Durable Medical Equipment and Supplies Category DME Description Max

05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Ambulatory, Positioning & 4631S Cane or Crutch, Ice Tips, Each 2 $8.00 X Transfer Aids E0100 Cane, Includes Canes of all Materials 2 $19.00 X Adjustable or Fixed, With Tip E0105 Cane, Quad or 3-Prong, Includes Canes 1 $44.00 X of all Materials, Adjustable or Fixed, With Tips 4645E Caster for Folding Walking Aid 2 $75.00 X 1001E Chair, Pediatric Transport/Positioning 1 $1,100.00 X Note: Maximum Age is 6 E0111 Crutch Forearm, Includes Crutches 2 $49.00 X of Various Materials, Adjustable or Fixed, Each, With Tip and Handgrips E0114 Crutches, Underarm, 2 $39.00 X Other Than Wood, Adjustable or Fixed, Pair, With Pads, Tips and Handgrips, E0935 Passive Motion Exercise Device 21 $40.00/Day X Note: 21-day Maximum, Rental Only, Per Day E0630 Patient Lift, Hydraulic, 1 $1,100.00 X With Seat or Sling 0008E Stander, Prone or Supine 1 $1,000.00 X E0940 Trapeze Bar, Freestanding, 1 $229.00 X Complete With Grab Bar E0135 Walker, Folding (Pickup), 1 $80.00 X Adjustable or Fixed Height No PA required E0141 Rigid Walker, Wheeled, Without Seat 1 $109.97 X effective 5/1/03 E0142 Rigid walker, wheeled, with seat 1 $375.00 X E0143 Folding walker, wheeled, without seat 1 $112.00 X Effective 1/1/03 E0145 Walker, wheeled, with seat and crutch 1 Approved X PA required attachments Amount effective 1/1/03 No PA required E0146 Folding walker, wheeled, with seat 1 $300.00 X effective 5/1/03 PA required E0148 Walker, heavy duty, without wheels, 1 $121.55 X effective 5/1/03 rigid or folding, any type, each PA required E0149 Walker, heavy duty, wheeled, rigid or 1 $213.53 X effective 5/1/03 folding, any type, each Bathroom Equipment E0242 Bathtub Rail, Floor Base 1 $65.67 X E0241 Bathtub Wall Rail, Each 2 $20.21 X 0166E Chair, Shower/Commode, Mobile; 1 $270.00 X Detached or Fixed Arms (for Non-ambulatory Recipient Only) E0168 Commode chair, extra wide and/or 1 $144.38 X heavy duty, stationary or mobile, with or without arms, any type, each

I-25

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Bathroom E0165 Commode Chair, Stationary, 1 $180.50 X Equipment With Detachable Arms (cont.) E0163 Commode Chair, Stationary, 1 $90.00 X With Fixed Arms 4617E Seat, Utility Bath, With Back 1 $63.00 X E0243 Toilet Rail, Each 2 $49.75 X E0244 Raised Toilet Seat 1 $48.00 X Effective 5/1/03 E0245 Tub Stool or Bench 1 $63.00 X price is $63, prior price is $40 E0326 Urinal, Female, Jug-type, 1 $5.61 X Any Material E0325 Urinal, Male, Jug-type, 1 $4.21 X Any Material Batteries 4614A Battery, Blood Glucose Monitor, Each 5 $5.50 X A4612 Battery Cables; Replacement for 2 $81.60 X Patient-owned Ventilator A4613 Battery Charger; Replacement for 2 $95.02 X Patient-owned Ventilator A4611 Battery, Heavy Duty; 2 $70.00 X Replacement for Patient-owned Ventilator A4631 Replacement Batteries for Medically 2 $127.00 X Necessary Electronic Wheelchair Owned by Patient Note: Maximum of Two Per 12-month Period 4400V Battery, Unlisted, Hearing Aid, 20 $0.90 X Per Battery 4170V Battery alkaline 9 volt, for portable 45 $1.90 X respirator, each Contraceptive 4260A Contraceptive prophylactic condom, 72 $.42 X Supplies male 4261A Contraceptive prophylactic condom, 72 $2.55 X female 0006S Diaphragm for Contraceptive use 1 $28.00 X Limited to females, ages 12-60 Decubitis Care Air Pressure Pad or Cushion, Equipment & E0176 1 $135.00 X Nonpositioning Supplies E0178 Gel or Gel-Like Pad or Cushion, 1 $135.00 X Nonpositioning E0179 Dry Pressure Pad or Cushion, 1 $27.00 X Nonpositioning E0180 Pressure Pad, Alternating with Pump 1 $163.75 X E0181 Pressure Pad, Alternating with Pump, 1 $163.75 X Heavy Duty E0185 Gel Or Gel-Like Pressure Pad for 1 $320.00 X Mattress, Standard Mattress Length and Width

I-26

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Decubitis Care Equipment & E0188 Synthetic Sheepskin Pad 1 $25.00 X Supplies (cont.) E0189 Lambswool Sheepskin Pad, Any Size 1 $72.00 X E0192 Low pressure and positioning 1 $365.00 X equalization pad, for wheelchair E0197 Air pressure pad for mattress, standard 1 $49.00 X mattress length and width E0199 Dry pressure pad for mattress, standard 1 $40.00 X mattress length and width E0184 Dry pressure mattress 1 $32.00 X E0186 Air pressure mattress 1 Approved X Amount E0187 Water Pressure Mattress 1 $36.00 X E0194 Air Fluidized Bed 31 $95.00 X Note: Rental, Per Day E0182 Pump For Alternating Pressure Pad 1 $26.00 X E0191 Heel or Elbow Protector, Each 2 $8.00 X Diabetic 4753S Alcohol Swabs/Wipes, Each 200 $.03 X Supplies 4253A Blood Glucose Test Strips, 100/Pkg, 300 $.93 X Each Strip Effective 5/1/03, A4253 Blood glucose test or reagent strips for 200 $48.00 X price is $48.00 home blood glucose monitor per 50 per 50 strips strips A4256 Normal, low, and high calibrator 1 $11.00 X solution/chips 4796S Diabetic Supplies: Clinitest, Acetest, 1 Approved X Test Tape, Diastix, Ketodiastix, Amount Albuminstix, Other; Glucose Tabs not Covered Note: Itemized Attachment Required and Medical Justification Required 4792S Dressing, Transparent, for Insulin Pump, 100 $.50 X Each 4789S Glass Cartridge for Insulin Pump, $4.50 X Disetronic, Each 4216A Insulin Delivery System Needles (e.g., 200 $.28 X Novofine), 1 Needle-1 Unit 4217A Insulin Delivery System 3 $49.00 X (e.g., Novopen) 4788S Infusion Set, 110 cm, for Disetronic 1 $23.00 X Insulin Pump, Each 4793E Insulin Pump 1 $4,495.00 X 4793S Insulin Pump Infusion Set With Bent 100 $5.33 X Needle, 42", Each

I-27

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Diabetic 4794S Insulin Pump Non-needle 100 $8.00 X Supplies (cont.) Subcutaneous Infusion Set, 42", Each 4259A Lancets, 200/Pkg, Each Lancet 200 $.09 X A4259 Lancets, 100/Pkg, Each Lancet 100 $.11 X 4254A Sharps Container, Any Size, 1 $5.03 X up to 1 Gallon, Each A4258 Spring-powered device for lancet, Each 1 $18.33 X 4797S Diabetic Syringe (1 Syringe = 1 unit) 200 $.28 X 4798S Syringe, Insulin Pump, 3.0 ml, Each 100 $3.14 X A4206 Syringe with Needle, sterile, 1 cc, Each 300 $.20 X A4208 Syringe with Needle, sterile, 3 cc, Each 300 $.30 X 4208A Syringe with Needle, 5 cc, Each 300 $.55 X 4209A Syringe with Needle, 10 cc, Each 300 $.55 X Hospital Beds/Equipment E0276 Bed Pan, Fracture, Metal or Plastic 3 $10.00 X & Accessories E0275 Bed Pan, Standard, Metal or Plastic 3 $10.00 X A4357 Bedside Drainage Bag, Day or Night, 8 $6.75 X with or without Anti-reflux Device, with or without Tube, Each A5102 Bedside Drainage Bottle, with or without 2 $27.66 X tubing, Rigid or Expandable, Each E0310 Bedside Rails, Full-Length Note: 1 $143.51 X Medical Justification required 5/1/03 E0305 Bedside Rails, Half-Length Note: 1 $150.00 X Medical Justification required 5/1/03 E0910 Trapeze bars, also known as Patient 1 $129.00 X Helper, attached to bed, with grab bar E0260 Hospital Bed, Semi-electric 1 $1,150.00 X (Head and Foot Adjustment), with Any Type Side Rails, with Mattress E0261 Hospital Bed, Semi-electric 1 $975.00 X (Head and Foot Adjustment), with Any Type Side Rails, without Mattress E0255 Hospital Bed, Variable Height, Hi-Lo, 1 $725.00 X with Any Type Side Rails, With Mattress E0256 Hospital Bed, Variable Height, Hi-Lo, 1 Approved X with Any Type Side Rails, Without Amount Mattress E0272 Mattress, Foam Rubber 1 $175.00 X E0271 Mattress, Inner Spring 1 $175.00 X E0371 Nonpowered advanced pressure 1 Approved X reducing overlay for mattress, standard Amount mattress length and width E0372 Powered air overlay for mattress, 1 Approved X standard mattress length and width Amount E0373 Nonpowered advanced pressure 1 Approved X reducing mattress Amount

