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Code Type AgeORTHOPEDIC
SPECIALTY
MAXIMUM
FEE
RENTAL
ONLY
RENT-TO-
PURCHASE
UNITS BY
REPORT
PRIOR
AUTHORIZATION
LIMIT
A4206 Medical and Surgical Supplies 0 - 999 0.29 60 720 PER YEAR
A4207 Medical and Surgical Supplies 0 - 999 0.29 60 720 PER YEAR
A4208 Medical and Surgical Supplies 0 - 999 0.29 60 720 PER YEAR
A4209 Medical and Surgical Supplies 0 - 999 0.29 60 720 PER YEAR
A4213 Medical and Surgical Supplies 0 - 999 1.94 31 372 PER YEAR
A4215 Medical and Surgical Supplies 0 - 999 0.19 100 1200 PER YEAR
A4216 Medical and Surgical Supplies 0 - 999 0.34 150 150 PER MONTH
A4217 Medical and Surgical Supplies 0 - 20 2.43 7MEDICAL NECESSITY UP TO 365 PER
YEAR MAX
A4221 Medical and Surgical Supplies 0 - 20 17.32 1 52 PER YEAR
A4222 Medical and Surgical Supplies 0 - 20 34.39 7MEDICAL NECESSITY UP TO 365 PER
YEAR MAX
A4223 Medical and Surgical Supplies 0 - 999 34.39 1 52 PER YEAR
A4230 Medical and Surgical Supplies 0 - 999 155.52 1 12 BOXES PER YEAR
A4231 Medical and Surgical Supplies 0 - 999 87.12 1 12 BOXES PER YEAR
A4232 Medical and Surgical Supplies 0 - 999 57.84 1 12 BOXES PER YEAR
A4244 Medical and Surgical Supplies 0 - 999 0.78 12 144 PER YEAR
A4245 Medical and Surgical Supplies 0 - 999 1.94 2 24 PER YEAR
A4246 Medical and Surgical Supplies 0 - 20 4.85 3 36 PER YEAR
A4247 Medical and Surgical Supplies 0 - 999 7.28 2 2 BOXES PER MONTH
A4250 Medical and Surgical Supplies 0 - 999 9.90 2 2 BOXES PER MONTH
A4253 Medical and Surgical Supplies 0 - 999 29.55 4 4 BOXES PER MONTH
A4255 Medical and Surgical Supplies 0 - 20 2.99 1 2 PER MONTH
A4256 Medical and Surgical Supplies 0 - 20 8.06 1 4 PER YEAR
A4258 Medical and Surgical Supplies 0 - 999 14.44 1 2 PER YEAR
A4259 Medical and Surgical Supplies 0 - 999 9.70 2 24 PER YEAR
A4265 Medical and Surgical Supplies 0 - 20 3.88 6 72 PER YEAR
A4280 Medical and Surgical Supplies 0 - 999 3.76 5 5 PER MONTH
A4310 Incontinence Appliance and Care Supplies 0 - 20 4.03 2 24 PER YEAR
A4311 Incontinence Appliance and Care Supplies 0 - 999 4.46 3 36 PER YEAR
A4312 Incontinence Appliance and Care Supplies 0 - 999 15.81 3 36 PER YEAR
A4313 Incontinence Appliance and Care Supplies 0 - 999 10.39 3 36 PER YEAR
A4314 Incontinence Appliance and Care Supplies 0 - 20 10.67 2 24 PER YEAR
A4315 Incontinence Appliance and Care Supplies 0 - 20 10.67 2 24 PER YEAR
A4316 Incontinence Appliance and Care Supplies 0 - 20 10.67 2 24 PER YEAR
A4320 Incontinence Appliance and Care Supplies 0 - 20 4.90 31 372 PER YEAR
A4322 Incontinence Appliance and Care Supplies 0 - 20 2.15 31 372 PER YEAR
A4326 Incontinence Appliance and Care Supplies 0 - 20 8.34 31 372 PER YEAR
A4327 Incontinence Appliance and Care Supplies 0 - 20 16.10 1 1 PER YEAR
A4328 Incontinence Appliance and Care Supplies 0 - 20 5.00 2 24 PER YEAR
A4330 Incontinence Appliance and Care Supplies 0 - 20 5.19 31 372 PER YEAR
A4331 Incontinence Appliance and Care Supplies 0 - 999 1.68 31 372 PER YEAR
A4332 Incontinence Appliance and Care Supplies 0 - 999 0.10 200 200 PER MONTH
A4333 Incontinence Appliance and Care Supplies 0 - 999 2.43 31 31 PER MONTH
Durable Medical Equipment and Medical Supply Services Provider Fee Schedule for All Medicaid Recipients
Effective 7-1-18
Florida Medicaid reimburses procedure codes identified with "OS" to physicians with an orthopedic specialty and durable medical equipment providers. Procedure codes not identified with "OS" are only reimbursable to durable medical equipment providers.
A4338 Incontinence Appliance and Care Supplies 0 - 20 6.16 3 36 PER YEAR
A4340 Incontinence Appliance and Care Supplies 0 - 20 6.69 3 36 PER YEAR
A4344 Incontinence Appliance and Care Supplies 0 - 20 5.34 3 36 PER YEAR
A4346 Incontinence Appliance and Care Supplies 0 - 20 8.73 3 36 PER YEAR
A4349 Incontinence Appliance and Care Supplies 0 - 999 1.66 35 35 PER MONTH
A4351 Incontinence Appliance and Care Supplies 0 - 999 1.60 186 186 PER MONTH
A4352 Incontinence Appliance and Care Supplies 0 - 999 1.84 186 186 PER MONTH
A4353 Incontinence Appliance and Care Supplies 0 - 999 5.33 186 186 PER MONTH
A4354 Incontinence Appliance and Care Supplies 0 - 20 3.88 3 36 PER YEAR
A4355 Incontinence Appliance and Care Supplies 0 - 20 2.52 4 48 PER YEAR
A4356 External Urinary Supplies 0 - 20 34.92 1 1 PER YEAR
A4357 External Urinary Supplies 0 - 999 7.76 2 24 PER YEAR
A4358 External Urinary Supplies 0 - 999 3.40 5 60 PER YEAR
A4361 Ostomy Supplies 0 - 999 17.52 1 12 PER YEAR
A4362 Ostomy Supplies 0 - 999 2.91 20 240 PER YEAR
A4363 Ostomy Supplies 0 - 999 4.15 12 144 PER YEAR
A4364 Ostomy Supplies 0 - 999 2.13 4 48 PER YEAR
A4367 Ostomy Supplies 0 - 999 5.61 1 12 PER YEAR
A4368 Ostomy Supplies 0 - 999 0.20 200 200 PER MONTH
A4369 Ostomy Supplies 0 - 999 1.84 12 144 PER YEAR
A4371 Ostomy Supplies 0 - 999 2.78 12 144 PER YEAR
A4372 Ostomy Supplies 0 - 999 3.18 20 240 PER YEAR
A4373 Ostomy Supplies 0 - 999 4.79 31 372 PER YEAR
A4375 Ostomy Supplies 0 - 999 13.10 10 10 PER MONTH
A4376 Ostomy Supplies 0 - 999 36.30 10 10 PER MONTH
A4377 Ostomy Supplies 0 - 999 3.27 10 10 PER MONTH
A4378 Ostomy Supplies 0 - 999 23.46 10 10 PER MONTH
A4379 Ostomy Supplies 0 - 999 11.46 10 10 PER MONTH
A4380 Ostomy Supplies 0 - 999 28.48 20 240 PER YEAR
A4381 Ostomy Supplies 0 - 999 3.52 10 10 PER MONTH
A4382 Ostomy Supplies 0 - 999 18.78 10 10 PER MONTH
A4383 Ostomy Supplies 0 - 999 21.51 10 10 PER MONTH
A4384 Ostomy Supplies 0 - 999 7.34 10 10 PER MONTH
A4385 Ostomy Supplies 0 - 999 3.88 10 10 PER MONTH
A4387 Ostomy Supplies 0 - 999 3.06 10 10 PER MONTH
A4388 Ostomy Supplies 0 - 999 3.32 10 10 PER MONTH
A4389 Ostomy Supplies 0 - 999 4.74 10 10 PER MONTH
A4390 Ostomy Supplies 0 - 999 7.33 10 10 PER MONTH
A4391 Ostomy Supplies 0 - 999 5.39 10 10 PER MONTH
A4392 Ostomy Supplies 0 - 999 5.07 10 10 PER MONTH
A4393 Ostomy Supplies 0 - 999 7.00 10 10 PER MONTH
A4394 Ostomy Supplies 0 - 999 1.96 10 10 PER MONTH
A4395 Ostomy Supplies 0 - 999 0.04 31 31 PER MONTH
A4396 Ostomy Supplies 0 - 999 30.89 2 2 PER MONTH
A4397 Ostomy Supplies 0 - 999 3.94 10 120 PER YEAR
A4398 Ostomy Supplies 0 - 999 23.28 2 24 PER YEAR
A4399 Ostomy Supplies 0 - 999 5.82 1 2 PER YEAR
A4400 Ostomy Supplies 0 - 999 31.70 1 6 PER YEAR
A4402 Ostomy Supplies 0 - 999 1.35 4 48 PER YEAR
A4404 Ostomy Supplies 0 - 999 1.29 31 372 PER YEAR
A4405 Ostomy Supplies 0 - 999 2.18 12 144 PER YEAR
A4406 Ostomy Supplies 0 - 999 3.67 12 144 PER YEAR
A4407 Ostomy Supplies 0 - 999 5.61 31 372 PER YEAR
A4408 Ostomy Supplies 0 - 999 6.32 31 372 PER YEAR
A4409 Ostomy Supplies 0 - 999 3.98 31 372 PER YEAR
A4410 Ostomy Supplies 0 - 999 5.78 31 372 PER YEAR
A4411 Ostomy Supplies 0 - 999 5.25 31 372 PER YEAR
A4412 Ostomy Supplies 0 - 999 3.00 31 31 PER MONTH
A4413 Ostomy Supplies 0 - 999 3.52 10 10 PER MONTH
A4414 Ostomy Supplies 0 - 999 3.15 31 372 PER YEAR
A4415 Ostomy Supplies 0 - 999 3.84 31 372 PER YEAR
A4416 Ostomy Supplies 0 - 999 1.76 31 31 PER MONTH
A4417 Ostomy Supplies 0 - 999 2.38 31 31 PER MONTH
A4418 Ostomy Supplies 0 - 999 1.16 31 31 PER MONTH
A4420 Ostomy Supplies 0 - 999 1.28 31 31 PER MONTH
A4421 Ostomy Supplies 0 - 999 0.00 1 PA 12 PER YEAR
A4423 Ostomy Supplies 0 - 999 1.28 31 31 PER MONTH
A4424 Ostomy Supplies 0 - 999 3.04 31 31 PER MONTH
A4425 Ostomy Supplies 0 - 999 2.29 31 372 PER YEAR
A4426 Ostomy Supplies 0 - 999 1.51 31 372 PER YEAR
A4427 Ostomy Supplies 0 - 999 1.89 31 372 PER YEAR
A4428 Ostomy Supplies 0 - 999 4.17 31 372 PER YEAR
A4429 Ostomy Supplies 0 - 999 4.82 31 372 PER YEAR
A4430 Ostomy Supplies 0 - 999 5.46 31 372 PER YEAR
A4431 Ostomy Supplies 0 - 999 3.25 31 31 PER MONTH
A4432 Ostomy Supplies 0 - 999 2.30 31 31 PER MONTH
A4433 Ostomy Supplies 0 - 999 2.14 31 31 PER MONTH
A4434 Ostomy Supplies 0 - 999 2.41 31 372 PER YEAR
A4450 Miscellaneous Supplies 0 - 999 0.30 200 2400 PER YEAR
A4452 Miscellaneous Supplies 0 - 999 0.40 200 2400 PER YEAR
A4455 Miscellaneous Supplies 0 - 999 1.16 4 48 PER YEAR
A4456 Miscellaneous Supplies 0 - 999 0.17 100 100 PER MONTH
A4481 Miscellaneous Supplies 0 - 999 0.28 31 31 PER MONTH
A4554 Miscellaneous Supplies 0 - 20 0.34 150 1800 PER YEAR
A4561 Miscellaneous Supplies 0 - 999 13.46 10 10 PER MONTH
A4562 Miscellaneous Supplies 0 - 999 36.46 10 10 PER MONTH
A4565 Miscellaneous Supplies 0 - 20 5.34 1 1 PER MEDICAL EVENT
A4570 Miscellaneous Supplies 0 -20 10.67 1 1 PER MEDICAL EVENT
A4605 Miscellaneous Supplies 0 - 999 2.15 7 372 PER YEAR
A4608 Miscellaneous Supplies 0 - 999 46.66 5 5 PER MONTH
A4611 Supplies for Respiratory and Oxygen Equipment 0 - 999 111.55 1 MEDICAL NECESSITY
A4612 Supplies for Respiratory and Oxygen Equipment 0 - 999 41.23 1 MEDICAL NECESSITY
A4613 Supplies for Respiratory and Oxygen Equipment 0 - 999 94.09 1 MEDICAL NECESSITY
A4614 Supplies for Respiratory and Oxygen Equipment 0 - 999 18.14 1 1 PER YEAR
A4616 Supplies for Respiratory and Oxygen Equipment 0 - 999 0.21 25 300 PER YEAR
A4618 Supplies for Respiratory and Oxygen Equipment 0 - 999 5.77 1 MEDICAL NECESSITY
A4623 Supplies for Respiratory and Oxygen Equipment 0 - 999 6.25 5 60 PER YEAR
A4624 Supplies for Respiratory and Oxygen Equipment 0 - 999 2.15 250 3000 PER YEAR
A4625 Supplies for Respiratory and Oxygen Equipment 0 - 999 6.61 14 14 PER MEDICAL EVENT
A4626 Supplies for Respiratory and Oxygen Equipment 0 - 999 1.46 1 12 PER YEAR
A4627 Supplies for Respiratory and Oxygen Equipment 0 - 999 27.50 1 1 PER YEAR
A4629 Supplies for Respiratory and Oxygen Equipment 0 - 999 3.44 31 31 PER MONTH
A4635 Supplies for Other Durable Medical Equipment 0 - 999 1.79 2 2 PER YEAR
A4636 Supplies for Other Durable Medical Equipment 0 - 999 1.65 2 2 PER YEAR
A4637 Supplies for Other Durable Medical Equipment 0 - 999 1.21 4 4 PER YEAR
A4640 Supplies for Other Durable Medical Equipment 0 - 20 33.95 1 1 PER YEAR
A4927 Supplies for Dialysis 0 - 999 4.00 4 48 PER YEAR
A4930 Supplies for Dialysis 0 - 999 0.34 100 1200 PER YEAR
A5051 Additional Ostomy Supplies 0 - 999 1.66 31 372 PER YEAR
A5052 Additional Ostomy Supplies 0 - 999 1.27 31 372 PER YEAR
A5053 Additional Ostomy Supplies 0 - 999 1.28 31 372 PER YEAR
A5054 Additional Ostomy Supplies 0 - 999 1.28 31 372 PER YEAR
A5055 Additional Ostomy Supplies 0 - 999 1.21 31 31 PER MONTH
A5061 Additional Ostomy Supplies 0 - 999 2.18 31 372 PER YEAR
A5062 Additional Ostomy Supplies 0 - 999 1.89 31 372 PER YEAR
A5063 Additional Ostomy Supplies 0 - 999 1.89 31 372 PER YEAR
A5071 Additional Ostomy Supplies 0 - 999 2.82 31 372 PER YEAR
A5072 Additional Ostomy Supplies 0 - 999 2.29 31 372 PER YEAR
A5073 Additional Ostomy Supplies 0 - 999 2.09 31 372 PER YEAR
A5081 Additional Ostomy Supplies 0 - 999 2.51 1 6 PER YEAR
A5082 Additional Ostomy Supplies 0 - 999 7.71 1 6 PER YEAR
A5093 Additional Ostomy Supplies 0 - 999 1.55 10 120 PER YEAR
A5102 Additional Incontinence and Ostomy Supplies 0 - 20 6.69 1 2 PER YEAR
A5105 Additional Incontinence and Ostomy Supplies 0 - 20 14.40 1 2 PER YEAR
A5112 Additional Incontinence and Ostomy Supplies 0 - 999 26.42 1 12 PER YEAR
A5113 Additional Incontinence and Ostomy Supplies 0 - 20 4.48 1 4 PER YEAR
A5114 Additional Incontinence and Ostomy Supplies 0 - 20 5.53 1 4 PER YEAR
A5120 Additional Incontinence and Ostomy Supplies 0 - 999 0.17 50 600 PER YEAR
A5121 Additional Incontinence and Ostomy Supplies 0 - 999 4.84 10 120 PER YEAR
A5122 Additional Incontinence and Ostomy Supplies 0 - 999 9.81 10 120 PER YEAR
A5126 Additional Incontinence and Ostomy Supplies 0 - 20 0.63 20 240 PER YEAR
A5131 Additional Incontinence and Ostomy Supplies 0 - 999 10.28 3 3 PER MONTH
A5200 Additional Incontinence and Ostomy Supplies 0 - 20 8.62 3 3 PER MONTH
A5500 Diabetic Shoes, Fitting, and Modifications 0 - 999 50.40 2 2 PER MEDICAL EVENT
A5501 Diabetic Shoes, Fitting, and Modifications 0 - 999 151.20 2 2 PER MEDICAL EVENT
A5503 Diabetic Shoes, Fitting, and Modifications 0 - 999 25.60 2 2 PER FOOT PER YEAR
A5504 Diabetic Shoes, Fitting, and Modifications 0 - 999 25.60 2 2 PER FOOT PER YEAR
A5505 Diabetic Shoes, Fitting, and Modifications 0 - 999 25.60 2 2 PER FOOT PER YEAR
A5506 Diabetic Shoes, Fitting, and Modifications 0 - 999 25.60 2 2 PER FOOT PER YEAR
