[XLS]DME-Fee Screens July 2006 - SOM - State of Michigan · Web viewPREP BK PTB SUPRAC SUS SACH PL...

July 1, 2009Rev 7/31/2009 MDCH Medical Supplier/DME/Prosthetics and Orthotics Database*

(See Database Explanation) 1 of 173

* This database is not a source for Medicaid coverage policy. For current coverage policy information, consult the Medicaid Policy Manual.

n Rate is effective 8/1/09

CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISA4206 A $0.26 000-099 Y N Y 000-099

A4207 A $0.17 000-099 Y N Y 000-099

A4208 A $0.17 000-099 Y N Y 000-099

A4209 A $0.59 000-099 Y N Y 000-099

A4210 A $708.79 000-099 N N Y 000-099

A4213 A $0.77 000-099 Y N Y 000-099

A4215 A $0.14 000-099 Y N Y 000-099

A4220 A $76.68 000-099 N N Y 000-099

A4230 A $9.79 000-099 Y N Y 000-099

A4231 A $5.06 000-099 Y N Y 000-099

SYRINGE W/ NEEDLE, STERILE 1CC

SYRINGE W/ NEEDLE,STERILE 2CC

SYRINGE W/ NEEDLE,STERILE 3CC

SYRINGE W/NEED.STER 5-20CC

NEEDLE FREE INJECTION DEVICE

SYRINGE STER 20-

35CC NEEDLES

ONLY,STERILE,ANY SIZE

REFILL KIT FOR INFUSION PUMP

INFUSION SET,NON

NEEDLE 30 PER

MONTH 250.00-250.13 250.20-250.23 250.30-250.33 250.40-250.43 250.50-250.53 250.60-250.63 250.70-250.73 250.80-250.83 250.90-250.93 648.00-648.04 INFUSION SET,

NEEDLE TYPE 30 PER

MONTH 250.00-250.13 250.20-250.23 250.30-250.33 250.40-250.43 250.50-250.53 250.60-250.63 250.70-250.73 250.80-250.83 250.90-250.93 648.00-648.04






A4244 A $0.96 000-099 Y N N

A4245 A $1.96 000-099 Y N N

A4246 A $7.86 000-099 Y N N

A4247 A $12.28 000-099 Y N N

A4250 A $15.78 000-099 Y N N

A4253 A $28.37 000-099 Y N Y 000-099

A4256 A $7.70 000-099 Y N Y 000-099

A4259 A $7.08 000-099 Y N Y 000-099

A4265 A $2.51 000-099 Y N Y 000-099

A4280 A $4.49 000-099 N N Y 000-099

SYRINGE WITH NEEDLE, STERILE 3

60 PER MONTH

250.00-250.13 250.20-250.23 250.30-250.33 250.40-250.43 250.50-250.53 250.60-250.63 250.70-250.73 250.80-250.83 250.90-250.93 648.00-648.04 ALCOHOL OR

PEROXIDE, PER PINT 8 PER

MONTH

ALCOHOL WIPES, PER BOX (EACH UNIT = 100)

2 PER MONTH

BETADINE OR PHISOHEX SOL EA PT

8 PER MONTH

BET OR IOD SWABS/WIPES,PER BOX (EACH UNIT = 50)

4 PER MONTH

URINE TEST/REAGENT STRIPS/TABS

2 PER MONTH

BLOOD GLUCOSE TEST STRIPS (EACH UNIT = 50)

4 PER MONTH

250.00 -250.93, 648.0 -648.04, 648.80-648.84

NORM,LOW/HIGH CAL.SOLUT. CHIPS

1 PER MONTH

250.00 -250.93, 648.0 -648.04, 648.80-648.84

LANCETS, PER BOX (EACH UNIT = 100)

2 PER MONTH

250.00 -250.93, 648.0 -648.04, 648.80-648.84

PARAFFIN

6 PER 6 MONTHS

714.0 -714.9 BRST PRSTHS

ADHSV ATTCHMNT






A4306 A $15.33 000-099 Y N Y 000-099

A4310 A $5.34 000-099 Y N N

A4311 A $13.68 000-099 Y N N

A4312 A $12.47 000-099 Y N N

A4313 A $14.51 000-099 Y N N

A4314 A $17.48 000-099 Y N N

A4315 A $18.24 000-099 Y N N

A4316 A $19.89 000-099 Y N N

A4320 A $3.41 000-099 Y N N

A4322 A $2.10 000-099 Y N N

A4326 A $6.47 000-099 Y N N

A4328 A $7.20 000-099 Y N N

A4330 A $6.59 000-099 Y N N

A4331 A $2.91 000-099 Y N N

A4333 A $2.03 000-099 Y N N

A4334 A $3.41 000-099 Y N N

A4335 A $0.58 003-099 N N N

DISPOSABLE DRUG DELIVERY SYST

DISPOSABLE DRUG

DELIVERY INSERT TRAY W/O

DRAIN BAG &CAT 2 PER

MONTH INSERT TRAY W/O

BAG W FOLEY,ET 2 PER


DRAIN ALL SILI 2 PER


BAG W CATH 3WY 2 PER

MONTH INSERT TRAY, TWO

WAY LATEX 2 PER

MONTH INSERT TRAY, TWO-

WAY SILICONE 2 PER

MONTH INSERT TRAY,

THREE WAY, CONT. 2 PER

MONTH IRRIGATION TRAY

FOR BLADDER 30 PER

MONTH IRRIGATION

SYRINGE 30 PER

MONTH MALE EXT. CATH.

SPEC. TYPE 30 PER

MONTH FEMALE EXT.URINE

COLL.-POUCH 10 PER

MONTH PERIANAL FECAL

COLL.POUCH 10 PER

MONTH EXTENSION

DRAINAGE TUBING 4 PER

MONTH URINARY CATH

ANCHOR DEVICE 4 PER

MONTH URINARY CATH LEG

STRAP 6 PER 6

MONTHS INCONT. SUPPLY;

MISC. 150 PER MONTH





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISA4338 A $11.30 000-099 Y N N

A4340 A $24.67 000-099 Y N N

A4344 A $12.29 000-099 Y N N

A4346 A $13.54 000-099 Y N N

A4349 A $0.96 000-099 Y N N

A4351 A $1.67 000-099 Y N N

A4351 U4 A $2.17 000-020 Y N Y 000-020

A4352 A $3.78 000-099 Y N N

A4352 U4 A $3.78 000-020 Y N Y 000-020

A4353 A $4.84 000-099 Y N Y 000-099

A4354 A $8.20 000-099 Y N N

A4355 A $6.15 000-020 Y N N

A4357 A $6.71 000-099 Y N N

A4358 A $5.03 000-099 Y N N

A4361 A $16.93 000-099 Y N N

A4362 A $2.73 000-099 Y N N

A4363 A $2.27 000-099 Y N N

INDWELLING CATH, FOLEY,TWO-WAY

2 PER MONTH

INDWELLING CATH.,

SPEC. TYPE 5 PER

MONTH INDW CATH,FOL,2-

WAY,ALL SIL 2 PER

MONTH IN CATH,FOL,3-

WAY,FOR CONT IRR 6 PER

MONTH DISPOSABLE MALE

EXTERNAL CAT96 PER MONTH

INTERMIT. URINARY CATH.

150 PER MONTH

INTERMIT. URINARY

CATH. 150 PER

MONTH

INTERMITT.URINARY CATH.,CURVED

150 PER MONTH

INTERMITT.URINARY

CATH.,CURVED 150 PER

MONTH

INTERMT. URINARY CATH.W/INSERT

150 PER MONTH

CATH INSERTION

TRAY W/BAG10 PER MONTH

3-WAY IRRIGATION SET FOR CATH

6 PER MONTH

URINARY DRAINAGE

BAG 3 PER

MONTH URINARY LEG BAG

10 PER

MONTH OSTOMY FACE

PLATE 2 PER

MONTH OSTOMY SKIN

BARRIER 36 PER

MONTH OSTOMY CLAMP,

REPL ONLYACEMENT 1 PER MONTH






A4365 A $10.25 000-099 Y N N

A4367 A $5.76 000-099 Y N N

A4368 A $0.24 000-099 Y N N

A4369 A $2.23 000-099 N N N

A4371 A $3.36 000-099 N N N

A4372 A $3.40 000-099 N N N

A4373 A $4.34 000-099 N N N

A4375 A $15.71 000-099 N N N

A4376 A $43.50 000-099 N N N

A4377 A $3.92 000-099 N N N

A4378 A $28.11 000-099 N N N

A4379 A $13.73 000-099 N N N

A4380 A $34.12 000-099 N N N

A4381 A $4.22 000-099 N N N

A4382 A $22.50 000-099 N N N

ADH. OSTOMY/CATH. PER OZ.

10 PER MONTH

OSTOMY ADHESIVE REMOVER WIPES

1 PER MONTH

OSTOMY BELT

2 PER

MONTH OSTOMY FILTER,

ANY TYPE, EACH 10 PER

MONTH SKIN BARRIER

LIQUID PER OZ 10 PER

MONTH SKIN BARRIER

POWDER PER OZ 10 PER

MONTH SKIN BARRIER SOLID

4X4 EQUIV 36 PER

MONTH SKIN BARRIER WITH

FLANGE 30 PER

MONTH DRAINABLE PLASTIC

PCH W FCPL 30 PER

MONTH

DRAINABLE RUBBER POUCH W/FCPLT

30 PER MONTH

DRAINABLE PLASTIC PCH W/O FP

30 PER MONTH

URINARY PLASTIC POUCH W FCPL

30 PER MONTH

URINARY PLASTIC

POUCH W FCPL 30 PER

MONTH URINARY RUBBER

POUCH W FCPLT 30 PER

MONTH URINARY PLASTIC

POUCH W/O FP 30 PER

MONTH URINARY HVY PLSTC

PCH W/O FP 30 PER

MONTH





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISA4383 A $25.78 000-099 N N N

A4385 A $4.48 000-099 N N N

A4387 A $3.67 000-099 N N N

A4388 A $3.99 000-099 N N N

A4389 A $5.68 000-099 N N N

A4390 A $8.79 000-099 N N N

A4391 A $6.46 000-099 N N N

A4392 A $6.08 000-099 N N N

A4393 A $8.33 000-099 N N N

A4394 A $2.36 000-099 N N N

A4395 A $0.05 000-099 N N N

A4397 A $4.42 000-099 Y N N

A4398 A $12.73 000-099 Y N N

A4399 A $8.40 000-099 Y N N

A4400 A $38.28 000-099 Y N N

A4402 A $0.31 000-099 Y N N

A4404 A $1.17 000-099 Y N N

A4405 A $3.13 000-099 N N N

OSTOMY POUCH,URINARY FP EA

30 PER MONTH

OST SKN BARRIER SLD EXT WEAR

15 PER MONTH

OST CLSD POUCH W

ATT ST BARR 30 PER

MONTH DRAINABLE PCH W

EX WEAR BARR 30 PER

MONTH DRAINABLE PCH W

ST WEAR BARR 30 PER

MONTH DRAINABLE PCH EX

WEAR CONVEX 30 PER

MONTH URINARY POUCH W

EX WEAR BARR 30 PER

MONTH URINE PCH W EX

WEAR BAR CONV 30 PER

MONTH URINE PCH W EX

WEAR BAR CONV 30 PER

MONTH OSTOMY POUCH LIQ

DEODORANT 16 PER

MONTH OSTOMY POUCH

SOLID DEODORANT 30 PER

MONTH IRRIGATION SUPPLY,

SLEEVE 25 PER

MONTH IRRIGATION

SUPPLIES BAGS 1 PER

MONTH IRRIGATION, CONE,

CATHETER 30 PER

MONTH IRRIGAT SET FOR

IRRIGAT OF OST 1 PER

MONTH LUBRICANT PER

OUNCE 10 PER MONTH

OSTOMY RINGS

8 PER

MONTH NONPECTIN BASED

OSTOMY PASTE10 PER MONTH






A4407 A $6.06 000-099 N N N

A4408 A $6.82 000-099 N N N

A4409 A $5.29 000-099 N N N

A4410 A $6.25 000-099 N N N

A4411 A $4.01 000-099 N N N

A4412 A $2.59 000-099 N N N

A4413 A $4.05 000-099 N N N

A4414 A $3.98 000-099 N N N

A4415 A $4.15 000-099 N N N

A4416 A $2.03 000-099 N N N

A4417 A $2.76 000-099 N N N

A4418 A $1.33 000-099 N N N

A4419 A $1.28 000-099 N N N

A4420 A $1.33 000-099 N N N

A4421 A $0.01 000-099 N N Y 000-099

A4422 A $0.10 000-099 N N N

PECTIN BASED OSTOMY PASTE

10 PER MONTH

EXT WEAR OST SKN BARR <=4 SQ "

15 PER MONTH

EXT WEAR OST SKN BARR >4 SQ "

15 PER MONTH

OST SKN BARR W FLNG <=4 SQ "

15 PER MONTH

OSTOMY SKN BARR W FLNG >4 SQ"

15 PER MONTH

OST SKN BARR EXTND=4SQ

30 PER MONTH

OST POUCH DRAIN HIGH OUTPUT

30 PER MONTH

2 PC DRAINABLE OST POUCH

30 PER MONTH

OSTOMY SKN BARR W FLNG <=4 SQ"

30 PER MONTH

OSTOMY SKN BARR W FLNG >4 SQ"

30 PER MONTH

OST PCH CLSD W BARRIER/FILTR

30 PER MONTH

OST PCH W BAR/BLTINCONV/FLTR

30 PER MONTH

OST PCH CLSD W/O BAR W FILTR

30 PER MONTH

OST PCH FOR BAR W FLANGE/FLT

30 PER MONTH

OST PCH CLSD FOR BAR W LK FL

30 PER MONTH

NOC OSTOMY SUPPLIES

OST POUCH ABSORBENT MATERIAL

30 PER MONTH






A4424 A $3.65 000-099 N N N

A4425 A $2.64 000-099 N N N

A4426 A $1.77 000-099 N N N

A4427 A $1.96 000-099 N N N

A4428 A $4.72 000-099 N N N

A4429 A $5.55 000-099 N N N

A4430 A $6.29 000-099 N N N

A4431 A $3.74 000-099 N N N

A4432 A $2.65 000-099 N N N

A4433 A $2.46 000-099 N N N

A4434 A $2.77 000-099 N N N

A4450 A $0.09 000-099 Y N N

A4452 WATERPROOF TAPE A $0.34 000-099 Y N N

A4455 A $1.32 000-099 Y N N

A4458 A $5.41 000-099 Y N N

A4481 A $0.31 000-099 N N N

OST PCH FOR BAR W LK FL/FLTR

30 PER MONTH

OST PCH DRAIN W BAR & FILTER

30 PER MONTH

OST PCH DRAIN FOR BARRIER FL

30 PER MONTH

OST PCH DRAIN 2 PIECE SYSTEM

30 PER MONTH

OST PCH DRAIN/BARR LK FLNG/G

30 PER MONTH

URINE OST POUCH W FAUCET/TAP

30 PER MONTH

URINE OST POUCH W BLTINCONV

30 PER MONTH

OST URINE PCH W B/BLTIN CONV

30 PER MONTH

OST PCH URINE W BARRIER/TAPV

30 PER MONTH

OS PCH URINE W BAR/FANGE/TAP

30 PER MONTH

URINE OST PCH BAR W LOCK FLN

30 PER MONTH

OST PCH URINE W LOCK FLNG/FT

30 PER MONTH

NON-WATERPROOF TAPE

240 PER MONTH

240 PER MONTH

ADHESIVE REMOVER OR SOLVENT802

1 PER MONTH

REUSABLE ENEMA BAG

30 PER MONTH

TRACHEOSTOMA FILTER ANY TYPE

6 PER MONTH






A4495 A $8.50 000-099 Y N N

A4500 A $5.63 000-099 Y N N

A4510 A $9.44 000-099 Y N N

A4520 A $14.39 1 PER MONTH 003-099 Y N N

A4556 A $8.40 000-099 Y N Y 000-099A4557 A $12.40 000-099 Y N Y 000-099A4558 A $3.93 000-099 Y N Y 000-099

A4595 A $19.92 000-999 N N N

A4606 A $118.89 1 PER YEAR 000-020 Y N N

A4614 A $21.92 000-099 Y N N A4615 A $0.01 000-099 Y N Y 000-099A4619 A $0.01 000-099 Y N Y 000-099A4620 A $0.01 000-099 Y N Y 000-099

A4623 A $4.52 000-099 Y N N

A4624 A $1.55 000-099 Y N N

A4625 A $5.31 000-099 Y N N

SURG. STOCK, ABOVE KNEE LEN,EA

4 PER PER SURGICAL EVENT

SURG. STOCK,THIGH LENGTH,EACH

4 PER SURGICAL EVENT

SURG. STOCK,BELOW KNEE LEN,EA


SURG.STOCK,FULL LENGTH,EACH


INCONTINENCE GARMENT ANYTYPE

ELECTRODES

LEAD WIRES

CONDUCTIVE PASTE

OR GEL TENS SUPPL 2 LEAD

PER MONTHONCE PER

MONTH

OXYGEN PROBE USED W OXIMETER

PEAK FLOW METER

1 PER YEAR

CANNULA NASAL

FACE TENT

VARIABLE

CONCENTRATION MASK

TRACH-,INNER CANNULA (REPL ONLYAC.)

4 PER MONTH

TRACHEAL SUCTION CATH. EA.

150 PER MONTH

TRACH.CARE OR

CLEAN.START. KIT 30 PER

MONTH






A4627 A $15.32 000-099 Y N N

A4628 A $2.59 000-099 Y N N

A4629 A $3.20 000-099 Y N N

A4635 A $3.00 000-099 Y N N

A4635 RR A $0.30 000-099 Y N N

A4636 A $2.48 000-099 Y N N

A4636 RR A $0.25 000-099 Y N N

A4637 A $1.62 000-099 Y N N

A4637 RR A $0.16 000-099 Y N N

TRACHEOSTOMY CLEANING BRUSH EA

30 PER MONTH

SPACER, BAG/RES, W/WO MASK

4 PER YEAR

OROPHARYNGEAL

SUCTION CATHETER 150 PER

MONTH

TRACHEOSTOMY CARE KIT/EST TRAC

30 PER MONTH

UNDERARM

PAD,CRUTCH,REPL ONLYACEMEN

2 PER YEAR

UNDERARM PAD,CRUTCH,REPL ONLYACEMEN

10 MONTHS = PURCHASE

REPL ONLYACEMENT HANDGRIP,CANE,CRUT

2 PER YEAR

REPL ONLYACEMENT HANDGRIP,CANE,CRUT


REPL ONLYACE,TIP,CANE,CRUTCH,WALKER

6 PER YEAR

REPL ONLYACE,TIP,CANE,CRUTCH,WALKER







A4640 RR A $4.20 000-099 Y N Y 000-099

A4649 A $0.01 000-099 N N Y 000-099

A4657 A $1.43 000-099 Y N Y 000-099

A4660 A $20.47 000-099 Y N Y 000-099

A4663 A $21.47 000-099 Y N Y 000-099

A4670 A $65.01 011-099 Y N Y 011-099

A4927 A $6.91 000-099 Y N N

A4930 A $0.62 000-099 Y N N

A5051 A $1.71 000-099 Y N N

A5052 A $1.16 000-099 Y N N

REPL ONLYACEMENT APP PAD OWNED/PT

1 PER 2 YEARS

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.0-806.39

REPL ONLYACEMENT APP PAD OWNED/PT


237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.0-806.39

SURGICAL SUPPLIES MISC

SYRINGE W/WO

NEEDLE 10 PER MONTH

SPHYG/BP APP W CUFF AND STET

BLOOD PRESSURE CUFF, ONLY

AUTOMATIC BP MONITOR, DIAL

NON-STERILE GLOVES, PER 100

4 UNITS PER MONTH

STERILE, GLOVES PER PAIR

200 PER MONTH

POUCH CLOSED; W/BARRIER ATT.

30 PER MONTH

POUCH CLOSED;

W/O BARRIER 30 PER

MONTH






A5054 A $1.31 000-099 Y N N

A5055 A $1.01 000-099 Y N N

A5061 A $1.92 000-099 Y N N

A5062 A $2.02 000-099 Y N N

A5063 A $1.92 000-099 Y N N

A5071 A $4.81 000-099 Y N N

A5072 A $3.13 000-099 Y N N

A5073 A $2.52 000-099 Y N N

A5081 A $1.95 000-099 Y N N

A5082 A $10.02 000-099 Y N N

A5083 A $0.01 000-099 Y N Y 000-099

A5093 A $1.34 000-099 Y N N

A5112 A $23.93 000-099 Y N N

A5120 A $0.20 000-099 Y N N

A5121 A $5.16 000-099 Y N N

A5122 A $9.40 000-099 Y N N

POUCH, CLOSED; FOR FACEPLATE

30 PER MONTH

POUCH,

CLOSED,FOR BARRIER W/FL

30 PER MONTH

STOMA CAP

30 PER MONTH

POUCH,DRAIN.;W/

BARR.(1 PIECE) 30 PER

MONTH POUCH, DRAINABLE

W/O BARRIER 30 PER

MONTH

POUCH,DRAIN.;ON BARR.WF/ANGE

30 PER MONTH

POUCH,DRAIN;W/

ATTACHED BARRIER 30 PER

MONTH POUCH,URI;-W/O

BARRIER 30 PER

MONTH POUCH,URI;W/

BARRIER W FL 2 PC 30 PER

MONTH CONT.DEV.;PLUG

CONT.STOMA 5 PER

MONTH CONT. DEV.CATH.

CONT.STOMA 5 PER

MONTH CONT. DEV. STOMA

ABSORB. COVER30 PER MONTH

OST. ACCESS; CONVEX INSERT

5 PER MONTH

URINARY LEG BAG;

LATEX 2 PER

MONTH SKIN BARRIER, WIPE

OR SWAB100 PER MONTH

SKIN BAR SOLID 6X6 EQ EA.

30 PER MONTH

SKIN BAR; SOLID 8X8

EQ.EACH 30 PER

MONTH






A5200 A $8.55 000-099 Y N N

A5500 LT-RT A $54.71 1 PER YEAR 000-099 N N N

A5501 LT-RT A $164.08 000-099 N N Y 000-099

A5503 LT-RT A $24.33 000-099 N N N

A5504 LT-RT A $24.33 000-099 N N N

A5505 LT-RT A $24.33 000-099 N N N

A5506 LT-RT A $24.33 000-099 N N N

A5507 LT-RT A $19.01 000-099 N N Y 000-099

A5510 LT-RT A $30.41 000-099 N N N

A5512 LT-RT A $22.29 000-099 N N N

A5513 LT-RT A $30.41 000-099 N N N

A6010 A1-A9 A $22.29 000-099 N N N

A6011 A1-A9 A $1.68 000-099 N N N

A6021 A1-A9 A $15.14 000-099 Y N N

A6022 A1-A9 A $15.14 000-099 Y N N

ADHESIVE; DISC OR FOAM PAD

30 PER MONTH

PERCUTANEOUS

CATH/TUBE ANCHOR 4 PER

MONTH

DIAB SHOE FOR DENSITY INSERT

DIABETIC SHOE, CUSTOM,PER SHOE

DIABETIC SHOE,

W/ROLLER/ROCKR1 PER 6

MONTHS

DIABETIC SHOE WITH WEDGE

1 PER 6 MONTHS

DIAB SHOE W/METATARSAL BAR

1 PER 6 MONTHS

DIABETIC SHOE W/OFF SET HEEL

1 PER 6 MONTHS

MODIFICATION DIABETIC SHOE

COMPRESSION FORM SHOE INSERT

UP TO 3 PER YEAR

MULTI DEN INSERT DIRECT FORM

UP TO 3 PER YEAR

MULTI DEN INSERT CUSTOM MOLD

UP TO 3 PER YEAR

COLLAGEN BASED WOUND FILLER

30 PER MONTH

COLLAGEN

GEL/PASTE WOUND FIL

30 PER MONTH

COLLAGEN DRESSING <+ 16 SQ IN

30 PER MONTH

COLLAGEN DRSG >6<=48 SQ IN

30 PER MONTH





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISA6023 A1-A9 A $137.02 000-099 Y N N

A6024 A1-A9 A $4.45 000-099 Y N N

A6025 A1-A9 A $37.86 000-099 Y N N

A6196 A1-A9 A $6.72 000-099 N N N

A6197 A1-A9 A $15.03 000-099 N N N

A6198 A1-A9 A $23.34 000-099 N N N

A6199 A1-A9 A $4.83 000-099 Y N N

A6200 A1-A9 A $6.84 000-099 Y N Y 000-099

A6201 A1-A9 A $14.98 000-099 Y N Y 000-099

A6202 A1-A9 A $25.11 000-099 Y N Y 000-099

A6203 A1-A9 A $3.06 000-099 N N N

A6204 A1-A9 A $5.69 000-099 N N N

A6205 A1-A9 A $8.33 000-099 N N N

A6206 A1-A9 A $4.79 000-099 N N N

A6207 A1-A9 A $6.71 000-099 N N N

A6208 A1-A9 A $8.63 000-099 N N N

COLLAGEN DRESSING > 48 SQ IN

30 PER MONTH

COLLAGEN DSG WOUND FILLER

30 PER MONTH

SILICONE GEL

SHEET, EACH 30 PER MONTH

ALGIN. DRESSING,

WOUND CVR-16< 30 PER

MONTH ALGIN. DRSSG.

WOUND CVR.>16<48 30 PER

MONTH

ALGIN DRESSING, WOUND CVR>48

30 PER MONTH

ALGIN,

DRSSG.,WOUND FILLER 6IN

30 PER MONTH

COMPOSITE DRESSING 16 SQ

COMPOSITE

DRESSING 48 SQ COMPOSITE

DRESSING 48 SQ COMP.DRSSG.<16

W.ADH. BORDER 30 PER

MONTH COMP.

DRSSG.>16<48, W/ADH.BORD

30 PER MONTH

COMP. DRSSG.>48, W/ADH.BORDER

30 PER MONTH

CONTACT LAYER, 16

SG.IN.OR < 30 PER

MONTH CONTACT LAYER >16

SG IN <48 30 PER

MONTH CONTACT LAYER,

>48 SQ. IN. 30 PER

MONTH





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISA6209 A1-A9 A $6.84 000-099 N N N

A6210 A1-A9 A $18.21 000-099 N N N

A6211 A1-A9 A $26.84 000-099 N N N

A6212 A1-A9 A $8.87 000-099 N N N

A6213 A1-A9 A $9.15 000-099 N N N

A6214 A1-A9 A $9.41 000-099 N N N

A6215 A1-A9 A $0.23 000-099 N N N

A6216 A1-A9 A $0.05 000-099 Y N N

A6217 A1-A9 A $0.10 000-099 Y N N

A6218 A1-A9 A $0.23 000-099 Y N N

A6219 A1-A9 A $0.87 000-099 N N N

A6220 A1-A9 A $2.36 000-099 N N N

A6221 A1-A9 A $3.84 000-099 N N N

A6222 A1-A9 A $1.95 000-099 Y N N

A6223 A1-A9 A $2.20 000-099 Y N N

A6224 A1-A9 A $3.30 000-099 Y N N

A6231 A1-A9 A $4.31 000-099 Y N N

A6232 A1-A9 A $5.61 000-099 Y N N

FOAM DRG, WD CVR. W/O ADH. 16<

30 PER MONTH

FOAM DRG.,WD CVR

W/O ADH>16<48 30 PER

MONTH FOAM DRG, WD CVR.

W/O ADH>48 30 PER

MONTH FOAM DRG, WD CVR

W/ADH <16 30 PER

MONTH FOAM DRG, WD CVR,

W/ADH >16<48 30 PER

MONTH FOAM DRG, WD CVR,

W/ADH >48 30 PER

MONTH FOAM DRG, WOUND

FILLER,PER GRM 240 PER

MONTH GAUZE,NON-IMP/

NON-STR/W/ADH<16 200 PER

MONTH

GAUZE,N-IMP/N-STR/W/ADH.>16<48

200 PER MONTH

GAUZE,N-IMP/N-

STR/W/ADH.>48 200 PER

MONTH GAUZE,NON-IMP.,W/

ADH. <16 200 PER

MONTH GAUZE,

NON-IMP,W/ADH. >16<48

200 PER MONTH

GAUZE, NON-IMP,

W/ADH. >48 200 PER

MONTH GAUZE,IMPREG,OTH

ER THAN 16 OR 200 PER


ER>16<48 200 PER


ER THAN > 48 200 PER

MONTH HYDROGEL DSG

<+16 SQ IN 30 PER

MONTH HYDROGEL

DSG>16<=48 SQ IN 30 PER

MONTH






A6234 A1-A9 A $5.98 000-099 N N N

A6235 A1-A9 A $15.38 000-099 N N N

A6236 A1-A9 A $24.91 000-099 N N N

A6237 A1-A9 A $7.23 000-099 N N N

A6238 A1-A9 A $20.84 000-099 N N N

A6239 A1-A9 A $34.44 000-099 N N N

A6240 A1-A9 A $8.46 000-099 N N N

A6241 A1-A9 A $1.78 000-099 N N N

A6242 A1-A9 A $5.55 000-099 N N N

A6243 A1-A9 A $11.26 000-099 N N N

A6244 A1-A9 A $35.90 000-099 N N N

A6245 A1-A9 A $6.64 000-099 N N N

A6246 A1-A9 A $9.07 000-099 N N N

A6247 A1-A9 A $21.74 000-099 N N N

A6248 A1-A9 A $11.22 000-099 N N N

HYDROGEL DRESSING >48 SQ IN

30 PER MONTH

HYDRO. DRG, WD CTR, W/O ADH<16

30 PER MONTH

HYDRO.DRG,WD

CTR,W/O ADH>16<48 30 PER

MONTH

HYDRO DRG,WD CTR,W/O ADH >48

30 PER MONTH

HYDRO DRG,WD

CTR,W/ADH <16 30 PER

MONTH HYDRO DRG, WD

CTR,W/ADH.>16<48 30 PER

MONTH HYDRO DRG,WD

CTR,W/ADH >48 30 PER

MONTH HYDRO.

DRG/WOUND FILLER,PASTE

10 PER MONTH

HYDRO DRG, WND FILLER,DRY FORM

240 PER MONTH

HYDRO DRG,WD

CTR, W/O ADH<16 30 PER

MONTH HYDRO DRG,WD

CTR,W.O ADH>16<48 30 PER

MONTH

HYDRO DRG,WD CTR,W/O ADH >48

30 PER MONTH

HYDRO DRG, WD

CTR, W/ADH <16 30 PER

MONTH HYDRO DRG,WD

CTR,W/ADH >16<48 30 PER

MONTH HYDRO DRG,WD

CTR,W/ADH >48 30 PER

MONTH HYDRO.

