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Medi-Cal Rates Information

Medi-Cal Rates as of 01/15/2020 (Codes A0130 thru L3253)

Medi-Cal Rates are updated and effective as of the 15th of the month and published to the Medi-Cal website on the 16th of the month


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Proc Type Proc Code Procedure Description Unit Value Basic Rate Child Rate ER Rate Conv Ind ER Ind Cut-back Ind Prof % Rental Rate Non-Physn. Med.Prac. Ind
1 A0130 NON-EMERGENCY TRANSPORTATION: WHEE 17.65 $17.65 --- -- 009 0 0 0.00 $0.00 N
1 A0225 NEONATAL EMERGENCY TRANSPORT 179.92 $179.92 --- -- 009 0 0 0.00 $0.00 N
1 A0380 BASIC LIFE SUPPORT MILEAGE 1.30 $1.30 --- -- 009 0 0 0.00 $0.00 N
1 A0390 ADVANCED LIFE SUPPORT MILEAGE 1.30 $1.30 --- -- 009 0 0 0.00 $0.00 N
1 A0420 AMBULANCE WAITING TIME 1/2 HR INCREMENTS 19.76 $19.76 --- -- 009 0 0 0.00 $0.00 N
1 A0422 AMBULANCE OXYGEN AND OXYGEN SUPPLY 9.98 $9.98 --- -- 009 0 0 0.00 $0.00 N
1 A0424 EXTRA AMBULANCE ATTENDANT 16.44 $16.44 --- -- 009 0 0 0.00 $0.00 N
1 A0425 GROUND MILEAGE 3.55 $3.55 --- -- 009 0 0 0.00 $0.00 N
E A0425 GROUND MILEAGE 0.65 $0.65 --- -- 009 0 0 0.00 $0.00 N
1 A0426 ALS 1 107.16 $107.16 --- -- 009 0 0 0.00 $0.00 N
1 A0427 ALS1-EMERGENCY 118.20 $118.20 --- -- 009 0 0 0.00 $0.00 N
1 A0428 BLS 107.16 $107.16 --- -- 009 0 0 0.00 $0.00 N
1 A0429 BLS-EMERGENCY 118.20 $118.20 --- -- 009 0 0 0.00 $0.00 N
1 A0430 FIXED WING AIR TRANSPORT 1275.00 $1275.00 --- -- 009 0 0 0.00 $0.00 N
1 A0431 ROTARY WING AIR TRANSPORT 1800.00 $1800.00 --- -- 009 0 0 0.00 $0.00 N
1 A0433 ALS 2 118.20 $118.20 --- -- 009 0 0 0.00 $0.00 N
1 A0434 SPECIALTY CARE TRANSPORT 118.20 $118.20 --- -- 009 0 0 0.00 $0.00 N
1 A0435 FIXED WING AIR MILEAGE 14.25 $14.25 --- -- 009 0 0 0.00 $0.00 N
1 A0436 ROTARY WING AIR MILEAGE 22.10 $22.10 --- -- 009 0 0 0.00 $0.00 N
1 A0999 UNLISTED AMBULANCE SERVICE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 A4217 STERILE WATER/SALINE, 500 ML 6.00 $6.00 --- -- 009 0 0 0.00 $0.00 Y
P A4217 STERILE WATER/SALINE, 500 ML 6.00 $6.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4226 WEEKLY SUPPLY MAINT CGS PUMP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4261 CERVICAL CAP CONTRACEPTIVE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
K A4264 INTRATUBAL OCCLUSION DEVICE 1299.00 $1299.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4266 DIAPHRAGM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4267 MALE CONDOM 14.99 $14.99 --- -- 009 0 0 0.00 $0.00 Y
1 A4268 FEMALE CONDOM 2.50 $2.50 --- -- 009 0 0 0.00 $0.00 Y
1 A4269 SPERMICIDE 14.99 $14.99 --- -- 009 0 0 0.00 $0.00 Y
1 A4280 BRST PRSTHS ADHSV ATTCHMNT 3.00 $3.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4281 REPLACEMENT BREASTPUMP TUBE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 A4282 REPLACEMENT BREASTPUMP ADPT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 A4283 REPLACEMENT BREASTPUMP CAP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 A4284 REPLCMNT BREAST PUMP SHIELD 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 A4285 REPLCMNT BREAST PUMP BOTTLE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 A4286 REPLCMNT BREASTPUMP LOK RING 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 A4556 ELECTRODES, PAIR 8.26 $8.26 --- -- 009 0 0 0.00 $0.00 Y
1 A4557 LEAD WIRES, PAIR 14.35 $14.35 --- -- 009 0 0 0.00 $0.00 Y
1 A4566 SHOULD SLING/VEST/ABRESTRAIN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4595 TENS SUPPLIES, 2 LEAD, PER MONTH 22.68 $22.68 --- -- 009 0 0 0.00 $0.00 Y
1 A4602 REPLACE LITHIUM BATTERY 1.5V 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4604 TUBING WITH HEATING ELEMENT 51.12 $51.12 --- -- 009 0 0 0.00 $0.00 Y
1 A4606 OXYGEN PROBE USED W OXIMETER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4615 CANNULA NASAL 0.64 $0.64 --- -- 009 0 0 0.00 $0.00 Y
1 A4619 FACE TENT 0.97 $0.97 --- -- 009 0 0 0.00 $0.00 Y
1 A4620 VARIABLE CONCENTRATION MASK 0.56 $0.56 --- -- 009 0 0 0.00 $0.00 Y
1 A4635 CRUTCH PAD, EACH 4.10 $4.10 --- -- 009 0 0 0.00 $0.00 Y
1 A4636 CRUTCH HANDGRIP, EACH 3.22 $3.22 --- -- 009 0 0 0.00 $0.00 Y
1 A4637 REPLACEMENT, TIP, CANE, CRUTCH, WA 1.64 $1.64 --- -- 009 0 0 0.00 $0.00 Y
1 A4640 REPLACEMENT PAD FOR USE WITH MEDIC 45.18 $45.18 --- -- 009 0 0 0.00 $4.38 Y
L A4641 RADIOPHARM DX AGENT NOC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A4642 IN111 SATUMOMAB 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A4648 *08IMPLANTABLE TISSUE MARKER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4649 SURGICAL SUPPLY; MISCELLANEOUS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A4650 *08IMPLANT RADIATION DOSIMETER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4660 SPHYG/BP APP W CUFF AND STET 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4663 DIALYSIS BLOOD PRESSURE CUFF 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A4670 AUTOMATIC BP MONITOR, DIAL 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A5500 FOR DIABETICS ONLY FITTING 47.49 $47.49 --- -- 009 0 0 0.00 $0.00 N
P A5500 FOR DIABETICS ONLY FITTING 47.49 $47.49 --- -- 009 0 0 0.00 $0.00 Y
P A5501 FOR DIABETICS ONLY FITTING 142.43 $142.43 --- -- 009 0 0 0.00 $0.00 Y
1 A5501 FOR DIABETICS ONLY FITTING 142.43 $142.43 --- -- 009 0 0 0.00 $0.00 N
1 A5503 FOR DIABETICS ONLY MODIFICATION 21.12 $21.12 --- -- 009 0 0 0.00 $0.00 N
1 A5504 FOR DIABETICS ONLY MODIFCATION 21.12 $21.12 --- -- 009 0 0 0.00 $0.00 N
1 A5505 FOR DIABETICS ONLY MODIFICATION 21.12 $21.12 --- -- 009 0 0 0.00 $0.00 N
1 A5506 FOR DIABETICS ONLY MODIFICATION 21.12 $21.12 --- -- 009 0 0 0.00 $0.00 N
1 A5507 FOR DIABETICS ONLY NOT SPECIFIED MOD 21.12 $21.12 --- -- 009 0 0 0.00 $0.00 N
P A5507 FOR DIABETICS ONLY NOT SPECIFIED MOD 21.12 $21.12 --- -- 009 0 0 0.00 $0.00 N
P A5512 MULTI DEN INSERT DIRECT FORM 19.38 $19.38 --- -- 009 0 0 0.00 $0.00 Y
1 A5512 MULTI DEN INSERT DIRECT FORM 19.38 $19.38 --- -- 009 0 0 0.00 $0.00 N
1 A5513 MULTI DEN INSERT CUSTOM MOLD 28.91 $28.91 --- -- 009 0 0 0.00 $0.00 N
P A5513 MULTI DEN INSERT CUSTOM MOLD 28.91 $28.91 --- -- 009 0 0 0.00 $0.00 Y
1 A6501 COMPRES BURNGARMENT BODYSUIT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6502 COMPRES BURNGARMENT CHINSTRP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6503 COMPRES BURNGARMENT FACEHOOD 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6504 CMPRSBURNGARMENT GLOVEWRIST 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6505 CMPRSBURNGARMENT GLOVEELBOW 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6506 CMPRSBURNGRMNT GLOVEAXILLA 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6507 CMPRS BURNGARMENT FOOTKNEE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6508 CMPRS BURNGARMENT FOOTTHIGH 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6509 COMPRES BURN GARMENT JACKET 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6510 COMPRES BURN GARMENT LEOTARD 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6511 COMPRES BURN GARMENT PANTY 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6512 COMPRES BURN GARMENT, NOC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6513 COMPRESS BURN MASK FACE/NECK 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6544 GC STOCKING GARTER BELT 11.50 $11.50 --- -- 009 0 0 0.00 $0.00 Y
P A6544 GC STOCKING GARTER BELT 11.50 $11.50 --- -- 009 0 0 0.00 $0.00 Y
P A6545 GRAD COMP NON-ELASTIC BK 71.56 $71.56 --- -- 009 0 0 0.00 $0.00 Y
1 A6545 GRAD COMP NON-ELASTIC BK 71.56 $71.56 --- -- 009 0 0 0.00 $0.00 Y
1 A6549 G COMPRESSION STOCKING 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P A6549 G COMPRESSION STOCKING 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A6550 NEG PRES WOUND THER DRSG SET 21.00 $21.00 --- -- 009 0 0 0.00 $0.00 N
1 A7000 DISPOSABLE CANISTER FOR PUMP 7.30 $7.30 --- -- 009 0 0 0.00 $0.00 Y
1 A7001 NONDISPOSABLE PUMP CANISTER 26.46 $26.46 --- -- 009 0 0 0.00 $0.00 Y
1 A7005 NONDISPOSABLE NEBULIZER SET 24.66 $24.66 --- -- 009 0 0 0.00 $0.00 Y
1 A7015 AEROSOL MASK USED W NEBULIZE 1.50 $1.50 --- -- 009 0 0 0.00 $0.00 Y
1 A7020 *11INTERFACE, COUGH STIM DEVICE 12.86 $12.86 --- -- 009 0 0 0.00 $0.00 N
1 A7027 COMBINATION ORAL/NASAL MASK 149.22 $149.22 --- -- 009 0 0 0.00 $0.00 Y
1 A7028 REPL ORAL CUSHION COMBO MASK 39.63 $39.63 --- -- 009 0 0 0.00 $0.00 Y
1 A7029 REPL NASAL PILLOW COMB MASK 16.19 $16.19 --- -- 009 0 0 0.00 $0.00 Y
1 A7030 CPAP FULL FACE MASK 75.00 $75.00 --- -- 009 0 0 0.00 $0.00 Y
1 A7031 REPLACEMENT FACEMASK INTERFA 53.40 $53.40 --- -- 009 0 0 0.00 $0.00 Y
1 A7032 REPLACEMENT NASAL CUSHION 31.02 $31.02 --- -- 009 0 0 0.00 $0.00 Y
1 A7033 REPLACEMENT NASAL PILLOWS 21.74 $21.74 --- -- 009 0 0 0.00 $0.00 Y
1 A7034 NASAL APPLICATION DEVICE 90.02 $90.02 --- -- 009 0 0 0.00 $0.00 Y
1 A7035 POS AIRWAY PRESS HEADGEAR 30.41 $30.41 --- -- 009 0 0 0.00 $0.00 Y
1 A7036 POS AIRWAY PRESS CHINSTRAP 13.92 $13.92 --- -- 009 0 0 0.00 $0.00 Y
1 A7037 POS AIRWAY PRESSURE TUBING 31.38 $31.38 --- -- 009 0 0 0.00 $0.00 Y
1 A7038 POS AIRWAY PRESSURE FILTER 4.14 $4.14 --- -- 009 0 0 0.00 $0.00 Y
1 A7039 FILTER, NON DISPOSABLE W PAP 11.73 $11.73 --- -- 009 0 0 0.00 $0.00 Y
1 A7044 PAP ORAL INTERFACE 92.54 $92.54 --- -- 009 0 0 0.00 $0.00 Y
1 A7045 REPL EXHALATION PORT FOR PAP 14.90 $14.90 --- -- 009 0 0 0.00 $0.00 Y
1 A7046 REPL WATER CHAMBER, PAP DEV 14.93 $14.93 --- -- 009 0 0 0.00 $0.00 Y
1 A7048 VACUUM DRAIN BOTTLE/TUBE KIT 36.66 $36.66 --- -- 009 0 0 0.00 $0.00 Y
1 A8000 SOFT PROTECT HELMET PREFAB 122.68 $122.68 --- -- 009 0 0 0.00 $0.00 Y
1 A8001 HARD PROTECT HELMET PREFAB 122.68 $122.68 --- -- 009 0 0 0.00 $0.00 Y
1 A8002 SOFT PROTECT HELMET CUSTOM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A8003 HARD PROTECT HELMET CUSTOM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A8004 REPL SOFT INTERFACE, HELMET 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A9281 REACHING/GRABBING DEVICE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A9284 NON-ELECTRONIC SPIROMETER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9500 TC99M SESTAMIBI 97.36 $97.36 --- -- 009 0 0 0.00 $0.00 Y
L A9501 TECHNETIUM TC99M TEBOROXIME 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9502 TC99M TETROFOSMIN 96.84 $96.84 --- -- 009 0 0 0.00 $0.00 Y
L A9503 TC99M MEDRONATE 18.87 $18.87 --- -- 009 0 0 0.00 $0.00 Y
L A9504 TC99M APCITIDE 380.00 $380.00 --- -- 009 0 0 0.00 $0.00 Y
L A9505 TL201 THALLIUM 26.58 $26.58 --- -- 009 0 0 0.00 $0.00 Y
L A9507 IN111 CAPROMAB 2252.27 $2252.27 --- -- 009 0 0 0.00 $0.00 Y
L A9508 I131 IODOBENGUATE, DX 460.96 $460.96 --- -- 009 0 0 0.00 $0.00 Y
L A9509 IODINE I123 SOD IODIDE MIL 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9510 TC99M DISOFENIN 34.83 $34.83 --- -- 009 0 0 0.00 $0.00 Y
L A9512 TC99M PERTECHNETATE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
I A9513 LUTETIUM LU 177 DOTATAT THER 248.96 $248.96 --- -- 030 0 0 0.00 $0.00 N
L A9515 CHOLINE C-11 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
L A9516 IODINE I123 SOD IODIDE MIC 51.38 $51.38 --- -- 009 0 0 0.00 $0.00 Y
L A9517 I131 IODIDE CAP, RX 152.28 $152.28 --- -- 009 0 0 0.00 $0.00 Y
L A9520 TC99 TILMANOCEPT DIAG 0.5MCI 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
L A9521 TC99M EXAMETAZIME 454.09 $454.09 --- -- 009 0 0 0.00 $0.00 Y
L A9524 I131 SERUM ALBUMIN, DX 45.45 $45.45 --- -- 009 0 0 0.00 $0.00 Y
L A9526 NITROGEN N13 AMMONIA 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9527 IODINE I125 SODIUM IODIDE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9528 IODINE I131 IODIDE CAP, DX 30.46 $30.46 --- -- 009 0 0 0.00 $0.00 Y
L A9529 I131 IODIDE SOL, DX 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9530 I131 IODIDE SOL, RX 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9531 I131 MAX 100UCI 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9532 I125 SERUM ALBUMIN, DX 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9536 TC99M DEPREOTIDE 608.00 $608.00 --- -- 009 0 0 0.00 $0.00 Y
L A9537 TC99M MEBROFENIN 45.36 $45.36 --- -- 009 0 0 0.00 $0.00 Y
L A9538 TC99M PYROPHOSPHATE 19.76 $19.76 --- -- 009 0 0 0.00 $0.00 Y
L A9539 TC99M PENTETATE 13.00 $13.00 --- -- 009 0 0 0.00 $0.00 Y
L A9540 TC99M MAA 17.22 $17.22 --- -- 009 0 0 0.00 $0.00 Y
L A9541 TC99M SULFUR COLLOID 42.56 $42.56 --- -- 009 0 0 0.00 $0.00 Y
I A9542 INDIUM IN-111 INBRITUMOMAB TIUXETAN,DX 3490.46 $3490.46 --- -- 030 0 0 0.00 $0.00 Y
I A9543 YTTRIUM Y-90 IBRITUMOMAB TIUXETAN,THERAP 48108.36 $48108.36 --- -- 030 0 0 0.00 $0.00 Y
L A9546 CO57/58 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9547 IN111 OXYQUINOLINE 233.29 $233.29 --- -- 009 0 0 0.00 $0.00 Y
L A9548 IN111 PENTETATE 205.20 $205.20 --- -- 009 0 0 0.00 $0.00 Y
L A9550 TC99M GLUCEPTATE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9551 TC99M SUCCIMER 101.30 $101.30 --- -- 009 0 0 0.00 $0.00 Y
L A9552 F18 FDG 360.00 $360.00 --- -- 009 0 0 0.00 $0.00 Y
L A9553 CR51 CHROMATE 168.04 $168.04 --- -- 009 0 0 0.00 $0.00 Y
L A9554 I125 IOTHALAMATE, DX 467.05 $467.05 --- -- 009 0 0 0.00 $0.00 Y
L A9556 GA67 GALLIUM 25.56 $25.56 --- -- 009 0 0 0.00 $0.00 Y
L A9557 TC99M BICISATE 339.34 $339.34 --- -- 009 0 0 0.00 $0.00 Y
L A9558 XE133 XENON 10MCI 31.17 $31.17 --- -- 009 0 0 0.00 $0.00 Y
L A9559 CO57 CYANO 129.94 $129.94 --- -- 009 0 0 0.00 $0.00 Y
L A9560 TC99M LABELED RBC 51.80 $51.80 --- -- 009 0 0 0.00 $0.00 Y
L A9561 TC99M OXIDRONATE 22.43 $22.43 --- -- 009 0 0 0.00 $0.00 Y
L A9562 TC99M MERTIATIDE 306.98 $306.98 --- -- 009 0 0 0.00 $0.00 Y
L A9563 P32 NA PHOSPHATE 98.18 $98.18 --- -- 009 0 0 0.00 $0.00 Y
L A9564 P32 CHROMIC PHOSPHATE 525.62 $525.62 --- -- 009 0 0 0.00 $0.00 Y
L A9566 TC99M FANOLESOMAB 794.81 $794.81 --- -- 009 0 0 0.00 $0.00 Y
L A9567 TECHNETIUM TC99M AEROSOL 61.74 $61.74 --- -- 009 0 0 0.00 $0.00 Y
L A9569 TECHNETIUM TC99M AUTO WBC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9570 INDIUM IN111 AUTO WBC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9571 INDIUM IN111 AUTO PLATELET 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9572 INDIUM IN111 PENTETREOTIDE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9575 INJ GADOTERATE MEGLUMI 0.1ML 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
L A9576 INJ PROHANCE MULTIPACK 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9577 INJ MULTIHANCE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9578 INJ MULTIHANCE MULTIPACK 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9579 GADBASE MR CONTRAST NOS,1ML 1.62 $1.62 --- -- 009 0 0 0.00 $0.00 Y
L A9580 SODIUM FLUORIDE F-18 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9581 GADOXETATE DISODIUM INJ 14.79 $14.79 --- -- 009 0 0 0.00 $0.00 Y
L A9582 IODINE I-123 IOBENGUANE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9583 GADOFOSVESET TRISODIUM INJ 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9584 IODINE I-123 IOFLUPANE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9585 GADOBUTROL INJECTION 0.39 $0.39 --- -- 009 0 0 0.00 $0.00 Y
L A9587 GALLIUM GA-68 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
L A9588 FLUCICLOVINE F-18 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
L A9589 INSTI HEXAMINOLEVULINATE HCL 1088.20 $4156.92 --- -- 005 0 0 0.00 $0.00 Y
I A9590 IODINE I-131 IOBENGUANE 1MCI 302.00 $302.00 --- -- 030 0 0 0.00 $0.00 Y
L A9597 PET, DX, FOR TUMOR ID, NOC 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
L A9598 PET DX FOR NON-TUMOR ID, NOC 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
L A9600 SR89 STRONTIUM 706.23 $706.23 --- -- 009 0 0 0.00 $0.00 Y
I A9604 SM 153 LEXIDRONAM 15222.10 $15222.10 --- -- 030 0 0 0.00 $0.00 Y
I A9606 RADIUM RA223 DICHLORIDE THER 138.52 $138.52 --- -- 030 0 0 0.00 $0.00 Y
L A9698 NONRAD CONTRAST MATERIALNOC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L A9699 RADIOPHARM RX AGENT NOC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
I A9699 RADIOPHARM RX AGENT NOC 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
1 A9900 DME SUPPLY/ACCESSORY/SERVICE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 A9999 DME SUPPLY OR ACCESSORY, NOS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 B4164 PARENTERAL 50% DEXTROSE SOLU 16.25 $16.25 --- -- 009 0 0 0.00 $0.00 Y