A5507 Diabetic Shoes, Fitting, and Modifications 0 - 999 26.83 2 2 PER FOOT PER YEAR
A5512 Diabetic Shoes, Fitting, and Modifications 0 - 999 19.37 2 2 PER FOOT PER YEAR
A5513 Diabetic Shoes, Fitting, and Modifications 0 - 999 28.91 2 2 PER FOOT PER YEAR
A6022 Dressings 0 - 999 16.04 31 31 PER MONTH
A6023 Dressings 0 - 999 145.21 15 15 PER MONTH
A6024 Dressings 0 - 999 4.72 31 31 PER MONTH
A6154 Dressings 0 - 20 10.64 15 15 PER MONTH
A6196 Dressings 0 - 20 5.61 31 31 PER MONTH
A6197 Dressings 0 - 20 12.50 31 31 PER MONTH
A6199 Dressings 0 - 20 4.04 31 31 PER MONTH
A6203 Dressings 0 - 20 2.56 31 31 PER MONTH
A6204 Dressings 0 - 20 4.76 31 31 PER MONTH
A6207 Dressings 0 - 20 5.60 31 31 PER MONTH
A6209 Dressings 0 - 20 5.72 31 31 PER MONTH
A6210 Dressings 0 - 20 15.20 31 31 PER MONTH
A6211 Dressings 0 - 20 22.40 31 31 PER MONTH
A6212 Dressings 0 - 20 7.40 31 31 PER MONTH
A6214 Dressings 0 - 20 7.86 31 31 PER MONTH
A6216 Dressings 0 - 20 0.04 200 200 PER MONTH
A6219 Dressings 0 - 20 0.73 62 62 PER MONTH
A6220 Dressings 0 - 20 1.97 62 62 PER MONTH
A6222 Dressings 0 - 20 1.63 31 31 PER MONTH
A6223 Dressings 0 - 20 1.84 31 31 PER MONTH
A6224 Dressings 0 - 20 2.76 31 31 PER MONTH
A6229 Dressings 0 - 20 2.75 31 31 PER MONTH
A6231 Dressings 0 - 999 3.56 31 31 PER MONTH
A6232 Dressings 0 - 999 5.26 31 31 PER MONTH
A6233 Dressings 0 - 999 14.64 31 31 PER MONTH
A6234 Dressings 0 - 20 5.00 31 31 PER MONTH
A6235 Dressings 0 - 20 12.84 31 31 PER MONTH
A6236 Dressings 0 - 20 20.80 31 31 PER MONTH
A6237 Dressings 0 - 20 6.04 31 31 PER MONTH
A6238 Dressings 0 - 20 17.40 31 31 PER MONTH
A6240 Dressings 0 - 20 9.35 31 31 PER MONTH
A6241 Dressings 0 - 20 1.96 31 31 PER MONTH
A6242 Dressings 0 - 20 4.63 31 31 PER MONTH
A6243 Dressings 0 - 20 9.40 31 31 PER MONTH
A6244 Dressings 0 - 20 29.95 31 31 PER MONTH
A6245 Dressings 0 - 20 5.55 31 31 PER MONTH
A6246 Dressings 0 - 20 7.55 31 31 PER MONTH
A6247 Dressings 0 - 20 18.15 31 31 PER MONTH
A6248 Dressings 0 - 20 12.40 15 15 PER MONTH
A6251 Dressings 0 - 20 1.52 31 31 PER MONTH
A6252 Dressings 0 - 20 2.48 31 31 PER MONTH
A6253 Dressings 0 - 20 4.84 31 31 PER MONTH
A6254 Dressings 0 - 20 0.90 31 31 PER MONTH
A6255 Dressings 0 - 20 2.32 31 31 PER MONTH
A6257 Dressings 0 - 999 1.15 31 31 PER MONTH
A6258 Dressings 0 - 20 3.28 31 31 PER MONTH
A6259 Dressings 0 - 20 8.35 31 31 PER MONTH
A6266 Dressings 0 - 20 1.45 31 31 PER MONTH
A6402 Dressings 0 - 20 0.10 200 200 PER MONTH
A6403 Dressings 0 - 20 0.33 200 200 PER MONTH
A6441 Dressings 0 - 20 0.40 31 31 PER MONTH
A6443 Dressings 0 - 20 0.40 31 31 PER MONTH
A6444 Dressings 0 - 20 0.40 31 31 PER MONTH
A6446 Dressings 0 - 20 0.40 31 31 PER MONTH
A6447 Dressings 0 - 20 0.40 31 31 PER MONTH
A6449 Dressings 0 - 20 0.50 31 31 PER MONTH
A6450 Dressings 0 - 20 0.50 31 31 PER MONTH
A6451 Dressings 0 - 20 0.50 31 31 PER MONTH
A6452 Dressings 0 - 20 0.50 31 31 PER MONTH
A6454 Dressings 0 - 20 0.50 31 31 PER MONTH
A6456 Dressings 0 - 20 9.10 31 31 PER MONTH
A6457 Dressings 0 - 999 0.91 2 2 EVERY 6 MONTHS
A6530 Gradient Compression Stockings 0 - 999 31.04 2 8 Stockings PER YEAR
A6531 Gradient Compression Stockings 0 - 999 34.61 2 8 Stockings PER YEAR
A6532 Gradient Compression Stockings 0 - 999 60.96 2 8 Stockings PER YEAR
A6533 Gradient Compression Stockings 0 - 999 40.74 2 8 Stockings PER YEAR
A6534 Gradient Compression Stockings 0 - 999 40.74 2 8 Stockings PER YEAR
A6535 Gradient Compression Stockings 0 - 999 40.74 2 8 Stockings PER YEAR
A6536 Gradient Compression Stockings 0 - 999 111.55 2 8 PER YEAR
A6537 Gradient Compression Stockings 0 - 999 111.55 2 8 PER YEAR
A6538 Gradient Compression Stockings 0 - 999 111.55 2 8 PER YEAR
A6539 Gradient Compression Stockings 0 - 999 111.55 2 8 PER YEAR
A6540 Gradient Compression Stockings 0 - 999 111.55 2 8 PER YEAR
A6541 Gradient Compression Stockings 0 - 999 111.55 2 8 PER YEAR
A7000 Respiratory Durable Medical Equipment 0 - 999 6.94 1 4 PER YEAR
A7001 Respiratory Durable Medical Equipment 0 - 999 21.45 1 1 PER 2 YEARS
A7002 Respiratory Durable Medical Equipment 0 - 999 2.48 1 12 PER YEAR
A7003 Respiratory Durable Medical Equipment 0 - 999 3.88 3 36 PER YEAR
A7004 Respiratory Durable Medical Equipment 0 - 999 1.16 3 36 PER YEAR
A7005 Respiratory Durable Medical Equipment 0 - 999 19.99 1 2 PER YEAR
A7006 Respiratory Durable Medical Equipment 0 - 999 7.24 3 36 PER YEAR
A7007 Respiratory Durable Medical Equipment 0 - 999 3.88 3 36 PER YEAR
A7008 Respiratory Durable Medical Equipment 0 - 999 7.13 3 36 PER YEAR
A7009 Respiratory Durable Medical Equipment 0 - 999 29.79 1 1 PER YEAR
A7010 Respiratory Durable Medical Equipment 0 - 999 15.30 1 12 PER YEAR
A7012 Respiratory Durable Medical Equipment 0 - 999 2.74 1 12 PER YEAR
A7013 Respiratory Durable Medical Equipment 0 - 999 0.53 31 372 PER YEAR
A7014 Respiratory Durable Medical Equipment 0 - 999 3.30 1 12 PER YEAR
A7015 Respiratory Durable Medical Equipment 0 - 999 1.43 1 12 PER YEAR
A7016 Respiratory Durable Medical Equipment 0 - 999 4.97 1 12 PER YEAR
A7017 Respiratory Durable Medical Equipment 0 - 999 102.28 1 1 PER YEAR
A7501 Respiratory Durable Medical Equipment 0 - 999 80.14 1 1 PER MONTH
A7502 Respiratory Durable Medical Equipment 0 - 999 38.09 1 1 PER MONTH
A7503 Respiratory Durable Medical Equipment 0 - 999 8.65 1 4 PER YEAR
A7504 Respiratory Durable Medical Equipment 0 - 999 0.51 31 372 PER YEAR
A7505 Respiratory Durable Medical Equipment 0 - 999 3.57 1 12 PER YEAR
A7506 Respiratory Durable Medical Equipment 0 - 999 0.26 31 31 PER MONTH
A7507 Respiratory Durable Medical Equipment 0 - 999 1.90 1 4 PER YEAR
A7508 Respiratory Durable Medical Equipment 0 - 999 2.19 31 31 PER MONTH
A7520 Respiratory Durable Medical Equipment 0 - 999 52.38 1 MEDICAL NECESSITY
A7521 Tracheostomy Supplies 0 - 999 52.38 1 MEDICAL NECESSITY
A7522 Tracheostomy Supplies 0 - 999 52.38 1 MEDICAL NECESSITY
A7525 Tracheostomy Supplies 0 - 999 1.18 4 4 PER MONTH
A7526 Tracheostomy Supplies 0 - 999 1.18 14 14 PER MONTH
A8000 Helmets 0 - 999 86.51 1 1 PER YEAR
A8001 Helmets 0 - 999 86.51 1 1 PER YEAR
A8002 Helmets 0 - 999 247.35 1 MEDICAL NECESSITY
A8003 Helmets 0 - 999 247.35 1 MEDICAL NECESSITY
A9276 Miscellaneous 0 - 20 399.20 1 (per box) PA 1 per month
A9277 Miscellaneous 0 - 20 639.20 1 PA 2 per year
A9278 Miscellaneous 0 - 20 559.20 1 PA 1 per year
A9900 Miscellaneous 0 - 999 0.00 1 PA MEDICAL NECESSITY
B4034 Enteral Formulae and Enteral Medical Supplies 0 - 999 4.69 31 31 PER MONTH
B4035 Enteral Formulae and Enteral Medical Supplies 0 - 20 8.60 31 31 PER MONTH
B4036 Enteral Formulae and Enteral Medical Supplies 0 - 999 6.10 31 31 PER MONTH
B4081 Enteral Formulae and Enteral Medical Supplies 0 - 20 14.55 8 96 PER YEAR
B4082 Enteral Formulae and Enteral Medical Supplies 0 - 20 11.64 8 96 PER YEAR
B4083 Enteral Formulae and Enteral Medical Supplies 0 - 20 1.46 15 180 PER YEAR
B4087 Enteral Formulae and Enteral Medical Supplies 0 - 999 14.55 2 24 PER YEAR
B4088 Enteral Formulae and Enteral Medical Supplies 0 - 999 115.00 1 6 PER YEAR
B4149 Enteral Formulae and Enteral Medical Supplies 0 - 20 1.52 930 930 PER MONTH
B4150 Enteral Formulae and Enteral Medical Supplies 0 - 999 0.62 930 930 PER MONTH
B4150SC Enteral Formulae and Enteral Medical Supplies 0 - 999 0.62 930 930 PER MONTH
B4152 Enteral Formulae and Enteral Medical Supplies 0 - 999 0.50 930 930 PER MONTH
B4152SC Enteral Formulae and Enteral Medical Supplies 0 - 999 0.50 930 930 PER MONTH
B4153 Enteral Formulae and Enteral Medical Supplies 0 - 999 2.04 930 930 PER MONTH
B4153SC Enteral Formulae and Enteral Medical Supplies 0 - 999 2.04 930 930 PER MONTH
B4154 Enteral Formulae and Enteral Medical Supplies 0 - 999 0.90 930 930 PER MONTH
B4154SC Enteral Formulae and Enteral Medical Supplies 0 - 999 0.90 930 930 PER MONTH
B4155 Enteral Formulae and Enteral Medical Supplies 0 - 999 0.74 930 930 PER MONTH
B4155SC Enteral Formulae and Enteral Medical Supplies 0 - 999 0.74 930 930 PER MONTH
B4157 Enteral Formulae and Enteral Medical Supplies 0 - 999 0.00 930 BR 930 PER MONTH
B4157SC Enteral Formulae and Enteral Medical Supplies 0 - 999 0.00 930 BR 930 PER MONTH
B4160 Enteral Formulae and Enteral Medical Supplies 0 - 20 0.78 930 930 PER MONTH
B4160 SC Enteral Formulae and Enteral Medical Supplies 0 - 20 0.78 930 930 PER MONTH
B4161 Enteral Formulae and Enteral Medical Supplies 0 - 20 0.00 930 BR 930 PER MONTH
B4161 SC Enteral Formulae and Enteral Medical Supplies 0 - 20 0.00 930 BR 930 PER MONTH
B4162 Enteral Formulae and Enteral Medical Supplies 0 - 20 0.00 930 BR 930 PER MONTH
B4162 SC Enteral Formulae and Enteral Medical Supplies 0 - 20 0.00 930 BR 930 PER MONTH
B9002 Enteral and Parenteral Pumps 0 - 20 0.00 RO 82.45 1 MEDICAL NECESSITY
B9004 Enteral and Parenteral Pumps 0 - 20 0.00 RO 82.45 1 MEDICAL NECESSITY
B9998 Enteral and Parenteral Pumps 0 - 20 0.00 10 PA 120 PER YEAR
E0100 Canes 0 - 999 15.52 1 1 PER YEAR
E0105 Canes 0 - 999 36.38 1 1 PER 3 YEARS
E0110 Crutches 0 - 999 59.38 1 1 PER 2 YEARS
E0111 Crutches 0 - 999 36.98 1 1 PER 2 YEARS
E0112 Crutches 0 - 999 21.34 1 1 PER 2 YEARS
E0113 Crutches 0 - 999 10.67 1 1 PER 2 YEARS
E0114 Crutches 0 - 999 24.25 1 1 PER 2 YEARS
E0116 Crutches 0 - 999 12.13 1 1 PER 2 YEARS
E0130 Walkers 0 - 999 53.35 1 1 PER 3 YEARS
E0135 Walkers 0 - 999 53.35 1 1 PER 3 YEARS
E0141 Walkers 0 - 999 81.48 1 1 PER 3 YEARS
E0143 Walkers 0 - 999 86.24 1 1 PER 3 YEARS
E0147 Walkers 0 - 999 439.93 1 1 PER 3 YEARS
E0148 Walkers 0 - 999 97.24 1 1 PER 3 YEARS
E0149 Walkers 0 - 999 170.82 1 1 PER 3 YEARS
E0153 Walkers 0 - 999 34.44 2 2 PER 3 YEARS
E0154 Walkers 0 - 999 40.26 2 2 PER 3 YEARS
E0155 Walkers 0 - 999 27.71 1 1 PER 3 YEARS
E0156 Attachments 0 - 999 17.14 1 1 PER 3 YEARS
E0157 Attachments 0 - 999 39.77 1 1 PER 3 YEARS
E0158 Attachments 0 - 999 16.98 4 4 PER 3 YEARS
E0159 Attachments 0 - 999 13.64 1 2 PER 2 YEARS
E0160 Commodes 0 - 999 9.70 1 1 PER 8 YEARS
E0161 Commodes 0 - 999 24.25 1 1 PER 8 YEARS
E0163 Commodes 0 - 999 71.78 1 1 PER 8 YEARS
E0165 Commodes 0 - 999 72.27 1 1 PER 3 YEARS
E0167 Commodes 0 - 999 7.28 1 1 PER YEAR
E0168 Commodes 0 - 999 115.50 1 1 PER 3 YEARS
E0171 Commodes 0 - 999 23.14 1 1 PER 3 YEARS
E0181 Decubitus Care Equipment 0 - 20 150.40 15.04 1 1 PER 3 YEARS
E0184 Decubitus Care Equipment 0 -20 276.50 27.65 1 1 PER 3 YEARS
E0185 Decubitus Care Equipment 0 - 999 121.25 1 1 PER 2 YEARS
E0186 Decubitus Care Equipment 0 - 20 184.30 1 1 PER 3 YEARS
E0187 Decubitus Care Equipment 0 - 20 184.30 1 1 PER 3 YEARS
E0189 Decubitus Care Equipment 0 - 20 77.60 1 1 PER 2 YEARS
E0190 Decubitus Care Equipment 0 - 20 26.39 1 1 PER 3 YEARS
E0191 Decubitus Care Equipment 0 - 20 6.79 2 4 PER YEAR
E0196 Decubitus Care Equipment 0 - 20 184.30 1 1 PER 3 YEARS
E0197 Decubitus Care Equipment 0 - 999 121.25 1 1 PER 2 YEARS
E0198 Decubitus Care Equipment 0 - 999 121.25 1 1 PER 2 YEARS
E0199 Decubitus Care Equipment 0 - 999 22.31 1 1 PER 2 YEARS
E0202 Heat/Cold Application 0 - 20 0.00 RO 42.68 1 1 PER MEDICAL EVENT (UP TO 5 DAYS)
E0205 Heat/Cold Application 0 - 20 38.80 1 1 PER LIFETIME
E0215 Heat/Cold Application 0 - 20 16.49 1 1 PER LIFETIME
E0217 Heat/Cold Application 0 - 20 322.02 1 1 PER 5 YEARS
E0235 Heat/Cold Application 0 - 20 116.40 11.64 1 1 PER 8 YEARS
E0244 Bath and Toilet Aids 0 - 999 29.10 1 1 PER 8 YEARS
E0245 Bath and Toilet Aids 0 - 999 35.00 1 1 PER 8 YEARS
E0246 Bath and Toilet Aids 0 - 999 14.55 1 1 PER 8 YEARS
E0249 Pad for Heating Unit 0 - 20 25.71 1 1 PER YEAR
E0250 Hospital Beds and Accessories 0 - 999 795.40 79.54 1 PA 1 PER 8 YEARS
E0255 Hospital Beds and Accessories 0 - 999 853.60 85.36 1 PA 1 PER 8 YEARS
E0260 Hospital Beds and Accessories 0 - 20 1071.85 1 1 PER 8 YEARS
E0265 Hospital Beds and Accessories 0 - 20 1343.45 1 1 PER 8 YEARS
E0271 Hospital Beds and Accessories 0 - 999 121.25 1 1 PER 4 YEARS
E0272 Hospital Beds and Accessories 0 - 999 121.25 1 1 PER 4 YEARS
E0275 Hospital Beds and Accessories 0 - 999 7.76 1 1 PER 4 YEARS
E0276 Hospital Beds and Accessories 0 - 999 9.22 1 1 PER 4 YEARS
E0303 Hospital Beds and Accessories 0 - 999 2414.10 241.41 1 PA 1 PER 8 YEARS
E0305 Hospital Beds and Accessories 0 - 20 105.73 1 1 PER 8 YEARS