DRG/WOUND FILLER, GEL

10 PER MONTH






A6251 A1-A9 A $1.82 000-099 N N N

A6252 A1-A9 A $2.97 000-099 N N N

A6253 A1-A9 A $5.80 000-099 N N N

A6254 A1-A9 A $1.11 000-099 N N N

A6255 A1-A9 A $2.77 000-099 N N N

A6256 A1-A9 A $4.43 000-099 N N N

A6257 A1-A9 A $1.40 000-099 N N N

A6258 A1-A9 A $3.93 000-099 N N N

A6259 A1-A9 A $10.00 000-099 N N N

A6260 A1-A9 A $7.67 000-099 Y N N

A6261 A1-A9 A $3.87 000-099 Y N N

A6262 A1-A9 A $0.23 000-099 Y N N

A6266 A1-A9 A $1.32 000-099 Y N N

A6402 A1-A9 A $0.12 000-099 Y N N

SKIN SEALANTS, PROTECTANTS

2 PER MONTH

SPLTY ABSP

DRSG,W/O ADH.<16 30 PER

MONTH SPLTY ABSP

DRSSG,W/O ADH>16<48

30 PER MONTH

SPLTY ABSP DRSSG,W/O ADH >48

30 PER MONTH

SPLTY ABSP DRSSG, W ADH <16

30 PER MONTH

SPLTY ABSP DRSSG,

W ADH >16<48 30 PER

MONTH

SPLTY ABSP DRSSG, W ADH >48

30 PER MONTH

TRANSPARENT FILM,

<16 30 PER

MONTH TRANSPARENT FILM,

>16 <48 30 PER

MONTH TRANSPARENT FILM,

>48 30 PER

MONTH WOUND

CLEANSERS,ANY TYP,ANY SZ

1 PER MONTH

WOUND FILLER, NOC, GEL/PASTE

10 PER MONTH

WOUND FILLER,

NOC, DRY FORM 240 PER

MONTH GAUZE,IMPREG,ANY

WIDTH,PER YD. 30 PER

MONTH GAUZE,NON-

IMPRG,PAD<16,W/O ADH

200 PER MONTH






A6404 A1-A9 A $0.67 000-099 Y N N

A6407 A1-A9 A $1.30 000-099 Y N N

A6410 STERILE EYE PAD A $0.36 000-09 Y N N

A6411 A $0.29 000-099 Y N N

A6412 A $0.01 000-099 Y N Y 000-099

A6441 A1-A9 A $0.48 000-099 Y N N

A6442 A1-A9 A $0.15 000-099 Y N N

A6443 A1-A9 A $0.27 000-099 Y N N

A6444 A1-A9 A $0.52 000-099 Y N N

A6445 A1-A9 A $0.30 000-099 Y N N

A6446 A1-A9 A $0.37 000-099 Y N N

A6447 A1-A9 A $0.61 000-099 Y N N

A6448 A1-A9 A $0.23 000-099 Y N N

A6449 A1-A9 A $0.28 000-099 Y N N

A6450 A1-A9 A $0.48 000-099 Y N N

A6451 A1-A9 A $0.60 000-099 Y N N

A6452 A1-A9 A $4.25 000-099 Y N Y 000-099

GAUZE,NON-IMPRG,>16<48,W/O ADH

200 PER MONTH

GAUZE,NON-IMPG, PAD>48,W/O ADH

200 PER MONTH

PACKING STRIPS,

NON-IMPREG30 PER MONTH

60 PER MONTH

NON-STERILE EYE PAD

60 PER MONTH

OCCLUSIVE EYE PATCH

60 PER MONTH

PAD BAD W>3" <5"/YD

12 PER MONTH

CONFORM BAND N/S W<3"/YD

72 PER MONTH

CONFORM BAND N/S W>3"<5"/YD

72 PER MONTH

CONFORM BAND N/S W>5"/YD

72 PER MONTH

CONFORM BAND S W <3"/YD

72 PER MONTH

CONFORM BAND S W>=3" <5"/YD

72 PER MONTH

CONFORM BAND S W >=5"/YD

72 PER MONTH

LT COMPRES BAND <3"/YD

20 PER MONTH

LT COMPRES BAND >=3" <5"/YD

20 PER MONTH

LT COMPRES BAND >=5"/YD

20 PER MONTH

MOD COMPRES BAND W>=3" <5"/YD

20 PER MONTH

HIGH COMPRES BAND W>=3" <5"/YD





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISA6453 A1-A9 A $0.44 000-099 Y N Y 000-099

A6454 A1-A9 A $0.56 000-099 Y N Y 000-099

A6455 A1-A9 A $1.00 000-099 Y N Y 000-099

A6456 A1-A9 A $0.60 000-099 Y N N

A6457 TUBULAR DRESSING A $0.80 000-099 Y N N

A6501 A $0.01 000-099 N N Y 000-099

A6502 A $0.01 000-099 N N Y 000-099

A6503 A $0.01 000-099 N N Y 000-099

A6504 A $0.01 000-099 N N Y 000-099

A6505 A $0.01 000-099 N N Y 000-099

A6506 A $0.01 000-099 N N Y 000-099

A6507 A $0.01 000-099 N N Y 000-099

A6508 A $0.01 000-099 N N Y 000-099

A6509 A $0.01 000-099 N N Y 000-099

SELF ADHER BAND W <3"/YD

SELF ADHER BAND W>=3" <5"/YD

SELF ADHER BAND >=5"/YD

ZINC PASTE BAND W>=3" <5"/YD

40 PER MONTH

30 PER MONTH

COMPRES BURNGRMENT BODYSUIT

COMPRES BURNGRMENT CHINSUIT

COMPRES BURNGRMENT FACEHOOD

CMPRES BURNGRMENT GLOVE-WRIST

CMPRES BURNGRMENT GLOVE-ELBOW

CMPRES BURNGRMENT GLOVE-AXILLA

CMPRES BURNGRMENT FOOT-KNEE

CMPRES BURNGRMENT FOOT-THIGH

COMPRES BURNGRMENT GARMENT JACKET





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISA6510 A $0.01 000-099 N N Y 000-099

A6511 A $0.01 000-099 N N Y 000-099

A6512 A $0.01 000-099 N N Y 000-099

A6513 A $0.01 000-099 N N Y 000-099

A6530 LT-RT A $19.05 000-099 N N N

A6531 LT-RT A $21.17 000-099 N N N

A6532 LT-RT A $27.00 000-099 N N N

A6533 LT-RT A $25.02 000-099 N N N

A6534 LT-RT A $28.45 000-099 N N N

A6535 LT-RT A $30.67 000-099 N N N

A6536 LT-RT A $45.46 000-099 N N N

A6537 LT-RT A $45.46 000-099 N N N

A6538 LT-RT A $57.43 000-099 N N N

A6539 A $74.30 000-099 N N N

A6540 A $74.30 000-099 N N N

A6541 A $82.69 000-099 N N N

COMPRES BURNGRMENT LEOTARD

COMPRES BURNGRMENT PANTY

COMPRES BURNGRMENT, NOC

COMPRESSION BURN MASK FACE/NECK

COMPRESSION STOCKING BK 18-30

2 PER 3 MONTHS


2 PER 3 MONTHS


2 PER 3 MONTHS

GC STOCKING THIGH LNGTH 18-30

2 PER 3 MONTHS


2 PER 3 MONTHS


2 PER 3 MONTHS

GC STOCKING FULL LNGTH 18-30Gc

2 PER 3 MONTHS

GC STOCKING FULL LNGHT 30-40

2 PER 3 MONTHS

GC STOCKING FULL LNGTH 40-50

2 PER 3 MONTHS

GC STOCKING WAIST LNGTH 18-30

2 PER 3 MONTHS


2 PER 3 MONTHS


2 PER 3 MONTHS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISA6542 A $0.01 000-099 N N Y 000-099

A6543 LT-RT A $58.88 000-099 N N Y 000-099

A6544 A $13.75 000-099 N N Y 000-099

A6545 LT-RT A $0.01 000-099 N N Y 000-099

A6549 A $0.01 000-099 N N Y 000-099

A6550 A $18.96 000-099 N N Y 000-099

A7000 A $8.10 000-099 N N N

A7002 A $2.65 000-099 N N N

A7003 A $2.16 000-099 N N N

A7004 A $1.65 000-099 N N N

A7005 A $21.31 000-099 N N N

A7006 A $8.72 000-099 N N Y 000-099

A7007 A $3.19 000-099 N N N

A7009 A $38.43 000-099 N N N

A7010 A $21.56 000-099 N N N

GC STOCKING CUSTOM MADE

GC STOCKING LYMPHEDEMA

2 PER 3 MONTHS

GC STOCKING GARTER BELT

2 PER 3 MONTHS

GC WRAP NON-ELAS. BK, 30-50 MM. HG. EACH

2 PER 3 MONTHS

G COMPRESSION STOCKING

NEG PRES WOUND THER DRSG SET

DISPOSABLE CANISTER FOR PUMP

12 PER YEAR

TUBING USED W SUCTION PUMP

4 PER MONTH

NEBULIZER

ADMINISTRATION SET

12 PER YEAR

DISPOSABLE NEBULIZER SML VOL

36 PER YEAR

NONDISPOSABLE NEBULIZER SET

2 PER YEAR

FILTERED

NEBULIZER ADMIN SET

LG VOL NEBULIZER DISPOSABLE

4 PER MONTH

NEBULIZER

RESERVOIR BOTTLE

1 PER YEAR

DISPOSABLE CORRUGATED TUBING

2 PER YEAR






A7015 A $1.54 000-099 N N N

A7016 A $6.62 000-099 N N N

A7018 A $0.35 000-099 Y N N

A7025 A $390.76 000-099 N N Y 000-099

A7026 A $21.20 000-099 N N Y 000-099

A7027 A $143.08 1 PER YEAR 000-099 N N N

A7028 A $38.04 1 PER YEAR 000-099 N N N

A7029 A $15.54 1 PER YEAR 000-099 N N N

A7030 A $139.08 1 PER YEAR 000-099 N N N

A7031 A $64.30 1 PER YEAR 000-099 N N N

A7032 A $29.88 1 PER YEAR 000-099 N N N

A7033 A $23.96 1 PER YEAR 000-099 N N N

A7034 A $81.31 1 PER YEAR 000-099 N N N

NEBULIZER WATER COLLECTION DEV

24 PER YEAR

AEROSOL MASK

USED W NEBULIZE 24 PER YEAR

NEBULIZER DOME &

MOUTHPIECE 1 PER YEAR

WATER DISTILLED

W/NEBULIZER 120 PER YEAR

REPL ONLYACE

CHEST COMPRES VEST

REPL ONLYACE CHEST COMPRSS SVS HOSE

COMB. ORAL/NASAL MASK

ORAL CUSHION COMBO MASK, REPL. ONLY

NASAL PILLOW COMB. MASK REPL. ONLY

CPAP FULL FACE MASK

REPL ONLYACEMENT FACEMASK INTERFA

REPL ONLYACEMENT NASAL CUSHION

REPL ONLYACEMENT NASAL PILLOWS

NASAL APPLICATION DEVICE





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISA7035 A $36.63 1 PER YEAR 000-099 N N N

A7036 A $13.76 1 PER YEAR 000-099 N N N

A7037 A $37.57 1 PER YEAR 000-099 N N N

A7038 A $4.19 18 PER YEAR 000-099 N N N

A7044 A $111.43 1 PER YEAR 000-099 N N N

A7045 A $17.94 1 PER YEAR 000-099 N N N

A7046 A $10.89 2 PER YEAR 000-099 N N N

A7501 A $75.62 000-099 N N Y 000-099

A7502 A $35.93 000-099 N N Y 000-099

A7503 A $8.16 000-099 N N Y 000-099

A7504 A $0.48 000-099 N N Y 000-099

A7505 A $3.37 000-099 N N Y 000-099

A7506 A $0.24 000-099 N N Y 000-099

A7507 A $1.80 000-099 N N Y 000-099

A7508 A $2.06 000-099 N N Y 000-099

A7509 A $1.05 000-099 N N Y 000-099

POS AIRWAY PRESS HEADGEAR

POS AIRWAY PRESS CHINSTRAP

POS AIRWAY PRESSURE TUBING

POS AIRWAY PRESSURE FILTER

PAP ORAL INTERFACE

REPL ONLY EXHALATION PORT FOR PAP

REPL ONLY WATER CHAMBER, PAP DEV

TRACHEOSTOMA VALVE W/DIAPHRA

REPL ONLYACEMENT

DIAPHRAGM/FPLATE

HMES FILTER HOLDER OR CAP

TRACHEOSTOMA

HMES FILTER HMES OR TRACH

VALVE HOUSING HMES/TRACHVALVE

ADHESIVEDISK INTEGRATED FILTER

& HOLDER HOUSING AND

INTEGRATED ADHESIV

HEAT & MOISTURE EXCHANGE SYSTE





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISA7520 U4 A $62.85 2 PER MONTH 000-020 Y N N

A7520 A $43.76 2 PER MONTH 000-099 Y N N

A7521 A $43.36 2 PER MONTH 000-099 Y N N

A7522 A $0.01 000-099 Y N Y 000-099

A7523 A $6.22 4 PER MONTH 000-099 Y N N

A7524 A $55.73 000-099 Y N Y 000-099

A7525 A $1.28 000-099 Y N N

A7526 A $2.44 000-099 Y N N

A7527 A $3.30 000-099 Y N Y 000-099

A8000 A $90.07 000-099 N N Y 000-099

A8001 A $90.07 000-099 N N Y 000-099

A8002 A $383.73 1 PER YEAR 000-099 N Y Y 000-099

A8003 A $0.01 1 PER YEAR 000-099 N Y Y 000-099

A8004 A $14.40 000-099 N N Y 000-099

A9999 A $0.01 000-099 N N Y 000-099

B4034 A $2.75 000-099 Y N N

B4035 A $7.95 000-099 Y N N

TRACH/LARYN TUBE NON-CUFFED

TRACH/LARYN TUBE NON-CUFFED

TRACH/LARYN TUBE CUFFED

TRACH/LARYN TUBE STAINLESS

TRACHEOSTOMY SHOWER PROTECT

TRACHEOSTOMA STENT/STUD/BTTN

TRACHEOSTOMY MASK

30 PER MONTH

TRACHEOSTOMY TUBE COLLAR

30 PER MONTH

TRACH/LARYN TUBE PLUG/STOPSOFT PROTECT HELMET PREFABHARD PROTECT HELMET PREFABSOFT PROTECT HELMET CUSTOMHARD PROTECT HELMET CUSTOMREPL ONLY SOFT INTERFACE, HELMETDME SUPPLY OR ACCESSORY, NOS

ENTER FEED SUPKIT SYR BY DAY

30 PER MONTH

ENT FEED SUPP KIT-PUMP FED

30 PER MONTH





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISB4036 A $6.81 000-099 Y N N

B4081 A $13.69 000-099 Y N N

B4082 A $11.62 000-099 Y N N

B4083 A $1.11 000-099 Y N N

B4087 U3 A $11.40 8 PER MONTH 000-099 Y N N

B4087 A $22.81 4 PER MONTH 000-099 Y N N

B4088 A $127.48 000-099 Y N N

B4102 BO A $0.01 000-099 Y N Y 000-099

B4102 A $0.01 000-099 Y N Y 000-099

B4149 A $0.01 000-099 Y N Y 000-099

B4150 A $0.58 000-099 Y N N

B4150 BO A $0.58 000-099 Y N Y 000-099

B4152 A $0.48 000-099 Y N N

B4152 BO A $0.48 000-099 Y N Y 000-099

B4153 A $0.01 000-099 Y N Y 000-099

B4153 BO A $0.01 000-099 Y N Y 000-099

ENTER FEED SUP KIT GRAV BY

30 PER MONTH

NASOGAS TUBING

W/STYLET 5 PER

MONTH NASOGAS TUBING

W/O STYLET 5 PER

MONTH STOMACH TUBE-

LEVINE 30 PER

MONTH GASTRO/JEJUNO

TUBE, (LOW PROFILE EXT.)

GASTRO/JEJUNO TUBE, STD.

GATRO/JEJUNO TUBE, LOW-PROFILE

3 PER 6 MONTHS

EF ADULT FLUIDS AND ELECTRO

EF ADULT FLUIDS AND ELECTRO

EF BLENDERIZED FOODS

EF COMPLET W/INTACT NUTRIENT

900 PER MONTH

EF COMPLET W/INTACT NUTRIENT

EF CALORIE DENSE>=1.5KCAL

900 PER MONTH

EF CALORIE

DENSE>=1.5KCAL

EF HYDROLYZED/ AMINO ACIDS

EF HYDROLYZED/

AMINO ACIDS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISB4154 A $0.01 000-099 Y N Y 000-099

B4154 BO A $0.01 000-099 Y N Y 000-099

B4155 A $0.01 000-099 Y N Y 000-099

B4155 BO A $0.01 000-099 Y N Y 000-099

B4157 BO A $0.01 000-099 Y N Y 000-099

B4157 A $0.01 000-099 Y N Y 000-099

B4158 BO A $0.58 000-020 Y N Y 000-020

B4158 A $0.58 000-020 Y N N

B4159 BO A $0.01 000-020 Y N Y 000-020

B4159 A $0.01 000-020 Y N Y 000-020

B4160 BO A $0.58 000-020 Y N Y 000-020

B4160 A $0.58 000-020 Y N N

B4161 BO A $0.01 000-020 Y N Y 000-020

B4161 A $0.01 000-020 Y N Y 000-020

B4162 BO A $0.01 000-020 Y N Y 000-020

EF SPECMETABOLIC NONINHERIT

EF SPECMETABOLIC NONINHERIT

EF INCOMPLETE/ MODULAR

EF INCOMPLETE/

MODULAR

EF SPECIAL METABOLIC INHERIT

EF SPECIAL METABOLIC INHERIT

EF PED COMPLETE INTACT NUT

EF PED COMPLETE INTACT NUT

900 PER MONTH

EF PED COMPLETE SOY BASED

EF PED COMPLETE SOY BASED

EF PED CALORIC DENSE>/=0.7kc

EF PED CALORIC DENSE>/=0.7kc

900 PER MONTH

EF PED HYDROLYZED/ AMINO ACID

EF PED HYDROLYZED/ AMINO ACID

EF PED SPEC METABOLIC INHERIT





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISB4162 A $0.01 000-020 Y N Y 000-020

B4185 A $6.53 000-099 N N Y 000-099

B4189 A $145.30 000-099 N N Y 000-099

B4193 A $145.30 000-099 N N Y 000-099

B4197 A $145.30 000-099 N N Y 000-099

B4199 A $145.30 000-099 N N Y 000-099

B4220 A $6.55 000-099 N N N

B4224 A $20.45 000-099 N N N

B9000 A $687.76 000-099 Y N Y 000-099

B9000 RA A $687.76 000-099 Y N Y 000-099

B9000 RB A $0.01 000-099 Y N Y 000-099

EF PED SPEC METABOLIC INHERIT

PARENTERAL SOL 10 GM LIPIDS

UP TO 300 UNITS PER

MONTH

555.0 - 555.1, 560.9 -560.9, 569.81-569.81, 577.0 -577.2 579.3 -579.3

PARENTERAL SOL AMINO ACID

30 PER MONTH

555.0 - 555.1, 560.9 -560.9, 569.81-569.81, 577.0 -577.2 579.3 -579.3

PARENTERAL SOL 52-73 GM PROT

30 PER MONTH

555.0 - 555.1, 560.9 -560.9, 569.81-569.81, 577.0 -577.2 579.3 -579.3

PARENTERAL SOL 74-100 GM PRO

30 PER MONTH

555.0 - 555.1, 560.9 -560.9, 569.81-569.81, 577.0 -577.2 579.3 -579.3

PARENTERAL SOL>100GM PROTE

30 PER MONTH

555.0 - 555.1, 560.9 -560.9, 569.81-569.81, 577.0 -577.2 579.3 -579.3

PARENTERAL SUPPLY KIT PREMIX

30 PER MONTH

PARENTERAL

ADMINISTRATION KIT 30 PER

MONTH

ENTERAL NUTRITION PUMP, EA







CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISB9000 RR A $68.77 000-099 Y N N

B9002 A $687.76 000-099 Y N Y

B9002 RA A $687.76 000-099 Y N Y 000-099

B9002 RB A $0.01 000-099 Y N Y 000-099

B9002 RR A $68.77 000-099 Y N N

B9004 RR A $10.89 000-099 N N N

B9006 RR A $10.89 000-099 N N N

B9998 A $0.01 000-099 Y N Y 000-099

B9999 A $0.01 000-099 N N Y 000-099

E0100 A $16.50 000-099 N N N

E0100 RR A $1.65 000-099 Y N N

E0105 A $37.33 000-099 Y N N

E0105 RA A $37.33 000-099 Y N N

E0105 RB A $0.01 000-099 Y N Y 000-099

E0105 RR A $3.93 000-099 Y N N

E0110 A $60.78 000-099 Y N N



ENTERAL NUT. PUMP W/ALARM, EA.

ENTERAL NUT. PUMP

W/ALARM EA. ENTERAL NUT. PUMP

W/ALARM EA. ENTERAL NUT.PUMP

W/ALARM, EA. 10 MONTHS = PURCHASE

PARENTERAL INFUS PUMP PORTAB

30 PER MONTH

PARENTERAL INFUS PUMP STATIO

30 PER MONTH

NOC FOR ENTERAL SUPPLIES

NOC FOR

PARENTERAL SUPPLIES

CANE,ADJ. OR FIXED

2 PER 2 YEARS

CANE,ADJUSTBLE

OR FIXED 10 MONTHS = PURCHASE

CANE,QUAD OR

THREE PRONGED 2 PER 2

YEARS CANE,QUAD OR

THREE PRONGED 2 PER 2

YEARS CANE,QUAD OR

THREE PRONGED CANE,QUAD OR

THREE PRONGED 10 MONTHS = PURCHASE

CRUTCHES,FOREAR

M,PAIR 1 PER 2

YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0110 RA A $60.78 000-099 Y N N

E0110 RB A $0.01 000-099 Y N Y 000-099

E0110 RR A $6.09 000-099 Y N N

E0111 A $36.82 000-099 Y N N

E0111 RA A $36.82 000-099 Y N N

E0111 RB A $0.01 000-099 Y N Y 000-099

E0111 RR A $3.69 000-099 Y N N

E0112 A $21.74 000-099 Y N N

E0112 RR A $2.18 000-099 Y N N

E0113 A $14.61 000-099 Y N N

E0113 RR A $1.47 000-099 Y N N

E0114 A $33.40 000-099 Y N N

E0114 RR A $3.34 000-099 Y N N

E0116 A $19.18 000-099 Y N N

E0116 RR A $3.17 000-099 Y N N

E0130 A $55.02 000-099 Y N N

E0130 RA A $55.02 000-099 Y N N

E0130 RB A $0.01 000-099 Y N Y 000-099

CRUTCHES,FOREARM,PAIR

1 PER 2 YEARS

CRUTCHES,FOREAR

M,PAIR CRUTCHES,

FOREARM PAIR 10 MONTHS = PURCHASE

CRUTCH,FOREARM,E

ACH 1 PER 2

YEARS CRUTCH,FOREARM,E

ACH 1 PER 2

YEARS CRUTCH,FOREARM,E

ACH CRUTCH, FOREARM

EACH 10 MONTHS = PURCHASE

CRUTCHES,UNDERA

RM,PAIR,WOOD 1 PER 2

YEARS CRUTCHES,UNDERA

RM,WOOD 10 MONTHS = PURCHASE

CRUTCH,UNDERARM

,EACH,WOOD 1 PER 2

YEARS CRUTCH,UNDERARM

,WOOD 10 MONTHS = PURCHASE

CRUTCHES,UNDERA

RM,PAIR,ALUM 1 PER 2

YEARS CRUTCHES,UNDERA

RM,ALUM. 10 MONTHS = PURCHASE

CRUTCH,UNDERARM

,EACH,ALUM 1 PER 2

YEARS CRUTCH,UNDERARM

,ALUM. 10 MONTHS = PURCHASE

WALKER,RIGID,ADJ.,

FIXED 1 PER 2

YEARS WALKER,RIGID,ADJ.

OR FIXED 1 PER 2

YEARS WALKER,RIGID,ADJ.

OR FIXED





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0130 RR A $5.50 000-099 Y N N

E0130 U4 A $0.01 000-020 Y N Y 000-099

E0135 A $67.80 000-099 Y N N

E0135 RA A $67.80 000-099 Y N N

E0135 RB A $0.01 000-099 Y N Y 000-099

E0135 RR A $6.79 000-099 Y N N

E0135 U4 A $0.01 000-020 Y N Y 000-099

E0140 A $294.91 000-020 Y N Y 000-020

E0140 RR A $29.49 000-020 Y N Y 000-020

E0140 U4 A $0.01 000-020 N N Y 000-099

E0141 A $101.19 000-099 Y N N

E0141 RA A $101.19 000-099 Y N N

E0141 RB A $0.01 000-099 Y N Y 000-099

E0141 RR A $10.13 000-099 Y N N

E0141 U4 A $0.01 000-020 Y N Y 000-099

E0143 A $92.35 000-099 Y N N

E0143 RA A $92.35 000-099 Y N N

E0143 RB A $0.01 000-099 Y N Y 000-099

WALKER,RIGID,ADJ.OR FIXED


WALKER,RIGID,ADJ.

OR FIXED 1 PER 2

YEARS WALKER,FOLDING,A

DJ.,FIXED 1 PER 2


DJ. OR FIXED 1 PER 2


DJ. OR FIXED WALKER,FOLDING,A

DJ.OR FIXED 10 MONTHS =

PURCHASE WALKER,FOLDING,A

DJ. OR FIXED 1 PER 2

YEARS WALKER W TRUNK

SUPPORT 1 PER 2

YEARS

WALKER W TRUNK SUPPORT

1 PER 2 YEARS

WALKER W TRUNK SUPPORT

1 PER 2 YEARS

WALKER,WHEELED,WITHOUTSEAT

1 PER 2 YEARS

WALKER,WHEELED,

W/O SEAT 1 PER 2

YEARS WALKER,WHEELED,

W/O SEAT WALKER,WHEELED,

W/O SEAT 10 MONTHS = PURCHASE

WALKER,WHEELED,

W/O SEAT 1 PER 2

YEARS FOLD.

WALKER,WHEEL W/O SEAT

1 PER 2 YEARS

FOLD. WALKER, WHEEL W/O SEAT

1 PER 2 YEARS

FOLD. WALKER,

WHEEL W/O SEAT






E0143 U4 A $0.01 000-020 Y N Y 000-099

E0144 A $293.48 000-099 Y N Y 000-099

E0144 RA A $293.48 000-099 Y N Y 000-099

E0144 RB A $0.01 000-099 Y N Y 000-099

E0144 U4 A $0.01 000-020 Y N Y 000-099

E0147 A $397.32 000-099 Y N Y 000-099

E0147 RA A $397.32 000-099 Y N Y 000-099

E0147 RB A $0.01 000-099 Y N Y 000-099

E0147 RR A $39.73 000-099 Y N Y 000-099

E0147 U4 A $0.01 000-020 Y N Y 000-099

E0148 A $72.84 000-099 Y N Y 000-099

E0148 RR A $8.79 000-099 Y N Y 000-099

E0148 U4 A $0.01 000-020 Y N Y 000-099

E0149 A $205.70 000-099 Y N Y 000-099

FOLD.WALKER, WHEEL W/O SEAT


FOLD. WALKER,

WHEEL W/O SEAT 1 PER 2 YEARS

FLDG FRMD

WALKER,WHEELS W/POST

1 PER 2 YEARS

FLDG FRMD WALKER,WHEELS W/POST

1 PER 2 YEARS



1 PER 2 YEARS

HEAVY DUTY WHEELED WALKER

1 PER 2 YEARS

HEAVY DUTY

WHEELED WALKER

1 PER 2 YEARS

HEAVY DUTY

WHEELED WALKER

HEAVY DUTY

WHEELED WALKER

HEAVY DUTY

WHEELED WALKER

1 PER 2 YEARS

WALKER HD W/O

WHEELS ANY TYPE 1 PER 2

YEARS WALKER HD W/O

WHEELS ANY TYPE 10 MONTHS = PURCHASE

WALKER HD W/O

WHEELS ANY TYPE 1 PER 2

YEARS WALKER HD

W/WHEELS ANY TYPE

1 PER 2 YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0149 RR A $20.57 000-099 Y N Y 000-099

E0149 U4 A $0.01 000-020 Y N Y 000-099

E0153 A $54.35 000-099 Y N N

E0153 RR A $5.52 000-099 Y N N

E0153 U4 A $0.01 000-020 Y N Y 000-099

E0154 A $55.23 000-099 Y N N

E0154 RR A $5.52 000-099 Y N N

E0154 U4 A $0.01 000-020 Y N Y 000-099

E0155 A $23.58 000-099 Y N N

E0155 RR A $2.31 000-099 Y N N

E0155 U4 A $0.01 000-020 Y N Y 000-099

E0156 A $18.27 000-099 Y N N E0156 RR A $1.83 000-099 Y N N

E0156 U4 A $0.01 000-020 Y N Y 000-099E0157 A $65.83 000-099 Y N N

E0157 RR A $6.45 000-099 Y N N

E0157 U4 A $0.01 000-020 Y N Y 000-099

WALKER HD W/WHEELS ANY TYPE


WALKER HD W/WHEELS ANY TYPE

1 PER 2 YEARS

PLATFORM,ATT.,FOREARM CRUTCH

2 PER YEAR

PLATFORM

ATT.FOREARM CRUTCH


PLATFORM,ATT.,FOREARM CRUTCH

2 PER YEAR

PLATFORM

ATT,WALKER,EACH

2 PER 2 YEARS

PLATFORM AH,

WALKER, EA. 10 MONTHS = PURCHASE

PLATFORM

ATT,WALKER,EACH

2 PER 2 YEARS

WHEEL ATT,RIGID

WALKER ATT 2 PER YEAR

WHEEL ATT,RIGID

WALKER ATT 10 MONTHS = PURCHASE

WHEEL ATT,RIGID

WALKER ATT 2 PER YEAR

SEAT ATT,WALKER

1 PER YEAR

SEAT ATT, WALKER

ONCE PER

MONTH SEAT ATT,WALKER

1 PER YEAR

CRUTCH

ATT,WALKER,EACH

2 PER MONTH

CRUTCH ATT,

WALKER, EACH ONCE PER

MONTH CRUTCH

ATT,WALKER,EACH

2 PER MONTH





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0158 A $23.58 000-099 Y N N

E0158 RR A $2.36 000-099 Y N N

E0158 U4 A $0.01 000-020 Y N Y 000-099

E0159 A $16.47 000-099 N N Y 000-099

E0159 RR A $1.65 000-099 N N Y 000-099

E0159 U4 A $0.01 000-020 N N Y 000-099

E0163 A $101.64 000-099 Y N Y 000-099

E0163 RA A $101.64 000-099 Y N Y 000-099

E0163 RB A $0.01 000-099 Y N Y 000-099

E0163 RR A $10.17 000-099 Y N Y 000-099

E0163 U4 A $0.01 000-020 Y N Y 000-099

LEG EXTENSIONS,WALKER

4 PER 2 YEARS




4 PER 2 YEARS

BRAKE ATTACHMT/WHEELED WALKER




COMMODE,FIXED ARMS

1 PER 2 YEARS

335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39

COMMODE,W/FIXED ARMS

1 PER 2 YEARS

335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39


COMMODE,W/ FIXED

ARMS 10 MONTHS = PURCHASE

335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39


1 PER 2 YEARS

335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0165 A $171.21 000-099 Y N Y 000-099

E0165 RA A $171.21 000-099 Y N Y 000-099

E0165 RB A $0.01 000-099 Y N Y 000-099

E0165 RR A $17.13 000-099 Y N Y 000-099

E0167 A $11.06 000-099 Y N Y 000-099

E0167 RR A $1.10 000-099 Y N Y 000-099

E0167 U4 A $0.01 000-020 Y N Y 000-099

E0168 A $114.10 000-099 Y N Y 000-099

E0168 RR A $11.41 000-099 Y N Y 000-099

E0171 RA A $222.11 000-099 Y N Y 000-099

COMMODE,DETACH. ARMS

1 PER 2 YEARS

335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39

COMMODE W/DETACH ARMS

1 PER 2 YEARS

335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39

COMMODE W/DETACH ARMS

COMMODE

W/DETACH ARMS


335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39

PAIL, PAN, COMMODE, REP.

1 PER YEAR

335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39



335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39


1 PER YEAR

335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39

COMMODE XTRA WIDE/HD ANY TYPE

1 PER 2 YEARS

335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39

COMMODE XTRA WIDE/HD ANY TYPE


335.20-335.20, 340 -340, 343.0 -343.9, 359.0 -359.1 806.00 -806.39

COMMODE CHAIR NON-ELECTRIC





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0171 RB A $0.01 000-099 Y N Y 000-099

E0171 RR A $22.21 000-099 Y N Y 000-099

E0171 A $222.11 000-099 Y N Y 000-099

E0175 A $57.00 000-099 Y N Y 000-099

E0175 RR A $5.70 000-099 Y N Y 000-099

E0175 U4 A $0.01 000-020 Y N Y 000-099

E0181 A $200.16 000-099 Y N Y 000-099

E0181 RA A $200.16 000-099 Y N Y 000-099

E0181 RB A $0.01 000-099 Y N Y 000-099




FOOTREST,COMMODE,EACH

FOOTREST,COMMOD

E,EACH 10 MONTHS = PURCHASE

FOOTREST,COMMODE,EACH

POWR. PRESS. REDUC. MATTRESS OVERLAY/PAD, ALTERNATING, W/PUMP,INCL. HVYD

1 PER 5 YEARS

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39


1 PER 5 YEARS

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.3-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39







E0182 A $170.88 000-099 Y N Y 000-099

E0182 RB A $0.01 000-099 Y N Y 000-099

E0182 RR A $17.09 000-099 Y N Y 000-099

E0184 A $152.52 000-099 Y N Y 000-099

E0184 RR A $15.25 000-099 Y N Y 000-099


10 MONTHS= PURCHASE

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39

PUMP FOR ALT. PAD, RPL. ONLY

PUMP FOR ALT. PAD,

RPL. ONLY PUMP FOR ALT. PAD,

RPL. ONLY FLOTATION

MATTRESS,DRY 1 PER 5 YEARS

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39

FLOTATION MATTRESS,DRY


237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39






E0185 RR A $25.06 000-099 Y N Y 000-099

E0186 A $187.08 000-099 Y N Y 000-099

E0186 RA A $187.08 000-099 Y N Y 000-099

DEC.CARE PAD, W LEVELING PAD

1 PER 5 YEARS

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39

DEC.CARE PAD, W LEVELING PAD


237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39

AIR PRESSURE MATTRESS

1 PER 5 YEARS

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39


1 PER 5 YEARS

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.0, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39






E0186 RR A $18.71 000-099 Y N Y 000-099

E0187 A $91.06 000-099 Y N Y 000-099

E0187 RA A $91.06 000-099 Y N Y 000-099

E0187 RB A $0.01 000-099 Y N Y 000-099


AIR PRESSURE

MATTRESS 10 MONTHS = PURCHASE

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39

WATER PRESSURE MATTRESS

1 PER 5 YEARS

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39


1 PER 5 YEARS

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.0, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39






CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0187 RR A $9.10 000-099 N N Y 000-099

E0188 A $9.82 000-099 Y N N

E0188 RR A $0.98 000-099 Y N N

E0189 A $40.70 000-099 Y N Y 000-099

E0189 RR A $4.07 000-099 Y N Y 000-099

E0190 A $102.22 000-099 Y N Y 000-099

E0191 A $6.90 000-099 Y N N

E0191 RR A $0.69 000-099 Y N N

E0193 MS A $517.57 000-099 N N Y 000-099

E0193 RR A $28.75 000-099 N N Y 000-099

E0194 MS A $862.62 000-099 N N Y 000-099

E0194 RR A $57.50 000-099 N N Y 000-099E0196 A $233.93 000-099 Y N Y 000-099

E0196 RA A $233.93 000-099 Y N Y 000-099

E0196 RB A $0.01 000-099 Y N Y 000-099



237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39

SYNTHETC SHEEPSKIN PAD

1 PER YEAR

SYNTHETC

SHEEPSKIN PAD 10 MONTHS = PURCHASE

LAMBSWOOL SHEEPSKIN PAD

LAMBSWOOL

SHEEPSKIN PAD 10 MONTHS = PURCHASE

POSITIONING CUSHION

HEEL OR ELBOW PROTECTOR

4 PER YEAR

HEEL OR ELBOW

PROTECTOR 10 MONTHS = PURCHASE

POWERED AIR FLOTATION BED

ONCE PER 6 MONTHS

POWERED AIR FLOTATION BED

AIR FLUIDIZED BED

ONCE PER 6 MONTHS

AIR FLUIDIZED BED GEL PRESSURE MATTRESS

GEL PRESSURE

MATTRESS GEL PRESSURE

MATTRESS






E0197 A $197.27 000-099 Y N Y 000-099

E0197 RA A $197.27 000-099 Y N Y 000-099

E0197 RB A $0.01 000-099 Y N Y 000-099

▪ E0197 RR A $19.73 000-099 Y N Y 000-099

E0198 A $147.96 000-099 Y N Y 000-099

E0198 RA A $147.96 000-099 Y N Y 000-099

E0198 RB A $0.01 000-099 Y N Y 000-099

GEL PRESSURE MATTRESS

AIR PRESSURE PAD

FOR MATTRESS 1 PER 5 YEARS

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39

AIR PRESSURE PAD FOR MATTRESS

1 PER 5 YEARS

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39

AIR PRESSURE PAD FOR MATTRESS

AIR PRESSURE PAD

FOR MATTRESS 10 MONTHS = PURCHASE

237.70-237.72, 330.0-330.9, 332.0-332.1, 333.4, 334.0-335.29, 340-344.1, 348.1, 348.30-348.5, 359.0-359.3, 707.02 - 707.05, 741.00-742.2, 780.01-780.03, 806.00-806.39

WATER PRESSURE PAD FOR MATTRES

1 PER 2 YEARS

WATER PRESSURE

PAD FOR MATTRES1 PER 2 YEARS

WATER PRESSURE

PAD FOR MATTRES






E0199 A $22.16 000-099 Y N Y 000-099

E0199 RR A $2.22 000-099 Y N Y 000-099

E0200 RR A $5.17 000-001 Y N Y 000-001

E0200 A $51.74 000-001 Y N Y 000-001

E0202 RR A $57.71 7 PER MONTH 000-001 Y N Y 000-001

E0205 RR A $13.07 000-001 Y N Y 000-001E0205 A $130.66 000-001 Y N Y 000-001E0217 A $322.04 000-020 N N Y 000-020

E0217 RR A $32.20 000-020 N N Y 000-020

E0235 A $125.56 000-099 Y N Y 000-099

E0235 RR A $12.56 000-099 Y N Y 000-099

E0236 RA A $270.82 000-020 N N Y 000-020

E0236 RB A $0.01 000-020 Y N Y 000-099

E0236 RR A $27.08 000-020 N N Y 000-020

E0240 A $300.96 000-020 Y N Y 000-020

E0240 U4 A $0.01 000-020 Y N Y 000-099

E0241 A $0.01 000-020 Y N Y 000-020

E0243 A $0.01 000-020 Y N Y 000-020

WATER PRESSURE PAD FOR MATTRES

DRY PRESSURE PAD

EG EGG CRATE DRY PRESSURE PAD

EG EGG CRATE 10 MONTHS = PURCHASE

HEAT LAMP,TABLE MODEL

HEAT LAMP,TABLE

MODEL

PHOTOTHERAPY LIGHT

377.31, 773.2, 774.1 -774.39, 774.6 -774.7 HEAT LAMP,STAND

HEAT LAMP,STAND

WATER CIRCULATING HEAT PAD

WATER CIRCULATING HEAT PAD

PARAFFIN BOTH UNIT,PORTABLE

1 PER 5 YEARS

714.0 -714.9 PARAFFIN BOTH

UNIT, PORTABLE 10 MONTHS = PURCHASE

714.0 -714.9 PUMP FOR WATER

CIRC PAD PUMP FOR WATER

CIRC PAD PUMP FOR WATER

CIRC PAD 10 MONTHS = PURCHASE

BATH/SHOWER CHAIR

BATH/SHOWER CHAIR

BATH TUB WALL RAIL EAC

TOILET RAIL EACH






E0245 A $0.01 000-020 Y N Y 000-020

E0246 A $50.10 000-099 Y N Y 000-099

E0247 A $0.01 000-020 Y N Y 000-020

E0248 A $0.01 000-020 Y N Y 000-020

E0249 A $62.30 000-020 N N Y 000-020

E0249 RA A $62.30 000-020 N N Y 000-020

E0249 RB A $0.01 000-020 Y N Y 000-099

E0249 RR A $6.23 000-020 N N Y 000-020

E0250 A $900.96 000-099 Y N Y 000-099

E0250 RA A $900.96 000-099 Y N Y 000-099

E0250 RB A $0.01 000-099 Y N Y 000-099

E0250 RR A $90.10 000-099 Y N Y 000-099

E0251 A $629.79 000-099 Y N Y 000-099

E0251 RA A $629.79 000-099 Y N Y 000-099

E0251 RB A $0.01 000-099 Y N Y 000-099

RAISED TOILET SEAT

TUB STOOL OR

BENCH TRANSFER TUB RAIL

ATT. TRANS BENCH W/WO

COMM OPEN

HDTRANS BENCH W/WO COMM OPEN

PAD FOR WATER CIRCULATING UNIT

1 PER 2 YEARS

PAD FOR WATER CIRCULATING UNIT

1 PER 2 YEARS

PAD FOR WATER

CIRCULATING UNIT PAD FOR WATER

CIRCULATING UNIT10 MONTHS = PURCHASE

HOSP.BED,SIDE RAILS,FIXED HGT.

