DRAFT: Durable Medical Equipment/-
Supply Fee Schedule

PROPOSED FEE

DESCRIPTION

A4214

$1.67

Sterile saline or water, 30 cc vial

A4221

$21.59

Supplies for maintenance of drug infusion catheter, per week (list drug separately)

A4222

$44.16

Supplies for external drug infusion pump, per cassette or bag (list drug separately)

A4253

$31.69

Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

A4254

$6.28

Replacement battery, any type, for use with medically necessary home blood glucose monitor owned by patient, each

A4255

$3.82

Platforms for home blood glucose monitor, 50 per box

A4256

$10.92

Normal, low, and high calibrator solution/chips

A4258

$17.21

Spring-powered device for lancet, each

A4259

$12.15

Lancets, per box of 100

A4310

$6.26

Insertion tray without drainage bag and without catheter (accessories only)

A4311

$14.16

Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

A4312

$17.20

Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone

A4313

$17.67

Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4314

$24.12

Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

A4315

$25.17

Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone

A4316

$27.09

Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4320

$4.32

Irrigation tray with bulb or piston syringe, any purpose

A4351

$1.47

Intermittent urinary catheter; straight tip, each

A4352

$5.67

Intermittent urinary catheter; coude (curved) tip, each

A4353

$6.67

Intermittent urinary catheter, with insertion supplies

A4354

$11.25

Insertion tray with drainage bag but without catheter

A4355

$8.50

Irrigation tubing set for continuous bladder irrigation through a three-way indwelling Foley catheter, each

A4356

$43.27

External urethral clamp or compression device (not to be used for catheter clamp), each

A4357

$9.25

Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each

A4358

$6.33

Urinary leg bag; vinyl, with or without tube, each

A4359

$26.69

Urinary suspensory without leg bag, each

A4361

$17.52

Ostomy faceplate, each

A4454

$2.12

Tape, all types, all sizes

A4460

$0.97

Elastic bandage, per roll (e.g., compression bandage)

A4550

$19.04

Surgical trays

A4556

$9.84

Electrodes (e.g., Apnea monitor), per pair

A4558

$5.20

Conductive paste or gel

A4613

$116.92

Battery charger; replacement for patient-owned ventilator

A4618

$7.21

Breathing circuits

A4619

$1.21

Face tent

A4621

$1.39

Tracheostomy mask or collar

A4622

$48.70

Tracheostomy or laryngectomy tube

A4623

$5.31

Tracheostomy, inner cannula (replacement only)

A4624

$2.13

Tracheal suction catheter, any type, each

A4625

$5.62

Tracheostomy care kit for new tracheostomy

A4626

$2.59

Tracheostomy cleaning brush, each

A4628

$3.57

Oropharyngeal suction catheter, each

A4629

$4.42

Tracheostomy care kit for established tracheostomy

A4630

$5.96

Replacement batteries for medically necessary transcutaneous electrical nerve stimulator (TENS) owned by patient

A4631

$96.43

Replacement batteries for medically necessary electronic wheelchair owned by patient

A4635

$4.15

Underarm pad, crutch, replacement, each

A4636

$3.46

Replacement, handgrip, cane, crutch, or walker, each

A4637

$2.03

Replacement, tip, cane, crutch, walker, each

A4640

$54.44

Replacement pad for use with medically necessary alternating pressure pad owned by patient

A5051

$2.14

Pouch, closed; with barrier attached (one piece)

A5052

$1.59

Pouch, closed; without barrier attached (one piece)

A5053

$1.41

Pouch, closed; for use on faceplate

A5054

$1.61

Pouch, closed; for use on barrier with flange (two piece)

A5055

$1.21

Stoma cap

A5061

$2.58

Pouch, drainable; with barrier attached (one piece)

A5062

$2.12

Pouch, drainable; without barrier attached (one piece)

A5063

$2.13

Pouch, drainable; for use on barrier with flange (two piece system)

A5071

$4.15

Pouch, urinary; with barrier attached (one piece)

A5072

$3.24

Pouch, urinary; without barrier attached (one piece)

A5073

$3.04

Pouch, urinary; for use on barrier with flange (two piece)

A5081

$2.77

Continent device; plug for continent stoma

A5082

$10.71

Continent device; catheter for continent stoma

A5093

$1.58

Ostomy accessory; convex insert

A5102

$21.53

Bedside drainage bottle, with or without tubing, rigid or expandable, each

A5105

$38.88

Urinary suspensory; with leg bag, with or without tube

A5112

$33.02

Urinary leg bag; latex

A5113

$3.81

Leg strap; latex, replacement only, per set

A5114

$7.24

Leg strap; foam or fabric, replacement only, per set

A5119

$9.67

Skin barrier; wipes, box per 50

A5121

$7.12

Skin barrier; solid, 6 x 6 or equivalent, each

A5122

$11.96

Skin barrier; solid, 8 x 8 or equivalent, each

A5123

$4.60

Skin barrier; with flange (solid, flexible or accordion), any size, each

A5126

$1.07

Adhesive or non-adhesive; disk or foam pad

A5131

$13.80

Appliance cleaner, incontinence and ostomy appliances, per 16 oz.