I-28

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Incontinence 5146S Appliance Cleanser, Per ml 1000 $.05 X Supplies 4342A Bed Pad, Reusable 4 $24.00 X 4341A Bed Pad, Reusable with Tuck-in Flaps 4 $29.00 X A4311 Insertion Tray without Drainage Bag $11.00 X with Indwelling Catheter, Foley Type, Two-Way, Latex with Coating (Teflon, Silicone, Silicone Elastomer or Hydrophilic, etc.) A4312 Insertion Tray without Drainage Bag $22.00 X with Indwelling Catheter, Foley Type, Two-Way, All Silicone A4314 Insertion Tray with Drainage Bag with X Indwelling Catheter, Foley Type, Two- $20.00 Way, Latex with Coating (Teflon, Silicone, Silicone Elastomer or Hydrophilic, etc.) A4315 Insertion Tray with Drainage Bag with 1 $15.80 X Indwelling Catheter, Foley Type, Two- Way, All Silicone A4316 Insertion Tray with Drainage Bag with $19.00 X Indwelling Catheter, Foley Type, Three- Way, For Continuous Irrigation A4354 Insertion Tray With Drainage Bag $11.00 X Without Catheter A4310 Insertion Tray Without Drainage Bag $9.00 X and Without Catheter (Accessories Only) A4324 Male external catheter, with adhesive 1 $2.14 X coating, adhesive A4325 Male external catheter, with adhesive 31 $1.75 X strip, each End date 3/31/02 A4329 External catheter starter set, 1 $23.43 X male/female, includes catheters/urinary collection device, bag/pouch and accessories (tubing, clamps, etc.), seven-day supply A4331 Extension drainage tubing, any type, 1 $3.07 X any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each A4332 Lubricant, individual sterile packet, for 100 $.12 X insertion of urinary catheter, each A4333 Urinary catheter anchoring device, 1 $2.74 X adhesive skin attachment, each A4334 Urinary catheter anchoring device, leg 1 $2.54 X strap, each A4344 Indwelling Catheter, Foley Type, 31 $13.85 X Two-Way, All Silicone, Each A4348 Male external catheter with integral 2 Approved X collection compartment, extended wear, Amount each (e.g., 2 per month)

I-29

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Incontinence A4338 Indwelling Catheter; Foley Type, Two- 31 $8.28 X Supplies (cont.) Way latex with Coating (Teflon, Silicone, Silicone Elastomer or Hydrophilic, etc.), Each A4346 Indwelling Catheter; Foley Type, 31 $28.72 X Three-Way, For Continuous Irrigation, Each A4340 Indwelling catheter; Specialty Type 31 $28.72 X (e.g., Coude, Mushroom, Wing, etc.), Each A4326 Male External Catheter Specialty Type, $9.00 X (e.g., Inflatable, Faceplate, etc.), Each Effective 5/1/03, A4347 Male External Catheter with or without 100 $18.84 X price is $18.84 Adhesive, with or without Anti-reflux per dozen Device, Per Dozen A4351 Intermittent Urinary Catheter; straight 250 $2.19 X tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), Each A4352 Intermittent Urinary Catheter, Coude 250 $8.00 X (Curved) Tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), Each 5142S Cleanser Wipes, Lotion, Each 200 $.08 X 4756S Cunningham Clamp, 1 $52.28 X Small/Regular/Large, Each Effective 1/1/03 A4528 Adult-sized incontinence product, brief, 300 $.93 X PA required extra-large size, each effective 1/1/03 Note: Minimum age is 3 Effective 1/1/03 A4531 Child-sized incontinence product, brief, 300 $.93 X PA required small/medium size, each effective 1/1/03 Note: Minimum age is 3 Effective 1/1/03 A4532 Child-sized incontinence product, brief, 400 $.93 X PA required large size, each effective 1/1/03 Note: Minimum age is 3 Effective 1/1/03 A4535 Disposable liner/shield for incontinence, 400 $.51 X PA required each Note: Minimum age is 3 effective 1/1/03 End date 4/30/02 0005S Diapers, Disposable, 320 $200.00/mo X Size Extra Large For Adult or Child Note: Minimum Age is 3 End date 4/30/02 0004S Diapers, Disposable, 320 $200.00/mo X Size Large, For Adult or Child Note: Minimum Age is 3 End date 4/30/02 0003S Diapers, Disposable, 308 $200.00/mo X Size Medium, For Adult or Child Note: Minimum Age is 3 End date 4/30/02 0002S Diapers, Disposable, 300 $200.00/mo X Size Small, For Adult or Child Note: Minimum Age is 3

I-30

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Incontinence S8403 Adult-sized incontinence garment, 300 $.93 X Supplies (cont.) disposable, pull-up brief, each Note: This code is for existing PAs only beyond 1/1/03 dates of service. Minimum age is 3 S8404 Child-size incontinence garment, 300 $.93 X disposable, pull-up brief, each Note: This code is for existing PAs only beyond 1/1/03 dates of service. Minimum age is 3 S8405 Disposable liner/shield for incontinence, 300 $.51 X each Note: This code is for existing PAs only beyond 1/1/03 dates of service. Minimum age is 3 5141S Disposable Washcloth, Each 1020 $.12 X 4321A Extension Tubing, Nonsterile, Each 30 $4.00 X 4320A Extension Tubing, Sterile, Each 3 $4.80 X End date 4/30/03 4328A Irrigation Solution, Sterile Saline, 500 ml 12 $1.78 X (1 Unit = 500 ml) See A4323 & A4319 A4214 Sterile Saline or Water, 30 cc Vial 5 $1.32 X A4319 Sterile water irrigation solution, 1000 ml 10 $5.51 X A4323 Sterile Saline Irrigation Solution, 12 $1.95 X 1000 ml Note: 1 Unit = 1000 ml End date 4/30/03 4712A Irrigation, Sterile Water 6 $1.92 X (1 Unit = 1000 ml) Note: See A4323 & A4319 A4322 Irrigation Syringe, Bulb or Piston, Each $3.50 X A4320 Irrigation Tray with Bulb or Piston 1 $4.25 X Syringe, any purpose A4355 Irrigation Tubing Set For Continuous 1 $12.08 X Bladder Irrigation Through a three-way Indwelling Foley Catheter, Each A5114 Leg Strap; Foam or Fabric, replacement $16.00 X only, Per Set A5113 Leg Strap; Latex, replacement only, Per $3.00 X Set A4330 Perianal Fecal Collection Pouch 3 $10.98 X with Adhesive, Each 5147S Protectant, Moisture Barrier Cream, Gm 500 $.05 X 5148S Protectant, Moisture Barrier Lotion, Gm 500 $.06 X 5149S Protectant, Moisture Barrier 500 $.05 X Ointment and Gel, Gm 5143S Protectant, Powder 500 $.01 X (e.g., Cornstarch-based Powder), Gm 4323A Quick Drain Valve – Outlet Valve, Each 1 $21.08 X 4324A Red Inlet Valve, Each 1 $3.92 X

