20 Miss. Code. R. 2-II

Current through December 10, 2024

Section 20-2-II - GUIDELINES

A. Rental or purchase of supplies or equipment over the amount of $300.00 per item requires Prior Authorization.

B.Transportation Services Including Ambulance (A0021-A0999)

1. Transportation service codes include ground and air ambulance, non-emergency transportation (taxi, bus, automobile, wheelchair van), and ancillary transportation-related fees.

2. No exemption for air ambulance according to the Airline Deregulation Act (ADA) is allowed based on the rules and regulations of the 2019 MWCC Fee Schedule.

3. Modifiers are required when reporting transportation services. Modifiers are single digits used to identify origin and destination. The first modifier identifies the transport place of origin and the second modifier the destination. Origin and destination modifiers are as follows:

D. Diagnostic or therapeutic site other than "P" or "H" when these are used as origin codes;

E. Residential, domiciliary, custodial facility (other than 1819 facility);

G. Hospital-based ESRD facility;

H. Hospital;

I. Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport;

J. Free-standing ESRD facility;

N Skilled nursing facility (SNF);

P. Physician's office;

R. Residence;

S. Scene of accident or acute event; and

X. Intermediate stop at physician's office on way to hospital (includes HMO non-hospital facility, clinic, etc. destination code only).

Note: Modifier X can only be used as a destination code in the second position of a modifier.

4. Transportation codes can also be found in the S codes. See S0207, S0208, S0209, and S0215.

C.Medical and Surgical Supplies (A4206-A9286)

1. These A codes include a wide variety of medical, surgical, and some DME related supplies and services.

2. For rules related to DME supplies, accessories, maintenance, and repair, see F. Durable Medical Equipment below.

D.Administrative, Miscellaneous, and Investigational (A9150-A9999)

1. These A codes include non-prescription drugs, exercise equipment, radiopharmaceutical diagnostic imaging agents, as well as other miscellaneous supplies.

E.Enteral and Parenteral Therapy (B4034-B9999)

1. B codes include supplies, formulae, nutrition solutions and infusion pumps.

F.Outpatient PPS (C1713-C9899)

1. C codes include drugs, biologicals, and devices used by hospitals.

2. These codes are only used for facility (technical) services.

G.Durable Medical Equipment (DME) (E0100-E8002)

1. E codes include durable medical equipment such as canes, crutches, walkers, commodes, decubitus care, bath and toilet aids, hospital beds, oxygen and related respiratory equipment, monitoring equipment, pacemakers, patient lifts, safety equipment, restraints, traction equipment, fracture frames, wheelchairs, and artificial kidney machines.

2. All durable medical equipment shall have prior authorization from the payer before obtaining the equipment. The payer has the choice of vendor for purchase or rental of DME.

3. If an injured/ill employee is receiving DME items for both compensable and non-compensable medical conditions, only those items that apply to the work related injury should be listed on claims and invoices submitted to the employer.

4. If the rental price for DME exceeds or equals the total purchase price, the employer shall purchase instead of renting equipment. The vendor shall make the payer aware of the price options.

5. When rental payments total the purchase price, the equipment is considered purchased and no additional reimbursement is made.

6. The return of rented equipment is the dual responsibility of the injured worker and the DME supplier. The employer is not responsible for additional rental periods solely due to delay in equipment return.

7. For codes E0676, E0935, and E0936 the MAR listed is per day.

8. Codes reported with modifier RR are reimbursed at ten (10) percent of the maximum allowed amount when reported with the NU modifier. Codes in the Fee Schedule with the RR modifier are reimbursed at the listed fee and should not be billed with the NU or UE modifier.

H.Procedures/Professional Services (Temporary) (G0008- G9987)

1. G codes identify professional health care procedures and services that would otherwise be reported using CPT codes.

2. Procedures and professional services identified by G codes may have a corresponding CPT code. When both a G code and CPT code describe the same procedure, the CPT code is required for reporting purposes.

3. G codes also include procedures and professional services that do not currently have a valid CPT code. In such cases, the applicable G code should be used for reporting purposes.

I.Drugs and Biologicals (J0120-J9999)

1. J codes include drugs that ordinarily cannot be self-administered, chemotherapy drugs, immunosuppressive drugs, inhalation solutions, and other miscellaneous drugs and solutions.

2. These codes report only the costs associated with provision of the drug. Administration including injection, infusion, or inhalation is reported separately using the applicable CPT code(s).

3. Additional codes for drugs and biologicals may be found in the Q codes and S codes.

J.Temporary Codes (K0001-K0900)

1. K codes are temporary codes used to report durable medical equipment that do not yet have a permanent national code.

2. For rules related to DME supplies, accessories, maintenance, and repair, see F. Durable Medical Equipment above.

K.Orthotic Procedures and Devices (L0112-L4631) and Prosthetic Procedures (L5000-L9900)

1. L codes include orthotic and prosthetic procedures and devices as well as scoliosis equipment, orthopedic shoes, and prosthetic implants.

2. The payer shall only pay for orthotics and prosthetics prescribed by the treating physician for a compensable injury/illness. Prior authorization must be obtained from the payer.

3. For orthotics, prosthetics and supplies that are not listed in the Fee Schedule, use CPT code 99070. Reimbursement may not exceed a twenty percent (20%) mark-up of the provider's cost and an invoice may be required by the payer before reimbursement is made for items without an allowable amount in the Fee Schedule.

L.Medical Services (M0075-M1071)

1. M codes include office services, cellular therapy, prolotherapy, intragastric hypothermia, IV chelation therapy, and fabric wrapping of an abdominal aneurysm.

2. These codes are not reimbursed as they represent services for which the therapeutic efficacy has not been established, the procedure is considered experimental, or the procedure has been replaced with a more effective treatment modality.

M.Pathology and Laboratory Services (P2028-P9615)

1. P codes include chemistry, toxicology, and microbiology tests, screening Papanicolaou procedures, and various blood products.

2. Blood and blood product codes report the supply of the blood or blood product only.

3. The administration of blood or blood product is reported separately.

4. Code 36430 for transfusion of blood or blood components is reported only once per encounter regardless of the number of units provided.

N.Temporary Codes (Q0035-Q9992)

1. Q codes include temporary codes developed for reporting services and supplies that do not have a permanent national HCPCS code or CPT code. Included in this section are codes for:

a. Oral anti-emetic drugs;

b. Casting supplies;

c. Splint supplies;

d. Low osmolar contrast;

e. High osmolar contrast; and

f. Other supplies/services.

2. Cast supplies and splints should be reported with the appropriate code from Q4001-Q4051. These codes report the cost of the supply only.

3. Cast supplies and splints are reported in addition to the CPT code for fracture management.

4. Cast supplies and splints are reported in addition to CPT codes for application of the cast or splint.

5. Refer to CPT for rules related to reporting fracture management and cast application.

O.Diagnostic Radiology Services (R0070-R0075)

1. R codes are used for the transportation of portable x-ray and/or EKG equipment.

2. Only a single reasonable transportation charge is allowed for each trip to a single location.

3. When more than one patient receives x-ray or EKG services at the same location, the maximum allowable reimbursement transport charge is divided among all patients.

P.Temporary National Codes (Non-Medicare) (S0012-S9999)

1. Mississippi uses S codes with modified descriptions to report home health services.

2. See J codes for reporting rules related to drugs and biologicals.

Q.Vision Services (V2020-V2799)

1. These V codes include vision-related supplies, including spectacles, lenses, contact lenses, prostheses, intraocular lenses, and miscellaneous lenses.

R.Hearing Services (V5008V5364)

1. These V codes include hearing tests and related supplies and equipment, speech-language pathology screenings, and repair of augmentative communicative systems.

