Durable Medical Equipment, Prosthetics, Orthotics, and ... · A4230 Infus Insulin Pump Non Needl Purchase $12.01 A4233 Alkalin Batt For Glucose Mon Purchase $0.74 A4234 J-Cell Batt

CODE PROCEDURE PURCHASE OR RENTAL

PRIOR AUTH STATUS FEE

A4206 Syringe With Needle, Sterile 1Cc Purchase $0.32A4207 Syringe With Needle, Sterile 2Cc Purchase $0.32A4208 Syringe With Needle, Sterile 3Cc Purchase $0.32A4209 Syringe With Needle, Sterile 5Cc Or Greater Purchase $0.45A4212 Huber-Type Needle, Each Purchase $15.27A4213 Syringe, Sterile, 20 Cc Or Greater Purchase $7.15A4215 Needles Only, Sterile, Any Size Purchase $0.28A4216 Sterile Water/Saline, 10 Ml Purchase $0.42A4217 Sterile Water/Saline, 500 Ml Purchase $3.36A4220 Refill Kit For Implantable Infusion Pump Purchase $32.74A4221 Supp Non-Insulin Inf Cath/Wk Purchase $21.73A4222 Drug Infusion Pump Supplies Purchase $43.10A4223 Infusion Supplies W/O Pump Purchase $56.39A4224 Supply Insulin Inf Cath/Wk Purchase $17.72A4225 Sup/Ext Insulin Inf Pump Syr Purchase $2.38A4230 Infus Insulin Pump Non Needl Purchase $12.01A4233 Alkalin Batt For Glucose Mon Purchase $0.74A4234 J-Cell Batt For Glucose Mon Purchase $3.34A4235 Lithium Batt For Glucose Mon Purchase $2.15A4236 Silvr Oxide Batt Glucose Mon Purchase $1.53A4245 Alcohol Wipes, Per Box Purchase $4.08A4246 Betadine Or Phisohex Solution, Per Pint Purchase $4.49A4247 Betadine Or Iodine Swabs/Wipes, Per Box Purchase $3.86A4250 Urine Test Or Reagent Strips Or Tablets (100 Tablets Or Purchase $0.71A4253 Blood glucose test or reagent strips, per 50 strips Purchase $8.44A4255 Glucose Monitor Platforms Purchase $4.38A4256 Normal, Low And High Calibrator Solution / Chips Purchase $8.90A4257 Replace Lensshield Cartridge Purchase $13.56A4258 Lancet Device Each Purchase $7.00A4259 Lancets, Per Box Purchase $10.58A4263 Permanent, Long Term, Non-Dissolvable Lacrimal Duct Imp Purchase $33.68A4265 Paraffin Purchase $3.62A4280 Brst Prsths Adhsv Attchmnt Purchase $5.68A4300 Implantable Vascular Access Portal/Catheter (Venous Art Purchase $33.68A4301 Implantable Access Syst Perc Purchase $8.74A4305 Disposable Drug Delivery System, Flow Rate Of 50 Ml Or Purchase $14.06A4310 Insertion Tray Without Drainage Bag And Without Cathete Purchase $7.94A4311 Insertion Tray Without Drainage Bag With Indwelling Cat Purchase $15.24A4312 Insertion Tray Without Drainage Bag With Indwelling Cat Purchase $15.42A4313 Insertiontray Without Drainage Bag With Indwelling Cat Purchase $15.42A4314 Insertion Tray With Drainage Bag With Indwelling Cathet Purchase $26.00A4315 Insertion Tray With Drainage Bag With Indwelling Cathet Purchase $27.12A4316 Insertion Tray With Drainage Bag With Indwelling Cathet Purchase $26.29

NOTE: One unit per month is billable for capped rental items. The item is considered purchased after 12 units have been paid by South Dakota Medicaid without a break in rental payments of three or more consecutive months.

Durable Medical Equipment, Prosthetics, Orthotics, and SuppliesEffective Date: 04/01/2019

A provider may request South Dakota Medicaid review a procedure code for a possible rate adjustment. A provider may also request the inclusion or exclusion of a procedure code from the fee schedule. Changes must be requested through the provider portal, which can be accessed at :

https://dss.sd.gov/medicaid/portal.aspxUnder the communications tab on the provider portal, select “reviews and requests.” Please include relevant documentation with your requests that supports the need for your requested change.

Rates displayed below do not reflect rates for codes billed containing modifiers. For information on how modifiers will affect payment see ARSD § 67:16:02:03.02.

https://dss.sd.gov/medicaid/portal.aspx







A4320 Irrigation Tray For Bladder Irrigation With Bulb Or Pis Purchase $5.49A4321 Cath Therapeutic Irrig Agent Purchase $41.48A4322 Irrigation Syringe, Bulb Or Piston, Each Purchase $3.13A4326 Male External Catheter Specialty Type, Eg; Inflatable, Purchase $9.36A4327 Female External Urinary Collection Device; Meatal Cup, Purchase $45.56A4328 Female External Urinary Collection Device; Pouch, Each Purchase $10.06A4330 Perianal Fecal Collection Pouch With Adhesive Purchase $6.87A4331 Extension Drainage Tubing Purchase $3.39A4332 Lubricant For Cath Insertion Purchase $0.14A4333 Urinary Cath Anchor Device Purchase $2.35A4334 Urinary Cath Leg Strap Purchase $5.23A4335 Incontinence Supply; Miscellaneous Purchase $0.98A4336 Urethral Insert Purchase $1.52A4338 Indwelling Catheter; Foley Type, Two-Way Latex With Coa Purchase $12.61A4340 Indwelling Catheter; Specialty Type, Eg; Coude, Mushroo Purchase $19.92A4344 Indwelling Catheter, Foley Type, Two-Way, All Silicone Purchase $15.77A4346 Indwelling Catheter, Foley Type, Three Way, Latex Or Te Purchase $18.83A4349 Disposable Male External Cat Purchase $19.55A4351 Intermittent Urinary Catheter; Straight Tip Purchase $1.58A4352 Intermittent Urinary Catheter; Coude (Curved) Tip Purchase $5.62A4353 Intermittent Urinary Cath Purchase $7.44A4354 Catheter Insertion Tray, Without Tube And Drainage Bag Purchase $11.88A4355 I.V. Setup For Continuous Irrigation Of Three Way Cath Purchase $7.28A4356 Incontinence Clamp Purchase $43.81A4357 Urinary Drainage Bag Purchase $9.98A4358 Urinary Leg Bag Purchase $5.79A4361 Ostomy Face Plate Purchase $14.99A4362 Ostomy Skin Barrier Purchase $3.56A4364 Ostomy Skin Bond Or Cement Purchase $2.57A4366 Ostomy Vent Purchase $1.39A4367 Ostomy Belt Purchase $7.56A4368 Ostomy Filter Purchase $0.27A4369 Skin Barrier Liquid Per Oz Purchase $2.19A4371 Skin Barrier Powder Per Oz Purchase $3.84A4372 Skin Barrier Solid 4X4 Equiv Purchase $4.43A4373 Skin Barrier With Flange Purchase $6.66A4375 Drainable Plastic Pch W Fcpl Purchase $18.26A4376 Drainable Rubber Pch W Fcplt Purchase $50.61A4377 Drainable Plstic Pch W/O Fp Purchase $4.58A4378 Drainable Rubber Pch W/O Fp Purchase $32.70A4379 Urinary Plastic Pouch W Fcpl Purchase $15.97A4380 Urinary Rubber Pouch W Fcplt Purchase $39.71A4381 Urinary Plastic Pouch W/O Fp Purchase $4.92A4382 Urinary Hvy Plstc Pch W/O Fp Purchase $26.17A4383 Urinary Rubber Pouch W/O Fp Purchase $29.98A4384 Ostomy Faceplt/Silicone Ring Purchase $10.23A4385 Ost Skn Barrier Sld Ext Wear Purchase $5.42A4388 Drainable Pch W Ex Wear Barr Purchase $4.65A4389 Drainable Pch W St Wear Barr Purchase $6.61A4390 Drainable Pch Ex Wear Convex Purchase $10.22A4391 Urinary Pouch W Ex Wear Barr Purchase $7.53A4392 Urinary Pouch W St Wear Barr Purchase $8.70A4393 Urine Pch W Ex Wear Bar Conv Purchase $9.61A4394 Ostomy Pouch Liq Deodorant Purchase $2.75A4396 Peristomal Hernia Supprt Blt Purchase $43.05A4397 Irrigation Supply; Sleeve Purchase $4.61A4398 Irrigation Supplies, Bags Purchase $13.03A4399 Irrigation Supplies, Cone/Catheter Purchase $9.69A4400 Irrigation Set For Irrigation Of Ostomy Purchase $46.95



A4402 Ostomy Lubricant Purchase $1.64A4404 Ostomy Rings Purchase $1.40A4405 Nonpectin Based Ostomy Paste Purchase $3.63A4406 Pectin Based Ostomy Paste Purchase $6.15A4407 Ext Wear Ost Barr <=4Sq Purchase $9.33A4408 Ext Wear Ost Barr >4Sq Purchase $10.49A4409 Ost Skn Barr Convex <=4 Sq I Purchase $6.61A4410 Ost Skn Barr Extnd >4 Sq Purchase $9.61A4411 Ost Skn Barr Extnd =4Sq Purchase $5.42A4412 Ost Pouch Drain High Output Purchase $2.88A4413 2 Pc Drainable Ost Pouch Purchase $5.85A4414 Ost Sknbar W/O Conv<=4 Sq In Purchase $5.23A4415 Ost Skn Barr W/O Conv >4 Sqi Purchase $6.38A4416 Ost Pch Clsd W Barrier/Filtr Purchase $2.93A4417 Ost Pch W Bar/Bltinconv/Fltr Purchase $3.96A4418 Ost Pch Clsd W/O Bar W Filtr Purchase $1.93A4419 Ost Pch For Bar W Flange/Flt Purchase $1.85A4422 Ost Pouch Absorbent Material Purchase $0.14A4423 Ost Pch For Bar W Lk Fl/Fltr Purchase $1.98A4424 Ost Pch Drain W Bar & Filter Purchase $5.07A4425 Ost Pch Drain For Barrier Fl Purchase $3.80A4426 Ost Pch Drain 2 Piece System Purchase $2.91A4427 Ost Pch Drain/Barr Lk Flng/F Purchase $2.96A4428 Urine Ost Pouch W Faucet/Tap Purchase $6.93A4429 Urine Ost Pouch W Bltinconv Purchase $8.78A4430 Ost Urine Pch W B/Bltin Conv Purchase $9.06A4431 Ost Pch Urine W Barrier/Tapv Purchase $6.61A4432 Os Pch Urine W Bar/Fange/Tap Purchase $3.82A4433 Urine Ost Pch Bar W Lock Fln Purchase $3.56A4434 Ost Pch Urine W Lock Flng/Ft Purchase $3.99A4435 1Pc Ost Pch Drain Hgh Output Purchase $6.15A4450 Non-Waterproof Tape Purchase $5.74A4452 Waterproof Tape Purchase $1.95A4455 Adhesive Remover Or Solvent (For Tape, Cement Or Other Purchase $1.47A4456 Adhesive Remover, Wipes Purchase $0.26A4458 Reusable Enema Bag Purchase $2.46A4461 Surgicl Dress Hold Non-Reuse Purchase $3.49A4463 Surgical Dress Holder Reuse Purchase $14.17A4465 Non-Elastic Binder For Extremity Purchase $43.29A4481 Tracheostoma Filter Purchase $0.41A4483 Moisture Exchanger Purchase $10.91A4490 Surgical Stockings Above Knee Length, Each Purchase $16.37A4495 Surgical Stockings Thigh Length, Each Purchase $23.27A4500 Surgical Stocking Below Knee Length, Each Purchase $12.20A4550 Surgical Trays Purchase $32.66A4556 Electrodes, E.G., Apnea Monitor Purchase $13.00A4557 Lead Wires, E.G., Apnea Monitor Purchase $22.61A4559 Coupling Gel Or Paste Purchase $0.10A4561 Pessary Rubber, Any Type Purchase $21.97A4562 Pessary, Non Rubber,Any Type Purchase $54.73A4563 Rectal Control System for vaginal Insertion Purchase $117.85A4565 Slings Purchase $17.25A4570 Splint Purchase $24.64A4580 Cast Supplies Purchase $29.64A4595 Suppl 2 Lead Per Month Tens Purchase $19.58A4604 Tubing With Heating Element Purchase $61.23A4605 Trach Suction Cath Close Sys Purchase $17.44A4606 Oxygen Probe Used W Oximeter Purchase $61.95A4608 Transtracheal Oxygen Cath Purchase $53.31



A4611 Battery, Heavy Duty; Replacement For Patient Owned Vent Purchase $188.71A4612 Battery Cables; Replacement For Patient-Owned Ventilato Purchase $76.77A4613 Battery Charger; Replacement For Patient-Owned Ventilat Purchase $117.74A4614 Hand-Held Pefr Meter Purchase $24.45A4615 Cannula, Nasal Purchase $0.76A4616 Tubing, Unspecified Length Purchase $0.06A4617 Mouth Piece Purchase $2.18A4618 Breathing Circuits Purchase $9.14A4619 Face Tent Purchase $1.97A4620 Variable Concentration Mask Purchase $0.67A4623 Tracheostomy, Inner Cannula (Replacement Only) Purchase $6.73A4624 Tracheal Suction Catheter, Any Type, Each Purchase $3.21A4625 Trach Care Kit For New Trach Purchase $6.05A4626 Tracheostomy Cleaning Brush, Each Purchase $2.61A4627 Spacer, Bag Or Reservoir, With Or Without Mask, For Use Purchase $17.03A4628 Oropharyngeal Suction Cath Purchase $3.89A4629 Tracheostomy Care Kit Purchase $4.92A4630 Replacement Batteries. Medically Necessary T.E.N.S. O Purchase $6.00A4633 Uvl Replacement Bulb Purchase $43.65A4635 Underarm Pad, Crutch, Replacement, Each Purchase $4.92A4636 Replacement, Handgrip, Cane, Crutch, Or Walker, Each Purchase $3.43A4637 Replacement, Tip, Cane, Crutch, Walker, Each. Purchase $2.03A4640 Replacement Pad For Use With Medically Necessary Altern Purchase $60.81A4641 Supply Of Radiopharmaceutical Diagnostic Imaging Agent Purchase $239.01A4657 Dialysis Syringe W/Wo Needle Purchase $0.44A4750 Art Or Venous Blood Tubing Purchase $6.55A4772 Blood Glucose Test Strips Purchase $5.20A4927 Non-Sterile Gloves Purchase $8.31A4930 Sterile, Gloves Per Pair Purchase $0.76A5051 Pouch, Closed; With Barrier Attached (1 Piece) Purchase $2.24A5052 Pouch, Closed; Without Barrier Attached (1 Piece) Purchase $1.37A5053 Pouch, Closed; For Use On Faceplate Purchase $1.42A5054 Pouch, Closed; For Use On Barrier With Flange (2 Piece) Purchase $1.85A5055 Stoma Cap Purchase $1.55A5056 1 Pc Ost Pouch W Filter Purchase $4.97A5057 1 Pc Ost Pou W Built-In Conv Purchase $10.22A5061 Pouch, Drainable; With Barrier Attached (1 Piece) Purchase $3.63A5062 Pouch, Drainable; Without Barrier Attached (1 Piece) Purchase $2.15A5063 Pouch, Drainable; For Use On Barrier With Flange (2 Pie Purchase $2.78A5071 Pouch, Urinary; With Barrier Attached (1 Piece) Purchase $6.18A5072 Pouch, Urinary; Without Barrier Attached (1 Piece) Purchase $3.58A5073 Pouch, Urinary; For Use On Barrier With Flange (2 Piece Purchase $3.09A5081 Continent Device; Plug For Continent Stoma Purchase $2.69A5082 Continent Device; Catheter For Continent Stoma Purchase $11.42A5083 Stoma Absorptive Cover Purchase $1.82A5093 Ostomy Accessory; Convex Insert Purchase $1.88A5102 Bedside Drainage Bottle, Rigid Or Expandable Purchase $28.26A5105 Urinary Suspensory; With Leg Bag, With Or Without Tube Purchase $37.30A5112 Urinary Leg Bag; Latex Purchase $30.25A5113 Leg Strap; Latex, Per Set Purchase $3.85A5114 Leg Strap; Foam Or Fabric, Per Set Purchase $9.21A5120 Skin Barrier, Wipe Or Swab Purchase $0.27A5121 Skin Barrier; Solid, 6 X 6 Or Equivalent, Each Purchase $7.66A5122 Skin Barrier; Solid, 8 X 8 Or Equivalent, Each Purchase $12.34A5126 Adhesive; Disc Or Foam Pad Purchase $1.28A5131 Appliance Cleaner, Incontinence And Ostomy Appliances, Purchase $15.24A5200 Percutaneous Catheter Anchor Purchase $12.09A5500 Diab Shoe For Density Insert Purchase $67.62A5501 Diabetic Custom Molded Shoe Purchase $202.83



