DRAFT: Durable Medical Equipment/-
Supply Fee Schedule

PROPOSED FEE

DESCRIPTION

A4214

$1.67

Sterile saline or water, 30 cc vial

A4221

$21.59

Supplies for maintenance of drug infusion catheter, per week (list drug separately)

A4222

$44.16

Supplies for external drug infusion pump, per cassette or bag (list drug separately)

A4253

$31.69

Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

A4254

$6.28

Replacement battery, any type, for use with medically necessary home blood glucose monitor owned by patient, each

A4255

$3.82

Platforms for home blood glucose monitor, 50 per box

A4256

$10.92

Normal, low, and high calibrator solution/chips

A4258

$17.21

Spring-powered device for lancet, each

A4259

$12.15

Lancets, per box of 100

A4310

$6.26

Insertion tray without drainage bag and without catheter (accessories only)

A4311

$14.16

Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

A4312

$17.20

Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone

A4313

$17.67

Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4314

$24.12

Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

A4315

$25.17

Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone

A4316

$27.09

Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4320

$4.32

Irrigation tray with bulb or piston syringe, any purpose

A4351

$1.47

Intermittent urinary catheter; straight tip, each

A4352

$5.67

Intermittent urinary catheter; coude (curved) tip, each

A4353

$6.67

Intermittent urinary catheter, with insertion supplies

A4354

$11.25

Insertion tray with drainage bag but without catheter

A4355

$8.50

Irrigation tubing set for continuous bladder irrigation through a three-way indwelling Foley catheter, each

A4356

$43.27

External urethral clamp or compression device (not to be used for catheter clamp), each

A4357

$9.25

Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each

A4358

$6.33

Urinary leg bag; vinyl, with or without tube, each

A4359

$26.69

Urinary suspensory without leg bag, each

A4361

$17.52

Ostomy faceplate, each

A4454

$2.12

Tape, all types, all sizes

A4460

$0.97

Elastic bandage, per roll (e.g., compression bandage)

A4550

$19.04

Surgical trays

A4556

$9.84

Electrodes (e.g., Apnea monitor), per pair

A4558

$5.20

Conductive paste or gel

A4613

$116.92

Battery charger; replacement for patient-owned ventilator

A4618

$7.21

Breathing circuits

A4619

$1.21

Face tent

A4621

$1.39

Tracheostomy mask or collar

A4622

$48.70

Tracheostomy or laryngectomy tube

A4623

$5.31

Tracheostomy, inner cannula (replacement only)

A4624

$2.13

Tracheal suction catheter, any type, each

A4625

$5.62

Tracheostomy care kit for new tracheostomy

A4626

$2.59

Tracheostomy cleaning brush, each

A4628

$3.57

Oropharyngeal suction catheter, each

A4629

$4.42

Tracheostomy care kit for established tracheostomy

A4630

$5.96

Replacement batteries for medically necessary transcutaneous electrical nerve stimulator (TENS) owned by patient

A4631

$96.43

Replacement batteries for medically necessary electronic wheelchair owned by patient

A4635

$4.15

Underarm pad, crutch, replacement, each

A4636

$3.46

Replacement, handgrip, cane, crutch, or walker, each

A4637

$2.03

Replacement, tip, cane, crutch, walker, each

A4640

$54.44

Replacement pad for use with medically necessary alternating pressure pad owned by patient

A5051

$2.14

Pouch, closed; with barrier attached (one piece)

A5052

$1.59

Pouch, closed; without barrier attached (one piece)

A5053

$1.41

Pouch, closed; for use on faceplate

A5054

$1.61

Pouch, closed; for use on barrier with flange (two piece)

A5055

$1.21

Stoma cap

A5061

$2.58

Pouch, drainable; with barrier attached (one piece)

A5062

$2.12

Pouch, drainable; without barrier attached (one piece)

A5063

$2.13

Pouch, drainable; for use on barrier with flange (two piece system)

A5071

$4.15

Pouch, urinary; with barrier attached (one piece)

