Equipment & supplies Medicaid rates by code
2,467 equipment & supplies codes with published Medicaid rates in five or more states. Each page compares every state's rate, unit and managed-care rule.
| Code | Service | States | Median rate |
|---|---|---|---|
| A2019 | Kerecis omega3 marigen shield, per square centimeter | 7 | $81.15 |
| A4206 | Syringe with needle, sterile, 1 cc or less, each | 32 | $0.27 |
| A4207 | Syringe with needle, sterile 2 cc, each | 31 | $0.27 |
| A4208 | Syringe with needle, sterile 3 cc, each | 31 | $0.25 |
| A4209 | Syringe with needle, sterile 5 cc or greater, each | 31 | $0.31 |
| A4210 | Needle-free injection device, each | 18 | $5.62 |
| A4211 | Supplies for self-administered injections | 7 | $0.94 |
| A4212 | Non-coring needle or stylet with or without catheter | 23 | $5.29 |
| A4213 | Syringe, sterile, 20 cc or greater, each | 33 | $0.83 |
| A4215 | Needle, sterile, any size, each | 30 | $0.23 |
| A4216 | Sterile water, saline and/or dextrose, diluent/flush, 10 ml | 30 | $0.45 |
| A4217 | Sterile water/saline, 500 ml | 35 | $3.13 |
| A4218 | Sterile saline or water, metered dose dispenser, 10 ml | 8 | $0.475 |
| A4220 | Refill kit for implantable infusion pump | 13 | $34.15 |
| A4221 | Supplies for maintenance of non-insulin drug infusion... | 33 | $21.99 |
| A4222 | Infusion supplies for external drug infusion pump | 34 | $41.95 |
| A4223 | Infusion supplies not used with external infusion pump | 19 | $16.16 |
| A4224 | Supplies for maintenance of insulin infusion catheter | 33 | $23.23 |
| A4225 | Supplies for external insulin infusion pump | 30 | $2.85 |
| A4230 | Infusion set for external insulin pump | 29 | $12.99 |
| A4231 | Infusion set for external insulin pump, needle type | 27 | $7.40 |
| A4232 | Syringe with needle for external insulin pump, sterile, 3 cc | 28 | $2.83 |
| A4233 | Replacement battery, alkaline (other than j cell) | 31 | $0.54 |
| A4234 | Replacement battery, alkaline, j cell | 31 | $2.36 |
| A4235 | Replacement battery, lithium | 31 | $1.06 |
| A4236 | Replacement battery, silver oxide | 30 | $1.16 |
| A4238 | Supply allowance for adjunctive | 26 | $261.95 |
| A4239 | Supply allowance for non-adjunctive | 26 | $251.61 |
| A4244 | Alcohol or peroxide, per pint | 30 | $0.985 |
| A4245 | Alcohol wipes, per box | 29 | $2.15 |
| A4246 | Betadine or phisohex solution, per pint | 30 | $5.64 |
| A4247 | Betadine or iodine swabs/wipes, per box | 30 | $6.97 |
| A4248 | Chlorhexidine containing antiseptic, 1 ml | 9 | $0.23 |
| A4250 | Urine test or reagent strips or tablets | 24 | $18.74 |
| A4252 | Blood ketone test or reagent strip, each | 7 | $4.49 |
| A4253 | Blood glucose test or reagent strips for home blood glucose... | 28 | $8.63 |
| A4255 | Platforms for home blood glucose monitor, 50 per box | 16 | $4.93 |
| A4256 | Normal, low and high calibrator solution / chips | 24 | $3.58 |
| A4257 | Replacement lens shield cartridge for use with laser skin... | 7 | $17.83 |
| A4258 | Spring-powered device for lancet, each | 25 | $2.12 |
| A4259 | Lancets, per box of 100 | 27 | $1.52 |
| A4261 | Cervical cap for contraceptive use | 15 | $49.45 |
| A4263 | Permanent, long term, non-dissolvable lacrimal duct implant | 10 | $31.95 |
| A4264 | Permanent implantable contraceptive intratubal occlusion... | 12 | $1,400.00 |
| A4265 | Paraffin, per pound | 25 | $3.72 |
| A4266 | Diaphragm for contraceptive use | 24 | $25.37 |
| A4267 | Contraceptive supply, condom, male, each | 29 | $0.40 |
| A4268 | Contraceptive supply, condom, female, each | 28 | $2.29 |
| A4269 | Contraceptive supply, spermicide (e.g., foam, gel), each | 21 | $6.29 |
| A4271 | Integrated lancing and blood sample testing cartridges for... | 12 | $32.06 |
| A4280 | Adhesive skin support attachment for use with external... | 28 | $5.85 |
| A4281 | Tubing for breast pump, replacement | 14 | $4.75 |
| A4282 | Adapter for breast pump, replacement | 13 | $7.49 |
| A4283 | Cap for breast pump bottle, replacement | 14 | $1.58 |
| A4284 | Breast shield and splash protector for use with breast pump | 15 | $8.85 |
| A4285 | Polycarbonate bottle for use with breast pump, replacement | 14 | $4.16 |
| A4286 | Locking ring for breast pump, replacement | 12 | $2.15 |
| A4287 | Disposable collection and storage bag for breast milk | 17 | $0.26 |
| A4290 | Sacral nerve stimulation test lead, each | 6 | $136.28 |
| A4295 | Intermittent urinary catheter; straight tip | 30 | $2.15 |
| A4296 | Intermittent urinary catheter; coude (curved) tip | 30 | $7.46 |
| A4297 | Intermittent urinary catheter; hydrophilic coating | 29 | $8.73 |
| A4300 | Implantable access catheter, (e.g., venous, arterial | 9 | $9.02 |
| A4305 | Disposable drug delivery system | 17 | $12.73 |
| A4306 | Disposable drug delivery system | 16 | $17.17 |
| A4310 | Insertion tray without drainage bag and without catheter | 37 | $7.49 |
| A4311 | Insertion tray without drainage bag with indwelling... | 36 | $14.80 |
| A4312 | Insertion tray without drainage bag with indwelling... | 34 | $18.48 |
| A4313 | Insertion tray without drainage bag with indwelling... | 33 | $19.07 |
| A4314 | Insertion tray with drainage bag with indwelling catheter | 36 | $25.47 |
| A4315 | Insertion tray with drainage bag with indwelling catheter | 36 | $27.18 |
| A4316 | Insertion tray with drainage bag with indwelling catheter | 34 | $29.49 |
| A4318 | Female external urinary collection cup | 10 | $7.60 |
| A4320 | Irrigation tray with bulb or piston syringe, any purpose | 37 | $5.42 |
| A4321 | Therapeutic agent for urinary catheter irrigation | 6 | $7.62 |
| A4322 | Irrigation syringe, bulb or piston, each | 36 | $3.27 |
| A4326 | Male external catheter with integral collection chamber | 34 | $11.44 |
| A4327 | Female external urinary collection device; meatal cup, each | 32 | $47.45 |
| A4328 | Female external urinary collection device; pouch, each | 34 | $10.78 |
| A4330 | Perianal fecal collection pouch with adhesive, each | 27 | $7.56 |
| A4331 | Extension drainage tubing, any type, any length | 35 | $3.41 |
| A4332 | Lubricant, individual sterile packet, each | 32 | $0.13 |
| A4333 | Urinary catheter anchoring device, adhesive skin attachment | 34 | $2.43 |
| A4334 | Urinary catheter anchoring device, leg strap, each | 31 | $5.61 |
| A4335 | Incontinence supply; miscellaneous | 14 | $1.53 |
| A4336 | Incontinence supply, urethral insert, any type, each | 15 | $1.67 |
| A4338 | Indwelling catheter; foley type, two-way latex with coating | 37 | $12.78 |
| A4340 | Indwelling catheter; specialty type, (e.g., coude, mushroom | 36 | $30.06 |
| A4341 | Indwelling intraurethral drainage device with valve | 12 | $306.72 |
| A4342 | Accessories for patient inserted indwelling intraurethral... | 12 | $774.45 |
| A4344 | Indwelling catheter, foley type, two-way | 37 | $15.93 |
| A4346 | Indwelling catheter; foley type | 32 | $20.15 |
| A4349 | Male external catheter, with or without adhesive | 38 | $2.15 |
| A4351 | Intermittent urinary catheter; straight tip | 38 | $1.80 |
| A4352 | Intermittent urinary catheter; coude (curved) tip | 38 | $6.32 |
| A4353 | Intermittent urinary catheter, with insertion supplies | 38 | $7.58 |
| A4354 | Insertion tray with drainage bag but without catheter | 37 | $12.16 |
| A4355 | Irrigation tubing set for continuous bladder irrigation... | 34 | $9.31 |
| A4356 | External urethral clamp or compression device | 33 | $44.98 |
| A4357 | Bedside drainage bag, day or night | 37 | $9.57 |
| A4358 | Urinary drainage bag, leg or abdomen, vinyl | 37 | $6.38 |
| A4360 | Disposable external urethral clamp or compression device | 19 | $0.47 |
| A4361 | Ostomy faceplate, each | 36 | $18.64 |
| A4362 | Skin barrier; solid, 4 x 4 or equivalent; each | 37 | $3.56 |
| A4363 | Ostomy clamp, any type, replacement only, each | 33 | $2.58 |
| A4364 | Adhesive, liquid or equal, any type, per oz | 37 | $3.21 |
| A4366 | Ostomy vent, any type, each | 31 | $1.47 |
| A4367 | Ostomy belt, each | 37 | $7.68 |
| A4368 | Ostomy filter, any type, each | 32 | $0.29 |
| A4369 | Ostomy skin barrier, liquid (spray, brush, etc.), per oz | 37 | $2.32 |
| A4371 | Ostomy skin barrier, powder, per oz | 37 | $3.92 |
| A4372 | Ostomy skin barrier, solid 4 x 4 or equivalent | 34 | $4.59 |
| A4373 | Ostomy skin barrier, with flange (solid | 35 | $6.84 |
| A4375 | Ostomy pouch, drainable, with faceplate attached, plastic | 35 | $18.79 |
| A4376 | Ostomy pouch, drainable, with faceplate attached, rubber | 33 | $51.94 |
| A4377 | Ostomy pouch, drainable, for use on faceplate, plastic, each | 35 | $4.68 |
| A4378 | Ostomy pouch, drainable, for use on faceplate, rubber, each | 34 | $33.59 |
| A4379 | Ostomy pouch, urinary, with faceplate attached, plastic | 35 | $16.39 |
| A4380 | Ostomy pouch, urinary, with faceplate attached, rubber, each | 34 | $40.79 |
| A4381 | Ostomy pouch, urinary, for use on faceplate, plastic, each | 35 | $5.05 |
| A4382 | Ostomy pouch, urinary, for use on faceplate, heavy plastic | 35 | $26.87 |
| A4383 | Ostomy pouch, urinary, for use on faceplate, rubber, each | 35 | $30.77 |
| A4384 | Ostomy faceplate equivalent, silicone ring, each | 34 | $10.50 |
| A4385 | Ostomy skin barrier, solid 4 x 4 or equivalent | 35 | $5.56 |
| A4387 | Ostomy pouch, closed, with barrier attached | 32 | $2.74 |
| A4388 | Ostomy pouch, drainable | 35 | $4.76 |
| A4389 | Ostomy pouch, drainable, with barrier attached | 35 | $6.78 |
| A4390 | Ostomy pouch, drainable | 36 | $10.39 |
| A4391 | Ostomy pouch, urinary, with extended wear barrier attached | 36 | $7.72 |
| A4392 | Ostomy pouch, urinary, with standard wear barrier attached | 35 | $8.92 |
| A4393 | Ostomy pouch, urinary, with extended wear barrier attached | 36 | $9.78 |
| A4394 | Ostomy deodorant, with or without lubricant | 35 | $2.86 |
| A4395 | Medical supplies | 34 | $0.05 |
| A4396 | Ostomy belt with peristomal hernia support | 32 | $44.23 |
| A4397 | Irrigation supply; sleeve, each | 9 | $4.41 |
| A4398 | Ostomy irrigation supply; bag, each | 36 | $15.19 |
| A4399 | Ostomy irrigation supply; cone/catheter | 34 | $12.34 |
| A4400 | Ostomy irrigation set | 32 | $47.12 |
| A4402 | Lubricant, per ounce | 37 | $1.72 |
| A4404 | Ostomy ring, each | 37 | $1.75 |
| A4405 | Ostomy skin barrier, non-pectin based, paste, per ounce | 36 | $3.75 |
| A4406 | Ostomy skin barrier, pectin-based, paste, per ounce | 37 | $6.17 |
| A4407 | Ostomy skin barrier, with flange (solid, flexible | 37 | $9.38 |
| A4408 | Ostomy skin barrier, with flange (solid | 36 | $10.68 |
| A4409 | Ostomy skin barrier, with flange (solid | 36 | $6.72 |
| A4410 | Ostomy skin barrier, with flange (solid | 36 | $9.78 |
| A4411 | Ostomy skin barrier, solid 4 x 4 or equivalent | 34 | $5.62 |
| A4412 | Ostomy pouch, drainable, high output | 35 | $3.00 |
| A4413 | Ostomy pouch, drainable, high output | 35 | $6.02 |
| A4414 | Ostomy skin barrier, with flange (solid | 37 | $5.27 |
| A4415 | Ostomy skin barrier, with flange (solid | 36 | $6.48 |
| A4416 | Ostomy pouch, closed, with barrier attached, with filter | 37 | $2.95 |
| A4417 | Ostomy pouch, closed, with barrier attached | 36 | $4.03 |
| A4418 | Ostomy pouch, closed; without barrier attached, with filter | 35 | $1.98 |
| A4419 | Ostomy pouch, closed | 37 | $1.86 |
| A4420 | Ostomy pouch, closed | 16 | $1.49 |
| A4421 | Ostomy supply; miscellaneous | 9 | $2.71 |
| A4422 | Ostomy absorbent material | 32 | $0.13 |
| A4423 | Ostomy pouch, closed | 36 | $2.01 |
| A4424 | Ostomy pouch, drainable, with barrier attached, with filter | 37 | $4.98 |
| A4425 | Ostomy pouch, drainable | 38 | $3.81 |
| A4426 | Ostomy pouch, drainable | 36 | $2.87 |
| A4427 | Ostomy pouch, drainable | 36 | $2.92 |
| A4428 | Ostomy pouch, urinary, with extended wear barrier attached | 36 | $7.05 |
| A4429 | Ostomy pouch, urinary, with barrier attached | 35 | $9.01 |
| A4430 | Ostomy pouch, urinary, with extended wear barrier attached | 35 | $9.30 |
| A4431 | Ostomy pouch, urinary; with barrier attached | 34 | $6.86 |
| A4432 | Ostomy pouch, urinary | 36 | $3.88 |
| A4433 | Ostomy pouch, urinary | 36 | $3.56 |
| A4434 | Ostomy pouch, urinary | 35 | $4.29 |
| A4435 | Ostomy pouch, drainable, high output | 31 | $6.38 |
| A4436 | Irrigation supply; sleeve, reusable, per month | 27 | $20.91 |
| A4437 | Irrigation supply; sleeve, disposable, per month | 27 | $20.91 |
| A4438 | Adhesive clip applied to the skin to secure external... | 12 | $1.86 |
| A4450 | Tape, non-waterproof, per 18 square inches | 37 | $0.09 |
| A4452 | Tape, waterproof, per 18 square inches | 37 | $0.40 |
| A4453 | Rectal catheter with or without balloon | 16 | $14.56 |
| A4455 | Adhesive remover or solvent (for tape | 35 | $1.62 |
| A4456 | Adhesive remover, wipes, any type, each | 35 | $0.27 |
| A4458 | Medical supplies | 11 | $4.04 |
| A4459 | Manual transanal irrigation system | 16 | $166.37 |
| A4461 | Surgical dressing holder, non-reusable, each | 26 | $3.80 |
| A4463 | Surgical dressing holder, reusable, each | 25 | $15.18 |
| A4465 | Non-elastic binder for extremity | 12 | $10.91 |
| A4479 | Electronic transanal irrigation system | 7 | $693.78 |
| A4480 | Vabra aspirator | 5 | $78.00 |
| A4481 | Medical supplies | 32 | $0.42 |
| A4483 | Moisture exchanger, disposable | 20 | $4.17 |
| A4490 | Surgical stockings above knee length, each | 19 | $11.98 |
| A4495 | Surgical stockings thigh length, each | 23 | $18.62 |
| A4500 | Surgical stockings below knee length, each | 24 | $14.49 |
| A4510 | Surgical stockings full length, each | 21 | $19.81 |
| A4541 | Monthly supplies for use of device coded at e0733 | 8 | $31.83 |
| A4542 | Supplies and accessories for external upper limb tremor... | 9 | $421.48 |
| A4544 | Electrode for external lower extremity nerve stimulator for... | 11 | $5.07 |
| A4545 | Supplies and accessories for external tibial nerve... | 9 | $31.37 |
| A4550 | Surgical trays | 13 | $9.06 |
| A4553 | Non-disposable underpads, all sizes | 5 | $10.85 |
| A4554 | Disposable underpads, all sizes | 20 | $0.365 |
| A4556 | Electrodes, (e.g., apnea monitor), per pair | 31 | $11.77 |
| A4557 | Lead wires, (e.g., apnea monitor), per pair | 32 | $15.70 |
| A4558 | Conductive gel or paste, for use with electrical device | 27 | $5.61 |
| A4559 | Coupling gel or paste, for use with ultrasound device | 11 | $0.12 |
| A4561 | Pessary, reusable, rubber, any type | 32 | $22.94 |
| A4562 | Pessary, reusable, non rubber, any type | 31 | $56.65 |
| A4563 | Rectal control system for vaginal insertion | 8 | $1,233.16 |
| A4565 | Slings | 32 | $8.90 |
| A4570 | Splint | 17 | $15.00 |
| A4580 | Cast supplies (e.g., plaster) | 8 | $15.01 |
| A4590 | Special casting material (e.g., fiberglass) | 12 | $31.72 |
| A4595 | Electrical stimulator supplies, 2 lead, per month, (e.g. | 28 | $13.62 |
| A4601 | Lithium ion battery, rechargeable, for non-prosthetic use | 6 | $14.67 |
| A4602 | Replacement battery for external infusion pump owned by... | 17 | $4.59 |
| A4604 | Tubing with integrated heating element for use with positive... | 30 | $49.42 |
| A4605 | Tracheal suction catheter, closed system, each | 36 | $18.02 |
| A4606 | Oxygen probe for use with oximeter device, replacement | 24 | $30.46 |
| A4608 | Transtracheal oxygen catheter, each | 23 | $58.14 |
| A4611 | Battery, heavy duty; replacement for patient owned... | 24 | $149.67 |
| A4612 | Battery cables; replacement for patient-owned ventilator | 24 | $63.77 |
| A4613 | Battery charger; replacement for patient-owned ventilator | 23 | $119.22 |
| A4614 | Peak expiratory flow rate meter, hand held | 34 | $26.24 |
| A4615 | Cannula, nasal | 28 | $0.83 |
| A4616 | Tubing (oxygen), per foot | 27 | $0.07 |
| A4617 | Mouth piece | 22 | $3.52 |
| A4618 | Breathing circuits | 29 | $8.20 |
| A4619 | Face tent | 29 | $2.07 |
| A4620 | Variable concentration mask | 29 | $0.73 |
| A4623 | Tracheostomy, inner cannula | 38 | $6.35 |
| A4624 | Tracheal suction catheter | 38 | $2.58 |
| A4625 | Tracheostomy care kit for new tracheostomy | 35 | $6.83 |
| A4626 | Tracheostomy cleaning brush, each | 30 | $3.47 |
| A4627 | Spacer, bag or reservoir, with or without mask | 27 | $29.79 |
| A4628 | Oral and/or oropharyngeal suction catheter, each | 36 | $3.99 |
| A4629 | Tracheostomy care kit for established tracheostomy | 38 | $4.78 |
| A4630 | Replacement batteries, medically necessary | 23 | $6.56 |
| A4633 | Replacement bulb/lamp for ultraviolet light therapy system | 15 | $47.60 |
| A4635 | Underarm pad, crutch, replacement, each | 38 | $4.45 |
| A4636 | Replacement, handgrip, cane, crutch, or walker, each | 37 | $3.18 |
| A4637 | Replacement, tip, cane, crutch, walker, each. | 38 | $1.85 |
| A4639 | Replacement pad for infrared heating pad system, each | 9 | $271.14 |
| A4640 | Replacement pad for use with medically necessary alternating... | 36 | $51.62 |
| A4642 | Indium in-111 satumomab pendetide, diagnostic | 7 | $710.55 |
| A4648 | Tissue marker, implantable, any type, each | 8 | $85.73 |
| A4649 | Surgical supply; miscellaneous | 5 | $22.45 |
| A4657 | Syringe, with or without needle, each | 18 | $0.46 |
| A4660 | Sphygmomanometer/blood pressure apparatus with cuff and... | 25 | $31.61 |
| A4663 | Blood pressure cuff only | 23 | $21.92 |
| A4670 | Automatic blood pressure monitor | 31 | $54.29 |
| A4680 | Activated carbon filter for hemodialysis, each | 6 | $50.06 |
| A4690 | Dialyzer (artificial kidneys), all types, all sizes | 5 | $47.72 |
| A4719 | "y set" tubing for peritoneal dialysis | 6 | $15.01 |
| A4722 | Dialysate solution, any concentration of dextrose | 5 | $18.04 |
| A4726 | Dialysate solution, any concentration of dextrose | 5 | $39.05 |
| A4750 | Blood tubing, arterial or venous, for hemodialysis, each | 9 | $7.06 |
| A4755 | Blood tubing, arterial and venous combined | 5 | $9.00 |
| A4770 | Blood collection tube, vacuum, for dialysis, per 50 | 5 | $20.15 |
| A4772 | Blood glucose test strips, for dialysis, per 50 | 10 | $29.38 |
| A4773 | Occult blood test strips, for dialysis, per 50 | 5 | $25.61 |
| A4802 | Protamine sulfate, for hemodialysis, per 50 mg | 5 | $7.21 |
| A4860 | Disposable catheter tips for peritoneal dialysis, per 10 | 9 | $0.67 |
| A4911 | Drain bag/bottle, for dialysis, each | 6 | $12.87 |
| A4927 | Gloves, non-sterile, per 100 | 34 | $8.65 |
| A4928 | Surgical mask, per 20 | 10 | $9.67 |
| A4930 | Gloves, sterile, per pair | 30 | $0.655 |
| A4931 | Oral thermometer, reusable, any type, each | 13 | $2.95 |
| A4932 | Rectal thermometer, reusable, any type, each | 10 | $2.41 |
| A5051 | Ostomy pouch, closed; with barrier attached (1 piece), each | 36 | $2.33 |
| A5052 | Ostomy pouch, closed; without barrier attached (1 piece) | 37 | $1.64 |
| A5053 | Ostomy pouch, closed; for use on faceplate, each | 36 | $1.74 |
| A5054 | Ostomy pouch, closed; for use on barrier with flange | 37 | $1.93 |
| A5055 | Stoma cap | 37 | $1.50 |
| A5056 | Ostomy pouch, drainable | 38 | $5.13 |
| A5057 | Ostomy pouch, drainable | 37 | $10.62 |
| A5061 | Ostomy pouch, drainable; with barrier attached, (1 piece) | 36 | $3.97 |
| A5062 | Ostomy pouch, drainable; without barrier attached (1 piece) | 36 | $2.37 |
| A5063 | Ostomy pouch, drainable; for use on barrier with flange | 37 | $2.99 |
| A5071 | Ostomy pouch, urinary; with barrier attached (1 piece), each | 37 | $6.00 |
| A5072 | Ostomy pouch, urinary; without barrier attached (1 piece) | 35 | $3.70 |
| A5073 | Ostomy pouch, urinary; for use on barrier with flange | 37 | $3.23 |
| A5081 | Stoma plug or seal, any type | 35 | $3.27 |
| A5082 | Continent device; catheter for continent stoma | 35 | $11.54 |
| A5083 | Continent device, stoma absorptive cover for continent stoma | 25 | $0.75 |
| A5093 | Ostomy accessory; convex insert | 35 | $1.94 |
| A5102 | Bedside drainage bottle with or without tubing | 32 | $25.09 |
| A5105 | Urinary suspensory with leg bag, with or without tube, each | 34 | $40.06 |
| A5112 | Urinary drainage bag, leg or abdomen, latex | 36 | $35.32 |
| A5113 | Leg strap; latex, replacement only, per set | 33 | $4.92 |
| A5114 | Leg strap; foam or fabric, replacement only, per set | 32 | $8.88 |
| A5120 | Skin barrier, wipes or swabs, each | 38 | $0.25 |
| A5121 | Skin barrier; solid, 6 x 6 or equivalent, each | 36 | $8.06 |
| A5122 | Skin barrier; solid, 8 x 8 or equivalent, each | 37 | $13.10 |
| A5126 | Adhesive or non-adhesive; disk or foam pad | 34 | $1.37 |
| A5131 | Appliance cleaner, incontinence and ostomy appliances | 32 | $15.30 |
| A5200 | Percutaneous catheter/tube anchoring device | 28 | $12.41 |
| A5500 | For diabetics only, fitting (including follow-up) | 35 | $67.07 |
| A5501 | For diabetics only, fitting (including follow-up) | 35 | $201.13 |
| A5503 | For diabetics only, modification | 34 | $33.40 |
| A5504 | For diabetics only, modification | 35 | $32.93 |
| A5505 | For diabetics only, modification | 34 | $33.40 |
| A5506 | For diabetics only, modification | 34 | $33.40 |
| A5507 | For diabetics only, not otherwise specified modification | 34 | $33.14 |
| A5508 | For diabetics only, deluxe feature of off-the-shelf... | 7 | $32.00 |
| A5510 | For diabetics only, direct formed | 13 | $29.14 |
| A5512 | For diabetics only, multiple density insert, direct formed | 34 | $27.42 |
| A5513 | For diabetics only, multiple density insert | 34 | $40.92 |
| A5514 | For diabetics only, multiple density insert | 28 | $44.56 |
| A6010 | Collagen based wound filler, dry form, sterile | 32 | $34.03 |
| A6011 | Collagen based wound filler, gel/paste, per gram of collagen | 31 | $2.52 |
| A6021 | Collagen dressing, sterile, size 16 sq. in. or less, each | 35 | $22.95 |
| A6022 | Collagen dressing, sterile | 35 | $22.95 |
| A6023 | Collagen dressing, sterile, size more than 48 sq. in., each | 34 | $205.79 |
| A6024 | Collagen dressing wound filler, sterile, per 6 inches | 34 | $6.95 |
| A6025 | Gel sheet for dermal or epidermal application, (e.g. | 10 | $12.86 |
| A6154 | Wound pouch, each | 31 | $15.89 |
| A6196 | Alginate or other fiber gelling dressing, wound cover | 37 | $8.03 |
| A6197 | Alginate or other fiber gelling dressing, wound cover | 37 | $17.95 |
| A6198 | Alginate or other fiber gelling dressing, wound cover | 23 | $19.29 |
| A6199 | Alginate or other fiber gelling dressing, wound filler | 35 | $5.79 |
| A6203 | Composite dressing, sterile, pad size 16 sq. in. or less | 36 | $3.64 |
| A6204 | Composite dressing, sterile | 36 | $6.73 |
| A6205 | Composite dressing, sterile, pad size more than 48 sq. in. | 21 | $5.16 |
