Procedure Code - PDF document

Procedure CodeDescriptionRateE0100CA
Procedure CodeDescriptionRateE0100CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIP$17.02E0105CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIPS$42.61E0110$60.57E0111CRUTCH FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED, EACH, WITH TIP AND HANDGRIPS$48.91E0112CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS$28.88E0113CRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIXED, EACH, WITH PAD, TIP AND HANDGRIP$19.41E0114$43.34E0116CRUTCH UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, EACH, WITH PAD, TIP AND HANDGRIP$25.48E0117CRUTCH, UNDERARM, ARTICULATION, SPRING ASSISTED, EACH$176.99E0130WALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHT$47.26E0135$56.41E0140WALKER, WITH TRUNK SUPPORT, ADJUSTABLE OR FIXED HEIGHT, ANY TYPE$285.52E0141RIGID WALKER, WHEELED, WITHOUT SEAT$77.57E0143FOLDING WALKER, WHEELED, WITHOUT SEAT$80.89E0144$252.07E0147HEAVY DUTY, MULTIPLE BREAKING SYSTEM, VARIABLE WHEEL RESISTANCE WALKER$454.99E0148WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH$100.58E0149WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE,EACH$176.68E0153$54.16E0154PLATFORM ATTACHMENT, WALKER, EACH$52.46E0155WHEEL ATTACHMENT, RIGID PICK-UP WALKER, PER PAIR$24.98E0156SEAT ATTACHMENT, WALKER$19.49E0157CRUTCH ATTACHMENT, WALKER, EACH$64.85E0158$25.47E0159BRAKE ATTACHMENT FOR WHEELED WALKER, REPLACEMENT, EACH$14.10E0160SITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODE$30.36E0161SITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODE, WITH FAUCET ATTACHMENTS$24.08E0162SITZ BATH CHAIR$113.74E0163COMMODE CHAIR, STATIONARY, WITH FIXED ARMS$86.09Procedure CodeDescriptionRateE0165COMMODE CHAIR, STATIONARY, WITH DETACHABLE ARMS$167.22E0167PAIL OR PAN FOR USE WITH COMMODE CHAIR$11.03E0168COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE,WITH OR WITHOUT ARMS, ANY TYPE, EACH$138.60E0170COMMODE CHAIR WITH INTERGRATED SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE$1,446.48E0171COMMODE CHAIR WITH INTERGRATED SEAT L

IFT MECHANISM, NON-ELECTRIC, ANY TYPE$2
IFT MECHANISM, NON-ELECTRIC, ANY TYPE$260.28E0175FOOT REST, FOR USE WITH COMMODE CHAIR, EACH$60.82E0181PRESSURE PAD, ALTERNATING WITH PUMP, HEAVY DUTY$184.23E0182PUMP FOR ALTERNATING PRESSURE PAD$200.25E0184DRY PRESSURE MATTRESS$178.81E0185GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH$293.74E0186AIR PRESSURE MATTRESS$167.40E0187WATER PRESSURE MATTRESS$177.57E0188SYNTHETIC SHEEPSKIN PAD$20.63E0189LAMBSWOOL SHEEPSKIN PAD, ANY SIZE$47.73E0191HEEL OR ELBOW PROTECTOR, EACH$9.17E0193POWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY)$6,911.46E0194AIR FLUIDIZED BED$27,368.64E0196GEL PRESSURE MATTRESS$248.58E0197AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH$203.50E0198WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH$203.50E0199DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH$27.04E0200HEAT LAMP, WITHOUT STAND (TABLE MODEL), INCLUDES BULB, OR INFRARED ELEMENT$72.81E0202PHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOTOMETER$478.98E0203THERAPEUTIC LIGHTBOX, MINIMUM 10,000 LUX, TABLE TOP MODEL$0.00E0205HEAT LAMP, WITH STAND, INCLUDES BULB, OR INFRARED ELEMENT$169.85E0210ELECTRIC HEAT PAD, STANDARD$29.98E0215ELECTRIC HEAT PAD, MOIST$65.06E0217WATER CIRCULATING HEAT PAD WITH PUMP$455.95E0218WATER CIRCULATING COLD PAD WITH PUMP$0.01E0221INFRARED HEATING PAD SYSTEM$2,113.46E0225HYDROCOLLATOR UNIT, INCLUDES PADS$356.92E0235PARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)$132.03E0236PUMP FOR WATER CIRCULATING PAD$338.49E0239HYDROCOLLATOR UNIT, PORTABLE$413.11Procedure CodeDescriptionRateE0249PAD FOR WATER CIRCULATING HEAT UNIT, FOR REPLACEMENT ONLY$91.48E0250HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS$758.61E0251HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS$666.72E0255HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS$898.74E0256HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS$750.15E0260HOSPITAL BED, SEIMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT)