E0310 Hospital Beds and Accessories 0 - 20 105.73 1 1 PER 8 YEARS
E0315 Hospital Beds and Accessories 0 - 20 82.45 1 1 PER 8 YEARS
E0316 Hospital Beds and Accessories 0 - 20 3500.00 1 PA 1 PER 5 YEARS
E0325 Hospital Beds and Accessories 0 - 999 6.31 1 1 PER 4 YEARS
E0326 Hospital Beds and Accessories 0 - 999 8.73 1 1 PER 4 YEARS
E0370 Hospital Beds and Accessories 0 - 20 19.92 1 2 PER 2 YEARS
E0424 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 213.40 1 1 PER MONTH
E0431 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 38.53 1 1 PER MONTH
E0434 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 38.53 1 1 PER MONTH
E0439 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 213.40 1 1 PER MONTH
E0441 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 126.10 1 1 PER MONTH
E0442 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 126.10 1 1 PER MONTH
E0443 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 19.52 1 1 PER MONTH
E0444 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 19.52 1 1 PER MONTH
E0445 Oxygen and Related Respiratory Equipment 0 - 20 0.00 RO 95.00 1 MEDICAL NECESSITY
E0457 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 36.86 1 MEDICAL NECESSITY
E0459 Oxygen and Related Respiratory Equipment 0 - 999 340.50 34.05 1 MEDICAL NECESSITY
E0465 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 756.60 1 MEDICAL NECESSITY
E0466 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 756.60 1 MEDICAL NECESSITY
E0470 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 177.75 1 1 PER MONTH
E0471 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 416.51 1 1 PER MONTH
E0472 Oxygen and Related Respiratory Equipment 0 - 999 0.00 RO 416.51 1 1 PER MONTH
E0480 Oxygen and Related Respiratory Equipment 0 - 999 373.50 37.35 1 1 PER 4 YEARS
E0482 Oxygen and Related Respiratory Equipment 0 - 999 5288.00 1 PA MEDICAL NECESSITY
E0483 Oxygen and Related Respiratory Equipment 0 - 999 10676.25 1 PA MEDICAL NECESSITY
E0485 Oxygen and Related Respiratory Equipment 0 - 999 0.00 1 PA 1 PER YEAR
E0500 IPPB Machines 0 - 999 0.00 RO 88.76 1 MEDICAL NECESSITY
E0550 Humidifiers/Nebulizers/Compressors for Use with Oxygen 0 - 999 0.00 RO 48.50 1 MEDICAL NECESSITY
E0555 Humidifiers/Nebulizers/Compressors for Use with Oxygen 0 - 999 31.53 1 1 PER 2 YEARS
E0560 Humidifiers/Nebulizers/Compressors for Use with Oxygen 0 - 999 0.00 RO 14.55 1 MEDICAL NECESSITY
E0561 Humidifiers/Nebulizers/Compressors for Use with Oxygen 0 - 999 0.00 RO 8.74 1 1 PER MONTH
E0562 Humidifiers/Nebulizers/Compressors for Use with Oxygen 0 - 999 0.00 RO 8.74 1 1 PER MONTH
E0565 Humidifiers/Nebulizers/Compressors for Use with Oxygen 0 - 999 0.00 RO 29.10 1 MEDICAL NECESSITY
E0570 Humidifiers/Nebulizers/Compressors for Use with Oxygen 0 - 999 106.70 1 1 PER 2 YEARS
E0572 Humidifiers/Nebulizers/Compressors for Use with Oxygen 0 - 999 0.00 RO 26.84 1 1 PER MONTH
E0574 Humidifiers/Nebulizers/Compressors for Use with Oxygen 0 - 999 0.00 RO 28.36 1 1 PER MONTH
E0585 Humidifiers/Nebulizers/Compressors for Use with Oxygen 0 - 999 150.40 15.04 1 1 PER 2 YEARS
E0600 Suction Pump/Room Vaporizers 0 - 999 303.90 30.39 1 1 PER 2 YEARS
E0601 Suction Pump/Room Vaporizers 0 - 999 0.00 RO 80.03 1 MEDICAL NECESSITY
E0603 Suction Pump/Room Vaporizers 0 - 999 124.00 1 PA 1 PER 5 YEARS
E0604 Suction Pump/Room Vaporizers 0 - 999 0.00 RO 58.07 PA 3 MONTHES MAX
E0605 Suction Pump/Room Vaporizers 0 - 999 18.92 1 1 PER 4 YEARS
E0606 Suction Pump/Room Vaporizers 0 - 999 160.10 16.01 1 1 PER 8 YEARS
E0607 Monitoring Equipment 0 - 999 59.90 1 1 EVERY 5 YEARS
E0618 Monitoring Equipment 0 - 20 0.00 RO 6.15 1 MEDICAL NECESSITY
E0619 Monitoring Equipment 0 - 20 0.00 RO 6.15 1 MEDICAL NECESSITY
E0621 Monitoring Equipment 0 - 999 58.20 1 1 PER 4 YEARS
E0630 Monitoring Equipment 0 - 999 664.50 66.45 1 PA 1 PER 8 YEARS
E0635 Monitoring Equipment 0 - 999 664.50 66.45 1 PA 1 PER 8 YEARS
E0650 Pneumatic Compressor and Appliances 0 - 20 485.00 48.50 1 1 PER 8 YEARS
E0651 Pneumatic Compressor and Appliances 0 - 20 941.90 94.19 1 1 PER 8 YEARS
E0652 Pneumatic Compressor and Appliances 0 - 20 3689.90 368.99 1 1 PER 8 YEARS
E0655 Pneumatic Compressor and Appliances 0 - 20 73.72 1 2 PER YEAR
E0660 Pneumatic Compressor and Appliances 0 - 20 67.90 1 2 PER YEAR
E0665 Pneumatic Compressor and Appliances 0 - 20 67.90 1 2 PER YEAR
E0666 Pneumatic Compressor and Appliances 0 - 20 101.37 1 2 PER YEAR
E0667 Pneumatic Compressor and Appliances 0 - 20 395.76 1 2 PER YEAR
E0668 Pneumatic Compressor and Appliances 0 - 20 395.76 1 2 PER YEAR
E0705 Safety Equipment 0 - 999 40.75 1 3 PER LIFETIME
E0744 Transcutaneous and/or Neuromuscular Electrical Nerve Stimulators (TENS) 0 - 20 810.00 81.00 1 MEDICAL NECESSITY
E0745 Transcutaneous and/or Neuromuscular Electrical Nerve Stimulators (TENS) 0 - 20 717.80 71.78 1 MEDICAL NECESSITY
E0747 Transcutaneous and/or Neuromuscular Electrical Nerve Stimulators 0 - 999 0.00 RO 247.35 1 MAXIMUM 6 MOS RENTAL
E0776 Infusion Supplies 0 - 20 106.70 10.67 1 1 PER 8 YEARS
E0779 Infusion Supplies 0 - 20 0.00 RO 11.74 1 MEDICAL NECESSITY
E0780 Infusion Supplies 0 - 20 0.00 RO 7.91 1 MEDICAL NECESSITY
E0781 Infusion Supplies 0 - 20 0.00 RO 9.41 1 MEDICAL NECESSITY
E0784 Infusion Supplies 0 - 999 0.00 1 PA MEDICAL NECESSITY
E0791 Infusion Supplies 0 - 20 0.00 RO 5.82 1 MEDICAL NECESSITY
E0840 Traction Equipment: All Types and Cervical 0 - 20 63.05 1 1 PER LIFETIME
E0850 Traction Equipment: All Types and Cervical 0 - 20 73.72 1 1 PER LIFETIME
E0860 Traction: Overdoor 0 - 999 24.74 1 1 PER LIFETIME
E0870 Traction: Extremity 0 - 20 63.05 1 1 PER LIFETIME
E0880 Traction: Extremity 0 - 20 70.81 1 1 PER LIFETIME
E0890 Traction: Pelvic 0 - 20 44.62 1 1 PER LIFETIME
E0900 Traction: Pelvic 0 - 20 77.60 1 1 PER LIFETIME
E0910 Trapeze Equipment, Fracture Frame, and Other Orthopedic Devices 0 - 999 150.40 15.04 1 1 PER 8 YEARS
E0920 Trapeze Equipment, Fracture Frame, and Other Orthopedic Devices 0 - 20 354.10 35.41 1 1 PER LIFETIME
E0930 Trapeze Equipment, Fracture Frame, and Other Orthopedic Devices 0 - 20 354.10 35.41 1 1 PER LIFETIME
E0935 Trapeze Equipment, Fracture Frame, and Other Orthopedic Devices 0 - 20 0.00 RO 13.57 1 21 DAYS PER MEDICAL EVENT
E0940 Trapeze Equipment, Fracture Frame, and Other Orthopedic Devices 0 - 999 266.80 26.68 1 1 PER 8 YEARS
E0942 Trapeze Equipment, Fracture Frame, and Other Orthopedic Devices 0 - 20 15.52 1 1 PER MEDICAL EVENT
E0944 Trapeze Equipment, Fracture Frame, and Other Orthopedic Devices 0 - 20 12.13 1 1 PER MEDICAL EVENT
E0945 Trapeze Equipment, Fracture Frame, and Other Orthopedic Devices 0 - 20 15.04 1 1 PER MEDICAL EVENT
E0947 Trapeze Equipment, Fracture Frame, and Other Orthopedic Devices 0 - 20 217.80 21.78 1 1 PER MEDICAL EVENT
E0948 Trapeze Equipment, Fracture Frame, and Other Orthopedic Devices 0 - 20 209.50 20.95 1 1 PER MEDICAL EVENT
E0950 Wheelchair: Accessories 0 - 999 67.42 1 2 PER 4 YEARS
E0951 Wheelchair: Accessories 0 - 999 19.02 2 2 PER YEAR
E0952 Wheelchair: Accessories 0 - 999 14.38 2 2 PER YEAR
E0955 Wheelchair: Accessories 0 - 999 161.74 1 PA 1 PER 3 YEARS
E0956 Wheelchair: Accessories 0 - 999 78.86 6 PA 6 PER 3 YEARS
E0957 Wheelchair: Accessories 0 - 999 110.34 1 PA 1 PER 3 YEARS
E0958 Wheelchair: Accessories 0 - 999 309.80 1 1 PER 4 YEARS
E0959 Wheelchair: Accessories 0 - 999 57.35 2 2 PER 5 YEARS
E0960 Wheelchair: Accessories 0 - 999 79.12 1 PA 1 PER 3 YEARS
E0961 Wheelchair: Accessories 0 - 999 38.60 2 2 PER 4 YEARS
E0966 Wheelchair: Accessories 0 - 999 53.42 1 1 PER 5 YEARS
E0967 Wheelchair: Accessories 0 - 999 53.63 2 2 PER 4 YEARS
E0968 Wheelchair: Accessories 0 - 999 14.27 1 2 PER 4 YEARS
E0969 Wheelchair: Accessories 0 - 999 124.69 1 2 PER 4 YEARS
E0971 Wheelchair: Accessories 0 - 999 48.14 2 2 PER 4 YEARS
E0973 Wheelchair: Accessories 0 - 999 74.57 2 2 PER 4 YEARS
E0974 Wheelchair: Accessories 0 - 999 101.70 1 2 PER 4 YEARS
E0978 Wheelchair: Accessories 0 - 999 29.65 1 1 PER MEDICAL EVENT
E0980 Wheelchair: Accessories 0 - 999 22.38 1 2 PER 4 YEARS
E0981 Wheelchair: Accessories 0 - 999 38.51 1 2 PER 4 YEARS
E0982 Wheelchair: Accessories 0 - 999 44.35 1 1 PER 5 YEARS
E0983 Wheelchair: Accessories 0 - 999 2225.04 1 PA 1 PER 5 YEARS
E0984 Wheelchair: Accessories 0 - 999 1457.89 1 PA 1 PER 5 YEARS
E0986 Wheelchair: Accessories 0 - 999 4864.24 1 PA 1 PER 5 YEARS
E0990 Wheelchair: Accessories 0 - 999 89.61 2 2 PER 4 YEARS
E0992 Wheelchair: Accessories 0 - 999 69.46 1 1 PER 5 YEARS
E0994 Wheelchair: Accessories 0 - 999 14.03 2 2 PER 4 YEARS
E0995 Wheelchair: Accessories 0 - 999 19.72 2 2 PER 4 YEARS
E1002 Wheelchair: Accessories 0 - 999 3290.41 1 PA 1 PER 5 YEARS
E1003 Wheelchair: Accessories 0 - 999 3513.04 1 PA 1 PER 5 YEARS
E1004 Wheelchair: Accessories 0 - 999 3895.24 1 PA 1 PER 5 YEARS
E1005 Wheelchair: Accessories 0 - 999 4216.28 1 PA 1 PER 5 YEARS
E1015 Wheelchair: Accessories 0 - 999 91.76 2 PA 2 PER 3 YEARS
E1016 Wheelchair: Accessories 0 - 999 105.04 2 PA 2 PER 3 YEARS
E1020 Wheelchair: Accessories 0 - 999 194.72 1 PA 1 PER 4 YEARS
E1028 Wheelchair: Accessories 0 - 999 165.32 6 PA 6 PER 5 YEARS
E1029 Wheelchair: Accessories 0 - 999 295.63 1 PA 1 PER 4 YEARS
E1030 Wheelchair: Accessories 0 - 20 932.21 1 PA 1 PER 4 YEARS
E1031 Rollabout Chair and Transfer System 0 - 999 341.70 34.17 1 1 PER 5 YEARS
E1050 Wheelchair: Fully Reclining 0 - 999 689.00 68.90 1 1 PER 5 YEARS
E1060 Wheelchair: Fully Reclining 0 - 999 853.00 85.30 1 1 PER 5 YEARS
E1070 Wheelchair: Fully Reclining 0 - 999 741.10 74.11 1 1 PER 5 YEARS
E1083 Wheelchair: Fully Reclining 0 - 999 532.80 53.28 1 1 PER 5 YEARS
E1084 Wheelchair: Fully Reclining 0 - 999 663.80 66.38 1 1 PER 5 YEARS
E1085 Wheelchair: Fully Reclining 0 - 20 489.90 48.99 1 1 PER 5 YEARS
E1087 Wheelchair: Fully Reclining 0 - 999 856.00 85.60 1 1 PER 5 YEARS
E1088 Wheelchair: Fully Reclining 0 - 999 1020.70 102.07 1 1 PER 5 YEARS
E1092 Wheelchair: Fully Reclining 0 - 999 869.50 86.95 1 1 PER 5 YEARS
E1093 Wheelchair: Fully Reclining 0 - 999 869.50 86.95 1 1 PER 5 YEARS
E1100 Wheelchair: Semi-reclining 0 - 999 702.50 70.25 1 1 PER 5 YEARS
E1110 Wheelchair: Semi-reclining 0 - 999 687.80 68.78 1 1 PER 5 YEARS
E1150 Wheelchair: Standard 0 - 999 552.00 55.20 1 1 PER 5 YEARS
E1160 Wheelchair: Standard 0 - 999 426.50 42.65 1 1 PER 5 YEARS
E1170 Wheelchair: Amputee 0 - 999 604.30 60.43 1 1 PER 5 YEARS
E1171 Wheelchair: Amputee 0 - 999 542.40 54.24 1 1 PER 5 YEARS
E1172 Wheelchair: Amputee 0 - 999 662.70 66.27 1 1 PER 5 YEARS
E1180 Wheelchair: Amputee 0 - 999 685.60 68.56 1 1 PER 5 YEARS
E1190 Wheelchair: Amputee 0 - 999 792.10 79.21 1 1 PER 5 YEARS
E1195 Wheelchair: Amputee 0 - 999 850.00 85.00 1 1 PER 5 YEARS
E1200 Wheelchair: Amputee 0 - 999 588.70 58.87 1 1 PER 5 YEARS
E1221 Wheelchair: Special Size 0 - 999 321.40 32.14 1 1 PER 5 YEARS
E1222 Wheelchair: Special Size 0 - 999 458.60 45.86 1 1 PER 5 YEARS
E1223 Wheelchair: Special Size 0 - 999 500.80 50.08 1 1 PER 5 YEARS
E1224 Wheelchair: Special Size 0 - 999 549.10 54.91 1 1 PER 5 YEARS
E1225 Wheelchair: Special Size 0 - 999 305.80 30.58 1 1 PER 5 YEARS
E1226 Wheelchair: Special Size 0 - 999 353.90 1 1 PER 5 YEARS
E1227 Wheelchair: Special Size 0 - 999 220.90 1 1 PER 5 YEARS
E1228 Wheelchair: Special Size 0 - 999 18.97 1 1 PER 5 YEARS
E1231 Wheelchair: Special Size 0 - 20 1892.87 1 PA 1 PER 5 YEARS
E1232 Wheelchair: Special Size 0 - 20 1710.73 1 PA 1 PER 5 YEARS
E1233 Wheelchair: Special Size 0 - 20 1772.58 1 PA 1 PER 5 YEARS
E1234 Wheelchair: Special Size 0 - 20 1543.16 1 PA 1 PER 5 YEARS
E1235 Wheelchair: Special Size 0 - 20 1485.94 1 PA 1 PER 5 YEARS
E1236 Wheelchair: Special Size 0 - 20 1310.98 1 PA 1 PER 5 YEARS
E1237 Wheelchair: Special Size 0 - 20 1322.44 1 PA 1 PER 5 YEARS
E1238 Wheelchair: Special Size 0 - 20 1378.84 1 PA 1 PER 5 YEARS
E1240 Wheelchair: Lightweight 0 - 999 697.00 69.70 1 1 PER 5 YEARS
E1270 Wheelchair: Lightweight 0 - 999 534.20 53.42 1 1 PER 5 YEARS
E1280 Wheelchair: Heavy Duty 0 - 999 888.20 88.82 1 1 PER 5 YEARS
E1295 Wheelchair: Heavy Duty 0 - 999 821.90 82.19 1 1 PER 5 YEARS
E1296 Wheelchair: Heavy Duty 0 - 999 391.39 1 1 PER 5 YEARS