1 B4168 PARENTERAL SOL AMINO ACID 3 23.70 $23.70 --- -- 009 0 0 0.00 $0.00 Y
1 B4172 PARENTERAL SOL AMINO ACID 5 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 B4176 PARENTERAL SOL AMINO ACID 7 45.85 $45.85 --- -- 009 0 0 0.00 $0.00 Y
1 B4178 PARENTERAL SOL AMINO ACID> 55.03 $55.03 --- -- 009 0 0 0.00 $0.00 Y
1 B4180 PARENTERAL SOL CARB > 50% 23.33 $23.33 --- -- 009 0 0 0.00 $0.00 Y
1 B4185 PARENTERAL NUTRITION SOL,NOS,10GM LIPID 10.74 $10.74 --- -- 009 0 0 0.00 $0.00 Y
1 B4187 OMEGAVEN, 10 GRAMS LIPIDS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 B4216 PARENTERAL NUTRITION ADDITIV 7.38 $7.38 --- -- 009 0 0 0.00 $0.00 Y
1 B9002 ENTERAL NUTRITION INFUSION PUMP 907.45 $907.45 --- -- 009 0 0 0.00 $87.89 Y
L C1204 TC 99M TILMANOCEPT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C1721 *04 AICD, DUAL CHAMBER 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C1722 *04 AICD, SINGLE CHAMBER 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C1734 ORTH/DEVIC/DRUG BN/BN,TIS/BN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C1767 *04 GENERATOR, NEUROSTIM, IMP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C1771 *04 REP DEV, URINARY, W/SLING 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 C1777 *04 LEAD, AICD, ENDO SINGLE COIL 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C1785 *04 PMKR, DUAL, RATE-RESP 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C1786 *04 PMKR, SINGLE, RATE-RESP 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C1820 GENERATOR NEURO RECHG BAT SYS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C1822 GEN, NEURO, HF, RECHG BAT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C1823 GEN, NEURO, TRANS SEN/STIM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C1824 GENERATOR, CCM, IMPLANT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C1830 POWER BONE MARROW BX NEEDLE 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
1 C1839 IRIS PROSTHESIS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C1840 TELESCOPIC INTRAOCULAR LENS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C1874 *04 STENT, COATED/COV W/DEL SYS 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C1875 *04 STENT, COATED/COV W/O DEL SY 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C1882 *04 AICD, OTHER THAN SING/DUAL 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C1886 CATHETER, ABLATION 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 N
1 C1895 *04 LEAD, AICD, ENDO DUAL COIL 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C1896 *04 LEAD, AICD, NON SING/DUAL 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C1982 CATH, PRESSURE,VALVE-OCCLU 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C2596 PROBE, ROBOTIC, WATER-JET 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C2619 *04 PMKR, DUAL, NON RATE-RESP 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C2620 PMKR, SINGLE, NON RATE-RESP 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C2621 *04 PMKR, OTHER THAN SING/DUAL 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 C2624 WIRELESS PRESSURE SENSOR 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L C2634 BRACHYTX, NONSTR, HA, I125 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L C2635 BRACHYTX, NONSTR, HA, P103 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L C2637 BRACHY,NONSTR,YTTERBIUM169 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L C2638 BRACHYTX, STRANDED, I125 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L C2639 BRACHYTX, NONSTRANDED,I125 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L C2640 BRACHYTX, STRANDED, P103 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L C2641 BRACHYTX, NONSTRANDED,P103 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L C2644 BRACHYTHERAPY SOURCE, CESIUM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L C2645 BRACHYTX PLANAR, P-103 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
L C2698 BRACHYTX, STRANDED, NOS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L C2699 BRACHYTX, NONSTRANDED, NOS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
I C9054 INJECTION, LEFAMULIN 5.14 $5.14 --- -- 030 0 0 0.00 $0.00 Y
I C9055 INJ, BREXANOLONE 78.96 $78.96 --- -- 030 0 0 0.00 $0.00 Y
I C9132 KCENTRA, PER I.U. 6.88 $6.88 --- -- 030 0 0 0.00 $0.00 Y
1 C9141 INJ., VIII, PEGYLATED-AUCL, 1 IU 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 C9250 ARTISS FIBRIN SEALANT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P C9250 ARTISS FIBRIN SEALANT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
I C9254 INJECTION, LACOSAMIDE 4.84 $4.84 --- -- 030 0 0 0.00 $0.00 Y
1 C9285 PATCH, LIDOCAINE/TETRACAINE 16.95 $16.95 --- -- 009 0 0 0.00 $0.00 Y
I C9290 BUPIVACAINE LIPOSOME 1 MG 5.73 $5.73 --- -- 030 0 0 0.00 $0.00 Y
I C9293 INJECTION, GLUCARPIDASE, 10 UNITS 321.04 $321.04 --- -- 030 0 0 0.00 $0.00 Y
1 C9360 SURGIMEND, NEONATAL 9.00 $9.00 --- -- 009 0 0 0.00 $0.00 Y
1 C9361 NEUROMEND NERVE WRAP 212.09 $212.09 --- -- 009 0 0 0.00 $0.00 Y
1 C9362 IMPLNT,BON VOID FILLER-STRIP 40.70 $40.70 --- -- 009 0 0 0.00 $0.00 Y
1 C9363 INTEGRA MESHED BIL WOUND MAT 14.30 $14.30 --- -- 009 0 0 0.00 $0.00 Y
P C9363 INTEGRA MESHED BIL WOUND MAT 14.30 $14.30 --- -- 009 0 0 0.00 $0.00 Y
1 C9364 PORCINE IMPLANT, PERMACOL 14.14 $14.14 --- -- 009 0 0 0.00 $0.00 Y
I C9460 INJECTION, CANGRELOR 19.44 $19.44 --- -- 030 0 0 0.00 $0.00 Y
I C9462 INJECTION, DELAFLOXACIN 4.90 $4.90 --- -- 030 0 0 0.00 $0.00 Y
I C9482 SOTALOL HYDROCHLORIDE IV 13.88 $13.88 --- -- 030 0 0 0.00 $0.00 Y
I C9488 INJECTION CONIVAPTAN HCL, 1 MG 37.22 $37.22 --- -- 030 0 0 0.00 $0.00 Y
K C9725 PLACE ENDORECTAL APP 0.00 $0.00 --- -- 004 1 0 0.00 $0.00 Y
N C9728 PLACE DEVICE/MARKER, NON PRO 155.26 $155.26 --- -- 007 0 0 0.00 $0.00 Y
L C9738 BLUE LIGHT CYSTO IMAG AGENT 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
K C9745 NASAL ENDO EUSTACHIAN TUBE 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
K C9747 ABLATION, HIFU, PROSTATE BENEFIT 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
K C9749 REPAIR NASAL, STENOSIS W/IMP 47.25 $1759.12 --- -- 004 0 0 0.00 $0.00 Y
K C9751 MICROWAVE BRONCH, 3D, EBUS 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
K C9752 INTRAOSSEOUS DES LUMB/SACRUM 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
K C9753 INTRAOSSEOUS DESTRUCT ADD'L 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
K C9754 PERC AV FISTULA, DIRECT 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
K C9755 RF MAGNETIC-GUIDE AV FISTULA 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
K C9756 FLUORESCENCE LYMPH MAP W/ICG 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
O C9756 FLUORESCENCE LYMPH MAP W/ICG 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
O C9757 SPINE/LUMBAR DISK SURGERY 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
K C9757 SPINE/LUMBAR DISK SURGERY 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
1 D1206 TOPICAL FLUORIDE VARNISH 18.00 $18.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0100 CANES OF ALL MATRLSADJUST OR FIX W/TIP 15.99 $15.99 --- -- 009 0 0 0.00 $4.75 Y
1 E0105 3 OR 4 PRNG CANE,ANY MTRLADJ/FIX W/TIP 37.50 $37.50 --- -- 009 0 0 0.00 $7.09 Y
1 E0110 CRUTCHES, FOREARM, INCLUDES CRUTCH 62.07 $62.07 --- -- 009 0 0 0.00 $12.79 Y
1 E0112 CRUTCHES UNDERARM, WOOD, ADJUSTABL 29.60 $29.60 --- -- 009 0 0 0.00 $7.94 Y
1 E0114 CRUTCHES UNDERARM, ALUMINUM, ADJUS 37.75 $37.75 --- -- 009 0 0 0.00 $6.86 Y
1 E0117 UNDERARM SPRINGASSIST CRUTCH 154.17 $154.17 --- -- 009 0 0 0.00 $15.41 Y
1 E0130 WALKERRIGID(PICKUP) ADJUST/FIXED HEIGHT 53.75 $53.75 --- -- 009 0 0 0.00 $12.86 Y
1 E0135 WALKERFOLDING(PICKUP) ADJUST OR FIXED 64.17 $64.17 --- -- 009 0 0 0.00 $13.20 Y
1 E0140 WALKER W TRUNK SUPPORT 210.56 $210.56 --- -- 009 0 0 0.00 $21.06 Y
1 E0141 RIGID WHEELED WALKER ADJ/FIX 88.24 $88.24 --- -- 009 0 0 0.00 $17.13 Y
1 E0143 WALKER FOLDING WHEELED W/O S 85.69 $85.69 --- -- 009 0 0 0.00 $16.53 Y
1 E0144 ENCLOSED WALKER W REAR SEAT 254.76 $254.76 --- -- 009 0 0 0.00 $24.38 Y
1 E0147 WALKER VARIABLE WHEEL RESIST 279.69 $279.69 --- -- 009 0 0 0.00 $28.41 Y
1 E0148 HEAVYDUTY WALKER NO WHEELS 97.25 $97.25 --- -- 009 0 0 0.00 $9.74 Y
1 E0149 HEAVY DUTY WHEELED WALKER 95.28 $95.28 --- -- 009 0 0 0.00 $9.53 Y
1 E0153 PLATFORM ATTACHMENT, FOREARM CRUTC 55.50 $55.50 --- -- 009 0 0 0.00 $6.27 Y
1 E0154 PLATFORM ATTACHMENT, WALKER, EACH 53.97 $53.97 --- -- 009 0 0 0.00 $6.55 Y
1 E0155 WALKER WHEEL ATTACHMENT,PAIR 24.14 $24.14 --- -- 009 0 0 0.00 $2.94 Y
1 E0156 SEAT ATTACHMENT, WALKER 20.23 $20.23 --- -- 009 0 0 0.00 $2.22 Y
1 E0157 CRUTCH ATTACHMENT, WALKER, EACH 53.30 $53.30 --- -- 009 0 0 0.00 $5.86 Y
1 E0158 WALKER LEG EXTENDERS SET OF4 24.62 $24.62 --- -- 009 0 0 0.00 $2.72 Y
1 E0159 BRAKE FOR WHEELED WALKER 13.67 $13.67 --- -- 009 0 0 0.00 $1.38 Y
1 E0163 COMMODE CHAIR WITH FIXED ARM 88.23 $88.23 --- -- 009 0 0 0.00 $19.54 Y
1 E0165 COMMODE CHAIR WITH DETACHARM 162.36 $162.36 --- -- 009 0 0 0.00 $13.53 Y
1 E0167 COMMODE CHAIR PAIL OR PAN 9.60 $9.60 --- -- 009 0 0 0.00 $0.00 Y
1 E0168 HEAVYDUTY/WIDE COMMODE CHAIR 120.74 $120.74 --- -- 009 0 0 0.00 $13.39 Y
1 E0170 COMMODE CHAIR ELECTRIC 1542.91 $1542.91 --- -- 009 0 0 0.00 $128.58 Y
1 E0171 COMMODE CHAIR NONELECTRIC 277.63 $277.63 --- -- 009 0 0 0.00 $23.14 Y
1 E0181 PRESS PAD ALTERNATING W/ PUM 250.20 $250.20 --- -- 009 0 0 0.00 $20.85 Y
1 E0182 REPLACE PUMP, ALT PRESS PAD 251.33 $251.33 --- -- 009 0 0 0.00 $0.00 Y
1 E0184 DRY PRESSURE MATTRESS 132.40 $132.40 --- -- 009 0 0 0.00 $19.66 Y
1 E0185 GEL PRESSURE MATTRESS PAD 255.89 $255.89 --- -- 009 0 0 0.00 $35.95 Y
1 E0186 AIR PRESSURE MATTRESS 194.88 $194.88 --- -- 009 0 0 0.00 $16.24 Y
1 E0187 WATER PRESSURE MATTRESS 222.82 $222.82 --- -- 009 0 0 0.00 $18.57 Y
1 E0188 SYNTHETIC SHEEPSKIN PAD 21.14 $21.14 --- -- 009 0 0 0.00 $2.47 Y
1 E0189 LAMBSWOOL SHEEPSKIN PAD, ANY SIZE 41.57 $41.57 --- -- 009 0 0 0.00 $4.50 Y
1 E0193 PWR AIR FLT BED(LW AIR LASS TPY)DLY RNTL 0.00 $0.00 --- -- 009 0 0 0.00 $24.09 Y
1 E0194 AIR FLUIDIZED BED DAILY RENTAL 0.00 $0.00 --- -- 009 0 0 0.00 $55.00 Y
1 E0196 GEL PRESSURE MATTRESS 311.90 $311.90 --- -- 009 0 0 0.00 $25.99 Y
1 E0197 AIR PRESSURE PAD FOR MATTRES 134.96 $134.96 --- -- 009 0 0 0.00 $13.50 Y
1 E0198 WATER PRESSURE PAD FOR MATTR 179.65 $179.65 --- -- 009 0 0 0.00 $18.61 Y
1 E0199 DRY PRESSURE PAD FOR MATTRES 25.64 $25.64 --- -- 009 0 0 0.00 $2.55 Y
1 E0210 ELECTRIC HEAT PAD, STANDARD 26.11 $26.11 --- -- 009 0 0 0.00 $2.46 Y
1 E0240 BATH/SHOWER CHAIR 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0241 BATH TUB WALL RAIL, EACH 14.62 $14.62 --- -- 009 0 0 0.00 $0.00 Y
1 E0242 BATH TUB RAIL, FLOOR BASE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0243 TOILET RAIL, EACH 42.76 $42.76 --- -- 009 0 0 0.00 $0.00 Y
1 E0244 RAISED TOILET SEAT 46.04 $46.04 --- -- 009 0 0 0.00 $0.00 Y
1 E0245 TUB STOOL OR BENCH 55.07 $55.07 --- -- 009 0 0 0.00 $0.00 Y
1 E0246 TRANSFER TUB RAIL ATTACHMENT 37.08 $37.08 --- -- 009 0 0 0.00 $0.00 Y
1 E0247 TRANS BENCH W/WO COMM OPEN 81.42 $81.42 --- -- 009 0 0 0.00 $0.00 Y
1 E0248 HDTRANS BENCH W/WO COMM OPEN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0271 MATTRESS, INNERSPRING 146.15 $146.15 --- -- 009 0 0 0.00 $17.66 Y
1 E0272 MATTRESS, FOAM RUBBER 154.88 $154.88 --- -- 009 0 0 0.00 $16.18 Y
1 E0273 BED BOARD 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0277 POWERED PRESREDU AIR MATTRS 0.00 $0.00 --- -- 009 0 0 0.00 $18.76 Y
1 E0291 HOSPITAL BED, FIXED HEIGHT, WITHOU 443.14 $443.14 --- -- 009 0 0 0.00 $35.33 Y
1 E0293 HOSP BED VAR HT NO SR NO MAT 583.49 $583.49 --- -- 009 0 0 0.00 $46.53 Y
1 E0295 HOSPITAL BED,SEMIELECTRIC (HEAD A 1222.56 $1222.56 --- -- 009 0 0 0.00 $97.46 Y
1 E0297 HOSPITAL BED, TOTAL ELECTRIC (HEAD 1302.24 $1302.24 --- -- 009 0 0 0.00 $103.82 Y
1 E0300 ENCLOSED PED CRIB HOSP GRADE 2270.90 $2270.90 --- -- 009 0 0 0.00 $217.24 Y
1 E0303 HOSP BED HVY DTY XTRA WIDE 2785.63 $2785.63 --- -- 009 0 0 0.00 $222.08 Y
1 E0304 HOSP BED XTRA HVY DTY X WIDE 7398.43 $7398.43 --- -- 009 0 0 0.00 $589.82 Y
1 E0305 BED SIDE RAILS, HALF LENGTH 170.78 $170.78 --- -- 009 0 0 0.00 $13.62 Y
1 E0310 BED SIDE RAILS, FULL LENGTH 145.76 $145.76 --- -- 009 0 0 0.00 $17.42 Y
1 E0316 BED SAFETY ENCLOSURE 1950.43 $1950.43 --- -- 009 0 0 0.00 $155.50 Y
1 E0328 PED HOSPITAL BED, MANUAL 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0329 PED HOSPITAL BED SEMI/ELECT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0350 CONTROL UNIT FOR ELECTRONIC BOWEL IRRIG 5442.80 $5442.80 --- -- 009 0 0 0.00 $544.28 Y
1 E0352 DISPOSABLE PACK(WATER RESERVOIR BAG 36.43 $36.43 --- -- 009 0 0 0.00 $0.00 Y
1 E0371 NONPOWER MATTRESS OVERLAY DAILY RENTAL 0.00 $0.00 --- -- 009 0 0 0.00 $10.62 Y
1 E0372 POWERED AIR MATTRESS OVERLAY DAILY RENT 0.00 $0.00 --- -- 009 0 0 0.00 $13.70 Y
1 E0373 NONPOWERED PRESSURE MATTRESS DAILY RENT 0.00 $0.00 --- -- 009 0 0 0.00 $14.76 Y
1 E0424 STATIONARY COMPRESSED GAS 02 0.00 $0.00 --- -- 009 0 0 0.00 $144.74 Y
1 E0425 STATIONARY COMPRESSED GAS SYS - PURCHASE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0430 PORTABLE GAS OXYGEN SYSTEM - PURCHASE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0431 PORTABLE GASEOUS 02 0.00 $0.00 --- -- 009 0 0 0.00 $24.34 Y
1 E0433 PORTABLE LIQUID OXYGEN SYS 0.00 $0.00 --- -- 009 0 0 0.00 $41.30 Y
1 E0434 PORTABLE GAS LIQ OXYGEN SYSTEM- RENTAL 0.00 $0.00 --- -- 009 0 0 0.00 $24.34 Y
1 E0435 PORTABLE GAS LIQ OXYGEN SYSTEM- PURCHASE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0439 STATIONARY LIQUID 02 0.00 $0.00 --- -- 009 0 0 0.00 $144.74 Y
1 E0440 OXYGEN SYSTEM, LIQUID, STATIONARY, 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0441 STATIONARY O2 CONTENTS, GAS 61.96 $61.96 --- -- 009 0 0 0.00 $0.00 Y
1 E0442 STATIONARY O2 CONTENTS, LIQ 61.96 $61.96 --- -- 009 0 0 0.00 $0.00 Y
1 E0443 PORTABLE 02 CONTENTS, GAS 61.96 $61.96 --- -- 009 0 0 0.00 $0.00 Y
1 E0444 PORTABLE 02 CONTENTS, LIQUID 61.96 $61.96 --- -- 009 0 0 0.00 $0.00 Y
1 E0445 OXIMETER NONINVASIVE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0465 HOME VENT INVASIVE INTERFACE 0.00 $0.00 --- -- 009 0 0 0.00 $717.56 Y
1 E0466 HOME VENT NON-INVASIVE INTER 0.00 $0.00 --- -- 009 0 0 0.00 $717.56 Y
1 E0470 RAD W/O BACKUP NONINV INTFC 2364.67 $2364.67 --- -- 009 0 0 0.00 $188.51 Y
1 E0471 RAD W/BACKUP NON INV INTRFC 6164.88 $6164.88 --- -- 009 0 0 0.00 $491.47 Y
1 E0472 RAD W BACKUP INVASIVE INTRFC 6164.88 $6164.88 --- -- 009 0 0 0.00 $491.47 Y
1 E0480 PERCUSSOR, ELECTRIC OR PNEUMATIC, 414.62 $414.62 --- -- 009 0 0 0.00 $34.55 Y
1 E0481 INTRPULMNRY PERCUSS VENT SYS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0482 COUGH STIMULATING DEVICE 3932.74 $3932.74 --- -- 009 0 0 0.00 $327.73 Y
1 E0483 CHEST COMPRESSION GEN SYSTEM 0.00 $0.00 --- -- 009 0 0 0.00 $410.96 Y
1 E0484 NONELEC OSCILLATORY PEP DVC 29.54 $29.54 --- -- 009 0 0 0.00 $0.00 Y
1 E0486 ORAL DEVICE/APPLIANCE CUSFAB 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0487 ELECTRONIC SPIROMETER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0555 HUMIDIFIER, DURABLE, GLASS OR AUTO 0.00 $0.00 --- -- 009 0 0 0.00 $8.72 Y
1 E0561 HUMIDIFIER NONHEATED W PAP 81.89 $81.89 --- -- 009 0 0 0.00 $8.18 Y
1 E0562 HUMIDIFIER HEATED USED W PAP 230.54 $230.54 --- -- 009 0 0 0.00 $23.04 Y
1 E0565 COMPRESSOR, AIR POWER SOURCE FOR E 585.70 $585.70 --- -- 009 0 0 0.00 $48.81 Y
1 E0570 NEBULIZER W/ COMPRESSOR 154.56 $154.56 --- -- 009 0 0 0.00 $12.88 Y
1 E0600 SUCTION PUMP PORTAB HOM MODL 439.58 $439.58 --- -- 009 0 0 0.00 $36.63 Y
1 E0601 CONTINUOUS AIRWAY PRESSURE (CPAP) 609.55 $609.55 --- -- 009 0 0 0.00 $80.55 Y
1 E0602 MANUAL BREAST PUMP 23.62 $23.62 --- -- 009 0 0 0.00 $0.00 Y
1 E0603 ELECTRIC BREAST PUMP 93.15 $93.15 --- -- 009 0 0 0.00 $0.00 Y
1 E0604 HOSP GRADE ELEC BREAST PUMP 0.00 $0.00 --- -- 009 0 0 0.00 $2.72 Y
1 E0605 VAPORIZER, ROOM TYPE 21.14 $21.14 --- -- 009 0 0 0.00 $0.00 Y
1 E0607 HOME BLOOD GLUCOSE MONITOR 53.46 $53.46 --- -- 009 0 0 0.00 $0.00 Y
1 E0616 CARDIAC EVENT RECORDER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0618 APNEA MONITOR 0.00 $0.00 --- -- 009 0 0 0.00 $208.80 Y
1 E0619 APNEA MONITOR W RECORDER 0.00 $0.00 --- -- 009 0 0 0.00 $208.80 Y