A6154

$13.69

Wound pouch, each

A6196

$7.01

Alginate dressing, wound cover, pad size 16 sq. in. or less, each dressing

A6197

$15.68

Alginate dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6199

$5.04

Alginate dressing, wound filler, per 6 inches

A6200

$9.06

Composite dressing, pad size 16 sq. in. or less, without adhesive border, each dressing

A6203

$3.19

Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6204

$5.94

Composite dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6207

$7.00

Contact layer, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6209

$7.14

Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6210

$19.00

Foam dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6211

$28.01

Foam dressing, wound cover, pad size more then 48 sq. in., without adhesive border, each dressing

A6212

$9.25

Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6214

$9.82

Foam dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing

A6216

$0.05

Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6219

$0.91

Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6220

$2.46

Gauze, non-impregnated, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6222

$2.03

Gauze, impregnated, other than water or normal saline, pad size 16 sq. in. or less, without adhesive border, each dressing

A6223

$2.30

Gauze, impregnated, other than water or normal saline, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6224

$3.44

Gauze, impregnated, other than water or normal saline, pad size more than 48 sq. in., without adhesive border, each dressing

A6234

$6.24

Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6235

$16.05

Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6236

$25.99

Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

A6237

$7.54

Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6238

$21.74

Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6240

$11.68

Hydrocolloid dressing, wound filler, paste, per fluid ounce

A6241

$2.45

Hydrocolloid dressing, wound filler, dry form, per gram

A6242

$5.79

Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6243

$11.75

Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6244

$37.46

Hydrogel dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

A6245

$6.93

Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6246

$9.46

Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6247

$22.68

Hydrogel dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing

A6248

$15.49

Hydrogel dressing, wound filler, gel, per fluid ounce

A6251

$1.90

Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6252

$3.10

Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6253

$6.05

Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

A6254

$1.16

Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6255

$2.89

Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6257

$1.46

Transparent film, 16 sq. in. or less, each dressing

A6258

$4.10

Transparent film, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6259

$10.43

Transparent film, more than 48 sq. in., each dressing

A6263

$0.28

Gauze, elastic, non-sterile, all types, per linear yard

A6264

$0.46

Gauze, non-elastic, non-sterile, per linear yard

A6265

$0.12

Tape, all types, per 18 sq. in.

A6266

$1.83

Gauze, impregnated, other than water or normal saline, any width, per linear yard

A6402

$0.12

Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6403

$0.41

Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6405

$0.32

Gauze, elastic, sterile, all types, per linear yard

A6406

$0.76

Gauze, non-elastic, sterile, all types, per linear yard

E0100

$17.09

Cane, includes canes of all materials, adjustable or fixed, with tip

E0105

$45.38

Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips

E0110

$71.38

Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips

E0111

$43.18

Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip

E0112

$32.06

Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips

E0113

$17.13

Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip

E0114

$38.26

Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips

E0116

$22.49

Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip

E0130

$63.04

Walker, rigid (pickup), adjustable or fixed height

E0135

$79.97

Walker, folding (pickup), adjustable or fixed height

E0141

$109.97

Rigid walker, wheeled, without seat

E0142

$160.57

Rigid walker, wheeled, with seat

E0143

$101.20

Folding walker, wheeled, without seat

E0147

$548.27

Heavy duty, multiple breaking system, variable wheel resistance walker

E0153

$66.18

Platform attachment, forearm crutch, each

E0154

$67.25

Platform attachment, walker, each

E0155

$25.59

Wheel attachment, rigid pick-up walker, per pair seat attachment, walker

E0156

$22.56

Seat attachment, walker

E0157

$78.14

Crutch attachment, walker, each

E0158

$29.00

Leg extensions for walker, per set of four (4)

E0159

$17.05

Brake attachment for wheeled walker, replacement, each

E0160

$26.80

Sitz type bath or equipment, portable, used with or without commode

E0161

$25.01

Sitz type bath or equipment, portable, used with or without commode, with faucet attachment/s

