Durable Medical Equipment CY 2014 Fee Schedule...Durable Medical Equipment CY 2014 Fee Schedule Disclaimer: Indication or presence of fee in the table below does not guarantee coverage

Durable Medical Equipment

CY 2014 Fee Schedule

Disclaimer: Indication or presence of fee in the table below does not guarantee coverage

or reimbursement of service. Please refer to the Durable Medical Equipment provider manual at www.dhhr.wv.gov/bms

for additional coverage information.

HCPCS Mod DESCRIPTION Medicare WV Medicaid

A4206 Syringe With Needle, Sterile 1cc Or Less, Each0.34 0.27

A4207 Syringe With Needle, Sterile 2cc, Each 0.39 0.31

A4208 Syringe With Needle, Sterile 3cc, Each 0.38 0.30

A4209 Syringe With Needle, Sterile 5cc Or Greater, Each0.38 0.30

A4213 Syringe, Sterile, 20 cc Or Greater, Each 5.40 4.32

A4215 Needle, Sterile, Any Size Each 0.30 0.24

A4216 Sterile Water, Saline And/Or Dextrose Diluent/Flush, 10 Ml0.46 0.37

A4217 Sterile Water/Saline, 500 Ml 3.43 2.74

A4221 Supplies For Maintenance Of Drug Infusion Catheter, Per Week (List Drug Separately)24.76 19.81

A4222 Infusion Supplies For External Drug Infusion Pump, Per Cassette Or Bag (List Drugs Separately)49.15 39.32

A4223 Infusion Supplies Not Used With External Infusion Pump, Per Cassette Or Bag (List Drugs Separately)26.89 21.51

A4230 Infusion Set For External Insulin Pump, Non Needle Cannula Type17.50 14.00

A4231 Infusion Set For External Insulin Pump, Needle Type17.50 14.00

A4232 Syringe With Needle For External Insulin Pump, Sterile, 3cc3.28 2.62

A4233 Replacement Battery, Alkaline 9 (Other Than T Cell) For Use With Medically Ncessary Home Blood Glucose Monitor Owned By The Patient, Each0.58 0.46

A4234 Replacement Battery, Alkaline, J Cell, For Use With Medically Necessary Home Blood Glucose Monitor Owned By Patient, Each2.50 2.00

A4235 Replacement Battery, Lithium, For Use With Medically Necessary Home Blood Glucose Monitor Owned By Patient, Each1.06 0.85

A4236 Replacement Battery, Silver Oxide, For Use With Medically Necessary Home Blood Glucose Monitor Owned By Patient, Each1.19 0.95

A4244 Alcohol Or Peroxide, Per Pint 1.18 0.94

A4245 Alcohol Wipes, Per Box 1.25 1.00

A4246 Betadine Or Phisohex Solution, Per Pint 14.29 11.43

A4247 Betadine Or Iodine Swabs/Wipes, Per Box 13.75 11.00

A4250 Urine Test Or Reagent Strips Or Tablets (100Tablets Or Strips)36.25 29.00

A4253 KX Blood Glucose Test Or Reagent Strips For Home Blood Glucose Monitor, Per 50 Strips34.81 31.33

A4253 KS Blood Glucose Test Or Reagent Strips For Home Blood Glucose Monitor, Per 50 Strips34.81 31.33

A4256 Normal, Low And High Calibrator Solution / Chips10.78 8.62

A4258 Spring-Powered Device For Lancet, Each 17.01 15.31

A4259 KX Lancets, Per Box Of 100 12.43 11.19

A4259 KS Lancets, Per Box Of 100 12.43 11.19

A4310 Insertion Tray Without Drainage Bag And Without Catheter (Accessories Only)8.44 6.75

A4311 Insertion Tray Without Drainage Bag With Indwelling Catheter, Foley Type, Two-Way Latex With Coating (Teflon, Silicone, Silicone Elastomer Or Hydrophilic, Etc.)16.22 12.98

A4312 Insertion Tray Without Drainage Bag With Indwelling Catheter, Foley Type, Two-Way, All Silicone19.72 15.78

A4313 Insertion Tray Without Drainage Bag With Indwelling Catheter, Foley Type,Three-Way, For Continuous Irrigation Latex With Coating (Teflon, Silicone, Silicone Elastomer Or Hydrophilic, Etc.)20.26 16.21

A4314 Insertion Tray With Drainage Bag With Indwelling Catheter, Foley Type, Two-Way27.65 22.12

A4315 Insertion Tray With Drainage Bag With Indwelling Catheter, Foley Type, Two-Way,All Silicone28.86 23.09

A4316 Insertion Tray With Drainage Bag With Indwelling Catheter, Foley Type, Three-Way, For Continuous Irrigation31.05 24.84

A4320 Irrigation Tray With Bulb Or Piston Syringe, Any Purpose5.20 4.16

A4322 Irrigation Syringe, Bulb Or Piston, Each 3.17 2.54

A4326 Male External Catheter With Integral Collection Chamber, Any Type, Each11.34 9.07

A4327 Female External Urinary Collection Device; Meatal Cup, Each46.22 36.98

A4328 Female External Urinary Collection Device; Pouch, Each11.07 8.86

A4330 Perianal Fecal Collection Pouch With Adhesive, Each6.65 5.32

A4331 Extension Drainage Tubing, Any Type, Any Length, With Connector/Adaptor, For Use With Urinary Leg Bag Or Urostomy Pouch, Each3.48 2.78

A4332 Lubricant, Individual Sterile Packet, Each 0.13 0.10

A4333 Urinary Catheter Anchoring Device, Adhesive Skin Attachment, Each2.41 1.93

A4334 Urinary Catheter Anchoring Device, Leg Strap, Each5.38 4.30

A4335 Incontinence Supply; Miscellaneous - -

A4338 Indwelling Catheter; Foley Type, Two-Way Latex With Coating (Teflon, Silicone, Elastomer, Or Hydrophilic, Etc.), Each13.41 10.73

A4340 Indwelling Catheter; Specialty Type, Eg; Coude, Mushroom, Wing, Etc.), Each29.51 23.61

A4344 Indwelling Catheter, Foley Type, Two-Way, All Silicone, Each17.51 14.01

A4346 Indwelling Catheter; Foley Type, Three Way For Continuous Irrigation, Each21.42 17.14

A4349 Male External Catheter, With Or Without Adhesive, Disposable, Each2.21 1.77

A4351 Intermittent Urinary Catheter; Straight Tip, With Or Without Coating (Teflon, Silicone Elastomer, Or Hydrophilic, Etc.), Each1.87 1.50

A4352 Intermittent Urinary Catheter; Coude (Curved) Tip, With Or Without Coating (Teflon, Silicone, Silicone Elastomeric, Or Hydrophilic, Etc.), Each5.97 4.78

A4353 Intermittent Urinary Catheter, With Insertion Supplies7.65 6.12

A4354 Insertion Tray With Drainage Bag But Without Catheter12.91 10.33

A4355 Irrigation Tubing Set For Continuous Bladder Irrigation Through A Three-Way Indwelling Foley Catheter, Each9.61 7.69

A4356 External Urethral Clamp Or Compression Device (Not To Be Used For Catheter Clamp), Each49.89 39.91

A4357 Bedside Drainage Bag, Day Or Night, With Or Without Anti-Reflux Device, With Or Without Tube, Each10.61 8.49

A4358 Urinary Drainage Bag, Leg Or Abdomen, Vinyl, With Or Without Tube, With Straps, Each7.25 5.80

A4361 Ostomy Faceplate, Each 20.09 16.07

A4362 Skin Barrier; Solid, 4 X 4 Or Equivalent; Each3.71 2.97

A4363 Ostomy Clamp, Replacement 2.59 2.07

A4364 Adhesive, Liquid Or Equal, Any Type, Per Oz2.73 2.18

A4366 Ostomy Vent, Any Type, Each 1.42 1.14

A4367 Ostomy Belt, Each 8.04 6.43

A4368 Ostomy Filter, Any Type, Each 0.28 0.22

A4369 Ostomy Skin Barrier, Liquid (Spray, Brush, Etc), Per Oz2.65 2.12

A4371 Ostomy Skin Barrier, Powder, Per Oz 3.99 3.19

A4372 Ostomy Skin Barrier, Solid 4 X 4 Or Equivalent, Standard Wear, With Built-In Convexity, Each4.59 3.67

A4373 Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordian), With Built-In Convexity, Any Size, Each6.86 5.49

A4375 Ostomy Pouch, Drainable, With Faceplate Attached, Plastic, Each18.79 15.03

A4376 Ostomy Pouch, Drainable, With Faceplate Attached, Rubber, Each52.04 41.63

A4377 Ostomy Pouch, Drainable, For Use On Faceplate, Plastic, Each4.70 3.76

A4378 Ostomy Pouch, Drainable, For Use On Faceplate, Rubber, Each33.62 26.90

A4379 Ostomy Pouch, Urinary, With Faceplate Attached, Plastic, Each16.42 13.14

A4380 Ostomy Pouch, Urinary, With Faceplate Attached, Rubber, Each40.82 32.66

A4381 Ostomy Pouch, Urinary, For Use On Faceplate, Plastic, Each5.05 4.04

A4382 Ostomy Pouch, Urinary, For Use On Faceplate, Heavy Plastic, Each26.92 21.54

A4383 Ostomy Pouch, Urinary, For Use On Faceplate, Rubber, Each30.83 24.66

A4384 Ostomy Faceplate Equivalent, Silicone Ring, Each10.51 8.41

A4385 Ostomy Skin Barrier, Solid 4X4 Or Equivalent, Extended Wear, Without Built-In Convexity, Each5.58 4.46

A4387 Ostomy Pouch, Closed, With Barrier Attached, With Built-In Convexity (1 Piece), Each2.45 1.96

A4388 Ostomy Pouch, Drainable, With Extended Wear Barrier Attached, (1 Piece), Each4.78 3.82

A4389 Ostomy Pouch, Drainable, With Barrier Attached, With Built-In Convexity (1 Piece), Each6.80 5.44

A4390 Ostomy Pouch, Drainable, With Extended Wear Barrier Attached, With Built-In Convexity (1Piece), Each10.50 8.40

A4391 Ostomy Pouch, Urinary, With Extended Wear Barrier Attached (1 Piece), Each7.73 6.18

A4392 Ostomy Pouch, Urinary, With Standard Wear Barrier Attached, With Built-In Convexity (1Piece), Each8.95 7.16