, WITH ANY TYPE SIDE RAILS, WITH MATTRES
, WITH ANY TYPE SIDE RAILS, WITH MATTRESS$1,289.88E0261HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS$1,047.60E0265HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITH MATTRESS$1,529.10E0266HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS$1,358.55E0271MATTRESS, INNERSPRING$149.39E0272MATTRESS, FOAM RUBBER$160.18E0274OVER-BED TABLE$150.00E0275BED PAN, STANDARD, METAL OR PLASTIC$12.96E0276BED PAN, FRACTURE, METAL OR PLASTIC$12.23E0277POWERED PRESSURE-REDUCING AIR MATTRESS$6,834.24E0280BED CRADLE, ANY TYPE$25.70E0290HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS$672.66E0291HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS$488.70E0292HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESS$672.39E0293HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITHOUT MATTRESS$547.02E0294HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITH MATTRESS$999.45E0295HOSPITAL BED,SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITHOUT MATTRESS$974.25E0296HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS). WITHOUT SIDE RAILS, WITH MATTRESS$1,256.13E0297HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS, WITHOUT MATTRESS$1,076.13E0300PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED$2,246.91E0301HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO$4,248.54Procedure CodeDescriptionRateE0302HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE$3,460.95E0303HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO$2,325.42E0304HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE$6,936.03E0305BED SIDE RAILS, HALF LENGTH$145.53E0310BED SIDE RAILS, FULL LENGTH$153.67E0316SAFETY ENCLOSURE FRAM

E/CANOPY FOR USE WITH HOSPITAL BED, ANY
E/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE$1,901.52E0325URINAL; MALE, JUG-TYPE, ANY MATERIAL$7.89E0326URINAL; FEMALE, JUG-TYPE, ANY MATERIAL$9.65E0328HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS$0.00E0329HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD$0.00E0370AIR PRESSURE ELEVATOR FOR HEEL$24.80E0371NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH$3,400.29E0372POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH$4,125.96E0373NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS$4,700.70E0424STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTENTS (PER UNIT), REGULATOR, FLOWMETER, HUMID$0.00E0431PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING$0.00E0434PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, R$0.00E0439STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES USE OF RESERVOIR, CONTENTS (PER UNIT), REGULATOR, FLOWMETER,$0.00E0441STATIONARY OXYGEN CONTENTS, GASEOUS,1 MONTH'S SUPPLY=1 UNIT$65.83E0442STATIONARY OXYGEN CONTENTS, LIQUID,1 MONTH'S SUPPLY=1 UNIT$65.83E0443PORTABLE OXYGEN CONTENTS, GASEOUS,1 MONTH'S SUPPLY=1 UNIT$65.83E0444PORTABLE OXYGEN CONTENTS, LIQUID,1 MONTH'S SUPPLY=1 UNIT$65.83E0445OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON- INVASIVELY$1,850.00E0450VOLUME VENTILATOR, STATIONARY OR PORTABLE, WITH BACKUP RATE FEATURE, USED WITH$0.21E0455OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTS$30.00Procedure CodeDescriptionRateE0457CHEST SHELL (CUIRASS)$564.35E0458NEGATIVE PRESSURE PUMP$3,258.37E0459CHEST WRAP$458.01E0460NEGATIVE PRESSURE VENTILATOR; PORTABLE OR STATIONARY$0.00E0461VOLUME VENTILATOR; STATIONARY OR PORTABLE, WITH BACK UP RATE FEATURE, USED WITH NON-INVASIVE INTERFACE$0.00E0462ROCKING BED WITH OR WITHOUT SIDE RAILS$2,229.21E0463PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE$0.00E0464PRESSURE SUPPORT

VENTILATOR WITH VOLUME CONTROL MODE, MA
VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE$0.01E0470RESPIRATORY ASSIST DEVICE, BI LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NONINVASICE$2,141.01E0471RESPIRATORY ASSIST DEVICE, BI LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE, USED WITH NONINVASIVE$0.01E0472RESPIRATORY ASSIST DEVICE, BI LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE, USED WITH INVASIVE$0.01E0480PERCUSSOR, ELECTRIC OR PNEUMATIC, HOME MODEL$336.15E0482COUGH STIMULATING DEVICE, ALTERNATION POSITIVE AND NEGATIVE AIRWAY PRESSURE$3,289.68E0483HIGH FREQUENCY CHEST WALL OSCILLATION AIR PULSE GENERATOR SYSTEM, (INCLUDES HOSES AND VEST), EACH$9,568.17E0484OSCILLATORY POSITIVE EXPIRATORY PRESSURE DEVICE, NON-ELECTRIC, ANY TYPE, EACH$33.98E0485ORAL DEVICE/ APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, PREFABRICATED$0.00E0486ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, CUSTOM$0.00E0500IPPB MACHINE, ALL TYPES, WITH BUILT-IN NEBULIZATION; MANUAL OR AUTOMATIC VALVES; INTERNAL OR EXTERNAL POWER SO$1,009.26E0550HUMIDIFIER, DURABLE FOR EXTENSIVE SUPPLEMENTAL HUMIDIFICATION DURING IPPB TREATMENTS OR OXYGEN DELIVERY$426.10E0555HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER$0.00E0560HUMIDIFIER, DURABLE FOR SUPPLEMENTAL HUMIDIFICATION DURING IPPB TREATMENT OR OXYGEN DELIVERY$135.77E0561HUMIDIFIER, NON HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE$84.70E0562HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE$238.44Procedure CodeDescriptionRateE0565COMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT SELF- CONTAINED OR CYLINDER DRIVEN$549.09E0570NEBULIZER, WITH COMPRESSOR$177.57E0572AEROSOL COMPRESSOR, ADJUSTABLE PRESSURE, LIGHT DUTY FOR INTERMITTENT USE$291.42E0574ULTRASONIC GENERATOR WITH SMALL VOLUME ULTRASONIC NEBULIZER$307.98E0575NEBULIZER; ULTRASONIC$944.91E0580NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER$106.11E0585NUBULIZER, WITH COMPRESSOR AND HEATER$315.63E0600SUCTIO