| A6206 | Contact layer, sterile, 16 sq. in. or less, each dressing | 25 | $2.00 |
| A6207 | Contact layer, sterile | 35 | $8.04 |
| A6208 | Contact layer, sterile, more than 48 sq. in., each dressing | 20 | $8.76 |
| A6209 | Foam dressing, wound cover, sterile | 36 | $8.39 |
| A6210 | Foam dressing, wound cover, sterile | 36 | $21.55 |
| A6211 | Foam dressing, wound cover, sterile | 36 | $32.98 |
| A6212 | Foam dressing, wound cover, sterile | 36 | $10.50 |
| A6213 | Foam dressing, wound cover, sterile | 29 | $10.13 |
| A6214 | Foam dressing, wound cover, sterile | 33 | $11.24 |
| A6215 | Foam dressing, wound filler, sterile, per gram | 17 | $1.96 |
| A6216 | Gauze, non-impregnated, non-sterile | 38 | $0.05 |
| A6217 | Gauze, non-impregnated, non-sterile | 26 | $0.275 |
| A6218 | Gauze, non-impregnated, non-sterile | 24 | $0.565 |
| A6219 | Gauze, non-impregnated, sterile | 36 | $1.05 |
| A6220 | Gauze, non-impregnated, sterile | 35 | $2.83 |
| A6221 | Gauze, non-impregnated, sterile | 19 | $2.31 |
| A6222 | Gauze, impregnated with other than water, normal saline | 36 | $2.31 |
| A6223 | Gauze, impregnated with other than water, normal saline | 35 | $2.65 |
| A6224 | Gauze, impregnated with other than water, normal saline | 35 | $3.93 |
| A6228 | Gauze, impregnated, water or normal saline, sterile | 13 | $1.64 |
| A6229 | Gauze, impregnated, water or normal saline, sterile | 31 | $3.87 |
| A6230 | Gauze, impregnated, water or normal saline, sterile | 15 | $1.84 |
| A6231 | Gauze, impregnated, hydrogel, for direct wound contact | 32 | $5.34 |
| A6232 | Gauze, impregnated, hydrogel, for direct wound contact | 32 | $7.71 |
| A6233 | Gauze, impregnated, hydrogel, for direct wound contact | 30 | $21.86 |
| A6234 | Hydrocolloid dressing, wound cover, sterile | 36 | $7.08 |
| A6235 | Hydrocolloid dressing, wound cover, sterile | 36 | $18.19 |
| A6236 | Hydrocolloid dressing, wound cover, sterile | 36 | $29.94 |
| A6237 | Hydrocolloid dressing, wound cover, sterile | 36 | $8.56 |
| A6238 | Hydrocolloid dressing, wound cover, sterile | 35 | $24.41 |
| A6239 | Hydrocolloid dressing, wound cover, sterile | 17 | $18.41 |
| A6240 | Hydrocolloid dressing, wound filler, paste, sterile | 34 | $13.24 |
| A6241 | Hydrocolloid dressing, wound filler, dry form, sterile | 35 | $2.81 |
| A6242 | Hydrogel dressing, wound cover, sterile | 36 | $6.55 |
| A6243 | Hydrogel dressing, wound cover, sterile | 35 | $13.19 |
| A6244 | Hydrogel dressing, wound cover, sterile | 34 | $42.48 |
| A6245 | Hydrogel dressing, wound cover, sterile | 35 | $7.94 |
| A6246 | Hydrogel dressing, wound cover, sterile | 35 | $10.84 |
| A6247 | Hydrogel dressing, wound cover, sterile | 34 | $26.13 |
| A6248 | Hydrogel dressing, wound filler, gel, per fluid ounce | 36 | $17.66 |
| A6250 | Skin sealants, protectants, moisturizers, ointments | 20 | $4.16 |
| A6251 | Specialty absorptive dressing, wound cover, sterile | 35 | $2.17 |
| A6252 | Specialty absorptive dressing, wound cover, sterile | 36 | $3.52 |
| A6253 | Specialty absorptive dressing, wound cover, sterile | 35 | $6.91 |
| A6254 | Specialty absorptive dressing, wound cover, sterile | 35 | $1.30 |
| A6255 | Specialty absorptive dressing, wound cover, sterile | 35 | $3.32 |
| A6256 | Specialty absorptive dressing, wound cover, sterile | 18 | $2.08 |
| A6257 | Transparent film, sterile, 16 sq. in. or less, each dressing | 36 | $1.66 |
| A6258 | Transparent film, sterile | 36 | $4.66 |
| A6259 | Transparent film, sterile, more than 48 sq. in. | 36 | $12.02 |
| A6260 | Wound cleansers, any type, any size | 17 | $7.68 |
| A6261 | Wound filler, gel/paste, per fluid ounce | 18 | $3.63 |
| A6262 | Wound filler, dry form, per gram, not otherwise specified | 18 | $0.98 |
| A6266 | Gauze, impregnated, other than water, normal saline | 35 | $2.10 |
| A6402 | Gauze, non-impregnated, sterile | 36 | $0.12 |
| A6403 | Gauze, non-impregnated, sterile | 37 | $0.46 |
| A6404 | Gauze, non-impregnated, sterile | 24 | $0.65 |
| A6407 | Packing strips, non-impregnated, sterile | 32 | $2.11 |
| A6410 | Eye pad, sterile, each | 30 | $0.425 |
| A6411 | Eye pad, non-sterile, each | 16 | $0.255 |
| A6412 | Eye patch, occlusive, each | 17 | $0.57 |
| A6441 | Padding bandage, non-elastic, non-woven/non-knitted | 34 | $0.76 |
| A6442 | Conforming bandage, non-elastic, knitted/woven, non-sterile | 34 | $0.18 |
| A6443 | Conforming bandage, non-elastic, knitted/woven, non-sterile | 35 | $0.32 |
| A6444 | Conforming bandage, non-elastic, knitted/woven, non-sterile | 35 | $0.62 |
| A6445 | Conforming bandage, non-elastic, knitted/woven, sterile | 32 | $0.36 |
| A6446 | Conforming bandage, non-elastic, knitted/woven, sterile | 36 | $0.435 |
| A6447 | Conforming bandage, non-elastic, knitted/woven, sterile | 34 | $0.76 |
| A6448 | Light compression bandage, elastic, knitted/woven | 34 | $1.30 |
| A6449 | Light compression bandage, elastic, knitted/woven | 35 | $1.94 |
| A6450 | Light compression bandage, elastic, knitted/woven | 30 | $1.97 |
| A6451 | Moderate compression bandage, elastic, knitted/woven | 26 | $2.02 |
| A6452 | High compression bandage, elastic, knitted/woven | 32 | $6.72 |
| A6453 | Self-adherent bandage, elastic, non-knitted/non-woven | 33 | $0.71 |
| A6454 | Self-adherent bandage, elastic, non-knitted/non-woven | 33 | $0.90 |
| A6455 | Self-adherent bandage, elastic, non-knitted/non-woven | 32 | $1.59 |
| A6456 | Zinc paste impregnated bandage, non-elastic, knitted/woven | 32 | $1.43 |
| A6457 | Tubular dressing with or without elastic, any width | 34 | $1.27 |
| A6501 | Compression burn garment, bodysuit (head to foot) | 8 | $121.47 |
| A6502 | Compression burn garment, chin strap, custom fabricated | 6 | $72.63 |
| A6503 | Compression burn garment, facial hood, custom fabricated | 6 | $86.46 |
| A6504 | Compression burn garment, glove to wrist, custom fabricated | 7 | $83.94 |
| A6505 | Compression burn garment, glove to elbow, custom fabricated | 6 | $152.27 |
| A6506 | Compression burn garment, glove to axilla, custom fabricated | 6 | $90.01 |
| A6507 | Compression burn garment, foot to knee length | 7 | $90.62 |
| A6509 | Compression burn garment | 8 | $222.85 |
| A6511 | Compression burn garment | 9 | $150.33 |
| A6513 | Compression burn mask, face and/or neck, plastic or equal | 7 | $30.37 |
| A6520 | Gradient compression garment, glove, padded | 19 | $119.54 |
| A6521 | Gradient compression garment, glove, padded | 18 | $468.01 |
| A6522 | Gradient compression garment, arm, padded | 20 | $286.60 |
| A6523 | Gradient compression garment, arm, padded | 18 | $679.99 |
| A6524 | Gradient compression garment, lower leg and foot, padded | 20 | $357.56 |
| A6525 | Gradient compression garment, lower leg and foot, padded | 19 | $712.10 |
| A6526 | Gradient compression garment, full leg and foot, padded | 21 | $637.71 |
| A6527 | Gradient compression garment, full leg and foot, padded | 19 | $1,172.68 |
| A6528 | Gradient compression garment, bra, for nighttime use, each | 22 | $606.49 |
| A6529 | Gradient compression garment, bra, for nighttime use | 19 | $968.96 |
| A6530 | Gradient compression stocking, below knee, 18-30 mmhg, each | 31 | $31.26 |
| A6531 | Gradient compression stocking, below knee, 30-40 mmhg | 31 | $47.17 |
| A6532 | Gradient compression stocking, below knee, 40-50 mmhg | 30 | $66.97 |
| A6533 | Gradient compression stocking, thigh length, 18-30 mmhg | 31 | $43.89 |
| A6534 | Gradient compression stocking, thigh length, 30-40 mmhg | 28 | $53.69 |
| A6535 | Gradient compression stocking, thigh length | 28 | $63.46 |
| A6536 | Gradient compression stocking, full length/chap style | 28 | $61.01 |
| A6537 | Gradient compression stocking, full length/chap style | 28 | $77.32 |
| A6538 | Gradient compression stocking, full length/chap style | 28 | $90.54 |
| A6539 | Gradient compression stocking, waist length, 18-30 mmhg | 29 | $83.18 |
| A6540 | Gradient compression stocking, waist length, 30-40 mmhg | 28 | $100.00 |
| A6541 | Gradient compression stocking, waist length | 29 | $119.69 |
| A6544 | Gradient compression stocking, garter belt | 23 | $27.03 |
| A6545 | Gradient compression wrap, non-elastic, below knee | 23 | $97.13 |
| A6548 | Accessory to custom gradient compression garment | 12 | $20.86 |
| A6549 | Gradient compression garment, not otherwise specified | 7 | $64.71 |
| A6550 | Wound care set, for negative pressure wound therapy... | 34 | $25.44 |
| A6552 | Gradient compression stocking, below knee, 30-40 mmhg, each | 25 | $50.08 |
| A6553 | Gradient compression stocking, below knee, 30-40 mmhg | 22 | $202.46 |
| A6554 | Gradient compression stocking, below knee | 25 | $68.88 |
| A6555 | Gradient compression stocking, below knee | 22 | $202.46 |
| A6556 | Gradient compression stocking, thigh length, 18-30 mmhg | 21 | $279.23 |
| A6557 | Gradient compression stocking, thigh length, 30-40 mmhg | 22 | $282.35 |
| A6558 | Gradient compression stocking, thigh length | 21 | $288.15 |
| A6562 | Gradient compression stocking, waist length, 18-30 mmhg | 22 | $908.06 |
| A6563 | Gradient compression stocking, waist length, 30-40 mmhg | 22 | $908.06 |
| A6564 | Gradient compression stocking, waist length | 22 | $978.18 |
| A6565 | Gradient compression gauntlet, custom, each | 20 | $159.67 |
| A6566 | Gradient compression garment, neck/head, each | 20 | $231.85 |
| A6567 | Gradient compression garment, neck/head, custom, each | 18 | $746.59 |
| A6568 | Gradient compression garment, torso and shoulder, each | 22 | $145.48 |
| A6569 | Gradient compression garment, torso/shoulder, custom, each | 20 | $861.61 |
| A6570 | Gradient compression garment, genital region, each | 21 | $101.95 |
| A6571 | Gradient compression garment, genital region, custom, each | 19 | $626.47 |
| A6572 | Gradient compression garment, toe caps, each | 20 | $95.66 |
| A6573 | Gradient compression garment, toe caps, custom, each | 20 | $227.00 |
| A6574 | Gradient compression arm sleeve and glove combination | 22 | $284.38 |
| A6575 | Gradient compression arm sleeve and glove combination, each | 22 | $93.79 |
| A6576 | Gradient compression arm sleeve, custom, medium weight, each | 21 | $175.64 |
| A6577 | Gradient compression arm sleeve, custom, heavy weight, each | 21 | $145.38 |
| A6578 | Gradient compression arm sleeve, each | 23 | $71.60 |
| A6579 | Gradient compression glove, custom, medium weight, each | 20 | $285.09 |
| A6580 | Gradient compression glove, custom, heavy weight, each | 20 | $283.00 |
| A6581 | Gradient compression glove, each | 21 | $68.77 |
| A6582 | Gradient compression gauntlet, each | 21 | $44.80 |
| A6583 | Gradient compression wrap with adjustable straps | 23 | $138.36 |
| A6585 | Gradient compression wrap with adjustable straps | 19 | $174.46 |
| A6586 | Gradient compression wrap with adjustable straps, full leg | 19 | $513.98 |
| A6587 | Gradient compression wrap with adjustable straps, foot, each | 20 | $66.59 |
| A6588 | Gradient compression wrap with adjustable straps, arm, each | 20 | $221.94 |
| A6589 | Gradient pressure wrap with adjustable straps, bra, each | 21 | $86.64 |
| A6590 | External urinary catheters; disposable | 12 | $338.61 |
| A6591 | External urinary catheter; non-disposable | 11 | $73.76 |
| A6594 | Gradient compression bandaging supply, bandage liner | 20 | $31.91 |
| A6595 | Gradient compression bandaging supply, bandage liner | 20 | $31.38 |
| A6596 | Gradient compression bandaging supply, conforming gauze | 21 | $0.16 |
| A6597 | Gradient compression bandage roll, elastic long stretch | 21 | $1.40 |
| A6598 | Gradient compression bandage roll, elastic medium stretch | 20 | $0.665 |
| A6599 | Gradient compression bandage roll, inelastic short stretch | 21 | $1.53 |
| A6600 | Gradient compression bandaging supply | 21 | $2.76 |
| A6601 | Gradient compression bandaging supply | 21 | $3.11 |
| A6602 | Gradient compression bandaging supply | 21 | $4.53 |
| A6603 | Gradient compression bandaging supply | 21 | $2.12 |
| A6604 | Gradient compression bandaging supply | 21 | $1.24 |
| A6605 | Gradient compression bandaging supply, padded foam | 21 | $1.41 |
| A6606 | Gradient compression bandaging supply, padded textile | 21 | $4.20 |
| A6607 | Gradient compression bandaging supply | 21 | $1.13 |
| A6608 | Gradient compression bandaging supply | 21 | $4.69 |
| A6610 | Gradient compression stocking, below knee, 18-30 mmhg | 20 | $206.03 |
| A7000 | Canister, disposable, used with suction pump, each | 39 | $8.45 |
| A7001 | Canister, non-disposable, used with suction pump, each | 32 | $36.20 |
| A7002 | Tubing, used with suction pump, each | 37 | $3.75 |
| A7003 | Administration set, with small volume nonfiltered pneumatic... | 36 | $2.08 |
| A7004 | Small volume nonfiltered pneumatic nebulizer, disposable | 33 | $1.51 |
| A7005 | Administration set, with small volume nonfiltered pneumatic... | 38 | $18.48 |
| A7006 | Administration set, with small volume filtered pneumatic... | 33 | $8.65 |
| A7007 | Large volume nebulizer, disposable, unfilled | 34 | $3.47 |
| A7008 | Large volume nebulizer, disposable, prefilled | 25 | $12.28 |
| A7009 | Reservoir bottle, non-disposable | 27 | $47.22 |
| A7010 | Corrugated tubing, disposable | 35 | $18.92 |
| A7012 | Water collection device, used with large volume nebulizer | 35 | $3.21 |
| A7013 | Filter, disposable, used with aerosol compressor or... | 34 | $0.675 |
| A7014 | Filter, nondisposable | 33 | $3.95 |
| A7015 | Aerosol mask, used with dme nebulizer | 37 | $1.56 |
| A7016 | Dome and mouthpiece, used with small volume ultrasonic... | 30 | $7.89 |
| A7017 | Nebulizer, durable, glass or autoclavable plastic | 25 | $106.48 |
| A7018 | Water, distilled, used with large volume nebulizer, 1000 ml | 28 | $0.365 |
| A7020 | Interface for cough stimulating device | 29 | $16.50 |
| A7021 | Supplies and accessories for lung expansion airway... | 15 | $116.27 |
| A7025 | High frequency chest wall oscillation system vest | 27 | $373.64 |
| A7026 | High frequency chest wall oscillation system hose | 26 | $32.28 |
| A7027 | Combination oral/nasal mask | 33 | $152.68 |
| A7028 | Oral cushion for combination oral/nasal mask | 31 | $40.86 |
| A7029 | Nasal pillows for combination oral/nasal mask | 31 | $18.85 |
| A7030 | Full face mask used with positive airway pressure device | 37 | $127.16 |
| A7031 | Face mask interface, replacement for full face mask, each | 37 | $47.03 |
| A7032 | Cushion for use on nasal mask interface, replacement only | 37 | $25.16 |
| A7033 | Pillow for use on nasal cannula type interface | 37 | $21.72 |
| A7034 | Nasal interface (mask or cannula type) used with positive... | 37 | $75.59 |
| A7035 | Headgear used with positive airway pressure device | 37 | $24.43 |
| A7036 | Chinstrap used with positive airway pressure device | 37 | $13.19 |
| A7037 | Tubing used with positive airway pressure device | 37 | $22.92 |
| A7038 | Filter, disposable, used with positive airway pressure... | 37 | $3.25 |
| A7039 | Filter, non disposable | 36 | $9.50 |
| A7040 | One way chest drain valve | 15 | $48.60 |
| A7041 | Water seal drainage container and tubing for use with... | 14 | $92.84 |
| A7044 | Oral interface used with positive airway pressure device | 29 | $102.46 |
| A7045 | Exhalation port with or without swivel used with accessories... | 28 | $14.10 |
| A7046 | Water chamber for humidifier | 38 | $15.87 |
| A7047 | Oral interface used with respiratory suction pump, each | 20 | $138.53 |
| A7048 | Vacuum drainage collection unit and tubing kit | 24 | $48.26 |
| A7501 | Tracheostoma valve, including diaphragm, each | 30 | $116.34 |
| A7502 | Replacement diaphragm/faceplate for tracheostoma valve, each | 29 | $55.41 |
| A7503 | Filter holder or filter cap, reusable | 28 | $12.77 |
| A7504 | Filter for use in a tracheostoma heat and moisture exchange... | 28 | $0.785 |
| A7505 | Housing, reusable without adhesive | 27 | $5.34 |
| A7506 | Adhesive disc for use in a heat and moisture exchange system... | 28 | $0.37 |
| A7507 | Filter holder and integrated filter without adhesive | 36 | $2.81 |
| A7508 | Housing and integrated adhesive | 35 | $3.18 |
| A7509 | Filter holder and integrated filter housing, and adhesive | 29 | $1.64 |
| A7520 | Tracheostomy/laryngectomy tube, non-cuffed | 35 | $54.47 |
| A7521 | Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride | 35 | $54.47 |
| A7522 | Tracheostomy/laryngectomy tube, stainless steel or equal | 34 | $51.49 |
| A7523 | Tracheostomy shower protector, each | 13 | $6.80 |
| A7524 | Tracheostoma stent/stud/button, each | 30 | $86.06 |
| A7525 | Tracheostomy mask, each | 38 | $2.21 |
| A7526 | Tracheostomy tube collar/holder, each | 38 | $3.63 |
| A7527 | Tracheostomy/laryngectomy tube plug/stop, each | 31 | $3.96 |
| A8000 | Helmet, protective, soft, prefabricated | 37 | $152.87 |
| A8001 | Helmet, protective, hard, prefabricated | 39 | $153.17 |
| A8002 | Helmet, protective, soft, custom fabricated | 16 | $364.16 |
| A8003 | Helmet, protective, hard, custom fabricated | 15 | $375.35 |
| A8004 | Soft interface for helmet, replacement only | 8 | $73.56 |
| A9274 | External ambulatory insulin delivery system, disposable | 16 | $38.68 |
| A9275 | Home glucose disposable monitor, includes test strips | 5 | $29.04 |
| A9276 | Sensor; invasive (e.g., subcutaneous), disposable | 11 | $12.95 |
| A9277 | Transmitter; external | 11 | $575.00 |
| A9278 | Receiver (monitor); external | 11 | $550.00 |
| A9284 | Spirometer, non-electronic, includes all accessories | 5 | $10.23 |
| A9286 | Hygienic item or device, disposable or non-disposable | 6 | $0.51 |
| A9500 | Technetium tc-99m sestamibi, diagnostic, per study dose | 28 | $105.08 |
| A9502 | Technetium tc-99m tetrofosmin, diagnostic, per study dose | 29 | $97.21 |
| A9503 | Technetium tc-99m medronate, diagnostic, per study dose | 27 | $16.83 |
| A9504 | Technetium tc-99m apcitide, diagnostic, per study dose | 11 | $380.00 |
| A9505 | Thallium tl-201 thallous chloride, diagnostic | 26 | $33.51 |
| A9506 | Graphite crucible for preparation of technetium tc... | 5 | $331.70 |
| A9507 | Indium in-111 capromab pendetide, diagnostic | 14 | $835.24 |
| A9508 | Iodine i-131 iobenguane sulfate, diagnostic | 13 | $163.40 |
| A9509 | Iodine i-123 sodium iodide, diagnostic, per millicurie | 7 | $194.66 |
| A9510 | Technetium tc-99m disofenin, diagnostic, per study dose | 17 | $59.84 |
| A9512 | Technetium tc-99m pertechnetate, diagnostic, per millicurie | 16 | $1.96 |
| A9513 | Lutetium lu 177, dotatate, therapeutic, 1 millicurie | 22 | $329.86 |
| A9515 | Choline c-11, diagnostic | 7 | $5,130.00 |
| A9516 | Iodine i-123 sodium iodide, diagnostic, per 100 microcuries | 16 | $79.51 |
| A9517 | Iodine i-131 sodium iodide capsule(s), therapeutic | 17 | $40.70 |
| A9520 | Technetium tc-99m tilmanocept, diagnostic | 11 | $508.79 |
| A9521 | Technetium tc-99m exametazime, diagnostic, per study dose | 17 | $1,528.77 |
| A9524 | Iodine i-131 iodinated serum albumin, diagnostic | 14 | $71.79 |
| A9526 | Nitrogen n-13 ammonia, diagnostic, per study dose | 16 | $412.49 |
| A9527 | Iodine i-125, sodium iodide solution, therapeutic | 5 | $5.00 |
| A9528 | Iodine i-131 sodium iodide capsule(s), diagnostic | 11 | $25.00 |
| A9529 | Iodine i-131 sodium iodide solution, diagnostic | 7 | $6.23 |
| A9530 | Iodine i-131 sodium iodide solution, therapeutic | 8 | $6.78 |
| A9531 | Iodine i-131 sodium iodide, diagnostic, per microcurie | 6 | $6.61 |
| A9532 | Iodine i-125 serum albumin, diagnostic, per 5 microcuries | 5 | $68.17 |
| A9536 | Technetium tc-99m depreotide, diagnostic, per study dose | 9 | $640.00 |
| A9537 | Technetium tc-99m mebrofenin, diagnostic, per study dose | 21 | $50.45 |
| A9538 | Technetium tc-99m pyrophosphate, diagnostic, per study dose | 19 | $43.58 |
| A9539 | Technetium tc-99m pentetate, diagnostic, per study dose | 14 | $26.52 |
| A9540 | Technetium tc-99m macroaggregated albumin, diagnostic | 16 | $30.00 |
| A9541 | Technetium tc-99m sulfur colloid, diagnostic | 20 | $51.44 |
| A9542 | Indium in-111 ibritumomab tiuxetan, diagnostic | 12 | $3,191.58 |
| A9543 | Yttrium y-90 ibritumomab tiuxetan, therapeutic | 16 | $66,754.35 |
| A9546 | Cobalt co-57/58, cyanocobalamin, diagnostic, per study dose | 7 | $5.64 |
| A9547 | Indium in-111 oxyquinoline, diagnostic, per 0.5 millicurie | 18 | $831.46 |
| A9548 | Indium in-111 pentetate, diagnostic, per 0.5 millicurie | 17 | $745.62 |
| A9551 | Technetium tc-99m succimer, diagnostic, per study dose | 15 | $589.83 |
| A9552 | Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose | 22 | $249.99 |
| A9553 | Chromium cr-51 sodium chromate, diagnostic, per study dose | 11 | $287.33 |
| A9554 | Iodine i-125 sodium iothalamate, diagnostic, per study dose | 15 | $42.75 |
| A9555 | Rubidium rb-82, diagnostic, per study dose | 14 | $330.62 |
| A9556 | Gallium ga-67 citrate, diagnostic, per millicurie | 13 | $130.14 |
| A9557 | Technetium tc-99m bicisate, diagnostic, per study dose | 15 | $449.63 |
| A9558 | Xenon xe-133 gas, diagnostic, per 10 millicuries | 20 | $231.37 |
| A9559 | Cobalt co-57 cyanocobalamin, oral, diagnostic | 9 | $88.97 |
| A9560 | Technetium tc-99m labeled red blood cells, diagnostic | 14 | $90.45 |
| A9561 | Technetium tc-99m oxidronate, diagnostic, per study dose | 15 | $40.13 |
| A9562 | Technetium tc-99m mertiatide, diagnostic, per study dose | 17 | $295.74 |
| A9563 | Sodium phosphate p-32, therapeutic, per millicurie | 14 | $273.08 |
| A9564 | Chromic phosphate p-32 suspension, therapeutic | 13 | $286.10 |
| A9567 | Technetium tc-99m pentetate, diagnostic, aerosol | 7 | $61.74 |
| A9568 | Technetium tc-99m arcitumomab, diagnostic, per study dose | 11 | $1,173.25 |
| A9569 | Technetium tc-99m exametazime labeled autologous white blood... | 12 | $1,569.15 |
| A9570 | Indium in-111 labeled autologous white blood cells | 11 | $4,146.64 |
| A9571 | Indium in-111 labeled autologous platelets, diagnostic | 10 | $3,967.80 |
| A9572 | Indium in-111 pentetreotide, diagnostic, per study dose | 14 | $3,840.90 |
| A9573 | Injection, gadopiclenol, 1 ml | 15 | $3.22 |
| A9574 | Injection, ferumoxytol, 1 mg | 11 | $0.40 |
| A9575 | Injection, gadoterate meglumine, 0.1 ml | 23 | $0.09 |
| A9576 | Injection, gadoteridol, (prohance multipack), per ml | 23 | $1.37 |
| A9577 | Injection, gadobenate dimeglumine (multihance), per ml | 23 | $1.79 |
| A9578 | Injection, gadobenate dimeglumine (multihance multipack) | 22 | $1.70 |
