New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 2 - HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:59-2.3 - HCPCS procedure codes and maximum fee allowance schedule for medical supplies and durable medical equipment

Current through Register Vol. 56, No. 14, July 15, 2024
HCPCS
Maximum Fee
Code
Description
Allowance
A4206
Syringe with needle, sterile 1cc
B.R.
A4207
Syringe with needle, sterile 2cc
B.R.
A4208
Syringe with needle, sterile 3cc
B.R.
A4209
Syringe with needle, sterile 5cc or greater
B.R.
A4210
Needle-free injection device
B.R.
A4211
Supplies for self-administered injections
B.R.
A4212
Huber-type needle, each
B.R.
A4213
Syringe, sterile, 20cc or greater
B.R.
A4214
Sterile saline or water, 30 cc vial
0.81/vial
A4215
Needles only, sterile, any size
B.R.
A4217
Sterile water/saline, 500 ml
2.50
A4230
Infusion set for external insulin pump,
B.R.
non-needle, cannula type
A4231
Infusion set for external insulin pump,
B.R.
needle type
A4232
Syringe with needle for external insulin
B.R.
pump, sterile 3 cc
A4244
Alcohol or peroxide, per pint
B.R.
A4245
Alcohol wipes, per box
B.R.
A4246
Betadine or Phisohex solution, per pint
B.R.
A4247
Betadine or iodine swabs/wipes, per box
B.R.
A4250
Urine test or reagent strips or tablets
B.R.
(100 tablets or strips)
A4253
Blood glucose test or reagent strips
B.R.
for home blood glucomitor, per 50 strips
A4256
Normal, low and high calibrator
B.R.
solution/chips
A4258
Spring powered device for lancet, each
B.R.
A4259
Lancets, per box
B.R.
A4265
Paraffin
B.R.
A4300
Implantable vascular access portal/catheter
B.R.
(venous, arterial, epidural or peritoneal)
A4305
Disposable drug delivery system, flow rate
B.R.
of 50 ml or greater per hour
A4306
Disposable drug delivery system, flow rate
B.R.
of 5 ml or less per hour
A4310
Insertion tray without drainage bag and
6.61
without catheter (accessories only)
A4311
Insertion tray without drainage bag with
8.34
indwelling catheter, foley type, two-way
latex with coating (teflon, silicone,
silicone elastomer or hydrophilic, etc.)
A4312
Insertion tray without drainage bag with
8.34
indwelling catheter, foley type, two-way,
all silicone
A4313
Insertion tray without drainage bag with
8.34
indwelling catheter, foley type, three-way,
for continuous irrigation
A4314
Insertion tray with drainage bag with
15.46
indwelling catheter, foley type, two-way
latex with coating (teflon, silicone,
silicone elastomer or hydrophilic, etc.)
A4315
Insertion tray with drainage bag
15.46
within dwelling catheter, foley type,
two-way,all silicone
A4316
Insertion tray with drainage bag with
15.46
indwelling catheter, foley type, three-way,
for continuous irrigation
A4320
Irrigation tray for bladder irrigation
5.00
with bulb or piston syringe
A4322
Irrigation syringe, bulb or piston
2.50
A4326
Male external catheter; specialty type
B.R.
(for example, inflatable or faceplate, each)
A4327
Female external urinary collection device;
B.R.
metal cup, each
A4328
Female external urinary collection device;
10.00
pouch
A4330
Perianal fecal collection pouch with
B.R.
adhesive
A4331
Extension drainage tubing, any type, any
2.54
length, with connector/adaptor, for use
with urinary leg bag or urostomy pouch, each
A4332
Lubricant, individual sterile packet, each
0.10
A4333
Urinary catheter anchoring device, adhesive
B.R.
skin attachment, each
A4334
Urinary catheter anchoring device, leg
3.94
strap, each
A4335
Incontinence supply; miscellaneous
B.R.
A4338
Indwelling catheter; foley type, two-way
8.14
latex with coating (such as teflon,
silicone, silicone elastomer, or hydrophilic)
A4340
Indwelling catheter; specialty type,
10.00
(such as coude, mushroom or wing)
A4344
Indwelling catheter, foley type, two-way,
15.52
all silicone
A4346
Indwelling catheter, foley type, three-way
15.00
for continuous irrigation
A4347
Male external catheter with or without
17.29
adhesive, with or without anti-reflux
device; per dozen
A4349
Male external catheter with integral
B.R.
collection compartment, extended wear,
each, (for example, two per month)
A4351
Intermittent urinary catheter; straight tip
5.00
A4352
Intermittent urinary catheter; coude
5.00
(curved) tip
A4354
Insertion tray with drainage bag,
9.00
without catheter
A4355
Irrigation tubing set for continuous bladder
6.86
irrigation through a three-way indwelling
foley catheter
A4356
External urethral clamp or compression
37.03
device (not to be used for catheter clamp)
A4357
Bedside drainage bag, day or night,
7.94
with or without anti-reflux device, with
or without tube
A4358
Urinary leg bag; vinyl, with or without
7.12
tube
A4359
Urinary suspensory without leg bag
27.00
A4361
Ostomy face plate
6.20
A4362
Skin barrier; solid, 4" x 4" or equivalent;
5.03
each
A4364
Adhesive for ostomy or catheter; liquid
4.58
paste; any composition (for example,
silicone, latex); per oz.
A4367
Ostomy belt
6.86
A4369
Ostomy skin barrier, liquid (spray, brush,
1.94
etc.), per oz.
A4371
Ostomy skin barrier, powder, per oz.
2.92
A4372
Ostomy skin barrier, solid 4 x 4 inches or
B.R.
equivalent, with built-in convexity, each
A4373
Ostomy skin barrier, with flange (solid,
B.R.
flexible or accordion), with built-in
convexity, any size, each
A4397
Irrigation supplies; sleeve
4.50
A4398
Irrigation supplies; bag
2.25
A4399
Irrigation supplies; cone/catheter
11.25
A4400
Ostomy irrigation set
24.61
A4402
Lubricant
1.08
A4404
Ostomy rings
1.22
A4405
Ostomy skin barrier, non-pectin based,
2.72
paste, per ounce
A4406
Ostomy skin barrier, pectin-based, paste,
4.59
per ounce
A4407
Ostomy skin barrier, with flange (solid,
B.R.
flexible, or accordion), extended wear,
with built-in convexity, 4 x 4 inches or
smaller, each
A4408
Ostomy skin barrier, with flange (solid,
B.R.
flexible or accordion), extended wear,
with built-in convexity, larger than 4 x 4
inches, each
A4409
Ostomy skin barrier, with flange (solid,
B.R.
flexible or accordion), extended wear,
without built-in convexity, 4 x 4 inches or
smaller, each
A4410
Ostomy skin barrier, with flange (solid,
B.R.
flexible or accordion), extended wear,
without built-in convexity, larger than
4 x 4 inches, each
A4414
Ostomy skin barrier, with flange (solid,
B.R.
flexible or accordion), without built-in
convexity, 4 x 4 inches or smaller, each
A4415
Ostomy skin barrier, with flange (solid,
B.R.
flexible or accordion), without built-in
convexity, larger than 4 x 4 inches, each
A4421
Not otherwise classified ostomy supplies;
B.R.
ureterostomy supplies
A4450
Tape, non-waterproof, per 18 square inches
0.07
A4452
Tape, waterproof, per 18 square inches
0.29
A4455
Adhesive remover or solvent (for tape,
B.R.
cement or other adhesive)
A4465
Nonelastic binder for extremity
B.R.
A4470
Gravlee jet washer
B.R.
A4480
Vabra aspirator
B.R.
A4550
Surgical trays
B.R.
A4554
Disposable underpads, all sizes (for
0.31
example, Chux's), each
A4556
Electrodes (for example, apnea monitor)
B.R.
A4557
Lead wires (for example, apnea monitor)
B.R.
A4558
Conductive paste or gel
B.R.
A4560
Pessary
20.94
A4561
Pessary, rubber, any type
B.R.
A4562
Pessary, non rubber, any type
B.R.
A4565
Slings
B.R.
A4570
Splint
B.R.
A4575
Topical hyperbaric oxygen chamber,
B.R.
disposable
A4595
TENS supplies, 2 lead, per month
B.R.
A4611
Battery, heavy duty; replacement for
180.00
patient-owned ventilator
A4612
Battery cables; replacement for
44.00
patient-owned ventilator
A4613
Battery charger; replacement for
B.R.
patient-owned ventilator
A4614
Peak expiratory flow rate meter, hand held
B.R.
A4615
Cannula, nasal
7.50
A4616
Tubing (oxygen), per foot
B.R.
A4617
Mouthpiece
5.00
A4618
Breathing circuits
9.15
A4619
Face tent
10.00
A4620
Variable concentration mask
10.00
A4621
Tracheostomy mask or collar
10.17
A4622
Tracheostomy or laryngectomy tube
75.00
A4623
Tracheostomy, inner cannula
6.00
(replacement only)
A4624
Tracheal suction catheter, any type, each
2.00
A4625
Tracheostomy care or cleaning starter kit
8.00
A4626
Tracheostomy cleaning brush, each
3.00
A4627
Spacer, bag or reservoir, with or
B.R.
without mask, for use with metered
dose inhaler
A4628
Oropharyngeal suction catheter, each
B.R.
A4629
Tracheostomy care kit for established
B.R.
tracheostomy
A4630
Replacement batteries for medically
B.R.
necessary TENS, owned by patient
A4631
Replacement batteries for medically
B.R.
necessary electronic wheelchair, owned
by patient
A4635
Underarm pad, crutch, replacement, each
B.R.
A4636
Replacement handgrip, cane, crutch,
B.R.
walker, each
A4637
Replacement tip, cane crutch, walker,
B.R.
each
A4640
Replacement pad for use with medically
B.R.
necessary alternating pressure pad, owned
by patient
A4649
Surgical supplies; miscellaneous
B.R.