1 PER 8 YEARS

340, 343.0 - 343.9, 359.0 - 359.1, 806.00 -806.39

HOSP BED W/SIDE RAILS,FIXED HT

1 PER 8 YEARS

340, 343. 0 - 343.9, 359.0 - 359.1, 806.00 -806.39

HOSP BED W/SIDE RAILS,FIXED HT

HOSP BED W/SIDE

RAILS,FIXED HT 10 MONTHS = PURCHASE

340 -340, 343. 0 -343.9, 359.0 -359.1, 806. 00 -806.39

HOSP.BED,SIDE RAILS,FIXED,N.M.

HOSP BED W/SIDE

RAILS,FIXED NM HOSP BED W/SIDE

RAILS,FIXED NM





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSIS▪ E0251 RR A $62.98 000-099 Y N Y 000-099

E0255 A $1,021.81 000-099 Y N Y 000-099

E0255 RA A $1,021.81 000-099 Y N Y 000-099

E0255 RB A $0.01 000-099 Y N Y 000-099

E0256 A $768.15 000-099 Y N Y 000-099

E0256 RA A $768.15 000-099 Y N Y 000-099

E0256 RB A $0.01 000-099 Y N Y 000-099

E0260 A $1,294.48 000-099 Y N Y 000-099

E0260 RA A $1,294.48 000-099 Y N Y 000-099

E0260 RB A $0.01 000-099 Y N Y 000-099

E0260 RR A $129.45 000-099 Y N Y 000-099

E0261 A $1,159.88 000-099 Y N Y 000-099

E0261 RA A $1,159.88 000-099 Y N Y 000-099

E0261 RB A $0.01 000-099 Y N Y 000-099

HOSP BED W/SIDE RAILS,FIXED,NM

HOSP.BED,SIDE

RAILS,VAR. HGT. 1 PER 5

YEARS 340, 343.0 - 343.9, 359.0 - 359.1, 806.00 -806.39

HOSP BED W/SIDE RAILS,VAR HGT

1 PER 5 YEARS

340, 343.0 - 343.9, 359.0 - 359.1, 806.00 -806.39

HOSP BED W/SIDE RAILS,VAR HGT

HOSP BED VAR HGT

S/RLS NO MAT HOSP BED VAR HGT

S/RLS NO MAT HOSP BED VAR HGT

S/RLS NO MAT HOSP.BED,SIDE

RAILS,SEMI-ELEC 1 PER 5 YEARS

340, 343.0 - 343.9, 359.0 - 359.1, 806.00 -806.39

HOSP BED W/SIDE RAILS,SEMI-ELC

1 PER 5 YEARS

340, 343.0 - 343.9, 359.0 - 359.1, 806.00 -806.39

HOSP BED W/SIDE RAILS,SEMI-ELC

HOSP BED W/SIDE

RAILS,SEMI-ELC10 MONTHS = PURCHASE

340 -340, 343.0 -343.9, 359. 0 -359.1, 806. 00 -806.39

HOSP BED,RAIL,SEMI-ELEC W/O MA








E0265 A $1,670.28 000-099 Y N Y 000-099

E0265 RA A $1,670.28 000-099 Y N Y 000-099

E0265 RB A $0.01 000-099 Y N Y 000-099

E0265 RR A $167.03 000-099 Y N Y 000-099

E0266 A $1,473.78 000-099 Y N Y 000-099

E0266 RA A $1,473.78 000-099 Y N Y 000-099

E0266 RB A $0.01 000-099 Y N Y 000-099

E0266 RR A $147.37 000-099 Y N Y 000-099

E0271 A $174.89 000-099 Y N N

E0271 RR A $17.49 000-099 Y N N

E0272 A $138.73 000-099 Y N N

E0272 RR A $13.87 000-099 Y N N

E0274 RR A $14.73 000-020 Y N N

E0274 A $147.26 000-020 Y N N

E0275 A $9.00 000-099 Y N N

E0275 RR A $0.90 000-099 Y N N


HOSP.BED,SIDE RAILS, ELECTRIC

HOSP BED W/SIDE

RAILS,ELECTRIC HOSP BED W/SIDE

RAILS,ELECTRIC HOSP BED W/SIDE

RAILS,ELECTRIC HOSP.BED,SIDE

RAILS,ELEC.,N.M. HOSP BED W/SIDE

RAILS,ELEC NM HOSP BED W/SIDE

RAILS,ELEC NM HOSP BED W/SIDE

RAILS,ELEC NM MATTRESS,INNERSP

RING 1 PER 2

YEARS MATTRESS,INNERSP

RING 10 MONTHS = PURCHASE

MATTRESS,FOAM RUBBER

1 PER 2 YEARS

MATTRESS,FOAM

RUBBER 10 MONTHS = PURCHASE

OVER-BED TABLE


OVER-BED TABLE


BED PAN STD METAL OR PLASTIC

1 PER YEAR

BED PAN STD METAL

OR PLASTIC 10 MONTHS = PURCHASE






E0276 RR A $1.23 000-099 Y N N

E0277 A $0.01 000-099 Y N Y 000-099

E0277 RA A $0.01 000-099 Y N Y 000-099

E0277 RB A $0.01 000-099 Y N Y 000-099

E0277 RR A $0.01 000-099 Y N Y 000-099

E0290 A $489.29 000-099 Y N Y 000-099

E0290 RA A $489.29 000-099 Y N Y 000-099

E0290 RB A $0.01 000-099 Y N Y 000-099

E0290 RR A $48.93 000-099 Y N Y 000-099

E0291 A $372.38 000-099 Y N Y 000-099

E0291 RA A $372.38 000-099 Y N Y 000-099

E0291 RB A $0.01 000-099 Y N Y 000-099

▪ E0291 RR A $37.24 000-099 Y N Y 000-099

E0292 A $774.51 000-099 Y N Y 000-099

BED PAN,FRACTURE,METAL,PLASTIC

1 PER YEAR

BED PAN,FRACTURE,METAL,PLASTIC


ALTERNATING PRESSURE MATTRESS

1 PER 2 YEARS


1 PER 2 YEARS



HOSPITAL BED FIXED HGT MATT

HOSPITAL BED FIXED

HGT MATT HOSPITAL BED FIXED

HGT MATT HOSP BED FIXED

HGT MATT HOSPITAL BED W/O

RAIL AND MATT HOSPITAL BED W/O

RAIL MATT HOSPITAL BED W/O

RAIL MATT HOSP BED W/O RAIL

MAT HOSPITAL BED VAR

HGT HI LO





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0292 RA A $774.51 000-099 Y N Y 000-099

E0292 RB A $0.01 000-099 Y N Y 000-099

E0292 RR A $77.45 000-099 Y N Y 000-099

E0293 A $652.40 000-099 Y N Y 000-099

E0293 RA A $652.40 000-099 Y N Y 000-099

E0293 RB A $0.01 000-099 Y N Y 000-099

E0293 RR A $65.24 000-099 Y N Y 000-099

E0294 A $1,204.07 000-099 Y N Y 000-099

E0294 RA A $1,204.07 000-099 Y N Y 000-099

E0294 RB A $0.01 000-099 Y N Y 000-099

E0294 RR A $120.40 000-099 Y N Y 000-099

E0295 A $1,119.08 000-099 Y N Y 000-099

E0295 RA A $1,119.08 000-099 Y N Y 000-099

E0295 RB A $0.01 000-099 Y N Y 000-099

E0295 RR A $111.90 000-099 Y N Y 000-099

E0296 A $1,513.27 000-099 Y N Y 000-099

E0296 RA A $1,513.27 000-099 Y N Y 000-099

E0296 RB A $0.01 000-099 Y N Y 000-099

HOSPITAL BED VAR HGT HI LO

HOSPITAL BED VAR

HGT HI LO HOSP BED VAR HGT

HI LO HOSPITAL BED VAR

HGT W/O RAIL HOSPITAL BED VAR

HGT W/O RAILS HOSPITAL BED VAR

HGT W/O RAILS HOSP BED VAR HGT

W/O RAILS HOSP BED SEMI

ELEC HOSP BED SEMI

ELEC HOSP BED SEMI

ELEC HOSP BED SEMI

ELEC HOSP BED SEMI W/O

RAILS MAT HOSP BED SEMI W/O

RAILS HOSP BED SEMI W/O

RAILS HOSP BED SEMI W/O

RAILS HOSP BED ELEC W/O



RAILS






E0297 A $1,223.88 000-099 Y N Y 000-099

E0297 RA A $1,223.88 000-099 Y N Y 000-099

E0297 RB A $0.01 000-099 Y N Y 000-099

E0297 RR A $122.39 000-099 Y N Y 000-099

E0301 RR A $193.83 000-099 N N Y 000-099

E0301 A $1,938.24 000-099 N N Y 000-099

E0302 RR A $305.07 000-099 N N Y 000-099

E0302 A $3,050.71 000-099 N N Y 000-099

E0303 RR A $211.32 000-099 N N Y 000-099

E0303 A $2,113.13 000-099 N N Y 000-099

E0304 RR A $322.56 000-099 N N Y 000-099

E0304 A $3,225.60 000-099 N N Y 000-099

E0305 A $141.37 000-099 Y N Y 000-099

E0305 RA A $141.37 000-099 Y N Y 000-099

E0305 RB A $0.01 000-099 Y N Y 000-099

E0305 RR A $14.14 000-099 Y N Y 000-099

HOSP BED ELECT W/O RAILS

HOSP BED ELEC W/O

RAILS MAT HOSP BED ELEC W/O



RAILS HD HOSP BED, 350-

600 LBS.

HD HOSP BED, 350-600 LBS.

EX HD HOSP BED > 600 LBS.

EX HD HOSP BED > 600 LBS.

HOSP BED HVY DTY XTRA WIDE

HOSP BED HVY DTY XTRA WIDE

HOSP BED XTRA HVY DTY X WIDE

HOSP BED XTRA HVY DTY X WIDE

BED RAILS,HALF LENGTH

BED SIDE

RAILS,HALF LENGTH

BED SIDE RAILS,HALF LENGTH

BED SIDE RAILS,HALF LENGTH






E0310 RA A $140.49 000-099 Y N Y 000-099

E0310 RB A $0.01 000-099 Y N Y 000-099

▪ E0310 RR A $14.05 000-099 Y N Y 000-099

E0316 A $1,803.57 000-099 N N Y 000-099

E0316 RR A $180.36 000-099 N N Y 000-099

E0325 A $7.92 000-099 Y N N E0325 RR A $0.80 000-099 Y N N

E0326 A $8.23 000-099 Y N N E0326 RR A $0.83 000-099 Y N N

E0328 RR A $0.01 000-020 Y N Y 000-020

E0328 A $0.01 000-020 Y N Y 000-020

E0329 RR A $0.01 000-020 Y N Y 000-020

E0329 A $0.01 000-020 Y N Y 000-020

E0371 RB A $0.01 000-099 Y N Y 000-099

E0371 RR A $293.81 000-099 Y N Y 000-099

E0372 RA A $0.01 000-099 Y N Y 000-099

BED RAILS,FULL LENGTH

BED SIDE

RAILS,FULL LENGTH

BED SIDE RAILS,FULL LENGTH

BED SIDE RAILS,FULL LENGTH

BED SAFETY ENCLOSURE

BED SAFETY

ENCLOSURE 10 MONTHS = PURCHASE

URINAL,MALE

2 PER YEAR

URINAL,MALE


URINAL,FEMALE

2 PER YEAR

URINAL,FEMALE


PED. HOSP. BED, MANUAL


PED. HOSP. BED, MANUAL

PED. HOSP. BED, SEMI/ELECT.


PED. HOSP. BED, SEMI/ELECT.

NONPWD PRESS OVERLAY/MATTRESS

NONPWD PRESS OVERLAY/MATTRESS

PWERED OVERLAY FOR MATT STD






E0372 RR A $356.62 000-099 Y N Y 000-099

E0373 RA A $0.01 000-099 Y N Y 000-099

E0373 RB A $0.01 000-099 Y N Y 000-099

E0373 RR A $408.38 000-099 Y N Y 000-099

E0424 RR A $184.69 000-099 N N Y 000-099

PWERED OVERLAY FOR MATT STD

PWERED OVERLAY

FOR MATT STD NONPWD PRES

REDUCING MATTRESS

NONPWD PRES REDUCING MATTRESS

NONPWD PRES REDUCING MATTRESS

STATIONARY COMPRESSED GAS RENT

ONCE PER MONTH

011.00 -011.99, 114.0 -114.9, 162.0 -169.9, 197.0 -197.3, 207.00 -207.10, 277.00-277.09, 281.2 -281.2, 289.0 -289.6, 357.0 -359.9, 416.0 -416.9, 428.0 -428.9, 481, 491-492.8, 494 - 494.1, 496-496, 505 -505, 515 - 515, 516.3- 516.3, 518.1 - 518.3, 748.3, 770.7 -770.84, 780.53-780.53, 780.55-780.55, 780.57-780.57






E0434 RR A $29.56 000-099 Y N Y 000-099

E0439 RR A $0.01 000-099 N N Y 000-099

E0441 A $59.48 000-099 N N Y 000-099

E0442 A $59.48 000-099 N N Y 000-099

PORTABLE GASEOUS RENTAL

ONCE PER MONTH

011.00 -011.99, 114.0 -114.9, 162.0 -169.9, 197.0 -197.3, 207.00 -207.10, 277.00-277.09, 281.2 -281.2, 289.0 -289.6, 357.0 -359.9, 416.0 -416.9, 428.0 -428.9, 481, 491-492.8, 494 - 494.1, 496-496, 505 -505, 515 - 515, 516.3- 516.3, 518.1 - 518.3, 748.3, 770.7 -770.84

PORTABLE LIQUID RENTAL

STATIONARY LIQUID

RENTAL OXYGEN CONTENTS,

GAS 1 PER

MONTH 011.00 -011.99, 114.0 -114.9, 162.0 -169.9, 197.0 -197.3, 207.00 -207.10, 277.00-277.09, 281.2 -281.2, 289.0 -289.6, 357.0 -359.9, 416.0 -416.9, 428.0 -428.9, 481, 491-492.8, 494 - 494.1, 496-496, 505 -505, 515 - 515, 516.3- 516.3, 518.1 - 518.3, 748.3, 770.7 -770.84

OXYGEN CONTENTS, LIQUID

1 PER MONTH





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0443 A $19.73 000-099 N N Y 000-099

E0444 A $1.25 000-099 N N Y 000-099

E0445 RR A $352.71 000-099 N N Y 000-099

E0450 RR A $879.69 000-099 Y N Y 000-099

E0455 A $26.84 000-099 Y N N

E0457 A $0.01 000-099 Y N Y 000-099

E0457 RR A $0.01 000-099 Y N Y 000-099

E0460 RR A $398.40 000-099 Y N Y 000-099

E0461 RR A $738.79 000-099 Y N Y 000-099

E0462 RR A $228.27 000-099 Y N Y 000-099

E0463 RR A $879.69 000-099 Y N Y 000-099

E0464 RR A $0.01 000-099 Y N Y 000-099

E0470 RR A $191.59 000-099 N N Y 000-099

PORTABLE OXYGEN CONT. GAS

1 PER MONTH

011.00 -011.99, 114.0 -114.9, 162.0 -169.9, 197.0 -197.3, 207.00 -207.10, 277.00-277.09, 281.2 -281.2, 289.0 -289.6, 357.0 -359.9, 416.0 -416.9, 428.0 -428.9, 481, 491-492.8, 494 - 494.1, 496-496, 505 -505, 515 - 515, 516.3- 516.3, 518.1 - 518.3, 748.3, 770.7 -770.84

PORTABLE OXYGEN CONT LIQUID

OXIMETER NON-

INVASIVE10 MONTHS = PURCHASE

V44.0-V44.0, V55.0 -V55.0 (UNDER 21) VOL CONTROL VENT

INVASIV INT ONCE PER

MONTH OXYGEN TENT

1 PER 3

MONTHS CHEST SHELL

(CUIRASS) CHEST SHELL

(CUIRASS) NEGATIVE PRESS

VENTILATOR;PORT VOL CONTROL VENT

NONINV INTONCE PER

MONTH

ROCK BED W/OR W/O RAILS

PRESS SUPP VENT

INVASIVE INT

PRES SUPP VENT NONINV INT

RAD W/O BACKUP NON-IV INTFC

10 MONTHS= PURCHASE






E0480 A $344.22 000-099 Y N Y 000-099

E0480 RA A $344.22 000-099 Y N Y 000-099

E0480 RB A $0.01 000-099 Y N Y 000-099

E0480 RR A $34.43 000-099 Y N Y 000-099

E0482 A $3,947.90 000-099 Y N Y 000-099

E0482 RA A $3,947.90 000-099 Y N Y 000-099

E0482 RB A $0.01 000-099 Y N Y 000-099

E0482 RR A $394.79 000-099 Y N Y 000-099

E0483 RR A $979.78 000-099 N N Y 000-099

E0484 RR A $2.44 000-099 Y N Y 000-099

E0484 A $24.42 1 PER YEAR 000-099 Y N Y 000-099

E0500 A $688.74 000-099 Y N Y 000-099

E0500 RA A $688.74 000-099 Y N Y 000-099

E0500 RB A $0.01 000-099 Y N Y 000-099

RAD W/BACKUP NON INV INTRFC

10 MONTHS= PURCHASE

PERCUSSOR,HOME MODEL

1 PER 2 YEARS

277.00 -277.09 PERCUSSOR,HOME

MODEL 1 PER 2

YEARS 277.00 -277.09 PERCUSSOR,HOME

MODEL PERCUSSOR,HOME

MODEL 10 MONTHS = PURCHASE

277.00 -277.09 COUGH

STIMULATING DEVICE

COUGH STIMULATING DEVICE



10 MONTHS= PURCHASE

CHEST COMPRESSION GEN SYSTEM

10 MONTHS= PURCHASE

NON-ELEC OSCILLATORY PEP DVC


277.00 -277.09

NON-ELEC OSCILLATORY PEP DVC

277.00 -277.09

IPPB,EXTERNAL POWER,MAN

IPPB,EXTERNAL

POWER,MAN IPPB,EXTERNAL

POWER,MAN





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSIS▪ E0500 RR A $68.87 000-099 Y N Y 000-099

E0550 A $360.96 000-020 Y N Y 000-020

E0550 RA A $360.96 000-020 Y N Y 000-020

E0550 RB A $0.01 000-020 Y N Y 000-020

E0550 RR A $36.10 000-020 Y N Y 000-020

E0560 A $144.72 000-020 Y N Y 000-020

E0560 RA A $144.72 000-020 Y N Y 000-020

E0560 RB A $0.01 000-020 Y N Y 000-020

E0560 RR A $14.48 000-020 Y N Y 000-020

E0561 RR A $9.42 000-099 Y N Y 000-099

E0561 A $94.19 000-099 Y N Y 000-099

E0562 RR A $14.93 000-099 Y N Y 000-099

E0562 A $149.28 000-099 Y N Y 000-099

E0565 A $393.00 000-099 Y N Y 000-099

E0565 RA A $393.00 000-099 Y N Y 000-099

E0565 RB A $0.01 000-099 Y N Y 000-099

E0565 RR A $39.29 000-099 Y N Y 000-099

IPPB,EXTERNAL POWER,MAN

HUMIDIFIER,DURABL

E,EXT. HUMIDIFIER,DURABL

E,EXT

HUMIDIFIER,DURABLE,EXT

HOMIDIFIER,DURABL

E,EXT HUMIDIFIER,DURABL

E,SUP. HUMIDIFIER,DURABL

E,SUP HUMIDIFIER,DURABL

E,SUP HUMIDIFIER,DURABL

E,SUP HUMIDIFIER

NONHEATED W PAP


327.21, 327.23-327.26,519.00-519.09, 748.3-748.3, 780.51-780.51, 780.53-780.53, 780.57-780.57

HUMIDIFIER NONHEATED W PAP HUMIDIFIER HEATED W PAP


HUMIDIFIER HEATED W PAP

COMPRESSOR,AIR POWER

COMPRESSOR,AIR

POWER COMPRESSOR,AIR

POWER COMPRESSOR,AIR

POWER 10 MONTHS = PURCHASE

V44.0-V44.0, V55.0 -V55.0






E0570 RA A $148.38 000-099 Y N N

E0570 RB A $0.01 000-099 Y N Y 000-099

E0570 RR A $14.84 000-099 Y N N

E0574 RR A $28.75 000-099 Y N Y 000-099

E0575 A $942.61 000-099 Y N Y 000-099

E0575 RA A $942.61 000-099 Y N Y 000-099

E0575 RB A $0.01 000-099 Y N Y 000-099

E0575 RR A $94.26 000-099 Y N Y 000-099

E0585 A $274.73 000-099 Y N N

E0585 RA A $274.73 000-099 Y N N

E0585 RB A $0.01 000-099 Y N Y 000-099

E0585 RR A $27.48 000-099 Y N N

E0600 A $312.46 000-099 Y N N

E0600 RA A $312.46 000-099 Y N N

E0600 RB A $0.01 000-099 Y N Y 000-099

NEBULIZER WITH COMPRESSOR

1 PER 5 YEARS

NEBULIZER,W/

COMPRESSOR 1 PER 5

YEARS NEBULIZER,W/

COMPRESSOR NEBULIZER,W/

COMPRESSOR 10 MONTHS = PURCHASE

ULTRASONIC

GENERATOR W/ NEBULIZER

NEBULIZER,ULTRASONIC

NEBULIZER,ULTRAS

ONIC NEBULIZER,ULTRAS

ONIC NEBULIZER,ULTRAS

ONIC NEBULIZER,WITH

COMPRESSOR/HEAT 1 PER 5

YEARS

NEBULIZER W/COMPRESSOR/HEAT

1 PER 5 YEARS




SUCTION PUMP,PORTABLE

1 PER 5 YEARS

SUCTION

PUMP,PORTABLE

1 PER 5 YEARS

SUCTION

PUMP,PORTABLE






E0601 RR A $79.40 000-099 Y N Y 000-099

E0604 KH A $64.51 000-099 N N N

E0604 RR A $33.54 000-099 N N N

E0605 A $18.27 000-099 Y N N

E0605 RR A $1.82 000-099 Y N N

E0606 A $29.71 000-099 Y N Y 000-099

E0606 RR A $2.98 000-099 Y N Y 000-099

E0607 A $61.58 000-099 Y N Y 000-099

E0607 RA A $61.58 000-099 Y N Y 000-099

E0607 RB A $0.01 000-099 Y N Y 000-099

E0607 RR A $6.15 000-099 Y N Y 000-099

E0619 RR A $235.80 000-020 N N Y 000-020

E0621 A $56.56 000-099 Y N N

E0621 RA A $56.56 000-099 Y N N

SUCTION PUMP,PORTABLE


CONT AIRWAY

PRESSURE DEVICE 10 MONTHS = PURCHASE

327.21,327.23-327.26,519.00-519.09, 748.3-748.3, 780.51-780.51 780.53-780.53 780.57-780.57

HOSP GRADE ELEC BREAST PUMP

ONCE PER MONTH

HOSP GRADE ELEC

BREAST PUMP ONCE PER

MONTH VAPORIZER,ROOM

TYPE 1 PER 2

YEARS VAPORIZER,ROOM

TYPE 10 MONTHS = PURCHASE

POSTURAL

DRAINAGE BOARD

1 PER 2 YEARS

277.00 -277.09 POSTURAL

DRAINAGE BOARD


277.00 -277.09 HOME GLUCOSE

MONITOR 1 PER 3

YEARS 250.00 -250.93, 648.0 -648.04, 648.80-648.84 HOME GLUCOSE

MONITOR 1 PER 3

YEARS 250.00 -250.93, 648.0 -648.04, 648.80-648.84 HOME GLUCOSE

MONITOR HOME GLUCOSE

MONITOR 10 MONTHS = PURCHASE

250.00 -250.93, 648.0 -648.04, 648.80-648.84

APNEA MONITOR W/RECORDER

033.0-033.9, 079.6, 486, 770.7, 770.81 - 770.84, 786.03

SLING/SEAT,PATIENT LIFT

1 PER 2 YEARS

SLING SEAT,

PATIENT LIFT 1 PER 2 YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0621 RB A $0.01 000-099 Y N Y

E0621 RR A $5.65 000-099 Y N N

E0625 U4 A $0.01 000-020 Y N Y 000-020

E0630 A $860.69 000-099 Y N N

E0630 RA A $860.69 000-099 Y N N

E0630 RB A $0.01 000-099 Y N Y 000-099

▪ E0630 RR A $86.07 000-099 Y N N

E0635 A $0.01 000-099 Y N Y 000-099

E0635 RA A $0.01 000-099 Y N Y 000-099

E0635 RB A $0.01 000-099 Y N Y 000-099

E0635 RR A $0.01 000-099 Y N Y 000-099

E0636 A $759.28 000-099 Y N Y 000-099

E0636 RA A $759.28 000-099 Y N Y 000-099

E0636 RB A $0.01 000-099 Y N Y 000-099

E0636 RR A $75.93 000-099 Y N Y 000-099

SLING SEAT, PATIENT LIFT

SLING/SEAT PATIENT

LIFT 10 MONTHS= PURCHASE

PATIENT LIFT, BATHROOM OR TOILET, NOT OTHERWISE CLASSIFIED

1 PER 5 YEARS

PATIENT LIFT,HYDRAULIC W/SLING

1 PER 10 YEARS


1 PER 10 YEARS




PATIENT LIFT ELECTRIC W/SEAT

PATIENT LIFT

ELECTRIC W/SEAT PATIENT LIFT

ELECTRIC W/SEAT PATIENT LIFT

ELECTRIC W/SEAT 10 MONTHS = PURCHASE

PT SUPPORT 7

POSITIONING SVS

PT SUPPORT 7 POSITIONING SVS



10 MONTHS= PURCHASE






E0638 RR A $412.37 000-020 N N Y 000-020

E0638 A $4,123.68 000-020 N N Y 000-020

E0639 A $0.01 000-099 N N Y 000-099

E0639 RA A $0.01 000-099 N N Y 000-099

E0639 RB A $0.01 000-099 N N Y 000-099

E0639 RR A $0.01 000-099 N N Y 000-099

E0641 A $0.01 000-020 N N Y 000-020

E0641 RA A $0.01 000-020 N N Y 000-020

E0641 RB A $0.01 000-020 N N Y 000-020

E0641 RR A $0.01 000-020 N N Y 000-020

E0642 A $4,123.68 000-020 N N Y 000-020

E0642 RA A $4,123.68 000-020 N N Y 000-020

E0642 RB A $0.01 000-020 N N Y 000-020

E0642 RR A $0.01 000-020 N N Y 000-020

E0650 A $564.19 000-099 Y N Y 000-099

E0650 RA A $564.19 000-099 Y N Y 000-099

E0650 RB A $0.01 000-099 Y N Y 000-099

SIT-STAND W SEATLIFT

STANDING FRAME SYS


STANDING FRAME SYS

MOVEABLE PATIENT LIFT SYSTEM




MULTI-POSITION STND FRAM SYS




DYNAMIC STANDING FRAME




PNEUMATIC COMPRESSOR

1 PER 2 YEARS

PNEUMATIC

COMPRESSOR 1 PER 2 YEARS

PNEUMATIC

COMPRESSOR






E0651 A $634.82 000-099 Y N Y 000-099

E0651 RA A $634.82 000-099 Y N Y 000-099

E0651 RB A $0.01 000-099 Y N Y 000-099

E0651 RR A $63.48 000-099 Y N Y 000-099

E0652 A $4,017.88 000-099 Y N Y 000-099

E0652 RA A $4,017.88 000-099 Y N Y 000-099

E0652 RB A $0.01 000-099 Y N Y 000-099

E0652 RR A $401.60 000-099 Y N Y 000-099

E0655 A $78.60 000-099 Y N Y 000-099

E0655 RR A $7.86 000-099 Y N Y 000-099

E0656 RR A $0.01 000-099 Y N Y 000-099

E0656 A $0.01 000-099 Y N Y 000-099

E0657 RR A $0.01 000-099 Y N Y 000-099

PNEUMATIC COMPRESSOR

10 MONTHS= PURCHASE

PNEUM.COMP.SEGM

ENT.HOME MODEL 1 PER 2 YEARS

PNEUM.COMP.SEGM

ENT.HOME MODEL 1 PER 2 YEARS

PNEUM.COMP.SEGM

ENT.HOME MODEL PNEUM.COMP.SEGM

ENT.HOME MODEL PNEM.

COMP.SEGMENTAL CALIBRATE

1 PER 2 YEARS

PNEM.COMP.SEG. CALIBRATED

1 PER 2 YEARS

PNEM.COMP.SEG.

CALIBRATED PNEM. COMP.

SEGMENTAL CALIBRAT

PNEUMATIC APPLIANCE,HALF ARM

PNEUMATIC APPLIANCE, HALF ARM

SEG. PNEU. APPL. USE W/ PNEU. COMP., TRUNK

SEG. PNEU. APPL. USE W/ PNEU. COMP., TRUNK

SEG. PNEU. APPL. USE W/ PNEU. COMP., CHEST






E0660 A $128.11 000-099 Y N Y 000-099

E0660 RR A $12.80 000-099 Y N Y 000-099

E0665 A $115.50 000-099 Y N Y 000-099

E0665 RR A $11.56 000-099 Y N Y 000-099

E0666 A $104.99 000-099 Y N Y 000-099

E0666 RR A $10.49 000-099 Y N Y 000-099

E0667 A $298.39 000-099 Y N Y 000-099

E0667 RR A $29.84 000-099 Y N Y 000-099

E0668 A $346.16 000-099 Y N Y 000-099

E0668 RR A $34.17 000-099 Y N Y 000-099

E0669 A $166.82 000-099 Y N Y 000-099

E0669 RR A $16.68 000-099 Y N Y 000-099

E0671 A $299.09 000-099 Y N Y 000-099

SEG. PNEU. APPL. USE W/ PNEU. COMP., CHEST

PNEUMATIC APPLIANCE,FULL LEG

PNEUMATIC APPLIANCE, FULL LEG

PNEUMATIC APPLIANCE,FULL ARM

PNEUMATIC APPLIANCE, FULL ARM

PNEUMATIC APPLIANCE,HALF LEG

PNEUMATIC APPLIANCE, HALF LEG

PNEUT. APPLIANCE, LEG

PNEUT. APPLIANCE,

LEG PNEUMAT.