I-31

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Incontinence 5145S Skin Cleanser, Liquid/Foam/Spray, 1000 $.04 X Supplies (cont.) Per ml 4325A Straight-through Adapter With Clamp – 5 $4.82 X Manual Clamp, Each A4554 Underpads, Disposable, All Sizes 300 $.30 X (e.g., Chux) A4356 Urethral Clamp or Compression Device, $48.00 X External (Not to be Used for Catheter Clamp), Each 4322A Uri-Drain Extension Connector, Each 5 $2.33 X 4326A Uri-Drain With Foam Adhesive Strap, 31 $1.75 X Each A4327 Female External Urinary Collection 1 $13.00 X Device, Metal Cup, Each A4328 Female External Urinary Collection 3 $12.33 X Device, Pouch, Each 4790S Urinary Drainage/Irrigation Supplies Approved X (Itemize) Note: Requires Medical Amount Justification A5112 Urinary Leg Bag, Latex 1 $38.41 X A4358 Urinary drainage bag, leg or abdomen, 30 $5.25 X Vinyl, With or Without Tube, with straps, Each 4327A Urinary Leg Bag Drain Tube 5 $4.82 X Extension to Night Bag, Each A5105 Urinary Suspensory; With Leg Bag, 1 $60.38 X With or Without Tube IV Therapy 4753S Alcohol Swabs/Wipes, Each 200 $.03 X 4172A Battery, Alkaline, 9 Volt; for Patient- 10 $1.50 X owned I.V. Pump, Maximum 10/Month 0798S Cassette (CADD), 50 ml 150 $21.50 X 0799S Cassette (CADD), 100 ml 150 $31.00 X 9022S Disposable IV Infusion System for 31 $20.00 X Antibiotics, Per Day 9023S Disposable IV Infusion System for 31 $20.00 X Chemotherapy, Per Day 0730S Epidural Filter, Any Size 10 $3.00 X 4211S Gauze, Sponge, 3x3, Each 200 $.05 X 4212S Gauze, Sponge, 4x4, Each 200 $.22 X 0786S IV Bag, 1 Liter, Each 31 $9.63 X 0787S IV Bag, 2 Liters, Each 31 $24.50 X 0788S IV Bag, 3 Liters, Each 31 $21.23 X 0777S IV Bag, Sterile, Empty, 3 $9.50 X 250 cc or 500 cc A4214 Sterile Saline or Water, 30 cc Vial 5 $1.32 X A4319 Sterile water irrigation solution, 1000 ml 10 $5.51 X A4323 Sterile Saline Irrigation Solution, 12 $1.95 X 1000 ml (1 Unit = 1000 ml) End date 4/30/03 4712A Irrigation, Sterile Water 6 $1.92 X (1 Unit = 1000 ml)

Note: Medicaid does not pay for supplies used in compounding. I-32

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No IV Therapy 0722S IV Cannula, Any 60 $.60 X (cont.) End date 4/30/03 0720S Catheter, Peripheral Central $65.00 X Note: See A4212 End date 4/30/03 0721S IV Catheter Peripheral Note: See A4212 120 $2.50 X End date 4/30/03 0726S IV Catheter Injection Site 5 $2.75 X Note: See 0724S A4305 Disposable drug delivery system, flow 124 $15.00 X rate of 50 ml or greater per hour A4306 Disposable drug delivery system, flow 124 $15.00 X rate of 5 ml or less per hour 0785S IV Extension Set, Any Size or Type, 31 $5.27 X Per Set 0724S IV Injection Site 6 $.95 X 9026S IV or TPN Administration Set, 50 $14.00 X Any Type, Each Set E0776 IV Pole 1 $100.00 X 0789S IV Start Kit, Any, Per Kit 5 $7.85 X A4212 Non coring needle or stylet with or 3 $11.00 X without catheter End date 4/30/03 4795S Needles, Hypodermic, Each $.19 X Note: See A4215 4204A PICC Dressing Change Kit 8 $8.29 X 0790E Pump, Portable, IV and TPN Infusion Rental Only, Per Day: 124 $20.00 X 0022E Pump Therapy, Terbutaline Infusion * (Includes Infusion Pump, Supplies for Delivery of Medication, Pharmacy Consultant for Dosing the Drug) Note: Limited to Females, Ages 13-55 Rental Only, Per Day: 31 $120.00 X A4220 Refill kit for implantable infusion pump 2 Approved X Amount E0781 Ambulatory infusion pump, single or 124 $20.00 X multiple channels, electric or battery operated, with administrative equipment, worn by patient 0797S RC 575 Large Bore Tubing, Per Unit 2 $3.75 X 0795S Remote Reservoir Adapter, 2 $22.75 X 30-inch Tubing 0796S Remote Reservoir Adapter, $31.50 X 60-inch Tubing 0778S Sponge, 2x2, With Slit, Fenestrated, 100 $.25 X Each 0779S Sponge, 4x4, With Slit, Fenestrated, 100 $.43 X Each

*Specific criteria for receiving Terbutaline Infusion Pump Therapy include a physician’s order, recipient currently on external uterine monitoring (which requires prior authorization), recipient recently hospitalized for pre-term labor or therapy before hospitalization if history of high-risk factors (e.g., failure on oral tocolytics, continued signs of pre-term labor, multiple gestation, etc.).

I-33

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Maintenance 4742E Durable Medical Equipment Repair, Approved X & Repair ** Labor (Written Justification Required) Amount 4741E Durable Medical Equipment Repair, Approved X *** Parts (Written Justification Required) Amount V5336 Repair/Modification of Augmentative 1 Approved X Communicative System or Device Amount (Excludes Adaptive Hearing Aid) Note: Medical Justification Required Miscellaneous E1399 Durable Medical Equipment, Approved X **** Miscellaneous Amount (Description, Retail Price List, and Medical Justification Required) 4751E Freight, Postage (From Urban to Rural Approved X Area), $15.01 or More, and Long- Amount distance Telephone Charges (Postage, Freight Invoice, or Phone Bill Must be Attached) 4752E Freight, Postage (From Urban to Rural $15.00 X Area), Actual Charges up to $15.00 E0202 Phototherapy (Bilirubin) Light With Photometer Note:10-day Maximum Rental Only, Per Day: 10 $50.00 X 4764S Ring, Foam or Inflatable Vinyl, 1 $12.38 X One Ring 4490A Stocking, Anti-embolism, Knee Length, Closed Toe (e.g., Jobst Anti/EM), Each 2 $15.42 X 4500A Stocking, Anti-embolism, Knee Length, Open Toe (e.g., Jobst Anti/EM), Each 2 $10.67 X 4495A Stocking, Anti-embolism, Thigh Length, Closed Toe (e.g., Jobst Anti/EM), Each 2 $15.90 X 4205A Syringe, 3 cc, without Needle, Any Tip 120 $.13 X 4203A Syringe, 5 cc, without Needle, Any Tip 120 $.23 X 4210A Syringe, 10 cc, without Needle, Any Tip 120 $.26 X A4213 Syringe, sterile, 20 cc or greater, each 120 $.70 X A4215 Needles only, sterile, any size, each 100 $.19 X A4290 Sacral nerve stimulation test lead, each 1 Approved X Amount A4462 Abdominal dressing holder, each 10 $3.18 X A4561 Pessary, rubber, any type 1 $17.78 X A4562 Pessary, non rubber, any type 1 Approved X Amount A4608 Transtracheal oxygen catheter, each 1 $58.32 X A4635 Underarm pad, crutch, replacement, 2 $2.75 X each PA required 4799S Unlisted Medical Supplies Approved X effective 5/1/03 Note: Attach Itemized List of Supplies Amount

** Written justification for labor must include time spent on labor and cost of labor. *** Written justification for parts must include reason for repair, description of part, and cost of part. **** Written justification must include the description and cost of the equipment or item being billed.

I-34

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Miscellaneous K0533 Respiratory assist device, bi-level 1 $630.10 X (cont.) pressure capacity, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) End date 4/30/03 K0551 Residual limb support system, solid 2 Approved X base with adjustable drop hooks, Amount mounts to wheelchair frame, each Monitoring Equipment End date 4/30/03 E0608 Apnea Monitor, Rental Only, Per Month 3 $300.00 X Effective 1/1/03 E0618 Apnea monitor, without recording 3 $300.00 X feature Note: Rental only, per month and maximum age is 3. E0619 Apnea monitor, with recording feature 1 Approved X Amount End date 3/31/02 E0609 Blood glucose monitor with special 1 $500.00 X features (e.g., voice synthesizers, automatic timers, etc.) Note: Voice model approval criteria: Diagnosis of Diabetes and blindness; Medical justification required for other special feature models E0607 Home Blood Glucose Monitor 1 $75.00 X Note: Purchase Only (The Price Billed is After All Product Rebates From Manufacturers) E2100 Blood glucose monitor with integrated 1 Approved X voice synthesizer Amount A4660 Sphygmomanometer/Blood Pressure 1 $35.00 X Apparatus With Cuff and Stethoscope A4670 Automatic Blood Pressure Monitor 1 $140.00 X 0044E# Pneumocardiogram, 4-channel: 3 $650.00 X Recording and Report (Ages 0-2) 0055E# Pneumocardiogram, 4-channel: 3 $550.00 X Recording Only (Ages 0-2) 0004E# Pneumocardiogram: Recording and 3 $160.00 X Report (Ages 0-2) 0005E# Pneumocardiogram: Recording Only 3 $65.00 X (Ages 0-2) 0006E# Pneumocardiogram: Screening and 3 $95.00 X Report (Ages 0-2) 0002E# Uterine Monitoring Device, External 91 Approved X Note: Limited to females, ages 13-55 Amount

