02/25/16 LOUISIANA MEDICAID DMEPOS FEE SCHEDULE 1 2 3 4 5 6 7 8 9 10 CODE TOS DESCRIPTION FEE ICFMR EXEMPT NHOME RESP MCARE EXEMPT AGE RESTRICTION PA REQUIRED EFFECT DATE A4206 9 "SYRINGE WITH NEEDLE, STERILE 1CC " MP Y R A4207 9 "SYRINGE WITH NEEDLE, STERILE 2CC " MP Y R A4208 9 "SYRINGE WITH NEEDLE, STERILE 3CC " MP Y R A4209 9 "SYRINGE W/ NEEDLE, STERILE 5CC OR GR" MP Y R A4210 9 NEEDLE-FREE INJECTION DEVICE 1.74 Y Y R 20120901 A4212 9 "HUBER-TYPE NEEDLE, EACH " 5.44 Y R 20120901 A4213 9 "SYRINGE, STERILE, 20 CC OR GREATER " MP Y R A4215 9 "NEEDLES ONLY, STERILE, ANY SIZE " MP Y R A4221 7 "SUPPLIES FOR DRUGS INF CATH,PER WEEK" MP Y 1 R A4221 9 "SUPPLIES FOR DRUG INF. CATH,PER WEEK" MP Y 2 R A4222 7 SUPPLIES FOR EXTERNAL DRUG INF PUMP MP Y 1 R A4222 9 SUPPLIES FOR EXTERNAL DRUG INF PUMP MP Y 2 R A4230 9 INFUSION SET FOR EXT INSULIN PUMP MP Y R A4231 9 INFUSION SET FOR EXT INSULIN PUMP MP Y R A4233 9 ALKALINE BATTERY FOR GLUCOSE MONITOR 0.49 Y 2 R 20120701 A4234 9 J-CELL BATTERY FOR GLUCOSE MONITOR 2.24 Y 2 R 20120701 A4235 9 LITHIUM BATTER FOR GLUCOSE MONITOR 1.44 Y 2 R 20120701 A4236 9 SILVER OXIDE BATTERY FOR GLUCOSE 1.04 Y 2 R 20120701 A4244 9 "ALCOHOL OR PEROXIDE, PER PINT " MP Y 1 R A4245 9 "ALCOHOL WIPES, PER BOX " MP Y 1 R A4246 9 "ALCOHOL OR PEROXIDE, PER BOTTLE " MP Y 1 R A4310 9 INSERTION TRAY ONLY 3.71 Y R 20120701 A4311 9 INSERTION TRAY W/O DRAUB BAG W FOLEY 10.24 Y R 20120701 A4320 9 CATHETER IRRIGATION WITH BULB SYRING 3.25 Y R 20120701 A4322 9 "IRRIGATION SYRINGE, BULB OR PISTON " MP Y 2 R A4326 9 MALE EXTERNAL CATHETER SPECIALTY TYP 6.59 Y R 20120701 A4327 9 FEMALE EXTERNAL URINARY COLLECTION D 27.25 Y R 20120701 A4328 9 FEMALE EXTERNAL URINARY COLLECTION D 6.18 Y R 20120701 A4331 9 EXTENSION DRAINAGE TUBING 1.95 Y 2 R 20120701 A4332 9 LUBRICANT FOR CATH INSERTION 0.13 Y R 20120701 A4335 9 INCONTINENCE SUPPLY; MISCELLANEOUS MP Y R A4336 9 "INCONTINENCE SUPPLY, URETHRAL INSERT" MP R A4338 9 INDWELLING CATHETER FOLEY TYPE 6.53 Y R 20120701 A4344 9 "INDWELLING CATH, FOLEY,2-WAY,SILICON" 10.26 Y R 20120701 A4349 9 DISPOSABLE MALE EXTERNAL CATHETERS 1.33 Y R 20120701 A4351 9 INTERMITTENT URINARY CATHETER; STRAI MP Y R A4352 9 INTERMITTENT URINARY CATHETER; COUDE 3.33 Y R 20120701 A4353 9 INTERMITTENT URINARY CATH W INS SUPP MP Y R A4354 9 INSERTION TRAY W/ DRAIN BAG 7.21 Y R 20120701 A4355 9 3-WAY IRRIGATION SET FOR CATHETER MP Y R A4356 9 INCONTINENCE CLAMP MP Y R A4357 9 URINARY DRAINAGE BAG 5.93 Y R 20120701 A4358 9 URINARY LEG BAG W/OR W/O TUBE 4.05 Y R 20120701 A4360 9 DISPOSABLE EXTERNAL URETHRAL CLAMP 0.37 20120701 A4361 9 OSTOMY FACE PLATE MP Y R A4362 9 OSTOMY SKIN BARRIER MP Y R A4364 9 OSTOMY SKIN BOND OR CEMENT MP Y R A4367 9 OSTOMY BELT MP Y R A4368 9 "OSTOMY FILTER,ANY TYPE, EACH " MP Y R A4369 9 "OSTOMY SKIN BARRIER,LIQUID,PER OZ " MP Y R A4371 9 SKIN BARRIER POWDER PER OZ MP Y R A4372 9 SKIN BARRIER SOLID 4X4 EQUIV MP Y R A4373 9 "SKIN BARRIER W FLANGE,STANDARD,EACH " MP Y R A4375 9 DRAINABLE PLASTIC PCH W FCPL MP Y R A4376 9 DRAINABLE RUBBER PCH W FCPLT MP Y R A4377 9 DRAINABLE PLSTIC PCH W/O FP MP Y R A4378 9 DRAINABLE RUBBER PCH W/O FP MP Y R A4379 9 URINARY PLASTIC POUCH W FCPL MP Y R A4380 9 ILEOSTOMY SET MP Y R A4381 9 URINARY PLASTIC POUCH W/O FP 6.53 Y R 20120701 A4382 9 URINARY HVY PLSTC PCH W/O FP MP Y R A4383 9 URINARY RUBBER POUCH W/O FP MP Y R A4384 9 OSTOMY FACEPLT/SILICONE RING MP Y R A4385 9 OST SKN BARRIER SLD EXT WEAR MP Y R A4387 9 OST CLSD POUCH W ATT ST BARR MP Y R A4388 9 DRAINABLE PCH W EX WEAR BARR MP Y R A4389 9 DRAINABLE PCH W ST WEAR BARR MP Y R A4390 9 ILEAL BLADDER SET MP Y R A4391 9 URINARY POUCH W EX WEAR BARR MP Y R A4392 9 URINARY POUCH W ST WEAR BARR MP Y R A4393 9 URINE PCH W EX WEAR BAR CONV MP Y R A4397 9 IRRIGATION SUPPLY; SLEEVE MP Y R A4398 9 IRRIGATION SUPPLIES-BAGS MP Y R A4399 9 IRRIGATION SUPPLIES CONE/CATHETER MP Y R A4400 9 IRRIGATION SET FOR IRRIGATION OF OST MP Y R A4402 9 OSTOMY LUBRICANT MP Y R A4404 9 OSTOMY RINGS MP Y R A4405 9 NONPECTIN BASED OSTOMY PASTE MP Y R A4406 9 PECTIN BASED OSTOMY PASTE MP Y R A4407 9 "EXT WEAR OST SKIN BARR <=4SQ"" " MP Y R A4408 9 EXT WEAR OST SKN BARR >4SQ MP Y R A4409 9 "OST SKN BARR W FLNG <=4SQ"" " MP Y R A4410 9 "OST SKN BARR W FLNG >4SQ"" " MP Y R A4411 9 OST SKIN BARR EXTND=4 SQ INCHES MP Y R A4413 9 2PC DRAINABLE OST POUCH MP Y R A4414 9 "OSTOMY SKNBARR W FLNG <=4SQ"" " MP Y R A4415 9 "OSTOMY SKN BARR W FLNG >4SQ"" " MP Y R A4416 9 OST PCH CLSD W BARRIER/FILTR 2.01 Y R 20120701 A4417 9 OST PCH W BAR/BLTINCONV/FLTR 2.72 Y R 20120701 A4418 9 OST PCH CLSD W/O BAR W FILTR 1.32 Y R 20120701 A4419 9 OST PCH FOR BAR W FLANGE/FLT 1.27 Y R 20120701 A4421 9 OSTOMY SUPPLY MISC MP Y R A4422 9 OST POUCH ABSORBENT MATERIAL MP Y R A4423 9 OST PCH FOR BAR W LK FL/FLTR 1.36 Y R 20120701 A4424 9 OST PCH DRAIN W BAR & FILTER 3.48 Y R 20120701 A4425 9 OST PCH DRAIN FOR BARRIER FL 2.62 Y R 20120701 A4426 9 OST PCH DRAIN 2 PIECE SYSTEM 1.73 Y R 20120701 A4427 9 OST PCH DRAIN/BARR LK FLNG/F 2.03 Y R 20120701 A4428 9 URINE OST POUCH W FAUCET/TAP 4.76 Y R 20120701 A4429 9 URINE OST POUCH W BLTINCONV 6.04 Y R 20120701 A4431 9 OST PCH URINE W BARRIER/TAPV 4.55 Y R 20120701 A4432 9 OSTOMY POUCH URINE W BAR/FLANGE/TAP MP Y R A4433 9 URINE OST PCH BAR W LOCK FLN 2.45 Y R 20120701 A4434 9 OST PCH URINE W LOCK FLNG/FT 2.74 Y R 20120701 A4450 9 TAPE NON-WATERPROOF PER 18 SQ INCHES MP Y R A4452 9 WATERPROOF TAPE MP Y R A4455 9 ADHESIVE REMOVER OR SOLVENT (FOR TAP MP Y R A4456 9 "ADHESIVE REMOVER, WIPES, ANY TYPE, E" 0.18 R 20120701 A4459 9 "MANUAL PUMP-OPERATED ENEMA SYSTEM, I" MP R A4461 9 "SURGICAL DRESSING HOLDER, NON-REUSAB" 2.11 Y R 20120701 A4463 9 "SURGICAL DRESSING HOLDER, REUSABLE, " 8.51 Y R 20120701 A4466 9 "GARMENT, BELT, SLEEVE OR OTHER COVER" MP R A4481 9 TRACHEOSTOMA FILTER MP Y R A4483 9 MOISTURE EXCHANGER MP R A4490 9 SURGICAL STOCKINGS ABOVE KNEE LENGTH 45.91 1 R 20120701 A4495 9 "SURGICAL STOCKINGS THIGH LENGTH, EAC" 54.38 1 R 20120701 A4500 9 SURGICAL STOCKINGS BELOW KNEE EACH 35.39 1 R 20120701 A4510 9 "SURGICAL STOCKINGS FULL LENGTH, EACH" 69.22 1 R 20120701 A4550 9 SURGICAL TRAYS MP Y R A4555 9 ELECTRODE TRANSDUCER USE WITH ELL ST 0.56 Y R 20140101 A4556 9 "ELECTRODES, (E.G., APNEA MONITOR) " MP Y R A4557 9 "LEAD WIRES, (E.G., APNEA MONITOR) " MP Y R A4565 9 SLINGS 8.83 1 R 20120701 A4570 9 SPLINT MP 1 R A4602 9 REPLACEMENT BATTERY EXT LITHIUM EACH 3.48 R 20160101 A4605 9 TRACH SUCTION CATH CLOSE SYS 15.06 Y 2 R 20120701 A4606 9 OXYGEN PROBE & USE W OXIMETER DEVICE 182.01 Y 1 00 20 R 20120701 A4611 9 "BATTERY,HEAVY DUTY, REPLACEMENT FOR " 144.45 Y 2 R 20120701 A4612 9 BATTERY CABLES; REPLACEMENT FOR PATI 73.42 Y 2 R 20120701 A4613 7 BATTERY CHARGER 13.25 Y 2 R 20120701 A4613 9 BATTERY CHARGER; REPLACEMENT FOR PAT 132.46 Y 2 R 20120701 A4614 9 HAND-HELD PEFR METER 22.9 Y 2 R 20120701 A4615 9 "CANNULA, NASAL " MP Y 2 R A4616 9 "TUBING (OXYGEN), PER FOOT " MP Y 2 R A4618 7 BREATHING CIRCUITS MP Y 2 R A4618 9 BREATHING CIRCUITS MP Y 2 R A4620 9 VARIABLE CONCENTRATION MASK 4.44 Y 2 R 20120701 A4623 9 "TRACHEOSTOMY, INNER CANNULA (REPLACE" MP Y 2 R A4624 9 TRACH SUCTION CATH - EACH 1.69 Y 2 R 20120701 A4625 9 TRACHEOSTOMY CARE OR CLEANING STARTE MP Y 2 R A4627 9 "SPACER, BAG OR RESERVOIR, WITH OR WI" 30.82 Y 00 20 R 20120701 A4628 9 OROPHARYNGEAL SUCTION CATH MP Y 2 R A4629 9 TRACHEOSTOMY CARE KIT 3.83 Y R 20120701 A4635 9 UNDERARM PAD CRUTCH REPLACEMENT EACH 3.66 Y 2 R 20120701 A4636 9 REPLACE HANDGRIP CANE CRUT WALK EAC 3.54 Y 2 R 20120701 A4637 9 REPLACEMENT TIP CANE CRUTCH R WALKER MP Y 2 R A4640 9 ALTERNATING PRESSURE PAD 46.97 Y 2 R 20120701 A4649 9 SURGICAL SUPPLIES NOT ELSEWHERE CLAS MP R A4660 9 SPHYGMOMANOMETER/BLOOD PRESSURE APPA MP Y 2 R A4663 9 BLOOD PRESSURE CUFF ONLY MP Y 2 R A4670 9 AUTOMATIC BLOOD PRESSURE MONITOR MP Y 2 R A4680 9 ACTIVATED CARBON FILTERS FOR DIALYSI MP Y R A4690 9 DIALYZER'S (ARTIFICIAL KIDNEY'S) AL MP Y R A4730 9 FISTULA CANNULATION SET FOR DIALYSIS MP Y R A4740 9 SHUNT ACCESSORIES FOR DIALYSIS ONLY MP Y R A4750 9 "BLOOD TUBING, ARTERIAL OR VENOUS, E " MP Y R A4755 9 "BLOOD TUBING, ARTERIAL AND VENOUS C " MP Y R A4760 9 DIALYSATE STANDARD TESTING SOLUTION MP Y R A4765 9 "DIALYSATE CONCENTRATE ADDITIVES, EA " MP Y R A4770 9 BLOOD TESTING SUPPLIES (E.G. VACUTA MP Y R A4771 9 "SERUM CLOTTING TIME TUBE, PER BOX " MP Y R A4860 9 DISPOSABLE CATHETER CAPS MP Y R A4913 9 "MISCELLANEOUS DIALYSIS SUPPLIES, NO " MP Y R A4918 9 "VENOUS PRESSURE CLAMPS, EACH " MP Y R A4927 9 GLOVES NON STERILE PER 100 6.4 Y 1 R 20120701 A4930 9 "GLOVES, STERILE, PER PAIR " 0.35 Y 1 R 20120701 A5051 9 CLOSED POUCH W/BARRIER ATTACHED MP Y R A5052 9 CLOSED POUCH W/O BARRIER ATTACHED MP Y R A5053 9 CLOSED POUCH FOR USE ON FACE PLATE MP Y R A5054 9 CLOSED POUCH FOR USE ON BARR W/FLANG MP Y R A5055 9 STOMA CAP MP Y R A5061 9 DRAINABLE POUCH W/BARRIER ATTACHED MP Y R A5062 9 DRAIN POUCH W/O BARRIER ATTACHED MP Y R A5063 9 DRAIN POUCH FOR USE ON BARR W/FLANGE MP Y R A5071 9 URINARY POUCH W/BARRIER ATTACHED MP Y R A5072 9 URINARY POUCH W/O BARRIER ATTACHED MP Y R A5073 9 URINARY POUCH FOR USE ON BARRIER W F MP Y R A5081 9 "STOMA PLUG OR SEAL, ANY TYPE " MP Y R A5082 9 CONTINENT DEVICE; CATHETER FOR CONTI MP Y R A5093 9 OSTOMY ACCESSORY; CONVEX INSERT MP Y R A5102 9 "BEDSIDE DRAINAGE BOTTLE, RIGID OR EX" 13.79 Y R 20120701 A5105 9 "URINARY SUSPENSORY; WITH LEG BAG, WI" 24 Y R 20120701 A5112 9 URINARY LEG BAG; LATEX 21.14 Y R 20120701 A5113 9 "LEG STRAP; LATEX, PER SET " 2.87 Y R 20120701 A5114 9 "LEG STRAP; FOAM OR FABRIC, PER SET " 5.45 Y R 20120701 A5120 9 SKIN BARRIER WIPES OR SWABS 0.16 Y R 20120701 A5121 9 SKIN BARRIER SOLID 6X6 MP Y R A5122 9 SKIN BARRIER SOLID 8X8 MP Y R A5126 9 ADHESIVE; DISC OR FOAM PAD MP Y R A5500 9 DIAB SHOE FOR DENSITY INSERT 52.53 R 20120701 A5501 9 DIABETIC CUSTOM MOLDED SHOE 155.17 R 20120701 A5503 9 DIABETIC SHOE W/ROLLER/ROCKR 25.16 R 20120701 A5504 9 DIABETIC SHOE WITH WEDGE 26.48 R 20120701 A5505 9 DIAB SHOE W/METATARSAL BAR 26.48 R 20120701 A5506 9 DIABETIC SHOE W/OFF SET HEEL 26.48 R 20120701 A5507 9 MODIFICATION DIABETIC SHOE 26.48 R 20120701 A5508 9 "DIABETIC DELUXE SHOE, PER SHOE " 28.25 R 20120701 A5510 9 DIEBETIC SHOE DIRECT FORMED PRE FAB 26.16 R 20120701 A5512 9 DIABETIC SHOE DIRECT FORMED W HEAT P 20.06 R 20120701 A5513 9 DIABETIC SHOE CUSTOM MOLDED 29.94 R 20120701 A6021 9 COLLAGEN DRESSING <=16 SQ IN 15.81 Y R 20120701 A6022 9 COLLAGEN DRSG>6<=48 SQ IN 15.81 Y R 20120701 A6023 9 COLLAGEN DRESSING >48 SQ IN 143.09 R 20120701 A6024 9 COLLAGEN DSG WOUND FILLER 4.66 R 20120701 A6025 9 "SILICONE GEL SHEET, EACH " MP Y R A6154 9 WOUND POUCH EACH MP Y R A6196 9 ALGINATE DRESSING <=16 SQ IN MP Y R A6197 9 ALGINATE DRSG >16 <=48 SQ IN MP Y R A6198 9 ALGINATE DRESSING > 48 SQ IN MP Y R A6199 9 ALGINATE DRSG WOUND FILLER MP Y R A6203 9 COMPOSITE DRSG <= 16 SQ IN MP Y R A6204 9 COMPOSITE DRSG >16<=48 SQ IN MP Y R A6205 9 COMPOSITE DRSG > 48 SQ IN MP Y R A6206 9 CONTACT LAYER <= 16 SQ IN MP Y R A6207 9 CONTACT LAYER >16<= 48 SQ IN MP Y R A6208 9 CONTACT LAYER > 48 SQ IN MP Y R A6209 9 FOAM DRSG <=16 SQ IN W/O BDR MP Y R A6210 9 FOAM DRG >16<=48 SQ IN W/O B MP Y R A6211 9 FOAM DRG > 48 SQ IN W/O BRDR MP Y R A6212 9 FOAM DRG <=16 SQ IN W/BORDER MP Y R A6213 9 FOAM DRG >16<=48 SQ IN W/BDR MP Y R A6214 9 FOAM DRG > 48 SQ IN W/BORDER MP Y R A6215 9 FOAM DRESSING WOUND FILLER MP Y R A6216 9 NON-STERILE GAUZE<=16 SQ IN MP Y R A6217 9 NON-STERILE GAUZE>16<=48 SQ MP Y R A6218 9 NON-STERILE GAUZE > 48 SQ IN MP Y R A6219 9 GAUZE <= 16 SQ IN W/BORDER MP Y R A6220 9 GAUZE >16 <=48 SQ IN W/BORDR MP Y R A6221 9 GAUZE > 48 SQ IN W/BORDER MP Y R A6222 9 GAUZE <=16 IN NO W/SAL W/O B MP Y R A6223 9 GAUZE >16<=48 NO W/SAL W/O B MP Y R A6224 9 GAUZE > 48 IN NO W/SAL W/O B MP Y R A6228 9 GAUZE <= 16 SQ IN WATER/SAL MP Y R A6229 9 GAUZE >16<=48 SQ IN WATR/SAL MP Y R A6230 9 GAUZE > 48 SQ IN WATER/SALNE MP Y R A6234 9 HYDROCOLLD DRG <=16 W/O BDR MP Y R A6235 9 HYDROCOLLD DRG >16<=48 W/O B MP Y R A6236 9 HYDROCOLLD DRG > 48 IN W/O B MP Y R A6237 9 HYDROCOLLD DRG <=16 IN W/BDR MP Y R A6238 9 HYDROCOLLD DRG >16<=48 W/BDR MP Y R A6240 9 HYDROCOLLD DRG FILLER PASTE MP Y R A6241 9 HYDROCOLLOID DRG FILLER DRY MP Y R A6242 9 HYDROGEL DRG <=16 IN W/O BDR MP Y R A6243 9 HYDROGEL DRG >16<=48 W/O BDR MP Y R A6244 9 HYDROGEL DRG >48 IN W/O BDR MP Y R A6245 9 HYDROGEL DRG <= 16 IN W/BDR MP Y R A6246 9 HYDROGEL DRG >16<=48 IN W/B MP Y R A6247 9 HYDROGEL DRG > 48 SQ IN W/B MP Y R A6248 9 HYDROGEL DRSG GEL FILLER-PER OUNCE MP Y R A6250 9 SKIN SEAL PROTECT MOISTURIZR MP Y 2 R A6251 9 ABSORPT DRG <=16 SQ IN W/O B MP Y R A6252 9 ABSORPT DRG >16 <=48 W/O BDR MP Y R A6253 9 ABSORPT DRG > 48 SQ IN W/O B MP Y R A6254 9 ABSORPT DRG <=16 SQ IN W/BDR MP Y R A6255 9 ABSORPT DRG >16<=48 IN W/BDR MP Y R A6256 9 ABSORPT DRG > 48 SQ IN W/BDR MP Y R A6257 9 TRANSPARENT FILM <= 16 SQ IN MP Y R A6258 9 TRANSPARENT FILM >16<=48 IN MP Y R A6259 9 TRANSPARENT FILM > 48 SQ IN MP Y R A6260 9 WOUND CLEANSER ANY TYPE/SIZE MP Y 2 R A6261 9 WOUND FILLER GEL/PASTE /OZ MP Y R A6262 9 WOUND FILLER DRY FORM / GRAM MP Y R A6266 9 IMPREG GAUZE NO H20/SAL/YARD MP Y R A6402 9 STERILE GAUZE <= 16 SQ IN MP Y 2 R A6403 9 STERILE GAUZE>16 <= 48 SQ IN MP Y R A6404 9 STERILE GAUZE > 48 SQ IN MP Y R A6410 9 STERILE EYE PAD MP Y R A6446 9 CONFORM BAND S W>=3” <5”/YD 0.26 Y R 20120701 A6501 9 COMPRES BURNGARMENT BODYSUIT MP R A6502 9 COMPRES BURNGARMETN CHINSTRP MP R A6504 9 COMPRES BURN GARMENT GLOVE-WRIST MP Y R A6505 9 COMPRS BURN GARMENT GLOVE-ELBOW MP R A6506 9 COMPRS BURN GARMENT GLOVE-AXILLA MP R A6507 9 CMPRS BURNGARMENT FOOT-KNEE MP R A6508 9 COMPRES BURNGARMENT FOOT-THIGH MP Y R A6510 9 COMPRES BURN GARMENT LEOTARD MP R A6511 9 COMPRES BURN GARMENT PANTY MP R A6513 9 "COMPRESS BURN MASK, FACE AND/OR " MP R A6530 9 "ELASTIC SUPPORTS, ELASTIC STOCKINGS " 32.37 1 R 20140501 A6531 7 GRAD COMP STOCKING BELOW KNEE 30-40M MP 1 R A6531 9 GRAD COMP STOCKING BELOW KNEE 30-40M 42.58 R 20140501 A6532 7 "ELASTIC SUPPORTS,ELASTIC STOCKING " MP A6532 9 "ELASTIC SUPPORTS,ELASTIC STOCKINGS " 59.99 R 20140501 