 100 calories = 1
							 unit (item furnished in conjunction with PEN services)
B4160BO
AAC+25%
Enteral formula, for pediatrics, nutritionally
							 complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact
							 nutrients, includes proteins, fats, carbohydrates, vitamins and minterals, may
							 include fiber, administered through an enteral feeding tube, 100 calories = 1
							 unit (orally administered, 1 can = 1 unit)
B4161BA
AAC+25%
Enter formula, for pediatrics, hydrolyzed/amino acids
							 and peptide chain proteins, includes fats, carbohydrates, vitamins and
							 minerals, may include fiber, administered through an enteral feeding tube, 100
							 calories = 1 unit (item furnished in conjunction with PEN services)
B4161BO
AAC+25%
Enter formula, for pediatrics, hydrolyzed/amino acids
							 and peptide chain proteins, includes fats, carbohydrates, vitamins and
							 minerals, may include fiber, administered through an enteral feeding tube, 100
							 calories = 1 unit (orally administered, 1 can = 1 unit)
B4162BA
AAC+25%
Enteral formula, for pediatrics, special metabolic
							 needs for inherited disease of metabolism, includes proteins, fats,
							 carbohydrates, vitamins and minerals, may include fiber, administered through
							 an enteral feeding tube, 100 calories = 1 unit (item furnished in conjunction
							 with PEN services)
B4162BO
AAC+25%
Enteral formula, for pediatrics, special metabolic
							 needs for inherited disease of metabolism, includes proteins, fats,
							 carbohydrates, vitamins and minerals, may include fiber, administered through
							 an enteral feeding tube, 100 calories = 1 unit (orally administered, 1 can = 1
							 unit)
Parenteral Nutrition Solutions and
							 Supplies
B4164
16.58
Parenteral nutrition solution: carbohydrates
							 (dextrose), 50% or less (500 ml = 1 unit) - homemix
B4168
24.17
Parenteral nutrition solution; amino acid, 3.5%, (500
							 ml = 1 unit) - homemix
B4172
AAC+25%
Parenteral nutrition solution; amino acid, 5.5%
							 through 7%, (500 ml = 1 unit) - homemix
B4176
46.78
Parenteral nutrition solution; amino acid, 7% through
							 8.5%, (500 ml = 1 unit) - homemix
B4178
56.14
Parenteral nutrition solution: amino acid, greater
							 than 8.5% (500 ml = 1 unit) - homemix
B4180
23.80
Parenteral nutrition solution; carbohydrates
							 (dextrose), greater than 50% (500 ml=1 unit) - home mix
B4185
10.97
Parenteral nutrition solution, not otherwise
							 specified, 10 grams lipids
B4187
I.C.
Omegaven, 10 grams lipids
B4189
173.45
Parenteral nutrition solution; compounded amino acid
							 and carbohydrates with electrolytes, trace elements, and vitamins, including
							 preparation, any strength, 10 to 51 grams of protein - premix
B4193
224.12
Parenteral nutrition solution; compounded amino acid
							 and carbohydrates with electrolytes, trace elements, and vitamins, including
							 preparation, any strength, 52 to 73 grams of protein - premix
B4197
272.86
Parenteral nutrition solution; compounded amino acid
							 and carbohydrates with electrolytes, trace elements and vitamins, including
							 preparation, any strength, 74 to 100 grams of protein - premix
B4199
311.79
Parenteral nutrition solution; compounded amino acid
							 and carbohydrates with electrolytes, trace elements and vitamins, including
							 preparation, any strength, over 100 grams of protein - premix
B4216
7.53
Parenteral nutrition; additives (vitamins, trace
							 elements, heparin, electrolytes) homemix per day
B4220
7.81
Parenteral nutrition supply kit; premix, per
							 day
B4222
9.63
Parenteral nutrition supply kit; home mix, per
							 day
B4224
24.40
Parenteral nutrition administration kit, per
							 day
B5000
11.60
Parenteral nutrition solution compounded amino acid
							 and carbohydrates with electrolytes, trace elements, and vitamins, including
							 preparation, any strength, renal - Aminosyn RF, NephrAmine, RenAmine -
							 premix
B5100
4.53
Parenteral nutrition solution compounded amino acid
							 and carbohydrates with electrolytes, trace elements, and vitamins, including
							 preparation, any strength, hepatic - f, HepatAmine - premix
B5200
AAC+25%
Parenteral nutrition solution compounded amino acid
							 and carbohydrates with electrolytes, trace elements, and vitamins, including
							 preparation, any strength, stress-branch chain amino acids - FreAmine-HBC -
							 premix
Enteral and Parenteral Pumps
B9002MS
41.90
Enteral nutrition infusion pump, any type (six month
							 maintenance and servicing fee for reasonable and necessary parts and labor
							 which are not covered under any manufacturer or supplier warranty)
B9002NU
801.69
Enteral nutrition infusion pump, any type(new
							 equipment)
B9002RR
78.49
Enteral nutrition infusion pump, any type
							 (rental)
B9002UE
601.26
Enteral nutrition infusion pump, any type (used
							 durable medical equipment)
B9004MS
194.88
Parenteral nutrition infusion pump, portable (six
							 month maintenance and servicing fee for reasonable and necessary parts and
							 labor which are not covered under any manufacturer or supplier
							 warranty)
B9004NU
2,462.07
Parenteral nutrition infusion pump, portable (new
							 equipment)
B9004RR
389.75
Parenteral nutrition infusion pump, portable
							 (rental)
B9004UE
1,846.55
Parenteral nutrition infusion pump, portable (used
							 durable medical equipment)
B9006MS
194.88
Parenteral nutrition infusion pump, stationary (six
							 month maintenance and servicing fee for reasonable and necessary parts and
							 labor which are not covered under any manufacturer or supplier
							 warranty)
B9006NU
2,462.07
Parenteral nutrition infusion pump, stationary (new
							 equipment)
B9006RR
389.75
Parenteral nutrition infusion pump, stationary
							 (rental)
B9006UE
1,846.55
Parenteral nutrition infusion pump, stationary (used
							 durable medical equipment)
B9998
AAC+20%
NOC for enteral supplies
B9999
AAC+20%
NOC for parenteral supplies
Durable Medical Equipment E0100-E9999
Canes
E0100NU
19.06
Cane, includes canes of all materials, adjustable or
							 fixed, with tip (new equipment)
E0100RR
5.00
Cane, includes canes of all materials, adjustable or
							 fixed, with tip (rental)
E0100UE
14.27
Cane, includes canes of all materials, adjustable or
							 fixed, with tip (used durable medical equipment)
E0105NU
45.53
Cane, quad or three prong, includes canes of all
							 materials, adjustable or fixed, with tips (new equipment)
E0105RR
7.08
Cane, quad or three prong, includes canes of all
							 materials, adjustable or fixed, with tips (rental)
E0105UD
AAC+30%
Cane, quad or three-prong, includes canes of all
							 materials, adjustable or fixed, with tips (bariatric equipment)
E0105UE
34.16
Cane, quad or three prong, includes canes of all
							 materials, adjustable or fixed, with tips (used durable medical
							 equipment)
Crutches
E0110NU
72.91
Crutches, forearm, includes crutches of various
							 materials, adjustable or fixed, pair, complete with tips and handgrips (new
							 equipment)
E0110RR
15.02
Crutches, forearm, includes crutches of various
							 materials, adjustable or fixed, pair, complete with tips and handgrips
							 (rental)
E0110UD
AAC+30%
Crutches, forearm, includes crutches of various
							 materials, adjustable or fixed, pair, complete with tips and handgrips
							 (bariatric equipment)
E0110UE
54.66
Crutches, forearm, includes crutches of various
							 materials, adjustable or fixed, pair, complete with tips and handgrips (used
							 durable medical equipment)
E0111NU
50.04
Crutch forearm, includes crutches of various
							 materials, adjustable or fixed, each, with tip and handgrips (new
							 equipment)
E0111RR
7.91
Crutch forearm, includes crutches of various
							 materials, adjustable or fixed, each, with tip and handgrips
							 (rental)
E0111UD
AAC+30%
Crutch forearm, includes crutches of various
							 materials, adjustable or fixed, each, with tip and handgrips (bariatric
							 equipment)
E0111UE
38.62
Crutch forearm, includes crutches of various
							 materials, adjustable or fixed, each, with tip and handgrips (used durable
							 medical equipment)
E0112NU
29.55
Crutches underarm, wood, adjustable or fixed, pair,
							 with pads, tips and handgrips (new equipment)
E0112RR
7.94
Crutches underarm, wood, adjustable or fixed, pair,
							 with pads, tips and handgrips (rental)
E0112UD
AAC+30%
Crutches underarm, wood, adjustable or fixed, pair,
							 with pads, tips and handgrips (bariatric equipment)
E0112UE
22.54
Crutches underarm, wood, adjustable or fixed, pair,
							 with pads, tips and handgrips (used durable medical equipment)
E0113NU
19.86
Crutch underarm, wood, adjustable or fixed, each,
							 with pad, tip and handgrip (new equipment)
E0113RR
4.84
Crutch underarm, wood, adjustable or fixed, each,
							 with pad, tip and handgrip (rental)
E0113UD
AAC+30%
Crutch underarm, wood, adjustable or fixed, each,
							 with pad, tip and handgrip (bariatric equipment)
E0113UE
14.90
Crutch underarm, wood, adjustable or fixed, each,
							 with pad, tip and handgrip (used durable medical equipment)
E0114NU
37.69
Crutches underarm, other than wood, adjustable or
							 fixed, pair, with pads, tips and handgrips (new equipment)
E0114RR
6.84
Crutches underarm, other than wood, adjustable or
							 fixed, pair, with pads, tips and handgrips (rental)
E0114UD
AAC+30%
Crutches underarm, other than wood, adjustable or
							 fixed, pair, with pads, tips and handgrips (bariatric equipment)
E0114UE
28.49
Crutches underarm, other than wood, adjustable or
							 fixed, pair, with pads, tips and handgrips (used durable medical
							 equipment)
E0116NU
26.08
Crutch underarm, other than wood, adjustable or
							 fixed, with pad, tip, handgrip, with or without shock absorber, each (new
							 equipment)
E0116RR
4.32
Crutch underarm, other than wood, adjustable or
							 fixed, with pad, tip, handgrip, with or without shock absorber, each
							 (rental)
E0116UD
AAC+30%
Crutch underarm, other than wood, adjustable or
							 fixed, each, with pad, tip and handgrip (bariatric equipment)
E0116UE
19.63
Crutch underarm, other than wood, adjustable or
							 fixed, with pad, tip, handgrip, with or without shock absorber, each (used
							 durable medical equipment)
E0117KH
18.10
Crutch, underarm, articulating, spring assisted, each
							 (capped rental)
E0117KI
18.10
Crutch, underarm, articulating, spring assisted, each
							 (capped rental)
E0117KJ
13.57
Crutch, underarm, articulating, spring assisted, each
							 (capped rental)
E0117NU
180.97
Crutch, underarm, articulating, spring assisted, each
							 (new equipment)
E0117UD
AAC+30%
Crutch, underarm, articulating, spring assisted, each
							 (bariatric equipment)
E0117UE
135.73
Crutch, underarm, articulating, spring assisted, each
							 (used durable medical equipment)
E0118NU
AAC+30%
Crutch substitute, lower leg platform, with or
							 without wheels, each (new equipment)
E0118RR
I.C.
Crutch substitute, lower leg platform, with or
							 without wheels, each (rental)
E0118UE
I.C.
Crutch substitute, lower leg platform, with or
							 without wheels, each (used durable medical equipment)
Walkers
E0130NU
45.33
Walker, rigid (pickup), adjustable or fixed height
							 (new equipment)
E0130RR
7.70
Walker, rigid (pickup), adjustable or fixed height
							 (rental)
E0130UD
AAC+30%
Walker, rigid (pickup), adjustable or fixed height
							 (bariatric equipment)
E0130UE
34.01
Walker, rigid (pickup), adjustable or fixed height
							 (used durable medical equipment)
E0135NU
52.16
Walker, folding (pickup), adjustable or fixed height
							 (new equipment)
E0135RR
7.76
Walker, folding (pickup), adjustable or fixed height
							 (rental)
E0135UD
AAC+30%
Walker, folding (pickup), adjustable or fixed height
							 (bariatric equipment)
E0135UE
39.71
Walker, folding (pickup), adjustable or fixed height
							 (used durable medical equipment)
E0140KH
26.10
Walker with trunk support, adjustable or fixed
							 height, any type (capped rental)
E0140KI
26.10
Walker with trunk support, adjustable or fixed
							 height, any type (capped rental)
E0140KJ
19.58
Walker with trunk support, adjustable or fixed
							 height, any type (capped rental)
E0140NU
260.87
Walker with trunk support, adjustable or fixed
							 height, any type (new equipment)
E0140UC
AAC+30%
Walker with trunk support, adjustable or fixed
							 height, any type (pediatric specialized rehabilitation equipment)
E0140UD
AAC+30%
Walker with trunk support, adjustable or fixed
							 height, any type (bariatric equipment)
E0140UE
195.65
Walker with trunk support, adjustable or fixed
							 height, any type (used durable medical equipment)
E0141NU
76.41
Walker, rigid, wheeled, adjustable or fixed height
							 (new equipment)
E0141RR
10.73
Walker, rigid, wheeled, adjustable or fixed height
							 (rental)
E0141UC
AAC+30%
Walker, rigid, wheeled, adjustable or fixed height
							 (pediatric specialized rehabilitation equipment)
E0141UD
AAC+30%
Walker, rigid, wheeled, adjustable or fixed height
							 (bariatric equipment)
E0141UE
57.31
Walker, rigid, wheeled, adjustable or fixed height
							 (used durable medical equipment)
E0143NU
71.87
Walker, folding, wheeled, adjustable or fixed height
							 (new equipment)
E0143RR
9.75
Walker, folding, wheeled, adjustable or fixed height
							 (rental)
E0143UC
AAC+30%
Walker, folding, wheeled, adjustable or fixed height
							 (pediatric specialized rehabilitation equipment)
E0143UD
AAC+30%
Walker, folding, wheeled, adjustable or fixed height
							 (bariatric equipment)
E0143UE
53.82
Walker, folding, wheeled, adjustable or fixed height
							 (used durable medical equipment)
E0144KH
23.70
Walker enclosed, four sided framed, rigid or folding,
							 wheeled, with posterior seat (capped rental)
E0144KI
23.70
Walker enclosed, four sided framed, rigid or folding,
							 wheeled, with posterior seat (capped rental)
E0144KJ
17.77
Walker enclosed, four sided framed, rigid or folding,
							 wheeled, with posterior seat (capped rental)
E0144NU
236.98
Walker, enclosed, four sided framed, rigid or
							 folding, wheeled, with posterior seat (new equipment)
E0144UC
AAC+30%
Walker enclosed, four sided framed, rigid or folding,
							 wheeled, with posterior seat (pediatric specialized rehabilitation
							 equipment)
E0144UD
AAC+30%
Walker enclosed, four sided framed, rigid or folding,
							 wheeled, with posterior seat (bariatric equipment)
E0144UE
177.74
Walker enclosed, four sided framed, rigid or folding,
							 wheeled, with posterior seat (used durable medical equipment)
E0147NU
392.85
Walker, heavy duty, multiple breaking system,
							 variable wheel resistance (new equipment)
E0147RR
39.29
Walker, heavy duty, multiple breaking system,
							 variable wheel resistance walker (rental)
E0147UD
AAC+30%
Walker, heavy duty, multiple breaking system,
							 variable wheel resistance walker (bariatric equipment)
E0147UE
294.64
Walker, heavy duty, multiple breaking system,
							 variable wheel resistance walker (used durable medical equipment)
E0148NU
85.87
Walker, heavy duty, without wheels, rigid or folding,
							 any type, each (new equipment)
E0148RR
8.59
Walker, heavy duty, without wheels, rigid or folding,
							 any type, each (rental)
E0148UD
AAC+30%
Walker, heavy duty, without wheels, rigid or folding,
							 any type, each (bariatric equipment)
E0148UE
64.40
Walker, heavy duty, without wheels, rigid or folding,
							 any type, each (used durable medical equipment)
E0149KH
13.97
Walker, heavy duty, wheeled, rigid or folding, any
							 type (capped rental)
E0149KI
13.97
Walker, heavy duty, wheeled, rigid or folding, any
							 type (capped rental)
E0149KJ
10.47
Walker, heavy duty, wheeled, rigid or folding, any
							 type (capped rental)
E0149NU
139.62
Walker, heavy duty, wheeled, rigid or folding, any
							 type (new equipment)
E0149UD
AAC+30%
Walker, heavy duty, wheeled, rigid or folding, any
							 type (bariatric equipment)
E0149UE
104.71
Walker, heavy duty, wheeled, rigid or folding, any
							 type (used durable medical equipment)
Attachments
E0153NU
55.42
Platform attachment, forearm crutch, each (new
							 equipment)
E0153RR
6.26
Platform attachment, forearm crutch, each
							 (rental)
E0153UC
AAC+30%
Platform attachment, forearm crutch, each (pediatric
							 specialized rehabilitation equipment)
E0153UD
AAC+30%
Platform attachment, forearm crutch, each
E0153UE
41.56
Platform attachment, forearm crutch, each (used
							 durable medical equipment)
E0154NU
44.47
Platform attachment, walker, each (new
							 equipment)
E0154RR
4.74
Platform attachment, walker, each
							 (rental)
E0154UC
AAC+30%
Platform attachment, walker, each (pediatric
							 specialized rehabilitation equipment)
E0154UD
AAC+30%
Platform attachment, walker, each (bariatric
							 equipment)
E0154UE
33.35
Platform attachment, walker, each (used durable
							 medical equipment)
E0155NU
20.60
Wheel attachment, rigid pick-up walker, per pair (new
							 equipment)
E0155RR
2.34
Wheel attachment, rigid pick-up walker, per pair
							 (rental)
E0155UD
AAC+30%
Wheel attachment, rigid pick-up walker, per pair
							 (bariatric equipment)
E0155UE
15.61
Wheel attachment, rigid pick-up walker, per pair
							 (used durable medical equipment)
E0156NU
17.03
Seat attachment, walker (new equipment)
E0156RR
2.01
Seat attachment, walker (rental)
E0156UD
AAC+30%
Seat attachment, walker (bariatric
							 equipment)
E0156UE
12.78
Seat attachment, walker (used durable medical
							 equipment)
E0157NU
57.04
Crutch attachment, walker, each (new
							 equipment)
E0157RR
6.03
Crutch attachment, walker, each (rental)
E0157UE
42.78
Crutch attachment, walker, each (used durable medical
							 equipment)
E0158NU
21.43
Leg extensions for walker, per set of four (4) (new
							 equipment)
E0158RR
2.28
Leg extensions for walker, per set of four (4)
							 (rental)
E0158UD
AAC+30%
Leg extensions for walker, per set of four (4)
							 (bariatric equipment)
E0158UE
16.07
Leg extensions for walker, per set of four (4) (used
							 durable medical equipment)
E0159NU
12.72
Brake attachment for wheeled walker, replacement,
							 each (new equipment)
E0159RR
1.28
Brake attachment for wheeled walker, replacement,
							 each (rental)
E0159UD
AAC+30%
Brake attachment for wheeled walker, replacement,
							 each (bariatric equipment)
E0159UE
9.55
Brake attachment for wheeled walker, replacement,
							 each (used durable medical equipment)
Commodes
E0160NU
27.36
Sitz type bath or equipment, portable, used with or
							 without commode (new equipment)
E0160RR
3.04
Sitz type bath or equipment, portable, used with or
							 without commode (rental)
E0160UE
20.51
Sitz type bath or equipment, portable, used with or
							 without commode (used durable medical equipment)
E0161NU
20.94
Sitz type bath or equipment, portable, used with or
							 without commode, with faucet attachment/s (new equipment)
E0161RR
2.76
Sitz type bath or equipment, portable, used with or
							 without commode, with faucet attachment/s (rental)
E0161UE
15.68
Sitz type bath or equipment, portable, used with or
							 without commode, with faucet attachment/s (used durable medical
							 equipment)
E0162NU
136.92
Sitz bath chair (new equipment)
E0162RR
14.36
Sitz bath chair (rental)
E0162UE
106.17
Sitz bath chair (used durable medical
							 equipment)
E0163NU
77.89
Commode chair, mobile or stationary, with fixed arms
							 (new equipment)
E0163RR
12.74
Commode chair, mobile or stationary, with fixed arms
							 (rental)
E0163UD
AAC+30%
Commode chair, mobile or stationary, with fixed arms
							 (bariatric equipment)
E0163UE
58.41
Commode chair, mobile or stationary, with fixed arms
							 (used durable medical equipment)
E0165KH
13.34
4 Commode chair, mobile or stationary, with
							 detachable arms (capped rental)
E0165KI
13.34
4 Commode chair, mobile or stationary, with
							 detachable arms (capped rental)
E0165KJ
10.00
Commode chair, mobile or stationary, with detachable
							 arms (capped rental)
E0165NU
133.37
Commode chair, mobile or stationary, with detachable
							 arms (new equipment purchase)
E0165UD
AAC+30%
Commode chair, mobile or stationary, with detachable
							 arms (bariatric equipment)
E0165UE
100.02
Commode chair, mobile or stationary, with detachable
							 arms (used durable medical equipment purchase)
E0167NU
10.20
Pail or pan for use with commode chair, replacement
							 only (new equipment)
E0167RR
0.95
Pail or pan for use with commode chair, replacement
							 only (rental)
E0167UD
AAC+30%
Pail or pan for use with commode chair, replacement
							 only (bariatric equipment)
E0167UE
7.68
Pail or pan for use with commode chair, replacement
							 only (used durable medical equipment)
E0168NU
129.25
Commode chair, extra wide and/or heavy duty,
							 stationary or mobile, with or without arms, any type, each (new
							 equipment)
E0168RR
12.95
Commode chair, extra wide and/or heavy duty,
							 stationary or mobile, with or without arms, any type, each (rental)
E0168UE
96.93
Commode chair, extra wide and/or heavy duty,
							 stationary or mobile, with or without arms, any type, each (used durable
							 medical equipment)
E0170KH
147.71
Commode chair with integrated seat lift mechanism,
							 electric, any type (capped rental)
E0170KI
147.71
Commode chair with integrated seat lift mechanism,
							 electric, any type (capped rental)
E0170KJ
110.78
Commode chair with integrated seat lift mechanism,
							 electric, any type (capped rental)
E0170NU
1,477.13
Commode chair with integrated seat lift mechanism,
							 electric, any type (new equipment purchase)
E0170UD
AAC+30%
Commode chair with integrated seat lift mechanism,
							 electric, any type (bariatric equipment)
E0170UE
1,107.85
Commode chair with integrated seat lift mechanism,
							 electric, any type
E0171KH
26.48
Commode chair with integrated seat lift mechanism,
							 non-electric, any type (capped rental)
E0171KI
26.48
Commode chair with integrated seat lift mechanism,
							 non-electric, any type (capped rental)
E0171KJ
19.86
Commode chair with integrated seat lift mechanism,
							 non-electric, any type (capped rental)
E0171NU
264.78
Commode chair with integrated seat lift mechanism,
							 non-electric, any type (new equipment purchase)
E0171UD
AAC+30%
Commode chair with integrated seat lift mechanism,
							 non-electric, any type (bariatric equipment)
E0171UE
198.58
Commode chair with integrated seat lift mechanism,
							 non-electric, any type (used durable medical equipment)
E0172
AAC+30%
Seat lift mechanism placed over or on top of toilet,
							 any type
E0175NU
61.06
Foot rest, for use with commode chair, each (new
							 equipment)
E0175RR
6.12
Foot rest, for use with commode chair, each
							 (rental)
E0175UE
45.81
Foot rest, for use with commode chair, each (used
							 durable medical equipment)
Decubitis Care Equipment
E0181KH
20.81
Powered pressure reducing mattress overlay/pad,
							 alternating with pump, includes heavy duty (capped rental)
E0181KI
20.81
Powered pressure reducing mattress overlay/pad,
							 alternating with pump, includes heavy duty (capped rental)
E0181KJ
15.61
Powered pressure reducing mattress overlay/pad,
							 alternating with pump, includes heavy duty (capped rental)
E0181NU
208.08
Powered pressure reducing mattress overlay/pad,
							 alternating with pump, includes heavy duty (new equipment purchase)
E0181UE
156.06
Powered pressure reducing mattress overlay/pad,
							 alternating with pump, includes heavy duty (used durable medical equipment
							 purchase)
E0182KH
18.79
Pump for alternating pressure pad, for replacement
							 only (capped rental)
E0182KI
18.79
Pump for alternating pressure pad, for replacement
							 only (capped rental)
E0182KJ
14.10
Pump for alternating pressure pad, for replacement
							 only (capped rental)
E0182NU
187.94
Pump for alternating pressure pad, for replacement
							 only (new equipment purchase)
E0182UE
140.95
Pump for alternating pressure pad, for replacement
							 only (used durable medical equipment purchase)
E0184NU
165.32
Dry pressure mattress (new equipment)
E0184RR
18.56
Dry pressure mattress (rental)
E0184UE
125.54
Dry pressure mattress (used durable medical
							 equipment)
E0185NU
238.83
Gel or gel-like pressure pad for mattress, standard
							 mattress length and width
E0185RR
29.97
Gel or gel-like pressure pad for mattress, standard
							 mattress length and width
E0185UE
181.76
Gel or gel-like pressure pad for mattress, standard
							 mattress length and width
E0186KH
16.21
Air pressure mattress (capped rental)
E0186KI
16.21
Air pressure mattress (capped rental)
E0186KJ
12.16
Air pressure mattress (capped rental)
E0186NU
162.10
Air pressure mattress (new equipment
							 purchase)
E0186UE
121.57
Air pressure mattress (used durable medical
							 equipment)
E0187KH
18.03
Water pressure mattress (capped rental)
E0187KI
18.03
Water pressure mattress (capped rental)
E0187KJ
13.52
Water pressure mattress (capped rental)
E0187NU
180.29
Water pressure mattress (new equipment
							 purchase)
E0187UE
135.21
Water pressure mattress (used durable medical
							 equipment purchase)
E0188NU
21.07
Synthetic sheepskin pad (new equipment)
E0188RR
2.30
Synthetic sheepskin pad (rental)
E0188UE
15.81
Synthetic sheepskin pad (used durable medical
							 equipment)
E0189NU
45.24
Lambswool sheepskin pad, any size (new
							 equipment)
E0189RR
4.58
Lambswool sheepskin pad, any size
							 (rental)
E0189UE
33.93
Lambswool sheepskin pad, any size (used durable
							 medical equipment)
E0190NU
AAC+30%
Positioning cushion/pillow/wedge, any shape or size,
							 includes all components and accessories (new equipment)
E0190RR
I.C.
Positioning cushion/pillow/wedge, any shape or size
							 includes all components and accessories (rental)
E0190UE
I.C.
Positioning cushion/pillow/wedge, any shape or size
							 includes all components and accessories (used durable medical
							 equipment)
E0191NU
9.39
Heel or elbow protector, each (new
							 equipment)
E0191RR
0.97
Heel or elbow protector, each (rental)
E0191UE
7.00
Heel or elbow protector, each (used durable medical
							 equipment)
E0193KH
625.46
Powered air flotation bed (low air loss therapy)
							 (capped rental)
E0193KI
625.46
Powered air flotation bed (low air loss therapy)
							 (capped rental)
E0193KJ
469.09
Powered air flotation bed (low air loss therapy)
							 (capped rental)
E0194KH
3,058.05
Air fluidized bed (capped rental)
E0194KI
3,058.05
Air fluidized bed (capped rental)
E0194KJ
2,293.53
Air fluidized bed (capped rental)
E0196KH
25.95
Gel pressure mattress (capped rental)
E0196KI
25.95
Gel pressure mattress (capped rental)
E0196KJ
19.46
Gel pressure mattress (capped rental)
E0196NU
259.51
Gel pressure mattress (new equipment
							 purchase)
E0196UE
194.63
Gel pressure mattress (used durable medical equipment
							 purchase)
E0197KH
19.78
Air pressure pad for mattress, standard mattress
							 length and width (capped rental)
E0197KI
19.78
Air pressure pad for mattress, standard mattress
							 length and width (capped rental)
E0197KJ
14.83
Air pressure pad for mattress, standard mattress
							 length and width (capped rental)
E0197NU
164.20
Air pressure pad for mattress, standard mattress
							 length and width (new equipment)
E0197UE
134.52
Air pressure pad for mattress, standard mattress
							 length and width (used durable medical equipment)
E0198KH
17.71
Water pressure pad for mattress, standard mattress
							 length and width (capped rental)
E0198KI
17.71
Water pressure pad for mattress, standard mattress
							 length and width (capped rental)
E0198KJ
13.28
Water pressure pad for mattress, standard mattress
							 length and width (capped rental)
E0198NU
177.06
Water pressure pad for mattress, standard mattress
							 length and width
E0198UE
132.80
Water pressure pad for mattress, standard mattress
							 length and width
E0199NU
25.67
Dry pressure pad for mattress, standard mattress
							 length and width
E0199RR
2.57
Dry pressure pad for mattress, standard mattress
							 length and width
E0199UE
19.24
Dry pressure pad for mattress, standard mattress
							 length and width
Heat/Cold Application
E0200NU
63.33
Heat lamp, without stand (table model), includes
							 bulb, or infrared element
E0200RR
8.60
Heat lamp, without stand (table model), includes
							 bulb, or infrared element
E0200UE
47.52
Heat lamp, without stand (table model), includes
							 bulb, or infrared element
E0202RR
125.00
Phototherapy (bilirubin) light with photometer (per
							 episode)
E0203
AAC+30%
Therapeutic lightbox, minimum 10,000 lux, table top
							 model
E0205NU
155.01
Heat lamp, with stand, includes bulb, or infrared
							 element (new equipment)
E0205RR
17.05
Heat lamp, with stand, includes bulb, or infrared
							 element (rental)
E0205UE
116.25
Heat lamp, with stand, includes bulb, or infrared
							 element (used durable medical equipment)
E0210NU
30.68
Electric heat pad, standard (new
							 equipment)
E0210RR
2.50
Electric heat pad, standard (rental)
E0210UE
23.00
Electric heat pad, standard (used durable medical
							 equipment)
E0215NU
56.58
Electric heat pad, moist (new equipment)
E0215RR
5.92
Electric heat pad, moist (rental)
E0215UE
42.45
Electric heat pad, moist (used durable medical
							 equipment)
E0217NU
466.53
Water circulating heat pad with pump (new
							 equipment)
E0217RR
51.94
Water circulating heat pad with pump
							 (rental)
E0217UE
349.87
Water circulating heat pad with pump (used durable
							 medical equipment)
E0218
AAC+30%
Fluid circulating cold pad with pump, any
							 type
E0221
1,690.77
Infrared heating pad system
E0225NU
310.42
Hydrocollator unit, includes pads (new
							 equipment)
E0225RR
30.60
Hydrocollator unit, includes pads
							 (rental)
E0225UE
232.82
Hydrocollator unit, includes pads (used durable
							 medical equipment)
E0231
AAC+30%
Non-contact wound warming device (temperature control
							 unit, AC adapter and power cord) for use with warming card and wound
							 cover
E0232
AAC+30%
Warming card for use with the non contact wound
							 warming device and non contact wound warming wound cover
E0235KH
14.82
Paraffin bath unit, portable (see medical supply code
							 A4265 for paraffin) (capped rental)
E0235KI
14.82
Paraffin bath unit, portable (see medical supply code
							 A4265 for paraffin) (capped rental)
E0235KJ
11.11
Paraffin bath unit, portable (see medical supply code
							 A4265 for paraffin) (capped rental)
E0235NU
148.16
Paraffin bath unit, portable (see medical supply code
							 A4265 for paraffin) (new equipment purchase)
E0235UE
111.12
Paraffin bath unit, portable (see medical supply code
							 A4265 for paraffin) (used durable medical equipment)
E0236KH
41.57
Pump for water circulating pad (capped
							 rental)
E0236KI
41.57
Pump for water circulating pad (capped
							 rental)
E0236KJ
31.18
Pump for water circulating pad (capped
							 rental)
E0236NU
415.74
Pump for water circulating pad (new equipment
							 purchase)
E0236UE
311.80
Pump for water circulating pad (used durable medical
							 equipment purchase)
E0239NU
422.70
Hydrocollator unit, portable (new
							 equipment)
E0239RR
42.28
Hydrocollator unit, portable (rental)
E0239UE
317.03
Hydrocollator unit, portable (used durable medical
							 equipment)
Bath and Toilet Aids
E0240NU
AAC+30%
Bath/shower chair, with or without wheels, any size
							 (new equipment)
E0240RR
I.C.
Bath/shower chair, with or without wheels, any size
							 (rental)
E0240UE
I.C.
Bath/shower chair, with or without wheels, any size
							 (used durable medical equipment)
E0241
32.36
Bath tub wall rail, each
E0242
69.79
Bath tub rail, floor base
E0243
38.14
Toilet rail, each
E0244
60.76
Raised toilet seat
E0244UD
AAC+30%
Raised toilet seat (bariatric equipment)
E0245
42.37
Tub stool or bench
E0245UD
AAC+30%
Tub stool or bench (bariatric equipment)
E0246
99.65
Transfer tub rail attachment
E0247NU
AAC+30%
Transfer bench, for tub or toilet with or without
							 commode opening (new equipment)
E0247RR
I.C.
Transfer bench, for tub or toilet with or without
							 commode opening (rental)
E0247UE
I.C.
Transfer bench, for tub or toilet with or without
							 commode opening (used durable medical equipment)
E0248NU
AAC+30%
Transfer bench, heavy duty, for tub or toilet with or
							 without commode opening (new equipment)
E0248RR
I.C.
Transfer bench, heavy duty, for tub or toilet with or
							 without commode opening (rental)
E0248UE
I.C.
Transfer bench, heavy duty, for tub or toilet with or
							 without commode opening (used durable medical equipment)
E0249NU
93.60
Pad for water circulating heat unit (new
							 equipment)
E0249RR
10.29
Pad for water circulating heat unit
							 (rental)
E0249UE
70.20
Pad for water circulating heat unit (used durable
							 medical equipment)
Hospital Beds and Accessories
E0250KH
67.97
Hospital bed, fixed height, with any type side rails,
							 with mattress (capped rental)
E0250KI
67.97
Hospital bed, fixed height, with any type side rails,
							 with mattress (capped rental)
E0250KJ
50.97
Hospital bed, fixed height, with any type side rails,
							 with mattress (capped rental)
E0250NU
679.66
Hospital bed, fixed height, with any type side rails,
							 with mattress (new equipment purchase)
E0250RB
AAC+30%
Hospital bed, fixed height, with any type side rails,
							 with mattress (replacement of a part of DME furnished as part of a
							 repair)
E0250UE
509.75
Hospital bed, fixed height, with any type side rails,
							 with mattress (used durable medical equipment purchase)
E0251KH
52.92
Hospital bed, fixed height, with any type side rails,
							 without mattress (capped rental)
E0251KI
52.92
Hospital bed, fixed height, with any type side rails,
							 without mattress (capped rental)
E0251KJ
39.69
Hospital bed, fixed height, with any type side rails,
							 without mattress (capped rental)
E0251NU
529.21
Hospital bed, fixed height, with any type side rails,
							 without mattress (new equipment purchase)
E0251RB
AAC+30%
Hospital bed, fixed height, with any type side rails,
							 without mattress (replacement of a part of DME furnished as part of a
							 repair)
E0251UE
396.91
Hospital bed, fixed height, with any type side rails,
							 without mattress (used durable medical equipment purchase)
E0255KH
79.03
Hospital bed, variable height, hi-lo, with any type
							 side rails, with mattress (capped rental)
E0255KI
79.03
Hospital bed, variable height, hi-lo, with any type
							 side rails, with mattress (capped rental)
E0255KJ
59.27
Hospital bed, variable height, hi-lo, with any type
							 side rails, with mattress (capped rental)
E0255NU
790.33
Hospital bed, variable height, hi-lo, with any type
							 side rails, with mattress (new equipment purchase)
E0255RB
AAC+30%
Hospital bed, variable height, hi-lo, with any type
							 side rails, with mattress (replacement of a part of DME furnished as part of a
							 repair)
E0255UE
592.75
Hospital bed, variable height, hi-lo, with any type
							 side rails, with mattress (used durable medical equipment purchase)
E0256KH
66.78
Hospital bed, variable height, hi-lo, with any type
							 side rails, without mattress (capped rental)
E0256KI
66.78
Hospital bed, variable height, hi-lo, with any type
							 side rails, without mattress (capped rental)
E0256KJ
50.08
Hospital bed, variable height, hi-lo, with any type
							 side rails, without mattress (capped rental)
E0256NU
585.31
Hospital bed, variable height, hi-lo, with any type
							 side rails, without mattress (new equipment purchase)
E0256RB
AAC+30%
Hospital bed, variable height, hi-lo, with any type
							 side rails, without mattress (replacement of a part of a DME furnished as part
							 of a repair)
E0256UE
438.98
Hospital bed, variable height, hi-lo, with any type
							 side rails, without mattress (used durable medical equipment
							 purchase)
E0260KH
89.03
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, with mattress (capped
							 rental)
E0260KI
89.03
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, with mattress (capped
							 rental)
E0260KJ
66.77
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, with mattress (capped
							 rental)
E0260NU
890.29
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, with mattress (new equipment
							 purchase)
E0260RB
AAC+30%
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, with mattress (replacement of a part of
							 a DME furnished as part of a repair)
E0260UE
667.72
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, with mattress (used durable medical
							 equipment purchase)
E0261KH
87.11
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, without mattress (capped
							 rental)
E0261KI
87.11
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, without mattress (capped
							 rental)
E0261KJ
65.33
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, without mattress (capped
							 rental)
E0261NU
871.08
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, without mattress (new equipment
							 purchase)
E0261RB
AAC+30%
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, without mattress
E0261UE
653.31
Hospital bed, semi-electric (head and foot
							 adjustment), with any type side rails, without mattress (used durable medical
							 equipment purchase)
E0265KH
138.78
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, with mattress (capped
							 rental)
E0265KI
138.78
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, with mattress (capped
							 rental)
E0265KJ
104.08
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, with mattress (capped
							 rental)
E0265NU
1,387.80
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, with mattress (new equipment
							 purchase)
E0265RB
AAC+30%
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, with mattress (replacement of a part of
							 a DME furnished as part of a repair)
E0265UE
1,040.85
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, with mattress (used durable medical
							 equipment purchase)
E0266KH
122.24
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, without mattress (capped
							 rental)
E0266KI
122.24
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, without mattress (capped
							 rental)
E0266KJ
91.68
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, without mattress (capped
							 rental)
E0266NU
1,222.39
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, without mattress (new equipment
							 purchase)
E0266RB
AAC+30%
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, without mattress (replacement of a part
							 of a DME furnished as part of a repair)
E0266UE
916.79
Hospital bed, total electric (head, foot and height
							 adjustments), with any type side rails, without mattress (used durable medical
							 equipment)
E0270
AAC+30%
Hospital bed, institutional type includes:
							 oscillating, circulating and Stryker frame, with mattress
E0271NU
142.77
Mattress, innerspring (new equipment)
E0271RR
14.63
Mattress, innerspring (rental)
E0271UE
109.88
Mattress, innerspring (used durable medical
							 equipment)
E0272NU
140.42
Mattress, foam rubber (new equipment)
E0272RR
14.41
Mattress, foam rubber (rental)
E0272UE
105.03
Mattress, foam rubber (used durable medical
							 equipment)
E0273
44.73
Bed board
E0274NU
60.99
Over-bed table (new equipment)
E0274RR
6.10
Over-bed table (rental)
E0274UE
45.74
Over-bed table (used durable medical
							 equipment)
E0275NU
13.06
Bed pan, standard, metal or plastic (new
							 equipment)
E0275RR
1.31
Bed pan, standard, metal or plastic
							 (rental)
E0275UE
9.81
Bed pan, standard, metal or plastic (used durable
							 medical equipment)
E0276NU
10.57
Bed pan, fracture, metal or plastic (new
							 equipment)
E0276RR
1.24
Bed pan, fracture, metal or plastic
							 (rental)
E0276UE
8.14
Bed pan, fracture, metal or plastic (used durable
							 medical equipment)
E0277KH
391.46
Powered pressure-reducing air mattress (capped
							 rental)
E0277KI
391.46
Powered pressure-reducing air mattress (capped
							 rental)
E0277KJ
293.59
Powered pressure-reducing air mattress (capped
							 rental)
E0277NU
3,914.59
Powered pressure-reducing air mattress (new equipment
							 purchase)
E0277UE
2,935.94
Powered pressure-reducing air mattress (used durable
							 medical equipment purchase)
E0280NU
26.72
Bed cradle, any type (new equipment)
E0280RR
2.67
Bed cradle, any type (rental)
E0280UE
20.04
Bed cradle, any type (used durable medical
							 equipment)
E0290KH
53.72
Hospital bed, fixed height, without side rails, with
							 mattress (capped rental)
E0290KI
53.72
Hospital bed, fixed height, without side rails, with
							 mattress (capped rental)
E0290KJ
40.29
Hospital bed, fixed height, without side rails, with
							 mattress (capped rental)
E0290NU
537.20
Hospital bed, fixed height, without side rails, with
							 mattress (new equipment purchase)
E0290RB
AAC+30%
Hospital bed, fixed height, without side rails, with
							 mattress (replacement of a part of a DME furnished as part of a
							 repair)
E0290UE
402.90
Hospital bed, fixed height, without side rails, with
							 mattress (used durable medical equipment purchase)
E0291KH
39.20
Hospital bed, fixed height, without side rails,
							 without mattress (capped rental)
E0291KI
39.20
Hospital bed, fixed height, without side rails,
							 without mattress (capped rental)
E0291KJ
29.40
Hospital bed, fixed height, without side rails,
							 without mattress (capped rental)
E0291NU
392.02
Hospital bed, fixed height, without side rails,
							 without mattress (new equipment purchase)
E0291RB
AAC+30%
Hospital bed, fixed height, without side rails,
							 without mattress (replacement of a part of a DME furnished as part of a
							 repair)
E0291UE
294.02
Hospital bed, fixed height, without side rails,
							 without mattress (used durable medical equipment purchase)
E0292KH
60.36
Hospital bed, variable height, hi-lo, without side
							 rails, with mattress (capped rental)
E0292KI
60.36
Hospital bed, variable height, hi-lo, without side
							 rails, with mattress (capped rental)
E0292KJ
45.27
Hospital bed, variable height, hi-lo, without side
							 rails, with mattress (capped rental)
E0292NU
603.59
Hospital bed, variable height, hi-lo, without side
							 rails, with mattress (new equipment purchase)
E0292RB
AAC+30%
Hospital bed, variable height, hi-lo, without side
							 rails, with mattress (replacement of a part of a DME furnished as part of a
							 repair)
E0292UE
452.69
Hospital bed, variable height, hi-lo, without side
							 rails, with mattress (used durable medical equipment purchase)
E0293
AAC+30%
Hospital bed, variable height, hi-lo, without side
							 rails, without mattress (replacement of a part of a DME furnished as part of a
							 repair)
E0293KH
51.37
Hospital bed, variable height, hi-lo, without side
							 rails, without mattress (capped rental)
E0293KI
51.37
Hospital bed, variable height, hi-lo, without side
							 rails, without mattress (capped rental)
E0293KJ
38.52
Hospital bed, variable height, hi-lo, without side
							 rails, without mattress (capped rental)
E0293NU
513.66
Hospital bed, variable height, hi-lo, without side
							 rails, without mattress (new equipment purchase)
E0293UE
385.24
Hospital bed, variable height, hi-lo, without side
							 rails, without mattress (used durable medical equipment purchase)
E0294KH
86.05
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, with mattress (capped rental)
E0294KI
86.05
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, with mattress (capped rental)
E0294KJ
64.53
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, with mattress (capped rental)
E0294NU
860.46
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, with mattress (new equipment
							 purchase)
E0294RB
AAC+30%
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, with mattress (replacement of a part of a DME
							 furnished as part of a repair)
E0294UE
645.34
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, with mattress (used durable medical equipment
							 purchase)
E0295KH
83.79
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, without mattress (capped rental)
E0295KI
83.79
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, without mattress (capped rental)
E0295KJ
62.84
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, without mattress (capped rental)
E0295NU
837.93
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, without mattress (new equipment
							 purchase)
E0295RB
AAC+30%
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, without mattress (replacement of a part of a
							 DME furnished as part of a repair)
E0295UE
628.45
Hospital bed, semi-electric (head and foot
							 adjustment), without side rails, without mattress (used durable medical
							 equipment purchase)
E0296KH
132.98
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, with mattress (capped rental)
E0296KI
132.98
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, with mattress (capped rental)
E0296KJ
99.74
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, with mattress (capped rental)
E0296NU
1,329.83
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, with mattress (new equipment
							 purchase)
E0296RB
AAC+30%
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, with mattress (replacement of a part of a DME
							 furnished as part of a repair)
E0296UE
997.37
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, with mattress (used durable medical equipment
							 purchase)
E0297KH
96.78
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, without mattress (capped rental)
E0297KI
96.78
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, without mattress (capped rental)
E0297KJ
72.59
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, without mattress (capped rental)
E0297NU
967.81
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, without mattress (new equipment
							 purchase)
E0297RB
AAC+30%
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, without (replacement of a part of a DME
							 furnished as part of a repair)
E0297UE
725.86
Hospital bed, total electric (head, foot and height
							 adjustments), without side rails, without mattress (used durable medical
							 equipment purchase)
E0300KH
I.C.
Pediatric crib, hospital grade, fully enclosed, with
							 or without top enclosure (capped rental)
E0300KI
I.C.
Pediatric crib, hospital grade, fully enclosed, with
							 or without top enclosure (capped rental)
E0300KJ
I.C.
Pediatric crib, hospital grade, fully enclosed, with
							 or without top enclosure (capped rental)
E0300NU
AAC+30%
Pediatric crib, hospital grade, fully enclosed, with
							 or without top enclosure (new equipment)
E0300RB
AAC+30%
Pediatric crib, hospital grade, fully enclosed, with
							 or without top enclosure (replacement of a part of a DME furnished as part of a
							 repair)
E0300UE
I.C.