# = Reimbursable only when performed in an outpatient or home setting.

I-35

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Nutrition: 4090B Bag, Topfill, Any Size, With or Without 31 $7.00 X Enteral Set, Each 4086B Bolus Feeding Set With Tube, etc. 15 $11.93 X (1 Unit = 1 Set) B4086 Gastrostomy/jejunostomy tube, any 4 $40.83 X material, any type (standard or low profile), each B4150 Enteral formulae; category I; semi- 600 $.76 X synthetic intact protein/protein isolates, administered through an enteral feeding tube, 100 calories = 1 unit B4151 Enteral formulae: category I: natural 600 $1.79 X intact protein/protein isolates, administered through an enteral feeding tube, 100 calories = 1 unit B4152 Enteral formulae; category II: intact 600 $.64 X protein/protein isolates (calorically dense), administered through an enteral feeding tube, 100 calories = 1 unit B4153 Enteral formulae; category III: hydrolized 600 $2.18 X protein/amino acids, administered through an enteral feeding tube, 100 calories = 1 unit B4154 Enteral formulae; Category IV: Defined 600 $1.40 X Formula for Special Metabolic Need, Administered through an Enteral feeding tube, 100 calories = 1 unit B4155 Enteral formulae; category V: modular 600 $1.09 X components, administered through an enteral feeding tube, 100 calories = 1 unit B4156 Enteral formulae; category VI: 600 $1.55 X standardized nutrients, administered through an enteral feeding tube, 100 calories = 1 unit 4095B Enteral Decompression Tube 1 $17.50 X 4096B Enteral Y Port Connector, Each 31 $8.00 X 4084B Extension for Skin Level Gastrostomy, 10 $11.42 X Any Size, Each End date 3/31/02 B4085 Gastronomy tube, silicone with sliding 5 $58.13 ring, each End date 3/31/02 B4084 Gastronomy/jejunostomy tubing 2 $16.52 4087B Gastrostomy Extension Set, Mic-Key, 15 $3.83 X 6-12 inches, Each

I-36

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Nutrition: Enteral (cont.) End date 4/30/03 0007M MCT Oil 960 ml/unit Bottle; and $81.00 X Lofenalac, 454 GM/unit Note: See B9998 4088B Mic-Key Gastrostomy Set, 2 $135.70 X Any Size, Each PA required 9002S Nutrition Supplies, Enteral Approved X effective 5/1/03 (Itemize) Amount End date 4/30/02 0002M Nutritional, Enteral (Ensure, Ensure HN, $2.45 X Ensure Plus Isocal, Isocal HCN, Enrich, Osmolite, Osmolite HN, 2-Cal HN, Vital, Jevity, Pediasure), 8 oz/240 cc/unit End date 4/30/02 0003M Nutritional, Enteral (Lipisorb, Impact, $24.50 X Nutramigen), 1 can/unit End date 4/30/02 0004M Nutritional, Enteral (Compleat Modular $3.50 X Formula, Compleat B), 8 oz/240 cc/unit End date 4/30/02 0005M Nutritional, Enteral, 1 can = 1 unit $5.00 X End date 4/30/02 0006M Nutritional, Enteral (Pulmocare, $2.65 X Glucerna, Promote), 8 oz/240 cc/unit B9000 Enteral Nutrition Infusion Pump - Without Alarm Purchase: 1 $750.00 X Rental, Per Month: $75.00 X B9002 Enteral Nutrition Infusion Pump - With Alarm Purchase: 1 $1,000.00 X Rental, Per Month: $100.00 X Approved Amount B9998 NOC for enteral supplies Note: Thick-It, Approved X Effective 5/1/03 Human mother’s milk; Attach itemized Amount statement 4089B Syringe, 60 cc, Catheter Tip or Luer 31 $1.73 X Lok, Each Nutrition: 0790S Container, TPN Mixing, Each Note: 1 $9.53 X Parenteral Medical Justification Required Effective 5/1/03 0791S Infusion Supplies, Parenteral Approved X Note: Itemized Bill with Descriptions Amount and Charges are Required 9006S Nutrition Supplies, Parenteral Approved X Note: Medical Justification Required Amount B9006 Parenteral Nutrition Infusion Pump, Stationary Note: Requires Authorized TPN State-specific NDC Rental, Per Day: 31 $20.00 X 0790E Pump, Portable, IV and TPN Infusion Rental Only, Per Day: 124 $20.00 X 0792S TPN Administration Set, .2 Micron Filter 35 $33.00 X 0793S TPN Administration Set, 1.2 Micron 35 $33.00 X Filter 0794S TPN Y Set 35 $15.00 X

I-37

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Orthopedic E0942 Cervical Head Harness/Halter 1 $20.00 X Equipment E0943 Cervical Pillow, All 2 $12.50 X E0830 Ambulatory traction device, all types, 1 Approved X each Amount E0855 Cervical traction equipment not requiring 1 Approved X additional stand or frame Note: Medical Amount Justification Required Effective 5/1/03 E0860 Traction Equipment, Overdoor, Cervical 1 $20.00 X 4567S Cryo Cuff, Complete, 1 $125.00 X With Vacuum Bottle, Each 4571A Knee Brace, Hinged 2 $80.00 X A4465 Nonelastic Binder for Extremity 2 $10.00 X End date 4/30/03 A4572 Rib Belt $18.62 X End date 4/30/03 A4460 Elastic Bandage, per roll (e.g., 5 $2.25 X compression bandage) A6430 Light compression bandage, elastic, 10 Approved X knitted/woven, load resistance less than Amount 1.25 pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per roll (at least three yards, unstretched) A6432 Light compression bandage, elastic, 10 Approved X knitted/woven, load resistance less than Amount 1.25 pounds at 50% maximum stretch, width greater than or equal to five inches per roll (at least three yards, unstretched) A6434 Moderate compression bandage, 10 Approved X elastic, knitted/woven, load resistance of Amount 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to three inches or less than five inches, per roll (at least three yards, unstretched) A6436 High compression bandage, elastic, 10 Approved X knitted/woven, load resistance greater Amount than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per roll (at least three yards, unstretched) 4460S Rubber Elastic Bandage, 3-inch, Each 5 $3.03 X 4461S Rubber Elastic Bandage, 4-inch, Each 5 $4.13 X 4462S Rubber Elastic Bandage, 6-inch, Each 5 $5.62 X A4565 Slings 2 $47.00 X 4566S Sling, with Collar 2 $4.50 X A4570 Splint 5 $39.00 X

I-38

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Ostomy A5126 Adhesive or non-adhesive; Disc or 30 $4.00 X Supplies Foam Pad A4364 Adhesive, Liquid, or equal, any type, per 6 $14.00 X ounce A4369 Ostomy skin barrier, liquid (spray, brush, 11 $3.40 X etc), per oz A4371 Ostomy skin barrier, powder, per oz 1 $9.60 X A4372 Ostomy skin barrier, solid 4x4 or 30 $7.30 X equivalent, with built-in convexity, each A4373 Ostomy skin barrier, with flange (solid, 30 $5.23 X flexible or accordian), with built-in convexity, any size, each A4385 Ostomy skin barrier, solid 4x4 or 30 $5.30 X equivalent, extended wear, without built- in convexity, each A4394 Ostomy deodorant for use in ostomy 8 $3.80 X pouch, liquid, per fluid ounce A4395 Ostomy deodorant for use in ostomy 60 $.10 X pouch, solid, per tablet A4396 Ostomy belt with peristomal hernia 1 $38.61 X support A4455 Adhesive Remover or Solvent (For 6 $1.58 X Tape, Cement, or Other Adhesive), Per Oz. A5082 Continent Device; Catheter for 10 $9.00 X Continent Stoma A5081 Continent Device; Plug for Continent 2 $3.75 X Stoma, Each A4398 Ostomy Irrigation Supply; Bag, each 10 $15.00 X A4402 Lubricant, per ounce 10 $4.00 X Effective 1/1/03 A4405 Ostomy skin barrier, non-pectin based, 10 $4.18 X paste, per ounce Effective 1/1/03 A4406 Ostomy skin barrier, pectin-based, 10 $4.18 X paste, per ounce A5093 Ostomy Accessory; Convex Insert 10 $3.00 X A4367 Ostomy Belt, Each 1 $7.04 X A4361 Ostomy Faceplate, each 10 $24.00 X A4400 Ostomy Irrigation Set 1 $56.18 X A4399 Ostomy Irrigation Supply; 1 $16.32 X Cone/Catheter, including brush A4397 Irrigation Supply; Sleeve, Each 1 $4.54 X A4404 Ostomy Ring, Each 10 $2.38 X A4421 Ostomy Supplies, Miscellaneous 30 Approved X Note: Itemized Attachment Required Amount