A6533 9 "ELASTIC SUPPORTS,ELASTIC STOCKINGS " 46.75 1 R 20140501 A6534 9 "ELASTIC SUPPORTS,ELASTIC STOCKINGS " 56.26 R 20140501 A6535 9 "ELASTIC SUPPORTS, ELASTIC STOCKINGS " 92.52 R 20140501 A6536 9 "ELASTIC SUPPORTS, ELASTIC STOCKINGS " 49.4 R 20140501 A6537 9 "ELASTIC SUPPORTS, ELASTIC STOCKINGS " 80.13 R 20140501 A6538 9 "ELASTIC SUPPORTS, ELASTIC STOCKINGS " 109.5 R 20140501 A6539 9 "ELASTIC SUPPORTS, ELASTIC STOCKINGS " MP R A6540 9 GRAIDENT COMPRESSION STOCKING MP R A6541 9 "ELASTIC SUPPORTS, ELASTIC STOCKINGS " MP R A6544 9 "ELASTIC SUPPORTS,ELASTIC STOCKINGS " MP R A6545 9 "GRADIENT COMPRESSION WRAP, NON-ELAST" MP R A6549 9 GRADIENT COMPRESSION STOCKING/SLEEVE MP R A6550 9 DRESSING SET FOR NPWT PUMP 20.07 Y R 20120701 A7000 9 DISPOSABLE CANISTER FOR PUMP 6.13 Y 2 R 20120701 A7001 9 NONDISPOSABLE PUMP CANISTER 19.52 Y 2 R 20120701 A7002 9 TUBING USED W SUCTION PUMP 2.09 Y 2 R 20120701 A7003 9 NEBULIZER ADMINISTRATION SET 1.76 Y 2 R 20120701 A7004 9 DISPOSABLE NEBULIZER SML VOL 0.98 Y 2 R 20120701 A7005 9 NONDISPOSABLE NEBULIZER SET 16.84 Y 2 R 20120701 A7006 9 SMALL VOL FILTERED NEB ADMIN SET 6.13 Y 2 R 20120701 A7007 9 LG VOL NEBULIZER DISP UNFILLED 2.91 Y 2 R 20120701 A7008 9 DISPOSABLE NEBULIZER PREFILL 6.01 Y 2 R 20120701 A7009 9 NEBULIZER RESERVOIR BOTTLE 27.03 Y 2 R 20120701 A7010 9 "DISP CORRUGATED TUBING, 100 FEET " 12.89 Y 2 R 20120701 A7012 9 NEBULIZER WATER COLLECTION DEVICE MP Y 2 R A7013 9 DISPOSABLE COMPRESSOR FILTER 0.45 Y 2 R 20120701 A7014 9 COMPRESSOR NONDISPOS FILTER 2.89 Y 2 R 20120701 A7015 9 AEROSOL MASK USED W NEBULIZE 1.2 Y 2 R 20120701 A7016 9 NEBULIZER DOME & MOUTHPIECE 4.55 Y 2 R 20120701 A7017 7 NEBULIZER-NOT USED WITH OXYGEN 8.62 Y 2 R 20120701 A7017 9 NEBULIZER-NOT USED WITH OXYGEN 86.19 Y 2 R 20120701 A7030 9 CPAP FULL FACE MASK 127.16 Y 2 R 20120701 A7031 9 REPLACEMENT FACEMASK INTERFACIAL 47.03 Y R 20120701 A7032 9 REPLACEMENT NASAL CUSHION 31.22 Y 2 R 20120701 A7033 9 REPLACEMENT NASAL PILLOWS 21.89 Y 2 R 20120701 A7034 9 NASAL APPLICATION DEVICE 90.63 Y 2 R 20120701 A7035 9 POS AIRWAY PRESS HEADGEAR 29.13 Y 2 R 20120701 A7036 9 POS AIRWAY PRESS CHINSTRAP 12.47 Y 2 R 20120701 A7037 9 POS AIRWAY PRESSURE TUBING 31.61 Y 2 R 20120701 A7038 9 POS AIRWAY PRESSURE FILTER 4.15 Y 2 R 20120701 A7039 9 CPAP FILTER 10.1 Y 2 R 20120701 A7045 9 REPL EXHALATION PORT FOR PAP 13.13 Y 2 R 20120701 A7046 9 "REPL WATER CHAMBER, PAP DEV " 13.14 Y 2 R 20120701 A7047 9 ORAL INTERFACE USED WITH RESPIRATORY 89.13 R 20140101 A7048 9 VACUUM DRAINAGE COLLECTION UNIT AND 42.49 R 20150101 A7501 9 TRACHEOSTOMA VALVE W DIAPHRA 0.91 Y 2 R 20120701 A7502 9 REPLACEMENT DIAPHRAGM/FPLATE 10.02 Y 2 R 20120701 A7520 9 TRACH/LARYN TUBE NON-CUFFED 36.57 Y R 20120701 A7521 9 TRACH/LARYNGETOMY TUBE CUFFED MP Y 2 R A7522 9 TRACH/LARYN TUBE STAINLESS 34.78 Y R 20120701 A7524 9 TRACHEOSTOMA STENT/STUD/BTTN 59.63 Y R 20120701 A7525 9 "TRACHESTOMY MASK, EACH " 1 Y R 20120701 A7526 9 TRACH TUBE HOLDER MP Y 2 R A7527 9 TRACH/LARYN TUBE PLUG/STOP 2.42 Y R 20120701 A8000 9 SOFT PROTECT HELMET PREFAB 94.77 R 20120701 A8001 9 HARD PROTECT HELMET PREFAB 94.77 R 20120701 A8002 9 SOFT ROTECT HELMET CUSTOM MP R A8003 9 HARD PROTECT HELMET CUSTOM MP R A8004 9 "SOFT INTERFACE FOR HELMET, REPLACEME" MP R A9274 9 EXTERNAL AMBULATORY INSULIN DELIVERY MP R A9284 9 "SPIROMETER, NON-ELECTRONIC, INCLUDES" MP R A9900 9 MISCELLANEOUS DME SUPPLY ACCESSORY MP Y 2 R A9999 9 MISCELLANEOUS DME SUPPLY ACCESSORY MP Y 2 R B4034 9 ENTERAL FEEDING SUPPLY KIT;-SYRINGE MP Y R B4035 9 ENTERAL FEEDING SUPPLY KIT;- PUMP FE MP Y R B4036 9 ENTERAL FEEDING SUPPLY KIT; GRAVITY MP Y R B4081 9 NASOGASTRIC TUBING WITH STYLET 13.34 Y R 20120701 B4082 9 NASOGASTRIC TUBING WITHOUT STYLET 9.93 Y R 20120701 B4083 9 STOMACH TUBE - LEVINE TYPE 1.52 Y R 20120701 B4088 9 "GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PR" MP R B4100 7 THICKENING AGENT; ORAL MP Y 1 R B4100 9 "THICKENING AGENT, ORAL " MP Y 2 R B4102 7 EF ADULT FLUIDS MP Y 1 R B4103 7 EF PED FLUID AND ELECTROLYTE MP Y 1 R B4104 7 "ADDITIVE FOR ENTERAL FORMULA (EG,G,F" MP Y 1 R B4104 9 ADDITIVE FOR ENTERAL FORMULA (E.G.FI MP Y R B4149 7 BF BLENDERIZED FOODS MP Y 1 00 20 R B4149 9 EF BLENDERIZED FOODS MP Y 2 R B4150 7 ORAL FORMULA MP Y 1 R B4150 9 ENTERAL FORMULA;CATEGORY I: SEMI-SYN MP Y 2 R B4152 7 ORAL FORMULA MP Y 1 R B4152 9 ENTERAL FORMULAE; CATEGORY II: INTAC MP Y 2 R B4153 7 ORAL FORMULA MP Y 1 R B4153 9 ENTERAL FORMULAE; CATEGORY III: HYD MP Y 2 R B4154 7 ORAL FORMULA MP Y 1 R B4154 9 ENTERAL FORMULAE; CATEGORY IV: DEFI MP Y 2 R B4155 7 ORAL FORMULA MP Y 1 R B4155 9 ENTERAL FORMULAE; CATEGORY V: MODUL MP Y 2 R B4157 7 EFF SPEC METABOLIC INHERITANCE DISEA MP R B4157 9 EF SPEC METABOLIC INHERITANCE DISEAS MP Y R B4158 7 EF PED COMPLETE INTACT NUT MP R B4159 7 EF PED COMPLETE INTACT NUT MP Y 1 R B4160 7 EF PED CALORIC DENSE>/=0.7 KC MP Y 1 R B4161 7 EF PED CALORIC DENSE>/=0.7KC MP Y 1 R B4161 9 "EF,PED,HYDROLYZED/AMINO ACIDS " MP Y R B4162 7 EF PED SPECMETABOLIC INHERIT MP R B4162 9 EF PED SPECMETABOLIC INHERIT MP Y R B9000 7 ENTERAL PUMP W/O ALARM 88.6 Y 2 R 20120701 B9000 9 ENTERAL PUMP WITHOUT ALARM MP Y 2 R B9002 7 ENTERAL PUMP WITH ALARM 88.6 Y 2 R 20120701 B9002 9 ENTERAL PUMP WITH ALARM MP Y 2 R B9998 9 NOC FOR ENTERNAL SUPPLIES MP Y R C1767 9 VNS GENERATOR 9396.95 Y 2 20120701 C1778 9 VNS LEADS 2243.79 Y 2 20120701 E0100 9 CANES; WOOD 14.19 Y 2 R 20120701 E0105 9 CANE QUAD OR THREE PRONG 33.09 Y 2 R 20120701 E0110 9 CRUTCHES FOREARM ADJ OR FIXED PAIR 52.27 Y 2 R 20120701 E0111 9 CRUTCH FOREARM ADJ OR FIXED EACH 30.49 Y 2 R 20120701 E0112 9 CRUTCHES UNDERARM WOOD ADJ PAIR 24.92 Y 2 R 20120701 E0113 7 CRUTCH UNDERARM EACH WOOD MP Y 2 R E0113 9 CRUTCH UNDERARM WOOD ADJ OR FIXED EA MP Y 2 R E0114 9 "CRUTCHES UNDERARM,OTHER THAN WOOD,PR" 31.79 Y 2 R 20120701 E0116 9 "CRUTCHES UNDERARM,OTHER THAN WOOD,EA" 18.69 Y 2 R 20120701 E0130 7 WALKER RIGID ADJUST/FIXED HT 4.73 Y 2 R 20120701 E0130 9 ADJUSTABLE WALKER - PURCHASE 47.3 Y 2 R 20120701 E0135 7 "WALKER, FOLDING " 5.59 Y 2 R 20120701 E0135 9 WALKER; FOLDING 55.85 Y 2 R 20120701 E0140 7 WALKER W/TRUNK SUPPORT 22.29 Y 2 R 20120701 E0140 9 WALKER W TRUNK SUPPORT 222.91 Y 2 R 20120701 E0141 7 RIGID WHEELED WALKER ADJ/FIX MP Y 2 R E0141 9 "WALKER WHEELED, WITHOUT SEAT " MP Y 2 R E0143 7 "FOLDING WALKER, WHEELED, WO SEAT " 8.1 Y 2 R 20120701 E0143 9 "FOLDING WALKER, WHEELED, WITHOUT SE " 80.99 Y 2 R 20120701 E0147 7 WALKER VARIABLE WHEEL RESIST MP Y 2 R E0147 9 "HEAVY DUTY, MULTIPLE BREAKING SYSTE " MP Y 2 R E0153 9 "PLATFORM ATTACHMENT, FOREARM CRUTCH " MP Y 2 R E0154 7 "PLATFORM ATTACHMENT, WALKER, EACH " 4.75 Y 2 R 20120701 E0154 9 "PLATFORM ATTACHMENT, WALKER, EACH " 47.5 Y 2 R 20120701 E0155 9 "WHEEL ATTACHMENT, RIGID PICK-UP WAL " 18.07 Y 2 R 20120701 E0156 9 "SEAT ATTACHMENT, WALKER " 17.81 Y 2 R 20120701 E0157 7 WALKER WITH CRUTCH ATTACHMENT 5.52 Y 2 R 20120701 E0157 9 WALKER WITH CRUTCH ATTACHMENT MP Y 2 R E0158 9 LEG EXTENSIONS FOR A WALKER 19.67 Y 2 R 20120701 E0159 9 BRAKE FOR WHEELED WALKER 12.04 Y 2 R 20120701 E0163 9 "COMMODE CHAIR, STATIONARY, WITH FIX " 48.56 Y 2 R 20120701 E0165 9 "COMMODE CHAIR, STATIONARY, WITH DET " 75.05 Y 2 R 20120701 E0167 7 COMMODE CHAIR PAIL OR PAN 0.89 Y 2 R 20120701 E0167 9 PAIL OR PAN FOR USE WITH COMMODE CH 6.87 Y 2 R 20120701 E0168 9 HEAVYDUTY/WIDE COMMODE CHAIR MP Y 2 R E0175 9 "FOOT REST, FOR USE WITH COMMODE CHA " 37.92 Y 1 R 20120701 E0181 9 "PRESSURE PAD, ALTERNATING WITH PUMP," 165.04 Y 2 R 20120701 E0182 9 PUMP FOR ALTERNATING PRESSURE PAD 155.38 Y 2 R 20120701 E0184 9 EGGCRATE TYPE MATTRESS 135.92 Y 2 R 20120701 E0185 9 GEL OR GEL-LIKE PRESSURE PAD FOR MAT 189.8 Y 2 R 20120701 E0186 9 AIR PRESSURE MATTRESS 121.78 Y 2 R 20120701 E0187 9 WATER PRESURE MATTRESS 137.74 Y 2 R 20120701 E0188 9 SYNTHETIC SHEEPSKIN PAD 20.37 Y 2 R 20120701 E0189 9 "LAMBSWOOL SHEEPSKIN PAD, ANY SIZE " 35.97 Y 2 R 20120701 E0196 9 GEL PRESSURE MATTRESS 240.97 Y 2 R 20120701 E0197 9 AIR PRESSURE PAD FOR MATTRESS 164.36 Y 2 R 20120701 E0198 9 WATER PRESSURE PAD FOR MATTRESS 164.36 Y 2 R 20120701 E0199 9 EGGCRATE TYPE PAD FOR MATTRESS 23.77 Y 2 R 20120701 E0202 7 PHOTOTHERAPY (BILIRUBIN) LIGHT 30.9 Y 2 00 20 R 20120701 E0202 9 PHOTOTHERAPY (BILIRUBIN) LIGHT WITH MP Y 2 00 20 R E0240 9 "BATH/SHOWER CHAIR, W OR W/O WHEELS " MP 1 R E0241 9 "BATH TUB WALL RAIL, EACH " MP Y 1 R E0242 9 "BATH TUB RAIL, FLOOR BASE " MP Y 1 R E0243 9 "TOILET RAIL, EACH " MP Y 1 R E0244 9 RAISED TOILET SEAT MP Y 1 R E0245 9 TUB STOOL OR BENCH MP Y 1 R E0246 9 TRANSFER TUB RAIL ATTACHMENT 42.37 Y 1 R 20120701 E0250 7 "HOSPITAL BED,WITH SIDE RAILS, FIXED " 56.5 Y 2 R 20120701 E0250 9 "HOSPITAL BED, WITH SIDE RAILS, FIXE " MP Y 2 R E0251 7 "HOSPITAL BED,WITH SIDE RAILS,FIXED " 46.57 Y 2 R 20120701 E0251 9 "HOSPITAL BED, WITH SIDE RAILS, FIXE " 465.72 Y 2 R 20120701 E0255 7 "HOSPITAL BED,WITH SIDE RAIL,VARIAB " 66.22 Y 2 R 20120701 E0255 9 "HOSPITAL BED, WITH SIDE RAILS VARIA " 573.84 Y 2 R 20120701 E0256 7 "HOSP BED, VARIABLE HEIGHT,HI LO WITH" 66.22 Y 2 R 20120701 E0256 9 HOSPITAL BED VARI HEIGHT HI LO WITH 701.85 Y 2 R 20120701 E0260 7 "HOSP BED, WITH SIDE RAILS, SEMI " 108.34 Y 2 R 20120701 E0260 9 "HOSPITAL BED, WITH SIDE RAILS, SEMI " 1083.41 Y 2 R 20120701 E0261 7 HOSPITAL BED SEMI ELECTRIC WITH ANY 115.32 Y 2 R 20120701 E0261 9 HOSPITAL BED SEMI ELECTRIC WITH ANY 1153.15 Y 2 R 20120701 E0265 7 "HOSPITAL BED,TOTAL ELECTRIC W/S " 110.36 Y 2 R 20120701 E0265 9 "HOSPITAL BED, TOTAL ELECTRIC WITH S " 1103.54 Y 2 R 20120701 E0266 7 HOSP BED FULLY ELECT WITHOUT 108.34 Y 2 R 20120701 E0266 9 HOSPITAL BED FULLY ELECTRIC WITHOUT 1083.41 Y 2 R 20120701 E0271 7 "MATTRESS, ZNNERSPRING " 12.96 Y 2 R 20120701 E0271 9 "MATTRESS, INNERSPRING " 129.64 Y 2 R 20120701 E0272 7 MATTRESS FOAM RUBBER 13.64 Y 2 R 20120701 E0272 9 "MATTRESS, FOAM RUBBER " 136.33 Y 2 R 20120701 E0275 9 "BED PAN, STANDARD, METAL OR PLASTIC " MP Y 2 R E0276 9 "BED PAN, FRACTURE, METAL OR PLASTIC " 8.96 Y 2 R 20120701 E0290 7 HOSP BED FIXED HEIGHT WITHOUT SI 62.93 Y 2 R 20120701 E0290 9 HOSPITAL BED FIXED HEIGHT WITHOUT SI 629.37 Y 2 R 20120701 E0291 7 HOSP BED FIXED HEIGHT W/O SIDE RAIL 45.72 Y 2 R 20120701 E0291 9 HOSP BED FIXED HEIGHT WITHO SIDE RAI 457.21 Y 2 R 20120701 E0292 7 HOSP BED VAR HEIGHT HI LO WITHOUT SI 70.76 Y 2 R 20120701 E0292 9 HOSP BED VAR HEIGHT HI LO WITHOUT SI 707.67 Y 2 R 20120701 E0293 7 HOSP BED VAR HEIGHT HI LO WITHOUT SI 60.22 Y 2 R 20120701 E0293 9 HOSP BED VAR HEI HI LO WITHOUT SIDE 602.18 Y 2 R 20120701 E0294 7 HOSP BED SEMI ELEC W/O SIDERAIL 110.02 Y 2 R 20120701 E0294 9 HOSP BED SEMI ELEC WITHOUT SIDE RAIL 1100.18 Y 2 R 20120701 E0295 7 HOSP BED SEMI ELCT W/O SIDERAIL 107.24 Y 2 R 20120701 E0295 9 HOSPIT BED SEMI ELEC WITHOUT SIDE RA 1072.38 Y 2 R 20120701 E0296 7 HOSP BED TOTAL ELEC WITHOUT SIDE 138.27 Y 2 R 20120701 E0296 9 HOSPITAL BED TOTAL ELEC WITHOUT SIDE 1382.69 Y 2 R 20120701 E0297 7 HOSP BED TOTAL ELEC WITHOUT SIDE 118.46 Y 2 R 20120701 E0297 9 HOSPITAL BED TOTAL ELEC WITHOUT SIDE 1184.59 Y 2 R 20120701 E0301 7 "HD HOSP BED,350-600 LBS " MP Y 2 R E0301 9 "HD HOSP BED, 350-600 LBS " MP Y 2 R E0302 7 EX HD HOSP BED>600 LBS MP Y 2 R E0302 9 EX HD HOSP BED > 600 LBS MP Y 2 R E0303 7 HOSP BED HVY DTY EXTRA WIDE MP Y 2 R E0303 9 HOSP BED HVY DTY XTRA WIDE MP Y 2 R E0304 7 HOSP BED XTRA HVY DTY X WIDE MP Y R E0304 9 HOSP BED XTRA HVY DTY X WIDE MP Y R E0305 7 "BED SIDE RAILS, HALF LENGHT " 10.19 Y 2 R 20120701 E0305 9 "BED SIDE RAILS, HALF LENGTH " MP Y 2 R E0310 7 RAILS BED SIDE FULL LENGTH 13.08 Y 2 R 20120701 E0310 9 "BED SIDE RAILS, FULL LENGTH " 130.79 Y 2 R 20120701 E0325 9 "URINAL, MALE, ANY MATERIAL " MP Y 2 R E0326 9 "URINAL, FEMALE, ANY MATERIAL " MP Y 2 R E0328 9 "HOSPITAL BED, PEDIATRIC, MANUAL, 360" MP Y 00 20 R E0329 9 "HOSPITAL BED, PEDIATRIC, ELECTRIC OR" MP Y 00 20 R E0370 9 AIR PAD ELEVATOR FOR HEEL 18.21 Y 2 R 20120701 E0424 7 "STA COMPRESSED GAS SYSTEM, RENTAL " 191.06 Y 00 20 R 20120701 E0430 7 "PORTABLE GASEOUS OXYGEN SYSTEM,RENTA" 15.64 Y R 20141215 E0430 9 "OXYGEN SYSTEM, GASEOUS, PORTABLE, I " 156.39 Y R 20141215 E0431 7 PORTABLE GASEOUS OXYGEN SYSTEM 15.64 00 20 R 20120701 E0433 9 "PORTABLE LIQUID OXYGEN SYSTEM,RENTAL" 34.8 R 20120701 E0439 7 STATIONARY LIQUID OXYGEN SYS 191.06 Y 00 20 R 20120701 E0443 9 "PORTABLE OXYGEN CONTENTS,GAS,PER UNI" MP Y 2 R E0444 9 "PORT OXYGEN CONTENTS,LIQUID,PER UNIT" 70.86 Y 00 20 R 20120701 E0445 7 OXIMETER DEVICE & MEASURING BLOOD OX 260.01 Y 1 00 20 R 20120701 E0445 9 OXIMETER DEVICE & MEASURING BLOOD OX 640.4 Y 1 00 20 R 20120701 E0465 7 HOME VENT ANY TYPE WITH INVASIVE INT MP Y 2 R E0465 9 HOME VENT ANY TYPE WITH INVASIVE INT MP Y 2 R E0466 7 HOME VENT ANY TYPE NON-INVASIVE INT MP Y 2 R E0466 9 HOME VENT ANY TYPE NON-INVASIVE INT MP Y 2 R E0470 7 NONINVASIVE ASSIST W/O BACKUP 235.65 Y 2 R 20120701 E0470 9 NONINVASIVE ASSIST WO BACKUP 2356.94 Y 2 R 20120701 E0471 7 NONINVASIVE ASSIST W BACKUP 501.38 Y 2 R 20120701 E0471 9 NONINVASIVE ASSIST W BACKUP 5013.76 Y 2 R 20120701 E0480 7 "PERCUSSOR,ELECTRIC OR PNEUMATIC,H " 24.01 Y 2 R 20120701 E0480 9 "PERCUSSOR, ELECTRIC OR PNEUMATIC, H " 358.04 Y 2 R 20120701 E0482 9 COUGH STIMULATION DEVICE 4455.81 Y 00 20 R 20130201 E0483 7 CHEST COMPRESSION GEN SYSTEM MP Y R E0483 9 CHEST COMPRESSION GEN SYSTEM MP Y R E0487 9 "SPIROMETER, ELECTRONIC, INCLUDES ALL" MP R E0550 7 "HUMIDIFIER,DURABLE FOR EXT " 27.39 Y 2 R 20120701 E0550 9 "HUMIDIFIER, DURABLE FOR EXTENSIVE SU" 273.95 Y 2 R 20120701 E0555 9 "HUMIDIFIER, DURABLE, GLASS OR AUTOCL" MP Y 2 R E0560 7 "HUMIDIFIER,DURABLE FOR SUPPLEMENTAL " 11.03 Y 2 R 20120701 E0560 9 "HUMIDIFIER, DURABLE FOR SUPPLEMENTAL" MP Y 2 R E0561 7 HUMIDIFIER NONHEATED USED W PAP 7.21 Y 2 R 20120701 E0561 9 HUMIDIFIER NONHEATED W PAP 68.8 Y 2 R 20120701 E0562 7 HUMIDIFIER HEATED USED WITH PAP 19.37 Y 2 R 20120701 E0562 9 HUMIDIFIER HEATED USED W PAP 193.68 Y 2 R 20120701 E0565 7 COMPRESSOR (NOT OXYGEN OR IPPB) 33.34 Y 2 R 20120701 E0565 9 COMPRESSOR (NOT OXYGEN OR IPPB) 333.48 Y 2 R 20120701 E0570 7 "NEBULIZER,WITH COMPRESSOR EA, DEV " 14.45 Y 2 R 20120701 E0570 