| A9579 | Injection, gadolinium-based magnetic resonance contrast... | 25 | $1.44 |
| A9580 | Sodium fluoride f-18, diagnostic, per study dose | 11 | $90.00 |
| A9581 | Injection, gadoxetate disodium, 1 ml | 24 | $14.72 |
| A9582 | Iodine i-123 iobenguane, diagnostic, per study dose | 14 | $2,944.27 |
| A9583 | Injection, gadofosveset trisodium, 1 ml | 11 | $17.93 |
| A9584 | Iodine 1-123 ioflupane, diagnostic, per study dose | 12 | $2,612.93 |
| A9585 | Injection, gadobutrol, 0.1 ml | 26 | $0.26 |
| A9586 | Florbetapir f18, diagnostic, per study dose | 11 | $2,811.68 |
| A9587 | Gallium ga-68, dotatate, diagnostic, 0.1 millicurie | 16 | $63.97 |
| A9588 | Fluciclovine f-18, diagnostic, 1 millicurie | 11 | $540.84 |
| A9589 | Instillation, hexaminolevulinate hydrochloride, 100 mg | 17 | $1,424.77 |
| A9590 | Iodine i-131, iobenguane, 1 millicurie | 11 | $324.85 |
| A9591 | Fluoroestradiol f 18, diagnostic, 1 millicurie | 7 | $780.25 |
| A9592 | Copper cu-64, dotatate, diagnostic, 1 millicurie | 13 | $948.03 |
| A9595 | Piflufolastat f 18 (pylarify), diagnostic, 1 millicurie | 21 | $623.37 |
| A9600 | Strontium sr-89 chloride, therapeutic, per millicurie | 20 | $3,690.00 |
| A9601 | Flortaucipir f 18 injection, diagnostic, 1 millicurie | 7 | $373.80 |
| A9602 | Fluorodopa f-18, diagnostic, per millicurie | 10 | $534.36 |
| A9604 | Samarium sm-153 lexidronam, therapeutic, per treatment dose | 12 | $16,030.18 |
| A9606 | Radium ra-223 dichloride, therapeutic, per microcurie | 23 | $174.59 |
| A9607 | Lutetium lu 177 vipivotide tetraxetan, therapeutic | 23 | $259.60 |
| A9608 | Flotufolastat f 18, diagnostic, 1 millicurie | 18 | $681.22 |
| A9611 | Flurpiridaz f 18, diagnostic, 1 millicurie | 9 | $515.00 |
| A9612 | Injection, fluorescein, 1 mg | 9 | $0.17 |
| A9616 | Gallium ga-68 gozetotide (gozellix), diagnostic | 8 | $1,138.15 |
| A9698 | Non-radioactive contrast imaging material | 7 | $11.51 |
| A9700 | Supply of injectable contrast material for use in... | 9 | $118.43 |
| A9800 | Gallium ga-68 gozetotide, diagnostic, (locametz) | 14 | $713.42 |
| A9900 | Miscellaneous dme supply, accessory | 6 | $91.58 |
| A9999 | Miscellaneous dme supply or accessory | 5 | $0.18 |
| B4034 | Enteral feeding supply kit; syringe fed, per day | 38 | $5.18 |
| B4035 | Enteral feeding supply kit; pump fed, per day | 38 | $9.71 |
| B4036 | Enteral feeding supply kit; gravity fed, per day | 38 | $6.88 |
| B4081 | Nasogastric tubing with stylet | 37 | $19.78 |
| B4082 | Nasogastric tubing without stylet | 38 | $14.46 |
| B4083 | Stomach tube - levine type | 35 | $2.18 |
| B4087 | Gastrostomy/jejunostomy tube, standard, any material | 35 | $32.00 |
| B4088 | Gastrostomy/jejunostomy tube, low-profile, any material | 32 | $44.79 |
| B4100 | Food thickener, administered orally, per ounce | 15 | $0.71 |
| B4102 | Enteral formula, for adults | 11 | $1.75 |
| B4103 | Enteral formula, for pediatrics | 17 | $3.29 |
| B4104 | Additive for enteral formula (e.g., fiber) | 6 | $1.34 |
| B4105 | In-line cartridge containing digestive enzyme(s) for enteral... | 11 | $120.16 |
| B4148 | Enteral feeding supply kit; elastomeric control fed | 11 | $8.74 |
| B4149 | Enteral formula, manufactured blenderized natural foods with... | 29 | $1.52 |
| B4150 | Enteral formula, nutritionally complete with intact... | 31 | $0.64 |
| B4152 | Enteral formula, nutritionally complete, calorically dense | 32 | $0.52 |
| B4153 | Enteral formula, nutritionally complete | 31 | $1.84 |
| B4154 | Enteral formula, nutritionally complete | 31 | $1.14 |
| B4155 | Enteral formula, nutritionally incomplete/modular nutrients | 32 | $0.945 |
| B4157 | Enteral formula, nutritionally complete | 13 | $3.73 |
| B4158 | Enteral formula, for pediatrics | 20 | $0.835 |
| B4159 | Enteral formula, for pediatrics | 19 | $0.8484 |
| B4160 | Enteral formula, for pediatrics | 21 | $0.85 |
| B4161 | Enteral formula, for pediatrics | 20 | $1.99 |
| B4162 | Enteral formula, for pediatrics | 13 | $4.00 |
| B4164 | Parenteral nutrition solution: carbohydrates (dextrose) | 22 | $19.00 |
| B4168 | Parenteral nutrition solution; amino acid, 3.5%, | 22 | $27.98 |
| B4172 | Parenteral nutrition solution; amino acid, 5.5% through 7%, | 16 | $33.13 |
| B4176 | Parenteral nutrition solution; amino acid, 7% through 8.5%, | 21 | $54.35 |
| B4178 | Parenteral nutrition solution: amino acid | 22 | $64.96 |
| B4180 | Parenteral nutrition solution; carbohydrates (dextrose) | 22 | $27.54 |
| B4185 | Parenteral nutrition solution, not otherwise specified | 26 | $11.75 |
| B4187 | Omegaven, 10 grams lipids | 16 | $13.41 |
| B4189 | Parenteral nutrition solution | 24 | $195.76 |
| B4193 | Parenteral nutrition solution | 24 | $252.95 |
| B4197 | Parenteral nutrition solution | 25 | $304.89 |
| B4199 | Parenteral nutrition solution | 25 | $348.40 |
| B4216 | Parenteral nutrition; additives (vitamins, trace elements | 21 | $8.75 |
| B4220 | Parenteral nutrition supply kit; premix, per day | 32 | $8.96 |
| B4222 | Parenteral nutrition supply kit; home mix, per day | 28 | $11.04 |
| B4224 | Parenteral nutrition administration kit, per day | 34 | $27.96 |
| B5000 | Enteral and parenteral nutrition | 22 | $14.20 |
| B5100 | Enteral and parenteral nutrition | 22 | $5.55 |
| B5200 | Enteral and parenteral nutrition | 14 | $5.28 |
| B9002 | Enteral nutrition infusion pump, any type | 39 | $100.96 |
| B9004 | Parenteral nutrition infusion pump, portable | 35 | $413.77 |
| B9006 | Parenteral nutrition infusion pump, stationary | 31 | $413.77 |
| B9998 | Noc for enteral supplies | 9 | $15.00 |
| E0100 | Cane, includes canes of all materials, adjustable or fixed | 38 | $16.76 |
| E0105 | Cane, quad or three prong, includes canes of all materials | 39 | $41.21 |
| E0110 | Crutches, forearm, includes crutches of various materials | 38 | $63.91 |
| E0111 | Crutch forearm, includes crutches of various materials | 36 | $38.99 |
| E0112 | Crutches underarm, wood, adjustable or fixed, pair | 38 | $24.34 |
| E0113 | Crutch underarm, wood, adjustable or fixed, each, with pad | 37 | $14.37 |
| E0114 | Crutches underarm, other than wood, adjustable or fixed | 38 | $35.19 |
| E0116 | Crutch, underarm, other than wood, adjustable or fixed | 35 | $20.44 |
| E0117 | Crutch, underarm, articulating, spring assisted, each | 22 | $154.17 |
| E0118 | Crutch substitute, lower leg platform | 10 | $49.12 |
| E0130 | Walker, rigid (pickup), adjustable or fixed height | 39 | $37.70 |
| E0135 | Walker, folding (pickup), adjustable or fixed height | 39 | $42.08 |
| E0140 | Walker, with trunk support, adjustable or fixed height | 32 | $96.10 |
| E0141 | Durable medical equipment | 38 | $37.94 |
| E0143 | Walker, folding, wheeled, adjustable or fixed height | 39 | $39.78 |
| E0144 | Walker, enclosed, four sided framed, rigid or folding | 26 | $34.99 |
| E0147 | Walker, heavy duty, multiple braking system | 35 | $150.00 |
| E0148 | Walker, heavy duty, without wheels, rigid or folding | 37 | $61.19 |
| E0149 | Walker, heavy duty, wheeled, rigid or folding, any type | 39 | $54.00 |
| E0153 | Platform attachment, forearm crutch, each | 38 | $55.26 |
| E0154 | Platform attachment, walker, each | 38 | $47.98 |
| E0155 | Wheel attachment, rigid pick-up walker, per pair | 39 | $22.50 |
| E0156 | Seat attachment, walker | 36 | $18.04 |
| E0157 | Crutch attachment, walker, each | 36 | $53.66 |
| E0158 | Leg extensions for walker, per set of four (4) | 37 | $20.79 |
| E0159 | Brake attachment for wheeled walker, replacement, each | 34 | $14.76 |
| E0160 | Sitz type bath or equipment, portable | 27 | $24.39 |
| E0161 | Sitz type bath or equipment, portable | 25 | $22.85 |
| E0162 | Sitz bath chair | 19 | $128.19 |
| E0163 | Commode chair, mobile or stationary, with fixed arms | 39 | $46.62 |
| E0165 | Commode chair, mobile or stationary, with detachable arms | 38 | $90.78 |
| E0167 | Pail or pan for use with commode chair, replacement only | 38 | $9.08 |
| E0168 | Commode chair, extra wide and/or heavy duty | 37 | $91.91 |
| E0170 | Commode chair with integrated seat lift mechanism, electric | 17 | $207.26 |
| E0171 | Commode chair with integrated seat lift mechanism | 18 | $38.50 |
| E0175 | Foot rest, for use with commode chair, each | 29 | $47.71 |
| E0181 | Powered pressure reducing mattress overlay/pad, alternating | 38 | $23.24 |
| E0182 | Pump for alternating pressure pad, for replacement only | 35 | $30.47 |
| E0183 | Powered pressure reducing underlay/pad, alternating | 17 | $19.29 |
| E0184 | Dry pressure mattress | 39 | $127.63 |
| E0185 | Gel or gel-like pressure pad for mattress | 39 | $110.45 |
| E0186 | Air pressure mattress | 36 | $23.50 |
| E0187 | Water pressure mattress | 34 | $26.66 |
| E0188 | Synthetic sheepskin pad | 33 | $22.11 |
| E0189 | Lambswool sheepskin pad, any size | 33 | $49.24 |
| E0190 | Positioning cushion/pillow/wedge, any shape or size | 19 | $39.50 |
| E0191 | Heel or elbow protector, each | 35 | $8.74 |
| E0193 | Powered air flotation bed (low air loss therapy) | 29 | $744.27 |
| E0194 | Air fluidized bed | 29 | $3,184.92 |
| E0196 | Gel pressure mattress | 35 | $39.69 |
| E0197 | Air pressure pad for mattress | 37 | $34.17 |
| E0198 | Water pressure pad for mattress | 35 | $109.00 |
| E0199 | Dry pressure pad for mattress | 35 | $24.71 |
| E0200 | Heat lamp, without stand (table model), includes bulb | 21 | $13.45 |
| E0201 | Penile contracture device, manual | 7 | $84.47 |
| E0202 | Phototherapy (bilirubin) light with photometer | 38 | $66.99 |
| E0203 | Therapeutic lightbox, minimum 10,000 lux, table top model | 5 | $121.71 |
| E0205 | Heat lamp, with stand, includes bulb, or infrared element | 22 | $30.13 |
| E0210 | Electric heat pad, standard | 21 | $21.56 |
| E0215 | Electric heat pad, moist | 19 | $25.21 |
| E0217 | Water circulating heat pad with pump | 24 | $59.46 |
| E0218 | Fluid circulating cold pad with pump, any type | 6 | $51.27 |
| E0221 | Infrared heating pad system | 7 | $282.16 |
| E0225 | Hydrocollator unit, includes pads | 13 | $53.52 |
| E0235 | Paraffin bath unit, portable | 26 | $20.29 |
| E0236 | Pump for water circulating pad | 19 | $42.04 |
| E0239 | Hydrocollator unit, portable | 10 | $53.51 |
| E0240 | Bath/shower chair, with or without wheels, any size | 20 | $103.54 |
| E0241 | Bath tub wall rail, each | 20 | $22.52 |
| E0242 | Bath tub rail, floor base | 11 | $55.57 |
| E0243 | Toilet rail, each | 22 | $34.10 |
| E0244 | Raised toilet seat | 28 | $43.35 |
| E0245 | Tub stool or bench | 25 | $42.37 |
| E0246 | Transfer tub rail attachment | 21 | $50.64 |
| E0247 | Transfer bench for tub or toilet with or without commode... | 21 | $92.00 |
| E0248 | Transfer bench, heavy duty | 20 | $160.68 |
| E0249 | Pad for water circulating heat unit, for replacement only | 19 | $27.59 |
| E0250 | Hospital bed, fixed height, with any type side rails | 35 | $76.95 |
| E0251 | Hospital bed, fixed height, with any type side rails | 28 | $68.52 |
| E0255 | Hospital bed, variable height, hi-lo | 36 | $81.55 |
| E0256 | Hospital bed, variable height, hi-lo | 29 | $72.80 |
| E0260 | Hospital bed, semi-electric (head and foot adjustment) | 36 | $107.88 |
| E0261 | Hospital bed, semi-electric (head and foot adjustment) | 32 | $89.80 |
| E0265 | Hospital bed, total electric (head | 31 | $184.01 |
| E0266 | Hospital bed, total electric (head | 27 | $153.75 |
| E0271 | Mattress, innerspring | 39 | $97.00 |
| E0272 | Mattress, foam rubber | 37 | $104.35 |
| E0273 | Bed board | 8 | $37.28 |
| E0274 | Over-bed table | 10 | $22.01 |
| E0275 | Bed pan, standard, metal or plastic | 32 | $10.41 |
| E0276 | Bed pan, fracture, metal or plastic | 36 | $10.87 |
| E0277 | Powered pressure-reducing air mattress | 34 | $277.39 |
| E0280 | Bed cradle, any type | 25 | $29.38 |
| E0290 | Hospital bed, fixed height, without side rails | 28 | $69.59 |
| E0291 | Hospital bed, fixed height, without side rails | 29 | $51.82 |
| E0292 | Hospital bed, variable height, hi-lo, without side rails | 26 | $74.37 |
| E0293 | Hospital bed, variable height, hi-lo, without side rails | 27 | $64.66 |
| E0294 | Hospital bed, semi-electric (head and foot adjustment) | 27 | $90.00 |
| E0295 | Hospital bed, semi-electric (head and foot adjustment) | 29 | $92.16 |
| E0296 | Hospital bed, total electric (head | 23 | $140.58 |
| E0297 | Hospital bed, total electric (head | 23 | $123.36 |
| E0300 | Pediatric crib, hospital grade, fully enclosed | 27 | $288.83 |
| E0301 | Hospital bed, heavy duty, extra wide | 30 | $207.91 |
| E0302 | Hospital bed, extra heavy duty, extra wide | 30 | $574.47 |
| E0303 | Hospital bed, heavy duty, extra wide | 37 | $232.46 |
| E0304 | Hospital bed, extra heavy duty, extra wide | 36 | $602.99 |
| E0305 | Bed side rails, half length | 35 | $15.05 |
| E0310 | Bed side rails, full length | 38 | $44.56 |
| E0315 | Bed accessory: board, table, or support device, any type | 9 | $32.09 |
| E0316 | Safety enclosure frame/canopy for use with hospital bed | 23 | $215.24 |
| E0325 | Urinal; male, jug-type, any material | 35 | $7.42 |
| E0326 | Urinal; female, jug-type, any material | 35 | $7.79 |
| E0328 | Hospital bed, pediatric, manual, 360 degree side enclosures | 10 | $548.21 |
| E0329 | Hospital bed, pediatric, electric or semi-electric | 7 | $650.15 |
| E0370 | Air pressure elevator for heel | 10 | $13.83 |
| E0371 | Nonpowered advanced pressure reducing overlay for mattress | 31 | $316.10 |
| E0372 | Powered air overlay for mattress | 30 | $334.80 |
| E0373 | Nonpowered advanced pressure reducing mattress | 28 | $413.76 |
| E0424 | Stationary compressed gaseous oxygen system, rental | 37 | $100.21 |
| E0425 | Stationary compressed gas system, purchase | 6 | $124.68 |
| E0430 | Portable gaseous oxygen system, purchase | 10 | $127.34 |
| E0431 | Portable gaseous oxygen system, rental | 37 | $24.31 |
| E0433 | Portable liquid oxygen system, rental | 21 | $41.30 |
| E0434 | Portable liquid oxygen system, rental | 35 | $40.40 |
| E0435 | Portable liquid oxygen system, purchase | 8 | $79.78 |
| E0439 | Stationary liquid oxygen system, rental; includes container | 35 | $101.12 |
| E0440 | Stationary liquid oxygen system, purchase | 5 | $151.80 |
| E0441 | Stationary oxygen contents, gaseous | 34 | $65.39 |
| E0442 | Stationary oxygen contents, liquid | 31 | $65.53 |
| E0443 | Portable oxygen contents, gaseous, 1 month's supply = 1 unit | 36 | $56.63 |
| E0444 | Portable oxygen contents, liquid, 1 month's supply = 1 unit | 33 | $57.93 |
| E0445 | Oximeter device for measuring blood oxygen levels... | 33 | $193.51 |
| E0447 | Portable oxygen contents, liquid, 1 month's supply = 1 unit | 22 | $75.04 |
| E0455 | Oxygen tent, excluding croup or pediatric tents | 14 | $13.76 |
| E0457 | Chest shell (cuirass) | 20 | $78.42 |
| E0459 | Chest wrap | 18 | $50.09 |
| E0462 | Rocking bed with or without side rails | 16 | $304.72 |
| E0465 | Home ventilator, any type, used with invasive interface, | 38 | $1,051.52 |
| E0466 | Home ventilator, any type, used with non-invasive interface | 38 | $1,044.86 |
| E0467 | Home ventilator, multi-function respiratory device | 27 | $1,224.75 |
| E0468 | Home ventilator, dual-function respiratory device | 17 | $1,081.40 |
| E0469 | Lung expansion airway clearance | 15 | $1,276.97 |
| E0470 | Respiratory assist device, bi-level pressure capability | 39 | $190.57 |
| E0471 | Respiratory assist device, bi-level pressure capability | 39 | $432.44 |
| E0472 | Respiratory assist device, bi-level pressure capability | 33 | $483.34 |
| E0480 | Percussor, electric or pneumatic, home model | 37 | $49.28 |
| E0481 | Intrapulmonary percussive ventilation system and related... | 7 | $873.60 |
| E0482 | Cough stimulating device | 39 | $490.29 |
| E0483 | High frequency chest wall oscillation system | 38 | $1,200.43 |
| E0484 | Oscillatory positive expiratory pressure device | 28 | $33.44 |
| E0486 | Oral device/appliance used to reduce upper airway... | 9 | $1,374.30 |
| E0490 | Power source and control electronics unit for oral... | 6 | $100.78 |
| E0491 | Oral device/appliance for neuromuscular electrical... | 6 | $81.67 |
| E0500 | Durable medical equipment | 33 | $108.38 |
| E0530 | Electronic positional obstructive sleep apnea treatment | 7 | $35.53 |
| E0550 | Humidifier, durable for extensive supplemental... | 31 | $50.34 |
| E0555 | Humidifier, durable, glass or autoclavable plastic bottle... | 23 | $8.72 |
| E0560 | Humidifier, durable for supplemental humidification during... | 26 | $50.10 |
| E0561 | Humidifier, non-heated | 39 | $11.55 |
| E0562 | Humidifier, heated, used with positive airway pressure... | 39 | $27.86 |
| E0565 | Compressor, air power source for equipment which is not... | 38 | $51.70 |
| E0570 | Nebulizer, with compressor | 39 | $17.95 |
| E0572 | Aerosol compressor, adjustable pressure | 23 | $33.61 |
| E0574 | Ultrasonic/electronic aerosol generator with small volume... | 26 | $50.11 |
| E0575 | Nebulizer, ultrasonic, large volume | 29 | $119.20 |
| E0580 | Nebulizer, durable, glass or autoclavable plastic | 28 | $56.08 |
| E0585 | Nebulizer, with compressor and heater | 33 | $32.17 |
| E0600 | Respiratory suction pump, home model | 39 | $55.46 |
| E0601 | Continuous positive airway pressure (cpap) device | 39 | $76.09 |
| E0602 | Breast pump, manual, any type | 29 | $25.68 |
| E0603 | Breast pump, electric (ac and/or dc), any type | 34 | $123.09 |
| E0604 | Breast pump, hospital grade, electric (ac and / or dc) | 22 | $54.34 |
| E0605 | Vaporizer, room type | 27 | $16.90 |
| E0606 | Postural drainage board | 26 | $28.21 |
| E0607 | Home blood glucose monitor | 26 | $57.90 |
| E0610 | Pacemaker monitor, self-contained, | 19 | $35.05 |
| E0615 | Pacemaker monitor, self contained | 18 | $82.56 |
| E0616 | Implantable cardiac event recorder with memory | 5 | $2,180.91 |
| E0617 | External defibrillator with integrated electrocardiogram... | 21 | $424.80 |
| E0618 | Apnea monitor, without recording feature | 23 | $319.64 |
| E0619 | Apnea monitor, with recording feature | 35 | $233.77 |
| E0620 | Skin piercing device for collection of capillary blood | 8 | $125.86 |
| E0621 | Sling or seat, patient lift, canvas or nylon | 38 | $68.38 |
| E0625 | Patient lift, bathroom or toilet, not otherwise classified | 6 | $102.83 |
| E0627 | Seat lift mechanism, electric, any type | 22 | $189.84 |
| E0629 | Seat lift mechanism, non-electric, any type | 20 | $200.65 |
| E0630 | Durable medical equipment | 39 | $81.50 |
| E0635 | Patient lift, electric with seat or sling | 31 | $145.04 |
| E0636 | Multipositional patient support system | 16 | $1,218.76 |
| E0637 | Combination sit to stand frame/table system | 21 | $409.43 |
| E0638 | Standing frame/table system, one position (e.g., upright | 22 | $710.29 |
| E0639 | Patient lift, moveable from room to room with disassembly... | 16 | $402.74 |
| E0640 | Patient lift, fixed system | 12 | $156.86 |
| E0641 | Standing frame/table system, multi-position (e.g. | 13 | $1,000.00 |
| E0642 | Standing frame/table system, mobile (dynamic stander) | 8 | $650.12 |
| E0650 | Pneumatic compressor, non-segmental home model | 35 | $110.95 |
| E0651 | Pneumatic compressor | 34 | $132.30 |
| E0652 | Pneumatic compressor | 32 | $746.69 |
| E0655 | Non-segmental pneumatic appliance for use with pneumatic... | 33 | $70.46 |
| E0656 | Segmental pneumatic appliance for use with pneumatic... | 20 | $81.55 |
| E0657 | Segmental pneumatic appliance for use with pneumatic... | 19 | $77.37 |
| E0658 | Segmental pneumatic appliance for use with pneumatic... | 16 | $149.29 |
| E0659 | Segmental pneumatic appliance for use with pneumatic... | 15 | $149.29 |
| E0660 | Non-segmental pneumatic appliance for use with pneumatic... | 34 | $81.85 |
| E0665 | Non-segmental pneumatic appliance for use with pneumatic... | 34 | $82.81 |
| E0666 | Non-segmental pneumatic appliance for use with pneumatic... | 33 | $89.94 |
| E0667 | Segmental pneumatic appliance for use with pneumatic... | 34 | $109.85 |
| E0668 | Segmental pneumatic appliance for use with pneumatic... | 34 | $106.08 |
| E0669 | Segmental pneumatic appliance for use with pneumatic... | 32 | $147.58 |
| E0670 | Segmental pneumatic appliance for use with pneumatic... | 26 | $171.46 |
| E0671 | Segmental gradient pressure pneumatic appliance, full leg | 31 | $302.95 |
| E0672 | Segmental gradient pressure pneumatic appliance, full arm | 30 | $251.51 |
| E0673 | Segmental gradient pressure pneumatic appliance, half leg | 30 | $209.01 |
| E0675 | Pneumatic compression device, high pressure | 20 | $435.56 |
| E0677 | Non-pneumatic sequential compression garment, trunk | 12 | $76.85 |
| E0678 | Non-pneumatic sequential compression garment, full leg | 16 | $38.17 |
| E0679 | Non-pneumatic sequential compression garment, half leg | 16 | $24.38 |
| E0680 | Non-pneumatic compression controller with sequential... | 16 | $671.97 |
| E0681 | Non-pneumatic compression controller without calibrated... | 14 | $107.20 |
| E0682 | Non-pneumatic sequential compression garment, full arm | 17 | $59.90 |
| E0683 | Non-pneumatic, non-sequential | 12 | $78.06 |
| E0691 | Ultraviolet light therapy system, includes bulbs/lamps | 18 | $128.05 |
| E0692 | Ultraviolet light therapy system panel | 17 | $160.78 |
| E0693 | Ultraviolet light therapy system panel | 16 | $198.25 |
| E0694 | Ultraviolet multidirectional light therapy system in 6 foot... | 18 | $2,227.07 |
| E0700 | Safety equipment, device or accessory, any type | 15 | $31.05 |
| E0705 | Transfer device, any type, each | 36 | $40.11 |
| E0710 | Restraints, any type (body, chest, wrist or ankle) | 10 | $12.95 |
| E0720 | Transcutaneous electrical nerve stimulation (tens) device | 30 | $55.72 |
| E0730 | Transcutaneous electrical nerve stimulation (tens) device | 31 | $49.41 |
| E0731 | Form fitting conductive garment for delivery of tens or nmes... | 21 | $87.58 |
| E0732 | Cranial electrotherapy stimulation (ces) system, any type | 8 | $46.39 |
| E0733 | Transcutaneous electrical nerve stimulator for electrical... | 10 | $41.38 |
| E0734 | External upper limb tremor stimulator of the peripheral... | 9 | $429.24 |
| E0735 | Non-invasive vagus nerve stimulator | 10 | $47.70 |
| E0736 | Transcutaneous tibial nerve stimulator | 7 | $36.67 |
| E0740 | Non-implanted pelvic floor electrical stimulator | 17 | $74.52 |
| E0743 | External lower extremity nerve stimulator for restless legs... | 10 | $185.88 |
| E0744 | Neuromuscular stimulator for scoliosis | 19 | $94.92 |
