DURABLE MEDICAL EQUIPMENT & SUPPLIESdss.sd.gov/sdmedx/docs/providers/feeschedules/DME 2.5.14...

Effective Date: 1/1/2014

Updated: 2/5/2014

Codes marked in red are discontinued effective 12/31/2013

CODE PROCEDURE FEE

A4206 SYRINGE WITH NEEDLE, STERILE 1CC $0.30



A4209 SYRINGE WITH NEEDLE, STERILE 5CC OR GREATER $0.42

A4212 HUBER-TYPE NEEDLE, EACH $13.99

A4213 SYRINGE, STERILE, 20 CC OR GREATER $6.50

A4215 NEEDLES ONLY, STERILE, ANY SIZE $0.27

A4216 Sterile water/saline, 10 ml $0.38

A4217 Sterile water/saline, 500 ml $3.06

A4220 REFILL KIT FOR IMPLANTABLE INFUSION PUMP $30.00

A4221 Maint drug infus cath per wk $19.91

A4222 Drug infusion pump supplies $39.50

A4223 Infusion supplies w/o pump $51.67

A4230 Infus insulin pump non needl $11.00

A4233 Alkalin batt for glucose mon $0.68

A4234 J-cell batt for glucose mon $3.06

A4235 Lithium batt for glucose mon $1.97

A4236 Silvr oxide batt glucose mon $1.41

A4245 ALCOHOL WIPES, PER BOX $3.74

A4246 BETADINE OR PHISOHEX SOLUTION, PER PINT $4.12

A4247 BETADINE OR IODINE SWABS/WIPES, PER BOX $3.53

A4250 URINE TEST OR REAGENT STRIPS OR TABLETS (100 TABLETS OR $0.65

A4253 BLOOD AND URINE CONTROL STRIPS/OR TABLETS (100 TABLETS $29.74

A4255 Glucose monitor platforms $4.01

A4256 NORMAL, LOW AND HIGH CALIBRATOR SOLUTION / CHIPS $8.16

A4257 Replace Lensshield Cartridge $12.43

A4258 Lancet device each $6.42

A4259 LANCETS, PER BOX $9.70

A4263 PERMANENT, LONG TERM, NON-DISSOLVABLE LACRIMAL DUCT IMP $30.86

A4265 PARAFFIN $3.31

A4280 Brst prsths adhsv attchmnt $5.20

A4300 IMPLANTABLE VASCULAR ACCESS PORTAL/CATHETER (VENOUS ART $30.86

A4301 Implantable access syst perc $8.00

A4305 DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF 50 ML OR $12.88

A4310 INSERTION TRAY WITHOUT DRAINAGE BAG AND WITHOUT CATHETE $6.80

A4311 INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CAT $13.06

A4312 INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CAT $14.13

A4313 INSERTIONTRAY WITHOUT DRAINAGE BAG WITH INDWELLING CAT $14.13

A4314 INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHET $22.25



A4320 IRRIGATION TRAY FOR BLADDER IRRIGATION WITH BULB OR PIS $4.69

A4321 Cath therapeutic irrig agent $38.00

A4322 IRRIGATION SYRINGE, BULB OR PISTON, EACH $2.86

A4326 MALE EXTERNAL CATHETER SPECIALTY TYPE, EG; INFLATABLE, $8.57

A4327 FEMALE EXTERNAL URINARY COLLECTION DEVICE; MEATAL CUP, $41.75

DURABLE MEDICAL EQUIPMENT & SUPPLIES

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.