E1297 Wheelchair: Heavy Duty 0 - 999 83.27 1 1 PER 5 YEARS
E1298 Wheelchair: Heavy Duty 0 - 999 299.29 1 1 PER 5 YEARS
E1390 Additional Oxygen Related Equipment 0 - 999 0.00 RO 170.48 1 1 PER MONTH
E1392 Additional Oxygen Related Equipment 0 - 999 0.00 RO 25.65 1 1 PER MONTH
E1399 Additional Oxygen Related Equipment 0 - 999 0.00 1 PA MEDICAL NECESSITY
E1800 Other Orthopedic Devices 0 - 20 73.50 2 2 PER 2 YEARS
E1801 Other Orthopedic Devices 0 - 999 73.50 1 2 PER 2 YEARS
E1805 Other Orthopedic Devices 75.50 2 2 PER 2 YEARS
E1806 Other Orthopedic Devices 0 - 999 73.50 1 2 PER 2 YEARS
E1810 Other Orthopedic Devices 0 - 999 73.50 1 2 PER 2 YEARS
E1811 Other Orthopedic Devices 0 - 999 73.50 1 2 PER 2 YEARS
E1815 Other Orthopedic Devices 0 - 20 75.50 2 2 PER 2 YEARS
E1816 Other Orthopedic Devices 0 - 999 73.50 1 2 PER 2 YEARS
E1818 Other Orthopedic Devices 0 - 999 73.50 1 2 PER 2 YEARS
E1821 Other Orthopedic Devices 0 - 999 6.06 8 8 PER YEAR
E1820 Other Orthopedic Devices 0 - 20 6.06 8 8 PER YEAR
E1825 Other Orthopedic Devices 0 - 20 75.50 2 2 PER 2 YEARS
E1830 Other Orthopedic Devices 0 - 20 75.50 2 2 PER 2 YEARS
E1840 Other Orthopedic Devices 0 - 999 73.50 2 2 PER 2 YEARS
E1902 Miscellaneous 0 - 999 0.00 1 PA 1 PER 5 YEARS
E2000 Miscellaneous 0 - 999 22.80 1 1 PER 2 YEARS
E2101 Miscellaneous 0 - 999 150.87 1 1 PER 2 YEARS
E2205 Wheelchair Accessories 0 - 999 26.13 1 2 PER 4 YEARS
E2206 Wheelchair Accessories 0 - 999 31.04 2 2 PER 4 YEARS
E2207 Wheelchair Accessories 0 - 999 34.68 1 1 PER 5 YEARS
E2208 Wheelchair Accessories 0 - 999 95.02 1 1 PER 5 YEARS
E2209 Wheelchair Accessories 0 - 999 86.08 2 2 PER 4 YEARS
E2210 Wheelchair Accessories 0 - 999 5.24 12 12 PER 4 YEARS
E2211 Wheelchair Accessories 0 - 999 32.72 2 2 PER 2 YEARS
E2212 Wheelchair Accessories 0 - 999 4.70 2 2 PER 2 YEARS
E2213 Wheelchair Accessories 0 - 999 24.32 2 2 PER 2 YEARS
E2214 Wheelchair Accessories 0 - 999 24.48 2 2 PER 2 YEARS
E2215 Wheelchair Accessories 0 - 999 7.68 2 2 PER 2 YEARS
E2217 Wheelchair Accessories 0 - 999 27.14 2 2 PER 2 YEARS
E2219 Wheelchair Accessories 0 - 999 28.45 2 2 PER 2 YEARS
E2220 Wheelchair Accessories 0 - 999 22.81 2 2 PER 2 YEARS
E2221 Wheelchair Accessories 0 - 999 20.44 2 2 PER 2 YEARS
E2224 Wheelchair Accessories 0 - 999 78.44 2 2 PER 2 YEARS
E2322 Wheelchair Accessories 0 - 999 1128.28 1 PA 1 PER 5 YEARS
E2323 Wheelchair Accessories 0 - 999 55.32 1 1 PER 5 YEARS
E2324 Wheelchair Accessories 0 - 999 35.05 1 1 PER 5 YEARS
E2325 Wheelchair Accessories 0 - 999 1077.46 1 PA 1 PER 5 YEARS
E2326 Wheelchair Accessories 0 - 999 277.71 1 1 PER 5 YEARS
E2327 Wheelchair Accessories 0 - 999 2089.90 1 PA 1 PER 5 YEARS
E2328 Wheelchair Accessories 0 - 999 3964.25 1 PA 1 PER 5 YEARS
E2329 Wheelchair Accessories 0 - 999 1412.90 1 PA 1 PER 5 YEARS
E2330 Wheelchair Accessories 0 - 999 2737.67 1 PA 1 PER 5 YEARS
E2360 Wheelchair Accessories 0 - 999 85.73 2 4 PER 3 YEARS
E2361 Wheelchair Accessories 0 - 999 106.42 2 4 PER 3 YEARS
E2362 Wheelchair Accessories 0 - 999 70.26 2 4 PER 3 YEARS
E2363 Wheelchair Accessories 0 - 999 141.94 2 4 PER 3 YEARS
E2364 Wheelchair Accessories 0 - 999 85.72 2 4 PER 3 YEARS
E2365 Wheelchair Accessories 0 - 999 85.59 2 4 PER 3 YEARS
E2366 Wheelchair Accessories 0 - 999 201.16 1 1 PER 5 YEARS
E2367 Wheelchair Accessories 0 - 999 319.78 1 1 PER LIFETIME
E2368 Wheelchair Accessories 0 - 999 413.25 2 PA 2 PER 5 YEARS
E2369 Wheelchair Accessories 0 - 999 359.95 2 PA 2 PER 5 YEARS
E2370 Wheelchair Accessories 0 - 999 642.27 2 PA 2 PER 5 YEARS
E2373 Wheelchair Accessories 0 - 999 820.72 1 PA 1 PER 5 YEARS
E2374 Wheelchair Accessories 0 - 999 427.22 1 PA 1 PER 5 YEARS
E2381 Wheelchair Accessories 0 - 999 58.13 2 2 PER 4 YEARS
E2382 Wheelchair Accessories 0 - 999 15.85 2 2 PER 4 YEARS
E2383 Wheelchair Accessories 0 - 999 115.90 2 2 PER 4 YEARS
E2384 Wheelchair Accessories 0 - 999 37.77 2 2 PER 4 YEARS
E2385 Wheelchair Accessories 0 - 999 37.77 2 2 PER 4 YEARS
E2386 Wheelchair Accessories 0 - 999 58.13 2 2 PER 4 YEARS
E2387 Wheelchair Accessories 0 - 999 61.74 2 2 PER 4 YEARS
E2388 Wheelchair Accessories 0 - 999 58.13 2 2 PER 4 YEARS
E2389 Wheelchair Accessories 0 - 999 61.74 2 2 PER 4 YEARS
E2390 Wheelchair Accessories 0 - 999 58.13 2 2 PER 4 YEARS
E2391 Wheelchair Accessories 0 - 999 61.74 2 2 PER 4 YEARS
E2394 Wheelchair Accessories 0 - 999 61.40 2 2 PER 4 YEARS
E2395 Wheelchair Accessories 0 - 999 30.47 2 2 PER 4 YEARS
E2396 Wheelchair Accessories 0 - 999 45.00 2 2 PER 4 YEARS
E2500 Speech Device 0 - 999 336.03 1 PA 1 PER 5 YEARS
E2502 Speech Device 0 - 999 1027.54 1 PA 1 PER 5 YEARS
E2504 Speech Device 0 - 999 1355.47 1 PA 1 PER 5 YEARS
E2506 Speech Device 0 - 999 1987.53 1 PA 1 PER 5 YEARS
E2508 Speech Device 0 - 999 3073.38 1 PA 1 PER 5 YEARS
E2510 Speech Device 0 - 999 5815.95 1 PA 1 PER 5 YEARS
E2511 Speech Device 0 - 999 0.00 1 PA 1 PER 5 YEARS
E2512 Speech Device 0 - 999 0.00 1 PA 1 PER 5 YEARS
E2599 Speech Device 0 - 999 0.00 1 PA 1 PER 5 YEARS
E2601 Wheelchair: Cushion 0 - 999 70.92 1 PA 1 PER 3 YEARS
E2602 Wheelchair: Cushion 0 - 999 129.50 1 PA 1 PER 3 YEARS
E2603 Wheelchair: Cushion 0 - 999 186.43 1 PA 1 PER 3 YEARS
E2604 Wheelchair: Cushion 0 - 999 252.60 1 PA 1 PER 3 YEARS
E2605 Wheelchair: Cushion 0 - 999 257.35 1 PA 1 PER 3 YEARS
E2606 Wheelchair: Cushion 0 - 999 348.85 1 PA 1 PER 3 YEARS
E2607 Wheelchair: Cushion 0 - 999 236.48 1 PA 1 PER 3 YEARS
E2608 Wheelchair: Cushion 0 - 999 283.20 1 PA 1 PER 3 YEARS
E2611 Wheelchair: Cushion 0 - 999 249.88 1 PA 1 PER 3 YEARS
E2612 Wheelchair: Cushion 0 - 999 338.03 1 PA 1 PER 3 YEARS
E2613 Wheelchair: Cushion 0 - 999 314.43 1 PA 1 PER 3 YEARS
E2614 Wheelchair: Cushion 0 - 999 435.14 1 PA 1 PER 3 YEARS
E2615 Wheelchair: Cushion 0 - 999 361.85 1 PA 1 PER 3 YEARS
E2616 Wheelchair: Cushion 0 - 999 486.86 1 PA 1 PER 3 YEARS
E2619 Wheelchair: Cushion 0 - 999 49.05 1 1 PER 3 YEARS
E2620 Wheelchair: Cushion 0 - 999 438.16 1 PA 1 PER 3 YEARS
E2621 Wheelchair: Cushion 0 - 999 459.81 1 PA 1 PER 3 YEARS
K0001 Wheelchair and Accessories 0 - 999 354.30 35.43 1 1 PER 5 YEARS
K0002 Wheelchair and Accessories 0 - 999 530.70 53.07 1 1 PER 5 YEARS
K0003 Wheelchair and Accessories 0 - 999 581.10 58.11 1 1 PER 5 YEARS
K0004 Wheelchair and Accessories 0 - 999 866.80 86.68 1 1 PER 5 YEARS
K0005 Wheelchair and Accessories 0 - 999 1410.70 1 1 PER 5 YEARS
K0006 Wheelchair and Accessories 0 - 999 813.40 81.34 1 1 PER 5 YEARS
K0007 Wheelchair and Accessories 0 - 999 1263.90 126.39 1 1 PER 5 YEARS
K0008 Wheelchair and Accessories 0 - 999 0.00 1 PA 1 PER 5 YEARS
K0009 Wheelchair and Accessories 0 - 999 0.00 1 PA 1 PER 5 YEARS
K0010 Wheelchair and Accessories 0 - 999 2763.00 276.30 1 PA 1 PER 5 YEARS
K0012 Wheelchair and Accessories 0 - 999 2269.40 226.94 1 PA 1 PER 5 YEARS
K0013 Wheelchair and Accessories 0 - 999 0.00 1 PA 1 PER 5 YEARS
K0014 Wheelchair and Accessories 0 - 999 0.00 1 PA 1 PER 5 YEARS
K0015 Wheelchair and Accessories 0 - 999 138.65 2 2 PER 5 YEARS
K0017 Wheelchair and Accessories 0 - 999 39.00 2 2 PER 5 YEARS
K0018 Wheelchair and Accessories 0 - 999 21.78 2 2 PER 5 YEARS
K0019 Wheelchair and Accessories 0 - 999 12.47 2 2 PER 5 YEARS
K0020 Wheelchair and Accessories 0 - 999 35.45 1 2 PER 4 YEARS
K0037 Wheelchair and Accessories 0 - 999 36.75 2 2 PER 4 YEARS
K0038 Wheelchair and Accessories 0 - 999 18.51 2 2 PER 4 YEARS
K0039 Wheelchair and Accessories 0 - 999 41.11 2 2 PER 4 YEARS
K0040 Wheelchair and Accessories 0 - 999 56.98 2 2 PER 2 YEARS
K0041 Wheelchair and Accessories 0 - 999 40.38 2 2 PER 2 YEARS
K0042 Wheelchair and Accessories 0 - 999 27.79 2 2 PER 2 YEARS
K0043 Wheelchair and Accessories 0 - 999 14.90 2 2 PER 2 YEARS
K0044 Wheelchair and Accessories 0 - 999 12.97 2 2 PER 2 YEARS
K0045 Wheelchair and Accessories 0 - 999 43.00 2 2 PER 2 YEARS
K0046 Wheelchair and Accessories 0 - 999 14.90 2 2 PER 4 YEARS
K0047 Wheelchair and Accessories 0 - 999 58.36 2 2 PER 4 YEARS
K0050 Wheelchair and Accessories 0 - 999 24.80 2 2 PER 4 YEARS
K0051 Wheelchair and Accessories 0 - 999 40.14 2 2 PER 4 YEARS
K0052 Wheelchair and Accessories 0 - 999 70.54 2 2 PER 4 YEARS
K0053 Wheelchair and Accessories 0 - 999 77.84 2 2 PER 4 YEARS
K0056 Wheelchair and Accessories 0 - 999 72.65 1 1 PER 4 YEARS
K0065 Wheelchair and Accessories 0 - 999 33.93 2 1 PER 4 YEARS
K0069 Wheelchair and Accessories 0 - 999 76.24 2 1 PER 4 YEARS
K0070 Wheelchair and Accessories 0 - 999 139.77 2 1 PER 4 YEARS
K0071 Wheelchair and Accessories 0 - 999 83.36 2 1 PER 4 YEARS
K0072 Wheelchair and Accessories 0 - 999 50.18 2 1 PER 4 YEARS
K0073 Wheelchair and Accessories 0 - 999 25.54 2 1 PER 4 YEARS
K0077 Wheelchair and Accessories 0 - 999 44.90 2 1 PER 4 YEARS
K0098 Wheelchair and Accessories 0 - 999 20.15 1 2 PER 4 YEARS
K0105 Wheelchair and Accessories 0 - 999 75.87 2 1 PER 5 YEARS
K0108 Wheelchair and Accessories 0 - 999 0.00 1 PA MEDICAL NECESSITY
K0195 Wheelchair and Accessories 0 - 999 150.60 15.06 1 2 PER 4 YEARS
K0739 Wheelchair and Accessories 0 - 999 10.00 16 $160.00 PER YEAR
K0800 Wheelchair and Accessories 0 - 999 957.40 95.74 1 PA 1 PER 5 YEARS
K0801 Wheelchair and Accessories 0 - 999 1543.60 154.36 1 PA 1 PER 5 YEARS
K0802 Wheelchair and Accessories 0 - 999 1746.90 174.69 1 PA 1 PER 5 YEARS
K0822 Wheelchair and Accessories 0 - 999 3699.70 369.97 1 PA 1 PER 5 YEARS
K0823 Wheelchair and Accessories 0 - 999 3699.70 369.97 1 PA 1 PER 5 YEARS
K0824 Wheelchair and Accessories 0 - 999 5379.90 537.99 1 PA 1 PER 5 YEARS
K0825 Wheelchair and Accessories 0 - 999 4925.30 492.53 1 PA 1 PER 5 YEARS
K0826 Wheelchair and Accessories 0 - 999 6965.00 696.50 1 PA 1 PER 5 YEARS
K0827 Wheelchair and Accessories 0 - 999 5922.30 592.23 1 PA 1 PER 5 YEARS
K0900 Wheelchair and Accessories 0 - 999 0.00 1 PA PER MEDICAL EVENT
L0120 Orthotic Devices: Spinal 0 - 999 12.13 1 2 PER MEDICAL EVENT
L0130 Orthotic Devices: Spinal 0 - 999 48.50 1 1 PER MEDICAL EVENT
L0140 Orthotic Devices: Spinal 0 - 999 38.80 1 1 PER YEAR
L0150 Orthotic Devices: Spinal 0 - 999 53.35 1 1 PER MEDICAL EVENT
L0160 Orthotic Devices: Spinal 0 - 999 87.30 1 1 PER MEDICAL EVENT
L0170 Orthotic Devices: Spinal 0 - 999 348.93 1 1 PER MEDICAL EVENT
L0172 Orthotic Devices: Spinal 0 - 999 43.17 1 2 PER MEDICAL EVENT
L0174 Orthotic Devices: Spinal 0 - 999 52.38 1 1 PER YEAR
L0180 Orthotic Devices: Spinal 0 - 999 180.42 1 1 PER MEDICAL EVENT
L0190 Orthotic Devices: Spinal 0 - 999 281.30 1 1 PER MEDICAL EVENT
L0200 Orthotic Devices: Spinal 0 - 999 197.88 1 1 PER MEDICAL EVENT
L0220 Orthotic Devices: Spinal 0 - 999 58.20 1 1 PER YEAR
L0450 Thoracic-Lumbar-Sacral 0 - 999 121.76 1 1 PER MEDICAL EVENT
L0452 Thoracic-Lumbar-Sacral 0 - 999 227.53 1 1 PER MEDICAL EVENT
L0454 Thoracic-Lumbar-Sacral 0 - 999 220.10 1 1 PER MEDICAL EVENT
L0456 Thoracic-Lumbar-Sacral 0 - 999 220.10 1 1 PER MEDICAL EVENT
L0458 Thoracic-Lumbar-Sacral 0 - 999 546.30 1 1 PER MEDICAL EVENT
L0460 Thoracic-Lumbar-Sacral 0 - 999 546.30 1 1 PER MEDICAL EVENT
L0462 Thoracic-Lumbar-Sacral 0 - 999 546.30 1 1 PER MEDICAL EVENT
L0464 Thoracic-Lumbar-Sacral 0 - 999 546.30 1 1 PER MEDICAL EVENT
L0466 Thoracic-Lumbar-Sacral 0 - 999 247.50 1 1 PER MEDICAL EVENT
L0468 Thoracic-Lumbar-Sacral 0 - 999 310.30 1 1 PER MEDICAL EVENT
L0470 Thoracic-Lumbar-Sacral 0 - 999 441.79 1 1 PER MEDICAL EVENT
L0472 Thoracic-Lumbar-Sacral 0 - 999 277.30 1 1 PER MEDICAL EVENT
L0480 Thoracic-Lumbar-Sacral 0 - 999 857.50 1 1 PER MEDICAL EVENT
L0482 Thoracic-Lumbar-Sacral 0 - 999 983.01 1 1 PER MEDICAL EVENT
L0484 Thoracic-Lumbar-Sacral 0 - 999 1145.74 1 1 PER MEDICAL EVENT
L0486 Thoracic-Lumbar-Sacral 0 - 999 1135.42 1 1 PER MEDICAL EVENT
L0488 Thoracic-Lumbar-Sacral 0 - 999 227.53 1 1 PER MEDICAL EVENT
L0490 Thoracic-Lumbar-Sacral 0 - 999 734.56 1 1 PER MEDICAL EVENT
L0491 Thoracic-Lumbar-Sacral 0 - 999 497.29 1 1 PER 2 YEARS
L0621 Sacroiliac, Lumbar, Sacral Orthosis 0 - 999 72.17 1 1 PER 2 YEARS
L0622 Sacroiliac, Lumbar, Sacral Orthosis 0 - 999 195.70 1 1 PER 2 YEARS
L0623 Sacroiliac, Lumbar, Sacral Orthosis 0 - 999 34.00 1 1 PER 2 YEARS
L0624 Sacroiliac, Lumbar, Sacral Orthosis 0 - 999 241.68 1 1 PER 2 YEARS
L0625 Sacroiliac, Lumbar, Sacral Orthosis 0 - 999 44.60 1 1 PER 2 YEARS
