NJ PIP Fee Schedule Exhibit 5: Durable Medical Equipment, Prosthetics, Orthotics and Supplies
Exhibit 5 is the only New Jersey PIP fee schedule with no region split. Its 2,991 rows carry one statewide price each, and they are retail prices: a purchase new, a purchase used, or a monthly rental, told apart by the modifier on the row rather than by the code. The code alone is not a key.
The schedule001
Exhibit 5 in full, all 2,991 rows
How to read this table
- Mod, Mod 2
- The modifiers that make the row. NU is purchased new, UE purchased used, RR rented. The rest are listed in the modifier key below the table.
- Category
- The Department's ten-category key, also below the table. CR is the one that changes the money: it marks a capped rental item.
- Fee
- One statewide amount. Exhibit 5 has no North and South columns, and 11:3-29.3(a) does not define regions for it.
A codes: medical and surgical supplies
398 rows| Code | Mod | Mod 2 | Cat. | Description | Fee |
|---|---|---|---|---|---|
| A4216 | OS | Sterile water/saline, 10 ml | $0.47 | ||
| A4217 | SU | Sterile water/saline, 500 ml | $3.29 | ||
| A4217 | AU | OS | Sterile water/saline, 500 ml | $3.29 | |
| A4221 | SU | Maint drug infus cath per wk | $23.77 | ||
| A4222 | SU | Infusion supplies with pump | $49.07 | ||
| A4233 | NU | IN | Alkalin batt for glucose mon | $0.84 | |
| A4233 | NU | KL | IN | Alkalin batt for glucose mon | $0.72 |
| A4234 | NU | IN | J-cell batt for glucose mon | $3.81 | |
| A4234 | NU | KL | IN | J-cell batt for glucose mon | $3.29 |
| A4235 | NU | IN | Lithium batt for glucose mon | $2.46 | |
| A4235 | NU | KL | IN | Lithium batt for glucose mon | $2.12 |
| A4236 | NU | IN | Silvr oxide batt glucose mon | $1.76 | |
| A4236 | NU | KL | IN | Silvr oxide batt glucose mon | $1.52 |
| A4253 | NU | IN | Blood glucose/reagent strips | $38.79 | |
| A4253 | NU | KL | IN | Blood glucose/reagent strips | $33.43 |
| A4255 | SU | Glucose monitor platforms | $4.11 | ||
| A4256 | SU | Calibrator solution/chips | $10.21 | ||
| A4256 | KL | SU | Calibrator solution/chips | $8.80 | |
| A4257 | SU | Replace Lensshield Cartridge | $13.39 | ||
| A4258 | SU | Lancet device each | $18.95 | ||
| A4258 | KL | SU | Lancet device each | $16.34 | |
| A4259 | SU | Lancets per box | $12.66 | ||
| A4259 | KL | SU | Lancets per box | $10.91 | |
| A4265 | SU | Paraffin | $3.56 | ||
| A4280 | PO | Brst prsths adhsv attchmnt | $5.55 | ||
| A4310 | OS | Insert tray w/o bag/cath | $7.50 | ||
| A4311 | OS | Catheter w/o bag 2-way latex | $13.24 | ||
| A4312 | OS | Cath w/o bag 2-way silicone | $16.10 | ||
| A4313 | OS | Catheter w/bag 3-way | $19.06 | ||
| A4314 | OS | Cath w/drainage 2-way latex | $25.21 | ||
| A4315 | OS | Cath w/drainage 2-way silcne | $27.09 | ||
| A4316 | OS | Cath w/drainage 3-way | $28.30 | ||
| A4320 | OS | Irrigation tray | $5.29 | ||
| A4321 | OS | Cath therapeutic irrig agent | $0.00 | ||
| A4322 | OS | Irrigation syringe | $3.09 | ||
| A4326 | OS | Male external catheter | $11.33 | ||
| A4327 | OS | Fem urinary collect dev cup | $44.38 | ||
| A4328 | OS | Fem urinary collect pouch | $10.97 | ||
| A4330 | OS | Stool collection pouch | $7.51 | ||
| A4331 | OS | Extension drainage tubing | $3.34 | ||
| A4332 | OS | Lube sterile packet | $0.13 | ||
| A4333 | OS | Urinary cath anchor device | $2.31 | ||
| A4334 | OS | Urinary cath leg strap | $5.18 | ||
| A4336 | OS | Urethral insert | $1.51 | ||
| A4338 | OS | Indwelling catheter latex | $11.09 | ||
| A4340 | OS | Indwelling catheter special | $33.34 | ||
| A4344 | OS | Cath indw foley 2 way silicn | $14.30 | ||
| A4346 | OS | Cath indw foley 3 way | $17.90 | ||
| A4349 | OS | Disposable male external cat | $2.12 | ||
| A4351 | OS | Straight tip urine catheter | $1.83 | ||
| A4352 | OS | Coude tip urinary catheter | $6.74 | ||
| A4353 | OS | Intermittent urinary cath | $7.34 | ||
| A4354 | OS | Cath insertion tray w/bag | $12.29 | ||
| A4355 | OS | Bladder irrigation tubing | $9.36 | ||
| A4356 | OS | Ext ureth clmp or compr dvc | $47.91 | ||
| A4357 | OS | Bedside drainage bag | $9.65 | ||
| A4358 | OS | Urinary leg or abdomen bag | $6.96 | ||
| A4360 | OS | Disposable ext urethral dev | $0.51 | ||
| A4361 | OS | Ostomy face plate | $19.17 | ||
| A4362 | OS | Solid skin barrier | $3.63 | ||
| A4363 | OS | Ostomy clamp, replacement | $2.48 | ||
| A4364 | OS | Adhesive, liquid or equal | $3.08 | ||
| A4366 | OS | Ostomy vent | $1.37 | ||
| A4367 | OS | Ostomy belt | $7.72 | ||
| A4368 | OS | Ostomy filter | $0.27 | ||
| A4369 | OS | Skin barrier liquid per oz | $2.54 | ||
| A4371 | OS | Skin barrier powder per oz | $3.83 | ||
| A4372 | OS | Skin barrier solid 4x4 equiv | $4.39 | ||
| A4373 | OS | Skin barrier with flange | $6.59 | ||
| A4375 | OS | Drainable plastic pch w fcpl | $18.04 | ||
| A4376 | OS | Drainable rubber pch w fcplt | $49.96 | ||
| A4377 | OS | Drainable plstic pch w/o fp | $4.50 | ||
| A4378 | OS | Drainable rubber pch w/o fp | $32.29 | ||
| A4379 | OS | Urinary plastic pouch w fcpl | $15.77 | ||
| A4380 | OS | Urinary rubber pouch w fcplt | $39.20 | ||
| A4381 | OS | Urinary plastic pouch w/o fp | $4.84 | ||
| A4382 | OS | Urinary hvy plstc pch w/o fp | $25.85 | ||
| A4383 | OS | Urinary rubber pouch w/o fp | $29.60 | ||
| A4384 | OS | Ostomy faceplt/silicone ring | $10.10 | ||
| A4385 | OS | Ost skn barrier sld ext wear | $5.36 | ||
| A4387 | OS | Ost clsd pouch w att st barr | $0.00 | ||
| A4388 | OS | Drainable pch w ex wear barr | $4.58 | ||
| A4389 | OS | Drainable pch w st wear barr | $6.53 | ||
| A4390 | OS | Drainable pch ex wear convex | $10.09 | ||
| A4391 | OS | Urinary pouch w ex wear barr | $7.42 | ||
| A4392 | OS | Urinary pouch w st wear barr | $8.59 | ||
| A4393 | OS | Urine pch w ex wear bar conv | $9.49 | ||
| A4394 | OS | Ostomy pouch liq deodorant | $2.71 | ||
| A4395 | OS | Ostomy pouch solid deodorant | $0.05 | ||
| A4396 | OS | Peristomal hernia supprt blt | $42.50 | ||
| A4397 | OS | Irrigation supply sleeve | $5.03 | ||
| A4398 | OS | Ostomy irrigation bag | $14.50 | ||
| A4399 | OS | Ostomy irrig cone/cath w brs | $12.87 | ||
| A4400 | OS | Ostomy irrigation set | $51.31 | ||
| A4402 | OS | Lubricant per ounce | $1.46 | ||
| A4404 | OS | Ostomy ring each | $1.62 | ||
| A4405 | OS | Nonpectin based ostomy paste | $3.57 | ||
| A4406 | OS | Pectin based ostomy paste | $6.03 | ||
| A4407 | OS | Ext wear ost skn barr <=4sq" | $9.20 | ||
| A4408 | OS | Ext wear ost skn barr >4sq" | $10.36 | ||
| A4409 | OS | Ost skn barr convex <=4 sq i | $6.53 | ||
| A4410 | OS | Ost skn barr extnd >4 sq | $9.49 | ||
| A4411 | OS | Ost skn barr extnd =4sq | $5.36 | ||
| A4412 | OS | Ost pouch drain high output | $2.84 | ||
| A4413 | OS | 2 pc drainable ost pouch | $5.78 | ||
| A4414 | OS | Ost sknbar w/o conv<=4 sq in | $5.18 | ||
| A4415 | OS | Ost skn barr w/o conv >4 sqi | $6.30 | ||
| A4416 | OS | Ost pch clsd w barrier/filtr | $2.89 | ||
| A4417 | OS | Ost pch w bar/bltinconv/fltr | $3.91 | ||
| A4418 | OS | Ost pch clsd w/o bar w filtr | $1.90 | ||
| A4419 | OS | Ost pch for bar w flange/flt | $1.83 | ||
| A4420 | OS | Ost pch clsd for bar w lk fl | $0.00 | ||
| A4422 | OS | Ost pouch absorbent material | $0.13 | ||
| A4423 | OS | Ost pch for bar w lk fl/fltr | $1.95 | ||
| A4424 | OS | Ost pch drain w bar & filter | $4.99 | ||
| A4425 | OS | Ost pch drain for barrier fl | $3.76 | ||
| A4426 | OS | Ost pch drain 2 piece system | $2.87 | ||
| A4427 | OS | Ost pch drain/barr lk flng/f | $2.92 | ||
| A4428 | OS | Urine ost pouch w faucet/tap | $6.84 | ||
| A4429 | OS | Urine ost pouch w bltinconv | $8.66 | ||
| A4430 | OS | Ost urine pch w b/bltin conv | $8.95 | ||
| A4431 | OS | Ost pch urine w barrier/tapv | $6.53 | ||
| A4432 | OS | Os pch urine w bar/fange/tap | $3.77 | ||
| A4433 | OS | Urine ost pch bar w lock fln | $3.51 | ||
| A4434 | OS | Ost pch urine w lock flng/ft | $3.95 | ||
| A4450 | AU | OS | Non-waterproof tape | $0.09 | |
| A4450 | AV | OS | Non-waterproof tape | $0.09 | |
| A4450 | AW | OS | Non-waterproof tape | $0.12 | |
| A4452 | AU | OS | Waterproof tape | $0.38 | |
| A4452 | AV | OS | Waterproof tape | $0.38 | |
| A4452 | AW | OS | Waterproof tape | $0.42 | |
| A4455 | OS | Adhesive remover per ounce | $1.47 | ||
| A4456 | OS | Adhesive remover, wipes | $0.26 | ||
| A4461 | SD | Surgicl dress hold non-reuse | $3.45 | ||
| A4463 | SD | Surgical dress holder reuse | $13.98 | ||
| A4481 | OS | Tracheostoma filter | $0.39 | ||
| A4483 | OS | Moisture exchanger | $0.00 | ||
| A4556 | SU | Electrodes, pair | $12.75 | ||
| A4557 | SU | Lead wires, pair | $18.84 | ||
| A4558 | SU | Conductive gel or paste | $5.72 | ||
| A4559 | SU | Coupling gel or paste | $0.11 | ||
| A4561 | PO | Pessary rubber, any type | $20.95 | ||
| A4562 | PO | Pessary, non rubber,any type | $52.16 | ||
| A4595 | SU | TENS suppl 2 lead per month | $30.25 | ||
| A4604 | NU | IN | Tubing with heating element | $60.46 | |
| A4605 | NU | IN | Trach suction cath close sys | $17.22 | |
| A4608 | OX | Transtracheal oxygen cath | $52.63 | ||
| A4611 | NU | IN | Heavy duty battery | $206.27 | |
| A4611 | RR | IN | Heavy duty battery | $21.39 | |
| A4611 | UE | IN | Heavy duty battery | $154.71 | |
| A4612 | NU | IN | Battery cables | $71.34 | |
| A4612 | RR | IN | Battery cables | $7.27 | |
| A4612 | UE | IN | Battery cables | $54.40 | |
| A4613 | NU | IN | Battery charger | $151.42 | |
| A4613 | RR | IN | Battery charger | $15.15 | |
| A4613 | UE | IN | Battery charger | $109.50 | |
| A4614 | IN | Hand-held PEFR meter | $24.97 | ||
| A4615 | SU | Cannula nasal | $0.75 | ||
| A4616 | SU | Tubing (oxygen) per foot | $0.07 | ||
| A4617 | SU | Mouth piece | $3.25 | ||
| A4618 | NU | IN | Breathing circuits | $9.33 | |
| A4618 | RR | IN | Breathing circuits | $1.07 | |
| A4618 | UE | IN | Breathing circuits | $7.00 | |
| A4619 | OX | Face tent | $1.27 | ||
| A4620 | SU | Variable concentration mask | $0.62 | ||
| A4623 | OS | Tracheostomy inner cannula | $6.88 | ||
| A4624 | NU | IN | Tracheal suction tube | $2.47 | |
| A4625 | OS | Trach care kit for new trach | $7.28 | ||
| A4626 | OS | Tracheostomy cleaning brush | $3.35 | ||
| A4628 | NU | IN | Oropharyngeal suction cath | $3.85 | |
| A4629 | OS | Tracheostomy care kit | $4.86 | ||
| A4630 | NU | IN | Repl bat t.e.n.s. own by pt | $5.97 | |
| A4633 | NU | IN | Uvl replacement bulb | $43.09 | |
| A4635 | NU | IN | Underarm crutch pad | $5.38 | |
| A4635 | RR | IN | Underarm crutch pad | $0.72 | |
| A4635 | UE | IN | Underarm crutch pad | $3.56 | |
| A4636 | NU | IN | Handgrip for cane etc | $3.24 | |
| A4636 | NU | KE | IN | Handgrip for cane etc | $3.76 |
| A4636 | RR | IN | Handgrip for cane etc | $0.39 | |
| A4636 | RR | KE | IN | Handgrip for cane etc | $0.45 |
| A4636 | UE | IN | Handgrip for cane etc | $2.36 | |
| A4636 | UE | KE | IN | Handgrip for cane etc | $2.74 |
| A4637 | NU | IN | Repl tip cane/crutch/walker | $1.93 | |
| A4637 | NU | KE | IN | Repl tip cane/crutch/walker | $2.24 |
| A4637 | RR | IN | Repl tip cane/crutch/walker | $0.27 | |
| A4637 | RR | KE | IN | Repl tip cane/crutch/walker | $0.32 |
| A4637 | UE | IN | Repl tip cane/crutch/walker | $1.46 | |
| A4637 | UE | KE | IN | Repl tip cane/crutch/walker | $1.69 |
| A4638 | NU | IN | Repl batt pulse gen sys | $0.00 | |
| A4638 | RR | IN | Repl batt pulse gen sys | $0.00 | |
| A4638 | UE | IN | Repl batt pulse gen sys | $0.00 | |
| A4639 | NU | IN | Infrared ht sys replcmnt pad | $301.57 | |
| A4640 | NU | IN | Alternating pressure pad | $62.79 | |
| A4640 | RR | IN | Alternating pressure pad | $6.28 | |
| A4640 | UE | IN | Alternating pressure pad | $47.10 | |
| A5051 | OS | Pouch clsd w barr attached | $2.17 | ||
| A5052 | OS | Clsd ostomy pouch w/o barr | $1.56 | ||
| A5053 | OS | Clsd ostomy pouch faceplate | $1.83 | ||
| A5054 | OS | Clsd ostomy pouch w/flange | $1.88 | ||
| A5055 | OS | Stoma cap | $1.49 | ||
| A5061 | OS | Pouch drainable w barrier at | $3.70 | ||
| A5062 | OS | Drnble ostomy pouch w/o barr | $2.33 | ||
| A5063 | OS | Drain ostomy pouch w/flange | $2.84 | ||
| A5071 | OS | Urinary pouch w/barrier | $6.31 | ||
| A5072 | OS | Urinary pouch w/o barrier | $3.70 | ||
| A5073 | OS | Urinary pouch on barr w/flng | $3.34 | ||
| A5081 | OS | Continent stoma plug | $3.47 | ||
| A5082 | OS | Continent stoma catheter | $12.48 | ||
| A5083 | OS | Stoma absorptive cover | $0.66 | ||
| A5093 | OS | Ostomy accessory convex inse | $2.04 | ||
| A5102 | OS | Bedside drain btl w/wo tube | $23.54 | ||
| A5105 | OS | Urinary suspensory | $42.80 | ||
| A5112 | OS | Urinary leg bag | $30.90 | ||
| A5113 | OS | Latex leg strap | $4.94 | ||
| A5114 | OS | Foam/fabric leg strap | $9.39 | ||
| A5120 | AU | OS | Skin barrier, wipe or swab | $0.26 | |
| A5120 | AV | PO | Skin barrier, wipe or swab | $0.25 | |
| A5121 | OS | Solid skin barrier 6x6 | $6.87 | ||
| A5122 | OS | Solid skin barrier 8x8 | $11.47 | ||
| A5126 | OS | Disk/foam pad +or- adhesive | $1.39 | ||
| A5131 | OS | Appliance cleaner | $16.65 | ||
| A5200 | OS | Percutaneous catheter anchor | $11.87 | ||
| A5500 | TS | Diab shoe for density insert | $66.76 | ||
| A5501 | TS | Diabetic custom molded shoe | $200.25 | ||
| A5503 | TS | Diabetic shoe w/roller/rockr | $29.69 | ||
| A5504 | TS | Diabetic shoe with wedge | $29.69 | ||
| A5505 | TS | Diab shoe w/metatarsal bar | $29.69 | ||
| A5506 | TS | Diabetic shoe w/off set heel | $29.69 | ||
| A5507 | TS | Modification diabetic shoe | $29.69 | ||
| A5512 | TS | Multi den insert direct form | $27.24 | ||
| A5513 | TS | Multi den insert custom mold | $40.65 | ||
| A6010 | SD | Collagen based wound filler | $32.51 | ||
| A6011 | SD | Collagen gel/paste wound fil | $2.39 | ||
| A6021 | SD | Collagen dressing <=16 sq in | $22.07 | ||
| A6022 | SD | Collagen drsg>16<=48 sq in | $22.07 | ||
| A6023 | SD | Collagen dressing >48 sq in | $199.82 | ||
| A6024 | SD | Collagen dsg wound filler | $6.50 | ||
| A6154 | SD | Wound pouch each | $15.10 | ||
| A6196 | SD | Alginate dressing <=16 sq in | $7.72 | ||
| A6197 | SD | Alginate drsg >16 <=48 sq in | $17.26 | ||
| A6199 | SD | Alginate drsg wound filler | $5.55 | ||
| A6203 | SD | Composite drsg <= 16 sq in | $3.52 | ||
| A6204 | SD | Composite drsg >16<=48 sq in | $6.54 | ||
| A6207 | SD | Contact layer >16<= 48 sq in | $7.71 | ||
| A6209 | SD | Foam drsg <=16 sq in w/o bdr | $7.85 | ||
| A6210 | SD | Foam drg >16<=48 sq in w/o b | $20.92 | ||
| A6211 | SD | Foam drg > 48 sq in w/o brdr | $30.84 | ||
| A6212 | SD | Foam drg <=16 sq in w/border | $10.19 | ||
| A6214 | SD | Foam drg > 48 sq in w/border | $10.80 | ||
| A6216 | SD | Non-sterile gauze<=16 sq in | $0.05 | ||
| A6217 | SD | Non-sterile gauze>16<=48 sq | $0.00 | ||
| A6219 | SD | Gauze <= 16 sq in w/border | $1.00 | ||
| A6220 | SD | Gauze >16 <=48 sq in w/bordr | $2.71 | ||
| A6222 | SD | Gauze <=16 in no w/sal w/o b | $2.24 | ||
| A6223 | SD | Gauze >16<=48 no w/sal w/o b | $2.54 | ||
| A6224 | SD | Gauze > 48 in no w/sal w/o b | $3.79 | ||
| A6229 | SD | Gauze >16<=48 sq in watr/sal | $3.79 | ||
| A6231 | SD | Hydrogel dsg<=16 sq in | $4.89 | ||
| A6232 | SD | Hydrogel dsg>16<=48 sq in | $7.22 | ||
| A6233 | SD | Hydrogel dressing >48 sq in | $20.15 | ||
| A6234 | SD | Hydrocolld drg <=16 w/o bdr | $6.87 | ||
| A6235 | SD | Hydrocolld drg >16<=48 w/o b | $17.66 | ||
| A6236 | SD | Hydrocolld drg > 48 in w/o b | $28.61 | ||
| A6237 | SD | Hydrocolld drg <=16 in w/bdr | $8.31 | ||
| A6238 | SD | Hydrocolld drg >16<=48 w/bdr | $23.93 | ||
| A6240 | SD | Hydrocolld drg filler paste | $12.85 | ||
| A6241 | SD | Hydrocolloid drg filler dry | $2.70 | ||
| A6242 | SD | Hydrogel drg <=16 in w/o bdr | $6.37 | ||
| A6243 | SD | Hydrogel drg >16<=48 w/o bdr | $12.93 | ||
| A6244 | SD | Hydrogel drg >48 in w/o bdr | $41.24 | ||
| A6245 | SD | Hydrogel drg <= 16 in w/bdr | $7.63 | ||
| A6246 | SD | Hydrogel drg >16<=48 in w/b | $10.42 | ||
| A6247 | SD | Hydrogel drg > 48 sq in w/b | $24.97 | ||
| A6248 | SD | Hydrogel drsg gel filler | $17.05 | ||
| A6251 | SD | Absorpt drg <=16 sq in w/o b | $2.09 | ||
| A6252 | SD | Absorpt drg >16 <=48 w/o bdr | $3.41 | ||
| A6253 | SD | Absorpt drg > 48 sq in w/o b | $6.66 | ||
| A6254 | SD | Absorpt drg <=16 sq in w/bdr | $1.27 | ||
| A6255 | SD | Absorpt drg >16<=48 in w/bdr | $3.18 | ||
| A6257 | SD | Transparent film <= 16 sq in | $1.61 | ||
| A6258 | SD | Transparent film >16<=48 in | $4.52 | ||
| A6259 | SD | Transparent film > 48 sq in | $11.49 | ||
| A6266 | SD | Impreg gauze no h20/sal/yard | $2.02 | ||
| A6402 | SD | Sterile gauze <= 16 sq in | $0.13 | ||
| A6403 | SD | Sterile gauze>16 <= 48 sq in | $0.45 | ||
| A6407 | SD | Packing strips, non-impreg | $1.97 | ||
| A6410 | SD | Sterile eye pad | $0.41 | ||
| A6411 | SD | Non-sterile eye pad | $0.00 | ||
| A6441 | SD | Pad band w>=3" <5"/yd | $0.70 | ||
| A6442 | SD | Conform band n/s w<3"/yd | $0.18 | ||
| A6443 | SD | Conform band n/s w>=3"<5"/yd | $0.30 | ||
| A6444 | SD | Conform band n/s w>=5"/yd | $0.59 | ||
| A6445 | SD | Conform band s w <3"/yd | $0.34 | ||
| A6446 | SD | Conform band s w>=3" <5"/yd | $0.43 | ||
| A6447 | SD | Conform band s w >=5"/yd | $0.70 | ||
| A6448 | SD | Lt compres band <3"/yd | $1.22 | ||
| A6449 | SD | Lt compres band >=3" <5"/yd | $1.84 | ||
| A6450 | SD | Lt compres band >=5"/yd | $0.00 | ||
| A6451 | SD | Mod compres band w>=3"<5"/yd | $0.00 | ||
| A6452 | SD | High compres band w>=3"<5"yd | $6.21 | ||
| A6453 | SD | Self-adher band w <3"/yd | $0.64 | ||
| A6454 | SD | Self-adher band w>=3" <5"/yd | $0.81 | ||
| A6455 | SD | Self-adher band >=5"/yd | $1.46 | ||
| A6456 | SD | Zinc paste band w >=3"<5"/yd | $1.34 | ||
| A6457 | SD | Tubular dressing | $1.20 | ||
| A6501 | SD | Compres burngarment bodysuit | $0.00 | ||
| A6502 | SD | Compres burngarment chinstrp | $0.00 | ||
| A6503 | SD | Compres burngarment facehood | $0.00 | ||
| A6504 | SD | Cmprsburngarment glove-wrist | $0.00 | ||
| A6505 | SD | Cmprsburngarment glove-elbow | $0.00 | ||
| A6506 | SD | Cmprsburngrmnt glove-axilla | $0.00 | ||
| A6507 | SD | Cmprs burngarment foot-knee | $0.00 | ||
| A6508 | SD | Cmprs burngarment foot-thigh | $0.00 | ||
| A6509 | SD | Compres burn garment jacket | $0.00 | ||
| A6510 | SD | Compres burn garment leotard | $0.00 | ||
| A6511 | SD | Compres burn garment panty | $0.00 | ||
| A6513 | SD | Compress burn mask face/neck | $0.00 | ||
| A6531 | AW | SD | Compression stocking BK30-40 | $45.43 | |
| A6532 | AW | SD | Compression stocking BK40-50 | $64.01 | |
| A6545 | SD | Grad comp non-elastic BK | $0.00 | ||
| A6545 | AW | SD | Grad comp non-elastic BK | $89.45 | |
| A6550 | SU | Neg pres wound ther drsg set | $24.82 | ||
| A7000 | NU | IN | Disposable canister for pump | $7.54 | |
| A7000 | NU | KE | IN | Disposable canister for pump | $8.75 |
| A7001 | NU | IN | Nondisposable pump canister | $31.32 | |
| A7002 | NU | IN | Tubing used w suction pump | $3.63 | |
| A7003 | NU | IN | Nebulizer administration set | $2.87 | |
| A7004 | NU | IN | Disposable nebulizer sml vol | $1.61 | |
| A7005 | NU | IN | Nondisposable nebulizer set | $29.18 | |
| A7006 | NU | IN | Filtered nebulizer admin set | $8.55 | |
| A7007 | NU | IN | Lg vol nebulizer disposable | $4.17 | |
| A7008 | NU | IN | Disposable nebulizer prefill | $11.55 | |
| A7009 | NU | IN | Nebulizer reservoir bottle | $39.80 | |
| A7010 | NU | IN | Disposable corrugated tubing | $24.48 | |
| A7012 | NU | IN | Nebulizer water collec devic | $3.76 | |
| A7013 | NU | IN | Disposable compressor filter | $0.79 | |
| A7014 | NU | IN | Compressor nondispos filter | $4.24 | |
| A7015 | NU | IN | Aerosol mask used w nebulize | $1.73 | |
| A7016 | NU | IN | Nebulizer dome & mouthpiece | $6.85 | |
| A7017 | NU | IN | Nebulizer not used w oxygen | $140.74 | |
| A7017 | RR | IN | Nebulizer not used w oxygen | $14.07 | |
| A7017 | UE | IN | Nebulizer not used w oxygen | $105.55 | |
| A7018 | SU | Water distilled w/nebulizer | $0.40 | ||
| A7025 | NU | IN | Replace chest compress vest | $456.69 | |
| A7026 | NU | IN | Replace chst cmprss sys hose | $30.19 | |
| A7027 | NU | IN | Combination oral/nasal mask | $188.32 | |
| A7028 | NU | IN | Repl oral cushion combo mask | $52.02 | |
| A7029 | NU | IN | Repl nasal pillow comb mask | $21.25 | |
| A7030 | NU | IN | CPAP full face mask | $170.72 | |
| A7031 | NU | IN | Replacement facemask interfa | $63.14 | |
| A7032 | NU | IN | Replacement nasal cushion | $36.68 | |
| A7033 | NU | IN | Replacement nasal pillows | $25.71 | |
| A7034 | NU | IN | Nasal application device | $106.46 | |
| A7035 | NU | IN | Pos airway press headgear | $32.06 | |
| A7036 | NU | IN | Pos airway press chinstrap | $16.47 | |
| A7037 | NU | IN | Pos airway pressure tubing | $35.49 | |
| A7038 | NU | IN | Pos airway pressure filter | $4.15 | |
| A7039 | NU | IN | Filter, non disposable w pap | $13.87 | |
| A7040 | PO | One way chest drain valve | $41.45 | ||
| A7041 | PO | Water seal drain container | $77.90 | ||
| A7042 | PO | Implanted pleural catheter | $173.36 | ||
| A7043 | PO | Vacuum drainagebottle/tubing | $29.52 | ||
| A7044 | NU | IN | PAP oral interface | $109.42 | |
| A7045 | NU | IN | Repl exhalation port for PAP | $17.62 | |
| A7045 | RR | IN | Repl exhalation port for PAP | $1.76 | |
| A7045 | UE | IN | Repl exhalation port for PAP | $13.21 | |
| A7046 | NU | IN | Repl water chamber, PAP dev | $17.66 | |
| A7501 | OS | Tracheostoma valve w diaphra | $110.28 | ||
| A7502 | OS | Replacement diaphragm/fplate | $52.41 | ||
| A7503 | OS | HMES filter holder or cap | $11.90 | ||
| A7504 | OS | Tracheostoma HMES filter | $0.70 | ||
| A7505 | OS | HMES or trach valve housing | $4.91 | ||
| A7506 | OS | HMES/trachvalve adhesivedisk | $0.35 | ||
| A7507 | OS | Integrated filter & holder | $2.61 | ||
| A7508 | OS | Housing & Integrated Adhesiv | $3.01 | ||
| A7509 | OS | Heat & moisture exchange sys | $1.48 | ||
| A7520 | OS | Trach/laryn tube non-cuffed | $49.85 | ||
| A7521 | OS | Trach/laryn tube cuffed | $49.40 | ||
| A7522 | OS | Trach/laryn tube stainless | $47.42 | ||
| A7524 | OS | Tracheostoma stent/stud/bttn | $81.27 | ||
| A7525 | OS | Tracheostomy mask | $2.17 | ||
| A7526 | OS | Tracheostomy tube collar | $3.54 | ||
| A7527 | OS | Trach/laryn tube plug/stop | $3.76 | ||
| A8000 | NU | IN | Soft protect helmet prefab | $161.02 | |
| A8000 | RR | IN | Soft protect helmet prefab | $16.10 | |
| A8000 | UE | IN | Soft protect helmet prefab | $120.78 | |
| A8001 | NU | IN | Hard protect helmet prefab | $161.02 | |
| A8001 | RR | IN | Hard protect helmet prefab | $16.10 | |
| A8001 | UE | IN | Hard protect helmet prefab | $120.78 | |
| A8002 | NU | IN | Soft protect helmet custom | $0.00 | |
| A8002 | RR | IN | Soft protect helmet custom | $0.00 | |