A4328 FEMALE EXTERNAL URINARY COLLECTION DEVICE; POUCH, EACH $9.21

A4330 PERIANAL FECAL COLLECTION POUCH WITH ADHESIVE $6.29

A4331 Extension drainage tubing $3.11

A4332 Lubricant for cath insertion $0.12

A4333 Urinary cath anchor device $2.15

A4334 Urinary cath leg strap $4.80

A4335 INCONTINENCE SUPPLY; MISCELLANEOUS $0.89

A4336 Urethral insert $1.40

A4338 INDWELLING CATHETER; FOLEY TYPE, TWO-WAY LATEX WITH COA $11.22

A4340 INDWELLING CATHETER; SPECIALTY TYPE, EG; COUDE, MUSHROO $18.25

A4344 INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE $13.13

A4346 INDWELLING CATHETER, FOLEY TYPE, THREE WAY, LATEX OR TE $17.25

A4349 Disposable male external cat $17.91

A4351 INTERMITTENT URINARY CATHETER; STRAIGHT TIP $1.36

A4352 INTERMITTENT URINARY CATHETER; COUDE (CURVED) TIP $4.80

A4353 Intermittent urinary cath $6.82

A4354 CATHETER INSERTION TRAY, WITHOUT TUBE AND DRAINAGE BAG $10.15

A4355 I.V. SETUP FOR CONTINUOUS IRRIGATION OF THREE WAY CATH $6.67

A4356 INCONTINENCE CLAMP $40.15

A4357 URINARY DRAINAGE BAG $8.54

A4358 URINARY LEG BAG $4.96

A4361 OSTOMY FACE PLATE $13.74

A4362 OSTOMY SKIN BARRIER $3.05

A4364 OSTOMY SKIN BOND OR CEMENT $2.19

A4366 Ostomy vent $1.27

A4367 OSTOMY BELT $6.47

A4368 Ostomy filter $0.25

A4369 Skin barrier liquid per oz $2.01

A4371 Skin barrier powder per oz $3.51

A4372 Skin barrier solid 4x4 equiv $4.06

A4373 Skin barrier with flange $6.11

A4375 Drainable plastic pch w fcpl $16.74

A4376 Drainable rubber pch w fcplt $46.37

A4377 Drainable plstic pch w/o fp $4.19

A4378 Drainable rubber pch w/o fp $29.96

A4379 Urinary plastic pouch w fcpl $14.63

A4380 Urinary rubber pouch w fcplt $36.38

A4381 Urinary plastic pouch w/o fp $4.50

A4382 Urinary hvy plstc pch w/o fp $23.98

A4383 Urinary rubber pouch w/o fp $27.47

A4384 Ostomy faceplt/silicone ring $9.37

A4385 Ost skn barrier sld ext wear $4.97

A4388 Drainable pch w ex wear barr $4.26

A4389 Drainable pch w st wear barr $6.06

A4390 Drainable pch ex wear convex $9.36

A4391 Urinary pouch w ex wear barr $6.89

A4392 Urinary pouch w st wear barr $7.97

A4393 Urine pch w ex wear bar conv $8.81

A4394 Ostomy pouch liq deodorant $2.52

A4396 Peristomal hernia supprt blt $39.45

A4397 IRRIGATION SUPPLY; SLEEVE $4.22

A4398 IRRIGATION SUPPLIES, BAGS $11.14

A4399 IRRIGATION SUPPLIES, CONE/CATHETER $8.88

A4400 IRRIGATION SET FOR IRRIGATION OF OSTOMY $43.02

A4402 OSTOMY LUBRICANT $1.41


A4404 OSTOMY RINGS $1.28

A4405 Nonpectin based ostomy paste $3.32

A4406 Pectin based ostomy paste $5.59

A4407 EXT WEAR OST BARR <=4SQ $8.54

A4408 EXT WEAR OST BARR >4SQ $9.61

A4409 Ost skn barr convex <=4 sq i $6.06

A4410 Ost skn barr extnd >4 sq $8.81

A4411 Ost skn barr extnd =4sq $4.97

A4412 Ost pouch drain high output $2.64

A4413 2 pc drainable ost pouch $5.36

A4414 Ost sknbar w/o conv<=4 sq in $4.80

A4415 Ost skn barr w/o conv >4 sqi $5.84

A4416 Ost pch clsd w barrier/filtr $2.68

A4417 Ost pch w bar/bltinconv/fltr $3.63

A4418 Ost pch clsd w/o bar w filtr $1.77

A4419 Ost pch for bar w flange/flt $1.69

A4421 NOT OTHERWISE CLASSIFIED OSTOMY SUPPLIES $7.18

A4422 Ost pouch absorbent material $0.12

A4423 Ost pch for bar w lk fl/fltr $1.82

A4424 Ost pch drain w bar & filter $4.64

A4425 Ost pch drain for barrier fl $3.49

A4426 Ost pch drain 2 piece system $2.66

A4427 Ost pch drain/barr lk flng/f $2.71

A4428 Urine ost pouch w faucet/tap $6.35

A4429 Urine ost pouch w bltinconv $8.04

A4430 Ost urine pch w b/bltin conv $8.30

A4431 Ost pch urine w barrier/tapv $6.06

A4432 Os pch urine w bar/fange/tap $3.50

A4433 Urine ost pch bar w lock fln $3.26

A4434 Ost pch urine w lock flng/ft $3.66

A4435 1pc ost pch drain hgh output $5.63

A4450 Non-waterproof tape $5.22

A4452 Waterproof tape $1.79

A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER $1.25

A4456 Adhesive remover, wipes $0.24

A4458 Reusable enema bag $2.25

A4461 Surgicl dress hold non-reuse $3.20

A4463 Surgical dress holder reuse $12.98

A4465 NON-ELASTIC BINDER FOR EXTREMITY $39.67

A4481 Tracheostoma filter $0.37

A4483 Moisture exchanger $10.00

A4490 SURGICAL STOCKINGS ABOVE KNEE LENGTH, EACH $15.00

A4495 SURGICAL STOCKINGS THIGH LENGTH, EACH $21.32

A4500 SURGICAL STOCKING BELOW KNEE LENGTH, EACH $11.17

A4550 SURGICAL TRAYS $29.92

A4556 ELECTRODES, E.G., APNEA MONITOR $11.83

A4557 LEAD WIRES, E.G., APNEA MONITOR $20.57

A4559 Coupling gel or paste $0.10

A4561 Pessary rubber, any type $20.14

A4562 Pessary, non rubber,any type $50.15

A4565 SLINGS $15.81

A4570 SPLINT $22.58

A4580 CAST SUPPLIES $27.16

A4595 suppl 2 lead per month TENS $8.98

A4604 Tubing with heating element $56.11


A4605 Trach suction cath close sys $15.98

A4606 Oxygen probe used w oximeter $56.77

A4608 Transtracheal oxygen cath $48.84

A4611 BATTERY, HEAVY DUTY; REPLACEMENT FOR PATIENT OWNED VENT $172.90

A4612 BATTERY CABLES; REPLACEMENT FOR PATIENT-OWNED VENTILATO $70.34

A4613 BATTERY CHARGER; REPLACEMENT FOR PATIENT-OWNED VENTILAT $107.88

A4614 Hand-held PEFR meter $11.50

A4615 CANNULA, NASAL $0.70

A4616 TUBING, UNSPECIFIED LENGTH $0.06

A4617 MOUTH PIECE $2.00

A4618 BREATHING CIRCUITS $7.83

A4619 FACE TENT $1.81

A4620 VARIABLE CONCENTRATION MASK $0.61

A4623 TRACHEOSTOMY, INNER CANNULA (REPLACEMENT ONLY) $5.76

A4624 TRACHEAL SUCTION CATHETER, ANY TYPE, EACH $2.94

A4625 Trach care kit for new trach $5.18

A4626 TRACHEOSTOMY CLEANING BRUSH, EACH $2.39

A4627 SPACER, BAG OR RESERVOIR, WITH OR WITHOUT MASK, FOR USE $15.60

A4628 Oropharyngeal suction cath $3.56

A4629 Tracheostomy care kit $4.50

A4630 REPLACEMENT BATTERIES. MEDICALLY NECESSARY T.E.N.S. O $5.50

A4633 Uvl replacement bulb $39.99

A4635 UNDERARM PAD, CRUTCH, REPLACEMENT, EACH $4.50

A4636 REPLACEMENT, HANDGRIP, CANE, CRUTCH, OR WALKER, EACH $3.15

A4637 REPLACEMENT, TIP, CANE, CRUTCH, WALKER, EACH. $1.86

A4639 Infrared ht sys replcmnt pad $279.87

A4640 REPLACEMENT PAD FOR USE WITH MEDICALLY NECESSARY ALTERN $55.72

A4641 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT $219.00

A4649 SURGICAL SUPPLIES NOT ELSEWHERE CLASSIFIED $7.79

A4750 BLOOD TUBING FOR DIALYSIS $6.00

A4772 DEXTROSTICK OR GLUCOSE TEST STRIPS, PER BOX $4.77

A4927 GLOVES, STERILE OR NON-STERILE, PER PAIR $7.61

A4930 Sterile, gloves per pair $0.69

A5051 POUCH, CLOSED; WITH BARRIER ATTACHED (1 PIECE) $2.06

A5052 POUCH, CLOSED; WITHOUT BARRIER ATTACHED (1 PIECE) $1.25

A5053 POUCH, CLOSED; FOR USE ON FACEPLATE $1.30

A5054 POUCH, CLOSED; FOR USE ON BARRIER WITH FLANGE (2 PIECE) $1.26

A5055 STOMA CAP $1.43

A5056 1 pc ost pouch w filter $4.55

A5057 1 pc ost pou w built-in conv $9.36

A5061 POUCH, DRAINABLE; WITH BARRIER ATTACHED (1 PIECE) $3.06

A5062 POUCH, DRAINABLE; WITHOUT BARRIER ATTACHED (1 PIECE) $1.94

A5063 POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE (2 PIE $1.96

A5071 POUCH, URINARY; WITH BARRIER ATTACHED (1 PIECE) $4.22

A5072 POUCH, URINARY; WITHOUT BARRIER ATTACHED (1 PIECE) $3.27

A5073 POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE (2 PIECE $2.83

A5081 CONTINENT DEVICE; PLUG FOR CONTINENT STOMA $2.47

A5082 CONTINENT DEVICE; CATHETER FOR CONTINENT STOMA $10.47

A5083 Stoma absorptive cover $1.67

A5093 OSTOMY ACCESSORY; CONVEX INSERT $1.72

A5102 BEDSIDE DRAINAGE BOTTLE, RIGID OR EXPANDABLE $25.89

A5105 URINARY SUSPENSORY; WITH LEG BAG, WITH OR WITHOUT TUBE $34.17

A5112 URINARY LEG BAG; LATEX $27.72

A5113 LEG STRAP; LATEX, PER SET $3.52

A5114 LEG STRAP; FOAM OR FABRIC, PER SET $7.87


A5120 Skin barrier, wipe or swab $9.44

A5121 SKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT, EACH $6.58

A5122 SKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT, EACH $11.31

A5126 ADHESIVE; DISC OR FOAM PAD $1.17

A5131 APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, $13.96

A5200 Percutaneous catheter anchor $11.00

A5500 Diab shoe for density insert $61.96

A5501 Diabetic custom molded shoe $185.84

A5503 Diabetic shoe w/roller/rockr $30.19

A5504 Diabetic shoe with wedge $30.19

A5505 Diab shoe w/metatarsal bar $30.19

A5506 Diabetic shoe w/off set heel $30.19

A5507 Modification diabetic shoe $30.19

A5512 Multi den insert direct form $25.27

A5513 Multi den insert custom mold $37.72

A6010 Collagen based wound filler $30.18

A6011 Collagen gel/paste wound fil $2.22

A6021 Collagen dressing <=16 sq in $7.50

A6022 Collagen drsg>6<=48 sq in $20.48

A6023 Collagen dressing >48 sq in $185.45

A6024 Collagen dsg wound filler $6.03

A6025 Silicone gel sheet, each $7.00

A6154 Wound pouch each $13.99

A6196 Alginate dressing <=16 sq in $7.16

A6197 Alginate drsg >16 <=48 sq in $16.01

A6199 Alginate drsg wound filler $5.15

A6203 Composite drsg <= 16 sq in $2.13

A6204 Composite drsg >16<=48 sq in $6.07

A6207 Contact layer >16<= 48 sq in $7.15

A6209 Foam drsg <=16 sq in w/o bdr $2.50

A6210 Foam drg >16<=48 sq in w/o b $19.41

A6211 Foam drg > 48 sq in w/o brdr $28.62

A6212 Foam drg <=16 sq in w/border $9.45

A6213 Foam drg >16<=48 sq in w/bdr $7.18

A6214 Foam drg > 48 sq in w/border $10.03

A6216 Non-sterile gauze<=16 sq in $0.05

A6219 Gauze <= 16 sq in w/border $0.93

A6220 Gauze >16 <=48 sq in w/bordr $0.90

A6222 Gauze <=16 in no w/sal w/o b $1.12

A6223 Gauze >16<=48 no w/sal w/o b $2.36

A6224 Gauze > 48 in no w/sal w/o b $3.52

A6229 Gauze >16<=48 sq in watr/sal $3.52

A6231 Hydrogel dsg<=16 sq in $4.56

A6232 Hydrogel dsg>16<=48 sq in $6.70

A6233 Hydrogel dressing >48 sq in $18.69

A6234 Hydrocolld drg <=16 w/o bdr $6.37

A6235 Hydrocolld drg >16<=48 w/o b $16.38

A6236 Hydrocolld drg > 48 in w/o b $26.55

A6237 Hydrocolld drg <=16 in w/bdr $7.71

A6238 Hydrocolld drg >16<=48 w/bdr $22.21

A6240 Hydrocolld drg filler paste $11.93

A6241 Hydrocolloid drg filler dry $2.50

A6242 Hydrogel drg <=16 in w/o bdr $5.90

A6243 Hydrogel drg >16<=48 w/o bdr $12.01

A6244 Hydrogel drg >48 in w/o bdr $38.28


A6245 Hydrogel drg <= 16 in w/bdr $7.07

A6246 Hydrogel drg >16<=48 in w/b $9.68

A6247 Hydrogel drg > 48 sq in w/b $23.18

A6248 Hydrogel drsg gel filler $15.82

A6250 Skin seal protect moisturizr $6.16

A6251 Absorpt drg <=16 sq in w/o b $1.94

A6252 Absorpt drg >16 <=48 w/o bdr $2.85

A6253 Absorpt drg > 48 sq in w/o b $4.75

A6254 Absorpt drg <=16 sq in w/bdr $1.18

A6255 Absorpt drg >16<=48 in w/bdr $2.96

A6257 Transparent film <= 16 sq in $1.49

A6258 Transparent film >16<=48 in $4.20

A6259 Transparent film > 48 sq in $10.67

A6261 Wound filler gel/paste /oz $35.00

A6266 Impreg gauze no h20/sal/yard $1.88

A6402 Sterile gauze <= 16 sq in $0.12

A6403 Sterile gauze>16 <= 48 sq in $0.29

A6407 Packing strips, non-impreg $1.84

A6410 Sterile eye pad $0.38

A6411 Non-sterile eye pad $4.00

A6412 Occlusive eye patch $2.54

A6441 Pad band w>=3" <5"/yd $0.66

A6442 Conform band n/s w<3"/yd $0.16

A6443 Conform band n/s w>=3"<5"/yd $0.28

A6444 Conform band n/s w>=5"/yd $0.54

A6445 Conform band s w <3"/yd $0.31

A6446 Conform band s w>=3" <5"/yd $0.40

A6447 Conform band s w >=5"/yd $0.66

A6448 Lt compres band <3"/yd $1.13

A6449 Lt compres band >=3" <5"/yd $1.71

A6450 Lt compres band >=5"/yd $5.03

A6451 Mod compres band w>=3"<5"/yd $10.46

A6452 High compres band w>=3"<5"yd $5.00

A6453 Self-adher band w <3"/yd $0.60

A6454 Self-adher band w>=3" <5"/yd $0.76

A6455 Self-adher band >=5"/yd $1.36

A6456 Zinc paste band w >=3"<5"/yd $0.80

A6457 Tubular dressing $1.12

A6550 Neg pres wound ther drsg set $23.04

A7000 Disposable canister for pump $7.53

A7001 Nondisposable pump canister $32.23

A7002 Tubing used w suction pump $3.74

A7003 Nebulizer administration set $2.67

A7004 Disposable nebulizer sml vol $1.76

A7005 Nondisposable nebulizer set $27.13

A7006 Filtered nebulizer admin set $9.30

A7007 Lg vol nebulizer disposable $4.50

A7008 Disposable nebulizer prefill $7.00

A7009 Nebulizer reservoir bottle $40.97

A7010 Disposable corrugated tubing $22.99

A7011 Nondispos corrugated tubing $4.00

A7012 Nebulizer water collec devic $3.69

A7013 Disposable compressor filter $0.81

A7014 Compressor nondispos filter $4.37

A7015 Aerosol mask used w nebulize $1.65


A7017 Nebulizer not used w oxygen $5.00

A7018 Water distilled w/nebulizer $0.37

A7020 INTERFACE FOR COUGH STIMULATING DEVICE $14.10

A7025 Replace chest compress vest $423.83

A7026 Replace chst cmprss sys hose $28.02

A7027 Combination oral/nasal mask $181.75

A7028 Repl oral cushion combo mask $48.29

A7029 Repl nasal pillow comb mask $19.72

A7030 CPAP full face mask $145.40

A7031 Replacement facemask interfa $58.60

A7032 Replacement nasal cushion $34.04

A7033 Replacement nasal pillows $23.86

A7034 Nasal application device $98.79

A7035 Pos airway press headgear $33.37

A7036 Pos airway press chinstrap $15.27

A7037 Pos airway pressure tubing $34.44

A7038 Pos airway pressure filter $4.54

A7039 Filter, non disposable w pap $12.87

A7040 One way chest drain valve $39.94

A7041 Water seal drain container $75.02

A7042 Implanted pleural catheter $173.46

A7043 Vacuum drainagebottle/tubing $28.42

A7044 PAP oral interface $101.55

A7045 Repl exhalation port for PAP $16.34

A7046 Repl water chamber, PAP dev $16.38

A7047 Resp suction oral interface $119.00

A7501 Tracheostoma valve w diaphra $102.34

A7502 Replacement diaphragm/fplate $48.64

A7503 HMES filter holder or cap $11.05

A7504 Tracheostoma HMES filter $0.66

A7505 HMES or trach valve housing $4.56

A7506 HMES/trachvalve adhesivedisk $0.32

A7507 Integrated filter & holder $2.42

A7508 Housing & Integrated Adhesiv $2.79

A7509 Heat & moisture exchange sys $1.38

A7520 Trach/laryn tube non-cuffed $46.27

A7521 Trach/laryn tube cuffed $45.84

A7522 Trach/laryn tube stainless $44.01

A7524 Tracheostoma stent/stud/bttn $75.43

A7525 Tracheostomy mask $2.02

A7526 Tracheostomy tube collar $3.29

A7527 Trach/laryn tube plug/stop $3.49

A8000 Soft protect helmet prefab $91.47

A8001 Hard protect helmet prefab $91.47

A8002 Soft protect helmet custom $403.12

A8003 Hard protect helmet custom $403.12

A9500 Technetium TC 99m sestamibi $84.36

A9502 Technetium TC99M tetrofosmin $241.80

A9505 Thallous chloride TL 201/mci $28.00

A9517 Th I131 so iodide cap millic $60.25

A9699 Noc therapeutic radiopharm $24.00

A9700 Echocardiography Contrast $217.25

B4034 ENTERAL FEEDING SUPPLY KIT;-SYRINGE $5.59

B4035 ENTERAL FEEDING SUPPLY KIT - PUMP FED (DAY) $10.65

B4036 ENTERAL FEEDING SUPPLY KIT; GRAVITY FED (MONTHLY) $7.30


B4081 NASOGASTRIC TUBING WITH STYLET (E.G., TRAVASORB, ENTRIF $19.74

B4082 NASOGASTRIC TUBING WITHOUT STYLET $14.69

B4083 STOMACH TUBE - LEVINE TYPE $7.99

B4088 Gastro/jejuno tube, low-pro $32.58

B4100 Food thickener oral $3.87

B4102 EF adult fluids and electro $1.21

B4103 EF ped fluid and electrolyte $1.21

B4149 EF blenderized foods $1.21

B4150 ENTERAL FORMULAE; CATEGORY I: INTACT PROTEIN/PROTEIN IS $0.76

B4152 ENTERAL FORMULAE; CATEGORY II: INTACT PROTEIN/PROTEIN I $0.47

B4153 ENTERAL FORMULAE; CATEGORY III: HYDROLIZED PROTEIN/AMIN $2.15

B4154 ENTERAL FORMULAE CATEGORY IV: DEFINED FORMULA FOR SPECI $1.57

B4155 ENTERAL FORMULAE; CATEGORY V: MODULAR COMPONENTS (PROTE $0.99

B4157 EF special metabolic inherit $0.76

B4158 EF ped complete intact nut $0.76

B4159 EF ped complete soy based $0.76

B4160 EF ped caloric dense>/=0.7kc $0.76

B4161 EF ped hydrolyzed/amino acid $2.15

B4162 EF ped specmetabolic inherit $0.76

B4164 50% DEXTROSE SOLUTION, (50 ML = 1 UNIT) $16.28

B4168 PARENTERAL NUTRITION SOLUTION; AMINO ACID, 3.5%, (500 M $22.90

B4172 PARENTERAL NUTRITION SOLUTION; AMINO ACID, 5.5% THROUGH $53.99

B4176 PARENTERAL NUTRITION SOLUTION; AMINO ACID, GREATER THAN $57.23

B4178 PARENTERAL NUTRITION SOLUTION: AMINO ACID, GREATER THAN $65.31

B4185 Parenteral sol 10 gm lipids $60.28

B5200 PARENTERAL NUTRITION SOLUTION: COMPOUNDED AMINO ACID AN $1.27

B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM $93.31

E0100 CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FI $16.80

E0105 CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERI $40.58

E0110 CRUTCH, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS $68.28

E0111 CRUTCH FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, $43.41

E0112 CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FIXED, PAIR, WIT $31.79

E0113 CRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIXED, EACH, WITH $18.59

E0114 CRUTCHES UNDERARM, ALUMINUM, ADJUSTABLE OR FIXED, PAIR, $41.52

E0116 CRUTCH UNDERARM, ALUMINUM, ADJUSTABLE OR FIXED, EACH, W $24.42

E0117 Underarm springassist crutch $187.79

E0130 WALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHT $61.81

E0135 WALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIGHT $72.39

E0140 Walker w trunk support $302.95

E0141 WALKER WHEELED, WITHOUT SEAT $101.46

E0143 FOLDING WALKER WHEELED WITHOUT SEAT $105.82

E0144 Enclosed walker w rear seat $267.46

E0147 HEAVY DUTY, MULTIPLE BREAKING SYSTEM, VARIABLE WHEEL RE $303.62

E0148 Heavyduty walker no wheels $106.71

E0149 Heavy duty wheeled walker $187.46

E0153 PLATFORM ATTACHMENT, FOREARM CRUTCH, EACH $52.35

E0154 PLATFORM ATTACHMENT, WALKER, EACH $61.64

E0155 WHEEL ATTACHMENT, RIGID PICK-UP WALKER $27.78

E0156 SEAT ATTACHMENT, WALKER $19.77

E0157 CRUTCH ATTACHMENT, WALKER, EACH $72.10

E0158 LEG EXTENSIONS FOR A WALKER $27.21

E0159 Brake for wheeled walker $15.00

E0160 COMMODE CHAIR, STATIONARY WITH PAIL OR PAN $29.09

E0161 SITZ TYPE BATH, PORTABLE, FITS OVER COMMODE SEAT, WITH $19.62

E0163 COMMODE CHAIR, STATIONARY, WITH FIXED ARMS $90.64


E0165 COMMODE CHAIR, MOBILE WITH PAIL OR PAN $150.45

E0167 PAIL OR PAN FOR USE WITH COMMODE CHAIR $10.57

E0168 Heavyduty/wide commode chair $147.07

E0170 Commode chair electric $156.62

E0171 Commode chair non-electric $28.19

E0175 FOOT REST, FOR USE WITH COMMODE CHAIR, EACH $58.29

E0181 PRESSURE PAD, ALTERNATING WITH PUMP, HEAVY DUTY $328.56

E0182 PUMP FOR ALTERNATING PRESSURE PAD $209.26

E0184 FLOTATION MATTRESS, DRY $145.64

E0185 DECUBITUS CARE PAD, FLOTATION OR GEL PAD WITH FOAM LEVE $239.28

E0186 AIR PRESSURE MATTRESS $240.33

E0187 WATER PRESSURE MATTRESS $243.56

E0188 SYNTHETIC SHEEPSKIN PAD $23.11

E0189 LAMBSWOOL SHEEPSKIN PAD, ANY SIZE $48.02

E0191 HEEL OR ELBOW PROTECTOR, EACH $8.79

E0193 POWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY) $56.66

E0194 AIR FLUIDIZED BED $25,376.08

E0196 GEL PRESSURE MATTRESS $283.51

E0197 AIR PRESSURE PAD FOR MATTRESS $195.00

E0198 WATER PRESSURE PAD FOR MATTRESS $195.00

E0199 DRY PRESSURE PAD FOR MATTRESS (E.G., EGGCRATE) $28.20

E0200 HEAT LAMP, WITHOUT STAND (TABLE MODEL), INCLUDES BULB, $59.31

E0202 PHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOTOMETER $41.28

E0205 HEAT LAMP, WITH STAND, INCLUDES BULB, OR INFRARED ELEME $170.79

E0235 PARAFFIN BATH UNIT, PORTABLE $140.88

E0240 Bath/shower chair $339.00

E0244 RAISED TOILET SEAT $44.52

E0245 TUB STOOL OR BENCH $58.62

E0249 PAD FOR WATER CIRCULATING HEAT UNIT $87.65

E0250 HOSPITAL BED, FIXED HEIGHT, WITH MATTRESS $696.78

E0251 HOSPITAL BED, WITH SIDE RAILS, FIXED HEIGHT, WITHOUT MA $615.88

E0255 HOSPITAL BED, VARIABLE HEIGHT, (HI-LO), WITH MATTRESS $936.62

E0256 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SID $744.25

E0260 HOSPITAL BED, SEMI-ELECTRIC, (HEAD AND FOOT ADJUSTMENT) $1,382.80

E0261 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), $1,094.69

E0265 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJ $1,650.68

E0266 HOSPITAL BED, WITH SIDE RAILS, TOTAL ELECTRIC HEAD, FOO $1,524.65

E0271 MATTRESS, INNERSPRING $195.40

E0272 MATTRESS, FOAM RUBBER $178.10

E0275 BED PAN, STANDARD, METAL OR PLASTIC $13.47

E0276 BED PAN, FRACTURE, METAL OR PLASTIC $11.70

E0277 ALTERNATING PRESSURE MATTRESS $6,711.75

E0290 HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH MA $600.15

E0291 HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT $442.56

E0292 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAIL $718.75

E0293 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAIL $621.05

E0294 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), $1,088.34

E0295 HOSPITAL BED,SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), $1,012.63