9 "NEBULIZER, WITH COMPRESSOR E.G., DEV" 57.78 Y 2 R 20120701 E0580 7 "NEBULIZER,DURABLE, GLASS OR AUTOCLAY" 14.45 Y 2 R 20120701 E0580 9 "NEBULIZER, DURABLE, GLASS OR AUTOCLA" 98.5 Y 2 R 20120701 E0585 7 NEBULIZER WITH COMPRESSER AND HEATER 14.45 Y 2 R 20120701 E0585 9 "NEBULIZER, WITH COMPRESSOR AND HEATE" 257.7 Y 2 R 20120701 E0600 7 "SUCTION PUMP,HOME MODEL,PORTABLE " 21.67 Y 2 R 20120701 E0600 9 "SUCTION PUMP, HOME MODEL, PORTABLE " MP Y 2 R E0601 7 CONTINUOUS POSITIVE AIRWAY PRESSURE 87.22 Y 2 R 20120701 E0601 9 CONTINUOUS POSITIVE AIRWAY PRESSURE 872.19 Y 2 R 20120701 E0607 9 HOME BLOOD GLUCOSE MONITOR 26.48 Y 2 R 20120701 E0619 7 APNEA MONITOR W RECORDER 233.77 Y 2 R 20120701 E0619 9 APNEA MONITOR WITH RECORDER 1829.7 Y 2 R 20120701 E0621 7 PATIENT LIFT SLING OR SEAT MP Y 2 R E0621 9 "SLING OR SEAT, PATIENT LIFT, CANVAS " MP Y 2 R E0630 7 "PATIENT LIFT,HYDRAULIC, WITH SEAT O " 85.79 Y 2 R 20120701 E0630 9 "PATIENT LIFT, HYDRAULIC, WITH SEAT O" 857.94 Y 2 R 20120701 E0638 9 "STANDING FRAME/TABLE SYSTEM, ONE POS" MP Y 2 00 20 R E0642 9 DYNAMIC STANDING FRAME MP Y 2 R E0650 9 "PNEUMATIC COMPRESSOR, NON-SEGMENTAL " 708.83 20140501 E0651 9 "PNEUMATIC COMPRESSOR,SEGMENTAL HOME " 903.9 R 20140501 E0652 9 "PNEUMATIC COMPRESS,SEGMENTAL HOME MO" 5217.63 R 20140501 E0656 9 SEGMENTAL PNEUMATIC APPLIANCE FOR US MP R E0657 9 SEGMENTAL PNEUMATIC APPLIANCE FOR US MP R E0665 9 PNEUMATIC APPLIANCE FOR USE WITH PN 134.83 R 20140501 E0667 9 "PNEUMATIC APPL.USE W/SPC,LEG " 318.65 R 20140501 E0668 9 "PNEUMATIC APPL.USE W/SPC,ARM " 434.89 R 20140501 E0669 9 "SEGMENTQL PNEUMATIC APP, HALF LEG " 180.41 R 20140501 E0671 9 PRESSURE PNEUM APPL FULL LEG 408.79 R 20140501 E0672 9 PRESSURE PNEUM APPL FULL ARM 317.62 R 20140501 E0673 9 PRESSURE PNEUM APPL HALF LEG 263.93 R 20140501 E0705 7 "TRANSFER BOARD, RENTAL " 3.71 Y 2 R 20120701 E0705 9 TRANSFER BOARD 37.13 Y 2 R 20120701 E0747 7 OSTEOGENESIS STIM NONSPINAL NONINV 237.6 Y 2 R 20120701 E0747 9 "OSTEOGENESIS STIM,NON-SPINAL,NON-INV" MP Y 2 R E0748 7 OSTEOGENIC STIMULATOR SPINAL 236.07 Y 2 R 20120701 E0748 9 OSTEOGENIC STIMULATOR SPINAL MP Y 2 R E0760 9 "OSTOGENESIS STIMULATOR, LOW " 2173.98 R 20120701 E0766 7 ELECTRICAL STIMULATION DEVICE 286.86 R 20140101 E0770 9 "FUNCTIONAL ELECTRICAL STIMULATOR, TR" MP R E0776 7 IV POLE 6.4 Y 1 R 20120701 E0776 9 IV POLE MP Y 2 R E0779 7 AMBULATORY INF PUMP REUSABLE 8HR/MOR 170.16 Y 2 R 20120701 E0779 9 AMBULATORY INF PUMP RESUABLE 8HR/MOR 106.24 Y R 20120701 E0781 7 EXTERNAL AMBULATORY INFUSION PUMP 170.31 Y 1 R 20120701 E0781 9 EXTERNAL AMBULATORY INFUSION P MP Y 2 R E0783 9 PROGRAMMABLE INFUSION PUMP 6948.5 Y 2 04 99 R 20120701 E0784 7 EXT AMB INFUSION PUMP INSULIN 485.12 Y 2 R 20120701 E0784 9 EXT AMB INFUSN PUMP INSULIN MP Y 2 R E0785 9 REPLACEMENT IMPL PUMP CATHET 304.61 04 99 R 20120701 E0786 9 IMPLANTABLE PUMP REPLACEMENT 5448.4 R 20120701 E0791 7 PARENTERAL INFUSION PUMP STATIONARY 172.38 Y 1 R 20120701 E0791 9 PARENTAL INFUSION PUMP STATIONARY MP Y 2 R E0840 7 TRACT FRAME ATTACH HEADBOARD MP Y 2 R E0840 9 "TRACTION FRAME, ATTACHED TO HEADBOAR" MP Y 2 R E0849 7 CERVICAL PNEUM TRACT EQUIP 31.41 Y 2 R 20120701 E0849 9 CERVICAL PNEUM TRAC EQUIP 317.21 Y 2 R 20120701 E0850 7 TRACTION ON CERVICAL W/O HEAD HALTER 5.26 Y 2 R 20120701 E0850 9 TRACTION CERVICL W/O HEAD HALTER MP Y 2 R E0855 9 CERVICAL TRACTION EQUIPMENT 22.72 Y 2 R 20120701 E0860 7 TRACT EQUIP CERVICAL TRACT MP Y 2 R E0860 9 TRACTION OVERDOOR MP Y 2 R E0870 7 "TRACTION FRAME,ATTACHED TO HEADBOARD" 5.83 Y 2 R 20120701 E0870 9 "TRACTION FRAME, ATTACHED TO FOOTBOA " MP Y 2 R E0880 7 TRANCTION STAND FREE STANDING SIMP 6.29 Y 2 R 20120701 E0880 9 "TRACTION STAND, FREE STANDING, SIMP " 62.9 Y 2 R 20120701 E0890 7 TRACTION FRAME ATTACHED TO FOOTBOAR 7.1 Y 2 R 20120701 E0890 9 "TRACTION FRAME, ATTACHED TO FOOTBOAR" MP Y 2 R E0900 7 TRACTION STAND FREE STANDING SIMP 7.55 Y 2 R 20120701 E0900 9 "TRACTION STAND, FREE STANDING, SIMP " 75.53 Y 2 R 20120701 E0910 7 TRAPEZE BAR FULL-LENGTH 2 POST 15.8 Y 2 R 20120701 E0910 9 "TRAPEZE BAR; FULL-LENGTH, 2 POST " 158.03 Y 2 R 20120701 E0920 7 FRACTURE FRAME ATTACHED TO BED IN 23.24 Y 2 R 20120701 E0920 9 "FRACTURE FRAME, ATTACHED TO BED, IN " MP Y 2 R E0930 7 FRACTURE FRAME FREE STANDING INCL 22.88 Y 2 R 20120701 E0930 9 "FRACTURE FRAME, FREE STANDING, INCL " MP Y 2 R E0935 7 CONT PAS MOTION EXERCISE DEV 15.49 Y 2 R 20120701 E0940 7 TRAPEZE BAR FREE STANDING COMPLETE 24.81 Y 2 R 20120701 E0940 9 "TRAPEZE BAR, FREE STANDING, COMPLETE" 248.87 Y 2 R 20120701 E0941 7 GRAVITY ASSISTED TRACTION DEVICE A 23.24 Y 2 R 20120701 E0941 9 "GRAVITY ASSISTED TRACTION DEVICE, A " MP Y 2 R E0942 9 "TRACTION,CERVICAL WITH HEAD HALTER " 9.95 Y 2 R 20120701 E0944 7 PELVIC BELT/HARNESS/BOOT MP Y 2 R E0944 9 PELVIC BELT/HARNESS/BOOT MP Y 2 R E0945 7 BELT/HARNESS EXTREMITY MP Y 2 R E0945 9 EXTREMITY BELT/HARNESS MP Y 2 R E0946 7 FRACTURE FRAME DUAL WITH CROSS BA 29.64 Y 2 R 20120701 E0946 9 "FRACTURE, FRAME, DUAL WITH CROSS BA " MP Y 2 R E0947 7 FRACTURE FRAME ATTACHMENTS FOR COM 30.38 Y 2 R 20120701 E0947 9 "FRACTURE FRAME, ATTACHMENTS FOR COM " MP Y 2 R E0948 7 FRACTURE FRAME ATTACHMENTS FOR COM 29.32 Y 2 R 20120701 E0948 9 "FRACTURE FRAME, ATTACHMENTS FOR COM " MP Y 2 R E0950 9 TRAY MP Y 2 R E0951 9 "LOOP HEEL, EACH " MP Y 2 R E0952 9 "LOOP TOE, EACH " MP Y 2 R E0955 9 CUSHIONED HEADREST MP Y 2 R E0956 9 W/C LATERAL TRUNK/HIP SUPPOR MP Y 2 R E0957 9 W/C MEDIAL THIGH SUPPORT MP Y 2 R E0958 9 WHEELCHAIR ATTACHMENT TO CONVERT AN 26.96 Y 2 R 20120701 E0959 9 AMPUTEE ADAPTER (DEVICE USED TO COM 27.33 Y 2 R 20120701 E0960 9 W/C SHOULDER HARNESS/STRAPS 56.22 Y 2 R 20120701 E0961 9 "BRAKE EXTENSION, FOR WHEELCHAIR " 18.38 Y 2 R 20120701 E0966 9 HOOK ON HEAD REST EXTENSION MP Y 2 R E0967 9 WHEELCHAIR HAND RIMS WITH 8 VERTICA MP Y 2 R E0968 9 "COMMODE SEAT, WHEELCHAIR " MP Y 2 R E0969 9 "NARROWING DEVICE, WHEELCHAIR " MP Y 2 R E0970 9 "NO.2 FOOTPLATES, EXCEPT FOR ELEVATI " MP Y 2 R E0971 9 ANTI-TIPPING DEVICE WHEELCHAIRS 26.81 Y 2 R 20120701 E0973 9 "ADJUSTABLE HEIGHT DETACHABLE ARMS, " MP Y 2 R E0974 9 GRADE-AID DEVICE TO PREVENT ROLL MP Y 2 R E0978 9 "BELT, SAFETY WITH AIRPLANE BUCKLE, " MP Y 2 R E0980 9 "SAFETY VEST, WHEELCHAIR " MP Y 2 R E0981 9 "SEAT UPHOLSTERY, REPLACEMENT " MP Y 2 R E0982 9 "BACK UPHOLSTERY, REPLACEMENT " MP Y 2 R E0984 9 ADD PWR TILLER MP Y 2 R E0985 9 W/C SEAT LIFT MECHANISM MP Y 2 R E0986 7 MAN W/C PUSH-RIM POW ASSIST MP Y 2 R E0986 9 MAN W/C PUSH-RIM POW ASSIST MP Y 2 R E0988 9 "MANUAL WHEELCHAIR ACCESSORY, LEVER-A" 216.74 Y R 20120701 E0990 9 "ELEVATING LEG REST, EACH " 72.56 Y 2 R 20120701 E0992 9 SOLID SEAT INSERT 58.81 Y 2 R 20120701 E0994 9 "ARM REST, EACH " MP Y 2 R E0995 9 "CALF REST, EACH " MP Y 2 R E1002 9 PWR SEAT TILT 2541.76 Y 2 R 20120701 E1003 9 PWR SEAT RECLINE MP Y 2 R E1004 9 PWR SEAT RECLINE MECH MP Y 2 R E1005 9 PWR SEAT RECLINE 3256.98 Y 2 R 20120701 E1006 9 PWR SEAT COMBO W/O SHEAR MP Y 2 R E1007 9 PWR SEAT COMBO W/SHEAR MP Y 2 R E1008 9 PWR SEAT COMBO PWR SHEAR MP Y 2 R E1009 9 ADD MECH LEG ELEVATION MP Y 2 R E1011 9 PED WC MODIFY WIDTH ADJUSTM MP Y 2 R E1014 9 RECLINING BACK ADD PED W/C MP Y 2 R E1015 9 SHOCK ABSORBER FOR MAN W/C MP Y 2 R E1016 9 SHOCK ABSORBER FOR POWER W/C MP Y 2 R E1017 9 HD SHOCK ABSRBER FOR HD MAN WC MP Y 2 R E1018 9 HD SHOCK ABSRBER MP Y 2 R E1020 9 RESIDUAL LIMB SUPPORT SYSTEM MP Y 2 R E1028 9 W/C MANUAL SWINGAWAY 127.63 Y 2 R 20120701 E1029 9 W/C VENT TRAY FIXED MP Y 2 R E1035 9 GERIATRIC CHAIR MP Y R E1036 9 MULTI-POSITIONAL PT TRANSFER SYS MP R E1038 9 TRANSPORT CHAIR 121.22 R 20120701 E1050 7 FULLY-RECLINING WHEELCHAIR FIXED F 60.02 Y 2 R 20120701 E1050 9 "FULLY-RECLINING WHEELCHAIR, FIXED F " MP Y 2 R E1060 7 FULLY-RECLINING WHEELCHAIR DETACHA 64.55 Y 2 R 20120701 E1060 9 "FULLY-RECLINING WHEELCHAIR, DETACHA " MP Y 2 R E1070 7 FULLY-RECLINING WHEELCHAIR DETACHAB 64.55 Y 2 R 20120701 E1070 9 "FULLY-RECLINING WHEELCHAIR, DETACHAB" MP Y 2 R E1083 7 HEMI-WHEELCHAIR FIXED FULL LENGTH 46.41 Y 2 R 20120701 E1083 9 "HEMI-WHEELCHAIR, FIXED FULL LENGTH " 464.11 Y 2 R 20120701 E1084 7 HEMI-WHEELCHAIR DETACHABLE ARMS DE 54.07 Y 2 R 20120701 E1084 9 "HEMI-WHEELCHAIR, DETACHABLE ARMS DE " 540.73 Y 2 R 20120701 E1085 7 HEMI-WHEELCHAIR FIXED FULL LENGTH 40.78 Y 2 R 20120701 E1085 9 "HEMI-WHEELCHAIR, FIXED FULL LENGTH " 407.94 Y 2 R 20120701 E1086 7 HEMI-WHEELCHAIR DETACHABLE ARMS DES 49.55 Y 2 R 20120701 E1086 9 HEMI-WHEELCHAIR DETACHABLE ARMS DES MP Y 2 R E1087 7 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR 64.16 Y 2 R 20120701 E1087 9 HIGH STRENGTH LIGHTWEIGHT WHEELCHAI MP Y 2 R E1088 7 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR 66.22 Y 2 R 20120701 E1088 9 HIGH STRENGTH LIGHTWEIGHT WHEELCHAI MP Y 2 R E1089 7 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR 60.22 Y 2 R 20120701 E1089 9 HIGH STRENGTH LIGHTWEIGHT WHEELCHAI MP Y 2 R E1090 7 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR 68.23 Y 2 R 20120701 E1090 9 HIGH STRENGTH LIGHTWEIGHT WHEELCHAI MP Y 2 R E1092 7 WIDE HEAVY DUTY WHEELCHAIR DETACH 66.22 Y 2 R 20120701 E1092 9 "WIDE HEAVY DUTY WHEEL CHAIR, DETACH " MP Y 2 R E1093 7 WIDE HEAVY DUTY WHEELCHAIR DETACHA 55.36 Y 2 R 20120701 E1093 9 "WIDE HEAVY DUTY WHEELCHAIR, DETACHA " MP Y 2 R E1100 7 SEMI-RECLINING WHEELCHAIR FIXED FU 55.23 Y 2 R 20120701 E1100 9 "SEMI-RECLINING WHEELCHAIR, FIXED FU " MP Y 2 R E1110 7 SEMI-RECLINING WHEELCHAIR DETACHABLE 50.93 Y 2 R 20120701 E1110 9 "SEMI-RECLINING WHEELCHAIR, DETACHABL" MP Y 2 R E1130 7 STANDARD WHEELCHAIR FIXED FULL LEN 30.9 Y 2 R 20120701 E1130 9 "STANDARD WHEELCHAIR, FIXED FULL LEN " 220.71 Y 2 R 20120701 E1140 7 WHEELCHAIR DETACHABLE ARMS DESK O 36.42 Y 2 R 20120701 E1140 9 "WHEELCHAIR, DETACHABLE ARMS, DESK O " 364.17 Y 2 R 20120701 E1150 7 WHEELCHAIR DETACHABLE ARMS DESK O 40.05 Y 2 R 20120701 E1150 9 "WHEELCHAIR, DETACHABLE ARMS, DESK O " 400.59 Y 2 R 20120701 E1160 7 WHEELCHAIR FIXED FULL LENGTH ARMS 33.11 Y 2 R 20120701 E1160 9 "WHEELCHAIR, FIXED FULL LENGTH ARMS, " 331.07 Y 2 R 20120701 E1161 7 MANUAL ADULT WC W TILTINSPAC MP Y 2 R E1161 9 MANUAL ADULT W/C W TILTN SPACE MP Y 2 R E1170 7 AMPUTEE WHEELCHAIR FIXED FULL LENGTH 46.92 Y 2 R 20120701 E1170 9 "AMPUTEE WHEELCHAIR, FIXED FULL LENG " 639.26 Y 2 R 20120701 E1171 7 AMPUTEE WHEELCHAIR FIXED FULL LENGTH 66.22 Y 2 R 20120701 E1171 9 "AMPUTEE WHEELCHAIR, FIXED FULL LENG " MP Y 2 R E1172 7 AMPUTEE WHEELCHAIR DETACHABLE ARMS 66.22 Y 2 R 20120701 E1172 9 "AMPUTEE WHEELCHAIR, DETACHABLE ARMS " MP Y 2 R E1180 7 AMPUTEE SHEELCHAIR DETACHABLE ARMS 66.22 Y 2 R 20120701 E1180 9 "AMPUTEE WHEELCHAIR, DETACHABLE ARMS " 725.33 Y 2 R 20120701 E1190 7 AMPUTEE WHEELCHAIR DETACHABLE ARMS 66.22 Y 2 R 20120701 E1190 9 "AMPUTEE WHEELCHAIR, DETACHABLE ARMS " 855.2 Y 2 R 20120701 E1195 7 HEAVY DUTY WHEELCHAIR FIXED FULL 66.22 Y 2 R 20120701 E1195 9 "HEAVY DUTY WHEELCHAIR, FIXED FULL L " MP Y 2 R E1200 7 AMPUTEE WHEELCHAIR FIXED FULL LENGTH 66.22 Y 2 R 20120701 E1200 9 "AMPUTEE WHEELCHAIR, FIXED FULL LENGT" MP Y 2 R E1220 9 SPECIAL SIZED/CONSTRUCTED WHEELCHAIR MP Y 2 R E1221 7 WHEELCHAIR WITH FIXED ARM FOOTREST 23.81 Y 2 R 20120701 E1221 9 "WHEELCHAIR WITH FIXED ARM, FOOTREST " 237.99 Y 2 R 20120701 E1222 7 WHEELCHAIR WIH FIXED ARM ELEVATING 36.44 Y 2 R 20120701 E1222 9 "WHEELCHAIR WITH FIXED ARM, ELEVATIN " 364.42 Y 2 R 20120701 E1223 7 WHEELCHAIR WITH DETACHABLE ARMS FO 39.84 Y 2 R 20120701 E1223 9 "WHEELCHAIR WITH DETACHABLE ARMS, FO " MP Y 2 R E1224 7 WHEELCHAIR WITH DETACHABLE ARMS EL 50.15 Y 2 R 20120701 E1224 9 "WHEELCHAIR WITH DETACHABLE ARMS, EL " MP Y 2 R E1225 9 SEMI-RECLINING BACK FOR CUSTOMIZED MP Y 2 R E1226 9 FULL RECLINING BACK FOR CUSTOMIZED MP Y 2 R E1227 9 SPECIAL HEIGHT ARMS FOR WHEELCHAIR MP Y 2 R E1228 9 SPECIAL BACK HEIGHT FOR WHEELCHAIR MP Y 2 R E1231 7 RIGID PED W/C TILT-IN-SPACE MP Y 2 R E1231 9 RIGID PED W/C TILT-IN-SPACE MP Y 2 R E1232 7 FOLDING PED WC TILT-IN-SPACE MP Y 2 R E1232 9 FOLDING PED W/C TILT-IN-SPACE 1321.51 Y 2 R 20120701 E1233 7 RIG PED WC TLTNSPC W/O SEAT MP Y 2 R E1233 9 RIG PED W/C TLTNSPC W/O SEAT MP Y 2 R E1234 7 FLD PED WC TLTNSPC W/O SEAT MP Y 2 R E1234 9 FLD PED W/C TLTNSPACE W/O SEAT 1192.06 Y 2 R 20120701 E1235 7 RIGID PED WC ADJUSTABLE MP Y 2 R E1235 9 RIGID PED W/C ADJUSTABLE 1147.86 Y 2 R 20120701 E1236 7 FOLDING PED WC ADJUSTABLE MP Y 2 R E1236 9 FOLDING PED W/C ADJUSTABLE MP Y 2 R E1237 7 RGD PED WC ADJSTABL W/O SEAT MP Y 2 R E1237 9 RIGID PED WC ADJUSTABLE W/O SEAT 1021.56 Y 2 R 20120701 E1238 7 FLD PED WC ADJUSTABLE W/O SEATING MP R E1240 7 LIGHTWEIGHT WHEELCHAIR DETACHABLE 51.61 Y 2 R 20120701 E1240 9 "LIGHTWEIGHT WHEELCHAIR, DETACHABLE " MP Y 2 R E1250 7 LIGHTWEIGHT WHEELCHAIR FIXED FULL L 44.79 Y 2 R 20120701 E1250 9 "LIGHTWEIGHT WHEELCHAIR, FIXED FULL L" MP Y 2 R E1260 7 LIGHTWEIGHT WHEELCHAIR DETACHABLE A 54.94 Y 2 R 20120701 E1260 9 "LIGHTWEIGHT WHEELCHAIR, DETACHABLE A" MP Y 2 R E1270 7 LIGHTWEIGHT WHEELCHAIR FIXED FULL 45.51 Y 2 R 20120701 E1270 9 "LIGHTWEIGHT WHEELCHAIR, FIXED FULL " MP Y 2 R E1280 7 HEVY DUTY WHEELCHAIR DETACHABLE ARM 65.76 Y 2 R 20120701 E1280 9 "HEAVY DUTY WHEELCHAIR, DETACHABLE AR" MP Y 2 R E1285 7 HEAVY DUTY WHEELCHAIR FIXED FULL LE 60.42 Y 2 R 20120701 E1285 9 "HEAVY DUTY WHEELCHAIR, FIXED FULL LE" MP Y 2 R E1290 7 HEAVY DUTY WHEELCHAIR DETACHABLE ARM 62.69 Y 2 R 20120701 E1290 9 "HEAVY DUTY WHEELCHAIR, DETACHABLE AR" MP Y 2 R E1295 7 HEAVY DUTY WHEELCHAIR FIXED FULL LE 60.85 Y 2 R 20120701 E1295 9 "HEAVY DUTY WHEELCHAIR, FIXED FULL LE" MP Y 2 R E1296 7 WHEELCHAIR SPECIAL SEAT HEIG MP Y 2 R E1296 9 SPECIAL WHEELCHAIR SEAT HEIGHT FROM MP Y 2 R E1297 9 "SPECIAL WHEELCHAIR SEAT DEPTH, BY U " MP Y 2 R E1298 9 SPECIAL WHEELCHAIR SEAT DEPTH AND/O MP Y 2 R E1355 7 STANDY/RACK 4.6 Y 2 R 20120701 E1355 9 STAND/RACK MP Y 2 R E1358 9 "OXYGEN ACCESSORY, DC POWER ADAPTER F" MP R E1390 7 OXYGEN CONCENTRATOR EQUIVALENT TO 132.42 Y 2 R 20120701 E1390 9 "OXYGEN CONCENTRATOR, EQUIVALENT TO " MP Y 2 R E1399 7 "DURABLE MEDICAL EQUIPMENT,NOR OTHER " MP Y 1 R E1399 9 "DURABLE MEDICAL EQUIPMENT, NOT OTHER" MP Y 2 R E1510 9 "KIDNEY, DIALYSATE DELIVERY SYST. KID" MP