| A8002 | UE | IN | Soft protect helmet custom | $0.00 | |
| A8003 | NU | IN | Hard protect helmet custom | $0.00 | |
| A8003 | RR | IN | Hard protect helmet custom | $0.00 | |
| A8003 | UE | IN | Hard protect helmet custom | $0.00 | |
| A8004 | NU | IN | Repl soft interface, helmet | $0.00 | |
| A8004 | RR | IN | Repl soft interface, helmet | $0.00 | |
| A8004 | UE | IN | Repl soft interface, helmet | $0.00 |
E codes: durable medical equipment
1,339 rows| Code | Mod | Mod 2 | Cat. | Description | Fee |
|---|---|---|---|---|---|
| E0100 | NU | IN | Cane adjust/fixed with tip | $19.69 | |
| E0100 | RR | IN | Cane adjust/fixed with tip | $5.30 | |
| E0100 | UE | IN | Cane adjust/fixed with tip | $15.25 | |
| E0105 | NU | IN | Cane adjust/fixed quad/3 pro | $51.57 | |
| E0105 | RR | IN | Cane adjust/fixed quad/3 pro | $7.91 | |
| E0105 | UE | IN | Cane adjust/fixed quad/3 pro | $38.05 | |
| E0110 | NU | IN | Crutch forearm pair | $76.20 | |
| E0110 | RR | IN | Crutch forearm pair | $14.27 | |
| E0110 | UE | IN | Crutch forearm pair | $57.14 | |
| E0111 | NU | IN | Crutch forearm each | $55.92 | |
| E0111 | RR | IN | Crutch forearm each | $8.75 | |
| E0111 | UE | IN | Crutch forearm each | $43.16 | |
| E0112 | NU | IN | Crutch underarm pair wood | $38.85 | |
| E0112 | RR | IN | Crutch underarm pair wood | $8.87 | |
| E0112 | UE | IN | Crutch underarm pair wood | $29.64 | |
| E0113 | NU | IN | Crutch underarm each wood | $22.19 | |
| E0113 | RR | IN | Crutch underarm each wood | $5.41 | |
| E0113 | UE | IN | Crutch underarm each wood | $16.65 | |
| E0114 | NU | IN | Crutch underarm pair no wood | $49.55 | |
| E0114 | RR | IN | Crutch underarm pair no wood | $9.00 | |
| E0114 | UE | IN | Crutch underarm pair no wood | $37.45 | |
| E0116 | NU | IN | Crutch underarm each no wood | $24.98 | |
| E0116 | RR | IN | Crutch underarm each no wood | $5.67 | |
| E0116 | UE | IN | Crutch underarm each no wood | $18.73 | |
| E0117 | NU | IN | Underarm springassist crutch | $202.35 | |
| E0117 | RR | IN | Underarm springassist crutch | $20.22 | |
| E0117 | UE | IN | Underarm springassist crutch | $151.78 | |
| E0130 | NU | IN | Walker rigid adjust/fixed ht | $63.42 | |
| E0130 | RR | IN | Walker rigid adjust/fixed ht | $15.22 | |
| E0130 | UE | IN | Walker rigid adjust/fixed ht | $47.52 | |
| E0135 | NU | IN | Walker folding adjust/fixed | $67.40 | |
| E0135 | RR | IN | Walker folding adjust/fixed | $15.62 | |
| E0135 | UE | IN | Walker folding adjust/fixed | $49.48 | |
| E0140 | NU | IN | Walker w trunk support | $326.44 | |
| E0140 | RR | IN | Walker w trunk support | $32.65 | |
| E0140 | UE | IN | Walker w trunk support | $244.84 | |
| E0141 | NU | IN | Rigid wheeled walker adj/fix | $104.34 | |
| E0141 | RR | IN | Rigid wheeled walker adj/fix | $20.24 | |
| E0141 | UE | IN | Rigid wheeled walker adj/fix | $78.26 | |
| E0143 | NU | IN | Walker folding wheeled w/o s | $108.81 | |
| E0143 | RR | IN | Walker folding wheeled w/o s | $19.54 | |
| E0143 | UE | IN | Walker folding wheeled w/o s | $81.43 | |
| E0144 | NU | IN | Enclosed walker w rear seat | $288.20 | |
| E0144 | RR | IN | Enclosed walker w rear seat | $24.51 | |
| E0144 | UE | IN | Enclosed walker w rear seat | $183.72 | |
| E0147 | NU | IN | Walker variable wheel resist | $520.20 | |
| E0147 | RR | IN | Walker variable wheel resist | $52.02 | |
| E0147 | UE | IN | Walker variable wheel resist | $390.17 | |
| E0148 | NU | IN | Heavyduty walker no wheels | $114.98 | |
| E0148 | RR | IN | Heavyduty walker no wheels | $11.51 | |
| E0148 | UE | IN | Heavyduty walker no wheels | $86.23 | |
| E0149 | NU | IN | Heavy duty wheeled walker | $202.00 | |
| E0149 | RR | IN | Heavy duty wheeled walker | $20.20 | |
| E0149 | UE | IN | Heavy duty wheeled walker | $151.49 | |
| E0153 | NU | IN | Forearm crutch platform atta | $72.85 | |
| E0153 | RR | IN | Forearm crutch platform atta | $8.23 | |
| E0153 | UE | IN | Forearm crutch platform atta | $54.63 | |
| E0154 | NU | IN | Walker platform attachment | $63.81 | |
| E0154 | RR | IN | Walker platform attachment | $7.75 | |
| E0154 | UE | IN | Walker platform attachment | $48.48 | |
| E0155 | NU | IN | Walker wheel attachment,pair | $28.56 | |
| E0155 | RR | IN | Walker wheel attachment,pair | $3.48 | |
| E0155 | UE | IN | Walker wheel attachment,pair | $21.77 | |
| E0156 | NU | IN | Walker seat attachment | $23.92 | |
| E0156 | RR | IN | Walker seat attachment | $3.06 | |
| E0156 | UE | IN | Walker seat attachment | $17.96 | |
| E0157 | NU | IN | Walker crutch attachment | $63.02 | |
| E0157 | RR | IN | Walker crutch attachment | $8.14 | |
| E0157 | UE | IN | Walker crutch attachment | $47.27 | |
| E0158 | NU | IN | Walker leg extenders set of4 | $29.12 | |
| E0158 | RR | IN | Walker leg extenders set of4 | $3.21 | |
| E0158 | UE | IN | Walker leg extenders set of4 | $21.98 | |
| E0159 | NU | IN | Brake for wheeled walker | $16.12 | |
| E0159 | RR | IN | Brake for wheeled walker | $1.63 | |
| E0159 | UE | IN | Brake for wheeled walker | $12.11 | |
| E0160 | NU | IN | Sitz type bath or equipment | $29.50 | |
| E0160 | RR | IN | Sitz type bath or equipment | $4.55 | |
| E0160 | UE | IN | Sitz type bath or equipment | $22.11 | |
| E0161 | NU | IN | Sitz bath/equipment w/faucet | $27.54 | |
| E0161 | RR | IN | Sitz bath/equipment w/faucet | $3.75 | |
| E0161 | UE | IN | Sitz bath/equipment w/faucet | $20.62 | |
| E0162 | NU | IN | Sitz bath chair | $152.99 | |
| E0162 | RR | IN | Sitz bath chair | $16.05 | |
| E0162 | UE | IN | Sitz bath chair | $118.65 | |
| E0163 | NU | IN | Commode chair with fixed arm | $115.80 | |
| E0163 | RR | IN | Commode chair with fixed arm | $25.65 | |
| E0163 | UE | IN | Commode chair with fixed arm | $80.80 | |
| E0165 | RR | CR | Commode chair with detacharm | $19.13 | |
| E0167 | NU | IN | Commode chair pail or pan | $12.60 | |
| E0167 | RR | IN | Commode chair pail or pan | $1.32 | |
| E0167 | UE | IN | Commode chair pail or pan | $9.49 | |
| E0168 | NU | IN | Heavyduty/wide commode chair | $158.47 | |
| E0168 | RR | IN | Heavyduty/wide commode chair | $15.93 | |
| E0168 | UE | IN | Heavyduty/wide commode chair | $118.84 | |
| E0170 | RR | CR | Commode chair electric | $168.76 | |
| E0171 | RR | CR | Commode chair non-electric | $30.37 | |
| E0175 | NU | IN | Commode chair foot rest | $69.54 | |
| E0175 | RR | IN | Commode chair foot rest | $5.91 | |
| E0175 | UE | IN | Commode chair foot rest | $43.50 | |
| E0181 | RR | CR | Press pad alternating w/ pum | $27.36 | |
| E0182 | RR | CR | Replace pump, alt press pad | $27.49 | |
| E0184 | NU | IN | Dry pressure mattress | $173.77 | |
| E0184 | RR | IN | Dry pressure mattress | $25.80 | |
| E0184 | UE | IN | Dry pressure mattress | $133.27 | |
| E0185 | NU | IN | Gel pressure mattress pad | $285.47 | |
| E0185 | RR | IN | Gel pressure mattress pad | $47.19 | |
| E0185 | UE | IN | Gel pressure mattress pad | $219.09 | |
| E0186 | RR | CR | Air pressure mattress | $21.32 | |
| E0187 | RR | CR | Water pressure mattress | $23.70 | |
| E0188 | NU | IN | Synthetic sheepskin pad | $27.75 | |
| E0188 | RR | IN | Synthetic sheepskin pad | $3.26 | |
| E0188 | UE | IN | Synthetic sheepskin pad | $20.84 | |
| E0189 | NU | IN | Lambswool sheepskin pad | $46.38 | |
| E0189 | RR | IN | Lambswool sheepskin pad | $5.91 | |
| E0189 | UE | IN | Lambswool sheepskin pad | $34.79 | |
| E0191 | NU | IN | Protector heel or elbow | $10.49 | |
| E0191 | RR | IN | Protector heel or elbow | $1.07 | |
| E0191 | UE | IN | Protector heel or elbow | $7.83 | |
| E0193 | RR | CR | Powered air flotation bed | $786.82 | |
| E0194 | RR | CR | Air fluidized bed | $3,307.35 | |
| E0196 | RR | CR | Gel pressure mattress | $28.99 | |
| E0197 | NU | IN | Air pressure pad for mattres | $197.76 | |
| E0197 | RR | IN | Air pressure pad for mattres | $32.10 | |
| E0197 | UE | IN | Air pressure pad for mattres | $173.71 | |
| E0198 | NU | IN | Water pressure pad for mattr | $197.76 | |
| E0198 | RR | IN | Water pressure pad for mattr | $24.10 | |
| E0198 | UE | IN | Water pressure pad for mattr | $150.07 | |
| E0199 | NU | IN | Dry pressure pad for mattres | $33.65 | |
| E0199 | RR | IN | Dry pressure pad for mattres | $3.35 | |
| E0199 | UE | IN | Dry pressure pad for mattres | $25.24 | |
| E0200 | NU | IN | Heat lamp without stand | $70.75 | |
| E0200 | RR | IN | Heat lamp without stand | $11.30 | |
| E0200 | UE | IN | Heat lamp without stand | $53.09 | |
| E0202 | RR | CR | Phototherapy light w/ photom | $65.74 | |
| E0205 | NU | IN | Heat lamp with stand | $173.20 | |
| E0205 | RR | IN | Heat lamp with stand | $20.84 | |
| E0205 | UE | IN | Heat lamp with stand | $129.90 | |
| E0210 | NU | IN | Electric heat pad standard | $34.27 | |
| E0210 | RR | IN | Electric heat pad standard | $3.22 | |
| E0210 | UE | IN | Electric heat pad standard | $25.70 | |
| E0215 | NU | IN | Electric heat pad moist | $63.22 | |
| E0215 | RR | IN | Electric heat pad moist | $6.95 | |
| E0215 | UE | IN | Electric heat pad moist | $47.43 | |
| E0217 | NU | IN | Water circ heat pad w pump | $443.10 | |
| E0217 | RR | IN | Water circ heat pad w pump | $49.33 | |
| E0217 | UE | IN | Water circ heat pad w pump | $332.30 | |
| E0220 | NU | IN | Hot water bottle | $7.56 | |
| E0220 | RR | IN | Hot water bottle | $0.79 | |
| E0220 | UE | IN | Hot water bottle | $5.65 | |
| E0225 | NU | IN | Hydrocollator unit | $346.87 | |
| E0225 | RR | IN | Hydrocollator unit | $34.20 | |
| E0225 | UE | IN | Hydrocollator unit | $260.14 | |
| E0230 | NU | IN | Ice cap or collar | $7.57 | |
| E0230 | RR | IN | Ice cap or collar | $0.85 | |
| E0230 | UE | IN | Ice cap or collar | $5.66 | |
| E0235 | RR | CR | Paraffin bath unit portable | $18.12 | |
| E0236 | RR | CR | Pump for water circulating p | $40.19 | |
| E0238 | NU | IN | Heat pad non-electric moist | $28.38 | |
| E0238 | RR | IN | Heat pad non-electric moist | $2.86 | |
| E0238 | UE | IN | Heat pad non-electric moist | $20.87 | |
| E0239 | NU | IN | Hydrocollator unit portable | $472.32 | |
| E0239 | RR | IN | Hydrocollator unit portable | $47.24 | |
| E0239 | UE | IN | Hydrocollator unit portable | $354.26 | |
| E0249 | NU | IN | Pad water circulating heat u | $104.58 | |
| E0249 | RR | IN | Pad water circulating heat u | $11.50 | |
| E0249 | UE | IN | Pad water circulating heat u | $78.44 | |
| E0250 | RR | CR | Hosp bed fixed ht w/ mattres | $84.09 | |
| E0251 | RR | CR | Hosp bed fixd ht w/o mattres | $61.24 | |
| E0255 | RR | CR | Hospital bed var ht w/ mattr | $91.93 | |
| E0256 | RR | CR | Hospital bed var ht w/o matt | $64.12 | |
| E0260 | RR | CR | Hosp bed semi-electr w/ matt | $127.12 | |
| E0261 | RR | CR | Hosp bed semi-electr w/o mat | $105.34 | |
| E0265 | RR | CR | Hosp bed total electr w/ mat | $173.87 | |
| E0266 | RR | CR | Hosp bed total elec w/o matt | $160.72 | |
| E0271 | NU | IN | Mattress innerspring | $191.13 | |
| E0271 | RR | IN | Mattress innerspring | $20.87 | |
| E0271 | UE | IN | Mattress innerspring | $143.32 | |
| E0272 | NU | IN | Mattress foam rubber | $176.39 | |
| E0272 | RR | IN | Mattress foam rubber | $19.12 | |
| E0272 | UE | IN | Mattress foam rubber | $132.29 | |
| E0275 | NU | IN | Bed pan standard | $16.08 | |
| E0275 | RR | IN | Bed pan standard | $1.68 | |
| E0275 | UE | IN | Bed pan standard | $12.05 | |
| E0276 | NU | IN | Bed pan fracture | $13.97 | |
| E0276 | RR | IN | Bed pan fracture | $1.65 | |
| E0276 | UE | IN | Bed pan fracture | $11.05 | |
| E0277 | RR | CR | Powered pres-redu air mattrs | $584.14 | |
| E0280 | NU | IN | Bed cradle | $33.49 | |
| E0280 | RR | IN | Bed cradle | $3.72 | |
| E0280 | UE | IN | Bed cradle | $25.11 | |
| E0290 | RR | CR | Hosp bed fx ht w/o rails w/m | $57.49 | |
| E0291 | RR | CR | Hosp bed fx ht w/o rail w/o | $41.77 | |
| E0292 | RR | CR | Hosp bed var ht w/o rail w/o | $64.65 | |
| E0293 | RR | CR | Hosp bed var ht w/o rail w/ | $62.16 | |
| E0294 | RR | CR | Hosp bed semi-elect w/ mattr | $100.88 | |
| E0295 | RR | CR | Hosp bed semi-elect w/o matt | $100.88 | |
| E0296 | RR | CR | Hosp bed total elect w/ matt | $127.56 | |
| E0297 | RR | CR | Hosp bed total elect w/o mat | $127.31 | |
| E0300 | NU | IN | Enclosed ped crib hosp grade | $2,568.95 | |
| E0300 | RR | IN | Enclosed ped crib hosp grade | $256.89 | |
| E0300 | UE | IN | Enclosed ped crib hosp grade | $1,926.71 | |
| E0301 | RR | CR | HD hosp bed, 350-600 lbs | $228.58 | |
| E0302 | RR | CR | Ex hd hosp bed > 600 lbs | $647.47 | |
| E0303 | RR | CR | Hosp bed hvy dty xtra wide | $258.68 | |
| E0304 | RR | CR | Hosp bed xtra hvy dty x wide | $697.46 | |
| E0305 | RR | CR | Rails bed side half length | $13.69 | |
| E0310 | NU | IN | Rails bed side full length | $175.70 | |
| E0310 | RR | IN | Rails bed side full length | $20.60 | |
| E0310 | UE | IN | Rails bed side full length | $132.95 | |
| E0316 | RR | CR | Bed safety enclosure | $191.21 | |
| E0325 | NU | IN | Urinal male jug-type | $9.03 | |
| E0325 | RR | IN | Urinal male jug-type | $1.59 | |
| E0325 | UE | IN | Urinal male jug-type | $6.48 | |
| E0326 | NU | IN | Urinal female jug-type | $11.03 | |
| E0326 | RR | IN | Urinal female jug-type | $1.25 | |
| E0326 | UE | IN | Urinal female jug-type | $8.26 | |
| E0371 | RR | CR | Nonpower mattress overlay | $377.47 | |
| E0372 | RR | CR | Powered air mattress overlay | $458.01 | |
| E0373 | RR | CR | Nonpowered pressure mattress | $524.67 | |
| E0424 | RR | OX | Stationary compressed gas 02 | $173.17 | |
| E0431 | RR | OX | Portable gaseous 02 | $28.77 | |
| E0433 | RR | OX | Portable liquid oxygen sys | $51.63 | |
| E0434 | RR | OX | Portable liquid 02 | $28.77 | |
| E0439 | RR | OX | Stationary liquid 02 | $173.17 | |
| E0441 | OX | Stationary O2 contents, gas | $77.45 | ||
| E0442 | OX | Stationary O2 contents, liq | $77.45 | ||
| E0443 | OX | Portable 02 contents, gas | $77.45 | ||
| E0444 | OX | Portable 02 contents, liquid | $77.45 | ||
| E0450 | RR | FS | Vol control vent invasiv int | $1,002.25 | |
| E0457 | NU | IN | Chest shell | $645.24 | |
| E0457 | RR | IN | Chest shell | $64.52 | |
| E0457 | UE | IN | Chest shell | $483.89 | |
| E0459 | RR | CR | Chest wrap | $53.43 | |
| E0460 | RR | FS | Neg press vent portabl/statn | $654.71 | |
| E0461 | RR | FS | Vol control vent noninv int | $1,002.25 | |
| E0462 | RR | CR | Rocking bed w/ or w/o side r | $305.97 | |
| E0463 | RR | FS | Press supp vent invasive int | $1,476.70 | |
| E0464 | RR | FS | Press supp vent noninv int | $1,476.70 | |
| E0470 | RR | CR | RAD w/o backup non-inv intfc | $197.39 | |
| E0471 | RR | CR | RAD w/backup non inv intrfc | $493.99 | |
| E0472 | RR | CR | RAD w backup invasive intrfc | $493.99 | |
| E0480 | RR | CR | Percussor elect/pneum home m | $46.14 | |
| E0482 | RR | CR | Cough stimulating device | $423.71 | |
| E0483 | RR | CR | Chest compression gen system | $1,116.29 | |
| E0484 | NU | IN | Non-elec oscillatory pep dvc | $38.77 | |
| E0484 | RR | IN | Non-elec oscillatory pep dvc | $3.87 | |
| E0484 | UE | IN | Non-elec oscillatory pep dvc | $29.09 | |
| E0485 | NU | IN | Oral device/appliance prefab | $0.00 | |
| E0485 | RR | IN | Oral device/appliance prefab | $0.00 | |
| E0485 | UE | IN | Oral device/appliance prefab | $0.00 | |
| E0486 | NU | IN | Oral device/appliance cusfab | $0.00 | |
| E0486 | RR | IN | Oral device/appliance cusfab | $0.00 | |
| E0486 | UE | IN | Oral device/appliance cusfab | $0.00 | |
| E0500 | RR | FS | Ippb all types | $115.26 | |
| E0550 | RR | CR | Humidif extens supple w ippb | $52.64 | |
| E0560 | NU | IN | Humidifier supplemental w/ i | $131.95 | |
| E0560 | RR | IN | Humidifier supplemental w/ i | $15.46 | |
| E0560 | UE | IN | Humidifier supplemental w/ i | $98.96 | |
| E0561 | NU | IN | Humidifier nonheated w PAP | $96.84 | |
| E0561 | RR | IN | Humidifier nonheated w PAP | $9.67 | |
| E0561 | UE | IN | Humidifier nonheated w PAP | $72.62 | |
| E0562 | NU | IN | Humidifier heated used w PAP | $272.60 | |
| E0562 | RR | IN | Humidifier heated used w PAP | $27.25 | |
| E0562 | UE | IN | Humidifier heated used w PAP | $204.45 | |
| E0565 | RR | CR | Compressor air power source | $54.45 | |
| E0570 | RR | CR | Nebulizer with compression | $16.91 | |
| E0571 | RR | CR | Aerosol compressor for svneb | $29.69 | |
| E0572 | RR | CR | Aerosol compressor adjust pr | $37.73 | |
| E0574 | RR | CR | Ultrasonic generator w svneb | $39.87 | |
| E0575 | RR | FS | Nebulizer ultrasonic | $107.92 | |
| E0580 | NU | IN | Nebulizer for use w/ regulat | $121.31 | |
| E0580 | RR | IN | Nebulizer for use w/ regulat | $12.13 | |
| E0580 | UE | IN | Nebulizer for use w/ regulat | $90.97 | |
| E0585 | RR | CR | Nebulizer w/ compressor & he | $36.82 | |
| E0600 | RR | CR | Suction pump portab hom modl | $46.23 | |
| E0601 | RR | CR | Cont airway pressure device | $90.59 | |
| E0602 | NU | IN | Manual breast pump | $31.00 | |
| E0602 | RR | IN | Manual breast pump | $3.11 | |
| E0602 | UE | IN | Manual breast pump | $23.25 | |
| E0605 | NU | IN | Vaporizer room type | $27.75 | |
| E0605 | RR | IN | Vaporizer room type | $3.22 | |
| E0605 | UE | IN | Vaporizer room type | $22.86 | |
| E0606 | RR | CR | Drainage board postural | $20.48 | |
| E0607 | NU | IN | Blood glucose monitor home | $70.16 | |
| E0607 | RR | IN | Blood glucose monitor home | $7.01 | |
| E0607 | UE | IN | Blood glucose monitor home | $52.61 | |
| E0610 | NU | IN | Pacemaker monitr audible/vis | $249.75 | |
| E0610 | RR | IN | Pacemaker monitr audible/vis | $26.34 | |
| E0610 | UE | IN | Pacemaker monitr audible/vis | $187.34 | |
| E0615 | NU | IN | Pacemaker monitr digital/vis | $442.62 | |
| E0615 | RR | IN | Pacemaker monitr digital/vis | $61.43 | |
| E0615 | UE | IN | Pacemaker monitr digital/vis | $331.97 | |
| E0617 | RR | CR | Automatic ext defibrillator | $319.25 | |
| E0617 | RR | KF | CR | Automatic ext defibrillator | $354.45 |
| E0618 | RR | CR | Apnea monitor | $257.49 | |
| E0619 | RR | CR | Apnea monitor w recorder | $0.00 | |
| E0620 | NU | IN | Cap bld skin piercing laser | $918.11 | |
| E0620 | RR | IN | Cap bld skin piercing laser | $91.80 | |
| E0620 | UE | IN | Cap bld skin piercing laser | $688.58 | |
| E0621 | NU | IN | Patient lift sling or seat | $85.67 | |
| E0621 | RR | IN | Patient lift sling or seat | $9.71 | |
| E0621 | UE | IN | Patient lift sling or seat | $64.58 | |
| E0627 | NU | IN | Seat lift incorp lift-chair | $347.25 | |
| E0627 | RR | IN | Seat lift incorp lift-chair | $34.73 | |
| E0627 | UE | IN | Seat lift incorp lift-chair | $260.41 | |
| E0628 | NU | IN | Seat lift for pt furn-electr | $347.25 | |
| E0628 | RR | IN | Seat lift for pt furn-electr | $34.73 | |
| E0628 | UE | IN | Seat lift for pt furn-electr | $260.41 | |
| E0629 | NU | IN | Seat lift for pt furn-non-el | $347.25 | |
| E0629 | RR | IN | Seat lift for pt furn-non-el | $34.73 | |
| E0629 | UE | IN | Seat lift for pt furn-non-el | $260.41 | |
| E0630 | RR | CR | Patient lift hydraulic | $101.67 | |
| E0635 | RR | CR | Patient lift electric | $109.21 | |
| E0636 | RR | CR | PT support & positioning sys | $1,107.29 | |
| E0650 | NU | IN | Pneuma compresor non-segment | $686.85 | |
| E0650 | RR | IN | Pneuma compresor non-segment | $93.31 | |
| E0650 | UE | IN | Pneuma compresor non-segment | $515.15 | |
| E0651 | NU | IN | Pneum compressor segmental | $964.34 | |
| E0651 | RR | IN | Pneum compressor segmental | $96.44 | |
| E0651 | UE | IN | Pneum compressor segmental | $723.26 | |
| E0652 | NU | IN | Pneum compres w/cal pressure | $4,731.54 | |
| E0652 | RR | IN | Pneum compres w/cal pressure | $467.63 | |
| E0652 | UE | IN | Pneum compres w/cal pressure | $4,126.23 | |
| E0655 | NU | IN | Pneumatic appliance half arm | $109.78 | |
| E0655 | RR | IN | Pneumatic appliance half arm | $13.31 | |
| E0655 | UE | IN | Pneumatic appliance half arm | $82.31 | |
| E0656 | NU | IN | Segmental pneumatic trunk | $606.60 | |
| E0656 | RR | IN | Segmental pneumatic trunk | $60.59 | |
| E0656 | UE | IN | Segmental pneumatic trunk | $455.01 | |
| E0657 | NU | IN | Segmental pneumatic chest | $569.88 | |
| E0657 | RR | IN | Segmental pneumatic chest | $56.89 | |
| E0657 | UE | IN | Segmental pneumatic chest | $427.44 | |
| E0660 | NU | IN | Pneumatic appliance full leg | $167.74 | |
| E0660 | RR | IN | Pneumatic appliance full leg | $17.46 | |
| E0660 | UE | IN | Pneumatic appliance full leg | $115.91 | |
| E0665 | NU | IN | Pneumatic appliance full arm | $122.26 | |
| E0665 | RR | IN | Pneumatic appliance full arm | $14.77 | |
| E0665 | UE | IN | Pneumatic appliance full arm | $91.82 | |
| E0666 | NU | IN | Pneumatic appliance half leg | $144.98 | |
| E0666 | RR | IN | Pneumatic appliance half leg | $14.94 | |
| E0666 | UE | IN | Pneumatic appliance half leg | $108.77 | |
| E0667 | NU | IN | Seg pneumatic appl full leg | $339.96 | |
| E0667 | RR | IN | Seg pneumatic appl full leg | $34.00 | |
| E0667 | UE | IN | Seg pneumatic appl full leg | $254.96 | |
| E0668 | NU | IN | Seg pneumatic appl full arm | $394.37 | |
| E0668 | RR | IN | Seg pneumatic appl full arm | $38.92 | |
| E0668 | UE | IN | Seg pneumatic appl full arm | $295.79 | |
| E0669 | NU | IN | Seg pneumatic appli half leg | $182.76 | |
| E0669 | RR | IN | Seg pneumatic appli half leg | $18.28 | |
| E0669 | UE | IN | Seg pneumatic appli half leg | $137.09 | |
| E0671 | NU | IN | Pressure pneum appl full leg | $436.12 | |
| E0671 | RR | IN | Pressure pneum appl full leg | $43.62 | |
| E0671 | UE | IN | Pressure pneum appl full leg | $327.08 | |
| E0672 | NU | IN | Pressure pneum appl full arm | $338.87 | |
| E0672 | RR | IN | Pressure pneum appl full arm | $33.89 | |
| E0672 | UE | IN | Pressure pneum appl full arm | $254.16 | |
| E0673 | NU | IN | Pressure pneum appl half leg | $281.58 | |
| E0673 | RR | IN | Pressure pneum appl half leg | $28.16 | |
| E0673 | UE | IN | Pressure pneum appl half leg | $211.21 | |
| E0675 | RR | CR | Pneumatic compression device | $403.78 | |
| E0691 | NU | IN | Uvl pnl 2 sq ft or less | $943.52 | |
| E0691 | RR | IN | Uvl pnl 2 sq ft or less | $94.35 | |
| E0691 | UE | IN | Uvl pnl 2 sq ft or less | $707.64 | |
| E0692 | NU | IN | Uvl sys panel 4 ft | $1,184.79 | |
| E0692 | RR | IN | Uvl sys panel 4 ft | $118.47 | |
| E0692 | UE | IN | Uvl sys panel 4 ft | $888.60 | |
| E0693 | NU | IN | Uvl sys panel 6 ft | $1,460.53 | |
| E0693 | RR | IN | Uvl sys panel 6 ft | $146.06 | |
| E0693 | UE | IN | Uvl sys panel 6 ft | $1,095.40 | |
| E0694 | NU | IN | Uvl md cabinet sys 6 ft | $4,648.71 | |
| E0694 | RR | IN | Uvl md cabinet sys 6 ft | $464.87 | |
| E0694 | UE | IN | Uvl md cabinet sys 6 ft | $3,486.56 | |
| E0705 | NU | IN | Transfer device | $49.59 | |
| E0705 | RR | IN | Transfer device | $5.01 | |
| E0705 | UE | IN | Transfer device | $37.21 | |
| E0720 | NU | TE | Tens two lead | $95.00 | |