E0300 Enclosed ped crib hosp grade $2,384.09

E0301 HD hosp bed, 350-600 lbs $222.96

E0302 Ex hd hosp bed > 600 lbs $600.88

E0303 Hosp bed hvy dty xtra wide $250.87

E0304 Hosp bed xtra hvy dty x wide $647.27


E0305 BED SIDE RAILS, HALF LENGTH $136.88

E0310 BED SIDE RAILS, FULL LENGTH $170.86

E0325 URINAL, MALE, STANDARD $7.56

E0326 URINAL, FEMALE, ANY MATERIAL $9.25

E0371 Nonpower mattress overlay $366.08

E0372 Powered air mattress overlay $444.21

E0373 Nonpowered pressure mattress $508.85

E0424 STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; IN $159.62

E0430 OXYGEN SYSTEM, PORTABLE USING GASEOUS OXYGEN, ALLOWANCE $298.87

E0431 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES REGULA $25.10

E0433 Portable liquid oxygen sys $46.47

E0434 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABL $26.70

E0435 OXYGEN SYSTEM, PORTABLE/STATIONARY LIQUID SYSTEM, INCLU $1,823.60

E0439 STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES USE O $159.62

E0440 STATIONARY LIQUID OXYGEN SYSTEM, INCLUDES USE OF RESERV $3,321.68

E0441 OXYGEN CONTENTS, GASEOUS, PER UNIT (FOR USE WITH OWNED $69.70

E0442 OXYGEN CONTENTS, LIQUID, PER UNIT (FOR USE WITH OWNED L $69.70

E0443 PORTABLE OXYGEN CONTENTS, GASEOUS, PER UNIT (FOR USE ON $69.70

E0444 PORTABLE OXYGEN CONTENTS, LIQUID, PER UNIT (FOR USE ONL $69.70

E0445 Oximeter non-invasive $191.66

E0450 VOLUME VENTILATOR $840.04

E0461 Vol vent noninvasive interfa $930.13

E0463 Press supp vent invasive int $1,287.83

E0464 Press supp vent noninv int $1,370.45

E0470 RAD w/o backup non-inv intfc $215.51

E0471 RAD w/backup non inv intrfc $430.80

E0472 RAD w backup invasive intrfc $458.44

E0480 PERCUSSER, MECHANICAL HOME MODEL $347.22

E0482 Cough stimulating device $421.10

E0483 Chest compression gen system $1,035.96

E0484 Non-elec oscillatory pep dvc $35.98

E0500 IPPB MACHINES WITH MANUAL VALVES EXTERNAL POWER SOURCE, $906.74

E0550 HUMIDIFIER, DURABLE FOR EXTENSIVE SUPPLEMENTAL HUMIDIFI $400.94

E0555 HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTT $34.88

E0560 HUMIDIFIER, DURABLE FOR SUPPLEMENTAL HUMIDIFICATION DUR $150.94

E0561 Humidifier nonheated w PAP $89.86

E0562 Humidifier heated used w PAP $252.99

E0565 COMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT $526.19

E0570 NEBULIZER, WITH COMPRESSOR E.G., DEVILBISS PULMO-AID $96.50

E0572 Aerosol compressor adjust pr $36.62

E0574 Ultrasonic generator w svneb $38.67

E0575 NEBULIZER, SELF-CONTAINED, ULTRASONIC $440.99

E0580 NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTT $24.96

E0585 NEBULIZER, WITH COMPRESSOR AND HEATER $618.20

E0600 SUCTION PUMP, HOME MODEL $341.05

E0601 NASAL CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE $978.82

E0602 BREAST PUMP, MANUAL $28.76

E0603 Electric breast pump $106.75

E0604 Hosp grade elec breast pump $50.00

E0605 VAPORIZER, ROOM TYPE $19.77

E0607 HOME BLOOD GLUCOSE MONITOR $186.04

E0617 Automatic ext defibrillator $39.42

E0618 Apnea monitor $243.75

E0619 Apnea monitor w recorder $251.37

E0620 Cap bld skin piercing laser $852.04


E0621 SLING OR SEAT, PATIENT LIFT, CANVAS OR NYLON $71.81

E0625 PATIENT LIFT, KARTOP, BATHTUB OR TOILET LIFT $861.68

E0627 SEAT LIFT MECHANISM INCORPORATED INTO A COMBINATION LIF $296.87

E0628 SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED $296.87

E0629 SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED $291.04

E0630 PATIENT LIFT, HYDRAULIC, WITH SEAT OR SLING $843.12

E0635 PATIENT LIFT, ELECTRIC WITH SEAT OR SLING $1,005.50

E0636 PT support & positioning sys $1,027.61

E0650 PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL, (LYMPHO $633.84

E0651 PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL (LYMPHEDEMA $808.28

E0652 PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL (LYMPHEDEMA $4,247.83

E0655 PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, $94.99

E0656 Segmental pneumatic trunk $562.94

E0657 Segmental pneumatic chest $528.87



E0666 PNEUMATIC APPLIANCE FOR USE WITHE PNEWMATIC COMPRESSOR, $116.28

E0667 PNEUMATIC APPLIANCE FOR USE WITH SEGMENTAL PNEUMATIC CO $242.20

E0668 PNEUMATIC APPLIANCE FOR USE WITH SEGMENTAL PNEUMATIC CO $330.55

E0669 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC CO $161.34

E0670 Seg pneum int legs/trunk $1,041.19

E0671 Pressure pneum appl full leg $404.74

E0672 Pressure pneum appl full arm $314.48

E0673 Pressure pneum appl half leg $261.32

E0675 Pneumatic compression device $374.72

E0691 Uvl pnl 2 sq ft or less $875.63

E0692 Uvl sys panel 4 ft $1,099.55

E0693 Uvl sys panel 6 ft $4,314.20

E0705 Transfer board or device $41.23

E0720 TENS, TWO LEAD, STIMULATES ONE AREA $25.40

E0730 TENS, FOUR LEAD, STIMULATES TWO AREAS $25.40

E0744 NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS $768.19

E0745 NEUROMUSCULAR STIMULANT, ELECTRONIC SHOCK UNIT, ANY TYP $661.80

E0747 OSTEOGENESIS STIMULATOR (NON-INVASIVE) $3,104.20

E0748 Osteogenic stimulator spinal $3,104.20

E0760 Osteogen ultrasound stimltor $315.06

E0762 Trans elec jt stim dev sys $1,071.47

E0764 Functional neuromuscularstim $1,071.47

E0765 Nerve stimulator for tx n&v $81.98

E0766 Elec stim cancer treatment $383.00

E0776 IV POLE $123.59

E0779 Amb infusion pump mechanical $15.59

E0780 Mech amb infusion pump <8hrs $10.11

E0781 EXTERNAL AMBULATORY INFUSION PUMP WITH ADMINISTRATIVE E $2,807.90

E0782 PARENTERAL INFUSION PUMP, IMPLANTABLE $2,892.80

E0783 Programmable infusion pump $678.12

E0784 Ext amb infusn pump insulin $406.82

E0786 Implantable pump replacement $778.16

E0791 PARENERAL INFUSION PUMP, STATIONARY $2,156.94

E0840 TRACTION FRAME,ATTACHED TO HEADBOARD, SIMPLE CERVICAL T $54.82

E0849 Cervical pneum trac equip $502.15

E0850 TRACTION STAND, FREE STANDING, SIMPLE CERVICAL TRACTION $92.46

E0855 Cervical traction equipment $481.59

E0856 Cervic collar w air bladder $150.09

E0860 TRACTION EQUIPMENT, OVERDOOR $33.91


E0870 TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE EXTREMITY $87.01

E0880 TRACTION STAND, FREE STANDING SIMPLE EXTREMITY TRACTION $110.48

E0890 TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE PELVIC TR $93.30

E0900 TRACTION STAND, FREE STANDING SIMPLE PELVIC TRACTION $112.77

E0910 TRAPEZE BARS, A/K/A PATIENT HELPER, ATTACHED TO BED, CO $180.94

E0911 HD trapeze bar attach to bed $180.94

E0912 HD trapeze bar free standing $180.94

E0920 FRACTURE FRAME, ATTACHED TO BED, SOPHISTICATED PELVIC T $391.37

E0930 FRACTURE FRAME, FREE STANDING SOPHISTICATED PELVIC TRAC $357.57

E0935 PASSIVE MOTION EXERCISE DEVICE $20.01

E0936 CPM device, other than knee $20.01

E0940 TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR $276.58

E0941 GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE $438.07

E0942 CERVCAL HEAD HARNESS/HALTER $16.29

E0944 PELVIC BELT/HARNESS/BOOT $40.38

E0945 EXTREMITY BELT/HARNESS $39.01

E0946 FRACTURE, FRAME, DUAL WITH CROSS BARS, ATTACHED TO BED, $492.58

E0947 FRACTURE FRAME, ATTACHMENTS FOR COMPLEX PELVIC TRACTION $533.73

E0948 FRACTURE FRAME, ATTACHMENTS FOR COMPLEX CERVICAL TRACTI $516.25

E0950 TRAY $91.49

E0951 LOOP HEEL, EACH $16.58

E0952 LOOP TOE, EACH $16.58

E0955 Cushioned headrest $156.78

E0956 W/c lateral trunk/hip suppor $75.98

E0957 W/c medial thigh support $106.32

E0958 WHEELCHAIR ATTACHMENT TO CONVERT ANY WHEELCHAIR TO ONE $330.90

E0959 AMPUTEE ADAPTER (DEVICE USED TO COMPENSATE FOR TRANSFER $74.44

E0960 W/c shoulder harness/straps $76.41

E0961 BRAKE EXTENSION, FOR WHEELCHAIR $26.18

E0966 HOOK ON HEAD REST EXTENTION $56.98

E0967 WHEELCHAIR HAND RIMS WITH 8 VERTICAL RUBBER TIPPED PROJ $101.17

E0968 COMMODE SEAT, WHEELCHAIR $152.70

E0969 NARROWING DEVICE, WHEELCHAIR $127.93

E0970 NO.2 FOOTPLATES, EXCEPT FOR ELEVATING LEG REST $36.48

E0971 ANTI-TIPPING DEVICE WHEELCHAIRS $57.86

E0973 ADJUSTABLE HEIGHT DETACHABLE ARMS, DESK OR FULL LENGTH, $94.91

E0974 "GRADE-AID" (DEVICE TO PREVENT ROLLING BACK ON AN INCLI $59.10

E0978 BELT, SAFETY WITH AIRPLANE BUCKLE, WHEELCHAIR $39.39

E0980 SAFETY VEST, WHEELCHAIR $29.09

E0981 Seat upholstery, replacement $39.60

E0982 Back upholstery, replacement $43.27

E0984 Add pwr tiller $1,861.76

E0985 W/c seat lift mechanism $197.67

E0986 Man w/c push-rim pow assist $4,349.79

E0988 Lever-activated wheel drive $291.70

E0990 ELEVATING LEG REST, EACH $103.35

E0992 SOLID SEAT INSERT $83.73

E0994 ARM REST, EACH $13.19

E0995 CALF REST, EACH $26.76

E1002 Pwr seat tilt $2,124.01

E1003 Pwr seat recline $3,688.16

E1004 Pwr seat recline mech $4,089.41

E1005 Pwr seat recline pwr $4,426.47

E1006 Pwr seat combo w/o shear $5,422.01

E1007 Pwr seat combo w/shear $6,899.02


E1008 Pwr seat combo pwr shear $6,737.94

E1010 Add pwr leg elevation $881.57

E1014 Reclining back add ped w/c $355.82

E1015 Shock absorber for man w/c $111.78

E1016 Shock absorber for power w/c $101.21

E1020 Residual limb support system $204.43

E1028 W/c manual swingaway $165.00

E1029 W/c vent tray fixed $310.37

E1030 W/c vent tray gimbaled $978.69

E1031 ROLLABOUT CHAIR, ANY AND ALL TYPES WITH CASTORS 5" OR G $357.18

E1035 Patient transfer system $597.54

E1036 Patient transfer system >300 $837.68

E1037 Transport chair, ped size $105.71

E1038 Transport chair, adult size $17.56

E1039 Transport chair pt wt>=250lb $33.32

E1050 FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS ELEV $857.19

E1060 FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FU $975.79

E1070 FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FU $899.30

E1083 HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DET $635.61

E1084 HEMI-WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH AR $807.08

E1085 HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DET $567.61

E1086 HEMI-WHEELCHAIR DETACHABLE ARMS DESK OR FULL LENGTH, SW $693.75

E1087 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR,FIXED FULL LENGTH $1,016.24

E1088 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR,DETACHABLE ARMS DE $1,107.58

E1089 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, FIXED LENGTH ARMS $889.62