L0626 Sacroiliac, Lumbar, Sacral Orthosis 0 - 999 63.10 1 1 PER 2 YEARS
L0627 Sacroiliac, Lumbar, Sacral Orthosis 0 - 999 332.72 1 1 PER 2 YEARS
L0628 Sacroiliac, Lumbar, Sacral Orthosis 0 - 999 67.89 1 1 PER 2 YEARS
L0629 Sacroiliac, Lumbar, Sacral Orthosis 0 - 999 173.63 MEDICAL NECESSITY
L0630 Sacroiliac, Lumbar, Sacral Orthosis 0 - 999 131.07 1 2 PER LIFETIME
L0631 Sacroiliac, Lumbar, Sacral Orthosis 0 - 999 830.92 1 2 PER LIFETIME
L0700 Cervical-Thoracic Lumbar Sacral 0 - 999 1406.50 1 1 PER MEDICAL EVENT
L0710 Cervical-Thoracic Lumbar Sacral 0 - 999 1552.00 1 1 PER MEDICAL EVENT
L0810 Halo Procedure 0 - 999 1552.00 1 1 PER MEDICAL EVENT
L0820 Halo Procedure 0 - 999 1164.00 1 1 PER MEDICAL EVENT
L0830 Halo Procedure 0 - 999 1527.75 1 1 PER MEDICAL EVENT
L0859 Halo Procedure 0 - 999 917.03 2 2 EVERY 2 YEARS
L0970 Additions to Spinal Orthoses 0 - 999 50.93 1 1 PER 2 YEARS
L0972 Additions to Spinal Orthoses 0 - 999 48.50 1 1 PER 2 YEARS
L0974 Additions to Spinal Orthoses 0 - 999 111.55 1 1 PER 2 YEARS
L0976 Additions to Spinal Orthoses 0 - 999 112.52 1 1 PER 2 YEARS
L0978 Additions to Spinal Orthoses 0 - 999 67.90 1 1 PER 2 YEARS
L0980 Additions to Spinal Orthoses 0 - 999 3.88 1 2 PER YEAR
L0984 Additions to Spinal Orthoses 0 - 999 33.84 2 2 PER YEAR
L0999 Additions to Spinal Orthoses 0 - 999 0.00 1 PA MEDICAL NECESSITY
L1000 Scoliosis: Cervical-Thoracic-Lumbar-Sacral 0 - 999 937.02 1 1 PER YEAR
L1005 Scoliosis: Cervical-Thoracic-Lumbar-Sacral 0 - 999 60.00 1 1 PER 2 YEARS
L1010 Scoliosis: Cervical-Thoracic-Lumbar-Sacral 0 - 999 33.95 1 1 PER YEAR
L1020 Correction Pads 0 - 999 59.66 2 2 PER YEAR
L1025 Correction Pads 0 - 999 78.57 1 1 PER YEAR
L1030 Correction Pads 0 - 999 59.17 2 2 PER YEAR
L1040 Correction Pads 0 - 999 67.90 2 2 PER YEAR
L1050 Correction Pads 0 - 999 39.77 1 1 PER YEAR
L1060 Correction Pads 0 - 999 45.59 2 2 PER YEAR
L1070 Correction Pads 0 - 999 33.95 2 2 PER YEAR
L1080 Correction Pads 0 - 999 43.65 2 2 PER YEAR
L1085 Correction Pads 0 - 999 66.93 1 1 PER YEAR
L1090 Correction Pads 0 - 999 43.65 2 2 PER YEAR
L1100 Correction Pads 0 - 999 72.75 1 1 PER YEAR
L1110 Correction Pads 0 - 999 121.25 1 1 PER YEAR
L1120 Correction Pads 0 - 999 21.34 6 6 PER YEAR
L1200 Scoliosis: Thoracic Lumbar-Sacral (Low Profile) 0 - 999 679.00 1 1 PER YEAR
L1210 Scoliosis: Thoracic Lumbar-Sacral (Low Profile) 0 - 999 45.59 2 2 PER YEAR
L1220 Scoliosis: Thoracic Lumbar-Sacral (Low Profile) 0 - 999 45.59 1 1 PER YEAR
L1230 Scoliosis: Thoracic Lumbar-Sacral (Low Profile) 0 - 999 266.75 1 1 PER 2 YEARS
L1240 Scoliosis: Thoracic Lumbar-Sacral (Low Profile) 0 - 999 48.50 2 2 PER YEAR
L1250 Scoliosis: Thoracic Lumbar-Sacral (Low Profile) 0 - 999 30.07 2 2 PER YEAR
L1260 Scoliosis: Thoracic Lumbar-Sacral (Low Profile) 0 - 999 58.20 2 2 PER YEAR
L1270 Scoliosis: Thoracic Lumbar-Sacral (Low Profile) 0 - 999 50.44 2 2 PER YEAR
L1280 Scoliosis: Thoracic Lumbar-Sacral (Low Profile) 0 - 999 46.56 2 2 PER YEAR
L1290 Scoliosis: Thoracic Lumbar-Sacral (Low Profile) 0 - 999 43.65 2 2 PER YEAR
L1300 Other Scoliosis Procedures 0 - 999 727.50 1 1 PER YEAR
L1310 Other Scoliosis Procedures 0 - 999 776.00 1 1 PER MEDICAL EVENT
L1499 Other Scoliosis Procedures 0 - 999 0.00 1 PA MEDICAL NECESSITY
L1600 Hip: Flexible 0 - 999 53.35 1 1 PER LIFETIME
L1620 Hip: Flexible 0 - 999 43.65 1 1 PER 5 YEARS
L1630 Hip: Flexible 0 - 999 53.35 1 1 PER LIFETIME
L1640 Hip: Flexible 0 - 999 116.40 1 1 PER 5 YEARS
L1650 Hip: Flexible 0 - 999 116.40 1 1 PER LIFETIME
L1652 Hip: Flexible 0 - 999 184.66 1 1 PER MEDICAL EVENT
L1660 Hip: Flexible 0 - 999 29.10 1 1 PER 5 YEARS
L1680 Hip: Flexible 0 - 999 460.75 1 1 PER MEDICAL EVENT
L1685 Hip: Flexible 0 - 999 819.65 1 1 PER MEDICAL EVENT
L1686 Hip: Flexible 0 - 999 567.45 1 1 PER MEDICAL EVENT
L1690 Hip: Flexible 0 - 999 1170.82 2 2 PER MEDICAL EVENT
L1700 Legg Perthes 0 - 999 904.04 1 1 PER MEDICAL EVENT
L1710 Legg Perthes 0 - 999 557.75 1 1 PER MEDICAL EVENT
L1720 Legg Perthes 0 - 999 834.20 1 1 PER MEDICAL EVENT
L1730 Legg Perthes 0 - 999 557.75 1 1 PER MEDICAL EVENT
L1755 Legg Perthes 0 - 999 732.35 1 1 PER MEDICAL EVENT
L1810 Knee 0 - 999 OS 79.06 2 2 PER YEAR
L1820 Knee 0 - 999 OS 58.20 2 2 PER YEAR
L1830 Knee 0 - 999 OS 48.50 2 2 PER YEAR
L1832 Knee 0 - 999 OS 559.32 2 2 PER 2 YEARS
L1834 Knee 0 - 999 630.50 2 2 PER YEAR
L1836 Knee 0 - 999 OS 69.12 2 2 PER YEAR
L1840 Knee 0 - 999 582.00 2 2 PER YEAR
L1843 Knee 0 - 999 OS 323.72 2 2 PER 2 YEARS
L1844 Knee 0 - 999 572.30 2 2 PER 2 YEARS
L1845 Knee 0 - 999 OS 572.30 2 2 PER 2 YEARS
L1846 Knee 0 - 999 577.15 2 2 PER YEAR
L1847 Knee 0 - 999 OS 348.25 2 2 PER MEDICAL EVENT
L1850 Knee 0 - 999 OS 134.83 2 2 PER 2 YEARS
L1860 Knee 0 - 999 485.00 2 2 PER 2 YEARS
L1900 Ankle-Foot 0 - 999 189.15 2 2 PER 2 YEARS
L1902 Ankle-Foot 0 - 999 OS 39.29 2 2 PER YEAR
L1904 Ankle-Foot 0 - 999 221.65 2 2 PER YEAR
L1906 Ankle-Foot 0 - 999 OS 83.91 2 2 PER MEDICAL EVENT
L1910 Ankle-Foot 0 - 999 OS 137.74 2 2 PER 2 YEARS
L1920 Ankle-Foot 0 - 999 126.10 2 2 PER YEAR
L1930 Ankle-Foot 0 - 999 OS 79.06 2 2 PER YEAR
L1940 Ankle-Foot 0 - 999 261.90 2 2 PER YEAR
L1945 Ankle-Foot 0 - 999 630.50 2 2 PER YEAR
L1950 Ankle-Foot 0 - 999 215.34 2 2 PER YEAR
L1960 Ankle-Foot 0 - 999 251.23 2 2 PER YEAR
L1970 Ankle-Foot 0 - 999 363.75 2 2 PER YEAR
L1980 Ankle-Foot 0 - 999 121.25 2 2 PER 2 YEARS
L1990 Ankle-Foot 0 - 999 223.10 2 2 PER 2 YEARS
L2000 Hip-Knee-Ankle-Foot 0 - 999 282.27 2 2 PER 2 YEARS
L2010 Hip-Knee-Ankle-Foot 0 - 999 237.65 2 2 PER 2 YEARS
L2020 Hip-Knee-Ankle-Foot 0 - 999 461.72 2 2 PER YEAR
L2030 Hip-Knee-Ankle-Foot 0 - 999 295.85 2 2 PER 2 YEARS
L2034 Hip-Knee-Ankle-Foot 0 - 999 OS 1236.00 1 2 PER 2 YEARS
L2036 Hip-Knee-Ankle-Foot 0 - 999 1047.60 2 2 PER YEAR
L2037 Hip-Knee-Ankle-Foot 0 - 999 1067.00 2 2 PER 2 YEARS
L2038 Hip-Knee-Ankle-Foot 0 - 999 582.00 2 2 PER YEAR
L2040 Torsion Control 0 - 999 97.00 1 1 PER YEAR
L2050 Torsion Control 0 - 999 232.80 1 1 PER YEAR
L2060 Torsion Control 0 - 999 291.00 1 1 PER YEAR
L2070 Torsion Control 0 - 999 60.14 1 1 PER YEAR
L2080 Torsion Control 0 - 999 189.15 1 1 PER YEAR
L2090 Torsion Control 0 - 999 262.79 2 2 PER 2 YEARS
L2106 Fracture Orthoses 0 - 999 228.92 2 2 PER MEDICAL EVENT
L2108 Fracture Orthoses 0 - 999 598.49 2 2 PER MEDICAL EVENT
L2112 Fracture Orthoses 0 - 999 OS 331.74 2 2 PER MEDICAL EVENT
L2114 Fracture Orthoses 0 - 999 OS 465.60 2 2 PER MEDICAL EVENT
L2116 Fracture Orthoses 0 - 999 OS 465.60 2 2 PER MEDICAL EVENT
L2126 Fracture Orthoses 0 - 999 776.49 2 2 PER MEDICAL EVENT
L2128 Fracture Orthoses 0 - 999 976.31 2 2 PER MEDICAL EVENT
L2132 Fracture Orthoses 0 - 999 OS 487.91 2 2 PER MEDICAL EVENT
L2134 Fracture Orthoses 0 - 999 487.91 2 2 PER MEDICAL EVENT
L2136 Fracture Orthoses 0 - 999 665.42 2 2 PER MEDICAL EVENT
L2180 Additions to Fracture Orthosis 0 - 999 43.65 2 2 PER MEDICAL EVENT
L2182 Additions to Fracture Orthosis 0 - 999 41.16 2 2 PER MEDICAL EVENT
L2184 Additions to Fracture Orthosis 0 - 999 74.11 2 2 PER MEDICAL EVENT
L2186 Additions to Fracture Orthosis 0 - 999 43.65 2 2 PER MEDICAL EVENT
L2188 Additions to Fracture Orthosis 0 - 999 288.09 2 2 PER MEDICAL EVENT
L2190 Additions to Fracture Orthosis 0 - 999 48.02 2 2 PER MEDICAL EVENT
L2192 Additions to Fracture Orthosis 0 - 999 150.35 1 1 PER MEDICAL EVENT
L2200 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 20.91 4 2 PER Individual ORTHOSIS
L2210 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 43.65 4 2 PER Individual ORTHOSIS
L2220 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 56.26 4 2 PER Individual ORTHOSIS
L2230 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 31.04 2 2 PER ORTHOSIS
L2240 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 31.04 2 2 PER ORTHOSIS
L2250 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 179.45 2 2 PER ORTHOSIS
L2260 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 67.90 2 2 PER ORTHOSIS
L2265 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 19.40 2 2 PER ORTHOSIS
L2270 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 31.04 4 1 PER ORTHOSIS
L2275 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 72.85 4 Only 2 PER ORTHOSIS
L2280 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 242.50 2 2 PER 3 YEARS
L2300 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 72.75 1 1 PER 2 YEARS
L2310 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 43.65 1 1 PER 2 YEARS
L2320 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 67.90 2 2 PER ORTHOSIS
L2330 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 161.99 2 2 PER ORTHOSIS
L2335 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 110.58 2 2 PER ORTHOSIS
L2340 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 290.03 2 2 PER ORTHOSIS
L2350 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 363.75 4 2 PER Individual ORTHOSIS
L2360 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 29.10 4 4 PER YEAR
L2370 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 65.96 4 2 PER Individual ORTHOSIS
L2375 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 43.65 4 4 PER ORTHOSIS
L2380 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 43.65 4 4 PER ORTHOSIS
L2385 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 21.83 4 4 PER ORTHOSIS
L2390 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 42.20 4 4 PER ORTHOSIS
L2395 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 73.46 4 4 PER ORTHOSIS
L2397 Additions to Lower Extremity Orthosis Shoe-Ankle-Shin-Knee 0 - 999 65.34 2 4 PER ORTHOSIS
L2405 Additions to Straight Knee or Offset Knee Joints 0 - 999 21.34 4 4 PER ORTHOSIS
L2415 Additions to Straight Knee or Offset Knee Joints 0 - 999 142.11 4 4 PER ORTHOSIS
L2425 Additions to Straight Knee or Offset Knee Joints 0 - 999 104.76 4 4 PER ORTHOSIS
L2430 Additions to Straight Knee or Offset Knee Joints 0 - 999 58.30 4 2 PER ORTHOSIS
L2492 Additions to Straight Knee or Offset Knee Joints 0 - 999 19.40 4 2 PER ORTHOSIS
L2500 Additions to Thigh/Weight Bearing Gluteal/Ischial Weight Bearing 0 - 999 98.94 2 1 PER Individual ORTHOSIS
L2510 Additions to Thigh/Weight Bearing Gluteal/Ischial Weight Bearing 0 - 999 334.65 2 1 PER ORTHOSIS
L2520 Additions to Thigh/Weight Bearing Gluteal/Ischial Weight Bearing 0 - 999 174.60 2 1 PER ORTHOSIS
L2525 Additions to Thigh/Weight Bearing Gluteal/Ischial Weight Bearing 0 - 999 630.50 2 1 PER ORTHOSIS
L2526 Additions to Thigh/Weight Bearing Gluteal/Ischial Weight Bearing 0 - 999 436.50 2 1 PER ORTHOSIS
L2530 Additions to Thigh/Weight Bearing Gluteal/Ischial Weight Bearing 0 - 999 87.30 2 1 PER ORTHOSIS
L2540 Additions to Thigh/Weight Bearing Gluteal/Ischial Weight Bearing 0 - 999 161.99 2 1 PER ORTHOSIS
L2550 Additions to Thigh/Weight Bearing Gluteal/Ischial Weight Bearing 0 - 999 113.49 2 1 PER ORTHOSIS
L2570 Additions to Pelvic and Thoracic Control 0 - 999 92.15 2 1 PER ORTHOSIS
L2580 Additions to Pelvic and Thoracic Control 0 - 999 355.99 1 1 PER 2 YEARS
L2600 Additions to Pelvic and Thoracic Control 0 - 999 82.45 2 2 PER ORTHOSIS
L2610 Additions to Pelvic and Thoracic Control 0 - 999 106.94 2 2 PER ORTHOSIS
L2620 Additions to Pelvic and Thoracic Control 0 - 999 117.89 2 1 PER ORTHOSIS
L2622 Additions to Pelvic and Thoracic Control 0 - 999 83.91 2 2 PER ORTHOSIS
L2624 Additions to Pelvic and Thoracic Control 0 - 999 266.27 2 1 PER ORTHOSIS
L2627 Additions to Pelvic and Thoracic Control 0 - 999 665.42 1 1 PER 2 YEARS
L2628 Additions to Pelvic and Thoracic Control 0 - 999 1018.50 1 1 PER YEAR
L2630 Additions to Pelvic and Thoracic Control 0 - 999 82.45 1 1 PER ORTHOSIS
L2640 Additions to Pelvic and Thoracic Control 0 - 999 121.25 1 1 PER YEAR
L2650 Additions to Pelvic and Thoracic Control 0 - 999 48.50 1 2 PER YEAR
L2660 Additions to Pelvic and Thoracic Control 0 - 999 87.30 1 1 PER 2 YEARS
L2670 Additions to Pelvic and Thoracic Control 0 - 999 67.90 1 1 PER 2 YEARS
L2680 Additions to Pelvic and Thoracic Control 0 - 999 58.20 2 2 PER YEAR
L2750 General Additions 0 - 999 46.60 2 4 PER ORTHOSIS
L2755 General Additions 0 - 999 77.50 2 1 PER ORTHOSIS
L2760 General Additions 0 - 999 27.16 8 4 PER ORTHOSIS
L2768 General Additions 0 - 999 15.00 2 2 PER 2 YEARS
