TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE v3.23 (January - December 2018) PAGE 1 of 95 Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2 A0100 Blank NONEMERGENCY TRANSPORT TAXI Blank $20.81 HCPCS - Non-Drugs A0110 Blank NONEMERGENCY TRANSPORT BUS Blank $61.62 HCPCS - Non-Drugs A0120 Blank NONER TRANSPORT MINI-BUS Blank $183.09 HCPCS - Non-Drugs A0130 Blank NONER TRANSPORT WHEELCH VAN Blank $85.54 HCPCS - Non-Drugs A0140 Blank NONEMERGENCY TRANSPORT AIR Blank $1,211.38 HCPCS - Non-Drugs A0160 Blank NONER TRANSPORT CASE WORKER Blank $2.42 HCPCS - Non-Drugs A0170 Blank TRANSPORT PARKING FEES/TOLLS Blank $303.72 HCPCS - Non-Drugs A0180 Blank NONER TRANSPORT LODGNG RECIP Blank $809.69 HCPCS - Non-Drugs A0190 Blank NONER TRANSPORT MEALS RECIP Blank $181.99 HCPCS - Non-Drugs A0398 Blank ALS ROUTINE DISPOSBLE SUPPLS Blank $132.93 HCPCS - Non-Drugs A0422 Blank AMBULANCE 02 LIFE SUSTAINING Blank $126.28 HCPCS - Non-Drugs A4206 Blank 1 CC STERILE SYRINGE&NEEDLE Blank $0.94 HCPCS - Non-Drugs A4207 Blank 2 CC STERILE SYRINGE&NEEDLE Blank $0.94 HCPCS - Non-Drugs A4208 Blank 3 CC STERILE SYRINGE&NEEDLE Blank $0.94 HCPCS - Non-Drugs A4209 Blank 5+ CC STERILE SYRINGE&NEEDLE Blank $0.94 HCPCS - Non-Drugs A4210 Blank NONNEEDLE INJECTION DEVICE Blank $1,233.33 HCPCS - Non-Drugs A4211 Blank SUPP FOR SELF-ADM INJECTIONS Blank $57.07 HCPCS - Non-Drugs A4212 Blank NON CORING NEEDLE OR STYLET Blank $13.31 HCPCS - Non-Drugs A4213 Blank 20+ CC SYRINGE ONLY Blank $1.88 HCPCS - Non-Drugs A4215 Blank STERILE NEEDLE Blank $1.29 HCPCS - Non-Drugs A4216 Blank STERILE WATER/SALINE, 10 ML Blank $1.09 HCPCS - Non-Drugs A4217 Blank STERILE WATER/SALINE, 500 ML Blank $6.97 HCPCS - Non-Drugs A4217 AU STERILE WATER/SALINE, 500 ML Blank $6.97 HCPCS - Non-Drugs A4218 Blank STERILE SALINE OR WATER Blank $3.59 HCPCS - Non-Drugs A4220 Blank INFUSION PUMP REFILL KIT Blank $86.92 HCPCS - Non-Drugs A4221 Blank SUPP NON-INSULIN INF CATH/WK Blank $111.76 HCPCS - Non-Drugs A4222 Blank INFUSION SUPPLIES WITH PUMP Blank $144.04 HCPCS - Non-Drugs A4223 Blank INFUSION SUPPLIES W/O PUMP Blank $131.27 HCPCS - Non-Drugs A4224 Blank SUPPLY INSULIN INF CATH/WK Blank $111.76 HCPCS - Non-Drugs A4225 Blank SUP/EXT INSULIN INF PUMP SYR Blank $25.36 HCPCS - Non-Drugs A4230 Blank INFUS INSULIN PUMP NON NEEDL Blank $22.52 HCPCS - Non-Drugs A4231 Blank INFUSION INSULIN PUMP NEEDLE Blank $9.38 HCPCS - Non-Drugs A4232 Blank SYRINGE W/NEEDLE INSULIN 3CC Blank $5.80 HCPCS - Non-Drugs A4233 Blank ALKALIN BATT FOR GLUCOSE MON Blank $4.98 HCPCS - Non-Drugs A4233 NU ALKALIN BATT FOR GLUCOSE MON Blank $4.98 HCPCS - Non-Drugs A4234 Blank J-CELL BATT FOR GLUCOSE MON Blank $23.02 HCPCS - Non-Drugs A4234 NU J-CELL BATT FOR GLUCOSE MON Blank $23.02 HCPCS - Non-Drugs A4235 Blank LITHIUM BATT FOR GLUCOSE MON Blank $9.76 HCPCS - Non-Drugs A4235 NU LITHIUM BATT FOR GLUCOSE MON Blank $9.76 HCPCS - Non-Drugs A4236 Blank SILVR OXIDE BATT GLUCOSE MON Blank $11.32 HCPCS - Non-Drugs A4236 NU SILVR OXIDE BATT GLUCOSE MON Blank $11.32 HCPCS - Non-Drugs A4244 Blank ALCOHOL OR PEROXIDE PER PINT Blank $1.88 HCPCS - Non-Drugs