Y R E1520 9 HEPARIN INFUSION PUMP FOR DIALYSIS MP Y R E1530 9 AIR BUBBLE DETECTOR FOR DIALYSIS MP Y R E1540 9 PRESSURE ALARM FOR DIALYSIS MP Y R E1550 9 BATH CONDUCTIVITY METER FOR DIALYSI MP Y R E1560 9 BLOOD LEAK DETECTOR FOR DIALYSIS MP Y R E1575 9 TRANSDUCER PROTECTORS/FLUID BARRIER MP Y R E1580 9 UNIPUNCTURE CONTROL SYSTEM FOR DIALY MP Y R E1590 9 HEMODIALYSIS MACHINE MP Y R E1592 9 AUTOMATIC INTERMITTENT PERITIONEAL MP Y R E1594 9 CYCLER DIALYSIS MACHINE MP Y R E1600 9 DELIVERY AND/OR INSTALLATION CHARGES MP Y R E1610 9 REVERSE OSMOSIS WATER PURIFICATION MP Y R E1615 9 DEIONIZER WATER PURIFICATION SYSTEM MP Y R E1620 9 BLOOD PUMP FOR DIALYSIS MP Y R E1625 9 WATER SOFTENING SYSTEM MP Y R E1630 9 RECIPROCATING PERITONEAL DIALYSIS SY MP Y R E1632 9 WEARABLE ARTIFICAL KIDNEY MP Y R E1635 9 COMPACT (PORTABLE) TRAVEL HEMODIALYZ MP Y R E1636 9 "SORBENT CARTRIDGES, PER CASE " MP Y R E1699 9 "DIALYSIS EQUIPMENT, UNSPECIFIED, BY " MP Y R E1800 7 ADJUST ELBOW EXT/FLEX DEVICE MP R E1802 7 ADJST FOREARM PRO/SUP DEVICE MP R E1805 7 ADJUST WRIST EXT/FLEX DEVICE MP R E1810 7 ADJUST KNEE EXT/FLEX DEVICE MP R E1815 7 ADJUST ANKLE EXT/FLEX DEVICE MP R E1825 7 ADJUST FINGER EXT/FLEX DEVC MP R E1830 7 ADJUST TOE EXT/FLEX DEVICE MP R E1840 7 ADJ SHOULDER EXT/FLEX DEVICE MP R E1902 9 AAC NON-ELECTRONIC BOARD MP Y 2 R E2201 9 MAN W/CH ACC SEAT W>=20”<24” MP Y 2 R E2202 9 SEAT WIDTH 24-27 IN MP Y 2 R E2203 9 FRAME DEPTH LESS THAN 22 IN 296.04 Y 2 R 20120701 E2204 9 FRAME DEPTH 22 TO 25 IN MP Y 2 R E2205 9 "MANUAL WC ACCESSORY, HANDRIM " 20.18 Y 2 R 20120701 E2206 9 COMPLETE WHEEL LOCK ASSEMBLY 25.13 Y 2 R 20120701 E2207 9 CRUTCH AND CANE HOLDER MP Y 2 R E2208 7 CYLINDER TANK CARRIER 7.83 Y 2 R 20130401 E2208 9 CYLINDER TANK CARRIER MP Y 2 R E2209 9 ARM TROUGH EACH MP Y 2 R E2210 9 WHEELCHAIR BEARINGS MP Y 2 R E2211 9 PNEUMATIC PROPULSION TIRE MP Y 2 R E2212 9 PNEUMATIC PROP TIRE TUBE MP Y 2 R E2213 9 PNEUMATIC PROP TIRE INSERT MP Y 2 R E2214 9 PNEUMATIC CASTER TIRE EACH MP Y 2 R E2215 9 PNEUMATIC CASTER TIRE TUBE MP Y 2 R E2216 9 FOAM FILLED PROPULSION TIRE MP Y 2 R E2217 9 FOAM FILLED CASTER TIRE EACH MP Y 2 R E2218 9 FOAM PROPULSION TIRE EACH MP Y 2 R E2219 9 FOAM CASTER TIRE ANY SIZE EACH MP Y 2 R E2220 9 SOLID PROPULSION TIRE EACH MP Y 2 R E2221 9 SOLID CASTER TIRE EACH MP Y 2 R E2222 9 SOLID CASTER INTEGRATED WHEEL MP Y 2 R E2224 9 PROPULSION WHEEL EXCLUDES TIRE MP Y 2 R E2225 9 CATER WHEEL EXCLUDES TIRE MP Y 2 R E2226 9 CASTER FORK REPLACEMENT ONLY MP Y 2 R E2230 9 "MANUAL WHEELCHAIR ACCESSORY, MANUAL " MP R E2231 9 "MANUAL WHEELCHAIR ACCESSORY, SOLID S" MP R E2295 9 "MANUAL WHEELCHAIR ACCESSORY, FOR PED" MP R E2310 9 ELECTRO CONNECT BTW CONTROL MP Y 2 R E2311 9 ELECTRO CONNECT BTW 2 SYS MP Y 2 R E2321 9 HAND INTERFACE JOYSTICK MP Y 2 R E2322 9 MULT MECH SWITCHES MP Y 2 R E2323 9 SPECIAL JOYSTICK HANDLE MP Y 2 R E2324 9 CHIN CUP INTERFACE MP Y 2 R E2325 9 SIP AND PUFF INTERFACE MP Y 2 R E2326 9 BREATH TUBE KIT MP Y 2 R E2327 9 HEAD CONTROL INTERFACE MECH MP Y 2 R E2328 9 HEAD/EXTREMITY CONTROL INTER MP Y 2 R E2329 9 HEAD CONTROL NONPROPORTIONAL MP Y 2 R E2330 9 HEAD CONTROL PROXIMITY SWITC MP Y 2 R E2340 9 W/C WDTH 20-23 IN SEAT FRAME MP Y 2 R E2341 9 W/C WDTH 24-27 IN SEAT FRAME MP Y 2 R E2342 9 W/C DPTH 20-21 IN SEAT FRAME 276.87 Y 2 R 20120701 E2343 9 W/C DPTH 22-25 IN SEAT FRAME MP Y 2 R E2351 9 ELECTRONIC SGD INTERFACE MP Y 2 R E2358 9 "POWER WHEELCHAIR ACCESSORY, GROUP 34" MP Y R E2359 9 "POWER WHEELCHAIR ACCESSORY, GROUP 34" 126.08 Y R 20120701 E2360 9 W/C BATTERY 22NF N/SEALED LEAD ACID MP Y 2 R E2361 9 W/C BATTERY 22NF SEALED LEAD ACID MP Y 2 R E2362 9 W/C BATTERY GP24 N/SEALED LEAD ACID MP Y 2 R E2363 9 W/C BATTERY-GP24 SEALED LEAD ACID MP Y 2 R E2364 9 W/C BATTERY U1 NONSEALED LEAD ACID MP Y 2 R E2365 9 W/C BATTERY-U1 SEALED LEAD ACID MP Y 2 R E2366 9 "BATTERY CHARGER, SINGLE MODE " MP Y 2 R E2367 9 "BATTERY CHARGER, DUAL MODE " MP Y 2 R E2368 9 POWER WC MOTOR REPLACEMENT 319.22 Y 2 R 20120701 E2369 9 PWR WC GEAR BOX REPLACEMENT 278.06 Y 2 R 20120701 E2370 9 PWR WC MOTOR/GEAR BOX COMBO 496.14 Y 2 R 20120701 E2373 9 "POWER WHEELCHAIR ACCESSORY, HAND OR " MP Y 2 R E2374 7 "POWER WHEELCHAIR ACCESSORY,HAND OR " 10.46 Y 2 R 20150101 E2374 9 "POWER WHEELCHAIR ACCESSORY, HAND OR " 104.66 Y 2 R 20120701 E2375 9 "POWER WHEELCHAIR ACCESSORY, NON-EXPA" 529.33 Y 2 R 20120701 E2376 9 "POWER WHEELCHAIR ACCESSORY, EXPANDAB" 829.49 Y 2 R 20120701 E2377 9 "POWER WHEELCHAIR ACCESSORY, EXPANDAB" 300.16 Y 2 R 20120701 E2381 9 "POWER WHEELCHAIR ACCESSORY, PNEUMATI" 47.07 Y 2 R 20120701 E2382 9 "POWER WHEELCHAIR ACCESSORY, TUBE FOR" 12.83 Y 2 R 20120701 E2383 9 "POWER WHEELCHAIR ACCESSORY, INSERT F" 93.85 Y 2 R 20120701 E2384 9 "POWER WHEELCHAIR ACCESSORY, PNEUMATI" 50 Y 2 R 20120701 E2385 9 "POWER WHEELCHAIR ACCESSORY, TUBE FOR" 30.59 Y 2 R 20120701 E2386 9 "POWER WHEELCHAIR ACCESSORY, FOAM FIL" 93.01 Y 2 R 20120701 E2387 9 "POWER WHEELCHAIR ACCESSORY, FOAM FIL" 41.71 Y 2 R 20120701 E2388 9 "POWER WHEELCHAIR ACCESSORY, FOAM DRI" 31.14 Y 2 R 20120701 E2389 9 "POWER WHEELCHAIR ACCESSORY, FOAM CAS" 16.91 Y 2 R 20120701 E2390 9 "POWER WHEELCHAIR ACCESSORY, SOLID (R" 26.44 Y 2 R 20120701 E2391 9 "POWER WHEELCHAIR ACCESSORY, SOLID (R" 12.67 Y 2 R 20120701 E2392 9 "POWER WHEELCHAIR ACCESSORY, SOLID (R" MP Y 2 R E2394 9 "POWER WHEELCHAIR ACCESSORY, DRIVE WH" MP Y 2 R E2395 9 "POWER WHEELCHAIR ACCESSORY, CASTER W" MP Y 2 R E2396 9 "POWER WHEELCHAIR ACCESSORY, CASTER F" 41.09 Y 2 R 20120701 E2402 7 NEGATIVE PRESSURE WOUND THERAPY PUMP 1256.24 Y 2 R 20120701 E2506 9 SGD PREREC MSG > 40 MIN 1635.49 Y 2 R 20120701 E2508 9 SGD SPELLING PHYS CONTACT 2529.01 Y 2 R 20120701 E2510 9 SGD W MULTI METHODS MSG/ACCS MP Y 2 R E2512 9 "SGD ACCESSORY, MOUNTING SYS " MP Y 2 R E2599 9 ACCESSORY FOR SGD NOC MP Y 2 R E2601 9 GEN W/C CUSHION WDTH < 22 IN 54.79 Y 2 R 20120701 E2602 9 GEN W/C CUSHION WDTH >=22 IN 100.04 Y 2 R 20120701 E2603 9 SKIN PROTECT WC CUS WD <22IN 137.84 Y 2 R 20120701 E2604 9 SKIN PROTECT WC CUS WD>=22IN 195.13 Y 2 R 20120701 E2605 9 POSITION WC CUSH WDTH <22 IN 198.8 Y 2 R 20120701 E2606 9 POSITION WC CUSH WDTH>=22 IN 269.49 Y 2 R 20120701 E2607 9 SKIN PRO/POS WC CUS WD <22IN 182.68 Y 2 R 20120701 E2608 9 SKIN PRO/POS WC CUS WD>=22IN 218.76 Y 2 R 20120701 E2609 9 SIGNATURE 2000 SEAT MP Y 2 R E2611 9 GEN USE BACK CUSH WDTH <22IN 193.03 Y 2 R 20120701 E2612 9 GEN USE BACK CUSH WDTH>=22IN 261.13 Y 2 R 20120701 E2613 9 POSITION BACK CUSH WD <22IN 242.9 Y 2 R 20120701 E2614 9 POSITION BACK CUSH WD>=22IN 336.14 Y 2 R 20120701 E2615 9 POS BACK POST/LAT WDTH <22IN 279.52 Y 2 R 20120701 E2616 9 POS BACK POST/LAT WDTH>=22IN 376.1 Y 2 R 20120701 E2617 9 SIGNATURE 2000 BACK MP Y 2 R E2619 9 REPLACE COVER W/C SEAT CUSH 31.71 Y 2 R 20120701 E2620 9 WC PLANAR BACK CUSH WD <22IN 355.19 Y 2 R 20120701 E2621 9 WC PLANAR BACK CUSH WD>=22IN 338.47 Y 2 R 20120701 E2622 9 SKIN PROTECTION WHEELCHAIR SEAT CUSH 202.01 R 20120701 E2623 9 SKIN PROTECTION WHEELCHAIR SEAT CUSH 257.05 R 20120701 E2624 9 SKIN PROTECTION AND POSITIONING WHEE 203.66 R 20120701 E2625 9 SKIN PROTECTION AND POSITIONING WHEE 257.83 R 20120701 E2626 9 "WHEELCHAIR ACCESSORY, SHOULDER ELBOW" 382.27 Y R 20120701 E2627 9 "WHEELCHAIR ACCESSORY, SHOULDER ELBOW" 609.98 Y R 20120701 E2628 9 "WHEELCHAIR ACCESSORY, SHOULDER ELBOW" 540.62 Y R 20120701 E2629 9 "WHEELCHAIR ACCESSORY, SHOULDER ELBOW" 684.14 Y R 20120701 E2630 9 "WHEELCHAIR ACCESSORY, SHOULDER ELBOW" 478.42 Y R 20120701 E2631 9 "WHEELCHAIR ACCESSORY, ADDITION TO MO" 191.38 Y R 20120701 E2632 9 "WHEELCHAIR ACCESSORY, ADDITION TO MO" 116.85 Y R 20120701 E2633 9 "WHEELCHAIR ACCESSORY, ADDITION TO MO" 98.19 Y R 20120701 E8000 9 POSTERIOR GAIT TRAINER MP Y R J7297 9 LEVONORGESTREL-RELEASING INTRAUTERIN 625 10 60 20160101 J7298 9 LEVONORGESTREL-RELEASING INTRAUTERIN 810.51 10 60 20160101 J7300 9 INTRAUTERINE COPPER CONTRACEPTIVE 739 10 60 20150101 J7301 9 LEVONORGESTREL-RELEASING INTRAUTERIN 650.32 10 60 20140901 J7307 9 ETONOGESTREL (CONTRACEPTIVE) IMPLANT 771.52 10 60 20150101 K0001 7 STANDARD WHEELCHAIR 30.9 Y 2 R 20120701 K0001 9 STANDARD WHEELCHAIR 220.71 Y 2 R 20120701 K0002 7 STANDARD HEMI (LOW SEAT) WHEELCHAIR 48.23 Y 2 R 20120701 K0002 9 STANDARD HEMI (LOW SEAT) WHEELCHAIR 482.34 Y 2 R 20120701 K0003 7 LIGHTWEIGHT WHEELCHAIR 52.81 Y 2 R 20120701 K0003 9 LIGHTWEIGHT WHEELCHAIR 528.13 Y 2 R 20120701 K0004 7 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR 66.22 Y 2 R 20120701 K0004 9 "HIGH STRENGTH, LIGHTWEIGHT WHEELCHAI" 669.58 Y 2 R 20120701 K0005 7 ULTRALIGHTWEIGHT WHEELCHAIR 66.22 Y 2 R 20120701 K0005 9 ULTRALIGHTWEIGHT WHEELCHAIR 1527.98 Y 2 R 20120701 K0006 7 HEAVY DUTY WHEELCHAIR 62.84 Y 2 R 20120701 K0006 9 HEAVY DUTY WHEELCHAIR 628.37 Y 2 R 20120701 K0007 7 EXTRA HEAVY DUTY WHEELCHAIR 66.22 Y 2 R 20120701 K0007 9 EXTRA HEAVY DUTY WHEELCHAIR 1047.78 Y 2 R 20120701 K0009 7 OTHER MANUAL WHEELCHAIR/BASE 66.22 Y 2 R 20120701 K0009 9 OTHER MANUAL WHEELCHAIR/BASE MP Y 2 R K0010 7 STANDARD-WEIGHT FRAME MOTORIZED/PO 66.22 Y 2 R 20120701 K0010 9 STANDARD - WEIGHT FRAME MOTORIZED/PO MP Y 2 R K0011 7 STANDARD-WEIGHT FRAME MOTORIZED/PO 66.22 Y 2 R 20120701 K0011 9 STANDARD - WEIGHT FRAME MOTORIZED/PO MP Y 2 R K0014 7 OTHER MOTORIZED/POWER WHEELCHAIR BAS 66.22 Y 2 R 20120701 K0014 9 OTHER MOTORIZED/POWER WHEELCHAIR BAS MP Y 2 R K0015 9 "DETACHABLE, NON-ADJUSTABLE HEIGHT AR" 122.41 Y 2 R 20120701 K0017 9 "DETACHABLE, ADJUSTABLE HEIGHT ARMRES" 34.44 Y 2 R 20120701 K0018 9 "DETACHABLE, ADJUSTABLE HEIGHT ARMRES" 19.23 Y 2 R 20120701 K0019 9 "ARM PAD, EACH " 11.61 Y 2 R 20120701 K0020 9 "FIXED, ADJUSTABLE HEIGHT ARMREST, PA" 31.3 Y 2 R 20120701 K0037 9 "HIGH MOUNT FLIP-UP FOOTREST, EACH " 27.58 Y 2 R 20120701 K0038 9 "LEG STRAP, EACH " 16.34 Y 2 R 20120701 K0039 9 "LEG STRAP, H STYLE, EACH " 36.3 Y 2 R 20120701 K0040 9 "ADJUSTABLE ANGLE FOOTPLATE, EACH " 50.31 Y 2 R 20120701 K0041 9 "LARGE SIZE FOOTPLATE, EACH " 35.65 Y 2 R 20120701 K0042 9 "STANDARD SIZE FOOTPLATE, EACH " 23.08 Y 2 R 20120701 K0043 9 "FOOTREST, LOWER EXTENSION TUBE, EACH" 13.15 Y 2 R 20120701 K0044 9 "FOOTREST, UPPER HANGER BRACKET, EACH" 11.22 Y 2 R 20120701 K0045 9 "FOOTREST, COMPLETE ASSEMBLY " 38.14 Y 2 R 20120701 K0046 9 "ELEVATING LEGREST, LOWER EXTENSION T" 13.15 Y 2 R 20120701 K0047 9 "ELEVATING LEGREST, UPPER HANGER BRAC" 51.52 Y 2 R 20120701 K0050 9 RATCHET ASSEMBLY 21.89 Y 2 R 20120701 K0051 9 "CAM RELEASE ASSEMBLY, FOOTREST OR LE" 35.44 Y 2 R 20120701 K0052 9 "SWINGAWAY, DETACHABLE FOOTRESTS, EAC" 62.28 Y 2 R 20120701 K0053 9 "ELEVATING FOOTRESTS, ARTICULATING (T" 68.72 Y 2 R 20120701 K0056 9 "SEAT HEIGHT < 17"" OR < OR EQUAL TO 2" 64.07 Y 2 R 20120701 K0065 9 SPOKE PROTECTORS 29.95 Y 2 R 20120701 K0069 9 "REAR WHEEL ASSEMBLY, COMPLETE, WITH " 67.3 Y 2 R 20120701 K0070 9 "REAR WHEEL ASSEMBLY, COMPLETE, WITH " 123.4 Y 2 R 20120701 K0071 9 "FRONT CASTER ASSEMBLY, COMPLETE, WIT" 73.59 Y 2 R 20120701 K0072 9 "FRONT CASTER ASSEMBLY, COMPLETE, WIT" 44.3 Y 2 R 20120701 K0073 9 "CASTER PIN LOCK,EACH " 23.44 Y 2 R 20120701 K0077 9 "FRONT CASTER ASSEMBLY, COMPLETE, WIT" 39.64 Y 2 R 20120701 K0098 9 DRIVE BELT FOR POWER WHEELCHAIR 18.33 Y 2 R 20120701 K0105 9 IV HANGER 66.98 Y 2 R 20120701 K0108 9 WHEELCHAIR ACCESSORIES MP Y 2 R K0195 9 "ELEVATING LEG RESTS, PAIR " 141.96 Y 2 R 20120701 K0283 7 "POWERWHEELCHAIR, GROUP 2 STANDARD " MP Y 2 R K0455 9 PUMP UNINTERRUPTED INFUSION 1946.34 Y 2 R 20120701 K0552 9 SUPPLY/EXT INF PUMP SYR TYPE MP Y R K0606 7 AED GARMENT W ELEC ANALYSIS 2518.27 R 20081001 K0672 9 ADDITION TO LOWER EXTREMITY ORTHOSIS 63.56 R 20120701 K0730 7 CONTROL DOSE INHALER DRUG DELIVERY 166.02 Y R 20120701 K0733 9 "POWER WHEELCHAIR ACCESSORY, 12 TO 24" 18.66 Y 2 R 20120701 K0738 7 "PORTABLE GAS OXYGEN SYSTEM, RENTAL " 31.91 Y 2 00 20 R 20120701 K0738 9 PORTABLE GASEOUS OXYGEN SYSTEM MP Y 2 00 20 R K0740 9 REPAIR OR NONROUTINE SERVICE FOR OXY MP R K0741 7 "PORTABLE GASEOUS OXYGEN SYSTEM, RENT" MP Y 00 20 R K0742 9 "PORTABLE OXYGEN CONTENTS, GASEOUS, 1" MP Y 00 20 R K0743 9 "SUCTION PUMP, HOME MODEL, PORTABLE, " MP Y R K0744 9 ABSORPTIVE WOUND DRESSING FOR USE WI MP Y R K0745 9 ABSORPTIVE WOUND DRESSING FOR USE WI MP Y R K0746 9 ABSORPTIVE WOUND DRESSING FOR USE WI MP Y R K0813 9 "POWER WHEELCHAIR, GROUP 1 STANDARD, " MP Y 2 R K0814 7 "POWER WHEELCHAIR, GROUP 1 STANDARD " 305.61 Y 2 R 20130401 K0814 9 "POWER WHEELCHAIR, GROUP 1 STANDARD, " MP Y 2 R K0815 9 "POWER WHEELCHAIR, GROUP 1 STANDARD, " MP Y 2 R K0816 9 "POWER WHEELCHAIR, GROUP 1 STANDARD, " MP Y 2 R K0820 9 "POWER WHEELCHAIR, GROUP 2 STANDARD, " MP Y 2 R K0821 9 "POWER WHEELCHAIR, GROUP 2 STANDARD, " MP Y 2 R K0822 9 "POWER WHEELCHAIR, GROUP 2 STANDARD, " MP Y 2 R K0823 7 "POWER WHEELCHAIR, GROUP 2 STANDARD " 367.85 Y 2 Y 20120701 K0823 9 "POWER WHEELCHAIR, GROUP 2 STANDARD, " MP Y 2 R K0824 9 "POWER WHEELCHAIR, GROUP 2 HEAVY DUTY" MP Y 2 R K0825 7 "POWER WHEELCHAIR, GROUP 2 HEAVY DUTY" 434.41 Y 2 R 20130401 K0825 9 "POWER WHEELCHAIR, GROUP 2 HEAVY DUTY" MP Y 2 R K0826 9 "POWER WHEELCHAIR, GROUP 2 VERY HEAVY" MP Y 2 R K0827 9 "POWER WHEELCHAIR, GROUP 2 VERY HEAVY" MP Y 2 R K0828 9 "POWER WHEELCHAIR, GROUP 2 EXTRA HEAV" MP Y 2 R K0829 9 "POWER WHEELCHAIR, GROUP 2 EXTRA HEAV" MP Y 2 R K0830 9 "POWER WHEELCHAIR, GROUP 2 STANDARD, " MP Y 2 R K0831 9 "POWER WHEELCHAIR, GROUP 2 STANDARD, " MP Y 2 R K0835 9 "POWER WHEELCHAIR, GROUP 2 STANDARD, " MP Y 2 R K0836 9 "POWER WHEELCHAIR, GROUP 2 STANDARD, " MP Y 2 R K0837 9 "POWER WHEELCHAIR, GROUP 2 HEAVY DUTY" MP Y 2 R K0838 9 "POWER WHEELCHAIR, GROUP 2 HEAVY DUTY" MP Y 2 R K0839 9 "POWER WHEELCHAIR, GROUP 2 VERY HEAVY" MP Y 2 R K0840 9 "POWER WHEELCHAIR, GROUP 2 EXTRA HEAV" MP Y 2 R K0841 9 "POWER WHEELCHAIR, GROUP 2 STANDARD, " MP Y 2 R K0842 9 "POWER WHEELCHAIR, GROUP 2 STANDARD, " MP Y 2 R K0843 9 "POWER WHEELCHAIR, GROUP 2 HEAVY DUTY" MP Y 2 R K0848 9 "POWER WHEELCHAIR, GROUP 3 STANDARD, " MP Y 2 R K0849 9 "POWER WHEELCHAIR, GROUP 3 STANDARD, " MP Y 2 R K0850 9 "POWER WHEELCHAIR, GROUP 3 HEAVY DUTY" MP Y 2 R K0851 9 "POWER WHEELCHAIR, GROUP 3 HEAVY DUTY" MP Y 2 R K0852 9 "POWER WHEELCHAIR, GROUP 