L2780 General Additions 0 - 999 40.06 4 4 PER ORTHOSIS
L2785 General Additions 0 - 999 21.34 4 2 PER KAFO
L2795 General Additions 0 - 999 35.89 2 1 PER KAFO
L2800 General Additions 0 - 999 48.99 2 1 PER KAFO
L2810 General Additions 0 - 999 48.02 2 2 PER KAFO
L2820 General Additions 0 - 999 30.56 2 1 PER KAFO
L2830 General Additions 0 - 999 30.56 2 1 PER KAFO
L2840 General Additions 0 - 999 37.60 2 2 PER MEDICAL EVENT
L2850 General Additions 0 - 999 29.10 2 2 PER MEDICAL EVENT
L2999 General Additions 0 - 999 0.00 1 PA MEDICAL NECESSITY
L3000 Insert, Removable, Molded to Patient Model 0 - 999 168.78 2 1 PER FOOT PER YEAR
L3001 Insert, Removable, Molded to Patient Model 0 - 999 29.10 2 2 PER FOOT PER YEAR
L3002 Insert, Removable, Molded to Patient Model 0 - 999 77.60 2 2 PER FOOT PER YEAR
L3010 Insert, Removable, Molded to Patient Model 0 - 999 77.60 2 1 PER FOOT PER YEAR
L3020 Insert, Removable, Molded to Patient Model 0 - 999 77.60 2 1 PER FOOT PER YEAR
L3030 Insert, Removable, Molded to Patient Model 0 - 999 72.75 2 2 PER FOOT PER YEAR
L3040 Arch Support, Removable, Premolded 0 - 999 58.20 2 2 PER FOOT PER YEAR
L3050 Arch Support, Removable, Premolded 0 - 999 58.20 2 2 PER FOOT PER YEAR
L3060 Arch Support, Removable, Premolded 0 - 999 77.60 2 2 PER FOOT PER YEAR
L3070 Arch Support, Non-removable, Attached to Shoe 0 - 999 8.73 2 1 PER FOOT PER YEAR
L3080 Arch Support, Non-removable, Attached to Shoe 0 - 999 4.37 2 1 PER FOOT PER YEAR
L3100 Arch Support, Non-removable, Attached to Shoe 0 - 999 24.25 2 2 PER YEAR
L3140 Abduction and Rotation Bars 0 - 999 35.41 1 2 PER YEAR
L3150 Abduction and Rotation Bars 0 - 999 28.13 1 2 PER YEAR
L3170 Abduction and Rotation Bars 0 - 999 15.52 2 2 PER FOOT PER YEAR
L3201 Orthopedic Footwear 0 - 20 36.38 2 3 PAIR PER YEAR
L3202 Orthopedic Footwear 0 - 20 36.38 2 3 PAIR PER YEAR
L3203 Orthopedic Footwear 0 - 20 36.38 2 3 PAIR PER YEAR
L3204 Orthopedic Footwear 0 - 20 34.92 2 3 PAIR PER YEAR
L3206 Orthopedic Footwear 0 - 20 41.71 2 3 PAIR PER YEAR
L3207 Orthopedic Footwear 0 - 20 52.38 2 3 PAIR PER YEAR
L3208 Orthopedic Footwear 0 - 20 17.46 2 2 PER FOOT PER YEAR
L3209 Orthopedic Footwear 0 - 20 17.46 2 2 PER FOOT PER YEAR
L3211 Orthopedic Footwear 0 - 20 19.40 2 2 PER FOOT PER YEAR
L3215 Orthopedic Footwear 0 - 999 79.54 2 2 PER FOOT PER YEAR
L3216 Orthopedic Footwear 0 - 999 79.54 2 2 PER FOOT PER YEAR
L3217 Orthopedic Footwear 0 - 999 91.18 2 2 PER FOOT PER YEAR
L3219 Orthopedic Footwear 0 - 999 79.54 2 2 PER FOOT PER YEAR
L3221 Orthopedic Footwear 0 - 999 69.84 2 2 PER FOOT PER YEAR
L3222 Orthopedic Footwear 0 - 999 96.03 2 2 PER FOOT PER YEAR
L3230 Orthopedic Footwear 0 - 999 79.54 2 2 PER FOOT PER YEAR
L3251 Orthopedic Footwear 0 - 999 213.44 2 2 PER FOOT PER YEAR
L3253 Orthopedic Footwear 0 - 999 65.96 2 1 PER FOOT PER YEAR
L3254 Orthopedic Footwear 0 - 999 1.99 2 6 PER YEAR
L3255 Orthopedic Footwear 0 - 999 3.15 2 6 PER YEAR
L3257 Orthopedic Footwear 0 - 999 0.00 1 PA 3 PER YEAR
L3300 Shoe Modifications Lifts 0 - 999 17.95 3 3 PER YEAR
L3310 Shoe Modifications Lifts 0 - 999 35.41 3 3 PER YEAR
L3320 Shoe Modifications Lifts 0 - 999 107.19 3 3 PER YEAR
L3330 Shoe Modifications Lifts 0 - 999 291.84 3 3 PER YEAR
L3332 Shoe Modifications Lifts 0 - 999 25.71 3 3 PER YEAR
L3334 Shoe Modifications Lifts 0 - 999 16.98 3 3 PER YEAR
L3340 Wedges 0 - 999 48.02 2 4 PER YEAR
L3350 Wedges 0 - 999 12.61 2 4 PER YEAR
L3360 Wedges 0 - 999 19.40 2 4 PER YEAR
L3370 Wedges 0 - 999 14.55 2 4 PER YEAR
L3380 Wedges 0 - 999 15.52 2 4 PER YEAR
L3390 Wedges 0 - 999 22.80 2 4 PER YEAR
L3400 Wedges 0 - 999 24.25 2 4 PER YEAR
L3410 Wedges 0 - 999 11.16 2 4 PER YEAR
L3420 Wedges 0 - 999 18.92 2 4 PER YEAR
L3430 Heels 0 - 999 19.89 2 2 PER YEAR
L3440 Heels 0 - 999 28.13 2 2 PER YEAR
L3450 Heels 0 - 999 25.71 2 2 PER YEAR
L3460 Heels 0 - 999 9.22 2 2 PER YEAR
L3465 Heels 0 - 999 11.16 2 2 PER YEAR
L3470 Heels 0 - 999 14.55 2 2 PER YEAR
L3480 Heels 0 - 999 9.70 2 2 PER FOOT PER YEAR
L3570 Additions to Orthopedic Shoes 0 - 999 20.37 2 6 PER YEAR
L3580 Additions to Orthopedic Shoes 0 - 999 33.69 2 2 PER YEAR
L3590 Additions to Orthopedic Shoes 0 - 999 27.74 2 2 PER YEAR
L3595 Additions to Orthopedic Shoes 0 - 999 20.37 2 2 PER YEAR
L3600 Transfer or Replacement 0 - 999 32.98 2 3 PER YEAR
L3610 Transfer or Replacement 0 - 999 52.18 2 3 PER YEAR
L3620 Transfer or Replacement 0 - 999 32.01 2 3 PER YEAR
L3630 Transfer or Replacement 0 - 999 52.18 2 3 PER YEAR
L3640 Transfer or Replacement 0 - 999 22.46 1 3 PER YEAR
L3649 Transfer or Replacement 0 - 999 0.00 1 PA MEDICAL NECESSITY
L3650 Shoulder 0 - 999 OS 27.16 2 2 PER MEDICAL EVENT
L3660 Shoulder 0 - 999 OS 43.17 2 2 PER MEDICAL EVENT
L3670 Shoulder 0 - 999 OS 58.20 2 2 PER MEDICAL EVENT
L3675 Shoulder 0 - 999 OS 96.70 1 1 PER 2 YEARS
L3677 Shoulder 0 - 999 OS 144.50 2 2 PER 2 YEARS
L3710 Elbow 0 - 999 OS 79.10 2 2 PER YEAR
L3720 Elbow 0 - 999 226.01 2 2 PER YEAR
L3730 Elbow 0 - 999 376.36 2 2 PER YEAR
L3740 Elbow 0 - 999 443.29 2 2 PER YEAR
L3760 Elbow 0 - 999 OS 268.57 2 PER MEDICAL EVENT
L3761 Elbow 0 - 999 OS 375.65 2 PER MEDICAL EVENT
L3762 Elbow 0 - 999 OS 50.70 2 2 PER YEAR
L3763 Elbow 0 - 999 218.25 2 2 PER MEDICAL EVENT
L3764 Elbow 0 - 999 288.09 2 2 PER MEDICAL EVENT
L3808 Wrist-Hand-Finder Orthosis 0 - 999 173.46 2 2 PER MEDICAL EVENT
L3900 Additions and Extensions 0 - 999 887.55 2 2 PER YEAR
L3901 Additions and Extensions 0 - 999 909.38 2 2 PER YEAR
L3904 External Power 0 - 999 1945.40 2 1 PER ORTHOSIS
L3906 Other Wrist-Hand-Finger Orthoses: Custom Fitted 0 - 999 241.53 2 2 PER MEDICAL EVENT
L3908 Other Wrist-Hand-Finger Orthoses: Custom Fitted 0 - 999 OS 17.46 2 4 PER YEAR
L3912 Other Wrist-Hand-Finger Orthoses: Custom Fitted 0 - 999 OS 19.40 2 2 PER 2 YEARS
L3923 Other Wrist-Hand-Finger Orthoses: Custom Fitted 0 - 999 OS 21.88 1 PER MEDICAL EVENT
L3925 Other Wrist-Hand-Finger Orthoses: Custom Fitted 0 - 999 OS 33.35 2 2 PER YEAR
L3929 Other Wrist-Hand-Finger Orthoses: Custom Fitted 0 - 999 OS 53.14 2 2 PER YEAR
L3931 Other Wrist-Hand-Finger Orthoses: Custom Fitted 0 - 999 OS 128.55 2 2 PER YEAR
L3960 Abduction Positioning: Custom Fitted 0 - 999 OS 296.34 2 2 PER MEDICAL EVENT
L3962 Abduction Positioning: Custom Fitted 0 - 999 OS 186.24 2 2 PER 2 YEARS
L3980 Fracture Orthoses 0 - 999 OS 121.25 2 2 PER MEDICAL EVENT
L3982 Fracture Orthoses 0 - 999 OS 218.25 2 2 PER MEDICAL EVENT
L3984 Fracture Orthoses 0 - 999 OS 244.44 2 2 PER MEDICAL EVENT
L3995 Fracture Orthoses 0 - 999 OS 11.64 2 6 PER MEDICAL EVENT
L3999 Fracture Orthoses 0 - 999 0.00 2 PA MEDICAL NECESSITY
L4000 Specific Repair 0 - 999 630.50 2 2 PER 2 YEARS
L4010 Specific Repair 0 - 999 174.60 2 2 PER LIFETIME
L4020 Specific Repair 0 - 999 334.65 2 2 PER YEAR
L4030 Specific Repair 0 - 999 174.60 2 2 PER YEAR
L4040 Specific Repair 0 - 999 176.54 2 2 PER YEAR
L4045 Specific Repair 0 - 999 177.03 2 2 PER YEAR
L4050 Specific Repair 0 - 999 160.05 2 2 PER YEAR
L4055 Specific Repair 0 - 999 154.72 2 2 PER YEAR
L4060 Specific Repair 0 - 999 205.64 2 2 PER YEAR
L4070 Specific Repair 0 - 999 87.30 4 4 PER YEAR
L4080 Specific Repair 0 - 999 46.01 2 2 PER YEAR
L4090 Specific Repair 0 - 999 41.19 2 2 PER YEAR
L4100 Specific Repair 0 - 999 36.86 2 2 PER YEAR
L4110 Specific Repair 0 - 999 32.98 2 2 PER YEAR
L4130 Specific Repair 0 - 999 290.03 2 2 PER YEAR
L4205 Repairs 0 - 999 10.00 16 $160.00 PER YEAR
L4210 Repairs 0 - 999 0.00 1 PA LIMITED TO $160 PER YEAR
L4350 Ancillary Orthotic Services 0 - 999 OS 60.14 2 2 PER MEDICAL EVENT (One per Leg)
L4360 Ancillary Orthotic Services 0 - 999 OS 184.78 2 2 PER MEDICAL EVENT (One per Leg)
L4370 Ancillary Orthotic Services 0 - 999 OS 72.75 2 2 PER MEDICAL EVENT
L4386 Ancillary Orthotic Services 0 - 999 OS 107.08 2 2 PER MEDICAL EVENT (One per Leg)
L4392 Ancillary Orthotic Services 0 - 999 13.95 1 2 PER YEAR
L4394 Ancillary Orthotic Services 0 - 999 10.20 1 2 PER YEAR
L4396 Ancillary Orthotic Services 0 - 999 99.60 2 2 PER YEAR
L4398 Ancillary Orthotic Services 0 - 999 45.80 2 2 PER 2 YEARS
L5000 Partial Foot 0 - 999 129.98 2 2 PER PROSTHETIC PER 2 YEARS
L5010 Partial Foot 0 - 999 527.20 2 2 PER PROSTHETIC PER 2 YEARS
L5020 Partial Foot 0 - 999 527.20 2 2 PER PROSTHETIC PER 2 YEARS
L5050 Ankle 0 - 999 1387.59 2 2 PER PROSTHETIC PER 2 YEARS
L5060 Ankle 0 - 999 1251.30 2 2 PER PROSTHETIC PER 2 YEARS
L5100 Below Knee 0 - 999 1377.40 2 2 PER PROSTHETIC PER YEAR
L5105 Below Knee 0 - 999 1719.81 2 2 PER PROSTHETIC PER YEAR
L5150 Knee Disarticulation 0 - 999 1940.00 2 2 PER PROSTHETIC PER YEAR
L5160 Knee Disarticulation 0 - 999 2037.00 2 2 PER PROSTHETIC PER YEAR
L5200 Above Knee 0 - 999 1713.02 2 2 PER PROSTHETIC PER YEAR
L5210 Above Knee 0 - 999 1261.00 2 2 PER PROSTHETIC PER YEAR
L5220 Above Knee 0 - 999 1261.00 2 2 PER PROSTHETIC PER YEAR
L5230 Above Knee 0 - 999 1746.00 2 2 PER PROSTHETIC PER YEAR
L5250 Hip Disarticulation 0 - 999 2840.16 2 2 PER PROSTHETIC PER YEAR
L5280 Hip Disarticulation 0 - 999 3007.00 2 2 PER PROSTHETIC PER YEAR
L5301 Endoskeleton: Below Knee 0 - 999 1457.05 2 2 PER PROSTHETIC PER 2 YEARS
L5312 Endoskeleton: Below Knee 0 - 999 2959.06 2 2 PER PROSTHETIC PER 2 YEARS
L5321 Endoskeletal: Above Knee 0 - 999 2530.27 2 2 PER PROSTHETIC PER 2 YEARS
L5331 Endoskeletal: Hip Disarticulation 0 - 999 3224.08 2 2 PER PROSTHETIC PER 2 YEARS
L5341 Endoskeletal: Hemipelvectomy 0 - 999 3356.28 2 2 PER PROSTHETIC PER 2 YEARS
L5400 Immediate Postsurgical or Early Fitting Procedures 0 - 999 679.00 2 1 PER AMPUTATION
L5410 Immediate Postsurgical or Early Fitting Procedures 0 - 999 203.70 2 1 PER AMPUTATION
L5420 Immediate Postsurgical or Early Fitting Procedures 0 - 999 732.35 2 1 PER AMPUTATION
L5430 Immediate Postsurgical or Early Fitting Procedures 0 - 999 203.70 2 1 PER AMPUTATION
L5450 Immediate Postsurgical or Early Fitting Procedures 0 - 999 227.95 2 1 PER AMPUTATION
L5460 Immediate Postsurgical or Early Fitting Procedures 0 - 999 378.30 2 1 PER AMPUTATION
L5530 Preparatory Prosthesis 0 - 999 877.85 2 1 PER AMPUTATION
L5535 Preparatory Prosthesis 0 - 999 727.50 2 1 PER AMPUTATION
L5540 Preparatory Prosthesis 0 - 999 877.85 2 1 PER AMPUTATION
L5560 Preparatory Prosthesis 0 - 999 873.00 4 2 PER AMPUTATION
L5580 Preparatory Prosthesis 0 - 999 945.75 2 1 PER AMPUTATION
L5585 Preparatory Prosthesis 0 - 999 803.16 2 1 PER AMPUTATION
L5590 Preparatory Prosthesis 0 - 999 1067.97 2 1 PER AMPUTATION
L5595 Preparatory Prosthesis 0 - 999 2075.80 2 1 PER AMPUTATION
L5600 Preparatory Prosthesis 0 - 999 2308.60 2 1 PER AMPUTATION
L5610 Additions to Lower Extremity 0 - 999 920.53 2 2 PER PROSTHETIC PER 4 YEARS
L5611 Additions to Lower Extremity 0 - 999 921.50 2 2 PER PROSTHETIC PER 4 YEARS
L5613 Additions to Lower Extremity 0 - 999 1697.50 2 2 PER PROSTHETIC PER 4 YEARS
L5616 Additions to Lower Extremity 0 - 999 485.00 2 2 PER PROSTHETIC PER 4 YEARS
L5617 Additions to Lower Extremity 0 - 999 323.00 2 2 PER PROSTHETIC PER 3 YEARS
L5618 Additions to Test Sockets 0 - 999 169.75 2 2 PER PROSTHETIC PER 2 YEARS
L5620 Additions to Test Sockets 0 - 999 145.50 2 2 PER PROSTHETIC PER 2 YEARS
L5622 Additions to Test Sockets 0 - 999 169.75 2 2 PER PROSTHETIC PER 2 YEARS
L5624 Additions to Test Sockets 0 - 999 162.96 2 2 PER PROSTHETIC PER 2 YEARS
L5626 Additions to Test Sockets 0 - 999 169.75 2 2 PER PROSTHETIC PER 2 YEARS
L5628 Additions to Test Sockets 0 - 999 169.75 2 2 PER PROSTHETIC PER 2 YEARS
L5629 Additions to Test Sockets 0 - 999 121.25 2 1 PER PROSTHESIS
L5630 Additions to Socket Variations 0 - 999 242.50 2 2 PER PROSTHETIC PER 4 YEARS
L5631 Additions to Socket Variations 0 - 999 194.00 2 2 PER PROSTHETIC PER 4 YEARS
L5632 Additions to Socket Variations 0 - 999 119.83 2 2 PER PROSTHETIC PER 4 YEARS
L5634 Additions to Socket Variations 0 - 999 72.75 2 2 PER PROSTHETIC PER 4 YEARS
L5636 Additions to Socket Variations 0 - 999 118.77 2 2 PER PROSTHETIC PER 4 YEARS
L5637 Additions to Socket Variations 0 - 999 121.25 2 2 PER PROSTHETIC PER 4 YEARS
L5638 Additions to Socket Variations 0 - 999 169.75 2 2 PER PROSTHETIC PER 4 YEARS
L5639 Additions to Socket Variations 0 - 999 563.28 2 1 PER PROSTHESIS