| E0730 | NU | TE | Tens four lead | $100.00 | |
| E0731 | NU | IN | Conductive garment for tens/ | $374.52 | |
| E0740 | NU | IN | Incontinence treatment systm | $549.01 | |
| E0740 | RR | IN | Incontinence treatment systm | $54.90 | |
| E0740 | UE | IN | Incontinence treatment systm | $411.79 | |
| E0744 | RR | CR | Neuromuscular stim for scoli | $96.15 | |
| E0745 (printed EO745) | NU | IN | Neuromuscular stim for shock | $200.00 | |
| E0745 | RR | CR | Neuromuscular stim for shock | $20.00 | |
| E0747 | NU | KF | IN | Elec osteogen stim not spine | $3,963.48 |
| E0747 | RR | KF | IN | Elec osteogen stim not spine | $396.32 |
| E0747 | UE | KF | IN | Elec osteogen stim not spine | $2,972.60 |
| E0748 | NU | KF | IN | Elec osteogen stim spinal | $4,085.24 |
| E0748 | RR | KF | IN | Elec osteogen stim spinal | $408.52 |
| E0748 | UE | KF | IN | Elec osteogen stim spinal | $3,063.94 |
| E0749 | RR | KF | CR | Elec osteogen stim implanted | $298.59 |
| E0760 | NU | KF | IN | Osteogen ultrasound stimltor | $3,394.76 |
| E0760 | RR | KF | IN | Osteogen ultrasound stimltor | $339.49 |
| E0760 | UE | KF | IN | Osteogen ultrasound stimltor | $2,546.07 |
| E0762 | NU | IN | Trans elec jt stim dev sys | $1,154.54 | |
| E0762 | RR | IN | Trans elec jt stim dev sys | $115.46 | |
| E0762 | UE | IN | Trans elec jt stim dev sys | $865.88 | |
| E0764 | NU | KF | IN | Functional neuromuscularstim | $11,620.16 |
| E0764 | RR | KF | IN | Functional neuromuscularstim | $1,162.00 |
| E0764 | UE | KF | IN | Functional neuromuscularstim | $8,715.13 |
| E0765 | NU | IN | Nerve stimulator for tx n&v | $88.34 | |
| E0765 | RR | IN | Nerve stimulator for tx n&v | $8.85 | |
| E0765 | UE | IN | Nerve stimulator for tx n&v | $66.28 | |
| E0776 | NU | IN | Iv pole | $127.77 | |
| E0776 | RR | IN | Iv pole | $19.58 | |
| E0776 | UE | IN | Iv pole | $94.01 | |
| E0779 | RR | CR | Amb infusion pump mechanical | $17.57 | |
| E0780 | NU | IN | Mech amb infusion pump <8hrs | $10.89 | |
| E0781 | RR | CR | External ambulatory infus pu | $236.39 | |
| E0782 | NU | KF | IN | Non-programble infusion pump | $4,508.08 |
| E0782 | RR | KF | IN | Non-programble infusion pump | $450.83 |
| E0782 | UE | KF | IN | Non-programble infusion pump | $3,381.07 |
| E0783 | NU | KF | IN | Programmable infusion pump | $8,202.34 |
| E0783 | RR | KF | IN | Programmable infusion pump | $820.25 |
| E0783 | UE | KF | IN | Programmable infusion pump | $6,151.77 |
| E0784 | RR | CR | Ext amb infusn pump insulin | $438.45 | |
| E0785 | KF | IN | Replacement impl pump cathet | $421.71 | |
| E0786 | NU | KF | IN | Implantable pump replacement | $8,082.48 |
| E0786 | RR | KF | IN | Implantable pump replacement | $808.25 |
| E0786 | UE | KF | IN | Implantable pump replacement | $6,061.88 |
| E0791 | RR | CR | Parenteral infusion pump sta | $282.21 | |
| E0840 | NU | IN | Tract frame attach headboard | $65.40 | |
| E0840 | RR | IN | Tract frame attach headboard | $14.57 | |
| E0840 | UE | IN | Tract frame attach headboard | $49.03 | |
| E0849 | NU | IN | Cervical pneum trac equip | $541.08 | |
| E0849 | RR | IN | Cervical pneum trac equip | $54.11 | |
| E0849 | UE | IN | Cervical pneum trac equip | $405.78 | |
| E0850 | NU | IN | Traction stand free standing | $93.76 | |
| E0850 | RR | IN | Traction stand free standing | $12.88 | |
| E0850 | UE | IN | Traction stand free standing | $70.33 | |
| E0855 | NU | IN | Cervical traction equipment | $527.76 | |
| E0855 | RR | IN | Cervical traction equipment | $52.77 | |
| E0855 | UE | IN | Cervical traction equipment | $395.81 | |
| E0856 | NU | IN | Cervic collar w air bladder | $161.73 | |
| E0856 | RR | IN | Cervic collar w air bladder | $16.19 | |
| E0856 | UE | IN | Cervic collar w air bladder | $121.31 | |
| E0860 | NU | IN | Tract equip cervical tract | $35.74 | |
| E0860 | RR | IN | Tract equip cervical tract | $6.84 | |
| E0860 | UE | IN | Tract equip cervical tract | $26.81 | |
| E0870 | NU | IN | Tract frame attach footboard | $110.31 | |
| E0870 | RR | IN | Tract frame attach footboard | $13.88 | |
| E0870 | UE | IN | Tract frame attach footboard | $82.74 | |
| E0880 | NU | IN | Trac stand free stand extrem | $112.05 | |
| E0880 | RR | IN | Trac stand free stand extrem | $20.70 | |
| E0880 | UE | IN | Trac stand free stand extrem | $84.80 | |
| E0890 | NU | IN | Traction frame attach pelvic | $107.47 | |
| E0890 | RR | IN | Traction frame attach pelvic | $34.47 | |
| E0890 | UE | IN | Traction frame attach pelvic | $86.56 | |
| E0900 | NU | IN | Trac stand free stand pelvic | $114.35 | |
| E0900 | RR | IN | Trac stand free stand pelvic | $29.00 | |
| E0900 | UE | IN | Trac stand free stand pelvic | $85.79 | |
| E0910 | RR | CR | Trapeze bar attached to bed | $17.70 | |
| E0911 | RR | CR | HD trapeze bar attach to bed | $45.11 | |
| E0912 | RR | CR | HD trapeze bar free standing | $103.60 | |
| E0920 | RR | CR | Fracture frame attached to b | $41.67 | |
| E0930 | RR | CR | Fracture frame free standing | $41.67 | |
| E0935 | RR | FS | Cont pas motion exercise dev | $23.87 | |
| E0940 | RR | CR | Trapeze bar free standing | $28.67 | |
| E0941 | RR | CR | Gravity assisted traction de | $40.67 | |
| E0942 | NU | IN | Cervical head harness/halter | $20.84 | |
| E0942 | RR | IN | Cervical head harness/halter | $2.46 | |
| E0942 | UE | IN | Cervical head harness/halter | $15.62 | |
| E0944 | NU | IN | Pelvic belt/harness/boot | $43.08 | |
| E0944 | RR | IN | Pelvic belt/harness/boot | $4.83 | |
| E0944 | UE | IN | Pelvic belt/harness/boot | $32.32 | |
| E0945 | NU | IN | Belt/harness extremity | $46.54 | |
| E0945 | RR | IN | Belt/harness extremity | $4.66 | |
| E0945 | UE | IN | Belt/harness extremity | $36.03 | |
| E0946 | RR | CR | Fracture frame dual w cross | $62.12 | |
| E0947 | NU | IN | Fracture frame attachmnts pe | $636.78 | |
| E0947 | RR | IN | Fracture frame attachmnts pe | $66.03 | |
| E0947 | UE | IN | Fracture frame attachmnts pe | $477.58 | |
| E0948 | NU | IN | Fracture frame attachmnts ce | $615.92 | |
| E0948 | RR | IN | Fracture frame attachmnts ce | $61.57 | |
| E0948 | UE | IN | Fracture frame attachmnts ce | $434.39 | |
| E0950 | NU | IN | Tray | $94.07 | |
| E0950 | NU | KE | IN | Tray | $109.15 |
| E0950 | RR | IN | Tray | $9.42 | |
| E0950 | RR | KE | IN | Tray | $10.93 |
| E0950 | UE | IN | Tray | $70.56 | |
| E0950 | UE | KE | IN | Tray | $81.87 |
| E0951 | NU | IN | Loop heel | $17.18 | |
| E0951 | NU | KE | IN | Loop heel | $19.93 |
| E0951 | RR | IN | Loop heel | $1.72 | |
| E0951 | RR | KE | IN | Loop heel | $2.00 |
| E0951 | UE | IN | Loop heel | $12.87 | |
| E0951 | UE | KE | IN | Loop heel | $14.93 |
| E0952 | NU | IN | Toe loop/holder, each | $17.04 | |
| E0952 | NU | KE | IN | Toe loop/holder, each | $19.77 |
| E0952 | RR | IN | Toe loop/holder, each | $1.71 | |
| E0952 | RR | KE | IN | Toe loop/holder, each | $1.98 |
| E0952 | UE | IN | Toe loop/holder, each | $12.79 | |
| E0952 | UE | KE | IN | Toe loop/holder, each | $14.84 |
| E0955 | NU | IN | Cushioned headrest | $182.97 | |
| E0955 | NU | KE | IN | Cushioned headrest | $212.29 |
| E0955 | RR | IN | Cushioned headrest | $18.31 | |
| E0955 | RR | KE | IN | Cushioned headrest | $21.24 |
| E0955 | UE | IN | Cushioned headrest | $137.23 | |
| E0955 | UE | KE | IN | Cushioned headrest | $159.21 |
| E0956 | NU | IN | W/c lateral trunk/hip suppor | $89.21 | |
| E0956 | NU | KE | IN | W/c lateral trunk/hip suppor | $103.51 |
| E0956 | RR | IN | W/c lateral trunk/hip suppor | $8.93 | |
| E0956 | RR | KE | IN | W/c lateral trunk/hip suppor | $10.36 |
| E0956 | UE | IN | W/c lateral trunk/hip suppor | $66.91 | |
| E0956 | UE | KE | IN | W/c lateral trunk/hip suppor | $77.63 |
| E0957 | NU | IN | W/c medial thigh support | $124.83 | |
| E0957 | NU | KE | IN | W/c medial thigh support | $144.83 |
| E0957 | RR | IN | W/c medial thigh support | $12.48 | |
| E0957 | RR | KE | IN | W/c medial thigh support | $14.48 |
| E0957 | UE | IN | W/c medial thigh support | $93.62 | |
| E0957 | UE | KE | IN | W/c medial thigh support | $108.62 |
| E0958 | RR | CR | Whlchr att- conv 1 arm drive | $44.53 | |
| E0959 | NU | IN | Amputee adapter | $46.42 | |
| E0959 | RR | IN | Amputee adapter | $4.67 | |
| E0959 | UE | IN | Amputee adapter | $35.13 | |
| E0960 | NU | IN | W/c shoulder harness/straps | $82.34 | |
| E0960 | NU | KE | IN | W/c shoulder harness/straps | $95.53 |
| E0960 | RR | IN | W/c shoulder harness/straps | $8.24 | |
| E0960 | RR | KE | IN | W/c shoulder harness/straps | $9.56 |
| E0960 | UE | IN | W/c shoulder harness/straps | $61.76 | |
| E0960 | UE | KE | IN | W/c shoulder harness/straps | $71.65 |
| E0961 | NU | IN | Wheelchair brake extension | $26.55 | |
| E0961 | RR | IN | Wheelchair brake extension | $2.77 | |
| E0961 | UE | IN | Wheelchair brake extension | $13.26 | |
| E0966 | NU | IN | Wheelchair head rest extensi | $67.97 | |
| E0966 | RR | IN | Wheelchair head rest extensi | $6.79 | |
| E0966 | UE | IN | Wheelchair head rest extensi | $50.98 | |
| E0967 | NU | IN | Manual wc hand rim w project | $68.94 | |
| E0967 | RR | IN | Manual wc hand rim w project | $6.89 | |
| E0967 | UE | IN | Manual wc hand rim w project | $51.71 | |
| E0968 | RR | CR | Wheelchair commode seat | $18.83 | |
| E0969 | NU | IN | Wheelchair narrowing device | $153.50 | |
| E0969 | RR | IN | Wheelchair narrowing device | $15.36 | |
| E0969 | UE | IN | Wheelchair narrowing device | $115.12 | |
| E0971 | NU | IN | Wheelchair anti-tipping devi | $45.56 | |
| E0971 | RR | IN | Wheelchair anti-tipping devi | $4.56 | |
| E0971 | UE | IN | Wheelchair anti-tipping devi | $34.19 | |
| E0973 | NU | IN | W/Ch access det adj armrest | $104.05 | |
| E0973 | NU | KE | IN | W/Ch access det adj armrest | $120.72 |
| E0973 | RR | IN | W/Ch access det adj armrest | $9.91 | |
| E0973 | RR | KE | IN | W/Ch access det adj armrest | $11.50 |
| E0973 | UE | IN | W/Ch access det adj armrest | $78.04 | |
| E0973 | UE | KE | IN | W/Ch access det adj armrest | $90.54 |
| E0974 | NU | IN | W/Ch access anti-rollback | $82.33 | |
| E0974 | RR | IN | W/Ch access anti-rollback | $8.73 | |
| E0974 | UE | IN | W/Ch access anti-rollback | $62.21 | |
| E0978 | NU | IN | W/C acc,saf belt pelv strap | $38.64 | |
| E0978 | NU | KE | IN | W/C acc,saf belt pelv strap | $44.84 |
| E0978 | RR | IN | W/C acc,saf belt pelv strap | $3.87 | |
| E0978 | RR | KE | IN | W/C acc,saf belt pelv strap | $4.49 |
| E0978 | UE | IN | W/C acc,saf belt pelv strap | $28.65 | |
| E0978 | UE | KE | IN | W/C acc,saf belt pelv strap | $33.24 |
| E0980 | NU | IN | Wheelchair safety vest | $34.71 | |
| E0980 | RR | IN | Wheelchair safety vest | $3.47 | |
| E0980 | UE | IN | Wheelchair safety vest | $25.89 | |
| E0981 | NU | IN | Seat upholstery, replacement | $42.67 | |
| E0981 | NU | KE | IN | Seat upholstery, replacement | $49.51 |
| E0981 | RR | IN | Seat upholstery, replacement | $4.34 | |
| E0981 | RR | KE | IN | Seat upholstery, replacement | $5.04 |
| E0981 | UE | IN | Seat upholstery, replacement | $32.31 | |
| E0981 | UE | KE | IN | Seat upholstery, replacement | $37.49 |
| E0982 | NU | IN | Back upholstery, replacement | $46.63 | |
| E0982 | NU | KE | IN | Back upholstery, replacement | $54.11 |
| E0982 | RR | IN | Back upholstery, replacement | $4.66 | |
| E0982 | RR | KE | IN | Back upholstery, replacement | $5.41 |
| E0982 | UE | IN | Back upholstery, replacement | $34.97 | |
| E0982 | UE | KE | IN | Back upholstery, replacement | $40.57 |
| E0983 | RR | CR | Add pwr joystick | $246.77 | |
| E0984 | NU | IN | Add pwr tiller | $1,705.19 | |
| E0984 | RR | IN | Add pwr tiller | $158.56 | |
| E0984 | UE | IN | Add pwr tiller | $1,315.78 | |
| E0985 | NU | IN | W/c seat lift mechanism | $212.99 | |
| E0985 | RR | IN | W/c seat lift mechanism | $21.32 | |
| E0985 | UE | IN | W/c seat lift mechanism | $159.73 | |
| E0986 | NU | IN | Man w/c push-rim pow assist | $5,107.45 | |
| E0986 | RR | IN | Man w/c push-rim pow assist | $510.75 | |
| E0986 | UE | IN | Man w/c push-rim pow assist | $3,830.61 | |
| E0990 | NU | IN | Wheelchair elevating leg res | $90.33 | |
| E0990 | NU | KE | IN | Wheelchair elevating leg res | $104.81 |
| E0990 | RR | IN | Wheelchair elevating leg res | $11.96 | |
| E0990 | RR | KE | IN | Wheelchair elevating leg res | $13.88 |
| E0990 | UE | IN | Wheelchair elevating leg res | $70.58 | |
| E0990 | UE | KE | IN | Wheelchair elevating leg res | $81.89 |
| E0992 | NU | IN | Wheelchair solid seat insert | $84.92 | |
| E0992 | RR | IN | Wheelchair solid seat insert | $8.25 | |
| E0992 | UE | IN | Wheelchair solid seat insert | $63.70 | |
| E0994 | NU | IN | Wheelchair arm rest | $17.65 | |
| E0994 | RR | IN | Wheelchair arm rest | $1.76 | |
| E0994 | UE | IN | Wheelchair arm rest | $13.25 | |
| E0995 | NU | IN | Wheelchair calf rest | $23.92 | |
| E0995 | NU | KE | IN | Wheelchair calf rest | $27.75 |
| E0995 | RR | IN | Wheelchair calf rest | $2.40 | |
| E0995 | RR | KE | IN | Wheelchair calf rest | $2.78 |
| E0995 | UE | IN | Wheelchair calf rest | $17.96 | |
| E0995 | UE | KE | IN | Wheelchair calf rest | $20.84 |
| E1002 | NU | IN | Pwr seat tilt | $3,668.16 | |
| E1002 | NU | KE | IN | Pwr seat tilt | $4,255.87 |
| E1002 | RR | IN | Pwr seat tilt | $366.81 | |
| E1002 | RR | KE | IN | Pwr seat tilt | $425.59 |
| E1002 | UE | IN | Pwr seat tilt | $2,751.11 | |
| E1002 | UE | KE | IN | Pwr seat tilt | $3,191.90 |
| E1003 | NU | IN | Pwr seat recline | $3,974.13 | |
| E1003 | NU | KE | IN | Pwr seat recline | $4,610.87 |
| E1003 | RR | IN | Pwr seat recline | $397.42 | |
| E1003 | RR | KE | IN | Pwr seat recline | $461.10 |
| E1003 | UE | IN | Pwr seat recline | $2,980.60 | |
| E1003 | UE | KE | IN | Pwr seat recline | $3,458.15 |
| E1004 | NU | IN | Pwr seat recline mech | $4,406.49 | |
| E1004 | NU | KE | IN | Pwr seat recline mech | $5,112.50 |
| E1004 | RR | IN | Pwr seat recline mech | $440.64 | |
| E1004 | RR | KE | IN | Pwr seat recline mech | $511.25 |
| E1004 | UE | IN | Pwr seat recline mech | $3,304.85 | |
| E1004 | UE | KE | IN | Pwr seat recline mech | $3,834.36 |
| E1005 | NU | IN | Pwr seat recline pwr | $4,769.68 | |
| E1005 | NU | KE | IN | Pwr seat recline pwr | $5,533.88 |
| E1005 | RR | IN | Pwr seat recline pwr | $476.96 | |
| E1005 | RR | KE | IN | Pwr seat recline pwr | $553.38 |
| E1005 | UE | IN | Pwr seat recline pwr | $3,577.27 | |
| E1005 | UE | KE | IN | Pwr seat recline pwr | $4,150.42 |
| E1006 | NU | IN | Pwr seat combo w/o shear | $5,842.41 | |
| E1006 | NU | KE | IN | Pwr seat combo w/o shear | $6,778.49 |
| E1006 | RR | IN | Pwr seat combo w/o shear | $584.22 | |
| E1006 | RR | KE | IN | Pwr seat combo w/o shear | $677.83 |
| E1006 | UE | IN | Pwr seat combo w/o shear | $4,381.81 | |
| E1006 | UE | KE | IN | Pwr seat combo w/o shear | $5,083.87 |
| E1007 | NU | IN | Pwr seat combo w/shear | $7,910.85 | |
| E1007 | NU | KE | IN | Pwr seat combo w/shear | $9,178.33 |
| E1007 | RR | IN | Pwr seat combo w/shear | $791.09 | |
| E1007 | RR | KE | IN | Pwr seat combo w/shear | $917.84 |
| E1007 | UE | IN | Pwr seat combo w/shear | $5,933.13 | |
| E1007 | UE | KE | IN | Pwr seat combo w/shear | $6,883.74 |
| E1008 | NU | IN | Pwr seat combo pwr shear | $7,911.56 | |
| E1008 | NU | KE | IN | Pwr seat combo pwr shear | $9,179.15 |
| E1008 | RR | IN | Pwr seat combo pwr shear | $791.15 | |
| E1008 | RR | KE | IN | Pwr seat combo pwr shear | $917.91 |
| E1008 | UE | IN | Pwr seat combo pwr shear | $5,933.68 | |
| E1008 | UE | KE | IN | Pwr seat combo pwr shear | $6,884.38 |
| E1009 | NU | IN | Add mech leg elevation | $0.00 | |
| E1009 | RR | IN | Add mech leg elevation | $0.00 | |
| E1009 | UE | IN | Add mech leg elevation | $0.00 | |
| E1010 | NU | IN | Add pwr leg elevation | $1,035.13 | |
| E1010 | NU | KE | IN | Add pwr leg elevation | $1,200.98 |
| E1010 | RR | IN | Add pwr leg elevation | $103.51 | |
| E1010 | RR | KE | IN | Add pwr leg elevation | $120.10 |
| E1010 | UE | IN | Add pwr leg elevation | $776.36 | |
| E1010 | UE | KE | IN | Add pwr leg elevation | $900.75 |
| E1011 | NU | IN | Ped wc modify width adjustm | $0.00 | |
| E1011 | RR | IN | Ped wc modify width adjustm | $0.00 | |
| E1011 | UE | IN | Ped wc modify width adjustm | $0.00 | |
| E1014 | NU | IN | Reclining back add ped w/c | $383.40 | |
| E1014 | RR | IN | Reclining back add ped w/c | $38.35 | |
| E1014 | UE | IN | Reclining back add ped w/c | $287.54 | |
| E1015 | NU | IN | Shock absorber for man w/c | $120.44 | |
| E1015 | RR | IN | Shock absorber for man w/c | $12.03 | |
| E1015 | UE | IN | Shock absorber for man w/c | $90.32 | |
| E1016 | NU | IN | Shock absorber for power w/c | $118.84 | |
| E1016 | NU | KE | IN | Shock absorber for power w/c | $137.88 |
| E1016 | RR | IN | Shock absorber for power w/c | $11.89 | |
| E1016 | RR | KE | IN | Shock absorber for power w/c | $13.80 |
| E1016 | UE | IN | Shock absorber for power w/c | $89.12 | |
| E1016 | UE | KE | IN | Shock absorber for power w/c | $103.40 |
| E1017 | NU | IN | HD shck absrbr for hd man wc | $0.00 | |
| E1017 | RR | IN | HD shck absrbr for hd man wc | $0.00 | |
| E1017 | UE | IN | HD shck absrbr for hd man wc | $0.00 | |
| E1018 | NU | IN | HD shck absrber for hd powwc | $0.00 | |
| E1018 | RR | IN | HD shck absrber for hd powwc | $0.00 | |
| E1018 | UE | IN | HD shck absrber for hd powwc | $0.00 | |
| E1020 | NU | IN | Residual limb support system | $220.29 | |
| E1020 | NU | KE | IN | Residual limb support system | $255.58 |
| E1020 | RR | IN | Residual limb support system | $22.01 | |
| E1020 | RR | KE | IN | Residual limb support system | $25.54 |
| E1020 | UE | IN | Residual limb support system | $165.21 | |
| E1020 | UE | KE | IN | Residual limb support system | $191.68 |
| E1028 | NU | IN | W/c manual swingaway | $186.92 | |
| E1028 | NU | KE | IN | W/c manual swingaway | $216.87 |
| E1028 | RR | IN | W/c manual swingaway | $18.69 | |
| E1028 | RR | KE | IN | W/c manual swingaway | $21.68 |
| E1028 | UE | IN | W/c manual swingaway | $140.18 | |
| E1028 | UE | KE | IN | W/c manual swingaway | $162.63 |
| E1029 | NU | IN | W/c vent tray fixed | $334.43 | |
| E1029 | NU | KE | IN | W/c vent tray fixed | $388.02 |
| E1029 | RR | IN | W/c vent tray fixed | $33.44 | |
| E1029 | RR | KE | IN | W/c vent tray fixed | $38.80 |
| E1029 | UE | IN | W/c vent tray fixed | $250.82 | |
| E1029 | UE | KE | IN | W/c vent tray fixed | $291.01 |
| E1030 | NU | IN | W/c vent tray gimbaled | $1,054.57 | |
| E1030 | NU | KE | IN | W/c vent tray gimbaled | $1,223.53 |
| E1030 | RR | IN | W/c vent tray gimbaled | $105.46 | |
| E1030 | RR | KE | IN | W/c vent tray gimbaled | $122.36 |
| E1030 | UE | IN | W/c vent tray gimbaled | $790.93 | |
| E1030 | UE | KE | IN | W/c vent tray gimbaled | $917.66 |
| E1031 | RR | CR | Rollabout chair with casters | $53.04 | |
| E1035 | RR | CR | Patient transfer system <300 | $643.86 | |
| E1036 | RR | CR | Patient transfer system >300 | $902.63 | |
| E1037 | RR | CR | Transport chair, ped size | $113.91 | |
| E1038 | RR | CR | Transport chair pt wt<=300lb | $18.93 | |
| E1039 | RR | CR | Transport chair pt wt >300lb | $35.91 | |
| E1050 | RR | CR | Whelchr fxd full length arms | $106.93 | |
| E1060 | RR | CR | Wheelchair detachable arms | $118.97 | |
| E1070 | RR | CR | Wheelchair detachable foot r | $115.01 | |
| E1083 | RR | CR | Hemi-wheelchair fixed arms | $75.78 | |
| E1084 | RR | CR | Hemi-wheelchair detachable a | $103.01 | |
| E1087 | RR | CR | Wheelchair lightwt fixed arm | $121.80 | |
| E1088 | RR | CR | Wheelchair lightweight det a | $158.31 | |
| E1092 | RR | CR | Wheelchair wide w/ leg rests | $134.94 | |
| E1093 | RR | CR | Wheelchair wide w/ foot rest | $116.05 | |
| E1100 | RR | CR | Whchr s-recl fxd arm leg res | $109.00 | |
| E1110 | RR | CR | Wheelchair semi-recl detach | $106.74 | |
| E1150 | RR | CR | Wheelchair standard w/ leg r | $82.07 | |
| E1160 | RR | CR | Wheelchair fixed arms | $64.53 | |
| E1161 | NU | IN | Manual adult wc w tiltinspac | $2,484.39 | |
| E1161 | RR | IN | Manual adult wc w tiltinspac | $248.44 | |
| E1161 | UE | IN | Manual adult wc w tiltinspac | $1,863.30 | |
| E1170 | RR | CR | Whlchr ampu fxd arm leg rest | $90.63 | |
| E1171 | RR | CR | Wheelchair amputee w/o leg r | $72.10 | |
| E1172 | RR | CR | Wheelchair amputee detach ar | $92.72 | |
| E1180 | RR | CR | Wheelchair amputee w/ foot r | $99.11 | |
| E1190 | RR | CR | Wheelchair amputee w/ leg re | $114.51 | |
| E1195 | RR | CR | Wheelchair amputee heavy dut | $112.12 | |
| E1200 | RR | CR | Wheelchair amputee fixed arm | $85.27 | |
| E1221 | RR | CR | Wheelchair spec size w foot | $44.02 | |
| E1222 | RR | CR | Wheelchair spec size w/ leg | $71.18 | |
| E1223 | RR | CR | Wheelchair spec size w foot | $77.72 | |
| E1224 | RR | CR | Wheelchair spec size w/ leg | $85.21 | |
| E1225 | RR | CR | Manual semi-reclining back | $47.46 | |
| E1226 | NU | IN | Manual fully reclining back | $572.93 | |
| E1226 | RR | IN | Manual fully reclining back | $58.97 | |
| E1226 | UE | IN | Manual fully reclining back | $429.66 | |
| E1227 | NU | IN | Wheelchair spec sz spec ht a | $291.38 | |
| E1227 | RR | IN | Wheelchair spec sz spec ht a | $28.67 | |
| E1227 | UE | IN | Wheelchair spec sz spec ht a | $218.56 | |
| E1228 | RR | CR | Wheelchair spec sz spec ht b | $25.01 | |
| E1230 | NU | IN | Power operated vehicle | $2,136.81 | |
| E1230 | RR | IN | Power operated vehicle | $233.57 | |
| E1230 | UE | IN | Power operated vehicle | $1,596.51 | |
| E1231 | NU | IN | Rigid ped w/c tilt-in-space | $0.00 | |
| E1231 | RR | IN | Rigid ped w/c tilt-in-space | $0.00 | |
| E1231 | UE | IN | Rigid ped w/c tilt-in-space | $0.00 | |
| E1232 | NU | IN | Folding ped wc tilt-in-space | $2,245.33 | |
| E1232 | RR | IN | Folding ped wc tilt-in-space | $224.54 | |
| E1232 | UE | IN | Folding ped wc tilt-in-space | $1,684.01 | |
| E1233 | NU | IN | Rig ped wc tltnspc w/o seat | $2,326.52 | |
| E1233 | RR | IN | Rig ped wc tltnspc w/o seat | $232.65 | |
| E1233 | UE | IN | Rig ped wc tltnspc w/o seat | $1,744.88 | |
| E1234 | NU | IN | Fld ped wc tltnspc w/o seat | $2,025.40 | |
| E1234 | RR | IN | Fld ped wc tltnspc w/o seat | $202.56 | |
| E1234 | UE | IN | Fld ped wc tltnspc w/o seat | $1,519.04 | |
| E1235 | NU | IN | Rigid ped wc adjustable | $1,950.30 | |
| E1235 | RR | IN | Rigid ped wc adjustable | $195.04 | |
| E1235 | UE | IN | Rigid ped wc adjustable | $1,462.72 | |
| E1236 | NU | IN | Folding ped wc adjustable | $1,720.67 | |
| E1236 | RR | IN | Folding ped wc adjustable | $172.06 | |
| E1236 | UE | IN | Folding ped wc adjustable | $1,290.50 | |
| E1237 | NU | IN | Rgd ped wc adjstabl w/o seat | $1,735.70 | |
| E1237 | RR | IN | Rgd ped wc adjstabl w/o seat | $173.57 | |
| E1237 | UE | IN | Rgd ped wc adjstabl w/o seat | $1,301.79 | |