1 E0621 SLING OR SEAT, PATIENT LIFT, CANVA 71.86 $71.86 --- -- 009 0 0 0.00 $7.19 Y
1 E0625 PATIENT LIFT BATHROOM OR TOI 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0630 PATIENT LIFT HYDRAULIC 852.38 $852.38 --- -- 009 0 0 0.00 $71.03 Y
1 E0635 PATIENT LIFT, ELECTRIC WITH SEAT 1174.66 $1174.66 --- -- 009 0 0 0.00 $97.89 Y
1 E0637 COMBINATION SIT TO STAND SYS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0638 STANDING FRAME SYS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0639 MOVEABLE PATIENT LIFT SYSTEM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E0641 MULTI-POSITION STND FRAM SYS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0642 DYNAMIC STANDING FRAME 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0650 PNEUMATIC COMPRESSOR, NON-SEGMENTA 576.18 $576.18 --- -- 009 0 0 0.00 $71.10 Y
1 E0651 PNEUMATIC COMPRESSOR, SEGMENTAL HO 624.53 $624.53 --- -- 009 0 0 0.00 $63.80 Y
1 E0655 PNEUMATIC APPLIANCE HALF ARM 86.34 $86.34 --- -- 009 0 0 0.00 $8.66 Y
1 E0656 SEGMENTAL PNEUMATIC TRUNK 505.39 $505.39 --- -- 009 0 0 0.00 $51.31 Y
1 E0657 SEGMENTAL PNEUMATIC CHEST 474.81 $474.81 --- -- 009 0 0 0.00 $48.20 Y
1 E0660 PNEUMATIC APPLIANCE FULL LEG 108.63 $108.63 --- -- 009 0 0 0.00 $11.31 Y
1 E0665 PNEUMATIC APPLIANCE FULL ARM 98.23 $98.23 --- -- 009 0 0 0.00 $9.81 Y
1 E0666 PNEUMATIC APPLIANCE HALF LEG 93.90 $93.90 --- -- 009 0 0 0.00 $9.68 Y
1 E0667 SEG PNEUMATIC APPL FULL LEG 259.02 $259.02 --- -- 009 0 0 0.00 $29.25 Y
1 E0668 SEG PNEUMATIC APPLIANCE FULL ARM 353.50 $353.50 --- -- 009 0 0 0.00 $34.89 Y
1 E0669 SEG PNEUMATIC APPL HALF LEG 146.65 $146.65 --- -- 009 0 0 0.00 $14.67 Y
1 E0670 SEG PNEUM INT LEGS/TRUNK 1088.82 $1088.82 --- -- 009 0 0 0.00 $108.88 Y
1 E0671 PRESSURE PNEUM APPL FULL LEG 332.28 $332.28 --- -- 009 0 0 0.00 $33.23 Y
1 E0672 PRESSURE PNEUM APPL FULL ARM 258.18 $258.18 --- -- 009 0 0 0.00 $25.82 Y
1 E0673 PRESSURE PNEUM APPL HALF LEG 214.54 $214.54 --- -- 009 0 0 0.00 $21.46 Y
1 E0705 TRANSFER DEVICE 40.54 $40.54 --- -- 009 0 0 0.00 $4.06 Y
1 E0710 RESTRAINTS, ANY TYPE (BODY, CHEST, 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0720 TENS TWO LEAD 249.95 $249.95 --- -- 009 0 0 0.00 $24.99 Y
1 E0730 TENS FOUR LEAD 251.98 $251.98 --- -- 009 0 0 0.00 $25.20 Y
1 E0747 ELEC OSTEOGEN STIM NOT SPINE 2398.50 $2398.50 --- -- 009 0 0 0.00 $238.34 Y
1 E0748 ELEC OSTEOGEN STIM SPINAL 3030.73 $3030.73 --- -- 009 0 0 0.00 $0.00 Y
1 E0760 OSTEOGEN ULTRASOUND STIMLTOR 2329.64 $2329.64 --- -- 009 0 0 0.00 $0.00 Y
1 E0766 ELEC STIM CANCER TREATMENT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0770 FUNCTIONAL ELECTRIC STIM NOS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0776 IV POLE 75.46 $75.46 --- -- 009 0 0 0.00 $14.92 Y
1 E0779 AMB INFUSION PUMP MECHANICAL 153.88 $153.88 --- -- 009 0 0 0.00 $12.82 Y
1 E0780 MECH AMB INFUSION PUMP <8HRS 8.30 $8.30 --- -- 009 0 0 0.00 $0.00 Y
1 E0781 EXTERNAL AMBULATORY INFUS PU 0.00 $0.00 --- -- 009 0 0 0.00 $7.06 Y
1 E0783 PROGRAMMABLE INFUSION PUMP 7269.63 $7269.63 --- -- 009 0 0 0.00 $726.98 Y
1 E0784 EXTERNAL AMBUL INFUS PUMP INSULIN 0.00 $0.00 --- -- 009 0 0 0.00 $265.90 Y
1 E0785 REPLACEMENT IMPL PUMP CATHET 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0786 IMPLANTABLE PUMP REPLACEMENT 6835.16 $6835.16 --- -- 009 0 0 0.00 $683.51 Y
1 E0787 CGS DOSE ADJ INSULIN INF PMP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0791 PARENTERAL INFUSION PUMP, STATIONA 2529.60 $2529.60 --- -- 009 0 0 0.00 $252.96 Y
1 E0840 TRACTION FRAME, ATTACHED TO HEADBO 58.62 $58.62 --- -- 009 0 0 0.00 $13.06 Y
1 E0849 CERVICAL PNEUM TRAC EQUIP 412.25 $412.25 --- -- 009 0 0 0.00 $41.22 N
1 E0850 TRACTION STAND, FREE STANDING, SIM 78.22 $78.22 --- -- 009 0 0 0.00 $11.54 Y
1 E0860 TRACTION EQUIP, OVERDOOR, CERVICAL 30.82 $30.82 --- -- 009 0 0 0.00 $5.21 Y
1 E0870 TRACT FRAME, ATT TO FTBRD SIMP EXT TRACT 58.62 $58.62 --- -- 009 0 0 0.00 $11.91 Y
1 E0880 TRACTION STAND, FREE STANDING, SIM 78.22 $78.22 --- -- 009 0 0 0.00 $11.54 Y
1 E0890 TRACTION FRAME, ATTACHED TO FOOTBO 58.62 $58.62 --- -- 009 0 0 0.00 $13.06 Y
1 E0900 TRACTION STAND, FREE STANDING, SIM 78.22 $78.22 --- -- 009 0 0 0.00 $11.54 Y
1 E0910 TRAP BAR,A/K/A PT HLPR ATT TO BED, W/BAR 169.25 $169.25 --- -- 009 0 0 0.00 $13.49 Y
1 E0911 HD TRAPEZE BAR ATTACH TO BED 478.56 $478.56 --- -- 009 0 0 0.00 $38.14 Y
1 E0912 HD TRAPEZE BAR FREE STANDING 1098.91 $1098.91 --- -- 009 0 0 0.00 $87.62 Y
1 E0920 FRACTURE FRAME ATT TO BED, INCLD WEIGHTS 376.51 $376.51 --- -- 009 0 0 0.00 $31.38 Y
1 E0930 FRAC FRAME,FREE STANDING,INCLD WEIGHTS 395.52 $395.52 --- -- 009 0 0 0.00 $32.96 Y
1 E0935 CONT PAS MOTION EXERCISE DEV 0.00 $0.00 --- -- 009 0 0 0.00 $15.97 Y
1 E0936 CPM DEVICE, OTHER THAN KNEE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0940 TRAP BAR,FREE STANDING, COMP W/GRAB BAR 325.25 $325.25 --- -- 009 0 0 0.00 $25.94 Y
1 E0942 CERVICAL HEAD HARNESS/HALTER 15.88 $15.88 --- -- 009 0 0 0.00 $1.87 Y
1 E0944 PELVIC BELT/HARNESS/BOOT 31.20 $31.20 --- -- 009 0 0 0.00 $3.13 Y
1 E0945 EXTREMITY BELT/HARNESS 35.46 $35.46 --- -- 009 0 0 0.00 $3.55 Y
1 E0947 FRACTURE FRAME, ATTACHMENTS FOR CO 485.17 $485.17 --- -- 009 0 0 0.00 $50.31 Y
1 E0948 FRACTURE FRAME, ATTACHMENTS FOR CO 469.27 $469.27 --- -- 009 0 0 0.00 $46.91 Y
1 E0950 TRAY 89.00 $89.00 --- -- 009 0 0 0.00 $8.89 Y
1 E0951 LOOP HEEL 18.16 $18.16 --- -- 009 0 0 0.00 $1.87 Y
1 E0952 TOE LOOP/HOLDER, EACH 15.32 $15.32 --- -- 009 0 0 0.00 $1.59 Y
1 E0953 W/C LATERAL THIGH/KNESS SUP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0954 FOOT BOX, ANY TYPE EACH FOOT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E0955 CUSHIONED HEADREST 133.70 $133.70 --- -- 009 0 0 0.00 $13.37 Y
1 E0956 W/C LATERAL TRUNK/HIP SUPPOR 94.30 $94.30 --- -- 009 0 0 0.00 $9.43 Y
1 E0957 W/C MEDIAL THIGH SUPPORT 131.96 $131.96 --- -- 009 0 0 0.00 $13.20 Y
1 E0958 WHLCHR ATT- CONV 1 ARM DRIVE 392.19 $392.19 --- -- 009 0 0 0.00 $35.94 Y
1 E0959 AMPUTEE ADAPTER 44.21 $44.21 --- -- 009 0 0 0.00 $4.45 Y
1 E0960 W/C SHOULDER HARNESS/STRAPS 87.04 $87.04 --- -- 009 0 0 0.00 $8.72 Y
1 E0961 WHEELCHAIR BRAKE EXTENSION 24.11 $24.11 --- -- 009 0 0 0.00 $2.52 Y
1 E0966 WHEELCHAIR HEAD REST EXTENSI 71.37 $71.37 --- -- 009 0 0 0.00 $7.04 Y
1 E0967 MANUAL WC HAND RIM W PROJECT 65.23 $65.23 --- -- 009 0 0 0.00 $0.00 Y
1 E0970 NO.2 FTPLATES, EXCEPT ELEVATING LEG REST 39.63 $39.63 --- -- 009 0 0 0.00 $4.10 Y
1 E0971 WHEELCHAIR ANTI-TIPPING DEVI 43.39 $43.39 --- -- 009 0 0 0.00 $4.34 Y
1 E0973 W/CH ACCESS DET ADJ ARMREST 93.49 $93.49 --- -- 009 0 0 0.00 $9.03 Y
1 E0974 W/CH ACCESS ANTI-ROLLBACK 75.36 $75.36 --- -- 009 0 0 0.00 $7.93 Y
1 E0978 W/C ACC,SAF BELT PELV STRAP 30.84 $30.84 --- -- 009 0 0 0.00 $3.30 Y
1 E0981 SEAT UPHOLSTERY, REPLACEMENT 35.89 $35.89 --- -- 009 0 0 0.00 $3.58 Y
1 E0982 BACK UPHOLSTERY, REPLACEMENT 41.90 $41.90 --- -- 009 0 0 0.00 $0.00 Y
1 E0983 ADD PWR JOYSTICK 2862.96 $2862.96 --- -- 009 0 0 0.00 $238.58 Y
1 E0984 ADD PWR TILLER 1623.99 $1623.99 --- -- 009 0 0 0.00 $144.19 Y
1 E0985 W/C SEAT LIFT MECHANISM 194.40 $194.40 --- -- 009 0 0 0.00 $19.44 Y
1 E0986 MAN W/C PUSH-RIM POW ASSIST 4864.24 $4864.24 --- -- 009 0 0 0.00 $486.43 Y
1 E0988 LEVER-ACTIVATED WHEEL DRIVE 0.00 $0.00 --- -- 009 0 0 0.00 $321.54 Y
1 E0990 WHELLCHAIR ELEVATING LEG RES 88.71 $88.71 --- -- 009 0 0 0.00 $10.72 Y
1 E0992 WHEELCHAIR SOLID SEAT INSERT 77.14 $77.14 --- -- 009 0 0 0.00 $7.50 Y
1 E0995 WHEELCHAIR CALF REST 24.94 $24.94 --- -- 009 0 0 0.00 $0.00 Y
1 E1002 PWR SEAT TILT 4053.21 $4053.21 --- -- 009 0 0 0.00 $387.74 Y
1 E1003 PWR SEAT RECLINE 4391.30 $4391.30 --- -- 009 0 0 0.00 $420.11 Y
1 E1004 PWR SEAT RECLINE MECH 4869.05 $4869.05 --- -- 009 0 0 0.00 $465.79 Y
1 E1005 PWR SEAT RECLINE PWR 5270.36 $5270.36 --- -- 009 0 0 0.00 $504.19 Y
1 E1006 PWR SEAT COMBO W/O SHEAR 6455.70 $6455.70 --- -- 009 0 0 0.00 $617.58 Y
1 E1007 PWR SEAT COMBO W/SHEAR 8741.27 $8741.27 --- -- 009 0 0 0.00 $836.26 Y
1 E1008 PWR SEAT COMBO PWR SHEAR 8742.05 $8742.05 --- -- 009 0 0 0.00 $836.32 Y
1 E1009 ADD MECH LEG ELEVATION 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1010 ADD PWR LEG ELEVATION 1143.79 $1143.79 --- -- 009 0 0 0.00 $109.43 Y
1 E1011 PED WC MODIFY WIDTH ADJUSTM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1012 CTR MOUNT PWR ELEV LEG REST 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1014 RECLINING BACK ADD PED W/C 365.14 $365.14 --- -- 009 0 0 0.00 $36.52 Y
1 E1015 SHOCK ABSORBER FOR MAN W/C 114.70 $114.70 --- -- 009 0 0 0.00 $11.46 Y
1 E1016 SHOCK ABSORBER FOR POWER W/C 125.63 $125.63 --- -- 009 0 0 0.00 $12.58 Y
1 E1017 HD SHCK ABSRBR FOR HD MAN WC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1018 HD SHCK ABSRBER FOR HD POWWC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1020 RESIDUAL LIMB SUPPORT SYSTEM 168.60 $168.60 --- -- 009 0 0 0.00 $16.86 Y
1 E1028 W/C MANUAL SWINGAWAY 127.10 $127.10 --- -- 009 0 0 0.00 $12.71 Y
1 E1029 W/C VENT TRAY FIXED 369.54 $369.54 --- -- 009 0 0 0.00 $35.34 Y
1 E1030 *04 W/C VENT TRAY GIMBALED 1165.27 $1165.27 --- -- 009 0 0 0.00 $111.48 Y
1 E1031 ROLLABOUT CHAIR, ANY TYPES 604.56 $604.56 --- -- 009 0 0 0.00 $44.74 Y
1 E1035 PATIENT TRANSFER SYSTEM <300 7726.32 $7726.32 --- -- 009 0 0 0.00 $544.50 Y
1 E1036 PATIENT TRANSFER SYSTEM >300 0.00 $0.00 --- -- 009 0 0 0.00 $763.34 Y
1 E1037 TRANSPORT CHAIR, PED SIZE 1084.90 $1084.90 --- -- 009 0 0 0.00 $96.33 Y
1 E1038 TRANSPORT CHAIR PT WT<=300LB 216.36 $216.36 --- -- 009 0 0 0.00 $16.01 Y
1 E1039 TRANSPORT CHAIR PT WT >300LB 410.40 $410.40 --- -- 009 0 0 0.00 $30.36 N
1 E1065 PWR ATT(TO CONVT ANY WLCHR TO MTR WLCHR) 2193.99 $2193.99 --- -- 009 0 0 0.00 $238.02 Y
1 E1161 MANUAL ADULT WC W TILTINSPAC 2366.09 $2366.09 --- -- 009 0 0 0.00 $236.61 Y
1 E1220 WHEELCHAIR; SPECIALLY SIZED OR CON 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1225 MANUAL SEMI-RECLINING BACK 373.73 $373.73 --- -- 009 0 0 0.00 $31.14 Y
1 E1226 MANUAL FULLY RECLINING BACK 376.02 $376.02 --- -- 009 0 0 0.00 $38.70 Y
1 E1228 BACK OF CHAIR - SPECIAL BACK HEIGHT 233.27 $233.27 --- -- 009 0 0 0.00 $19.44 Y
1 E1229 PEDIATRIC WHEELCHAIR NOS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E1230 POWER OPERATED VEHICLE (THREE OR F 1707.13 $1707.13 --- -- 009 0 0 0.00 $0.00 Y
1 E1231 RIGID PED W/C TILTINSPACE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1232 FOLDING PED WC TILTINSPACE 2138.41 $2138.41 --- -- 009 0 0 0.00 $213.85 Y
1 E1233 RIG PED WC TLTNSPC W/O SEAT 2215.73 $2215.73 --- -- 009 0 0 0.00 $221.57 Y
1 E1234 FLD PED WC TLTNSPC W/O SEAT 1928.95 $1928.95 --- -- 009 0 0 0.00 $192.91 Y
1 E1235 RIGID PED WC ADJUSTABLE 1857.43 $1857.43 --- -- 009 0 0 0.00 $185.75 Y
1 E1236 FOLDING PED WC ADJUSTABLE 1638.73 $1638.73 --- -- 009 0 0 0.00 $163.87 Y
1 E1237 RGD PED WC ADJSTABL W/O SEAT 1653.05 $1653.05 --- -- 009 0 0 0.00 $165.30 Y
1 E1238 FLD PED WC ADJSTABL W/O SEAT 1638.73 $1638.73 --- -- 009 0 0 0.00 $163.87 Y
1 E1239 PED POWER WHEELCHAIR NOS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E1296 SPECAL WHEELCHAIR SEAT HEIGHT FROM FLOOR 374.93 $374.93 --- -- 009 0 0 0.00 $37.50 Y
1 E1297 SPEC WHEELCHAIR SEAT DEPTH,BY UPHOLSTERY 72.09 $72.09 --- -- 009 0 0 0.00 $9.42 Y
1 E1298 SPEC WHLCHR ST DEPTH &/OR WIDTH BY CONST 325.53 $325.53 --- -- 009 0 0 0.00 $32.56 Y
1 E1353 REGULATOR 26.30 $26.30 --- -- 009 0 0 0.00 $0.00 Y
1 E1354 WHEELED CART, PORT CYL/CONC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1355 STAND/RACK 18.94 $18.94 --- -- 009 0 0 0.00 $0.00 Y
1 E1356 BATT PACK/CART, PORT CONC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1357 BATTERY CHARGER, PORT CONC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1358 DC POWER ADAPTER, PORT CONC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1390 *00 OXYGEN CONCENTRATOR 0.00 $0.00 --- -- 009 0 0 0.00 $144.74 Y
1 E1391 *04 OXYGEN CONCENTRATOR 0.00 $0.00 --- -- 009 0 0 0.00 $144.74 Y
1 E1392 *06 PORTABLE OXYGEN CONCENTRATOR 0.00 $0.00 --- -- 009 0 0 0.00 $41.30 Y
1 E1399 MISCELLANEOUS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E1810 ADJUST KNEE EXT/FLEX DEVICE 1195.97 $1195.97 --- -- 009 0 0 0.00 $0.00 Y
1 E1902 AAC NON-ELECTRONIC BOARD 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E2000 GASTRIC SUCTION PUMP HME MDL 473.86 $473.86 --- -- 009 0 0 0.00 $39.49 Y
1 E2100 BLD GLUCOSE MONITOR W VOICE 437.37 $437.37 --- -- 009 0 0 0.00 $43.74 Y
1 E2101 BLD GLUCOSE MONITOR W LANCE 150.85 $150.85 --- -- 009 0 0 0.00 $15.09 Y
1 E2201 MAN W/CH ACC SEAT W>=20"<24" 373.10 $373.10 --- -- 009 0 0 0.00 $37.31 Y
1 E2202 SEAT WIDTH 2427 IN 473.98 $473.98 --- -- 009 0 0 0.00 $47.40 Y
1 E2203 FRAME DEPTH LESS THAN 22 IN 479.05 $479.05 --- -- 009 0 0 0.00 $47.89 Y
1 E2204 FRAME DEPTH 22 TO 25 IN 813.40 $813.40 --- -- 009 0 0 0.00 $81.35 Y
1 E2205 MANUAL WC ACCESSORY, HANDRIM 32.10 $32.10 --- -- 009 0 0 0.00 $3.19 N
1 E2206 COMPLETE WHEEL LOCK ASSEMBLY 35.26 $35.26 --- -- 009 0 0 0.00 $0.00 Y
1 E2207 CRUTCH AND CANE HOLDER 42.62 $42.62 --- -- 009 0 0 0.00 $4.27 Y
1 E2208 CYLINDER TANK CARRIER 111.72 $111.72 --- -- 009 0 0 0.00 $11.18 Y
1 E2209 ARM TROUGH EACH 100.82 $100.82 --- -- 009 0 0 0.00 $10.07 Y
1 E2210 WHEELCHAIR BEARINGS 6.26 $6.26 --- -- 009 0 0 0.00 $0.00 Y
1 E2211 PNEUMATIC PROPULSION TIRE 40.91 $40.91 --- -- 009 0 0 0.00 $4.01 Y
1 E2212 PNEUMATIC PROP TIRE TUBE 5.78 $5.78 --- -- 009 0 0 0.00 $0.61 Y
1 E2213 PNEUMATIC PROP TIRE INSERT 29.91 $29.91 --- -- 009 0 0 0.00 $3.01 Y
1 E2214 PNEUMATIC CASTER TIRE EACH 36.00 $36.00 --- -- 009 0 0 0.00 $3.96 Y
1 E2215 PNEUMATIC CASTER TIRE TUBE 9.45 $9.45 --- -- 009 0 0 0.00 $0.94 Y
1 E2218 FOAM PROPULSION TIRE EACH 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E2219 FOAM CASTER TIRE ANY SIZE EA 41.85 $41.85 --- -- 009 0 0 0.00 $4.72 Y
1 E2220 SOLID PROPULSION TIRE EACH 26.61 $26.61 --- -- 009 0 0 0.00 $0.00 Y
1 E2221 SOLID CASTER TIRE EACH 23.84 $23.84 --- -- 009 0 0 0.00 $0.00 Y
1 E2222 SOLID CASTER INTEGRATED WHL 19.86 $19.86 --- -- 009 0 0 0.00 $0.00 Y
1 E2224 PROPULSION WHL EXCLUDES TIRE 81.48 $81.48 --- -- 009 0 0 0.00 $0.00 Y
1 E2225 CASTER WHEEL EXCLUDES TIRE 17.40 $17.40 --- -- 009 0 0 0.00 $1.74 Y
1 E2226 CASTER FORK REPLACEMENT ONLY 37.94 $37.94 --- -- 009 0 0 0.00 $3.79 Y
1 E2227 GEAR REDUCTION DRIVE WHEEL 1569.13 $1569.13 --- -- 009 0 0 0.00 $156.93 Y
1 E2228 MWC ACC, WHEELCHAIR BRAKE 865.90 $865.90 --- -- 009 0 0 0.00 $86.59 Y
1 E2231 SOLID SEAT SUPPORT BASE 161.36 $161.36 --- -- 009 0 0 0.00 $16.14 Y
1 E2291 PLANAR BACK FOR PED SIZE WC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E2292 PLANAR SEAT FOR PED SIZE WC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E2293 CONTOUR BACK FOR PED SIZE WC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E2294 CONTOUR SEAT FOR PED SIZE WC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E2295 PED DYNAMIC SEATING FRAME 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E2300 PWR SEAT ELEVATION SYS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E2301 PWR STANDING 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E2310 ELECTRO CONNECT BTW CONTROL 1170.24 $1170.24 --- -- 009 0 0 0.00 $111.94 Y
1 E2311 ELECTRO CONNECT BTW 2 SYS 2369.20 $2369.20 --- -- 009 0 0 0.00 $226.66 Y
1 E2312 MINIPROP REMOTE JOYSTICK 1764.30 $1764.30 --- -- 009 0 0 0.00 $223.84 Y
1 E2313 PWC HARNESS, EXPAND CONTROL 320.26 $320.26 --- -- 009 0 0 0.00 $32.03 Y
1 E2321 HAND INTERFACE JOYSTICK 1198.22 $1198.22 --- -- 009 0 0 0.00 $152.04 Y
1 E2322 MULT MECH SWITCHES 1063.45 $1063.45 --- -- 009 0 0 0.00 $134.91 Y
1 E2323 SPECIAL JOYSTICK HANDLE 66.17 $66.17 --- -- 009 0 0 0.00 $6.61 Y
1 E2324 CHIN CUP INTERFACE 41.92 $41.92 --- -- 009 0 0 0.00 $4.17 Y
1 E2325 SIP AND PUFF INTERFACE 1346.83 $1346.83 --- -- 009 0 0 0.00 $128.86 Y
1 E2326 BREATH TUBE KIT 347.14 $347.14 --- -- 009 0 0 0.00 $33.22 Y
1 E2327 HEAD CONTROL INTERFACE MECH 1969.80 $1969.80 --- -- 009 0 0 0.00 $249.91 Y
1 E2328 HEAD/EXTREMITY CONTROL INTER 4955.32 $4955.32 --- -- 009 0 0 0.00 $474.05 Y
1 E2329 HEAD CONTROL NONPROPORTIONAL 1766.13 $1766.13 --- -- 009 0 0 0.00 $168.96 Y
1 E2330 HEAD CONTROL PROXIMITY SWITC 3422.09 $3422.09 --- -- 009 0 0 0.00 $327.37 Y
1 E2331 ATTENDANT CONTROL 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E2340 W/C WDTH 20-23 IN SEAT FRAME 358.36 $358.36 --- -- 009 0 0 0.00 $35.85 Y