I-39

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Ostomy 4785S Ostomy Supplies, 3-month Supply 500 Approved X Supplies (cont.) (Itemized Attachment Required) Amount A5054 Ostomy Pouch, Closed; For Use on 450 $1.87 X Barrier With Flange (Two Piece), Each A5053 Ostomy Pouch, Closed; for Use on 62 $2.00 X Faceplate, Each A5051 Ostomy Pouch, Closed; With Barrier 62 $3.14 X Attached (One Piece), Each A5052 Ostomy Pouch, Closed; Without Barrier 62 $2.07 X Attached (One Piece), Each A5063 Ostomy Pouch, Drainable; for Use on 12 $5.07 X Barrier With Flange (Two Piece System), Each A5061 Ostomy Pouch, Drainable; With Barrier 62 $4.02 X Attached, (One Piece), Each End date 3/31/02 A5064 Pouch, drainable; with faceplate 62 attached; plastic or rubber A5062 Ostomy Pouch, Drainable; Without 30 $3.80 X Barrier Attached (one Piece), Each A5073 Ostomy Pouch, Urinary; for Use on 62 $5.10 X Barrier With Flange (Two Piece), Each A5071 Ostomy Pouch, Urinary; With Barrier 62 $6.22 X Attached (One Piece), Each End date 3/31/02 A5074 Pouch, urinary; with faceplate attached; 62 $6.32 X plastic or rubber A5072 Ostomy Pouch, Urinary; Without Barrier 62 $4.93 X Attached (One Piece), Each A4362 Skin Barrier; Solid, 4x4 or Equivalent; 31 $4.93 X Each A5121 Skin Barrier; Solid, 6x6 or Equivalent, 31 $8.00 X Each A5122 Skin Barrier; Solid, 8x8 or Equivalent, 31 $19.80 X Each A5119 Skin Barrier; Wipes, Box per 50 8 $11.00 X Note: Medical Justification Required and Attach Prescription Effective 5/1/03 A5200 Percutaneous catheter/tube anchoring 31 $3.30 device, adhesive skin attachment A4407 Ostomy skin barrier, with flange (solid, 10 $8.78 X flexible, or accordion), extended wear, with built-in convexity, 4x4 inches or smaller, each

I-40

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Ostomy A4408 Ostomy skin barrier, with flange (solid, 10 Approved X Supplies (cont.) flexible or accordion), extended wear, Amount with built-in convexity, larger than 4x4 inches, each A4409 Ostomy skin barrier, with flange (solid, 10 $9.15 X flexible or accordion), extended wear, without built-in convexity, 4x4 inches or smaller, each A4410 Ostomy skin barrier, with flange (solid, 10 $12.12 X flexible or accordion), extended wear, without built-in convexity, larger than 4x4 inches, each End date 3/31/03 A5123 Skin Barrier; With Flange (Solid, Flexible 10 $4.00 X or Accordion), Any Size, Each A5055 Stoma Cap 31 $2.97 X Oxygen & 0554S Artificial Nose and Supplies 200 $4.50 X Respiratory (Ties, Adapter, etc.) Equipment/ Supplies 4170A Battery, Alkaline, 9-volt, for Portable 45 $1.90 X Respirator (Restricted for Use with Portable Respirator Only), Per Battery A4614 Peak expiratory flow rate meter, hand 1 $30.00 X held PA required A4618 Breathing Circuits Note: For patient $19.00 X effective 5/1/03 owned systems only 4620S Canister, Suction, 1000 cc or Less, 1 $3.63 X Disposable, Each 4621S Canister, Suction, 1000 cc or Less, 1 $14.96 X Glass, Each 4622S Canister, Suction, 1200 cc, Disposable, 1 $8.43 X Each 4623S Canister, Suction, 1500 cc, Disposable, 1 $5.63 X Each A7000 Canister, disposable, used with suction 2 $4.24 X pump, each A7001 Canister, non-disposable, used with 1 $19.00 X suction pump, each A7002 Tubing, used with suction pump, each 60 $3.15 X A4615 Cannula, Nasal Note: For use with 5 $3.00 X patient owned systems only and requires medical justification 4644S Catheter, Suction, with Kit 100 $2.50 X (Gloves/Sterile Wrap/Suction Catheter and/or Tip)

I-41

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Oxygen & 0556S Compressor Valves 31 Approved X Respiratory (Written Justification Required) Amount Equipment/ Supplies (cont.) PA required 0565E Compressor, Low Pressure effective 5/1/03 Purchase: 1 $150.00 X Rental: $22.00 X PA required 0566E Compressor, High Pressure effective 5/1/03 Purchase: 1 $400.00 X Rental: $45.00 X S8999 Resuscitation bag (for use by patient on 1 $27.00 X artificial respiration during power failure or other catastropic event) 0378E Intermittent assist device with biphasic + 30 $2200.00 X air pressure E0601 Continuous Airway Pressure (CPAP) ** device Purchase: 30 $995.00 X Rental: $135.00 X PA required 0601E CPAP Pressure Valve Purchase Note: 1 $37.00 X effective 5/1/03 For use with patient owned systems only PA required 0602E CPAP Mask Note: For use with patient 1 $58.00 X effective 5/1/03 owned systems only PA required 0603E CPAP Tubing/Rebreathing Valve Note: 1 $28.00 X effective 5/1/03 For use with patient owned systems only 4609A Disinfectant, Germicide, Per Oz 33 $.85 X A4619 Face Tent 30 Approved X Note: Medical Justification Required Amount 4618A Flutter Device, Each 1 $55.00 X PA required 0555S Heated Aerosol System Supplies $22.00 X effective 5/1/03 (Bottle, Chamber, Adapter, Tubing) Note: For use with patient owned systems only PA required E0555 Humidifier, Durable, Glass or 1 $35.00 X effective 5/1/03 Autoclavable Plastic Bottle Type, for Use with Regulator or Flowmeter Note: For use with patient owned systems only End date 4/30/03 4328A Irrigation Solution, Sterile Saline, 12 $1.78 X 500 ml (1 Unit = 500 ml); See A4323 or A4319 A4214 Sterile Saline or Water, 30 cc Vial 5 $1.32 X A4319 Sterile water irrigation solution, 1000 ml 10 $5.51 X A4323 Sterile Saline Irrigation Solution, 12 $1.95 X 1000 ml (1 Unit = 1000 ml) End date 4/30/03 4712A Irrigation, Sterile Water 6 $1.92 X (1 Unit = 1000 ml)

** Reimbursed only when provider employs or contracts for services of a respiratory therapy renderer.

I-42

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Oxygen & A4617 Mouthpiece 2 $3.50 X Respiratory Equipment/ Supplies (cont.) 0580E Nebulizer T-Piece, Reusable, Each 20 $19.25 X 0581E Nebulizer, Micro-Mist, Disposable, Each 3 $2.92 X 0582E Nebulizer, Pulmo-Neb, Disposable, 3 $3.68 X Each 0583E Nebulizer Filter, Replacement Air Inlet, 31 $.12 X for DV5610D and DV6610D, Each 0584E Nebulizer Pulmonaide Traveler Battery, 1 $66.67 X Large, Rechargeable, Each 0585E Nebulizer Supplies 100 Approved X (Itemized Attachment Required) Amount 0586E Nebulizer Valve, Clear Plastic Finger, 3 $2.01 X for Pulmo-Neb and Micro-Mist, Each 0587E Nebulizer Filter, Replacement Air Inlet, 3 $1.33 X for DV5650D and DV4650D, Each 0588E Nebulizer Mask Pediatric Aerosol – 3 $8.60 X Devilbiss and Others, Each E0570 Nebulizer, with Compressor 1 $200.00 X E0575 Nebulizer, ultrasonic, large volume 1 $180.00 X E0585 Nebulizer, with Compressor and Heater 1 Approved X Amount A7004 Small volume nonfiltered pneumatic 4 $1.45 X nebulizer, disposable A7006 Administration set, with small volume 4 $11.15 X filtered pneumatic nebulizer A7007 Large volume nebulizer, disposable, 4 $5.60 X unfilled, used with aerosol compressor A7008 Large volume nebulizer, disposable, 4 $4.75 X prefilled, used with aerosol compressor A7010 Corrugated tubing, disposable, used 1 $17.80 X with large volume nebulizer, 100 feet A7012 Water collection device, used with large 1 $15.40 X volume nebulizer A7013 Filter, disposable, used with aerosol 10 $.08 X compressor A7014 Filter, non-disposable, used with aerosol 25 $1.00 X compressor or ultrasonic generator A7015 Aerosol mask, used with DME nebulizer 4 $2.00 X A7016 Dome and mouthpiece, used with small 1 $12.15 X volume ultrasonic nebulizer