A4393 Ostomy Pouch, Urinary, With Extended Wear Barrier Attached, With Built-In Convexity (1Piece), Each9.89 7.91

A4394 Ostomy Deodorant For Use In Ostomy Pouch, Liquid, Per Fluid Ounce2.83 2.26

A4395 Ostomy Deodorant For Use In Ostomy Pouch, Solid, Per Tablet0.05 0.04

A4396 Ostomy Belt With Peristomal Hernia Support44.27 35.42

A4397 Irrigation Supply; Sleeve, Each 5.23 4.18

A4398 Ostomy Irrigation Supply; Bag, Each 15.11 12.09

A4399 Ostomy Irrigation Supply; Cone/Catheter, Including Brush11.40 9.12

A4400 Ostomy Irrigation Set 53.44 42.75

A4402 Lubricant, Per Ounce 1.75 1.40

A4404 Ostomy Ring, Each 1.69 1.35

A4405 Ostomy Skin Barrier, Non-Pectin Based, Paste, Per Ounce3.73 2.98

A4406 Ostomy Skin Barrier, Pectin-Based, Paste, Per Ounce6.27 5.02

A4407 Ostomy Skin Barrier, With Flange (Solid, Flexible, Or Accordion), Extended Wear, With Built-In Convexity, 4 X 4 Inches Or Smaller, Each9.58 7.66

A4408 Ostomy Skin Barrier, Wtih Flange (Solid, Flexible Or Accordion), Extended Wear, With Built-In Convexity, Larger Than 4 X 4 Inches, Each10.79 8.63

A4409 Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion), Extended Wear, Without Built-In Convexity, 4 X 4 Inches Or Smaller, Each6.80 5.44

A4410 Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion), Extended Wear, Ithout Built-In Convexity, Larger Than 4 X 4 Inches, Each9.89 7.91

A4411 Ostomy Skin Barrier, Solid 4 X 4 Or Equivalent, Extended Wear, With Built-In Convexity, Each5.58 4.46

A4412 Ostomy Pouch, Drainable, High Output, For Use On A Barrier With Flange (2 Piece System), Without Filter, Each2.96 2.37

A4413 Ostomy Pouch, Drainable, High Output, For Use On A Barrier With Flange (2 Piece System), WithFilter, Each6.02 4.82

A4414 Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion), Without Built-In Convexity, 4 X 4Inches Or Smaller, Each5.38 4.30

A4415 Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion), Without Built-In Convexity, Larger Than 4X4 Inches, Each6.55 5.24

A4416 Ostomy Pouch, Closed, With Barrier Attached, With Filter (1 Piece), Each3.01 2.41

A4417 Ostomy Pouch, Closed, With Barrier Attached, With Built-In Convexity, With Filter (1 Piece), Each4.07 3.26

A4418 Ostomy Pouch, Closed; Without Barrier Attached, With Filter (1 Piece), Each1.99 1.59

A4419 Ostomy Pouch, Closed; For Use On Barrier With Non-Locking Flange, With Filter (2 Piece), Each1.90 1.52

A4420 Ostomy Pouch, Closed; For Use On Barrier With Locking Flange (2 Piece), Each- -

A4421 Ostomy Supply; Miscellaneous - -

A4422 Ostomy Absorbent Material (Sheet/Pad/Crystal Packet) For Use In Ostomy Pouch To Thicken Liquid Stomal Output, Each0.13 0.10

A4423 Ostomy Pouch, Closed; For Use On Barrier With Locking Flange, With Filter (2 Piece), Each2.04 1.63

A4424 Ostomy Pouch, Drainable, With Barrier Attached, With Filter (1 Piece), Each5.20 4.16

A4425 Ostomy Pouch, Drainable; For Use On Barrier With Non-Locking Flange, With Filter (2 Piece System), Each3.92 3.14

A4426 Ostomy Pouch, Drainable; For Use On Barrier With Locking Flange (2 Piece System), Each2.99 2.39

A4427 Ostomy Pouch, Drainable; For Use On Barrier With Locking Flange, With Filter (2 Piece System), Each3.04 2.43

A4428 Ostomy Pouch, Urinary, With Extended Wear Barrier Attached, With Faucet-Type Tap With Valve (1 Piece), Each7.12 5.70

A4429 Ostomy Pouch, Urinary, With Barrier Attached, With Built-In Convexity, With Faucet-Type Tap With Valve (1 Piece), Each9.02 7.22

A4430 Ostomy Pouch, Urinary, With Extended Wear Barrier Attached, With Built-In Convexity, With Faucet-Type Tap With Valve (1 Piece), Each9.31 7.45

A4431 Ostomy Pouch, Urinary; With Barrier Attached, With Faucet-Type Tap With Valve (1 Piece), Each6.80 5.44

A4432 Ostomy Pouch, Urinary; For Use On Barrier With Non-Locking Flange, With Faucet-Type Tap With Valve (2 Piece), Each3.93 3.14

A4433 Ostomy Pouch, Urinary; For Use On Barrier With Locking Flange (2 Piece), Each3.66 2.93

A4434 Ostomy Pouch, Urinary; For Use On Barrier With Locking Flange, With Faucet-Type Tap With Valve (2 Piece), Each4.11 3.29

A4435 1Pc Ost Pch Drain Hgh Output 6.32 5.06

A4450 Tape, Non-Waterproof, Per 18 Square Inches0.09 0.07

A4452 Tape, Waterproof, Per 18 Square Inches 0.39 0.31

A4455 Adhesive Remover Or Solvent (For Tape, Cement Or Other Adhesive), Per Ounce1.57 1.26

A4456 Adhesive remover, wipes 0.27 0.22

A4461 Surgical Dressing Holder, Non-Reusable, Each3.60 2.88

A4463 Surgical Dressing Holder, Reusable, Each 14.56 11.65

A4481 Tracheostoma Filter, Any Type, Any Size, Each0.40 0.32

A4490 Surgical Stockings Above Knee Length, Each37.13 29.70

A4495 Surgical Stockings Thigh Length, Each 37.13 29.70

A4500 Surgical Stockings Below Knee Length, Each39.38 31.50

A4510 Surgical Stockings Full Length, Each 105.19 84.15

A4520 Incontinence Garment, Any Type, (E.G. Brief, Diaper), Each0.94 0.75

A4554 Disposable Underpads, All Sizes, (E.G., Chux'S)0.39 0.31

A4555 Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only- -

A4556 Electrodes, (E.G., Apnea Monitor), Per Pair11.29 9.03

A4557 Lead Wires, (E.G., Apnea Monitor), Per Pair19.62 15.70

A4561 Pessary, Rubber, Any Type 21.82 17.46

A4562 Pessary, Non Rubber, Any Type 54.33 43.46

A4565 Slings 7.31 5.85

A4570 Splint 84.38 67.50

A4595 Electrical Stimulator Supplies, 2 Lead, Per Month, (E.G. Tens, Nmes)31.51 25.21

A4601 Lithium Ion Battery For Non-Prosthetic Use, Replacement32.50 26.00

A4604 Tubing With Integrated Hearing Element For Use With Positive Airway Pressure Device62.96 50.37

A4605 Tracheal Suction Catheter, Closed System, Each17.93 14.34

A4606 Oxygen Probe For Use With Oximeter Device, Replacement125.00 100.00

A4614 Peak Expiratory Flow Rate Meter, Hand Held26.01 20.81

A4619 Face Tent 2.03 1.62

A4623 Tracheostomy, Inner Cannula 6.09 4.87

A4624 Tracheal Suction Catheter, Any Type Other Than Closed System, Each2.88 2.30

A4625 Tracheostomy Care Kit For New Tracheostomy7.58 6.06

A4627 Spacer, Bag Or Reservoir, With Or Without Mask, For Use With Metered Dose Inhaler25.76 20.61 Corrected 8/04/14

A4628 Oropharyngeal Suction Catheter, Each 4.09 3.27

A4629 Tracheostomy Care Kit For Established Tracheostomy5.07 4.06

A4635 Underarm Pad, Crutch, Replacement, Each 5.60 4.48

A4636 Replacement, Handgrip, Cane, Crutch, Or Walker, Each3.37 2.70

A4637 Replacement, Tip, Cane, Crutch, Walker, Each.2.02 1.62

A4640 Replacement Pad For Use With Medically Necessary Alternating Pressure Pad Owned By Patient59.32 47.46

A4649 Surgical Supply; Miscellaneous - -

A4927 Gloves, Non-Sterile, Per 100 53.39 42.71

A5051 Ostomy Pouch, Closed; With Barrier Attached (1Piece), Each2.26 1.81

A5052 Ostomy Pouch, Closed; Without Barrier Attached (1 Piece), Each1.63 1.30

A5053 Ostomy Pouch, Closed; For Use On Faceplate, Each1.90 1.52

A5054 Ostomy Pouch, Closed; For Use On Barrier With Flange (2 Piece), Each1.97 1.58

A5055 Stoma Cap 1.45 1.16

A5056 1 Pc Ost Pouch W Filter 5.10 4.08

A5057 1 Pc Ost Pou W Built-In Conv 10.50 8.40

A5061 Ostomy Pouch, Drainable; With Barrier Attached, (1 Piece), Each3.86 3.09

A5062 Ostomy Pouch, Drainable; Without Barrier Attached (1 Piece), Each2.28 1.82

A5063 Ostomy Pouch, Drainable; For Use On Barrier With Flange (2 Piece System), Each2.96 2.37

A5071 Ostomy Pouch, Urinary; With Barrier Attached (1 Piece), Each6.57 5.26

A5072 Ostomy Pouch, Urinary; Without Barrier Attached (1 Piece), Each3.86 3.09

A5073 Ostomy Pouch, Urinary; For Use On Barrier With Flange (2 Piece), Each3.42 2.74

A5081 Continent Device; Plug For Continent Stoma3.62 2.90

A5082 Continent Device; Catheter For Continent Stoma13.00 10.40

A5083 Continent Device, Stoma Absorptive Cover For Continent Stoma0.70 0.56

A5093 Ostomy Accessory; Convex Insert 1.82 1.46

A5102 Bedside Drainage Bottle With Or Without Tubing, Rigid Or Expandable, Each24.51 19.61