A4651
Calibrated microcapillary tube, each
B.R.
A4652
Microcapillary tube sealant
B.R.
A4653
Peritoneal dialysis catheter anchoring
B.R.
device, belt, each
A4656
Needle, any size, each
B.R.
A4657
Syringe, with or without needle, each
B.R.
A4660
Sphygmomanometer/blood pressure apparatus
B.R.
with cuff and stethoscope
A4663
Blood pressure cuff, only
B.R.
A4670
Automatic blood pressure monitor
B.R.
A4671
Disposable cycler set used with cycler
B.R.
dialysis machine, each
A4672
Drainage extension line, sterile, for
B.R.
dialysis, each
A4673
Extension line with easy lock connectors,
B.R.
used with dialysis
A4674
Chemicals/antiseptics solution used to
B.R.
clean/sterilize dialysis equipment, per
eight oz.
A4680
Activated carbon filter for hemodialysis,
B.R.
each
A4690
Dialyzer (artificial kidneys), all types,
B.R.
all sizes, for hemodialysis, each
A4705
Bicarbonate dialysate solution, each
B.R.
A4706
Bicarbonate concentrate, solution, for
B.R.
hemodialysis, per gallon
A4707
Bicarbonate concentrate, powder, for
B.R.
hemodialysis, per packet
A4708
Acetate concentrate solution, for
B.R.
hemodialysis, per gallon
A4709
Acid concentrate, solution, for
B.R.
hemodialysis, per gallon
A4712
Water, sterile
B.R.
A4714
Treated water (deionized, distilled,
B.R.
reverse osmosis) for use in dialysis system
A4719
"Y set" tubing for peritoneal dialysis
B.R.
A4720
Dialysate solution, any concentration of
B.R.
dextrose, fluid volume greater than 249 cc,
but less than or equal to 999 cc, for
peritoneal dialysis
A4721
Dialysate solution, any concentration of
B.R.
dextrose, fluid volume greater than 999 cc
but less than or equal to 1999 cc, for
peritoneal dialysis
A4722
Dialysate solution, any concentration of
B.R.
dextrose, fluid volume greater than 1999 cc
but less than or equal to 2999 cc, for
peritoneal dialysis
A4723
Dialysate solution, any concentration of
B.R.
dextrose, fluid volume greater than 2999 cc
but less than or equal to 3999 cc, for
peritoneal dialysis
A4724
Dialysate solution, any concentration of
B.R.
dextrose, fluid volume greater than 3999 cc
but less than or equal to 4999 cc, for
peritoneal dialysis
A4725
Dialysate solution, any concentration of
B.R.
dextrose, fluid volume greater than 4999 cc
but less than or equal to 5999 cc, for
peritoneal dialysis
A4726
Dialysate solution, any concentration of
B.R.
dextrose, fluid volume greater than 5999 cc,
for peritoneal dialysis
A4730
Fistula cannulation set for dialysis
B.R.
only
A4735
Local/topical anesthetics for dialysis only
B.R.
A4736
Topical anesthetic, for dialysis, per gram
B.R.
A4737
Injectable anesthetic, for dialysis, per
B.R.
10 ml
A4740
Shunt accessories for dialysis only
B.R.
A4750
Blood tubing, arterial or venous, each
B.R.
A4755
Blood tubing, arterial and venous combined
B.R.
A4760
Dialysate standard testing solution,
B.R.
supplies
A4765
Dialysate concentrate additives, each
B.R.
A4766
Dialysate concentrate, solution, additive
B.R.
for peritoneal dialysis, per 10 ml
A4770
Blood testing supplies (for example,
B.R.
vacutainers and tubes)
A4771
Serum clotting time tube, per box
B.R.
A4772
Dextrostick or glucose test strips,
B.R.
per box
A4773
Hemostix, per bottle
B.R.
A4774
Ammonia test paper, per box
B.R.
A4802
Protamine sulfate, for hemodialysis, per
B.R.
50 mg
A4860
Disposable catheter caps
B.R.
A4911
Drain bag/bottle, for dialysis, each
B.R.
A4913
Miscellaneous dialysis supplies, not
B.R.
identified elsewhere
A4918
Venous pressure clamps, each
B.R.
A4927
Gloves, non-sterile, per 100
9.00
A4928
Surgical mask, per 20
B.R.
A4929
Tourniquet for dialysis, each
B.R.
A4930
Gloves, sterile, per pair
0.60
A5051
Pouch, closed; with barrier attached
3.05
(1 piece)
A5052
Pouch, closed; without barrier attached
3.05
(1 piece)
A5053
Pouch, closed; for use on faceplate
3.05
A5054
Pouch, closed; for use on barrier with
3.05
flange (2 piece)
A5055
Stoma cap
2.00
A5061
Pouch, drainable; with barrier attached
4.07
(1 piece)
A5062
Pouch, drainable; without barrier attached
4.07
(1 piece)
A5063
Pouch, drainable; for use on barrier with
4.07
flange (2 piece system)
A5071
Pouch, urinary; with barrier attached
4.07
(1 piece)
A5072
Pouch, urinary; without barrier attached
4.07
(1 piece)
A5073
Pouch, urinary; for use on barrier with
4.07
flange (2 piece system)
A5081
Continent device; plug for continent
3.50
stoma
A5082
Continent device; catheter for continent
11.00
stoma
A5093
Ostomy accessory; convex insert
1.65
A5102
Bedside drainage bottle, rigid or expandable
28.00
A5105
Urinary suspensory; with leg bag, with or
31.90
without tube
A5112
Urinary leg bag; latex
7.12
A5113
Leg strap; latex, per set
4.00
A5114
Leg strap; foam or fabric, per set
8.95
A5119
Skin barrier; wipes, box per 50
9.50
A5121
Skin barrier; solid, 6' x 6' or equivalent,
5.03
each
A5122
Skin barrier; solid, 8' x 8' or equivalent,
5.03
each
A5126
Adhesive; disc or foam pad
1.25
A5131
Appliance cleaner, incontinence and ostomy
16.25
appliances, 16 oz.
A5200
Percutaneous catheter/tube anchoring device,
B.R.
adhesive skin attachment
A5508
For diabetics only, deluxe feature of
B.R.
off-the-shelf depth-inlay shoe or
custom-molded shoe, per shoe
A6010
Collagen based wound filler, dry form, per
B.R.
gram of collagen
A6011
Collagen based wound filler, gel/paste, per
B.R.
gram of collagen
A6021
Collagen dressing, pad size 16 square inches
B.R.
or less, each
A6022
Collagen dressing, pad size more than
B.R.
16 square inches but less than or equal to
48 square inches, each
A6023
Collagen dressing, pad size more than
B.R.
48 square inches, each
A6024
Collagen dressing wound filler, per
B.R.
six inches
A6154
Wound pouch, each
B.R.
A6196
Alginate dressing, wound cover, pad size
B.R.
16 sq. in. or less, each
A6197
Alginate dressing, wound cover, pad size
B.R.
more than 16 but less than or equal to
48 sq. in., each dressing
A6198
Alginate dressing, wound cover, pad size
B.R.
more than 48 sq. in., each dressing
A6199
Alginate dressing, wound filler, per
B.R.
6 inches
A6200
Composite dressing, pad size 16 sq. in. or
B.R.
less, without adhesive border, each dressing
A6201
Composite dressing, pad size more than
B.R.
16 sq. in, but less than or equal to
48 sq. in., without adhesive border, each
dressing
A6202
Composite dressing, pad size more than
B.R.
48 sq. in, without adhesive border, each
dressing
A6203
Composite dressing, pad size 16 sq. in. or
B.R.
less with any size adhesive border, each
dressing
A6204
Composite dressing, pad size more than
B.R.
16 but less than or equal to 48 sq. in.,
with any size adhesive border, each dressing
A6205
Composite dressing, pad size more than
B.R.
48 sq. in, with any size adhesive border,
each dressing
A6206
Contact layer, 16 sq. in. or less, each
B.R.
dressing
A6207
Contact layer, more than 16 but less than
B.R.
or equal to 48 sq. in., each dressing
A6208
Contact layer, more than 48 sq. in., each
B.R.
dressing
A6209
Foam dressing, wound cover, pad size
B.R.
16 sq. in., or less, without adhesive
border, each dressing
A6210
Foam dressing, wound cover, pad size more
B.R.
than 16 but less than or equal to 48 sq. in.,
without adhesive border, each dressing
A6211
Foam dressing, wound cover, pad size more
B.R.
than 48 sq. in., without adhesive border,
each dressing
A6212
Foam dressing, wound cover, pad size
B.R.
16 sq. in. less, with any size adhesive
border, each dressing
A6213
Foam dressing, wound cover, pad size more
B.R.
than 16 but less than or equal to 48 sq. in.
with any size adhesive border, each
A6214
Foam dressing, wound cover, pad size more
B.R.
than 48 sq. in., with any size adhesive
border, each dressing
A6215
Foam dressing, wound filler, per gram
B.R.
A6216
Gauze, non-impregnated, non-sterile, pad
B.R.
size 16 sq in. or less, without adhesive
border, each dressing
A6217
Gauze, non-impregnated, non-sterile, pad
B.R.
size more than 16 but less than or equal to
48 sq. in., without adhesive border, each
dressing
A6218
Gauze, non-impregnated, non-sterile, pad
B.R.
size more than 48 sq. in., without adhesive
border, each dressing
A6219
Gauze, non-impregnated, pad size 16 sq. in.
B.R.
or less, with any size adhesive border,
each dressing
A6220
Gauze, non-impregnated, pad size more than
B.R.
16 but less than or equal to 48 sq. in.,
with any size adhesive border, each dressing
A6221
Gauze, non-impregnated, pad size more than
B.R.