E1090 SEMI-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWIN $1,009.79

E1092 WIDE HEAVY DUTY WHEEL CHAIR, DETACHABLE ARMS DESK OF FU $1,023.96

E1093 WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FUL $928.51

E1100 SEMI-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEV $808.54

E1110 SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FUL $873.80

E1130 STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY $402.41

E1140 STANDARD WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENG $595.37

E1150 STANDARD WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENG $675.28

E1160 STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING $524.24

E1161 Manual adult wc w tiltinspac $2,115.85

E1170 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING L $685.34

E1171 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, WITHOUT FOO $659.65

E1172 AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGT $684.76



E1195 HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AW $880.05

E1200 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY $699.40

E1221 WC FIXED ARM, FOOTRESTS $46.31

E1222 WC FIXED ARM ,ELEVATING LEGRESTS $66.06

E1223 WC DETACHABLE ARMS, FOOTRESTS $72.13

E1224 WC DETACHABLE ARMS, ELEVATING LEG RESTS $79.07

E1225 MANUAL WHEELCHAIR ACCESORY $44.05

E1226 MANUAL WHEELCHAIR ACCESSORY $451.95

E1227 SPECIAL HEIGHT ARMS FOR WC $229.85

E1228 SPECIAL BACK HEIGHT FOR WC $27.31

E1230 POWER OPERATED VEHICLE, (E.G. AMIGO) INDICATE BRAND NA $1,990.54

E1232 Folding ped wc tilt-in-space $2,083.76

E1233 Rig ped wc tltnspc w/o seat $2,159.11

E1234 Fld ped wc tltnspc w/o seat $1,879.66

E1235 Rigid ped wc adjustable $1,809.96


E1236 Folding ped wc adjustable $1,596.85

E1237 Rgd ped wc adjstabl w/o seat $1,610.80

E1238 Fld ped wc adjstabl w/o seat $1,596.85

E1240 LIGTHWEIGHT WHEELCHAIR, DETACHABLE ARMS,(DESK OR FULL L $809.81

E1250 LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING A $593.41

E1260 LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL L $779.81

E1270 LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATI $648.21

E1280 HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LE $1,006.96

E1285 HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AW $887.77

E1290 HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LE $977.84

E1295 HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATIN $952.44

E1296 SPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOOR $432.71

E1297 SPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERY $92.06

E1298 SPECIAL WHEELCHAIR SEAT DEPTH AND/OR WIDTH, BY CONSTRUC $316.92

E1300 WHIRLPOOL, PORTABLE (OVERTUB TYPE) $382.97

E1310 WHIRLPOOL, NON-PORTABLE (BUILT-IN TYPE) $1,889.87

E1353 REGULATOR $122.12

E1355 STAND/RACK $43.96

E1372 IMMERSION EXTERNAL HEATER FOR NEBULIZER $163.64

E1390 Oxygen concentrator $163.64

E1391 Oxygen concentrator, dual $81.82

E1392 Portable oxygen concentrator $163.64

E1405 OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITH HEATED DEL $188.67

E1406 OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITHOUT HEATED $175.33

E1700 JAW MOTION REHABILITATION SYSTEM $303.48

E1701 REPLACEMENT CUSHIONS FOR JAW MOTION REHABILITATION SYST $9.33

E1702 REPLACEMENT MEASURING SCALES FOR JAW MOTION REHABILITAT $19.86

E1800 Adjust elbow ext/flex device $119.37

E1801 SPS elbow device $123.33

E1802 Adjst forearm pro/sup device $318.46

E1805 Adjust wrist ext/flex device $123.12

E1806 SPS wrist device $101.20

E1810 Adjust knee ext/flex device $121.40

E1811 SPS knee device $128.19

E1812 Knee ext/flex w act res ctrl $83.79

E1815 Adjust ankle ext/flex device $60.35

E1816 SPS ankle device $130.18

E1818 SPS forearm device $132.90

E1820 Soft interface material $75.14

E1821 Replacement interface SPSD $102.55

E1825 Adjust finger ext/flex devc $123.12

E1830 Adjust toe ext/flex device $123.12

E1831 Static str toe dev ext/flex $64.39

E1840 Adj shoulder ext/flex device $372.93

E1841 Static str shldr dev rom adj $441.41

E2000 Gastric suction pump hme mdl $49.52

E2100 Bld glucose monitor w voice $626.75

E2101 Bld glucose monitor w lance $183.74

E2120 Pulse gen sys tx endolymp fl $276.28

E2201 Man w/ch acc seat w>=20"<24" $363.57

E2202 Seat width 24-27 in $50.00

E2203 Frame depth less than 22 in $466.81

E2204 Frame depth 22 to 25 in $792.62

E2205 Manual wc accessory, handrim $28.71

E2206 Complete wheel lock assembly $37.10


E2207 Crutch and cane holder $37.51

E2208 Cylinder tank carrier $102.80

E2209 Arm trough each $92.75

E2210 Wheelchair bearings $5.08

E2211 Pneumatic propulsion tire $36.00

E2212 Pneumatic prop tire tube $5.09

E2213 Pneumatic prop tire insert $26.75

E2214 Pneumatic caster tire each $31.68

E2215 Pneumatic caster tire tube $8.32

E2219 Foam caster tire any size ea $32.39

E2220 Solid propulsion tire each $22.76

E2221 Solid caster tire each $22.11

E2222 Solid caster integrated whl $20.52

E2224 Propulsion whl excludes tire $95.55

E2225 Caster wheel excludes tire $16.96

E2226 Caster fork replacement only $50.65

E2227 Gear reduction drive wheel $1,822.84

E2228 Mwc acc, wheelchair brake $912.34

E2231 Solid seat support base $149.75

E2310 Electro connect btw control $982.86

E2311 Electro connect btw 2 sys $1,826.06

E2312 Mini-prop remote joystick $1,965.18

E2313 PWC harness, expand control $286.39

E2321 Hand interface joystick $1,334.65

E2322 Mult mech switches $1,184.54

E2323 Special joystick handle $58.09

E2324 Chin cup interface $36.80

E2325 Sip and puff interface $1,131.17

E2326 Breath tube kit $291.56

E2327 Head control interface mech $2,194.08

E2328 Head/extremity control inter $4,161.87

E2329 Head control nonproportional $1,483.34

E2330 Head control proximity switc $2,637.57

E2340 W/c wdth 20-23 in seat frame $349.20

E2341 W/c wdth 24-27 in seat frame $523.84

E2342 W/c dpth 20-21 in seat frame $436.54

E2343 W/c dpth 22-25 in seat frame $698.46

E2351 Electronic SGD interface $586.76

E2359 Gr34 sealed leadacid battery $169.69

E2360 22nf nonsealed leadacid $98.87

E2361 22nf sealed leadacid battery $120.70

E2362 Gr24 nonsealed leadacid $79.60


E2364 U1nonsealed leadacid battery $98.87

E2365 U1 sealed leadacid battery $97.08

E2366 Battery charger, single mode $232.01

E2367 Battery charger, dual mode $232.01

E2368 Power wc motor replacement $433.86

E2369 Pwr wc gear box replacement $377.89

E2370 Pwr wc motor/gear box combo $674.29


E2373 Hand/chin ctrl spec joystick $643.72

E2374 Hand/chin ctrl std joystick $421.48

E2375 Non-expandable controller $719.41

E2376 Expandable controller, repl $1,127.34


E2377 Expandable controller, initl $374.37

E2381 Pneum drive wheel tire $62.90

E2382 Tube, pneum wheel drive tire $17.14

E2383 Insert, pneum wheel drive $125.42

E2384 Pneumatic caster tire $66.83

E2385 Tube, pneumatic caster tire $40.89

E2386 Foam filled drive wheel tire $124.29

E2387 Foam filled caster tire $53.62

E2388 Foam drive wheel tire $42.31

E2389 Foam caster tire $22.98

E2390 Solid drive wheel tire $35.94

E2391 Solid caster tire $17.21

E2392 Solid caster tire, integrate $45.25

E2394 Drive wheel excludes tire $64.47

E2395 Caster wheel excludes tire $45.81

E2396 Caster fork $48.35

E2397 Pwc acc, lith-based battery $403.56

E2402 Neg press wound therapy pump $114.30

E2500 SGD digitized pre-rec <=8min $381.06

E2502 SGD prerec msg >8min <=20min $1,165.24

E2504 SGD prerec msg>20min <=40min $1,537.10

E2506 SGD prerec msg > 40 min $2,253.86

E2508 SGD spelling phys contact $3,485.20

E2510 SGD w multi methods msg/accs $5,791.79

E2511 SGD sftwre prgrm for PC/PDA $25.95

E2512 SGD accessory, mounting sys $367.93

E2599 SGD accessory noc $167.02

E2601 Gen w/c cushion wdth < 22 in $47.13

E2602 Gen w/c cushion wdth >=22 in $100.28

E2603 Skin protect wc cus wd <22in $116.84

E2604 Skin protect wc cus wd>=22in $158.25

E2605 Position wc cush wdth <22 in $226.07

E2606 Position wc cush wdth>=22 in $352.69

E2607 Skin pro/pos wc cus wd <22in $223.40

E2608 Skin pro/pos wc cus wd>=22in $292.35

E2611 Gen use back cush wdth <22in $240.75

E2612 Gen use back cush wdth>=22in $325.68

E2613 Position back cush wd <22in $302.93

E2614 Position back cush wd>=22in $419.24

E2615 Pos back post/lat wdth <22in $348.63

E2616 Pos back post/lat wdth>=22in $469.06

E2619 Replace cover w/c seat cush $39.55

E2620 WC planar back cush wd <22in $422.13

E2621 WC planar back cush wd>=22in $443.00

E2622 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, $255.48

E2623 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE $325.09

E2624 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION $257.58

E2625 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION $326.08

E2626 Seo mobile arm sup att to wc $514.47

E2627 Arm supp att to wc rancho ty $820.93

E2628 Mobile arm supports reclinin $618.44

E2629 Friction dampening arm supp $782.61

E2630 Monosuspension arm/hand supp $547.28

E2631 Elevat proximal arm support $218.92

E2632 Offset/lat rocker arm w/ela $139.20


E2633 Mobile arm support supinator $118.07

K0001 STANDARD WHEELCHAIR $51.90

K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR $79.73

K0003 LIGHTWEIGHT WHEELCHAIR $87.31

K0004 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR $130.22

K0005 ULTRALIGHTWEIGHT WHEELCHAIR $1,599.83

K0006 HEAVY DUTY WHEELCHAIR $122.21

K0007 EXTRA HEAVY DUTY WHEELCHAIR $122.21

K0010 STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR $122.21

K0011 STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR WITH $122.21

K0012 LIGHTWEIGHT PORTABLE MOTORIZED/POWER WHEELCHAIR $122.21

K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH $157.25

K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, EACH $44.21

K0018 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION EA $24.72

K0019 ARM PAD, EACH $15.16

K0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR $40.19

K0037 HIGH MOUNT FLIP-UP FOOTREST, EACH $36.48

K0038 LEG STRAP, EACH $20.98

K0039 LEG STRAP, H STYLE, EACH $46.63

K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH $64.60

K0041 LARGE SIZE FOOTPLATE, EACH $45.80

K0042 STANDARD SIZE FOOTPLATE, EACH $27.24

K0043 FOOTREST, LOWER EXTENSION TUBE, EACH $16.89

K0044 FOOTREST, UPPER HANGER BRACKET, EACH $14.40

K0045 FOOTREST, COMPLETE ASSEMBLY $42.35

K0046 ELEVATING LEGREST, LOWER EXTENSION TUBE, EACH $16.89

K0047 ELEVATING LEGREST, UPPER HANGER BRACKET, EACH $66.17

K0050 RATCHET ASSEMBLY $28.12

K0051 CAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, EACH $45.51

K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH $80.00

K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH $88.27

K0056 SEAT HEIGHT < 17" OR < OR EQUAL TO 21" FOR A HIGH STREN $82.29

K0065 SPOKE PROTECTORS $38.46

K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES $86.45

K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPO $153.68

K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, E $94.54

K0072 FRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI-PNEUMATIC TI $53.48

K0073 CASTER PIN LOCK,EACH $28.96

K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH $49.93

K0098 DRIVE BELT FOR POWER WHEELCHAIR $22.16

K0105 IV HANGER $86.04

K0195 ELEVATING LEG RESTS, PAIR $17.70

K0455 Pump uninterrupted infusion $253.12

K0552 Supply/ext inf pump syr type $2.55

K0601 Repl batt silver oxide 1.5 v $1.08

K0602 Repl batt silver oxide 3 v $6.19

K0603 Repl batt alkaline 1.5 v $0.55

K0604 Repl batt lithium 3.6 v $5.92

K0605 Repl batt lithium 4.5 v $14.23

K0606 AED garment w elec analysis $2,453.92

K0607 Repl batt for AED $189.27

K0608 Repl garment for AED $118.11

K0609 Repl electrode for AED $785.48

K0672 Removable soft interface LE $72.05

K0730 Ctrl dose inh drug deliv sys $1,679.96


K0733 12-24hr sealed lead acid $25.37

K0738 Portable gas oxygen system $167.99

K0739 REPAIR/SVC DME NON-OXYGEN EQ $13.38

K0740 REPAIR/SVC OXYGEN EQUIPMENT $14.13

K0807 POV group 2 hd 301-450 lbs $1,993.08

K0813 PWC gp 1 std port seat/back $2,056.63

K0814 PWC gp 1 std port cap chair $2,632.36

K0815 PWC gp 1 std seat/back $2,997.71

K0816 PWC gp 1 std cap chair $2,870.78

K0820 PWC gp 2 std port seat/back $2,196.54

K0821 PWC gp 2 std port cap chair $2,819.81



K0824 PWC gp 2 hd seat/back $4,128.42

K0825 PWC gp 2 hd cap chair $3,779.36

K0826 PWC gp 2 vhd seat/back $5,344.66

K0827 PWC gp vhd cap chair $4,544.63

K0828 PWC gp 2 xtra hd seat/back $5,889.32

K0829 PWC gp 2 xtra hd cap chair $5,408.03

K0835 PWC gp2 std sing pow opt s/b $3,459.01

K0836 PWC gp2 std sing pow opt cap $3,589.82

K0837 PWC gp 2 hd sing pow opt s/b $4,128.42

K0838 PWC gp 2 hd sing pow opt cap $3,693.35

K0839 PWC gp2 vhd sing pow opt s/b $46.47

K0840 PWC gp2 xhd sing pow opt s/b $8,097.41

K0841 PWC gp2 std mult pow opt s/b $2,629.23

K0842 PWC gp2 std mult pow opt cap $3,681.61

K0843 PWC gp2 hd mult pow opt s/b $4,432.67



K0850 PWC gp 3 hd seat/back $5,225.69

K0851 PWC gp 3 hd cap chair $5,024.40

K0852 PWC gp 3 vhd seat/back $6,037.94

K0853 PWC gp 3 vhd cap chair $6,202.48

K0854 PWC gp 3 xhd seat/back $8,216.95

K0855 PWC gp 3 xhd cap chair $7,762.19

K0856 PWC gp3 std sing pow opt s/b $4,835.71

K0857 PWC gp3 std sing pow opt cap $4,932.62

K0858 PWC gp3 hd sing pow opt s/b $5,999.58

K0859 PWC gp3 hd sing pow opt cap $5,721.75

K0860 PWC gp3 vhd sing pow opt s/b $8,571.22

K0861 PWC gp3 std mult pow opt s/b $5,377.34

K0862 PWC gp3 hd mult pow opt s/b $6,660.97

K0863 PWC gp3 vhd mult pow opt s/b $5,999.58

K0864 PWC gp3 xhd mult pow opt s/b $10,199.79

K0870 PWC gp 4 hd seat/back $789.84

L0112 Cranial cervical orthosis $1,189.01

L0113 Cranial cervical torticollis $242.27

L0120 CERVICAL, FLEXIBLE, NON-ADJUSTABLE (FOAM COLLAR) $16.89

L0130 CERVICAL, FLEXIBLE THERMOPLASTIC MOLDED TO PATIENT $103.87

L0140 CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTIC COLLAR) $46.02

L0150 CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDED CHIN CUP (PLAST $68.81