| E0745 | Neuromuscular stimulator, electronic shock unit | 23 | $103.83 |
| E0746 | Electromyography (emg), biofeedback device | 5 | $29.63 |
| E0747 | Osteogenesis stimulator, electrical, non-invasive | 36 | $1,566.10 |
| E0748 | Osteogenesis stimulator, electrical, non-invasive | 34 | $2,284.30 |
| E0749 | Osteogenesis stimulator, electrical, surgically implanted | 9 | $2,498.35 |
| E0760 | Osteogenesis stimulator, low intensity ultrasound | 31 | $2,173.98 |
| E0762 | Transcutaneous electrical joint stimulation device system | 13 | $108.40 |
| E0764 | Functional neuromuscular stimulation | 9 | $1,340.57 |
| E0765 | Fda approved nerve stimulator | 7 | $84.03 |
| E0766 | Electrical stimulation device used for cancer treatment | 24 | $12,571.49 |
| E0776 | Iv pole | 37 | $17.73 |
| E0779 | Ambulatory infusion pump, mechanical, reusable | 27 | $19.87 |
| E0780 | Ambulatory infusion pump, mechanical, reusable | 27 | $11.41 |
| E0781 | Ambulatory infusion pump, single or multiple channels | 38 | $251.85 |
| E0782 | Infusion pump, implantable, non-programmable | 14 | $3,826.17 |
| E0783 | Infusion pump system, implantable, programmable | 17 | $7,337.00 |
| E0784 | External ambulatory infusion pump, insulin | 38 | $479.60 |
| E0785 | Implantable intraspinal | 12 | $537.93 |
| E0786 | Implantable programmable infusion pump, replacement | 15 | $7,078.82 |
| E0791 | Parenteral infusion pump, stationary | 31 | $287.96 |
| E0840 | Traction frame, attached to headboard, cervical traction | 32 | $43.54 |
| E0849 | Traction equipment, cervical, free-standing stand/frame | 24 | $68.14 |
| E0850 | Traction stand, free standing, cervical traction | 31 | $17.82 |
| E0855 | Cervical traction equipment not requiring additional stand... | 23 | $70.23 |
| E0856 | Cervical traction device, with inflatable air bladder(s) | 17 | $123.22 |
| E0860 | Traction equipment, overdoor, cervical | 33 | $24.78 |
| E0870 | Traction frame, attached to footboard, extremity traction, | 31 | $67.46 |
| E0880 | Traction stand, free standing, extremity traction | 31 | $28.09 |
| E0890 | Traction frame, attached to footboard, pelvic traction | 34 | $46.88 |
| E0900 | Traction stand, free standing, pelvic traction, (e.g. | 33 | $39.37 |
| E0910 | Trapeze bars, a/k/a patient helper, attached to bed | 39 | $15.29 |
| E0911 | Trapeze bar, heavy duty | 35 | $48.73 |
| E0912 | Trapeze bar, heavy duty | 35 | $99.76 |
| E0920 | Fracture frame, attached to bed, includes weights | 32 | $54.18 |
| E0930 | Fracture frame, free standing, includes weights | 31 | $45.69 |
| E0935 | Continuous passive motion exercise device for use on knee... | 33 | $25.71 |
| E0936 | Continuous passive motion exercise device for use other than... | 8 | $19.63 |
| E0940 | Trapeze bar, free standing, complete with grab bar | 39 | $26.79 |
| E0941 | Gravity assisted traction device, any type | 26 | $50.81 |
| E0942 | Cervical head harness/halter | 34 | $16.88 |
| E0944 | Pelvic belt/harness/boot | 32 | $33.34 |
| E0945 | Extremity belt/harness | 29 | $26.32 |
| E0946 | Fracture, frame, dual with cross bars, attached to bed, | 28 | $69.45 |
| E0947 | Fracture frame, attachments for complex pelvic traction | 31 | $86.42 |
| E0948 | Fracture frame, attachments for complex cervical traction | 29 | $76.47 |
| E0950 | Wheelchair accessory, tray, each | 37 | $81.40 |
| E0951 | Heel loop/holder, any type, with or without ankle strap | 39 | $13.09 |
| E0952 | Toe loop/holder, any type, each | 38 | $14.60 |
| E0953 | Wheelchair accessory, lateral thigh or knee support | 37 | $58.32 |
| E0954 | Wheelchair accessory, foot box, any type | 36 | $40.15 |
| E0955 | Wheelchair accessory, headrest, cushioned, any type | 38 | $144.39 |
| E0956 | Wheelchair accessory, lateral trunk or hip support | 39 | $71.90 |
| E0957 | Wheelchair accessory, medial thigh support, any type | 38 | $117.87 |
| E0958 | Manual wheelchair accessory, one-arm drive attachment, each | 38 | $323.65 |
| E0959 | Manual wheelchair accessory, adapter for amputee, each | 38 | $37.75 |
| E0960 | Wheelchair accessory | 39 | $75.05 |
| E0961 | Manual wheelchair accessory, wheel lock brake extension | 38 | $20.20 |
| E0966 | Manual wheelchair accessory, headrest extension, each | 37 | $61.05 |
| E0967 | Manual wheelchair accessory, hand rim with projections | 38 | $60.31 |
| E0968 | Commode seat, wheelchair | 26 | $111.01 |
| E0969 | Narrowing device, wheelchair | 28 | $135.14 |
| E0970 | No. 2 footplates, except for elevating leg rest | 20 | $36.17 |
| E0971 | Manual wheelchair accessory, anti-tipping device, each | 39 | $34.51 |
| E0973 | Wheelchair accessory, adjustable height, detachable armrest | 39 | $64.06 |
| E0974 | Manual wheelchair accessory, anti-rollback device, each | 38 | $63.66 |
| E0978 | Wheelchair accessory | 39 | $28.93 |
| E0980 | Safety vest, wheelchair | 31 | $28.79 |
| E0981 | Wheelchair accessory, seat upholstery, replacement only | 37 | $39.44 |
| E0982 | Wheelchair accessory, back upholstery, replacement only | 37 | $41.90 |
| E0983 | Manual wheelchair accessory | 30 | $1,025.77 |
| E0984 | Manual wheelchair accessory | 28 | $1,544.03 |
| E0985 | Wheelchair accessory, seat lift mechanism | 25 | $136.75 |
| E0986 | Manual wheelchair accessory, power assist system | 33 | $3,891.39 |
| E0988 | Manual wheelchair accessory, lever-activated, wheel drive | 19 | $333.82 |
| E0990 | Wheelchair accessory, elevating leg rest, complete assembly | 38 | $74.87 |
| E0992 | Manual wheelchair accessory, solid seat insert | 39 | $74.89 |
| E0994 | Arm rest, each | 30 | $15.63 |
| E0995 | Wheelchair accessory, calf rest/pad, replacement only, each | 37 | $23.23 |
| E1002 | Wheelchair accessory, power seating system, tilt only | 39 | $3,290.42 |
| E1003 | Wheelchair accessory, power seating system, recline only | 34 | $3,479.86 |
| E1004 | Wheelchair accessory, power seating system, recline only | 35 | $4,179.59 |
| E1005 | Wheelchair accessory, power seating system, recline only | 35 | $3,973.98 |
| E1006 | Wheelchair accessory, power seating system | 34 | $4,887.10 |
| E1007 | Wheelchair accessory, power seating system | 38 | $6,969.86 |
| E1008 | Wheelchair accessory, power seating system | 35 | $6,591.74 |
| E1010 | Wheelchair accessory, addition to power seating system | 34 | $885.71 |
| E1011 | Modification to pediatric size wheelchair | 5 | $56.23 |
| E1012 | Wheelchair accessory, addition to power seating system | 30 | $140.16 |
| E1014 | Reclining back, addition to pediatric size wheelchair | 35 | $294.85 |
| E1015 | Shock absorber for manual wheelchair, each | 32 | $100.89 |
| E1016 | Shock absorber for power wheelchair, each | 31 | $104.27 |
| E1020 | Residual limb support system for wheelchair, any type | 38 | $167.05 |
| E1028 | Wheelchair accessory, manual swingaway | 37 | $128.10 |
| E1029 | Wheelchair accessory, ventilator tray, fixed | 36 | $292.26 |
| E1030 | Wheelchair accessory, ventilator tray, gimbaled | 31 | $878.64 |
| E1031 | Rollabout chair, any and all types with casters 5" or... | 29 | $52.04 |
| E1032 | Wheelchair accessory, manual swingaway | 32 | $23.62 |
| E1033 | Wheelchair accessory, manual swingaway | 32 | $23.62 |
| E1034 | Wheelchair accessory, manual swingaway | 32 | $23.62 |
| E1035 | Multi-positional patient transfer system | 23 | $731.87 |
| E1036 | Multi-positional patient transfer system, extra-wide | 16 | $1,093.50 |
| E1037 | Transport chair, pediatric size | 25 | $125.69 |
| E1038 | Transport chair, adult size | 26 | $18.71 |
| E1039 | Transport chair, adult size, heavy duty | 24 | $39.58 |
| E1050 | Fully-reclining wheelchair, fixed full length arms | 26 | $111.88 |
| E1060 | Fully-reclining wheelchair, detachable arms | 28 | $138.48 |
| E1070 | Fully-reclining wheelchair, detachable arms | 26 | $109.96 |
| E1083 | Hemi-wheelchair, fixed full length arms | 24 | $78.57 |
| E1084 | Hemi-wheelchair, detachable arms desk or full length arms | 25 | $108.45 |
| E1085 | Hemi-wheelchair, fixed full length arms | 15 | $64.92 |
| E1086 | Hemi-wheelchair detachable arms desk or full length | 18 | $87.03 |
| E1087 | High strength lightweight wheelchair | 24 | $130.37 |
| E1088 | High strength lightweight wheelchair | 25 | $174.86 |
| E1089 | High strength lightweight wheelchair, fixed length arms | 17 | $115.83 |
| E1090 | High strength lightweight wheelchair | 19 | $128.27 |
| E1092 | Wide heavy duty wheel chair, detachable arms | 24 | $141.18 |
| E1093 | Wide heavy duty wheelchair | 24 | $128.41 |
| E1100 | Semi-reclining wheelchair, fixed full length arms | 23 | $118.34 |
| E1110 | Semi-reclining wheelchair, detachable arms | 23 | $114.35 |
| E1130 | Standard wheelchair, fixed full length arms | 20 | $46.44 |
| E1140 | Wheelchair, detachable arms, desk or full length | 19 | $59.84 |
| E1150 | Wheelchair, detachable arms | 25 | $94.93 |
| E1160 | Wheelchair, fixed full length arms | 24 | $74.24 |
| E1161 | Manual adult size wheelchair, includes tilt in space | 39 | $337.19 |
| E1170 | Amputee wheelchair, fixed full length arms | 25 | $94.67 |
| E1171 | Amputee wheelchair, fixed full length arms | 23 | $88.61 |
| E1172 | Amputee wheelchair, detachable arms | 25 | $105.77 |
| E1180 | Amputee wheelchair, detachable arms | 26 | $108.19 |
| E1190 | Amputee wheelchair, detachable arms | 25 | $112.01 |
| E1195 | Heavy duty wheelchair, fixed full length arms | 23 | $138.88 |
| E1200 | Amputee wheelchair, fixed full length arms | 26 | $95.59 |
| E1220 | Wheelchair; specially sized or constructed, | 6 | $509.99 |
| E1221 | Wheelchair with fixed arm, footrests | 21 | $52.53 |
| E1222 | Wheelchair with fixed arm, elevating legrests | 21 | $74.57 |
| E1223 | Wheelchair with detachable arms, footrests | 21 | $75.37 |
| E1224 | Wheelchair with detachable arms, elevating legrests | 22 | $77.34 |
| E1225 | Wheelchair accessory, manual semi-reclining back, | 37 | $47.22 |
| E1226 | Wheelchair accessory, manual fully reclining back, | 38 | $280.04 |
| E1227 | Special height arms for wheelchair | 24 | $228.82 |
| E1228 | Special back height for wheelchair | 27 | $34.95 |
| E1230 | Power operated vehicle | 22 | $1,695.38 |
| E1231 | Wheelchair, pediatric size, tilt-in-space, rigid | 11 | $227.05 |
| E1232 | Wheelchair, pediatric size, tilt-in-space, folding | 37 | $259.06 |
| E1233 | Wheelchair, pediatric size, tilt-in-space, rigid | 38 | $272.35 |
| E1234 | Wheelchair, pediatric size, tilt-in-space, folding | 38 | $274.91 |
| E1235 | Wheelchair, pediatric size, rigid, adjustable | 37 | $259.53 |
| E1236 | Wheelchair, pediatric size, folding, adjustable | 38 | $216.66 |
| E1237 | Wheelchair, pediatric size, rigid, adjustable | 37 | $200.23 |
| E1238 | Wheelchair, pediatric size, folding, adjustable | 37 | $204.35 |
| E1240 | Lightweight wheelchair, detachable arms, | 25 | $109.01 |
| E1250 | Lightweight wheelchair, fixed full length arms | 16 | $77.56 |
| E1260 | Lightweight wheelchair, detachable arms | 21 | $99.41 |
| E1270 | Lightweight wheelchair, fixed full length arms | 24 | $87.06 |
| E1280 | Heavy duty wheelchair, detachable arms | 24 | $148.67 |
| E1285 | Heavy duty wheelchair, fixed full length arms | 18 | $115.31 |
| E1290 | Heavy duty wheelchair, detachable arms | 20 | $129.12 |
| E1295 | Heavy duty wheelchair, fixed full length arms | 24 | $128.28 |
| E1296 | Special wheelchair seat height from floor | 27 | $384.49 |
| E1297 | Special wheelchair seat depth, by upholstery | 29 | $74.69 |
| E1298 | Special wheelchair seat depth and/or width, by construction | 28 | $303.37 |
| E1300 | Whirlpool, portable (overtub type) | 7 | $153.43 |
| E1310 | Whirlpool, non-portable (built-in type) | 13 | $1,854.36 |
| E1353 | Regulator | 21 | $32.29 |
| E1355 | Stand/rack | 21 | $23.85 |
| E1372 | Immersion external heater for nebulizer | 28 | $95.95 |
| E1390 | Oxygen concentrator, single delivery port | 38 | $118.00 |
| E1391 | Oxygen concentrator, dual delivery port | 25 | $99.31 |
| E1392 | Portable oxygen concentrator, rental | 31 | $42.65 |
| E1399 | Durable medical equipment, miscellaneous | 10 | $489.67 |
| E1405 | Oxygen and water vapor enriching system with heated delivery | 18 | $130.54 |
| E1406 | Oxygen and water vapor enriching system without heated... | 20 | $121.68 |
| E1510 | Kidney, dialysate delivery syst kidney machine | 9 | $562.74 |
| E1520 | Heparin infusion pump for hemodialysis | 8 | $35.72 |
| E1530 | Air bubble detector for hemodialysis, each, replacement | 6 | $81.35 |
| E1540 | Pressure alarm for hemodialysis, each, replacement | 5 | $33.68 |
| E1570 | Adjustable chair, for esrd patients | 6 | $107.05 |
| E1575 | Transducer protectors/fluid barriers, for hemodialysis | 5 | $31.47 |
| E1590 | Hemodialysis machine | 7 | $565.28 |
| E1592 | Automatic intermittent peritoneal dialysis system | 5 | $335.23 |
| E1594 | Cycler dialysis machine for peritoneal dialysis | 10 | $371.13 |
| E1600 | Delivery and/or installation charges for hemodialysis... | 9 | $294.69 |
| E1610 | Reverse osmosis water purification system, for hemodialysis | 6 | $285.89 |
| E1615 | Deionizer water purification system, for hemodialysis | 5 | $212.89 |
| E1620 | Blood pump for hemodialysis, replacement | 5 | $63.44 |
| E1637 | Hemostats, each | 5 | $4.67 |
| E1639 | Scale, each | 7 | $29.28 |
| E1700 | Jaw motion rehabilitation system | 19 | $37.81 |
| E1701 | Replacement cushions for jaw motion rehabilitation system | 17 | $11.84 |
| E1702 | Replacement measuring scales for jaw motion rehabilitation... | 17 | $24.95 |
| E1800 | Dynamic adjustable elbow extension and flexion device | 31 | $123.02 |
| E1801 | Static progressive stretch/patient actualized serial stretch... | 25 | $136.60 |
| E1802 | Dynamic adjustable forearm pronation/supination device | 26 | $370.16 |
| E1803 | Dynamic adjustable elbow extension only device | 21 | $144.73 |
| E1804 | Dynamic adjustable elbow flexion only device | 21 | $144.73 |
| E1805 | Dynamic adjustable wrist extension and flexion device | 30 | $138.80 |
| E1806 | Static progressive stretch wrist device | 25 | $117.23 |
| E1807 | Dynamic adjustable wrist extension only device | 20 | $150.06 |
| E1808 | Dynamic adjustable wrist flexion only device | 20 | $150.06 |
| E1810 | Dynamic adjustable knee extension and flexion device | 33 | $128.32 |
| E1811 | Static progressive stretch/patient actualized serial stretch... | 25 | $142.02 |
| E1812 | Dynamic knee, extension/flexion device with active... | 23 | $98.04 |
| E1813 | Dynamic adjustable knee extension only device | 21 | $146.73 |
| E1814 | Dynamic adjustable knee flexion only device | 21 | $146.73 |
| E1815 | Dynamic adjustable ankle extension and flexion device | 30 | $138.80 |
| E1816 | Static progressive stretch/patient actualized serial stretch... | 26 | $141.15 |
| E1818 | Static progressive stretch/patient actualized serial stretch... | 25 | $147.23 |
| E1820 | Replacement soft interface material | 25 | $63.94 |
| E1821 | Replacement soft interface material/cuffs for bi-directional... | 20 | $89.43 |
| E1822 | Dynamic adjustable ankle extension only device | 21 | $150.06 |
| E1823 | Dynamic adjustable ankle flexion only device | 21 | $150.06 |
| E1825 | Dynamic adjustable finger extension and flexion device | 29 | $139.68 |
| E1826 | Dynamic adjustable finger extension only device | 21 | $150.06 |
| E1827 | Dynamic adjustable finger flexion only device | 21 | $150.06 |
| E1828 | Dynamic adjustable toe extension only device | 20 | $150.06 |
| E1829 | Dynamic adjustable toe flexion only device | 20 | $150.06 |
| E1830 | Dynamic adjustable toe extension and flexion device | 25 | $146.54 |
| E1831 | Static progressive stretch toe device | 13 | $73.70 |
| E1832 | Static progressive stretch finger device | 14 | $76.85 |
| E1840 | Dynamic adjustable shoulder flexion / abduction / rotation... | 25 | $443.87 |
| E1841 | Static progressive stretch/patient actualized serial stretch... | 19 | $525.37 |
| E2000 | Gastric suction pump, home model, portable or stationary | 28 | $57.03 |
| E2001 | Suction pump, home model, portable or stationary, electric | 10 | $58.24 |
| E2100 | Blood glucose monitor with integrated voice synthesizer | 29 | $462.69 |
| E2101 | Blood glucose monitor with integrated lancing/blood sample | 20 | $164.16 |
| E2102 | Adjunctive, non-implanted continuous glucose monitor or... | 24 | $174.17 |
| E2103 | Non-adjunctive, non-implanted continuous glucose monitor or... | 26 | $202.60 |
| E2104 | Home blood glucose monitor for use with integrated... | 12 | $43.57 |
| E2120 | Pulse generator system for tympanic treatment of inner ear... | 7 | $404.05 |
| E2201 | Manual wheelchair accessory, nonstandard seat frame | 39 | $310.56 |
| E2202 | Manual wheelchair accessory, nonstandard seat frame width | 38 | $398.86 |
| E2203 | Manual wheelchair accessory, nonstandard seat frame depth | 39 | $395.26 |
| E2204 | Manual wheelchair accessory, nonstandard seat frame depth | 38 | $650.89 |
| E2205 | Manual wheelchair accessory, handrim without projections | 37 | $29.69 |
| E2206 | Manual wheelchair accessory, wheel lock assembly, complete | 39 | $36.63 |
| E2207 | Wheelchair accessory, crutch and cane holder, each | 35 | $37.21 |
| E2208 | Wheelchair accessory, cylinder tank carrier, each | 37 | $86.00 |
| E2209 | Accessory, arm trough, with or without hand support, each | 39 | $78.17 |
| E2210 | Wheelchair accessory, bearings, any type, replacement only | 39 | $5.57 |
| E2211 | Manual wheelchair accessory, pneumatic propulsion tire | 38 | $29.30 |
| E2212 | Manual wheelchair accessory | 38 | $5.52 |
| E2213 | Manual wheelchair accessory | 37 | $26.82 |
| E2214 | Manual wheelchair accessory, pneumatic caster tire | 38 | $27.67 |
| E2215 | Manual wheelchair accessory, tube for pneumatic caster tire | 38 | $8.26 |
| E2216 | Manual wheelchair accessory, foam filled propulsion tire | 29 | $28.42 |
| E2217 | Manual wheelchair accessory, foam filled caster tire | 29 | $31.71 |
| E2218 | Manual wheelchair accessory, foam propulsion tire, any size | 33 | $37.82 |
| E2219 | Manual wheelchair accessory, foam caster tire, any size | 37 | $30.91 |
| E2220 | Manual wheelchair accessory, solid | 38 | $23.42 |
| E2221 | Manual wheelchair accessory, solid | 38 | $22.73 |
| E2222 | Manual wheelchair accessory, solid | 35 | $19.37 |
| E2224 | Manual wheelchair accessory, propulsion wheel excludes tire | 37 | $79.74 |
| E2225 | Manual wheelchair accessory, caster wheel excludes tire | 36 | $16.20 |
| E2226 | Manual wheelchair accessory, caster fork, any size | 37 | $34.01 |
| E2227 | Manual wheelchair accessory, gear reduction drive wheel | 27 | $1,255.30 |
| E2228 | Manual wheelchair accessory, wheel braking system and lock | 29 | $130.21 |
| E2231 | Manual wheelchair accessory, solid seat support base | 36 | $129.21 |
| E2291 | Back, planar, for pediatric size wheelchair including fixed... | 13 | $344.79 |
| E2292 | Seat, planar, for pediatric size wheelchair including fixed... | 12 | $294.47 |
| E2293 | Back, contoured, for pediatric size wheelchair including... | 11 | $403.93 |
| E2294 | Seat, contoured, for pediatric size wheelchair including... | 11 | $326.17 |
| E2298 | Complex rehabilitative power wheelchair accessory | 26 | $204.39 |
| E2310 | Power wheelchair accessory | 38 | $924.74 |
| E2311 | Power wheelchair accessory | 38 | $1,889.09 |
| E2312 | Power wheelchair accessory, hand or chin control interface | 34 | $1,579.64 |
| E2313 | Power wheelchair accessory | 36 | $256.16 |
| E2321 | Power wheelchair accessory, hand control interface | 36 | $1,244.59 |
| E2322 | Power wheelchair accessory, hand control interface | 35 | $1,128.29 |
| E2323 | Power wheelchair accessory | 38 | $61.63 |
| E2324 | Power wheelchair accessory | 37 | $40.02 |
| E2325 | Power wheelchair accessory, sip and puff interface | 38 | $1,077.46 |
| E2326 | Power wheelchair accessory | 38 | $292.66 |
| E2327 | Power wheelchair accessory, head control interface | 37 | $2,160.66 |
| E2328 | Power wheelchair accessory | 36 | $3,921.51 |
| E2329 | Power wheelchair accessory, head control interface | 35 | $1,461.88 |
| E2330 | Power wheelchair accessory, head control interface | 37 | $2,832.57 |
| E2331 | Power wheelchair accessory, attendant control, proportional | 5 | $553.78 |
| E2340 | Power wheelchair accessory, nonstandard seat frame width | 36 | $327.44 |
| E2341 | Power wheelchair accessory, nonstandard seat frame width | 35 | $478.07 |
| E2342 | Power wheelchair accessory, nonstandard seat frame depth | 35 | $425.58 |
| E2343 | Power wheelchair accessory, nonstandard seat frame depth | 35 | $660.89 |
| E2351 | Power wheelchair accessory | 31 | $578.27 |
| E2359 | Power wheelchair accessory | 39 | $168.43 |
| E2360 | Power wheelchair accessory | 36 | $92.90 |
| E2361 | Power wheelchair accessory, 22nf sealed lead acid battery | 39 | $128.11 |
| E2362 | Power wheelchair accessory | 34 | $87.86 |
| E2363 | Power wheelchair accessory | 39 | $162.77 |
| E2364 | Power wheelchair accessory | 34 | $94.03 |
| E2365 | Power wheelchair accessory, u-1 sealed lead acid battery | 38 | $88.56 |
| E2366 | Power wheelchair accessory, battery charger, single mode | 39 | $177.70 |
| E2367 | Power wheelchair accessory, battery charger, dual mode | 34 | $306.70 |
| E2368 | Power wheelchair component, drive wheel motor | 38 | $430.95 |
| E2369 | Power wheelchair component, drive wheel gear box | 38 | $373.05 |
| E2370 | Power wheelchair component | 38 | $635.75 |
| E2371 | Power wheelchair accessory | 37 | $134.60 |
| E2372 | Power wheelchair accessory | 11 | $150.00 |
| E2373 | Power wheelchair accessory, hand or chin control interface | 37 | $675.75 |
| E2374 | Power wheelchair accessory, hand or chin control interface | 38 | $441.86 |
| E2375 | Power wheelchair accessory, non-expandable controller | 39 | $677.84 |
| E2376 | Power wheelchair accessory, expandable controller | 37 | $1,066.70 |
| E2377 | Power wheelchair accessory, expandable controller | 38 | $390.39 |
| E2378 | Power wheelchair component, actuator, replacement only | 28 | $246.95 |
| E2381 | Power wheelchair accessory, pneumatic drive wheel tire | 37 | $62.37 |
| E2382 | Power wheelchair accessory | 38 | $17.16 |
| E2383 | Power wheelchair accessory | 38 | $123.35 |
| E2384 | Power wheelchair accessory, pneumatic caster tire, any size | 38 | $64.52 |
| E2385 | Power wheelchair accessory, tube for pneumatic caster tire | 38 | $42.44 |
| E2386 | Power wheelchair accessory, foam filled drive wheel tire | 38 | $117.74 |
| E2387 | Power wheelchair accessory, foam filled caster tire | 38 | $54.13 |