S.Facility Fee

1. The facility fee for outpatient services is the APC Amount.

Code	Mod	Description	Amount	APC Amount
A0021	OUTSIDE STATE AMBULANCE SERV	15.26
A0080	NONINTEREST ESCORT IN NON ER	0.00
A0090	INTEREST ESCORT IN NON ER	0.00
A0100	NONEMERGENCY TRANSPORT TAXI	0.00
A0110	NONEMERGENCY TRANSPORT BUS	0.00
A0120	NONER TRANSPORT MINI-BUS	0.00
A0130	NONER TRANSPORT WHEELCH VAN	0.00
A0140	NONEMERGENCY TRANSPORT AIR	0.00
A0160	NONER TRANSPORT CASE WORKER	0.14
A0170	TRANSPORT PARKING FEES/TOLLS	0.00
A0180	NONER TRANSPORT LODGNG RECIP	0.00
A0190	NONER TRANSPORT MEALS RECIP	0.00
A0200	NONER TRANSPORT LODGNG ESCRT	0.00
A0210	NONER TRANSPORT MEALS ESCORT	0.00
A0225	NEONATAL EMERGENCY TRANSPORT	1361.49
A0380	BASIC LIFE SUPPORT MILEAGE	0.49
A0382	BASIC SUPPORT ROUTINE SUPPLS	0.00
A0384	BLS DEFIBRILLATION SUPPLIES	6.63
A0390	ADVANCED LIFE SUPPORT MILEAG	4.61
A0392	ALS DEFIBRILLATION SUPPLIES	17.23
A0394	ALS IV DRUG THERAPY SUPPLIES	0.00
A0396	ALS ESOPHAGEAL INTUB SUPPLS	17.23
A0398	ALS ROUTINE DISPOSBLE SUPPLS	0.00
A0420	AMBULANCE WAITING 1/2 HR	BR
A0422	AMBULANCE 02 LIFE SUSTAINING	0.00
A0424	EXTRA AMBULANCE ATTENDANT	BR
A0425	GROUND MILEAGE	8.38
A0426	ALS 1	348.36
A0427	ALS1-EMERGENCY	551.56
A0428	BLS	290.30
A0429	BLS-EMERGENCY	464.48
A0430	FIXED WING AIR TRANSPORT	9978.53
A0431	ROTARY WING AIR TRANSPORT	11482.73
A0432	PI VOLUNTEER AMBULANCE CO	BR
A0433	ALS 2	BR
A0434	SPECIALTY CARE TRANSPORT	BR
A0435	FIXED WING AIR MILEAGE	30.01
A0436	ROTARY WING AIR MILEAGE	80.14
A0888	NONCOVERED AMBULANCE MILEAGE	BR
A0998	AMBULANCE RESPONSE/TREATMENT	BR
A0999	UNLISTED AMBULANCE SERVICE	BR
A4206	1 CC STERILE SYRINGE&NEEDLE	0.00
A4207	2 CC STERILE SYRINGE&NEEDLE	0.00
A4208	3 CC STERILE SYRINGE&NEEDLE	0.00
A4209	5+ CC STERILE SYRINGE&NEEDLE	0.00
A4210	NONNEEDLE INJECTION DEVICE	0.00
A4211	SUPP FOR SELF-ADM INJECTIONS	0.00
A4212	NON CORING NEEDLE OR STYLET	0.00
A4213	20+ CC SYRINGE ONLY	0.00
A4215	STERILE NEEDLE	0.00
A4216	STERILE WATER/SALINE, 10 ML	0.56
A4217	STERILE WATER/SALINE, 500 ML	3.58
A4218	STERILE SALINE OR WATER	0.00
A4220	INFUSION PUMP REFILL KIT	0.00
A4221	SUPP NON-INSULIN INF CATH/WK	25.49
A4222	INFUSION SUPPLIES WITH PUMP	50.74
A4223	INFUSION SUPPLIES W/O PUMP	0.00
A4224	SUPPLY INSULIN INF CATH/WK	25.49
A4225	SUP/EXT INSULIN INF PUMP SYR	3.17
A4230	INFUS INSULIN PUMP NON NEEDL	0.00
A4231	INFUSION INSULIN PUMP NEEDLE	0.00
A4232	SYRINGE W/NEEDLE INSULIN 3CC	0.00
A4233	NU	ALKALIN BATT FOR GLUCOSE MON	0.56
A4234	NU	J-CELL BATT FOR GLUCOSE MON	2.60
A4235	NU	LITHIUM BATT FOR GLUCOSE MON	1.10
A4236	NU	SILVR OXIDE BATT GLUCOSE MON	1.28
A4244	ALCOHOL OR PEROXIDE PER PINT	0.00
A4245	ALCOHOL WIPES PER BOX	0.00
A4246	BETADINE/PHISOHEX SOLUTION	0.00
A4247	BETADINE/IODINE SWABS/WIPES	0.00
A4248	CHLORHEXIDINE ANTISEPT	0.00
A4250	URINE REAGENT STRIPS/TABLETS	16.30
A4252	BLOOD KETONE TEST OR STRIP	0.00
A4253	NU	BLOOD GLUCOSE/REAGENT STRIPS	9.15
A4255	GLUCOSE MONITOR PLATFORMS	5.21
A4256	CALIBRATOR SOLUTION/CHIPS	3.72
A4257	REPLACE LENSSHIELD CARTRIDGE	16.16
A4258	LANCET DEVICE EACH	2.33
A4259	LANCETS PER BOX	0.00
A4261	CERVICAL CAP CONTRACEPTIVE	0.00
A4262	TEMPORARY TEAR DUCT PLUG	29.27
A4263	PERMANENT TEAR DUCT PLUG	71.82
A4264	INTRATUBAL OCCLUSION DEVICE	0.00
A4265	PARAFFIN	4.31
A4266	DIAPHRAGM	0.00
A4267	MALE CONDOM	0.00
A4268	FEMALE CONDOM	0.00
A4269	SPERMICIDE	0.00
A4270	DISPOSABLE ENDOSCOPE SHEATH	0.00
A4280	BRST PRSTHS ADHSV ATTCHMNT	6.77
A4281	REPLACEMENT BREASTPUMP TUBE	0.00
A4282	REPLACEMENT BREASTPUMP ADPT	0.00
A4283	REPLACEMENT BREASTPUMP CAP	0.00
A4284	REPLCMNT BREAST PUMP SHIELD	0.00
A4285	REPLCMNT BREAST PUMP BOTTLE	0.00
A4286	REPLCMNT BREASTPUMP LOK RING	0.00
A4290	SACRAL NERVE STIM TEST LEAD	0.00
A4300	CATH IMPL VASC ACCESS PORTAL	0.00
A4301	IMPLANTABLE ACCESS SYST PERC	0.00
A4305	DRUG DELIVERY SYSTEM >=50 ML	85.14
A4306	DRUG DELIVERY SYSTEM <=50 ML	76.62
A4310	INSERT TRAY W/O BAG/CATH	8.32
A4311	CATHETER W/O BAG 2-WAY LATEX	18.77
A4312	CATH W/O BAG 2-WAY SILICONE	22.85
A4313	CATHETER W/BAG 3-WAY	23.46
A4314	CATH W/DRAINAGE 2-WAY LATEX	27.21
A4315	CATH W/DRAINAGE 2-WAY SILCNE	33.41
A4316	CATH W/DRAINAGE 3-WAY	35.97
A4320	IRRIGATION TRAY	5.75
A4321	CATH THERAPEUTIC IRRIG AGENT	BR
A4322	IRRIGATION SYRINGE	3.84
A4326	MALE EXTERNAL CATHETER	13.66
A4327	FEM URINARY COLLECT DEV CUP	56.50
A4328	FEM URINARY COLLECT POUCH	13.22
A4330	STOOL COLLECTION POUCH	7.71
A4331	EXTENSION DRAINAGE TUBING	4.03
A4332	LUBE STERILE PACKET	0.14
A4333	URINARY CATH ANCHOR DEVICE	2.81
A4334	URINARY CATH LEG STRAP	BR
A4335	INCONTINENCE SUPPLY	BR
A4336	URETHRAL INSERT	1.83
A4337	INCONTINENT RECTAL INSERT	BR
A4338	INDWELLING CATHETER LATEX	15.53
A4340	INDWELLING CATHETER SPECIAL	34.19
A4344	CATH INDW FOLEY 2 WAY SILICN	18.55
A4346	CATH INDW FOLEY 3 WAY	21.98
A4349	DISPOSABLE MALE EXTERNAL CAT	2.55
A4351	STRAIGHT TIP URINE CATHETER	2.12
A4352	COUDE TIP URINARY CATHETER	8.14
A4353	INTERMITTENT URINARY CATH	8.87
A4354	CATH INSERTION TRAY W/BAG	14.95
A4355	BLADDER IRRIGATION TUBING	11.30
A4356	EXT URETH CLMP OR COMPR DVC	52.70
A4357	BEDSIDE DRAINAGE BAG	10.45
A4358	URINARY LEG OR ABDOMEN BAG	7.50
A4360	DISPOSABLE EXT URETHRAL DEV	0.56
A4361	OSTOMY FACE PLATE	23.27
A4362	SOLID SKIN BARRIER	3.73
A4363	OSTOMY CLAMP, REPLACEMENT	2.55
A4364	ADHESIVE, LIQUID OR EQUAL	3.73
A4366	OSTOMY VENT	1.64
A4367	OSTOMY BELT	7.92
A4368	OSTOMY FILTER	0.32
A4369	SKIN BARRIER LIQUID PER OZ	3.07
A4371	SKIN BARRIER POWDER PER OZ	4.61
A4372	SKIN BARRIER SOLID 4X4 EQUIV	5.31
A4373	SKIN BARRIER WITH FLANGE	7.94
A4375	DRAINABLE PLASTIC PCH W FCPL	21.75
A4376	DRAINABLE RUBBER PCH W FCPLT	60.27
A4377	DRAINABLE PLSTIC PCH W/O FP	5.43
A4378	DRAINABLE RUBBER PCH W/O FP	38.94
A4379	URINARY PLASTIC POUCH W FCPL	19.02
A4380	URINARY RUBBER POUCH W FCPLT	47.28
A4381	URINARY PLASTIC POUCH W/O FP	5.86
A4382	URINARY HVY PLSTC PCH W/O FP	31.17
A4383	URINARY RUBBER POUCH W/O FP	35.71
A4384	OSTOMY FACEPLT/SILICONE RING	12.18
A4385	OST SKN BARRIER SLD EXT WEAR	6.46
A4387	OST CLSD POUCH W ATT ST BARR	2.85
A4388	DRAINABLE PCH W EX WEAR BARR	5.52
A4389	DRAINABLE PCH W ST WEAR BARR	7.88
A4390	DRAINABLE PCH EX WEAR CONVEX	12.17
A4391	URINARY POUCH W EX WEAR BARR	8.95
A4392	URINARY POUCH W ST WEAR BARR	10.35
A4393	URINE PCH W EX WEAR BAR CONV	11.45
A4394	OSTOMY POUCH LIQ DEODORANT	3.28
A4395	OSTOMY POUCH SOLID DEODORANT	0.06
A4396	PERISTOMAL HERNIA SUPPRT BLT	51.27
A4397	IRRIGATION SUPPLY SLEEVE	5.52
A4398	OSTOMY IRRIGATION BAG	17.51
A4399	OSTOMY IRRIG CONE/CATH W BRS	13.66
A4400	OSTOMY IRRIGATION SET	52.61
A4402	LUBRICANT PER OUNCE	1.72
A4404	OSTOMY RING EACH	1.85
A4405	NONPECTIN BASED OSTOMY PASTE	4.32
A4406	PECTIN BASED OSTOMY PASTE	7.25
A4407	EXT WEAR OST SKN BARR <=4SQ"	11.10
A4408	EXT WEAR OST SKN BARR >4SQ"	12.51
A4409	OST SKN BARR CONVEX <=4 SQ I	7.88
A4410	OST SKN BARR EXTND >4 SQ	11.45
A4411	OST SKN BARR EXTND =4SQ	6.46
A4412	OST POUCH DRAIN HIGH OUTPUT	3.42
A4413	2 PC DRAINABLE OST POUCH	6.97
A4414	OST SKNBAR W/O CONV<=4 SQ IN	6.24
A4415	OST SKN BARR W/O CONV >4 SQI	7.59
A4416	OST PCH CLSD W BARRIER/FILTR	3.49
A4417	OST PCH W BAR/BLTINCONV/FLTR	4.72
A4418	OST PCH CLSD W/O BAR W FILTR	2.30
A4419	OST PCH FOR BAR W FLANGE/FLT	2.19
A4420	OST PCH CLSD FOR BAR W LK FL	BR
A4421	OSTOMY SUPPLY MISC	BR
A4422	OST POUCH ABSORBENT MATERIAL	0.14
A4423	OST PCH FOR BAR W LK FL/FLTR	2.35
A4424	OST PCH DRAIN W BAR & FILTER	6.03
A4425	OST PCH DRAIN FOR BARRIER FL	4.53
A4426	OST PCH DRAIN 2 PIECE SYSTEM	3.45
A4427	OST PCH DRAIN/BARR LK FLNG/F	3.52
A4428	URINE OST POUCH W FAUCET/TAP	8.25
A4429	URINE OST POUCH W BLTINCONV	10.44
A4430	OST URINE PCH W B/BLTIN CONV	10.78
A4431	OST PCH URINE W BARRIER/TAPV	7.88
A4432	OS PCH URINE W BAR/FANGE/TAP	4.54
A4433	URINE OST PCH BAR W LOCK FLN	4.25
A4434	OST PCH URINE W LOCK FLNG/FT	4.76
A4435	1PC OST PCH DRAIN HGH OUTPUT	7.30
A4450	NON-WATERPROOF TAPE	0.12
A4452	WATERPROOF TAPE	0.36
A4455	ADHESIVE REMOVER PER OUNCE	1.82
A4456	ADHESIVE REMOVER, WIPES	0.31
A4458	REUSABLE ENEMA BAG	BR
A4459	MANUAL PUMP ENEMA, REUSABLE	BR
A4461	SURGICL DRESS HOLD NON-REUSE	4.18
A4463	SURGICAL DRESS HOLDER REUSE	16.85
A4465	NON-ELASTIC EXTREMITY BINDER	22.34
A4467	BELT STRAP SLEEV GRMNT COVER	42.56
A4470	GRAVLEE JET WASHER	5.23
A4480	VABRA ASPIRATOR	42.56
A4481	TRACHEOSTOMA FILTER	0.47
A4483	MOISTURE EXCHANGER	BR
A4490	ABOVE KNEE SURGICAL STOCKING	22.84
A4495	THIGH LENGTH SURG STOCKING	22.84
A4500	BELOW KNEE SURGICAL STOCKING	22.84
A4510	FULL LENGTH SURG STOCKING	81.57
A4520	INCONTINENCE GARMENT ANYTYPE	BR
A4550	SURGICAL TRAYS	32.63
A4553	NONDISP UNDERPADS, ALL SIZES	8.32
A4554	DISPOSABLE UNDERPADS	0.40
A4555	CA TX E-STIM ELECTR/TRANSDUC	BR
A4556	ELECTRODES, PAIR	13.07
A4557	LEAD WIRES, PAIR	17.40
A4558	CONDUCTIVE GEL OR PASTE	6.24
A4559	COUPLING GEL OR PASTE	0.12
A4561	PESSARY RUBBER, ANY TYPE	26.08
A4562	PESSARY, NON RUBBER, ANY TYPE	64.83
A4563	VAG INSER RECTAL CONTROL SYS	141.17
A4565	SLINGS	9.75
A4566	SHOULD SLING/VEST/ABRESTRAIN	BR
A4570	SPLINT	37.25
A4575	HYPERBARIC O2 CHAMBER DISPS	BR
A4580	CAST SUPPLIES (PLASTER)	90.45
A4590	SPECIAL CASTING MATERIAL	79.82
A4595	TENS SUP PL 2 LEAD PER MONTH	24.28
A4600	SLEEVE, INTER LIMB COMP DEV	BR
A4601	LITH ION NON PROSTH RECHARGE	BR
A4602	NU	REPLACE LITHIUM BATTERY 1.5V	4.72
A4604	NU	TUBING WITH HEATING ELEMENT	60.28
A4605	NU	TRACH SUCTION CATH CLOSE SYS	20.77
A4606	OXYGEN PROBE USED W OXIMETER	BR
A4608	TRANSTRACHEAL OXYGEN CATH	63.48
A4611	NU	HEAVY DUTY BATTERY	648.36
A4612	NU	BATTERY CABLES	211.93
A4613	NU	BATTERY CHARGER	576.47
A4614	HAND-HELD PEFR METER	30.12
A4615	CANNULA NASAL	0.92
A4616	TUBING (OXYGEN) PER FOOT	0.08
A4617	MOUTH PIECE	3.93
A4618	NU	BREATHING CIRCUITS	9.57
A4619	NU	FACE TENT	2.28
A4620	VARIABLE CONCENTRATION MASK	0.80
A4623	TRACHEOSTOMY INNER CANNULA	7.05
A4624	NU	TRACHEAL SUCTION TUBE	2.84
A4625	TRACH CARE KIT FOR NEW TRACH	7.45
A4626	TRACHEOSTOMY CLEANING BRUSH	4.03
A4627	SPACER BAG/RESERVOIR	42.56
A4628	NU	OROPHARYNGEAL SUCTION CATH	4.74
A4629	TRACHEOSTOMY CARE KIT	5.89
A4630	NU	REPL BAT T.E.N.S. OWN BY PT	7.91
A4633	NU	UVL REPLACEMENT BULB	51.96
A4634	REPLACEMENT BULB TH LIGHTBOX	BR
A4635	NU	UNDERARM CRUTCH PAD	6.48
A4636	NU	HANDGRIP FOR CANE ETC	4.33
A4637	NU	REPL TIP CANE/CRUTCH/WALKER	2.29
A4638	NU	REPL BATT PULSE GEN SYS	0.00
A4639	RR	INFRARED HT SYS REPLCMNT PAD	36.38
A4640	NU	ALTERNATING PRESSURE PAD	65.21
A4641	RADIOPHARM DX AGENT NOC	BR
A4642	IN111 SATUMOMAB	BR
A4648	IMPLANTABLE TISSUE MARKER	BR
A4649	SURGICAL SUPPLIES	BR
A4650	IMPLANT RADIATION DOSIMETER	BR
A4651	CALIBRATED MICROCAP TUBE	BR
A4652	MICROCAPILLARY TUBE SEALANT	BR
A4653	PD CATHETER ANCHOR BELT	BR
A4657	SYRINGE W/WO NEEDLE	0.00
A4660	SPHYG/BP APP W CUFF AND STET	37.25
A4663	DIALYSIS BLOOD PRESSURE CUFF	57.46
A4670	AUTOMATIC BP MONITOR, DIAL	119.46
A4671	DISPOSABLE CYCLER SET	BR
A4672	DRAINAGE EXT LINE, DIALYSIS	BR
A4673	EXT LINE W EASY LOCK CONNECT	BR
A4674	CHEM/ANTISEPT SOLUTION, 8OZ	BR
A4680	ACTIVATED CARBON FILTER, EA	266.02
A4690	DIALYZER, EACH	200.27
A4706	BICARBONATE CONC SOL PER GAL	BR
A4707	BICARBONATE CONC POW PER PAC	BR
A4708	ACETATE CONC SOL PER GALLON	BR
A4709	ACID CONC SOL PER GALLON	BR
A4714	TREATED WATER PER GALLON	BR
A4719	"Y SET" TUBING	BR
A4720	DIALYSAT SOL FLD VOL > 249CC	BR
A4721	DIALYSAT SOL FLD VOL > 999CC	BR
A4722	DIALYS SOL FLD VOL > 1999CC	BR
A4723	DIALYS SOL FLD VOL > 2999CC	BR
A4724	DIALYS SOL FLD VOL > 3999CC	BR
A4725	DIALYS SOL FLD VOL > 4999CC	BR
A4726	DIALYS SOL FLD VOL > 5999CC	BR
A4728	DIALYSATE SOLUTION, NON-DEX	BR
A4730	FISTULA CANNULATION SET, EA	BR
A4736	TOPICAL ANESTHETIC, PER GRAM	BR
A4737	INJ ANESTHETIC PER 10 ML	BR
A4740	SHUNT ACCESSORY	BR
A4750	ART OR VENOUS BLOOD TUBING	69.17
A4755	COMB ART/VENOUS BLOOD TUBING	BR
A4760	DIALYSATE SOL TEST KIT, EACH	BR
A4765	DIALYSATE CONC POW PER PACK	BR
A4766	DIALYSATE CONC SOL ADD 10 ML	BR
A4770	BLOOD COLLECTION TUBE/VACUUM	BR
A4771	SERUM CLOTTING TIME TUBE	BR
A4772	BLOOD GLUCOSE TEST STRIPS	21.34
A4773	OCCULT BLOOD TEST STRIPS	156.62
A4774	AMMONIA TEST STRIPS	BR
A4802	PROTAMINE SULFATE PER 50 MG	4.03
A4860	DISPOSABLE CATHETER TIPS	BR
A4870	PLUMB/ELEC WK HM HEMO EQUIP	BR
A4890	REPAIR/MAINT CONT HEMO EQUIP	BR
A4911	DRAIN BAG/BOTTLE	BR
A4913	MISC DIALYSIS SUPPLIES NOC	BR
A4918	VENOUS PRESSURE CLAMP	BR
A4927	NON-STERILE GLOVES	7.58
A4928	SURGICAL MASK	0.00
A4929	TOURNIQUET FOR DIALYSIS, EA	0.40
A4930	STERILE, GLOVES PER PAIR	0.00
A4931	REUSABLE ORAL THERMOMETER	0.00
A4932	REUSABLE RECTAL THERMOMETER	0.00
A5051	POUCH CLSD W BARR ATTACHED	2.62
A5052	CLSD OSTOMY POUCH W/O BARR	1.88
A5053	CLSD OSTOMY POUCH FACEPLATE	1.87
A5054	CLSD OSTOMY POUCH W/FLANGE	2.28
A5055	STOMA CAP	1.66
A5056	1 PC OST POUCH W FILTER	5.92
A5057	1 PC OST POU W BUILT-IN CONV	12.17
A5061	POUCH DRAINABLE W BARRIER AT	4.47
A5062	DRNBLE OSTOMY POUCH W/O BARR	2.83
A5063	DRAIN OSTOMY POUCH W/FLANGE	3.42
A5071	URINARY POUCH W/BARRIER	7.61
A5072	URINARY POUCH W/O BARRIER	3.99
A5073	URINARY POUCH ON BARR W/FLNG	3.42
A5081	STOMA PLUG OR SEAL, ANY TYPE	3.58
A5082	CONTINENT STOMA CATHETER	12.82
A5083	STOMA ABSORPTIVE COVER	0.81
A5093	OSTOMY ACCESSORY CONVEX INSE	2.38
A5102	BEDSIDE DRAIN BTL W/WO TUBE	28.59
A5105	URINARY SUSPENSORY	51.65
A5112	URINARY LEG BAG	43.85
A5113	LATEX LEG STRAP	5.97
A5114	FOAM/FABRIC LEG STRAP	9.64
A5120	SKIN BARRIER, WIPE OR SWAB	0.52
A5121	SOLID SKIN BARRIER 6X6	9.44
A5122	SOLID SKIN BARRIER 8X8	16.27
A5126	DISK/FOAM PAD +OR- ADHESIVE	1.66
A5131	APPLIANCE CLEANER	20.08
A5200	PERCUTANEOUS CATHETER ANCHOR	14.32
A5500	DIAB SHOE FOR DENSITY INSERT	80.53
A5501	DIABETIC CUSTOM MOLDED SHOE	241.55
A5503	DIABETIC SHOE W/ROLLER/ROCKR	39.86
A5504	DIABETIC SHOE WITH WEDGE	39.86
A5505	DIAB SHOE W/METATARSAL BAR	39.86
A5506	DIABETIC SHOE W/OFF SET HEEL	39.86
A5507	MODIFICATION DIABETIC SHOE	39.86
A5508	DIABETIC DELUXE SHOE	BR
A5510	COMPRESSION FORM SHOE INSERT	BR
A5512	MULTI DEN INSERT DIRECT FORM	32.85
A5513	MULTI DEN INSERT CUSTOM MOLD	49.02
A5514	MULT DEN INSERT DIR CARV/CAM	49.02
A6000	WOUND WARMING WOUND COVER	0.00
A6010	COLLAGEN BASED WOUND FILLER	39.23
A6011	COLLAGEN GEL/PASTE WOUND FIL	2.89
A6021	COLLAGEN DRESSING <=16 SQ IN	26.62
A6022	COLLAGEN DRSG>16<=48 SQ IN	26.62
A6023	COLLAGEN DRESSING >48 SQ IN	241.03
A6024	COLLAGEN DSG WOUND FILLER	7.84
A6025	SILICONE GEL SHEET, EACH	29.45
A6154	WOUND POUCH EACH	18.22
A6196	ALGINATE DRESSING <=16 SQ IN	9.32
A6197	ALGINATE DRSG >16 <=48 SQ IN	20.82
A6198	ALGINATE DRESSING > 48 SQ IN	BR
A6199	ALGINATE DRSG WOUND FILLER	6.70
A6203	COMPOSITE DRSG <= 16 SQ IN	4.27
A6204	COMPOSITE DRSG >16<=48 SQ IN	7.89
A6205	COMPOSITE DRSG > 48 SQ IN	BR
A6206	CONTACT LAYER <= 16 SQ IN	14.63
A6207	CONTACT LAYER >16<= 48 SQ IN	9.30
A6208	CONTACT LAYER > 48 SQ IN	BR
A6209	FOAM DRSG <=16 SQ IN W/O BDR	9.46
A6210	FOAM DRG >16<=48 SQ IN W/O B	25.23
A6211	FOAM DRG > 48 SQ IN W/O BRDR	37.20
A6212	FOAM DRG <=16 SQ IN W/BORDER	12.30
A6213	FOAM DRG >16<=48 SQ IN W/BDR	24.63
A6214	FOAM DRG > 48 SQ IN W/BORDER	13.04
A6215	FOAM DRESSING WOUND FILLER	BR
A6216	NON-STERILE GAUZE<=16 SQ IN	0.06
A6217	NON-STERILE GAUZE>16<=48 SQ	BR
A6218	NON-STERILE GAUZE > 48 SQ IN	0.97
A6219	GAUZE <= 16 SQ IN W/BORDER	1.21
A6220	GAUZE >16 <=48 SQ IN W/BORDR	3.28
A6221	GAUZE > 48 SQ IN W/BORDER	BR
A6222	GAUZE <=16 IN NO W/SAL W/O B	2.71
A6223	GAUZE >16<=48 NO W/SAL W/O B	3.07
A6224	GAUZE > 48 IN NO W/SAL W/O B	4.57
A6228	GAUZE <= 16 SQ IN WATER/SAL	5.32
A6229	GAUZE >16<=48 SQ IN WATR/SAL	4.57
A6230	GAUZE > 48 SQ IN WATER/SALNE	1.96
A6231	HYDROGEL DSG<=16 SQ IN	5.94
A6232	HYDROGEL DSG>16<=48 SQ IN	8.69
A6233	HYDROGEL DRESSING >48 SQ IN	24.29
A6234	HYDROCOLLD DRG <=16 W/O BDR	8.28
A6235	HYDROCOLLD DRG >16<=48 W/O B	21.31
A6236	HYDROCOLLD DRG > 48 IN W/O B	34.52
A6237	HYDROCOLLD DRG <=16 IN W/BDR	10.02
A6238	HYDROCOLLD DRG >16<=48 W/BDR	28.88
A6239	HYDROCOLLD DRG > 48 IN W/BDR	BR
A6240	HYDROCOLLD DRG FILLER PASTE	15.51
A6241	HYDROCOLLOID DRG FILLER DRY	3.26
A6242	HYDROGEL DRG <=16 IN W/O BDR	7.68
A6243	HYDROGEL DRG >16<=48 W/O BDR	15.61
A6244	HYDROGEL DRG >48 IN W/O BDR	49.75
A6245	HYDROGEL DRG <= 16 IN W/BDR	9.21
A6246	HYDROGEL DRG >16<=48 IN W/B	12.58
A6247	HYDROGEL DRG > 48 SQ IN W/B	30.12
A6248	HYDROGEL DRSG GEL FILLER	20.58
A6250	SKIN SEAL PROTECT MOISTURIZR	BR
A6251	ABSORPT DRG <=16 SQ IN W/O B	2.52
A6252	ABSORPT DRG >16 <=48 W/O BDR	4.13
A6253	ABSORPT DRG > 48 SQ IN W/O B	8.02
A6254	ABSORPT DRG <=16 SQ IN W/BDR	1.52
A6255	ABSORPT DRG >16<=48 IN W/BDR	3.85
A6256	ABSORPT DRG > 48 SQ IN W/BDR	BR
A6257	TRANSPARENT FILM <= 16 SQ IN	1.95
A6258	TRANSPARENT FILM >16<=48 IN	5.46
A6259	TRANSPARENT FILM > 48 SQ IN	13.85
A6260	WOUND CLEANSER ANY TYPE/SIZE	0.42
A6261	WOUND FILLER GEL/PASTE /OZ	5.32
A6262	WOUND FILLER DRY FORM / GRAM	6.03
A6266	IMPREG GAUZE NO H20/SAL/YARD	2.43
A6402	STERILE GAUZE <= 16 SQ IN	0.14
A6403	STERILE GAUZE>16 <= 48 SQ IN	0.54
A6404	STERILE GAUZE > 48 SQ IN	0.53
A6407	PACKING STRIPS, NON-IMPREG	2.38
A6410	STERILE EYE PAD	0.48
A6411	NON-STERILE EYE PAD	0.00
A6412	OCCLUSIVE EYE PATCH	0.39
A6413	ADHESIVE BANDAGE, FIRST-AID	0.00
A6441	PAD BAND W>=3" GREATER THAN 5"/YD	0.87
A6442	CONFORM BAND N/S W<3"/YD	0.20
A6443	CONFORM BAND N/S W>=3"GREATER THAN 5"/YD	0.35
A6444	CONFORM BAND N/S W>=5"/YD	0.70
A6445	CONFORM BAND S W <3"/YD	0.41
A6446	CONFORM BAND S W>=3" GREATER THAN 5"/YD	0.51
A6447	CONFORM BAND S W >=5"/YD	0.87
A6448	LT COMPRES BAND <3"/YD	1.46
A6449	LT COMPRES BAND >=3" GREATER THAN 5"/YD	2.22
A6450	LT COMPRES BAND >=5"/YD	BR
A6451	MOD COMPRES BAND W>=3"GREATER THAN 5"/YD	BR
A6452	HIGH COMPRES BAND W>=3"GREATER THAN 5"YD	7.48
A6453	SELF-ADHER BAND W <3"/YD	0.79
A6454	SELF-ADHER BAND W>=3" GREATER THAN 5"/YD	0.99
A6455	SELF-ADHER BAND >=5"/YD	1.77
A6456	ZINC PASTE BAND W >=3"GREATER THAN 5"/YD	1.61
A6457	TUBULAR DRESSING	1.44
A6460	SYNTHETIC DRSG <= 16 SQ IN	BR
A6461	SYNTHETIC DRSG >16<=48 SQ IN	BR
A6501	COMPRES BURNGARMENT BODYSUIT	BR
A6502	COMPRES BURNGARMENT CHINSTRP	BR
A6503	COMPRES BURNGARMENT FACEHOOD	BR
A6504	CMPRSBURNGARMENT GLOVE-WRIST	BR
A6505	CMPRSBURNGARMENT GLOVE-ELBOW	BR
A6506	CMPRSBURNGRMNT GLOVE-AXILLA	BR
A6507	CMPRS BURNGARMENT FOOT-KNEE	BR
A6508	CMPRS BURNGARMENT FOOT-THIGH	BR
A6509	COMPRES BURN GARMENT JACKET	BR
A6510	COMPRES BURN GARMENT LEOTARD	BR
A6511	COMPRES BURN GARMENT PANTY	BR
A6512	COMPRES BURN GARMENT, NOC	BR
A6513	COMPRESS BURN MASK FACE/NECK	BR
A6530	COMPRESSION STOCKING BK18-30	49.73
A6531	COMPRESSION STOCKING BK30-40	61.29
A6532	COMPRESSION STOCKING BK40-50	86.37
A6533	GC STOCKING THIGHLNGTH 18-30	43.18
A6534	GC STOCKING THIGHLNGTH 30-40	57.58
A6535	GC STOCKING THIGHLNGTH 40-50	91.60
A6536	GC STOCKING FULL LNGTH 18-30	91.60
A6537	GC STOCKING FULL LNGTH 30-40	104.69
A6538	GC STOCKING FULL LNGTH 40-50	143.94
A6539	GC STOCKING WAISTLNGTH 18-30	200.21
A6540	GC STOCKING WAISTLNGTH 30-40	108.61
A6541	GC STOCKING WAISTLNGTH 40-50	146.56
A6544	GC STOCKING GARTER BELT	52.34
A6545	GRAD COMP NON-ELASTIC BK	120.69
A6549	G COMPRESSION STOCKING	0.00
A6550	NEG PRES WOUND THER DRSG SET	29.88
A7000	NU	DISPOSABLE CANISTER FOR PUMP	10.88
A7001	NU	NONDISPOSABLE PUMP CANISTER	37.38
A7002	NU	TUBING USED W SUCTION PUMP	4.13
A7003	NU	NEBULIZER ADMINISTRATION SET	2.63
A7004	NU	DISPOSABLE NEBULIZER SML VOL	1.72
A7005	NU	NONDISPOSABLE NEBULIZER SET	23.61
A7006	NU	FILTERED NEBULIZER ADMIN SET	10.31
A7007	NU	LG VOL NEBULIZER DISPOSABLE	4.66
A7008	NU	DISPOSABLE NEBULIZER PREFILL	11.84
A7009	NU	NEBULIZER RESERVOIR BOTTLE	52.45
A7010	NU	DISPOSABLE CORRUGATED TUBING	21.78
A7012	NU	NEBULIZER WATER COLLEC DEVIC	4.06
A7013	NU	DISPOSABLE COMPRESSOR FILTER	0.77
A7014	NU	COMPRESSOR NONDISPOS FILTER	4.76
A7015	NU	AEROSOL MASK USED W NEBULIZE	1.94
A7016	NU	NEBULIZER DOME & MOUTHPIECE	8.73
A7017	NU	NEBULIZER NOT USED W OXYGEN	153.57
A7018	WATER DISTILLED W/NEBULIZER	0.40
A7020	NU	INTERFACE, COUGH STIM DEVICE	18.34
A7025	RR	REPLACE CHEST COMPRESS VEST	55.10
A7026	NU	REPLACE CHST CMPRSS SYS HOSE	36.40
A7027	NU	COMBINATION ORAL/NASAL MASK	189.57
A7028	NU	REPL ORAL CUSHION COMBO MASK	51.43
A7029	NU	REPL NASAL PILLOW COMB MASK	22.00
A7030	NU	CPAP FULL FACE MASK	156.23
A7031	NU	REPLACEMENT FACEMASK INTERFA	58.33
A7032	NU	REPLACEMENT NASAL CUSHION	33.44
A7033	NU	REPLACEMENT NASAL PILLOWS	24.78
A7034	NU	NASAL APPLICATION DEVICE	97.53
A7035	NU	POS AIRWAY PRESS HEADGEAR	31.10
A7036	NU	POS AIRWAY PRESS CHINSTRAP	14.91
A7037	NU	POS AIRWAY PRESSURE TUBING	29.33
A7038	NU	POS AIRWAY PRESSURE FILTER	4.20
A7039	NU	FILTER, NON DISPOSABLE W PAP	10.74
A7040	ONE WAY CHEST DRAIN VALVE	51.51
A7041	WATER SEAL DRAIN CONTAINER	96.80
A7044	NU	PAP ORAL INTERFACE	115.54
A7045	NU	REPL EXHALATION PORT FOR PAP	17.83
A7046	NU	REPL WATER CHAMBER, PAP DEV	18.60
A7047	NU	RESP SUCTION ORAL INTERFACE	153.13
A7048	VACUUM DRAIN BOTTLE/TUBE KIT	53.88
A7501	TRACHEOSTOMA VALVE W DIAPHRA	133.01
A7502	REPLACEMENT DIAPHRAGM/FPLATE	63.23
A7503	HMES FILTER HOLDER OR CAP	14.37
A7504	TRACHEOSTOMA HMES FILTER	0.87
A7505	HMES OR TRACH VALVE HOUSING	5.94
A7506	HMES/TRACHVALVE ADHESIVEDISK	0.42
A7507	INTEGRATED FILTER & HOLDER	3.15
A7508	HOUSING & INTEGRATED ADHESIV	3.63
A7509	HEAT & MOISTURE EXCHANGE SYS	1.79
A7520	TRACH/LARYN TUBE NON-CUFFED	60.14
A7521	TRACH/LARYN TUBE CUFFED	59.58
A7522	TRACH/LARYN TUBE STAINLESS	57.20
A7523	TRACHEOSTOMY SHOWER PROTECT	BR
A7524	TRACHEOSTOMA STENT/STUD/BTTN	98.04
A7525	TRACHEOSTOMY MASK	2.62
A7526	TRACHEOSTOMY TUBE COLLAR	4.29
A7527	TRACH/LARYN TUBE PLUG/STOP	4.53
A8000	NU	SOFT PROTECT HELMET PREFAB	194.24
A8001	NU	HARD PROTECT HELMET PREFAB	194.24
A8002	NU	SOFT PROTECT HELMET CUSTOM	BR
A8003	NU	HARD PROTECT HELMET CUSTOM	BR
A8004	NU	REPL SOFT INTERFACE, HELMET	BR
A9150	MISC/EXPER NON-PRESCRIPT DRU	BR
A9152	SINGLE VITAMIN NOS	BR
A9153	MULTI-VITAMIN NOS	BR
A9155	ARTIFICIAL SALIVA	BR
A9180	LICE TREATMENT, TOPICAL	BR
A9270	NON-COVERED ITEM OR SERVICE	BR
A9272	DISP WOUND SUCT, DRSG/ACCESS	BR
A9273	HOT/COLD BOTLE/CAP/COL/WRAP	BR
A9274	EXT AMB INSULIN DELIVERY SYS	BR
A9275	DISP HOME GLUCOSE MONITOR	BR
A9276	DISPOSABLE SENSOR, CGM SYS	BR
A9277	EXTERNAL TRANSMITTER, CGM	BR
A9278	EXTERNAL RECEIVER, CGM SYS	BR
A9279	MONITORING FEATURE/DEVICENOC	BR
A9280	ALERT DEVICE, NOC	BR
A9281	REACHING/GRABBING DEVICE	BR
A9282	WIG ANY TYPE	BR
A9283	FOOT PRESS OFF LOAD SUPP DEV	BR
A9284	NON-ELECTRONIC SPIROMETER	BR
A9285	INVERSION EVERSION COR DEVIC	BR
A9286	ANY HYGIENIC ITEM, DEVICE	0.32
A9300	EXERCISE EQUIPMENT	BR
A9500	TC99M SESTAMIBI	BR
A9501	TECHNETIUM TC-99M TEBOROXIME	BR
A9502	TC99M TETROFOSMIN	BR
A9503	TC99M MEDRONATE	BR
A9504	TC99M APCITIDE	BR
A9505	TL201 THALLIUM	BR
A9507	IN111 CAPROMAB	BR
A9508	I131 IODOBENGUATE, DX	BR
A9509	IODINE I-123 SOD IODIDE MIL	BR
A9510	TC99M DISOFENIN	BR
A9512	TC99M PERTECHNETATE	BR
A9513	LUTETIUM LU 177 DOTATAT THER	BR	357.49
A9515	CHOLINE C-11	4607.04
A9516	IODINE I-123 SOD IODIDE MIC	BR
A9517	I131 IODIDE CAP, RX	BR	29.48
A9520	TC99 TILMANOCEPT DIAG 0.5MCI	0.00
A9521	TC99M EXAMETAZIME	BR
A9524	I131 SERUM ALBUMIN, DX	BR
A9526	NITROGEN N-13 AMMONIA	BR
A9527	IODINE I-125 SODIUM IODIDE	BR	53.78
A9528	IODINE I-131 IODIDE CAP, DX	146.49
A9529	I131 IODIDE SOL, DX	BR
A9530	I131 IODIDE SOL, RX	BR	19.27
A9531	I131 MAX 100UCI	BR
A9532	I125 SERUM ALBUMIN, DX	255.27
A9536	TC99M DEPREOTIDE	BR
A9537	TC99M MEBROFENIN	BR
A9538	TC99M PYROPHOSPHATE	BR
A9539	TC99M PENTETATE	BR
A9540	TC99M MAA	BR
A9541	TC99M SULFUR COLLOID	BR
A9542	IN111 IBRITUMOMAB, DX	BR
A9543	Y90 IBRITUMOMAB, RX	BR	67696.91
A9546	CO57/58	BR
A9547	IN111 OXYQUINOLINE	1032.23
A9548	IN111 PENTETATE	1505.43
A9550	TC99M GLUCEPTATE	BR
A9551	TC99M SUCCIMER	BR
A9552	F18 FDG	BR
A9553	CR51 CHROMATE	BR
A9554	I125 IOTHALAMATE, DX	BR
A9555	RB82 RUBIDIUM	BR
A9556	GA67 GALLIUM	34.10
A9557	TC99M BICISATE	BR
A9558	XE133 XENON 10MCI	BR
A9559	CO57 CYANO	BR
A9560	TC99M LABELED RBC	BR
A9561	TC99M OXIDRONATE	BR
A9562	TC99M MERTIATIDE	BR
A9563	P32 NA PHOSPHATE	BR	1036.64
A9564	P32 CHROMIC PHOSPHATE	188.44
A9566	TC99M FANOLESOMAB	BR
A9567	TECHNETIUM TC-99M AEROSOL	BR
A9568	TECHNETIUM TC99M ARCITUMOMAB	BR
A9569	TECHNETIUM TC-99M AUTO WBC	BR
A9570	INDIUM IN-111 AUTO WBC	BR
A9571	INDIUM IN-111 AUTO PLATELET	BR
A9572	INDIUM IN-111 PENTETREOTIDE	BR
A9575	INJ GADOTERATE MEGLUMI 0.1ML	0.00
A9576	INJ PROHANCE MULTIPACK	1.82
A9577	INJ MULTIHANCE	2.37
A9578	INJ MULTIHANCE MULTIPACK	2.22
A9579	GAD-BASE MR CONTRAST NOS, 1ML	2.09
A9580	SODIUM FLUORIDE F-18	BR
A9581	GADOXETATE DISODIUM INJ	15.50
A9582	IODINE I-123 IOBENGUANE	0.00
A9583	GADOFOSVESET TRISODIUM INJ	35.64
A9584	IODINE I-123 IOFLUPANE	BR
A9585	GADOBUTROL INJECTION	0.43
A9586	FLORBETAPIR F18	BR	4300.96
A9587	GALLIUM GA-68	125.34	94.77
A9588	FLUCICLOVINE F-18	460.72	553.16
A9589	INSTI HEXAMINOLEVULINATE HCL	BR
A9597	PET, DX, FOR TUMOR ID, NOC	BR
A9598	PET DX FOR NON-TUMOR ID, NOC	BR
A9600	SR89 STRONTIUM	475.92	2123.84
A9604	SM 153 LEXIDRONAM	4457.22	20803.31
A9606	RADIUM RA223 DICHLORIDE THER	0.00	194.11
A9698	NON-RAD CONTRAST MATERIALNOC	BR
A9699	RADIOPHARM RX AGENT NOC	BR
A9700	ECHOCARDIOGRAPHY CONTRAST	BR
A9900	SUPPLY/ACCESSORY/SERVICE	BR
A9901	DELIVERY/SET UP/DISPENSING	BR
A9999	DME SUPPLY OR ACCESSORY, NOS	BR
B4034	ENTER FEED SUPKIT SYR BY DAY	5.41
B4035	ENTERAL FEED SUPP PUMP PER D	10.00
B4036	ENTERAL FEED SUP KIT GRAV BY	7.19
B4081	ENTERAL NG TUBING W/ STYLET	21.89
B4082	ENTERAL NG TUBING W/O STYLET	16.02
B4083	ENTERAL STOMACH TUBE LEVINE	2.43
B4087	GASTRO/JEJUNO TUBE, STD	37.03
B4088	GASTRO/JEJUNO TUBE, LOW-PRO	39.78
B4100	FOOD THICKENER ORAL	BR
B4102	EF ADULT FLUIDS AND ELECTRO	BR
B4103	EF PED FLUID AND ELECTROLYTE	BR
B4104	ADDITIVE FOR ENTERAL FORMULA	BR
B4105	ENZYME CARTRIDGE ENTERAL NUT	BR
B4149	EF BLENDERIZED FOODS	1.53
B4150	EF COMPLET W/INTACT NUTRIENT	0.63
B4152	EF CALORIE DENSE>/=1.5KCAL	0.52
B4153	EF HYDROLYZED/AMINO ACIDS	1.84
B4154	EF SPEC METABOLIC NONINHERIT	1.11
B4155	EF INCOMPLETE/MODULAR	0.99
B4157	EF SPECIAL METABOLIC INHERIT	BR
B4158	EF PED COMPLETE INTACT NUT	BR
B4159	EF PED COMPLETE SOY BASED	BR
B4160	EF PED CALORIC DENSE>/=0.7KC	BR
B4161	EF PED HYDROLYZED/AMINO ACID	BR
B4162	EF PED SPECMETABOLIC INHERIT	BR
B4164	PARENTERAL 50% DEXTROSE SOLU	22.35
B4168	PARENTERAL SOL AMINO ACID 3.	32.59
B4172	PARENTERAL SOL AMINO ACID 5.	131.78
B4176	PARENTERAL SOL AMINO ACID 7-	63.05
B4178	PARENTERAL SOL AMINO ACID >	75.67
B4180	PARENTERAL SOL CARB > 50%	32.09