A5105 Urinary Suspensory With Leg Bag, With Or Without Tube, Each44.58 35.66

A5112 Urinary Leg Bag; Latex 34.45 27.56

A5113 Leg Strap; Latex, Replacement Only, Per Set4.38 3.50

A5114 Leg Strap; Foam Or Fabric, Replacement Only, Per Set8.32 6.66

A5120 Skin Barrier, Wipes Or Swabs, Each 0.24 0.19

A5121 Skin Barrier; Solid, 6 X 6 Or Equivalent, Each7.80 6.24

A5122 Skin Barrier; Solid, 8 X 8 Or Equivalent, Each14.05 11.24

A5126 Adhesive Or Non-Adhesive; Disk Or Foam Pad1.22 0.98

A5131 Appliance Cleaner, Incontinence And Ostomy Appliances, Per 16 Oz.14.74 11.79

A5500 For Diabetics Only, Fitting (Including Follow Up), Custom Preparation And Supply Of Off-The-Shelf Depth- Inlay Shoe Manufactured To Accommodate Multi- Density Insert(S), Per Shoe69.53 55.62

A5501 For Diabetics Only, Fitting (Including Follow Up), Custom Preparation And Supply Of Shoe Molded From Cast(S) Of Patient'S Foot (Custom Molded Shoe), Per Shoe208.55 166.84

A5503 For Diabetics Only, Modification (Including Fitting) Of Off-The-Shelf Depth-Inlay Shoe Or Custom-Molded Shoe With Roller Or Rigid Rocker Bottom, Per Shoe33.97 27.18

A5504 For Diabetics Only, Modification (Including Fitting) Of Off-The-Shelf Depth Inlay Shoe With Wedge(S), Per Shoe33.97 27.18

A5505 For Diabetics Only, Modification (Including Fitting) Of Off-The-Shelf Depth-Inlay Shoe Or Custom-Molded Shoe With Metatarsal Bar, Per Shoe33.97 27.18

A5506 For Diabetics Only, Modification (Including Fitting) Of Off-The-Shelf Depth-Inlay Shoe Or Custom-Molded Shoe With Off-Set Heel(S), Per Shoe33.97 27.18

A5507 For Diabetics Only, Not Otherwise Specified Modification (Including Fitting) Of Off-The-Shelf Depth- Inlay Shoe Or Custom-Molded Shoe, Per Shoe33.97 27.18

A5512 For Diabetics Only, Multiple Density Insert, DirectForm, Molded To Foot After External Heat Source Of 230 Degrees Fahrenheit Or Higher, Total Contact WithPatient’S Foot, Including Arch, Base Layer Minimum Of¼ Inch Material Of Shore A 35 Durometer Or 3/16 Inch Material Of Shore A 40 Durometer (Or Higher), Prefabricated, Each28.36 22.69

A5513 For Diabetics Only, Multiple Density Insert, Custom Molded From Model Of Patient’S Foot, Total Contact With Patient’S Foot, Including Arch, Base Layer Minimum Of ¼ Inch Material Of Shore A 35 Durometer Of 3/16 Inch Material (Or Higher), Includes Arch Filler And Other Shaping Material Custom Fabricated, Each42.33 33.86

A6154 Wound Pouch, Each 15.24 12.19

A6196 Alginate Or Other Fiber Gelling Dressing, Wound Cover, Pad Size 16 Sq. In. Or Less, Each Dressing8.04 6.43

A6197 Alginate Or Other Fiber Gelling Dressing, Wound Cover, Pad Size More Than 16 Sq. In. But Less Than Or Equal To 48 Sq. In., Each Dressing17.97 14.38

A6198 Alginate Or Other Fiber Gelling Dressing, Wound Cover, Pad Size More Than 48 Sq. In., Each Dressing17.65 14.12

A6199 Alginate Or Other Fiber Gelling Dressing, Wound Filler, Per 6 Inches5.78 4.62

A6203 Composite Dressing, Pad Size 16 Sq. In. Or Less, With Any Size Adhesive Border, Each Dressing3.67 2.94

A6204 Composite Dressing, Pad Size More Than 16 Sq. In. But Less Than Or Equal To 48 Sq. In., With Any Size Adhesive Border, Each Dressing6.81 5.45

A6205 Composite Dressing, Pad Size More Than 48 Sq. In., With Any Size Adhesive Border, Each Dressing6.69 5.35

A6206 Contact Layer, 16 Sq. In. Or Less, Each Dressing6.69 5.35

A6207 Contact Layer, More Than 16 Sq. In. But Less Than Or Equal To 48 Sq. In., Each Dressing8.02 6.42

A6208 Contact Layer, More Than 48 Sq. In., Each Dressing7.88 6.30

A6209 Foam Dressing, Wound Cover, Pad Size 16 Sq. In. Or Less, Without Adhesive Border, Each Dressing8.17 6.54

A6210 Foam Dressing, Wound Cover, Pad Size More Than16 Sq. In. But Less Than Or Equal To 48 Sq. In., Without Adhesive Border, Each Dressing21.79 17.43

A6211 Foam Dressing, Wound Cover, Pad Size More Than48 Sq. In., Without Adhesive Border, Each Dressing32.12 25.70

A6212 Foam Dressing, Wound Cover, Pad Size 16 Sq. In. Or Less, With Any Size Adhesive Border, Each Dressing10.61 8.49

A6213 Foam Dressing, Wound Cover, Pad Size More Than16 Sq. In. But Less Than Or Equal To 48 Sq. In., With Any Size Adhesive Border, Each Dressing10.42 8.34

A6214 Foam Dressing, Wound Cover, Pad Size More Than48 Sq. In., With Any Size Adhesive Border, Each Dressing11.25 9.00

A6215 Foam Dressing, Wound Filler, Per Gram - -

A6216 Gauze, Non-Impregnated, Non-Sterile, Pad Size 16Sq. In. Or Less, Without Adhesive Border, Each Dressing0.05 0.04

A6217 Gauze, Non-Impregnated, Non-Sterile, Pad Size More Than 16 Sq. In. But Less Than Or Equal To 48Sq. In., Without Adhesive Border, Each Dressing0.40 0.32

A6218 Gauze, Non-Impregnated, Non-Sterile, Pad Size More Than 48 Sq. In., Without Adhesive Border, Each Dressing0.68 0.54

A6219 Gauze, Non-Impregnated, Pad Size 16 Sq. In. Or Less, With Any Size Adhesive Border, Each Dressing1.04 0.83

A6220 Gauze, Non-Impregnated, Pad Size More Than 16 Sq. In. But Less Than Or Equal To 48 Sq. In., With Any Size Adhesive Border, Each Dressing2.83 2.26

A6221 Gauze, Non-Impregnated, Pad Size More Than 48 Sq. In., With Any Size Adhesive Border, Each Dressing2.41 1.93

A6222 Gauze, Impregnated With Other Than Water, Normal Saline, Or Hydrogel, Pad Size 16 Sq. In. Or Less, Without Adhesive Border, Each Dressing2.33 1.86

A6223 Gauze, Impregnated With Other Than Water, Normal Saline, Or Hydrogel, Pad Size More Than16 Square Inches, But Less Than Or Equal To 48Square Inches, Without Adhesive Border, Each Dressing2.65 2.12

A6224 Gauze, Impregnated With Other Than Water,Normal Saline, Or Hydrogel, Pad Size More Than48 Square Inches, Without Adhesive Border, Each Dressing3.95 3.16

A6231 Gauze, Impregnated, Hydrogel, For Direct Wound Contact, Pad Size 16 Sq. In. Or Less, Each Dressing5.10 4.08

A6232 Gauze, Impregnated, Hydrogel, For Direct Wound Contact, Pad Size Greater Than 16 Sq. In., But Less Than Or Equal To 48 Sq. In., Each Dressing7.51 6.01

A6233 Gauze, Impregnated, Hydrogel For Direct Wound Contact, Pad Size More Than 48 Sq. In., Each Dressing20.98 16.78

A6234 Hydrocolloid Dressing, Wound Cover, Pad Size 16Sq. In. Or Less, Without Adhesive Border, Each Dressing7.15 5.72

A6235 Hydrocolloid Dressing, Wound Cover, Pad Size More Than 16 Sq. In. But Less Than Or Equal To 48Sq. In., Without Adhesive Border, Each Dressing18.38 14.70

A6236 Hydrocolloid Dressing, Wound Cover, Pad Size More Than 48 Sq. In., Without Adhesive Border, Each Dressing29.80 23.84

A6237 Hydrocolloid Dressing, Wound Cover, Pad Size 16Sq. In. Or Less, With Any Size Adhesive Border, Each Dressing8.66 6.93

A6238 Hydrocolloid Dressing, Wound Cover, Pad Size More Than 16 Sq. In. But Less Than Or Equal To 48Sq. In., With Any Size Adhesive Border, Each Dressing24.93 19.94

A6239 Hydrocolloid Dressing, Wound Cover, Pad Size More Than 48 Sq. In., With Any Size Adhesive Border, Each Dressing19.80 15.84

A6240 Hydrocolloid Dressing, Wound Filler, Paste, Per Fluid Ounce13.39 10.71

A6241 Hydrocolloid Dressing, Wound Filler, Dry Form, Per Gram2.81 2.25

A6242 Hydrogel Dressing, Wound Cover, Pad Size 16 Sq. In. Or Less, Without Adhesive Border, Each Dressing6.63 5.30

A6243 Hydrogel Dressing, Wound Cover, Pad Size More Than 16 Sq. In. But Less Than Or Equal To 48 Sq. In., Without Adhesive Border, Each Dressing13.47 10.78

A6244 Hydrogel Dressing, Wound Cover, Pad Size More Than 48 Sq. In., Without Adhesive Border, Each Dressing42.96 34.37

A6245 Hydrogel Dressing, Wound Cover, Pad Size 16 Sq. In. Or Less, With Any Size Adhesive Border, Each Dressing7.94 6.35

A6246 Hydrogel Dressing, Wound Cover, Pad Size More Than 16 Sq. In. But Less Than Or Equal To 48 Sq. In., With Any Size Adhesive Border, Each Dressing10.86 8.69

A6247 Hydrogel Dressing, Wound Cover, Pad Size More Than 48 Sq. In., With Any Size Adhesive Border, Each Dressing26.01 20.81

A6248 Hydrogel Dressing, Wound Filler, Gel, Per Fluid Ounce17.76 14.21

A6250 Skin Sealants, Protectants, Moisturizers, Ointments, Any Type, Any Size18.75 15.00

A6251 Specialty Absorptive Dressing, Wound Cover, Pad Size 16 Sq. In. Or Less, Without Adhesive Border, Each Dressing2.18 1.74