48 sq. in., with any size adhesive border,
each dressing
A6222
Gauze, impregnated, other than water or
B.R.
normal saline, pad size 16 sq. in. or less,
without adhesive border, each dressing
A6223
Gauze, impregnated, other than water or
B.R.
normal saline, pad size more than 16 but
less than or equal to 48 sq. in., without
adhesive border, each dressing
A6224
Gauze, impregnated, other than water or
B.R.
normal saline, pad size more than 48 sq. in.,
without adhesive border, each dressing
A6228
Gauze, impregnated, water or normal saline,
B.R.
pad size 16 sq. in. or less, without
adhesive border, each dressing
A6229
Gauze, impregnated, water or normal saline,
B.R.
pad size more than 16 but less than or equal
to 48 sq. in., without adhesive border,
each dressing
A6230
Gauze, impregnated, water or normal saline,
B.R.
pad size more than 48 sq. in., without
adhesive border, each dressing
A6234
Hydrocolloid dressing, wound cover, pad
B.R.
size 16 sq. in. or less, without adhesive
border, each dressing
A6235
Hydrocolloid dressing, wound cover, pad
B.R.
size more than 16 but less than or equal to
48 sq. in., without adhesive border, each
dressing
A6236
Hydrocolloid dressing, wound cover, pad
B.R.
size more than 48 sq. in., without adhesive
border, each dressing
A6237
Hydrocolloid dressing, wound cover, pad
B.R.
size 16 sq. in. or less, with any size
adhesive border, each dressing
A6238
Hydrocolloid dressing, wound cover, pad
B.R.
size more than 16 but less than or equal to
48 sq. in., with any size adhesive border,
each dressing
A6239
Hydrocolloid dressing, wound cover, pad
B.R.
size more than 48 sq. in., with any size
adhesive border, each dressing
A6240
Hydrocolloid dressing, wound filler, paste,
B.R.
per fluid ounce
A6241
Hydrocolloid dressing, wound filler, dry
B.R.
form, per gram
A6242
Hydrogel dressing, wound cover, pad
B.R.
size 16 sq. in. or less, without adhesive
border, each dressing
A6243
Hydrogel dressing, wound cover, pad size
B.R.
more than 16 but less than or equal to
48 sq. in., without adhesive border, each
dressing
A6244
Hydrogel dressing, wound cover, pad size
B.R.
more than 48 sq. in., without adhesive
border, each dressing
A6245
Hydrogel dressing, wound cover, pad size
B.R.
16 sq. in. or less, with any size adhesive
border, each dressing
A6246
Hydrogel dressing, wound cover, pad size
B.R.
more than 16 but less than or equal to
48 sq. in., with any size adhesive border,
each dressing
A6247
Hydrogel dressing, wound cover, pad size
B.R.
more than 48 sq. in., with any size adhesive
border, each dressing
A6248
Hydrogel dressing, wound filler, gel, per
B.R.
fluid ounce
A6249
Hydrogel dressing, wound filler, dry form,
B.R.
per gram
A6250
Skin sealants, protectants, moisturizers
B.R.
any type, any size
A6251
Specialty absorptive dressing, wound cover,
B.R.
pad size 16 sq. in. or less, without
adhesive border, each dressing
A6252
Specialty absorptive dressing, wound cover,
B.R.
pad size more than 16 but less than or equal
to 48 sq. in., without adhesive border, each
dressing
A6253
Specialty absorptive dressing, wound cover,
B.R.
pad size more than 48 sq. in., without
adhesive border, each dressing
A6254
Specialty absorptive dressing, wound cover,
B.R.
pad size 16 sq. in. or less, any size
adhesive border, each dressing
A6255
Specialty absorptive dressing, wound cover,
B.R.
pad size more than 16 but less than or equal
to 48 sq. in., with any size adhesive border,
each dressing
A6256
Specialty absorptive dressing, wound cover,
B.R.
pad size more than 48 sq. in., with any size
adhesive border, each dressing
A6257
Transparent film, 16 sq. in. or less, each
B.R.
dressing
A6258
Transparent film, more than 16 but less than
B.R.
or equal to 48 sq. in., each dressing
A6259
Transparent film, more than 48 sq. in.,
B.R.
each dressing
A6260
Wound cleansers, any type, any size
B.R.
A6261
Wound filler, not elsewhere classified,
B.R.
gel/paste, per fluid ounce
A6262
Wound filler, not elsewhere classified,
B.R.
dry form, per gram
A6266
Gauze, impregnated, other than water or
B.R.
normal saline, any width, per linear yard
A6402
Gauze, non-impregnated, sterile, pad size
B.R.
16 sq. in. or less, without adhesive border,
each dressing
A6403
Gauze, non-impregnated, sterile, pad size
B.R.
more than 16 but less than or equal to
48 sq. in., without adhesive border, each
dressing
A6404
Gauze, non-impregnated, sterile, pad size
B.R.
more than 48 sq. in., without adhesive
border, each dressing
A6442
Conforming bandage, non-elastic,
B.R.
knitted/woven, non-sterile, width less than
three inches, per yard
A6443
Conforming bandage, non-elastic,
B.R.
knitted/woven, non-sterile, width greater
than or equal to three inches and less than
five inches, per yard
A6444
Conforming bandage, non-elastic,
B.R.
knitted/woven, non-sterile, width greater
than or equal to five inches, per yard
A6445
Conforming bandage, non-elastic,
B.R.
knitted/woven, sterile, width less than
three inches, per yard
A6446
Conforming bandage, non-elastic,
B.R.
knitted/woven, sterile, width greater than
or equal to three inches and less than five
inches, per yard
A6447
Conforming bandage, non-elastic,
B.R.
knitted/woven, sterile, width greater than
or equal to five inches, per yard
A6448
Light compression bandage, elastic,
B.R.
knitted/woven, width less than three inches,
per yard
A6449
Light compression bandage, elastic,
B.R.
knitted/woven, width greater than or equal
to three inches and less than five inches,
per yard
A6450
Light compression bandage, elastic,
B.R.
knitted/woven, width greater than or equal
to five inches, per yard
A7000
Canister, disposable, used with suction
6.66
pump, each
A7001
Canister, non-disposable, used with suction
23.86
pump, each
A7002
Tubing, used with suction pump, each
2.77
A7003
Administration set, with small volume
2.18
nonfiltered pneumatic nebulizer, disposable
A7004
Small volume nonfiltered pneumatic
1.22
nebulizer, disposable
A7005
Administration set, with small volume
22.23
nonfiltered pneumatic nebulizer,
non-disposable
A7006
Administration set, with small volume
6.51
filtered pneumatic nebulizer
A7007
Large volume nebulizer, disposable,
3.18
unfilled, used with aerosol compressor
A7008
Large volume nebulizer, disposable,
8.80
prefilled, used with aerosol compressor
A7009
Reservoir bottle, non-disposable, used with
30.32
large volume ultrasonic nebulizer
A7010
Corrugated tubing, disposable, used with
18.65
large volume nebulizer, 100 feet
A7012
Water collection device, used with large
2.86
volume nebulizer
A7013
Filter, disposable, used with aerosol
0.60
compressor
A7014
Filter, nondisposable, used with aerosol
3.23
compressor or ultrasonic generator
A7015
Aerosol mask, used with DME nebulizer
1.32
A7016
Dome and mouthpiece, used with small volume
5.22
ultrasonic nebulizer
A7018
Water, distilled, used with large volume
0.30
nebulizer, 1000 ml
A7033
Replacement pillows for nasal application
22.73
device, pair
A7034
Nasal interface (mask or cannula type) used
94.11
with positive airway pressure device, with
or without head strap
A7035
Headgear used with positive airway pressure
28.34
device
A7036
Chinstrap used with positive airway pressure
14.56
device
A7037
Tubing used with positive airway pressure
31.37
device
A7038
Filter, disposable, used with positive
3.66
airway pressure device
A7039
Filter, non disposable, used with positive
12.26
airway pressure device
B4034
Enteral feeding supply kit; syringe
150.00
(monthly)
B4035
Enteral feeding supply kit; pump fed
275.00
(monthly)
B4036
Enteral feeding supply kit; gravity fed
195.00
(monthly)
B4081
Nasogastric tubing with stylet
16.75
B4082
Nasogastric tubing without stylet
12.98
B4083
Stomach tube--Levine type
1.90
B4086
Gastrostomy/jejunostomy tube, any material,
B.R.
any type, (standard or low profile), each
B4150
Enteral formulae; category I:
B.R.
Semi-synthetic intact protein/protein
isolates (for example, Enrich, Ensure,
Ensure HN, Ensure Powder, Isocal, Lonalac
Powder, Meritene, Meritene Powder, Osmolite,
Osmolite HN, Portagen Powder, Sustacal,
Renu, Sustagen Powder, Travasorb)
1 package = 1 unit
B4151
Enteral formulae; category I: Natural
B.R.
intact protein/protein isolates (for example,
Compleat B, Vitaneed, Compleat B Modified)
1 package = 1 unit
B4152
Enteral formulae; category II: Intact
B.R.
protein/protein isolates (calorically dense)
(for example, Magnacal, Isocal HCN, Sustacal
HC, Ensure Plus, Ensure Plus HN)
1 package = 1 unit
B4153
Enteral formulae; category III: hydrolyzed
B.R
protein/amino acids (e.g., Criticare HN,
Vivonex T.E.N. (Total Enteral Nutrition),
Vivonex HN, Precision HN, Precision Isotonic)
1 package = 1 unit
B4156
Enteral formulae; category VI: standardized
B.R.