L0160 CERVICAL, SEMI-RIGID, WIRE FRAME OCCIPITAL/MANDIBULAR S $99.71

L0170 CERVICAL, COLLAR, MOLDED TO PATIENT MODEL $410.58

L0172 CERVICAL, COLLAR, SEMI-RIGID THERMOPLASTIC FOAM, TWO PI $83.96


L0174 CERVICAL, COLLAR, SEMI-RIGID, THERMOPLASTIC FOAM, TWO P $204.56

L0180 CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SU $235.88



L0220 THORACIC, RIB BELT, CUSTOM FABRICATED $77.96

L0430 TLSO, ANTERIOR-POSTERIOR-LATERAL CONTROL (BODY JACKET), $964.87

L0450 TLSO flex prefab thoracic $136.56

L0454 TLSO flex prefab sacrococ-T9 $294.63

L0455 TLSO flex trnk sj-T9 pre ots $297.58

L0456 TLSO flex prefab $844.92

L0457 TLSO flex trnk sj-ss pre ots $853.37

L0458 TLSO 2Mod symphis-xipho pre $757.63

L0460 TLSO2Mod symphysis-stern pre $852.79

L0462 TLSO 3Mod sacro-scap pre $1,060.70

L0464 TLSO 4Mod sacro-scap pre $1,262.75

L0466 TLSO rigid frame pre soft ap $306.72

L0467 TLSO r fram soft pre ots $309.79

L0468 TLSO rigid frame prefab pelv $360.15

L0469 TLSO rig fram pelvic pre ots $363.75

L0470 TLSO rigid frame pre subclav $500.94

L0472 TLSO rigid frame hyperex pre $317.70

L0480 TLSO rigid plastic custom fa $1,390.28

L0482 TLSO rigid lined custom fab $1,554.57

L0484 TLSO rigid plastic cust fab $1,677.83

L0486 TLSO rigidlined cust fab two $1,700.01

L0488 TLSO rigid lined pre one pie $852.79

L0490 TLSO rigid plastic pre one $240.28

L0491 TLSO 2 piece rigid shell $652.44

L0492 TLSO 3 piece rigid shell $411.17

L0621 SIO flex pelvisacral prefab $89.64

L0622 SIO flex pelvisacral custom $202.98

L0625 LO flexibl L1-below L5 pre $46.90

L0626 LO sag stays/panels pre-fab $66.33

L0627 LO sagitt rigid panel prefab $349.88

L0628 LO flex w/o rigid stays pre $71.40

L0630 LSO post rigid panel pre $137.84

L0631 LSO sag-coro rigid frame pre $873.85

L0633 LSO flexion control prefab $244.09

L0635 LSO sagit rigid panel prefab $752.09

L0636 LSO sagittal rigid panel cus $1,308.76

L0637 LSO sag-coronal panel prefab $881.09

L0638 LSO sag-coronal panel custom $1,120.46

L0639 LSO s/c shell/panel prefab $881.09

L0640 LSO s/c shell/panel custom $888.93

L0641 Lo rig pos pnl l1-l5 pre ots $67.00

L0642 Lo sag ri an/pos pnl pre ots $353.39

L0643 LSO sag ctr rigi pos pre ots $139.22

L0648 LSO Sag r an/pos pnl pre ots $882.59

L0649 LSO sc r pos/lat pnl pre ots $246.53

L0650 LSO sc r ant/pos pnl pre $889.90

L0651 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), $889.90

L0700 CERVICAL-THORACIC-LUMBARSACRAL-ORTHOSES (CTLSO), $1,302.04

L0710 CTLSO, ANTERIOR-POSTERIORLATERAL-CONTROL, MOLDED TO PAT $1,519.39

L0810 HALO PROCEDURES, CERVICAL HALO INCORPORATED INTO SPINAL $1,715.58

L0820 HALO PROCEDURES, CERVICAL HALO INCORPORATED INTO PLASTE $1,484.20


L0830 HALO PROCEDURES, CERVICAL HALO INCORPORATED INTO MILWAU $1,996.34

L0859 MRI compatible system $1,034.08

L0861 Halo repl liner/interface $183.10

L0970 TLSO, CORSET FRONT $97.01

L0972 LSO, CORSET FRONT $70.47

L0974 TLSO, FULL CORSET $113.98

L0976 LSO, FULL CORSET $129.14

L0978 AXILLARY CRUTCH EXTENSION $122.55

L0980 PERONEAL STRAPS, PAIR $11.12

L0982 STOCKING SUPPORTER GRIPS, SET OF FOUR (4) $10.36

L0984 PROTECTIVE BODY SOCK, EACH $42.43

L0999 Add to spinal orthosis NOS $298.33

L1000 CERVICAL-THORACIC-LUMBAR-SACRAL (CTLSO) (MILWAUKEE), IN $1,506.15

L1005 Tension based scoliosis orth $2,719.03

L1010 ADDITIONS TO CERVICAL-THORACICLUMBAR-SACRAL ORTHOSES (C $42.72

L1020 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSES, KYPHOSIS PAD $55.04

L1025 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD, $79.38

L1030 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSES, LUMBAR BOLSTE $40.49

L1040 ADDITIONS TO CTLSO OR SCLOIOSIS ORTHOSES, LUMBAR OR LUM $49.67

L1050 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSES, STERNAL PAD $53.00

L1060 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSES, THORACIC PAD $60.89

L1070 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSES, TRAPEZE SLING $57.29

L1080 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSES, OUTRIGGER $45.28

L1085 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER, BIL $98.00

L1090 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSES, LUMBAR SLING $63.02

L1100 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSES, RING FLANGE, $101.25

L1110 ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSES, RING FLANGE, $162.60

L1120 ADDITIONS TO CTLSO OR SIO, SCOLIOSIS ORTHOSES, COVERS F $27.32

L1200 THORACIC-LUMBAR-SACAL-ORTHOSES (TLSO), INCLUSIVE OF FUR $1,196.20

L1210 ADDITIONS TO TLSO, (LOW PROFILE) LATERAL THORACIC EXTEN $222.10

L1220 ADDITIONS TO TLSO, (LOW PROFILE) ANTERIOR THORACIC EXTE $147.06

L1230 ADDITIONS TO TLSO, (LOW PROFILE) MILWAUKEE TYPE SUPERST $481.02

L1240 ADDITION TO TLSO (LOW PROFILE), LUMBAR DEROTATION PAD $49.43

L1250 ADDITION TO TLSO (LOW PROFILE), ANTERIOR ASIS PAD $45.99

L1260 ADDITION TO TLSO (LOW PROFILE), ANTERIOR THORACIC DEROT $48.16

L1270 ADDITION TO TLSO (LOW PROFILE), ABDOMINAL PAD $49.33

L1280 ADDITION TO TLSO (LOW PROFILE), RIB GUSSET (ELASTIC), E $54.91

L1290 ADDITION TO TLSO (LOW PROFILE), LATERAL TROCHANTERIC PA $50.05

L1300 OTHER SCOLIOSIS PROCEDURES, BODY JACKET MOLDED TO PATIE $1,321.60

L1310 OTHER SCOLIOSIS PROCEDURES, POST-OPERATIVE BODY JACKET $1,399.47

L1600 HIP ORTHOSES (HO), ABDUCTION CONTROL OF HIP JOINTS, FLE $83.90

L1610 HO, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, FREJKA C $27.94

L1620 HO, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, PAVLIK H $85.30

L1630 HO, ABDUCTION CONTROL OF HIP JOINTS, SEMI-FLEXIBLE (VON $107.88

L1640 HO, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PELVIC BAN $360.42

L1650 HO, ABDUCTION CONTROL OF HIP JOINTS, STATIC, ADJUSTABLE $166.08

L1652 HO bi thighcuffs w sprdr bar $302.83

L1660 HO, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PLASTIC, C $108.95

L1680 HO, ABDUCTION CONTROL OF HIP JOINTS, DYNAMIC, PELVIC CO $775.68

L1685 HO, ABDUCTION CONTROL OF HIP JOINTS, POST-OPERATIVE HIP $757.27

L1686 HO, ABDUCTION CONTROL OF HIP JOINT, POST-OPERATIVE HIP $654.54

L1690 Combination bilateral HO $1,642.74

L1700 LEGG PERTHES ORTHOSIS, TORONTO TYPE $972.20

L1710 LEGG PERTHES ORTHOSIS, NEWINGTON TYPE $1,138.08

L1720 LEGG PERTHES ORTHOSIS, TRILATERAL, (TACHDIJAN TYPE) $838.90


L1730 LEGG PERTHES ORTHOSIS, SCOTTISH RITE TYPE $721.74

L1755 LEGG PERTHES ORTHOSIS, PATTEN BOTTOM TYPE $1,007.94

L1810 KO, ELASTIC WITH JOINTS $64.28

L1812 KO elastic w/joints pre ots $80.12

L1820 KO, ELASTIC WITH CONDYLE PADS AND JOINTS $90.27

L1830 KO, IMMOBILIZER; CANVAS LONGITUDINAL $58.80

L1831 Knee orth pos locking joint $250.03

L1832 KO, ADJUSTABLE KNEE JOINTS, POSITIONAL ORTHOSIS, RIGID $387.05

L1833 KO adj jnt pos r sup pre ots $482.47

L1834 KO, WITHOUT KNEE JOINT, RIGID, MOLDED TO PATIENT MODEL $522.03

L1836 Rigid KO wo joints $113.37

L1840 KO, DEROTATION, FABRICATED TO PATIENT MODEL (LENNOX HIL $585.37

L1843 KO single upright custom fit $762.26

L1844 Ko w/adj jt rot cntrl molded $1,142.74

L1845 KO, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLE $537.44

L1846 KO, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLE $675.92

L1847 KO adjustable w air chambers $488.61

L1848 KO dbl upright w/air pre ots $493.50

L1850 KO, SWEDISH TYPE $208.69

L1860 KO, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET, MO $683.14

L1900 ANKLE-FOOT ORTHOSES (AFO), SPRING WIRE, DORSIFLEXION AS $187.28

L1902 Afo ankle gauntlet $50.82

L1904 AFO, MOLDED ANKLE GAUNTLET, MOLDED TO PATIENT MODEL $299.37

L1906 AFO, MULTILIGAMENTUS ANKLE SUPPORT $102.10

L1907 AFO supramalleolar custom $478.01

L1910 AFO, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE CO $172.13

L1920 AFO, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHE $279.93

L1930 AFO, CUSTOM FITTED, PLASTIC $164.39

L1932 Afo rig ant tib prefab TCF/= $758.04

L1940 AFO, MOLDED TO PATIENT MODEL, PLASTIC $314.84

L1945 AFO, MOLDED TO PATIENT MODEL, PLASTIC, RIGID ANTERIOR T $606.39

L1950 AFO, SPIRAL, MOLDED TO PATIENT MODEL (IRM TYPE), PLASTI $513.04

L1951 AFO spiral prefabricated $713.45

L1960 AFO, POSTERIOR SOLID ANKLE, MOLDED TO PATIENT MODEL, PL $352.88

L1970 AFO, PLASTIC MOLDED TO PATIENT MODEL, WITH ANKLE JOINT $475.92

L1971 AFO w/ankle joint, prefab $398.19

L1980 AFO, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID ST $251.92

L1990 AFO, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID ST $283.79

L2000 KNEE-ANKLE-FOOT-ORTHOSES (KAFO), SINGLE UPRIGHT, FREE K $669.02

L2005 KAFO sng/dbl mechanical act $3,488.08

L2010 KAFO, SINGLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID STIR $688.73

L2020 KAFO, DOUBLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID STIR $743.36

L2030 KAFO, DOUBLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID STIR $644.93

L2034 KAFO pla sin up w/wo k/a cus $1,768.07

L2035 KAFO plastic pediatric size $147.16

L2036 KAFO, FULL PLASTIC, MOLDED TO PATIENT MODEL $1,296.58

L2037 KAFO, FULL PLASTIC, SINGLE UPRIGHT, FREE KNEE, MOLDED T $1,060.37

L2038 KAFO, FULL PLASTIC, WITHOUT KNEE JOINT, MULTI-AXIS ANKL $910.20

L2040 HIP-KNEE-ANKLE-FOOT ORTHOSES TORSION CONTROL, BILATERAL $146.87

L2050 HKAFO, TORSION CONTROL, BILATERAL TORSION CABLES, HIP J $335.54

L2060 HKAFO, TORSION CONTROL, BILATERAL TORSION CABLES, BALL $376.79

L2070 HKAFO, TORSION CONTROL, UNILATERAL ROTATION STRAPS, PEL $85.61

L2080 HKAFO, TORSION CONTROL, UNILATERAL, TORSION CABLE, HIP $228.98

L2090 HKAFO, TORSION CONTROL UNILATERAL TORSION CABLE, BALL B $310.35

L2106 AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, $432.85


L2108 AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, $774.58

L2112 AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT $297.03

L2114 AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SEMI- $372.56

L2116 AFO, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID $453.22

L2126 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS $856.08

L2128 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS $1,091.65




L2180 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC $97.09

L2182 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROP LOC $62.13

L2184 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, LIMITED $86.39

L2186 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, ADJUSTAB $114.76

L2188 ADDITION TO LOWER EXTREMITY FRACTURE OTHOSIS, QUADRILAT $190.68

L2190 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, WAIST BE $57.56

L2192 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIP JOIN $226.99

L2200 ADDITIONS TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EAC $40.35

L2210 ADDITIONS TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLAN $57.05

L2220 ADDITIONS TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR $67.56

L2230 ADDITIONS TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRU $53.29

L2232 Rocker bottom, contact AFO $81.62

L2240 ADDITIONS TO LOWER EXTREMITY, ROUND CALIPER AND PLATE A $53.25

L2250 ADDITIONS TO LOWER EXTREMITY, FOOT PLATE, MOLDED TO PAT $267.80

L2260 ADDITIONS TO LOWER EXTREMITY, REINFORCED SOLID STIRRUP $145.94

L2265 ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRRUP $74.97

L2270 ADDITIONS TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION ( $37.54

L2275 ADDITION TO LOWER EXTREMITY, VARUS/VULGUS CORRECTION, P $94.83

L2280 ADDITIONS TO LOWER EXTREMITY, MOLDED INNER BOOT $288.27

L2300 ADDITIONS TO LOWER EXTREMITY, ADBUCTION BAR (BILATERAL $171.40

L2310 ADDITIONS TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHT $85.00

L2320 ADDITIONS TO LOWER EXTREMITY, NON-MOLDED LACER $167.16

L2330 ADDITIONS TO LOWER EXTREMITY, LACER MOLDED TO PATIENT M $275.53

L2335 ADDITION TO LOWER EXTREMITY, ANTERIOR SWING BAND $151.76

L2340 ADDITIONS TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDED $284.53