APPLIANCE, ARM PNEUMAT.

APPLIANCE, ARM SEG PNEU APP

COMP HALF LEG PNEUMAT.

APPLIANCE, HALF LEG

SEG GRAD PRES PNEU APP FUL LEG






E0672 A $232.40 000-099 Y N Y 000-099

E0672 RR A $23.24 000-099 Y N Y 000-099

E0673 A $193.10 000-099 Y N Y 000-099

E0673 RR A $19.32 000-099 Y N Y 000-099

E0700 A $65.83 000-099 Y N N

E0700 RA A $65.83 000-099 Y N N

E0700 RB A $0.01 000-099 Y N Y 000-099

E0705 A $42.83 000-099 Y N N

E0705 RA A $42.83 000-099 Y N N

E0705 RB A $0.01 000-099 Y N N

E0705 RR A $4.28 000-099 Y N N

E0710 A $11.50 000-099 Y N N

E0720 A $319.73 000-099 N N Y 000-099E0720 RA A $319.73 000-099 N N Y 000-099E0720 RB A $0.01 000-099 N N Y 000-099E0720 RR A $31.97 000-099 N N Y 000-099E0730 A $341.51 000-099 N N Y 000-099E0730 RA A $341.51 000-099 N N Y 000-099E0730 RB A $0.01 000-099 N N Y 000-099E0730 RR A $34.16 000-099 N N Y 000-099

SEG GRAD PRES PNEU APP FUL LEG

SEG GRAD PRES

PNEU APP FUL ARM SEG GRAD PRES

PNEU APP FUL ARM SEG GRAD PRES

PNEU APP HAF LEG SEG GRAD PRES

PNEU APP HAF LEG SAFETY

EQUIPMENT,BELT,HARNESS

1 PER YEAR

SAFETY EQUIPMENT,BELT,HARNESS

1 PER YEAR

SAFETY EQUIPMENT,BELT,HARNESS

TRANSFER BOARD OR DEVICE

1 PER 2 YEARS


1 PER 2 YEARS




RESTRAINTS,ANY TYPE

1 PER YEAR

TENS, TWO LEAD

TENS, TWO LEAD

TENS, TWO LEAD

TENS, TWO LEAD

TENS, FOUR LEAD

TENS,FOUR LEAD

TENS,FOUR LEAD

TENS, FOUR LEAD






E0747 A $2,569.39 000-099 Y N Y 000-099

E0748 A $2,727.66 000-099 Y N Y 000-099

E0776 IV POLE A $98.96 000-099 Y N Y 000-099E0776 RA IV POLE A $98.96 000-099 Y N Y 000-099E0776 RB IV POLE A $0.01 000-099 Y N Y 000-099E0776 RR IV POLE A $9.90 000-099 Y N NE0784 A $3,848.32 000-099 Y N Y 000-099

E0784 RA A $3,848.32 000-099 Y N Y 000-099

E0784 RB A $0.01 000-099 Y N Y 000-099

E0840 A $43.06 000-099 Y N N

E0840 RR A $4.30 000-099 Y N N

E0850 A $61.73 000-099 Y N N

E0850 RR A $6.17 000-099 Y N N

FORM FITT.COND.GAR.FOR DEL.TNS

OSTEOGENESIS STIMULATOR

OSTEOGENIC

STIMULATOR EXT. AMBULATORY

INF. PUMP 1 PER 5

YEARS 250.00-250.13, 250.20-250.23, 250.30-250.33, 250.40-250.43, 250.50-250.53, 250.60-250.63 250.70-250.73, 250.80-250.83, 250.90-250.93, 648.00-648.04

EXT. AMBULATORY INF. PUMP

1 PER 5 YEARS

250.00-250.13, 250.20-250.23, 250.30-250.33, 250.40-250.43, 250.50-250.53, 250.60-250.63 250.70-250.73, 250.80-250.83, 250.90-250.93, 648.00-648.04

EXT. AMBULATORY INF. PUMP

TRACTION

FRAME,CERVICAL 1 PER

LIFETIME TRACTION

FRAME,CERVICAL 10 MONTHS = PURCHASE

TRACTION

STAND,CERVICAL 1 PER

LIFETIME TRACTION

STAND,CERVICAL 10 MONTHS = PURCHASE






E0860 RR A $2.94 000-099 Y N N

E0870 A $80.39 000-099 Y N N

E0870 RR A $8.04 000-099 Y N N

E0880 A $86.77 000-099 Y N N

E0880 RR A $8.68 000-099 Y N N

E0890 A $70.74 000-099 Y N N

E0890 RR A $7.08 000-099 Y N N

E0900 A $77.62 000-099 Y N N

E0900 RR A $7.86 000-099 Y N N

E0910 A $145.41 000-099 Y N Y 000-099

E0910 RA A $145.41 000-099 Y N Y 000-099

E0910 RB A $0.01 000-099 Y N Y 000-099

E0910 RR A $14.73 000-099 Y N Y 000-099

E0911 A $329.28 000-099 N N Y 000-099

TRACTION,OVERDOOR,CERVICAL

1 PER LIFETIME

TRACTION,OVERDOO

R,CERVICAL 10 MONTHS = PURCHASE

TRACTION

FRAME,EXTREMITY

1 PER LIFETIME

TRACTION

FRAME,EXTREMITY


TRACTION

STAND,EXTREMITY

1 PER LIFETIME

TRACTION

STAND,EXTREMITY


TRACTION FRAME,PELVIC

1 PER LIFETIME

TRACTION

FRAME,PELVIC 10 MONTHS = PURCHASE

TRACTION

STAND,PELVIC 1 PER

LIFETIME TRACTION STAND,

PELVIC 10 MONTHS = PURCHASE

TRAPEZE,ATT TO

BED 1 PER

LIFETIME 340, 343 - 343.99, 359.0 - 359.1, 806 - 806.39

TRAPEZE,ATT TO BED

1 PER LIFETIME

340, 343 - 343.99, 359.0 - 359.1, 806 - 806.39

TRAPEZE,ATT TO BED

TRAPEZE,ATT TO

BED 10 MONTHS = PURCHASE

340. -340. 343. -343.99 359.0 -359.1 806. -806.39

HD TRAPEZE BAR ATTACH TO BED

1 PER LIFETIME

340, 343 - 343.99, 359.0 - 359.1, 806 - 806.39





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0911 RA A $329.28 000-099 N N Y 000-099

E0911 RB A $0.01 000-099 N N Y 000-099

E0911 RR A $32.93 000-099 N N Y 000-099

E0912 A $329.28 000-099 N N Y 000-099

E0912 RA A $329.28 000-099 N N Y 000-099

E0912 RB A $0.01 000-099 N N Y 000-099

E0912 RR A $32.93 000-099 N N Y 000-099

E0920 A $361.45 000-099 Y N Y 000-099

E0920 RR A $36.14 000-099 Y N Y 000-099

E0930 A $113.97 000-099 Y N Y 000-099

▪ E0930 RR A $11.40 000-099 Y N Y 000-099

E0935 RR A $21.82 000-099 N N Y 000-099

E0936 RR A $21.82 000-099 N N Y 000-099


1 PER LIFETIME

340, 343 - 343.99, 359.0 - 359.1, 806 - 806.39




340. -340. 343. -343.99 359.0 -359.1 806. -806.39

HD TRAPEZE BAR FREE STANDING

1 PER LIFETIME

340, 343 - 343.99, 359.0 - 359.1, 806 - 806.39


1 PER LIFETIME

340, 343 - 343.99, 359.0 - 359.1, 806 - 806.39




340. -340. 343. -343.99 359.0 -359.1 806. -806.39

FRACTURE FRAME,ATT. BED W WGTS

FRACTURE FRAME,ATT. BED W WGTS

FRACTURE FRAME,STAND,W WGTS

FRACTURE FRAME,STAND,W WGTS

PASSIVE MOTION EXERCISE DEVICE

UP TO 21 DAYS OF RENTAL

CONT. PASSIVE MOTION DEVICE OTHER THAN KNEE

UP TO 21 DAYS OF RENTAL






E0940 RA A $289.84 000-099 Y N Y 000-099

E0940 RB A $0.01 000-099 Y N Y 000-099

▪ E0940 RR A $28.98 000-099 Y N Y 000-099

E0942 A $13.72 000-099 Y N N

E0942 RR A $1.37 000-099 Y N N

E0944 A $34.38 000-099 Y N N

E0944 RA A $34.38 000-099 Y N N

E0944 RR A $3.44 000-099 Y N N

E0945 A $34.38 000-099 Y N N

E0945 RA A $34.38 000-099 Y N N

E0945 RR A $3.44 000-099 Y N N

E0946 A $212.23 000-099 Y N Y 000-099

TRAPEZE BAR,STAND,W GRAB BAR




CERVICAL HEAD HARNESS/HALTER

1 PER MEDICAL EVENT

CERVICAL HEAD HARNESS/HALTER


PELVIC BELT/HARNESS/BOOT

1 PER MEDICAL EVENT


1 PER MEDICAL EVENT



EXTREMITY BELT/HARNESS

1 PER MEDICAL EVENT


1 PER MEDICAL EVENT



FRACTURE

FRAME,DUAL CROSSBARS






E0947 A $384.91 000-099 Y N Y 000-099

E0947 RR A $38.50 000-099 Y N Y 000-099

E0948 A $358.85 000-099 Y N Y 000-099

E0948 RR A $35.88 000-099 Y N Y 000-099

E0950 TRAY A $95.80 000-099 N N Y 000-099E0950 RA TRAY A $95.80 000-099 N N Y 000-099E0950 RB TRAY A $0.01 000-099 N N Y 000-099E0950 RR TRAY A $9.59 000-099 N N Y 000-099E0950 U4 TRAY A $0.01 000-020 N N Y 000-099E0951 LOOP HEEL A $15.14 1 PER YEAR 000-099 N N NE0951 RA LOOP HEEL A $15.14 1 PER YEAR 000-099 N N NE0951 RR LOOP HEEL A $1.51 000-099 N N N

E0952 A $14.63 1 PER YEAR 000-099 N N N

E0952 RA A $14.63 1 PER YEAR 000-099 N N N

E0952 RR A $1.47 000-099 N N N

E0955 A $186.33 000-099 N N Y 000-099

E0955 RA A $186.33 000-099 N N Y 000-099

E0955 RB A $0.01 000-099 N N Y 000-099

FRACTURE FRAME,DUAL CROSSBARS

FRACTURE FRAME,ATT.PELVIC

FRACTURE

FRAME,ATT.PELVIC

FRACTURE

FRAME,ATT.CERVICAL

FRACTURE FRAME,ATT.CERVICAL



TOE LOOP/HOLDER, EACH




CUSHIONED HEADREST

CUSHIONED HEADREST

CUSHIONED HEADREST






E0955 U4 A $0.01 000-020 N N Y 000-099

E0956 A $90.85 000-099 N N Y 000-099

E0956 RA A $90.85 000-099 N N Y 000-099

E0956 RB A $0.01 000-099 N N Y 000-099

E0956 RR A $9.08 000-099 N N Y 000-099

E0957 A $127.11 000-099 N N Y 000-099

E0957 RA A $127.11 000-099 N N Y 000-099

E0957 RB A $0.01 000-099 N N Y 000-099

E0957 RR A $12.71 000-099 N N Y 000-099

E0958 A $383.66 000-099 N N Y 000-099

E0958 RA A $383.66 000-099 N N Y 000-099

E0958 RB A $0.01 000-099 N N Y 000-099

E0958 RR A $38.36 000-099 N N Y 000-099

E0959 A $37.23 000-099 N N Y 000-099

E0959 RA A $37.23 000-099 N N Y 000-099

CUSHIONED HEADREST


CUSHIONED HEADREST

W/C LATERAL TRUNK/HIP SUPPOR





W/C MEDIAL THIGH SUPPOR





WHLCH ATT-CONV 1 ARM DRIVE





AMPUTEE ADAPTER

1 PER 2 YEARS

AMPUTEE ADAPTER

1 PER 2 YEARS






E0960 A $83.85 000-099 N N Y 000-099

E0960 RA A $83.85 000-099 N N Y 000-099

E0960 RR A $8.38 000-099 N N Y 000-099

E0960 U4 A $0.01 000-020 N N Y 000-099

E0961 A $24.84 000-099 N N Y 000-099

E0961 RA A $24.84 000-099 N N N 000-099

E0961 RR A $2.49 000-099 N N Y 000-099

E0966 A $65.76 000-099 N N Y 000-099

E0966 RA A $65.76 000-099 N N N

E0966 RR A $6.49 000-099 N N Y 000-099

E0967 A $60.54 000-099 N N N

E0967 RA A $60.54 000-099 N N N

E0967 RR A $6.06 000-099 N N N

E0968 A $164.69 000-099 N N Y 000-099

E0968 RR A $16.47 000-099 N N Y 000-099

E0969 A $143.19 000-099 N N Y 000-099

AMPUTEE ADAPTER


W/C SHOULDER HARNESS/STRAPS





WHEECHAIR BRAKE EXTENSION

2 PER 2 YEARS


2 PER 2 YEARS



WHEELCHAIR HEAD REST EXTENSI

1 PER 2 YEARS


1 PER 2 YEARS



WHEELCHAIR HAND RIMS

1 EACH PER SIDE FOR 5

YEARS



YEARS



COMMODE SEAT,WHEELCHAIR

COMMODE

SEAT,WHEELCHAIR


NARROWING DEVICE,WC






E0971 RR A $4.17 000-099 N N N

E0971 A $41.65 000-099 N N N

E0973 A $67.55 000-099 N N Y 000-099

E0973 RA A $67.55 000-099 N N N

E0973 RB A $0.01 000-099 N N Y 000-099

E0973 RR A $6.76 000-099 N N Y 000-099

E0974 A $72.26 000-099 N N Y 000-099

E0974 RA A $72.26 000-099 N N N

E0974 RR A $7.23 000-099 N N Y 000-099

E0978 A $33.54 000-099 N N N

E0978 RA A $33.54 000-099 N N N

E0978 RR A $3.35 000-099 N N N

E0978 U4 A $0.01 000-020 N N Y 000-099

E0980 A $26.98 000-099 Y N N

E0980 RR A $2.70 000-099 Y N N

E0981 RB A $0.01 000-099 N N Y 000-099

NARROWING DEVICE,WC


WHEELCHAIR ANTI-TIPPING DEVICE


WHEELCHAIR ANTI-TIPPING DEVICE


YEARS

W/CH ACCESS DET ADJ ARMREST

2 PER 2 YEARS


2 PER 2 YEARS




W/CH ACCESS ANTI-ROLLBACK

2 PER 2 YEARS


2 PER 2 YEARS



W/C ACC SAF BELT PELV STRAP

1 PER 5 YEARS


1 PER 5 YEARS




1 PER 5 YEARS

SAFETY VEST,WC

1 PER 2 YEARS

SAFETY VEST,WC


SEAT UPHOLSTERY, REPL ONLYACEMENT





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0981 RR A $3.82 000-099 N N N

E0981 A $38.25 000-099 N N N

E0982 RB A $0.01 000-099 N N Y 000-099

E0982 RR A $3.63 000-099 N N N

E0982 A $36.31 000-099 N N N

E0983 RR ADD PWR JOYSTICK A $219.09 000-099 N N Y 000-099

▪ E0983 ADD PWR JOYSTICK A $2,190.90 000-099 N N Y 000-099E0984 RR ADD PWR TILLER A $149.66 000-099 N N Y 000-099

E0984 ADD PWR TILLER A $1,496.67 000-099 N N Y 000-099E0986 A $4,309.40 000-099 N N Y 000-099

E0986 RA A $4,309.40 000-099 N N Y 000-099

E0986 RB A $0.01 000-099 N N Y 000-099

E0986 RR A $430.94 000-099 N N Y 000-099

E0990 A $92.00 000-099 N N Y 000-099




1 PER 3 YEARS

BACK UPHOLSTERY, REPL ONLYACEMENT




1 PER 3 YEARS



MAN W/C PUSH-RIM POW ASSIST





WHEELCHAIR ELEVATING LEG RES

2 PER 2 YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE0990 RA A $92.00 000-099 N N N

E0990 RB A $0.01 000-099 N N Y 000-099

E0990 RR A $9.20 000-099 N N Y 000-099

E0992 A $74.53 000-099 N N N

E0992 RA A $74.53 000-099 N N N

E0992 RR A $7.25 000-099 N N N

E0995 A $27.79 000-099 N N N

E0995 RA A $27.79 000-099 N N N

E0995 RR A $2.78 000-099 N N N

E1002 RR PWR SEAT TILT A $379.06 000-099 N N Y 000-099

E1002 PWR SEAT TILT A $3,790.56 000-099 N N Y 000-099E1003 RR PWR SEAT RECLINE A $404.71 000-099 N N Y 000-099

E1003 PWR SEAT RECLINE A $4,047.02 000-099 N N Y 000-099

E1006 RR A $594.96 000-099 N N Y 000-099

E1006 A $5,949.57 000-099 N N Y 000-099

E1010 A $768.62 000-099 N N Y 000-099

E1011 RR A $18.43 000-020 N N Y 000-020


2 PER 2 YEARS




WHEELCHAIR SOLID SEAT INSERT

1 PER 5 YEARS


1 PER 5 YEARS



WHEELCHAIR CALF REST

1 PER 5 YEARS


1 PER 5 YEARS





PWR SEAT COMBO W/O SHEAR


PWR SEAT COMBO W/O SHEAR

ADD PWR LEG ELEVATION

PED WC MODIFY WIDTH ADJUSTM


335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3






E1014 RR A $33.66 000-020 N N Y 000-020

E1014 A $336.51 000-020 N N Y 000-020

E1015 RR A $10.56 000-099 N N Y 000-099

E1015 A $105.71 000-099 N N Y 000-099

E1016 RR A $12.11 000-099 N N Y 000-099

E1016 A $121.02 000-099 N N Y 000-099

E1017 RR A $0.01 000-099 N N Y 000-099

E1017 A $0.01 000-099 N N Y 000-099

E1018 RR A $0.01 000-099 N N Y 000-099

E1018 A $0.01 000-099 N N Y 000-099

E1020 A $224.32 000-099 N N Y 000-099

E1020 RA A $224.32 000-099 N N Y 000-099

E1020 RR A $22.42 000-099 N N Y 000-099

E1028 RR A $13.88 000-099 N N Y 000-099

E1028 A $138.79 000-099 N N Y 000-099

E1029 RR A $24.84 000-099 N N Y 000-099

E1029 A $248.32 000-099 N N Y 000-099

PED WC MODIFY WIDTH ADJUSTM

1 PER 2 YEARS

335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3

RECLINING BACK ADD PED W/C


RECLINING BACK ADD PED W/C

SHOCK ABSORBER FOR MAN W/C


SHOCK ABSORBER FOR MAN W/C

SHOCK ABSORBER FOR POWER W/C


SHOCK ABSORBER FOR POWER W/C

HD SHCK ABSRBR FOR HD MAN WC


HD SHCK ABSRBR FOR HD MAN WC

HD SHCK ABSRBER FOR HD POW WC

10 MONTHS = PURCHSE

HD SHCK ABSRBER FOR HD POW WC

RESIDUAL LIMB SUPPORT SYSTEM




W/C MANUAL SWINGAWAY


W/C MANUAL SWINGAWAY

W/C VENT TRAY FIXED


W/C VENT TRAY FIXED






E1030 A $783.05 000-099 N N Y 000-099

E1037 A $508.40 000-020 Y N Y 000-020

E1037 RA A $508.40 000-020 Y N Y 000-020

E1037 RB A $0.01 000-020 Y N Y 000-020

E1037 RR A $50.83 000-020 Y N Y 000-020

E1038 A $173.09 000-099 Y N Y 000-099

E1038 RA A $173.09 000-099 Y N Y 000-099

E1038 RB A $0.01 000-099 Y N Y 000-099

E1038 RR A $17.31 000-099 Y N Y 000-099

E1039 RR A $32.83 000-099 Y N Y 000-099

E1039 A $328.32 000-099 Y N Y 000-099

E1161 A $2,174.24 000-099 N N Y 000-099

E1161 RA A $2,174.24 000-099 N N Y 000-099

E1161 RB A $0.01 000-099 N N Y 000-099

E1161 RR A $217.42 000-099 N N Y 000-099

E1226 A $502.87 000-099 N N Y 000-099

W/C VENT TRAY GIMBALED


W/C VENT TRAY GIMBALED

TRANSPORT CHAIR, PED SIZE

1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3


1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3




335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3

TRANSPORT CHAIR PT WT<250LB





TRANSPORT CHAIR PT WT>=250LB


TRANSPORT CHAIR PT WT>=250LB

MANUAL ADULT WC W TILTINSPAC





MANUAL FULLY RECLINING BACK

1 PER 2 YEARS






E1226 RB A $0.01 000-099 N N Y 000-099

E1226 RR A $50.29 000-099 N N Y 000-099

E1227 A $255.74 000-099 N N Y 000-099

E1227 RA A $255.74 000-099 N N Y 000-099

E1227 RR A $25.57 000-099 N N Y 000-099

E1228 A $258.23 000-099 N N Y 000-099

E1228 RA A $258.23 000-099 N N Y 000-099

E1228 RR A $25.82 000-099 N N Y 000-099

E1229 A $0.01 000-020 N N Y 000-020

E1229 RA A $0.01 000-020 N N Y 000-020

E1229 RB A $0.01 000-020 N N Y 000-020

E1230 A $1,771.80 000-099 N N Y 000-099

E1230 RA A $1,771.80 000-099 N N Y 000-099

E1230 RR A $177.18 000-099 N N Y 000-099

E1231 A $2,300.31 000-020 N N Y 000-020

E1231 RA A $2,300.31 000-020 N N Y 000-020


1 PER 2 YEARS




SPECIAL HGT ARMS WC

SPECIAL HGT. ARMS

WC SPECIAL HGT. ARMS

WC 10 MONTHS = PURCHASE

SPECIAL BACK HGT WC

SPECIAL BACK HGT.

WC SPECIAL BACK HGT.

WC 10 MONTHS = PURCHASE

PEDIATRIC WHEELCHAIR NOS



POWER VEHICLE 3 WHEEL

POWER VEHICLE 3

WHEEL POWER VEHICLE 3

WHEEL 10 MONTHS = PURCHASE

RIGID PED W/C TILT-

IN-SPACE1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3

RIGID PED W/C TILT-IN-SPACE

1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE1231 RB A $0.01 000-020 N N Y 000-020

E1231 RR A $230.04 000-020 N N Y 000-020

E1232 A $1,966.88 000-020 N N Y 000-020

E1232 RA A $1,966.88 000-020 N N Y 000-099

E1232 RB A $0.01 000-020 N N Y 000-020

E1233 A $2,042.02 000-020 N N Y 000-020

E1233 RA A $2,042.02 000-020 N N Y 000-020

E1233 RB A $0.01 000-020 N N Y 000-020

E1233 RR A $204.20 000-020 N N Y 000-020

E1234 A $1,777.72 000-020 N N Y 000-020

E1234 RA A $1,777.72 000-020 N N Y 000-020

E1234 RB A $0.01 000-020 N N Y 000-020

E1234 RR A $177.77 000-020 N N Y 000-020




335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3

FOLDING PED WC TILT-IN-SPACE

1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3


1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3


RIG PED WC TILTNSPC W/O SEAT

1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3


1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3




335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3

FLD PED WC TILTNSPC W/O SEAT

1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3


1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3




335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE1235 A $1,711.80 000-020 N N Y 000-020

E1235 RA A $1,711.80 000-020 N N Y 000-020

E1235 RB A $0.01 000-020 N N Y 000-020

E1235 RR A $171.18 000-020 N N Y 000-020

E1236 A $1,133.87 000-020 N N Y 000-020

E1236 RA A $1,133.87 000-020 N N Y 000-020

E1236 RB A $0.01 000-020 N N Y 000-020

E1236 RR A $113.39 000-020 N N Y 000-020

E1237 A $1,523.45 000-020 N N Y 000-020

E1237 RA A $1,523.45 000-020 N N Y 000-020

E1237 RB A $0.01 000-020 N N Y 000-020

E1237 RR A $152.34 000-020 N N Y 000-020

E1238 A $1,133.87 000-020 N N Y 000-020

RIGID PED W/C ADJUSTABLE

1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3


1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3



10 M0NTHS = PURCHASE

335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3

FOLDING PED WC ADJUSTABLE

1 PER 2 YEARS

335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3


1 PER 2 YEARS

335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3




335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3

RGD PED WC ADJSTABL W/O SEAT

1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3


1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3




335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3

FLD PED WC ADJSTABLE W/O SEAT

1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE1238 RA A $1,133.87 000-020 N N Y 000-020

E1238 RB A $0.01 000-020 N N Y 000-020

E1238 RR A $113.39 000-020 N N Y 000-020

E1239 A $0.01 000-020 N N Y 000-020

E1239 RA A $0.01 000-020 N N Y 000-020

E1239 RB A $0.01 000-020 N N Y 000-020

E1296 A $382.06 000-099 N N Y 000-099

E1296 RR A $38.21 000-099 N N Y 000-099

E1297 A $96.41 000-099 N N Y 000-099

E1297 RR A $9.64 000-099 N N Y 000-099

E1298 A $331.87 000-099 N N Y 000-099

E1298 RR A $33.19 000-099 N N Y 000-099

E1356 A $0.01 1 PER YEAR 000-099 N N Y 000-099

E1357 A $0.01 000-099 N N Y 000-099


1 PER 2 YEARS

335.0 - 335.9, 342.00-343.9, 358.8-359.9, 741.00-742.3




335.0 - 335.9 342.00-343.9 358.8-359.9 741.00-742.3

PED POWER WHEELCHAIR NOS



SPECIAL WC SEAT HEIGHT

SPECIAL WC SEAT

HEIGHT 10 MONTHS = PURCHASE

SPECIAL WC SEAT DEPTH UPH.

SPECIAL WC SEAT

DEPTH UPH. 10 MONTHS = PURCHASE

SPECIAL WC SEAT DEPTH/WIDTH

SPECIAL WC SEAT

DEPTH/WIDTH 10 MONTHS = PURCHASE

OXYGEN ACCESS., BATT. PACK/CART. FOR PORT. CONC., REPLC. ONLY

OXYGEN ACCESS., BATT. CHRGR. PACK/CART. FOR PORT. CONC., REPLC. ONLY

1 PER 3 YEARS






E1391 RR A $153.92 000-099 N N Y 000-099

E1399 A $0.01 000-099 N N Y 000-099

E1399 RA A $0.01 000-099 N N Y 000-099

E1399 RB A $0.01 000-099 N N Y 000-099

E1399 RR A $0.01 000-099 N N Y 000-099

E1405 RR A $212.17 000-099 N N N

E1406 RR A $164.74 000-099 N N N

E1639 SCALE, EACH A $0.01 000-020 N N Y 000-020E1902 A $27.65 000-099 N N Y 000-099

OXYGEN CONCENTRATOR "The rate for nursing facility residents is $107.74"

ONCE PER MONTH

011.00 -011.99, 114.0 -114.9, 162.0 -169.9, 197.0 -197.3, 207.00 -207.10, 277.00-277.09, 281.2 -281.2, 289.0 -289.6, 327.21, 327.23-327.26, 357.0 -359.9, 416.0 -416.9, 428.0 -428.9, 481, 491-492.8, 494 - 494.1, 496-496, 505 -505, 515 - 515, 516.3- 516.3, 518.1 - 518.3, 748.3, 770.7 -770.84, 780.53-780.53, 780.55-780.55, 780.57-780.57

OXYGEN CONCENTRATOR, DUAL

DURABLE MEDICAL EQUIPMENT NOC

DURABLE MEDICAL

EQUIPMENT NOC DURABLE MEDICAL

EQUIPMENT NOC DURABLE MEDICAL

EQUIPMENT NOC OXYGEN & WATER

SYS W/HEAT ONCE PER

MONTH OXYGEN & WATER

SYS W/O HEAT ONCE PER

MONTH

AAC NON-ELECTRONIC BOARD






E1902 RB A $0.01 000-099 N N Y 000-099

E2000 RR A $35.68 000-099 Y N Y 000-099

E2100 A $393.63 000-099 Y N Y 000-099

E2100 RR A $39.36 000-099 Y N Y 000-099

E2201 RR A $26.86 000-099 N N Y 000-099

E2201 A $268.64 000-099 N N Y 000-099

E2202 RR SEAT WIDTH 24-27 IN A $34.13 000-099 N N Y 000-099

E2202 SEAT WIDTH 24-27 IN A $341.27 000-099 N N Y 000-099

E2203 RR A $34.49 000-099 N N Y 000-099

E2203 A $344.92 000-099 N N Y 000-099

E2204 RR A $58.57 000-099 N N Y 000-099

E2204 A $585.65 000-099 N N Y 000-099

E2205 A $30.12 000-099 N N N

E2205 RA A $30.12 000-099 N N N

E2205 RR A $3.01 000-099 N N N



GASTRIC SUCTION PUMP HME MDL

BLD GLUCOSE

MONITOR W VOICE BLD GLUCOSE

MONITOR W VOICE MAN W/CH ACC SEAT

W>=20"<24"

MAN W/CH ACC SEAT W>=20"<24"

FRAME DEPTH LESS THAN 22 IN

FRAME DEPTH LESS THAN 22 IN

FRAME DEPTH 22 TO 25 IN

FRAME DEPTH 22 TO 25 IN

MANUAL WC ACCESSORY, HANDRIM

1 PER 2 YEARS


1 PER 2 YEARS







CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISE2206 A $37.19 000-099 N N N

E2206 RA A $37.19 000-099 N N N

E2207 A $39.63 000-099 N N N

E2207 RA A $39.63 000-099 N N N

E2207 RR A $3.97 000-099 N N N

E2208 A $108.60 000-099 N N Y 000-099

E2208 RA A $108.60 000-099 N N Y 000-099

E2208 RR A $10.86 000-099 N N Y 000-099

E2209 ARM TROUGH EACH A $97.97 000-099 N N Y 000-099

E2209 RA ARM TROUGH EACH A $97.97 000-099 N N Y 000-099

E2209 RR ARM TROUGH EACH A $9.79 000-099 N N Y 000-099

E2210 A $6.29 000-099 N N N

E2210 RA A $6.29 000-099 N N N

E2210 RR A $0.63 000-099 N N N

E2211 A $31.43 000-099 N N Y 000-099

E2211 RA A $31.43 000-099 N N Y 000-099

E2211 RR A $3.14 000-099 N N Y 000-099

E2212 A $5.38 000-099 N N N

COMPLETE WHEEL LOCK ASSEMBLY

1 PER 2 YEARS

COMPLETE WHEEL LOCK ASSEMBLY

1 PER 2 YEARS

CRUTCH AND CANE HOLDER

1 PER 2 YEARS


1 PER 2 YEARS



CYLINDER TANK CARRIER

1 PER 2 YEARS


1 PER 2 YEARS



1 PER 2 YEARS

1 PER 2 YEARS


WHEELCHAIR BEARINGS

ONCE PER YEAR

WHEELCHAIR BEARINGS

ONCE PER YEAR

WHEELCHAIR BEARINGS


PNEUMATIC PROPULSION TIRE

1 PER 2 YEARS


1 PER 2 YEARS



PNEUMATIC PROP TIRE TUBE

1 PER SIDE PER 2 YEARS






E2212 RR A $0.54 000-099 N N N

E2213 A $28.02 000-099 N N N

E2213 RA A $28.02 000-099 N N N

E2213 RR A $2.80 000-099 N N N

E2214 A $32.91 000-099 N N Y 000-099

E2214 RA A $32.91 000-099 N N Y 000-099

E2214 RR A $3.29 000-099 N N Y 000-099

E2215 A $8.78 000-099 N N N

E2215 RA A $8.78 000-099 N N N

E2215 RR A $0.88 000-099 N N N

E2216 A $53.76 000-099 N N Y 000-099

E2216 RA A $53.76 000-099 N N Y 000-099

E2216 RR A $5.38 000-099 N N Y 000-099

E2217 A $40.32 000-099 N N Y 000-099

E2217 RA A $40.32 000-099 N N Y 000-099

E2217 RR A $4.03 000-099 N N Y 000-099

E2219 A $40.18 000-099 N N N





PNEUMATIC PROP TIRE INSERT






PNEUMATIC CASTER TIRE EACH

1 PER 2 YEARS


1 PER 2 YEARS



PNEUMATIC CASTER TIRE TUBE






FOAM FILLED PROPULSION TIRE

1 PER 2 YEARS


1 PER 2 YEARS



FOAM FILLED CASTER TIRE EACH

1 PER 2 YEARS


1 PER 2 YEARS



FOAM CASTER TIRE ANY SIZE EA







E2219 RR A $4.02 000-099 N N N

E2220 A $22.16 000-099 N N N

E2220 RA A $22.16 000-099 N N N

E2220 RR A $2.22 000-099 N N N

E2221 A $23.36 000-099 N N N

E2221 RA A $23.36 000-099 N N N

E2221 RR A $2.33 000-099 N N N

E2222 A $16.03 000-099 N N N

E2222 RA A $16.03 000-099 N N N

E2222 RR A $1.60 000-099 N N N

E2223 A $4.80 000-099 N N N

E2223 RB A $0.01 000-099 N N Y 000-099

E2223 RR A $0.48 000-099 N N N

E2224 A $80.02 000-099 N N N





SOLID PROPULSION TIRE EACH

1 PER 2 YEARS


1 PER 2 YEARS



SOLID CASTER TIRE EACH






SOLID CASTER INTEGRATED WHL






VALVE REPL ONLYACEMENT ONLY EACH





PROPULSION WHL EXCLUDES TIRE







E2224 RR A $8.01 000-099 N N N

E2225 A $16.70 000-099 N N N

E2225 RA A $16.70 000-099 N N N

E2225 RR A $1.67 000-099 N N N

E2226 A $36.42 000-099 N N N

E2226 RB A $0.01 000-099 N N Y 000-099

E2226 RR A $3.64 000-099 N N N

E2231 RA A $123.92 000-099 N N Y 000-099

E2231 A $123.92 000-099 N N Y 000-099

E2291 A $0.01 000-020 N N Y 000-020

E2292 A $0.01 000-020 N N Y 000-020





CASTER WHEELEXCLUDES TIRE






CASTER FORK REPL ACEMENT ONLY





MAN. W/C ACCESS., SOLID SEAT SUPP. BASE, INCL. ANY TYPE MOUNT. HRDWR.