Pediatric crib, hospital grade, fully enclosed, with
							 or without top enclosure (used durable medical equipment)
E0301KH
185.10
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, without mattress (capped rental)
E0301KI
186.10
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, without mattress (capped rental)
E0301KJ
138.82
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, without mattress (capped rental)
E0301NU
1,850.96
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, without mattress (new equipment purchase)
E0301RB
AAC+30%
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, without mattress (replacement of a part of a DME furnished
							 as part of a repair)
E0301UE
1,388.22
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, without mattress (used durable medical
							 equipment)
E0302KH
499.90
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 600 pounds, with any type side rails, without mattress
							 (capped rental)
E0302KI
499.90
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 600 pounds, with any type side rails, without mattress
							 (capped rental)
E0302KJ
374.93
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 600 pounds, with any type side rails, without mattress
							 (capped rental)
E0302NU
4,999.02
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 600 pounds, with any type side rails, without mattress
							 (new equipment purchase)
E0302RB
AAC+30%
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 600 pounds, with any type side rails, without mattress
							 (replacement of a part of a DME furnished as part of a repair)
E0302UE
3,749.27
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 600 pounds, with any type side rails, without mattress
							 (used durable medical equipment)
E0303KH
204.80
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, with mattress (capped rental)
E0303KI
204.80
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, with mattress (capped rental)
E0303KJ
153.60
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, with mattress (capped rental)
E0303NU
2,047.99
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, with mattress (new equipment purchase)
E0303RB
AAC+30%
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, with mattress (replacement of a part of a DME furnished as
							 part of a repair)
E0303UE
1,535.99
Hospital bed, heavy duty, extra wide, with weight
							 capacity greater than 350 pounds, but less than or equal to 600 pounds, with
							 any type side rails, with mattress (used durable medical equipment
							 purchase)
E0304KH
535.17
Hospital bed, extra heavy duty, extra wide, with
							 weight capacity greater than 600 pounds, with any type side rails, with
							 mattress (capped rental)
E0304KI
536.17
Hospital bed, extra heavy duty, extra wide, with
							 weight capacity greater than 600 pounds, with any type side rails, with
							 mattress (capped rental)
E0304KJ
401.38
Hospital bed, extra heavy duty, extra wide, with
							 weight capacity greater than 600 pounds, with any type side rails, with
							 mattress (capped rental)
E0304NU
5,351.69
Hospital bed, extra heavy duty, extra wide, with
							 weight capacity greater than 600 pounds, with any type side rails, with
							 mattress (new equipment purchase)
E0304RB
AAC+30%
Hospital bed, extra heavy duty, extra wide, with
							 weight capacity greater than 600 pounds, with any type side rails, with
							 mattress (replacement of a part of a DME furnished as part of a
							 repair)
E0304UE
4,013.76
Hospital bed, extra heavy duty, extra wide, with
							 weight capacity greater than 600 pounds, with any type side rails, with
							 mattress (used durable medical equipment purchase) (used durable medical
							 equipment purchase)
E0305KH
12.27
Bed side rails, half length (capped
							 rental)
E0305KI
12.27
Bed side rails, half length (capped
							 rental)
E0305KJ
9.20
Bed side rails, half length (capped
							 rental)
E0305NU
122.66
Bed side rails, half length (new equipment
							 purchase)
E0305UE
91.99
Bed side rails, half length (used durable medical
							 equipment purchase)
E0310NU
128.61
Bed side rails, full length (new
							 equipment)
E0310RR
14.59
Bed side rails, full length (rental)
E0310UE
96.46
Bed side rails, full length (used durable medical
							 equipment)
E0315NU
74.32
Bed accessory: board, table, or support device, any
							 type (new equipment)
E0315RR
7.43
Bed accessory: board, table, or support device, any
							 type (rental)
E0315UE
55.74
Bed accessory: board, table, or support device, any
							 type (used durable medical equipment)
E0316KH
157.89
Safety enclosure frame/canopy for use with hospital
							 bed, any type (capped rental)
E0316KI
157.89
Safety enclosure frame/canopy for use with hospital
							 bed, any type (capped rental)
E0316KJ
118.42
Safety enclosure frame/canopy for use with hospital
							 bed, any type (capped rental)
E0316NU
1,578.88
Safety enclosure frame/canopy for use with hospital
							 bed, any type (new equipment purchase)
E0316UE
1,184.16
Safety enclosure frame/canopy for use with hospital
							 bed, any type (used durable medical equipment purchase)
E0325NU
8.69
Urinal; male, jug-type, any material (new
							 equipment)
E0325RR
1.11
Urinal; male, jug-type, any material
							 (rental)
E0325UE
6.09
Urinal; male, jug-type, any material (used durable
							 medical equipment)
E0326NU
9.17
Urinal; female, jug-type, any material (new
							 equipment)
E0326RR
0.99
Urinal; female, jug-type, any material
							 (rental)
E0326UE
6.89
Urinal; female, jug-type, any material (used durable
							 medical equipment)
E0328
AAC+30%
Hospital bed, pediatric, manual, 360 degree side
							 enclosures, top of headboard, footboard and side rails up to 24 inches above
							 the spring, includes mattress
E0328UA
AAC+30%
Hospital bed, pediatric, manual, 360 degree side
							 enclosures, top of headboard, footboard and side rails up to 24 inches above
							 the spring, includes mattress (Medicaid level of care ten, use for adults for
							 safety beds)
E0329
AAC+30%
Hospital bed, pediatric, electric or semi-electric,
							 360 degree side enclosures, top of headboard, footboard and side rails up to 24
							 inches above the spring, includes mattress
E0329UA
AAC+30%
Hospital bed, pediatric, electric or semi-electric,
							 360 degree side enclosures, top of headboard, footboard and side rails up to 24
							 inches above the spring, includes mattress (Medicaid level of care ten, use for
							 adults for safety beds)
E0350
AAC+30%
Control unit for electronic bowel
							 irrigation/evacuation system
E0352
AAC+20%
Disposable pack (water reservoir bag, speculum,
							 valving mechanism and collection bag/box) for use with the electronic bowel
							 irrigation/evacuation system
E0370
AAC+20%
Air pressure elevator for heel
E0371KH
286.02
Nonpowered advanced pressure reducing overlay for
							 mattress, standard mattress length and width (capped rental)
E0371KI
286.02
Nonpowered advanced pressure reducing overlay for
							 mattress, standard mattress length and width (capped rental)
E0371KJ
214.51
Nonpowered advanced pressure reducing overlay for
							 mattress, standard mattress length and width (capped rental)
E0371NU
2,860.17
Nonpowered advanced pressure reducing overlay for
							 mattress, standard mattress length and width (new equipment
							 purchase)
E0371UE
2,145.12
Nonpowered advanced pressure reducing overlay for
							 mattress, standard mattress length and width (used durable medical equipment
							 purchase)
E0372KH
315.53
Powered air overlay for mattress, standard mattress
							 length and width (capped rental)
E0372KI
315.53
Powered air overlay for mattress, standard mattress
							 length and width (capped rental)
E0372KJ
236.65
Powered air overlay for mattress, standard mattress
							 length and width (capped rental)
E0372NU
3,155.29
Powered air overlay for mattress, standard mattress
							 length and width (new equipment purchase)
E0372UE
2,366.46
Powered air overlay for mattress, standard mattress
							 length and width (used durable medical equipment purchase)
E0373KH
376.82
Nonpowered advanced pressure reducing mattress
							 (capped rental)
E0373KI
376.82
Nonpowered advanced pressure reducing mattress
							 (capped rental)
E0373KJ
282.62
Nonpowered advanced pressure reducing mattress
							 (capped rental)
E0373NU
3,768.22
Nonpowered advanced pressure reducing mattress (new
							 equipment purchase)
E0373UE
2,826.17
Nonpowered advanced pressure reducing mattress (used
							 durable medical equipment purchase)
Oxygen and Related Respiratory Equipment
E0424RR
119.48
Stationary compressed gaseous oxygen system, rental;
							 includes container, contents, regulator, flowmeter, humidifier, nebulizer,
							 cannula or mask, and tubing (rental)
E0425
AAC+30%
Stationary compressed gas system, purchase; includes
							 regulator, flowmeter, humidifier, nebulizer, cannula or mask, and
							 tubing
E0430
AAC+30%
Portable gaseous oxygen system, purchase; includes
							 regulator, flowmeter, humidifier, cannula or mask, and tubing
E0431RR
21.34
Portable gaseous oxygen system, rental; includes
							 portable container, regulator, flowmeter, humidifier, cannula or mask, and
							 tubing (rental)
E0433RR
40.26
Portable liquid oxygen system, rental; home liquefier
							 used to fill portable liquid oxygen containers, includes portable containers,
							 regulator, flowmeter, humidifier, cannula or mask and tubing, with or without
							 supply reservoir and contents gauge
E0434RR
21.34
Portable liquid oxygen system, rental; includes
							 portable container, supply reservoir, humidifier, flowmeter, refill adaptor,
							 contents gauge, cannula or mask, and tubing (rental)
E0435
AAC+30%
Portable liquid oxygen system, purchase; includes
							 portable container, supply reservoir, flowmeter, humidifier, contents gauge,
							 cannula or mask, tubing and refill adaptor
E0439QF
119.48
Stationary liquid oxygen system, rental; includes
							 container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or
							 mask, and tubing (rental) (prescribed amount of oxygen exceeds 4 LPM and
							 portable oxygen is prescribed)
E0439QG
119.48
Stationary liquid oxygen system, rental; includes
							 container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or
							 mask, and tubing (rental) (prescribed amount of oxygen is greater than 4
							 LPM)
E0439RR
119.48
Stationary liquid oxygen system, rental; includes
							 container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or
							 mask, and tubing (rental)
E0440
AAC+30%
Stationary liquid oxygen system, purchase; includes
							 use of reservoir, contents indicator, regulator, flowmeter, humidifier,
							 nebulizer, cannula or mask, and tubing
E0441
58.57
Oxygen contents, gaseous (for use with owned gaseous
							 stationary systems or when both a stationary and portable gaseous system are
							 owned), one month's supply = 1 unit
E0442
58.57
Oxygen contents, liquid (for use with owned liquid
							 stationary systems or when both a stationary and portable liquid system are
							 owned), one month's supply = 1 unit
E0443RR
57.33
Portable oxygen contents, gaseous (for use only with
							 portable gaseous systems when no stationary gas or liquid system is used), one
							 month's supply = 1 unit (rental)
E0444RR
57.33
Portable oxygen contents, liquid (for use only with
							 portable liquid systems when no stationary gas or liquid system is used), one
							 month's supply = 1 unit (rental)
E0445NU
856.30
Oximeter device for measuring blood oxygen levels
							 non-invasively (new equipment)
E0445RR
85.63
Oximeter device for measuring blood oxygen levels
							 non-invasively (rental)
E0445UE
642.23
Oximeter device for measuring blood oxygen levels
							 non-invasively (used durable medical equipment)
E0446
AAC+30%
Topical oxygen delivery system, not otherwise
							 specified, includes all supplies and accessories
E0447
56.94
Portable oxygen contents, liquid, 1 month's supply =
							 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute
							 (LPM)
E0455
AAC+20%
Oxygen tent, excluding croup or pediatric
							 tents
E0457NU
548.45
Chest shell (cuirass) (new equipment)
E0457RR
54.84
Chest shell (cuirass) (rental)
E0457UE
411.31
Chest shell (cuirass) (used durable medical
							 equipment)
E0459KH
45.42
Chest wrap (capped rental)
E0459KI
45.42
Chest wrap (capped rental)
E0459KJ
34.06
Chest wrap (capped rental)
E0459NU
476.86
Chest wrap (new equipment purchase)
E0459UE
357.65
Chest wrap (used durable medical equipment
							 purchase)
E0462KH
232.76
Rocking bed with or without side rails (capped
							 rental)
E0462KI
232.76
Rocking bed with or without side rails (capped
							 rental)
E0462KJ
174.57
Rocking bed with or without side rails (capped
							 rental)
E0462NU
2,327.56
Rocking bed with or without side rails (new equipment
							 purchase)
E0462UE
1,745.67
Rocking bed with or without side rails (used durable
							 medical equipment purchase)
E0465RR
896.95
Home ventilator, any type, used with invasive
							 interface (
e.g.
, tracheostomy tube) (rental, months seven and
							 beyond)
E0465U2
1,055.23
Home ventilator, any type, used with invasive
							 interface (
e.g.
, tracheostomy tube) (rental, first six
							 months)
E0466RR
896.95
Home ventilator, any type, used with non-invasive
							 interface (
e.g.
, mask, chest shell) (rental, months seven and
							 beyond)
E0466U2
1,055.23
Home ventilator, any type, used with non-invasive
							 interface (
e.g.
, mask, chest shell) (rental, first six
							 months)
E0467RR
1,091.46
Home ventilator, multi-function respiratory device,
							 also performs any or all of the additional functions of oxygen concentration,
							 drug nebulization, aspiration, and cough stimulation, includes all accessories,
							 components and supplies for all functions (rental, months seven and
							 beyond)
E0467U2
1,284.07
Home ventilator, multi-function respiratory device,
							 also performs any or all of the additional functions of oxygen concentration,
							 drug nebulization, aspiration, and cough stimulation, includes all accessories,
							 components and supplies for all functions (rental, first six
							 months)
E0470KH
146.83
Respiratory assist device, bi-level pressure
							 capability, without backup rate feature, used with noninvasive interface,
e.g.
, nasal or facial mask (intermittent assist device with
							 continuous positive airway pressure device) (capped rental) (humidifier not
							 included)
E0470KI
146.83
Respiratory assist device, bi-level pressure
							 capability, without backup rate feature, used with noninvasive interface,
e.g.
, nasal or facial mask (intermittent assist device with
							 continuous positive airway pressure device) (capped rental) (humidifier not
							 included)
E0470KJ
110.12
Respiratory assist device, bi-level pressure
							 capability, without backup rate feature, used with noninvasive interface,
e.g.
, nasal or facial mask (intermittent assist device with
							 continuous positive airway pressure device) (capped rental) (humidifier not
							 included)
E0470NU
1,468.29
Respiratory assist device, bi-level pressure
							 capability, without backup rate feature, used with noninvasive interface,
e.g.
, nasal or facial mask (intermittent assist device with
							 continuous positive airway pressure device) (new equipment) (humidifier not
							 included)
E0470UE
1,101.22
Respiratory assist device, bi-level pressure
							 capability, without backup rate feature, used with noninvasive interface,
e.g.
, nasal or facial mask (intermittent assist device with
							 continuous positive airway pressure device) (used durable medical equipment
							 purchase) (humidifier not included)
E0471KH
392.40
Respiratory assist device, bi-level pressure
							 capability, with back-up rate feature, used with noninvasive interface,
e.g.
, nasal or facial mask (intermittent assist device with
							 continuous positive airway pressure device) (capped rental) (humidifier not
							 included)
E0471KI
392.40
Respiratory assist device, bi-level pressure
							 capability, with back-up rate feature, used with noninvasive interface,
e.g.
, nasal or facial mask (intermittent assist device with
							 continuous positive airway pressure device) (capped rental) (humidifier not
							 included)
E0471KJ
294.30
Respiratory assist device, bi-level pressure
							 capability, with back-up rate feature, used with noninvasive interface,
e.g.
, nasal or facial mask (intermittent assist device with
							 continuous positive airway pressure device) (capped rental) (humidifier not
							 included)
E0471NU
3,924.03
Respiratory assist device, bi-level pressure
							 capability, with back-up rate feature, used with noninvasive interface,
e.g.
, nasal or facial mask (intermittent assist device with
							 continuous positive airway pressure device) (new equipment purchase)
							 (humidifier not included)
E0471UE
2,943.02
Respiratory assist device, bi-level pressure
							 capability, with back-up rate feature, used with noninvasive interface,
e.g.
, nasal or facial mask (intermittent assist device with
							 continuous positive airway pressure device) (used durable medical equipment
							 purchase) (humidifier not included)
E0472KH
431.07
Respiratory assist device, bi-level pressure
							 capability, with backup rate feature, used with invasive interface,
e.g.
, tracheostomy tube (intermittent assist device with
							 continuous positive airway pressure device) (capped rental) (humidifier not
							 included)
E0472KI
431.07
Respiratory assist device, bi-level pressure
							 capability, with backup rate feature, used with invasive interface,
e.g.
, tracheostomy tube (intermittent assist device with
							 continuous positive airway pressure device) (capped rental) (humidifier not
							 included)
E0472KJ
323.30
Respiratory assist device, bi-level pressure
							 capability, with backup rate feature, used with invasive interface,
e.g.
, tracheostomy tube (intermittent assist device with
							 continuous positive airway pressure device) (capped rental) (humidifier not
							 included)
E0472NU
4,310.69
Respiratory assist device, bi-level pressure
							 capability, with backup rate feature, used with invasive interface,
e.g.
, tracheostomy tube (intermittent assist device with
							 continuous positive airway pressure device) (new equipment purchase)
							 (humidifier not included)
E0472UE
3,233.02
Respiratory assist device, bi-level pressure
							 capability, with backup rate feature, used with invasive interface,
e.g.
, tracheostomy tube (intermittent assist device with
							 continuous positive airway pressure device) (used durable medical equipment
							 purchase) (humidifier not included)
E0480KH
41.29
Percussor, electric or pneumatic, home model (capped
							 rental)
E0480KI
41.29
Percussor, electric or pneumatic, home model (capped
							 rental)
E0480KJ
30.97
Percussor, electric or pneumatic, home model (capped
							 rental)
E0480NU
412.93
Percussor, electric or pneumatic, home model (new
							 equipment purchase)
E0480UE
309.70
Percussor, electric or pneumatic, home model (used
							 durable medical equipment purchase)
E0481
AAC+30%
Intrapulmonary percussive ventilation system and
							 related accessories
E0482KH
404.09
Cough stimulating device, alternating positive and
							 negative airway pressure (capped rental)
E0482KI
404.09
Cough stimulating device, alternating positive and
							 negative airway pressure (capped rental)
E0482KJ
303.07
Cough stimulating device, alternating positive and
							 negative airway pressure (capped rental)
E0482NU
4,040.90
Cough stimulating device, alternating positive and
							 negative airway pressure (new equipment purchase)
E0482UE
3,030.68
Cough stimulating device, alternating positive and
							 negative airway pressure (used durable medical equipment purchase)
E0483KH
999.01
High frequency chest wall oscillation air-pulse
							 generator system, includes all accessories and supplies, each (capped
							 rental)
E0483KI
999.01
High frequency chest wall oscillation air-pulse
							 generator system, includes all accessories and supplies, each (capped
							 rental)
E0483KJ
749.25
High frequency chest wall oscillation air-pulse
							 generator system, includes all accessories and supplies, each (capped
							 rental)
E0483NU
9,990.05
High frequency chest wall oscillation air-pulse
							 generator system, includes all accessories and supplies, each (new
							 equipment)
E0483UE
7,492.54
High frequency chest wall oscillation air-pulse
							 generator system, includes all accessories and supplies, each (used durable
							 medical equipment)
E0484NU
34.71
Oscillatory positive expiratory pressure device,
							 non-electric, any type, each (new equipment)
E0484RR
3.46
Oscillatory positive expiratory pressure device,
							 non-electric, any type, each (rental)
E0484UE
26.04
Oscillatory positive expiratory pressure device,
							 non-electric, any type, each (used durable medical equipment)
E0485NU
AAC+30%
Oral device/appliance used to reduce upper airway
							 collapsibility, adjustable or non-adjustable, prefabricated, includes fitting
							 and adjustment (new equipment)
E0485RR
I.C.
Oral device/appliance used to reduce upper airway
							 collapsibility, adjustable or non-adjustable, prefabricated, includes fitting
							 and adjustment (rental)
E0485UE
I.C.
Oral device/appliance used to reduce upper airway
							 collapsibility, adjustable or non-adjustable, prefabricated, includes fitting
							 and adjustment (used durable medical equipment)
E0486NU
$1881.22
Oral device/appliance used to reduce upper airway
							 collapsibility, adjustable or non-adjustable, custom fabricated, includes
							 fitting and adjustment (new equipment)
E0487
AAC+30%
Spirometer, electronic, includes all
							 accessories
IPPB Machines
E0500RR
103.14
IPPB machine, all types, with built-in nebulization;
							 manual or automatic valves; internal or external power source
							 (rental)
Humidifiers/Compressors/Nebulizers
E0550KH
40.04
Humidifier, durable for extensive supplemental
							 humidification during IPPB treatments or oxygen delivery (capped
							 rental)
E0550KI
40.04
Humidifier, durable for extensive supplemental
							 humidification during IPPB treatments or oxygen delivery (capped
							 rental)
E0550KJ
30.03
Humidifier, durable for extensive supplemental
							 humidification during IPPB treatments or oxygen delivery (capped
							 rental)
E0550NU
400.44
Humidifier, durable for extensive supplemental
							 humidification during IPPB treatments or oxygen delivery (new equipment
							 purchase)
E0550UE
300.33
Humidifier, durable for extensive supplemental
							 humidification during IPPB treatments or oxygen delivery (used durable medical
							 equipment purchase)
E0555
AAC+30%
Humidifier, durable, glass or autoclavable plastic
							 bottle type, for use with regulator or flowmeter
E0560NU
138.91
Humidifier, durable for supplemental humidification
							 during IPPB treatment or oxygen delivery (new equipment)
E0560RR
16.28
Humidifier, durable for supplemental humidification
							 during IPPB treatment or oxygen delivery (rental)
E0560UE
104.18
Humidifier, durable for supplemental humidification
							 during IPPB treatment or oxygen delivery (used durable medical
							 equipment)
E0561NU
73.66
Humidifier, non-heated, used with positive airway
							 pressure device (new equipment)
E0561RR
7.36
Humidifier, non-heated, used with positive airway
							 pressure device (rental)
E0561UE
55.24
Humidifier, non-heated, used with positive airway
							 pressure device (used durable medical equipment)
E0562NU
189.83
Humidifier, heated, used with positive airway
							 pressure device (new equipment)
E0562RR
18.97
Humidifier, heated, used with positive airway
							 pressure device (rental)
E0562UE
142.37
Humidifier, heated, used with positive airway
							 pressure device (used durable medical equipment)
E0565KH
50.84
Compressor, air power source for equipment which is
							 not selfcontained or cylinder driven (capped rental)
E0565KI
50.84
Compressor, air power source for equipment which is
							 not selfcontained or cylinder driven (capped rental)
E0565KJ
38.13
Compressor, air power source for equipment which is
							 not self- contained or cylinder driven (capped rental)
E0565NU
508.39
Compressor, air power source for equipment which is
							 not self- contained or cylinder driven (new equipment purchase)
E0565UE
381.29
Compressor, air power source for equipment which is
							 not self- contained or cylinder driven (used durable medical
							 equipment
E0570KH
12.32
Nebulizer, with compressor (capped
							 rental)
E0570KI
12.32
Nebulizer, with compressor (capped
							 rental)
E0570KJ
9.24
Nebulizer, with compressor (capped
							 rental)
E0570NU
123.17
Nebulizer, with compressor (new equipment
							 purchase)
E0570UE
92.37
Nebulizer, with compressor (used durable medical
							 equipment purchase)
E0572KH
34.83
Aerosol compressor, adjustable pressure, light duty
							 for intermittent use (capped rental)
E0572KI
34.83
Aerosol compressor, adjustable pressure, light duty
							 for intermittent use (capped rental)
E0572KJ
26.12
Aerosol compressor, adjustable pressure, light duty
							 for intermittent use (capped rental)
E0572NU
348.33
Aerosol compressor, adjustable pressure, light duty
							 for intermittent use (new equipment purchase)
E0572UE
261.25
Aerosol compressor, adjustable pressure, light duty
							 for intermittent use (used durable medical equipment purchase)
E0574KH
37.83
Ultrasonic/electronic aerosol generator with small
							 volume nebulizer (capped rental)
E0574KI
37.83
Ultrasonic/electronic aerosol generator with small
							 volume nebulizer (capped rental)
E0574KJ
28.38
Ultrasonic/electronic aerosol generator with small
							 volume nebulizer (capped rental)
E0574NU
378.34
Ultrasonic/electronic aerosol generator with small
							 volume nebulizer (new equipment purchase)
E0574UE
283.75
Ultrasonic/electronic aerosol generator with small
							 volume nebulizer (used durable medical equipment purchase)
E0575KH
96.58
Nebulizer, ultrasonic, large volume (capped rental
							 rental)
E0575KI
96.58
Nebulizer, ultrasonic, large volume (capped rental
							 rental)
E0575KJ
72.43
Nebulizer, ultrasonic, large volume (capped rental
							 rental)
E0575NU
965.77
Nebulizer, ultrasonic, large volume (new equipment
							 purchase)
E0575UE
724.33
Nebulizer, ultrasonic, large volume (used durable
							 medical equipment purchase)
E0580NU
107.29
Nebulizer, durable, glass or autoclavable plastic,
							 bottle type, for use with regulator or flowmeter (new equipment)
E0580RR
10.74
Nebulizer, durable, glass or autoclavable plastic,
							 bottle type, for use with regulator or flowmeter (rental)
E0580UE
80.46
Nebulizer, durable, glass or autoclavable plastic,
							 bottle type, for use with regulator or flowmeter (used durable medical
							 equipment)
E0585KH
28.01
Nebulizer, with compressor and heater (capped
							 rental)
E0585KI
28.01
Nebulizer, with compressor and heater (capped
							 rental)
E0585KJ
21.01
Nebulizer, with compressor and heater (capped
							 rental)
E0585NU
280.08
Nebulizer, with compressor and heater (new equipment
							 purchase)
E0585UE
210.06
Nebulizer, with compressor and heater (used durable
							 medical equipment purchase)
Pumps and Vaporizers
E0600KH
43.03
Respiratory suction pump, home model, portable or
							 stationary, electric (capped rental)
E0600KI
43.03
Respiratory suction pump, home model, portable or
							 stationary, electric (capped rental)
E0600KJ
32.27
Respiratory suction pump, home model, portable or
							 stationary, electric (capped rental)
E0600NU
430.27
Respiratory suction pump, home model, portable or
							 stationary, electric (new equipment purchase)
E0600UE
322.70
Respiratory suction pump, home model, portable or
							 stationary, electric (used durable medical equipment)
E0601KH
60.50
Continuous positive airway pressure (CPAP) device
							 (capped rental) (humidifier not included)
E0601KI
60.50
Continuous positive airway pressure (CPAP) device
							 (capped rental) (humidifier not included)
E0601KJ
45.38
Continuous positive airway pressure (CPAP) device
							 (capped rental) (humidifier not included)
E0601NU
605.03
Continuous positive airway pressure (CPAP) device
							 (new equipment purchase) (humidifier not included)
E0601UE
453.77
Continuous positive airway pressure (CPAP) device
							 (used durable medical equipment purchase) (humidifier not included)
E0602NU
27.74
Breast pump, manual, any type (new
							 equipment)
E0602RR
2.79
Breast pump, manual, any type (rental)
E0602UE
20.81
Breast pump, manual, any type (used durable medical
							 equipment)
E0603NU
213.20
Breast pump, electric (AC and/or DC), any
							 type
E0604RR
70.00
Breast pump, hospital grade, electric (AC and /or
							 DC), any type (rental)
E0605NU
24.84
Vaporizer, room type (new equipment)
E0605RR
2.50
Vaporizer, room type (rental)
E0605UE
18.65
Vaporizer, room type (used durable medical
							 equipment)
E0606KH
21.57
Postural drainage board (capped rental)
E0606KI
21.57
Postural drainage board (capped rental)
E0606KJ
16.18
Postural drainage board (capped rental)
E0606NU
215.73
Postural drainage board (new equipment
							 purchase)
E0606UE
161.80
Postural drainage board (used durable medical
							 equipment purchase)
Monitoring Devices
E0607NU
62.78
Home blood glucose monitor (new
							 equipment)
E0607RR
6.27
Home blood glucose monitor (rental)
E0607UE
47.08
Home blood glucose monitor (used durable medical
							 equipment)
E0610NU
189.98
Pacemaker monitor, self-contained, (checks battery
							 depletion, includes audible and visible check systems) (new
							 equipment)
E0610RR
20.03
Pacemaker monitor, self-contained, (checks battery
							 depletion, includes audible and visible check systems) (rental)
E0610UE
142.50
Pacemaker monitor, self-contained, (checks battery
							 depletion, includes audible and visible check systems) (used durable medical
							 equipment)
E0615NU
449.92
Pacemaker monitor, self contained, checks battery
							 depletion and other pacemaker components, includes digital/visible check
							 systems (new equipment)
E0615RR
54.97
Pacemaker monitor, self contained, checks battery
							 depletion and other pacemaker components, includes digital/visible check
							 systems (rental)
E0615UE
337.47
Pacemaker monitor, self contained, checks battery
							 depletion and other pacemaker components, includes digital/visible check
							 systems (used durable medical equipment)
E0616
AAC+30%
Implantable cardiac event recorder with memory,
							 activator and programmer
E0617KH
285.70
External defibrillator with integrated
							 electrocardiogram analysis (capped rental)
E0617KHKF
317.22
External defibrillator with integrated
							 electrocardiogram analysis (capped rental) (FDA class III device)
E0617KI
285.70
External defibrillator with integrated
							 electrocardiogram analysis (capped rental)
E0617KIKF
317.22
External defibrillator with integrated
							 electrocardiogram analysis (capped rental) (FDA class III device)
E0617KJ
214.28
External defibrillator with integrated
							 electrocardiogram analysis (capped rental)
E0617KJKF
237.92
External defibrillator with integrated
							 electrocardiogram analysis (capped rental) (FDA class III device)
E0617NU
2,857.02
External defibrillator with integrated
							 electrocardiogram analysis (new equipment purchase)
E0617NUKF
3,172.20
External defibrillator with integrated
							 electrocardiogram analysis (new equipment purchase) (FDA class III
							 device)
E0617UE
2,142.77
External defibrillator with integrated
							 electrocardiogram analysis (used durable medical equipment
							 purchase)
E0617UEKF
2,379.15
External defibrillator with integrated
							 electrocardiogram analysis (used durable medical equipment purchase) (FDA class
							 III device)
E0618KH
263.46
Apnea monitor, without recording feature (capped
							 rental)
E0618KI
263.46
Apnea monitor, without recording feature (capped
							 rental)
E0618KJ
195.45
Apnea monitor, without recording feature (capped
							 rental)
E0619KH
224.28
Apnea monitor, with recording feature (capped
							 rental)
E0619KI
224.28
Apnea monitor, with recording feature (capped
							 rental)
E0619KJ
168.21
Apnea monitor, with recording feature (capped
							 rental)
E0620KH
81.27
Skin piercing device for collection of capillary
							 blood, laser, each (capped rental)
E0620KI
81.27
Skin piercing device for collection of capillary
							 blood, laser, each (capped rental)
E0620KJ
60.95
Skin piercing device for collection of capillary
							 blood, laser, each (capped rental)
E0620NU
821.53
Skin piercing device for collection of capillary
							 blood, laser, each (new equipment)
E0620UE
616.15
Skin piercing device for collection of capillary
							 blood, laser, each (used durable medical equipment)
Patient Lifts
E0621NU
80.25
Sling or seat, patient lift, canvas or nylon (new
							 equipment)
E0621RR
7.85
Sling or seat, patient lift, canvas or nylon
							 (rental)
E0621UE
60.36
Sling or seat, patient lift, canvas or nylon (used
							 durable medical equipment)
E0625NU
AAC+30%
Patient lift, bathroom or toilet, not otherwise
							 classified (new equipment)
E0625RR
I.C.
Patient lift, bathroom or toilet, not otherwise
							 classified (rental)
E0625UE
I.C.
Patient lift, bathroom or toilet, not otherwise
							 classified (used durable medical equipment)
E0627NU
278.85
Seat lift mechanism, electric, any type (new
							 equipment)
E0627RR
27.89
Seat lift mechanism, electric, any type
							 (rental)
E0627UE
209.14
Seat lift mechanism, electric, any type (used durable
							 medical equipment)
E0629NU
279.55
Seat lift mechanism, non-electric, any type (new
							 equipment)
E0629RR
27.96
Seat lift mechanism, non-electric, any type
							 (rental)
E0629UE
209.65
Seat lift mechanism, non-electric, any type (used
							 durable medical equipment)
E0630KH
77.45
Patient lift, hydraulic or mechanical, includes any
							 seat, sling, strap(s) or pad(s) (capped rental)
E0630KI
77.45
Patient lift, hydraulic or mechanical, includes any
							 seat, sling, strap(s) or pad(s) (capped rental)
E0630KJ
58.09
Patient lift, hydraulic or mechanical, includes any
							 seat, sling, strap(s) or pad(s) (capped rental)
E0630NU
774.52
Patient lift, hydraulic or mechanical, includes any
							 seat, sling, strap(s) or pad(s) (new equipment purchase)
E0630RB
AAC+30%
Patient lift, hydraulic or mechanical, includes any
							 seat, sling, strap(s) or pad(s) (replacement of a part of a DME furnished as
							 part of a repair)
E0630UE
580.89
Patient lift, hydraulic or mechanical, includes any
							 seat, sling, strap(s) or pad(s) (used durable medical equipment
							 purchase)
E0635KH
106.66
Patient lift, electric with seat or sling (capped
							 rental)
E0635KI
106.66
Patient lift, electric with seat or sling (capped
							 rental)
E0635KJ
79.99
Patient lift, electric with seat or sling (capped
							 rental)
E0635NU
1,066.58
Patient lift, electric with seat or sling (new
							 equipment purchase)
E0635RB
AAC+30%
Patient lift, electric with seat or sling
							 (replacement of a part of a DME furnished as part of a repair)
E0635U1
AAC+35%
Patient lift, electric with seat or sling
							 (nonstandard lift involving customization, special orders, or special sizing
							 requirements)
E0635UE
799.94
Patient lift, electric with seat or sling (used
							 durable medical equipment purchase)
E0636KH
1,107.26
Multipositional patient support system, with
							 integrated lift, patient accessible controls (capped rental)
E0636KI
1,107.26
Multipositional patient support system, with
							 integrated lift, patient accessible controls (capped rental)
E0636KJ
830.45
Multipositional patient support system, with
							 integrated lift, patient accessible controls (capped rental)
E0636NU
11,072.60
Multipositional patient support system, with
							 integrated lift, patient accessible controls (new equipment
							 purchase)
E0636RB
AAC+30%
Multipositional patient support system, with
							 integrated lift, patient accessible controls (replacement of a part of a DME
							 furnished as part of a repair)
E0636UE
8,304.45
Multipositional patient support system, with
							 integrated lift, patient accessible controls (used durable medical equipment
							 purchase)
E0637NU
2,104.97
Combination sit to stand system, any size including
							 pediatric, with seat lift feature, with or without wheels (new
							 equipment)
E0637RR
210.51
Combination sit to stand system, any size including
							 pediatric, with seat lift feature, with or without wheels (rental)
E0637UE
1,578.72
Combination sit to stand system, any size including
							 pediatric, with seat lift feature, with or without wheels (used durable medical
							 equipment)
E0638NU
853.57
Standing frame system, one position
							 (
e.g.
, upright, supine or prone stander), any size including
							 pediatric, with or without wheels (new equipment)
E0638RR
85.36
Standing frame system, one position
							 (
e.g.
, upright, supine or prone stander), any size, with or
							 without wheels (rental)
E0638UE
640.18
Standing frame system, one position
							 (
e.g.
, upright, supine or prone stander), any size including
							 pediatric, with or without wheels (used durable medical equipment)
E0639KH
123.32
Patient lift, moveable from room to room with
							 disassembly and reassembly, includes all components/accessories) (capped
							 rental)
E0639KI
123.32
Patient lift, moveable from room to room with
							 disassembly and reassembly, includes all components/accessories) (capped
							 rental)
E0639KJ
92.49
Patient lift, moveable from room to room with
							 disassembly and reassembly, includes all components/accessories) (capped
							 rental)
E0639NU
AAC+35%
Patient lift, moveable from room to room with
							 disassembly and reassembly, includes all components/accessories) (new
							 equipment)
E0639RB
AAC+35%
Patient lift, moveable from room to room with
							 disassembly and reassembly, includes all components/accessories (replacement of
							 a part of DME furnished as part of a repair)
E0639UE
924.90
Patient lift, moveable from room to room with
							 disassembly and reassembly, includes all components/accessories) (used durable
							 medical equipment purchase)
E0640KH
123.32
Patient lift, fixed system, includes all
							 components/accessories (capped rental)
E0640KI
123.32
Patient lift, fixed system, includes all
							 components/accessories (capped rental)
E0640KJ
92.49
Patient lift, fixed system, includes all
							 components/accessories (capped rental)
E0640NU
AAC+35%
Patient lift, fixed system, includes all
							 components/accessories (new equipment)
E0640RB
AAC+35%
Patient lift, fixed system, includes all
							 components/accessories (replacement of a part of DME furnished as part of a
							 repair)
E0640UE
924.90
Patient lift, fixed system, includes all
							 components/accessories (used durable medical equipment purchase)
E0641
AAC+30%
Standing frame system, multi-position
							 (
e.g.
three-way stander), any size including pediatric, with
							 or without wheels
E0642
AAC+30%
Standing frame system, mobile (dynamic stander), any
							 size including pediatric
Compression Devices
E0650NU
676.77
Pneumatic compressor, non-segmental home model (new
							 equipment)
E0650RR
83.51
Pneumatic compressor, non-segmental home model
							 (rental)
E0650UE
507.58
Pneumatic compressor, non-segmental home model (used
							 durable medical equipment)
E0651NU
733.56
Pneumatic compressor, segmental home model without
							 calibrated gradient pressure (new equipment purchase)
E0651RR
86.90
Pneumatic compressor, segmental home model without
							 calibrated gradient pressure (rental)
E0651UE
550.19
Pneumatic compressor, segmental home model without
							 calibrated gradient pressure (used durable medical equipment)
E0652NU
4,981.67
Pneumatic compressor, segmental home model with
							 calibrated gradient pressure (new equipment)
E0652RR
418.49
Pneumatic compressor, segmental home model with
							 calibrated gradient pressure (rental)
E0652UE
3,732.92
Pneumatic compressor, segmental home model with
							 calibrated gradient pressure (used durable medical equipment)
E0655NU
95.61
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, half arm (new equipment)
E0655RR
10.13
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, half arm (rental)
E0655UE
71.71
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, half arm (used durable medical equipment)
E0656KH
54.30
Segmental pneumatic appliance for use with pneumatic
							 compressor, trunk (rental)
E0656KI
54.30
Segmental pneumatic appliance for use with pneumatic
							 compressor, trunk (rental)
E0656KJ
40.72
Segmental pneumatic appliance for use with pneumatic
							 compressor, trunk (rental)
E0656NU
542.98
Segmental pneumatic appliance for use with pneumatic
							 compressor, trunk (new equipment)
E0656UE
407.24
Segmental pneumatic appliance for use with pneumatic
							 compressor, trunk (used durable medical equipment)
E0657KH
51.01
Segmental pneumatic appliance for use with pneumatic
							 compressor, chest (capped rental)
E0657KI
51.01
Segmental pneumatic appliance for use with pneumatic
							 compressor, chest (capped rental)
E0657KJ
38.26
Segmental pneumatic appliance for use with pneumatic
							 compressor, chest (capped rental)
E0657NU
510.09
Segmental pneumatic appliance for use with pneumatic
							 compressor, chest (new equipment)
E0657UE
382.57
Segmental pneumatic appliance for use with pneumatic
							 compressor, chest (used durable medical equipment)
E0660NU
148.69
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, full leg (new equipment)
E0660RR
13.28
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, full leg (rental)
E0660UE
111.53
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, full leg (used durable medical equipment)
E0665NU
128.73
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, full arm (new equipment)
E0665RR
12.42
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, full arm (rental)
E0665UE
96.66
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, full arm (used durable medical equipment)
E0666NU
129.77
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, half leg (new equipment)
E0666RR
13.37
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, half leg (rental)
E0666UE
97.34
Non-segmental pneumatic appliance for use with
							 pneumatic compressor, half leg (used durable medical equipment)
E0667NU
258.60
Segmental pneumatic appliance for use with pneumatic
							 compressor, full leg
E0667RR
34.36
Segmental pneumatic appliance for use with pneumatic
							 compressor, full leg
E0667UE
193.95
Segmental pneumatic appliance for use with pneumatic
							 compressor, full leg
E0668NU
415.23
Segmental pneumatic appliance for use with pneumatic
							 compressor, full arm (new equipment)
E0668RR
40.98
Segmental pneumatic appliance for use with pneumatic
							 compressor, full arm (rental)
E0668UE
311.43
Segmental pneumatic appliance for use with pneumatic
							 compressor, full arm (used durable rental equipment)
E0669NU
163.57
Segmental pneumatic appliance for use with pneumatic
							 compressor, half leg (new equipment)
E0669RR
16.36
Segmental pneumatic appliance for use with pneumatic
							 compressor, half leg (rental)
E0669UE
122.68
Segmental pneumatic appliance for use with pneumatic
							 compressor, half leg (used durable rental equipment)
E0670NU
1,004.05
Segmental pneumatic appliance for use with pneumatic
							 compressor, integrated, two full legs and trunk (new equipment
							 purchase)
E0670RR
126.45
Segmental pneumatic appliance for use with pneumatic
							 compressor, integrated, two full legs and trunk (rental)
E0670UE
753.00
Segmental pneumatic appliance for use with pneumatic
							 compressor, integrated, two full legs and trunk (used durable medical equipment
							 purchase)
E0671NU
390.30
Segmental gradient pressure pneumatic appliance, full
							 leg (new equipment)
E0671RR
39.05
Segmental gradient pressure pneumatic appliance, full
							 leg (rental)
E0671UE
292.71
Segmental gradient pressure pneumatic appliance, full
							 leg (used durable rental equipment)
E0672NU
303.25
Segmental gradient pressure pneumatic appliance, full
							 arm (new equipment)
E0672RR
30.34
Segmental gradient pressure pneumatic appliance, full
							 arm (rental)
E0672UE
227.46
Segmental gradient pressure pneumatic appliance, full
							 arm (used durable medical equipment)
E0673NU
251.99
Segmental gradient pressure pneumatic appliance, half
							 leg (new equipment)
E0673RR
25.20
Segmental gradient pressure pneumatic appliance, half
							 leg (rental)
E0673UE
189.02
Segmental gradient pressure pneumatic appliance, half
							 leg (used durable medical equipment)
E0675KH
361.35
Pneumatic compression device, high pressure, rapid
							 inflation/ deflation cycle, for arterial insufficiency (unilateral or bilateral
							 system) (capped rental)
E0675KI
361.35
Pneumatic compression device, high pressure, rapid
							 inflation/ deflation cycle, for arterial insufficiency (unilateral or bilateral
							 system) (capped rental)
E0675KJ
271.01
Pneumatic compression device, high pressure, rapid
							 inflation/
E0675NU
3,613.52
Pneumatic compression device, high pressure, rapid
							 inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral
							 system) (new equipment purchase)
E0675UE
2,710.14
Pneumatic compression device, high pressure, rapid
							 inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral
							 system) (used durable medical equipment purchase)
E0676
AAC+30%
Intermittent limb compression device (includes all
							 accessories), not otherwise specified
Ultraviolet Light
E0691NU
844.39
Ultraviolet light therapy system panel, includes
							 bulbs/lamps, timer and eye protection; treatment area two square feet or less
							 (new equipment)
E0691RR
84.43
Ultraviolet light therapy system panel, includes
							 bulbs/lamps, timer and eye protection; treatment area two square feet or less
							 (rental)
E0691UE
633.29
Ultraviolet light therapy system panel, includes
							 bulbs/lamps, timer and eye protection; treatment area two square feet or less
							 (used durable medical equipment purchase)
E0692NU
1,060.32
Ultraviolet light therapy system panel, includes
							 bulbs/lamps, timer and eye protection, four foot panel (new
							 equipment)
E0692RR
106.02
Ultraviolet light therapy system panel, includes
							 bulbs/lamps, timer and eye protection, four foot panel (rental)
E0692UE
795.23
Ultraviolet light therapy system panel, includes
							 bulbs/lamps, timer and eye protection, four foot panel (used durable medical
							 equipment)
E0693NU
1,307.08
Ultraviolet light therapy system panel, includes
							 bulbs/lamps, timer and eye protection, six foot panel (new
							 equipment)
E0693RR
130.71
Ultraviolet light therapy system panel, includes
							 bulbs/lamps, timer and eye protection, six foot panel (rental)
E0693UE
980.31
Ultraviolet light therapy system panel, includes
							 bulbs/lamps, timer and eye protection, six foot panel (used durable medical
							 equipment)
E0694NU
4,160.29
Ultraviolet multidirectional light therapy system in
							 six foot cabinet, includes bulbs/lamps, timer and eye protection (new
							 equipment)
E0694RR
416.02
Ultraviolet multidirectional light therapy system in
							 six foot cabinet, includes bulbs/lamps, timer and eye protection
							 (rental)
E0694UE
3,120.24
Ultraviolet multidirectional light therapy system in
							 six foot cabinet, includes bulbs/lamps, timer and eye protection (used durable
							 medical equipment)
Safety Equipment
E0700
AAC+30%
Safety equipment (
e.g.
, belt,
							 harness or vest)
E0705NU
45.79
Transfer device, any type, each (new
							 equipment)
E0705NUKU
61.76
Transfer device, any type, each (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0705RR
4.63
Transfer device, any type, each (rental)
E0705RRKU
6.31
Transfer device, any type, each (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E0705UE
33.97
Transfer device, any type, each (used durable medical
							 equipment)
E0705UEKU
45.43
Transfer device, any type, each (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
Restraints
E0710
AAC+20%
Restraints, any type (body, chest, wrist or
							 ankle)
Nerve Stimulators and Devices
E0720NU
268.58
Transcutaneous electrical nerve stimulation (TENS)
							 device, two lead, localized stimulation (new equipment)
E0730NU
251.77
Transcutaneous electrical nerve stimulation (TENS)
							 device, four or more leads, for multiple nerve stimulation (new
							 equipment)
E0731NU
245.57
Form fitting conductive garment for delivery of TENS
							 or NMES (with conductive fibers separated from the patient's skin by layers of
							 fabric) (new equipment)
E0740KH
49.15
Non-implanted, pelvic floor stimulator, monitor,
							 sensor and/or trainer (capped rental)
E0740KI
49.15
Non-implanted, pelvic floor stimulator, monitor,
							 sensor and/or trainer (capped rental)
E0740KJ
36.86
Non-implanted pelvic floor stimulator, monitor,
							 sensor and/or trainer capped rental)
E0740NU
491.47
Non-implanted pelvic floor stimulator, complete
							 system (new equipment)
E0740UE
368.60
Non-implanted pelvic floor stimulator, complete
							 system (used durable medical equipment)
E0744KH
86.05
Neuromuscular stimulator for scoliosis (capped
							 rental)
E0744KI
86.05
Neuromuscular stimulator for scoliosis (capped
							 rental)
E0744KJ
64.53
Neuromuscular stimulator for scoliosis (capped
							 rental)
E0744NU
860.46
Neuromuscular stimulator for scoliosis (new equipment
							 purchase)
E0744UE
645.35
Neuromuscular stimulator for scoliosis (new equipment
							 purchase)
E0745KH
84.12
Neuromuscular stimulator, electronic shock unit
							 (capped rental)
E0745KI
84.12
Neuromuscular stimulator, electronic shock unit
							 (capped rental)
E0745KJ
63.09
Neuromuscular stimulator, electronic shock unit
							 (capped rental)
E0745NU
841.16
Neuromuscular stimulator, electronic shock unit (new
							 equipment purchase)
E0745UE
630.87
Neuromuscular stimulator, electronic shock unit (used
							 durable medical equipment purchase)
E0746
AAC+30%
Electromyography (EMG), biofeedback
							 device
E0747NUKF
3,127.88
Osteogenesis stimulator, electrical, non-invasive,
							 other than spinal applications (new equipment) (FDA class III
							 device)
E0747RRKF
310.82
Osteogenesis stimulator, electrical, non-invasive,
							 other than spinal applications (rental) (FDA class III device)
E0747UEKF
2,323.96
Osteogenesis stimulator, electrical, non-invasive,
							 other than spinal applications (used durable medical equipment) (FDA class III
							 device)
E0748NUKF
3,656.03
Osteogenesis stimulator, electrical, non-invasive,
							 spinal applications (new equipment) (FDA class III device)
E0748RRKF
365.59
Osteogenesis stimulator, electrical, non-invasive,
							 spinal applications (rental) (FDA class III device)
E0748UEKF
2,742.02
Osteogenesis stimulator, electrical, non-invasive,
							 spinal applications (used durable medical equipment) (FDA class III
							 device)
E0749KHKF
267.21
Osteogenesis stimulator, electrical, surgically
							 implanted (capped rental) (FDA class III device)
E0749KIKF
267.21
Osteogenesis stimulator, electrical, surgically
							 implanted (capped rental) (FDA class III device)
E0749KJKF
200.41
Osteogenesis stimulator, electrical, surgically
							 implanted (capped rental) (FDA class III device)
E0749NUKF
2,672.15
Osteogenesis stimulator, electrical, surgically
							 implanted (new equipment purchase) (FDA class III device)
E0749UEKF
2,004.11
Osteogenesis stimulator, electrical, surgically
							 implanted (used durable medical equipment purchase) (FDA class III
							 device)
E0755
AAC+30%
Electronic salivary reflex stimulator
							 (intra-oral/non-invasive)
E0760NUKF
3,038.10
Ostogenesis stimulator, low intensity ultrasound,
							 non-invasive (new equipment) (FDA class III device)
E0760RRKF
303.82
Ostogenesis stimulator, low intensity ultrasound,
							 non-invasive (rental) (FDA class III device)
E0760UEKF
2,278.55
Ostogenesis stimulator, low intensity ultrasound,
							 non-invasive (used durable medical equipment) (FDA class III
							 device)
E0761
AAC+30%
Non-thermal pulsed high frequency radiowaves, high
							 peak power electromagnetic energy treatment device
E0762KH
87.82
Transcutaneous electrical joint stimulation device
							 system, includes all accessories (capped rental)
E0762KI
87.82
Transcutaneous electrical joint stimulation device
							 system, includes all accessories (capped rental)
E0762KJ
65.87
Transcutaneous electrical joint stimulation device
							 system, includes all accessories (capped rental)
E0762NU
878.22
Transcutaneous electrical joint stimulation device
							 system, includes all accessories (new equipment)
E0762UE
658.67
Transcutaneous electrical joint stimulation device
							 system, includes all accessories (used durable medical equipment)
E0764KHKF
1,039.92
Functional neuromuscular stimulator, transcutaneous
							 stimulation of muscles of ambulation with computer control, used for walking by
							 spinal cord injured, entire system, after completion of training program
							 (capped rental) (FDA class III device)
E0764KIKF
1,039.92
Functional neuromuscular stimulator, transcutaneous
							 stimulation of muscles of ambulation with computer control, used for walking by
							 spinal cord injured, entire system, after completion of training program
							 (capped rental) (FDA class III device)
E0764KJKF
779.93
Functional neuromuscular stimulator, transcutaneous
							 stimulation of muscles of ambulation with computer control, used for walking by
							 spinal cord injured, entire system, after completion of training program
							 (capped rental) (FDA class III device)
E0764NUKF
10,399.16
Functional neuromuscular stimulator, transcutaneous
							 stimulation of muscles of ambulation with computer control, used for walking by
							 spinal cord injured, entire system, after completion of training program (new
							 equipment) (FDA class III device)
E0764UEKF
7,799.37
Functional neuromuscular stimulator, transcutaneous
							 stimulation of muscles of ambulation with computer control, used for walking by
							 spinal cord injured, entire system, after completion of training program (used
							 durable medical equipment) (FDA class III device)
E0765NU
79.06
FDA approved nerve stimulator, with replaceable
							 batteries, for treatment of nausea and vomiting (new equipment)
E0765RR
7.91
FDA approved nerve stimulator, with replaceable
							 batteries, for treatment of nausea and vomiting (rental)
E0765UE
59.31
FDA approved nerve stimulator, with replaceable
							 batteries, for treatment of nausea and vomiting (used durable medical
							 equipment)
E0766RRKF
11,643.37
Electrical stimulation device used for cancer
							 treatment, includes all accessories, any type (rental) (FDA Class III
							 device)
E0769
AAC+30%
Electrical stimulation or electromagnetic wound
							 treatment device, not otherwise classified
E0770NU
AAC+30%
Functional electrical stimulator, transcutaneous
							 stimulation of nerve and/or muscle groups, any type, complete system, not
							 otherwise specified (new equipment)
Infusion Supplies
E0776NU
125.81
IV pole (new equipment)
E0776NUBA
68.49
IV pole (new equipment) (item furnished in
							 conjunction with parenteral enteral nutrition (PEN) services)
E0776RR
14.62
IV pole (rental)
E0776RRBA
13.62
IV pole (rental) (item furnished in conjunction with
							 parenteral enteral nutrition (PEN) services)
E0776UE
93.41
IV pole (used durable medical equipment)
E0776UEBA
51.37
IV pole (used durable medical equipment) (item
							 furnished in conjunction with parenteral enteral nutrition (PEN)
							 services)
E0779KH
15.45
Ambulatory infusion pump, mechanical, reusable, for
							 infusion 8 hours or greater (capped rental)
E0779KI
15.45
Ambulatory infusion pump, mechanical, reusable, for
							 infusion 8 hours or greater (capped rental)
E0779KJ
11.59
Ambulatory infusion pump, mechanical, reusable, for
							 infusion 8 hours or greater (capped rental)
E0779NU
154.53
Ambulatory infusion pump, mechanical, reusable, for
							 infusion 8 hours or greater (new equipment purchase)
E0779UE
115.90
Ambulatory infusion pump, mechanical, reusable, for
							 infusion 8 hours or greater (used durable medical equipment)
E0780NU
9.70
Ambulatory infusion pump, mechanical, reusable, for
							 infusion less than 8 hours (new equipment)
E0781KH
204.36
Ambulatory infusion pump, single or multiple
							 channels, electric or battery operated, with administrative equipment, worn by
							 patient (capped rental)
E0781KI
204.36
Ambulatory infusion pump, single or multiple
							 channels, electric or battery operated, with administrative equipment, worn by
							 patient (capped rental)
E0781KJ
153.27
Ambulatory infusion pump, single or multiple
							 channels, electric or battery operated, with administrative equipment, worn by
							 patient (capped rental)
E0781NU
2,043.57
Ambulatory infusion pump, single or multiple
							 channels, electric or battery operated, with administrative equipment, worn by
							 patient (new equipment purchase)
E0781UE
1,532.68
Ambulatory infusion pump, single or multiple
							 channels, electric or battery operated, with administrative equipment, worn by
							 patient
E0782NUKF
3,429.28
Infusion pump, implantable, non-programmable
							 (includes all components,
e.g.