A5503 Diabetic Shoe W/Roller/Rockr Purchase $32.95A5504 Diabetic Shoe With Wedge Purchase $32.95A5505 Diab Shoe W/Metatarsal Bar Purchase $32.95A5506 Diabetic Shoe W/Off Set Heel Purchase $32.95A5507 Modification Diabetic Shoe Purchase $32.95A5512 Multi Den Insert Direct Form Purchase $27.58A5513 Multi Den Insert Custom Mold Purchase $41.16A5514 Multiple Density Insert - For Diabetics Only Purchase $40.70A6010 Collagen Based Wound Filler Purchase $32.94A6011 Collagen Gel/Paste Wound Fil Purchase $2.43A6021 Collagen Dressing <=16 Sq In Purchase $21.61A6022 Collagen Drsg>6<=48 Sq In Purchase $22.35A6023 Collagen Dressing >48 Sq In Purchase $202.39A6024 Collagen Dsg Wound Filler Purchase $6.58A6025 Silicone Gel Sheet, Each Purchase $7.64A6154 Wound Pouch Each Purchase $15.27A6196 Alginate Dressing <=16 Sq In Purchase $7.81A6197 Alginate Drsg >16 <=48 Sq In Purchase $17.59A6199 Alginate Drsg Wound Filler Purchase $5.62A6203 Composite Drsg <= 16 Sq In Purchase $2.32A6204 Composite Drsg >16<=48 Sq In Purchase $6.62A6207 Contact Layer >16<= 48 Sq In Purchase $7.80A6209 Foam Drsg <=16 Sq In W/O Bdr Purchase $7.68A6210 Foam Drg >16<=48 Sq In W/O B Purchase $21.18A6211 Foam Drg > 48 Sq In W/O Brdr Purchase $50.60A6212 Foam Drg <=16 Sq In W/Border Purchase $10.38A6213 Foam Drg >16<=48 Sq In W/Bdr Purchase $7.84A6214 Foam Drg > 48 Sq In W/Border Purchase $10.95A6216 Non-Sterile Gauze<=16 Sq In Purchase $0.05A6219 Gauze <= 16 Sq In W/Border Purchase $1.02A6220 Gauze >16 <=48 Sq In W/Bordr Purchase $2.66A6222 Gauze <=16 In No W/Sal W/O B Purchase $2.19A6223 Gauze >16<=48 No W/Sal W/O B Purchase $2.57A6224 Gauze > 48 In No W/Sal W/O B Purchase $3.85A6229 Gauze >16<=48 Sq In Watr/Sal Purchase $3.85A6231 Hydrogel Dsg<=16 Sq In Purchase $4.98A6232 Hydrogel Dsg>16<=48 Sq In Purchase $7.31A6233 Hydrogel Dressing >48 Sq In Purchase $20.40A6234 Hydrocolld Drg <=16 W/O Bdr Purchase $6.95A6235 Hydrocolld Drg >16<=48 W/O B Purchase $17.88A6236 Hydrocolld Drg > 48 In W/O B Purchase $28.98A6237 Hydrocolld Drg <=16 In W/Bdr Purchase $8.47A6238 Hydrocolld Drg >16<=48 W/Bdr Purchase $24.25A6240 Hydrocolld Drg Filler Paste Purchase $13.02A6241 Hydrocolloid Drg Filler Dry Purchase $2.72A6242 Hydrogel Drg <=16 In W/O Bdr Purchase $6.49A6243 Hydrogel Drg >16<=48 W/O Bdr Purchase $13.10A6244 Hydrogel Drg >48 In W/O Bdr Purchase $41.78A6245 Hydrogel Drg <= 16 In W/Bdr Purchase $7.71A6246 Hydrogel Drg >16<=48 In W/B Purchase $10.56A6247 Hydrogel Drg > 48 Sq In W/B Purchase $25.30A6248 Hydrogel Drsg Gel Filler Purchase $17.26A6250 Skin Seal Protect Moisturizr Purchase $6.71A6251 Absorpt Drg <=16 Sq In W/O B Purchase $2.13A6252 Absorpt Drg >16 <=48 W/O Bdr Purchase $3.35A6253 Absorpt Drg > 48 Sq In W/O B Purchase $5.18A6254 Absorpt Drg <=16 Sq In W/Bdr Purchase $1.29A6255 Absorpt Drg >16<=48 In W/Bdr Purchase $3.23A6257 Transparent Film <= 16 Sq In Purchase $1.63



A6258 Transparent Film >16<=48 In Purchase $4.59A6259 Transparent Film > 48 Sq In Purchase $11.64A6261 Wound Filler Gel/Paste /Oz Purchase $38.19A6266 Impreg Gauze No H20/Sal/Yard Purchase $2.05A6402 Sterile Gauze <= 16 Sq In Purchase $0.14A6403 Sterile Gauze>16 <= 48 Sq In Purchase $0.44A6407 Packing Strips, Non-Impreg Purchase $2.03A6410 Sterile Eye Pad Purchase $0.42A6411 Non-Sterile Eye Pad Purchase $4.37A6412 Occlusive Eye Patch Purchase $2.77A6441 Pad Band W>=3" <5"/Yd Purchase $0.72A6442 Conform Band N/S W<3"/Yd Purchase $0.17A6443 Conform Band N/S W>=3"<5"/Yd Purchase $0.30A6444 Conform Band N/S W>=5"/Yd Purchase $0.59A6445 Conform Band S W <3"/Yd Purchase $0.34A6446 Conform Band S W>=3" <5"/Yd Purchase $0.44A6447 Conform Band S W >=5"/Yd Purchase $0.72A6448 Lt Compres Band <3"/Yd Purchase $1.23A6449 Lt Compres Band >=3" <5"/Yd Purchase $1.87A6450 Lt Compres Band >=5"/Yd Purchase $5.49A6451 Mod Compres Band W>=3"<5"/Yd Purchase $11.41A6452 High Compres Band W>=3"<5"Yd Purchase $5.45A6453 Self-Adher Band W <3"/Yd Purchase $0.66A6454 Self-Adher Band W>=3" <5"/Yd Purchase $0.83A6455 Self-Adher Band >=5"/Yd Purchase $1.48A6456 Zinc Paste Band W >=3"<5"/Yd Purchase $1.31A6457 Tubular Dressing Purchase $1.22A6550 Neg Pres Wound Ther Drsg Set Purchase $25.14A7000 Disposable Canister For Pump Purchase $8.31A7001 Nondisposable Pump Canister Purchase $35.18A7002 Tubing Used W Suction Pump Purchase $4.08A7003 Nebulizer Administration Set Purchase $2.92A7004 Disposable Nebulizer Sml Vol Purchase $1.92A7005 Nondisposable Nebulizer Set Purchase $29.60A7006 Filtered Nebulizer Admin Set Purchase $10.15A7007 Lg Vol Nebulizer Disposable Purchase $3.93A7008 Disposable Nebulizer Prefill Purchase $11.31A7009 Nebulizer Reservoir Bottle Purchase $43.57A7010 Disposable Corrugated Tubing Purchase $25.09A7012 Nebulizer Water Collec Devic Purchase $4.02A7013 Disposable Compressor Filter Purchase $0.88A7014 Compressor Nondispos Filter Purchase $4.76A7015 Aerosol Mask Used W Nebulize Purchase $1.82A7017 Nebulizer Not Used W Oxygen Capped Rental $10.48A7018 Water Distilled W/Nebulizer Purchase $0.41A7020 Interface For Cough Stimulating Device Purchase $15.39A7025 Replace Chest Compress Vest Purchase $462.56A7026 Replace Chst Cmprss Sys Hose Purchase $30.58A7027 Combination Oral/Nasal Mask Purchase $198.36A7028 Repl Oral Cushion Combo Mask Purchase $52.70A7029 Repl Nasal Pillow Comb Mask Purchase $21.53A7030 Cpap Full Face Mask Purchase $158.69A7031 Replacement Facemask Interfa Purchase $63.96A7032 Replacement Nasal Cushion Purchase $37.15A7033 Replacement Nasal Pillows Purchase $26.05A7034 Nasal Application Device Purchase $107.82A7035 Pos Airway Press Headgear Purchase $36.42A7036 Pos Airway Press Chinstrap Purchase $16.67A7037 Pos Airway Pressure Tubing Purchase $37.59



A7038 Pos Airway Pressure Filter Purchase $4.96A7039 Filter, Non Disposable W Pap Purchase $14.05A7040 One Way Chest Drain Valve Purchase $43.59A7041 Water Seal Drain Container Purchase $81.87A7044 Pap Oral Interface Purchase $110.84A7045 Repl Exhalation Port For Pap Purchase $17.84A7046 Repl Water Chamber, Pap Dev Purchase $17.88A7047 Resp Suction Oral Interface Purchase $129.87A7048 Vacuum Drain Bottle/Tube Kit Purchase $45.37A7501 Tracheostoma Valve W Diaphra Purchase $111.69A7502 Replacement Diaphragm/Fplate Purchase $53.09A7503 Hmes Filter Holder Or Cap Purchase $12.06A7504 Tracheostoma Hmes Filter Purchase $0.72A7505 Hmes Or Trach Valve Housing Purchase $4.98A7506 Hmes/Trachvalve Adhesivedisk Purchase $0.35A7507 Integrated Filter & Holder Purchase $2.64A7508 Housing & Integrated Adhesiv Purchase $3.04A7509 Heat & Moisture Exchange Sys Purchase $1.50A7520 Trach/Laryn Tube Non-Cuffed Purchase $50.50A7521 Trach/Laryn Tube Cuffed Purchase $50.39A7522 Trach/Laryn Tube Stainless Purchase $48.03A7524 Tracheostoma Stent/Stud/Bttn Purchase $82.32A7525 Tracheostomy Mask Purchase $2.20A7526 Tracheostomy Tube Collar Purchase $3.60A7527 Trach/Laryn Tube Plug/Stop Purchase $3.80A8000 Soft Protect Helmet Prefab Purchase $157.68A8001 Hard Protect Helmet Prefab Purchase $157.68A8002 Soft Protect Helmet Custom Purchase $439.96A8003 Hard Protect Helmet Custom Purchase $439.96A9277 External Transmitter, CGM Purchase PA Required 75% of MSRPA9278 External Receiver, CGM Sys Purchase PA Required 75% of MSRPA9500 Technetium Tc 99M Sestamibi Purchase $92.07A9502 Technetium Tc99M Tetrofosmin Purchase $263.90A9505 Thallous Chloride Tl 201/Mci Purchase $30.56A9517 Th I131 So Iodide Cap Millic Purchase $65.75A9551 TC-99M Succimer Purchase 75% of MSRPA9584 Iodine I-123 Ioflupane Purchase 75% of MSRPA9589 Instillation Hexaminoevulinate Hydrochloride 100 Mg Purchase $994.07A9699 Noc Therapeutic Radiopharm Purchase $26.20A9700 Echocardiography Contrast Purchase $237.11B4034 Enteral Feeding Supply Kit;-Syringe Purchase $6.24B4035 Enteral Feeding Supply Kit - Pump Fed (Day) Purchase $12.23B4036 Enteral Feeding Supply Kit; Gravity Fed (Monthly) Purchase $8.46B4081 Nasogastric Tubing With Stylet (E.G., Travasorb, Entrif Purchase $24.47B4087 Gastro/Jejuno Tube, Std Purchase $37.21B4103 Ef Ped Fluid And Electrolyte Purchase $3.77B4149 Ef Blenderized Foods Purchase $1.58B4152 Enteral Formulae; Category Ii: Intact Protein/Protein I Purchase $0.59B4158 Ef Ped Complete Intact Nut Purchase $1.28B4159 Ef Ped Complete Soy Based Purchase $1.12B4160 Ef Ped Caloric Dense>/=0.7Kc Purchase $0.91B4162 Ef Ped Specmetabolic Inherit Purchase $2.60B4220 Parenteral Nutrition Supply Kit Premix, Per Day Purchase $9.53E0100 Cane Adjust/Fixed With Tip Purchase $19.77E0105 Cane Adjust/Fixed Quad/3 Pro Purchase $47.80E0110 Crutch Forearm Pair Purchase $80.41E0111 Crutch Forearm Each Purchase $51.10E0112 Crutch Underarm Pair Wood Purchase $37.44E0113 Crutch Underarm Each Wood Purchase $21.91



E0114 Crutch Underarm Pair No Wood Purchase $48.91E0116 Crutch Underarm Each No Wood Purchase $28.76E0117 Underarm Springassist Crutch Purchase $204.95E0130 Walker Rigid Adjust/Fixed Ht Purchase $53.18E0135 Walker Folding Adjust/Fixed Purchase $58.59E0140 Walker W Trunk Support Capped Rental $24.64E0141 Rigid Wheeled Walker Adj/Fix Purchase $74.27E0143 Walker Folding Wheeled W/O S Purchase $76.46E0144 Enclosed Walker W Rear Seat Purchase $262.98E0147 Walker Variable Wheel Resist Purchase $452.46E0148 Heavyduty Walker No Wheels Purchase $96.43E0149 Heavy Duty Wheeled Walker Purchase $155.97E0153 Platform Attachment, Forearm Crutch, Each Purchase $57.13E0154 Platform Attachment, Walker, Each Purchase $67.28E0155 Wheel Attachment, Rigid Pick-Up Walker Purchase $30.31E0156 Seat Attachment, Walker Purchase $21.58E0157 Crutch Attachment, Walker, Each Purchase $78.69E0158 Leg Extensions For A Walker Purchase $29.70E0159 Brake For Wheeled Walker Purchase $16.37E0160 Sitz Type Bath Or Equipment Purchase $30.99E0161 Sitz Bath/Equipment W/Faucet Purchase $23.09E0163 Commode Chair With Fixed Arm Purchase $78.69E0165 Commode Chair With Detacharm Purchase $155.07E0167 Commode Chair Pail Or Pan Purchase $11.42E0168 Heavyduty/Wide Commode Chair Purchase $134.38E0170 Commode Chair Electric Capped Rental $134.70E0171 Commode Chair Non-Electric Capped Rental $24.74E0175 Foot Rest, For Use With Commode Chair, Each Purchase $63.62E0181 Press Pad Alternating W/ Pum Capped Rental $17.47E0182 Pump For Alternating Pressure Pad Capped Rental $19.03E0184 Dry Pressure Mattress Purchase $162.98E0185 Gel Pressure Mattress Pad Purchase $222.22E0186 Air Pressure Mattress Purchase $194.94E0187 Water Pressure Mattress Purchase $265.82E0188 Synthetic Sheepskin Pad Purchase $23.28E0189 Lambswool Sheepskin Pad Purchase $45.77E0191 Heel Or Elbow Protector, Each Purchase $9.59E0193 Powered Air Flotation Bed Capped Rental PA Required $613.93E0194 Air Fluidized Bed Capped Rental PA Required $2,810.23E0196 Gel Pressure Mattress Purchase $320.40E0197 Air Pressure Pad For Mattres Purchase $227.07E0198 Water Pressure Pad For Mattr Purchase $212.82E0199 Dry Pressure Pad For Mattres Purchase $31.23E0200 Heat Lamp, Without Stand (Table Model), Includes Bulb, Purchase $64.73E0202 Phototherapy (Bilirubin) Light With Photometer Daily Rental $57.02E0205 Heat Lamp, With Stand, Includes Bulb, Or Infrared Eleme Capped Rental $15.53E0235 Paraffin Bath Unit Portable Capped Rental $12.66E0240 Bath/Shower Chair Purchase $369.98E0244 Raised Toilet Seat Purchase $48.60E0245 Tub Stool Or Bench Purchase $63.98E0249 Pad For Water Circulating Heat Unit Purchase $95.66E0250 Hosp Bed Fixed Ht W/ Mattres Capped Rental $55.25E0251 Hosp Bed Fixd Ht W/O Mattres Capped Rental $50.43E0255 Hospital Bed Var Ht W/ Mattr Capped Rental $66.56E0256 Hospital Bed Var Ht W/O Matt Capped Rental $54.81E0260 Hosp Bed Semi-Electr W/ Matt Capped Rental $76.80E0261 Hosp Bed Semi-Electr W/O Mat Capped Rental $75.47E0265 Hosp Bed Total Electr W/ Mat Capped Rental $128.27E0266 Hosp Bed Total Elec W/O Matt Capped Rental PA Required $112.98



E0271 Mattress, Innerspring Purchase $213.26E0272 Mattress, Foam Rubber Purchase $194.38E0275 Bed Pan, Standard, Metal Or Plastic Purchase $14.70E0276 Bed Pan, Fracture, Metal Or Plastic Purchase $12.77E0277 Powered Pres-Redu Air Mattrs Capped Rental PA Required $338.81E0290 Hosp Bed Fx Ht W/O Rails W/M Capped Rental $50.63E0291 Hosp Bed Fx Ht W/O Rail W/O Capped Rental $37.96E0292 Hosp Bed Var Ht No Sr W/Matt Capped Rental $55.35E0293 Hosp Bed Var Ht No Sr No Mat Capped Rental $49.10E0294 Hosp Bed Semi-Elect W/ Mattr Capped Rental $73.13E0295 Hosp Bed Semi-Elect W/O Matt Capped Rental $71.89E0296 Hosp Bed Total Elect W/ Matt Capped Rental $103.15E0297 Hospital Bed, Total Electric (Head, Foot And Height Adj Capped Rental $105.94E0300 Enclosed Ped Crib Hosp Grade Capped Rental $199.31E0301 Hd Hosp Bed, 350-600 Lbs Capped Rental $163.16E0302 Ex Hd Hosp Bed > 600 Lbs Capped Rental $454.49E0303 Hosp Bed Hvy Dty Xtra Wide Capped Rental $176.42E0304 Hosp Bed Xtra Hvy Dty X Wide Capped Rental $480.22E0305 Bed Side Rails, Half Length Capped Rental $12.45E0310 Bed Side Rails, Full Length Capped Rental $15.54E0325 Urinal, Male, Standard Purchase $8.84E0326 Urinal, Female, Any Material Purchase $10.10E0328 Ped Hospital Bed, Manual Purchase PA Required 75% of MSRPE0329 Ped Hospital Bed, Electric or Semi-Electric Purchase PA Required 75% of MSRPE0371 Nonpower Mattress Overlay Capped Rental $239.15E0372 Powered Air Mattress Overlay Capped Rental $273.86E0373 Nonpowered Pressure Mattress Capped Rental $302.50E0424 Stationary Compressed Gas 02 Capped Rental $101.03E0430 Oxygen System, Portable Using Gaseous Oxygen, Allowance Purchase $326.19E0431 Portable Gaseous 02 Continuous Rental $18.00E0433 Portable Liquid Oxygen Sys Continuous Rental $49.96E0434 Portable Liquid 02 Continuous Rental $33.24E0435 Oxygen System, Portable/Stationary Liquid System, Inclu Purchase $1,990.26E0439 Stationary Liquid 02 Continuous Rental $101.03E0440 Stationary Liquid Oxygen System, Includes Use Of Reserv Purchase $3,625.26E0441 Oxygen Contents, Gaseous Purchase $57.78E0442 Oxygen Contents, Liquid Purchase $57.78E0443 Portable Oxygen Contents, Gas Purchase $55.52E0444 Portable Oxtgen Contents, Liquid Purchase $55.52E0445 Oximeter Non-Invasive Capped Rental $209.18E0447 Portable Oxygen Contents, Liq Over 4 LPM Purchase $63.64E0465 Home Vent Invasive Interface Continuous Rental $989.12E0466 Home Vent Non-Invasive Inter Continuous Rental $989.12E0467 Home Venilator Multi Function Continuous Rental $1,160.97E0470 Rad W/O Backup Non-Inv Intfc Capped Rental $139.14E0471 Rad W/Backup Non Inv Intrfc Capped Rental $311.56E0472 Rad W Backup Invasive Intrfc Capped Rental $365.42E0480 Percusser, Mechanical Home Model Capped Rental $31.57E0482 Cough Stimulating Device Capped Rental PA Required $364.18E0483 Chest Compression Gen System Capped Rental PA Required $918.05E0484 Non-Elec Oscillatory Pep Dvc Purchase $39.27E0500 Ippb All Types Capped Rental $94.78E0550 Humidifier, Durable For Extensive Supplemental Humidifi Capped Rental $42.95E0555 Humidifier, Durable, Glass Or Autoclavable Plastic Bott Purchase $38.07E0560 Humidifier, Durable For Supplemental Humidification Dur Purchase $164.74E0561 Humidifier Nonheated W Pap Purchase $98.08E0562 Humidifier Heated Used W Pap Capped Rental $23.02E0565 Compressor, Air Power Source For Equipment Which Is Not Capped Rental $47.87E0570 Nebulizer With Compression Purchase $111.24



