N.J. Admin. Code § 10:59-2.3

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:59-2.3 - HCPCS procedure codes and maximum fee allowance schedule for medical supplies and durable medical equipment

HCPCS	Maximum Fee
Code	Description	Allowance
A4206	Syringe with needle, sterile 1cc	B.R.
A4207	Syringe with needle, sterile 2cc	B.R.
A4208	Syringe with needle, sterile 3cc	B.R.
A4209	Syringe with needle, sterile 5cc or greater	B.R.
A4210	Needle-free injection device	B.R.
A4211	Supplies for self-administered injections	B.R.
A4212	Huber-type needle, each	B.R.
A4213	Syringe, sterile, 20cc or greater	B.R.
A4214	Sterile saline or water, 30 cc vial	0.81/vial
A4215	Needles only, sterile, any size	B.R.
A4217	Sterile water/saline, 500 ml	2.50
A4230	Infusion set for external insulin pump,	B.R.
non-needle, cannula type
A4231	Infusion set for external insulin pump,	B.R.
needle type
A4232	Syringe with needle for external insulin	B.R.
pump, sterile 3 cc
A4244	Alcohol or peroxide, per pint	B.R.
A4245	Alcohol wipes, per box	B.R.
A4246	Betadine or Phisohex solution, per pint	B.R.
A4247	Betadine or iodine swabs/wipes, per box	B.R.
A4250	Urine test or reagent strips or tablets	B.R.
(100 tablets or strips)
A4253	Blood glucose test or reagent strips	B.R.
for home blood glucomitor, per 50 strips
A4256	Normal, low and high calibrator	B.R.
solution/chips
A4258	Spring powered device for lancet, each	B.R.
A4259	Lancets, per box	B.R.
A4265	Paraffin	B.R.
A4300	Implantable vascular access portal/catheter	B.R.
(venous, arterial, epidural or peritoneal)
A4305	Disposable drug delivery system, flow rate	B.R.
of 50 ml or greater per hour
A4306	Disposable drug delivery system, flow rate	B.R.
of 5 ml or less per hour
A4310	Insertion tray without drainage bag and	6.61
without catheter (accessories only)
A4311	Insertion tray without drainage bag with	8.34
indwelling catheter, foley type, two-way
latex with coating (teflon, silicone,
silicone elastomer or hydrophilic, etc.)
A4312	Insertion tray without drainage bag with	8.34
indwelling catheter, foley type, two-way,
all silicone
A4313	Insertion tray without drainage bag with	8.34
indwelling catheter, foley type, three-way,
for continuous irrigation
A4314	Insertion tray with drainage bag with	15.46
indwelling catheter, foley type, two-way
latex with coating (teflon, silicone,
silicone elastomer or hydrophilic, etc.)
A4315	Insertion tray with drainage bag	15.46
within dwelling catheter, foley type,
two-way,all silicone
A4316	Insertion tray with drainage bag with	15.46
indwelling catheter, foley type, three-way,
for continuous irrigation
A4320	Irrigation tray for bladder irrigation	5.00
with bulb or piston syringe
A4322	Irrigation syringe, bulb or piston	2.50
A4326	Male external catheter; specialty type	B.R.
(for example, inflatable or faceplate, each)
A4327	Female external urinary collection device;	B.R.
metal cup, each
A4328	Female external urinary collection device;	10.00
pouch
A4330	Perianal fecal collection pouch with	B.R.
adhesive
A4331	Extension drainage tubing, any type, any	2.54
length, with connector/adaptor, for use
with urinary leg bag or urostomy pouch, each
A4332	Lubricant, individual sterile packet, each	0.10
A4333	Urinary catheter anchoring device, adhesive	B.R.
skin attachment, each
A4334	Urinary catheter anchoring device, leg	3.94
strap, each
A4335	Incontinence supply; miscellaneous	B.R.
A4338	Indwelling catheter; foley type, two-way	8.14
latex with coating (such as teflon,
silicone, silicone elastomer, or hydrophilic)
A4340	Indwelling catheter; specialty type,	10.00
(such as coude, mushroom or wing)
A4344	Indwelling catheter, foley type, two-way,	15.52
all silicone
A4346	Indwelling catheter, foley type, three-way	15.00
for continuous irrigation
A4347	Male external catheter with or without	17.29
adhesive, with or without anti-reflux
device; per dozen
A4349	Male external catheter with integral	B.R.
collection compartment, extended wear,
each, (for example, two per month)
A4351	Intermittent urinary catheter; straight tip	5.00
A4352	Intermittent urinary catheter; coude	5.00
(curved) tip
A4354	Insertion tray with drainage bag,	9.00
without catheter
A4355	Irrigation tubing set for continuous bladder	6.86
irrigation through a three-way indwelling
foley catheter
A4356	External urethral clamp or compression	37.03
device (not to be used for catheter clamp)
A4357	Bedside drainage bag, day or night,	7.94
with or without anti-reflux device, with
or without tube
A4358	Urinary leg bag; vinyl, with or without	7.12
tube
A4359	Urinary suspensory without leg bag	27.00
A4361	Ostomy face plate	6.20
A4362	Skin barrier; solid, 4" x 4" or equivalent;	5.03
each
A4364	Adhesive for ostomy or catheter; liquid	4.58
paste; any composition (for example,
silicone, latex); per oz.
A4367	Ostomy belt	6.86
A4369	Ostomy skin barrier, liquid (spray, brush,	1.94
etc.), per oz.
A4371	Ostomy skin barrier, powder, per oz.	2.92
A4372	Ostomy skin barrier, solid 4 x 4 inches or	B.R.
equivalent, with built-in convexity, each
A4373	Ostomy skin barrier, with flange (solid,	B.R.
flexible or accordion), with built-in
convexity, any size, each
A4397	Irrigation supplies; sleeve	4.50
A4398	Irrigation supplies; bag	2.25
A4399	Irrigation supplies; cone/catheter	11.25
A4400	Ostomy irrigation set	24.61
A4402	Lubricant	1.08
A4404	Ostomy rings	1.22
A4405	Ostomy skin barrier, non-pectin based,	2.72
paste, per ounce
A4406	Ostomy skin barrier, pectin-based, paste,	4.59
per ounce
A4407	Ostomy skin barrier, with flange (solid,	B.R.
flexible, or accordion), extended wear,
with built-in convexity, 4 x 4 inches or
smaller, each
A4408	Ostomy skin barrier, with flange (solid,	B.R.
flexible or accordion), extended wear,
with built-in convexity, larger than 4 x 4
inches, each
A4409	Ostomy skin barrier, with flange (solid,	B.R.
flexible or accordion), extended wear,
without built-in convexity, 4 x 4 inches or
smaller, each
A4410	Ostomy skin barrier, with flange (solid,	B.R.
flexible or accordion), extended wear,
without built-in convexity, larger than
4 x 4 inches, each
A4414	Ostomy skin barrier, with flange (solid,	B.R.
flexible or accordion), without built-in
convexity, 4 x 4 inches or smaller, each
A4415	Ostomy skin barrier, with flange (solid,	B.R.
flexible or accordion), without built-in
convexity, larger than 4 x 4 inches, each
A4421	Not otherwise classified ostomy supplies;	B.R.
ureterostomy supplies
A4450	Tape, non-waterproof, per 18 square inches	0.07
A4452	Tape, waterproof, per 18 square inches	0.29
A4455	Adhesive remover or solvent (for tape,	B.R.
cement or other adhesive)
A4465	Nonelastic binder for extremity	B.R.
A4470	Gravlee jet washer	B.R.
A4480	Vabra aspirator	B.R.
A4550	Surgical trays	B.R.
A4554	Disposable underpads, all sizes (for	0.31
example, Chux's), each
A4556	Electrodes (for example, apnea monitor)	B.R.
A4557	Lead wires (for example, apnea monitor)	B.R.
A4558	Conductive paste or gel	B.R.
A4560	Pessary	20.94
A4561	Pessary, rubber, any type	B.R.
A4562	Pessary, non rubber, any type	B.R.
A4565	Slings	B.R.
A4570	Splint	B.R.
A4575	Topical hyperbaric oxygen chamber,	B.R.
disposable
A4595	TENS supplies, 2 lead, per month	B.R.
A4611	Battery, heavy duty; replacement for	180.00
patient-owned ventilator
A4612	Battery cables; replacement for	44.00
patient-owned ventilator
A4613	Battery charger; replacement for	B.R.
patient-owned ventilator
A4614	Peak expiratory flow rate meter, hand held	B.R.
A4615	Cannula, nasal	7.50
A4616	Tubing (oxygen), per foot	B.R.
A4617	Mouthpiece	5.00
A4618	Breathing circuits	9.15
A4619	Face tent	10.00
A4620	Variable concentration mask	10.00
A4621	Tracheostomy mask or collar	10.17
A4622	Tracheostomy or laryngectomy tube	75.00
A4623	Tracheostomy, inner cannula	6.00
(replacement only)
A4624	Tracheal suction catheter, any type, each	2.00
A4625	Tracheostomy care or cleaning starter kit	8.00
A4626	Tracheostomy cleaning brush, each	3.00
A4627	Spacer, bag or reservoir, with or	B.R.
without mask, for use with metered
dose inhaler
A4628	Oropharyngeal suction catheter, each	B.R.
A4629	Tracheostomy care kit for established	B.R.
tracheostomy
A4630	Replacement batteries for medically	B.R.
necessary TENS, owned by patient
A4631	Replacement batteries for medically	B.R.
necessary electronic wheelchair, owned
by patient
A4635	Underarm pad, crutch, replacement, each	B.R.
A4636	Replacement handgrip, cane, crutch,	B.R.
walker, each
A4637	Replacement tip, cane crutch, walker,	B.R.
each
A4640	Replacement pad for use with medically	B.R.
necessary alternating pressure pad, owned
by patient
A4649	Surgical supplies; miscellaneous	B.R.
A4651	Calibrated microcapillary tube, each	B.R.
A4652	Microcapillary tube sealant	B.R.
A4653	Peritoneal dialysis catheter anchoring	B.R.
device, belt, each
A4656	Needle, any size, each	B.R.