< 21 2 PER YEARS 21 & > 1 PER 5

YEARS

MAN. W/C ACCESS., SOLID SEAT SUPP. BASE, INCL. ANY TYPE MOUNT. HRDWR.

< 21 2 PER YEARS 21 & > 1 PER 5

YEARS

PLANAR BACK FOR PED SIZE WC

PLANAR SEAT FOR PED SIZE WC






E2294 A $0.01 000-020 N N Y 000-020

E2295 RA A $0.01 000-099 N N Y 000-099

E2295 A $0.01 000-099 N N Y 000-099

E2300 A $0.01 000-099 N N Y 000-099

E2301 PWR STANDING A $0.01 000-099 N N Y 000-099E2310 RR A $78.64 000-099 Y N Y 000-099

E2310 A $786.39 000-099 Y N Y 000-099

E2311 RR A $159.21 000-099 Y N Y 000-099

E2311 A $1,592.10 000-099 Y N Y 000-099

E2321 RR A $114.41 000-099 N N Y 000-099

E2321 A $1,144.16 000-099 N N Y 000-099

E2325 RR A $96.97 000-099 N N Y 000-099

CONTOUR BACK FOR PED SIZE WC

CONTOUR SEAT FOR PED SIZE WC

MAN. W/C ACCESS. FOR PED. SZ. W/C, DYNAMIC SEAT. FRAME, ALLOWS COORD. MVMT OF MULT. POSITION.

< 21 2 PER YEARS 21 & > 1 PER 5

YEARS

MAN. W/C ACCESS. FOR PED. SZ. W/C, DYNAMIC SEAT. FRAME, ALLOWS COORD. MVMT OF MULT. POSITION.

< 21 2 PER YEARS 21 & > 1 PER 5

YEARS

PWR SEAT ELEVATION SYS

ELECTRO. CONNECT BTW. CONTRL.


ELECTRO. CONNECT BTW. CONTRL.

1 PER 2 YEARS

ELECTRO. CONNECT BTW. 2 SYS.


ELECTRO. CONNECT BTW. 2 SYS.

1 PER 2 YEARS

HAND INTERFACE JOYSTICK


HAND INTERFACE JOYSTICK

SIP AND PUFF INTERFACE







E2327 RR A $188.09 000-099 N N Y 000-099

E2327 A $1,880.92 000-099 N N Y 000-099

E2328 RR A $260.78 000-099 N N Y 000-099

E2328 A $2,607.83 000-099 N N Y 000-099

E2329 RR A $127.16 000-099 N N Y 000-099

E2329 A $1,271.62 000-099 N N Y 000-099

E2330 RR A $246.39 000-099 N N Y 000-099

E2330 A $2,463.91 000-099 N N Y 000-099

E2331 A $0.01 000-099 N N Y 000-099

E2340 RR A $25.80 000-099 N N Y 000-099

E2340 A $258.02 000-099 N N Y 000-099

E2341 RR A $38.71 000-099 N N Y 000-099

E2341 A $387.06 000-099 N N Y 000-099

E2342 RR A $32.26 000-099 N N Y 000-099

E2342 A $322.55 000-099 N N Y 000-099

E2343 RR A $51.61 000-099 N N Y 000-099

SIP AND PUFF INTERFACE

HEAD CONTROL INTERFACE MECH


HEAD CONTROL INTERFACE MECH

HEAD/EXTREMITY CONTROL INTER


HEAD/EXTREMITY CONTROL INTER

HEAD CONTROL NONPROPORTIONAL


HEAD CONTROL NONPROPORTIONAL

HEAD CONTROL PROXIMITY SWITC


HEAD CONTROL PROXIMITY SWITC

ATTENDANT CONTROL

W/C WDTH 20-23 IN SEAT FRAME






W/C DPTH 20-21 IN SEAT FRAME










E2351 RR A $50.30 000-099 N N Y 000-099

E2351 A $503.01 000-099 N N Y 000-099

E2360 A $87.30 000-099 N N N

E2360 RA A $87.30 000-099 N N N

E2360 RR A $8.74 000-099 N N N

E2361 A $127.51 000-099 N N Y 000-099

E2361 RA A $127.51 000-099 N N Y 000-099

E2361 RR A $12.75 000-099 N N Y 000-099

E2362 A $84.09 000-099 N N N

E2362 RA A $84.09 000-099 N N N

E2362 RR A $8.37 000-099 N N N

E2363 A $170.05 000-099 N N Y 000-099

E2363 RA A $170.05 000-099 N N Y 000-099

E2363 RR A $17.00 000-099 N N Y 000-099

E2364 A $87.30 000-099 N N N

E2364 RA A $87.30 000-099 N N N

E2364 RR A $8.73 000-099 N N N


ELECTRONIC SGD INTERFACE


ELECTRONIC SGD INTERFACE

22NF NONSEALED LEADACID

1 EACH PER 2 YEARS


1 EACH PER 2 YEARS



22NF SEALED LEADACID BATTERY




GR24 NONSEALED LEADACID

1 EACH PER 2 YEARS


1 EACH PER 2 YEARS



GR24 SEALED LEADACID BATTERY




UFNONSEALED LEADACID BATTERY

1 EACH PER 2 YEARS


1 EACH PER 2 YEARS








E2365 RA A $102.55 000-099 N N Y 000-099

E2365 RR A $10.25 000-099 N N Y 000-099

E2366 A $154.89 000-099 N N N

E2366 RA A $154.89 000-099 N N N

E2366 RR A $15.48 000-099 N N N

E2367 A $289.67 000-099 N N Y 000-099

E2367 RA A $289.67 000-099 N N Y 000-099

E2367 RR A $28.96 000-099 N N Y 000-099

E2368 A $347.13 000-099 N N Y 000-099

E2368 RB A $0.01 000-099 N N Y 000-099

E2368 RR A $34.71 000-099 N N Y 000-099

E2369 A $302.35 000-099 N N Y 000-099

U1 SEALED LEADACID BATTERY




BATTERY CHARGER, SINGLE MODE

1 PER 5 YEARS


1 PER 5 YEARS



BATTERY CHARGER, DUAL MODE




POWER WC MOTOR REPL ONLYACEMENT




PWR WC GEAR BOX REPL ONLYACEMENT






E2369 RR A $30.24 000-099 N N Y 000-099

E2370 A $539.50 000-099 N N Y 000-099

E2370 RA A $539.50 000-099 N N Y 000-099

E2370 RB A $0.01 000-099 N N Y 000-099

E2370 RR A $53.95 000-099 N N Y 000-099

E2371 A $144.71 1 PER YEAR 000-099 N N Y 000-099

E2371 RA A $144.71 1 PER YEAR 000-099 N N Y 000-099

E2371 RR A $14.47 000-099 N N Y 000-099

E2372 A $93.69 1 PER YEAR 000-099 N N Y 000-099

E2372 RA A $93.69 1 PER YEAR 000-099 N N Y 000-099

E2372 RR A $9.37 000-099 N N Y 000-099

E2373 A $845.61 000-099 N N Y 000-099

E2373 RA A $845.61 000-099 N N Y 000-099

E2374 A $358.86 000-099 N N Y 000-099




PWR WC MOTOR/GEAR BOX COMBO









GR27 NON-SEALED LEADACID




HAND/CHIN CTRL SPEC JOYSTICK

HAND/CHIN CTRL SPEC JOYSTICK

HAND/CHIN CTRL STD JOYSTICK, REPL ONLY






E2375 A $575.61 000-099 N N Y 000-099

E2375 RA A $575.61 000-099 N N Y 000-099

E2376 A $902.00 000-099 N N Y 000-099

E2376 RB A $0.01 000-099 N N Y 000-099

E2377 A $326.39 000-099 N N Y 000-099

E2381 A $69.65 000-099 N N N

E2381 RB A $0.01 000-099 N N Y 000-099

E2382 A $15.96 000-099 N N N

E2382 RB A $0.01 000-099 N N Y 000-099

E2383 A $116.20 000-099 N N N

HAND/CHIN CTRL STD JOYSTICK, REPL ONLY

NON-EXPANDABLE CONTROLLER

NON-EXPANDABLE CONTROLLER

EXPANDABLE CONTROLLER, REPL ONLY

EXPANDABLE CONTROLLER, REPL ONLY

EXPANDABLE CONTROLLER, INITL

PNEUM DRIVE WHEEL TIRE, ANY SIZE, EACH, REPL ONLY

2 EVERY 2 YEARS

PNEUM DRIVE WHEEL TIRE, ANY SIZE, EACH, REPL ONLY

TUBE, PNEUM WHEEL DRIVE TIRE, ANY SIZE, EACH, REPL ONLY

2 EVERY 2 YEARS

TUBE, PNEUM WHEEL DRIVE TIRE, ANY SIZE, EACH, REPL ONLY

INSERT, PNEUM WHEEL DRIVE, ANY SIZE, EACH, REPL ONLY

2 EVERY 2 YEARS






E2384 A $45.25 000-099 N N N

E2384 RB A $0.01 000-099 N N Y 000-099

E2385 A $45.25 000-099 N N N

E2385 RB A $0.01 000-099 N N Y 000-099

E2386 A $69.65 000-099 N N N

E2386 RB A $0.01 000-099 N N Y 000-099

E2387 A $45.25 000-099 N N N

E2387 RB A $0.01 000-099 N N Y 000-099

INSERT, PNEUM WHEEL DRIVE, ANY SIZE, EACH, REPL ONLY

PNEUMATIC CASTER TIRE, ANY SIZE, EACH, REPL ONLY

2 EVERY 2 YEARS

PNEUMATIC CASTER TIRE, ANY SIZE, EACH, REPL ONLY

TUBE, PNEUMATIC CASTER TIRE,ANY SIZE, EACH, REPL ONLY

2 EVERY 2 YEARS

TUBE, PNEUMATIC CASTER TIRE,ANY SIZE, EACH, REPL ONLY

FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, EACH, REPL ONLY

2 EVERY 2 YEARS

FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, EACH, REPL ONLY

FOAM FILLED CASTER TIRE, ANY SIZE, EACH, REPL ONLY

2 EVERY 2 YEARS

FOAM FILLED CASTER TIRE, ANY SIZE, EACH, REPL ONLY






E2388 RB A $0.01 000-099 N N Y 000-099

E2389 A $18.38 000-099 N N Y 000-099

E2389 RB A $0.01 000-099 N N Y 000-099

E2390 A $28.75 000-099 N N N

E2390 RB A $0.01 000-099 N N Y 000-099

E2391 A $15.74 000-099 N N N

E2391 RB A $0.01 000-099 N N Y 000-099

E2392 A $36.20 000-099 N N Y 000-099

E2392 RB A $0.01 000-099 N N Y 000-099

E2393 A $0.01 000-099 N N Y 000-099

FOAM DRIVE WHEEL TIRE, ANY SIZE, EACH, REPL ONLY

2 EVERY 2 YEARS

FOAM DRIVE WHEEL TIRE, ANY SIZE, EACH, REPL ONLY

FOAM CASTER TIRE, ANY SIZE, EACH, REPL ONLY

2 EVERY 2 YEARS

FOAM CASTER TIRE, ANY SIZE, EACH, REPL ONLY

SOLID DRIVE WHEEL TIRE, ANY SIZE, EACH, REPL ONLY

2 EVERY 2 YEARS

SOLID DRIVE WHEEL TIRE, ANY SIZE, EACH, REPL ONLY

SOLID CASTER TIRE, ANY SIZE, EACH, REPL ONLY

2 EVERY 2 YEARS

SOLID CASTER TIRE, ANY SIZE, EACH, REPL ONLY

SOLID CASTER TIRE, INTEGRATE, REPL ONLY

2 EVERY 2 YEARS

SOLID CASTER TIRE, INTEGRATE, REPL ONLY

VALVE, PNEUMATIC TIRE TUBE, REPL ONLY

4 EVERY 2 YEARS






E2394 A $51.57 000-099 N N Y 000-099

E2394 RB A $0.01 000-099 N N Y 000-099

E2395 A $36.65 000-099 N N Y 000-099

E2395 RB A $0.01 000-099 N N Y 000-099

E2396 A $43.41 000-099 N N N

E2396 RB A $0.01 000-099 N N Y 000-099

E2399 NOC INTERFACE A $0.01 000-099 N N Y 000-099E2402 RR A $39.54 000-099 N N Y 000-099

E2500 A $344.77 000-099 N N Y 000-099

E2500 RA A $344.77 000-099 N N Y 000-099

E2500 RB A $0.01 000-099 N N Y 000-099

E2500 RR A $34.47 000-099 N N Y 000-099

E2502 A $826.54 000-099 N N Y 000-099

VALVE, PNEUMATIC TIRE TUBE, REPL ONLY

DRIVE WHEEL, EXCLUDES TIRE, ANY SIZE, REPL ONLY

2 EVERY 2 YEARS

DRIVE WHEEL, EXCLUDES TIRE, ANY SIZE, REPL ONLY

CASTER WHEL EXCLUDES TIRE, ANY SIZE, REPL ONLY

2 EVERY 2 YEARS

CASTER WHEL EXCLUDES TIRE, ANY SIZE, REPL ONLY

CASTER FORK , ANY SIZE, REPL ONLY

2 EVERY 2 YEARS

CASTER FORK , ANY SIZE, REPL ONLY

NEG PRESS WOUND THERAPY PUMP

SGD DIGITIZED PRE-REC <=8MIN





SGD PREREC MSG >8MIN <=20MIN






E2502 RB A $0.01 000-099 N N Y 000-099

E2502 RR A $82.66 000-099 N N Y 000-099

E2504 A $1,332.68 000-099 N N Y 000-099

E2504 RA A $1,332.68 000-099 N N Y 000-099

E2504 RB A $0.01 000-099 N N Y 000-099

E2504 RR A $133.45 000-099 N N Y 000-099

E2506 A $1,775.62 000-099 N N Y 000-099

E2506 RA A $1,775.62 000-099 N N Y 000-099

E2506 RB A $0.01 000-099 N N Y 000-099

E2506 RR A $177.56 000-099 N N Y 000-099

E2508 A $3,153.45 000-099 N N Y 000-099

E2508 RA A $3,153.45 000-099 N N Y 000-099

E2508 RB A $0.01 000-099 N N Y 000-099

E2508 RR A $315.35 000-099 N N Y 000-099

E2510 A $5,967.48 000-099 N N Y 000-099

E2510 RA A $5,967.48 000-099 N N Y 000-099










SGD PREREC MSG >40 MIN





SGD SPELLING PHYS CONTACT





SGD W MULTI METHODS MSG/ACCS







E2510 RR A $596.75 000-099 N N Y 000-099

E2511 RR A $0.01 000-099 N N Y 000-099

E2511 A $0.01 000-099 N N Y 000-099

E2512 A $0.01 000-099 N N Y 000-099

E2512 RA A $0.01 000-099 N N Y 000-099

E2512 RR A $0.01 000-099 N N Y 000-099

E2599 A $0.01 000-099 N N Y 000-099

E2599 RA A $0.01 000-099 N N Y 000-099

E2599 RR A $0.01 000-099 N N Y 000-099

E2601 RR A $5.40 000-099 Y N N

E2601 A $54.04 000-099 Y N N

E2602 RR A $9.17 000-099 Y N N

E2602 A $91.68 000-099 Y N N

E2603 RR A $14.56 000-099 Y N Y 000-099

E2603 A $145.53 000-099 Y N Y 000-099

E2604 RR A $12.66 000-099 Y N Y 000-099




SGD SFTWRE PRGM FOR PC/PKA


SGD SFTWRE PRGM FOR PC/PKA

SGD ACCESSORY, MOUNTING SYS




SGD ACCESSORY NOC

SGD ACCESSORY NOC

SGD ACCESSORY NOC


GEN W/C CUSHION WDTH <22 IN


GEN W/C CUSHION WDTH <22 IN

1 PER 2 YEARS

GEN W/C CUSHION WDTH >=22 IN


GEN W/C CUSHION WDTH >=22 IN

1 PER 2 YEARS

SKIN PROTECT WC CUS WD <22 IN


SKIN PROTECT WC CUS WD <22 IN

SKIN PROTECT WC CUS WD >=22 IN







E2605 RR A $18.09 000-099 N N Y 000-099

E2605 A $180.87 000-099 N N Y 000-099

E2606 RR A $28.22 000-099 N N Y 000-099

E2606 A $282.19 000-099 N N Y 000-099

E2607 RR A $27.24 000-099 Y N Y 000-099

E2607 A $272.43 000-099 Y N Y 000-099

E2608 RR A $23.40 000-099 Y N Y 000-099

E2608 A $233.91 000-099 Y N Y 000-099

E2609 A $0.01 000-099 N N Y 000-099

E2611 RR A $23.03 000-099 N N Y 000-099

E2611 A $230.28 000-099 N N Y 000-099

E2612 RR A $28.40 000-099 N N Y 000-099

E2612 A $283.94 000-099 N N Y 000-099

E2613 RR A $36.22 000-099 N N Y 000-099

E2613 A $362.23 000-099 N N Y 000-099

SKIN PROTECT WC CUS WD >=22 IN

POSITION WC CUSH WDTH <22 IN


POSITION WC CUSH WDTH <22 IN

POSITION WC CUSH WDTH >=22 IN


POSITION WC CUSH WDTH >=22 IN

SKIN PRO/POS WC CUS WD <22 IN


SKIN PRO/POS WC CUS WD <22 IN

SKIN PRO/POS WC CUS WD >=22 IN


SKIN PRO/POS WC CUS WD >=22 IN

CUSTOM FABRICATE W/C CUSHION

GEN USE BACK CUSH WDTH <22 IN


GEN USE BACK CUSH WDTH <22 IN

GEN USE BACK CUSH WDTH >=22 IN


GEN USE BACK CUSH WDTH >=22 IN

POSITION BACK CUSH WD <22 IN


POSITION BACK CUSH WD <22 IN






E2614 A $365.52 000-099 N N Y 000-099

E2615 RR A $30.39 000-099 N N Y 000-099

E2615 A $303.96 000-099 N N Y 000-099

E2616 RR A $40.90 000-099 N N Y 000-099

E2616 A $408.96 000-099 N N Y 000-099

E2617 A $0.01 000-099 N N Y 000-099

E2619 A $46.92 000-099 Y N N

E2619 RB A $0.01 000-099 Y N Y 000-099

E2619 RR A $4.69 000-099 Y N N

E2620 RR A $36.81 000-099 N N Y 000-099

E2620 A $368.05 000-099 N N Y 000-099

E2621 RR A $38.62 000-099 N N Y 000-099

E2621 A $386.24 000-099 N N Y 000-099

E8000 RR A $0.01 000-020 N N Y 000-020

E8000 A $0.01 000-020 N N Y 000-020

E8001 RR A $0.01 000-020 N N Y 000-020

POSITION BACK CUSH WD >=22 IN


POSITION BACK CUSH WD >=22 IN

POS BACK POST/ LAT WDTH <22 IN


POS BACK POST/ LAT WDTH <22 IN

POS BACK POST/ LAT WDTH >=22 IN


POS BACK POST/ LAT WDTH >=22 IN

CUSTOM FAB W/C BACK CUSHION

REPL ONLYACE COVER W/C SEAT CUSH

1 PER 2 YEARS




WC PLANAR BACK CUSH WD <22 IN


WC PLANAR BACK CUSH WD <22 IN

WC PLANAR BACK CUSH WD >=22IN


WC PLANAR BACK CUSH WD >=22IN

POSTERIOR GAIT TRAINER


POSTERIOR GAIT TRAINER

UPRIGHT GAIT TRAINER







E8002 RR A $0.01 000-020 N N Y 000-020

E8002 A $0.01 000-020 N N Y 000-020

K0001 A $490.93 000-099 Y N Y 000-099

K0001 RA A $490.93 000-099 Y N Y 000-099

K0001 RB A $0.01 000-099 Y N Y 000-099

K0001 RR A $49.15 000-099 Y N Y

K0002 A $496.72 000-099 Y N Y 000-099

K0002 RA A $496.72 000-099 Y N Y 000-099

K0002 RB A $0.01 000-099 Y N Y 000-099

K0002 RR A $49.67 000-099 Y N Y 000-099

K0003 A $714.70 000-099 Y N Y 000-099

K0003 RA A $714.70 000-099 Y N Y 000-099

K0003 RB A $0.01 000-099 Y N Y 000-099

K0003 RR A $71.47 000-099 Y N Y 000-099

K0004 A $1,044.62 000-099 N N Y 000-099

K0004 RA A $1,044.62 000-099 N N Y 000-099

K0004 RB A $0.01 000-099 N N Y 000-099

UPRIGHT GAIT TRAINER

ANTERIOR GAIT TRAINER


ANTERIOR GAIT TRAINER

STANDARD WHEELCHAIR

STANDARD

WHEELCHAIR STANDARD

WHEELCHAIR STANDARD

WHEELCHAIR STANDARD HEMI

(LOW SEAT) W/C STANDARD HEMI



(LOW SEAT) W/C 10 MONTHS = PURCHASE

LIGHTWEIGHT

WHEELCHAIR LIGHTWEIGHT



WHEELCHAIR 10 MONTHS = PURCHASE

HIGH STRENGTH

LIGHTWEIGHT W/C HIGH STRENGH

LIGHTWEIGHT W/C HIGH STRENGH

LIGHTWEIGHT W/C





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISK0004 RR A $104.47 000-099 N N Y 000-099

K0005 A $1,703.82 000-099 N N Y 000-099

K0005 RA A $1,703.82 000-099 N N Y 000-099

K0005 RB A $0.01 000-099 N N Y 000-099

K0005 RR A $170.37 000-099 N N Y 000-099

K0006 A $755.99 000-099 N N Y 000-099

K0006 RA A $755.99 000-099 N N Y 000-099

K0006 RB A $0.01 000-099 N N Y 000-099

K0006 RR A $75.59 000-099 N N Y 000-099

K0007 A $699.26 000-099 N N Y 000-099

K0007 RA A $699.26 000-099 N N Y 000-099

K0007 RB A $0.01 000-099 N N Y 000-099

K0007 RR A $69.93 000-099 N N Y 000-099

K0009 A $0.01 000-099 N N Y 000-099

K0009 RA A $0.01 000-099 N N Y 000-099

K0009 RB A $0.01 000-099 N N Y 000-099

HIGH STRENGTH LIGHTWEIGHT W/C


ULTRA LIGHTWEIGHT

WHEELCHAIR

ULTRA LIGHTWEIGHT WHEELCHAIR




HEAVY DUTY WHEELCHAIR

HEAVY DUTY

WHEELCHAIR HEAVY DUTY

WHEELCHAIR HEAVY DUTY


EXTRA HEAVY DUTY

WHEELCHAIR EXTRA HEAVY DUTY




OTHER MANUAL

WHEELCHAIRS OTHER MANUAL

WHEELCHAIRS OTHER MANUAL

WHEELCHAIRS






K0010 A $3,832.42 000-099 N N Y 000-099

K0010 RA A $3,832.42 000-099 N N Y 000-099

K0010 RB A $0.01 000-099 N N Y 000-099

K0010 RR A $383.24 000-099 N N Y 000-099

K0011 A $4,668.36 000-099 N N Y 000-099

K0011 RA A $4,668.36 000-099 N N Y 000-099

K0011 RB A $0.01 000-099 N N Y 000-099

K0011 RR A $466.84 000-099 N N Y 000-099

K0012 A $2,863.78 000-099 N N Y 000-099

K0012 RA A $2,863.78 000-099 N N Y 000-099

K0012 RB A $0.01 000-099 N N Y 000-099

K0012 RR A $286.38 000-099 N N Y 000-099

K0014 A $0.01 000-099 N N Y 000-099

K0014 RA A $0.01 000-099 N N Y 000-099

K0014 RB A $0.01 000-099 N N Y 000-099

OTHER MANUAL WHEELCHAIRS


STANDARD WT. FRAME/MOTORZ. W/C

STANDARD WT. FRAME MOTRZ/W/C

STANDARD WT.

FRAME MOTRZ/W/C STANDARD WT.

FRAME MOTRZ/W/C 10 MONTHS = PURCHASE

STANDARD WT.

MOTZ/POWER W/C STANDARD WT

MOTZ./POWER W/C STANDARD WT

MOTZ./POWER W/C STANDARD WT

MOTZ./POWER W/C 10 MONTHS = PURCHASE

LT/WT PROTABLE

MOTZ/POWER W/C LT/WT. PORTABLE

MOTZ/POWER W/C LT/WT. PORTABLE

MOTZ/POWER W/C LT/WT

PORT.MOTZ/POWER W/C


OTHER MOTZ/POWER W/C BASE








K0015 LT-RT A $166.11 000-099 N N N

K0015 RA A $166.11 000-099 N N N

K0015 RB A $0.01 000-099 N N Y 000-099

K0015 RR A $16.35 000-099 N N N

K0017 LT-RT A $46.18 000-099 N N N

K0017 RA A $46.18 000-099 N N N

K0017 RB A $0.01 000-099 N N Y 000-099

K0017 RR A $4.62 000-099 N N N

K0018 A $26.10 000-099 N N N

K0018 RA A $26.10 000-099 N N N

K0018 RB A $0.01 000-099 N N Y 000-099

K0018 RR A $2.61 000-099 N N N

K0019 A $15.55 000-099 N N N



DETACH, NON-ADJ ARMREST, EACH

1 PER 2 YEARS


1 PER 2 YEARS




DETACH, ADJ

ARMREST, BASE, EA.1 PER 2 YEARS

DETACH, ADJ ARMREST, BASE, EA.

1 PER 2 YEARS




DETACH. ADJ. ARMREST, UPPER,EA

1 PER 2 YEARS


1 PER 2 YEARS




ARM PAD, EACH

1 PER 2 YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISK0019 RB A $0.01 000-099 N N Y 000-099K0019 RR A $1.56 000-099 N N N

K0020 A $42.47 000-099 N N Y 000-099

K0020 RB A $0.01 000-099 N N Y 000-099

K0020 RR A $4.25 000-099 N N Y 000-099

K0037 LT-RT A $28.30 000-099 N N N

K0037 RA A $28.30 000-099 N N N

K0037 RB A $0.01 000-099 N N Y 000-099

K0037 RR A $2.83 000-099 N N N

K0038 A $22.36 000-099 N N N

K0038 RA A $22.36 000-099 N N N

K0038 RR A $2.24 000-099 N N N

K0039 A $49.26 000-099 N N N

K0039 RA A $49.26 000-099 N N N

K0039 RR A $4.93 000-099 Y N N

K0040 A $51.61 000-099 N N N

K0040 RA A $51.61 000-099 N N N

K0040 RB A $0.01 000-099 N N Y 000-099

ARM PAD, EACH ARM PAD, EACH


FIXED,ADJ. HEIGHT

ARMREST,PR. FIXED ADJ HEIGHT

ARMREST, PR. FIXED,ADJ. HEIGHT

ARMREST,PR. 10 MONTHS = PURCHASE

HIGH MOUNT FLIP UP

FOOTRS,EACH1 EACH PER 4

YEARS HIGH MOUNT FLIP UP

FOOTRS,EACH1 EACH PER 4

YEARS HIGH MOUNT FLIP UP

FOOTRS,EACH HIGH MOUNT FLIP UP

FOOTRS,EACH10 MONTHS= PURCHASE

LEG STRAP, EACH

1 EACH PER 5

YEARS LEG STRAP, EACH

1 EACH PER 5

YEARS LEG STRAP, EACH


LEG STRAP, H

STYLE, EACH 1 EACH PER 5

YEARS LEG STRAP, H

STYLE, EACH 1 EACH PER 5

YEARS LEG STRAP, H

STYLE, EACH 10 MONTHS = PURCHASE

ADJUSTABLE ANGLE

FOOTPLATE,EA 1 EACH PER 5

YEARS ADJUSTABLE ANGLE

FOOTPLATE,EA 1 EACH PER 5

YEARS ADJUSTABLE ANGLE

FOOTPLATE,EA





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISK0040 RR A $5.16 000-099 N N N

K0041 A $36.58 000-099 N N N

K0041 RA A $36.58 000-099 N N N

K0041 RB A $0.01 000-099 N N Y 000-099

K0041 RR A $3.67 000-099 N N N

K0042 LT-RT A $29.94 000-099 N N N

K0042 RB A $0.01 000-099 N N Y 000-099

K0042 RR A $3.00 000-099 N N N

K0043 A $17.86 000-099 N N N

K0043 RB A $0.01 000-099 N N Y 000-099

K0043 RR A $1.79 000-099 N N N

K0044 A $15.21 000-099 N N N

K0044 RB A $0.01 000-099 N N Y 000-099

K0044 RR A $1.52 000-099 N N N

K0045 A $51.75 000-099 N N N

K0045 RB A $0.01 000-099 N N Y 000-099

K0045 RR A $5.17 000-099 N N N

K0046 A $17.86 000-099 N N N

ADJUSTABLE ANGLE FOOTPLATE,EA.


LARGE SIZE

FOOTPLATE, EACH 1 EACH PER 5

YEARS LARGE SIZE

FOOTPLATE, EACH 1 EACH PER 5

YEARS LARGE SIZE

FOOTPLATE, EACH LARGE SIZE

FOOTPLATE, EACH 10 MONTHS = PURCHASE

STANDARD SIZED

FOOTPLATE, EACH1 EACH PER 5

YEARS

STANDARD SIZED FOOTPLATE, EACH

STANDARD SIZED FOOTPLATE, EACH


FOOTREST, LOWER

EXTENS.TUBE,EA1 EACH PER 5

YEARS

FOOTREST, LOWER EXTENS.TUBE,EA

FOOTREST, LOWER EXTENS.TUBE,EA


FOOTREST, UPPER

HANGER BRAC.EA1 EACH PER 5

YEARS

FOOTREST, UPPER HANGER BRAC.EA

FOOTREST, UPPER HANGER BRAC.EA


FOOTREST,COMPLE

TE ASSEMBLY 1 EACH PER 5

YEARS

FOOTREST,COMPLETE ASSEMBLY

FOOTREST,COMPLETE ASSEMBLY


ELEVATING LEGRT, L

EXT.TUBE EA1 EACH PER 5

YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISK0046 RB A $0.01 000-099 N N Y 000-099

K0046 RR A $1.79 000-099 N N N

K0047 A $69.93 000-099 N N N

K0047 RB A $0.01 000-099 N N Y 000-099

K0047 RR A $6.99 000-099 N N N

K0050 A $29.71 000-099 N N N

K0050 RB A $0.01 000-099 N N Y 000-099

K0050 RR A $2.98 000-099 N N N

K0051 A $48.10 000-099 N N N

K0051 RB A $0.01 000-099 N N Y 000-099

K0051 RR A $4.81 000-099 N N N

K0052 A $84.51 000-099 N N N

K0052 RA A $84.51 000-099 N N N

K0052 RR A $8.45 000-099 N N N

K0053 A $94.01 000-099 N N Y 000-099

ELEVATING LEGRT, L EXT.TUBE EA

ELEVATING LEGRT, L EXT.TUBE EA


ELEVATING

LEGRST,U HANGER,EA.

1 EACH PER 5 YEARS

ELEVATING LEGRST,U HANGER,EA.

ELEVATING LEGRST,U HANGER,EA.


RATCHET ASSEMBLY, EACH

1 EACH PER 5 YEARS

RATCHET ASSEMBLY, EACH RATCHET ASSEMBLY, EACH


CAM RELEASE

ASSEMBLY, EACH 1 EACH PER 5

YEARS

CAM RELEASE ASSEMBLY, EACH

CAM RELEASE ASSEMBLY, EACH


SWING-AWAY

DETACH.FOOTRESTS,EA

1 EACH PER 5 YEARS

SWING-AWAY DETACH.FOOTRESTS,EA

1 EACH PER 5 YEARS

SWING-AWAY DETACH.FOOTRESTS,EA


ELEVATING LEGRT,ARTIC.,EACH





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISK0053 RA A $94.01 000-099 N N Y 000-099

K0053 RR A $9.39 000-099 N N Y 000-099

K0056 A $86.95 000-099 N N Y 000-099

K0056 RR A $8.69 000-099 N N Y 000-099

K0065 A $40.97 000-099 N N Y 000-099

K0065 RA A $40.97 000-099 N N Y 000-099

K0065 RR A $4.10 000-099 N N Y 000-099

K0069 RB A $0.01 000-099 N N Y 000-099

K0069 RR A $9.14 000-099 N N N

K0069 A $91.34 000-099 N N N

K0070 A $167.45 000-099 N N N

K0070 RB A $0.01 000-099 N N Y 000-099

K0070 RR A $16.74 000-099 N N N

K0071 A $99.88 000-099 N N N

ELEVATING LEGRT,ARTIC.,EACH

ELEVATING LEGRT.,ARTIC.,EACH


SEAT HT/HIGH STR.OR ULT. H W/C

SEAT HT/HIGH STR.

OR ULT. H WC10 MONTHS = PURCHASE

SPOKE

PROTECTORS

1 PER 2 YEARS

SPOKE

PROTECTORS

1 PER 2 YEARS

SPOKE

PROTECTORS


REAR WHL

ASSEMBLY,COMP W/S.T.

REAR WHL ASSEMBLY,COMP W/S.T.


REAR WHL ASSEMBLY,COMP W/S.T.