E0162

$118.12

Sitz bath chair

E0163

$89.82

Commode chair, stationary, with fixed arms

E0164

$173.03

Commode chair, mobile, with fixed arms

E0167

$11.02

Pail or pan for use with commode chair

E0175

$63.17

Foot rest, for use with commode chair, each

E0176

$86.84

Air pressure pad or cushion, nonpositioning

E0177

$90.97

Water pressure pad or cushion, nonpositioning

E0178

$98.38

Gel or gel-like pressure pad or cushion, nonpositioning

E0179

$11.41

Dry pressure pad or cushion, nonpositioning

E0182

$21.23

Pump for alternating pressure pad

E0184

$185.71

Dry pressure mattress

E0185

$305.09

Gel or gel-like pressure pad for mattress, standard mattress length and width

E0191

$8.10

Heel or elbow protector, each

E0192

$369.14

Low pressure and positioning equalization pad, for wheelchair

E0197

$179.65

Air pressure pad for mattress, standard mattress length and width

E0198

$208.45

Water pressure pad for mattress, standard mattress length and width

E0199

$25.98

Dry pressure pad for mattress, standard mattress length and width

E0200

$75.62

Heat lamp, without stand (table model), includes bulb, or infrared element

E0202

$59.72

Phototherapy (bilirubin) light with photometer

E0205

$185.10

Heat lamp, with stand, includes bulb, or infrared element

E0210

$26.46

Electric heat pad, standard

E0217

$473.55

Water circulating heat pad with pump

E0225

$370.70

Hydrocollator unit, includes pads

E0230

$7.55

Ice cap or collar

E0238

$25.26

Nonelectric heat pad, moist

E0239

$364.70

Hydrocollator unit, portable

E0249

$95.00

Pad for water circulating heat unit

E0271

$211.78

Mattress, inner spring

E0272

$193.03

Mattress, foam rubber

E0275

$13.96

Bed pan, standard, metal or plastic

E0276

$10.79

Bed pan, fracture, metal or plastic

E0280

$30.97

Bed cradle, any type

E0310

$169.55

Bedside rails, full-length

E0325

$8.19

Urinal; male, jug-type, any material

E0326

$8.52

Urinal; female, jug-type, any material

E0441

$147.84

Oxygen contents, gaseous, per unit (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned; 1 unit = 50 cubic ft)

E0442

$147.84

Oxygen contents, liquid, per unit (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned; 1 unit = 10 lbs)

E0443

$18.20

Portable oxygen contents, gaseous, per unit (for use only with portable gaseous systems when no stationary gas or liquid system is used; 1 unit = 5 cubic ft)

E0444

$18.20

Portable oxygen contents, liquid, per unit (for use only with portable liquid systems when no stationary gas or liquid system is used; 1 unit = 1 lb)

E0560

$155.83

Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery

E0570

$18.34

Nebulizer, with compressor

E0575

$83.33

Nebulizer, ultrasonic

E0580

$127.85

Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter

E0607

$63.73

Home blood glucose monitor

E0609

$605.02

Blood glucose monitor with special features (e.g., voice synthesizers, automatic timers, etc.)

E0610

$200.68

Pacemaker monitor, self-contained, checks battery depletion, includes audible and visible check systems

E0615

$456.71

Pacemaker monitor, self-contained, checks battery depletion and other pacemaker components, includes digital/visible check systems