B4185	PARENTERAL SOL 10 GM LIPIDS	14.77
B4189	PARENTERAL SOL AMINO ACID &	233.78
B4193	PARENTERAL SOL 52-73 GM PROT	302.07
B4197	PARENTERAL SOL 74-100 GM PRO	367.77
B4199	PARENTERAL SOL > 100GM PROTE	420.23
B4216	PARENTERAL NUTRITION ADDITIV	10.15
B4220	PARENTERAL SUPPLY KIT PREMIX	10.53
B4222	PARENTERAL SUPPLY KIT HOMEMI	12.99
B4224	PARENTERAL ADMINISTRATION KI	32.88
B5000	PARENTERAL SOL RENAL-AMIROSY	15.64
B5100	PARENTERAL SOLUTION HEPATIC	6.11
B5200	PARENTERAL SOL HEPATIC FREAM	BR
B9002	NU	ENTER NUTR INF PUMP ANY TYPE	1089.51
B9004	NU	PARENTERAL INFUS PUMP PORTAB	3318.43
B9006	NU	PARENTERAL INFUS PUMP STATIO	3318.43
B9998	ENTERAL SUPP NOT OTHERWISE C	BR
B9999	PARENTERAL SUPP NOT OTHRWS C	BR
C1713	ANCHOR/SCREW BN/BN, TIS/BN	0.00
C1714	CATH, TRANS ATHERECTOMY, DIR	0.00
C1715	BRACHYTHERAPY NEEDLE	0.00
C1716	BRACHYTX, NON-STR, GOLD-198	0.00	122.53
C1717	BRACHYTX, NON-STR, HDR IR-192	0.00	412.91
C1719	BRACHYTX, NS, NON-HDRIR-192	0.00	120.59
C1721	AICD, DUAL CHAMBER	0.00
C1722	AICD, SINGLE CHAMBER	0.00
C1724	CATH, TRANS ATHEREC, ROTATION	0.00
C1725	CATH, TRANSLUMIN NON-LASER	0.00
C1726	CATH, BAL DIL, NON-VASCULAR	0.00
C1727	CATH, BAL TIS DIS, NON-VAS	0.00
C1728	CATH, BRACHYTX SEED ADM	0.00
C1729	CATH, DRAINAGE	0.00
C1730	CATH, EP, 19 OR FEW ELECT	0.00
C1731	CATH, EP, 20 OR MORE ELEC	0.00
C1732	CATH, EP, DIAG/ABL, 3D/VECT	0.00
C1733	CATH, EP, OTHR THAN COOL-TIP	0.00
C1749	ENDO, COLON, RETRO IMAGING	0.00
C1750	CATH, HEMODIALYSIS, LONG-TERM	0.00
C1751	CATH, INF, PER/CENT/MIDLINE	0.00
C1752	CATH, HEMODIALYSIS, SHORT-TERM	0.00
C1753	CATH, INTRAVAS ULTRASOUND	0.00
C1754	CATHETER, INTRADISCAL	0.00
C1755	CATHETER, INTRASPINAL	0.00
C1756	CATH, PACING, TRANSESOPH	0.00
C1757	CATH, THROMBECTOMY/EMBOLECT	0.00
C1758	CATHETER, URETERAL	0.00
C1759	CATH, INTRA ECHOCARDIOGRAPHY	0.00
C1760	CLOSURE DEV, VASC	0.00
C1762	CONN TISS, HUMAN(INC FASCIA)	0.00
C1763	CONN TISS, NON-HUMAN	0.00
C1764	EVENT RECORDER, CARDIAC	0.00
C1765	ADHESION BARRIER	0.00
C1766	INTRO/SHEATH, STRBLE, NON-PEEL	0.00
C1767	GENERATOR, NEURO NON-RECHARG	0.00
C1768	GRAFT, VASCULAR	0.00
C1769	GUIDE WIRE	0.00
C1770	IMAGING COIL, MR, INSERTABLE	0.00
C1771	REP DEV, URINARY, W/SLING	0.00
C1772	INFUSION PUMP, PROGRAMMABLE	0.00
C1773	RET DEV, INSERTABLE	0.00
C1776	JOINT DEVICE (IMPLANTABLE)	0.00
C1777	LEAD, AICD, ENDO SINGLE COIL	0.00
C1778	LEAD, NEUROSTIMULATOR	0.00
C1779	LEAD, PMKR, TRANSVENOUS VDD	0.00
C1780	LENS, INTRAOCULAR (NEW TECH)	0.00
C1781	MESH (IMPLANTABLE)	0.00
C1782	MORCELLATOR	0.00
C1783	OCULAR IMP, AQUEOUS DRAIN DE	0.00
C1784	OCULAR DEV, INTRAOP, DET RET	0.00
C1785	PMKR, DUAL, RATE-RESP	0.00
C1786	PMKR, SINGLE, RATE-RESP	0.00
C1787	PATIENT PROGR, NEUROSTIM	0.00
C1788	PORT, INDWELLING, IMP	0.00
C1789	PROSTHESIS, BREAST, IMP	0.00
C1813	PROSTHESIS, PENILE, INFLATAB	0.00
C1814	RETINAL TAMP, SILICONE OIL	0.00
C1815	PROS, URINARY SPH, IMP	0.00
C1816	RECEIVER/TRANSMITTER, NEURO	0.00
C1817	SEPTAL DEFECT IMP SYS	0.00
C1818	INTEGRATED KERATOPROSTHESIS	0.00
C1819	TISSUE LOCALIZATION-EXCISION	0.00
C1820	GENERATOR NEURO RECHG BAT SY	0.00
C1821	INTERSPINOUS IMPLANT	0.00
C1822	GEN, NEURO, HF, RECHG BAT	BR
C1823	GEN, NEURO, TRANS SEN/STIM	BR
C1830	POWER BONE MARROW BX NEEDLE	0.00
C1840	TELESCOPIC INTRAOCULAR LENS	0.00
C1841	RETINAL PROSTH INT/EXT COMP	BR
C1842	RETINAL PROSTH, ADD-ON	BR
C1874	STENT, COATED/COV W/DEL SYS	0.00
C1875	STENT, COATED/COV W/O DEL SY	0.00
C1876	STENT, NON-COA/NON-COV W/DEL	0.00
C1877	STENT, NON-COAT/COV W/O DEL	0.00
C1878	MATRL FOR VOCAL CORD	0.00
C1880	VENA CAVA FILTER	0.00
C1881	DIALYSIS ACCESS SYSTEM	0.00
C1882	AICD, OTHER THAN SING/DUAL	0.00
C1883	ADAPT/EXT, PACING/NEURO LEAD	0.00
C1884	EMBOLIZATION PROTECT SYST	0.00
C1885	CATH, TRANSLUMIN ANGIO LASER	0.00
C1886	CATHETER, ABLATION	0.00
C1887	CATHETER, GUIDING	0.00
C1888	ENDOVAS NON-CARDIAC ABL CATH	0.00
C1889	IMPLANT/INSERT DEVICE, NOC	BR
C1890	NO DEVICE W/DEV-INTENSIVE PX	BR
C1891	INFUSION PUMP, NON-PROG, PERM	0.00
C1892	INTRO/SHEATH, FIXED, PEEL-AWAY	0.00
C1893	INTRO/SHEATH, FIXED, NON-PEEL	0.00
C1894	INTRO/SHEATH, NON-LASER	0.00
C1895	LEAD, AICD, ENDO DUAL COIL	0.00
C1896	LEAD, AICD, NON SING/DUAL	0.00
C1897	LEAD, NEUROSTIM TEST KIT	0.00
C1898	LEAD, PMKR, OTHER THAN TRANS	0.00
C1899	LEAD, PMKR/AICD COMBINATION	0.00
C1900	LEAD, CORONARY VENOUS	0.00
C2613	LUNG BX PLUG W/DEL SYS	BR
C2614	PROBE, PERC LUMB DISC	0.00
C2615	SEALANT, PULMONARY, LIQUID	0.00
C2616	BRACHYTX, NON-STR, YTTRIUM-90	0.00	23608.75
C2617	STENT, NON-COR, TEM W/O DEL	0.00
C2618	PROBE/NEEDLE, CRYO	0.00
C2619	PMKR, DUAL, NON RATE-RESP	0.00
C2620	PMKR, SINGLE, NON RATE-RESP	0.00
C2621	PMKR, OTHER THAN SING/DUAL	0.00
C2622	PROSTHESIS, PENILE, NON-INF	0.00
C2623	CATH, TRANSLUMIN, DRUG-COAT	BR
C2624	WIRELESS PRESSURE SENSOR	BR
C2625	STENT, NON-COR, TEM W/DEL SY	0.00
C2626	INFUSION PUMP, NON-PROG, TEMP	0.00
C2627	CATH, SUPRAPUBIC/CYSTOSCOPIC	0.00
C2628	CATHETER, OCCLUSION	0.00
C2629	INTRO/SHEATH, LASER	0.00
C2630	CATH, EP, COOL-TIP	0.00
C2631	REP DEV, URINARY, W/O SLING	0.00
C2634	BRACHYTX, NON-STR, HA, I-125	0.00	196.80
C2635	BRACHYTX, NON-STR, HA, P-103	0.00	38.51
C2636	BRACHY LINEAR, NON-STR, P-103	0.00	70.05
C2637	BRACHY, NON-STR, YTTERBIUM-169	0.00
C2638	BRACHYTX, STRANDED, I-125	0.00	51.69
C2639	BRACHYTX, NON-STRANDED, I-125	0.00	49.71
C2640	BRACHYTX, STRANDED, P-103	0.00	106.03
C2641	BRACHYTX, NON-STRANDED, P-103	0.00	85.38
C2642	BRACHYTX, STRANDED, C-131	0.00	113.51
C2643	BRACHYTX, NON-STRANDED, C-131	0.00	111.27
C2644	BRACHYTX CESIUM-131 CHLORIDE	BR	17.79
C2645	BRACHYTX PLANAR, P-103	BR	6.66
C2698	BRACHYTX, STRANDED, NOS	0.00	51.69
C2699	BRACHYTX, NON-STRANDED, NOS	0.00	38.51
C5271	LOW COST SKIN SUBSTITUTE APP	BR	685.70
C5272	LOW COST SKIN SUBSTITUTE APP	BR
C5273	LOW COST SKIN SUBSTITUTE APP	BR	2199.52
C5274	LOW COST SKIN SUBSTITUTE APP	BR
C5275	LOW COST SKIN SUBSTITUTE APP	BR	685.70
C5276	LOW COST SKIN SUBSTITUTE APP	BR
C5277	LOW COST SKIN SUBSTITUTE APP	BR	685.70
C5278	LOW COST SKIN SUBSTITUTE APP	BR
C8900	MRA W/CONT, ABD	0.00	547.95
C8901	MRA W/O CONT, ABD	0.00	327.40
C8902	MRA W/O FOL W/CONT, ABD	0.00	547.95
C8903	MRI W/CONT, BREAST, UNI	0.00	286.47
C8905	MRI W/O FOL W/CONT, BRST, UN	0.00	547.95
C8906	MRI W/CONT, BREAST, BI	0.00	547.95
C8908	MRI W/O FOL W/CONT, BREAST,	0.00	547.95
C8909	MRA W/CONT, CHEST	0.00	547.95
C8910	MRA W/O CONT, CHEST	0.00	327.40
C8911	MRA W/O FOL W/CONT, CHEST	0.00	547.95
C8912	MRA W/CONT, LWR EXT	0.00	547.95
C8913	MRA W/O CONT, LWR EXT	0.00	327.40
C8914	MRA W/O FOL W/CONT, LWR EXT	0.00	547.95
C8918	MRA W/CONT, PELVIS	0.00	547.95
C8919	MRA W/O CONT, PELVIS	0.00	327.40
C8920	MRA W/O FOL W/CONT, PELVIS	0.00	547.95
C8921	TTE W OR W/O FOL W/CONT, COM	0.00	982.29
C8922	TTE W OR W/O FOL W/CONT, F/U	0.00	982.29
C8923	2D TTE W OR W/O FOL W/CON, CO	0.00	982.29
C8924	2D TTE W OR W/O FOL W/CON, FU	0.00	547.95
C8925	2D TEE W OR W/O FOL W/CON, IN	0.00	982.29
C8926	TEE W OR W/O FOL W/CONT, CONG	0.00	982.29
C8927	TEE W OR W/O FOL W/CONT, MON	0.00	982.29
C8928	TTE W OR W/O FOL W/CON, STRES	0.00	982.29
C8929	TTE W OR WO FOL WCON, DOPPLER	0.00	982.29
C8930	TTE W OR W/O CONTR, CONT ECG	0.00	982.29
C8931	MRA, W/DYE, SPINAL CANAL	0.00	547.95
C8932	MRA, W/O DYE, SPINAL CANAL	0.00	327.40
C8933	MRA, W/O&W/DYE, SPINAL CANAL	0.00	547.95
C8934	MRA, W/DYE, UPPER EXTREMITY	0.00	547.95
C8935	MRA, W/O DYE, UPPER EXTR	0.00	327.40
C8936	MRA, W/O&W/DYE, UPPER EXTR	0.00	547.95
C8937	CAD BREAST MRI	BR
C8957	PROLONGED IV INF, REQ PUMP	0.00	409.50
C9035	INJECTION, ARISTADA INITIO	BR	4.05
C9036	INJECTION, PATISIRAN	BR	138.95
C9037	INJECTION, RISPERIDONE	BR	13.89
C9038	INJ MOGAMULIZUMAB-KPKC	BR	277.16
C9039	INJECTION, PLAZOMICIN	BR	4.61
C9113	INJ PANTOPRAZOLE SODIUM, VIA	0.00
C9132	KCENTRA, PER I.U.	BR	2.75
C9248	INJ, CLEVIDIPINE BUTYRATE	0.00	3.95
C9250	ARTISS FIBRIN SEALANT	0.00	222.72
C9254	INJECTION, LACOSAMIDE	0.00
C9257	BEVACIZUMAB INJECTION	0.00	2.88
C9285	PATCH, LIDOCAINE/TETRACAINE	0.00
C9290	INJ, BUPIVACAINE LIPOSOME	0.00
C9293	INJECTION, GLUCARPIDASE	0.00	444.74
C9352	NEURAGEN NERVE GUIDE, PER CM	0.00
C9353	NEURAWRAP NERVE PROTECTOR, CM	0.00
C9354	VERITAS COLLAGEN MATRIX, CM2	0.00
C9355	NEUROMATRIX NERVE CUFF, CM	0.00
C9356	TENOGLIDE TENDON PROT, CM2	0.00
C9358	SURGIMEND, FETAL	0.00
C9359	IMPLNT, BON VOID FILLER-PUTTY	0.00
C9360	SURGIMEND, NEONATAL	0.00
C9361	NEUROMEND NERVE WRAP	0.00
C9362	IMPLNT, BON VOID FILLER-STRIP	0.00
C9363	INTEGRA MESHED BIL WOUND MAT	0.00
C9364	PORCINE IMPLANT, PERMACOL	0.00
C9399	UNCLASSIFIED DRUGS OR BIOLOG	0.00
C9407	IODINE I-131 IOBENGUANE, DX	BR	441.71
C9408	IODINE I-131 IOBENGUANE, TX	BR	441.71
C9447	INJ, PHENYLEPHRINE KETOROLAC	0.00	672.01
C9460	INJECTION, CANGRELOR	0.00	21.95
C9462	INJECTION, DELAFLOXACIN	BR	0.64
C9482	SOTALOL HYDROCHLORIDE IV	BR	14.18
C9488	CONIVAPTAN HCL	BR	45.54
J1	C9600	PERC DRUG-EL COR STENT SING	0.00	17440.05
C9601	PERC DRUG-EL COR STENT BRAN	0.00
J1	C9602	PERC D-E COR STENT ATHER S	0.00	26888.04
C9603	PERC D-E COR STENT ATHER BR	0.00
J1	C9604	PERC D-E COR REVASC T CABG S	0.00	17440.05
C9605	PERC D-E COR REVASC T CABG B	0.00
C9606	PERC D-E COR REVASC W AMI S	0.00	20948.17
J1	C9607	PERC D-E COR REVASC CHRO SIN	0.00	26888.04
C9608	PERC D-E COR REVASC CHRO ADD	0.00
C9725	PLACE ENDORECTAL APP	0.00	1057.74
C9726	RXT BREAST APPL PLACE/REMOV	0.00
J1	C9727	INSERT PALATE IMPLANTS	0.00	2543.11
C9728	PLACE DEVICE/MARKER, NON PRO	0.00	1692.53
C9733	NON-OPHTHALMIC FVA	0.00	547.95
J1	C9734	U/S TRTMT, NOT LEIOMYOMATA	0.00	19120.53
C9738	BLUE LIGHT CYSTO IMAG AGENT	BR
J1	C9739	CYSTOSCOPY PROSTATIC IMP 1-3	BR	7926.90
J1	C9740	CYSTO IM PL 4 OR MORE	BR	13305.84
J1	C9745	NASAL ENDO EUSTACHIAN TUBE	BR	8765.29
J1	C9746	TRANS IMP BALLOON CONT	BR	26963.98
J1	C9747	ABLATION, HIFU, PROSTATE	BR	7926.90
J1	C9749	REPAIR NASAL STENOSIS W/IMP	BR	8765.29
C9751	MICROWAVE BRONCH, 3D, EBUS	BR	11715.71
J1	C9752	INTRAOSSEOUS DES LUMB/SACRUM	BR	19120.53
C9753	INTRAOSSEOUS DESTRUCT ADD'L	BR
J1	C9754	PERC AV FISTULA, DIRECT	BR	17440.05
J1	C9755	RF MAGNETIC-GUIDE AV FISTULA	BR	17440.05
C9898	INPNT STAY RADIOLABELED ITEM	0.00
C9899	INPT IMPLANT PROS DEV, NO COV	0.00
E0100	NU	CANE ADJUST/FIXED WITH TIP	20.63
E0105	NU	CANE ADJUST/FIXED QUAD/3 PRO	56.55
E0110	NU	CRUTCH FOREARM PAIR	84.68
E0111	NU	CRUTCH FOREARM EACH	52.11
E0112	NU	CRUTCH UNDERARM PAIR WOOD	42.61
E0113	NU	CRUTCH UNDERARM EACH WOOD	24.34
E0114	NU	CRUTCH UNDERARM PAIR NO WOOD	54.34
E0116	NU	CRUTCH UNDERARM EACH NO WOOD	30.31
E0117	NU	UNDERARM SPRINGASSIST CRUTCH	303.28
E0118	CRUTCH SUBSTITUTE	1138.46
E0130	NU	WALKER RIGID ADJUST/FIXED HT	53.97
E0135	NU	WALKER FOLDING ADJUST/FIXED	59.65
E0140	NU	WALKER W TRUNK SUPPORT	317.61
E0141	NU	RIGID WHEELED WALKER ADJ/FIX	82.50
E0143	NU	WALKER FOLDING WHEELED W/O S	79.65
E0144	NU	ENCLOSED WALKER W REAR SEAT	956.71
E0147	NU	WALKER VARIABLE WHEEL RESIST	502.73
E0148	NU	HEAVYDUTY WALKER NO WHEELS	107.14
E0149	NU	HEAVY DUTY WHEELED WALKER	275.31
E0153	NU	FOREARM CRUTCH PLATFORM ATTA	79.90
E0154	NU	WALKER PLATFORM ATTACHMENT	61.10
E0155	NU	WALKER WHEEL ATTACHMENT, PAIR	24.44
E0156	NU	WALKER SEAT ATTACHMENT	21.50
E0157	NU	WALKER CRUTCH ATTACHMENT	64.45
E0158	NU	WALKER LEG EXTENDERS SET OF4	25.09
E0159	NU	BRAKE FOR WHEELED WALKER	16.69
E0160	NU	SITZ TYPE BATH OR EQUIPMENT	34.43
E0161	NU	SITZ BATH/EQUIPMENT W/FAUCET	28.28
E0162	NU	SITZ BATH CHAIR	167.76
E0163	NU	COMMODE CHAIR WITH FIXED ARM	85.46
E0165	NU	COMMODE CHAIR WITH DETACHARM	256.99
E0167	NU	COMMODE CHAIR PAIL OR PAN	12.69
E0168	NU	HEAVYDUTY/WIDE COMMODE CHAIR	149.31
E0170	RR	COMMODE CHAIR ELECTRIC	179.60
E0171	RR	COMMODE CHAIR NON-ELECTRIC	32.99
E0172	SEAT LIFT MECHANISM TOILET	0.00
E0175	NU	COMMODE CHAIR FOOT REST	76.26
E0181	NU	PRESS PAD ALTERNATING W/ PUM	370.73
E0182	NU	REPLACE PUMP, ALT PRESS PAD	370.73
E0184	NU	DRY PRESSURE MATTRESS	197.90
E0185	NU	GEL PRESSURE MATTRESS PAD	246.91
E0186	NU	AIR PRESSURE MATTRESS	196.58
E0187	NU	WATER PRESSURE MATTRESS	215.01
E0188	NU	SYNTHETIC SHEEPSKIN PAD	28.36
E0189	NU	LAMBSWOOL SHEEPSKIN PAD	50.86
E0190	NU	POSITIONING CUSHION	79.80
E0191	NU	PROTECTOR HEEL OR ELBOW	11.06
E0193	RR	POWERED AIR FLOTATION BED	751.33
E0194	NU	AIR FLUIDIZED BED	42347.42
E0196	NU	GEL PRESSURE MATTRESS	529.54
E0197	NU	AIR PRESSURE PAD FOR MATTRES	431.14
E0198	NU	WATER PRESSURE PAD FOR MATTR	234.34
E0199	NU	DRY PRESSURE PAD FOR MATTRES	31.38
E0200	NU	HEAT LAMP WITHOUT STAND	77.59
E0202	RR	PHOTOTHERAPY LIGHT W/ PHOTOM	72.09
E0203	THERAPEUTIC LIGHTBOX TABLETP	BR
E0205	NU	HEAT LAMP WITH STAND	189.92
E0210	NU	ELECTRIC HEAT PAD STANDARD	32.21
E0215	NU	ELECTRIC HEAT PAD MOIST	69.33
E0217	NU	WATER CIRC HEAT PAD W PUMP	568.51
E0218	NU	FLUID CIRC COLD PAD W PUMP	1895.41
E0221	INFRARED HEATING PAD SYSTEM	0.00
E0225	NU	HYDROCOLLATOR UNIT	447.48
E0231	WOUND WARMING DEVICE	BR
E0232	WARMING CARD FOR NWT	BR
E0235	NU	PARAFFIN BATH UNIT PORTABLE	814.80
E0236	NU	PUMP FOR WATER CIRCULATING P	4298.82
E0239	NU	HYDROCOLLATOR UNIT PORTABLE	517.92
E0240	NU	BATH/SHOWER CHAIR	103.72
E0241	BATH TUB WALL RAIL	73.00
E0242	BATH TUB RAIL FLOOR	55.16
E0243	TOILET RAIL	74.19
E0244	TOILET SEAT RAISED	66.51
E0245	TUB STOOL OR BENCH	74.49
E0246	TRANSFER TUB RAIL ATTACHMENT	77.30
E0247	NU	TRANS BENCH W/WO COMM OPEN	129.81
E0248	NU	HDTRANS BENCH W/WO COMM OPEN	186.01
E0249	NU	PAD WATER CIRCULATING HEAT U	97.49
E0250	NU	HOSP BED FIXED HT W/ MATTRES	1849.69
E0251	NU	HOSP BED FIXD HT W/O MATTRES	1852.78
E0255	NU	HOSPITAL BED VAR HT W/ MATTR	1606.51
E0256	NU	HOSPITAL BED VAR HT W/O MATT	787.51
E0260	NU	HOSP BED SEMI-ELECTR W/ MATT	1852.89
E0261	NU	HOSP BED SEMI-ELECTR W/O MAT	1694.19
E0265	NU	HOSP BED TOTAL ELECTR W/ MAT	2065.00
E0266	NU	HOSP BED TOTAL ELEC W/O MATT	1834.67
E0270	NU	HOSPITAL BED INSTITUTIONAL T	0.00
E0271	NU	MATTRESS INNERSPRING	159.61
E0272	NU	MATTRESS FOAM RUBBER	160.18
E0273	NU	BED BOARD	26.57
E0274	NU	OVER-BED TABLE	370.51
E0275	NU	BED PAN STANDARD	16.26
E0276	NU	BED PAN FRACTURE	14.06
E0277	NU	POWERED PRES-REDU AIR MATTRS	7846.78
E0280	NU	BED CRADLE	32.23
E0290	NU	HOSP BED FX HT W/O RAILS W/M	791.38
E0291	NU	HOSP BED FX HT W/O RAIL W/O	635.11
E0292	NU	HOSP BED VAR HT NO SR W/MATT	671.60
E0293	NU	HOSP BED VAR HT NO SR NO MAT	571.35
E0294	NU	HOSP BED SEMI-ELECT W/ MATTR	1429.04
E0295	NU	HOSP BED SEMI-ELECT W/O MATT	1146.21
E0296	NU	HOSP BED TOTAL ELECT W/ MATT	1384.20
E0297	NU	HOSP BED TOTAL ELECT W/O MAT	5006.93
E0300	NU	ENCLOSED PED CRIB HOSP GRADE	2268.47
E0301	NU	HD HOSP BED, 350-600 LBS	3177.45
E0302	NU	EX HD HOSP BED > 600 LBS	21286.79
E0303	NU	HOSP BED HVY DTY XTRA WIDE	3473.75
E0304	NU	HOSP BED XTRA HVY DTY X WIDE	8938.55
E0305	NU	RAILS BED SIDE HALF LENGTH	201.21
E0310	NU	RAILS BED SIDE FULL LENGTH	146.55
E0315	BED ACCESSORY BRD/TBL/SUPPRT	BR
E0316	NU	BED SAFETY ENCLOSURE	4107.67
E0325	NU	URINAL MALE JUG-TYPE	10.69
E0326	NU	URINAL FEMALE JUG-TYPE	11.25
E0328	PED HOSPITAL BED, MANUAL	BR
E0329	PED HOSPITAL BED SEMI/ELECT	BR
E0350	NU	CONTROL UNIT BOWEL SYSTEM	BR
E0352	DISPOSABLE PACK W/BOWEL SYST	BR
E0370	AIR ELEVATOR FOR HEEL	BR
E0371	RR	NONPOWER MATTRESS OVERLAY	300.22
E0372	RR	POWERED AIR MATTRESS OVERLAY	342.51
E0373	RR	NONPOWERED PRESSURE MATTRESS	377.40
E0424	RR	STATIONARY COMPRESSED GAS 02	134.71
E0425	GAS SYSTEM STATIONARY COMPRE	30.46
E0430	OXYGEN SYSTEM GAS PORTABLE	3.06
E0431	RR	PORTABLE GASEOUS 02	67.36
E0433	RR	PORTABLE LIQUID OXYGEN SYS	67.36
E0434	RR	PORTABLE LIQUID 02	67.36
E0435	OXYGEN SYSTEM LIQUID PORTABL	BR
E0439	RR	STATIONARY LIQUID 02	134.71
E0440	OXYGEN SYSTEM LIQUID STATION	14.97
E0441	STATIONARY O2 CONTENTS, GAS	64.20
E0442	STATIONARY O2 CONTENTS, LIQ	64.20
E0443	PORTABLE 02 CONTENTS, GAS	61.69
E0444	PORTABLE 02 CONTENTS, LIQUID	61.69
E0445	OXIMETER NON-INVASIVE	BR
E0446	TOPICAL OX DELIVER SYS, NOS	BR
E0447	PORT O2 CONT, LIQ OVER 4 LPM	92.54
E0455	NU	OXYGEN TENT EXCL CROUP/PED T	1694.08
E0457	NU	CHEST SHELL	569.74
E0459	NU	CHEST WRAP	471.89
E0462	NU	ROCKING BED W/ OR W/O SIDE R	3079.39
E0465	RR	HOME VENT INVASIVE INTERFACE	934.17
E0466	RR	HOME VENT NON-INVASIVE INTER	934.17
E0467	RR	HOME VENT MULTI-FUNCTION	1122.96
E0470	NU	RAD W/O BACKUP NON-INV INTFC	3229.03
E0471	NU	RAD W/BACKUP NON INV INTRFC	7516.14
E0472	NU	RAD W BACKUP INVASIVE INTRFC	6799.63
E0480	NU	PERCUSSOR ELECT/PNEUM HOME M	734.18
E0481	INTRPULMNRY PERCUSS VENT SYS	BR
E0482	RR	COUGH STIMULATING DEVICE	443.68
E0483	NU	HI FREQ CHEST WALL OSCIL SYS	15763.14
E0484	NU	NON-ELEC OSCILLATORY PEP DVC	42.53
E0485	NU	ORAL DEVICE/APPLIANCE PREFAB	212.65
E0486	NU	ORAL DEVICE/APPLIANCE CUSFAB	6917.19
E0487	NU	ELECTRONIC SPIROMETER	0.00
E0500	NU	IPPB ALL TYPES	1651.45
E0550	NU	HUMIDIF EXTENS SUPPLE W IPPB	847.05
E0555	NU	HUMIDIFIER FOR USE W/ REGULA	6.58
E0560	NU	HUMIDIFIER SUPPLEMENTAL W/ I	168.59
E0561	NU	HUMIDIFIER NONHEATED W PAP	92.05
E0562	NU	HUMIDIFIER HEATED USED W PAP	223.90
E0565	NU	COMPRESSOR AIR POWER SOURCE	899.94
E0570	NU	NEBULIZER WITH COMPRESSION	341.14
E0572	NU	AEROSOL COMPRESSOR ADJUST PR	340.81
E0574	NU	ULTRASONIC GENERATOR W SVNEB	1373.38
E0575	NU	NEBULIZER ULTRASONIC	479.28
E0580	NU	NEBULIZER FOR USE W/ REGULAT	131.71
E0585	NU	NEBULIZER W/ COMPRESSOR & HE	1070.13
E0600	NU	SUCTION PUMP PORTAB HOM MODL	794.14
E0601	NU	CONT AIRWAY PRESSURE DEVICE	1482.38
E0602	NU	MANUAL BREAST PUMP	33.98
E0603	NU	ELECTRIC BREAST PUMP	319.24
E0604	NU	HOSP GRADE ELEC BREAST PUMP	952.62
E0605	NU	VAPORIZER ROOM TYPE	30.42
E0606	NU	DRAINAGE BOARD POSTURAL	242.39
E0607	NU	BLOOD GLUCOSE MONITOR HOME	76.93
E0610	NU	PACEMAKER MONITR AUDIBLE/VIS	273.86
E0615	NU	PACEMAKER MONITR DIGITAL/VIS	551.28
E0616	CARDIAC EVENT RECORDER	BR
E0617	RR	AUTOMATIC EXT DEFIBRILLATOR	388.68
E0618	RR	APNEA MONITOR	322.81
E0619	RR	APNEA MONITOR W RECORDER	0.00
E0620	NU	CAP BLD SKIN PIERCING LASER	923.66
E0621	NU	PATIENT LIFT SLING OR SEAT	99.89
E0625	NU	PATIENT LIFT BATHROOM OR TOI	0.00
E0627	NU	SEAT LIFT MECH, ELECTRIC ANY	330.47
E0629	NU	SEAT LIFT MECH, NON-ELECTRIC	328.89
E0630	NU	PATIENT LIFT HYDRAULIC	1324.78
E0635	NU	PATIENT LIFT ELECTRIC	2301.15
E0636	NU	PT SUPPORT & POSITIONING SYS	9777.31
E0637	NU	COMBINATION SIT TO STAND SYS	4384.85
E0638	NU	STANDING FRAME SYS	3010.84
E0639	RR	MOVEABLE PATIENT LIFT SYSTEM	128.44
E0640	RR	FIXED PATIENT LIFT SYSTEM	128.44
E0641	MULTI-POSITION STND FRAM SYS	BR
E0642	DYNAMIC STANDING FRAME	BR
E0650	NU	PNEUMA COMPRESOR NON-SEGMENT	704.85
E0651	NU	PNEUM COMPRESSOR SEGMENTAL	1057.44
E0652	NU	PNEUM COMPRES W/CAL PRESSURE	5188.38
E0655	NU	PNEUMATIC APPLIANCE HALF ARM	105.63
E0656	NU	SEGMENTAL PNEUMATIC TRUNK	670.49
E0657	NU	SEGMENTAL PNEUMATIC CHEST	868.05
E0660	NU	PNEUMATIC APPLIANCE FULL LEG	183.94
E0665	NU	PNEUMATIC APPLIANCE FULL ARM	134.08
E0666	NU	PNEUMATIC APPLIANCE HALF LEG	135.15
E0667	NU	SEG PNEUMATIC APPL FULL LEG	316.86
E0668	NU	SEG PNEUMATIC APPL FULL ARM	432.45
E0669	NU	SEG PNEUMATIC APPLI HALF LEG	211.07
E0670	NU	SEG PNEUM INT LEGS/TRUNK	1276.02
E0671	NU	PRESSURE PNEUM APPL FULL LEG	478.23
E0672	NU	PRESSURE PNEUM APPL FULL ARM	371.57
E0673	NU	PRESSURE PNEUM APPL HALF LEG	308.76
E0675	NU	PNEUMATIC COMPRESSION DEVICE	7867.54
E0676	INTER LIMB COMPRESS DEV NOS	24.16
E0691	NU	UVL PNL 2 SQ FT OR LESS	1034.61
E0692	NU	UVL SYS PANEL 4 FT	1299.20
E0693	NU	UVL SYS PANEL 6 FT	1601.54
E0694	NU	UVL MD CABINET SYS 6 FT	5097.55
E0700	SAFETY EQUIPMENT	BR
E0705	NU	TRANSFER DEVICE	63.48
E0710	RESTRAINTS ANY TYPE	BR
E0720	NU	TENS TWO LEAD	BR
E0730	NU	TENS FOUR LEAD	249.38
E0731	NU	CONDUCTIVE GARMENT FOR TENS/	250.04
E0740	NU	NON-IMPLANT PELV FLR E-STIM	688.34
E0744	NU	NEUROMUSCULAR STIM FOR SCOLI	2022.09
E0745	NU	NEUROMUSCULAR STIM FOR SHOCK	1266.37
E0746	NU	ELECTROMYOGRAPH BIOFEEDBACK	688.23
E0747	NU	ELEC OSTEOGEN STIM NOT SPINE	4508.88
E0748	NU	ELEC OSTEOGEN STIM SPINAL	4479.68
E0749	RR	ELEC OSTEOGEN STIM IMPLANTED	327.41
E0755	ELECTRONIC SALIVARY REFLEX S	BR
E0760	NU	OSTEOGEN ULTRASOUND STIMLTOR	3722.53
E0761	NONTHERM ELECTROMGNTC DEVICE	BR
E0762	NU	TRANS ELEC JT STIM DEV SYS	1841.11
E0764	NU	FUNCTIONAL NEUROMUSCULARSTIM	1629.15
E0765	NU	NERVE STIMULATOR FOR TX N&V	96.87
E0766	ELEC STIM CANCER TREATMENT	0.00
E0769	ELECTRIC WOUND TREATMENT DEV	BR
E0770	NU	FUNCTIONAL ELECTRIC STIM NOS	8406.69
E0776	NU	IV POLE	154.40
E0779	RR	AMB INFUSION PUMP MECHANICAL	17.35
E0780	NU	MECH AMB INFUSION PUMP <8HRS	11.91
E0781	RR	EXTERNAL AMBULATORY INFUS PU	258.71
E0782	NU	NON-PROGRAMBLE INFUSION PUMP	4943.35
E0783	NU	PROGRAMMABLE INFUSION PUMP	9426.22
E0784	NU	EXT AMB INFUSN PUMP INSULIN	8407.56
E0785	REPLACEMENT IMPL PUMP CATHET	499.27
E0786	NU	IMPLANTABLE PUMP REPLACEMENT	9194.70
E0791	NU	PARENTERAL INFUSION PUMP STA	3176.35
E0830	AMBULATORY TRACTION DEVICE	BR
E0840	NU	TRACT FRAME ATTACH HEADBOARD	84.36
E0849	NU	CERVICAL PNEUM TRAC EQUIP	789.83
E0850	NU	TRACTION STAND FREE STANDING	120.95
E0855	NU	CERVICAL TRACTION EQUIPMENT	743.75
E0856	NU	CERVIC COLLAR W AIR BLADDERS	739.63
E0860	NU	TRACT EQUIP CERVICAL TRACT	44.37
E0870	NU	TRACT FRAME ATTACH FOOTBOARD	113.83
E0880	NU	TRAC STAND FREE STAND EXTREM	122.87
E0890	NU	TRACTION FRAME ATTACH PELVIC	117.83
E0900	NU	TRAC STAND FREE STAND PELVIC	125.40
E0910	NU	TRAPEZE BAR ATTACHED TO BED	264.60
E0911	RR	HD TRAPEZE BAR ATTACH TO BED	47.18
E0912	RR	HD TRAPEZE BAR FREE STANDING	100.37
E0920	NU	FRACTURE FRAME ATTACHED TO B	487.60
E0930	RR	FRACTURE FRAME FREE STANDING	44.70
E0935	RR	CONT PAS MOTION EXERCISE DEV	22.26
E0936	RR	CPM DEVICE, OTHER THAN KNEE	24.16
E0940	NU	TRAPEZE BAR FREE STANDING	370.51
E0941	RR	GRAVITY ASSISTED TRACTION DE	42.47
E0942	NU	CERVICAL HEAD HARNESS/HALTER	19.41
E0944	NU	PELVIC BELT/HARNESS/BOOT	45.17
E0945	NU	BELT/HARNESS EXTREMITY	43.38
E0946	RR	FRACTURE FRAME DUAL W CROSS	57.90
E0947	NU	FRACTURE FRAME ATTACHMNTS PE	593.53
E0948	NU	FRACTURE FRAME ATTACHMNTS CE	589.58
E0950	NU	TRAY	103.16
E0951	NU	LOOP HEEL	16.06
E0952	NU	TOE LOOP/HOLDER, EACH	18.80
E0953	NU	W/C LATERAL THIGH/KNEE SUP	97.82
E0954	NU	FOOT BOX, ANY TYPE EACH FOOT	58.80
E0955	NU	CUSHIONED HEADREST	271.41
E0956	NU	W/C LATERAL TRUNK/HIP SUPPOR	97.82
E0957	NU	W/C MEDIAL THIGH SUPPORT	141.54
E0958	NU	WHLCHR ATT- CONV 1 ARM DRIVE	635.44
E0959	NU	AMPUTEE ADAPTER	48.24
E0960	NU	W/C SHOULDER HARNESS/STRAPS	90.29
E0961	NU	WHEELCHAIR BRAKE EXTENSION	25.31
E0966	NU	WHEELCHAIR HEAD REST EXTENSI	69.85
E0967	NU	MAN WC RIM/PROJECTION REP EA	75.62
E0968	NU	WHEELCHAIR COMMODE SEAT	189.24
E0969	NU	WHEELCHAIR NARROWING DEVICE	180.34
E0970	NU	WHEELCHAIR NO. 2 FOOTPLATES	52.34
E0971	NU	WHEELCHAIR ANTI-TIPPING DEVI	40.85
E0973	NU	W/CH ACCESS DET ADJ ARMREST	96.99
E0974	NU	W/CH ACCESS ANTI-ROLLBACK	83.70
E0978	NU	W/C ACC, SAF BELT PELV STRAP	42.37
E0980	NU	WHEELCHAIR SAFETY VEST	37.51
E0981	NU	SEAT UPHOLSTERY, REPLACEMENT	42.65
E0982	NU	BACK UPHOLSTERY, REPLACEMENT	46.62
E0983	NU	ADD PWR JOYSTICK	9772.82
E0984	NU	ADD PWR TILLER	2018.84
E0985	NU	W/C SEAT LIFT MECHANISM	193.83
E0986	NU	MAN W/C PUSH-RIM POWR SYSTEM	7590.29
E0988	RR	LEVER-ACTIVATED WHEEL DRIVE	344.67
E0990	NU	WHEELCHAIR ELEVATING LEG RES	99.05
E0992	NU	WHEELCHAIR SOLID SEAT INSERT	96.05
E0994	NU	WHEELCHAIR ARM REST	17.26
E0995	NU	WC CALF REST, PAD REPLACEMNT	27.50
E1002	NU	PWR SEAT TILT	7442.08
E1003	NU	PWR SEAT RECLINE	3509.01
E1004	NU	PWR SEAT RECLINE MECH	5763.40
E1005	NU	PWR SEAT RECLINE PWR	4211.61
E1006	NU	PWR SEAT COMBO W/O SHEAR	5158.62
E1007	NU	PWR SEAT COMBO W/SHEAR	12765.40
E1008	NU	PWR SEAT COMBO PWR SHEAR	10956.06
E1009	NU	ADD MECH LEG ELEVATION	0.00
E1010	NU	ADD PWR LEG ELEVATION	2548.59
E1011	NU	PED WC MODIFY WIDTH ADJUSTM	0.00
E1012	RR	CTR MOUNT PWR ELEV LEG REST	113.51
E1014	NU	RECLINING BACK ADD PED W/C	425.52
E1015	NU	SHOCK ABSORBER FOR MAN W/C	128.58
E1016	NU	SHOCK ABSORBER FOR POWER W/C	133.32
E1017	NU	HD SHCK ABSRBR FOR HD MAN WC	0.00
E1018	NU	HD SHCK ABSRBER FOR HD POWWC	0.00
E1020	NU	RESIDUAL LIMB SUPPORT SYSTEM	295.63
E1028	NU	W/C MANUAL SWINGAWAY	279.82
E1029	NU	W/C VENT TRAY FIXED	494.90
E1030	NU	W/C VENT TRAY GIMBALED	828.91
E1031	NU	ROLLABOUT CHAIR WITH CASTERS	588.07
E1035	RR	PATIENT TRANSFER SYSTEM <300	663.00
E1036	RR	PATIENT TRANSFER SYSTEM >300	945.89
E1037	NU	TRANSPORT CHAIR, PED SIZE	1474.21
E1038	NU	TRANSPORT CHAIR PT WT<=300LB	292.66
E1039	NU	TRANSPORT CHAIR PT WT >300LB	484.37
E1050	NU	WHELCHR FXD FULL LENGTH ARMS	1060.51
E1060	NU	WHEELCHAIR DETACHABLE ARMS	3175.91
E1070	NU	WHEELCHAIR DETACHABLE FOOT R	3131.18
E1083	NU	HEMI-WHEELCHAIR FIXED ARMS	2549.41
E1084	NU	HEMI-WHEELCHAIR DETACHABLE A	2644.05
E1085	NU	HEMI-WHEELCHAIR FIXED ARMS	335.28
E1086	NU	HEMI-WHEELCHAIR DETACHABLE A	2205.40
E1087	NU	WHEELCHAIR LIGHTWT FIXED ARM	1301.93
E1088	NU	WHEELCHAIR LIGHTWEIGHT DET A	3913.84
E1089	NU	WHEELCHAIR LIGHTWT FIXED ARM	543.01
E1090	NU	WHEELCHAIR LIGHTWEIGHT DET A	3599.42
E1092	NU	WHEELCHAIR WIDE W/ LEG RESTS	3474.64
E1093	NU	WHEELCHAIR WIDE W/ FOOT REST	4327.98
E1100	NU	WHCHR S-RECL FXD ARM LEG RES	1096.79
E1110	NU	WHEELCHAIR SEMI-RECL DETACH	879.96
E1130	NU	WHLCHR STAND FXD ARM FT REST	242.51
E1140	NU	WHEELCHAIR STANDARD DETACH A	2034.78
E1150	NU	WHEELCHAIR STANDARD W/ LEG R	2122.35
E1160	NU	WHEELCHAIR FIXED ARMS	1281.28
E1161	NU	MANUAL ADULT WC W TILTINSPAC	4447.25
E1170	NU	WHLCHR AMPU FXD ARM LEG REST	943.79
E1171	NU	WHEELCHAIR AMPUTEE W/O LEG R	847.15
E1172	NU	WHEELCHAIR AMPUTEE DETACH AR	1035.19
E1180	NU	WHEELCHAIR AMPUTEE W/ FOOT R	1071.02
E1190	NU	WHEELCHAIR AMPUTEE W/ LEG RE	1105.24
E1195	NU	WHEELCHAIR AMPUTEE HEAVY DUT	1232.24
E1200	NU	WHEELCHAIR AMPUTEE FIXED ARM	919.63
E1220	WHLCHR SPECIAL SIZE/CONSTRC	BR
E1221	NU	WHEELCHAIR SPEC SIZE W FOOT	502.09
E1222	NU	WHEELCHAIR SPEC SIZE W/ LEG	716.30
E1223	NU	WHEELCHAIR SPEC SIZE W FOOT	635.11
E1224	NU	WHEELCHAIR SPEC SIZE W/ LEG	857.62
E1225	NU	MANUAL SEMI-RECLINING BACK	531.30
E1226	NU	MANUAL FULLY RECLINING BACK	513.08
E1227	NU	WHEELCHAIR SPEC SZ SPEC HT A	319.51
E1228	NU	WHEELCHAIR SPEC SZ SPEC HT B	233.15
E1229	PEDIATRIC WHEELCHAIR NOS	BR
E1230	NU	POWER OPERATED VEHICLE	2213.56
E1231	NU	RIGID PED W/C TILT-IN-SPACE	0.00
E1232	NU	FOLDING PED WC TILT-IN-SPACE	2626.00
E1233	NU	RIG PED WC TLTNSPC W/O SEAT	3924.66
E1234	NU	FLD PED WC TLTNSPC W/O SEAT	2978.85
E1235	NU	RIGID PED WC ADJUSTABLE	3291.78
E1236	NU	FOLDING PED WC ADJUSTABLE	2166.48
E1237	NU	RGD PED WC ADJSTABL W/O SEAT	2647.69
E1238	NU	FLD PED WC ADJSTABL W/O SEAT	5170.48
E1239	PED POWER WHEELCHAIR NOS	BR
E1240	NU	WHCHR LITWT DET ARM LEG REST	3237.75