1 EACH PER 5 YEARS

REAR WHL ASSM.,COMP W/ST OR SP

1 EACH PER 5 YEARS




FRONT CASTER ASSMBY,W/PNE.TIRE

1 EACH PER 5 YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISK0071 RA A $99.88 000-099 N N N

K0071 RB A $0.01 000-099 N N Y 000-099

K0071 RR A $9.98 000-099 N N N

K0072 A $60.12 000-099 N N N

K0072 RA A $60.12 000-099 N N N

K0072 RB A $0.01 000-099 N N Y 000-099

K0072 RR A $6.01 000-099 N N N

K0073 A $32.07 000-099 N N N

K0073 RB A $0.01 000-099 N N Y 000-099

K0073 RR A $3.21 000-099 N N N

K0098 A $24.68 000-099 N N N

K0098 RB A $0.01 000-099 N N Y 000-099

K0098 RR A $2.47 000-099 N N N

K0105 A $66.82 000-099 N N Y 000-099

K0105 RA A $66.82 000-099 N N N

FRONT CASTER ASSEMB,W/PNE.TIRE

1 EACH PER 5 YEARS




FRONT CASTER ASSEMB,W/S.PNE,TR

1 EACH PER 5 YEARS


1 EACH PER 5 YEARS




CASTER PIN LOCK, EACH

1 EACH PER 5 YEARS

CASTER PIN LOCK,

EACH CASTER PIN LOCK,

EACH 10 MONTHS = PURCHASE

DRIVE BELT FOR

POWER CHAIR 1 EACH PER 2

YEARS

DRIVE BELT FOR POWER CHAIR

DRIVE BELT FOR POWER CHAIR


IV HANGER

1 PER 2 YEARS

IV HANGER

1 PER 2 YEARS






K0108 A $0.01 000-099 N N Y 000-099

K0108 RA A $0.01 000-099 N N Y 000-099

K0108 RB A $0.01 000-099 N N Y 000-099

K0108 RR A $0.01 000-099 N N Y 000-099

K0195 RR A $15.84 000-099 N N Y 000-099

K0603 A $0.42 000-099 Y N N

K0733 A $23.20 000-099 N N N

K0733 RA A $23.20 000-099 N N N

K0734 RR A $31.82 000-099 N N Y 000-099

K0734 A $318.21 000-099 N N Y 000-099

K0735 RR A $40.50 000-099 N N Y 000-099

K0735 A $404.91 000-099 N N Y 000-099

K0736 RR A $32.08 000-099 N N Y 000-099

K0736 A $320.82 000-099 N N Y 000-099

K0737 RR A $40.61 000-099 N N Y 000-099

K0737 A $406.14 000-099 N N Y 000-099

IV HANGER


OTHER

ACCESSORIES

OTHER

ACCESSORIES

OTHER

ACCESSORIES

OTHER

ACCESSORIES


WHEELCHAIR ELEV.

LEG RESTS, PAIR10 MONTHS = PURCHASE

REPL ONLY BATT ALKALINE 1.5 V

6 PER 3 MONTHS

12-24 AMP HR SEALED LEAD ACID BATTERY

2 PER 6 MONTHS

12-24 AMP HR SEALED LEAD ACID BATTERY

2 PER 6 MONTHS

ADJ SKIN PRO WC CUS WD<22IN


ADJ SKIN PRO WC CUS WD<22IN

ADJ SKIN PRO WC CUS WD>22IN


ADJ SKIN PRO WC CUS WD>=22IN

ADJ SKIN PRO/POS WC CUS<22IN


ADJ SKIN PRO/POS WC CUS<22"

ADJ SKIN PRO/POS WC CUS>=22"


ADJ SKIN PRO/POS WC CUS>=22"





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISK0739 A $10.37 000-099 N N Y 000-099

K0800 RR A $86.87 000-099 N N Y 000-099

K0800 A $868.73 000-099 N N Y 000-099

K0801 RR A $140.06 000-099 N N Y 000-099

K0801 A $1,400.59 000-099 N N Y 000-099

K0802 RR A $158.51 000-099 N N Y 000-099

K0802 A $1,585.02 000-099 N N Y 000-099

K0806 RR A $105.09 000-099 N N Y 000-099

K0806 A $1,050.94 000-099 N N Y 000-099

K0807 RR A $159.47 000-099 N N Y 000-099

K0807 A $1,594.68 000-099 N N Y 000-099

K0808 RR A $246.73 000-099 N N Y 000-099

K0808 A $2,467.32 000-099 N N Y 000-099

K0812 RR A $0.01 000-099 N N Y 000-099

K0812 A $0.01 000-099 N N Y 000-099

K0813 RR A $162.12 000-099 N N Y 000-099

K0813 A $1,621.13 000-099 N N Y 000-099

K0814 RR A $207.50 000-099 N N Y 000-099

REPAIR/SVC DME NON-OXYGEN EQUIP PER 15

MIN

POV GROUP 1 STD UP TO 300 LBS



POV GROUP 1 HD 301-450 LBS



POV GROUP 1 VHD 451-600 LBS












POWER OPERATED VEHICLE NOC


POWER OPERATED VEHICLE NOC

PWC GP 1 STD PORT SEAT/BACK



PWC GP 1 STD PORT CAP CHAIR






CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISK0814 A $2,075.00 000-099 N N Y 000-099

K0815 RR A $236.29 000-099 N N Y 000-099

K0815 A $2,362.95 000-099 N N Y 000-099

K0816 RR A $226.29 000-099 N N Y 000-099

K0816 A $2,262.89 000-099 N N Y 000-099

K0820 RR A $173.15 000-099 N N Y 000-099

K0820 A $1,731.48 000-099 N N Y 000-099

K0821 RR A $222.28 000-099 N N Y 000-099

K0821 A $2,222.77 000-099 N N Y 000-099

K0822 RR A $268.64 000-099 N N Y 000-099

K0822 A $2,686.32 000-099 N N Y 000-099

K0823 RR A $270.39 000-099 N N Y 000-099

K0823 A $2,703.93 000-099 N N Y 000-099

K0824 RR A $325.43 000-099 N N Y 000-099

K0824 A $3,254.29 000-099 N N Y 000-099

K0825 RR A $297.91 000-099 N N Y 000-099

K0825 A $2,979.11 000-099 N N Y 000-099

K0826 RR A $421.30 000-099 N N Y 000-099


PWC GP 1 STD SEAT/BACK



PWC GP 1 STD CAP CHAIR















PWC GP 2 HD SEAT/BACK



PWC GP 2 HD CAP CHAIR



PWC GP 2 VHD SEAT/BACK







K0827 RR A $358.23 000-099 N N Y 000-099

K0827 A $3,582.36 000-099 N N Y 000-099

K0828 RR A $464.23 000-099 N N Y 000-099

K0828 A $4,642.31 000-099 N N Y 000-099

K0829 RR A $422.46 000-099 N N Y 000-099

K0829 A $4,262.97 000-099 N N Y 000-099

K0830 RR A $0.01 000-099 N N Y 000-099

K0830 A $0.01 000-099 N N Y 000-099

K0831 RR A $0.01 000-099 N N Y 000-099

K0831 A $0.01 000-099 N N Y 000-099

K0835 RR A $272.66 000-099 N N Y 000-099

K0835 A $2,726.57 000-099 N N Y 000-099

K0836 RR A $282.75 000-099 N N Y 000-099

K0836 A $2,827.44 000-099 N N Y 000-099

K0837 RR A $325.43 000-099 N N Y 000-099

K0837 A $3,254.29 000-099 N N Y 000-099

K0838 RR A $291.13 000-099 N N Y 000-099


PWC GP 2 VHD CAP CHAIR



PWC GP 2 XTRA HD SEAT/BACK


PWC GP 2 XTRA HD SEAT/BACK

PWC GP 2 XTRA HD CAP CHAIR


PWC GP 2 XTRA HD CAP CHAIR

PWC GP2 STD SEAT ELEVATE S/B


PWC GP2 STD SEAT ELEVATE S/B

PWC GP2 STD SEAT ELEVATE CAP


PWC GP2 STD SEAT ELEVATE CAP

PWC CP2 STD SING POW OPT S/B


PWC GP2 STD SING POW OPT S/B

PWC GP2 STD SING POWER OPT CAP


PWC GP2 STD SING POWER OPT CAP

PWC GP 2 HD SING POW OPT S/B


PWC GP 2 HD SING POW OPT S/B

PWC GP 2 HD SING POW OPT CAP







K0839 RR A $421.30 000-099 N N Y 000-099

K0839 A $4,212.97 000-099 N N Y 000-099

K0840 RR A $638.28 000-099 N N Y 000-099

K0840 A $6,382.86 000-099 N N Y 000-099

K0841 RR A $290.21 000-099 N N Y 000-099

K0841 A $2,902.10 000-099 N N Y 000-099

K0842 RR A $290.21 000-099 N N Y 000-099

K0842 A $2,902.10 000-099 N N Y 000-099

K0843 RR A $349.41 000-099 N N Y 000-099

K0843 A $3,494.13 000-099 N N Y 000-099

K0848 RR A $355.11 000-099 N N Y 000-099

K0848 A $3,551.12 000-099 N N Y 000-099

K0849 RR A $341.42 000-099 N N Y 000-099

K0849 A $3,414.23 000-099 N N Y 000-099

K0850 RR A $411.93 000-099 N N Y 000-099

K0850 A $4,119.23 000-099 N N Y 000-099

K0851 RR A $396.06 000-099 N N Y 000-099

PWC GP 2 HD SING POW OPT CAP

PWC GP2 VHD SING POW OPT S/B



PWC GP2 XHD SING POW OPT S/B


PWC GP2 XHD SING POW OPT S/B

PWC GP2 STD MULT POW OPT S/B



PWC GP2 STD MULT POW OPT CAP



PWC GP2 HD MULT POW OPT S/B



















K0852 RR A $475.95 000-099 N N Y 000-099

K0852 A $4,759.51 000-099 N N Y 000-099

K0853 RR A $488.92 000-099 N N Y 000-099

K0853 A $4,889.20 000-099 N N Y 000-099

K0854 RR A $647.71 000-099 N N Y 000-099

K0854 A $6,477.14 000-099 N N Y 000-099

K0855 RR A $611.87 000-099 N N Y 000-099

K0855 A $6,118.63 000-099 N N Y 000-099

K0856 RR A $381.18 000-099 N N Y 000-099

K0856 A $3,811.79 000-099 N N Y 000-099

K0857 RR A $388.82 000-099 N N Y 000-099

K0857 A $3,888.19 000-099 N N Y 000-099

K0858 RR A $472.92 000-099 N N Y 000-099

K0858 A $4,729.27 000-099 N N Y 000-099

K0859 RR A $451.03 000-099 N N Y 000-099

K0859 A $4,510.26 000-099 N N Y 000-099

K0860 RR A $675.64 000-099 N N Y 000-099








PWC GP 3 XHD SEAT/BACK


PWC GP 3 XHD SEAT/BACK

PWC GP 3 XHD CAP CHAIR


PWC GP 3 XHD CAP CHAIR




PWC GP3 STD SING POW OPT CAP



PWC GP3 HD SING POW OPT S/B



PWC GP3 HD SING POW OPT CAP


PWC GP3 HD SING POW OPT CAP








K0861 RR A $381.79 000-099 N N Y 000-099

K0861 A $3,817.90 000-099 N N Y 000-099

K0862 RR A $472.92 000-099 N N Y 000-099

K0862 A $4,729.27 000-099 N N Y 000-099

K0863 RR A $675.64 000-099 N N Y 000-099

K0863 A $6,756.36 000-099 N N Y 000-099

K0864 RR A $804.02 000-099 N N Y 000-099

K0864 A $8,040.14 000-099 N N Y 000-099

K0868 RR A $0.01 000-099 N N Y 000-099

K0868 A $0.01 000-099 N N Y 000-099

K0869 RR A $0.01 000-099 N N Y 000-099

K0869 A $0.01 000-099 N N Y 000-099

K0870 RR A $0.01 000-099 N N Y 000-099

K0870 A $0.01 000-099 N N Y 000-099

K0871 RR A $0.01 000-099 N N Y 000-099

K0871 A $0.01 000-099 N N Y 000-099

K0877 RR A $0.01 000-099 N N Y 000-099








PWC GP3 VHD MULT POW OPT S/B


PWC GP3 VHD MULT POW OPT S/B

PWC GP3 XHD MULT POW OPT S/B


PWC GP3 XHD MULT POW OPT S/B




















K0878 RR A $0.01 000-099 N N Y 000-099

K0878 A $0.01 000-099 N N Y 000-099

K0879 RR A $0.01 000-099 N N Y 000-099

K0879 A $0.01 000-099 N N Y 000-099

K0880 RR A $0.01 000-099 N N Y 000-099

K0880 A $0.01 000-099 N N Y 000-099

K0884 RR A $0.01 000-099 N N Y 000-099

K0884 A $0.01 000-099 N N Y 000-099

K0885 RR A $0.01 000-099 N N Y 000-099

K0885 A $0.01 000-099 N N Y 000-099

K0886 RR A $0.01 000-099 N N Y 000-099

K0886 A $0.01 000-099 N N Y 000-099

K0890 RR A $0.01 000-099 N N Y 000-099

K0890 A $0.01 000-099 N N Y 000-099

K0891 RR A $0.01 000-099 N N Y 000-099

K0891 A $0.01 000-099 N N Y 000-099

K0898 RR A $0.01 000-099 N N Y 000-099

















PWC GP4 HD MULT POW S/B


PWC GP4 HD MULT POW S/B

PWC GP5 PED SING POW OPT S/B


PWC GP5 PED SING POW OPT S/B

PWC GP5 PED MULT POW OPT S/B


PWC GP5 PED MULT POW OPT S/B

POW WHEELCHAIR NOC







L0112 A $0.01 000-099 N Y Y 000-099

L0120 A $19.61 000-099 N N N

L0130 A $84.94 1 PER YEAR 000-099 N Y N

L0140 A $33.30 1 PER YEAR 000-099 N N N

L0150 A $61.32 1 PER YEAR 000-099 N Y N

L0170 A $536.46 1 PER YEAR 000-099 N Y N

L0172 A $78.82 1 PER YEAR 000-099 N Y N

L0174 A $154.95 1 PER YEAR 000-099 N Y N

L0180 A $265.68 1 PER YEAR 000-099 N Y N

L0190 A $296.08 1 PER YEAR 000-099 N Y N

L0200 A $343.43 1 PER YEAR 000-099 N Y N

L0210 A $27.06 000-099 N N N

L0220 A $71.89 000-099 N Y Y 000-099

L0430 A $0.01 000-099 N Y Y 000-099

L0450 A $96.45 000-099 N N N

POW WHEELCHAIR NOC

CRANIAL CERIVAL ORTHOSIS

CERV. FLEX,THERMOPLASTIC,MOLD.

1 PER YEAR

CERV.THERMOPLASTIC COLLAR MOLD

CERV. ADJ.COLLAR

PLAST. CERV.S.RIGID

ADJ.CHIN CUP, ETC CERV. COLLAR

MOLDED TO PATIENT

CERVICAL COLLAR S-R TWO PIECE

CERV. COLLAR S-R TWO PC THOR E

CERV. POST COLLAR ADJ.

CERV. POST O/M

ADJ. CERV. BARS

CERV. POST O/M ADJ.C BAR T.EXT

THORACIC RIB BELT,

FITTED 1 PER YEAR

THORACIC RIB BELT

CUSTOM FAB DEWALL POSTURE

PROTECTOR

TLSO FLEX PREFAB THORACIC

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL0452 A $234.66 000-099 N Y Y 000-099

L0454 A $257.32 000-099 N N N

L0456 TLSO FLEX PREFAB A $561.79 000-099 N N N

L0458 A $544.20 000-099 N N N

L0460 A $567.00 000-099 N N N

L0462 A $544.20 000-099 N N N

L0464 A $839.60 000-099 N N N

L0466 A $225.20 000-099 N N N

L0468 A $282.22 000-099 N N N

TLSO FLEX CUSTOM FAB THORACIC

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71 356.1 737.30 737.32 737.43 754.2 756.12

TLSO FLEX PREFAB SACROCOC-T9

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

TLSO 2 MOD SYMPHIS-XIPHO PRE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

TLSO 2 MOD SYMPHYSIS-STERN PRE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

TLSO 3 MOD SACRO-SCAP PRE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

TLSO 4 MOD SACRO-SCAP PRE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

TLSO RIGID FRAME PRE SOFT AP

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

TLSO RIGID FRAME PREFAB PELV

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL0470 A $390.52 000-099 N N N

L0472 A $240.30 000-099 N N N

L0480 A $1,008.59 000-099 N Y Y 000-099

L0482 A $1,126.60 000-099 N Y Y 000-099

L0484 A $1,216.70 000-099 N Y Y 000-099

L0486 A $875.04 000-099 N Y Y 000-099

L0488 A $744.79 000-099 N N N

L0490 A $209.88 000-099 N N N

L0491 A $552.96 000-099 N N N

TLSO RIGID FRAME PRE SUBCLAV

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

TLSO RIGID FRAME HYPEREX PRE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

TLSO RIGID PLASTIC CUSTOM FA

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71 356.1 737.30 737.32 737.43 754.2 756.12

TLSO RIGID LINED CUSTOM FAB

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71 356.1 737.30 737.32 737.43 754.2 756.12

TLSO RIGID PLASTIC CUST FAB

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71 356.1 737.30 737.32 737.43 754.2 756.12

TLSO RIGID LINED CUSTOM FAB TWO

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71 356.1 737.30 737.32 737.43 754.2 756.12

TLSO RIGID LINE PRE ONE PIE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

TLSO RIGID PLASTIC PRE ONE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

TLSO 2 PIECE RIGID SHELL

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS






L0621 A $59.81 000-099 N Y N

L0622 A $159.41 000-099 N Y Y 000-0099

L0623 SIO PANEL PREFAB A $46.08 000-099 N Y N

L0624 SIO PANEL CUSTOM A $220.29 000-099 N Y Y 000-099

L0625 A $40.87 000-099 N N N

L0626 A $57.47 000-099 N N N

L0627 A $48.91 000-099 N N N

L0628 A $62.24 000-099 N N N

TLSO 3 PIECE RIGID SHELL

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

SIO FLEX PELVISACRAL PREFAB

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

SIO FLEX PELVISACRAL CUSTOM

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71 356.1 737.30 737.32 737.43 754.2 756.12

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71 356.1 737.30 737.32 737.43 754.2 756.12

LO FLEXIBLE L1-BELOW L5 PRE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

LO SAG STAYS/ PANELS PRE-FAB

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

LO SAGITT RIGID PANEL PREFAB

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

LO FLEX W/O RIGID STAYS PRE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS






L0630 A $120.17 000-099 N Y N

L0631 A $116.70 000-099 N Y N

L0632 A $0.01 000-099 N Y Y 000-099

L0633 A $212.76 000-099 N Y N

L0634 A $0.01 000-099 N Y Y 000-099

L0635 A $221.91 000-099 N Y N

L0636 A $306.55 000-099 N Y Y 000-099

L0637 A $154.33 000-099 N Y N

LSO FLEX W/O RIGID STAYS CUST

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71 356.1 737.30 737.32 737.43 754.2 756.12

LSO POST RIGID PANEL PRE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

LSO SAG-CORO RIGID FRAME PRE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

LSO SAG RIGID FRAME CUST

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

LSO FLEXION CONTROL PREFAB

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

LSO FLEXION CONTROL CUSTOM

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

LSO SAGIT RIGID PANEL PREFAB

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

LSO SAGITTAL RIGID PANEL CUS

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

LSO SAG-CORONAL PANEL PREFAB

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS






L0639 A $720.87 000-099 N Y Y 000-099

L0640 A $776.36 000-099 N Y Y 000-099

L0700 A $1,107.76 000-099 N Y Y 000-099

L0710 A $1,217.73 000-099 N Y Y 000-099

L0970 A $59.46 000-099 N Y N

L0972 A $54.12 000-099 N Y N

L0974 A $97.25 000-099 N Y N

L0976 A $83.19 000-099 N Y N L0980 A $9.52 000-099 N N N

L0984 A $48.44 000-099 N Y N

L0999 A $0.01 000-099 N N Y 000-099

L1000 A $1,155.68 000-099 N Y Y 000-099

LSO SAG-CORONAL PANEL CUSTOM

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

LSO S/C SHELL/PANEL PREFAB

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71 356.1 737.30 737.32 737.43 754.2 756.12

LSO S/C SHELL/PANEL CUSTOM

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71 356.1 737.30 737.32 737.43 754.2 756.12

CTLSO A/P/L MOLDED MINERVA

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

737.30-737.39, 737.43, 754.2,

CTLSO A/P/L MOLD INT M MINERVA

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

737.30-737.39, 737.43, 754.2

TLSO, CORSET FRONT

1 PER YEAR

LSO, CORSET FRONT

1 PER YEAR

TLSO, FULL CORSET

1 PER YEAR

LSO, FULL CORSET

1 PER YEAR

PERONEAL STRAPS,

PAIR 1 PER YEAR

PROTECTIVE BODY

SOCK 4 PER YEAR

ADD TO SPINAL

ORTHOSIS NOSCTLSO MILWAUKEE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

737.30-737.39, 737.43, 754.2





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL1001 A $0.01 000-002 N N Y 000-002

L1005 A $1,781.02 000-099 N N Y 000-099

L1010 A $46.56 000-099 N Y Y 000-099

L1020 A $69.48 000-099 N Y Y 000-099

L1030 A $56.21 000-099 N Y Y 000-099

L1040 A $49.34 000-099 N Y Y 000-099

L1050 A $55.83 000-099 N Y Y 000-099

L1060 A $60.26 000-099 N Y Y 000-099

L1070 A $62.42 000-099 N Y Y 000-099

CTLSO, IMMOBILIZER, INFANT SIZE, PREFAB

1 PER 2 YEARS

343.4, 343.8-343.9, 737.30-737.39, 737.43, 754.2

TENSION BASED SCOLIOSIS ORTH

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

737.30-737.39, 737.43, 754.2

AXILLA SLING, ADDITIONS CTLSO

< 21 2 PER YEAR 21 & > 2 PER 2

YEARS

737.30-737.39, 737.43, 754.2

KYPHOSIS,ADDITIONS CTLSO

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

737.30-737.39, 737.43, 754.2

LUMBAR BOLSTER PAD ADD CTLSO

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

737.30-737.39, 737.43, 754.2

LUMBAR/LUMBAR RIB PAD AD CTLSO

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

737.30-737.39, 737.43, 754.2

STERNAL PAD ADD CTLSO

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

737.30-737.39, 737.43, 754.2

THORACIC PAD ADD CTLSO

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

737.30-737.39, 737.43, 754.2

TRAPEZE SLING ADD CTLSO

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

737.30-737.39, 737.43, 754.2






L1200 A $995.79 000-099 N Y Y 000-099

L1210 A $136.15 000-099 N Y Y 000-099

L1220 A $132.52 000-099 N Y Y 000-099

L1230 A $371.23 000-099 N Y Y 000-099

L1240 A $50.61 000-099 N Y Y 000-099

L1250 A $43.99 000-099 N Y Y 000-099

L1260 A $52.48 000-099 N Y Y 000-099

L1270 A $46.14 000-099 N Y Y 000-099

LUMBAR SLING ADD CTLSO

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

737.30-737.39, 737.43, 754.2

TLSO LOW PROFILE

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71, 356.1, 737.30, 737.32, 737.43, 754.2, 756.12

LATERAL THORACIC EXT TLSO LP

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71, 356.1, 737.30, 737.32, 737.43, 754.2, 756.12

ANT THORACIC EXT TLSO LP

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71, 356.1, 737.30, 737.32, 737.43, 754.2, 756.12

MILWAKEE SUPERSTRUC TLSO LP

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71, 356.1, 737.30, 737.32, 737.43, 754.2, 756.12

ADD TLSO LUMBAR DEROT. PAD

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71, 356.1, 737.30, 737.32, 737.43, 754.2, 756.12

ADD TLSO ANT.ASIS PAD

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71, 356.1, 737.30, 737.32, 737.43, 754.2, 756.12

ADD. TLSO ANT. THOR. DEROT.PAD

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71, 356.1, 737.30, 737.32, 737.43, 754.2, 756.12

ADD TLSO ABD PAD

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71, 356.1, 737.30, 737.32, 737.43, 754.2, 756.12






L1290 A $43.23 000-099 N Y Y 000-099

L1300 A $983.00 000-099 N Y Y 000-099

L1499 A $0.01 000-099 N N Y 000-099

L1500 A $1,074.41 000-099 N Y Y 000-099

L1510 A $882.49 000-099 N Y Y 000-099

L1520 A $1,187.00 000-099 N Y Y 000-099

L1600 A $75.13 000-099 N N N

L1620 A $87.44 000-001 N N N

L1630 A $153.27 000-099 N Y N

L1640 A $263.41 000-099 N Y N

ADD TLSO RIB GUSSETS

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71, 356.1, 737.30, 737.32, 737.43, 754.2, 756.12

ADD TLSO LAT. TROCHANTERIC PAD

< 21 1 PER YEAR 21 & > 1 PER 2

YEARS

237.71, 356.1, 737.30, 737.32, 737.43, 754.2, 756.12

BODY JACKET MOLDED TO PATIENT

UNLISTED PROC.FOR SPINAL ORTHO

THKAO PARAPODIUM TYPE

THKAO,STANDING

FRAME THKAO, SWIVEL

WALKER HIP ORTHOSES AO

FREJKA TYPE <21 1 PER 6 MONTHS 21 & > 1 PER 2 YEARS

HIP ORTHOSIS AO PAVLIK HARNESS

<21 1 PER 6 MONTHS

21 & > 1 PER 2 YEARS

HIP ABD O S-FLEX VANROSEN

<21 1 PER 6 MONTHS


HO PELVIC BAND/BAR THIGH CUFFS

<21 1 PER 6 MONTHS







L1652 LT-RT A $264.47 000-099 N N N

L1660 A $127.73 000-099 N Y N

L1680 A $633.96 000-099 N Y Y 000-099

L1690 A $1,212.48 000-099 N N Y 000-099L1700 A $919.64 000-099 N Y Y 000-099

L1710 A $1,102.44 000-099 N Y Y 000-099

L1720 A $1,041.66 000-099 N Y Y 000-099

L1730 A $715.28 000-099 N Y Y 000-099

L1755 A $996.34 000-099 N Y Y 000-099

HO ADJ CUSTOM FIT. ILFLED

<21 1 PER 6 MONTHS


HO BI THIGH CUFFS W SPRDR BAR

<21 1 PER 6 MONTHS


HO STATIC PLASTIC CUSTOM FIT

<21 1 PER 6 MONTHS


HO DYNAMIC ADJ HIP THIGH CUFFS

BILAT. LSFHO

LEGG PERTHES

ORTHO,TORONTO TYP

<21 1 PER 6 MONTHS


732.1 -732.1

LEGG PERTHES ORTHO,NEWINGTON T

<21 1 PER 6 MONTHS


732.1 -732.1

LEGG PERTHES TRILATERAL

<21 1 PER 6 MONTHS


732.1 -732.1

LEGG PERTHES SCOTTISH RITE

<21 1 PER 6 MONTHS


732.1 -732.1

LEGG PERTHES, PATTEN BOTTOM TY

<21 1 PER 6 MONTHS


732.1 -732.1





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL1800 LT-RT A $46.64 000-099 N N N

L1810 LT-RT A $67.44 000-099 N Y N

L1815 LT-RT A $58.97 000-099 N N N

L1820 LT-RT A $88.90 000-099 N N N

L1825 LT-RT A $33.04 000-099 N N N

L1830 LT-RT A $52.10 000-099 N N N

L1831 LT-RT A $218.37 000-099 N N N

L1832 LT-RT A $383.29 000-099 N N N

L1834 LT-RT A $472.48 000-099 N Y Y 000-099

KNEE ORTHO, ELASTIC WITH STAYS

<21 1 PER 6 MONTHS


KNEE ORTHO, ELASTIC W/ JOINTS

<21 1 PER 6 MONTHS


KO, ELASTIC W/CONDVLAR PADS

<21 1 PER 6 MONTHS


KO ELASTIC CONDYLE PADS/JOINTS

<21 1 PER 6 MONTHS


KNEE ORTHO,ELASTIC KNEE CAP

<21 1 PER 6 MONTHS


KO IMMOBILIZER CANVAS

<21 1 PER 6 MONTHS


KNEE ORTH POS LOCKING JOINT

<21 1 PER 6 MONTHS


KO,ADJ.KJ, PDS.O,R.S,C.F.

<21 1 PER 6 MONTHS


KO, W/O KJ, RIGID, MOLDED

<21 1 PER 6 MONTHS


717.83-717.83






L1840 LT-RT A $651.92 000-099 N Y Y 000-099

L1843 LT-RT A $499.29 000-099 N N N

L1844 LT-RT A $847.40 000-099 N Y Y 000-099

L1845 LT-RT A $466.12 000-099 N N N

L1846 LT-RT A $624.01 000-099 N Y Y 000-099

L1847 LT-RT A $333.39 000-099 N N Y 000-099

L1850 LT-RT A $175.31 000-099 N N N

L1860 LT-RT A $738.78 000-099 N Y Y 000-099

RIGID KNEE ORTHO WO JOINTS

<21 1 PER 6 MONTHS


KNEE ORTHO DEROTATION

<21 1 PER 6 MONTHS


717.83-717.83

KNEE UPRIGHT W/RESISTANCE

<21 1 PER 6 MONTHS


KO SINGLE UPR THIGH/CALF ADJ P

<21 1 PER 6 MONTHS


717.83-717.83

KO,DU,ADJ-JT-M-LCONT-,CF

<21 1 PER 6 MONTHS


KODU,ADJ. FLEX/EXT ROT. CTRL.

<21 1 PER 6 MONTHS


717.83-717.83

KO DOUBLE UPRIGHT

KNEE ORTHO,

SWEDISH TYPE <21 1 PER 6 MONTHS


KO SUPRALONDYLAR PROSTH SOCKET

<21 1 PER 6 MONTHS


717.83-717.83





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL1900 LT-RT A $185.33 000-099 N Y N

L1901 LT-RT A $13.12 000-099 N N N

L1902 LT-RT A $42.40 000-099 N N N

L1906 LT-RT A $80.47 000-099 N N N

L1907 LT-RT A $368.64 000-099 N Y Y 000-099

L1920 LT-RT A $231.95 000-099 N Y N

L1930 LT-RT A $186.93 000-099 N N N

L1940 LT-RT A $350.48 000-099 N Y N

L1945 LT-RT A $624.60 000-099 N Y N

AFO SPRING WIRE

<21 1 PER 6 MONTHS


PREFAB ANKLE ORTHOSIS

<21 1 PER 6 MONTHS


AFO ANKLE GAUNTLET

<21 1 PER 6 MONTHS


AFO MULTILIGAMENTUS ANKLE SUPP

<21 1 PER 6 MONTHS


AFO SUPRAMALLEOLAR CUSTOM

<21 1 PER 6 MONTHS


359.0-359.0, 359.1-359.1, 343.0-343.0, 343.8-343.8, 343.9-343.9

AFO SU PHELPS/PERLSTEIN

<21 1 PER 6 MONTHS


AFO, CUSTOM FITTED, PLASTIC

<21 1 PER 6 MONTHS


AFO CUSTOM MOLDED PLASTIC

<21 1 PER 6 MONTHS


AFO,MOLDED TO PATIENT MODEL,PL

<21 1 PER 6 MONTHS







L1960 LT-RT A $344.93 000-099 N Y N

L1970 LT-RT A $419.96 000-099 N Y N

L1971 LT-RT A $184.32 000-099 N N N

L1980 LT-RT A $242.17 000-099 N Y N

L1990 LT-RT A $281.00 000-099 N Y N

L2000 LT-RT A $689.72 000-099 N Y N

L2010 LT-RT A $561.99 000-099 N N N

L2020 LT-RT A $802.14 000-099 N Y N

AFO SPIRAL MOLDED

<21 1 PER 6 MONTHS


AFO POST SA MOLDED PLASTIC

<21 1 PER 6 MONTHS


AFO MOLDED PLASTIC W/ANKLE JT

<21 1 PER 6 MONTHS


AFO W/ANKLE JOINT, PREFAB

<21 1 PER 6 MONTHS


AFO SU FREE A JT SOLID STIRRUP

<21 1 PER 6 MONTHS


AFO DU FREE A JT SOLID STIRRUP

<21 1 PER 6 MONTHS


KAFO SU FREE K/A WO KJT

<21 1 PER 6 MONTHS


KAFO SU FREE A WO KNEE JOINT

<21 1 PER 6 MONTHS


KAFO DU FREE K/A

<21 1 PER 6 MONTHS







L2034 LT-RT A $983.52 000-099 N Y Y 000-099

L2035 LT-RT A $100.42 000-099 N N Y 000-099

L2036 LT-RT A $1,031.64 000-099 N Y N

L2037 LT-RT A $1,186.58 000-099 N Y N

L2038 LT-RT A $743.89 000-099 N Y N

L2040 A $127.73 000-099 N Y Y 000-099

L2050 A $271.16 000-099 N Y Y 000-099

L2060 A $339.17 000-099 N Y Y 000-099

L2070 A $97.08 000-099 N Y Y 000-099

L2080 A $207.67 000-099 N Y Y 000-099

L2090 A $276.69 000-099 N Y Y 000-099

L2106 LT-RT A $542.30 000-099 N Y Y 000-099 823.00-824.7

KAFO DY FREE A WO KNEE JT

<21 1 PER 6 MONTHS


KAFO PLA SIN UP W/WO K/A CUS

1 PER 6 MONTHS

KAFO PLASTIC PEDIATRIC SIZE

KAFO PLAS DOUB

FREE KNEE MOL <21 1 PER 6 MONTHS


KAFO PLAS SING FREE KNEE MOL

<21 1 PER 6 MONTHS


KAFO W/O JOINT MULTI-AXIS AN

<21 1 PER 6 MONTHS


HKAO TOR BI ROT STPP P BD/BT

HKAFO BIL. TOR C H

JT.P BD/BT HKAFO B1 TOR C

BALL B HJ ETC. HKAFO UNI ROT

STRP.TC P BD/BT HKAFO UNI TOR CHJ

P BD/BT HKAFO UNIL.TOR.C

BALL HJ ETC. AFO,THERMOPL

CAST MOLD TO PAT <21 1 PER 6 MONTHS






CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL2108 LT-RT A $639.72 000-099 N Y Y 000-099

L2112 LT-RT A $286.63 000-099 N N N

L2114 LT-RT A $359.00 000-099 N N N

L2116 LT-RT A $428.89 000-099 N N Y 000-099

L2128 LT-RT A $892.19 000-099 N N Y 000-099

L2136 LT-RT A $701.75 000-099 N Y Y 000-099

L2180 LT-RT A $73.77 000-099 N Y Y 000-099

L2182 LT-RT A $63.58 000-099 N Y Y 000-099

L2184 LT-RT A $64.45 000-099 N Y Y 000-099

L2186 LT-RT A $85.72 000-099 N Y Y 000-099

AFO FX ORTH TIBIAL FX O MOLDED

1 PER 6 MONTHS

AFO TIBIAL

FRACTURE SOFT <21 1 PER 6 MONTHS


AFO TIB FX SEMI-RIGID

<21 1 PER 6 MONTHS


AFO FXO TIBIAL FX O RIGID C.FI

<21 1 PER 6 MONTHS


823.00 -824.7

KAFO FEMORAL FX CAST O

KAFO FR O FFC O

RIGID CF <21 1 PER 6 MONTHS


823.00 -824.7

ADD FX O PLAS SHOE INS W/A JT

<21 1 PER 6 MONTHS


823.00 -824.7

AD LE FXO DROP LK KN JOINT

<21 1 PER 6 MONTHS


823.00 -824.7

ADD LE FX O LTD. MOT KN JOINT

<21 1 PER 6 MONTHS


823.00 -824.7

LE FX O ADJ MOT.K JT LERMAN

<21 1 PER 6 MONTHS


823.00 -824.7






L2210 LT-RT A $34.97 000-099 N Y N

L2220 LT-RT A $45.03 000-099 N Y N

L2230 LT-RT A $58.24 000-099 N Y N

L2240 LT-RT A $58.24 000-099 N Y Y 000-099

L2250 LT-RT A $185.87 000-099 N Y Y 000-099

L2260 LT-RT A $79.71 000-099 N Y Y 000-099

L2265 LT-RT A $96.18 000-099 N Y N

L2270 LT-RT A $43.92 000-099 N Y N

L2275 LT-RT A $93.26 000-099 N Y N

L2280 LT-RT A $383.18 000-099 N Y Y 000-099

LIMITED ANKLE MOTION

<21 2 PER 6 MONTHS


ADD LE D FA/PER EA. JT

<21 2 PER 6 MONTHS


DORSIFLEXION PLANTAR ASSIST

<21 2 PER 6 MONTHS


SPLIT FLAT CALIPER STIRRUP PLT

<21 1 PER 6 MONTHS


ROUND CALIPER AND PLATE

MOLDED FOOTPLATE

STIRRUP ATT

REINFORCED SOLID STIRRUP

ADD LOWER EXTRE,

LTS <21 1 PER 6 MONTHS


T STRAP PADDED/LINED/MALLEOLUS

<21 2 PER 6 MONTHS


ADD LOWER EXTRE PLAS MODIF

<21 1 PER 6 MONTHS


MOLDED INNER BOOT





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL2310 A $64.00 000-099 N Y N

L2320 LT-RT NON-MOLDED LACER A $132.83 000-099 N Y N

L2330 LT-RT A $204.36 000-099 N Y N

L2335 LT-RT A $195.27 000-099 N Y N

L2340 LT-RT A $232.54 000-099 N Y N

L2350 LT-RT A $575.29 000-099 N Y Y 000-099

L2360 LT-RT A $33.72 000-099 N Y N

L2370 LT-RT A $222.33 000-099 N Y Y 000-099

L2375 LT-RT A $91.29 000-020 N Y Y 000-020

L2380 LT-RT A $71.81 000-020 Y Y Y 000-020L2385 LT-RT A $81.76 000-099 N Y Y 000-099

L2387 A $91.01 000-099 N Y Y 000-099

ADD LE ABD BAR ST.