1 E2341 W/C WDTH 24-27 IN SEAT FRAME 537.58 $537.58 --- -- 009 0 0 0.00 $53.76 Y
1 E2342 W/C DPTH 20-21 IN SEAT FRAME 447.98 $447.98 --- -- 009 0 0 0.00 $44.80 Y
1 E2343 W/C DPTH 22-25 IN SEAT FRAME 716.78 $716.78 --- -- 009 0 0 0.00 $71.67 Y
1 E2351 ELECTRONIC SGD INTERFACE 698.63 $698.63 --- -- 009 0 0 0.00 $66.86 Y
1 E2358 GR 34 NONSEALED LEADACID 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E2359 GR34 SEALED LEADACID BATTERY 187.04 $187.04 --- -- 009 0 0 0.00 $18.71 Y
1 E2360 22NF NONSEALED LEADACID 106.53 $106.53 --- -- 009 0 0 0.00 $10.65 Y
1 E2361 22NF SEALED LEADACID BATTERY 131.22 $131.22 --- -- 009 0 0 0.00 $13.13 Y
1 E2362 GR24 NONSEALED LEADACID 90.44 $90.44 --- -- 009 0 0 0.00 $9.04 Y
1 E2363 GR24 SEALED LEADACID BATTERY 174.97 $174.97 --- -- 009 0 0 0.00 $17.51 Y
1 E2364 U1NONSEALED LEADACID BATTERY 106.53 $106.53 --- -- 009 0 0 0.00 $10.65 Y
1 E2365 U1 SEALED LEADACID BATTERY 105.53 $105.53 --- -- 009 0 0 0.00 $10.55 Y
1 E2366 BATTERY CHARGER, SINGLE MODE 252.20 $252.20 --- -- 009 0 0 0.00 $25.29 Y
1 E2367 BATTERY CHARGER, DUAL MODE 263.62 $263.62 --- -- 009 0 0 0.00 $26.43 Y
1 E2368 PWR WC DRIVEWHEEL MOTOR REPL 379.50 $379.50 --- -- 009 0 0 0.00 $0.00 N
1 E2369 PWR WC DRIVEWHEEL GEAR REPL 358.60 $358.60 --- -- 009 0 0 0.00 $0.00 N
1 E2370 PWR WC DR WH MOTOR/GEAR COMB 493.20 $493.20 --- -- 009 0 0 0.00 $0.00 N
1 E2371 GR27 SEALED LEADACID BATTERY 144.21 $144.21 --- -- 009 0 0 0.00 $14.43 Y
1 E2372 GR27 NONSEALED LEADACID 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E2373 HAND/CHIN CTRL SPEC JOYSTICK 614.99 $614.99 --- -- 009 0 0 0.00 $0.00 Y
1 E2374 HAND/CHIN CTRL STD JOYSTICK 534.02 $534.02 --- -- 009 0 0 0.00 $51.10 Y
1 E2375 NON-EXPANDABLE CONTROLLER 602.20 $602.20 --- -- 009 0 0 0.00 $0.00 Y
1 E2376 EXPANDABLE CONTROLLER, REPL 1342.27 $1342.27 --- -- 009 0 0 0.00 $128.41 Y
1 E2377 EXPANDABLE CONTROLLER, INITL 485.71 $485.71 --- -- 009 0 0 0.00 $46.46 Y
1 E2378 PW ACTUATOR REPLACEMENT 447.62 $447.62 --- -- 009 0 0 0.00 $0.00 Y
1 E2381 PNEUM DRIVE WHEEL TIRE 57.32 $57.32 --- -- 009 0 0 0.00 $0.00 Y
1 E2382 TUBE, PNEUM WHEEL DRIVE TIRE 19.52 $19.52 --- -- 009 0 0 0.00 $0.00 Y
1 E2383 INSERT, PNEUM WHEEL DRIVE 142.86 $142.86 --- -- 009 0 0 0.00 $0.00 Y
1 E2384 PNEUMATIC CASTER TIRE 76.13 $76.13 --- -- 009 0 0 0.00 $0.00 Y
1 E2385 TUBE, PNEUMATIC CASTER TIRE 46.57 $46.57 --- -- 009 0 0 0.00 $0.00 Y
1 E2386 FOAM FILLED DRIVE WHEEL TIRE 141.57 $141.57 --- -- 009 0 0 0.00 $0.00 Y
1 E2387 FOAM FILLED CASTER TIRE 61.08 $61.08 --- -- 009 0 0 0.00 $0.00 Y
1 E2388 FOAM DRIVE WHEEL TIRE 48.19 $48.19 --- -- 009 0 0 0.00 $0.00 Y
1 E2389 FOAM CASTER TIRE 26.18 $26.18 --- -- 009 0 0 0.00 $0.00 Y
1 E2390 SOLID DRIVE WHEEL TIRE 40.93 $40.93 --- -- 009 0 0 0.00 $0.00 Y
1 E2391 SOLID CASTER TIRE 19.60 $19.60 --- -- 009 0 0 0.00 $0.00 Y
1 E2392 SOLID CASTER TIRE, INTEGRATE 51.54 $51.54 --- -- 009 0 0 0.00 $0.00 Y
1 E2394 DRIVE WHEEL EXCLUDES TIRE 73.44 $73.44 --- -- 009 0 0 0.00 $0.00 Y
1 E2395 CASTER WHEEL EXCLUDES TIRE 52.18 $52.18 --- -- 009 0 0 0.00 $0.00 Y
1 E2396 CASTER FORK 63.62 $63.62 --- -- 009 0 0 0.00 $0.00 Y
1 E2397 PWC ACC, LITHBASED BATTERY 414.13 $414.13 --- -- 009 0 0 0.00 $41.41 Y
1 E2398 WC DYNAMIC POS BACK HARDWARE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 E2402 NEGATIVE PRESSURE WOUND THERAPY PUMP 0.00 $0.00 --- -- 009 0 0 0.00 $45.77 N
1 E2500 SGD DIGITIZED PRE-REC <=8MIN 391.06 $391.06 --- -- 009 0 0 0.00 $34.73 N
1 E2502 SGD PREREC MSG >8MIN <=20MIN 1195.80 $1195.80 --- -- 009 0 0 0.00 $106.18 N
1 E2504 SGD PREREC MSG>20MIN <=40MIN 1577.42 $1577.42 --- -- 009 0 0 0.00 $140.09 N
1 E2506 SGD PREREC MSG > 40 MIN 2312.96 $2312.96 --- -- 009 0 0 0.00 $205.37 N
1 E2508 SGD SPELLING PHYS CONTACT 3576.61 $3576.61 --- -- 009 0 0 0.00 $317.58 N
1 E2510 SGD W MULTI METHODS MSG/ACCS 6768.25 $6768.25 --- -- 009 0 0 0.00 $600.99 N
1 E2511 SGD SFTWRE PRGRM FOR PC/PDA 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E2512 SGD ACCESSORY, MOUNTING SYS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E2599 SGD ACCESSORY NOC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E2601 GEN W/C CUSHION WDTH < 22 IN 58.50 $58.50 --- -- 009 0 0 0.00 $5.87 N
1 E2602 GEN W/C CUSHION WDTH >=22 IN 114.22 $114.22 --- -- 009 0 0 0.00 $11.43 N
1 E2603 SKIN PROTECT WC CUS WD <22IN 145.01 $145.01 --- -- 009 0 0 0.00 $14.51 N
1 E2604 SKIN PROTECT WC CUS WD>=22IN 180.25 $180.25 --- -- 009 0 0 0.00 $18.02 N
1 E2605 POSITION WC CUSH WDTH <22 IN 257.51 $257.51 --- -- 009 0 0 0.00 $25.76 N
1 E2606 POSITION WC CUSH WDTH>=22 IN 401.74 $401.74 --- -- 009 0 0 0.00 $40.18 N
1 E2607 SKIN PRO/POS WC CUS WD <22IN 277.29 $277.29 --- -- 009 0 0 0.00 $27.73 N
1 E2608 SKIN PRO/POS WC CUS WD>=22IN 333.00 $333.00 --- -- 009 0 0 0.00 $33.29 N
1 E2609 CUSTOM FABRICATE W/C CUSHION 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E2610 POWERED W/C CUSHION 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E2611 GEN USE BACK CUSH WDTH <22IN 298.82 $298.82 --- -- 009 0 0 0.00 $29.87 N
1 E2612 GEN USE BACK CUSH WDTH>=22IN 404.23 $404.23 --- -- 009 0 0 0.00 $40.42 N
1 E2613 POSITION BACK CUSH WD <22IN 376.01 $376.01 --- -- 009 0 0 0.00 $37.61 N
1 E2614 POSITION BACK CUSH WD>=22IN 520.37 $520.37 --- -- 009 0 0 0.00 $52.04 N
1 E2615 POS BACK POST/LAT WDTH <22IN 432.71 $432.71 --- -- 009 0 0 0.00 $43.28 N
1 E2616 POS BACK POST/LAT WDTH>=22IN 582.21 $582.21 --- -- 009 0 0 0.00 $58.22 N
1 E2617 CUSTOM FAB W/C BACK CUSHION 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E2619 REPLACE COVER W/C SEAT CUSH 49.09 $49.09 --- -- 009 0 0 0.00 $4.91 N
1 E2620 WC PLANAR BACK CUSH WD <22IN 523.96 $523.96 --- -- 009 0 0 0.00 $52.40 N
1 E2621 WC PLANAR BACK CUSH WD>=22IN 549.86 $549.86 --- -- 009 0 0 0.00 $54.99 N
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1 E2623 ADJ SKIN PRO WC CUS WD>=22IN 381.33 $381.33 --- -- 009 0 0 0.00 $38.14 N
1 E2624 ADJ SKIN PRO/POS CUS<22IN 302.14 $302.14 --- -- 009 0 0 0.00 $30.22 N
1 E2625 ADJ SKIN PRO/POS WC CUS>=22 382.49 $382.49 --- -- 009 0 0 0.00 $38.24 N
1 E2626 SEO MOBILE ARM SUP ATT TO WC 667.16 $667.16 --- -- 009 0 0 0.00 $66.70 Y
1 E2627 ARM SUPP ATT TO WC RANCHO TY 1064.58 $1064.58 --- -- 009 0 0 0.00 $106.49 Y
1 E2628 MOBILE ARM SUPPORTS RECLININ 801.99 $801.99 --- -- 009 0 0 0.00 $80.20 Y
1 E2629 FRICTION DAMPENING ARM SUPP 1014.90 $1014.90 --- -- 009 0 0 0.00 $101.48 Y
1 E2630 MONOSUSPENSION ARM/HAND SUPP 709.72 $709.72 --- -- 009 0 0 0.00 $70.97 Y
1 E2631 ELEVAT PROXIMAL ARM SUPPORT 283.90 $283.90 --- -- 009 0 0 0.00 $28.39 Y
1 E2632 OFFSET/LAT ROCKER ARM W/ELA 180.52 $180.52 --- -- 009 0 0 0.00 $18.05 Y
1 E2633 MOBILE ARM SUPPORT SUPINATOR 152.60 $152.60 --- -- 009 0 0 0.00 $15.24 Y
1 E8000 POSTERIOR GAIT TRAINER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E8001 UPRIGHT GAIT TRAINER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 E8002 ANTERIOR GAIT TRAINER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 G0071 COMM SVCS BY RHC/FQHC 5 MIN 11.74 $11.74 --- -- 009 0 0 0.00 $0.00 Y
1 G0108 DIAB MANAGE TRN PER INDIV 45.74 $45.74 --- -- 009 0 0 0.00 $0.00 N
1 G0109 DIAB MANAGE TRN IND/GROUP 12.26 $12.26 --- -- 009 0 0 0.00 $0.00 N
1 G0151 HHCP-SERV OF PT,EA 15 MIN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 G0152 HHCP-SERV OF OT,EA 15 MIN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 G0153 HHCP-SVS OF S/L PATH,EA 15MN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 G0155 HHCP-SVS OF CSW,EA 15 MIN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 G0156 HHCP-SVS OF AIDE,EA 15 MIN 7.09 $7.09 --- -- 009 0 0 0.00 $0.00 Y
T G0156 SVCS HH/HSPC AIDE,HH/HSPC PER 15MINS 7.09 $7.09 --- -- 009 0 0 0.00 $0.00 Y
G G0156 SVCS OF HOME HLTH AIDE IN HOME HLTH SETT 5.01 $5.01 --- -- 009 0 0 0.00 $0.00 N
T G0162 SKILLED SVC RN MGT EVAL/PLAN PER 15MIN 17.04 $17.04 --- -- 009 0 0 0.00 $0.00 Y
1 G0162 HHC RN E&M PLAN SVS, 15 MIN 17.04 $17.04 --- -- 009 0 0 0.00 $0.00 Y
1 G0176 OPPS/PHP;ACTIVITY THERAPY 35.00 $35.00 --- -- 009 0 0 0.00 $0.00 Y
L G0279 DIAGNOSTIC-DIGITAL BREAST TOMOSYTHESIS 49.49 $49.49 --- -- 009 0 0 0.53 $0.00 Y
L G0297 LDCT FOR LUNG CA SCREEN 60.43 $230.84 --- -- 005 0 0 0.19 $0.00 Y
T G0299 SKILLED NURS RN HH/HSPC EACH 15MINS 15.21 $15.21 --- -- 009 0 0 0.00 $0.00 Y
G G0299 RN SKILLED NURSING IN HOME HEALTH SETTIN 10.15 $10.15 --- -- 009 0 0 0.00 $0.00 N
G G0300 LPN/LVN NURSING IN HOME HEALTH SETTING 7.36 $7.36 --- -- 009 0 0 0.00 $0.00 N
T G0300 SKILLED NURS LPN, HH/HSPC PER 15MIN 11.03 $11.03 --- -- 009 0 0 0.00 $0.00 Y
M G0416 SAT BIOPSY PROSTATE 1-20 SPC 438.50 $438.50 --- -- 009 0 0 0.27 $0.00 N
N G0422 INTENS CARDIAC REHAB W/EXERC 94.80 $94.80 --- -- 009 0 0 0.00 $0.00 Y
N G0423 INTENS CARDIAC REHAB NO EXER 94.80 $94.80 --- -- 009 0 0 0.00 $0.00 Y
N G0424 PULMONARY REHAB W EXER 26.55 $265.50 $289.66 -- 001 0 0 0.00 $0.00 Y
M G0432 EIA HIV-1/HIV-2 SCREEN 14.93 $14.93 --- -- 009 0 0 0.00 $0.00 N
M G0433 ELISA HIV-1/HIV-2 SCREEN 14.93 $14.93 --- -- 009 0 0 0.00 $0.00 N
M G0435 ORAL HIV-1/HIV-2 SCREEN 10.10 $10.10 --- -- 009 0 0 0.00 $0.00 N
N G0442 ANNUAL ALCOHOL SCREEN 15 MIN 20.12 $16.50 --- -- 007 0 0 0.00 $0.00 Y
N G0443 BRIEF ALCOHOL MISUSE COUNSEL 20.12 $16.50 --- -- 007 0 0 0.00 $0.00 Y
N G0444 DEPRESSION SCREEN ANNUAL 16.16 $16.16 --- -- 009 0 0 0.00 $0.00 Y
N G0446 INTENS BEHAVE THER CARDIO DX 21.28 $21.28 --- -- 009 0 0 0.00 $0.00 Y
N G0447 BEHAVIOR COUNSEL OBESITY 15M 22.26 $22.26 --- -- 009 0 0 0.00 $0.00 Y
N G0452 MOLECULAR PATHOLOGY INTERPR 15.89 $15.89 --- -- 009 0 0 1.00 $0.00 Y
L G0458 LDR PROSTATE BRACHY COMP RAT 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
M G0472 HEP C SCREEN HIGH RISK/OTHER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
N G0473 GROUP BEHAVE COUNS 2-10 10.68 $10.68 --- -- 009 0 0 0.00 $0.00 Y
M G0475 HIV COMBINATION ASSAY 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
M G0480 DRUG TEST DEF 1-7 CLASSES 63.95 $63.95 --- -- 009 0 0 0.00 $0.00 N
M G0481 DRUG TEST DEF 8-14 CLASSES 98.39 $98.39 --- -- 009 0 0 0.00 $0.00 N
M G0482 DRUG TEST DEF 15-21 CLASSES 132.82 $132.82 --- -- 009 0 0 0.00 $0.00 N
M G0483 DRUG TEST DEF 22+ CLASSES 172.18 $172.18 --- -- 009 0 0 0.00 $0.00 N
N G0492 MD/OTH EVAL ACUT KID NO ESRD 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
N G0493 RN CARE EA 15 MIN HH/HOSPICE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
N G0494 LPN CARE EA 15MIN HH/HOSPICE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
N G0495 RN CARE TRAIN/EDU IN HH 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
N G0496 LPN CARE TRAIN/EDU IN HH 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
M G0499 HEPB SCREEN HIGH RISK INDIV 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
N G0500 MOD SEDAT ENDO SERVICE >5YRS 53.85 $53.85 --- -- 009 0 0 0.00 $0.00 Y
N G0506 COMP ASSES CARE PLAN CCM SVC 55.57 $55.57 --- -- 009 0 0 0.00 $0.00 Y
N G0508 CRIT CARE TELEHEA CONSULT 60 168.71 $168.71 --- -- 009 0 0 0.00 $0.00 N
N G0509 CRIT CARE TELEHEA CONSULT 50 162.69 $162.69 --- -- 009 0 0 0.00 $0.00 N
M G0659 DRUG TEST DEF SIMPLE ALL CL 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 G2010 REMOT IMAGE SUBMIT BY PT 10.87 $10.87 --- -- 009 0 0 0.00 $0.00 Y
N G2012 BRIEF CHECK IN BY MD/QHP 12.48 $12.48 --- -- 009 0 0 0.00 $0.00 Y
L G6001 ECHO GUIDANCE RADIOTHERAPY 11.84 $45.23 --- -- 005 0 0 0.56 $0.00 Y
L G6002 STEREOSCOPIC X-RAY GUIDANCE 17.67 $67.50 --- -- 005 0 0 0.25 $0.00 Y
L G6003 RADIATION TREATMENT DELIVERY 38.89 $148.56 --- -- 005 0 0 0.00 $0.00 Y
L G6004 RADIATION TREATMENT DELIVERY 30.11 $115.02 --- -- 005 0 0 0.00 $0.00 Y
L G6005 RADIATION TREATMENT DELIVERY 33.64 $128.50 --- -- 005 0 0 0.00 $0.00 Y
L G6006 RADIATION TREATMENT DELIVERY 33.46 $127.82 --- -- 005 0 0 0.00 $0.00 Y
L G6007 RADIATION TREATMENT DELIVERY 61.88 $236.38 --- -- 005 0 0 0.00 $0.00 Y
L G6008 RADIATION TREATMENT DELIVERY 41.64 $159.06 --- -- 005 0 0 0.00 $0.00 Y
L G6009 RADIATION TREATMENT DELIVERY 46.12 $176.18 --- -- 005 0 0 0.00 $0.00 Y
L G6010 RADIATION TREATMENT DELIVERY 46.12 $176.18 --- -- 005 0 0 0.00 $0.00 Y
L G6011 RADIATION TREATMENT DELIVERY 66.18 $252.81 --- -- 005 0 0 0.00 $0.00 Y
L G6012 RADIATION TREATMENT DELIVERY 54.82 $209.41 --- -- 005 0 0 0.00 $0.00 Y
L G6013 RADIATION TREATMENT DELIVERY 61.71 $235.73 --- -- 005 0 0 0.00 $0.00 Y
L G6014 RADIATION TREATMENT DELIVERY 61.71 $235.73 --- -- 005 0 0 0.00 $0.00 Y
L G6015 RADIATION TX DELIVERY IMRT 96.23 $367.60 --- -- 005 0 0 0.00 $0.00 Y
L G6016 DELIVERY COMP IMRT 96.06 $366.95 --- -- 005 0 0 0.00 $0.00 Y
L G6017 INTRAFRACTION TRACK MOTION 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
N G8431 POS CLIN DEPRES SCRN F/U DOC 29.68 $29.68 --- -- 009 0 0 0.00 $0.00 Y
N G8510 PT INGELIG NEG SCRN DEPRES 10.70 $10.70 --- -- 009 0 0 0.00 $0.00 Y
1 G9001 COORDINATED CARE FEE, INITIAL RATE 1000.00 $1000.00 --- -- 009 0 0 0.00 $0.00 N
1 G9002 COORDINATED CARE FEE, MAINTENANCE RATE 200.00 $200.00 --- -- 009 0 0 0.00 $0.00 N
1 G9012 OTHER SPECIFIED CASE MGMT 35.77 $35.77 --- -- 009 0 0 0.00 $0.00 N
1 G9654 MON ANESTH CARE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9873 1 EM CORE SESSION 20.00 $20.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9874 4 EM CORE SESSIONS 40.00 $40.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9875 9 EM CORE SESSIONS 72.00 $72.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9876 2 EM CORE MS MO 7-9 NO WL 12.00 $12.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9877 2 EM CORE MS MO 10-12 NO WL 12.00 $12.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9878 2 EM CORE MS MO 7-9 WL 48.00 $48.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9879 2 EM CORE MS MO 10-12 WL 48.00 $48.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9880 EM 5 PERCENT WL 128.00 $128.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9881 EM 9 PERCENT WL 20.00 $20.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9882 2 EM ONGOING MS MO 13-15 WL 40.00 $40.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9883 2 EM ONGOING MS MO 16-18 WL 40.00 $40.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9884 2 EM ONGOING MS MO 19-21 WL 40.00 $40.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9885 2 EM ONGOING MS MO 22-24 WL 40.00 $40.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9890 EM BRIDGE PAYMENT 20.00 $20.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9919 SCRN ND POS ND PROV OF REC 29.00 $29.00 --- -- 009 0 0 0.00 $0.00 Y
1 G9920 SCRNING PERF AND NEGATIVE 29.00 $29.00 --- -- 009 0 0 0.00 $0.00 Y
1 H0014 ALCOHOL AND/OR DRUG SERVICES 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 H0033 ORAL MED ADM DIRECT OBSERVE 19.23 $19.23 --- -- 009 0 0 0.00 $0.00 Y
1 H0045 RESPITE NOT-IN-HOME PER DIEM 91.28 $91.28 --- -- 009 0 0 0.00 $0.00 N
1 H2000 COMP MULTIDISIPLN EVALUATION 80.08 $80.08 --- -- 009 0 0 0.00 $0.00 N
I J0121 INJ., OMADACYCLINE, 1 MG 7.91 $7.91 --- -- 030 0 0 0.00 $0.00 Y
I J0122 INJ., ERAVACYCLINE, 1 MG 5.44 $5.44 --- -- 030 0 0 0.00 $0.00 Y
I J0129 ABATACEPT INJECTION 58.40 $58.40 --- -- 030 0 0 0.00 $0.00 Y
I J0131 ACETAMINOPHEN INJECTION 4.89 $4.89 --- -- 030 0 0 0.00 $0.00 Y
I J0132 ACETYLCYSTEINE INJECTION 5.77 $5.77 --- -- 030 0 0 0.00 $0.00 Y
I J0133 ACYCLOVIR INJECTION 4.50 $4.50 --- -- 030 0 0 0.00 $0.00 Y
I J0135 ADALIMUMAB INJECTION 1927.87 $1927.87 --- -- 030 0 0 0.00 $0.00 Y
I J0153 ADENOSINE INJ 1MG 5.09 $5.09 --- -- 030 0 0 0.00 $0.00 Y
I J0171 ADRENALIN EPINEPHRINE INJECT 5.32 $5.32 --- -- 030 0 0 0.00 $0.00 Y
I J0178 AFLIBERCEPT INJECTION 961.82 $961.82 --- -- 030 0 0 0.00 $0.00 Y
I J0179 INJ, BROLUCIZUMAB-DBLL, 1 MG 322.04 $322.04 --- -- 030 0 0 0.00 $0.00 Y
I J0180 AGALSIDASE BETA 1 MG 186.89 $186.89 --- -- 030 0 0 0.00 $0.00 Y
I J0185 INJ., APREPITANT, 1 MG 6.69 $6.69 --- -- 030 0 0 0.00 $0.00 Y
I J0202 INJECTION, ALEMTUZUMAB 1922.81 $1922.81 --- -- 030 0 0 0.00 $0.00 Y
I J0207 AMIFOSTINE 981.77 $981.77 --- -- 030 0 0 0.00 $0.00 Y
I J0210 INJECTION, METHYLDOPATE HCL, UP TO 44.46 $44.46 --- -- 030 0 0 0.00 $0.00 Y
I J0220 ALGLUCOSIDASE ALFA INJECTION 211.10 $211.10 --- -- 030 0 0 0.00 $0.00 Y
I J0221 LUMIZYME INJECTION 174.54 $174.54 --- -- 030 0 0 0.00 $0.00 Y
I J0222 INJ., PATISIRAN, 0.1 MG 99.46 $99.46 --- -- 030 0 0 0.00 $0.00 Y
