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Medi-Cal Rates Information

Medi-Cal Rates as of 02/15/2020 (Codes L6905 thru V2300)

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 L6905 PROSTHETIC PARTIAL HAND MULTI FING REMAI 624.89 $624.89 --- -- 009 0 0 0.00 $0.00 Y
1 L6910 PROSTHETIC PARTIAL HAND NO FINGERS 648.48 $648.48 --- -- 009 0 0 0.00 $0.00 Y
1 L6915 PROSTHETIC COSMETIC GLOVE REAL CUST PART 417.30 $417.30 --- -- 009 0 0 0.00 $0.00 Y
1 L6920 WRIST DISARTICULATION, EXTERNAL PO 3360.79 $3360.79 --- -- 009 0 0 0.00 $0.00 Y
1 L6925 WRIST DISARTICULATION, EXTERNAL PO 3830.58 $3830.58 --- -- 009 0 0 0.00 $0.00 Y
1 L6930 BELOW ELBOW, EXTERNAL POWER, SELF 3675.00 $3675.00 --- -- 009 0 0 0.00 $0.00 Y
1 L6935 PROSTHETIC COSM GLOVE MYOELECTRIC STD WR 4188.31 $4188.31 --- -- 009 0 0 0.00 $0.00 Y
1 L6940 ELBOW DISARTICULATION, EXTERNAL PO 3950.33 $3950.33 --- -- 009 0 0 0.00 $0.00 Y
1 L6945 ELBOW DISARTICULATION, EXTERNAL PO 4546.50 $4546.50 --- -- 009 0 0 0.00 $0.00 Y
1 L6950 ABOVE ELBOW, EXTERNAL POWER, MOLDE 4404.17 $4404.17 --- -- 009 0 0 0.00 $0.00 Y
1 L6955 ABOVE ELBOW, EXTERNAL POWER, MOLDE 5262.83 $5262.83 --- -- 009 0 0 0.00 $0.00 Y
1 L6960 SHOULDER DISARTICULATION, EXTERNAL 5740.00 $5740.00 --- -- 009 0 0 0.00 $0.00 Y
1 L6965 SHOULDER DISARTICULATION, EXTERNAL 6667.50 $6667.50 --- -- 009 0 0 0.00 $0.00 Y
1 L6970 INTERSCAPULARTHORACIC, EXTERNAL P 7070.00 $7070.00 --- -- 009 0 0 0.00 $0.00 Y
1 L6975 INTERSCAPULARTHORACIC, EXTERNAL P 8050.00 $8050.00 --- -- 009 0 0 0.00 $0.00 Y
1 L7007 ADULT ELECTRIC HAND 2302.63 $2302.63 --- -- 009 0 0 0.00 $0.00 Y
1 L7008 PEDIATRIC ELECTRIC HAND 3870.97 $3870.97 --- -- 009 0 0 0.00 $0.00 Y
1 L7009 ADULT ELECTRIC HOOK 2349.42 $2349.42 --- -- 009 0 0 0.00 $0.00 Y
1 L7040 PREHENSILE ACTUATOR 1281.88 $1281.88 --- -- 009 0 0 0.00 $0.00 Y
1 L7045 PEDIATRIC ELECTRIC HOOK 675.62 $675.62 --- -- 009 0 0 0.00 $0.00 Y
1 L7170 ELECTRONIC ELBOW, HOSMER OR EQUAL, 2572.50 $2572.50 --- -- 009 0 0 0.00 $0.00 Y
1 L7180 ELECTRONIC ELBOW SEQUENTIAL 16310.00 $16310.00 --- -- 009 0 0 0.00 $0.00 Y
1 L7181 ELECTRONIC ELBO SIMULTANEOUS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L7185 ELECTRONIC ELBOW, ADOLESCENT, VARI 2695.00 $2695.00 --- -- 009 0 0 0.00 $0.00 Y
1 L7186 ELECTRONIC ELBOW, CHILD, VARIETY V 3797.50 $3797.50 --- -- 009 0 0 0.00 $0.00 Y
1 L7190 ELECTRONIC ELBOW, ADOLESCENT, VARI 3543.75 $3543.75 --- -- 009 0 0 0.00 $0.00 Y
1 L7191 ELECTRONIC ELBOW, CHILD, VARIETY V 4706.24 $4706.24 --- -- 009 0 0 0.00 $0.00 Y
1 L7259 ELECTRONIC WRIST ROTATOR ANY 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L7360 SIX VOLT BAT OTTO BOCK/EQ EA 111.21 $111.21 --- -- 009 0 0 0.00 $0.00 Y
1 L7362 BATTERY CHRGR SIX VOLT OTTO 116.81 $116.81 --- -- 009 0 0 0.00 $0.00 Y
1 L7364 TWELVE VOLT BATTERY UTAH/EQU 214.03 $214.03 --- -- 009 0 0 0.00 $0.00 Y
1 L7366 BATTERY CHRGR 12 VOLT UTAH/E 280.00 $280.00 --- -- 009 0 0 0.00 $0.00 Y
1 L7367 REPLACEMNT LITHIUM IONBATTER 245.21 $245.21 --- -- 009 0 0 0.00 $0.00 Y
1 L7368 LITHIUM ION BATTERY CHARGER 317.87 $317.87 --- -- 009 0 0 0.00 $0.00 Y
1 L7400 ADD UE PROST BE/WD, ULTLITE 193.03 $193.03 --- -- 009 0 0 0.00 $0.00 Y
1 L7401 ADD UE PROST A/E ULTLITE MAT 216.10 $216.10 --- -- 009 0 0 0.00 $0.00 Y
1 L7402 ADD UE PROST S/D ULTLITE MAT 233.38 $233.38 --- -- 009 0 0 0.00 $0.00 Y
1 L7403 ADD UE PROST B/E ACRYLIC 231.94 $231.94 --- -- 009 0 0 0.00 $0.00 Y
1 L7404 ADD UE PROST A/E ACRYLIC 350.06 $350.06 --- -- 009 0 0 0.00 $0.00 Y
1 L7405 ADD UE PROST S/D ACRYLIC 457.84 $457.84 --- -- 009 0 0 0.00 $0.00 Y
1 L7510 PROSTHETIC DEVICE REPAIR REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L7520 REPAIR PROSTHESIS PER 15 MIN 16.47 $16.47 --- -- 009 0 0 0.00 $0.00 Y
1 L7700 PROS SOC INSERT GASKET/SEAL 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8000 MASTECTOMY BRA 30.71 $30.71 --- -- 009 0 0 0.00 $0.00 Y
1 L8001 BREAST PROSTHESIS BRA & FORM 78.99 $78.99 --- -- 009 0 0 0.00 $0.00 Y
1 L8002 BRST PRSTH BRA & BILAT FORM 103.90 $103.90 --- -- 009 0 0 0.00 $0.00 Y
1 L8010 MASTECTOMY SLEEVE 27.93 $27.93 --- -- 009 0 0 0.00 $0.00 Y
1 L8015 EXTERNAL BREAST PROSTHESIS GARMENT 37.75 $37.75 --- -- 009 0 0 0.00 $0.00 Y
1 L8020 BREAST PROSTHESIS, MASTECTOMY FORM 91.47 $91.47 --- -- 009 0 0 0.00 $0.00 Y
1 L8030 BREAST PROSTHES W/O ADHESIVE 245.02 $245.02 --- -- 009 0 0 0.00 $0.00 Y
1 L8031 BREAST PROSTHESIS W ADHESIVE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8032 REUSABLE NIPPLE PROSTHESIS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8033 NIPPLE PROSTHESIS CUSTOM, EA 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8035 CUSTOM BREAST PROSTHESIS 2196.13 $2196.13 --- -- 009 0 0 0.00 $0.00 Y
1 L8300 SINGLE W/STANDARD PAD 72.16 $72.16 --- -- 009 0 0 0.00 $0.00 Y
1 L8310 DOUBLE W/STANDARD PADS 113.93 $113.93 --- -- 009 0 0 0.00 $0.00 Y
1 L8320 OROTHOSES TRUSS PADS WATER 26.96 $26.96 --- -- 009 0 0 0.00 $0.00 Y
1 L8330 OROTHOSES TRUSS SCROTAL WITH LEG STRAP 26.07 $26.07 --- -- 009 0 0 0.00 $0.00 Y
1 L8400 PROSTHETIC STUMP SOX SHEATH DAW O EQUAL 11.88 $11.88 --- -- 009 0 0 0.00 $0.00 Y
1 L8410 PROSTHETIC STUMP SOX SHEATH DAW O EQUAL 11.88 $11.88 --- -- 009 0 0 0.00 $0.00 Y
1 L8415 PROSTHETIC SHEATH, UPPER LIMB, EAC 10.94 $10.94 --- -- 009 0 0 0.00 $0.00 Y
1 L8417 PROS SHEATH/SOCK W GEL CUSHN 36.31 $36.31 --- -- 009 0 0 0.00 $0.00 Y
P L8417 PROS SHEATH/SOCK W GEL CUSHN 36.31 $36.31 --- -- 009 0 0 0.00 $0.00 Y
1 L8420 PROSTHETIC SOCK MULTI PLY BK 11.79 $11.79 --- -- 009 0 0 0.00 $0.00 Y
1 L8430 PROSTHETIC SOCK MULTI PLY AK 11.79 $11.79 --- -- 009 0 0 0.00 $0.00 Y
1 L8435 PROS SOCK MULTI PLY UPPER LM 11.99 $11.99 --- -- 009 0 0 0.00 $0.00 Y
1 L8440 PROSTHETIC STUMP SHRINKER BELOW KNEE 25.68 $25.68 --- -- 009 0 0 0.00 $0.00 Y
1 L8460 PROSTHETIC SHRINKER 57.02 $57.02 --- -- 009 0 0 0.00 $0.00 Y
1 L8465 PROSTHETIC SHRINKER, UPPER LIMB, E 19.08 $19.08 --- -- 009 0 0 0.00 $0.00 Y
1 L8470 PROS SOCK SINGLE PLY BK 4.48 $4.48 --- -- 009 0 0 0.00 $0.00 Y
P L8470 PROS SOCK SINGLE PLY BK 4.48 $4.48 --- -- 009 0 0 0.00 $0.00 Y
1 L8480 PROS SOCK SINGLE PLY AK 5.22 $5.22 --- -- 009 0 0 0.00 $0.00 Y
1 L8485 PROSTHETIC SOCK 9.22 $9.22 --- -- 009 0 0 0.00 $0.00 Y
1 L8500 ARTIFICIAL LARYNX, ANY TYPE 339.06 $339.06 --- -- 009 0 0 0.00 $0.00 Y
1 L8501 TRACHEOSTOMY SPEAKING VALVE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8505 ARTIFICIAL LARYNX, ACCESSORY 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8507 TRACHEOESOPHAGEAL VOICE PROSTHESIS PATI 26.38 $26.38 --- -- 009 0 0 0.00 $0.00 Y