E0572 Aerosol Compressor Adjust Pr Capped Rental $27.78E0574 Ultrasonic Generator W Svneb Capped Rental $34.28E0575 Nebulizer, Self-Contained, Ultrasonic Capped Rental $40.10E0580 Nebulizer, Durable, Glass Or Autoclavable Plastic, Bott Capped Rental $12.24E0585 Nebulizer W/ Compressor & He Capped Rental $24.26E0600 Suction Pump Portab Hom Modl Capped Rental $38.77E0601 Cont Airway Pressure Device Capped Rental $58.22E0602 Breast Pump, Manual Purchase $31.39E0603 Electric Breast Pump Purchase $116.50E0604 Hosp Grade Elec Breast Pump Capped Rental $54.57E0605 Vaporizer, Room Type Purchase $21.58E0607 Blood Glucose Monitor Home Purchase $69.24E0618 Apnea Monitor Capped Rental $266.02E0619 Apnea Monitor W Recorder Capped Rental $274.34E0620 Cap Bld Skin Piercing Laser Purchase $905.94E0621 Sling Or Seat, Patient Lift, Canvas Or Nylon Purchase $82.71E0625 Patient Lift, Kartop, Bathtub Or Toilet Lift Purchase $940.43E0627 Seat Lift Incorp Lift-Chair Capped Rental $25.07E0629 Seat Lift For Pt Furn-Non-El Purchase $296.00E0630 Patient Lift Hydraulic Capped Rental $67.52E0635 Patient Lift Electric Capped Rental $99.79E0636 Pt Support & Positioning Sys Capped Rental $850.58E0637 Sit-Stand W Seatlift Purchase 75% of MSRPE0638 Standing Frame Sys Purchase 75% of MSRPE0639 Moveable Patient Lift System Capped Rental $96.33E0640 Fixed Patient Lift System Capped Rental $96.33E0641 Multi-Position Stnd Fram Sys Purchase 75% of MSRPE0642 Dynamic Standing Frame Purchase 75% of MSRPE0650 Pneuma Compresor Non-Segment Capped Rental PA Required $76.75E0651 Pneum Compressor Segmental Capped Rental PA Required $81.02E0652 Pneum Compres W/Cal Pressure Capped Rental PA Required $416.78E0655 Pneumatic Appliance For Use With Pneumatic Compressor, Purchase PA Required $103.67E0656 Segmental Pneumatic Trunk Purchase $614.39E0657 Segmental Pneumatic Chest Purchase $577.21E0660 Pneumatic Appliance For Use With Pneumatic Compressor, Purchase PA Required $153.43E0665 Pneumatic Appliance For Use With Pneumatic Compressor, Purchase PA Required $131.59E0666 Pneumatic Appliance For Use Withe Pnewmatic Compressor, Purchase PA Required $126.91E0667 Pneumatic Appliance For Use With Segmental Pneumatic Co Purchase PA Required $264.34E0668 Pneumatic Appliance For Use With Segmental Pneumatic Co Purchase PA Required $360.77E0669 Segmental Pneumatic Appliance For Use With Pneumatic Co Purchase PA Required $176.08E0670 Seg Pneum Int Legs/Trunk Purchase $1,136.36E0671 Pressure Pneum Appl Full Leg Purchase PA Required $441.73E0672 Pressure Pneum Appl Full Arm Purchase PA Required $343.21E0673 Pressure Pneum Appl Half Leg Purchase PA Required $285.20E0675 Pneumatic Compression Device Capped Rental $408.97E0691 Uvl Pnl 2 Sq Ft Or Less Capped Rental $77.60E0692 Uvl Sys Panel 4 Ft Capped Rental $97.43E0693 Uvl Sys Panel 6 Ft Capped Rental $120.12E0694 Uvl Md Cabinet Sys 6 Ft Capped Rental $373.72E0705 Transfer Board Or Device Purchase $46.62E0720 Tens Two Lead Capped Rental $18.55E0730 Tens Four Lead Capped Rental $18.70E0744 Neuromuscular Stimulator For Scoliosis Capped Rental $69.87E0745 Neuromuscular Stim For Shock Capped Rental $65.71E0747 Elec Osteogen Stim Not Spine Purchase PA Required $4,057.99E0748 Elec Osteogen Stim Spinal Purchase PA Required $4,031.71E0760 Osteogen Ultrasound Stimltor Capped Rental PA Required $279.20E0762 Trans Elec Jt Stim Dev Sys Purchase $1,169.39E0764 Functional Neuromuscularstim Purchase $11,639.73



E0765 Nerve Stimulator For Tx N&V Purchase $89.47E0766 Elec Stim Cancer Treatment Purchase $418.00E0776 IV Pole Capped Rental $11.32E0779 Amb Infusion Pump Mechanical Capped Rental $14.13E0780 Mech Amb Infusion Pump <8Hrs Purchase $11.03E0781 External Ambulatory Infus Pu Capped Rental $203.05E0782 Parenteral Infusion Pump, Implantable Purchase $3,157.19E0783 Programmable Infusion Pump Capped Rental $740.09E0784 Ext Amb Infusn Pump Insulin Purchase $4,129.83E0785 Replacement Impl Pump Cathet Purchase $500.15E0786 Implantable Pump Replacement Purchase $8,492.73E0791 Parenteral Infusion Pump Sta Capped Rental $224.03E0840 Traction Frame,Attached To Headboard, Simple Cervical T Capped Rental $4.92E0849 Cervical Pneum Trac Equip Capped Rental $44.51E0850 Traction Stand, Free Standing, Simple Cervical Traction Capped Rental $8.41E0855 Cervical Traction Equipment Capped Rental $42.69E0856 Cervic Collar W Air Bladders Purchase $163.80E0860 Tract Equip Cervical Tract Purchase $39.93E0870 Tract Frame Attach Footboard Capped Rental $9.84E0880 Trac Stand Free Stand Extrem Capped Rental $14.47E0890 Traction Frame, Attached To Footboard, Simple Pelvic Tr Capped Rental $8.36E0900 Trac Stand Free Stand Pelvic Capped Rental $20.28E0910 Trapeze Bar Attached To Bed Capped Rental $11.47E0911 Hd Trapeze Bar Attach To Bed Purchase $424.62E0912 Hd Trapeze Bar Free Standing Purchase $903.33E0920 Fracture Frame Attached To B Capped Rental $39.86E0930 Fracture Frame Free Standing Capped Rental $37.82E0935 Cont Pas Motion Exercise Dev Daily Rental PA Required $23.57E0936 Cpm Device, Other Than Knee Purchase PA Required $21.84E0940 Trapeze Bar Free Standing Capped Rental $21.34E0941 Gravity Assisted Traction De Capped Rental $37.48E0942 Cervcal Head Harness/Halter Purchase $17.78E0944 Pelvic Belt/Harness/Boot Purchase $47.15E0945 Extremity Belt/Harness Purchase $42.57E0946 Fracture Frame Dual W Cross Capped Rental $51.09E0947 Fracture Frame Attachmnts Pe Capped Rental $54.30E0948 Fracture Frame, Attachments For Complex Cervical Tracti Capped Rental $46.26E0950 Tray Purchase $99.84E0951 Loop Heel, Each Purchase $18.10E0952 Loop Toe, Each Purchase $18.10E0955 Cushioned Headrest Purchase $171.10E0956 W/C Lateral Trunk/Hip Suppor Purchase $82.92E0957 W/C Medial Thigh Support Purchase $118.83E0958 Wheelchair Attachment To Convert Any Wheelchair To One Purchase PA Required $361.14E0959 Amputee Adapter (Device Used To Compensate For Transfer Purchase $44.75E0960 W/C Shoulder Harness/Straps Purchase $83.39E0961 Brake Extension, For Wheelchair Purchase $28.58E0966 Hook On Head Rest Extention Purchase $66.56E0967 Man Wc Rim/Projection Rep Ea Capped Rental $6.39E0968 Commode Seat, Wheelchair Purchase $161.80E0969 Narrowing Device, Wheelchair Capped Rental $11.63E0970 No.2 Footplates, Except For Elevating Leg Rest Purchase $39.81E0971 Anti-Tipping Device Wheelchairs Purchase $53.67E0973 Adjustable Height Detachable Arms, Desk Or Full Length, Purchase $111.11E0974 Grade-Aid (Device To Prevent Rolling Back On An Incli Purchase $64.46E0978 Belt, Safety With Airplane Buckle, Wheelchair Purchase $42.98E0980 Safety Vest, Wheelchair Purchase $31.74E0981 Seat Upholstery, Replacement Purchase $43.22E0982 Back Upholstery, Replacement Purchase $47.23



E0985 W/C Seat Lift Mechanism Purchase $215.74E0986 Man W/C Push-Rim Powr System Purchase PA Required $5,001.23E0988 Lever-Activated Wheel Drive Capped Rental $318.36E0990 Elevating Leg Rest, Each Capped Rental $9.40E0992 Solid Seat Insert Purchase $91.38E0994 Arm Rest, Each Purchase $14.40E0995 Wc Calf Rest, Pad Replacemnt Purchase $29.20E1002 Pwr Seat Tilt Purchase PA Required $3,212.78E1003 Pwr Seat Recline Purchase PA Required $4,025.23E1004 Pwr Seat Recline Mech Purchase PA Required $4,463.15E1005 Pwr Seat Recline Pwr Purchase PA Required $4,831.02E1006 Pwr Seat Combo W/O Shear Purchase PA Required $5,917.55E1007 Pwr Seat Combo W/Shear Purchase PA Required $7,529.54E1008 Pwr Seat Combo Pwr Shear Purchase PA Required $7,353.74E1010 Add Pwr Leg Elevation Purchase PA Required $964.56E1012 Ctr Mount Pwr Elev Leg Rest Purchase PA Required $964.56E1014 Reclining Back Add Ped W/C Purchase PA Required $388.34E1015 Shock Absorber For Man W/C Purchase $121.99E1016 Shock Absorber For Power W/C Purchase $110.46E1020 Residual Limb Support System Purchase $223.11E1028 W/C Manual Swingaway Purchase $180.08E1029 W/C Vent Tray Fixed Purchase $338.73E1030 W/C Vent Tray Gimbaled Purchase $1,068.13E1035 Patient Transfer System Capped Rental $497.25E1036 Patient Transfer System Capped Rental $709.42E1050 Fully-Reclining Wheelchair, Fixed Full Length Arms Elev Purchase $935.54E1060 Fully-Reclining Wheelchair, Detachable Arms (Desk Or Fu Purchase $1,064.96E1070 Fully-Reclining Wheelchair, Detachable Arms (Desk Or Fu Purchase $981.48E1083 Hemi-Wheelchair, Fixed Full Length Arms, Swing Away Det Purchase $693.70E1084 Hemi-Wheelchair, Detachable Arms Desk Or Full Length Ar Purchase $880.84E1087 High Strength Lightweight Wheelchair,Fixed Full Length Purchase $1,109.12E1088 Wheelchair Lightweight Det A Purchase $1,562.40E1089 High Strength Lightweight Wheelchair, Fixed Length Arms Purchase $970.93E1092 Wide Heavy Duty Wheel Chair, Detachable Arms Desk Of Fu Purchase $1,117.54E1093 Wheelchair Wide W/ Foot Rest Purchase $1,145.25E1100 Semi-Reclining Wheelchair, Fixed Full Length Arms, Elev Purchase $882.44E1110 Semi-Reclining Wheelchair, Detachable Arms (Desk Or Ful Purchase $953.65E1150 Wheelchair Standard W/ Leg R Purchase $845.28E1160 Wheelchair Fixed Arms Purchase $647.73E1161 Manual Adult Wc W Tiltinspac Purchase PA Required $2,451.78E1170 Amputee Wheelchair, Fixed Full Length Arms, Elevating L Purchase $747.98E1171 Amputee Wheelchair, Fixed Full Length Arms, Without Foo Purchase $719.94E1172 Amputee Wheelchair, Detachable Arms (Desk Or Full Lengt Purchase $747.34E1180 Amputee Wheelchair, Detachable Arms (Desk Or Full Lengt Purchase $876.04E1190 Amputee Wheelchair, Detachable Arms (Desk Or Full Lengt Purchase $985.76E1195 Heavy Duty Wheelchair, Fixed Full Length Arms, Swing Aw Purchase $960.48E1200 Amputee Wheelchair, Fixed Full Length Arms, Swing Away Purchase $763.32E1221 Wheelchair with Fixed Arm, Footrests Capped Rental $50.55E1222 Wheelchair with Fixed Arm ,Elevating Legrests Capped Rental $72.09E1223 Wheelchair with Detachable Arms, Footrests Capped Rental $78.72E1224 Wheelchair with Detachable Arms, Elevating Leg Rests Capped Rental $86.29E1225 Manual Wheelchair Accesory Purchase PA Required $48.08E1226 Manual Wheelchair Accessory Purchase PA Required $496.71E1227 Special Height Arms For Wc Purchase PA Required $250.87E1228 Special Back Height For Wc Purchase $29.80E1232 Folding Ped Wc Tilt-In-Space Purchase PA Required $2,216.07E1233 Rig Ped Wc Tltnspc W/O Seat Purchase PA Required $2,295.99E1234 Fld Ped Wc Tltnspc W/O Seat Purchase PA Required $1,998.90E1235 Rigid Ped Wc Adjustable Purchase PA Required $1,924.92



E1236 Folding Ped Wc Adjustable Purchase PA Required $1,698.12E1237 Rgd Ped Wc Adjstabl W/O Seat Purchase PA Required $1,712.97E1238 Fld Ped Wc Adjstabl W/O Seat Purchase PA Required $1,698.12E1240 Whchr Litwt Det Arm Leg Rest Purchase $999.09E1270 Lightweight Wheelchair, Fixed Full Length Arms, Elevati Purchase $707.46E1280 Heavy Duty Wheelchair, Detachable Arms (Desk Or Full Le Purchase $1,098.99E1285 Heavy Duty Wheelchair, Fixed Full Length Arms, Swing Aw Purchase $968.90E1295 Heavy Duty Wheelchair, Fixed Full Length Arms, Elevatin Purchase $1,039.49E1296 Special Wheelchair Seat Height From Floor Purchase $472.25E1297 Special Wheelchair Seat Depth, By Upholstery Purchase $100.47E1298 Special Wheelchair Seat Depth And/Or Width, By Construc Purchase $345.89E1310 Whirlpool, Non-Portable (Built-In Type) Purchase PA Required $2,062.60E1353 Regulator Purchase $29.99E1355 Stand/Rack Purchase $22.58E1372 Immersion External Heater For Nebulizer Capped Rental $14.89E1390 Oxygen Concentrator Continuous Rental $121.24E1391 Oxygen Concentrator, Dual Purchase $1,212.39E1392 Portable Oxygen Concentrator Continuous Rental $39.89E1399 Durable Medical Equipement, Not Otherwise Classified Purchase 75% of MSRPE1405 Oxygen And Water Vapor Enriching System With Heated Del Purchase $205.92E1406 Oxygen And Water Vapor Enriching System Without Heated Purchase $191.35E1700 Jaw Motion Rehab System Purchase $331.21E1701 Replacement Cushions For Jaw Motion Rehabilitation Syst Purchase $10.18E1702 Replacement Measuring Scales For Jaw Motion Rehabilitat Purchase $21.68E1800 Adjust Elbow Ext/Flex Device Capped Rental $105.79E1801 Sps Elbow Device Capped Rental $109.30E1802 Adjst Forearm Pro/Sup Device Capped Rental $282.21E1805 Adjust Wrist Ext/Flex Device Capped Rental $109.11E1806 Sps Wrist Device Capped Rental $89.68E1810 Adjust Knee Ext/Flex Device Capped Rental $107.59E1811 Sps Knee Device Capped Rental $113.60E1812 Knee Ext/Flex W Act Res Ctrl Capped Rental $74.26E1815 Adjust Ankle Ext/Flex Device Capped Rental $109.11E1816 Sps Ankle Device Capped Rental $115.37E1818 Sps Forearm Device Capped Rental $117.78E1820 Soft Interface Material Purchase $79.90E1821 Replacement Interface Spsd Purchase $109.05E1825 Adjust Finger Ext/Flex Devc Capped Rental $109.11E1830 Adjust Toe Ext/Flex Device Capped Rental $109.11E1831 Static Str Toe Dev Ext/Flex Capped Rental $57.06E1840 Adj Shoulder Ext/Flex Device Capped Rental $367.21E1841 Static Str Shldr Dev Rom Adj Capped Rental $434.64E2000 Gastric Suction Pump Hme Mdl Capped Rental $43.88E2100 Bld Glucose Monitor W Voice Purchase $666.50E2101 Bld Glucose Monitor W Lance Purchase $195.39E2120 Pulse Gen Sys Tx Endolymp Fl Capped Rental $301.54E2201 Man W/Ch Acc Seat W>=20"<24" Purchase $396.80E2202 Seat Width 24-27 In Capped Rental $41.81E2203 Frame Depth Less Than 22 In Purchase $509.47E2204 Frame Depth 22 To 25 In Purchase $865.06E2205 Manual Wc Accessory, Handrim Purchase $33.02E2206 Man Wc Whl Lock Comp Repl Ea Purchase $40.49E2207 Crutch And Cane Holder Purchase $40.95E2208 Cylinder Tank Carrier Purchase $112.19E2209 Arm Trough Each Purchase $101.23E2210 Wheelchair Bearings Purchase $5.55E2211 Pneumatic Propulsion Tire Purchase $39.29E2212 Pneumatic Prop Tire Tube Purchase $5.94E2213 Pneumatic Prop Tire Insert Purchase $29.69