N PUMP, HOME MODEL, PORTABLE$412.11E06
N PUMP, HOME MODEL, PORTABLE$412.11E0601CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE$864.41E0602BREAST PUMP, MANUAL, ANY TYPE$27.11E0603BREAST PUMP, ELECTRIC (AC AND/OR DC), ANY TYPE$0.00E0604BREAST PUMP, HEAVY DUTY, HOSPITAL GRADE, PISTON OPERATED PULSATILE VACUUM SUCTION/RELEASE CYCLES, VACUUM REGUL$0.21E0605VAPORIZER, ROOM TYPE$23.87E0606POSTURAL DRAINAGE BOARD$175.50E0607HOME BLOOD GLUCOSE MONITOR$61.36E0610PACEMAKER MONITOR, SELF-CONTAINED, (CHECKS BATTERY DEPLETION, INCLUDES AUDIBLE AND VISIBLE CHECK SYSTEMS)$185.68E0615PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION AND OTHER PACEMAKER COMPONENTS, INCLUDES DIGITAL/V$439.73E0618APNEA MONITOR, WITHOUT RECORDING FEATURE$2,523.15E0619APNEA MONITOR, WITH RECORDING FEATURE$2,413.80E0620SKIN PIERCING DEVICE FOR COLLECTION OF CAPILLARY BLOOD, LASER, EACH$803.02E0621SLING OR SEAT, PATIENT LIFT, CANVAS OR NYLON$88.16E0625PATIENT LIFT, KARTOP, BATHROOM OR TOILET$0.00E0627SEAT LIFT MECHANISM INCORPORATED INTO A COMBINATION LIFT-CHAIR MECHANISM$309.79E0628SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-ELECTRIC$309.79E0629SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-NON-ELECTRIC$303.72E0630PATIENT LIFT, HYDRAULIC, WITH SEAT OR SLING$877.05E0635PATIENT LIFT, ELECTRIC WITH SEAT OR SLING$936.09E0636MULTIPOSITIONAL PATIENT SUPPORT SYSTEM, WITH INTEGRATED LIFT, PATIENT ACCESSIBLE CONTROLS$9,491.04Procedure CodeDescriptionRateE0637COMBINATION SIT TO STAND SYSTEM, ANY SIZE, WITH SEAT LIFT FEATURE, WITH OR WITHOUT WHEELS$0.00E0638STANDING FRAME SYSTEM, ANY SIZE, WITH OR WITHOUT WHEELS$0.00E0639PATIENT LIFT, MOVEABLE FROM ROOM TO ROOM WITH DISASSEMBLY AND REASSEMBLY,$0.00E0640PATIENT LIFT, FIXED SYSTEM, INCLUDES ALL COMPONENTS/ACCESSORIES$0.00E0641STANDING FRAME SYSTEM, MULTI-POSITION, ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS$0.00E0642STANDING FRAME SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC$0.00E0650PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL, (LYMPHEDEMA PUMP)$661.43E0651PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL (LYMPHEDEMA PUMP) WITHOUT

CALIBRATED GRADIENT PRESSURE$843.46E06
CALIBRATED GRADIENT PRESSURE$843.46E0652PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL (LYMPHEDEMA PUMP) WITH CALIBRATED GRADIENT PRESSURE$4,864.36E0655PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF ARM$91.88E0660PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG$142.88E0665PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM$124.71E0666PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG$124.71E0667PNEUMATIC APPLIANCE FOR USE WITH SEGMENTAL PNEUMATIC COMPRESSOR, LEG$297.34E0668PNEUMATIC APPLIANCE FOR USE WITH SEGMENTAL PNEUMATIC COMPRESSOR, ARM$405.81E0669SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG$166.25E0670SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, INTERGRATED, 2 FULL LEGS AND TRUNK$1,163.68E0671SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEG$381.45E0672SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL ARM$296.39E0673SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALF LEG$246.29E0675PNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE, RAPID INFLATION, DEFLATION CYCLE, FOR ARTERIAL INSUFFICIENCY$2,897.91E0676INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL ACCESSORIES), NOT OTHEWISE SPECIFIED$0.00E0691ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQUAR$825.25E0692ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/ LAMPS, TIMER AND EYE PROTECTION, FOUR FOOT PANEL$1,036.28E0693ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/ LAMPS, TIMER AND EYE PROTECTION, SIX FOOT PANEL$1,277.45Procedure CodeDescriptionRateE0694ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTE$4,065.97E0700SAFETY EQUIPMENT, DEVICE OR ACCESSORY, ANY TYPE$0.00E0705TRANSFER BOARD OR DEVICE, ANY TYPE, EACH$0.00E0710RESTRAINTS, ANY TYPE (BODY, CHEST, WRIST OR ANKLE)$0.00E0720TENS, TWO LEAD, LOCALIZED STIMULATION$337.57E0730TENS, FOUR LEAD, LARGER AREA/MULTIPLE NERVE STIMULATION$340.32E0731FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (WITH CONDUCTIVE FIB