E1250	NU	WHEELCHAIR LIGHTWT FIXED ARM	800.05
E1260	NU	WHEELCHAIR LIGHTWT FOOT REST	2712.96
E1270	NU	WHEELCHAIR LIGHTWEIGHT LEG R	834.27
E1280	NU	WHCHR H-DUTY DET ARM LEG RES	3640.62
E1285	NU	WHEELCHAIR HEAVY DUTY FIXED	1205.10
E1290	NU	WHEELCHAIR HVY DUTY DETACH A	583.21
E1295	NU	WHEELCHAIR HEAVY DUTY FIXED	1283.62
E1296	NU	WHEELCHAIR SPECIAL SEAT HEIG	566.08
E1297	NU	WHEELCHAIR SPECIAL SEAT DEPT	120.45
E1298	NU	WHEELCHAIR SPEC SEAT DEPTH/W	487.80
E1300	NU	WHIRLPOOL PORTABLE	BR
E1310	NU	WHIRLPOOL NON-PORTABLE	2472.48
E1352	O2 FLOW REG POS INSPIR PRESS	BR
E1353	NU	OXYGEN SUPPLIES REGULATOR	0.00
E1354	WHEELED CART, PORT CYL/CONC	BR
E1355	NU	OXYGEN SUPPLIES STAND/RACK	0.00
E1356	BATT PACK/CART, PORT CONC	BR
E1357	BATTERY CHARGER, PORT CONC	BR
E1358	DC POWER ADAPTER, PORT CONC	BR
E1372	NU	OXY SUPPL HEATER FOR NEBULIZ	145.76
E1390	NU	OXYGEN CONCENTRATOR	3705.89
E1391	RR	OXYGEN CONCENTRATOR, DUAL	134.71
E1392	RR	PORTABLE OXYGEN CONCENTRATOR	67.36
E1399	DURABLE MEDICAL EQUIPMENT MI	BR
E1405	NU	O2/WATER VAPOR ENRICH W/HEAT	3017.66
E1406	NU	O2/WATER VAPOR ENRICH W/O HE	BR
E1500	CENTRIFUGE	BR
E1510	NU	KIDNEY DIALYSATE DELIVRY SYS	929.65
E1520	NU	HEPARIN INFUSION PUMP	0.00
E1530	NU	REPLACEMENT AIR BUBBLE DETEC	0.00
E1540	NU	REPLACEMENT PRESSURE ALARM	0.00
E1550	NU	BATH CONDUCTIVITY METER	0.00
E1560	NU	REPLACE BLOOD LEAK DETECTOR	BR
E1570	NU	ADJUSTABLE CHAIR FOR ESRD PT	BR
E1575	NU	TRANSDUCER PROTECT/FLD BAR	BR
E1580	NU	UNIPUNCTURE CONTROL SYSTEM	BR
E1590	NU	HEMODIALYSIS MACHINE	BR
E1592	AUTO INTERM PERITONEAL DIALY	BR
E1594	NU	CYCLER DIALYSIS MACHINE	8400.62
E1600	DELI/INSTALL CHRG HEMO EQUIP	0.00
E1610	NU	REVERSE OSMOSIS H2O PURI SYS	346.21
E1615	DEIONIZER H2O PURI SYSTEM	BR
E1620	REPLACEMENT BLOOD PUMP	BR
E1625	WATER SOFTENING SYSTEM	BR
E1630	RECIPROCATING PERITONEAL DIA	BR
E1632	WEARABLE ARTIFICIAL KIDNEY	BR
E1634	PERITONEAL DIALYSIS CLAMP	BR
E1635	NU	COMPACT TRAVEL HEMODIALYZER	0.00
E1636	SORBENT CARTRIDGES PER 10	0.00
E1637	HEMOSTATS FOR DIALYSIS, EACH	BR
E1639	SCALE, EACH	BR
E1699	DIALYSIS EQUIPMENT NOC	BR
E1700	NU	JAW MOTION REHAB SYSTEM	514.19
E1701	REPL CUSHIONS FOR JAW MOTION	10.37
E1702	REPL MEASR SCALES JAW MOTION	22.08
E1800	RR	ADJUST ELBOW EXT/FLEX DEVICE	119.89
E1801	RR	SPS ELBOW DEVICE	133.11
E1802	RR	ADJST FOREARM PRO/SUP DEVICE	376.28
E1805	RR	ADJUST WRIST EXT/FLEX DEVICE	123.66
E1806	RR	SPS WRIST DEVICE	109.24
E1810	RR	ADJUST KNEE EXT/FLEX DEVICE	121.93
E1811	RR	SPS KNEE DEVICE	138.39
E1812	NU	KNEE EXT/FLEX W ACT RES CTRL	20646.82
E1815	RR	ADJUST ANKLE EXT/FLEX DEVICE	123.66
E1816	RR	SPS ANKLE DEVICE	140.53
E1818	RR	SPS FOREARM DEVICE	143.51
E1820	NU	SOFT INTERFACE MATERIAL	94.12
E1821	NU	REPLACEMENT INTERFACE SPSD	121.17
E1825	RR	ADJUST FINGER EXT/FLEX DEVC	123.66
E1830	RR	ADJUST TOE EXT/FLEX DEVICE	123.66
E1831	RR	STATIC STR TOE DEV EXT/FLEX	76.08
E1840	RR	ADJ SHOULDER EXT/FLEX DEVICE	386.19
E1841	RR	STATIC STR SHLDR DEV ROM ADJ	521.57
E1902	AAC NON-ELECTRONIC BOARD	0.00
E2000	RR	GASTRIC SUCTION PUMP HME MDL	53.46
E2100	NU	BLD GLUCOSE MONITOR W VOICE	740.55
E2101	NU	BLD GLUCOSE MONITOR W LANCE	217.10
E2120	RR	PULSE GEN SYS TX ENDOLYMP FL	326.44
E2201	NU	MAN W/CH ACC SEAT W>=20"<24"	375.68
E2202	NU	SEAT WIDTH 24-27 IN	507.25
E2203	NU	FRAME DEPTH LESS THAN 22 IN	495.04
E2204	NU	FRAME DEPTH 22 TO 25 IN	851.97
E2205	NU	MANUAL WC ACCESSORY, HANDRIM	36.95
E2206	NU	MAN WC WHL LOCK COMP REPL EA	43.31
E2207	NU	CRUTCH AND CANE HOLDER	49.91
E2208	NU	CYLINDER TANK CARRIER	117.88
E2209	NU	ARM TROUGH EACH	106.34
E2210	NU	WHEELCHAIR BEARINGS	6.51
E2211	NU	PNEUMATIC PROPULSION TIRE	37.76
E2212	NU	PNEUMATIC PROP TIRE TUBE	6.63
E2213	NU	PNEUMATIC PROP TIRE INSERT	33.01
E2214	NU	PNEUMATIC CASTER TIRE EACH	34.68
E2215	NU	PNEUMATIC CASTER TIRE TUBE	10.88
E2216	NU	FOAM FILLED PROPULSION TIRE	0.00
E2217	NU	FOAM FILLED CASTER TIRE EACH	0.00
E2218	NU	FOAM PROPULSION TIRE EACH	0.00
E2219	NU	FOAM CASTER TIRE ANY SIZE EA	40.95
E2220	NU	SOLID PROPULS TIRE, REPL, EA	31.63
E2221	NU	SOLID CASTER TIRE REPL, EACH	28.57
E2222	NU	SOLID CASTER INTEG WHL, REPL	23.71
E2224	NU	PROPULSION WHL EXCL TIRE REP	100.39
E2225	NU	CASTER WHEEL EXCLUDES TIRE	19.79
E2226	NU	CASTER FORK REPLACEMENT ONLY	42.32
E2227	NU	GEAR REDUCTION DRIVE WHEEL	1976.96
E2228	NU	MWC ACC, WHEELCHAIR BRAKE	1048.47
E2230	MANUAL STANDING SYSTEM	BR
E2231	NU	SOLID SEAT SUPPORT BASE	160.91
E2291	PLANAR BACK FOR PED SIZE WC	BR
E2292	PLANAR SEAT FOR PED SIZE WC	BR
E2293	CONTOUR BACK FOR PED SIZE WC	BR
E2294	CONTOUR SEAT FOR PED SIZE WC	BR
E2295	PED DYNAMIC SEATING FRAME	BR
E2300	PWR SEAT ELEVATION SYS	BR
E2301	PWR STANDING	BR
E2310	NU	ELECTRO CONNECT BTW CONTROL	2016.48
E2311	NU	ELECTRO CONNECT BTW 2 SYS	3760.50
E2312	NU	MINI-PROP REMOTE JOYSTICK	3436.17
E2313	NU	PWC HARNESS, EXPAND CONTROL	597.06
E2321	NU	HAND INTERFACE JOYSTICK	1714.48
E2322	NU	MULT MECH SWITCHES	1126.99
E2323	NU	SPECIAL JOYSTICK HANDLE	72.45
E2324	NU	CHIN CUP INTERFACE	46.64
E2325	NU	SIP AND PUFF INTERFACE	1596.42
E2326	NU	BREATH TUBE KIT	478.82
E2327	NU	HEAD CONTROL INTERFACE MECH	2087.69
E2328	NU	HEAD/EXTREMITY CONTROL INTER	6218.40
E2329	NU	HEAD CONTROL NONPROPORTIONAL	1411.25
E2330	NU	HEAD CONTROL PROXIMITY SWITC	5117.94
E2331	ATTENDANT CONTROL	BR
E2340	NU	W/C WDTH 20-23 IN SEAT FRAME	412.61
E2341	NU	W/C WDTH 24-27 IN SEAT FRAME	618.96
E2342	NU	W/C DPTH 20-21 IN SEAT FRAME	515.81
E2343	NU	W/C DPTH 22-25 IN SEAT FRAME	825.30
E2351	NU	ELECTRONIC SGD INTERFACE	741.79
E2358	GR 34 NONSEALED LEADACID	BR
E2359	NU	GR34 SEALED LEADACID BATTERY	200.51
E2360	NU	22NF NONSEALED LEADACID	109.96
E2361	NU	22NF SEALED LEADACID BATTERY	139.42
E2362	NU	GR24 NONSEALED LEADACID	105.91
E2363	NU	GR24 SEALED LEADACID BATTERY	184.59
E2364	NU	U1NONSEALED LEADACID BATTERY	109.96
E2365	NU	U1 SEALED LEADACID BATTERY	111.31
E2366	NU	BATTERY CHARGER, SINGLE MODE	261.61
E2367	NU	BATTERY CHARGER, DUAL MODE	421.36
E2368	NU	PWR WC DRIVEWHEEL MOTOR REPL	612.31
E2369	NU	PWR WC DRIVEWHEEL GEAR REPL	526.69
E2370	NU	PWR WC DR WH MOTOR/GEAR COMB	998.93
E2371	NU	GR27 SEALED LEADACID BATTERY	158.67
E2372	NU	GR27 NON-SEALED LEADACID	0.00
E2373	NU	HAND/CHIN CTRL SPEC JOYSTICK	1255.85
E2374	NU	HAND/CHIN CTRL STD JOYSTICK	831.02
E2375	NU	NON-EXPANDABLE CONTROLLER	1002.68
E2376	NU	EXPANDABLE CONTROLLER, REPL	1530.58
E2377	NU	EXPANDABLE CONTROLLER, INITL	739.52
E2378	RR	PW ACTUATOR REPLACEMENT	58.92
E2381	NU	PNEUM DRIVE WHEEL TIRE	75.59
E2382	NU	TUBE, PNEUM WHEEL DRIVE TIRE	20.69
E2383	NU	INSERT, PNEUM WHEEL DRIVE	153.06
E2384	NU	PNEUMATIC CASTER TIRE	80.30
E2385	NU	TUBE, PNEUMATIC CASTER TIRE	49.48
E2386	NU	FOAM FILLED DRIVE WHEEL TIRE	149.35
E2387	NU	FOAM FILLED CASTER TIRE	66.97
E2388	NU	FOAM DRIVE WHEEL TIRE	51.86
E2389	NU	FOAM CASTER TIRE	28.54
E2390	NU	SOLID DRIVE WHEEL TIRE	44.42
E2391	NU	SOLID CASTER TIRE	20.86
E2392	NU	SOLID CASTER TIRE, INTEGRATE	53.46
E2394	NU	DRIVE WHEEL EXCLUDES TIRE	76.18
E2395	NU	CASTER WHEEL EXCLUDES TIRE	54.13
E2396	NU	CASTER FORK	65.99
E2397	NU	PWC ACC, LITH-BASED BATTERY	476.82
E2402	RR	NEG PRESS WOUND THERAPY PUMP	1203.27
E2500	NU	SGD DIGITIZED PRE-REC <=8MIN	450.24
E2502	NU	SGD PREREC MSG >8MIN <=20MIN	1376.80
E2504	NU	SGD PREREC MSG>20MIN <=40MIN	1816.20
E2506	NU	SGD PREREC MSG > 40 MIN	2663.09
E2508	NU	SGD SPELLING PHYS CONTACT	4118.03
E2510	NU	SGD W MULTI METHODS MSG/ACCS	7792.82
E2511	NU	SGD SFTWRE PRGRM FOR PC/PDA	0.00
E2512	NU	SGD ACCESSORY, MOUNTING SYS	0.00
E2599	SGD ACCESSORY NOC	BR
E2601	NU	GEN W/C CUSHION WDTH < 22 IN	60.69
E2602	NU	GEN W/C CUSHION WDTH >=22 IN	118.48
E2603	NU	SKIN PROTECT WC CUS WD <22IN	150.42
E2604	NU	SKIN PROTECT WC CUS WD>=22IN	186.98
E2605	NU	POSITION WC CUSH WDTH <22 IN	267.13
E2606	NU	POSITION WC CUSH WDTH>=22 IN	416.73
E2607	NU	SKIN PRO/POS WC CUS WD <22IN	287.64
E2608	NU	SKIN PRO/POS WC CUS WD>=22IN	345.43
E2609	CUSTOM FABRICATE W/C CUSHION	BR
E2610	POWERED W/C CUSHION	BR
E2611	NU	GEN USE BACK CUSH WDTH <22IN	309.97
E2612	NU	GEN USE BACK CUSH WDTH>=22IN	419.32
E2613	NU	POSITION BACK CUSH WD <22IN	390.05
E2614	NU	POSITION BACK CUSH WD>=22IN	547.45
E2615	NU	POS BACK POST/LAT WDTH <22IN	448.86
E2616	NU	POS BACK POST/LAT WDTH>=22IN	603.94
E2617	CUSTOM FAB W/C BACK CUSHION	BR
E2619	NU	REPLACE COVER W/C SEAT CUSH	53.08
E2620	NU	WC PLANAR BACK CUSH WD <22IN	543.51
E2621	NU	WC PLANAR BACK CUSH WD>=22IN	570.38
E2622	NU	ADJ SKIN PRO W/C CUS WD<22IN	340.10
E2623	NU	ADJ SKIN PRO WC CUS WD>=22IN	431.57
E2624	NU	ADJ SKIN PRO/POS CUS<22IN	344.11
E2625	NU	ADJ SKIN PRO/POS WC CUS>=22	431.25
E2626	NU	SEO MOBILE ARM SUP ATT TO WC	715.16
E2627	NU	ARM SUPP ATT TO WC RANCHO TY	969.99
E2628	NU	MOBILE ARM SUPPORTS RECLININ	859.68
E2629	NU	FRICTION DAMPENING ARM SUPP	1087.90
E2630	NU	MONOSUSPENSION ARM/HAND SUPP	760.76
E2631	NU	ELEVAT PROXIMAL ARM SUPPORT	258.68
E2632	NU	OFFSET/LAT ROCKER ARM W/ELA	177.75
E2633	NU	MOBILE ARM SUPPORT SUPINATOR	139.51
E8000	POSTERIOR GAIT TRAINER	BR
E8001	UPRIGHT GAIT TRAINER	BR
E8002	ANTERIOR GAIT TRAINER	BR
G0008	ADMIN INFLUENZA VIRUS VAC	34.03	53.79
G0009	ADMIN PNEUMOCOCCAL VACCINE	35.75	53.79
G0010	ADMIN HEPATITIS B VACCINE	38.31	53.79
G0027	SEMEN ANALYSIS	7.95
G0068	ADM OF INFUSION DRUG IN HOME	152.63
G0069	ADM OF IMMUNE DRUG IN HOME	238.25
G0070	ADM OF CHEMO DRUG IN HOME	259.67
G0071	COMM SVCS BY RHC/FQHC 5 MIN	15.61
G0076	CARE MANAG H VST NEW PT 20 M	63.70
G0077	CARE MANAG H VST NEW PT 30 M	91.66
G0078	CARE MANAG H VST NEW PT 45 M	149.60
G0079	CARE MANAG H VST NEW PT 60 M	210.02
G0080	CARE MANAG H VST NEW PT 75 M	255.23
G0081	CARE MAN H V EXT PT 20 MI	63.70
G0082	CARE MAN H V EXT PT 30 M	96.58
G0083	CARE MAN H V EXT PT 45 M	148.78
G0084	CARE MAN H V EXT PT 60 M	206.33
G0085	CARE MAN H V EXT PT 75 M	255.23
G0086	CARE MAN HOME CARE PLAN 30 M	89.18
G0087	CARE MAN HOME CARE PLAN 60 M	125.36
G0101	CA SCREEN;PELVIC/BREAST EXAM	45.21	108.47
G0102	PROSTATE CA SCREENING; DRE	25.89
G0103	PSA SCREENING	22.48
G0104	CA SCREEN; FLEXI SIGMOIDSCOPE	200.57	1057.74
G0105	COLORECTAL SCRN; HI RISK IND	376.89	1057.74
G0106	COLON CA SCREEN;BARIUM ENEMA	266.73	286.47
G0108	DIAB MANAGE TRN PER INDIV	64.11
G0109	DIAB MANAGE TRN IND/GROUP	17.68
G0117	GLAUCOMA SCRN HGH RISK DIREC	64.94	45.61
G0118	GLAUCOMA SCRN HGH RISK DIREC	48.50	45.61
G0120	COLON CA SCRN; BARIUM ENEMA	265.50	547.95
G0121	COLON CA SCRN NOT HI RSK IND	377.30	1057.74
G0122	COLON CA SCRN; BARIUM ENEMA	336.61
G0123	SCREEN CERV/VAG THIN LAYER	24.76
G0124	SCREEN C/V THIN LAYER BY MD	37.00
G0127	TRIM NAIL(S)	27.95	79.38
G0128	CORF SKILLED NURSING SERVICE	9.04
G0129	PARTIAL HOSP PROG SERVICE	BR
G0130	SINGLE ENERGY X-RAY STUDY	40.69	159.76
G0141	SCR C/V CYTO, AUTOSYS AND MD	37.00
G0143	SCR C/V CYTO, THINLAYER, RESCR	29.76
G0144	SCR C/V CYTO, THINLAYER, RESCR	48.37
G0145	SCR C/V CYTO, THINLAYER, RESCR	32.38
G0147	SCR C/V CYTO, AUTOMATED SYS	16.49
G0148	SCR C/V CYTO, AUTOSYS, RESCR	35.13
G0151	HHCP-SERV OF PT, EA 15 MIN	See Rule
G0152	HHCP-SERV OF OT, EA 15 MIN	See Rule
G0153	HHCP-SVS OF S/L PATH, EA 15MN	See Rule
G0155	HHCP-SVS OF CSW, EA 15 MIN	See Rule
G0156	HHCP-SVS OF AIDE, EA 15 MIN	See Rule
G0157	HHC PT ASSISTANT EA 15	BR
G0158	HHC OT ASSISTANT EA 15	BR
G0159	HHC PT MAINT EA 15 MIN	BR
G0160	HHC OCCUP THERAPY EA 15	BR
G0161	HHC SLP EA 15 MIN	BR
G0162	HHC RN E&M PLAN SVS, 15 MIN	See Rule
G0166	EXTRNL COUNTERPULSE, PER TX	132.35	151.20
G0168	WOUND CLOSURE BY ADHESIVE	110.98
G0175	OPPS SERVICE, SCHED TEAM CONF	BR	511.73
G0176	OPPS/PHP;ACTIVITY THERAPY	BR
G0177	OPPS/PHP; TRAIN & EDUC SERV	BR
G0179	MD RECERTIFICATION HHA PT	47.68
G0180	MD CERTIFICATION HHA PATIENT	61.65
G0181	HOME HEALTH CARE SUPERVISION	124.95
G0182	HOSPICE CARE SUPERVISION	124.95
G0186	DSTRY EYE LESN, FDR VSSL TECH	BR	704.58
G0219	PET IMG WHOLBOD MELANO NONCO	BR
G0235	PET NOT OTHERWISE SPECIFIED	BR
G0237	THERAPEUTIC PROCD STRG ENDUR	11.10	45.61
G0238	OTH RESP PROC, INDIV	11.51	45.61
G0239	OTH RESP PROC, GROUP	14.38	45.61
G0245	INITIAL FOOT EXAM PT LOPS	77.26	164.51
G0246	FOLLOWUP EVAL OF FOOT PT LOP	45.62	164.51
G0247	ROUTINE FOOTCARE PT W LOPS	89.18	250.56
G0248	DEMONSTRATE USE HOME INR MON	83.02	164.51
G0249	PROVIDE INR TEST MATER/EQUIP	83.43	164.51
G0250	MD INR TEST REVIE INTER MGMT	10.69
G0252	PET IMAGING INITIAL DX	87.29
G0255	CURRENT PERCEP THRESHOLD TST	BR
G0257	UNSCHED DIALYSIS ESRD PT HOS	BR	868.66
G0259	INJECT FOR SACROILIAC JOINT	BR
G0260	INJ FOR SACROILIAC JT ANESTH	BR	850.31
G0268	REMOVAL OF IMPACTED WAX MD	57.53
G0269	OCCLUSIVE DEVICE IN VEIN ART	BR
G0270	MNT SUBS TX FOR CHANGE DX	37.41
G0271	GROUP MNT 2 OR MORE 30 MINS	19.73
J1	G0276	PILD/PLACEBO CONTROL CLIN TR	0.00	10775.65
G0277	HBOT, FULL BODY CHAMBER, 30M	127.41	162.45
G0278	ILIAC ART ANGIO, CARDIAC CATH	16.44
G0279	TOMOSYNTHESIS, MAMMO	63.70
G0281	ELEC STIM UNATTEND FOR PRESS	22.68
G0282	ELECT STIM WOUND CARE NOT PD	22.68	60.67
G0283	ELEC STIM OTHER THAN WOUND	22.68
G0288	RECON, CTA FOR SURG PLAN	41.51
G0289	ARTHRO, LOOSE BODY + CHONDRO	103.16
G0293	NON-COV SURG PROC, CLIN TRIAL	BR	45.61
G0294	NON-COV PROC, CLINICAL TRIAL	BR	45.61
G0295	ELECTROMAGNETIC THERAPY ONC	BR
G0296	VISIT TO DETERM LDCT ELIG	33.29	108.47
G0297	LDCT FOR LUNG CA SCREEN	274.96	88.47
G0299	HHS/HOSPICE OF RN EA 15 MIN	0.00
G0300	HHS/HOSPICE OF LPN EA 15 MIN	0.00
G0302	PRE-OP SERVICE LVRS COMPLETE	BR	646.48
G0303	PRE-OP SERVICE LVRS 10-15DOS	BR	193.05
G0304	PRE-OP SERVICE LVRS 1-9 DOS	BR	646.48
G0305	POST OP SERVICE LVRS MIN 6	BR	646.48
G0306	CBC/DIFFWBC W/O PLATELET	9.49
G0307	CBC WITHOUT PLATELET	7.90
G0328	FECAL BLOOD SCRN IMMUNOASSAY	19.86
G0329	ELECTROMAGNTIC TX FOR ULCERS	12.74
G0333	DISPENSE FEE INITIAL 30 DAY	BR
G0337	HOSPICE EVALUATION PREELECTI	84.25
G0339	ROBOT LIN-RADSURG COM, FIRST	BR
G0340	ROBT LIN-RADSURG FRACTX 2-5	BR
G0341	PERCUTANEOUS ISLET CELLTRANS	2447.92
G0342	LAPAROSCOPY ISLET CELL TRANS	831.45
G0343	LAPAROTOMY ISLET CELL TRANSP	1373.16
G0365	VESSEL MAPPING HEMO ACCESS	224.40	159.76
G0372	MD SERVICE REQUIRED FOR PMD	10.28
G0378	HOSPITAL OBSERVATION PER HR	BR
G0379	DIRECT REFER HOSPITAL OBSERV	BR	745.93
G0380	LEV 1 HOSP TYPE B ED VISIT	BR	110.53
G0381	LEV 2 HOSP TYPE B ED VISIT	BR	131.83
G0382	LEV 3 HOSP TYPE B ED VISIT	BR	232.40
G0383	LEV 4 HOSP TYPE B ED VISIT	BR	307.29
G0384	LEV 5 HOSP TYPE B ED VISIT	BR	456.20
G0390	TRAUMA RESPONS W/HOSP CRITI	BR	1342.40
G0396	ALCOHOL/SUBS INTERV 15-30MN	41.51	47.40
G0397	ALCOHOL/SUBS INTERV >30 MIN	77.67	108.47
G0398	HOME SLEEP TEST/TYPE 2 PORTA	BR	193.05
G0399	HOME SLEEP TEST/TYPE 3 PORTA	BR	193.05
G0400	HOME SLEEP TEST/TYPE 4 PORTA	BR	193.05
G0402	INITIAL PREVENTIVE EXAM	192.76	164.51
G0403	EKG FOR INITIAL PREVENT EXAM	19.73
G0404	EKG TRACING FOR INITIAL PREV	9.86	24.38
G0405	EKG INTERPRET & REPORT PREVE	9.86
G0406	INPT/TELE FOLLOW UP 15	44.80
G0407	INPT/TELE FOLLOW UP 25	83.43
G0408	INPT/TELE FOLLOW UP 35	120.01
G0409	CORF RELATED SERV 15 MINS EA	18.91
G0410	GRP PSYCH PARTIAL HOSP 45-50	BR
G0411	INTER ACTIVE GRP PSYCH PARTI	BR
G0412	OPEN TX ILIAC SPINE UNI/BIL	855.70
J1	G0413	PELVIC RING FRACTURE UNI/BIL	1263.00	5184.51
G0414	PELVIC RING FX TREAT INT FIX	1188.20
G0415	OPEN TX POST PELVIC FXCTURE	1630.85
G0416	PROSTATE BIOPSY, ANY MTHD	440.59	389.39
G0420	ED SVC CKD IND PER SESSION	128.23
G0421	ED SVC CKD GRP PER SESSION	30.00
G0422	INTENS CARDIAC REHAB W/EXERC	134.81	167.77
G0423	INTENS CARDIAC REHAB NO EXER	134.81	167.77
G0424	PULMONARY REHAB W EXER	34.11	79.38
G0425	INPT/ED TELECONSULT30	115.49
G0426	INPT/ED TELECONSULT50	157.00
G0427	INPT/ED TELECONSULT70	233.04
G0428	COLLAGEN MENISCUS IMPLANT	BR
G0429	DERMAL FILLER INJECTION(S)	115.08	2199.52
G0432	EIA HIV-1/HIV-2 SCREEN	21.53
G0433	ELISA HIV-1/HIV-2 SCREEN	20.12
G0435	ORAL HIV-1/HIV-2 SCREEN	14.65
G0438	PPPS, INITIAL VISIT	198.92
G0439	PPPS, SUBSEQ VISIT	134.81
G0442	ANNUAL ALCOHOL SCREEN 15 MIN	20.96	47.40
G0443	BRIEF ALCOHOL MISUSE COUNSEL	30.42	108.47
G0444	DEPRESSION SCREEN ANNUAL	20.96	47.40
G0445	HIGH INTEN BEH COUNS STD 30M	32.06	108.47
G0446	INTENS BEHAVE THER CARDIO DX	30.42	47.40
G0447	BEHAVIOR COUNSEL OBESITY 15M	30.00	108.47
G0448	PLACE PERM PACING CARDIOVERT	BR
G0451	DEVLOPMENT TEST INTERPT&REP	11.51	108.47
G0452	MOLECULAR PATHOLOGY INTERPR	85.12
G0453	CONT INTRAOP NEURO MONITOR	38.23
G0454	MD DOCUMENT VISIT BY NPP	10.69
G0455	FECAL MICROBIOTA PREP INSTIL	149.60	1081.40
G0458	LDR PROSTATE BRACHY COMP RAT	BR
G0459	TELEHEALTH INPT PHARM MGMT	47.68
G0460	AUTOLOGOUS PRP FOR ULCERS	BR	2199.52
G0463	HOSPITAL OUTPT CLINIC VISIT	0.00	164.51
G0466	FQHC VISIT NEW PATIENT	0.00
G0467	FQHC VISIT, ESTAB PT	0.00
G0468	FQHC VISIT, IPPE OR AWV	0.00
G0469	FQHC VISIT, MH NEW PT	0.00
G0470	FQHC VISIT, MH ESTAB PT	0.00
G0471	VEN BLOOD COLL SNF/HHA	0.00
G0472	HEP C SCREEN HIGH RISK/OTHER	50.99
G0473	GROUP BEHAVE COUNS 2-10	14.79	108.47
G0475	HIV COMBINATION ASSAY	BR
G0476	HPV COMBO ASSAY CA SCREEN	BR
G0480	DRUG TEST DEF 1-7 CLASSES	0.00
G0481	DRUG TEST DEF 8-14 CLASSES	0.00
G0482	DRUG TEST DEF 15-21 CLASSES	0.00
G0483	DRUG TEST DEF 22+ CLASSES	0.00
G0490	HOME VISIT RN, LPN BY RHC/FQ	BR
G0491	DIALYSIS ACU KIDNEY NO ESRD	130.37
G0492	MD/OTH EVAL ACUT KID NO ESRD	BR
G0493	RN CARE EA 15 MIN HH/HOSPICE	36.23
G0494	LPN CARE EA 15MIN HH/HOSPICE	7.17
G0495	RN CARE TRAIN/EDU IN HH	64.87
G0496	LPN CARE TRAIN/EDU IN HH	11.27
G0498	CHEMO EXTEND IV INFUS W/PUMP	153.90	409.50
G0499	HEPB SCREEN HIGH RISK INDIV	34.55
G0500	MOD SEDAT ENDO SERVICE >5YRS	66.99
G0501	RESOURCE-INTEN SVC DURING OV	BR
G0506	COMP ASSES CARE PLAN CCM SVC	72.34
G0508	CRIT CARE TELEHEA CONSULT 60	242.49
G0509	CRIT CARE TELEHEA CONSULT 50	228.93
G0511	CCM/BHI BY RHC/FQHC 20MIN MO	76.44
G0512	COCM BY RHC/FQHC 60 MIN MO	166.46
G0513	PROLONG PREV SVCS, FIRST 30M	75.21
G0514	PROLONG PREV SVCS, ADDL 30M	75.21
G0515	COGNITIVE SKILLS DEVELOPMENT	37.41
G0516	INSERT DRUG DEL IMPLANT, >=4	280.31	494.39
G0517	REMOVE DRUG IMPLANT	302.50	494.39
G0518	REMOVE W INSERT DRUG IMPLANT	528.54	494.39
G0659	DRUG TEST DEF SIMPLE ALL CL	71.12
G0913	IMPROVE VISUAL FUNCT	BR
G0914	SURVEY NOT COMPLETE	BR
G0915	NO IMPROVE VISUAL FUNCT	BR
G0916	SATISFY WITH CARE	BR
G0917	SATISFY SURVEY NOT COMPLETE	BR
G0918	NO SATISFY WITH CARE	BR
G2000	BLINDED CONV. TX MDD CLIN TR	BR	646.48
G2010	REMOT IMAGE SUBMIT BY PT	14.38
G2011	ALCOHOL/SUB ABUSE ASSESS	19.32	24.38
G2012	BRIEF CHECK IN BY MD/QHP	16.86
G6001	ECHO GUIDANCE RADIOTHERAPY	BR
G6002	STEREOSCOPIC X-RAY GUIDANCE	BR
G6003	RADIATION TREATMENT DELIVERY	BR
G6004	RADIATION TREATMENT DELIVERY	BR
G6005	RADIATION TREATMENT DELIVERY	BR
G6006	RADIATION TREATMENT DELIVERY	BR
G6007	RADIATION TREATMENT DELIVERY	BR
G6008	RADIATION TREATMENT DELIVERY	BR
G6009	RADIATION TREATMENT DELIVERY	BR
G6010	RADIATION TREATMENT DELIVERY	BR
G6011	RADIATION TREATMENT DELIVERY	BR
G6012	RADIATION TREATMENT DELIVERY	BR
G6013	RADIATION TREATMENT DELIVERY	BR
G6014	RADIATION TREATMENT DELIVERY	BR
G6015	RADIATION TX DELIVERY IMRT	BR
G6016	DELIVERY COMP IMRT	BR
G6017	INTRAFRACTION TRACK MOTION	0.00
J0120	TETRACYCLIN INJECTION	0.00
J0129	ABATACEPT INJECTION	47.64	73.29
J0130	ABCIXIMAB INJECTION	1226.69
J0131	ACETAMINOPHEN INJECTION	BR
J0132	ACETYLCYSTEINE INJECTION	2.07
J0133	ACYCLOVIR INJECTION	0.09
J0135	ADALIMUMAB INJECTION	1347.06	1833.34
J0153	ADENOSINE INJ 1MG	1.16
J0171	ADRENALIN EPINEPHRINE INJECT	0.15
J0178	AFLIBERCEPT INJECTION	1184.37	1368.22
J0180	AGALSIDASE BETA INJECTION	191.43	253.00
J0185	INJ., APREPITANT, 1 MG	BR	2.99
J0190	INJ BIPERIDEN LACTATE/5 MG	BR
J0200	ALATROFLOXACIN MESYLATE	BR
J0202	INJECTION, ALEMTUZUMAB	2106.39	2672.53
J0205	ALGLUCERASE INJECTION	37.45
J0207	AMIFOSTINE	456.45	1391.24
J0210	METHYLDOPATE HCL INJECTION	47.51
J0215	ALEFACEPT	31.41
J0220	ALGLUCOSIDASE ALFA INJECTION	249.68	200.42
J0221	LUMIZYME INJECTION	185.54	236.00
J0256	ALPHA 1 PROTEINASE INHIBITOR	5.55	6.46
J0257	GLASSIA INJECTION	5.16	6.67
J0270	ALPROSTADIL FOR INJECTION	9.21
J0275	ALPROSTADIL URETHRAL SUPPOS	BR
J0278	AMIKACIN SULFATE INJECTION	1.40
J0280	AMINOPHYLLIN 250 MG INJ	10.72
J0282	AMIODARONE HCL	7.39
J0285	AMPHOTERICIN B	23.58
J0287	AMPHOTERICIN B LIPID COMPLEX	15.73	11.46
J0288	AMPHO B CHOLESTERYL SULFATE	41.47
J0289	AMPHOTERICIN B LIPOSOME INJ	21.96	31.51
J0290	AMPICILLIN 500 MG INJ	1.72
J0295	AMPICILLIN SULBACTAM 1.5 GM	2.75
J0300	AMOBARBITAL 125 MG INJ	14.09	80.40
J0330	SUCCINYCHOLINE CHLORIDE INJ	18.44
J0348	ANIDULAFUNGIN INJECTION	0.70
J0350	INJECTION ANISTREPLASE 30 U	BR
J0360	HYDRALAZINE HCL INJECTION	12.68
J0364	APOMORPHINE HYDROCHLORIDE	3.62
J0365	APROTONIN, 10, 000 KIU	31.33
J0380	INJ METARAMINOL BITARTRATE	1.21
J0390	CHLOROQUINE INJECTION	BR
J0395	ARBUTAMINE HCL INJECTION	BR
J0400	ARIPIPRAZOLE INJECTION	1.84
J0401	INJ ARIPIPRAZOLE EXT REL 1MG	5.13	7.77
J0456	AZITHROMYCIN	4.30
J0461	ATROPINE SULFATE INJECTION	0.06
J0470	DIMECAPROL INJECTION	46.76
J0475	BACLOFEN 10 MG INJECTION	200.46	241.04
J0476	BACLOFEN INTRATHECAL TRIAL	92.28
J0480	BASILIXIMAB	3633.38	5222.21
J0485	BELATACEPT INJECTION	4.59	5.38
J0490	BELIMUMAB INJECTION	50.08	62.71
J0500	DICYCLOMINE INJECTION	69.76
J0515	INJ BENZTROPINE MESYLATE	24.55
J0517	INJ., BENRALIZUMAB, 1 MG	BR	237.20
J0520	BETHANECHOL CHLORIDE INJECT	BR
J0558	PENG BENZATHINE/PROCAINE INJ	7.96	15.57
J0561	PENICILLIN G BENZATHINE INJ	10.06	19.67
J0565	INJ, BEZLOTOXUMAB, 10 MG	BR	56.93
J0567	INJ., CERLIPONASE ALFA 1 MG	BR	132.94
J0570	BUPRENORPHINE IMPLANT 74.2MG	BR	1803.27
J0571	BUPRENORPHINE ORAL 1MG	BR
J0572	BUPREN/NAL UP TO 3MG BUPRENO	BR
J0573	BUPREN/NAL 3.1 TO 6MG BUPREN	BR
J0574	BUPREN/NAL 6.1 TO 10MG BUPRE	BR
J0575	BUPREN/NAL OVER 10MG BUPRENO	BR
J0583	BIVALIRUDIN	3.63
J0584	INJECTION, BUROSUMAB-TWZA 1M	BR	501.83
J0585	INJECTION, ONABOTULINUMTOXINA	6.92	8.71
J0586	ABOBOTULINUMTOXINA	9.54	12.12
J0587	INJ, RIMABOTULINUMTOXINB	14.02	17.04
J0588	INCOBOTULINUMTOXIN A	5.76	7.21
J0592	BUPRENORPHINE HYDROCHLORIDE	3.61
J0594	BUSULFAN INJECTION	40.07	15.37
J0595	BUTORPHANOL TARTRATE 1 MG	2.89
J0596	INJECTION, RUCONEST	BR	39.00
J0597	C-1 ESTERASE, BERINERT	55.96	69.46
J0598	C-1 ESTERASE, CINRYZE	65.80	76.71
J0599	INJ., HAEGARDA 10 UNITS	BR	13.73
J0600	EDETATE CALCIUM DISODIUM INJ	6757.62	7944.08
J0604	CINACALCET, ESRD ON DIALYSIS	3.91
J0606	INJ, ETELCALCETIDE, 0.1 MG	11.98	4.09
J0610	CALCIUM GLUCONATE INJECTION	3.74
J0620	CALCIUM GLYCER & LACT/10 ML	9.21
J0630	CALCITONIN SALMON INJECTION	2413.14	3764.56
J0636	INJ CALCITRIOL PER 0.1 MCG	0.42
J0637	CASPOFUNGIN ACETATE	15.63	14.23
J0638	CANAKINUMAB INJECTION	111.27	157.60
J0640	LEUCOVORIN CALCIUM INJECTION	4.63
J0641	LEVOLEUCOVORIN INJECTION	1.95	0.17
J0670	INJ MEPIVACAINE HCL/10 ML	2.38
J0690	CEFAZOLIN SODIUM INJECTION	1.08
J0692	CEFEPIME HCL FOR INJECTION	3.03
J0694	CEFOXITIN SODIUM INJECTION	5.91
J0695	INJ CEFTOLOZANE TAZOBACTAM	BR	7.70
J0696	CEFTRIAXONE SODIUM INJECTION	0.94
J0697	STERILE CEFUROXIME INJECTION	2.92
J0698	CEFOTAXIME SODIUM INJECTION	28.80
J0702	BETAMETHASONE ACET&SOD PHOSP	7.05
J0706	CAFFEINE CITRATE INJECTION	1.51
J0710	CEPHAPIRIN SODIUM INJECTION	BR
J0712	CEFTAROLINE FOSAMIL INJ	2.74	4.13
J0713	INJ CEFTAZIDIME PER 500 MG	2.90
J0714	CEFTAZIDIME AND AVIBACTAM	BR	119.61
J0715	CEFTIZOXIME SODIUM / 500 MG	BR
J0716	CENTRUROIDES IMMUNE F(AB)	BR	6521.78
J0717	CERTOLIZUMAB PEGOL INJ 1MG	7.81	11.20
J0720	CHLORAMPHENICOL SODIUM INJEC	38.33
J0725	CHORIONIC GONADOTROPIN/1000U	24.41	32.09
J0735	CLONIDINE HYDROCHLORIDE	13.94
J0740	CIDOFOVIR INJECTION	684.73	742.30
J0743	CILASTATIN SODIUM INJECTION	5.49
J0744	CIPROFLOXACIN IV	1.23
J0745	INJ CODEINE PHOSPHATE /30 MG	1.21
J0770	COLISTIMETHATE SODIUM INJ	12.56
J0775	COLLAGENASE, CLOST HIST INJ	46.45	63.99
J0780	PROCHLORPERAZINE INJECTION	15.81
J0795	CORTICORELIN OVINE TRIFLUTAL	9.33	12.68
J0800	CORTICOTROPIN INJECTION	4322.60
J0834	INJ., COSYNTROPIN, 0.25 MG	53.74
J0840	CROTALIDAE POLY IMMUNE FAB	3071.72	4673.60
J0841	INJ CROTALIDAE IM F(AB')2 EQ	BR	1784.37
J0850	CYTOMEGALOVIRUS IMM IV /VIAL	1286.15	1603.40
J0875	INJECTION, DALBAVANCIN	17.62	19.25
J0878	DAPTOMYCIN INJECTION	0.97	0.59
J0881	DARBEPOETIN ALFA, NON-ESRD	5.01	5.44
J0882	DARBEPOETIN ALFA, ESRD USE	5.01	5.44
J0883	ARGATROBAN NONESRD USE 1MG	BR	1.45
J0884	ARGATROBAN ESRD DIALYSIS 1MG	BR	1.45
J0885	EPOETIN ALFA, NON-ESRD	14.90	16.97
J0887	EPOETIN BETA ESRD USE	BR
J0888	EPOETIN BETA NON ESRD	BR
J0890	PEGINESATIDE INJECTION	BR
J0894	DECITABINE INJECTION	26.30	17.94
J0895	DEFEROXAMINE MESYLATE INJ	18.13
J0897	DENOSUMAB INJECTION	18.71	26.43
J0945	BROMPHENIRAMINE MALEATE INJ	4.61
J1000	DEPO-ESTRADIOL CYPIONATE INJ	16.67
J1020	METHYLPREDNISOLONE 20 MG INJ	5.43
J1030	METHYLPREDNISOLONE 40 MG INJ	5.20
J1040	METHYLPREDNISOLONE 80 MG INJ	10.07
J1050	MEDROXYPROGESTERONE ACETATE	0.43
J1071	INJ TESTOSTERONE CYPIONATE	0.04
J1094	INJ DEXAMETHASONE ACETATE	1.84
J1095	INJECTION, DEXAMETHASONE 9%	BR	1.57
J1100	DEXAMETHASONE SODIUM PHOS	0.17
J1110	INJ DIHYDROERGOTAMINE MESYLT	92.70
J1120	ACETAZOLAMID SODIUM INJECTIO	25.07
J1130	INJ DICLOFENAC SODIUM 0.5MG	BR
J1160	DIGOXIN INJECTION	5.53
J1162	DIGOXIN IMMUNE FAB (OVINE)	3192.18	5236.59
J1165	PHENYTOIN SODIUM INJECTION	0.80
J1170	HYDROMORPHONE INJECTION	2.49
J1180	DYPHYLLINE INJECTION	BR
J1190	DEXRAZOXANE HCL INJECTION	201.46	313.77
J1200	DIPHENHYDRAMINE HCL INJECTIO	0.59
J1205	CHLOROTHIAZIDE SODIUM INJ	139.93
J1212	DIMETHYL SULFOXIDE 50% 50 ML	262.77	769.08
J1230	METHADONE INJECTION	12.39
J1240	DIMENHYDRINATE INJECTION	7.52
J1245	DIPYRIDAMOLE INJECTION	0.99
J1250	INJ DOBUTAMINE HCL/250 MG	6.69
J1260	DOLASETRON MESYLATE	18.44
J1265	DOPAMINE INJECTION	0.73
J1267	DORIPENEM INJECTION	0.97
J1270	INJECTION, DOXERCALCIFEROL	1.12
J1290	ECALLANTIDE INJECTION	488.83	679.67
J1300	ECULIZUMAB INJECTION	260.82	327.28
J1301	INJECTION, EDARAVONE, 1 MG	BR	27.21
J1320	AMITRIPTYLINE INJECTION	BR
J1322	ELOSULFASE ALFA, INJECTION	BR	336.48
J1324	ENFUVIRTIDE INJECTION	368.64
J1325	EPOPROSTENOL INJECTION	18.69
J1327	EPTIFIBATIDE INJECTION	25.37	21.68
J1330	ERGONOVINE MALEATE INJECTION	BR
J1335	ERTAPENEM INJECTION	50.29
J1364	ERYTHRO LACTOBIONATE /500 MG	58.46	111.99
J1380	ESTRADIOL VALERATE 10 MG INJ	12.41
J1410	INJ ESTROGEN CONJUGATE 25 MG	275.85	438.65
J1428	INJ, ETEPLIRSEN, 10 MG	176.93	238.57
J1430	ETHANOLAMINE OLEATE 100 MG	488.11	630.62
J1435	INJECTION ESTRONE PER 1 MG	0.40
J1436	ETIDRONATE DISODIUM INJ	BR
J1438	ETANERCEPT INJECTION	6140.60	916.67
J1439	INJ FERRIC CARBOXYMALTOS 1MG	1.28	1.54