3 VERY HEAVY" MP Y 2 R K0853 9 "POWER WHEELCHAIR, GROUP 3 VERY HEAVY" MP Y 2 R K0854 9 "POWER WHEELCHAIR, GROUP 3 EXTRA HEAV" MP Y 2 R K0855 9 "POWER WHEELCHAIR, GROUP 3 EXTRA HEAV" MP Y 2 R K0856 9 "POWER WHEELCHAIR, GROUP 3 STANDARD, " MP Y 2 R K0857 9 "POWER WHEELCHAIR, GROUP 3 STANDARD, " MP Y 2 R K0858 9 "POWER WHEELCHAIR, GROUP 3 HEAVY DUTY" MP Y 2 R K0859 9 "POWER WHEELCHAIR, GROUP 3 HEAVY DUTY" MP Y 2 R K0860 9 "POWER WHEELCHAIR, GROUP 3 VERY HEAVY" MP Y 2 R K0861 9 "POWER WHEELCHAIR, GROUP 3 STANDARD, " MP Y 2 R K0862 9 "POWER WHEELCHAIR, GROUP 3 HEAVY DUTY" MP Y 2 R K0863 9 "POWER WHEELCHAIR, GROUP 3 VERY HEAVY" MP Y 2 R K0864 9 "POWER WHEELCHAIR, GROUP 3 EXTRA HEAV" MP Y 2 R K0868 9 "POWER WHEELCHAIR, GROUP 4 STANDARD, " MP Y 2 R K0869 9 "POWER WHEELCHAIR, GROUP 4 STANDARD, " MP Y 2 R K0870 9 "POWER WHEELCHAIR, GROUP 4 HEAVY DUTY" MP Y 2 R K0871 9 "POWER WHEELCHAIR, GROUP 4 VERY HEAVY" MP Y 2 R K0877 9 "POWER WHEELCHAIR, GROUP 4 STANDARD, " MP Y 2 R K0878 9 "POWER WHEELCHAIR, GROUP 4 STANDARD, " MP Y 2 R K0879 9 "POWER WHEELCHAIR, GROUP 4 HEAVY DUTY" MP Y 2 R K0880 9 "POWER WHEELCHAIR, GROUP 4 VERY HEAVY" MP Y 2 R K0884 9 "POWER WHEELCHAIR, GROUP 4 STANDARD, " MP Y 2 R K0885 9 "POWER WHEELCHAIR, GROUP 4 STANDARD, " MP Y 2 R K0886 9 "POWER WHEELCHAIR, GROUP 4 HEAVY DUTY" MP Y 2 R K0890 9 "POWER WHEELCHAIR, GROUP 5 PEDIATRIC," MP Y 2 R K0891 9 "POWER WHEELCHAIR, GROUP 5 PEDIATRIC," MP Y 2 R K0898 9 "POWER WHEELCHAIR, NOT OTHERWISE CLAS" MP Y 2 R K0899 9 "POWER MOBILITY DEVICE, NOT CODED BY " MP Y 2 R K0901 9 "KNEE ORTHOSIS (KO), SINGLE UPRIGHT, " 777.04 R 20150101 K0902 9 "KNEE ORTHOSIS (KO), DOUBLE UPRIGHT, " 754.45 R 20150101 L0113 9 "CRANIAL CERVICAL ORTHOSIS, TORTICOLL" MP R L0120 9 "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, " 16.54 R 20120701 L0130 9 "CERVICAL, FLEXIBLE, THERMOPLASTIC CO" 101.78 R 20120701 L0140 9 "CERVICAL, SEMI-RIGID, ADJUSTABLE (PL" 40.74 R 20120701 L0150 9 "CERVICAL, SEMI-RIGID, ADJUSTABLE MOL" 67.41 R 20120701 L0160 9 "CERVICAL, SEMI-RIGID, WIRE FRAME OCC" 130.27 R 20120701 L0170 9 "CERVICAL, COLLAR, MOLDED TO PATIENT " 426.7 R 20120701 L0172 9 "CERVICAL, COLLAR, SEMI-RIGID THERMOP" 87.91 R 20120701 L0174 9 "CERVICAL, COLLAR, SEMI-RIGID, THERMO" 171.37 R 20120701 L0180 9 NECK BR FORRESTER - NON SWIVEL POSTS 256.77 R 20120701 L0190 9 "CERVICAL, MULTIPLE POST COLLAR, OCCI" 332.51 R 20120701 L0200 9 "CERVICAL, MULTIPLE POST COLLAR, OCCI" 371.53 R 20120701 L0220 9 "THORACIC, RIB BELT, CUSTOM FABRICATE" 101.86 R 20120701 L0450 9 "TLSO, FLEXIBLE, PROVIDES TRUNK SUPPO" 108.41 R 20120701 L0455 9 "TLSO, FLEXIBLE, PROVIDES TRUNK SUPPO" 284.96 R 20140101 L0457 9 "TLSO, FLEXIBLE, PROVIDES TRUNK SUPPO" 845.12 R 20140101 L0460 9 "TLSO, TRIPLANAR CONTROL, MODULAR SEG" 673.29 R 20120701 L0464 9 TLSO 4MOD SACRO-SCAP PRE 996.97 R 20120701 L0467 9 "TLSO, SAGITTAL CONTROL, RIGID POSTER" 327.14 R 20140101 L0469 9 "TLSO, SAGITTAL-CORONAL CONTROL, RIGI" 378.75 R 20140101 L0472 9 TLSO RIGID FRAME HYPEREX PRE 277.61 R 20120701 L0482 9 TLSO RIGID LINED CUSTOM FAB 967.36 R 20120701 L0484 9 TLSO RIGID PLASTIC CUST FAB 1108.61 R 20120701 L0486 9 TLSO RIGID LINED CUST FAB TWO 1196.26 R 20120701 L0621 9 "SACROILIAC ORTHOSIS, FLEXIBLE, PROVI" 62.31 R 20120701 L0622 9 SIO FLEX PELVISACRAL CUSTOM 161.16 R 20120701 L0625 9 "LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES " 36.95 R 20120701 L0627 9 "LUMBAR ORTHOSIS, SAGITTAL CONTROL, W" 275.7 R 20120701 L0631 9 "LUMBAR-SACRAL ORTHOSIS, SAGITTAL CON" 688.54 R 20120701 L0633 9 "LUMBAR-SACRAL ORTHOSIS, SAGITTAL-COR" 192.33 R 20120701 L0639 9 "LUMBAR-SACRAL ORTHOSIS, SAGITTAL-COR" 814.86 R 20120701 L0641 9 "LUMBAR ORTHOSIS, SAGITTAL CONTROL, W" 64.05 R 20140101 L0642 9 "LUMBAR ORTHOSIS, SAGITTAL CONTROL, W" 337.75 R 20140101 L0643 9 "LUMBAR-SACRAL ORTHOSIS, SAGITTAL CON" 133.06 R 20140101 L0648 9 "LUMBAR-SACRAL ORTHOSIS, SAGITTAL CON" 843.52 R 20140101 L0649 9 "LUMBAR-SACRAL ORTHOSIS, SAGITTAL-COR" 235.62 R 20140101 L0650 9 "LUMBAR-SACRAL ORTHOSIS, SAGITTAL-COR" 998.24 R 20140101 L0651 9 "LUMBAR-SACRAL ORTHOSIS, SAGITTAL-COR" 998.24 R 20140101 L0700 9 CERVICAL-THORACIC-LUMBAR-SACRAL-ORTH 1280.15 R 20120701 L0710 9 "CTLSO, ANTERIOR-POSTERIOR-LATERAL-CO" 1379.04 R 20120701 L0810 9 "HALO PROCEDURES, CERVICAL HALO INCOR" 1708.47 R 20120701 L0820 9 "HALO PROCEDURES, CERVICAL HALO INCOR" 1441.19 R 20120701 L0830 9 SPINAL BR MILW SCOL BR W/HALO ATTACH 2309.12 R 20120701 L0970 9 "TLSO, CORSET FRONT " 90.69 R 20120701 L0972 9 "LSO, CORSET FRONT " 82.93 R 20120701 L0974 9 "TLSO, FULL CORSET " 125.38 R 20120701 L0976 9 "LSO, FULL CORSET " 117.4 R 20120701 L0978 9 AXILLARY CRUTCH EXTENSION 122.99 R 20120701 L0980 9 "PERONEAL STRAPS, PREFABRICATED, OFF-" 14.52 R 20120701 L0982 9 "STOCKING SUPPORTER GRIPS, PREFABRICA" 13.53 R 20120701 L0984 9 "PROTECTIVE BODY SOCK, PREFABRICATED " 37.87 R 20120701 L0999 9 ADD TO SPINAL ORTHOSIS NOS 882.83 R 20120701 L1000 9 CERVICAL-THORACIC-LUMBAR-SACRAL (CTL 1376.93 R 20120701 L1001 9 CERVICAL THORACIC LUMBAR SACRAL ORTH MP R L1010 9 ADDITIONS TO CERVICAL-THORACIC-LUMBA 49.32 R 20120701 L1020 9 ADDITIONS TO CTLSO OR SCOLIOSIS ORTH 68.35 R 20120701 L1025 9 "ADDITION TO CTLSO/SCOLIOSIS ORTHO,KY" 77.79 R 20120701 L1030 9 ADDITIONS TO CTLSO OR SCOLIOSIS ORTH 52.92 R 20120701 L1040 9 ADDITIONS TO CTLSO OR SCOLIOSIS ORTH 55.32 R 20120701 L1050 9 ADDITIONS TO CTLSO OR SCOLIOSIS ORTH 66.95 R 20120701 L1060 9 ADDITIONS TO CTLSO OR SCOLIOSIS ORTH 64.97 R 20120701 L1070 9 ADDITIONS TO CTLSO OR SCOLIOSIS ORTH 63.55 R 20120701 L1080 9 ADDITIONS TO CTLSO OR SCOLIOSIS ORTH 35.76 R 20120701 L1090 9 ADDITIONS TO CTLSO OR SCOLIOSIS ORTH 63.95 R 20120701 L1100 9 ADDITIONS TO CTLSO OR SCOLIOSIS ORTH 110.21 R 20120701 L1110 9 ADDITIONS TO CTLSO OR SCOLIOSIS ORTH 160.74 R 20120701 L1120 9 "ADDITIONS TO CTLSO OR SIO, SCOLIOSIS" 29.14 R 20120701 L1200 9 THORACIC-LUMBAR-SACAL-ORTHOSES (TLSO 1124.11 R 20120701 L1210 9 "ADDITIONS TO TLSO, (LOW PROFILE) LAT" 163.23 R 20120701 L1220 9 "ADDITIONS TO TLSO, (LOW PROFILE) ANT" 157.96 R 20120701 L1230 9 "ADDITIONS TO TLSO, (LOW PROFILE) MIL" 354.61 R 20120701 L1240 9 ADDIT.TO TLSO LUMBAR DEROTATION PAD 52.3 R 20120701 L1250 9 ADDIT.TO TLSO ANTERIOR ASIS PAD(LOW 50.75 R 20120701 L1260 9 "ADDIT.TO TLSO,ANTERIOR THORAC DEROTA" 51.06 R 20120701 L1270 9 "ADDIT.TO TLSO,ABDOMINAL PAD(LOW RROF" 49.08 R 20120701 L1280 9 "ADDIT.TO TLSO,RIB GUSSET(ELASTIC),EA" 53.81 R 20120701 L1290 9 "ADDIT.TO TLSO,LATERAL TROCHANTERIC P" 49.03 R 20120701 L1300 9 "OTHER SCOLIOSIS PROCEDURES, BODY JAC" 1201.12 R 20120701 L1310 9 "OTHER SCOLIOSIS PROCEDURES, POST-OPE" 1157.07 R 20120701 L1499 9 UNLISTED PROCEDURE SPINAL ORTHOSIS MP R L1600 9 "HIP ORTHOSIS, ABDUCTION CONTROL OF H" 107.18 R 20120701 L1610 9 "HIP ORTHOSIS, ABDUCTION CONTROL OF H" 28.39 R 20120701 L1620 9 "HIP ORTHOSIS, ABDUCTION CONTROL OF H" 83.58 R 20120701 L1630 9 "HO, ABDUCTION CONTROL OF HIP JOINTS," 105.7 R 20120701 L1640 9 "HO, ABDUCTION CONTROL OF HIP JOINTS," 331.46 R 20120701 L1650 9 "HO, ABDUCTION CONTROL OF HIP JOINTS," 152.22 R 20120701 L1660 9 "HO, ABDUCTION CONTROL OF HIP JOINTS," 142.34 R 20120701 L1680 9 "HO, ABDUCTION CONTROL OF HIP JOINTS," 898.54 R 20120701 L1685 9 HO CUSTOM ABDUCTION CONTROL OF HIP J 742.02 R 20120701 L1686 9 HO ABDUCTION CONTROL OF HIP JOINT PO 569.05 R 20120701 L1690 9 "COMB BILATER, LUMBO-SACRAL, HIP, " 1296.99 R 20120701 L1700 9 "LEGG PERTHES ORTHOSIS, TORONTO TYPE " 1070.06 R 20120701 L1710 9 "LEGG PERTHES ORTHOSIS, NEWINGTON TYP" 1376 R 20120701 L1720 9 "LEGG PERTHES ORTHOSIS, TRILATERAL, (" 1020.77 R 20120701 L1730 9 "LEGG PERTHES ORTHOSIS, SCOTTISH RITE" 808.03 R 20120701 L1755 9 "LEG PERTHES ORTHOSIS,PATTEN BOTTOM T" 987.64 R 20120701 L1810 9 "KNEE ORTHOSIS, ELASTIC WITH JOINTS P" 66.72 R 20120701 L1812 9 "KNEE ORTHOSIS, ELASTIC WITH JOINTS, " 81.74 R 20140101 L1820 9 "KO, ELASTIC WITH CONDYLE PADS AND JO" 89.75 R 20120701 L1830 9 "KNEE ORTHOSIS, IMMOBILIZER, CANVAS L" 54.57 R 20120701 L1831 9 KNEE ORTH POS LOCKING JOINT 212.88 00 20 R 20120701 L1832 9 "KNEE ORTHOSIS, ADJUSTABLE KNEE JOINT" 379.25 R 20120701 L1833 9 "KNEE ORTHOSIS, ADJUSTABLE KNEE JOINT" 464.62 R 20140101 L1834 9 KO W/O KNEE JOINT RIGID MOLDED TO PA 484.23 R 20120701 L1840 9 "KO, DEROTATION, FABRICATED TO PATIEN" 704.79 R 20120701 L1843 9 "KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH" 601.8 R 20120701 L1844 9 "KO, SINGLE UPRIGHT, THIGH AND CALF, " 1041.05 R 20120701 L1845 9 "KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH" 584.3 R 20120701 L1846 9 "KO,DBL UPRIGHT THIGH/CALF MOLDED TO " 721.58 R 20120701 L1847 9 "KNEE ORTHOSIS, DOUBLE UPRIGHT WITH A" 385.78 R 20120701 L1848 9 "KNEE ORTHOSIS, DOUBLE UPRIGHT WITH A" 472.59 R 20140101 L1850 9 "KNEE ORTHOSIS, SWEDISH TYPE, PRFABRI" 207.62 R 20120701 L1860 9 "KO, MODIFICATION OF SUPRACONDYLAR PR" 682.23 R 20120701 L1900 9 "SHORT LEG BRACE, SPRING WIRE " 216.12 R 20120701 L1902 9 "ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET " 66.4 R 20120701 L1904 9 "ANKLE ORTHOSIS, ANKLE GAUNTLET, CUST" 293.35 R 20120701 L1906 9 "ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS" 75.02 R 20120701 L1907 9 "ANKLE ORTHOSIS, SUPRAMALLEOLAR WITH " 377.41 R 20120701 L1910 9 "SHORT LEG BRACE, SINGLE UPRIGHT PERL" 187.94 R 20120701 L1920 9 "AFO,SINGLE UPRIGHT WITH STATIC OR A " 225.81 R 20120701 L1930 9 "AFO,CUSTOM FITTED, PLASTIC " 196.76 R 20120701 L1932 9 AFO RIG ANT TIB PREFAB TCF/= 598.51 R 20120701 L1940 9 "AFO,MOLDED TO PATIENT MODEL, PLASTI " 315.88 R 20120701 L1945 9 "AFO,PLASTIC FLOOR REACTION MOLDED TO" 577.47 R 20120701 L1950 9 "AFO,SPIRAL, MOLDED TO PATIENT MODEL " 466.25 R 20120701 L1960 9 "AFO,POSTERIOR SOLID ANKLE, MOLDED T " 345.77 R 20120701 L1970 9 "AFO,PLASTIC MOLDED TO PATIENT MODEL " 443.89 R 20120701 L1971 9 "AFO W/ANKLE JOINT, PREFAB " 314.38 R 20120701 L1980 9 "AFO,SINGLE UPRIGHT FREE PLANTAR DOR " 239.32 R 20120701 L1990 9 SHT LEG BR 2 BAR UP-RIGHT LOWER LEG 278.07 R 20120701 L2000 9 "KNEE-ANKLE-FOOT-ORTHOSES (KAFO), SIN" 632.73 R 20120701 L2005 9 "KNEE ANKLE FOOT ORTHOSIS, ANY MATERI" 2748.37 R 20120701 L2010 9 "KAFO, SINGLE UPRIGHT, FREE KNEE, FRE" 617.87 R 20120701 L2020 9 "KAFO, DOUBLE UPRIGHT, FREE KNEE, FRE" 728.39 R 20120701 L2030 9 "LONG LEG BRACE, FULL-LENGTH W/O KNEE" 638.91 R 20120701 L2035 9 KAFO PLASTIC PEDIATRIC SIZE 116.19 R 20120701 L2036 9 KAFO FULL PLASTIC MOLDED TO PT.MODEL 1216.15 R 20120701 L2037 9 KAFO PLASTIC SINGLE WPRIGHT FREE KNE 1039.03 R 20120701 L2038 9 KAFO PLASTIC W/O KNEE JOINT MULTI AX 891.89 R 20120701 L2040 9 "HIP-KNEE-ANKLE-FOOT, ORTHOSES TORSIO" 110.75 R 20120701 L2050 9 "HKAFO, TORSION CONTROL, BILATERAL TO" 352.5 R 20120701 L2060 9 "HKAFO, TORSION CONTROL, BILATERAL TO" 407.83 R 20120701 L2070 9 "HKAFO, TORSION CONTROL, UNILATERAL R" 84.51 R 20120701 L2080 9 "HKAFO, TORSION CONTROL, UNILATERAL, " 239.75 R 20120701 L2090 9 "HKAFO, TORSION CONTROL, UNILATERAL T" 290.55 R 20120701 L2106 9 "AFO,FRACTURE ORTHOSIS TIBIAL THERMOP" 522 R 20120701 L2108 9 "AFO,FRACTURE ORTHOSIS,TICIAL MOLD TO" 725.22 R 20120701 L2112 9 "AFO,TIBIAL FRACTURE ORTHOSIS-SOFT EU" 353.33 R 20120701 L2114 9 "AFO,FRACTURE ORTHOSIS TIBIAL SEMI RI" 409.03 R 20120701 L2116 9 "AFO,TIBIAL FRACTURE ORTHO.RIGID CUST" 490.04 R 20120701 L2126 9 KAFO FRACTURE ORTHOSIS MOLDED TP PAT 746.99 R 20120701 L2128 9 "KAFO,FEMORAL FRACTURE CAST ORTHO.MOL" 1069.68 R 20120701 L2132 9 "SOFT CUST.FIT,KAFO-FEMORAL FRACTURE " 567.69 R 20120701 L2134 9 KAFO FRACTURE ORTHOSIS FEMORAL FRACT 710.02 R 20120701 L2136 9 "KAFO,FEMORAL FRACTURE CAST RIGID CUS" 803.85 R 20120701 L2180 9 "AFO,FRACTURE ORTHOSIS TIBIAL FRACTUR" 97.41 R 20120701 L2182 9 ADD TO LOW EXTREMITY FX ORTH DROP LO 71.56 R 20120701 L2184 9 "LIMITED MOTION KNEE JOINT,ADDIT.TO L" 92.97 R 20120701 L2186 9 "ADJ.MOTION KNEE JOINT,ADDIT.TO LOWER" 93.92 R 20120701 L2188 9 QUADRILATERAL BRIM-ADDIT.TO LOWER EX 218.53 R 20120701 L2190 9 WAIST BELT-ADDIT.TO LOWER ESTREM.FRA 62.45 R 20120701 L2192 9 "HIP JOINT,PELVIC BAND.FLANGE,PELVIC " 246.04 R 20120701 L2200 9 "ADDITIONS TO LOWER EXTREMITY, LIMITE" 39.54 R 20120701 L2210 9 "ADDITIONS TO LOWER EXTREMITY, DORSIF" 41.94 R 20120701 L2220 9 "ADDITIONS TO LOWER EXTREMITY, DORSIF" 54.5 R 20120701 L2230 9 "ADDITIONS TO LOWER EXTREMITY, SPLIT " 50.36 R 20120701 L2240 9 "ADDITIONS TO LOWER EXTREMITY, ROUND " 52.17 R 20120701 L2250 9 "ADDITIONS TO LOWER EXTREMITY, FOOT P" 221.66 R 20120701 L2260 9 "ADDITIONS TO LOWER EXTREMITY, REINFO" 129.04 R 20120701 L2265 9 ADDITION TO LOWER EXTREMITY LONG TON 97.96 R 20120701 L2270 9 "ADDITIONS TO LOWER EXTREMITY, VARUS/" 33.49 R 20120701 L2275 9 "ADDITION TO LOWER EXT,VARUS/VALGUS C" 81.51 R 20120701 L2280 9 "ADDITIONS TO LOWER EXTREMITY, MOLDED" 282.47 R 20120701 L2300 9 "ADDITIONS TO LOWER EXTREMITY, ABDUCT" 223.94 R 20120701 L2310 9 "ADDITIONS TO LOWER EXTREMITY,ABDUC " 102.32 R 20120701 L2320 9 BRACE; LONG BOWLEG OR KNOCK-KNEE 140.02 R 20120701 L2330 9 "ADDITIONS TO LOWER EXTREMITY, LACER " 259.61 R 20120701 L2335 9 ANTERIOR SWING BAND-ADDIT.TO LOWER E 141.72 R 20120701 L2340 9 "ADDITIONS TO LOWER EXTREMITY, PRE-T " 345.73 R 20120701 L2350 9 "ADDITIONS TO LOWER EXTREMITY, PROSTH" 592.31 R 20120701 L2360 9 "ADDITIONS TO LOWER EXTREMITY, EXTEN " 43.03 R 20120701 L2370 9 PATTEM BOTTOM-ADDIT TO LOWER EXTREMI 183.07 R 20120701 L2375 9 "TORSON CTRL,ANKLE JOINT/HALF SOL STI" 93.97 R 20120701 L2380 9 "TORSION CTRL,STRAIGHT KNEE JOINT,ADD" 102.4 R 20120701 L2385 9 ADDITION TO LOWER EXTREMITY STRAIGHT 107.87 R 20120701 L2390 9 ADDITION TO LOWER EXTREMITY OFFSET K 68.28 R 20120701 L2395 9 ADDITION TO LOWER EXTREMITY OFFSET K 130.14 R 20120701 L2397 9 "ADDITION TO LOWER EXT,SUSPENSION SLE" 73.1 R 20120701 L2405 9 "DROP LOCK,EACH JOINT ADD TO STRAIGHT" 58.47 R 20120701 L2415 9 "ADD.TO KNEE JOINT,CAM LOCK,EA.JOINT " 81.47 R 20120701 L2425 9 "ADD.TO KNEE JOINT,DISC/DIAL LOCK FOR" 96.14 R 20120701 L2430 9 "LONG LEG BRACES FOR HEMOPHILIACS, BI" 96.14 R 20120701 L2492 9 ADDITION TO LOWER EXTREMITY OFFSET K 71 R 20120701 L2500 9 "ADDITIONS LOWER EXTREMITY BRACE,RING" 229.47 R 20120701 L2510 9 "ADDITIONS TO LOWER