ERS SEPARATED FROM THE PATIEN$278.44E07
ERS SEPARATED FROM THE PATIEN$278.44E0744NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS$700.47E0745NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT$684.72E0747OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINAL APPLICATIONS$2,847.71E0748OSTEOGENIC STIMULATOR, ELECTRICAL, NONIVASIVE, SPINAL APPLICATIONS$3,220.15E0749OSTEOGENESIS STIMULATOR, ELECTRICAL, SURGICALLY IMPLANTED$2,000.52E0760OSTEOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON-INVASIVE$3,148.10E0762TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ACCESSORIES$858.34E0764FUNCTIONAL NEUROMUSCULAR STIMULATOR, TRANSCUTANEOUS STIMULATION OF MUSCLES OF AMBULATION WITH COMPUTER$9,698.28E0765FDA APPROVED NERVE STIMULATOR, WITH REPLACEABLE BATTERIES, FOR TREATMENT OF NAUSEA AND VOMITING$77.27E0769ELECTRICAL STIMULATION OR ELECTROMAGNETIC WOUND TREATMENT DEVICE, NOT OTHERWISE$0.00E0776IV POLE$131.47E0779AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION 8 HOURS OR GREATER$132.30E0780AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION LESS THAN 8 HOURS$9.52E0781AMBULATORY INFUSION PUMP, SINGLE OR MULTIPLE CHANNELS, ELECTRIC OR BATTERY$2,081.43E0782INFUSION PUMP, IMPLANTABLE$3,020.45E0783INFUSION PUMP SYSTEM, IMPLANTABLE, PROGRAMMABLE (INCLUDES ALL COMPONENTS, E.G., PUMP, CATHETER, CONNECTORS,$6,775.91E0784EXTERNAL AMBULATORY INFUSION PUMP; INSULIN$3,758.13E0785IMPLANTABLE INTRASPINAL (EPIDURAL/INTRATHECAL) CATHETER USED WITH IMPLANTABLE INFUSION PUMP, REPLACEMENT$368.85Procedure CodeDescriptionRateE0786IMPLANTABLE PROGRAMMABLE INFUSION PUMP, REPLACEMENT (EXCLUDES IMPLANTABLE INTRASPINAL CATHETER$6,370.94E0791PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTI-CHANNEL$2,446.83E0840TRACTION FRAME, ATTACHED TO HEADBOARD, SIMPLE CERVICAL TRACTION$61.04E0849TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING$473.25E0850TRACTION STAND, FREE STANDING, SIMPLE CERVICAL TRACTION$96.43E0855CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME$461.60E0856CERVICAL TRACTION DEVICE, CERVICAL COLLAR WITH INFLATABLE AIR BLADDER$141.46E0860TRACT

ION EQUIPMENT, OVERDOOR, CERVICAL$35.39
ION EQUIPMENT, OVERDOOR, CERVICAL$35.39E0870TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE EXTREMITY TRACTION, (E.G. BUCK'S)$106.82E0880TRACTION STAND, FREE STANDING, SIMPLE EXTREMITY TRACTION, (E.G., BUCK'S)$115.30E0890TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE PELVIC TRACTION$110.57E0900TRACTION STAND, FREE STANDING, SIMPLE PELVIC TRACTION, (E.G., BUCK'S)$117.68E0910TRAPEZE BARS, A/K/A PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR$180.00E0911TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED WITH GRAB BAR$439.65E0912TRAPEZE BAR, HEAVY DUTY FOR PATIENT WEIGHT CAPACITY GREATER THAT 250 POUNDS, FREE STANDING, COMPLETE WITH GRAB$1,030.23E0920FRACTURE FRAME, ATTACHED TO BED, INCLUDES WEIGHTS$415.26E0930FRACTURE FRAME, FREE STANDING, INCLUDES WEIGHTS$411.21E0935PASSIVE MOTION EXERCISE DEVICE$177.66E0940TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR$312.93E0941GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE$390.69E0942CERVICAL HEAD HARNESS/HALTER$15.49E0944PELVIC BELT/HARNESS/BOOT$42.13E0945EXTREMITY BELT/HARNESS$40.71E0946FRACTURE, FRAME, DUAL WITH CROSS BARS, ATTACHED TO BED, (E.G. BALKEN, 4 POSTER)$532.44E0947FRACTURE FRAME, ATTACHMENTS FOR COMPLEX PELVIC TRACTION$556.96E0948FRACTURE FRAME, ATTACHMENTS FOR COMPLEX CERVICAL TRACTION$538.71E0950TRAY, WHEELCHAIR$69.94E0951LOOP HEEL, EACH$15.02E0952LOOP TOE, EACH$14.90E0955WHEELCHAIR ACCESSORY, HEADSET, CUSHIONED, PREFABRICATED, INCLUDING FIXED MOUNTING HARDWARE, EACH$160.04E0956WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, PREFABRICATED, INCLUDING FIXED MOUNTING HARDWARE, EACH$78.03Procedure CodeDescriptionRateE0957WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT. PREFABRICATED, INCLUDING FIXED MOUNTING HARDWARE, EACH$109.19E0958WHEELCHAIR ATTACHMENT TO CONVERT ANY WHEELCHAIR TO ONE ARM DRIVE$333.81E0959AMPUTEE ADAPTER (DEVICE USED TO COMPENSATE FOR TRANSFER OF WEIGHT DUE TO LOST LIMBS TO MAINTAIN PROPER BALANCE$40.60E0960WHEELCHAIR ACCESSORY, SHOULDER, HARNESS STRAPS OR CHEST STRAP, INCLUDING ANY TYPE MOUNTING HARDWARE$72.02E0961BRAKE EXTENSION, FOR WHEELCHAIR$27.3