1 L8509 TRACHEOESOPHAGEAL VOICE PROSTHESIS PATI 68.78 $68.78 --- -- 009 0 0 0.00 $0.00 Y
1 L8510 VOICE AMPLIFIER 159.15 $159.15 --- -- 009 0 0 0.00 $0.00 Y
1 L8603 COLLAGEN IMP URINARY 2.5 ML 281.33 $281.33 --- -- 009 0 0 0.00 $0.00 Y
1 L8604 DEXTRANOMER/HYALURONIC ACID 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8605 INJ BULKING AGENT ANAL CANAL 523.18 $523.18 --- -- 009 0 0 0.00 $0.00 Y
1 L8606 SYNTHETIC IMPLNT URINARY 1ML 146.09 $146.09 --- -- 009 0 0 0.00 $0.00 Y
1 L8607 INJ VOCAL CORD BULKING AGENT 31.98 $31.98 --- -- 009 0 0 0.00 $0.00 Y
1 L8608 ARG II EXT COM/SUP/ACC MISC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8614 COCHLEAR DEVICE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8615 *05 COCH IMPLANT HEADSET REPLACE 284.06 $284.06 --- -- 009 0 0 0.00 $0.00 Y
1 L8616 *05 COCH IMPLANT MICROPHONE REPL 66.16 $66.16 --- -- 009 0 0 0.00 $0.00 Y
1 L8617 *05 COCH IMPLANT TRANS COIL REPL 57.78 $57.78 --- -- 009 0 0 0.00 $0.00 Y
1 L8618 *05 COCH IMPLANT TRAN CABLE REPL 16.51 $16.51 --- -- 009 0 0 0.00 $0.00 Y
1 L8619 COCH IMP EXT PROC/CONTR RPLC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8621 *05 REPL ZINC AIR BATTERY 0.42 $0.42 --- -- 009 0 0 0.00 $0.00 Y
1 L8622 *05 REPL ALKALINE BATTERY 0.22 $0.22 --- -- 009 0 0 0.00 $0.00 Y
1 L8623 *04 *06 LITH ION BATT CID,NONEARLVL 40.74 $40.74 --- -- 009 0 0 0.00 $0.00 Y
1 L8624 *04 *06 LITH ION BATT CID, EAR LEVEL 101.57 $101.57 --- -- 009 0 0 0.00 $0.00 Y
1 L8625 CHARGER COCH IMPL/AOI BATTRY 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8627 *10CID EXT SPEECH PROCESS REPL 5189.60 $5189.60 --- -- 009 0 0 0.00 $0.00 Y
1 L8628 *10CID EXT CONTROLLER REPL 920.17 $920.17 --- -- 009 0 0 0.00 $0.00 Y
1 L8629 *10CID TRANSMIT COIL AND CABLE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8680 IMPLT NEUROSTIM ELCTR EACH 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8681 PT PRGRM FOR IMPLT NEUROSTIM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8682 IMPLT NEUROSTIM RADIOFQ REC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8683 RADIOFQ TRSMTR FOR IMPLT NEU 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8685 IMPLT NROSTM PLS GEN SNG REC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8686 IMPLT NROSTM PLS GEN SNG NON 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8687 IMPLT NROSTM PLS GEN DUA REC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8688 IMPLT NROSTM PLS GEN DUA NON 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8689 EXTERNAL RECHARG SYS INTERN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8695 EXTERNAL RECHARG SYS EXTERN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8696 EXT ANTENNA PHREN NERVE STIM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L8699 PROSTHETIC IMPLANT NOS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L9900 O&P SUPPLY/ACCESSORY/SERVICE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 P9010 BLOOD (WHOLE), FOR TRANSFUSION, PE 254.85 $254.85 --- -- 009 0 0 0.00 $0.00 Y
1 P9011 BLOOD SPLIT UNIT 149.20 $149.20 --- -- 009 0 0 0.00 $0.00 Y
1 P9012 CRYOPRECIPITATE, EACH UNIT 41.24 $41.24 --- -- 009 0 0 0.00 $0.00 Y
1 P9016 RBC LEUKOCYTES REDUCED 185.15 $185.15 --- -- 009 0 0 0.00 $0.00 Y
1 P9017 PLASMA 1 DONOR FRZ W/IN 8 HR 67.03 $67.03 --- -- 009 0 0 0.00 $0.00 Y
1 P9019 PLATELETS, EACH UNIT 69.50 $69.50 --- -- 009 0 0 0.00 $0.00 Y
1 P9020 PLATELET RICH PLASMA, EACH UNIT 363.50 $363.50 --- -- 009 0 0 0.00 $0.00 Y
1 P9021 RED BLOOD CELLS, EACH UNIT 129.66 $129.66 --- -- 009 0 0 0.00 $0.00 Y
1 P9022 WASHED RED BLOOD CELLS UNIT 277.03 $277.03 --- -- 009 0 0 0.00 $0.00 Y
1 P9023 FROZEN PLASMA, POOLED, SD 73.87 $73.87 --- -- 009 0 0 0.00 $0.00 Y
1 P9031 PLATELETS LEUKOCYTES REDUCED 107.51 $107.51 --- -- 009 0 0 0.00 $0.00 Y
1 P9032 PLATELETS, IRRADIATED 121.72 $121.72 --- -- 009 0 0 0.00 $0.00 Y
1 P9033 PLATELETS LEUKOREDUCED IRRAD 139.94 $139.94 --- -- 009 0 0 0.00 $0.00 Y
1 P9034 PLATELETS, PHERESIS 441.03 $441.03 --- -- 009 0 0 0.00 $0.00 Y
1 P9035 PLATELET PHERES LEUKOREDUCED 499.53 $499.53 --- -- 009 0 0 0.00 $0.00 Y
1 P9036 PLATELET PHERESIS IRRADIATED 417.71 $417.71 --- -- 009 0 0 0.00 $0.00 Y
1 P9037 PLATE PHERES LEUKOREDU 624.66 $624.66 --- -- 009 0 0 0.00 $0.00 Y
1 P9038 RBC IRRADIATED 195.18 $195.18 --- -- 009 0 0 0.00 $0.00 Y
1 P9039 RBC DEGLYCEROLIZED 347.23 $347.23 --- -- 009 0 0 0.00 $0.00 Y
1 P9040 RBC LEUKOREDUCED IRRADIATED 240.27 $240.27 --- -- 009 0 0 0.00 $0.00 Y
1 P9041 ALBUMIN (HUMAN), 5%, 50ML 10.49 $10.49 --- -- 009 0 0 0.00 $0.00 Y
1 P9043 PLASMA PROTEIN FRACT, 5%, 50ML 22.52 $22.52 --- -- 009 0 0 0.00 $0.00 Y
1 P9044 CRYOPRECIPITATEREDUCEDPLASMA 83.69 $83.69 --- -- 009 0 0 0.00 $0.00 Y
1 P9045 ALBUMIN (HUMAN), 5%, 250 ML 52.45 $52.45 --- -- 009 0 0 0.00 $0.00 Y
1 P9046 ALBUMIN (HUMAN), 25%, 20 ML 20.98 $20.98 --- -- 009 0 0 0.00 $0.00 Y
1 P9047 ALBUMIN (HUMAN), 25%, 50ML 52.45 $52.45 --- -- 009 0 0 0.00 $0.00 Y
1 P9048 PLASMAPROTEIN FRACT, 5%, 250ML 57.35 $57.35 --- -- 009 0 0 0.00 $0.00 Y
1 P9050 GRANULOCYTES, PHERESIS UNIT 1387.55 $1387.55 --- -- 009 0 0 0.00 $0.00 Y
1 P9051 BLOOD, L/R, CMVNEG 147.90 $147.90 --- -- 009 0 0 0.00 $0.00 Y
1 P9052 PLATELETS, HLAM, L/R, UNIT 645.94 $645.94 --- -- 009 0 0 0.00 $0.00 Y
1 P9053 PLT, PHER, L/R CMVNEG, IRR 686.54 $686.54 --- -- 009 0 0 0.00 $0.00 Y
1 P9054 BLOOD, L/R, FROZ/DEGLY/WASH 218.81 $218.81 --- -- 009 0 0 0.00 $0.00 Y
1 P9055 PLT, APH/PHER, L/R, CMVNEG 488.74 $488.74 --- -- 009 0 0 0.00 $0.00 Y
1 P9056 BLOOD, L/R, IRRADIATED 147.13 $147.13 --- -- 009 0 0 0.00 $0.00 Y
1 P9057 RBC, FRZ/DEG/WSH, L/R, IRRAD 373.99 $373.99 --- -- 009 0 0 0.00 $0.00 Y
1 P9058 RBC, L/R, CMVNEG, IRRAD 263.49 $263.49 --- -- 009 0 0 0.00 $0.00 Y
1 P9059 PLASMA, FRZ BETWEEN 824 HOUR 77.93 $77.93 --- -- 009 0 0 0.00 $0.00 Y
1 P9060 FR FRZ PLASMA DONOR RETESTED 52.64 $52.64 --- -- 009 0 0 0.00 $0.00 Y
1 P9073 PLATELETS PHERESIS PATH REDU 624.66 $624.66 --- -- 009 0 0 0.00 $0.00 Y
M P9100 PATHOGEN TEST FOR PLATELETS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L Q0092 SET-UP PORTABLE XRAY EQUIPMENT 14.27 $14.27 --- -- 009 0 0 0.00 $0.00 N
M Q0111 WET MOUNTS, INCL PREP VAGINAL, CERV OR/S 3.66 $3.66 --- -- 009 0 0 0.20 $0.00 N
1 Q0111 WET MOUNTS,INCL PREP VAGINAL, CERV OR S 4.72 $4.72 --- -- 009 0 0 0.20 $0.00 N