, pump, catheter, connectors,
							 etc.) (new equipment) (FDA class III device)
E0782RRKF
342.94
Infusion pump, implantable, non-programmable
							 (includes all components,
e.g.
, pump, catheter, connectors,
							 etc.) (rental) (FDA class III device)
E0782UEKF
2,571.96
Infusion pump, implantable, non-programmable
							 (includes all components,
e.g.
, pump, catheter, connectors,
							 etc.) (used durable medical equipment) (FDA class III device)
E0783NUKF
7,693.09
Infusion pump system, implantable, programmable
							 (includes all components,
e.g.
, pump, catheter, connectors,
							 etc.) (new equipment) (FDA class III device)
E0783RRKF
769.33
Infusion pump system, implantable, programmable
							 (includes all components,
e.g.
, pump, catheter, connectors,
							 etc.) (rental) (FDA class III device)
E0783UEKF
5,769.83
Infusion pump system, implantable, programmable
							 (includes all components,
e.g.
, pump, catheter, connectors,
							 etc.) (used durable medical equipment) (FDA class III device)
E0784KH
418.23
External ambulatory infusion pump, insulin (capped
							 rental)
E0784KI
418.23
External ambulatory infusion pump, insulin (capped
							 rental)
E0784KJ
313.67
External ambulatory infusion pump, insulin (capped
							 rental)
E0784NU
AAC+30%
External ambulatory infusion pump, insulin (new
							 equipment purchase, Non-Medicare)
E0784UE
3,136.73
External ambulatory infusion pump, insulin (used
							 durable medical equipment)
E0785KF
444.01
Implantable intraspinal (epidural/intrathecal)
							 catheter used with implantable infusion pump, replacement (FDA class III
							 device)
E0786NUKF
7,233.30
Implantable programmable infusion pump, replacement
							 (excludes implantable intraspinal catheter) (new equipment) (FDA class III
							 device)
E0786RRKF
723.32
Implantable programmable infusion pump, replacement
							 (excludes implantable intraspinal catheter) (rental) (FDA class III
							 device)
E0786UEKF
5,425.00
Implantable programmable infusion pump, replacement
							 (excludes implantable intraspinal catheter) (used durable medical equipment)
							 (FDA class III device)
E0787
I.C.
External ambulatory infusion pump, insulin, dosage
							 rate adjustment using therapeutic continuous glucose sensing
E0791KH
265.68
Parenteral infusion pump, stationary, single or
							 multi-channel (capped rental)
E0791KI
266.68
Parenteral infusion pump, stationary, single or
							 multi-channel (capped rental)
E0791KJ
199.26
Parenteral infusion pump, stationary, single or
							 multi-channel (capped rental)
E0791NU
2,656.76
Parenteral infusion pump, stationary, single or
							 multi-channel (new equipment purchase)
E0791UE
1,992.57
Parenteral infusion pump, stationary, single or
							 multi-channel (used durable medical equipment)
Traction Equipment
E0830NU
AAC+30%
Ambulatory traction device, all types,
							 each
E0840NU
68.84
Traction frame, attached to headboard, cervical
							 traction (new equipment)
E0840RR
13.66
Traction frame, attached to headboard, cervical
							 traction (rental)
E0840UE
51.61
Traction frame, attached to headboard, cervical
							 traction (used durable medical equipment)
E0849KH
48.43
Traction equipment, cervical, freestanding
							 stand/frame, pneumatic, applying traction force to other than mandible (capped
							 rental)
E0849KI
48.43
Traction equipment, cervical, freestanding
							 stand/frame, pneumatic, applying traction force to other than mandible (capped
							 rental)
E0849KJ
36.33
Traction equipment, cervical, freestanding
							 stand/frame, pneumatic, applying traction force to other than mandible (capped
							 rental)
E0849NU
484.33
Traction equipment, cervical, freestanding
							 stand/frame, pneumatic, applying traction force to other than mandible (new
							 equipment)
E0849UE
363.25
Traction equipment, cervical, freestanding
							 stand/frame, pneumatic, applying traction force to other than mandible (used
							 durable medical equipment)
E0850NU
98.71
Traction stand, free standing, cervical traction (new
							 equipment)
E0850RR
11.53
Traction stand, free standing, cervical traction
							 (rental)
E0850UE
74.04
Traction stand, free standing, cervical traction
							 (used durable medical equipment)
E0855KH
47.23
Cervical traction equipment not requiring additional
							 stand or frame (capped rental)
E0855KI
47.23
Cervical traction equipment not requiring additional
							 stand or frame (capped rental)
E0855KJ
35.42
Cervical traction equipment not requiring additional
							 stand or frame (capped rental)
E0855NU
472.26
Cervical traction equipment not requiring additional
							 stand or frame (new equipment)
E0855UE
354.20
Cervical traction equipment not requiring additional
							 stand or frame (used durable medical equipment)
E0856KH
14.46
Cervical traction device, cervical collar with
							 inflatable air bladder (capped rental)
E0856KI
14.46
Cervical traction device, cervical collar with
							 inflatable air bladder (capped rental)
E0856KJ
10.85
Cervical traction device, cervical collar with
							 inflatable air bladder (capped rental)
E0856NU
144.59
Cervical traction device, with inflatable air
							 bladder(s) (new equipment)
E0856UE
108.44
Cervical traction device, with inflatable air
							 bladder(s) (used durable medical equipment)
E0860NU
36.21
Traction equipment, overdoor, cervical (new
							 equipment)
E0860RR
6.12
Traction equipment, overdoor, cervical
							 (rental)
E0860UE
27.73
Traction equipment, overdoor, cervical (used durable
							 medical equipment)
E0870NU
109.30
Traction frame, attached to footboard, extremity
							 traction, (
e.g.
, buck's) (new equipment)
E0870RR
12.61
Traction frame, attached to footboard, extremity
							 traction, (
e.g.
, buck's) (rental)
E0870UE
82.34
Traction frame, attached to footboard, extremity
							 traction, (
e.g.
, buck's) (used durable medical
							 equipment)
E0880NU
117.97
Traction stand, free standing, extremity traction,
							 (
e.g.
, buck's) (new equipment)
E0880RR
18.52
Traction stand, free standing, extremity traction,
							 (
e.g.
, buck's) (rental)
E0880UE
89.29
Traction stand, free standing, extremity traction,
							 (
e.g.
, buck's) (used durable medical equipment)
E0890NU
113.14
Traction frame, attached to footboard, pelvic
							 traction (new equipment)
E0890RR
30.86
Traction frame, attached to footboard, pelvic
							 traction (rental)
E0890UE
91.14
Traction frame, attached to footboard, pelvic
							 traction (used durable medical equipment)
E0900NU
120.40
Traction stand, free standing, pelvic traction,
							 (
e.g.
, buck's) (new equipment)
E0900RR
25.96
Traction stand, free standing, pelvic traction,
							 (
e.g.
, buck's) (rental)
E0900UE
90.33
Traction stand, free standing, pelvic traction,
							 (
e.g.
, buck's) (used durable medical equipment)
Orthopedic Devices
E0910KH
13.30
Trapeze bars, a/k/a patient helper, attached to bed,
							 with grab bar (capped rental)
E0910KI
13.30
Trapeze bars, a/k/a patient helper, attached to bed,
							 with grab bar (capped rental)
E0910KJ
9.98
Trapeze bars, a/k/a patient helper, attached to bed,
							 with grab bar (capped rental)
E0910NU
133.03
Trapeze bars, a/k/a patient helper, attached to bed,
							 with grab bar (new equipment purchase)
E0910UE
99.77
Trapeze bars, a/k/a patient helper, attached to bed,
							 with grab bar (used durable medical equipment purchase)
E0911KH
37.63
Trapeze bar, heavy duty, for patient weight capacity
							 greater than 250 pounds, attached to bed with grab bar (capped
							 rental)
E0911KI
37.63
Trapeze bar, heavy duty, for patient weight capacity
							 greater than 250 pounds, attached to bed with grab bar (capped
							 rental)
E0911KJ
28.22
Trapeze bar, heavy duty, for patient weight capacity
							 greater than 250 pounds, attached to bed with grab bar (capped
							 rental)
E0911NU
376.30
Trapeze bar, heavy duty, for patient weight capacity
							 greater than 250 pounds, attached to bed with grab bar (new equipment
							 purchase)
E0911UE
282.23
Trapeze bar, heavy duty, for patient weight capacity
							 greater than 250 pounds, attached to bed with grab bar (used durable medical
							 equipment purchase)
E0912KH
83.56
Trapeze bar, heavy duty, for patient weight capacity
							 greater than 250 pounds, free standing, complete with grab bar (capped
							 rental)
E0912KI
83.56
Trapeze bar, heavy duty, for patient weight capacity
							 greater than 250 pounds, free standing, complete with grab bar (capped
							 rental)
E0912KJ
62.67
Trapeze bar, heavy duty, for patient weight capacity
							 greater than 250 pounds, free standing, complete with grab bar (capped
							 rental)
E0912NU
835.64
Trapeze bar, heavy duty, for patient weight capacity
							 greater than 250 pounds, free standing, complete with grab bar (new equipment
							 purchase)
E0912UE
626.73
Trapeze bar, heavy duty, for patient weight capacity
							 greater than 250 pounds, free standing, complete with grab bar (used durable
							 medical equipment purchase)
E0920KH
43.37
Fracture frame, attached to bed, includes weights
							 (capped rental)
E0920KI
43.37
Fracture frame, attached to bed, includes weights
							 (capped rental)
E0920KJ
32.53
Fracture frame, attached to bed, includes weights
							 (capped rental)
E0920NU
433.67
Fracture frame, attached to bed, includes weights
							 (new equipment purchase)
E0920UE
325.25
Fracture frame, attached to bed, includes weights
							 (used durable medical equipment purchase)
E0930KH
42.93
Fracture frame, free standing, includes weights
							 (capped rental)
E0930KI
42.93
Fracture frame, free standing, includes weights
							 (capped rental)
E0930KJ
32.20
Fracture frame, free standing, includes weights
							 (capped rental)
E0930NU
429.25
Fracture frame, free standing, includes weights (new
							 equipment purchase)
E0930UE
321.94
Fracture frame, free standing, includes weights (used
							 durable medical equipment)
E0935RR
21.37
Continuous passive motion exercise device for use on
							 knee only (daily rental)
E0936
AAC+30%
Continuous passive motion exercise device for use
							 other than knee
E0940KH
23.36
Trapeze bar, free standing, complete with grab bar
							 (capped rental)
E0940KI
23.36
Trapeze bar, free standing, complete with grab bar
							 (capped rental)
E0940KJ
17.52
Trapeze bar, free standing, complete with grab bar
							 (capped rental)
E0940NU
233.58
Trapeze bar, free standing, complete with grab bar
							 (new equipment purchase)
E0940UE
175.19
Trapeze bar, free standing, complete with grab bar
							 (used durable medical equipment purchase)
E0941KH
34.29
Gravity assisted traction device, any type (capped
							 rental)
E0941KI
34.29
Gravity assisted traction device, any type (capped
							 rental)
E0941KJ
25.72
Gravity assisted traction device, any type (capped
							 rental)
E0941NU
342.89
Gravity assisted traction device, any type (new
							 equipment purchase)
E0941UE
257.17
Gravity assisted traction device, any type (used
							 durable medical equipment purchase)
E0942NU
18.65
Cervical head harness/halter (new
							 equipment)
E0942RR
1.88
Cervical head harness/halter (rental)
E0942UE
13.97
Cervical head harness/halter (used durable medical
							 equipment)
E0944NU
43.10
Pelvic belt/harness/boot (new equipment)
E0944RR
3.73
Pelvic belt/harness/boot (rental)
E0944UE
32.33
Pelvic belt/harness/boot (used durable medical
							 equipment)
E0945NU
41.65
Extremity belt/harness (new equipment)
E0945RR
3.54
Extremity belt/harness (rental)
E0945UE
32.23
Extremity belt/harness (used durable medical
							 equipment)
E0946KH
55.60
Fracture, frame, dual with cross bars, attached to
							 bed, (
e.g.
, balken, 4 poster) (capped rental)
E0946KI
55.60
Fracture, frame, dual with cross bars, attached to
							 bed, (
e.g.
, balken, 4 poster) (capped rental)
E0946KJ
41.70
Fracture, frame, dual with cross bars, attached to
							 bed, (
e.g.
, balken, 4 poster) (capped rental)
E0946NU
555.99
Fracture, frame, dual with cross bars, attached to
							 bed, (
e.g.
, balken, 4 poster) (new equipment
							 purchase)
E0946UE
416.99
Fracture, frame, dual with cross bars, attached to
							 bed, (
e.g.
, balken, 4 poster) (used durable medical equipment
							 purchase)
E0947NU
569.88
Fracture frame, attachments for complex pelvic
							 traction (new equipment)
E0947RR
59.08
Fracture frame, attachments for complex pelvic
							 traction (rental)
E0947UE
427.40
Fracture frame, attachments for complex pelvic
							 traction (used durable medical equipment)
E0948NU
551.21
Fracture frame, attachments for complex cervical
							 traction (new equipment)
E0948RR
55.10
Fracture frame, attachments for complex cervical
							 traction
E0948UE
388.76
Fracture frame, attachments for complex cervical
							 traction (used durable medical equipment)
Wheelchair Accessories (see also
							 K0001-K0109)
E0950NU
81.53
Wheelchair accessory, tray, each (new equipment)
							 (standard tray)
E0950NUKU
85.71
Wheelchair accessory, tray, each (new equipment)
							 (standard tray), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E0950RR
8.16
Wheelchair accessory, tray, each (rental)
E0950RRKU
8.59
Wheelchair accessory, tray, each (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E0950U1
AAC+35%
Wheelchair accessory, tray, each (nonstandard tray
							 for customized mobility system)
E0950UE
61.15
Wheelchair accessory, tray, each (used durable
							 medical equipment)
E0950UEKU
64.29
Wheelchair accessory, tray, each (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E0951NU
14.31
Heel loop/holder, any type, with or without ankle
							 strap, each (new equipment)
E0951NUKU
16.56
Heel loop/holder, any type, with or without ankle
							 strap, each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E0951RR
1.55
Heel loop/holder, any type, with or without ankle
							 strap, each (rental)
E0951RRKU
1.89
Heel loop/holder, any type, with or without ankle
							 strap, each (rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E0951UE
10.73
Heel loop/holder, any type, with or without ankle
							 strap, each (used durable medical equipment)
E0951UEKU
12.42
Heel loop/holder, any type, with or without ankle
							 strap, each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E0952NU
15.72
Toe loop/holder, any type, each (new
							 equipment)
E0952NUKU
16.40
Toe loop/holder, any type, each (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0952RR
1.70
Toe loop/holder, any type, each (rental)
E0952RRKU
1.89
Toe loop/holder, any type, each (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E0952UE
11.78
Toe loop/holder, any type, each (used durable medical
							 equipment)
E0952UEKU
12.27
Toe loop/holder, any type, each (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0953NU
71.22
Wheelchair accessory, lateral thigh or knee support,
							 any type including fixed mounting hardware, each (new equipment)
E0953NUKU
95.62
Wheelchair accessory, lateral thigh or knee support,
							 any type including fixed mounting hardware, each (new equipment) (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E0953RR
7.12
Wheelchair accessory, lateral thigh or knee support,
							 any type including fixed mounting hardware, each (rental)
E0953RRKU
9.56
Wheelchair accessory, lateral thigh or knee support,
							 any type including fixed mounting hardware, each (rental) (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E0953UE
53.42
Wheelchair accessory, lateral thigh or knee support,
							 any type including fixed mounting hardware, each (used durable medical
							 equipment)
E0953UEKU
71.72
Wheelchair accessory, lateral thigh or knee support,
							 any type including fixed mounting hardware, each (used durable medical
							 equipment) (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0954NU
49.86
Wheelchair accessory, foot box, any type, includes
							 attachment and mounting hardware, each foot (new equipment)
E0954NUKU
56.51
Wheelchair accessory, foot box, any type, includes
							 attachment and mounting hardware, each foot (new equipment) (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E0954RR
4.98
Wheelchair accessory, foot box, any type, includes
							 attachment and mounting hardware, each foot (rental)
E0954RRKU
5.65
Wheelchair accessory, foot box, any type, includes
							 attachment and mounting hardware, each foot (rental) (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E0954UE
37.40
Wheelchair accessory, foot box, any type, includes
							 attachment and mounting hardware, each foot (used durable medical
							 equipment)
E0954UEKU
42.38
Wheelchair accessory, foot box, any type, includes
							 attachment and mounting hardware, each foot (used durable medical equipment)
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0955KH
16.05
Wheelchair accessory, headrest, cushioned, any type,
							 including fixed mounting hardware, each (capped rental)
E0955KHKU
19.62
Wheelchair accessory, headrest, cushioned, any type,
							 including fixed mounting hardware, each (capped rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E0955KI
16.05
Wheelchair accessory, headrest, cushioned, any type,
							 including fixed mounting hardware, each (capped rental)
E0955KIKU
19.62
Wheelchair accessory, headrest, cushioned, any type,
							 including fixed mounting hardware, each (capped rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E0955KJ
12.04
Wheelchair accessory, headrest, cushioned, any type,
							 including fixed mounting hardware, each (capped rental)
E0955KJKU
14.72
Wheelchair accessory, headrest, cushioned, any type,
							 including fixed mounting hardware, each (capped rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E0955NU
160.42
Wheelchair accessory, headrest, cushioned, any type,
							 including fixed mounting hardware, each (new equipment)
E0955NUKU
196.20
Wheelchair accessory, headrest, cushioned, any type,
							 including fixed mounting hardware, each (new equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E0955UE
120.31
Wheelchair accessory, headrest, cushioned, any type,
							 including fixed mounting hardware, each (used durable medical
							 equipment)
E0955UEKU
147.15
Wheelchair accessory, headrest, cushioned, any type,
							 including fixed mounting hardware, each (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0956NU
86.78
Wheelchair accessory, lateral trunk or hip support,
							 any type, including fixed mounting hardware, each (new equipment)
E0956NUKU
95.62
Wheelchair accessory, lateral trunk or hip support,
							 any type, including fixed mounting hardware, each (new equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E0956RR
8.68
Wheelchair accessory, lateral trunk or hip support,
							 any type, including fixed mounting hardware, each (rental)
E0956RRKU
9.56
Wheelchair accessory, lateral trunk or hip support,
							 any type, including fixed mounting hardware, each (rental), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E0956UE
65.09
Wheelchair accessory, lateral trunk or hip support,
							 any type, including fixed mounting hardware, each (used durable medical
							 equipment)
E0956UEKU
71.72
Wheelchair accessory, lateral trunk or hip support,
							 any type, including fixed mounting hardware, each (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0957NU
122.46
Wheelchair accessory, medial thigh support, any type,
							 including any type mounting hardware (new equipment)
E0957NUKU
133.81
Wheelchair accessory, medial thigh support, any type,
							 including any type mounting hardware (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E0957RR
12.25
Wheelchair accessory, medial thigh support, any type,
							 including any type mounting hardware (rental)
E0957RRKU
13.39
Wheelchair accessory, medial thigh support, any type,
							 including any type mounting hardware (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E0957UE
91.85
Wheelchair accessory, medial thigh support, any type,
							 including any type mounting hardware (used durable medical
							 equipment)
E0957UEKU
100.35
Wheelchair accessory, medial thigh support, any type,
							 including any type mounting hardware (used durable medical equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E0958KH
40.92
Manual wheelchair accessory, one-arm drive
							 attachment, each (capped rental)
E0958KHKU
43.08
Manual wheelchair accessory, one-arm drive
							 attachment, each
E0958KI
40.92
Manual wheelchair accessory, one-arm drive
							 attachment, each (capped rental)
E0958KIKU
43.08
Manual wheelchair accessory, one-arm drive
							 attachment, each
E0958KJ
30.69
Manual wheelchair accessory, one-arm drive
							 attachment, each (capped rental)
E0958KJKU
32.31
Manual wheelchair accessory, one-arm drive
							 attachment, each
E0958NU
409.20
Manual wheelchair accessory, one-arm drive
							 attachment, each (new equipment purchase)
E0958NUKU
430.80
Manual wheelchair accessory, one-arm drive
							 attachment, each
E0958UE
306.90
Manual wheelchair accessory, one-arm drive
							 attachment, each (used durable medical equipment purchase)
E0958UEKU
323.10
Manual wheelchair accessory, one-arm drive
							 attachment, each
E0959NU
45.46
Manual wheelchair accessory, adapter for amputee,
							 each (new equipment)
E0959NUKU
51.35
Manual wheelchair accessory, adapter for amputee,
							 each
E0959RR
4.26
Manual wheelchair accessory, adapter for amputee,
							 each (rental)
E0959RRKU
4.54
Manual wheelchair accessory, adapter for amputee,
							 each
E0959UE
34.26
Manual wheelchair accessory, adapter for amputee,
							 each (used durable medical equipment)
E0959UEKU
38.87
Manual wheelchair accessory, adapter for amputee,
							 each
E0960NU
76.13
Wheelchair accessory, shoulder harness/straps or
							 chest strap, including any type mounting hardware, each (new
							 equipment)
E0960NUKU
88.26
Wheelchair accessory, shoulder harness/straps or
							 chest strap, including any type mounting hardware, each (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0960RR
7.62
Wheelchair accessory, shoulder harness/straps or
							 chest strap, including any type mounting hardware, each (rental)
E0960RRKU
8.85
Wheelchair accessory, shoulder harness/straps or
							 chest strap, including any type mounting hardware, each (rental), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E0960UE
57.11
Wheelchair accessory, shoulder harness/straps or
							 chest strap, including any type mounting hardware, each (used durable medical
							 equipment)
E0960UEKU
66.21
Wheelchair accessory, shoulder harness/straps or
							 chest strap, including any type mounting hardware, each (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0961NU
25.17
Manual wheelchair accessory, wheel lock brake
							 extension (handle), each (new equipment)
E0961NUKU
34.56
Manual wheelchair accessory, wheel lock brake
							 extension (handle), each
E0961RR
2.33
Manual wheelchair accessory, wheel lock brake
							 extension (handle), each (rental)
E0961RRKU
3.07
Manual wheelchair accessory, wheel lock brake
							 extension (handle), each
E0961UE
13.53
Manual wheelchair accessory, wheel lock brake
							 extension (handle), each (used durable medical equipment)
E0961UEKU
14.65
Manual wheelchair accessory, wheel lock brake
							 extension (handle), each
E0966NU
72.77
Manual wheelchair accessory, headrest extension, each
							 (new equipment)
E0966NUKU
82.91
Manual wheelchair accessory, headrest extension,
							 each
E0966RR
6.99
Manual wheelchair accessory, headrest extension, each
							 (rental)
E0966RRKU
7.69
Manual wheelchair accessory, headrest extension,
							 each
E0966UE
54.58
Manual wheelchair accessory, headrest extension, each
							 (used durable medical equipment)
E0966UEKU
62.18
Manual wheelchair accessory, headrest extension,
							 each
E0967NU
68.93
Manual wheelchair accessory, hand rim with
							 projections, any type, replacement only, each (new equipment)
E0967NUKU
76.30
Manual wheelchair accessory, hand rim with
							 projections, any type, replacement only, each
E0967RR
6.90
Manual wheelchair accessory, hand rim with
							 projections, any type, replacement only, each (rental)
E0967RRKU
7.64
Manual wheelchair accessory, hand rim with
							 projections, any type, replacement only, each
E0967UE
51.69
Manual wheelchair accessory, hand rim with
							 projections, any type, replacement only, each (used durable medical
							 equipment)
E0967UEKU
57.20
Manual wheelchair accessory, hand rim with
							 projections, any type, replacement only, each
E0968KH
18.73
Commode seat, wheelchair (capped rental)
E0968KI
18.73
Commode seat, wheelchair (capped rental)
E0968KJ
14.05
Commode seat, wheelchair (capped rental)
E0968NU
187.30
Commode seat, wheelchair (new equipment
							 purchase)
E0968UE
140.48
Commode seat, wheelchair (used durable medical
							 equipment purchase)
E0969NU
173.16
Narrowing device, wheelchair (new
							 equipment)
E0969RR
14.61
Narrowing device, wheelchair (rental)
E0969UE
129.88
Narrowing device, wheelchair (used durable medical
							 equipment)
E0971NU
39.76
Manual wheelchair accessory, anti-tipping device,
							 each (new equipment)
E0971NUKU
50.40
Manual wheelchair accessory, anti-tipping device,
							 each
E0971RR
3.98
Manual wheelchair accessory, anti-tipping device,
							 each (rental)
E0971RRKU
5.05
Manual wheelchair accessory, anti-tipping device,
							 each
E0971UE
29.83
Manual wheelchair accessory, anti-tipping device,
							 each (used durable medical equipment)
E0971UEKU
37.83
Manual wheelchair accessory, anti-tipping device,
							 each
E0973NU
79.05
Wheelchair accessory, adjustable height, detachable
							 armrest, complete assembly, each (new equipment)
E0973NUKU
111.53
Wheelchair accessory, adjustable height, detachable
							 armrest, complete assembly, each (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E0973RR
6.86
Wheelchair accessory, adjustable height, detachable
							 armrest, complete assembly, each (rental)
E0973RRKU
9.03
Wheelchair accessory, adjustable height, detachable
							 armrest, complete assembly, each (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E0973UE
59.29
Wheelchair accessory, adjustable height detachable
							 armrest, complete assembly, each (used durable medical equipment)
E0973UEKU
83.65
Wheelchair accessory, adjustable height detachable
							 armrest, complete assembly, each (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E0974NU
76.25
Manual wheelchair accessory, anti-rollback device,
							 each (new equipment)
E0974NUKU
86.04
Manual wheelchair accessory, anti-rollback device,
							 each
E0974RR
7.44
Manual wheelchair accessory, anti-rollback device,
							 each (rental)
E0974RRKU
8.21
Manual wheelchair accessory, anti-rollback device,
							 each
E0974UD
AAC+35%
Manual wheelchair accessory, anti-rollback devise,
							 each (bariatric equipment)
E0974UE
57.19
Manual wheelchair accessory, anti-rollback device,
							 each (used durable medical equipment)
E0974UEKU
64.53
Manual wheelchair accessory, anti-rollback device,
							 each
E0978NU
31.42
Wheelchair accessory, positioning belt/safety
							 belt/pelvic strap, each (new equipment)
E0978NUKU
41.42
Wheelchair accessory, positioning belt/safety
							 belt/pelvic strap, each (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E0978RR
3.15
Wheelchair accessory, positioning belt/safety
							 belt/pelvic strap, each (rental)
E0978RRKU
4.15
Wheelchair accessory, positioning belt/safety
							 belt/pelvic strap, each (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E0978UE
23.39
Wheelchair accessory, positioning belt/safety
							 belt/pelvic strap, each (used durable medical equipment)
E0978UEKU
30.71
Wheelchair accessory, positioning belt/safety
							 belt/pelvic strap, each (used durable medical equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E0980NU
36.54
Safety vest, wheelchair (new equipment)
E0980RR
3.66
Safety vest, wheelchair (rental)
E0980UE
27.25
Safety vest, wheelchair (used durable medical
							 equipment)
E0981NU
41.68
Wheelchair accessory, seat upholstery, replacement
							 only, each (new equipment)
E0981NUKU
45.74
Wheelchair accessory, seat upholstery, replacement
							 only, each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E0981RR
3.86
Wheelchair accessory, seat upholstery, replacement
							 only, each (rental)
E0981RRKU
3.95
Wheelchair accessory, seat upholstery, replacement
							 only, each (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E0981UC
AAC+35%
Wheelchair accessory, seat upholstery, replacement
							 only, each (pediatric specialized rehabilitation equipment)
E0981UE
31.42
Wheelchair accessory, seat upholstery, replacement
							 only, each (used durable medical equipment)
E0981UEKU
34.62
Wheelchair accessory, seat upholstery, replacement
							 only, each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E0982NU
45.83
Wheelchair accessory, back upholstery, replacement
							 only, each (new equipment) (bid under round one of the DMEPOS competitive
							 bidding program for use with noncompetitive bid base equipment)
E0982NUKU
49.97
Wheelchair accessory, back upholstery, replacement
							 only, each (new equipment) (bid under round one of the DMEPOS competitive
							 bidding program for use with noncompetitive bid base equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E0982RR
4.17
Wheelchair accessory, back upholstery, replacement
							 only, each (rental)
E0982RRKU
4.24
Wheelchair accessory, back upholstery, replacement
							 only, each (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E0982UE
34.38
Wheelchair accessory, back upholstery, replacement
							 only, each (used durable medical equipment)
E0982UEKU
37.50
Wheelchair accessory, back upholstery, replacement
							 only, each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E0983KH
276.31
Manual wheelchair accessory, power add-on to convert
							 manual wheelchair to motorized wheelchair, joystick control (capped
							 rental)
E0983KI
276.31
Manual wheelchair accessory, power add-on to convert
							 manual wheelchair to motorized wheelchair, joystick control (capped
							 rental)
E0983KJ
207.23
Manual wheelchair accessory, power add-on to convert
							 manual wheelchair to motorized wheelchair, joystick control (capped
							 rental)
E0983NU
2,763.10
Manual wheelchair accessory, power add-on to convert
							 manual wheelchair to motorized wheelchair, joystick control (new equipment
							 purchase)
E0983UE
2,072.33
Manual wheelchair accessory, power add-on to convert
							 manual wheelchair to motorized wheelchair, joystick control (used durable
							 medical equipment purchase)
E0984KH
194.67
Manual wheelchair accessory, power add-on to convert
							 manual wheelchair to motorized wheelchair, tiller control (capped
							 rental)
E0984KI
194.67
Manual wheelchair accessory, power add-on to convert
							 manual wheelchair to motorized wheelchair, tiller control (capped
							 rental)
E0984KJ
146.00
Manual wheelchair accessory, power add-on to convert
							 manual wheelchair to motorized wheelchair, tiller control (capped
							 rental)
E0984NU
1,946.70
Manual wheelchair accessory, power add-on to convert
							 manual wheelchair to motorized wheelchair, tiller control (new
							 equipment)
E0984UE
1,460.03
Manual wheelchair accessory, power add-on to convert
							 manual wheelchair to motorized wheelchair, tiller control (used durable medical
							 equipment)
E0985KH
21.40
Wheelchair accessory, seat lift mechanism (capped
							 rental)
E0985KHKU
22.85
Wheelchair accessory, seat lift mechanism (capped
							 rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0985KI
21.40
Wheelchair accessory, seat lift mechanism (capped
							 rental)
E0985KIKU
22.85
Wheelchair accessory, seat lift mechanism (capped
							 rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0985KJ
18.31
Wheelchair accessory, seat lift mechanism (capped
							 rental)
E0985KJKU
17.14
Wheelchair accessory, seat lift mechanism (capped
							 rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0985NU
213.95
Wheelchair accessory, seat lift mechanism (new
							 equipment)
E0985NUKU
228.50
Wheelchair accessory, seat lift mechanism (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E0985UE
160.46
Wheelchair accessory, seat lift mechanism (used
							 durable medical equipment)
E0985UEKU
171.38
Wheelchair accessory, seat lift mechanism (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E0986KH
537.76
Manual wheelchair accessory, push activated power
							 assist, each (capped rental)
E0986KI
537.76
Manual wheelchair accessory, push activated power
							 assist, each (capped rental)
E0986KJ
403.32
Manual wheelchair accessory, push activated power
							 assist, each (capped rental)
E0986NU
5,377.60
Manual wheelchair accessory, push-rim activated power
							 assist system, each (new equipment)
E0986UE
4,033.20
Manual wheelchair accessory, push-rim activated power
							 assist system, each (used durable medical equipment)
E0988KH
314.76
Manual wheelchair accessory, lever-activated, wheel
							 drive, pair (capped rental)
E0988KI
314.76
Manual wheelchair accessory, lever-activated, wheel
							 drive, pair (capped rental)
E0988KJ
236.07
Manual wheelchair accessory, lever-activated, wheel
							 drive, pair (capped rental)
E0988NU
3,147.60
Manual wheelchair accessory, lever-activated, wheel
							 drive, pair (new equipment)
E0988UE
2,360.70
Manual wheelchair accessory, lever-activated, wheel
							 drive, pair (used durable medical equipment)
E0990NU
89.61
Wheelchair accessory, elevating leg rest, complete
							 assembly, each (new equipment)
E0990NUKU
113.91
Wheelchair accessory, elevating leg rest, complete
							 assembly, each (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E0990RR
9.67
Wheelchair accessory, elevating leg rest, complete
							 assembly, each (rental)
E0990RRKU
12.83
Wheelchair accessory, elevating leg rest, complete
							 assembly, each (rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E0990UE
68.96
Wheelchair accessory, elevating leg rest, complete
							 assembly, each (used durable medical equipment)
E0990UEKU
89.01
Wheelchair accessory, elevating leg rest, complete
							 assembly, each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E0992NU
88.26
Manual wheelchair accessory, solid seat insert (new
							 equipment)
E0992NUKU
110.56
Manual wheelchair accessory, solid seat
							 insert
E0992RR
7.95
Manual wheelchair accessory, solid seat insert
							 (rental)
E0992RRKU
9.21
Manual wheelchair accessory, solid seat
							 insert
E0992UE
66.20
Manual wheelchair accessory, solid seat insert (used
							 durable medical equipment)
E0992UEKU
82.91
Manual wheelchair accessory, solid seat
							 insert
E0994NU
19.48
Arm rest, each (new equipment)
E0994RR
1.97
Arm rest, each (rental)
E0994UE
14.62
Arm rest, each (used durable medical
							 equipment)
E0995NU
24.62
Wheelchair accessory, calf rest/pad, replacement
							 only, each (new equipment)
E0995NUKU
25.06
Wheelchair accessory, calf rest/pad, replacement
							 only, each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E0995RR
2.51
Wheelchair accessory, calf rest/pad, replacement
							 only, each (rental)
E0995RRKU
2.59
Wheelchair accessory, calf rest/pad, replacement
							 only, each (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E0995UE
18.45
Wheelchair accessory, calf rest/pad, replacement
							 only, each (used durable medical equipment)
E0995UEKU
18.78
Wheelchair accessory, calf rest/pad, replacement
							 only, each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E1002KH
364.46
Wheelchair accessory, power seating system, tilt only
							 (capped rental)
E1002KHKU
393.17
Wheelchair accessory, power seating system, tilt only
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1002KI
365.46
Wheelchair accessory, power seating system, tilt only
							 (capped rental)
E1002KIKU
393.17
Wheelchair accessory, power seating system, tilt only
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1002KJ
273.35
Wheelchair accessory, power seating system, tilt only
							 (capped rental)
E1002KJKU
294.88
Wheelchair accessory, power seating system, tilt only
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1002NU
3,644.60
Wheelchair accessory, power seating system, tilt only
							 (new equipment)
E1002NUKU
3,931.70
Wheelchair accessory, power seating system, tilt only
							 (new equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1002UE
2,733.45
Wheelchair accessory, power seating system, tilt only
							 (used durable medical equipment)
E1002UEKU
2,948.78
Wheelchair accessory, power seating system, tilt only
							 (used durable medical equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E1003KH
409.80
Wheelchair accessory, power seating system, recline
							 only, without shear reduction (capped rental)
E1003KHKU
425.99
Wheelchair accessory, power seating system, recline
							 only, without shear reduction (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E1003KI
409.80
Wheelchair accessory, power seating system, recline
							 only, without shear reduction (capped rental)
E1003KIKU
425.99
Wheelchair accessory, power seating system, recline
							 only, without shear reduction (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E1003KJ
307.35
Wheelchair accessory, power seating system, recline
							 only, without shear reduction (capped rental)
E1003KJKU
319.49
Wheelchair accessory, power seating system, recline
							 only, without shear reduction (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E1003NU
4,098.00
Wheelchair accessory, power seating system, recline
							 only, without shear reduction (new equipment)
E1003NUKU
4,259.90
Wheelchair accessory, power seating system, recline
							 only, without shear reduction (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E1003UE
3,073.50
Wheelchair accessory, power seating system, recline
							 only, without shear reduction (used durable medical equipment)
E1003UEKU
3,194.93
Wheelchair accessory, power seating system, recline
							 only, without shear reduction (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E1004KH
452.43
Wheelchair accessory, power seating system, recline
							 only, with mechanical shear reduction (capped rental)
E1004KHKU
472.32
Wheelchair accessory, power seating system, recline
							 only, with mechanical shear reduction (capped rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E1004KI
452.43
Wheelchair accessory, power seating system, recline
							 only, with mechanical shear reduction (capped rental)
E1004KIKU
472.32
Wheelchair accessory, power seating system, recline
							 only, with mechanical shear reduction (capped rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E1004KJ
339.32
Wheelchair accessory, power seating system, recline
							 only, with mechanical shear reduction (capped rental)
E1004KJKU
354.24
Wheelchair accessory, power seating system, recline
							 only, with mechanical shear reduction (capped rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E1004NU
4,524.30
Wheelchair accessory, power seating system, recline
							 only, with mechanical shear reduction (new equipment)
E1004NUKU
4,723.20
Wheelchair accessory, power seating system, recline
							 only, with mechanical shear reduction (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E1004UE
3,393.23
Wheelchair accessory, power seating system, recline
							 only, with mechanical shear reduction (used durable medical
							 equipment)
E1004UEKU
3,542.40
Wheelchair accessory, power seating system, recline
							 only, with mechanical shear reduction (used durable medical equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E1005KH
492.26
Wheelchair accessory, power seating system, recline
							 only, with power shear reduction (capped rental)
E1005KHKU
511.25
Wheelchair accessory, power seating system, recline
							 only, with power shear reduction (capped rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E1005KI
492.26
Wheelchair accessory, power seating system, recline
							 only, with power shear reduction (capped rental)
E1005KIKU
511.25
Wheelchair accessory, power seating system, recline
							 only, with power shear reduction (capped rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E1005KJ
369.20
Wheelchair accessory, power seating system, recline
							 only, with power shear reduction (capped rental)
E1005KJKU
383.44
Wheelchair accessory, power seating system, recline
							 only, with power shear reduction (capped rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E1005NU
4,922.60
Wheelchair accessory, power seating system, recline
							 only, with power shear reduction (new equipment)
E1005NUKU
5,112.50
Wheelchair accessory, power seating system, recline
							 only, with power shear reduction (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E1005UE
3,691.95
Wheelchair accessory, power seating system, recline
							 only, with power shear reduction (used durable medical equipment)
E1005UEKU
3,834.38
Wheelchair accessory, power seating system, recline
							 only, with power shear reduction (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E1006KH
604.91
Wheelchair accessory, power seating system,
							 combination tilt and recline, without shear reduction (capped
							 rental)
E1006KHKU
626.23
Wheelchair accessory, power seating system,
							 combination tilt and recline, without shear reduction (capped rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E1006KI
604.91
Wheelchair accessory, power seating system,
							 combination tilt and recline, without shear reduction (capped
							 rental)
E1006KIKU
626.23
Wheelchair accessory, power seating system,
							 combination tilt and recline, without shear reduction (capped rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E1006KJ
453.68
Wheelchair accessory, power seating system,
							 combination tilt and recline, without shear reduction (capped
							 rental)
E1006KJKU
469.67
Wheelchair accessory, power seating system,
							 combination tilt and recline, without shear reduction (capped rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E1006NU
6,049.10
Wheelchair accessory, power seating system,
							 combination tilt and recline, without shear reduction (new
							 equipment)
E1006NUKU
6,262.30
Wheelchair accessory, power seating system,
							 combination tilt and recline, without shear reduction (new equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E1006UE
4,536.83
Wheelchair accessory, power seating system,
							 combination tilt and recline, without shear reduction (used durable medical
							 equipment)
E1006UEKU
4,696.73
Wheelchair accessory, power seating system,
							 combination tilt and recline, without shear reduction (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1007KH
785.57
Wheelchair accessory, power seating system,
							 combination tilt and recline, with mechanical shear reduction (capped
							 rental)
E1007KHKU
847.97
Wheelchair accessory, power seating system,
							 combination tilt and recline, with mechanical shear reduction (capped rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1007KI
785.57
Wheelchair accessory, power seating system,
							 combination tilt and recline, with mechanical shear reduction (capped
							 rental)
E1007KIKU
847.97
Wheelchair accessory, power seating system,
							 combination tilt and recline, with mechanical shear reduction (capped rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1007KJ
589.18
Wheelchair accessory, power seating system,
							 combination tilt and recline, with mechanical shear reduction (capped
							 rental)
E1007KJKU
635.98
Wheelchair accessory, power seating system,
							 combination tilt and recline, with mechanical shear reduction (capped rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1007NU
7,855.70
Wheelchair accessory, power seating system,
							 combination tilt and recline, with mechanical shear reduction (new
							 equipment)
E1007NUKU
8,479.70
Wheelchair accessory, power seating system,
							 combination tilt and recline, with mechanical shear reduction (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1007UE
5,891.78
Wheelchair accessory, power seating system,
							 combination tilt and recline, with mechanical shear reduction (used durable
							 medical equipment)
E1007UEKU
6,359.78
Wheelchair accessory, power seating system,
							 combination tilt and recline, with mechanical shear reduction (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1008KH
795.09
Wheelchair accessory, power seating system,
							 combination tilt and recline, with power shear reduction (capped
							 rental)
E1008KHKU
848.03
Wheelchair accessory, power seating system,
							 combination tilt and recline, with power shear reduction (capped rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1008KI
795.09
Wheelchair accessory, power seating system,
							 combination tilt and recline, with power shear reduction (capped
							 rental)
E1008KIKU
848.03
Wheelchair accessory, power seating system,
							 combination tilt and recline, with power shear reduction (capped rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1008KJ
596.32
Wheelchair accessory, power seating system,
							 combination tilt and recline, with power shear reduction (capped
							 rental)
E1008KJKU
636.02
Wheelchair accessory, power seating system,
							 combination tilt and recline, with power shear reduction (capped rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1008NU
7,950.90
Wheelchair accessory, power seating system,
							 combination tilt and recline, with power shear reduction (new
							 equipment)
E1008NUKU
8,480.30
Wheelchair accessory, power seating system,
							 combination tilt and recline, with power shear reduction (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1008UE
5,963.18
Wheelchair accessory, power seating system,
							 combination tilt and recline, with power shear reduction (used durable medical
							 equipment)
E1008UEKU
6,360.23
Wheelchair accessory, power seating system,
							 combination tilt and recline, with power shear reduction (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1009NU
AAC+35%
Wheelchair accessory, addition to power seating
							 system, mechanically linked leg elevation system, including pushrod and
							 legrest, each (new equipment)
E1009RR
I.C.
Wheelchair accessory, addition to power seating
							 system, mechanically linked leg elevation system, including pushrod and
							 legrest, each (rental)
E1009UE
I.C.
Wheelchair accessory, addition to power seating
							 system, mechanically linked leg elevation system, including pushrod and
							 legrest, each (used durable medical equipment)
E1010KH
105.95
Wheelchair accessory, addition to power seating
							 system, power leg elevation system, including leg rest, pair (capped
							 rental)
E1010KHKU
110.96
Wheelchair accessory, addition to power seating
							 system, power leg elevation system, including leg rest, pair (capped rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1010KI
105.95
Wheelchair accessory, addition to power seating
							 system, power leg elevation system, including leg rest, pair (capped
							 rental)
E1010KIKU
110.96
Wheelchair accessory, addition to power seating
							 system, power leg elevation system, including leg rest, pair (capped rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1010KJ
79.46
Wheelchair accessory, addition to power seating
							 system, power leg elevation system, including leg rest, pair (capped
							 rental)
E1010KJKU
83.22
Wheelchair accessory, addition to power seating
							 system, power leg elevation system, including leg rest, pair (capped rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1010NU
1,059.50
Wheelchair accessory, addition to power seating
							 system, power leg elevation system, including legrest, pair (new
							 equipment)
E1010NUKU
1,109.60
Wheelchair accessory, addition to power seating
							 system, power leg elevation system, including legrest, pair (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E1010UE
794.63
Wheelchair accessory, addition to power seating
							 system, power leg elevation system, including legrest, pair (used durable
							 medical equipment)
E1010UEKU
832.20
Wheelchair accessory, addition to power seating
							 system, power leg elevation system, including legrest, pair (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1011NU
AAC+35%
Modification to pediatric size wheelchair, width
							 adjustment package (not to be dispensed with initial chair) (new
							 equipment)
E1011RR
I.C.
Modification to pediatric size wheelchair, width
							 adjustment package (not to be dispensed with initial chair)
							 (rental)
E1011UE
I.C.
Modification to pediatric size wheelchair, width
							 adjustment package (not to be dispensed with initial chair) (used durable
							 medical equipment)
E1012KH
94.99
Wheelchair accessory, addition to power seating
							 system, center mount power elevating leg rest/platform, complete system, any
							 type, each (capped rental)
E1012KHKU
110.96
Wheelchair accessory, addition to power seating
							 system, center mount power elevating leg rest/platform, complete system, any
							 type, each (capped rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E1012KI
94.99
Wheelchair accessory, addition to power seating
							 system, center mount power elevating leg rest/platform, complete system, any
							 type, each (capped rental)
E1012KIKU
110.96
Wheelchair accessory, addition to power seating
							 system, center mount power elevating leg rest/platform, complete system, any
							 type, each (capped rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E1012KJ
71.24
Wheelchair accessory, addition to power seating
							 system, center mount power elevating leg rest/platform, complete system, any
							 type, each (capped rental)
E1012KJKU
83.22
Wheelchair accessory, addition to power seating
							 system, center mount power elevating leg rest/platform, complete system, any
							 type, each (capped rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E1012NU
949.90
Wheelchair accessory, addition to power seating
							 system, center mount power elevating leg rest/platform, complete system, any
							 type, each (new equipment)
E1012NUKU
1,109.60
Wheelchair accessory, addition to power seating
							 system, center mount power elevating leg rest/platform, complete system, any
							 type, each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E1012UE
712.43
Wheelchair accessory, addition to power seating
							 system, center mount power elevating leg rest/platform, complete system, any
							 type, each (used durable medical equipment)
E1012UEKU
832.20
Wheelchair accessory, addition to power seating
							 system, center mount power elevating leg rest/platform, complete system, any
							 type, each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E1014KH
40.38
Reclining back, addition to pediatric size wheelchair
							 (capped rental)
E1014KI
40.38
Reclining back, addition to pediatric size wheelchair
							 (capped rental)
E1014KJ
30.29
Reclining back, addition to pediatric size wheelchair
							 (capped rental)
E1014NU
403.80
Reclining back, addition to pediatric size wheelchair
							 (new equipment)
E1014UE
302.85
Reclining back, addition to pediatric size wheelchair
							 (used durable medical equipment)
E1015NU
121.49
Shock absorber for manual wheelchair, each (new
							 equipment)
E1015NUKU
133.26
Shock absorber for manual wheelchair,
							 each
E1015RR
12.14
Shock absorber for manual wheelchair, each
							 (rental)
E1015RRKU
13.32
Shock absorber for manual wheelchair,
							 each
E1015UE
91.11
Shock absorber for manual wheelchair, each (used
							 durable medical equipment)
E1015UEKU
99.94
Shock absorber for manual wheelchair,
							 each
E1016NU
110.79
Shock absorber for power wheelchair, each (new
							 equipment)
E1016RR
11.09
Shock absorber for power wheelchair, each
							 (rental)
E1016UE
83.09
Shock absorber for power wheelchair, each (used
							 durable medical equipment)
E1017NU
AAC+35%
Heavy duty shock absorber for heavy duty or extra
							 heavy duty manual wheelchair, each (new equipment)
E1017RR
I.C.
Heavy duty shock absorber for heavy duty or extra
							 heavy duty manual wheelchair, each (rental)
E1017UE
I.C.
Heavy duty shock absorber for heavy duty or extra
							 heavy duty manual wheelchair, each (used durable medical equipment)
E1018NU
AAC+35%
Heavy duty shock absorber for heavy duty or extra
							 heavy duty power wheelchair, each (new equipment)
E1018RR
I.C.