J1442	INJ FILGRASTIM EXCL BIOSIMIL	1.22	1.43
J1443	INJ FERRIC PYROPHOSPHATE CIT	BR
J1447	INJ TBO FILGRASTIM 1 MICROG	0.93	0.83
J1450	FLUCONAZOLE	5.83
J1451	FOMEPIZOLE, 15 MG	8.46	12.15
J1452	INTRAOCULAR FOMIVIRSEN NA	BR
J1453	FOSAPREPITANT INJECTION	2.08	2.99
J1454	INJ FOSNETUPITANT, PALONOSET	BR	751.92
J1455	FOSCARNET SODIUM INJECTION	82.97	116.82
J1457	GALLIUM NITRATE INJECTION	1.61
J1458	GALSULFASE INJECTION	440.16	554.46
J1459	INJ IVIG PRIVIGEN 500 MG	46.21	57.25
J1460	GAMMA GLOBULIN 1 CC INJ	40.40	56.76
J1555	INJ CUVITRU, 100 MG	BR	19.32
J1556	INJ, IMM GLOB BIVIGAM, 500MG	46.94	100.13
J1557	GAMMAPLEX INJECTION	45.07	65.16
J1559	HIZENTRA INJECTION	10.23	14.36
J1560	GAMMA GLOBULIN > 10 CC INJ	404.06	567.60
J1561	GAMUNEX-C/GAMMAKED	50.45	56.96
J1562	VIVAGLOBIN, INJ	11.27
J1566	IMMUNE GLOBULIN, POWDER	42.15	61.22
J1568	OCTAGAM INJECTION	51.27	50.37
J1569	GAMMAGARD LIQUID INJECTION	46.04	59.96
J1570	GANCICLOVIR SODIUM INJECTION	79.94
J1571	HEPAGAM B IM INJECTION	67.41	91.36
J1572	FLEBOGAMMA INJECTION	47.54	48.84
J1573	HEPAGAM B INTRAVENOUS, INJ	BR	91.36
J1575	HYQVIA 100MG IMMUNEGLOBULIN	13.09	20.13
J1580	GARAMYCIN GENTAMICIN INJ	1.52
J1595	INJECTION GLATIRAMER ACETATE	289.87	276.29
J1599	IVIG NON-LYOPHILIZED, NOS	BR
J1600	GOLD SODIUM THIOMALEATE INJ	36.86
J1602	GOLIMUMAB FOR IV USE 1MG	29.42	33.13
J1610	GLUCAGON HYDROCHLORIDE/1 MG	239.11	312.28
J1620	GONADORELIN HYDROCH/ 100 MCG	BR
J1626	GRANISETRON HCL INJECTION	0.52
J1627	INJ, GRANISETRON, XR, 0.1 MG	BR	4.53
J1628	INJ., GUSELKUMAB, 1 MG	BR	139.04
J1630	HALOPERIDOL INJECTION	1.84
J1631	HALOPERIDOL DECANOATE INJ	24.50
J1640	HEMIN, 1 MG	26.29	32.63
J1642	INJ HEPARIN SODIUM PER 10 U	0.22
J1644	INJ HEPARIN SODIUM PER 1000U	0.25
J1645	DALTEPARIN SODIUM	18.84
J1650	INJ ENOXAPARIN SODIUM	1.38
J1652	FONDAPARINUX SODIUM	3.06
J1655	TINZAPARIN SODIUM INJECTION	4.43
J1670	TETANUS IMMUNE GLOBULIN INJ	486.58	594.42
J1675	HISTRELIN ACETATE	1.21
J1700	HYDROCORTISONE ACETATE INJ	BR
J1710	HYDROCORTISONE SODIUM PH INJ	BR
J1720	HYDROCORTISONE SODIUM SUCC I	9.06
J1726	MAKENA, 10 MG	36.86	34.88
J1729	INJ HYDROXYPROGST CAPOAT NOS	1.65
J1730	DIAZOXIDE INJECTION	122.40
J1740	IBANDRONATE SODIUM INJECTION	130.88	78.73
J1741	IBUPROFEN INJECTION	BR
J1742	IBUTILIDE FUMARATE INJECTION	113.85	334.38
J1743	IDURSULFASE INJECTION	627.79	770.94
J1744	ICATIBANT INJECTION	0.00	516.02
J1745	INFLIXIMAB NOT BIOSIMIL 10MG	96.52	108.84
J1746	INJ., IBALIZUMAB-UIYK, 10 MG	BR	83.27
J1750	INJ IRON DEXTRAN	14.73	19.34
J1756	IRON SUCROSE INJECTION	0.32
J1786	IMUGLUCERASE INJECTION	50.73	59.81
J1790	DROPERIDOL INJECTION	7.37
J1800	PROPRANOLOL INJECTION	3.49
J1810	DROPERIDOL/FENTANYL INJ	BR
J1815	INSULIN INJECTION	0.96
J1817	INSULIN FOR INSULIN PUMP USE	10.10
J1826	INTERFERON BETA-1A INJ	1738.00	3956.08
J1830	INTERFERON BETA-1B / .25 MG	BR	526.56
J1833	INJECTION, ISAVUCONAZONIUM	BR	1.06
J1835	ITRACONAZOLE INJECTION	22.05
J1840	KANAMYCIN SULFATE 500 MG INJ	44.24
J1850	KANAMYCIN SULFATE 75 MG INJ	1.21
J1885	KETOROLAC TROMETHAMINE INJ	0.84
J1890	CEPHALOTHIN SODIUM INJECTION	BR
J1930	LANREOTIDE INJECTION	58.18	83.45
J1931	LARONIDASE INJECTION	35.56	44.33
J1940	FUROSEMIDE INJECTION	3.49
J1942	ARIPIPRAZOLE LAUROXIL 1MG	BR	3.65
J1945	LEPIRUDIN	180.79
J1950	LEUPROLIDE ACETATE /3.75 MG	1122.10	1688.36
J1953	LEVETIRACETAM INJECTION	0.24
J1955	INJ LEVOCARNITINE PER 1 GM	21.06
J1956	LEVOFLOXACIN INJECTION	2.89
J1960	LEVORPHANOL TARTRATE INJ	3.62
J1980	HYOSCYAMINE SULFATE INJ	29.45
J1990	CHLORDIAZEPOXIDE INJECTION	24.96
J2001	LIDOCAINE INJECTION	0.02
J2010	LINCOMYCIN INJECTION	13.54
J2020	LINEZOLID INJECTION	28.64
J2060	LORAZEPAM INJECTION	0.92
J2062	LOXAPINE FOR INHALATION 1 MG	BR	20.89
J2150	MANNITOL INJECTION	1.94
J2170	MECASERMIN INJECTION	8.46
J2175	MEPERIDINE HYDROCHL /100 MG	5.47
J2180	MEPERIDINE/PROMETHAZINE INJ	71.89
J2182	INJECTION, MEPOLIZUMAB, 1MG	BR	41.89
J2185	MEROPENEM	1.59
J2186	INJ., MEROPENEM, VABORBACTAM	BR	2.36
J2210	METHYLERGONOVIN MALEATE INJ	5.94
J2212	METHYLNALTREXONE INJECTION	0.00
J2248	MICAFUNGIN SODIUM INJECTION	1.17
J2250	INJ MIDAZOLAM HYDROCHLORIDE	0.16
J2260	INJ MILRINONE LACTATE / 5 MG	4.03
J2265	MINOCYCLINE HYDROCHLORIDE	0.00	2.34
J2270	MORPHINE SULFATE INJECTION	1.47
J2274	INJ MORPHINE PF EPID ITHC	10.35
J2278	ZICONOTIDE INJECTION	8.67	10.98
J2280	INJ, MOXIFLOXACIN 100 MG	11.08
J2300	INJ NALBUPHINE HYDROCHLORIDE	2.87
J2310	INJ NALOXONE HYDROCHLORIDE	33.81
J2315	NALTREXONE, DEPOT FORM	3.85	4.61
J2320	NANDROLONE DECANOATE 50 MG	55.30	30.80
J2323	NATALIZUMAB INJECTION	20.55	28.02
J2325	NESIRITIDE INJECTION	36.24	106.22
J2326	INJ, NUSINERSEN, 0.1MG	1152.03	1564.45
J2350	INJECTION, OCRELIZUMAB, 1 MG	BR	81.47
J2353	OCTREOTIDE INJECTION, DEPOT	191.71	280.99
J2354	OCTREOTIDE INJ, NON-DEPOT	1.48
J2355	OPRELVEKIN INJECTION	530.35	232.85
J2357	OMALIZUMAB INJECTION	36.20	52.61
J2358	OLANZAPINE LONG-ACTING INJ	3.52
J2360	ORPHENADRINE INJECTION	6.89
J2370	PHENYLEPHRINE HCL INJECTION	9.21
J2400	CHLOROPROCAINE HCL INJECTION	27.56
J2405	ONDANSETRON HCL INJECTION	0.12
J2407	INJECTION, ORITAVANCIN	30.94	33.59
J2410	OXYMORPHONE HCL INJECTION	3.43
J2425	PALIFERMIN INJECTION	19.82	28.71
J2426	PALIPERIDONE PALMITATE INJ	10.49	15.54
J2430	PAMIDRONATE DISODIUM /30 MG	13.98
J2440	PAPAVERIN HCL INJECTION	2.76
J2460	OXYTETRACYCLINE INJECTION	BR
J2469	PALONOSETRON HCL	25.93	21.22
J2501	PARICALCITOL	1.15
J2502	INJ, PASIREOTIDE LONG ACTING	BR	412.19
J2503	PEGAPTANIB SODIUM INJECTION	1251.59
J2504	PEGADEMASE BOVINE, 25 IU	339.91	522.50
J2505	INJECTION, PEGFILGRASTIM 6MG	4624.03	6648.16
J2507	PEGLOTICASE INJECTION	1646.88	3352.68
J2510	PENICILLIN G PROCAINE INJ	27.21
J2513	PENTASTARCH 10% SOLUTION	BR
J2515	PENTOBARBITAL SODIUM INJ	50.34	68.57
J2540	PENICILLIN G POTASSIUM INJ	1.15
J2543	PIPERACILLIN/TAZOBACTAM	3.13
J2545	PENTAMIDINE NON-COMP UNIT	137.39
J2547	INJECTION, PERAMIVIR	BR	2.29
J2550	PROMETHAZINE HCL INJECTION	1.98
J2560	PHENOBARBITAL SODIUM INJ	35.27
J2562	PLERIXAFOR INJECTION	371.89	469.27
J2590	OXYTOCIN INJECTION	13.83
J2597	INJ DESMOPRESSIN ACETATE	16.33	17.69
J2650	PREDNISOLONE ACETATE INJ	BR
J2670	TOTAZOLINE HCL INJECTION	BR
J2675	INJ PROGESTERONE PER 50 MG	1.17
J2680	FLUPHENAZINE DECANOATE 25 MG	26.90
J2690	PROCAINAMIDE HCL INJECTION	55.74
J2700	OXACILLIN SODIUM INJECITON	2.18
J2704	INJ, PROPOFOL, 10 MG	0.15
J2710	NEOSTIGMINE METHYLSLFTE INJ	10.78
J2720	INJ PROTAMINE SULFATE/10 MG	1.41
J2724	PROTEIN C CONCENTRATE	18.28	21.49
J2725	INJ PROTIRELIN PER 250 MCG	BR
J2730	PRALIDOXIME CHLORIDE INJ	103.48
J2760	PHENTOLAINE MESYLATE INJ	460.80	539.09
J2765	METOCLOPRAMIDE HCL INJECTION	0.85
J2770	QUINUPRISTIN/DALFOPRISTIN	401.19	593.22
J2778	RANIBIZUMAB INJECTION	468.26	516.85
J2780	RANITIDINE HYDROCHLORIDE INJ	1.28
J2783	RASBURICASE	280.09	397.34
J2785	REGADENOSON INJECTION	65.28
J2786	INJECTION, RESLIZUMAB, 1MG	BR	13.26
J2787	RIBOFLAVIN 5'PHOS OPTH<=3ML	BR
J2788	RHO D IMMUNE GLOBULIN 50 MCG	29.46
J2790	RHO D IMMUNE GLOBULIN INJ	101.14
J2791	RHOPHYLAC INJECTION	5.72
J2792	RHO(D) IMMUNE GLOBULIN H, SD	24.42	39.45
J2793	RILONACEPT INJECTION	27.75
J2794	RISPERIDONE, LONG ACTING	8.80	13.36
J2795	ROPIVACAINE HCL INJECTION	0.09
J2796	ROMIPLOSTIM INJECTION	71.40	101.68
J2797	INJ., ROLAPITANT, 0.5 MG	BR	1.33
J2800	METHOCARBAMOL INJECTION	52.21
J2805	SINCALIDE INJECTION	111.23
J2810	INJ THEOPHYLLINE PER 40 MG	0.35
J2820	SARGRAMOSTIM INJECTION	41.40	55.32
J2840	INJ SEBELIPASE ALFA 1 MG	494.12	768.40
J2850	INJ SECRETIN SYNTHETIC HUMAN	39.63	49.39
J2860	INJECTION, SILTUXIMAB	BR	135.44
J2910	AUROTHIOGLUCOSE INJECITON	BR
J2916	NA FERRIC GLUCONATE COMPLEX	3.10
J2920	METHYLPREDNISOLONE INJECTION	3.50
J2930	METHYLPREDNISOLONE INJECTION	4.96
J2940	SOMATREM INJECTION	BR
J2941	SOMATROPIN INJECTION	695.26
J2950	PROMAZINE HCL INJECTION	BR
J2993	RETEPLASE INJECTION	2588.57	717.07
J2995	INJ STREPTOKINASE /250000 IU	88.58
J2997	ALTEPLASE RECOMBINANT	90.22	124.60
J3000	STREPTOMYCIN INJECTION	14.31
J3010	FENTANYL CITRATE INJECTION	0.59
J3030	SUMATRIPTAN SUCCINATE / 6 MG	101.35
J3060	INJ, TALIGLUCERASE ALFA 10 U	46.58	57.28
J3070	PENTAZOCINE INJECTION	149.75
J3090	INJ TEDIZOLID PHOSPHATE	1.47	2.02
J3095	TELAVANCIN INJECTION	6.39	7.89
J3101	TENECTEPLASE INJECTION	113.45	172.97
J3105	TERBUTALINE SULFATE INJ	1.03
J3110	TERIPARATIDE INJECTION	9.66
J3121	INJ TESTOSTERO ENANTHATE 1MG	0.05
J3145	TESTOSTERONE UNDECANOATE 1MG	BR	1.93
J3230	CHLORPROMAZINE HCL INJECTION	23.20
J3240	THYROTROPIN INJECTION	1729.70	2348.10
J3243	TIGECYCLINE INJECTION	2.93	2.66
J3245	INJ., TILDRAKIZUMAB, 1 MG	BR
J3246	TIROFIBAN HCL	10.07	10.96
J3250	TRIMETHOBENZAMIDE HCL INJ	28.66
J3260	TOBRAMYCIN SULFATE INJECTION	3.24
J3262	TOCILIZUMAB INJECTION	4.83	7.00
J3265	INJECTION TORSEMIDE 10 MG/ML	BR
J3280	THIETHYLPERAZINE MALEATE INJ	5.64
J3285	TREPROSTINIL INJECTION	73.96	93.90
J3300	TRIAMCINOLONE A INJ PRS-FREE	4.53	5.47
J3301	TRIAMCINOLONE ACET INJ NOS	2.18
J3302	TRIAMCINOLONE DIACETATE INJ	1.73
J3303	TRIAMCINOLONE HEXACETONL INJ	9.21
J3304	INJ TRIAMCINOLONE ACE XR 1MG	BR	26.81
J3305	INJ TRIMETREXATE GLUCORONATE	BR
J3310	PERPHENAZINE INJECITON	BR
J3315	TRIPTORELIN PAMOATE	288.66	347.18
J3316	INJ., TRIPTORELIN XR 3.75 MG	BR	4082.77
J3320	SPECTINOMYCN DI-HCL INJ	BR
J3350	UREA INJECTION	BR
J3355	UROFOLLITROPIN, 75 IU	73.68
J3357	USTEKINUMAB SUB CU INJ, 1 MG	206.53	261.35
J3358	USTEKINUMAB, IV INJECT, 1 MG	BR	17.31
J3360	DIAZEPAM INJECTION	8.02
J3364	UROKINASE 5000 IU INJECTION	BR
J3365	UROKINASE 250, 000 IU INJ	BR
J3370	VANCOMYCIN HCL INJECTION	4.67
J3380	INJECTION, VEDOLIZUMAB	20.56	28.46
J3385	VELAGLUCERASE ALFA	414.15	490.78
J3396	VERTEPORFIN INJECTION	13.26	15.59
J3397	INJ., VESTRONIDASE ALFA-VJBK	BR	310.65
J3398	INJ LUXTURNA 1 BILLION VEC G	BR	4176.93
J3400	TRIFLUPROMAZINE HCL INJ	BR
J3410	HYDROXYZINE HCL INJECTION	2.64
J3411	THIAMINE HCL 100 MG	3.89
J3415	PYRIDOXINE HCL 100 MG	11.92
J3420	VITAMIN B12 INJECTION	3.18
J3430	VITAMIN K PHYTONADIONE INJ	3.31
J3465	INJECTION, VORICONAZOLE	4.69
J3470	HYALURONIDASE INJECTION	27.65
J3471	OVINE, UP TO 999 USP UNITS	0.38
J3472	OVINE, 1000 USP UNITS	132.47
J3473	HYALURONIDASE RECOMBINANT	0.43
J3475	INJ MAGNESIUM SULFATE	0.27
J3480	INJ POTASSIUM CHLORIDE	0.17
J3485	ZIDOVUDINE	1.81
J3486	ZIPRASIDONE MESYLATE	18.81
J3489	ZOLEDRONIC ACID 1MG	33.25
J3490	DRUGS UNCLASSIFIED INJECTION	BR
J3520	EDETATE DISODIUM PER 150 MG	3.23
J3530	NASAL VACCINE INHALATION	BR
J3535	METERED DOSE INHALER DRUG	BR
J3570	LAETRILE AMYGDALIN VIT B17	BR
J3590	UNCLASSIFIED BIOLOGICS	BR
J3591	ESRD ON DIALYSI DRUG/BIO NOC	BR
J7030	NORMAL SALINE SOLUTION INFUS	2.26
J7040	NORMAL SALINE SOLUTION INFUS	1.14
J7042	5% DEXTROSE/NORMAL SALINE	0.71
J7050	NORMAL SALINE SOLUTION INFUS	0.55
J7060	5% DEXTROSE/WATER	2.22
J7070	D5W INFUSION	4.32
J7100	DEXTRAN 40 INFUSION	18.42
J7110	DEXTRAN 75 INFUSION	BR
J7120	RINGERS LACTATE INFUSION	2.20
J7121	5% DEXTROSE IN LAC RINGERS	18.44
J7131	HYPERTONIC SALINE SOL	BR
J7170	INJ., EMICIZUMAB-KXWH 0.5 MG	BR	69.01
J7175	INJ, FACTOR X, (HUMAN), 1IU	BR	10.19
J7177	INJ., FIBRYGA, 1 MG	BR	1.52
J7178	INJ HUMAN FIBRINOGEN CON NOS	0.00	1.66
J7179	VONVENDI INJ 1 IU VWF:RCO	24.10	2.78
J7180	FACTOR XIII ANTI-HEM FACTOR	9.39	11.66
J7181	FACTOR XIII RECOMB A-SUBUNIT	BR	21.04
J7182	FACTOR VIII RECOMB NOVOEIGHT	1.75	1.89
J7183	WILATE INJECTION	1.21	1.45
J7185	XYNTHA INJ	1.48	1.73
J7186	ANTIHEMOPHILIC VIII/VWF COMP	1.17	1.42
J7187	HUMATE-P, INJ	1.21	1.60
J7188	FACTOR VIII RECOMB OBIZUR	BR	4.33
J7189	FACTOR VIIA	2.38	2.95
J7190	FACTOR VIII	1.16	1.53
J7191	FACTOR VIII (PORCINE)	BR
J7192	FACTOR VIII RECOMBINANT NOS	1.42	1.85
J7193	FACTOR IX NON-RECOMBINANT	1.33	1.62
J7194	FACTOR IX COMPLEX	1.47	2.02
J7195	FACTOR IX RECOMBINANT NOS	1.75	2.13
J7196	ANTITHROMBIN RECOMBINANT	BR	146.76
J7197	ANTITHROMBIN III INJECTION	4.37	4.97
J7198	ANTI-INHIBITOR	2.30	2.84
J7199	HEMOPHILIA CLOT FACTOR NOC	BR
J7200	FACTOR IX RECOMBINAN RIXUBIS	1.50	1.86
J7201	FACTOR IX ALPROLIX RECOMB	3.39	4.26
J7202	FACTOR IX IDELVION INJ	BR	6.12
J7203	FACTOR IX RECOMB GLY REBINYN	BR	5.18
J7205	FACTOR VIII FC FUSION RECOMB	2.28	2.86
J7207	FACTOR VIII PEGYLATED RECOMB	BR	2.40
J7209	FACTOR VIII NUWIQ RECOMB 1IU	2.26	1.91
J7210	INJ, AFSTYLA, 1 I.U.	5.13	1.93
J7211	INJ, KOVALTRY, 1 I.U.	2.63	1.80
J7296	KYLEENA, 19.5 MG	1331.75
J7297	LILETTA, 52 MG	0.00
J7298	MIRENA, 52 MG	0.00
J7300	INTRAUT COPPER CONTRACEPTIVE	921.49
J7301	SKYLA, 13.5 MG	0.00
J7303	CONTRACEPTIVE VAGINAL RING	138.24
J7304	CONTRACEPTIVE HORMONE PATCH	BR
J7306	LEVONORGESTREL IMPLANT SYS	875.33
J7307	ETONOGESTREL IMPLANT SYSTEM	BR
J7308	AMINOLEVULINIC ACID HCL TOP	353.39	574.52
J7309	METHYL AMINOLEVULINATE, TOP	BR
J7310	GANCICLOVIR LONG ACT IMPLANT	19072.65
J7311	FLUOCINOLONE ACETONIDE IMPLT	24340.23	28602.17
J7312	DEXAMETHASONE INTRA IMPLANT	242.93	284.13
J7313	FLUOCINOL ACET INTRAVIT IMP	593.03	696.74
J7315	OPHTHALMIC MITOMYCIN	BR
J7316	INJ, OCRIPLASMIN, 0.125 MG	1264.39	1486.64
J7318	INJ, DUROLANE 1 MG	390.00	24.46
J7320	GENVISC 850, INJ, 1MG	14.81	10.22
J7321	HYALGAN SUPARTZ VISCO-3 DOSE	106.44	113.48
J7322	HYMOVIS INJECTION 1 MG	28.80	27.34
J7323	EUFLEXXA INJ PER DOSE	180.10	200.26
J7324	ORTHOVISC INJ PER DOSE	203.58	208.61
J7325	SYNVISC OR SYNVISC-ONE	15.85	16.85
J7326	GEL-ONE	1013.74	1502.19
J7327	MONOVISC INJ PER DOSE	1129.41	1123.56
J7328	GELSYN-3 INJECTION 0.1 MG	BR	3.09
J7329	INJ, TRIVISC 1 MG	BR	9.93
J7330	CULTURED CHONDROCYTES IMPLNT	BR
J7336	CAPSAICIN 8% PATCH	3.49	4.47
J7340	CARBIDOPA LEVODOPA ENT 100ML	BR
J7342	CIPROFLOXACIN OTIC SUSP 6 MG	BR	42.55
J7345	AMINOLEVULINIC ACID, 10% GEL	BR	1.95
J7500	AZATHIOPRINE ORAL 50MG	0.43
J7501	AZATHIOPRINE PARENTERAL	77.31	339.23
J7502	CYCLOSPORINE ORAL 100 MG	4.06
J7503	TACROL ENVARSUS EX REL ORAL	BR
J7504	LYMPHOCYTE IMMUNE GLOBULIN	1373.32	2933.89
J7505	MONOCLONAL ANTIBODIES	1081.09
J7507	TACROLIMUS IMME REL ORAL 1MG	1.03
J7508	TACROL ASTAGRAF EX REL ORAL	0.47
J7509	METHYLPREDNISOLONE ORAL	0.39
J7510	PREDNISOLONE ORAL PER 5 MG	0.15
J7511	ANTITHYMOCYTE GLOBULN RABBIT	776.69	1038.48
J7512	PREDNISONE IR OR DR ORAL 1MG	0.02
J7513	DACLIZUMAB, PARENTERAL	466.66
J7515	CYCLOSPORINE ORAL 25 MG	1.18
J7516	CYCLOSPORIN PARENTERAL 250MG	51.57
J7517	MYCOPHENOLATE MOFETIL ORAL	1.22
J7518	MYCOPHENOLIC ACID	3.69
J7520	SIROLIMUS, ORAL	11.68
J7525	TACROLIMUS INJECTION	198.63	292.54
J7527	ORAL EVEROLIMUS	9.05
J7599	IMMUNOSUPPRESSIVE DRUG NOC	BR
J7604	ACETYLCYSTEINE COMP UNIT	BR
J7605	ARFORMOTEROL NON-COMP UNIT	9.98
J7606	FORMOTEROL FUMARATE, INH	11.36
J7607	LEVALBUTEROL COMP CON	BR
J7608	ACETYLCYSTEINE NON-COMP UNIT	4.86
J7609	ALBUTEROL COMP UNIT	BR
J7610	ALBUTEROL COMP CON	BR
J7611	ALBUTEROL NON-COMP CON	0.14
J7612	LEVALBUTEROL NON-COMP CON	0.34
J7613	ALBUTEROL NON-COMP UNIT	0.06
J7614	LEVALBUTEROL NON-COMP UNIT	0.09
J7615	LEVALBUTEROL COMP UNIT	13.83
J7620	ALBUTEROL IPRATROP NON-COMP	0.18
J7622	BECLOMETHASONE COMP UNIT	BR
J7624	BETAMETHASONE COMP UNIT	BR
J7626	BUDESONIDE NON-COMP UNIT	6.42
J7627	BUDESONIDE COMP UNIT	7.37
J7628	BITOLTEROL MESYLATE COMP CON	BR
J7629	BITOLTEROL MESYLATE COMP UNT	BR
J7631	CROMOLYN SODIUM NONCOMP UNIT	0.97
J7632	CROMOLYN SODIUM COMP UNIT	0.40
J7633	BUDESONIDE NON-COMP CON	BR
J7634	BUDESONIDE COMP CON	BR
J7635	ATROPINE COMP CON	BR
J7636	ATROPINE COMP UNIT	BR
J7637	DEXAMETHASONE COMP CON	BR
J7638	DEXAMETHASONE COMP UNIT	BR
J7639	DORNASE ALFA NON-COMP UNIT	47.09
J7640	FORMOTEROL COMP UNIT	BR
J7641	FLUNISOLIDE COMP UNIT	12.48
J7642	GLYCOPYRROLATE COMP CON	BR
J7643	GLYCOPYRROLATE COMP UNIT	BR
J7644	IPRATROPIUM BROMIDE NON-COMP	0.25
J7645	IPRATROPIUM BROMIDE COMP	BR
J7647	ISOETHARINE COMP CON	BR
J7648	ISOETHARINE NON-COMP CON	BR
J7649	ISOETHARINE NON-COMP UNIT	BR
J7650	ISOETHARINE COMP UNIT	BR
J7657	ISOPROTERENOL COMP CON	BR
J7658	ISOPROTERENOL NON-COMP CON	BR
J7659	ISOPROTERENOL NON-COMP UNIT	BR
J7660	ISOPROTERENOL COMP UNIT	BR
J7665	MANNITOL FOR INHALER	0.81
J7667	METAPROTERENOL COMP CON	BR
J7668	METAPROTERENOL NON-COMP CON	BR
J7669	METAPROTERENOL NON-COMP UNIT	BR
J7670	METAPROTERENOL COMP UNIT	BR
J7674	METHACHOLINE CHLORIDE, NEB	0.62
J7676	PENTAMIDINE COMP UNIT DOSE	BR
J7680	TERBUTALINE SULF COMP CON	15.70
J7681	TERBUTALINE SULF COMP UNIT	15.70
J7682	TOBRAMYCIN NON-COMP UNIT	67.17
J7683	TRIAMCINOLONE COMP CON	35.94
J7684	TRIAMCINOLONE COMP UNIT	BR
J7685	TOBRAMYCIN COMP UNIT	168.10
J7686	TREPROSTINIL, NON-COMP UNIT	611.73
J7699	INHALATION SOLUTION FOR DME	BR
J7799	NON-INHALATION DRUG FOR DME	BR
J7999	COMPOUNDED DRUG, NOC	BR
J8498	ANTIEMETIC RECTAL/SUPP NOS	BR
J8499	ORAL PRESCRIP DRUG NON CHEMO	BR
J8501	ORAL APREPITANT	12.32
J8510	ORAL BUSULFAN	14.91
J8515	CABERGOLINE, ORAL 0.25MG	16.91
J8520	CAPECITABINE, ORAL, 150 MG	6.33
J8521	CAPECITABINE, ORAL, 500 MG	20.11
J8530	CYCLOPHOSPHAMIDE ORAL 25 MG	4.44
J8540	ORAL DEXAMETHASONE	0.15
J8560	ETOPOSIDE ORAL 50 MG	82.88	107.58
J8562	ORAL FLUDARABINE PHOSPHATE	BR	115.62
J8565	GEFITINIB ORAL	64.42
J8597	ANTIEMETIC DRUG ORAL NOS	BR
J8600	MELPHALAN ORAL 2 MG	13.55	17.04
J8610	METHOTREXATE ORAL 2.5 MG	1.67
J8650	NABILONE ORAL	18.92
J8655	ORAL NETUPITANT, PALONOSETRO	596.80	401.61
J8670	ROLAPITANT, ORAL, 1MG	BR	1.86
J8700	TEMOZOLOMIDE	4.37
J8705	TOPOTECAN ORAL	122.20
J8999	ORAL PRESCRIPTION DRUG CHEMO	BR
J9000	DOXORUBICIN HCL INJECTION	3.74
J9015	ALDESLEUKIN INJECTION	4317.48	5876.17
J9017	ARSENIC TRIOXIDE INJECTION	71.58	109.21
J9019	ERWINAZE INJECTION	469.50	589.05
J9020	ASPARAGINASE, NOS	72.48
J9022	INJ, ATEZOLIZUMAB, 10 MG	BR	110.42
J9023	INJECTION, AVELUMAB, 10 MG	BR	116.17
J9025	AZACITIDINE INJECTION	3.61	1.86
J9027	CLOFARABINE INJECTION	167.09	134.80
J9031	BCG LIVE INTRAVESICAL VAC	149.49	199.16
J9032	INJECTION, BELINOSTAT, 10MG	39.26	54.30
J9033	INJ., TREANDA 1 MG	29.69	42.98
J9034	INJ., BENDEKA 1 MG	BR	33.84
J9035	BEVACIZUMAB INJECTION	85.57	115.27
J9039	INJECTION, BLINATUMOMAB	BR	156.42
J9040	BLEOMYCIN SULFATE INJECTION	25.61
J9041	INJ., VELCADE 0.1 MG	56.48	64.77
J9042	BRENTUXIMAB VEDOTIN INJ	150.30	222.55
J9043	CABAZITAXEL INJECTION	178.43	239.00
J9044	INJ, BORTEZOMIB, NOS, 0.1 MG	BR	50.65
J9045	CARBOPLATIN INJECTION	4.39
J9047	INJECTION, CARFILZOMIB, 1 MG	37.30	51.55
J9050	CARMUSTINE INJECTION	3886.50	5754.33
J9055	CETUXIMAB INJECTION	65.00	86.01
J9057	INJ., COPANLISIB, 1 MG	BR	110.00
J9060	CISPLATIN 10 MG INJECTION	1.87
J9065	INJ CLADRIBINE PER 1 MG	21.18	31.06
J9070	CYCLOPHOSPHAMIDE 100 MG INJ	58.80	53.71
J9098	CYTARABINE LIPOSOME INJ	702.22	892.28
J9100	CYTARABINE HCL 100 MG INJ	1.07
J9120	DACTINOMYCIN INJECTION	1401.60	2066.64
J9130	DACARBAZINE 100 MG INJ	4.57
J9145	INJECTION, DARATUMUMAB 10 MG	BR	74.27
J9150	DAUNORUBICIN INJECTION	31.97	68.41
J9151	DAUNORUBICIN CITRATE INJ	7.15	0.45
J9153	INJ DAUNORUBICIN, CYTARABINE	BR	270.25
J9155	DEGARELIX INJECTION	4.41	5.40
J9160	DENILEUKIN DIFTITOX INJ	1567.07
J9165	DIETHYLSTILBESTROL INJECTION	BR
J9171	DOCETAXEL INJECTION	3.13	1.91
J9173	INJ., DURVALUMAB, 10 MG	BR	104.87
J9175	ELLIOTTS B SOLUTION PER ML	7.29
J9176	INJECTION, ELOTUZUMAB, 1MG	BR	9.09
J9178	INJ, EPIRUBICIN HCL, 2 MG	1.94
J9179	ERIBULIN MESYLATE INJECTION	126.14	163.74
J9181	ETOPOSIDE INJECTION	0.77
J9185	FLUDARABINE PHOSPHATE INJ	81.40
J9190	FLUOROURACIL INJECTION	2.18
J9200	FLOXURIDINE INJECTION	84.06
J9201	GEMCITABINE HCL INJECTION	10.53
J9202	GOSERELIN ACETATE IMPLANT	334.19	711.71
J9203	GEMTUZUMAB OZOGAMICIN 0.1 MG	460.79	275.50
J9205	INJ IRINOTECAN LIPOSOME 1 MG	BR	64.82
J9206	IRINOTECAN INJECTION	5.04
J9207	IXABEPILONE INJECTION	88.75	109.19
J9208	IFOSFAMIDE INJECTION	37.36
J9209	MESNA INJECTION	5.01
J9211	IDARUBICIN HCL INJECTION	47.17
J9212	INTERFERON ALFACON-1 INJ	7.65
J9213	INTERFERON ALFA-2A INJ	42.28	240.45
J9214	INTERFERON ALFA-2B INJ	28.87	48.33
J9215	INTERFERON ALFA-N3 INJ	20.53
J9216	INTERFERON GAMMA 1-B INJ	360.36
J9217	LEUPROLIDE ACETATE SUSPNSION	305.11	335.34
J9218	LEUPROLIDE ACETATE INJECITON	19.52
J9219	LEUPROLIDE ACETATE IMPLANT	BR
J9225	VANTAS IMPLANT	3632.70	5196.81
J9226	SUPPRELIN LA IMPLANT	28734.47	45247.21
J9228	IPILIMUMAB INJECTION	168.21	214.28
J9229	INJ INOTUZUMAB OZOGAM 0.1 MG	BR	3135.74
J9230	MECHLORETHAMINE HCL INJ	291.97	454.52
J9245	INJ MELPHALAN HYDROCHL 50 MG	1937.56	1142.58
J9250	METHOTREXATE SODIUM INJ	0.28
J9260	METHOTREXATE SODIUM INJ	2.79
J9261	NELARABINE INJECTION	178.91	215.87
J9262	INJ, OMACETAXINE MEP, 0.01MG	BR	4.22
J9263	OXALIPLATIN	0.46
J9264	PACLITAXEL PROTEIN BOUND	12.12	16.85
J9266	PEGASPARGASE INJECTION	10819.55	21386.86
J9267	PACLITAXEL INJECTION	0.18
J9268	PENTOSTATIN INJECTION	1957.72	2864.61
J9270	PLICAMYCIN (MITHRAMYCIN) INJ	BR	8.69
J9271	INJ PEMBROLIZUMAB	55.19	69.56
J9280	MITOMYCIN INJECTION	129.97	177.60
J9285	INJ, OLARATUMAB, 10 MG	BR	72.48
J9293	MITOXANTRONE HYDROCHL / 5 MG	33.06	39.17
J9295	INJECTION, NECITUMUMAB, 1 MG	BR	7.96
J9299	INJECTION, NIVOLUMAB	30.64	39.05
J9301	OBINUTUZUMAB INJ	66.87	91.76
J9302	OFATUMUMAB INJECTION	61.03	83.06
J9303	PANITUMUMAB INJECTION	124.89	162.88
J9305	PEMETREXED INJECTION	74.60	96.71
J9306	INJECTION, PERTUZUMAB, 1 MG	12.64	17.32
J9307	PRALATREXATE INJECTION	267.86	392.25
J9308	INJECTION, RAMUCIRUMAB	65.25	81.83
J9311	INJ RITUXIMAB, HYALURONIDASE	BR	66.22
J9312	INJ., RITUXIMAB, 10 MG	BR	135.46
J9315	ROMIDEPSIN INJECTION	361.53	449.83
J9320	STREPTOZOCIN INJECTION	386.54	491.86
J9325	INJ TALIMOGENE LAHERPAREPVEC	BR	71.07
J9328	TEMOZOLOMIDE INJECTION	8.14	14.85
J9330	TEMSIROLIMUS INJECTION	76.98	93.09
J9340	THIOTEPA INJECTION	1645.11	1081.45
J9351	TOPOTECAN INJECTION	2.42
J9352	INJECTION TRABECTEDIN 0.1MG	BR	426.89
J9354	INJ, ADO-TRASTUZUMAB EMT 1MG	35.28	44.33
J9355	TRASTUZUMAB INJECTION	108.12	151.93
J9357	VALRUBICIN INJECTION	1345.82	1890.19
J9360	VINBLASTINE SULFATE INJ	3.60
J9370	VINCRISTINE SULFATE 1 MG INJ	7.84
J9371	INJ, VINCRISTINE SUL LIP 1MG	2802.61	4141.61
J9390	VINORELBINE TARTRATE INJ	13.29
J9395	INJECTION, FULVESTRANT	113.04	138.44
J9400	INJ, ZIV-AFLIBERCEPT, 1MG	9.92	11.48
J9600	PORFIMER SODIUM INJECTION	2738.35	30131.79
J9999	CHEMOTHERAPY DRUG	BR
K0001	NU	STANDARD WHEELCHAIR	740.14
K0002	NU	STND HEMI (LOW SEAT) WHLCHR	961.90
K0003	NU	LIGHTWEIGHT WHEELCHAIR	1186.08
K0004	NU	HIGH STRENGTH LTWT WHLCHR	1570.95
K0005	NU	ULTRALIGHTWEIGHT WHEELCHAIR	1915.78
K0006	NU	HEAVY DUTY WHEELCHAIR	1534.72
K0007	NU	EXTRA HEAVY DUTY WHEELCHAIR	2117.06
K0008	CSTM MANUAL WHEELCHAIR/BASE	BR
K0009	RR	OTHER MANUAL WHEELCHAIR/BASE	77.05
K0010	NU	STND WT FRAME POWER WHLCHR	4501.52
K0011	NU	STND WT PWR WHLCHR W CONTROL	BR
K0012	NU	LTWT PORTBL POWER WHLCHR	3433.71
K0013	CUSTOM POWER WHLCHR BASE	BR
K0014	OTHER POWER WHLCHR BASE	BR
K0015	NU	DETACH NON-ADJ HT ARMRST REP	186.21
K0017	NU	DETACH ADJUST ARMREST BASE	46.86
K0018	NU	DETACH ADJUST ARMRST UPPER	26.32
K0019	NU	ARM PAD REPL, EACH	15.37
K0020	NU	FIXED ADJUST ARMREST PAIR	44.07
K0037	NU	HI MOUNT FLIP-UP FOOTREST EA	39.21
K0038	NU	LEG STRAP EACH	22.77
K0039	NU	LEG STRAP H STYLE EACH	49.80
K0040	NU	ADJUSTABLE ANGLE FOOTPLATE	66.70
K0041	NU	LARGE SIZE FOOTPLATE EACH	48.32
K0042	NU	STANDARD SIZE FTPLATE REP EA	29.49
K0043	NU	FTRST LOWR EXTEN TUBE REP EA	18.41
K0044	NU	FTRST UPR HANGER BRAC REP EA	15.84
K0045	NU	FTRST COMPL ASSEMBLY REPL EA	53.08
K0046	NU	ELEV LGRST LWR EXTEN REPL EA	18.47
K0047	NU	ELEV LEGRST UPR HANGR REP EA	69.08
K0050	NU	RATCHET ASSEMBLY REPLACEMENT	30.53
K0051	NU	CAM REL ASM FT/LEGRST REP EA	48.91
K0052	NU	SWINGAWAY DETACH FTREST REPL	82.58
K0053	NU	ELEVATE FOOTREST ARTICULATE	91.98
K0056	NU	SEAT HT <17 OR >=21 LTWT WC	98.55
K0065	NU	SPOKE PROTECTORS	46.05
K0069	NU	RR WHL COMPL SOL TIRE REP EA	103.55
K0070	NU	RR WHL COMPL PNE TIRE REP EA	246.32
K0071	NU	FR CSTR COMP PNE TIRE REP EA	113.21
K0072	NU	FR CSTR SEMI-PNE TIRE REP EA	68.16
K0073	NU	CASTER PIN LOCK EACH	36.07
K0077	NU	FR CSTR ASMB SOL TIRE REP EA	60.99
K0098	NU	DRIVE BELT FOR PWC, REPL	25.25
K0105	NU	IV HANGER	103.03
K0108	W/C COMPONENT-ACCESSORY NOS	BR
K0195	RR	ELEVATING WHLCHAIR LEG RESTS	15.02
K0455	RR	PUMP UNINTERRUPTED INFUSION	247.54
K0462	TEMPORARY REPLACEMENT EQPMNT	BR
K0552	SUP/EXT NON-INS INF PUMP SYR	2.59
K0553	THER CGM SUPPLY ALLOWANCE	231.20
K0554	NU	THER CGM RECEIVER/MONITOR	243.22
K0601	NU	REPL BATT SILVER OXIDE 1.5 V	1.13
K0602	NU	REPL BATT SILVER OXIDE 3 V	6.42
K0603	NU	REPL BATT ALKALINE 1.5 V	0.58
K0604	NU	REPL BATT LITHIUM 3.6 V	6.17
K0605	NU	REPL BATT LITHIUM 4.5 V	14.78
K0606	RR	AED GARMENT W ELEC ANALYSIS	2609.55
K0607	NU	REPL BATT FOR AED	205.35
K0608	NU	REPL GARMENT FOR AED	139.46
K0609	REPL ELECTRODE FOR AED	835.30
K0669	SEAT/BACK CUS NO DMEPDAC VER	BR
K0672	REMOVABLE SOFT INTERFACE LE	76.19
K0730	NU	CTRL DOSE INH DRUG DELIV SYS	1821.95
K0733	NU	12-24HR SEALED LEAD ACID	28.89
K0738	RR	PORTABLE GAS OXYGEN SYSTEM	60.62
K0739	REPAIR/SVC DME NON-OXYGEN EQ	36.18
K0740	REPAIR/SVC OXYGEN EQUIPMENT	BR
K0743	PORTABLE HOME SUCTION PUMP	BR
K0744	ABSORP DRG <= 16 SUC PUMP	BR
K0745	ABSORP DRG >16<=48 SUC PUMP	BR
K0746	ABSORP DRG >48 SUC PUMP	BR
K0800	NU	POV GROUP 1 STD UP TO 300LBS	974.60
K0801	NU	POV GROUP 1 HD 301-450 LBS	1657.29
K0802	NU	POV GROUP 1 VHD 451-600 LBS	2021.50
K0806	NU	POV GROUP 2 STD UP TO 300LBS	1312.95
K0807	NU	POV GROUP 2 HD 301-450 LBS	2012.14
K0808	NU	POV GROUP 2 VHD 451-600 LBS	3111.89
K0812	POWER OPERATED VEHICLE NOC	BR
K0813	RR	PWC GP 1 STD PORT SEAT/BACK	286.60
K0814	RR	PWC GP 1 STD PORT CAP CHAIR	336.15
K0815	RR	PWC GP 1 STD SEAT/BACK	378.19
K0816	RR	PWC GP 1 STD CAP CHAIR	357.86
K0820	RR	PWC GP 2 STD PORT SEAT/BACK	301.02
K0821	RR	PWC GP 2 STD PORT CAP CHAIR	354.09
K0822	RR	PWC GP 2 STD SEAT/BACK	410.29
K0823	RR	PWC GP 2 STD CAP CHAIR	402.16
K0824	RR	PWC GP 2 HD SEAT/BACK	528.79
K0825	RR	PWC GP 2 HD CAP CHAIR	486.36
K0826	RR	PWC GP 2 VHD SEAT/BACK	766.04
K0827	RR	PWC GP VHD CAP CHAIR	659.47
K0828	RR	PWC GP 2 XTRA HD SEAT/BACK	891.65
K0829	RR	PWC GP 2 XTRA HD CAP CHAIR	841.86
K0830	PWC GP2 STD SEAT ELEVATE S/B	BR
K0831	PWC GP2 STD SEAT ELEVATE CAP	BR
K0835	RR	PWC GP2 STD SING POW OPT S/B	429.70
K0836	RR	PWC GP2 STD SING POW OPT CAP	445.64
K0837	RR	PWC GP 2 HD SING POW OPT S/B	526.91
K0838	RR	PWC GP 2 HD SING POW OPT CAP	469.70
K0839	RR	PWC GP2 VHD SING POW OPT S/B	689.00
K0840	RR	PWC GP2 XHD SING POW OPT S/B	1049.28
K0841	RR	PWC GP2 STD MULT POW OPT S/B	467.24
K0842	RR	PWC GP2 STD MULT POW OPT CAP	466.98
K0843	RR	PWC GP2 HD MULT POW OPT S/B	559.23
K0848	RR	PWC GP 3 STD SEAT/BACK	707.97
K0849	RR	PWC GP 3 STD CAP CHAIR	680.65
