2007 Alph # HCPC,s File - PUF___2007_Web_File HCP C S eq N...

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Unformatted text preview: PUF___2007_Web_File HCP C S eq N u m RIC L o n g D es c ri p ti o n S h o rt D es c ri p ti o n A1 A2 A3 A4 A5 A6 A7 A8 A9 AA AD AD AE AF AG AH AJ AK AM AP AP AQ AQ AR AS AS AT AT AU AV AW AX BA BL BO BP BP BR BR BU BU CA CA CB CB CB CC CC CD CD CE CE CE CF CF CR E1 E2 E3 E4 EJ EJ EM EP EP ET EY EY F1 F2 F3 F4 F5 F6 F7 F8 F9 FA FB FB FB FP G1 G2 G3 G4 G5 G6 G6 G7 G7 G8 G8 G9 G9 GA GB GB GC GC GE GE GF GF GF GG GG GH GJ GK GL GL GM GN GO GP GQ GR GR GR GS GS GT GV GV GW GY GY GZ H9 HA HB HC HD HE HF HG HH HI HI HJ HK HL HM HN HO HP HQ HR HS HT HU HV HW HX HY HZ J1 J2 J2 J3 J3 JA JB JW K0 K0 K0 K1 K1 K1 K2 K2 K2 K2 K3 K3 K3 K3 K3 K4 K4 K4 K4 KA KB KC KD KF KH KI KJ KJ KM KN KO KP KQ KR KS KX KZ LC LD LL LL LR LS LT M2 MS MS NR NR NU P1 P2 P3 P4 P5 P6 PL Q2 Q3 Q4 Q5 Q5 Q6 Q7 Q8 Q9 QA QB QC QD QE QF QF QG QH QJ QJ QJ QK QK QL QM QN QP QP QP QQ QR QS QT QU QV QW QX QY QY QZ RC RD RP RP RP RP RR RT SA SB SC SD SD SE SF SF SG SH SJ SK SL SM SN SQ SS ST SU SU SV SW SY SY T1 T2 T3 T4 T5 T6 T7 T8 T9 TA TC TC TC TC TC TC TC TD TE TF TG TH TJ TK TL TM TN TP TQ TR TR TS TT TU TV TW U1 U2 U3 U4 U5 U6 U7 U8 U9 UA UB UC UD UE UF UG UH UJ UK UK UN UP UQ UR US VP A0021 A0080 A0080 A009 0 A009 0 A0100 A0110 A0120 A0120 A0130 A014 0 A014 0 A016 0 A0170 A0180 A019 0 A0200 A0210 A0225 A0380 A0382 A0384 A0384 A0384 A039 0 A039 2 A039 2 A039 4 A039 6 A039 8 A04 20 A04 22 A04 24 A04 24 A04 25 A04 26 A04 26 A04 27 A04 27 A04 28 A04 29 A04 30 A04 31 A04 32 A04 32 A04 32 A04 33 A04 34 A04 35 A04 36 A0800 A0888 A0888 A09 9 8 A09 9 9 A4 206 A4 207 A4 208 A4 209 A4 210 A4 211 A4 212 A4 213 A4 214 A4 215 A4 216 A4 217 A4 218 A4 220 A4 221 A4 221 A4 222 A4 222 A4 223 A4 223 A4 230 A4 231 A4 232 A4 233 A4 233 A4 234 A4 234 A4 235 A4 235 A4 236 A4 236 A4 24 4 A4 24 5 A4 24 6 A4 24 7 A4 24 8 A4 250 A4 253 A4 253 A4 254 A4 254 A4 255 A4 256 A4 257 A4 258 A4 259 A4 26 0 A4 26 1 A4 26 2 A4 26 3 A4 26 5 A4 26 6 A4 26 7 A4 26 8 A4 26 9 A4 270 A4 280 A4 281 A4 282 A4 283 A4 284 A4 285 A4 286 A4 29 0 A4 300 A4 300 A4 301 A4 301 A4 305 A4 306 A4 310 A4 311 A4 311 A4 311 A4 312 A4 312 A4 313 A4 313 A4 314 A4 314 A4 315 A4 315 A4 316 A4 316 A4 319 A4 320 A4 321 A4 322 A4 323 A4 324 A4 325 A4 326 A4 327 A4 328 A4 330 A4 331 A4 331 A4 332 A4 333 A4 334 A4 335 A4 338 A4 338 A4 34 0 A4 34 4 A4 34 6 A4 34 7 A4 34 7 A4 34 8 A4 34 8 A4 34 9 100 100 100 100 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 100 200 100 200 100 100 200 100 200 100 100 100 100 100 100 100 100 200 100 200 100 200 100 200 100 200 300 100 200 100 200 100 200 300 100 200 100 100 100 100 100 100 200 100 100 200 100 100 200 100 100 100 100 100 100 100 100 100 100 100 200 300 100 100 100 100 100 100 100 200 100 200 100 200 100 200 100 100 200 100 200 100 200 100 200 300 100 200 100 100 100 100 200 100 100 100 100 100 100 200 300 100 200 100 100 200 100 100 200 100 100 100 100 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 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PHYSICIAN PHYSICIAN, TEAM MEMBER SERVICE DETERMINATION OF REFRACTIVE STATE WAS NOT PERFORMED IN THE COURSE OF DIAGNOSTIC OPHTHALMOLOGICAL EXAMINATION PHYSICIAN PROVIDING A SERVICE IN AN UNLISTED HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) PHYSICIAN PROVIDER SERVICES IN A PHYSICIAN SCARCITY AREA PHYSICIAN ASSISTANT, NURSE PRACTITIONER, OR CLINICAL NURSE SPECIALIST SERVICES FOR ASSISTANT AT SURGERY ACUTE TREATMENT (THIS MODIFIER SHOULD BE USED WHEN REPORTING SERVICE 9 89 4 0, 9 89 4 1, 9 89 4 2) ITEM FURNISHED IN CONJUNCTION WITH A UROLOGICAL, OSTOMY, OR TRACHEOSTOMY SUPPLY ITEM FURNISHED IN CONJUNCTION WITH A PROSTHETIC DEVICE, PROSTHETIC OR ORTHOTIC ITEM FURNISHED IN CONJUNCTION WITH A SURGICAL DRESSING ITEM FURNISHED IN CONJUNCTION WITH DIALYSIS SERVICES ITEM FURNISHED IN CONJUNCTION WITH PARENTERAL ENTERAL NUTRITION (PEN) SERVICES SPECIAL ACQUISITION OF BLOOD AND BLOOD PRODUCTS ORALLY ADMINISTERED NUTRITION, NOT BY FEEDING TUBE THE BENEFICIARY HAS BEEN INFORMED OF THE PURCHASE AND RENTAL OPTIONS AND HAS ELECTED TO PURCHASE THE ITEM THE BENEFICIARY HAS BEEN INFORMED OF THE PURCHASE AND RENTAL OPTIONS AND HAS ELECTED TO RENT THE ITEM THE BENEFICIARY HAS BEEN INFORMED OF THE PURCHASE AND RENTAL OPTIONS AND AFTER 30 DAYS HAS NOT INFORMED THE SUPPLIER OF HIS/HER DECISION PROCEDURE PAYABLE ONLY IN THE INPATIENT SETTING WHEN PERFORMED EMERGENTLY ON AN OUTPATIENT WHO EXPIRES PRIOR TO ADMISSION SERVICE ORDERED BY A RENAL DIALYSIS FACILITY (RDF) PHYSICIAN AS PART OF THE ESRD BENEFICIARY'S DIALYSIS BENEFIT, IS NOT PART OF THE COMPOSITE RATE, AND IS SEPARATELY REIMBURSABLE PROCEDURE CODE CHANGE (USE 'CC' WHEN THE PROCEDURE CODE SUBMITTED WAS CHANGED EITHER FOR ADMINISTRATIVE REASONS OR BECAUSE AN INCORRECT CODE WAS FILED) AMCC TEST HAS BEEN ORDERED BY AN ESRD FACILITY OR MCP PHYSICIAN THAT IS PART OF THE COMPOSITE RATE AND IS NOT SEPARATELY BILLABLE AMCC TEST HAS BEEN ORDERED BY AN ESRD FACILITY OR MCP PHYSICIAN THAT IS A COMPOSITE RATE TEST BUT IS BEYOND THE NORMAL FREQUENCY COVERED UNDER THE RATE AND IS SEPARATELY REIMBURSABLE BASED ON MEDICAL NECESSITY AMCC TEST HAS BEEN ORDERED BY AN ESRD FACILITY OR MCP PHYSICIAN THAT IS NOT PART OF THE COMPOSITE RATE AND IS SEPARATELY BILLABLE CATASTROPHE/DISASTER RELATED UPPER LEFT, EYELID LOWER LEFT, EYELID UPPER RIGHT, EYELID LOWER RIGHT, EYELID SUBSEQUENT CLAIMS FOR A DEFINED COURSE OF THERAPY, E.G., EPO, SODIUM HYALURONATE, INFLIXIMAB EMERGENCY RESERVE SUPPLY (FOR ESRD BENEFIT ONLY) SERVICE PROVIDED AS PART OF MEDICAID EARLY PERIODIC SCREENING DIAGNOSIS AND TREATMENT (EPSDT) PROGRAM EMERGENCY SERVICES NO PHYSICIAN OR OTHER LICENSED HEALTH CARE PROVIDER ORDER FOR THIS ITEM OR SERVICE LEFT HAND, SECOND DIGIT LEFT HAND, THIRD DIGIT LEFT HAND, FOURTH DIGIT LEFT HAND, FIFTH DIGIT RIGHT HAND, THUMB RIGHT HAND, SECOND DIGIT RIGHT HAND, THIRD DIGIT RIGHT HAND, FOURTH DIGIT RIGHT HAND, FIFTH DIGIT LEFT HAND, THUMB ITEM PROVIDED WITHOUT COST TO PROVIDER, SUPPLIER OR PRACTITIONER, OR CREDIT RECEIVED FOR REPLACED DEVICE (EXAMPLES, BUT NOT LIMITED TO COVERED UNDER WARRANTY, REPLACED DUE TO DEFECT, FREE SAMPLES) SERVICE PROVIDED AS PART OF FAMILY PLANNING PROGRAM MOST RECENT URR READING OF LESS THAN 6 0 MOST RECENT URR READING OF 6 0 TO 6 4 .9 MOST RECENT URR READING OF 6 5 TO 6 9 .9 MOST RECENT URR READING OF 70 TO 74 .9 MOST RECENT URR READING OF 75 OR GREATER ESRD PATIENT FOR WHOM LESS THAN SIX DIALYSIS SESSIONS HAVE BEEN PROVIDED IN A MONTH PREGNANCY RESULTED FROM RAPE OR INCEST OR PREGNANCY CERTIFIED BY PHYSICIAN AS LIFE THREATENING MONITORED ANESTHESIA CARE (MAC) FOR DEEP COMPLEX, COMPLICATED, OR MARKEDLY INVASIVE SURGICAL PROCEDURE MONITORED ANESTHESIA CARE FOR PATIENT WHO HAS HISTORY OF SEVERE CARDIO-PULMONARY CONDITION WAIVER OF LIABILITY STATEMENT ON FILE CLAIM BEING RE-SUBMITTED FOR PAYMENT BECAUSE IT IS NO LONGER COVERED UNDER A GLOBAL PAYMENT DEMONSTRATION THIS SERVICE HAS BEEN PERFORMED IN PART BY A RESIDENT UNDER THE DIRECTION OF A TEACHING PHYSICIAN THIS SERVICE HAS BEEN PERFORMED BY A RESIDENT WITHOUT THE PRESENCE OF A TEACHING PHYSICIAN UNDER THE PRIMARY CARE EXCEPTION NON-PHYSICIAN (E.G. NURSE PRACTITIONER (NP), CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA), CERTIFIED REGISTERED NURSE (CRN), CLINICAL NURSE SPECIALIST (CNS), PHYSICIAN ASSISTANT (PA)) SERVICES IN A CRITICAL ACCESS HOSPITAL PERFORMANCE AND PAYMENT OF A SCREENING MAMMOGRAM AND DIAGNOSTIC MAMMOGRAM ON THE SAME PATIENT, SAME DAY DIAGNOSTIC MAMMOGRAM CONVERTED FROM SCREENING MAMMOGRAM ON SAME DAY "OPT OUT" PHYSICIAN OR PRACTITIONER EMERGENCY OR URGENT SERVICE ACTUAL ITEM/SERVICE ORDERED BY PHYSICIAN, ITEM ASSOCIATED WITH GA OR GZ MODIFIER MEDICALLY UNNECESSARY UPGRADE PROVIDED INSTEAD OF STANDARD ITEM, NO CHARGE, NO ADVANCE BENEFICIARY NOTICE (ABN) MULTIPLE PATIENTS ON ONE AMBULANCE TRIP SERVICES DELIVERED UNDER AN OUTPATIENT SPEECH LANGUAGE PATHOLOGY PLAN OF CARE SERVICES DELIVERED UNDER AN OUTPATIENT OCCUPATIONAL THERAPY PLAN OF CARE SERVICES DELIVERED UNDER AN OUTPATIENT PHYSICAL THERAPY PLAN OF CARE VIA ASYNCHRONOUS TELECOMMUNICATIONS SYSTEM THIS SERVICE WAS PERFORMED IN WHOLE OR IN PART BY A RESIDENT IN A DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER OR CLINIC, SUPERVISED IN ACCORDANCE WITH VA POLICY DOSAGE OF EPO OR DARBEPOIETIN ALFA HAS BEEN REDUCED AND MAINTAINED IN RESPONSE TO HEMATOCRIT OR HEMOGLOBIN LEVEL VIA INTERACTIVE AUDIO AND VIDEO TELECOMMUNICATION SYSTEMS ATTENDING PHYSICIAN NOT EMPLOYED OR PAID UNDER ARRANGEMENT BY THE PATIENT'S HOSPICE PROVIDER SERVICE NOT RELATED TO THE HOSPICE PATIENT'S TERMINAL CONDITION ITEM OR SERVICE STATUTORILY EXCLUDED OR DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT ITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE AND NECESSARY COURT-ORDERED CHILD/ADOLESCENT PROGRAM ADULT PROGRAM, NON GERIATRIC ADULT PROGRAM, GERIATRIC PREGNANT/PARENTING WOMEN'S PROGRAM MENTAL HEALTH PROGRAM SUBSTANCE ABUSE PROGRAM OPIOID ADDICTION TREATMENT PROGRAM INTEGRATED MENTAL HEALTH/SUBSTANCE ABUSE PROGRAM INTEGRATED MENTAL HEALTH AND MENTAL RETARDATION/DEVELOPMENTAL DISABILITIES PROGRAM EMPLOYEE ASSISTANCE PROGRAM SPECIALIZ ED MENTAL HEALTH PROGRAMS FOR HIGH-RISK POPULATIONS INTERN LESS THAN BACHELOR DEGREE LEVEL BACHELORS DEGREE LEVEL MASTERS DEGREE LEVEL DOCTORAL LEVEL GROUP SETTING FAMILY/COUPLE WITH CLIENT PRESENT FAMILY/COUPLE WITHOUT CLIENT PRESENT MULTI-DISCIPLINARY TEAM FUNDED BY CHILD WELFARE AGENCY FUNDED STATE ADDICTIONS AGENCY FUNDED BY STATE MENTAL HEALTH AGENCY FUNDED BY COUNTY/LOCAL AGENCY FUNDED BY JUVENILE JUSTICE AGENCY FUNDED BY CRIMINAL JUSTICE AGENCY COMPETITIVE ACQUISITION PROGRAM NO-PAY SUBMISSION FOR A PRESCRIPTION NUMBER COMPETITIVE ACQUISITION PROGRAM, RESTOCKING OF EMERGENCY DRUGS AFTER EMERGENCY ADMINISTRATION COMPETITIVE ACQUISITION PROGRAM (CAP), DRUG NOT AVAILABLE THROUGH CAP AS WRITTEN, REIMBURSED UNDER AVERAGE SALES PRICE METHODOLOGY ADMINISTERED INTRAVENOUSLY ADMINISTERED SUBCUTANEOUSLY DRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENT LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 0 - DOES NOT HAVE THE ABILITY OR POTENTIAL TO AMBULATE OR TRANSFER SAFELY WITH OR WITHOUT ASSISTANCE AND A PROSTHESIS DOES NOT ENHANCE THEIR QUALITY OF LIFE OR MOBILITY. LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 1 - HAS THE ABILITY OR POTENTIAL TO USE A PROSTHESIS FOR TRANSFERS OR AMBULATION ON LEVEL SURFACES AT FIXED CADENCE. TYPICAL OF THE LIMITED AND UNLIMITED HOUSEHOLD AMBULATOR. LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 2 - HAS THE ABILITY OR POTENTIAL FOR AMBULATION WITH THE ABILITY TO TRAVERSE LOW LEVEL ENVIRONMENTAL BARRIERS SUCH AS CURBS, STAIRS OR UNEVEN SURFACES. TYPICAL OF THE LIMITED COMMUNITY AMBULATOR. LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 3 - HAS THE ABILITY OR POTENTIAL FOR AMBULATION WITH VARIABLE CADENCE. TYPICAL OF THE COMMUNITY AMBULATOR WHO HAS THE ABILITY TO TRANSVERSE MOST ENVIRONMENTAL BARRIERS AND MAY HAVE VOCATIONAL, THERAPEUTIC, OR EXERCISE ACTIVITY THAT DEMANDS PROSTHETIC UTILIZ ATION BEYOND SIMPLE LOCOMOTION. LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 4 - HAS THE ABILITY OR POTENTIAL FOR PROSTHETIC AMBULATION THAT EXCEEDS THE BASIC AMBULATION SKILLS, EXHIBITING HIGH IMPACT, STRESS, OR ENERGY LEVELS, TYPICAL OF THE PROSTHETIC DEMANDS OF THE CHILD, ACTIVE ADULT, OR ATHLETE. ADD ON OPTION/ACCESSORY FOR WHEELCHAIR BENEFICIARY REQUESTED UPGRADE FOR ABN, MORE THAN 4 MODIFIERS IDENTIFIED ON CLAIM REPLACEMENT OF SPECIAL POWER WHEELCHAIR INTERFACE DRUG OR BIOLOGICAL INFUSED THROUGH DME ITEM DESIGNATED BY FDA AS CLASS III DEVICE DMEPOS ITEM, INITIAL CLAIM, PURCHASE OR FIRST MONTH RENTAL DMEPOS ITEM, SECOND OR THIRD MONTH RENTAL DMEPOS ITEM, PARENTERAL ENTERAL NUTRITION (PEN) PUMP OR CAPPED RENTAL, MONTHS FOUR TO FIFTEEN REPLACEMENT OF FACIAL PROSTHESIS INCLUDING NEW IMPRESSION/MOULAGE REPLACEMENT OF FACIAL PROSTHESIS USING PREVIOUS MASTER MODEL SINGLE DRUG UNIT DOSE FORMULATION FIRST DRUG OF A MULTIPLE DRUG UNIT DOSE FORMULATION SECOND OR SUBSEQUENT DRUG OF A MULTIPLE DRUG UNIT DOSE FORMULATION RENTAL ITEM, BILLING FOR PARTIAL MONTH GLUCOSE MONITOR SUPPLY FOR DIABETIC BENEFICIARY NOT TREATED WITH INSULIN SPECIFIC REQUIRED DOCUMENTATION ON FILE NEW COVERAGE NOT IMPLEMENTED BY MANAGED CARE LEFT CIRCUMFLEX CORONARY ARTERY LEFT ANTERIOR DESCENDING CORONARY ARTERY LEASE/RENTAL (USE THE 'LL' MODIFIER WHEN DME EQUIPMENT RENTAL IS TO BE APPLIED AGAINST THE PURCHASE PRICE) LABORATORY ROUND TRIP FDA-MONITORED INTRAOCULAR LENS IMPLANT LEFT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE LEFT SIDE OF THE BODY) MEDICARE SECONDARY PAYER (MSP) SIX MONTH MAINTENANCE AND SERVICING FEE FOR REASONABLE AND NECESSARY PARTS AND LABOR WHICH ARE NOT COVERED UNDER ANY MANUFACTURER OR SUPPLIER WARRANTY NEW WHEN RENTED (USE THE 'NR' MODIFIER WHEN DME WHICH WAS NEW AT THE TIME OF RENTAL IS SUBSEQUENTLY PURCHASED) NEW EQUIPMENT A NORMAL HEALTHY PATIENT A PATIENT WITH MILD SYSTEMIC DISEASE A PATIENT WITH SEVERE SYSTEMIC DISEASE A PATIENT WITH SEVERE SYSTEMIC DISEASE THAT IS A CONSTANT THREAT TO LIFE A MORIBUND PATIENT WHO IS NOT EXPECTED TO SURVIVE WITHOUT THE OPERATION A DECLARED BRAIN-DEAD PATIENT WHOSE ORGANS ARE BEING REMOVED FOR DONOR PURPOSES PROGRESSIVE ADDITION LENSES HCFA/ORD DEMONSTRATION PROJECT PROCEDURE/SERVICE LIVE KIDNEY DONOR SURGERY AND RELATED SERVICES SERVICE FOR ORDERING/REFERRING PHYSICIAN QUALIFIES AS A SERVICE EXEMPTION SERVICE FURNISHED BY A SUBSTITUTE PHYSICIAN UNDER A RECIPROCAL BILLING ARRANGEMENT SERVICE FURNISHED BY A LOCUM TENENS PHYSICIAN ONE CLASS A FINDING TWO CLASS B FINDINGS ONE CLASS B AND TWO CLASS C FINDINGS FDA INVESTIGATIONAL DEVICE EXEMPTION PHYSICIAN PROVIDING SERVICE IN A RURAL HPSA SINGLE CHANNEL MONITORING RECORDING AND STORAGE IN SOLID STATE MEMORY BY A DIGITAL RECORDER PRESCRIBED AMOUNT OF OXYGEN IS LESS THAN 1 LITER PER MINUTE (LPM) PRESCRIBED AMOUNT OF OXYGEN EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED PRESCRIBED AMOUNT OF OXYGEN IS GREATER THAN 4 LITERS PER MINUTE(LPM) OXYGEN CONSERVING DEVICE IS BEING USED WITH AN OXYGEN DELIVERY SYSTEM SERVICES/ITEMS PROVIDED TO A PRISONER OR PATIENT IN STATE OR LOCAL CUSTODY, HOWEVER THE STATE OR LOCAL GOVERNMENT, AS APPLICABLE, MEETS THE REQUIREMENTS IN 4 2 CFR 4 11.4 (B) MEDICAL DIRECTION OF TWO, THREE, OR FOUR CONCURRENT ANESTHESIA PROCEDURES INVOLVING QUALIFIED INDIVIDUALS PATIENT PRONOUNCED DEAD AFTER AMBULANCE CALLED AMBULANCE SERVICE PROVIDED UNDER ARRANGEMENT BY A PROVIDER OF SERVICES AMBULANCE SERVICE FURNISHED DIRECTLY BY A PROVIDER OF SERVICES DOCUMENTATION IS ON FILE SHOWING THAT THE LABORATORY TEST(S) WAS ORDERED INDIVIDUALLY OR ORDERED AS A CPT-RECOGNIZ ED PANEL OTHER THAN AUTOMATED PROFILE CODES 80002-80019 , G0058, G0059 , AND G006 0. CLAIM SUBMITTED WITH A WRITTEN STATEMENT OF INTENT ITEM OR SERVICE PROVIDED IN A MEDICARE SPECIFIED STUDY MONITORED ANESTHESIA CARE SERVICE RECORDING AND STORAGE ON TAPE BY AN ANALOG TAPE RECORDER PHYSICIAN PROVIDING SERVICE IN AN URBAN HPSA ITEM OR SERVICE PROVIDED AS ROUTINE CARE IN A MEDICARE QUALIFYING CLINICAL TRIAL CLIA WAIVED TEST CRNA SERVICE: WITH MEDICAL DIRECTION BY A PHYSICIAN MEDICAL DIRECTION OF ONE CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA) BY AN ANESTHESIOLOGIST CRNA SERVICE: WITHOUT MEDICAL DIRECTION BY A PHYSICIAN RIGHT CORONARY ARTERY DRUG PROVIDED TO BENEFICIARY, BUT NOT ADMINISTERED "INCIDENT-TO" REPLACEMENT AND REPAIR -RP MAY BE USED TO INDICATE REPLACEMENT OF DME, ORTHOTIC AND PROSTHETIC DEVICES WHICH HAVE BEEN IN USE FOR SOMETIME. THE CLAIM SHOWS THE CODE FOR THE PART, FOLLOWED BY THE 