2E0966HOOK ON HEAD REST EXTENSION$65.
2E0966HOOK ON HEAD REST EXTENSION$65.56E0967WHEELCHAIR HAND RIM WITH PROJECTIONS, ANY TYPE, EACH$60.29E0968COMMODE SEAT, WHEELCHAIR$137.16E0969NARROWING DEVICE, WHEELCHAIR$143.85E0970NO.2 FOOTPLATES, EXCEPT FOR ELEVATING LEG REST$49.20E0971ANTI-TIPPING DEVICE WHEELCHAIRS$39.84E0973ADJUSTABLE HEIGHT DETACHABLE ARMS, DESK OR FULL LENGTH, WHEELCHAIR$91.01E0974"GRADE-AID" (DEVICE TO PREVENT ROLLING BACK ON AN INCLINE) FOR WHEELCHAIR$72.01E0978BELT, SAFETY WITH AIRPLANE BUCKLE, WHEELCHAIR$33.80E0980SAFETY VEST, WHEELCHAIR$30.36E0981WHEELCHAIR ACCESSORY, SEAT UPHOLSTREY, REPLACEMENT ONLY, EACH$37.32E0982WHEELCHAIR ACCESSORY, BACK UPHOLSTERY, REPLACEMENT ONLY, EACH$40.79E0983MANUAL WHEELCHAIR ACCESSORY, POWER ADD ON TO CONVERT MANUAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, JOYSTICK$1,911.96E0984MANUAL WHEELCHAIR ACCESSORY, POWER ADD ON TO CONVERT MANUAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, TILLER CONTROL$1,614.91E0985WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM$186.30E0986MANUAL WHEELCHAIR ACCESSORY, OUSH RIM ACTIVATED POWER ASSIST, EACH$4,467.20E0988MANUEL WHEELCHAIR ACCESSORY,LEVER-ACTIVATED,WHEEL DRIVE,PAIR$0.01E0990ELEVATING LEG REST, EACH$92.94E0992SOLID SEAT INSERT$87.39E0994ARM REST, EACH$16.18E0995CALF REST, EACH$20.45E1002WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY$3,208.34E1003WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION$3,475.95E1004WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION$3,854.11Procedure CodeDescriptionRateE1005WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION$4,171.78E1006WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT SHEAR REDUCTION$5,110.04E1007WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH MECHANICAL SHEAR REDUCTION$6,919.18E1008WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER SHEAR REDUCTION$6,919.80E1009WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG ELEVATION SYSTEM, INCLUDING$0.00E1010

WHEELCHAIR ACCESSORY, ADDITION TO POWER
WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, EACH$905.36E1011MODIFICATION TO PEDIATRIC WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPENSED WITH INITIAL CHAIR$0.00E1014RECLINING BACK, ADDITION TO PEDIATRIC WHEELCHAIR$335.34E1015SHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACH$105.35E1016SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH$103.94E1017HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEEL CHAIR, EACH$0.00E1018HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, EACH$0.00E1020RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR$192.67E1028WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTRL$163.49E1029WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED$292.51E1030WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED$922.37E1031ROLLABOUT CHAIR, ANY AND ALL TYPES WITH CASTORS 5" OR GREATER$448.97E1035MULTI-POSITIONAL PATIENT TRANSFER SYSTEM, WITH INTEGRATED SEAT, OPERATED BY CARE GIVER,PATIENT$5,449.80E1037TRANSPORT CHAIR, PEDIATRIC SIZE$964.15E1038TRANSPORT CHAIR, ADULT SIZE$160.20E1039TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY 250 POUNDS OR$303.92E1050FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS$769.38E1060FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE ELEVATING LEGRESTS$1,057.00Procedure CodeDescriptionRateE1070FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTREST$923.17E1083HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACH ABLE ELEVATING LEG REST$594.92E1084HEMI-WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS$741.13E1085HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACH ABLE FOOT RESTS$621.40E1086HEMI-WHEELCHAIR DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS$729.80E1087HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR,FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS$1,124.44E1088HIGH STR

ENGTH LIGHTWEIGHT WHEELCHAIR,DETACHABLE
ENGTH LIGHTWEIGHT WHEELCHAIR,DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE ELEVATING LEG$1,339.97E1089HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, FIXED LENGTH ARMS, SWING AWAY DETACHABLE FOOTREST$1,227.90E1090HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR,DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOT RESTS$1,391.10E1092WIDE HEAVY DUTY WHEEL CHAIR, DETACHABLE ARMS DESK OF FULL LENGTH, SWING AWAY DETACHABLE ELEVATING LEG RESTS$970.83E1093WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS$834.96E1100SEMI-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS$887.44E1110SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEG REST$903.47E1130STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLE FOOTRESTS$477.10E1140WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS$733.90E1150WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE ELEVATING LEGRESTS$616.30E1160WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS$555.54E1161MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE$2,172.97E1170AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS$683.19Procedure CodeDescriptionRateE1171AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, WITHOUT FOOTRESTS OR LEGREST$646.20E1172AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) WITHOUT FOOTRESTS OR LEGREST$749.34E1180AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTRESTS$775.26E1190AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE ELEVATING LEGRESTS$895.59E1195HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS$961.11E1200AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTREST$665.64E1220WHEELCHAIR; SPECIALLY SIZED OR CONSTRUCTED, (INDICATE BRAND NAME, MODEL NUMBER, IF ANY) AND JUSTIFICATION$0.00E1221WHEELCHAIR WITH FIXED ARM, FOOTRESTS$363.42E1222WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS

$518.58E1223WHEELCHAIR WITH DETACHABL
$518.58E1223WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS$566.28E1224WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS$620.82E1225SEMI-RECLINING BACK FOR CUSTOMIZED WHEEL CHAIR$345.78E1226FULL RECLINING BACK FOR CUSTOMIZED WHEELCHAIR$425.95E1227SPECIAL HEIGHT ARMS FOR WHEELCHAIR$216.63E1228SPECIAL BACK HEIGHT FOR WHEELCHAIR$214.38E1229WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISE SPECIFIED$0.00E1230POWER OPERATED VEHICLE (THREE OR FOUR WHEEL NONHIGHWAY) SPECIFY BRAND NAME AND MODEL NUMBER$2,077.18E1231WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM$0.00E1232WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM$1,963.85E1233WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE WITHOUT SEATING SYSTEM$2,034.87E1234WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM$1,771.50E1235WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM$1,705.82E1236WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM$1,504.97E1237WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM$1,518.12E1238WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM$1,504.97E1240LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, (DESK OR FULL LENGTH) SWING AWAY DETACHABLE, ELEVATING LEGREST$788.13Procedure CodeDescriptionRateE1250LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTREST$776.40E1260LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTREST$809.30E1270LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS$603.90E1280HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS$1,017.18E1285HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTREST$1,108.10E1290HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTREST$1,086.70E1295HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEGREST$997.02E1296SPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOOR$451.53E1297SPECIAL WHEELCHAIR SEAT D

EPTH, BY UPHOLSTERY$81.66E1298SPECIAL
EPTH, BY UPHOLSTERY$81.66E1298SPECIAL WHEELCHAIR SEAT DEPTH AND/OR WIDTH, BY CONSTRUCTION$389.08E1310WHIRLPOOL, NON-PORTABLE (BUILT-IN TYPE)$1,972.13E1372IMMERSION EXTERNAL HEATER FOR NEBULIZER$149.72E1390OXYGEN CONCENTRATOR (EQUIVALENT TO 732 CUBIC FEET/1993)CAPABLE OF DELIVERING�OR = 85% OXYGEN CONCENT. (2000)$0.01E1391OXYGEN CONCENTRATOR, DUAL DELIVERY PORT, CAPABLE OF DELIVIERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT$0.01E1392PORTABLE OXYGEN CONCENTRATOR, RENTAL$0.01E1399DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS$0.00E1405OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITH HEATED DELIVERY$0.00E1406OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITHOUT HEATED DELIVERY$0.00E1700JAW MOTION REHABILITATION SYSTEM$286.88E1701REPLACEMENT CUSHIONS FOR JAW MOTION REHABILITATION SYSTEM, PKG. OF 6$9.52E1702REPLACEMENT MEASURING SCALES FOR JAW MOTION REHABILITATION SYSTEM, PKG. OF 200$20.74E1800DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE$0.01E1802DYNAMIC ADJUSTABLE FOREARM PRONATION/SUPINATION DEVICE INCLUDES SOFT INTERFACE MATERIAL$0.01E1805DYNAMIC ADJUSTABLE WRIST EXTENSION/FLEXION DEVICE$0.01E1810DYNAMIC ADJUSTABLE KNEE EXTENSION/FLEXION DEVICE$0.01E1812DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROL$0.01Procedure CodeDescriptionRateE1815DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE$0.01E1820SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/ FLEXION DEVICE$75.07E1821REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH DEVICE$96.66E1825DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE$0.01E1841MULTI-DIRECTIONAL STATIC PROGRESSIVE STRETCH SHOULDER DEVICE, WITH RANGE OF$0.00E2000GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC$0.01E2100BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER$590.69E2101BLOOD GLUCOSE MONITOR WITH INTEGRATED LANCING/BLOOD SAMPLE$173.17E2120PULSE GENERATOR SYSTEM FOR TYMPANIC TREATMENT OF INNER EAR ENDOLYMPHATIC FLUID$2,567.88E2201MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR EQUAL TO 20 INCHES AND LESS THAN 24$342.65E2