L2350 ADDITIONS TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOC $662.57

L2360 ADDITIONS TO LOWER EXTREMITY, EXTENDED STEEL SHANK $36.61

L2370 ADDITION TO LOWER EXTREMITY, PATTEN BOTTOM $163.42

L2375 ADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOI $71.94

L2380 ADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT $104.51

L2385 ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY $113.70

L2387 Add LE poly knee custom KAFO $130.03

L2390 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JO $92.92

L2395 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY D $118.36

L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE $81.98

L2405 ADDITION TO KNEE JOINT, DROP LOCK, EACH JOINT $43.20

L2415 ADDITION TO KNEE JOINT, CAM LOCK (SWISS, FRENCH, BAIL T $121.03

L2425 ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABL $138.52

L2430 Knee jnt ratchet lock ea jnt $85.23

L2492 ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING $81.29

L2500 ADDITIONS TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, GUL $200.85

L2510 ADDITIONS TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUA $462.44

L2520 ADDITIONS TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUA $313.88

L2525 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCH $872.56

L2526 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCH $564.83

L2530 ADDITIONS TO LOWER EXTREMITY, THIGH-WEIGHT BEARING, LAC $199.43


L2540 ADDITIONS TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LAC $305.51

L2550 ADDITIONS TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, HIG $243.78

L2570 ADDITIONS TO LOWER EXTREMITY, GLUTEAL/ISCHIAL WEIGHT BE $303.23

L2580 ADDITIONS TO LOWER EXTREMITY, GLUTEAL/ISCHIAL WEIGHT BE $386.45

L2600 ADDITIONS TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT $141.97



L2622 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, $195.23

L2624 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, $210.81

L2627 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PLASTIC, M $1,455.15

L2628 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, METAL FRAM $1,422.13

L2630 ADDITIONS TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND $210.20

L2640 ADDITIONS TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND $213.95

L2650 ADDITIONS TO LOWER EXTREMITY, PELVIC AND THORACIC CONTR $76.40

L2660 ADDITIONS TO LOWER EXTREMITY, THORACIC CONTROL, THORACI $158.21

L2670 ADDITIONS TO LOWER EXTREMITY, THORACIC CONTROL, PARASPI $144.80

L2680 ADDITIONS TO LOWER EXTREMITY, THORACIC CONTROL, LATERAL $132.83

L2750 ADDITION TO LOWER EXTREMITY ORTHOSES, PLATING CHROME OR $53.22

L2755 Carbon graphite lamination $50.00

L2760 ADDITIONS TO LOWER EXTREMITY ORTHOSES, EXTENSION, PER E $51.57

L2768 Ortho sidebar disconnect $110.69

L2780 ADDITIONS TO LOWER EXTREMITY, NON-CORROSIVE FINISH $43.09

L2785 ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINE $20.18

L2795 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FUL $54.10

L2800 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNE $74.46

L2810 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CON $49.73

L2820 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FO $73.72

L2830 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FO $79.74

L2840 ADDITION TO LOWER EXTREMITY ORTHOSIS, TIBIAL LENGTH SOC $27.83

L2850 ADDITION TO LOWER EXTREMITY ORTHOSIS, FEMORAL LENGTH SO $50.63

L3000 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, "UCB" $258.86

L3001 FOOT INSERT, REMOVABLE-MOLDED TO PATIENT MODEL, SPENCO, $109.00

L3002 FOOT INSERT, REMOVABLE-MOLDED TO PATIENT MODEL, PLASTAZ $133.10

L3003 FOOT INSERT, REMOVABLE-MOLDED TO PATIENT MODEL, SILICON $143.60

L3010 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGI $64.81

L3020 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGI $163.49

L3030 FOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT $62.88

L3040 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL, $38.79

L3050 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, METATARSAL, E $38.79

L3060 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL/ $25.49

L3070 FOOT, ARCH SUPPORT, NONREMOVABLE ATTACHED TO SHOE, LONG $9.66

L3080 FOOT, ARCH SUPPORT, NONREMOVABLE ATTACHED TO SHOE, META $9.55

L3090 FOOT, ARCH SUPPORT, NONREMOVABLE ATTACHED TO SHOE, LONG $33.54

L3100 HALLUS-VALGUS NIGHT DYNAMIC SPLINT $35.63

L3140 FOOT, ABDUCTION ROTATION BARS (DENNIS BROWNE TYPE), ATT $73.38

L3150 FOOT, ABDUCTION ROTATION BARS, (DENNIS BROWNE TYPE), CL $67.06

L3170 FOOT-PLASTIC HEEL STABILZER $9.38

L3201 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR-INFA $65.00

L3202 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR-CHIL $81.00

L3204 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR-INF $84.00

L3206 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR-CHI $56.80

L3215 ORTHROPEDIC FOOTWEAR, LADIES SHOES, OXFORD $77.84

L3216 ORTHROPEDIC FOOTWEAR, LADIES SHOES, DEPTH INLAY $85.24

L3219 ORTHOPEDIC FOOTWEAR, MENS SHOES-OXFORD $103.89

L3221 ORTHOPEDIC FOOTWEAR, MENS SHOES-DEPTH INLAY $108.35


L3222 ORTHOPEDIC FOOTWEAR, MENS SHOES-HIGHTOP-DEPTH INLAY $112.62

L3224 Woman's shoe oxford brace $46.61

L3225 Man's shoe oxford brace $62.19

L3230 ORTHOPEDIC FOOTWEAR, CUSTOM SHOES DEPTH INLAY $89.63

L3252 FOOT-SHOE MOLDED TO PATIENT MODEL-PLASTAZOTE %OR SIMILA $338.84

L3253 FOOT-MOLDED SHOE PLASTAZOTE %OR SIMILAR< CUSTOM FITTED, $48.77

L3257 ORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE FOR SPLIT SIZE $178.23

L3260 AMBULATORY SURGICAL BOOT-EACH $16.48

L3265 PLASTAZOTE SANDAL-EACH $30.70

L3300 LIFTS-ELEVATION, HEEL, TAPERED TO METATARSALS, PER INCH $8.79

L3310 LIFTS-ELEVATION, HEEL AND SOLE, NEOPRENE, PER INCH $35.09

L3320 LIFTS-ELEVATION, HEEL AND SOLE, CORK, PER INCH $93.33

L3330 LIFTS-ELEVATION, METAL EXTENSION *SKATE* $421.46

L3332 LIFTS-ELEVATION, INSIDE SHOE, TAPERED, UP TO ONE-HALF I $5.37

L3334 LIFTS-ELEVATION, HEEL, PER INCH $20.38

L3340 HEEL WEDGE, SACH $32.17

L3350 HEEL WEDGE $8.32

L3360 SOLE WEDGE-OUTSIDE SOLE $29.34

L3370 SOLE WEDGE-BETWEEN SOLE $18.23

L3380 CLUBFOOT WEDGE $40.88

L3390 OUTFLARE WEDGE $43.23

L3400 METATARSAL BAR WEDGE-ROCKER $33.42

L3410 METATARSAL BAR WEDGE-BETWEEN SOLE $10.73

L3420 FULL SOLE AND HEEL WEDGE *BETWEEN SOLE* $11.81

L3430 HEEL, COUNTER, PLASTIC REINFORCED $132.08

L3440 HEEL-COUNTER, LEATHER REINFORCED $62.88

L3450 HEEL-SACH CUSHION TYPE $10.95

L3455 HEEL-NEW LEATHER, STANDARD $5.89

L3460 HEEL-NEW RUBBER, STANDARD $5.42

L3465 HEEL-THOMAS WITH WEDGE $48.23

L3470 HEEL-THOMAS EXTENDED TO BALL $51.37

L3480 HEEL-PAD AND DEPRESSION FOR SPUR $5.28

L3485 HEEL-PAD, REMOVABLE FOR SPUR $10.54

L3500 MISCELLANEOUS SHOE ADDITIONS, INSOLE-LEATHER $24.10

L3510 MISCELLANEOUS SHOE ADDITIONS, INSOLE RUBBER $7.50

L3520 MISCELLANEOUS SHOE ADDITIONS, INSOLE-FELT COVERED WITH $26.19

L3530 MISCELLANEOUS SHOE ADDITIONS, SOLE-HALF $26.19

L3540 MISCELLANEOUS SHOE ADDITIONS, SOLE-FULL $12.87

L3550 MISCELLANEOUS SHOE ADDITIONS, TOE TAP-STANDARD $7.35

L3560 MISCELLANEOUS SHOE ADDITIONS, TOE TAP-HORSESHOE $18.83

L3570 MISCELLANEOUS SHOE ADDITIONS, SPECIAL EXTENSION TO INST $70.23

L3580 MISCELLANEOUS SHOE ADDITIONS, CONVERT INSTEP TO VELCO C $6.54

L3590 MISCELLANEOUS SHOE ADDITIONS, CONVERT FIRM SHOE COUNTER $44.04

L3595 MISCELLANEOUS SHOE ADDITIONS, MARCH BAR $34.57

L3600 TRANSFERS OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALI $21.45

L3610 TRANSFERS OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALI $50.55

L3620 TRANSFERS OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLI $49.62

L3630 TRANSFERS OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLI $50.09

L3640 TRANSFERS OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, DENN $50.55

L3650 SHOULDER ORTHOSES, (SO), FIGURE OF "8" DESIGN ABDUCTION $36.95

L3660 SO, FIGURE OF "8" DESIGN ABDUCTION RESTRAINER, CANVAS A $83.56

L3670 SO, ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE) $70.45

L3671 SO cap design w/o jnts CF $696.64

L3674 SO airplane w/wo joint CF $913.91

L3675 Canvas vest SO $135.67


L3702 EO w/o joints CF $223.25

L3710 EO, ELASTIC WITH METAL JOINTS $77.01

L3720 EO, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, FREE MOTION $407.47

L3730 EO, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, EXTENSION/ F $561.59

L3740 EO, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, ADJUSTABLE P $665.80

L3760 EO withjoint, Prefabricated $195.50

L3762 Rigid EO wo joints $15.00

L3763 EWHO rigid w/o jnts CF $519.34

L3764 EWHO w/joint(s) CF $593.66

L3765 EWHFO rigid w/o jnts CF $991.36

L3766 EWHFO w/joint(s) CF $1,049.78

L3806 WHFO w/joint(s) custom fab $351.20

L3807 Whfo w inflatable airchamber $36.75

L3808 WHFO, rigid w/o joints $280.58

L3809 WHFO w/o joints pre ots $195.23

L3900 WHFO, DYNAMIC FLEXOR HINGE; RECIPROCAL WRIST EXTENSION $806.09

L3901 WHFO, DYNAMIC FLEXOR HINGE; RECIPROCAL WRIST EXTENSION $1,282.71

L3904 WHFO, EXTERNAL POWERED, ELECTRIC $2,432.47

L3905 WHO w/nontorsion jnt(s) CF $766.72

L3906 Wrist gauntlet molded to pt $254.77

L3908 WHFO, WRIST EXTENSION CONTROL (COCK-UP), CANVAS OR LEAT $37.33

L3912 Flex glove w/elastic finger $59.08

L3913 HFO w/o joints CF $209.39

L3915 WHO w nontor jnt(s) prefab $53.40

L3916 WHO nontorsion jnts pre ots $415.11

L3917 Prefab metacarpl fx orthosis $81.65

L3918 Metacarp fx orthosis pre ots $82.47

L3919 HO w/o joints CF $209.39

L3921 HFO w/joint(s) CF $248.32

L3923 HFO, no joint, prefabricated $28.90

L3924 HFO without joints pre ots $67.55

L3925 FO pip/dip with joint/spring $37.95

L3927 FO pip/dip w/o joint/spring $27.04

L3929 HFO nontorsion joint, prefab $60.10

L3930 HFO nontorsion jnts pre ots $60.71

L3931 WHFO nontorsion joint prefab $148.47

L3933 FO w/o joints CF $164.97

L3935 FO nontorsion joint CF $170.84

L3960 SHOULDER-ELBOW-WRIST-HAND ORTHOSES, (SEWHO), ABDUCTION $457.83

L3961 SEWHO cap design w/o jnts CF $1,298.97

L3962 SEWHO, ABDUCTION POSITIONING, ERBS PALSEY DESIGN $446.98

L3967 SEWHO airplane w/o jnts CF $1,533.65

L3971 SEWHO cap design w/jnt(s) CF $1,455.76

L3973 SEWHO airplane w/jnt(s) CF $1,533.65

L3975 SEWHFO cap design w/o jnt CF $1,298.97

L3976 SEWHFO airplane w/o jnts CF $1,298.97

L3977 SEWHFO cap desgn w/jnt(s) CF $1,455.76

L3978 SEWHFO airplane w/jnt(s) CF $1,533.65

L3980 UPPER EXTREMITY FRACTURE ORTHOSIS, HUMERAL $192.59

L3982 UPPER EXTREMITY FRACTURE ORTHOSIS, RADIUS/ULNER $238.12

L3984 UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST $246.39

L3995 ADDITION TO UPPER EXTREMITY ORTHOSIS, SOCK, FRACTURE OR $20.37

L4000 REPLACE GIRDLE FOR MILWAUKEE ORTHOSIS $920.59

L4002 Replace strap, any orthosis $32.66

L4010 REPLACE TRILATERAL SOCKET BRIM $463.15


L4020 REPLACE QUADRILATERAL SOCKET BRIM, MOLDED TO PATIENT MO $548.35

L4030 REPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTED $321.42

L4040 REPLACE MOLDED THIGH LACER $271.27

L4045 REPLACE NON-MOLDED THIGH LACER $251.36

L4050 REPLACE MOLDED CALF LACER $262.83

L4055 REPLACE NON-MOLDED CALF LACER $170.19

L4060 REPLACE HIGH ROLL CUFF $269.75

L4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR AKO $179.17

L4080 REPLACE METAL BANDS KAFO-AFO, PROXIMAL THIGH $64.39

L4090 REPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGH $57.48

L4100 REPLACE METAL BANDS KAFO-AFO, PROXIMAL THIGH $66.40

L4110 REPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGH $54.71

L4130 REPLACE PRETIBIAL SHELL $362.99

L4205 Ortho dvc repair per 15 min $26.42

L4210 REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PART $37.87

L4350 PNEUMATIC ANKLE CONTROL SPLINT (AIRCAST OR EQUAL) $56.91

L4360 PNEUMATIC WALKING SPLINT (AIRCAST OR EQUAL) $190.23

L4361 Pneuma/vac walk boot pre ots $237.12

L4370 PNEUMATIC FULL LEG SPLINT (AIRCAST OR EQUAL) $131.83

L4386 Non-pneumatic walking splint $105.71

L4387 Non-pneum walk boot pre ots $136.03

L4392 Replace ankle contrac splint $19.63

L4394 Replace foot drop spint $14.34

L4396 Ankle contracture splint $97.50

L4397 Static or dynami afo pre ots $141.40

L4398 Foot drop splint recumbent $64.47

L4631 Afo, walk boot type, cus fab $1,169.26

L5000 PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE F $342.69

L5010 PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGHT, WITH TOE FIL $905.86