nutrients (Vivonex STD, Precision LR and
Tolerex) 1 package = 1 unit
B4164
Parenteral nutrition solution:
13.26
carbohydrates (dextrose), 50% or
less (500 ml = 1 unit)--home mix
B4168
Parenteral nutrition solution; amino
18.59
acid, 3.5%, (500 ml = 1 unit) --home mix
B4172
Parenteral nutrition solution; amino
30.50
acid 5.5% through 7% (500 ml = 1 unit)--
home mix
B4176
Parenteral nutrition solution; amino
43.22
acid, 7% through 8.5% (500 ml
= 1 unit)--home mix
B4178
Parenteral nutrition solution; amino
43.22
acid, greater than 8.5% (500 ml
= 1 unit)
B4180
Parenteral nutrition solution;
18.30
carbohydrates, (dextrose), greater than
50% (500 ml = 1 unit)--home mix
B4184
Parenteral nutrition solution; lipids, 10%
60.00
with administration set (500 ml = 1 unit)
(12 per month)
B4186
Parenteral nutrition solution, lipids, 20%
80.00
with administration set (500 ml = 1 unit)
(12 per month)
B4189
Parenteral nutrition solution; compounded
133.50
amino acid and carbohydrates with
electrolytes, trace elements and vitamins,
including preparation, any strength, 10
to 51 grams of protein--premix
B4193
Parenteral nutrition solution; compounded
172.50
amino acid and carbohydrates with
electrolytes, trace elements, and vitamins,
including preparation, any strength, 52 to
73 grams of protein--premix
B4197
Parenteral nutrition solution; compounded
210.00
amino acid and carbohydrates with
electrolytes, trace elements and vitamins,
including preparation, any strength,
74 to 100 grams of protein--premix
B4199
Parenteral nutrition solution; compounded
252.69
amino acid and carbohydrates with
electrolytes, trace elements and vitamins,
including preparation, any strength, over
100 grams of protein--premix
B4216
Parenteral nutrition; additives (vitamins,
11.65
trace elements, heparin, electrolytes)--
(per day)
home mix
B4220
Parenteral nutrition supply kit for
182.98
1 month--premix
B4222
Parenteral nutrition supply kit for
283.25
one month--home mix
B4224
Parenteral nutrition administration kit
600.00
for 1 month
B5000
Parenteral nutrition solution; compounded
9.28
amino acid and carbohydrates with
electrolytes, trace elements, and vitamins,
including preparation, any strength,
renal--Amirosyn RF, NephrAmine, RenAmin
--premix
B5100
Parenteral nutrition solution; compounded
3.63
amino acid and carbohydrates with
electrolytes, trace elements, and vitamins,
including preparation, any strength,
hepatic--FreAmine HBC, HepatAmine--premix
B5200
Parenteral nutrition solution; compounded
4.94
amino acid and carbohydrates with
electrolytes, trace elements, and vitamins,
including preparation, any strength,
stress--branch chain amino acids--premix
B9000
Enteral nutrition infusion pump--without
950.00
alarm
B9002
Enteral nutrition infusion pump--with
950.00
alarm
B9004
Parenteral nutrition infusion pump, portable
$ 227.40
per month
B9006
Parenteral nutrition infusion pump,
$ 227.40
stationary
per month
B9998
Not otherwise classified (NOC) for
B.R.
enteral supplies
E0100
Cane, includes canes of all materials,
14.97
adjustable or fixed with tips
E0105
Cane, quad or three prong, includes canes
39.48
of all materials, adjustable or fixed
with tips
E0110
Crutches forearm, includes crutches of various
65.43
materials, adjusted or fixed, complete with tips and handgrips, pair
E0111
Crutch forearm, includes crutches of various
57.92
materials, adjustable or fixed, with tip and
handgrip, each
E0112
Crutches underarm, wood, adjustable or
47.46
fixed, with pads, tips and handgrips, pair
E0113
Crutch underarm, wood, adjustable or fixed,
19.51
with pad, tip and handgrip, each
E0114
Crutches underarm, aluminum, adjustable or
68.56
fixed, with pads, tips and handgrips, pair
E0116
Crutch underarm, aluminum, adjustable or
18.99
fixed, with pad, tip and handgrip, each
E0130
Walker, rigid (pickup), adjustable or
55.94
fixed height
E0135
Walker, folding (pickup), adjustable or
59.43
fixed height
E0141
Walker, wheeled, without seat
95.86
E0142
Rigid walker, wheeled, with seat
343.81
E0143
Folding walker, wheeled, without seat
109.05
E0145
Walker, wheeled, with seat and crutch
176.60
attachments
E0146
Walker, wheeled, with seat
318.23
E0147
Heavy duty, multiple breaking system, variable wheel resistance walker
206.71
E0148
Walker, heavy duty, without wheels, rigid or folding, any type, each
B.R.
E0149
Walker, heavy duty, wheeled, rigid or folding, any type
B.R.
E0153
Platform attachment, forearm crutch,
55.37
each
E0154
Platform attachment, walker, each
68.56
E0155
Wheel attachment, rigid pick-up walker
25.62
E0156
Seat attachment, walker
21.09
E0157
Crutch attachment, walker, each
55.37
E0158
Leg extensions, walker
33.74
E0160
Sitz type bath, portable, fits
9.50
over commode seat
E0161
Sitz type bath, portable, fits
52.73
over commode seat, with faucet
attachments
E0162
Sitz bath, chair
B.R.
E0163
Commode chair, stationary, with
89.16
fixed arms
E0164
Commode chair, mobile, with fixed
210.93
arms
E0165
Commode chair, stationary, with
181.01
detachable arms
E0166
Commode chair, mobile, with detachable
265.35
arms
E0167
Pail or pan for use with commode chair
10.19
E0168
Commode chair, extra wide and/or heavy duty,
120.74
stationary or mobile, with or without arms,
any type, each
E0175
Foot rest, for use with commode chair,
44.07
each
E0176
Air pressure pad or cushion, non-
B.R.
positioning
E0177
Water pressure pad or cushion, non-
B.R.
positioning
E0178
Gel pressure pad or cushion, non-
B.R.
positioning
E0179
Dry pressure pad or cushion, non-
B.R.
positioning
E0180
Pressure pad, alternating with pump
240.44
E0181
Pressure pad, alternating with pump, heavy
263.73
duty
E0182
Pump for alternating pressure pad
291.08
E0184
Dry pressure mattress
68.56
E0185
Gel pressure pad for mattress
62.22
E0186
Air pressure mattress
B.R.
E0187
Water pressure mattress
B.R.
E0188
Synthetic sheepskin pad
21.09
E0189
Lambswool sheepskin pad, any size
21.09
E0191
Heel or elbow protector, each
10.34
E0192
Low pressure and positioning
326.66
equalization pad
E0193
Powered air flotation bed (low air
36.00
loss therapy)
(per day)
E0194
Air fluidized bed
65.20
(per day)
E0200
Heat lamp, without stand (table model),
36.92
includes bulb, or infrared element
E0202
Phototherapy (bilirubin) light with
B.R.
photometer
E0217
Water circulating heat pad with pump
337.60
E0235
Paraffin bath unit, portable (see medical
194.38
supply code A4265 for paraffin)
E0236
Pump for water circulating pad
B.R.
E0241
Bathtub wall rail, each
B.R.
E0242
Bathtub rail, floor base
B.R.
E0243
Toilet rail, each
B.R.
E0244
Raised toilet seat
B.R.
E0245
Tub stool or bench
B.R.
E0246
Transfer tub rail attachment
B.R.
E0249
Pad for water circulating heat unit
124.44
E0250
Hospital bed, fixed height, with any
881.42
type side rails, with mattress
E0251
Hospital bed, fixed height, with any
672.33
type side rails, without mattress
E0255
Hospital bed, variable height, hi-lo,
964.20
with any type side rails, with mattress
E0256
Hospital bed, variable height, hi-lo,
B.R.
with any type side rails, without mattress
E0260
Hospital bed, semi-electric (head and
1,542.26
foot adjustments), with any type side
rails, with mattress
E0261
Hospital bed, semi-electric (head and foot
B.R.
adjustments), with any type side rails,
without mattress
E0265
Hospital bed, total electric (head, foot,
1,940.52
and height adjustments), with any type side
rails, with mattress
E0266
Hospital bed, total electric (head, foot,
1,909.20
and height adjustments), with any type side
rails, without mattress
E0270
Hospital bed, institutional type includes:
B.R.
oscillating, circulating and stryker frame,
with mattress
E0271
Mattress, inner spring
168.73
E0272
Mattress, foam rubber
155.55
E0273
Bed board
B.R.
E0274
Over-bed table
B.R.
E0275
Bed pan, standard, metal or plastic
15.82
E0276
Bed pan, fracture, metal or plastic
12.60
E0277
Alternating pressure mattress
B.R.
E0280
Bed cradle, any type
29.53
E0290
Hospital bed, fixed height, without
B.R.
side rails, with mattress
E0291
Hospital bed, fixed height, without
B.R.
side rails, without mattress
E0292
Hospital bed, variable height, hi-lo,
B.R.
without side rails, with mattress
E0293
Hospital bed, variable height, hi-lo,
B.R.
without side rails, without mattress
E0294
Hospital bed, semi-electric (head and
B.R.
foot adjustments), without side rails,
with mattress
E0295
Hospital bed, semi-electric (head and
B.R.
foot adjustments), without side rails,
without mattress
E0296
Hospital bed, total electric (head,
B.R.
foot and height adjustments), without
side rails, with mattress
E0297
Hospital bed, total electric (head,
B.R.
foot and height adjustments), without
side rails, without mattress
E0303
Hospital bed, heavy duty, extra wide, with
B.R.
weight capacity greater than 350 pounds,
but less than or equal to 600 pounds, with
any type side rails
E0305
Bedside rails, half length
143.77
E0310
Bedside rails, full length
164.74
E0325
Urinal; male, jug-type, any material
6.53
E0326
Urinal; female, jug-type, any material
9.28
E0371
Nonpowered advanced pressure reducing
B.R.
overlay for mattress, standard mattress
length and width
E0372
Powered air overlay for mattress, standard
B.R.
mattress length and width
E0424
Stationary compressed gaseous oxygen system,
250.00(per month)
rental; includes contents (per unit),
regulator, flowmeter, humidifier, nebulizer,
cannula or mask and tubing;
1 unit = 50 cubic ft.