E2214 Pneumatic Caster Tire Each Purchase $34.58E2215 Pneumatic Caster Tire Tube Purchase $9.08E2219 Foam Caster Tire Any Size Ea Purchase $37.23E2220 Solid Propuls Tire, Repl, Ea Purchase $24.84E2221 Solid Caster Tire Repl, Each Purchase $25.58E2222 Solid Caster Integ Whl, Repl Purchase $22.40E2224 Propulsion Whl Excl Tire Rep Purchase $104.28E2225 Caster Wheel Excludes Tire Purchase $18.51E2226 Caster Fork Replacement Only Purchase $40.17E2227 Gear Reduction Drive Wheel Purchase $1,989.44E2228 Mwc Acc, Wheelchair Brake Purchase $995.73E2231 Solid Seat Support Base Purchase $163.43E2300 Pwr Seat Elevation Sys Purchase PA Required 75% of MSRPE2310 Electro Connect Btw Control Purchase $1,072.69E2311 Electro Connect Btw 2 Sys Purchase $1,992.94E2312 Mini-Prop Remote Joystick Purchase PA Required $2,144.79E2313 Pwc Harness, Expand Control Purchase $329.50E2321 Hand Interface Joystick Purchase PA Required $1,456.63E2322 Mult Mech Switches Purchase PA Required $1,292.80E2323 Special Joystick Handle Purchase PA Required $63.40E2324 Chin Cup Interface Purchase PA Required $40.16E2325 Sip And Puff Interface Purchase PA Required $1,234.55E2326 Breath Tube Kit Purchase PA Required $318.21E2327 Head Control Interface Mech Purchase PA Required $2,394.60E2328 Head/Extremity Control Inter Purchase PA Required $4,542.24E2329 Head Control Nonproportional Purchase PA Required $1,618.91E2330 Head Control Proximity Switc Purchase PA Required $2,954.62E2340 W/C Wdth 20-23 In Seat Frame Purchase $381.11E2341 W/C Wdth 24-27 In Seat Frame Purchase $571.72E2342 W/C Dpth 20-21 In Seat Frame Purchase $476.44E2343 W/C Dpth 22-25 In Seat Frame Purchase $762.29E2351 Electronic Sgd Interface Purchase $640.38E2359 Gr34 Sealed Leadacid Battery Purchase $185.19E2360 22Nf Nonsealed Leadacid Purchase $107.91E2361 22Nf Sealed Leadacid Battery Purchase $144.96E2362 Gr24 Nonsealed Leadacid Purchase $86.87E2363 Gr24 Sealed Leadacid Battery Purchase $189.28E2364 U1Nonsealed Leadacid Battery Purchase $107.91E2365 U1 Sealed Leadacid Battery Purchase $105.95E2366 Battery Charger, Single Mode Purchase $253.21E2367 Battery Charger, Dual Mode Purchase $253.21E2368 Power Wc Motor Replacement Purchase $473.51E2369 Pwr Wc Gear Box Replacement Purchase $412.43E2370 Pwr Wc Motor/Gear Box Combo Purchase $735.92E2371 Gr27 Sealed Leadacid Battery Purchase $138.17E2373 Hand/Chin Ctrl Spec Joystick Purchase PA Required $702.55E2374 Hand/Chin Ctrl Std Joystick Purchase $459.99E2375 Non-Expandable Controller Purchase $785.16E2376 Expandable Controller, Repl Purchase $1,230.37E2377 Expandable Controller, Initl Purchase $408.58E2378 Pw Actuator Replacement Purchase $541.66E2381 Pneum Drive Wheel Tire Purchase $68.65E2382 Tube, Pneum Wheel Drive Tire Purchase $18.70E2383 Insert, Pneum Wheel Drive Purchase $136.88E2384 Pneumatic Caster Tire Purchase $72.94E2385 Tube, Pneumatic Caster Tire Purchase $44.63E2386 Foam Filled Drive Wheel Tire Purchase $135.65E2387 Foam Filled Caster Tire Purchase $58.52E2388 Foam Drive Wheel Tire Purchase $46.18



E2389 Foam Caster Tire Purchase $25.08E2390 Solid Drive Wheel Tire Purchase $39.23E2391 Solid Caster Tire Purchase $18.78E2392 Solid Caster Tire, Integrate Purchase $49.39E2394 Drive Wheel Excludes Tire Purchase $70.36E2395 Caster Wheel Excludes Tire Purchase $49.99E2396 Caster Fork Purchase $52.77E2397 Pwc Acc, Lith-Based Battery Purchase $440.45E2402 Neg Press Wound Therapy Pump Capped Rental PA Required $902.45E2500 Sgd Digitized Pre-Rec <=8Min Purchase PA Required $405.22E2502 Sgd Prerec Msg >8Min <=20Min Purchase PA Required $1,239.12E2504 Sgd Prerec Msg>20Min <=40Min Purchase PA Required $1,677.57E2506 Sgd Prerec Msg > 40 Min Purchase PA Required $2,423.49E2508 Sgd Spelling Phys Contact Purchase PA Required $3,706.23E2510 Sgd W Multi Methods Msg/Accs Purchase PA Required $7,013.54E2511 Sgd Sftwre Prgrm For Pc/Pda Purchase PA Required $27.90E2512 Sgd Accessory, Mounting Sys Purchase PA Required $401.56E2599 Sgd Accessory Noc Purchase PA Required $182.29E2601 Gen W/C Cushion Wdth < 22 In Purchase PA Required $51.43E2602 Gen W/C Cushion Wdth >=22 In Purchase $109.44E2603 Skin Protect Wc Cus Wd <22In Purchase $127.53E2604 Skin Protect Wc Cus Wd>=22In Purchase $172.72E2605 Position Wc Cush Wdth <22 In Purchase $246.73E2606 Position Wc Cush Wdth>=22 In Purchase $384.92E2607 Skin Pro/Pos Wc Cus Wd <22In Purchase $243.82E2608 Skin Pro/Pos Wc Cus Wd>=22In Purchase $319.07E2609 Custom Fabricate W/C Cushion Purchase PA Required 75% of MSRPE2611 Gen Use Back Cush Wdth <22In Purchase $262.75E2612 Gen Use Back Cush Wdth>=22In Purchase $355.44E2613 Position Back Cush Wd <22In Purchase $330.62E2614 Position Back Cush Wd>=22In Purchase $457.56E2615 Pos Back Post/Lat Wdth <22In Purchase $380.49E2616 Pos Back Post/Lat Wdth>=22In Purchase $511.93E2617 Custom Fab W/C Back Cushion Purchase 75% of MSRPE2619 Replace Cover W/C Seat Cush Purchase $43.17E2620 Wc Planar Back Cush Wd <22In Purchase $579.91E2621 Wc Planar Back Cush Wd>=22In Purchase $483.49E2622 Skin Protection Wheelchair Seat Cushion, Adjustable, Purchase $278.82E2623 Skin Protection Wheelchair Seat Cushion, Adjustable Purchase $354.79E2624 Skin Protection And Positioning Wheelchair Seat Cushion Purchase $281.13E2625 Skin Protection And Positioning Wheelchair Seat Cushion Purchase $355.88E2626 Seo Mobile Arm Sup Att To Wc Purchase $561.48E2627 Arm Supp Att To Wc Rancho Ty Purchase $895.96E2628 Mobile Arm Supports Reclinin Purchase $674.96E2629 Friction Dampening Arm Supp Purchase $854.14E2630 Monosuspension Arm/Hand Supp Purchase $597.30E2631 Elevat Proximal Arm Support Purchase $238.93E2632 Offset/Lat Rocker Arm W/Ela Purchase $151.93E2633 Mobile Arm Support Supinator Purchase $128.86E8000 Posterior Gait Trainer Purchase PA Required 75% of MSRPE8001 Upright Gait Trainer Purchase PA Required 75% of MSRPE8002 Anterior Gait Trainer Purchase PA Required 75% of MSRPK0001 Standard Wheelchair Capped Rental $32.18K0002 Stnd Hemi (Low Seat) Whlchr Capped Rental PA Required $51.18K0003 Lightweight Wheelchair Capped Rental PA Required $52.46K0004 High Strength Ltwt Whlchr Capped Rental PA Required $74.67K0005 Ultralightweight Wheelchair Purchase PA Required $1,883.72K0006 Heavy Duty Wheelchair Capped Rental PA Required $79.34K0007 Extra Heavy Duty Wheelchair Capped Rental PA Required $110.72



K0009 Other Manual Wheelchair/Base Capped Rental PA Required $64.21K0010 Stnd Wt Frame Power Whlchr Capped Rental PA Required $367.86K0011 Stnd Wt Pwr Whlchr W Control Capped Rental PA Required $442.35K0012 Ltwt Portbl Power Whlchr Capped Rental PA Required $275.17K0015 Detachable, Non-Adjustable Height Armrest, Each Purchase $171.62K0017 Detach Adjust Armrest Base Purchase $48.25K0018 Detach Adjust Armrst Upper Purchase $26.98K0019 Arm Pad Repl, Each Purchase $16.54K0020 Fixed, Adjustable Height Armrest, Pair Purchase $43.86K0037 Hi Mount Flip-Up Ftrest Repl Purchase $39.81K0038 Leg Strap, Each Purchase $22.90K0039 Leg Strap, H Style, Each Purchase $50.89K0040 Adjustable Angle Footplate, Each Purchase $70.51K0041 Large Size Footplate, Each Purchase $49.98K0042 Standard Size Ftplate Rep Ea Purchase $29.73K0043 Ftrst Lowr Exten Tube Rep Ea Purchase $18.44K0044 Ftrst Upr Hanger Brac Rep Ea Purchase $15.71K0045 Ftrst Compl Assembly Repl Ea Purchase $46.22K0046 Elev Lgrst Lwr Exten Repl Ea Purchase $18.44K0047 Elev Legrst Upr Hangr Rep Ea Purchase $72.22K0050 Ratchet Assembly Replacement Purchase $30.69K0051 Cam Rel Asm Ft/Legrst Rep Ea Purchase $49.67K0052 Swingaway Detach Ftrest Repl Purchase $87.31K0053 Elevating Footrests, Articulating (Telescoping), Each Purchase $96.34K0056 Seat Height < 17" Or < Or Equal To 21" For A High Stren Purchase $93.12K0065 Spoke Protectors Purchase $41.97K0069 Rr Whl Compl Sol Tire Rep Ea Purchase $95.83K0070 Rear Wheel Assembly, Complete, With Pneumatic Tire, Spo Purchase $167.72K0071 Fr Cstr Comp Pne Tire Rep Ea Purchase $103.19K0072 Fr Cstr Semi-Pne Tire Rep Ea Purchase $62.47K0073 Caster Pin Lock,Each Purchase $31.61K0077 Fr Cstr Asmb Sol Tire Rep Ea Purchase $55.36K0098 Drive Belt For Pwc, Repl Purchase $24.18K0105 Iv Hanger Purchase $97.90K0108 Wheelchair component or accessory, not otherwise specified Purchase PA Required 75% of MSRPK0195 Elevating Leg Rests, Pair Capped Rental $19.45K0455 Pump Uninterrupted Infusion Capped Rental $224.30K0552 Sup/Ext Non-Ins Inf Pump Syr Purchase $2.78K0553 Ther Cgm Supply Allowance Purchase PA Required $229.39K0554 Ther Cgm Receiver/Monitor Purchase PA Required $243.22K0601 Repl Batt Silver Oxide 1.5 V Purchase $1.18K0602 Repl Batt Silver Oxide 3 V Purchase $6.77K0603 Repl Batt Alkaline 1.5 V Purchase $0.60K0604 Repl Batt Lithium 3.6 V Purchase $6.46K0605 Repl Batt Lithium 4.5 V Purchase $15.53K0606 Aed Garment W Elec Analysis Capped Rental $2,678.19K0607 Repl Batt For Aed Purchase $206.57K0608 Repl Garment For Aed Purchase $128.90K0609 Repl Electrode For Aed Purchase $857.26K0672 Removable Soft Interface Le Purchase $78.63K0730 Ctrl Dose Inh Drug Deliv Sys Purchase $1,786.41K0733 12-24Hr Sealed Lead Acid Purchase $27.69K0738 Portable Gas Oxygen System Continuous Rental $39.89K0739 Repair/Svc Dme Non-Oxygen Eq Purchase $14.60K0740 Repair/Svc Oxygen Equipment Purchase $15.42K0813 Pwc Gp 1 Std Port Seat/Back Purchase PA Required $2,865.96K0814 Pwc Gp 1 Std Port Cap Chair Purchase PA Required $3,361.50K0815 Pwc Gp 1 Std Seat/Back Purchase PA Required $3,781.89K0816 Pwc Gp 1 Std Cap Chair Purchase PA Required $3,578.58



K0820 Pwc Gp 2 Std Port Seat/Back Purchase PA Required $3,010.23K0821 Pwc Gp 2 Std Port Cap Chair Purchase PA Required $3,540.87K0822 Pwc Gp 2 Std Seat/Back Purchase PA Required $4,102.92K0823 Pwc Gp 2 Std Cap Chair Purchase PA Required $4,021.56K0824 Pwc Gp 2 Hd Seat/Back Purchase PA Required $5,287.86K0825 Pwc Gp 2 Hd Cap Chair Purchase PA Required $4,863.60K0826 Pwc Gp 2 Vhd Seat/Back Purchase PA Required $7,660.35K0827 Pwc Gp Vhd Cap Chair Purchase PA Required $6,594.66K0828 Pwc Gp 2 Xtra Hd Seat/Back Purchase PA Required $8,916.48K0829 Pwc Gp 2 Xtra Hd Cap Chair Purchase PA Required $8,418.60K0830 Pwc Gp2 Std Seat Elevate S/B Purchase PA Required $3,970.30K0831 Pwc Gp2 Std Seat Elevate Cap Purchase PA Required $3,970.30K0835 Pwc Gp2 Std Sing Pow Opt S/B Purchase PA Required $4,296.96K0836 Pwc Gp2 Std Sing Pow Opt Cap Purchase PA Required $4,456.35K0837 Pwc Gp 2 Hd Sing Pow Opt S/B Purchase PA Required $5,269.14K0838 Pwc Gp 2 Hd Sing Pow Opt Cap Purchase PA Required $4,697.01K0839 Pwc Gp2 Vhd Sing Pow Opt S/B Purchase PA Required $6,889.95K0840 Pwc Gp2 Xhd Sing Pow Opt S/B Purchase PA Required $10,492.83K0841 Pwc Gp2 Std Mult Pow Opt S/B Purchase PA Required $4,672.35K0842 Pwc Gp2 Std Mult Pow Opt Cap Purchase PA Required $4,669.83K0843 Pwc Gp2 Hd Mult Pow Opt S/B Purchase PA Required $5,592.33K0848 Pwc Gp 3 Std Seat/Back Purchase PA Required $7,079.67K0849 Pwc Gp 3 Std Cap Chair Purchase PA Required $6,806.52K0850 Pwc Gp 3 Hd Seat/Back Purchase PA Required $8,211.96K0851 Pwc Gp 3 Hd Cap Chair Purchase PA Required $7,895.88K0852 Pwc Gp 3 Vhd Seat/Back Purchase PA Required $9,488.43K0853 Pwc Gp 3 Vhd Cap Chair Purchase PA Required $9,747.09K0854 Pwc Gp 3 Xhd Seat/Back Purchase PA Required $8,967.92K0855 Pwc Gp 3 Xhd Cap Chair Purchase PA Required $8,471.60K0856 Pwc Gp3 Std Sing Pow Opt S/B Purchase PA Required $7,599.06K0857 Pwc Gp3 Std Sing Pow Opt Cap Purchase PA Required $7,751.43K0858 Pwc Gp3 Hd Sing Pow Opt S/B Purchase PA Required $9,428.31K0859 Pwc Gp3 Hd Sing Pow Opt Cap Purchase PA Required $8,991.72K0860 Pwc Gp3 Vhd Sing Pow Opt S/B Purchase PA Required $13,469.58K0861 Pwc Gp3 Std Mult Pow Opt S/B Purchase PA Required $7,611.21K0862 Pwc Gp3 Hd Mult Pow Opt S/B Purchase PA Required $9,428.31K0863 Pwc Gp3 Vhd Mult Pow Opt S/B Purchase PA Required $13,469.58K0864 Pwc Gp3 Xhd Mult Pow Opt S/B Purchase PA Required $11,131.87K0870 Pwc Gp 4 Hd Seat/Back Purchase PA Required $862.03K0877 Pwc Gp4 Std Sing Pow Opt S/B Purchase PA Required 75% of MSRPL0112 Cranial Cervical Orthosis Purchase $1,297.68L0113 Cranial Cervical Torticollis Purchase $264.42L0120 Cervical, Flexible, Non-Adjustable (Foam Collar) Purchase $22.00L0130 Cervical, Flexible Thermoplastic Molded To Patient Purchase $135.25L0140 Cervical, Semi-Rigid, Adjustable (Plastic Collar) Purchase $59.92L0150 Cervical, Semi-Rigid, Adjustable Molded Chin Cup (Plast Purchase $89.59L0160 Cervical, Semi-Rigid, Wire Frame Occipital/Mandibular S Purchase $108.82L0170 Cervical, Collar, Molded To Patient Model Purchase $448.11L0172 Cervical, Collar, Semi-Rigid Thermoplastic Foam, Two Pi Purchase $109.34L0174 Cervical, Collar, Semi-Rigid, Thermoplastic Foam, Two P Purchase $266.37L0180 Cervical, Multiple Post Collar, Occipital/Mandibular Su Purchase $257.44L0190 Cervical, Multiple Post Collar, Occipital/Mandibular Su Purchase $357.39L0200 Cervical, Multiple Post Collar, Occipital/Mandibular Su Purchase $388.12L0220 Thoracic, Rib Belt, Custom Fabricated Purchase $101.53L0450 Tlso Flex Prefab Thoracic Purchase $149.04L0454 Tlso Flex Prefab Sacrococ-T9 Purchase $321.56L0455 Tlso Flex Trnk Sj-T9 Pre Ots Purchase $324.78L0456 Tlso Flex Prefab Purchase $922.14L0457 Tlso Flex Trnk Sj-Ss Pre Ots Purchase $931.36