L5020 PARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBERCLE HEIGHT, WI $1,589.36

L5050 ANKLE, SYMES, MOLDED SOCKET, SACH FOOT $1,688.59

L5060 ANKLE, SYMES, METAL FRAME, MOLDED LEATHER SOCKET, ARTIC $2,288.74

L5100 BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT $1,576.36

L5105 BELOW KNEE, PLASTIC SOCKET, JOINTS AND THIGH LACER, SAC $2,584.77

L5150 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, $2,638.13

L5160 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, $2,905.30

L5200 ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS CONSTANT FRICTIO $2,240.60

L5210 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ("STUBBIES" $1,774.00

L5220 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ("STUBBIES" $2,044.08

L5230 ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL DEFICIENCY, CONS $3,440.25

L5250 HIP DISARTICULATION, CANADIAN TYPE; MOLDED SOCKET, HIP $4,420.41

L5270 HIP DISARTICULATION, TILT TABLE TYPE; MOLDED SOCKET, L $4,032.26

L5280 HEMIPELVECTOMY, CANADIAN TYPE; MOLDED SOCKET, HIP JOIN $4,580.29

L5301 BK mold socket SACH ft endo $1,971.76

L5312 Knee disart, SACH ft, endo $3,052.91

L5321 AK open end SACH $2,875.80

L5331 Hip disart canadian SACH ft $4,728.17

L5341 Hemipelvectomy canadian SACH $5,042.75

L5400 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION O $832.39


L5420 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION O $1,159.46




L5500 Init bk ptb plaster direct $1,147.52


L5505 Init ak ischal plstr direct $1,335.74

L5510 Prep BK ptb plaster molded $1,143.35

L5520 Perp BK ptb thermopls direct $975.35

L5530 Prep BK ptb thermopls molded $1,283.61

L5535 Prep BK ptb open end socket $1,150.18

L5540 Prep BK ptb laminated socket $1,377.77

L5560 Prep AK ischial plast molded $1,610.70

L5570 Prep AK ischial direct form $1,743.08

L5580 Prep AK ischial thermo mold $1,957.88

L5585 Prep AK ischial open end $1,963.02

L5590 Prep AK ischial laminated $2,085.33

L5595 PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, $2,730.98

L5600 PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, $3,015.81

L5610 ADDITIONS TO LOWER EXTREMITY, ABOVE KNEE, HYDRACADENCE $1,818.52

L5611 ADDITION TO LOWER EXTREMITY, ABOVE KNEE-KNEE DISARTICUL $1,457.05

L5613 ADDITION TO LOWER EXTREMITY, ABOVE KNEE-KNEE DISARTICUL $2,083.81

L5614 ADD. TO LOWER EXT. ABOVE KNEE, DISARTIC.,4-BAR LINK $2,958.90

L5616 ADDITIONS TO LOWER EXTREMITY, ABOVE KNEE, UNIVERSAL MUL $1,209.56

L5617 AK/BK self-aligning unit ea $435.68

L5618 ADDITIONS TO LOWER EXTREMITY, TEST SOCKET, SYMES $190.75

L5620 ADDITIONS TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEE $188.56

L5622 ADDITIONS TO LOWER EXTREMITY, TEST SOCKET, KNEE DISARTI $245.89

L5624 ADDITIONS TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEE $247.35

L5626 ADDITIONS TO LOWER EXTREMITY, TEST SOCKET, HIP DISARTIC $323.37

L5628 ADDITIONS TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVECTO $327.48

L5629 ADDITION TO LOWER EXTREMITY, BELOW KNEE, ACRYLIC SOCKET $215.56

L5630 ADDITIONS TO LOWER EXTREMITY, SYMES TYPE, EXPANDABLE WA $332.41

L5631 ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTI $298.01

L5632 ADDITIONS TO LOWER EXTREMITY, SYMES TYPE, "PTB" BRIM DE $185.13

L5634 ADDITIONS TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPE $275.08

L5636 ADDITIONS TO LOWER EXTREMITY, SYMES TYPE, MEDIAL OPENIN $230.43

L5637 ADDITION TO LOWER EXTREMITY, BELOW KNEE, TOTAL CONTACT $195.94

L5638 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, LEATHER SOCKE $440.10

L5639 ADDITION TO LOWER EXTREMITY, BELOW KNEE, WOOD SOCKET $1,013.93

L5640 ADDITIONS TO LOWER EXTREMITY, KNEE DISARTICULATION, LEA $578.25

L5642 ADDITIONS TO LOWER EXTREMITY, ABOVE KNEE, LEATHER SOCKE $560.29

L5643 ADDITION TO LOWER EXTREMITY, HIP DISARTICULATION, FLEXI $1,407.55

L5644 ADDITIONS TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKET $534.14

L5645 ADDITION TO LOWER EXTREMITY, BELOW KNEE, FLEXIBLE INNER $721.56

L5646 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, AIR CUSHION S $481.34

L5647 ADDITION TO LOWER EXTREMITY, BELOW KNEE SUCTION SOCKET $658.74

L5648 ADDITIONS TO LOWER EXTREMITY, ABOVE KNEE, AIR CUSHION S $595.40

L5649 ADDITION TO LOWER EXTREMITY, CAT-CAM SOCKET $1,437.88

L5650 ADDITIONS TO LOWER EXTREMITY, TOTAL CONTACT, ABOVE KNEE $441.48

L5651 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, FLEXIBLE INNER $1,086.03

L5652 ADDITIONS TO LOWER EXTREMITY, SUCTION SUSPENSION, ABOVE $394.27

L5653 ADDITIONS TO LOWER EXTREMITY, KNEE DISARTICULATION, EXP $526.32

L5654 ADDITIONS TO LOWER EXTREMITY, SOCKET INSERT, SYMES, (KE $226.13

L5655 ADDITIONS TO LOWER EXTREMITY, SOCKET INSERT, BELOW KNEE $179.89

L5656 ADDITIONS TO LOWER EXTREMITY, SOCKET INSERT, KNEE DISAR $259.64

L5658 ADDITIONS TO LOWER EXTREMITY, SOCKET INSERT, ABOVE KNEE $282.69

L5661 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROM $412.74

L5665 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROM $347.28

L5666 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, CUFF SUSPENSI $47.48

L5668 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, MOLDED DISTAL $68.50


L5670 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, MOLDED SUPREC $245.39

L5671 BK/AK locking mechanism $509.47

L5672 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, REMOVABLE MED $269.66

L5673 Socket insert w lock mech $582.04

L5676 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, $303.97

L5677 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, $334.42

L5678 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, JOINTS COVERS $35.06

L5679 Socket insert w/o lock mech $485.01

L5680 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, $252.04

L5681 Intl custm cong/latyp insert $1,121.88

L5682 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, $424.18

L5683 Initial custom socket insert $1,121.88

L5684 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, FORK STRAP $33.29

L5685 Below knee sus/seal sleeve $109.03

L5686 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, BACK CHECK (E $40.93

L5688 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, W $41.42

L5690 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, P $66.36

L5692 ADDITIONS TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTRO $93.27

L5694 ADDITIONS TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTRO $137.17

L5695 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL $134.46

L5696 ADDITIONS TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISART $125.50



L5699 ALL LOWER EXTREMITY PROSTHESIS, SHOULDER HARNESS $126.46

L5700 REPL. SOCKET, BELOW KNEE, MOLDED TO PATIENT MODEL $1,924.62

L5701 REPL. SOCKET, ABOVE KNEE DISARTICULATION, INC. ATTACHME $2,568.80

L5702 REPL. SOCKET, HIP DISARTICULATION, INCL. HIP JOIN, MOLD $3,540.57

L5703 Symes ankle w/o (SACH) foot $1,893.95

L5704 REPL. CUSTOM SHAPED PROTECTIVE COVER, BELOW KNEE $401.63

L5705 REPLACEMENT, CUSTOM SHAPED PROTECTIVE COVER, ABOVE KNEE $681.95

L5706 REPL. CUSTOM SHAPED PROTECTIVE COVER, KNEE DISARTICULAT $672.88

L5707 REPL. CUSTOM SHAPED PROCTECTIVE COVER HIP DISARTICULATI $928.37

L5710 ADDITIONS, KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK $287.85

L5711 ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MA $354.15

L5712 ADDITIONS, KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWIN $292.26

L5714 ADDITIONS, KNEE-SHIN SYSTEM, SINGLE AXIS, VARIABLE FRIC $344.24

L5716 ADDITIONS, KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL ST $659.11

L5718 ADDITIONS, KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWIN $823.81

L5722 ADDITIONS, KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWI $681.26

L5724 ADDITIONS, KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING P $1,070.02

L5726 ADDITIONS, KNEE-SHIN SYSTEM, SINGLE AXIS, EXTERNAL JOIN $1,179.86

L5728 ADDITIONS, KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING A $1,942.70

L5780 ADDITIONS, KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/HYD $779.52

L5781 Lower limb pros vacuum pump $3,405.73

L5782 HD low limb pros vacuum pump $3,590.41

L5785 ADDITION, EXOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT M $352.38

L5790 ADDITION, EXOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT M $487.68

L5795 ADDITION, EXOSKELETAL SYSTEM, HIP DISARTICULATION, ULTR $728.23

L5810 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, M $366.61

L5811 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, M $640.74

L5812 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, F $471.65

L5814 Endo knee-shin hydral swg ph $3,161.18

L5816 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, M $769.08

L5818 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, F $868.47

L5822 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, P $1,277.46


L5824 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, F $1,386.85

L5826 Miniature knee joint $2,658.17

L5828 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, F $2,153.79

L5830 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, P $1,287.01

L5840 ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, MULTIAXIAL, PN $1,918.94

L5845 Knee-shin sys stance flexion $1,525.62

L5848 Knee-shin sys hydraul stance $915.27

L5850 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISART $115.69

L5855 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, MEC $277.68

L5856 Elec knee-shin swing/stance $20,418.89

L5857 Elec knee-shin swing only $7,236.11

L5858 Stance phase only $15,819.33

L5910 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ALIGNABLE SY $327.53

L5920 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISART $476.53

L5925 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE DISARTI $303.86

L5930 High activity knee frame $2,856.06

L5940 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT $453.61

L5950 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT $548.28

L5960 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, ULT $653.86

L5961 Endo poly hip, pneu/hyd/rot $4,292.11

L5962 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, FLEXIBLE PRO $507.90

L5964 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, FLEXIBLE PRO $717.74

L5966 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, FLE $912.71

L5968 Multiaxial shck absorb ankle $3,093.11

L5969 ak/ft power asst incl motors $12,473.51

L5970 ALL LOWER EXTREMITY PROSTHESES, FOOT, EXTERNAL KEEL, SA $154.00

L5971 SACH foot, replacement $190.07

L5972 ALL LOWER EXTREMITY PROSTHESES, FLEXIBLE KEEL FOOT (SAF $298.61

L5973 Ank-foot sys dors-plant flex $14,845.42

L5974 ALL LOWER EXTREMITY PROSTHESES, FOOT, SINGLE AXIS ANKLE $160.26

L5975 Combo ankle/foot prosthesis $394.61

L5976 ALL LOWER EXTREMITY PROSTHESES, ENERGY STORING FOOT (SE $410.12

L5978 ALL LOWER EXTREMITY PROSTHESES, FOOT, MULTIAXIAL ANKLE/ $197.93

L5979 ALL LOWER EXTREMITY PROSTHESES, MULTIAXIAL ANKLE/FOOT, $1,873.35

L5980 ALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEM $3,353.01

L5981 ALL LOWER EXTREMITY PROSTHESES, FLEX-WALK SYSTEM OR EQU $2,191.11

L5982 ALL EXOSKELETAL LOWER EXTREMITY PROSTHESES, AXIAL ROTAT $522.80

L5984 ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESES, AXIAL ROTA $409.13