A4657	Syringe, with or without needle, each	B.R.
A4660	Sphygmomanometer/blood pressure apparatus	B.R.
with cuff and stethoscope
A4663	Blood pressure cuff, only	B.R.
A4670	Automatic blood pressure monitor	B.R.
A4671	Disposable cycler set used with cycler	B.R.
dialysis machine, each
A4672	Drainage extension line, sterile, for	B.R.
dialysis, each
A4673	Extension line with easy lock connectors,	B.R.
used with dialysis
A4674	Chemicals/antiseptics solution used to	B.R.
clean/sterilize dialysis equipment, per
eight oz.
A4680	Activated carbon filter for hemodialysis,	B.R.
each
A4690	Dialyzer (artificial kidneys), all types,	B.R.
all sizes, for hemodialysis, each
A4705	Bicarbonate dialysate solution, each	B.R.
A4706	Bicarbonate concentrate, solution, for	B.R.
hemodialysis, per gallon
A4707	Bicarbonate concentrate, powder, for	B.R.
hemodialysis, per packet
A4708	Acetate concentrate solution, for	B.R.
hemodialysis, per gallon
A4709	Acid concentrate, solution, for	B.R.
hemodialysis, per gallon
A4712	Water, sterile	B.R.
A4714	Treated water (deionized, distilled,	B.R.
reverse osmosis) for use in dialysis system
A4719	"Y set" tubing for peritoneal dialysis	B.R.
A4720	Dialysate solution, any concentration of	B.R.
dextrose, fluid volume greater than 249 cc,
but less than or equal to 999 cc, for
peritoneal dialysis
A4721	Dialysate solution, any concentration of	B.R.
dextrose, fluid volume greater than 999 cc
but less than or equal to 1999 cc, for
peritoneal dialysis
A4722	Dialysate solution, any concentration of	B.R.
dextrose, fluid volume greater than 1999 cc
but less than or equal to 2999 cc, for
peritoneal dialysis
A4723	Dialysate solution, any concentration of	B.R.
dextrose, fluid volume greater than 2999 cc
but less than or equal to 3999 cc, for
peritoneal dialysis
A4724	Dialysate solution, any concentration of	B.R.
dextrose, fluid volume greater than 3999 cc
but less than or equal to 4999 cc, for
peritoneal dialysis
A4725	Dialysate solution, any concentration of	B.R.
dextrose, fluid volume greater than 4999 cc
but less than or equal to 5999 cc, for
peritoneal dialysis
A4726	Dialysate solution, any concentration of	B.R.
dextrose, fluid volume greater than 5999 cc,
for peritoneal dialysis
A4730	Fistula cannulation set for dialysis	B.R.
only
A4735	Local/topical anesthetics for dialysis only	B.R.
A4736	Topical anesthetic, for dialysis, per gram	B.R.
A4737	Injectable anesthetic, for dialysis, per	B.R.
10 ml
A4740	Shunt accessories for dialysis only	B.R.
A4750	Blood tubing, arterial or venous, each	B.R.
A4755	Blood tubing, arterial and venous combined	B.R.
A4760	Dialysate standard testing solution,	B.R.
supplies
A4765	Dialysate concentrate additives, each	B.R.
A4766	Dialysate concentrate, solution, additive	B.R.
for peritoneal dialysis, per 10 ml
A4770	Blood testing supplies (for example,	B.R.
vacutainers and tubes)
A4771	Serum clotting time tube, per box	B.R.
A4772	Dextrostick or glucose test strips,	B.R.
per box
A4773	Hemostix, per bottle	B.R.
A4774	Ammonia test paper, per box	B.R.
A4802	Protamine sulfate, for hemodialysis, per	B.R.
50 mg
A4860	Disposable catheter caps	B.R.
A4911	Drain bag/bottle, for dialysis, each	B.R.
A4913	Miscellaneous dialysis supplies, not	B.R.
identified elsewhere
A4918	Venous pressure clamps, each	B.R.
A4927	Gloves, non-sterile, per 100	9.00
A4928	Surgical mask, per 20	B.R.
A4929	Tourniquet for dialysis, each	B.R.
A4930	Gloves, sterile, per pair	0.60
A5051	Pouch, closed; with barrier attached	3.05
(1 piece)
A5052	Pouch, closed; without barrier attached	3.05
(1 piece)
A5053	Pouch, closed; for use on faceplate	3.05
A5054	Pouch, closed; for use on barrier with	3.05
flange (2 piece)
A5055	Stoma cap	2.00
A5061	Pouch, drainable; with barrier attached	4.07
(1 piece)
A5062	Pouch, drainable; without barrier attached	4.07
(1 piece)
A5063	Pouch, drainable; for use on barrier with	4.07
flange (2 piece system)
A5071	Pouch, urinary; with barrier attached	4.07
(1 piece)
A5072	Pouch, urinary; without barrier attached	4.07
(1 piece)
A5073	Pouch, urinary; for use on barrier with	4.07
flange (2 piece system)
A5081	Continent device; plug for continent	3.50
stoma
A5082	Continent device; catheter for continent	11.00
stoma
A5093	Ostomy accessory; convex insert	1.65
A5102	Bedside drainage bottle, rigid or expandable	28.00
A5105	Urinary suspensory; with leg bag, with or	31.90
without tube
A5112	Urinary leg bag; latex	7.12
A5113	Leg strap; latex, per set	4.00
A5114	Leg strap; foam or fabric, per set	8.95
A5119	Skin barrier; wipes, box per 50	9.50
A5121	Skin barrier; solid, 6' x 6' or equivalent,	5.03
each
A5122	Skin barrier; solid, 8' x 8' or equivalent,	5.03
each
A5126	Adhesive; disc or foam pad	1.25
A5131	Appliance cleaner, incontinence and ostomy	16.25
appliances, 16 oz.
A5200	Percutaneous catheter/tube anchoring device,	B.R.
adhesive skin attachment
A5508	For diabetics only, deluxe feature of	B.R.
off-the-shelf depth-inlay shoe or
custom-molded shoe, per shoe
A6010	Collagen based wound filler, dry form, per	B.R.
gram of collagen
A6011	Collagen based wound filler, gel/paste, per	B.R.
gram of collagen
A6021	Collagen dressing, pad size 16 square inches	B.R.
or less, each
A6022	Collagen dressing, pad size more than	B.R.
16 square inches but less than or equal to
48 square inches, each
A6023	Collagen dressing, pad size more than	B.R.
48 square inches, each
A6024	Collagen dressing wound filler, per	B.R.
six inches
A6154	Wound pouch, each	B.R.
A6196	Alginate dressing, wound cover, pad size	B.R.
16 sq. in. or less, each
A6197	Alginate dressing, wound cover, pad size	B.R.
more than 16 but less than or equal to
48 sq. in., each dressing
A6198	Alginate dressing, wound cover, pad size	B.R.
more than 48 sq. in., each dressing
A6199	Alginate dressing, wound filler, per	B.R.
6 inches
A6200	Composite dressing, pad size 16 sq. in. or	B.R.
less, without adhesive border, each dressing
A6201	Composite dressing, pad size more than	B.R.
16 sq. in, but less than or equal to
48 sq. in., without adhesive border, each
dressing
A6202	Composite dressing, pad size more than	B.R.
48 sq. in, without adhesive border, each
dressing
A6203	Composite dressing, pad size 16 sq. in. or	B.R.
less with any size adhesive border, each
dressing
A6204	Composite dressing, pad size more than	B.R.
16 but less than or equal to 48 sq. in.,
with any size adhesive border, each dressing
A6205	Composite dressing, pad size more than	B.R.
48 sq. in, with any size adhesive border,
each dressing
A6206	Contact layer, 16 sq. in. or less, each	B.R.
dressing
A6207	Contact layer, more than 16 but less than	B.R.
or equal to 48 sq. in., each dressing
A6208	Contact layer, more than 48 sq. in., each	B.R.
dressing
A6209	Foam dressing, wound cover, pad size	B.R.
16 sq. in., or less, without adhesive
border, each dressing
A6210	Foam dressing, wound cover, pad size more	B.R.
than 16 but less than or equal to 48 sq. in.,
without adhesive border, each dressing
A6211	Foam dressing, wound cover, pad size more	B.R.
than 48 sq. in., without adhesive border,
each dressing
A6212	Foam dressing, wound cover, pad size	B.R.
16 sq. in. less, with any size adhesive
border, each dressing
A6213	Foam dressing, wound cover, pad size more	B.R.
than 16 but less than or equal to 48 sq. in.
with any size adhesive border, each
A6214	Foam dressing, wound cover, pad size more	B.R.
than 48 sq. in., with any size adhesive
border, each dressing
A6215	Foam dressing, wound filler, per gram	B.R.
A6216	Gauze, non-impregnated, non-sterile, pad	B.R.
size 16 sq in. or less, without adhesive
border, each dressing
A6217	Gauze, non-impregnated, non-sterile, pad	B.R.
size more than 16 but less than or equal to
48 sq. in., without adhesive border, each
dressing
A6218	Gauze, non-impregnated, non-sterile, pad	B.R.
size more than 48 sq. in., without adhesive
border, each dressing
A6219	Gauze, non-impregnated, pad size 16 sq. in.	B.R.
or less, with any size adhesive border,
each dressing
A6220	Gauze, non-impregnated, pad size more than	B.R.
16 but less than or equal to 48 sq. in.,
with any size adhesive border, each dressing
A6221	Gauze, non-impregnated, pad size more than	B.R.