1 Q0112 ALL POTASSIUM HYDROXIDE (KOH) PREPARATIO 4.72 $4.72 --- -- 009 0 0 0.20 $0.00 N
M Q0112 ALL POTASSIUM HIDROXIDE (KOH) PREPS 4.65 $4.65 --- -- 009 0 0 0.20 $0.00 N
M Q0113 PINWORM EXAMINATIONS 4.72 $4.72 --- -- 009 0 0 0.20 $0.00 N
1 Q0113 PINWORM EXAMINATIONS 4.72 $4.72 --- -- 009 0 0 0.20 $0.00 N
I Q0138 FERUMOXYTOL, NON-ESRD 5.46 $5.46 --- -- 030 0 0 0.00 $0.00 Y
I Q0139 FERUMOXYTOL, ESRD USE 5.46 $5.46 --- -- 030 0 0 0.00 $0.00 Y
1 Q0144 AZITHROMYCIN DIHYDRATE, ORAL 5.08 $5.08 --- -- 009 0 0 0.00 $0.00 Y
1 Q0166 GRANISETRON HCL 1 MG ORAL 3.01 $3.01 --- -- 009 0 0 0.00 $0.00 Y
1 Q0477 PWR MODULE PT CABLE LVAD RPL 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
K Q0478 POWER ADAPTER, COMBO VAD 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
O Q0478 POWER ADAPTER, COMBO VAD 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
O Q0479 POWER MODULE COMBO VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
K Q0479 POWER MODULE COMBO VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0480 DRIVER PNEUMATIC VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0481 MICROPRCSR CU ELEC VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0482 MICROPRCSR CU COMBO VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0483 MONITOR ELEC VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0484 MONITOR ELEC OR COMB VAD REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0485 MONITOR CABLE ELEC VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0486 MON CABLE ELEC/PNEUM VAD REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0487 LEADS ANY TYPE VAD, REP ONLY 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0488 PWR PACK BASE ELEC VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0489 PWR PCK BASE COMBO VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0490 EMR PWR SOURCE ELEC VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0491 EMR PWR SOURCE COMBO VAD REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0492 EMR PWR CBL ELEC VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0493 EMR PWR CBL COMBO VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0494 EMR HD PMP ELEC/COMBO, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0495 CHARGER ELEC/COMBO VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0496 BATTERY ELEC/COMBO VAD, REP 1062.02 $1062.02 --- -- 009 0 0 0.00 $0.00 Y
1 Q0497 BAT CLPS ELEC/COMB VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0498 HOLSTER ELEC/COMBO VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0499 BELT/VEST ELEC/COMBO VAD REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0500 FILTERS ELEC/COMBO VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0501 SHWR COV ELEC/COMBO VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0502 MOBILITY CART PNEUM VAD, REP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0503 BATTERY PNEUM VAD REPLACEMNT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0504 PWR ADPT PNEUM VAD, REP VEH 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0506 LITH-ION BATT ELEC/PNEUM VAD 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0507 MISC SUPP/ACC EXT VAD 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0508 MISC SUPP/ACC IMP VAD 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q0509 MISC SUPP/AC IMP VAD NOPAY MED 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
I Q2041 AXICABTAGENE CILOLEUCEL CAR 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I Q2042 TISAGENLECLEUCEL CAR-POS T 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I Q2043 SIPULEUCEL-T 44029.06 $44029.06 --- -- 030 0 0 0.00 $0.00 Y
I Q2049 DOXORUBICIN HCL,LIPOSOMAL,LIPODOX 10MG 505.86 $505.86 --- -- 030 0 0 0.00 $0.00 Y
I Q2050 DOXORUBICIN HCL LIPOSOMAL 353.76 $353.76 --- -- 030 0 0 0.00 $0.00 Y
1 Q3014 TELEHEALTH FACILITY FEE 22.94 $22.94 --- -- 009 0 0 0.00 $0.00 Y
I Q4081 EPOETIN ALFA, 100 UNITS ESRD 5.61 $5.61 --- -- 030 0 0 0.00 $0.00 Y
I Q4082 DRUG/BIO NOC PART B DRUG CAP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4100 SKIN SUBSTITUTE, NOS 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
P Q4100 SKIN SUBSTITUTE, NOS 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
P Q4101 APLIGRAF 30.80 $30.80 --- $30.80 009 1 0 0.00 $0.00 Y
1 Q4101 APLIGRAF 30.80 $30.80 --- $30.80 009 1 0 0.00 $0.00 Y
1 Q4102 OASIS WOUND MATRIX 11.92 $11.92 --- $11.92 009 1 0 0.00 $0.00 Y
P Q4102 OASIS WOUND MATRIX 11.92 $11.92 --- $11.92 009 1 0 0.00 $0.00 Y
P Q4103 OASIS BURN MATRIX 4.35 $4.35 --- $4.35 009 1 0 0.00 $0.00 Y
1 Q4103 OASIS BURN MATRIX 4.35 $4.35 --- $4.35 009 1 0 0.00 $0.00 Y
1 Q4104 INTEGRA BMWD 11.87 $11.87 --- $11.87 009 1 0 0.00 $0.00 Y
P Q4104 INTEGRA BMWD 11.87 $11.87 --- $11.87 009 1 0 0.00 $0.00 Y
P Q4105 INTEGRA DRT 11.87 $11.87 --- $11.87 009 1 0 0.00 $0.00 Y
1 Q4105 INTEGRA DRT 11.87 $11.87 --- $11.87 009 1 0 0.00 $0.00 Y
1 Q4106 DERMAGRAFT 32.74 $32.74 --- $32.74 009 1 0 0.00 $0.00 Y
P Q4106 DERMAGRAFT 32.74 $32.74 --- $32.74 009 1 0 0.00 $0.00 Y
P Q4107 GRAFTJACKET 95.72 $95.72 --- $95.72 009 1 0 0.00 $0.00 Y
1 Q4107 GRAFTJACKET 95.72 $95.72 --- $95.72 009 1 0 0.00 $0.00 Y
1 Q4108 INTEGRA MATRIX 18.85 $18.85 --- $18.85 009 1 0 0.00 $0.00 Y
P Q4108 INTEGRA MATRIX 18.85 $18.85 --- $18.85 009 1 0 0.00 $0.00 Y
P Q4110 PRIMATRIX 48.84 $48.84 --- $48.84 009 1 0 0.00 $0.00 Y
1 Q4110 PRIMATRIX 48.84 $48.84 --- $48.84 009 1 0 0.00 $0.00 Y
1 Q4111 GAMMAGRAFT 7.37 $7.37 --- $7.37 009 1 0 0.00 $0.00 Y
P Q4111 GAMMAGRAFT 7.37 $7.37 --- $7.37 009 1 0 0.00 $0.00 Y
P Q4112 CYMETRA INJECTABLE 311.36 $311.36 --- $311.36 009 1 0 0.00 $0.00 Y
1 Q4112 CYMETRA INJECTABLE 311.36 $311.36 --- $311.36 009 1 0 0.00 $0.00 Y
1 Q4113 GRAFTJACKET XPRESS 311.36 $311.36 --- $311.36 009 1 0 0.00 $0.00 Y
P Q4113 GRAFTJACKET XPRESS 311.36 $311.36 --- $311.36 009 1 0 0.00 $0.00 Y
P Q4114 INTEGRA FLOWABLE WOUND MATRI 897.11 $897.11 --- $897.11 009 1 0 0.00 $0.00 Y
1 Q4114 INTEGRA FLOWABLE WOUND MATRI 897.11 $897.11 --- $897.11 009 1 0 0.00 $0.00 Y
1 Q4116 ALLODERM 25.78 $25.78 --- $25.78 009 1 0 0.00 $0.00 Y
P Q4116 ALLODERM 25.78 $25.78 --- $25.78 009 1 0 0.00 $0.00 Y
P Q4117 HYALOMATRIX 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
1 Q4117 HYALOMATRIX 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
1 Q4118 MATRISTEM MICROMATRIX 1.86 $1.86 --- $1.86 009 1 0 0.00 $0.00 Y