| E1238 | NU | IN | Fld ped wc adjstabl w/o seat | $1,720.67 | |
| E1238 | RR | IN | Fld ped wc adjstabl w/o seat | $172.06 | |
| E1238 | UE | IN | Fld ped wc adjstabl w/o seat | $1,290.50 | |
| E1240 | RR | CR | Whchr litwt det arm leg rest | $108.17 | |
| E1270 | RR | CR | Wheelchair lightweight leg r | $80.68 | |
| E1280 | RR | CR | Whchr h-duty det arm leg res | $128.96 | |
| E1295 | RR | CR | Wheelchair heavy duty fixed | $124.10 | |
| E1296 | NU | IN | Wheelchair special seat heig | $438.81 | |
| E1296 | RR | IN | Wheelchair special seat heig | $44.57 | |
| E1296 | UE | IN | Wheelchair special seat heig | $329.11 | |
| E1297 | NU | IN | Wheelchair special seat dept | $93.36 | |
| E1297 | RR | IN | Wheelchair special seat dept | $10.37 | |
| E1297 | UE | IN | Wheelchair special seat dept | $70.01 | |
| E1298 | NU | IN | Wheelchair spec seat depth/w | $401.01 | |
| E1298 | RR | IN | Wheelchair spec seat depth/w | $40.11 | |
| E1298 | UE | IN | Wheelchair spec seat depth/w | $300.75 | |
| E1310 | NU | IN | Whirlpool non-portable | $2,254.77 | |
| E1310 | RR | IN | Whirlpool non-portable | $192.85 | |
| E1310 | UE | IN | Whirlpool non-portable | $1,691.08 | |
| E1353 | OX | Oxygen supplies regulator | $29.75 | ||
| E1355 | OX | Oxygen supplies stand/rack | $22.40 | ||
| E1372 | NU | IN | Oxy suppl heater for nebuliz | $171.18 | |
| E1372 | RR | IN | Oxy suppl heater for nebuliz | $24.87 | |
| E1372 | UE | IN | Oxy suppl heater for nebuliz | $107.70 | |
| E1390 | RR | OX | Oxygen concentrator | $173.17 | |
| E1391 | RR | OX | Oxygen concentrator, dual | $173.17 | |
| E1392 | RR | OX | Portable oxygen concentrator | $51.63 | |
| E1405 | RR | OX | O2/water vapor enrich w/heat | $209.99 | |
| E1406 | RR | OX | O2/water vapor enrich w/o he | $190.08 | |
| E1700 | NU | IN | Jaw motion rehab system | $307.77 | |
| E1700 | RR | IN | Jaw motion rehab system | $30.18 | |
| E1700 | UE | IN | Jaw motion rehab system | $230.83 | |
| E1701 | SU | Repl cushions for jaw motion | $10.89 | ||
| E1702 | SU | Repl measr scales jaw motion | $21.85 | ||
| E1800 | RR | CR | Adjust elbow ext/flex device | $109.34 | |
| E1801 | RR | CR | SPS elbow device | $127.14 | |
| E1802 | RR | CR | Adjst forearm pro/sup device | $343.14 | |
| E1805 | RR | CR | Adjust wrist ext/flex device | $118.01 | |
| E1806 | RR | CR | SPS wrist device | $104.34 | |
| E1810 | RR | CR | Adjust knee ext/flex device | $118.01 | |
| E1811 | RR | CR | SPS knee device | $132.16 | |
| E1812 | RR | CR | Knee ext/flex w act res ctrl | $90.29 | |
| E1815 | RR | CR | Adjust ankle ext/flex device | $118.01 | |
| E1816 | RR | CR | SPS ankle device | $134.24 | |
| E1818 | RR | CR | SPS forearm device | $137.05 | |
| E1820 | NU | IN | Soft interface material | $85.83 | |
| E1820 | RR | IN | Soft interface material | $8.58 | |
| E1820 | UE | IN | Soft interface material | $64.38 | |
| E1821 | NU | IN | Replacement interface SPSD | $110.51 | |
| E1821 | RR | IN | Replacement interface SPSD | $11.04 | |
| E1821 | UE | IN | Replacement interface SPSD | $82.90 | |
| E1825 | RR | CR | Adjust finger ext/flex devc | $118.01 | |
| E1830 | RR | CR | Adjust toe ext/flex device | $118.01 | |
| E1840 | RR | CR | Adj shoulder ext/flex device | $390.41 | |
| E1841 | RR | CR | Static str shldr dev rom adj | $475.65 | |
| E2000 | RR | CR | Gastric suction pump hme mdl | $51.05 | |
| E2100 | NU | IN | Bld glucose monitor w voice | $666.03 | |
| E2100 | RR | IN | Bld glucose monitor w voice | $66.60 | |
| E2100 | UE | IN | Bld glucose monitor w voice | $499.54 | |
| E2101 | NU | IN | Bld glucose monitor w lance | $197.99 | |
| E2101 | RR | IN | Bld glucose monitor w lance | $19.80 | |
| E2101 | UE | IN | Bld glucose monitor w lance | $148.49 | |
| E2120 | RR | CR | Pulse gen sys tx endolymp fl | $297.70 | |
| E2201 | NU | IN | Man w/ch acc seat w>=20"<24" | $391.76 | |
| E2201 | RR | IN | Man w/ch acc seat w>=20"<24" | $39.18 | |
| E2201 | UE | IN | Man w/ch acc seat w>=20"<24" | $293.82 | |
| E2202 | NU | IN | Seat width 24-27 in | $497.68 | |
| E2202 | RR | IN | Seat width 24-27 in | $49.77 | |
| E2202 | UE | IN | Seat width 24-27 in | $373.28 | |
| E2203 | NU | IN | Frame depth less than 22 in | $503.00 | |
| E2203 | RR | IN | Frame depth less than 22 in | $50.28 | |
| E2203 | UE | IN | Frame depth less than 22 in | $377.24 | |
| E2204 | NU | IN | Frame depth 22 to 25 in | $854.07 | |
| E2204 | RR | IN | Frame depth 22 to 25 in | $85.42 | |
| E2204 | UE | IN | Frame depth 22 to 25 in | $640.55 | |
| E2205 | NU | IN | Manual wc accessory, handrim | $34.30 | |
| E2205 | RR | IN | Manual wc accessory, handrim | $3.41 | |
| E2205 | UE | IN | Manual wc accessory, handrim | $25.73 | |
| E2206 | NU | IN | Complete wheel lock assembly | $42.71 | |
| E2206 | RR | IN | Complete wheel lock assembly | $4.26 | |
| E2206 | UE | IN | Complete wheel lock assembly | $32.03 | |
| E2207 | NU | IN | Crutch and cane holder | $45.52 | |
| E2207 | RR | IN | Crutch and cane holder | $4.56 | |
| E2207 | UE | IN | Crutch and cane holder | $34.14 | |
| E2208 | NU | IN | Cylinder tank carrier | $107.50 | |
| E2208 | NU | KE | IN | Cylinder tank carrier | $124.72 |
| E2208 | RR | IN | Cylinder tank carrier | $10.74 | |
| E2208 | RR | KE | IN | Cylinder tank carrier | $12.46 |
| E2208 | UE | IN | Cylinder tank carrier | $80.63 | |
| E2208 | UE | KE | IN | Cylinder tank carrier | $93.54 |
| E2209 | NU | IN | Arm trough each | $96.98 | |
| E2209 | NU | KE | IN | Arm trough each | $112.52 |
| E2209 | RR | IN | Arm trough each | $9.72 | |
| E2209 | RR | KE | IN | Arm trough each | $11.28 |
| E2209 | UE | IN | Arm trough each | $72.74 | |
| E2209 | UE | KE | IN | Arm trough each | $84.40 |
| E2210 | NU | IN | Wheelchair bearings | $5.93 | |
| E2210 | NU | KE | IN | Wheelchair bearings | $6.88 |
| E2210 | RR | IN | Wheelchair bearings | $0.51 | |
| E2210 | RR | KE | IN | Wheelchair bearings | $0.59 |
| E2210 | UE | IN | Wheelchair bearings | $4.45 | |
| E2210 | UE | KE | IN | Wheelchair bearings | $5.17 |
| E2211 | NU | IN | Pneumatic propulsion tire | $42.96 | |
| E2211 | RR | IN | Pneumatic propulsion tire | $4.21 | |
| E2211 | UE | IN | Pneumatic propulsion tire | $30.77 | |
| E2212 | NU | IN | Pneumatic prop tire tube | $6.17 | |
| E2212 | RR | IN | Pneumatic prop tire tube | $0.64 | |
| E2212 | UE | IN | Pneumatic prop tire tube | $4.64 | |
| E2213 | NU | IN | Pneumatic prop tire insert | $31.92 | |
| E2213 | RR | IN | Pneumatic prop tire insert | $3.20 | |
| E2213 | UE | IN | Pneumatic prop tire insert | $23.92 | |
| E2214 | NU | IN | Pneumatic caster tire each | $37.80 | |
| E2214 | RR | IN | Pneumatic caster tire each | $4.16 | |
| E2214 | UE | IN | Pneumatic caster tire each | $28.34 | |
| E2215 | NU | IN | Pneumatic caster tire tube | $10.08 | |
| E2215 | RR | IN | Pneumatic caster tire tube | $1.00 | |
| E2215 | UE | IN | Pneumatic caster tire tube | $7.54 | |
| E2216 | NU | IN | Foam filled propulsion tire | $0.00 | |
| E2216 | RR | IN | Foam filled propulsion tire | $0.00 | |
| E2216 | UE | IN | Foam filled propulsion tire | $0.00 | |
| E2217 | NU | IN | Foam filled caster tire each | $0.00 | |
| E2217 | RR | IN | Foam filled caster tire each | $0.00 | |
| E2217 | UE | IN | Foam filled caster tire each | $0.00 | |
| E2218 | NU | IN | Foam propulsion tire each | $0.00 | |
| E2218 | RR | IN | Foam propulsion tire each | $0.00 | |
| E2218 | UE | IN | Foam propulsion tire each | $0.00 | |
| E2219 | NU | IN | Foam caster tire any size ea | $43.94 | |
| E2219 | RR | IN | Foam caster tire any size ea | $4.96 | |
| E2219 | UE | IN | Foam caster tire any size ea | $32.96 | |
| E2220 | NU | IN | Solid propulsion tire each | $29.95 | |
| E2220 | RR | IN | Solid propulsion tire each | $2.89 | |
| E2220 | UE | IN | Solid propulsion tire each | $22.80 | |
| E2221 | NU | IN | Solid caster tire each | $26.83 | |
| E2221 | RR | IN | Solid caster tire each | $2.71 | |
| E2221 | UE | IN | Solid caster tire each | $20.14 | |
| E2222 | NU | IN | Solid caster integrated whl | $22.11 | |
| E2222 | RR | IN | Solid caster integrated whl | $2.19 | |
| E2222 | UE | IN | Solid caster integrated whl | $16.60 | |
| E2224 | NU | IN | Propulsion whl excludes tire | $102.96 | |
| E2224 | RR | IN | Propulsion whl excludes tire | $10.80 | |
| E2224 | UE | IN | Propulsion whl excludes tire | $77.23 | |
| E2225 | NU | IN | Caster wheel excludes tire | $18.27 | |
| E2225 | RR | IN | Caster wheel excludes tire | $1.83 | |
| E2225 | UE | IN | Caster wheel excludes tire | $13.69 | |
| E2226 | NU | IN | Caster fork replacement only | $39.84 | |
| E2226 | RR | IN | Caster fork replacement only | $3.98 | |
| E2226 | UE | IN | Caster fork replacement only | $29.88 | |
| E2227 | NU | IN | Gear reduction drive wheel | $1,888.65 | |
| E2227 | RR | IN | Gear reduction drive wheel | $188.85 | |
| E2227 | UE | IN | Gear reduction drive wheel | $1,416.48 | |
| E2228 | NU | IN | Mwc acc, wheelchair brake | $983.07 | |
| E2228 | RR | IN | Mwc acc, wheelchair brake | $98.30 | |
| E2228 | UE | IN | Mwc acc, wheelchair brake | $737.33 | |
| E2231 | NU | IN | Solid seat support base | $161.36 | |
| E2231 | RR | IN | Solid seat support base | $16.14 | |
| E2231 | UE | IN | Solid seat support base | $121.01 | |
| E2310 | NU | IN | Electro connect btw control | $1,059.07 | |
| E2310 | NU | KE | IN | Electro connect btw control | $1,228.75 |
| E2310 | RR | IN | Electro connect btw control | $105.90 | |
| E2310 | RR | KE | IN | Electro connect btw control | $122.87 |
| E2310 | UE | IN | Electro connect btw control | $794.30 | |
| E2310 | UE | KE | IN | Electro connect btw control | $921.56 |
| E2311 | NU | IN | Electro connect btw 2 sys | $2,144.13 | |
| E2311 | NU | KE | IN | Electro connect btw 2 sys | $2,487.66 |
| E2311 | RR | IN | Electro connect btw 2 sys | $214.42 | |
| E2311 | RR | KE | IN | Electro connect btw 2 sys | $248.78 |
| E2311 | UE | IN | Electro connect btw 2 sys | $1,608.09 | |
| E2311 | UE | KE | IN | Electro connect btw 2 sys | $1,865.75 |
| E2312 | NU | IN | Mini-prop remote joystick | $2,036.14 | |
| E2312 | NU | KC | IN | Mini-prop remote joystick | $2,596.84 |
| E2312 | RR | IN | Mini-prop remote joystick | $203.62 | |
| E2312 | RR | KC | IN | Mini-prop remote joystick | $259.69 |
| E2312 | UE | IN | Mini-prop remote joystick | $1,527.08 | |
| E2312 | UE | KC | IN | Mini-prop remote joystick | $1,947.62 |
| E2313 | NU | IN | PWC harness, expand control | $323.33 | |
| E2313 | RR | IN | PWC harness, expand control | $32.35 | |
| E2313 | UE | IN | PWC harness, expand control | $242.50 | |
| E2321 | NU | IN | Hand interface joystick | $1,438.14 | |
| E2321 | NU | KC | IN | Hand interface joystick | $2,342.55 |
| E2321 | NU | KE | IN | Hand interface joystick | $1,668.56 |
| E2321 | RR | IN | Hand interface joystick | $143.82 | |
| E2321 | RR | KC | IN | Hand interface joystick | $234.26 |
| E2321 | RR | KE | IN | Hand interface joystick | $166.87 |
| E2321 | UE | IN | Hand interface joystick | $1,078.62 | |
| E2321 | UE | KC | IN | Hand interface joystick | $1,756.91 |
| E2321 | UE | KE | IN | Hand interface joystick | $1,251.43 |
| E2322 | NU | IN | Mult mech switches | $1,276.38 | |
| E2322 | NU | KC | IN | Mult mech switches | $2,480.72 |
| E2322 | NU | KE | IN | Mult mech switches | $1,480.88 |
| E2322 | RR | IN | Mult mech switches | $127.63 | |
| E2322 | RR | KC | IN | Mult mech switches | $248.07 |
| E2322 | RR | KE | IN | Mult mech switches | $148.08 |
| E2322 | UE | IN | Mult mech switches | $957.29 | |
| E2322 | UE | KC | IN | Mult mech switches | $1,860.54 |
| E2322 | UE | KE | IN | Mult mech switches | $1,110.67 |
| E2323 | NU | IN | Special joystick handle | $62.59 | |
| E2323 | NU | KE | IN | Special joystick handle | $72.62 |
| E2323 | RR | IN | Special joystick handle | $6.26 | |
| E2323 | RR | KE | IN | Special joystick handle | $7.27 |
| E2323 | UE | IN | Special joystick handle | $46.94 | |
| E2323 | UE | KE | IN | Special joystick handle | $54.46 |
| E2324 | NU | IN | Chin cup interface | $39.66 | |
| E2324 | NU | KE | IN | Chin cup interface | $46.01 |
| E2324 | RR | IN | Chin cup interface | $3.95 | |
| E2324 | RR | KE | IN | Chin cup interface | $4.59 |
| E2324 | UE | IN | Chin cup interface | $29.75 | |
| E2324 | UE | KE | IN | Chin cup interface | $34.51 |
| E2325 | NU | IN | Sip and puff interface | $1,218.88 | |
| E2325 | NU | KE | IN | Sip and puff interface | $1,414.17 |
| E2325 | RR | IN | Sip and puff interface | $121.90 | |
| E2325 | RR | KE | IN | Sip and puff interface | $141.44 |
| E2325 | UE | IN | Sip and puff interface | $914.17 | |
| E2325 | UE | KE | IN | Sip and puff interface | $1,060.64 |
| E2326 | NU | IN | Breath tube kit | $314.16 | |
| E2326 | NU | KE | IN | Breath tube kit | $364.50 |
| E2326 | RR | IN | Breath tube kit | $31.43 | |
| E2326 | RR | KE | IN | Breath tube kit | $36.47 |
| E2326 | UE | IN | Breath tube kit | $235.61 | |
| E2326 | UE | KE | IN | Breath tube kit | $273.36 |
| E2327 | NU | IN | Head control interface mech | $2,364.20 | |
| E2327 | NU | KC | IN | Head control interface mech | $3,591.81 |
| E2327 | NU | KE | IN | Head control interface mech | $2,743.00 |
| E2327 | RR | IN | Head control interface mech | $236.42 | |
| E2327 | RR | KC | IN | Head control interface mech | $359.18 |
| E2327 | RR | KE | IN | Head control interface mech | $274.30 |
| E2327 | UE | IN | Head control interface mech | $1,773.15 | |
| E2327 | UE | KC | IN | Head control interface mech | $2,693.85 |
| E2327 | UE | KE | IN | Head control interface mech | $2,057.24 |
| E2328 | NU | IN | Head/extremity control inter | $4,484.56 | |
| E2328 | NU | KE | IN | Head/extremity control inter | $5,203.09 |
| E2328 | RR | IN | Head/extremity control inter | $448.45 | |
| E2328 | RR | KE | IN | Head/extremity control inter | $520.30 |
| E2328 | UE | IN | Head/extremity control inter | $3,363.43 | |
| E2328 | UE | KE | IN | Head/extremity control inter | $3,902.33 |
| E2329 | NU | IN | Head control nonproportional | $1,598.35 | |
| E2329 | NU | KE | IN | Head control nonproportional | $1,854.44 |
| E2329 | RR | IN | Head control nonproportional | $159.83 | |
| E2329 | RR | KE | IN | Head control nonproportional | $185.44 |
| E2329 | UE | IN | Head control nonproportional | $1,198.76 | |
| E2329 | UE | KE | IN | Head control nonproportional | $1,390.83 |
| E2330 | NU | IN | Head control proximity switc | $3,096.99 | |
| E2330 | NU | KE | IN | Head control proximity switc | $3,593.19 |
| E2330 | RR | IN | Head control proximity switc | $309.69 | |
| E2330 | RR | KE | IN | Head control proximity switc | $359.31 |
| E2330 | UE | IN | Head control proximity switc | $2,322.75 | |
| E2330 | UE | KE | IN | Head control proximity switc | $2,694.91 |
| E2340 | NU | IN | W/c wdth 20-23 in seat frame | $376.28 | |
| E2340 | RR | IN | W/c wdth 20-23 in seat frame | $37.64 | |
| E2340 | UE | IN | W/c wdth 20-23 in seat frame | $282.23 | |
| E2341 | NU | IN | W/c wdth 24-27 in seat frame | $564.46 | |
| E2341 | RR | IN | W/c wdth 24-27 in seat frame | $56.45 | |
| E2341 | UE | IN | W/c wdth 24-27 in seat frame | $423.35 | |
| E2342 | NU | IN | W/c dpth 20-21 in seat frame | $470.38 | |
| E2342 | RR | IN | W/c dpth 20-21 in seat frame | $47.04 | |
| E2342 | UE | IN | W/c dpth 20-21 in seat frame | $352.79 | |
| E2343 | NU | IN | W/c dpth 22-25 in seat frame | $752.62 | |
| E2343 | RR | IN | W/c dpth 22-25 in seat frame | $75.25 | |
| E2343 | UE | IN | W/c dpth 22-25 in seat frame | $564.46 | |
| E2351 | NU | IN | Electronic SGD interface | $632.26 | |
| E2351 | NU | KE | IN | Electronic SGD interface | $733.56 |
| E2351 | RR | IN | Electronic SGD interface | $63.24 | |
| E2351 | RR | KE | IN | Electronic SGD interface | $73.37 |
| E2351 | UE | IN | Electronic SGD interface | $474.18 | |
| E2351 | UE | KE | IN | Electronic SGD interface | $550.16 |
| E2360 | NU | IN | 22nf nonsealed leadacid | $117.96 | |
| E2360 | RR | IN | 22nf nonsealed leadacid | $11.85 | |
| E2360 | UE | IN | 22nf nonsealed leadacid | $88.47 | |
| E2361 | NU | IN | 22nf sealed leadacid battery | $126.22 | |
| E2361 | NU | KE | IN | 22nf sealed leadacid battery | $146.44 |
| E2361 | RR | IN | 22nf sealed leadacid battery | $12.62 | |
| E2361 | RR | KE | IN | 22nf sealed leadacid battery | $14.65 |
| E2361 | UE | IN | 22nf sealed leadacid battery | $94.68 | |
| E2361 | UE | KE | IN | 22nf sealed leadacid battery | $109.85 |
| E2362 | NU | IN | Gr24 nonsealed leadacid | $96.58 | |
| E2362 | RR | IN | Gr24 nonsealed leadacid | $9.66 | |
| E2362 | UE | IN | Gr24 nonsealed leadacid | $72.43 | |
| E2363 | NU | IN | Gr24 sealed leadacid battery | $168.33 | |
| E2363 | NU | KE | IN | Gr24 sealed leadacid battery | $195.30 |
| E2363 | RR | IN | Gr24 sealed leadacid battery | $16.84 | |
| E2363 | RR | KE | IN | Gr24 sealed leadacid battery | $19.54 |
| E2363 | UE | IN | Gr24 sealed leadacid battery | $126.25 | |
| E2363 | UE | KE | IN | Gr24 sealed leadacid battery | $146.48 |
| E2364 | NU | IN | U1nonsealed leadacid battery | $117.96 | |
| E2364 | RR | IN | U1nonsealed leadacid battery | $11.85 | |
| E2364 | UE | IN | U1nonsealed leadacid battery | $88.47 | |
| E2365 | NU | IN | U1 sealed leadacid battery | $101.51 | |
| E2365 | NU | KE | IN | U1 sealed leadacid battery | $117.78 |
| E2365 | RR | IN | U1 sealed leadacid battery | $10.15 | |
| E2365 | RR | KE | IN | U1 sealed leadacid battery | $11.78 |
| E2365 | UE | IN | U1 sealed leadacid battery | $76.16 | |
| E2365 | UE | KE | IN | U1 sealed leadacid battery | $88.36 |
| E2366 | NU | IN | Battery charger, single mode | $238.58 | |
| E2366 | NU | KE | IN | Battery charger, single mode | $276.80 |
| E2366 | RR | IN | Battery charger, single mode | $23.92 | |
| E2366 | RR | KE | IN | Battery charger, single mode | $27.75 |
| E2366 | UE | IN | Battery charger, single mode | $178.94 | |
| E2366 | UE | KE | IN | Battery charger, single mode | $207.61 |
| E2367 | NU | IN | Battery charger, dual mode | $379.27 | |
| E2367 | NU | KE | IN | Battery charger, dual mode | $440.03 |
| E2367 | RR | IN | Battery charger, dual mode | $37.93 | |
| E2367 | RR | KE | IN | Battery charger, dual mode | $44.01 |
| E2367 | UE | IN | Battery charger, dual mode | $284.45 | |
| E2367 | UE | KE | IN | Battery charger, dual mode | $330.03 |
| E2368 | NU | IN | Power wc motor replacement | $467.50 | |
| E2368 | NU | KE | IN | Power wc motor replacement | $542.40 |
| E2368 | RR | IN | Power wc motor replacement | $46.76 | |
| E2368 | RR | KE | IN | Power wc motor replacement | $54.25 |
| E2368 | UE | IN | Power wc motor replacement | $350.63 | |
| E2368 | UE | KE | IN | Power wc motor replacement | $406.81 |
| E2369 | NU | IN | Pwr wc gear box replacement | $407.20 | |
| E2369 | NU | KE | IN | Pwr wc gear box replacement | $472.44 |
| E2369 | RR | IN | Pwr wc gear box replacement | $40.73 | |
| E2369 | RR | KE | IN | Pwr wc gear box replacement | $47.25 |
| E2369 | UE | IN | Pwr wc gear box replacement | $305.39 | |
| E2369 | UE | KE | IN | Pwr wc gear box replacement | $354.32 |
| E2370 | NU | IN | Pwr wc motor/gear box combo | $726.57 | |
| E2370 | NU | KE | IN | Pwr wc motor/gear box combo | $842.98 |
| E2370 | RR | IN | Pwr wc motor/gear box combo | $72.66 | |
| E2370 | RR | KE | IN | Pwr wc motor/gear box combo | $84.30 |
| E2370 | UE | IN | Pwr wc motor/gear box combo | $544.92 | |
| E2370 | UE | KE | IN | Pwr wc motor/gear box combo | $632.23 |
| E2371 | NU | IN | Gr27 sealed leadacid battery | $136.42 | |
| E2371 | NU | KE | IN | Gr27 sealed leadacid battery | $158.28 |
| E2371 | RR | IN | Gr27 sealed leadacid battery | $13.65 | |
| E2371 | RR | KE | IN | Gr27 sealed leadacid battery | $15.83 |
| E2371 | UE | IN | Gr27 sealed leadacid battery | $102.32 | |
| E2371 | UE | KE | IN | Gr27 sealed leadacid battery | $118.71 |
| E2372 | NU | IN | Gr27 non-sealed leadacid | $0.00 | |
| E2372 | RR | IN | Gr27 non-sealed leadacid | $0.00 | |
| E2372 | UE | IN | Gr27 non-sealed leadacid | $0.00 | |
| E2373 | NU | IN | Hand/chin ctrl spec joystick | $709.72 | |
| E2373 | NU | KC | IN | Hand/chin ctrl spec joystick | $1,094.99 |
| E2373 | NU | KE | IN | Hand/chin ctrl spec joystick | $709.72 |
| E2373 | RR | IN | Hand/chin ctrl spec joystick | $70.99 | |
| E2373 | RR | KC | IN | Hand/chin ctrl spec joystick | $109.51 |
| E2373 | RR | KE | IN | Hand/chin ctrl spec joystick | $70.99 |
| E2373 | UE | IN | Hand/chin ctrl spec joystick | $532.31 | |
| E2373 | UE | KC | IN | Hand/chin ctrl spec joystick | $821.26 |
| E2373 | UE | KE | IN | Hand/chin ctrl spec joystick | $532.31 |
| E2374 | NU | IN | Hand/chin ctrl std joystick | $483.29 | |
| E2374 | NU | KE | IN | Hand/chin ctrl std joystick | $560.72 |
| E2374 | RR | IN | Hand/chin ctrl std joystick | $48.33 | |
| E2374 | RR | KE | IN | Hand/chin ctrl std joystick | $56.07 |
| E2374 | UE | IN | Hand/chin ctrl std joystick | $362.48 | |
| E2374 | UE | KE | IN | Hand/chin ctrl std joystick | $420.56 |
| E2375 | NU | IN | Non-expandable controller | $775.19 | |
| E2375 | NU | KE | IN | Non-expandable controller | $899.39 |
| E2375 | RR | IN | Non-expandable controller | $77.51 | |
| E2375 | RR | KE | IN | Non-expandable controller | $89.93 |
| E2375 | UE | IN | Non-expandable controller | $581.37 | |
| E2375 | UE | KE | IN | Non-expandable controller | $674.52 |
| E2376 | NU | IN | Expandable controller, repl | $1,214.75 | |
| E2376 | NU | KE | IN | Expandable controller, repl | $1,409.38 |
| E2376 | RR | IN | Expandable controller, repl | $121.48 | |
| E2376 | RR | KE | IN | Expandable controller, repl | $140.94 |
| E2376 | UE | IN | Expandable controller, repl | $911.08 | |
| E2376 | UE | KE | IN | Expandable controller, repl | $1,057.06 |
| E2377 | NU | IN | Expandable controller, initl | $439.57 | |
| E2377 | NU | KE | IN | Expandable controller, initl | $510.00 |
| E2377 | RR | IN | Expandable controller, initl | $43.95 | |
| E2377 | RR | KE | IN | Expandable controller, initl | $50.99 |
| E2377 | UE | IN | Expandable controller, initl | $329.69 | |
| E2377 | UE | KE | IN | Expandable controller, initl | $382.52 |
| E2381 | NU | IN | Pneum drive wheel tire | $68.94 | |
| E2381 | NU | KE | IN | Pneum drive wheel tire | $79.99 |
| E2381 | RR | IN | Pneum drive wheel tire | $6.91 | |
| E2381 | RR | KE | IN | Pneum drive wheel tire | $8.01 |
| E2381 | UE | IN | Pneum drive wheel tire | $51.71 | |
| E2381 | UE | KE | IN | Pneum drive wheel tire | $60.00 |
| E2382 | NU | IN | Tube, pneum wheel drive tire | $18.80 | |
| E2382 | NU | KE | IN | Tube, pneum wheel drive tire | $21.81 |
| E2382 | RR | IN | Tube, pneum wheel drive tire | $1.87 | |
| E2382 | RR | KE | IN | Tube, pneum wheel drive tire | $2.17 |
| E2382 | UE | IN | Tube, pneum wheel drive tire | $14.09 | |