48 sq. in., with any size adhesive border,
each dressing
A6222	Gauze, impregnated, other than water or	B.R.
normal saline, pad size 16 sq. in. or less,
without adhesive border, each dressing
A6223	Gauze, impregnated, other than water or	B.R.
normal saline, pad size more than 16 but
less than or equal to 48 sq. in., without
adhesive border, each dressing
A6224	Gauze, impregnated, other than water or	B.R.
normal saline, pad size more than 48 sq. in.,
without adhesive border, each dressing
A6228	Gauze, impregnated, water or normal saline,	B.R.
pad size 16 sq. in. or less, without
adhesive border, each dressing
A6229	Gauze, impregnated, water or normal saline,	B.R.
pad size more than 16 but less than or equal
to 48 sq. in., without adhesive border,
each dressing
A6230	Gauze, impregnated, water or normal saline,	B.R.
pad size more than 48 sq. in., without
adhesive border, each dressing
A6234	Hydrocolloid dressing, wound cover, pad	B.R.
size 16 sq. in. or less, without adhesive
border, each dressing
A6235	Hydrocolloid dressing, wound cover, pad	B.R.
size more than 16 but less than or equal to
48 sq. in., without adhesive border, each
dressing
A6236	Hydrocolloid dressing, wound cover, pad	B.R.
size more than 48 sq. in., without adhesive
border, each dressing
A6237	Hydrocolloid dressing, wound cover, pad	B.R.
size 16 sq. in. or less, with any size
adhesive border, each dressing
A6238	Hydrocolloid dressing, wound cover, pad	B.R.
size more than 16 but less than or equal to
48 sq. in., with any size adhesive border,
each dressing
A6239	Hydrocolloid dressing, wound cover, pad	B.R.
size more than 48 sq. in., with any size
adhesive border, each dressing
A6240	Hydrocolloid dressing, wound filler, paste,	B.R.
per fluid ounce
A6241	Hydrocolloid dressing, wound filler, dry	B.R.
form, per gram
A6242	Hydrogel dressing, wound cover, pad	B.R.
size 16 sq. in. or less, without adhesive
border, each dressing
A6243	Hydrogel dressing, wound cover, pad size	B.R.
more than 16 but less than or equal to
48 sq. in., without adhesive border, each
dressing
A6244	Hydrogel dressing, wound cover, pad size	B.R.
more than 48 sq. in., without adhesive
border, each dressing
A6245	Hydrogel dressing, wound cover, pad size	B.R.
16 sq. in. or less, with any size adhesive
border, each dressing
A6246	Hydrogel dressing, wound cover, pad size	B.R.
more than 16 but less than or equal to
48 sq. in., with any size adhesive border,
each dressing
A6247	Hydrogel dressing, wound cover, pad size	B.R.
more than 48 sq. in., with any size adhesive
border, each dressing
A6248	Hydrogel dressing, wound filler, gel, per	B.R.
fluid ounce
A6249	Hydrogel dressing, wound filler, dry form,	B.R.
per gram
A6250	Skin sealants, protectants, moisturizers	B.R.
any type, any size
A6251	Specialty absorptive dressing, wound cover,	B.R.
pad size 16 sq. in. or less, without
adhesive border, each dressing
A6252	Specialty absorptive dressing, wound cover,	B.R.
pad size more than 16 but less than or equal
to 48 sq. in., without adhesive border, each
dressing
A6253	Specialty absorptive dressing, wound cover,	B.R.
pad size more than 48 sq. in., without
adhesive border, each dressing
A6254	Specialty absorptive dressing, wound cover,	B.R.
pad size 16 sq. in. or less, any size
adhesive border, each dressing
A6255	Specialty absorptive dressing, wound cover,	B.R.
pad size more than 16 but less than or equal
to 48 sq. in., with any size adhesive border,
each dressing
A6256	Specialty absorptive dressing, wound cover,	B.R.
pad size more than 48 sq. in., with any size
adhesive border, each dressing
A6257	Transparent film, 16 sq. in. or less, each	B.R.
dressing
A6258	Transparent film, more than 16 but less than	B.R.
or equal to 48 sq. in., each dressing
A6259	Transparent film, more than 48 sq. in.,	B.R.
each dressing
A6260	Wound cleansers, any type, any size	B.R.
A6261	Wound filler, not elsewhere classified,	B.R.
gel/paste, per fluid ounce
A6262	Wound filler, not elsewhere classified,	B.R.
dry form, per gram
A6266	Gauze, impregnated, other than water or	B.R.
normal saline, any width, per linear yard
A6402	Gauze, non-impregnated, sterile, pad size	B.R.
16 sq. in. or less, without adhesive border,
each dressing
A6403	Gauze, non-impregnated, sterile, pad size	B.R.
more than 16 but less than or equal to
48 sq. in., without adhesive border, each
dressing
A6404	Gauze, non-impregnated, sterile, pad size	B.R.
more than 48 sq. in., without adhesive
border, each dressing
A6442	Conforming bandage, non-elastic,	B.R.
knitted/woven, non-sterile, width less than
three inches, per yard
A6443	Conforming bandage, non-elastic,	B.R.
knitted/woven, non-sterile, width greater
than or equal to three inches and less than
five inches, per yard
A6444	Conforming bandage, non-elastic,	B.R.
knitted/woven, non-sterile, width greater
than or equal to five inches, per yard
A6445	Conforming bandage, non-elastic,	B.R.
knitted/woven, sterile, width less than
three inches, per yard
A6446	Conforming bandage, non-elastic,	B.R.
knitted/woven, sterile, width greater than
or equal to three inches and less than five
inches, per yard
A6447	Conforming bandage, non-elastic,	B.R.
knitted/woven, sterile, width greater than
or equal to five inches, per yard
A6448	Light compression bandage, elastic,	B.R.
knitted/woven, width less than three inches,
per yard
A6449	Light compression bandage, elastic,	B.R.
knitted/woven, width greater than or equal
to three inches and less than five inches,
per yard
A6450	Light compression bandage, elastic,	B.R.
knitted/woven, width greater than or equal
to five inches, per yard
A7000	Canister, disposable, used with suction	6.66
pump, each
A7001	Canister, non-disposable, used with suction	23.86
pump, each
A7002	Tubing, used with suction pump, each	2.77
A7003	Administration set, with small volume	2.18
nonfiltered pneumatic nebulizer, disposable
A7004	Small volume nonfiltered pneumatic	1.22
nebulizer, disposable
A7005	Administration set, with small volume	22.23
nonfiltered pneumatic nebulizer,
non-disposable
A7006	Administration set, with small volume	6.51
filtered pneumatic nebulizer
A7007	Large volume nebulizer, disposable,	3.18
unfilled, used with aerosol compressor
A7008	Large volume nebulizer, disposable,	8.80
prefilled, used with aerosol compressor
A7009	Reservoir bottle, non-disposable, used with	30.32
large volume ultrasonic nebulizer
A7010	Corrugated tubing, disposable, used with	18.65
large volume nebulizer, 100 feet
A7012	Water collection device, used with large	2.86
volume nebulizer
A7013	Filter, disposable, used with aerosol	0.60
compressor
A7014	Filter, nondisposable, used with aerosol	3.23
compressor or ultrasonic generator
A7015	Aerosol mask, used with DME nebulizer	1.32
A7016	Dome and mouthpiece, used with small volume	5.22
ultrasonic nebulizer
A7018	Water, distilled, used with large volume	0.30
nebulizer, 1000 ml
A7033	Replacement pillows for nasal application	22.73
device, pair
A7034	Nasal interface (mask or cannula type) used	94.11
with positive airway pressure device, with
or without head strap
A7035	Headgear used with positive airway pressure	28.34
device
A7036	Chinstrap used with positive airway pressure	14.56
device
A7037	Tubing used with positive airway pressure	31.37
device
A7038	Filter, disposable, used with positive	3.66
airway pressure device
A7039	Filter, non disposable, used with positive	12.26
airway pressure device
B4034	Enteral feeding supply kit; syringe	150.00
(monthly)
B4035	Enteral feeding supply kit; pump fed	275.00
(monthly)
B4036	Enteral feeding supply kit; gravity fed	195.00
(monthly)
B4081	Nasogastric tubing with stylet	16.75
B4082	Nasogastric tubing without stylet	12.98
B4083	Stomach tube--Levine type	1.90
B4086	Gastrostomy/jejunostomy tube, any material,	B.R.
any type, (standard or low profile), each
B4150	Enteral formulae; category I:	B.R.
Semi-synthetic intact protein/protein
isolates (for example, Enrich, Ensure,
Ensure HN, Ensure Powder, Isocal, Lonalac
Powder, Meritene, Meritene Powder, Osmolite,
Osmolite HN, Portagen Powder, Sustacal,
Renu, Sustagen Powder, Travasorb)
1 package = 1 unit
B4151	Enteral formulae; category I: Natural	B.R.
intact protein/protein isolates (for example,
Compleat B, Vitaneed, Compleat B Modified)
1 package = 1 unit
B4152	Enteral formulae; category II: Intact	B.R.
protein/protein isolates (calorically dense)
(for example, Magnacal, Isocal HCN, Sustacal
HC, Ensure Plus, Ensure Plus HN)
1 package = 1 unit
B4153	Enteral formulae; category III: hydrolyzed	B.R
protein/amino acids (e.g., Criticare HN,
Vivonex T.E.N. (Total Enteral Nutrition),
Vivonex HN, Precision HN, Precision Isotonic)
1 package = 1 unit
B4156	Enteral formulae; category VI: standardized	B.R.