'RP' MODIFIER AND THE CHARGE FOR THE PART. RENTAL (USE THE 'RR' MODIFIER WHEN DME IS TO BE RENTED) RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY) NURSE PRACTITIONER RENDERING SERVICE IN COLLABORATION WITH A PHYSICIAN NURSE MIDWIFE MEDICALLY NECESSARY SERVICE OR SUPPLY SERVICES PROVIDED BY REGISTERED NURSE WITH SPECIALIZ ED, HIGHLY TECHNICAL HOME INFUSION TRAINING STATE AND/OR FEDERALLY-FUNDED PROGRAMS/SERVICES SECOND OPINION ORDERED BY A PROFESSIONAL REVIEW ORGANIZ ATION (PRO) PER SECTION 9 4 01, P.L. 9 9 -272 (100% REIMBURSEMENT - NO MEDICARE DEDUCTIBLE OR COINSURANCE) AMBULATORY SURGICAL CENTER (ASC) FACILITY SERVICE SECOND CONCURRENTLY ADMINISTERED INFUSION THERAPY THIRD OR MORE CONCURRENTLY ADMINISTERED INFUSION THERAPY MEMBER OF HIGH RISK POPULATION (USE ONLY WITH CODES FOR IMMUNIZ ATION) STATE SUPPLIED VACCINE SECOND SURGICAL OPINION THIRD SURGICAL OPINION ITEM ORDERED BY HOME HEALTH HOME INFUSION SERVICES PROVIDED IN THE INFUSION SUITE OF THE IV THERAPY PROVIDER RELATED TO TRAUMA OR INJURY PROCEDURE PERFORMED IN PHYSICIAN'S OFFICE (TO DENOTE USE OF FACILITY AND EQUIPMENT) PHARMACEUTICALS DELIVERED TO PATIENT'S HOME BUT NOT UTILIZ ED SERVICES PROVIDED BY A CERTIFIED DIABETIC EDUCATOR PERSONS WHO ARE IN CLOSE CONTACT WITH MEMBER OF HIGH-RISK POPULATION (USE ONLY WITH CODES FOR IMMUNIZ ATION) LEFT FOOT, SECOND DIGIT LEFT FOOT, THIRD DIGIT LEFT FOOT, FOURTH DIGIT LEFT FOOT, FIFTH DIGIT RIGHT FOOT, GREAT TOE RIGHT FOOT, SECOND DIGIT RIGHT FOOT, THIRD DIGIT RIGHT FOOT, FOURTH DIGIT RIGHT FOOT, FIFTH DIGIT LEFT FOOT, GREAT TOE TECHNICAL COMPONENT. UNDER CERTAIN CIRCUMSTANCES, A CHARGE MAY BE MADE FOR THE TECHNICAL COMPONENT ALONE. UNDER THOSE CIRCUMSTANCES THE TECHNICAL COMPONENT CHARGE IS IDENTIFIED BY ADDING MODIFIER 'TC' TO THE USUAL PROCEDURE NUMBER. TECHNICAL COMPONENT CHARGES ARE INSTITUTIONAL CHARGES AND NOT BILLED SEPARATELY BY PHYSICIANS. HOWEVER, PORTABLE X-RAY SUPPLIERS ONLY BILL FOR TECHNICAL COMPONENT AND SHOULD UTILIZ E MODIFIER TC. THE CHARGE DATA FROM PORTABLE X-RAY SUPPLIERS WILL THEN BE USED TO BUILD CUSTOMARY AND PREVAILING PROFILES. RN LPN/LVN INTERMEDIATE LEVEL OF CARE COMPLEX/HIGH TECH LEVEL OF CARE OBSTETRICAL TREATMENT/SERVICES, PRENATAL OR POSTPARTUM PROGRAM GROUP, CHILD AND/OR ADOLESCENT EXTRA PATIENT OR PASSENGER, NON-AMBULANCE EARLY INTERVENTION/INDIVIDUALIZ ED FAMILY SERVICE PLAN (IFSP) INDIVIDUALIZ ED EDUCATION PROGRAM (IEP) RURAL/OUTSIDE PROVIDERS' CUSTOMARY SERVICE AREA MEDICAL TRANSPORT, UNLOADED VEHICLE BASIC LIFE SUPPORT TRANSPORT BY A VOLUNTEER AMBULANCE PROVIDER SCHOOL-BASED INDIVIDUALIZ ED EDUCATION PROGRAM (IEP) SERVICES PROVIDED OUTSIDE THE PUBLIC SCHOOL DISTRICT RESPONSIBLE FOR THE STUDENT FOLLOW-UP SERVICE INDIVIDUALIZ ED SERVICE PROVIDED TO MORE THAN ONE PATIENT IN SAME SETTING SPECIAL PAYMENT RATE, OVERTIME SPECIAL PAYMENT RATES, HOLIDAYS/WEEKENDS BACK-UP EQUIPMENT MEDICAID LEVEL OF CARE 1, AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 2, AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 3, AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 4 , AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 5, AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 6 , AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 7, AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 8, AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 9 , AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 10, AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 11, AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 12, AS DEFINED BY EACH STATE MEDICAID LEVEL OF CARE 13, AS DEFINED BY EACH STATE USED DURABLE MEDICAL EQUIPMENT SERVICES PROVIDED IN THE MORNING SERVICES PROVIDED IN THE AFTERNOON SERVICES PROVIDED IN THE EVENING SERVICES PROVIDED AT NIGHT SERVICES PROVIDED ON BEHALF OF THE CLIENT TO SOMEONE OTHER THAN THE CLIENT (COLLATERAL RELATIONSHIP) TWO PATIENTS SERVED THREE PATIENTS SERVED FOUR PATIENTS SERVED FIVE PATIENTS SERVED SIX OR MORE PATIENTS SERVED APHAKIC PATIENT AMBULANCE SERVICE, OUTSIDE STATE PER MILE, TRANSPORT (MEDICAID ONLY) NON-EMERGENCY TRANSPORTATION, PER MILE - VEHICLE PROVIDED BY VOLUNTEER (INDIVIDUAL OR ORGANIZ ATION), WITH NO VESTED INTEREST NON-EMERGENCY TRANSPORTATION, PER MILE - VEHICLE PROVIDED BY INDIVIDUAL (FAMILY MEMBER, SELF, NEIGHBOR) WITH VESTED INTEREST NON-EMERGENCY TRANSPORTATION; TAXI NON-EMERGENCY TRANSPORTATION AND BUS, INTRA OR INTER STATE CARRIER NON-EMERGENCY TRANSPORTATION: MINI-BUS, MOUNTAIN AREA TRANSPORTS, OR OTHER TRANSPORTATION SYSTEMS NON-EMERGENCY TRANSPORTATION: WHEEL-CHAIR VAN NON-EMERGENCY TRANSPORTATION AND AIR TRAVEL (PRIVATE OR COMMERCIAL) INTRA OR INTER STATE NON-EMERGENCY TRANSPORTATION: PER MILE - CASE WORKER OR SOCIAL WORKER TRANSPORTATION ANCILLARY: PARKING FEES, TOLLS, OTHER NON-EMERGENCY TRANSPORTATION: ANCILLARY: LODGING-RECIPIENT NON-EMERGENCY TRANSPORTATION: ANCILLARY: MEALS-RECIPIENT NON-EMERGENCY TRANSPORTATION: ANCILLARY: LODGING ESCORT NON-EMERGENCY TRANSPORTATION: ANCILLARY: MEALS-ESCORT AMBULANCE SERVICE, NEONATAL TRANSPORT, BASE RATE, EMERGENCY TRANSPORT, ONE WAY BLS MILEAGE (PER MILE) BLS ROUTINE DISPOSABLE SUPPLIES BLS SPECIALIZ ED SERVICE DISPOSABLE SUPPLIES; DEFIBRILLATION (USED BY ALS AMBULANCES AND BLS AMBULANCES IN JURISDICTIONS WHERE DEFIBRILLATION IS PERMITTED IN BLS AMBULANCES) ALS MILEAGE (PER MILE) ALS SPECIALIZ ED SERVICE DISPOSABLE SUPPLIES; DEFIBRILLATION (TO BE USED ONLY IN JURISDICTIONS WHERE DEFIBRILLATION CANNOT BE PERFORMED IN BLS AMBULANCES) ALS SPECIALIZ ED SERVICE DISPOSABLE SUPPLIES; IV DRUG THERAPY ALS SPECIALIZ ED SERVICE DISPOSABLE SUPPLIES; ESOPHAGEAL INTUBATION ALS ROUTINE DISPOSABLE SUPPLIES AMBULANCE WAITING TIME (ALS OR BLS), ONE HALF (1/2) HOUR INCREMENTS AMBULANCE (ALS OR BLS) OXYGEN AND OXYGEN SUPPLIES, LIFE SUSTAINING SITUATION EXTRA AMBULANCE ATTENDANT, GROUND (ALS OR BLS) OR AIR (FIXED OR ROTARY WINGED); (REQUIRES MEDICAL REVIEW) GROUND MILEAGE, PER STATUTE MILE AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY TRANSPORT, LEVEL 1 (ALS 1) AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS1-EMERGENCY) AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, (BLS) AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY) AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (FIXED WING) AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (ROTARY WING) PARAMEDIC INTERCEPT (PI), RURAL AREA, TRANSPORT FURNISHED BY A VOLUNTEER AMBULANCE COMPANY WHICH IS PROHIBITED BY STATE LAW FROM BILLING THIRD PARTY PAYERS ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2) SPECIALTY CARE TRANSPORT (SCT) FIXED WING AIR MILEAGE, PER STATUTE MILE ROTARY WING AIR MILEAGE, PER STATUTE MILE AMBULANCE TRANSPORT PROVIDED BETWEEN THE HOURS OF 7PM AND 7AM NONCOVERED AMBULANCE MILEAGE, PER MILE (E.G., FOR MILES TRAVELED BEYOND CLOSEST APPROPRIATE FACILITY) AMBULANCE RESPONSE AND TREATMENT, NO TRANSPORT UNLISTED AMBULANCE SERVICE SYRINGE WITH NEEDLE, STERILE 1CC, EACH SYRINGE WITH NEEDLE, STERILE 2CC, EACH SYRINGE WITH NEEDLE, STERILE 3CC, EACH SYRINGE WITH NEEDLE, STERILE 5CC OR GREATER, EACH NEEDLE-FREE INJECTION DEVICE, EACH SUPPLIES FOR SELF-ADMINISTERED INJECTIONS NON-CORING NEEDLE OR STYLET WITH OR WITHOUT CATHETER SYRINGE, STERILE, 20 CC OR GREATER, EACH STERILE SALINE OR WATER, 30 CC VIAL NEEDLE, STERILE, ANY SIZ E, EACH STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML STERILE WATER/SALINE, 500 ML STERILE SALINE OR WATER, METERED DOSE DISPENSER, 10 ML REFILL KIT FOR IMPLANTABLE INFUSION PUMP SUPPLIES FOR MAINTENANCE OF DRUG INFUSION CATHETER, PER WEEK (LIST DRUG SEPARATELY) INFUSION SUPPLIES FOR EXTERNAL DRUG INFUSION PUMP, PER CASSETTE OR BAG (LIST DRUGS SEPARATELY) INFUSION SUPPLIES NOT USED WITH EXTERNAL INFUSION PUMP, PER CASSETTE OR BAG (LIST DRUGS SEPARATELY) INFUSION SET FOR EXTERNAL INSULIN PUMP, NON NEEDLE CANNULA TYPE INFUSION SET FOR EXTERNAL INSULIN PUMP, NEEDLE TYPE SYRINGE WITH NEEDLE FOR EXTERNAL INSULIN PUMP, STERILE, 3CC REPLACEMENT BATTERY, ALKALINE (OTHER THAN J CELL), FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH REPLACEMENT BATTERY, ALKALINE, J CELL, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH REPLACEMENT BATTERY, LITHIUM, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH REPLACEMENT BATTERY, SILVER OXIDE, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH ALCOHOL OR PEROXIDE, PER PINT ALCOHOL WIPES, PER BOX BETADINE OR PHISOHEX SOLUTION, PER PINT BETADINE OR IODINE SWABS/WIPES, PER BOX CHLORHEXIDINE CONTAINING ANTISEPTIC, 1 ML URINE TEST OR REAGENT STRIPS OR TABLETS (100 TABLETS OR STRIPS) BLOOD GLUCOSE TEST OR REAGENT STRIPS FOR HOME BLOOD GLUCOSE MONITOR, PER 50 STRIPS REPLACEMENT BATTERY, ANY TYPE, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH PLATFORMS FOR HOME BLOOD GLUCOSE MONITOR, 50 PER BOX NORMAL, LOW AND HIGH CALIBRATOR SOLUTION / CHIPS REPLACEMENT LENS SHIELD CARTRIDGE FOR USE WITH LASER SKIN PIERCING DEVICE, EACH SPRING-POWERED DEVICE FOR LANCET, EACH LANCETS, PER BOX OF 100 LEVONORGESTREL (CONTRACEPTIVE) IMPLANTS SYSTEM, INCLUDING IMPLANTS AND SUPPLIES CERVICAL CAP FOR CONTRACEPTIVE USE TEMPORARY, ABSORBABLE LACRIMAL DUCT IMPLANT, EACH PERMANENT, LONG TERM, NON-DISSOLVABLE LACRIMAL DUCT IMPLANT, EACH PARAFFIN, PER POUND DIAPHRAGM FOR CONTRACEPTIVE USE CONTRACEPTIVE SUPPLY, CONDOM, MALE, EACH CONTRACEPTIVE SUPPLY, CONDOM, FEMALE, EACH CONTRACEPTIVE SUPPLY, SPERMICIDE (E.G., FOAM, GEL), EACH DISPOSABLE ENDOSCOPE SHEATH, EACH ADHESIVE SKIN SUPPORT ATTACHMENT FOR USE WITH EXTERNAL BREAST PROSTHESIS, EACH TUBING FOR BREAST PUMP, REPLACEMENT ADAPTER FOR BREAST PUMP, REPLACEMENT CAP FOR BREAST PUMP BOTTLE, REPLACEMENT BREAST SHIELD AND SPLASH PROTECTOR FOR USE WITH BREAST PUMP, REPLACEMENT POLYCARBONATE BOTTLE FOR USE WITH BREAST PUMP, REPLACEMENT LOCKING RING FOR BREAST PUMP, REPLACEMENT SACRAL NERVE STIMULATION TEST LEAD, EACH IMPLANTABLE ACCESS CATHETER, (E,G., VENOUS, ARTERIAL, EPIDURAL SUBARACHNOID, OR PERITONEAL, ETC.) EXTERNAL ACCESS IMPLANTABLE ACCESS TOTAL CATHETER, PORT/RESERVOIR (E.G., VENOUS, ARTERIAL, EPIDURAL, SUBARACHNOID, PERITONEAL, ETC.) DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF 50 ML OR GREATER PER HOUR DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR INSERTION TRAY WITHOUT DRAINAGE BAG AND WITHOUT CATHETER (ACCESSORIES ONLY) INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.) INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.) INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION STERILE WATER IRRIGATION SOLUTION, 1000 ML IRRIGATION TRAY WITH BULB OR PISTON SYRINGE, ANY PURPOSE THERAPEUTIC AGENT FOR URINARY CATHETER IRRIGATION IRRIGATION SYRINGE, BULB OR PISTON, EACH STERILE SALINE IRRIGATION SOLUTION, 1000 ML. MALE EXTERNAL CATHETER, WITH ADHESIVE COATING, EACH MALE EXTERNAL CATHETER, WITH ADHESIVE STRIP, EACH MALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION CHAMBER, ANY TYPE, EACH FEMALE EXTERNAL URINARY COLLECTION DEVICE; MEATAL CUP, EACH FEMALE EXTERNAL URINARY COLLECTION DEVICE; POUCH, EACH PERIANAL FECAL COLLECTION POUCH WITH ADHESIVE, EACH EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH LUBRICANT, INDIVIDUAL STERILE PACKET, EACH URINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT, EACH URINARY CATHETER ANCHORING DEVICE, LEG STRAP, EACH INCONTINENCE SUPPLY; MISCELLANEOUS INDWELLING CATHETER; FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH INDWELLING CATHETER; SPECIALTY TYPE, EG; COUDE, MUSHROOM, WING, ETC.), EACH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE, EACH INDWELLING CATHETER; FOLEY TYPE, THREE WAY FOR CONTINUOUS IRRIGATION, EACH MALE EXTERNAL CATHETER WITH OR WITHOUT ADHESIVE, WITH OR WITHOUT ANTI-REFLUX DEVICE; PER DOZ EN MALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION COMPARTMENT, EXTENDED WEAR, EACH (E.G., 2 PER MONTH) MALE EXTERNAL CATHETER, WITH OR WITHOUT ADHESIVE, DISPOSABLE, EACH Dressing for one wound Dressing for two wounds Dressing for three wounds Dressing for four wounds Dressing for five wounds Dressing for six wounds Dressing for seven wounds Dressing for eight wounds Dressing for 9 or more wound Anesthesia perf by a nesgst MD supervision, >4 a nes proc P age 1 PI1 PI2 PI3 PI4 MPI CIM1 CIM2 CIM3 MCM1 MCM2 MCM3 S ta tu te L a b C ert1 L a b C ert2 L a b C ert3 L a b C ert4 L a b C ert5 L a b C ert6 L a b C ert7 L a b C ert8 X-R ef1 2150 2152 5112 5113 4 105.7 QM Physicia n service HPSA a rea X-R ef2 X-R ef3 X-R ef4 X-R ef5 C o d e Ad d D a te Ac ti o n Eff D a te C C C C C C C C C D D 3350.5 3350.5 Registered dieticia n Specia lty physicia n Prima ry physicia n Clinica l psychologist Clinica l socia l worker Non pa rticipa ting physicia n Physicia n, tea m member svc No dtmn of refra ctive sta te C o vera g e 0 0 0 0 0 0 0 0 0 0 0 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 19 84 0101 19 84 0101 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20010101 20010101 N N N N N N N N N N N C C C D D C D C AS C P a y Grp AS C P a y Grp Eff D a te M O G P a y Grp M O G P a y I nd M O G Eff D a te P ro c N o te B ET O S F I L L ER TO S 1 TO S 2 TO S 3 0 0 0 0 0 0 0 0 20050101 20050101 20050101 19 9 10101 19 9 10101 20050101 19 9 10101 19 84 0101 20050101 20050101 20050101 19 9 70101 19 9 70101 20050101 19 9 70101 19 9 70101 N N N N N N N N 0 2006 0101 2006 0101 N 006 9 C Physicia n sca rcity a rea Assista nt a t surgery service C C Acute trea tment C C C C C C C C TO S 5 An es t B a s e U n i ts 0 0 006 9 C Uro, ostomy or tra ch item Item w prosthetic/orthotic Item w a surgica l dressing Item w dia lysis services Item w pen services Spec a cquisition blood prods Nutrition ora l a dmin no tube Bene electd to purcha se item TO S 4 20050101 19 880101 T erm D a te 20050101 19 9 9 0101 Ac ti o n C o d e N N 0 19 84 0101 19 9 80101 N 0 0 0 0 0 0 0 0 0000 20030101 20030101 20030101 20030101 20030101 20050701 20030101 19 9 20101 20030101 20030101 20030101 20030101 20030101 20050701 20030101 19 9 70101 N N N N N N N N Bene elected to rent item C 0 19 9 20101 19 9 70101 N Bene undecided on purch/rent C 0 19 9 20101 19 9 70101 N Procedure pa ya ble inpa tient C 0 20030101 20030101 N ESRD bene pa rt a snf-sep pa y C 0 200304 01 2004 0101 N Procedure code cha nge C 0 19 9 00101 19 9 70101 N AMCC test for ESRD or MCP MD 4 270.2 D 0 2004 0101 2004 0101 N Med neces AMCC tst sep reimb 4 270.2 D 0 2004 0101 2004 0101 N AMCC tst not composite ra te 4 270.2 D 0 2004 0101 2004 0101 N 4 273.2 C C C C C D 0 0 0 0 0 0 20050821 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 10101 20050821 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 20000101 N N N N N N Ca ta strophe/disa ster rela ted Upper left eyelid Lower left eyelid Upper right eyelid Lower right eyelid Subsequent cla im D C 0 0 19 9 10101 19 870101 19 9 70101 19 9 70101 N N Emergency Services No md order for item/service Emer reserve supply (ESRD) Medica id EPSDT progra m svc 304 5.7 C C 0 0 19 84 0101 20030101 20020101 20030101 N N Left ha nd, second digit Left ha nd, third digit Left ha nd, fourth digit Left ha nd, fifth digit Right ha nd, thumb Right ha nd, second digit Right ha nd, third digit Right ha nd, fourth digit Right ha nd, fifth digit Left ha nd, thumb Item provided without cost C C C C C C C C C C I 0 0 0 0 0 0 0 0 0 0 0 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 2006 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 20070101 N N N N N N N N N N C Svc pa rt of fa mily pla n pgm URR rea ding of less tha n 6 0 URR rea ding of 6 0 to 6 4 .9 URR rea ding of 6 5 to 6 9 .9 URR rea ding of 70 to 74 .9 URR rea ding of 75 or grea ter ESRD pa tient <6 dia lysis/mth C C C C C C C 0 0 0 0 0 0 0 19 870101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 