| E2382 | UE | KE | IN | Tube, pneum wheel drive tire | $16.35 |
| E2383 | NU | IN | Insert, pneum wheel drive | $137.45 | |
| E2383 | NU | KE | IN | Insert, pneum wheel drive | $159.47 |
| E2383 | RR | IN | Insert, pneum wheel drive | $13.75 | |
| E2383 | RR | KE | IN | Insert, pneum wheel drive | $15.95 |
| E2383 | UE | IN | Insert, pneum wheel drive | $103.09 | |
| E2383 | UE | KE | IN | Insert, pneum wheel drive | $119.61 |
| E2384 | NU | IN | Pneumatic caster tire | $73.22 | |
| E2384 | NU | KE | IN | Pneumatic caster tire | $84.96 |
| E2384 | RR | IN | Pneumatic caster tire | $7.34 | |
| E2384 | RR | KE | IN | Pneumatic caster tire | $8.52 |
| E2384 | UE | IN | Pneumatic caster tire | $54.92 | |
| E2384 | UE | KE | IN | Pneumatic caster tire | $63.71 |
| E2385 | NU | IN | Tube, pneumatic caster tire | $44.80 | |
| E2385 | NU | KE | IN | Tube, pneumatic caster tire | $51.98 |
| E2385 | RR | IN | Tube, pneumatic caster tire | $4.49 | |
| E2385 | RR | KE | IN | Tube, pneumatic caster tire | $5.21 |
| E2385 | UE | IN | Tube, pneumatic caster tire | $33.58 | |
| E2385 | UE | KE | IN | Tube, pneumatic caster tire | $38.97 |
| E2386 | NU | IN | Foam filled drive wheel tire | $136.21 | |
| E2386 | NU | KE | IN | Foam filled drive wheel tire | $158.04 |
| E2386 | RR | IN | Foam filled drive wheel tire | $13.62 | |
| E2386 | RR | KE | IN | Foam filled drive wheel tire | $15.80 |
| E2386 | UE | IN | Foam filled drive wheel tire | $102.15 | |
| E2386 | UE | KE | IN | Foam filled drive wheel tire | $118.51 |
| E2387 | NU | IN | Foam filled caster tire | $61.08 | |
| E2387 | NU | KE | IN | Foam filled caster tire | $70.86 |
| E2387 | RR | IN | Foam filled caster tire | $6.11 | |
| E2387 | RR | KE | IN | Foam filled caster tire | $7.09 |
| E2387 | UE | IN | Foam filled caster tire | $45.84 | |
| E2387 | UE | KE | IN | Foam filled caster tire | $53.18 |
| E2388 | NU | IN | Foam drive wheel tire | $45.60 | |
| E2388 | NU | KE | IN | Foam drive wheel tire | $52.91 |
| E2388 | RR | IN | Foam drive wheel tire | $4.56 | |
| E2388 | RR | KE | IN | Foam drive wheel tire | $5.29 |
| E2388 | UE | IN | Foam drive wheel tire | $34.21 | |
| E2388 | UE | KE | IN | Foam drive wheel tire | $39.69 |
| E2389 | NU | IN | Foam caster tire | $24.76 | |
| E2389 | NU | KE | IN | Foam caster tire | $28.73 |
| E2389 | RR | IN | Foam caster tire | $2.48 | |
| E2389 | RR | KE | IN | Foam caster tire | $2.88 |
| E2389 | UE | IN | Foam caster tire | $18.56 | |
| E2389 | UE | KE | IN | Foam caster tire | $21.54 |
| E2390 | NU | IN | Solid drive wheel tire | $38.72 | |
| E2390 | NU | KE | IN | Solid drive wheel tire | $44.93 |
| E2390 | RR | IN | Solid drive wheel tire | $3.87 | |
| E2390 | RR | KE | IN | Solid drive wheel tire | $4.49 |
| E2390 | UE | IN | Solid drive wheel tire | $29.02 | |
| E2390 | UE | KE | IN | Solid drive wheel tire | $33.67 |
| E2391 | NU | IN | Solid caster tire | $18.55 | |
| E2391 | NU | KE | IN | Solid caster tire | $21.53 |
| E2391 | RR | IN | Solid caster tire | $1.86 | |
| E2391 | RR | KE | IN | Solid caster tire | $2.15 |
| E2391 | UE | IN | Solid caster tire | $13.92 | |
| E2391 | UE | KE | IN | Solid caster tire | $16.15 |
| E2392 | NU | IN | Solid caster tire, integrate | $48.76 | |
| E2392 | NU | KE | IN | Solid caster tire, integrate | $56.57 |
| E2392 | RR | IN | Solid caster tire, integrate | $4.89 | |
| E2392 | RR | KE | IN | Solid caster tire, integrate | $5.67 |
| E2392 | UE | IN | Solid caster tire, integrate | $36.57 | |
| E2392 | UE | KE | IN | Solid caster tire, integrate | $42.43 |
| E2394 | NU | IN | Drive wheel excludes tire | $69.46 | |
| E2394 | NU | KE | IN | Drive wheel excludes tire | $80.59 |
| E2394 | RR | IN | Drive wheel excludes tire | $6.96 | |
| E2394 | RR | KE | IN | Drive wheel excludes tire | $8.07 |
| E2394 | UE | IN | Drive wheel excludes tire | $52.10 | |
| E2394 | UE | KE | IN | Drive wheel excludes tire | $60.45 |
| E2395 | NU | IN | Caster wheel excludes tire | $49.37 | |
| E2395 | NU | KE | IN | Caster wheel excludes tire | $57.28 |
| E2395 | RR | IN | Caster wheel excludes tire | $4.94 | |
| E2395 | RR | KE | IN | Caster wheel excludes tire | $5.73 |
| E2395 | UE | IN | Caster wheel excludes tire | $37.04 | |
| E2395 | UE | KE | IN | Caster wheel excludes tire | $42.98 |
| E2396 | NU | IN | Caster fork | $60.19 | |
| E2396 | NU | KE | IN | Caster fork | $69.84 |
| E2396 | RR | IN | Caster fork | $6.45 | |
| E2396 | RR | KE | IN | Caster fork | $7.49 |
| E2396 | UE | IN | Caster fork | $45.15 | |
| E2396 | UE | KE | IN | Caster fork | $52.38 |
| E2397 | NU | IN | Pwc acc, lith-based battery | $434.84 | |
| E2397 | RR | IN | Pwc acc, lith-based battery | $43.48 | |
| E2397 | UE | IN | Pwc acc, lith-based battery | $326.12 | |
| E2402 | RR | CR | Neg press wound therapy pump | $1,553.40 | |
| E2500 | NU | IN | SGD digitized pre-rec <=8min | $410.61 | |
| E2500 | RR | IN | SGD digitized pre-rec <=8min | $41.07 | |
| E2500 | UE | IN | SGD digitized pre-rec <=8min | $307.95 | |
| E2502 | NU | IN | SGD prerec msg >8min <=20min | $1,255.59 | |
| E2502 | RR | IN | SGD prerec msg >8min <=20min | $125.57 | |
| E2502 | UE | IN | SGD prerec msg >8min <=20min | $941.70 | |
| E2504 | NU | IN | SGD prerec msg>20min <=40min | $1,656.29 | |
| E2504 | RR | IN | SGD prerec msg>20min <=40min | $165.65 | |
| E2504 | UE | IN | SGD prerec msg>20min <=40min | $1,242.20 | |
| E2506 | NU | IN | SGD prerec msg > 40 min | $2,428.61 | |
| E2506 | RR | IN | SGD prerec msg > 40 min | $242.85 | |
| E2506 | UE | IN | SGD prerec msg > 40 min | $1,821.42 | |
| E2508 | NU | IN | SGD spelling phys contact | $3,755.44 | |
| E2508 | RR | IN | SGD spelling phys contact | $375.55 | |
| E2508 | UE | IN | SGD spelling phys contact | $2,816.59 | |
| E2510 | NU | IN | SGD w multi methods msg/accs | $7,106.66 | |
| E2510 | RR | IN | SGD w multi methods msg/accs | $710.66 | |
| E2510 | UE | IN | SGD w multi methods msg/accs | $5,329.99 | |
| E2511 | NU | IN | SGD sftwre prgrm for PC/PDA | $0.00 | |
| E2511 | RR | IN | SGD sftwre prgrm for PC/PDA | $0.00 | |
| E2511 | UE | IN | SGD sftwre prgrm for PC/PDA | $0.00 | |
| E2512 | NU | IN | SGD accessory, mounting sys | $0.00 | |
| E2512 | RR | IN | SGD accessory, mounting sys | $0.00 | |
| E2512 | UE | IN | SGD accessory, mounting sys | $0.00 | |
| E2601 | NU | IN | Gen w/c cushion wdth < 22 in | $55.35 | |
| E2601 | NU | KE | IN | Gen w/c cushion wdth < 22 in | $64.22 |
| E2601 | RR | IN | Gen w/c cushion wdth < 22 in | $5.55 | |
| E2601 | RR | KE | IN | Gen w/c cushion wdth < 22 in | $6.44 |
| E2601 | UE | IN | Gen w/c cushion wdth < 22 in | $41.51 | |
| E2601 | UE | KE | IN | Gen w/c cushion wdth < 22 in | $48.16 |
| E2602 | NU | IN | Gen w/c cushion wdth >=22 in | $108.06 | |
| E2602 | NU | KE | IN | Gen w/c cushion wdth >=22 in | $125.37 |
| E2602 | RR | IN | Gen w/c cushion wdth >=22 in | $10.81 | |
| E2602 | RR | KE | IN | Gen w/c cushion wdth >=22 in | $12.54 |
| E2602 | UE | IN | Gen w/c cushion wdth >=22 in | $81.04 | |
| E2602 | UE | KE | IN | Gen w/c cushion wdth >=22 in | $94.03 |
| E2603 | NU | IN | Skin protect wc cus wd <22in | $137.19 | |
| E2603 | NU | KE | IN | Skin protect wc cus wd <22in | $159.17 |
| E2603 | RR | IN | Skin protect wc cus wd <22in | $13.73 | |
| E2603 | RR | KE | IN | Skin protect wc cus wd <22in | $15.93 |
| E2603 | UE | IN | Skin protect wc cus wd <22in | $102.89 | |
| E2603 | UE | KE | IN | Skin protect wc cus wd <22in | $119.37 |
| E2604 | NU | IN | Skin protect wc cus wd>=22in | $170.51 | |
| E2604 | NU | KE | IN | Skin protect wc cus wd>=22in | $197.83 |
| E2604 | RR | IN | Skin protect wc cus wd>=22in | $17.04 | |
| E2604 | RR | KE | IN | Skin protect wc cus wd>=22in | $19.77 |
| E2604 | UE | IN | Skin protect wc cus wd>=22in | $127.90 | |
| E2604 | UE | KE | IN | Skin protect wc cus wd>=22in | $148.40 |
| E2605 | NU | IN | Position wc cush wdth <22 in | $243.60 | |
| E2605 | NU | KE | IN | Position wc cush wdth <22 in | $282.63 |
| E2605 | RR | IN | Position wc cush wdth <22 in | $24.37 | |
| E2605 | RR | KE | IN | Position wc cush wdth <22 in | $28.28 |
| E2605 | UE | IN | Position wc cush wdth <22 in | $182.73 | |
| E2605 | UE | KE | IN | Position wc cush wdth <22 in | $212.01 |
| E2606 | NU | IN | Position wc cush wdth>=22 in | $380.04 | |
| E2606 | NU | KE | IN | Position wc cush wdth>=22 in | $440.93 |
| E2606 | RR | IN | Position wc cush wdth>=22 in | $38.02 | |
| E2606 | RR | KE | IN | Position wc cush wdth>=22 in | $44.11 |
| E2606 | UE | IN | Position wc cush wdth>=22 in | $285.02 | |
| E2606 | UE | KE | IN | Position wc cush wdth>=22 in | $330.69 |
| E2607 | NU | IN | Skin pro/pos wc cus wd <22in | $262.31 | |
| E2607 | NU | KE | IN | Skin pro/pos wc cus wd <22in | $304.34 |
| E2607 | RR | IN | Skin pro/pos wc cus wd <22in | $26.24 | |
| E2607 | RR | KE | IN | Skin pro/pos wc cus wd <22in | $30.44 |
| E2607 | UE | IN | Skin pro/pos wc cus wd <22in | $196.74 | |
| E2607 | UE | KE | IN | Skin pro/pos wc cus wd <22in | $228.26 |
| E2608 | NU | IN | Skin pro/pos wc cus wd>=22in | $315.02 | |
| E2608 | NU | KE | IN | Skin pro/pos wc cus wd>=22in | $365.49 |
| E2608 | RR | IN | Skin pro/pos wc cus wd>=22in | $31.49 | |
| E2608 | RR | KE | IN | Skin pro/pos wc cus wd>=22in | $36.54 |
| E2608 | UE | IN | Skin pro/pos wc cus wd>=22in | $236.27 | |
| E2608 | UE | KE | IN | Skin pro/pos wc cus wd>=22in | $274.12 |
| E2611 | NU | IN | Gen use back cush wdth <22in | $282.68 | |
| E2611 | NU | KE | IN | Gen use back cush wdth <22in | $327.97 |
| E2611 | RR | IN | Gen use back cush wdth <22in | $28.26 | |
| E2611 | RR | KE | IN | Gen use back cush wdth <22in | $32.79 |
| E2611 | UE | IN | Gen use back cush wdth <22in | $212.03 | |
| E2611 | UE | KE | IN | Gen use back cush wdth <22in | $246.00 |
| E2612 | NU | IN | Gen use back cush wdth>=22in | $382.40 | |
| E2612 | NU | KE | IN | Gen use back cush wdth>=22in | $443.67 |
| E2612 | RR | IN | Gen use back cush wdth>=22in | $38.24 | |
| E2612 | RR | KE | IN | Gen use back cush wdth>=22in | $44.36 |
| E2612 | UE | IN | Gen use back cush wdth>=22in | $286.79 | |
| E2612 | UE | KE | IN | Gen use back cush wdth>=22in | $332.73 |
| E2613 | NU | IN | Position back cush wd <22in | $355.70 | |
| E2613 | NU | KE | IN | Position back cush wd <22in | $412.69 |
| E2613 | RR | IN | Position back cush wd <22in | $35.58 | |
| E2613 | RR | KE | IN | Position back cush wd <22in | $41.28 |
| E2613 | UE | IN | Position back cush wd <22in | $266.78 | |
| E2613 | UE | KE | IN | Position back cush wd <22in | $309.52 |
| E2614 | NU | IN | Position back cush wd>=22in | $492.26 | |
| E2614 | NU | KE | IN | Position back cush wd>=22in | $571.13 |
| E2614 | RR | IN | Position back cush wd>=22in | $49.23 | |
| E2614 | RR | KE | IN | Position back cush wd>=22in | $57.12 |
| E2614 | UE | IN | Position back cush wd>=22in | $369.21 | |
| E2614 | UE | KE | IN | Position back cush wd>=22in | $428.37 |
| E2615 | NU | IN | Pos back post/lat wdth <22in | $409.35 | |
| E2615 | NU | KE | IN | Pos back post/lat wdth <22in | $474.94 |
| E2615 | RR | IN | Pos back post/lat wdth <22in | $40.94 | |
| E2615 | RR | KE | IN | Pos back post/lat wdth <22in | $47.50 |
| E2615 | UE | IN | Pos back post/lat wdth <22in | $307.00 | |
| E2615 | UE | KE | IN | Pos back post/lat wdth <22in | $356.19 |
| E2616 | NU | IN | Pos back post/lat wdth>=22in | $550.76 | |
| E2616 | NU | KE | IN | Pos back post/lat wdth>=22in | $639.01 |
| E2616 | RR | IN | Pos back post/lat wdth>=22in | $55.08 | |
| E2616 | RR | KE | IN | Pos back post/lat wdth>=22in | $63.90 |
| E2616 | UE | IN | Pos back post/lat wdth>=22in | $413.09 | |
| E2616 | UE | KE | IN | Pos back post/lat wdth>=22in | $479.27 |
| E2619 | NU | IN | Replace cover w/c seat cush | $46.44 | |
| E2619 | NU | KE | IN | Replace cover w/c seat cush | $53.89 |
| E2619 | RR | IN | Replace cover w/c seat cush | $4.64 | |
| E2619 | RR | KE | IN | Replace cover w/c seat cush | $5.39 |
| E2619 | UE | IN | Replace cover w/c seat cush | $34.85 | |
| E2619 | UE | KE | IN | Replace cover w/c seat cush | $40.44 |
| E2620 | NU | IN | WC planar back cush wd <22in | $495.67 | |
| E2620 | NU | KE | IN | WC planar back cush wd <22in | $575.09 |
| E2620 | RR | IN | WC planar back cush wd <22in | $49.57 | |
| E2620 | RR | KE | IN | WC planar back cush wd <22in | $57.51 |
| E2620 | UE | IN | WC planar back cush wd <22in | $371.76 | |
| E2620 | UE | KE | IN | WC planar back cush wd <22in | $431.33 |
| E2621 | NU | IN | WC planar back cush wd>=22in | $520.16 | |
| E2621 | NU | KE | IN | WC planar back cush wd>=22in | $603.50 |
| E2621 | RR | IN | WC planar back cush wd>=22in | $52.01 | |
| E2621 | RR | KE | IN | WC planar back cush wd>=22in | $60.34 |
| E2621 | UE | IN | WC planar back cush wd>=22in | $390.13 | |
| E2621 | UE | KE | IN | WC planar back cush wd>=22in | $452.63 |
K codes: temporary durable medical equipment
284 rows| Code | Mod | Mod 2 | Cat. | Description | Fee |
|---|---|---|---|---|---|
| K0001 | RR | CR | Standard wheelchair | $55.10 | |
| K0002 | RR | CR | Stnd hemi (low seat) whlchr | $85.92 | |
| K0003 | RR | CR | Lightweight wheelchair | $94.07 | |
| K0004 | RR | CR | High strength ltwt whlchr | $119.83 | |
| K0005 | NU | IN | Ultralightweight wheelchair | $1,941.20 | |
| K0005 | RR | IN | Ultralightweight wheelchair | $194.10 | |
| K0005 | UE | IN | Ultralightweight wheelchair | $1,455.88 | |
| K0006 | RR | CR | Heavy duty wheelchair | $128.51 | |
| K0007 | RR | CR | Extra heavy duty wheelchair | $178.30 | |
| K0010 | RR | CR | Stnd wt frame power whlchr | $380.20 | |
| K0011 | RR | CR | Stnd wt pwr whlchr w control | $521.87 | |
| K0011 | RR | KF | CR | Stnd wt pwr whlchr w control | $579.42 |
| K0012 | RR | CR | Ltwt portbl power whlchr | $320.12 | |
| K0015 | NU | IN | Detach non-adjus hght armrst | $164.44 | |
| K0015 | NU | KE | IN | Detach non-adjus hght armrst | $190.79 |
| K0015 | RR | IN | Detach non-adjus hght armrst | $16.45 | |
| K0015 | RR | KE | IN | Detach non-adjus hght armrst | $19.09 |
| K0015 | UE | IN | Detach non-adjus hght armrst | $123.32 | |
| K0015 | UE | KE | IN | Detach non-adjus hght armrst | $143.08 |
| K0017 | NU | IN | Detach adjust armrest base | $46.25 | |
| K0017 | NU | KE | IN | Detach adjust armrest base | $53.67 |
| K0017 | RR | IN | Detach adjust armrest base | $4.62 | |
| K0017 | RR | KE | IN | Detach adjust armrest base | $5.37 |
| K0017 | UE | IN | Detach adjust armrest base | $34.69 | |
| K0017 | UE | KE | IN | Detach adjust armrest base | $40.25 |
| K0018 | NU | IN | Detach adjust armrst upper | $25.84 | |
| K0018 | NU | KE | IN | Detach adjust armrst upper | $29.98 |
| K0018 | RR | IN | Detach adjust armrst upper | $2.57 | |
| K0018 | RR | KE | IN | Detach adjust armrst upper | $2.98 |
| K0018 | UE | IN | Detach adjust armrst upper | $19.39 | |
| K0018 | UE | KE | IN | Detach adjust armrst upper | $22.50 |
| K0019 | NU | IN | Arm pad each | $14.80 | |
| K0019 | NU | KE | IN | Arm pad each | $17.17 |
| K0019 | RR | IN | Arm pad each | $1.48 | |
| K0019 | RR | KE | IN | Arm pad each | $1.72 |
| K0019 | UE | IN | Arm pad each | $11.09 | |
| K0019 | UE | KE | IN | Arm pad each | $12.86 |
| K0020 | NU | IN | Fixed adjust armrest pair | $42.05 | |
| K0020 | NU | KE | IN | Fixed adjust armrest pair | $48.78 |
| K0020 | RR | IN | Fixed adjust armrest pair | $4.21 | |
| K0020 | RR | KE | IN | Fixed adjust armrest pair | $4.88 |
| K0020 | UE | IN | Fixed adjust armrest pair | $31.52 | |
| K0020 | UE | KE | IN | Fixed adjust armrest pair | $36.57 |
| K0037 | NU | IN | High mount flip-up footrest | $43.58 | |
| K0037 | NU | KE | IN | High mount flip-up footrest | $50.57 |
| K0037 | RR | IN | High mount flip-up footrest | $3.89 | |
| K0037 | RR | KE | IN | High mount flip-up footrest | $4.52 |
| K0037 | UE | IN | High mount flip-up footrest | $32.70 | |
| K0037 | UE | KE | IN | High mount flip-up footrest | $37.94 |
| K0038 | NU | IN | Leg strap each | $21.96 | |
| K0038 | NU | KE | IN | Leg strap each | $25.47 |
| K0038 | RR | IN | Leg strap each | $2.20 | |
| K0038 | RR | KE | IN | Leg strap each | $2.55 |
| K0038 | UE | IN | Leg strap each | $16.47 | |
| K0038 | UE | KE | IN | Leg strap each | $19.11 |
| K0039 | NU | IN | Leg strap h style each | $48.76 | |
| K0039 | NU | KE | IN | Leg strap h style each | $56.57 |
| K0039 | RR | IN | Leg strap h style each | $4.89 | |
| K0039 | RR | KE | IN | Leg strap h style each | $5.67 |
| K0039 | UE | IN | Leg strap h style each | $36.57 | |
| K0039 | UE | KE | IN | Leg strap h style each | $42.43 |
| K0040 | NU | IN | Adjustable angle footplate | $67.58 | |
| K0040 | NU | KE | IN | Adjustable angle footplate | $78.40 |
| K0040 | RR | IN | Adjustable angle footplate | $6.74 | |
| K0040 | RR | KE | IN | Adjustable angle footplate | $7.82 |
| K0040 | UE | IN | Adjustable angle footplate | $50.67 | |
| K0040 | UE | KE | IN | Adjustable angle footplate | $58.79 |
| K0041 | NU | IN | Large size footplate each | $47.89 | |
| K0041 | NU | KE | IN | Large size footplate each | $55.57 |
| K0041 | RR | IN | Large size footplate each | $4.81 | |
| K0041 | RR | KE | IN | Large size footplate each | $5.58 |
| K0041 | UE | IN | Large size footplate each | $35.92 | |
| K0041 | UE | KE | IN | Large size footplate each | $41.67 |
| K0042 | NU | IN | Standard size footplate each | $32.97 | |
| K0042 | NU | KE | IN | Standard size footplate each | $38.25 |
| K0042 | RR | IN | Standard size footplate each | $3.29 | |
| K0042 | RR | KE | IN | Standard size footplate each | $3.81 |
| K0042 | UE | IN | Standard size footplate each | $24.72 | |
| K0042 | UE | KE | IN | Standard size footplate each | $28.69 |
| K0043 | NU | IN | Ftrst lower extension tube | $17.67 | |
| K0043 | NU | KE | IN | Ftrst lower extension tube | $20.51 |
| K0043 | RR | IN | Ftrst lower extension tube | $1.76 | |
| K0043 | RR | KE | IN | Ftrst lower extension tube | $2.05 |
| K0043 | UE | IN | Ftrst lower extension tube | $13.27 | |
| K0043 | UE | KE | IN | Ftrst lower extension tube | $15.39 |
| K0044 | NU | IN | Ftrst upper hanger bracket | $15.06 | |
| K0044 | NU | KE | IN | Ftrst upper hanger bracket | $17.47 |
| K0044 | RR | IN | Ftrst upper hanger bracket | $1.51 | |
| K0044 | RR | KE | IN | Ftrst upper hanger bracket | $1.75 |
| K0044 | UE | IN | Ftrst upper hanger bracket | $11.29 | |
| K0044 | UE | KE | IN | Ftrst upper hanger bracket | $13.10 |
| K0045 | NU | IN | Footrest complete assembly | $51.24 | |
| K0045 | NU | KE | IN | Footrest complete assembly | $59.45 |
| K0045 | RR | IN | Footrest complete assembly | $5.13 | |
| K0045 | RR | KE | IN | Footrest complete assembly | $5.95 |
| K0045 | UE | IN | Footrest complete assembly | $38.44 | |
| K0045 | UE | KE | IN | Footrest complete assembly | $44.59 |
| K0046 | NU | IN | Elevat legrst low extension | $17.67 | |
| K0046 | NU | KE | IN | Elevat legrst low extension | $20.51 |
| K0046 | RR | IN | Elevat legrst low extension | $1.76 | |
| K0046 | RR | KE | IN | Elevat legrst low extension | $2.05 |
| K0046 | UE | IN | Elevat legrst low extension | $13.27 | |
| K0046 | UE | KE | IN | Elevat legrst low extension | $15.39 |
| K0047 | NU | IN | Elevat legrst up hangr brack | $69.21 | |
| K0047 | NU | KE | IN | Elevat legrst up hangr brack | $80.30 |
| K0047 | RR | IN | Elevat legrst up hangr brack | $6.94 | |
| K0047 | RR | KE | IN | Elevat legrst up hangr brack | $8.05 |
| K0047 | UE | IN | Elevat legrst up hangr brack | $51.89 | |
| K0047 | UE | KE | IN | Elevat legrst up hangr brack | $60.21 |
| K0050 | NU | IN | Ratchet assembly | $29.41 | |
| K0050 | NU | KE | IN | Ratchet assembly | $34.13 |
| K0050 | RR | IN | Ratchet assembly | $2.93 | |
| K0050 | RR | KE | IN | Ratchet assembly | $3.40 |
| K0050 | UE | IN | Ratchet assembly | $22.07 | |
| K0050 | UE | KE | IN | Ratchet assembly | $25.61 |
| K0051 | NU | IN | Cam relese assem ftrst/lgrst | $47.61 | |
| K0051 | NU | KE | IN | Cam relese assem ftrst/lgrst | $55.24 |
| K0051 | RR | IN | Cam relese assem ftrst/lgrst | $4.79 | |
| K0051 | RR | KE | IN | Cam relese assem ftrst/lgrst | $5.55 |
| K0051 | UE | IN | Cam relese assem ftrst/lgrst | $35.69 | |
| K0051 | UE | KE | IN | Cam relese assem ftrst/lgrst | $41.41 |
| K0052 | NU | IN | Swingaway detach footrest | $83.66 | |
| K0052 | NU | KE | IN | Swingaway detach footrest | $97.06 |
| K0052 | RR | IN | Swingaway detach footrest | $8.36 | |
| K0052 | RR | KE | IN | Swingaway detach footrest | $9.70 |
| K0052 | UE | IN | Swingaway detach footrest | $62.73 | |
| K0052 | UE | KE | IN | Swingaway detach footrest | $72.79 |
| K0053 | NU | IN | Elevate footrest articulate | $92.32 | |
| K0053 | NU | KE | IN | Elevate footrest articulate | $107.11 |
| K0053 | RR | IN | Elevate footrest articulate | $9.22 | |
| K0053 | RR | KE | IN | Elevate footrest articulate | $10.70 |
| K0053 | UE | IN | Elevate footrest articulate | $69.24 | |
| K0053 | UE | KE | IN | Elevate footrest articulate | $80.34 |
| K0056 | NU | IN | Seat ht <17 or >=21 ltwt wc | $99.86 | |
| K0056 | RR | IN | Seat ht <17 or >=21 ltwt wc | $9.99 | |
| K0056 | UE | IN | Seat ht <17 or >=21 ltwt wc | $74.91 | |
| K0065 | NU | IN | Spoke protectors | $46.68 | |
| K0065 | RR | IN | Spoke protectors | $4.67 | |
| K0065 | UE | IN | Spoke protectors | $35.01 | |
| K0069 | NU | IN | Rear whl complete solid tire | $104.92 | |
| K0069 | RR | IN | Rear whl complete solid tire | $10.49 | |
| K0069 | UE | IN | Rear whl complete solid tire | $78.69 | |
| K0070 | NU | IN | Rear whl compl pneum tire | $192.32 | |
| K0070 | RR | IN | Rear whl compl pneum tire | $19.25 | |
| K0070 | UE | IN | Rear whl compl pneum tire | $144.24 | |
| K0071 | NU | IN | Front castr compl pneum tire | $114.71 | |
| K0071 | RR | IN | Front castr compl pneum tire | $11.48 | |
| K0071 | UE | IN | Front castr compl pneum tire | $86.02 | |
| K0072 | NU | IN | Frnt cstr cmpl sem-pneum tir | $69.05 | |
| K0072 | RR | IN | Frnt cstr cmpl sem-pneum tir | $6.90 | |
| K0072 | UE | IN | Frnt cstr cmpl sem-pneum tir | $51.79 | |
| K0073 | NU | IN | Caster pin lock each | $36.54 | |
| K0073 | RR | IN | Caster pin lock each | $3.65 | |
| K0073 | UE | IN | Caster pin lock each | $27.41 | |
| K0077 | NU | IN | Front caster assem complete | $61.79 | |
| K0077 | RR | IN | Front caster assem complete | $6.17 | |
| K0077 | UE | IN | Front caster assem complete | $46.34 | |
| K0098 | NU | IN | Drive belt power wheelchair | $24.63 | |
| K0098 | NU | KE | IN | Drive belt power wheelchair | $28.57 |
| K0098 | RR | IN | Drive belt power wheelchair | $2.46 | |
| K0098 | RR | KE | IN | Drive belt power wheelchair | $2.86 |
| K0098 | UE | IN | Drive belt power wheelchair | $18.45 | |
| K0098 | UE | KE | IN | Drive belt power wheelchair | $21.41 |
| K0105 | NU | IN | Iv hanger | $104.40 | |
| K0105 | RR | IN | Iv hanger | $10.43 | |