I J0256 ALPHA 1 PROTEINASE INHIBITOR 8.97 $8.97 --- -- 030 0 0 0.00 $0.00 Y
I J0257 GLASSIA INJECTION 9.35 $9.35 --- -- 030 0 0 0.00 $0.00 Y
I J0278 AMIKACIN SULFATE INJECTION 5.67 $5.67 --- -- 030 0 0 0.00 $0.00 Y
I J0285 AMPHOTERICIN B 44.74 $44.74 --- -- 030 0 0 0.00 $0.00 Y
I J0287 AMPHOTERICIN B LIPID COMPLEX 11.58 $11.58 --- -- 030 0 0 0.00 $0.00 Y
I J0288 AMPHO B CHOLESTERYL SULFATE 25.49 $25.49 --- -- 030 0 0 0.00 $0.00 Y
I J0289 AMPHOTERICIN B LIPOSOME INJ 22.79 $22.79 --- -- 030 0 0 0.00 $0.00 Y
I J0290 AMPICILLIN 500 MG INJ 5.38 $5.38 --- -- 030 0 0 0.00 $0.00 Y
I J0291 INJ., PLAZOMICIN, 5 MG 7.61 $7.61 --- -- 030 0 0 0.00 $0.00 Y
I J0300 INJECTION, AMOBARBITAL, UP TO 125 187.72 $187.72 --- -- 030 0 0 0.00 $0.00 Y
I J0330 INJECTION, SUCCINYCHOLINE CHLORIDE 6.38 $6.38 --- -- 030 0 0 0.00 $0.00 Y
I J0348 ANIDULAFUNGIN INJECTION 5.01 $5.01 --- -- 030 0 0 0.00 $0.00 Y
I J0360 INJECTION, HYDRALAZINE HCL, UP TO 8.53 $8.53 --- -- 030 0 0 0.00 $0.00 Y
I J0400 *08ARIPIPRAZOLE INJECTION 5.22 $5.22 --- -- 030 0 0 0.00 $0.00 Y
I J0401 INJ ARIPIPRAZOLE EXT REL 1MG 9.91 $9.91 --- -- 030 0 0 0.00 $0.00 Y
I J0456 AZITHROMYCIN 7.21 $7.21 --- -- 030 0 0 0.00 $0.00 Y
I J0461 ATROPINE SULFATE INJECTION 4.53 $4.53 --- -- 030 0 0 0.00 $0.00 Y
I J0470 INJECTION, DIMERCAPROL, UP TO 100 M 58.74 $58.74 --- -- 030 0 0 0.00 $0.00 Y
I J0475 INJECTION, BACLOFEN, 10 MG 177.85 $177.85 --- -- 030 0 0 0.00 $0.00 Y
I J0476 BACLOFEN INTRATHECAL TRIAL 54.90 $54.90 --- -- 030 0 0 0.00 $0.00 Y
I J0480 BASILIXIMAB 3794.09 $3794.09 --- -- 030 0 0 0.00 $0.00 Y
I J0485 BELATACEPT INJECTION 8.24 $8.24 --- -- 030 0 0 0.00 $0.00 Y
I J0490 BELIMUMAB INJECTION 49.28 $49.28 --- -- 030 0 0 0.00 $0.00 Y
I J0500 INJECTION, DICYCLOMINE, UP TO 20 M 74.43 $74.43 --- -- 030 0 0 0.00 $0.00 Y
I J0515 INJECTION, BENZTROPINE 24.35 $24.35 --- -- 030 0 0 0.00 $0.00 Y
I J0517 INJ., BENRALIZUMAB, 1 MG 173.30 $173.30 --- -- 030 0 0 0.00 $0.00 Y
I J0558 PENG BENZATHINE/PROCAINE INJ 15.48 $15.48 --- -- 030 0 0 0.00 $0.00 Y
I J0561 PENICILLIN G BENZATHINE INJ 18.31 $18.31 --- -- 030 0 0 0.00 $0.00 Y
I J0565 INJ, BEZLOTOXUMAB, 10 MG 44.36 $44.36 --- -- 030 0 0 0.00 $0.00 Y
I J0567 INJ., CERLIPONASE ALFA 1 MG 93.56 $93.56 --- -- 030 0 0 0.00 $0.00 Y
1 J0570 BUPRENORPHINE IMPLANT 74.2MG 1261.87 $1261.87 --- -- 009 0 0 0.00 $0.00 Y
I J0585 BOTULINUM TOXIN TYPE A, PER 1 UNIT 10.58 $10.58 --- -- 030 0 0 0.00 $0.00 Y
I J0586 ABOBOTULINUMTOXINA 12.88 $12.88 --- -- 030 0 0 0.00 $0.00 Y
I J0587 BOTULINUM TOXIN TYPE B, PER 100 UNITS 16.48 $16.48 --- -- 030 0 0 0.00 $0.00 Y
I J0588 INCOBOTULINUMTOXIN A 9.51 $9.51 --- -- 030 0 0 0.00 $0.00 Y
I J0593 INJ., LANADELUMAB-FLYO, 1 MG 78.03 $78.03 --- -- 030 0 0 0.00 $0.00 Y
I J0595 BUTORPHANOL TARTRATE 1 MG 6.72 $6.72 --- -- 030 0 0 0.00 $0.00 Y
I J0596 INJECTION, RUCONEST 32.28 $32.28 --- -- 030 0 0 0.00 $0.00 Y
I J0597 C-1 ESTERASE, BERINERT 55.81 $55.81 --- -- 030 0 0 0.00 $0.00 Y
I J0598 C-1 ESTERASE, CINRYZE 61.62 $61.62 --- -- 030 0 0 0.00 $0.00 Y
I J0606 INJECTION, ETELCALCETIDE, 0.1 MG 7.73 $7.73 --- -- 030 0 0 0.00 $0.00 Y
I J0630 INJECTION, CALCITONIN SALMON, UP T 2651.72 $2651.72 --- -- 030 0 0 0.00 $0.00 Y
I J0636 INJ CALCITRIOL PER 0.1 MCG 5.18 $5.18 --- -- 030 0 0 0.00 $0.00 Y
I J0638 CANAKINUMAB INJECTION 115.47 $115.47 --- -- 030 0 0 0.00 $0.00 Y
I J0640 INJECTION, LEUCOVORIN CALCIUM, PER 7.48 $7.48 --- -- 030 0 0 0.00 $0.00 Y
I J0641 INJ., LEVOLEUCOVORIN, 0.5 MG 4.62 $4.62 --- -- 030 0 0 0.00 $0.00 Y
I J0642 INJECTION, KHAPZORY, 0.5 MG 6.42 $6.42 --- -- 030 0 0 0.00 $0.00 Y
I J0670 INJECTION, MEPIVACAINE 6.46 $6.46 --- -- 030 0 0 0.00 $0.00 Y
I J0690 CEFAZOLIN SODIUM INJECTION 5.21 $5.21 --- -- 030 0 0 0.00 $0.00 Y
I J0694 INJECTION, CEFOXITIN SODIUM, 1 GM 9.42 $9.42 --- -- 030 0 0 0.00 $0.00 Y
I J0696 INJECTION, CEFTRIAXONE SODIUM, PER 4.95 $4.95 --- -- 030 0 0 0.00 $0.00 Y
I J0698 CEFOTAXIME SODIUM, PER GM 6.79 $6.79 --- -- 030 0 0 0.00 $0.00 Y
I J0702 BETAMETHASONE ACET&SOD PHOSP 11.37 $11.37 --- -- 030 0 0 0.00 $0.00 Y
I J0712 CEFTAROLINE FOSAMIL INJ 7.62 $7.62 --- -- 030 0 0 0.00 $0.00 Y
I J0714 CEFTAZIDIME AND AVIBACTAM 95.59 $95.59 --- -- 030 0 0 0.00 $0.00 Y
I J0716 CENTRUROIDES IMMUNE F(AB) 4646.77 $4646.77 --- -- 030 0 0 0.00 $0.00 Y
I J0717 CERTOLIZUMAB PEGOL INJ 1MG 12.59 $12.59 --- -- 030 0 0 0.00 $0.00 Y
I J0720 INJECTION, CHLORAMPHENICOL SODIUM 42.79 $42.79 --- -- 030 0 0 0.00 $0.00 Y
I J0725 CHORIONIC GONADOTROPIN PER 1000 USP UNIT 26.83 $26.83 --- -- 030 0 0 0.00 $0.00 Y
I J0735 CLONIDINE HYDROCHLORIDE, 1 MG 16.03 $16.03 --- -- 030 0 0 0.00 $0.00 Y
I J0740 CIDOFOVIR INJECTION 647.75 $647.75 --- -- 030 0 0 0.00 $0.00 Y
I J0775 COLLAGENASE, CLOST HIST INJ 51.55 $51.55 --- -- 030 0 0 0.00 $0.00 Y
I J0780 INJECTION, PROCHLORPERAZINE, UP TO 14.80 $14.80 --- -- 030 0 0 0.00 $0.00 Y
I J0795 CORTICORELIN OVINE TRIFLUTATE, 1 MCG 13.51 $13.51 --- -- 030 0 0 0.00 $0.00 Y
I J0834 COSYNTROPIN CORTROSYN INJ 48.54 $48.54 --- -- 030 0 0 0.00 $0.00 Y
I J0840 *12CROTALIDAE POLY IMMUNE FAB 3241.47 $3241.47 --- -- 030 0 0 0.00 $0.00 Y
I J0841 INJ CROTALIDAE IM F(AB')2 EQ 1224.46 $1224.46 --- -- 030 0 0 0.00 $0.00 Y
I J0875 INJECTION, DALBAVANCIN 19.08 $19.08 --- -- 030 0 0 0.00 $0.00 Y
I J0878 DAPTOMYCIN INJECTION 4.81 $4.81 --- -- 030 0 0 0.00 $0.00 Y
I J0881 DARBEPOETIN ALFA, NON-ESRD 8.29 $8.29 --- -- 030 0 0 0.00 $0.00 Y
I J0882 DARBEPOETIN ALFA, ESRD USE 8.29 $8.29 --- -- 030 0 0 0.00 $0.00 Y
I J0883 ARGATROBAN NONESRD USE 1MG 7.79 $7.79 --- -- 030 0 0 0.00 $0.00 Y
I J0884 ARGATROBAN ESRD DIALYSIS 1MG 7.79 $7.79 --- -- 030 0 0 0.00 $0.00 Y
I J0885 EPOETIN ALFA, NON-ESRD 15.92 $15.92 --- -- 030 0 0 0.00 $0.00 Y
I J0887 EPOETIN BETA ESRD USE 6.11 $6.11 --- -- 030 0 0 0.00 $0.00 Y
I J0894 DECITABINE INJECTION 11.92 $11.92 --- -- 030 0 0 0.00 $0.00 Y
I J0895 DEFEROXAMINE MESYLATE 500 MG 12.67 $12.67 --- -- 030 0 0 0.00 $0.00 Y
I J0897 DENOSUMAB INJECTION 23.56 $23.56 --- -- 030 0 0 0.00 $0.00 Y
I J1000 INJECTION, DEPOESTRADIOL CYPIONAT 26.42 $26.42 --- -- 030 0 0 0.00 $0.00 Y
I J1020 INJECTION, METHYLPREDNISOLONE ACET 8.12 $8.12 --- -- 030 0 0 0.00 $0.00 Y
I J1030 INJECTION, METHYLPREDNISOLONE ACET 10.70 $10.70 --- -- 030 0 0 0.00 $0.00 Y
I J1040 INJECTION, METHYLPREDNISOLONE ACET 16.48 $16.48 --- -- 030 0 0 0.00 $0.00 Y
I J1050 MEDROXYPROGESTERONE INJ 5.03 $5.03 --- -- 030 0 0 0.00 $0.00 Y
I J1071 INJ TESTOSTERONE CYPIONATE 4.49 $4.49 --- -- 030 0 0 0.00 $0.00 Y
I J1095 INJECTION, DEXAMETHASONE 9% 5.65 $5.65 --- -- 030 0 0 0.00 $0.00 Y
1 J1096 DEXAMETHA OPTH INSERT 0.1 MG 134.71 $134.71 --- -- 009 0 0 0.00 $0.00 Y
1 J1097 PHENYLEP KETOROLAC OPTH SOLN 116.25 $116.25 --- -- 009 0 0 0.00 $0.00 Y
I J1100 DEXAMETHASONE SODIUM PHOS 4.58 $4.58 --- -- 030 0 0 0.00 $0.00 Y
I J1110 INJECTION, DEHYDROERGOTAMINE, UP T 61.75 $61.75 --- -- 030 0 0 0.00 $0.00 Y
I J1120 INJECTION, ACETAZOLAMIDE SODIUM, U 19.97 $19.97 --- -- 030 0 0 0.00 $0.00 Y
I J1130 INJ DICLOFENAC SODIUM 0.5MG 4.67 $4.67 --- -- 030 0 0 0.00 $0.00 Y
I J1160 INJECTION, DIGOXIN, UP TO 0.5 MG 9.67 $9.67 --- -- 030 0 0 0.00 $0.00 Y
I J1162 DIGOXIN IMMUNE FAB (OVINE) 3784.72 $3784.72 --- -- 030 0 0 0.00 $0.00 Y
I J1165 INJECTION, PHENYTOIN SODIUM 5.21 $5.21 --- -- 030 0 0 0.00 $0.00 Y
I J1170 INJECTION, HYDROMORPHONE, UP TO 4 8.66 $8.66 --- -- 030 0 0 0.00 $0.00 Y
I J1200 INJECTION, DIPHENHYDRAMINE HCL, UP 5.32 $5.32 --- -- 030 0 0 0.00 $0.00 Y
I J1205 INJECTION, CHLOROTHIAZIDE SODIUM 55.10 $55.10 --- -- 030 0 0 0.00 $0.00 Y
I J1230 INJECTION, METHADONE HCL, UP TO 10 22.61 $22.61 --- -- 030 0 0 0.00 $0.00 Y
I J1250 DOUBUTAMINE HYDROCHLORIDE, 250 MG 12.99 $12.99 --- -- 030 0 0 0.00 $0.00 Y
I J1260 DOLASETRON MESYLATE 10.63 $10.63 --- -- 030 0 0 0.00 $0.00 Y
I J1265 DOPAMINE INJECTION 5.22 $5.22 --- -- 030 0 0 0.00 $0.00 Y
I J1267 DORIPENEM INJECTION 5.22 $5.22 --- -- 030 0 0 0.00 $0.00 Y
I J1270 INJECTION, DOXERCALCIFEROL 4.69 $4.69 --- -- 030 0 0 0.00 $0.00 Y
I J1290 ECALLANTIDE INJECTION 485.01 $485.01 --- -- 030 0 0 0.00 $0.00 Y
I J1300 ECULIZUMAB INJECTION 234.94 $234.94 --- -- 030 0 0 0.00 $0.00 Y
I J1301 INJECTION, EDARAVONE, 1 MG 23.96 $23.96 --- -- 030 0 0 0.00 $0.00 Y
I J1303 INJ., RAVULIZUMAB-CWVZ 10 MG 230.74 $230.74 --- -- 030 0 0 0.00 $0.00 Y
I J1322 ELOSULFASE ALFA, INJECTION 241.22 $241.22 --- -- 030 0 0 0.00 $0.00 Y
I J1364 INJECTION ERYTHROMYCIN LACTOBIONATE PER 83.33 $83.33 --- -- 030 0 0 0.00 $0.00 Y
I J1380 INJECTION, ESTRADIOL VALERATE, UP 13.80 $13.80 --- -- 030 0 0 0.00 $0.00 Y
I J1410 INJECTION, ESTROGEN CONJUGATED,PER 25 MG 313.79 $313.79 --- -- 030 0 0 0.00 $0.00 Y
I J1428 INJ, ETEPLIRSEN, 10 MG 164.46 $164.46 --- -- 030 0 0 0.00 $0.00 Y
I J1439 INJ FERRIC CARBOXYMALTOS 1MG 5.55 $5.55 --- -- 030 0 0 0.00 $0.00 Y
I J1442 INJ, FILGRASTIM G-CSF 1MCG 5.44 $5.44 --- -- 030 0 0 0.00 $0.00 Y
I J1447 INJ TBO FILGRASTIM 1 MICROG 5.04 $5.04 --- -- 030 0 0 0.00 $0.00 Y
I J1451 FOMEPIZOLE, 15 MG 17.75 $17.75 --- -- 030 0 0 0.00 $0.00 Y
I J1453 FOSAPREPITANT INJECTION 6.46 $6.46 --- -- 030 0 0 0.00 $0.00 Y
I J1454 INJ FOSNETUPITANT, PALONOSET 464.88 $464.88 --- -- 030 0 0 0.00 $0.00 Y
I J1455 INJECTION, FOSCARNET SODIUM, PER 1000MG 82.66 $82.66 --- -- 030 0 0 0.00 $0.00 Y
I J1458 GALSULFASE 1 MG 394.53 $394.53 --- -- 030 0 0 0.00 $0.00 Y
I J1459 INJ IVIG PRIVIGEN 500 MG 45.06 $45.06 --- -- 030 0 0 0.00 $0.00 Y
I J1460 INJECTION, GAMMA GLOBULIN, INTRAMU 45.00 $45.00 --- -- 030 0 0 0.00 $0.00 Y
I J1555 INJ CUVITRU, 100 MG 18.32 $18.32 --- -- 030 0 0 0.00 $0.00 Y
I J1556 INJ, IMM GLOB BIVIGAM, 500MG 74.98 $74.98 --- -- 030 0 0 0.00 $0.00 Y
I J1557 GAMMAPLEX INJECTION 50.49 $50.49 --- -- 030 0 0 0.00 $0.00 Y
I J1559 HIZENTRA INJECTION 14.65 $14.65 --- -- 030 0 0 0.00 $0.00 Y
I J1560 INJECTION, GAMMA GLOBULIN, INTRAMU 409.82 $409.82 --- -- 030 0 0 0.00 $0.00 Y
I J1561 *08GAMUNEX INJECTION 43.10 $43.10 --- -- 030 0 0 0.00 $0.00 Y
I J1562 VIVAGLOBIN, INJ 16.41 $16.41 --- -- 030 0 0 0.00 $0.00 Y
I J1566 IMMUNE GLOBULIN, POWDER 66.68 $66.68 --- -- 030 0 0 0.00 $0.00 Y
I J1568 OCTAGAM INJECTION 43.14 $43.14 --- -- 030 0 0 0.00 $0.00 Y
I J1569 GAMMAGARD LIQUID INJECTION 45.43 $45.43 --- -- 030 0 0 0.00 $0.00 Y
I J1571 HEPAGAM B IM INJECTION 64.81 $64.81 --- -- 030 0 0 0.00 $0.00 Y
I J1572 FLEBOGAMMA INJECTION 40.32 $40.32 --- -- 030 0 0 0.00 $0.00 Y
I J1573 HEPAGAM B INTRAVENOUS, INJ 95.34 $95.34 --- -- 030 0 0 0.00 $0.00 Y
I J1575 HYQVIA 100MG IMMUNEGLOBULIN 18.48 $18.48 --- -- 030 0 0 0.00 $0.00 Y
I J1580 INJECTION, GARAMYCIN, GENTAMICIN, 6.29 $6.29 --- -- 030 0 0 0.00 $0.00 Y
I J1599 IVIG NON-LYOPHILIZED, NOS 87.46 $87.46 --- -- 030 0 0 0.00 $0.00 Y
I J1600 INJECTION, GOLD SODIUM THIOMALEATE 26.97 $26.97 --- -- 030 0 0 0.00 $0.00 Y
I J1602 GOLIMUMAB FOR IV USE 1MG 26.35 $26.35 --- -- 030 0 0 0.00 $0.00 Y
I J1610 INJECTION GLUCAGON HYDROCHLORIDE PER 1MG 204.72 $204.72 --- -- 030 0 0 0.00 $0.00 Y
I J1626 GRANISETRON HCL INJECTION 4.76 $4.76 --- -- 030 0 0 0.00 $0.00 Y
I J1627 INJ, GRANISETRON, XR, 0.1 MG 7.51 $7.51 --- -- 030 0 0 0.00 $0.00 Y
I J1628 INJ., GUSELKUMAB, 1 MG 113.05 $113.05 --- -- 030 0 0 0.00 $0.00 Y
I J1630 INJECTION, HALOPERIDOL, UP TO 5 MG 5.59 $5.59 --- -- 030 0 0 0.00 $0.00 Y
I J1631 HALOPERIDOL DECANOATE, 50 MG 21.11 $21.11 --- -- 030 0 0 0.00 $0.00 Y
I J1640 *04 *06 HEMIN, 1 MG 28.22 $28.22 --- -- 030 0 0 0.00 $0.00 Y
I J1642 INJECTION HEPARIN SODIUM PER 10 UNITS 4.63 $4.63 --- -- 030 0 0 0.00 $0.00 Y
I J1644 INJECTION HEPARIN SODIUM PER 1000 UNITS 4.66 $4.66 --- -- 030 0 0 0.00 $0.00 Y
I J1650 INJ ENOXAPARIN SODIUM 5.30 $5.30 --- -- 030 0 0 0.00 $0.00 Y
I J1675 HISTRELIN ACETATE 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I J1720 INJECTION, HYDROCORTISONE SODIUM S 17.50 $17.50 --- -- 030 0 0 0.00 $0.00 Y
I J1726 MAKENA, 10 MG 36.58 $36.58 --- -- 030 0 0 0.00 $0.00 Y
I J1729 INJ HYDROXYPROGST CAPOAT NOS 30.81 $30.81 --- -- 030 0 0 0.00 $0.00 Y
I J1740 IBANDRONATE SODIUM INJECTION 50.19 $50.19 --- -- 030 0 0 0.00 $0.00 Y
I J1741 IBUPROFEN INJECTION 6.47 $6.47 --- -- 030 0 0 0.00 $0.00 Y
I J1743 IDURSULFASE INJECTION 547.35 $547.35 --- -- 030 0 0 0.00 $0.00 Y
I J1745 INFLIXIMAB INJECTION 69.42 $69.42 --- -- 030 0 0 0.00 $0.00 Y
I J1746 INJ., IBALIZUMAB-UIYK, 10 MG 61.21 $61.21 --- -- 030 0 0 0.00 $0.00 Y
I J1750 INJ IRON DEXTRAN 18.87 $18.87 --- -- 030 0 0 0.00 $0.00 Y
I J1756 IRON SUCROSE INJECTION 4.69 $4.69 --- -- 030 0 0 0.00 $0.00 Y
I J1786 IMUGLUCERASE INJECTION 47.33 $47.33 --- -- 030 0 0 0.00 $0.00 Y
I J1790 INJECTION, DROPERIDOL, UP TO 5 MG 7.37 $7.37 --- -- 030 0 0 0.00 $0.00 Y
I J1800 INJECTION, PROPRANOLOL HCL, UP TO 5.69 $5.69 --- -- 030 0 0 0.00 $0.00 Y
I J1815 INSULIN INJECTION 5.36 $5.36 --- -- 030 0 0 0.00 $0.00 Y
I J1826 INTERFERON BETA-1A INJ 1621.16 $1621.16 --- -- 030 0 0 0.00 $0.00 Y
I J1840 INJECTION, KANAMYCIN SULFATE, UP T 9.71 $9.71 --- -- 030 0 0 0.00 $0.00 Y
I J1885 INJECTION, KETOROLAC TROMETHAMINE, 15MG 5.12 $5.12 --- -- 030 0 0 0.00 $0.00 Y
I J1930 *09 LANREOTIDE INJECTION 67.67 $67.67 --- -- 030 0 0 0.00 $0.00 Y
I J1931 LARONIDASE 0.1MG 36.41 $36.41 --- -- 030 0 0 0.00 $0.00 Y
I J1940 INJECTION, FUROSEMIDE, UP TO 20 MG 5.23 $5.23 --- -- 030 0 0 0.00 $0.00 Y
I J1943 INJ., ARISTADA INITIO,1 MG 7.32 $7.32 --- -- 030 0 0 0.00 $0.00 Y
I J1944 INJ., ARISTADA,1 MG 7.24 $7.24 --- -- 030 0 0 0.00 $0.00 Y
I J1945 LEPIRUDIN 540.55 $540.55 --- -- 030 0 0 0.00 $0.00 Y
I J1950 INJECTION LEUPROLIDE ACETATE PER 3 1272.23 $1272.23 --- -- 030 0 0 0.00 $0.00 Y
I J1953 LEVETIRACETAM INJECTION 4.57 $4.57 --- -- 030 0 0 0.00 $0.00 Y
I J2001 LIDOCAINE INJECTION 4.50 $4.50 --- -- 030 0 0 0.00 $0.00 Y
I J2010 INJECTION, LINCOMYCIN HCL, UP TO 3 17.62 $17.62 --- -- 030 0 0 0.00 $0.00 Y
I J2060 INJECTION, LORAZEPAM, 2 MG 5.10 $5.10 --- -- 030 0 0 0.00 $0.00 Y
1 J2062 LOXAPINE FOR INHALATION 1 MG 15.00 $15.00 --- -- 009 0 0 0.00 $0.00 Y
I J2150 INJECTION, MANNITOL, 25% IN 50 ML 6.57 $6.57 --- -- 030 0 0 0.00 $0.00 Y
I J2175 INJECT MEPERIDINE HYDROCHLORID PER 100MG 9.84 $9.84 --- -- 030 0 0 0.00 $0.00 Y
I J2182 INJECTION, MEPOLIZUMAB, 1MG 34.50 $34.50 --- -- 030 0 0 0.00 $0.00 Y
I J2210 INJECTION, METHYLERGONOVINE MALEAT 21.68 $21.68 --- -- 030 0 0 0.00 $0.00 Y
I J2248 MICAFUNGIN SODIUM INJECTION 5.50 $5.50 --- -- 030 0 0 0.00 $0.00 Y
I J2250 INJECT MIDAZ HYDROCHLOR PER 1 MG 4.57 $4.57 --- -- 030 0 0 0.00 $0.00 Y
I J2265 MINOCYCLINE HYDROCHLORIDE 5.79 $5.79 --- -- 030 0 0 0.00 $0.00 Y
I J2270 INJECTION, MORPHINE SULFATE, UP TO 9.19 $9.19 --- -- 030 0 0 0.00 $0.00 Y
I J2274 IN MORPHINE PRESERVATIV FREE 16.17 $16.17 --- -- 030 0 0 0.00 $0.00 Y
I J2278 ZICONOTIDE INJECTION 12.37 $12.37 --- -- 030 0 0 0.00 $0.00 Y
I J2300 NALBUPHINE HYDROCHLORIDE, 10 MG 7.36 $7.36 --- -- 030 0 0 0.00 $0.00 Y
I J2310 INJECT NALOX HYDROCHLOR PER 1 MG 21.92 $21.92 --- -- 030 0 0 0.00 $0.00 Y
I J2315 NALTREXONE, DEPOT FORM 7.69 $7.69 --- -- 030 0 0 0.00 $0.00 Y
I J2323 NATALIZUMAB INJECTION 24.75 $24.75 --- -- 030 0 0 0.00 $0.00 Y
I J2325 NESIRITIDE INJECTION 75.06 $75.06 --- -- 030 0 0 0.00 $0.00 Y
I J2326 INJ, NUSINERSEN, 0.1MG 1046.96 $1046.96 --- -- 030 0 0 0.00 $0.00 Y
I J2350 INJECTION, OCRELIZUMAB, 1MG 61.88 $61.88 --- -- 030 0 0 0.00 $0.00 Y
I J2353 OCTREOTIDE INJECTION, DEPOT 209.15 $209.15 --- -- 030 0 0 0.00 $0.00 Y
I J2354 OCTREOTIDE INJ, NON-DEPOT 5.28 $5.28 --- -- 030 0 0 0.00 $0.00 Y
I J2357 OMALIZUMAB INJECTION 5MG 41.51 $41.51 --- -- 030 0 0 0.00 $0.00 Y
I J2358 OLANZAPINE LONG-ACTING INJ 7.38 $7.38 --- -- 030 0 0 0.00 $0.00 Y
I J2360 INJECTION, ORPHENADRINE, UP TO 60 10.87 $10.87 --- -- 030 0 0 0.00 $0.00 Y
I J2370 INJECTION, PHENYLEPHRINE HCL, UP T 10.46 $10.46 --- -- 030 0 0 0.00 $0.00 Y
I J2400 INJECTION, CHLOROPROCAINE HCL 31.51 $31.51 --- -- 030 0 0 0.00 $0.00 Y
I J2405 ODANSETRON HYDROCHLORIDE, PER 1MG 4.58 $4.58 --- -- 030 0 0 0.00 $0.00 Y
I J2407 INJECTION, ORITAVANCIN 28.60 $28.60 --- -- 030 0 0 0.00 $0.00 Y
I J2425 PALIFERMIN INJECTION 25.76 $25.76 --- -- 030 0 0 0.00 $0.00 Y
I J2426 PALIPERIDONE PALMITATE INJ 15.94 $15.94 --- -- 030 0 0 0.00 $0.00 Y
I J2430 INJECTION PAMIDRONATE DISODIUM PER 30MG 16.93 $16.93 --- -- 030 0 0 0.00 $0.00 Y
I J2469 PALONOSETRON HCL 13.39 $13.39 --- -- 030 0 0 0.00 $0.00 Y
I J2501 PARICALCITOL 5.12 $5.12 --- -- 030 0 0 0.00 $0.00 Y
I J2503 PEGAPTANIB SODIUM INJECTION 725.13 $725.13 --- -- 030 0 0 0.00 $0.00 Y
I J2504 PEGADEMASE BOVINE, 25 IU 372.42 $372.42 --- -- 030 0 0 0.00 $0.00 Y