nutrients (Vivonex STD, Precision LR and
Tolerex) 1 package = 1 unit
B4164	Parenteral nutrition solution:	13.26
carbohydrates (dextrose), 50% or
less (500 ml = 1 unit)--home mix
B4168	Parenteral nutrition solution; amino	18.59
acid, 3.5%, (500 ml = 1 unit) --home mix
B4172	Parenteral nutrition solution; amino	30.50
acid 5.5% through 7% (500 ml = 1 unit)--
home mix
B4176	Parenteral nutrition solution; amino	43.22
acid, 7% through 8.5% (500 ml
= 1 unit)--home mix
B4178	Parenteral nutrition solution; amino	43.22
acid, greater than 8.5% (500 ml
= 1 unit)
B4180	Parenteral nutrition solution;	18.30
carbohydrates, (dextrose), greater than
50% (500 ml = 1 unit)--home mix
B4184	Parenteral nutrition solution; lipids, 10%	60.00
with administration set (500 ml = 1 unit)	(12 per month)
B4186	Parenteral nutrition solution, lipids, 20%	80.00
with administration set (500 ml = 1 unit)	(12 per month)
B4189	Parenteral nutrition solution; compounded	133.50
amino acid and carbohydrates with
electrolytes, trace elements and vitamins,
including preparation, any strength, 10
to 51 grams of protein--premix
B4193	Parenteral nutrition solution; compounded	172.50
amino acid and carbohydrates with
electrolytes, trace elements, and vitamins,
including preparation, any strength, 52 to
73 grams of protein--premix
B4197	Parenteral nutrition solution; compounded	210.00
amino acid and carbohydrates with
electrolytes, trace elements and vitamins,
including preparation, any strength,
74 to 100 grams of protein--premix
B4199	Parenteral nutrition solution; compounded	252.69
amino acid and carbohydrates with
electrolytes, trace elements and vitamins,
including preparation, any strength, over
100 grams of protein--premix
B4216	Parenteral nutrition; additives (vitamins,	11.65
trace elements, heparin, electrolytes)--	(per day)
home mix
B4220	Parenteral nutrition supply kit for	182.98
1 month--premix
B4222	Parenteral nutrition supply kit for	283.25
one month--home mix
B4224	Parenteral nutrition administration kit	600.00
for 1 month
B5000	Parenteral nutrition solution; compounded	9.28
amino acid and carbohydrates with
electrolytes, trace elements, and vitamins,
including preparation, any strength,
renal--Amirosyn RF, NephrAmine, RenAmin
--premix
B5100	Parenteral nutrition solution; compounded	3.63
amino acid and carbohydrates with
electrolytes, trace elements, and vitamins,
including preparation, any strength,
hepatic--FreAmine HBC, HepatAmine--premix
B5200	Parenteral nutrition solution; compounded	4.94
amino acid and carbohydrates with
electrolytes, trace elements, and vitamins,
including preparation, any strength,
stress--branch chain amino acids--premix
B9000	Enteral nutrition infusion pump--without	950.00
alarm
B9002	Enteral nutrition infusion pump--with	950.00
alarm
B9004	Parenteral nutrition infusion pump, portable	$ 227.40
per month
B9006	Parenteral nutrition infusion pump,	$ 227.40
stationary	per month
B9998	Not otherwise classified (NOC) for	B.R.
enteral supplies
E0100	Cane, includes canes of all materials,	14.97
adjustable or fixed with tips
E0105	Cane, quad or three prong, includes canes	39.48
of all materials, adjustable or fixed
with tips
E0110	Crutches forearm, includes crutches of various	65.43
materials, adjusted or fixed, complete with tips and handgrips, pair
E0111	Crutch forearm, includes crutches of various	57.92
materials, adjustable or fixed, with tip and
handgrip, each
E0112	Crutches underarm, wood, adjustable or	47.46
fixed, with pads, tips and handgrips, pair
E0113	Crutch underarm, wood, adjustable or fixed,	19.51
with pad, tip and handgrip, each
E0114	Crutches underarm, aluminum, adjustable or	68.56
fixed, with pads, tips and handgrips, pair
E0116	Crutch underarm, aluminum, adjustable or	18.99
fixed, with pad, tip and handgrip, each
E0130	Walker, rigid (pickup), adjustable or	55.94
fixed height
E0135	Walker, folding (pickup), adjustable or	59.43
fixed height
E0141	Walker, wheeled, without seat	95.86
E0142	Rigid walker, wheeled, with seat	343.81
E0143	Folding walker, wheeled, without seat	109.05
E0145	Walker, wheeled, with seat and crutch	176.60
attachments
E0146	Walker, wheeled, with seat	318.23
E0147	Heavy duty, multiple breaking system, variable wheel resistance walker	206.71
E0148	Walker, heavy duty, without wheels, rigid or folding, any type, each	B.R.
E0149	Walker, heavy duty, wheeled, rigid or folding, any type	B.R.
E0153	Platform attachment, forearm crutch,	55.37
each
E0154	Platform attachment, walker, each	68.56
E0155	Wheel attachment, rigid pick-up walker	25.62
E0156	Seat attachment, walker	21.09
E0157	Crutch attachment, walker, each	55.37
E0158	Leg extensions, walker	33.74
E0160	Sitz type bath, portable, fits	9.50
over commode seat
E0161	Sitz type bath, portable, fits	52.73
over commode seat, with faucet
attachments
E0162	Sitz bath, chair	B.R.
E0163	Commode chair, stationary, with	89.16
fixed arms
E0164	Commode chair, mobile, with fixed	210.93
arms
E0165	Commode chair, stationary, with	181.01
detachable arms
E0166	Commode chair, mobile, with detachable	265.35
arms
E0167	Pail or pan for use with commode chair	10.19
E0168	Commode chair, extra wide and/or heavy duty,	120.74
stationary or mobile, with or without arms,
any type, each
E0175	Foot rest, for use with commode chair,	44.07
each
E0176	Air pressure pad or cushion, non-	B.R.
positioning
E0177	Water pressure pad or cushion, non-	B.R.
positioning
E0178	Gel pressure pad or cushion, non-	B.R.
positioning
E0179	Dry pressure pad or cushion, non-	B.R.
positioning
E0180	Pressure pad, alternating with pump	240.44
E0181	Pressure pad, alternating with pump, heavy	263.73
duty
E0182	Pump for alternating pressure pad	291.08
E0184	Dry pressure mattress	68.56
E0185	Gel pressure pad for mattress	62.22
E0186	Air pressure mattress	B.R.
E0187	Water pressure mattress	B.R.
E0188	Synthetic sheepskin pad	21.09
E0189	Lambswool sheepskin pad, any size	21.09
E0191	Heel or elbow protector, each	10.34
E0192	Low pressure and positioning	326.66
equalization pad
E0193	Powered air flotation bed (low air	36.00
loss therapy)	(per day)
E0194	Air fluidized bed	65.20
(per day)
E0200	Heat lamp, without stand (table model),	36.92
includes bulb, or infrared element
E0202	Phototherapy (bilirubin) light with	B.R.
photometer
E0217	Water circulating heat pad with pump	337.60
E0235	Paraffin bath unit, portable (see medical	194.38
supply code A4265 for paraffin)
E0236	Pump for water circulating pad	B.R.
E0241	Bathtub wall rail, each	B.R.
E0242	Bathtub rail, floor base	B.R.
E0243	Toilet rail, each	B.R.
E0244	Raised toilet seat	B.R.
E0245	Tub stool or bench	B.R.
E0246	Transfer tub rail attachment	B.R.
E0249	Pad for water circulating heat unit	124.44
E0250	Hospital bed, fixed height, with any	881.42
type side rails, with mattress
E0251	Hospital bed, fixed height, with any	672.33
type side rails, without mattress
E0255	Hospital bed, variable height, hi-lo,	964.20
with any type side rails, with mattress
E0256	Hospital bed, variable height, hi-lo,	B.R.
with any type side rails, without mattress
E0260	Hospital bed, semi-electric (head and	1,542.26
foot adjustments), with any type side
rails, with mattress
E0261	Hospital bed, semi-electric (head and foot	B.R.
adjustments), with any type side rails,
without mattress
E0265	Hospital bed, total electric (head, foot,	1,940.52
and height adjustments), with any type side
rails, with mattress
E0266	Hospital bed, total electric (head, foot,	1,909.20
and height adjustments), with any type side
rails, without mattress
E0270	Hospital bed, institutional type includes:	B.R.
oscillating, circulating and stryker frame,
with mattress
E0271	Mattress, inner spring	168.73
E0272	Mattress, foam rubber	155.55
E0273	Bed board	B.R.
E0274	Over-bed table	B.R.
E0275	Bed pan, standard, metal or plastic	15.82
E0276	Bed pan, fracture, metal or plastic	12.60
E0277	Alternating pressure mattress	B.R.
E0280	Bed cradle, any type	29.53
E0290	Hospital bed, fixed height, without	B.R.
side rails, with mattress
E0291	Hospital bed, fixed height, without	B.R.
side rails, without mattress
E0292	Hospital bed, variable height, hi-lo,	B.R.
without side rails, with mattress
E0293	Hospital bed, variable height, hi-lo,	B.R.
without side rails, without mattress
E0294	Hospital bed, semi-electric (head and	B.R.
foot adjustments), without side rails,
with mattress
E0295	Hospital bed, semi-electric (head and	B.R.
foot adjustments), without side rails,
without mattress
E0296	Hospital bed, total electric (head,	B.R.
foot and height adjustments), without
side rails, with mattress
E0297	Hospital bed, total electric (head,	B.R.
foot and height adjustments), without
side rails, without mattress
E0303	Hospital bed, heavy duty, extra wide, with	B.R.
weight capacity greater than 350 pounds,
but less than or equal to 600 pounds, with
any type side rails
E0305	Bedside rails, half length	143.77
E0310	Bedside rails, full length	164.74
E0325	Urinal; male, jug-type, any material	6.53
E0326	Urinal; female, jug-type, any material	9.28
E0371	Nonpowered advanced pressure reducing	B.R.
overlay for mattress, standard mattress
length and width
E0372	Powered air overlay for mattress, standard	B.R.
mattress length and width
E0424	Stationary compressed gaseous oxygen system,	250.00(per month)
rental; includes contents (per unit),
regulator, flowmeter, humidifier, nebulizer,
cannula or mask and tubing;
1 unit = 50 cubic ft.
E0431	Portable gaseous oxygen system, rental;	47.33
includes regulator, flowmeter, humidifier,	(per month)
cannula or mask, and tubing
E0434	Portable liquid oxygen system, rental;	47.33(per month)
includes portable container, supply
reservoir, humidifier, flowmeter, refill
adaptor, contents gauge, cannula or mask,
and tubing

E0439	Stationary liquid oxygen system, rental;	250.00(per month)
includes use of reservoir, contents (per
unit), regulator, flowmeter, humidifier,
nebulizer, cannula or mask, and tubing;
1 unit = 10 lbs.
E0441	Oxygen contents, gaseous, per unit (for use	6.50
with owned gaseous stationary systems or
when both a stationary and portable gaseous
system are owned; 1 unit = 50 cubic ft.)
E0442	Oxygen contents, liquid, per unit (for use	14.00
with owned liquid stationary systems or when
both a stationary and portable liquid system
are owned; l unit = 10 lbs.)