Heavy duty shock absorber for heavy duty or extra
							 heavy duty power wheelchair, each (rental)
E1018UE
I.C.
Heavy duty shock absorber for heavy duty or extra
							 heavy duty power wheelchair, each (used durable medical equipment)
E1020KH
20.53
Residual limb support system for wheelchair, any type
							 (capped rental)
E1020KHKU
23.60
Residual limb support system for wheelchair, any type
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1020KI
20.53
Residual limb support system for wheelchair, any type
							 (capped rental)
E1020KIKU
23.60
Residual limb support system for wheelchair, any type
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1020KJ
15.40
Residual limb support system for wheelchair, any type
							 (capped rental)
E1020KJKU
17.70
Residual limb support system for wheelchair, any type
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1020NU
205.35
Residual limb support system for wheelchair, any type
							 (new equipment)
E1020NUKU
236.00
Residual limb support system for wheelchair, any type
							 (new equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1020UE
154.01
Residual limb support system for wheelchair, any type
							 (used durable medical equipment)
E1020UEKU
177.00
Residual limb support system for wheelchair, any type
							 (used durable medical equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E1028KH
16.52
Wheelchair accessory, manual swingaway, retractable,
							 or removable mounting hardware (capped rental)
E1028KHKU
20.03
Wheelchair accessory, manual swingaway, retractable,
							 or removable mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E1028KI
16.52
Wheelchair accessory, manual swingaway, retractable,
							 or removable mounting hardware (capped rental)
E1028KIKU
20.03
Wheelchair accessory, manual swingaway, retractable,
							 or removable mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E1028KJ
12.39
Wheelchair accessory, manual swingaway, retractable,
							 or removable mounting hardware (capped rental)
E1028KJKU
15.02
Wheelchair accessory, manual swingaway, retractable,
							 or removable mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E1028NU
165.19
Wheelchair accessory, manual swingaway, retractable,
							 or removable mounting hardware (new equipment)
E1028NUKU
200.30
Wheelchair accessory, manual swingaway, retractable,
							 or removable mounting hardware (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E1028UE
123.90
Wheelchair accessory, manual swingaway, retractable,
							 or removable mounting hardware (used durable medical equipment)
E1028UEKU
150.23
Wheelchair accessory, manual swingaway, retractable,
							 or removable mounting hardware (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E1029KH
34.93
Wheelchair accessory, manual ventilator tray, fixed
							 (capped rental)
E1029KHKU
35.84
Wheelchair accessory, manual ventilator tray, fixed
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1029KI
34.93
Wheelchair accessory, manual ventilator tray, fixed
							 (capped rental)
E1029KIKU
35.84
Wheelchair accessory, manual ventilator tray, fixed
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1029KJ
26.20
Wheelchair accessory, manual ventilator tray, fixed
							 (capped rental)
E1029KJKU
26.88
Wheelchair accessory, manual ventilator tray, fixed
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1029NU
349.30
Wheelchair accessory, manual ventilator tray, fixed
							 (new equipment)
E1029NUKU
358.40
Wheelchair accessory, manual ventilator tray, fixed
							 (new equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E1029UE
261.98
Wheelchair accessory, manual ventilator tray, fixed
							 (used durable medical equipment)
E1029UEKU
268.80
Wheelchair accessory, manual ventilator tray, fixed
							 (used durable medical equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E1030KH
109.66
Wheelchair accessory, manual ventilator tray,
							 gimbaled (capped rental)
E1030KHKU
113.04
Wheelchair accessory, manual ventilator tray,
							 gimbaled (capped rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E1030KI
109.66
Wheelchair accessory, manual ventilator tray,
							 gimbaled (capped rental)
E1030KIKU
113.04
Wheelchair accessory, manual ventilator tray,
							 gimbaled (capped rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E1030KJ
82.25
Wheelchair accessory, manual ventilator tray,
							 gimbaled (capped rental)
E1030KJKU
84.78
Wheelchair accessory, manual ventilator tray,
							 gimbaled (capped rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E1030NU
1,096.60
Wheelchair accessory, manual ventilator tray,
							 gimbaled (new equipment)
E1030NUKU
1,130.40
Wheelchair accessory, manual ventilator tray,
							 gimbaled (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E1030UE
822.45
Wheelchair accessory, manual ventilator tray,
							 gimbaled (used durable medical equipment)
E1030UEKU
847.80
Wheelchair accessory, manual ventilator tray,
							 gimbaled (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E1031KH
40.21
Rollabout chair, any and all types with castors 5
							 inches or greater (capped rental)
E1031KI
40.21
Rollabout chair, any and all types with castors 5
							 inches or greater (capped rental)
E1031KJ
30.16
Rollabout chair, any and all types with castors 5
							 inches or greater (capped rental)
E1031NU
402.14
Rollabout chair, any and all types with castors 5
							 inches or greater (new equipment purchase)
E1031UE
301.61
Rollabout chair, any and all types with castors 5
							 inches or greater (used durable medical equipment purchase)
E1035KH
551.35
Multi-positional patient transfer system, with
							 integrated seat, operated by care giver (capped rental)
E1035KI
551.35
Multi-positional patient transfer system, with
							 integrated seat, operated by care giver (capped rental)
E1035KJ
413.52
Multi-positional patient transfer system, with
							 integrated seat, operated by care giver (capped rental)
E1035NU
5,513.53
Multi-positional patient transfer system, with
							 integrated seat, operated by care giver (new equipment purchase)
E1035UE
4,135.15
Multi-positional patient transfer system, with
							 integrated seat, operated by care giver (used durable medical equipment
							 purchase)
E1036KH
783.48
Multi-positional patient transfer system, extra-wide,
							 with integrated seat, operated by caregiver, patient weight capacity great than
							 300 pounds (capped rental)
E1036KI
783.48
Multi-positional patient transfer system, extra-wide,
							 with integrated seat, operated by caregiver, patient weight capacity great than
							 300 pounds (capped rental)
E1036KJ
587.61
Multi-positional patient transfer system, extra-wide,
							 with integrated seat, operated by caregiver, patient weight capacity great than
							 300 pounds (capped rental)
E1036NU
7,834.79
Multi-positional patient transfer system, extra-wide,
							 with integrated seat, operated by caregiver, patient weight capacity great than
							 300 pounds (new equipment purchase)
E1036UE
5,876.09
Multi-positional patient transfer system, extra-wide,
							 with integrated seat, operated by caregiver, patient weight capacity great than
							 300 pounds (used durable medical equipment purchase)
E1037KH
93.21
Transport chair, pediatric size (capped
							 rental)
E1037KI
93.21
Transport chair, pediatric size (capped
							 rental)
E1037KJ
69.91
Transport chair, pediatric size (capped
							 rental)
E1037NU
932.11
Transport chair, pediatric size (new equipment
							 purchase)
E1037UE
699.08
Transport chair, pediatric size (used durable medical
							 equipment purchase)
E1038KH
14.89
Transport chair, adult size, patient weight capacity
							 up to and including 300 pounds (capped rental)
E1038KI
14.89
Transport chair, adult size, patient weight capacity
							 up to and including 300 pounds (capped rental)
E1038KJ
11.17
Transport chair, adult size, patient weight capacity
							 up to and including 300 pounds (capped rental)
E1038NU
148.92
Transport chair, adult size, patient weight capacity
							 up to and including 300 pounds (new equipment purchase)
E1038UE
111.69
Transport chair, adult size, patient weight capacity
							 up to and including 300 pounds (used durable medical equipment
							 purchase)
E1039KH
29.76
Transport chair, adult size, heavy duty, patient
							 weight capacity greater than 300 pounds (capped rental)
E1039KI
29.76
Transport chair, adult size, heavy duty, patient
							 weight capacity greater than 300 pounds (capped rental)
E1039KJ
22.32
Transport chair, adult size, heavy duty, patient
							 weight capacity greater than 300 pounds (capped rental)
E1039NU
297.59
Transport chair, adult size, heavy duty, patient
							 weight capacity greater than 300 pounds (new equipment purchase
E1039UE
223.19
Transport chair, adult size, heavy duty, patient
							 weight capacity greater than 300 pounds (used durable medical equipment
							 purchase)
Wheelchairs E1050KH
81.34
Fully reclining wheelchair, fixed full length arms,
							 swing away detachable elevating leg rests (capped rental)
E1050KI
81.34
Fully reclining wheelchair, fixed full length arms,
							 swing away detachable elevating leg rests (capped rental)
E1050KJ
61.00
Fully reclining wheelchair, fixed full length arms,
							 swing away detachable elevating leg rests (capped rental)
E1050NU
813.37
Fully reclining wheelchair, fixed full length arms,
							 swing away detachable elevating leg rests (new equipment purchase)
E1050UE
610.03
Fully reclining wheelchair, fixed full length arms,
							 swing away detachable elevating leg rests (used durable medical equipment
							 purchase)
E1060KH
118.46
Fully reclining wheelchair, detachable arms, desk or
							 full length, swing away detachable elevating legrests (capped
							 rental)
E1060KI
118.46
Fully reclining wheelchair, detachable arms, desk or
							 full length, swing away detachable elevating legrests (capped
							 rental)
E1060KJ
88.84
Fully reclining wheelchair, detachable arms, desk or
							 full length, swing away detachable elevating legrests (capped
							 rental)
E1060NU
1,184.56
Fully reclining wheelchair, detachable arms, desk or
							 full length, swing away detachable elevating legrests (new equipment
							 purchase)
E1060UE
888.42
Fully reclining wheelchair, detachable arms, desk or
							 full length, swing away detachable elevating legrests (used durable medical
							 equipment purchase)
E1070KH
102.93
Fully reclining wheelchair, detachable arms (desk or
							 full length) swing away detachable footrest (capped rental)
E1070KI
102.93
Fully reclining wheelchair, detachable arms (desk or
							 full length) swing away detachable footrest (capped rental)
E1070KJ
77.20
Fully reclining wheelchair, detachable arms (desk or
							 full length) swing away detachable footrest (capped rental)
E1070NU
1,029.27
Fully reclining wheelchair, detachable arms (desk or
							 full length) swing away detachable footrest (new equipment
							 purchase)
E1070UE
771.95
Fully reclining wheelchair, detachable arms (desk or
							 full length) swing away detachable footrest (used durable medical equipment
							 purchase)
E1083KH
68.33
Hemi-wheelchair, fixed full length arms, swing away
							 detachable elevating leg rest (capped rental)
E1083KI
68.33
Hemi-wheelchair, fixed full length arms, swing away
							 detachable elevating leg rest (capped rental)
E1083KJ
51.25
Hemi-wheelchair, fixed full length arms, swing away
							 detachable elevating leg rest (capped rental)
E1083NU
683.32
Hemi-wheelchair, fixed full length arms, swing away
							 detachable elevating leg rest (new equipment purchase)
E1083UE
512.49
Hemi-wheelchair, fixed full length arms, swing away
							 detachable elevating leg rest (used durable medical equipment
							 purchase)
E1084KH
90.75
Hemi-wheelchair, detachable arms desk or full length
							 arms, swing away detachable elevating leg rests (capped rental)
E1084KI
90.75
Hemi-wheelchair, detachable arms desk or full length
							 arms, swing away detachable elevating leg rests (capped rental)
E1084KJ
68.06
Hemi-wheelchair, detachable arms desk or full length
							 arms, swing away detachable elevating leg rests (capped rental)
E1084NU
907.46
Hemi-wheelchair, detachable arms desk or full length
							 arms, swing away detachable elevating leg rests (new equipment
							 purchase)
E1084UE
680.60
Hemi-wheelchair, detachable arms desk or full length
							 arms, swing away detachable elevating leg rests (used durable medical
							 equipment)
E1087KH
118.90
High strength lightweight wheelchair, fixed full
							 length arms, swing away detachable elevating leg rests (capped
							 rental)
E1087KI
118.90
High strength lightweight wheelchair, fixed full
							 length arms, swing away detachable elevating leg rests (capped
							 rental)
E1087KJ
89.17
High strength lightweight wheelchair, fixed full
							 length arms, swing away detachable elevating leg rests (capped
							 rental)
E1087NU
1,188.98
High strength lightweight wheelchair, fixed full
							 length arms, swing away detachable elevating leg rests (new equipment
							 purchase)
E1087UE
891.74
High strength lightweight wheelchair, fixed full
							 length arms, swing away detachable elevating leg rests (used durable medical
							 equipment purchase)
E1088KH
141.68
High strength lightweight wheelchair, detachable arms
							 desk or full length, swing away detachable elevating leg rests (capped
							 rental)
E1088KI
141.68
High strength lightweight wheelchair, detachable arms
							 desk or full length, swing away detachable elevating leg rests (capped
							 rental)
E1088KJ
106.26
High strength lightweight wheelchair, detachable arms
							 desk or full length, swing away detachable elevating leg rests(capped
							 rental)
E1088NU
1,416.78
High strength lightweight wheelchair, detachable arms
							 desk or full length, swing away detachable elevating leg rests (new equipment
							 purchase)
E1088UE
1,062.59
High strength lightweight wheelchair, detachable arms
							 desk or full length, swing away detachable elevating leg rests (used durable
							 medical equipment purchase)
E1092KH
102.65
Wide heavy duty wheel chair, detachable arms (desk or
							 full length), swing away detachable elevating leg rests (capped
							 rental)
E1092KI
102.65
Wide heavy duty wheel chair, detachable arms (desk or
							 full length), swing away detachable elevating leg rests (capped
							 rental)
E1092KJ
76.99
Wide heavy duty wheel chair, detachable arms (desk or
							 full length), swing away detachable elevating leg rests (capped
							 rental)
E1092NU
1,026.55
Wide heavy duty wheel chair, detachable arms (desk or
							 full length), swing away detachable elevating leg rests (new equipment
							 purchase)
E1092UE
769.91
Wide heavy duty wheel chair, detachable arms (desk or
							 full length), swing away detachable elevating leg rests (used durable medical
							 equipment purchase)
E1093KH
88.27
Wide heavy duty wheelchair, detachable arms desk or
							 full length arms, swing away detachable footrests (capped rental)
E1093KI
88.27
Wide heavy duty wheelchair, detachable arms desk or
							 full length arms, swing away detachable footrests (capped rental)
E1093KJ
66.20
Wide heavy duty wheelchair, detachable arms desk or
							 full length arms, swing away detachable footrests (capped rental)
E1093NU
882.73
Wide heavy duty wheelchair, detachable arms desk or
							 full length arms, swing away detachable footrests (new equipment
							 purchase)
E1093UE
662.04
Wide heavy duty wheelchair, detachable arms desk or
							 full length arms, swing away detachable footrests (used durable medical
							 equipment purchase)
E1100KH
97.54
Semi-reclining wheelchair, fixed full length arms,
							 swing away detachable elevating leg rests (capped rental)
E1100KI
97.54
Semi-reclining wheelchair, fixed full length arms,
							 swing away detachable elevating leg rests (capped rental)
E1100KJ
73.15
Semi-reclining wheelchair, fixed full length arms,
							 swing away detachable elevating leg rests (capped rental)
E1100NU
975.38
Semi-reclining wheelchair, fixed full length arms,
							 swing away detachable elevating leg rests (new equipment purchase)
E1100UE
731.53
Semi-reclining wheelchair, fixed full length arms,
							 swing away detachable elevating leg rests (used durable medical
							 equipment)
E1110KH
94.49
Semi-reclining wheelchair, detachable arms (desk or
							 full length) elevating leg rest (capped rental)
E1110KI
94.49
Semi-reclining wheelchair, detachable arms (desk or
							 full length) elevating leg rest (capped rental)
E1110KJ
70.86
Semi-reclining wheelchair, detachable arms (desk or
							 full length) elevating leg rest (capped rental)
E1110NU
944.86
Semi-reclining wheelchair, detachable arms (desk or
							 full length) elevating leg rest (new equipment purchase)
E1110UE
708.65
Semi-reclining wheelchair, detachable arms (desk or
							 full length) elevating leg rest (used durable medical equipment
							 purchase)
E1150KH
76.65
Wheelchair, detachable arms, desk or full length
							 swing away detachable elevating legrests (capped rental)
E1150KI
76.65
Wheelchair, detachable arms, desk or full length
							 swing away detachable elevating legrests (capped rental)
E1150KJ
57.49
Wheelchair, detachable arms, desk or full length
							 swing away detachable elevating legrests (capped rental)
E1150NU
766.53
Wheelchair, detachable arms, desk or full length
							 swing away detachable elevating legrests (new equipment purchase)
E1150UE
574.90
Wheelchair, detachable arms, desk or full length
							 swing away detachable elevating legrests (used durable medical equipment
							 purchase)
E1160KH
58.74
Wheelchair, fixed full length arms, swing away
							 detachable elevating legrests (capped rental)
E1160KI
58.74
Wheelchair, fixed full length arms, swing away
							 detachable elevating legrests (capped rental)
E1160KJ
44.05
Wheelchair, fixed full length arms, swing away
							 detachable elevating legrests (capped rental)
E1160NU
587.35
Wheelchair, fixed full length arms, swing away
							 detachable elevating legrests (new equipment purchase)
E1160UE
440.51
Wheelchair, fixed full length arms, swing away
							 detachable elevating legrests (used durable medical equipment
							 purchase)
E1161KH
261.57
Manual adult size wheelchair, includes tilt in space
							 (capped rental)
E1161KI
261.57
Manual adult size wheelchair, includes tilt in space
							 (capped rental)
E1161KJ
196.18
Manual adult size wheelchair, includes tilt in space
							 (capped rental)
E1161NU
2,615.70
Manual adult size wheelchair, includes tilt in space
							 (new equipment)
E1161UE
1,961.78
Manual adult size wheelchair, includes tilt in space
							 (used durable medical equipment)
E1170KH
83.03
Amputee wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (capped rental)
E1170KI
83.03
Amputee wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (capped rental)
E1170KJ
62.27
Amputee wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (capped rental)
E1170NU
830.28
Amputee wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (new equipment purchase)
E1170UE
622.71
Amputee wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (used durable medical equipment
							 purchase)
E1171KH
75.32
Amputee wheelchair, fixed full length arms, without
							 footrests or legrest (capped rental)
E1171KI
75.32
Amputee wheelchair, fixed full length arms, without
							 footrests or legrest (capped rental)
E1171KJ
56.49
Amputee wheelchair, fixed full length arms, without
							 footrests or legrest (capped rental)
E1171NU
753.19
Amputee wheelchair, fixed full length arms, without
							 footrests or legrest (new equipment purchase)
E1171UE
564.89
Amputee wheelchair, fixed full length arms, without
							 footrests or legrest (used durable medical equipment purchase)
E1172KH
92.06
Amputee wheelchair, detachable arms (desk or full
							 length) without footrests or legrest (capped rental)
E1172KI
92.06
Amputee wheelchair, detachable arms (desk or full
							 length) without footrests or legrest (capped rental)
E1172KJ
69.05
Amputee wheelchair, detachable arms (desk or full
							 length) without footrests or legrest (capped rental)
E1172NU
920.55
Amputee wheelchair, detachable arms (desk or full
							 length) without footrests or legrest (new equipment purchase)
E1172UE
690.41
Amputee wheelchair, detachable arms (desk or full
							 length) without footrests or legrest (used durable medical equipment
							 purchase)
E1180KH
95.23
Amputee wheelchair, detachable arms (desk or full
							 length) swing away detachable footrests (capped rental)
E1180KI
95.23
Amputee wheelchair, detachable arms (desk or full
							 length) swing away detachable footrests (capped rental)
E1180KJ
71.42
Amputee wheelchair, detachable arms (desk or full
							 length) swing away detachable footrests (capped rental)
E1180NU
952.26
Amputee wheelchair, detachable arms (desk or full
							 length) swing away detachable footrests (new equipment purchase)
E1180UE
714.20
Amputee wheelchair, detachable arms (desk or full
							 length) swing away detachable footrests (used durable medical equipment
							 purchase)
E1190KH
101.42
Amputee wheelchair, detachable arms (desk or full
							 length) swing away detachable elevating legrests (capped rental)
E1190KI
101.42
Amputee wheelchair, detachable arms (desk or full
							 length) swing away detachable elevating legrests (capped rental)
E1190KJ
76.07
Amputee wheelchair, detachable arms (desk or full
							 length) swing away detachable elevating legrests (capped rental)
E1190NU
1,014.22
Amputee wheelchair, detachable arms (desk or full
							 length) swing away detachable elevating legrests (new equipment
							 purchase)
E1190UE
760.67
Amputee wheelchair, detachable arms (desk or full
							 length) swing away detachable elevating legrests (used durable medical
							 equipment purchase)
E1195KH
118.05
Heavy duty wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (capped rental)
E1195KI
118.05
Heavy duty wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (capped rental)
E1195KJ
88.54
Heavy duty wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (capped rental)
E1195NU
1,180.48
Heavy duty wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (new equipment purchase)
E1195UE
885.36
Heavy duty wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (used durable medical equipment
							 purchase)
E1200KH
81.76
Amputee wheelchair, fixed full length arms, swing
							 away detachable footrest (capped rental)
E1200KI
81.76
Amputee wheelchair, fixed full length arms, swing
							 away detachable footrest (capped rental)
E1200KJ
60.66
Amputee wheelchair, fixed full length arms, swing
							 away detachable footrest (capped rental)
E1200NU
808.78
Amputee wheelchair, fixed full length arms, swing
							 away detachable footrest (new equipment purchase)
E1200UE
606.58
Amputee wheelchair, fixed full length arms, swing
							 away detachable footrest (used durable medical equipment purchase)
E1221KH
44.65
Wheelchair with fixed arm, footrests (capped
							 rental)
E1221KI
44.65
Wheelchair with fixed arm, footrests (capped
							 rental)
E1221KJ
33.49
Wheelchair with fixed arm, footrests (capped
							 rental)
E1221NU
446.51
Wheelchair with fixed arm, footrests (new equipment
							 purchase)
E1221UE
334.88
Wheelchair with fixed arm, footrests (used durable
							 medical equipment purchase)
E1222KH
63.70
Wheelchair with fixed arm, elevating legrests (capped
							 rental)
E1222KI
63.70
Wheelchair with fixed arm, elevating legrests (capped
							 rental)
E1222KJ
47.78
Wheelchair with fixed arm, elevating legrests (capped
							 rental)
E1222NU
636.99
Wheelchair with fixed arm, elevating legrests (new
							 equipment purchase)
E1222UE
477.74
Wheelchair with fixed arm, elevating legrests (used
							 durable medical equipment)
E1223KH
69.55
Wheelchair with detachable arms, footrests (capped
							 rental)
E1223KI
69.55
Wheelchair with detachable arms, footrests (capped
							 rental)
E1223KJ
52.16
Wheelchair with detachable arms, footrests (capped
							 rental)
E1223NU
695.47
Wheelchair with detachable arms, footrests (new
							 equipment purchase)
E1223UE
521.60
Wheelchair with detachable arms, footrests (used
							 durable medical equipment)
E1224KH
76.25
Wheelchair with detachable arms, elevating legrests
							 (capped rental)
E1224KI
76.25
Wheelchair with detachable arms, elevating legrests
							 (capped rental)
E1224KJ
57.19
Wheelchair with detachable arms, elevating
							 legrests(capped rental)
E1224NU
762.54
Wheelchair with detachable arms, elevating legrests
							 (new equipment purchase)
E1224UE
571.91
Wheelchair with detachable arms, elevating legrests
							 (used durable medical equipment)
E1225KH
32.66
Wheelchair accessory, manual semi-reclining back,
							 (recline greater than 15 degrees, but less than 80E), each (capped
							 rental)
E1225KHKU
44.63
Wheelchair accessory, manual semi-reclining back,
							 (recline greater than 15 degrees, but less than 80E), each
E1225KI
32.66
Wheelchair accessory, manual semi-reclining back,
							 (recline greater than 15 degrees, but less than 80E), each (capped
							 rental)
E1225KIKU
44.63
Wheelchair accessory, manual semi-reclining back,
							 (recline greater than 15 degrees, but less than 80E), each
E1225KJ
24.50
Wheelchair accessory, manual semi-reclining back,
							 (recline greater than 15 degrees, but less than 80E), each (capped
							 rental)
E1225KJKU
33.47
Wheelchair accessory, manual semi-reclining back,
							 (recline greater than 15 degrees, but less than 80E), each
E1225NU
326.57
Wheelchair accessory, manual semi-reclining back,
							 (recline greater than 15 degrees, but less than 80E), each (new equipment
							 purchase)
E1225NUKU
446.30
Wheelchair accessory, manual semi-reclining back,
							 (recline greater than 15 degrees, but less than 80E), each
E1225UE
244.93
Wheelchair accessory, manual semi-reclining back,
							 (recline greater than 15 degrees, but less than 80E) (used durable medical
							 equipment)
E1225UEKU
334.73
Wheelchair accessory, manual semi-reclining back,
							 (recline greater than 15 degrees, but less than 80E), each
E1226NU
375.26
Wheelchair accessory, manual fully reclining back,
							 (recline greater than 80E), each (new equipment)
E1226NUKU
538.82
Wheelchair accessory, manual fully reclining back,
							 (recline greater than 80E), each
E1226RR
38.16
Wheelchair accessory, manual fully reclining back,
							 (recline greater than 80E), each (rental)
E1226RRKU
55.45
Wheelchair accessory, manual fully reclining back,
							 (recline greater than 80E), each
E1226UE
281.43
Wheelchair accessory, manual fully reclining back,
							 (recline greater than 80E), each (used durable medical equipment)
E1226UEKU
404.07
Wheelchair accessory, manual fully reclining back,
							 (recline greater than 80E), each
E1227NU
260.76
Special height arms for wheelchair (new
							 equipment)
E1227RR
26.09
Special height arms for wheelchair
							 (rental)
E1227UE
195.59
Special height arms for wheelchair (used durable
							 medical equipment)
E1228KH
30.98
Special back height for wheelchair (capped
							 rental)
E1228KI
30.98
Special back height for wheelchair (capped
							 rental)
E1228KJ
23.24
Special back height for wheelchair (capped
							 rental)
E1228NU
309.80
Special back height for wheelchair (new equipment
							 purchase)
E1228UE
232.35
Special back height for wheelchair (used durable
							 medical equipment purchase)
E1229
AAC+35%
Wheelchair, pediatric size, not otherwise
							 specified
E1230NU
2,473.38
Power operated vehicle (three or four wheel
							 nonhighway) specify brand name and model number (new equipment)
E1230RR
243.26
Power operated vehicle (three or four wheel
							 nonhighway) specify brand name and model number (rental)
E1230UE
1,956.14
Power operated vehicle (three or four wheel
							 nonhighway) specify brand name and model number (used durable medical
							 equipment)
E1231NU
AAC+35%
Wheelchair, pediatric size, tilt-in-space, rigid,
							 adjustable, with seating system (new equipment)
E1231RR
I.C.
Wheelchair, pediatric size, tilt-in-space, rigid,
							 adjustable, with seating system (rental)
E1231UE
I.C.
Wheelchair, pediatric size, tilt-in-space, rigid,
							 adjustable, with seating system (used durable medical equipment)
E1232KH
236.42
Wheelchair, pediatric size, tilt-in-space, folding,
							 adjustable, with seating system (capped rental)
E1232KI
236.42
Wheelchair, pediatric size, tilt-in-space, folding,
							 adjustable, with seating system (capped rental)
E1232KJ
177.32
Wheelchair, pediatric size, tilt-in-space, folding,
							 adjustable, with seating system (capped rental)
E1232NU
2,364.20
Wheelchair, pediatric size, tilt-in-space, folding,
							 adjustable, with seating system (new equipment)
E1232UE
1,773.15
Wheelchair, pediatric size, tilt-in-space, folding,
							 adjustable, with seating system (used durable medical equipment)
E1233KH
244.95
Wheelchair, pediatric size, tilt-in-space, rigid,
							 adjustable, without seating system (capped rental)
E1233KI
244.95
Wheelchair, pediatric size, tilt-in-space, rigid,
							 adjustable, without seating system (capped rental)
E1233KJ
183.71
Wheelchair, pediatric size, tilt-in-space, rigid,
							 adjustable, without seating system (capped rental)
E1233NU
2,449.50
Wheelchair, pediatric size, tilt-in-space, rigid,
							 adjustable, without seating system (new equipment)
E1233UE
1,837.13
Wheelchair, pediatric size, tilt-in-space, rigid,
							 adjustable, without seating system (used durable medical equipment)
E1234KH
213.26
Wheelchair, pediatric size, tilt-in-space, folding,
							 adjustable, without seating system (capped rental)
E1234KI
213.26
Wheelchair, pediatric size, tilt-in-space, folding,
							 adjustable, without seating system (capped rental)
E1234KJ
159.95
Wheelchair, pediatric size, tilt-in-space, folding,
							 adjustable, without seating system (capped rental)
E1234NU
2,132.60
Wheelchair, pediatric size, tilt-in-space, folding,
							 adjustable, without seating system (new equipment)
E1234UE
1,599.45
Wheelchair, pediatric size, tilt-in-space, folding,
							 adjustable, without seating system (used durable medical equipment)
E1235KH
205.36
Wheelchair, pediatric size, rigid, adjustable, with
							 seating system (capped rental)
E1235KI
205.36
Wheelchair, pediatric size, rigid, adjustable, with
							 seating system (capped rental)
E1235KJ
154.02
Wheelchair, pediatric size, rigid, adjustable, with
							 seating system (capped rental)
E1235NU
2,053.60
Wheelchair, pediatric size, rigid, adjustable, with
							 seating system (new equipment)
E1235UE
1,540.20
Wheelchair, pediatric size, rigid, adjustable, with
							 seating system (used durable medical equipment)
E1236KH
181.16
Wheelchair, pediatric size, folding, adjustable, with
							 seating system (capped rental)
E1236KI
181.16
Wheelchair, pediatric size, folding, adjustable, with
							 seating system (capped rental)
E1236KJ
135.87
Wheelchair, pediatric size, folding, adjustable, with
							 seating system (capped rental)
E1236NU
1,811.60
Wheelchair, pediatric size, folding, adjustable, with
							 seating system (new equipment)
E1236UE
1,358.70
Wheelchair, pediatric size, folding, adjustable, with
							 seating system (used durable medical equipment)
E1237KH
182.75
Wheelchair, pediatric size, rigid, adjustable,
							 without seating system (capped rental)
E1237KI
182.75
Wheelchair, pediatric size, rigid, adjustable,
							 without seating system (capped rental)
E1237KJ
137.06
Wheelchair, pediatric size, rigid, adjustable,
							 without seating system (capped rental)
E1237NU
1,827.50
Wheelchair, pediatric size, rigid, adjustable,
							 without seating system (new equipment)
E1237UE
1,370.63
Wheelchair, pediatric size, rigid, adjustable,
							 without seating system (used durable medical equipment)
E1238KH
181.16
Wheelchair, pediatric size, folding, adjustable,
							 without seating system (capped rental)
E1238KI
181.16
Wheelchair, pediatric size, folding, adjustable,
							 without seating system (capped rental)
E1238KJ
135.87
Wheelchair, pediatric size, folding, adjustable,
							 without seating system (capped rental)
E1238NU
1,811.60
Wheelchair, pediatric size, folding, adjustable,
							 without seating system (new equipment)
E1238UE
1,358.70
Wheelchair, pediatric size, folding, adjustable,
							 without seating system (used durable medical equipment)
E1239
AAC+35%
Power wheelchair, pediatric size, not otherwise
							 specified
E1240KH
96.81
Lightweight wheelchair, detachable arms, (desk or
							 full length) swing away detachable, elevating legrest (capped
							 rental)
E1240KI
96.81
Lightweight wheelchair, detachable arms, (desk or
							 full length) swing away detachable, elevating legrest (capped
							 rental)
E1240KJ
72.60
Lightweight wheelchair, detachable arms, (desk or
							 full length) swing away detachable, elevating legrest (capped
							 rental)
E1240NU
968.07
Lightweight wheelchair, detachable arms, (desk or
							 full length) swing away detachable, elevating legrest (new equipment
							 purchase)
E1240UE
726.05
Lightweight wheelchair, detachable arms, (desk or
							 full length) swing away detachable, elevating legrest (used durable medical
							 equipment purchase)
E1270KH
74.18
Lightweight wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (capped rental)
E1270KI
74.18
Lightweight wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (capped rental)
E1270KJ
55.63
Lightweight wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (capped rental)
E1270NU
741.80
Lightweight wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (new equipment purchase)
E1270UE
556.35
Lightweight wheelchair, fixed full length arms, swing
							 away detachable elevating legrests (used durable medical equipment)
E1280KH
123.34
Heavy duty wheelchair, detachable arms (desk or full
							 length) elevating legrests (capped rental)
E1280KI
123.34
Heavy duty wheelchair, detachable arms (desk or full
							 length) elevating legrests (capped rental)
E1280KJ
92.50
Heavy duty wheelchair, detachable arms (desk or full
							 length) elevating legrests (capped rental)
E1280NU
1,233.35
Heavy duty wheelchair, detachable arms (desk or full
							 length) elevating legrests (new equipment purchase)
E1280UE
925.01
Heavy duty wheelchair, detachable arms (desk or full
							 length) elevating legrests (used durable medical equipment)
E1295KH
114.14
Heavy duty wheelchair, fixed full length arms,
							 elevating legrest (capped rental)
E1295KI
114.14
Heavy duty wheelchair, fixed full length arms,
							 elevating legrest (capped rental)
E1295KJ
85.60
Heavy duty wheelchair, fixed full length arms,
							 elevating legrest (capped rental)
E1295NU
1,141.38
Heavy duty wheelchair, fixed full length arms,
							 elevating legrest (new equipment purchase)
E1295UE
856.04
Heavy duty wheelchair, fixed full length arms,
							 elevating legrest (used durable medical equipment purchase)
E1296NU
543.53
Special wheelchair seat height from floor (new
							 equipment)
E1296RR
55.22
Special wheelchair seat height from floor
							 (rental)
E1296UE
407.65
Special wheelchair seat height from floor (used
							 durable medical equipment)
E1297NU
98.30
Special wheelchair seat depth, by upholstery (new
							 equipment)
E1297RR
10.92
Special wheelchair seat depth, by upholstery
							 (rental)
E1297UE
73.71
Special wheelchair seat depth, by upholstery (used
							 durable medical equipment)
E1298NU
398.11
Special wheelchair seat depth and/or width, by
							 construction (new equipment)
E1298RR
40.73
Special wheelchair seat depth and/or width, by
							 construction (rental)
E1298UE
298.57
Special wheelchair seat depth and/or width, by
							 construction (used durable medical equipment)
Whirlpool-Equipment
E1300
AAC+30%
Whirlpool, portable (overtub type)
E1310NU
1,715.19
Whirlpool, non-portable (built-in type) (new
							 equipment)
E1310RR
146.69
Whirlpool, non-portable (built-in type)
							 (rental)
E1310UE
1,286.41
Whirlpool, non-portable (built-in type) (used durable
							 medical equipment)
Additional Oxygen Related Equipment
E1352
AAC+20%
Oxygen accessory, flow regulator capable of positive
							 inspiratory pressure
E1353
26.61
Regulator
E1354
AAC+30%
Oxygen accessory, wheeled cart for portable cylinder
							 or portable concentrator, any type, replacement only, each
E1355
20.05
Stand/rack
E1356
AAC+30%
Oxygen accessory, battery pack/cartridge for portable
							 concentrator, any type, replacement only, each
E1357
AAC+30%
Oxygen accessory, battery charger for portable
							 concentrator, any type, replacement only, each
E1358
AAC+30%
Oxygen accessory, dc power adapter for portable
							 concentrator, any type, replacement only, each
E1372NU
141.66
Immersion external heater for nebulizer (new
							 equipment)
E1372RR
17.64
Immersion external heater for nebulizer
							 (rental)
E1372UE
105.50
Immersion external heater for nebulizer (used durable
							 medical equipment)
E1390RR
119.48
Oxygen concentrator, single delivery port, capable of
							 delivering 85 percent or greater oxygen concentration at the prescribed flow
							 rate (rental)
E1391RR
119.48
Oxygen concentrator, dual delivery port, capable of
							 delivering 85 percent or greater oxygen concentration at the prescribed flow
							 rate, each (rental)
E1392RR
40.26
Portable oxygen concentrator, rental
E1399NU
AAC+30%
Durable medical equipment, miscellaneous (new
							 equipment)
E1399RB
AAC+30%
Durable medical equipment, miscellaneous (replacement
							 of a part of DME furnished as part of a repair)
E1399U1
AAC+35%
Durable medical equipment miscellaneous (used only
							 for installation of patient lift systems with RE1-RE23)
E1399U3
AAC+30%
Supplies for maintenance of insulin infusion catheter
							 each (used for MassHealth members instead of A4224) Supplies for external
							 insulin infusion pump, syringe type cartridge, sterile each (used for
							 MassHealth members instead of A4225)
E1399U4
AAC+30%
Supplies for maintenance of insulin infusion catheter
							 each (used for MassHealth members instead of A4224)Supplies for external
							 insulin infusion pump, syringe type cartridge, sterile each (used for
							 MassHealth members instead of A4225)
E1399UC
AAC+35%
Durable medical equipment, miscellaneous (used for
							 pediatric specialized rehabilitation equipment only)
E1405RR
147.53
Oxygen and water vapor enriching system with heated
							 delivery (rental)
E1406RR
131.89
Oxygen and water vapor enriching system without
							 heated delivery (rental)
Artificial Kidney Machines and
							 Accessories
E1500
AAC+30%
Centrifuge, for dialysis
E1510
AAC+30%
Kidney, dialysate delivery system kidney machine,
							 pump recirculating, air removal syst, flowrate meter, power off, heater and
							 temperature control with alarm, i.v. poles, pressure gauge, concentrate
							 container
E1520
AAC+30%
Heparin infusion pump for hemodialysis
E1530
AAC+30%
Air bubble detector for hemodialysis, each,
							 replacement
E1540
AAC+20%
Pressure alarm for hemodialysis, each,
							 replacement
E1550
AAC+20%
Bath conductivity meter for hemodialysis,
							 each
E1560
AAC+20%
Blood leak detector for hemodialysis, each,
							 replacement
E1570
AAC+30%
Adjustable chair, for esrd patients
E1575
AAC+30%
Transducer protectors/fluid barriers, for
							 hemodialysis, any size, per 10
E1580
AAC+20%
Unipuncture control system for
							 hemodialysis
E1590
AAC+30%
Hemodialysis machine
E1592
AAC+30%
Automatic intermittent peritioneal dialysis
							 system
E1594
AAC+30%
Cycler dialysis machine for peritoneal
							 dialysis
E1610
AAC+30%
Reverse osmosis water purification system, for
							 hemodialysis
E1615
AAC+30%
Deionizer water purification system, for
							 hemodialysis
E1620
AAC+30%
Blood pump for hemodialysis, replacement
E1625
AAC+30%
Water softening system, for hemodialysis
E1630
AAC+30%
Reciprocating peritoneal dialysis system
E1632
AAC+30%
Wearable artificial kidney, each
E1634
AAC+30%
Peritoneal dialysis clamps, each
E1635
AAC+30%
Compact (portable) travel hemodialyzer
							 system
E1636
AAC+30%
Sorbent cartridges, for hemodialysis, per
							 10
E1637
AAC+30%
Hemostats, each
E1639
AAC+30%
Scale, each
E1699
AAC+30%
Dialysis equipment, not otherwise
							 specified
Jaw Motion Rehabilitation System and
							 Accessories
E1700KH
9.74
Jaw motion rehabilitation system (capped
							 rental)
E1700KI
9.74
Jaw motion rehabilitation system (capped
							 rental)
E1700KJ
21.21
Jaw motion rehabilitation system (capped
							 rental)
E1700NU
293.51
Jaw motion rehabilitation system (new
							 equipment)
E1700UE
220.13
Jaw motion rehabilitation system (used durable
							 medical equipment)
E1701
9.64
Replacement cushions for jaw motion rehabilitation
							 system, pkg. of 6
E1702
20.98
Replacement measuring scales for jaw motion
							 rehabilitation system, pkg. of 200
Flexion/Extension Device
E1800KH
97.85
Dynamic adjustable elbow extension/flexion device,
							 includes soft interface material (capped rental)
E1800KI
97.85
Dynamic adjustable elbow extension/flexion device,
							 includes soft interface material (capped rental)
E1800KJ
73.39
Dynamic adjustable elbow extension/flexion device,
							 includes soft interface material (capped rental)
E1800NU
978.52
Dynamic adjustable elbow extension/flexion device,
							 includes soft interface material (new equipment purchase)
E1800UE
733.89
Dynamic adjustable elbow extension/flexion device,
							 includes soft interface material (used durable medical equipment)
E1801KH
121.23
Static progressive stretch elbow device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1801KI
121.23
Static progressive stretch elbow device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1801KJ
90.92
Static progressive stretch elbow device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1801NU
1,212.27
Static progressive stretch elbow device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and accessories (new equipment purchase)
E1801UE
909.20
Static progressive stretch elbow device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and accessories (used durable medical equipment)
E1802KH
307.10
Dynamic adjustable forearm pronation/supination
							 device, includes soft interface material (capped rental)
E1802KI
307.10
Dynamic adjustable forearm pronation/supination
							 device, includes soft interface material (capped rental)
E1802KJ
230.32
Dynamic adjustable forearm pronation/supination
							 device, includes soft interface material (capped rental)
E1802NU
3,070.97
Dynamic adjustable forearm pronation/supination
							 device, includes soft interface material (new equipment purchase)
E1802UE
2,303.22
Dynamic adjustable forearm pronation/supination
							 device, includes soft interface material (used durable medical
							 equipment)
E1805KH
118.73
Dynamic adjustable wrist extension/flexion device,
							 includes soft interface material (capped rental)
E1805KI
118.73
Dynamic adjustable wrist extension/flexion device,
							 includes soft interface material (capped rental)
E1805KJ
89.05
Dynamic adjustable wrist extension/flexion device,
							 includes soft interface material (capped rental)
E1805NU
1,187.28
Dynamic adjustable wrist extension/flexion device,
							 includes soft interface material (new equipment purchase)
E1805UE
890.46
Dynamic adjustable wrist extension/flexion device,
							 includes soft interface material (used durable medical equipment
							 purchase)
E1806KH
99.54
Static progressive stretch wrist device, flexion
							 and/or extension, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1806KI
99.54
Static progressive stretch wrist device, flexion
							 and/or extension, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1806KJ
74.65
Static progressive stretch wrist device, flexion
							 and/or extension, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1806NU
995.35
Static progressive stretch wrist device, flexion
							 and/or extension, with or without range of motion adjustment, includes all
							 components and accessories (new equipment purchase)
E1806UE
746.51
Static progressive stretch wrist device, flexion
							 and/or extension, with or without range of motion adjustment, includes all
							 components and accessories (used durable medical equipment
							 purchase)
E1810KH
99.51
Dynamic adjustable knee extension/flexion device,
							 includes soft interface material (capped rental)
E1810KI
99.51
Dynamic adjustable knee extension/flexion device,
							 includes soft interface material (capped rental)
E1810KJ
74.63
Dynamic adjustable knee extension/flexion device,
							 includes soft interface material (capped rental)
E1810NU
995.10
Dynamic adjustable knee extension/flexion device,
							 includes soft interface material (new equipment purchase)
E1810UE
746.32
Dynamic adjustable knee extension/flexion device,
							 includes soft interface material (used durable medical equipment)
E1811KH
126.03
Static progressive stretch knee device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1811KI
126.03
Static progressive stretch knee device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1811KJ
94.52
Static progressive stretch knee device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1811NU
1,260.30
Static progressive stretch knee device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and accessories (new equipment purchase)
E1811UE
945.22
Static progressive stretch knee device, extension
							 and/or flexion, or without with range of motion adjustment, includes all
							 components and accessories (used durable medical equipment)
E1812KH
80.80
Dynamic knee, extension/flexion device with active
							 resistance control (capped rental)
E1812KI
80.80
Dynamic knee, extension/flexion device with active
							 resistance control (capped rental)
E1812KJ
60.60
Dynamic knee, extension/flexion device with active
							 resistance control (capped rental)
E1812NU
808.01
Dynamic knee, extension/flexion device with active
							 resistance control (new equipment purchase)
E1812UE
606.01
Dynamic knee, extension/flexion device with active
							 resistance control (used durable medical equipment purchase)
E1815KH
118.73
Dynamic adjustable ankle extension/flexion device,
							 includes soft interface material (capped rental)
E1815KI
118.73
Dynamic adjustable ankle extension/flexion device,
							 includes soft interface material (capped rental)
E1815KJ
89.05
Dynamic adjustable ankle extension/flexion device,
							 includes soft interface material (capped rental)
E1815NU
1,187.28
Dynamic adjustable ankle extension/flexion device,
							 includes soft interface material(new equipment purchase)
E1815UE
890.46
Dynamic adjustable ankle extension/flexion device,
							 includes soft interface material (used durable medical equipment)
E1816KH
128.03
Static progressive stretch ankle device, flexion
							 and/or extension, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1816KI
128.03
Static progressive stretch ankle device, flexion
							 and/or extension, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1816KJ
96.02
Static progressive stretch ankle device, flexion
							 and/or extension, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1816NU
1,280.27
Static progressive stretch ankle device, flexion
							 and/or extension, with or without range of motion adjustment, includes all
							 components and accessories (new equipment purchase)
E1816UE
960.20
Static progressive stretch ankle device, flexion
							 and/or extension, with or without range of motion adjustment, includes all
							 components and accessories (used durable medical equipment)
E1818KH
130.70
Static progressive stretch forearm
							 pronation/supination device with or without range of motion adjustment,
							 includes cuffs (capped rental)
E1818KI
130.70
Static progressive stretch forearm
							 pronation/supination device with or without range of motion adjustment,
							 includes cuffs (capped rental)
E1818KJ
98.02
Static progressive stretch forearm
							 pronation/supination device with or without range of motion adjustment,
							 includes all components and accessories (capped rental)
E1818NU
1,306.96
Static progressive stretch forearm
							 pronation/supination device with or without range of motion adjustment,
							 includes all components and accessories (new equipment purchase)
E1818UE
980.22
Static progressive stretch forearm
							 pronation/supination device with or without range of motion adjustment,
							 includes all components and accessories (used durable medical
							 equipment)
E1820NU
76.81
Replacement soft interface material, dynamic
							 adjustable extension/flexion device (new equipment)
E1820RR
7.68
Replacement soft interface material, dynamic
							 adjustable extension/flexion device (rental)
E1820UE
57.62
Replacement soft interface material, dynamic
							 adjustable extension/flexion device (used durable medical
							 equipment)
E1821NU
98.90
Replacement soft interface material/cuffs for
							 bi-directional static progressive stretch device (new equipment)
E1821RR
9.87
Replacement soft interface material/cuffs for
							 bi-directional static progressive stretch device (rental)
E1821UE
74.20
Replacement soft interface material/cuffs for
							 bi-directional static progressive stretch device (used durable medical
							 equipment)
E1825KH
118.73
Dynamic adjustable finger extension/flexion device,
							 includes soft interface material (capped rental)
E1825KI
118.73
Dynamic adjustable finger extension/flexion device,
							 includes soft interface material (capped rental)
E1825KJ
89.05
Dynamic adjustable finger extension/flexion device,
							 includes soft interface material (capped rental)
E1825NU
1,187.28
Dynamic adjustable finger extension/flexion device,
							 includes soft interface material (new equipment purchase)
E1825UE
890.46
Dynamic adjustable finger extension/flexion device,
							 includes soft interface material (used durable medical equipment
							 purchase)
E1830KH
118.73
Dynamic adjustable toe extension/flexion device,
							 includes soft interface material (capped rental)
E1830KI
118.73
Dynamic adjustable toe extension/flexion device,
							 includes soft interface material (capped rental)
E1830KJ
89.05
Dynamic adjustable toe extension/flexion device,
							 includes soft interface material (capped rental)
E1830NU
1,187.28
Dynamic adjustable toe extension/flexion device,
							 includes soft interface material (new equipment purchase)
E1830UE
890.46
Dynamic adjustable toe extension/flexion device,
							 includes soft interface material (used durable medical equipment
							 purchase)
E1831KH
59.71
Static progressive stretch toe device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1831KI
59.71
Static progressive stretch toe device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and accessories (capped rental)
E1831KJ
44.78
Static progressive stretch toe device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and
E1831NU
626.98
Static progressive stretch toe device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and
E1831UE
470.24
Static progressive stretch toe device, extension
							 and/or flexion, with or without range of motion adjustment, includes all
							 components and
E1840KH
359.63
Dynamic adjustable shoulder
							 flexion/abduction/rotation device, includes soft interface material (capped
							 rental)
E1840KI
359.63
Dynamic adjustable shoulder
							 flexion/abduction/rotation device, includes soft interface material (capped
							 rental)
E1840KJ
269.72
Dynamic adjustable shoulder
							 flexion/abduction/rotation device, includes soft interface material (capped
							 rental)
E1840NU
3,596.27
Dynamic adjustable shoulder
							 flexion/abduction/rotation device, includes soft interface material (new
							 equipment purchase)
E1840UE
2,697.20
Dynamic adjustable shoulder
							 flexion/abduction/rotation device, includes soft interface material (used
							 durable medical equipment purchase)
E1841KH
425.66
Static progressive stretch shoulder device, with or
							 without range of motion adjustment, includes all components and accessories
							 (capped rental)
E1841KI
425.66
Static progressive stretch shoulder device, with or
							 without range of motion adjustment, includes all components and accessories
							 (capped rental)
E1841KJ
319.25
Static progressive stretch shoulder device, with or
							 without range of motion adjustment, includes all components and accessories
							 (capped rental)
E1841NU
4,256.63
Static progressive stretch shoulder device, with or
							 without range of motion adjustment, includes all components and accessories
							 (new equipment purchase)
E1841UE
3,192.47
Static progressive stretch shoulder device, with
							 range of motion adjustment, includes all components and accessories (used
							 durable medical equipment purchase)
E1902
AAC+30%
Communication board, non-electronic augmentative or
							 alternative communication device
E2000KH
48.71
Gastric suction pump, home model, portable or
							 stationary, electric (capped rental)
E2000KI
48.71
Gastric suction pump, home model, portable or
							 stationary, electric (capped rental)
E2000KJ
36.53
Gastric suction pump, home model, portable or
							 stationary, electric (capped rental)
E2000NU
487.05
Gastric suction pump, home model, portable or
							 stationary, electric (new equipment purchase)
E2000UE
365.29
Gastric suction pump, home model, portable or
							 stationary, electric (used durable medical equipment purchase)
E2100NU
604.38
Blood glucose monitor with integrated voice
							 synthesizer (new equipment purchase)
E2100RR
60.44
Blood glucose monitor with integrated voice
							 synthesizer (rental)
E2100UE
453.30
Blood glucose monitor with integrated voice
							 synthesizer (used durable medical equipment)
E2101NU
177.18
Blood glucose monitor with integrated lancing/blood
							 sample (new equipment)
E2101RR
17.71
Blood glucose monitor with integrated lancing/blood
							 sample (rental)
E2101UE
132.89
Blood glucose monitor with integrated lancing/blood
							 sample (used durable medical equipment)
E2120KH
266.42
Pulse generator system for tympanic treatment of
							 inner ear endolymphatic fluid (capped rental)
E2120KI
266.42
Pulse generator system for tympanic treatment of
							 inner ear endolymphatic fluid (capped rental)
E2120KJ
199.82
Pulse generator system for tympanic treatment of
							 inner ear endolymphatic fluid (capped rental)
E2120NU
2,664.24
Pulse generator system for tympanic treatment of
							 inner ear endolymphatic fluid (new equipment purchase)
E2120UE
1,998.18
Pulse generator system for tympanic treatment of
							 inner ear endolymphatic fluid (used durable medical equipment)
DME Wheelchair Accessory
E2201NU
377.75
Manual wheelchair accessory, nonstandard seat frame
							 width, greater than or equal to 20 inches but less than 24 inches (new
							 equipment)
E2201NUKU
433.46
Manual wheelchair accessory, nonstandard seat frame
							 width, greater than or equal to 20 inches but less than 24 inches
E2201RR
37.77
Manual wheelchair accessory, nonstandard seat frame
							 width, greater than or equal to 20 inches but less than 24 inches
							 (rental)
E2201RRKU
43.35
Manual wheelchair accessory, nonstandard seat frame
							 width, greater than or equal to 20 inches but less than 24 inches
E2201UE
283.31
Manual wheelchair accessory, nonstandard seat frame
							 width, greater than or equal to 20 inches but less than 24 inches (used durable
							 medical equipment)
E2201UEKU
325.09
Manual wheelchair accessory, nonstandard seat frame
							 width, greater than or equal to 20 inches but less than 24 inches
E2202NU
483.23
Manual wheelchair accessory, nonstandard seat frame
							 width, 24 - 27 inches (new equipment)
E2202NUKU
550.63
Manual wheelchair accessory, nonstandard seat frame
							 width, 24 - 27 inches
E2202RR
48.32
Manual wheelchair accessory, nonstandard seat frame
							 width, 24 - 27 inches (rental)
E2202RRKU
55.07
Manual wheelchair accessory, nonstandard seat frame
							 width, 24 - 27 inches
E2202UE
362.44
Manual wheelchair accessory, nonstandard seat frame
							 width, 24 - 27 inches (used durable medical equipment)
E2202UEKU
412.99
Manual wheelchair accessory, nonstandard seat frame
							 width, 24 - 27 inches
E2203NU
468.42
Manual wheelchair accessory, nonstandard seat frame
							 depth, greater than or equal to 20 inches but less than 22 inches (new
							 equipment)
E2203NUKU
556.54
Manual wheelchair accessory, nonstandard seat frame
							 depth, greater than or equal to 20 inches but less than 22 inches
E2203RR
46.84
Manual wheelchair accessory, nonstandard seat frame
							 depth, greater than or equal to 20 inches but less than 22 inches
							 (rental)
E2203RRKU
55.65
Manual wheelchair accessory, nonstandard seat frame
							 depth, greater than or equal to 20 inches but less than 22 inches
E2203UE
351.30
Manual wheelchair accessory, nonstandard seat frame
							 depth, greater than or equal to 20 inches but less than 22 inches (used durable
							 medical equipment)
E2203UEKU
417.37
Manual wheelchair accessory, nonstandard seat frame
							 depth, greater than or equal to 20 inches but less than 22 inches
E2204NU
780.89
Manual wheelchair accessory, nonstandard seat frame
							 depth, 22 - 25 inches (new equipment)
E2204NUKU
944.97
Manual wheelchair accessory, nonstandard seat frame
							 depth, 22 - 25 inches
E2204RR
78.09
Manual wheelchair accessory, nonstandard seat frame
							 depth, 22 - 25 inches (rental)
E2204RRKU
94.51
Manual wheelchair accessory, nonstandard seat frame
							 depth, 22 - 25 inches
E2204UE
585.67
Manual wheelchair accessory, nonstandard seat frame
							 depth, 22 - 25 inches (used durable medical equipment)
E2204UEKU
708.72
Manual wheelchair accessory, nonstandard seat frame
							 depth, 22 - 25 inches
E2205NU
34.19
Manual wheelchair accessory, handrim without
							 projections (includes ergonomic or contoured), any type, replacement only, each
							 (new equipment)
E2205NUKU
37.95
Manual wheelchair accessory, handrim without
							 projections (includes ergonomic or contoured), any type, replacement only,
							 each
E2205RR
3.41
Manual wheelchair accessory, handrim without
							 projections (includes ergonomic or contoured), any type, replacement only, each
							 (rental)
E2205RRKU
3.78
Manual wheelchair accessory, handrim without
							 projections (includes ergonomic or contoured), any type, replacement only,
							 each
E2205UE
25.66
Manual wheelchair accessory, handrim without
							 projections (includes ergonomic or contoured), any type, replacement only, each
							 (used durable medical equipment)
E2205UEKU
28.48
Manual wheelchair accessory, handrim without
							 projections (includes ergonomic or contoured), any type, replacement only,
							 each
E2206NU
40.33
Manual wheelchair accessory, wheel lock assembly,
							 complete, replacement only, each (new equipment)
E2206NUKU
47.25
Manual wheelchair accessory, wheel lock assembly,
							 complete, replacement only each
E2206RR
4.03
Manual wheelchair accessory, wheel lock assembly,
							 complete, replacement only, each (rental)
E2206RRKU
4.70
Manual wheelchair accessory, wheel lock assembly,
							 complete, replacement only each
E2206UE
30.25
Manual wheelchair accessory, wheel lock assembly,
							 complete, replacement only, each (used durable medical equipment)
E2206UEKU
35.44
Manual wheelchair accessory, wheel lock assembly,
							 complete, replacement only each
E2207NU
38.74
Wheelchair accessory, crutch and cane holder, each
							 (new equipment)
E2207NUKU
48.79
Wheelchair accessory, crutch and cane holder, each
							 (new equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2207RR
3.88
Wheelchair accessory, crutch and cane holder, each
							 (rental)
E2207RRKU
4.89
Wheelchair accessory, crutch and cane holder, each
							 (rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2207UE
29.06
Wheelchair accessory, crutch and cane holder, each
							 (used durable medical equipment)
E2207UEKU
36.60
Wheelchair accessory, crutch and cane holder, each
							 (used durable medical equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2208NU
77.79
Wheelchair accessory, cylinder tank carrier, each
							 (new equipment)
E2208NUKU
115.23
Wheelchair accessory, cylinder tank carrier, each
							 (new equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2208RR
7.78
Wheelchair accessory, cylinder tank carrier, each
							 (rental)
E2208RRKU
11.52
Wheelchair accessory, cylinder tank carrier, each
							 (rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2208UE
58.34
Wheelchair accessory, cylinder tank carrier, each
							 (used durable medical equipment)
E2208UEKU
86.42
Wheelchair accessory, cylinder tank carrier, each
							 (used durable medical equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2209NU
92.97
Accessory, arm trough, with or without hand support,
							 each (new equipment)
E2209NUKU
103.95
Accessory, arm trough, with or without hand support,
							 each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2209RR
9.31
Accessory, with or without hand support, arm trough,
							 each (rental)
E2209RRKU
10.41
Accessory, with or without hand support, arm trough,
							 each (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2209UE
69.74
Accessory, arm trough, with or without hand support,
							 each (used durable medical equipment)
E2209UEKU
77.98
Accessory, arm trough, with or without hand support,
							 each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2210NU
5.40
Wheelchair accessory, bearings, any type, replacement
							 only, each (new equipment)
E2210NUKU
6.34
Wheelchair accessory, bearings, any type, replacement
							 only, each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2210RR
0.50
Wheelchair accessory, bearings, any type, replacement
							 only, each (rental)
E2210RRKU
0.54
Wheelchair accessory, bearings, any type, replacement
							 only, each (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2210UE
4.06
Wheelchair accessory, bearings, any type, replacement
							 only, each (used durable medical equipment)
E2210UEKU
4.78
Wheelchair accessory, bearings, any type, replacement
							 only, each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2211NU
38.03
Manual wheelchair accessory, pneumatic propulsion
							 tire, any size, each (new equipment)
E2211NUKU
47.53
Manual wheelchair accessory, pneumatic propulsion
							 tire, any size, each
E2211RR
3.73
Manual wheelchair accessory, pneumatic propulsion
							 tire, any size, each (rental)
E2211RRKU
4.59
Manual wheelchair accessory, pneumatic propulsion
							 tire, any size, each
E2211UE
27.77
Manual wheelchair accessory, pneumatic propulsion
							 tire, any size, each (used durable medical equipment)
E2211UEKU
34.05
Manual wheelchair accessory, pneumatic propulsion
							 tire, any size, each
E2212NU
6.29
Manual wheelchair accessory, tube for pneumatic
							 propulsion tire, any size, each (new equipment)
E2212NUKU
6.82
Manual wheelchair accessory, tube for pneumatic
							 propulsion tire, any size, each
E2212RR
0.65
Manual wheelchair accessory, tube for pneumatic
							 propulsion tire, any size, each (rental)
E2212RRKU
0.73
Manual wheelchair accessory, tube for pneumatic
							 propulsion tire, any size, each
E2212UE
4.73
Manual wheelchair accessory, tube for pneumatic
							 propulsion tire, any size, each (used durable medical equipment)
E2212UEKU
5.13
Manual wheelchair accessory, tube for pneumatic
							 propulsion tire, any size, each
E2213NU
30.93
Manual wheelchair accessory, insert for pneumatic
							 propulsion tire (removable), any type, any size, each (new
							 equipment)
E2213NUKU
35.34
Manual wheelchair accessory, insert for pneumatic
							 propulsion tire, (removable) any size, each
E2213RR
3.10
Manual wheelchair accessory, insert for pneumatic
							 propulsion tire (removable), any type, any size, each (rental)
E2213RRKU
3.55
Manual wheelchair accessory, insert for pneumatic
							 propulsion tire, (removable) any size, each
E2213UE
23.18
Manual wheelchair accessory, insert for pneumatic
							 propulsion tire (removable), any type, any size, each (used durable medical
							 equipment)
E2213UEKU
26.49
Manual wheelchair accessory, insert for pneumatic
							 propulsion tire, (removable) any size, each
E2214NU
35.50
Manual wheelchair accessory, pneumatic caster tire,
							 any size, each (new equipment)
E2214NUKU
41.82
Manual wheelchair accessory, pneumatic caster tire,
							 any size each
E2214RR
3.75
Manual wheelchair accessory, pneumatic caster tire,
							 any size, each (rental)
E2214RRKU
4.59
Manual wheelchair accessory, pneumatic caster tire,
							 any size each
E2214UE
26.62
Manual wheelchair accessory, pneumatic caster tire,
							 any size, each (used durable medical equipment)
E2214UEKU
31.25
Manual wheelchair accessory, pneumatic caster tire,
							 any size each
E2215NU
10.19
Manual wheelchair accessory, tube for pneumatic
							 caster tire, any size, each (new equipment)
E2215NUKU
11.15
Manual wheelchair accessory, tube for pneumatic
							 caster tire, any size each
E2215RR
1.02
Manual wheelchair accessory, tube for pneumatic
							 caster tire, any size, each (rental)
E2215RRKU
1.11
Manual wheelchair accessory, tube for pneumatic
							 caster tire, any size each
E2215UE
7.64
Manual wheelchair accessory, tube for pneumatic
							 caster tire, any size, each (used durable medical equipment)
E2215UEKU
8.35
Manual wheelchair accessory, tube for pneumatic
							 caster tire, any size each
E2216NU
AAC+30%
Manual wheelchair accessory, foam filled propulsion
							 tire, any size, each (new equipment)
E2216NUKU
52.92
Manual wheelchair accessory, foam filled propulsion
							 tire, any size each
E2216RR
I.C.