| K0105 | UE | IN | Iv hanger | $78.30 | |
| K0195 | RR | CR | Elevating whlchair leg rests | $16.21 | |
| K0195 | RR | KE | CR | Elevating whlchair leg rests | $18.80 |
| K0455 | RR | FS | Pump uninterrupted infusion | $236.39 | |
| K0552 | SU | Supply/ext inf pump syr type | $2.78 | ||
| K0601 | NU | IN | Repl batt silver oxide 1.5 v | $1.16 | |
| K0602 | NU | IN | Repl batt silver oxide 3 v | $6.68 | |
| K0603 | NU | IN | Repl batt alkaline 1.5 v | $0.60 | |
| K0604 | NU | IN | Repl batt lithium 3.6 v | $6.39 | |
| K0605 | NU | IN | Repl batt lithium 4.5 v | $15.33 | |
| K0606 | RR | KF | CR | AED garment w elec analysis | $2,644.18 |
| K0607 | NU | IN | Repl batt for AED | $203.94 | |
| K0607 | NU | KF | IN | Repl batt for AED | $226.42 |
| K0607 | RR | IN | Repl batt for AED | $20.40 | |
| K0607 | RR | KF | IN | Repl batt for AED | $22.65 |
| K0607 | UE | IN | Repl batt for AED | $152.95 | |
| K0607 | UE | KF | IN | Repl batt for AED | $169.82 |
| K0608 | NU | IN | Repl garment for AED | $127.27 | |
| K0608 | NU | KF | IN | Repl garment for AED | $141.31 |
| K0608 | RR | IN | Repl garment for AED | $12.75 | |
| K0608 | RR | KF | IN | Repl garment for AED | $14.14 |
| K0608 | UE | IN | Repl garment for AED | $95.46 | |
| K0608 | UE | KF | IN | Repl garment for AED | $105.98 |
| K0609 | SU | Repl electrode for AED | $846.39 | ||
| K0609 | KF | SU | Repl electrode for AED | $939.71 | |
| K0672 | PO | Removable soft interface LE | $74.92 | ||
| K0730 | NU | IN | Ctrl dose inh drug deliv sys | $1,810.22 | |
| K0730 | RR | IN | Ctrl dose inh drug deliv sys | $181.02 | |
| K0730 | UE | IN | Ctrl dose inh drug deliv sys | $1,357.66 | |
| K0733 | NU | IN | 12-24hr sealed lead acid | $27.34 | |
| K0733 | NU | KE | IN | 12-24hr sealed lead acid | $31.72 |
| K0733 | RR | IN | 12-24hr sealed lead acid | $2.75 | |
| K0733 | RR | KE | IN | 12-24hr sealed lead acid | $3.19 |
| K0733 | UE | IN | 12-24hr sealed lead acid | $20.52 | |
| K0733 | UE | KE | IN | 12-24hr sealed lead acid | $23.80 |
| K0734 | NU | IN | Adj skin pro w/c cus wd<22in | $299.98 | |
| K0734 | NU | KE | IN | Adj skin pro w/c cus wd<22in | $348.04 |
| K0734 | RR | IN | Adj skin pro w/c cus wd<22in | $30.00 | |
| K0734 | RR | KE | IN | Adj skin pro w/c cus wd<22in | $34.81 |
| K0734 | UE | IN | Adj skin pro w/c cus wd<22in | $224.98 | |
| K0734 | UE | KE | IN | Adj skin pro w/c cus wd<22in | $261.03 |
| K0735 | NU | IN | Adj skin pro wc cus wd>=22in | $381.71 | |
| K0735 | NU | KE | IN | Adj skin pro wc cus wd>=22in | $442.87 |
| K0735 | RR | IN | Adj skin pro wc cus wd>=22in | $38.18 | |
| K0735 | RR | KE | IN | Adj skin pro wc cus wd>=22in | $44.30 |
| K0735 | UE | IN | Adj skin pro wc cus wd>=22in | $286.28 | |
| K0735 | UE | KE | IN | Adj skin pro wc cus wd>=22in | $332.15 |
| K0736 | NU | IN | Adj skin pro/pos wc cus<22in | $302.44 | |
| K0736 | NU | KE | IN | Adj skin pro/pos wc cus<22in | $350.90 |
| K0736 | RR | IN | Adj skin pro/pos wc cus<22in | $30.25 | |
| K0736 | RR | KE | IN | Adj skin pro/pos wc cus<22in | $35.09 |
| K0736 | UE | IN | Adj skin pro/pos wc cus<22in | $226.85 | |
| K0736 | UE | KE | IN | Adj skin pro/pos wc cus<22in | $263.19 |
| K0737 | NU | IN | Adj skin pro/pos wc cus>=22" | $382.87 | |
| K0737 | NU | KE | IN | Adj skin pro/pos wc cus>=22" | $444.21 |
| K0737 | RR | IN | Adj skin pro/pos wc cus>=22" | $38.28 | |
| K0737 | RR | KE | IN | Adj skin pro/pos wc cus>=22" | $44.42 |
| K0737 | UE | IN | Adj skin pro/pos wc cus>=22" | $287.15 | |
| K0737 | UE | KE | IN | Adj skin pro/pos wc cus>=22" | $333.15 |
| K0738 | RR | OX | Portable gas oxygen system | $51.63 | |
| K0800 | NU | IN | POV group 1 std up to 300lbs | $1,169.96 | |
| K0800 | RR | IN | POV group 1 std up to 300lbs | $117.00 | |
| K0800 | UE | IN | POV group 1 std up to 300lbs | $877.47 | |
| K0801 | NU | IN | POV group 1 hd 301-450 lbs | $1,886.22 | |
| K0801 | RR | IN | POV group 1 hd 301-450 lbs | $188.60 | |
| K0801 | UE | IN | POV group 1 hd 301-450 lbs | $1,414.65 | |
| K0802 | NU | IN | POV group 1 vhd 451-600 lbs | $2,134.59 | |
| K0802 | RR | IN | POV group 1 vhd 451-600 lbs | $213.45 | |
| K0802 | UE | IN | POV group 1 vhd 451-600 lbs | $1,600.95 | |
| K0806 | NU | IN | POV group 2 std up to 300lbs | $1,415.34 | |
| K0806 | RR | IN | POV group 2 std up to 300lbs | $141.53 | |
| K0806 | UE | IN | POV group 2 std up to 300lbs | $1,061.50 | |
| K0807 | NU | IN | POV group 2 hd 301-450 lbs | $2,147.61 | |
| K0807 | RR | IN | POV group 2 hd 301-450 lbs | $214.76 | |
| K0807 | UE | IN | POV group 2 hd 301-450 lbs | $1,610.72 | |
| K0808 | NU | IN | POV group 2 vhd 451-600 lbs | $3,322.80 | |
| K0808 | RR | IN | POV group 2 vhd 451-600 lbs | $332.27 | |
| K0808 | UE | IN | POV group 2 vhd 451-600 lbs | $2,492.09 | |
| K0813 | RR | CR | PWC gp 1 std port seat/back | $218.32 | |
| K0814 | RR | CR | PWC gp 1 std port cap chair | $279.45 | |
| K0815 | RR | CR | PWC gp 1 std seat/back | $318.23 | |
| K0816 | RR | CR | PWC gp 1 std cap chair | $304.75 | |
| K0820 | RR | CR | PWC gp 2 std port seat/back | $233.18 | |
| K0821 | RR | CR | PWC gp 2 std port cap chair | $299.35 | |
| K0822 | RR | CR | PWC gp 2 std seat/back | $361.77 | |
| K0823 | RR | CR | PWC gp 2 std cap chair | $364.14 | |
| K0824 | RR | CR | PWC gp 2 hd seat/back | $438.26 | |
| K0825 | RR | CR | PWC gp 2 hd cap chair | $401.20 | |
| K0826 | RR | CR | PWC gp 2 vhd seat/back | $567.37 | |
| K0827 | RR | CR | PWC gp vhd cap chair | $482.45 | |
| K0828 | RR | CR | PWC gp 2 xtra hd seat/back | $625.19 | |
| K0829 | RR | CR | PWC gp 2 xtra hd cap chair | $574.10 | |
| K0835 | RR | CR | PWC gp2 std sing pow opt s/b | $367.19 | |
| K0836 | RR | CR | PWC gp2 std sing pow opt cap | $380.78 | |
| K0837 | RR | CR | PWC gp 2 hd sing pow opt s/b | $438.26 | |
| K0838 | RR | CR | PWC gp 2 hd sing pow opt cap | $392.07 | |
| K0839 | RR | CR | PWC gp2 vhd sing pow opt s/b | $567.37 | |
| K0840 | RR | CR | PWC gp2 xhd sing pow opt s/b | $859.60 | |
| K0841 | RR | CR | PWC gp2 std mult pow opt s/b | $390.83 | |
| K0842 | RR | CR | PWC gp2 std mult pow opt cap | $390.83 | |
| K0843 | RR | CR | PWC gp2 hd mult pow opt s/b | $470.56 | |
| K0848 | RR | CR | PWC gp 3 std seat/back | $478.24 | |
| K0849 | RR | CR | PWC gp 3 std cap chair | $459.80 | |
| K0850 | RR | CR | PWC gp 3 hd seat/back | $554.75 | |
| K0851 | RR | CR | PWC gp 3 hd cap chair | $533.38 | |
| K0852 | RR | CR | PWC gp 3 vhd seat/back | $640.98 | |
| K0853 | RR | CR | PWC gp 3 vhd cap chair | $658.44 | |
| K0854 | RR | CR | PWC gp 3 xhd seat/back | $872.29 | |
| K0855 | RR | CR | PWC gp 3 xhd cap chair | $824.01 | |
| K0856 | RR | CR | PWC gp3 std sing pow opt s/b | $513.34 | |
| K0857 | RR | CR | PWC gp3 std sing pow opt cap | $523.63 | |
| K0858 | RR | CR | PWC gp3 hd sing pow opt s/b | $636.90 | |
| K0859 | RR | CR | PWC gp3 hd sing pow opt cap | $607.41 | |
| K0860 | RR | CR | PWC gp3 vhd sing pow opt s/b | $909.90 | |
| K0861 | RR | CR | PWC gp3 std mult pow opt s/b | $514.17 | |
| K0861 | RR | KF | CR | PWC gp3 std mult pow opt s/b | $662.31 |
| K0862 | RR | CR | PWC gp3 hd mult pow opt s/b | $636.90 | |
| K0863 | RR | CR | PWC gp3 vhd mult pow opt s/b | $909.90 | |
| K0864 | RR | CR | PWC gp3 xhd mult pow opt s/b | $1,082.79 |
L codes: orthotics and prosthetics
847 rows| Code | Mod | Mod 2 | Cat. | Description | Fee |
|---|---|---|---|---|---|
| L0112 | PO | Cranial cervical orthosis | $1,236.93 | ||
| L0113 | PO | Cranial cervical torticollis | $252.02 | ||
| L0120 | PO | Cerv flexible non-adjustable | $22.46 | ||
| L0130 | PO | Flex thermoplastic collar mo | $184.17 | ||
| L0140 | PO | Cervical semi-rigid adjustab | $54.20 | ||
| L0150 | PO | Cerv semi-rig adj molded chn | $104.69 | ||
| L0160 | PO | Cerv semi-rig wire occ/mand | $141.88 | ||
| L0170 | PO | Cervical collar molded to pt | $546.01 | ||
| L0172 | PO | Cerv col thermplas foam 2 pi | $123.90 | ||
| L0174 | PO | Cerv col foam 2 piece w thor | $232.58 | ||
| L0180 | PO | Cer post col occ/man sup adj | $343.37 | ||
| L0190 | PO | Cerv collar supp adj cerv ba | $459.91 | ||
| L0200 | PO | Cerv col supp adj bar & thor | $442.87 | ||
| L0220 | PO | Thor rib belt custom fabrica | $130.69 | ||
| L0430 | PO | Dewall posture protector | $1,258.46 | ||
| L0450 | PO | TLSO flex prefab thoracic | $172.35 | ||
| L0452 | PO | tlso flex custom fab thoraci | $0.00 | ||
| L0454 | PO | TLSO flex prefab sacrococ-T9 | $306.51 | ||
| L0456 | PO | TLSO flex prefab | $878.98 | ||
| L0458 | PO | TLSO 2Mod symphis-xipho pre | $788.16 | ||
| L0460 | PO | TLSO2Mod symphysis-stern pre | $887.12 | ||
| L0462 | PO | TLSO 3Mod sacro-scap pre | $1,103.45 | ||
| L0464 | PO | TLSO 4Mod sacro-scap pre | $1,313.63 | ||
| L0466 | PO | TLSO rigid frame pre soft ap | $316.31 | ||
| L0468 | PO | TLSO rigid frame prefab pelv | $388.08 | ||
| L0470 | PO | TLSO rigid frame pre subclav | $629.34 | ||
| L0472 | PO | TLSO rigid frame hyperex pre | $409.96 | ||
| L0480 | PO | TLSO rigid plastic custom fa | $1,455.56 | ||
| L0482 | PO | TLSO rigid lined custom fab | $1,622.12 | ||
| L0484 | PO | TLSO rigid plastic cust fab | $1,611.53 | ||
| L0486 | PO | TLSO rigidlined cust fab two | $1,713.40 | ||
| L0488 | PO | TLSO rigid lined pre one pie | $887.12 | ||
| L0490 | PO | TLSO rigid plastic pre one | $250.01 | ||
| L0491 | PO | TLSO 2 piece rigid shell | $678.74 | ||
| L0492 | PO | TLSO 3 piece rigid shell | $445.87 | ||
| L0621 | PO | SIO flex pelvisacral prefab | $81.90 | ||
| L0622 | PO | SIO flex pelvisacral custom | $218.72 | ||
| L0623 | PO | SIO panel prefab | $0.00 | ||
| L0624 | PO | SIO panel custom | $0.00 | ||
| L0625 | PO | LO flexibl L1-below L5 pre | $48.67 | ||
| L0626 | PO | LO sag stays/panels pre-fab | $68.88 | ||
| L0627 | PO | LO sagitt rigid panel prefab | $363.27 | ||
| L0628 | PO | LO flex w/o rigid stays pre | $74.14 | ||
| L0629 | PO | LSO flex w/rigid stays cust | $0.00 | ||
| L0630 | PO | LSO post rigid panel pre | $143.13 | ||
| L0631 | PO | LSO sag-coro rigid frame pre | $907.25 | ||
| L0632 | PO | LSO sag rigid frame cust | $0.00 | ||
| L0633 | PO | LSO flexion control prefab | $253.42 | ||
| L0634 | PO | LSO flexion control custom | $0.00 | ||
| L0635 | PO | LSO sagit rigid panel prefab | $861.51 | ||
| L0636 | PO | LSO sagittal rigid panel cus | $1,277.69 | ||
| L0637 | PO | LSO sag-coronal panel prefab | $949.40 | ||
| L0638 | PO | LSO sag-coronal panel custom | $1,165.59 | ||
| L0639 | PO | LSO s/c shell/panel prefab | $949.40 | ||
| L0640 | PO | LSO s/c shell/panel custom | $924.76 | ||
| L0700 | PO | Ctlso a-p-l control molded | $1,711.65 | ||
| L0710 | PO | Ctlso a-p-l control w/ inter | $1,776.81 | ||
| L0810 | PO | Halo cervical into jckt vest | $2,217.73 | ||
| L0820 | PO | Halo cervical into body jack | $1,828.81 | ||
| L0830 | PO | Halo cerv into milwaukee typ | $2,654.88 | ||
| L0859 | PO | MRI compatible system | $1,031.40 | ||
| L0861 | PO | Halo repl liner/interface | $190.48 | ||
| L0970 | PO | Tlso corset front | $100.15 | ||
| L0972 | PO | Lso corset front | $96.54 | ||
| L0974 | PO | Tlso full corset | $151.58 | ||
| L0976 | PO | Lso full corset | $135.38 | ||
| L0978 | PO | Axillary crutch extension | $162.97 | ||
| L0980 | PO | Peroneal straps pair | $14.78 | ||
| L0982 | PO | Stocking supp grips set of f | $13.78 | ||
| L0984 | PO | Protective body sock each | $55.43 | ||
| L1000 | PO | Ctlso milwauke initial model | $1,718.88 | ||
| L1001 | PO | CTLSO infant immobilizer | $0.00 | ||
| L1005 | PO | Tension based scoliosis orth | $2,828.58 | ||
| L1010 | PO | Ctlso axilla sling | $56.82 | ||
| L1020 | PO | Kyphosis pad | $73.18 | ||
| L1025 | PO | Kyphosis pad floating | $140.77 | ||
| L1030 | PO | Lumbar bolster pad | $53.86 | ||
| L1040 | PO | Lumbar or lumbar rib pad | $66.05 | ||
| L1050 | PO | Sternal pad | $70.49 | ||
| L1060 | PO | Thoracic pad | $80.97 | ||
| L1070 | PO | Trapezius sling | $76.18 | ||
| L1080 | PO | Outrigger | $46.86 | ||
| L1085 | PO | Outrigger bil w/ vert extens | $130.32 | ||
| L1090 | PO | Lumbar sling | $85.17 | ||
| L1100 | PO | Ring flange plastic/leather | $138.22 | ||
| L1110 | PO | Ring flange plas/leather mol | $216.23 | ||
| L1120 | PO | Covers for upright each | $33.62 | ||
| L1200 | PO | Furnsh initial orthosis only | $1,326.54 | ||
| L1210 | PO | Lateral thoracic extension | $295.37 | ||
| L1220 | PO | Anterior thoracic extension | $250.09 | ||
| L1230 | PO | Milwaukee type superstructur | $641.70 | ||
| L1240 | PO | Lumbar derotation pad | $66.35 | ||
| L1250 | PO | Anterior asis pad | $61.17 | ||
| L1260 | PO | Anterior thoracic derotation | $64.05 | ||
| L1270 | PO | Abdominal pad | $65.60 | ||
| L1280 | PO | Rib gusset (elastic) each | $78.46 | ||
| L1290 | PO | Lateral trochanteric pad | $66.54 | ||
| L1300 | PO | Body jacket mold to patient | $1,885.67 | ||
| L1310 | PO | Post-operative body jacket | $1,878.10 | ||
| L1500 | PO | Thkao mobility frame | $1,608.16 | ||
| L1510 | PO | Thkao standing frame | $1,356.53 | ||
| L1520 | PO | Thkao swivel walker | $2,516.64 | ||
| L1600 | PO | Abduct hip flex frejka w cvr | $109.10 | ||
| L1610 | PO | Abduct hip flex frejka covr | $40.61 | ||
| L1620 | PO | Abduct hip flex pavlik harne | $125.53 | ||
| L1630 | PO | Abduct control hip semi-flex | $143.46 | ||
| L1640 | PO | Pelv band/spread bar thigh c | $456.47 | ||
| L1650 | PO | HO abduction hip adjustable | $196.02 | ||
| L1652 | PO | HO bi thighcuffs w sprdr bar | $315.03 | ||
| L1660 | PO | HO abduction static plastic | $144.89 | ||
| L1680 | PO | Pelvic & hip control thigh c | $1,031.57 | ||
| L1685 | PO | Post-op hip abduct custom fa | $1,007.06 | ||
| L1686 | PO | HO post-op hip abduction | $1,029.73 | ||
| L1690 | PO | Combination bilateral HO | $1,708.96 | ||
| L1700 | PO | Leg perthes orth toronto typ | $1,292.91 | ||
| L1710 | PO | Legg perthes orth newington | $1,513.50 | ||
| L1720 | PO | Legg perthes orthosis trilat | $1,115.63 | ||
| L1730 | PO | Legg perthes orth scottish r | $983.88 | ||
| L1755 | PO | Legg perthes patten bottom t | $1,379.70 | ||
| L1810 | PO | Ko elastic with joints | $90.95 | ||
| L1820 | PO | Ko elas w/ condyle pads & jo | $124.61 | ||
| L1830 | PO | Ko immobilizer canvas longit | $87.80 | ||
| L1831 | PO | Knee orth pos locking joint | $260.10 | ||
| L1832 | PO | KO adj jnt pos rigid support | $686.31 | ||
| L1834 | PO | Ko w/0 joint rigid molded to | $744.08 | ||
| L1836 | PO | Rigid KO wo joints | $117.92 | ||
| L1840 | PO | Ko derot ant cruciate custom | $876.12 | ||
| L1843 | PO | KO single upright custom fit | $792.96 | ||
| L1844 | PO | Ko w/adj jt rot cntrl molded | $1,384.28 | ||
| L1845 | PO | Ko w/ adj flex/ext rotat cus | $869.76 | ||
| L1846 | PO | Ko w adj flex/ext rotat mold | $1,141.23 | ||
| L1847 | PO | KO adjustable w air chambers | $508.31 | ||
| L1850 | PO | Ko swedish type | $267.60 | ||
| L1860 | PO | Ko supracondylar socket mold | $1,106.55 | ||
| L1900 | PO | Afo sprng wir drsflx calf bd | $228.40 | ||
| L1902 | PO | Afo ankle gauntlet | $88.45 | ||
| L1904 | PO | Afo molded ankle gauntlet | $411.73 | ||
| L1906 | PO | Afo multiligamentus ankle su | $102.82 | ||
| L1907 | PO | AFO supramalleolar custom | $497.28 | ||
| L1910 | PO | Afo sing bar clasp attach sh | $281.66 | ||
| L1920 | PO | Afo sing upright w/ adjust s | $316.64 | ||
| L1930 | PO | Afo plastic | $200.28 | ||
| L1932 | PO | Afo rig ant tib prefab TCF/= | $788.63 | ||
| L1940 | PO | Afo molded to patient plasti | $531.48 | ||
| L1945 | PO | Afo molded plas rig ant tib | $783.73 | ||
| L1950 | PO | Afo spiral molded to pt plas | $840.82 | ||
| L1951 | PO | AFO spiral prefabricated | $742.21 | ||
| L1960 | PO | Afo pos solid ank plastic mo | $625.71 | ||
| L1970 | PO | Afo plastic molded w/ankle j | $799.03 | ||
| L1971 | PO | AFO w/ankle joint, prefab | $414.24 | ||
| L1980 | PO | Afo sing solid stirrup calf | $348.77 | ||
| L1990 | PO | Afo doub solid stirrup calf | $450.06 | ||
| L2000 | PO | Kafo sing fre stirr thi/calf | $968.33 | ||
| L2005 | PO | KAFO sng/dbl mechanical act | $3,621.39 | ||
| L2010 | PO | Kafo sng solid stirrup w/o j | $1,043.76 | ||
| L2020 | PO | Kafo dbl solid stirrup band/ | $1,074.01 | ||
| L2030 | PO | Kafo dbl solid stirrup w/o j | $1,101.22 | ||
| L2034 | PO | KAFO pla sin up w/wo k/a cus | $1,842.24 | ||
| L2035 | PO | KAFO plastic pediatric size | $155.72 | ||
| L2036 | PO | Kafo plas doub free knee mol | $2,094.38 | ||
| L2037 | PO | Kafo plas sing free knee mol | $1,853.19 | ||
| L2038 | PO | Kafo w/o joint multi-axis an | $1,590.19 | ||
| L2040 | PO | Hkafo torsion bil rot straps | $150.31 | ||
| L2050 | PO | Hkafo torsion cable hip pelv | $413.47 | ||
| L2060 | PO | Hkafo torsion ball bearing j | $520.42 | ||
| L2070 | PO | Hkafo torsion unilat rot str | $114.59 | ||
| L2080 | PO | Hkafo unilat torsion cable | $323.11 | ||
| L2090 | PO | Hkafo unilat torsion ball br | $371.24 | ||
| L2106 | PO | Afo tib fx cast plaster mold | $738.57 | ||
| L2108 | PO | Afo tib fx cast molded to pt | $1,097.86 | ||
| L2112 | PO | Afo tibial fracture soft | $501.71 | ||
| L2114 | PO | Afo tib fx semi-rigid | $654.70 | ||
| L2116 | PO | Afo tibial fracture rigid | $720.29 | ||
| L2126 | PO | Kafo fem fx cast thermoplas | $1,351.75 | ||
| L2128 | PO | Kafo fem fx cast molded to p | $1,749.02 | ||
| L2132 | PO | Kafo femoral fx cast soft | $910.62 | ||
| L2134 | PO | Kafo fem fx cast semi-rigid | $1,091.80 | ||
| L2136 | PO | Kafo femoral fx cast rigid | $1,334.99 | ||
| L2180 | PO | Plas shoe insert w ank joint | $99.15 | ||
| L2182 | PO | Drop lock knee | $77.60 | ||
| L2184 | PO | Limited motion knee joint | $104.88 | ||
| L2186 | PO | Adj motion knee jnt lerman t | $140.15 | ||
| L2188 | PO | Quadrilateral brim | $338.08 | ||
| L2190 | PO | Waist belt | $79.61 | ||
| L2192 | PO | Pelvic band & belt thigh fla | $385.26 | ||
| L2200 | PO | Limited ankle motion ea jnt | $41.70 | ||
| L2210 | PO | Dorsiflexion assist each joi | $62.19 | ||
| L2220 | PO | Dorsi & plantar flex ass/res | $78.65 | ||
| L2230 | PO | Split flat caliper stirr & p | $64.96 | ||
| L2232 | PO | Rocker bottom, contact AFO | $87.95 | ||
| L2240 | PO | Round caliper and plate atta | $70.80 | ||
| L2250 | PO | Foot plate molded stirrup at | $300.84 | ||
| L2260 | PO | Reinforced solid stirrup | $226.29 | ||
| L2265 | PO | Long tongue stirrup | $99.70 | ||
| L2270 | PO | Varus/valgus strap padded/li | $46.48 | ||
| L2275 | PO | Plastic mod low ext pad/line | $106.72 | ||
| L2280 | PO | Molded inner boot | $442.02 | ||
| L2300 | PO | Abduction bar jointed adjust | $303.93 | ||
| L2310 | PO | Abduction bar-straight | $104.15 | ||
| L2320 | PO | Non-molded lacer | $208.49 | ||
| L2330 | PO | Lacer molded to patient mode | $443.25 | ||
| L2335 | PO | Anterior swing band | $192.33 | ||
| L2340 | PO | Pre-tibial shell molded to p | $411.27 | ||
| L2350 | PO | Prosthetic type socket molde | $1,002.62 | ||
| L2360 | PO | Extended steel shank | $58.41 | ||
| L2370 | PO | Patten bottom | $289.79 | ||
| L2375 | PO | Torsion ank & half solid sti | $95.66 | ||
| L2380 | PO | Torsion straight knee joint | $104.23 | ||
| L2385 | PO | Straight knee joint heavy du | $113.40 | ||
| L2387 | PO | Add LE poly knee custom KAFO | $140.12 | ||
| L2390 | PO | Offset knee joint each | $98.79 | ||
| L2395 | PO | Offset knee joint heavy duty | $132.46 | ||
| L2397 | PO | Suspension sleeve lower ext | $99.93 | ||
| L2405 | PO | Knee joint drop lock ea jnt | $77.05 | ||
| L2415 | PO | Knee joint cam lock each joi | $107.33 | ||
| L2425 | PO | Knee disc/dial lock/adj flex | $126.68 | ||
| L2430 | PO | Knee jnt ratchet lock ea jnt | $126.68 | ||
| L2492 | PO | Knee lift loop drop lock rin | $98.36 | ||
| L2500 | PO | Thi/glut/ischia wgt bearing | $267.09 | ||
| L2510 | PO | Th/wght bear quad-lat brim m | $715.81 | ||
| L2520 | PO | Th/wght bear quad-lat brim c | $480.56 | ||
| L2525 | PO | Th/wght bear nar m-l brim mo | $1,187.84 | ||
| L2526 | PO | Th/wght bear nar m-l brim cu | $579.90 | ||
| L2530 | PO | Thigh/wght bear lacer non-mo | $259.22 | ||
| L2540 | PO | Thigh/wght bear lacer molded | $365.67 | ||
| L2550 | PO | Thigh/wght bear high roll cu | $295.50 | ||
| L2570 | PO | Hip clevis type 2 posit jnt | $403.26 | ||
| L2580 | PO | Pelvic control pelvic sling | $450.84 | ||
| L2600 | PO | Hip clevis/thrust bearing fr | $173.88 | ||
| L2610 | PO | Hip clevis/thrust bearing lo | $239.94 | ||
| L2620 | PO | Pelvic control hip heavy dut | $301.83 | ||
| L2622 | PO | Hip joint adjustable flexion | $259.63 | ||
| L2624 | PO | Hip adj flex ext abduct cont | $300.21 | ||
| L2627 | PO | Plastic mold recipro hip & c | $1,765.80 | ||
| L2628 | PO | Metal frame recipro hip & ca | $1,823.23 | ||
| L2630 | PO | Pelvic control band & belt u | $255.33 | ||
| L2640 | PO | Pelvic control band & belt b | $379.36 | ||
| L2650 | PO | Pelv & thor control gluteal | $104.32 | ||
| L2660 | PO | Thoracic control thoracic ba | $157.80 | ||
| L2670 | PO | Thorac cont paraspinal uprig | $178.37 | ||
| L2680 | PO | Thorac cont lat support upri | $165.80 | ||
| L2750 | PO | Plating chrome/nickel pr bar | $83.30 | ||
| L2755 | PO | Carbon graphite lamination | $115.44 | ||
| L2760 | PO | Extension per extension per | $63.27 | ||
| L2768 | PO | Ortho sidebar disconnect | $115.14 | ||
| L2780 | PO | Non-corrosive finish | $68.99 | ||
| L2785 | PO | Drop lock retainer each | $31.59 | ||
| L2795 | PO | Knee control full kneecap | $80.83 | ||
| L2800 | PO | Knee cap medial or lateral p | $90.31 | ||
| L2810 | PO | Knee control condylar pad | $66.13 | ||
| L2820 | PO | Soft interface below knee se | $84.45 | ||
| L2830 | PO | Soft interface above knee se | $97.94 | ||
| L2840 | PO | Tibial length sock fx or equ | $43.76 | ||
| L2850 | PO | Femoral lgth sock fx or equa | $56.28 | ||
| L3000 | PO | Ft insert ucb berkeley shell | $277.61 | ||
| L3001 | PO | Foot insert remov molded spe | $116.89 | ||
| L3002 | PO | Foot insert plastazote or eq | $142.73 | ||
| L3003 | PO | Foot insert silicone gel eac | $154.00 | ||
| L3010 | PO | Foot longitudinal arch suppo | $154.00 | ||
| L3020 | PO | Foot longitud/metatarsal sup | $175.35 | ||
| L3030 | PO | Foot arch support remov prem | $67.45 | ||
| L3031 | PO | Foot lamin/prepreg composite | $0.00 | ||
| L3040 | PO | Ft arch suprt premold longit | $41.58 | ||
| L3050 | PO | Foot arch supp premold metat | $41.58 | ||
| L3060 | PO | Foot arch supp longitud/meta | $65.19 | ||
| L3070 | PO | Arch suprt att to sho longit | $28.07 | ||
| L3080 | PO | Arch supp att to shoe metata | $28.07 | ||
| L3090 | PO | Arch supp att to shoe long/m | $35.98 | ||
| L3100 | PO | Hallus-valgus nght dynamic s | $38.21 | ||
| L3140 | PO | Abduction rotation bar shoe | $78.69 | ||
| L3150 | PO | Abduct rotation bar w/o shoe | $71.94 | ||