A5072

$3.24

Pouch, urinary; without barrier attached (one piece)

A5073

$3.04

Pouch, urinary; for use on barrier with flange (two piece)

A5081

$2.77

Continent device; plug for continent stoma

A5082

$10.71

Continent device; catheter for continent stoma

A5093

$1.58

Ostomy accessory; convex insert

A5102

$21.53

Bedside drainage bottle, with or without tubing, rigid or expandable, each

A5105

$38.88

Urinary suspensory; with leg bag, with or without tube

A5112

$33.02

Urinary leg bag; latex

A5113

$3.81

Leg strap; latex, replacement only, per set

A5114

$7.24

Leg strap; foam or fabric, replacement only, per set

A5119

$9.67

Skin barrier; wipes, box per 50

A5121

$7.12

Skin barrier; solid, 6 x 6 or equivalent, each

A5122

$11.96

Skin barrier; solid, 8 x 8 or equivalent, each

A5123

$4.60

Skin barrier; with flange (solid, flexible or accordion), any size, each

A5126

$1.07

Adhesive or non-adhesive; disk or foam pad

A5131

$13.80

Appliance cleaner, incontinence and ostomy appliances, per 16 oz.

A6154

$13.69

Wound pouch, each

A6196

$7.01

Alginate dressing, wound cover, pad size 16 sq. in. or less, each dressing

A6197

$15.68

Alginate dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6199

$5.04

Alginate dressing, wound filler, per 6 inches

A6200

$9.06

Composite dressing, pad size 16 sq. in. or less, without adhesive border, each dressing

A6203

$3.19

Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6204

$5.94

Composite dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6207

$7.00

Contact layer, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6209

$7.14

Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6210

$19.00

Foam dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6211

$28.01

Foam dressing, wound cover, pad size more then 48 sq. in., without adhesive border, each dressing

A6212

$9.25

Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6214

$9.82

Foam dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing

A6216

$0.05

Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6219

$0.91

Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6220

$2.46

Gauze, non-impregnated, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6222

$2.03

Gauze, impregnated, other than water or normal saline, pad size 16 sq. in. or less, without adhesive border, each dressing

A6223

$2.30

Gauze, impregnated, other than water or normal saline, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6224

$3.44

Gauze, impregnated, other than water or normal saline, pad size more than 48 sq. in., without adhesive border, each dressing

A6234

$6.24

Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6235

$16.05

Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6236

$25.99

Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

A6237

$7.54

Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6238

$21.74

Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6240

$11.68

Hydrocolloid dressing, wound filler, paste, per fluid ounce

A6241

$2.45

Hydrocolloid dressing, wound filler, dry form, per gram

A6242

$5.79

Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6243

$11.75

Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6244

$37.46

Hydrogel dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

A6245

$6.93

Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6246

$9.46

Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6247

$22.68

Hydrogel dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing

A6248

$15.49

Hydrogel dressing, wound filler, gel, per fluid ounce

A6251

$1.90

Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6252

$3.10

Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6253

$6.05

Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

A6254

$1.16

Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6255

$2.89

Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6257

$1.46

Transparent film, 16 sq. in. or less, each dressing

A6258

$4.10

Transparent film, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6259

$10.43

Transparent film, more than 48 sq. in., each dressing

A6263

$0.28

Gauze, elastic, non-sterile, all types, per linear yard

A6264

$0.46

Gauze, non-elastic, non-sterile, per linear yard

A6265

$0.12

Tape, all types, per 18 sq. in.