<21 1 PER 6 MONTHS


<21 1 PER 6 MONTHS


LACER MOLDED TO PATIENT MODE

<21 1 PER 6 MONTHS


ADD. TO LOWER EXTR./ANT. SWING

<21 1 PER 6 MONTHS


PRE TIBIAL SHELL MOLDED

<21 1 PER 6 MONTHS


PROSTH SOCKET PTB AFO

EXTENDED STEEL

SHANK <21 1 PER 6 MONTHS


ADD. TO LOWERE EXTR./PATTEN

ADD.TORS.CTRL.AJ

HALF-STIR TC KJ STRAIGHT

ADD. L.E. STKN JT A

DY JT ADD LE POLY KNEE

CUSTOM KAFO






L2395 LT-RT A $81.42 000-099 N Y Y 000-099

L2397 A $87.33 000-099 N Y Y 000-099

L2405 LT-RT A $48.51 000-099 N Y N

L2415 LT-RT A $67.61 000-099 N Y N

L2425 LT-RT A $79.78 000-099 N Y N

L2430 LT-RT A $79.78 000-099 N Y N

L2492 LT-RT A $65.26 000-099 N Y N

L2500 LT-RT A $174.13 000-099 N Y Y 000-099

L2510 LT-RT A $526.23 000-099 N Y Y 000-099

L2520 LT-RT A $299.09 000-099 N Y Y 000-099

L2530 LT-RT A $149.18 000-099 N Y Y 000-099

ADD LE OFFSET KJT EA

<21 2 PER 6 MONTHS


ADD-LE,OFFSET KJT HDY, EA.

ADD LOWER EXTRE

SUSPENSION SLE ADD KN JT, DROP

LOCK EA. JT. <21 2 PER 6 MONTHS


ADO KN JT CAM LOCK EA JT

<21 1 PER 6 MONTHS


ADD KN JT DISC/DIAL LOCK EA JT

<21 1 PER 6 MONTHS


STRAIGHT K JT POLYCENTRIC JT

<21 1 PER 6 MONTHS


ADD KN JOINT LIFT LOOP FOR D L

<21 1 PER 6 MONTHS


GLUTEAL/ISCHIAL WGT BEAR RING

QUAD BRIM C MOLD

TH/WT BRG QUAD BRIM C FIT

TH/WT BRG LACER NON-MOLDED

G/I WGT






L2550 LT-RT A $189.33 000-099 N Y N

L2570 A $318.67 000-099 N Y Y 000-099

L2580 A $241.48 000-099 N Y Y 000-099

L2600 LT-RT A $118.68 000-099 N Y Y 000-099

L2610 LT-RT A $143.05 000-099 N Y Y 000-099

L2620 LT-RT A $139.11 000-099 N Y Y 000-099

L2627 A $1,529.25 000-020 N Y Y 000-020

L2628 A $1,120.92 000-020 N Y Y 000-020

L2630 A $153.27 000-099 N Y Y 000-099

L2640 A $214.59 000-099 N Y Y 000-099

L2650 A $77.00 000-099 N Y Y 000-099

L2660 A $132.94 000-099 N Y Y 000-099

L2670 A $102.18 000-099 N Y Y 000-099

L2680 LT-RT A $102.18 000-099 N Y Y 000-099

L2760 LT-RT A $31.61 000-099 N Y N

L2768 LT-RT A $72.51 000-099 N N Y 000-099

LACER MOLDED G/I WGT

HIGH ROLL CUFF G/I

WGT 1 PER YEAR

ADD LOW EXTRE

PELVIC CONTROL PELVIC SLING GLI

WGT HIP JT

CLEVIS/THRUST PELVIC C

HIP JT CLEVIS/THRUST LOCK HJ

ADD LE HJT P/CON HDY EA.

ADD LOW EXTRE

PELVIC CONTROL ADD LOW EXTRE

PELVIC CONTROL PELVIC CONT

BAND/BELT UNILAT. PELVIC BAND/BELT

BILATERAL PELVIC/THORACIC C

GLUTEAL PAD THORACIC BAND TC

PARASPINAL

UPRIGHTS TC LATERAL SUPPORT

UPRIGHTS TC EXTENSION PER BAR

4 PER 2

YEARS

ORTHO SIDEBAR DISCONNECT






L2780 LT-RT A $35.21 000-099 N Y N

L2795 LT-RT A $56.94 000-099 N Y N

L2800 LT-RT A $56.94 000-099 N Y N

L2810 LT-RT A $45.45 000-099 N Y N

L2820 LT-RT A $59.73 000-099 N Y N

L2850 LT-RT A $33.67 000-099 N Y Y 000-099

L2999 A $0.01 000-099 N N Y 000-099

L3000 LT-RT A $125.67 2 PER YEAR 000-099 N Y Y 000-099

L3001 LT-RT A $41.07 2 PER YEAR 000-099 N N Y 000-099


STAINLESS STEEL PER BAR JT

4 PER 2 YEARS

NON CORROSIVE FINISH PER BAR

<21 4 PER 6 MONTHS


KNEE CONTROL, FULL KNEECAP

<21 1 PER 6 MONTHS


KNEE CAP MEDIAL OR LATERAL P

<21 1 PER 6 MONTHS


ADD. LE ORTH CONDY/PD

<21 1 PER 6 MONTHS


ADD.LOWER EXT., BELOW KNEE

<21 1 PER 6 MONTHS


ADD LOW EXTRE ORTHO FEMORAL L

1 PER YEAR

821.10-821.10 NOC LOWER

EXTREMITY ORTHOSIS

FOOT INSERT,UCB,BERKELEY SHELL

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

FOOT INSERT MOLDED SPENCO, EA

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

FOOT INSERT MOLD PLASTAZOTE,EA

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL3003 LT-RT A $94.17 2 PER YEAR 000-099 N N Y 000-099




L3040 LT-RT A $20.04 000-099 N N Y 000-099

L3050 LT-RT A $24.04 000-099 N N Y 000-099

L3060 LT-RT A $34.06 000-099 N N Y 000-099

L3070 LT-RT A $12.02 000-099 N N Y 000-099

L3140 A $40.88 000-099 N N Y 000-099

L3150 A $33.72 000-099 N N Y 000-099

L3160 A $0.01 000-099 N N Y 000-099

L3170 LT-RT A $39.32 000-099 N N N 000-099

L3201 LT-RT A $17.88 000-099 N N Y 000-099

FOOT INSERT MOLDED SILICONE,EA

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

FT-INSERT MOLD LONGITUDINAL EA

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

FOOT INSERT MOLD LONGIMET, EA.

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

FOOT INSERT CUSTOM MOLDED

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

FOOT ARCH PREMOLD LONG. EA.

FOOT ARCH PREMOLD MET EA.

FOOT ARCH

PREMOLD LONGIMET EA.

FOOT ARCH SUP.NONREM LONG EA.

FT ROT POS DEV W/SH

ABDUCTION BARS

DBROWNE CLAMPED

FOOT,ADJUSTABLE SHOE-STYLED

FOOT PLASTIC HEEL

STABILIZER1 PER 6

MONTHS

ORTHO OXFORD SUP/PRO INFANT

1 PER 6 MONTHS

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL3202 LT-RT A $23.50 000-099 N N Y 000-099

L3203 LT-RT A $26.06 000-099 N N Y 000-099

L3204 LT-RT A $20.94 000-099 N N Y 000-099

L3206 LT-RT A $24.50 000-099 N N Y 000-099

L3207 LT-RT A $29.13 000-099 N N Y 000-099

L3208 LT-RT A $21.46 000-099 N N N

L3209 LT-RT A $25.54 000-099 N N N

L3211 LT-RT A $27.58 000-099 N N N

L3212 A $41.88 000-099 N N N

L3213 A $51.08 000-099 N N N

L3214 A $58.24 000-099 N N N

L3215 LT-RT A $43.42 000-099 N N Y 000-099

L3216 LT-RT A $45.98 000-099 N N Y 000-099

ORTH OXFORD SUP/PRO CHILD

1 PER 6 MONTHS

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

ORTHO OXFORD SUP/PRO JUNIOR

1 PER 6 MONTHS

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

ORTH SHOE HT SUP/PRO INFANT

1 PER 6 MONTHS

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

ORTHO SHOE HT SUPIPRO CHILD

1 PER 6 MONTHS

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

ORTHO SHOE HT SUP/PRO CHILD

1 PER 6 MONTHS

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

SURGICAL BOOT,EACH,INFANT

1 PER 6 MONTHS

SURGICAL

BOOT,EACH,CHILD

1 PER 6 MONTHS

SURGICAL

BOOT,EACH,JUNIOR

1 PER 6 MONTHS

BENESCH BOOT,PAIR,INFANT

1 PER 6 MONTHS

BENESCH BOOT,

PAIR, CHILD 1 PER 6

MONTHS BENESCH

BOOT,PAIR,JUNIOR

1 PER 6 MONTHS

ORTHO

FOOTWEAR,LADIES SHOES

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

ORTHO FOOTWEAR,LADIES,DEPTH, EA.

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL3217 LT-RT A $51.09 000-099 N N Y 000-099

L3219 LT-RT A $45.48 000-099 N N Y 000-099

L3221 LT-RT A $45.98 000-099 N N Y 000-099

L3222 LT-RT A $55.69 000-099 N N Y 000-099

L3224 LT-RT A $38.39 000-099 N N N 000-099

L3225 LT-RT A $41.93 0.099 N N N 000-099

L3230 LT-RT A $159.40 000-099 N N Y 000-099

L3250 LT-RT A $149.52 000-099 N N Y 000-099

L3251 LT-RT A $149.18 000-099 N N Y 000-099

ORTHO FOOTWR,LADIES,HIGHTOP, EA.

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

ORTHO FOOTWEAR,MENS SHOES, EA.

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

ORTHO FOOTWR,MEN,DEPTH INLAY, EA.

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

MENS SHOES HIGHTOP DEPTH INLY, EA

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

WOMAN'S SHOE OXFORD BRACE

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

MAN'S SHOE OXFORD BRACE

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

ORTH CUSTOM SHOES DEPTH INLAY, EA.

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

CUST SHOE INNER MOLD PROSTHETC

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3

MOLDED SHOE,SILICONE,EA.

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

728.10-728.19, 736.81, 754.51, 755.32, 896.0- 896.3





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL3252 LT-RT A $115.46 000-099 N N Y 000-099 250.10 - 250.93, 707.15

L3253 LT-RT A $76.64 000-099 N Y Y 000-099 250.10 - 250.93, 707.15

L3254 A $9.19 000-099 N N N

L3255 A $8.84 000-099 N N N

L3257 A $64.51 000-099 N N N

L3260 LT-RT A $51.08 000-099 N N N

L3265 LT-RT A $20.43 000-099 N N Y 000-099

L3300 LT-RT A $24.52 000-099 N N N

L3310 LT-RT A $31.67 000-099 N N N

L3320 LT-RT A $76.64 000-099 N N N


MOLD SHOE,PLASTAZOTE,CUSTOM,EA

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

MOLD SHOE,PLASTAZOTE,CUST.FIT

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

NON-STANDARD SIZE OR WIDTH

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

NON-STANDARD SIZE OR LENGTH

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

ORTHO FOOT ADD CHARGE SPLIT S

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

AMBULATORY SURGICAL BOOT,EACH

<21 1 PER 6 MONTHS

21 & > 1 PER YEAR

PLASTAZOTE SANDAL,EACH

707.15, 825.20 - 825.29, 826.0, 845.10, 845.11, 845.12, 895.0, V66.0

LIFTS,ELEV.HEEL,PER INCH

2 PER YEAR (UP TO 2" EA.)

LIFTS,ELEVATION,HE

EL/SOLE/INCH 2 PER YEAR (UP TO 2" EA.)

LIFTS ELEV

HEEL/SOLE CORK INCH

2 PER YEAR (UP TO 2"

EA.)

LIFTS ELEV.METAL EXT. SKATE





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL3332 LT-RT A $12.26 2 PER YEAR 000-099 N N N

L3334 LT-RT A $19.41 000-099 N N N

L3340 LT-RT A $55.18 000-099 N N N L3350 LT-RT A $9.19 000-099 N N N L3360 LT-RT A $12.26 000-099 N N N

L3370 LT-RT A $15.32 000-099 N N N

L3380 LT-RT A $15.62 000-099 N N N L3390 LT-RT A $38.33 000-099 N N N L3400 LT-RT A $31.47 000-099 N N N

L3410 LT-RT A $38.82 000-099 N N N

L3420 LT-RT A $30.65 000-099 N N N

L3430 LT-RT A $27.58 000-099 N N N

L3440 LT-RT A $30.65 000-099 N N N

L3450 LT-RT A $45.96 000-099 N N N

L3455 LT-RT A $12.26 000-099 N N N

L3460 LT-RT A $12.26 000-099 N N N

L3465 LT-RT A $16.35 000-099 N N N

L3470 LT-RT A $23.49 000-099 N N Y 000-099

LIFTS ELEV INSIDE TAPER TO 1/2

LIFTS ELEV HEEL

PER INCH 2 PER YEAR

(UP TO 2" EA.) HEEL WEDGE SACH

4 PER YEAR

HEEL WEDGE

4 PER YEAR

SOLE

WEDGE,OUTSIDE SOLE

4 PER YEAR

SOLE WEDGE,BETWEEN SOLE

4 PER YEAR

CLUBFOOT WEDGE

4 PER YEAR

OUTFLARE WEDGE

4 PER YEAR

METATARSAL BAR

WEDGE ROCKER 2 PER YEAR

METATARSAL BAR

WEDGE BET SOLE 2 PER YEAR

FULL SOLE/HEEL

WEDGE BET SOLE 2 PER YEAR

HEEL COUNTER

PLASTIC REINF 2 PER YEAR

HEEL COUNTER

LEATHER REINF 2 PER YEAR

HEEL SACH

CUSHION TYPE 2 PER YEAR

HEEL NEW LEATHER

STANDARD 2 PER YEAR

HEEL, NEW RUBBER, STANDARD

2 PER YEAR

HEEL, THOMAS WITH WEDGE

2 PER YEAR

HEEL, THOMAS

EXTENDED TO BALL






L3510 LT-RT A $8.18 000-099 N N N

L3520 LT-RT A $14.73 000-099 N N N

L3530 LT-RT A $12.26 000-099 N N N

L3540 LT-RT A $24.52 000-099 N N N

L3550 LT-RT A $2.04 000-099 N N N

L3560 LT-RT A $3.06 000-099 N N N

L3570 LT-RT A $20.43 000-099 N N N

L3580 LT-RT A $15.32 000-099 N N N

L3590 LT-RT A $19.41 000-099 N N N

L3595 LT-RT A $19.41 000-099 N N N

L3600 LT-RT A $44.85 000-099 N Y N

L3610 LT-RT A $77.65 000-099 N Y N

L3620 LT-RT A $44.85 2 PER YEAR 000-099 N Y N

L3630 LT-RT A $77.65 000-099 N Y N


L3649 A $0.01 000-099 N N Y 000-099

MISC. SHOE ADD, INSOLE,LEATHER

2 PER YEAR

MISC. SHOE ADD,

INSOLE, RUBBER 2 PER YEAR

MISC SHOE ADD

INSOLE FELT 2 PER YEAR

MISC. SHOE ADD,

SOLE, HALF 2 PER YEAR

MISC. SHOE ADD,

SOLE, FULL 2 PER YEAR

MISC SHOE ADD,TOE

TAP,STANDARD 2 PER YEAR

MISC SHOE ADD,TOE TAP HORSESHO

2 PER YEAR

MISC SHOE ADD EXT TO INSTEP

2 PER YEAR

MSA CONVERT

INSTEP TO VELCRO 2 PER YEAR

MSA CONVERT FIRM

TO SOFT COUNT 2 PER YEAR

MISC SHOE ADD,

MARCH BAR 2 PER YEAR

TRANSFER SHOE

CALIPER PLATE EX 2 PER YEAR

TRANSFER SHOE

CALIPER PLTE NEW 2 PER YEAR

TRANS SHOE SOLID

STIRP EXISTG TRANS SHOE SOLID

STIRP NEW 2 PER YEAR

TRANS SHOE DENIS

BRWNE UNLISTED PROC

SHOES MOD TRANS






L3651 LT-RT A $44.46 000-099 N N N

L3652 LT-RT A $107.18 000-099 N N N

L3660 LT-RT A $52.33 000-099 N N N

L3670 LT-RT A $57.58 000-099 N N N

L3672 LT-RT A $287.95 000-099 N Y N

L3675 A $92.58 000-020 N N Y 000-020L3677 A $175.93 000-099 N N N

L3700 LT-RT A $38.42 2 PER YEAR 000-099 N N N

L3701 LT-RT A $13.76 000-099 N N N

SO FIG 8 ABD RESTRAINER

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

PREFAB SHOULDER ORTHOSIS

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

PREFAB DBL SHOULDER ORTHOSIS

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

SO FIG 8 ABD RESTR CANVAS

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

SO ACROMIO CLAVICULAR CANVAS

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

SO AIREPL ONLYANE W/O JNTS CF

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

SO VEST TYPE

SO HARD PLASTIC

STABILIZER <21 1 PER

YEAR 21 & > 1 PER 2

YEARS

ELBOW ORTHO, ELASTIC W/ STAYS

PREFAB ELBOW

ORTHOSIS<21 1 PER

YEAR 21 & > 1 PER 2

YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL3702 LT-RT EO W/O JOINTS CF A $133.39 000-099 N Y N


L3720 LT-RT A $346.00 000-099 N N N

L3730 LT-RT A $458.98 000-099 N N N

L3740 LT-RT A $544.15 000-099 N N N

L3760 LT-RT A $258.59 000-099 N N N

L3762 LT-RT A $72.60 000-099 N N N

L3807 LT-RT A $129.29 000-099 N N N

L3808 A $0.01 000-099 N Y Y 000-099

L3900 LT-RT A $1,054.89 000-099 N Y Y 000-099

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

EO, ELASTIC W/ PLASTIC JOINTS

EO DU

FOREARM/ARM CUFFS FREE

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

EO DU FOREARM/ARM CUFFS EXT/FL

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

EO DU FOREARM/ARM CUFFS ADJ C

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

EO WITH JOINT, PREFABRICATED

<21 1 PER YEAR 21 &> 1 PER 2

YEARS

RIGID ELBOW ORTHO W/O JOINTS

<21 1 PER YEAR 21 &> 1 PER 2

YEARS

WHFO, NO JOINT, PREFABRICATED

<21 1 PER YEAR 21 &> 1 PER 2

YEARS

WHFO, RIGID NO JOINT, CUSTOM FABRICATED

WHFO DYN F HINGE WRIST/F DRIVN





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL3904 LT-RT A $1,711.55 000-020 N Y Y 000-020

L3906 LT-RT A $256.64 000-099 N Y Y 000-099

L3908 LT-RT A $40.88 000-099 N N N

L3909 LT-RT A $9.56 000-099 N N N

L3911 LT-RT A $17.42 000-099 N N N

L3912 LT-RT A $53.36 000-099 N N N

L3913 LT-RT HFO W/O JOINTS CF A $56.15 000-099 N Y N


L3919 LT-RT HO W/O JOINTS CF A $31.63 000-099 N Y N

L3925 A $39.59 000-099 N N N

L3927 A $0.01 000-099 N N Y 000-099

WHFO EXT POWERED ELECTRIC

WHFO WRIST GAUNTLET MOLDED

WHFO COCK UP NON-MLD

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

PREFAB WRIST ORTHOSIS

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

PREFAB HAND FINGER ORTHOSIS

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

WHFO FLEX GLOVE W/ELASTIC FC

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

PREFAB METACAREPL ONLY FX ORTHOSIS

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

FO PIP/DIP W/ JOINT/SPRING

1 PER 2 YEARS

FO PIP/DIPW/O JOINT/SPRING

1 PER 2 YEARS






L3931 A $125.66 000-099 N N N

L3960 A $498.65 000-099 N N N

L3962 LT-RT A $412.39 000-099 N N N


L3964 RR LT-RT A $42.93 000-020 N N N


L3965 RR LT-RT A $68.51 000-020 N N N


L3966 RR LT-RT A $51.61 000-020 N N N

L3980 LT-RT A $229.90 000-099 N N N

L3982 LT-RT A $229.90 000-099 N N N

HFO NONTORSION JOINT, PREFAB.

1 PER 2 YEARS

WHFO NONTORSIN JOINT PREFAB.

1 PER 2 YEARS

SEWHO ABD AIREPL ONLYANE DESIGN

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

SEWHO ERBS PALSEY DESIGN ABD

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

SEWHO MOBILE ARM SUPP ADJ

SEWHO MOBILE ARM

SUPP ADJ 10 MONTHS = PURCHASE

SEWHO RAD ARM SUPPORT RANCHO

SEWHO RAD ARM

SUPPORT RANCHO 10 MONTHS = PURCHASE

SEWHO MOBILE ARM SUPP RECLING

SEWHO MOBILE ARM SUPP RECLING


UE FX ORTH HUMERAL

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

UE FX ORTH RADIUS/ULNAR

<21 1 PER YEAR 21 & > 1 PER 2

YEARS






L3995 LT-RT A $20.80 000-099 N Y Y 000-099

L3999 A $0.01 000-099 N N Y 000-099

L3999 RR A $0.01 000-099 N N Y 000-099

L4000 A $735.31 000-099 N Y Y 000-099

L4002 A $13.82 2 PER YEAR 000-099 N N N

L4010 A $574.69 000-020 N Y Y 000-020

L4020 A $536.88 000-099 N Y Y 000-099

L4030 A $383.18 000-099 N Y Y 000-099

L4045 LT-RT A $170.68 000-099 N Y Y 000-099

L4050 A $228.84 000-099 N Y Y 000-099

L4055 LT-RT A $139.08 000-099 N Y N

L4060 LT-RT A $180.81 000-099 N Y N

UE FX ORTH WRIST

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

ADD U EX O SOCK, FX. EACH

UNLISTED PROC U

LIMB ORTH UNLISTED PROC U

LIMB ORTH REP GIRDLE FOR

MILWAUKEE ORTH REPL ONLYACE

STRAP, ANY ORTHOSIS

REP TRILATERAL SOCKET BRIM

REP QUAD SOCKET

BRIM MOLDED REP QUAD SOCKET

BRIM CUSTOMFIT REPL ONLYACE NON-

MOLDEN THIGH LACER

REPL ONLYACE MOLDED CALF LACER

REPL ONLYACE NON-MOLDED CALF LACER

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

REP HIGH ROL CUFF

<21 1 PER YEAR 21 & > 1 PER 2

YEARS






L4080 LT-RT A $55.27 000-099 N Y N

L4090 LT-RT A $47.02 000-099 N Y Y 000-099

L4100 LT-RT A $56.51 000-099 N Y N

L4110 LT-RT A $44.12 000-099 N Y N

L4130 A $266.71 000-099 N Y N

L4205 A $11.50 000-099 N N N

L4210 A $46.08 000-099 N N N

L4350 LT-RT A $68.11 000-099 N N Y 000-099

L4360 LT-RT A $144.07 000-099 N N Y 000-099

L4370 LT-RT A $130.97 000-099 N N Y 000-099

L4380 LT-RT A $63.68 000-099 N N Y 000-099

REP PROX/DISTAL UPRIGHT AKO

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

REP METAL BDS KAFO-AFO PROX TH

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

REP METAL BDS KAFO-AFO CALF DT

REP LEAT CUFF

KAFO-AFO PROX TH<21 1 PER

YEAR 21 & > 1 PER 2

YEARS

REP LEA CUFF KAFO-AFO CALF DTH

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

REP PRETIBIAL SHELL

<21 2 PER YEAR 21 & > 2 PER 2

YEARS

ORTHO DVC REPAIR PER 15 MIN

UP TO 1 HOUR TWICE A YR

ORTH DEV REPAIR/REPL ONLY MINOR P

TWICE PER YEAR

PNEUM A CTRL (EG,AIRCAST)

1 PER YEAR

824.0 -824.9 845.00 -845.09 PNEUM. WALK SPL

(AIRCAST) DNEUM. FULL LEG

SPL. (AIRCAST) PNEUM. KNEE SPL

(AIRCAST)





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL4386 LT-RT A $94.12 1 PER YEAR 000-099 N N N

L4392 LT-RT A $16.64 000-099 N Y N


L4396 LT-RT A $123.44 000-099 N Y Y 000-099

L4398 LT-RT A $56.82 000-099 N Y Y 000-099L5000 LT-RT A $319.53 000-099 N Y N

L5010 LT-RT A $892.81 000-099 N Y N

L5020 LT-RT A $1,519.44 000-099 N Y N

L5050 LT-RT A $1,668.63 000-099 N Y N

L5060 LT-RT A $1,883.20 000-099 N Y N

L5100 LT-RT A $1,788.19 000-099 N Y N

NON-PNEUMATIC WALKING SPLINT

REPL ONLYACE INTR MAT'L ANKLE

1 PER YEAR

REPL ONLYACE INTR

MAT'L FOOT DROP

ANKLE CONTRACTURE SPLINT

FOOT DROP SPLINT

PARTIAL FOOT INST

ARCH/TOE FIL <21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

PARTIAL FT MOLDED SOCKT TOE FR

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

PARTIAL FT MLD SOCKT TIB HGTTF

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

ANKLE SYMES SACH FOOT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

ANKLE SYMES LEA SOCKT ART A/F

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK MOLDED SOCKT SHIN SACH FT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL5105 LT-RT A $2,591.68 000-099 N Y N

L5150 LT-RT A $2,386.60 000-099 N Y N

L5160 LT-RT A $2,620.38 000-099 N Y N

L5200 LT-RT A $2,352.24 000-099 N Y N

L5210 LT-RT A $1,609.17 000-099 N Y N

L5220 LT-RT A $1,772.61 000-099 N Y N

L5230 LT-RT A $2,682.28 000-099 N Y N

L5250 LT-RT A $3,227.93 000-099 N Y N

L5270 LT-RT A $3,473.33 000-099 N Y N

BK, PLAST SOC., JTS TH LACER S

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

K DISART M SOC EXT KJTS SACH F

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

K DIS M SOC EX KJTS BENT/KSF

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

AK SING AXIS C FRIC K SACH FT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

AK SHORT FOOD BLKS NO K/A JTS

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

AK SHORT W/ART AIF DYN NO KJTS

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

AK PROY FFD CFRICK SACH FT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

HIP D CANADIAN CFRICK SACH FT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

HIP D TILT SCFRICK SACH FT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS






L5301 LT-RT A $1,732.97 000-099 N Y N

L5311 LT-RT A $2,357.31 000-099 N Y N

L5321 LT-RT A $2,630.81 000-099 N Y N

L5331 LT-RT A $3,561.75 000-099 N Y N

L5341 LT-RT A $3,863.54 000-099 N Y N

L5500 LT-RT A $822.18 000-099 N Y N

L5505 LT-RT A $1,156.59 000-099 N Y N

L5510 LT-RT A $981.84 000-099 N Y N

L5520 LT-RT A $1,086.20 000-099 N Y N

HEMIPEL CAN HIPJ CFRICK SACH

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK MOLD SOCKET SACH FT ENDO

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

KNEE DISART, SACH FT, ENDO

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

AK OPEN END SACH

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

HIP DISART CANADIAN SACH FT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

HEMIPELVECTOMY CANADIAN SACH

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

PREP BK PTB SUPRAC SUS SACH PL

1 PER MEDICAL EVENT

PREP BK ISH SOC SACH PLASTER

1 PER MEDICAL EVENT

PREP BK PTB SACH PL MOLDED SOC

1 PER MEDICAL EVENT

PREP PTB SACH THERMOPLASTIC

1 PER MEDICAL EVENT






L5535 LT-RT A $1,196.16 000-099 N Y Y 000-099

L5540 LT-RT A $1,292.60 000-099 N Y N

L5560 LT-RT A $1,301.60 000-099 N Y N

L5570 LT-RT A $1,583.83 000-099 N Y N

L5580 LT-RT A $1,788.19 000-099 N Y N

L5590 LT-RT A $1,797.39 000-099 N Y N

L5595 LT-RT A $2,554.53 000-099 N Y N

L5600 LT-RT A $2,911.66 000-099 N Y Y 000-099

L5610 A $1,402.24 000-099 N Y Y 000-099

L5611 A $971.88 000-099 N Y Y 000-099

L5613 A $1,470.29 000-099 N Y Y 000-099

L5616 A $819.13 000-099 N Y Y 000-099

L5618 LT-RT A $248.38 000-099 N Y N

L5620 LT-RT A $220.38 000-099 N Y N

PREP BK PTB SACH THERMOP MOLD

1 PER MEDICAL EVENT

PREP. BK PTB SF PREFAB OES

PREP BK PTB SACH

LAMINATED MOL1 PER

MEDICAL EVENT

PREP AK ISOC SACH PLASTER MOLD

1 PER MEDICAL EVENT

PREP AK ISOC SACH THERMOPL DF

1 PER MEDICAL EVENT

PREP AK ISOC SACH THERMOP MOLD

1 PER MEDICAL EVENT

PREP AK ISOC SACH LAMINATED MO

1 PER MEDICAL EVENT

PREP. HDA HEMIPEL THERP/ MO.