EXTREMITY, THIGH/" 520.49 R 20120701 L2520 9 "ADDITIONS TO LOWER EXTREMITY, THIGH/" 328.57 R 20120701 L2525 9 ADD TO LOWER EXTREMITY THIGH/WEIGHT 760.42 R 20120701 L2526 9 ADD TO LOWER EXTREMITY CUSTOM FITTED 427.28 R 20120701 L2530 9 "ADDITION/LOWER EXTREMITY BRACE,LACER" 147.77 R 20120701 L2540 9 "ADDITIONS TO LOWER EXTREMITY, THIGH/" 280.54 R 20120701 L2550 9 "ADDITIONS TO LOWER EXTREMITY, THIGH/" 179.17 R 20120701 L2570 9 "ADDITIONS TO LOWER EXTREMITY, GLUTEA" 396.17 R 20120701 L2580 9 ADDS TO LOWER EXT.BRACE PELVIC SLING 289.52 R 20120701 L2600 9 "ADDITIONS TO LOWER EXTREMITY, PELVIC" 170.82 R 20120701 L2610 9 "ADDITIONS TO LOWER EXTREMITY, PELVIC" 201.98 R 20120701 L2620 9 "LONG LEG BRACE; PELVIC BAND, REG. HI" 195.16 R 20120701 L2622 9 "PELVIC CTRL,HIP JOINT,ADJ.FLEX-ADD T" 255.06 R 20120701 L2624 9 "PELVIC CTRL,HIP JOINT,ADJ.FLEX EXT A" 221.81 R 20120701 L2627 9 ADD TO LOWER EXTREMITY PELVIC CONTRO 1069.39 R 20120701 L2628 9 ADD TO LOWER EXTREMITY PELVIC CONTRO 1045.14 R 20120701 L2630 9 "ADDITIONS TO LOWER EXTREMITY, PELVIC" 182.66 R 20120701 L2640 9 BRACE; PELVIC BAND W/ BALL-BEARING J 240.13 R 20120701 L2650 9 COVERED ATTACHMENTS TO BRACES; PELVI 90.18 R 20120701 L2660 9 "ADDITIONS TO LOWER EXTREMITY, THORAC" 140.42 R 20120701 L2670 9 ATTACHMENT TO BRACE; SHOULDER HARNES 141.89 R 20120701 L2680 9 "ADDITIONS TO LOWER EXTREMITY, THORAC" 130.16 R 20120701 L2750 9 ADDITION TO LOWER EXTREMITY ORTHOSES 68.56 R 20120701 L2755 9 CARBON GRAPHITE LAMINATION 87.65 R 20120701 L2760 9 ADDITIONS TO LOWER EXTREMITY ORTHOSE 50.54 R 20120701 L2768 9 ORTHO SIDEBAR DISCONNECT 102.68 R 20120701 L2780 9 "ADDITIONS TO LOWER EXTREMITY, NON-CO" 42.21 R 20120701 L2785 9 "ADD.TO LOWER EXTREM.ORTH,DROP LOCK R" 19.77 R 20120701 L2795 9 ADD TO LOWER EXTREMITY FULL KNEE CAP 61.08 R 20120701 L2800 9 "KNEE CTRL,KNEE CAP,MEDIAL/PULL ADDIT" 66.52 R 20120701 L2810 9 "KNEE CTRL,CONDYLAR PAD-ADD.TO LOW EX" 54.24 R 20120701 L2820 9 SOFT INTERFACE FOR MOLD PLASTIC KNEE 54.17 R 20120701 L2830 9 ADDIT.TO LOWER EXTREMITY-SOFT INTERF 58.61 R 20120701 L2840 9 ADD TO LOWER EXTREMITY ORTHOSIS EACH 36.33 R 20120701 L2850 9 ADD TO LOWER EXTREMITY ORTHOSIS EACH 41.55 R 20120701 L2861 9 "ADDITION TO LOWER EXTREMITY JOINT, K" MP R L2999 9 UNLISTED PROCEDURES FOR LOWER EXTREM MP R L3000 7 "FOOT,INSERT,REMOVEABLE,MOLDED TO P " 105.94 1 R 20120701 L3000 9 "FOOT, INSERT, REMOVABLE, MOLDED TO P" 210.69 R 20120701 L3001 7 "FOOT,INSERT,REMOVABLE,MOLDED TO " 53.86 1 R 20120701 L3001 9 "FOOT, INSERT, REMOVABLE, MOLDED TO " 88.69 R 20120701 L3002 7 "FOOT,INSERT,REMOVABLE,MOLDED TO " 46.79 1 R 20120701 L3002 9 "FOOT, INSERT, REMOVABLE, MOLDED TO " 108.32 R 20120701 L3003 7 "FOOT,INSERT,REMOVABLE,MOLDED TO " 46.79 1 R 20120701 L3003 9 "FOOT, INSERT, REMOVABLE, MOLDED TO " 116.86 R 20120701 L3010 7 "FOOT,INSERTM REMOVABLE,MOLDED TO P " 53.86 1 R 20120701 L3010 9 "FOOT, INSERT, REMOVABLE, MOLDED TO P" 116.86 R 20120701 L3020 7 "FOOT,INSERT,REMOVABLE MOLDED TO P " 53.86 1 R 20120701 L3020 9 "FOOT, INSERT, REMOVABLE, MOLDED TO P" 133.06 R 20120701 L3030 7 "FOOT,INSERT,REMOVABLE FORMED TO P " 53.86 1 R 20120701 L3030 9 "FOOT, INSERT, REMOVABLE, FORMED TO P" 53.86 R 20120701 L3040 7 "FOOT,ARCH SUPPORT,REMOVABLE,PREMO " 53.86 1 R 20120701 L3040 9 "FOOT, ARCH SUPPORT, REMOVABLE, PREMO" 53.86 R 20120701 L3050 7 "FOOT,ARCH SUPPORT,REMOVABLE,PREMO " 53.86 1 R 20120701 L3050 9 "FOOT, ARCH SUPPORT, REMOVABLE, PREMO" 53.86 R 20120701 L3060 7 "FOOT,ARCH SUPPORT,REMOVABLE,PREMO " 53.86 1 R 20120701 L3060 9 "FOOT, ARCH SUPPORT, REMOVABLE, PREMO" 53.86 R 20120701 L3070 7 "FOOT,ARCH SUPPORT,NON-REMOVABLE AT " 7.95 1 R 20120701 L3070 9 "FOOT, ARCH SUPPORT, NON-REMOVABLE AT" 21.32 R 20120701 L3080 7 METATARSAL PAD 7.95 1 R 20120701 L3080 9 METATARSAL PAD 21.32 R 20120701 L3090 7 "FOOT, ARCH SUPPORT, NONREMOVABLE AT " 7.95 1 R 20120701 L3090 9 "FOOT, ARCH SUPPORT, NON-REMOVABLE AT" 27.31 R 20120701 L3100 7 "HALLUS-VALGUS NIGHT DYNAMIC SPLINT, " 21.62 1 R 20120701 L3100 9 "HALLUS-VALGUS NIGHT DYNAMIC SPLINT, " 29 R 20120701 L3140 9 "FOOT, ABDUCTION ROTATION BARS (DENNI" 59.72 R 20120701 L3150 9 "FOOT, ABDUCTION ROTATION BARS (DENNI" 54.59 R 20120701 L3160 7 "FOOT, TORQUE HEELS " 61.8 1 R 20120701 L3160 9 "FOOT, TORQUE HEELS " MP R L3170 7 "FOOT, PLASTIC, SILICONE OR EQUAL, HE" 44.14 1 R 20120701 L3170 9 "FOOT, PLASTIC, SILICONE OR EQUAL, HE" 44.14 R 20120701 L3201 9 "ORTHOPEDIC SHOE, OXFORD WITH SUPINA " 44.14 1 R 20120701 L3202 9 "ORTHOPEDIC SHOE, OXFORD WITH SUPINA " 44.14 1 R 20120701 L3203 9 "ORTHOPEDIC SHOE, OXFORD WITH SUPINA " 44.14 1 R 20120701 L3204 9 "ORTHOPEDIC SHOE, HIGHTOP WITH SUPIN " 44.14 1 R 20120701 L3206 9 "ORTHOPEDIC SHOE, HIGHTOP WITH SUPIN " 44.14 1 R 20120701 L3207 9 "ORTHOPEDIC SHOE, HIGHTOP WITH SUPIN " 44.14 1 R 20120701 L3208 9 "SURGICAL BOOT, EACH, INFANT " 60.03 1 R 20120701 L3209 9 "SURGICAL BOOT, EACH, CHILD " 60.03 1 R 20120701 L3211 9 "SURGICAL BOOT, EACH, JUNIOR " 60.03 1 R 20120701 L3212 9 "BENESCH BOOT,INFANT,PAIR " 88.29 1 R 20120701 L3213 9 "BENESCH BOOT,CHILD,PAIR " 88.29 1 R 20120701 L3214 9 "BENESCH BOOT,JUNIOR,PAIR " 88.29 1 R 20120701 L3215 9 "ORTHOPEDIC FOOTWEAR, LADIES SHOES, O" 69.69 1 R 20120701 L3216 9 "ORTHOFOOTWEAR,LADIESSHOES DEPTHINLAY" 88.29 1 R 20120701 L3217 9 "ORTHOFOOTWEAR,LADIESHITOP DEPTHINLAY" 88.29 1 R 20120701 L3219 9 "ORTHOPEDICFOOTWEAR,MENS SHOES,OXFORD" 81.68 1 R 20120701 L3221 9 "ORTHOPEDIC FOOTWEAR, MENS SHOES, DE " 88.29 1 R 20120701 L3222 9 "ORTHOPEDIC FOOTWEAR, MENS SHOES, HI " 88.29 1 R 20120701 L3224 9 WOMAN'S SHOE OXFORD BRACE MP R L3225 9 MAN'S SHOE OXFORD BRACE MP R L3230 9 "ORTHOPEDIC FOOTWEAR, CUSTOM SHOES, D" 317.82 1 R 20120701 L3250 7 "ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED " 158.91 1 R 20120701 L3250 9 "ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED " 158.91 R 20120701 L3251 9 "FOOT, SHOE MOLDED TO PATIENT MODEL, " 158.91 1 R 20120701 L3252 9 "FOOT, SHOE MOLDED TO PATIENT MODEL, " 158.91 1 R 20120701 L3253 9 "FOOT, MOLDED SHOE PLASTAZOTE (OR SI " 158.91 1 R 20120701 L3254 9 NON-STANDARD SIZE OR WIDTH 57.39 1 R 20120701 L3255 9 NON-STANDARD SIZE OR LENGTH 57.39 1 R 20120701 L3260 9 "AMBULATORY SURGICAL BOOT, EACH " 60.03 1 R 20120701 L3265 9 "PLASTAZOTE SANDAL, EACH " 158.91 1 R 20120701 L3300 7 "LIFTS,ELEVATION,HEELTAPERED TO M " 12.36 1 R 20120701 L3300 9 "LIFTS, ELEVATION, HEEL, TAPERED TO M" 34.96 R 20120701 L3310 7 "LIFTS,ELEV,HEEL&SOLE,NEOPRENE,PERINC" 43.27 1 R 20120701 L3310 9 "LIFT,ELEV,HEEL&SOLE,NEOPRENE,PERINCH" 54.59 R 20120701 L3320 7 "SHOE EXTENSION, CORK " 43.27 1 R 20120701 L3320 9 "SHOE EXTENSION, CORK " 81.66 R 20120701 L3330 9 "SHOE EXTENSION, METAL " 379.59 R 20120701 L3332 7 "LIFT,ELEV,IN SHOE TAPERED,UP TO 1/2I" 81.66 1 R 20120701 L3332 9 "LIFT,ELEV,IN SHOE,TAPERED,UPTO 1/2IN" 51.2 R 20120701 L3334 7 "LIFTS,ELEVATION,HEL PER INCH " 12.36 1 R 20120701 L3334 9 "LIFTS, ELEVATION, HEEL, PER INCH " 25.59 R 20120701 L3340 7 "HEEL WEDGE,SACH " 9.72 1 R 20120701 L3340 9 "HEEL WEDGE, SACH " 57.15 R 20120701 L3350 7 HEEL WEDGE 9.72 1 R 20120701 L3350 9 HEEL WEDGE 15.33 R 20120701 L3360 7 "SOLE WEDGE,OUTSIDE SOLE " 9.72 1 R 20120701 L3360 9 "SOLE WEDGE, OUTSIDE SOLE " 23.88 R 20120701 L3370 7 "SOLE WEDGE,BETWEEN SOLE " 9.72 1 R 20120701 L3370 9 "SOLE WEDGE, BETWEEN SOLE " 33.25 R 20120701 L3380 7 CLUBFOOT WEDGE 9.72 1 R 20120701 L3380 9 CLUBFOOT WEDGE 33.25 R 20120701 L3390 7 OUTFLARE WEDGE 9.72 1 R 20120701 L3390 9 OUTFLARE WEDGE 33.25 R 20120701 L3400 7 "METATARSAL BAR WEDGE,ROCKER " 16.78 1 R 20120701 L3400 9 "METATARSAL BAR WEDGE, ROCKER " 27.31 R 20120701 L3410 9 "METATARSAL BAR WEDGE, BETWEEN SOLE " 62.29 1 R 20120701 L3420 9 "FULL SOLE AND HEEL WEDGE, BETWEEN SO" 65.77 1 R 20120701 L3430 9 "HEEL, COUNTER, PLASTIC REINFORCED " 107.49 1 R 20120701 L3440 9 "HEEL, COUNTER, LEATHER REINFORCED " 65.77 1 R 20120701 L3450 7 "HEEL, SAC CUSHION TYPE " 65.77 1 R 20120701 L3450 9 "HEEL, SACH CUSHION TYPE " 70.78 R 20120701 L3455 7 "HEEL, NEW LEATHER,STANDARD " 65.81 1 R 20120701 L3455 9 "HEEL, NEW LEATHER, STANDARD " 65.77 R 20120701 L3460 7 "HEEL, NEW RUBBER,STANDARD " 65.77 1 R 20120701 L3460 9 "HEEL, NEW RUBBER, STANDARD " 65.77 R 20120701 L3465 7 "HEEL,THOMAS WITH EDGE " 7.95 1 R 20120701 L3465 9 "HEEL, THOMAS WITH WEDGE " 39.23 R 20120701 L3470 7 "HEE, THOMAS EXTENDED TO BALL " 7.95 1 R 20120701 L3470 9 "HEEL, THOMAS EXTENDED TO BALL " 41.79 R 20120701 L3480 7 "HEEL,PAD AND DEPRESSION FOR SPUR " 65.77 1 R 20120701 L3480 9 "HEEL, PAD AND DEPRESSION FOR SPUR " 65.77 R 20120701 L3485 7 "HEEL, PAD REMOVABLE FOR SPUR " 65.77 1 R 20120701 L3485 9 "HEEL, PAD, REMOVABLE FOR SPUR " 65.77 R 20120701 L3500 7 "MISCELLANEOUS SHOE ADDITIONS, INSOLE" 65.77 1 R 20120701 L3500 9 "MISCELLANEOUS SHOE ADDITIONS, INSOLE" 65.77 R 20120701 L3510 7 "MISCELLANEOUS SHOE ADDITIONS, INSOLE" 65.77 1 R 20120701 L3510 9 "MISCELLANEOUS SHOE ADDITIONS, INSOLE" 65.77 R 20120701 L3520 7 "MISCELLANEOUS SHOE ADDITIONS, INSOLE" 65.77 1 R 20120701 L3520 9 "MISCELLANEOUS SHOE ADDITIONS, INSOLE" 65.77 R 20120701 L3530 9 "MISCELLANEOUS SHOE ADDITIONS, SOLE, " 65.77 R 20120701 L3540 7 "MISCELLANEOUS SHOE ADDITIONS, SOLE " MP R L3540 9 "MISCELLANEOUS SHOE ADDITIONS, SOLE, " 65.77 R 20120701 L3550 7 "MISCELLANEOUS SHOE ADDITIONS, TOE TA" 2.66 1 R 20120701 L3550 9 "MISCELLANEOUS SHOE ADDITIONS, TOE TA" 5.97 R 20120701 L3560 7 "MISCELLANEOUS SHOE ADDITIONS, TOE,TA" 2.66 1 R 20120701 L3560 9 "MISCELLANEOUS SHOE ADDITIONS, TOE TA" 15.33 R 20120701 L3570 7 "MISCELLANEOUS SHOE ADDITIONS, SPECIA" 65.77 1 R 20120701 L3570 9 "MISCELLANEOUS SHOE ADDITIONS, SPECIA" 65.77 R 20120701 L3580 7 "MISCELLANEOUS SHOE ADDITIONS,CONVER " MP 1 R L3580 9 "MISCELLANEOUS SHOE ADDITIONS, CONVER" 65.77 R 20120701 L3590 7 "MISCELLANEOUS SHOE ADDITIONS, CONVER" 65.77 1 R 20120701 L3590 9 "MISCELLANEOUS SHOE ADDITIONS, CONVER" 65.77 R 20120701 L3595 7 "MISCELLANEOUS SHOE ADDITIONS, MARCH " 65.77 1 R 20120701 L3595 9 "MISCELLANEOUS SHOE ADDITIONS, MARCH " 65.77 R 20120701 L3600 7 "TRANS ORTHO,1 SHOE-ANOTHER,CALIPER P" 26.48 1 R 20120701 L3600 9 "TRANS ORTHO,1SHOE-ANOTHER,CALIPER PL" 51.16 R 20120701 L3610 7 "TRANS ORTHO,1 SHOE-ANOTHER,CALIPER P" 26.48 1 R 20120701 L3610 9 "TRANS ORTHO,1SHOE-ANOTHER,CALIPER PL" 67.39 R 20120701 L3620 7 TRANSFERS OF AN ORTHOSIS FROM ONE SH 26.48 1 R 20120701 L3620 9 TRANSFERS OF AN ORTHOSIS FROM ONE SH 51.16 R 20120701 L3630 7 "TRANS ORTHO,1 SHOE-ANOTHER,SOLID STI" 26.48 1 R 20120701 L3630 9 "TRANS ORTHO,1SHOE-ANOTHER,SOLID STIR" 67.39 R 20120701 L3640 9 TRANSFERS OF AN ORTHOSIS FROM ONE SH 29 R 20120701 L3649 9 UNLISTED PROCEDURES FOR FOOT ORTHOPE MP 1 R L3650 9 "SHOULDER ORTHOSIS, FIGURE OF EIGHT D" 39.67 R 20120701 L3670 9 "SHOULDER ORTHOSIS, FIGURE OF EIGHT D" 71.67 R 20120701 L3710 9 "ELBOW ORTHOSIS, ELASTIC WITH METAL J" 90.68 R 20120701 L3720 9 "EO, DOUBLE UPRIGHT WITH FOREARM/ARM " 463.15 R 20120701 L3730 9 "EO, DOUBLE UPRIGHT WITH FOREARM/ARM " 677.44 R 20120701 L3740 9 "EO, DOUBLE UPRIGHT WITH FOREARM/ARM " 869.87 R 20120701 L3760 9 "EO WITHJOINT, PREFABRICATED " 305.27 R 20120701 L3763 9 "UPPEREXTREMITY FRACTURE ORTHOSIS, C " 371.81 R 20120701 L3764 9 UPPER EXTREM FRAC OTHO FOREARM HAND 356.78 R 20120701 L3806 9 "WRIST HAND FINGER ORTHOSIS, INCLUDES" MP R L3807 9 "WRIST HAND FINGER ORTHOSIS, WITHOUT " 152.64 R 20120701 L3808 9 "WRIST HAND FINGER ORTHOSIS, RIGID WI" MP R L3809 9 "WRIST HAND FINGER ORTHOSIS, PREFABRI" 187 R 20140101 L3891 9 "ADDITION TO UPPER EXTREMITY JOINT, W" MP R L3900 9 HAND SPLINT 797.92 R 20120701 L3901 9 "WHFO, DYNAMIC FLEXOR HINGE, RECIPROC" 980.99 R 20120701 L3904 9 "WHFO, EXTERNAL POWERED, ELECTRIC " 1787.64 R 20120701 L3906 9 "WHFO, WRIST (GAUNTLET), MOLDED TO PA" 241.21 R 20120701 L3908 9 "WRIST HAND ORTHOSIS, WRIST EXTENSION" 36.57 R 20120701 L3912 9 "HAND FINGER ORTHOSIS (HFO), FLEXION " 76.09 R 20120701 L3915 9 "WRIST HAND ORTHOSIS, INCLUDES ONE OR" MP R L3916 9 "WHFO, WRIST EXTENSION (COCK-UP), WIT" 397.51 R 20140101 L3918 9 "HAND ORTHOSIS, METACARPAL FRAC ORTHO" 78.97 R 20140101 L3923 9 "HAND FINGER ORTHOSIS, WITHOUT JOINTS" 69.88 R 20120701 L3924 9 "HAND FINGER ORTHOSIS, WITHOUT JOINTS" 65.08 R 20140101 L3930 9 "HAND FINGER ORTHOSIS, INC NONTORSION" 68.78 R 20140101 L3956 9 ADD JOINT UPPER EXT ORTHOSIS MP R L3960 9 "SHOULDER-ELBOW-WRIST-HAND ORTHOSES, " 546.98 R 20120701 L3962 9 ERBS PALSY SPLINT 437.98 R 20120701 L3980 9 "UPPER EXTREMITY FRACTURE ORTHOSIS, H" 224.71 R 20120701 L3981 9 "UPPER EXTREMITY FRACTURE ORTHOSIS, H" 793.34 R 20150101 L3982 9 "UPPER EXTREMITY FRACTURE ORTHOSIS, R" 253.58 R 20120701 L3984 9 "UPPER EXTREMITY FRACTURE ORTHOSIS, W" 220.6 R 20120701 L3995 9 ADD TO UPPER EXTREMITY ORTHOSIS SOCK 26.04 R 20120701 L3999 9 UNLISTED PROCEDURES FOR UPPER LIMB O MP R L4000 9 REPLACE GIRDLE FOR MILWAUKEE ORTHOSI 840.57 R 20120701 L4010 9 REPLACE TRILATERAL SOCKET BRIM 429.58 R 20120701 L4020 9 "REPLACE QUADRILATERAL SOCKET BRIM, M" 628.2 R 20120701 L4030 9 "REPLACE QUADRILATERAL SOCKET BRIM, C" 410.82 R 20120701 L4040 9 REPLACE MOLDED THIGH LACER 267.75 R 20120701 L4045 9 REPLACE NON-MOLDED THIGH LACER 204.63 R 20120701 L4050 9 REPLACE MOLDED CALF LACER 257.54 R 20120701 L4055 9 REPLACE NON-MOLDED CALF LACER 169.88 R 20120701 L4060 9 REPLACE HIGH ROLL CUFF 198.24 R 20120701 L4070 9 REPLACE PROXIMAL AND DISTAL UPRIGHT 221 R 20120701 L4080 9 METAL THIGH BAND 63.09 R 20120701 L4090 9 BR REPAIR METAL CALF BAND 71.27 R 20120701 L4100 9 BR REPAIR LEATHER THIGH BAND 73.18 R 20120701 L4110 9 BR REPAIR LEATHER CALF BAND 58.54 R 20120701 L4130 9 REPLACE PRETIBIAL SHELL 360.71 R 20120701 L4205 9 ORTHO DVC REPAIR PER 15 MIN MP R L4210 9 "REPAIR OF ORTHOTIC DEVICE, REPAIR OR" MP R L4350 9 "ANKLE CONTROL ORTHOSIS, STIRRUP STYL" 57.35 R 20120701 L4360 9 "WALKING BOOT, PNEUMATIC AND/OR VACUU" 172.72 R 20120701 L4361 9 "WALKING BOOT, PNEUMATIC AND/OR VACUU" 211.61 R 20140101 L4370 9 "PNEUMATIC FULL LEG SPLINT, PREFABRIC" 117.76 R 20120701 L4386 9 "WALKING BOOT, NON-PNEUMATIC, WITH OR" 106.34 R 20120701 L4387 9 "WALKING BOOT, NON-PNEUMATIC, WITH OR" 130.28 R 20140101 L4392 9 REPLACE ANKLE CONTRAC SPLINT MP R L4394 