P Q4118 MATRISTEM MICROMATRIX 1.86 $1.86 --- $1.86 009 1 0 0.00 $0.00 Y
P Q4121 THERASKIN 41.96 $41.96 --- $41.96 009 1 0 0.00 $0.00 Y
1 Q4121 THERASKIN 41.96 $41.96 --- $41.96 009 1 0 0.00 $0.00 Y
1 Q4122 DERMACELL, AWM, POROUS SQ CM 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
P Q4122 DERMACELL, AWM, POROUS SQ CM 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
P Q4123 ALLOSKIN 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
1 Q4123 ALLOSKIN 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
1 Q4124 OASIS TRI-LAYER WOUND MATRIX 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
P Q4124 OASIS TRI-LAYER WOUND MATRIX 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
P Q4125 ARTHROFLEX 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
1 Q4125 ARTHROFLEX 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
1 Q4126 MEMODERM 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
P Q4126 MEMODERM 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
P Q4127 TALYMED 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
1 Q4127 TALYMED 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
1 Q4128 FLEXHD OR ALLOPATCH HD 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
P Q4128 FLEXHD OR ALLOPATCH HD 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
P Q4130 STRATTICE TM 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
1 Q4130 STRATTICE TM 0.00 $0.00 --- -- 009 1 0 0.00 $0.00 Y
1 Q4131 EPIFIX 165.00 $165.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4131 EPIFIX 165.00 $165.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4132 GRAFIX CORE 131.42 $131.42 --- -- 009 0 0 0.00 $0.00 Y
1 Q4132 GRAFIX CORE 131.42 $131.42 --- -- 009 0 0 0.00 $0.00 Y
1 Q4133 GRAFIX PRIME 139.04 $139.04 --- -- 009 0 0 0.00 $0.00 Y
P Q4133 GRAFIX PRIME 139.04 $139.04 --- -- 009 0 0 0.00 $0.00 Y
P Q4134 HMATRIX 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4134 HMATRIX 0.00 $0.00 --- -- 007 0 0 0.00 $0.00 N
1 Q4135 MEDISKIN 0.00 $0.00 --- -- 007 0 0 0.00 $0.00 N
P Q4135 MEDISKIN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4136 EZDERM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4136 EZDERM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4159 AFFINITY, PER SQUARE CENTIMETER 175.45 $175.45 --- -- 009 0 0 0.00 $0.00 Y
P Q4159 AFFINITY, PER SQUARE CENTIMETER 175.45 $175.45 --- -- 009 0 0 0.00 $0.00 Y
P Q4160 NUSHIELD, PER SQUARE CENTIMETER 110.32 $110.32 --- -- 009 0 0 0.00 $0.00 Y
1 Q4160 NUSHIELD, PER SQUARE CENTIMETER 110.32 $110.32 --- -- 009 0 0 0.00 $0.00 Y
1 Q4166 CYTAL, PER SQUARE CENTIMETER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4166 CYTAL, PER SQUARE CENTIMETER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4167 TRUSKIN, PER SQ CENTIMETE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4167 TRUSKIN, PER SQ CENTIMETER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4168 AMNIOBAND, 1 MG 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4168 AMNIOBAND, 1 MG 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4169 ARTACENT WOUND, PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4169 ARTACENT WOUND, PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4170 CYGNUS, PER SQ CM 68.41 $68.41 --- -- 009 0 0 0.00 $0.00 Y
P Q4170 CYGNUS, PER SQ CM 68.41 $68.41 --- -- 009 0 0 0.00 $0.00 Y
P Q4171 INTERFYL, 1 MG 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4171 INTERFYL, 1 MG 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4172 PURAPLY OR PURAPLY AM 96.08 $96.08 --- -- 009 0 0 0.00 $0.00 Y
P Q4172 PURAPLY OR PURAPLY AM 96.08 $96.08 --- -- 009 0 0 0.00 $0.00 Y
P Q4173 PALINGEN OR PALINGEN XPLUS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4173 PALINGEN OR PALINGEN XPLUS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4174 PALINGEN OR PROMATRX 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4174 PALINGEN OR PROMATRX 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4175 MIRODERM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4175 MIRODERM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4176 NEOPATCH, PER SQ CENTIMETER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4176 NEOPATCH, PER SQ CENTIMETER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4177 FLOWERAMNIOFLO, 0.1 CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4177 FLOWERAMNIOFLO, 0.1 CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4178 FLOWERAMNIOPATCH, PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4178 FLOWERAMNIOPATCH, PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4179 FLOWERDERM, PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4179 FLOWERDERM, PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4180 REVITA, PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4180 REVITA, PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4181 AMNIO WOUND, PER SQUARE CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4181 AMNIO WOUND, PER SQUARE CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4182 TRANSCYTE, PER SQ CENTIMETER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4182 TRANSCYTE, PER SQ CENTIMETER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4183 SURGIGRAFT, 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4183 SURGIGRAFT, 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4184 CELLESTA OR DUO PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4184 CELLESTA OR DUO PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4185 CELLESTA FLOWAB AMNION 0.5CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4185 CELLESTA FLOWAB AMNION 0.5CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4186 EPIFIX 1 SQ CM 160.01 $160.01 --- -- 009 0 0 0.00 $0.00 Y
P Q4186 EPIFIX 1 SQ CM 160.01 $160.01 --- -- 009 0 0 0.00 $0.00 Y
P Q4187 EPICORD 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4187 EPICORD 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4188 AMNIOARMOR 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4188 AMNIOARMOR 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4189 ARTACENT AC, 1 MG 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4189 ARTACENT AC, 1 MG 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4190 ARTACENT AC 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4190 ARTACENT AC 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4191 RESTORIGIN 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4191 RESTORIGIN 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4192 RESTORIGIN, 1 CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4192 RESTORIGIN, 1 CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4193 COLL-E-DERM 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4193 COLL-E-DERM 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4194 NOVACHOR 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4194 NOVACHOR 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4195 PURAPLY 1 SQ CM 99.92 $99.92 --- -- 009 0 0 0.00 $0.00 Y