I J2505 INJECTION, PEGFILGRASTIM 6MG 4532.77 $4532.77 --- -- 030 0 0 0.00 $0.00 Y
I J2507 PEGLOTICASE INJECTION 2489.70 $2489.70 --- -- 030 0 0 0.00 $0.00 Y
I J2510 INJECTION, PENICILLIN G PROCAINE, 34.28 $34.28 --- -- 030 0 0 0.00 $0.00 Y
I J2515 INJECTION, PENTOBARBITAL SODIUM 42.50 $42.50 --- -- 030 0 0 0.00 $0.00 Y
I J2540 INJECTION, PENICILLIN G POTASSIUM, 5.48 $5.48 --- -- 030 0 0 0.00 $0.00 Y
I J2547 INJECTION, PERAMIVIR 6.04 $6.04 --- -- 030 0 0 0.00 $0.00 Y
I J2550 INJECTION, PROMETHAZINE HCL, UP TO 6.89 $6.89 --- -- 030 0 0 0.00 $0.00 Y
I J2560 INJECTION, PHENOBARBITAL SODIUM, U 45.89 $45.89 --- -- 030 0 0 0.00 $0.00 Y
I J2562 PLERIXAFOR INJECTION 351.70 $351.70 --- -- 030 0 0 0.00 $0.00 Y
I J2590 INJECTION, OXYTOCIN, UP TO 10 UNIT 6.48 $6.48 --- -- 030 0 0 0.00 $0.00 Y
I J2675 INJ PROGESTERONE PER 50 MG 6.72 $6.72 --- -- 030 0 0 0.00 $0.00 Y
I J2680 INJECTION, FLUPHENAZINE DECANOATE, 15.92 $15.92 --- -- 030 0 0 0.00 $0.00 Y
I J2690 INJECTION, PROCAINAMIDE HCL, UP TO 74.61 $74.61 --- -- 030 0 0 0.00 $0.00 Y
I J2700 INJECTION, OXACILLIN SODIUM, UP TO 5.94 $5.94 --- -- 030 0 0 0.00 $0.00 Y
I J2704 INJ, PROPOFOL, 10 MG 4.56 $4.56 --- -- 030 0 0 0.00 $0.00 Y
I J2710 INJECTION, NEOSTIGMINE METHYLSULFA 6.92 $6.92 --- -- 030 0 0 0.00 $0.00 Y
I J2720 INJECTION, PROTAMINE SULFATE,PER 10 MG 5.65 $5.65 --- -- 030 0 0 0.00 $0.00 Y
I J2724 PROTEIN C CONCENTRATE 19.52 $19.52 --- -- 030 0 0 0.00 $0.00 Y
I J2760 INJECTION, PHENTOLAINE MESYLATE, U 396.61 $396.61 --- -- 030 0 0 0.00 $0.00 Y
I J2765 INJECTION, METOCLOPRAMIDE HCL, UP 5.71 $5.71 --- -- 030 0 0 0.00 $0.00 Y
I J2778 RANIBIZUMAB INJECTION 361.80 $361.80 --- -- 030 0 0 0.00 $0.00 Y
I J2780 RANITIDINE HYDROCHLORIDE INJ 8.99 $8.99 --- -- 030 0 0 0.00 $0.00 Y
I J2785 REGADENOSON INJECTION 63.73 $63.73 --- -- 030 0 0 0.00 $0.00 Y
I J2786 INJECTION, RESLIZUMAB, 1MG 13.93 $13.93 --- -- 030 0 0 0.00 $0.00 Y
I J2792 RHO(D) IMMUNE GLOBULIN H, SD 34.56 $34.56 --- -- 030 0 0 0.00 $0.00 Y
I J2793 RILONACEPT INJECTION 26.96 $26.96 --- -- 030 0 0 0.00 $0.00 Y
I J2794 INJ., RISPERDAL CONSTA, 0.5 MG 14.41 $14.41 --- -- 030 0 0 0.00 $0.00 Y
I J2796 ROMIPLOSTIM INJECTION 77.97 $77.97 --- -- 030 0 0 0.00 $0.00 Y
I J2797 INJ., ROLAPITANT, 0.5 MG 5.35 $5.35 --- -- 030 0 0 0.00 $0.00 Y
I J2798 INJ., PERSERIS, 0.5 MG 14.33 $14.33 --- -- 030 0 0 0.00 $0.00 Y
I J2800 INJECTION, METHOCARBAMOL, UP TO 10 16.98 $16.98 --- -- 030 0 0 0.00 $0.00 Y
I J2805 SINCALIDE INJECTION 112.51 $112.51 --- -- 030 0 0 0.00 $0.00 Y
I J2820 SARGRAMOSTIM INJECTION 46.86 $46.86 --- -- 030 0 0 0.00 $0.00 Y
I J2840 INJ SEBELIPASE ALFA 1 MG 514.96 $514.96 --- -- 030 0 0 0.00 $0.00 Y
I J2850 INJ SECRETIN SYNTHETIC HUMAN 37.27 $37.27 --- -- 030 0 0 0.00 $0.00 Y
I J2860 INJECTION, SILTUXIMAB 105.23 $105.23 --- -- 030 0 0 0.00 $0.00 Y
I J2916 NA FERRIC GLUCONATE COMPLEX 6.19 $6.19 --- -- 030 0 0 0.00 $0.00 Y
I J2920 INJECTION, METHYLPREDNISOLONE SODI 8.95 $8.95 --- -- 030 0 0 0.00 $0.00 Y
I J2930 INJECTION, METHYLPREDNISOLONE SODI 10.63 $10.63 --- -- 030 0 0 0.00 $0.00 Y
I J2997 ALTEPLASE RECOMBINANT 92.15 $92.15 --- -- 030 0 0 0.00 $0.00 Y
I J3010 FENTANYL CITRATE INJECITON 5.27 $5.27 --- -- 030 0 0 0.00 $0.00 Y
I J3031 INJ., FREMANEZUMAB-VFRM 1 MG 6.93 $6.93 --- -- 030 0 0 0.00 $0.00 Y
I J3060 INJ, TALIGLUCERACE ALFA 10 U 44.80 $44.80 --- -- 030 0 0 0.00 $0.00 Y
I J3070 PENTAZOCINE INJECTION, 30 MG 112.85 $112.85 --- -- 030 0 0 0.00 $0.00 Y
I J3090 INJ TEDIZOLID PHOSPHATE 5.94 $5.94 --- -- 030 0 0 0.00 $0.00 Y
I J3095 TELEVANCINTELAVANCIN INJECTION 10.31 $10.31 --- -- 030 0 0 0.00 $0.00 Y
I J3105 INJECTION, TERBUTALINE SULFATE, UP 7.02 $7.02 --- -- 030 0 0 0.00 $0.00 Y
I J3111 INJ. ROMOSOZUMAB-AQQG 1 MG 13.15 $13.15 --- -- 030 0 0 0.00 $0.00 Y
I J3145 TESTOSTERONE UNDECANOATE 1MG 5.87 $5.87 --- -- 030 0 0 0.00 $0.00 Y
I J3230 INJECTION, CHLORPROMAZINE HCL, UP 37.66 $37.66 --- -- 030 0 0 0.00 $0.00 Y
I J3240 THYROTROPIN INJECTION 1694.76 $1694.76 --- -- 030 0 0 0.00 $0.00 Y
I J3243 TIGECYCLINE INJECTION 6.15 $6.15 --- -- 030 0 0 0.00 $0.00 Y
I J3260 INJECTION, TOBRAMYCIN SULFATE, UP 7.40 $7.40 --- -- 030 0 0 0.00 $0.00 Y
I J3262 TOCILIZUMAB INJECTION 9.39 $9.39 --- -- 030 0 0 0.00 $0.00 Y
I J3285 TREPROSTINIL INJECTION 69.38 $69.38 --- -- 030 0 0 0.00 $0.00 Y
I J3300 TRIAMCINOLONE A INJ PRS-FREE 8.31 $8.31 --- -- 030 0 0 0.00 $0.00 Y
I J3301 INJECTION TRIAMCINOLONE ACETONIDE, 6.05 $6.05 --- -- 030 0 0 0.00 $0.00 Y
I J3303 INJECTION TRIAMCINOLONE HEXACETONI 8.07 $8.07 --- -- 030 0 0 0.00 $0.00 Y
I J3315 TRIPTORELIN PAMOATE 252.85 $252.85 --- -- 030 0 0 0.00 $0.00 Y
I J3316 INJ., TRIPTORELIN XR 3.75 MG 2738.34 $2738.34 --- -- 030 0 0 0.00 $0.00 Y
I J3357 USTEKINUMAB INJECTION 195.17 $195.17 --- -- 030 0 0 0.00 $0.00 Y
I J3358 USTEKINUMAB, IV INJECT, 1 MG 16.46 $16.46 --- -- 030 0 0 0.00 $0.00 Y
I J3360 INJECTION, DIAZEPAM, UP TO 5 MG 14.57 $14.57 --- -- 030 0 0 0.00 $0.00 Y
I J3370 VANCOMYCIN HCL INJECITON 8.11 $8.11 --- -- 030 0 0 0.00 $0.00 Y
I J3380 INJECTION, VEDOLIZUMAB 24.59 $24.59 --- -- 030 0 0 0.00 $0.00 Y
I J3385 VELAGLUCERASE ALFA 349.60 $349.60 --- -- 030 0 0 0.00 $0.00 Y
I J3396 VERTEPORFIN INJECTION 15.51 $15.51 --- -- 030 0 0 0.00 $0.00 Y
I J3398 INJ LUXTURNA 1 BILLION VEC G 2809.46 $2809.46 --- -- 030 0 0 0.00 $0.00 Y
I J3410 INJECTION, HYDROXYZINE HCL, UP TO 11.74 $11.74 --- -- 030 0 0 0.00 $0.00 Y
I J3420 INJECTION, VITAMIN B 12 CYANOCOBA 6.29 $6.29 --- -- 030 0 0 0.00 $0.00 Y
I J3430 INJECTION, VITAMIN K, PHYTONADIONE 8.65 $8.65 --- -- 030 0 0 0.00 $0.00 Y
I J3475 INJECTION, MAGNESIUM SULFATE, PER 500 MG 5.14 $5.14 --- -- 030 0 0 0.00 $0.00 Y
I J3486 ZIPRASIDONE MESYLATE 22.91 $22.91 --- -- 030 0 0 0.00 $0.00 Y
I J3489 ZOLEDRONIC ACID 1MG 16.06 $16.06 --- -- 030 0 0 0.00 $0.00 Y
I J3490 UNCLASSIFIED DRUGS 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I J3590 UNCLASSIFIED BIOLOGICS 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I J3591 ESRD ON DIALYSI DRUG/BIO NOC 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I J7030 INFUSION, NORMAL SALINE SOLUTION , 6.94 $6.94 --- -- 030 0 0 0.00 $0.00 Y
I J7040 INFUSION, NORMAL SALINE SOLUTION, 5.70 $5.70 --- -- 030 0 0 0.00 $0.00 Y
I J7042 5% DEXTROSE/NORMAL SALINE (500 ML 5.43 $5.43 --- -- 030 0 0 0.00 $0.00 Y
I J7050 INFUSION, NORMAL SALINE SOLUTION , 5.08 $5.08 --- -- 030 0 0 0.00 $0.00 Y
I J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT 6.42 $6.42 --- -- 030 0 0 0.00 $0.00 Y
I J7070 INFUSION, D5W, 1000 CC 8.35 $8.35 --- -- 030 0 0 0.00 $0.00 Y
I J7120 RINGERS LACTATE INFUSION, UP TO 10 6.83 $6.83 --- -- 030 0 0 0.00 $0.00 Y
I J7170 INJ., EMICIZUMAB-KXWH 0.5 MG 51.83 $51.83 --- -- 030 0 0 0.00 $0.00 Y
1 J7175 INJ, FACTOR X, (HUMAN), 1 IU 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
I J7178 HUMAN FIBRINOGEN CONC INJ 5.66 $5.66 --- -- 030 0 0 0.00 $0.00 Y
1 J7179 VONVENDI INJ 1 IU VWF:RCO 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7180 FACTOR XIII ANTI-HEM FACTOR 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7181 FACTOR XIII RECOMB A-SUBUNIT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7182 FACTOR VIII RECOMB NOVOEIGHT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7183 WILATE INJECTION 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7185 XYNTHA INJ 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7186 ANTIHEMOPHILIC VIII/VWF COMP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7187 HUMATEP, INJ 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7188 FACTOR VIII RECOMB OBIZUR 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7189 FACTOR VIIA 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7190 FACTOR VIII 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7192 FACTOR VIII RECOMBINANT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7193 FACTOR IX NONRECOMBINANT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7194 HEATTREATED AHF IX 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7195 FACTOR IX RECOMBINANT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7197 ANTITHROMBIN III(HUMAN), PER I.U. 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7198 ANTI-INHIBITOR 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7199 HEMOPHILLIA CLOT FACTOR,NO OTHER CLASSIF 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7200 FACTOR IX RECOMBINAN RIXUBIS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7201 FACTOR IX FC FUSION RECOMB 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7202 FACTOR IX IDELVION INJ 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7203 FACTOR IX RECOMB GLY REBINYN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7205 FACTOR VIII FC FUSION RECOMB 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7207 FACTOR VIII PEGYLATED RECOMB 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7208 FACTOR VIII, PEGYLATED-AUCL 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7209 FACTOR VIII NUWIQ RECOMB 1 IU 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7210 INJ, AFSTYLA, 1 I.U. 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7211 INJ, KOVALTRY, 1 I.U. 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7296 KYLEENA, 19.5 MG 953.51 $953.51 --- -- 009 0 0 0.00 $0.00 Y
1 J7297 LEVONORGESTREL IU 52MG 3 YR 749.40 $749.40 --- -- 009 0 0 0.00 $0.00 Y
1 J7298 LEVONORGESTREL IU 52MG 5 YR 953.51 $953.51 --- -- 009 0 0 0.00 $0.00 Y
1 J7300 INTRAUTERINE COPPER CONTRACEPTIVE 808.50 $808.50 --- -- 009 0 0 0.00 $0.00 Y
1 J7301 SKYLA 13.5MG 793.96 $793.96 --- -- 009 0 0 0.00 $0.00 Y
1 J7303 CONTRACEPTIVE VAGINAL RING 156.26 $156.26 --- -- 009 0 0 0.00 $0.00 Y
1 J7304 CONTRACEPTIVE HORMONE PATCH 35.38 $35.38 --- -- 009 0 0 0.00 $0.00 Y
1 J7307 ETONOGESTREL IMPLANT SYSTEM 934.82 $934.82 --- -- 009 0 0 0.00 $0.00 Y
1 J7309 METHYL AMINOLEVULINATE, TOP 74.17 $74.17 --- -- 009 0 0 0.00 $0.00 Y
1 J7310 GANCICLOVIR LONG ACT IMPLANT 16960.00 $16960.00 --- -- 009 0 0 0.00 $0.00 Y
1 J7311 INJ., RETISERT, 0.01 MG 20125.83 $20125.83 --- -- 009 0 0 0.00 $0.00 Y
1 J7312 DEXAMETHASONE INTRA IMPLANT 199.81 $199.81 --- -- 009 0 0 0.00 $0.00 Y
1 J7313 INJ., ILUVIEN, 0.01 MG 490.94 $490.94 --- -- 009 0 0 0.00 $0.00 Y
1 J7314 INJ., YUTIQ, 0.01 MG 463.33 $463.33 --- -- 009 0 0 0.00 $0.00 Y
1 J7315 OPTHALMIC MITOMYCIN 359.00 $359.00 --- -- 009 0 0 0.00 $0.00 Y
I J7316 OCRIPLASMIN 0.125 MG 1051.39 $1051.39 --- -- 030 0 0 0.00 $0.00 Y
I J7320 GENVISC 850, INJ, 1MG 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I J7321 HYALGAN/SUPARTZ INJ PER DOSE 75.58 $75.58 --- -- 030 0 0 0.00 $0.00 Y
I J7322 HYMOVIS INJECTION 1 MG 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I J7323 EUFLEXXA INJ PER DOSE 128.16 $128.16 --- -- 030 0 0 0.00 $0.00 Y
I J7324 ORTHOVISC INJ PER DOSE 144.26 $144.26 --- -- 030 0 0 0.00 $0.00 Y
I J7325 SYNVISC OR SYNVISC-ONE, 1 MG 14.65 $14.65 --- -- 030 0 0 0.00 $0.00 Y
1 J7326 GEL-ONE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
I J7327 MONOVISC INJ PER DOSE 795.16 $795.16 --- -- 030 0 0 0.00 $0.00 Y
I J7328 GEL-SYN INJECTION 0.1 MG 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
I J7331 SYNOJOYNT, INJ., 1 MG 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I J7332 INJ., TRILURON, 1 MG 28.91 $28.91 --- -- 030 0 0 0.00 $0.00 Y
1 J7336 CAPSAICIN 8% PATCH 3.15 $3.15 --- -- 009 0 0 0.00 $0.00 Y
1 J7340 CARBIDOPA LEVODOPA ENT 100ML 218.88 $218.88 --- -- 009 0 0 0.00 $0.00 Y
1 J7342 CIPROFLOXACIN OTIC SUSP 6 MG 28.32 $28.32 --- -- 009 0 0 0.00 $0.00 Y
1 J7345 AMINOLEVULINIC ACID, 10% GEL 1.46 $1.46 --- -- 009 0 0 0.00 $0.00 Y
1 J7401 MOMETASONE FUROATE SINUS IMP 9.44 $9.44 --- -- 009 0 0 0.00 $0.00 Y
1 J7605 ARFORMOTEROL NON-COMP UNIT 10.23 $10.23 --- -- 009 0 0 0.00 $0.00 Y
1 J7606 FORMOTEROL FUMARATE, INH 11.55 $11.55 --- -- 009 0 0 0.00 $0.00 Y
1 J7611 ALBUTEROL NON-COMP CON 0.17 $0.17 --- -- 009 0 0 0.00 $0.00 Y
1 J7613 ALBUTEROL NON-COMP UNIT 0.04 $0.04 --- -- 009 0 0 0.00 $0.00 Y
1 J7639 DORNASE ALFA NON-COMP UNIT 47.78 $47.78 --- -- 009 0 0 0.00 $0.00 Y
1 J7999 COMPOUNDED DRUG, NOC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 J8499 PRESCRIPTION DRUG ORAL NOC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 J8670 ROLAPITANT, ORAL, 1MG 2.22 $2.22 --- -- 009 0 0 0.00 $0.00 Y
I J9000 DOXORUBICIN HCL, 10 MG 7.35 $7.35 --- -- 030 0 0 0.00 $0.00 Y
I J9015 ALDESLEUKIN INJECTION 3908.37 $3908.37 --- -- 030 0 0 0.00 $0.00 Y
I J9017 ARSENIC TRIOXIDE INJECTION 55.69 $55.69 --- -- 030 0 0 0.00 $0.00 Y
I J9019 ERWINAZE INJECTION 419.29 $419.29 --- -- 030 0 0 0.00 $0.00 Y
I J9020 ASPARAGINASE INJECTION 69.02 $69.02 --- -- 030 0 0 0.00 $0.00 Y
I J9022 INJ, ATEZOLIZUMAB,10 MG 81.64 $81.64 --- -- 030 0 0 0.00 $0.00 Y
I J9023 INJECTION, AVELUMAB, 10 MG 87.20 $87.20 --- -- 030 0 0 0.00 $0.00 Y
I J9025 AZACITIDINE 1MG 5.73 $5.73 --- -- 030 0 0 0.00 $0.00 Y
I J9027 CLOFARABINE, 1 MG 62.04 $62.04 --- -- 030 0 0 0.00 $0.00 Y
1 J9030 BCG LIVE INTRAVESICAL 1MG 2.82 $2.82 --- -- 009 0 0 0.00 $0.00 Y
I J9032 INJECTION, BELINOSTAT, 10MG 43.90 $43.90 --- -- 030 0 0 0.00 $0.00 Y
I J9033 BENDAMUSTINE INJECTION 33.34 $33.34 --- -- 030 0 0 0.00 $0.00 Y
I J9034 INJ., BENDEKA 1 MG 28.26 $28.26 --- -- 030 0 0 0.00 $0.00 Y
I J9035 BEVACIZUMAB INJECTION 85.74 $85.74 --- -- 030 0 0 0.00 $0.00 Y
I J9036 INJ., BELRAPZO, 1 MG 27.95 $27.95 --- -- 030 0 0 0.00 $0.00 Y
I J9039 INJECTION, BLINATUMOMAB 117.42 $117.42 --- -- 030 0 0 0.00 $0.00 Y
I J9040 BLEOMYCIN SULFATE, 15 UNITS 32.10 $32.10 --- -- 030 0 0 0.00 $0.00 Y
I J9041 BORTEZOMIB INJECTION 48.99 $48.99 --- -- 030 0 0 0.00 $0.00 Y
I J9042 BRENTUXIMAB VEDOTIN INJ 167.53 $167.53 --- -- 030 0 0 0.00 $0.00 Y
I J9043 CABAZITAXEL INJECTION 177.92 $177.92 --- -- 030 0 0 0.00 $0.00 Y
I J9044 INJ, BORTEZOMIB, NOS, 0.1 MG 29.65 $29.65 --- -- 030 0 0 0.00 $0.00 Y
I J9045 CARBOPLATIN 50 MG 7.35 $7.35 --- -- 030 0 0 0.00 $0.00 Y
I J9047 INJECTION, CARFILZOMIB, 1 MG 41.71 $41.71 --- -- 030 0 0 0.00 $0.00 Y
I J9050 CARMUSTINE, 100 MG 3539.31 $3539.31 --- -- 030 0 0 0.00 $0.00 Y
I J9055 CETUXIMAB, 10MG 66.57 $66.57 --- -- 030 0 0 0.00 $0.00 Y
I J9057 INJ., COPANLISIB, 1 MG 82.37 $82.37 --- -- 030 0 0 0.00 $0.00 Y
I J9060 CISPLATIN 10 MG INJECTION 6.35 $6.35 --- -- 030 0 0 0.00 $0.00 Y
I J9065 INJECTION CLADRIBINE PER 1 MG 24.19 $24.19 --- -- 030 0 0 0.00 $0.00 Y
I J9070 CYCLOPHOSPHAMIDE, 100 MG 39.19 $39.19 --- -- 030 0 0 0.00 $0.00 Y
I J9100 CYTARABINE 100 MG 5.04 $5.04 --- -- 030 0 0 0.00 $0.00 Y
I J9119 INJ., CEMIPLIMAB-RWLC, 1 MG 31.91 $31.91 --- -- 030 0 0 0.00 $0.00 Y
I J9120 DACTINOMYCIN, 0.5MG 1098.64 $1098.64 --- -- 030 0 0 0.00 $0.00 Y
I J9130 DACARBAZINE 100 MG INJ 8.52 $8.52 --- -- 030 0 0 0.00 $0.00 Y
I J9145 INJECTION, DARATUMUMAB 10 MG 58.21 $58.21 --- -- 030 0 0 0.00 $0.00 Y
I J9150 DAUNORUBICIN 51.60 $51.60 --- -- 030 0 0 0.00 $0.00 Y
I J9155 DEGARELIX INJECTION 8.36 $8.36 --- -- 030 0 0 0.00 $0.00 Y
I J9160 DENILEUKIN DIFTITOX, 300 MCG 1650.64 $1650.64 --- -- 030 0 0 0.00 $0.00 Y
I J9171 DOCETAXEL INJECTION 5.31 $5.31 --- -- 030 0 0 0.00 $0.00 Y
I J9173 INJ., DURVALUMAB, 10 MG 79.32 $79.32 --- -- 030 0 0 0.00 $0.00 Y
I J9175 ELLIOTTS B SOLUTION PER ML 13.45 $13.45 --- -- 030 0 0 0.00 $0.00 Y
I J9176 INJECTION, ELOTUZUMAB, 1MG 10.95 $10.95 --- -- 030 0 0 0.00 $0.00 Y
I J9178 INJ, EPIRUBICIN HCL, 2 MG 5.39 $5.39 --- -- 030 0 0 0.00 $0.00 Y
I J9179 ERIBULIN MESYLATE INJECTION 120.22 $120.22 --- -- 030 0 0 0.00 $0.00 Y
I J9181 ETOPOSIDE 10 MG. 5.08 $5.08 --- -- 030 0 0 0.00 $0.00 Y
I J9185 FLUDARABINE PHOSPHATE, 50 MG 64.19 $64.19 --- -- 030 0 0 0.00 $0.00 Y
I J9190 FLUOROURACIL, 500 MGM AMP 6.30 $6.30 --- -- 030 0 0 0.00 $0.00 Y
I J9199 INJECTION, INFUGEM, 200 MG 80.46 $80.46 --- -- 030 0 0 0.00 $0.00 Y
I J9200 FLOXURIDINE, 500 MG 79.29 $79.29 --- -- 030 0 0 0.00 $0.00 Y
I J9201 IN GEMCITABINE HCL NOS 200MG 8.92 $8.92 --- -- 030 0 0 0.00 $0.00 Y
1 J9202 GOSERELIN ACETATE IMPLANT, PER 3.6 500.25 $500.25 --- -- 009 0 0 0.00 $0.00 Y
I J9203 GEMTUZUMAB OZOGAMICIN 0.1 MG 192.15 $192.15 --- -- 030 0 0 0.00 $0.00 Y
I J9204 INJ, MOGAMULIZUMAB-KPKC, 1 MG 205.33 $205.33 --- -- 030 0 0 0.00 $0.00 Y
I J9205 INJ IRINOTECAN LIPOSOME 1 MG 54.25 $54.25 --- -- 030 0 0 0.00 $0.00 Y
I J9206 IRINOTECAN INJECTION 7.20 $7.20 --- -- 030 0 0 0.00 $0.00 Y
I J9207 IXABEPILONE INJECTION 93.91 $93.91 --- -- 030 0 0 0.00 $0.00 Y