| E2388 | Power wheelchair accessory, foam drive wheel tire, any size | 37 | $45.17 |
| E2389 | Power wheelchair accessory, foam caster tire, any size | 37 | $24.99 |
| E2390 | Power wheelchair accessory, solid | 37 | $39.07 |
| E2391 | Power wheelchair accessory, solid | 37 | $18.78 |
| E2392 | Power wheelchair accessory, solid | 36 | $46.73 |
| E2394 | Power wheelchair accessory, drive wheel excludes tire | 36 | $61.14 |
| E2395 | Power wheelchair accessory, caster wheel excludes tire | 36 | $43.64 |
| E2396 | Power wheelchair accessory, caster fork, any size | 36 | $51.64 |
| E2397 | Power wheelchair accessory, lithium-based battery, each | 24 | $426.43 |
| E2398 | Wheelchair accessory, dynamic positioning hardware for back | 17 | $141.25 |
| E2402 | Negative pressure wound therapy electrical pump | 37 | $797.39 |
| E2500 | Speech generating device, digitized speech | 35 | $337.68 |
| E2502 | Speech generating device, digitized speech | 34 | $919.90 |
| E2504 | Speech generating device, digitized speech | 34 | $1,213.47 |
| E2506 | Speech generating device, digitized speech | 35 | $1,917.71 |
| E2508 | Speech generating device, synthesized speech | 35 | $2,739.28 |
| E2510 | Speech generating device, synthesized speech | 34 | $5,397.73 |
| E2512 | Accessory for speech generating device, mounting system | 7 | $633.92 |
| E2513 | Accessory for speech generating device | 9 | $2,741.10 |
| E2601 | General use wheelchair seat cushion | 39 | $47.91 |
| E2602 | General use wheelchair seat cushion | 38 | $97.86 |
| E2603 | Skin protection wheelchair seat cushion | 37 | $121.95 |
| E2604 | Skin protection wheelchair seat cushion | 37 | $160.28 |
| E2605 | Positioning wheelchair seat cushion | 37 | $217.35 |
| E2606 | Positioning wheelchair seat cushion | 37 | $342.10 |
| E2607 | Skin protection and positioning wheelchair seat cushion | 37 | $220.48 |
| E2608 | Skin protection and positioning wheelchair seat cushion | 37 | $281.09 |
| E2609 | Custom fabricated wheelchair seat cushion, any size | 5 | $800.27 |
| E2611 | General use wheelchair back cushion | 38 | $188.98 |
| E2612 | General use wheelchair back cushion | 38 | $341.31 |
| E2613 | Positioning wheelchair back cushion, posterior | 37 | $314.43 |
| E2614 | Positioning wheelchair back cushion, posterior | 37 | $462.72 |
| E2615 | Positioning wheelchair back cushion, posterior-lateral | 37 | $365.25 |
| E2616 | Positioning wheelchair back cushion, posterior-lateral | 37 | $484.13 |
| E2617 | Custom fabricated wheelchair back cushion, any size | 5 | $793.04 |
| E2619 | Replacement cover for wheelchair seat cushion or back... | 37 | $46.85 |
| E2620 | Positioning wheelchair back cushion | 38 | $421.86 |
| E2621 | Positioning wheelchair back cushion | 39 | $464.12 |
| E2622 | Skin protection wheelchair seat cushion, adjustable | 38 | $243.61 |
| E2623 | Skin protection wheelchair seat cushion, adjustable | 38 | $323.19 |
| E2624 | Skin protection and positioning wheelchair seat cushion | 38 | $272.84 |
| E2625 | Skin protection and positioning wheelchair seat cushion | 38 | $341.42 |
| E2626 | Wheelchair accessory, shoulder elbow | 30 | $567.09 |
| E2627 | Wheelchair accessory, shoulder elbow | 29 | $841.57 |
| E2628 | Wheelchair accessory, shoulder elbow | 29 | $688.43 |
| E2629 | Wheelchair accessory, shoulder elbow | 29 | $872.53 |
| E2630 | Wheelchair accessory, shoulder elbow, mobile arm support | 30 | $573.03 |
| E2631 | Wheelchair accessory, addition to mobile arm support | 30 | $233.81 |
| E2632 | Wheelchair accessory, addition to mobile arm support | 30 | $152.50 |
| E2633 | Wheelchair accessory, addition to mobile arm support | 30 | $128.30 |
| E3000 | Speech volume modulation system, any type | 9 | $234.41 |
| E8002 | Gait trainer, pediatric size, anterior support | 6 | $1,340.88 |
| G0237 | Therapeutic procedures to increase strength or endurance of... | 15 | $10.20 |
| G0238 | Therapeutic procedures to improve respiratory function | 14 | $8.92 |
| G0249 | Provision of test materials and equipment for home inr... | 13 | $53.65 |
| K0001 | Standard wheelchair | 37 | $39.02 |
| K0002 | Standard hemi (low seat) wheelchair | 37 | $62.96 |
| K0003 | Lightweight wheelchair | 37 | $62.35 |
| K0004 | High strength, lightweight wheelchair | 39 | $90.87 |
| K0005 | Ultralightweight wheelchair | 39 | $263.45 |
| K0006 | Heavy duty wheelchair | 37 | $94.95 |
| K0007 | Extra heavy duty wheelchair | 37 | $140.41 |
| K0009 | Other manual wheelchair/base | 25 | $101.86 |
| K0010 | Standard - weight frame motorized/power wheelchair | 26 | $495.84 |
| K0011 | Standard - weight frame motorized/power wheelchair with... | 25 | $638.81 |
| K0012 | Lightweight portable motorized/power wheelchair | 24 | $403.24 |
| K0014 | Other motorized/power wheelchair base | 6 | $567.58 |
| K0015 | Detachable, non-adjustable height armrest, replacement only | 38 | $133.43 |
| K0017 | Detachable, adjustable height armrest, base | 39 | $41.85 |
| K0018 | Detachable, adjustable height armrest, upper portion | 39 | $23.65 |
| K0019 | Arm pad, replacement only, each | 39 | $13.38 |
| K0020 | Fixed, adjustable height armrest, pair | 38 | $37.78 |
| K0037 | High mount flip-up footrest, each | 38 | $39.13 |
| K0038 | Leg strap, each | 39 | $20.91 |
| K0039 | Leg strap, h style, each | 39 | $44.89 |
| K0040 | Adjustable angle footplate, each | 39 | $59.11 |
| K0041 | Large size footplate, each | 38 | $42.82 |
| K0042 | Standard size footplate, replacement only, each | 38 | $28.73 |
| K0043 | Footrest, lower extension tube, replacement only, each | 39 | $17.16 |
| K0044 | Footrest, upper hanger bracket, replacement only, each | 38 | $14.65 |
| K0045 | Footrest, complete assembly, replacement only, each | 39 | $48.68 |
| K0046 | Elevating legrest, lower extension tube, replacement only | 38 | $16.87 |
| K0047 | Elevating legrest, upper hanger bracket, replacement only | 39 | $62.62 |
| K0050 | Ratchet assembly, replacement only | 37 | $27.62 |
| K0051 | Cam release assembly, footrest or legrest, replacement only | 37 | $44.41 |
| K0052 | Swingaway, detachable footrests, replacement only, each | 38 | $69.71 |
| K0053 | Elevating footrests, articulating (telescoping), each | 36 | $83.88 |
| K0056 | Seat height less than 17" or equal to or greater than 21"... | 39 | $77.23 |
| K0065 | Spoke protectors, each | 38 | $37.14 |
| K0069 | Rear wheel assembly, complete, with solid tire | 37 | $82.62 |
| K0070 | Rear wheel assembly, complete, with pneumatic tire | 38 | $149.07 |
| K0071 | Front caster assembly, complete, with pneumatic tire | 39 | $89.45 |
| K0072 | Front caster assembly, complete, with semi-pneumatic tire | 39 | $53.41 |
| K0073 | Caster pin lock, each | 39 | $28.10 |
| K0077 | Front caster assembly, complete, with solid tire | 39 | $48.18 |
| K0098 | Drive belt for power wheelchair, replacement only | 32 | $22.31 |
| K0105 | Iv hanger, each | 38 | $88.91 |
| K0108 | Wheelchair component or accessory, not otherwise specified | 6 | $580.00 |
| K0195 | Elevating leg rests, pair | 33 | $18.69 |
| K0455 | Infusion pump used for uninterrupted parenteral... | 18 | $314.01 |
| K0552 | Supplies for external non-insulin drug infusion pump | 29 | $2.73 |
| K0601 | Replacement battery for external infusion pump owned by... | 27 | $1.26 |
| K0602 | Replacement battery for external infusion pump owned by... | 27 | $7.13 |
| K0603 | Replacement battery for external infusion pump owned by... | 28 | $0.625 |
| K0604 | Replacement battery for external infusion pump owned by... | 27 | $6.88 |
| K0605 | Replacement battery for external infusion pump owned by... | 25 | $16.43 |
| K0606 | Automatic external defibrillator | 36 | $2,292.51 |
| K0607 | Replacement battery for automated external defibrillator | 18 | $84.14 |
| K0608 | Replacement garment for use with automated external... | 15 | $105.43 |
| K0609 | Replacement electrodes for use with automated external... | 16 | $926.95 |
| K0672 | Addition to lower extremity orthosis | 25 | $81.89 |
| K0730 | Controlled dose inhalation drug delivery system | 25 | $240.87 |
| K0733 | Power wheelchair accessory | 37 | $26.77 |
| K0738 | Portable gaseous oxygen system, rental | 30 | $44.83 |
| K0739 | Repair or nonroutine service for durable medical equipment... | 37 | $16.47 |
| K0740 | Repair or nonroutine service for oxygen equipment requiring... | 15 | $13.41 |
| K0800 | Durable medical equipment | 34 | $117.10 |
| K0801 | Power operated vehicle, group 1 heavy duty | 35 | $200.23 |
| K0802 | Power operated vehicle, group 1 very heavy duty | 34 | $264.24 |
| K0806 | Power operated vehicle, group 2 standard | 30 | $180.66 |
| K0807 | Power operated vehicle, group 2 heavy duty | 30 | $276.92 |
| K0808 | Power operated vehicle, group 2 very heavy duty | 30 | $414.75 |
| K0813 | Power wheelchair, group 1 standard, portable | 35 | $320.08 |
| K0814 | Power wheelchair, group 1 standard, portable | 36 | $326.87 |
| K0815 | Power wheelchair, group 1 standard | 36 | $373.37 |
| K0816 | Power wheelchair, group 1 standard, captains chair | 36 | $362.24 |
| K0820 | Power wheelchair, group 2 standard, portable | 35 | $329.93 |
| K0821 | Power wheelchair, group 2 standard, portable | 35 | $343.40 |
| K0822 | Durable medical equipment | 36 | $398.79 |
| K0823 | Durable medical equipment | 37 | $392.50 |
| K0824 | Power wheelchair, group 2 heavy duty, sling/solid seat/back | 36 | $519.40 |
| K0825 | Power wheelchair, group 2 heavy duty, captains chair | 37 | $475.29 |
| K0826 | Power wheelchair, group 2 very heavy duty | 35 | $832.25 |
| K0827 | Power wheelchair, group 2 very heavy duty, captains chair | 36 | $735.99 |
| K0828 | Power wheelchair, group 2 extra heavy duty | 36 | $1,031.73 |
| K0829 | Power wheelchair, group 2 extra heavy duty, captains chair | 36 | $1,064.43 |
| K0830 | Power wheelchair, group 2 standard, seat elevator | 22 | $411.10 |
| K0831 | Power wheelchair, group 2 standard, seat elevator | 22 | $411.10 |
| K0835 | Power wheelchair, group 2 standard, single power option | 37 | $456.11 |
| K0836 | Power wheelchair, group 2 standard, single power option | 36 | $480.61 |
| K0837 | Power wheelchair, group 2 heavy duty, single power option | 36 | $580.90 |
| K0838 | Power wheelchair, group 2 heavy duty, single power option | 35 | $510.83 |
| K0839 | Power wheelchair, group 2 very heavy duty | 34 | $765.59 |
| K0840 | Power wheelchair, group 2 extra heavy duty | 35 | $1,170.17 |
| K0841 | Power wheelchair, group 2 standard, multiple power option | 37 | $506.38 |
| K0842 | Power wheelchair, group 2 standard, multiple power option | 36 | $512.26 |
| K0843 | Power wheelchair, group 2 heavy duty, multiple power option | 37 | $600.26 |
| K0848 | Power wheelchair, group 3 standard, sling/solid seat/back | 37 | $932.20 |
| K0849 | Power wheelchair, group 3 standard, captains chair | 37 | $896.24 |
| K0850 | Power wheelchair, group 3 heavy duty, sling/solid seat/back | 37 | $1,081.29 |
| K0851 | Power wheelchair, group 3 heavy duty, captains chair | 37 | $1,039.68 |
| K0852 | Power wheelchair, group 3 very heavy duty | 37 | $1,249.37 |
| K0853 | Power wheelchair, group 3 very heavy duty, captains chair | 37 | $1,283.43 |
| K0854 | Power wheelchair, group 3 extra heavy duty | 36 | $1,465.11 |
| K0855 | Power wheelchair, group 3 extra heavy duty, captains chair | 36 | $1,384.00 |
| K0856 | Power wheelchair, group 3 standard, single power option | 37 | $1,000.59 |
| K0857 | Power wheelchair, group 3 standard, single power option | 36 | $1,032.90 |
| K0858 | Power wheelchair, group 3 heavy duty, single power option | 37 | $1,241.45 |
| K0859 | Power wheelchair, group 3 heavy duty, single power option | 37 | $1,183.96 |
| K0860 | Power wheelchair, group 3 very heavy duty | 37 | $1,773.57 |
| K0861 | Power wheelchair, group 3 standard, multiple power option | 37 | $1,002.20 |
| K0862 | Power wheelchair, group 3 heavy duty, multiple power option | 37 | $1,102.16 |
| K0863 | Power wheelchair, group 3 very heavy duty | 36 | $1,794.86 |
| K0864 | Power wheelchair, group 3 extra heavy duty | 36 | $1,818.65 |
| K0868 | Power wheelchair, group 4 standard, sling/solid seat/back | 7 | $3,112.44 |
| K0869 | Power wheelchair, group 4 standard, captains chair | 7 | $669.15 |
| K0877 | Power wheelchair, group 4 standard, single power option | 7 | $2,618.42 |
| K0879 | Power wheelchair, group 4 heavy duty, single power option | 6 | $2,234.10 |
| K0880 | Power wheelchair, group 4 very heavy duty | 6 | $3,145.11 |
| K0884 | Power wheelchair, group 4 standard, multiple power option | 10 | $5,711.27 |
| K0885 | Power wheelchair, group 4 standard, multiple power option | 7 | $749.63 |
| K0886 | Power wheelchair, group 4 heavy duty, multiple power option | 8 | $2,290.36 |
| K0890 | Power wheelchair, group 5 pediatric, single power option | 8 | $3,164.15 |
| K0891 | Power wheelchair, group 5 pediatric, multiple power option | 6 | $1,097.22 |
| K1005 | Disposable collection and storage bag for breast milk | 6 | $0.295 |
| K1034 | Provision of covid-19 test | 9 | $12.00 |
| L0112 | Cranial cervical orthosis, congenital torticollis type | 36 | $1,339.10 |
| L0113 | Cranial cervical orthosis, torticollis type | 27 | $273.66 |
| L0120 | Cervical, flexible, non-adjustable, prefabricated | 39 | $23.56 |
| L0130 | Cervical, flexible, thermoplastic collar, molded to patient | 39 | $162.27 |
| L0140 | Cervical, semi-rigid, adjustable (plastic collar) | 39 | $57.00 |
| L0150 | Cervical, semi-rigid, adjustable molded chin cup | 39 | $97.88 |
| L0160 | Cervical, semi-rigid | 37 | $135.26 |
| L0170 | Cervical, collar, molded to patient model | 38 | $577.73 |
| L0172 | Cervical, collar, semi-rigid thermoplastic foam, two-piece | 39 | $117.72 |
| L0174 | Cervical, collar, semi-rigid, thermoplastic foam | 39 | $252.54 |
| L0180 | Cervical, multiple post collar | 38 | $346.81 |
| L0190 | Cervical, multiple post collar | 38 | $464.31 |
| L0200 | Cervical, multiple post collar | 39 | $479.10 |
| L0220 | Thoracic, rib belt, custom fabricated | 39 | $113.77 |
| L0450 | Tlso, flexible, provides trunk support | 39 | $133.29 |
| L0452 | Tlso, flexible, provides trunk support | 24 | $264.25 |
| L0454 | Tlso flexible, provides trunk support | 37 | $318.63 |
| L0455 | Tlso, flexible, provides trunk support | 35 | $255.38 |
| L0456 | Tlso, flexible, provides trunk support, thoracic region | 38 | $919.59 |
| L0457 | Tlso, flexible, provides trunk support, thoracic region | 36 | $732.34 |
| L0458 | Tlso, triplanar control, modular segmented spinal system | 36 | $824.59 |
| L0460 | Tlso, triplanar control, modular segmented spinal system | 38 | $917.58 |
| L0462 | Tlso, triplanar control, modular segmented spinal system | 36 | $1,146.57 |
| L0464 | Tlso, triplanar control, modular segmented spinal system | 36 | $1,350.84 |
| L0466 | Tlso, sagittal control | 38 | $345.63 |
| L0467 | Tlso, sagittal control | 36 | $284.03 |
| L0468 | Tlso, sagittal-coronal control | 38 | $419.47 |
| L0469 | Tlso, sagittal-coronal control | 34 | $371.78 |
| L0470 | Tlso, triplanar control | 38 | $597.72 |
| L0472 | Tlso, triplanar control, hyperextension | 39 | $371.71 |
| L0480 | Tlso, triplanar control | 38 | $1,386.88 |
| L0482 | Tlso, triplanar control | 39 | $1,500.63 |
| L0484 | Tlso, triplanar control | 39 | $1,577.80 |
| L0486 | Tlso, triplanar control | 39 | $1,702.56 |
| L0488 | Tlso, triplanar control | 36 | $921.79 |
| L0490 | Tlso, sagittal-coronal control | 38 | $261.57 |
| L0491 | Tlso, sagittal-coronal control | 37 | $704.90 |
| L0492 | Tlso, sagittal-coronal control | 36 | $463.99 |
| L0621 | Sacroiliac orthosis, flexible | 36 | $71.29 |
| L0622 | Sacroiliac orthosis, flexible | 38 | $239.22 |
| L0623 | Sacroiliac orthosis, provides pelvic-sacral support | 29 | $121.95 |
| L0624 | Sacroiliac orthosis, provides pelvic-sacral support | 8 | $217.21 |
| L0625 | Lumbar orthosis, flexible, provides lumbar support | 38 | $41.16 |
| L0626 | Lumbar orthosis, sagittal control | 38 | $71.21 |
| L0627 | Lumbar orthosis, sagittal control | 39 | $370.58 |
| L0628 | Lumbar-sacral orthosis, flexible | 37 | $62.71 |
| L0629 | Lumbar-sacral orthosis, flexible | 14 | $175.43 |
| L0630 | Lumbar-sacral orthosis, sagittal control | 38 | $146.66 |
| L0631 | Lumbar-sacral orthosis, sagittal control | 38 | $937.91 |
| L0632 | Orthotics and prosthetics | 10 | $644.29 |
| L0633 | Lumbar-sacral orthosis, sagittal-coronal control | 38 | $259.65 |
| L0634 | Orthotics and prosthetics | 11 | $341.03 |
| L0635 | Lumbar-sacral orthosis, sagittal-coronal control | 36 | $893.68 |
| L0636 | Lumbar sacral orthosis, sagittal-coronal control | 37 | $1,313.51 |
| L0637 | Lumbar-sacral orthosis, sagittal-coronal control | 38 | $1,088.90 |
| L0638 | Lumbar-sacral orthosis, sagittal-coronal control | 38 | $1,226.26 |
| L0639 | Lumbar-sacral orthosis, sagittal-coronal control | 39 | $1,085.82 |
| L0640 | Lumbar-sacral orthosis, sagittal-coronal control | 38 | $956.51 |
| L0641 | Lumbar orthosis, sagittal control | 36 | $58.06 |
| L0642 | Lumbar orthosis, sagittal control | 36 | $306.18 |
| L0643 | Lumbar-sacral orthosis, sagittal control | 36 | $121.95 |
| L0648 | Lumbar-sacral orthosis, sagittal control | 37 | $761.86 |
| L0649 | Lumbar-sacral orthosis, sagittal-coronal control | 37 | $214.37 |
| L0650 | Lumbar-sacral orthosis, sagittal-coronal control | 37 | $890.84 |
| L0651 | Lumbar-sacral orthosis, sagittal-coronal control | 35 | $930.50 |
| L0700 | Cervical-thoracic-lumbar-sacral-orthoses (ctlso) | 39 | $1,746.05 |
| L0710 | Ctlso, anterior-posterior-lateral-control | 38 | $1,941.32 |
| L0720 | Cervical-thoracic-lumbar-sacral-orthoses (ctlso) | 23 | $1,867.64 |
| L0810 | Halo procedure, cervical halo incorporated into jacket vest | 38 | $2,351.51 |
| L0820 | Halo procedure, cervical halo incorporated into plaster body... | 37 | $1,996.49 |
| L0830 | Halo procedure, cervical halo incorporated into milwaukee... | 38 | $2,916.44 |
| L0859 | Addition to halo procedure | 35 | $1,119.91 |
| L0861 | Addition to halo procedure | 33 | $198.02 |
| L0970 | Tlso, corset front | 38 | $100.51 |
| L0972 | Lso, corset front | 38 | $90.54 |
| L0974 | Tlso, full corset | 38 | $160.83 |
| L0976 | Lso, full corset | 38 | $148.65 |
| L0978 | Axillary crutch extension | 37 | $176.96 |
| L0980 | Peroneal straps, prefabricated, off-the-shelf, pair | 38 | $15.81 |
| L0982 | Stocking supporter grips, prefabricated, off-the-shelf | 34 | $15.35 |
| L0984 | Protective body sock, prefabricated, off-the-shelf, each | 39 | $53.91 |
| L1000 | Cervical-thoracic-lumbar-sacral orthosis (ctlso) | 39 | $1,844.11 |
| L1001 | Cervical thoracic lumbar sacral orthosis, immobilizer | 5 | $808.00 |
| L1005 | Tension based scoliosis orthosis and accessory pads | 34 | $2,939.13 |
| L1006 | Scoliosis orthosis, sagittal-coronal control provided by a... | 19 | $1,047.27 |
| L1010 | Addition to cervical-thoracic-lumbar-sacral orthosis | 39 | $61.26 |
| L1020 | Addition to ctlso or scoliosis orthosis, kyphosis pad | 39 | $83.33 |
| L1025 | Addition to ctlso or scoliosis orthosis, kyphosis pad | 37 | $114.64 |
| L1030 | Addition to ctlso or scoliosis orthosis, lumbar bolster pad | 39 | $60.90 |
| L1040 | Addition to ctlso or scoliosis orthosis | 39 | $76.16 |
| L1050 | Addition to ctlso or scoliosis orthosis, sternal pad | 39 | $81.25 |
| L1060 | Addition to ctlso or scoliosis orthosis, thoracic pad | 39 | $92.48 |
| L1070 | Addition to ctlso or scoliosis orthosis, trapezius sling | 38 | $85.35 |
| L1080 | Addition to ctlso or scoliosis orthosis, outrigger | 38 | $51.79 |
| L1085 | Addition to ctlso or scoliosis orthosis, outrigger | 37 | $141.50 |
| L1090 | Addition to ctlso or scoliosis orthosis, lumbar sling | 39 | $84.26 |
| L1100 | Addition to ctlso or scoliosis orthosis, ring flange | 36 | $152.38 |
| L1110 | Addition to ctlso or scoliosis orthosis, ring flange | 38 | $221.03 |
| L1120 | Addition to ctlso, scoliosis orthosis, cover for upright | 38 | $35.84 |
| L1200 | Thoracic-lumbar-sacral-orthosis (tlso) | 39 | $1,530.40 |
| L1210 | Addition to tlso, (low profile), lateral thoracic extension | 39 | $237.35 |
| L1220 | Addition to tlso, (low profile), anterior thoracic extension | 39 | $210.85 |
| L1230 | Addition to tlso, (low profile) | 39 | $522.58 |
| L1240 | Addition to tlso, (low profile), lumbar derotation pad | 39 | $73.04 |
| L1250 | Addition to tlso, (low profile), anterior asis pad | 38 | $66.61 |
| L1260 | Addition to tlso, (low profile) | 39 | $72.67 |
| L1270 | Addition to tlso, (low profile), abdominal pad | 38 | $71.10 |
| L1280 | Addition to tlso, (low profile), rib gusset (elastic), each | 39 | $77.51 |
| L1290 | Addition to tlso, (low profile), lateral trochanteric pad | 39 | $70.66 |
| L1300 | Other scoliosis procedure | 39 | $1,565.11 |
| L1310 | Other scoliosis procedure, post-operative body jacket | 38 | $1,612.98 |
| L1600 | Hip orthosis, abduction control of hip joints, flexible | 39 | $117.19 |
| L1610 | Hip orthosis, abduction control of hip joints, flexible, | 38 | $39.87 |
| L1620 | Hip orthosis, abduction control of hip joints, flexible, | 39 | $121.92 |
| L1630 | Hip orthosis, abduction control of hip joints | 39 | $155.78 |
| L1640 | Hip orthosis, abduction control of hip joints, static | 39 | $424.85 |
| L1650 | Hip orthosis, abduction control of hip joints, static | 38 | $204.76 |
| L1652 | Hip orthosis, bilateral thigh cuffs with adjustable abductor... | 37 | $331.68 |
| L1653 | Hip orthosis, bilateral thigh cuffs with adjustable abductor... | 20 | $348.37 |
| L1660 | Hip orthosis, abduction control of hip joints, static | 38 | $157.33 |
| L1680 | Hip orthosis, abduction control of hip joints, dynamic | 38 | $1,113.55 |
| L1681 | Hip orthosis, bilateral hip joints and thigh cuffs | 18 | $1,941.28 |
| L1685 | Hip orthosis, abduction control of hip joint | 39 | $1,046.93 |
| L1686 | Hip orthosis, abduction control of hip joint | 39 | $814.14 |
| L1690 | Combination, bilateral, lumbo-sacral, hip | 39 | $1,756.07 |
| L1700 | Legg perthes orthosis, (toronto type), custom fabricated | 38 | $1,409.39 |
| L1710 | Legg perthes orthosis, (newington type), custom fabricated | 38 | $1,688.30 |
| L1720 | Legg perthes orthosis, trilateral, (tachdijan type) | 39 | $1,220.07 |
| L1730 | Legg perthes orthosis, (scottish rite type) | 39 | $1,040.45 |
| L1755 | Legg perthes orthosis, (patten bottom type) | 39 | $1,393.50 |
| L1810 | Knee orthosis, elastic with joints | 38 | $94.29 |