80501 20050101 19 9 80101 19 9 80101 19 9 80101 19 9 70101 19 9 80101 19 9 80501 N N N N N N N 0 19 9 9 0701 19 9 9 0701 N Pa yment limits do not a pply 35-9 9 2005.1 D C Monitored a nesthesia ca re MAC for a t risk pa tient 0084 0083 0 C C 3350.5 4 116 4 116 19 9 9 0701 19 9 9 0701 N 0 C Wa iver of Lia bility on file Cla im resubmitted Resident/tea ching phys serv Resident prim ca re exception 19 9 9 0701 19 9 9 0701 N 0 0 19 9 50101 20020101 19 9 70101 20020101 N N D 0 19 9 70101 20010101 N D 0 19 9 70101 19 9 70101 N Nonphysicia n serv c a hosp C 0 200304 01 200304 01 N Pa yment screen ma m + dia gma m C 0 20020101 20020101 N Dia g ma mmo to screening ma mo Opt out provider of er srvc Actua l item/service ordered Upgra ded item, no cha rge C C C C 0 0 0 0 19 9 81001 19 9 81001 20020101 20020101 19 9 81001 19 9 81001 20020101 20020101 N N N N Multiple tra nsports OP speech la ngua ge service OP occupa tiona l thera py serv OP PT services Telehea lth store a nd forwa rd Service by va resident C C C C C C 0 0 0 0 0 0 20020101 19 9 9 0101 19 9 9 0101 19 9 9 0101 20011001 2006 0101 20020101 20030101 20030101 20030101 20011001 2006 0101 N N N N N N Epo/da rbepoietin reduced 25% 4 273.1 D 4 175-5 Intera ctiveTelecommunica tion Attending phys not hospice D D 0 2006 0101 2006 1001 C 0 0 0073 19 9 9 0101 20020101 19 9 9 0101 20020101 N N Service unrela ted to term co Sta tutorily excluded 4 175-5 D S 0 0 20020101 20020101 20020101 20020101 N N Not rea sona ble a nd necessa ry Court-ordered Child/a dolescent progra m Adult progra m non-geria tric Adult progra m geria tric Pregna nt/pa renting progra m Menta l hea lth progra m Substa nce a buse progra m Opioid a ddiction tx progra m Menta l hlth/substa nce a bs pr M hlth/m retrdtn/dev dis pro 2000 M I I I I I I I I I I 0 0 0 0 0 0 0 0 0 0 0 20020101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20020101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 N N N N N N N N N N N Employee a ssista nce progra m Spec hgh rsk mntl hlth pop p intern Less tha n ba chelor degree lv Ba chelors degree level Ma sters degree level Doctora l level Group setting Fa mily/couple w client prsnt Fa mily/couple w/o client prs Multi-disciplina ry tea m Child welfa re a gency funded Funded sta te a ddiction a gncy Sta te mntl hlth a gncy funded County/loca l a gency funded Funded by juvenile justice Crimina l justice a gncy fund CAP no-pa y for prescript num CAP restock of emerg drugs I I I I I I I I I I I I I I I I I C C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 2006 0101 2006 0101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 2006 0101 2006 0101 N N N N N N N N N N N N N N N N N N N CAP drug una va il thru ca p C 0 2006 0101 2006 0101 N Administered intra venously Administered subcuta neously Disca rded drug not a dministe Lwr ext prost functnl lvl 0 C C C C 0 0 0 0 20070101 20070101 20030101 19 9 30101 20070101 20070101 20030101 20030101 A A N N Lwr ext prost functnl lvl 1 C 0 19 9 30101 19 9 70101 N Lwr ext prost functnl lvl 2 C 0 19 9 30101 19 9 70101 N Lwr ext prost functnl lvl 3 C 0 19 9 30101 19 9 70101 N Lwr ext prost functnl lvl 4 C 0 19 9 30101 19 9 70101 N Wheelcha ir a dd-on option/a cc >4 modifiers on cla im Repl specia l pwr wc intrfa ce Drug/biologica l DME infused FDA cla ss III device DMEPOS ini clm, pur/1 mo rnt DMEPOS 2nd or 3rd mo renta l DMEPOS PEN pmp or 4 -15mo rnt C C C C C C C C 0 0 0 0 0 0 0 0 19 9 4 0101 20030101 20050101 2004 0101 2004 04 01 19 9 4 0101 19 9 4 0101 19 9 4 0101 19 9 70101 20030101 20050101 2004 0101 2004 04 01 19 9 70101 19 9 70101 19 9 70101 N N N N N N N N Rplc fa cia l prosth new imp Rplc fa cia l prosth old mod Single drug unit dose form First drug of multi drug u d 2nd/subsqnt drg multi drg ud Renta l item pa rtia l month Glucose monitor supply Documenta tion on file New cov not implement by m+c Lft circum corona ry a rtery Left a nt des corona ry a rtery Lea se/renta l (a ppld to pur) C C C C C C D C C C C C 0 0 0 0 0 0 0 0 0 0 0 0 19 9 6 0101 19 9 6 0101 19 9 704 01 19 9 704 01 19 9 704 01 20020101 19 9 81001 20020701 20031001 19 9 70101 19 9 70101 19 84 0101 20010101 20010101 19 9 704 01 19 9 704 01 19 9 704 01 20020101 19 9 81001 20020701 20031001 19 9 70101 19 9 70101 19 9 70101 N N N N N N N N N N N N 0 0 0 0 0 19 870101 19 9 10101 19 84 0101 20070101 19 89 0101 19 9 70101 19 9 70101 19 9 70101 20070101 19 9 70101 N N N A N La bora tory round trip FDA-monitored IOL impla nt Left side Medica re seconda ry pa yer 6 -mo ma int/svc fee pa rts/lbr 0074 C D C C C 6 5-7 New when rented C New equipment Norma l hea lthy pa tient Pa tient w/mild syst disea se Pa tient w/severe sys disea se Pt w/sev sys dis threa t life Pt not expect surv w/o oper Bra in-dea d pt orga ns removed Progressive a ddition lenses HCFA/ORD demo procedure/svc Liver donor surgery/services Svc exempt - ordrg/rfrng MD Subst MD svc, recip bill a rr C C C C C C C C C C C D 306 0.6 Locum tenens MD service One Cla ss A finding Two Cla ss B findings 1 Cla ss B & 2 Cla ss C fndngs FDA investiga tiona l device MD prvdg svc in rura l HPSA Single cha nnel monitoring Rcrdg/strg in sld st memory Prescribed oxygen < 1 LPM Prscrbd oxygen >4 LPM & port 306 0.7 D C C C C D C C C C 3350.3 Prescribed oxygen > 4 LPM Oxygen cnsrvg dvc w del sys Pa tient in sta te/locl custod C C D Med dir 2-4 cncrnt a nes proc 3350.5 SOI submitted Item/serv in medica re study Monitored a nesthesia ca re Rcrdg/strg ta pe a na log recdr MD providing svc urba n HPSA Item or service provided CLIA wa ived test CRNA svc w/ MD med direction Medica lly directed CRNA C D D C D D C C D 3350.3 30-1 3350.5 19 9 70101 19 9 70101 20030101 19 9 50101 20010101 19 9 9 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 6 0301 0 0 0 0 0 0 0 0 0 0122 006 9 19 89 0101 19 89 0101 20030101 0 0 0 0 C C C D 15018I 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 6 1001 2006 0101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 0 0111 19 9 70101 19 9 70101 2006 0101 2006 0101 2006 0101 2006 0101 2006 0101 2006 0101 19 9 70101 19 9 70101 20030101 19 9 70101 19 9 70101 19 9 30101 19 9 50101 19 9 50101 19 9 50101 19 9 6 0101 19 9 20101 19 89 0101 19 89 0101 19 89 0101 19 89 0101 0 0 0 006 9 19 84 0101 19 84 0101 2006 0101 2006 0101 2006 0101 2006 0101 2006 0101 2006 0101 19 89 0101 19 9 20101 19 9 50101 19 9 4 0101 19 9 30101 0 0 0 0 0 0 0 0 0 0 D 7517.1 Pa tient died a fter a mb ca ll Ambula nce a rr by provider Ambula nce furn by provider Individua lly ordered la b tst 0 0 0 0 0 0 0 0 0 0 0 0 0 004 6 20001001 20050101 19 9 00101 19 89 0101 19 9 10101 200009 19 19 9 6 0101 19 9 30101 19 9 80101 2006 0101 20050101 19 9 6 0701 19 9 70101 2006 0101 200009 19 19 9 6 1001 19 9 70101 20010101 N N N N N N N N N N N N N 20051231 N N N N N N N N N N N N N N N N N N 20051231 20051231 N N N N N N N N N CRNA svc w/o med dir by MD Right corona ry a rtery Drug a dmin not incident-to Repla cement & repa ir(DMEPOS) C C C C 0 0 0 0 19 9 30101 19 9 70101 2004 0101 19 84 0101 19 9 70101 19 9 70101 2004 0101 19 9 70101 N N N N Renta l (DME) Right side Nurse pra ctitioner w physici Nurse midwife Medica lly necessa ry serv/sup Serv by home infusion RN C C I I I I 0 0 0 0 0 0 19 84 0101 19 84 0101 20010701 20010701 20010701 20010701 19 9 70101 19 9 70101 20010701 20010701 20010701 20010701 N N N N N N Sta te/fed funded progra m/ser 2nd opinion ordered by PRO I C 0 0 20010701 19 870101 20010701 19 9 70101 N N ASC fa cility service 2nd concurrent infusion ther 3rd concurrent infusion ther High risk popula tion Sta te supplied va ccine Second opinion Third opinion Item ordered by home hea lth HIT in infusion suite Rela ted to tra uma or injury Performed in phys office C I I I I I I I I I I 0 0 0 0 0 0 0 0 0 0 0 19 9 20101 20010701 20010701 200204 01 200204 01 20020701 20020701 20021001 2004 1001 20030101 20030101 19 9 70101 20010701 20010701 200204 01 200204 01 20020701 20020701 20021001 2004 1001 20030101 20030101 N N N N N N N N N N N Drugs delivered not used Serv by cert dia b educa tor Conta ct w/high-risk pop I C I 0 0 0 20030101 2004 04 01 20050101 20030101 2004 04 01 20050101 N N N Left foot, second digit Left foot, third digit Left foot, fourth digit Left foot, fifth digit Right foot, grea t toe Right foot, second digit Right foot, third digit Right foot, fourth digit Right foot, fifth digit Left foot, grea t toe Technica l component C C C C C C C C C C C 0 0 0 0 0 0 0 0 0 0 0 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 84 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 9 0101 19 9 70101 N N N N N N N N N N N RN LPN/LVN Intermedia te level of ca re Complex/High Tech level ca re OB TX/Srvcs prena tl/postpa rt Child/a dolescent progra m gp Extra pa tient or pa ssenger Ea rly intervention IFSP Individua liz ed ed prgrm(IEP) Rura l/out of service a rea Med tra nsprt unloa ded vehicl BLS by volunteer a mb providr School-ba sed IEP out of dist I I I I I I I I I I I I I 0 0 0 0 0 0 0 0 0 0 0 0 0 20010701 20010701 20010701 20010701 20010701 20010701 200204 01 200204 01 200204 01 200204 01 200204 01 200204 01 20020701 20010701 20010701 20010701 20010701 20010701 20010701 200204 01 200204 01 200204 01 200204 01 200204 01 200204 01 20020701 N N N N N N N N N N N N N Follow-up service Additiona l pa tient Overtime pa yment ra te Holida y/weekend pa yment ra te Ba ck-up equipment M/ca id ca re lev 1 sta te def M/ca id ca re lev 2 sta te def M/ca id ca re lev 3 sta te def M/ca id ca re lev 4 sta te def M/ca id ca re lev 5 sta te def M/ca id ca re lev 6 sta te def M/ca id ca re lev 7 sta te def M/ca id ca re lev 8 sta te def M/ca id ca re lev 9 sta te def M/ca id ca re lev 10 sta te def M/ca id ca re lev 11 sta te def M/ca id ca re lev 12 sta te def M/ca id ca re lev 13 sta te def Used dura ble med equipment Services provided, morning Services provided, a fternoon Services provided, evening Services provided, night Svc on beha lf client-colla t C I I I I I I I I I I I I I I I I I C I I I I I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20021001 20021001 20030101 20030101 20030101 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 19 84 0101 200304 01 200304 01 200304 01 200304 01 200304 01 2006 0101 20021001 20030101 20030101 20030101 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 19 9 70101 200304 01 200304 01 200304 01 200304 01 200304 01 N N N N N N N N N N N N N N N N N N N N N N N N Two pa tients served Three pa tients served Four pa tients served Five pa tients served Six or more pa tients served Apha kic pa tient Outside sta te a mbula nce serv Noninterest escort in non er 00 00 9 9 Interest escort in non er 00 9 A0030 C C C C C C I I 0114 0114 0114 0114 0114 O1A O1A D D 0 0 0 0 0 0 0 0 2004 0101 2004 0101 2004 0101 2004 0101 2004 0101 19 84 0101 19 850101 19 820101 2004 0101 2004 0101 2004 0101 2004 0101 2004 0101 19 9 70101 19 9 6 09 10 20030101 N N N N N N N N O1A I D 0 19 820101 20030101 N Nonemergency tra nsport ta xi Nonemergency tra nsport bus Noner tra nsport mini-bus 00 00 00 9 9 9 I I I O1A O1A O1A D D D 0 0 0 19 820101 19 84 0101 19 820101 20030101 19 9 50101 20030101 N N N Noner tra nsport wheelch va n Nonemergency tra nsport a ir 00 00 9 9 I I O1A O1A D D 0 0 19 820101 19 850101 19 9 50101 19 9 6 09 10 N N Noner tra nsport ca se worker Tra nsport pa rking fees/tolls Noner tra nsport lodgng recip Noner tra nsport mea ls recip Noner tra nsport lodgng escrt Noner tra nsport mea ls escort Neona ta l emergency tra nsport Ba sic life support milea ge Ba sic support routine suppls Bls defibrilla tion supplies 00 00 00 00 00 00 00 00 52 52 9 9 9 9 9 9 9 9 A A I I I I I I I I C C O1A O1A O1A O1A O1A O1A O1A O1A O1A O1A D D D D D D D D D D 0 0 0 0 0 0 0 0 0 0 19 84 0101 19 820101 19 820101 19 84 0101 19 820101 19 84 0101 19 850101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 20030101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 200304 01 20030101 19 9 50101 19 9 50101 N N N N N N N N N N Adva nced life support milea g Als defibrilla tion supplies 00 52 9 A I C O1A O1A D D 0 0 19 9 50101 19 9 50101 20030101 19 9 50101 N N Als IV drug thera py supplies Als esopha gea l intub suppls Als routine disposble suppls Ambula nce wa iting 1/2 hr Ambula nce 02 life susta ining Extra a mbula nce a ttenda nt 52 52 52 52 52 52 A A A A A A C C C C C C O1A O1A O1A O1A O1A O1A D D D D D D 0 0 0 0 0 0 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 20030101 N N N N N N A04 25 A04 25 Ground milea ge Als 1 52 52 A A C C O1A O1A D D 0 0 20010101 20010101 20010101 20010101 ALS1-emergency 52 A C O1A D 0 20010101 20010101 bls BLS-emergency Fixed wing a ir tra nsport Rota ry wing a ir tra nsport PI volunteer a mbula nce co 52 52 52 52 52 A A A A A C C C C C O1A O1A O1A O1A O1A D D D D D 0 0 0 0 0 20010101 20010101 20010101 20010101 20010101 20010101 20010101 20010101 20010101 20010101 a ls 2 Specia lty ca re tra nsport Fixed wing a ir milea ge Rota ry wing a ir milea ge Amb tra ns 7pm-7a m Noncovered a mbula nce milea ge 52 52 52 52 00 00 A A A A 9 9 C C C C I M O1A O1A O1A O1A O1A O1A D D D D D D 0 0 0 0 0 0 20010101 20010101 20010101 20010101 2004 0101 19 9 50101 20010101 20010101 20010101 20010101 20070101 19 9 50101 Ambula nce response/trea tment Unlisted a mbula nce service 1 CC sterile syringe&needle 2 CC sterile syringe&needle 3 CC sterile syringe&needle 5+ CC sterile syringe&needle Nonneedle injection device Supp for self-a dm injections Non coring needle or stylet 20+ CC syringe only 30 CC sterile wa ter/sa line Sterile needle Sterile wa ter/sa line, 10 ml Sterile wa ter/sa line, 500 ml Sterile sa line or wa ter Infusion pump refill kit Ma int drug infus ca th per wk 00 57 00 00 00 00 00 00 57 00 37 00 37 37 51 57 34 9 A 9 9 9 9 9 9 A 9 A 9 A A A A A I D C C C C M D C C C C D D D D C O1A O1A D1A D1A D1A D1A D1A D1A D1A D1A D1F D1A D1F D1F O1E D1A D1E D D S S S S S S S S P L 1 1 1 P P 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2006 0101 19 870101 19 850101 19 850101 19 850101 19 850101 19 89 0101 19 9 30101 19 9 30101 19 850101 19 84 0101 19 850101 2004 0101 2004 0101 2006 0101 19 9 4 0101 19 9 70101 2006 0101 19 9 80101 20070101 20070101 20070101 20070101 19 9 6 0101 19 9 70101 20000101 20070101 2004 0101 20070101 20070101 2004 0101 2006 0101 19 9 80303 19 9 70101 Infusion supplies with pump 34 2125 2120.1 2125 6 0-9 204 9 204 9 204 9 6 0-14 A Infusion supplies w/o pump 00 34 34 00 36 A A 9 A J-cell ba tt for glucose mon 36 C 9 Infus insulin pump non needl Infusion insulin pump needle Syringe w/needle insulin 3cc Alka lin ba tt for glucose mon A Lithium ba tt for glucose mon 36 36 9 9 9 9 A 9 A 0 P P P P P D1E P C D1E 19 9 70101 N N N N N 20031231 20050101 N 20050101 20070101 F 19 9 6 0101 19 9 6 0101 19 9 6 0101 2006 0101 20000101 20000101 200304 01 2006 0101 N N N N 0 2006 0101 2006 0101 0 P L L L L L 9 P S S S S P 2006 0101 2006 0101 N 2006 0101 19 850101 19 850101 19 850101 19 850101 2004 0101 19 9 00101 19 86 0101 20070101 20070101 20070101 20070101 2004 0101 19 9 70101 19 9 80701 32 A 6 0-11 D D1E A 34 34 34 34 34 00 00 00 11 34 00 00 00 00 00 38 00 00 00 00 00 00 00 11 A A A A A 9 9 9 A A 9 9 9 9 9 A 9 9 9 9 9 9 9 A 6 0-11 6 0-11 2130 D D C D D S S D D D I I I I C C C C C C C C C D D1E D1E D1E D1E D1E P6 C Z2 D1A Y1 D1E Z2 Z2 Z2 Z2 P8D D1F Z2 Z2 Z2 Z2 Z2 Z2 Z2 Y1 P P P P P 9 9 9 9 9 9 9 9 9 9 P 9 9 9 9 9 9 9 S C D1A S 0 19 9 6 0101 C C D D D1A D1A D1F D1F 9 9 P P 0 0 0 0 19 9 30101 19 9 30101 19 9 00101 19 9 00101 9 9 9 A A 19 9 6 0101 2006 0101 19 9 70101 19 850101 20020101 19 9 6 0101 19 850101 19 9 30101 19 9 9 0101 19 9 4 0101 19 9 4 0101 19 86 0101 20030101 20030101 20030101 20030101 