1 PER MEDICAL EVENT

PREP. HDA HEMIPEL LAM MOLD

LT-RT

K1-K4AK ADD HYDRACADENCE

LT-RT

K1-K4ADD. LE AK KOISART. FSPC

LT-RT

K1-K4ADD LE AK K DISART HYD S PC

LT-RT

K1-K4AK ADD UMS FRIC SWING CONTROL

SYMES ADD TEST

SOCKET 1 PREP/

2 DEFIN. BK ADD TEST

SOCKET 1 PREP/

2 DEFIN.






L5624 LT-RT A $296.79 000-099 N Y N

L5626 LT-RT A $469.85 000-099 N Y N

L5628 A $475.80 000-099 N Y N

L5629 LT-RT A $176.16 000-099 N Y N

L5630 LT-RT A $318.80 000-099 N Y N

L5631 LT-RT A $274.12 000-099 N Y N

L5632 LT-RT A $159.41 000-099 N Y N

L5634 LT-RT A $187.74 000-099 N Y N

L5636 LT-RT A $143.48 000-099 N Y N

L5637 LT-RT A $284.69 000-099 N Y N

K DISART ADD TEST SOCKET

1 PREP/ 2 DEFIN.

AK ADD TEST

SOCKET 1 PREP/

2 DEFIN. HIP DISART ADD

TEST SOCKET 1 PREP/

2 DEFIN. HEMIPELVEC ADD

TEST SOCKET 1 PREP/

2 DEFIN. ADD.L.EXT.BK.ACRYL

IC SOCKET <21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

SYMES ADD EXP WALL SOCKET

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

ADD L.E. AK-K DISART ACRY. SOC

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

SYMES ADD PTB BRIM SOCKET

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

SYMES ADD POST OPENING SOCKET

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

ADD SYMES MEDIAL OPEN SOCKET

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

ADD LE BK TOT CON

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS






L5639 LT-RT A $621.49 000-099 N Y Y 000-099

L5640 LT-RT A $478.21 000-099 N Y Y 000-099

L5642 LT-RT A $459.81 000-099 N Y Y 000-099

L5644 LT-RT A $383.18 000-099 N Y Y 000-099

L5646 LT-RT A $344.21 000-099 N Y Y 000-099

L5648 LT-RT A $406.70 000-099 N Y Y 000-099

L5650 LT-RT A $360.82 000-099 N Y N

L5652 LT-RT A $322.22 000-099 N Y N

L5653 LT-RT A $377.06 000-099 N Y Y 000-099

L5654 LT-RT A $239.10 000-099 N Y N

L5655 LT-RT A $210.44 000-099 N Y N

L5656 LT-RT A $279.98 000-099 N Y N

BK ADD LEATHER SOCKET

ADD LE BK WOOD

SOCK K DISART ADD

LEATHER SOCKET AK ADD LEATHER

SOCKET AK ADD WOOD

SOCKET BK ADD AIR

CUSHION SOCKET AK ADD AIR

CUSHION SOCKET AK/KDISART ADD

TOTAL C SOCKET <21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

AK/KDISART SOCKT SUCTION SUSPN

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

K DISART EXPAND WALL SOCKET AD

SYMES ADD SOCKET

INSERT <21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK ADD SOCKET INSERT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

K DISART ADD SOCKET INSERT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS






L5666 LT-RT A $57.00 000-099 N Y N

L5668 LT-RT A $63.69 000-099 N Y N

L5670 LT-RT A $200.55 000-099 N Y N

L5671 LT-RT A $367.63 000-099 N Y N

L5672 LT-RT A $235.37 000-099 N Y N

L5673 LT-RT A $340.23 000-099 N Y N

L5676 LT-RT A $270.79 000-099 N Y Y 000-099

L5678 LT-RT A $23.49 000-099 N Y N

AK ADD SOCKET INSERT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK ADD CUFF SUSPENSION

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK ADD MOLDED DISTAL CUSHION

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK AK MOLD SUPC SUSP PTS

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK/AK LOCKING MECHANISM

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK ADD REMOV MED BRIM SUSPENSN

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

SOCKET INSERT W LOCK MECH

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK ADD KNEE JOINTS PAIR

BK ADD JOINT

COVERS PAIR <21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS






L5680 LT-RT A $189.04 000-099 N Y N

L5681 LT-RT A $603.39 000-099 N Y Y

L5682 A $346.67 000-099 N Y Y 000-099

L5683 LT-RT A $529.74 000-099 N Y N

L5684 LT-RT A $26.68 000-099 N Y N

L5685 LT-RT A $50.40 000-099 N Y N

L5686 LT-RT A $32.07 000-099 N Y N

L5688 A $37.80 000-099 N Y N

SOCKET INSERT W/O LOCK MECH

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK ADD THIGH LACER NON-MOLDED

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

INTL CUSTM CONG/LATYP INSERT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK ADD THIGH LACER G/I MOLDED

INITIAL CUSTOM

SOCKET INSERT <21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK ADD FORK STRAP

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BELOW KNEE SUS/SEAL SLEEVE

<21 4 PER YEAR 21 & > 1 PER

YEAR

BK ADD BACK CHECK (EXT CONTL)

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

BK ADD WAIST BELT WEBBING

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL5690 A $92.76 000-099 N Y N

L5692 A $73.65 000-099 N Y N

L5694 A $100.57 000-099 N Y N

L5695 LT-RT A $94.69 000-099 N Y N

L5696 LT-RT A $122.62 000-099 N Y N

L5697 LT-RT A $59.27 000-099 N Y N

L5698 LT-RT A $66.52 000-099 N Y N

L5699 LT-RT A $102.18 000-099 N Y N

L5700 LT-RT A $1,710.16 000-099 N Y Y 000-099

BK ADD WAIST BELT PADDED/LINED

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

AK ADD PELVIC CONTROL BELT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

AK ADD PELVIC CONTRL BELT PAD

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

ADD.LW EXT.ABOVE KNEE-PEL CONT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

AK/KD ADD PELVIC JOINT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

AK/KD ADD PELVIC BAND

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

AK/KD ADD SILESION BANDAGE

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

SHOULDER HARNESS ALL LE PROSTH

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

REPL ONLYACEMENT SOCKET BELOW KNEE





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL5701 A $2,121.62 000-099 N Y Y 000-099

L5702 A $2,673.97 000-099 N Y Y 000-099

L5703 A $137.76 000-099 N Y N

L5704 A $448.37 000-099 N Y N

L5705 A $639.27 000-099 N Y N

L5706 A $623.55 000-099 N Y Y 000-099

L5707 A $837.73 000-099 N Y Y 000-099

L5710 A $199.37 000-099 N Y N

L5712 A $238.86 000-099 N Y N

L5714 A $243.04 000-099 N Y N

L5716 A $480.57 000-099 N Y Y 000-099

L5718 A $513.89 000-099 N Y Y 000-099

L5722 A $624.91 000-099 N Y Y 000-099

L5724 A $963.20 000-099 N Y Y 000-099

SCKT REPL ONLYC AK/DSAR

SCKT REPL ONLYC

H/DSAR SYMES ANKLE W/O

(SACH) FOOT <21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

CS PROT CVR BK

2 PER 2 YEARS

CS PROT CVR AK

2 PER 2

YEARS CS PROT CVR

K/DSAR CS PROT CVR

H/DSAR LT-RT

K1-K4KNEE SHIN SYS ADD MANUAL LOCK

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

LT-RT K1-K4

ADD K SHIN SYS FSSPC SAFETY K

<21 1 PER 2 YEARS 21

& > 1 PER 5 YEARS

LT-RT K1-K4

ADD KSHIN SYS VARIABLE FSPC

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

LT-RT K1-K4

ADD KSHIN SYS POLYCENTRIC LOCK

LT-RT K1-K4

ADD KSHIN SYS POLYCENT FSSPC

LT-RT

K1-K4ADD KSHIN SYS PNEUMATIC SFSPC

LT-RT

K1-K4ADD KSHIN SYS FLUID SWING CONT





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL5726 A $1,146.73 000-099 N Y Y 000-099

L5728 A $1,343.83 000-099 N Y Y 000-099

L5780 A $739.89 000-099 N Y Y 000-099

L5810 A $317.12 000-099 N Y N

L5812 A $329.31 000-099 N Y N

L5816 A $471.42 000-099 N Y Y 000-099

L5818 A $532.33 000-099 N Y Y 000-099

L5822 A $976.54 000-099 N Y Y 000-099

L5824 A $923.12 000-099 N Y Y 000-099

L5828 A $1,642.91 000-099 N Y Y 000-099

L5830 A $1,107.76 000-099 N Y Y 000-099

L5840 A $0.01 000-099 N Y Y 000-099

L5845 A $999.33 000-099 N Y Y 000-099

L5850 LT-RT A $70.91 000-099 N Y N

LT-RT K1-K4

ADD KSHIN SYS SA EXT JTS FSPC

LT-RT

K1-K4ADD KSHIN SYS SA FLUID SSPC

LT-RT

K1-K4ADD KSHIN SYS SA PNEUM/HPNEUM

LT-RT

K1-K4ADD.EKSYS SINGLE AXIS MANUAL

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

LT-RT K1-K4

ADD EKSYS SA FRICTION S/S PHAS

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

LT-RT K1-K4

ADD EK SYS POLENTRIC MSP LOCK

LT-RT K1-K4

ADD EK SYS POLYC.FS/SP CONTROL

LT-RT K1-K4

ADD EK SYS SA PSFSPC

LT-RT

K1-K4ADD EK SYS SA FLUID SWG P CONT

LT-RT

K1-K4ADD EK SYS SA FLUID S/SP CONTR

LT-RT

K1-K4ADD EKSYS SA PNEU/.HYDRA. CONT

LT-RT K1-K4

ADD ENDO KS MA PNEU S

LT-RT

K1-K4ADD.ENDOSKELETEL KNEE SKIN SYS

ADD EK SYS AK/H

KNEE EXTENS. <21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS






L5925 LT-RT A $194.02 000-099 N Y Y 000-099

L5962 LT-RT A $418.98 000-099 N Y Y 000-099

L5964 LT-RT A $803.66 000-099 N Y Y 000-099

L5966 LT-RT A $1,035.24 000-099 N Y Y 000-099

L5970 A $130.24 000-099 N Y N

L5971 A $122.88 000-099 N Y N

L5972 A $220.61 000-099 N Y N

L5974 A $172.22 000-099 N Y N

L5975 A $269.24 000-099 N Y Y 000-099

L5976 A $380.77 000-099 N Y N

L5978 A $208.38 000-099 N Y N

ADD ENDO H/DSAR MECH

ADD ENDO K/DSAR

MAN ADD ENDOSKEL

BELOW KNEE PROT ADD ENDOSKEL

ABOVE KNEE FLEX ADD ENDOSKEL HIP

DISARTIC FLEX LT-RT

K1-K4L.E.PROSTH.,SACH FT.,EX. KEEL

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

LT-RT K1-K4

SACH FOOT, REPL ONLYACEMENT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

LT-RT K1-K4

FLEX KEEL FOOT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

LT-RT K1-K4

SINGLE AXIS ANKLE/FOOT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

LT-RT K1-K4

LOWER EXTREMITY PROSTHESIS

LT-RT

K1-K4L.E. PROSTH.,EN.S.,SEATTLE, EQ

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS

LT-RT K1-K4

FT PROSTH MULTI AXIAL ANKL/FT

<21 1 PER 2 YEARS 21 & > 1 PER 5

YEARS






L5980 A $2,117.94 000-099 N Y Y 000-099

L5981 A $2,446.28 000-099 N Y Y 000-099

L5982 A $357.39 000-099 N Y Y 021-099

L5984 A $358.49 000-099 N Y Y 000-099

L5990 LT-RT A $1,011.48 000-099 N Y Y 000-099

L5999 A $0.01 000-099 N Y Y 000-099

L6000 LT-RT A $982.03 000-099 N Y Y 000-099

L6010 LT-RT A $1,092.84 000-099 N Y Y 000-099

L6020 LT-RT A $1,018.91 000-099 N Y Y 000-099

L6050 LT-RT A $1,674.76 000-099 N Y Y 000-099

L6100 LT-RT A $1,683.96 000-099 N Y Y 021-099

L6110 LT-RT A $1,632.87 000-099 N Y Y 021-099

L6120 LT-RT A $1,926.12 000-099 N Y Y 021-099

L6130 LT-RT A $2,003.80 000-099 N Y Y 021-099

L6200 LT-RT A $2,141.73 000-099 N Y Y 021-099

L6250 LT-RT A $2,123.35 000-099 N Y Y 021-099

L6300 LT-RT A $2,764.02 000-099 N Y Y 021-099

MULTI AXIAL ANKLE/FT PROSTH

LT-RT K1-K4

PROSTHETIC FLEX FOOT SYSTEM

LT-RT

K1-K4ALL LOW EXTRE PROS FLEX-WALK

LT-RT

K1-K4AXIAL ROTATION UNIT WEBER-WATR

1 PER 5 YEARS

LT-RT

K1-K4AXIAL ROT.UNIT RANCHO/HUSMER

USER ADJUSTABLE

HEEL HEIGHT UNLISTED PROC FOR

LE PROSTH PARTIAL HAND

THUMB PARTIAL HAND

LITTLE RING PARTIAL HAND NO

FINGERS WD MOLDED

SOCKET FLEX ELBOW

1 PER 5 YEARS

BE MOLDED SOCKT FLEX ELBOW HGE

1 PER 5 YEARS

BE MOLDED SOCKT

NORTHWESTERN 1 PER 5

YEARS BE M DOUBLE W

SPLIT SOCKT 1 PER 5

YEARS BE MDWSS STUMP

ACT LOCKG HGE 1 PER 5

YEARS ED MDWS OUTSIDE

LOCKG HGE FORM 1 PER 5

YEARS AE DW INT LOCKG

EIB FOREARM 1 PER 5

YEARS SD M SOCKT INT

LOCKG ELBON 1 PER 5

YEARS






L6400 LT-RT A $1,594.05 000-099 N Y Y 000-099

L6450 LT-RT A $1,992.56 000-099 N Y Y 000-099

L6500 LT-RT A $1,947.09 000-099 N Y Y 000-099

L6550 LT-RT A $2,778.33 000-099 N Y Y 000-099

L6570 LT-RT A $2,931.61 000-099 N Y Y 000-099

L6600 LT-RT A $168.62 000-099 N Y Y 021-099

L6605 LT-RT A $173.56 000-099 N Y Y 021-099

L6610 LT-RT A $123.05 000-099 N Y Y 021-099

L6615 LT-RT A $119.44 000-099 N Y Y 021-099

L6616 LT-RT A $37.63 000-099 N Y Y 021-099

L6620 LT-RT A $208.82 000-099 N Y Y 021-099

L6625 LT-RT A $294.82 000-099 N Y Y 000-099

L6630 LT-RT A $159.29 000-099 N Y Y 000-099

L6635 LT-RT A $115.13 000-099 N Y Y 021-099

L6640 LT-RT A $210.49 000-099 N Y Y 000-099

L6645 LT-RT A $208.44 000-099 N Y Y 021-099

INTER THOR INT LOCKG ELBOW

BE MS ENDOSK

SOFT TISSUE SHPG ED MS ENDOSKE

SOFT TISSUE SHPG AE MS ENDOSK

SOFT TISSUE SHPG SD MS ENDOSK

SOFT TISSUE SHPG IT MS ENDOSK SOFT

TISSUE SHPG UE ADD

POLYCENTRIC HINGE DR

1 PER 5 YEARS

UE ADD SINGLE PIVOT HGE PR

1 PER 5 YEARS

UE ADD FLEX METAL

HGE PR 1 PER 2

YEARS UE ADD

DISCONNECT LOCKG W UNIT

1 PER 2 YEARS

UPPER EX.ADD DIS LOCK.WRIST EA

1 PER 2 YEARS

UE ADD FLEX-FRIC

WRIST UNIT 1 PER 2

YEARS UE ADD ROT W UNIT

WICABLE LOCK

UE ADD STAINLESS STEEL

UE ADD LIFT ASSIST

ELBOW 1 PER 2

YEARS UE ADD SHOULDER

ABD JOINT PR UE ADD SHOULDER

FLEX-ADD ST 1 PER 2

YEARS






L6647 LT-RT A $347.41 000-099 N Y Y 000-099

L6650 LT-RT A $220.18 000-099 N Y Y 021-099

L6655 LT-RT A $42.71 000-099 N Y Y 021-099

L6660 LT-RT A $57.15 000-099 N Y Y 021-099

L6665 LT-RT A $25.54 000-099 N Y Y 021-099

L6670 LT-RT A $26.59 000-099 N Y Y 000-099

L6672 LT-RT A $122.00 000-099 N Y Y 021-099

L6675 LT-RT A $66.57 000-099 N Y Y 021-099

L6676 LT-RT A $69.64 000-099 N Y Y 021-099

L6677 LT-RT A $83.52 000-099 N Y Y 021-099

L6680 LT-RT A $228.64 000-099 N Y Y 021-099

L6682 LT-RT A $252.79 000-099 N Y Y 021-099

L6684 LT-RT A $343.51 000-099 N Y Y 021-099

L6691 A $261.33 000-099 N Y Y 021-099

MULTIPO LOCKING SHOULDER JNT

SHOULDER LOCK ACTUATOR

UE ADD SHOULDER UNIV JT

1 PER 2 YEARS

UE ADD STD

CONTROL CABLE EA

1 PER 2 YEARS

UE ADD HEAVY DUTY CONTROL CABL

1 PER 2 YEARS

UE ADD TEFLON,CABLE LINING

1 PER 2 YEARS

UE ADD HOOK-HAND CABLE ADAPTOR

1 PER 2 YEARS

UE ADD HARN/CHEST/SHLDR/SADDLE

1 PER 2 YEARS

UE ADD HARNS FIG/8 SINGLE CONT

1 PER 2 YEARS

UE ADD FIG/8 DUAL

CONTROL 1 PER 2

YEARS UE TRIPLE CONTROL

HARNESS1 PER 2 YEARS

UE AD WD/BE TEST SOCKET

2 PER 5 YEARS

UE ADD ED/BE TEST

SOCKET 2 PER 5

YEARS UE ADD SD/IT TEST

SOCKET 2 PER 5

YEARS REMOVABLE INSERT

EACH1 PER 2 YEARS






L6693 A $1,648.82 000-099 N Y Y 000-099

L6694 LT-RT A $0.01 000-099 N Y Y 000-099

L6695 LT-RT A $0.01 000-099 N Y Y 000-099

L6696 LT-RT A $0.01 000-099 N Y Y 000-099

L6697 LT-RT A $0.01 000-099 N Y Y 000-099

L6698 LT-RT A $0.01 000-099 N Y Y 000-099

L6706 LT-RT A $0.01 000-099 N Y Y 000-099

L6707 LT-RT A $0.01 000-099 N Y Y 000-099

L6708 LT-RT A $0.01 000-099 N Y Y 000-099

L6709 LT-RT A $0.01 000-099 N Y Y 000-099

L6711 A $468.42 1 PER YEAR 000-020 N Y Y 000-020

L6712 A $862.49 1 PER YEAR 000-020 N Y Y 000-020

UP EX ADD,SIL.GEL.IN. EA.

1 PER 2 YEARS

UPPER EXTREMITY

COUNTERBALANCE ELBOW SOCKET INS

USE W/LOCK

ELBOW SOCKET INS USE W/O LCK

CUS ELBO SKT IN FOR CON/ATYP

CUS ELBO SKT IN NOT CON/ATYP

BELOW/ABOVE ELBOW LOCK MECH

TERM. DEVICE, HOOK, MECH, VO, ANY SIZE, LINED/UL

2 EVERY 2 YEARS

TERM. DEVICE, HOOK, MECH,VC,ANY SIZE, LINED/UL

2 EVERY 2 YEARS

TERM . DEVICE, HAND, MECH, VO, ANY SIZE

2 EVERY 2 YEARS

TERM. DEVICE, HAND, MECH, VC, ANY SIZE

2 EVERY 2 YEARS

PED. TERM. DEV., HOOK. VOL. OPEN/ANY MATER. LINED/UNLINED

PED. TERM. DEV., HOOK. VOL. CLOS./ANY MATER. LINED/UNLINED





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISL6713 A $1,088.52 1 PER YEAR 000-020 N Y Y 000-020

L6714 A $921.98 1 PER YEAR 000-020 N Y Y 000-020

L6721 A $1,638.74 000-099 N Y Y 000-099

L6722 A $1,412.70 000-099 N Y Y 000-099

L6805 LT-RT A $213.84 000-099 N Y Y 021-099

L6810 LT-RT A $113.68 000-099 N Y Y 021-099

L6881 LT-RT A $2,279.37 000-099 N Y Y 000-099

L6883 LT-RT A $1,224.00 000-099 N Y N

L6884 LT-RT A 1591.92 000-099 N Y N

L6885 LT-RT A 1874.88 000-099 N Y N


PED. TERM. DEV., HAND, VOL, OPEN/ANY MATER. LINED/UNLINED

PED. TERM. DEV., HAND, VOL. CLOS./ANY MATER. LINED/UNLINED

HOOK/HAND. HVY. DTY., VOL. OPEN/ANY MATER. LINED/UNLINED

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

HOOK/HAND. HVY. DTY., VOL. CLOS./ANY MATER. LINED/UNLINED

<21 1 PER YEAR 21 & > 1 PER 2

YEARS

TD MODIFIER WRIST FLEXION UNIT

1 PER 5 YEARS

TERM DEVICE PINCHER TOOL OTTO

1 PER 5 YEARS

AUTOGRASP FEATURE UL TERM DV

REPL ONLYC SOCKT BELOW E/W DISA

2 PER 2 YEARS

REPL ONLYC SOCKT ABOVE ELBOW DISA

2 PER 2 YEARS

REPL ONLYC SOCKT SHLDR DIS/INTERC

2 PER 2 YEARS

PREFAB GLOVE FOR TERM DEVICE






L6935 A $6,621.58 000-020 N Y Y 000-020

L7186 A $0.01 000-020 N Y Y 000-020

L7499 A $0.01 000-099 N Y Y 000-099

L7510 A $46.08 000-099 N Y N

L7520 A $11.50 000-099 N Y N

L7600 A $60.29 000-099 N N N

L8000 A $30.65 000-099 N N N

L8001 A $93.25 000-099 N N Y 000-099

L8002 A $122.65 000-099 N N Y 000-099

L8010 LT-RT A $30.65 000-099 N N N

L8015 A $44.56 021-099 Y N N

L8020 LT-RT A $126.07 000-099 N N N

L8030 LT-RT A $194.88 000-099 N N N

L8300 A $48.02 000-099 N N Y 000-099

CUSTOM GLOVE FOR TERM DEVICE

2 PER 2 YEARS

MYDEL

C.TER.DEV.BELOW ELBOW

EL-EL-CH- VARIETY, SW CON

UNLISTED PROC UE

PROSTHESIS PROSTHETIC DEVICE

REPAIR REP TWICE PER

YEAR

REPAIR PROSTHESIS PER 15 MIN

UP TO 1 HOUR TWICE A YR

PROSTHETIC DONNING SLEEVE

2 PER 6 MONTHS

BREAST PROTH MASTECTOMY BRA

2 PER 6 MONTHS

BREAST

PROSTHESIS BRA & FORM

BRST PRSTH BRA & BILAT FORM

BREAST PROSTH

MASTECTOMY SLEEV

2 PER 6 MONTHS

EXTERNAL BREAST PROS. GARMENT

2 PER 6 MONTHS

BREAST PROTH

MASTECTOMY FORM

2 PER 2 YEARS

BREAST PROSTHESIS, SILICONE

2 PER 2 YEARS

TRUSSES,SINGLE W/STD PAP






L8320 A $34.39 000-099 N N Y 000-099

L8330 A $27.36 000-099 Y N Y 000-099

L8400 LT-RT A $8.73 000-099 N N N

L8410 LT-RT A $11.48 000-099 N N N

L8415 LT-RT A $11.88 000-099 N N N

L8417 LT-RT A $51.83 000-099 N N N

L8420 LT-RT A $14.30 000-099 N N N

L8430 LT-RT A $16.35 000-099 N N N

L8435 LT-RT A $14.23 000-099 N N N

L8440 LT-RT A $33.72 000-099 N N N

L8460 LT-RT A $37.80 000-099 N N N

L8465 LT-RT A $34.16 000-099 N N N

L8470 LT-RT A $3.70 000-099 N N N

L8480 LT-RT A $5.11 000-099 N N N

L8485 LT-RT A $8.92 000-099 N N N

TRUSSES,DOUBLE W/STD PADS

TRUSSES,ADD

WATER PAD TRUSSES,ADD

SCROTAL PAD PROSTHETIC

SHEATH BK EA 6 PER 6

MONTHS PROSTHETIC

SHEATH,AK EA 6 PER 6

MONTHS PROSTH SHEATH

UPPER LIMB EA. 3 PER 6

MONTHS PROSTHETIC

SHEATH/SOCK,INC GEL

6 PER 6 MONTHS

PROSTHETIC SOCK WOOL BK EA

6 PER 6 MONTHS

PROSTHETIC SOCK

WOOL AK EA 6 PER 6

MONTHS PROSTH SOCK,

WOOL UPPER LIMB 3 PER 6

MONTHS PROSTHETIC

SHRINKER BK EA 1 PER 6

MONTHS PROSTHETIC

SHRINKER AK EA 1 PER 6

MONTHS PROSTH SHRINKER,

UPPER LIMB EA 1 PER YEAR

STUMP SOCK S PLY BK EA

6 PER 6 MONTHS

STUMP SOCK S PLY

AK EA 6 PER 6

MONTHS STUMP SOCK

SINGLE PLY UPPER LI

3 PER 6 MONTHS






L8500 A $489.20 000-099 N N Y 000-099

L8501 A $66.96 000-099 N N N

L8509 A $70.56 1 PER YEAR 000-099 N N N

L8510 A $0.01 000-099 N N Y 000-099L8515 A $46.92 000-099 N N Y 000-099

S1040 A $943.72 000-099 N Y Y 000-099 754.0

S5199 A $0.10 000-099 N N N

S5498 A $4.11 000-099 N N N

S5501 A $4.11 000-099 N N N

S5502 A $3.70 000-099 N N N

S5520HIT PICC INSERT KIT

A $115.02 000-099 N N Y 000-099

S5521 A $115.02 000-099 N N Y 000-099

S8185 A $42.47 000-099 Y N Y 000-099S8186 A $3.59 000-099 Y N N

S8189 A $4.56 000-099 Y N N

S8210 MUCUS TRAP A $2.35 000-099 Y N N

S8265 A $13.23 4 PER MONTH 000-020 N N N

UNLISTED PROC MISC PROSTH SERV

ARTIFICIAL LARNYX, ANY TYPE

TRACHEOSTOMY SPEAKING VALVE

2 PER 2 MONTHS

TRACH-ESOPH

VOICE PROS.

VOICE AMPLIFIER

GEL CAP APP

DEVICE FOR TRACH

CRANIAL REMOLDING ORTHOSIS

1 PER 2 YEARS

PERS. CARE ITEM NOS, EACH

100 PER MONTH

HIT SIMPLE CATH CARE

ONCE PER DAY

HIT COMPLEX CATH CARE

ONCE PER DAY

MAINTENANCE OF IMPLANTED

ONCE PER DAY

HIT MIDLINE CATH INSERT KIT

FLUTTER DEVICE

1 PER YEAR

277.00-277.09 SWIVEL ADAPTOR

4 PER

MONTH TRACH SUPPLY NOC

90 PER MONTH

15 PER

MONTH

HABERMAN FEEDER FOR CLEFT LIP





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISS8421 A $38.38 000-099 Y N N

S8422 A $0.01 000-099 Y N Y 000-099

S8423 A $0.01 000-099 Y N Y 000-099

S8424 A $39.97 000-099 Y N N

S8425 A $0.01 000-099 Y N Y 000-099

S8426 A $0.01 000-099 Y N Y 000-099

S8427 A $55.54 000-099 Y N N

S8428 A $18.40 000-099 Y N N

S8999 RESUSCITATION BAG A $97.27 000-099 Y N N

S9001 RR A $48.88 014-045 Y N Y 014-045

S9326 A $39.29 005-099 Y N Y 005-099 140.0 - 239.9

S9327 A $13.59 005-099 Y N Y 005-099 140.0 - 239.9

S9330 SH A $46.00 005-099 Y N Y 005-099 140.0 - 239.9

S9330 A $23.00 005-099 Y N Y 005-099 140.0 - 239.9

S9331 SH A $46.00 005-099 Y N Y 005-099 140.0 - 239.9

S9331 A $23.00 005-099 Y N Y 005-099 140.0 - 239.9

S9338 A $23.00 005-099 Y N Y 005-099 279.0 - 279.2

S9345 A $23.00 005-099 Y N Y 005-099 286.0 - 286.2, 286.4

READY GRADIENT SLEEV/GLOV

4 PER 3 MONTHS

CUSTOM GRAD

SLEEVE MED CUSTOM GRAD

SLEEVE HEAVY READY GRADIENT

SLEEVE 4 PER 3

MONTHS CUSTOM GRAD

GLOVE MED CUSTOM GRAD

GLOVE HEAVY READY GRADIENT

GLOVE 4 PER 3

MONTHS READY GRADIENT

GAUNTLET 4 PER 3

MONTHS 1 PER 2

YEARS

HOME UTERINE MONITOR WITH OR HIT CONT PAIN PER DIEM

ONCE PER DAY

HIT INT PAIN PER DIEM

ONCE PER DAY

HIT CONT CHEM DIEM

ONCE PER DAY

HIT CONT CHEM DIEM

ONCE PER DAY

HIT INTERMIT CHEMO DIEM

ONCE PER DAY

HIT INTERMIT CHEMO DIEM

ONCE PER DAY

HIT IMMUNOTHERAPY DIEM

UP TO 8 DAYS PER MONTH

HIT ANTI-HEMOPHIL DIEM

ONCE PER DAY





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISS9346 A $23.00 005-099 Y N Y 005-099

S9348 A $23.00 005-099 Y N Y 005-099

S9351 A $23.00 005-099 Y N Y 005-099

S9355 HIT CHELATION DIEM A $23.00 005-099 Y N Y 005-099

S9374 A $23.00 005-099 Y N Y 005-099

S9375 A $23.00 005-099 Y N Y 005-099

S9376 A $23.00 005-099 Y N Y 005-099

S9377 A $23.00 005-099 Y N Y 005-099

S9379 HIT NOC PER DIEM A $0.01 005-099 Y N Y 005-099S9490 A $23.00 005-099 Y N Y 005-099 340, 996.8 - 996.99

S9497 SH A $46.00 005-099 Y N Y 005-099

HIT ALPHA-1-PROTEINAS DIEM

HIT SYMPATHOMIM DIEM

HIT CONT ANTIEMETIC DIEM

UP TO 210 DAYS PER

YEAR

140.0 - 239.9 643.00-643.23

ONCE PER DAY

275.0, 282.4 – 282.69, 284.0-284.9

HIT HYDRA 1 LITER DIEM

UP TO 210 DAYS PER

YEAR

275.2 - 275.49, 276.0 - 276.1, 276.7 - 276.8, 643.00 - 643.23


UP TO 210 DAYS PER

YEAR

275.2 - 275.49, 276.0 - 276.1, 276.7 - 276.8, 643.00 - 643.23


UP TO 210 DAYS PER

YEAR

275.2 - 275.49, 276.0 - 276.1, 276.7 - 276.8, 643.00 - 643.23

HIT HYDRA OVER 3 L DIEM

UP TO 210 DAYS PER

YEAR

275.2 - 275.49, 276.0 - 276.1, 276.7 - 276.8, 643.00 - 643.23

HIT CORTICOSTERIOD

UP TO 60 DAYS PER 4

MONTHS

HIT ANTIBIOTIC Q3H DIEM

UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISS9497 SJ A $57.50 005-099 Y N Y 005-099

S9497 A $23.00 005-099 Y N Y 005-099

S9500 SH A $46.00 005-099 Y N Y 005-099

S9500 SJ A $57.50 005-099 Y N Y 005-099


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3

HIT ANTIIBIOTIC Q24H DIEM

UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3






S9501 SH A $46.00 005-099 Y N Y 005-099

S9501 SJ A $57.50 005-099 Y N Y 005-099

S9501 A $23.00 005-099 Y N Y 005-099


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISS9502 SH A $46.00 005-099 Y N Y 005-099

S9502 SJ A $57.50 005-099 Y N Y 005-099

S9502 A $23.00 005-099 Y N Y 005-099

S9503 SH A $46.00 005-099 Y N Y 005-099


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSISS9503 SJ A $57.50 005-099 Y N Y 005-099

S9503 A $23.00 005-099 Y N Y 005-099

S9504 SH A $46.00 005-099 Y N Y 005-099

S9504 SJ A $57.50 005-099 Y N Y 005-099


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3






S9537 A $13.59 005-099 Y N Y 005-099 140.0 - 239.9

T4521 A $0.55 003-099 Y N N

T4522 A $0.55 003-099 Y N N

T4523 A $0.68 003-099 Y N N

T4524 A $1.10 003-099 Y N N

T4525 A $1.48 003-099 Y N N

T4526 A $1.48 003-099 Y N N

T4527 A $1.48 003-099 Y N N

T4528 A $1.48 003-099 Y N N

T4529 A $0.54 003-013 Y N N

T4530 A $0.55 003-013 Y N N

T4531 A $1.20 003-099 Y N N

T4532 A $1.20 003-099 Y N N

T4533 A $0.55 003-099 Y N N


UP TO 60 DAYS PER 4

MONTHS

036 - 054.79, 078.5, 112.0-112.89, 117.3, 136.3, 277.00-277.09, 320.0-321.31, 324.0-326, 383.0-383.11, 421.0-422.93, 590.00-590.9, 681.00-682.9, 711.00-711.99, 730-730.3

HIT HEM HORM INJ DIEM

ONCE PER DAY

ADULT SIZE BRIEF/DIAPER SM

300 PER MONTH

ADULT SIZE BRIEF/DIAPER MED

300 PER MONTH

ADULT SIZE BRIEF/DIAPER LG

300 PER MONTH

ADULT SIZE BRIEF/DIAPER XL

300 PER MONTH

ADULT SIZE PULL-ON SM

150 PER MONTH

ADULT SIZE PULL-ON MED

150 PER MONTH

ADULT SIZE PULL-ON LG

150 PER MONTH

ADULT SIZE PULL-ON XL

150 PER MONTH

PED SIZE BRIEF/ DIAPER SM/MED

300 PER MONTH

PED SIZE BRIEF/ DIAPER LG

300 PER MONTH

PED SIZE PULL-ON SM/MED

150 PER MONTH

PED SIZE PULL-ON LG

150 PER MONTH

YOUTH SIZE BRIEF/DIAPER

300 PER MONTH





CODE R-MOD I-MOD DESCRIPTION STATUS FEE LIMITS AGE NF ABC PA PA AGE DIAGNOSIST4534 A $1.48 003-099 Y N N

T4535 A $0.35 003-099 Y N N

T4536 A $1.83 003-099 Y N N

T4541 A $0.40 000-099 Y N N

T4542 A $0.40 000-099 Y N N

T4543 A $1.80 014-099 Y N N

T5001 A $0.01 000-099 N N Y 000-099

YOUTH SIZE PULL-ON

150 PER MONTH

DISPOSABLE LINER/SHIELD/PAD

300 PER MONTH

REUSABLE PULL-ON ANY SIZE

10 PER MONTH

LARGE DISPOSABLE UNDER PAD

180 PER MONTH

SMALL DISPOSABLE UNDERPAD

180 PER MONTH

BARIATRIC, DISPOSABLE, INC., BRIEF/DIAPER

300 PER MONTH

SPECIAL POSITION SEAT/VEHICL

[XLS]DME-Fee Screens July 2006 - SOM - State of Michigan · Web viewPREP BK PTB SUPRAC SUS SACH PL...

Documents

Transcript of [XLS]DME-Fee Screens July 2006 - SOM - State of Michigan · Web viewPREP BK PTB SUPRAC SUS SACH PL...