E0431
Portable gaseous oxygen system, rental;
47.33
includes regulator, flowmeter, humidifier,
(per month)
cannula or mask, and tubing
E0434
Portable liquid oxygen system, rental;
47.33(per month)
includes portable container, supply
reservoir, humidifier, flowmeter, refill
adaptor, contents gauge, cannula or mask,
and tubing
E0439
Stationary liquid oxygen system, rental;
250.00(per month)
includes use of reservoir, contents (per
unit), regulator, flowmeter, humidifier,
nebulizer, cannula or mask, and tubing;
1 unit = 10 lbs.
E0441
Oxygen contents, gaseous, per unit (for use
6.50
with owned gaseous stationary systems or
when both a stationary and portable gaseous
system are owned; 1 unit = 50 cubic ft.)
E0442
Oxygen contents, liquid, per unit (for use
14.00
with owned liquid stationary systems or when
both a stationary and portable liquid system
are owned; l unit = 10 lbs.)
E0443
Portable oxygen contents, gaseous, per unit
.65
(for use only with portable gaseous systems
when no stationary gas or liquid system is
used; 1 unit = 5 cubic ft.)
E0444
Portable oxygen contents, liquid, per unit
1.40
(for use only with portable liquid systems
when no stationary gas or liquid system is
used; 1 unit = 1 lb.)
E0450
Volume ventilator; stationary or portable
10,546.29
E0455
Oxygen tent, excluding croup or pediatric
B.R.
tents
E0457
Chest shell (cuirass)
414.80
E0459
Chest wrap
539.24
E0460
Negative pressure ventilator; portable
B.R.
or stationary
E0462
Rocking bed with or without rails
B.R.
E0470
Respiratory assist device, bi-level
B.R.
pressure capability, without backup rate
feature, used with noninvasive interface,
for example, nasal or facial mask
(intermittent assist device with continuous
positive airway pressure device)
E0471
Respiratory assist device, bi-level
B.R.
pressure capability, with back-up rate
feature, used with noninvasive interface,
for example, nasal or facial mask
(intermittent assist device with continuous
positive airway pressure device)
E0472
Respiratory assist device, bi-level
B.R.
pressure capability, with backup rate
feature, used with invasive interface, for
example, tracheostomy tube (intermittent
assist device with continuous positive
airway pressure device)
E0480
Percussor, electric or pneumatic,
279.47
home model
E0500
IPPB machine, all types, with built-in
469.32
nebulization; manual or automatic valves;
internal or external power source
E0550
Humidifier, durable for extensive
315.33
supplemental humidification during
IPPB treatments or oxygen delivery
E0555
Humidifier, durable, glass or autoclavable
15.00
plastic bottle type, for use with regulator
or flowmeter
E0560
Humidifier, durable for supplemental
64.64
humidification during IPPB treatment
or oxygen delivery
E0565
Compressor, air power source for
506.07
equipment which is not self-contained
or cylinder driven
E0570
Nebulizer, with compressor
166.19
E0575
Nebulizer, ultrasonic
732.97
E0580
Nebulizer, durable, glass or autoclavable
121.29
plastic, bottle type, for use with
regulator or flowmeter
E0585
Nebulizer, with compressor and heater
121.29
E0600
Suction pump, home model, portable
409.72
E0601
Continuous positive airway pressure (CPAP)
834.17
device
E0601
Continuous positive airway pressure (CPAP)
100.10
device
(per month)
NOTE: Medicaid and NJ KidCare
fee-for-service reimbursement, all supplies
necessary for the use and maintenance of the
device
E0605
Vaporizer, room type
30.58
E0606
Postural drainage board
158.19
E0607
Home blood glucose monitor
90.00
E0609
Blood glucose monitor with special features
B.R.
(for example, voice synthesizers, automatic
timers, etc.)
E0610
Pacemaker monitor, self-contained (checks
336.42
battery depletion, includes audible and
visible check systems)
E0615
Pacemaker monitor, self-contained, (checks
336.42
battery depletion and other pacemaker
components, includes digital/visible
check systems
E0618
Apnea monitor, without recording feature
1666.67
E0618
Apnea monitor, without recording feature
200.00
(per month)
E0619
Apnea monitor, with recording feature
2083.33
E0619
Apnea monitor, with recording feature
200.00
(per month)
E0621
Sling or seat, patient lift, canvas or nylon
63.36
E0625
Patient lift, Kartop, bathroom or toilet
B.R.
E0630
Patient lift, hydraulic, with seat or sling
932.66
E0635
Patient lift, electric with seat or sling
770.15
E0650
Pneumatic compressor, nonsegmental home
522.05
model, (lymphedema pump)
E0651
Pneumatic compressor, segmental home model,
732.97
(lymphedema pump) without calibrated
gradient pressure
E0652
Pneumatic compressor, segmental home model,
3,374.81
(lymphedema pump) with calibrated gradient
pressure
E0655
Nonsegmental pneumatic appliance for use
83.42
with pneumatic compressor, half arm
E0660
Nonsegmental pneumatic appliance for use
137.10
with pneumatic compressor, full leg
E0665
Nonsegmental pneumatic appliance for use
89.75
with pneumatic compressor, full arm
E0666
Nonsegmental pneumatic appliance for use
131.83
with pneumatic compressor, half leg
E0667
Segmental pneumatic appliance for use with
258.39
pneumatic compressor, full leg
E0668
Segmental pneumatic appliance for use with
226.75
pneumatic compressor, full arm
E0669
Segmental pneumatic appliance for use with
B.R.
pneumatic compressor, half leg
E0670
Segmental pneumatic appliance for use with
B.R.
pneumatic compressor, half arm
E0671
Segmental gradient pressure pneumatic
B.R.
appliance, full leg
E0672
Segmental gradient pressure pneumatic
B.R.
appliance, full arm
E0673
Segmental gradient pressure pneumatic
B.R.
appliance, half leg
E0700
Safety equipment (for example, belt,
B.R.
harness or vest)
E0710
Restraints, any type (body, chest, wrist
B.R.
or ankle)
E0720
TENS, two lead, localized stimulation
452.02
E0730
TENS, four lead, larger area/multiple
448.08
nerve stimulation
E0731
Form-fitting conductive garment for
B.R.
delivery of TENS or NMES (with conductive
fibers separated from the patient's skin by
layers of fabric)
E0740
Incontinence treatment system, pelvic floor
B.R.
stimulator, monitor, sensor and/or trainer
E0744
Neuromuscular stimulator for scoliosis
1,031.82
E0745
Neuromuscular stimulator, electronic
1,049.36
shock unit
E0746
Electromyography (EMG), biofeedback
694.79
device
E0747
Osteogenesis stimulator (noninvasive)
2,742.04
E0748
Osteogenic stimulator, noninvasive, spinal
B.R.
applications
E0755
Electronic salivary reflex stimulator
B.R.
(intraoral/noninvasive)
E0776
IV pole
69.74
E0780
Ambulatory infusion pump, mechanical,
8.30
reusable, for infusion less than eight hours
E0781
Ambulatory infusion pump, single or multiple
B.R.
channels with administrative equipment, worn
by patient
E0784
External ambulatory infusion pump, insulin
B.R.
E0791
Parenteral infusion pump, stationary, single
B.R.
or multichannel
E0840
Traction frame, attached to headboard,
36.92
simple cervical traction
E0850
Traction stand, freestanding, simple
36.92
cervical traction
E0860
Traction equipment, overdoor, cervical
27.17
E0870
Traction frame, attached to footboard,
83.84
simple extremity traction (for example,
Buck's)
E0880
Traction stand, freestanding simple
68.56
extremity traction (for example, Buck's)
E0890
Traction frame, attached to footboard,
80.47
simple pelvic traction
E0900
Traction stand, freestanding simple
80.47
pelvic traction (for example, Buck's)
E0910
Trapeze bars, a/k/a patient helper,
163.74
attached to bed, with grab bar
E0920
Fracture frame, attached to bed,
394.43
includes weights
E0930
Fracture frame, freestanding,
394.43
includes weights
E0935
Passive motion exercise device
17.00
(per day)
E0940
Trapeze bar, freestanding,
314.78
complete with grab bar
E0941
Gravity assisted traction
384.94
device, any type
E0942
Cervical head harness/halter
15.82
E0943
Cervical pillow
41.48
E0944
Pelvic belt/harness/boot
32.74
E0945
Extremity belt/harness
36.92
E0946
Fracture, frame, dual with cross bars,
894.33
attached to bed, (for example, balkan, 4
poster)
E0947
Fracture frame, attachments for complex
B.R.
pelvic traction
E0948
Fracture frame, attachments for complex
B.R.
cervical traction
E0950
Tray
82.96
E0951
Loop heel, each
15.04
E0952
Loop toe, each
15.04
E0953
Pneumatic tire, each
92.59
E0954
Semi-pneumatic caster, each
47.46
E0958
Wheelchair attachment to convert
421.32
any wheelchair to one arm drive
E0959
Amputee adapter (device used to compensate
73.82
for transfer of weight due to lost limbs
to maintain proper balance)
E0961
Brake extension, for wheelchair
11.61
E0962
1' cushion, for wheelchair
47.46
E0963
2' cushion, for wheelchair
61.17
E0964
3' cushion, for wheelchair
70.66
E0965
4' cushion, for wheelchair
79.10
E0966
Hook-on headrest extension
51.67
E0967
Wheelchair hand rims with 8 vertical
105.46
rubber-tipped projections, pair
E0968
Commode seat, wheelchair
181.39
E0969
rrowing device, wheelchair
B.R.
E0970
No. 2 footplates, except for elevating
94.92
leg rest
E0971
Anti-tipping device wheelchairs
50.28
E0972
Transfer board, wheelchair
B.R.