19 9 4 0101 20000101 20030101 20030101 20030101 20030101 20030101 20030101 20010101 19 86 0101 20020101 20020101 20020101 20020101 19 9 6 0101 2006 0101 19 9 9 0101 19 9 80101 19 9 80101 20020101 20030101 20030101 20030101 20030101 19 9 504 01 20000101 20070101 20070101 20070101 20070101 20070101 20070101 20020101 20020101 N 2006 0101 20070101 19 9 00101 19 9 00101 00 00 00 37 37 15030 6 0-9 0052 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 F F F F N N N 20030101 2130 2130 Impla nta ble a ccess syst perc Drug delivery system >=50 ML Drug delivery system <=50 ml Insert tra y w/o ba g/ca th Ca theter w/o ba g 2-wa y la tex J7306 R N 2006 0101 0 0 0 0 0 0 0 0 Ba ttery for glucose monitor 186 2a 1A 186 2a 1 Ca th w/o ba g 2-wa y silicone 37 A 2130 D D1F P 0 19 9 00101 37 A 2130 D D1F P 0 19 9 00101 20051231 20051231 N 19 9 00101 37 A 2130 D D1F P 0 19 9 00101 N N N N N N N N N N N N N N N N N F F F F F F N N N C N N 19 9 00101 Ca theter w/ba g 3-wa y Ca th w/dra ina ge 2-wa y la tex N N F F F F N N N F N F C N N N N 0 D1E D1A D1A D1A D1A P9 B T1E D1E Glucose monitor pla tforms Ca libra tor solution/chips Repla ce Lensshield Ca rtridge La ncet device ea ch La ncets per box Levonorgestrel impla nt Cervica l ca p contra ceptive Tempora ry tea r duct plug Perma nent tea r duct plug Pa ra ffin Dia phra gm Ma le condom Fema le condom Spermicide Disposa ble endoscope shea th Brst prsths a dhsv a ttchmnt Repla cement brea stpump tube Repla cement brea stpump a dpt Repla cement brea stpump ca p Replcmnt brea st pump shield Replcmnt brea st pump bottle Replcmnt brea stpump lok ring Sa cra l nerve stim test lea d Ca th impl va sc a ccess porta l 6 0-11 6 0-11 N N N N D N 0 0 0 0 P C C C C C C M D 2100 6 0-11 P P P P D1A D1E D1E D1E D1E C A 00 00 00 00 52 00 32 D1E C D D I C 6 0-14 6 0-14 6 0-14 A Silvr oxide ba tt glucose mon Alcohol or peroxide per pint Alcohol wipes per box Beta dine/phisohex solution Beta dine/iodine swa bs/wipes Chlorhexidine a ntisept Urine rea gent strips/ta blets Blood glucose/rea gent strips 0127 0050 S L L L N N N 2006 1231 N N 19 9 00101 N Ca th w/dra ina ge 2-wa y silcne 37 A 2130 D D1F P 0 19 9 00101 19 9 00101 Ca th w/dra ina ge 3-wa y 37 A 2130 D D1F P 0 19 9 00101 19 9 00101 Sterile H2O irriga tion solut Irriga tion tra y Ca th thera peutic irrig a gent Irriga tion syringe Sa line irriga tion solution Ma le ext ca th w/a dh coa ting Ma le ext ca th w/a dh strip Ma le externa l ca theter Fem urina ry collect dev cup Fem urina ry collect pouch Stool collection pouch Extension dra ina ge tubing 37 37 37 37 37 37 37 37 37 37 37 37 A A A A A A A A A A A A 2130 2130 2130 2130 2130 2130 2130 2130 2130 2130 2130 2130 D D D D D D D D D D D D D1F D1A D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F P P P P P P P P P P P P 0 0 0 0 0 0 0 0 0 0 0 0 20010101 19 9 00101 19 9 70101 19 9 00101 19 9 00101 20010101 20010101 19 9 00101 19 9 00101 19 9 00101 19 9 00101 20010101 2004 0101 19 9 20101 20030101 19 9 6 0101 2004 0101 20050101 20050101 20070101 19 9 00101 19 9 00101 19 9 6 0101 20030101 Lube sterile pa cket Urina ry ca th a nchor device Urina ry ca th leg stra p Incontinence supply Indwelling ca theter la tex 37 37 37 46 37 A A A A A 2130 2130 2130 2130 2130 D D D D D D1F D1F D1F D1F D1F P P P P P 0 0 0 0 0 20010101 20010101 20010101 19 9 00101 19 9 00101 20050101 20030101 20030101 19 9 00101 19 9 6 0101 Indwelling ca theter specia l Ca th indw foley 2 wa y silicn Ca th indw foley 3 wa y Ma le externa l ca theter 37 37 37 37 A A A A 2130 2130 2130 2130 D D D D D1F D1F D1F D1F P P P P 0 0 0 0 19 9 00101 19 830101 19 830101 19 830101 19 9 6 0101 19 9 6 0101 19 9 6 0101 20050101 2004 1231 N N N N Ma le ext ca th extended wea r 37 A 2130 D D1F P 0 20010101 20070101 2006 1231 D Disposa ble ma le exte A4 34 9 A4 34 9 N N 20031231 20031231 2004 1231 2004 1231 N N N N N N N C N N N N N N N N N PUF___2007_Web_File D7876 D7877 D7880 D789 9 D79 10 D79 11 D79 12 D79 20 D79 4 0 D79 4 1 D79 4 3 D79 4 4 D79 4 5 D79 4 6 D79 4 7 D79 4 8 D79 4 8 D79 4 9 D79 50 D79 50 D79 51 D79 53 D79 55 D79 6 0 D79 6 3 D79 70 D79 71 D79 72 D79 80 D79 81 D79 82 D79 83 D79 9 0 D79 9 1 D79 9 5 D79 9 6 D79 9 7 D79 9 7 D79 9 8 D79 9 9 D8010 D8020 D8030 D804 0 D8050 D806 0 D8070 D8080 D809 0 D8210 D8220 D86 6 0 D86 70 D86 80 D86 80 D86 9 0 D86 9 1 D86 9 2 D86 9 3 D89 9 9 D9 110 D9 120 D9 210 D9 211 D9 212 D9 215 D9 220 D9 221 D9 230 D9 24 1 D9 24 2 D9 24 8 D9 310 D9 310 D9 4 10 D9 4 20 D9 4 30 D9 4 30 D9 4 4 0 D9 4 50 D9 6 10 D9 6 12 D9 6 30 D9 9 10 D9 9 11 D9 9 20 D9 9 30 D9 9 4 0 D9 9 4 1 D9 9 4 2 D9 9 50 D9 9 51 D9 9 52 D9 9 70 D9 9 71 D9 9 72 D9 9 73 D9 9 74 D9 9 9 9 E0100 E0105 E0105 E0110 E0110 E0111 E0111 E0112 E0112 E0113 E0114 E0114 E0116 E0116 E0117 E0118 E0130 E0135 E014 0 E014 1 E014 2 E014 3 E014 4 E014 4 E014 5 E014 6 E014 7 E014 8 E014 9 E0153 E0154 E0155 E0156 E0157 E0158 E0159 E016 0 E016 1 E016 1 E016 2 E016 3 E016 4 E016 5 E016 6 E016 7 E016 8 E016 8 E016 9 E0170 E0171 E0172 E0175 E0176 E0177 E0178 E0179 E0180 E0181 E0181 E0182 E0184 E0185 E0186 E0187 E0188 E0189 E019 0 E019 0 E019 1 E019 2 E019 3 E019 4 E019 6 E019 7 E019 8 E019 9 E0200 E0202 E0203 E0205 E0210 E0215 E0217 E0218 E0220 E0221 E0225 E0230 E0231 E0231 E0232 E0232 E0235 E0236 E0238 E0239 E024 0 E024 1 E024 2 E024 3 E024 4 E024 5 E024 6 E024 7 E024 8 E024 9 E0250 E0251 E0255 E0256 E026 0 E026 0 E026 1 E026 1 E026 5 E026 5 E026 6 E026 6 E0270 E0270 E0271 E0272 E0273 E0274 E0275 E0276 E0277 E0280 E029 0 E029 1 E029 2 E029 3 E029 4 E029 4 E029 5 E029 5 E029 6 E029 6 E029 7 E029 7 E0300 E0301 E0301 E0301 E0302 E0302 E0303 E0303 E0303 E0304 E0304 E0305 E0310 E0315 E0316 E0325 E0326 E0350 E0352 E0352 E0352 E0370 E0371 E0371 E0372 E0373 E04 24 E04 24 E04 24 E04 25 E04 25 E04 30 E04 30 E04 31 E04 31 E04 34 E04 34 E04 34 E04 35 E04 35 E04 35 E04 39 E04 39 E04 4 0 E04 4 0 E04 4 0 E04 4 1 E04 4 1 E04 4 1 E04 4 2 E04 4 2 E04 4 2 E04 4 3 E04 4 3 E04 4 4 E04 4 4 E04 4 5 E04 50 E04 50 E04 54 E04 54 E04 55 E04 57 E04 59 E04 6 0 E04 6 1 E04 6 1 E04 6 2 E04 6 3 E04 6 3 E04 6 4 E04 6 4 E04 70 E04 70 E04 70 E04 71 E04 71 E04 71 E04 72 E04 72 E04 72 E04 80 E04 81 E04 82 E04 83 E04 83 E04 84 E04 85 E04 85 E04 86 E04 86 E0500 E0500 E0550 E0550 E0555 E0555 E056 0 E056 0 E056 1 E056 2 E056 5 E056 5 E0570 E0571 E0572 E0574 E0575 E0580 E0580 E0585 E059 0 E06 00 E06 01 E06 02 E06 03 E06 04 E06 04 E06 04 E06 05 E06 06 E06 07 E06 10 E06 10 E06 15 E06 15 E06 16 E06 17 E06 18 E06 19 E06 20 E06 21 E06 25 E06 27 E06 28 E06 29 E06 30 E06 35 E06 36 E06 36 E06 37 E06 37 E06 38 E06 38 E06 39 E06 39 E06 4 0 E06 4 1 E06 4 1 E06 4 2 E06 50 E06 51 E06 52 E06 55 E06 6 0 E06 6 5 E06 6 6 E06 6 7 E06 6 8 E06 6 9 E06 71 E06 72 E06 73 E06 75 E06 75 E06 76 E06 76 E06 9 1 E06 9 1 E06 9 2 E06 9 2 E06 9 3 E06 9 3 E06 9 4 E06 9 4 E0700 E0701 E0705 E0710 E0720 E0720 E0730 E0730 E0731 E0731 E074 0 E074 0 E074 4 E074 5 E074 6 E074 7 E074 7 E074 8 E074 9 E0752 E0754 E0754 E0755 E0756 E0757 E0758 E0758 E0759 E0759 E076 0 E076 1 E076 1 E076 2 E076 2 E076 4 E076 4 E076 4 E076 5 E076 5 E076 9 E076 9 E0776 E0779 E0780 E0781 E0781 E0782 E0782 E0783 E0783 E0784 E0785 E0785 E0786 E0786 E079 1 E0830 E084 0 E084 9 E084 9 E0850 E0855 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 100 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 200 100 200 100 200 100 100 200 100 200 100 100 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 200 100 200 100 200 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 200 100 200 100 200 100 100 200 300 100 200 100 200 300 100 200 100 100 100 100 100 100 100 100 200 300 100 100 200 100 100 100 200 300 100 200 100 200 100 200 100 200 300 100 200 300 100 200 100 200 300 100 200 300 100 200 300 100 200 100 200 100 100 200 100 200 100 100 100 100 100 200 100 100 200 100 200 100 200 300 100 200 300 100 200 300 100 100 100 100 200 100 100 200 100 200 100 200 100 200 100 200 100 200 100 100 100 200 100 100 100 100 100 100 200 100 100 100 100 100 100 100 200 300 100 100 100 100 200 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 200 100 200 100 200 100 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 200 100 200 100 200 100 200 100 200 100 100 100 100 100 200 100 200 100 200 100 200 100 100 100 100 200 100 100 100 100 200 100 100 100 100 200 100 200 100 100 200 100 200 100 200 300 100 200 100 200 100 100 100 100 200 100 200 100 200 100 100 200 100 200 100 100 100 100 200 100 100 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 4 3 4 3 3 4 3 4 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 4 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 4 3 4 3 3 4 4 3 4 3 4 4 3 4 3 3 3 3 3 3 3 3 4 4 3 3 4 3 3 3 4 4 3 4 3 4 3 4 3 4 4 3 4 4 3 4 3 4 4 3 4 4 3 4 4 3 4 3 4 3 3 4 3 4 3 3 3 3 3 4 3 3 4 3 4 3 4 4 3 4 4 3 4 4 3 3 3 3 4 3 3 4 3 4 3 4 3 4 3 4 3 4 3 3 3 4 3 3 3 3 3 3 4 3 3 3 3 3 3 3 4 4 3 3 3 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 4 3 4 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 4 3 4 3 4 3 4 3 3 3 3 3 4 3 4 3 4 3 4 3 3 3 3 4 3 3 3 3 4 3 3 3 3 4 3 4 3 3 4 3 4 3 4 4 3 4 3 4 3 3 3 3 4 3 4 3 4 3 3 4 3 4 3 3 3 3 4 3 3 ARTHROSCOPY-SURGICAL: DISCECTOMY ARTHROSCOPY-SURGICAL: DEBRIDEMENT OCCLUSAL ORTHOTIC APPLIANCE UNSPECIFIED TMD THERAPY, BY REPORT SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM COMPLICATED SUTURE-UP TO 5 CM COMPLICATED SUTURE-GREATER THAN 5 CM SKIN GRAFT (IDENTIFY DEFECT COVERED, LOCATION, AND TYPE OF GRAFT) OSTEOPLASTY-FOR ORTHOGNATHIC DEFORMITIES OSTEOTOMY - MANDIBULAR RAMI OSTEOTOMY - MANDIBULAR RAMI WITH BONE GRAFT; INCLUDES OBTAINING THE GRAFT OSTEOTOMY-SEGMENTED OR SUBAPICAL OSTEOTOMY-BODY OF MANDIBLE LEFORT I (MAXILLA-TOTAL) LEFORT I (MAXILLA-SEGMENTED) LEFORT II OR LEFORT III (OSTEOPLASTY OF FACIAL BONES FOR MIDFACE HYPOPLASIA OR RETRUSION)-WITHOUT BONE GRAFT LEFORT II OR LEFORT III-WITH BONE GRAFT OSSEOUS, OSTEOPERIOSTEAL, OR CARTILAGE GRAFT OF THE MANDIBLE OR MAXILLA AUTOGENOUS OR NONAUTOGENOUS, BY REPORT SINUS AUGMENTATION WITH BONE OR BONE SUBSTITUTES BONE REPLACEMENT GRAFT FOR RIDGE PRESERVATION - PER SITE REPAIR OF MAXILLOFACIAL SOFT AND/OR HARD TISSUE DEFECT FRENULECTOMY (FRENECTOMY OR FRENOTOMY)-SEPARATE PROCEDURE FRENULOPLASTY EXCISION OF HYPERPLASTIC TISSUE-PER ARCH EXCISION OF PERICORONAL GINGIVA SURGICAL REDUCTION OF FIBROUS TUBEROSITY SIALOLITHOTOMY EXCISION OF SALIVARY GLAND, BY REPORT SIALODOCHOPLASTY CLOSURE OF SALIVARY FISTULA EMERGENCY TRACHEOTOMY CORONOIDECTOMY SYNTHETIC GRAFT-MANDIBLE OR FACIAL BONES, BY REPORT IMPLANT-MANDIBLE FOR AUGMENTATION PURPOSES (EXCLUDING ALVEOLAR RIDGE), BY REPORT APPLIANCE REMOVAL (NOT BY DENTIST WHO PLACED APPLIANCE), INCLUDES REMOVAL OF ARCHBAR INTRAORAL PLACEMENT OF A FIXATION DEVICE NOT IN CONJUNCTION WITH A FRACTURE UNSPECIFIED ORAL SURGERY PROCEDURE, BY REPORT LIMITED ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION LIMITED ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION LIMITED ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITION LIMITED ORTHODONTIC TREATMENT OF THE ADULT DENTITION INTERCEPTIVE ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION INTERCEPTIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADULT DENTITION REMOVABLE APPLIANCE THERAPY FIXED APPLIANCE THERAPY PRE-ORTHODONTIC VISIT PERIODIC ORTHODONTIC TREATMENT VISIT (AS PART OF CONTRACT) ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION AND PLACEMENT OF RETAINER(S)) ORTHODONTIC TREATMENT (ALTERNATIVE BILLING TO A CONTRACT FEE) REPAIR OF ORTHODONTIC APPLIANCE REPLACEMENT OF LOST OR BROKEN RETAINER REBONDING OR RECEMENTING; AND/OR REPAIR, AS REQUIRED, OF FIXED RETAINERS UNSPECIFIED ORTHODONTIC PROCEDURE, BY REPORT PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN-MINOR PROCEDURES FIXED PARTIAL DENTURE SECTIONING LOCAL ANESTHESIA N0T IN CONJUNCTION WITH OPERATIVE OR SURGICAL PROCEDURES REGIONAL BLOCK ANESTHESIA TRIGEMINAL DIVISION BLOCK ANESTHESIA LOCAL ANESTHESIA DEEP SEDATION/GENERAL ANESTHESIA-FIRST 30 MINUTES DEEP SEDATION/GENERAL ANESTHESIA-EACH ADDITIONAL 15 MINUTES ANALGESIA, ANXIOLYSIS, INHALATION OF NITROUS OXIDE INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA - FIRST 30 MINUTES INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA - EACH ADDITIONAL 15 MINUTES NON-INTRAVENOUS CONSCIOUS SEDATION CONSULTATION - DIAGNOSTIC SERVICE PROVIDED BY DENTIST OR PHYSICIAN OTHER THAN REQUESTING DENTIST OR PHYSICIAN HOUSE/EXTENDED CARE FACILITY CALL HOSPITAL CALL OFFICE VISIT FOR OBSERVATION (DURING REGULARLY SCHEDULED HOURS) NO OTHER SERVICES PERFORMED OFFICE VISIT-AFTER REGULARLY SCHEDULED HOURS CASE PRESENTATION, DETAILED AND EXTENSIVE TREATMENT PLANNING THERAPEUTIC PARENTERAL DRUG, SINGLE ADMINISTRATION THERAPEUTIC PARENTERAL DRUGS, TWO OR MORE ADMINISTRATIONS, DIFFERENT MEDICATIONS OTHER DRUGS AND/OR MEDICAMENTS, BY REPORT APPLICATION OF DESENSITIZ ING MEDICAMENT APPLICATION OF DESENSITIZ ING RESIN FOR CERVICAL AND/OR ROOT SURFACE, PER TOOTH BEHAVIOR MANAGEMENT, BY REPORT TREATMENT OF COMPLICATIONS (POSTSURGICAL) - UNUSUAL CIRCUMSTANCES, BY REPORT OCCLUSAL GUARDS, BY REPORT FABRICATION OF ATHLETIC MOUTHGUARD REPAIR AND/OR RELINE OF OCCLUSAL GUARD OCCLUSION ANALYSIS-MOUNTED CASE OCCLUSAL ADJUSTMENT-LIMITED OCCLUSAL ADJUSTMENT-COMPLETE ENAMEL MICROABRASION ODONTOPLASTY 1 - 2 TEETH; INCLUDES REMOVAL OF ENAMEL PROJECTIONS EXTERNAL BLEACHING - PER ARCH EXTERNAL BLEACHING - PER TOOTH INTERNAL BLEACHING - PER TOOTH UNSPECIFIED ADJUNCTIVE PROCEDURE, BY REPORT CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIP CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIPS CRUTCHES, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED, PAIR, COMPLETE WITH TIPS AND HANDGRIPS CRUTCH FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED, EACH, WITH TIP AND HANDGRIPS CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS CRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIXED, EACH, WITH PAD, TIP AND HANDGRIP CRUTCHES UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS CRUTCH, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, WITH PAD, TIP, HANDGRIP, WITH OR WITHOUT SHOCK ABSORBER, EACH CRUTCH, UNDERARM, ARTICULATING, SPRING ASSISTED, EACH CRUTCH SUBSTITUTE, LOWER LEG PLATFORM, WITH OR WITHOUT WHEELS, EACH WALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHT WALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIGHT WALKER, WITH TRUNK SUPPORT, ADJUSTABLE OR FIXED HEIGHT, ANY TYPE WALKER, RIGID, WHEELED, ADJUSTABLE OR FIXED HEIGHT RIGID WALKER, WHEELED, WITH SEAT WALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED HEIGHT WALKER, ENCLOSED, FOUR SIDED FRAMED, RIGID OR FOLDING, WHEELED WITH POSTERIOR SEAT WALKER, WHEELED, WITH SEAT AND CRUTCH ATTACHMENTS FOLDING WALKER, WHEELED, WITH SEAT WALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE PLATFORM ATTACHMENT, FOREARM CRUTCH, EACH PLATFORM ATTACHMENT, WALKER, EACH WHEEL ATTACHMENT, RIGID PICK-UP WALKER, PER PAIR SEAT ATTACHMENT, WALKER CRUTCH ATTACHMENT, WALKER, EACH LEG EXTENSIONS FOR WALKER, PER SET OF FOUR (4 ) BRAKE ATTACHMENT FOR WHEELED WALKER, REPLACEMENT, EACH SITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODE SITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODE, WITH FAUCET ATTACHMENT/S SITZ BATH CHAIR COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED ARMS COMMODE CHAIR, MOBILE, WITH FIXED ARMS COMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS COMMODE CHAIR, MOBILE, WITH DETACHABLE ARMS PAIL OR PAN FOR USE WITH COMMODE CHAIR, REPLACEMENT ONLY COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH OR WITHOUT ARMS, ANY TYPE, EACH COMMODE CHAIR WITH SEAT LIFT MECHANISM COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, NON-ELECTRIC, ANY TYPE SEAT LIFT MECHANISM