I-43

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Oxygen & A7018 Water, distilled, used with large volume 12 $.45 X Respiratory nebulizer, 1000 ml Equipment/ Supplies (cont.) A7020 Sterile water or sterile saline, 1000 ml, 12 $2.69 X used with large volume nebulizer E0460 Negative Pressure Ventilator, Portable ** or Stationary Approved Rental Only: 1 Amount X M0592 Oximeter, Non-invasive, Ear or Pulse Purchase: 1 $2,100.00 X Rental, Per Month: $210.00 X 0592E Oximetry Probe, Each Note: Medical 2 $45.00 X Justification Required Effective 5/1/03 1592E Oximetry Probes, Per Case Note: 1 $90.00 X Medical Justification Required Effective 5/1/03 PA required E0441 Oxygen Contents, Gaseous, (For Use $1.00 X effective 5/1/03; with Owned Gaseous Stationary $1.00 per cubic Systems or When Both a Stationary and foot effective Portable Gaseous System are Owned), 5/1/03 one month’s supply = one unit Note: Alaska Medicaid will reimburse per cubic foot; one cubic foot = one unit PA required E0442 Oxygen Contents, Liquid, (For Use with Approved X effective 5/1/03 Owned Liquid Stationary Systems or Amount When Both a Stationary and Portable Liquid System are Owned), one month’s supply = one unit Note: Alaska Medicaid will reimburse per cubic foot; one cubic foot = one unit PA required E0443 Portable Oxygen Contents, Gaseous, $1.00 X effective 5/1/03; (For Use Only with Portable Gaseous $1.00 per cubic Systems When No Stationary Gas or foot effective Liquid System is Used), one month’s 5/1/03 supply = one unit Note: Alaska Medicaid will reimburse per cubic foot; one cubic foot = one unit PA required E0444 Portable Oxygen Contents, Liquid (For Approved X effective 5/1/03 Use Only with Portable Liquid Systems Amount When No Stationary Gas or Liquid System is Used), one month’s supply = one unit Note: Alaska Medicaid will reimburse per cubic foot; one cubic foot = one unit 4683E Oxygen Cylinder, H or K Note: Use for ** existing PAs only Rental Only: 100 $42.00 X 4684E Oxygen Cylinder, E Note: Use for ** existing PAs only Rental Only: 100 $20.00 X

** Reimbursed only when provider employs or contracts for services of a respiratory therapy renderer.

I-44

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Oxygen & Respiratory Equipment/ Supplies (cont.) End date 4/30/03 4687E Oxygen Cylinder Stand, Small Note: 1 $68.00 X Use for existing PAs only, See E1355 PA required 4693E Oxygen Mask or Nasal Cannula 5 $8.00 X effective 5/1/03 Note: Use for patient owned systems only and Requires Medical Justification Effective 5/1/03 E0424 Stationary Compressed Gaseous $59.00 X ** Oxygen System, Rental; Includes Container, Contents, Regulator, Flowmeter, Humidifier, Nebulizer, Cannula Or Mask, and Tubing E0431 Portable Gaseous Oxygen System, $59.00 X ** Rental; Includes Portable Container, Regulator, Flowmeter, Humidifier, Cannula or Mask, and Tubing E0434 Portable Liquid Oxygen System, Rental; $59.00 X ** Includes Portable Container, Supply Reservoir, Humidifier, Flowmeter, Refill Adaptor, Contents Gauge, Cannula Or Mask, and Tubing E0439 Stationary Liquid Oxygen System, Approved X ** Rental; Includes container, contents, Amount regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing Note: 1 Unit = 10 lbs 0553S Passy-Muir Valve and Tube 65 $80.00 X E0480 Percussor, Electric or Pneumatic, Home 1 $333.00 X Model 0570E Pulmoaide Traveler (All-inclusive of 1 $398.00 X Equipment and Supplies Needed) PA required E1353 Regulator Note: Use with patient owned 1 $148.00 X effective 5/1/03 systems only PA required E1355 Stand/Rack Note: Use with patient 1 $67.00 X effective 5/1/03 owned systems only E1390 Oxygen concentrator, capable of $235.58 X delivering 85 percent or greater oxygen concentration at the prescribed flow rate (Monthly Rental) Note: Additional concentrator may be approved for school use, See policy under Respiratory Therapy in Section I PA required E1405 Oxygen and water vapor enriching Approved X effective 5/1/03 system with heated delivery Note: Use Amount with patient owned systems only; Rentals include this service

** Reimbursed only when provider employs or contracts for services of a respiratory therapy renderer.

I-45

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Oxygen & Respiratory Equipment/ Supplies (cont.) PA required E1406 Oxygen and water vapor enriching Approved X effective 5/1/03 system without heated delivery Note: Amount Use with patient owned systems only; Rentals include this service 4627A Replacement Bag for Use with 100 $3.00 X Metered Dose Inhaler (e.g., Inspirease Replacement Bag) A4627 Spacer, Bag or Reservoir, with or 3 $49.00 X without Mask, for Use with Metered Dose Inhaler 4694E Respirator/IPPB with Accessories ** Including Set-up Purchase: 1 $900.00 X Rental: $125.00 X 0401E Resuscitator Bag, Nondisposable, 1 $125.00 X Adult/Pediatric End date 4/30/03 4772S Saline, Sterile Normal, for Support Approved X System Note: See A4319 or A4323 Amount 0600E Suction Machine, Stationary 1 $220.00 X E0600 Respiratory Suction Pump, Home Model, Portable or Stationary, Electric Purchase: 1 $400.00 X Rental: $40.00 X 4624S Suction Tip (Yankauer), Each 31 $2.50 X A7501 Tracheostoma valve, including 1 $100.18 X diaphragm, each A7502 Replacement diaphragm/faceplate for 1 $47.61 X tracheostoma valve, each A7503 Filter holder or filter cap, reusable, for 1 $10.81 X use in a tracheostoma heat and moisture exchange system, each A7504 Filter for use in a tracheostoma heat and 5 $.64 X moisture exchange system, each A7505 Housing, reusable without adhesive, for 1 $4.46 X use in a heat and moisture exchange system and/or with a tracheostoma valve, each A7506 Adhesive disc for use in a heat and 5 $.32 X moisture exchange system and/or with tracheostoma valve, any type, each A7507 Filter holder and integrated filter without 4 $2.37 X adhesive, for use in a tracheostoma heat and moisture exchange system, each A7508 Housing and integrated adhesive, for 1 $2.74 X use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each

** Reimbursed only when provider employs or contracts for services of a respiratory therapy renderer. I-46

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Oxygen & A7509 Filter holder and integrated filter 1 $1.34 X Respiratory housing, and adhesive, for use as a Equipment/ tracheostoma heat and moisture Supplies (cont.) exchange system, each A4624 Tracheal Suction Catheter, Any Type, 100 $2.00 X other than closed system, Each A4625 Tracheostomy Care Kit for new 62 $3.00 X tracheostomy A4626 Tracheostomy Cleaning Brush, Each 62 $1.50 X 4626S Tracheostomy Collar With Strap, 2 $3.42 X Rubber, Each 4628S Tracheostomy Elbow With Suction Port 31 $1.33 X for Ventilator With and Without Cap, Each A4623 Tracheostomy, Inner Cannula 31 $4.50 X (Replacement Only) 4625S Tracheostomy Neck Band, Each 30 $4.12 X A4622 Tracheostomy or Laryngectomy Tube 31 $56.00 X 4664S Tracheostomy Supplies (Ties, Tubing, 1 $3.00 X Adapter) Note: Requires Medical Justification and Itemized Statement End date 4/30/03 4629S Tracheostomy Swivel, Adapter for 1 $4.58 X Anesthesia, Each 4627S Tracheostomy Tube, Flexible, Each 3 $24.40 X 4630S Tracheostomy Tubing, Suction, 10 $.58 X All Brands, 6-10 Feet, Per Foot 4632S Suction tip with attached tubing 15 $3.29 X A4621 Tracheotomy Mask or Collar 31 $2.20 X PA required A4616 Tubing (Oxygen), Per Foot Note: For 100 $2.00 X effective 5/1/03 patient owned systems only; Rentals include this service PA required A4620 Variable Concentration Mask Note: For 1 $10.00 X effective 5/1/03 patient owned systems only PA required 4645S Ventilator Replacement Parts for Repair Approved X effective 5/1/03 (Specify) Note: For patient owned Amount systems only PA required 4654S Ventilator Supplies, Disposable, Approved X effective 5/1/03 Non-reusable (Tubing, Condenser, Amount Filters, Circuits); Reusable Supplies are Included in the Rental Price (Written Justification Required) Effectice 1/1/03 E0450 Volume Ventilator, Stationary or 6 $781.48 X price is $781.48, ** portable, with backup rate feature, used prior price is with invasive interface $300.00 (e.g., tracheostomy tube) Note: Includes Maintenance, Backup, and Reusable Supplies, Rental Only, Per Month; 6 Months Maximum at One Time