L5985 Lwr ext dynamic prosth pylon $239.59

L5986 ALL LOWER EXTREMITY PROSTHESES, MULTI-AXIAL ROTATION UN $573.05

L5987 Shank ft w vert load pylon $6,123.17

L5988 Verticalshock/rotation pylon $1,700.37

L5990 User adjustable heel height $1,544.22

L6000 PARTIAL HAND, ROBIN-AIDS, THUMB REMAINING (OR EQUAL) $901.18

L6010 PARTIAL HAND, ROBIN-AIDS, LITTLE AND/OR RING FINGER REM $1,067.72

L6020 PARTIAL HAND, ROBIN-AIDS, NO FINGER REMAINING (OR EQUAL $950.52

L6025 Part hand disart myoelectric $6,811.45

L6050 WRIST DISARTICULATION, MOLDED SOCKET, FLEXIBLE ELBOW HI $1,386.51

L6055 WRIST DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE IN $1,919.61

L6100 BELOW ELBOW, MOLDED SOCKET, FLEXIBLE ELBOW HINGE, TRICE $1,372.41

L6110 BELOW ELBOW, MOLDED SOCKET, (MUENSTER OR NORTHWESTERN S $1,416.37

L6120 BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STEP-UP H $1,778.29

L6130 BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STUMP ACT $1,788.29

L6200 ELBOW DISARTICULATION, MOLDED SOCKET, OUTSIDE LOCKING H $2,068.15

L6205 ELBOW DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE IN $2,533.02


L6250 ABOVE ELBOW, MOLDED DOUBLE WALL SOCKET, INTERNAL LOCKIN $1,841.38

L6300 SHOULDER DISARTICULATION, MOLDED SOCKET, SHOULDER BULKH $2,700.03

L6310 SHOULDER DISARTICULATION, PASSIVE RESTORATION (COMPLETE $2,058.22

L6320 SHOULDER DISARTICULATION, PASSIVE RESTORATION (SHOULDER $1,235.69

L6350 INTERSCAPULAR THORACIC, MOLDED SOCKET, SHOULDER BULKHEA $3,102.37

L6360 INTERSACPULAR THORACIC, PASSIVE RESTORATION (COMPLETE P $2,160.35

L6370 INTERSCAPULAR THORACIC, PASSIVE RESTORATION (SHOULDER C $1,377.59




L6386 IMMEDIATE POST SURGICAL OR EARLY FITTING, EACH ADDITION $272.36


L6400 BELOW ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUD $2,098.41

L6450 ELBOW DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYST $2,788.15

L6500 ABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUD $2,741.82

L6550 SHOULDER DISATICULATION, MOLDED SOCKET, ENDOSKELETAL SY $3,429.46

L6570 INTERSCAPULAR THORACIC, MOLDED SOCKET, ENDOSKELETAL SYS $3,568.31

L6580 PREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SING $1,275.85

L6582 PREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SING $1,244.64

L6584 PREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SING $1,388.25

L6586 PREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SING $1,444.40

L6588 PREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR $1,917.10

L6590 PREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR $1,922.73

L6600 UPPER EXTREMITY ADDITIONS, POLYCENTRIC HINGE, PAIR $127.22

L6605 UPPER EXTREMITY ADDITIONS, SINGLE PIVOT HINGE, PAIR $125.61

L6610 UPPER EXTREMITY ADDITIONS, FLEXIBLE METAL HINGE, PAIR $114.95

L6611 Additional switch, ext power $350.45

L6615 UPPER EXTREMITY ADDITIONS, DISCONNECT LOCKING WRIST UNI $132.42

L6616 UPPER EXTREMITY ADDITION, ADDITIONAL DISCONNECT INSERT $43.99

L6620 UPPER EXTREMITY ADDITIONS, FLEXION-FRICTION WRIST UNIT $230.75

L6621 Flex/ext wrist w/wo friction $1,946.93

L6623 UPPER EXTREMITY ADDITION, SPRING ASSISTED ROTATIONAL WR $435.07

L6624 Flex/ext/rotation wrist unit $3,205.65

L6625 UPPER EXTREMITY ADDITIONS, ROTATION WRIST UNIT WITH CAB $360.72

L6628 UPPER EXTREMITY ADDITION, QUICK DISCONNECT HOOK ADAPTER $433.23

L6629 UPPER EXTREMITY ADDITION, QUICK DISCONNECT LAMINATION C $124.33

L6630 UPPER EXTREMITY ADDITIONS, STAINLESS STEEL, ANY WRIST $146.19

L6632 UPPER EXTREMITY ADDITION, LATEX SUSPENSION SLEEVE, EACH $58.75

L6635 UPPER EXTREMITY ADDITIONS, LIFT ASSIST FOR ELBOW $140.51

L6637 UPPER EXTREMITY ADDITION, NUDGE CONTROL ELBOW LOCK $249.05

L6638 Elec lock on manual pw elbow $2,128.58

L6640 UPPER EXTREMITY ADDITIONS, SHOULDER ABDUCTION JOINT, PA $198.94

L6641 UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, PULLEY T $109.50

L6642 UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, LEVER TY $147.49

L6645 UPPER EXTREMITY ADDITIONS, SHOULDER FLEXION-ABDUCTION J $216.52

L6646 Multipo locking shoulder jnt $2,684.62

L6647 Shoulder lock actuator $442.02

L6648 Ext pwrd shlder lock/unlock $2,768.80

L6650 UPPER EXTREMITY ADDITIONS, SHOULDER UNIVERSAL JOINT, EA $229.58

L6655 UPPER EXTREMITY ADDITIONS, STANDARD CONTROL CABLE, EXTR $50.95

L6660 UPPER EXTREMITY ADDITIONS, HEAVY DUTY CONTROL CABLE $63.76

L6665 UPPER EXTREMITY ADDITIONS, TEFLON, OR EQUAL, CABLE LINI $32.52

L6670 UPPER EXTREMITY ADDITIONS, HOOK TO HAND, CABLE ADAPTER $32.52

L6672 UPPER EXTREMITY ADDITIONS, HARNESS, CHEST OR SHOULDER, $137.15

L6675 UPPER EXTREMITY ADDITIONS, HARNESS, FIGURE OF ("8") EIG $81.45


L6676 UPPER EXTREMITY ADDITIONS, HARNESS, FIGURE OF ("8") EIG $96.03

L6677 UE triple control harness $252.49

L6680 UPPER EXTREMITY ADDITIONS, TEST SOCKET, WRIST DISARTICU $166.67

L6682 UPPER EXTREMITY ADDITIONS, TEST SOCKET, ELBOW DISARTICU $181.66

L6684 UPPER EXTREMITY ADDITIONS, TEST SOCKET, SHOULDER DIS- A $258.25

L6686 UPPER EXTREMITY ADDITION, SUCTION SOCKET $400.41

L6687 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, BELOW ELBO $521.65

L6688 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, ABOVE ELBO $359.30

L6689 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, SHOULDER D $609.34

L6690 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, INTERSCAPU $466.38

L6691 UPPER EXTREMITY ADDITION, REMOVABLE INSERT, EACH $234.12

L6692 UPPER EXTREMITY ADDITION, SILICONE GEL INSERT OR EQUAL, $474.57

L6693 Lockingelbow forearm cntrbal $2,416.50

L6694 Elbow socket ins use w/lock $634.24

L6695 Elbow socket ins use w/o lck $528.51

L6696 Cus elbo skt in for con/atyp $1,121.88

L6697 Cus elbo skt in not con/atyp $1,121.88

L6698 Below/above elbow lock mech $555.16

L6703 Term dev, passive hand mitt $309.60

L6704 Term dev, sport/rec/work att $602.65

L6706 Term dev mech hook vol open $387.38

L6707 Term dev mech hook vol close $1,196.34

L6708 Term dev mech hand vol open $833.66

L6709 Term dev mech hand vol close $1,292.73

L6711 Ped term dev, hook, vol open $572.30

L6712 Ped term dev, hook, vol clos $1,053.65

L6713 Ped term dev, hand, vol open $1,329.80

L6714 Ped term dev, hand, vol clos $1,126.33

L6721 Hook/hand, hvy dty, vol open $2,001.94

L6722 Hook/hand, hvy dty, vol clos $1,725.83

L6805 TERMINAL DEVICE, MODIFIER WRIST FLEXION UNIT $241.52

L6810 TERMINAL DEVICE, PINCHER TOOL, OTTO BOCK OR EQUAL $149.32

L6881 Autograsp feature ul term dv $3,479.80

L6882 Microprocessor control uplmb $2,639.65

L6883 Replc sockt below e/w disa $1,434.65

L6884 Replc sockt above elbow disa $1,868.80

L6885 Replc sockt shldr dis/interc $2,666.27

L6890 TERMINAL DEVICE, GLOVES FOR ABOVE HANDS, PRODUCTION GLO $123.25

L6895 TERMINAL DEVICES, GLOVES FOR ABOVE HANDS, CUSTOM GLOVE $387.09

L6900 HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLU $1,024.47

L6905 HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS, INCL $995.82

L6910 HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLU $970.13

L6915 HAND RESTORATION (SHADING, AND MEASUREMENTS INCLUDED), $424.60

L6920 WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED I $5,502.27

L6925 WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED I $5,934.39

L6930 BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKE $5,781.20

L6935 BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKE $6,206.83

L6940 ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOC $7,934.39

L6945 ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOC $9,230.74

L6950 ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOV $9,018.55

L6955 ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOV $10,800.95

L6960 SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER $10,893.56

L6965 SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER $11,802.58

L6970 INTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SO $11,948.29

L6975 INTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SO $12,801.39


L7007 Adult electric hand $3,984.06

L7008 Pediatric electric hand $3,984.06

L7009 Adult electric hook $3,016.17

L7040 PREHENSILE ACTUATOR, HOSMER OR EQUAL, SWITCH CONTROLLED $1,912.11

L7045 ELECTRONIC HOOK, CHILD, MICHIGAN OR EQUAL, SWITCH CONTR $1,096.28

L7170 ELECTRONIC ELBOW, HOSMER OR EQUAL, SWITCH CONTROLLED $4,172.75

L7180 ELECTRONIC ELBOW, UTAH OR EQUAL, MYOELECTRONICALLY CONT $24,216.55

L7181 Electronic elbo simultaneous $34,105.13

L7185 ELECTRONIC ELBOW, VARIETY VILLAGE OR EQUAL, SWITCH CONT $4,329.15

L7186 ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, SWIT $7,846.16

L7190 ELECTRONIC ELBOW, VARIETY VILLAGE OR EQUAL, MYOELECTRON $5,477.23

L7191 ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, MYOE $8,038.99

L7260 ELECTRONIC WRIST ROTATOR, OTTO BOCK OR EQUAL $1,556.58

L7261 ELECTRONIC WRIST ROTATOR, FOR UTAH ARM $2,948.87

L7360 SIX VOLT BATTERY, OTTO BOCK OR EQUAL, EACH $154.24

L7362 BATTERY CHARGER, SIX VOLT, OTTO BOCK OR EQUAL $226.56

L7364 TWELVE VOLT BATTERY, UTAH OR EQUAL, EACH $270.27

L7366 BATTERY CHARGER, TWELVE VOLT, UTAH OR EQUAL $364.07

L7367 Replacemnt lithium ionbatter $331.38

L7368 Lithium ion battery charger $429.60

L7400 Add UE prost be/wd, ultlite $260.89

L7401 Add UE prost a/e ultlite mat $292.06

L7402 Add UE prost s/d ultlite mat $315.41

L7403 Add UE prost b/e acrylic $313.45

L7404 Add UE prost a/e acrylic $473.10

L7405 Add UE prost s/d acrylic $618.72

L7510 REPAIR PROSTHETIC DEVICE, REPAIR OR REPLACE MINOR PARTS $258.07

L7520 Repair prosthesis per 15 min $14.13

L8000 BREAST PROSTHESES, MASTECTOMY BRA $25.50

L8001 Breast prosthesis bra & form $106.76

L8002 Brst prsth bra & bilat form $140.45

L8010 BREAST PROSTHESES, MASTECTOMY SLEEVE $83.75

L8015 Ext breastprosthesis garment $51.03

L8020 BREAST PROSTHESES, MASTECTOMY FORM $136.07

L8030 BREAST PROSTHESIS, SILICONE OR EQUAL $241.44

L8031 Breast prosthesis w adhesive $298.00

L8035 Custom breast prosthesis $3,118.39

L8040 Nasal prosthesis $1,966.06

L8041 Midfacial prosthesis $2,369.87

L8042 Orbital prosthesis $2,662.77

L8043 Upper facial prosthesis $2,982.31

L8044 Hemi-facial prosthesis $3,301.82

L8045 Auricular prosthesis $2,067.42

L8046 Partial facial prosthesis $2,130.20

L8047 Nasal septal prosthesis $1,091.72

L8400 PROSTHETIC SHEATH, BELOW KNEE, EACH $10.68

L8410 PROSTHETIC SHEATH, ABOVE KNEE, EACH $14.86

L8415 PROSTHETIC SHEATH, UPPER LIMB, EACH $16.05

L8417 Pros sheath/sock w gel cushn $64.00

L8420 PROSTHETIC SOCK, WOOL, BELOW KNEE, EACH $13.20

L8430 PROSTHETIC SOCK, WOOL, ABOVE KNEE, EACH $16.66

L8435 PROSTHETIC SOCK, WOOL, UPPER LIMB, EACH $14.26

L8440 PROSTHETIC SHRINKER, BELOW KNEE, EACH $28.36

L8460 PROSTHETIC SHRINKER, ABOVE KNEE, EACH $45.21

L8465 PROSTHETIC SHRINKER, UPPER LIMB, EACH $33.09


L8470 STUMP SOCK, SINGLE PLY, FITTING, BELOW KNEE, EACH $6.04

L8480 STUMP SOCK, SINGLE PLY, FITTING, ABOVE KNEE, EACH $8.33

L8485 STUMP SOCK, SINGLE PLY, FITTING, UPPER LIMB, EACH $9.02

L8500 ARTIFICIAL LARYNX, ANY TYPE $447.60

L8501 TRACHEOSTOMY SPEAKING VALVE $81.93

L8507 Trach-esoph voice pros pt in $35.64

L8509 Trach-esoph voice pros md in $92.94

L8510 Voice amplifier $215.09

L8511 Indwelling trach insert $61.90

L8512 Gel cap for trach voice pros $1.87

L8513 Trach pros cleaning device $4.43

L8514 Repl trach puncture dilator $80.27

L8515 Gel cap app device for trach $53.73

L8600 IMPLANTABLE BREAST PROSTHESIS, SILICONE OR EQUAL $696.95

L8603 Collagen imp urinary 2.5 CC $366.55

L8606 Synthetic implnt urinary 1ml $184.73

L8610 OCULAR $653.27

L8612 AQUEOUS SHUNT $563.07

L8613 OSSICULA $215.24

L8614 COCHLEAR DEVICE/SYSTEM $16,251.77

L8615 HEADSET/HEADPIECE FOR COCHLEAR IMPLANT DEVICE $384.68

L8616 MICROPHONE FOR COCHLEAR IMPLANT DEVICE $89.57

L8617 TRANSMITTING COIL FOR COCHLEAR IMPLANT DEVICE $78.24

L8618 TANSMITTER CABLE FOR COCHLEAR IMPLANT DEVICE $22.37

L8619 REPLACE COCHLEAR PROCESSOR $6,976.76

L8621 ZINC AIR BATTERY FOR COCHLEAR IMPLANT DEVICE $0.53

L8622 ALKALINE BATTERY FOR COCHLEAR IMPLANT DEVICE $0.28

L8623 LITHIUM BATTERY FOR COCHLEAR IMPLANT $55.18

L8624 LITHIUM ION BATTERY FOR COCHLEAR IMPLANT $137.52

L8630 METACARPOPHALANGEAL JOINT $370.74

L8631 MCP joint repl 2 pc or more $1,847.82

L8641 METATARSAL JOINT $390.69

L8642 HALLUX IMPLANT $255.74

L8658 INTERPHALANGEAL JOINT $340.64

L8659 Interphalangeal joint repl $1,645.80

L8670 VASCULAR GRAFT MATERIAL, SYNTHETIC $465.97

L8679 LMP neurosti pls gn any type $7,265.66

L8681 Pt prgrm for implt neurostim $903.04

L8689 External recharging system $1,471.18

L8690 AUDITORY OSSEOINTEGRATED DEVICE $4,057.32

L8691 Osseointegrated snd proc rpl $2,274.23

L8693 Aud osseo dev, abutment $1,293.25

L8695 External recharg sys extern $14.21

V2623 PROSTHETIC EYE, PLASTIC, CUSTOM $730.35

V2624 POLISHING/RESURFACING OF OCULAR PROSTHESIS $59.55

V2625 ENLARGEMENT OF OCULAR PROSTHESIS $375.28

V2626 REDUCTION OF OCULAR PROSTHESIS $153.41

V2627 SCLERAL COVER SHELL $1,287.51

V2628 FABRICATION AND FITTING OF OCULAR CONFORMER $311.94

V5050 Hearing aid monaural in ear $607.78

V5060 HEARING AID, MONAURAL, BEHIND THE EAR $590.09

V5130 BINAURAL, IN THE EAR $1,056.59

V5140 BINAURAL, BEHIND THE EAR $1,056.59

V5264 Ear mold/insert $48.00

V5299 HEARING AID, NOT OTHERWISE CLASSIFIED $211.32


W4020 MISCELANEOUS NUTRITIONAL THERP/SUPPLMT $1.48

NOTE: Fee schedules are subject to review and amendment under

the provisions of § 67:16:01:28. A provider may request that the

department review a particular reimbursement rate for possible

adjustment or request the inclusion or exclusion of a particular code

from the list. When reviewing the requests, the department shall review

paid claims information, Medicare fee schedules, national coding lists,

and documentation submitted by the provider or the associated medical

professional organization to determine whether a change is warranted.

DURABLE MEDICAL EQUIPMENT & SUPPLIESdss.sd.gov/sdmedx/docs/providers/feeschedules/DME 2.5.14...

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