PLACED OVER OR ON TOP OF TOILET, ANY TYPE FOOT REST, FOR USE WITH COMMODE CHAIR, EACH AIR PRESSURE PAD OR CUSHION, NONPOSITIONING WATER PRESSURE PAD OR CUSHION, NONPOSITIONING GEL OR GEL-LIKE PRESSURE PAD OR CUSHION, NONPOSITIONING DRY PRESSURE PAD OR CUSHION, NONPOSITIONING PRESSURE PAD, ALTERNATING WITH PUMP POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP, INCLUDES HEAVY DUTY PUMP FOR ALTERNATING PRESSURE PAD, FOR REPLACEMENT ONLY DRY PRESSURE MATTRESS GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH AIR PRESSURE MATTRESS WATER PRESSURE MATTRESS SYNTHETIC SHEEPSKIN PAD LAMBSWOOL SHEEPSKIN PAD, ANY SIZ E POSITIONING CUSHION/PILLOW/WEDGE, ANY SHAPE OR SIZ E, INCLUDES ALL COMPONENTS AND ACCESSORIES HEEL OR ELBOW PROTECTOR, EACH LOW PRESSURE AND POSITIONING EQUALIZ ATION PAD, FOR WHEELCHAIR POWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY) AIR FLUIDIZ ED BED GEL PRESSURE MATTRESS AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH HEAT LAMP, WITHOUT STAND (TABLE MODEL), INCLUDES BULB, OR INFRARED ELEMENT PHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOTOMETER THERAPEUTIC LIGHTBOX, MINIMUM 10,000 LUX, TABLE TOP MODEL HEAT LAMP, WITH STAND, INCLUDES BULB, OR INFRARED ELEMENT ELECTRIC HEAT PAD, STANDARD ELECTRIC HEAT PAD, MOIST WATER CIRCULATING HEAT PAD WITH PUMP WATER CIRCULATING COLD PAD WITH PUMP HOT WATER BOTTLE INFRARED HEATING PAD SYSTEM HYDROCOLLATOR UNIT, INCLUDES PADS ICE CAP OR COLLAR NON-CONTACT WOUND WARMING DEVICE (TEMPERATURE CONTROL UNIT, AC ADAPTER AND POWER CORD) FOR USE WITH WARMING CARD AND WOUND COVER WARMING CARD FOR USE WITH THE NON CONTACT WOUND WARMING DEVICE AND NON CONTACT WOUND WARMING WOUND COVER PARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4 26 5 FOR PARAFFIN) PUMP FOR WATER CIRCULATING PAD NON-ELECTRIC HEAT PAD, MOIST HYDROCOLLATOR UNIT, PORTABLE BATH/SHOWER CHAIR, WITH OR WITHOUT WHEELS, ANY SIZ E BATH TUB WALL RAIL, EACH BATH TUB RAIL, FLOOR BASE TOILET RAIL, EACH RAISED TOILET SEAT TUB STOOL OR BENCH TRANSFER TUB RAIL ATTACHMENT TRANSFER BENCH FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING TRANSFER BENCH, HEAVY DUTY, FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING PAD FOR WATER CIRCULATING HEAT UNIT HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, INSTITUTIONAL TYPE INCLUDES: OSCILLATING, CIRCULATING AND STRYKER FRAME, WITH MATTRESS MATTRESS, INNERSPRING MATTRESS, FOAM RUBBER BED BOARD OVER-BED TABLE BED PAN, STANDARD, METAL OR PLASTIC BED PAN, FRACTURE, METAL OR PLASTIC POWERED PRESSURE-REDUCING AIR MATTRESS BED CRADLE, ANY TYPE HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESS HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITH MATTRESS HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS). WITHOUT SIDE RAILS, WITH MATTRESS HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS, WITHOUT MATTRESS PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 6 00 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 6 00 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 6 00 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 6 00 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS BED SIDE RAILS, HALF LENGTH BED SIDE RAILS, FULL LENGTH BED ACCESSORY: BOARD, TABLE, OR SUPPORT DEVICE, ANY TYPE SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE URINAL; MALE, JUG-TYPE, ANY MATERIAL URINAL; FEMALE, JUG-TYPE, ANY MATERIAL CONTROL UNIT FOR ELECTRONIC BOWEL IRRIGATION/EVACUATION SYSTEM DISPOSABLE PACK (WATER RESERVOIR BAG, SPECULUM, VALVING MECHANISM AND COLLECTION BAG/BOX) FOR USE WITH THE ELECTRONIC BOWEL IRRIGATION/EVACUATION SYSTEM AIR PRESSURE ELEVATOR FOR HEEL NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZ ER, CANNULA OR MASK, AND TUBING STATIONARY COMPRESSED GAS SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZ ER, CANNULA OR MASK, AND TUBING PORTABLE GASEOUS OXYGEN SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR MASK, AND TUBING PORTABLE LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, FLOWMETER, HUMIDIFIER, CONTENTS GAUGE, CANNULA OR MASK, TUBING AND REFILL ADAPTOR STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZ ER, CANNULA OR MASK, & TUBING STATIONARY LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES USE OF RESERVOIR, CONTENTS INDICATOR, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZ ER, CANNULA OR MASK, AND TUBING OXYGEN CONTENTS, GASEOUS (FOR USE WITH OWNED GASEOUS STATIONARY SYSTEMS OR WHEN BOTH A STATIONARY AND PORTABLE GASEOUS SYSTEM ARE OWNED), 1 MONTH'S SUPPLY = 1 UNIT OXYGEN CONTENTS, LIQUID (FOR USE WITH OWNED LIQUID STATIONARY SYSTEMS OR WHEN BOTH A STATIONARY AND PORTABLE LIQUID SYSTEM ARE OWNED), 1 MONTH'S SUPPLY = 1 UNIT PORTABLE OXYGEN CONTENTS, GASEOUS (FOR USE ONLY WITH PORTABLE GASEOUS SYSTEMS WHEN NO STATIONARY GAS OR LIQUID SYSTEM IS USED), 1 MONTH'S SUPPLY = 1 UNIT PORTABLE OXYGEN CONTENTS, LIQUID (FOR USE ONLY WITH PORTABLE LIQUID SYSTEMS WHEN NO STATIONARY GAS OR LIQUID SYSTEM IS USED), 1 MONTH'S SUPPLY = 1 UNIT OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH INVASIVE INTERFACE (E.G., TRACHEOSTOMY TUBE) PRESSURE VENTILATOR WITH PRESSURE CONTROL, PRESSURE SUPPORT AND FLOW TRIGGERING FEATURES OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTS CHEST SHELL (CUIRASS) CHEST WRAP NEGATIVE PRESSURE VENTILATOR; PORTABLE OR STATIONARY VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK) ROCKING BED WITH OR WITHOUT SIDE RAILS PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH INVASIVE INTERFACE (E.G. TRACHEOSTOMY TUBE) PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK) RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE, USED WITH INVASIVE INTERFACE, E.G., TRACHEOSTOMY TUBE (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) PERCUSSOR, ELECTRIC OR PNEUMATIC, HOME MODEL INTRAPULMONARY PERCUSSIVE VENTILATION SYSTEM AND RELATED ACCESSORIES COUGH STIMULATING DEVICE, ALTERNATING POSITIVE AND NEGATIVE AIRWAY PRESSURE HIGH FREQUENCY CHEST WALL OSCILLATION AIR-PULSE GENERATOR SYSTEM, (INCLUDES HOSES AND VEST), EACH OSCILLATORY POSITIVE EXPIRATORY PRESSURE DEVICE, NON-ELECTRIC, ANY TYPE, EACH ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT IPPB MACHINE, ALL TYPES, WITH BUILT-IN NEBULIZ ATION; MANUAL OR AUTOMATIC VALVES; INTERNAL OR EXTERNAL POWER SOURCE HUMIDIFIER, DURABLE FOR EXTENSIVE SUPPLEMENTAL HUMIDIFICATION DURING IPPB TREATMENTS OR OXYGEN DELIVERY HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER HUMIDIFIER, DURABLE FOR SUPPLEMENTAL HUMIDIFICATION DURING IPPB TREATMENT OR OXYGEN DELIVERY HUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE COMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT SELF- CONTAINED OR CYLINDER DRIVEN NEBULIZ ER, WITH COMPRESSOR AEROSOL COMPRESSOR, BATTERY POWERED, FOR USE WITH SMALL VOLUME NEBULIZ ER AEROSOL COMPRESSOR, ADJUSTABLE PRESSURE, LIGHT DUTY FOR INTERMITTENT USE ULTRASONIC/ELECTRONIC AEROSOL GENERATOR WITH SMALL VOLUME NEBULIZ ER NEBULIZ ER, ULTRASONIC, LARGE VOLUME NEBULIZ ER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER NEBULIZ ER, WITH COMPRESSOR AND HEATER DISPENSING FEE COVERED DRUG ADMINISTERED THROUGH DME NEBULIZ ER RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE BREAST PUMP, MANUAL, ANY TYPE BREAST PUMP, ELECTRIC (AC AND/OR DC), ANY TYPE BREAST PUMP, HEAVY DUTY, HOSPITAL GRADE, PISTON OPERATED, PULSATILE VACUUM SUCTION/RELEASE CYCLES, VACUUM REGULATOR, SUPPLIES, TRANSFORMER, ELECTRIC (AC AND / OR DC) VAPORIZ ER, ROOM TYPE POSTURAL DRAINAGE BOARD HOME BLOOD GLUCOSE MONITOR PACEMAKER MONITOR, SELF-CONTAINED, (CHECKS BATTERY DEPLETION, INCLUDES AUDIBLE AND VISIBLE CHECK SYSTEMS) PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION AND OTHER PACEMAKER COMPONENTS, INCLUDES DIGITAL/VISIBLE CHECK SYSTEMS IMPLANTABLE CARDIAC EVENT RECORDER WITH MEMORY, ACTIVATOR AND PROGRAMMER EXTERNAL DEFIBRILLATOR WITH INTEGRATED ELECTROCARDIOGRAM ANALYSIS APNEA MONITOR, WITHOUT RECORDING FEATURE APNEA MONITOR, WITH RECORDING FEATURE SKIN PIERCING DEVICE FOR COLLECTION OF CAPILLARY BLOOD, LASER, EACH SLING OR SEAT, PATIENT LIFT, CANVAS OR NYLON PATIENT LIFT, BATHROOM OR TOILET, NOT OTHERWISE CLASSIFIED SEAT LIFT MECHANISM INCORPORATED INTO A COMBINATION LIFT-CHAIR MECHANISM SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-ELECTRIC SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-NON-ELECTRIC PATIENT LIFT, HYDRAULIC, WITH SEAT OR SLING PATIENT LIFT, ELECTRIC WITH SEAT OR SLING MULTIPOSITIONAL PATIENT SUPPORT SYSTEM, WITH INTEGRATED LIFT, PATIENT ACCESSIBLE CONTROLS COMBINATION SIT TO STAND SYSTEM, ANY SIZ E INCLUDING PEDIATRIC, WITH SEATLIFT FEATURE, WITH OR WITHOUT WHEELS STANDING FRAME SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER), ANY SIZ E INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS PATIENT LIFT, MOVEABLE FROM ROOM TO ROOM WITH DISASSEMBLY AND REASSEMBLY, INCLUDES ALL COMPONENTS/ACCESSORIES PATIENT LIFT, FIXED SYSTEM, INCLUDES ALL COMPONENTS/ACCESSORIES STANDING FRAME SYSTEM, MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZ E INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS STANDING FRAME SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZ E INCLUDING PEDIATRIC PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITHOUT CALIBRATED GRADIENT PRESSURE PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF ARM NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEG SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL ARM SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALF LEG PNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE, RAPID INFLATION/DEFLATION CYCLE, FOR ARTERIAL INSUFFICIENCY (UNILATERAL OR BILATERAL SYSTEM) INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL ACCESSORIES), NOT OTHERWISE SPECIFIED ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESS ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, 4 FOOT PANEL ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, 6 FOOT PANEL ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION SAFETY EQUIPMENT (E.G., BELT, HARNESS OR VEST) HELMET WITH FACE GUARD AND SOFT INTERFACE MATERIAL, PREFABRICATED TRANSFER BOARD OR DEVICE, ANY TYPE, EACH RESTRAINTS, ANY TYPE (BODY, CHEST, WRIST OR ANKLE) TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZ ED STIMULATION TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (WITH CONDUCTIVE FIBERS SEPARATED FROM THE PATIENT'S SKIN BY LAYERS OF FABRIC) INCONTINENCE TREATMENT SYSTEM, PELVIC FLOOR STIMULATOR, MONITOR, SENSOR AND/OR TRAINER NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT ELECTROMYOGRAPHY (EMG), BIOFEEDBACK DEVICE OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINAL APPLICATIONS OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, SPINAL APPLICATIONS OSTEOGENESIS STIMULATOR, ELECTRICAL, SURGICALLY IMPLANTED IMPLANTABLE NEUROSTIMULATOR ELECTRODE, EACH PATIENT PROGRAMMER (EXTERNAL) FOR USE WITH IMPLANTABLE PROGRAMMABLE NEUROSTIMULATOR PULSE GENERATOR ELECTRONIC SALIVARY REFLEX STIMULATOR (INTRA-ORAL/NON-INVASIVE) IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR IMPLANTABLE NEUROSTIMULATOR RADIOFREQUENCY RECEIVER RADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATOR RADIOFREQUENCY RECEIVER RADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH IMPLANTABLE SACRAL ROOT NEUROSTIMULATOR RECEIVER FOR BOWEL AND BLADDER MANAGEMENT, REPLACEMENT OSTEOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON-INVASIVE NON-THERMAL PULSED HIGH FREQUENCY RADIOWAVES, HIGH PEAK POWER ELECTROMAGNETIC ENERGY TREATMENT DEVICE TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES FUNCTIONAL NEUROMUSCULAR STIMULATOR, TRANSCUTANEOUS STIMULATION OF MUSCLES OF AMBULATION WITH COMPUTER CONTROL, USED FOR WALKING BY SPINAL CORD INJURED, ENTIRE SYSTEM, AFTER COMPLETION OF TRAINING PROGRAM FDA APPROVED NERVE STIMULATOR, WITH REPLACEABLE BATTERIES, FOR TREATMENT OF NAUSEA AND VOMITING ELECTRICAL STIMULATION OR ELECTROMAGNETIC WOUND TREATMENT DEVICE, NOT OTHERWISE CLASSIFIED IV POLE AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION 8 HOURS OR GREATER AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION LESS THAN 8 HOURS AMBULATORY INFUSION PUMP, SINGLE OR MULTIPLE CHANNELS, ELECTRIC OR BATTERY OPERATED, WITH ADMINISTRATIVE EQUIPMENT, WORN BY PATIENT INFUSION PUMP, IMPLANTABLE, NON-PROGRAMMABLE (INCLUDES ALL COMPONENTS, E.G., PUMP, CATHETER, CONNECTORS, ETC.) INFUSION PUMP SYSTEM, IMPLANTABLE, PROGRAMMABLE (INCLUDES ALL COMPONENTS, E.G., PUMP, CATHETER, CONNECTORS, ETC.) EXTERNAL AMBULATORY INFUSION PUMP, INSULIN IMPLANTABLE INTRASPINAL (EPIDURAL/INTRATHECAL) CATHETER USED WITH IMPLANTABLE INFUSION PUMP, REPLACEMENT IMPLANTABLE PROGRAMMABLE INFUSION PUMP, REPLACEMENT (EXCLUDES IMPLANTABLE INTRASPINAL CATHETER) PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTI-CHANNEL AMBULATORY TRACTION DEVICE, ALL TYPES, EACH TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE TRACTION STAND, FREE STANDING, CERVICAL TRACTION CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME P age 2 Tmj a rthroscopy discectomy Tmj a rthroscopy debridement Occlusa l orthotic a pplia nce Tmj unspecified thera py Dent sutur recent wnd to 5cm Denta l suture wound to 5 cm Suture complica te wnd > 5 cm Denta l skin gra ft Resha ping bone orthogna thic Bone cutting ra mus closed Cutting ra mus open w/gra ft Bone cutting segmented Bone cutting body ma ndible Reconstruction ma xilla tota l Reconstruct ma xilla segment Reconstruct midfa ce no gra ft 00 00 00 00 00 00 00 00 13 00 00 00 00 00 00 00 9 9 9 9 9 9 9 9 A 9 9 9 9 9 9 9 Reconstruct midfa ce w/gra ft Ma ndible gra ft 00 00 9 9 Sinus a ug w bone/bone sup Bone repla cement gra ft Repa ir ma xillofa cia l defects Frenulectomy/frenulotomy Frenulopla sty Excision hyperpla stic tissue Excision pericorona l gingiva Surg redct fibrous tuberosit Sia lolithotomy Excision of sa liva ry gla nd Sia lodochopla sty Closure of sa liva ry fistula Emergency tra cheotomy Denta l coronoidectomy Synthetic gra ft fa cia l bones Impla nt ma ndible for a ugment Applia nce remova l 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Intra ora l pla ce of fix dev Ora l surgery procedure Limited denta l tx prima ry Limited denta l tx tra nsition Limited denta l tx a dolescent Limited denta l tx a dult Intercep denta l tx prima ry Intercep denta l tx tra nsitn Compre denta l tx tra nsition Compre denta l tx a dolescent Compre denta l tx a dult Orthodontic rem a pplia nce tx Fixed a pplia nce thera py ha bt Preorthodontic tx visit Periodic orthodontc tx visit Orthodontic retention 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Orthodontic trea tment Repa ir ortho a pplia nce Repla cement reta iner Rebond/cement/repa ir reta in Orthodontic procedure Tx denta l pa in minor proc Fix pa rtia l denture section Dent a nesthesia w/o surgery Regiona l block a nesthesia Trigemina l block a nesthesia Loca l a nesthesia Genera l a nesthesia Genera l a nesthesia ea a d 15m Ana lgesia Intra venous seda tion IV seda tion ea a d 30 m Seda tion (non-iv) Denta l consulta tion 00 00 00 00 00 13 00 00 00 00 00 00 00 13 00 00 00 00 9 9 9 9 9 A 9 9 9 9 9 9 9 A 9 9 9 9 Denta l house ca ll Hospita l ca ll Office visit during hours 00 00 00 00 00 00 00 13 00 00 00 13 13 00 00 13 13 13 00 00 00 00 00 00 32 32 9 9 9 9 A 9 9 9 A A 9 9 A A A 9 9 9 9 9 9 A A Crutch forea rm pa ir 32 A 12013 12052 2136 2119 3 2119 4 2119 8 2119 3 2114 7 2114 5 21150 2119 5 2119 6 21206 2119 4 2119 5 2114 6 CPT 2124 7 2129 9 4 0819 4 1010 4 1115 4 2335 4 234 0 186 2a (12) CPT 4 1821 4 2330 4 24 08 4 2500 4 26 00 316 05 21070 2129 9 2129 9 186 2a (12) 186 2a (12) 2129 9 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 