E0973
Adjustable height detachable arms,
91.75
desk or full length, wheelchair
E0974
"Grade-aid" (device to prevent rolling
68.56
back on an incline) for wheelchair
E0975
Reinforced seat upholstery, wheelchair
55.89
E0976
Reinforced back, wheelchair, upholstery
55.89
or other material
E0977
Wedge cushion, wheelchair
49.57
E0978
Belt, safety with airplane buckle,
36.92
wheelchair
E0979
Belt, safety with velcro closure,
25.93
wheelchair
E0980
Safety vest, wheelchair
26.37
E0990
Elevating leg rest, each
77.14
E0991
Upholstery seat
36.92
E0992
Solid seat insert
43.49
E0993
Back, upholstery
27.97
E0994
Armrest, each
13.42
E0995
Calf rest, each
21.09
E0996
Tire, solid, each
23.07
E0997
Caster with a fork
56.95
E0998
Caster without fork
31.64
E0999
Pneumatic tire with wheel
91.75
E1000
Tire, pneumatic caster
49.57
E1001
Wheel, single
92.81
E1031
Rollabout chair, any and all types with
B.R.
castors 5' or greater
E1050
Fully-reclining wheelchair, fixed
1,222.53
full-length arms, swing away detachable
elevating leg rests
E1060
Fully-reclining wheelchair, detachable
1,222.53
arms, desk or full-length, swing away
detachable elevating leg rests
E1065
Power attachment (to convert any wheelchair
2,404.55
to motorized wheelchair (for example, solo)
E1066
Battery charger
242.56
E1069
Deep cycle battery
92.99
E1070
Fully-reclining wheelchair, detachable
909.61
arms, desk or full-length, swing away
detachable foot rest
E1083
Hemi-wheelchair, fixed full-length arms,
717.15
swing away detachable elevating leg rests
E1084
Hemi-wheelchairs, detachable arms, desk
1,049.29
or full-length arms, swing away detachable
elevating leg rests
E1085
Hemi-wheelchair, fixed full-length arms,
829.21
swing away detachable foot rests
E1086
Hemi-wheelchair, detachable arms, desk
1,105.41
or full-length, swing away detachable
foot rests
E1087
High strength lightweight wheelchair,
1,152.71
fixed-full length arms, swing away
detachable leg rests
E1088
High strength lightweight wheelchair,
1,536.80
detachable arms, desk or full-length,
swing away detachable elevating leg rests
E1089
High strength lightweight wheelchair,
1,133.99
fixed length arms, swing away detachable
foot rest
E1090
High strength lightweight wheelchair,
1,499.05
detachable arms, desk or full-length,
swing away detachable foot rests
E1092
Wide heavy duty wheelchair, detachable
1,367.22
arms, desk or full-length, swing
away detachable elevating leg rests
E1093
Wide heavy duty wheelchair, detachable
1,255.01
arms, desk or full-length arms, swing
away detachable foot rests
E1100
Semi-reclining wheelchair, fixed
1,054.63
full-length arms, swing away detachable
elevating leg rests
E1110
Semi-reclining wheelchair, detachable
1,139.73
arms, desk or full-length, elevating
leg rests
E1130
Standard wheelchair, fixed full-length
424.49
arms, fixed or swing away detachable foot
rests
E1140
Wheelchair, detachable arms,
697.26
desk or full-length, swing away detachable
foot rests
E1150
Wheelchair, detachable arms, desk or
776.52
full-length, swing away detachable
elevating leg rests
E1160
Wheelchair, fixed full-length arms,
601.55
swing away detachable elevating leg rests
E1170
Amputee wheelchair, fixed full
1,179.70
length arms, swing away detachable
elevating leg rests
E1171
Amputee wheelchair, fixed full length
682.35
arms, without foot rests or leg rests
E1172
Amputee wheelchair, detachable arms
877.45
(desk or full-length) without foot
rests or leg rests
E1180
Amputee wheelchair, detachable arms
937.91
(desk or full-length) swing away
detachable foot rests
E1190
Amputee wheelchair, detachable arms
1,083.63
(desk or full-length) swing away
detachable elevating leg rests
E1195
Heavy duty wheelchair, fixed
1,029.11
full-length arms, swing away
detachable elevating leg rests
E1200
Amputee wheelchair, fixed full-length
807.14
arms, swing away detachable foot rest
E1210
Motorized wheelchair, fixed full-length
3,646.69
arms, swing away detachable elevating
leg rests
E1211
Motorized wheelchair, detachable arms
3,269.35
(desk or full-length) swing away,
detachable elevating leg rests
E1212
Motorized wheelchair, fixed
2,913.94
full-length arms, swing away
detachable foot rests
E1213
Motorized wheelchair, detachable arms
3,269.35
(desk or full-length) swing away
detachable foot rests
E1220
Wheelchair; specially sized or constructed
B.R.
(indicate brand name, model number,
and justification)
E1221
Wheelchair with fixed arm, foot rests
758.38
E1222
Wheelchair with fixed arm, elevating leg
955.49
rest
E1223
Wheelchair with detachable arms,
831.05
foot rests
E1224
Wheelchair with detachable arms,
1,174.02
elevating leg rests
E1225
Semi-reclining back for customized
449.27
wheelchair
E1226
Full-reclining back for customized
514.66
wheelchair
E1227
Special height arms for wheelchair
221.47
E1228
Special back height for wheelchair
189.83
E1230
Power operated vehicle (three or four
1,624.13
wheel nonhighway), specify brand name
and model number
E1240
Lightweight wheelchair, detachable
1,057.14
arms, (desk or full-length) swing away
detachable, elevating leg rest
E1250
Lightweight wheelchair, fixed
630.67
full-length arms, swing away
detachable foot rest
E1260
Lightweight wheelchair, detachable
870.81
arms, (desk or full-length)swing away
detachable foot rest
E1270
Lightweight wheelchair, fixed
727.69
full-length arms, swing away
detachable elevating leg rests
E1280
Heavy duty wheelchair, detachable
1,272.04
arms (desk or full-length) elevating
leg rests
E1285
Heavy duty wheelchair, fixed
999.66
full-length arms, swing away
detachable foot rest
E1290
Heavy duty wheelchair, detachable
1,386.25
arms (desk or full-length) swing away
detachable foot rest
E1295
Heavy duty wheelchair, fixed
943.05
full-length arms, elevating leg rest
E1296
Special wheelchair seat height from
282.64
the floor
E1297
Special wheelchair seat depth, by
61.17
upholstery
E1298
Special wheelchair seat depth and/or
304.78
width, by construction
E1300
Whirlpool, portable (overtub type)
B.R.
E1310
Whirlpool, nonportable (built-in type)
3,269.35
E1340
Repair or nonroutine service for durable
10.00
medical equipment requiring the skill of a
technician, labor component, per 15 minutes
E1353
Regulator
B.R.
E1355
Stand/rack
46.67
E1372
Immersion external heater for nebulizer
179.29
E1390
Oxygen concentrator, equiv. not determined
250.00
per month
E1399
Durable medical equipment, miscellaneous
B.R.
E1405
Oxygen and water vapor enriching system
B.R.
with heated delivery
E1406
Oxygen and water vapor enriching system
B.R.
without heated delivery
E1500
Centrifuge, for dialysis
B.R.
E1510
Kidney, dialysate delivery system, Kidney
B.R.
machine, pump recirculating, air removal
system, flow rate meter, power off, heater
and temperature control with alarm, i.v.
poles, pressure gauge, concentrate container
E1520
Heparin infusion pump for hemodialysis
B.R.
E1530
Air bubble detector for hemodialysis, each,
B.R.
replacement
E1540
Pressure alarm for hemodialysis, each
B.R.
replacement
E1550
Bath conductivity meter for hemodialysis,
B.R.
each
E1575
Transducer protectors/fluid barriers, for
B.R.
hemodialysis, any size, per 10
E1580
Unipuncture control system for hemodialysis
B.R.
E1590
Hemodialysis machine
B.R.
E1592
Automatic intermittent peritoneal
B.R.
dialysis system
E1594
Cycler dialysis machine for peritoneal
B.R.
dialysis
E1610
Reverse osmosis water purification
B.R.
system
E1615
Deionizer water purification system
B.R.
E1620
Blood pump for hemodialysis, replacement
B.R.
E1630
Reciprocating peritoneal dialysis system
B.R.
E1632
Wearable artificial kidney
B.R.
E1634
Peritoneal dialysis clamps, each
B.R.
E1635
Compact (portable) travel hemodialyzer
B.R.
system
E1636
Sorbent cartridges, for hemodialysis, per 10
B.R.
E1637
Hemostats, each
B.R.
E1699
Dialysis equipment, unspecified, by report
B.R.
E1700
Jaw motion rehabilitation system
B.R.
E1701
Replacement cushions for jaw motion
B.R.
rehabilitation system, pkg. of 6
E1702
Replacement measuring scales for jaw
B.R.
motion rehabilitation system, pkg. of 200
E1800
Dynamic adjustable elbow extension/flexion
B.R.
device
E1805
Dynamic adjustable wrist extension/flexion
B.R.
device
E1810
Dynamic adjustable knee extension/flexion
B.R.
device
E1815
Dynamic adjustable ankle extension/flexion
B.R.
device
E1820
Soft interface material, dynamic adjustable
B.R.
extension/flexion device
E1825
Dynamic adjustable finger extension/flexion
B.R.
device
E1830
Dynamic adjustable toe extension/flexion
B.R.
device
E2100
Blood glucose monitor with integrated voice
507.45
synthesizer
K0001
Standard wheelchair
539.00
K0002
Standard hemi (low seat) wheelchair
870.00
K0003
Lightweight wheelchair
802.00
K0004
High strength, lightweight wheelchair
1,385.00
K0005
Ultra lightweight wheelchair
B.R.
K0006
Heavy duty wheelchair
1,274.00
K0007
Extra heavy duty wheelchair
B.R.
K0009
Other manual wheelchair/base
B.R.