A6252 Specialty Absorptive Dressing, Wound Cover, Pad Size More Than 16 Sq. In. But Less Than Or Equal To48 Sq. In., Without Adhesive Border, Each Dressing3.56 2.85

A6253 Specialty Absorptive Dressing, Wound Cover, Pad Size More Than 48 Sq. In., Without AdhesiveBorder, Each Dressing6.93 5.54

A6254 Specialty Absorptive Dressing, Wound Cover, Pad Size 16 Sq. In. Or Less, With Any Size Adhesive Border, Each Dressing1.32 1.06

A6255 Specialty Absorptive Dressing, Wound Cover, PadSize More Than 16 Sq. In. But Less Than Or Equal To48 Sq. In., With Any Size Adhesive Border, Each Dressing3.32 2.66

A6256 Specialty Absorptive Dressing, Wound Cover, Pad Size More Than 48 Sq. In., With Any Size Adhesive Border, Each Dressing3.26 2.61

A6257 Transparent Film, 16 Sq. In. Or Less, Each Dressing1.68 1.34

A6258 Transparent Film, More Than 16 Sq. In. But Less Than Or Equal To 48 Sq. In., Each Dressing4.72 3.78

A6259 Transparent Film, More Than 48 Sq. In., Each Dressing11.97 9.58

A6260 Wound Cleansers, Any Type, Any Size 22.50 18.00

A6261 Wound Filler, Gel/Paste, Per Fluid Ounce, Not Elsewhere Classified- -

A6262 Wound Filler, Dry Form, Per Gram, Not Elsewhere Classified- -

A6266 Gauze, Impregnated, Other Than Water, Normal Saline, Or Zinc Paste, Any Width, Per Linear Yard2.11 1.69

A6402 Gauze, Non-Impregnated, Sterile, Pad Size 16 Sq. In. Or Less, Without Adhesive Border, Each Dressing0.13 0.10

A6403 Gauze, Non-Impregnated, Sterile, Pad Size More Than 16 Sq. In. Less Than Or Equal To 48 Sq. In., Without Adhesive Border, Each Dressing0.46 0.37

A6404 Gauze, Non-Impregnated, Sterile, Pad Size More Than 48 Sq. In., Without Adhesive Border, Each Dressing2.70 2.16

A6407 Packing Strips, Non-Impregnated, Up To 2 Inches In Width, Per Linear Yard2.06 1.65

A6441 Padding Bandage, Non-Elastic, Non-Woven/Non- Knitted, Width Greater Than Or Equal To Three Inches And Less Than Five Inches, Per Yard0.74 0.59

A6442 Conforming Bandage, Non-Elastic, Knitted/Woven, Non-Sterile, Width Less Than Three Inches, Per Yard0.18 0.14

A6443 Conforming Bandage, Non-Elastic, Knitted/Woven, Non-Sterile, Width Greater Than Or Equal To Three Inches And Less Than Five Inches, Per Yard0.31 0.25

A6444 Conforming Bandage, Non-Elastic, Knitted/Woven, Non-Sterile, Width Greater Than Or Equal To 5Inches, Per Yard0.61 0.49

A6445 Conforming Bandage, Non-Elastic, Knitted/Woven, Sterile, Width Less Than Three Inches, Per Yard0.35 0.28

A6446 Conforming Bandage, Non-Elastic, Knitted/Woven, Sterile, Width Greater Than Or Equal To Three Inches And Less Than Five Inches, Per Yard0.44 0.35

A6447 Conforming Bandage, Non-Elastic, Knitted/Woven, Sterile, Width Greater Than Or Equal To Five Inches, Per Yard0.74 0.59

A6448 Light Compression Bandage, Elastic, Knitted/Woven, Width Less Than Three Inches, Per Yard1.27 1.02

A6449 Light Compression Bandage, Elastic, Knitted/Woven, Width Greater Than Or Equal To Three Inches And Less Than Five Inches, Per Yard1.92 1.54

A6450 Light Compression Bandage, Elastic, Knitted/Woven, Width Greater Than Or Equal To Five Inches, Per Yard- -

A6451 Moderate Compression Bandage, Elastic, Knitted/Woven, Load Resistance Of 1.25 To 1.34Foot Pounds At 50% Maximum Stretch, Width Greater Than Or Equal To Three Inches And Less Than Five Inches, Per Yard- -

A6452 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 And Less Than Five Inches, Per Yard6.46 5.17

A6453 Self-Adherent Bandage, Elastic, Non-Knitted/Non- Woven, Width Less Than Three Inches, Per Yard0.68 0.54

A6454 Self-Adherent Bandage, Elastic, Non-Knitted/Non- Woven, Width Greater Than Or Equal To Three Inches And Less Than Five Inches, Per Yard0.85 0.68

A6455 Self-Adherent Bandage, Elastic, Non-Knitted/Non- Woven, Width Greater Than Or Equal To Five Inches, Per Yard1.53 1.22

A6456 Zinc Paste Impregnated Bandage, Non-Elastic, Knitted/Woven, Width Greater Than Or Equal To Three Inches And Less Than Five Inches, Per Yard1.39 1.11

A6501 Compression Burn Garment, Body Suite (Head To Foot), Custom Fabricated- -

A6502 Compression Burn Garment, Chin Strap, Custom Fabricated- -

A6503 Compression Burn Garment, Facial Hood, Custom Fabricated- -

A6504 Compression Burn Garment, Glove To Wrist, Custom Fabricated- -

A6505 Compression Burn Garment, Glove To Elbow, Custom Fabricated- -

A6506 Compression Burn Garment, Glove To Axilla, Custom Fabricated- -

A6507 Compression Burn Garment, Foot To Knee Length, Custom Fabricated- -

A6508 Compression Burn Garment, Foot To Thigh Length, Custom Fabricated- -

A6509 Compression Burn Garment, Upper Trunk To Waist Including Arm Openings (Vest), Custom Fabricated- -

A6510 Compression Burn Garment, Trunk, Including Arms Down To Leg Openings (Leotard), Custom Fabricated- -

A6511 Compression Burn Garment, Lower Trunk Including Leg Openings (Panty), Custom Fabricated- -

A6512 Compression Burn Garment, Not Otherwise Classified- -

A6513 Compression Burn Mask, Face And/Or Neck, Plastic Or Equal, Custom Fabricated- -

A6530 Gradient Compression Stocking, Below Knee, 18-30 Mm Hg, Each31.50 25.20



A6533 Gradient Compression Stocking, Thigh Length, 18-30 Mmhg, Each37.13 29.70

A6534 Gradient Compression Stocking, Thigh Length, 30-40 Mm Hg, Each37.13 29.70

A6535 Gradient Compression Stocking, Thigh Length, 40-50 Mm Hg, Each37.13 29.70

A6536 Gradient Compression Stocking, Full Length/Chap Style,18-30 Mm Hg, Each37.13 29.70

A6537 Gradient Compression Stocking Full Length/Chap Style,30-40 Mm Hg, Each37.13 29.70

A6538 Gradient Compression Stocking, Full Length/Chap Style,40-50 Mm Hg, Each- -

A6539 Gradient Compression Stocking, Waist Length,18-30 Mm Hg, Each105.19 84.15

A6540 Gradient Compression Stocking, Waist Length, 30-40 Mm Hg, Each- -

A6541 Gradient Compression Stocking, Waist Length, 40-50 Mm Hg, Each- -

A6544 Gradient Compression Stocking, Garter Belt16.88 13.50

A6549 Gradient Compression Stocking, Not Otherwise Specified- -

A6550 Wound Care Set, For Negative Pressure Wound Therapy Electrical Pump, Includes All Supplies And Accessories25.86 20.69

A7000 Canister, Disposable, Used With Suction Pump, Each8.01 6.41

A7002 Tubing, Used With Suction Pump, Each 4.19 3.35

A7003 Administration Set, With Small Volume Nonfiltered Pneumatic Nebulizer, Disposable2.55 2.04

A7004 Small Volume Nonfiltered Pneumatic Nebulizer, Disposable1.98 1.58

A7005 Administration Set, With Small Volume Nonfiltered Pneumatic Nebulizer, Non-Disposable33.71 26.97

A7006 Administration Set, With Small Volume Filtered Pneumatic Nebulizer10.43 8.34

A7010 Disposable Corrugated Tubing 25.80 20.64

A7012 Nebulizer Water Collec Devic 3.52 2.82

A7013 Filter, Disposable, Used With Aerosol Compressor0.91 0.73

A7015 Aerosol Mask, Used With Dme Nebulizer 1.79 1.43

A7020 Interface, Cough Stim Device 15.83 12.66

A7030 Full Face Mask Used With Positive Airway Pressure Device, Each177.80 142.24

A7031 Face Mask Interface, Replacement For Full Face Mask, Each65.76 52.61

A7032 Cushion For Use On Nasal Mask Interface, Replacement Only, Each38.20 30.56

A7033 Pillow For Use On Nasal Cannula Type Interface, Replacement Only, Pair26.78 21.42

A7034 Nasal Interface (Mask Or Cannula Type) Used With Positive Airway Pressure Device, With Or Without Head Strap110.87 88.70

A7035 Headgear Used With Positive Airway Pressure Device37.45 29.96

A7036 Chinstrap Used With Positive Airway Pressure Device14.57 11.66

A7037 Tubing Used With Positive Airway Pressure Device38.52 30.82

A7038 Filter, Disposable, Used With Positive Airway Pressure Device4.33 3.46

A7039 Filter, Non Disposable, Used With Positive Airway Pressure Device13.18 10.54

A7045 Exhalation Port With Or Without Swivel Used With Accessories For Positive Airway Devices, Replacement Only18.34 14.67

A7046 Water Chamber For Humidifier, Used With Positive Airway Pressure Device, Replacement, Each18.38 14.70

A7507 Filter Holder And Integrated Filter Without Adhesive, For Use In A Tracheostoma Heat And Moisture Exchange System, Each2.72 2.18

A7508 Housing And Integrated Adhesive, For Use In A Tracheostoma Heat And Moisture Exchange System And/Or With A Tracheostoma Valve, Each3.13 2.50

A7509 Filter Holder And Integrated Filter Housing, And Adhesive, For Use As A Tracheostoma Heat And Moisture Exchange System, Each1.55 1.24