2336 2136 2136 2136 2336 2336 186 2a (12) 9 0784 019 9 5 6 4 4 00 9 0784 CPT 9 0784 9 0784 CPT 2119 6 I I I I I I I I D I I I I I I I Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 9 20101 19 9 20101 19 86 0101 19 9 20101 19 84 0101 19 84 0101 19 84 0101 19 84 0101 19 820101 19 84 0101 19 84 0101 19 84 0101 19 84 0101 19 84 0101 19 84 0101 19 84 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 30101 20000101 20000101 20070101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 N N N N N N N N N N N C N N N N Y1 Y1 2 2 0 0 19 84 0101 19 84 0101 19 9 6 0101 20070101 N C Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20070101 20050101 19 820101 19 84 0101 20050101 19 84 0101 19 86 0101 20030101 19 820101 19 820101 19 84 0101 19 820101 19 820101 19 850101 19 9 6 0101 19 9 6 0101 20000101 20070101 20050101 20050101 19 9 6 0101 20050101 19 9 6 0101 19 9 6 0101 20030101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 20000101 A N N N N N N N N N N N N N N N N S I S S S S S S S S S S S S S S Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 9 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20070101 19 84 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 820101 19 84 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 20070101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 A N N N N N N N N N N N N N N N S S S S S D S I I I I I I D I I D I Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 1 1 1 9 1 1 2 7 7 7 7 7 7 7 7 7 7 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 9 6 0101 20000101 20000101 20070101 19 84 0101 19 84 0101 20070101 19 84 0101 19 820101 19 850101 19 850101 19 820101 19 9 20101 19 820101 20000101 20000101 20000101 19 820101 19 9 6 0101 20000101 20000101 20070101 19 9 6 0101 19 9 6 0101 20070101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 20030101 20030101 20000101 20030101 20030101 20000101 20070101 N N N A N N A N N N N N N N N N N C I I 186 2a (12) 186 2a (12) 9 9 9 Office visit a fter hours Ca se presenta tion tx pla n Dent thera peutic drug inject Thera pa r drugs 2 or > a dmin Other drugs/medica ments Dent a ppl desensitiz ing med Appl desensitiz ing resin Beha vior ma na gement Trea tment of complica tions Denta l occlusa l gua rd Fa brica tion a thletic gua rd Repa ir/reline occlusa l gua rd Occlusion a na lysis Limited occlusa l a djustment Complete occlusa l a djustment Ena mel microa bra sion Odontopla sty 1-2 teeth Extrnl blea ching per a rch Extrnl blea ching per tooth Intrnl blea ching per tooth Adjunctive procedure Ca ne a djust/fixed with tip Ca ne a djust/fixed qua d/3 pro 29 804 29 804 214 9 9 214 9 9 12011 12051 13132 CPT 2336 S S I I S I I I I I I I I I I I S CPT CPT CPT I I I 9 9 050 2136 186 2a (12) 186 2a (12) 186 2a (12) 2336 2336 2136 2136 2336 2336 2336 2136 2136 2136 186 2a (12) 186 2a (12) 21089 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 186 2a (12) 214 9 9 6 0-3 6 0-15 6 0-9 6 0-9 6 0-9 0031 0032 0034 0052 0035 I I I S D S S S D D S S D D D S S S S S I D D 186 2a (12) 2336 0030 2100.1 2100.1 2100.1 0036 0037 0038 D Y1 Y1 Y1 1 1 1 0 0 0 19 84 0101 19 84 0101 19 84 0101 20000101 19 9 6 0101 19 9 6 0101 N N N Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 Y1 D1E D1E 1 1 9 9 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 A A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 84 0101 20030101 19 84 0101 20070101 19 84 0101 19 850101 20000101 19 86 0101 19 84 0101 19 86 0101 19 86 0101 20050101 19 84 0101 19 86 0101 19 86 0101 19 9 6 0101 20000101 20000101 20000101 20000101 19 84 0101 19 86 0101 19 86 0101 19 9 6 0101 20030101 20070101 20070101 19 9 30101 19 9 6 0101 20000101 19 9 6 0101 19 9 30101 19 9 6 0101 19 9 6 0101 20050101 19 9 30101 19 9 30101 19 9 30101 19 9 6 0101 20000101 20000101 20000101 20000101 19 9 6 0101 19 9 6 0101 19 9 6 0101 N N B A N N N N N N N N N N N N N N N N N N N D1E A P P P R R R 0 19 86 0101 19 9 6 0101 Crutch forea rm ea ch 32 A 6 0-9 2100.1 D D1E A P R 0 19 86 0101 32 A 6 0-9 2100.1 D D1E A P R 0 19 86 0101 N 19 9 6 0101 Crutch undera rm pa ir wood 19 9 6 0101 N N Crutch undera rm ea ch wood Crutch undera rm pa ir no wood 32 32 A A 6 0-9 6 0-9 2100.1 2100.1 D D D1E D1E A A P P R R 0 0 19 86 0101 19 86 0101 19 9 6 0101 19 9 70101 Crutch undera rm ea ch no wood 32 A 6 0-9 2100.1 D D1E A P R 0 19 86 0101 2006 0101 Undera rm springa ssist crutch Crutch substitute Wa lker rigid a djust/fixed ht Wa lker folding a djust/fixed Wa lker w trunk support Rigid wheeled wa lker a dj/fix Wa lker rigid wheeled with se Wa lker folding wheeled w/o s Enclosed wa lker w rea r sea t 32 32 32 32 32 32 32 32 36 A A A A A A A A A 2100.1 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 2100.1 2100.1 2100.1 2100.1 2100.1 2100.1 2100.1 D C D D D D D D D D1E D1E D1E D1E D1E D1E D1E D1E D1E A A A A A A A A A P P P P P P P P P R R R R R R R R R 0 0 0 0 0 0 0 0 0 20030101 2004 0101 19 86 0101 19 86 0101 2004 0101 19 86 0101 19 86 0101 19 86 0101 20000101 20030101 2004 04 01 19 9 6 0101 19 9 6 0101 2004 0101 2004 0101 2004 0101 2004 0101 2004 0101 Wa lker whled sea t/crutch a tt Folding wa lker wheels w sea t Wa lker va ria ble wheel resist Hea vyduty wa lker no wheels Hea vy duty wheeled wa lker Forea rm crutch pla tform a tta Wa lker pla tform a tta chment Wa lker wheel a tta chment,pa ir Wa lker sea t a tta chment Wa lker crutch a tta chment Wa lker leg extenders set of4 Bra ke for wheeled wa lker Sitz type ba th or equipment Sitz ba th/equipment w/fa ucet 36 36 32 32 32 32 32 32 32 32 32 32 32 32 A A A A A A A A A A A A A A 6 0-9 6 0-9 6 0-15 2100.1 2100.1 2100.1 D D D C C C C C C C C C D D D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E R R A A A A A A A A A A A A P P P P P P P P P P P P R R R R R R R R R R R R 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 86 0101 19 86 0101 19 86 0101 20010101 20010101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 9 70101 19 86 0101 19 86 0101 2004 0101 2004 0101 2004 0101 20010101 2004 0101 19 9 6 0101 19 9 6 0101 20000101 19 9 6 0101 19 9 6 0101 20000101 19 9 80101 19 9 6 0101 19 9 6 0101 Sitz ba th cha ir Commode cha ir with fixed a rm Commode cha ir mobile fixed a Commode cha ir with deta cha rm Commode cha ir mobile deta ch Commode cha ir pa il or pa n Hea vyduty/wide commode cha ir 32 32 32 36 36 32 32 A A A A A A A 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 D D D D D D C D1E D1E D1E D1E D1E D1E D1E A A A R R A A P P P R R R P P R R 0 0 0 0 0 0 0 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 20010101 19 9 6 0101 20070101 20070101 20070101 20070101 20070101 20010101 Sea tlift incorp commodecha ir Commode cha ir electric Commode cha ir non-electric Sea t lift mecha nism toilet Commode cha ir foot rest Air pressre pa d/cushion nonp Wa ter press pa d/cushion nonp Gel pressre pa d/cushion nonp Dry pressre pa d/cushion nonp Press pa d a lterna ting w pump Press pa d a lterna ting w/ pum 36 36 36 00 32 32 32 32 32 36 36 A A A 9 A A A A A A A C C C S C D D D D D D D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E R A A A A A A A A R R P P P P P P P P R R R R R R R R 0 0 0 0 0 0 0 0 0 0 0 20020101 2006 0101 2006 0101 2006 0101 19 86 0101 19 9 10101 19 9 10101 19 9 10101 19 9 10101 19 86 0101 19 86 0101 2006 0101 2006 0101 2006 0101 2006 0101 19 9 6 0101 20050101 20050101 20050101 20050101 20070101 20070101 Repla ce pump, a lt press pa d Dry pressure ma ttress Gel pressure ma ttress pa d Air pressure ma ttress Wa ter pressure ma ttress Synthetic sheepskin pa d La mbswool sheepskin pa d Positioning cushion 36 32 32 36 36 32 32 00 A A A A A A A 9 D D D D D D D D D1E D1E D1E D1E D1E D1E D1E D1E R A A R R A A 9 P P R R 0 0 0 0 0 0 0 0 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 2004 0101 20070101 19 9 6 0101 19 9 80101 19 9 6 0101 19 9 6 0101 20010101 20010101 20070101 Protector heel or elbow Pa d wheelchr low press/posit Powered a ir flota tion bed Air fluidiz ed bed Gel pressure ma ttress Air pressure pa d for ma ttres Wa ter pressure pa d for ma ttr Dry pressure pa d for ma ttres Hea t la mp without sta nd Photothera py light w/ photom Thera peutic lightbox ta bletp Hea t la mp with sta nd Electric hea t pa d sta nda rd Electric hea t pa d moist Wa ter circ hea t pa d w pump Wa ter circ cold pa d w pump Hot wa ter bottle Infra red hea ting pa d system Hydrocolla tor unit Ice ca p or colla r Wound wa rming device 32 00 36 36 36 32 32 32 32 36 00 32 32 32 32 36 32 00 32 32 00 A 9 A A A A A A A A 9 A A A A A A 9 A A 9 D1E D1D D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E A A R R R A A A A R 9 A A A A A A A A A R 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 86 0101 19 870101 19 9 00101 19 9 10101 19 9 10101 19 9 10101 19 9 10101 19 9 10101 19 86 0101 19 850101 20030101 19 86 0101 19 86 0101 19 86 0101 19 9 70101 19 9 70101 19 86 0101 20020101 19 86 0101 19 86 0101 20020101 19 9 6 0101 20050101 19 9 30101 19 9 10101 19 9 10101 19 9 80101 19 9 80101 19 9 80101 19 9 6 0101 19 9 6 0101 20050101 19 9 6 0101 20030101 19 9 6 0101 19 9 70101 19 9 70101 19 9 6 0101 20070101 19 9 6 0101 19 9 6 0101 20020701 Wa rming ca rd for NWT 00 9 0 20020101 20020701 N Pa ra ffin ba th unit porta ble Pump for wa ter circula ting p Hea t pa d non-electric moist Hydrocolla tor unit porta ble Ba th/shower cha ir Ba th tub wa ll ra il Ba th tub ra il floor Toilet ra il Toilet sea t ra ised Tub stool or bench Tra nsfer tub ra il a tta chment Tra ns bench w/wo comm open HDtra ns bench w/wo comm open Pa d wa ter circula ting hea t u Hosp bed fixed ht w/ ma ttres Hosp bed fixd ht w/o ma ttres Hospita l bed va r ht w/ ma ttr Hospita l bed va r ht w/o ma tt Hosp bed semi-electr w/ ma tt 36 36 32 32 00 00 00 00 00 00 00 00 00 32 36 36 36 36 36 A A A A 9 9 9 9 9 9 9 9 9 A A A A A A 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-18 6 0-18 6 0-18 6 0-18 6 0-18 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 86 0101 19 86 0101 19 86 0101 19 86 0101 2004 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 2004 0101 2004 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 9 10101 19 86 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 2006 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 2004 0101 2004 0101 19 9 6 0101 19 9 10101 19 9 10101 19 9 10101 19 9 10101 19 9 10101 N N N N N N N N N N N N N N N N N N N Hosp bed semi-electr w/o ma t 36 A 6 0-18 0 19 9 10101 19 9 10101 N Hosp bed tota l electr w/ ma t 36 A 6 0-9 6 0-9 2100.1 2100.1 2100.1 2100.1 186 1SSA 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 4 107.6 4 107.6 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 4 107.6 4 107.6 4 107.6 4 107.6 4 107.6 2100.1 2303 2303 M D1E 2100.1 2100.1 2100.1 2100.1 2100.1 D D D D M M M M M M C D D D D D D D D D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1B D1B D1B D1B D1B R R A A 9 A A A A A A A A A R R R R R 2100.1 D D1B 2100.1 6 0-9 2210.3 2210.3 2100.1 2100.1 2100.1 6 0-18 R R R R P P P P R R R R P L P P P P P P P R P R R R R R R R P P R R P P P P P P P P P R R R R R R R R R R 2100.1 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 P P P P P 2210.3 6 0-19 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 C I C D D D D D D C M D D D D D C C D C M 2100.1 0013 D D1B R Hosp bed tota l elec w/o ma tt 36 A 6 0-18 D D1B 00 9 6 0-9 M D1B R Ma ttress innerspring Ma ttress foa m rubber Bed boa rd Over-bed ta ble Bed pa n sta nda rd Bed pa n fra cture Powered pres-redu a ir ma ttrs Bed cra dle Hosp bed fx ht w/o ra ils w/m Hosp bed fx ht w/o ra il w/o Hosp bed va r ht w/o ra il w/o Hosp bed va r ht w/o ra il w/ Hosp bed semi-elect w/ ma ttr 32 32 00 00 32 32 36 32 36 36 36 36 36 A A 9 9 A A A A A A A A A 6 0-18 6 0-18 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-18 6 0-18 6 0-18 6 0-18 6 0-18 2100.1 2100.1 2100.1 2100.1 2100.1 D D M M D D D C D D D D D D1B D1B D1B D1B D1E D1E D1E D1B D1B D1B D1B D1B D1B A A A A A A R A R R R R R Hosp bed semi-elect w/o ma tt 36 A 6 0-18 2100.1 D D1B 0 R Hospita l bed institutiona l t R Hosp bed tota l elect w/ ma tt 36 2100.1 R 6 0-9 6 0-9 A 6 0-18 2100.1 Hosp bed tota l elect w/o ma t 36 A 6 0-18 2100.1 Enclosed ped crib hosp gra de HD hosp bed, 350-6 00 lbs 32 36 A A D D1B 6 0-18 D1B A R 2006 1231 20051231 2004 1231 2004 1231 2004 1231 2004 1231 2006 1231 N N N N N N N N N N N N N N N C D C D C N N N N N N N N N N D C C N N N N N N C 2004 1231 19 9 10101 N N N N N N N N N N N N N N N N N F N N N N 0 19 86 0101 19 9 10101 N 19 9 30101 N 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 9 20101 19 86 0101 19 9 10101 19 9 10101 19 9 10101 19 9 10101 19 9 10101 19 9 30101 19 9 30101 19 89 0101 19 89 0101 19 9 6 0101 19 9 6 0101 19 9 80101 19 89 0101 19 9 10101 19 9 10101 19 9 10101 19 9 10101 19 9 10101 N N N N N N N N N N N N N 0 R 19 86 0101 0 0 0 0 0 0 0 0 0 0 0 0 0 R R R R R R P 19 9 10101 19 9 10101 N 0 R D1B D1B 2006 1231 N N N N N N N N N 0 P P P P P P R D C D 19 86 0101 N N N 20031231 20031231 20031231 19 9 10101 19 9 20101 N 0 P 19 9 10101 19 9 10101 N 0 0 R 2004 0101 2004 0101 2004 0101 2004 0101 N N Ex hd hosp bed > 6 00 lbs 36 A 6 0-18 D D1B R 0 2004 0101 2004 0101 N Hosp bed hvy dty xtra wide 36 A 6 0-18 D D1B R 0 2004 0101 2004 0101 N Hosp bed xtra hvy dty x wide 36 A 6 0-18 D D1B R 0 2004 0101 2004 0101 N Ra ils bed side ha lf length Ra ils bed side full length Bed a ccessory brd/tbl/supprt Bed sa fety enclosure Urina l ma le jug-type Urina l fema le jug-type Control unit bowel system Disposa ble pa ck w/bowel syst 36 32 00 36 32 32 57 57 A A 9 A A A A A 6 0-18 6 0-18 6 0-9 D D M C D D C C D1B D1B D1B D1B D1E D1E Z2 Z2 R A A A A A 9 9 0 0 0 0 0 0 0 0 19 86 0101 19 86 0101 19 86 0101 20020101 19 86 0101 19 86 0101 19 9 50101 19 9 50101 19 9 00101 19 9 00101 19 9 70101 20020101 19 9 6 0101 19 9 6 0101 19 9 50101 19 9 50101 N N N N N N N N Air eleva tor for heel Nonpower ma ttress overla y 00 36 9 A C C D1E D1E Powered a ir ma ttress overla y Nonpowered pressure ma ttress Sta tiona ry compressed ga s 02 36 36 33 A A A C C D D1E D1E D1C Ga s system sta tiona ry compre 00 9 6 0-9 6 0-9 6 0-4 4 107.9 6 0-4 4 107.9 D D1C P P P P P R R R R R A A P P R R 0 0 19 9 70101 19 9 80101 19 9 80101 19 9 80101 N N A A R P P R R 0 0 0 19 9 80101 19 9 80101 19 9 30101 19 9 80101 19 9 80101 20010101 N N N R 0 19 86 0101 19 9 30101 N Oxygen system ga s porta ble 00 9 6 0-4 4 107.9 D D1C R 0 19 86 0101 19 9 30101 N Porta ble ga seous 02 33 A 6 0-4 4 107.9 D D1C R 0 19 9 30101 20010101 N Porta ble liquid 02 33 A 6 0-4 4 107.9 D D1C R 0 19 9 30101 19 9 30101 N Oxygen system liquid porta bl 00 9 6 0-4 4 107.9 D D1C R 0 19 86 0101 19 9 30101 N Sta tiona ry liquid 02 33 A 6 0-4 4 107.9 D D1C R 0 19 9 30101 20010101 Oxygen system liquid sta tion 00 9 6 0-4 4 107.9 D D1C R 0 19 86 0101 19 9 30101 Oxygen contents, ga seous 33 A 6 0-4 4 107.9 D D1C P 0 19 9 30101 33 A 6 0-4 4 107.9 D D1C P 0 19 9 30101 N N 20030101 Oxygen contents, liquid 20030101 N N Porta ble 02 contents, ga s 33 A 6 0-4 4 107.9 D D1C P 0 19 9 30101 20030101 Porta ble 02 contents, liquid 33 A 6 0-4 4 107.9 D D1C P 0 19 9 30101 20030101 D D1E R 0 20030101 20050101 4 107.9 D C C D D D1C D1E D1E D1E D1E R A R R R 0 0 0 0 0 19 86 0101 19 9 00101 19 9 00101 19 9 00101 20030101 19 9 00101 20010101 19 9 6 0101 19 9 6 0101 20050101 N N N N N C C D1B D1E R R 0 0 19 9 00101 20050101 19 9 6 0101 20050101 N N Oximeter non-inva sive Vol control vent inva siv int 00 31 9 A C D 6 0-9 Pressure ventila tor 31 A 6 0-9 Oxygen tent excl croup/ped t Chest shell Chest wra p Neg press vent porta bl/sta tn Vol control vent noninv int 33 32 36 31 31 A A A A A 6 0-4 Rocking bed w/ or w/o side r Press supp vent inva sive int 36 31 A A Press