1 Q4195 PURAPLY 1 SQ CM 99.92 $99.92 --- -- 009 0 0 0.00 $0.00 Y
1 Q4196 PURAPLY AM 1 SQ CM 104.48 $104.48 --- -- 009 0 0 0.00 $0.00 Y
P Q4196 PURAPLY AM 1 SQ CM 104.48 $104.48 --- -- 009 0 0 0.00 $0.00 Y
P Q4197 PURAPLY XT 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4197 PURAPLY XT 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4198 GENESIS AMNIO MEMBRANE 1SQCM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4198 GENESIS AMNIO MEMBRANE 1SQCM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4200 SKIN TE 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4200 SKIN TE 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4201 MATRION 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4201 MATRION 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4202 KEROXX (2.5G/CC), 1CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4202 KEROXX (2.5G/CC), 1CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4203 DERMA-GIDE, 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4203 DERMA-GIDE, 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4204 XWRAP 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4204 XWRAP 1 SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4205 MEMBRANE GRAFT OR WRAP SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4205 MEMBRANE GRAFT OR WRAP SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4206 FLUID FLOW OR FLUID GF 1 CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4206 FLUID FLOW OR FLUID GF 1 CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4208 NOVAFIX PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4208 NOVAFIX PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4209 SURGEGRAFT PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4209 SURGEGRAFT PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4210 AXOLOTL GRAF DUALGRAF SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4210 AXOLOTL GRAF DUALGRAF SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4211 AMNION BIO OR AXOBIO SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4211 AMNION BIO OR AXOBIO SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4212 ALLOGEN, PER CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4212 ALLOGEN, PER CC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4213 ASCENT, 0.5 MG 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4213 ASCENT, 0.5 MG 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4214 CELLESTA CORD PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4214 CELLESTA CORD PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4215 AXOLOTL AMBIENT, CRYO 0.1 MG 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4215 AXOLOTL AMBIENT, CRYO 0.1 MG 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4216 ARTACENT CORD PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4216 ARTACENT CORD PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4217 WOUNDFIX BIOWOUND PLUS XPLUS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4217 WOUNDFIX BIOWOUND PLUS XPLUS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4218 SURGICORD PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4218 SURGICORD PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4219 SURGIGRAFT DUAL PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4219 SURGIGRAFT DUAL PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4220 BELLACELL HD, SUREDERM SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4220 BELLACELL HD, SUREDERM SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4221 AMNIOWRAP2 PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4221 AMNIOWRAP2 PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4222 PROGENAMATRIX, PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4222 PROGENAMATRIX, PER SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
P Q4226 MYOWN HARV PREP PROC SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 Q4226 MYOWN HARV PREP PROC SQ CM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
I Q5101 INJECTION, ZARXIO 5.07 $5.07 --- -- 030 0 0 0.00 $0.00 Y
I Q5103 INJECTION, INFLECTRA 55.78 $55.78 --- -- 030 0 0 0.00 $0.00 Y
I Q5104 INJECTION, (RENFLEXIS), 10MG 59.11 $59.11 --- -- 030 0 0 0.00 $0.00 Y
I Q5105 INJ RETACRIT ESRD ON DIALYSI 5.48 $5.48 --- -- 030 0 0 0.00 $0.00 Y
I Q5106 INJ RETACRIT NON-ESRD USE 14.64 $14.64 --- -- 030 0 0 0.00 $0.00 Y
I Q5107 INJ MVASI 10 MG 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I Q5108 INJECTION, FULPHILA 337.01 $337.01 --- -- 030 0 0 0.00 $0.00 Y
I Q5109 INJECTION, IXIFI, 10 MG 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I Q5110 NIVESTYM 5.15 $5.15 --- -- 030 0 0 0.00 $0.00 Y
I Q5111 INJECTION, UDENYCA 0.5 MG 363.67 $363.67 --- -- 030 0 0 0.00 $0.00 Y
I Q5112 INJ ONTRUZANT 10 MG 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I Q5113 INJ HERZUMA 10 MG 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I Q5114 INJ OGIVRI 10 MG 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I Q5115 INJ RITUXIMAB-ABBS BIO 10 MG 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I Q5116 INJ., TRAZIMERA, 10 MG 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
I Q5117 INJ., KANJINTI, 10 MG 95.13 $95.13 --- -- 030 0 0 0.00 $0.00 Y
I Q5118 INJ., ZIRABEV, 10 MG 0.00 $0.00 --- -- 030 0 0 0.00 $0.00 Y
L Q9950 INJ SULF HEXA LIPID MICROSPH 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
L Q9951 LOCM >= 400 MG/ML IODINE,1ML 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L Q9953 INJ FEBASED MR CONTRAST,1ML 24.33 $24.33 --- -- 009 0 0 0.00 $0.00 Y
L Q9954 ORAL MR CONTRAST, 100 ML 7.18 $7.18 --- -- 009 0 0 0.00 $0.00 Y
L Q9956 INJ OCTAFLUOROPROPANE MIC,ML 32.18 $32.18 --- -- 009 0 0 0.00 $0.00 Y
L Q9957 INJ PERFLUTREN LIP MICROS,ML 48.27 $48.27 --- -- 009 0 0 0.00 $0.00 Y