K0010
Standard-weight frame motorized/power
3,345.00
wheelchair
K0011
Standard-weight frame motorized/power
B.R.
wheelchair with programmable control
parameters for speed adjustment,
tremor dampening, acceleration control
and braking
K0012
Lightweight portable motorized/power
B.R.
wheelchair
K0014
Other motorized/power wheelchair base
B.R.
K0015
Detachable, nonadjustable height
157.00
armrest, each
K0016
Detachable, adjustable height armrest,
100.00
complete assembly, each
K0017
Detachable, adjustable height armrest,
B.R.
base, each
K0018
Detachable, adjustable height armrest,
B.R.
upper portion, each
K0019
Arm pad, each
B.R.
K0020
Fixed, adjustable height armrest, pair
B.R.
K0022
Reinforced back upholstery
43.00
K0023
Solid back insert, planar back, single
B.R.
density foam, attached with straps
K0024
Solid back insert, planar back, single
B.R.
density foam, with adjustable hook-on
hardware
K0025
Hook-on headrest extension
56.00
K0026
Back upholstery for ultra lightweight or
27.97
high-strength lightweight wheelchair
K0027
Back upholstery for wheelchair type other
34.00
than ultra lightweight or high-strength
lightweight wheelchair
K0028
Fully reclining back
472.00
K0029
Reinforced seat upholstery
43.00
K0030
Solid seat insert, planar seat, single
70.00
density foam
K0031
Safety belt/pelvic strap
37.00
K0032
Seat upholstery for ultra lightweight or
36.92
high-strength lightweight wheelchair
K0033
Seat upholstery for wheelchair type other
36.92
than ultra lightweight or high-strength
lightweight wheelchair
K0035
Heel loop with ankle strap, each
B.R.
K0036
Toe loop, each
17.00
K0037
High mount flip-up footrest, each
47.46
K0038
Leg strap, each
B.R.
K0039
Leg strap, H style, each
B.R.
K0040
Adjustable angle footplate, each
B.R.
K0041
Large size footplate, each
B.R.
K0042
Standard size footplate, each
32.00
K0043
Footrest, lower extension tube, each
B.R.
K0044
Footrest, upper hanger bracket, each
B.R.
K0045
Footrest, complete assembly
B.R.
K0046
Elevating legrest, lower extension
B.R.
tube, each
K0047
Elevating legrest, upper hanger bracket,
B.R.
each
K0048
Elevating legrest, complete assembly
87.00
K0049
Calf pad, each
23.00
K0050
Ratchet assembly
B.R.
K0051
Cam release assembly, footrest or legrest,
B.R.
each
K0052
Swingaway, detachable footrests, each
B.R.
K0053
Elevating footrests, articulating
B.R.
(telescoping), each
K0054
Seat width of 10', 11', 12', 15', 17', or
B.R.
20' for a high strength, lightweight or
ultra lightweight wheelchair
K0055
Seat depth of 15', 17', or 18' for a
B.R.
high strength lightweight or ultra
lightweight wheelchair
K0056
Seat height less than 17' or less than
83.00
or equal to 21' for a high strength,
lightweight or ultra lightweight
wheelchair
K0057
Seat width 19' or 20' for heavy duty
107.00
or extra heavy duty chair
K0058
Seat depth 17' or 18' for motorized/
52.00
power wheelchair
K0059
Plastic coated handrim, each
B.R.
K0060
Steel handrim, each
B.R.
K0061
Aluminum handrim, each
B.R.
K0062
Handrim with 8-10 vertical or
53.00
oblique projections, each
K0063
Handrim with 12-16 vertical or
B.R.
oblique projections, each
K0064
Zero pressure tube (flat free inserts),
B.R.
any size, each
K0065
Spoke protectors
B.R.
K0066
Solid tire, any size, each
25.00
K0067
Pneumatic tire, any size, each
35.00
K0068
Pneumatic tire tube, each
B.R.
K0069
Rear wheel assembly, complete with solid
87.00
tire, spokes or molded, each
K0070
Rear wheel assembly, complete, with
158.00
pneumatic tire, spokes or molded, each
K0071
Front caster assembly, complete, with
B.R.
pneumatic tire, each
K0072
Front caster assembly, complete, with
57.00
semi-pneumatic tire, each
K0073
Caster pinlock, each
B.R.
K0074
Pneumatic caster tire, any size, each
31.00
K0075
Semi-pneumatic caster tire, any size,
47.46
each
K0076
Solid caster tire, any size, each
B.R.
K0077
Front caster assembly, complete, with
B.R.
solid tire, each
K0078
Pneumatic caster tire tube, each
B.R.
K0079
Wheel lock extension, pair
43.00
K0080
Anti-rollback device, pair
136.00
K0081
Wheel lock assembly, complete, each
B.R.
K0082
22 NF deep cycle lead acid battery,
92.99
each
K0083
22 NF gel cell battery, each
B.R.
K0084
Group 24 deep cycle lead acid battery,
B.R.
each
K0085
Group 24 gel cell battery, each
B.R.
K0086
U-1 lead acid battery, each
92.99
K0087
U-1 gel cell battery, each
B.R.
K0088
Battery charger, lead acid or gel cell
242.56
K0089
Battery charger, dual mode
B.R.
K0090
Rear wheel tire for power wheelchair,
B.R.
any size, each
K0091
Rear wheel tire tube other than zero
B.R.
pressure for power wheelchair, any
size, each
K0092
Rear wheel assembly for power wheelchair,
B.R.
complete, each
K0093
Rear wheel zero pressure tire tube (flat
B.R.
free insert) for power wheelchair, any
size, each
K0094
Wheel tire for power base, any size, each
B.R.
K0095
Wheel tire tube other than zero pressure
B.R.
for each base, any size, each
K0096
Wheel assembly for power base, complete,
B.R.
each
K0097
Wheel zero pressure tire tube (flat free
B.R.
insert) for power base, any size, each
K0098
Drive belt for power wheelchair
B.R.
K0099
Front caster for power wheelchair
B.R.
K0100
Amputee adapter, pair
77.00
K0102
Crutch and cane holder
B.R.
K0103
Transfer board, less than 25 inches
B.R.
K0104
Cylinder tank carrier
B.R.
K0105
IV hanger
B.R.
K0106
Arm trough, each
B.R.
K0107
Wheelchair tray
89.00
K0108
Other accessories
B.R.
K0109
Customization of wheelchair base frame
B.R.
(options or accessories)
K0112
Trunk support device, vest type, with
B.R.
inner frame, prefabricated
K0113
Trunk support device, vest type, without
B.R.
inner frame, prefabricated
K0114
Back support system for use with a
B.R.
wheelchair, with inner frame,
prefabricated
K0115
Orthotic seating system, back module,
B.R.
posterior--lateral control, with or
without lateral supports, custom
fabricated, for attachment to wheelchair
base
K0116
Orthotic seating system, combined back
B.R.
and seat module, custom fabricated, for
attachment to wheelchair base
K0127
Replace soft interface material, ankle
B.R.
contracture splint
K0128
Replace soft interface material, foot
B.R.
drop splint
K0129
Ankle contracture splint
B.R.
K0130
Foot drop splint, recumbent positioning
B.R.
device
K0137
Skin barrier; liquid (spray brush, etc.)
B.R.
per oz.
K0138
Skin barrier; paste, per oz.
B.R.
K0139
Skin barrier, powder, per oz.
B.R.
K0152
Pastes, powders, granules, beads,
B.R.
contact layers
K0163
Vacuum erection system
B.R.
tracheostomy
K0168
Administration set, small volume
B.R.
pneumatic nebulizer, disposable
K0169
Small volume nonfiltered pneumatic
B.R.
nebulizer, disposable
K0170
Administration set, small volume non-
B.R.
filtered pneumatic nebulizer, non-
disposable
K0171
Administration set, small volume
B.R.
nonfiltered pneumatic nebulizer
K0172
Large volume nebulizer, disposable,
B.R.
unfilled, used with aerosol compressor
K0173
Large volume nebulizer, disposable,
B.R.
prefilled, used with aerosol compressor
K0174
Reservoir bottle, non-disposable, used
B.R.
with large volume ultrasonic nebulizer
K0175
Corrugated tubing, disposable, used with
B.R.
large volume nebulizer, 100 feet
K0176
Corrugated tubing, non-disposable, used
B.R.
with large volume nebulizer, 100 feet
K0177
Water collection device, used with large
B.R.
volume nebulizer
K0178
Filter, disposable, used with aerosol
B.R.
compressor
K0179
Filter, non-disposable, used with aerosol
B.R.
compressor or ultrasonic generator
K0180
Aerosol mask, used with DME nebulizer
B.R.
K0181
Dome and mouthpiece, used with small
B.R.
volume ultrasonic nebulizer
K0182
Water, distilled, used with large volume
B.R.
nebulizer, 1000 ml
K0183
Nasal application device, used with
B.R.
CPAP device
K0184
Nasal pillows/seals, replacement for
B.R.
nasal application device, pair
K0185
Headgear, used with CPAP device
B.R.
K0186
Chin strap, used with CPAP device
B.R.
K0187
Tubing, used with CPAP device
B.R.
K0188
Filter, disposable, used with CPAP
B.R.
device
K0189
Filter, non-disposable, used with
B.R.
CPAP device
K0190
Canister, disposable, used with
B.R.
suction pump
K0191
Canister, non-disposable, used with
B.R.
suction pump
K0192
Tubing, used with suction pump
B.R.
K0193
Continuous positive airway pressure
B.R.
(CPAP) device, with humidifier
K0194
Intermittent assist device with
B.R.
continuous positive airway pressure
(CPAP), with humidifier
K0195
Elevating leg rest, pair (for use
B.R.
with capped rental wheelchair base)
K0268
Humidifier, used with CPAP device
B.R.