K0850	RR	PWC GP 3 HD SEAT/BACK	821.20
K0851	RR	PWC GP 3 HD CAP CHAIR	789.59
K0852	RR	PWC GP 3 VHD SEAT/BACK	948.84
K0853	RR	PWC GP 3 VHD CAP CHAIR	974.71
K0854	RR	PWC GP 3 XHD SEAT/BACK	1291.28
K0855	RR	PWC GP 3 XHD CAP CHAIR	1219.80
K0856	RR	PWC GP3 STD SING POW OPT S/B	759.91
K0857	RR	PWC GP3 STD SING POW OPT CAP	775.14
K0858	RR	PWC GP3 HD SING POW OPT S/B	942.83
K0859	RR	PWC GP3 HD SING POW OPT CAP	899.17
K0860	RR	PWC GP3 VHD SING POW OPT S/B	1346.96
K0861	RR	PWC GP3 STD MULT POW OPT S/B	761.12
K0862	RR	PWC GP3 HD MULT POW OPT S/B	942.83
K0863	RR	PWC GP3 VHD MULT POW OPT S/B	1346.96
K0864	RR	PWC GP3 XHD MULT POW OPT S/B	1602.88
K0868	PWC GP 4 STD SEAT/BACK	BR
K0869	PWC GP 4 STD CAP CHAIR	BR
K0870	PWC GP 4 HD SEAT/BACK	BR
K0871	PWC GP 4 VHD SEAT/BACK	BR
K0877	PWC GP4 STD SING POW OPT S/B	BR
K0878	PWC GP4 STD SING POW OPT CAP	BR
K0879	PWC GP4 HD SING POW OPT S/B	BR
K0880	PWC GP4 VHD SING POW OPT S/B	BR
K0884	PWC GP4 STD MULT POW OPT S/B	BR
K0885	PWC GP4 STD MULT POW OPT CAP	BR
K0886	PWC GP4 HD MULT POW S/B	BR
K0890	PWC GP5 PED SING POW OPT S/B	BR
K0891	PWC GP5 PED MULT POW OPT S/B	BR
K0898	POWER WHEELCHAIR NOC	BR
K0899	POW MOBIL DEV NO DMEPDAC	BR
K0900	CSTM DME OTHER THAN WHEELCHR	BR
L0112	CRANIAL CERVICAL ORTHOSIS	1397.19
L0113	CRANIAL CERVICAL TORTICOLLIS	284.69
L0120	CERV FLEX N/ADJ FOAM PRE OTS	27.93
L0130	FLEX THERMOPLASTIC COLLAR MO	201.95
L0140	CERVICAL SEMI-RIGID ADJUSTAB	69.69
L0150	CERV SEMI-RIG ADJ MOLDED CHN	116.21
L0160	CERV SR WIRE OCC/MAN PRE OTS	165.46
L0170	CERVICAL COLLAR MOLDED TO PT	700.18
L0172	CERV COL SR FOAM 2PC PRE OTS	141.96
L0174	CERV SR 2PC THOR EXT PRE OTS	255.03
L0180	CER POST COL OCC/MAN SUP ADJ	346.84
L0190	CERV COLLAR SUPP ADJ CERV BA	522.12
L0200	CERV COL SUPP ADJ BAR & THOR	479.42
L0220	THOR RIB BELT CUSTOM FABRICA	113.70
L0450	TLSO FLEX TRUNK/THOR PRE OTS	187.71
L0452	TLSO FLEX CUSTOM FAB THORACI	BR
L0454	TLSO TRNK SJ-T9 PRE CST	346.21
L0455	TLSO FLEX TRNK SJ-T9 PRE OTS	346.21
L0456	TLSO FLEX TRNK SJ-SS PRE CST	992.85
L0457	TLSO FLEX TRNK SJ-SS PRE OTS	992.85
L0458	TLSO 2MOD SYMPHIS-XIPHO PRE	890.29
L0460	TLSO 2 SHL SYMPHYS-STERN CST	1002.11
L0462	TLSO 3MOD SACRO-SCAP PRE	1246.43
L0464	TLSO 4MOD SACRO-SCAP PRE	1483.85
L0466	TLSO R FRAM SOFT ANT PRE CST	381.56
L0467	TLSO R FRAM SOFT PRE OTS	381.56
L0468	TLSO RIG FRAM PELVIC PRE CST	478.39
L0469	TLSO RIG FRAM PELVIC PRE OTS	478.39
L0470	TLSO RIGID FRAME PRE SUBCLAV	681.07
L0472	TLSO RIGID FRAME HYPEREX PRE	427.51
L0480	TLSO RIGID PLASTIC CUSTOM FA	1321.96
L0482	TLSO RIGID LINED CUSTOM FAB	1515.46
L0484	TLSO RIGID PLASTIC CUST FAB	1766.99
L0486	TLSO RIGIDLINED CUST FAB TWO	1750.42
L0488	TLSO RIGID LINED PRE ONE PIE	1002.11
L0490	TLSO RIGID PLASTIC PRE ONE	282.38
L0491	TLSO 2 PIECE RIGID SHELL	766.64
L0492	TLSO 3 PIECE RIGID SHELL	496.86
L0621	SIO FLEX PELVIC/SACR PRE OTS	89.02
L0622	SIO FLEX PELVISACRAL CUSTOM	241.37
L0623	SIO RIG PNL PELV/SAC PRE OTS	BR
L0624	SIO PANEL CUSTOM	BR
L0625	LO FLEX L1-BELOW L5 PRE OTS	55.02
L0626	LO SAG RIG PNL STAYS PRE CST	77.82
L0627	LO SAG RI AN/POS PNL PRE CST	410.36
L0628	LSO FLEX NO RI STAYS PRE OTS	83.72
L0629	LSO FLEX W/RIGID STAYS CUST	BR
L0630	LSO R POST PNL SJ-T9 PRE CST	161.65
L0631	LSO SAG R AN/POS PNL PRE CST	1024.80
L0632	LSO SAG RIGID FRAME CUST	BR
L0633	LSO SC R POS/LAT PNL PRE CST	286.26
L0634	LSO FLEXION CONTROL CUSTOM	BR
L0635	LSO SAGIT RIGID PANEL PREFAB	1061.52
L0636	LSO SAGITTAL RIGID PANEL CUS	1566.34
L0637	LSO SC R ANT/POS PNL PRE CST	1358.99
L0638	LSO SAG-CORONAL PANEL CUSTOM	1316.62
L0639	LSO S/C SHELL/PANEL PREFAB	1358.99
L0640	LSO S/C SHELL/PANEL CUSTOM	1044.59
L0641	LO RIG POS PNL L1-L5 PRE OTS	77.82
L0642	LO SAG RI AN/POS PNL PRE OTS	410.36
L0643	LSO SAG CTR RIGI POS PRE OTS	161.65
L0648	LSO SAG R AN/POS PNL PRE OTS	1024.80
L0649	LSO SC R POS/LAT PNL PRE OTS	286.26
L0650	LSO SC R ANT/POS PNL PRE OTS	1358.99
L0651	LSO SAG-CO SHELL PNL PRE OTS	1358.99
L0700	CTLSO A-P-L CONTROL MOLDED	2149.29
L0710	CTLSO A-P-L CONTROL W/ INTER	2346.09
L0810	HALO CERVICAL INTO JCKT VEST	2492.38
L0820	HALO CERVICAL INTO BODY JACK	2016.22
L0830	HALO CERV INTO MILWAUKEE TYP	2911.21
L0859	MRI COMPATIBLE SYSTEM	1130.99
L0861	HALO REPL LINER/INTERFACE	215.17
L0970	TLSO CORSET FRONT	106.11
L0972	LSO CORSET FRONT	108.46
L0974	TLSO FULL CORSET	221.61
L0976	LSO FULL CORSET	197.93
L0978	AXILLARY CRUTCH EXTENSION	178.71
L0980	PERONEAL STRAPS PAIR PRE OTS	16.21
L0982	STOCKING SUP GRIPS 4 PRE OTS	17.67
L0984	PROTECT BODY SOCK EA PRE OTS	56.37
L0999	ADD TO SPINAL ORTHOSIS NOS	BR
L1000	CTLSO MILWAUKE INITIAL MODEL	1884.83
L1001	CTLSO INFANT IMMOBILIZER	BR
L1005	TENSION BASED SCOLIOSIS ORTH	3195.11
L1010	CTLSO AXILLA SLING	75.91
L1020	KYPHOSIS PAD	103.71
L1025	KYPHOSIS PAD FLOATING	117.87
L1030	LUMBAR BOLSTER PAD	78.74
L1040	LUMBAR OR LUMBAR RIB PAD	94.78
L1050	STERNAL PAD	82.05
L1060	THORACIC PAD	92.56
L1070	TRAPEZIUS SLING	94.65
L1080	OUTRIGGER	65.58
L1085	OUTRIGGER BIL W/ VERT EXTENS	182.18
L1090	LUMBAR SLING	85.10
L1100	RING FLANGE PLASTIC/LEATHER	150.22
L1110	RING FLANGE PLAS/LEATHER MOL	254.44
L1120	COVERS FOR UPRIGHT EACH	40.53
L1200	FURNSH INITIAL ORTHOSIS ONLY	1613.41
L1210	LATERAL THORACIC EXTENSION	242.92
L1220	ANTERIOR THORACIC EXTENSION	205.68
L1230	MILWAUKEE TYPE SUPERSTRUCTUR	527.74
L1240	LUMBAR DEROTATION PAD	90.82
L1250	ANTERIOR ASIS PAD	89.43
L1260	ANTERIOR THORACIC DEROTATION	91.91
L1270	ABDOMINAL PAD	91.80
L1280	RIB GUSSET (ELASTIC) EACH	81.82
L1290	LATERAL TROCHANTERIC PAD	92.77
L1300	BODY JACKET MOLD TO PATIENT	1550.80
L1310	POST-OPERATIVE BODY JACKET	1595.77
L1499	SPINAL ORTHOSIS NOS	BR
L1600	HO FLEX FREJKA W/COV PRE CST	119.63
L1610	HO FREJKA COV ONLY PRE CST	40.75
L1620	HO FLEX PAVLIK HARNS PRE CST	134.21
L1630	ABDUCT CONTROL HIP SEMI-FLEX	160.16
L1640	PELV BAND/SPREAD BAR THIGH C	428.38
L1650	HO ABDUCTION HIP ADJUSTABLE	227.19
L1652	HO BI THIGHCUFFS W SPRDR BAR	355.86
L1660	HO ABDUCTION STATIC PLASTIC	158.88
L1680	PELVIC & HIP CONTROL THIGH C	1306.22
L1685	POST-OP HIP ABDUCT CUSTOM FA	1378.29
L1686	HO POST-OP HIP ABDUCTION	924.64
L1690	COMBINATION BILATERAL HO	1930.40
L1700	LEG PERTHES ORTH TORONTO TYP	1605.97
L1710	LEGG PERTHES ORTH NEWINGTON	1887.72
L1720	LEGG PERTHES ORTHOSIS TRILAT	1394.46
L1730	LEGG PERTHES ORTH SCOTTISH R	1052.08
L1755	LEGG PERTHES PATTEN BOTTOM T	1531.34
L1810	KO ELASTIC WITH JOINTS	120.86
L1812	KO ELASTIC W/JOINTS PRE OTS	120.86
L1820	KO ELAS W/ CONDYLE PADS & JO	120.37
L1830	KO IMMOB CANVAS LONG PRE OTS	100.69
L1831	KNEE ORTH POS LOCKING JOINT	293.79
L1832	KO ADJ JNT POS R SUP PRE CST	752.57
L1833	KO ADJ JNT POS R SUP PRE OTS	752.57
L1834	KO W/0 JOINT RIGID MOLDED TO	885.39
L1836	KO RIGID W/O JOINTS PRE OTS	133.19
L1840	KO DEROT ANT CRUCIATE CUSTOM	930.69
L1843	KO SINGLE UPRIGHT PRE CST	895.70
L1844	KO W/ADJ JT ROT CNTRL MOLDED	1552.04
L1845	KO DOUBLE UPRIGHT PRE CST	935.02
L1846	KO W ADJ FLEX/EXT ROTAT MOLD	1186.39
L1847	KO DBL UPRIGHT W/AIR PRE CST	574.19
L1848	KO DBL UPRIGHT W/AIR PRE OTS	574.19
L1850	KO SWEDISH TYPE PRE OTS	267.23
L1851	KO SINGLE UPRIGHT PREFAB OTS	895.70
L1852	KO DOUBLE UPRIGHT PREFAB OTS	935.02
L1860	KO SUPRACONDYLAR SOCKET MOLD	1036.47
L1900	AFO SPRNG WIR DRSFLX CALF BD	280.79
L1902	AFO ANKLE GAUNTLET PRE OTS	76.26
L1904	AFO MOLDED ANKLE GAUNTLET	436.56
L1906	AFO MULTILIG ANK SUP PRE OTS	127.58
L1907	AFO SUPRAMALLEOLAR CUSTOM	561.71
L1910	AFO SING BAR CLASP ATTACH SH	248.27
L1920	AFO SING UPRIGHT W/ ADJUST S	324.56
L1930	AFO PLASTIC	219.62
L1932	AFO RIG ANT TIB PREFAB TCF/=	890.81
L1940	AFO MOLDED TO PATIENT PLASTI	496.32
L1945	AFO MOLDED PLAS RIG ANT TIB	911.44
L1950	AFO SPIRAL MOLDED TO PT PLAS	691.50
L1951	AFO SPIRAL PREFABRICATED	838.37
L1960	AFO POS SOLID ANK PLASTIC MO	514.59
L1970	AFO PLASTIC MOLDED W/ANKLE J	761.12
L1971	AFO W/ANKLE JOINT, PREFAB	467.91
L1980	AFO SING SOLID STIRRUP CALF	340.72
L1990	AFO DOUB SOLID STIRRUP CALF	437.78
L2000	KAFO SING FRE STIRR THI/CALF	941.65
L2005	KAFO SNG/DBL MECHANICAL ACT	4090.63
L2010	KAFO SNG SOLID STIRRUP W/O J	858.40
L2020	KAFO DBL SOLID STIRRUP BAND/	1084.03
L2030	KAFO DBL SOLID STIRRUP W/O J	940.49
L2034	KAFO PLA SIN UP W/WO K/A CUS	2049.75
L2035	KAFO PLASTIC PEDIATRIC SIZE	172.93
L2036	KAFO PLAS DOUB FREE KNEE MOL	1722.45
L2037	KAFO PLAS SING FREE KNEE MOL	1587.34
L2038	KAFO W/O JOINT MULTI-AXIS AN	1327.34
L2040	HKAFO TORSION BIL ROT STRAPS	169.55
L2050	HKAFO TORSION CABLE HIP PELV	451.52
L2060	HKAFO TORSION BALL BEARING J	579.50
L2070	HKAFO TORSION UNILAT ROT STR	166.47
L2080	HKAFO UNILAT TORSION CABLE	355.02
L2090	HKAFO UNILAT TORSION BALL BR	437.59
L2106	AFO TIB FX CAST PLASTER MOLD	631.23
L2108	AFO TIB FX CAST MOLDED TO PT	991.93
L2112	AFO TIBIAL FRACTURE SOFT	470.99
L2114	AFO TIB FX SEMI-RIGID	538.86
L2116	AFO TIBIAL FRACTURE RIGID	709.96
L2126	KAFO FEM FX CAST THERMOPLAS	1263.22
L2128	KAFO FEM FX CAST MOLDED TO P	1591.93
L2132	KAFO FEMORAL FX CAST SOFT	748.91
L2134	KAFO FEM FX CAST SEMI-RIGID	897.91
L2136	KAFO FEMORAL FX CAST RIGID	1097.90
L2180	PLAS SHOE INSERT W ANK JOINT	108.72
L2182	DROP LOCK KNEE	85.09
L2184	LIMITED MOTION KNEE JOINT	153.34
L2186	ADJ MOTION KNEE JNT LERMAN T	169.92
L2188	QUADRILATERAL BRIM	370.72
L2190	WAIST BELT	96.29
L2192	PELVIC BAND & BELT THIGH FLA	331.02
L2200	LIMITED ANKLE MOTION EA JNT	44.14
L2210	DORSIFLEXION ASSIST EACH JOI	71.62
L2220	DORSI & PLANTAR FLEX ASS/RES	82.23
L2230	SPLIT FLAT CALIPER STIRR & P	71.23
L2232	ROCKER BOTTOM, CONTACT AFO	96.45
L2240	ROUND CALIPER AND PLATE ATTA	77.65
L2250	FOOT PLATE MOLDED STIRRUP AT	329.88
L2260	REINFORCED SOLID STIRRUP	186.10
L2265	LONG TONGUE STIRRUP	109.33
L2270	VARUS/VALGUS STRAP PADDED/LI	49.86
L2275	PLASTIC MOD LOW EXT PAD/LINE	121.32
L2280	MOLDED INNER BOOT	450.67
L2300	ABDUCTION BAR JOINTED ADJUST	254.40
L2310	ABDUCTION BAR-STRAIGHT	114.21
L2320	NON-MOLDED LACER	191.02
L2330	LACER MOLDED TO PATIENT MODE	364.54
L2335	ANTERIOR SWING BAND	214.45
L2340	PRE-TIBIAL SHELL MOLDED TO P	506.05
L2350	PROSTHETIC TYPE SOCKET MOLDE	827.24
L2360	EXTENDED STEEL SHANK	48.03
L2370	PATTEN BOTTOM	238.32
L2375	TORSION ANK & HALF SOLID STI	104.90
L2380	TORSION STRAIGHT KNEE JOINT	114.29
L2385	STRAIGHT KNEE JOINT HEAVY DU	124.35
L2387	ADD LE POLY KNEE CUSTOM KAFO	168.75
L2390	OFFSET KNEE JOINT EACH	101.63
L2395	OFFSET KNEE JOINT HEAVY DUTY	155.16
L2397	SUSPENSION SLEEVE LOWER EXT	108.81
L2405	KNEE JOINT DROP LOCK EA JNT	87.04
L2415	KNEE JOINT CAM LOCK EACH JOI	121.28
L2425	KNEE DISC/DIAL LOCK/ADJ FLEX	143.09
L2430	KNEE JNT RATCHET LOCK EA JNT	143.09
L2492	KNEE LIFT LOOP DROP LOCK RIN	94.67
L2500	THI/GLUT/ISCHIA WGT BEARING	292.88
L2510	TH/WGHT BEAR QUAD-LAT BRIM M	784.16
L2520	TH/WGHT BEAR QUAD-LAT BRIM C	427.69
L2525	TH/WGHT BEAR NAR M-L BRIM MO	1467.30
L2526	TH/WGHT BEAR NAR M-L BRIM CU	790.89
L2530	THIGH/WGHT BEAR LACER NON-MO	218.13
L2540	THIGH/WGHT BEAR LACER MOLDED	392.50
L2550	THIGH/WGHT BEAR HIGH ROLL CU	266.64
L2570	HIP CLEVIS TYPE 2 POSIT JNT	589.59
L2580	PELVIC CONTROL PELVIC SLING	558.90
L2600	HIP CLEVIS/THRUST BEARING FR	190.67
L2610	HIP CLEVIS/THRUST BEARING LO	225.46
L2620	PELVIC CONTROL HIP HEAVY DUT	248.23
L2622	HIP JOINT ADJUSTABLE FLEXION	284.70
L2624	HIP ADJ FLEX EXT ABDUCT CONT	387.04
L2627	PLASTIC MOLD RECIPRO HIP & C	1594.58
L2628	METAL FRAME RECIPRO HIP & CA	1873.12
L2630	PELVIC CONTROL BAND & BELT U	229.89
L2640	PELVIC CONTROL BAND & BELT B	311.99
L2650	PELV & THOR CONTROL GLUTEAL	111.41
L2660	THORACIC CONTROL THORACIC BA	173.03
L2670	THORAC CONT PARASPINAL UPRIG	158.36
L2680	THORAC CONT LAT SUPPORT UPRI	145.28
L2750	PLATING CHROME/NICKEL PR BAR	77.60
L2755	CARBON GRAPHITE LAMINATION	130.47
L2760	EXTENSION PER EXTENSION PER	56.41
L2768	ORTHO SIDEBAR DISCONNECT	130.07
L2780	NON-CORROSIVE FINISH	66.73
L2785	DROP LOCK RETAINER EACH	39.23
L2795	KNEE CONTROL FULL KNEECAP	78.89
L2800	KNEE CAP MEDIAL OR LATERAL P	99.03
L2810	KNEE CONTROL CONDYLAR PAD	72.51
L2820	SOFT INTERFACE BELOW KNEE SE	80.62
L2830	SOFT INTERFACE ABOVE KNEE SE	90.66
L2840	TIBIAL LENGTH SOCK FX OR EQU	50.60
L2850	FEMORAL LGTH SOCK FX OR EQUA	57.48
L2861	TORSION MECHANISM KNEE/ANKLE	BR
L2999	LOWER EXTREMITY ORTHOSIS NOS	BR
L3000	FT INSERT UCB BERKELEY SHELL	313.60
L3001	FOOT INSERT REMOV MOLDED SPE	132.02
L3002	FOOT INSERT PLASTAZOTE OR EQ	161.22
L3003	FOOT INSERT SILICONE GEL EAC	173.93
L3010	FOOT LONGITUDINAL ARCH SUPPO	173.93
L3020	FOOT LONGITUD/METATARSAL SUP	198.06
L3030	FOOT ARCH SUPPORT REMOV PREM	76.19
L3031	FOOT LAMIN/PREPREG COMPOSITE	122.25
L3040	FT ARCH SUPRT PREMOLD LONGIT	46.99
L3050	FOOT ARCH SUPP PREMOLD METAT	46.99
L3060	FOOT ARCH SUPP LONGITUD/META	73.63
L3070	ARCH SUPRT ATT TO SHO LONGIT	31.74
L3080	ARCH SUPP ATT TO SHOE METATA	31.74
L3090	ARCH SUPP ATT TO SHOE LONG/M	40.63
L3100	HALLUS-VALGUS NT DYN PRE OTS	43.14
L3140	ABDUCTION ROTATION BAR SHOE	88.89
L3150	ABDUCT ROTATION BAR W/O SHOE	81.27
L3160	SHOE STYLED POSITIONING DEV	BR
L3170	FOOT PLAS HEEL STABI PRE OTS	50.79
L3201	OXFORD W SUPINAT/PRONAT INF	52.13
L3202	OXFORD W/ SUPINAT/PRONATOR C	58.49
L3203	OXFORD W/ SUPINATOR/PRONATOR	58.53
L3204	HIGHTOP W/ SUPP/PRONATOR INF	57.47
L3206	HIGHTOP W/ SUPP/PRONATOR CHI	55.26
L3207	HIGHTOP W/ SUPP/PRONATOR JUN	74.51
L3208	SURGICAL BOOT EACH INFANT	43.62
L3209	SURGICAL BOOT EACH CHILD	30.88
L3211	SURGICAL BOOT EACH JUNIOR	42.59
L3212	BENESCH BOOT PAIR INFANT	47.51
L3213	BENESCH BOOT PAIR CHILD	57.58
L3214	BENESCH BOOT PAIR JUNIOR	61.20
L3215	ORTHOPEDIC FTWEAR LADIES OXF	101.12
L3216	ORTHOPED LADIES SHOES DPTH I	101.36
L3217	LADIES SHOES HIGHTOP DEPTH I	266.06
L3219	ORTHOPEDIC MENS SHOES OXFORD	107.62
L3221	ORTHOPEDIC MENS SHOES DPTH I	117.01
L3222	MENS SHOES HIGHTOP DEPTH INL	170.26
L3224	WOMAN'S SHOE OXFORD BRACE	54.60
L3225	MAN'S SHOE OXFORD BRACE	62.80
L3230	CUSTOM SHOES DEPTH INLAY	160.75
L3250	CUSTOM MOLD SHOE REMOV PROST	319.24
L3251	SHOE MOLDED TO PT SILICONE S	36.64
L3252	SHOE MOLDED PLASTAZOTE CUST	319.33
L3253	SHOE MOLDED PLASTAZOTE CUST	71.96
L3254	ORTH FOOT NON-STNDARD SIZE/W	BR
L3255	ORTH FOOT NON-STANDARD SIZE/	BR
L3257	ORTH FOOT ADD CHARGE SPLIT S	63.85
L3260	AMBULATORY SURGICAL BOOT EAC	37.25
L3265	PLASTAZOTE SANDAL EACH	26.59
L3300	SHO LIFT TAPER TO METATARSAL	52.04
L3310	SHOE LIFT ELEV HEEL/SOLE NEO	81.27
L3320	SHOE LIFT ELEV HEEL/SOLE COR	154.25
L3330	LIFTS ELEVATION METAL EXTENS	564.95
L3332	SHOE LIFTS TAPERED TO ONE-HA	73.63
L3334	SHOE LIFTS ELEVATION HEEL /I	38.09
L3340	SHOE WEDGE SACH	85.08
L3350	SHOE HEEL WEDGE	22.82
L3360	SHOE SOLE WEDGE OUTSIDE SOLE	35.55
L3370	SHOE SOLE WEDGE BETWEEN SOLE	49.52
L3380	SHOE CLUBFOOT WEDGE	49.52
L3390	SHOE OUTFLARE WEDGE	49.52
L3400	SHOE METATARSAL BAR WEDGE RO	40.63
L3410	SHOE METATARSAL BAR BETWEEN	92.70
L3420	FULL SOLE/HEEL WEDGE BTWEEN	54.58
L3430	SHO HEEL COUNT PLAST REINFOR	159.97
L3440	HEEL LEATHER REINFORCED	76.19
L3450	SHOE HEEL SACH CUSHION TYPE	105.35
L3455	SHOE HEEL NEW LEATHER STANDA	40.63
L3460	SHOE HEEL NEW RUBBER STANDAR	34.26
L3465	SHOE HEEL THOMAS WITH WEDGE	58.39
L3470	SHOE HEEL THOMAS EXTEND TO B	62.19
L3480	SHOE HEEL PAD & DEPRESS FOR	62.19
L3485	SHOE HEEL PAD REMOVABLE FOR	35.12
L3500	ORTHO SHOE ADD LEATHER INSOL	29.23
L3510	ORTHOPEDIC SHOE ADD RUB INSL	29.23
L3520	O SHOE ADD FELT W LEATH INSL	31.74
L3530	ORTHO SHOE ADD HALF SOLE	31.74
L3540	ORTHO SHOE ADD FULL SOLE	50.79
L3550	O SHOE ADD STANDARD TOE TAP	8.90
L3560	O SHOE ADD HORSESHOE TOE TAP	22.82
L3570	O SHOE ADD INSTEP EXTENSION	85.08
L3580	O SHOE ADD INSTEP VELCRO CLO	64.75
L3590	O SHOE CONVERT TO SOF COUNTE	53.33
L3595	ORTHO SHOE ADD MARCH BAR	41.89
L3600	TRANS SHOE CALIP PLATE EXIST	76.19
L3610	TRANS SHOE CALIPER PLATE NEW	100.29
L3620	TRANS SHOE SOLID STIRRUP EXI	76.19
L3630	TRANS SHOE SOLID STIRRUP NEW	100.29
L3640	SHOE DENNIS BROWNE SPLINT BO	43.14
L3649	ORTHOPEDIC SHOE MODIFICA NOS	BR
L3650	SO 8 ABD RESTRAINT PRE OTS	54.38
L3660	SO 8 AB RSTR CAN/WEB PRE OTS	93.37
L3670	SO ACRO/CLAV CAN WEB PRE OTS	130.14
L3671	SO CAP DESIGN W/O JNTS CF	818.60
L3674	SO AIRPLANE W/WO JOINT CF	1073.89
L3675	SO VEST CANVAS/WEB PRE OTS	159.44
L3677	SO HARD PLAS STABILI PRE CST	159.55
L3678	SO HARD PLAS STABILI PRE OTS	BR
L3702	EO W/O JOINTS CF	262.34
L3710	EO ELAS W/METAL JNTS PRE OTS	131.72
L3720	FOREARM/ARM CUFFS FREE MOTIO	657.16
L3730	FOREARM/ARM CUFFS EXT/FLEX A	865.06
L3740	CUFFS ADJ LOCK W/ ACTIVE CON	972.20
L3760	EO ADJ JT PREFAB CUSTOM FIT	454.32
L3761	EO, ADJ LOCK JOINT PREFAB OT	908.66
L3762	EO RIGID W/O JOINTS PRE OTS	97.70
L3763	EWHO RIGID W/O JNTS CF	721.31
L3764	EWHO W/JOINT(S) CF	719.35
L3765	EWHFO RIGID W/O JNTS CF	1164.93
L3766	EWHFO W/JOINT(S) CF	1233.58
L3806	WHFO W/JOINT(S) CUSTOM FAB	412.68
L3807	WHFO W/O JOINTS PRE CST	227.19
L3808	WHFO, RIGID W/O JOINTS	303.45
L3809	WHFO W/O JOINTS PRE OTS	227.19
L3891	TORSION MECHANISM WRIST/ELBO	BR
L3900	HINGE EXTENSION/FLEX WRIST/F	1419.25
L3901	HINGE EXT/FLEX WRIST FINGER	1591.36
L3904	WHFO ELECTRIC CUSTOM FITTED	3239.54
L3905	WHO W/NONTORSION JNT(S) CF	900.97
L3906	WHO W/O JOINTS CF	383.26
L3908	WHO COCK-UP NONMOLDE PRE OTS	54.43
L3912	HFO FLEXION GLOVE PRE OTS	87.31
L3913	HFO W/O JOINTS CF	246.07
L3915	WHO NONTORSION JNTS PRE CST	482.95
L3916	WHO NONTORSION JNTS PRE OTS	482.95
L3917	METACARP FX ORTHOSIS PRE CST	95.98
L3918	METACARP FX ORTHOSIS PRE OTS	95.98
L3919	HO W/O JOINTS CF	246.07
L3921	HFO W/JOINT(S) CF	291.79
L3923	HFO WITHOUT JOINTS PRE CST	79.02
L3924	HFO WITHOUT JOINTS PRE OTS	79.02
L3925	FO PIP DIP JNT/SPRNG PRE OTS	47.99
L3927	FO PIP DIP NO JT SPR PRE OTS	31.79
L3929	HFO NONTORSION JNTS PRE CST	76.48
L3930	HFO NONTORSION JNTS PRE OTS	76.48
L3931	WHFO NONTORSION JOINT PREFAB	185.02
L3933	FO W/O JOINTS CF	193.85
L3935	FO NONTORSION JOINT CF	200.73
L3956	ADD JOINT UPPER EXT ORTHOSIS	BR
L3960	SEWHO AIRPLAN DESIG ABDU POS	748.86
L3961	SEWHO CAP DESIGN W/O JNTS CF	1526.40
L3962	SEWHO ERBS PALSEY DESIGN ABD	779.73
L3967	SEWHO AIRPLANE W/O JNTS CF	1802.16
L3971	SEWHO CAP DESIGN W/JNT(S) CF	1710.64
L3973	SEWHO AIRPLANE W/JNT(S) CF	1802.16
L3975	SEWHFO CAP DESIGN W/O JNT CF	1526.40
L3976	SEWHFO AIRPLANE W/O JNTS CF	1526.40
L3977	SEWHFO CAP DESGN W/JNT(S) CF	1710.64
L3978	SEWHFO AIRPLANE W/JNT(S) CF	1802.16
L3980	UP EXT FX ORTHOS HUMERAL NOS	280.85
L3981	UE FX ORTH SHOUL CAP FOREARM	914.47
L3982	UPPER EXT FX ORTHOSIS RAD/UL	346.98
L3984	UPPER EXT FX ORTHOSIS WRIST	370.38
L3995	SOCK FRACTURE OR EQUAL EACH	31.08
L3999	UPPER LIMB ORTHOSIS NOS	BR
L4000	REPL GIRDLE MILWAUKEE ORTH	1211.11
L4002	REPLACE STRAP, ANY ORTHOSIS	BR
L4010	REPLACE TRILATERAL SOCKET BR	681.54
L4020	REPLACE QUADLAT SOCKET BRIM	851.30
L4030	REPLACE SOCKET BRIM CUST FIT	468.72
L4040	REPLACE MOLDED THIGH LACER	378.96
L4045	REPLACE NON-MOLDED THIGH LAC	304.54
L4050	REPLACE MOLDED CALF LACER	383.28
L4055	REPLACE NON-MOLDED CALF LACE	248.19
L4060	REPLACE HIGH ROLL CUFF	295.04
L4070	REPLACE PROX & DIST UPRIGHT	281.48
L4080	REPL MET BAND KAFO-AFO PROX	99.24
L4090	REPL MET BAND KAFO-AFO CALF/	87.83
L4100	REPL LEATH CUFF KAFO PROX TH	99.07
L4110	REPL LEATH CUFF KAFO-AFO CAL	78.73
L4130	REPLACE PRETIBIAL SHELL	541.85
L4205	ORTHO DVC REPAIR PER 15 MIN	35.72
L4210	ORTH DEV REPAIR/REPL MINOR P	BR
L4350	ANKLE CONTROL ORTHO PRE OTS	97.62
L4360	PNEUMAT WALKING BOOT PRE CST	273.12
L4361	PNEUMA/VAC WALK BOOT PRE OTS	273.12
L4370	PNEUM FULL LEG SPLNT PRE OTS	175.27
L4386	NON-PNEUM WALK BOOT PRE CST	158.27
L4387	NON-PNEUM WALK BOOT PRE OTS	158.27
L4392	REPLACE AFO SOFT INTERFACE	23.51
L4394	REPLACE FOOT DROP SPINT	17.16
L4396	STATIC OR DYNAMI AFO PRE CST	167.56
L4397	STATIC OR DYNAMI AFO PRE OTS	167.56
L4398	FOOT DROP SPLINT PRE OTS	77.11
L4631	AFO, WALK BOOT TYPE, CUS FAB	1489.72
L5000	SHO INSERT W ARCH TOE FILLER	523.44
L5010	MOLD SOCKET ANK HGT W/ TOE F	1264.23
L5020	TIBIAL TUBERCLE HGT W/ TOE F	2146.94
L5050	ANK SYMES MOLD SCKT SACH FT	2374.90
L5060	SYMES MET FR LEATH SOCKET AR	2731.84
L5100	MOLDED SOCKET SHIN SACH FOOT	2380.15
L5105	PLAST SOCKET JTS/THGH LACER	3436.01
L5150	MOLD SCKT EXT KNEE SHIN SACH	3473.33
L5160	MOLD SOCKET BENT KNEE SHIN S	3777.87
L5200	KNE SING AXIS FRIC SHIN SACH	3617.85
L5210	NO KNEE/ANKLE JOINTS W/ FT B	2400.08
L5220	NO KNEE JOINT WITH ARTIC ALI	2728.13
L5230	FEM FOCAL DEFIC CONSTANT FRI	3762.62
L5250	HIP CANAD SING AXI CONS FRIC	5131.88
L5270	TILT TABLE LOCKING HIP SING	5109.11
L5280	HEMIPELVECT CANAD SING AXIS	5069.99
L5301	BK MOLD SOCKET SACH FT ENDO	2720.67
L5312	KNEE DISART, SACH FT, ENDO	3894.45
L5321	AK OPEN END SACH	3943.68
L5331	HIP DISART CANADIAN SACH FT	5025.03
L5341	HEMIPELVECTOMY CANADIAN SACH	5231.09
L5400	POSTOP DRESS & 1 CAST CHG BK	1346.96
L5410	POSTOP DSG BK EA ADD CAST CH	413.25
L5420	POSTOP DSG & 1 CAST CHG AK/D	1650.65
L5430	POSTOP DSG AK EA ADD CAST CH	497.72
L5450	POSTOP APP NON-WGT BEAR DSG	404.91
L5460	POSTOP APP NON-WGT BEAR DSG	539.48
L5500	INIT BK PTB PLASTER DIRECT	1270.30
L5505	INIT AK ISCHAL PLSTR DIRECT	1756.87
L5510	PREP BK PTB PLASTER MOLDED	1439.97
L5520	PERP BK PTB THERMOPLS DIRECT	1422.35
L5530	PREP BK PTB THERMOPLS MOLDED	1708.37
L5535	PREP BK PTB OPEN END SOCKET	1677.29
L5540	PREP BK PTB LAMINATED SOCKET	1790.19
L5560	PREP AK ISCHIAL PLAST MOLDED	1922.35
L5570	PREP AK ISCHIAL DIRECT FORM	1998.57
L5580	PREP AK ISCHIAL THERMO MOLD	2333.19
L5585	PREP AK ISCHIAL OPEN END	2871.37
L5590	PREP AK ISCHIAL LAMINATED	2377.68
L5595	HIP DISARTIC SACH THERMOPLS	4200.49
L5600	HIP DISART SACH LAMINAT MOLD	4515.33
L5610	ABOVE KNEE HYDRACADENCE	2047.77
L5611	AK 4 BAR LINK W/FRIC SWING	1593.57
L5613	AK 4 BAR LING W/HYDRAUL SWIG	2491.51
L5614	4-BAR LINK ABOVE KNEE W/SWNG	1687.82
L5616	AK UNIV MULTIPLEX SYS FRICT	1346.39
L5617	AK/BK SELF-ALIGNING UNIT EA	559.62
L5618	TEST SOCKET SYMES	296.06
L5620	TEST SOCKET BELOW KNEE	274.98
L5622	TEST SOCKET KNEE DISARTICULA	358.57
L5624	TEST SOCKET ABOVE KNEE	359.58
L5626	TEST SOCKET HIP DISARTICULAT	471.58
L5628	TEST SOCKET HEMIPELVECTOMY	504.24
L5629	BELOW KNEE ACRYLIC SOCKET	314.33
L5630	SYME TYP EXPANDABL WALL SCKT	443.89
L5631	AK/KNEE DISARTIC ACRYLIC SOC	434.58
L5632	SYMES TYPE PTB BRIM DESIGN S	242.54
L5634	SYMES TYPE POSTER OPENING SO	300.86
L5636	SYMES TYPE MEDIAL OPENING SO	252.02
L5637	BELOW KNEE TOTAL CONTACT	285.73
L5638	BELOW KNEE LEATHER SOCKET	497.74
L5639	BELOW KNEE WOOD SOCKET	1108.93
L5640	KNEE DISARTICULAT LEATHER SO	632.45
L5642	ABOVE KNEE LEATHER SOCKET	612.80
L5643	HIP FLEX INNER SOCKET EXT FR	1539.44
L5644	ABOVE KNEE WOOD SOCKET	584.19
L5645	BK FLEX INNER SOCKET EXT FRA	789.18
L5646	BELOW KNEE CUSHION SOCKET	541.92
L5647	BELOW KNEE SUCTION SOCKET	786.77
L5648	ABOVE KNEE CUSHION SOCKET	651.18
L5649	ISCH CONTAINMT/NARROW M-L SO	2359.61
L5650	TOT CONTACT AK/KNEE DISART S	482.85
L5651	AK FLEX INNER SOCKET EXT FRA	1187.80
L5652	SUCTION SUSP AK/KNEE DISART	431.22
L5653	KNEE DISART EXPAND WALL SOCK	575.64
L5654	SOCKET INSERT SYMES	328.02
L5655	SOCKET INSERT BELOW KNEE	277.98
L5656	SOCKET INSERT KNEE ARTICULAT	372.90
L5658	SOCKET INSERT ABOVE KNEE	359.62
L5661	MULTI-DUROMETER SYMES	601.90
L5665	MULTI-DUROMETER BELOW KNEE	506.43
L5666	BELOW KNEE CUFF SUSPENSION	69.23
L5668	BK MOLDED DISTAL CUSHION	111.67
L5670	BK MOLDED SUPRACONDYLAR SUSP	268.38
L5671	BK/AK LOCKING MECHANISM	568.74
L5672	BK REMOVABLE MEDIAL BRIM SUS	294.93
L5673	SOCKET INSERT W LOCK MECH	703.29
L5676	BK KNEE JOINTS SINGLE AXIS P	358.41
L5677	BK KNEE JOINTS POLYCENTRIC P	487.67
L5678	BK JOINT COVERS PAIR	39.27
L5679	SOCKET INSERT W/O LOCK MECH	586.05
L5680	BK THIGH LACER NON-MOLDED	327.83
L5681	INTL CUSTM CONG/LATYP INSERT	1315.68
L5682	BK THIGH LACER GLUT/ISCHIA M	618.56
L5683	INITIAL CUSTOM SOCKET INSERT	1315.68
L5684	BK FORK STRAP	47.60
L5685	BELOW KNEE SUS/SEAL SLEEVE	128.11
L5686	BK BACK CHECK	50.53
L5688	BK WAIST BELT WEBBING	60.42
L5690	BK WAIST BELT PADDED AND LIN	96.78
L5692	AK PELVIC CONTROL BELT LIGHT	131.43
L5694	AK PELVIC CONTROL BELT PAD/L	179.43
L5695	AK SLEEVE SUSP NEOPRENE/EQUA	165.64
L5696	AK/KNEE DISARTIC PELVIC JOIN	183.00
L5697	AK/KNEE DISARTIC PELVIC BAND	79.40
L5698	AK/KNEE DISARTIC SILESIAN BA	129.84
L5699	SHOULDER HARNESS	233.90
L5700	REPLACE SOCKET BELOW KNEE	2833.89
L5701	REPLACE SOCKET ABOVE KNEE	3403.30
L5702	REPLACE SOCKET HIP	4305.66
L5703	SYMES ANKLE W/O (SACH) FOOT	2228.23
L5704	CUSTOM SHAPE COVER BK	530.16
L5705	CUSTOM SHAPE COVER AK	947.31
L5706	CUSTOM SHAPE CVR KNEE DISART	928.60
L5707	CUSTOM SHAPE CVR HIP DISART	1224.21
L5710	KNE-SHIN EXO SNG AXI MNL LOC	369.90
L5711	KNEE-SHIN EXO MNL LOCK ULTRA	516.97
L5712	KNEE-SHIN EXO FRICT SWG & ST	433.17
L5714	KNEE-SHIN EXO VARIABLE FRICT	444.93
L5716	KNEE-SHIN EXO MECH STANCE PH	720.87
L5718	KNEE-SHIN EXO FRCT SWG & STA	901.02
L5722	KNEE-SHIN PNEUM SWG FRCT EXO	951.89
L5724	KNEE-SHIN EXO FLUID SWING PH	1492.93
L5726	KNEE-SHIN EXT JNTS FLD SWG E	1720.56
L5728	KNEE-SHIN FLUID SWG & STANCE	2353.50
L5780	KNEE-SHIN PNEUM/HYDRA PNEUM	1132.41
L5781	LOWER LIMB PROS VACUUM PUMP	4002.03
L5782	HD LOW LIMB PROS VACUUM PUMP	4219.06
L5785	EXOSKELETAL BK ULTRALT MATER	636.55
L5790	EXOSKELETAL AK ULTRA-LIGHT M	711.17
L5795	EXOSKEL HIP ULTRA-LIGHT MATE	1415.95
L5810	ENDOSKEL KNEE-SHIN MNL LOCK	481.54
L5811	ENDO KNEE-SHIN MNL LCK ULTRA	721.35
L5812	ENDO KNEE-SHIN FRCT SWG & ST	559.12
L5814	ENDO KNEE-SHIN HYDRAL SWG PH	3714.67
L5816	ENDO KNEE-SHIN POLYC MCH STA	846.23
L5818	ENDO KNEE-SHIN FRCT SWG & ST	949.83
L5822	ENDO KNEE-SHIN PNEUM SWG FRC	1684.30
L5824	ENDO KNEE-SHIN FLUID SWING P	1516.81
L5826	MINIATURE KNEE JOINT	3123.55
L5828	ENDO KNEE-SHIN FLUID SWG/STA	2793.09
L5830	ENDO KNEE-SHIN PNEUM/SWG PHA	1876.81
L5840	MULTI-AXIAL KNEE/SHIN SYSTEM	3470.23
L5845	KNEE-SHIN SYS STANCE FLEXION	1792.78
L5848	KNEE-SHIN SYS HYDRAUL STANCE	1075.53
L5850	ENDO AK/HIP KNEE EXTENS ASSI	126.53
L5855	MECH HIP EXTENSION ASSIST	339.99
L5856	ELEC KNEE-SHIN SWING/STANCE	24010.98
L5857	ELEC KNEE-SHIN SWING ONLY	8519.97
L5858	STANCE PHASE ONLY	18589.18
L5859	KNEE-SHIN PRO FLEX/EXT CONT	14512.42
L5910	ENDO BELOW KNEE ALIGNABLE SY	358.22
L5920	ENDO AK/HIP ALIGNABLE SYSTEM	524.80
L5925	ABOVE KNEE MANUAL LOCK	443.12
L5930	HIGH ACTIVITY KNEE FRAME	3366.61
L5940	ENDO BK ULTRA-LIGHT MATERIAL	496.13
L5950	ENDO AK ULTRA-LIGHT MATERIAL	775.73
L5960	ENDO HIP ULTRA-LIGHT MATERIA	953.51
L5961	ENDO POLY HIP, PNEU/HYD/ROT	4546.73
L5962	BELOW KNEE FLEX COVER SYSTEM	627.51
L5964	ABOVE KNEE FLEX COVER SYSTEM	926.29
L5966	HIP FLEXIBLE COVER SYSTEM	1180.32