Manual wheelchair accessory, foam filled propulsion
							 tire, any size, each (rental)
E2216RRKU
5.30
Manual wheelchair accessory, foam filled propulsion
							 tire, any size each
E2216UE
I.C.
Manual wheelchair accessory, foam filled propulsion
							 tire, any size, each (used durable medical equipment)
E2216UEKU
39.68
Manual wheelchair accessory, foam filled propulsion
							 tire, any size each
E2217NU
AAC+30%
Manual wheelchair accessory, foam filled caster tire,
							 any size, each (new equipment)
E2217NUKU
46.83
Manual wheelchair accessory, foam filled caster tire,
							 any size each
E2217RR
I.C.
Manual wheelchair accessory, foam filled caster tire,
							 any size, each (rental)
E2217RRKU
4.68
Manual wheelchair accessory, foam filled caster tire,
							 any size each
E2217UE
I.C.
Manual wheelchair accessory, foam filled caster tire,
							 any size, each (used durable medical equipment)
E2217UEKU
35.13
Manual wheelchair accessory, foam filled caster tire,
							 any size each
E2218NU
AAC+30%
Manual wheelchair accessory, foam propulsion tire,
							 any size, each (new equipment)
E2218NUKU
52.92
Manual wheelchair accessory, foam propulsion tire,
							 any size each
E2218RR
I.C.
Manual wheelchair accessory, foam propulsion tire,
							 any size, each (rental)
E2218RRKU
5.30
Manual wheelchair accessory, foam propulsion tire,
							 any size each
E2218UE
I.C.
Manual wheelchair accessory, foam propulsion tire,
							 any size, each (used durable medical equipment)
E2218UEKU
39.68
Manual wheelchair accessory, foam propulsion tire,
							 any size each
E2219NU
41.68
Manual wheelchair accessory, foam caster tire, any
							 size, each (new equipment)
E2219NUKU
46.83
Manual wheelchair accessory, foam caster tire, any
							 size each
E2219RR
4.16
Manual wheelchair accessory, foam caster tire, any
							 size, each (rental)
E2219RRKU
4.68
Manual wheelchair accessory, foam caster tire, any
							 size each
E2219UE
31.26
Manual wheelchair accessory, foam caster tire, any
							 size, each (used durable medical equipment)
E2219UEKU
35.13
Manual wheelchair accessory, foam caster tire, any
							 size each
E2220NU
29.67
Manual wheelchair accessory, solid (rubber/plastic)
							 propulsion tire, any size, replacement only, each (new equipment)
E2220NUKU
33.15
Manual wheelchair accessory, solid (rubber/plastic)
							 propulsion tire, any size, replacement only, each
E2220RR
2.91
Manual wheelchair accessory, solid (rubber/plastic)
							 propulsion tire, any size, replacement only, each (rental)
E2220RRKU
3.20
Manual wheelchair accessory, solid (rubber/plastic)
							 propulsion tire, any size, replacement only, each
E2220UE
22.49
Manual wheelchair accessory, solid (rubber/plastic)
							 propulsion tire, any size, replacement only, each (used durable medical
							 equipment)
E2220UEKU
25.35
Manual wheelchair accessory, solid (rubber/plastic)
							 propulsion tire, any size, replacement only, each
E2221NU
26.81
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each (new
							 equipment)
E2221NUKU
29.68
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each
E2221RR
2.70
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each (rental)
E2221RRKU
3.01
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each
E2221UE
20.12
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each (used durable medical
							 equipment)
E2221UEKU
22.27
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each
E2222NU
22.15
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size, replacement only, each (new
							 equipment)
E2222NUKU
24.48
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size each
E2222RR
2.20
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size, replacement only, each
							 (rental)
E2222RRKU
2.42
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size each
E2222UE
16.62
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size, replacement only, each (used
							 durable medical equipment)
E2222UEKU
18.36
Manual wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size each
E2224NU
98.55
Manual wheelchair accessory, propulsion wheel
							 excludes tire, any size, replacement only, each (new equipment)
E2224NUKU
113.92
Manual wheelchair accessory, propulsion wheel
							 excludes tire, any size, replacement only, each
E2224RR
10.12
Manual wheelchair accessory, propulsion wheel
							 excludes tire, any size, replacement only, each (rental)
E2224RRKU
11.96
Manual wheelchair accessory, propulsion wheel
							 excludes tire, any size, replacement only, each
E2224UE
73.92
Manual wheelchair accessory, propulsion wheel
							 excludes tire, any size, replacement only, each (used durable medical
							 equipment)
E2224UEKU
85.44
Manual wheelchair accessory, propulsion wheel
							 excludes tire, any size, replacement only, each
E2225NU
18.52
Manual wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only, each (new equipment)
E2225NUKU
20.21
Manual wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only each
E2225RR
1.85
Manual wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only, each (rental)
E2225RRKU
2.01
Manual wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only each
E2225UE
13.88
Manual wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only, each (used durable medical
							 equipment)
E2225UEKU
15.15
Manual wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only each
E2226NU
39.54
Manual wheelchair accessory, caster fork, any size,
							 replacement only, each (new equipment)
E2226NUKU
44.07
Manual wheelchair accessory, caster fork, any size,
							 replacement only each
E2226RR
3.95
Manual wheelchair accessory, caster fork, any size,
							 replacement only, each (rental)
E2226RRKU
4.41
Manual wheelchair accessory, caster fork, any size,
							 replacement only each
E2226UE
29.65
Manual wheelchair accessory, caster fork, any size,
							 replacement only, each (used durable medical equipment)
E2226UEKU
33.06
Manual wheelchair accessory, caster fork, any size,
							 replacement only each
E2227KH
198.84
Manual wheelchair accessory, gear reduction drive
							 wheel, each (capped rental)
E2227KI
198.84
Manual wheelchair accessory, gear reduction drive
							 wheel, each (capped rental)
E2227KJ
149.13
Manual wheelchair accessory, gear reduction drive
							 wheel, each (capped rental)
E2227NU
1,988.40
Manual wheelchair accessory, gear reduction drive
							 wheel, each (new equipment)
E2227UE
1,491.30
Manual wheelchair accessory, gear reduction drive
							 wheel, each (used durable medical equipment)
E2228KH
99.40
Manual wheelchair accessory, wheel braking system and
							 lock, complete, each (capped rental)
E2228KHKU
108.75
Manual wheelchair accessory, wheel braking system and
							 lock, complete, each
E2228KI
99.40
Manual wheelchair accessory, wheel braking system and
							 lock, complete, each (capped rental)
E2228KIKU
108.75
Manual wheelchair accessory, wheel braking system and
							 lock, complete, each
E2228KJ
74.55
Manual wheelchair accessory, wheel braking system and
							 lock, complete, each (capped rental)
E2228KJKU
81.53
Manual wheelchair accessory, wheel braking system and
							 lock, complete, each
E2228NU
994.07
Manual wheelchair accessory, wheel braking system and
							 lock, complete, each (new equipment)
E2228NUKU
1,087.50
Manual wheelchair accessory, wheel braking system and
							 lock, complete, each
E2228UE
745.56
Manual wheelchair accessory, wheel braking system and
							 lock, complete, each (used durable medical equipment)
E2228UEKU
815.62
Manual wheelchair accessory, wheel braking system and
							 lock, complete, each
E2230
AAC+35%
Manual wheelchair accessory, manual standing
							 system
E2231NU
154.15
Manual wheelchair accessory, solid seat support base
							 (replaces sling seat), includes any type mounting hardware (new
							 equipment)
E2231NUKU
178.53
Manual wheelchair accessory, solid seat support base
							 (replaces sling seat), includes any type mounting hardware
E2231RR
15.42
Manual wheelchair accessory, solid seat support base
							 (replaces sling seat), includes any type mounting hardware (rental)
E2231RRKU
17.86
Manual wheelchair accessory, solid seat support base
							 (replaces sling seat), includes any type mounting hardware
E2231UE
115.61
Manual wheelchair accessory, solid seat support base
							 (replaces sling seat), includes any type mounting hardware (used durable
							 medical equipment)
E2231UEKU
133.88
Manual wheelchair accessory, solid seat support base
							 (replaces sling seat), includes any type mounting hardware
E2291
AAC+35%
Back, planar, for pediatric size wheelchair including
							 fixed attaching hardware
E2292
AAC+35%
Seat, planar, for pediatric size wheelchair including
							 fixed attaching hardware
E2293
AAC+35%
Back, contoured, for pediatric size wheelchair
							 including fixed attaching hardware
E2294
AAC+35%
Seat, contoured, for pediatric size wheelchair
							 including fixed attaching hardware
E2295
AAC+35%
Manual wheelchair accessory, for pediatric size
							 wheelchair, dynamic seating frame, allows coordinated movement of multiple
							 positioning features
E2300
AAC+35%
Wheelchair accessory, power seat elevation system,
							 any type
E2301
AAC+35%
Wheelchair accessory, power standing system, any
							 type
E2310KH
105.93
Power wheelchair accessory, electronic connection
							 between wheelchair controller and one power seating system motor, including all
							 related electronics, indicator feature, mechanical function selection switch,
							 and fixed mounting hardware (capped rental)
E2310KHKU
113.50
Power wheelchair accessory, electronic connection
							 between wheelchair controller and one power seating system motor, including all
							 related electronics, indicator feature, mechanical function selection switch,
							 and fixed mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2310KI
105.93
Power wheelchair accessory, electronic connection
							 between wheelchair controller and one power seating system motor, including all
							 related electronics, indicator feature, mechanical function selection switch,
							 and fixed mounting hardware (capped rental)
E2310KIKU
113.50
Power wheelchair accessory, electronic connection
							 between wheelchair controller and one power seating system motor, including all
							 related electronics, indicator feature, mechanical function selection switch,
							 and fixed mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2310KJ
79.45
Power wheelchair accessory, electronic connection
							 between wheelchair controller and one power seating system motor, including all
							 related electronics, indicator feature, mechanical function selection switch,
							 and fixed mounting hardware (capped rental)
E2310KJKU
85.13
Power wheelchair accessory, electronic connection
							 between wheelchair controller and one power seating system motor, including all
							 related electronics, indicator feature, mechanical function selection switch,
							 and fixed mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2310NU
1,059.30
Power wheelchair accessory, electronic connection
							 between wheelchair controller and one power seating system motor, including all
							 related electronics, indicator feature, mechanical function selection switch,
							 and fixed mounting hardware (new equipment)
E2310NUKU
1,135.00
Power wheelchair accessory, electronic connection
							 between wheelchair controller and one power seating system motor, including all
							 related electronics, indicator feature, mechanical function selection switch,
							 and fixed mounting hardware (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2310UE
794.48
Power wheelchair accessory, electronic connection
							 between wheelchair controller and one power seating system motor, including all
							 related electronics, indicator feature, mechanical function selection switch,
							 and fixed mounting hardware (used durable medical equipment)
E2310UEKU
851.25
Power wheelchair accessory, electronic connection
							 between wheelchair controller and one power seating system motor, including all
							 related electronics, indicator feature, mechanical function selection switch,
							 and fixed mounting hardware (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2311KH
214.14
Power wheelchair accessory, electronic connection
							 between wheelchair controller and two or more power seating system motors,
							 including all related electronics, indicator feature, mechanical function
							 selection switch, and fixed mounting hardware (capped rental)
E2311KHKU
229.83
Power wheelchair accessory, electronic connection
							 between wheelchair controller and two or more power seating system motors,
							 including all related electronics, indicator feature, mechanical function
							 selection switch, and fixed mounting hardware (capped rental) \, (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2311KI
214.14
Power wheelchair accessory, electronic connection
							 between wheelchair controller and two or more power seating system motors,
							 including all related electronics, indicator feature, mechanical function
							 selection switch, and fixed mounting hardware (capped rental)
E2311KIKU
229.83
Power wheelchair accessory, electronic connection
							 between wheelchair controller and two or more power seating system motors,
							 including all related electronics, indicator feature, mechanical function
							 selection switch, and fixed mounting hardware (capped rental) \, (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2311KJ
160.61
Power wheelchair accessory, electronic connection
							 between wheelchair controller and two or more power seating system motors,
							 including all related electronics, indicator feature, mechanical function
							 selection switch, and fixed mounting hardware (capped rental) \
E2311KJKU
172.37
Power wheelchair accessory, electronic connection
							 between wheelchair controller and two or more power seating system motors,
							 including all related electronics, indicator feature, mechanical function
							 selection switch, and fixed mounting hardware (capped rental) \, (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2311NU
2,141.40
Power wheelchair accessory, electronic connection
							 between wheelchair controller and two or more power seating system motors,
							 including all related electronics, indicator feature, mechanical function
							 selection switch, and fixed mounting hardware (new equipment)
E2311NUKU
2,298.30
Power wheelchair accessory, electronic connection
							 between wheelchair controller and two or more power seating system motors,
							 including all related electronics, indicator feature, mechanical function
							 selection switch, and fixed mounting hardware (new equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2311UE
1,606.05
Power wheelchair accessory, electronic connection
							 between wheelchair controller and two or more power seating system motors,
							 including all related electronics, indicator feature, mechanical function
							 selection switch, and fixed mounting hardware (used durable medical
							 equipment)
E2311UEKU
1,723.73
Power wheelchair accessory, electronic connection
							 between wheelchair controller and two or more power seating system motors,
							 including all related electronics, indicator feature, mechanical function
							 selection switch, and fixed mounting hardware (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2312KH
214.39
Power wheelchair accessory, hand or chin control,
							 interface, miniproportional remote joystick, proportional, including fixed
							 mounting hardware (capped rental)
E2312KHKC
273.43
Power wheelchair accessory, hand or chin control,
							 interface, miniproportional remote joystick, proportional, including fixed
							 mounting hardware (capped rental) (replacement of special power wheelchair
							 interface)
E2312KI
214.39
Power wheelchair accessory, hand or chin control,
							 interface, miniproportional remote joystick, proportional, including fixed
							 mounting hardware (capped rental)
E2312KIKC
273.43
Power wheelchair accessory, hand or chin control,
							 interface, miniproportional remote joystick, proportional, including fixed
							 mounting hardware (capped rental) (replacement of special power wheelchair
							 interface)
E2312KJ
160.79
Power wheelchair accessory, hand or chin control,
							 interface, mini-proportional remote joystick, proportional, including fixed
							 mounting hardware (capped rental)
E2312KJKC
205.07
Power wheelchair accessory, hand or chin control,
							 interface, mini-proportional remote joystick, proportional, including fixed
							 mounting hardware (capped rental) (replacement of special power wheelchair
							 interface) (
E2312NU
2,143.90
Power wheelchair accessory, hand or chin control,
							 interface, mini-proportional remote joystick, proportional, including fixed
							 mounting hardware (new equipment)
E2312NUKC
2,734.30
Power wheelchair accessory, hand or chin control,
							 interface, mini-proportional remote joystick, proportional, including fixed
							 mounting hardware (new equipment) (replacement of special power wheelchair
							 interface)
E2312UE
1,607.93
Power wheelchair accessory, hand or chin control,
							 interface, mini-proportional remote joystick, proportional, including fixed
							 mounting hardware (used durable medical equipment)
E2312UEKC
2,050.73
Power wheelchair accessory, hand or chin control,
							 interface, mini-proportional remote joystick, proportional, including fixed
							 mounting hardware (used durable medical equipment) (replacement of special
							 power wheelchair interface)
E2313KH
34.06
Power wheelchair accessory, harness for upgrade to
							 expandable controller, including all fasteners, connectors and mounting
							 hardware, each (capped rental)
E2313KI
34.06
Power wheelchair accessory, harness for upgrade to
							 expandable controller, including all fasteners, connectors and mounting
							 hardware, each (capped rental)
E2313KJ
25.55
Power wheelchair accessory, harness for upgrade to
							 expandable controller, including all fasteners, connectors and mounting
							 hardware, each (capped rental)
E2313NU
340.60
Power wheelchair accessory, harness for upgrade to
							 expandable controller, including all fasteners, connectors and mounting
							 hardware, each (new equipment)
E2313UE
255.45
Power wheelchair accessory, harness for upgrade to
							 expandable controller, including all fasteners, connectors and mounting
							 hardware, each (used durable medical equipment)
E2321KH
143.90
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (capped rental)
E2321KHKC
191.51
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (capped rental) (replacement of special
							 power wheelchair interface)
E2321KHKU
251.12
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (capped rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E2321KI
143.90
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (capped rental)
E2321KIKC
191.51
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (capped rental) (replacement of special
							 power wheelchair interface)
E2321KIKU
251.12
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (capped rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E2321KJ
107.93
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (capped rental)
E2321KJKC
143.63
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (capped rental) (replacement of special
							 power wheelchair interface)
E2321KJKU
188.34
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (capped rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E2321NU
1,439.00
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (new equipment)
E2321NUKC
1,915.10
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (new equipment) (replacement of special
							 power wheelchair interface)
E2321NUKU
2,511.20
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (new equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E2321UE
1,079.25
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (used durable medical
							 equipment)
E2321UEKC
1,436.33
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (used durable medical equipment)
							 (replacement of special power wheelchair interface)
E2321UEKU
1,883.40
Power wheelchair accessory, hand control interface,
							 remote joystick, nonproportional, including all related electronics, mechanical
							 stop switch and fixed mounting hardware (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2322KH
131.60
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (capped
							 rental)
E2322KHKC
195.01
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (capped rental)
							 (replacement of special power wheelchair interface)
E2322KHKU
265.91
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (capped
							 rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2322KI
131.60
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (capped
							 rental)
E2322KIKC
195.01
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (capped rental)
							 (replacement of special power wheelchair interface)
E2322KIKU
265.91
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (capped
							 rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2322KJ
98.70
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (capped
							 rental)
E2322KJKC
146.26
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (capped rental)
							 (replacement of special power wheelchair interface)
E2322KJKU
199.43
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (capped
							 rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2322NU
1,316.00
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (new
							 equipment)
E2322NUKC
1,950.10
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (new equipment)
							 (replacement of special power wheelchair interface)
E2322NUKU
2,659.10
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2322UE
987.00
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (used durable
							 medical equipment)
E2322UEKC
1,462.58
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (used durable
							 medical equipment) (replacement of special power wheelchair
							 interface)
E2322UEKU
1,994.33
Power wheelchair accessory, hand control interface,
							 multiple mechanical switches, nonproportional, including all related
							 electronics, mechanical stop switch and fixed mounting hardware (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2323NU
64.35
Power wheelchair accessory, specialty joystick handle
							 for hand control interface, prefabricated (new equipment)
E2323NUKU
67.10
Power wheelchair accessory, specialty joystick handle
							 for hand control interface, prefabricated (new equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E2323RR
6.43
Power wheelchair accessory, specialty joystick handle
							 for hand control interface, prefabricated (rental)
E2323RRKU
6.70
Power wheelchair accessory, specialty joystick handle
							 for hand control interface, prefabricated (rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2323UE
48.26
Power wheelchair accessory, specialty joystick handle
							 for hand control interface, prefabricated (used durable medical
							 equipment)
E2323UEKU
50.31
Power wheelchair accessory, specialty joystick handle
							 for hand control interface, prefabricated (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2324NU
41.61
Power wheelchair accessory, chin cup for chin control
							 interface (new equipment)
E2324NUKU
42.50
Power wheelchair accessory, chin cup for chin control
							 interface (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2324RR
4.15
Power wheelchair accessory, chin cup for chin control
							 interface (rental)
E2324RRKU
4.23
Power wheelchair accessory, chin cup for chin control
							 interface (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2324UE
31.20
Power wheelchair accessory, chin cup for chin control
							 interface (used durable medical equipment)
E2324UEKU
31.88
Power wheelchair accessory, chin cup for chin control
							 interface (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2325KH
125.74
Power wheelchair accessory, sip and puff interface,
							 nonproportional, including all related electronics, mechanical stop switch, and
							 manual SwingAway mounting hardware (rental)
E2325KHKU
130.66
Power wheelchair accessory, sip and puff interface,
							 nonproportional, including all related electronics, mechanical stop switch, and
							 manual SwingAway mounting hardware (rental) (for Medicare billing only),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2325KI
125.74
Power wheelchair accessory, sip and puff interface,
							 nonproportional, including all related electronics, mechanical stop switch, and
							 manual SwingAway mounting hardware (rental)
E2325KIKU
130.66
Power wheelchair accessory, sip and puff interface,
							 nonproportional, including all related electronics, mechanical stop switch, and
							 manual SwingAway mounting hardware (rental) (for Medicare billing only),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2325KJ
94.31
Power wheelchair accessory, sip and puff interface,
							 nonproportional, including all related electronics, mechanical stop switch, and
							 manual SwingAway mounting hardware (rental)
E2325KJKU
98.00
Power wheelchair accessory, sip and puff interface,
							 nonproportional, including all related electronics, mechanical stop switch, and
							 manual SwingAway mounting hardware (rental) (for Medicare billing only),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2325NU
1,257.40
Power wheelchair accessory, sip and puff interface,
							 nonproportional, including all related electronics, mechanical stop switch, and
							 manual swingaway mounting hardware (new equipment)
E2325NUKU
1,306.60
Power wheelchair accessory, sip and puff interface,
							 nonproportional, including all related electronics, mechanical stop switch, and
							 manual swingaway mounting hardware (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2325UE
943.05
Power wheelchair accessory, sip and puff interface,
							 nonproportional, including all related electronics, mechanical stop switch, and
							 manual swingaway mounting hardware (used durable medical equipment)
E2325UEKU
979.95
Power wheelchair accessory, sip and puff interface,
							 nonproportional, including all related electronics, mechanical stop switch, and
							 manual swingaway mounting hardware (used durable medical equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2326KH
32.69
Power wheelchair accessory, breath tube kit for sip
							 and puff interface (capped rental)
E2326KHKU
33.69
Power wheelchair accessory, breath tube kit for sip
							 and puff interface (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2326KI
32.69
Power wheelchair accessory, breath tube kit for sip
							 and puff interface (capped rental)
E2326KIKU
33.69
Power wheelchair accessory, breath tube kit for sip
							 and puff interface (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2326KJ
24.52
Power wheelchair accessory, breath tube kit for sip
							 and puff interface (capped rental)
E2326KJKU
25.27
Power wheelchair accessory, breath tube kit for sip
							 and puff interface (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2326NU
326.90
Power wheelchair accessory, breath tube kit for sip
							 and puff interface (new equipment)
E2326NUKU
336.90
Power wheelchair accessory, breath tube kit for sip
							 and puff interface (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2326UE
245.18
Power wheelchair accessory, breath tube kit for sip
							 and puff interface (used durable medical equipment)
E2326UEKU
252.68
Power wheelchair accessory, breath tube kit for sip
							 and puff interface (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2327KH
244.88
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (capped
							 rental)
E2327KHKC
309.51
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (capped rental)
							 (replacement of special power wheelchair interface)
E2327KHKU
385.00
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (capped rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2327KI
244.88
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (capped
							 rental)
E2327KIKC
309.51
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (capped rental)
							 (replacement of special power wheelchair interface)
E2327KIKU
385.00
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (capped rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2327KJ
183.66
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (capped
							 rental)
E2327KJKC
232.13
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (capped rental)
							 (replacement of special power wheelchair interface)
E2327KJKU
288.75
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (capped rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2327NU
2,448.80
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (new
							 equipment)
E2327NUKC
3,095.10
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (new equipment)
							 (replacement of special power wheelchair interface)
E2327NUKU
3,850.00
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (new equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2327UE
1,836.60
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (used durable medical
							 equipment)
E2327UEKC
2,321.33
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (used durable medical
							 equipment) (replacement of special power wheelchair interface)
E2327UEKU
2,887.50
Power wheelchair accessory, head control interface,
							 mechanical proportional, including all related electronics, mechanical
							 direction change switch, and fixed mounting hardware (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2328KH
463.38
Power wheelchair accessory, head control or extremity
							 control interface, electronic, proportional, including all related electronics,
							 and fixed mounting hardware (capped rental)
E2328KHKU
480.69
Power wheelchair accessory, head control or extremity
							 control interface, electronic, proportional, including all related electronics,
							 and fixed mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2328KI
463.38
Power wheelchair accessory, head control or extremity
							 control interface, electronic, proportional, including all related electronics,
							 and fixed mounting hardware (capped rental)
E2328KIKU
480.69
Power wheelchair accessory, head control or extremity
							 control interface, electronic, proportional, including all related electronics,
							 and fixed mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2328KJ
347.54
Power wheelchair accessory, head control or extremity
							 control interface, electronic, proportional, including all related electronics,
							 and fixed mounting hardware (capped rental)
E2328KJKU
360.52
Power wheelchair accessory, head control or extremity
							 control interface, electronic, proportional, including all related electronics,
							 and fixed mounting hardware (capped rental), (DMEPOS item
E2328NU
4,633.80
Power wheelchair accessory, head control or extremity
							 control interface, electronic, proportional, including all related electronics,
							 and fixed mounting hardware (new equipment)
E2328NUKU
4,806.90
Power wheelchair accessory, head control or extremity
							 control interface, electronic, proportional, including all related electronics,
							 and fixed mounting hardware (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2328UE
3,475.35
Power wheelchair accessory, head control or extremity
							 control interface, electronic, proportional, including all related electronics,
							 and fixed mounting hardware (used durable medical equipment)
E2328UEKU
3,605.18
Power wheelchair accessory, head control or extremity
							 control interface, electronic, proportional, including all related electronics,
							 and fixed mounting hardware (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2329KH
166.22
Power wheelchair accessory, head control interface,
							 contact switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental)
E2329KHKU
171.32
Power wheelchair accessory, head control interface,
							 contact switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2329KI
166.22
Power wheelchair accessory, head control interface,
							 contact switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental)
E2329KIKU
171.32
Power wheelchair accessory, head control interface,
							 contact switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2329KJ
124.67
Power wheelchair accessory, head control interface,
							 contact switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental)
E2329KJKU
128.49
Power wheelchair accessory, head control interface,
							 contact switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2329NU
1,662.20
Power wheelchair accessory, head control interface,
							 contact switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (new equipment)
E2329NUKU
1,713.20
Power wheelchair accessory, head control interface,
							 contact switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2329UE
1,246.65
Power wheelchair accessory, head control interface,
							 contact switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (used durable medical equipment)
E2329UEKU
1,284.90
Power wheelchair accessory, head control interface,
							 contact switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (used durable medical equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E2330KH
320.63
Power wheelchair accessory, head control interface,
							 proximity switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental)
E2330KHKU
331.95
Power wheelchair accessory, head control interface,
							 proximity switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2330KI
320.63
Power wheelchair accessory, head control interface,
							 proximity switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental)
E2330KIKU
331.95
Power wheelchair accessory, head control interface,
							 proximity switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2330KJ
240.47
Power wheelchair accessory, head control interface,
							 proximity switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental)
E2330KJKU
248.96
Power wheelchair accessory, head control interface,
							 proximity switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2330NU
3,206.30
Power wheelchair accessory, head control interface,
							 proximity switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (new equipment)
E2330NUKU
3,319.50
Power wheelchair accessory, head control interface,
							 proximity switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2330UE
2,404.73
Power wheelchair accessory, head control interface,
							 proximity switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (used durable medical equipment)
E2330UEKU
2,489.63
Power wheelchair accessory, head control interface,
							 proximity switch mechanism, nonproportional, including all related electronics,
							 mechanical stop switch, mechanical direction change switch, head array, and
							 fixed mounting hardware (used durable medical equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E2331NU
AAC+35%
Power wheelchair accessory, attendant control,
							 proportional, including all related electronics and fixed mounting hardware
							 (new equipment)
E2331RR
I.C.
Power wheelchair accessory, attendant control,
							 proportional, including all related electronics and fixed mounting hardware
							 (rental)
E2331UE
I.C.
Power wheelchair accessory, attendant control,
							 proportional, including all related electronics and fixed mounting hardware
							 (used durable mental medical equipment)
E2340NU
396.17
Power wheelchair accessory, nonstandard seat frame
							 width, 20 - 23 inches (new equipment)
E2340RR
39.63
Power wheelchair accessory, nonstandard seat frame
							 width, 20 - 23 inches (rental)
E2340UE
297.16
Power wheelchair accessory, nonstandard seat frame
							 width, 20 - 23 inches (used durable medical equipment)
E2341NU
594.30
Power wheelchair accessory, nonstandard seat frame
							 width, 24 - 27 inches (new equipment)
E2341RR
59.42
Power wheelchair accessory, nonstandard seat frame
							 width, 24 - 27 inches (rental)
E2341UE
445.73
Power wheelchair accessory, nonstandard seat frame
							 width, 24 - 27 inches (used durable medical equipment)
E2342NU
495.25
Power wheelchair accessory, nonstandard seat frame
							 depth, 20 - 21 inches (new equipment)
E2342RR
49.52
Power wheelchair accessory, nonstandard seat frame
							 depth, 20 - 21 inches (rental)
E2342UE
371.45
Power wheelchair accessory, nonstandard seat frame
							 depth, 20 - 21 inches (used durable medical equipment)
E2343NU
792.41
Power wheelchair accessory, nonstandard seat frame
							 depth, 22 - 25 inches (new equipment)
E2343RR
79.23
Power wheelchair accessory, nonstandard seat frame
							 depth, 22 - 25 inches (rental)
E2343UE
594.30
Power wheelchair accessory, nonstandard seat frame
							 depth, 22 - 25 inches (used durable medical equipment)
E2351NU
659.43
Power wheelchair accessory, electronic interface to
							 operate speech generating device using power wheelchair control interface (new
							 equipment)
E2351NUKU
677.72
Power wheelchair accessory, electronic interface to
							 operate speech generating device using power wheelchair control interface (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2351RR
65.94
Power wheelchair accessory, electronic interface to
							 operate speech generating device using power wheelchair control interface
							 (rental)
E2351RRKU
67.80
Power wheelchair accessory, electronic interface to
							 operate speech generating device using power wheelchair control interface
							 (rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2351UE
494.58
Power wheelchair accessory, electronic interface to
							 operate speech generating device using power wheelchair control interface (used
							 durable medical equipment)
E2351UEKU
508.27
Power wheelchair accessory, electronic interface to
							 operate speech generating device using power wheelchair control interface (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2358NU
AAC+35%
Power wheelchair accessory, group 34 non-sealed lead
							 acid battery, each (new equipment)
E2358RR
I.C.
Power wheelchair accessory, group 34 non-sealed lead
							 acid battery, each (rental)
E2358UE
I.C.
Power wheelchair accessory, group 34 non-sealed lead
							 acid battery, each (used durable medical equipment)
E2359NU
177.83
Power wheelchair accessory, group 34 sealed lead acid
							 battery, each (
e.g.
, Gel cell, absorbed glassmat) (new
							 equipment)
E2359NUKU
188.44
Power wheelchair accessory, group 34 sealed lead acid
							 battery, each (
e.g.
Gel cell, absorbed glassmat) (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2359RR
17.78
Power wheelchair accessory, group 34 sealed lead acid
							 battery, each (
e.g.
, Gel cell, absorbed glassmat)
							 (rental)
E2359RRKU
18.85
Power wheelchair accessory, group 34 sealed lead acid
							 battery, each (
e.g.
Gel cell, absorbed glassmat) (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2359UE
133.38
Power wheelchair accessory, group 34 sealed lead acid
							 battery, each (
e.g.
, Gel cell, absorbed glassmat) (used
							 durable medical equipment)
E2359UEKU
141.33
Power wheelchair accessory, group 34 sealed lead acid
							 battery, each (
e.g.
Gel cell, absorbed glassmat) (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2360NU
113.10
Power wheelchair accessory, 22 NF non-sealed lead
							 acid battery, each (new equipment)
E2360NUKU
126.45
Power wheelchair accessory, 22 NF non-sealed lead
							 acid battery, each (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2360RR
11.34
Power wheelchair accessory, 22 NF non-sealed lead
							 acid battery, each (rental)
E2360RRKU
12.71
Power wheelchair accessory, 22 NF non-sealed lead
							 acid battery, each (rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2360UE
84.82
Power wheelchair accessory, 22 NF non-sealed lead
							 acid battery, each (used durable medical equipment)
E2360UEKU
94.82
Power wheelchair accessory, 22 NF non-sealed lead
							 acid battery, each (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2361NU
120.25
Power wheelchair accessory, 22 NF sealed lead acid
							 battery, each, (
e.g.
, gel cell, absorbed glassmat) (new
							 equipment)
E2361NUKU
135.29
Power wheelchair accessory, 22 NF sealed lead acid
							 battery, each, (
e.g.
gel cell, absorbed glassmat) (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2361RR
12.02
Power wheelchair accessory, 22 NF sealed lead acid
							 battery, each, (
e.g.
, gel cell, absorbed glassmat)
							 (rental)
E2361RRKU
13.53
Power wheelchair accessory, 22 NF sealed lead acid
							 battery, each, (
e.g.
gel cell, absorbed glassmat) (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2361UE
90.20
Power wheelchair accessory, 22 NF sealed lead acid
							 battery, each, (
e.g.
, gel cell, absorbed glassmat) (used
							 durable medical equipment)
E2361UEKU
101.49
Power wheelchair accessory, 22 NF sealed lead acid
							 battery, each, (
e.g.
gel cell, absorbed glassmat) (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2362NU
96.25
Power wheelchair accessory, group 24 non-sealed lead
							 acid battery, each (new equipment)
E2362NUKU
103.53
Power wheelchair accessory, group 24 non-sealed lead
							 acid battery, each (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2362RR
9.62
Power wheelchair accessory, group 24 non-sealed lead
							 acid battery, each (rental)
E2362RRKU
10.35
Power wheelchair accessory, group 24 non-sealed lead
							 acid battery, each (rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2362UE
72.18
Power wheelchair accessory, group 24 non-sealed lead
							 acid battery, each (used durable medical equipment)
E2362UEKU
77.63
Power wheelchair accessory, group 24 non-sealed lead
							 acid battery, each (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2363NU
157.57
Power wheelchair accessory, group 24 sealed lead acid
							 battery, each (
e.g.
gel cell, absorbed glassmat) (new
							 equipment)
E2363NUKU
180.44
Power wheelchair accessory, group 24 sealed lead acid
							 battery, each (
e.g.
gel cell, absorbed glassmat) (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2363RR
15.75
Power wheelchair accessory, group 24 sealed lead acid
							 battery, each (
e.g.
, gel cell, absorbed glassmat)
							 (rental)
E2363RRKU
18.04
Power wheelchair accessory, group 24 sealed lead acid
							 battery, each (
e.g.
gel cell, absorbed glassmat) (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2363UE
118.18
Power wheelchair accessory, group 24 sealed lead acid
							 battery, each (
e.g.
, gel cell, absorbed glassmat) (used
							 durable medical equipment)
E2363UEKU
135.32
Power wheelchair accessory, group 24 sealed lead acid
							 battery, each (
e.g.
gel cell, absorbed glassmat) (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2364NU
107.09
Power wheelchair accessory, u-1 non-sealed lead acid
							 battery, each (new equipment)
E2364NUKU
126.45
Power wheelchair accessory, u-1 non-sealed lead acid
							 battery, each (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2364RR
10.74
Power wheelchair accessory, u-1 non-sealed lead acid
							 battery, each (rental)
E2364RRKU
12.71
Power wheelchair accessory, u-1 non-sealed lead acid
							 battery, each (rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2364UE
80.31
Power wheelchair accessory, u-1 non-sealed lead acid
							 battery, each (used durable medical equipment)
E2364UEKU
94.82
Power wheelchair accessory, u-1 non-sealed lead acid
							 battery, each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2365NU
88.76
Power wheelchair accessory, u-1 sealed lead acid
							 battery, each (
e.g.
, gel cell, absorbed glassmat) (new
							 equipment)
E2365NUKU
108.81
Power wheelchair accessory, u-1 sealed lead acid
							 battery, each (
e.g.
gel cell, absorbed glassmat) (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2365RR
8.87
Power wheelchair accessory, u-1 sealed lead acid
							 battery, each (
e.g.
, gel cell, absorbed glassmat)
							 (rental)
E2365RRKU
10.87
Power wheelchair accessory, u-1 sealed lead acid
							 battery, each (
e.g.
gel cell, absorbed glassmat) (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2365UE
66.58
Power wheelchair accessory, u-1 sealed lead acid
							 battery, each (
e.g.