K0460
Power add-on, to convert manual wheelchair
B.R.
to motorized wheel chair, joystick control
K0461
Power add-on, to convert manual wheelchair
B.R.
to motorized wheel chair, tiller control
L0210
Thoracic rib belt, custom fitted
13.20
L0300
Thoracic-lumbar-sacral-orthoses (TLSO),
101.68
flexible (dorso-lumbar surgical support),
custom fitted
L0315
TLSO, flexible dorso-lumbar surgical
120.00
support
L0515
LSO, flexible (lumbo-sacral surgical
69.16
support), elastic type, with rigid
posterior panel
L0600
Sacroiliac, flexible (sacroiliac surgical
40.72
support), custom fitted
L0900
Torso support, ptosis support, custom
102.11
fitted
L0920
Torso support, pendulous abdomen
118.36
support, custom fitted
L0940
Torso support, postsurgical support,
110.18
custom fitted
L0960
Torso support, postsurgical support
48.71
pads, for postsurgical support
L0974
TLSO, full corset
88.20
L0976
LSO, full corset
103.88
L0980
Peroneal straps, pair
11.33
L0982
Stocking supporter grips, set of
9.60
four (4)
L1600
Hip orthoses (HO), abduction control
40.32
of hip joints, flexible, Frejka type
with cover
L1610
HO, abduction control of hip joints,
25.00
flexible, flexible, (Frejka cover only)
L1620
HO, abduction control of hip joints,
75.00
flexible, (Pavlik harness)
L1800
Knee orthosis (KO), elastic with stays
32.56
L1810
KO, elastic with joints
61.04
L1815
KO, elastic with condylar pads
63.19
L1820
KO, elastic with condyle pads and joints
72.40
L1825
KO, elastic knee cap
28.00
L1830
KO, immobilizer; canvas longitudinal
52.88
L1902
AFO, ankle gauntlet, custom fitted
48.81
L1906
AFO, multiligamentus ankle support
75.00
L3201
Orthopedic shoe, oxford with supinator
48.00
or pronator, infant
L3202
Orthopedic shoe, oxford with supinator
48.00
or pronator, child
L3203
Orthopedic shoe, oxford with supinator
48.00
or pronator, junior
L3204
Orthopedic shoe, hightop with supinator
48.00
or pronator, infant
L3206
Orthopedic shoe, hightop with supinator
48.00
or pronator, child
L3207
Orthopedic shoe, hightop with supinator
48.00
or pronator, junior
L3208
Surgical boot, each, infant
24.00
L3209
Surgical boot, each, child
24.00
L3211
Surgical boot, each, junior
24.00
L3212
Benesch boot, pair, infant
48.00
L3213
Benesch boot, pair, child
48.00
L3214
Benesch boot, pair, junior
48.00
L3215
Orthopedic footwear, woman's shoes,
76.00
oxford
L3216
Orthopedic footwear, woman's shoes,
100.00
depth inlay
L3217
Orthopedic footwear, woman's shoes,
116.00
hightop, depth inlay
L3218
Orthopedic footwear, woman's surgical
64.00
boot, each
L3219
Orthopedic footwear, man's shoes,
76.00
oxford
L3221
Orthopedic footwear, man's shoes,
100.00
depth inlay
L3222
Orthopedic footwear, man's shoes,
116.00
hightop, depth inlay
L3223
Orthopedic footwear, man's surgical
64.00
boot, each
L3253
Foot, molded shoe Plastazote
112.00
(or similar), custom fitted, each
L3254
Nonstandard size or width
20.00
L3255
Nonstandard size or length
20.00
L3257
Orthopedic footwear, additional
50.00
charge for split size
L3260
Ambulatory surgical boot, each
88.00
L3265
Plastazote sandal, each
56.00
L3300
Lift, elevation, heel, tapered to
64.00
metatarsals, per inch
L3310
Lift, elevation, heel and sole,
64.00
neoprene, per inch
L3320
Lift, elevation, heel and sole,
100.00
cork, per inch
L3332
Lift, elevation, inside shoe, tapered,
44.00
up to one-half inch
L3334
Lift, elevation, heel, per inch
36.00
L3340
Heel wedge, sach
10.40
L3350
Heel wedge
12.00
L3360
Sole wedge, outside sole
12.00
L3370
Sole wedge, between sole
14.40
L3380
Clubfoot wedge
12.00
L3390
Outflare wedge
16.00
L3400
Metatarsal bar wedge, rocker
16.00
L3410
Metatarsal bar wedge, between sole
16.00
L3420
Full sole and heel wedge, between sole
24.00
L3430
Heel, counter, plastic reinforced
24.00
L3440
Heel, counter, leather reinforced
24.00
L3450
Heel, Sach cushion type
64.00
L3455
Heel, new leather, standard
8.00
L3460
Heel, new rubber, standard
8.00
L3465
Heel, Thomas with wedge
20.00
L3470
Heel, Thomas extended to ball
24.00
L3480
Heel, pad and depression for spur
16.00
L3485
Heel, pad, removable for spur
32.00
L3500
Miscellaneous shoe addition, insole,
4.00
leather
L3510
Miscellaneous shoe addition, insole,
8.00
rubber
L3520
Miscellaneous shoe additions, insole,
8.00
felt covered with leather
L3530
Miscellaneous shoe addition, sole,
12.00
half
L3540
Miscellaneous shoe addition, sole,
36.00
full
L3550
Miscellaneous shoe addition, toe tap,
4.00
standard
L3560
Miscellaneous shoe addition, toe
6.40
tap, horseshoe
L3570
Miscellaneous shoe addition,
152.00
special extension to instep
(leather with eyelets)
L3580
Miscellaneous shoe addition,
13.60
convert instep to velcro closure
L3590
Miscellaneous shoe addition,
28.00
convert firm shoe counter to
soft counter
L3595
Miscellaneous shoe addition,
12.00
March bar
L3600
Transfer of an orthosis from one
48.00
shoe to another, caliper plate,
existing
L3610
Transfer of an orthosis from one
76.00
shoe to another, caliper plate,
new
L3620
Transfer of an orthosis from one
39.04
shoe to another, solid stirrup,
existing
L3630
Transfer of an orthosis from one
76.00
shoe to another, solid stirrup,
new
L3640
Transfer of an orthosis from one
28.00
shoe to another, Dennis Browne
splint (Riveton), both shoes
L3649
Unlisted procedures for foot orthopedic
B.R.
shoes, shoe modifications and transfers
L3800
Wrist-hand-finger-orthoses (WHFO),
124.28
short opponens, no attachments
L3908
WHFO, wrist extension control cock-up,
50.13
nonmolded
L3914
WHFO, wrist extension cock-up
60.00
L3916
WHFO, wrist extension cock-up,
72.00
with outrigger
L8000
Breast prosthesis, mastectomy bra
B.R.
L8010
Breast prosthesis, mastectomy sleeve
40.56
L8020
Breast prosthesis, mastectomy form
132.00
L8030
Breast prosthesis, silicone or equal
B.R.
L8100
Elastic support, elastic stocking,
24.00
below knee, medium weight, each
L8110
Elastic support, elastic stocking,
30.40
below knee, heavy weight, each
L8120
Elastic support, elastic stocking,
32.00
below knee, surgical weight, (Linton
type or equal), each
L8130
Elastic support, elastic stocking,
33.60
above knee, medium weight, each
L8140
Elastic support, elastic stocking,
36.00
above knee, heavy weight, each
L8150
Elastic support, elastic stocking,
44.00
above knee, surgical weight, (Linton
type or equal), each
L8160
Elastic support, elastic stocking,
40.00
full-length, medium weight, each
L8170
Elastic support, elastic stocking,
48.00
full-length, heavy weight, each
L8180
Elastic support, elastic stocking,
52.00
full-length, heavy surgical weight
(Linton type or equal), each
L8190
Elastic support, elastic stocking,
108.00
leotards, medium weight, each
L8200
Elastic supports, elastic stocking,
120.00
leotards surgical weight (Linton type),
each
L8210
Elastic support, elastic stocking,
B.R.
custom-made
L8220
Elastic support, elastic stocking,
B.R.
lymphedema
L8230
Elastic support, elastic stocking,
B.R.
garter belt
L8300
Truss, single with standard pad
51.28
L8310
Truss, double with standard pads
101.68
L8320
Truss, addition to standard pad,
24.00
water pad
L8330
Truss, addition to standard pad,
33.65
scrotal pad
L8400
Prosthetic sheath, below knee, each
12.00
L8410
Prosthetic sheath, above knee, each
12.00
L8415
Prosthetic sheath, upper limb, each
11.20
L8420
Prosthetic sock, wool, below knee, each
14.94
L8430
Prosthetic sock, wool, above knee, each
18.40
L8435
Prosthetic sock, wool, upper limb, each
8.14
L8440
Prosthetic shrinker, below knee, each
33.60
L8460
Prosthetic shrinker, above knee, each
41.60
L8465
Prosthetic shrinker, upper limb, each
33.60
L8470
Stump sock, single ply, fitting, below
2.52
knee, each
L8480
Stump sock, single ply, fitting, above
2.52
knee, each
X4810
Velcro straps, attached to a pair
14.00
of shoes, per pair
X6005
Two piece flange, stoma size: 4'
4.70/unit
and two piece flange, stoma size:
3 1/4', "picture frame" design
X6460
Ostomy deodorant
B.R.
X7200
Hypodermic syringes over 5cc
B.R.
X7300
Rectal syringes
B.R.
X8334
Parenteral infusion by gravity (includes
$ 39.00/day
parenteral therapy supplies and base
solution cost)
X8335
Parenteral infusion by disposable pump
$ 39.00/day
(includes supplies and base solution cost
X8336
Parenteral infusion with external
$ 60.00/day
ambulatory infusion pump and administration
equipment (includes pump, supplies and base
solution cost)
X8337
Parenteral line maintenance (includes all
$ 8.00/day
supplies necessary)
X8339
Gloves, sterile, each
.30
X8433
Gloves, non-sterile, each
.09
X8434
Parenteral infusion with external stationary
$ 39.00/day
pump and administration equipment (includes
pump, supplies and base solution cost)