L5968	MULTIAXIAL ANKLE W DORSIFLEX	3634.71
L5969	AK/FT POWER ASST INCL MOTORS	BR
L5970	FOOT EXTERNAL KEEL SACH FOOT	200.87
L5971	SACH FOOT, REPLACEMENT	200.87
L5972	FLEXIBLE KEEL FOOT	375.21
L5973	ANK-FOOT SYS DORS-PLANT FLEX	17208.35
L5974	FOOT SINGLE AXIS ANKLE/FOOT	230.49
L5975	COMBO ANKLE/FOOT PROSTHESIS	463.72
L5976	ENERGY STORING FOOT	553.91
L5978	FT PROSTH MULTIAXIAL ANKL/FT	288.64
L5979	MULTI-AXIAL ANKLE/FT PROSTH	2256.84
L5980	FLEX FOOT SYSTEM	3667.21
L5981	FLEX-WALK SYS LOW EXT PROSTH	2962.61
L5982	EXOSKELETAL AXIAL ROTATION U	571.80
L5984	ENDOSKELETAL AXIAL ROTATION	563.45
L5985	LWR EXT DYNAMIC PROSTH PYLON	282.44
L5986	MULTI-AXIAL ROTATION UNIT	626.77
L5987	SHANK FT W VERT LOAD PYLON	7195.28
L5988	VERTICAL SHOCK REDUCING PYLO	1998.12
L5990	USER ADJUSTABLE HEEL HEIGHT	1814.60
L5999	LOWR EXTREMITY PROSTHES NOS	BR
L6000	PART HAND THUMB REM	1314.18
L6010	PART HAND LITTLE/RING	1462.46
L6020	PART HAND NO FINGERS	1363.52
L6026	PART HAND MYO EXCLU TERM DEV	4944.33
L6050	WRST MLD SCK FLX HNG TRI PAD	1878.87
L6055	WRST MOLD SOCK W/EXP INTERFA	2618.67
L6100	ELB MOLD SOCK FLEX HINGE PAD	1903.59
L6110	ELBOW MOLD SOCK SUSPENSION T	2019.07
L6120	ELBOW MOLD DOUB SPLT SOC STE	2352.94
L6130	ELBOW STUMP ACTIVATED LOCK H	2560.44
L6200	ELBOW MOLD OUTSID LOCK HINGE	2698.29
L6205	ELBOW MOLDED W/ EXPAND INTER	3601.79
L6250	ELBOW INTER LOC ELBOW FORARM	2827.18
L6300	SHLDER DISART INT LOCK ELBOW	3684.93
L6310	SHOULDER PASSIVE RESTOR COMP	3181.78
L6320	SHOULDER PASSIVE RESTOR CAP	1738.13
L6350	THORACIC INTERN LOCK ELBOW	3874.14
L6360	THORACIC PASSIVE RESTOR COMP	3484.18
L6370	THORACIC PASSIVE RESTOR CAP	2084.82
L6380	POSTOP DSG CAST CHG WRST/ELB	1208.11
L6382	POSTOP DSG CAST CHG ELB DIS/	1817.54
L6384	POSTOP DSG CAST CHG SHLDER/T	2514.38
L6386	POSTOP EA CAST CHG & REALIGN	397.20
L6388	POSTOP APPLICAT RIGID DSG ON	434.82
L6400	BELOW ELBOW PROSTH TISS SHAP	2295.05
L6450	ELB DISART PROSTH TISS SHAP	3066.13
L6500	ABOVE ELBOW PROSTH TISS SHAP	3207.81
L6550	SHLDR DISAR PROSTH TISS SHAP	3855.84
L6570	SCAP THORAC PROSTH TISS SHAP	4329.07
L6580	WRIST/ELBOW BOWDEN CABLE MOL	1652.75
L6582	WRIST/ELBOW BOWDEN CBL DIR F	1496.95
L6584	ELBOW FAIR LEAD CABLE MOLDED	2347.60
L6586	ELBOW FAIR LEAD CABLE DIR FO	2196.98
L6588	SHDR FAIR LEAD CABLE MOLDED	2886.77
L6590	SHDR FAIR LEAD CABLE DIRECT	2741.98
L6600	POLYCENTRIC HINGE PAIR	185.53
L6605	SINGLE PIVOT HINGE PAIR	183.19
L6610	FLEXIBLE METAL HINGE PAIR	175.92
L6611	ADDITIONAL SWITCH, EXT POWER	411.79
L6615	DISCONNECT LOCKING WRIST UNI	189.55
L6616	DISCONNECT INSERT LOCKING WR	70.24
L6620	FLEXION/EXTENSION WRIST UNIT	303.27
L6621	FLEX/EXT WRIST W/WO FRICTION	2287.76
L6623	SPRING-ASS ROT WRST W/ LATCH	845.94
L6624	FLEX/EXT/ROTATION WRIST UNIT	3766.86
L6625	ROTATION WRST W/ CABLE LOCK	601.05
L6628	QUICK DISCONN HOOK ADAPTER O	473.82
L6629	LAMINATION COLLAR W/ COUPLIN	144.71
L6630	STAINLESS STEEL ANY WRIST	213.17
L6632	LATEX SUSPENSION SLEEVE EACH	74.03
L6635	LIFT ASSIST FOR ELBOW	174.21
L6637	NUDGE CONTROL ELBOW LOCK	371.57
L6638	ELEC LOCK ON MANUAL PW ELBOW	2501.26
L6640	SHOULDER ABDUCTION JOINT PAI	330.10
L6641	EXCURSION AMPLIFIER PULLEY T	158.67
L6642	EXCURSION AMPLIFIER LEVER TY	215.07
L6645	SHOULDER FLEXION-ABDUCTION J	396.99
L6646	MULTIPO LOCKING SHOULDER JNT	3154.67
L6647	SHOULDER LOCK ACTUATOR	519.35
L6648	EXT PWRD SHLDER LOCK/UNLOCK	3253.57
L6650	SHOULDER UNIVERSAL JOINT	412.17
L6655	STANDARD CONTROL CABLE EXTRA	81.00
L6660	HEAVY DUTY CONTROL CABLE	90.79
L6665	TEFLON OR EQUAL CABLE LINING	45.55
L6670	HOOK TO HAND CABLE ADAPTER	50.37
L6672	HARNESS CHEST/SHLDER SADDLE	199.87
L6675	HARNESS FIGURE OF 8 SING CON	118.78
L6676	HARNESS FIGURE OF 8 DUAL CON	137.30
L6677	UE TRIPLE CONTROL HARNESS	296.75
L6680	TEST SOCK WRIST DISART/BEL E	229.47
L6682	TEST SOCK ELBW DISART/ABOVE	253.71
L6684	TEST SOCKET SHLDR DISART/THO	344.76
L6686	SUCTION SOCKET	778.55
L6687	FRAME TYP SOCKET BEL ELBOW/W	570.51
L6688	FRAME TYP SOCK ABOVE ELB/DIS	567.07
L6689	FRAME TYP SOCKET SHOULDER DI	679.43
L6690	FRAME TYP SOCK INTERSCAP-THO	740.38
L6691	REMOVABLE INSERT EACH	342.67
L6692	SILICONE GEL INSERT OR EQUAL	553.12
L6693	LOCKINGELBOW FOREARM CNTRBAL	2839.58
L6694	ELBOW SOCKET INS USE W/LOCK	703.29
L6695	ELBOW SOCKET INS USE W/O LCK	586.05
L6696	CUS ELBO SKT IN FOR CON/ATYP	1315.68
L6697	CUS ELBO SKT IN NOT CON/ATYP	1315.68
L6698	BELOW/ABOVE ELBOW LOCK MECH	568.74
L6703	TERM DEV, PASSIVE HAND MITT	359.56
L6704	TERM DEV, SPORT/REC/WORK ATT	579.24
L6706	TERM DEV MECH HOOK VOL OPEN	345.11
L6707	TERM DEV MECH HOOK VOL CLOSE	1272.02
L6708	TERM DEV MECH HAND VOL OPEN	831.56
L6709	TERM DEV MECH HAND VOL CLOSE	1198.30
L6711	PED TERM DEV, HOOK, VOL OPEN	672.45
L6712	PED TERM DEV, HOOK, VOL CLOS	1238.14
L6713	PED TERM DEV, HAND, VOL OPEN	1562.61
L6714	PED TERM DEV, HAND, VOL CLOS	1323.57
L6715	TERM DEVICE, MULTI ART DIGIT	3157.83
L6721	HOOK/HAND, HVY DTY, VOL OPEN	2352.48
L6722	HOOK/HAND, HVY DTY, VOL CLOS	2028.00
L6805	TERM DEV MODIFIER WRIST UNIT	336.52
L6810	TERM DEV PRECISION PINCH DEV	190.74
L6880	ELEC HAND IND ART DIGITS	23897.62
L6881	TERM DEV AUTO GRASP FEATURE	4089.09
L6882	MICROPROCESSOR CONTROL UPLMB	3101.81
L6883	REPLC SOCKT BELOW E/W DISA	1569.55
L6884	REPLC SOCKT ABOVE ELBOW DISA	2329.54
L6885	REPLC SOCKT SHLDR DIS/INTERC	3484.18
L6890	PREFAB GLOVE FOR TERM DEVICE	168.23
L6895	CUSTOM GLOVE FOR TERM DEVICE	618.87
L6900	HAND RESTORAT THUMB/1 FINGER	1766.11
L6905	HAND RESTORATION MULTIPLE FI	1756.07
L6910	HAND RESTORATION NO FINGERS	1501.61
L6915	HAND RESTORATION REPLACMNT G	757.09
L6920	WRIST DISARTICUL SWITCH CTRL	6600.83
L6925	WRIST DISART MYOELECTRONIC C	8885.87
L6930	BELOW ELBOW SWITCH CONTROL	6641.76
L6935	BELOW ELBOW MYOELECTRONIC CT	9023.76
L6940	ELBOW DISARTICULATION SWITCH	8677.90
L6945	ELBOW DISART MYOELECTRONIC C	10603.35
L6950	ABOVE ELBOW SWITCH CONTROL	9863.66
L6955	ABOVE ELBOW MYOELECTRONIC CT	11813.07
L6960	SHLDR DISARTIC SWITCH CONTRO	13381.27
L6965	SHLDR DISARTIC MYOELECTRONIC	14271.61
L6970	INTERSCAPULAR-THOR SWITCH CT	14871.25
L6975	INTERSCAP-THOR MYOELECTRONIC	16264.34
L7007	ADULT ELECTRIC HAND	3403.48
L7008	PEDIATRIC ELECTRIC HAND	5356.72
L7009	ADULT ELECTRIC HOOK	3472.63
L7040	PREHENSILE ACTUATOR	2788.38
L7045	PEDIATRIC ELECTRIC HOOK	1598.67
L7170	ELECTRONIC ELBOW HOSMER SWIT	7360.91
L7180	ELECTRONIC ELBOW SEQUENTIAL	32310.29
L7181	ELECTRONIC ELBO SIMULTANEOUS	40076.58
L7185	ELECTRON ELBOW ADOLESCENT SW	7269.00
L7186	ELECTRON ELBOW CHILD SWITCH	8748.94
L7190	ELBOW ADOLESCENT MYOELECTRON	7634.93
L7191	ELBOW CHILD MYOELECTRONIC CT	9142.12
L7259	ELECTRONIC WRIST ROTATOR ANY	3161.01
L7360	SIX VOLT BAT OTTO BOCK/EQ EA	236.01
L7362	BATTERY CHRGR SIX VOLT OTTO	247.81
L7364	TWELVE VOLT BATTERY UTAH/EQU	394.13
L7366	BATTERY CHRGR 12 VOLT UTAH/E	530.90
L7367	REPLACEMNT LITHIUM IONBATTER	389.39
L7368	LITHIUM ION BATTERY CHARGER	504.80
L7400	ADD UE PROST BE/WD, ULTLITE	306.56
L7401	ADD UE PROST A/E ULTLITE MAT	343.20
L7402	ADD UE PROST S/D ULTLITE MAT	370.58
L7403	ADD UE PROST B/E ACRYLIC	368.36
L7404	ADD UE PROST A/E ACRYLIC	555.91
L7405	ADD UE PROST S/D ACRYLIC	727.07
L7499	UPPER EXTREMITY PROSTHES NOS	BR
L7510	PROSTHETIC DEVICE REPAIR REP	BR
L7520	REPAIR PROSTHESIS PER 15 MIN	51.08
L7600	PROSTHETIC DONNING SLEEVE	BR
L7700	PROS SOC INSERT GASKET/SEAL	111.63
L7900	MALE VACUUM ERECTION SYSTEM	555.95
L7902	TENSION RING, VAC ERECT DEV	BR
L8000	MASTECTOMY BRA	43.50
L8001	BREAST PROSTHESIS BRA & FORM	125.45
L8002	BRST PRSTH BRA & BILAT FORM	165.03
L8010	MASTECTOMY SLEEVE	88.30
L8015	EXT BREASTPROSTHESIS GARMENT	59.95
L8020	MASTECTOMY FORM	225.49
L8030	BREAST PROSTHES W/O ADHESIVE	326.16
L8031	BREAST PROSTHESIS W ADHESIVE	326.16
L8032	REUSABLE NIPPLE PROSTHESIS	39.18
L8035	CUSTOM BREAST PROSTHESIS	3664.41
L8039	BREAST PROSTHESIS NOS	0.00
L8040	NASAL PROSTHESIS	2417.69
L8041	MIDFACIAL PROSTHESIS	2914.07
L8042	ORBITAL PROSTHESIS	3274.21
L8043	UPPER FACIAL PROSTHESIS	3667.13
L8044	HEMI-FACIAL PROSTHESIS	4060.02
L8045	AURICULAR PROSTHESIS	2542.50
L8046	PARTIAL FACIAL PROSTHESIS	2619.38
L8047	NASAL SEPTAL PROSTHESIS	1342.41
L8048	UNSPEC MAXILLOFACIAL PROSTH	BR
L8049	REPAIR MAXILLOFACIAL PROSTH	BR
L8300	TRUSS SINGLE W/ STANDARD PAD	96.33
L8310	TRUSS DOUBLE W/ STANDARD PAD	148.12
L8320	TRUSS ADDITION TO STD PAD WA	64.69
L8330	TRUSS ADD TO STD PAD SCROTAL	64.12
L8400	SHEATH BELOW KNEE	18.75
L8410	SHEATH ABOVE KNEE	21.33
L8415	SHEATH UPPER LIMB	21.20
L8417	PROS SHEATH/SOCK W GEL CUSHN	75.21
L8420	PROSTHETIC SOCK MULTI PLY BK	24.79
L8430	PROSTHETIC SOCK MULTI PLY AK	27.25
L8435	PROS SOCK MULTI PLY UPPER LM	24.46
L8440	SHRINKER BELOW KNEE	51.86
L8460	SHRINKER ABOVE KNEE	72.17
L8465	SHRINKER UPPER LIMB	64.33
L8470	PROS SOCK SINGLE PLY BK	6.60
L8480	PROS SOCK SINGLE PLY AK	9.10
L8485	PROS SOCK SINGLE PLY UPPER L	11.00
L8499	UNLISTED MISC PROSTHETIC SER	BR
L8500	ARTIFICIAL LARYNX	652.75
L8501	TRACHEOSTOMY SPEAKING VALVE	144.97
L8505	ARTIFICIAL LARYNX, ACCESSORY	BR
L8507	TRACH-ESOPH VOICE PROS PT IN	41.90
L8509	TRACH-ESOPH VOICE PROS MD IN	109.25
L8510	VOICE AMPLIFIER	252.77
L8511	INDWELLING TRACH INSERT	72.75
L8512	GEL CAP FOR TRACH VOICE PROS	2.19
L8513	TRACH PROS CLEANING DEVICE	5.22
L8514	REPL TRACH PUNCTURE DILATOR	94.32
L8515	GEL CAP APP DEVICE FOR TRACH	63.12
L8600	IMPLANT BREAST SILICONE/EQ	617.63
L8603	COLLAGEN IMP URINARY 2.5 ML	433.76
L8604	DEXTRANOMER/HYALURONIC ACID	BR
L8605	INJ BULKING AGENT ANAL CANAL	716.39
L8606	SYNTHETIC IMPLNT URINARY 1ML	227.69
L8607	INJ VOCAL CORD BULKING AGENT	42.91
L8608	ARG II EXT COM/SUP/ACC MISC	BR
L8609	ARTIFICIAL CORNEA	6516.84
L8610	OCULAR IMPLANT	633.54
L8612	AQUEOUS SHUNT PROSTHESIS	668.19
L8613	OSSICULAR IMPLANT	299.16
L8614	COCHLEAR DEVICE	18935.62
L8615	COCH IMPLANT HEADSET REPLACE	451.11
L8616	COCH IMPLANT MICROPHONE REPL	105.07
L8617	COCH IMPLANT TRANS COIL REPL	91.80
L8618	COCH IMPLANT TRAN CABLE REPL	26.22
L8619	COCH IMP EXT PROC/CONTR RPLC	8122.67
L8621	REPL ZINC AIR BATTERY	0.61
L8622	REPL ALKALINE BATTERY	0.32
L8623	LITH ION BATT CID, NON-EARLVL	64.69
L8624	LITH ION BATT CID, EAR LEVEL	161.27
L8625	CHARGER COCH IMPL/AOI BATTRY	188.91
L8627	CID EXT SPEECH PROCESS REPL	6885.33
L8628	CID EXT CONTROLLER REPL	1237.36
L8629	CID TRANSMIT COIL AND CABLE	179.09
L8630	METACARPOPHALANGEAL IMPLANT	333.22
L8631	MCP JOINT RE PL 2 PC OR MORE	2236.30
L8641	METATARSAL JOINT IMPLANT	361.67
L8642	HALLUX IMPLANT	296.88
L8658	INTERPHALANGEAL JOINT SPACER	310.27
L8659	INTERPHALANGEAL JOINT REPL	1930.08
L8670	VASCULAR GRAFT, SYNTHETIC	550.58
L8679	IMP NEUROSTI PLS GN ANY TYPE	8345.84
L8680	IMPLT NEUROSTIM ELCTR EACH	825.93
L8681	PT PRGRM FOR IMPLT NEUROSTIM	1129.71
L8682	IMPLT NEUROSTIM RADIOFQ REC	5962.94
L8683	RADIOFQ TRSMTR FOR IMPLT NEU	5248.73
L8684	RADIOF TRSMTR IMPLT SCRL NEU	689.26
L8685	IMPLT NROSTM PLS GEN SNG REC	7942.48
L8686	IMPLT NROSTM PLS GEN SNG NON	12557.08
L8687	IMPLT NROSTM PLS GEN DUA REC	10336.57
L8688	IMPLT NROSTM PLS GEN DUA NON	6595.65
L8689	EXTERNAL RECHARG SYS INTERN	1725.30
L8690	AUD OSSEO DEV, INT/EXT COMP	4758.18
L8691	AOI SND PROC REPL EXCL ACTUA	1722.52
L8692	NON-OSSEOINTEGRATED SND PROC	BR
L8693	AUD OSSEO DEV, ABUTMENT	1516.65
L8694	AOI TRANSDUCER/ACTUATOR REPL	944.60
L8695	EXTERNAL RECHARG SYS EXTERN	16.66
L8696	EXT ANTENNA PHREN NERVE STIM	216.81
L8698	MISC USED WITH TOT ART HEART	BR
L8699	PROSTHETIC IMPLANT NOS	BR
L8701	POW UE ROM DEV EWH UPRT CUST	BR
L8702	POW UE ROM DEV EWHF UPRT CUS	BR
L9900	O&P SUPPLY/ACCESSORY/SERVICE	BR
M0075	CELLULAR THERAPY	0.00
M0076	PROLOTHERAPY	0.00
M0100	INTRAGASTRIC HYPOTHERMIA	0.00
M0300	IV CHELATIONTHERAPY	0.00
M0301	FABRIC WRAPPING OF ANEURYSM	0.00
M1000	PAIN SCR AS MOD TO SEVR	0.00
M1001	PLN TO ADRS PAIN DOC	0.00
M1002	PLN TO ADRS PAIN NOT DOC	0.00
M1003	TB SCR 12 MO PRI FST BIO DZ	0.00
M1004	DOC MED RSN NO SRN TB	0.00
M1005	TB SCR NO PERF	0.00
M1006	DZ NOT ASES, NO RSN	0.00
M1007	>=50% TOTAL PT OUTPT RA ENCT	0.00
M1008	GREATER THAN 50% TOTAL PT OUTPT RA ENCTS	0.00
M1009	PT TX AND FINAL EVAL COMP	0.00
M1010	PT TX AND FINAL EVAL COMP	0.00
M1011	PT TX AND FINAL EVAL COMP	0.00
M1012	PT TX AND FINAL EVAL COMP	0.00
M1013	PT TX AND FINAL EVAL COMP	0.00
M1014	PT TX AND FINAL EVAL COMP	0.00
M1015	PT TX AND FINAL EVAL COMP	0.00
M1016	PT DX MEOP OR SUR STERI	0.00
M1017	PT ADMT TO PALITVE SERV	0.00
M1018	PT DX HST CR PT SK LG CR SCR	0.00
M1019	ADL PT MJ DEP DS RS 12 PHQGREATER THAN 5	0.00
M1020	ADL PT MJ DEP DS NO RS 12 MO	0.00
M1021	PT UC IN PP	0.00
M1022	PT HOSPICE DURING PERF PD	0.00
M1023	ADL PT MJ DEP DS RS 6 PHQGREATER THAN 5	0.00
M1024	ADL PT MJ DEP DS NO RS 6 MO	0.00
M1025	PT HOSPICE DURING PERF PD	0.00
M1026	PT HOSPICE DURING PERF PD	0.00
M1027	IMG HEAD (CT OR MRI) OBTND	0.00
M1028	DOC OF PT PRM HDA DX AND OTR	0.00
M1029	DOC SYSM RSN IMG HD	0.00
M1030	PT CLIN IND IMG HD	0.00
M1031	PT CLIN IND IMG HD	0.00
M1032	ADT TKNG PHARMTHRY FOR OUD	0.00
M1033	PHARMTHRY FOR OUD AFR 6.30	0.00
M1034	ADT 180 DYS PHARMTHRY OUD	0.00
M1035	ADT PD OUT MAT PR 180 DYS TX	0.00
M1036	ADT NO 180 DYS PHARMTHRY OUD	0.00
M1037	PT DX LUM SP REG CACR	0.00
M1038	PT DX LUM SP REG FRACT	0.00
M1039	PT DX LUM SP REG INF	0.00
M1040	PT DX LUM IDI OR CONG SCOL	0.00
M1041	PT CR FT INF LM OR PT ID SL	0.00
M1042	FTL ST MEA SCO OT ODI 3 MO	0.00
M1043	FTL ST MEA SCO NO OT ODI	0.00
M1044	FTL ST MEA ODI 3 MO	0.00
M1045	FSM WTH SCR OKS PRE AND POST	0.00
M1046	FSM WTH SCR NO OKS PRE AND P	0.00
M1047	FS MSRD OKS PRE AND POST	0.00
M1048	FSM WTH SCR ODI PRE AND POST	0.00
M1049	FSM WTH SCR NO ODI PRE AND P	0.00
M1050	FS MSRD ODI PRE AND POST	0.00
M1051	PT W/CANCER SCOLIOSIS	0.00
M1052	LG PN NT MSR VAS SCL PRE/PST	0.00
M1053	PRE AND POST VAS WTHN 3 MOS	0.00
M1054	PT UC IN PP	0.00
M1055	ASPIRIN USED	0.00
M1056	PRESC ANTICO MED IN PP	0.00
M1057	ASPIRIN NOT USED, NO RSN	0.00
M1058	PT PRM NURS HM RES IN PP	0.00
M1059	PT NO PRM NURS HM RES IN PP	0.00
M1060	PT DIED IN PP	0.00
M1061	PT PREG	0.00
M1062	PT IMCOMPRMD	0.00
M1063	PT REC HG DOS IMSUP THPY	0.00
M1064	SHING VAC DOC ADM OR PV REC	0.00
M1065	SHING VAC NO ADM CLINC RSN	0.00
M1066	SHING VAC NO DOC NO RSN	0.00
M1067	HSPC PT PRV TIME MEAM PER	0.00
M1068	PT NOT AMBULATORY	0.00
M1069	PT SCR FT FALL RSK	0.00
M1070	PT NOT SCRN FUT FALL NO RSN	0.00
M1071	PT HAD ADD'L SP PCR PERF	0.00
P2028	CEPHALIN FLOCULATION TEST	BR
P2029	CONGO RED BLOOD TEST	BR
P2031	HAIR ANALYSIS	BR
P2033	BLOOD THYMOL TURBIDITY	BR
P2038	BLOOD MUCOPROTEIN	7.65
P3000	SCREEN PAP BY TECH W MD SUPV	16.11
P3001	SCREENING PAP SMEAR BY PHYS	36.01
P7001	CULTURE BACTERIAL URINE	16.58
P9010	WHOLE BLOOD FOR TRANSFUSION	51.54	157.88
P9011	BLOOD SPLIT UNIT	73.68	179.01
P9012	CRYOPRECIPITATE EACH UNIT	BR	70.15
P9016	RBC LEUKOCYTES REDUCED	BR	262.39
P9017	PLASMA 1 DONOR FRZ W/IN 8 HR	BR	101.57
P9019	PLATELETS, EACH UNIT	BR	153.30
P9020	PLAELET RICH PLASMA UNIT	BR	177.83
P9021	RED BLOOD CELLS UNIT	BR	198.97
P9022	WASHED RED BLOOD CELLS UNIT	BR	505.42
P9023	FROZEN PLASMA, POOLED, SD	BR	107.86
P9031	PLATELETS LEUKOCYTES REDUCED	BR	193.99
P9032	PLATELETS, IRRADIATED	BR	244.11
P9033	PLATELETS LEUKOREDUCED IRRAD	BR	237.34
P9034	PLATELETS, PHERESIS	BR	478.65
P9035	PLATELET PHERES LEUKOREDUCED	BR	690.55
P9036	PLATELET PHERESIS IRRADIATED	BR	785.13
P9037	PLATE PHERES LEUKOREDU IRRAD	BR	887.40
P9038	RBC IRRADIATED	BR	314.33
P9039	RBC DEGLYCEROLIZED	BR	470.22
P9040	RBC LEUKOREDUCED IRRADIATED	BR	362.92
P9041	ALBUMIN (HUMAN), 5%, 50ML	10.98	14.90
P9043	PLASMA PROTEIN FRACT, 5%, 50ML	16.91	38.27
P9044	CRYOPRECIPITATEREDUCEDPLASMA	BR	126.00
P9045	ALBUMIN (HUMAN), 5%, 250 ML	54.90	74.48
P9046	ALBUMIN (HUMAN), 25%, 20 ML	22.64	29.79
P9047	ALBUMIN (HUMAN), 25%, 50ML	53.79	74.48
P9048	PLASMAPROTEIN FRACT, 5%, 250ML	34.22	109.31
P9050	GRANULOCYTES, PHERESIS UNIT	BR	2176.90
P9051	BLOOD, L/R, CMV-NEG	BR	249.83
P9052	PLATELETS, HLA-M, L/R, UNIT	BR	1199.66
P9053	PLT, PHER, L/R CMV-NEG, IRR	BR	699.08
P9054	BLOOD, L/R, FROZ/DEGLY/WASH	BR	423.69
P9055	PLT, APH/PHER, L/R, CMV-NEG	BR	631.99
P9056	BLOOD, L/R, IRRADIATED	BR	320.17
P9057	RBC, FRZ/DEG/WSH, L/R, IRRAD	BR	318.80
P9058	RBC, L/R, CMV-NEG, IRRAD	BR	325.59
P9059	PLASMA, FRZ BETWEEN 8-24HOUR	BR	108.86
P9060	FR FRZ PLASMA DONOR RETESTED	BR	89.19
P9070	PATHOGEN REDUCED PLASMA POOL	BR	58.83
P9071	PATHOGEN REDUCED PLASMA SING	BR	111.26
P9073	PLATELETS PHERESIS PATH REDU	BR	887.40
P9100	PATHOGEN TEST FOR PLATELETS	BR	36.21
P9603	ONE-WAY ALLOW PRORATED MILES	BR
P9604	ONE-WAY ALLOW PRORATED TRIP	10.60
P9612	CATHETERIZE FOR URINE SPEC	26.57
P9615	URINE SPECIMEN COLLECT MULT	BR
Q0035	CARDIOKYMOGRAPHY	22.80	45.61
Q0081	INFUSION THER OTHER THAN CHE	BR
Q0083	CHEMO BY OTHER THAN INFUSION	BR
Q0084	CHEMOTHERAPY BY INFUSION	414.28
Q0085	CHEMO BY BOTH INFUSION AND O	BR
Q0091	OBTAINING SCREEN PAP SMEAR	49.20	24.38
Q0092	SET UP PORT XRAY EQUIPMENT	27.20
Q0111	WET MOUNTS/ W PREPARATIONS	16.49
Q0112	POTASSIUM HYDROXIDE PREPS	6.41
Q0113	PINWORM EXAMINATIONS	5.23
Q0114	FERN TEST	10.71
Q0115	POST-COITAL MUCOUS EXAM	27.50
Q0138	FERUMOXYTOL, NON-ESRD	0.92	1.43
Q0139	FERUMOXYTOL, ESRD USE	0.92	1.43
Q0144	AZITHROMYCIN DIHYDRATE, ORAL	33.16
Q0161	CHLORPROMAZINE HCL 5MG ORAL	0.00
Q0162	ONDANSETRON ORAL	0.03
Q0163	DIPHENHYDRAMINE HCL 50MG	0.28
Q0164	PROCHLORPERAZINE MALEATE 5MG	0.05
Q0166	GRANISETRON HCL 1 MG ORAL	1.44
Q0167	DRONABINOL 2.5MG ORAL	1.81
Q0169	PROMETHAZINE HCL 12.5MG ORAL	0.03
Q0173	TRIMETHOBENZAMIDE HCL 250MG	0.81
Q0174	THIETHYLPERAZINE MALEATE10MG	0.81
Q0175	PERPHENAZINE 4MG ORAL	0.81
Q0177	HYDROXYZINE PAMOATE 25MG	1.84
Q0180	DOLASETRON MESYLATE ORAL	123.48
Q0181	UNSPECIFIED ORAL ANTI-EMETIC	BR
Q0477	PWR MODULE PT CABLE LVAD RPL	853.64
Q0478	POWER ADAPTER, COMBO VAD	202.18
Q0479	POWER MODULE COMBO VAD, REP	13183.85
Q0480	DRIVER PNEUMATIC VAD, REP	99092.11
Q0481	MICROPRCSR CU ELEC VAD, REP	15987.38
Q0482	MICROPRCSR CU COMBO VAD, REP	5007.55
Q0483	MONITOR ELEC VAD, REP	20628.82
Q0484	MONITOR ELEC OR COMB VAD REP	4006.06
Q0485	MONITOR CABLE ELEC VAD, REP	386.78
Q0486	MON CABLE ELEC/PNEUM VAD REP	321.90
Q0487	LEADS ANY TYPE VAD, REP ONLY	375.57
Q0488	PWR PACK BASE ELEC VAD, REP	BR
Q0489	PWR PCK BASE COMBO VAD, REP	17884.05
Q0490	EMR PWR SOURCE ELEC VAD, REP	773.59
Q0491	EMR PWR SOURCE COMBO VAD REP	1216.13
Q0492	EMR PWR CBL ELEC VAD, REP	98.01
Q0493	EMR PWR CBL COMBO VAD, REP	278.94
Q0494	EMR HD PMP ELEC/COMBO, REP	236.05
Q0495	CHARGER ELEC/COMBO VAD, REP	4595.79
Q0496	BATTERY ELEC/COMBO VAD, REP	1649.51
Q0497	BAT CLPS ELEC/COMB VAD, REP	515.05
Q0498	HOLSTER ELEC/COMBO VAD, REP	565.13
Q0499	BELT/VEST ELEC/COMBO VAD REP	183.62
Q0500	FILTERS ELEC/COMBO VAD, REP	33.61
Q0501	SHWR COV ELEC/COMBO VAD, REP	561.87
Q0502	MOBILITY CART PNEUM VAD, REP	715.34
Q0503	BATTERY PNEUM VAD REPLACEMNT	1430.70
Q0504	PWR ADPT PNEUM VAD, REP VEH	754.93
Q0506	LITH-ION BATT ELEC/PNEUM VAD	939.74
Q0507	MISC SUP/ACC EXT VAD	BR
Q0508	MIS SUP/ACC IMP VAD	BR
Q0509	MIS SUP/AC IMP VAD NOPAY MED	BR
Q0510	DISPENS FEE IMMUNOSUPRESSIVE	BR
Q0511	SUP FEE ANTIEM, ANTICA, IMMUNO	BR
Q0512	PX SUP FEE ANTI-CAN SUB PRES	BR
Q0513	DISP FEE INHAL DRUGS/30 DAYS	BR
Q0514	DISP FEE INHAL DRUGS/90 DAYS	BR
Q0515	SERMORELIN ACETATE INJECTION	1.61
Q1004	NTIOL CATEGORY 4	BR
Q1005	NTIOL CATEGORY 5	BR
Q2004	BLADDER CALCULI IRRIG SOL	17.31
Q2009	FOSPHENYTOIN INJ PE	24.88
Q2017	TENIPOSIDE, 50 MG	266.55	3669.24
Q2026	RADIESSE INJECTION	BR	672.94
Q2028	INJ, SCULPTRA, 0.5MG	0.00	4.66
Q2034	AGRIFLU VACCINE	BR
Q2035	AFLURIA VACC, 3 YRS & >, IM	14.42
Q2036	FLULAVAL VACC, 3 YRS & >, IM	BR
Q2037	FLUVIRIN VACC, 3 YRS & >, IM	24.85
Q2038	FLUZONE VACC, 3 YRS & >, IM	24.85
Q2039	INFLUENZA VIRUS VACCINE, NOS	BR
Q2041	AXICABTAGENE CILOLEUCEL CAR+	BR	561439.60
Q2042	TISAGENLECLEUCEL CAR-POS T	BR	623931.39
Q2043	SIPULEUCEL-T AUTO CD54+	40319.18	60515.14
Q2049	IMPORTED LIPODOX INJ	716.88	667.97
Q2050	DOXORUBICIN INJ 10MG	477.80	541.49
Q2052	IVIG DEMO, SERVICES/SUPPLIES	0.00
Q3001	BRACHYTHERAPY RADIOELEMENTS	BR
Q3014	TELEHEALTH FACILITY FEE	BR
Q3027	INJ BETA INTERFERON IM 1 MCG	46.27	76.15
Q3028	INJ BETA INTERFERON SQ 1 MCG	BR
Q3031	COLLAGEN SKIN TEST	BR
Q4001	CAST SUP BODY CAST PLASTER	55.43
Q4002	CAST SUP BODY CAST FIBERGLAS	209.42
Q4003	CAST SUP SHOULDER CAST PLSTR	39.79
Q4004	CAST SUP SHOULDER CAST FBRGL	137.78
Q4005	CAST SUP LONG ARM ADULT PLST	14.67
Q4006	CAST SUP LONG ARM ADULT FBRG	33.07
Q4007	CAST SUP LONG ARM PED PLSTER	7.34
Q4008	CAST SUP LONG ARM PED FBRGLS	16.52
Q4009	CAST SUP SHT ARM ADULT PLSTR	9.80
Q4010	CAST SUP SHT ARM ADULT FBRGL	22.04
Q4011	CAST SUP SHT ARM PED PLASTER	4.88
Q4012	CAST SUP SHT ARM PED FBRGLAS	11.04
Q4013	CAST SUP GAUNTLET PLASTER	17.83
Q4014	CAST SUP GAUNTLET FIBERGLASS	30.06
Q4015	CAST SUP GAUNTLET PED PLSTER	8.93
Q4016	CAST SUP GAUNTLET PED FBRGLS	15.04
Q4017	CAST SUP LNG ARM SPLINT PLST	10.31
Q4018	CAST SUP LNG ARM SPLINT FBRG	16.43
Q4019	CAST SUP LNG ARM SPLNT PED P	5.17
Q4020	CAST SUP LNG ARM SPLNT PED F	8.24
Q4021	CAST SUP SHT ARM SPLINT PLST	7.63
Q4022	CAST SUP SHT ARM SPLINT FBRG	13.76
Q4023	CAST SUP SHT ARM SPLNT PED P	3.84
Q4024	CAST SUP SHT ARM SPLNT PED F	6.90
Q4025	CAST SUP HIP SPICA PLASTER	42.77
Q4026	CAST SUP HIP SPICA FIBERGLAS	133.58
Q4027	CAST SUP HIP SPICA PED PLSTR	21.41
Q4028	CAST SUP HIP SPICA PED FBRGL	66.84
Q4029	CAST SUP LONG LEG PLASTER	32.73
Q4030	CAST SUP LONG LEG FIBERGLASS	86.13
Q4031	CAST SUP LNG LEG PED PLASTER	16.35
Q4032	CAST SUP LNG LEG PED FBRGLS	43.07
Q4033	CAST SUP LNG LEG CYLINDER PL	30.53
Q4034	CAST SUP LNG LEG CYLINDER FB	75.89
Q4035	CAST SUP LNGLEG CYLNDR PED P	15.26
Q4036	CAST SUP LNGLEG CYLNDR PED F	37.97
Q4037	CAST SUP SHRT LEG PLASTER	18.60
Q4038	CAST SUP SHRT LEG FIBERGLASS	46.63
Q4039	CAST SUP SHRT LEG PED PLSTER	9.33
Q4040	CAST SUP SHRT LEG PED FBRGLS	23.32
Q4041	CAST SUP LNG LEG SPLNT PLSTR	22.64
Q4042	CAST SUP LNG LEG SPLNT FBRGL	38.64
Q4043	CAST SUP LNG LEG SPLNT PED P	11.33
Q4044	CAST SUP LNG LEG SPLNT PED F	19.34
Q4045	CAST SUP SHT LEG SPLNT PLSTR	13.15
Q4046	CAST SUP SHT LEG SPLNT FBRGL	21.13
Q4047	CAST SUP SHT LEG SPLNT PED P	6.55
Q4048	CAST SUP SHT LEG SPLNT PED F	10.57
Q4049	FINGER SPLINT, STATIC	2.39
Q4050	CAST SUPPLIES UNLISTED	BR
Q4051	SPLINT SUPPLIES MISC	BR
Q4074	ILOPROST NON-COMP UNIT DOSE	123.55
Q4081	EPOETIN ALFA, 100 UNITS ESRD	1.37
Q4082	DRUG/BIO NOC PART B DRUG CAP	BR
Q4100	SKIN SUBSTITUTE, NOS	BR
Q4101	APLIGRAF	34.56
Q4102	OASIS WOUND MATRIX	11.82
Q4103	OASIS BURN MATRIX	BR
Q4104	INTEGRA BMWD	35.25
Q4105	INTEGRA DRT OR OMNIGRAFT	140.29
Q4106	DERMAGRAFT	36.38
Q4107	GRAFTJACKET	109.59
Q4108	INTEGRA MATRIX	39.45
Q4110	PRIMATRIX	61.53
Q4111	GAMMAGRAFT	7.66
Q4112	CYMETRA INJECTABLE	247.73
Q4113	GRAFTJACKET XPRESS	247.73
Q4114	INTEGRA FLOWABLE WOUND MATRI	1746.92
Q4115	ALLOSKIN	10.59
Q4116	ALLODERM	36.06
Q4117	HYALOMATRIX	BR
Q4118	MATRISTEM MICROMATRIX	BR
Q4121	THERASKIN	42.60
Q4122	DERMACELL	BR
Q4123	ALLOSKIN	24.63
Q4124	OASIS TRI-LAYER WOUND MATRIX	BR
Q4125	ARTHROFLEX	BR
Q4126	MEMODERM/DERMA/TRANZ/INTEGUP	BR
Q4127	TALYMED	BR
Q4128	FLEXHD/ALLOPATCHHD/MATRIXHD	BR
Q4130	STRATTICE TM	BR
Q4132	GRAFIX CORE, GRAFIXPL CORE	BR
Q4133	GRAFIX STRAVIX PRIME PL SQCM	BR
Q4134	HMATRIX	BR
Q4135	MEDISKIN	BR
Q4136	EZDERM	BR
Q4137	AMNIOEXCEL BIODEXCEL 1SQ CM	0.00
Q4138	BIODFENCE DRYFLEX, 1CM	0.00
Q4139	AMNIO OR BIODMATRIX, INJ 1CC	0.00
Q4140	BIODFENCE 1CM	0.00
Q4141	ALLOSKIN AC, 1 CM	0.00
Q4142	XCM BIOLOGIC TISS MATRIX 1CM	0.00
Q4143	REPRIZA, 1CM	0.00
Q4145	EPIFIX, INJ, 1MG	0.00
Q4146	TENSIX, 1CM	0.00
Q4147	ARCHITECT ECM PX FX 1 SQ CM	0.00
Q4148	NEOX NEOX RT OR CLARIX CORD	0.00
Q4149	EXCELLAGEN, 0.1 CC	0.00
Q4150	ALLOWRAP DS OR DRY 1 SQ CM	0.00
Q4151	AMNIOBAND, GUARDIAN 1 SQ CM	0.00
Q4152	DERMAPURE 1 SQUARE CM	0.00
Q4153	DERMAVEST, PLURIVEST SQ CM	0.00
Q4154	BIOVANCE 1 SQUARE CM	0.00
Q4155	NEOXFLO OR CLARIXFLO 1 MG	0.00
Q4156	NEOX 100 OR CLARIX 100	0.00
Q4157	REVITALON 1 SQUARE CM	0.00
Q4158	KERECIS OMEGA3, PER SQ CM	0.00
Q4159	AFFINITY1 SQUARE CM	0.00
Q4160	NUSHIELD 1 SQUARE CM	0.00
Q4161	BIO-CONNEKT PER SQUARE CM	0.00
Q4162	WNDEX FLW, BIOSKN FLW, 0.5CC	0.00
Q4163	WOUNDEX, BIOSKIN, PER SQ CM	0.00
Q4164	HELICOLL, PER SQUARE CM	0.00
Q4165	KERAMATRIX, PER SQUARE CM	0.00
Q4166	CYTAL, PER SQUARE CENTIMETER	29.37
Q4167	TRUSKIN, PER SQ CENTIMETER	BR
Q4168	AMNIOBAND, 1 MG	BR
Q4169	ARTACENT WOUND, PER SQ CM	189.24
Q4170	CYGNUS, PER SQ CM	522.04
Q4171	INTERFYL, 1 MG	97.88
Q4173	PALINGEN OR PALINGEN XPLUS	228.40
Q4174	PALINGEN OR PROMATRX	649.29
Q4175	MIRODERM	BR
Q4176	NEOPATCH, PER SQ CENTIMETER	BR
Q4177	FLOWERAMNIOFLO, 0.1 CC	BR
Q4178	FLOWERAMNIOPATCH, PER SQ CM	155.63
Q4179	FLOWERDERM, PER SQ CM	BR
Q4180	REVITA, PER SQ CM	BR
Q4181	AMNIO WOUND, PER SQUARE CM	BR
Q4182	TRANSCYTE, PER SQ CENTIMETER	BR
Q4183	SURGIGRAFT, 1 SQ CM	BR
Q4184	CELLESTA, 1 SQ CM	BR
Q4185	CELLESTA FLOWAB AMNION 0.5CC	BR
Q4186	EPIFIX 1 SQ CM	BR
Q4187	EPICORD 1 SQ CM	BR
Q4188	AMNIOARMOR 1 SQ CM	BR
Q4189	ARTACENT AC, 1 MG	BR
Q4190	ARTACENT AC 1 SQ CM	BR
Q4191	RESTORIGIN 1 SQ CM	BR
Q4192	RESTORIGIN, 1 CC	BR
Q4193	COLL-E-DERM 1 SQ CM	BR
Q4194	NOVACHOR 1 SQ CM	BR
Q4195	PURAPLY 1 SQ CM	BR	171.51
Q4196	PURAPLY AM 1 SQ CM	BR	171.51
Q4197	PURAPLY XT 1 SQ CM	BR
Q4198	GENESIS AMNIO MEMBRANE 1SQCM	BR
Q4200	SKIN TE 1 SQ CM	BR
Q4201	MATRION 1 SQ CM	BR
Q4202	KEROXX (2.5G/CC), 1CC	BR
Q4203	DERMA-GIDE, 1 SQ CM	BR
Q4204	XWRAP 1 SQ CM	BR
Q5001	HOSPICE OR HOME HLTH IN HOME	See Home Health Rules
Q5002	HOSPICE/HOME HLTH IN ASST LV	See Home Health Rules
Q5003	HOSPICE IN LT/NON-SKILLED NF	See Home Health Rules
Q5004	HOSPICE IN SNF	See Home Health Rules
Q5005	HOSPICE, INPATIENT HOSPITAL	See Home Health Rules
Q5006	HOSPICE IN HOSPICE FACILITY	See Home Health Rules
Q5007	HOSPICE IN LTCH	See Home Health Rules
Q5008	HOSPICE IN INPATIENT PSYCH	See Home Health Rules
Q5009	HOSPICE/HOME HLTH, PLACE NOS	See Home Health Rules
Q5010	HOSPICE HOME CARE IN HOSPICE	See Home Health Rules
Q5101	INJECTION, ZARXIO	1.08	0.90
Q5103	INJECTION, INFLECTRA	BR	81.33
Q5104	INJECTION, RENFLEXIS	BR	87.90
Q5105	INJ RETACRIT ESRD ON DIALYSI	BR	1.61
Q5106	INJ RETACRIT NON-ESRD USE	BR	16.13
Q5107	INJ MVASI 10 MG	BR
Q5108	INJECTION, FULPHILA	BR	508.86
Q5109	INJECTION, IXIFI, 10 MG	BR
Q5110	NIVESTYM	BR	1.07
Q5111	INJECTION, UDENYCA 0.5 MG	BR
Q9950	INJ SULF HEXA LIPID MICROSPH	36.61	30.17
Q9951	LOCM >= 400 MG/ML IODINE, 1ML	BR
Q9953	INJ FE-BASED MR CONTRAST, 1ML	BR
Q9954	ORAL MR CONTRAST, 100 ML	BR