I J9208 IFOSFAMIDE INJECTION 30.15 $30.15 --- -- 030 0 0 0.00 $0.00 Y
I J9209 MESNA, 200 MG. 5.93 $5.93 --- -- 030 0 0 0.00 $0.00 Y
I J9210 INJ., EMAPALUMAB-LZSG, 1 MG 746.66 $746.66 --- -- 030 0 0 0.00 $0.00 Y
I J9214 INTERFERON ALFA2B, RECOMBINANT 1 MILL U 38.45 $38.45 --- -- 030 0 0 0.00 $0.00 Y
I J9217 LEUPROLIDE ACETATE, FOR DEPOT SUSP 7.5MG 233.98 $233.98 --- -- 030 0 0 0.00 $0.00 Y
1 J9219 LEUPROLIDE ACETATE IMPLANT 4528.81 $4528.81 --- -- 009 0 0 0.00 $0.00 Y
1 J9225 VANTAS IMPLANT 3897.40 $3897.40 --- -- 009 0 0 0.00 $0.00 Y
1 J9226 SUPPRELIN LA IMPLANT 34994.49 $34994.49 --- -- 009 0 0 0.00 $0.00 Y
I J9228 IPILIMUMAB INJECTION 157.52 $157.52 --- -- 030 0 0 0.00 $0.00 Y
I J9230 MECHLORETHAMINE HCL,(NITRO MUSTARD) 10MG 326.18 $326.18 --- -- 030 0 0 0.00 $0.00 Y
I J9260 METHOTREXATE SODIUM, 50MG 6.86 $6.86 --- -- 030 0 0 0.00 $0.00 Y
I J9261 NELARABINE INJECTION 156.78 $156.78 --- -- 030 0 0 0.00 $0.00 Y
I J9263 OXALIPLATIN 0.5 MG 4.59 $4.59 --- -- 030 0 0 0.00 $0.00 Y
I J9264 PACLITAXEL PROTEIN BOUND 16.76 $16.76 --- -- 030 0 0 0.00 $0.00 Y
I J9266 PEGASPARGASE, PER SINGLE DOSE VIAL 16434.52 $16434.52 --- -- 030 0 0 0.00 $0.00 Y
I J9267 PACLITAXEL INJECTION 4.60 $4.60 --- -- 030 0 0 0.00 $0.00 Y
I J9269 INJ. TAGRAXOFUSP-ERZS 10 MCG 259.75 $259.75 --- -- 030 0 0 0.00 $0.00 Y
I J9271 INJ PEMBROLIZUMAB 54.04 $54.04 --- -- 030 0 0 0.00 $0.00 Y
I J9280 MITOMYCIN, 5 MG 104.84 $104.84 --- -- 030 0 0 0.00 $0.00 Y
I J9285 INJ, OLARATUMAB, 10 MG 56.52 $56.52 --- -- 030 0 0 0.00 $0.00 Y
I J9293 MITOXANTRONE HYDROCHLORIDE PER 5 MG 31.73 $31.73 --- -- 030 0 0 0.00 $0.00 Y
I J9295 INJECTION, NECITUMUMAB, 1 MG 10.20 $10.20 --- -- 030 0 0 0.00 $0.00 Y
I J9299 INJECTION, NIVOLUMAB, 1 MG 32.26 $32.26 --- -- 030 0 0 0.00 $0.00 Y
I J9301 OBINUTUZUMAB INJ 67.80 $67.80 --- -- 030 0 0 0.00 $0.00 Y
I J9302 OFATUMUMAB INJECTION 64.26 $64.26 --- -- 030 0 0 0.00 $0.00 Y
I J9303 PANITUMUMAB INJECTION 122.22 $122.22 --- -- 030 0 0 0.00 $0.00 Y
I J9305 PEMETREXED 10 MG INJECTION 74.00 $74.00 --- -- 030 0 0 0.00 $0.00 Y
I J9306 INJECTION, PERTUZUMAB, 1 MG 16.71 $16.71 --- -- 030 0 0 0.00 $0.00 Y
I J9307 PRALATREXATE INJECTION 290.99 $290.99 --- -- 030 0 0 0.00 $0.00 Y
I J9308 INJECTION, RAMUCIRUMAB 62.85 $62.85 --- -- 030 0 0 0.00 $0.00 Y
I J9309 INJ, POLATUZUMAB VEDOTIN 1MG 117.84 $117.84 --- -- 030 0 0 0.00 $0.00 Y
I J9311 INJ RITUXIMAB, HYALURONIDASE 48.78 $48.78 --- -- 030 0 0 0.00 $0.00 Y
I J9312 INJ., RITUXIMAB, 10 MG 99.43 $99.43 --- -- 030 0 0 0.00 $0.00 Y
I J9313 INJ., LUMOXITI, 0.01 MG 25.29 $25.29 --- -- 030 0 0 0.00 $0.00 Y
I J9315 ROMIDEPSIN INJECTION 315.01 $315.01 --- -- 030 0 0 0.00 $0.00 Y
I J9320 STREPTOZOCIN, 1GM 349.30 $349.30 --- -- 030 0 0 0.00 $0.00 Y
I J9325 INJ TALIMOGENE LAHERPAREPVEC 55.56 $55.56 --- -- 030 0 0 0.00 $0.00 Y
I J9328 TEMOZOLOMIDE INJECTION 14.86 $14.86 --- -- 030 0 0 0.00 $0.00 Y
I J9330 TEMSIROLIMUS INJECTION 62.39 $62.39 --- -- 030 0 0 0.00 $0.00 Y
I J9340 THIOTEPA, 15 MG 424.89 $424.89 --- -- 030 0 0 0.00 $0.00 Y
I J9351 TOPOTECAN INJECTION 5.47 $5.47 --- -- 030 0 0 0.00 $0.00 Y
I J9352 INJECTION TRABECTEDIN 0.1MG 315.30 $315.30 --- -- 030 0 0 0.00 $0.00 Y
I J9354 INJ, ADO-TRASTUZUMAB EMT 1MG 35.75 $35.75 --- -- 030 0 0 0.00 $0.00 Y
I J9355 INJ TRASTUZUMAB EXCL BIOSIMI 111.44 $111.44 --- -- 030 0 0 0.00 $0.00 Y
I J9356 INJ. HERCEPTIN HYLECTA, 10MG 84.72 $84.72 --- -- 030 0 0 0.00 $0.00 Y
I J9360 VINBLASTINE SULFATE, 1 MG 7.56 $7.56 --- -- 030 0 0 0.00 $0.00 Y
I J9370 VINCRISTINE SULFATE, 1 MG 9.25 $9.25 --- -- 030 0 0 0.00 $0.00 Y
I J9371 INJ, VINCRISTINE SUL LIP 1MG 3034.83 $3034.83 --- -- 030 0 0 0.00 $0.00 Y
I J9390 VINORELBINE TARTRATE, PER 10 MG 13.31 $13.31 --- -- 030 0 0 0.00 $0.00 Y
I J9395 INJECTION, FULVESTRANT 103.24 $103.24 --- -- 030 0 0 0.00 $0.00 Y
I J9400 INJ, ZIV-AFLIBERCEPT, 1MG 12.88 $12.88 --- -- 030 0 0 0.00 $0.00 Y
1 K0001 STANDARD WHEELCHAIR 639.24 $639.24 --- -- 009 0 0 0.00 $47.30 Y
1 K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR 871.92 $871.92 --- -- 009 0 0 0.00 $64.51 Y
1 K0003 LIGHTWEIGHT WHEELCHAIR 943.80 $943.80 --- -- 009 0 0 0.00 $69.84 Y
1 K0004 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR 1363.08 $1363.08 --- -- 009 0 0 0.00 $100.86 Y
1 K0005 ULTRALIGHTWEIGHT WHEELCHAIR 1817.84 $1817.84 --- -- 009 0 0 0.00 $181.78 Y
1 K0006 HEAVY DUTY WHEELCHAIR 1279.20 $1279.20 --- -- 009 0 0 0.00 $94.66 Y
1 K0007 EXTRA HEAVY DUTY WHEELCHAIR 2034.00 $2034.00 --- -- 009 0 0 0.00 $150.52 Y
1 K0008 CSTM MANUAL WHEELCHAIR/BASE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0009 OTHER MANUAL WHEELCHAIR/BASE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0010 STANDARDWEIGHT FRAME MOTOR/POWER WHLCHR 4259.90 $4259.90 --- -- 009 0 0 0.00 $0.00 Y
1 K0011 STANDARDWEIGHT FRAME MOTOR/POWER WHLCHR 5046.00 $5046.00 --- -- 009 0 0 0.00 $504.60 Y
1 K0012 LIGHTWEIGHT PORTABLE MOTORIZED/POWER WHC 3095.10 $3095.10 --- -- 009 0 0 0.00 $0.00 Y
1 K0013 CUSTOM POWER WHLCHR BASE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0014 OTHER MOTORIZED/POWER WHEELCHAIR BASE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0015 DETACH, NONADJUST HEIGHT ARMREST, EACH 107.68 $107.68 --- -- 009 0 0 0.00 $0.00 Y
1 K0017 DETACH,ADJUST HEIGHT ARMREST,BASE,EACH 38.46 $38.46 --- -- 009 0 0 0.00 $0.00 Y
1 K0018 DETACH.ADJUST HEIGHT ARMREST,UPPER PORTI 21.50 $21.50 --- -- 009 0 0 0.00 $0.00 Y
1 K0019 ARM PAD, EACH 16.48 $16.48 --- -- 009 0 0 0.00 $0.00 Y
1 K0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR 43.70 $43.70 --- -- 009 0 0 0.00 $4.37 Y
1 K0037 HI MOUNT FLIP-UP FOOTREST EA 42.12 $42.12 --- -- 009 0 0 0.00 $4.17 Y
1 K0038 LEG STRAP, EACH 22.82 $22.82 --- -- 009 0 0 0.00 $2.27 Y
1 K0039 LEG STRAP, H STYLE, EACH 50.69 $50.69 --- -- 009 0 0 0.00 $5.10 Y
1 K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH 70.23 $70.23 --- -- 009 0 0 0.00 $7.02 Y
1 K0041 LARGE SIZE FOOTPLATE, EACH 49.81 $49.81 --- -- 009 0 0 0.00 $4.97 Y
1 K0042 STANDARD SIZE FOOTPLATE, EACH 29.03 $29.03 --- -- 009 0 0 0.00 $0.00 Y
1 K0043 FOOTREST, LOWER EXTENSTION TUBE, EACH 17.92 $17.92 --- -- 009 0 0 0.00 $0.00 Y
1 K0044 FOOTREST, UPPER HANGER BRACKET, EACH 15.59 $15.59 --- -- 009 0 0 0.00 $0.00 Y
1 K0045 FOOTREST, COMPLETE ASSEMBLY 51.28 $51.28 --- -- 009 0 0 0.00 $0.00 Y
1 K0046 ELEVATING LEGREST,LOWER EXT TUBE, EACH 18.04 $18.04 --- -- 009 0 0 0.00 $0.00 Y
1 K0047 ELEVATING LEGREST,UPPER HANGER BRACKET,E 63.74 $63.74 --- -- 009 0 0 0.00 $0.00 Y
1 K0050 RATCHET ASSEMBLY 29.57 $29.57 --- -- 009 0 0 0.00 $0.00 Y
1 K0051 CAM RELEASE ASSY,FOOTREST OR LEGREST,EAC 46.78 $46.78 --- -- 009 0 0 0.00 $0.00 Y
1 K0052 SWINGAWAY,DETACHABLE FOOTREST, EACH 65.40 $65.40 --- -- 009 0 0 0.00 $0.00 Y
1 K0053 ELEVATING FOOTRESTS,ARTICULATING(TELESCO 95.97 $95.97 --- -- 009 0 0 0.00 $9.60 Y
1 K0056 SEAT HT <17 OR >=21 LTWT WC 93.51 $93.51 --- -- 009 0 0 0.00 $9.36 Y
1 K0069 REAR WHEEL ASSY,COMP,W/SOLID TIRE,SPOKES 98.23 $98.23 --- -- 009 0 0 0.00 $0.00 Y
1 K0070 REAR WHEEL,ASSY,COMP,W/PNEUMATIC TIRE,SP 146.10 $146.10 --- -- 009 0 0 0.00 $0.00 Y
1 K0071 FRONT CASTER ASSY,COMP W/PNEUMATIC TIRE, 98.30 $98.30 --- -- 009 0 0 0.00 $0.00 Y
1 K0072 FRONT CASTER ASSY,COMP,W/SEMIPNEUMATIC 61.00 $61.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0073 CASTER PIN LOCK, EACH 31.60 $31.60 --- -- 009 0 0 0.00 $3.16 Y
1 K0077 FRONT CASTER ASSY,COMP,W/SOLID TIRE,EACH 50.40 $50.40 --- -- 009 0 0 0.00 $0.00 Y
1 K0098 DRIVE BELT FOR POWER WHEELCHAIR 16.92 $16.92 --- -- 009 0 0 0.00 $0.00 Y
1 K0105 IV HANGER 97.76 $97.76 --- -- 009 0 0 0.00 $9.76 Y
1 K0108 W/C COMPONENTACCESSORY NOS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0195 ELEVATING LEG RESTS PAIR 246.60 $246.60 --- -- 009 0 0 0.00 $19.66 Y
1 K0455 PUMP UNINTERRUPTED INFUSION 0.00 $0.00 --- -- 009 0 0 0.00 $211.90 Y
1 K0552 SUPP FOR EXTERNAL PUMP 2.09 $2.09 --- -- 009 0 0 0.00 $0.00 Y
1 K0601 REPL BATT SILVER OXIDE 1.5 V 0.88 $0.88 --- -- 009 0 0 0.00 $0.00 Y
1 K0602 REPL BATT SILVER OXIDE 3 V 5.09 $5.09 --- -- 009 0 0 0.00 $0.00 Y
1 K0603 REPL BATT ALKALINE 1.5 V 0.46 $0.46 --- -- 009 0 0 0.00 $0.00 Y
1 K0604 REPL BATT LITHIUM 3.6 V 4.87 $4.87 --- -- 009 0 0 0.00 $0.00 Y
1 K0605 REPL BATT LITHIUM 4.5 V 11.68 $11.68 --- -- 009 0 0 0.00 $0.00 Y
1 K0606 AED GARMENT W ELEC ANALYSIS 0.00 $0.00 --- -- 009 0 0 0.00 $1814.56 N
1 K0669 SEAT/BACK CUS NO DMEPDAC VER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0672 REMOVE SOFT INTERFACE, REPL 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P K0672 REMOVE SOFT INTERFACE, REPL 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0733 12/24 HR SEALEDLEAD W/C BATTERY 28.90 $28.90 --- -- 009 0 0 0.00 $2.91 Y
1 K0738 PORTABLE GAS OXYGEN SYSTEM 0.00 $0.00 --- -- 009 0 0 0.00 $41.30 Y
1 K0739 REPAIR/SVC DME NON-OXYGEN EQ 16.47 $16.47 --- -- 009 0 0 0.00 $0.00 Y
1 K0740 REPAIR/SVC OXYGEN EQUIPMENT 16.47 $16.47 --- -- 009 0 0 0.00 $0.00 Y
1 K0743 PORTABLE HOME SUCTION PUMP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0744 ABSORP DRG <= 16 SUC PUMP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0745 ABSORP DRG >16<=48 SUC PUMP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0746 ABSORP DRG >48 SUC PUMP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0800 POV GROUP 1 STD UP TO 300LBS 989.40 $989.40 --- -- 009 0 0 0.00 $98.95 Y
1 K0801 POV GROUP 1 HD 301-450 LBS 1595.13 $1595.13 --- -- 009 0 0 0.00 $159.49 Y
1 K0802 POV GROUP 1 VHD 451-600 LBS 1805.18 $1805.18 --- -- 009 0 0 0.00 $180.51 Y
1 K0806 POV GROUP 2 STD UP TO 300LBS 1196.90 $1196.90 --- -- 009 0 0 0.00 $119.69 Y
1 K0807 POV GROUP 2 HD 301-450 LBS 1816.18 $1816.18 --- -- 009 0 0 0.00 $181.62 Y
1 K0808 POV GROUP 2 VHD 451-600 LBS 2810.01 $2810.01 --- -- 009 0 0 0.00 $281.00 Y
1 K0812 POWER OPERATED VEHICLE NOC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0813 PWC GP 1 STD PORT SEAT/BACK 2894.88 $2894.88 --- -- 009 0 0 0.00 $241.24 Y
1 K0814 PWC GP 1 STD PORT CAP CHAIR 3705.36 $3705.36 --- -- 009 0 0 0.00 $308.78 Y
1 K0815 PWC GP 1 STD SEAT/BACK 4219.56 $4219.56 --- -- 009 0 0 0.00 $351.63 Y
1 K0816 PWC GP 1 STD CAP CHAIR 4040.88 $4040.88 --- -- 009 0 0 0.00 $336.74 Y
1 K0820 PWC GP 2 STD PORT SEAT/BACK 3091.92 $3091.92 --- -- 009 0 0 0.00 $257.66 Y
1 K0821 PWC GP 2 STD PORT CAP CHAIR 3969.24 $3969.24 --- -- 009 0 0 0.00 $330.77 Y
1 K0822 PWC GP 2 STD SEAT/BACK 3997.50 $3997.50 --- -- 009 0 0 0.00 $399.75 Y
1 K0823 PWC GP 2 STD CAP CHAIR 4828.44 $4828.44 --- -- 009 0 0 0.00 $402.37 Y
1 K0824 PWC GP 2 HD SEAT/BACK 5811.24 $5811.24 --- -- 009 0 0 0.00 $484.27 Y
1 K0825 PWC GP 2 HD CAP CHAIR 4433.20 $4433.20 --- -- 009 0 0 0.00 $443.32 Y
1 K0826 PWC GP 2 VHD SEAT/BACK 7523.16 $7523.16 --- -- 009 0 0 0.00 $626.93 Y
1 K0827 PWC GP VHD CAP CHAIR 6397.08 $6397.08 --- -- 009 0 0 0.00 $533.09 Y
1 K0828 PWC GP 2 XTRA HD SEAT/BACK 8289.84 $8289.84 --- -- 009 0 0 0.00 $690.82 Y
1 K0829 PWC GP 2 XTRA HD CAP CHAIR 7612.44 $7612.44 --- -- 009 0 0 0.00 $634.37 Y
1 K0830 PWC GP2 STD SEAT ELEVATE S/B 4696.92 $4696.92 --- -- 009 0 0 0.00 $391.41 Y
1 K0831 PWC GP2 STD SEAT ELEVATE CAP 4696.92 $4696.92 --- -- 009 0 0 0.00 $391.41 Y
1 K0835 PWC GP2 STD SING POW OPT S/B 4057.40 $4057.40 --- -- 009 0 0 0.00 $405.74 Y
1 K0836 PWC GP2 STD SING POW OPT CAP 5049.00 $5049.00 --- -- 009 0 0 0.00 $420.75 Y
1 K0837 PWC GP 2 HD SING POW OPT S/B 5811.24 $5811.24 --- -- 009 0 0 0.00 $484.27 Y
1 K0838 PWC GP 2 HD SING POW OPT CAP 4332.20 $4332.20 --- -- 009 0 0 0.00 $433.23 Y
1 K0839 PWC GP2 VHD SING POW OPT S/B 7523.16 $7523.16 --- -- 009 0 0 0.00 $626.93 Y
1 K0840 PWC GP2 XHD SING POW OPT S/B 11397.96 $11397.96 --- -- 009 0 0 0.00 $949.83 Y
1 K0841 PWC GP2 STD MULT POW OPT S/B 5182.32 $5182.32 --- -- 009 0 0 0.00 $431.86 Y
1 K0842 PWC GP2 STD MULT POW OPT CAP 5182.32 $5182.32 --- -- 009 0 0 0.00 $431.86 Y
1 K0843 PWC GP2 HD MULT POW OPT S/B 6239.52 $6239.52 --- -- 009 0 0 0.00 $519.96 Y
1 K0848 PWC GP 3 STD SEAT/BACK 5284.40 $5284.40 --- -- 009 0 0 0.00 $528.44 Y
1 K0849 PWC GP 3 STD CAP CHAIR 6096.84 $6096.84 --- -- 009 0 0 0.00 $508.07 Y
1 K0850 PWC GP 3 HD SEAT/BACK 6129.80 $6129.80 --- -- 009 0 0 0.00 $612.98 Y
1 K0851 PWC GP 3 HD CAP CHAIR 5893.70 $5893.70 --- -- 009 0 0 0.00 $589.37 Y
1 K0852 PWC GP 3 VHD SEAT/BACK 8499.12 $8499.12 --- -- 009 0 0 0.00 $708.26 Y
1 K0853 PWC GP 3 VHD CAP CHAIR 8730.72 $8730.72 --- -- 009 0 0 0.00 $727.56 Y
1 K0854 PWC GP 3 XHD SEAT/BACK 11566.32 $11566.32 --- -- 009 0 0 0.00 $963.86 Y
1 K0855 PWC GP 3 XHD CAP CHAIR 10926.12 $10926.12 --- -- 009 0 0 0.00 $910.51 Y
1 K0856 PWC GP3 STD SING POW OPT S/B 6806.76 $6806.76 --- -- 009 0 0 0.00 $567.23 Y
1 K0857 PWC GP3 STD SING POW OPT CAP 6943.20 $6943.20 --- -- 009 0 0 0.00 $578.60 Y
1 K0858 PWC GP3 HD SING POW OPT S/B 8445.12 $8445.12 --- -- 009 0 0 0.00 $703.76 Y
1 K0859 PWC GP3 HD SING POW OPT CAP 6711.70 $6711.70 --- -- 009 0 0 0.00 $671.17 Y
1 K0860 PWC GP3 VHD SING POW OPT S/B 12064.92 $12064.92 --- -- 009 0 0 0.00 $1005.41 Y
1 K0861 PWC GP3 STD MULT POW OPT S/B 6817.68 $6817.68 --- -- 009 0 0 0.00 $568.14 Y
1 K0862 PWC GP3 HD MULT POW OPT S/B 8445.12 $8445.12 --- -- 009 0 0 0.00 $703.76 Y
1 K0863 PWC GP3 VHD MULT POW OPT S/B 12064.92 $12064.92 --- -- 009 0 0 0.00 $1005.41 Y
1 K0864 PWC GP3 XHD MULT POW OPT S/B 11964.50 $11964.50 --- -- 009 0 0 0.00 $1196.45 Y
1 K0868 PWC GP 4 STD SEAT/BACK 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0869 PWC GP 4 STD CAP CHAIR 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0870 PWC GP 4 HD SEAT/BACK 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0871 PWC GP 4 VHD SEAT/BACK 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0877 PWC GP4 STD SING POW OPT S/B 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0878 PWC GP4 STD SING POW OPT CAP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0879 PWC GP4 HD SING POW OPT S/B 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0880 PWC GP4 VHD SING POW OPT S/B 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0884 PWC GP4 STD MULT POW OPT S/B 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0885 PWC GP4 STD MULT POW OPT CAP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0886 PWC GP4 HD MULT POW S/B 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0890 PWC GP5 PED SING POW OPT S/B 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0891 PWC GP5 PED MULT POW OPT S/B 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K0898 POWER WHEELCHAIR NOC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 K1005 DISP COL STO BAG BREAST MILK 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L0113 CRANIAL CERVICAL TORTICOLLIS 201.62 $201.62 --- -- 009 0 0 0.00 $0.00 Y
1 L0120 CERV FLEX N/ADJ FOAM PRE OTS 21.30 $21.30 --- -- 009 0 0 0.00 $0.00 Y
1 L0130 CERVICAL, FLEXIBLE, THERMOPLASTIC 74.10 $74.10 --- -- 009 0 0 0.00 $0.00 Y
1 L0140 SEMIRIGID, ADJUSTABLE 38.55 $38.55 --- -- 009 0 0 0.00 $0.00 Y
1 L0150 ORTHOSES CERVICAL PLASTIC COLLAR W 68.26 $68.26 --- -- 009 0 0 0.00 $0.00 Y
1 L0160 CERV SR WIRE OCC/MAN PRE OTS 76.48 $76.48 --- -- 009 0 0 0.00 $0.00 Y
1 L0170 CERVICAL, COLLAR, MOLDED TO PATIEN 357.73 $357.73 --- -- 009 0 0 0.00 $0.00 Y
1 L0172 CERV COL SR FOAM 2PC PRE OTS 90.81 $90.81 --- -- 009 0 0 0.00 $0.00 Y
1 L0174 CERV SR 2PC THOR EXT PRE OTS 182.93 $182.93 --- -- 009 0 0 0.00 $0.00 Y
1 L0180 ORTHOSES CERVICAL FOUR POSTER 177.53 $177.53 --- -- 009 0 0 0.00 $0.00 Y
1 L0190 ORTHOSES CERVICAL,SOMI/BENJAMIN/GU 259.73 $259.73 --- -- 009 0 0 0.00 $0.00 Y
1 L0200 CERVICAL, MULTIPLE POST COLLAR, OC 349.54 $349.54 --- -- 009 0 0 0.00 $0.00 Y
1 L0220 THORACIC, RIB BELT, CUSTOM FABRICA 34.48 $34.48 --- -- 009 0 0 0.00 $0.00 Y
1 L0450 TLSO FLEX TRUNK/THOR PRE OTS 139.55 $139.55 --- -- 009 0 0 0.00 $0.00 Y
1 L0452 TLSO FLEX CUSTOM FAB THORACI 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L0454 TLSO TRNK SJ-T9 PRE CST 218.02 $218.02 --- -- 009 0 0 0.00 $0.00 Y
1 L0455 TLSO FLEX TRNK SJ-T9 PRE OTS 255.37 $255.37 --- -- 009 0 0 0.00 $0.00 Y
1 L0456 TLSO FLEX TRNK SJ-SS PRE CST 625.21 $625.21 --- -- 009 0 0 0.00 $0.00 Y
1 L0457 TLSO FLEX TRNK SJ-SS PRE OTS 732.33 $732.33 --- -- 009 0 0 0.00 $0.00 Y
1 L0458 TLSO 2MOD SYMPHISXIPHO PRE 560.62 $560.62 --- -- 009 0 0 0.00 $0.00 Y
1 L0460 TLSO 2 SHL SYMPHYS-STERN CST 631.00 $631.00 --- -- 009 0 0 0.00 $0.00 Y
1 L0462 TLSO 3MOD SACROSCAP PRE 784.86 $784.86 --- -- 009 0 0 0.00 $0.00 Y