202MANUAL WHEELCHAIR ACCESSORY, NONSTAN
202MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH 24-27 INCHES$435.29E2203MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN 22 INCHES$439.95E2204MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES$747.02E2205MANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUT PROJECTIONS, ANY TYPE, REPLACEMENT$30.01E2206MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH$37.36E2207WHEELCHAIR ACCESSORY, CRUTCH AND CANE HOLDER, EACH$39.81E2208WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH$94.02E2209WHEELCHAIR ACCESSORY, ARM TROUGH, EACH$84.83E2210WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE REPLACEMENT ONLY, EACH$5.18E2211MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH$37.58E2212MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC PROPULSION TIRE, ANY SIZE$5.39E2213MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE (REMOVABLE), ANY TYPE, ANY SIZE, EACH$27.93E2214MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE EACH$33.07E2215MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, EACH$8.81E2216MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED PROPULSION TIRE, ANY SIZE, EACH$0.00E2217MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, EACH$0.00E2218MANUAL WHEELCHAIR ACCESSORY, FOAM PROPULSION TIRE, ANY SIZE, EACH$0.00E2219MANUAL WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, EACH$32.67E2220MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC), PROPULSION TIRE, ANY SIZE, EACH$26.20Procedure CodeDescriptionRateE2221MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE EACH$23.46E2222MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED WHEEL, ANY SIZE, EACH$19.34E2224MANUAL WHEELCHAIR ACCESSORY, PROPULSION WHEEL EXCLUDES TIRE, ANY SIZE, EACH$90.05E2225MANUAL WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH$15.98E2226MANUAL WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH$34.85E2227MANUAL WHEELCHAIR ACCESSORY, GEAR REDUCTION DRIVE WHEEL, EACH$1,651.90E2

228MANUAL WHEELCHAIR ACCESSORY, WHEEL B
228MANUAL WHEELCHAIR ACCESSORY, WHEEL BRAKING SYSTEM AND LOCK, COMPLETE, EACH$859.84E2231MANUAL WHEELCHAIR ACCESSARY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT),INCLUDES ANY TYPE MOUNTING HARDWARE$141.14E2291BACK, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE$0.00E2292SEAT, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE$0.00E2293BACK, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING$0.00E2294SEAT, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING$0.00E2300POWER WHEELCHAIR ACCESSORY, POWER SEAT ELEVATION SYSTEM$0.00E2310POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND ONE POWER SEATING SYSTEM$926.31E2311POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND TWO OR MORE POWER SEATING$1,875.36E2312POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, MINI-PROPORTIONAL REMOTE JOYSTICK, PROPORTIONAL$1,780.89E2313POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO EXPANDABLE CONTROLLER, INCLUDING ALL FASTENERS, CONNECTORS$282.80E2321POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK, NON PROPORTIONAL, INCLUDING ALL RELATED$1,257.86E2322POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICAL SWITCHES, NONPROPORTIONAL, INCLUDING$1,116.38E2323POWER WHEELCHAIR ACCESSORY, SPECIALITY JOYSTICK HANDLE FOR HAND CONTROL INTERFACE, PREFABRICATED$54.75E2324POWER WHEELCHAIR ACCESSORY, CHIN UP FOR CHIN CONTROL INTERFACE$34.69E2325POWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS,$1,066.09Procedure CodeDescriptionRateE2326POWER WHEELCHAIR ACCESSORY, BREATH TUBE KIT FOR SIP AND PUFF INTERFACE$274.78E2327POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL, PROPORTIONAL, INCLUDING ALL RELATED$2,067.83E2328POWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXREMITY CONTROL INTERFACE, ELECTRONIC, PROPORTIONAL, INCLUDING$3,922.40E2329POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH MECHANISM, NONPROPORTIONAL$1,397.99E2330POWER WHEELCHAIR ACCESSORY,

HEAD CONTROL INTERFACE, PROXIMITY SWITC
HEAD CONTROL INTERFACE, PROXIMITY SWITCH MECHANISM, NONPROPORTIONAL, INCLUDING ALL$2,708.76E2331POWER WHEELCHAIR ACCESSORY, ATTENDANT CONTROL, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED$0.00E2340POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH 20-23 INCHES$329.10E2341POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH 24-27 INCHES$493.70E2342POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH 20-21 INCHES$411.42E2343POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH 22-25 INCHES$658.27E2351POWER WHEELCHAIR ACCESSORY, ELECTRONIC INTERFACE TO OPERATE SPEECH GENERATING DEVICE USING POWER WHEELCHAIR$553.01E2358POWER WHEELCHAIR ACCESSORY,GROUP 34 NON-SEALED LEAD ACID BATTERY,EACH$0.00E2359POWER WHEELCHAIR ACCESSORY,GROUP 34 SEALED LEAD ACID BATTERY,EACH(E.G. GEL CELL,ABSORBED GLASSMAT)$170.84E2360POWER WHEELCHAIR ACCESSORY, 22 NF NON SEALED LEAD ACID BATTERY, EACH$103.18E2361POWER WHEELCHAIR ACCESSORY, 22 NF SEALED LEAD ACID BATTERY, EACH$110.39E2362POWER WHEELCHAIR ACCESSORY, 24 NON SEALED LEAD ACID BATTERY, EACH$84.47E2363POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH$147.23E2364POWER WHEELCHAIR ACCESSORY, U 1 NON SEALED LEAD ACID BATTERY, EACH$103.18E2365POWER WHEELCHAIR ACCESSORY, U 1 SEALED LEAD ACID BATTERY, EACH$88.79E2366POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE FOR USE WITH ONLY ONE BATTERY TYPE$207.19E2367POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER BATTERY TYPE, SEALED OR NON SEAL$331.72E2368POWER WHEELCHAIR COMPONENT, MOTOR, REPLACEMENT ONLY$408.90E2369POWER WHEELCHAIR COMPONENT, GEAR BOX, REPLACEMENT ONLY$356.15E2370POWER WHEELCHAIR COMPONENT, MOTOR AND GEAR BOX COMBINATION, REPLACEMENT ONLY$635.49E2371POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E.G. GEL CELL, ABSORBED GLASSMAT), EACH$119.31Procedure CodeDescriptionRateE2372POWER WHEELCHAIR ACCESSORY. GROUP 27 NONSEALED LEAD ACID BATTERY, EACH$0.00E2373POWER WHEELCHAIR ACCESORY, HAND OR CHIN CONTROL INTERFACE, MINI-PROPORTIONAL, COMPACT, OR SHORT THROW REMOTE$620.76E2374POWER WHEELCHAIR AC