Q9955	INJ PERFLEXANE LIP MICROS, ML	BR
Q9956	INJ OCTAFLUOROPROPANE MIC, ML	38.65
Q9957	INJ PERFLUTREN LIP MICROS, ML	57.99
Q9958	HOCM <=149 MG/ML IODINE, 1ML	0.09
Q9959	HOCM 150-199MG/ML IODINE, 1ML	BR
Q9960	HOCM 200-249MG/ML IODINE, 1ML	0.21
Q9961	HOCM 250-299MG/ML IODINE, 1ML	0.22
Q9962	HOCM 300-349MG/ML IODINE, 1ML	BR
Q9963	HOCM 350-399MG/ML IODINE, 1ML	0.21
Q9964	HOCM>= 400MG/ML IODINE, 1ML	BR
Q9965	LOCM 100-199MG/ML IODINE, 1ML	0.97
Q9966	LOCM 200-299MG/ML IODINE, 1ML	0.19
Q9967	LOCM 300-399MG/ML IODINE, 1ML	0.14
Q9968	VISUALIZATION ADJUNCT	BR	6.06
Q9969	NON-HEU TC-99M ADD-ON/DOSE	BR	14.20
Q9982	FLUTEMETAMOL F18 DIAGNOSTIC	2695.22
Q9983	FLORBETABEN F18 DIAGNOSTIC	2580.81
Q9991	BUPRENORPH XR 100 MG OR LESS	BR	2378.22
Q9992	BUPRENORPHINE XR OVER 100 MG	BR	2378.22
R0070	TRANSPORT PORTABLE X-RAY	0.00
R0075	TRANSPORT PORT X-RAY MULTIPL	0.00
R0076	TRANSPORT PORTABLE EKG	0.00
S0012	BUTORPHANOL TARTRATE, NASAL	65.75
S0014	TACRINE HYDROCHLORIDE, 10 MG	2.31
S0017	INJECTION, AMINOCAPROIC ACID	44.01
S0020	INJECTION, BUPIVICAINE HYDRO	BR
S0021	INJECTION, CEFOPERAZONE SOD	BR
S0023	INJECTION, CIMETIDINE HYDROC	10.56
S0028	INJECTION, FAMOTIDINE, 20 MG	7.04
S0030	INJECTION, METRONIDAZOLE	13.21
S0032	INJECTION, NAFCILLIN SODIUM	87.10
S0034	INJECTION, OFLOXACIN, 400 MG	BR
S0039	INJECTION, SULFAMETHOXAZOLE	BR
S0040	INJECTION, TICARCILLIN DISOD	12.30
S0073	INJECTION, AZTREONAM, 500 MG	52.81
S0074	INJECTION, CEFOTETAN DISODIU	BR
S0077	INJECTION, CLINDAMYCIN PHOSP	13.21
S0078	INJECTION, FOSPHENYTOIN SODI	151.12
S0080	INJECTION, PENTAMIDINE ISETH	142.60
S0081	INJECTION, PIPERACILLIN SODI	1.54
S0088	IMATINIB 100 MG	BR
S0090	SILDENAFIL CITRATE, 25 MG	95.05
S0091	GRANISETRON 1MG	66.02
S0092	HYDROMORPHONE 250 MG	189.25
S0093	MORPHINE 500 MG	4.88
S0104	ZIDOVUDINE, ORAL, 100 MG	1.54
S0106	BUPROPION HCL SR 60 TABLETS	93.83
S0108	MERCAPTOPURINE 50 MG	3.08
S0109	METHADONE ORAL 5MG	0.54
S0117	TRETINOIN TOPICAL 5 G	BR
S0119	ONDANSETRON 4 MG	22.00
S0122	INJ MENOTROPINS 75 IU	161.60
S0126	INJ FOLLITROPIN ALFA 75 IU	1291.94
S0128	INJ FOLLITROPIN BETA 75 IU	1973.34
S0132	INJ GANIRELIX ACETAT 250 MCG	114.40
S0136	CLOZAPINE, 25 MG	1.16
S0137	DIDANOSINE, 25 MG	BR
S0138	FINASTERIDE, 5 MG	2.31
S0139	MINOXIDIL, 10 MG	0.77
S0140	SAQUINAVIR, 200 MG	1.54
S0142	COLISTIMETHATE INH SOL MG	BR
S0145	PEG INTERFERON ALFA-2A/180	BR
S0148	PEG INTERFERON ALFA-2B/10	BR
S0155	EPOPROSTENOL DILUTANT	BR
S0156	EXEMESTANE, 25 MG	7.31
S0157	BECAPLERMIN GEL 1%, 0.5 GM	15.00
S0160	DEXTROAMPHETAMINE	35.20
S0164	INJECTION PANTROPRAZOLE	15.85
S0166	INJ OLANZAPINE 2.5MG	5.00
S0169	CALCITROL	1.16
S0170	ANASTROZOLE 1 MG	11.44
S0171	BUMETANIDE 0.5 MG	4.10
S0172	CHLORAMBUCIL 2 MG	1.92
S0174	DOLASETRON 50 MG	44.60
S0175	FLUTAMIDE 125 MG	1.92
S0176	HYDROXYUREA 500 MG	1.16
S0177	LEVAMISOLE 50 MG	4.23
S0178	LOMUSTINE 10 MG	21.91
S0179	MEGESTROL 20 MG	0.38
S0182	PROCARBAZINE, ORAL	44.22
S0183	PROCHLORPERAZINE 5 MG	0.38
S0187	TAMOXIFEN 10 MG	1.92
S0189	TESTOSTERONE PELLET 75 MG	BR
S0190	MIFEPRISTONE, ORAL, 200 MG	132.05
S0191	MISOPROSTOL, ORAL, 200 MCG	7.04
S0194	VITAMIN SUP PL 100 CAPS	BR
S0197	PRENATAL VITAMINS 30 DAY	BR
S0199	MED ABORTION INC ALL EX DRUG	BR
S0201	PARTIAL HOSPITALIZATION SERV	BR
S0207	PARAMEDICINTERCEP NONHOSPALS	BR
S0208	PARAMED INTRCEPT NONVOL	BR
S0209	WC VAN MILEAGE PER MI	BR
S0215	NONEMERG TRANSP MILEAGE	BR
S0220	MEDICAL CONFERENCE BY PHYSIC	BR
S0221	MEDICAL CONFERENCE, 60 MIN	BR
S0250	COMP GERIATR ASSMT TEAM	BR
S0255	HOSPICE REFER VISIT NONMD	BR
S0257	END OF LIFE COUNSELING	BR
S0260	H&P FOR SURGERY	BR
S0265	GENETIC COUNSEL 15 MINS	BR
S0270	HOME STD CASE RATE 30 DAYS	BR
S0271	HOME HOSPICE CASE 30 DAYS	BR
S0272	HOME EPISODIC CASE 30 DAYS	BR
S0273	MD HOME VISIT OUTSIDE CAP	BR
S0274	NURSE PRACTR VISIT OUTS CAP	BR
S0280	MEDICAL HOME, INITIAL PLAN	BR
S0281	MEDICAL HOME, MAINTENANCE	BR
S0285	CNSLT BEFORE SCREEN COLONOSC	170.90
S0302	COMPLETED EPSDT	BR
S0310	HOSPITALIST VISIT	BR
S0311	COMP MGMT CARE COORD ADV ILL	BR
S0315	DISEASE MANAGEMENT PROGRAM	BR
S0316	FOLLOW-UP/REASSESSMENT	BR
S0317	DISEASE MGMT PER DIEM	BR
S0320	RN TELEPHONE CALLS TO DMP	BR
S0340	LIFESTYLE MOD 1ST STAGE	BR
S0341	LIFESTYLE MOD 2 OR 3 STAGE	BR
S0342	LIFESTYLE MOD 4TH STAGE	BR
S0353	CANCER TREATMENTPLAN INITIAL	BR
S0354	CANCER TREATMENT PLAN CHANGE	BR
S0390	ROUT FOOT CARE PER VISIT	BR
S0395	IMPRESSION CASTING FT	BR
S0400	GLOBAL ESWL KIDNEY	BR
S0500	DISPOS CONT LENS	BR
S0504	SINGL PRSCRP LENS	BR
S0506	BIFOC PRSCP LENS	BR
S0508	TRIFOC PRSCRP LENS	BR
S0510	NON-PRSCRP LENS	BR
S0512	DAILY CONT LENS	BR
S0514	COLOR CONT LENS	BR
S0515	SCLERAL LENS LIQUID BANDAGE	BR
S0516	SAFETY FRAMES	BR
S0518	SUNGLASS FRAMES	BR
S0580	POLYCARB LENS	BR
S0581	NONSTND LENS	BR
S0590	MISC INTEGRAL LENS SERV	BR
S0592	COMP CONT LENS EVAL	BR
S0595	NEW LENSES IN PTS OLD FRAME	BR
S0596	PHAKIC IOL REFRACTIVE ERROR	BR
S0601	SCREENING PROCTOSCOPY	BR
S0610	ANNUAL GYNECOLOGICAL EXAMINA	BR
S0612	ANNUAL GYNECOLOGICAL EXAMINA	BR
S0613	ANN BREAST EXAM	BR
S0618	AUDIOMETRY FOR HEARING AID	BR
S0620	ROUTINE OPHTHALMOLOGICAL EXA	BR
S0621	ROUTINE OPHTHALMOLOGICAL EXA	BR
S0622	PHYS EXAM FOR COLLEGE	BR
S0630	REMOVAL OF SUTURES	BR
S0800	LASER IN SITU KERATOMILEUSIS	BR
S0810	PHOTOREFRACTIVE KERATECTOMY	BR
S0812	PHOTOTHERAP KERATECT	BR
S1001	DELUXE ITEM	BR
S1002	CUSTOM ITEM	BR
S1015	IV TUBING EXTENSION SET	BR
S1016	NON-PVC INTRAVENOUS ADMINIST	BR
S1030	GLUC MONITOR PURCHASE	BR
S1031	GLUC MONITOR RENTAL	BR
S1034	ART PANCREAS SYSTEM	BR
S1035	ART PANCREAS INV DISP SENSOR	BR
S1036	ART PANCREAS EXT TRANSMITTER	BR
S1037	ART PANCREAS EXT RECEIVER	BR
S1040	CRANIAL REMOLDING ORTHOSIS	BR
S1090	MOMETASONE SINUS IMPLANT	BR
S2053	TRANSPLANTATION OF SMALL INT	BR
S2054	TRANSPLANTATION OF MULTIVISC	BR
S2055	HARVESTING OF DONOR MULTIVIS	BR
S2060	LOBAR LUNG TRANSPLANTATION	BR
S2061	DONOR LOBECTOMY (LUNG)	BR
S2065	SIMULT PANC KIDN TRANS	BR
S2066	BREAST GAP FLAP RECONST	BR
S2067	BREAST "STACKED" DIEP/GAP	BR
S2068	BREAST DIEP OR SIEA FLAP	BR
S2070	CYSTO LASER TX URETERAL CALC	BR
S2079	LAP ESOPHAGOMYOTOMY	BR
S2080	LAUP	BR
S2083	ADJUSTMENT GASTRIC BAND	BR
S2095	TRANSCATH EMBOLIZ MICROSPHER	BR
S2102	ISLET CELL TISSUE TRANSPLANT	BR
S2103	ADRENAL TISSUE TRANSPLANT	BR
S2107	ADOPTIVE IMMUNOTHERAPY	BR
S2112	KNEE ARTHROSCP HARV	BR
S2115	PERIACETABULAR OSTEOTOMY	BR
S2117	ARTHROEREISIS, SUBTALAR	BR
S2118	TOTAL HIP RESURFACING	BR
S2120	LOW DENSITY LIPOPROTEIN(LDL)	BR
S2140	CORD BLOOD HARVESTING	BR
S2142	CORD BLOOD-DERIVED STEM-CELL	BR
S2150	BMT HARV/TRANS PL 28 D PKG	BR
S2152	SOLID ORGAN TRANSPL PKG	BR
S2202	ECHOSCLEROTHERAPY	BR
S2205	MINIMALLY INVASIVE DIRECT CO	BR
S2206	MINIMALLY INVASIVE DIRECT CO	BR
S2207	MINIMALLY INVASIVE DIRECT CO	BR
S2208	MINIMALLY INVASIVE DIRECT CO	BR
S2209	MINIMALLY INVASIVE DIRECT CO	BR
S2225	MYRINGOTOMY LASER-ASSIST	BR
S2230	IMPLANT SEMI-IMP HEAR	BR
S2235	IMPLANT AUDITORY BRAIN IMP	BR
S2260	INDUCED ABORTION 17-24 WEEKS	BR
S2265	INDUCED ABORTION 25-28 WKS	BR
S2266	INDUCED ABORTION 29-31 WKS	BR
S2267	INDUCED ABORTION 32 OR MORE	BR
S2300	ARTHROSCOPY, SHOULDER, SURGI	BR
S2325	HIP CORE DECOMPRESSION	BR
S2340	CHEMODENERVATION OF ABDUCTOR	BR
S2341	CHEMODENERV ADDUCT VOCAL	BR
S2342	NASAL ENDOSCOP PO DEBRID	BR
S2348	DECOMPRESS DISC RF LUMBAR	BR
S2350	DISKECTOMY, ANTERIOR, WITH D	BR
S2351	DISKECTOMY, ANTERIOR, WITH D	BR
S2400	FETAL SURG CONGEN HERNIA	BR
S2401	FETAL SURG URIN TRAC OBSTR	BR
S2402	FETAL SURG CONG CYST MALF	BR
S2403	FETAL SURG PULMON SEQUEST	BR
S2404	FETAL SURG MYELOMENINGO	BR
S2405	FETAL SURG SACROCOC TERATOMA	BR
S2409	FETAL SURG NOC	BR
S2411	FETOSCOP LASER THER TTTS	BR
S2900	ROBOTIC SURGICAL SYSTEM	BR
S3000	BILAT DIL RETINAL EXAM	BR
S3005	EVAL SELF-ASSESS DEPRESSION	BR
S3600	STAT LAB	BR
S3601	STAT LAB HOME/NF	BR
S3620	NEWBORN METABOLIC SCREENING	BR
S3630	EOSINOPHIL BLOOD COUNT	BR
S3645	HIV-1 ANTIBODY TESTING OF OR	BR
S3650	SALIVA TEST, HORMONE LEVEL;	BR
S3652	SALIVA TEST, HORMONE LEVEL;	BR
S3655	ANTISPERM ANTIBODIES TEST	BR
S3708	GASTROINTESTINAL FAT ABSORPT	BR
S3722	DOSE OPTIMIZATION AUC - 5FU	BR
S3800	GENETIC TESTING ALS	BR
S3840	DNA ANALYSIS RET-ONCOGENE	BR
S3841	GENE TEST RETINOBLASTOMA	BR
S3842	GENE TEST HIPPEL-LINDAU	BR
S3844	DNA ANALYSIS DEAFNESS	BR
S3845	GENE TEST ALPHA-THALASSEMIA	BR
S3846	GENE TEST BETA-THALASSEMIA	BR
S3849	GENE TEST NIEMANN-PICK	BR
S3850	GENE TEST SICKLE CELL	BR
S3852	DNA ANALYSIS APOE ALZHEIMER	BR
S3853	GENE TEST MYO MUSCLR DYST	BR
S3854	GENE PROFILE PANEL BREAST	3323.01
S3861	GENETIC TEST BRUGADA	BR
S3865	COMP GENET TEST HYP CARDIOMY	BR
S3866	SPEC GENE TEST HYP CARDIOMY	BR
S3870	CGH TEST DEVELOPMENTAL DELAY	BR
S3900	SURFACE EMG	BR
S3902	BALLISTOCARDIOGRAM	BR
S3904	MASTERS TWO STEP	BR
S4005	INTERIM LABOR FACILITY GLOBA	BR
S4011	IVF PACKAGE	BR
S4013	COMPL GIFT CASE RATE	BR
S4014	COMPL ZIFT CASE RATE	BR
S4015	COMPLETE IVF NOS CASE RATE	BR
S4016	FROZEN IVF CASE RATE	BR
S4017	IVF CANC A STIM CASE RATE	BR
S4018	F EMB TRNS CANC CASE RATE	BR
S4020	IVF CANC A ASPIR CASE RATE	BR
S4021	IVF CANC P ASPIR CASE RATE	BR
S4022	ASST OOCYTE FERT CASE RATE	BR
S4023	INCOMPL DONOR EGG CASE RATE	BR
S4025	DONOR SERV IVF CASE RATE	BR
S4026	PROCURE DONOR SPERM	BR
S4027	STORE PREV FROZ EMBRYOS	BR
S4028	MICROSURG EPI SPERM ASP	BR
S4030	SPERM PROCURE INIT VISIT	BR
S4031	SPERM PROCURE SUBS VISIT	BR
S4035	STIMULATED IUI CASE RATE	BR
S4037	CRYO EMBRYO TRANSF CASE RATE	BR
S4040	MONIT STORE CRYO EMBRYO 30 D	BR
S4042	OVULATION MGMT PER CYCLE	BR
S4981	INSERT LEVONORGESTREL IUS	BR
S4989	CONTRACEPT IUD	BR
S4990	NICOTINE PATCH LEGEND	BR
S4991	NICOTINE PATCH NONLEGEND	BR
S4993	CONTRACEPTIVE PILLS FOR BC	BR
S4995	SMOKING CESSATION GUM	BR
S5000	PRESCRIPTION DRUG, GENERIC	BR
S5001	PRESCRIPTION DRUG, BRAND NAME	BR
S5010	5% DEXTROSE AND 0.45% SALINE	BR
S5012	5% DEXTROSE WITH POTASSIUM	BR
S5013	5%DEXTROSE/0.45%SALINE1000ML	BR
S5014	D5W/0.45NS W KCL AND MGS04	BR
S5035	HIT ROUTINE DEVICE MAINT	BR
S5036	HIT DEVICE REPAIR	BR
S5100	ADULT DAYCARE SERVICES 15MIN	BR
S5101	ADULT DAY CARE PER HALF DAY	BR
S5102	ADULT DAY CARE PER DIEM	BR
S5105	CENTERBASED DAY CARE PERDIEM	BR
S5108	HOMECARE TRAIN PT 15 MIN	BR
S5109	HOMECARE TRAIN PT SESSION	BR
S5110	FAMILY HOMECARE TRAINING 15M	BR
S5111	FAMILY HOMECARE TRAIN/SESSIO	BR
S5115	NONFAMILY HOMECARE TRAIN/15M	BR
S5116	NONFAMILY HC TRAIN/SESSION	BR
S5120	CHORE SERVICES PER 15 MIN	BR
S5121	CHORE SERVICES PER DIEM	BR
S5125	ATTENDANT CARE SERVICE /15M	BR
S5126	ATTENDANT CARE SERVICE /DIEM	BR
S5130	HOMAKER SERVICE NOS PER 15M	BR
S5131	HOMEMAKER SERVICE NOS /DIEM	BR
S5135	ADULT COMPANIONCARE PER 15M	BR
S5136	ADULT COMPANIONCARE PER DIEM	BR
S5140	ADULT FOSTER CARE PER DIEM	BR
S5141	ADULT FOSTER CARE PER MONTH	BR
S5145	CHILD FOSTERCARE TH PER DIEM	BR
S5146	THER FOSTERCARE CHILD /MONTH	BR
S5150	UNSKILLED RESPITE CARE /15M	See Home Health Rules
S5151	UNSKILLED RESPITECARE /DIEM	See Home Health Rules
S5160	EMER RESPONSE SYS INSTAL&TST	BR
S5161	EMER RSPNS SYS SERV PERMONTH	BR
S5162	EMER RSPNS SYSTEM PURCHASE	BR
S5165	HOME MODIFICATIONS PER SERV	BR
S5170	HOMEDELIVERED PREPARED MEAL	BR
S5175	LAUNDRY SERV, EXT, PROF, /ORDER	BR
S5180	HH RESPIRATORY THRPY IN EVAL	BR
S5181	HH RESPIRATORY THRPY NOS/DAY	BR
S5185	MED REMINDER SERV PER MONTH	BR
S5190	WELLNESS ASSESSMENT BY NONPH	BR
S5199	PERSONAL CARE ITEM NOS EACH	BR
S5497	HIT CATH CARE NOC	BR
S5498	HIT SIMPLE CATH CARE	BR
S5501	HIT COMPLEX CATH CARE	BR
S5502	HIT INTERIM CATH CARE	BR
S5517	HIT DECLOTTING KIT	BR
S5518	HIT CATH REPAIR KIT	BR
S5520	HIT PICC INSERT KIT	BR
S5521	HIT MIDLINE CATH INSERT KIT	BR
S5522	HIT PICC INSERT NO SUPP	BR
S5523	HIP MIDLINE CATH INSERT KIT	BR
S5550	INSULIN RAPID 5 U	BR
S5551	INSULIN MOST RAPID 5 U	BR
S5552	INSULIN INTERMED 5 U	BR
S5553	INSULIN LONG ACTING 5 U	BR
S5560	INSULIN REUSE PEN 1.5 ML	BR
S5561	INSULIN REUSE PEN 3 ML	BR
S5565	INSULIN CARTRIDGE 150 U	BR
S5566	INSULIN CARTRIDGE 300 U	BR
S5570	INSULIN DISPOS PEN 1.5 ML	BR
S5571	INSULIN DISPOS PEN 3 ML	BR
S8030	TANTALUM RING APPLICATION	BR
S8035	MAGNETIC SOURCE IMAGING	BR
S8037	MRCP	BR
S8040	TOPOGRAPHIC BRAIN MAPPING	BR
S8042	MRI LOW FIELD	BR
S8055	US GUIDANCE FETAL REDUCT	BR
S8080	SCINTIMAMMOGRAPHY	BR
S8085	FLUORINE-18 FLUORODEOXYGLUCO	BR
S8092	ELECTRON BEAM COMPUTED TOMOG	BR
S8096	PORTABLE PEAK FLOW METER	BR
S8097	ASTHMA KIT	BR
S8100	SPACER WITHOUT MASK	BR
S8101	SPACER WITH MASK	BR
S8110	PEAK EXPIRATORY FLOW RATE (P	BR
S8120	O2 CONTENTS GAS CUBIC FT	BR
S8121	O2 CONTENTS LIQUID LB	BR
S8130	INTERFERENTIAL STIM 2 CHAN	BR
S8131	INTERFERENTIAL STIM 4 CHAN	BR
S8185	FLUTTER DEVICE	BR
S8186	SWIVEL ADAPTOR	BR
S8189	TRACH SUPPLY NOC	BR
S8210	MUCUS TRAP	BR
S8265	HABERMAN FEEDER	BR
S8270	ENURESIS ALARM	BR
S8301	INFECT CONTROL SUPPLIES NOS	BR
S8415	SUPPLIES FOR HOME DELIVERY	BR
S8420	CUSTOM GRADIENT SLEEV/GLOV	BR
S8421	READY GRADIENT SLEEV/GLOV	BR
S8422	CUSTOM GRAD SLEEVE MED	BR
S8423	CUSTOM GRAD SLEEVE HEAVY	BR
S8424	READY GRADIENT SLEEVE	BR
S8425	CUSTOM GRAD GLOVE MED	BR
S8426	CUSTOM GRAD GLOVE HEAVY	BR
S8427	READY GRADIENT GLOVE	BR
S8428	READY GRADIENT GAUNTLET	BR
S8429	GRADIENT PRESSURE WRAP	BR
S8430	PADDING FOR COMPRSSN BDG	BR
S8431	COMPRESSION BANDAGE	BR
S8450	SPLINT DIGIT	BR
S8451	SPLINT WRIST OR ANKLE	BR
S8452	SPLINT ELBOW	BR
S8460	CAMISOLE POST-MAST	BR
S8490	100 INSULIN SYRINGES	BR
S8930	AURICULAR ELECTROSTIMULATION	BR
S8940	HIPPOTHERAPY PER SESSION	BR
S8948	LOW-LEVEL LASER TRMT 15 MIN	BR
S8950	COMPLEX LYMPHEDEMA THERAPY,	BR
S8990	PT OR MANIP FOR MAINT	BR
S8999	RESUSCITATION BAG	BR
S9001	HOME UTERINE MONITOR WITH OR	BR
S9007	ULTRAFILTRATION MONITOR	BR
S9024	PARANASAL SINUS ULTRASOUND	BR
S9025	OMNICARDIOGRAM/CARDIOINTEGRA	BR
S9034	ESWL FOR GALLSTONES	BR
S9055	PROCUREN OR OTHER GROWTH FAC	BR
S9056	COMA STIMULATION PER DIEM	BR
S9061	MEDICAL SUPPLIES AND EQUIPME	BR
S9083	URGENT CARE CENTER GLOBAL	BR
S9088	SERVICES PROVIDED IN URGENT	BR
S9090	VERTEBRAL AXIAL DECOMPRESSIO	BR
S9097	HOME VISIT WOUND CARE	BR
S9098	HOME PHOTOTHERAPY VISIT	BR
S9110	TELEMONITORING/HOME PER MNTH	BR
S9117	BACK SCHOOL VISIT	BR
S9122	HOME HEALTH AIDE OR CERTIFIE	55.00
S9123	NURSING CARE IN HOME RN	125.00
S9124	NURSING CARE, IN THE HOME; B	BR
S9125	RESPITE CARE, IN THE HOME, P	See Home Health Rules
S9126	HOSPICE CARE, IN THE HOME, P	See Home Health Rules
S9127	SOCIAL WORK VISIT, IN THE HO	125.00
S9128	SPEECH THERAPY, IN THE HOME,	125.00
S9129	OCCUPATIONAL THERAPY, IN THE	125.00
S9131	PT IN THE HOME PER DIEM	125.00
S9140	DIABETIC MANAGEMENT PROGRAM,	BR
S9141	DIABETIC MANAGEMENT PROGRAM,	BR
S9145	INSULIN PUMP INITIATION	BR
S9150	EVALUATION BY OCULARIST	BR
S9152	SPEECH THERAPY, RE-EVAL	BR
S9208	HOME MGMT PRETERM LABOR	BR
S9209	HOME MGMT PPROM	BR
S9211	HOME MGMT GEST HYPERTENSION	BR
S9212	HM POSTPAR HYPER PER DIEM	BR
S9213	HM PREECLAMP PER DIEM	BR
S9214	HM GEST DM PER DIEM	BR
S9325	HIT PAIN MGMT PER DIEM	BR
S9326	HIT CONT PAIN PER DIEM	BR
S9327	HIT INT PAIN PER DIEM	BR
S9328	HIT PAIN IMP PUMP DIEM	BR
S9329	HIT CHEMO PER DIEM	BR
S9330	HIT CONT CHEM DIEM	BR
S9331	HIT INTERMIT CHEMO DIEM	BR
S9335	HT HEMODIALYSIS DIEM	BR
S9336	HIT CONT ANTICOAG DIEM	BR
S9338	HIT IMMUNOTHERAPY DIEM	BR
S9339	HIT PERITON DIALYSIS DIEM	BR
S9340	HIT ENTERAL PER DIEM	BR
S9341	HIT ENTERAL GRAV DIEM	BR
S9342	HIT ENTERAL PUMP DIEM	BR
S9343	HIT ENTERAL BOLUS NURS	BR
S9345	HIT ANTI-HEMOPHIL DIEM	BR
S9346	HIT ALPHA-1-PROTEINAS DIEM	BR
S9347	HIT LONGTERM INFUSION DIEM	BR
S9348	HIT SYMPATHOMIM DIEM	BR
S9349	HIT TOCOLYSIS DIEM	BR
S9351	HIT CONT ANTIEMETIC DIEM	BR
S9353	HIT CONT INSULIN DIEM	BR
S9355	HIT CHELATION DIEM	BR
S9357	HIT ENZYME REPLACE DIEM	BR
S9359	HIT ANTI-TNF PER DIEM	BR
S9361	HIT DIURETIC INFUS DIEM	BR
S9363	HIT ANTI-SPASMOTIC DIEM	BR
S9364	HIT TPN TOTAL DIEM	BR
S9365	HIT TPN 1 LITER DIEM	BR
S9366	HIT TPN 2 LITER DIEM	BR
S9367	HIT TPN 3 LITER DIEM	BR
S9368	HIT TPN OVER 3L DIEM	BR
S9370	HT INJ ANTIEMETIC DIEM	BR
S9372	HT INJ ANTICOAG DIEM	BR
S9373	HIT HYDRA TOTAL DIEM	BR
S9374	HIT HYDRA 1 LITER DIEM	BR
S9375	HIT HYDRA 2 LITER DIEM	BR
S9376	HIT HYDRA 3 LITER DIEM	BR
S9377	HIT HYDRA OVER 3L DIEM	BR
S9379	HIT NOC PER DIEM	BR
S9381	HIT HIGH RISK/ESCORT	BR
S9401	ANTICOAG CLINIC PER SESSION	BR
S9430	PHARMACY COMP/DISP SERV	see page 75
S9433	MEDICAL FOOD ORAL 100% NUTR	BR
S9434	MOD SOLID FOOD SUPPL	BR
S9435	MEDICAL FOODS FOR INBORN ERR	BR
S9436	LAMAZE CLASS	BR
S9437	CHILDBIRTH REFRESHER CLASS	BR
S9438	CESAREAN BIRTH CLASS	BR
S9439	VBAC CLASS	BR
S9441	ASTHMA EDUCATION	BR
S9442	BIRTHING CLASS	BR
S9443	LACTATION CLASS	BR
S9444	PARENTING CLASS	BR
S9445	PT EDUCATION NOC INDIVID	BR
S9446	PT EDUCATION NOC GROUP	BR
S9447	INFANT SAFETY CLASS	BR
S9449	WEIGHT MGMT CLASS	BR
S9451	EXERCISE CLASS	BR
S9452	NUTRITION CLASS	BR
S9453	SMOKING CESSATION CLASS	BR
S9454	STRESS MGMT CLASS	BR
S9455	DIABETIC MANAGEMENT PROGRAM,	BR
S9460	DIABETIC MANAGEMENT PROGRAM,	BR
S9465	DIABETIC MANAGEMENT PROGRAM,	BR
S9470	NUTRITIONAL COUNSELING, DIET	BR
S9472	CARDIAC REHABILITATION PROGR	BR
S9473	PULMONARY REHABILITATION PRO	BR
S9474	ENTEROSTOMAL THERAPY BY A RE	BR
S9475	AMBULATORY SETTING SUBSTANCE	BR
S9476	VESTIBULAR REHAB PER DIEM	BR
S9480	INTENSIVE OUTPATIENT PSYCHIA	BR
S9482	FAMILY STABILIZATION 15 MIN	BR
S9484	CRISIS INTERVENTION PER HOUR	BR
S9485	CRISIS INTERVENTION MENTAL H	BR
S9490	HIT CORTICOSTEROID/DIEM	BR
S9494	HIT ANTIBIOTIC TOTAL DIEM	BR
S9497	HIT ANTIBIOTIC Q3H DIEM	BR
S9500	HIT ANTIBIOTIC Q24H DIEM	BR
S9501	HIT ANTIBIOTIC Q12H DIEM	BR
S9502	HIT ANTIBIOTIC Q8H DIEM	BR
S9503	HIT ANTIBIOTIC Q6H DIEM	BR
S9504	HIT ANTIBIOTIC Q4H DIEM	BR
S9529	VENIPUNCTURE HOME/SNF	BR
S9537	HT HEM HORM INJ DIEM	BR
S9538	HIT BLOOD PRODUCTS DIEM	BR
S9542	HT INJ NOC PER DIEM	BR
S9558	HT INJ GROWTH HORM DIEM	BR
S9559	HIT INJ INTERFERON DIEM	BR
S9560	HT INJ HORMONE DIEM	BR
S9562	HT INJ PALIVIZUMAB DIEM	BR
S9590	HT IRRIGATION DIEM	BR
S9810	HT PHARM PER HOUR	BR
S9900	CHRISTIAN SCI PRACT VISIT	BR
S9901	CHRISTIAN SCI NURSE VISIT	BR
S9960	AIR AMBULANC NONEMERG FIXED	BR
S9961	AIR AMBULAN NONEMERG ROTARY	BR
S9970	HEALTH CLUB MEMBERSHIP YR	BR
S9975	TRANSPLANT RELATED PER DIEM	BR
S9976	LODGING PER DIEM	BR
S9977	MEALS PER DIEM	BR
S9981	MED RECORD COPY ADMIN	BR
S9982	MED RECORD COPY PER PAGE	BR
S9986	NOT MEDICALLY NECESSARY SVC	BR
S9988	SERV PART OF PHASE I TRIAL	BR
S9989	SERVICES OUTSIDE US	BR
S9990	SERVICES PROVIDED AS PART OF	BR
S9991	SERVICES PROVIDED AS PART OF	BR
S9992	TRANSPORTATION COSTS TO AND	BR
S9994	LODGING COSTS (E.G. HOTEL CH	BR
S9996	MEALS FOR CLINICAL TRIAL PAR	BR
S9999	SALES TAX	BR
V2020	VISION SVCS FRAMES PURCHASES	87.69
V2025	EYEGLASSES DELUX FRAMES	BR
V2100	LENS SPHER SINGLE PLANO 4.00	42.63
V2101	SINGLE VISN SPHERE 4.12-7.00	44.91
V2102	SINGL VISN SPHERE 7.12-20.00	63.69
V2103	SPHEROCYLINDR 4.00D/12-2.00D	37.00
V2104	SPHEROCYLINDR 4.00D/2.12-4D	40.99
V2105	SPHEROCYLINDER 4.00D/4.25-6D	50.18
V2106	SPHEROCYLINDER 4.00D/>6.00D	50.92
V2107	SPHEROCYLINDER 4.25D/12-2D	53.52
V2108	SPHEROCYLINDER 4.25D/2.12-4D	51.91
V2109	SPHEROCYLINDER 4.25D/4.25-6D	59.66
V2110	SPHEROCYLINDER 4.25D/OVER 6D	69.64
V2111	SPHEROCYLINDR 7.25D/.25-2.25	61.38
V2112	SPHEROCYLINDR 7.25D/2.25-4D	60.58
V2113	SPHEROCYLINDR 7.25D/4.25-6D	83.69
V2114	SPHEROCYLINDER OVER 12.00D	74.02
V2115	LENS LENTICULAR BIFOCAL	80.48
V2118	LENS ANISEIKONIC SINGLE	79.78
V2121	LENTICULAR LENS, SINGLE	82.37
V2199	LENS SINGLE VISION NOT OTH C	BR
V2200	LENS SPHER BIFOC PLANO 4.00D	55.78
V2201	LENS SPHERE BIFOCAL 4.12-7.0	60.79
V2202	LENS SPHERE BIFOCAL 7.12-20.	71.53
V2203	LENS SPHCYL BIFOCAL 4.00D/.1	56.28
V2204	LENS SPHCY BIFOCAL 4.00D/2.1	61.02
V2205	LENS SPHCY BIFOCAL 4.00D/4.2	66.95
V2206	LENS SPHCY BIFOCAL 4.00D/OVE	81.51
V2207	LENS SPHCY BIFOCAL 4.25-7D/.	68.04
V2208	LENS SPHCY BIFOCAL 4.25-7/2.	68.87
V2209	LENS SPHCY BIFOCAL 4.25-7/4.	75.75
V2210	LENS SPHCY BIFOCAL 4.25-7/OV	97.46
V2211	LENS SPHCY BIFO 7.25-12/.25-	83.11
V2212	LENS SPHCYL BIFO 7.25-12/2.2	90.43
V2213	LENS SPHCYL BIFO 7.25-12/4.2	92.74
V2214	LENS SPHCYL BIFOCAL OVER 12.	99.41
V2215	LENS LENTICULAR BIFOCAL	107.57
V2218	LENS ANISEIKONIC BIFOCAL	110.06
V2219	LENS BIFOCAL SEG WIDTH OVER	48.44
V2220	LENS BIFOCAL ADD OVER 3.25D	39.29
V2221	LENTICULAR LENS, BIFOCAL	104.96
V2299	LENS BIFOCAL SPECIALITY	BR
V2300	LENS SPHERE TRIFOCAL 4.00D	72.44
V2301	LENS SPHERE TRIFOCAL 4.12-7.	84.01
V2302	LENS SPHERE TRIFOCAL 7.12-20	92.03
V2303	LENS SPHCY TRIFOCAL 4.0/.12-	76.25
V2304	LENS SPHCY TRIFOCAL 4.0/2.25	79.78
V2305	LENS SPHCY TRIFOCAL 4.0/4.25	97.85
V2306	LENS SPHCYL TRIFOCAL 4.00/>6	91.22
V2307	LENS SPHCY TRIFOCAL 4.25-7/.	90.45
V2308	LENS SPHC TRIFOCAL 4.25-7/2.	96.53
V2309	LENS SPHC TRIFOCAL 4.25-7/4.	112.93
V2310	LENS SPHC TRIFOCAL 4.25-7/>6	124.22
V2311	LENS SPHC TRIFO 7.25-12/.25-	118.29
V2312	LENS SPHC TRIFO 7.25-12/2.25	104.28
V2313	LENS SPHC TRIFO 7.25-12/4.25	142.34
V2314	LENS SPHCYL TRIFOCAL OVER 12	155.91
V2315	LENS LENTICULAR TRIFOCAL	173.10
V2318	LENS ANISEIKONIC TRIFOCAL	159.60
V2319	LENS TRIFOCAL SEG WIDTH > 28	54.03
V2320	LENS TRIFOCAL ADD OVER 3.25D	57.00
V2321	LENTICULAR LENS, TRIFOCAL	170.61
V2399	LENS TRIFOCAL SPECIALITY	BR
V2410	LENS VARIAB ASPHERICITY SING	97.56
V2430	LENS VARIABLE ASPHERICITY BI	127.01
V2499	VARIABLE ASPHERICITY LENS	BR
V2500	CONTACT LENS PMMA SPHERICAL	88.43
V2501	CNTCT LENS PMMA-TORIC/PRISM	134.71
V2502	CONTACT LENS PMMA BIFOCAL	165.95
V2503	CNTCT LENS PMMA COLOR VISION	158.79
V2510	CNTCT GAS PERMEABLE SPHERICL	120.71
V2511	CNTCT TORIC PRISM BALLAST	173.45
V2512	CNTCT LENS GAS PERMBL BIFOCL	204.95
V2513	CONTACT LENS EXTENDED WEAR	172.06
V2520	CONTACT LENS HYDROPHILIC	113.47
V2521	CNTCT LENS HYDROPHILIC TORIC	197.55
V2522	CNTCT LENS HYDROPHIL BIFOCL	192.25
V2523	CNTCT LENS HYDROPHIL EXTEND	163.83
V2530	CONTACT LENS GAS IMPERMEABLE	242.66
V2531	CONTACT LENS GAS PERMEABLE	595.73
V2599	CONTACT LENS/ES OTHER TYPE	BR
V2600	HAND HELD LOW VISION AIDS	BR
V2610	SINGLE LENS SPECTACLE MOUNT	BR
V2615	TELESCOP/OTHR COMPOUND LENS	BR
V2623	PLASTIC EYE PROSTH CUSTOM	976.61
V2624	POLISHING ARTIFICAL EYE	66.23
V2625	ENLARGEMNT OF EYE PROSTHESIS	429.02
V2626	REDUCTION OF EYE PROSTHESIS	272.18
V2627	SCLERAL COVER SHELL	1558.28
V2628	FABRICATION & FITTING	356.28
V2629	PROSTHETIC EYE OTHER TYPE	BR
V2630	ANTER CHAMBER INTRAOCUL LENS	129.50
V2631	IRIS SUPPORT INTRAOCLR LENS	129.50
V2632	POST CHMBR INTRAOCULAR LENS	129.50
V2700	BALANCE LENS	47.66
V2702	DELUXE LENS FEATURE	BR
V2710	GLASS/PLASTIC SLAB OFF PRISM	69.76
V2715	PRISM LENS/ES	12.65
V2718	FRESNELL PRISM PRESS-ON LENS	31.06
V2730	SPECIAL BASE CURVE	22.95
V2744	TINT PHOTOCHROMATIC LENS/ES	23.79
V2745	TINT, ANY COLOR/SOLID/GRAD	13.50
V2750	ANTI-REFLECTIVE COATING	27.69
V2755	UV LENS/ES	20.01
V2756	EYE GLASS CASE	BR
V2760	SCRATCH RESISTANT COATING	17.42
V2761	MIRROR COATING	47.89
V2762	POLARIZATION, ANY LENS	65.59
V2770	OCCLUDER LENS/ES	22.51
V2780	OVERSIZE LENS/ES	18.18
V2781	PROGRESSIVE LENS PER LENS	BR
V2782	LENS, 1.54-1.65 P/1.60-1.79G	70.82
V2783	LENS, >= 1.66 P/>=1.80 G	79.86
V2784	LENS POLYCARB OR EQUAL	51.93
V2785	CORNEAL TISSUE PROCESSING	BR
V2786	OCCUPATIONAL MULTIFOCAL LENS	BR
V2787	ASTIGMATISM-CORRECT FUNCTION	BR
V2788	PRESBYOPIA-CORRECT FUNCTION	BR
V2790	AMNIOTIC MEMBRANE	BR
V2797	VIS ITEM/SVC IN OTHER CODE	BR
V2799	MISC VISION ITEM OR SERVICE	BR
V5008	HEARING SCREENING	49.70
V5010	ASSESSMENT FOR HEARING AID	91.94
V5011	HEARING AID FITTING/CHECKING	165.70
V5014	HEARING AID REPAIR/MODIFYING	159.58
V5020	CONFORMITY EVALUATION	106.40
V5030	BODY-WORN HEARING AID AIR	1277.15
V5040	BODY-WORN HEARING AID BONE	627.72
V5050	HEARING AID MONAURAL IN EAR	1596.10
V5060	BEHIND EAR HEARING AID	2389.21
V5070	GLASSES AIR CONDUCTION	337.01
V5080	GLASSES BONE CONDUCTION	846.75
V5090	HEARING AID DISPENSING FEE	292.69
V5095	IMPLANT MID EAR HEARING PROS	BR
V5100	BODY-WORN BILAT HEARING AID	1436.20
V5110	HEARING AID DISPENSING FEE	532.01
V5120	BODY-WORN BINAUR HEARING AID	1754.26
V5130	IN EAR BINAURAL HEARING AID	3192.41
V5140	BEHIND EAR BINAUR HEARING AI	4363.17
V5150	GLASSES BINAURAL HEARING AID	1402.80
V5160	DISPENSING FEE BINAURAL	638.47
V5171	HEARING AID MONAURAL ITE	BR
V5172	HEARING AID MONAURAL ITC	BR
V5181	HEARING AID MONAURAL BTE	BR
V5190	HEARING AID MONAURAL GLASSES	965.13
V5200	DISP FEE CONTRALATERAL MONAU	425.63
V5211	HEARING AID BINAURAL ITE/ITE	BR
V5212	HEARING AID BINAURAL ITE/ITC	BR
V5213	HEARING AID BINAURAL ITE/BTE	BR
V5214	HEARING AID BINAURAL ITC/ITC	BR
V5215	HEARING AID BINAURAL ITC/BTE	BR
V5221	HEARING AID BINAURAL BTE/BTE	BR
V5230	HEARING AID BINAURAL GLASSES	1052.90
V5240	DISP FEE CONTRALATERAL BINAU	691.68
V5241	DISPENSING FEE, MONAURAL	BR
V5242	HEARING AID, MONAURAL, CIC	BR
V5243	HEARING AID, MONAURAL, ITC	BR
V5244	HEARING AID, PROG, MON, CIC	BR
V5245	HEARING AID, PROG, MON, ITC	BR
V5246	HEARING AID, PROG, MON, ITE	BR
V5247	HEARING AID, PROG, MON, BTE	BR
V5248	HEARING AID, BINAURAL, CIC	BR
V5249	HEARING AID, BINAURAL, ITC	BR
V5250	HEARING AID, PROG, BIN, CIC	BR
V5251	HEARING AID, PROG, BIN, ITC	BR
V5252	HEARING AID, PROG, BIN, ITE	BR
V5253	HEARING AID, PROG, BIN, BTE	BR
V5254	HEARING ID, DIGIT, MON, CIC	BR
V5255	HEARING AID, DIGIT, MON, ITC	BR
V5256	HEARING AID, DIGIT, MON, ITE	BR
V5257	HEARING AID, DIGIT, MON, BTE	BR
V5258	HEARING AID, DIGIT, BIN, CIC	BR
V5259	HEARING AID, DIGIT, BIN, ITC	BR
V5260	HEARING AID, DIGIT, BIN, ITE	BR
V5261	HEARING AID, DIGIT, BIN, BTE	BR
V5262	HEARING AID, DISP, MONAURAL	BR
V5263	HEARING AID, DISP, BINAURAL	BR
V5264	EAR MOLD/INSERT	BR
V5265	EAR MOLD/INSERT, DISP	BR
V5266	BATTERY FOR HEARING DEVICE	BR
V5267	HEARING AID SUP/ACCESS/DEV	BR
V5268	ALD TELEPHONE AMPLIFIER	BR
V5269	ALERTING DEVICE, ANY TYPE	BR
V5270	ALD, TV AMPLIFIER, ANY TYPE	BR
V5271	ALD, TV CAPTION DECODER	BR
V5272	TDD	BR
V5273	ALD FOR COCHLEAR IMPLANT	BR
V5274	ALD UNSPECIFIED	BR
V5275	EAR IMPRESSION	BR
V5281	ALD FM/DM SYSTEM, MONAURAL	BR
V5282	ALD FM/DM SYSTEM BINAURAL	BR
V5283	ALD NECK, LOOP IND RECEIVER	BR
V5284	ALD FM/DM EAR LEVEL RECEIVER	BR
V5285	ALD FM/DM AUD INPUT RECEIVER	BR
V5286	ALD BLU TOOTH FM/DM RECEIVER	BR
V5287	ALD FM/DM RECEIVER, NOS	BR
V5288	ALD FM/DM TRANSMITTER ALD	BR
V5289	ALD FM/DM ADAPT/BOOT COUPLIN	BR
V5290	ALD TRANSMITTER MICROPHONE	BR
V5298	HEARING AID NOC	BR
V5299	HEARING SERVICE	BR
V5336	REPAIR COMMUNICATION DEVICE	BR
V5362	SPEECH SCREENING	BR
V5363	LANGUAGE SCREENING	BR
V5364	DYSPHAGIA SCREENING	BR

20 Miss. Code. R. 2-II

Amended 6/14/2017

Amended 6/15/2019.