1 L0464 TLSO 4MOD SACROSCAP PRE 934.38 $934.38 --- -- 009 0 0 0.00 $0.00 Y
1 L0466 TLSO R FRAM SOFT ANT PRE CST 299.99 $299.99 --- -- 009 0 0 0.00 $0.00 Y
1 L0467 TLSO R FRAM SOFT PRE OTS 351.40 $351.40 --- -- 009 0 0 0.00 $0.00 Y
1 L0468 TLSO RIG FRAM PELVIC PRE CST 363.60 $363.60 --- -- 009 0 0 0.00 $0.00 Y
1 L0469 TLSO RIG FRAM PELVIC PRE OTS 425.90 $425.90 --- -- 009 0 0 0.00 $0.00 Y
1 L0470 TLSO RIGID FRAME PRE SUBCLAV 511.92 $511.92 --- -- 009 0 0 0.00 $0.00 Y
1 L0472 TLSO RIGID FRAME HYPEREX PRE 324.66 $324.66 --- -- 009 0 0 0.00 $0.00 Y
1 L0480 TLSO RIGID PLASTIC CUSTOM FA 974.23 $974.23 --- -- 009 0 0 0.00 $0.00 Y
1 L0482 TLSO RIGID LINED CUSTOM FAB 1111.01 $1111.01 --- -- 009 0 0 0.00 $0.00 Y
1 L0484 TLSO RIGID PLASTIC CUST FAB 1250.29 $1250.29 --- -- 009 0 0 0.00 $0.00 Y
1 L0486 TLSO RIGIDLINED CUST FAB TWO 1354.09 $1354.09 --- -- 009 0 0 0.00 $0.00 Y
1 L0488 TLSO RIGID LINED PRE ONE PIE 631.00 $631.00 --- -- 009 0 0 0.00 $0.00 Y
1 L0490 TLSO RIGID PLASTIC PRE ONE 177.82 $177.82 --- -- 009 0 0 0.00 $0.00 Y
1 L0491 TLSO 2 PIECE RIGID SHELL 482.78 $482.78 --- -- 009 0 0 0.00 $0.00 Y
1 L0492 TLSO 3 PIECE RIGID SHELL 333.14 $333.14 --- -- 009 0 0 0.00 $0.00 Y
1 L0621 SIO FLEX PELVIC/SACR PRE OTS 74.04 $74.04 --- -- 009 0 0 0.00 $0.00 Y
1 L0622 SIO FLEX PELVISACRAL CUSTOM 207.43 $207.43 --- -- 009 0 0 0.00 $0.00 Y
1 L0623 SIO RIG PNL PELV/SAC PRE OTS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L0624 SIO PANEL CUSTOM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L0625 LO FLEX L1-BELOW L5 PRE OTS 34.62 $34.62 --- -- 009 0 0 0.00 $0.00 Y
1 L0626 LO SAG RIG PNL STAYS PRE CST 49.00 $49.00 --- -- 009 0 0 0.00 $0.00 Y
1 L0627 LO SAG RI AN/POS PNL PRE CST 258.38 $258.38 --- -- 009 0 0 0.00 $0.00 Y
1 L0628 LSO FLEX NO RI STAYS PRE OTS 52.74 $52.74 --- -- 009 0 0 0.00 $0.00 Y
1 L0629 LSO FLEX W/RIGID STAYS CUST 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L0630 LSO R POST PNL SJ-T9 PRE CST 101.81 $101.81 --- -- 009 0 0 0.00 $0.00 Y
1 L0631 LSO SAG R AN/POS PNL PRE CST 645.31 $645.31 --- -- 009 0 0 0.00 $0.00 Y
1 L0632 LSO SAG RIGID FRAME CUST 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L0633 LSO SC R POS/LAT PNL PRE CST 180.25 $180.25 --- -- 009 0 0 0.00 $0.00 Y
1 L0634 LSO FLEXION CONTROL CUSTOM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L0635 LSO SAGIT RIGID PANEL PREFAB 768.58 $768.58 --- -- 009 0 0 0.00 $0.00 Y
1 L0636 LSO SAGITTAL RIGID PANEL CUS 1137.77 $1137.77 --- -- 009 0 0 0.00 $0.00 Y
1 L0637 LSO SC R ANT/POS PNL PRE CST 760.51 $760.51 --- -- 009 0 0 0.00 $0.00 Y
1 L0638 LSO SAGCORONAL PANEL CUSTOM 829.08 $829.08 --- -- 009 0 0 0.00 $0.00 Y
1 L0639 LSO S/C SHELL/PANEL PREFAB 760.51 $760.51 --- -- 009 0 0 0.00 $0.00 Y
1 L0640 LSO S/C SHELL/PANEL CUSTOM 657.77 $657.77 --- -- 009 0 0 0.00 $0.00 Y
1 L0641 LO RIG POS PNL L1-L5 PRE OTS 57.38 $57.38 --- -- 009 0 0 0.00 $0.00 Y
1 L0642 LO SAG RI AN/POS PNL PRE OTS 302.67 $302.67 --- -- 009 0 0 0.00 $0.00 Y
1 L0643 LSO SAG CTR RIGI POS PRE OTS 119.25 $119.25 --- -- 009 0 0 0.00 $0.00 Y
1 L0648 LSO SAG R AN/POS PNL PRE OTS 755.89 $755.89 --- -- 009 0 0 0.00 $0.00 Y
1 L0649 LSO SC R POS/LAT PNL PRE OTS 211.14 $211.14 --- -- 009 0 0 0.00 $0.00 Y
1 L0650 LSO SC R ANT/POS PNL PRE OTS 890.84 $890.84 --- -- 009 0 0 0.00 $0.00 Y
1 L0651 LSO SAG-CO SHELL PNL PRE OTS 890.84 $890.84 --- -- 009 0 0 0.00 $0.00 Y
1 L0700 CERVICALTHORACICLUMBARSACRALOR 917.54 $917.54 --- -- 009 0 0 0.00 $0.00 Y
1 L0710 CTLSO, ANTERIORPOSTERIORLATERAL 1036.20 $1036.20 --- -- 009 0 0 0.00 $0.00 Y
1 L0810 HALO PROCEDURE, CERVICAL HALO INCO 1861.11 $1861.11 --- -- 009 0 0 0.00 $0.00 Y
1 L0820 HALO PROCEDURE, CERVICAL HALO INCO 1109.32 $1109.32 --- -- 009 0 0 0.00 $0.00 Y
1 L0830 CERVICAL HALO 2517.85 $2517.85 --- -- 009 0 0 0.00 $0.00 Y
1 L0859 MRI COMPATIBLE SYSTEM 733.62 $733.62 --- -- 009 0 0 0.00 $0.00 Y
1 L0861 HALO REPL LINER/INTERFACE 135.49 $135.49 --- -- 009 0 0 0.00 $0.00 Y
1 L0970 ORTHOSES LUMBO SACRAL FULL CORSET 74.83 $74.83 --- -- 009 0 0 0.00 $0.00 Y
1 L0972 ORTHOSES LUMBO SACRAL FULL CORSET 74.83 $74.83 --- -- 009 0 0 0.00 $0.00 Y
1 L0974 ORTHOSES CUSTOM DORSAL LUMBAR 114.88 $114.88 --- -- 009 0 0 0.00 $0.00 Y
1 L0976 ORTHOSES CUSTOM LUMBAR SIDE LACE 82.00 $82.00 --- -- 009 0 0 0.00 $0.00 Y
1 L0978 AXILLARY CRUTCH EXTENSION 154.56 $154.56 --- -- 009 0 0 0.00 $0.00 Y
P L0978 AXILLARY CRUTCH EXTENSION 154.56 $154.56 --- -- 009 0 0 0.00 $0.00 Y
P L0980 PERONEAL STRAPS PAIR PRE OTS 5.99 $5.99 --- -- 009 0 0 0.00 $0.00 Y
1 L0980 PERONEAL STRAPS PAIR PRE OTS 5.99 $5.99 --- -- 009 0 0 0.00 $0.00 Y
1 L0982 STOCKING SUP GRIPS 4 PRE OTS 7.12 $7.12 --- -- 009 0 0 0.00 $0.00 Y
P L0982 STOCKING SUP GRIPS 4 PRE OTS 7.12 $7.12 --- -- 009 0 0 0.00 $0.00 Y
1 L0984 PROTECT BODY SOCK EA PRE OTS 38.10 $38.10 --- -- 009 0 0 0.00 $0.00 Y
1 L1000 CERVICAL-THORACIC-LUMBAR-SACRAL OR 1260.07 $1260.07 --- -- 009 0 0 0.00 $0.00 Y
1 L1001 CTLSO INFANT IMMOBILIZER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L1005 TENSION BASED SCOLIOSIS ORTHOSIS 2011.94 $2011.94 --- -- 009 0 0 0.00 $0.00 Y
1 L1010 ORTHOSES CORRECT PAD AXILLA 31.31 $31.31 --- -- 009 0 0 0.00 $0.00 Y
1 L1020 ORTHOSES CORRECT PAD KYPHOSIS 62.06 $62.06 --- -- 009 0 0 0.00 $0.00 Y
1 L1025 ADDITION TO CTLSO OR SCOLIOSIS ORT 68.69 $68.69 --- -- 009 0 0 0.00 $0.00 Y
1 L1030 ORTHOSES CORRECT PAD LUMBAR BOLSTE 23.75 $23.75 --- -- 009 0 0 0.00 $0.00 Y
1 L1040 ORTHOSES CORRECT PAD LUMBAR 54.85 $54.85 --- -- 009 0 0 0.00 $0.00 Y
1 L1050 ORTHOSES CORRECT PAD STERNAL 58.02 $58.02 --- -- 009 0 0 0.00 $0.00 Y
1 L1060 ORTHOSES CORRECT PAD THORACIC 57.78 $57.78 --- -- 009 0 0 0.00 $0.00 Y
1 L1070 ORTHOSES CORRECT PAD TRAPEZE SLING 53.75 $53.75 --- -- 009 0 0 0.00 $0.00 Y
1 L1080 ORTHOSES CORRECT PAD OUTRIGGER 29.15 $29.15 --- -- 009 0 0 0.00 $0.00 Y
1 L1085 ADDITION TO CTLSO OR SCOLIOSIS ORT 102.92 $102.92 --- -- 009 0 0 0.00 $0.00 Y
1 L1090 ADDITION TO CTLSO OR SCOLIOSIS ORT 57.13 $57.13 --- -- 009 0 0 0.00 $0.00 Y
1 L1100 ORTHOSES CORRECT PAD.RING PHLANGE 118.66 $118.66 --- -- 009 0 0 0.00 $0.00 Y
1 L1110 ADDITION TO CTLSO OR SCOLIOSIS ORT 167.60 $167.60 --- -- 009 0 0 0.00 $0.00 Y
1 L1120 ORTHOSES CORRECT PAD COVERS FOR UPRIGHTS 31.89 $31.89 --- -- 009 0 0 0.00 $0.00 Y
1 L1200 THORACIC-LUMBAR-SACRAL-ORTHOSIS (T 1237.87 $1237.87 --- -- 009 0 0 0.00 $0.00 Y
1 L1210 ORTHOSES CORRECT PAD LAT O ANT EXTENSION 139.61 $139.61 --- -- 009 0 0 0.00 $0.00 Y
1 L1220 ORTHOSES CORRECT PAD LAT O ANT EXTENSION 139.61 $139.61 --- -- 009 0 0 0.00 $0.00 Y
1 L1230 ORTHOSES CORRECT PAD MILWAUKEE TYPE SUPE 139.61 $139.61 --- -- 009 0 0 0.00 $0.00 Y
1 L1240 ADDITION TO TLSO, (LOW PROFILE), L 50.40 $50.40 --- -- 009 0 0 0.00 $0.00 Y
1 L1250 ADDITION TO TLSO, (LOW PROFILE), A 38.06 $38.06 --- -- 009 0 0 0.00 $0.00 Y
1 L1260 ADDITION TO TLSO, (LOW PROFILE), A 41.96 $41.96 --- -- 009 0 0 0.00 $0.00 Y
1 L1270 ADDITION TO TLSO, (LOW PROFILE), A 56.61 $56.61 --- -- 009 0 0 0.00 $0.00 Y
1 L1280 ADDITION TO TLSO, (LOW PROFILE), R 64.40 $64.40 --- -- 009 0 0 0.00 $0.00 Y
1 L1290 ADDITION TO TLSO, (LOW PROFILE), L 63.11 $63.11 --- -- 009 0 0 0.00 $0.00 Y
1 L1300 OTHER SCOLIOSIS PROCEDURE, BODY JA 1026.38 $1026.38 --- -- 009 0 0 0.00 $0.00 Y
1 L1310 OTHER SCOLIOSIS PROCEDURE, POST-OP 811.44 $811.44 --- -- 009 0 0 0.00 $0.00 Y
1 L1600 HO FLEX FREJKA W/COV PRE CST 74.47 $74.47 --- -- 009 0 0 0.00 $0.00 Y
1 L1610 HO FREJKA COV ONLY PRE CST 18.63 $18.63 --- -- 009 0 0 0.00 $0.00 Y
1 L1620 HO FLEX PAVLIK HARNS PRE CST 100.03 $100.03 --- -- 009 0 0 0.00 $0.00 Y
1 L1630 ABDUCT CONTROL HIP SEMI-FLEX 77.60 $77.60 --- -- 009 0 0 0.00 $0.00 Y
1 L1640 PELV BAND/SPREAD BAR THIGH C 167.12 $167.12 --- -- 009 0 0 0.00 $0.00 Y
1 L1650 HO ABDUCTION HIP ADJUSTABLE 154.60 $154.60 --- -- 009 0 0 0.00 $0.00 Y
1 L1652 HO BI THIGHCUFFS W SPRDR BAR 224.08 $224.08 --- -- 009 0 0 0.00 $0.00 Y
1 L1660 HO ABDUCTION STATIC PLASTIC 73.10 $73.10 --- -- 009 0 0 0.00 $0.00 Y
1 L1680 PELVIC & HIP CONTROL THIGH C 780.18 $780.18 --- -- 009 0 0 0.00 $0.00 Y
1 L1685 POST-OP HIP ABDUCT CUSTOM FA 955.08 $955.08 --- -- 009 0 0 0.00 $0.00 Y
1 L1686 HO POST-OP HIP ABDUCTION 654.94 $654.94 --- -- 009 0 0 0.00 $0.00 Y
1 L1690 COMBINATION BILATERAL HO 977.03 $977.03 --- -- 009 0 0 0.00 $0.00 Y
1 L1700 LEG PERTHES ORTH TORONTO TYP 850.78 $850.78 --- -- 009 0 0 0.00 $0.00 Y
1 L1710 LEGG PERTHES ORTH NEWINGTON 1263.72 $1263.72 --- -- 009 0 0 0.00 $0.00 Y
1 L1720 LEGG PERTHES ORTHOSIS TRILAT 827.65 $827.65 --- -- 009 0 0 0.00 $0.00 Y
1 L1730 LEGG PERTHES ORTH SCOTTISH R 820.70 $820.70 --- -- 009 0 0 0.00 $0.00 Y
1 L1755 LEGG PERTHES PATTEN BOTTOM T 565.86 $565.86 --- -- 009 0 0 0.00 $0.00 Y
1 L1810 KO ELASTIC WITH JOINTS 72.69 $72.69 --- -- 009 0 0 0.00 $0.00 Y
1 L1812 KO ELASTIC W/JOINTS PRE OTS 91.64 $91.64 --- -- 009 0 0 0.00 $0.00 N
1 L1820 KO ELAS W/ CONDYLE PADS & JO 80.69 $80.69 --- -- 009 0 0 0.00 $0.00 Y
1 L1830 KO IMMOB CANVAS LONG PRE OTS 70.24 $70.24 --- -- 009 0 0 0.00 $0.00 Y
1 L1831 KNEE ORTH POS LOCKING JOINT 185.01 $185.01 --- -- 009 0 0 0.00 $0.00 Y
1 L1832 KO ADJ JNT POS R SUP PRE CST 384.13 $384.13 --- -- 009 0 0 0.00 $0.00 Y
1 L1833 KO ADJ JNT POS R SUP PRE OTS 512.10 $512.10 --- -- 009 0 0 0.00 $0.00 Y
1 L1834 KO W/0 JOINT RIGID MOLDED TO 400.40 $400.40 --- -- 009 0 0 0.00 $0.00 Y
1 L1836 KO RIGID W/O JOINTS PRE OTS 83.37 $83.37 --- -- 009 0 0 0.00 $0.00 Y
1 L1840 KO DEROT ANT CRUCIATE CUSTOM 655.72 $655.72 --- -- 009 0 0 0.00 $0.00 Y
1 L1843 KO SINGLE UPRIGHT PRE CST 259.70 $259.70 --- -- 009 0 0 0.00 $0.00 Y
1 L1844 KO W/ADJ JT ROT CNTRL MOLDED 980.95 $980.95 --- -- 009 0 0 0.00 $0.00 Y
1 L1845 KO DOUBLE UPRIGHT PRE CST 349.56 $349.56 --- -- 009 0 0 0.00 $0.00 Y
1 L1846 KO W ADJ FLEX/EXT ROTAT MOLD 644.44 $644.44 --- -- 009 0 0 0.00 $0.00 Y
1 L1847 KO DBL UPRIGHT W/AIR PRE CST 290.60 $290.60 --- -- 009 0 0 0.00 $0.00 Y
1 L1848 KO DBL UPRIGHT W/AIR PRE OTS 423.51 $423.51 --- -- 009 0 0 0.00 $0.00 Y
1 L1850 KO SWEDISH TYPE PRE OTS 174.42 $174.42 --- -- 009 0 0 0.00 $0.00 Y
1 L1851 KO SINGLE UPRIGHT PREFAB OTS 672.58 $672.58 --- -- 009 0 0 0.00 $0.00 Y
1 L1852 KO DOUBLE UPRIGHT PREFAB OTS 586.95 $586.95 --- -- 009 0 0 0.00 $0.00 Y
1 L1860 KO SUPRACONDYLAR SOCKET MOLD 518.05 $518.05 --- -- 009 0 0 0.00 $0.00 Y
1 L1900 AFO SPRNG WIR DRSFLX CALF BD 132.35 $132.35 --- -- 009 0 0 0.00 $0.00 Y
P L1900 AFO SPRNG WIR DRSFLX CALF BD 132.35 $132.35 --- -- 009 0 0 0.00 $0.00 Y
P L1904 AFO MOLDED ANKLE GAUNTLET 337.31 $337.31 --- -- 009 0 0 0.00 $0.00 Y
1 L1904 AFO MOLDED ANKLE GAUNTLET 337.31 $337.31 --- -- 009 0 0 0.00 $0.00 Y
1 L1906 AFO MULTILIG ANK SUP PRE OTS 96.56 $96.56 --- -- 009 0 0 0.00 $0.00 Y
P L1906 AFO MULTILIG ANK SUP PRE OTS 96.56 $96.56 --- -- 009 0 0 0.00 $0.00 Y
P L1907 AFO SUPRAMALLEOLAR CUSTOM 353.71 $353.71 --- -- 009 0 0 0.00 $0.00 Y
1 L1907 AFO SUPRAMALLEOLAR CUSTOM 353.71 $353.71 --- -- 009 0 0 0.00 $0.00 Y
1 L1910 AFO SING BAR CLASP ATTACH SH 147.95 $147.95 --- -- 009 0 0 0.00 $0.00 Y
P L1910 AFO SING BAR CLASP ATTACH SH 147.95 $147.95 --- -- 009 0 0 0.00 $0.00 Y
P L1920 AFO SING UPRIGHT W/ ADJUST S 219.54 $219.54 --- -- 009 0 0 0.00 $0.00 Y
1 L1920 AFO SING UPRIGHT W/ ADJUST S 219.54 $219.54 --- -- 009 0 0 0.00 $0.00 Y
1 L1930 AFO PLASTIC 132.43 $132.43 --- -- 009 0 0 0.00 $0.00 Y
P L1930 AFO PLASTIC 132.43 $132.43 --- -- 009 0 0 0.00 $0.00 Y
P L1932 AFO RIG ANT TIB PREFAB TCF/= 560.94 $560.94 --- -- 009 0 0 0.00 $0.00 Y
1 L1932 AFO RIG ANT TIB PREFAB TCF/= 560.94 $560.94 --- -- 009 0 0 0.00 $0.00 Y
1 L1940 AFO MOLDED TO PATIENT PLASTI 347.88 $347.88 --- -- 009 0 0 0.00 $0.00 Y
P L1940 AFO MOLDED TO PATIENT PLASTI 347.88 $347.88 --- -- 009 0 0 0.00 $0.00 Y
P L1945 AFO MOLDED PLAS RIG ANT TIB 554.40 $554.40 --- -- 009 0 0 0.00 $0.00 Y
1 L1945 AFO MOLDED PLAS RIG ANT TIB 554.40 $554.40 --- -- 009 0 0 0.00 $0.00 Y
1 L1950 AFO SPIRAL MOLDED TO PT PLAS 437.48 $437.48 --- -- 009 0 0 0.00 $0.00 Y
P L1950 AFO SPIRAL MOLDED TO PT PLAS 437.48 $437.48 --- -- 009 0 0 0.00 $0.00 Y
P L1951 AFO SPIRAL PREFABRICATED 527.93 $527.93 --- -- 009 0 0 0.00 $0.00 Y
1 L1951 AFO SPIRAL PREFABRICATED 527.93 $527.93 --- -- 009 0 0 0.00 $0.00 Y
1 L1960 AFO POS SOLID ANK PLASTIC MO 332.00 $332.00 --- -- 009 0 0 0.00 $0.00 Y
P L1960 AFO POS SOLID ANK PLASTIC MO 332.00 $332.00 --- -- 009 0 0 0.00 $0.00 Y
P L1970 AFO PLASTIC MOLDED W/ANKLE J 449.28 $449.28 --- -- 009 0 0 0.00 $0.00 Y
1 L1970 AFO PLASTIC MOLDED W/ANKLE J 449.28 $449.28 --- -- 009 0 0 0.00 $0.00 Y
1 L1971 AFO W/ANKLE JOINT, PREFAB 294.64 $294.64 --- -- 009 0 0 0.00 $0.00 Y
P L1971 AFO W/ANKLE JOINT, PREFAB 294.64 $294.64 --- -- 009 0 0 0.00 $0.00 Y
P L1980 AFO SING SOLID STIRRUP CALF 235.66 $235.66 --- -- 009 0 0 0.00 $0.00 Y
1 L1980 AFO SING SOLID STIRRUP CALF 235.66 $235.66 --- -- 009 0 0 0.00 $0.00 Y
1 L1990 AFO DOUB SOLID STIRRUP CALF 274.89 $274.89 --- -- 009 0 0 0.00 $0.00 Y
P L1990 AFO DOUB SOLID STIRRUP CALF 274.89 $274.89 --- -- 009 0 0 0.00 $0.00 Y
P L2000 KAFO SING FRE STIRR THI/CALF 814.41 $814.41 --- -- 009 0 0 0.00 $0.00 Y
1 L2000 KAFO SING FRE STIRR THI/CALF 814.41 $814.41 --- -- 009 0 0 0.00 $0.00 Y
1 L2005 KAFO SNG/DBL MECHANICAL ACT 2575.86 $2575.86 --- -- 009 0 0 0.00 $0.00 N
P L2005 KAFO SNG/DBL MECHANICAL ACT 2575.86 $2575.86 --- -- 009 0 0 0.00 $0.00 N
P L2006 KAF SNG/DBL SWG/STN MCPR CUS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L2006 KAF SNG/DBL SWG/STN MCPR CUS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L2010 KAFO SNG SOLID STIRRUP W/O J 742.41 $742.41 --- -- 009 0 0 0.00 $0.00 Y
P L2010 KAFO SNG SOLID STIRRUP W/O J 742.41 $742.41 --- -- 009 0 0 0.00 $0.00 Y
P L2020 KAFO DBL SOLID STIRRUP BAND/ 925.91 $925.91 --- -- 009 0 0 0.00 $0.00 Y
1 L2020 KAFO DBL SOLID STIRRUP BAND/ 925.91 $925.91 --- -- 009 0 0 0.00 $0.00 Y
1 L2030 KAFO DBL SOLID STIRRUP W/O J 753.20 $753.20 --- -- 009 0 0 0.00 $0.00 Y
P L2030 KAFO DBL SOLID STIRRUP W/O J 753.20 $753.20 --- -- 009 0 0 0.00 $0.00 Y
P L2034 KAFO PLA SIN UP W/WO K/A CUS 1259.40 $1259.40 --- -- 009 0 0 0.00 $0.00 Y
1 L2034 KAFO PLA SIN UP W/WO K/A CUS 1259.40 $1259.40 --- -- 009 0 0 0.00 $0.00 Y
1 L2035 KAFO PLASTIC PEDIATRIC SIZE 83.31 $83.31 --- -- 009 0 0 0.00 $0.00 Y
P L2035 KAFO PLASTIC PEDIATRIC SIZE 83.31 $83.31 --- -- 009 0 0 0.00 $0.00 Y
P L2036 KAFO PLAS DOUB FREE KNEE MOL 943.12 $943.12 --- -- 009 0 0 0.00 $0.00 Y
1 L2036 KAFO PLAS DOUB FREE KNEE MOL 943.12 $943.12 --- -- 009 0 0 0.00 $0.00 Y
1 L2037 KAFO PLAS SING FREE KNEE MOL 943.12 $943.12 --- -- 009 0 0 0.00 $0.00 Y
P L2037 KAFO PLAS SING FREE KNEE MOL 943.12 $943.12 --- -- 009 0 0 0.00 $0.00 Y
P L2038 KAFO W/O JOINT MULTI-AXIS AN 811.87 $811.87 --- -- 009 0 0 0.00 $0.00 Y
1 L2038 KAFO W/O JOINT MULTI-AXIS AN 811.87 $811.87 --- -- 009 0 0 0.00 $0.00 Y
1 L2040 HKAFO TORSION BIL ROT STRAPS 68.52 $68.52 --- -- 009 0 0 0.00 $0.00 Y
P L2040 HKAFO TORSION BIL ROT STRAPS 68.52 $68.52 --- -- 009 0 0 0.00 $0.00 Y
P L2050 HKAFO TORSION CABLE HIP PELV 249.84 $249.84 --- -- 009 0 0 0.00 $0.00 Y
1 L2050 HKAFO TORSION CABLE HIP PELV 249.84 $249.84 --- -- 009 0 0 0.00 $0.00 Y
1 L2060 HKAFO TORSION BALL BEARING J 427.86 $427.86 --- -- 009 0 0 0.00 $0.00 Y
P L2060 HKAFO TORSION BALL BEARING J 427.86 $427.86 --- -- 009 0 0 0.00 $0.00 Y
P L2070 HKAFO TORSION UNILAT ROT STR 61.09 $61.09 --- -- 009 0 0 0.00 $0.00 Y
1 L2070 HKAFO TORSION UNILAT ROT STR 61.09 $61.09 --- -- 009 0 0 0.00 $0.00 Y
1 L2080 HKAFO UNILAT TORSION CABLE 173.82 $173.82 --- -- 009 0 0 0.00 $0.00 Y
P L2080 HKAFO UNILAT TORSION CABLE 173.82 $173.82 --- -- 009 0 0 0.00 $0.00 Y
P L2090 HKAFO UNILAT TORSION BALL BR 264.25 $264.25 --- -- 009 0 0 0.00 $0.00 Y
1 L2090 HKAFO UNILAT TORSION BALL BR 264.25 $264.25 --- -- 009 0 0 0.00 $0.00 Y
1 L2106 AFO TIB FX CAST PLASTER MOLD 162.40 $162.40 --- -- 009 0 0 0.00 $0.00 Y
P L2106 AFO TIB FX CAST PLASTER MOLD 162.40 $162.40 --- -- 009 0 0 0.00 $0.00 Y
P L2108 AFO TIB FX CAST MOLDED TO PT 565.16 $565.16 --- -- 009 0 0 0.00 $0.00 Y
1 L2108 AFO TIB FX CAST MOLDED TO PT 565.16 $565.16 --- -- 009 0 0 0.00 $0.00 Y
1 L2112 AFO TIBIAL FRACTURE SOFT 237.44 $237.44 --- -- 009 0 0 0.00 $0.00 Y
P L2112 AFO TIBIAL FRACTURE SOFT 237.44 $237.44 --- -- 009 0 0 0.00 $0.00 Y
P L2114 AFO TIB FX SEMIRIGID 434.00 $434.00 --- -- 009 0 0 0.00 $0.00 Y
1 L2114 AFO TIB FX SEMIRIGID 434.00 $434.00 --- -- 009 0 0 0.00 $0.00 Y
1 L2116<