L5640 Additions to Socket Variations 0 - 999 371.51 2 2 PER PROSTHETIC PER 4 YEARS
L5642 Additions to Socket Variations 0 - 999 371.51 2 2 PER PROSTHETIC PER 4 YEARS
L5643 Additions to Socket Variations 0 - 999 399.16 2 2 PER PROSTHETIC PER 4 YEARS
L5644 Additions to Socket Variations 0 - 999 97.00 2 2 PER PROSTHETIC PER 4 YEARS
L5645 Additions to Socket Variations 0 - 999 132.89 2 2 PER PROSTHETIC PER 4 YEARS
L5646 Additions to Socket Variations 0 - 999 211.46 2 2 PER PROSTHETIC PER 4 YEARS
L5647 Additions to Socket Variations 0 - 999 266.27 2 2 PER PROSTHETIC PER 4 YEARS
L5648 Additions to Socket Variations 0 - 999 211.46 2 2 PER PROSTHETIC PER 2 YEARS
L5649 Additions to Socket Variations 0 - 999 1331.33 2 2 PER PROSTHETIC PER 2 YEARS
L5650 Additions to Socket Variations 0 - 999 97.00 2 2 PER PROSTHETIC PER 4 YEARS
L5651 Additions to Socket Variations 0 - 999 443.29 2 2 PER PROSTHETIC PER 2 YEARS
L5652 Additions to Socket Variations 0 - 999 218.25 2 2 PER PROSTHETIC PER 2 YEARS
L5653 Additions to Socket Variations 0 - 999 242.50 2 2 PER PROSTHETIC PER 2 YEARS
L5654 Additions to Socket Insert and Suspension 0 - 999 203.70 2 2 PER PROSTHETIC PER YEAR
L5655 Additions to Socket Insert and Suspension 0 - 999 162.96 2 2 PER PROSTHETIC PER YEAR
L5656 Additions to Socket Insert and Suspension 0 - 999 218.25 2 2 PER PROSTHETIC PER YEAR
L5658 Additions to Socket Insert and Suspension 0 - 999 218.25 2 2 PER PROSTHETIC PER YEAR
L5661 Additions to Socket Insert and Suspension 0 - 999 221.16 2 2 PER PROSTHETIC PER YEAR
L5665 Additions to Socket Insert and Suspension 0 - 999 198.85 2 2 PER PROSTHETIC PER YEAR
L5666 Additions to Socket Insert and Suspension 0 - 999 29.10 2 2 PER PROSTHETIC PER YEAR
L5668 Additions to Socket Insert and Suspension 0 - 999 77.60 2 2 PER PROSTHETIC PER YEAR
L5670 Additions to Socket Insert and Suspension 0 - 999 106.70 2 2 PER PROSTHETIC PER 2 YEARS
L5671 Additions to Socket Insert and Suspension 0 - 999 376.66 2 2 PER PROSTHETIC PER 2 YEARS
L5672 Additions to Socket Insert and Suspension 0 - 999 93.12 2 2 PER PROSTHETIC PER 2 YEARS
L5673 Additions to Socket Insert and Suspension 0 - 999 451.23 2 1 PER PROSTHESIS
L5676 Additions to Socket Insert and Suspension 0 - 999 214.37 2 2 PER PROSTHETIC PER 4 YEARS
L5677 Additions to Socket Insert and Suspension 0 - 999 252.69 2 2 PER PROSTHETIC PER 4 YEARS
L5678 Additions to Socket Insert and Suspension 0 - 999 9.70 2 2 PER PROSTHETIC PER 2 YEARS
L5679 Additions to Socket Insert and Suspension 0 - 999 376.02 2 2 PER PROSTHETIC PER YEAR
L5680 Additions to Socket Insert and Suspension 0 - 999 184.30 2 2 PER PROSTHETIC PER 4 YEARS
L5681 Additions to Socket Insert and Suspension 0 - 999 799.71 2 1 PER ORTHOSIS
L5682 Additions to Socket Insert and Suspension 0 - 999 194.00 2 2 PER PROSTHETIC PER 4 YEARS
L5684 Additions to Socket Insert and Suspension 0 - 999 14.55 2 2 PER PROSTHETIC PER 4 YEARS
L5685 Additions to Socket Insert and Suspension 0 - 999 45.59 2 6 PER PROSTHETIC PER YEAR
L5686 Additions to Socket Insert and Suspension 0 - 999 9.70 2 2 PER PROSTHETIC PER 2 YEARS
L5688 Additions to Socket Insert and Suspension 0 - 999 34.92 2 2 PER PROSTHETIC PER YEAR
L5690 Additions to Socket Insert and Suspension 0 - 999 50.44 2 2 PER PROSTHETIC PER YEAR
L5692 Additions to Socket Insert and Suspension 0 - 999 43.65 2 2 PER PROSTHETIC PER YEAR
L5694 Additions to Socket Insert and Suspension 0 - 999 81.48 2 2 PER PROSTHETIC PER YEAR
L5695 Additions to Socket Insert and Suspension 0 - 999 89.73 2 4 PER PROSTHETIC PER YEAR
L5696 Additions to Socket Insert and Suspension 0 - 999 92.15 2 2 PER PROSTHETIC PER 2 YEARS
L5697 Additions to Socket Insert and Suspension 0 - 999 48.50 2 2 PER PROSTHETIC PER 2 YEARS
L5698 Additions to Socket Insert and Suspension 0 - 999 72.75 2 2 PER PROSTHETIC PER YEAR
L5699 Additions to Socket Insert and Suspension 0 - 999 38.80 2 2 PER PROSTHETIC PER YEAR
L5700 Additions/Replacements to Feet-Ankle Units 0 - 999 1701.79 2 2 PER PROSTHETIC PER 4 YEARS
L5701 Additions/Replacements to Feet-Ankle Units 0 - 999 2043.73 2 2 PER PROSTHETIC PER 4 YEARS
L5702 Additions/Replacements to Feet-Ankle Units 0 - 999 2585.62 2 2 PER PROSTHETIC PER 4 YEARS
L5704 Additions/Replacements to Feet-Ankle Units 0 - 999 318.36 2 2 PER PROSTHETIC PER 4 YEARS
L5705 Additions/Replacements to Feet-Ankle Units 0 - 999 568.86 2 2 PER PROSTHETIC PER 4 YEARS
L5706 Additions/Replacements to Feet-Ankle Units 0 - 999 557.64 2 2 PER PROSTHETIC PER 4 YEARS
L5707 Additions/Replacements to Feet-Ankle Units 0 - 999 735.17 2 2 PER PROSTHETIC PER 4 YEARS
L5710 Additions to Exoskeletal-Knee Shin System 0 - 999 97.00 2 2 PER PROSTHETIC PER 4 YEARS
L5711 Additions to Exoskeletal-Knee Shin System 0 - 999 88.27 2 2 PER PROSTHETIC PER 4 YEARS
L5712 Additions to Exoskeletal-Knee Shin System 0 - 999 242.50 2 2 PER PROSTHETIC PER 4 YEARS
L5714 Additions to Exoskeletal-Knee Shin System 0 - 999 209.87 2 2 PER PROSTHETIC PER 4 YEARS
L5716 Additions to Exoskeletal-Knee Shin System 0 - 999 242.50 2 2 PER PROSTHETIC PER 4 YEARS
L5718 Additions to Exoskeletal-Knee Shin System 0 - 999 399.16 2 2 PER PROSTHETIC PER 4 YEARS
L5722 Additions to Exoskeletal-Knee Shin System 0 - 999 492.76 2 2 PER PROSTHETIC PER 4 YEARS
L5724 Additions to Exoskeletal-Knee Shin System 0 - 999 650.87 2 2 PER PROSTHETIC PER 4 YEARS
L5726 Additions to Exoskeletal-Knee Shin System 0 - 999 643.11 2 2 PER PROSTHETIC PER 4 YEARS
L5728 Additions to Exoskeletal-Knee Shin System 0 - 999 1070.88 2 2 PER PROSTHETIC PER 4 YEARS
L5780 Additions to Exoskeletal-Knee Shin System 0 - 999 680.02 2 2 PER PROSTHETIC PER 4 YEARS
L5785 Component Modification 0 - 999 309.92 2 2 PER PROSTHETIC PER 4 YEARS
L5790 Component Modification 0 - 999 528.55 2 2 PER PROSTHETIC PER 4 YEARS
L5795 Component Modification 0 - 999 1052.35 2 2 PER PROSTHETIC PER 4 YEARS
L5810 Endoskeletal 0 - 999 88.27 2 2 PER PROSTHETIC PER 4 YEARS
L5811 Endoskeletal 0 - 999 341.97 2 2 PER PROSTHETIC PER 4 YEARS
L5812 Endoskeletal 0 - 999 315.25 2 2 PER PROSTHETIC PER 4 YEARS
L5814 Endoskeletal 0 - 999 2200.00 2 2 PER PROSTHETIC PER 2 YEARS
L5816 Endoskeletal 0 - 999 221.16 2 2 PER PROSTHETIC PER 4 YEARS
L5818 Endoskeletal 0 - 999 398.67 2 2 PER PROSTHETIC PER 4 YEARS
L5822 Endoskeletal 0 - 999 451.05 2 2 PER PROSTHETIC PER 4 YEARS
L5824 Endoskeletal 0 - 999 607.22 2 2 PER PROSTHETIC PER 4 YEARS
L5828 Endoskeletal 0 - 999 1065.06 2 2 PER PROSTHETIC PER 4 YEARS
L5830 Endoskeletal 0 - 999 785.70 2 2 PER PROSTHETIC PER 4 YEARS
L5840 Endoskeletal 0 - 999 2083.91 2 2 PER PROSTHETIC PER 4 YEARS
L5845 Endoskeletal 0 - 999 1066.00 2 2 PER PROSTHETIC PER 3 YEARS
L5850 Endoskeletal 0 - 999 43.65 2 2 PER PROSTHETIC PER 4 YEARS
L5855 Endoskeletal 0 - 999 204.18 2 2 PER PROSTHETIC PER 4 YEARS
L5910 Endoskeletal 0 - 999 88.27 2 2 PER PROSTHETIC PER 4 YEARS
L5920 Endoskeletal 0 - 999 177.03 2 2 PER PROSTHETIC PER 4 YEARS
L5940 Endoskeletal 0 - 999 340.47 2 2 PER PROSTHETIC PER 2 YEARS
L5950 Endoskeletal 0 - 999 576.54 2 2 PER PROSTHETIC PER 2 YEARS
L5960 Endoskeletal 0 - 999 1196.98 2 2 PER PROSTHETIC PER 4 YEARS
L5962 Endoskeletal 0 - 999 376.82 2 2 PER PROSTHETIC PER 4 YEARS
L5964 Endoskeletal 0 - 999 556.26 2 2 PER PROSTHETIC PER 4 YEARS
L5966 Endoskeletal 0 - 999 708.80 2 2 PER PROSTHETIC PER 4 YEARS
L5968 Endoskeletal 0 - 999 2204.51 2 2 PER PROSTHETIC PER 4 YEARS
L5970 Endoskeletal 0 - 999 48.50 2 2 PER PROSTHETIC PER 2 YEARS
L5972 Endoskeletal 0 - 999 177.03 2 2 PER PROSTHETIC PER 2 YEARS
L5974 Endoskeletal 0 - 999 67.90 2 2 PER PROSTHETIC PER 2 YEARS
L5975 Endoskeletal 0 - 999 281.24 2 2 PER PROSTHETIC PER 4 YEARS
L5976 Endoskeletal 0 - 999 291.00 2 2 PER PROSTHETIC PER 2 YEARS
L5978 Endoskeletal 0 - 999 135.80 2 2 PER PROSTHETIC PER 2 YEARS
L5979 Endoskeletal 0 - 999 1355.26 2 2 PER PROSTHETIC PER 2 YEARS
L5980 Endoskeletal 0 - 999 2202.21 2 2 PER PROSTHETIC PER 2 YEARS
L5981 Endoskeletal 0 - 999 1779.08 2 2 PER PROSTHETIC PER 2 YEARS
L5982 Endoskeletal 0 - 999 204.67 2 2 PER PROSTHETIC PER 2 YEARS
L5984 Endoskeletal 0 - 999 243.47 2 2 PER PROSTHETIC PER 2 YEARS
L5985 Endoskeletal 0 - 999 163.00 2 2 PER PROSTHETIC PER 3 YEARS
L5986 Endoskeletal 0 - 999 203.70 2 2 PER PROSTHETIC PER 2 YEARS
L5987 Endoskeletal 0 - 999 4275.00 2 2 PER PROSTHETIC PER 2 YEARS
L5988 Endoskeletal 0 - 999 1211.88 2 2 PER PROSTHETIC PER 4 YEARS
L5990 Endoskeletal 0 - 999 39.45 2 2 PER PROSTHETIC PER 2 YEARS
L5999 Endoskeletal 0 - 999 0.00 1 PA MEDICAL NECESSITY
L6000 Partial Hand 0 - 999 638.26 2 2 PER 4 YEARS
L6010 Partial Hand 0 - 999 638.26 2 2 PER 4 YEARS
L6020 Partial Hand 0 - 999 638.26 2 2 PER 2 YEARS
L6050 Wrist Disarticulation 0 - 999 1013.65 2 2 PER 2 YEARS
L6055 Wrist Disarticulation 0 - 999 1237.72 2 2 PER 4 YEARS
L6100 Below Elbow 0 - 999 1009.77 2 2 PER 2 YEARS
L6110 Below Elbow 0 - 999 1057.30 2 2 PER 2 YEARS
L6120 Below Elbow 0 - 999 1231.90 2 2 PER 4 YEARS
L6130 Below Elbow 0 - 999 1231.90 2 2 PER 4 YEARS
L6200 Elbow Disarticulation 0 - 999 1421.05 2 2 PER 4 YEARS
L6205 Elbow Disarticulation 0 - 999 1641.24 2 2 PER 4 YEARS
L6250 Above Elbow 0 - 999 1425.90 2 2 PER 2 YEARS
L6300 Shoulder Disarticulation 0 - 999 1891.50 2 2 PER 2 YEARS
L6310 Shoulder Disarticulation 0 - 999 1891.50 2 2 PER 4 YEARS
L6320 Shoulder Disarticulation 0 - 999 630.50 2 2 PER 4 YEARS
L6350 Interscapular Thoracic 0 - 999 1891.50 2 2 PER 2 YEARS
L6360 Interscapular Thoracic 0 - 999 2085.50 2 2 PER 4 YEARS
L6370 Interscapular Thoracic 0 - 999 630.50 2 2 PER 4 YEARS
L6380 Immediate and Early Postsurgical Procedures 0 - 999 725.48 2 1 PER ORTHOSIS
L6382 Immediate and Early Postsurgical Procedures 0 - 999 1091.47 2 1 PER ORTHOSIS
L6384 Immediate and Early Postsurgical Procedures 0 - 999 1509.92 2 1 PER ORTHOSIS
L6386 Immediate and Early Postsurgical Procedures 0 - 999 238.52 2 1 PER ORTHOSIS
L6388 Immediate and Early Postsurgical Procedures 0 - 999 261.12 2 1 PER ORTHOSIS
L6400 Endoskeletal: Below Elbow 0 - 999 1261.00 2 2 PER 4 YEARS
L6450 Endoskeletal: Elbow Disarticulation 0 - 999 1818.75 2 2 PER 4 YEARS
L6500 Endoskeletal: Above Elbow 0 - 999 1818.75 2 2 PER 4 YEARS
L6550 Endoskeletal: Shoulder Disarticulation 0 - 999 1891.50 2 2 PER 4 YEARS
L6570 Endoskeletal: Interscapular Thoracic 0 - 999 2085.50 2 2 PER 4 YEARS
L6580 Endoskeletal: Interscapular Thoracic 0 - 999 992.50 2 2 PER 4 YEARS
L6582 Endoskeletal: Interscapular Thoracic 0 - 999 898.93 2 2 PER 4 YEARS
L6584 Endoskeletal: Interscapular Thoracic 0 - 999 1409.60 2 2 PER 4 YEARS
L6586 Endoskeletal: Interscapular Thoracic 0 - 999 1319.30 2 2 PER 4 YEARS
L6588 Endoskeletal: Interscapular Thoracic 0 - 999 2166.92 2 2 PER 4 YEARS
L6590 Endoskeletal: Interscapular Thoracic 0 - 999 1646.61 2 2 PER 4 YEARS
L6600 Additions to Upper Limb 0 - 999 53.35 2 2 PER 4 YEARS
L6605 Additions to Upper Limb 0 - 999 53.35 2 2 PER 4 YEARS
L6610 Additions to Upper Limb 0 - 999 53.35 2 2 PER 4 YEARS
L6615 Additions to Upper Limb 0 - 999 128.04 2 2 PER 2 YEARS
L6616 Additions to Upper Limb 0 - 999 43.65 2 6 PER 4 YEARS
L6620 Additions to Upper Limb 0 - 999 163.93 2 2 PER 2 YEARS
L6624 Additions to Upper Limb 0 - 999 1407.61 2 1 PER ORTHOSIS
L6625 Additions to Upper Limb 0 - 999 145.50 2 2 PER 4 YEARS
L6628 Additions to Upper Limb 0 - 999 284.54 2 2 PER 4 YEARS
L6629 Additions to Upper Limb 0 - 999 86.90 2 2 PER 4 YEARS
L6630 Additions to Upper Limb 0 - 999 102.15 2 2 PER 2 YEARS
L6632 Additions to Upper Limb 0 - 999 30.56 2 12 PER YEAR
L6635 Additions to Upper Limb 0 - 999 75.66 2 2 PER 2 YEARS
L6637 Additions to Upper Limb 0 - 999 223.14 2 2 PER 4 YEARS
L6640 Additions to Upper Limb 0 - 999 156.66 2 2 PER 4 YEARS
L6641 Additions to Upper Limb 0 - 999 52.87 2 2 PER 4 YEARS
L6642 Additions to Upper Limb 0 - 999 66.93 2 2 PER 4 YEARS
L6645 Additions to Upper Limb 0 - 999 236.20 2 2 PER 4 YEARS
L6650 Additions to Upper Limb 0 - 999 249.29 2 2 PER 4 YEARS
L6655 Additions to Upper Limb 0 - 999 19.40 2 2 PER YEAR
L6660 Additions to Upper Limb 0 - 999 24.25 2 2 PER YEAR
L6665 Additions to Upper Limb 0 - 999 21.15 2 2 PER YEAR
L6670 Additions to Upper Limb 0 - 999 11.64 2 2 PER YEAR
L6672 Additions to Upper Limb 0 - 999 38.80 2 2 PER YEAR