L0458 Tlso 2Mod Symphis-Xipho Pre Purchase $826.88L0460 Tlso2Mod Symphysis-Stern Pre Purchase $930.72L0462 Tlso 3Mod Sacro-Scap Pre Purchase $1,157.64L0464 Tlso 4Mod Sacro-Scap Pre Purchase $1,378.15L0466 Tlso Rigid Frame Pre Soft Ap Purchase $334.75L0467 Tlso R Fram Soft Pre Ots Purchase $338.09L0468 Tlso Rigid Frame Prefab Pelv Purchase $393.06L0469 Tlso Rig Fram Pelvic Pre Ots Purchase $396.99L0470 Tlso Rigid Frame Pre Subclav Purchase $546.72L0472 Tlso Rigid Frame Hyperex Pre Purchase $346.74L0480 Tlso Rigid Plastic Custom Fa Purchase $1,517.35L0482 Tlso Rigid Lined Custom Fab Purchase $1,696.65L0484 Tlso Rigid Plastic Cust Fab Purchase $1,831.16L0486 Tlso Rigidlined Cust Fab Two Purchase $1,855.38L0488 Tlso Rigid Lined Pre One Pie Purchase $930.72L0490 Tlso Rigid Plastic Pre One Purchase $262.24L0491 Tlso 2 Piece Rigid Shell Purchase $712.07L0492 Tlso 3 Piece Rigid Shell Purchase $448.76L0621 Sio Flex Pelvisacral Prefab Purchase $97.83L0622 Sio Flex Pelvisacral Custom Purchase $221.53L0625 Lo Flexibl L1-Below L5 Pre Purchase $51.19L0626 Lo Sag Stays/Panels Pre-Fab Purchase $72.40L0627 Lo Sagitt Rigid Panel Prefab Purchase $381.86L0628 Lo Flex W/O Rigid Stays Pre Purchase $77.92L0630 Lso Post Rigid Panel Pre Purchase $150.44L0631 Lso Sag-Coro Rigid Frame Pre Purchase $953.72L0633 Lso Flexion Control Prefab Purchase $266.40L0635 Lso Sagit Rigid Panel Prefab Purchase $820.82L0636 Lso Sagittal Rigid Panel Cus Purchase $1,428.37L0637 Lso Sag-Coronal Panel Prefab Purchase $961.61L0638 Lso Sag-Coronal Panel Custom Purchase $1,222.86L0639 Lso S/C Shell/Panel Prefab Purchase $961.61L0640 Lso S/C Shell/Panel Custom Purchase $970.18L0641 Lo Rig Pos Pnl L1-L5 Pre Ots Purchase $73.12L0642 Lo Sag Ri An/Pos Pnl Pre Ots Purchase $385.69L0643 Lso Sag Ctr Rigi Pos Pre Ots Purchase $151.95L0648 Lso Sag R An/Pos Pnl Pre Ots Purchase $963.26L0649 Lso Sc R Pos/Lat Pnl Pre Ots Purchase $269.07L0650 Lso Sc R Ant/Pos Pnl Pre Ots Purchase $971.23L0651 Lumbar-Sacral Orthosis, Sagittal-Coronal Control Purchase $971.23L0700 Cervical-Thoracic-Lumbarsacral-Orthoses (Ctlso), Purchase $1,421.04L0710 Ctlso, Anterior-Posteriorlateral-Control, Molded To Pat Purchase $1,658.25L0810 Halo Procedures, Cervical Halo Incorporated Into Spinal Purchase $1,872.38L0820 Halo Procedures, Cervical Halo Incorporated Into Plaste Purchase $1,619.85L0830 Halo Procedures, Cervical Halo Incorporated Into Milwau Purchase $2,178.79L0859 Mri Compatible System Purchase $1,128.58L0861 Halo Repl Liner/Interface Purchase $199.83L0970 Tlso, Corset Front Purchase $105.88L0972 Lso, Corset Front Purchase $76.91L0974 Tlso, Full Corset Purchase $124.40L0976 Lso, Full Corset Purchase $140.93L0978 Axillary Crutch Extension Purchase $133.75L0980 Peroneal Straps, Pair Purchase $12.13L0982 Stocking Supporter Grips, Set Of Four (4) Purchase $11.31L0984 Protective Body Sock, Each Purchase $55.24L0999 Add To Spinal Orthosis Nos Purchase $325.60L1000 Cervical-Thoracic-Lumbar-Sacral (Ctlso) (Milwaukee), In Purchase $1,643.80L1005 Tension Based Scoliosis Orth Purchase $2,967.53L1010 Additions To Cervical-Thoraciclumbar-Sacral Orthoses (C Purchase $46.63



L1020 Additions To Ctlso Or Scoliosis Orthoses, Kyphosis Pad Purchase $60.07L1025 Addition To Ctlso Or Scoliosis Orthosis, Kyphosis Pad, Purchase $86.63L1030 Additions To Ctlso Or Scoliosis Orthoses, Lumbar Bolste Purchase $44.19L1040 Additions To Ctlso Or Scloiosis Orthoses, Lumbar Or Lum Purchase $54.21L1050 Additions To Ctlso Or Scoliosis Orthoses, Sternal Pad Purchase $57.84L1060 Additions To Ctlso Or Scoliosis Orthoses, Thoracic Pad Purchase $66.45L1070 Additions To Ctlso Or Scoliosis Orthoses, Trapeze Sling Purchase $62.52L1080 Additions To Ctlso Or Scoliosis Orthoses, Outrigger Purchase $49.42L1085 Addition To Ctlso Or Scoliosis Orthosis, Outrigger, Bil Purchase $106.96L1090 Additions To Ctlso Or Scoliosis Orthoses, Lumbar Sling Purchase $68.78L1100 Additions To Ctlso Or Scoliosis Orthoses, Ring Flange, Purchase $110.51L1110 Additions To Ctlso Or Scoliosis Orthoses, Ring Flange, Purchase $177.46L1120 Additions To Ctlso Or Sio, Scoliosis Orthoses, Covers F Purchase $29.81L1200 Thoracic-Lumbar-Sacal-Orthoses (Tlso), Inclusive Of Fur Purchase $1,557.65L1210 Additions To Tlso, (Low Profile) Lateral Thoracic Exten Purchase $289.22L1220 Additions To Tlso, (Low Profile) Anterior Thoracic Exte Purchase $191.50L1230 Additions To Tlso, (Low Profile) Milwaukee Type Superst Purchase $524.98L1240 Addition To Tlso (Low Profile), Lumbar Derotation Pad Purchase $64.37L1250 Addition To Tlso (Low Profile), Anterior Asis Pad Purchase $59.90L1260 Addition To Tlso (Low Profile), Anterior Thoracic Derot Purchase $62.71L1270 Addition To Tlso (Low Profile), Abdominal Pad Purchase $53.84L1280 Addition To Tlso (Low Profile), Rib Gusset (Elastic), E Purchase $71.52L1290 Addition To Tlso (Low Profile), Lateral Trochanteric Pa Purchase $65.16L1300 Other Scoliosis Procedures, Body Jacket Molded To Patie Purchase $1,720.94L1310 Other Scoliosis Procedures, Post-Operative Body Jacket Purchase $1,527.36L1499 Unlisted Procedure For Spinal Orthosis Purchase 75% of MSRPL1600 Hip Orthoses (Ho), Abduction Control Of Hip Joints, Fle Purchase $91.58L1610 Ho, Abduction Control Of Hip Joints, Flexible, Frejka C Purchase $30.49L1620 Ho, Abduction Control Of Hip Joints, Flexible, Pavlik H Purchase $111.07L1630 Ho, Abduction Control Of Hip Joints, Semi-Flexible (Von Purchase $117.74L1640 Ho, Abduction Control Of Hip Joints, Static, Pelvic Ban Purchase $393.36L1650 Ho, Abduction Control Of Hip Joints, Static, Adjustable Purchase $181.25L1652 Ho Bi Thighcuffs W Sprdr Bar Purchase $330.50L1660 Ho, Abduction Control Of Hip Joints, Static, Plastic, C Purchase $141.88L1680 Ho, Abduction Control Of Hip Joints, Dynamic, Pelvic Co Purchase $846.57L1685 Ho, Abduction Control Of Hip Joints, Post-Operative Hip Purchase $826.48L1686 Ho, Abduction Control Of Hip Joint, Post-Operative Hip Purchase $852.32L1690 Combination Bilateral Ho Purchase $1,792.87L1700 Legg Perthes Orthosis, Toronto Type Purchase $1,061.05L1710 Legg Perthes Orthosis, Newington Type Purchase $1,242.09L1720 Legg Perthes Orthosis, Trilateral, (Tachdijan Type) Purchase $915.58L1730 Legg Perthes Orthosis, Scottish Rite Type Purchase $787.70L1755 Legg Perthes Orthosis, Patten Bottom Type Purchase $1,100.06L1810 Ko, Elastic With Joints Purchase $83.70L1812 Ko Elastic W/Joints Pre Ots Purchase $87.44L1820 Ko, Elastic With Condyle Pads And Joints Purchase $117.56L1830 Ko, Immobilizer; Canvas Longitudinal Purchase $76.59L1831 Knee Orth Pos Locking Joint Purchase $272.88L1832 Ko, Adjustable Knee Joints, Positional Orthosis, Rigid Purchase $504.01L1833 Ko Adj Jnt Pos R Sup Pre Ots Purchase $526.56L1834 Ko, Without Knee Joint, Rigid, Molded To Patient Model Purchase $569.74L1836 Rigid Ko Wo Joints Purchase $123.73L1840 Ko, Derotation, Fabricated To Patient Model (Lennox Hil Purchase $638.87L1843 Ko Single Upright Custom Fit Purchase $831.92L1844 Ko W/Adj Jt Rot Cntrl Molded Purchase $1,247.18L1845 Ko, Double Upright, Thigh And Calf, With Adjustable Fle Purchase $699.83L1846 Ko, Double Upright, Thigh And Calf, With Adjustable Fle Purchase $737.70L1847 Ko Adjustable W Air Chambers Purchase $533.26L1848 Ko Dbl Upright W/Air Pre Ots Purchase $538.61



L1850 Ko, Swedish Type Purchase $227.77L1851 Ko Single Upright Prefab Ots Purchase $804.25L1852 Ko Double Upright Prefab Ots Purchase $699.83L1860 Ko, Modification Of Supracondylar Prosthetic Socket, Mo Purchase $745.57L1900 Ankle-Foot Orthoses (Afo), Spring Wire, Dorsiflexion As Purchase $204.39L1902 Afo Ankle Gauntlet Pre Ots Purchase $66.18L1904 Afo Molded Ankle Gauntlet Purchase $326.73L1906 Afo Multilig Ank Sup Pre Ots Purchase $132.93L1907 Afo Supramalleolar Custom Purchase $521.69L1910 Afo, Posterior, Single Bar, Clasp Attachment To Shoe Co Purchase $187.86L1920 Afo, Single Upright With Static Or Adjustable Stop (Phe Purchase $305.52L1930 Afo, Custom Fitted, Plastic Purchase $214.04L1932 Afo Rig Ant Tib Prefab Tcf/= Purchase $827.32L1940 Afo, Molded To Patient Model, Plastic Purchase $409.99L1945 Afo, Molded To Patient Model, Plastic, Rigid Anterior T Purchase $789.61L1950 Afo, Spiral, Molded To Patient Model (Irm Type), Plasti Purchase $559.93L1951 Afo Spiral Prefabricated Purchase $778.66L1960 Afo, Posterior Solid Ankle, Molded To Patient Model, Pl Purchase $459.51L1970 Afo, Plastic Molded To Patient Model, With Ankle Joint Purchase $619.73L1971 Afo W/Ankle Joint, Prefab Purchase $434.59L1980 Afo, Single Upright Free Plantar Dorsiflexion, Solid St Purchase $274.94L1990 Afo, Double Upright Free Plantar Dorsiflexion, Solid St Purchase $309.72L2000 Knee-Ankle-Foot-Orthoses (Kafo), Single Upright, Free K Purchase $730.16L2005 Kafo Sng/Dbl Mechanical Act Purchase $3,806.86L2010 Kafo, Single Upright, Free Knee, Free Ankle, Solid Stir Purchase $896.86L2020 Kafo, Double Upright, Free Knee, Free Ankle, Solid Stir Purchase $811.29L2030 Kafo, Double Upright, Free Knee, Free Ankle, Solid Stir Purchase $703.87L2034 Kafo Pla Sin Up W/Wo K/A Cus Purchase $1,929.66L2035 Kafo Plastic Pediatric Size Purchase $160.60L2036 Kafo, Full Plastic, Molded To Patient Model Purchase $1,688.37L2037 Kafo, Full Plastic, Single Upright, Free Knee, Molded T Purchase $1,380.79L2038 Kafo, Full Plastic, Without Knee Joint, Multi-Axis Ankl Purchase $993.39L2040 Hip-Knee-Ankle-Foot Orthoses Torsion Control, Bilateral Purchase $191.25L2050 Hkafo, Torsion Control, Bilateral Torsion Cables, Hip J Purchase $366.21L2060 Hkafo, Torsion Control, Bilateral Torsion Cables, Ball Purchase $411.22L2070 Hkafo, Torsion Control, Unilateral Rotation Straps, Pel Purchase $93.43L2080 Hkafo, Torsion Control, Unilateral, Torsion Cable, Hip Purchase $298.18L2090 Hkafo, Torsion Control Unilateral Torsion Cable, Ball B Purchase $338.71L2106 Afo, Fracture Orthosis, Tibial Fracture Cast Orthosis, Purchase $472.42L2108 Afo, Fracture Orthosis, Tibial Fracture Cast Orthosis, Purchase $845.37L2112 Afo, Fracture Orthosis, Tibial Fracture Orthosis, Soft Purchase $324.18L2114 Afo, Fracture Orthosis, Tibial Fracture Orthosis, Semi- Purchase $406.61L2116 Afo, Fracture Orthosis, Tibial Fracture Orthosis, Rigid Purchase $590.17L2126 Kafo, Fracture Orthosis, Femoral Fracture Cast Orthosis Purchase $934.32L2128 Kafo, Fracture Orthosis, Femoral Fracture Cast Orthosis Purchase $1,191.42L2132 Kafo, Fracture Orthosis, Femoral Fracture Cast Orthosis Purchase $724.72L2134 Kafo, Fracture Orthosis, Femoral Fracture Cast Orthosis Purchase $672.00L2136 Kafo, Fracture Orthosis, Femoral Fracture Cast Orthosis Purchase $923.57L2180 Addition To Lower Extremity Fracture Orthosis, Plastic Purchase $126.43L2182 Addition To Lower Extremity Fracture Orthosis, Drop Loc Purchase $80.90L2184 Addition To Lower Extremity Fracture Orthosis, Limited Purchase $94.29L2186 Addition To Lower Extremity Fracture Orthosis, Adjustab Purchase $125.25L2188 Addition To Lower Extremity Fracture Othosis, Quadrilat Purchase $208.11L2190 Addition To Lower Extremity Fracture Orthosis, Waist Be Purchase $62.83L2192 Addition To Lower Extremity Fracture Orthosis, Hip Join Purchase $247.74L2200 Additions To Lower Extremity, Limited Ankle Motion, Eac Purchase $52.55L2210 Additions To Lower Extremity, Dorsiflexion Assist (Plan Purchase $74.29L2220 Additions To Lower Extremity, Dorsiflexion And Plantar Purchase $87.96L2230 Additions To Lower Extremity, Split Flat Caliper Stirru Purchase $58.17