A7520 Tracheostomy/Laryngectomy Tube, Non-Cuffed, Polyvinylchloride (Pvc), Silicone Or Equal, Each51.92 41.54

A7521 Tracheostomy/Laryngectomy Tube, Cuffed, Polyvinylchloride (Pvc), Silicone Or Equal, Each51.44 41.15

A7522 Tracheostomy/Laryngectomy Tube, Stainless Steel Or Equal (Sterilizable And Reusable), Each49.39 39.51

A7523 Tracheostomy Shower Protector, Each - -

A7524 Tracheostoma Stent/Stud/Button, Each 84.65 67.72

A7525 Tracheostomy Mask, Each 2.26 1.81

A7526 Tracheostomy Tube Collar/Holder, Each 3.69 2.95

A7527 Tracheostomy/Laryngectomy Tube Plug/Stop, Each3.92 3.14

A8000 Helmet, Protective, Soft Prefabricated, Includes All Components And Accessories167.70 134.16

A8001 Helmet, Protective, Hard, Prefabricated, Includes All Components And Accessories167.70 134.16

A8002 Helmet, Protective, Soft, Custom Fabricated, Includes All Components And Accessories469.19 375.35

A8003 Helmet, Protective, Hard, Custom Fabricated, Includes All Components And Accessories469.19 375.35

B4034 Enteral Feeding Supply Kit; Syringe Fed, Per Day6.17 4.94

B4035 Enteral Feeding Supply Kit; Pump Fed, Per Day11.77 9.42

B4036 Enteral Feeding Supply Kit; Gravity Fed, Per Day8.08 6.46

B4081 Nasogastric Tubing With Stylet 21.83 17.46

B4082 Nasogastric Tubing Without Stylet 16.23 12.98

B4083 Stomach Tube - Levine Type 2.49 1.99

B4087 Gastrostomy/Jejunostomy Tube, Standard, Any Material Any Type, Each36.03 28.82

B4088 Gastrostomy/Jejunostomy Tube, Low-Profile, Any Material, Any Type, Each36.03 28.82

B4164 Parenteral Nutrition Solution: Carbohydrates (Dextrose), 50% Or Less (500 Ml = 1 Unit) - Homemix19.29 15.43

B4168 Parenteral Nutrition Solution; Amino Acid, 3.5%, (500 Ml = 1 Unit) - Homemix28.13 22.50

B4172 Parenteral Nutrition Solution; Amino Acid, 5.5% Through 7%, (500 Ml = 1 Unit) - Homemix38.13 30.50

B4176 Parenteral Nutrition Solution; Amino Acid, 7% Through 8.5%, (500 Ml = 1 Unit) - Homemix54.43 43.54

B4178 Parenteral Nutrition Solution: Amino Acid, Greater Than 8.5% (500 Ml = 1 Unit) Homemix65.34 52.27

B4180 Parenteral Nutrition Solution; Carbohydrates (Dextrose), Greater Than 50% (500 Ml=1 Unit) - Homemix27.69 22.15

B4185 Parental Nutrition Solution, Per 10 Grams Lipids12.76 10.21

B4189 Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes, Trace Elements, And Vitamins, Including Preparation, Any Strength, 10 To 51Grams Of Protein - Premix201.85 161.48

B4193 Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes, Trace Elements, And Vitamins, Including Preparation, Any Strength, 52 To 73Grams Of Protein - Premix260.82 208.66

B4197 Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes, Trace Elements And Vitamins, Including Preparation, Any Strength, 74 To 100Grams Of Protein - Premix317.54 254.03

B4199 Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes, Trace Elements And Vitamins, Including Preparation, Any Strength, Over 100Grams Of Protein - Premix362.84 290.27

B4216 Parenteral Nutrition; Additives (Vitamins, Trace Elements, Heparin, Electrolytes) Homemix Per Day8.77 7.02

B4220 Parenteral Nutrition Supply Kit; Premix, Per Day9.09 7.27

B4222 Parenteral Nutrition Supply Kit; Home Mix, Per Day11.21 8.97

B4224 Parenteral Nutrition Administration Kit, Per Day28.39 22.71

B5000 Parenteral Nutrition Solution: Compounded Amino Acid And Carbohydrates With Electrolytes, Trace Elements, And Vitamins, Including Preparation, Any Strength, Renal - Amirosyn Rf, Nephramine, Renamine - Premix13.50 10.80

B5100 Parenteral Nutrition Solution: Compounded Amino Acid And Carbohydrates With Electrolytes, Trace Elements, And Vitamins, Including Preparation, Any Strength, Hepatic - Freamine Hbc, Hepatamine - Premix5.27 4.22

B5200 Parenteral Nutrition Solution: Compounded Amino Acid And Carbohydrates With Electrolytes, Trace Elements, And Vitamins, Including Preparation, Any Strength, Stress - Branch Chain Amino Acids - Premix6.18 4.94

B9000 Enteral Nutrition Infusion Pump - Without Alarm1,238.04 99.04

B9002 Enteral Nutrition Infusion Pump - With Alarm1,238.04 99.04

B9004 Parenteral Nutrition Infusion Pump, Portable2,865.20 229.22

B9006 Parenteral Nutrition Infusion Pump, Stationary2,865.20 229.22

B9998 Noc For Enteral Supplies - -

B9999 Noc For Parenteral Supplies - -

E0100 Cane, Includes Canes Of All Materials, Adjustable Or Fixed, With Tip21.36 17.09

E0105 Cane, Quad Or Three Prong, Includes Canes Of All Materials, Adjustable Or Fixed, With Tips49.66 39.73

E0110 Crutches, Forearm, Includes Crutches Of Various Materials, Adjustable Or Fixed, Pair, Complete With Tips And Handgrips72.12 57.70

E0111 Crutch Forearm, Includes Crutches Of Various Materials, Adjustable Or Fixed, Each, With Tip And Handgrips52.95 42.36

E0112 Crutches Underarm, Wood, Adjustable Or Fixed, Pair, With Pads, Tips And Handgrips36.69 29.35

E0113 Crutch Underarm, Wood, Adjustable Or Fixed, Each, With Pad, Tip And Handgrip19.64 15.71

E0114 Crutches Underarm, Other Than Wood, Adjustable Or Fixed, Pair, With Pads, Tips And Handgrips43.87 35.10

E0116 Crutch, Underarm, Other Than Wood, Adjustable Or Fixed, Each, With Pad, Tip Handgrip, With Or Without Shock Absorber, Each25.79 20.63

E0130 Walker, Rigid (Pickup), Adjustable Or Fixed Height66.20 52.96

E0135 Walker, Folding (Pickup), Adjustable Or Fixed Height72.08 57.66

E0140 Walker, With Trunk Support, Adjustable Or Fixed Height, Any Type339.98 271.98

E0141 Walker, Rigid, Wheeled, Adjustable Or Fixed Height92.37 73.90

E0143 Walker, Folding, Wheeled, Adjustable Or Fixed Height96.32 77.06

E0147 Walker, Heavy Duty, Multiple Braking System, Variable Wheel Resistance541.77 433.42

E0148 Walker, Heavy Duty, Without Wheels, Rigid Or Folding, Any Type, Each119.76 95.81

E0149 Walker, Heavy Duty, Wheeled, Rigid Or Folding, Any Type210.37 168.30

E0153 Platform Attachment, Forearm Crutch, Each64.50 51.60

E0154 Platform Attachment, Walker, Each 56.49 45.19

E0155 Wheel Attachment, Rigid Pick-Up Walker, Per Pair29.73 23.78

E0156 Seat Attachment, Walker 21.18 16.94

E0157 Crutch Attachment, Walker, Each 65.64 52.51

E0158 Leg Extensions For Walker, Per Set Of Four (4)30.33 24.26

E0159 Brake Attachment For Wheeled Walker, Replacement, Each16.84 13.47

E0160 Sitz Type Bath Or Equipment, Portable, Used With Or Without Commode30.73 24.58

E0161 Sitz Type Bath Or Equipment, Portable, Used With Or Without Commode, With Faucet Attachment/S28.68 22.94

E0162 Sitz Bath Chair 152.99 122.39

E0163 Commode Chair, Mobile Or Stationary, With Fixed Arms116.32 93.06

E0165 Commode Chair, Mobile Or Stationary, With Detachable Arms172.70 138.16

E0167 Pail Or Pan For Use With Commode Chair, Replacement Only13.12 10.50

E0168 Commode Chair, Extra Wide And/Or Heavy Duty, Stationary Or Mobile, With Or Without Arms, Any Type, Each165.04 132.03

E0181 Powered Pressure Reducing Mattress Overlay/Pad, Alternating, With Pump, Includes Heavy Duty284.90 227.92

E0182 Pump For Alternating Pressure Pad, For Replacement Only243.30 194.64

E0184 Dry Pressure Mattress 180.98 144.78

E0185 Gel Or Gel-Like Pressure Pad For Mattress, Standard Mattress Length And Width297.30 237.84

E0186 Air Pressure Mattress 222.00 177.60

E0187 Water Pressure Mattress 253.80 203.04

E0188 Synthetic Sheepskin Pad 28.91 23.13

E0189 Lambswool Sheepskin Pad, Any Size 56.83 45.46

E0190 Positioning Cushion/Pillow/Wedge, Any Shape Or Size, Includes All Components And Accessores17.73 14.18

E0191 Heel Or Elbow Protector, Each 10.87 8.70

E0196 Gel Pressure Mattress 345.20 276.16

E0197 Air Pressure Pad For Mattress, Standard Mattress Length And Width242.31 193.85

E0198 Water Pressure Pad For Mattress, Standard Mattress Length And Width242.31 193.85

E0199 Dry Pressure Pad For Mattress, Standard Mattress Length And Width29.80 23.84

E0202 Phototherapy (Bilirubin) Light With Photometer68.47 54.78

E0240 Bath/Shower Chair, With Or Without Wheels, Any Size- -

E0241 Bath Tub Wall Rail, Each 78.75 63.00

E0243 Toilet Rail, Each 35.44 28.35

E0244 Raised Toilet Seat 101.25 81.00

E0245 Tub Stool Or Bench 177.19 141.75

E0247 Transfer Bench For Tub Or Toilet With Or Without Commode Opening- -

E0248 Transfer Bench, Heavy Duty, For Tub Or Toilet With Or Without Commode Opening- -

E0250 Hospital Bed, Fixed Height, With Any Type Side Rails, With Mattress92.13 73.70