A4245 Blank ALCOHOL WIPES PER BOX Blank $5.45 HCPCS - Non-Drugs A4246 Blank BETADINE/PHISOHEX SOLUTION Blank $5.45 HCPCS - Non-Drugs A4247 Blank BETADINE/IODINE SWABS/WIPES Blank $7.59 HCPCS - Non-Drugs A4248 Blank CHLORHEXIDINE ANTISEPT Blank $5.40 HCPCS - Non-Drugs A4250 Blank URINE REAGENT STRIPS/TABLETS Blank $26.16 HCPCS - Non-Drugs A4252 Blank BLOOD KETONE TEST OR STRIP Blank $11.55 HCPCS - Non-Drugs A4253 Blank BLOOD GLUCOSE/REAGENT STRIPS Blank $113.18 HCPCS - Non-Drugs A4253 NU BLOOD GLUCOSE/REAGENT STRIPS Blank $113.18 HCPCS - Non-Drugs A4255 Blank GLUCOSE MONITOR PLATFORMS Blank $43.63 HCPCS - Non-Drugs A4256 Blank CALIBRATOR SOLUTION/CHIPS Blank $32.97 HCPCS - Non-Drugs A4256 KL CALIBRATOR SOLUTION/CHIPS Blank $28.96 HCPCS - Non-Drugs A4257 Blank REPLACE LENSSHIELD CARTRIDGE Blank $102.17 HCPCS - Non-Drugs A4258 Blank LANCET DEVICE EACH Blank $20.68 HCPCS - Non-Drugs A4258 KL LANCET DEVICE EACH Blank $17.89 HCPCS - Non-Drugs A4259 Blank LANCETS PER BOX Blank $13.85 HCPCS - Non-Drugs 1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE v3.23 (January - December 2018) PAGE 2 of 95 Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2 A4259 KL LANCETS PER BOX Blank $12.13 HCPCS - Non-Drugs A4261 Blank CERVICAL CAP CONTRACEPTIVE Blank $77.88 HCPCS - Non-Drugs A4262 Blank TEMPORARY TEAR DUCT PLUG Blank $0.94 HCPCS - Non-Drugs A4263 Blank PERMANENT TEAR DUCT PLUG Blank $58.28 HCPCS - Non-Drugs A4264 Blank INTRATUBAL OCCLUSION DEVICE Blank $2,243.66 HCPCS - Non-Drugs A4265 Blank PARAFFIN Blank $37.05 HCPCS - Non-Drugs A4266 Blank DIAPHRAGM Blank $87.22 HCPCS - Non-Drugs A4267 Blank MALE CONDOM Blank $0.94 HCPCS - Non-Drugs A4268 Blank FEMALE CONDOM Blank $1.20 HCPCS - Non-Drugs A4269 Blank SPERMICIDE Blank $1.88 HCPCS - Non-Drugs A4270 Blank DISPOSABLE ENDOSCOPE SHEATH Blank $17.96 HCPCS - Non-Drugs A4280 Blank BRST PRSTHS ADHSV ATTCHMNT Blank $8.48 HCPCS - Non-Drugs A4281 Blank REPLACEMENT BREASTPUMP TUBE Blank $20.04 HCPCS - Non-Drugs A4282 Blank REPLACEMENT BREASTPUMP ADPT Blank $21.39 HCPCS - Non-Drugs A4283 Blank REPLACEMENT BREASTPUMP CAP Blank $116.11 HCPCS - Non-Drugs A4284 Blank REPLCMNT BREAST PUMP SHIELD Blank $26.16 HCPCS - Non-Drugs A4285 Blank REPLCMNT BREAST PUMP BOTTLE Blank $17.67 HCPCS - Non-Drugs A4286 Blank REPLCMNT BREASTPUMP LOK RING Blank $68.50 HCPCS - Non-Drugs A4290 Blank SACRAL NERVE STIM TEST LEAD Blank $703.49 HCPCS - Non-Drugs A4300 Blank CATH IMPL VASC ACCESS PORTAL Blank $40.41 HCPCS - Non-Drugs A4301 Blank IMPLANTABLE ACCESS SYST PERC Blank $19.73 HCPCS - Non-Drugs A4305 Blank DRUG DELIVERY SYSTEM >=50 ML Blank $19.73 HCPCS - Non-Drugs A4306 Blank DRUG DELIVERY SYSTEM <=50 ML Blank $26.87 HCPCS - Non-Drugs A4310 Blank INSERT TRAY W/O BAG/CATH Blank $15.90 HCPCS - Non-Drugs A4311 Blank CATHETER W/O BAG 2-WAY LATEX Blank $28.68 HCPCS - Non-Drugs A4312 Blank CATH W/O BAG 2-WAY SILICONE Blank $35.28 HCPCS - Non-Drugs A4313 Blank CATHETER W/BAG 3-WAY Blank $36.29 HCPCS - Non-Drugs A4314 Blank CATH W/DRAINAGE 2-WAY LATEX Blank $49.02 HCPCS - Non-Drugs A4315 Blank CATH W/DRAINAGE 2-WAY SILCNE Blank $51.24 