E0443	Portable oxygen contents, gaseous, per unit	.65
(for use only with portable gaseous systems
when no stationary gas or liquid system is
used; 1 unit = 5 cubic ft.)
E0444	Portable oxygen contents, liquid, per unit	1.40
(for use only with portable liquid systems
when no stationary gas or liquid system is
used; 1 unit = 1 lb.)
E0450	Volume ventilator; stationary or portable	10,546.29
E0455	Oxygen tent, excluding croup or pediatric	B.R.
tents
E0457	Chest shell (cuirass)	414.80
E0459	Chest wrap	539.24
E0460	Negative pressure ventilator; portable	B.R.
or stationary
E0462	Rocking bed with or without rails	B.R.
E0470	Respiratory assist device, bi-level	B.R.
pressure capability, without backup rate
feature, used with noninvasive interface,
for example, nasal or facial mask
(intermittent assist device with continuous
positive airway pressure device)
E0471	Respiratory assist device, bi-level	B.R.
pressure capability, with back-up rate
feature, used with noninvasive interface,
for example, nasal or facial mask
(intermittent assist device with continuous
positive airway pressure device)
E0472	Respiratory assist device, bi-level	B.R.
pressure capability, with backup rate
feature, used with invasive interface, for
example, tracheostomy tube (intermittent
assist device with continuous positive
airway pressure device)
E0480	Percussor, electric or pneumatic,	279.47
home model
E0500	IPPB machine, all types, with built-in	469.32
nebulization; manual or automatic valves;
internal or external power source
E0550	Humidifier, durable for extensive	315.33
supplemental humidification during
IPPB treatments or oxygen delivery
E0555	Humidifier, durable, glass or autoclavable	15.00
plastic bottle type, for use with regulator
or flowmeter
E0560	Humidifier, durable for supplemental	64.64
humidification during IPPB treatment
or oxygen delivery
E0565	Compressor, air power source for	506.07
equipment which is not self-contained
or cylinder driven
E0570	Nebulizer, with compressor	166.19
E0575	Nebulizer, ultrasonic	732.97
E0580	Nebulizer, durable, glass or autoclavable	121.29
plastic, bottle type, for use with
regulator or flowmeter
E0585	Nebulizer, with compressor and heater	121.29
E0600	Suction pump, home model, portable	409.72
E0601	Continuous positive airway pressure (CPAP)	834.17
device
E0601	Continuous positive airway pressure (CPAP)	100.10
device	(per month)
NOTE: Medicaid and NJ KidCare
fee-for-service reimbursement, all supplies
necessary for the use and maintenance of the
device
E0605	Vaporizer, room type	30.58
E0606	Postural drainage board	158.19
E0607	Home blood glucose monitor	90.00
E0609	Blood glucose monitor with special features	B.R.
(for example, voice synthesizers, automatic
timers, etc.)
E0610	Pacemaker monitor, self-contained (checks	336.42
battery depletion, includes audible and
visible check systems)
E0615	Pacemaker monitor, self-contained, (checks	336.42
battery depletion and other pacemaker
components, includes digital/visible
check systems
E0618	Apnea monitor, without recording feature	1666.67
E0618	Apnea monitor, without recording feature	200.00
(per month)
E0619	Apnea monitor, with recording feature	2083.33
E0619	Apnea monitor, with recording feature	200.00
(per month)
E0621	Sling or seat, patient lift, canvas or nylon	63.36
E0625	Patient lift, Kartop, bathroom or toilet	B.R.
E0630	Patient lift, hydraulic, with seat or sling	932.66
E0635	Patient lift, electric with seat or sling	770.15
E0650	Pneumatic compressor, nonsegmental home	522.05
model, (lymphedema pump)
E0651	Pneumatic compressor, segmental home model,	732.97
(lymphedema pump) without calibrated
gradient pressure
E0652	Pneumatic compressor, segmental home model,	3,374.81
(lymphedema pump) with calibrated gradient
pressure
E0655	Nonsegmental pneumatic appliance for use	83.42
with pneumatic compressor, half arm
E0660	Nonsegmental pneumatic appliance for use	137.10
with pneumatic compressor, full leg
E0665	Nonsegmental pneumatic appliance for use	89.75
with pneumatic compressor, full arm
E0666	Nonsegmental pneumatic appliance for use	131.83
with pneumatic compressor, half leg
E0667	Segmental pneumatic appliance for use with	258.39
pneumatic compressor, full leg
E0668	Segmental pneumatic appliance for use with	226.75
pneumatic compressor, full arm
E0669	Segmental pneumatic appliance for use with	B.R.
pneumatic compressor, half leg
E0670	Segmental pneumatic appliance for use with	B.R.
pneumatic compressor, half arm
E0671	Segmental gradient pressure pneumatic	B.R.
appliance, full leg
E0672	Segmental gradient pressure pneumatic	B.R.
appliance, full arm
E0673	Segmental gradient pressure pneumatic	B.R.
appliance, half leg
E0700	Safety equipment (for example, belt,	B.R.
harness or vest)
E0710	Restraints, any type (body, chest, wrist	B.R.
or ankle)
E0720	TENS, two lead, localized stimulation	452.02
E0730	TENS, four lead, larger area/multiple	448.08
nerve stimulation
E0731	Form-fitting conductive garment for	B.R.
delivery of TENS or NMES (with conductive
fibers separated from the patient's skin by
layers of fabric)
E0740	Incontinence treatment system, pelvic floor	B.R.
stimulator, monitor, sensor and/or trainer
E0744	Neuromuscular stimulator for scoliosis	1,031.82
E0745	Neuromuscular stimulator, electronic	1,049.36
shock unit
E0746	Electromyography (EMG), biofeedback	694.79
device
E0747	Osteogenesis stimulator (noninvasive)	2,742.04
E0748	Osteogenic stimulator, noninvasive, spinal	B.R.
applications
E0755	Electronic salivary reflex stimulator	B.R.
(intraoral/noninvasive)
E0776	IV pole	69.74
E0780	Ambulatory infusion pump, mechanical,	8.30
reusable, for infusion less than eight hours
E0781	Ambulatory infusion pump, single or multiple	B.R.
channels with administrative equipment, worn
by patient
E0784	External ambulatory infusion pump, insulin	B.R.
E0791	Parenteral infusion pump, stationary, single	B.R.
or multichannel
E0840	Traction frame, attached to headboard,	36.92
simple cervical traction
E0850	Traction stand, freestanding, simple	36.92
cervical traction
E0860	Traction equipment, overdoor, cervical	27.17
E0870	Traction frame, attached to footboard,	83.84
simple extremity traction (for example,
Buck's)
E0880	Traction stand, freestanding simple	68.56
extremity traction (for example, Buck's)
E0890	Traction frame, attached to footboard,	80.47
simple pelvic traction
E0900	Traction stand, freestanding simple	80.47
pelvic traction (for example, Buck's)
E0910	Trapeze bars, a/k/a patient helper,	163.74
attached to bed, with grab bar
E0920	Fracture frame, attached to bed,	394.43
includes weights
E0930	Fracture frame, freestanding,	394.43
includes weights
E0935	Passive motion exercise device	17.00
(per day)
E0940	Trapeze bar, freestanding,	314.78
complete with grab bar
E0941	Gravity assisted traction	384.94
device, any type
E0942	Cervical head harness/halter	15.82
E0943	Cervical pillow	41.48
E0944	Pelvic belt/harness/boot	32.74
E0945	Extremity belt/harness	36.92
E0946	Fracture, frame, dual with cross bars,	894.33
attached to bed, (for example, balkan, 4
poster)
E0947	Fracture frame, attachments for complex	B.R.
pelvic traction
E0948	Fracture frame, attachments for complex	B.R.
cervical traction
E0950	Tray	82.96
E0951	Loop heel, each	15.04
E0952	Loop toe, each	15.04
E0953	Pneumatic tire, each	92.59
E0954	Semi-pneumatic caster, each	47.46
E0958	Wheelchair attachment to convert	421.32
any wheelchair to one arm drive
E0959	Amputee adapter (device used to compensate	73.82
for transfer of weight due to lost limbs
to maintain proper balance)
E0961	Brake extension, for wheelchair	11.61
E0962	1' cushion, for wheelchair	47.46
E0963	2' cushion, for wheelchair	61.17
E0964	3' cushion, for wheelchair	70.66
E0965	4' cushion, for wheelchair	79.10
E0966	Hook-on headrest extension	51.67
E0967	Wheelchair hand rims with 8 vertical	105.46
rubber-tipped projections, pair
E0968	Commode seat, wheelchair	181.39
E0969	rrowing device, wheelchair	B.R.
E0970	No. 2 footplates, except for elevating	94.92
leg rest
E0971	Anti-tipping device wheelchairs	50.28
E0972	Transfer board, wheelchair	B.R.