, gel cell, absorbed glassmat) (used
							 durable medical equipment)
E2365UEKU
81.64
Power wheelchair accessory, u-1 sealed lead acid
							 battery, each (
e.g.
gel cell, absorbed glassmat) (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2366NU
198.25
Power wheelchair accessory, battery charger, single
							 mode, for use with only one battery type, sealed or non-sealed, each (new
							 equipment)
E2366NUKU
255.73
Power wheelchair accessory, battery charger, single
							 mode, for use with only one battery type, sealed or non-sealed, each (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2366RR
19.86
Power wheelchair accessory, battery charger, single
							 mode, for use with only one battery type, sealed or non-sealed, each
							 (rental)
E2366RRKU
25.65
Power wheelchair accessory, battery charger, single
							 mode, for use with only one battery type, sealed or non-sealed, each (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2366UE
148.69
Power wheelchair accessory, battery charger, single
							 mode, for use with only one battery type, sealed or non-sealed, each (used
							 durable medical equipment)
E2366UEKU
191.81
Power wheelchair accessory, battery charger, single
							 mode, for use with only one battery type, sealed or non-sealed, each (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2367NU
346.96
Power wheelchair accessory, battery charger, dual
							 mode, for use with either battery type, sealed or non-sealed, each (new
							 equipment)
E2367NUKU
406.53
Power wheelchair accessory, battery charger, dual
							 mode, for use with either battery type, sealed or non-sealed, each (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2367RR
34.70
Power wheelchair accessory, battery charger, dual
							 mode, for use with either battery type, sealed or non-sealed, each
							 (rental)
E2367RRKU
40.65
Power wheelchair accessory, battery charger, dual
							 mode, for use with either battery type, sealed or non-sealed, each (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2367UE
260.23
Power wheelchair accessory, battery charger, dual
							 mode, for use with either battery type, sealed or non-sealed, each (used
							 durable medical equipment)
E2367UEKU
304.91
Power wheelchair accessory, battery charger, dual
							 mode, for use with either battery type, sealed or non-sealed, each (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2368KH
42.63
Power wheelchair component, drive wheel motor,
							 replacement only (capped rental)
E2368KHKU
50.11
Power wheelchair component, drive wheel motor,
							 replacement only (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2368KI
42.63
Power wheelchair component, drive wheel motor,
							 replacement only (capped rental)
E2368KIKU
50.11
Power wheelchair component, drive wheel motor,
							 replacement only (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2368KJ
31.97
Power wheelchair component, drive wheel motor,
							 replacement only (capped rental)
E2368KJKU
37.58
(Power wheelchair component, drive wheel motor,
							 replacement only capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2368NU
426.25
Power wheelchair component, drive wheel motor,
							 replacement only (new equipment)
E2368NUKU
501.10
Power wheelchair component, drive wheel motor,
							 replacement only (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2368UE
319.69
Power wheelchair component, drive wheel motor,
							 replacement only (used durable medical equipment)
E2368UEKU
375.83
Power wheelchair component, drive wheel motor,
							 replacement only (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2369KH
37.75
Power wheelchair component, drive wheel gear box,
							 replacement only (capped rental)
E2369KHKU
43.67
Power wheelchair component, drive wheel gear box,
							 replacement only (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2369KI
37.75
Power wheelchair component, drive wheel gear box,
							 replacement only (capped rental)
E2369KIKU0
43.67
Power wheelchair component, drive wheel gear box,
							 replacement only (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2369KJ
28.31
Power wheelchair component, drive wheel gear box,
							 replacement only (capped rental) (for Medicare billing only)
E2369KJKU
32.75
Power wheelchair component, drive wheel gear box,
							 replacement only (capped rental) (for Medicare billing only), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2369NU
377.37
Power wheelchair component, drive wheel gear box,
							 replacement only (new equipment)
E2369NUKU
436.70
Power wheelchair component, drive wheel gear box,
							 replacement only (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2369UE
283.03
Power wheelchair component, drive wheel gear box,
							 replacement only (used durable medical equipment)
E2369UEKU
327.53
Power wheelchair component, drive wheel gear box,
							 replacement only (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2370KH
65.60
Power wheelchair component, integrated drive wheel
							 motor and gear box combination, replacement only (capped rental)
E2370KHKU
77.89
Power wheelchair component, integrated drive wheel
							 motor and gear box combination, replacement only (capped rental), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2370KI
65.60
Power wheelchair component, integrated drive wheel
							 motor and gear box combination, replacement only (capped rental)
E2370KIKU
77.89
Power wheelchair component, integrated drive wheel
							 motor and gear box combination, replacement only (capped rental), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2370KJ
49.20
Power wheelchair component, integrated drive wheel
							 motor and gear box combination, replacement only (capped rental)
E2370KJKU
58.42
Power wheelchair component, integrated drive wheel
							 motor and gear box combination, replacement only (capped rental), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2370NU
655.96
Power wheelchair component, integrated drive wheel
							 motor and gear box combination, replacement only
E2370NUKU
778.90
Power wheelchair component, integrated drive wheel
							 motor and gear box combination, replacement only, (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2370UE
491.97
Power wheelchair component, integrated drive wheel
							 motor and gear box combination, replacement only (used durable medical
							 equipment)
E2370UEKU
584.18
Power wheelchair component, integrated drive wheel
							 motor and gear box combination, replacement only (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2371NU
135.77
Power wheelchair accessory, group 27 sealed lead acid
							 battery, (
e.g.
, gel cell, absorbed glassmat), each (new
							 equipment)
E2371NUKU
146.23
Power wheelchair accessory, group 27 sealed lead acid
							 battery, (
e.g.
, gel cell, absorbed glassmat), each (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2371RR
13.58
Power wheelchair accessory, group 27 sealed lead acid
							 battery, (
e.g.
, gel cell, absorbed glassmat), each
							 (rental)
E2371RRKU
14.63
Power wheelchair accessory, group 27 sealed lead acid
							 battery, (
e.g.
, gel cell, absorbed glassmat), each (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2371UE
101.84
Power wheelchair accessory, group 27 sealed lead acid
							 battery, (
e.g.
, gel cell, absorbed glassmat), each (used
							 durable medical equipment)
E2371UEKU
109.68
Power wheelchair accessory, group 27 sealed lead acid
							 battery, (
e.g.
, gel cell, absorbed glassmat), each (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2372NU
AAC+35%
Power wheelchair accessory, group 27 nonsealed lead
							 acid battery, each (new equipment)
E2372RR
I.C.
Power wheelchair accessory, group 27 nonsealed lead
							 acid battery, each (rental)
E2372UE
I.C.
Power wheelchair accessory, group 27 nonsealed lead
							 acid battery, each (used durable medical equipment)
E2373KH
74.74
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (capped rental)
E2373KHKC
114.06
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (capped rental) (replacement of special power wheelchair
							 interface)
E2373KHKU
117.40
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (capped rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2373KI
74.74
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (capped rental)
E2373KIKC
114.06
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (capped rental) (replacement of special power wheelchair
							 interface)
E2373KIKU
117.40
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (capped rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2373KJ
56.06
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (capped rental)
E2373KJKC
85.55
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (capped rental) (replacement of special power wheelchair
							 interface)
E2373KJKU
88.05
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (capped rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2373NU
747.40
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (new equipment)
E2373NUKC
1,140.60
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (new equipment) (replacement of special power wheelchair
							 interface)
E2373NUKU
1,174.00
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2373UE
560.55
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (used durable medical equipment)
E2373UEKC
855.45
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (used durable medical equipment) (replacement of special power
							 wheelchair interface)
E2373UEKU
880.50
Power wheelchair accessory, hand or chin control
							 interface, compact remote joystick, proportional, including fixed mounting
							 hardware (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2374KH
48.57
Power wheelchair accessory, hand or chin control
							 interface, standard remote joystick (not including controller), proportional,
							 including all related electronics and fixed mounting hardware, replacement only
							 (capped rental)
E2374KHKU
51.82
Power wheelchair accessory, hand or chin control
							 interface, standard remote joystick (not including controller), proportional,
							 including all related electronics and fixed mounting hardware, replacement only
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2374KI
48.57
Power wheelchair accessory, hand or chin control
							 interface, standard remote joystick (not including controller), proportional,
							 including all related electronics and fixed mounting hardware, replacement only
							 (capped rental)
E2374KIKU
51.82
Power wheelchair accessory, hand or chin control
							 interface, standard remote joystick (not including controller), proportional,
							 including all related electronics and fixed mounting hardware, replacement only
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2374KJ
36.43
Power wheelchair accessory, hand or chin control
							 interface, standard remote joystick (not including controller), proportional,
							 including all related electronics and fixed mounting hardware, replacement only
							 (capped rental)
E2374KJKU
38.87
Power wheelchair accessory, hand or chin control
							 interface, standard remote joystick (not including controller), proportional,
							 including all related electronics and fixed mounting hardware, replacement only
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2374NU
485.70
Power wheelchair accessory, hand or chin control
							 interface, standard remote joystick (not including controller), proportional,
							 including all related electronics and fixed mounting hardware, replacement only
							 (new equipment)
E2374NUKU
518.20
Power wheelchair accessory, hand or chin control
							 interface, standard remote joystick (not including controller), proportional,
							 including all related electronics and fixed mounting hardware, replacement only
							 (new equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2374UE
364.28
Power wheelchair accessory, hand or chin control
							 interface, standard remote joystick (not including controller), proportional,
							 including all related electronics and fixed mounting hardware, replacement only
							 (used durable medical equipment)
E2374UEKU
388.65
Power wheelchair accessory, hand or chin control
							 interface, standard remote joystick (not including controller), proportional,
							 including all related electronics and fixed mounting hardware, replacement only
							 (used durable medical equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2375KH
74.72
Power wheelchair accessory, non-expandable
							 controller, including all related electronics and mounting hardware,
							 replacement only (capped rental)
E2375KHKU
83.07
Power wheelchair accessory, non-expandable
							 controller, including all related electronics and mounting hardware,
							 replacement only (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2375KI
74.72
Power wheelchair accessory, non-expandable
							 controller, including all related electronics and mounting hardware,
							 replacement only (capped rental)
E2375KIKU
83.07
Power wheelchair accessory, non-expandable
							 controller, including all related electronics and mounting hardware,
							 replacement only (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2375KJ
56.04
Power wheelchair accessory, non-expandable
							 controller, including all related electronics and mounting hardware,
							 replacement only (capped rental)
E2375KJKU
62.30
Power wheelchair accessory, non-expandable
							 controller, including all related electronics and mounting hardware,
							 replacement only (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2375NU
747.30
Power wheelchair accessory, non-expandable
							 controller, including all related electronics and mounting hardware,
							 replacement only (new equipment)
E2375NUKU
830.70
Power wheelchair accessory, non-expandable
							 controller, including all related electronics and mounting hardware,
							 replacement only (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2375UE
560.47
Power wheelchair accessory, non-expandable
							 controller, including all related electronics and mounting hardware,
							 replacement only (used durable medical equipment)
E2375UEKU
623.03
Power wheelchair accessory, non-expandable
							 controller, including all related electronics and mounting hardware,
							 replacement only (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2376KH
121.39
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, replacement only
							 (capped rental)
E2376KHKU
130.22
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, replacement only
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2376KI
121.39
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, replacement only
							 (capped rental)
E2376KIKU
130.22
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, replacement only
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2376KJ
91.04
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, replacement only
							 (capped rental)
E2376KJKU
97.67
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, replacement only
							 (capped rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2376NU
1,213.90
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, replacement only (new
							 equipment)
E2376NUKU
1,302.20
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, replacement only (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2376UE
910.43
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, replacement only (used
							 durable medical equipment)
E2376UEKU
976.65
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, replacement only (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2377KH
45.77
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, upgrade provided at
							 initial issue (capped rental)
E2377KHKU
47.10
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, upgrade provided at
							 initial issue (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2377KI
45.77
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, upgrade provided at
							 initial issue (capped rental)
E2377KIKU
47.10
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, upgrade provided at
							 initial issue (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2377KJ
34.33
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, upgrade provided at
							 initial issue (capped rental)
E2377KJKU
35.33
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, upgrade provided at
							 initial issue (capped rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2377NU
444.20
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, upgrade provided at
							 initial issue (new equipment)
E2377NUKU
471.00
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, upgrade provided at
							 initial issue (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2377UE
333.15
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, upgrade provided at
							 initial issue (used durable medical equipment)
E2377UEKU
353.25
Power wheelchair accessory, expandable controller,
							 including all related electronics and mounting hardware, upgrade provided at
							 initial issue (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2378KH
56.57
Power wheelchair component, actuator, replacement
							 only (rental)
E2378KHKU
57.60
Power wheelchair component, actuator, replacement
							 only (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2378KI
56.57
Power wheelchair component, actuator, replacement
							 only (rental)
E2378KIKU
57.60
Power wheelchair component, actuator, replacement
							 only (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2378KJ
42.43
Power wheelchair component, actuator, replacement
							 only (rental)
E2378KJKU
43.20
Power wheelchair component, actuator, replacement
							 only (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2378NU
565.70
Power wheelchair component, actuator, replacement
							 only (new equipment purchase)
E2378NUKU
576.00
Power wheelchair component, actuator, replacement
							 only (new equipment purchase), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2378UE
424.28
Power wheelchair component, actuator, replacement
							 only (used durable medical equipment purchase)
E2378UEKU
432.00
Power wheelchair component, actuator, replacement
							 only (used durable medical equipment purchase), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2381NU
63.25
Power wheelchair accessory, pneumatic drive wheel
							 tire, any size, replacement only, each (new equipment)
E2381NUKU
73.89
Power wheelchair accessory, pneumatic drive wheel
							 tire, any size, replacement only, each (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2381RR
6.34
Power wheelchair accessory, pneumatic drive wheel
							 tire, any size, replacement only, each (rental)
E2381RRKU
7.41
Power wheelchair accessory, pneumatic drive wheel
							 tire, any size, replacement only, each (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2381UE
47.45
Power wheelchair accessory, pneumatic drive wheel
							 tire, any size, replacement only, each (used durable medical
							 equipment)
E2381UEKU
55.42
Power wheelchair accessory, pneumatic drive wheel
							 tire, any size, replacement only, each (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2382NU
18.32
Power wheelchair accessory, tube for pneumatic drive
							 wheel tire, any size, replacement only, each (new equipment)
E2382NUKU
20.14
Power wheelchair accessory, tube for pneumatic drive
							 wheel tire, any size, replacement only, each (new equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2382RR
1.83
Power wheelchair accessory, tube for pneumatic drive
							 wheel tire, any size, replacement only, each (rental)
E2382RRKU
2.00
Power wheelchair accessory, tube for pneumatic drive
							 wheel tire, any size, replacement only, each (rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2382UE
13.75
Power wheelchair accessory, tube for pneumatic drive
							 wheel tire, any size, replacement only, each (used durable medical
							 equipment)
E2382UEKU
15.11
Power wheelchair accessory, tube for pneumatic drive
							 wheel tire, any size, replacement only, each (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2383NU
127.85
Power wheelchair accessory, insert for pneumatic
							 drive wheel tire (removable), any type, any size, replacement only, each (new
							 equipment)
E2383NUKU
147.33
Power wheelchair accessory, insert for pneumatic
							 drive wheel tire (removable), any type, any size, replacement only, each (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2383RR
12.79
Power wheelchair accessory, insert for pneumatic
							 drive wheel tire (removable), any type, any size, replacement only, each
							 (rental)
E2383RRKU
14.73
Power wheelchair accessory, insert for pneumatic
							 drive wheel tire (removable), any type, any size, replacement only, each
							 (rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2383UE
95.89
Power wheelchair accessory, insert for pneumatic
							 drive wheel tire (removable), any type, any size, replacement only, each (used
							 durable medical equipment)
E2383UEKU
110.49
Power wheelchair accessory, insert for pneumatic
							 drive wheel tire (removable), any type, any size, replacement only, each (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2384NU
66.33
Power wheelchair accessory, pneumatic caster tire,
							 any size, replacement only, each (new equipment)
E2384NUKU
78.49
Power wheelchair accessory, pneumatic caster tire,
							 any size, replacement only, each (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2384RR
6.64
Power wheelchair accessory, pneumatic caster tire,
							 any size, replacement only, each (rental)
E2384RRKU
7.87
Power wheelchair accessory, pneumatic caster tire,
							 any size, replacement only, each (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2384UE
49.75
Power wheelchair accessory, pneumatic caster tire,
							 any size, replacement only, each (used durable medical equipment)
E2384UEKU
58.88
Power wheelchair accessory, pneumatic caster tire,
							 any size, replacement only, each (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2385NU
43.81
Power wheelchair accessory, tube for pneumatic caster
							 tire, any size, replacement only, each (new equipment)
E2385NUKU
48.02
Power wheelchair accessory, tube for pneumatic caster
							 tire, any size, replacement only, each (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2385RR
4.39
Power wheelchair accessory, tube for pneumatic caster
							 tire, any size, replacement only, each (rental)
E2385RRKU
4.82
Power wheelchair accessory, tube for pneumatic caster
							 tire, any size, replacement only, each (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2385UE
32.85
Power wheelchair accessory, tube for pneumatic caster
							 tire, any size, replacement only, each (used durable medical
							 equipment)
E2385UEKU
36.00
Power wheelchair accessory, tube for pneumatic caster
							 tire, any size, replacement only, each (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2386NU
117.14
Power wheelchair accessory, foam filled drive wheel
							 tire, any size, replacement only, each (new equipment)
E2386NUKU
145.99
Power wheelchair accessory, foam filled drive wheel
							 tire, any size, replacement only, each (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2386RR
11.71
Power wheelchair accessory, foam filled drive wheel
							 tire, any size, replacement only, each (rental)
E2386RRKU
14.60
Power wheelchair accessory, foam filled drive wheel
							 tire, any size, replacement only, each (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2386UE
87.86
Power wheelchair accessory, foam filled drive wheel
							 tire, any size, replacement only, each (used durable medical
							 equipment)
E2386UEKU
109.50
Power wheelchair accessory, foam filled drive wheel
							 tire, any size, replacement only, each (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2387NU
53.36
Power wheelchair accessory, foam filled caster tire,
							 any size, replacement only, each (new equipment)
E2387NUKU
65.46
Power wheelchair accessory, foam filled caster tire,
							 any size, replacement only, each (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2387RR
5.34
Power wheelchair accessory, foam filled caster tire,
							 any size, replacement only, each (rental)
E2387RRKU
6.55
Power wheelchair accessory, foam filled caster tire,
							 any size, replacement only, each (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2387UE
40.04
Power wheelchair accessory, foam filled caster tire,
							 any size, replacement only, each (used durable medical equipment)
E2387UEKU
49.14
Power wheelchair accessory, foam filled caster tire,
							 any size, replacement only, each (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2388NU
46.01
Power wheelchair accessory, foam drive wheel tire,
							 any size, replacement only, each (new equipment)
E2388NUKU
48.87
Power wheelchair accessory, foam drive wheel tire,
							 any size, replacement only, each (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2388RR
4.61
Power wheelchair accessory, foam drive wheel tire,
							 any size, replacement only, each (rental)
E2388RRKU
4.89
Power wheelchair accessory, foam drive wheel tire,
							 any size, replacement only, each (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2388UE
34.51
Power wheelchair accessory, foam drive wheel tire,
							 any size, replacement only, each (used durable medical equipment)
E2388UEKU
36.67
Power wheelchair accessory, foam drive wheel tire,
							 any size, replacement only, each (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2389NU
25.34
Power wheelchair accessory, foam caster tire, any
							 size, replacement only, each (new equipment)
E2389NUKU
26.55
Power wheelchair accessory, foam caster tire, any
							 size, replacement only, each (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2389RR
2.54
Power wheelchair accessory, foam caster tire, any
							 size, replacement only, each (rental)
E2389RRKU
2.67
Power wheelchair accessory, foam caster tire, any
							 size, replacement only, each (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2389UE
18.99
Power wheelchair accessory, foam caster tire, any
							 size, replacement only, each (used durable medical equipment)
E2389UEKU
19.89
Power wheelchair accessory, foam caster tire, any
							 size, replacement only, each (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2390NU
39.43
Power wheelchair accessory, solid (rubber/plastic)
							 drive wheel tire, any size, replacement only, each (new equipment)
E2390NUKU
41.51
Power wheelchair accessory, solid (rubber/plastic)
							 drive wheel tire, any size, replacement only, each (new equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2390RR
3.94
Power wheelchair accessory, solid (rubber/plastic)
							 drive wheel tire, any size, replacement only, each (rental)
E2390RRKU
4.15
Power wheelchair accessory, solid (rubber/plastic)
							 drive wheel tire, any size, replacement only, each (rental), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2390UE
29.56
Power wheelchair accessory, solid (rubber/plastic)
							 drive wheel tire, any size, replacement only, each (used durable medical
							 equipment)
E2390UEKU
31.11
Power wheelchair accessory, solid (rubber/plastic)
							 drive wheel tire, any size, replacement only, each (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2391NU
17.13
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each (new
							 equipment)
E2391NUKU
19.88
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2391RR
1.72
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each (rental)
E2391RRKU
1.99
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2391UE
12.85
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each (used durable medical
							 equipment)
E2391UEKU
14.91
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire (removable), any size, replacement only, each (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2392NU
42.71
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size, replacement only, each (new
							 equipment)
E2392NUKU
52.26
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size, replacement only, each (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2392RR
4.28
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size, replacement only, each
							 (rental)
E2392RRKU
5.26
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size, replacement only, each (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2392UE
32.04
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size, replacement only, each (used
							 durable medical equipment)
E2392UEKU
39.21
Power wheelchair accessory, solid (rubber/plastic)
							 caster tire with integrated wheel, any size, replacement only, each (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2394NU
64.63
Power wheelchair accessory, drive wheel excludes
							 tire, any size, replacement only, each (new equipment)
E2394NUKU
74.47
Power wheelchair accessory, drive wheel excludes
							 tire, any size, replacement only, each (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2394RR
6.47
Power wheelchair accessory, drive wheel excludes
							 tire, any size, replacement only, each (rental)
E2394RRKU
7.46
Power wheelchair accessory, drive wheel excludes
							 tire, any size, replacement only, each (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2394UE
48.47
Power wheelchair accessory, drive wheel excludes
							 tire, any size, replacement only, each (used durable medical
							 equipment)
E2394UEKU
55.85
Power wheelchair accessory, drive wheel excludes
							 tire, any size, replacement only, each (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2395NU
45.24
Power wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only, each (new equipment)
E2395NUKU
52.91
Power wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only, each (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2395RR
4.53
Power wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only, each (rental)
E2395RRKU
5.31
Power wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only, each (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2395UE
33.94
Power wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only, each (used durable medical
							 equipment)
E2395UEKU
39.69
Power wheelchair accessory, caster wheel excludes
							 tire, any size, replacement only, each (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2396NU
53.61
Power wheelchair accessory, caster fork, any size,
							 replacement only, each (new equipment)
E2396NUKU
62.15
Power wheelchair accessory, caster fork, any size,
							 replacement only, each (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2396RR
5.70
Power wheelchair accessory, caster fork, any size,
							 replacement only, each (rental)
E2396RRKU
6.91
Power wheelchair accessory, caster fork, any size,
							 replacement only, each (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2396UE
40.22
Power wheelchair accessory, caster fork, any size,
							 replacement only, each (used durable medical equipment)
E2396UEKU
46.64
Power wheelchair accessory, caster fork, any size,
							 replacement only, each (used durable medical equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E2397NU
443.59
Power wheelchair accessory, lithium-based battery,
							 each (new equipment)
E2397NUKU
466.10
Power wheelchair accessory, lithium-based battery,
							 each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2397RR
44.36
Power wheelchair accessory, lithium-based battery,
							 each (rental)
E2397RRKU
46.62
Power wheelchair accessory, lithium-based battery,
							 each (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2397UE
332.68
Power wheelchair accessory, lithium-based battery,
							 each (used durable medical equipment)
E2397UEKU
349.55
Power wheelchair accessory, lithium-based battery,
							 each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2398
I.C.
Wheelchair accessory, dynamic positioning hardware
							 for back
Wound Therapy
E2402KH
1,026.17
Negative pressure wound therapy electrical pump,
							 stationary or portable (capped rental)
E2402KI
1,026.17
Negative pressure wound therapy electrical pump,
							 stationary or portable (capped rental)
E2402KJ
769.63
Negative pressure wound therapy electrical pump,
							 stationary or portable (capped rental)
E2402NU
10,261.71
Negative pressure wound therapy electrical pump,
							 stationary or portable (new equipment purchase)
E2402UE
7,696.28
Negative pressure wound therapy electrical pump,
							 stationary or portable (used durable medical equipment purchase)
Speech Generating Device
E2500NU
367.46
Speech generating device, digitized speech, using
							 pre-recorded messages, less than or equal to 8 minutes recording time (new
							 equipment)
E2500RR
36.75
Speech generating device, digitized speech, using
							 pre-recorded messages, less than or equal to 8 minutes recording time
							 (rental)
E2500UE
275.60
Speech generating device, digitized speech, using
							 pre-recorded messages, less than or equal to 8 minutes recording time (used
							 durable medical equipment)
E2502NU
1,123.67
Speech generating device, digitized speech, using
							 pre-recorded messages, greater than 8 minutes but less than or equal to 20
							 minutes recording time (new equipment)
E2502RR
112.37
Speech generating device, digitized speech, using
							 pre-recorded messages, greater than 8 minutes but less than or equal to 20
							 minutes recording time (rental)
E2502UE
842.77
Speech generating device, digitized speech, using
							 pre-recorded messages, greater than 8 minutes but less than or equal to 20
							 minutes recording time (used durable medical equipment)
E2504NU
1,482.26
Speech generating device, digitized speech, using
							 pre-recorded messages, greater than 20 minutes but less than or equal to 40
							 minutes recording time (new equipment)
E2504RR
148.25
Speech generating device, digitized speech, using
							 pre-recorded messages, greater than 20 minutes but less than or equal to 40
							 minutes recording time (rental)
E2504UE
1,111.70
Speech generating device, digitized speech, using
							 pre-recorded messages, greater than 20 minutes but less than or equal to 40
							 minutes recording time (used durable medical equipment)
E2506NU
2,173.45
Speech generating device, digitized speech, using
							 pre-recorded messages, greater than 40 minutes recording time (new
							 equipment)
E2506RR
217.33
Speech generating device, digitized speech, using
							 pre-recorded messages, greater than 40 minutes recording time
							 (rental)
E2506UE
1,630.05
Speech generating device, digitized speech, using
							 pre-recorded messages, greater than 40 minutes recording time (used durable
							 medical equipment)
E2508NU
3,360.87
Speech generating device, synthesized speech,
							 requiring message formulation by spelling and access by physical contact with
							 the device (new equipment)
E2508RR
336.08
Speech generating device, synthesized speech,
							 requiring message formulation by spelling and access by physical contact with
							 the device (rental)
E2508UE
2,520.66
Speech generating device, synthesized speech,
							 requiring message formulation by spelling and access by physical contact with
							 the device (used durable medical equipment)
E2510NU
6,360.00
Speech generating device, synthesized speech,
							 permitting multiple methods of message formulation and multiple methods of
							 device access (new equipment)
E2510RR
636.00
Speech generating device, synthesized speech,
							 permitting multiple methods of message formulation and multiple methods of
							 device access (rental)
E2510TW
-
Speech generating device, synthesized speech,
							 permitting multiple methods of message formulation and multiple methods of
							 device access (MassHealth-only usage of this code with modifier is for a
							 non-dedicated alternative and augmentative communication device pursuant to
							 130 CMR 409.000:
Durable Medical Equipment and Medical Supplies
							 Services
).
E2510UE
4,770.00
Speech generating device, synthesized speech,
							 permitting multiple methods of message formulation and multiple methods of
							 device access (used durable medical equipment)
E2511NU
AAC+30%
Speech generating software program, for personal
							 computer or personal digital assistant (new equipment)
E2511RR
I.C.
Speech generating software program, for personal
							 computer or personal digital assistant (rental)
E2511TW
-
Speech generating software program (MassHealth-only
							 usage of this code with modifier is for a non-dedicated alternative and
							 augmentative communication device pursuant to
							 130 CMR 409.000:
Durable Medical Equipment and Medical Supplies
							 Services
.)
E2511UE
I.C.
Speech generating software program, for personal
							 computer or personal digital assistant (used durable medical
							 equipment)
E2512NU
AAC+30%
Accessory for speech generating device, mounting
							 system (new equipment)
E2512RR
I.C.
Accessory for speech generating device, mounting
							 system (rental)
E2512TW
-
Accessory for speech generating device, mounting
							 system (MassHealth-only usage of this code with modifier is for a non-dedicated
							 alternative and augmentative communication device pursuant to
							 130 CMR 409.000:
Durable Medical Equipment and Medical Supplies
							 Services
.)
E2512UE
I.C.
Accessory for speech generating device, mounting
							 system (used durable medical equipment)
E2599NU
AAC+30%
Accessory for speech generating device, not otherwise
							 classified (new equipment)
E2599RR
AAC+30%
Accessory for speech generating device, not otherwise
							 classified (rental)
E2599TW
-
Accessory for speech generating device, not otherwise
							 classified (protective case) [not covered if used as a modification to home
							 internet or phone services.] (MassHealth-only usage of this code with modifier
							 is for a non-dedicated alternative and augmentative communication device
							 pursuant to
							 130 CMR 409.000:
Durable Medical Equipment and Medical Supplies
							 Services
.)
E2599UE
I.C.
Accessory for speech generating device, not otherwise
							 classified (used durable medical equipment)
Wheelchair Cushion
E2601NU
49.64
General use wheelchair seat cushion, width less than
							 22 inches, any depth (new equipment)
E2601NUKU
59.33
General use wheelchair seat cushion, width less than
							 22 inches, any depth (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2601RR
4.97
General use wheelchair seat cushion, width less than
							 22 inches, any depth (rental)
E2601RRKU
5.95
General use wheelchair seat cushion, width less than
							 22 inches, any depth (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2601UE
37.24
General use wheelchair seat cushion, width less than
							 22 inches, any depth (used durable medical equipment)
E2601UEKU
44.50
General use wheelchair seat cushion, width less than
							 22 inches, any depth (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2602NU
98.59
General use wheelchair seat cushion, width 22 inches
							 or greater, any depth (new equipment)
E2602NUKU
115.82
General use wheelchair seat cushion, width 22 inches
							 or greater, any depth (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2602RR
9.86
General use wheelchair seat cushion, width 22 inches
							 or greater, any depth (rental)
E2602RRKU
11.59
General use wheelchair seat cushion, width 22 inches
							 or greater, any depth (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2602UE
73.94
General use wheelchair seat cushion, width 22 inches
							 or greater, any depth (used durable medical equipment)
E2602UEKU
86.88
General use wheelchair seat cushion, width 22 inches
							 or greater, any depth (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2603NU
121.14
Skin protection wheelchair seat cushion, width less
							 than 22 inches, any depth (new equipment)
E2603NUKU
147.04
Skin protection wheelchair seat cushion, width less
							 than 22 inches, any depth (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2603RR
12.12
Skin protection wheelchair seat cushion, width less
							 than 22 inches, any depth (rental)
E2603RRKU
14.71
Skin protection wheelchair seat cushion, width less
							 than 22 inches, any depth (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2603UE
90.86
Skin protection wheelchair seat cushion, width less
							 than 22 inches, any depth (used durable medical equipment)
E2603UEKU
110.29
Skin protection wheelchair seat cushion, width less
							 than 22 inches, any depth (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2604NU
156.83
Skin protection wheelchair seat cushion, width 22
							 inches or greater, any depth (new equipment)
E2604NUKU
182.78
Skin protection wheelchair seat cushion, width 22
							 inches or greater, any depth (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2604RR
15.68
Skin protection wheelchair seat cushion, width 22
							 inches or greater, any depth (rental)
E2604RRKU
18.28
Skin protection wheelchair seat cushion, width 22
							 inches or greater, any depth (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2604UE
117.63
Skin protection wheelchair seat cushion, width 22
							 inches or greater, any depth (used durable medical equipment)
E2604UEKU
137.10
Skin protection wheelchair seat cushion, width 22
							 inches or greater, any depth (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2605NU
227.94
Positioning wheelchair seat cushion, width less than
							 22 inches, any depth (new equipment)
E2605NUKU
261.12
Positioning wheelchair seat cushion, width less than
							 22 inches, any depth (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2605RR
22.80
Positioning wheelchair seat cushion, width less than
							 22 inches, any depth (rental)
E2605RRKU
26.12
Positioning wheelchair seat cushion, width less than
							 22 inches, any depth (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2605UE
170.97
Positioning wheelchair seat cushion, width less than
							 22 inches, any depth (used durable medical equipment)
E2605UEKU
195.87
Positioning wheelchair seat cushion, width less than
							 22 inches, any depth (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2606NU
344.73
Positioning wheelchair seat cushion, width 22 inches
							 or greater, any depth (new equipment)
E2606NUKU
407.36
Positioning wheelchair seat cushion, width 22 inches
							 or greater, any depth (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2606RR
34.48
Positioning wheelchair seat cushion, width 22 inches
							 or greater, any depth (rental)
E2606RRKU
40.74
Positioning wheelchair seat cushion, width 22 inches
							 or greater, any depth (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2606UE
258.54
Positioning wheelchair seat cushion, width 22 inches
							 or greater, any depth (used durable medical equipment)
E2606UEKU
305.49
Positioning wheelchair seat cushion, width 22 inches
							 or greater, any depth (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2607NU
238.61
Skin protection and positioning wheelchair seat
							 cushion, width less than 22 inches, any depth (new equipment)
E2607NUKU
281.17
Skin protection and positioning wheelchair seat
							 cushion, width less than 22 inches, any depth (new equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2607RR
23.86
Skin protection and positioning wheelchair seat
							 cushion, width less than 22 inches, any depth (rental)
E2607RRKU
28.12
Skin protection and positioning wheelchair seat
							 cushion, width less than 22 inches, any depth (rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2607UE
178.96
Skin protection and positioning wheelchair seat
							 cushion, width less than 22 inches, any depth (used durable medical
							 equipment)
E2607UEKU
210.88
Skin protection and positioning wheelchair seat
							 cushion, width less than 22 inches, any depth (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2608NU
283.40
Skin protection and positioning wheelchair seat
							 cushion, width 22 inches or greater, any depth (new equipment)
E2608NUKU
337.66
Skin protection and positioning wheelchair seat
							 cushion, width 22 inches or greater, any depth (new equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2608RR
28.34
Skin protection and positioning wheelchair seat
							 cushion, width 22 inches or greater, any depth (rental)
E2608RRKU
33.76
Skin protection and positioning wheelchair seat
							 cushion, width 22 inches or greater, any depth (rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E2608UE
212.55
Skin protection and positioning wheelchair seat
							 cushion, width 22 inches or greater, any depth (used durable medical
							 equipment)
E2608UEKU
253.25
Skin protection and positioning wheelchair seat
							 cushion, width 22 inches or greater, any depth (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2609NU
AAC+35%
Custom fabricated wheelchair seat cushion, any
							 size
E2609RR
I.C.
Custom fabricated wheelchair seat cushion, any size
							 (rental)
E2609UE
I.C.
Custom fabricated wheelchair seat cushion, any size
							 (used durable medical equipment)
E2610NU
AAC+35%
Wheelchair seat cushion, powered (new
							 equipment)
E2610RR
I.C.
Wheelchair seat cushion, powered (rental)
E2610UE
I.C.
Wheelchair seat cushion, powered (used durable
							 medical equipment)
E2611NU
226.54
General use wheelchair back cushion, width less than
							 22 inches, any height, including any type mounting hardware (new
							 equipment)
E2611NUKU
303.00
General use wheelchair back cushion, width less than
							 22 inches, any height, including any type mounting hardware (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2611RR
22.65
General use wheelchair back cushion, width less than
							 22 inches, any height, including any type mounting hardware
							 (rental)
E2611RRKU
30.29
General use wheelchair back cushion, width less than
							 22 inches, any height, including any type mounting hardware (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2611UE
169.92
General use wheelchair back cushion, width less than
							 22 inches, any height, including any type mounting hardware (used durable
							 medical equipment)
E2611UEKU
227.27
General use wheelchair back cushion, width less than
							 22 inches, any height, including any type mounting hardware (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2612NU
340.36
General use wheelchair back cushion, width 22 inches
							 or greater, any height, including any type mounting hardware (new
							 equipment)
E2612NUKU
409.89
General use wheelchair back cushion, width 22 inches
							 or greater, any height, including any type mounting hardware (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2612RR
34.03
General use wheelchair back cushion, width 22 inches
							 or greater, any height, including any type mounting hardware
							 (rental)
E2612RRKU
40.99
General use wheelchair back cushion, width 22 inches
							 or greater, any height, including any type mounting hardware (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2612UE
255.27
General use wheelchair back cushion, width 22 inches
							 or greater, any height, including any type mounting hardware (used durable
							 medical equipment)
E2612UEKU
307.41
General use wheelchair back cushion, width 22 inches
							 or greater, any height, including any type mounting hardware (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2613NU
338.48
Positioning wheelchair back cushion, posterior, width
							 less than 22 inches, any height, including any type mounting hardware (new
							 equipment)
E2613NUKU
381.28
Positioning wheelchair back cushion, posterior, width
							 less than 22 inches, any height, including any type mounting hardware (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2613RR
33.85
Positioning wheelchair back cushion, posterior, width
							 less than 22 inches, any height, including any type mounting hardware
							 (rental)
E2613RRKU
38.13
Positioning wheelchair back cushion, posterior, width
							 less than 22 inches, any height, including any type mounting hardware (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2613UE
253.86
Positioning wheelchair back cushion, posterior, width
							 less than 22 inches, any height, including any type mounting hardware (used
							 durable medical equipment)
E2613UEKU
285.96
Positioning wheelchair back cushion, posterior, width
							 less than 22 inches, any height, including any type mounting hardware (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2614NU
451.17
Positioning wheelchair back cushion, posterior, 22
							 inches or greater, any height, including any type mounting hardware (new
							 equipment)
E2614NUKU
527.66
Positioning wheelchair back cushion, posterior, 22
							 inches or greater, any height, including any type mounting hardware (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2614RR
45.12
Positioning wheelchair back cushion, posterior, 22
							 inches or greater, any height, including any type mounting hardware
							 (rental)
E2614RRKU
52.76
Positioning wheelchair back cushion, posterior, 22
							 inches or greater, any height, including any type mounting hardware (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2614UE
338.38
Positioning wheelchair back cushion, posterior, 22
							 inches or greater, any height, including any type mounting hardware (used
							 durable medical equipment)
E2614UEKU
395.76
Positioning wheelchair back cushion, posterior, 22
							 inches or greater, any height, including any type mounting hardware (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2615NU
391.46
Positioning wheelchair back cushion,
							 posterior-lateral, width less than 22 inches, any height, including any type
							 mounting hardware (new equipment)
E2615NUKU
438.77
Positioning wheelchair back cushion,
							 posterior-lateral, width less than 22 inches, any height, including any type
							 mounting hardware (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2615RR
39.15
Positioning wheelchair back cushion,
							 posterior-lateral, width less than 22 inches, any height, including any type
							 mounting hardware (rental)
E2615RRKU
43.89
Positioning wheelchair back cushion,
							 posterior-lateral, width less than 22 inches, any height, including any type
							 mounting hardware (rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2615UE
293.59
Positioning wheelchair back cushion,
							 posterior-lateral, width less than 22 inches, any height, including any type
							 mounting hardware (used durable medical equipment)
E2615UEKU
329.07
Positioning wheelchair back cushion,
							 posterior-lateral, width less than 22 inches, any height, including any type
							 mounting hardware (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2616NU
501.23
Positioning wheelchair back cushion,
							 posterior-lateral, width 22 inches or greater, any height, including any type
							 mounting hardware (new equipment)
E2616NUKU
590.36
Positioning wheelchair back cushion,
							 posterior-lateral, width 22 inches or greater, any height, including any type
							 mounting hardware (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2616RR
50.12
Positioning wheelchair back cushion,
							 posterior-lateral, width 22 inches or greater, any height, including any type
							 mounting hardware (rental)
E2616RRKU
59.04
Positioning wheelchair back cushion,
							 posterior-lateral, width 22 inches or greater, any height, including any type
							 mounting hardware (rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2616UE
375.93
Positioning wheelchair back cushion,
							 posterior-lateral, width 22 inches or greater, any height, including any type
							 mounting hardware (used durable medical equipment)
E2616UEKU
442.78
Positioning wheelchair back cushion,
							 posterior-lateral, width 22 inches or greater, any height, including any type
							 mounting hardware (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2617NU
AAC+35%
Custom fabricated wheelchair back cushion, any size,
							 including any type mounting hardware (new equipment)
E2617RR
I.C.
Custom fabricated wheelchair back cushion, any size,
							 including any type mounting hardware (rental)
E2617UE
I.C.
Custom fabricated wheelchair back cushion, any size,
							 including any type mounting hardware (used durable medical
							 equipment)
E2619NU
47.11
Replacement cover for wheelchair seat cushion or back
							 cushion, each (new equipment)
E2619NUKU
49.77
Replacement cover for wheelchair seat cushion or back
							 cushion, each (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2619RR
4.71
Replacement cover for wheelchair seat cushion or back
							 cushion (rental)
E2619RRKU
4.97
Replacement cover for wheelchair seat cushion or back
							 cushion (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2619UE
35.35
Replacement cover for wheelchair seat cushion or back
							 cushion (used durable medical equipment)
E2619UEKU
37.37
Replacement cover for wheelchair seat cushion or back
							 cushion (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2620NU
451.25
Positioning wheelchair back cushion, planar back with
							 lateral supports, width less than 22 inches, any height, including any type
							 mounting hardware (new equipment)
E2620NUKU
531.29
Positioning wheelchair back cushion, planar back with
							 lateral supports, width less than 22 inches, any height, including any type
							 mounting hardware (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2620RR
45.13
Positioning wheelchair back cushion, planar back with
							 lateral supports, width less than 22 inches, any height, including any type
							 mounting hardware (rental)
E2620RRKU
53.14
Positioning wheelchair back cushion, planar back with
							 lateral supports, width less than 22 inches, any height, including any type
							 mounting hardware (rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2620UE
338.44
Positioning wheelchair back cushion, planar back with
							 lateral supports, width less than 22 inches, any height, including any type
							 mounting hardware (used durable medical equipment)
E2620UEKU
398.49
Positioning wheelchair back cushion, planar back with
							 lateral supports, width less than 22 inches, any height, including any type
							 mounting hardware (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2621NU
470.39
Positioning wheelchair back cushion, planar back with
							 lateral supports, width 22 inches or greater, any height, including any type
							 mounting hardware (new equipment)
E2621NUKU
557.56
Positioning wheelchair back cushion, planar back with
							 lateral supports, width 22 inches or greater, any height, including any type
							 mounting hardware (new equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2621RR
47.04
Positioning wheelchair back cushion, planar back with
							 lateral supports, width 22 inches or greater, any height, including any type
							 mounting hardware (rental)
E2621RRKU
55.76
Positioning wheelchair back cushion, planar back with
							 lateral supports, width 22 inches or greater, any height, including any type
							 mounting hardware (rental), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2621UE
352.79
Positioning wheelchair back cushion, planar back with
							 lateral supports, width 22 inches or greater, any height, including any type
							 mounting hardware (used durable medical equipment)
E2621UEKU
418.17
Positioning wheelchair back cushion, planar back with
							 lateral supports, width 22 inches or greater, any height, including any type
							 mounting hardware (used durable medical equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2622NU
301.67
Skin protection wheelchair seat cushion, adjustable,
							 width less than 22 inches, any depth (new equipment)
E2622NUKU
321.54
Skin protection wheelchair seat cushion, adjustable,
							 width less than 22 inches, any depth (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2622RR
30.17
Skin protection wheelchair seat cushion, adjustable,
							 width less than 22 inches, any depth (rental)
E2622RRKU
32.16
Skin protection wheelchair seat cushion, adjustable,
							 width less than 22 inches, any depth (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2622UE
226.25
Skin protection wheelchair seat cushion, adjustable,
							 width less than 22 inches, any depth (used durable medical
							 equipment)
E2622UEKU
241.15
Skin protection wheelchair seat cushion, adjustable,
							 width less than 22 inches, any depth (used durable medical equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2623NU
382.72
Skin protection wheelchair seat cushion,
							 adjustable,width 22 inches or greater, any depth (new equipment)
E2623NUKU
409.15
kin protection wheelchair seat cushion, adjustable,
							 width 22 inches or greater, any depth (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2623RR
38.28
Skin protection wheelchair seat cushion, adjustable,
							 width 22 inches or greater, any depth (rental)
E2623RRKU
40.93
Skin protection wheelchair seat cushion, adjustable,
							 width 22 inches or greater, any depth (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2623UE
287.04
Skin protection wheelchair seat cushion, adjustable,
							 width 22 inches or greater, any depth (used durable medical
							 equipment)
E2623UEKU
306.85
Skin protection wheelchair seat cushion, adjustable,
							 width 22 inches or greater, any depth (used durable medical equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2624NU
305.29
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width less than 22 inches, any depth (new
							 equipment)
E2624NUKU
324.19
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width less than 22 inches, any depth (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2624RR
30.53
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width less than 22 inches, any depth (rental)
E2624RRKU
32.42
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width less than 22 inches, any depth (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2624UE
228.98
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width less than 22 inches, any depth (used durable medical
							 equipment)
E2624UEKU
243.16
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width less than 22 inches, any depth (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2625NU
382.34
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width 22 inches or greater, any depth (new
							 equipment)
E2625NUKU
410.40
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width 22 inches or greater, any depth (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2625RR
38.23
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width 22 inches or greater, any depth (rental)
E2625RRKU
41.03
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width 22 inches or greater, any depth (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2625UE
286.75
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width 22 inches or greater, any depth (used durable
							 medical equipment)
E2625UEKU
307.80
Skin protection and positioning wheelchair seat
							 cushion, adjustable, width 22 inches or greater, any depth (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
Wheelchair Arm Support
E2626NU
651.51
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable (new
							 equipment)
E2626NUKU
699.08
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable (new equipment), (DMEPOS
							 item subject to
DMEPOS competitive bidding program number
							 3)
E2626RR
65.14
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable (rental)
E2626RRKU
69.88
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable (rental), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2626UE
488.61
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable (used durable medical
							 equipment)
E2626UEKU
524.24
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2627NU
1,033.91
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable rancho type (new
							 equipment)
E2627NUKU
1,115.50
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable rancho type (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2627RR
103.41
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable rancho type
							 (rental)
E2627RRKU
111.58
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable rancho type (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2627UE
775.43
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable rancho type (used durable
							 medical equipment)
E2627UEKU
836.61
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, adjustable rancho type (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2628NU
775.09
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, reclining (new equipment)
E2628NUKU
840.35
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, reclining (new equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2628RR
77.51
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, reclining (rental)
E2628RRKU
84.03
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, reclining (rental), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
E2628UE
581.31
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, reclining (used durable medical
							 equipment)
E2628UEKU
630.25
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, reclining (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2629NU
949.59
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, friction arm support (friction
							 dampening to proximal and distal joints) (new equipment)
E2629NUKU
966.76
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, friction arm support (friction
							 dampening to proximal and distal joints) (new equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E2629RR
94.95
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, friction arm support (friction
							 dampening to proximal and distal joints) (rental)
E2629RRKU
96.66
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, friction arm support (friction
							 dampening to proximal and distal joints) (rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2629UE
712.20
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, friction arm support (friction
							 dampening to proximal and distal joints) (used durable medical
							 equipment)
E2629UEKU
725.08
Wheelchair accessory, shoulder elbow, mobile arm
							 support attached to wheelchair, balanced, friction arm support (friction
							 dampening to proximal and distal joints) (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2630NU
684.22
Wheelchair accessory, shoulder elbow, mobile arm
							 support, monosuspension arm and hand support, overhead elbow forearm hand sling
							 support, yoke type suspension support (new equipment)
E2630NUKU
743.66
Wheelchair accessory, shoulder elbow, mobile arm
							 support, monosuspension arm and hand support, overhead elbow forearm hand sling
							 support, yoke type suspension support (new equipment), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
E2630RR
68.42
Wheelchair accessory, shoulder elbow, mobile arm
							 support, monosuspension arm and hand support, overhead elbow forearm hand sling
							 support, yoke type suspension support (rental)
E2630RRKU
74.37
Wheelchair accessory, shoulder elbow, mobile arm
							 support, monosuspension arm and hand support, overhead elbow forearm hand sling
							 support, yoke type suspension support (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2630UE
513.16
Wheelchair accessory, shoulder elbow, mobile arm
							 support, monosuspension arm and hand support, overhead elbow forearm hand sling
							 support, yoke type suspension support (used durable medical
							 equipment)
E2630UEKU
557.74
Wheelchair accessory, shoulder elbow, mobile arm
							 support, monosuspension arm and hand support, overhead elbow forearm hand sling
							 support, yoke type suspension support (used durable medical equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2631NU
248.36
Wheelchair accessory, addition to mobile arm support,
							 elevating proximal arm (new equipment)
E2631NUKU
252.87
Wheelchair accessory, addition to mobile arm support,
							 elevating proximal arm (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
E2631RR
24.84
Wheelchair accessory, addition to mobile arm support,
							 elevating proximal arm (rental)
E2631RRKU
25.28
Wheelchair accessory, addition to mobile arm support,
							 elevating proximal arm (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
E2631UE
186.27
Wheelchair accessory, addition to mobile arm support,
							 elevating proximal arm (used durable medical equipment)
E2631UEKU
189.64
Wheelchair accessory, addition to mobile arm support,
							 elevating proximal arm (used durable medical equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
E2632NU
174.58
Wheelchair accessory, addition to mobile arm support,
							 offset or lateral rocker arm with elastic balance control (new
							 equipment)
E2632NUKU
189.15
Wheelchair accessory, addition to mobile arm support,
							 offset or lateral rocker arm with elastic balance control (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2632RR
17.46
Wheelchair accessory, addition to mobile arm support,
							 offset or lateral rocker arm with elastic balance control (rental)
E2632RRKU
18.92
Wheelchair accessory, addition to mobile arm support,
							 offset or lateral rocker arm with elastic balance control (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
E2632UE
130.93
Wheelchair accessory, addition to mobile arm support,
							 offset or lateral rocker arm with elastic balance control (used durable medical
							 equipment)
E2632UEKU
141.86
Wheelchair accessory, addition to mobile arm support,
							 offset or lateral rocker arm with elastic balance control (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
E2633NU
146.61
Wheelchair accessory, addition to mobile arm support,
							 supinator (new equipment)
E2633NUKU
160.44
Wheelchair accessory, addition to mobile arm support,
							 supinator (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
E2633RR
14.66
Wheelchair accessory, addition to mobile arm support,
							 supinator (rental)
E2633RRKU
16.05
Wheelchair accessory, addition to mobile arm support,
							 supinator (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
E2633UE
109.96
Wheelchair accessory, addition to mobile arm support,
							 supinator (used durable medical equipment)
E2633UEKU
120.34
Wheelchair accessory, addition to mobile arm support,
							 supinator (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
Gait Trainer E8000
AAC+35%
Gait trainer, pediatric size, posterior support,
							 includes all accessories and components
E8001
AAC+35%
Gait trainer, pediatric size, upright support,
							 includes all accessories and components
E8002
AAC+35%
Gait trainer, pediatric size, anterior support,
							 includes all accessories and components
Drugs Administered Other Than Oral Method
G0333
48.45
Pharmacy dispensing fee for inhalation drug(s);
							 initial 30-day supply as a beneficiary
J0133
0.40
Injection, acyclovir, 5 mg
J0153
0.82
Injection, adenosine, 1 mg (not to be used to report
							 any adenosine phosphate compounds)
J0285
8.74
Injection, amphotericin b, 50 mg
J0287
18.57
Injection, amphotericin b lipid complex, 10
							 mg
J0288
12.92
Injection, amphotericin b cholesteryl sulfate
							 complex, 10 mg
J0289
30.43
Injection, amphotericin b liposome, 10 mg
J0882
3.53
Injection, darbepoetin alfa, 1 microgram (for ESRD on
							 dialysis)
J0895
13.29
Injection, deferoxamine mesylate, 500 mg
J1170
1.27
Injection, hydromorphone, up to 4 mg
J1250
4.03
Injection, dobutamine hydrochloride, per 250
							 mg
J1265
0.52
Injection, dopamine hcl, 40 mg
J1325
10.74
Injection, epoprostenol, 0.5 mg
J1455
11.11
Injection, foscarnet sodium, per 1000 mg
J1459
32.52
Injection, immune globulin (privigen), intravenous,
							 non-lyophilized (
e.g.
liquid), 500 mg
J1555
AAC+20%
Injection, immune globulin (cuvitru), 100
							 mg
J1557
31.72
Injection, immune globulin, (gammaplex), intravenous,
							 non-lyophilized (
e.g.
liquid), 500 mg
J1559
12.21
Injection, immune globulin (hizentra),100
							 mg
J1561
35.50
Injection, immune globulin, (gamunex-c/cammaked),
							 intravenous, non-lyophilized (
e.g.