A6266

$1.83

Gauze, impregnated, other than water or normal saline, any width, per linear yard

A6402

$0.12

Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6403

$0.41

Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6405

$0.32

Gauze, elastic, sterile, all types, per linear yard

A6406

$0.76

Gauze, non-elastic, sterile, all types, per linear yard

E0100

$17.09

Cane, includes canes of all materials, adjustable or fixed, with tip

E0105

$45.38

Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips

E0110

$71.38

Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips

E0111

$43.18

Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip

E0112

$32.06

Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips

E0113

$17.13

Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip

E0114

$38.26

Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips

E0116

$22.49

Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip

E0130

$63.04

Walker, rigid (pickup), adjustable or fixed height

E0135

$79.97

Walker, folding (pickup), adjustable or fixed height

E0141

$109.97

Rigid walker, wheeled, without seat

E0142

$160.57

Rigid walker, wheeled, with seat

E0143

$101.20

Folding walker, wheeled, without seat

E0147

$548.27

Heavy duty, multiple breaking system, variable wheel resistance walker

E0153

$66.18

Platform attachment, forearm crutch, each

E0154

$67.25

Platform attachment, walker, each

E0155

$25.59

Wheel attachment, rigid pick-up walker, per pair seat attachment, walker

E0156

$22.56

Seat attachment, walker

E0157

$78.14

Crutch attachment, walker, each

E0158

$29.00

Leg extensions for walker, per set of four (4)

E0159

$17.05

Brake attachment for wheeled walker, replacement, each

E0160

$26.80

Sitz type bath or equipment, portable, used with or without commode

E0161

$25.01

Sitz type bath or equipment, portable, used with or without commode, with faucet attachment/s

E0162

$118.12

Sitz bath chair

E0163

$89.82

Commode chair, stationary, with fixed arms

E0164

$173.03

Commode chair, mobile, with fixed arms

E0167

$11.02

Pail or pan for use with commode chair

E0175

$63.17

Foot rest, for use with commode chair, each

E0176

$86.84

Air pressure pad or cushion, nonpositioning

E0177

$90.97

Water pressure pad or cushion, nonpositioning

E0178

$98.38

Gel or gel-like pressure pad or cushion, nonpositioning

E0179

$11.41

Dry pressure pad or cushion, nonpositioning

E0182

$21.23

Pump for alternating pressure pad

E0184

$185.71

Dry pressure mattress

E0185

$305.09

Gel or gel-like pressure pad for mattress, standard mattress length and width

E0191

$8.10

Heel or elbow protector, each

E0192

$369.14

Low pressure and positioning equalization pad, for wheelchair

E0197

$179.65

Air pressure pad for mattress, standard mattress length and width

E0198

$208.45

Water pressure pad for mattress, standard mattress length and width

E0199

$25.98

Dry pressure pad for mattress, standard mattress length and width

E0200

$75.62

Heat lamp, without stand (table model), includes bulb, or infrared element

E0202

$59.72

Phototherapy (bilirubin) light with photometer

E0205

$185.10

Heat lamp, with stand, includes bulb, or infrared element

E0210

$26.46

Electric heat pad, standard

E0217

$473.55

Water circulating heat pad with pump

E0225

$370.70

Hydrocollator unit, includes pads

E0230

$7.55

Ice cap or collar

E0238

$25.26

Nonelectric heat pad, moist

E0239

$364.70

Hydrocollator unit, portable

E0249

$95.00

Pad for water circulating heat unit

E0271

$211.78

Mattress, inner spring

E0272

$193.03

Mattress, foam rubber

E0275

$13.96

Bed pan, standard, metal or plastic

E0276

$10.79

Bed pan, fracture, metal or plastic

E0280

$30.97

Bed cradle, any type

E0310

$169.55

Bedside rails, full-length

E0325

$8.19

Urinal; male, jug-type, any material

E0326

$8.52

Urinal; female, jug-type, any material

E0441

$147.84

Oxygen contents, gaseous, per unit (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned; 1 unit = 50 cubic ft)

E0442

$147.84

Oxygen contents, liquid, per unit (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned; 1 unit = 10 lbs)

E0443

$18.20

Portable oxygen contents, gaseous, per unit (for use only with portable gaseous systems when no stationary gas or liquid system is used; 1 unit = 5 cubic ft)

E0444

$18.20

Portable oxygen contents, liquid, per unit (for use only with portable liquid systems when no stationary gas or liquid system is used; 1 unit = 1 lb)

E0560

$155.83

Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery

E0570

$18.34

Nebulizer, with compressor

E0575

$83.33

Nebulizer, ultrasonic

E0580

$127.85

Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter

E0607

$63.73

Home blood glucose monitor

E0609

$605.02

Blood glucose monitor with special features (e.g., voice synthesizers, automatic timers, etc.)