L Q9958 HOCM <=149 MG/ML IODINE, 1ML 0.08 $0.08 --- -- 009 0 0 0.00 $0.00 Y
L Q9959 HOCM 150199MG/ML IODINE,1ML 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L Q9960 HOCM 200249MG/ML IODINE,1ML 0.22 $0.22 --- -- 009 0 0 0.00 $0.00 Y
L Q9961 HOCM 250299MG/ML IODINE,1ML 0.26 $0.26 --- -- 009 0 0 0.00 $0.00 Y
L Q9962 HOCM 300349MG/ML IODINE,1ML 0.15 $0.15 --- -- 009 0 0 0.00 $0.00 Y
L Q9963 HOCM 350399MG/ML IODINE,1ML 0.20 $0.20 --- -- 009 0 0 0.00 $0.00 Y
L Q9964 HOCM>= 400MG/ML IODINE, 1ML 0.16 $0.16 --- -- 009 0 0 0.00 $0.00 Y
L Q9965 LOCM 100199MG/ML IODINE,1ML 1.01 $1.01 --- -- 009 0 0 0.00 $0.00 Y
L Q9966 LOCM 200299MG/ML IODINE,1ML 0.32 $0.32 --- -- 009 0 0 0.00 $0.00 Y
L Q9967 LOCM 300399MG/ML IODINE,1ML 0.12 $0.12 --- -- 009 0 0 0.00 $0.00 Y
1 Q9968 VISUALIZATION ADJUNCT 16.49 $16.49 --- -- 009 0 0 0.00 $0.00 Y
L Q9969 NON-HEU TC-99M ADD-ON/DOSE 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
L Q9982 FLUTEMETAMOL F18 DIAGNOSTIC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
L Q9983 FLORBETABEN F18 DIAGNOSTIC 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
I Q9991 BUPRENORPH XR 100 MG OR LESS 1679.26 $1679.26 --- -- 030 0 0 0.00 $0.00 Y
I Q9992 BUPRENORPHINE XR OVER 100 MG 1679.26 $1679.26 --- -- 030 0 0 0.00 $0.00 Y
L R0070 PORTABLE X-RAY ONE PATIENT PER TRIP 174.06 $174.06 --- -- 009 0 0 0.00 $0.00 N
L R0075 PORTABLE X-RAY, MULTIPLE PATIENTS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
I S0017 AMINOCAPROIC ACID 11.02 $11.02 --- -- 030 0 0 0.00 $0.00 Y
I S0020 BUPIVACAINE HCL 30 CC 9.97 $9.97 --- -- 030 0 0 0.00 $0.00 Y
I S0032 INJECTION, NAFCILLIN SODIUM 27.16 $27.16 --- -- 030 0 0 0.00 $0.00 Y
I S0077 INJECTION, CLINDAMYCIN PHOSP 7.99 $7.99 --- -- 030 0 0 0.00 $0.00 Y
I S0080 PENTAMIDINE ISETHIONATE 300 MG 171.35 $171.35 --- -- 030 0 0 0.00 $0.00 Y
1 S0140 SAQUINAVIR, 200 MG 4.13 $4.13 --- -- 009 0 0 0.00 $0.00 Y
I S0145 PEG INTERFERON ALFA2A/180 1025.95 $1025.95 --- -- 030 0 0 0.00 $0.00 Y
I S0148 PEG INTERFERON ALFA-2B/10 116.35 $116.35 --- -- 030 0 0 0.00 $0.00 Y
I S0164 INJECTION PANTOPRAZOLE 9.49 $9.49 --- -- 030 0 0 0.00 $0.00 Y
1 S0189 TESTOSTERONE PELLET 75 MG 102.17 $102.17 --- -- 009 0 0 0.00 $0.00 Y
1 S0190 MIFEPRISTONE, ORAL, 200 MG 67.33 $67.33 --- -- 009 0 0 0.00 $0.00 Y
1 S0191 MISOPROSTOL, ORAL, 200 MCG 0.75 $0.75 --- -- 009 0 0 0.00 $0.00 Y
1 S0197 PRENATAL VITAMINS 30 DAY 1.34 $1.34 --- -- 009 0 0 0.00 $0.00 Y
N S0199 MEDICAL ABORTION 14.41 $536.48 --- -- 035 0 0 0.00 $0.00 Y
N S0257 END OF LIFE COUNSELING 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
N S0265 GENETIC COUNSLING PHY SUP EA 15 MIN 15.00 $15.00 --- -- 009 0 0 0.00 $0.00 N
N S0500 DISPOSABLE CONTACT LENS, PER LENS 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 S0500 DISPOSABLE CONTACT LENS, PER LENS 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 S0512 DAILY WEAR SPECIALTY CONTACT LENS/LENS 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
N S0512 DAILY WEAR SPECIALTY CONTACT LENS/LENS 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
N S0514 COLOR CONTACT LENS, PER LENS 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 S0514 COLOR CONTACT LENS, PER LENS 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 S0516 SAFETY EYEGLASS FRAMES 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
N S0516 SAFETY EYEGLASS FRAMES 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 N
1 S1040 CRANIAL REMOLDING ORTHOSIS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
K S2065 SIMULT PANC KIDN TRANS 0.00 $0.00 --- -- 004 1 0 0.00 $0.00 Y
O S2065 SIMULT PANC KIDN TRANS 0.00 $0.00 --- -- 004 1 0 0.00 $0.00 Y
O S2066 BREAST GAP FLAP RECONST 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
K S2066 BREAST GAP FLAP RECONST 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
K S2067 BREAST "STACKED" DIEP/GAP 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
O S2067 BREAST "STACKED" DIEP/GAP 0.00 $0.00 --- -- 004 0 0 0.00 $0.00 Y
O S2068 BREAST DIEP OR SIEA FLAP 0.00 $0.00 --- -- 004 1 0 0.00 $0.00 Y
K S2068 BREAST DIEP OR SIEA FLAP 0.00 $0.00 --- -- 004 1 0 0.00 $0.00 Y
K S2079 LAP ESOPHAGOMYOTOMY 21.52 $801.19 --- $1010.36 004 1 0 0.00 $0.00 Y
K S2117 ARTHROEREISIS, SUBTALAR 0.00 $0.00 --- -- 004 1 0 0.00 $0.00 Y
P S2117 ARTHROEREISIS, SUBTALAR 0.00 $0.00 --- -- 015 1 0 0.00 $0.00 Y
O S2117 ARTHROEREISIS, SUBTALAR 0.00 $0.00 --- -- 004 1 0 0.00 $0.00 Y
O S2118 TOTAL HIP RESURFACING 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
K S2118 TOTAL HIP RESURFACING 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
K S2230 IMPLANT SEMIIMP HEAR 10.57 $393.52 --- $496.26 004 1 0 0.00 $0.00 Y
O S2230 IMPLANT SEMIIMP HEAR 2.11 $78.56 --- $99.06 004 1 0 0.00 $0.00 Y
O S2235 IMPLANT AUDITORY BRAIN IMP 2.78 $103.50 --- $130.52 004 1 0 0.00 $0.00 Y
K S2235 IMPLANT AUDITORY BRAIN IMP 13.92 $518.24 --- $653.54 004 1 0 0.00 $0.00 Y
M S3620 NEWBORN METABOLIC SCREENING 142.25 $142.25 --- -- 009 0 0 0.80 $0.00 N
1 S4993 CONTRACEPTIVE PILLS FOR BC 12.00 $12.00 --- -- 009 0 0 0.00 $0.00 Y
1 S5102 DAY CARE SVS, ADLT PER DIEM 76.27 $76.27 --- -- 009 0 0 0.00 $0.00 N
1 S5110 HOMECARE TRAIN, FM 15 MIN 11.36 $11.36 --- -- 009 0 0 0.00 $0.00 N
1 S5111 HOMECARE TRAIN, FM PER SESS 35.77 $35.77 --- -- 009 0 0 0.00 $0.00 N
G S5130 HOMEMAKER SERVICE, NOS-AID WAIVER 3.72 $3.72 --- -- 009 0 0 0.00 $0.00 N
1 S5160 EMG RESPON SYS; INST/TST 0.01 $0.01 --- -- 009 0 0 0.00 $0.00 N
1 S5161 ERS/SVS FEE, PER MONTH 0.01 $0.01 --- -- 009 0 0 0.00 $0.00 N
1 S5165 HOME MODIFICATION; PER SYS 1500.00 $1500.00 --- -- 009 0 0 0.00 $0.00 N
G S5165 HOME MODIFICATIONS, PER SERVICE 1000.00 $1000.00 --- -- 009 0 0 0.00 $0.00 N
G S5170 HOME DLVRD MEALS, INC PREP, PER MEAL 150.00 $150.00 --- -- 009 0 0 0.00 $0.00 N
1 S5190 WELLNESS ASSESSMENT PERF BY NON-PHYS 100.00 $100.00 --- -- 009 0 0 0.00 $0.00 N
1 S5199 PERSONAL CARE ITEM, NOS EA 14.99 $14.99 --- -- 009 0 0 0.00 $0.00 Y
L S8032 LOW DOSE CT LUNG SCREENING 0.00 $0.00 --- -- 005 0 0 0.00 $0.00 Y
L S8037 MRCP 147.18 $562.23 --- -- 005 0 0 0.30 $0.00 Y
1 S8130 INTERFERENTIAL STIM 2 CHAN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 S8131 INTERFERENTIAL STIM 4 CHAN 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 S8265 HABERMAN FEEDER 18.52 $18.52 --- -- 009 0 0 0.00 $0.00 Y
1 S9122 HOME HEALTH AIDE OR CERTIFIE 18.90 $18.90 --- -- 009 0 0 0.00 $0.00 N
1 S9123 NURSING CARE IN HOME RN 47.91 $47.91 --- -- 009 0 0 0.00 $0.00 N