** Reimbursed only when provider employs or contracts for services of a respiratory therapy renderer.

I-47

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Oxygen & 0014E Respiratory Therapy Visit for Oxygen 1 $75.00 X Respiratory Therapy Patient (Every 90 Days) Therapy Services End date 4/30/03 0010E Assessment for Ventilator-dependent 1 $125.00 X Patient, One per 6-month Period Note: See 0012E 0012E Respiratory Therapy Visit for Ventilator- 1 $100.00 X dependent Patient (Number of Visits Must be on the Prior Authorization Request) Pumps, Equipment, Supplies, & Accessories End date 4/30/03 4774S Breast Pump Kit (To Be Used with Initial 1 $35.00 X Authorization of 4754S, Breast Pump) Note: See E0603 End date 4/30/03 4754S Breast Pump, Electric (Use 4774S One Time for Breast Pump Kit) Note: See E0603 Daily Rental: 31 $3.00 X E0652 Pneumatic Compressor, Segmental 1 $2,500.00 X Home Model with Calibrated Gradient Pressure Note: Medical Justification Required E0651 Pneumatic Compressor, Segmental 1 $876.02 X Home Model without Calibrated Gradient Pressure Note: Medical Justification Required E0667 Segmental pneumatic appliance for use 1 Approved X with pneumatic compressor, full leg Amount Note: Medical justification required effective 5/1/03 E0668 Segmental pneumatic appliance for use 1 Approved X with pneumatic compressor, full arm Amount Note: Medical justification required effective 5/1/03 E0669 Segmental pneumatic appliance for use 1 Approved X with pneumatic compressor, half leg Amount Note: Medical justification required effective 5/1/03 E0603 Breast pump, electric (AC and/or DC), any type Daily Rental: 31 $3.00 X Note: Breast Pump Supplies Included End date 4/30/03 E0604 Breast pump, heavy duty, hospital 1 Approved X grade, piston operated, pulsatile Amount vacuum suction/release cycles, vacuum regulator, supplies, transformer, electric (AC and/or DC) Note: Breast Pump Supplies Included

I-48

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Specialized 7523M Bib 30 Approved X Equipment Amount & Supplies for 7512M Car Seat 1 $900.00 X Waiver Services 7521M Communication Device 1 Approved X Amount 7522M Eating Device 3 $13.00 X End date 4/30/03 7532M Four-Wheel Walker with Seat 1 Approved X and Handbrake Note: Covered under Amount DME, See E0146 7515M Floor Base 1 Approved X Amount 7516M Gait Trainer 1 $980.00 X 7507M Hand Controls for Vehicle 1 $700.00 X 7533M Hand Held Shower 1 $48.00 X 7534M Microwave Oven 1 Approved X Amount End date 4/30/03 7751M Nutritional, Enteral, Ensure, 1 Unit = 1 Can $2.45 X (8 oz/240 cc) Note: See B4150; Covered under DME since 5/1/02 End date 4/30/03 7750M Nutritional, Enteral, Thick-it, 8 oz. Can 2 $7.00 X Note: See B9998; Covered under DME since 5/1/02 7504M Pediatric Bath Chair 1 $485.00 X 7517M Pediatric Bed 1 $3,800.00 X 7514M Pediatric Corner Chair 1 $760.00 X 7513M Pediatric Potty Chair 1 $525.00 X 7506M Pediatric Transport Chair Tray 1 $375.00 X Effective 4/1/03 7543M Personal Emergency Response System, 1 $45.00 X price is $45, prior Installation, One Time Charge Per price is $40 Recipient 7542M Personal Emergency Response System (Includes Routine Maintenance and Parts) Rental, Per Month: 1 $40.00 X 7508M Ramp 1 Approved X Amount 7531M Reacher 1 Approved X Amount 7530M Reclining Lift Chair 1 $895.00 X 7518M Therapy Mat 1 $400.00 X 7501M Tumbleform 1 $400.00 X 7503M Tumbleform Floor Sitter With Wheels 1 $230.00 X 7502M Tumbleform Wedge 1 $150.00 X 7799M Unlisted Specialized Equipment/Medical Approved X Supplies (Documentation Requirements) Amount 7511M Van Lift 1 Approved X Amount 7505M Wheelchair Tray 1 $450.00 X Effective 1/1/03 4741M S.M.E. Repair Parts (Written Medical Approved X Justification Required) Amount Effective 1/1/03 4742M S.M.E. Repair Labor (Written Medical Approved X Justification Required) Amount

ALL SME PRODUCTS ARE AUTHORIZED BY THE APPROPRIATE WAIVER AGENCY.

I-49

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Tape Elastic Tape, With Adhesive, 4477A 2-inch x 5 Yards, Per Roll 5 $4.58 X 4478A Elastic Tape, With Adhesive, 5 $7.48 X 3-inch x 5 Yards, Per Roll 4450A Foam Tape, 1-inch, 1 x 10 Yards, 5 $3.77 X Per Roll 4451A Foam Tape, 2-inch, 1 x 10 Yards, 5 $7.55 X Per Roll 4452A Foam Tape, 3-inch, 1 x 10 Yards, 5 $11.33 X Per Roll 4453A Foam Tape, 4-inch, 1 x 10 Yards, 5 $15.10 X Per Roll 4462A Hypoallergenic Cloth Tape, ½-inch, 5$.82X 1 x 10 Yards, Per Roll 4463A Hypoallergenic Cloth Tape, 1-inch, 5 $1.63 X 1 x 10 Yards, Per Roll 4464A Hypoallergenic Cloth Tape, 2-inch, 5 $3.27 X 1 x 10 Yards, Per Roll 4465A Hypoallergenic Cloth Tape, 3-inch, 5 $4.90 X 1 x 10 Yards, Per Roll 4466A Hypoallergenic Knitted Tape, 5 $2.05 X 1 x 5 Yards, Per Roll 4467A Hypoallergenic Knitted Tape, 5 $3.80 X 2 x 5 Yards, Per Roll 4472A Multi-purpose Dressing Tape, 5 $5.32 X Hypoallergenic, 3-inch, 1 x 10 Yards, Per Roll 4454A Paper Tape, ½-Inch, 1 x 10 Yards, 5$.71X Per Roll 4455A Paper Tape, 1-inch, 1 x 10 Yards, 5 $1.42 X Per Roll 4456A Paper Tape, 2-inch, 1 x 10 Yards, 5 $2.85 X Per Roll 4457A Paper Tape, 3-inch, 1 x 10 Yards, 5 $4.28 X Per Roll 4468A Porous Tape, for Positioning 5 $1.37 X and Support, 1-inch, 1 x 10 Yards, Per Roll 4469A Porous Tape, for Positioning 5 $2.05 X and Support, 1 ½-inch, 1 x 10 Yards, Per Roll 4470A Porous Tape, for Positioning 5 $2.73 X and Support, 2-inch, 1 x 10 Yards, Per Roll 4471A Porous Tape, for Positioning 5 $4.10 X and Support, 3-inch, 1 x 10 Yards, Per Roll A4450 Tape, non-waterproof, per 18 square 5$.37X inches

I-50

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Tape (cont.) A4452 Tape, waterproof, per 18 square inches 300 $.50 X 4458A Waterproof Tape, ½-inch, 5 $1.18 X 1 x 10 Yards, Per Roll 4763S Tape, medical, all types, per roll 12 Approved X Amount 4460A Waterproof Tape, 2-inch, 5 $4.78 X 1 x 10 Yards, Per Roll 4459A Waterproof Tape, 1-inch, 5 $2.53 X 1 x 10 Yards, Per Roll 4461A Waterproof Tape, 3-inch, 5 $7.18 X 1 x 10 Yards, Per Roll 4473A Woven Compression Tape, 1-inch, 5 $3.03 X Per Roll 4474A Woven Compression Tape, 2-inch, 5 $5.58 X Per Roll 4475A Woven Compression Tape, 3-inch, 5 $8.35 X Per Roll 4476A Woven Compression Tape, 4-inch, 5 $10.98 X Per Roll TENS E0731 Form-Fitting Conductive Garment for 3 Approved X (Transcutaneous Delivery of TENS or NMES (with Amount Electrical Nerve conductive fibers separated from the Stimulator) patient’s skin by layers of fabric) 4679E TENS Replacement Supplies 250 Approved X Amount E0720 TENS, Two Lead, Localized Stimulation Note: Requires Prior Authorization With 30-Day Test at Rental Price Rental, Per Month: $57.50 X Purchase: 1 $575.00 X E0730 Transcutaneous electrical nerve stimulation device, four or more leads, for multiple nerve stimulation Note: Requires Prior Authorization With 30-Day Test at Rental Price Rental, Per Month: $62.50 X Purchase: 1 $625.00 X E0745 Neuromuscular stimulator, electronic 12 $65.29 X shock unit E0747 Osteogenesis stimulator, electrical, 1 $3375.95 X noninvasive, other than spinal applications