HCPCS - Non-Drugs A4316 Blank CATH W/DRAINAGE 3-WAY Blank $55.32 HCPCS - Non-Drugs A4320 Blank IRRIGATION TRAY Blank $10.99 HCPCS - Non-Drugs A4321 Blank CATH THERAPEUTIC IRRIG AGENT Blank $10.00 HCPCS - Non-Drugs A4322 Blank IRRIGATION SYRINGE Blank $7.03 HCPCS - Non-Drugs A4326 Blank MALE EXTERNAL CATHETER Blank $21.44 HCPCS - Non-Drugs A4327 Blank FEM URINARY COLLECT DEV CUP Blank $87.51 HCPCS - Non-Drugs A4328 Blank FEM URINARY COLLECT POUCH Blank $21.09 HCPCS - Non-Drugs A4330 Blank STOOL COLLECTION POUCH Blank $14.54 HCPCS - Non-Drugs A4331 Blank EXTENSION DRAINAGE TUBING Blank $7.45 HCPCS - Non-Drugs A4332 Blank LUBE STERILE PACKET Blank $0.30 HCPCS - Non-Drugs A4333 Blank URINARY CATH ANCHOR DEVICE Blank $3.55 HCPCS - Non-Drugs A4334 Blank URINARY CATH LEG STRAP Blank $7.87 HCPCS - Non-Drugs A4335 Blank INCONTINENCE SUPPLY Blank $0.61 HCPCS - Non-Drugs A4336 Blank URETHRAL INSERT Blank $3.80 HCPCS - Non-Drugs A4338 Blank INDWELLING CATHETER LATEX Blank $24.51 HCPCS - Non-Drugs A4340 Blank INDWELLING CATHETER SPECIAL Blank $59.98 HCPCS - Non-Drugs A4344 Blank CATH INDW FOLEY 2 WAY SILICN Blank $31.41 HCPCS - Non-Drugs A4346 Blank CATH INDW FOLEY 3 WAY Blank $37.59 HCPCS - Non-Drugs A4349 Blank DISPOSABLE MALE EXTERNAL CAT Blank $5.16 HCPCS - Non-Drugs A4351 Blank STRAIGHT TIP URINE CATHETER Blank $4.53 HCPCS - Non-Drugs A4352 Blank COUDE TIP URINARY CATHETER Blank $13.25 HCPCS - Non-Drugs A4353 Blank INTERMITTENT URINARY CATH Blank $14.97 HCPCS - Non-Drugs A4354 Blank CATH INSERTION TRAY W/BAG Blank $23.63 HCPCS - Non-Drugs A4355 Blank BLADDER IRRIGATION TUBING Blank $18.60 HCPCS - Non-Drugs A4356 Blank EXT URETH CLMP OR COMPR DVC Blank $86.78 HCPCS - Non-Drugs A4357 Blank BEDSIDE DRAINAGE BAG Blank $19.52 HCPCS - Non-Drugs A4358 Blank URINARY LEG OR ABDOMEN BAG Blank $13.62 HCPCS - Non-Drugs A4360 Blank DISPOSABLE EXT URETHRAL DEV Blank $1.20 HCPCS - Non-Drugs 1, 2 - See end of the table for notes regarding these fields. TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE v3.23 (January - December 2018) PAGE 3 of 95 Status/ Usage HCPCS Code Modifier 1 HCPCS Code Description Charge GAAF Category Indicator 2 A4361 Blank OSTOMY FACE PLATE Blank $36.08 HCPCS - Non-Drugs A4362 Blank SOLID SKIN BARRIER Blank $7.66 HCPCS - Non-Drugs A4363 Blank OSTOMY CLAMP, REPLACEMENT Blank $5.64 HCPCS - Non-Drugs A4364 Blank ADHESIVE, LIQUID OR EQUAL Blank $4.45 HCPCS - Non-Drugs A4366 Blank OSTOMY VENT Blank $2.08 HCPCS - Non-Drugs A4367 Blank OSTOMY BELT Blank $15.02 HCPCS - Non-Drugs A4368 Blank OSTOMY FILTER Blank $0.65 HCPCS - Non-Drugs A4369 Blank SKIN BARRIER LIQUID PER OZ Blank $5.77 HCPCS - Non-Drugs A4371 Blank SKIN BARRIER POWDER PER OZ Blank $8.35 HCPCS - Non-Drugs A4372 Blank SKIN BARRIER SOLID 4X4 EQUIV Blank $9.45 HCPCS - Non-Drugs A4373 Blank SKIN BARRIER WITH FLANGE Blank $13.55 HCPCS - Non-Drugs A4375 Blank DRAINABLE PLASTIC PCH W FCPL Blank $35.07 HCPCS - Non-Drugs A4376 Blank DRAINABLE RUBBER PCH W FCPLT Blank $95.12 HCPCS - Non-Drugs A4377 Blank DRAINABLE PLSTIC PCH W/O FP Blank $9.65 HCPCS - Non-Drugs A4378 Blank DRAINABLE RUBBER PCH