E0973	Adjustable height detachable arms,	91.75
desk or full length, wheelchair
E0974	"Grade-aid" (device to prevent rolling	68.56
back on an incline) for wheelchair
E0975	Reinforced seat upholstery, wheelchair	55.89
E0976	Reinforced back, wheelchair, upholstery	55.89
or other material
E0977	Wedge cushion, wheelchair	49.57
E0978	Belt, safety with airplane buckle,	36.92
wheelchair
E0979	Belt, safety with velcro closure,	25.93
wheelchair
E0980	Safety vest, wheelchair	26.37
E0990	Elevating leg rest, each	77.14
E0991	Upholstery seat	36.92
E0992	Solid seat insert	43.49
E0993	Back, upholstery	27.97
E0994	Armrest, each	13.42
E0995	Calf rest, each	21.09
E0996	Tire, solid, each	23.07
E0997	Caster with a fork	56.95
E0998	Caster without fork	31.64
E0999	Pneumatic tire with wheel	91.75
E1000	Tire, pneumatic caster	49.57
E1001	Wheel, single	92.81
E1031	Rollabout chair, any and all types with	B.R.
castors 5' or greater
E1050	Fully-reclining wheelchair, fixed	1,222.53
full-length arms, swing away detachable
elevating leg rests
E1060	Fully-reclining wheelchair, detachable	1,222.53
arms, desk or full-length, swing away
detachable elevating leg rests
E1065	Power attachment (to convert any wheelchair	2,404.55
to motorized wheelchair (for example, solo)
E1066	Battery charger	242.56
E1069	Deep cycle battery	92.99
E1070	Fully-reclining wheelchair, detachable	909.61
arms, desk or full-length, swing away
detachable foot rest
E1083	Hemi-wheelchair, fixed full-length arms,	717.15
swing away detachable elevating leg rests
E1084	Hemi-wheelchairs, detachable arms, desk	1,049.29
or full-length arms, swing away detachable
elevating leg rests
E1085	Hemi-wheelchair, fixed full-length arms,	829.21
swing away detachable foot rests
E1086	Hemi-wheelchair, detachable arms, desk	1,105.41
or full-length, swing away detachable
foot rests
E1087	High strength lightweight wheelchair,	1,152.71
fixed-full length arms, swing away
detachable leg rests
E1088	High strength lightweight wheelchair,	1,536.80
detachable arms, desk or full-length,
swing away detachable elevating leg rests
E1089	High strength lightweight wheelchair,	1,133.99
fixed length arms, swing away detachable
foot rest
E1090	High strength lightweight wheelchair,	1,499.05
detachable arms, desk or full-length,
swing away detachable foot rests
E1092	Wide heavy duty wheelchair, detachable	1,367.22
arms, desk or full-length, swing
away detachable elevating leg rests
E1093	Wide heavy duty wheelchair, detachable	1,255.01
arms, desk or full-length arms, swing
away detachable foot rests
E1100	Semi-reclining wheelchair, fixed	1,054.63
full-length arms, swing away detachable
elevating leg rests
E1110	Semi-reclining wheelchair, detachable	1,139.73
arms, desk or full-length, elevating
leg rests
E1130	Standard wheelchair, fixed full-length	424.49
arms, fixed or swing away detachable foot
rests
E1140	Wheelchair, detachable arms,	697.26
desk or full-length, swing away detachable
foot rests
E1150	Wheelchair, detachable arms, desk or	776.52
full-length, swing away detachable
elevating leg rests
E1160	Wheelchair, fixed full-length arms,	601.55
swing away detachable elevating leg rests
E1170	Amputee wheelchair, fixed full	1,179.70
length arms, swing away detachable
elevating leg rests
E1171	Amputee wheelchair, fixed full length	682.35
arms, without foot rests or leg rests
E1172	Amputee wheelchair, detachable arms	877.45
(desk or full-length) without foot
rests or leg rests
E1180	Amputee wheelchair, detachable arms	937.91
(desk or full-length) swing away
detachable foot rests
E1190	Amputee wheelchair, detachable arms	1,083.63
(desk or full-length) swing away
detachable elevating leg rests
E1195	Heavy duty wheelchair, fixed	1,029.11
full-length arms, swing away
detachable elevating leg rests
E1200	Amputee wheelchair, fixed full-length	807.14
arms, swing away detachable foot rest
E1210	Motorized wheelchair, fixed full-length	3,646.69
arms, swing away detachable elevating
leg rests
E1211	Motorized wheelchair, detachable arms	3,269.35
(desk or full-length) swing away,
detachable elevating leg rests
E1212	Motorized wheelchair, fixed	2,913.94
full-length arms, swing away
detachable foot rests
E1213	Motorized wheelchair, detachable arms	3,269.35
(desk or full-length) swing away
detachable foot rests
E1220	Wheelchair; specially sized or constructed	B.R.
(indicate brand name, model number,
and justification)
E1221	Wheelchair with fixed arm, foot rests	758.38
E1222	Wheelchair with fixed arm, elevating leg	955.49
rest
E1223	Wheelchair with detachable arms,	831.05
foot rests
E1224	Wheelchair with detachable arms,	1,174.02
elevating leg rests
E1225	Semi-reclining back for customized	449.27
wheelchair
E1226	Full-reclining back for customized	514.66
wheelchair
E1227	Special height arms for wheelchair	221.47
E1228	Special back height for wheelchair	189.83
E1230	Power operated vehicle (three or four	1,624.13
wheel nonhighway), specify brand name
and model number
E1240	Lightweight wheelchair, detachable	1,057.14
arms, (desk or full-length) swing away
detachable, elevating leg rest
E1250	Lightweight wheelchair, fixed	630.67
full-length arms, swing away
detachable foot rest
E1260	Lightweight wheelchair, detachable	870.81
arms, (desk or full-length)swing away
detachable foot rest
E1270	Lightweight wheelchair, fixed	727.69
full-length arms, swing away
detachable elevating leg rests
E1280	Heavy duty wheelchair, detachable	1,272.04
arms (desk or full-length) elevating
leg rests
E1285	Heavy duty wheelchair, fixed	999.66
full-length arms, swing away
detachable foot rest
E1290	Heavy duty wheelchair, detachable	1,386.25
arms (desk or full-length) swing away
detachable foot rest
E1295	Heavy duty wheelchair, fixed	943.05
full-length arms, elevating leg rest
E1296	Special wheelchair seat height from	282.64
the floor
E1297	Special wheelchair seat depth, by	61.17
upholstery
E1298	Special wheelchair seat depth and/or	304.78
width, by construction
E1300	Whirlpool, portable (overtub type)	B.R.
E1310	Whirlpool, nonportable (built-in type)	3,269.35
E1340	Repair or nonroutine service for durable	10.00
medical equipment requiring the skill of a
technician, labor component, per 15 minutes
E1353	Regulator	B.R.
E1355	Stand/rack	46.67
E1372	Immersion external heater for nebulizer	179.29
E1390	Oxygen concentrator, equiv. not determined	250.00
per month
E1399	Durable medical equipment, miscellaneous	B.R.
E1405	Oxygen and water vapor enriching system	B.R.
with heated delivery
E1406	Oxygen and water vapor enriching system	B.R.
without heated delivery
E1500	Centrifuge, for dialysis	B.R.
E1510	Kidney, dialysate delivery system, Kidney	B.R.
machine, pump recirculating, air removal
system, flow rate meter, power off, heater
and temperature control with alarm, i.v.
poles, pressure gauge, concentrate container
E1520	Heparin infusion pump for hemodialysis	B.R.
E1530	Air bubble detector for hemodialysis, each,	B.R.
replacement
E1540	Pressure alarm for hemodialysis, each	B.R.
replacement
E1550	Bath conductivity meter for hemodialysis,	B.R.
each
E1575	Transducer protectors/fluid barriers, for	B.R.
hemodialysis, any size, per 10
E1580	Unipuncture control system for hemodialysis	B.R.
E1590	Hemodialysis machine	B.R.
E1592	Automatic intermittent peritoneal	B.R.
dialysis system
E1594	Cycler dialysis machine for peritoneal	B.R.
dialysis
E1610	Reverse osmosis water purification	B.R.
system
E1615	Deionizer water purification system	B.R.
E1620	Blood pump for hemodialysis, replacement	B.R.
E1630	Reciprocating peritoneal dialysis system	B.R.
E1632	Wearable artificial kidney	B.R.
E1634	Peritoneal dialysis clamps, each	B.R.
E1635	Compact (portable) travel hemodialyzer	B.R.
system
E1636	Sorbent cartridges, for hemodialysis, per 10	B.R.
E1637	Hemostats, each	B.R.
E1699	Dialysis equipment, unspecified, by report	B.R.
E1700	Jaw motion rehabilitation system	B.R.
E1701	Replacement cushions for jaw motion	B.R.
rehabilitation system, pkg. of 6
E1702	Replacement measuring scales for jaw	B.R.
motion rehabilitation system, pkg. of 200
E1800	Dynamic adjustable elbow extension/flexion	B.R.
device
E1805	Dynamic adjustable wrist extension/flexion	B.R.
device
E1810	Dynamic adjustable knee extension/flexion	B.R.
device
E1815	Dynamic adjustable ankle extension/flexion	B.R.
device
E1820	Soft interface material, dynamic adjustable	B.R.
extension/flexion device
E1825	Dynamic adjustable finger extension/flexion	B.R.
device
E1830	Dynamic adjustable toe extension/flexion	B.R.
device
E2100	Blood glucose monitor with integrated voice	507.45
synthesizer
K0001	Standard wheelchair	539.00
K0002	Standard hemi (low seat) wheelchair	870.00
K0003	Lightweight wheelchair	802.00
K0004	High strength, lightweight wheelchair	1,385.00
K0005	Ultra lightweight wheelchair	B.R.
K0006	Heavy duty wheelchair	1,274.00
K0007	Extra heavy duty wheelchair	B.R.
K0009	Other manual wheelchair/base	B.R.
K0010	Standard-weight frame motorized/power	3,345.00
wheelchair
K0011	Standard-weight frame motorized/power	B.R.
wheelchair with programmable control
parameters for speed adjustment,
tremor dampening, acceleration control
and braking
K0012	Lightweight portable motorized/power	B.R.
wheelchair
K0014	Other motorized/power wheelchair base	B.R.
K0015	Detachable, nonadjustable height	157.00
armrest, each
K0016	Detachable, adjustable height armrest,	100.00
complete assembly, each
K0017	Detachable, adjustable height armrest,	B.R.
base, each
K0018	Detachable, adjustable height armrest,	B.R.
upper portion, each
K0019	Arm pad, each	B.R.
K0020	Fixed, adjustable height armrest, pair	B.R.
K0022	Reinforced back upholstery	43.00
K0023	Solid back insert, planar back, single	B.R.
density foam, attached with straps
K0024	Solid back insert, planar back, single	B.R.
density foam, with adjustable hook-on
hardware
K0025	Hook-on headrest extension	56.00
K0026	Back upholstery for ultra lightweight or	27.97
high-strength lightweight wheelchair
K0027	Back upholstery for wheelchair type other	34.00
than ultra lightweight or high-strength
lightweight wheelchair
K0028	Fully reclining back	472.00
K0029	Reinforced seat upholstery	43.00
K0030	Solid seat insert, planar seat, single	70.00
density foam
K0031	Safety belt/pelvic strap	37.00
K0032	Seat upholstery for ultra lightweight or	36.92
high-strength lightweight wheelchair
K0033	Seat upholstery for wheelchair type other	36.92
than ultra lightweight or high-strength
lightweight wheelchair
K0035	Heel loop with ankle strap, each	B.R.