E0610

$200.68

Pacemaker monitor, self-contained, checks battery depletion, includes audible and visible check systems

E0615

$456.71

Pacemaker monitor, self-contained, checks battery depletion and other pacemaker components, includes digital/visible check systems

E0621

$80.25

Sling or seat, patient lift, canvas or nylon

E0627

$321.75

Seat lift mechanism incorporated into a combination lift-chair mechanism

E0628

$321.75

Separate seat lift mechanism for use with patient owned furniture - electric

E0629

$315.44

Separate seat lift mechanism for use with patient owned furniture - nonelectric

E0650

$605.50

Pneumatic compressor, nonsegmental home model

E0651

$876.02

Pneumatic compressor, segmental home model without calibrated gradient pressure

E0652

$5,056.67

Pneumatic compressor, segmental home model with calibrated gradient pressure

E0655

$92.14

Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm

E0660

$152.37

Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg

E0665

$125.42

Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm

E0666

$123.60

Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg

E0667

$308.82

Segmental pneumatic appliance for use with pneumatic compressor, full leg

E0668

$421.48

Segmental pneumatic appliance for use with pneumatic compressor, full arm

E0669

$171.02

Segmental pneumatic appliance for use with pneumatic compressor, half leg

E0671

$396.17

Segmental gradient pressure pneumatic appliance, full leg

E0672

$307.83

Segmental gradient pressure pneumatic appliance, full arm

E0673

$255.79

Segmental gradient pressure pneumatic appliance, half leg

E0690

$1,299.85

Ultraviolet cabinet, appropriate for home use

E0720

$350.61

TENS, two lead, localized stimulation

E0730

$353.45

TENS, four lead, larger area/multiple nerve stimulation

E0747

$3,364.35

Osteogenesis stimulator, electrical, noninvasive, other than spinal applications

E0748

$3,342.55

Osteogenesis stimulator, electrical, noninvasive, spinal applications

E0776

$136.55

IV pole

E0781

$252.64

Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient

E0791

$301.60

Parenteral infusion pump, stationary, single or multichannel

E0840

$59.41

Traction frame, attached to headboard, cervical traction

E0850

$89.48

Traction stand, freestanding, cervical traction

E0855

$479.42

Cervical traction equipment not requiring additional stand or frame

E0860

$32.40

Traction equipment, overdoor, cervical

E0870

$94.30

Traction frame, attached to footboard, extremity traction (e.g., Buck's)

E0880

$101.78

Traction stand, freestanding, extremity traction (e.g., Buck's)

E0890

$97.62

Traction frame, attached to footboard, pelvic traction

E0900

$103.88

Traction stand, freestanding, pelvic traction (e.g., Buck's)

E0942

$16.09

Cervical head harness/halter

E0943

$26.39

Cervical pillow

E0944

$39.73

Pelvic belt/harness/boot

E0945

$40.87

Extremity belt/harness

E0947

$503.87

Fracture frame, attachments for complex pelvic traction

E0948

$503.87

Fracture frame, attachments for complex cervical traction

E0950

$99.15

Tray

E0951

$16.81

Loop heel, each

E0952

$17.97

Loop toe, each

E0953

$39.02

Pneumatic tire, each

E0954

$39.91

Semi-pneumatic caster, each

E0959

$81.51

Amputee adapter (device used to compensate for transfer of weight due to lost limbs to maintain proper balance)