E0255 Hospital Bed, Variable Height, Hi-Lo, With Any Type Side Rails, With Mattress110.73 88.58

E0260 Hospital Bed, Semi-Electric (Head And Foot Adjustment), With Any Type Side Rails, With Mattress132.39 105.91

E0271 Mattress, Innerspring 177.89 142.31

E0272 Mattress, Foam Rubber 179.66 143.73

E0275 Bed Pan, Standard, Metal Or Plastic 16.75 13.40

E0276 Bed Pan, Fracture, Metal Or Plastic 14.55 11.64

E0277 Powered Pressure-Reducing Air Mattress 663.01 530.41

E0300 Pediatric Crib, Hospital Grade, Fully Enclosed267.54 214.03

E0303 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 Mattress277.39 221.91

E0304 Hospital Bed, Extra Heavy Duty, Extra Wide, With Weight Capacity Greater Than 600 Pounds, With Any Type Side Rails, With Mattress726.38 581.10

E0305 Bed Side Rails, Half Length 142.50 114.00

E0310 Bed Side Rails, Full Length 174.29 139.43

E0325 Urinal; Male, Jug-Type, Any Material 9.40 7.52

E0326 Urinal; Female, Jug-Type, Any Material 11.48 9.18

E0371 Nonpowered Advanced Pressure Reducing Overlay For Mattress, Standard Mattress Length And Width404.78 323.82

E0424 Stationary Compressed Gaseous Oxygen System, Rental; Includes Container, Contents, Regulator, Flowmeter, Humidifier, Nebulizer, Cannula Or Mask, And Tubing178.24 142.59

E0431 Portable Gaseous Oxygen System, Rental; Includes Portable Container, Regulator, Flowmeter, Humidifier, Cannula Or Mask, And Tubing29.97 23.98

E0434 Portable Liquid Oxygen System, Rental; Includes Portable Container, Supply Reservoir, Humidifier, Flowmeter, Refill Adaptor, Contents Gauge, Cannula Or Mask, And Tubing29.97 23.98

E0439 Stationary Liquid Oxygen System, Rental; Includes Container, Contents, Regulator, Flowmeter, Humidifier, Nebulizer, Cannula Or Mask, & Tubing178.24 142.59

E0441 Oxygen Contents, Gaseous (For Use With Owned Gaseous Stationary Systems Or When Both A Stationary And Portable Gaseous System Are Owned), 1 Month'S Supply = 1 Unit77.45 61.96

E0443 Portable Oxygen Contents, Gaseous (For Use Only With Portable Gaseous Systems When No Stationary Gas Or Liquid System Is Used), 1Month'S Supply = 1 Unit77.45 61.96

E0445 Oximeter Device For Measuring Blood Oxygen Levels Non-Invasively312.50 250.00

E0450 Volume Control Ventilator, Without Pressure Support Mode, May Include Pressure Control Mode, Used With Invasive Interface (E.G., Tracheostomy Tube)1,043.81 835.05

E0460 RR Negative Pressure Ventilator; Portable Or Stationary802.19 641.75

E0463 RR Pressure Support Ventilator With Volume Control Mode, May Include Pressure Control Mode, Used With Invasive Interface (E.G. Tracheostomy Tube)1,537.95 1,230.36

E0464 RR Pressure Support Ventilator With Volume Control Mode, May Include Pressure Control Mode, Used With Non-Invasive Interface (E.G. Mask)1,537.95 1,230.36

E0470 RR 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)241.85 193.48

E0471 RR 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)605.26 484.21

E0472 RR 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)605.26 484.21

E0480 Percussor, Electric Or Pneumatic, Home Model44.08 35.26

E0482 Cough Stimulating Device, Alternating Positive And Negative Airway Pressure454.34 363.47

E0483 High Frequency Chest Wall Oscillation Air-Pulse Generator System, (Includes Hoses And Vest), Each1,162.58 930.06

E0484 Oscillatory Positive Expiratory Pressure Device, Non-Electric, Any Type, Each40.38 32.30

E0561 Humidifier, Non-Heated, Used With Positive Airway Pressure Device100.85 80.68

E0562 Humidifier, Heated, Used With Positive Airway Pressure Device283.91 227.13

E0565 Compressor, Air Power Source For Equipment Which Is Not Self- Contained Or Cylinder Driven56.71 45.37

E0570 Nebulizer, With Compressor 176.10 140.88

E0600 Respiratory Suction Pump, Home Model, Portable Or Stationary, Electric500.70 400.56

E0601 Continuous Airway Pressure (Cpap) Device102.24 81.79

E0602 Breast Pump, Manual, Any Type 32.28 25.82

E0603 Breast Pump, Electric (Ac And/Or Dc), Any Type68.75 55.00

E0605 Vaporizer, Room Type 27.37 21.90

E0606 Postural Drainage Board 251.00 200.80

E0607 Home Blood Glucose Monitor 73.06 58.45

E0619 Apnea Monitor, With Recording Feature 403.75 323.00

E0621 Sling Or Seat, Patient Lift, Canvas Or Nylon89.22 71.38

E0630 Patient Lift, Hydraulic Or Mechanical, Includes Any Seat, Sling, Straps(S), Or Pads107.49 85.99

E0650 Pneumatic Compressor, Non-Segmental Home Model97.18 77.74

E0651 Pneumatic Compressor, Segmental Home Model Without Calibrated Gradient Pressure87.21 69.77

E0652 Pneumatic Compressor, Segmental Home Model With Calibrated Gradient Pressure572.95 458.36

E0655 Non-Segmental Pneumatic Appliance For Use With Pneumatic Compressor, Half Arm118.03 94.42

E0660 Non-Segmental Pneumatic Appliance For Use With Pneumatic Compressor, Full Leg174.69 139.75

E0665 Non-Segmental Pneumatic Appliance For Use With Pneumatic Compressor, Full Arm127.34 101.87

E0666 Non-Segmental Pneumatic Appliance For Use With Pneumatic Compressor, Half Leg151.01 120.81

E0667 Segmental Pneumatic Appliance For Use With Pneumatic Compressor, Full Leg354.05 283.24

E0668 Segmental Pneumatic Appliance For Use With Pneumatic Compressor, Full Arm410.73 328.58

E0669 Segmental Pneumatic Appliance For Use With Pneumatic Compressor, Half Leg190.33 152.26

E0671 Segmental Gradient Pressure Pneumatic Appliance, Full Leg454.21 363.37

E0672 Segmental Gradient Pressure Pneumatic Appliance, Full Arm352.91 282.33

E0673 Segmental Gradient Pressure Pneumatic Appliance, Half Leg293.25 234.60

E0705 Transfer Device, Any Type, Each 51.24 40.99

E0720 Transcutanteous Electrical Nerve Stimulation (Tens) Device, Two Lead, Localized Stimulation401.96 321.57

E0730 Transcutaneous Electrical Nerve Stimulation (Tens) Device, Four Or More Leads, For Multiple Nerve Stimulation401.81 321.45

E0747 Osteogenesis Stimulator, Electrical, Non- Invasive, Other Than Spinal Applications4,282.40 3,425.92

E0748 Osteogenesis Stimulator, Electrical, Non- Invasive, Spinal Applications4,254.66 3,403.73

E0760 Osteogenesis Stimulator, Low Intensity Ultrasound, Non-Invasive3,535.55 2,828.44

E0766 Elec stim cancer treatment 425.55 340.44

E0781 Ambulatory Infusion Pump, Single Or Multiple Channels, Electric Or Battery Operated, With Administrative Equipment, Worn By Patient272.36 217.89

E0784 External Ambulatory Infusion Pump, Insulin456.54 365.23

E0860 Traction Equipment, Overdoor, Cervical 40.68 32.54

E0910 Trapeze Bars, A/K/A Patient Helper, Attached To Bed, With Grab Bar174.10 139.28

E0911 Trapeze Bar, Heavy Duty, For Patient Weight Capacity Greater Than 250 Pounds, Attached To Bed, With Grab Bar469.80 375.84

E0912 Trapeze Bar, Heavy Duty, For Patient Weight Capacity Greater Than 250 Pounds, Free Standing, Complete With Grab Bar1,079.00 863.20

E0935 RR Continuous Passive Motion Exercise Device For Use On Knee Only24.87 19.90

E0940 Trapeze Bar, Free Standing, Complete With Grab Bar278.50 222.80

E0942 Cervical Head Harness/Halter 19.31 15.45

E0950 Wheelchair Accessory, Tray, Each 83.28 66.62

E0951 Heel Loop/Holder, Any Type, With Or Without Ankle Strap, Each15.21 12.17

E0952 Toe Loop/Holder, Any Type, Each 15.09 12.07

E0955 Wheelchair Accessory, Headrest, Cushioned, Any Type, Including Fixed Mounting Hardware, Each190.57 152.46

E0956 Wheelchair Accessory, Lateral Trunk Or Hip Support, Any Type, Including Fixed Mounting Hardware, Each92.91 74.33

E0957 Wheelchair Accessory, Medial Thigh Support, Any Type, Including Fixed Mounting Hardware, Each130.01 104.01

E0958 Manual Wheelchair Accessory, One-Arm Drive Attachment, Each477.00 381.60

E0959 Manual Wheelchair Accessory, Adapter For Amputee, Each41.09 32.87

E0960 Wheelchair Accessory, Shoulder Harness/Straps Or Chest Strap, Including Any Type Mounting Hardware85.75 68.60

E0961 Manual Wheelchair Accessory, Wheel Lock Brake Extension (Handle), Each32.53 26.02

E0966 Manual Wheelchair Accessory, Headrest Extension, Each67.73 54.18

E0967 Manual Wheelchair Accessory, Hand Rim With Projections, Any Type, Each71.82 57.46

E0968 Commode Seat, Wheelchair 196.00 156.80

E0969 Narrowing Device, Wheelchair 162.57 130.06

E0970 No.2 Footplates, Except For Elevating Leg Rest- -

E0971 Manual Wheelchair Accessory, Anti-Tipping Device Each47.44 37.95

E0973 Wheelchair Accessory, Adjustable Height, Detachable Armrest, Complete Assembly, Each92.11 73.69

E0974 Manual Wheelchair Accessory, Anti-Rollback Device, Each85.74 68.59

E0978 Wheelchair Accessory, Positioning Belt/Safety Belt/Pelvic Strap, Each39.56 31.65