| L1812 | Knee orthosis, elastic with joints, prefabricated | 36 | $75.40 |
| L1820 | Knee orthosis, elastic with condylar pads and joints | 39 | $122.02 |
| L1821 | Knee orthosis, elastic with condylar pads and joints | 22 | $138.07 |
| L1830 | Knee orthosis, immobilizer, canvas longitudinal | 38 | $65.29 |
| L1831 | Knee orthosis, locking knee joint(s), positional orthosis | 37 | $270.41 |
| L1832 | Knee orthosis, adjustable knee joints | 37 | $600.15 |
| L1833 | Knee orthosis, adjustable knee joints | 36 | $505.23 |
| L1834 | Knee orthosis, without knee joint, rigid, custom fabricated | 38 | $709.17 |
| L1836 | Knee orthosis, rigid, without joint(s) | 37 | $98.54 |
| L1840 | Knee orthosis, derotation, medial-lateral | 37 | $908.80 |
| L1843 | Knee orthosis, single upright, thigh and calf | 37 | $816.01 |
| L1844 | Knee orthosis, single upright, thigh and calf | 35 | $1,479.71 |
| L1845 | Knee orthosis, double upright, thigh and calf | 38 | $757.62 |
| L1846 | Knee orthosis, double upright, thigh and calf | 38 | $1,089.89 |
| L1847 | Knee orthosis, double upright with adjustable joint | 37 | $527.92 |
| L1848 | Knee orthosis, double upright with adjustable joint | 34 | $525.76 |
| L1850 | Knee orthosis, swedish type, prefabricated, off-the-shelf | 38 | $207.15 |
| L1851 | Knee orthosis (ko), single upright, thigh and calf | 36 | $625.02 |
| L1852 | Knee orthosis (ko), double upright, thigh and calf | 36 | $603.98 |
| L1860 | Knee orthosis, modification of supracondylar prosthetic... | 38 | $1,042.29 |
| L1900 | Ankle foot orthosis, spring wire | 38 | $260.13 |
| L1902 | Ankle orthosis, ankle gauntlet or similar | 37 | $77.45 |
| L1904 | Ankle orthosis, ankle gauntlet or similar | 37 | $423.80 |
| L1906 | Ankle foot orthosis, multiligamentous ankle support | 38 | $106.32 |
| L1907 | Ankle orthosis, supramalleolar with straps | 38 | $520.27 |
| L1910 | Ankle foot orthosis, posterior, single bar | 37 | $248.27 |
| L1920 | Ankle foot orthosis, single upright with static or... | 37 | $321.38 |
| L1930 | Ankle foot orthosis, plastic or other material | 38 | $225.93 |
| L1932 | Ankle foot orthosis, rigid anterior tibial section | 38 | $819.44 |
| L1933 | Ankle foot orthosis, rigid anterior tibial section | 22 | $895.97 |
| L1940 | Ankle foot orthosis, plastic or other material | 38 | $463.22 |
| L1945 | Ankle foot orthosis, plastic, rigid anterior tibial section | 38 | $876.57 |
| L1950 | Ankle foot orthosis, spiral, | 38 | $707.49 |
| L1951 | Ankle foot orthosis, spiral, | 37 | $771.58 |
| L1952 | Ankle foot orthosis, spiral, | 21 | $856.26 |
| L1960 | Ankle foot orthosis, posterior solid ankle, plastic | 38 | $512.08 |
| L1970 | Ankle foot orthosis, plastic with ankle joint | 38 | $652.60 |
| L1971 | Ankle foot orthosis, plastic or other material with ankle... | 37 | $430.21 |
| L1980 | Ankle foot orthosis, single upright free plantar... | 38 | $339.00 |
| L1990 | Ankle foot orthosis, double upright free plantar... | 38 | $426.30 |
| L2000 | Knee ankle foot orthosis, single upright, free knee | 38 | $932.43 |
| L2005 | Knee ankle foot orthosis, any material | 37 | $3,855.06 |
| L2006 | Knee ankle foot device, any material | 12 | $34,545.39 |
| L2010 | Knee ankle foot orthosis, single upright, free ankle | 38 | $852.29 |
| L2020 | Knee ankle foot orthosis, double upright, free ankle | 38 | $1,053.75 |
| L2030 | Knee ankle foot orthosis, double upright, free ankle | 38 | $962.79 |
| L2034 | Knee ankle foot orthosis, full plastic, single upright | 36 | $1,909.69 |
| L2035 | Knee ankle foot orthosis, full plastic, static | 38 | $161.44 |
| L2036 | Knee ankle foot orthosis, full plastic, double upright | 38 | $1,714.02 |
| L2037 | Knee ankle foot orthosis, full plastic, single upright | 37 | $1,571.81 |
| L2038 | Knee ankle foot orthosis, full plastic | 37 | $1,314.35 |
| L2040 | Hip knee ankle foot orthosis, torsion control | 38 | $165.55 |
| L2050 | Hip knee ankle foot orthosis, torsion control | 38 | $437.91 |
| L2060 | Hip knee ankle foot orthosis, torsion control | 38 | $543.18 |
| L2070 | Hip knee ankle foot orthosis, torsion control | 37 | $127.99 |
| L2080 | Hip knee ankle foot orthosis, torsion control | 37 | $339.39 |
| L2090 | Hip knee ankle foot orthosis, torsion control | 37 | $428.30 |
| L2106 | Ankle foot orthosis, fracture orthosis | 37 | $625.05 |
| L2108 | Ankle foot orthosis, fracture orthosis | 38 | $999.11 |
| L2112 | Ankle foot orthosis, fracture orthosis | 38 | $458.48 |
| L2114 | Ankle foot orthosis, fracture orthosis | 38 | $536.23 |
| L2116 | Ankle foot orthosis, fracture orthosis | 38 | $688.57 |
| L2126 | Knee ankle foot orthosis, fracture orthosis | 37 | $1,053.94 |
| L2128 | Knee ankle foot orthosis, fracture orthosis | 37 | $1,557.94 |
| L2132 | Kafo, fracture orthosis, femoral fracture cast orthosis | 36 | $741.32 |
| L2134 | Kafo, fracture orthosis, femoral fracture cast orthosis | 37 | $889.13 |
| L2136 | Kafo, fracture orthosis, femoral fracture cast orthosis | 37 | $1,040.86 |
| L2180 | Addition to lower extremity fracture orthosis | 39 | $107.66 |
| L2182 | Addition to lower extremity fracture orthosis | 39 | $91.37 |
| L2184 | Addition to lower extremity fracture orthosis | 39 | $110.42 |
| L2186 | Addition to lower extremity fracture orthosis | 39 | $136.52 |
| L2188 | Addition to lower extremity fracture orthosis | 38 | $286.17 |
| L2190 | Addition to lower extremity fracture orthosis, waist belt | 38 | $77.42 |
| L2192 | Addition to lower extremity fracture orthosis, hip joint | 38 | $314.08 |
| L2200 | Addition to lower extremity, limited ankle motion | 39 | $44.69 |
| L2210 | Addition to lower extremity, dorsiflexion assist | 39 | $59.68 |
| L2220 | Addition to lower extremity | 39 | $75.28 |
| L2221 | Addition to lower extremity orthosis, ankle system | 9 | $1,606.43 |
| L2230 | Addition to lower extremity | 39 | $70.54 |
| L2232 | Addition to lower extremity orthosis | 33 | $92.60 |
| L2240 | Addition to lower extremity | 38 | $73.59 |
| L2250 | Addition to lower extremity, foot plate | 39 | $315.47 |
| L2260 | Addition to lower extremity, reinforced solid stirrup | 39 | $180.77 |
| L2265 | Addition to lower extremity, long tongue stirrup | 38 | $108.26 |
| L2270 | Addition to lower extremity, varus/valgus correction | 38 | $49.37 |
| L2275 | Addition to lower extremity, varus/valgus correction | 38 | $118.46 |
| L2280 | Addition to lower extremity, molded inner boot | 39 | $402.02 |
| L2300 | Addition to lower extremity, abduction bar | 38 | $266.90 |
| L2310 | Addition to lower extremity, abduction bar-straight | 39 | $113.10 |
| L2320 | Addition to lower extremity, non-molded lacer | 39 | $198.10 |
| L2330 | Addition to lower extremity, lacer molded to patient model | 39 | $369.49 |
| L2335 | Addition to lower extremity, anterior swing band | 39 | $214.45 |
| L2340 | Addition to lower extremity, pre-tibial shell | 38 | $428.64 |
| L2350 | Addition to lower extremity, prosthetic type, (bk) socket | 39 | $820.70 |
| L2360 | Addition to lower extremity, extended steel shank | 39 | $48.03 |
| L2370 | Addition to lower extremity, patten bottom | 38 | $243.42 |
| L2375 | Addition to lower extremity, torsion control | 38 | $105.24 |
| L2380 | Addition to lower extremity, torsion control | 37 | $117.20 |
| L2385 | Addition to lower extremity, straight knee joint | 38 | $123.75 |
| L2387 | Addition to lower extremity, polycentric knee joint | 35 | $168.75 |
| L2390 | Addition to lower extremity, offset knee joint, each joint | 38 | $96.77 |
| L2395 | Addition to lower extremity, offset knee joint, heavy duty | 38 | $140.78 |
| L2397 | Addition to lower extremity orthosis, suspension sleeve | 38 | $108.08 |
| L2405 | Addition to knee joint, drop lock, each | 39 | $79.18 |
| L2415 | Addition to knee lock with integrated release mechanism | 39 | $111.58 |
| L2425 | Addition to knee joint | 39 | $130.61 |
| L2430 | Addition to knee joint | 38 | $131.98 |
| L2492 | Addition to knee joint, lift loop for drop lock ring | 39 | $93.74 |
| L2500 | Addition to lower extremity, thigh/weight bearing | 39 | $284.59 |
| L2510 | Addition to lower extremity, thigh/weight bearing | 39 | $712.23 |
| L2520 | Addition to lower extremity, thigh/weight bearing | 39 | $427.69 |
| L2525 | Addition to lower extremity, thigh/weight bearing | 37 | $1,134.81 |
| L2526 | Addition to lower extremity, thigh/weight bearing | 38 | $632.58 |
| L2530 | Addition to lower extremity, thigh-weight bearing, lacer | 39 | $215.99 |
| L2540 | Addition to lower extremity, thigh/weight bearing, lacer | 39 | $388.66 |
| L2550 | Addition to lower extremity, thigh/weight bearing | 39 | $270.63 |
| L2570 | Addition to lower extremity, pelvic control, hip joint | 38 | $446.93 |
| L2580 | Addition to lower extremity, pelvic control, pelvic sling | 39 | $428.34 |
| L2600 | Addition to lower extremity, pelvic control, hip joint | 39 | $193.69 |
| L2610 | Addition to lower extremity, pelvic control, hip joint | 39 | $225.46 |
| L2620 | Addition to lower extremity, pelvic control, hip joint | 39 | $257.19 |
| L2622 | Addition to lower extremity, pelvic control, hip joint | 38 | $283.31 |
| L2624 | Addition to lower extremity, pelvic control, hip joint | 38 | $307.71 |
| L2627 | Addition to lower extremity, pelvic control, plastic | 37 | $1,575.95 |
| L2628 | Addition to lower extremity, pelvic control, metal frame | 38 | $1,576.58 |
| L2630 | Addition to lower extremity, pelvic control, band and belt | 38 | $227.64 |
| L2640 | Addition to lower extremity, pelvic control, band and belt | 39 | $308.94 |
| L2650 | Addition to lower extremity, pelvic and thoracic control | 39 | $116.29 |
| L2660 | Addition to lower extremity, thoracic control, thoracic band | 38 | $163.50 |
| L2670 | Addition to lower extremity, thoracic control | 38 | $157.88 |
| L2680 | Addition to lower extremity, thoracic control | 39 | $143.86 |
| L2750 | Addition to lower extremity orthosis | 37 | $77.60 |
| L2755 | Addition to lower extremity orthosis, high strength | 36 | $118.94 |
| L2760 | Addition to lower extremity orthosis, extension | 39 | $55.86 |
| L2768 | Orthotic side bar disconnect device, per bar | 37 | $119.69 |
| L2780 | Addition to lower extremity orthosis, non-corrosive finish | 37 | $62.22 |
| L2785 | Addition to lower extremity orthosis, drop lock retainer | 39 | $30.21 |
| L2795 | Addition to lower extremity orthosis, knee control | 39 | $78.12 |
| L2800 | Addition to lower extremity orthosis, knee control | 39 | $92.27 |
| L2810 | Addition to lower extremity orthosis, knee control | 39 | $71.80 |
| L2820 | Addition to lower extremity orthosis | 38 | $79.83 |
| L2830 | Addition to lower extremity orthosis | 39 | $83.41 |
| L2840 | Addition to lower extremity orthosis, tibial length sock | 37 | $39.17 |
| L2850 | Addition to lower extremity orthosis, femoral length sock | 37 | $56.92 |
| L2861 | Addition to lower extremity joint, knee or ankle | 11 | $244.94 |
| L3000 | Foot, insert, removable, molded to patient model | 38 | $284.44 |
| L3001 | Foot, insert, removable, molded to patient model, spenco | 34 | $122.30 |
| L3002 | Foot, insert, removable, molded to patient model | 35 | $148.38 |
| L3003 | Foot, insert, removable, molded to patient model | 33 | $164.89 |
| L3010 | Foot, insert, removable, molded to patient model | 36 | $159.28 |
| L3020 | Foot, insert, removable, molded to patient model | 36 | $182.26 |
| L3030 | Foot, insert, removable, formed to patient foot, each | 36 | $71.85 |
| L3031 | Foot, insert/plate, removable | 28 | $121.66 |
| L3040 | Foot, arch support, removable, premolded, longitudinal, each | 34 | $43.51 |
| L3050 | Foot, arch support, removable, premolded, metatarsal, each | 33 | $43.78 |
| L3060 | Foot, arch support, removable, premolded | 33 | $67.68 |
| L3070 | Foot, arch support, non-removable attached to shoe | 32 | $29.37 |
| L3080 | Foot, arch support, non-removable attached to shoe | 31 | $29.18 |
| L3090 | Foot, arch support, non-removable attached to shoe | 30 | $38.08 |
| L3100 | Hallus-valgus night dynamic splint, prefabricated | 35 | $38.55 |
| L3140 | Foot, abduction rotation bar, including shoes | 38 | $81.35 |
| L3150 | Foot, abduction rotation bar, without shoes | 37 | $74.04 |
| L3160 | Foot, adjustable shoe-styled positioning device | 15 | $55.42 |
| L3170 | Foot, plastic, silicone or equal, heel stabilizer | 36 | $46.51 |
| L3201 | Orthopedic shoe, oxford with supinator or pronator, infant | 32 | $47.24 |
| L3202 | Orthopedic shoe, oxford with supinator or pronator, child | 32 | $46.73 |
| L3203 | Orthopedic shoe, oxford with supinator or pronator, junior | 31 | $42.93 |
| L3204 | Orthopedic shoe, hightop with supinator or pronator, infant | 30 | $40.89 |
| L3206 | Orthopedic shoe, hightop with supinator or pronator, child | 31 | $44.14 |
| L3207 | Orthopedic shoe, hightop with supinator or pronator, junior | 30 | $45.04 |
| L3208 | Surgical boot, each, infant | 27 | $27.00 |
| L3209 | Surgical boot, each, child | 28 | $32.68 |
| L3211 | Surgical boot, each, junior | 27 | $33.77 |
| L3212 | Benesch boot, pair, infant | 26 | $53.76 |
| L3213 | Benesch boot, pair, child | 24 | $57.35 |
| L3214 | Benesch boot, pair, junior | 24 | $62.38 |
| L3215 | Orthopedic footwear, ladies shoe, oxford, each | 31 | $75.78 |
| L3216 | Orthopedic footwear, ladies shoe, depth inlay, each | 28 | $80.86 |
| L3217 | Orthopedic footwear, ladies shoe, hightop, depth inlay, each | 30 | $86.04 |
| L3219 | Orthopedic footwear, mens shoe, oxford, each | 32 | $83.56 |
| L3221 | Orthopedic footwear, mens shoe, depth inlay, each | 29 | $79.57 |
| L3222 | Orthopedic footwear, mens shoe, hightop, depth inlay, each | 31 | $94.78 |
| L3224 | Orthopedic footwear, woman's shoe, oxford | 34 | $54.69 |
| L3225 | Orthopedic footwear, man's shoe, oxford | 34 | $62.51 |
| L3230 | Orthopedic footwear, custom shoe, depth inlay, each | 29 | $201.72 |
| L3250 | Orthopedic footwear, custom molded shoe | 29 | $231.77 |
| L3251 | Foot, shoe molded to patient model, silicone shoe, each | 21 | $227.29 |
| L3252 | Foot, shoe molded to patient model, plastazote (or similar) | 26 | $171.65 |
| L3253 | Foot, molded shoe plastazote (or similar) custom fitted | 26 | $73.19 |
| L3254 | Non-standard size or width | 15 | $21.28 |
| L3255 | Non-standard size or length | 15 | $20.81 |
| L3257 | Orthopedic footwear, additional charge for split size | 23 | $39.20 |
| L3260 | Surgical boot/shoe, each | 30 | $39.19 |
| L3265 | Plastazote sandal, each | 23 | $37.83 |
| L3300 | Lift, elevation, heel, tapered to metatarsals, per inch | 35 | $47.43 |
| L3310 | Lift, elevation, heel and sole, neoprene, per inch | 37 | $74.04 |
| L3320 | Lift, elevation, heel and sole, cork, per inch | 31 | $67.38 |
| L3330 | Lift, elevation, metal extension (skate) | 35 | $526.60 |
| L3332 | Lift, elevation, inside shoe, tapered, up to one-half inch | 36 | $67.03 |
| L3334 | Lift, elevation, heel, per inch | 37 | $35.06 |
| L3340 | Heel wedge, sach | 36 | $78.82 |
| L3350 | Heel wedge | 36 | $21.19 |
| L3360 | Sole wedge, outside sole | 36 | $32.55 |
| L3370 | Sole wedge, between sole | 36 | $45.33 |
| L3380 | Clubfoot wedge | 35 | $45.39 |
| L3390 | Outflare wedge | 35 | $45.54 |
| L3400 | Metatarsal bar wedge, rocker | 37 | $36.97 |
| L3410 | Metatarsal bar wedge, between sole | 38 | $85.84 |
| L3420 | Full sole and heel wedge, between sole | 37 | $50.90 |
| L3430 | Heel, counter, plastic reinforced | 37 | $149.11 |
| L3440 | Heel, counter, leather reinforced | 36 | $70.57 |
| L3450 | Heel, sach cushion type | 36 | $96.49 |
| L3455 | Heel, new leather, standard | 35 | $37.87 |
| L3460 | Heel, new rubber, standard | 36 | $31.73 |
| L3465 | Heel, thomas with wedge | 35 | $53.24 |
| L3470 | Heel, thomas extended to ball | 35 | $57.24 |
| L3480 | Heel, pad and depression for spur | 34 | $59.24 |
| L3485 | Heel, pad, removable for spur | 28 | $18.63 |
| L3500 | Orthopedic shoe addition, insole, leather | 33 | $27.95 |
| L3510 | Orthopedic shoe addition, insole, rubber | 33 | $27.95 |
| L3520 | Orthopedic shoe addition, insole, felt covered with leather | 33 | $29.55 |
| L3530 | Orthopedic shoe addition, sole, half | 33 | $30.35 |
| L3540 | Orthopedic shoe addition, sole, full | 33 | $47.36 |
| L3550 | Orthopedic shoe addition, toe tap standard | 33 | $8.26 |
| L3560 | Orthopedic shoe addition, toe tap, horseshoe | 33 | $21.32 |
| L3570 | Orthopedic shoe addition, special extension to instep | 34 | $77.92 |
| L3580 | Orthopedic shoe addition, convert instep to velcro closure | 36 | $59.29 |
| L3590 | Orthopedic shoe addition | 34 | $49.39 |
| L3595 | Orthopedic shoe addition, march bar | 34 | $38.79 |
| L3600 | Transfer of an orthosis from one shoe to another | 38 | $69.35 |
| L3610 | Transfer of an orthosis from one shoe to another | 37 | $93.48 |
| L3620 | Transfer of an orthosis from one shoe to another | 38 | $69.76 |
| L3630 | Transfer of an orthosis from one shoe to another | 37 | $92.30 |
| L3640 | Transfer of an orthosis from one shoe to another | 35 | $39.72 |
| L3649 | Orthopedic shoe, modification, addition or transfer | 6 | $37.12 |
| L3650 | Shoulder orthosis, figure of eight design abduction... | 38 | $53.73 |
| L3660 | Shoulder orthosis, figure of eight design abduction... | 34 | $90.31 |
| L3670 | Shoulder orthosis, acromio/clavicular | 37 | $102.01 |
| L3671 | Shoulder orthosis, shoulder joint design, without joints | 34 | $777.16 |
| L3674 | Shoulder orthosis, abduction positioning (airplane design) | 29 | $1,000.97 |
| L3675 | Shoulder orthosis, vest type abduction restrainer | 33 | $145.27 |
| L3677 | Shoulder orthosis, shoulder joint design, without joints | 10 | $161.83 |
| L3678 | Shoulder orthosis, shoulder joint design, without joints | 8 | $192.51 |
| L3702 | Elbow orthosis, without joints, may include soft interface | 35 | $250.88 |
| L3710 | Elbow orthosis, elastic with metal joints, prefabricated | 38 | $114.08 |
| L3720 | Elbow orthosis, double upright with forearm/arm cuffs | 38 | $621.65 |
| L3730 | Elbow orthosis, double upright with forearm/arm cuffs | 37 | $861.61 |
| L3740 | Elbow orthosis, double upright with forearm/arm cuffs | 37 | $962.69 |
| L3760 | Elbow orthosis (eo), with adjustable position locking... | 37 | $417.72 |
| L3761 | Elbow orthosis (eo), with adjustable position locking... | 34 | $444.70 |
| L3762 | Elbow orthosis, rigid, without joints | 37 | $89.90 |
| L3763 | Elbow wrist hand orthosis, rigid, without joints | 38 | $625.74 |
| L3764 | Elbow wrist hand orthosis | 35 | $713.32 |
| L3765 | Elbow wrist hand finger orthosis, rigid, without joints | 35 | $1,119.05 |
| L3766 | Elbow wrist hand finger orthosis | 35 | $1,169.54 |
| L3806 | Wrist hand finger orthosis | 32 | $399.20 |
| L3807 | Wrist hand finger orthosis, without joint(s) | 36 | $217.81 |
| L3808 | Wrist hand finger orthosis, rigid without joints | 37 | $301.30 |
| L3809 | Wrist hand finger orthosis, without joint(s), prefabricated | 36 | $207.92 |
| L3891 | Addition to upper extremity joint, wrist or elbow | 8 | $296.25 |
| L3900 | Wrist hand finger orthosis, dynamic flexor hinge | 37 | $1,254.29 |
| L3901 | Wrist hand finger orthosis, dynamic flexor hinge | 36 | $1,503.91 |
| L3904 | Wrist hand finger orthosis, external powered, electric | 33 | $2,634.37 |
| L3905 | Wrist hand orthosis, includes one or more nontorsion joints | 34 | $851.66 |
| L3906 | Wrist hand orthosis, without joints | 38 | $350.11 |
| L3908 | Wrist hand orthosis, wrist extension control cock-up | 38 | $54.17 |
| L3912 | Hand finger orthosis (hfo) | 38 | $87.26 |
| L3913 | Hand finger orthosis, without joints | 35 | $233.29 |
| L3915 | Wrist hand orthosis, includes one or more nontorsion... | 34 | $441.99 |
| L3916 | Wrist hand orthosis, includes one or more nontorsion... | 32 | $441.99 |
| L3917 | Hand orthosis, metacarpal fracture orthosis | 36 | $90.73 |
| L3918 | Hand orthosis, metacarpal fracture orthosis, prefabricated | 34 | $87.34 |
| L3919 | Hand orthosis, without joints, may include soft interface | 34 | $233.59 |
| L3921 | Hand finger orthosis | 32 | $279.78 |
| L3923 | Hand finger orthosis, without joints | 36 | $78.96 |
| L3924 | Hand finger orthosis, without joints | 36 | $75.32 |
| L3925 | Finger orthosis, proximal interphalangeal | 38 | $47.33 |
| L3927 | Finger orthosis, proximal interphalangeal | 31 | $30.13 |
| L3929 | Hand finger orthosis | 37 | $77.39 |
| L3930 | Hand finger orthosis | 33 | $75.60 |
| L3931 | Wrist hand finger orthosis | 37 | $172.57 |
| L3933 | Finger orthosis, without joints, may include soft interface | 36 | $184.59 |
| L3935 | Finger orthosis, nontorsion joint | 32 | $190.55 |
| L3956 | Addition of joint to upper extremity orthosis, any material | 7 | $120.00 |
| L3960 | Shoulder elbow wrist hand orthosis, abduction positioning | 38 | $680.06 |
| L3961 | Shoulder elbow wrist hand orthosis, shoulder cap design | 32 | $1,449.05 |
| L3962 | Shoulder elbow wrist hand orthosis, abduction positioning | 37 | $645.44 |
| L3967 | Shoulder elbow wrist hand orthosis, abduction positioning | 32 | $1,715.97 |
| L3971 | Shoulder elbow wrist hand orthosis, shoulder cap design | 34 | $1,615.16 |
| L3973 | Shoulder elbow wrist hand orthosis, abduction positioning | 32 | $1,703.51 |
| L3975 | Shoulder elbow wrist hand finger orthosis | 33 | $1,459.59 |
| L3976 | Shoulder elbow wrist hand finger orthosis | 33 | $1,459.59 |
| L3977 | Shoulder elbow wrist hand finger orthosis | 33 | $1,635.80 |
| L3978 | Shoulder elbow wrist hand finger orthosis | 33 | $1,723.33 |
| L3980 | Upper extremity fracture orthosis, humeral, prefabricated | 39 | $288.06 |
| L3981 | Upper extremity fracture orthosis, humeral, prefabricated | 28 | $880.31 |
| L3982 | Upper extremity fracture orthosis, radius/ulnar | 39 | $326.98 |
| L3984 | Upper extremity fracture orthosis, wrist, prefabricated | 38 | $304.40 |
| L3995 | Addition to upper extremity orthosis, sock | 37 | $31.26 |
| L3999 | Upper limb orthosis, not otherwise specified | 7 | $500.00 |
| L4000 | Replace girdle for spinal orthosis (ctlso or so) | 38 | $1,141.57 |
| L4002 | Replacement strap, any orthosis, includes all components | 18 | $14.94 |
| L4010 | Replace trilateral socket brim | 39 | $636.58 |
| L4020 | Replace quadrilateral socket brim, molded to patient model | 38 | $840.63 |
| L4030 | Replace quadrilateral socket brim, custom fitted | 37 | $493.14 |
| L4040 | Replace molded thigh lacer | 37 | $378.74 |
| L4045 | Replace non-molded thigh lacer | 39 | $285.78 |
| L4050 | Orthotics and prosthetics | 39 | $379.52 |