L2232 Rocker Bottom, Contact Afo Purchase $89.08L2240 Additions To Lower Extremity, Round Caliper And Plate A Purchase $58.12L2250 Additions To Lower Extremity, Foot Plate, Molded To Pat Purchase $292.27L2260 Additions To Lower Extremity, Reinforced Solid Stirrup Purchase $159.28L2265 Addition To Lower Extremity, Long Tongue Stirrup Purchase $81.82L2270 Additions To Lower Extremity, Varus/Valgus Correction ( Purchase $48.89L2275 Addition To Lower Extremity, Varus/Vulgus Correction, P Purchase $123.50L2280 Additions To Lower Extremity, Molded Inner Boot Purchase $375.38L2300 Additions To Lower Extremity, Adbuction Bar (Bilateral Purchase $223.20L2310 Additions To Lower Extremity, Abduction Bar-Straight Purchase $92.76L2320 Additions To Lower Extremity, Non-Molded Lacer Purchase $182.43L2330 Additions To Lower Extremity, Lacer Molded To Patient M Purchase $358.79L2335 Addition To Lower Extremity, Anterior Swing Band Purchase $165.63L2340 Additions To Lower Extremity, Pre-Tibial Shell, Molded Purchase $370.52L2350 Additions To Lower Extremity, Prosthetic Type, (Bk) Soc Purchase $723.13L2360 Additions To Lower Extremity, Extended Steel Shank Purchase $39.96L2370 Addition To Lower Extremity, Patten Bottom Purchase $178.36L2375 Addition To Lower Extremity, Torsion Control, Ankle Joi Purchase $78.51L2380 Addition To Lower Extremity, Torsion Control, Straight Purchase $114.07L2385 Addition To Lower Extremity, Straight Knee Joint, Heavy Purchase $148.05L2387 Add Le Poly Knee Custom Kafo Purchase $141.91L2390 Addition To Lower Extremity, Offset Knee Joint, Each Jo Purchase $101.42L2395 Addition To Lower Extremity, Offset Knee Joint, Heavy D Purchase $129.17L2397 Addition To Lower Extremity Orthosis, Suspension Sleeve Purchase $106.75L2405 Addition To Knee Joint, Drop Lock, Each Joint Purchase $78.13L2415 Addition To Knee Joint, Cam Lock (Swiss, French, Bail T Purchase $132.09L2425 Addition To Knee Joint, Disc Or Dial Lock For Adjustabl Purchase $151.18L2430 Knee Jnt Ratchet Lock Ea Jnt Purchase $93.02L2492 Addition To Knee Joint, Lift Loop For Drop Lock Ring Purchase $88.72L2500 Additions To Lower Extremity, Thigh/Weight Bearing, Gul Purchase $219.21L2510 Additions To Lower Extremity, Thigh/Weight Bearing, Qua Purchase $504.70L2520 Additions To Lower Extremity, Thigh/Weight Bearing, Qua Purchase $342.57L2525 Addition To Lower Extremity, Thigh/Weight Bearing, Isch Purchase $952.31L2526 Addition To Lower Extremity, Thigh/Weight Bearing, Isch Purchase $616.45L2530 Additions To Lower Extremity, Thigh-Weight Bearing, Lac Purchase $217.65L2540 Additions To Lower Extremity, Thigh/Weight Bearing, Lac Purchase $333.43L2550 Additions To Lower Extremity, Thigh/Weight Bearing, Hig Purchase $266.05L2570 Additions To Lower Extremity, Gluteal/Ischial Weight Be Purchase $330.94L2580 Additions To Lower Extremity, Gluteal/Ischial Weight Be Purchase $421.77L2600 Additions To Lower Extremity, Pelvic Control, Hip Joint Purchase $154.94L2610 Additions To Lower Extremity, Pelvic Control, Hip Joint Purchase $176.65L2620 Additions To Lower Extremity, Pelvic Control, Hip Joint Purchase $185.78L2622 Addition To Lower Extremity, Pelvic Control, Hip Joint, Purchase $213.08L2624 Addition To Lower Extremity, Pelvic Control, Hip Joint, Purchase $230.07L2627 Addition To Lower Extremity, Pelvic Control, Plastic, M Purchase $1,588.14L2628 Addition To Lower Extremity, Pelvic Control, Metal Fram Purchase $1,552.10L2630 Additions To Lower Extremity, Pelvic Control, Band And Purchase $229.41L2640 Additions To Lower Extremity, Pelvic Control, Band And Purchase $278.59L2650 Additions To Lower Extremity, Pelvic And Thoracic Contr Purchase $83.38L2660 Additions To Lower Extremity, Thoracic Control, Thoraci Purchase $172.67L2670 Additions To Lower Extremity, Thoracic Control, Paraspi Purchase $158.03L2680 Additions To Lower Extremity, Thoracic Control, Lateral Purchase $144.97L2750 Addition To Lower Extremity Orthoses, Plating Chrome Or Purchase $69.29L2755 Carbon Graphite Lamination Purchase $117.08L2760 Additions To Lower Extremity Orthoses, Extension, Per E Purchase $56.29L2768 Ortho Sidebar Disconnect Purchase $120.80L2780 Additions To Lower Extremity, Non-Corrosive Finish Purchase $56.11L2785 Addition To Lower Extremity Orthosis, Drop Lock Retaine Purchase $26.27L2795 Addition To Lower Extremity Orthosis, Knee Control, Ful Purchase $70.44



L2800 Addition To Lower Extremity Orthosis, Knee Control, Kne Purchase $81.27L2810 Addition To Lower Extremity Orthosis, Knee Control, Con Purchase $64.75L2820 Addition To Lower Extremity Orthosis, Soft Interface Fo Purchase $95.99L2830 Addition To Lower Extremity Orthosis, Soft Interface Fo Purchase $103.85L2840 Addition To Lower Extremity Orthosis, Tibial Length Soc Purchase $36.22L2850 Addition To Lower Extremity Orthosis, Femoral Length So Purchase $65.92L2999 Unlisted Procedures For Lower Extremity Orthoses Purchase 75% of MSRPL3000 Foot, Insert, Removable, Molded To Patient Model, "Ucb" Purchase $282.52L3001 Foot Insert, Removable-Molded To Patient Model, Spenco, Purchase $118.96L3002 Foot Insert, Removable-Molded To Patient Model, Plastaz Purchase $145.26L3003 Foot Insert, Removable-Molded To Patient Model, Silicon Purchase $156.73L3010 Foot, Insert, Removable, Molded To Patient Model, Longi Purchase $156.18L3020 Foot, Insert, Removable, Molded To Patient Model, Longi Purchase $178.43L3030 Foot, Insert, Removable, Formed To Patient Foot Purchase $68.63L3040 Foot, Arch Support, Removable, Premolded, Longitudinal, Purchase $42.33L3050 Foot, Arch Support, Removable, Premolded, Metatarsal, E Purchase $42.33L3060 Foot, Arch Support, Removable, Premolded, Longitudinal/ Purchase $27.81L3070 Foot, Arch Support, Nonremovable Attached To Shoe, Long Purchase $10.54L3080 Foot, Arch Support, Nonremovable Attached To Shoe, Meta Purchase $10.42L3090 Foot, Arch Support, Nonremovable Attached To Shoe, Long Purchase $36.61L3100 Hallus-Valgus Night Dynamic Splint Purchase $38.89L3140 Foot, Abduction Rotation Bars (Dennis Browne Type), Att Purchase $80.09L3150 Foot, Abduction Rotation Bars, (Dennis Browne Type), Cl Purchase $73.19L3170 Foot-Plastic Heel Stabilzer Purchase $10.24L3201 Orthopedic Shoe, Oxford With Supinator Or Pronator-Infa Purchase $70.94L3202 Orthopedic Shoe, Oxford With Supinator Or Pronator-Chil Purchase $88.41L3204 Orthopedic Shoe, Hightop With Supinator Or Pronator-Inf Purchase $91.68L3206 Orthopedic Shoe, Hightop With Supinator Or Pronator-Chi Purchase $61.99L3215 Orthropedic Footwear, Ladies Shoes, Oxford Purchase $84.96L3216 Orthropedic Footwear, Ladies Shoes, Depth Inlay Purchase $93.03L3219 Orthopedic Footwear, Mens Shoes-Oxford Purchase $113.39L3221 Orthopedic Footwear, Mens Shoes-Depth Inlay Purchase $118.25L3222 Orthopedic Footwear, Mens Shoes-Hightop-Depth Inlay Purchase $122.91L3224 Woman'S Shoe Oxford Brace Purchase $50.87L3225 Man'S Shoe Oxford Brace Purchase $67.88L3230 Orthopedic Footwear, Custom Shoes Depth Inlay Purchase $97.82L3252 Foot-Shoe Molded To Patient Model-Plastazote %Or Simila Purchase $369.81L3253 Foot-Molded Shoe Plastazote %Or Similar< Custom Fitted, Purchase $53.23L3257 Orthopedic Footwear, Additional Charge For Split Size Purchase $194.52L3260 Ambulatory Surgical Boot-Each Purchase $17.98L3265 Plastazote Sandal-Each Purchase $33.50L3300 Lifts-Elevation, Heel, Tapered To Metatarsals, Per Inch Purchase $9.59L3310 Lifts-Elevation, Heel And Sole, Neoprene, Per Inch Purchase $72.95L3320 Lifts-Elevation, Heel And Sole, Cork, Per Inch Purchase $101.86L3330 Lifts-Elevation, Metal Extension *Skate* Purchase $459.97L3332 Lifts-Elevation, Inside Shoe, Tapered, Up To One-Half I Purchase $66.12L3334 Lifts-Elevation, Heel, Per Inch Purchase $22.24L3340 Heel Wedge, Sach Purchase $35.12L3350 Heel Wedge Purchase $9.08L3360 Sole Wedge-Outside Sole Purchase $32.02L3370 Sole Wedge-Between Sole Purchase $19.90L3380 Clubfoot Wedge Purchase $44.61L3390 Outflare Wedge Purchase $47.18L3400 Metatarsal Bar Wedge-Rocker Purchase $36.47L3410 Metatarsal Bar Wedge-Between Sole Purchase $11.71L3420 Full Sole And Heel Wedge *Between Sole* Purchase $12.88L3430 Heel, Counter, Plastic Reinforced Purchase $144.14L3440 Heel-Counter, Leather Reinforced Purchase $68.63L3450 Heel-Sach Cushion Type Purchase $11.96



L3455 Heel-New Leather, Standard Purchase $6.43L3460 Heel-New Rubber, Standard Purchase $5.91L3465 Heel-Thomas With Wedge Purchase $52.64L3470 Heel-Thomas Extended To Ball Purchase $56.06L3480 Heel-Pad And Depression For Spur Purchase $5.76L3485 Heel-Pad, Removable For Spur Purchase $11.51L3500 Miscellaneous Shoe Additions, Insole-Leather Purchase $26.30L3510 Miscellaneous Shoe Additions, Insole Rubber Purchase $8.19L3520 Miscellaneous Shoe Additions, Insole-Felt Covered With Purchase $28.59L3530 Miscellaneous Shoe Additions, Sole-Half Purchase $28.59L3540 Miscellaneous Shoe Additions, Sole-Full Purchase $14.05L3550 Miscellaneous Shoe Additions, Toe Tap-Standard Purchase $8.02L3560 Miscellaneous Shoe Additions, Toe Tap-Horseshoe Purchase $20.55L3570 Miscellaneous Shoe Additions, Special Extension To Inst Purchase $76.65L3580 Miscellaneous Shoe Additions, Convert Instep To Velco C Purchase $7.14L3590 Miscellaneous Shoe Additions, Convert Firm Shoe Counter Purchase $48.07L3595 Miscellaneous Shoe Additions, March Bar Purchase $37.74L3600 Transfers Of An Orthosis From One Shoe To Another, Cali Purchase $23.40L3610 Transfers Of An Orthosis From One Shoe To Another, Cali Purchase $55.17L3620 Transfers Of An Orthosis From One Shoe To Another, Soli Purchase $54.15L3630 Transfers Of An Orthosis From One Shoe To Another, Soli Purchase $54.66L3640 Transfers Of An Orthosis From One Shoe To Another, Denn Purchase $55.17L3650 Shoulder Orthoses, (So), Figure Of "8" Design Abduction Purchase $48.11L3660 So, Figure Of "8" Design Abduction Restrainer, Canvas A Purchase $108.83L3670 So, Acromio/Clavicular (Canvas And Webbing Type) Purchase $91.73L3671 So Cap Design W/O Jnts Cf Purchase $760.31L3674 So Airplane W/Wo Joint Cf Purchase $997.44L3675 Canvas Vest So Purchase $148.07L3702 Eo W/O Joints Cf Purchase $243.65L3710 Eo, Elastic With Metal Joints Purchase $84.05L3720 Eo, Double Upright With Forearm/Arm Cuffs, Free Motion Purchase $530.61L3730 Eo, Double Upright With Forearm/Arm Cuffs, Extension/ F Purchase $731.28L3740 Eo, Double Upright With Forearm/Arm Cuffs, Adjustable P Purchase $866.99L3760 Eo Withjoint, Prefabricated Purchase $213.36L3762 Rigid Eo Wo Joints Purchase $87.70L3763 Ewho Rigid W/O Jnts Cf Purchase $566.81L3764 Ewho W/Joint(S) Cf Purchase $647.92L3765 Ewhfo Rigid W/O Jnts Cf Purchase $1,081.96L3766 Ewhfo W/Joint(S) Cf Purchase $1,145.72L3806 Whfo W/Joint(S) Custom Fab Purchase $383.30L3807 Whfo W Inflatable Airchamber Purchase $203.95L3808 Whfo, Rigid W/O Joints Purchase $306.23L3809 Whfo W/O Joints Pre Ots Purchase $213.08L3900 Whfo, Dynamic Flexor Hinge; Reciprocal Wrist Extension Purchase $879.76L3901 Whfo, Dynamic Flexor Hinge; Reciprocal Wrist Extension Purchase $1,399.94L3904 Whfo, External Powered, Electric Purchase $2,654.78L3905 Who W/Nontorsion Jnt(S) Cf Purchase $836.79L3906 Wrist Gauntlet Molded To Pt Purchase $331.75L3908 Whfo, Wrist Extension Control (Cock-Up), Canvas Or Leat Purchase $48.60L3912 Flex Glove W/Elastic Finger Purchase $76.93L3913 Hfo W/O Joints Cf Purchase $228.53L3915 Who W Nontor Jnt(S) Prefab Purchase $58.28L3916 Who Nontorsion Jnts Pre Ots Purchase $453.04L3917 Prefab Metacarpl Fx Orthosis Purchase $89.12L3918 Metacarp Fx Orthosis Pre Ots Purchase $90.00L3919 Ho W/O Joints Cf Purchase $228.53L3921 Hfo W/Joint(S) Cf Purchase $271.01L3923 Hfo, No Joint, Prefabricated Purchase $70.57L3924 Hfo Without Joints Pre Ots Purchase $73.73



L3925 Fo Pip/Dip With Joint/Spring Purchase $41.41L3927 Fo Pip/Dip W/O Joint/Spring Purchase $29.51L3929 Hfo Nontorsion Joint, Prefab Purchase $65.59L3930 Hfo Nontorsion Jnts Pre Ots Purchase $66.26L3931 Whfo Nontorsion Joint Prefab Purchase $162.03L3933 Fo W/O Joints Cf Purchase $180.04L3935 Fo Nontorsion Joint Cf Purchase $186.45L3960 Shoulder-Elbow-Wrist-Hand Orthoses, (Sewho), Abduction Purchase $499.67L3961 Sewho Cap Design W/O Jnts Cf Purchase $1,417.69L3962 Sewho, Abduction Positioning, Erbs Palsey Design Purchase $487.84L3967 Sewho Airplane W/O Jnts Cf Purchase $1,673.81L3971 Sewho Cap Design W/Jnt(S) Cf Purchase $1,588.80L3973 Sewho Airplane W/Jnt(S) Cf Purchase $1,673.81L3975 Sewhfo Cap Design W/O Jnt Cf Purchase $1,417.69L3976 Sewhfo Airplane W/O Jnts Cf Purchase $1,417.69L3977 Sewhfo Cap Desgn W/Jnt(S) Cf Purchase $1,588.80L3978 Sewhfo Airplane W/Jnt(S) Cf Purchase $1,673.81L3980 Up Ext Fx Orthos Humeral Nos Purchase $250.78L3981 Ue Fx Orth Shoul Cap Forearm Purchase $847.06L3982 Upper Extremity Fracture Orthosis, Radius/Ulner Purchase $310.08L3984 Upper Extremity Fracture Orthosis, Wrist Purchase $320.83L3995 Addition To Upper Extremity Orthosis, Sock, Fracture Or Purchase $26.53L3999 Unlisted Procedures For Upper Limb Orthosis Purchase 75% of MSRPL4000 Replace Girdle For Milwaukee Orthosis Purchase $1,004.73L4002 Replace Strap, Any Orthosis Purchase $35.65L4010 Replace Trilateral Socket Brim Purchase $505.47L4020 Replace Quadrilateral Socket Brim, Molded To Patient Mo Purchase $598.47L4030 Replace Quadrilateral Socket Brim, Custom Fitted Purchase $350.79L4040 Replace Molded Thigh Lacer Purchase $296.06L4045 Replace Non-Molded Thigh Lacer Purchase $274.33L4050 Replace Molded Calf Lacer Purchase $286.85L4055 Replace Non-Molded Calf Lacer Purchase $185.75L4060 Replace High Roll Cuff Purchase $294.40L4070 Replace Proximal And Distal Upright For Ako Purchase $195.56L4080 Replace Metal Bands Kafo-Afo, Proximal Thigh Purchase $70.27L4090 Replace Metal Bands Kafo-Afo, Calf Or Distal Thigh Purchase $62.73L4100 Replace Metal Bands Kafo-Afo, Proximal Thigh Purchase $72.47L4110 Replace Leather Cuff Kafo-Afo, Calf Or Distal Thigh Purchase $59.71L4130 Replace Pretibial Shell Purchase $396.17L4205 Ortho Dvc Repair Per 15 Min Purchase $28.83L4210 Repair Of Orthotic Device, Repair Or Replace Minor Part Purchase $41.33L4350 Pneumatic Ankle Control Splint (Aircast Or Equal) Purchase $74.11L4360 Pneumatic Walking Splint (Aircast Or Equal) Purchase $247.70L4361 Pneuma/Vac Walk Boot Pre Ots Purchase $258.79L4370 Pneumatic Full Leg Splint (Aircast Or Equal) Purchase $171.66L4386 Non-Pneumatic Walking Splint Purchase $142.10L4387 Non-Pneum Walk Boot Pre Ots Purchase $148.46L4392 Replace Ankle Contrac Splint Purchase $21.42L4394 Replace Foot Drop Spint Purchase $15.65L4396 Ankle Contracture Splint Purchase $147.71L4397 Static Or Dynami Afo Pre Ots Purchase $154.32L4398 Foot Drop Splint Recumbent Purchase $70.36L4631 Afo, Walk Boot Type, Cus Fab Purchase $1,276.12L5000 Partial Foot, Shoe Insert With Longitudinal Arch, Toe F Purchase $446.24L5010 Partial Foot, Molded Socket, Ankle Height, With Toe Fil Purchase $988.66L5020 Partial Foot, Molded Socket, Tibial Tubercle Height, Wi Purchase $2,069.67L5050 Ankle, Symes, Molded Socket, Sach Foot Purchase $1,842.92L5060 Ankle, Symes, Metal Frame, Molded Leather Socket, Artic Purchase $2,497.92L5100 Below Knee, Molded Socket, Shin, Sach Foot Purchase $1,720.43