E0980 Safety Vest, Wheelchair 34.95 27.96

E0981 Wheelchair Accessory, Seat Upholstery, Replacement Only, Each37.77 30.22

E0982 Wheelchair Accessory, Back Upholstery, Replacement Only, Each41.28 33.02

E0983 Manual Wheelchair Accessory, Power Add-On To Convert Manual Wheelchair To Motorized Wheelchair, Joystick Control2,646.30 2,117.04

E0984 Manual Wheelchair Accessory, Power Add-On To Convert Manual Wheelchair To Motorized Wheelchair, Tiller Control1,849.62 1,479.70

E0988 RR Lever-Activated Wheel Drive 3,273.50 2,618.80

E0990 Wheelchair Accessory, Elevating Leg Rest, Complete Assembly, Each94.08 75.26

E0992 Manual Wheelchair Accessory, Solid Seat Insert88.45 70.76

E1002 Wheelchair Accessory, Power Seating System, Tilt Only3,820.28 3,056.22

E1003 Wheelchair Accessory, Power Seating System, Recline Only, Without Shear Reduction4,138.94 3,311.15

E1004 Wheelchair Accessory, Power Seating System, Recline Only, With Mechanical Shear Reduction4,589.23 3,671.38

E1005 Wheelchair Accessory, Power Seatng System, Recline Only, With Power Shear Reduction4,967.48 3,973.98

E1006 Wheelchair Accessory, Power Seating System, Combination Tilt And Recline, Without Shear Reduction6,084.70 4,867.76

E1007 Wheelchair Accessory, Power Seating System, Combination Tilt And Recline, With Mechanical Shear Reduction8,238.92 6,591.14

E1008 Wheelchair Accessory, Power Seating System, Combination Tilt And Recline, With Power Shear Reduction8,239.67 6,591.74

E1009 Wheelchair Accessory, Addition To Power Seating System, Mechanically Linked Leg Elevation System, Including Pushrod And Leg Rest, Each- -

E1010 Wheelchair Accessory, Addition To Power Seating System, Power Leg Elevation System, Including Leg Rest, Pair1,078.05 862.44

E1011 Modification To Pediatric Size Wheelchair, Width Adjustment Package (Not To Be Dispensed With Initial Chair)- -

E1014 Reclining Back, Addition To Pediatric Size Wheelchair399.30 319.44

E1015 Shock Absorber For Manual Wheelchair, Each125.44 100.35

E1016 Shock Absorber For Power Wheelchair, Each123.77 99.02

E1020 Residual Limb Support System For Wheelchair229.42 183.54

E1028 Wheelchair Accessory, Manual Swingaway, Retractable Or Removable Mounting Hardware For Joystick, Other Control Interface Or Positioning Accessory194.67 155.74

E1029 Wheelchair Accessory, Ventilator Tray, Fixed348.31 278.65

E1030 Wheelchair Accessory, Ventilator Tray, Gimbaled1,098.30 878.64

E1031 Rollabout Chair, Any And All Types With Castors5" Or Greater55.24 44.19

E1161 Manual Adult Size Wheelchair, Includes Tilt In Space2,587.43 2,069.94

E1225 Wheelchair Accessory, Manual Semi-Reclining Back, (Recline Greater Than 15 Degrees, But Less Than 80 Degrees), Each494.30 395.44

E1226 Wheelchair Accessory, Manual Fully Reclining Back, (Recline Greater Than 80 Degrees), Each578.02 462.42

E1229 Wheelchair, Pediatric Size, Not Otherwise Specified- -

E1231 Wheelchair, Pediatric Size, Tilt-In-Space, Rigid, Adjustable, With Seating System2,138.41 1,710.73

E1232 Wheelchair, Pediatric Size, Tilt-In-Space, Folding, Adjustable, With Seating System2,338.44 1,870.75

E1233 Wheelchair, Pediatric Size, Tilt-In-Space, Rigid, Adjustable, Without Seating Systen2,423.00 1,938.40

E1234 Wheelchair, Pediatric Size, Tilt-In-Space, Folding, Adjustable, Without Seating System2,109.40 1,687.52

E1235 Wheelchair, Pediatric Size, Rigid, Adjustable, With Seating System2,031.18 1,624.94

E1236 Wheelchair, Pediatric Size, Folding, Adjustable, With Seating System1,792.02 1,433.62

E1237 Wheelchair, Pediatric Size, Rigid, Adjustable, Without Seating System1,807.68 1,446.14

E1238 Wheelchair, Pediatric Size, Folding, Adjustable, Without Seating System1,792.02 1,433.62

E1239 Power Wheelchair, Pediatric Size, Not Otherwise Specified- -

E1372 Immersion External Heater For Nebulizer 151.54 121.23

E1390 Oxygen Concentrator, Single Delivery Port, Capable Of Delivering 85 Percent Or Greater Oxygen Concentration At The Prescribed Flow Rate178.24 142.59

E1399 Durable Medical Equipment, Miscellaneous - -

E2100 Blood Glucose Monitor With Integrated Voice Synthesizer703.35 562.68

E2201 Manual Wheelchair Accessory, Nonstandard Seat Frame, Width Greater Than Or Equal To 20Inches And Less Than 24 Inches408.01 326.41

E2202 Manual Wheelchair Accessory, Nonstandard Seat Frame Width, 24-27 Inches518.31 414.65

E2203 Manual Wheelchair Accessory, Nonstandard Seat Frame Depth, 20 To Less Than 22 Inches523.87 419.10

E2204 Manual Wheelchair Accessory, Nonstandard Seat Frame Depth, 22 To 25 Inches889.50 711.60

E2205 Manual Wheelchair Accessory, Handrim WithoutProjections (Includes Ergonomic Or Contoured), Any Type, Replacement Only, Each35.72 28.58

E2206 Manual Wheelchair Accessory, Wheel Lock Assembly, Complete, Each44.48 35.58

E2207 Wheelchair Accessory, Crutch And Cane Holder, Each47.40 37.92

E2208 Wheelchair Accessory, Cylinder Tank Carrier, Each111.96 89.57

E2209 Accessory, Arm Tough, With Or Without Handsupport, Each101.00 80.80

E2210 Wheelchair Accessory, Bearngs, Any Type, Replacement Only, Each6.17 4.94

E2211 Manual Wheelchair Accessory, Pneumatic Propulsion Tire, Any Size, Each38.03 30.42

E2212 Manual Wheelchair Accessory, Tube For Pneumatic Propulsion Tire, Any Size, Each6.42 5.14

E2213 Manual Wheelchair Accessory, Insert For Pneumatic Propulsion Tire (Removable), Any Type, Any Size, Each33.26 26.61

E2214 Manual Wheelchair Accessory, Pneumatic Caster Tire, Any Size, Each33.46 26.77

E2215 Manual Wheelchair Accessory, Tube For Pneumatic Caster Tire, Any Size Each10.49 8.39

E2216 Manual Wheelchair Accessory, Foam Filled Propulsion Tire, Any Size, Each- -

E2217 Manual Wheelchair Accessory, Foam Filled Caster Tire, Any Size, Each- -

E2218 Manual Wheelchair Accesory, Foam Propulsion Tire, Any Size, Each- -

E2219 Manual Wheelchair Accessory, Foam Caster Tire, Any Size, Each45.76 36.61

E2220 Manual Wheelchair Accesory, Solid (Rubber/Plastic) Propulsion Tire, Any Size, Each28.17 22.54

E2221 Manual Wheelchair Acessory, Solid (Rubber/Plastic) Caster Tire With Integrated Wheel, Any Size, Each27.94 22.35

E2222 Manual Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire With Integrated Wheel, Any Size, Each23.03 18.42

E2224 Manual Wheelchair Accessory, Propulsion Wheel Excludes Tire, Any Size, Each91.15 72.92

E2225 Manual Wheelchair Accessory, Caster Wheel Excludes Tire, Any Size, Replacement Only, Each19.03 15.22

E2226 Manual Wheelchair Accessory, Caster Fork, Any Size, Replacement Only, Each41.50 33.20

E2227 Manual Wheelchair Accessory, Gear Reduction Drive Wheel, Each2,045.63 1,636.50

E2228 Manual Wheelchair Accessory, Wheel Braking System And Lock,Complete Each1,023.85 819.08

E2231 Solid Seat Support Base 168.05 134.44

E2291 Back, Planar, For Pediatric Size Wheelchair Including Fixed Attaching Hardware- -

E2292 Seat, Planar, For Pediatric Size Wheelchair Including Fixed Attaching Hardware- -

E2293 Back, Contoured, For Pediatric Size Wheelchair Including Fixed Attaching Hardware- -

E2294 Seat, Contoured, For Pediatric Size Wheelchair Including Fixed Attaching Hardware- -

E2295 Manual Wheelchair Accessory, For Pediatric Size Wheelchair, Dynamic Seating Grame, Allows Coordinated Movement Of Multiple Positioning Features- -

E2310 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 Hardware1,102.99 882.39

E2311 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 Hardware2,233.06 1,786.45

E2312 Power Wheelchair Accessory, Hand Or Chin Control Interface, Mini-Proportional Remote Joystick, Proportional, Including Fixed Mounting Hardware2,205.37 1,764.30

E2313 Power Wheelchair Accessory, Harness For Upgrade To Expandable Controller, Including All Fasteners, Connectors And Mounting Hardware, Each350.21 280.17

E2321 Power Wheelchair Accessory, Hand Control Interface, Remote Joystick, Nonproportional, Including All Related Electronics, Mechanical Stop Switch, And Fixed Mounting Hardware1,497.78 1,198.22

E2322 Power Wheelchair Accessory, Hand Control Interface, Multiple Mechanical Switches, Nonproportional, Including All Related Electronics, Mechanical Stop Switches, Nonproportional, Including All Related Electronics, Mechanical Stop1,329.31 1,063.45

E2323 Power Wheelchair Accessory, Specialty Joystick Handle For Hand Control Interface, Prefabricated65.19 52.15

E2324 Power Wheelchair Accessory, Chin Cup For Chin Control Interface41.30 33.04

E2325 Power Wheelchair Accessory, Sip And Puff Interface, Nonproportional, Including All Related Electronics, Mechanical Stop Switch, And Manual Swingaway Mounting Hardware1,269.43 1,015.54

E2326 Power Wheelchair Accessory, Breath Tube Kit For Sip And Puff Interface327.19 261.75

E2327 Power Wheelchair Accessory, Head Control Interface, Mechanical, Proportional, Including All Related Electronics, Mechanical Direction Change Switch, And Fixed Mounting Hardware2,462.25 1,969.80