CESORY, HAND OR CHIN CONTROL INTERFACE,
CESORY, HAND OR CHIN CONTROL INTERFACE, STANDARD REMOTE JOYSTICK (NOT INCLUDING CONTROLLER)$422.71E2375POWER WHEELCHAIR ACCESSORY, NONEXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS$678.02E2376POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING$1,062.48E2377POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING$384.47E2378POWER WHEELCHAIR COMPONENT, ACTUATOR; REPLACEMENT ONLY$0.00E2381POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH$60.29E2382POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH$16.44E2383POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL (REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY$120.22E2384POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH$64.04E2385POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH$39.19E2386POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH$119.13E2387POWER WHEELCHAIR ACCESORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH$53.42E2388POWER WHEELCHAIR ACCESSORY, FOAM DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH$39.88E2389POWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH$21.65E2390POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY , EACH$33.87E2391POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE, REPLACEMENT ONLY, EACH$16.22E2392POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTERGRATED WHEEL, ANY SIZE, REPLACEMENT$42.65Procedure CodeDescriptionRateE2394POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE REPLACEMENT ONLY, EACH$60.76E2395POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH$43.18E2396POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY , EACH$52.64E2397POWER WHEELCHAIR ACCESSORY, LITHIUM-BASED BATTERY, EACH$380.34E2402NEGATIVE

PRESSURE WOUND THERAPY ELECTRICAL PUMP,
PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE$15,448.14E2500SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE RECORDED MESSAGES, LESS THAN OR EQUAL TO 8 MINUTES$359.14E2502SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE RECORDED MESSAGES, GREATER THAN 8 MINUTES BUT LESS$1,098.19E2504SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE RECORDED MESSAGES, GREATER THAN 20 MINUTES BUT LESS THAN$1,448.66E2506SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE RECORDED MESSAGES, GREATER THAN 40 MINUTES RECORDING$2,124.17E2508SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, REQUIRING MESSAGE FORMULATION BY SPELLING AND ACCESS BY PHYSICAL$3,284.67E2510SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, PERMITTING MULTIPLE METHODS OF MESSAGE FORMULATION AND MULTIPLE$6,215.80E2511SPEECH GENERATING SOFTWARE PROGRAM, FOR PERSONAL COMPUTER OR PERSONAL DIGITAL ASSISTANT$0.00E2512ACCESSORY FOR SPEECH GENERATING DEVICE, MOUNTING SYSTEM$0.00E2599ACCESSORY FOR SPEECH GENERATING DEVICE, NOT OTHERWISE CLASSIFIED$0.00E2601GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH$48.41E2602GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH$94.51E2603SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH$119.99E2604SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH$149.14E2605POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH$213.07E2606POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH$332.40E2607SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22$229.43E2608SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR$275.53E2609CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE$0.00E2610WHEELCHAIR SEAT CUSHION, POWERED$0.00E2611GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT,$247.25E2612GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT,$334.47Procedure CodeDescriptionRateE2613POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES

, ANY$311.11E2614POSITIONING WHEELCHA
, ANY$311.11E2614POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY$430.55E2615POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22$358.03E2616POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR$481.73E2617CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE$0.00E2619REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACH$40.62E2620POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH$433.53E2621POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH$454.95E2622SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH$262.38E2623SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH THAN 22 INCHES OR GREATER, ANY DEPTH$333.86E2624SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH$264.53E2625SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH$334.88E2626WHEELCHAIR ACCESSORY,SHOULDER ELBOW,MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,ADJUSTABLE$15.01E2627WHEELCHAIR ACCESSORY,SHOULDER,ELBOW,MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR,BALANCED,ADJUSTABLE RANCHO TYPE$910.22E2628WHEELCHAIR ACCESSORY,SHOULDER,ELBOW,MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR,BALANCED,RECLINING$685.70E2629WHEELCHAIR ACCESSORY,SHOULDER ELBOW,MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR,BALANCED,FRICTION ARM$867.74E2630WHEELCHAIR ACCESSORY,SHOULDER ELBOW,MOBILE ARM SUPPORT,MONOSUSPENSION ARM AND HAND$590.55E2631WHEELCHAIR ACCESSORY,ADDITION TO MOBILE ARM SUPPORT,ELEVATING PROXIMAL ARM$236.65E2632WHEELCHAIR ACCESSORY,ADDITION TO MOBILE ARM SUPPORT,OFFSET OR LATERAL ROCKER ARM WITH ELASTIC BALANCE CONTROL$154.34E2633WHEELCHAIR ACCESSORY,ADDITION TO MOBILE ARM SUPPORT,SUPINATOR$130.91E8000GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND$0.00E8001GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND$0.00E8002GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL AC