L6675 Additions to Upper Limb 0 - 999 31.04 2 2 PER YEAR
L6676 Additions to Upper Limb 0 - 999 77.60 2 2 PER YEAR
L6680 Additions to Upper Limb 0 - 999 67.90 2 2 PER PROSTHESIS
L6682 Additions to Upper Limb 0 - 999 77.60 2 2 PER PROSTHESIS
L6684 Additions to Upper Limb 0 - 999 82.45 2 2 PER PROSTHESIS
L6686 Additions to Upper Limb 0 - 999 309.92 2 2 PER 4 YEARS
L6687 Additions to Upper Limb 0 - 999 266.27 2 2 PER 4 YEARS
L6688 Additions to Upper Limb 0 - 999 266.27 2 2 PER 4 YEARS
L6689 Additions to Upper Limb 0 - 999 398.67 2 2 PER 4 YEARS
L6690 Additions to Upper Limb 0 - 999 398.67 2 2 PER 4 YEARS
L6691 Additions to Upper Limb 0 - 999 199.34 2 2 PER YEAR
L6692 Additions to Upper Limb 0 - 999 363.75 2 2 PER 2 YEARS
L6693 Additions to Upper Limb 0 - 999 1722.26 2 2 PER 4 YEARS
L6703 Hooks 0 - 999 270.50 2 2 PER 4 YEARS
L6706 Hooks 0 - 999 259.62 2 2 PER 4 YEARS
L6707 Hooks 0 - 999 956.93 2 2 PER 4 YEARS
L6708 Hooks 0 - 999 625.58 2 2 PER 4 YEARS
L6709 Hooks 0 - 999 901.47 2 2 PER 4 YEARS
L6805 Hooks 0 - 999 156.17 2 2 PER 4 YEARS
L6810 Hooks 0 - 999 81.48 2 2 PER 4 YEARS
L6881 Hands 0 - 999 500.00 2 2 PER 2 YEARS
L6882 Hands 0 - 999 2333.46 1 2 PER 2 YEARS
L6890 Gloves for Above Hands 0 - 999 78.09 2 2 PER YEAR
L6900 Hand Restoration 0 - 999 526.71 2 2 PER 4 YEARS
L6905 Hand Restoration 0 - 999 526.71 2 2 PER 4 YEARS
L6910 Hand Restoration 0 - 999 526.71 2 2 PER 4 YEARS
L6915 Hand Restoration 0 - 999 276.45 2 2 PER 4 YEARS
L6920 Base Devices 0 - 999 2522.00 2 2 PER LIFETIME
L6925 Base Devices 0 - 999 3201.00 2 2 PER LIFETIME
L6930 Base Devices 0 - 999 2522.00 2 2 PER LIFETIME
L6935 Base Devices 0 - 999 3201.00 2 2 PER LIFETIME
L6940 Base Devices 0 - 999 3622.95 2 2 PER LIFETIME
L6945 Base Devices 0 - 999 4301.95 2 2 PER LIFETIME
L6950 Base Devices 0 - 999 4186.52 2 2 PER LIFETIME
L6955 Base Devices 0 - 999 4865.52 2 2 PER LIFETIME
L6960 Base Devices 0 - 999 6106.15 2 2 PER LIFETIME
L6965 Base Devices 0 - 999 5427.15 2 2 PER LIFETIME
L6970 Base Devices 0 - 999 6106.15 2 2 PER LIFETIME
L6975 Base Devices 0 - 999 6785.15 2 2 PER LIFETIME
L7007 Terminal Devices 0 - 999 2638.56 2 2 PER LIFETIME
L7008 Terminal Devices 0 - 999 2172.80 2 2 PER LIFETIME
L7009 Terminal Devices 0 - 999 2586.02 2 2 PER LIFETIME
L7040 Terminal Devices 0 - 999 985.52 2 2 PER LIFETIME
L7045 Terminal Devices 0 - 999 467.54 2 2 PER LIFETIME
L7170 Elbow 0 - 999 3415.37 2 2 PER LIFETIME
L7185 Elbow 0 - 999 3415.37 2 2 PER LIFETIME
L7186 Elbow 0 - 999 6294.33 2 2 PER LIFETIME
L7360 Battery Components 0 - 999 79.54 2 2 PER 3 YEARS
L7362 Battery Components 0 - 999 79.54 2 1 PER LIFETIME
L7364 Battery Components 0 - 999 121.25 2 2 PER 3 YEARS
L7366 Battery Components 0 - 999 249.29 1 1 PER 3 YEARS
L7499 Other/Repair 0 - 999 0.00 2 PA MEDICAL NECESSITY
L7520 Other/Repair 0 - 999 0.00 1 PA MEDICAL NECESSITY
L8000 Breast Prostheses 0 - 999 26.13 2 2 PER YEAR
L8001 Breast Prostheses 0 - 999 125.00 2 2 PER 2 YEARS
L8002 Breast Prostheses 0 - 999 165.00 2 2 PER 2 YEARS
L8010 Breast Prostheses 0 - 999 37.15 6 6 PER YEAR
L8015 Breast Prostheses 0 - 999 34.42 2 2 PER 4 YEARS
L8020 Breast Prostheses 0 - 999 135.42 2 2 PER YEAR
L8030 Breast Prostheses 0 - 999 146.47 2 2 PER 2 YEARS
L8300 Trusses 0 - 999 63.05 1 2 PER YEAR
L8310 Trusses 0 - 999 169.75 1 2 PER YEAR
L8400 Prosthetic Socks 0 - 999 5.82 6 72 PER PROSTHETIC PER YEAR
L8410 Prosthetic Socks 0 - 999 5.82 6 72 PER PROSTHETIC PER YEAR
L8415 Prosthetic Socks 0 - 999 8.73 6 72 PER PROSTHETIC PER YEAR
L8417 Prosthetic Socks 0 - 999 44.50 2 6 PER PROSTHETIC PER YEAR
L8420 Prosthetic Socks 0 - 999 12.61 6 72 PER PROSTHETIC PER YEAR
L8430 Prosthetic Socks 0 - 999 13.58 6 72 PER PROSTHETIC PER YEAR
L8435 Prosthetic Socks 0 - 999 12.61 6 72 PER PROSTHETIC PER YEAR
L8440 Prosthetic Socks 0 - 999 29.10 2 4 PER PROSTHETIC PER YEAR
L8460 Prosthetic Socks 0 - 999 43.17 2 4 PER PROSTHETIC PER YEAR
L8465 Prosthetic Socks 0 - 999 35.41 2 4 PER PROSTHETIC PER YEAR
L8470 Prosthetic Socks 0 - 999 1.94 6 72 PER PROSTHETIC PER YEAR
L8480 Prosthetic Socks 0 - 999 2.43 6 72 PER PROSTHETIC PER YEAR
L8485 Prosthetic Socks 0 - 999 6.60 2 72 PER PROSTHETIC PER YEAR
L8499 Prosthetic Socks 0 - 999 0.00 1 PA MEDICAL NECESSITY
L8500 Larynx, Tracheoesophageal 0 - 999 392.00 1 1 PER LIFETIME
L8501 Larynx, Tracheoesophageal 0 - 999 116.40 1 6 PER YEAR
L8507 Larynx, Tracheoesophageal 0 - 999 116.40 1 1 PER 5 YEARS
Q4074 Drugs 0 - 999 24.88 5 155 PER MONTH
S1040 Temporary National Codes Established by Private Payers 0 - 20 3000.00 1 PA MEDICAL NECESSITY
S5560 Temporary National Codes Established by Private Payers 0 - 999 25.00 1 1 EVERY 3 YEARS
S5561 Temporary National Codes Established by Private Payers 0 - 999 29.00 1 1 EVERY 3 YEARS
S8490 Temporary National Codes Established by Private Payers 0 - 999 27.90 1 1 PER MONTH
T4521* 4 - 20 0.63 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4522* 4 - 20 0.69 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4523* 4 - 20 0.80 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4524* 4 - 20 0.90 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4525* 4 - 20 0.78 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4526* 4 - 20 0.85 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4527* 4 - 20 0.94 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4528* 4 - 20 1.02 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4529* 4 - 20 0.53 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4530* 4 - 20 0.58 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4531* 4 - 20 0.69 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4532* 4 - 20 0.75 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4533* 4 - 20 0.65 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4534* 4 - 20 0.84 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4535* 4 - 20 0.44 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4543* 4 - 20 1.52 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
T4544* 4 - 20 1.52 200
UP TO 200 PER MONTH
Any combination of these codes can be billed
but only up to 200 units.*
V2623 Prosthetic Eye 0 - 999 567.45 2 MEDICAL NECESSITY
V2624 Prosthetic Eye 0 - 999 38.80 2 2 PER YEAR
V2625 Prosthetic Eye 0 - 999 242.50 2 1 PER PROSTHESIS
V2626 Prosthetic Eye 0 - 999 155.20 2 1 PER PROSTHESIS
V2627 Prosthetic Eye 0 - 999 902.10 2 MEDICAL NECESSITY
V2628 Prosthetic Eye 0 - 999 208.55 2 MEDICAL NECESSITY
V5336 Repair/Modifications 0 - 999 0.00 1 PA MEDICAL NECESSITY
Code Rate
E0988 247.34
E1006 4,781.32
E1007 6,474.09
E1008 6,474.67
E1010 847.13
E1014 313.77
E1017 122.59
E1086 786.60
E1089 1,187.10
E1090 1,268.90
eQ Health Prior Authorization Pricing Reference Guide
The below codes, descriptions, and reimbursement rates are used by eQHealth Solutions for pricing
purposes only. These codes are not separately available through the DME program.
Fee-for-Service p roviders will be reimbursed for codes submitted in conjunction with custom wheelchair and
wheelchair repair requests.
E1130 456.12
E1140 636.11
E1161 2,033.18
E1250 729.30
E1260 900.90
E1285 1,183.60
E1290 1,034.50
E2201 320.61
E2202 407.29
E2203 411.65
E2204 698.96
E2216 29.24
E2218 45.10
E2219 40.65
E2225 14.95
E2226 32.61
E2227 1,545.63
E2228 804.53
E2231 132.06
E2310 866.72
E2311 1,754.72
E2312 1,666.34
E2313 264.61
E2321 1,176.94
E2340 307.94
E2341 461.94
E2342 384.95
E2343 615.93
E2351 517.43
E2359 143.86
E2371 111.64
E2375 634.40
E2376 994.13
E2392 39.90
E2622 245.50
E2623 312.38
E2624 247.51
E2625 313.34
E2626 533.73
E2627 851.66
E2628 641.59
E2629 811.92
E2630 567.78
E2631 227.12
E2632 144.42
E2633 120.24
K0733 22.38
K0806 1,158.28
K0807 1,757.56
K0808 2,719.32
K0813 1,875.92
K0814 2,401.54
K0815 2,734.35
K0816 2,618.82
K0820 2,003.83
K0821 2,572.34
K0828 5,372.34
K0829 4,933.34
K0835 3,155.32
K0836 3,272.25
K0837 3,765.94
K0838 3,369.02
K0839 4,875.53
K0840 7,386.34
K0841 3,358.49
K0842 3,358.49
K0843 4,043.54
K0848 4,109.45
K0849 3,951.14
K0850 4,766.89
K0851 4,583.32
K0852 5,507.82
K0853 5,657.96
K0854 7,495.49
K0855 7,080.58
K0856 4,411.12
K0857 4,499.49
K0858 5,472.94
K0859 5,219.42
K0860 7,818.72
K0861 5,691.22
K0862 4,418.18
K0863 5,472.94
K0864 7,818.72
Code Name Age Max Fee Units Limit
Compleat Pediatric
Compleat Pediatric Reduced Calorie
Compleat
Boost
Boost High Protein
Ensure
Ensure High Protein
Fibersource HN
Isosource HN
Isosource
Jevity 1 Cal
Jevity 1.2 Cal
Lipistart
Nutren 1.0
Nutren Replete
Nutren 1.0 Fiber
B4150
B4150SC0 - 999 0.62 930 930 PER MONTH
Enteral Formula Category List for All Medicaid Recipients
B4149 0 - 20 1.52 930 930 PER MONTH
Osmolite
Osmolite 1 Cal
Osmolite 1.2 Cal
Promote
Promote with Fiber
Replete
Replete with Fiber
Boost Plus
Ensure Complete
Ensure Plus
Ensure Plus HN
Isosource 1.5
Jevity 1.5
Resource 2.0
Nutren 1.5
Nutren 2.0
Osmolite 1.5 Cal
Resurgex Plus
TwoCal HN
Impact Peptide 1.5
Impact Glutamine
L-Emental
Peptamen
Peptamen 1.5
Peptamen AF
Peptamen with PreBio1
Perative
Tolerex
Vital 1.0 Cal
Vital AF 1.2 Cal
Vital 1.5 Cal
Vital HN
Vivonex Plus
Vivonex RTF
Vivonex TEN
Glucerna 1.0
Glucerna 1.2
Glucerna 1.5
Glytrol
Impact
Impact with Fiber
Impact 1.5
Impact Advanced Recovery
KetoCal
KetoCal 3.1
KetoCal 4.1
KetoVie
Nutren Pulmonary
NutriHep
NutriRenal
Nepro
NovaSource Renal
B4153
B4153SC0 - 999 2.04 930 930 PER MONTH
B4154
B4154SC0 - 999 0.90 930 930 PER MONTH
B4150
B4150SC0 - 999 0.62 930 930 PER MONTH
B4152
B4152SC0 - 999 0.50 930 930 PER MONTH
Oxepa
Pulmocare
Renalcal
Ren/Gen
Resource Diabetic
Suplena
Complex MSD Amino Acid Blend
Duocal
GlutarAde GA-1 Amino Acid Blend
Liquigen
Glycosade
Microlipid
MCT Oil
MCT procal
OS 2
(Milupa OS 2)
PhenylAde Amino Acid Blend MTE
Polycose
ProMod
ProPhree
Proteinex Liquid
ProViMin
Beneprotein
Ross Carbohydrate Free
SolCarb
Acerflex 454g
Camino pro- MSUD 140ml
Camino pro- PKU 140ml
Complex Essential MSD 454g
Cyclinex - 2 400g
Glutarex - 2 400g
HCY 2 454g
Hominex - 2 400g
I – Valex - 2 400g
Ketonex – 2 400g
MSUD Maxamum 454g
Periflex Junior 454g
Phenex - 2 400g
PhenylAde Essential 454g
Phenyl-Free 2 454g
Phenyl-Free 2HP 454g
Propimex – 2 400g
Tyrex - 2 400g
WND 2 400g
XLEU Maxamum 454g
XLYS, TRY Maxamum 500g
XMET Maxamum 454g
XP Maxamum 500g
MSUD 2 (Milupa) 500g
Boost Kid Essentials
Boost Kid Essentials 1.5
Boost Kid Essentials 1.5 with
B4160
B4160SC0 - 20 0.78 930 930 PER MONTH
B4155
B4155SC0 - 999 0.74 930 930 PER MONTH
B4157
B4157SC0 - 999 0.00 930 BR 930 PER MONTH
B4154
B4154SC0 - 999 0.90 930 930 PER MONTH
Fiber
Kindercal
Kindercal with Fiber
Kindercal TF
Kindercal TF with Fiber
Nutren Junior
Nutren Junior with Fiber
PediaSure
PediaSure 1.5 Cal
PediaSure 1.5 Cal with Fiber
PediaSure Enteral
PediaSure Enteral with Fiber
PediaSure with Fiber
Alfamino Infant 400g
Alfamino Junior 400g
EleCare (for infants) 400g
EleCare Junior 400g
Gerber Extensive HA 400g
Homactin AA Plus 250ml
Isovactin AA Plus 250ml
Neocate 400g
Neocate Nutra 400g
Neocate Junior 400g
Nutramigen with Enflora LGG 357g
E028 Splash 237mL
PediaSure Peptide 1.0 Cal 237mL
PediaSure Peptide 1.5 Cal 237mL
Pepdite One+ (Pepdite Junior) 51g
Peptamen Junior 250mL
Peptamen Junior Fiber 250mL
Peptamen Junior Prebio 250mL
Peptamen Junior 1.5 250mL
Phenactin AA Plus 250ml
Portagen 454g
Pregestimil 454g
Pregestimil 24 454g
Promactin AA Plus 250ml
Similac Expert Care Alimentum 454g
Vilactin AA Plus 250mL
Vivonex Pediatric 250mL
3232A 454g
Calcilo XD 375g
Complex JR MSD 400g
Cyclinex - 1 400g
GlutarAde Junior GA-1 400g
Glutarex - 1 400g
Glytactin RTD 250mL
Milupa HOM 2 500g
Hominex - 1 400g
I – Valex - 1 400g
Ketonex - 1 400g
MSUD 1 500g
B4162
B4162SC0 - 20 0.00 930 BR 930 PER MONTH
B4160
B4160SC0 - 20 0.78 930 930 PER MONTH
B4161
B4161SC0 - 20 0.00 930 BR 930 PER MONTH
MSUD Analog 400g
OS 1 500g
Periflex Infant 400g
Phenex - 1 400g
PhenylAde60 454g
Phenyl-Free 1 454g
PKU 1 500g
PKU 2 500g
PKU 3 500g
Propimex – 1 400g
Tylactin RTD 15 250ml
TYROS 1 454g
TYROS 2 454g
TYR 2 500g
Tyrex – 1 400g
UCD 2 450g
XLEU Analog 400g
XLEU Maxamaid 454g
XLYS, XTrp Analog 400g
XLYS, XTrp Maxamaid 454g
XMET Analog 400g
XMET Maxamaid 454g
XMTVI Analog 400g
XMTVI Maxamaid 454g
XPhe, XTyr Analog 400g
XPTM Analog 400g
B4162
B4162SC0 - 20 0.00 930 BR 930 PER MONTH