| L4055 | Replace non-molded calf lacer | 39 | $227.33 |
| L4060 | Replace high roll cuff | 39 | $292.15 |
| L4070 | Replace proximal and distal upright for kafo | 39 | $258.71 |
| L4080 | Replace metal bands kafo, proximal thigh | 39 | $90.35 |
| L4090 | Replace metal bands kafo-afo, calf or distal thigh | 39 | $86.45 |
| L4100 | Replace leather cuff kafo, proximal thigh | 37 | $101.13 |
| L4110 | Replace leather cuff kafo-afo, calf or distal thigh | 39 | $77.96 |
| L4130 | Replace pretibial shell | 39 | $449.62 |
| L4205 | Repair of orthotic device, labor component, per 15 minutes | 35 | $20.94 |
| L4210 | Repair of orthotic device, repair or replace minor parts | 20 | $39.76 |
| L4350 | Ankle control orthosis, stirrup style, rigid | 36 | $84.41 |
| L4360 | Walking boot, pneumatic and/or vacuum | 37 | $251.57 |
| L4361 | Walking boot, pneumatic and/or vacuum | 35 | $235.63 |
| L4370 | Pneumatic full leg splint, prefabricated, off-the-shelf | 36 | $173.55 |
| L4386 | Walking boot, non-pneumatic, with or without joints | 37 | $145.65 |
| L4387 | Walking boot, non-pneumatic, with or without joints | 35 | $142.94 |
| L4392 | Replacement, soft interface material, static afo | 33 | $21.39 |
| L4394 | Replace soft interface material, foot drop splint | 34 | $16.02 |
| L4396 | Static or dynamic ankle foot orthosis | 39 | $152.61 |
| L4397 | Static or dynamic ankle foot orthosis | 34 | $150.17 |
| L4398 | Foot drop splint, recumbent positioning device | 37 | $70.55 |
| L4631 | Ankle foot orthosis, walking boot type | 34 | $1,409.99 |
| L5000 | Partial foot, shoe insert with longitudinal arch, toe filler | 39 | $516.94 |
| L5010 | Partial foot, molded socket, ankle height, with toe filler | 39 | $1,192.36 |
| L5020 | Partial foot, molded socket, tibial tubercle height | 39 | $1,968.70 |
| L5050 | Ankle, symes, molded socket, sach foot | 38 | $2,308.73 |
| L5060 | Ankle, symes, metal frame, molded leather socket | 37 | $2,705.10 |
| L5100 | Below knee, molded socket, shin, sach foot | 38 | $2,368.50 |
| L5105 | Below knee, plastic socket, joints and thigh lacer | 38 | $3,189.73 |
| L5150 | Knee disarticulation (or through knee), molded socket | 38 | $3,390.96 |
| L5160 | Knee disarticulation (or through knee), molded socket | 39 | $3,733.58 |
| L5200 | Above knee, molded socket | 38 | $3,251.71 |
| L5210 | Above knee, short prosthesis, no knee joint ('stubbies') | 39 | $2,398.41 |
| L5220 | Above knee, short prosthesis, no knee joint ('stubbies') | 38 | $2,701.42 |
| L5230 | Above knee, for proximal femoral focal deficiency | 38 | $3,578.96 |
| L5250 | Hip disarticulation, canadian type; molded socket | 39 | $4,834.98 |
| L5270 | Hip disarticulation, tilt table type; molded socket | 37 | $5,037.14 |
| L5280 | Hemipelvectomy, canadian type; molded socket, hip joint | 38 | $4,833.42 |
| L5301 | Below knee, molded socket, shin, sach foot | 38 | $2,415.27 |
| L5312 | Knee disarticulation (or through knee), molded socket | 34 | $3,654.33 |
| L5321 | Above knee, molded socket, open end, sach foot | 38 | $3,276.37 |
| L5331 | Hip disarticulation, canadian type, molded socket | 38 | $4,803.79 |
| L5341 | Hemipelvectomy, canadian type, molded socket | 37 | $5,180.31 |
| L5400 | Immediate post surgical or early fitting | 35 | $1,152.00 |
| L5410 | Immediate post surgical or early fitting | 34 | $414.97 |
| L5420 | Immediate post surgical or early fitting | 34 | $1,475.47 |
| L5430 | Immediate post surgical or early fitting | 32 | $491.41 |
| L5450 | Immediate post surgical or early fitting | 35 | $412.46 |
| L5460 | Immediate post surgical or early fitting | 34 | $534.56 |
| L5500 | Initial, below knee 'ptb' type socket, non-alignable system | 37 | $1,229.79 |
| L5505 | Initial, above knee - knee disarticulation | 38 | $1,686.78 |
| L5510 | Preparatory, below knee 'ptb' type socket | 37 | $1,425.87 |
| L5520 | Preparatory, below knee 'ptb' type socket | 38 | $1,408.42 |
| L5530 | Preparatory, below knee 'ptb' type socket | 39 | $1,782.78 |
| L5535 | Preparatory, below knee 'ptb' type socket | 39 | $1,660.87 |
| L5540 | Preparatory, below knee 'ptb' type socket | 39 | $1,802.89 |
| L5560 | Preparatory, above knee- knee disarticulation | 39 | $1,922.35 |
| L5570 | Preparatory, above knee - knee disarticulation | 37 | $2,064.54 |
| L5580 | Preparatory, above knee - knee disarticulation ischial level... | 39 | $2,333.19 |
| L5585 | Preparatory, above knee - knee disarticulation | 37 | $2,426.68 |
| L5590 | Preparatory, above knee - knee disarticulation ischial level... | 37 | $2,354.41 |
| L5595 | Preparatory, hip disarticulation-hemipelvectomy, pylon | 39 | $3,898.91 |
| L5600 | Preparatory, hip disarticulation-hemipelvectomy, pylon | 39 | $4,252.62 |
| L5610 | Addition to lower extremity, endoskeletal system | 37 | $2,027.73 |
| L5611 | Addition to lower extremity, endoskeletal system | 39 | $1,459.63 |
| L5613 | Addition to lower extremity, endoskeletal system | 38 | $2,283.14 |
| L5614 | Addition to lower extremity, exoskeletal system | 33 | $1,573.20 |
| L5615 | Addition, endoskeletal knee-shin system | 19 | $6,372.75 |
| L5616 | Addition to lower extremity, endoskeletal system | 39 | $1,273.53 |
| L5617 | Addition to lower extremity | 35 | $506.81 |
| L5618 | Addition to lower extremity, test socket, symes | 39 | $274.23 |
| L5620 | Addition to lower extremity, test socket, below knee | 38 | $272.61 |
| L5622 | Addition to lower extremity, test socket | 39 | $360.01 |
| L5624 | Addition to lower extremity, test socket, above knee | 38 | $356.06 |
| L5626 | Addition to lower extremity, test socket | 38 | $461.57 |
| L5628 | Addition to lower extremity, test socket, hemipelvectomy | 38 | $476.53 |
| L5629 | Addition to lower extremity, below knee, acrylic socket | 38 | $307.13 |
| L5630 | Addition to lower extremity, symes type | 39 | $443.28 |
| L5631 | Addition to lower extremity | 38 | $430.33 |
| L5632 | Addition to lower extremity, symes type | 39 | $217.46 |
| L5634 | Addition to lower extremity, symes type, posterior opening | 38 | $303.23 |
| L5636 | Addition to lower extremity, symes type | 39 | $241.98 |
| L5637 | Addition to lower extremity, below knee, total contact | 38 | $284.34 |
| L5638 | Addition to lower extremity, below knee, leather socket | 37 | $485.05 |
| L5639 | Addition to lower extremity, below knee, wood socket | 38 | $1,056.90 |
| L5640 | Addition to lower extremity, knee disarticulation | 39 | $654.87 |
| L5642 | Addition to lower extremity, above knee, leather socket | 39 | $606.80 |
| L5643 | Addition to lower extremity, hip disarticulation | 38 | $1,501.24 |
| L5644 | Addition to lower extremity, above knee, wood socket | 38 | $563.00 |
| L5645 | Addition to lower extremity, below knee | 39 | $748.18 |
| L5646 | Addition to lower extremity, below knee, air, fluid | 39 | $536.62 |
| L5647 | Addition to lower extremity, below knee suction socket | 39 | $752.41 |
| L5648 | Addition to lower extremity, above knee, air, fluid | 39 | $625.24 |
| L5649 | Addition to lower extremity | 37 | $1,864.71 |
| L5650 | Additions to lower extremity, total contact | 38 | $480.49 |
| L5651 | Addition to lower extremity, above knee | 38 | $1,176.18 |
| L5652 | Addition to lower extremity, suction suspension | 38 | $415.42 |
| L5653 | Addition to lower extremity, knee disarticulation | 39 | $570.01 |
| L5654 | Addition to lower extremity, socket insert, symes, (kemblo | 39 | $324.82 |
| L5655 | Addition to lower extremity, socket insert, below knee | 38 | $268.92 |
| L5656 | Addition to lower extremity, socket insert | 39 | $372.90 |
| L5658 | Addition to lower extremity, socket insert, above knee | 38 | $353.12 |
| L5661 | Addition to lower extremity, socket insert | 37 | $548.05 |
| L5665 | Addition to lower extremity, socket insert, multi-durometer | 38 | $476.29 |
| L5666 | Addition to lower extremity, below knee, cuff suspension | 39 | $67.40 |
| L5668 | Addition to lower extremity, below knee | 38 | $101.67 |
| L5670 | Addition to lower extremity, below knee | 38 | $267.07 |
| L5671 | Addition to lower extremity | 38 | $518.11 |
| L5672 | Addition to lower extremity, below knee | 38 | $285.05 |
| L5673 | Addition to lower extremity, below knee/above knee | 38 | $690.52 |
| L5676 | Additions to lower extremity, below knee, knee joints | 39 | $354.90 |
| L5677 | Additions to lower extremity, below knee, knee joints | 36 | $482.90 |
| L5678 | Additions to lower extremity, below knee, joint covers, pair | 39 | $38.89 |
| L5679 | Addition to lower extremity, below knee/above knee | 38 | $575.42 |
| L5680 | Addition to lower extremity, below knee, thigh lacer | 39 | $287.85 |
| L5681 | Addition to lower extremity, below knee/above knee | 38 | $1,195.06 |
| L5682 | Addition to lower extremity, below knee, thigh lacer | 39 | $566.57 |
| L5683 | Addition to lower extremity, below knee/above knee | 37 | $1,198.61 |
| L5684 | Addition to lower extremity, below knee, fork strap | 39 | $43.54 |
| L5685 | Addition to lower extremity prosthesis, below knee | 39 | $116.02 |
| L5686 | Addition to lower extremity, below knee, back check | 39 | $52.37 |
| L5688 | Addition to lower extremity, below knee, waist belt, webbing | 39 | $59.82 |
| L5690 | Addition to lower extremity, below knee, waist belt | 39 | $95.84 |
| L5692 | Addition to lower extremity, above knee | 39 | $128.00 |
| L5694 | Addition to lower extremity, above knee | 39 | $169.91 |
| L5695 | Addition to lower extremity, above knee, pelvic control | 38 | $156.32 |
| L5696 | Addition to lower extremity | 39 | $178.21 |
| L5697 | Addition to lower extremity | 39 | $78.62 |
| L5698 | Addition to lower extremity | 38 | $106.45 |
| L5699 | All lower extremity prostheses, shoulder harness | 37 | $182.61 |
| L5700 | Replacement, socket, below knee, molded to patient model | 38 | $2,752.42 |
| L5701 | Replacement, socket, above knee/knee disarticulation | 38 | $3,312.18 |
| L5702 | Replacement, socket, hip disarticulation | 38 | $4,271.72 |
| L5703 | Ankle, symes, molded to patient model | 34 | $2,191.62 |
| L5704 | Custom shaped protective cover, below knee | 38 | $515.97 |
| L5705 | Custom shaped protective cover, above knee | 38 | $913.48 |
| L5706 | Custom shaped protective cover, knee disarticulation | 38 | $929.50 |
| L5707 | Custom shaped protective cover, hip disarticulation | 37 | $1,293.36 |
| L5710 | Addition, exoskeletal knee-shin system, single axis | 39 | $343.25 |
| L5711 | Additions exoskeletal knee-shin system, single axis | 38 | $475.80 |
| L5712 | Addition, exoskeletal knee-shin system, single axis | 39 | $422.02 |
| L5714 | Addition, exoskeletal knee-shin system, single axis | 39 | $396.63 |
| L5716 | Addition, exoskeletal knee-shin system, polycentric | 39 | $702.23 |
| L5718 | Addition, exoskeletal knee-shin system, polycentric | 39 | $838.20 |
| L5722 | Addition, exoskeletal knee-shin system, single axis | 38 | $904.11 |
| L5724 | Addition, exoskeletal knee-shin system, single axis | 38 | $1,478.32 |
| L5726 | Addition, exoskeletal knee-shin system, single axis | 38 | $1,754.53 |
| L5728 | Addition, exoskeletal knee-shin system, single axis | 37 | $2,196.27 |
| L5780 | Addition, exoskeletal knee-shin system, single axis | 38 | $1,098.96 |
| L5781 | Addition to lower limb prosthesis, vacuum pump | 30 | $3,835.65 |
| L5782 | Addition to lower limb prosthesis, vacuum pump | 24 | $4,043.61 |
| L5783 | Addition to lower extremity, user adjustable, mechanical | 20 | $2,620.78 |
| L5785 | Addition, exoskeletal system, below knee | 37 | $508.85 |
| L5790 | Addition, exoskeletal system, above knee | 37 | $687.61 |
| L5795 | Addition, exoskeletal system, hip disarticulation | 37 | $1,051.57 |
| L5810 | Addition, endoskeletal knee-shin system, single axis | 39 | $460.66 |
| L5811 | Addition, endoskeletal knee-shin system, single axis | 37 | $682.38 |
| L5812 | Addition, endoskeletal knee-shin system, single axis | 39 | $553.65 |
| L5814 | Addition, endoskeletal knee-shin system, polycentric | 38 | $3,375.69 |
| L5816 | Addition, endoskeletal knee-shin system, polycentric | 39 | $784.72 |
| L5818 | Addition, endoskeletal knee-shin system, polycentric | 38 | $869.37 |
| L5822 | Addition, endoskeletal knee-shin system, single axis | 37 | $1,617.20 |
| L5824 | Addition, endoskeletal knee-shin system, single axis | 38 | $1,505.33 |
| L5826 | Addition, endoskeletal knee-shin system, single axis | 35 | $2,911.46 |
| L5827 | Endoskeletal knee-shin system, single axis | 14 | $6,869.77 |
| L5828 | Addition, endoskeletal knee-shin system, single axis | 38 | $2,678.09 |
| L5830 | Addition, endoskeletal knee-shin system, single axis | 38 | $1,797.60 |
| L5840 | Addition, endoskeletal knee/shin system | 36 | $3,407.97 |
| L5841 | Addition, endoskeletal knee-shin system, polycentric | 18 | $2,786.79 |
| L5845 | Addition, endoskeletal, knee-shin system | 38 | $1,642.34 |
| L5848 | Addition to endoskeletal knee-shin system | 35 | $1,002.52 |
| L5850 | Addition, endoskeletal system | 38 | $118.83 |
| L5855 | Addition, endoskeletal system, hip disarticulation | 37 | $294.64 |
| L5856 | Addition to lower extremity prosthesis | 26 | $22,688.38 |
| L5857 | Addition to lower extremity prosthesis | 26 | $7,855.28 |
| L5858 | Addition to lower extremity prosthesis | 24 | $17,571.43 |
| L5859 | Addition to lower extremity prosthesis | 17 | $14,493.42 |
| L5910 | Addition, endoskeletal system, below knee, alignable system | 38 | $339.58 |
| L5920 | Addition, endoskeletal system | 38 | $492.87 |
| L5925 | Addition, endoskeletal system, above knee | 37 | $360.83 |
| L5926 | Addition to lower extremity prosthesis, endoskeletal | 22 | $763.41 |
| L5930 | Addition, endoskeletal system | 36 | $3,118.23 |
| L5940 | Addition, endoskeletal system, below knee | 38 | $493.71 |
| L5950 | Addition, endoskeletal system, above knee | 38 | $762.59 |
| L5960 | Addition, endoskeletal system, hip disarticulation | 38 | $960.12 |
| L5961 | Addition, endoskeletal system, polycentric hip joint | 22 | $4,664.83 |
| L5962 | Addition, endoskeletal system, below knee | 37 | $600.07 |
| L5964 | Addition, endoskeletal system, above knee | 37 | $926.29 |
| L5966 | Addition, endoskeletal system, hip disarticulation | 37 | $1,251.43 |
| L5968 | Addition to lower limb prosthesis | 35 | $3,291.70 |
| L5969 | Addition, endoskeletal ankle-foot or ankle system | 12 | $12,718.72 |
| L5970 | All lower extremity prostheses, foot, external keel | 39 | $195.05 |
| L5971 | All lower extremity prosthesis, solid ankle cushion heel | 36 | $208.56 |
| L5972 | All lower extremity prostheses, foot, flexible keel | 38 | $367.39 |
| L5973 | Endoskeletal ankle foot system | 19 | $17,039.95 |
| L5974 | All lower extremity prostheses, foot, single axis ankle/foot | 38 | $226.37 |
| L5975 | All lower extremity prosthesis | 39 | $419.93 |
| L5976 | All lower extremity prostheses, energy storing foot | 38 | $548.49 |
| L5978 | All lower extremity prostheses, foot, multiaxial ankle/foot | 38 | $285.82 |
| L5979 | All lower extremity prosthesis, multi-axial ankle | 38 | $2,264.36 |
| L5980 | All lower extremity prostheses, flex foot system | 37 | $3,631.32 |
| L5981 | All lower extremity prostheses, flex-walk system or equal | 38 | $2,945.38 |
| L5982 | All exoskeletal lower extremity prostheses | 38 | $566.20 |
| L5984 | All endoskeletal lower extremity prosthesis | 38 | $569.80 |
| L5985 | All endoskeletal lower extremity prostheses | 39 | $255.80 |
| L5986 | All lower extremity prostheses, multi-axial rotation unit | 38 | $625.35 |
| L5987 | All lower extremity prosthesis | 36 | $6,535.63 |
| L5988 | Addition to lower limb prosthesis | 38 | $1,807.03 |
| L5990 | Addition to lower extremity prosthesis | 33 | $1,670.05 |
| L5991 | Addition to lower extremity prostheses | 16 | $9,638.18 |
| L5992 | All lower extremity prosthesis | 16 | $114.40 |
| L6000 | Partial hand, thumb remaining | 18 | $1,205.10 |
| L6010 | Partial hand, little and/or ring finger remaining | 18 | $1,272.64 |
| L6020 | Partial hand, no finger remaining | 18 | $1,242.55 |
| L6026 | Transcarpal/metacarpal or partial hand disarticulation... | 26 | $4,521.49 |
| L6028 | Partial hand, finger | 13 | $1,693.00 |
| L6029 | Upper extremity addition, test socket/interface | 7 | $300.81 |
| L6030 | Upper extremity addition, external frame | 7 | $626.77 |
| L6031 | Replacement socket/interface | 7 | $1,535.20 |
| L6032 | Addition to upper extremity prosthesis | 7 | $354.53 |
| L6033 | Addition to upper extremity prosthesis | 7 | $442.58 |
| L6034 | Partial hand, finger | 6 | $405.74 |
| L6035 | Single prosthetic digit, mechanical | 5 | $1,614.12 |
| L6036 | Prosthetic thumb, mechanical | 5 | $1,600.31 |
| L6037 | Immediate post-surgical or early fitting | 7 | $1,360.55 |
| L6038 | Addition to single prosthetic digit or thumb, mechanical | 6 | $332.79 |
| L6039 | Passive prosthetic digit or thumb prosthesis not including... | 6 | $1,628.46 |
| L6050 | Wrist disarticulation, molded socket, flexible elbow hinges | 39 | $1,860.48 |
| L6055 | Wrist disarticulation | 39 | $2,593.04 |
| L6100 | Below elbow, molded socket, flexible elbow hinge | 38 | $1,952.13 |
| L6110 | Below elbow, molded socket, | 39 | $2,100.80 |
| L6120 | Below elbow, molded double wall split socket | 39 | $2,329.91 |
| L6130 | Below elbow, molded double wall split socket | 39 | $2,535.38 |
| L6200 | Elbow disarticulation, molded socket, outside locking hinge | 39 | $2,671.88 |
| L6205 | Elbow disarticulation | 39 | $3,566.54 |
| L6250 | Above elbow, molded double wall socket | 38 | $2,712.21 |
| L6300 | Shoulder disarticulation, molded socket, shoulder bulkhead | 39 | $3,648.87 |
| L6310 | Shoulder disarticulation, passive restoration | 38 | $2,813.11 |
| L6320 | Shoulder disarticulation, passive restoration | 38 | $1,589.66 |
| L6350 | Interscapular thoracic, molded socket, shoulder bulkhead | 39 | $3,836.23 |
| L6360 | Interscapular thoracic, passive restoration | 38 | $2,932.93 |
| L6370 | Interscapular thoracic, passive restoration | 38 | $1,903.78 |
| L6380 | Immediate post surgical or early fitting | 35 | $1,186.56 |
| L6382 | Immediate post surgical or early fitting | 35 | $1,473.35 |
| L6384 | Immediate post surgical or early fitting | 35 | $1,875.23 |
| L6386 | Immediate post surgical or early fitting | 34 | $390.23 |
| L6388 | Immediate post surgical or early fitting | 35 | $430.57 |
| L6400 | Below elbow, molded socket, endoskeletal system | 38 | $2,274.99 |
| L6450 | Elbow disarticulation, molded socket, endoskeletal system | 39 | $2,844.80 |
| L6500 | Above elbow, molded socket, endoskeletal system | 38 | $2,923.58 |
| L6550 | Shoulder disarticulation, molded socket | 39 | $3,312.65 |
| L6570 | Interscapular thoracic, molded socket, endoskeletal system | 39 | $4,269.19 |
| L6580 | Preparatory, wrist disarticulation or below elbow | 37 | $1,581.77 |
| L6582 | Preparatory, wrist disarticulation or below elbow | 38 | $1,329.70 |
| L6584 | Preparatory, elbow disarticulation or above elbow | 37 | $2,032.61 |
| L6586 | Preparatory, elbow disarticulation or above elbow | 37 | $1,877.12 |
| L6588 | Preparatory, shoulder disarticulation or interscapular... | 37 | $2,858.52 |
| L6590 | Preparatory, shoulder disarticulation or interscapular... | 38 | $2,663.65 |
| L6600 | Upper extremity additions, polycentric hinge, pair | 38 | $188.80 |
| L6605 | Upper extremity additions, single pivot hinge, pair | 39 | $181.40 |
| L6610 | Upper extremity additions, flexible metal hinge, pair | 39 | $162.20 |
| L6611 | Addition to upper extremity prosthesis, external powered | 31 | $375.52 |
| L6615 | Upper extremity addition, disconnect locking wrist unit | 39 | $173.98 |
| L6616 | Upper extremity addition | 38 | $64.18 |
| L6620 | Upper extremity addition, flexion/extension wrist unit | 39 | $300.31 |
| L6621 | Upper extremity prosthesis addition | 31 | $2,169.03 |
| L6623 | Upper extremity addition | 37 | $650.11 |
| L6624 | Upper extremity addition | 33 | $3,431.67 |
| L6625 | Upper extremity addition | 39 | $495.19 |
| L6628 | Upper extremity addition, quick disconnect hook adapter | 38 | $462.06 |
| L6629 | Upper extremity addition | 38 | $144.00 |
| L6630 | Upper extremity addition, stainless steel, any wrist | 39 | $198.30 |
| L6632 | Upper extremity addition, latex suspension sleeve, each | 37 | $59.49 |
| L6635 | Upper extremity addition, lift assist for elbow | 38 | $180.69 |
| L6637 | Upper extremity addition, nudge control elbow lock | 38 | $367.89 |
| L6638 | Upper extremity addition to prosthesis | 30 | $2,298.33 |
| L6640 | Upper extremity additions, shoulder abduction joint, pair | 39 | $287.30 |
| L6641 | Upper extremity addition, excursion amplifier, pulley type | 38 | $159.20 |
| L6642 | Upper extremity addition, excursion amplifier, lever type | 38 | $214.39 |
| L6645 | Upper extremity addition, shoulder flexion-abduction joint | 39 | $323.00 |
| L6646 | Upper extremity addition, shoulder joint | 29 | $2,940.45 |
| L6647 | Upper extremity addition, shoulder lock mechanism | 32 | $481.02 |
| L6648 | Upper extremity addition, shoulder lock mechanism | 27 | $3,066.24 |
| L6650 | Upper extremity addition, shoulder universal joint, each | 39 | $331.51 |
| L6655 | Upper extremity addition, standard control cable, extra | 39 | $72.00 |
| L6660 | Upper extremity addition, heavy duty control cable | 39 | $89.90 |
| L6665 | Upper extremity addition, teflon, or equal, cable lining | 39 | $45.10 |
| L6670 | Upper extremity addition, hook to hand, cable adapter | 39 | $46.91 |
| L6672 | Upper extremity addition, harness, chest or shoulder | 39 | $168.29 |
| L6675 | Upper extremity addition, harness, (e.g. | 39 | $108.79 |
| L6676 | Upper extremity addition, harness, (e.g. | 38 | $118.87 |
| L6677 | Upper extremity addition, harness, triple control | 32 | $281.68 |
| L6680 | Upper extremity addition, test socket | 39 | $227.22 |
| L6682 | Upper extremity addition, test socket | 39 | $254.66 |
| L6684 | Upper extremity addition, test socket | 38 | $337.35 |
| L6686 | Upper extremity addition, suction socket | 39 | $611.75 |
| L6687 | Upper extremity addition, frame type socket | 39 | $530.73 |
| L6688 | Upper extremity addition, frame type socket | 39 | $546.47 |
| L6689 | Upper extremity addition, frame type socket | 38 | $676.10 |
| L6690 | Upper extremity addition, frame type socket | 39 | $714.06 |
| L6691 | Upper extremity addition, removable insert, each | 39 | $320.33 |
| L6692 | Upper extremity addition, silicone gel insert or equal | 39 | $524.38 |