E0961

$24.11

Brake extension, for wheelchair

E0962

$56.74

One-inch cushion, for wheelchair

E0963

$67.78

Two-inch cushion, for wheelchair

E0964

$75.62

Three-inch cushion, for wheelchair

E0965

$80.84

Four-inch cushion, for wheelchair

E0966

$66.80

Hook on headrest extension

E0967

$107.13

Wheelchair hand rims with eight vertical rubber-tipped projections, pair

E0969

$149.40

Narrowing device, wheelchair

E0970

$39.05

No. 2 footplates, except for elevating legrest

E0971

$53.30

Anti-tipping device, wheelchair

E0972

$52.57

Transfer board or device

E0973

$109.66

Adjustable height detachable arms, desk or full-length, wheelchair

E0974

$64.06

'Grade-aid' (device to prevent rolling back on an incline) for wheelchair

E0975

$40.33

Reinforced seat upholstery, wheelchair

E0976

$40.72

Reinforced back, wheelchair, upholstery or other material

E0977

$55.47

Wedge cushion, wheelchair

E0978

$41.60

Belt, safety with airplane buckle, wheelchair

E0979

$31.93

Belt, safety with Velcro closure, wheelchair

E0980

$26.80

Safety vest, wheelchair

E0990

$105.09

Elevating leg rest, each

E0991

$43.76

Upholstery seat

E0992

$90.75

Solid seat insert

E0993

$44.35

Back, upholstery

E0994

$15.98

Armrest, each

E0995

$27.51

Calf rest, each

E0996

$27.20

Tire, solid, each

E0997

$63.44

Caster with fork

E0998

$31.03

Caster without fork

E0999

$93.21

Pneumatic tire with wheel

E1000

$29.20

Tire, pneumatic caster

E1001

$91.15

Wheel, single

E1065

$2,691.70

Power attachment (to convert any wheelchair to motorized wheelchair, e.g., Solo)

E1066

$213.73

Battery charger

E1069

$107.16

Deep cycle battery

E1226

$442.38

Full reclining back for customized wheelchair

E1227

$264.69

Special height arms for wheelchair

E1230

$1,833.76

Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number

E1296

$438.01

Special wheelchair seat height from floor

E1297

$89.53

Special wheelchair seat depth, by upholstery

E1298

$404.09

Special wheelchair seat depth and/or width, by construction

E1310

$2,048.25

Whirlpool, nonportable (built-in type)

E1372

$138.21

Immersion external heater for nebulizer

E1375

$216.56

Nebulizer portable with small compressor, with limited flow

E1700

$328.92

Jaw motion rehabilitation system

E1701

$10.12

Replacement cushions for jaw motion rehabilitation system, package of six

E1702

$21.52

Replacement measuring scales for jaw motion rehabilitation system, package of 200

E1820

$77.97

Soft interface material, dynamic adjustable extension/flexion device

K0005

$1,763.39

Ultralightweight wheelchair

K0015

$173.31

Detachable, nonadjustable height armrest, each

K0016

$109.66

Detachable, adjustable height armrest, complete assembly, each

K0017

$48.75

Detachable, adjustable height armrest, base, each

K0018

$27.23

Detachable, adjustable height armrest, upper portion, each

K0019

$16.07

Arm pad, each

K0020

$44.31

Fixed, adjustable height armrest, pair

K0021

$53.30

Antitipping device, each

K0022

$40.72

Reinforced back upholstery

K0023

$88.05

Solid back insert, planar back, single density foam, attached with straps

K0024

$104.22

Solid back insert, planar back, single density foam, with adjustable hook-on hardware

K0025

$66.80

Hook-on headrest extension

K0026

$44.35

Back upholstery for ultralightweight or high-strength lightweight wheelchair

K0027

$44.35

Back upholstery for wheelchair type other than ultralightweight or high-strength lightweight wheelchair

K0028

$442.38

Fully reclining back

K0029

$40.33

Reinforced seat upholstery

K0030

$90.75

Solid seat insert, planar seat, single density foam

K0031

$39.55

Safety belt/pelvic strap, each

K0032

$43.76

Seat upholstery for ultralightweight or high-strength lightweight wheelchair

K0033

$43.76

Seat upholstery for wheelchair type other than ultralightweight or high-strength lightweight wheelchair