9 REPLACE FOOT DROP SPINT MP R L4396 9 STATIC OR DYNAMIC ANKLE FOOT ORTHOSI 123.24 R 20150601 L4397 9 STATIC OR DYNAMIC ANKLE FOOT ORTHOSI 137.92 R 20140101 L4398 9 "FOOT DROP SPLINT, RECUMBENT POSITION" MP R L5000 9 "PARTIAL FOOT, SHOE INSERT WITH LONGI" 447.73 R 20120701 L5010 9 "PARTIAL FOOT, MOLDED SOCKET, ANKLE H" 1016.63 R 20120701 L5020 9 "PARTIAL FOOT, MOLDED SOCKET, TIBIAL " 1527.21 R 20120701 L5050 9 "ANKLE, SYMES, MOLDED SOCKET, SACH FO" 1922.55 R 20120701 L5060 9 "ANKLE, SYMES, METAL FRAME, MOLDED LE" 2172.37 R 20120701 L5100 9 "BELOW KNEE, MOLDED SOCKET, SHIN, SAC" 1889.2 R 20120701 L5105 9 B/K PLASTIC SOCKET SACH FOOT JOINTS 2308.8 R 20120701 L5150 9 KNEE DISARTICULATION (OR THROUGH KNE 2752.03 R 20120701 L5160 9 KNEE DISARTICULATION (OR THROUGH KNE 2895.47 R 20120701 L5200 9 "ABOVE KNEE MOLDED SOCKET, SINGLE AX " 2516.39 R 20120701 L5210 9 "ABOVE KNEE SHORT PROSTHESIS, NO KNE " 1860.01 R 20120701 L5220 9 "ABOVE KNEE SHORT PROSTHESIS, NO KNE " 2336.74 R 20120701 L5230 9 ABOVE KNEE FOR PROXIMAL FEMORAL FOC 2769.69 R 20120701 L5250 9 "HIP DISARTICULATION, CANADIAN TYPE; " 3749.63 R 20120701 L5270 9 "HIP DISARTICULATION, TILT TABLE TYPE" 3562.91 R 20120701 L5280 9 "HEMIPELVECTOMY, CANADIAN TYPE; MOLDE" 3878.42 R 20120701 L5301 9 "BELOW KNEE, MOLDED SOCKET, SACH FOOT" 1832.91 R 20120701 L5311 9 "KNEE DISART, SACH FT, ENDO " 2446.41 R 20120701 L5312 9 KNEE DISARTICULATION (OR THROUGH KNE 2289.59 R 20120701 L5321 9 ENDOSKELETAL ALK/W FOAM BODY 2557.17 R 20120701 L5331 9 HIP DISART CANADIAN SACH FT 3849.75 R 20120701 L5500 9 "PREPARATORY, BELOW KNEE (""PTB"" (TYPE" 953.73 R 20120701 L5505 9 "PREPARATORY, ABOVE KNEE DISARTICULAT" 1541.26 R 20120701 L5510 9 "PREPARATORY, BELOW KNEE (""PTB"" (TYPE" 1133.85 R 20120701 L5520 9 "PREPARATORY, BELOW KNEE, (""PTB"" (TYP" 1274.3 R 20120701 L5530 9 "PREPARATORY, BELOW KNEE (""PTB"" (TYPE" 1316.93 R 20120701 L5535 9 PREP B/K PTB SOCKET USMC SACH FOOT 1319.5 R 20120701 L5540 9 "PREPARATORY, BELOW KNEE (""PTB"" (TYPE" 1414.76 R 20120701 L5560 9 "PREPARATORY, ABOVE KNEE, DISARTICULA" 1701.49 R 20120701 L5570 9 "PREPARATORY, ABOVE KNEE, DISARTICULA" 1679.92 R 20120701 L5580 9 "PREPARATORY, ABOVE KNEE DISARTICULAT" 1875.76 R 20120701 L5585 9 KNEE DISART SACH FOOT ISCHIAL SOCKET 1881.94 R 20120701 L5590 9 "PREPARATORY, ABOVE KNEE DISARTICULAT" 1841.33 R 20120701 L5595 9 PREP HIP DISART-HEMIPEL SACH MOLDED 2676.02 R 20120701 L5600 9 PREP HIP DISART-HEMIPEL SACH LAMINAT 2955.12 R 20120701 L5610 9 "ADDITIONS TO LOWER EXTREMITY, ABOVE " 1594.74 R 20120701 L5611 9 ADD TO LOWER EXTREMITY A/K W/FRICTIO 1070.79 R 20120701 L5613 9 ADD TO LOWER EXTREMITY A/K HYDRAULIC 1649.33 R 20120701 L5614 9 "ADDITION TO LOWER EXT, AK DISARTICUL" 1133.98 R 20120701 L5616 9 "ADDITIONS TO LOWER EXTREMITY, ABOVE " 1203.5 R 20120701 L5617 9 AK/BK SELF-ALIGNING UNIT EA 375.98 R 20120701 L5618 9 "ADDITIONS TO LOWER EXTREMITY, TEST S" 200.78 R 20120701 L5620 9 BELOW KNEE ADD TEST SOCKETS 246.35 R 20120701 L5622 9 "ADDITIONS TO LOWER EXTREMITY, TEST S" 321.23 R 20120701 L5624 9 OPEN-END SOCKET FOR TEMP. A/K (WOOD) 322.16 R 20120701 L5626 9 "ADDITIONS TO LOWER EXTREMITY, TEST S" 353.78 R 20120701 L5628 9 "ADDITIONS TO LOWER EXTREMITY, TEST S" 381.8 R 20120701 L5629 9 BELOW KNEE ACRYLIC SOCKET ADD TEST S 281.61 R 20120701 L5630 9 "ADDITIONS TO LOWER EXTREMITY, SYMES " 343.77 R 20120701 L5631 9 ADD TO LOWER EXTREMITY A/K ACRYLIC 389.34 R 20120701 L5632 9 PLASTIC HARD SOCKET FOR PTB ENDOSKEL 147.57 R 20120701 L5634 9 "ADDITIONS TO LOWER EXTREMITY, SYMES " 202.16 R 20120701 L5636 9 "ADDITIONS TO LOWER EXTREMITY, SYMES " 169.34 R 20120701 L5637 9 ADD TO LOWER EXTREMITY B/K TOTAL COM 255.99 R 20120701 L5638 9 "ADDITIONS TO LOWER EXTREMITY, BELOW " 335.47 R 20120701 L5639 9 ADD TO LOWER EXTREMITY B/K WOOD SOCK 745.13 R 20120701 L5640 9 "ADDITIONS TO LOWER EXTREMITY, KNEE D" 424.96 R 20120701 L5642 9 SOCKET/THIGH; MOLDED GLUTEAL CORSET; 424.67 R 20120701 L5643 9 ADD TO LOW EXT HIP DISARTIC FLEX INN 1112.53 R 20120701 L5644 9 "SOCKET/THIGH; WOOD, OPEN-END (STANDA" 468.29 R 20120701 L5645 9 ADD TO LOW EXT BELOW KNEE FLEX INNER 531.34 R 20120701 L5646 9 AIR-CUSHION PTB SOCKET FOR ENDOSKELE 472.68 R 20120701 L5647 9 ADD TO LOW EXT BELOW KNEE SUCTION SO 528.66 R 20120701 L5648 9 "SOCKET/THIGH; PLASTIC, A/K, TOTAL CO" 515.58 R 20120701 L5649 9 "ADD TO LOW EXT, ISCHIAL CONTAINMENT " 1614.79 R 20120701 L5650 9 PLASTIC TOTAL CONTACT STD A/K SOCKET 380.71 R 20120701 L5651 9 ADD TO LOW EXT ABOVE KNEE FLEX INNER 1064.17 R 20120701 L5652 9 "ADDITIONS TO LOWER EXTREMITY, SUCTIO" 338.04 R 20120701 L5653 9 "ADDITIONS TO LOWER EXTREMITY, KNEE D" 395.93 R 20120701 L5654 9 "ADDITIONS TO LOWER EXTREMITY, SOCKET" 261.98 R 20120701 L5655 9 "ADDITIONS TO LOWER EXTREMITY, SOCKET" 203.82 R 20120701 L5656 9 "ADDITIONS TO LOWER EXTREMITY, SOCKET" 252.61 R 20120701 L5658 9 "ADDITIONS TO LOWER EXTREMITY, SOCKET" 241.64 R 20120701 L5661 9 ADD TO LOW EXT SOCKET INSERT MULTI D 404.44 R 20120701 L5665 9 ADD TO LOW EXT BELOW KNEE SOCKET INS 363.67 R 20120701 L5666 9 "ADDITIONS TO LOWER EXTREMITY, BELOW " 62.03 R 20120701 L5668 9 "ADDITIONS TO LOWER EXTREMITY, BELOW " 89.47 R 20120701 L5670 9 "ADDITIONS TO LOWER EXTREMITY, BELOW " 240.45 R 20120701 L5671 9 BK/AK LOCKING MECHANISM 382.11 R 20120701 L5672 9 "ADDITIONS TO LOWER EXTREMITY, BELOW " 198.17 R 20120701 L5673 9 SOCKET INSERT W LOCK MECH 486.89 R 20120701 L5676 9 "ADDITIONS TO LOWER EXTREMITY, BELOW " 313.65 R 20120701 L5678 9 "ADDITIONS TO LOWER EXTREMITY, BELOW " 35.19 R 20120701 L5679 9 SOCKET INSERT W/O LOCK MECH 405.73 R 20120701 L5680 9 THIGH CORSET; STANDARD LEATHER FOR B 216.93 R 20120701 L5681 9 INTL CUSTM CONG/LATYP INSERT 883.97 R 20120701 L5682 9 "THIGH CORSET; GLUTEAL, MOLDED FOR B/" 424.06 R 20120701 L5683 9 INITIAL CUSTOM SOCKET INSERT 883.97 R 20120701 L5684 9 "ADDITIONS TO LOWER EXTREMITY, BELOW " 35.77 R 20120701 L5685 9 BELOW KNEE SUS/SEAL SLEEVE 86.07 R 20120701 L5686 9 "ADDITIONS TO LOWER EXTREMITY, BELOW " 35.91 R 20120701 L5688 9 "ADDITIONS TO LOWER EXTREMITY, BELOW " 51.04 R 20120701 L5690 9 HVY. DUTY UNILATERAL B/K BELT 71.7 R 20120701 L5692 9 "ADDITIONS TO LOWER EXTREMITY, ABOVE " 117.75 R 20120701 L5694 9 "ADDITIONS TO LOWER EXTREMITY, ABOVE " 160.75 R 20120701 L5695 9 ADD TO LOWER EXTREMITY A/K SLEEVE SO 144.51 R 20120701 L5696 9 "ADDITIONS TO LOWER EXTREMITY, ABOVE " 147.52 R 20120701 L5697 9 "ADDITIONS TO LOWER EXTREMITY, ABOVE " 53.34 R 20120701 L5698 9 STD. SILESION BANDAGE 79.53 R 20120701 L5699 9 "ALL LOWER EXTREMITY PROSTHESIS, SHOU" 123.92 R 20120701 L5700 9 "REPLACEMENT SOCKET,BK MOLDED TO PT. " 1904.02 R 20120701 L5701 9 REPLACEMENT SOCKET AK DISARTICULATIO 2286.6 R 20120701 L5702 9 "REPLACEMENT SOCKET,HIP DISARTICULATI" 2892.89 R 20120701 L5704 9 REPLACEMENT CUSTOM SHAPED BK PROTECT 356.19 R 20120701 L5705 9 REPLACEMENT CUSTOM SHAPED BK PROTECT 636.46 R 20120701 L5706 9 "REPLACEMENT, CUSTOM SHAPED KNEE DISA" 623.91 R 20120701 L5707 9 REPLACEMENT CUSTOM SHAPED HIP DISART 822.55 R 20120701 L5710 9 "KNEE, ARTIFICIAL; BOCK, 3P4 W/ KNEE " 284.44 R 20120701 L5711 9 ADD EXOSKEL KNEE-SHIN SYSTEM SINGLE 360.33 R 20120701 L5712 9 BOCK 3P23 KNEE ASSEMBLY 377.59 R 20120701 L5714 9 "ADDITIONS, KNEE-SHIN SYSTEM, SINGLE " 319.01 R 20120701 L5716 9 "ADDITIONS, KNEE-SHIN SYSTEM, POLYCEN" 563.88 R 20120701 L5718 9 "ADDITIONS, KNEE-SHIN SYSTEM, POLYCEN" 622.12 R 20120701 L5722 9 "ADDITIONS, KNEE-SHIN SYSTEM, SINGLE " 604.77 R 20120701 L5724 9 "ADDITIONS, KNEE-SHIN SYSTEM, SINGLE " 1337.54 R 20120701 L5726 9 "ADDITIONS, KNEE-SHIN SYSTEM, SINGLE " 1541.49 R 20120701 L5728 9 "ADDITIONS, KNEE-SHIN SYSTEM, SINGLE " 1646.88 R 20120701 L5780 9 "ADDITIONS, KNEE-SHIN SYSTEM, SINGLE " 876.7 R 20120701 L5785 9 ADD EXOSKEL SYS BELOW KNEE ULTRA 384.98 R 20120701 L5790 9 ABOVE KNEE ADD TO EXOSKEL SYS ULTRA 637.15 R 20120701 L5795 9 HIP DISARTICULATION ULTRA-LIGHT RATE 951.43 R 20120701 L5810 9 ENDOSKEL KNEE-SHIN SYS SINGLE AXIS M 357.25 R 20120701 L5811 9 ULTRA-LIGHT ADD TO ENDOSKEL KNEE-SHI 529.2 R 20120701 L5812 9 ENDOSKELETAL SINGLE AXIS VARIFRICTIO 400.44 R 20120701 L5814 9 ADD ENDOSKEL KNEE-SHIN SINGLE AXIS 2732.04 R 20150601 L5816 9 ADD ENDOSKEL KNEE-SHIN POLYCENTRI 644.14 R 20120701 L5818 9 POLYCENTRIC KNEE 645.86 R 20120701 L5822 9 ADD ENDOSKEL KNEE-SHIN SINGLE AXIS P 1131.75 R 20120701 L5824 9 ADD ENDOSKEL KNEE-SHIN FLUID SWING S 1214.12 R 20120701 L5826 9 PEDIATRIC KNEE JOINT 2098.64 R 20120701 L5828 9 ENDOSKEL KNEE-SHIN SYS-SGL AXIS STAN 1876.79 R 20120701 L5830 9 PNEUMATIC/HYDRAPNEU SWING CTRL ENDOS 1384.1 R 20120701 L5840 9 ADDITION ENDOSKELETAL KNEE/SHIN SYST 2331.56 R 20120701 L5845 9 KNEE-SHIN SYS STANCE FLEXION 1204.51 R 20120701 L5850 9 ABOVE KNEE/HIP DISARTICULATE KNEE EX 113.35 R 20120701 L5855 9 ADDITION ENDOSKELETAL HIP DISARTICUL 228.43 R 20120701 L5859 9 ADDITION TO LOWER EXTREMITY PROSTHES .MP Y R L5910 9 ADD ENDOSKEL SYS BELOW KNEE ALIGNABL 320.93 R 20120701 L5920 9 ABOVE KNEE/HIP DIS ALIGNABLE SYST 470.17 R 20120701 L5925 9 ADDITION ENDOSKELETAL AK DISARTICULA 297.75 R 20120701 L5930 9 HIGH ACTIVITY KNEE FRAME 2261.95 R 20120701 L5940 9 ULTRA-LIGHT ADD ENDOSKEL SYS BELOW K 444.49 R 20120701 L5950 9 ULTRA-LIGHT ABOVE KNEE ADD ENDOSKEL 689.42 R 20120701 L5960 9 ULTRA-LIGHT MATERIAL FOR HIP DISC 854.27 R 20120701 L5962 9 ADDITION ENDOSKELETAL BK FLEXIBLE 421.62 R 20120701 L5964 9 ADDITION ENDOSKELETAL AK FLEXIBLE 622.41 R 20120701 L5966 9 ADDITION ENDOSKELETAL HIP DISARTICUL 793.11 R 20120701 L5969 9 "ADDITION, ENDOSKELETAL ANKLE-FOOT OR" 11944.99 R 20140101 L5970 9 "ALL LOWER EXTREMITY PROSTHESES FOOT," 151.27 R 20120701 L5972 9 ALL LOWER EXTREMITY PROSTHESES FLEXI 284.76 R 20120701 L5973 9 "ENDOSKELETAL ANKLE FOOT SYSTEM, MICR" 12919.99 R 20120701 L5974 9 "ALL LOWER EXTREMITY PROSTHESES FOOT," 176.15 R 20120701 L5975 9 COMBO ANKLE/FOOT PROSTHESIS 313.44 R 20120701 L5976 9 ENERGY STORING FOOT DR EQUAL 403.42 R 20120701 L5978 9 LOWER EXTREMITY PROST.MULTIAXIAL FOO 226.18 R 20120701 L5979 9 ALL LOWER EXT PROSTHESES MULTIAXIAL 1516.46 R 20120701 L5980 9 FLEX FOOT SYSTEM LOWER EXTREMITY PRO 2606.41 R 20120701 L5981 9 "ALL LOWER EXT PROSTHESES,FLEX-WALK S" 1990.5 R 20120701 L5982 9 AXIAL ROTATION UNIT LOWER EXTER PROS 415.98 R 20120701 L5984 9 AXIAL ROTATION UNIT LOWER ENDOSKELET 446.82 R 20120701 L5985 9 LWR EXT DYNAMIC PROSTH PYLON 189.76 R 20120701 L5986 9 MULTI-AXIAL ROTATION UNIT LOWER EXTR 444.57 R 20120701 L5987 9 SHANK FT W VERT LOAD PYLON 5291.95 R 20150601 L5988 9 VERTICALSHOCK/ROTATION PYLON 1428.75 R 20120701 L5990 9 USER ADJUSTABLE HEEL HEIGHT 1219.19 R 20120701 L5999 9 UNLISTED PROCEDURES FOR LOWER EXTREM MP R L6000 9 "PARTIAL HAND, THUMB REMAINING " 994.74 R 20120701 L6010 9 "PARTIAL HAND, LITTLE AND/OR RING FIN" 1000.81 R 20120701 L6020 9 "PARTIAL HAND, NO FINGER REMAINING " 995.51 R 20120701 L6026 9 TRANSCARPAL/METACARPAL OR PARTIAL HA 3217.33 R 20150101 L6050 9 "WRIST DISARTICULATION, MOLDED SOCKET" 1529.35 R 20120701 L6055 9 WRIST DISARTICULATION MOLDED SOCKET 1886.57 R 20120701 L6100 9 "BELOW ELBOW, MOLDED SOCKET, FLEXIBLE" 1569.05 R 20120701 L6110 9 "BELOW ELBOW, MOLDED SOCKET, (MUENSTE" 1665.6 R 20120701 L6120 9 "BELOW ELBOW, MOLDED DOUBLE WALL SPLI" 1877.95 R 20120701 L6130 9 "BELOW ELBOW, MOLDED DOUBLE WALL SPLI" 1740.15 R 20120701 L6200 9 "ELBOW DISARTICULATION, MOLDED SOCKET" 2117.22 R 20120701 L6205 9 ELBOW DISARTICULATION MOLDED SOCKET 2420.19 R 20120701 L6250 9 ABOVE ELBOW MOLDED DOUBLE WALL SOCK 2195.57 R 20120701 L6300 9 "SHOULDER DISARTICULATION, MOLDED SOC" 2643.93 R 20120701 L6310 9 "SHOULDER DISARTICULATION, PASSIVE RE" 2122.84 R 20120701 L6320 9 "SHOULDER DISARTICULATION, PASSIVE RE" 1277.14 R 20120701 L6350 9 "INTERSCAPULAR THORACIC, MOLDED SOCKE" 2603.19 R 20120701 L6360 9 "INTERSACPULAR THORACIC, PASSIVE REST" 2116.88 R 20120701 L6370 9 "INTERSCAPULAR THORACIC, PASSIVE REST" 1475.85 R 20120701 L6400 9 "BELOW ELBOW, MOLDED SOCKET, ENDOSKEL" 1666.95 R 20120701 L6450 9 "ELBOW DISARTICULATION, MOLDED SOCKET" 2049.02 R 20120701 L6500 9 ABOVE ELBOW MOLDED SOCKET ENDOSKEL 2067.48 R 20120701 L6550 9 "SHOULDER DISARTICULATION, MOLDED SOC" 2534.29 R 20120701 L6570 9 "INTERSCAPULAR THORACIC, MOLDED SOCKE" 2908.88 R 20120701 L6580 9 PREP WRIST DISARTIC/BELOW ELBOW SGL 1092.1 R 20120701 L6582 9 DIRECT FORMED PREP WRIST DISARTICULA 1012.82 R 20120701 L6584 9 MOLDED/PREP ELBOW DISARTICULATION OR 1479.59 R 20120701 L6586 9 DIRECT FORMED PREP ELBOW/ABOVE ELBOW 1455.76 R 20120701 L6588 9 PREP SHOULDER DISARTICULATE/INTERSCA 2004.21 R 20120701 L6590 9 DIRECT FORMED PREP SHOULDER/INTERSCA 1965.58 R 20120701 L6600 9 HOSMER POLYCENTRIC HINGE 166.22 R 20120701 L6605 9 HOSMER ELBOW HINGES FOR WD OR BE ARM 164.11 R 20120701 L6610 9 FLEXIBLE METAL HINGES FOR WD OR BE A 134.41 R 20120701 L6611 9 ADDITION TO UPPER EXTREMITY PROSTHES 302.87 R 20150601 L6615 9 "FM WRIST DISCONNECT,FM-100 " 129.03 R 20120701 L6616 9 UPPER EXTREM ADD INSERT FOR LOCKING 54.84 R 20120701 L6620 9 "HOSMER FLEXION WRIST,FW-500 " 222.95 R 20120701 L6623 9 UPPER EXTREMITY SPRING ASSISTED ROTA 447.66 R 20120701 L6624 9 "UPPER EXTREMITY ADDITION, FLEXION/EX" 2770.46 R 20150601 L6625 9 "ECONOMY FRICTION WRIST,WE-500 " 471.29 R 20120701 L6628 9 UPPER EXTREMITY QUICK RELEASE HOOK A 343.07 R 20120701 L6629 9 UPPER EXTREMITY QUICK DISCONNET LAM 117.95 R 20120701 L6630 9 "OVAL FRICTION WRIST,OW-100N " 190.97 R 20120701 L6632 9 UPPER EXTREMITY LATEX SUSP SLEEVE EA 43.17 R 20120701 L6635 9 "HOSMER FOREARM LIFT ASSIST ELBOW,E-4" 147.03 R 20120701 L6637 9 UPPER EXTREMITY NUDGE CONTROL ELBOW 286.51 R 20120701 L6640 9 "HOSMER SHOULDER ABDUCTION JOINTS,SAJ" 239.73 R 20120701 L6641 9 UPPER EXTREMITY EXCURSION AMPLIFIER 129.63 R 20120701 L6642 9 LEVER TYPE EXCURSION AMP UPPER EXTRA 154.34 R 20120701 L6645 9 "HOSMER FLEXION-ABDUCTION JOINTS,FAJ-" 267.68 R 20120701 L6650 9 "UPPER EXTREMITY ADDS,UNIVERSAL JOINT" 281.06 R 20120701 L6655 9 "UPPER EXTREMITY ADDITIONS, STANDARD " 61.54 R 20120701 L6660 9 "UPPER EXTREMITY ADDITIONS, HEAVY DUT" 68.59 R 20120701 L6665 9 "UPPER EXTREMITY ADDITIONS, TEFLON, O" 40.81 R 20120701 L6670 9 "UPPER EXTREMITY ADDITIONS, HOOK TO H" 42.5 R 20120701 L6672 9 "UPPER EXTREMITY ADDITIONS, HARNESS, " 118.25 R 20120701 L6675 9 UNI. SWTCH CNTRL-RING/FIG.8 HARN.FOR 82.91 R 20120701 L6676 9 "UNILATERAL FIG.