| L3170 | PO | Foot plastic heel stabilizer | $44.98 | ||
| L3224 | PO | Woman's shoe oxford brace | $54.83 | ||
| L3225 | PO | Man's shoe oxford brace | $61.58 | ||
| L3300 | PO | Sho lift taper to metatarsal | $46.07 | ||
| L3310 | PO | Shoe lift elev heel/sole neo | $71.94 | ||
| L3330 | PO | Lifts elevation metal extens | $500.16 | ||
| L3332 | PO | Shoe lifts tapered to one-ha | $65.19 | ||
| L3334 | PO | Shoe lifts elevation heel /i | $33.72 | ||
| L3340 | PO | Shoe wedge sach | $75.32 | ||
| L3350 | PO | Shoe heel wedge | $20.24 | ||
| L3360 | PO | Shoe sole wedge outside sole | $31.47 | ||
| L3370 | PO | Shoe sole wedge between sole | $43.81 | ||
| L3380 | PO | Shoe clubfoot wedge | $43.81 | ||
| L3390 | PO | Shoe outflare wedge | $43.81 | ||
| L3400 | PO | Shoe metatarsal bar wedge ro | $35.98 | ||
| L3410 | PO | Shoe metatarsal bar between | $82.04 | ||
| L3420 | PO | Full sole/heel wedge btween | $48.33 | ||
| L3430 | PO | Sho heel count plast reinfor | $141.62 | ||
| L3440 | PO | Heel leather reinforced | $67.45 | ||
| L3450 | PO | Shoe heel sach cushion type | $93.29 | ||
| L3455 | PO | Shoe heel new leather standa | $35.98 | ||
| L3460 | PO | Shoe heel new rubber standar | $30.33 | ||
| L3465 | PO | Shoe heel thomas with wedge | $51.71 | ||
| L3470 | PO | Shoe heel thomas extend to b | $55.07 | ||
| L3480 | PO | Shoe heel pad & depress for | $55.07 | ||
| L3500 | PO | Ortho shoe add leather insol | $25.85 | ||
| L3510 | PO | Orthopedic shoe add rub insl | $25.85 | ||
| L3520 | PO | O shoe add felt w leath insl | $28.07 | ||
| L3530 | PO | Ortho shoe add half sole | $28.07 | ||
| L3540 | PO | Ortho shoe add full sole | $44.98 | ||
| L3550 | PO | O shoe add standard toe tap | $7.85 | ||
| L3560 | PO | O shoe add horseshoe toe tap | $20.24 | ||
| L3570 | PO | O shoe add instep extension | $75.32 | ||
| L3580 | PO | O shoe add instep velcro clo | $57.32 | ||
| L3590 | PO | O shoe convert to sof counte | $47.20 | ||
| L3595 | PO | Ortho shoe add march bar | $37.09 | ||
| L3600 | PO | Trans shoe calip plate exist | $67.45 | ||
| L3610 | PO | Trans shoe caliper plate new | $88.78 | ||
| L3620 | PO | Trans shoe solid stirrup exi | $67.45 | ||
| L3630 | PO | Trans shoe solid stirrup new | $88.78 | ||
| L3640 | PO | Shoe dennis browne splint bo | $38.21 | ||
| L3650 | PO | Shlder fig 8 abduct restrain | $56.44 | ||
| L3660 | PO | Abduct restrainer canvas&web | $87.15 | ||
| L3670 | PO | Acromio/clavicular canvas&we | $111.07 | ||
| L3671 | PO | SO cap design w/o jnts CF | $724.74 | ||
| L3672 | PO | SO airplane w/o jnts CF | $901.26 | ||
| L3673 | PO | SO airplane w/joint CF | $982.26 | ||
| L3675 | PO | Canvas vest SO | $141.14 | ||
| L3702 | PO | EO w/o joints CF | $232.24 | ||
| L3710 | PO | Elbow elastic with metal joi | $106.90 | ||
| L3720 | PO | Forearm/arm cuffs free motio | $722.52 | ||
| L3730 | PO | Forearm/arm cuffs ext/flex a | $974.00 | ||
| L3740 | PO | Cuffs adj lock w/ active con | $1,092.33 | ||
| L3760 | PO | EO withjoint, Prefabricated | $402.22 | ||
| L3762 | PO | Rigid EO wo joints | $86.49 | ||
| L3763 | PO | EWHO rigid w/o jnts CF | $619.76 | ||
| L3764 | PO | EWHO w/joint(s) CF | $779.98 | ||
| L3765 | PO | EWHFO rigid w/o jnts CF | $1,031.30 | ||
| L3766 | PO | EWHFO w/joint(s) CF | $1,092.07 | ||
| L3806 | PO | WHFO w/joint(s) custom fab | $365.35 | ||
| L3807 | PO | WHFO,no joint, prefabricated | $201.12 | ||
| L3808 | PO | WHFO, rigid w/o joints | $326.34 | ||
| L3900 | PO | Hinge extension/flex wrist/f | $1,072.01 | ||
| L3901 | PO | Hinge ext/flex wrist finger | $1,472.96 | ||
| L3904 | PO | Whfo electric custom fitted | $2,426.16 | ||
| L3905 | PO | WHO w/nontorsion jnt(s) CF | $797.64 | ||
| L3906 | PO | WHO w/o joints CF | $338.28 | ||
| L3908 | PO | Wrist cock-up non-molded | $66.19 | ||
| L3912 | PO | Flex glove w/elastic finger | $78.57 | ||
| L3913 | PO | HFO w/o joints CF | $217.84 | ||
| L3915 | PO | WHO w nontor jnt(s) prefab | $427.53 | ||
| L3917 | PO | Prefab metacarpl fx orthosis | $84.97 | ||
| L3919 | PO | HO w/o joints CF | $217.84 | ||
| L3921 | PO | HFO w/joint(s) CF | $258.36 | ||
| L3923 | PO | HFO w/o joints PF | $72.07 | ||
| L3925 | PO | FO pip/dip with joint/spring | $40.89 | ||
| L3927 | PO | FO pip/dip w/o joint/spring | $28.10 | ||
| L3929 | PO | HFO nontorsion joint, prefab | $64.76 | ||
| L3931 | PO | WHFO nontorsion joint prefab | $158.21 | ||
| L3933 | PO | FO w/o joints CF | $171.61 | ||
| L3935 | PO | FO nontorsion joint CF | $177.68 | ||
| L3956 | PO | Add joint upper ext orthosis | $0.00 | ||
| L3960 | PO | Sewho airplan desig abdu pos | $624.54 | ||
| L3961 | PO | SEWHO cap design w/o jnts CF | $1,351.31 | ||
| L3962 | PO | Sewho erbs palsey design abd | $594.43 | ||
| L3964 | NU | IN | Seo mobile arm sup att to wc | $652.17 | |
| L3964 | RR | IN | Seo mobile arm sup att to wc | $65.21 | |
| L3964 | UE | IN | Seo mobile arm sup att to wc | $489.09 | |
| L3965 | NU | IN | Arm supp att to wc rancho ty | $1,040.67 | |
| L3965 | RR | IN | Arm supp att to wc rancho ty | $104.09 | |
| L3965 | UE | IN | Arm supp att to wc rancho ty | $780.50 | |
| L3966 | NU | IN | Mobile arm supports reclinin | $783.97 | |
| L3966 | RR | IN | Mobile arm supports reclinin | $78.40 | |
| L3966 | UE | IN | Mobile arm supports reclinin | $587.98 | |
| L3967 | PO | SEWHO airplane w/o jnts CF | $1,595.45 | ||
| L3968 | NU | IN | Friction dampening arm supp | $992.10 | |
| L3968 | RR | IN | Friction dampening arm supp | $99.20 | |
| L3968 | UE | IN | Friction dampening arm supp | $744.08 | |
| L3969 | NU | IN | Monosuspension arm/hand supp | $675.03 | |
| L3969 | RR | IN | Monosuspension arm/hand supp | $67.52 | |
| L3969 | UE | IN | Monosuspension arm/hand supp | $506.29 | |
| L3970 | NU | IN | Elevat proximal arm support | $277.53 | |
| L3970 | RR | IN | Elevat proximal arm support | $27.75 | |
| L3970 | UE | IN | Elevat proximal arm support | $208.14 | |
| L3971 | PO | SEWHO cap design w/jnt(s) CF | $1,514.45 | ||
| L3972 | NU | IN | Offset/lat rocker arm w/ ela | $176.47 | |
| L3972 | RR | IN | Offset/lat rocker arm w/ ela | $17.65 | |
| L3972 | UE | IN | Offset/lat rocker arm w/ ela | $132.35 | |
| L3973 | PO | SEWHO airplane w/jnt(s) CF | $1,595.45 | ||
| L3974 | NU | IN | Mobile arm support supinator | $149.68 | |
| L3974 | RR | IN | Mobile arm support supinator | $14.98 | |
| L3974 | UE | IN | Mobile arm support supinator | $112.26 | |
| L3975 | PO | SEWHFO cap design w/o jnt CF | $1,351.31 | ||
| L3976 | PO | SEWHFO airplane w/o jnts CF | $1,351.31 | ||
| L3977 | PO | SEWHFO cap desgn w/jnt(s) CF | $1,514.45 | ||
| L3978 | PO | SEWHFO airplane w/jnt(s) CF | $1,595.45 | ||
| L3980 | PO | Upp ext fx orthosis humeral | $292.85 | ||
| L3982 | PO | Upper ext fx orthosis rad/ul | $412.38 | ||
| L3984 | PO | Upper ext fx orthosis wrist | $305.04 | ||
| L3995 | PO | Sock fracture or equal each | $36.12 | ||
| L4000 | PO | Repl girdle milwaukee orth | $1,079.50 | ||
| L4002 | PO | Replace strap, any orthosis | $0.00 | ||
| L4010 | PO | Replace trilateral socket br | $670.03 | ||
| L4020 | PO | Replace quadlat socket brim | $930.03 | ||
| L4030 | PO | Replace socket brim cust fit | $569.94 | ||
| L4040 | PO | Replace molded thigh lacer | $408.64 | ||
| L4045 | PO | Replace non-molded thigh lac | $277.72 | ||
| L4050 | PO | Replace molded calf lacer | $466.04 | ||
| L4055 | PO | Replace non-molded calf lace | $226.33 | ||
| L4060 | PO | Replace high roll cuff | $269.06 | ||
| L4070 | PO | Replace prox & dist upright | $238.27 | ||
| L4080 | PO | Repl met band kafo-afo prox | $87.52 | ||
| L4090 | PO | Repl met band kafo-afo calf/ | $91.00 | ||
| L4100 | PO | Repl leath cuff kafo prox th | $109.71 | ||
| L4110 | PO | Repl leath cuff kafo-afo cal | $94.65 | ||
| L4130 | PO | Replace pretibial shell | $420.05 | ||
| L4350 | PO | Ankle control orthosi prefab | $75.68 | ||
| L4360 | PO | Pneumati walking boot prefab | $243.20 | ||
| L4370 | PO | Pneumatic full leg splint | $159.83 | ||
| L4380 | PO | Pneumatic knee splint | $112.46 | ||
| L4386 | PO | Non-pneum walk boot prefab | $140.12 | ||
| L4392 | PO | Replace AFO soft interface | $20.80 | ||
| L4394 | PO | Replace foot drop spint | $15.17 | ||
| L4396 | PO | Static AFO | $148.29 | ||
| L4398 | PO | Foot drop splint recumbent | $68.28 | ||
| L5000 | PO | Sho insert w arch toe filler | $455.74 | ||
| L5010 | PO | Mold socket ank hgt w/ toe f | $1,393.98 | ||
| L5020 | PO | Tibial tubercle hgt w/ toe f | $1,787.52 | ||
| L5050 | PO | Ank symes mold sckt sach ft | $2,206.49 | ||
| L5060 | PO | Symes met fr leath socket ar | $3,321.74 | ||
| L5100 | PO | Molded socket shin sach foot | $2,286.02 | ||
| L5105 | PO | Plast socket jts/thgh lacer | $3,818.81 | ||
| L5150 | PO | Mold sckt ext knee shin sach | $3,518.16 | ||
| L5160 | PO | Mold socket bent knee shin s | $3,445.23 | ||
| L5200 | PO | Kne sing axis fric shin sach | $2,981.01 | ||
| L5210 | PO | No knee/ankle joints w/ ft b | $2,918.33 | ||
| L5220 | PO | No knee joint with artic ali | $2,663.70 | ||
| L5230 | PO | Fem focal defic constant fri | $3,431.32 | ||
| L5250 | PO | Hip canad sing axi cons fric | $4,998.89 | ||
| L5270 | PO | Tilt table locking hip sing | $4,639.02 | ||
| L5280 | PO | Hemipelvect canad sing axis | $4,592.63 | ||
| L5301 | PO | BK mold socket SACH ft endo | $2,071.00 | ||
| L5311 | PO | Knee disart, SACH ft, endo | $3,026.74 | ||
| L5321 | PO | AK open end SACH | $2,964.57 | ||
| L5331 | PO | Hip disart canadian SACH ft | $4,194.98 | ||
| L5341 | PO | Hemipelvectomy canadian SACH | $4,592.78 | ||
| L5400 | PO | Postop dress & 1 cast chg bk | $1,085.58 | ||
| L5410 | PO | Postop dsg bk ea add cast ch | $376.87 | ||
| L5420 | PO | Postop dsg & 1 cast chg ak/d | $1,371.04 | ||
| L5430 | PO | Postop dsg ak ea add cast ch | $605.19 | ||
| L5450 | PO | Postop app non-wgt bear dsg | $408.79 | ||
| L5460 | PO | Postop app non-wgt bear dsg | $491.84 | ||
| L5500 | PO | Init bk ptb plaster direct | $1,158.45 | ||
| L5505 | PO | Init ak ischal plstr direct | $1,568.85 | ||
| L5510 | PO | Prep BK ptb plaster molded | $1,313.18 | ||
| L5520 | PO | Perp BK ptb thermopls direct | $1,584.72 | ||
| L5530 | PO | Prep BK ptb thermopls molded | $1,557.95 | ||
| L5535 | PO | Prep BK ptb open end socket | $1,710.89 | ||
| L5540 | PO | Prep BK ptb laminated socket | $1,632.56 | ||
| L5560 | PO | Prep AK ischial plast molded | $2,048.48 | ||
| L5570 | PO | Prep AK ischial direct form | $2,063.30 | ||
| L5580 | PO | Prep AK ischial thermo mold | $2,338.67 | ||
| L5585 | PO | Prep AK ischial open end | $2,307.80 | ||
| L5590 | PO | Prep AK ischial laminated | $2,406.26 | ||
| L5595 | PO | Hip disartic sach thermopls | $4,009.37 | ||
| L5600 | PO | Hip disart sach laminat mold | $4,435.46 | ||
| L5610 | PO | Above knee hydracadence | $1,867.47 | ||
| L5611 | PO | Ak 4 bar link w/fric swing | $1,453.26 | ||
| L5613 | PO | Ak 4 bar ling w/hydraul swig | $2,210.50 | ||
| L5614 | PO | 4-bar link above knee w/swng | $1,494.20 | ||
| L5616 | PO | Ak univ multiplex sys frict | $1,225.04 | ||
| L5617 | PO | AK/BK self-aligning unit ea | $505.39 | ||
| L5618 | PO | Test socket symes | $267.34 | ||
| L5620 | PO | Test socket below knee | $296.69 | ||
| L5622 | PO | Test socket knee disarticula | $435.99 | ||
| L5624 | PO | Test socket above knee | $378.87 | ||
| L5626 | PO | Test socket hip disarticulat | $430.06 | ||
| L5628 | PO | Test socket hemipelvectomy | $449.66 | ||
| L5629 | PO | Below knee acrylic socket | $382.20 | ||
| L5630 | PO | Syme typ expandabl wall sckt | $408.92 | ||
| L5631 | PO | Ak/knee disartic acrylic soc | $528.42 | ||
| L5632 | PO | Symes type ptb brim design s | $218.16 | ||
| L5634 | PO | Symes type poster opening so | $321.65 | ||
| L5636 | PO | Symes type medial opening so | $306.44 | ||
| L5637 | PO | Below knee total contact | $332.45 | ||
| L5638 | PO | Below knee leather socket | $528.12 | ||
| L5639 | PO | Below knee wood socket | $1,288.34 | ||
| L5640 | PO | Knee disarticulat leather so | $769.02 | ||
| L5642 | PO | Above knee leather socket | $666.91 | ||
| L5643 | PO | Hip flex inner socket ext fr | $1,403.89 | ||
| L5644 | PO | Above knee wood socket | $532.75 | ||
| L5645 | PO | Bk flex inner socket ext fra | $719.69 | ||
| L5646 | PO | Below knee cushion socket | $523.31 | ||
| L5647 | PO | Below knee suction socket | $751.02 | ||
| L5648 | PO | Above knee cushion socket | $659.98 | ||
| L5649 | PO | Isch containmt/narrow m-l so | $1,717.33 | ||
| L5650 | PO | Tot contact ak/knee disart s | $587.11 | ||
| L5651 | PO | Ak flex inner socket ext fra | $1,083.21 | ||
| L5652 | PO | Suction susp ak/knee disart | $393.25 | ||
| L5653 | PO | Knee disart expand wall sock | $524.95 | ||
| L5654 | PO | Socket insert symes | $316.80 | ||
| L5655 | PO | Socket insert below knee | $307.80 | ||
| L5656 | PO | Socket insert knee articulat | $437.29 | ||
| L5658 | PO | Socket insert above knee | $353.07 | ||
| L5661 | PO | Multi-durometer symes | $550.50 | ||
| L5665 | PO | Multi-durometer below knee | $461.84 | ||
| L5666 | PO | Below knee cuff suspension | $70.93 | ||
| L5668 | PO | Socket insert w/o lock lower | $94.93 | ||
| L5670 | PO | Bk molded supracondylar susp | $253.22 | ||
| L5671 | PO | BK/AK locking mechanism | $448.66 | ||
| L5672 | PO | Bk removable medial brim sus | $268.96 | ||
| L5673 | PO | Socket insert w lock mech | $602.72 | ||
| L5676 | PO | Bk knee joints single axis p | $326.85 | ||
| L5677 | PO | Bk knee joints polycentric p | $444.73 | ||
| L5678 | PO | Bk joint covers pair | $35.81 | ||
| L5679 | PO | Socket insert w/o lock mech | $502.25 | ||
| L5680 | PO | Bk thigh lacer non-molded | $351.57 | ||
| L5681 | PO | Intl custm cong/latyp insert | $1,164.74 | ||
| L5682 | PO | Bk thigh lacer glut/ischia m | $588.04 | ||
| L5683 | PO | Initial custom socket insert | $1,164.74 | ||
| L5684 | PO | Bk fork strap | $44.57 | ||
| L5685 | PO | Below knee sus/seal sleeve | $113.41 | ||
| L5686 | PO | Bk back check | $61.44 | ||
| L5688 | PO | Bk waist belt webbing | $73.46 | ||
| L5690 | PO | Bk waist belt padded and lin | $93.38 | ||
| L5692 | PO | Ak pelvic control belt light | $119.86 | ||
| L5694 | PO | Ak pelvic control belt pad/l | $163.63 | ||
| L5695 | PO | Ak sleeve susp neoprene/equa | $171.09 | ||
| L5696 | PO | Ak/knee disartic pelvic join | $181.28 | ||
| L5697 | PO | Ak/knee disartic pelvic band | $72.41 | ||
| L5698 | PO | Ak/knee disartic silesian ba | $118.13 | ||
| L5699 | PO | Shoulder harness | $171.57 | ||
| L5700 | PO | Replace socket below knee | $2,516.16 | ||
| L5701 | PO | Replace socket above knee | $3,121.51 | ||
| L5702 | PO | Replace socket hip | $3,934.19 | ||
| L5703 | PO | Symes ankle w/o (SACH) foot | $2,098.10 | ||
| L5704 | PO | Custom shape cover BK | $513.04 | ||
| L5705 | PO | Custom shape cover AK | $940.57 | ||
| L5706 | PO | Custom shape cvr knee disart | $917.40 | ||
| L5707 | PO | Custom shape cvr hip disart | $1,232.53 | ||
| L5710 | PO | Kne-shin exo sng axi mnl loc | $341.39 | ||
| L5711 | PO | Knee-shin exo mnl lock ultra | $512.58 | ||
| L5712 | PO | Knee-shin exo frict swg & st | $444.22 | ||
| L5714 | PO | Knee-shin exo variable frict | $391.36 | ||
| L5716 | PO | Knee-shin exo mech stance ph | $657.41 | ||
| L5718 | PO | Knee-shin exo frct swg & sta | $821.69 | ||
| L5722 | PO | Knee-shin pneum swg frct exo | $814.38 | ||
| L5724 | PO | Knee-shin exo fluid swing ph | $1,695.67 | ||
| L5726 | PO | Knee-shin ext jnts fld swg e | $1,569.07 | ||
| L5728 | PO | Knee-shin fluid swg & stance | $2,388.06 | ||
| L5780 | PO | Knee-shin pneum/hydra pneum | $1,032.69 | ||
| L5781 | PO | Lower limb pros vacuum pump | $3,542.95 | ||
| L5782 | PO | HD low limb pros vacuum pump | $3,735.08 | ||
| L5785 | PO | Exoskeletal bk ultralt mater | $468.63 | ||
| L5790 | PO | Exoskeletal ak ultra-light m | $648.55 | ||
| L5795 | PO | Exoskel hip ultra-light mate | $968.46 | ||
| L5810 | PO | Endoskel knee-shin mnl lock | $453.75 | ||
| L5811 | PO | Endo knee-shin mnl lck ultra | $657.83 | ||
| L5812 | PO | Endo knee-shin frct swg & st | $509.89 | ||
| L5814 | PO | Endo knee-shin hydral swg ph | $3,288.54 | ||
| L5816 | PO | Endo knee-shin polyc mch sta | $767.09 | ||
| L5818 | PO | Endo knee-shin frct swg & st | $928.33 | ||
| L5822 | PO | Endo knee-shin pneum swg frc | $1,904.52 | ||
| L5824 | PO | Endo knee-shin fluid swing p | $1,712.64 | ||
| L5826 | PO | Miniature knee joint | $2,812.31 | ||
| L5828 | PO | Endo knee-shin fluid swg/sta | $3,112.56 | ||
| L5830 | PO | Endo knee-shin pneum/swg pha | $1,836.77 | ||
| L5840 | PO | Multi-axial knee/shin system | $3,198.98 | ||
| L5845 | PO | Knee-shin sys stance flexion | $1,587.11 | ||
| L5848 | PO | Knee-shin sys hydraul stance | $952.18 | ||
| L5850 | PO | Endo ak/hip knee extens assi | $120.91 | ||
| L5855 | PO | Mech hip extension assist | $278.56 | ||
| L5856 | PO | Elec knee-shin swing/stance | $21,353.09 | ||
| L5857 | PO | Elec knee-shin swing only | $7,639.05 | ||
| L5858 | PO | Stance phase only | $16,456.85 | ||
| L5910 | PO | Endo below knee alignable sy | $357.37 | ||
| L5920 | PO | Endo ak/hip alignable system | $478.58 | ||
| L5925 | PO | Above knee manual lock | $303.07 | ||
| L5930 | PO | High activity knee frame | $3,040.28 | ||
| L5940 | PO | Endo bk ultra-light material | $491.52 | ||
| L5950 | PO | Endo ak ultra-light material | $796.83 | ||
| L5960 | PO | Endo hip ultra-light materia | $1,154.32 | ||
| L5962 | PO | Below knee flex cover system | $530.18 | ||
| L5964 | PO | Above knee flex cover system | $919.55 | ||
| L5966 | PO | Hip flexible cover system | $1,184.53 | ||
| L5968 | PO | Multiaxial ankle w dorsiflex | $3,217.78 | ||
| L5970 | PO | Foot external keel sach foot | $183.19 | ||
| L5971 | PO | SACH foot, replacement | $183.19 | ||
| L5972 | PO | Flexible keel foot | $317.89 | ||
| L5973 | PO | Ank-foot sys dors-plant flex | $15,410.73 | ||
| L5974 | PO | Foot single axis ankle/foot | $210.19 | ||
| L5975 | PO | Combo ankle/foot prosthesis | $410.50 | ||
| L5976 | PO | Energy storing foot | $637.40 | ||
| L5978 | PO | Ft prosth multiaxial ankl/ft | $263.23 | ||
| L5979 | PO | Multi-axial ankle/ft prosth | $2,058.12 | ||
| L5980 | PO | Flex foot system | $4,391.63 | ||
| L5981 | PO | Flex-walk sys low ext prosth | $2,799.03 | ||
| L5982 | PO | Exoskeletal axial rotation u | $521.45 | ||
| L5984 | PO | Endoskeletal axial rotation | $513.84 | ||
| L5985 | PO | Lwr ext dynamic prosth pylon | $255.06 | ||
| L5986 | PO | Multi-axial rotation unit | $571.58 | ||
| L5987 | PO | Shank ft w vert load pylon | $6,369.90 | ||
| L5988 | PO | Vertical shock reducing pylo | $1,768.94 | ||
| L5990 | PO | User adjustable heel height | $1,606.45 | ||
| L6000 | PO | Par hand robin-aids thum rem | $1,225.74 | ||
| L6010 | PO | Hand robin-aids little/ring | $1,400.35 | ||
| L6020 | PO | Part hand robin-aids no fing | $1,243.46 | ||
| L6025 | PO | Part hand disart myoelectric | $7,085.97 | ||
| L6050 | PO | Wrst MLd sck flx hng tri pad | $1,998.97 | ||
| L6055 | PO | Wrst mold sock w/exp interfa | $2,604.97 | ||
| L6100 | PO | Elb mold sock flex hinge pad | $2,314.64 | ||
| L6110 | PO | Elbow mold sock suspension t | $2,455.06 | ||
| L6120 | PO | Elbow mold doub splt soc ste | $2,667.06 | ||
| L6130 | PO | Elbow stump activated lock h | $2,886.40 | ||
| L6200 | PO | Elbow mold outsid lock hinge | $2,460.70 | ||
| L6205 | PO | Elbow molded w/ expand inter | $3,692.89 | ||
| L6250 | PO | Elbow inter loc elbow forarm | $2,552.59 | ||
| L6300 | PO | Shlder disart int lock elbow | $4,078.78 | ||
| L6310 | PO | Shoulder passive restor comp | $2,912.39 | ||
| L6320 | PO | Shoulder passive restor cap | $1,541.44 | ||
| L6350 | PO | Thoracic intern lock elbow | $4,710.70 | ||
| L6360 | PO | Thoracic passive restor comp | $2,873.00 | ||
| L6370 | PO | Thoracic passive restor cap | $2,442.68 | ||
| L6380 | PO | Postop dsg cast chg wrst/elb | $1,248.88 | ||
| L6382 | PO | Postop dsg cast chg elb dis/ | $1,780.73 | ||
| L6384 | PO | Postop dsg cast chg shlder/t | $2,292.98 | ||
| L6386 | PO | Postop ea cast chg & realign | $482.97 | ||
| L6388 | PO | Postop applicat rigid dsg on | $396.54 | ||
| L6400 | PO | Below elbow prosth tiss shap | $2,436.00 | ||
| L6450 | PO | Elb disart prosth tiss shap | $2,798.60 | ||
| L6500 | PO | Above elbow prosth tiss shap | $2,883.85 | ||
| L6550 | PO | Shldr disar prosth tiss shap | $3,439.51 | ||
| L6570 | PO | Scap thorac prosth tiss shap | $4,204.05 | ||
| L6580 | PO | Wrist/elbow bowden cable mol | $1,413.43 | ||
| L6582 | PO | Wrist/elbow bowden cbl dir f | $1,248.88 | ||
| L6584 | PO | Elbow fair lead cable molded | $1,895.51 | ||
| L6586 | PO | Elbow fair lead cable dir fo | $1,698.83 | ||
| L6588 | PO | Shdr fair lead cable molded | $2,602.47 | ||
| L6590 | PO | Shdr fair lead cable direct | $2,423.98 | ||
| L6600 | PO | Polycentric hinge pair | $225.59 | ||
| L6605 | PO | Single pivot hinge pair | $222.75 | ||
| L6610 | PO | Flexible metal hinge pair | $150.17 | ||
| L6611 | PO | Additional switch, ext power | $364.58 | ||
| L6615 | PO | Disconnect locking wrist uni | $165.77 | ||
| L6616 | PO | Disconnect insert locking wr | $68.22 | ||
| L6620 | PO | Flexion/extension wrist unit | $273.49 | ||
| L6621 | PO | Flex/ext wrist w/wo friction | $2,025.37 | ||
| L6623 | PO | Spring-ass rot wrst w/ latch | $578.59 | ||
| L6624 | PO | Flex/ext/rotation wrist unit | $3,334.81 | ||
| L6625 | PO | Rotation wrst w/ cable lock | $479.73 | ||
| L6628 | PO | Quick disconn hook adapter o | $432.10 | ||
| L6629 | PO | Lamination collar w/ couplin | $158.07 | ||
| L6630 | PO | Stainless steel any wrist | $194.40 | ||
| L6632 | PO | Latex suspension sleeve each | $58.60 | ||
| L6635 | PO | Lift assist for elbow | $182.27 | ||
| L6637 | PO | Nudge control elbow lock | $331.20 | ||
| L6638 | PO | Elec lock on manual pw elbow | $2,214.36 | ||
| L6640 | PO | Shoulder abduction joint pai | $336.88 | ||
| L6641 | PO | Excursion amplifier pulley t | $192.94 | ||
| L6642 | PO | Excursion amplifier lever ty | $261.51 | ||
| L6645 | PO | Shoulder flexion-abduction j | $291.09 | ||
| L6646 | PO | Multipo locking shoulder jnt | $2,792.80 | ||
| L6647 | PO | Shoulder lock actuator | $459.77 | ||
| L6648 | PO | Ext pwrd shlder lock/unlock | $2,880.38 | ||
| L6650 | PO | Shoulder universal joint | $349.67 | ||
| L6655 | PO | Standard control cable extra | $72.10 | ||
| L6660 | PO | Heavy duty control cable | $82.79 | ||
| L6665 | PO | Teflon or equal cable lining | $48.11 | ||
| L6670 | PO | Hook to hand cable adapter | $53.31 | ||
| L6672 | PO | Harness chest/shlder saddle | $184.88 | ||
| L6675 | PO | Harness figure of 8 sing con | $122.61 | ||
| L6676 | PO | Harness figure of 8 dual con | $131.59 | ||
| L6677 | PO | UE triple control harness | $262.67 | ||