| L6693 | Upper extremity addition, locking elbow | 37 | $2,571.65 |
| L6694 | Addition to upper extremity prosthesis | 37 | $692.96 |
| L6695 | Addition to upper extremity prosthesis | 34 | $578.88 |
| L6696 | Addition to upper extremity prosthesis | 33 | $1,249.47 |
| L6697 | Addition to upper extremity prosthesis | 31 | $1,258.08 |
| L6698 | Addition to upper extremity prosthesis, lock mechanism | 37 | $534.16 |
| L6700 | Upper extremity addition, external powered feature | 11 | $28,931.56 |
| L6703 | Terminal device, passive hand/mitt, any material, any size | 36 | $328.90 |
| L6704 | Terminal device, sport/recreational/work attachment | 29 | $604.84 |
| L6706 | Terminal device, hook, mechanical, voluntary opening | 37 | $350.80 |
| L6707 | Terminal device, hook, mechanical, voluntary closing | 35 | $1,269.98 |
| L6708 | Terminal device, hand, mechanical, voluntary opening | 36 | $834.12 |
| L6709 | Terminal device, hand, mechanical, voluntary closing | 34 | $1,192.44 |
| L6711 | Terminal device, hook, mechanical, voluntary opening | 34 | $612.90 |
| L6712 | Terminal device, hook, mechanical, voluntary closing | 32 | $1,128.50 |
| L6713 | Terminal device, hand, mechanical, voluntary opening | 32 | $1,430.84 |
| L6714 | Terminal device, hand, mechanical, voluntary closing | 32 | $1,211.91 |
| L6715 | Terminal device, multiple articulating digit | 15 | $3,269.50 |
| L6721 | Terminal device, hook or hand, heavy duty, mechanical | 34 | $2,154.03 |
| L6722 | Terminal device, hook or hand, heavy duty, mechanical | 34 | $1,877.45 |
| L6805 | Addition to terminal device, modifier wrist unit | 37 | $341.26 |
| L6810 | Addition to terminal device, precision pinch device | 38 | $186.73 |
| L6880 | Electric hand, switch or myoelectric controlled | 14 | $25,290.44 |
| L6881 | Automatic grasp feature | 28 | $3,832.56 |
| L6882 | Microprocessor control feature | 28 | $2,907.17 |
| L6883 | Replacement socket, below elbow/wrist disarticulation | 34 | $1,693.60 |
| L6884 | Replacement socket, above elbow/elbow disarticulation | 31 | $2,399.92 |
| L6885 | Replacement socket, shoulder disarticulation/interscapular... | 31 | $3,149.34 |
| L6890 | Addition to upper extremity prosthesis | 38 | $169.55 |
| L6895 | Addition to upper extremity prosthesis | 35 | $570.44 |
| L6900 | Hand restoration (casts, shading and measurements included) | 37 | $1,521.10 |
| L6905 | Hand restoration (casts, shading and measurements included) | 37 | $1,502.96 |
| L6910 | Hand restoration (casts, shading and measurements included) | 37 | $1,486.91 |
| L6915 | Hand restoration (shading, and measurements included) | 37 | $608.32 |
| L6920 | Wrist disarticulation, external power | 28 | $6,968.56 |
| L6925 | Wrist disarticulation, external power | 28 | $7,813.77 |
| L6930 | Below elbow, external power, self-suspended inner socket | 28 | $6,912.53 |
| L6935 | Below elbow, external power, self-suspended inner socket | 29 | $8,185.84 |
| L6940 | Elbow disarticulation, external power, molded inner socket | 28 | $8,692.80 |
| L6945 | Elbow disarticulation, external power, molded inner socket | 28 | $10,014.94 |
| L6950 | Above elbow, external power, molded inner socket | 28 | $9,452.70 |
| L6955 | Above elbow, external power, molded inner socket | 28 | $11,387.14 |
| L6960 | Shoulder disarticulation, external power | 28 | $11,818.18 |
| L6965 | Shoulder disarticulation, external power | 28 | $14,086.35 |
| L6970 | Interscapular-thoracic, external power, molded inner socket | 28 | $14,692.19 |
| L6975 | Interscapular-thoracic, external power, molded inner socket | 28 | $15,795.76 |
| L7007 | Electric hand, switch or myoelectric controlled, adult | 27 | $3,397.40 |
| L7008 | Electric hand, switch or myoelectric, controlled, pediatric | 27 | $5,559.86 |
| L7009 | Electric hook, switch or myoelectric controlled, adult | 28 | $3,455.20 |
| L7040 | Prehensile actuator, switch controlled | 29 | $2,771.41 |
| L7045 | Electric hook, switch or myoelectric controlled, pediatric | 29 | $1,551.99 |
| L7170 | Electronic elbow, hosmer or equal, switch controlled | 29 | $5,692.81 |
| L7180 | Electronic elbow, microprocessor sequential control of elbow... | 26 | $33,724.03 |
| L7181 | Electronic elbow, microprocessor simultaneous control of... | 20 | $38,045.79 |
| L7185 | Electronic elbow, adolescent, variety village or equal | 28 | $5,890.45 |
| L7186 | Electronic elbow, child, variety village or equal | 29 | $8,663.31 |
| L7190 | Electronic elbow, adolescent, variety village or equal | 27 | $7,646.16 |
| L7191 | Electronic elbow, child, variety village or equal | 28 | $9,295.74 |
| L7259 | Electronic wrist rotator, any type | 24 | $3,639.73 |
| L7360 | Six volt battery, each | 30 | $232.20 |
| L7362 | Battery charger, six volt, each | 31 | $248.19 |
| L7364 | Twelve volt battery, each | 29 | $455.32 |
| L7366 | Battery charger, twelve volt, each | 29 | $613.32 |
| L7367 | Lithium ion battery, rechargeable, replacement | 27 | $362.97 |
| L7368 | Lithium ion battery charger, replacement only | 30 | $460.87 |
| L7400 | Addition to upper extremity prosthesis | 37 | $285.74 |
| L7401 | Addition to upper extremity prosthesis | 33 | $312.93 |
| L7402 | Addition to upper extremity prosthesis | 33 | $349.28 |
| L7403 | Addition to upper extremity prosthesis | 37 | $338.98 |
| L7404 | Addition to upper extremity prosthesis | 35 | $511.66 |
| L7405 | Addition to upper extremity prosthesis | 34 | $681.47 |
| L7406 | Addition to upper extremity prosthesis, user adjustable | 14 | $2,917.70 |
| L7510 | Repair of prosthetic device, repair or replace minor parts | 19 | $38.06 |
| L7520 | Repair prosthetic device, labor component, per 15 minutes | 32 | $20.82 |
| L7600 | Prosthetic donning sleeve, any material, each | 5 | $61.44 |
| L7700 | Gasket or seal, for use with prosthetic socket insert | 29 | $126.27 |
| L7900 | Male vacuum erection system | 6 | $458.97 |
| L8000 | Breast prosthesis, mastectomy bra | 39 | $34.96 |
| L8001 | Breast prosthesis, mastectomy bra | 34 | $116.21 |
| L8002 | Breast prosthesis, mastectomy bra | 34 | $152.83 |
| L8010 | Breast prosthesis, mastectomy sleeve | 13 | $45.26 |
| L8015 | External breast prosthesis garment, with mastectomy form | 36 | $55.51 |
| L8020 | Breast prosthesis, mastectomy form | 39 | $205.52 |
| L8030 | Breast prosthesis, silicone or equal | 39 | $299.08 |
| L8031 | Breast prosthesis, silicone or equal | 25 | $317.14 |
| L8032 | Nipple prosthesis, prefabricated, reusable, any type, each | 22 | $38.26 |
| L8035 | Custom breast prosthesis, post mastectomy | 29 | $3,474.16 |
| L8040 | Nasal prosthesis, provided by a non-physician | 21 | $2,301.47 |
| L8041 | Midfacial prosthesis, provided by a non-physician | 22 | $2,724.67 |
| L8042 | Orbital prosthesis, provided by a non-physician | 23 | $3,005.75 |
| L8043 | Upper facial prosthesis, provided by a non-physician | 21 | $3,491.10 |
| L8044 | Hemi-facial prosthesis, provided by a non-physician | 21 | $3,865.14 |
| L8045 | Auricular prosthesis, provided by a non-physician | 20 | $2,534.74 |
| L8046 | Partial facial prosthesis, provided by a non-physician | 21 | $2,404.59 |
| L8047 | Nasal septal prosthesis, provided by a non-physician | 22 | $1,255.16 |
| L8049 | Repair or modification of maxillofacial prosthesis | 11 | $20.75 |
| L8300 | Truss, single with standard pad | 37 | $77.40 |
| L8310 | Truss, double with standard pads | 38 | $132.76 |
| L8320 | Truss, addition to standard pad, water pad | 37 | $52.35 |
| L8330 | Truss, addition to standard pad, scrotal pad | 36 | $47.32 |
| L8400 | Prosthetic sheath, below knee, each | 38 | $15.93 |
| L8410 | Prosthetic sheath, above knee, each | 38 | $20.23 |
| L8415 | Prosthetic sheath, upper limb, each | 39 | $19.89 |
| L8417 | Prosthetic sheath/sock, including a gel cushion layer | 36 | $68.00 |
| L8420 | Prosthetic sock, multiple ply, below knee, each | 38 | $19.09 |
| L8430 | Prosthetic sock, multiple ply, above knee, each | 38 | $21.56 |
| L8435 | Prosthetic sock, multiple ply, upper limb, each | 39 | $20.45 |
| L8440 | Prosthetic shrinker, below knee, each | 39 | $40.11 |
| L8460 | Prosthetic shrinker, above knee, each | 38 | $62.83 |
| L8465 | Prosthetic shrinker, upper limb, each | 39 | $46.32 |
| L8470 | Prosthetic sock, single ply, fitting, below knee, each | 38 | $6.20 |
| L8480 | Prosthetic sock, single ply, fitting, above knee, each | 38 | $9.02 |
| L8485 | Prosthetic sock, single ply, fitting, upper limb, each | 38 | $10.93 |
| L8500 | Artificial larynx, any type | 35 | $621.49 |
| L8501 | Tracheostomy speaking valve | 38 | $114.39 |
| L8505 | Artificial larynx replacement battery / accessory, any type | 9 | $49.40 |
| L8507 | Tracheo-esophageal voice prosthesis, patient inserted | 25 | $38.55 |
| L8509 | Tracheo-esophageal voice prosthesis | 25 | $99.60 |
| L8510 | Voice amplifier | 23 | $238.19 |
| L8511 | Insert for indwelling tracheoesophageal prosthesis | 22 | $69.65 |
| L8512 | Gelatin capsules or equivalent | 19 | $2.03 |
| L8513 | Cleaning device used with tracheoesophageal voice... | 20 | $4.95 |
| L8514 | Tracheoesophageal puncture dilator, replacement only, each | 19 | $88.87 |
| L8515 | Gelatin capsule, application device for use with... | 23 | $58.09 |
| L8600 | Implantable breast prosthesis, silicone or equal | 12 | $644.07 |
| L8603 | Injectable bulking agent, collagen implant, urinary tract | 17 | $413.78 |
| L8605 | Injectable bulking agent | 12 | $638.85 |
| L8606 | Injectable bulking agent, synthetic implant, urinary tract | 15 | $214.47 |
| L8607 | Injectable bulking agent for vocal cord medialization | 11 | $41.17 |
| L8609 | Artificial cornea | 14 | $6,244.06 |
| L8610 | Ocular implant | 14 | $618.66 |
| L8612 | Aqueous shunt | 14 | $657.54 |
| L8613 | Ossicula implant | 12 | $290.85 |
| L8614 | Cochlear device, includes all internal and external... | 22 | $18,474.93 |
| L8615 | Headset/headpiece for use with cochlear implant device | 36 | $409.85 |
| L8616 | Microphone for use with cochlear implant device, replacement | 36 | $96.21 |
| L8617 | Transmitting coil for use with cochlear implant device | 37 | $83.15 |
| L8618 | Transmitter cable for use with cochlear implant device or... | 37 | $23.77 |
| L8619 | Cochlear implant, external speech processor and controller | 36 | $7,589.89 |
| L8621 | Zinc air battery for use with cochlear implant device and... | 35 | $0.58 |
| L8622 | Alkaline battery for use with cochlear implant device | 34 | $0.30 |
| L8623 | Lithium ion battery for use with cochlear implant device... | 34 | $58.61 |
| L8624 | Lithium ion battery for use with cochlear implant or... | 35 | $146.08 |
| L8625 | External recharging system for battery for use with cochlear... | 27 | $185.17 |
| L8627 | Cochlear implant, external speech processor, component | 31 | $6,379.13 |
| L8628 | Cochlear implant, external controller component, replacement | 32 | $1,129.23 |
| L8629 | Transmitting coil and cable, integrated | 31 | $164.82 |
| L8630 | Metacarpophalangeal joint implant | 11 | $323.49 |
| L8631 | Metacarpal phalangeal joint replacement, two or more pieces | 10 | $2,151.77 |
| L8641 | Metatarsal joint implant | 11 | $364.27 |
| L8642 | Hallux implant | 11 | $301.59 |
| L8658 | Interphalangeal joint spacer, silicone or equal, each | 12 | $354.49 |
| L8659 | Interphalangeal finger joint replacement, 2 or more pieces | 10 | $1,900.41 |
| L8670 | Vascular graft material, synthetic, implant | 10 | $552.73 |
| L8678 | Electrical stimulator supplies | 12 | $12.76 |
| L8679 | Implantable neurostimulator, pulse generator, any type | 17 | $8,676.97 |
| L8680 | Implantable neurostimulator electrode, each | 10 | $390.45 |
| L8681 | Patient programmer (external) for use with implantable... | 13 | $1,106.51 |
| L8682 | Implantable neurostimulator radiofrequency receiver | 12 | $6,018.63 |
| L8683 | Radiofrequency transmitter | 12 | $5,502.64 |
| L8684 | Radiofrequency transmitter | 14 | $784.19 |
| L8685 | Implantable neurostimulator pulse generator, single array | 9 | $11,940.07 |
| L8686 | Implantable neurostimulator pulse generator, single array | 10 | $7,604.19 |
| L8687 | Implantable neurostimulator pulse generator, dual array | 9 | $15,479.58 |
| L8688 | Implantable neurostimulator pulse generator, dual array | 9 | $9,877.22 |
| L8689 | External recharging system for battery | 14 | $1,594.24 |
| L8690 | Auditory osseointegrated device | 17 | $4,543.97 |
| L8691 | Auditory osseointegrated device, external sound processor | 34 | $1,798.22 |
| L8692 | Auditory osseointegrated device, external sound processor | 17 | $2,649.18 |
| L8693 | Auditory osseointegrated device abutment, any length | 22 | $1,422.05 |
| L8694 | Auditory osseointegrated device, transducer/actuator | 32 | $915.64 |
| L8695 | External recharging system for battery | 15 | $14.43 |
| L8696 | Antenna (external) for use with implantable... | 13 | $204.30 |
| L8701 | Powered upper extremity range of motion assist device | 7 | $29,298.32 |
| L8702 | Powered upper extremity range of motion assist device | 7 | $57,642.76 |
| Q0477 | Power module patient cable for use with electric or... | 14 | $768.43 |
| Q0480 | Driver for use with pneumatic ventricular assist device | 10 | $92,211.51 |
| Q0481 | Microprocessor control unit for use with electric... | 12 | $14,877.25 |
| Q0482 | Microprocessor control unit for use with electric/pneumatic... | 11 | $4,593.63 |
| Q0483 | Monitor/display module for use with electric ventricular... | 11 | $18,923.59 |
| Q0484 | Monitor/display module for use with electric or... | 11 | $3,674.89 |
| Q0485 | Monitor control cable for use with electric ventricular... | 11 | $354.79 |
| Q0486 | Monitor control cable for use with electric/pneumatic... | 11 | $295.30 |
| Q0487 | Leads (pneumatic/electrical) for use with any type... | 11 | $344.51 |
| Q0489 | Power pack base for use with electric/pneumatic ventricular... | 11 | $16,405.71 |
| Q0490 | Emergency power source for use with electric ventricular... | 10 | $696.44 |
| Q0491 | Emergency power source for use with electric/pneumatic... | 10 | $1,094.87 |
| Q0492 | Emergency power supply cable for use with electric... | 10 | $88.19 |
| Q0493 | Emergency power supply cable for use with electric/pneumatic... | 10 | $251.18 |
| Q0494 | Emergency hand pump for use with electric or... | 10 | $212.55 |
| Q0495 | Battery/power pack charger for use with electric or... | 10 | $4,137.40 |
| Q0496 | Battery, other than lithium-ion | 12 | $1,449.04 |
| Q0497 | Battery clips for use with electric or electric/pneumatic... | 11 | $486.12 |
| Q0498 | Holster for use with electric or electric/pneumatic... | 11 | $533.40 |
| Q0499 | Belt/vest/bag for use to carry external peripheral... | 11 | $173.30 |
| Q0500 | Filters for use with electric or electric/pneumatic... | 10 | $34.22 |
| Q0501 | Shower cover for use with electric or electric/pneumatic... | 11 | $530.28 |
| Q0502 | Mobility cart for pneumatic ventricular assist device | 10 | $643.99 |
| Q0503 | Battery for pneumatic ventricular assist device | 10 | $1,288.03 |
| Q0504 | Power adapter for pneumatic ventricular assist device | 10 | $679.66 |
| Q4012 | Cast supplies, short arm cast, pediatric (0-10 years) | 18 | $10.05 |
| Q4020 | Cast supplies, long arm splint, pediatric (0-10 years) | 19 | $7.55 |
| Q4049 | Finger splint, static | 19 | $2.19 |
| Q4102 | Oasis wound matrix, per square centimeter (add-on | 27 | $12.07 |
| Q4103 | Oasis burn matrix, per square centimeter (add-on | 19 | $12.59 |
| Q4104 | Integra bilayer matrix wound dressing (bmwd) | 23 | $51.00 |
| Q4105 | Integra dermal regeneration template | 23 | $30.28 |
| Q4107 | Graftjacket, per square centimeter (add-on | 21 | $91.83 |
| Q4108 | Integra matrix, per square centimeter (add-on | 20 | $46.98 |
| Q4110 | Primatrix, per square centimeter (add-on | 19 | $65.41 |
| Q4111 | Gammagraft, per square centimeter (add-on | 18 | $7.87 |
| Q4115 | Alloskin, per square centimeter (add-on | 16 | $15.73 |
| Q4116 | Alloderm, per square centimeter (add-on | 19 | $36.69 |
| Q4121 | Theraskin, per square centimeter (add-on | 28 | $49.50 |
| Q4122 | Dermacell, dermacell awm or dermacell awm porous | 6 | $82.32 |
| Q4123 | Alloskin rt, per square centimeter (add-on | 14 | $71.55 |
| Q4124 | Oasis ultra tri-layer wound matrix, per square centimeter | 18 | $10.22 |
| Q4126 | Memoderm, dermaspan, tranzgraft or integuply | 12 | $62.41 |
| Q4127 | Talymed, per square centimeter (add-on | 12 | $68.49 |
| Q4143 | Repriza, per square centimeter (add-on | 11 | $33.92 |
| Q4150 | Allowrap ds or dry, per square centimeter (add-on | 12 | $80.08 |
| Q4152 | Dermapure, per square centimeter (add-on | 12 | $50.72 |
| Q4175 | Miroderm, per square centimeter (add-on | 11 | $81.15 |
| Q4201 | Matrion, per square centimeter (add-on | 11 | $83.49 |
| Q4209 | Surgraft, per square centimeter (add-on | 5 | $83.49 |
| Q4211 | Amnion bio or axobiomembrane, per square centimeter (add-on | 5 | $83.49 |
| Q4214 | Cellesta cord, per square centimeter (add-on | 5 | $83.49 |
| Q4216 | Artacent cord, per square centimeter (add-on | 5 | $83.49 |
| Q4218 | Surgicord, per square centimeter (add-on | 5 | $83.49 |
| Q4219 | Surgigraft-dual, per square centimeter (add-on | 5 | $83.49 |
| Q4220 | Bellacell hd or surederm, per square centimeter (add-on | 5 | $83.49 |
| Q4258 | Enverse, per square centimeter (add-on | 10 | $78.81 |
| Q4272 | Esano a, per square centimeter (add-on | 5 | $83.49 |
| Q4273 | Esano aaa, per square centimeter (add-on | 5 | $83.49 |
| Q4284 | Dermabind sl, per square centimeter (add-on | 5 | $83.49 |
| S1015 | Iv tubing extension set | 7 | $4.48 |
| S1040 | Cranial remolding orthosis, pediatric, rigid | 28 | $2,043.70 |
| S5498 | Home infusion therapy, catheter care / maintenance, simple | 8 | $8.50 |
| S5501 | Home infusion therapy, catheter care / maintenance, complex | 8 | $8.82 |
| S5502 | Home infusion therapy, catheter care / maintenance | 5 | $10.00 |
| S5521 | Home infusion therapy, all supplies | 7 | $85.00 |
| S5561 | Insulin delivery device, reusable pen; 3 ml size | 5 | $29.86 |
| S8101 | Holding chamber or spacer for use with an inhaler or... | 9 | $28.03 |
| S8265 | Haberman feeder for cleft lip/palate | 13 | $19.28 |
| S8270 | Enuresis alarm, using auditory buzzer and/or vibration... | 7 | $54.00 |
| S8415 | Supplies for home delivery of infant | 8 | $209.76 |
| S8421 | Gradient pressure aid (sleeve and glove combination) | 8 | $75.09 |
| S8424 | Gradient pressure aid (sleeve), ready made | 9 | $50.00 |
| S8427 | Gradient pressure aid (glove), ready made | 9 | $70.00 |
| S8428 | Gradient pressure aid (gauntlet), ready made | 8 | $35.91 |
| S8451 | Splint, prefabricated, wrist or ankle | 5 | $16.05 |
| S8490 | Insulin syringes (100 syringes, any size) | 11 | $22.65 |
| S9001 | Home uterine monitor with or without associated nursing... | 6 | $62.28 |
| S9326 | Home infusion therapy, continuous | 9 | $37.65 |
| S9327 | Home infusion therapy, intermittent | 8 | $33.89 |
| S9328 | Home infusion therapy | 6 | $40.95 |
| S9330 | Home infusion therapy, continuous | 9 | $46.68 |
| S9331 | Home infusion therapy, intermittent | 8 | $48.34 |
| S9336 | Home infusion therapy | 7 | $44.86 |
| S9338 | Home infusion therapy, immunotherapy | 9 | $51.51 |
| S9346 | Home infusion therapy, alpha-1-proteinase inhibitor (e.g. | 7 | $44.86 |
| S9347 | Home infusion therapy, uninterrupted, long-term | 6 | $47.43 |
| S9348 | Home infusion therapy | 7 | $72.79 |
| S9351 | Home infusion therapy | 9 | $44.86 |
| S9355 | Home infusion therapy, chelation therapy | 8 | $58.90 |
| S9359 | Home infusion therapy | 6 | $73.01 |
| S9361 | Home infusion therapy, diuretic intravenous therapy | 5 | $72.79 |
| S9365 | Home infusion therapy, total parenteral nutrition (tpn) | 7 | $101.09 |
| S9366 | Home infusion therapy, total parenteral nutrition (tpn) | 7 | $110.02 |
| S9367 | Home infusion therapy, total parenteral nutrition (tpn) | 7 | $110.02 |
| S9368 | Home infusion therapy, total parenteral nutrition (tpn) | 7 | $110.02 |
| S9375 | Home infusion therapy, hydration therapy | 8 | $35.02 |
| S9376 | Home infusion therapy, hydration therapy | 9 | $40.00 |
| S9377 | Home infusion therapy, hydration therapy | 9 | $50.00 |
| S9379 | Home infusion therapy, infusion therapy | 7 | $40.00 |
| S9490 | Home infusion therapy, corticosteroid infusion | 8 | $45.92 |
| S9497 | Home infusion therapy, antibiotic, antiviral | 9 | $60.00 |
| S9500 | Home infusion therapy, antibiotic, antiviral | 11 | $45.00 |
| S9501 | Home infusion therapy, antibiotic, antiviral | 9 | $51.73 |
| S9502 | Home infusion therapy, antibiotic, antiviral | 10 | $58.10 |
| S9503 | Home infusion therapy, antibiotic, antiviral, or antifungal | 10 | $60.94 |
| S9504 | Home infusion therapy, antibiotic, antiviral, or antifungal | 10 | $66.61 |
| T2101 | Human breast milk processing, storage and distribution only | 12 | $4.55 |
| T4521 | Adult sized disposable incontinence product, brief/diaper | 36 | $0.615 |
| T4522 | Adult sized disposable incontinence product, brief/diaper | 36 | $0.64 |
| T4524 | Adult sized disposable incontinence product, brief/diaper | 35 | $0.90 |
| T4525 | Adult sized disposable incontinence product | 33 | $0.71 |
| T4526 | Adult sized disposable incontinence product | 33 | $0.78 |
| T4527 | Adult sized disposable incontinence product | 33 | $0.86 |
| T4528 | Adult sized disposable incontinence product | 33 | $0.92 |
| T4529 | Pediatric sized disposable incontinence product | 35 | $0.50 |
| T4530 | Pediatric sized disposable incontinence product | 34 | $0.55 |
| T4531 | Pediatric sized disposable incontinence product | 33 | $0.70 |
| T4532 | Pediatric sized disposable incontinence product | 33 | $0.80 |
| T4534 | Youth sized disposable incontinence product | 32 | $0.80 |
| T4536 | Incontinence product, protective underwear/pull-on | 14 | $7.45 |
| T4537 | Incontinence product, protective underpad, reusable | 19 | $13.51 |
| T4539 | Incontinence product, diaper/brief, reusable, any size, each | 12 | $6.81 |
| T4540 | Incontinence product, protective underpad, reusable | 15 | $10.00 |
| T4541 | Incontinence product, disposable underpad, large, each | 20 | $0.395 |
| T4542 | Incontinence product, disposable underpad, small size, each | 17 | $0.38 |
| T4543 | Adult sized disposable incontinence product | 30 | $1.43 |
| T5001 | Medical supplies | 6 | $448.11 |
Equipment & supplies rates in your statesRates, managed-care rules, Medicare comparison and changes, for the codes you bill.