, liquid), 500
							 mg
J1561JB
39.24
Injection, immune globulin, (gamunex-c/cammaked),
							 intravenous, non-lyophilized (
e.g.
, liquid), 500 mg
							 (administered subcutaneously)
J1562
9.69
Injection, immune globulin (vivaglobin), 100
							 mg
J1566
29.66
Injection, immune globulin, intravenous, lyophilized
							 (
e.g.
powder), not otherwise specified, 500 mg
J1568
36.08
Injection, immune globulin (octagam), intravenous,
							 non-lyophilized (
e.g.
, liquid), 500 mg
J1569
32.40
Injection, immune globulin, (gammagard liquid),
							 intravenous, non-lyophilized (
e.g.
liquid), 500 mg
J1569JB
44.62
Injection, immune globulin, (gammagard liquid),
							 intravenous, non-lyophilized (
e.g.
liquid), 500 mg
							 (administered subcutaneously)
J1570
29.96
Injection, ganciclovir sodium, 500 mg
J1572
33.46
Injection, immune globulin, (flebogamma/flebogama
							 dif), intravenous, non-lyophilized (
e.g.
liquid), 500
							 mg
J1575
14.72
Injection, immune globulin/hyaluronidase, (Hyqvia),
							 100 mg immune globulin
J1599
AAC
Injection, immune globulin, intravenous,
							 non-lyophilized (
e.g.
liquid), not otherwise specified, 500
							 mg
J1644AX
0.18
Injection, heparin sodium, per 1000 units
J1815
0.67
Injection, insulin, per 5 units
J1817
2.38
Insulin for administration through DME
							 (
i.e.
, insulin pump) per 50 units
J2175
0.48
Injection, meperidine hydrochloride, per 100
							 mg
J2260
43.84
Injection, milrinone lactate, 5 mg
J2270
0.60
Injection, morphine sulfate, up to 10 mg
J2274
7.28
Injection, morphine sulfate, preservative-free for
							 epidural or intrathecal use, 10mg
J2407
21.77
Injection, oritavancin, 10 mg
J2545
96.68
Pentamidine isethionate, inhalation solution,
							 FDA-approved final product, on-compounded, administered through DME, unit dose
							 form, per 300 mg
J2920
2.46
Injection, methylprednisolone sodium succinate, up to
							 40 mg
J2930
3.49
Injection, methylprednisolone sodium succinate, up to
							 125 mg
J3010
0.60
Injection, fentanyl citrate, 0.1 mg
J3090
1.03
Injection, tedizolid phosphate, 1 mg
J3285
52.49
Injection, treprostinil, 1 mg
J3380
14.47
Injection, vedolizumab, 1 mg
J3489
23.40
Injection, zoledronic acid, 1 mg
Miscellaneous Drugs and Solutions
J7340
AAC
Carbidopa 5 mg/levodopa 20 mg enteral
							 suspension
J7500
0.14
Azathioprine, oral, 50 mg
J7501
77.66
Azathioprine, parenteral, 100 mg
J7502
2.86
Cyclosporine, oral, 100 mg
J7503
AAC
Tacrolimus, extended release, (Envarsus XR), oral,
							 0.25 mg
J7504
966.39
Lymphocyte immune globulin, antithymocyte globulin,
							 equine, parenteral, 250 mg
J7505
982.67
Muromonab-CD3, parenteral, 5 mg
J7507
0.72
Tacrolimus, oral, per 1 mg
J7508
0.33
Tacrolimus, extended release, (Astagraf XL). oral,
							 0.1 mg
J7509
0.28
Methylprednisolone oral, per 4 mg
J7510
0.11
Prednisolone oral, per 5 mg
J7511
546.55
Lymphocyte immune globulin, antithymocyte globulin,
							 rabbit, parenteral, 25mg
J7512
0.01
Prednisone, immediate release or delayed release,
							 oral, 1 mg
J7513
447.39
Daclizumab, parenteral, 25 mg
J7515
0.83
Cyclosporine, oral, 25 mg
J7516
36.29
Cyclosporine, parenteral, 250 mg
J7517
0.86
Mycophenolate mofetil, oral, 250 mg
J7518
2.60
Mycophenolic acid, oral, 180 mg
J7520
7.50
Sirolimus, oral, 1 mg
J7525
139.77
Tacrolimus, parenteral, 5 mg
J7527
AAC
Everolimus, oral, 0.25 mg
Inhalation Drugs
J7605KO
7.02
Arformoterol, inhalation solution, FDA approved final
							 product, non-compounded administered through DME, unit dose form, 15 micrograms
							 (single drug unit dose formulation)
J7606KO
8.00
Formoterol fumarate, inhalation solution, FDA
							 approved final product, non-compounded, administered through DME, unit dose
							 form, 20 micrograms
J7608KO
3.42
Acetylcysteine, inhalation solution, FDA-approved
							 final product, non-compunded, administered through DME, unit dose form, per
							 gram (single drug unit dose formulation)
J7609
0.05
Albuterol, inhalation solution, compounded product,
							 administered through DME, unit dose, 1 mg
J7611
0.10
Albuterol, inhalation solution, FDA-approved final
							 product, non-compounded, administered through DME, concentrated form, 1
							 mg
J7612
0.24
Levalbuterol, inhalation solution, FDA-approved final
							 product, non-compounded, administered through DME, concentrated form, 0.5
							 mg
J7613KO
0.04
Albuterol, inhalation solution, FDA-approved final
							 product, non-compounded, administered through DME, unit dose, 1mg (single drug
							 unit dose formulation)
J7614KO
0.07
Levalbuterol, inhalation solution, FDA-approved final
							 product, non-compounded, administered through DME, unit dose, 0.5mg (single
							 drug unit dose formulation)
J7620
0.13
Albuterol, up to 2.5 mg and ipratropium bromide, up
							 to 0.5 mg, FDA-approved final product, non-compounded, administered through
							 DME
J7626KO
4.52
Budesonide inhalation solution, FDA-approved final
							 product, non-compounded, administered through DME, unit dose form, up to 0.50
							 mg (single drug unit dose formulation)
J7631KO
0.68
Cromolyn sodium, inhalation solution, FDA-approved
							 final product, non-compounded, administered through DME, unit dose form, per 10
							 milligrams (single drug unit dose formulation)
J7639KO
33.14
Dornase alpha, inhalation solution, FDA-approved
							 final product, non-compounded, administered through DME, unit dose form, per
							 milligram (single drug unit dose formulation)
J7644KO
0.18
Ipratropium bromide, inhalation solution,
							 FDA-approved final product, non-compounded, administered through DME, unit dose
							 form, per milligram (single drug unit dose formulation)
J7669KO
0.37
Metaproterenol sulfate, inhalation solution,
							 FDA-approved final product, non-compounded, administered through DME, unit dose
							 form, per 10 milligrams (single drug unit dose formulation)
J7682KO
47.27
Tobramycin, inhalation solution, FDA-approved final
							 product, non-compounded, unit dose form, 300 mg, inhalation solution,
							 administered through DME (single drug unit dose formulation)
J7686KO
430.47
Treprostinil, inhalation solution, FDA-approved final
							 product, non-compounded, administered through dme, unit dose form, 1.74
							 mg
J7999
AAC
Compounded drug, not otherwise classified
J8501
8.67
Aprepitant, oral, 5 mg
J8520
4.45
Capecitabine, oral, 150 mg
J8521
14.15
Capecitabine, oral, 500 mg
J8530
3.12
Cyclophosphamide; oral, 25 mg
J8540
0.11
Dexamethasone, oral, 0.25 mg
J8610
1.18
Methotrexate; oral, 2.5 mg
J8650
28.99
Nabilone, oral, 1 mg
J8655
419.97
Netupitant 300 Mg and Palonosetron 0.5 Mg,
							 oral
J8670
2.65
Rolapitant, oral, 1 mg
Chemotherapy Drugs
J9000
10.66
Injection, doxorubicin hydrochloride, 10
							 mg
J9032
27.63
Injection, belinostat, 10 mg
J9039
AAC
Injection, blinatumomab, 1 microgram
J9040
245.96
Injection, bleomycin sulfate, 15 units
J9065
52.46
Injection, cladribine, per 1 mg
J9100
6.96
Cytarabine, 100 mg
J9190
1.76
Injection, fluorouracil, 500 mg
J9200
116.28
Floxuridine, 500 mg
J9208
127.82
Ifosfamide, 1 gm
J9271
38.84
Injection, pembrolizumab, 1 mg
J9299
21.56
Injection, nivolumab, 1 mg
J9308
45.91
Injection, ramucirumab, 5 mg
J9360
3.49
Injection, vinblastine sulfate, 1 mg
J9370
28.88
Vincristine sulfate, 1 mg
J9390
92.65
Injection, vinorelbine tartrate, 10 mg
K Codes (Temporary) K0000-K9999
Wheelchair and Wheelchair Accessories
K0001KH
36.41
Standard wheelchair (capped rental)
K0001KI
36.41
Standard wheelchair (capped rental)
K0001KJ
27.31
Standard wheelchair (capped rental)
K0001NU
364.14
Standard wheelchair (new equipment
							 purchase)
K0001UE
273.11
Standard wheelchair (used equipment
							 purchase)
K0002KH
53.61
Standard hemi (low seat) wheelchair (capped
							 rental)
K0002KI
53.61
Standard hemi (low seat) wheelchair (capped
							 rental)
K0002KJ
40.21
Standard hemi (low seat) wheelchair (capped
							 rental)
K0002NU
536.10
Standard hemi (low seat) wheelchair (new equipment
							 purchase)
K0002UE
402.08
Standard hemi (low seat) wheelchair (used durable
							 medical equipment purchase)
K0003KH
59.43
Lightweight wheelchair (capped rental)
K0003KI
59.43
Lightweight wheelchair (capped rental)
K0003KJ
44.57
Lightweight wheelchair (capped rental)
K0003NU
594.32
Lightweight wheelchair (new equipment
							 purchase)
K0003UE
445.74
Lightweight wheelchair (used durable medical
							 equipment purchase)
K0004KH
84.77
High strength, lightweight wheelchair (capped
							 rental)
K0004KI
84.77
High strength, lightweight wheelchair (capped
							 rental)
K0004KJ
63.58
High strength, lightweight wheelchair (capped
							 rental)
K0004NU
847.71
High strength, lightweight wheelchair (new equipment
							 purchase)
K0004UE
635.78
High strength, lightweight wheelchair (used durable
							 medical equipment purchase)
K0005NU
1,737.26
Ultralightweight wheelchair (new
							 equipment)
K0005RR
173.71
Ultralightweight wheelchair (rental)
K0005UE
1,302.91
Ultralightweight wheelchair (used durable medical
							 equipment)
K0006KH
90.73
Heavy duty wheelchair (capped rental)
K0006KI
90.73
Heavy duty wheelchair (capped rental)
K0006KJ
68.05
Heavy duty wheelchair (capped rental)
K0006NU
907.29
Heavy duty wheelchair (new equipment
							 purchase)
K0006UE
680.47
Heavy duty wheelchair (used durable medical
							 equipment)
K0007KH
132.20
Extra heavy duty wheelchair (capped
							 rental)
K0007KI
132.20
Extra heavy duty wheelchair (capped
							 rental)
K0007KJ
99.15
Extra heavy duty wheelchair (capped
							 rental)
K0007NU
1,322.01
Extra heavy duty wheelchair (new equipment
							 purchase)
K0007UE
991.51
Extra heavy duty wheelchair (used durable medical
							 equipment)
K0008
AAC+35%
Custom manual wheelchair base
K0009KH
79.01
Other manual wheelchair/base (capped
							 rental)
K0009KI
79.01
Other manual wheelchair/base (capped
							 rental)
K0009KJ
59.26
Other manual wheelchair/base (capped
							 rental)
K0009NU
790.10
Other manual wheelchair/base (new
							 equipment)
K0009UE
592.58
Other manual wheelchair/base (used durable medical
							 equipment)
K0010KH
470.93
Standard-weight frame, motorized/power wheelchair
							 (capped rental)
K0010KI
470.93
Standard-weight frame, motorized/power wheelchair
							 (capped rental)
K0010KJ
353.20
Standard-weight frame, motorized/power wheelchair
							 (capped rental)
K0010NU
4,709.30
Standard-weight frame, motorized/power wheelchair
							 (new equipment purchase)
K0010UE
3,531.98
Standard-weight frame, motorized/power wheelchair
							 (used durable medical equipment)
K0011KH
566.33
Standard - weight frame motorized/power wheelchair
							 with programmable control parameters for speed adjustment, tremor dampening,
							 acceleration control and braking (capped rental)
K0011KHKF
628.76
Standard - weight frame motorized/power wheelchair
							 with programmable control parameters for speed adjustment, tremor dampening,
							 acceleration control and braking (capped rental) (FDA class III
							 device)
K0011KI
566.33
Standard - weight frame motorized/power wheelchair
							 with programmable control parameters for speed adjustment, tremor dampening,
							 acceleration control and braking (capped rental)
K0011KIKF
628.76
Standard - weight frame motorized/power wheelchair
							 with programmable control parameters for speed adjustment, tremor dampening,
							 acceleration control and braking (capped rental) (FDA class III
							 device)
K0011KJ
424.75
Standard - weight frame motorized/power wheelchair
							 with programmable control parameters for speed adjustment, tremor dampening,
							 acceleration control and braking (capped rental)
K0011KJKF
471.57
Standard - weight frame motorized/power wheelchair
							 with programmable control parameters for speed adjustment, tremor dampening,
							 acceleration control and braking (capped rental) (FDA class III
							 device)
K0011NU
5,663.30
Standard - weight frame motorized/power wheelchair
							 with programmable control parameters for speed adjustment, tremor dampening,
							 acceleration control and braking (new equipment purchase)
K0011NUKF
6,287.60
Standard - weight frame motorized/power wheelchair
							 with programmable control parameters for speed adjustment, tremor dampening,
							 acceleration control and braking (new equipment purchase) (FDA class III
							 device)
K0011UE
4,247.48
Standard - weight frame motorized/power wheelchair
							 with programmable control parameters for speed adjustment, tremor dampening,
							 acceleration control and braking (used durable medical equipment)
K0011UEKF
4,715.70
Standard - weight frame motorized/power wheelchair
							 with programmable control parameters for speed adjustment, tremor dampening,
							 acceleration control and braking (used durable medical equipment) (FDA class
							 III device)
K0012KH
359.21
Lightweight portable motorized/power wheelchair
							 (capped rental)
K0012KI
359.21
Lightweight portable motorized/power wheelchair
							 (capped rental)
K0012KJ
269.41
Lightweight portable motorized/power wheelchair
							 (capped rental)
K0012NU
3,592.10
Lightweight portable motorized/power wheelchair (new
							 equipment purchase)
K0012UE
2,694.08
Lightweight portable motorized/power wheelchair (used
							 durable medical equipment)
K0013
AAC+35%
Custom motorized/power wheelchair base
K0015KH
14.59
Detachable, non-adjustable height armrest,
							 replacement only, each (capped rental)
K0015KHKU
17.62
Detachable, non-adjustable height armrest,
							 replacement only, each (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0015KI
14.59
Detachable, non-adjustable height armrest,
							 replacement only, each (capped rental)
K0015KIKU
17.62
Detachable, non-adjustable height armrest,
							 replacement only, each (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0015KJ
10.94
Detachable, non-adjustable height armrest,
							 replacement only, each (capped rental)
K0015KJKU
13.22
Detachable, non-adjustable height armrest,
							 replacement only, each (capped rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0015NU
145.89
Detachable, non-adjustable height armrest,
							 replacement only, each (new equipment)
K0015NUKU
176.20
Detachable, non-adjustable height armrest,
							 replacement only, each (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0015UE
109.41
Detachable, non-adjustable height armrest,
							 replacement only, each (used durable medical equipment)
K0015UEKU
132.15
Detachable, non-adjustable height armrest,
							 replacement only, each (used durable medical equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0017NU
46.16
Detachable, adjustable height armrest, base,
							 replacement only, each (new equipment)
K0017NUKU
49.57
Detachable, adjustable height armrest, base,
							 replacement only, each (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0017RR
4.62
Detachable, adjustable height armrest, base,
							 replacement only, each (rental)
K0017RRKU
4.95
Detachable, adjustable height armrest, base,
							 replacement only, each (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
K0017UE
34.62
Detachable, adjustable height armrest, base,
							 replacement only, each (used durable medical equipment)
K0017UEKU
37.18
Detachable, adjustable height armrest, base,
							 replacement only, each (used durable medical equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0018NU
25.93
Detachable, adjustable height armrest, upper portion,
							 replacement only, each (new equipment)
K0018NUKU
27.69
Detachable, adjustable height armrest, upper portion,
							 replacement only, each (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0018RR
2.59
Detachable, adjustable height armrest, upper portion,
							 replacement only, each (rental)
K0018RRKU
2.76
Detachable, adjustable height armrest, upper portion,
							 replacement only, each (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
K0018UE
19.45
Detachable, adjustable height armrest, upper portion,
							 replacement only, each (used durable medical equipment)
K0018UEKU
20.78
Detachable, adjustable height armrest, upper portion,
							 replacement only, each (used durable medical equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0019NU
13.59
Arm pad, replacement only, each (new
							 equipment)
K0019NUKU
16.65
Arm pad, replacement only, each (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0019RR
1.36
Arm pad, replacement only, each (rental)
K0019RRKU
1.66
Arm pad, replacement only, each (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
K0019UE
10.19
Arm pad, replacement only, each (used durable medical
							 equipment)
K0019UEKU
12.50
Arm pad, replacement only, each (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0020NU
43.51
Fixed, adjustable height armrest, pair (new
							 equipment)
K0020NUKU
45.07
Fixed, adjustable height armrest, pair (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0020RR
4.35
Fixed, adjustable height armrest, pair
							 (rental)
K0020RRKU
4.51
Fixed, adjustable height armrest, pair (rental),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0020UE
32.63
Fixed, adjustable height armrest, pair (used durable
							 medical equipment)
K0020UEKU
33.80
Fixed, adjustable height armrest, pair (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0037NU
43.47
High mount flip-up footrest, each (new
							 equipment)
K0037NUKU
46.72
High mount flip-up footrest, each (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0037RR
3.78
High mount flip-up footrest, each
							 (rental)
K0037RRKU
3.85
High mount flip-up footrest, each (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
K0037UE
32.61
High mount flip-up footrest, each (used durable
							 medical equipment)
K0037UEKU
35.05
High mount flip-up footrest, each (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0038NU
22.47
Leg strap, each (new equipment)
K0038NUKU
23.55
Leg strap, each (new equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0038RR
2.25
Leg strap, each (rental)
K0038RRKU
2.36
Leg strap, each (rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
K0038UE
16.84
Leg strap, each (used durable medical
							 equipment)
K0038UEKU
17.64
Leg strap, each (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0039NU
49.08
Leg strap, H style, each (new equipment)
K0039NUKU
52.26
Leg strap, H style, each (new equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
K0039RR
4.92
Leg strap, H style, each (rental)
K0039RRKU
5.26
Leg strap, H style, each (rental), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
K0039UE
36.81
Leg strap, H style, each (used durable medical
							 equipment)
K0039UEKU
39.21
Leg strap, H style, each (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0040NU
59.48
Adjustable angle footplate, each (new
							 equipment)
K0040NUKU
72.44
Adjustable angle footplate, each (new equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0040RR
5.94
Adjustable angle footplate, each (rental)
K0040RRKU
7.23
Adjustable angle footplate, each (rental), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
K0040UE
44.60
Adjustable angle footplate, each (used durable
							 medical equipment)
K0040UEKU
54.30
Adjustable angle footplate, each (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0041NU
47.58
Large size footplate, each (new
							 equipment)
K0041NUKU
51.33
Large size footplate, each (new equipment), (DMEPOS
							 item subject to DMEPOS competitive bidding program number 3)
K0041RR
4.78
Large size footplate, each (rental)
K0041RRKU
5.18
Large size footplate, each (rental), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
K0041UE
35.69
Large size footplate, each (used durable medical
							 equipment)
K0041UEKU
38.49
Large size footplate, each (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0042NU
31.73
Standard size footplate, replacement only, each (new
							 equipment)
K0042NUKU
35.34
Standard size footplate, replacement only, each (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0042RR
3.17
Standard size footplate, replacement only, each
							 (rental)
K0042RRKU
3.53
Standard size footplate, replacement only, each
							 (rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0042UE
23.79
Standard size footplate, replacement only, each (used
							 durable medical equipment)
K0042UEKU
26.50
Standard size footplate, replacement only, each (used
							 durable medical equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
K0043NU
18.17
Footrest, lower extension tube, replacement only,
							 each (new equipment)
K0043NUKU
18.94
Footrest, lower extension tube, replacement only,
							 each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
K0043RR
1.81
Footrest, lower extension tube, replacement only,
							 each (rental)
K0043RRKU
1.88
Footrest, lower extension tube, replacement only,
							 each (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0043UE
13.65
Footrest, lower extension tube, replacement only,
							 each (used durable medical equipment)
K0043UEKU
14.23
Footrest, lower extension tube, replacement only,
							 each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0044NU
15.65
Footrest, upper hanger bracket, replacement only,
							 each (new equipment)
K0044NUKU
16.15
Footrest, upper hanger bracket, replacement only,
							 each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
K0044RR
1.57
Footrest, upper hanger bracket, replacement only,
							 each (rental)
K0044RRKU
1.62
Footrest, upper hanger bracket, replacement only,
							 each (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0044UE
11.73
Footrest, upper hanger bracket, replacement only,
							 each (used durable medical equipment)
K0044UEKU
12.10
Footrest, upper hanger bracket, replacement only,
							 each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0045NU
52.36
Footrest, complete assembly, replacement only, each
							 (new equipment)
K0045NUKU
54.93
Footrest, complete assembly, replacement only, each
							 (new equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0045RR
5.32
Footrest, complete assembly, replacement only, each
							 (rental)
K0045RRKU
5.66
Footrest, complete assembly, replacement only, each
							 (rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0045UE
39.28
Footrest, complete assembly, replacement only, each
							 (used durable medical equipment)
K0045UEKU
41.20
Footrest, complete assembly, replacement only, each
							 (used durable medical equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
K0046NU
18.23
Elevating legrest, lower extension tube, replacement
							 only, each (new equipment)
K0046NUKU
18.94
Elevating legrest, lower extension tube, replacement
							 only, each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
K0046RR
1.82
Elevating legrest, lower extension tube, replacement
							 only, each (rental)
K0046RRKU
1.88
Elevating legrest, lower extension tube, replacement
							 only, each (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0046UE
13.69
Elevating legrest, lower extension tube, replacement
							 only, each (used durable medical equipment)
K0046UEKU
14.23
Elevating legrest, lower extension tube, replacement
							 only, each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0047NU
67.99
Elevating legrest, upper hanger bracket, replacement
							 only, each (new equipment)
K0047NUKU
74.19
Elevating legrest, upper hanger bracket, replacement
							 only, each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
K0047RR
6.81
Elevating legrest, upper hanger bracket, replacement
							 only, each (rental)
K0047RRKU
7.44
Elevating legrest, upper hanger bracket, replacement
							 only, each (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0047UE
50.98
Elevating legrest, upper hanger bracket, replacement
							 only, each (used durable medical equipment)
K0047UEKU
55.62
Elevating legrest, upper hanger bracket, replacement
							 only, each (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0050NU
30.12
Ratchet assembly replacement only (new
							 equipment)
K0050NUKU
32.55
Ratchet assembly, replacement only
K0050RR
3.01
Ratchet assembly replacement only
							 (rental)
K0050RRKU
3.24
Ratchet assembly, replacement only
K0050UE
22.60
Ratchet assembly replacement only (used durable
							 medical equipment)
K0050UEKU
24.62
Ratchet assembly, replacement only
K0051NU
48.22
Cam release assembly, footrest or legrest,
							 replacement only, each (new equipment)
K0051NUKU
51.03
Cam release assembly, footrest or legrest,
							 replacement only, each (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0051RR
4.84
Cam release assembly, footrest or legrest,
							 replacement only, each (rental)
K0051RRKU
5.14
Cam release assembly, footrest or legrest,
							 replacement only, each (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
K0051UE
36.16
Cam release assembly, footrest or legrest,
							 replacement only, each (used durable medical equipment)
K0051UEKU
38.26
Cam release assembly, footrest or legrest,
							 replacement only, each (used durable medical equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0052NU
74.44
Swingaway, detachable footrests, replacement only,
							 each (new equipment)
K0052NUKU
89.69
Swingaway, detachable footrests, replacement only,
							 each (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
K0052RR
7.44
Swingaway, detachable footrests, replacement only,
							 each (rental)
K0052RRKU
8.96
Swingaway, detachable footrests, replacement only,
							 each (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0052UE
55.82
Swingaway, detachable footrests, each (used durable
							 medical equipment)
K0052UEKU
67.23
Swingaway, detachable footrests, each (used durable
							 medical equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0053NU
90.84
Elevating footrests, articulating (telescoping), each
							 (new equipment)
K0053NUKU
98.96
Elevating footrests, articulating (telescoping), each
							 (new equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0053RR
9.08
Elevating footrests, articulating (telescoping), each
							 (rental)
K0053RRKU
9.89
Elevating footrests, articulating (telescoping), each
							 (rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0053UD
AAC+35%
Elevating footrests, articulating (telescoping), each
							 (bariatric equipment)
K0053UE
68.13
Elevating footrests, articulating (telescoping), each
							 (used durable medical equipment)
K0053UEKU
74.22
Elevating footrests, articulating (telescoping), each
							 (used durable medical equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
K0056NU
96.40
Seat height less than 17 inches or equal to or
							 greater than 21 inches for a high strength, lightweight, or ultralightweight
							 wheelchair (new equipment)
K0056NUKU
107.04
Seat height less than 17 inches or equal to or
							 greater than 21 inches for a high strength, lightweight, or ultralightweight
							 wheelchair (new equipment), (DMEPOS item subject to DMEPOS competitive bidding
							 program number 3)
K0056RR
9.64
Seat height less than 17 inches or equal to or
							 greater than 21 inches for a high strength, lightweight, or ultralightweight
							 wheelchair (rental)
K0056RRKU
10.71
Seat height less than 17 inches or equal to or
							 greater than 21 inches for a high strength, lightweight, or ultralightweight
							 wheelchair (rental), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0056UE
72.31
Seat height less than 17 inches or equal to or
							 greater than 21 inches for a high strength, lightweight, or ultralightweight
							 wheelchair (used durable medical equipment)
K0056UEKU
80.29
Seat height less than 17 inches or equal to or
							 greater than 21 inches for a high strength, lightweight, or ultralightweight
							 wheelchair (used durable medical equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0065NU
46.17
Spoke protectors, each (new equipment)
K0065NUKU
50.02
Spoke protectors, each (new equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
K0065RR
4.62
Spoke protectors, each (rental)
K0065RRKU
5.00
Spoke protectors, each (rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0065UE
34.63
Spoke protectors, each (used durable medical
							 equipment)
K0065UEKU
37.53
Spoke protectors, each (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0069NU
97.90
Rear wheel assembly, complete, with solid tire,
							 spokes or molded, replacement only, each (new equipment)
K0069NUKU
112.47
Rear wheel assembly, complete, with solid tire,
							 spokes or molded, replacement only, each (new equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0069RR
10.02
Rear wheel assembly, complete, with solid tire,
							 spokes or molded, replacement only, each (rental)
K0069RRKU
11.71
Rear wheel assembly, complete, with solid tire,
							 spokes or molded, replacement only, each (rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
K0069UE
73.42
Rear wheel assembly, complete, with solid tire,
							 spokes or molded, replacement only, each (used durable medical
							 equipment)
K0069UEKU
84.35
Rear wheel assembly, complete, with solid tire,
							 spokes or molded, replacement only, each (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0070KH
17.48
Rear wheel assembly, complete, with pneumatic tire,
							 spokes or molded, replacement only, each (capped rental)
K0070KHKU
20.63
Rear wheel assembly, complete, with pneumatic tire,
							 spokes or molded, replacement only, each (capped rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0070KI
17.48
Rear wheel assembly, complete, with pneumatic tire,
							 spokes or molded, replacement only, each (capped rental)
K0070KIKU
20.63
Rear wheel assembly, complete, with pneumatic tire,
							 spokes or molded, replacement only, each (capped rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0070KJ
13.11
Rear wheel assembly, complete, with pneumatic tire,
							 spokes or molded, replacement only, each (capped rental)
K0070KJKU
15.47
Rear wheel assembly, complete, with pneumatic tire,
							 spokes or molded, replacement only, each (capped rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0070NU
174.74
Rear wheel assembly, complete, with pneumatic tire,
							 spokes or molded, replacement only, each (new equipment)
K0070NUKU
206.30
Rear wheel assembly, complete, with pneumatic tire,
							 spokes or molded, replacement only, each (new equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0070UE
131.06
Rear wheel assembly, complete, with pneumatic tire,
							 spokes or molded, replacement only, each (used durable medical
							 equipment)
K0070UEKU
154.73
Rear wheel assembly, complete, with pneumatic tire,
							 spokes or molded, replacement only, each (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0071NU
112.26
Front caster assembly, complete, with pneumatic tire,
							 replacement only, each (new equipment)
K0071NUKU
122.96
Front caster assembly, complete, with pneumatic tire,
							 replacement only, each (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0071RR
11.23
Front caster assembly, complete, with pneumatic tire,
							 replacement only, each (rental)
K0071RRKU
12.30
Front caster assembly, complete, with pneumatic tire,
							 replacement only, each (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
K0071UE
84.18
Front caster assembly, complete, with pneumatic tire,
							 replacement only, each (used durable medical equipment)
K0071UEKU
92.19
Front caster assembly, complete, with pneumatic tire,
							 replacement only, each (used durable medical equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0072NU
68.29
Front caster assembly, complete, with semi-pneumatic
							 tire, replacement only, each (new equipment)
K0072NUKU
74.03
Front caster assembly, complete, with semi-pneumatic
							 tire, replacement only, each (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0072RR
6.83
Front caster assembly, complete, with semi-pneumatic
							 tire, replacement only, each (rental)
K0072RRKU
7.40
Front caster assembly, complete, with semi-pneumatic
							 tire, replacement only, each (rental), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0072UE
51.21
Front caster assembly, complete, with semi-pneumatic
							 tire, replacement only, each (used durable medical equipment)
K0072UEKU
55.50
Front caster assembly, complete, with semi-pneumatic
							 tire, replacement only, each (used durable medical equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
K0073NU
36.51
Caster pin lock, each (new equipment)
K0073NUKU
39.18
Caster pin lock, each (new equipment), (DMEPOS item
							 subject to DMEPOS competitive bidding program number 3)
K0073RR
3.65
Caster pin lock, each (rental)
K0073RRKU
3.92
Caster pin lock, each (rental), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0073UE
27.38
Caster pin lock, each (used durable medical
							 equipment)
K0073UEKU
29.37
Caster pin lock, each (used durable medical
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0077NU
55.88
Front caster assembly, complete, with solid tire,
							 replacement only, each (new equipment)
K0077NUKU
66.25
Front caster assembly, complete, with solid tire,
							 replacement only, each (new equipment), (DMEPOS item subject to DMEPOS
							 competitive bidding program number 3)
K0077RR
5.58
Front caster assembly, complete, with solid tire,
							 replacement only, each (rental)
K0077RRKU
6.61
Front caster assembly, complete, with solid tire,
							 replacement only, each (rental), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
K0077UE
41.90
Front caster assembly, complete, with solid tire,
							 replacement only, each (used durable medical equipment)
K0077UEKU
49.66
Front caster assembly, complete, with solid tire,
							 replacement only, each (used durable medical equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0098NU
24.56
Drive belt for power wheelchair replacement only (new
							 equipment)
K0098NUKU
26.40
Drive belt for power wheelchair replacement only (new
							 equipment), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0098RR
2.46
Drive belt for power wheelchair replacement only
							 (rental)
K0098RRKU
2.65
Drive belt for power wheelchair replacement only
							 (rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0098UE
18.41
Drive belt for power wheelchair replacement only
							 (used durable medical equipment)
K0098UEKU
19.78
Drive belt for power wheelchair replacement only
							 (used durable medical equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
K0105NU
102.99
IV hanger, each (new equipment)
K0105NUKU
111.91
IV hanger, each (new equipment), (DMEPOS item subject
							 to DMEPOS competitive bidding program number 3)
K0105RR
10.30
IV hanger, each (rental)
K0105RRKU
11.19
IV hanger, each (rental), (DMEPOS item subject to
							 DMEPOS competitive bidding program number 3)
K0105UE
77.25
IV hanger, each (used durable medical
							 equipment)
K0105UEKU
83.93
IV hanger, each (used durable medical equipment),
							 (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0108NU
AAC+35%
Wheelchair component or accessory, not otherwise
							 specified (new equipment)
K0108RA
47.03
Wheelchair component or accessory, not otherwise
							 specified (for MassHealth purposes only K0108RA is to be a separate line item
							 on a PA/claim for the sole usage of the direct service components RE1-RE23)
							 (per hour)
K0108RB
AAC+35%
Wheelchair component or accessory, not otherwise
							 specified (for MassHealth purposes only K0108RB is to be used for replacement
							 of a part that has no HIPAA-compliant HCPCCS code)
K0195KH
14.01
Elevating leg rests, pair (for use with capped rental
							 wheelchair base) (capped rental)
K0195KHKU
17.94
Elevating leg rests, pair (for use with capped rental
							 wheelchair base)
K0195KI
14.01
Elevating leg rests, pair (for use with capped rental
							 wheelchair base) (capped rental)
K0195KIKU
17.94
Elevating leg rests, pair (for use with capped rental
							 wheelchair base)
K0195KJ
10.51
Elevating leg rests, pair (for use with capped rental
							 wheelchair base) (capped rental)
K0195KJKU
13.46
Elevating leg rests, pair (for use with capped rental
							 wheelchair base)
K0195NU
140.10
Elevating leg rests, pair (for use with capped rental
							 wheelchair base) (new equipment purchase)
K0195NUKU
179.40
Elevating leg rests, pair (for use with capped rental
							 wheelchair base)
K0195UE
105.08
Elevating leg rests, pair (for use with capped rental
							 wheelchair base) (used durable medical equipment purchase)
K0195UEKU
134.55
Elevating leg rests, pair (for use with capped rental
							 wheelchair base)
Equipment, Replacement, Repair, Rental
K0455RR
248.89
Infusion pump used for uninterrupted parenteral
							 administration of medication, epoprostenol or treprostinol (rental)
K0462
I.C.
Temporary replacement of patient-owned equipment
							 being repaired, any type
K0552
2.35
Supplies for external non-insulin infusion pump,
							 syringe type cartridge, sterile, each
K0553
248.38
Supply allowance for therapeutic continuous glucose
							 monitor (CGM), includes all supplies and accessories, 1 unit = 1 month's
							 supply
K0554NU
239.37
Receiver (monitor), dedicated, for use with
							 therapeutic continuous glucose monitor system (new equipment)
K0554RR
23.94
Receiver (monitor), dedicated, for use with
							 therapeutic continuous glucose monitor system (rental)
K0554UE
179.53
Receiver (monitor), dedicated, for use with
							 therapeutic continuous glucose monitor system (used durable medical
							 equipment)
K0601NU
1.02
Replacement battery for external infusion pump owned
							 by patient, silver oxide, 1.5 volt, each
K0602NU
5.81
Replacement battery for external infusion pump owned
							 by patient, silver oxide, 3 volt, each
K0603NU
0.52
Replacement battery for external infusion pump owned
							 by patient, alkaline, 1.5 volt, each
K0604NU
5.58
Replacement battery for external infusion pump owned
							 by patient, lithium, 3.6 volt, each
K0605NU
13.38
Replacement battery for external infusion pump owned
							 by patient, lithium, 4.5 volt, each
K0606KHKF
2,366.38
Automatic external defibrillator with integrated
							 electrocardiogram analysis, garment type (capped rental) (FDA class III
							 device)
K0606KIKF
2,366.38
Automatic external defibrillator with integrated
							 electrocardiogram analysis, garment type (capped rental) (FDA class III
							 device)
K0606KJKF
1,774.79
Automatic external defibrillator with integrated
							 electrocardiogram analysis, garment type (capped rental) (FDA class III
							 device)
K0606NUKF
23,663.83
Automatic external defibrillator with integrated
							 electrocardiogram analysis, garment type (new equipment purchase) (FDA class
							 III device)
K0606UEKF
17,747.87
Automatic external defibrillator with integrated
							 electrocardiogram analysis, garment type (used durable medical equipment
							 purchase) (FDA class III device)
K0607KH
18.26
Replacement battery for automatic external
							 defibrillator, each (capped rental)
K0607KHKF
20.26
Replacement battery for automatic external
							 defibrillator, each (capped rental) (FDA class III device)
K0607KI
18.26
Replacement battery for automatic external
							 defibrillator, each (capped rental)
K0607KIKF
20.26
Replacement battery for automatic external
							 defibrillator, each (capped rental) (FDA class III device)
K0607KJ
13.69
Replacement battery for automatic external
							 defibrillator, each (capped rental)
K0607KJKF
15.20
Replacement battery for automatic external
							 defibrillator, each (capped rental) (FDA class III device)
K0607NU
182.58
Replacement battery for automatic external
							 defibrillator, each (new equipment)
K0607NUKF
202.64
Replacement battery for automatic external
							 defibrillator, each (new equipment) (FDA class III device)
K0607UE
136.94
Replacement battery for automatic external
							 defibrillator, each (used durable medical equipment)
K0607UEKF
151.98
Replacement battery for automatic external
							 defibrillator, each (used durable medical equipment) (FDA class III
							 device)
K0608NU
113.89
Replacement garment for use with automatic external
							 defibrillator, each (new equipment)
K0608NUKF
126.47
Replacement garment for use with automatic external
							 defibrillator, each (new equipment) (FDA class III device)
K0608RR
11.42
Replacement garment for use with automatic external
							 defibrillator, each (rental)
K0608RRKF
12.67
Replacement garment for use with automatic external
							 defibrillator, each (rental) (FDA class III device)
K0608UE
85.43
Replacement garment for use with automatic external
							 defibrillator, each (used durable medical equipment)
K0608UEKF
94.84
Replacement garment for use with automatic external
							 defibrillator, each (used durable medical equipment) (FDA class III
							 device)
K0609NU
757.46
Replacement electrodes for use with automatic
							 external defibrillator, each (new equipment)
K0609NUKF
840.98
Replacement electrodes for use with automatic
							 external defibrillator, each (new equipment) (FDA class III device)
K0669
AAC+35%
Wheelchair accessory, wheelchair seat or back
							 cushion, does not meet specific code criteria or no written coding verification
							 from DME PDAC
K0730KH
162.00
Controlled dose inhalation drug delivery system
							 (capped rental)
K0730KI
162.00
Controlled dose inhalation drug delivery system
							 (capped rental)
K0730KJ
121.50
Controlled dose inhalation drug delivery system
							 (capped rental)
K0730NU
1,620.02
Controlled dose inhalation drug delivery system (new
							 equipment)
K0730UE
1,215.02
Controlled dose inhalation drug delivery system (used
							 durable medical equipment purchase)
K0733NU
23.32
Power wheelchair accessory, 12 to 24 amp hour sealed
							 lead acid battery, each (
e.g.
gel cell, absorbed glassmat)
							 (new equipment)
K0733NUKU
29.30
Power wheelchair accessory, 12 to 24 amp hour sealed
							 lead acid battery, each (
e.g.
gel cell, absorbed glassmat)
							 (new equipment), (DMEPOS item subject to DMEPOS competitive bidding program
							 number 3)
K0733RR
2.34
Power wheelchair accessory, 12 to 24 amp hour sealed
							 lead acid battery, each (
e.g.
gel cell, absorbed glassmat)
							 (rental)
K0733RRKU
2.95
Power wheelchair accessory, 12 to 24 amp hour sealed
							 lead acid battery, each (
e.g.
gel cell, absorbed glassmat)
							 (rental), (DMEPOS item subject to DMEPOS competitive bidding program number
							 3)
K0733UE
17.50
Power wheelchair accessory, 12 to 24 amp hour sealed
							 lead acid battery, each (
e.g.
gel cell, absorbed glassmat)
							 (used durable medical equipment)
K0733UEKU
21.99
Power wheelchair accessory, 12 to 24 amp hour sealed
							 lead acid battery, each (
e.g.
gel cell, absorbed glassmat)
							 (used durable medical equipment), (DMEPOS item subject to DMEPOS competitive
							 bidding program number 3)
K0738RR
40.26
Portable gaseous oxygen system, rental; home
							 compressor used to fill portable oxygen cylinders; includes portable
							 containers, regulator, flowmeter, humidifier, cannula or mask, and tubing
							 (rental)
K0739RB
21.11
Repair or nonroutine service for durable medical
							 equipment other than oxygen requiring the skill of a technician, labor
							 component, per 15 minutes (repair, excluding ATP providers)
K0739U5
46.33
Direct Service Component (RE) units for evaluation of
							 complex mobility systems, for installation of custom movable and fixed patient
							 lift systems RE1-RE23, and installation of pediatric/turned adult safety beds
							 RE1-RE5. One RE unit equals 1 hour
K0739UB
24.83
Repair or nonroutine service for durable medical
							 equipment other than oxygen requiring the skill of a technician, labor
							 component, per 15 minutes (repair, ATP providers only)
K0740RB
24.83
Repair or nonroutine service for oxygen equipment
							 requiring the skill of a technician, labor component, per 15 minutes (repair,
							 excluding ATP providers)
K0743RR
I.C.
Suction pump, home model, portable, for use on wounds
							 (rental)
K0744
AAC+20%
Absorptive wound dressing for use with suction pump,
							 home model, portable, pad size 16 square inches or less
K0745
AAC+20%
Absorptive wound dressing for use with suction pump,
							 home model, portable, pad size more than 16 square inches but less than or
							 equal to 48 square inches
K0746
AAC+20%
Absorptive wound dressing for use with suction pump,
							 home model, portable, pad size greater than 48 square inches
Power Operated Vehicle and Accessories
K0800NU
1,041.09
Power operated vehicle, group 1 standard, patient
							 weight capacity up to and including 300 pounds (new equipment)
K0800RR
104.12
Power operated vehicle, group 1 standard, patient
							 weight capacity up to and including 300 pounds (rental)
K0800UE
780.82
Power operated vehicle, group 1 standard, patient
							 weight capacity up to and including 300 pounds (used durable medical
							 equipment)
K0801NU
1,802.66
Power operated vehicle, group 1 heavy duty, patient
							 weight capacity, 301 to 450 pounds (new equipment)
K0801RR
180.25
Power operated vehicle, group 1 heavy duty, patient
							 weight capacity, 301 to 450 pounds (rental)
K0801UE
1,351.99
Power operated vehicle, group 1 heavy duty, patient
							 weight capacity, 301 to 450 pounds (used durable medical equipment)
K0802NU
2,036.55
Power operated vehicle, group 1 very heavy duty,
							 patient weight capacity 451 to 600 pounds (new equipment)
K0802RR
203.65
Power operated vehicle, group 1 very heavy duty,
							 patient weight capacity 451 to 600 pounds (rental)
K0802UE
1,527.41
Power operated vehicle, group 1 very heavy duty,
							 patient weight capacity 451 to 600 pounds (used durable medical
							 equipment)
K0806NU
1,391.75
Power operated vehicle, group 2 standard, patient
							 weight capacity up to and including 300 pounds (new equipment)
K0806RR
139.17
Power operated vehicle, group 2 standard, patient
							 weight capacity up to and including 300 pounds (rental)
K0806UE
1,043.82
Power operated vehicle, group 2 standard, patient
							 weight capacity up to and including 300 pounds (used durable medical
							 equipment)
K0807NU
2,132.76
Power operated vehicle, group 2 heavy duty, patient
							 weight capacity 301 to 450 pounds (new equipment)
K0807RR
213.28
Power operated vehicle, group 2 heavy duty, patient
							 weight capacity 301 to 450 pounds (rental)
K0807UE
1,599.58
Power operated vehicle, group 2 heavy duty, patient
							 weight capacity 301 to 450 pounds (used durable medical equipment)
K0808NU
3,298.44
Power operated vehicle, group 2 very heavy duty,
							 patient weight capacity 451 to 600 pounds (new equipment)
K0808RR
329.84
Power operated vehicle, group 2 very heavy duty,
							 patient weight capacity 451 to 600 pounds (rental)
K0808UE
2,473.83
Power operated vehicle, group 2 very heavy duty,
							 patient weight capacity 451 to 600 pounds (used durable medical
							 equipment)
K0812NU
AAC+35%
Power operated vehicle, not otherwise classified (new
							 equipment)
K0812RR
I.C.
Power operated vehicle, not otherwise classified
							 (rental)
K0812UE
I.C.