I-51

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Wheelchairs, E0971 Anti-tipping Device, Wheelchair 1 $76.37 X Equipment, Supplies, & Maintenance E0962 One- inch Cushion, for Wheelchair 1 Approved X Amount E0963 Two-inch Cushion, for Wheelchair 1 Approved X Amount E0964 Three-inch Cushion, for Wheelchair 1 Approved X Amount E0965 Four-inch Cushion, for Wheelchair 1 Approved X Amount E1069 Deep Cycle Battery 2 Approved X Note: Maximum of Two Per 12-month Amount Period Effective 1/1/03 E1020 Residual limb support system for 2 Approved X PA required wheelchair Note: Requires Medical Amount effective 1/1/03 Justification 4662E Desk/Full Length Arms, 1 $100.00 X 17 Necessary For Transfer E1084 Hemi-wheelchair; Detachable Arms, 1 $700.00 X Desk or Full Length, Swing-away, Detachable, Elevating Legrests E1086 Hemi-wheelchair; Detachable Arms, 1 $510.00 X Desk or Full-Length, Swing-away, Detachable Footrests E1085 Hemi-wheelchair; Fixed Full-Length 1 $510.00 X Arms, Swing-away, Detachable Footrests E1083 Hemi-wheelchair; Fixed Full-Length 1 $510.00 X Arms, Swing-away, Detachable, Elevating Leg Rests 4653E Leg Rests, Detach/Swing/Elevating, 1 $129.67 X Per Pair E1230 Power operated vehicle (three- or four- 1 $4000.00 X wheel nonhighway), specify brand name and model number E1240 Lightweight Wheelchair; 1 $1,500.00 X Detachable Arms, Desk or Full-Length, Swing-away, Detachable, Elevating Leg Rests E1260 Lightweight Wheelchair; Detachable 1 $1,500.00 X Arms, Desk or Full-Length, Swing-away, Detachable Footrests E1211 Motorized Wheelchair; Detachable 1 Approved X Arms, Desk or Full-Length, Swing-away, Amount Detachable, Elevating Leg Rests

I-52

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Wheelchairs, E1212 Motorized Wheelchair; 1 Approved X Equipment, Fixed Full-Length Arms, Amount Supplies, & Swing-away, Detachable Footrests Maintenance (cont.) E1213 Motorized Wheelchair, Detachable 1 Approved X Arms, Desk or Full-Length, Swing-away, Amount Detachable Footrests E0970 No. 2 Footplates, Except for Elevating 1 Approved X Leg Rests Amount E1298 Special Wheelchair Seat Depth and/or 1 Approved X Width, by Construction Amount 4652E Standard Wheelchair, Adult 1 $390.00 X E1130 Standard Wheelchair; Fixed Full-Length 1 $510.00 X Arms, Fixed or Swing-away Detachable Footrests E0972 Transfer Board or device 1 $50.00 X E1035 Multi-positional patient transfer system, 1 Approved X with integrated seat, operated by care Amount giver E0977 Wedge Cushion, 1 Approved X Wheelchair Amount E1140 Wheelchair; Detachable Arms, Desk or 1 $510.00 X Full Length, Swing-away, detachable footrests E1220 Wheelchair; Specially Sized 1 Approved X or Constructed (Indicate Brand Name, Amount Model Number, if any, and Justification) E1092 Wide, Heavy-Duty Wheelchair; 1 $2,500.00 X Detachable Arms, Desk or Full-Length, Swing-away, Detachable, Elevating Leg Rests E1093 Wide, Heavy-Duty Wheelchair; 1 $2,500.00 X Detachable Arms, Desk or Full Length arms, Swing-away, Detachable Footrests Wound A4244 Alcohol or Peroxide, Per Pint 1 $.90 X Care/Cleansing 4215S Applicator - Cotton Tipped Stick 400 $.02 X (e.g., Q-Tip), 2-inch, Each 4214S Applicator - Cotton Tipped Stick, 200 $.02 X Non-sterile, 6-inch, Each 4216S Applicator, Sterile, 6-inch, Each 200 $.05 X 4770S Bandages, Medicated 62 $8.45 X 4771S Bandages, Nonmedicated (2 x 2, 4 x 4) 62 $.50 X 4213S Chlorhexidine Dressing, Each 62 $7.97 X 5142S Cleanser Wipes, Lotion, Each 200 $.08 X 4767S Cotton Balls/rolls/swabs/sticks/wipes 500 $.02 X 4768S Cotton Rolls, Per Oz. 32 $.57 X

I-53

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Wound 4241S Debrisan, 10 Gm, Per Gm 20 $1.16 X Care/Cleansing (cont.) 4243S Debrisan, 56 Gm, Per Gm 168 $1.24 X 4242S Debrisan, 60 Gm, Per Gm 180 $.08 X 4757S Douche Apparatus, One Unit 3 $3.00 X (Medical Procedure Only, Disposable) End date 3/31/03 A6405 Gauze, Elastic (e.g., Kerlix), Per Yd. 120 $.70 X 4201S Gauze, Sterile, 2 x 2, Each 100 $.08 X 4202S Gauze, Sterile, 4 x 4, Each 480 $.23 X 4206S Gauze, Impregnated, Water or Saline, 62 $3.20 X Without Border, Up to 4 x 4, Each 4210S Gauze Sponge, 2 x 2, Each 200 $.09 X 4211S Gauze Sponge, 3 x 3, Each 200 $.05 X 4212S Gauze Sponge, 4 x 4, Each 200 $.22 X 4773S Germicide for Oxygen Support Systems, 12 $15.00 X Per Pint 4766S Glove, Nonsterile, 1 Unit = 1 Glove 200 $.14 X 4765S Glove, Sterile, 1 Unit = 1 Glove 240 $.55 X 4782S Hibiclens, 8 oz 6 $8.57 X 4245S Hydrocolloid Dressing, 62 $6.99 X Up to 2 3/4 x 3 1/2, Each 4246S Hydrocolloid Dressing, Up to 4 x 4, Each 62 $9.66 X 4247S Hydrocolloid Dressing, Up to 6 x 8, Each 62 $13.00 X A6201 Composite dressing, pad size more than 20 $.29 X 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing A6202 Composite dressing, pad size more than 20 $.49 X 48 sq. in., without adhesive border, each dressing A6231 Gauze, impregnated, hydrogel, for direct 100 $4.46 X wound contact, pad size 16 sq. in. or less, each dressing A6232 Gauze, impregnated, hydrogel, for direct 100 $6.57 X wound contact, pad size greater that 16 sq. in., but less than or equal to 48 sq. in., each dressing A6233 Gauze, impregnated, hydrogel for direct 100 $18.30 X wound contact, pad size more than 48 sq. in., each dressing A6252 Specialty absorptive dressing, wound 50 $.35 X cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing A6253 Specialty absorptive dressing, wound 100 $2.19 X cover, pad size more than 48 sq. in., without adhesive border, each dressing

I-54

DME & Supplies 05/03 Table I-4. Procedure Codes: Durable Medical Equipment and Supplies, continued Category DME Description Max. Maximum P. A. of Code Code Units Allowable Yes No Wound 4248S Hydrogel Wound Care (e.g., Biolex), 120 $.60 X Care/Cleansing Per Gm (cont.) 4207S IV Dressing, 2 3/8 x 2 3/4, Each 32 $1.33 X 4208S IV Dressing, 4 x 4 3/4, Each 32 $3.25 X 4209S IV Dressing, 6 x 8, Each 32 $8.28 X 4759S Montgomery Straps, Per Sheet 10 $2.75 X 4203S Petrolatum Dressing, 3 x 3, Each 62 $.79 X 4204S Petrolatum Dressing, 3 x 8, Each 62 $1.90 X 4205S Petrolatum Dressing, 3 x 16, Each 62 $2.74 X 4247A Povidone Sol., 1 Pint 6 $5.25 X A4247 Betadine or iodine swabs/wipes, per box 200 $.20 X Note: Alaska Medicaid reimburses per each 5144S Protectant, Hydrocolloid Alginate Gel 60 $2.24 X Powder (e.g., Comfeel), Per Gm E1300 Whirlpool, Portable (Overtub Type) 1 $150.00 X 4244S Wound Gel Filler (e.g., Duoderm), Per 100 $.17 X Gm K0538 Negative pressure wound therapy 3 $1642.11 X electrical pump, stationary or portable Note: Rental Only K0539 Dressing set for negative pressure 30 $26.23 X wound therapy electrical pump, stationary or portable, each K0540 Canister set for negative pressure 1 $23.46 X wound therapy electrical pump, stationary or portable, each

I-55

DME & Supplies