K0036	Toe loop, each	17.00
K0037	High mount flip-up footrest, each	47.46
K0038	Leg strap, each	B.R.
K0039	Leg strap, H style, each	B.R.
K0040	Adjustable angle footplate, each	B.R.
K0041	Large size footplate, each	B.R.
K0042	Standard size footplate, each	32.00
K0043	Footrest, lower extension tube, each	B.R.
K0044	Footrest, upper hanger bracket, each	B.R.
K0045	Footrest, complete assembly	B.R.
K0046	Elevating legrest, lower extension	B.R.
tube, each
K0047	Elevating legrest, upper hanger bracket,	B.R.
each
K0048	Elevating legrest, complete assembly	87.00
K0049	Calf pad, each	23.00
K0050	Ratchet assembly	B.R.
K0051	Cam release assembly, footrest or legrest,	B.R.
each
K0052	Swingaway, detachable footrests, each	B.R.
K0053	Elevating footrests, articulating	B.R.
(telescoping), each
K0054	Seat width of 10', 11', 12', 15', 17', or	B.R.
20' for a high strength, lightweight or
ultra lightweight wheelchair
K0055	Seat depth of 15', 17', or 18' for a	B.R.
high strength lightweight or ultra
lightweight wheelchair
K0056	Seat height less than 17' or less than	83.00
or equal to 21' for a high strength,
lightweight or ultra lightweight
wheelchair
K0057	Seat width 19' or 20' for heavy duty	107.00
or extra heavy duty chair
K0058	Seat depth 17' or 18' for motorized/	52.00
power wheelchair
K0059	Plastic coated handrim, each	B.R.
K0060	Steel handrim, each	B.R.
K0061	Aluminum handrim, each	B.R.
K0062	Handrim with 8-10 vertical or	53.00
oblique projections, each
K0063	Handrim with 12-16 vertical or	B.R.
oblique projections, each
K0064	Zero pressure tube (flat free inserts),	B.R.
any size, each
K0065	Spoke protectors	B.R.
K0066	Solid tire, any size, each	25.00
K0067	Pneumatic tire, any size, each	35.00
K0068	Pneumatic tire tube, each	B.R.
K0069	Rear wheel assembly, complete with solid	87.00
tire, spokes or molded, each
K0070	Rear wheel assembly, complete, with	158.00
pneumatic tire, spokes or molded, each
K0071	Front caster assembly, complete, with	B.R.
pneumatic tire, each
K0072	Front caster assembly, complete, with	57.00
semi-pneumatic tire, each
K0073	Caster pinlock, each	B.R.
K0074	Pneumatic caster tire, any size, each	31.00
K0075	Semi-pneumatic caster tire, any size,	47.46
each
K0076	Solid caster tire, any size, each	B.R.
K0077	Front caster assembly, complete, with	B.R.
solid tire, each
K0078	Pneumatic caster tire tube, each	B.R.
K0079	Wheel lock extension, pair	43.00
K0080	Anti-rollback device, pair	136.00
K0081	Wheel lock assembly, complete, each	B.R.
K0082	22 NF deep cycle lead acid battery,	92.99
each
K0083	22 NF gel cell battery, each	B.R.
K0084	Group 24 deep cycle lead acid battery,	B.R.
each
K0085	Group 24 gel cell battery, each	B.R.
K0086	U-1 lead acid battery, each	92.99
K0087	U-1 gel cell battery, each	B.R.
K0088	Battery charger, lead acid or gel cell	242.56
K0089	Battery charger, dual mode	B.R.
K0090	Rear wheel tire for power wheelchair,	B.R.
any size, each
K0091	Rear wheel tire tube other than zero	B.R.
pressure for power wheelchair, any
size, each
K0092	Rear wheel assembly for power wheelchair,	B.R.
complete, each
K0093	Rear wheel zero pressure tire tube (flat	B.R.
free insert) for power wheelchair, any
size, each
K0094	Wheel tire for power base, any size, each	B.R.
K0095	Wheel tire tube other than zero pressure	B.R.
for each base, any size, each
K0096	Wheel assembly for power base, complete,	B.R.
each
K0097	Wheel zero pressure tire tube (flat free	B.R.
insert) for power base, any size, each
K0098	Drive belt for power wheelchair	B.R.
K0099	Front caster for power wheelchair	B.R.
K0100	Amputee adapter, pair	77.00
K0102	Crutch and cane holder	B.R.
K0103	Transfer board, less than 25 inches	B.R.
K0104	Cylinder tank carrier	B.R.
K0105	IV hanger	B.R.
K0106	Arm trough, each	B.R.
K0107	Wheelchair tray	89.00
K0108	Other accessories	B.R.
K0109	Customization of wheelchair base frame	B.R.
(options or accessories)
K0112	Trunk support device, vest type, with	B.R.
inner frame, prefabricated
K0113	Trunk support device, vest type, without	B.R.
inner frame, prefabricated
K0114	Back support system for use with a	B.R.
wheelchair, with inner frame,
prefabricated
K0115	Orthotic seating system, back module,	B.R.
posterior--lateral control, with or
without lateral supports, custom
fabricated, for attachment to wheelchair
base
K0116	Orthotic seating system, combined back	B.R.
and seat module, custom fabricated, for
attachment to wheelchair base
K0127	Replace soft interface material, ankle	B.R.
contracture splint
K0128	Replace soft interface material, foot	B.R.
drop splint
K0129	Ankle contracture splint	B.R.
K0130	Foot drop splint, recumbent positioning	B.R.
device
K0137	Skin barrier; liquid (spray brush, etc.)	B.R.
per oz.
K0138	Skin barrier; paste, per oz.	B.R.
K0139	Skin barrier, powder, per oz.	B.R.
K0152	Pastes, powders, granules, beads,	B.R.
contact layers
K0163	Vacuum erection system	B.R.
tracheostomy
K0168	Administration set, small volume	B.R.
pneumatic nebulizer, disposable
K0169	Small volume nonfiltered pneumatic	B.R.
nebulizer, disposable
K0170	Administration set, small volume non-	B.R.
filtered pneumatic nebulizer, non-
disposable
K0171	Administration set, small volume	B.R.
nonfiltered pneumatic nebulizer
K0172	Large volume nebulizer, disposable,	B.R.
unfilled, used with aerosol compressor
K0173	Large volume nebulizer, disposable,	B.R.
prefilled, used with aerosol compressor
K0174	Reservoir bottle, non-disposable, used	B.R.
with large volume ultrasonic nebulizer
K0175	Corrugated tubing, disposable, used with	B.R.
large volume nebulizer, 100 feet
K0176	Corrugated tubing, non-disposable, used	B.R.
with large volume nebulizer, 100 feet
K0177	Water collection device, used with large	B.R.
volume nebulizer
K0178	Filter, disposable, used with aerosol	B.R.
compressor
K0179	Filter, non-disposable, used with aerosol	B.R.
compressor or ultrasonic generator
K0180	Aerosol mask, used with DME nebulizer	B.R.
K0181	Dome and mouthpiece, used with small	B.R.
volume ultrasonic nebulizer
K0182	Water, distilled, used with large volume	B.R.
nebulizer, 1000 ml
K0183	Nasal application device, used with	B.R.
CPAP device
K0184	Nasal pillows/seals, replacement for	B.R.
nasal application device, pair
K0185	Headgear, used with CPAP device	B.R.
K0186	Chin strap, used with CPAP device	B.R.
K0187	Tubing, used with CPAP device	B.R.
K0188	Filter, disposable, used with CPAP	B.R.
device
K0189	Filter, non-disposable, used with	B.R.
CPAP device
K0190	Canister, disposable, used with	B.R.
suction pump
K0191	Canister, non-disposable, used with	B.R.
suction pump
K0192	Tubing, used with suction pump	B.R.
K0193	Continuous positive airway pressure	B.R.
(CPAP) device, with humidifier
K0194	Intermittent assist device with	B.R.
continuous positive airway pressure
(CPAP), with humidifier
K0195	Elevating leg rest, pair (for use	B.R.
with capped rental wheelchair base)
K0268	Humidifier, used with CPAP device	B.R.
K0460	Power add-on, to convert manual wheelchair	B.R.
to motorized wheel chair, joystick control
K0461	Power add-on, to convert manual wheelchair	B.R.