Power operated vehicle, not otherwise classified
							 (used durable medical equipment)
Power Wheelchairs
K0813KH
301.04
Power wheelchair, group 1 standard, portable,
							 sling/solid seat and back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0813KI
301.04
Power wheelchair, group 1 standard, portable,
							 sling/solid seat and back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0813KJ
120.42
Power wheelchair, group 1 standard, portable,
							 sling/solid seat and back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0813NU
2,006.93
Power wheelchair, group 1 standard, portable,
							 sling/solid seat and back, patient weight capacity up to and including 300
							 pounds (new equipment purchase)
K0813UE
1,505.20
Power wheelchair, group 1 standard, portable,
							 sling/solid seat and back, patient weight capacity up to and including 300
							 pounds (used durable medical equipment)
K0814KH
358.84
Power wheelchair, group 1 standard, portable,
							 captains chair, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0814KI
358.84
Power wheelchair, group 1 standard, portable,
							 captains chair, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0814KJ
143.54
Power wheelchair, group 1 standard, portable,
							 captains chair, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0814NU
2,392.27
Power wheelchair, group 1 standard, portable,
							 captains chair, patient weight capacity up to and including 300 pounds (new
							 equipment)
K0814UE
1,794.20
Power wheelchair, group 1 standard, portable,
							 captains chair, patient weight capacity up to and including 300 pounds (used
							 durable medical equipment)
K0815KH
383.91
Power wheelchair, group 1 standard, sling/solid seat
							 and back, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0815KI
383.91
Power wheelchair, group 1 standard, sling/solid seat
							 and back, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0815KJ
153.56
Power wheelchair, group 1 standard, sling/solid seat
							 and back, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0815NU
2,559.40
Power wheelchair, group 1 standard, sling/solid seat
							 and back, patient weight capacity up to and including 300 pounds (new
							 equipment)
K0815UE
1,919.55
Power wheelchair, group 1 standard, sling/solid seat
							 and back, patient weight capacity up to and including 300 pounds (used durable
							 medical equipment)
K0816KH
380.17
Power wheelchair, group 1 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (capped
							 rental)
K0816KI
380.17
Power wheelchair, group 1 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (capped
							 rental)
K0816KJ
152.07
Power wheelchair, group 1 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (capped
							 rental)
K0816NU
2,534.47
Power wheelchair, group 1 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (new equipment
							 purchase)
K0816UE
1,900.85
Power wheelchair, group 1 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (used durable medical
							 equipment)
K0820KH
316.77
Power wheelchair, group 2 standard, portable,
							 sling/solid seat/back, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0820KI
316.77
Power wheelchair, group 2 standard, portable,
							 sling/solid seat/back, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0820KJ
126.71
Power wheelchair, group 2 standard, portable,
							 sling/solid seat/back, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0820NU
2,111.80
Power wheelchair, group 2 standard, portable,
							 sling/solid seat/back, patient weight capacity up to and including 300 pounds
							 (new equipment purchase)
K0820UE
1,583.85
Power wheelchair, group 2 standard, portable,
							 sling/solid seat/back, patient weight capacity up to and including 300 pounds
							 (used durable medical equipment)
K0821KH
375.89
Power wheelchair, group 2 standard, portable,
							 captains chair, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0821KI
375.89
Power wheelchair, group 2 standard, portable,
							 captains chair, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0821KJ
150.36
Power wheelchair, group 2 standard, portable,
							 captains chair, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0821NU
2,505.93
Power wheelchair, group 2 standard, portable,
							 captains chair, patient weight capacity up to and including 300 pounds (new
							 equipment purchase)
K0821UE
1,879.45
Power wheelchair, group 2 standard, portable,
							 captains chair, patient weight capacity up to and including 300 pounds (used
							 durable medical equipment)
K0822KH
452.62
Power wheelchair, group 2 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds
							 (rental)
K0822KI
452.62
Power wheelchair, group 2 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds
							 (rental)
K0822KJ
181.05
Power wheelchair, group 2 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds
							 (rental)
K0822NU
3,017.47
Power wheelchair, group 2 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds (new
							 equipment)
K0822UE
2,263.10
Power wheelchair, group 2 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds (used durable
							 medical equipment)
K0823KH
427.33
Power wheelchair, group 2 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (capped
							 rental)
K0823KI
427.33
Power wheelchair, group 2 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (capped
							 rental)
K0823KJ
170.93
Power wheelchair, group 2 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (capped
							 rental)
K0823NU
2,848.87
Power wheelchair, group 2 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (new equipment
							 purchase)
K0823UE
2,136.65
Power wheelchair, group 2 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (used durable medical
							 equipment)
K0824KH
568.43
Power wheelchair, group 2 heavy duty, sling/solid
							 seat/back, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0824KI
568.43
Power wheelchair, group 2 heavy duty, sling/solid
							 seat/back, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0824KJ
227.37
Power wheelchair, group 2 heavy duty, sling/solid
							 seat/back, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0824NU
3,789.53
Power wheelchair, group 2 heavy duty, sling/solid
							 seat/back, patient weight capacity 301 to 450 pounds (new equipment
							 purchase)
K0824UE
2,842.15
Power wheelchair, group 2 heavy duty, sling/solid
							 seat/back, patient weight capacity 301 to 450 pounds (used durable medical
							 equipment)
K0825KH
507.85
Power wheelchair, group 2 heavy duty, captains chair,
							 patient weight capacity 301 to 450 pounds (capped rental)
K0825KI
507.85
Power wheelchair, group 2 heavy duty, captains chair,
							 patient weight capacity 301 to 450 pounds (capped rental)
K0825KJ
203.14
Power wheelchair, group 2 heavy duty, captains chair,
							 patient weight capacity 301 to 450 pounds (capped rental)
K0825NU
3,385.67
Power wheelchair, group 2 heavy duty, captains chair,
							 patient weight capacity 301 to 450 pounds (new equipment equipment)
K0825UE
2,539.25
Power wheelchair, group 2 heavy duty, captains chair,
							 patient weight capacity 301 to 450 pounds (used durable medical
							 equipment)
K0826KH
768.52
Power wheelchair, group 2 very heavy duty,
							 sling/solid seat/back, patient weight capacity 451 to 600 pounds (capped
							 rental)
K0826KI
768.52
Power wheelchair, group 2 very heavy duty,
							 sling/solid seat/back, patient weight capacity 451 to 600 pounds (capped
							 rental)
K0826KJ
307.41
Power wheelchair, group 2 very heavy duty,
							 sling/solid seat/back, patient weight capacity 451 to 600 pounds (capped
							 rental)
K0826NU
5,123.47
Power wheelchair, group 2 very heavy duty,
							 sling/solid seat/back, patient weight capacity 451 to 600 pounds (new equipment
							 purchase)
K0826UE
3,842.60
Power wheelchair, group 2 very heavy duty,
							 sling/solid seat/back, patient weight capacity 451 to 600 pounds (used durable
							 medical equipment)
K0827KH
667.58
Power wheelchair, group 2 very heavy duty, captains
							 chair, patient weight capacity 451 to 600 pounds (capped rental)
K0827KI
667.58
Power wheelchair, group 2 very heavy duty, captains
							 chair, patient weight capacity 451 to 600 pounds (capped rental)
K0827KJ
267.03
Power wheelchair, group 2 very heavy duty, captains
							 chair, patient weight capacity 451 to 600 pounds (capped rental)
K0827NU
4,450.53
Power wheelchair, group 2 very heavy duty, captains
							 chair, patient weight capacity 451 to 600 pounds (new equipment
							 purchase)
K0827UE
3,337.90
Power wheelchair, group 2 very heavy duty, captains
							 chair, patient weight capacity 451 to 600 pounds (used durable medical
							 equipment)
K0828KH
865.25
Power wheelchair, group 2 extra heavy duty,
							 sling/solid seat/back, patient weight capacity 601 pounds or more (capped
							 rental)
K0828KI
866.25
Power wheelchair, group 2 extra heavy duty,
							 sling/solid seat/back, patient weight capacity 601 pounds or more (capped
							 rental)
K0828KJ
346.10
Power wheelchair, group 2 extra heavy duty,
							 sling/solid seat/back, patient weight capacity 601 pounds or more (capped
							 rental)
K0828NU
5,768.33
Power wheelchair, group 2 extra heavy duty,
							 sling/solid seat/back, patient weight capacity 601 pounds or more (new
							 equipment purchase)
K0828UE
4,326.25
Power wheelchair, group 2 extra heavy duty,
							 sling/solid seat/back, patient weight capacity 601 pounds or more (used durable
							 medical equipment)
K0829KH
840.60
Power wheelchair, group 2 extra heavy duty, captains
							 chair, patient weight capacity 601 pounds or more (capped rental)
K0829KI
840.60
Power wheelchair, group 2 extra heavy duty, captains
							 chair, patient weight capacity 601 pounds or more (capped rental)
K0829KJ
336.24
Power wheelchair, group 2 extra heavy duty, captains
							 chair, patient weight capacity 601 pounds or more (capped rental)
K0829NU
5,604.00
Power wheelchair, group 2 extra heavy duty, captains
							 chair, patient weight capacity 601 pounds or more (new equipment
							 purchase)
K0829UE
4,203.00
Power wheelchair, group 2 extra heavy duty, captains
							 chair, patient weight capacity 601 pounds or more (used durable medical
							 equipment)
K0830NU
3,914.10
Power wheelchair, group 2 standard, seat elevator,
							 sling/solid seat/back, patient weight capacity up to and including 300 pounds
							 (new equipment)
K0830RR
391.41
Power wheelchair, group 2 standard, seat elevator,
							 sling/solid seat/back, patient weight capacity up to and including 300 pounds
							 (rental)
K0830UE
2,935.58
Power wheelchair, group 2 standard, seat elevator,
							 sling/solid seat/back, patient weight capacity up to and including 300 pounds
							 (used durable medical equipment)
K0831NU
3,914.10
Power wheelchair, group 2 standard, seat elevator,
							 captains chair, patient weight capacity up to and including 300 pounds (new
							 equipment)
K0831RR
391.41
Power wheelchair, group 2 standard, seat elevator,
							 captains chair, patient weight capacity up to and including 300 pounds
							 (rental)
K0831UE
2,935.58
Power wheelchair, group 2 standard, seat elevator,
							 captains chair, patient weight capacity up to and including 300 pounds (used
							 durable medical equipment)
K0835KH
456.11
Power wheelchair, group 2 standard, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0835KI
456.11
Power wheelchair, group 2 standard, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0835KJ
182.44
Power wheelchair, group 2 standard, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0835NU
3,040.73
Power wheelchair, group 2 standard, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (new equipment purchase)
K0835UE
2,280.55
Power wheelchair, group 2 standard, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (used durable medical equipment)
K0836KH
473.04
Power wheelchair, group 2 standard, single power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0836KI
473.04
Power wheelchair, group 2 standard, single power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0836KJ
189.22
Power wheelchair, group 2 standard, single power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0836NU
3,153.60
Power wheelchair, group 2 standard, single power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (new equipment purchase)
K0836UE
2,365.20
Power wheelchair, group 2 standard, single power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (used durable medical equipment)
K0837KH
559.19
Power wheelchair, group 2 heavy duty, single power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0837KI
559.19
Power wheelchair, group 2 heavy duty, single power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0837KJ
223.68
Power wheelchair, group 2 heavy duty, single power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0837NU
3,727.93
Power wheelchair, group 2 heavy duty, single power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (new
							 equipment purchase)
K0837UE
2,795.95
Power wheelchair, group 2 heavy duty, single power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (used
							 durable medical equipment)
K0838KH
498.48
Power wheelchair, group 2 heavy duty, single power
							 option, captains chair, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0838KI
498.48
Power wheelchair, group 2 heavy duty, single power
							 option, captains chair, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0838KJ
199.39
Power wheelchair, group 2 heavy duty, single power
							 option, captains chair, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0838NU
3,323.20
Power wheelchair, group 2 heavy duty, single power
							 option, captains chair, patient weight capacity 301 to 450 pounds (new
							 equipment purchase)
K0838UE
2,492.40
Power wheelchair, group 2 heavy duty, single power
							 option, captains chair, patient weight capacity 301 to 450 pounds (used durable
							 medical equipment)
K0839KH
731.13
Power wheelchair, group 2 very heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (capped rental)
K0839KI
731.13
Power wheelchair, group 2 very heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (capped rental)
K0839KJ
292.45
Power wheelchair, group 2 very heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (capped rental)
K0839NU
4,874.20
Power wheelchair, group 2 very heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (new equipment purchase)
K0839UE
3,655.65
Power wheelchair, group 2 very heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (used durable medical equipment)
K0840KH
1,113.40
Power wheelchair, group 2 extra heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 601 pounds or more
							 (capped rental)
K0840KI
1,113.40
Power wheelchair, group 2 extra heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 601 pounds or more
							 (capped rental)
K0840KJ
445.36
Power wheelchair, group 2 extra heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 601 pounds or more
							 (capped rental)
K0840NU
7,422.67
Power wheelchair, group 2 extra heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 601 pounds or more
							 (new equipment purchase)
K0840UE
5,567.00
Power wheelchair, group 2 extra heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 601 pounds or more
							 (used durable medical equipment)
K0841KH
495.88
Power wheelchair, group 2 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0841KI
495.88
Power wheelchair, group 2 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0841KJ
198.35
Power wheelchair, group 2 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0841NU
3,305.87
Power wheelchair, group 2 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (new equipment purchase)
K0841UE
2,479.40
Power wheelchair, group 2 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (used durable medical equipment)
K0842KH
495.60
Power wheelchair, group 2 standard, multiple power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0842KI
495.60
Power wheelchair, group 2 standard, multiple power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0842KJ
198.24
Power wheelchair, group 2 standard, multiple power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0842NU
3,304.00
Power wheelchair, group 2 standard, multiple power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (new equipment purchase)
K0842UE
2,478.00
Power wheelchair, group 2 standard, multiple power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (used durable medical equipment)
K0843KH
593.54
Power wheelchair, group 2 heavy duty, multiple power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0843KI
593.54
Power wheelchair, group 2 heavy duty, multiple power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0843KJ
237.42
Power wheelchair, group 2 heavy duty, multiple power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0843NU
3,956.93
Power wheelchair, group 2 heavy duty, multiple power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (new
							 equipment purchase)
K0843UE
2,967.70
Power wheelchair, group 2 heavy duty, multiple power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (used
							 durable medical equipment)
K0848KH
755.28
Power wheelchair, group 3 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0848KI
755.28
Power wheelchair, group 3 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0848KJ
302.11
Power wheelchair, group 3 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds (capped
							 rental)
K0848NU
5,035.20
Power wheelchair, group 3 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds (new
							 equipment purchase)
K0848UE
3,776.40
Power wheelchair, group 3 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds (used durable
							 medical equipment)
K0849KH
726.16
Power wheelchair, group 3 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (capped
							 rental)
K0849KI
726.16
Power wheelchair, group 3 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (capped
							 rental)
K0849KJ
290.46
Power wheelchair, group 3 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (capped
							 rental)
K0849NU
4,841.07
Power wheelchair, group 3 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (new equipment
							 purchase)
K0849UE
3,630.80
Power wheelchair
K0850KH
876.10
Power wheelchair, group 3 heavy duty, sling/solid
							 seat/back, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0850KI
876.10
Power wheelchair, group 3 heavy duty, sling/solid
							 seat/back, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0850KJ
350.44
Power wheelchair, group 3 heavy duty, sling/solid
							 seat/back, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0850NU
5,840.67
Power wheelchair, group 3 heavy duty, sling/solid
							 seat/back, patient weight capacity 301 to 450 pounds (new equipment
							 purchase)
K0850UE
4,380.50
Power wheelchair, group 3 heavy duty, sling/solid
							 seat/back, patient weight capacity 301 to 450 pounds (used durable medical
							 equipment)
K0851KH
842.37
Power wheelchair, group 3 heavy duty, captains chair,
							 patient weight capacity 301 to 450 pounds (capped rental)
K0851KI
842.37
Power wheelchair, group 3 heavy duty, captains chair,
							 patient weight capacity 301 to 450 pounds (capped rental)
K0851KJ
336.95
Power wheelchair, group 3 heavy duty, captains chair,
							 patient weight capacity 301 to 450 pounds (capped rental)
K0851NU
5,615.80
Power wheelchair, group 3 heavy duty, captains chair,
							 patient weight capacity 301 to 450 pounds (new equipment purchase)
K0851UE
4,211.85
Power wheelchair, group 3 heavy duty, captains chair,
							 patient weight capacity 301 to 450 pounds (used durable medical
							 equipment)
K0852KH
1,012.27
Power wheelchair, group 3 very heavy duty,
							 sling/solid seat/back, patient weight capacity 451 to 600 pounds (capped
							 rental)
K0852KI
1,012.27
Power wheelchair, group 3 very heavy duty,
							 sling/solid seat/back, patient weight capacity 451 to 600 pounds (capped
							 rental)
K0852KJ
404.91
Power wheelchair, group 3 very heavy duty,
							 sling/solid seat/back, patient weight capacity 451 to 600 pounds (capped
							 rental)
K0852NU
6,748.47
Power wheelchair, group 3 very heavy duty,
							 sling/solid seat/back, patient weight capacity 451 to 600 pounds (new equipment
							 purchase)
K0852UE
5,061.35
Power wheelchair, group 3 very heavy duty,
							 sling/solid seat/back, patient weight capacity 451 to 600 pounds (used durable
							 medical equipment)
K0853KH
1,039.86
Power wheelchair, group 3 very heavy duty, captains
							 chair, patient weight capacity, 451 to 600 pounds (capped rental)
K0853KI
1,039.86
Power wheelchair, group 3 very heavy duty, captains
							 chair, patient weight capacity, 451 to 600 pounds (capped rental)
K0853KJ
415.94
Power wheelchair, group 3 very heavy duty, captains
							 chair, patient weight capacity, 451 to 600 pounds (capped rental)
K0853NU
6,932.40
Power wheelchair, group 3 very heavy duty, captains
							 chair, patient weight capacity, 451 to 600 pounds (new equipment
							 purchase)
K0853UE
5,199.30
Power wheelchair, group 3 very heavy duty, captains
							 chair, patient weight capacity, 451 to 600 pounds (used durable medical
							 equipment)
K0854KH
1,377.59
Power wheelchair, group 3 extra heavy duty,
							 sling/solid seat/back, patient weight capacity 601 pounds or more (capped
							 rental)
K0854KI
1,377.59
Power wheelchair, group 3 extra heavy duty,
							 sling/solid seat/back, patient weight capacity 601 pounds or more (capped
							 rental)
K0854KJ
551.04
Power wheelchair, group 3 extra heavy duty,
							 sling/solid seat/back, patient weight capacity 601 pounds or more (capped
							 rental)
K0854NU
9,183.93
Power wheelchair, group 3 extra heavy duty,
							 sling/solid seat/back, patient weight capacity 601 pounds or more (new
							 equipment purchase)
K0854UE
6,887.95
Power wheelchair, group 3 extra heavy duty,
							 sling/solid seat/back, patient weight capacity 601 pounds or more (used durable
							 medical equipment)
K0855KH
1,301.34
Power wheelchair, group 3 extra heavy duty, captains
							 chair, patient weight capacity 601 pounds or more (capped rental)
K0855KI
1,301.34
Power wheelchair, group 3 extra heavy duty, captains
							 chair, patient weight capacity 601 pounds or more (capped rental)
K0855KJ
520.54
Power wheelchair, group 3 extra heavy duty, captains
							 chair, patient weight capacity 601 pounds or more (capped rental)
K0855NU
8,675.60
Power wheelchair, group 3 extra heavy duty, captains
							 chair, patient weight capacity 601 pounds or more (new equipment
							 purchase)
K0855UE
6,506.70
Power wheelchair, group 3 extra heavy duty, captains
							 chair, patient weight capacity 601 pounds or more (used durable medical
							 equipment)
K0856KH
810.71
Power wheelchair, group 3 standard, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0856KI
810.71
Power wheelchair, group 3 standard, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0856KJ
324.28
Power wheelchair, group 3 standard, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0856NU
5,404.73
Power wheelchair, group 3 standard, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (new equipment purchase)
K0856UE
4,053.55
Power wheelchair, group 3 standard, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (used durable medical equipment)
K0857KH
826.96
Power wheelchair, group 3 standard, single power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0857KI
826.96
Power wheelchair, group 3 standard, single power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0857KJ
330.78
Power wheelchair, group 3 standard, single power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (capped rental)
K0857NU
5,513.07
Power wheelchair, group 3 standard, single power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (new equipment purchase)
K0857UE
4,134.80
Power wheelchair, group 3 standard, single power
							 option, captains chair, patient weight capacity up to and including 300 pounds
							 (used durable medical equipment)
K0858KH
1,005.86
Power wheelchair, group 3 heavy duty, single power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0858KI
1,005.86
Power wheelchair, group 3 heavy duty, single power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0858KJ
402.34
Power wheelchair, group 3 heavy duty, single power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0858NU
6,705.73
Power wheelchair, group 3 heavy duty, single power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (new
							 equipment purchase)
K0858UE
5,029.30
Power wheelchair, group 3 heavy duty, single power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (used
							 durable medical equipment)
K0859KH
959.28
Power wheelchair, group 3 heavy duty, single power
							 option, captains chair, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0859KI
959.28
Power wheelchair, group 3 heavy duty, single power
							 option, captains chair, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0859KJ
383.71
Power wheelchair, group 3 heavy duty, single power
							 option, captains chair, patient weight capacity 301 to 450 pounds (capped
							 rental)
K0859NU
6,395.20
Power wheelchair, group 3 heavy duty, single power
							 option, captains chair, patient weight capacity 301 to 450 pounds (new
							 equipment purchase)
K0859UE
4,796.40
Power wheelchair, group 3 heavy duty, single power
							 option, captains chair, patient weight capacity 301 to 450 pounds (used durable
							 medical equipment)
K0860KH
1,436.99
Power wheelchair, group 3 very heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (capped rental)
K0860KI
1,436.99
Power wheelchair, group 3 very heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (capped rental)
K0860KJ
574.80
Power wheelchair, group 3 very heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (capped rental)
K0860NU
9,579.93
Power wheelchair, group 3 very heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (new equipment purchase)
K0860UE
7,184.95
Power wheelchair, group 3 very heavy duty, single
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (used durable medical equipment)
K0861KH
812.01
Power wheelchair, group 3 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0861KHKF
1,045.98
Power wheelchair, group 3 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental) (FDA class III device)
K0861KI
812.01
Power wheelchair, group 3 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0861KIKF
1,046.98
Power wheelchair, group 3 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental) (FDA class III device)
K0861KJ
324.80
Power wheelchair, group 3 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental)
K0861KJKF
418.39
Power wheelchair, group 3 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (capped rental) (FDA class III device)
K0861NU
5,413.40
Power wheelchair, group 3 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (new equipment purchase)
K0861NUKF
6,973.20
Power wheelchair, group 3 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds (new equipment purchase) (FDA class III device)
(
4,060.05
Power wheelchair, group 3 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds ((used durable medical equipment)
K0861UEKF
5,229.90
Power wheelchair, group 3 standard, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 300
							 pounds ((used durable medical equipment) (FDA class III device)
K0862KH
1,005.86
Power wheelchair, group 3 heavy duty, multiple power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0862KI
1,005.86
Power wheelchair, group 3 heavy duty, multiple power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0862KJ
402.34
Power wheelchair, group 3 heavy duty, multiple power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
							 (capped rental)
K0862NU
6,705.73
Power wheelchair, group 3 heavy duty, multiple power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (new
							 equipment purchase)
K0862UE
5,029.30
Power wheelchair, group 3 heavy duty, multiple power
							 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (used
							 durable medical equipment)
K0863KH
1,421.44
Power wheelchair, group 3 very heavy duty, multiple
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (capped rental)
K0863KI
1,421.44
Power wheelchair, group 3 very heavy duty, multiple
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (capped rental)
K0863KJ
568.58
Power wheelchair, group 3 very heavy duty, multiple
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (capped rental)
K0863NU
9,476.27
Power wheelchair, group 3 very heavy duty, multiple
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (new equipment purchase)
K0863UE
7,107.20
Power wheelchair, group 3 very heavy duty, multiple
							 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
							 (used durable medical equipment)
K0864KH
1,691.53
Power wheelchair, group 3 extra heavy duty, multiple
							 power option, sling/solid seat/back, patient weight capacity 601 pounds or more
							 (capped rental)
K0864KI
1,691.53
Power wheelchair, group 3 extra heavy duty, multiple
							 power option, sling/solid seat/back, patient weight capacity 601 pounds or more
							 (capped rental)
K0864KJ
676.61
Power wheelchair, group 3 extra heavy duty, multiple
							 power option, sling/solid seat/back, patient weight capacity 601 pounds or more
							 (capped rental)
K0864NU
11,276.87
Power wheelchair, group 3 extra heavy duty, multiple
							 power option, sling/solid seat/back, patient weight capacity 601 pounds or more
							 (new equipment)
K0864UE
8,457.65
Power wheelchair, group 3 extra heavy duty, multiple
							 power option, sling/solid seat/back, patient weight capacity 601 pounds or more
							 (used durable medical equipment)
K0868NU
AAC+35%
Power wheelchair, group 4 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds (new
							 equipment)
K0868RR
I.C.
Power wheelchair, group 4 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds (new
							 equipment) (rental)
K0868UE
I.C.
Power wheelchair, group 4 standard, sling/solid
							 seat/back, patient weight capacity up to and including 300 pounds (new
							 equipment) (used durable medical equipment)
K0869NU
AAC+35%
Power wheelchair, group 4 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (new
							 equipment)
K0869RR
I.C.
Power wheelchair, group 4 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (rental)
K0869UE
I.C.
Power wheelchair, group 4 standard, captains chair,
							 patient weight capacity up to and including 300 pounds (used durable medical
							 equipment)
K0870NU
AAC+35%
Power wheelchair, group 4 heavy duty, sling/solid
							 seat/back, patient weight capacity 301 to 450 pounds (new
							 equipment)
K0890RR
I.C.
Power wheelchair, group 5 pediatric, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 125
							 pounds (rental)
K0890UE
I.C.
Power wheelchair, group 5 pediatric, single power
							 option, sling/solid seat/back, patient weight capacity up to and including 125
							 pounds (used durable medical equipment)
K0891NU
AAC+35%
Power wheelchair, group 5 pediatric, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 125
							 pounds (new equipment)
K0891RR
I.C.
Power wheelchair, group 5 pediatric, multiple power
							 option, sling/solid seat/back, patient weight cpacity up to and including 125
							 pounds (rental)
K0891UE
I.C.
Power wheelchair, group 5 pediatric, multiple power
							 option, sling/solid seat/back, patient weight capacity up to and including 125
							 pounds (used durable medical equipment)
K0898NU
AAC+35%
Power wheelchair, not otherwise classified (new
							 equipment)
K0898RR
I.C.
Power wheelchair, not otherwise classified
							 (rental)
K0898UE
I.C.
Power wheelchair, not otherwise classified (used
							 durable medical equipment)
K0899NU
AAC+35%
Power mobility device, not coded by DME PDAC or does
							 not meet criteria (new equipment)
K0899RR
I.C.
Power mobility device, not coded by DME PDAC or does
							 not meet criteria (rental)
K0899UE
I.C.
Power mobility device, not coded by DME PDAC or does
							 not meet criteria (used durable medical equipment)
K0900
AAC+30%
Custom durable medical equipment, other than
							 wheelchair
K1001
I.C.
Electronic positional obstructive sleep apnea
							 treatment, with sensor, includes all components and accessories, any
							 type
K1002
I.C.
Cranial electrotherapy stimulation(CES) system,
							 includes all supplies and accessories, any type
K1003
I.C.
Whirlpool tub, walk-in, portable
K1005
0.20
Disposable collection and storage for bag for breast
							 milk, any size, any type, each
Prosthetic Procedures
Larynx and Trachea Prosthetics and
							 Accessories
L8501
130.02
Tracheostomy speaking valve
Q Codes (Temporary)
Q0161
AAC
Chlorpromazine hydrochloride, 5 mg, oral, FDA
							 approved prescription anti-emetic, for use as a complete therapeutic substitute
							 for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48
							 hour dosage regimen
Q0162
0.02
Ondansetron 1 mg, oral, FDA approved prescription
							 anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic
							 at the time of chemotherapy treatment, not to exceed a 48 hour dosage
							 regimen
Q0163
0.22
Diphenhydramine hydrochloride, 50 mg, oral, FDA
							 approved prescription anti-emetic, for use as a complete therapeutic substitute
							 for an IV anti-emetic at time of chemotherapy treatment not to exceed a 48 hour
							 dosage regimen
Q0164
0.04
Prochlorperazine maleate, 5 mg, oral, FDA approved
							 prescription anti-emetic, for use as a complete therapeutic substitute for an
							 IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour
							 dosage regimen
Q0166
1.11
Granisetron hydrochloride, 1 mg, oral, FDA approved
							 prescription anti-emetic, for use as a complete therapeutic substitute for an
							 iv anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour
							 dosage regimen
Q0167
1.39
Dronabinol, 2.5 mg, oral, FDA approved prescription
							 anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic
							 at the time of chemotherapy treatment, not to exceed a 48 hour dosage
							 regimen
Q0169
0.03
Promethazine hydrochloride, 12.5 mg, oral, FDA
							 approved prescription anti-emetic, for use as a complete therapeutic substitute
							 for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48
							 hour dosage regimen
Q0173
0.30
Trimethobenzamide hydrochloride, 250 mg, oral, FDA
							 approved prescription anti-emetic, for use as a complete therapeutic substitute
							 for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48
							 hour dosage regimen
Q0174
AAC
Thiethylperazine maleate, 10 mg, oral, FDA approved
							 prescription anti-emetic, for use as a complete therapeutic substitute for an
							 IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour
							 dosage regimen
Q0175
1.72
Perphenazine, 4 mg, oral, FDA approved prescription
							 anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic
							 at the time of chemotherapy treatment, not to exceed a 48 hour dosage
							 regimen
Q0177
0.12
Hydroxyzine pamoate, 25 mg, oral, FDA approved
							 prescription anti-emetic, for use as a complete therapeutic substitute for an
							 iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour
							 dosage regimen
Q0180
94.79
Dolasetron mesylate, 100 mg, oral, FDA approved
							 prescription anti-emetic, for use as a complete therapeutic substitute for an
							 IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour
							 dosage regimen
Q0510
42.50
Pharmacy supply fee for initial immunosuppressive
							 drug(s), first month following transplant
Q0511
20.40
Pharmacy supply fee for oral anti-cancer, oral
							 anti-emetic or immunosuppressive drug(s); for the first prescription in a
							 30-day period
Q0512
13.60
Pharmacy supply fee for oral anti-cancer, oral
							 anti-emetic or immunosuppressive drug(s); for a subsequent prescription in a
							 30-day period
Q0513
28.05
Pharmacy dispensing fee for inhalation drug(s); per
							 30 days
Q0514
56.10
Pharmacy dispensing fee for inhalation drug(s); per
							 90 days
Q2052
AAC
Services, supplies and accessories used in the home
							 under the Medicare Intravenous Immune Globulin (IVIG) Demonstration
Q4074
94.85
Iloprost, inhalation solution, FDA-approved final
							 product, non-compounded, administered through dme, unit dose form, up to 20
							 micrograms
Q5101
0.82
Injection, filgrastim (g-csf), biosimilar, one
							 microgram
Temporary National Codes (Non-Medicare)
S5035
I.C.
Home infusion therapy, routine service of infusion
							 device (
e.g.
pump maintenance)
S5036
I.C.
Home infusion therapy, repair of infusion device
							 (
e.g.
pump repair)
S5160
38.53
Emergency response system; installation and
							 testing
S5161RR
20.00
Emergency response system; service fee, per month
							 (excludes installation and testing)
S5162
AAC+30%
Emergency response system; purchase only
S5162TW
30.00
Emergency response system; purchase only (back-up
							 equipment; for MassHealth members only, use this HCPCS code and modifier
							 combination for a replacement auto alert transmitter button for PERS, used for
							 a lost button only, cannot be billed separately at the time the unit is
							 installed)
S5497
13.95
Home infusion therapy, catheter care / maintenance,
							 not otherwise classified; includes administrative services, professional
							 pharmacy services, care coordination, and all necessary supplies and equipment
							 (drugs and nursing visits coded separately),
per
							 diem
S5498
13.95
Home infusion therapy, catheter care / maintenance,
							 simple (single lumen), includes administrative services, professional pharmacy
							 services, care coordination and all necessary supplies and equipment, (drugs
							 and nursing visits coded separately),
per diem
S5501
13.95
Home infusion therapy, catheter care / maintenance,
							 complex (more than one lumen), includes administrative services, professional
							 pharmacy services, care coordination, and all necessary supplies and equipment
							 (drugs and nursing visits coded separately),
per
							 diem
S5502
13.95
Home infusion therapy, catheter care / maintenance,
							 implanted access device, includes administrative services, professional
							 pharmacy services, care coordination and all necessary supplies and equipment,
							 (drugs and nursing visits coded separately),
per diem
(use
							 this code for interim maintenance of vascular access not currently in
							 use)
S5517
13.95
Home infusion therapy, all supplies necessary for
							 restoration of catheter patency or declotting
S5518
13.95
Home infusion therapy, all supplies necessary for
							 catheter repair
S5520
125.83
Home infusion therapy, all supplies (including
							 catheter) necessary for a peripherally inserted central venous catheter (PICC)
							 line insertion
S5521
120.79
Home infusion therapy, all supplies (including
							 catheter) necessary for a midline catheter insertion
S5522SD
86.99
Home infusion therapy, insertion of peripherally
							 inserted central venous catheter (PICC), nursing services only (no supplies or
							 catheter included) (services provided by registered nurse with specialized,
							 highly technical home infusion training)
S5523SD
86.99
Home infusion therapy, insertion of midline central
							 venous catheter, nursing services only (no supplies or catheter included)
							 (services provided by registered nurse with specialized, highly technical home
							 infusion training)
S8097
AAC+20%
Asthma kit (including but not limited to portable
							 peak expiratory flow meter, instructional video, brochure, and/or
							 spacer)
S8186
AAC+20%
Swivel adaptor
S8189
AAC+20%
Tracheostomy supply, not otherwise
							 classified
S8210
AAC+20%
Mucus trap
S8262
AAC+30%
Mandibular orthopedic repositioning device,
							 each
S8265
AAC+20%
Haberman feeder for cleft lip/palate
S8420
AAC+20%
Gradient pressure aid (sleeve and glove combination),
							 custom made
S8421
AAC+20%
Gradient pressure aid (sleeve and glove combination),
							 ready made
S8422
AAC+20%
Gradient pressure aid (sleeve), custom made, medium
							 weight
S8423
AAC+20%
Gradient pressure aid (sleeve), custom made, heavy
							 weight
S8424
AAC+20%
Gradient pressure aid (sleeve), ready
							 made
S8425
AAC+20%
Gradient pressure aid (glove), custom made, medium
							 weight
S8426
AAC+20%
Gradient pressure aid (glove), custom made, heavy
							 weight
S8427
AAC+20%
Gradient pressure aid (glove), ready made
S8428
AAC+20%
Gradient pressure aid (gauntlet), ready
							 made
S8429
AAC+20%
Gradient pressure exterior wrap
S8430
AAC+20%
Padding for compression bandage, roll
S8431
AAC+20%
Compression bandage, roll
S8450
AAC+20%
Splint, prefabricated, digit (specify digit by use of
							 modifier)
S8451
AAC+20%
Splint, prefabricated, wrist or ankle
S8452
AAC+20%
Splint, prefabricated, elbow
S8490
AAC+20%
Insulin syringes (100 syringes, any size)
S8999
AAC+20%
Resuscitation bag (for use by patient on artificial
							 respiration during power failure or other catastrophic event)
S9325
37.51
Home infusion therapy, pain management infusion;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment, (drugs and nursing visits coded
							 separately),
per diem
(do not use this code with S9326, SS9327
							 or S9328)
S9326
37.51
Home infusion therapy, continuous pain management
							 infusion; administrative services, professional pharmacy services, care
							 coordination and all necessary supplies and equipment (drugs and nursing visits
							 coded separately),
per diem
S9327
37.51
Home infusion therapy, intermittent pain management
							 infusion; administrative services, professional pharmacy services, care
							 coordination, and all necessary supplies and equipment (drugs and nursing
							 visits coded separately),
per diem
S9328
37.51
Home infusion therapy, implanted pump pain management
							 infusion; administrative services, professional pharmacy services, care
							 coordination, and all necessary supplies and equipment (drugs and nursing
							 visits coded separately),
per diem
S9329
46.68
Home infusion therapy, chemotherapy infusion;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (drugs and nursing visits coded
							 separately),
per diem
(do not use this code with S9330 or
							 S9331)
S9330
46.68
Home infusion therapy, continuous chemotherapy
							 infusion; administrative services, professional pharmacy services, care
							 coordination, and all necessary supplies and equipment (drugs and nursing
							 visits coded separately),
per diem
S9331
46.68
Home infusion therapy, intermittent chemotherapy
							 infusion; administrative services, professional pharmacy services, care
							 coordination, and all necessary supplies and equipment (drugs and nursing
							 visits coded separately),
per diem
S9336
44.86
Home infusion therapy, continuous anticoagulant
							 infusion therapy (
e.g.
heparin), administrative services,
							 professional pharmacy services, care coordination and all necessary supplies
							 and equipment (drugs and nursing visits coded separately),
per
							 diem
S9338
51.51
Home infusion therapy, immunotherapy therapy;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (drug and nursing visits coded
							 separately),
per diem
S9339
35.58
Home therapy; peritoneal dialysis, administrative
							 services, professional pharmacy services, care coordination and all necessary
							 supplies and equipment (drugs and nursing visits coded separately),
per
							 diem
S9340
14.84
Home therapy; enteral nutrition; administrative
							 services, professional pharmacy services, care coordination, and all necessary
							 supplies and equipment (enteral formula and nursing visits coded separately),
per diem
S9341
12.28
Home therapy; enteral nutrition via gravity;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (enteral formula and nursing visits coded
							 separately),
per diem
S9342
14.84
Home therapy; enteral nutrition via pump;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (enteral formula and nursing visits coded
							 separately),
per diem
S9343
12.28
Home therapy; enteral nutrition via bolus;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (enteral formula and nursing visits coded
							 separately),
per diem
S9345
51.51
Home infusion therapy, anti-hemophilic agent infusion
							 therapy (
e.g.
, factor viii); administrative services,
							 professional pharmacy services, care coordination, and all necessary supplies
							 and equipment (drugs and nursing visits coded separately),
per
							 diem
S9346
44.86
Home infusion therapy, alpha-1-proteinase inhibitor
							 (
e.g.
, prolastin); administrative services, professional
							 pharmacy services, care coordination, and all necessary supplies and equipment
							 (drugs and nursing visits coded separately),
per
							 diem
S9347
44.86
Home infusion therapy, uninterrupted, long-term,
							 controlled rate intravenous or subcutaneous infusion therapy
							 (
e.g.
epoprostenol); administrative services, professional
							 pharmacy services, care coordination, and all necessary supplies and equipment
							 (drugs and nursing visits coded separately),
per
							 diem
S9348
73.22
Home infusion therapy, sympathomimetic/inotropic
							 agent infusion therapy (
e.g.
, dobutamine); administrative
							 services, professional pharmacy services, care coordination, all necessary
							 supplies and equipment (drugs and nursing visits coded separately),
per
							 diem
S9349
44.86
Home infusion therapy, tocolytic infusion therapy;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (drugs and nursing visits coded
							 separately),
per diem
S9351
44.86
Home infusion therapy, continuous anti-emetic
							 infusion therapy; administrative services, professional pharmacy services, care
							 coordination, all necessary supplies and equipment (drugs and nursing visits
							 coded separately),
per diem
S9353
44.86
Home infusion therapy, continuous insulin infusion
							 therapy; administrative services, professional pharmacy services, care
							 coordination, and all necessary supplies and equipment (drugs and nursing
							 visits coded separately),
per diem
S9355
73.22
Home infusion therapy, chelation therapy;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (drugs and nursing visits coded
							 separately),
per diem
S9357
73.22
Home infusion therapy, enzyme replacement intravenous
							 therapy; (
e.g.
imiglucerase); administrative services,
							 professional pharmacy services, care coordination, and all necessary supplies
							 and equipment (drugs and nursing visits coded separately),
per
							 diem
S9359
73.22
Home infusion therapy, anti-tumor necrosis factor
							 intravenous therapy; (
e.g.
infliximab); administrative
							 services, professional pharmacy services, care coordination, and all necessary
							 supplies and equipment (drugs and nursing visits coded separately),
per
							 diem
S9361
73.22
Home infusion therapy, diuretic intravenous therapy;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (drugs and nursing visits coded
							 separately),
per diem
S9363
73.22
Home infusion therapy, anti-spasmotic therapy;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (drugs and nursing visits coded
							 separately),
per diem
S9364
43.95
Home infusion therapy, total parenteral nutrition
							 (TPN); administrative services, professional pharmacy services, care
							 coordination, and all necessary supplies and equipment (standard TPN formula,
							 lipids, specialty amino acid formulas, drugs, and nursing visits coded
							 separately),
per diem
(do not use with home infusion codes
							 S9365-S9368 using daily volume scales)
S9365
43.95
Home infusion therapy, total parenteral nutrition
							 (TPN); one liter per day, administrative services, professional pharmacy
							 services, care coordination, and all necessary supplies and equipment (standard
							 TPN formula, lipids, specialty amino acid formulas, drugs, and nursing visits
							 coded separately),
per diem
S9366
43.95
Home infusion therapy, total parenteral nutrition
							 (TPN); more than one liter but no more than two liters per day, administrative
							 services, professional pharmacy services, care coordination, and all necessary
							 supplies and equipment (standard TPN formula, lipids, specialty amino acid
							 formulas, drugs, and nursing visits coded separately),
per
							 diem
S9367
43.95
Home infusion therapy, total parenteral nutrition
							 (TPN); more than two liters but no more than three liters per day,
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (standard TPN formula, lipids, specialty
							 amino acids, drugs, and nursing visits coded separately),
per
							 diem
S9368
43.95
Home infusion therapy, total parenteral nutrition
							 (TPN); more than three liters per day, administrative services, professional
							 pharmacy services, care coordination, and all necessary supplies and equipment
							 (standard TPN formula, lipids, specialty amino acid formulas, drugs, and
							 nursing visits coded separately),
per diem
S9370
9.62
Home therapy, intermittent anti-emetic injection
							 therapy; administrative services, professional pharmacy services, care
							 coordination, and all necessary supplies and equipment (drugs and nursing
							 visits coded separately),
per diem
S9372
9.62
Home therapy; intermittent anticoagulant injection
							 therapy (
e.g.
heparin); administrative services, professional
							 pharmacy services, care coordination, and all necessary supplies and equipment
							 (drugs and nursing visits coded separately),
per diem
(do not
							 use this code with hydration therapy codes S9374-S9377)
S9373
30.04
Home infusion therapy, hydration therapy;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (drugs and nursing visits coded
							 separately),
per diem
(do not use with hydration therapy codes
							 S9374-S9377 using daily volume scales)
S9374
30.04
Home infusion therapy, hydration therapy; one liter
							 per day, administrative services, professional pharmacy services, care
							 coordination, and all necessary supplies and equipment (drugs and nursing
							 visits coded separately),
per diem
S9375
30.04
Home infusion therapy, hydration therapy; more than
							 one liter but no more than two liters per day, administrative services,
							 professional pharmacy services, care coordination, and all necessary supplies
							 and equipment (drugs and nursing visits coded separately),
per
							 diem
S9376
30.04
Home infusion therapy, hydration therapy; more than
							 two liters but no more than three liters per day, administrative services,
							 professional pharmacy services, care coordination, and all necessary supplies
							 and equipment (drugs and nursing visits coded separately),
per
							 diem
S9377
30.04
Home infusion therapy, hydration therapy; more than
							 three liters per day, administrative services, professional pharmacy services,
							 care coordination, and all necessary supplies (drugs and nursing visits coded
							 separately),
per diem
S9379 AA
C+20%+$8.00
Home infusion therapy, infusion therapy, not
							 otherwise classified; administrative services, professional pharmacy services,
							 care coordination, and all necessary supplies and equipment (drugs and nursing
							 visits coded separately),
per diem
S9434
AAC+20%
Modified solid food supplements for inborn errors of
							 metabolism
S9435
AAC+20%
Medical foods for inborn errors of
							 metabolism
S9490
44.86
Home infusion therapy, corticosteroid infusion;
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (drugs and nursing visits coded
							 separately),
per diem
S9494
44.86
Home infusion therapy, antibiotic, antiviral, or
							 antifungal therapy; administrative services, professional pharmacy services,
							 care coordination, and all necessary supplies and equipment (drug and nursing
							 visits coded separately),
per diem
(do not use
							 with
S9497
51.51
Home infusion therapy, antibiotic, antiviral, or
							 antifungal therapy; once every 3 hours; administrative services, professional
							 pharmacy services, care coordination, and all necessary supplies and equipment
							 (drugs and nursing visits coded separately),
per
							 diem
S9500
44.86
Home infusion therapy, antibiotic, antiviral, or
							 antifungal therapy; once every 24 hours; administrative services, professional
							 pharmacy services, care coordination, and all necessary supplies and equipment
							 (drugs and nursing visits coded separately),
per
							 diem
S9501
51.73
Home infusion therapy, antibiotic, antiviral, or
							 antifungal therapy; once every 12 hours; administrative services, professional
							 pharmacy services, care coordination, and all necessary supplies and equipment
							 (drugs and nursing visits coded separately),
per
							 diem
S9502
56.20
Home infusion therapy, antibiotic, antiviral, or
							 antifungal therapy; once every 8 hours, administrative services, professional
							 pharmacy services, care coordination, and all necessary supplies and equipment
							 (drugs and nursing visits coded separately),
per
							 diem
S9503
61.87
Home infusion therapy, antibiotic, antiviral, or
							 antifungal; once every 6 hours; administrative services, professional pharmacy
							 services, care coordination, and all necessary supplies and equipment (drugs
							 and nursing visits coded separately),
per diem
S9504
73.22
Home infusion therapy, antibiotic, antiviral, or
							 antifungal; once every 4 hours; administrative services, professional pharmacy
							 services, care coordination, and all necessary supplies and equipment (drugs
							 and nursing visits coded separately),
per diem
S9537
9.62
Home therapy; hematopoietic hormone injection therapy
							 (
e.g.
, crythropoietin, G-CSF, GM-CSF); administrative
							 services, professional pharmacy services, care coordination, and all necessary
							 supplies and equipment (drugs and nursing visits coded separately),
per
							 diem
S9538
51.51
Home transfusion of blood product(s); administrative
							 services, professional pharmacy services, care coordination and all necessary
							 supplies and equipment (blood products, drugs, and nursing visits coded
							 separately),
per diem
S9542
9.62
Home injectable therapy; not otherwise classified,
							 including administrative services, professional pharmacy services, coordination
							 of care, and all necessary supplies and equipment (drugs and nursing visits
							 coded separately),
per diem
S9558
9.62
Home injectable therapy; growth hormone, including
							 administrative services, professional pharmacy services, coordination of care,
							 and all necessary supplies and equipment (drugs and nursing visits coded
							 separately),
per diem
S9559
9.62
Home injectable therapy; interferon, including
							 administrative services, professional pharmacy services, coordination of care,
							 and all necessary supplies and equipment (drugs and nursing visits coded
							 separately),
per diem
S9560
9.62
Home injectable therapy; hormonal therapy
							 (
e.g.
; leuprolide, goserelin), including administrative
							 services, professional pharmacy services, care coordination, and all necessary
							 supplies and equipment (drugs and nursing visits coded separately),
per
							 diem
S9562
9.62
Home injectable therapy, palivizumab, including
							 administrative services, professional pharmacy services, care coordination, and
							 all necessary supplies and equipment (drugs and nursing visits coded
							 separately),
per diem
S9590
23.55
Home therapy, irrigation therapy
							 (
e.g.
sterile irrigation of an organ or anatomical cavity);
							 including administrative services, professional pharmacy services, care
							 coordination, and all necessary supplies and equipment (drugs and nursing
							 visits coded separately),
per diem
Miscellaneous
T4521
0.46
Adult sized disposable incontinence product,
							 brief/diaper, small each
T4522
0.53
Adult sized disposable incontinence product,
							 brief/diaper, medium each
T4522U6
0.65
Enhanced: Adult sized disposable incontinence
							 product, brief/diaper, medium, each
T4523
0.71
Adult sized disposable incontinence product,
							 brief/diaper, large each
T4523U6
0.87
Enhanced: Adult sized disposable incontinence
							 product, brief/diaper, large each
T4524
0.74
Adult sized disposable incontinence product,
							 brief/diaper, extra large each
T4524U6
1.04
Enhanced: Adult sized disposable incontinence
							 product, brief/diaper, extralarge, each
T4525
0.66
Adult sized disposable incontinence product,
							 protective underwear/pull-on, small size, each
T4526
0.79
Adult sized disposable incontinence product,
							 protective underwear/pull-on, medium size, each
T4527
0.79
Adult sized disposable incontinence product,
							 protective underwear/pull-on, large size, each
T4528
0.79
Adult sized disposable incontinence product,
							 protective underwear/pull-on, extra large size, each
T4529
0.66
Pediatric sized disposable incontinence product,
							 brief/diaper, small/medium, each
T4530
0.83
Pediatric sized disposable incontinence product,
							 brief/diaper, large size, each
T4531
0.70
Pediatric sized disposable incontinence product,
							 protective underwear/pull-on, small/medium size each
T4532
0.58
Pediatric sized disposable incontinence product,
							 protective underwear/pull-on, large size each
T4533
0.46
Youth sized disposable incontinence product,
							 brief/diaper, each
T4534
0.72
Youth sized disposable incontinence product,
							 protective underwear/pull-on, each
T4535
0.40
Disposable liner/shield/guard/pad/undergarment, for
							 incontinence, each
T4535UD
AAC+20%
Disposable liner/shield/guard/pad/undergarment, for
							 incontinence, each (bariatric)
T4536
AAC+20%
Incontinence product, protective underwear/pull-on,
							 reusable, bed size, each
T4537
13.83
Incontinence product, protective underpad, reusable,
							 bed size, each
T4538
AAC+20%
Diaper service, reusable diaper, each
							 diaper
T4539
AAC+20%
Incontinence product, diaper/brief, reusable, any
							 size, each
T4540
AAC+20%
Incontinence product, protective underpad, reusable,
							 chair size, each
T4541
0.34
Incontinence product, disposable underpad, large,
							 each
T4542
0.29
Incontinence product, disposable underpad, small
							 size, each
T4543
AAC+20%
Disposable incontinence product, brief/diaper,
							 bariatric, size up to XXL, each
T4543UD
2.19
Disposable incontinence product, brief/diaper,
							 bariatric, size XXXL and above, each
T4544
AAC+20%
Adult sized disposable incontinence product,
							 protective underwear/pull-on, above extra large, each
T5001NU
AAC+35%
Positioning seat for persons with special orthopedic
							 needs, for use in vehicle (new equipment)
T5001RR
I.C.
Positioning seat for persons with special orthopedic
							 needs, for use in vehicle (rental)
T5001UE
I.C.
Positioning seat for persons with special orthopedic
							 needs, for use in vehicle (used durable medical equipment)
Home Infusion
99601SD
86.99
Home infusion/specialty drug administration, per
							 visit (up to two hours) (services provided by registered nurse with
							 specialized, highly technical home infusion training)
99602SD
45.48
Home infusion/specialty drug administration, each
							 additional hour (services provided by registered nurse with specialized, highly
							 technical home infusion training) (use in conjunction with
							 (99601SD)