K0034

$16.81

Heel loop, each

K0035

$24.49

Heel loop with ankle strap, each

K0036

$17.97

Toe loop, each

K0037

$39.05

High mount flip-up footrest, each

K0038

$23.14

Leg strap, each

K0039

$51.39

Leg strap, H style, each

K0040

$71.22

Adjustable angle footplate, each

K0041

$50.47

Large size footplate, each

K0042

$29.53

Standard size footplate, each

K0043

$18.63

Footrest, lower extension tube, each

K0044

$15.87

Footrest, upper hanger bracket, each

K0045

$54.00

Footrest, complete assembly

K0046

$18.63

Elevating legrest, lower extension tube, each

K0047

$72.95

Elevating legrest, upper hanger bracket, each

K0048

$105.09

Elevating legrest, complete assembly

K0049

$27.51

Calf pad, each

K0050

$31.00

Ratchet assembly

K0051

$50.18

Cam release assembly, footrest or legrest, each

K0052

$88.17

Swingaway, detachable footrests, each

K0053

$97.30

Elevating footrests, articulating (telescoping), each

K0054

$99.81

Seat width of 10, 11, 12, 15, 17, or 20 inches for a high-strength, lightweight or ultralightweight wheelchair

K0055

$90.71

Seat depth of 15, 17, or 18 inches for a high strength, lightweight or ultralightweight wheelchair

K0056

$90.71

Seat height less than 17 inches or equal to or greater than 21 inches for a high strength, lightweight, or ultralightweight wheelchair

K0057

$118.47

Seat width 19 or 20 inches for heavy duty or extra heavy-duty chair

K0058

$57.58

Seat depth 17 or 18 inches for a motorized/power wheelchair

K0059

$30.25

Plastic coated handrim, each

K0060

$26.47

Steel handrim, each

K0061

$37.55

Aluminum handrim, each

K0062

$58.20

Handrim with 8 to 10 vertical or oblique projections, each

K0063

$77.70

Handrim with 12 to 16 vertical or oblique projections, each

K0064

$29.01

Zero pressure tube (flat free insert), any size, each

K0065

$42.41

Spoke protectors, each

K0066

$27.20

Solid tire, any size, each

K0067

$39.02

Pneumatic tire, any size, each

K0068

$5.61

Pneumatic tire tube, each

K0069

$95.30

Rear wheel assembly, complete, with solid tire, spokes or molded, each

K0070

$174.71

Rear wheel assembly, complete with pneumatic tire, spokes or molded, each

K0071

$104.20

Front caster assembly, complete, with pneumatic tire, each

K0072

$62.72

Front caster assembly, complete, with semipneumatic tire, each

K0073

$32.88

Caster pin lock, each

K0074

$29.20

Pneumatic caster tire, any size, each

K0075

$39.91

Semipneumatic caster tire, any size, each

K0076

$24.37

Solid caster tire, any size, each

K0077

$56.13

Front caster assembly, complete, with solid tire, each

K0078

$9.16

Pneumatic caster tire tube, each

K0079

$48.25

Wheel lock extension, pair

K0080

$127.13

Antirollback device, pair

K0081

$38.80

Wheel lock assembly, complete, each

K0082

$107.16

22 NF deep cycle lead acid battery, each

K0083

$133.03

22 NF gel cell battery, each

K0084

$87.73

Group 24 deep cycle lead acid battery, each

K0085

$177.42

Group 24 gel cell battery, each

K0086

$107.16

U-1 lead acid battery, each

K0087

$106.99

U-1 gel cell battery, each

K0088

$213.73

Battery charger, lead acid or gel cell

K0089

$399.73

Battery charger, dual mode

K0090

$72.66

Rear wheel tire for power wheelchair, any size, each

K0091

$19.81

Rear wheel tire tube other than zero pressure for power wheelchair, any size, each