to motorized wheel chair, tiller control
L0210	Thoracic rib belt, custom fitted	13.20
L0300	Thoracic-lumbar-sacral-orthoses (TLSO),	101.68
flexible (dorso-lumbar surgical support),
custom fitted
L0315	TLSO, flexible dorso-lumbar surgical	120.00
support
L0515	LSO, flexible (lumbo-sacral surgical	69.16
support), elastic type, with rigid
posterior panel
L0600	Sacroiliac, flexible (sacroiliac surgical	40.72
support), custom fitted
L0900	Torso support, ptosis support, custom	102.11
fitted
L0920	Torso support, pendulous abdomen	118.36
support, custom fitted
L0940	Torso support, postsurgical support,	110.18
custom fitted
L0960	Torso support, postsurgical support	48.71
pads, for postsurgical support
L0974	TLSO, full corset	88.20
L0976	LSO, full corset	103.88
L0980	Peroneal straps, pair	11.33
L0982	Stocking supporter grips, set of	9.60
four (4)
L1600	Hip orthoses (HO), abduction control	40.32
of hip joints, flexible, Frejka type
with cover
L1610	HO, abduction control of hip joints,	25.00
flexible, flexible, (Frejka cover only)
L1620	HO, abduction control of hip joints,	75.00
flexible, (Pavlik harness)
L1800	Knee orthosis (KO), elastic with stays	32.56
L1810	KO, elastic with joints	61.04
L1815	KO, elastic with condylar pads	63.19
L1820	KO, elastic with condyle pads and joints	72.40
L1825	KO, elastic knee cap	28.00
L1830	KO, immobilizer; canvas longitudinal	52.88
L1902	AFO, ankle gauntlet, custom fitted	48.81
L1906	AFO, multiligamentus ankle support	75.00
L3201	Orthopedic shoe, oxford with supinator	48.00
or pronator, infant
L3202	Orthopedic shoe, oxford with supinator	48.00
or pronator, child
L3203	Orthopedic shoe, oxford with supinator	48.00
or pronator, junior
L3204	Orthopedic shoe, hightop with supinator	48.00
or pronator, infant
L3206	Orthopedic shoe, hightop with supinator	48.00
or pronator, child
L3207	Orthopedic shoe, hightop with supinator	48.00
or pronator, junior
L3208	Surgical boot, each, infant	24.00
L3209	Surgical boot, each, child	24.00
L3211	Surgical boot, each, junior	24.00
L3212	Benesch boot, pair, infant	48.00
L3213	Benesch boot, pair, child	48.00
L3214	Benesch boot, pair, junior	48.00
L3215	Orthopedic footwear, woman's shoes,	76.00
oxford
L3216	Orthopedic footwear, woman's shoes,	100.00
depth inlay
L3217	Orthopedic footwear, woman's shoes,	116.00
hightop, depth inlay
L3218	Orthopedic footwear, woman's surgical	64.00
boot, each
L3219	Orthopedic footwear, man's shoes,	76.00
oxford
L3221	Orthopedic footwear, man's shoes,	100.00
depth inlay
L3222	Orthopedic footwear, man's shoes,	116.00
hightop, depth inlay
L3223	Orthopedic footwear, man's surgical	64.00
boot, each
L3253	Foot, molded shoe Plastazote	112.00
(or similar), custom fitted, each
L3254	Nonstandard size or width	20.00
L3255	Nonstandard size or length	20.00
L3257	Orthopedic footwear, additional	50.00
charge for split size
L3260	Ambulatory surgical boot, each	88.00
L3265	Plastazote sandal, each	56.00
L3300	Lift, elevation, heel, tapered to	64.00
metatarsals, per inch
L3310	Lift, elevation, heel and sole,	64.00
neoprene, per inch
L3320	Lift, elevation, heel and sole,	100.00
cork, per inch
L3332	Lift, elevation, inside shoe, tapered,	44.00
up to one-half inch
L3334	Lift, elevation, heel, per inch	36.00
L3340	Heel wedge, sach	10.40
L3350	Heel wedge	12.00
L3360	Sole wedge, outside sole	12.00
L3370	Sole wedge, between sole	14.40
L3380	Clubfoot wedge	12.00
L3390	Outflare wedge	16.00
L3400	Metatarsal bar wedge, rocker	16.00
L3410	Metatarsal bar wedge, between sole	16.00
L3420	Full sole and heel wedge, between sole	24.00
L3430	Heel, counter, plastic reinforced	24.00
L3440	Heel, counter, leather reinforced	24.00
L3450	Heel, Sach cushion type	64.00
L3455	Heel, new leather, standard	8.00
L3460	Heel, new rubber, standard	8.00
L3465	Heel, Thomas with wedge	20.00
L3470	Heel, Thomas extended to ball	24.00
L3480	Heel, pad and depression for spur	16.00
L3485	Heel, pad, removable for spur	32.00
L3500	Miscellaneous shoe addition, insole,	4.00
leather
L3510	Miscellaneous shoe addition, insole,	8.00
rubber
L3520	Miscellaneous shoe additions, insole,	8.00
felt covered with leather
L3530	Miscellaneous shoe addition, sole,	12.00
half
L3540	Miscellaneous shoe addition, sole,	36.00
full
L3550	Miscellaneous shoe addition, toe tap,	4.00
standard
L3560	Miscellaneous shoe addition, toe	6.40
tap, horseshoe
L3570	Miscellaneous shoe addition,	152.00
special extension to instep
(leather with eyelets)
L3580	Miscellaneous shoe addition,	13.60
convert instep to velcro closure
L3590	Miscellaneous shoe addition,	28.00
convert firm shoe counter to
soft counter
L3595	Miscellaneous shoe addition,	12.00
March bar
L3600	Transfer of an orthosis from one	48.00
shoe to another, caliper plate,
existing
L3610	Transfer of an orthosis from one	76.00
shoe to another, caliper plate,
new
L3620	Transfer of an orthosis from one	39.04
shoe to another, solid stirrup,
existing
L3630	Transfer of an orthosis from one	76.00
shoe to another, solid stirrup,
new
L3640	Transfer of an orthosis from one	28.00
shoe to another, Dennis Browne
splint (Riveton), both shoes
L3649	Unlisted procedures for foot orthopedic	B.R.
shoes, shoe modifications and transfers
L3800	Wrist-hand-finger-orthoses (WHFO),	124.28
short opponens, no attachments
L3908	WHFO, wrist extension control cock-up,	50.13
nonmolded
L3914	WHFO, wrist extension cock-up	60.00
L3916	WHFO, wrist extension cock-up,	72.00
with outrigger
L8000	Breast prosthesis, mastectomy bra	B.R.
L8010	Breast prosthesis, mastectomy sleeve	40.56
L8020	Breast prosthesis, mastectomy form	132.00
L8030	Breast prosthesis, silicone or equal	B.R.
L8100	Elastic support, elastic stocking,	24.00
below knee, medium weight, each
L8110	Elastic support, elastic stocking,	30.40
below knee, heavy weight, each
L8120	Elastic support, elastic stocking,	32.00
below knee, surgical weight, (Linton
type or equal), each
L8130	Elastic support, elastic stocking,	33.60
above knee, medium weight, each
L8140	Elastic support, elastic stocking,	36.00
above knee, heavy weight, each
L8150	Elastic support, elastic stocking,	44.00
above knee, surgical weight, (Linton
type or equal), each
L8160	Elastic support, elastic stocking,	40.00
full-length, medium weight, each
L8170	Elastic support, elastic stocking,	48.00
full-length, heavy weight, each
L8180	Elastic support, elastic stocking,	52.00
full-length, heavy surgical weight
(Linton type or equal), each
L8190	Elastic support, elastic stocking,	108.00
leotards, medium weight, each
L8200	Elastic supports, elastic stocking,	120.00
leotards surgical weight (Linton type),
each
L8210	Elastic support, elastic stocking,	B.R.
custom-made
L8220	Elastic support, elastic stocking,	B.R.
lymphedema
L8230	Elastic support, elastic stocking,	B.R.
garter belt
L8300	Truss, single with standard pad	51.28
L8310	Truss, double with standard pads	101.68
L8320	Truss, addition to standard pad,	24.00
water pad
L8330	Truss, addition to standard pad,	33.65
scrotal pad
L8400	Prosthetic sheath, below knee, each	12.00
L8410	Prosthetic sheath, above knee, each	12.00
L8415	Prosthetic sheath, upper limb, each	11.20
L8420	Prosthetic sock, wool, below knee, each	14.94
L8430	Prosthetic sock, wool, above knee, each	18.40
L8435	Prosthetic sock, wool, upper limb, each	8.14
L8440	Prosthetic shrinker, below knee, each	33.60
L8460	Prosthetic shrinker, above knee, each	41.60
L8465	Prosthetic shrinker, upper limb, each	33.60
L8470	Stump sock, single ply, fitting, below	2.52
knee, each
L8480	Stump sock, single ply, fitting, above	2.52
knee, each
X4810	Velcro straps, attached to a pair	14.00
of shoes, per pair
X6005	Two piece flange, stoma size: 4'	4.70/unit
and two piece flange, stoma size:
3 1/4', "picture frame" design
X6460	Ostomy deodorant	B.R.
X7200	Hypodermic syringes over 5cc	B.R.
X7300	Rectal syringes	B.R.
X8334	Parenteral infusion by gravity (includes	$ 39.00/day
parenteral therapy supplies and base
solution cost)
X8335	Parenteral infusion by disposable pump	$ 39.00/day
(includes supplies and base solution cost
X8336	Parenteral infusion with external	$ 60.00/day
ambulatory infusion pump and administration
equipment (includes pump, supplies and base
solution cost)
X8337	Parenteral line maintenance (includes all	$ 8.00/day
supplies necessary)
X8339	Gloves, sterile, each	.30
X8433	Gloves, non-sterile, each	.09
X8434	Parenteral infusion with external stationary	$ 39.00/day
pump and administration equipment (includes
pump, supplies and base solution cost)

N.J. Admin. Code § 10:59-2.3

Amended by R.1999 d.41, effective 2/1/1999.
See: 30 N.J.R. 1019(a), 31 N.J.R. 440(a).
Rewrote the section.
Amended by R.1999 d.265, effective 8/16/1999.
See: 31 N.J.R. 1308(a), 31 N.J.R. 2401(a).
In HCPCS Code E0452 and E0601, inserted notes in the Description, in HCPCS Code E0601, L8000, L8030 and X7520, changed Maximum Fee Allowance, and deleted HCPCS Code X6000.
Amended by R.2000 d.368, effective 9/18/2000.
See: 32 N.J.R. 2201(a), 32 N.J.R. 3425(a).
Inserted references to A4614, A5200, A6154, A6200, A6201, A6202, A6209, K0456 through K0461, and deleted a reference to K0154.
Amended by R.2000 d.391, effective 10/2/2000.
See: 32 N.J.R. 2198(a), 32 N.J.R. 3568(a).
In HCPCS Codes B9004 and B9006, changed Maximum Fee Allowances; inserted HCPCS Codes X8334 through X8337 and X8434; and deleted HCPCS Code B9999.
Amended by R.2001 d.64, effective 2/20/2001.
See: 32 N.J.R. 4098(a), 33 N.J.R. 661(c).
In HCPCS Codes E0424 and E0439, substituted "regulator" for "regulatory"; in HCPCS Codes A4214, E0110, E0111, E0424, E0434, E0439, E0781, and E1400 through E1403, changed Maximum Fee Allowances; deleted HCPCS Codes K0224 and K0228; in X4890 through X4892, inserted "casting"; and inserted HCPCS Code X7533.
Amended by R.2006 d.297, effective 9/5/2006.
See: 38 N.J.R. 1371(b), 38 N.J.R. 3578(a).
Rewrote the section.