E2328 Power Wheelchair Accessory, Head Control Or Extremity Control Interface, Electronic, Proportional, Including All Related Electronics And Fixed Mounting Hardware4,670.54 3,736.43

E2329 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 Hardware1,664.63 1,331.70

E2330 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 Hardware3,225.42 2,580.34

E2340 Power Wheelchair Accessory, Nonstandard Seat Frame Width, 20-23 Inches391.88 313.50

E2341 Power Wheelchair Accessory, Nonstandard Seat Frame Width, 24-27 Inches587.87 470.30

E2342 Power Wheelchair Accessory, Nonstandard Seat Frame Depth, 20 Or 21 Inches489.89 391.91

E2343 Power Wheelchair Accessory, Nonstandard Seat Frame Depth, 22-25 Inches783.83 627.06

E2351 Power Wheelchair Accessory, Electronic Interface To Operate Speech Generating Device Using Power Wheelchair Control Interface658.48 526.78

E2360 Power Wheelchair Accessory, 22 Nf Non-Sealed Lead Acid Battery, Each122.86 98.29

E2361 Power Wheelchair Accessory, 22Nf Sealed Lead Acid Battery, Each, (E.G. Gel Cell, Absorbed Glassmat)131.45 105.16

E2362 Power Wheelchair Accessory, Group 24 Non- Sealed Lead Acid Battery, Each100.59 80.47

E2363 Power Wheelchair Accessory, Group 24 Sealed Lead Acid Battery, Each (E.G. Gel Cell, Absorbed Glassmat)175.32 140.26

E2364 Power Wheelchair Accessory, U-1 Non-Sealed Lead Acid Battery, Each122.86 98.29

E2365 Power Wheelchair Accessory, U-1 Sealed Lead Acid Battery, Each (E.G. Gel Cell, Absorbed Glassmat)105.72 84.58

E2366 Power Wheelchair Accessory, Battery Charger, Single Mode, For Use With Only One Battery Type, Sealed Or Non-Sealed, Each248.47 198.78

E2368 Power Wheelchair Component, Motor, Replacement Only486.89 389.51

E2369 Power Wheelchair Component, Gear Box, Replacement Only424.08 339.26

E2370 Power Wheelchair Component, Motor And Gear Box Combination, Replacement Only756.70 605.36

E2371 Power Wheelchair Accessory, Group 27 Sealed Lead Acid Battery, (E.G. Gel Cell, Absorbed Glassmat), Each142.08 113.66

E2372 Power Wheelchair Accessory, Group 27 Non- Sealed Lead Acid Battery, Each- -

E2373 Power Wheelchair Accessory, Hand Or ChinControl Interface, Compact Remote Joystick, Proportional, Including Fixed Mounting Hardware768.74 614.99

E2374 Power Wheelchair Accessory, Hand Or Chin Control Interface, Standard Remote Joystick (Not Including Controller), Proprotional, Including All Related Electronics And Fxed Mounting Hardware, Replacement Only503.34 402.67

E2375 Power Wheelchair Accessory, Non-Expandable Controller, Including All Related Electronics And Mounting Hardware, Replacement Only807.33 645.86

E2376 Power Wheelchair Accessory, Expandable Controller, Including All Relatedelectronics And Mounting Hardware, Replacement Only1,265.13 1,012.10

E2377 Power Wheelchair Accessory, ExpandableController, Inluding All Related Electronics And Mounting Hardware, Upgrade Provided At Initial Issue457.80 366.24

E2378 Pw Actuator Replacement 559.53 447.62

E2381 Power Wheelchair Accessory, Pneumatic Drive Wheel Tire, Any Size, Replacement71.79 57.43

E2382 Power Wheelchair Accessory, Tube For Pneumatic Drive Wheel Tire, Any Size, Replacement Only, Each19.57 15.66

E2383 Power Wheelchair Accesssory, Insert For Pneumatic Drive Wheel Tire (Removable), Any Type, Any Size, Replacement Only, Each143.15 114.52

E2384 Power Wheelchair Accessory, Pneumatic Caster Tire, Any Size, Replacement Only76.27 61.02

E2385 Power Wheelchair Accessory, Tube ForPneumatic Caster Tire, Any Size, Replacement Only, Each46.66 37.33

E2386 Power Wheelchair Accessory, Foam Filled Drive Wheel Tire, Any Size Replacement Only, Each141.85 113.48

E2387 Power Wheelchair Accessory, Foam Filled Caster Tire, Any Size, Replacement Only, Each61.20 48.96

E2388 Power Wheelchair Accessory, Foam Drive Wheel Tire, Any Size, Replacment Only, Each47.48 37.98

E2389 Power Wheelchair Accessory, Foam Caster Tire, Any Size, Replacement Only, Each25.79 20.63

E2390 Power Wheelchair Accessory, Solid (Rubber/Plastic) Drive Wheel Tire, Any Size, Replacement Only, Each40.33 32.26

E2391 Power Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire (Removable), Any Size, Replacement Only, Each19.31 15.45

E2392 Power Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire With Integratedwheel, Any Size, Replacement Only, Each50.78 40.62

E2394 Power Wheelchair Accessory, Drive Wheel Excludes Tire, Any Size, Replacement72.35 57.88

E2395 Power Wheelchair Accessory, Caster Wheel Excludes Tire, Any Size, Replacement51.41 41.13

E2396 Power Wheelchair Accessory, Caster Fork, Any Size, Replacement Only, Each58.20 46.56

E2397 Power Wheelchair Accessory, Lithium-Based Battery, Each452.88 362.30

E2402 Negative Pressure Wound Therapy Electrical Pump, Stationary Or Portable1,617.82 1,294.26

E2500 Sgd Digitized Pre-Rec 8Min 20Min 40 Min 2,529.33 2,023.46

E2508 Sgd Spelling Phys Contact 3,911.17 3,128.94

E2510 Sgd W Multi Methods Msg/Accs 7,401.38 5,921.10

E2512 Sgd Accessory, Mounting Sys - -

E2599 Accessory For Speech Generating Device - -

E2601 General Use Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth57.64 46.11

E2602 General Use Wheelchair Seat Cushion, Width 22Inches Or Greater, Any Depth112.53 90.02

E2603 Skin Protection Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth142.87 114.30

E2604 Skin Protection Wheelchair Seat Cushion, Width22 Inches Or Greater, Any Depth177.59 142.07

E2605 Positioning Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth253.70 202.96

E2606 Positioning Wheelchair Seat Cushion, Width 22Inches Or Greater, Any Depth395.80 316.64

E2607 Skin Protection And Positioning Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth273.19 218.55

E2608 Skin Protection And Positioning Wheelchair Seat Cushion, Width 22 Inches Or Greater, Any Depth328.08 262.46

E2609 Custom Fabricated Wheelchair Seat Cushion, Any Size- -

E2611 General Use Wheelchair Back Cushion, Width Less Than 22 Inches, Any Height, Including Any Type Mounting Hardware294.40 235.52

E2612 General Use Wheelchair Back Cushion, Width 22Inches Or Greater, Any Height, Including Any Type Mounting Hardware398.26 318.61

E2613 Positioning Wheelchair Back Cushion, Posterior, Width Less Than 22 Inches, Any Height, Including Any Type Mounting Hardware370.45 296.36

E2614 Positioning Wheelchair Back Cushion, Posterior, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting Hardware512.68 410.14

E2615 Positioning Wheelchair Back Cushion, Posterior- Lateral, Width Less Than 22 Nches, Any Height, Including Any Type Mounting Hardware426.32 341.06

E2616 Positioning Wheelchair Back Cushion, Posterior- Lateral, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting Hardware573.61 458.89

E2617 Custom Fabricated Wheelchair Back Cushion, Any Size, Including Any Type Mounting Hardware- -

E2619 RP Replacement Cover For Wheelchair Seat Cushion Or Back Cushion, Each48.36 38.69

E2620 Positioning Wheelchair Back Cushion, Planar Back With Lateral Supports, Width Less Than 22Inches, Any Height, Including Any Type Mounting Hardware516.22 412.98

E2621 Positioning Wheelchair Back Cushion, Planar Back With Lateral Supports, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting Hardware541.73 433.38

E2622 Adj Skin Pro W/C Cus Wd=22In 397.54 318.03

E2624 Adj Skin Pro/Pos Cus=22 398.75 319.00

E2626 Seo Mobile Arm Sup Att To Wc 669.80 535.84

E2627 Arm Supp Att To Wc Rancho Ty 921.26 737.01

E2628 Mobile Arm Supports Reclinin 694.02 555.22

E2629 Friction Dampening Arm Supp 1,033.25 826.60

E2630 Monosuspension Arm/Hand Supp 614.17 491.34

E2631 Elevat Proximal Arm Support 245.68 196.54

E2632 Offset/Lat Rocker Arm W/Ela 156.21 124.97

E2633 Mobile Arm Support Supinator 132.50 106.00

K0001 Standard Wheelchair 58.25 46.60

K0002 Standard Hemi (Low Seat) Wheelchair 76.36 61.09

K0003 Lightweight Wheelchair 97.98 78.38

K0004 High Strength, Lightweight Wheelchair 134.60 107.68

K0005 Ultralightweight Wheelchair 202.15 161.72

K0006 Heavy Duty Wheelchair 116.58 93.26

K0007 Extra Heavy Duty Wheelchair 191.19 152.95

K0009 Other Manual Wheelchair/Base 81.31 65.05

K0015 Detachable, Non-Adjustable Height Armrest, Each171.27 137.02

K0017 Detachable, Adjustable Height Armrest, Base, Each48.17 38.54

K0018 Detachable, Adjustable Height Armrest, Upper Portion, Each26.90 21.52

K0019 Arm Pad, Each 15.41 12.33

K0020 Fixed, Adjustable Height Armrest, Pair 43.79 35.03

K0037 High Mount Flip-Up Footrest, Each 38.58 30.86

K0038 Leg Strap, Each 22.88 18.30

K0039 Leg Strap, H Style, Each 50.78 40.62

K0040 Adjustable Angle Footplate, Each 70.38 56.30

K0041 Large Size Footplate, Each 49.87 39.90

K0042 Sta

Documents

Durable Medical Equipment CY 2014 Fee Schedule...Durable Medical Equipment CY 2014 Fee Schedule Disclaimer: Indication or presence of fee in the table below does not guarantee coverage