L5105 Below Knee, Plastic Socket, Joints And Thigh Lacer, Sac Purchase $2,821.00L5150 Knee Disarticulation (Or Through Knee), Molded Socket, Purchase $2,879.23L5160 Knee Disarticulation (Or Through Knee), Molded Socket, Purchase $3,170.83L5200 Above Knee, Molded Socket, Single Axis Constant Frictio Purchase $2,445.38L5210 Above Knee, Short Prosthesis, No Knee Joint ("Stubbies" Purchase $1,936.13L5220 Above Knee, Short Prosthesis, No Knee Joint ("Stubbies" Purchase $2,230.89L5230 Above Knee, For Proximal Femoral Focal Deficiency, Cons Purchase $3,754.67L5250 Hip Disarticulation, Canadian Type; Molded Socket, Hip Purchase $4,824.40L5270 Hip Disarticulation, Tilt Table Type; Molded Socket, L Purchase $4,400.78L5280 Hemipelvectomy, Canadian Type; Molded Socket, Hip Join Purchase $4,998.89L5301 Bk Mold Socket Sach Ft Endo Purchase $2,151.96L5312 Knee Disart, Sach Ft, Endo Purchase $3,331.92L5321 Ak Open End Sach Purchase $3,138.62L5331 Hip Disart Canadian Sach Ft Purchase $5,160.30L5341 Hemipelvectomy Canadian Sach Purchase $5,503.62L5400 Immediate Post Surgical Or Early Fitting, Application O Purchase $908.47L5410 Immediate Post Surgical Or Early Fitting, Application O Purchase $309.29L5420 Immediate Post Surgical Or Early Fitting, Application O Purchase $1,265.42L5430 Immediate Post Surgical Or Early Fitting, Application O Purchase $372.49L5450 Immediate Post Surgical Or Early Fitting, Application O Purchase $362.67L5460 Immediate Post Surgical Or Early Fitting, Application O Purchase $424.77L5500 Init Bk Ptb Plaster Direct Purchase $1,252.40L5505 Init Ak Ischal Plstr Direct Purchase $1,457.81L5510 Prep Bk Ptb Plaster Molded Purchase $1,247.84L5520 Perp Bk Ptb Thermopls Direct Purchase $1,064.49L5530 Prep Bk Ptb Thermopls Molded Purchase $1,400.92L5535 Prep Bk Ptb Open End Socket Purchase $1,255.31L5540 Prep Bk Ptb Laminated Socket Purchase $1,794.08L5560 Prep Ak Ischial Plast Molded Purchase $1,757.90L5570 Prep Ak Ischial Direct Form Purchase $1,902.38L5580 Prep Ak Ischial Thermo Mold Purchase $2,136.82L5585 Prep Ak Ischial Open End Purchase $2,142.42L5590 Prep Ak Ischial Laminated Purchase $2,711.56L5595 Preparatory, Hip Disarticulation-Hemipelvectomy, Pylon, Purchase $2,980.57L5600 Preparatory, Hip Disarticulation-Hemipelvectomy, Pylon, Purchase $3,291.43L5610 Additions To Lower Extremity, Above Knee, Hydracadence Purchase $1,984.73L5611 Addition To Lower Extremity, Above Knee-Knee Disarticul Purchase $1,897.34L5613 Addition To Lower Extremity, Above Knee-Knee Disarticul Purchase $2,274.25L5614 Add. To Lower Ext. Above Knee, Disartic.,4-Bar Link Purchase $3,229.33L5616 Additions To Lower Extremity, Above Knee, Universal Mul Purchase $1,320.11L5617 Ak/Bk Self-Aligning Unit Ea Purchase $475.49L5618 Additions To Lower Extremity, Test Socket, Symes Purchase $208.18L5620 Additions To Lower Extremity, Test Socket, Below Knee Purchase $245.55L5622 Additions To Lower Extremity, Test Socket, Knee Disarti Purchase $268.37L5624 Additions To Lower Extremity, Test Socket, Above Knee Purchase $322.09L5626 Additions To Lower Extremity, Test Socket, Hip Disartic Purchase $352.93L5628 Additions To Lower Extremity, Test Socket, Hemipelvecto Purchase $357.41L5629 Addition To Lower Extremity, Below Knee, Acrylic Socket Purchase $280.68L5630 Additions To Lower Extremity, Symes Type, Expandable Wa Purchase $362.79L5631 Addition To Lower Extremity, Above Knee Or Knee Disarti Purchase $388.06L5632 Additions To Lower Extremity, Symes Type, "Ptb" Brim De Purchase $202.05L5634 Additions To Lower Extremity, Symes Type, Posterior Ope Purchase $300.21L5636 Additions To Lower Extremity, Symes Type, Medial Openin Purchase $251.49L5637 Addition To Lower Extremity, Below Knee, Total Contact Purchase $255.15L5638 Additions To Lower Extremity, Below Knee, Leather Socke Purchase $480.32L5639 Addition To Lower Extremity, Below Knee, Wood Socket Purchase $1,106.60L5640 Additions To Lower Extremity, Knee Disarticulation, Lea Purchase $631.10L5642 Additions To Lower Extremity, Above Knee, Leather Socke Purchase $611.50L5643 Addition To Lower Extremity, Hip Disarticulation, Flexi Purchase $1,536.19



L5644 Additions To Lower Extremity, Above Knee, Wood Socket Purchase $582.95L5645 Addition To Lower Extremity, Below Knee, Flexible Inner Purchase $939.61L5646 Additions To Lower Extremity, Below Knee, Air Cushion S Purchase $525.33L5647 Addition To Lower Extremity, Below Knee Suction Socket Purchase $857.80L5648 Additions To Lower Extremity, Above Knee, Air Cushion S Purchase $649.81L5649 Addition To Lower Extremity, Cat-Cam Socket Purchase $1,872.39L5650 Additions To Lower Extremity, Total Contact, Above Knee Purchase $574.89L5651 Addition To Lower Extremity, Above Knee, Flexible Inner Purchase $1,414.22L5652 Additions To Lower Extremity, Suction Suspension, Above Purchase $430.30L5653 Additions To Lower Extremity, Knee Disarticulation, Exp Purchase $574.42L5654 Additions To Lower Extremity, Socket Insert, Symes, (Ke Purchase $246.79L5655 Additions To Lower Extremity, Socket Insert, Below Knee Purchase $196.34L5656 Additions To Lower Extremity, Socket Insert, Knee Disar Purchase $283.37L5658 Additions To Lower Extremity, Socket Insert, Above Knee Purchase $308.52L5661 Addition To Lower Extremity, Socket Insert, Multi-Durom Purchase $450.45L5665 Addition To Lower Extremity, Socket Insert, Multi-Durom Purchase $379.02L5666 Additions To Lower Extremity, Below Knee, Cuff Suspensi Purchase $51.82L5668 Bk Molded Distal Cushion Purchase $89.19L5670 Additions To Lower Extremity, Below Knee, Molded Suprec Purchase $267.81L5671 Bk/Ak Locking Mechanism Purchase $585.75L5672 Additions To Lower Extremity, Below Knee, Removable Med Purchase $294.30L5673 Socket Insert W Lock Mech Purchase $669.19L5676 Additions To Lower Extremity, Below Knee, Knee Joints, Purchase $331.76L5677 Additions To Lower Extremity, Below Knee, Knee Joints, Purchase $364.98L5678 Additions To Lower Extremity, Below Knee, Joints Covers Purchase $38.27L5679 Socket Insert W/O Lock Mech Purchase $557.63L5680 Additions To Lower Extremity, Below Knee, Thigh Lacer, Purchase $275.07L5681 Intl Custm Cong/Latyp Insert Purchase $1,224.42L5682 Additions To Lower Extremity, Below Knee, Thigh Lacer, Purchase $462.95L5683 Initial Custom Socket Insert Purchase $1,224.42L5684 Additions To Lower Extremity, Below Knee, Fork Strap Purchase $36.34L5685 Below Knee Sus/Seal Sleeve Purchase $118.99L5686 Additions To Lower Extremity, Below Knee, Back Check (E Purchase $44.68L5688 Additions To Lower Extremity, Below Knee, Waist Belt, W Purchase $45.20L5690 Additions To Lower Extremity, Below Knee, Waist Belt, P Purchase $72.43L5692 Additions To Lower Extremity, Above Knee, Pelvic Contro Purchase $101.80L5694 Additions To Lower Extremity, Above Knee, Pelvic Contro Purchase $149.71L5695 Addition To Lower Extremity, Above Knee, Pelvic Control Purchase $146.75L5696 Additions To Lower Extremity, Above Knee Or Knee Disart Purchase $136.97L5697 Additions To Lower Extremity, Above Knee Or Knee Disart Purchase $64.74L5698 Additions To Lower Extremity, Above Knee Or Knee Disart Purchase $77.21L5699 All Lower Extremity Prosthesis, Shoulder Harness Purchase $138.01L5700 Repl. Socket, Below Knee, Molded To Patient Model Purchase $2,506.21L5701 Repl. Socket, Above Knee Disarticulation, Inc. Attachme Purchase $2,803.57L5702 Repl. Socket, Hip Disarticulation, Incl. Hip Join, Mold Purchase $3,864.15L5703 Symes Ankle W/O (Sach) Foot Purchase $2,067.05L5704 Repl. Custom Shaped Protective Cover, Below Knee Purchase $523.00L5705 Replacement, Custom Shaped Protective Cover, Above Knee Purchase $744.28L5706 Repl. Custom Shaped Protective Cover, Knee Disarticulat Purchase $734.38L5707 Repl. Custom Shaped Proctective Cover Hip Disarticulati Purchase $1,013.22L5710 Additions, Knee-Shin System, Single Axis, Manual Lock Purchase $314.16L5711 Additions Exoskeletal Knee-Shin System, Single Axis, Ma Purchase $386.51L5712 Additions, Knee-Shin System, Single Axis, Friction Swin Purchase $318.98L5714 Additions, Knee-Shin System, Single Axis, Variable Fric Purchase $375.70L5716 Additions, Knee-Shin System, Polycentric, Mechanical St Purchase $719.34L5718 Additions, Knee-Shin System, Polycentric, Friction Swin Purchase $899.10L5722 Additions, Knee-Shin System, Single Axis, Pneumatic Swi Purchase $743.53L5724 Additions, Knee-Shin System, Single Axis, Fluid Swing P Purchase $1,167.81L5726 Additions, Knee-Shin System, Single Axis, External Join Purchase $1,287.69



L5728 Additions, Knee-Shin System, Single Axis, Fluid Swing A Purchase $2,120.25L5780 Additions, Knee-Shin System, Single Axis, Pneumatic/Hyd Purchase $850.77L5781 Lower Limb Pros Vacuum Pump Purchase $3,716.99L5782 Hd Low Limb Pros Vacuum Pump Purchase $3,918.55L5785 Addition, Exoskeletal System, Below Knee, Ultra-Light M Purchase $384.58L5790 Addition, Exoskeletal System, Above Knee, Ultra-Light M Purchase $532.25L5795 Addition, Exoskeletal System, Hip Disarticulation, Ultr Purchase $794.79L5810 Addition, Endoskeletal Knee-Shin System, Single Axis, M Purchase $400.12L5811 Addition, Endoskeletal Knee-Shin System, Single Axis, M Purchase $699.30L5812 Addition, Endoskeletal Knee-Shin System, Single Axis, F Purchase $514.76L5814 Endo Knee-Shin Hydral Swg Ph Purchase $3,450.09L5816 Addition, Endoskeletal Knee-Shin System, Polycentric, M Purchase $839.37L5818 Addition, Endoskeletal Knee-Shin System, Polycentric, F Purchase $947.84L5822 Addition, Endoskeletal Knee-Shin System, Single Axis, P Purchase $1,394.21L5824 Addition, Endoskeletal Knee-Shin System, Single Axis, F Purchase $1,513.60L5826 Miniature Knee Joint Purchase $2,901.12L5828 Addition, Endoskeletal Knee-Shin System, Single Axis, F Purchase $2,804.67L5830 Addition, Endoskeletal Knee-Shin System, Single Axis, P Purchase $1,404.63L5840 Addition, Endoskeletal Knee/Shin System, Multiaxial, Pn Purchase $2,094.32L5845 Knee-Shin Sys Stance Flexion Purchase $1,665.05L5848 Knee-Shin Sys Hydraul Stance Purchase $998.93L5850 Addition, Endoskeletal System, Above Knee Or Hip Disart Purchase $150.65L5855 Addition, Endoskeletal System, Hip Disarticulation, Mec Purchase $303.06L5856 Elec Knee-Shin Swing/Stance Purchase $22,284.93L5857 Elec Knee-Shin Swing Only Purchase $7,897.44L5858 Stance Phase Only Purchase $17,265.07L5910 Addition, Endoskeletal System, Below Knee, Alignable Sy Purchase $426.50L5920 Addition, Endoskeletal System, Above Knee Or Hip Disart Purchase $620.54L5925 Addition, Endoskeletal System, Above Knee, Knee Disarti Purchase $395.69L5930 High Activity Knee Frame Purchase $3,117.08L5940 Addition, Endoskeletal System, Below Knee, Ultra-Light Purchase $590.70L5950 Addition, Endoskeletal System, Above Knee, Ultra-Light Purchase $713.96L5960 Addition, Endoskeletal System, Hip Disarticulation, Ult Purchase $713.62L5961 Endo Poly Hip, Pneu/Hyd/Rot Purchase $4,684.37L5962 Addition, Endoskeletal System, Below Knee, Flexible Pro Purchase $554.32L5964 Addition, Endoskeletal System, Above Knee, Flexible Pro Purchase $783.34L5966 Addition, Endoskeletal System, Hip Disarticulation, Fle Purchase $996.12L5968 Multiaxial Shck Absorb Ankle Purchase $3,375.80L5969 Ak/Ft Power Asst Incl Motors Purchase $13,613.51L5970 All Lower Extremity Prostheses, Foot, External Keel, Sa Purchase $168.08L5971 Sach Foot, Replacement Purchase $207.44L5972 All Lower Extremity Prostheses, Flexible Keel Foot (Saf Purchase $388.83L5973 Ank-Foot Sys Dors-Plant Flex Purchase $16,202.16L5974 All Lower Extremity Prostheses, Foot, Single Axis Ankle Purchase $208.70L5975 Combo Ankle/Foot Prosthesis Purchase $430.68L5976 All Lower Extremity Prostheses, Energy Storing Foot (Se Purchase $534.03L5978 All Lower Extremity Prostheses, Foot, Multiaxial Ankle/ Purchase $216.02L5979 All Lower Extremity Prostheses, Multiaxial Ankle/Foot, Purchase $2,044.56L5980 All Lower Extremity Prostheses, Flex Foot System Purchase $3,659.45L5981 All Lower Extremity Prostheses, Flex-Walk System Or Equ Purchase $2,853.24L5982 All Exoskeletal Lower Extremity Prostheses, Axial Rotat Purchase $570.57L5984 All Endoskeletal Lower Extremity Prostheses, Axial Rota Purchase $446.51L5985 Lwr Ext Dynamic Prosth Pylon Purchase $261.49L5986 All Lower Extremity Prostheses, Multi-Axial Rotation Un Purchase $746.24L5987 Shank Ft W Vert Load Pylon Purchase $6,682.79L5988 Verticalshock/Rotation Pylon Purchase $1,855.77L5990 User Adjustable Heel Height Purchase $1,685.35L6000 Partial Hand, Robin-Aids, Thumb Remaining (Or Equal) Purchase $983.55L6010 Partial Hand, Robin-Aids, Little And/Or Ring Finger Rem Purchase $1,165.30



L6020 Partial Hand, Robin-Aids, No Finger Remaining (Or Equal Purchase $1,037.39L6026 Part Hand Myo Exclu Term Dev Purchase $4,331.02L6050 Wrist Disarticulation, Molded Socket, Flexible Elbow Hi Purchase $1,513.23L6055 Wrist Disarticulation, Molded Socket With Expandable In Purchase $2,095.05L6100 Below Elbow, Molded Socket, Flexible Elbow Hinge, Trice Purchase $1,497.83L6110 Below Elbow, Molded Socket, (Muenster Or Northwestern S Purchase $1,545.81L6120 Below Elbow, Molded Double Wall Split Socket, Step-Up H Purchase $1,940.81L6130 Below Elbow, Molded Double Wall Split Socket, Stump Act Purchase $1,951.73L6200 Elbow Disarticulation, Molded Socket, Outside Locking H Purchase $2,257.16L6205 Elbow Disarticulation, Molded Socket With Expandable In Purchase $2,764.52L6250 Above Elbow, Molded Double Wall Socket, Internal Lockin Purchase $2,009.66L6300 Shoulder Disarticulation, Molded Socket, Shoulder Bulkh Purchase $2,946.80L6310 Shoulder Disarticulation, Passive Restoration (Complete Purchase $2,246.33L6320 Shoulder Disarticulation, Passive Restoration (Shoulder Purchase $1,348.62L6350 Interscapular Thoracic, Molded Socket, Shoulder Bulkhea Purchase $3,385.90L6360 Intersacpular Thoracic, Passive Restoration (Complete P Purchase $2,357.80L6370 Interscapular Thoracic, Passive Restoration (Shoulder C Purchase $1,503.49L6380 Immediate Post Surgical Or Early Fitting, Application O Purchase $861.96L6382 Immediate Post Surgical Or Early Fitting, Application O Purchase $1,171.56L6384 Immediate Post Surgical Or Early Fitting, Application O Purchase $1,624.63L6386 Immediate Post Surgical Or Early Fitting, Each Addition Purchase $297.25L6388 Immediate Post Surgical Or Early Fitting, Application O Purchase $374.25L6400 Below Elbow, Molded Socket, Endoskeletal System, Includ Purchase $2,290.18L6450 Elbow Disarticulation, Molded Socket, Endoskeletal Syst Purchase $3,042.96L6500 Above Elbow, Molded Socket, Endoskeletal System, Includ Purchase $2,992.40L6550 Shoulder Disaticulation, Molded Socket, Endoskeletal Sy Purchase $3,742.88L6570 Interscapular Thoracic, Molded Socket, Endoskeletal Sys Purchase $3,894.43L6580 Preparatory, Wrist Disarticulation Or Below Elbow, Sing Purchase $1,392.46L6582 Preparatory, Wrist Disarticulation Or Below Elbow, Sing Purchase $1,358.39L6584 Preparatory, Elbow Disarticulation Or Above Elbow, Sing Purchase $1,515.13L6586 Preparatory, Elbow Disarticulation Or Above Elbow, Sing Purchase $1,576.41L6588 Preparatory, Shoulder Disarticulation Or Interscapular Purchase $2,092.30L6590 Preparatory, Shoulder Disarticulation Or Interscapular Purchase $2,098.46L6600 Upper Extremity Additions, Polycentric Hinge, Pair Purchase $138.85L6605 Upper Extremity Additions, Single Pivot Hinge, Pair Purchase $137.09L6610 Upper Extremity Additions, Flexible Metal Hinge, Pair Purchase $125.45L6611 Additional Switch, Ext Power Purchase $382.48L6615 Upper Extremity Additions, Disconnect Locking Wrist Uni Purchase $144.52L6616 Upper Extremity Addition, Additional Disconnect Insert Purchase $48.01L6620 Upper Extremity Additions, Flexion-Friction Wrist Unit Purchase $251.83L6621 Flex/Ext Wrist W/Wo Friction Purchase $2,124.87L6623 Upper Extremity Addition, Spring Assisted Rotational Wr Purchase $474.83L6624 Flex/Ext/Rotation Wrist Unit Purchase $3,498.62L6625 Upper Extremity Additions, Rotation Wrist Unit With Cab Purchase $393.69L6628 Upper Extremity Addition, Quick Disconnect Hook Adapter Purchase $472.82L6629 Upper Extremity Addition, Quick Disconnect Lamination C Purchase $135.69L6630 Upper Extremity Additions, Stainless Steel, Any Wrist Purchase $159.55L6632 Upper Extremity Addition, Latex Suspension Sleeve, Each Purchase $64.12L6635 Upper Extremity Additions, Lift Assist For Elbow Purchase $153.36L6637 Upper Extremity Addition, Nudge Control Elbow Lock Purchase $271.81L6638 Elec Lock On Manual Pw Elbow Purchase $2,323.12L6640 Upper Extremity Additions, Shoulder Abduction Joint, Pa Purchase $217.12L6641 Upper Extremity Addition, Excursion Amplifier, Pulley T Purchase $119.51L6642 Upper Extremity Addition, Excursion Amplifier, Lever Ty Purchase $160.97L6645 Upper Extremity Additions, Shoulder Flexion-Abduction J Purchase $236.31L6646 Multipo Locking Shoulder Jnt Purchase $2,929.98L6647 Shoulder Lock Actuator Purchase $482.41L6648 Ext Pwrd Shlder Lock/Unlock Purchase $3,021.85L6650 Upper Extremity Additions, Shoulder Universal Joint, Ea Purchase $250.56



