New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 59 - MEDICAL SUPPLIER MANUAL
Subchapter 2 - HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS)
Section 10:59-2.3 - HCPCS procedure codes and maximum fee allowance schedule for medical supplies and durable medical equipment
Universal Citation: NJ Admin Code 10:59-2.3
Current through Register Vol. 56, No. 18, September 16, 2024
| 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) |
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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