T S9123 NURSING CARE HOME;RN PER HR 47.91 $47.91 --- -- 009 0 0 0.00 $0.00 Y
T S9124 NURSING CARE HOME;LPN PER HR 36.63 $36.63 --- -- 009 0 0 0.00 $0.00 Y
1 S9124 NURSING CARE, IN THE HOME; B 36.63 $36.63 --- -- 009 0 0 0.00 $0.00 N
G S9470 NUTRITIONAL COUNSELING, DIETITIAN VISIT 33.48 $33.48 --- -- 009 0 0 0.00 $0.00 N
E T1001 NURSING ASSESS/EVAL 27.52 $27.52 --- -- 009 0 0 0.00 $0.00 N
E T1002 RN SVCS, UP TO 15 MIN 10.42 $10.42 --- -- 009 0 0 0.00 $0.00 Y
T T1002 RN SERVICE UP TO 15MINS 16.74 $16.74 --- -- 009 0 0 0.00 $0.00 Y
T T1003 LPN/LVN SVCS UP TO 15MINS 12.13 $12.13 --- -- 009 0 0 0.00 $0.00 Y
E T1003 LPN/LVN SVCS, UP TO 15 MIN 5.53 $5.53 --- -- 009 0 0 0.00 $0.00 Y
E T1004 NSG AIDE SVCS, UP TO 15 MIN 4.58 $4.58 --- -- 009 0 0 0.00 $0.00 Y
1 T1005 RESPITE CARE SERVICE 15 MIN 2.63 $2.63 --- -- 009 0 0 0.00 $0.00 N
1 T1013 SIGN LANG/ORAL INTERPRETIVE SERV/15 MIN 14.75 $14.75 --- -- 009 0 0 0.00 $0.00 N
N T1013 SIGN LANG/ORAL INTERPRETIVE SERV/15 MIN 4.84 $4.84 --- -- 009 0 0 0.00 $0.00 Y
1 T1014 TELEHEALTH TRANSMIT, PER MIN 0.24 $0.24 --- -- 009 0 0 0.00 $0.00 Y
F T1015 CLINC VISIT/ENCOUNTER-ALL INCLUSIVE-EAPC 71.50 $71.50 --- -- 009 0 0 0.00 $0.00 N
1 T1016 CASE MANAGEMENT, PER 15 MIN 13.41 $13.41 --- -- 009 0 0 0.00 $0.00 N
T T1016 CASE MNGMNT, EACH 15MINS 13.41 $13.41 --- -- 009 0 0 0.00 $0.00 Y
1 T1017 TARGETED CASE MANAGEMENT 50.00 $50.00 --- -- 009 0 0 0.00 $0.00 N
E T1017 TARGETED CASE MGMT 6.19 $6.19 --- -- 009 0 0 0.00 $0.00 N
1 T1019 PERSONAL CARE SER PER 15 MIN 3.62 $3.62 --- -- 009 0 0 0.00 $0.00 N
1 T1023 PROGRAM INTAKE ASSESSMENT 64.83 $64.83 --- -- 009 0 0 0.00 $0.00 N
T T1026 PED COMPR CARE PKG. PER HOUR 44.12 $44.12 --- -- 009 0 0 0.00 $0.00 Y
T T1029 DWELLING LEAD INVESTIGATION 270.00 $270.00 --- -- 009 0 0 0.00 $0.00 N
1 T2001 N-ET; PATIENT ATTEND/ESCORT 5.52 $5.52 --- -- 009 0 0 0.00 $0.00 N
E T2003 N-ET; ENCOUNTER/TRIP 9.27 $9.27 --- -- 009 0 0 0.00 $0.00 N
G T2003 NON-EMERGENCY MEDICAL TRANSPORTATION 100.00 $100.00 --- -- 009 0 0 0.00 $0.00 N
1 T2005 N-ET; STRETCHER VAN 26.29 $26.29 --- -- 009 0 0 0.00 $0.00 N
1 T2007 NON-EMER TRANSPORT WAIT TIME 11.30 $11.30 --- -- 009 0 0 0.00 $0.00 N
1 T2013 HABIL ED WAIVER PER HOUR 22.00 $22.00 --- -- 009 0 0 0.00 $0.00 N
1 T2017 HABIL RES WAIVER 15 MIN 8.94 $8.94 --- -- 009 0 0 0.00 $0.00 N
1 T2022 CASE MANAGEMENT, PER MONTH 229.17 $229.17 --- -- 009 0 0 0.00 $0.00 N
G T2022 CASE MGMT. PER MONTH-AIDS WAIVER 229.17 $229.17 --- -- 009 0 0 0.00 $0.00 N
1 T2024 SERV ASMNT/CARE PLAN WAIVER 200.00 $200.00 --- -- 009 0 0 0.00 $0.00 N
1 T2025 WAIVER SERVVICE, NOS 35.77 $35.77 --- -- 009 0 0 0.00 $0.00 N
G T2025 WAIVER SERVICES, NOS 170.28 $170.28 --- -- 009 0 0 0.00 $0.00 N
G T2026 SPECIALIZED CHILDCARE,WAIVER-PER DIEM 338.00 $338.00 --- -- 009 0 0 0.00 $0.00 N
G T2028 SPECIALIZED SUPPLY, NOS-AIDS WVR 1000.00 $1000.00 --- -- 009 0 0 0.00 $0.00 N
1 T2028 SPECIAL SUPPLY, NOS WAIVER 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
G T2029 SPECIALIZED MEDICAL EQUIP, NOS-AIDS WVR 1000.00 $1000.00 --- -- 009 0 0 0.00 $0.00 N
1 T2031 ASSIST LIVING WAIVER/DIEM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 T2033 RES, NOS WAIVER PER DIEM 91.28 $91.28 --- -- 009 0 0 0.00 $0.00 N
1 T2035 UTILITY SERVICES WAIVER 0.01 $0.01 --- -- 009 0 0 0.00 $0.00 N
1 T2038 COMM TRANS WAIVER, PER SERVICE 2500.00 $2500.00 --- -- 009 0 0 0.00 $0.00 N
1 T2039 VEHICLE MOD WAIVER/SERVICE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 T2045 HOSPICE GENERAL CARE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 T2101 BREAST MILK PROC/STORE/DIST 3.00 $3.00 --- -- 009 0 0 0.00 $0.00 N
1 T5001 POSITION SEAT SPEC ORTH NEED 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 V2020 FRAMES, PURCHASES 21.31 $21.31 --- -- 009 0 0 0.00 $0.00 Y
N V2020 FRAMES, PURCHASES 21.31 $21.31 --- -- 009 0 0 0.00 $0.00 Y
N V2025 DELUXE FRAME 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 Y
1 V2025 DELUXE FRAMES 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 Y
1 V2100 LENS SPHER SINGLE PLANO 4.00 18.30 $18.30 --- -- 009 0 0 0.00 $0.00 Y
3 V2100 LENS SPHER SINGLE PLANO 4.00 8.29 $8.29 --- -- 009 0 0 0.00 $0.00 Y
N V2100 LENS SPHER SINGLE PLANO 4.00 18.30 $18.30 --- -- 009 0 0 0.00 $0.00 Y
N V2101 SINGLE VISN SPHERE 4.127.00 21.69 $21.69 --- -- 009 0 0 0.00 $0.00 Y
3 V2101 SINGLE VISN SPHERE 4.127.00 9.53 $9.53 --- -- 009 0 0 0.00 $0.00 Y
1 V2101 SINGLE VISN SPHERE 4.127.00 21.69 $21.69 --- -- 009 0 0 0.00 $0.00 Y
1 V2102 SINGL VISN SPHERE 7.1220.00 25.75 $25.75 --- -- 009 0 0 0.00 $0.00 Y
3 V2102 SINGL VISN SPHERE 7.1220.00 12.85 $12.85 --- -- 009 0 0 0.00 $0.00 Y
N V2102 SINGL VISN SPHERE 7.1220.00 25.75 $25.75 --- -- 009 0 0 0.00 $0.00 Y
N V2103 SPHEROCYLINDR 4.00D/122.00D 18.48 $18.48 --- -- 009 0 0 0.00 $0.00 Y
3 V2103 SPHEROCYLINDR 4.00D/12-2.00D 8.29 $8.29 --- -- 009 0 0 0.00 $0.00 N
1 V2103 SPHEROCYLINDR 4.00D/122.00D 18.48 $18.48 --- -- 009 0 0 0.00 $0.00 Y
1 V2104 SPHEROCYLINDR 4.00D/2.124D 18.62 $18.62 --- -- 009 0 0 0.00 $0.00 Y
3 V2104 SPHEROCYLINDR 4.00D/2.12-4D 8.29 $8.29 --- -- 009 0 0 0.00 $0.00 N
N V2104 SPHEROCYLINDR 4.00D/2.124D 18.62 $18.62 --- -- 009 0 0 0.00 $0.00 Y
N V2105 SPHEROCYLINDER 4.00D/4.256D 29.39 $29.39 --- -- 009 0 0 0.00 $0.00 Y
3 V2105 SPHEROCYLINDER 4.00D/4.25-6D 8.29 $8.29 --- -- 009 0 0 0.00 $0.00 N
1 V2105 SPHEROCYLINDER 4.00D/4.256D 29.39 $29.39 --- -- 009 0 0 0.00 $0.00 Y
1 V2106 SPHEROCYLINDER 4.00D/>6.00D 31.14 $31.14 --- -- 009 0 0 0.00 $0.00 Y
3 V2106 SPHEROCYLINDER 4.00D/>6.00D 8.29 $8.29 --- -- 009 0 0 0.00 $0.00 N
N V2106 SPHEROCYLINDER 4.00D/>6.00D 31.14 $31.14 --- -- 009 0 0 0.00 $0.00 Y
N V2107 SPHEROCYLINDER 4.25D/122D 21.89 $21.89 --- -- 009 0 0 0.00 $0.00 Y
3 V2107 SPHEROCYLINDER 4.25D/12-2D 9.53 $9.53 --- -- 009 0 0 0.00 $0.00 N
1 V2107 SPHEROCYLINDER 4.25D/122D 21.89 $21.89 --- -- 009 0 0 0.00 $0.00 Y
1 V2108 SPHEROCYLINDER 4.25D/2.124D 22.18 $22.18 --- -- 009 0 0 0.00 $0.00 Y
3 V2108 SPHEROCYLINDER 4.25D/2.12-4D 9.53 $9.53 --- -- 009 0 0 0.00 $0.00 N
N V2108 SPHEROCYLINDER 4.25D/2.124D 22.18 $22.18 --- -- 009 0 0 0.00 $0.00 Y
N V2109 SPHEROCYLINDER 4.25D/4.256D 33.01 $33.01 --- -- 009 0 0 0.00 $0.00 Y
3 V2109 SPHEROCYLINDER 4.25D/4.25-6D 9.53 $9.53 --- -- 009 0 0 0.00 $0.00 N
1 V2109 SPHEROCYLINDER 4.25D/4.256D 33.01 $33.01 --- -- 009 0 0 0.00 $0.00 Y
1 V2110 SPHEROCYLINDER 4.25D/OVER 6D 37.34 $37.34 --- -- 009 0 0 0.00 $0.00 Y