L6655 Upper Extremity Additions, Standard Control Cable, Extr Purchase $55.61L6660 Upper Extremity Additions, Heavy Duty Control Cable Purchase $69.58L6665 Upper Extremity Additions, Teflon, Or Equal, Cable Lini Purchase $35.49L6670 Upper Extremity Additions, Hook To Hand, Cable Adapter Purchase $35.49L6672 Upper Extremity Additions, Harness, Chest Or Shoulder, Purchase $149.68L6675 Upper Extremity Additions, Harness, Figure Of ("8") Eig Purchase $88.89L6676 Upper Extremity Additions, Harness, Figure Of ("8") Eig Purchase $104.80L6677 Ue Triple Control Harness Purchase $275.56L6680 Upper Extremity Additions, Test Socket, Wrist Disarticu Purchase $181.90L6682 Upper Extremity Additions, Test Socket, Elbow Disarticu Purchase $198.27L6684 Upper Extremity Additions, Test Socket, Shoulder Dis- A Purchase $281.86L6686 Upper Extremity Addition, Suction Socket Purchase $437.00L6687 Upper Extremity Addition, Frame Type Socket, Below Elbo Purchase $569.33L6688 Upper Extremity Addition, Frame Type Socket, Above Elbo Purchase $392.14L6689 Upper Extremity Addition, Frame Type Socket, Shoulder D Purchase $665.03L6690 Upper Extremity Addition, Frame Type Socket, Interscapu Purchase $509.01L6691 Upper Extremity Addition, Removable Insert, Each Purchase $255.51L6692 Upper Extremity Addition, Silicone Gel Insert Or Equal, Purchase $517.95L6693 Lockingelbow Forearm Cntrbal Purchase $2,637.36L6694 Elbow Socket Ins Use W/Lock Purchase $692.21L6695 Elbow Socket Ins Use W/O Lck Purchase $576.81L6696 Cus Elbo Skt In For Con/Atyp Purchase $1,224.42L6697 Cus Elbo Skt In Not Con/Atyp Purchase $1,224.42L6698 Below/Above Elbow Lock Mech Purchase $605.89L6703 Term Dev, Passive Hand Mitt Purchase $337.90L6704 Term Dev, Sport/Rec/Work Att Purchase $657.73L6706 Term Dev Mech Hook Vol Open Purchase $422.78L6707 Term Dev Mech Hook Vol Close Purchase $1,305.67L6708 Term Dev Mech Hand Vol Open Purchase $909.85L6709 Term Dev Mech Hand Vol Close Purchase $1,410.87L6711 Ped Term Dev, Hook, Vol Open Purchase $624.61L6712 Ped Term Dev, Hook, Vol Clos Purchase $1,149.95L6713 Ped Term Dev, Hand, Vol Open Purchase $1,451.33L6714 Ped Term Dev, Hand, Vol Clos Purchase $1,229.27L6721 Hook/Hand, Hvy Dty, Vol Open Purchase $2,184.90L6722 Hook/Hand, Hvy Dty, Vol Clos Purchase $1,883.55L6805 Terminal Device, Modifier Wrist Flexion Unit Purchase $263.59L6810 Terminal Device, Pincher Tool, Otto Bock Or Equal Purchase $162.97L6881 Autograsp Feature Ul Term Dv Purchase $3,797.83L6882 Microprocessor Control Uplmb Purchase $2,880.89L6883 Replc Sockt Below E/W Disa Purchase $1,565.77L6884 Replc Sockt Above Elbow Disa Purchase $2,039.59L6885 Replc Sockt Shldr Dis/Interc Purchase $2,909.95L6890 Terminal Device, Gloves For Above Hands, Production Glo Purchase $134.51L6895 Terminal Devices, Gloves For Above Hands, Custom Glove Purchase $422.47L6900 Hand Restoration (Casts, Shading And Measurements Inclu Purchase $1,118.09L6905 Hand Restoration (Casts, Shading And Measurements, Incl Purchase $1,086.82L6910 Hand Restoration (Casts, Shading And Measurements Inclu Purchase $1,058.79L6915 Hand Restoration (Shading, And Measurements Included), Purchase $463.41L6920 Wrist Disarticulation, External Power, Self-Suspended I Purchase $6,005.14L6925 Wrist Disarticulation, External Power, Self-Suspended I Purchase $6,476.74L6930 Below Elbow, External Power, Self-Suspended Inner Socke Purchase $6,309.56L6935 Below Elbow, External Power, Self-Suspended Inner Socke Purchase $6,774.08L6940 Elbow Disarticulation, External Power, Molded Inner Soc Purchase $8,659.53L6945 Elbow Disarticulation, External Power, Molded Inner Soc Purchase $10,074.36L6950 Above Elbow, External Power, Molded Inner Socket, Remov Purchase $9,842.78L6955 Above Elbow, External Power, Molded Inner Socket, Remov Purchase $11,788.03L6960 Shoulder Disarticulation, External Power, Molded Inner Purchase $11,889.09L6965 Shoulder Disarticulation, External Power, Molded Inner Purchase $12,881.15



L6970 Interscapular-Thoracic, External Power, Molded Inner So Purchase $13,040.18L6975 Interscapular-Thoracic, External Power, Molded Inner So Purchase $13,971.25L7007 Adult Electric Hand Purchase $4,348.17L7008 Pediatric Electric Hand Purchase $4,348.17L7009 Adult Electric Hook Purchase $3,291.83L7040 Prehensile Actuator, Hosmer Or Equal, Switch Controlled Purchase $2,086.86L7045 Electronic Hook, Child, Michigan Or Equal, Switch Contr Purchase $1,196.47L7170 Electronic Elbow, Hosmer Or Equal, Switch Controlled Purchase $4,554.11L7180 Electronic Elbow, Utah Or Equal, Myoelectronically Cont Purchase $26,429.71L7181 Electronic Elbo Simultaneous Purchase $37,222.06L7185 Electronic Elbow, Variety Village Or Equal, Switch Cont Purchase $4,724.79L7186 Electronic Elbow, Child, Variety Village Or Equal, Swit Purchase $8,563.24L7190 Electronic Elbow, Variety Village Or Equal, Myoelectron Purchase $5,977.82L7191 Electronic Elbow, Child, Variety Village Or Equal, Myoe Purchase $8,773.69L7259 Electronic Wrist Rotator Any Purchase $3,506.39L7360 Six Volt Battery, Otto Bock Or Equal, Each Purchase $168.34L7362 Battery Charger, Six Volt, Otto Bock Or Equal Purchase $247.27L7364 Twelve Volt Battery, Utah Or Equal, Each Purchase $294.97L7366 Battery Charger, Twelve Volt, Utah Or Equal Purchase $397.34L7367 Replacemnt Lithium Ionbatter Purchase $361.66L7368 Lithium Ion Battery Charger Purchase $468.86L7400 Add Ue Prost Be/Wd, Ultlite Purchase $284.73L7401 Add Ue Prost A/E Ultlite Mat Purchase $318.75L7402 Add Ue Prost S/D Ultlite Mat Purchase $344.23L7403 Add Ue Prost B/E Acrylic Purchase $342.10L7404 Add Ue Prost A/E Acrylic Purchase $516.33L7405 Add Ue Prost S/D Acrylic Purchase $675.27L7510 Repair Prosthetic Device, Repair Or Replace Minor Parts Purchase $281.66L7520 Repair Prosthesis Per 15 Min Purchase $15.42L8000 Breast Prostheses, Mastectomy Bra Purchase $33.22L8001 Breast Prosthesis Bra & Form Purchase $116.51L8002 Brst Prsth Bra & Bilat Form Purchase $153.29L8010 Breast Prostheses, Mastectomy Sleeve Purchase $91.40L8015 Ext Breastprosthesis Garment Purchase $55.70L8020 Breast Prostheses, Mastectomy Form Purchase $177.18L8030 Breast Prosthesis, Silicone Or Equal Purchase $314.42L8031 Breast Prosthesis W Adhesive Purchase $325.23L8035 Custom Breast Prosthesis Purchase $3,403.39L8040 Nasal Prosthesis Purchase $2,145.74L8041 Midfacial Prosthesis Purchase $2,586.47L8042 Orbital Prosthesis Purchase $2,906.12L8043 Upper Facial Prosthesis Purchase $3,254.87L8044 Hemi-Facial Prosthesis Purchase $3,603.57L8045 Auricular Prosthesis Purchase $2,256.37L8046 Partial Facial Prosthesis Purchase $2,324.89L8047 Nasal Septal Prosthesis Purchase $1,191.49L8400 Prosthetic Sheath, Below Knee, Each Purchase $13.90L8410 Prosthetic Sheath, Above Knee, Each Purchase $16.22L8415 Prosthetic Sheath, Upper Limb, Each Purchase $17.51L8417 Pros Sheath/Sock W Gel Cushn Purchase $69.85L8420 Prosthetic Sock, Wool, Below Knee, Each Purchase $17.17L8430 Prosthetic Sock, Wool, Above Knee, Each Purchase $21.69L8435 Prosthetic Sock, Wool, Upper Limb, Each Purchase $15.56L8440 Prosthetic Shrinker, Below Knee, Each Purchase $36.93L8460 Prosthetic Shrinker, Above Knee, Each Purchase $58.87L8465 Prosthetic Shrinker, Upper Limb, Each Purchase $36.11L8470 Stump Sock, Single Ply, Fitting, Below Knee, Each Purchase $7.86L8480 Stump Sock, Single Ply, Fitting, Above Knee, Each Purchase $10.83L8485 Stump Sock, Single Ply, Fitting, Upper Limb, Each Purchase $9.84



L8500 Artificial Larynx, Any Type Purchase $488.51L8501 Tracheostomy Speaking Valve Purchase $106.69L8507 Trach-Esoph Voice Pros Pt In Purchase $38.90L8509 Trach-Esoph Voice Pros Md In Purchase $101.44L8510 Voice Amplifier Purchase $234.75L8511 Indwelling Trach Insert Purchase $67.56L8512 Gel Cap For Trach Voice Pros Purchase $2.04L8513 Trach Pros Cleaning Device Purchase $4.84L8514 Repl Trach Puncture Dilator Purchase $87.60L8515 Gel Cap App Device For Trach Purchase $58.64L8600 Implantable Breast Prosthesis, Silicone Or Equal Purchase $760.64L8603 Collagen Imp Urinary 2.5 Cc Purchase $400.05L8606 Synthetic Implnt Urinary 1Ml Purchase $201.61L8610 Ocular Purchase $712.97L8612 Aqueous Shunt Purchase $614.53L8613 Ossicula Purchase $234.92L8614 Cochlear Device/System Purchase PA Required $17,736.99L8615 Headset/Headpiece For Cochlear Implant Device Purchase $419.84L8616 Microphone For Cochlear Implant Device Purchase $97.76L8617 Transmitting Coil For Cochlear Implant Device Purchase $85.39L8618 Tansmitter Cable For Cochlear Implant Device Purchase $24.41L8619 Replace Cochlear Processor Purchase PA Required $7,614.38L8621 Repl Zinc Air Battery Purchase $0.58L8622 Alkaline Battery For Cochlear Implant Device Purchase $0.30L8623 Lithium Battery For Cochlear Implant Purchase $60.23L8624 Lithium Ion Battery For Cochlear Implant Purchase $150.10L8627 Cochlear Implant Ext Speech Processor Purchase $6,325.12L8628 Cochlear Implant Ext Contr Purchase $1,141.43L8629 Cochlear Trnsmt Coil Integrated Purchase $163.43L8630 Metacarpophalangeal Joint Purchase $404.62L8631 Mcp Joint Repl 2 Pc Or More Purchase $2,016.69L8641 Metatarsal Joint Purchase $426.40L8642 Hallux Implant Purchase $279.11L8658 Interphalangeal Joint Purchase $371.77L8659 Interphalangeal Joint Repl Purchase $1,796.21L8670 Vascular Graft Material, Synthetic Purchase $508.56L8679 Imp Neurosti Pls Gn Any Type Purchase $7,929.69L8681 Pt Prgrm For Implt Neurostim Purchase $985.57L8689 External Recharging System Purchase PA Required $1,605.64L8690 Auditory Osseointegrated Device Purchase $4,428.13L8691 Osseointegrated Snd Proc Rpl Purchase $2,482.08L8692 Non-Osseointegrated Snd Proc Purchase 75% of MSRPL8693 Aud Osseo Dev, Abutment Purchase $1,411.45L8695 External Recharg Sys Extern Purchase $15.51L8696 Ext Antenna Phren Nerve Stim Purchase $200.82Q0477 Purchase $87.93Q0478 Power Adapter, Combo Vad Purchase $171.05Q0479 Power Module Combo Vad, Rep Purchase $11,242.21Q0480 Driver Pneumatic Vad, Rep Purchase $83,834.68Q0481 Microprcsr Cu Elec Vad, Rep Purchase $13,525.74Q0482 Microprcsr Cu Combo Vad, Rep Purchase $4,236.52Q0483 Monitor Elec Vad, Rep Purchase $17,452.57Q0484 Monitor Elec Or Comb Vad Rep Purchase $3,389.21Q0485 Monitor Cable Elec Vad, Rep Purchase $327.25Q0486 Mon Cable Elec/Pneum Vad Rep Purchase $272.34Q0487 Leads Any Type Vad, Rep Only Purchase $317.73Q0489 Pwr Pck Base Combo Vad, Rep Purchase $15,130.41Q0490 Emr Pwr Source Elec Vad, Rep Purchase $654.45Q0491 Emr Pwr Source Combo Vad Rep Purchase $1,028.91



Q0492 Emr Pwr Cbl Elec Vad, Rep Purchase $82.89Q0493 Emr Pwr Cbl Combo Vad, Rep Purchase $236.04Q0494 Emr Hd Pmp Elec/Combo, Rep Purchase $199.74Q0495 Charger Elec/Combo Vad, Rep Purchase $3,888.16Q0496 Battery Elec/Combo Vad, Rep Purchase $1,395.51Q0497 Bat Clps Elec/Comb Vad, Rep Purchase $435.78Q0498 Holster Elec/Combo Vad, Rep Purchase $478.13Q0499 Belt/Vest Elec/Combo Vad Rep Purchase $155.34Q0500 Filters Elec/Combo Vad, Rep Purchase $28.41Q0501 Shwr Cov Elec/Combo Vad, Rep Purchase $475.37Q0502 Mobility Cart Pneum Vad, Rep Purchase $605.21Q0503 Battery Pneum Vad Replacemnt Purchase $1,210.44Q0504 Pwr Adpt Pneum Vad, Rep Veh Purchase $638.72Q0506 Lith-Ion Batt Elec/Pneum Vad Purchase $795.03Q4006 Cast Sup Long Arm Adult Fbrg Purchase $28.10Q4008 Cast Sup Long Arm Ped Fbrgls Purchase $35.47Q4010 Cast Sup Sht Arm Adult Fbrgl Purchase $19.07Q4012 Cast Sup Sht Arm Ped Fbrglas Purchase $22.72Q4101 Apligraf Skin Sub Purchase $41.97Q4121 Theraskin Purchase $34.65S1040 Cranial Remolding Orthosis Purchase PA Required $1,649.18S8096 Portable Peak Flow Meter Purchase $23.46S8101 Spacer With Mask Purchase $27.42S8450 Splint Digit Purchase $8.19S8451 Splint Wrist Or Ankle Purchase $26.55S8490 100 Insulin Syringes Purchase $0.34S9445 Patient Education - Dme Purchase $15.23S9500 Hit Antibiotic Q24H Diem Purchase $244.35S9501 Hit Antibiotic Q12H Diem Purchase $259.63S9502 Hit Antibiotic Q8H Diem Purchase $298.18S9503 Hit Antibiotic Q6H Diem Purchase $260.32T2029 Special Med Equipment, Nos Purchase $314.91T5001 Special Position Seat/Vehicl Purchase 75% of MSRPV5014 Repair/Modification Of A Hearing Aid Purchase $141.83V5050 Hearing Aid Monaural In Ear Purchase $663.32V5060 Hearing Aid, Monaural, Behind The Ear Purchase $644.02V5130 Binaural, In The Ear Purchase $1,153.16V5140 Binaural, Behind The Ear Purchase $1,153.16V5256 Digital In The Ear, Monaural Purchase $663.32V5257 Digital Behind The Ear, Monaural Purchase $644.02V5260 Digital In The Ear, Binaural Purchase $1,153.16V5261 Digital Behind The Ear, Binaural Purchase $1,153.16V5264 Ear Mold/Insert Purchase $52.39V5299 Hearing Aid, Pocket Amplifier Purchase $230.63W8680 Other EPSDT DME Purchase PA Required 75% of MSRP

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Durable Medical Equipment, Prosthetics, Orthotics, and ... · A4230 Infus Insulin Pump Non Needl Purchase $12.01 A4233 Alkalin Batt For Glucose Mon Purchase $0.74 A4234 J-Cell Batt