K0092

$231.90

Rear wheel assembly for power wheelchair, complete, each

K0093

$144.87

Rear wheel zero pressure tire tube (flat free insert) for power wheelchair, any size, each

K0094

$47.21

Wheel tire for power base, any size, each

K0095

$47.21

Wheel tire tube other than zero pressure for each base, any size, each

K0096

$261.63

Wheel assembly for power base, complete, each

K0097

$59.58

Wheel zero-pressure tire tube (flat free insert) for power base, any size, each

K0098

$25.95

Drive belt for power wheelchair

K0099

$77.17

Front caster for power wheelchair

K0100

$81.51

Wheelchair adapter for amputee, pair

K0102

$41.35

Crutch and cane holder, each

K0103

$52.57

Transfer board, less than 25 inches

K0104

$113.30

Cylinder tank carrier, each

K0105

$94.84

IV hanger, each

K0106

$102.21

Arm trough, each

K0107

$99.15

Wheelchair tray

K0112

$227.46

Trunk support device, vest type, with inner frame, prefabricated

K0113

$138.74

Trunk support device, vest type, without inner frame, prefabricated

K0114

$723.19

Back support system for use with a wheelchair, with inner frame, prefabricated

K0115

$829.24

Seating system, back module, posterior-lateral control, with or without lateral supports, custom fabricated for attachment to wheelchair base

K0116

$1,730.82

Seating system, combined back and seat module, custom fabricated for attachment to wheelchair base

K0182

$0.31

Water, distilled, used with large volume nebulizer, 1000 ml

K0183

$75.21

Nasal application device used with positive airway pressure device

K0184

$22.82

Nasal pillows/seals, replacement for nasal application device, pair

K0185

$34.11

Headgear used with positive airway pressure device

K0186

$14.76

Chin strap used with positive airway pressure device

K0187

$37.66

Tubing used with positive airway pressure device

K0188

$5.05

Filter, disposable, used with positive airway pressure device

K0189

$12.43

Filter, nondisposable, used with positive airway pressure device

K0268

$102.26

Humidifier, nonheated, used with positive airway pressure device

K0270

$38.40

Ultrasonic generator with small volume ultrasonic nebulizer

K0280

$3.04

Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each

K0281

$0.12

Lubricant, individual sterile packet, for insertion of urinary catheter, each

K0283

$0.33

Saline solution, per 10 ml, metered dose dispenser, for use with inhalation drugs

K0407

$2.10

Urinary catheter anchoring device, adhesive skin attachment

K0408

$4.71

Urinary catheter anchoring device, leg strap

K0409

$6.04

Sterile water irrigation solution, 1000 ml

K0410

$2.07

Male external catheter, with adhesive coating, each

K0411

$1.72

Male external catheter, with adhesive strip, each

K0452

$6.25

Wheelchair bearings, any type

K0529

$2.62

Sterile water or sterile saline, 1,000 ml, used with large volume nebulizer

L0100

$432.50

Cervical, craniostenosis, helmet molded to patient model

L0110

$127.60

Cervical, craniostenosis, helmet, nonmolded

L0120

$21.39

Cervical, flexible, nonadjustable (foam collar)

L0130

$154.64

Cervical, flexible, thermoplastic collar, molded to patient

L0140

$53.37

Cervical, semi-rigid, adjustable (plastic collar)

L0150

$88.99

Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)

L0160

$126.69

Cervical, semi-rigid, wire frame occipital/mandibular support

L0170

$536.13

Cervical, collar, molded to patient model

L0172

$108.71

Cervical, collar, semi-rigid thermoplastic foam, two piece

L0174

$195.29

Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension

L0180

$265.60

Cervical, multiple post collar, occipital/mandibular supports, adjustable

L0190

$399.80

Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types)

L0200

$367.11

Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension

L0210

$38.10

Thoracic, rib belt

L0220

$87.07

Thoracic, rib belt, custom fabricated

L0300

$143.73

TLSO, flexible (dorso-lumbar surgical support)

L0310