| L6680 | PO | Test sock wrist disart/bel e | $263.73 | ||
| L6682 | PO | Test sock elbw disart/above | $282.84 | ||
| L6684 | PO | Test socket shldr disart/tho | $401.49 | ||
| L6686 | PO | Suction socket | $540.30 | ||
| L6687 | PO | Frame typ socket bel elbow/w | $529.49 | ||
| L6688 | PO | Frame typ sock above elb/dis | $491.68 | ||
| L6689 | PO | Frame typ socket shoulder di | $810.35 | ||
| L6690 | PO | Frame typ sock interscap-tho | $697.00 | ||
| L6691 | PO | Removable insert each | $332.43 | ||
| L6692 | PO | Silicone gel insert or equal | $511.61 | ||
| L6693 | PO | Lockingelbow forearm cntrbal | $2,513.89 | ||
| L6694 | PO | Elbow socket ins use w/lock | $602.72 | ||
| L6695 | PO | Elbow socket ins use w/o lck | $502.25 | ||
| L6696 | PO | Cus elbo skt in for con/atyp | $1,164.74 | ||
| L6697 | PO | Cus elbo skt in not con/atyp | $1,164.74 | ||
| L6698 | PO | Below/above elbow lock mech | $448.66 | ||
| L6703 | PO | Term dev, passive hand mitt | $390.97 | ||
| L6704 | PO | Term dev, sport/rec/work att | $529.24 | ||
| L6706 | PO | Term dev mech hook vol open | $314.73 | ||
| L6707 | PO | Term dev mech hook vol close | $1,236.49 | ||
| L6708 | PO | Term dev mech hand vol open | $828.61 | ||
| L6709 | PO | Term dev mech hand vol close | $1,109.29 | ||
| L6711 | PO | Ped term dev, hook, vol open | $595.31 | ||
| L6712 | PO | Ped term dev, hook, vol clos | $1,096.10 | ||
| L6713 | PO | Ped term dev, hand, vol open | $1,383.40 | ||
| L6714 | PO | Ped term dev, hand, vol clos | $1,171.72 | ||
| L6721 | PO | Hook/hand, hvy dty, vol open | $2,082.62 | ||
| L6722 | PO | Hook/hand, hvy dty, vol clos | $1,795.38 | ||
| L6805 | PO | Term dev modifier wrist unit | $360.23 | ||
| L6810 | PO | Term dev precision pinch dev | $168.25 | ||
| L6881 | PO | Term dev auto grasp feature | $3,620.07 | ||
| L6882 | PO | Microprocessor control uplmb | $2,745.98 | ||
| L6883 | PO | Replc sockt below e/w disa | $1,908.47 | ||
| L6884 | PO | Replc sockt above elbow disa | $2,098.76 | ||
| L6885 | PO | Replc sockt shldr dis/interc | $2,873.00 | ||
| L6890 | PO | Prefab glove for term device | $204.56 | ||
| L6895 | PO | Custom glove for term device | $503.66 | ||
| L6900 | PO | Hand restorat thumb/1 finger | $1,601.01 | ||
| L6905 | PO | Hand restoration multiple fi | $1,581.91 | ||
| L6910 | PO | Hand restoration no fingers | $1,644.79 | ||
| L6915 | PO | Hand restoration replacmnt g | $564.67 | ||
| L6920 | PO | Wrist disarticul switch ctrl | $6,019.63 | ||
| L6925 | PO | Wrist disart myoelectronic c | $6,949.58 | ||
| L6930 | PO | Below elbow switch control | $6,056.96 | ||
| L6935 | PO | Below elbow myoelectronic ct | $7,079.68 | ||
| L6940 | PO | Elbow disarticulation switch | $8,389.82 | ||
| L6945 | PO | Elbow disart myoelectronic c | $9,406.38 | ||
| L6950 | PO | Above elbow switch control | $8,995.16 | ||
| L6955 | PO | Above elbow myoelectronic ct | $10,772.93 | ||
| L6960 | PO | Shldr disartic switch contro | $10,865.31 | ||
| L6965 | PO | Shldr disartic myoelectronic | $12,783.55 | ||
| L6970 | PO | Interscapular-thor switch ct | $13,155.45 | ||
| L6975 | PO | Interscap-thor myoelectronic | $14,414.20 | ||
| L7007 | PO | Adult electric hand | $3,535.52 | ||
| L7008 | PO | Pediatric electric hand | $5,543.02 | ||
| L7009 | PO | Adult electric hook | $3,354.86 | ||
| L7040 | PO | Prehensile actuator | $2,752.06 | ||
| L7045 | PO | Pediatric electric hook | $1,457.92 | ||
| L7170 | PO | Electronic elbow hosmer swit | $5,288.82 | ||
| L7180 | PO | Electronic elbow sequential | $32,424.45 | ||
| L7181 | PO | Electronic elbo simultaneous | $35,479.56 | ||
| L7185 | PO | Electron elbow adolescent sw | $6,467.88 | ||
| L7186 | PO | Electron elbow child switch | $9,853.56 | ||
| L7190 | PO | Elbow adolescent myoelectron | $9,085.38 | ||
| L7191 | PO | Elbow child myoelectronic ct | $10,187.64 | ||
| L7260 | PO | Electron wrist rotator otto | $1,775.14 | ||
| L7261 | PO | Electron wrist rotator utah | $3,231.43 | ||
| L7266 | PO | Servo control steeper or equ | $893.04 | ||
| L7272 | PO | Analogue control unb or equa | $2,007.51 | ||
| L7274 | PO | Proportional ctl 12 volt uta | $5,662.80 | ||
| L7360 | PO | Six volt bat otto bock/eq ea | $273.48 | ||
| L7362 | PO | Battery chrgr six volt otto | $252.04 | ||
| L7364 | PO | Twelve volt battery utah/equ | $479.23 | ||
| L7366 | PO | Battery chrgr 12 volt utah/e | $645.54 | ||
| L7367 | PO | Replacemnt lithium ionbatter | $344.74 | ||
| L7368 | PO | Lithium ion battery charger | $446.90 | ||
| L7400 | PO | Add UE prost be/wd, ultlite | $271.39 | ||
| L7401 | PO | Add UE prost a/e ultlite mat | $303.82 | ||
| L7402 | PO | Add UE prost s/d ultlite mat | $328.10 | ||
| L7403 | PO | Add UE prost b/e acrylic | $326.09 | ||
| L7404 | PO | Add UE prost a/e acrylic | $492.16 | ||
| L7405 | PO | Add UE prost s/d acrylic | $643.68 | ||
| L7900 | PO | Male vacuum erection system | $465.26 | ||
| L8000 | PO | Mastectomy bra | $33.23 | ||
| L8001 | PO | Breast prosthesis bra & form | $111.06 | ||
| L8002 | PO | Brst prsth bra & bilat form | $146.08 | ||
| L8015 | PO | Ext breastprosthesis garment | $53.08 | ||
| L8020 | PO | Mastectomy form | $216.32 | ||
| L8030 | PO | Breast prosthes w/o adhesive | $291.72 | ||
| L8031 | PO | Breast prosthesis w adhesive | $291.72 | ||
| L8032 | PO | Reusable nipple prosthesis | $34.69 | ||
| L8035 | PO | Custom breast prosthesis | $3,244.08 | ||
| L8040 | PO | Nasal prosthesis | $2,461.37 | ||
| L8040 | KM | PO | Nasal prosthesis | $2,338.31 | |
| L8040 | KN | PO | Nasal prosthesis | $984.54 | |
| L8041 | PO | Midfacial prosthesis | $2,966.74 | ||
| L8041 | KM | PO | Midfacial prosthesis | $2,818.41 | |
| L8041 | KN | PO | Midfacial prosthesis | $1,186.69 | |
| L8042 | PO | Orbital prosthesis | $3,333.44 | ||
| L8042 | KM | PO | Orbital prosthesis | $3,166.75 | |
| L8042 | KN | PO | Orbital prosthesis | $1,333.37 | |
| L8043 | PO | Upper facial prosthesis | $3,733.45 | ||
| L8043 | KM | PO | Upper facial prosthesis | $3,546.76 | |
| L8043 | KN | PO | Upper facial prosthesis | $1,493.37 | |
| L8044 | PO | Hemi-facial prosthesis | $4,133.46 | ||
| L8044 | KM | PO | Hemi-facial prosthesis | $3,926.79 | |
| L8044 | KN | PO | Hemi-facial prosthesis | $1,653.38 | |
| L8045 | PO | Auricular prosthesis | $2,598.34 | ||
| L8045 | KM | PO | Auricular prosthesis | $2,468.43 | |
| L8045 | KN | PO | Auricular prosthesis | $1,039.33 | |
| L8046 | PO | Partial facial prosthesis | $2,666.74 | ||
| L8046 | KM | PO | Partial facial prosthesis | $2,533.42 | |
| L8046 | KN | PO | Partial facial prosthesis | $1,066.70 | |
| L8047 | PO | Nasal septal prosthesis | $1,366.71 | ||
| L8047 | KM | PO | Nasal septal prosthesis | $1,298.39 | |
| L8047 | KN | PO | Nasal septal prosthesis | $546.68 | |
| L8300 | PO | Truss single w/ standard pad | $76.08 | ||
| L8310 | PO | Truss double w/ standard pad | $159.29 | ||
| L8320 | PO | Truss addition to std pad wa | $48.22 | ||
| L8330 | PO | Truss add to std pad scrotal | $44.53 | ||
| L8400 | PO | Sheath below knee | $18.93 | ||
| L8410 | PO | Sheath above knee | $22.92 | ||
| L8415 | PO | Sheath upper limb | $21.68 | ||
| L8417 | PO | Pros sheath/sock w gel cushn | $66.49 | ||
| L8420 | PO | Prosthetic sock multi ply BK | $20.33 | ||
| L8430 | PO | Prosthetic sock multi ply AK | $23.50 | ||
| L8435 | PO | Pros sock multi ply upper lm | $19.82 | ||
| L8440 | PO | Shrinker below knee | $48.81 | ||
| L8460 | PO | Shrinker above knee | $60.12 | ||
| L8465 | PO | Shrinker upper limb | $44.00 | ||
| L8470 | PO | Pros sock single ply BK | $6.02 | ||
| L8480 | PO | Pros sock single ply AK | $8.30 | ||
| L8485 | PO | Pros sock single ply upper l | $10.08 | ||
| L8500 | PO | Artificial larynx | $685.49 | ||
| L8501 | PO | Tracheostomy speaking valve | $108.96 | ||
| L8507 | PO | Trach-esoph voice pros pt in | $37.10 | ||
| L8509 | PO | Trach-esoph voice pros md in | $96.71 | ||
| L8510 | PO | Voice amplifier | $223.74 | ||
| L8511 | PO | Indwelling trach insert | $64.40 | ||
| L8512 | PO | Gel cap for trach voice pros | $1.91 | ||
| L8513 | PO | Trach pros cleaning device | $4.60 | ||
| L8514 | PO | Repl trach puncture dilator | $83.50 | ||
| L8515 | PO | Gel cap app device for trach | $55.89 | ||
| L8600 | PO | Implant breast silicone/eq | $563.24 | ||
| L8603 | PO | Collagen imp urinary 2.5 ml | $393.90 | ||
| L8606 | PO | Synthetic implnt urinary 1ml | $193.99 | ||
| L8609 | PO | Artificial cornea | $5,769.31 | ||
| L8610 | PO | Ocular implant | $625.30 | ||
| L8612 | PO | Aqueous shunt prosthesis | $597.23 | ||
| L8613 | PO | Ossicular implant | $302.32 | ||
| L8614 | PO | Cochlear device | $17,284.73 | ||
| L8615 | PO | Coch implant headset replace | $399.36 | ||
| L8616 | PO | Coch implant microphone repl | $93.02 | ||
| L8617 | PO | Coch implant trans coil repl | $81.24 | ||
| L8618 | PO | Coch implant tran cable repl | $23.22 | ||
| L8619 | PO | Coch imp ext proc/contr rplc | $7,420.22 | ||
| L8621 | PO | Repl zinc air battery | $0.55 | ||
| L8622 | PO | Repl alkaline battery | $0.29 | ||
| L8623 | PO | Lith ion batt CID,non-earlvl | $57.28 | ||
| L8624 | PO | Lith ion batt CID, ear level | $142.80 | ||
| L8627 | PO | CID ext speech process repl | $6,324.80 | ||
| L8628 | PO | CID ext controller repl | $1,095.43 | ||
| L8629 | PO | CID transmit coil and cable | $158.55 | ||
| L8630 | PO | Metacarpophalangeal implant | $303.88 | ||
| L8631 | PO | MCP joint repl 2 pc or more | $1,957.77 | ||
| L8641 | PO | Metatarsal joint implant | $315.74 | ||
| L8642 | PO | Hallux implant | $276.79 | ||
| L8658 | PO | Interphalangeal joint spacer | $275.29 | ||
| L8659 | PO | Interphalangeal joint repl | $1,708.71 | ||
| L8670 | PO | Vascular graft, synthetic | $502.09 | ||
| L8680 | PO | Implt neurostim elctr each | $406.73 | ||
| L8681 | PO | Pt prgrm for implt neurostim | $1,297.42 | ||
| L8682 | PO | Implt neurostim radiofq rec | $5,278.95 | ||
| L8683 | PO | Radiofq trsmtr for implt neu | $4,646.68 | ||
| L8684 | PO | Radiof trsmtr implt scrl neu | $614.20 | ||
| L8685 | PO | Implt nrostm pls gen sng rec | $11,579.27 | ||
| L8686 | PO | Implt nrostm pls gen sng non | $7,388.47 | ||
| L8687 | PO | Implt nrostm pls gen dua rec | $15,069.25 | ||
| L8688 | PO | Implt nrostm pls gen dua non | $9,615.40 | ||
| L8689 | PO | External recharg sys intern | $1,527.41 | ||
| L8690 | PO | Aud osseo dev, int/ext comp | $4,212.39 | ||
| L8691 | PO | Osseointegrated snd proc rpl | $2,361.18 | ||
| L8695 | PO | External recharg sys extern | $14.74 |
Q codes: temporary codes
25 rows| Code | Mod | Mod 2 | Cat. | Description | Fee |
|---|---|---|---|---|---|
| Q0480 | PO | Driver pneumatic vad, rep | $79,750.51 | ||
| Q0481 | PO | Microprcsr cu elec vad, rep | $12,866.81 | ||
| Q0482 | PO | Microprcsr cu combo vad, rep | $4,030.13 | ||
| Q0483 | PO | Monitor elec vad, rep | $16,602.32 | ||
| Q0484 | PO | Monitor elec or comb vad rep | $3,224.12 | ||
| Q0485 | PO | Monitor cable elec vad, rep | $311.28 | ||
| Q0486 | PO | Mon cable elec/pneum vad rep | $259.09 | ||
| Q0487 | PO | Leads any type vad, rep only | $302.26 | ||
| Q0489 | PO | Pwr pck base combo vad, rep | $14,393.32 | ||
| Q0490 | PO | Emr pwr source elec vad, rep | $622.58 | ||
| Q0491 | PO | Emr pwr source combo vad rep | $978.78 | ||
| Q0492 | PO | Emr pwr cbl elec vad, rep | $78.84 | ||
| Q0493 | PO | Emr pwr cbl combo vad, rep | $224.53 | ||
| Q0494 | PO | Emr hd pmp elec/combo, rep | $190.00 | ||
| Q0495 | PO | Charger elec/combo vad, rep | $3,698.71 | ||
| Q0496 | PO | Battery elec/combo vad, rep | $1,327.53 | ||
| Q0497 | PO | Bat clps elec/comb vad, rep | $414.53 | ||
| Q0498 | PO | Holster elec/combo vad, rep | $454.83 | ||
| Q0499 | PO | Belt/vest elec/combo vad rep | $147.78 | ||
| Q0500 | PO | Filters elec/combo vad, rep | $27.04 | ||
| Q0501 | PO | Shwr cov elec/combo vad, rep | $452.21 | ||
| Q0502 | PO | Mobility cart pneum vad, rep | $575.73 | ||
| Q0503 | PO | Battery pneum vad replacemnt | $1,151.46 | ||
| Q0504 | PO | Pwr adpt pneum vad, rep veh | $607.60 | ||
| Q0506 | PO | Lith-ion batt elec/pneum VAD | $756.33 |
V codes: vision and hearing services
98 rows| Code | Mod | Mod 2 | Cat. | Description | Fee |
|---|---|---|---|---|---|
| V2020 | PO | Vision svcs frames purchases | $56.55 | ||
| V2100 | PO | Lens spher single plano 4.00 | $47.11 | ||
| V2101 | PO | Single visn sphere 4.12-7.00 | $49.64 | ||
| V2102 | PO | Singl visn sphere 7.12-20.00 | $57.49 | ||
| V2103 | PO | Spherocylindr 4.00d/12-2.00d | $40.91 | ||
| V2104 | PO | Spherocylindr 4.00d/2.12-4d | $45.30 | ||
| V2105 | PO | Spherocylinder 4.00d/4.25-6d | $49.32 | ||
| V2106 | PO | Spherocylinder 4.00d/>6.00d | $54.46 | ||
| V2107 | PO | Spherocylinder 4.25d/12-2d | $52.05 | ||
| V2108 | PO | Spherocylinder 4.25d/2.12-4d | $51.82 | ||
| V2109 | PO | Spherocylinder 4.25d/4.25-6d | $57.62 | ||
| V2110 | PO | Spherocylinder 4.25d/over 6d | $58.84 | ||
| V2111 | PO | Spherocylindr 7.25d/.25-2.25 | $61.34 | ||
| V2112 | PO | Spherocylindr 7.25d/2.25-4d | $66.96 | ||
| V2113 | PO | Spherocylindr 7.25d/4.25-6d | $73.58 | ||
| V2114 | PO | Spherocylinder over 12.00d | $81.74 | ||
| V2115 | PO | Lens lenticular bifocal | $68.90 | ||
| V2118 | PO | Lens aniseikonic single | $75.59 | ||
| V2121 | PO | Lenticular lens, single | $76.05 | ||
| V2200 | PO | Lens spher bifoc plano 4.00d | $61.66 | ||
| V2201 | PO | Lens sphere bifocal 4.12-7.0 | $66.76 | ||
| V2202 | PO | Lens sphere bifocal 7.12-20. | $75.75 | ||
| V2203 | PO | Lens sphcyl bifocal 4.00d/.1 | $62.20 | ||
| V2204 | PO | Lens sphcy bifocal 4.00d/2.1 | $63.86 | ||
| V2205 | PO | Lens sphcy bifocal 4.00d/4.2 | $69.62 | ||
| V2206 | PO | Lens sphcy bifocal 4.00d/ove | $70.32 | ||
| V2207 | PO | Lens sphcy bifocal 4.25-7d/. | $64.74 | ||
| V2208 | PO | Lens sphcy bifocal 4.25-7/2. | $66.85 | ||
| V2209 | PO | Lens sphcy bifocal 4.25-7/4. | $67.97 | ||
| V2210 | PO | Lens sphcy bifocal 4.25-7/ov | $72.61 | ||
| V2211 | PO | Lens sphcy bifo 7.25-12/.25- | $75.41 | ||
| V2212 | PO | Lens sphcyl bifo 7.25-12/2.2 | $76.61 | ||
| V2213 | PO | Lens sphcyl bifo 7.25-12/4.2 | $79.47 | ||
| V2214 | PO | Lens sphcyl bifocal over 12. | $96.83 | ||
| V2215 | PO | Lens lenticular bifocal | $90.00 | ||
| V2218 | PO | Lens aniseikonic bifocal | $117.06 | ||
| V2219 | PO | Lens bifocal seg width over | $50.39 | ||
| V2220 | PO | Lens bifocal add over 3.25d | $43.43 | ||
| V2221 | PO | Lenticular lens, bifocal | $87.23 | ||
| V2300 | PO | Lens sphere trifocal 4.00d | $76.06 | ||
| V2301 | PO | Lens sphere trifocal 4.12-7. | $73.45 | ||
| V2302 | PO | Lens sphere trifocal 7.12-20 | $74.50 | ||
| V2303 | PO | Lens sphcy trifocal 4.0/.12- | $72.61 | ||
| V2304 | PO | Lens sphcy trifocal 4.0/2.25 | $78.29 | ||
| V2305 | PO | Lens sphcy trifocal 4.0/4.25 | $80.77 | ||
| V2306 | PO | Lens sphcyl trifocal 4.00/>6 | $82.90 | ||
| V2307 | PO | Lens sphcy trifocal 4.25-7/. | $79.89 | ||
| V2308 | PO | Lens sphc trifocal 4.25-7/2. | $80.01 | ||
| V2309 | PO | Lens sphc trifocal 4.25-7/4. | $82.31 | ||
| V2310 | PO | Lens sphc trifocal 4.25-7/>6 | $83.69 | ||
| V2311 | PO | Lens sphc trifo 7.25-12/.25- | $80.66 | ||
| V2312 | PO | Lens sphc trifo 7.25-12/2.25 | $81.17 | ||
| V2313 | PO | Lens sphc trifo 7.25-12/4.25 | $91.43 | ||
| V2314 | PO | Lens sphcyl trifocal over 12 | $104.24 | ||
| V2315 | PO | Lens lenticular trifocal | $129.87 | ||
| V2318 | PO | Lens aniseikonic trifocal | $176.41 | ||
| V2319 | PO | Lens trifocal seg width > 28 | $51.33 | ||
| V2320 | PO | Lens trifocal add over 3.25d | $63.01 | ||
| V2321 | PO | Lenticular lens, trifocal | $128.30 | ||
| V2410 | PO | Lens variab asphericity sing | $99.73 | ||
| V2430 | PO | Lens variable asphericity bi | $129.96 | ||
| V2500 | PO | Contact lens pmma spherical | $97.75 | ||
| V2501 | PO | Cntct lens pmma-toric/prism | $148.90 | ||
| V2502 | PO | Contact lens pmma bifocal | $183.43 | ||
| V2503 | PO | Cntct lens pmma color vision | $168.94 | ||
| V2510 | PO | Cntct gas permeable sphericl | $113.95 | ||
| V2511 | PO | Cntct toric prism ballast | $191.73 | ||
| V2512 | PO | Cntct lens gas permbl bifocl | $226.56 | ||
| V2513 | PO | Contact lens extended wear | $190.21 | ||
| V2520 | PO | Contact lens hydrophilic | $125.43 | ||
| V2521 | PO | Cntct lens hydrophilic toric | $218.37 | ||
| V2522 | PO | Cntct lens hydrophil bifocl | $212.51 | ||
| V2523 | PO | Cntct lens hydrophil extend | $169.30 | ||
| V2530 | PO | Contact lens gas impermeable | $201.17 | ||
| V2531 | PO | Contact lens gas permeable | $489.09 | ||
| V2623 | PO | Plastic eye prosth custom | $1,045.38 | ||
| V2624 | PO | Polishing artifical eye | $54.91 | ||
| V2625 | PO | Enlargemnt of eye prosthesis | $333.85 | ||
| V2626 | PO | Reduction of eye prosthesis | $179.96 | ||
| V2627 | PO | Scleral cover shell | $1,426.01 | ||
| V2628 | PO | Fabrication & fitting | $278.76 | ||
| V2700 | PO | Balance lens | $45.54 | ||
| V2710 | PO | Glass/plastic slab off prism | $77.11 | ||
| V2715 | PO | Prism lens/es | $13.98 | ||
| V2718 | PO | Fresnell prism press-on lens | $31.89 | ||
| V2730 | PO | Special base curve | $19.02 | ||
| V2744 | PO | Tint photochromatic lens/es | $14.98 | ||
| V2745 | PO | Tint, any color/solid/grad | $12.02 | ||
| V2750 | PO | Anti-reflective coating | $18.47 | ||
| V2755 | PO | UV lens/es | $14.99 | ||
| V2760 | PO | Scratch resistant coating | $15.31 | ||
| V2762 | PO | Polarization, any lens | $52.77 | ||
| V2770 | PO | Occluder lens/es | $22.59 | ||
| V2780 | PO | Oversize lens/es | $11.30 | ||
| V2782 | PO | Lens, 1.54-1.65 p/1.60-1.79g | $57.00 | ||
| V2783 | PO | Lens, >= 1.66 p/>=1.80 g | $64.27 | ||
| V2784 | PO | Lens polycarb or equal | $41.80 | ||
| V2786 | PO | Occupational multifocal lens | $0.00 |
Modifier key, Exhibit 5
- NU
- Purchased, new
- RR
- Rented
- UE
- Purchased, used
- KM
- Replacement of facial prosthesis including new impression or moulage
- KN
- Replacement of facial prosthesis using previous master mold
- AU
- Urological, ostomy or tracheostomy item
- AV
- Item with prosthetic or orthotic device
- AW
- Item with a surgical dressing
- KE
- Bid under round I of the DMEPOS competitive bid program, for use with non-competitive bid base equipment
- KF
- Class III device
- KL
- DMEPOS item delivered via mail
- KC
- Replacement of special power wheelchair interface
Printed only at the foot of the State’s workbook. One repair: the source wraps the KE entry across two rows, so the fragment naming the class III device lands at the end of the KE line. KE and KF are separate modifiers and are listed separately here.
Category key, Exhibit 5
- IN
- Inexpensive and other routinely purchased items
- FS
- Frequently serviced items
- CR
- Capped rental items
- OX
- Oxygen and oxygen equipment
- OS
- Ostomy, tracheostomy and urological items
- SD
- Surgical dressings
- PO
- Prosthetics and orthotics
- SU
- Supplies
- TE
- Transcutaneous electrical nerve stimulators
- TS
- Therapeutic shoes
Source
- The schedule: N.J.A.C. 11:3-29 Appendix, Exhibit 5, published by the New Jersey Department of Banking and Insurance and effective for treatment rendered on or after January 4, 2013. It has not been amended since.
- Official files: the Department’s auto medical fee schedule page, the rule text and the Department’s own FAQ.
- This page: parsed from the Department’s Excel file, with every row count and every figure cross-checked against the Department’s PDF of the same exhibit. Free to download as one CSV of all seven exhibits, 7,553 rows, no sign-up.
Amounts are the maximum reimbursable under the New Jersey PIP fee schedule, not what a provider billed and not what an insurer paid. N.J.A.C. 11:3-29caps reimbursement at the lesser of the provider’s charge or the scheduled amount, and 11:3-29.6 bars a provider from billing a patient the difference. This page reproduces the schedule; it does not decide whether a service was medically necessary, correctly coded, or covered. Verify any figure against the Department’s own file before relying on it. Descriptions are the short descriptors published by the State in this exhibit.
Reading exhibit 5002
What the rule says about this schedule
Why does the same HCPCS code appear several times?
Because the same item is priced differently depending on how it was supplied. 11:3-29.4(c) makes the Exhibit 5 amounts retail prices that may cover a purchase of new equipment, a purchase of used equipment, or a monthly rental. New is marked NU, used UE and rental RR, and each is its own priced row under the same code.
A second modifier column narrows some rows further, for competitive bidding, mail delivery and a few device classes. The practical consequence for anyone matching a bill against this schedule is that a lookup keyed on the code alone will return the wrong row a good part of the time. The key is the code plus both modifiers.
How much can be paid to rent one item?
11:3-29.4(c)1 caps it. The insurer's total liability for renting a single item of durable medical equipment on this schedule is 15 times the monthly rental fee, or the purchase price of the item, whichever is less. Rental past that ceiling is not additional money, however many months the equipment stays with the patient.
191 rows on this exhibit carry the CR category, capped rental items. 11:3-29.4(c)2 also sends payors to chapter 20 of the Medicare Claims Processing Manual, as it stood when the equipment was provided, for how DME is billed and paid.
Are the supplies for a TENS or EMS unit billed separately?
Not while the unit is rented. 11:3-29.4(g)6 puts leads, pads, batteries and any other supplies for a TENS or EMS device inside the rental fee for the unit, so they are not separately reimbursable. Where the unit is purchased outright, the first month's supply is included in the purchase.
This is one of the rules most visible on a real New Jersey PIP bill, because the supply codes exist, carry their own prices on this very schedule, and are routinely billed alongside a rental. Their presence on Exhibit 5 is not permission to bill them in that combination.
Which row in this exhibit carries a typo from the State?
One. The neuromuscular stimulator row is printed EO745, with a capital letter O where the HCPCS code has a zero. The real code is E0745. The row is shown here under the correct code, and the printed spelling is kept beside it so it can still be found by what a reader sees in the official file.
It is a small thing that matters for a specific reason: a bill carrying E0745 will not match a copy of this schedule that reproduces the typo, and the claim will look unpriced when it is not. The generator that builds these pages fails the build if that typo ever disappears from the source, so the correction cannot quietly go stale.
The other exhibits003