E0621

$80.25

Sling or seat, patient lift, canvas or nylon

E0627

$321.75

Seat lift mechanism incorporated into a combination lift-chair mechanism

E0628

$321.75

Separate seat lift mechanism for use with patient owned furniture - electric

E0629

$315.44

Separate seat lift mechanism for use with patient owned furniture - nonelectric

E0650

$605.50

Pneumatic compressor, nonsegmental home model

E0651

$876.02

Pneumatic compressor, segmental home model without calibrated gradient pressure

E0652

$5,056.67

Pneumatic compressor, segmental home model with calibrated gradient pressure

E0655

$92.14

Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm

E0660

$152.37

Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg

E0665

$125.42

Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm

E0666

$123.60

Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg

E0667

$308.82

Segmental pneumatic appliance for use with pneumatic compressor, full leg

E0668

$421.48

Segmental pneumatic appliance for use with pneumatic compressor, full arm

E0669

$171.02

Segmental pneumatic appliance for use with pneumatic compressor, half leg

E0671

$396.17

Segmental gradient pressure pneumatic appliance, full leg

E0672

$307.83

Segmental gradient pressure pneumatic appliance, full arm

E0673

$255.79

Segmental gradient pressure pneumatic appliance, half leg

E0690

$1,299.85

Ultraviolet cabinet, appropriate for home use

E0720

$350.61

TENS, two lead, localized stimulation

E0730

$353.45

TENS, four lead, larger area/multiple nerve stimulation

E0747

$3,364.35

Osteogenesis stimulator, electrical, noninvasive, other than spinal applications

E0748

$3,342.55

Osteogenesis stimulator, electrical, noninvasive, spinal applications

E0776

$136.55

IV pole

E0781

$252.64

Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient

E0791

$301.60

Parenteral infusion pump, stationary, single or multichannel

E0840

$59.41

Traction frame, attached to headboard, cervical traction

E0850

$89.48

Traction stand, freestanding, cervical traction

E0855

$479.42

Cervical traction equipment not requiring additional stand or frame

E0860

$32.40

Traction equipment, overdoor, cervical

E0870

$94.30

Traction frame, attached to footboard, extremity traction (e.g., Buck's)

E0880

$101.78

Traction stand, freestanding, extremity traction (e.g., Buck's)

E0890

$97.62

Traction frame, attached to footboard, pelvic traction

E0900

$103.88

Traction stand, freestanding, pelvic traction (e.g., Buck's)

E0942

$16.09

Cervical head harness/halter

E0943

$26.39

Cervical pillow

E0944

$39.73

Pelvic belt/harness/boot

E0945

$40.87

Extremity belt/harness

E0947

$503.87

Fracture frame, attachments for complex pelvic traction

E0948

$503.87

Fracture frame, attachments for complex cervical traction

E0950

$99.15

Tray

E0951

$16.81

Loop heel, each

E0952

$17.97

Loop toe, each

E0953

$39.02

Pneumatic tire, each

E0954

$39.91

Semi-pneumatic caster, each

E0959

$81.51

Amputee adapter (device used to compensate for transfer of weight due to lost limbs to maintain proper balance)

E0961

$24.11

Brake extension, for wheelchair

E0962

$56.74

One-inch cushion, for wheelchair

E0963

$67.78

Two-inch cushion, for wheelchair

E0964

$75.62

Three-inch cushion, for wheelchair

E0965

$80.84

Four-inch cushion, for wheelchair

E0966

$66.80

Hook on headrest extension

E0967

$107.13

Wheelchair hand rims with eight vertical rubber-tipped projections, pair

E0969

$149.40

Narrowing device, wheelchair

E0970

$39.05

No. 2 footplates, except for elevating legrest

E0971

$53.30

Anti-tipping device, wheelchair

E0972

$52.57

Transfer board or device

E0973

$109.66

Adjustable height detachable arms, desk or full-length, wheelchair

E0974

$64.06

'Grade-aid' (device to prevent rolling back on an incline) for wheelchair

E0975

$40.33

Reinforced seat upholstery, wheelchair

E0976

$40.72

Reinforced back, wheelchair, upholstery or other material

E0977

$55.47

Wedge cushion, wheelchair

E0978

$41.60

Belt, safety with airplane buckle, wheelchair

E0979

$31.93

Belt, safety with Velcro closure, wheelchair

E0980

$26.80

Safety vest, wheelchair

E0990

$105.09

Elevating leg rest, each

E0991

$43.76

Upholstery seat

E0992

$90.75

Solid seat insert

E0993

$44.35

Back, upholstery

E0994

$15.98

Armrest, each

E0995

$27.51

Calf rest, each

E0996

$27.20

Tire, solid, each

E0997

$63.44

Caster with fork

E0998

$31.03

Caster without fork

E0999

$93.21

Pneumatic tire with wheel

E1000

$29.20

Tire, pneumatic caster

E1001

$91.15

Wheel, single

E1065

$2,691.70

Power attachment (to convert any wheelchair to motorized wheelchair, e.g., Solo)

E1066

$213.73

Battery charger

E1069

$107.16

Deep cycle battery

E1226

$442.38

Full reclining back for customized wheelchair

E1227

$264.69

Special height arms for wheelchair

E1230

$1,833.76

Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number

E1296

$438.01

Special wheelchair seat height from floor

E1297

$89.53

Special wheelchair seat depth, by upholstery

E1298

$404.09

Special wheelchair seat depth and/or width, by construction

E1310

$2,048.25

Whirlpool, nonportable (built-in type)

E1372

$138.21

Immersion external heater for nebulizer

E1375

$216.56

Nebulizer portable with small compressor, with limited flow

E1700

$328.92

Jaw motion rehabilitation system

E1701