& HARNESS FOR WD,BE,O" 87.16 R 20120701 L6680 9 "SOCKET & FOREARM FOR BE, PLASTIC TOT" 205.59 R 20120701 L6682 9 "SOCKET&UPPER ARM FORED,AE W,W/O MYO-" 201.31 R 20120701 L6684 9 "ADJUSTABLE-FRICTION BULKHEAD JOINTS," 231.66 R 20120701 L6686 9 UPPER EXTREMITY ADDIT SUCTION SOCKET 430.7 R 20120701 L6687 9 FRAME TYPE SOCKET BELOW UPPER 383.35 R 20120701 L6688 9 FRAME TYPE SOCKET ABOVE ELBOW UPPER 453.08 R 20120701 L6689 9 FRAME TYPE SOCKET SHOULDER DISARTICU 474.1 R 20120701 L6690 9 FRAME TYPE SOCKET INTERSCAPULAR-THOR 514.42 R 20120701 L6691 9 UPPER EXTREMITY ADDIT REMOVABLE INSE 229.41 R 20120701 L6692 9 UPPER EXTER.ADD. SILICONE GEL INSERT 472.88 R 20120701 L6693 9 UPPER EXTR ADD.LOCKING ELBOW-FOREARM 2314.09 R 20130801 L6694 9 ELBOW SOCKET INS USE W/LOCK 544.09 R 20120701 L6698 9 BELOW/ABOVE ELBOW LOCK MECH 426.99 R 20120701 L6703 9 "TERMINAL DEVICE, PASSIVE HAND/MITT, " 219.8 R 20120701 L6704 9 "TERMINAL DEVICE, SPORT/RECREATIONAL/" 515.45 R 20120701 L6706 9 "TERMINAL DEVICE, HOOK, MECHANICAL, V" 267.42 R 20120701 L6707 9 "TERMINAL DEVICE, HOOK, MECHANICAL, V" 951.53 R 20120701 L6708 9 "TERMINAL DEVICE, HAND, MECHANICAL, V" 639.51 R 20120701 L6709 9 "TERMINAL DEVICE, HAND, MECHANICAL, V" 938.28 R 20120701 L6711 9 "TERMINAL DEVICE, HOOK, MECHANICAL, V" 504.88 R 20120701 L6712 9 "TERMINAL DEVICE, HOOK, MECHANICAL, V" 929.59 R 20120701 L6713 9 "TERMINAL DEVICE, HAND, MECHANICAL, V" 1173.23 R 20120701 L6714 9 "TERMINAL DEVICE, HAND, MECHANICAL, V" 993.72 R 20120701 L6721 9 "TERMINAL DEVICE, HOOK OR HAND, HEAVY" 1766.12 R 20120701 L6722 9 "TERMINAL DEVICE, HOOK OR HAND, HEAVY" 1522.61 R 20120701 L6881 9 AUTOGRASP FEATURE UL TERM DV 3332.38 R 20130901 L6882 9 MICROPROCESSOR CONTROL UPLMB 2084.02 R 20120701 L6883 9 REPLE SOCKT BELOW E/W DISA 1240.12 R 20120701 L6884 9 REPLC SOCKT ABOVE ELBOW DISA 1861.18 R 20120701 L6885 9 REPLC SOCKT SHLDR DIS/INTERC 2116.88 R 20120701 L6890 9 REALASTIC GLOVES; PRODUCTION MODEL 122.51 R 20120701 L6895 9 REALASTIC GLOVES; CUSTOM MADE 371.11 R 20120701 L6900 9 "HAND RESTORATION (CASTS, SHADING AND" 1027.58 R 20120701 L6905 9 "HAND RESTORATION (CASTS, SHADING AND" 975.78 R 20120701 L6910 9 "HAND RESTORATION (CASTS, SHADING AND" 961.55 R 20120701 L6915 9 "HAND RESTORATION (SHADING, AND MEASU" 416.05 R 20120701 L6920 9 WRIST DISARTICULATION EXTERNAL POWER 4870.26 R 20120701 L6925 9 WRIST DISARTICULATION EXT POWER SELF 5142.57 R 20120701 L6930 9 BELOW ELBOW EXTERNAL POWER 5228.79 R 20120701 L6935 9 BELOW ELBOW ETT PWR SELF-SUSP INNER 5751.61 R 20120701 L6940 9 ELBOW DISARTIC EXT PWR MOLDED INNER 6534.85 R 20120701 L6945 9 ELBOW DISARTIC EXT MOLDED INNER- 7392.45 R 20120701 L6950 9 ABOVE ELBOW EXTERNAL POWER 6947.81 R 20120701 L6955 9 ABOVE ELBOW EXTERNAL POWER 8718.53 R 20120701 L6960 9 SHOU PROSTH EXTERNAL POWER 8596.91 R 20120701 L6965 9 SHOU PROST EXT POWER MOLDED MYOELECT 12558.85 R 20120701 L6970 9 INTERSCAPULAR-THORACIC EXT PWR MOLDE 12765.22 R 20120701 L6975 9 INTERSCAPULAR-THORACIC EXT PWR MOLDE 12833.74 R 20120701 L7007 9 "ELECTRIC HAND, SWITCH OR MYOELECTRIC" 3337.88 R 20150601 L7008 9 "ELECTRIC HAND, SWITCH OR MYOELECTRIC" 4799.2 R 20120701 L7009 9 "ELECTRIC HOOK, SWITCH OR MYOELECTRIC" 3111.2 R 20120701 L7040 9 PREHENSILE ACTUATOR HOSMER/EQUAL SWI 2498.18 R 20120701 L7045 9 ELEC HOOK CHILD MICH OR EQUAL SWITCH 1432.29 R 20120701 L7170 9 SWITCH CTRL ELEC ELBOW HOSMER/EQUAL 5195.87 R 20120701 L7180 9 MYOELEC CTRL ELBOW UTAH OR EQUAL 27147.16 R 20120701 L7185 9 SWITCH CTRL ELEC ELBOW VARIETY VILLA 5261.5 R 20120701 L7186 9 ELECTRONIC ELBOW CHILD SWITCH CONTRO 7593.64 R 20120701 L7190 9 MYOELEC CTRL ELBOW VARIETY VILLAGE O 6694.26 R 20120701 L7191 9 ELECTRONIC ELBOW CHILD MYOELECTRONIC 8071.8 R 20120701 L7259 9 "ELECTRONIC WRIST ROTATOR, ANY TYPE " 3295.02 R 20150101 L7360 9 SIX VOLT BATTERY OTTO BOCK/EQUAL EA 160.03 R 20120701 L7362 9 BATTERY CHARGER 6 VOLT OTTO BOCK OR 192.47 R 20120701 L7364 9 TWELVE VOLT BATTERY UTAH OR EQUAL EA 350.62 R 20120701 L7366 9 BATTERY CHARGER 12 VOLT UTAH OR EQUA 475.64 R 20120701 L7367 9 REPLACEMENT LITHIUM ZONBATTER 261.63 R 20120701 L7368 9 "LITHIUM ION BATTERY CHARGER, REPLACE" 339.16 R 20120701 L7400 9 "ADD UE PROST BE/WD,ULTLITE " 205.95 R 20120701 L7401 9 ADD UE PROST ALE ULTITE MGT 230.57 R 20120701 L7402 9 ADD UE PROST S/D ULTLITE MAT 249 R 20120701 L7403 9 ADD UE PROST B/C ACRYLIC 247.48 R 20120701 L7404 9 ADD UE PROST S/D ACRYLIC 373.51 R 20120701 L7405 9 ADD UE PROST S/D ACRYLIC 488.48 R 20120701 L7499 9 UNLISTED PROCEDURES FOR UPPER EXTREM MP R L7510 9 "REPAIR PROSTHETIC DEVICE, REPAIR OR " 35.31 R 20120701 L7520 9 REPAIR PROSTHESIS PER 15 MIN MP R L8000 9 MAMMARY PROSTHESIS INCLUDING SURGICA 24.93 R 20120701 L8001 9 BREAST PROSTHESIS BRA & FORM 84.28 R 20120701 L8002 9 BRST PRSTH BRA & BILAT FORM 110.86 R 20120701 L8010 9 "BREAST PROSTHESES, MASTECTOMY SLEEVE" 74.79 R 20140501 L8020 9 "BREAST PROSTHESES, MASTECTOMY FORM " 151 R 20120701 L8030 9 "BREAST PROTHESIS, SILICONE OR EQUAL," 221.68 R 20120701 L8031 9 "BREAST PROSTHESIS, SILICONE OR EQUAL" MP R L8032 9 "NIPPLE PROSTHESIS, REUSABLE, ANY TYP" MP R L8040 9 NASAL PROSTHESIS MP R L8041 9 MIDFACIAL PROSTHESIS MP R L8042 9 ORBITAL PROSTHESIS MP R L8300 9 "TRUSSES, SINGLE WITH STANDARD PAD " 56.07 R 20120701 L8310 9 "TRUSSES, DOUBLE WITH STANDARD PADS " 88.51 R 20120701 L8320 9 "TRUSSES, ADDITION TO STANDARD PADS, " 40.86 R 20120701 L8330 9 "TRUSSES, ADDITION TO STANDARD PADS, " 43.75 R 20120701 L8400 9 "PROSTHETIC SHEATH, BELOW KNEE, EACH " 10.47 R 20120701 L8410 9 "PROSTHETIC SHEATH, ABOVE KNEE, EACH " 15.29 R 20120701 L8415 9 PROSTHETIC SHEATH UPPER LIMB EACH 15.53 R 20120701 L8417 9 PROS SHEATH/SOCK W GEL CUSHN 50.53 R 20120701 L8420 9 "PROSTHETIC SOCK, WOOL, BELOW KNEE, E" 13.82 R 20120701 L8430 9 PROSTHETIC SOCK WOOL ABOVE KNEE 15.18 R 20120701 L8435 9 PROSTHETIC SOCK WOOL UPPER LIMB EACH 16.01 R 20120701 L8440 9 BELOW KNEE STUMP SHRINKER ONE 29.36 R 20120701 L8460 9 ABOVE KNEE STUMP SHRINKER ONE 51.08 R 20120701 L8465 9 PROSTHETIC SHRINKER UPPER LIMB EACH 36.39 R 20120701 L8470 9 "STUMP SOCK, SINGLE PLY, FITTING, BEL" 5.33 R 20120701 L8480 9 STUMP SOCK SINGLE PLY FITTING 6.98 R 20120701 L8485 9 "STUMP SOCK, SINGLE PLY, FITTING, UPP" 7.4 R 20120701 L8499 9 UNLISTED PROCEDURE FOR MISCELLANEOUS MP R L8500 9 "ARTIFICIAL LARYNX, ANY TYPE " 516.69 R 20120701 L8501 9 TRACHEOSTOMY SPEAKING VALVE 89.71 R 20120701 L8505 9 "ARTIFICIAL LARYNX, ACCESSORY " 31.78 R 20120701 L8515 9 GEL CAP APP DEVICE FOR TRACH 42.42 R 20120701 L8603 9 COLLAGEN IMP URINARY 2.5 CC 291.02 R 20120701 L8604 9 "INJECTABLE BULKING AGENT, DEXTRANOME" MP R L8614 9 COCHLEAR IMPLANT DEVICE 16199.93 01 20 R 20120701 L8615 9 COCH IMPLANT HEADSET REPLACE 317.82 01 20 R 20120701 L8616 9 COCH IMPLANT MICROPHONE REPL 70.59 01 20 R 20120701 L8617 9 COCH IMPLANT TRANS COIL REPL 61.66 01 20 R 20120701 L8618 9 COCH IMPLANT TRAN CABLE REPL 17.6 01 20 R 20120701 L8619 9 COCHLEAR IMPLANT EXTERNAL 5522.18 00 20 R 20120701 L8621 9 REPL ZINC AIR BATTERY 0.4 01 20 R 20120701 L8622 9 REPL ALKALINE BATTERY 0.22 01 20 0 20120701 L8623 9 REPL LITHIUM ION FOR USE WITH CO 53.03 Y 2 00 20 R 20111101 L8624 9 REPL LITHIUM ION BAT FOR USE WITH CO 132.21 Y 2 01 20 R 20111101 L8627 9 "COCHLEAR IMPLANT, EXTERNAL SPEECH PR" 5241.82 00 20 R 20120701 L8628 9 "COCHLEAR IMPLANT, EXTERNAL CONTROLLE" 929.01 00 20 R 20120701 L8629 9 "TRANSMITTING COIL AND CABLE, INTEGRA" MP R L8690 9 "AUDITORY OSSEOINTEGRATED DEVICE, INC" 3196.91 00 20 R 20120701 L8691 9 "AUDITORY OSSEOINTEGRATED DEVICE, EXT" 1791.99 00 20 R 20120701 L8692 9 "AUDITORY OSSEOINTEGRATED DEVICE, EXT" MP R L8695 9 EXTERNAL RECHARGING SYSTEM FOR BATTE 11.21 00 20 R 20120701 L8696 9 ANTENNA (EXTERNAL) FOR USE WITH IMPL 188.06 R 20150101 L9900 9 O&P SUPPLY/ACCESSORY/SERVICE MP R Q0480 7 DRIVER FOR USE W/PNEUMATIC VENTRICUL 5531.76 Y R 20120701 S1015 9 IV TUBING EXTENSION SET MP Y 1 R S1040 9 "CRANIAL REMOLDING ORTHOSIS,CUSTOM FA" MP 00 20 R S8185 9 FLUTTER DEVICE 33.97 Y 1 R 20120701 S8186 9 SWIVEL ADAPTOR MP Y 1 R S8189 9 "TRACHESOTOMY SUPPLY, NOC " MP Y 1 R S8420 9 "GRAD PRESSURE AID,SLEEVE/GLOVE CUSTO" MP R S8421 9 GRAD PRESSURE SLEEVE/GLOVE READ MADE MP R S8422 9 "GRAD PRESS AID,SLEEVE,CUSTOM MEDIUM " MP R S8423 9 "GRAD PRESS AID,SLEEVE,CUSTOM HEAVY W" MP R S8424 9 GRADIENT PRESSURE AID (SLEEVE) READY MP R S8427 9 GRADIENT PRESSURE AID (GLOVE) READY MP R S8999 9 RESUSCITATION BAG MP Y 1 R T4521 9 ADULT SIZE BRIEF/DIAPER SM 0.5 Y 1 04 20 R 20120701 T4522 9 ADULT SIZE BRIEF/DIAPER MED 0.6 Y 1 04 20 R 20120701 T4523 9 ADULT SIZE BRIEF/DIAPER LG 0.87 Y 1 04 20 R 20120701 T4524 9 ADULT SIZE BRIEF/DIAPER XL 0.87 Y 1 04 20 R 20120701 T4525 9 ADULT SIZE PULL-ON SM 0.85 Y 1 04 20 R 20120701 T4526 9 ADULT SIZE PULL-ON MED 0.85 Y 1 04 20 R 20120701 T4527 9 ADULT SIZE PULL-ON LG 0.94 Y 1 04 20 R 20120701 T4528 9 ADULT SIZE PULL-ON XL 1.17 Y 1 04 20 R 20120701 T4529 9 PED SIZE BRIEF/DIAPER SM/MED 0.5 Y 1 04 20 R 20120701 T4530 9 PED SIZE BRIEF/DIAPER LG 0.5 Y 1 04 20 R 20120701 T4531 9 PED SIZE PULL-ON SM/MED 0.81 Y 1 04 20 R 20120701 T4532 9 PED SIZE PULL-ON LG 0.92 Y 1 04 20 R 20120701 T4533 9 YOUTH SIZE BRIEF/DIAPER 0.55 Y 1 04 20 R 20120701 T4534 9 YOUTH SIZE PULL-ON 0.97 Y 1 04 20 R 20120701 T4535 9 DISPOSABLE LINER/SHIELD/PAD MP Y 1 04 20 R T4539 9 "DIAPER/BRIEF, REUSABLE, ANY SIZE " 2.49 Y 1 04 20 R 20120701 T4543 9 ADULT SIZED DISPOSABLE INCONTINENCE 1.46 Y 1 04 20 R 20120701 V2623 9 "PROSTHETIC EYE, PLASTIC, CUSTOM " 795.43 R 20120701 V2624 9 POLISHING/RESURFACING OF OCULAR PROS 53.08 R 20120701 V2625 9 ENLARGEMENT OF OCULAR PROSTHESIS 254.93 R 20120701 V2626 9 REDUCTION OF OCULAR PROSTHESIS 176.79 R 20120701 V2627 9 SCLERAL COVER SHELL 962.47 R 20120701 V2628 9 "FABRICATION,FITTING OF OCULAR CONFOR" 250.38 R 20120701 V2629 9 "PROSTHETIC EYE,INTRAOCULAR LENES NOC" MP R V5014 9 REPAIR/MODIFICATION OF A HEARING AID 553.73 1 00 20 20120701 V5030 9 "HEARING AID, MONAURAL, BODY NORN, AI" 553.73 1 00 20 R 20120701 V5040 9 "HEARING AID, MONAURAL, BODY WORN BON" 553.73 1 00 20 R 20120701 V5050 9 "HEARING AID, MONAURAL, IN THE EAR " 553.73 1 00 20 R 20120701 V5060 9 "HEARING AID, MONAURAL, BEHIND THE EA" 553.73 1 00 20 R 20120701 V5070 9 "GLASSES, AIR CONDUCTION " 553.73 1 00 20 R 20120701 V5080 9 "GLASSES, BONE CONDUCTION " 553.73 1 00 20 R 20120701 V5100 9 "HEARING AID, BILATERAL, BODY WORN " 553.73 1 00 20 R 20120701 V5120 9 "BINAURAL, BODY " 1107.46 1 00 20 R 20140701 V5130 9 "BINAURAL, IN THE EAR " 1107.46 1 00 20 R 20140701 V5140 9 "BINAURAL, BEHIND THE EAR " 1107.46 1 00 20 R 20140701 V5150 9 "BINAURAL, GLASSES " 1107.46 1 00 20 R 20140701 V5170 9 "HEARING AID, CROS, IN THE EAR " 553.73 1 00 20 R 20120701 V5180 9 "HEARING AID, CROS, BEHIND THE EAR " 553.73 1 00 20 R 20120701 V5190 9 "HEARING AID, CROS, GLASSES " 553.73 1 00 20 R 20120701 V5210 9 "HEARING AID, BICROS, IN THE EAR " 553.73 1 00 20 R 20120701 V5220 9 "HEARING AID, BICROS, BEHIND THE EAR " 553.73 1 00 20 R 20120701 V5230 9 "HEARING AID, BICROS, GLASSES " 553.73 1 00 20 R 20120701 V5261 9 "HEARING AID, DIGIT, BIN, BTE " 553.73 1 00 20 R 20120701 V5264 9 EAR MOLD/INSERT NONDISPOSABLE 57.78 1 00 20 20120701 V5266 9 BATTERY FOR USE IN HEARING DEVICE 0.78 1 00 20 20120701 V5269 9 "ALERTING DEVICE, ANY TYPE " MP Y 00 20 R V5272 9 "ASSISTIVE LISTENING DEVICE, TDD " MP Y 00 20 R LEGEND ------------------------------------------------------------------------------------------------------------------------------------ " Listed below are some aids we hope will help you understand this fee schedule. If, after reading the information below, you " " need further clarification of an item, please call Molina Provider Relations at 1-800-473-2783. " ------------------------------------------------------------------------------------------------------------------------------------ COLUMN 1. CODE: The medical billing procedure code. J CODES LISTED ON THIS FEE SCHEDULE ARE FOR THE USE OF INPATIENT HOSPITALS ONLY. ________________________________________________________________________________ COLUMN 2. TOS: TOS 07 is used for procedure codes in which a modifier is required. TOS 09 is used for all other procedure codes. COLUMN 3. DESCRIPTION: A short description of the medical billing procedure code. " COLUMN 4. FEE: The fee listed refers to the maximum, allowable payment for one unit of that item. When a fee must be manually " " priced, instead of a fee, the letters MP will appear. " " COLUMN 5. ICFMR EXEMPT: ""Y"" in the ""ICFMR EXEMPT"" field indicates that the Intermediate Care Facility for the Mentally " Retarded is not responsible for payment of this item for those Medicaid recipients residing in its' facility on the date of delivery. " COLUMN 6. NHOME RESP: ""Y"" in the ""NH RESP"" field indicates that nursing home is responsible for payment of this item for those " Medicaid Recipients residing in the facility on the date of delivery. " COLUMN 7. MCARE EXEMPT: ""1"" indicates Medicare does not cover this item. ""2"" indicates that Medicare does not cover this " " item for nursing home residents. If there is nothing in this field, Medicare covers this item in all locations. " " COLUMN 8. AGE RESTRICTION: If there is an age restriction for this procedure, the eligible age group will be given. " " COLUMN 9. PA REQUIRED: ""R"" in this field indicates that Prior Authorization by the Fiscal Intermediary is required. " COLUMN 10. EFFECT DATE: The date in this column represents the date on which the fee from column 4 becomes effective. THIS IS NOT AN ALL INCLUSIVE LIST. PAYMENT OF OTHER PROCEDURES CODES NOT INCLUDED IN THIS LIST MAY BE CONSIDERED BY THE DEPARTMENT OF HEALTH AND HOSPITALS ON A CASE BY CASE BASIS. IMPORTANT INFORMATION: THE 'J' CODES LISTED ON THIS FEE SCHEDULE ARE PAYABLE TO HOSPITALS ONLY!! _________________________________________________________________________________________________