3 V2110 SPHEROCYLINDER 4.25D/OVER 6D 9.53 $9.53 --- -- 009 0 0 0.00 $0.00 N
N V2110 SPHEROCYLINDER 4.25D/OVER 6D 37.34 $37.34 --- -- 009 0 0 0.00 $0.00 Y
N V2111 SPHEROCYLINDR 7.25D/.252.25 25.74 $25.74 --- -- 009 0 0 0.00 $0.00 Y
3 V2111 SPHEROCYLINDR 7.25D/.25-2.25 12.85 $12.85 --- -- 009 0 0 0.00 $0.00 N
1 V2111 SPHEROCYLINDR 7.25D/.252.25 25.74 $25.74 --- -- 009 0 0 0.00 $0.00 Y
1 V2112 SPHEROCYLINDR 7.25D/2.254D 25.74 $25.74 --- -- 009 0 0 0.00 $0.00 Y
3 V2112 SPHEROCYLINDR 7.25D/2.25-4D 12.85 $12.85 --- -- 009 0 0 0.00 $0.00 N
N V2112 SPHEROCYLINDR 7.25D/2.254D 25.74 $25.74 --- -- 009 0 0 0.00 $0.00 Y
N V2113 SPHEROCYLINDR 7.25D/4.256D 37.40 $37.40 --- -- 009 0 0 0.00 $0.00 Y
3 V2113 SPHEROCYLINDR 7.25D/4.25-6D 12.85 $12.85 --- -- 009 0 0 0.00 $0.00 N
1 V2113 SPHEROCYLINDR 7.25D/4.256D 37.40 $37.40 --- -- 009 0 0 0.00 $0.00 Y
1 V2114 SPHEROCYLINDER OVER 12.00D 29.90 $29.90 --- -- 009 0 0 0.00 $0.00 Y
3 V2114 SPHEROCYLINDER OVER 12.00D 12.85 $12.85 --- -- 009 0 0 0.00 $0.00 N
N V2114 SPHEROCYLINDER OVER 12.00D 29.90 $29.90 --- -- 009 0 0 0.00 $0.00 Y
N V2115 LENS LENTICULAR MYODISC SINGLE VISION 77.05 $77.05 --- -- 009 0 0 0.00 $0.00 Y
3 V2115 LENS LENTICULAR MYODISC SINGLE VISION 29.41 $29.41 --- -- 009 0 0 0.00 $0.00 N
1 V2115 LENS LENTICULAR MYODISC SINGLE VISION 77.05 $77.05 --- -- 009 0 0 0.00 $0.00 Y
1 V2121 LENTICULAR LENS, SINGLE 64.77 $64.77 --- -- 009 0 0 0.00 $0.00 Y
3 V2121 LENTICULAR LENS, SINGLE 29.41 $29.41 --- -- 009 0 0 0.00 $0.00 Y
N V2121 LENTICULAR LENS, SINGLE 64.77 $64.77 --- -- 009 0 0 0.00 $0.00 Y
N V2199 LENS SINGLE VISION NOT OTH CLASSIFIED 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 Y
1 V2199 LENS SINGLE VISION NOT OTH CLASSIFIED 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 Y
1 V2200 LENS SPHER BIFOC PLANO 4.00D 29.39 $29.39 --- -- 009 0 0 0.00 $0.00 Y
3 V2200 LENS SPHER BIFOC PLANO 4.00D 12.93 $12.93 --- -- 009 0 0 0.00 $0.00 Y
N V2200 LENS SPHER BIFOC PLANO 4.00D 29.39 $29.39 --- -- 009 0 0 0.00 $0.00 Y
N V2201 LENS SPHERE BIFOCAL 4.127.0 36.38 $36.38 --- -- 009 0 0 0.00 $0.00 Y
3 V2201 LENS SPHERE BIFOCAL 4.127.0 15.23 $15.23 --- -- 009 0 0 0.00 $0.00 Y
1 V2201 LENS SPHERE BIFOCAL 4.127.0 36.38 $36.38 --- -- 009 0 0 0.00 $0.00 Y
1 V2202 LENS SPHERE BIFOCAL 7.1220. 42.60 $42.60 --- -- 009 0 0 0.00 $0.00 Y
3 V2202 LENS SPHERE BIFOCAL 7.1220. 19.44 $19.44 --- -- 009 0 0 0.00 $0.00 Y
N V2202 LENS SPHERE BIFOCAL 7.1220. 42.60 $42.60 --- -- 009 0 0 0.00 $0.00 Y
N V2203 LENS SPHCYL BIFOCAL 4.00D/.1 29.76 $29.76 --- -- 009 0 0 0.00 $0.00 Y
3 V2203 LENS SPHCYL BIFOCAL 4.00D/.1 12.93 $12.93 --- -- 009 0 0 0.00 $0.00 N
1 V2203 LENS SPHCYL BIFOCAL 4.00D/.1 29.76 $29.76 --- -- 009 0 0 0.00 $0.00 Y
1 V2204 LENS SPHCY BIFOCAL 4.00D/2.1 29.77 $29.77 --- -- 009 0 0 0.00 $0.00 Y
3 V2204 LENS SPHCY BIFOCAL 4.00D/2.1 12.93 $12.93 --- -- 009 0 0 0.00 $0.00 N
N V2204 LENS SPHCY BIFOCAL 4.00D/2.1 29.77 $29.77 --- -- 009 0 0 0.00 $0.00 Y
N V2205 LENS SPHCY BIFOCAL 4.00D/4.2 43.91 $43.91 --- -- 009 0 0 0.00 $0.00 Y
3 V2205 LENS SPHCY BIFOCAL 4.00D/4.2 12.93 $12.93 --- -- 009 0 0 0.00 $0.00 N
1 V2205 LENS SPHCY BIFOCAL 4.00D/4.2 43.91 $43.91 --- -- 009 0 0 0.00 $0.00 Y
1 V2206 LENS SPHCY BIFOCAL 4.00D/OVE 44.17 $44.17 --- -- 009 0 0 0.00 $0.00 Y
3 V2206 LENS SPHCY BIFOCAL 4.00D/OVE 12.93 $12.93 --- -- 009 0 0 0.00 $0.00 N
N V2206 LENS SPHCY BIFOCAL 4.00D/OVE 44.17 $44.17 --- -- 009 0 0 0.00 $0.00 Y
N V2207 LENS SPHCY BIFOCAL 4.257D/. 36.41 $36.41 --- -- 009 0 0 0.00 $0.00 Y
3 V2207 LENS SPHCY BIFOCAL 4.25-7D/. 15.23 $15.23 --- -- 009 0 0 0.00 $0.00 N
1 V2207 LENS SPHCY BIFOCAL 4.257D/. 36.41 $36.41 --- -- 009 0 0 0.00 $0.00 Y
1 V2208 LENS SPHCY BIFOCAL 4.257/2. 38.48 $38.48 --- -- 009 0 0 0.00 $0.00 Y
3 V2208 LENS SPHCY BIFOCAL 4.25-7/2. 15.23 $15.23 --- -- 009 0 0 0.00 $0.00 N
N V2208 LENS SPHCY BIFOCAL 4.257/2. 38.48 $38.48 --- -- 009 0 0 0.00 $0.00 Y
N V2209 LENS SPHCY BIFOCAL 4.257/4. 49.81 $49.81 --- -- 009 0 0 0.00 $0.00 Y
3 V2209 LENS SPHCY BIFOCAL 4.25-7/4. 15.23 $15.23 --- -- 009 0 0 0.00 $0.00 N
1 V2209 LENS SPHCY BIFOCAL 4.257/4. 49.81 $49.81 --- -- 009 0 0 0.00 $0.00 Y
1 V2210 LENS SPHCY BIFOCAL 4.257/OV 51.64 $51.64 --- -- 009 0 0 0.00 $0.00 Y
3 V2210 LENS SPHCY BIFOCAL 4.25-7/OV 15.23 $15.23 --- -- 009 0 0 0.00 $0.00 N
N V2210 LENS SPHCY BIFOCAL 4.257/OV 51.64 $51.64 --- -- 009 0 0 0.00 $0.00 Y
N V2211 LENS SPHCY BIFO 7.2512/.25 42.31 $42.31 --- -- 009 0 0 0.00 $0.00 Y
3 V2211 LENS SPHCY BIFO 7.25-12/.25- 19.44 $19.44 --- -- 009 0 0 0.00 $0.00 N
1 V2211 LENS SPHCY BIFO 7.2512/.25 42.31 $42.31 --- -- 009 0 0 0.00 $0.00 Y
1 V2212 LENS SPHCYL BIFO 7.2512/2.2 42.60 $42.60 --- -- 009 0 0 0.00 $0.00 Y
3 V2212 LENS SPHCYL BIFO 7.25-12/2.2 19.44 $19.44 --- -- 009 0 0 0.00 $0.00 N
N V2212 LENS SPHCYL BIFO 7.2512/2.2 42.60 $42.60 --- -- 009 0 0 0.00 $0.00 Y
N V2213 LENS SPHCYL BIFO 7.2512/4.2 52.37 $52.37 --- -- 009 0 0 0.00 $0.00 Y
3 V2213 LENS SPHCYL BIFO 7.25-12/4.2 19.44 $19.44 --- -- 009 0 0 0.00 $0.00 N
1 V2213 LENS SPHCYL BIFO 7.2512/4.2 52.37 $52.37 --- -- 009 0 0 0.00 $0.00 Y
1 V2214 LENS SPHCYL BIFOCAL OVER 12. 44.87 $44.87 --- -- 009 0 0 0.00 $0.00 Y
3 V2214 LENS SPHCYL BIFOCAL OVER 12. 19.44 $19.44 --- -- 009 0 0 0.00 $0.00 N
N V2214 LENS SPHCYL BIFOCAL OVER 12. 44.87 $44.87 --- -- 009 0 0 0.00 $0.00 Y
N V2215 LENS LENTICULAR MYODISC BIFOCAL 95.89 $95.89 --- -- 009 0 0 0.00 $0.00 Y
3 V2215 LENS LENTICULAR MYODISC BIFOCAL 45.99 $45.99 --- -- 009 0 0 0.00 $0.00 N
1 V2215 LENS LENTICULAR MYODISC BIFOCAL 95.89 $95.89 --- -- 009 0 0 0.00 $0.00 Y
1 V2220 LENS BIFOCAL ADD OVER 3.25D 14.31 $14.31 --- -- 009 0 0 0.00 $0.00 Y
3 V2220 LENS BIFOCAL ADD OVER 3.25D 10.57 $10.57 --- -- 009 0 0 0.00 $0.00 Y
N V2220 LENS BIFOCAL ADD OVER 3.25D 14.31 $14.31 --- -- 009 0 0 0.00 $0.00 Y
N V2221 LENTICULAR LENS, BIFOCAL 75.56 $75.56 --- -- 009 0 0 0.00 $0.00 Y
3 V2221 LENTICULAR LENS, BIFOCAL 45.99 $45.99 --- -- 009 0 0 0.00 $0.00 Y
1 V2221 LENTICULAR LENS, BIFOCAL 75.56 $75.56 --- -- 009 0 0 0.00 $0.00 Y
1 V2299 SPECIALTY BIFOCAL 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 Y
N V2299 SPECIALTY BIFOCAL 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 Y
N V2300 LENS SPHERE TRIFOCAL 4.00D 42.35 $42.35 --- -- 009 0 0 0.00 $0.00 Y
1 V2300 LENS SPHERE TRIFOCAL 4.00D 42.35 $42.35 --- -- 009 0 0 0.00 $0.00 Y
3 V2300 LENS SPHERE TRIFOCAL 4.00D 19.61 $19.61 --- -- 009 0 0 0.00 $0.00 Y