supp vent noninv int 31 A RAD w/o ba ckup non-inv intfc 36 A 6 0-9 6 0-9 Z2 D1E 9 R 0 0 P R 20030101 19 850101 N N 20030101 20050101 N N 2004 1231 N C D1E R 0 20050101 20050101 N D 6 0-9 D1E R 0 2004 0101 2004 0101 N RAD w/ba ckup non inv intrfc 36 A 6 0-9 D D1E R 0 2004 0101 2006 04 01 P RAD w ba ckup inva sive intrfc 36 A 6 0-9 D D1E R 0 2004 0101 2006 04 01 P Percussor elect/pneum home m Intrpulmnry percuss vent sys Cough stimula ting device Chest compression gen system 36 00 36 36 A 9 A A 6 0-9 6 0-21 D M C C D1E D1E D1E D1E R A R R 0 0 0 0 19 86 0101 20020101 20020101 20030101 19 9 6 0101 20020701 20020101 20030101 N N N N Non-elec oscilla tory pep dvc Ora l device/a pplia nce prefa b 32 32 A A C C D1E D1E A P Ora l device/a pplia nce cusfa b 32 A C D1E P R P R P 0 0 20030101 2006 0101 20030101 2006 0101 N N 0 2006 0101 2006 0101 N Ippb a ll types 31 A 6 0-9 D D1E R 0 19 86 0101 19 9 6 0101 Humidif extens supple w ippb 33 A 6 0-9 D D1E R 0 19 86 0101 20050701 A 6 0-9 Humidifier supplementa l w/ i 33 A 6 0-9 Humidifier nonhea ted w PAP Humidifier hea ted used w PAP Compressor a ir power source Humidifier for use w/ regula 32 32 36 33 A A A Nebuliz er with compression Aerosol compressor for svneb Aerosol compressor a djust pr Ultra sonic genera tor w svneb Nebuliz er ultra sonic Nebuliz er for use w/ regula t 36 36 36 36 31 32 A A A A A A 6 0-9 6 0-9 6 0-9 6 0-9 4 107.9 Nebuliz er w/ compressor & he Dispensing fee dme neb drug Suction pump porta b hom modl Cont a irwa y pressure device Ma nua l brea st pump Electric brea st pump Hosp gra de elec brea st pump 36 46 36 36 32 00 00 A A A A A 9 9 6 0-9 4 107.9 Va poriz er room type Dra ina ge boa rd postura l Blood glucose monitor home Pa cema ker monitr a udible/vis 32 36 32 32 A A A A 6 0-9 6 0-9 6 0-11 6 0-7 50-1 6 0-7 50-1 Pa cema ker monitr digita l/vis 32 A Ca rdia c event recorder Automa tic ext defibrilla tor Apnea monitor Apnea monitor w recorder Ca p bld skin piercing la ser Pa tient lift sling or sea t Pa tient lift ba throom or toi Sea t lift incorp lift-cha ir Sea t lift for pt furn-electr Sea t lift for pt furn-non-el Pa tient lift hydra ulic Pa tient lift electric PT support & positioning sys 00 36 00 00 32 32 00 32 32 32 36 36 36 9 A 9 9 A A 9 A A A A A A Combina tion sit to sta nd sys 32 4 107.9 D 6 0-9 6 0-9 6 0-8 6 0-8 A 9 4 107.8 4 107.8 4 107.8 Q0080 Q0078 Q0079 6 0-9 9 9 9 A A A A A A A A A A A A A A Inter limb compress dev NOS 00 Uvl pnl 2 sq ft or less 32 32 P P P R R R 0 0 0 0 0 0 19 86 0101 20010101 20010101 20010101 19 86 0101 19 86 0101 19 9 6 0101 20010101 20010101 20030101 20010101 19 9 80101 D1E D1G D1E D1E D1E Z2 Z2 R 9 R R 9 9 9 0 0 0 0 0 0 0 19 86 0101 20000101 19 86 0101 19 880101 20000101 20020101 20020101 19 9 6 0101 2006 0101 20020101 19 9 6 0101 20020101 20020101 20020101 D1E D1E D1E D1E A R A A 0 0 0 0 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 D1E A C C C C C D M D D D D D C D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E 9 9 R R A A A A A A R R R D1E R P R P P R R P R A P R D1E A P R 9 35-4 6 R 0 0 20050101 2006 0101 20070101 2006 0101 F N R R R R R R R R R R R R R R 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2006 0101 19 86 0101 19 880101 19 880101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 880101 19 880101 19 9 4 0101 19 9 50101 19 9 50101 19 9 50101 2004 0101 2006 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 4 0101 19 9 50101 19 9 50101 19 9 50101 2004 0101 N N N N N N N N N N N N N N N D1E A P R 0 20070101 20070101 D1E A P R 0 P R 0 20030101 R 0 20030101 20030101 P R 0 20030101 R R R R R 0 0 0 0 0 19 86 0101 20030101 2006 0101 19 86 0101 19 86 0101 19 9 6 0101 20070101 2006 0101 19 9 6 0101 20070101 N D T N C R 0 19 86 0101 20070101 R 0 19 89 0101 19 9 6 0101 P R 0 19 86 0101 200104 01 0 0 0 0 19 89 0101 19 86 0101 19 89 0101 19 86 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 70101 0 0 0 0 19 9 6 0101 19 86 0101 20020101 20020101 19 9 70101 20000701 2006 0101 2006 0101 20051231 20051231 N N N N 0 0 0 0 19 9 00101 20010101 20010101 20010101 19 9 504 01 2006 0101 2006 0101 2006 0101 20051231 20051231 20051231 N N N N 20051231 A 6 0.24 D D1E A 35-77 35-27 35-4 8 C D D D D1E D1E D1E D1E R R A A P P R R Elec osteogen stim spina l Elec osteogen stim impla nted Neurostimula tor electrode Pulsegenera tor pt progra mmer 32 36 38 38 A A A A D1E D1E D1F D1F A 9 P P R 6 5-8 D D D D P L86 80 L86 81 Electronic sa liva ry reflex s Impla nta ble pulse genera tor Impla nta ble RF receiver Externa l RF tra nsmitter 52 38 38 38 A A A A L86 82 L86 83 C D D D Z2 D1F D1F D1F A P P P P 6 5-8 6 5-8 6 5-8 35-4 8 35-4 8 6 5-8 A L86 84 R P A 9 C D1E A P R 0 2006 0101 2006 0101 N 35-77 D D1F A P R 0 2006 0101 2006 0101 N C D1E A P R P 00 9 35-102 D Y2 9 32 36 32 36 A A A A D1E D1E D1E D1E A A A 9 E P P R P R R 6 0-14 C C C D Non-progra mble infusion pump 32 A 6 0-14 D D1E A P R P R Progra mma ble infusion pump 32 A 6 0-14 36 32 A A 6 0-14 D Impla nta ble pump repla cement 32 A 6 0-14 Pa rentera l infusion pump sta Ambula tory tra ction device Tra ct fra me a tta ch hea dboa rd Cervica l pneum tra c equip 36 00 32 32 A 9 A A 6 5-10 6 0-9 6 0-9 Tra ction sta nd free sta nding Cervica l tra ction e 32 A 6 0-9 D1E A D D 6 0-14 D1E D1E 2006 0101 20010101 20050101 0 Electric wound trea tment dev Iv pole Amb infusion pump mecha nica l Mech a mb infusion pump <8hrs Externa l a mbula tory infus pu Ext a mb infusn pump insulin Repla cement impl pump ca thet 20020101 19 9 70101 20030101 N D1F D1E D1E A 0 N N N N C C D 35-4 8 0 0 C N 35-102 A 32 N 2006 1231 P P A A A A Nerve stimula tor for tx n&v N N 20030101 P P P P P A A 32 A N 20030101 P A A A A A A D1E D1E 36 36 52 32 36 A 20030101 A A D1E D1E D1E D1E Z2 D1E Incontinence trea tment systm 32 20030101 D1E D1E 0125 D D Neuromuscula r stim for scoli Neuromuscula r stim for shock Electromyogra ph biofeedba ck Elec osteogen stim not spine Tra ns elec jt stim dev sys N N F P P P P P P P P P P P P P P P C C D C D 4 107.6 Functiona l neuromuscula rstim 2006 0101 2006 0101 20070101 9 A C 35-20 4 5-25 A 9 2004 0101 2004 0101 20050101 A A A A A A A A A A A A A A R C 4 107.6 A A 38 N N N N N N N N N N N N N N 0 0 0 Y2 D1E C 35-4 6 32 34 32 00 19 9 6 0101 200504 01 20010101 20030101 20030101 20020101 19 9 6 0101 20050101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 20030101 D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E D1E C 35-20 Tens four lea d Repla ce rdfrquncy tra nsmittr N N N N 19 86 0101 20000101 20010101 20030101 20030101 20020101 19 86 0101 19 86 0101 19 9 20101 19 9 20101 19 9 20101 19 86 0101 19 86 0101 20030101 C Conductive ga rment for tens/ Osteogen ultra sound stimltor Nontherm electromgntc device N N N N N N N 0 R R R R R R Y2 N N N N N N 0 0 0 0 0 0 0 0 0 0 0 0 0 R P P P P P P N N N N 20051231 C M A 9 A A A A R A A A R P M D D D D D D D D D D D D D C 6 0-9 6 0-9 6 0-16 6 0-16 6 0-16 6 0-16 6 0-16 6 0-16 6 0-16 6 0-16 6 0-16 6 0-16 6 0-16 6 0-16 6 0-16 A 32 00 32 32 57 32 D1E D1E D1E D1E D1E D1E N 20050701 2004 0101 2004 0101 19 9 6 0101 D A 32 Uvl md ca binet sys 6 ft Sa fety equipment Helmet w fa ce gua rd prefa b Tra nsfer boa rd or device Restra ints a ny type Tens two lea d 19 86 0101 2004 0101 2004 0101 19 820101 M A Uvl sys pa nel 4 ft N N 19 9 6 0101 0 0 0 0 C 9 Uvl sys pa nel 6 ft 19 86 0101 R R R D 9 00 00 0 P P P D D D D 6 0-9 00 00 00 32 32 32 32 32 32 32 32 32 32 32 32 32 36 R A A A R D C D D C C C 6 0-9 6 0-9 Sta nding fra me sys Fixed pa tient lift system Multi-position stnd fra m sys P D1E D1E D1E D1E D D C C D D 4 107.9 6 0-9 6 0-17 Movea ble pa tient lift system Dyna mic sta nding fra me Pneuma compresor non-segment Pneum compressor segmenta l Pneum compres w/ca l pressure Pneuma tic a pplia nce ha lf a rm Pneuma tic a pplia nce full leg Pneuma tic a pplia nce full a rm Pneuma tic a pplia nce ha lf leg Seg pneuma tic a ppl full leg Seg pneuma tic a ppl full a rm Seg pneuma tic a ppli ha lf leg Pressure pneum a ppl full leg Pressure pneum a ppl full a rm Pressure pneum a ppl ha lf leg Pneuma tic compression device D1C D C C C 20010101 20010101 N N N N 0 R P R 20050101 20050101 N 0 0 0 0 19 850101 20000101 20000101 19 870101 19 9 504 01 20000101 20000101 20000701 N N N N 0 19 86 0101 20030101 N 0 19 9 50101 19 9 80101 N 0 0 19 9 6 0101 19 9 9 0101 20000701 19 9 9 0101 N N D 2130 4 4 50 D1E 9 0 20010101 20010101 N D D D C D1E D1E D1E D1E R P A A P P R R 0 0 0 0 19 89 0101 20010101 19 84 0101 20050101 19 9 6 0101 20010101 19 9 4 0101 20050101 N N N N D D1E A P R 0 19 820101 19 9 4 0101 N PUF___2007_Web_File G9 088 G9 088 G9 088 G9 088 G9 089 G9 089 G9 089 G9 09 0 G9 09 0 G9 09 0 G9 09 0 G9 09 0 G9 09 1 G9 09 1 G9 09 1 G9 09 1 G9 09 1 G9 09 2 G9 09 2 G9 09 2 G9 09 2 G9 09 2 G9 09 3 G9 09 3 G9 09 3 G9 09 3 G9 09 3 G9 09 4 G9 09 4 G9 09 4 G9 09 5 G9 09 5 G9 09 5 G9 09 6 G9 09 6 G9 09 6 G9 09 6 G9 09 6 G9 09 7 G9 09 7 G9 09 7 G9 09 7 G9 09 7 G9 09 8 G9 09 8 G9 09 8 G9 09 8 G9 09 9 G9 09 9 G9 09 9 G9 09 9 G9 100 G9 100 G9 100 G9 100 G9 101 G9 101 G9 101 G9 101 G9 102 G9 102 G9 102 G9 102 G9 103 G9 103 G9 103 G9 103 G9 104 G9 104 G9 104 G9 105 G9 105 G9 105 G9 105 G9 106 G9 106 G9 106 G9 107 G9 107 G9 107 G9 108 G9 108 G9 108 G9 109 G9 109 G9 109 G9 109 G9 109 G9 110 G9 110 G9 110 G9 110 G9 110 G9 111 G9 111 G9 111 G9 111 G9 112 G9 112 G9 112 G9 112 G9 113 G9 113 G9 113 G9 114 G9 114 G9 114 G9 114 G9 115 G9 115 G9 115 G9 116 G9 116 G9 116 G9 117 G9 117 G9 117 G9 118 G9 118 G9 118 G9 118 G9 119 G9 119 G9 119 G9 119 G9 120 G9 120 G9 120 G9 121 G9 121 G9 121 G9 121 G9 122 G9 122 G9 122 G9 122 G9 122 G9 123 G9 123 G9 123 G9 123 G9 124 G9 124 G9 124 G9 124 G9 125 G9 125 G9 125 G9 125 G9 126 G9 126 G9 126 G9 127 G9 127 G9 127 G9 128 G9 128 G9 129 G9 129 G9 130 G9 130 G9 130 G9 131 G9 131 G9 131 G9 131 G9 132 G9 132 G9 132 G9 132 G9 133 G9 133 G9 133 G9 134 G9 134 G9 134 G9 135 G9 135 G9 135 G9 136 G9 136 G9 136 G9 137 G9 137 G9 138 G9 138 G9 138 G9 138 G9 139 G9 139 G9 139 H0001 H0002 H0002 H0003 H0003 H0004 H0005 H0006 H0007 H0008 H0009 H0010 H0010 H0011 H0011 H0012 H0012 H0013 H0013 H0014 H0015 H0015 H0015 H0015 H0016 H0016 H0017 H0017 H0018 H0018 H0019 H0019 H0019 H0020 H0020 H0021 H0021 H0022 H0023 H0023 H0024 H0024 H0025 H0025 H0026 H0026 H0027 H0027 H0027 H0028 H0028 H0028 H0029 H0029 H0030 H0031 H0032 H0033 H0034 H0035 H0036 H0037 H0038 H0039 H004 0 H004 1 H004 2 H004 3 H004 4 H004 5 H004 6 H004 7 H004 8 H004 8 H004 9 H0050 H1000 H1001 H1002 H1003 H1004 H1005 H1010 H1011 H1011 H2000 H2001 H2010 H2011 H2012 H2013 H2014 H2015 H2016 H2017 H2018 H2019 H2020 H2021 H2022 H2023 H2024 H2025 H2026 H2027 H2028 H2029 H2030 H2031 H2032 H2033 H2034 H2035 H2036 H2037 H2037 J0120 J0128 J0129 J0130 J0132 J0133 J0135 J0150 J0150 J0151 J0151 J0152 J0152 J0170 J0180 J019 0 J0200 J0205 J0207 J0210 J0215 J0256 J0270 J0270 J0270 J0275 J0275 J0275 J0278 J0280 J0282 J0285 J0287 J0288 J0289 J029 0 J029 5 J0300 J0330 J034 8 J0350 J036 0 J036 4 J036 5 J0380 J039 0 J039 5 J04 56 J04 6 0 J04 70 J04 75 J04 76 J04 80 J0500 J0515 J0520 J0530 J0530 J054 0 J054 0 J0550 J0550 J056 0 J0570 J0580 J0583 J0585 J0587 J059 2 J059 4 J059 5 J06 00 J06 10 J06 20 J06 30 J06 36 J06 37 J06 4 0 J06 70 J06 9 0 J06 9 2 J06 9 4 J06 9 6 J06 9 7 J06 9 8 J0702 J0704 J0706 J0710 J0713 J0715 J0720 J0725 J0735 J074 0 J074 3 J074 4 J074 5 J076 0 J0770 J0780 J079 5 J0800 J0835 J0850 J0878 J0880 J0881 J0882 J0885 J0886 J089 4 J089 5 J09 00 J09 4 5 J09 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300 4 00 100 200 300 100 200 300 100 200 300 100 200 300 4 00 100 200 300 4 00 100 200 300 100 200 300 4 00 100 200 300 4 00 500 100 200 300 4 00 100 200 300 4 00 100 200 300 4 00 100 200 300 100 200 300 100 200 100 200 100 200 300 100 200 300 4 00 100 200 300 4 00 100 200 300 100 200 300 100 200 300 100 200 300 100 200 100 200 300 4 00 100 200 300 100 100 200 100 200 100 100 100 100 100 100 100 200 100 200 100 200 100 200 100 100 200 300 4 00 100 200 100 200 100 200 100 200 300 100 200 100 200 100 100 200 100 200 100 200 100 200 100 200 300 100 200 300 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 100 100 100 100 100 100 100 200 100 200 100 200 100 100 100 100 100 100 100 100 100 100 200 300 100 200 300 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 200 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 300 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 3 4 4 4 3 4 4 3 4 4 4 4 3 4 4 4 4 3 4 4 4 4 3 4 4 4 4 3 4 4 3 4 4 3 4 4 4 4 3 4 4 4 4 3 4 4 4 3 4 4 4 3 4 4 4 3 4 4 4 3 4 4 4 3 4 4 4 3 4 4 3 4 4 4 3 4 4 3 4 4 3 4 4 3 4 4 4 4 3 4 4 4 4 3 4 4 4 3 4 4 4 3 4 4 3 4 4 4 3 4 4 3 4 4 3 4 4 3 4 4 4 3 4 4 4 3 4 4 3 4 4 4 3 4 4 4 4 3 4 4 4 3 4 4 4 3 4 4 4 3 4 4 3 4 4 3 4 3 4 3 4 4 3 4 4 4 3 4 4 4 3 4 4 3 4 4 3 4 4 3 4 4 3 4 3 4 4 4 3 4 4 3 3 4 3 4 3 3 3 3 3 3 3 4 3 4 3 4 3 4 3 3 4 4 4 3 4 3 4 3 4 3 4 4 3 4 3 4 3 3 4 3 4 3 4 3 4 3 4 4 3 4 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 4 3 4 3 4 3 3 3 3 3 3 3 3 3 3 4 4 3 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER, ADENOCARCINOMA AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE WITHOUT CURRENT CLINICAL, RADIOLOGIC, OR BIOCHEMICAL EVIDENCE OF DISEASE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER, ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER, ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY ESTABLISHED AS T1-2, N0, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER, ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY ESTABLISHED AS T3, N0, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER, ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY ESTABLISHED AS T1-3, N1-2, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER, ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY ESTABLISHED AS T4 , ANY N, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER, ADENOCARCINOMA AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER, ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA OR SQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY ESTABLISHED AS T1-T3, N0-N1 OR NX (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA OR SQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY ESTABLISHED AS T4 , ANY N, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA OR SQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA OR SQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA AS PREDOMINANT CELL TYPE; POST R0 RESECTION (WITH OR WITHOUT NEOADJUVANT THERAPY) WITH NO EVIDENCE OF DISEASE RECURRENCE, PROGRESSION, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA AS PREDOMINANT CELL TYPE; POST R1 OR R2 RESECTION (WITH OR WITHOUT NEOADJUVANT THERAPY) WITH NO EVIDENCE OF DISEASE PROGRESSION, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA AS PREDOMINANT CELL TYPE; CLINICAL OR PATHOLOGIC M0, UNRESECTABLE WITH NO EVIDENCE OF DISEASE PROGRESSION, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA AS PREDOMINANT CELL TYPE; CLINICAL OR PATHOLOGIC M1 AT DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA AS PREDOMINANT CELL TYPE; POST R0 RESECTION WITHOUT EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA; POST R1 OR R2 RESECTION WITH NO EVIDENCE OF DISEASE PROGRESSION, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA; UNRESECTABLE AT DIAGNOSIS, M1 AT DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORAL CAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY ESTABLISHED AS T1-T2 AND N0, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORAL CAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY ESTABLISHED AS T3-4 AND/OR N1-3, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORAL CAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORAL CAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER; PATHOLOGIC STAGE IA-B (GRADE 1) WITHOUT EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER; PATHOLOGIC STAGE IA-B (GRADE 2-3); OR STAGE IC (ALL GRADES); OR STAGE II; WITHOUT EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER; PATHOLOGIC STAGE III-IV; WITHOUT EVIDENCE OF PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER; EVIDENCE OF DISEASE PROGRESSION, OR RECURRENCE, AND/OR PLATINUM RESISTANCE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, LIMITED TO FOLLICULAR LYMPHOMA, MANTLE CELL LYMPHOMA, DIFFUSE LARGE B-CELL LYMPHOMA, SMALL LYMPHOCYTIC LYMPHOMA; STAGE I, II AT DIAGNOSIS, NOT RELAPSED, NOT REFRACTORY (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, LIMITED TO FOLLICULAR LYMPHOMA, MANTLE CELL LYMPHOMA, DIFFUSE LARGE B-CELL LYMPHOMA, SMALL LYMPHOCYTIC LYMPHOMA; STAGE III, IV NOT RELAPSED, NOT REFRACTORY (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA; TRANSFORMED FROM FOLLICULAR LYMPHOMA TO DIFFUSE LARGE B-CELL LYMPHOMA (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, LIMITED TO FOLLICULAR LYMPHOMA, MANTLE CELL LYMPHOMA, DIFFUSE LARGE B-CELL LYMPHOMA, SMALL LYMPHOCYTIC LYMPHOMA; RELAPSED/REFRACTORY (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, LIMITED TO FOLLICULAR LYMPHOMA, MANTLE CELL LYMPHOMA, DIFFUSE LARGE B-CELL LYMPHOMA, SMALL LYMPHOCYTIC LYMPHOMA; DIAGNOSTIC EVALUATION, STAGE NOT DETERMINED, EVALUATION OF POSSIBLE RELAPSE OR NON-RESPONSE TO THERAPY, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIA CHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; CHRONIC PHASE NOT IN HEMATOLOGIC, CYTOGENETIC, OR MOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIA CHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; ACCELERATED PHASE NOT IN HEMATOLOGIC CYTOGENETIC, OR MOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIA CHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; BLAST PHASE NOT IN HEMATOLOGIC, CYTOGENETIC, OR MOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIA CHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; IN HEMATOLOGIC, CYTOGENETIC, OR MOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIA CHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; EXTENT OF DISEASE UNKNOWN, UNDER EVALUATION, NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; LIMITED TO MULTIPLE MYELOMA, SYSTEMIC DISEASE; SMOLDERING, STAGE I (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; LIMITED TO MULTIPLE MYELOMA, SYSTEMIC DISEASE; STAGE II OR HIGHER (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; LIMITED TO MULTIPLE MYELOMA, SYSTEMIC DISEASE; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDE DUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA; HORMONE-REFRACTORY/ANDROGEN-INDEPENDENT (E.G., RISING PSA ON ANTI-ANDROGEN THERAPY OR POST-ORCHIECTOMY); CLINICAL METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA; HORMONE-RESPONSIVE; CLINICAL METASTASES OR M1 AT DIAGNOSIS (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION; STAGE I, II AT DIAGNOSIS, NOT RELAPSED, NOT REFRACTORY (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION; STAGE III, IV, NOT RELAPSED, NOT REFRACTORY (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, TRANSFORMED FROM ORIGINAL CELLULAR DIAGNOSIS TO A SECOND CELLULAR CLASSIFICATION (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION; RELAPSED/REFRACTORY (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION; DIAGNOSTIC EVALUATION, STAGE NOT DETERMINED, EVALUATION OF POSSIBLE RELAPSE OR NON-RESPONSE TO THERAPY, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIA CHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT) ALCOHOL AND/OR DRUG ASSESSMENT BEHAVIORAL HEALTH SCREENING TO DETERMINE ELIGIBILITY FOR ADMISSION TO TREATMENT PROGRAM ALCOHOL AND/OR DRUG SCREENING; LABORATORY ANALYSIS OF SPECIMENS FOR PRESENCE OF ALCOHOL AND/OR DRUGS BEHAVIORAL HEALTH COUNSELING AND THERAPY, PER 15 MINUTES ALCOHOL AND/OR DRUG SERVICES; GROUP COUNSELING BY A CLINICIAN ALCOHOL AND/OR DRUG SERVICES; CASE MANAGEMENT ALCOHOL AND/OR DRUG SERVICES; CRISIS INTERVENTION (OUTPATIENT) ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (HOSPITAL INPATIENT) ALCOHOL AND/OR DRUG SERVICES; ACUTE DETOXIFICATION (HOSPITAL INPATIENT) ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (RESIDENTIAL ADDICTION PROGRAM INPATIENT) ALCOHOL AND/OR DRUG SERVICES; ACUTE DETOXIFICATION (RESIDENTIAL ADDICTION PROGRAM INPATIENT) ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (RESIDENTIAL ADDICTION PROGRAM OUTPATIENT) ALCOHOL AND/OR DRUG SERVICES; ACUTE DETOXIFICATION (RESIDENTIAL ADDICTION PROGRAM OUTPATIENT) ALCOHOL AND/OR DRUG SERVICES; AMBULATORY DETOXIFICATION ALCOHOL AND/OR DRUG SERVICES; INTENSIVE OUTPATIENT (TREATMENT PROGRAM THAT OPERATES AT LEAST 3 HOURS/DAY AND AT LEAST 3 DAYS/WEEK AND IS BASED ON AN INDIVIDUALIZ ED TREATMENT PLAN), INCLUDING ASSESSMENT, COUNSELING; CRISIS INTERVENTION, AND ACTIVITY THERAPIES OR EDUCATION ALCOHOL AND/OR DRUG SERVICES; MEDICAL/SOMATIC (MEDICAL INTERVENTION IN AMBULATORY SETTING) BEHAVIORAL HEALTH; RESIDENTIAL (HOSPITAL RESIDENTIAL TREATMENT PROGRAM), WITHOUT ROOM AND BOARD, PER DIEM BEHAVIORAL HEALTH; SHORT-TERM RESIDENTIAL (NON-HOSPITAL RESIDENTIAL TREATMENT PROGRAM), WITHOUT ROOM AND BOARD, PER DIEM BEHAVIORAL HEALTH; LONG-TERM RESIDENTIAL (NON-MEDICAL, NON-ACUTE CARE IN A RESIDENTIAL TREATMENT PROGRAM WHERE STAY IS TYPICALLY LONGER THAN 30 DAYS), WITHOUT ROOM AND BOARD, PER DIEM ALCOHOL AND/OR DRUG SERVICES; METHADONE ADMINISTRATION AND/OR SERVICE (PROVISION OF THE DRUG BY A LICENSED PROGRAM) ALCOHOL AND/OR DRUG TRAINING SERVICE (FOR STAFF AND PERSONNEL NOT EMPLOYED BY PROVIDERS) ALCOHOL AND/OR DRUG INTERVENTION SERVICE (PLANNED FACILITATION) BEHAVIORAL HEALTH OUTREACH SERVICE (PLANNED APPROACH TO REACH A TARGETED POPULATION) BEHAVIORAL HEALTH PREVENTION INFORMATION DISSEMINATION SERVICE (ONE-WAY DIRECT OR NON-DIRECT CONTACT WITH SERVICE AUDIENCES TO AFFECT KNOWLEDGE AND ATTITUDE) BEHAVIORAL HEALTH PREVENTION EDUCATION SERVICE (DELIVERY OF SERVICES WITH TARGET POPULATION TO AFFECT KNOWLEDGE, ATTITUDE AND/OR BEHAVIOR) ALCOHOL AND/OR DRUG PREVENTION PROCESS SERVICE, COMMUNITY-BASED (DELIVERY OF SERVICES TO DEVELOP SKILLS OF IMPACTORS) ALCOHOL AND/OR DRUG PREVENTION ENVIRONMENTAL SERVICE (BROAD RANGE OF EXTERNAL ACTIVITIES GEARED TOWARD MODIFYING SYSTEMS IN ORDER TO MAINSTREAM PREVENTION THROUGH POLICY AND LAW) ALCOHOL AND/OR DRUG PREVENTION PROBLEM IDENTIFICATION AND REFERRAL SERVICE (E.G. STUDENT ASSISTANCE AND EMPLOYEE ASSISTANCE PROGRAMS), DOES NOT INCLUDE ASSESSMENT ALCOHOL AND/OR DRUG PREVENTION ALTERNATIVES SERVICE (SERVICES FOR POPULATIONS THAT EXCLUDE ALCOHOL AND OTHER DRUG USE E.G. ALCOHOL FREE SOCIAL EVENTS) BEHAVIORAL HEALTH HOTLINE SERVICE MENTAL HEALTH ASSESSMENT, BY NON-PHYSICIAN MENTAL HEALTH SERVICE PLAN DEVELOPMENT BY NON-PHYSICIAN ORAL MEDICATION ADMINISTRATION, DIRECT OBSERVATION MEDICATION TRAINING AND SUPPORT, PER 15 MINUTES MENTAL HEALTH PARTIAL HOSPITALIZ ATION, TREATMENT, LESS THAN 24 HOURS COMMUNITY PSYCHIATRIC SUPPORTIVE TREATMENT, FACE-TO-FACE, PER 15 MINUTES COMMUNITY PSYCHIATRIC SUPPORTIVE TREATMENT PROGRAM, PER DIEM SELF-HELP/PEER SERVICES, PER 15 MINUTES ASSERTIVE COMMUNITY TREATMENT, FACE-TO-FACE, PER 15 MINUTES ASSERTIVE COMMUNITY TREATMENT PROGRAM, PER DIEM FOSTER CARE, CHILD, NON-THERAPEUTIC, PER DIEM FOSTER CARE, CHILD, NON-THERAPEUTIC, PER MONTH SUPPORTED HOUSING, PER DIEM SUPPORTED HOUSING, PER MONTH RESPITE CARE SERVICES, NOT IN THE HOME, PER DIEM MENTAL HEALTH SERVICES, NOT OTHERWISE SPECIFIED ALCOHOL AND/OR OTHER DRUG ABUSE SERVICES, NOT OTHERWISE SPECIFIED ALCOHOL AND/OR OTHER DRUG TESTING: COLLECTION AND HANDLING ONLY, SPECIMENS OTHER THAN BLOOD ALCOHOL AND/OR DRUG SCREENING ALCOHOL AND/OR DRUG SERVICES, BRIEF INTERVENTION, PER 15 MINUTES PRENATAL CARE, AT-RISK ASSESSMENT PRENATAL CARE, AT-RISK ENHANCED SERVICE; ANTEPARTUM MANAGEMENT PRENATAL CARE, AT RISK ENHANCED SERVICE; CARE COORDINATION PRENATAL CARE, AT-RISK ENHANCED SERVICE; EDUCATION PRENATAL CARE, AT-RISK ENHANCED SERVICE; FOLLOW-UP HOME VISIT PRENATAL CARE, AT-RISK ENHANCED SERVICE PACKAGE (INCLUDES H1001-H1004 ) NON-MEDICAL FAMILY PLANNING EDUCATION, PER SESSION FAMILY ASSESSMENT BY LICENSED BEHAVIORAL HEALTH PROFESSIONAL FOR STATE DEFINED PURPOSES COMPREHENSIVE MULTIDISCIPLINARY EVALUATION REHABILITATION PROGRAM, PER 1/2 DAY COMPREHENSIVE MEDICATION SERVICES, PER 15 MINUTES CRISIS INTERVENTION SERVICE, PER 15 MINUTES BEHAVIORAL HEALTH DAY TREATMENT, PER HOUR PSYCHIATRIC HEALTH FACILITY SERVICE, PER DIEM SKILLS TRAINING AND DEVELOPMENT, PER 15 MINUTES COMPREHENSIVE COMMUNITY SUPPORT SERVICES, PER 15 MINUTES COMPREHENSIVE COMMUNITY SUPPORT SERVICES, PER DIEM PSYCHOSOCIAL REHABILITATION SERVICES, PER 15 MINUTES PSYCHOSOCIAL REHABILITATION SERVICES, PER DIEM THERAPEUTIC BEHAVIORAL SERVICES, PER 15 MINUTES THERAPEUTIC BEHAVIORAL SERVICES, PER DIEM COMMUNITY-BASED WRAP-AROUND SERVICES, PER 15 MINUTES COMMUNITY-BASED WRAP-AROUND SERVICES, PER DIEM SUPPORTED EMPLOYMENT, PER 15 MINUTES SUPPORTED EMPLOYMENT, PER DIEM ONGOING SUPPORT TO MAINTAIN EMPLOYMENT, PER 15 MINUTES ONGOING SUPPORT TO MAINTAIN EMPLOYMENT, PER DIEM PSYCHOEDUCATIONAL SERVICE, PER 15 MINUTES SEXUAL OFFENDER TREATMENT SERVICE, PER 15 MINUTES SEXUAL OFFENDER TREATMENT SERVICE, PER DIEM MENTAL HEALTH CLUBHOUSE SERVICES, PER 15 MINUTES MENTAL HEALTH CLUBHOUSE SERVICES, PER DIEM ACTIVITY THERAPY, PER 15 MINUTES MULTISYSTEMIC THERAPY FOR JUVENILES, PER 15 MINUTES ALCOHOL AND/OR DRUG ABUSE HALFWAY HOUSE SERVICES, PER DIEM ALCOHOL AND/OR OTHER DRUG TREATMENT PROGRAM, PER HOUR ALCOHOL AND/OR OTHER DRUG TREATMENT PROGRAM, PER DIEM DEVELOPMENTAL DELAY PREVENTION ACTIVITIES, DEPENDENT CHILD OF CLIENT, PER 15 MINUTES INJECTION, TETRACYCLINE, UP TO 250 MG INJECTION, ABARELIX, 10 MG INJECTION, ABATACEPT, 10 MG INJECTION ABCIXIMAB, 10 MG INJECTION, ACETYLCYSTEINE, 100 MG INJECTION, ACYCLOVIR, 5 MG INJECTION, ADALIMUMAB, 20 MG INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS, INSTEAD USE A9 270) INJECTION, ADENOSINE, 9 0 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS, INSTEAD USE A9 270) INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS; INSTEAD USE A9 270) INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, AGALSIDASE BETA, 1 MG INJECTION, BIPERIDEN LACTATE, PER 5 MG INJECTION, ALATROFLOXACIN MESYLATE, 100 MG INJECTION, ALGLUCERASE, PER 10 UNITS INJECTION, AMIFOSTINE, 500 MG INJECTION, METHYLDOPATE HCL, UP TO 250 MG INJECTION, ALEFACEPT, 0.5 MG INJECTION, ALPHA 1 - PROTEINASE INHIBITOR - HUMAN, 10 MG INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) INJECTION, AMIKACIN SULFATE, 100 MG INJECTION, AMINOPHYLLIN, UP TO 250 MG INJECTION, AMIODARONE HYDROCHLORIDE, 30 MG INJECTION, AMPHOTERICIN B, 50 MG INJECTION, AMPHOTERICIN B LIPID COMPLEX, 10 MG INJECTION, AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, 10 MG INJECTION, AMPHOTERICIN B LIPOSOME, 10 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM INJECTION, AMOBARBITAL, UP TO 125 MG INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, ANADULAFUNGIN, 1 MG INJECTION, ANISTREPLASE, PER 30 UNITS INJECTION, HYDRALAZ INE HCL, UP TO 20 MG INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG INJECTION, APROTONIN, 10,000 KIU INJECTION, METARAMINOL BITARTRATE, PER 10 MG INJECTION, CHLOROQUINE HYDROCHLORIDE, UP TO 250 MG INJECTION, ARBUTAMINE HCL, 1 MG INJECTION, AZ ITHROMYCIN, 500 MG INJECTION, ATROPINE SULFATE, UP TO 0.3 MG INJECTION, DIMERCAPROL, PER 100 MG INJECTION, BACLOFEN, 10 MG INJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL INJECTION, BASILIXIMAB, 20 MG INJECTION, DICYCLOMINE HCL, UP TO 20 MG INJECTION, BENZ TROPINE MESYLATE, PER 1 MG INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, UP TO 5 MG INJECTION, PENICILLIN G BENZ ATHINE AND PENICILLIN G PROCAINE, UP TO 6 00,000 UNITS INJECTION, PENICILLIN G BENZ ATHINE AND PENICILLIN G PROCAINE, UP TO 1,200,000 UNITS INJECTION, PENICILLIN G BENZ ATHINE AND PENICILLIN G PROCAINE, UP TO 2,4 00,000 UNITS INJECTION, PENICILLIN G BENZ ATHINE, UP TO 6 00,000 UNITS INJECTION, PENICILLIN G BENZ ATHINE, UP TO 1,200,000 UNITS INJECTION, PENICILLIN G BENZ ATHINE, UP TO 2,4 00,000 UNITS INJECTION, BIVALIRUDIN, 1 MG BOTULINUM TOXIN TYPE A, PER UNIT BOTULINUM TOXIN TYPE B, PER 100 UNITS INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUSULFAN, 1 MG INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG INJECTION, CALCIUM GLUCONATE, PER 10 ML INJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE, PER 10 ML INJECTION, CALCITONIN SALMON, UP TO 4 00 UNITS INJECTION, CALCITRIOL, 0.1 MCG INJECTION, CASPOFUNGIN ACETATE, 5 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, CEFAZ OLIN SODIUM, 500 MG INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, BETAMETHASONE ACETATE AND BETAMETHASONE SODIUM PHOSPHATE, PER 3 MG INJECTION, BETAMETHASONE SODIUM PHOSPHATE, PER 4 MG INJECTION, CAFFEINE CITRATE, 5MG INJECTION, CEPHAPIRIN SODIUM, UP TO 1 GM INJECTION, CEFTAZ IDIME, PER 500 MG INJECTION, CEFTIZ OXIME SODIUM, PER 500 MG INJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 GM INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CIDOFOVIR, 375 MG INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, 200 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, COLCHICINE, PER 1MG INJECTION, COLISTIMETHATE SODIUM, UP TO 150 MG INJECTION, PROCHLORPERAZ INE, UP TO 10 MG INJECTION, CORTICORELIN OVINE TRIFLUTATE, 1 MICROGRAM INJECTION, CORTICOTROPIN, UP TO 4 0 UNITS INJECTION, COSYNTROPIN, PER 0.25 MG INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER VIAL INJECTION, DAPTOMYCIN, 1 MG INJECTION, DARBEPOETIN ALFA, 5 MCG INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYSIS) INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS INJECTION, EPOETIN ALFA, 1000 UNITS (FOR ESRD ON DIALYSIS) INJECTION, DECITABINE, 1 MG INJECTION, DEFEROXAMINE MESYLATE, 500 MG INJECTION, TESTOSTERONE ENANTHATE AND ESTRADIOL VALERATE, UP TO 1 CC INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG INJECTION, ESTRADIOL VALERATE, UP TO 4 0 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG INJECTION, METHYLPREDNISOLONE ACETATE, 4 0 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE, 150 MG INJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL CYPIONATE, 5MG / 25MG INJECTION, TESTOSTERONE CYPIONATE AND ESTRADIOL CYPIONATE, UP TO 1 ML INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG INJECTION, ACETAZ OLAMIDE SODIUM, UP TO 500 MG INJECTION, DIGOXIN, UP TO 0.5 MG INJECTION, DIGOXIN IMMUNE FAB (OVINE), PER VIAL INJECTION, PHENYTOIN SODIUM, PER 50 MG INJECTION, HYDROMORPHONE, UP TO 4 MG INJECTION, DYPHYLLINE, UP TO 500 MG INJECTION, DEXRAZ OXANE HYDROCHLORIDE, PER 250 MG INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG INJECTION, CHLOROTHIAZ IDE SODIUM, PER 500 MG INJECTION, DMSO, DIMETHYL SULFOXIDE, 50% , 50 ML INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, DIMENHYDRINATE, UP TO 50 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOLASETRON MESYLATE, 10 MG INJECTION, DOPAMINE HCL, 4 0 MG INJECTION, DOXERCALCIFEROL, 1 MCG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, ENFUVIRTIDE, 1 MG INJECTION, EPOPROSTENOL, 0.5 MG INJECTION, EPTIFIBATIDE, 5 MG INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, ERTAPENEM SODIUM, 500 MG INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG INJECTION, ESTRADIOL VALERATE, UP TO 10 MG INJECTION, ESTRADIOL VALERATE, UP TO 20 MG INJECTION, ESTROGEN CONJUGATED, PER 25 MG INJECTION, ETHANOLAMINE OLEATE, 100 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ETIDRONATE DISODIUM, PER 300 MG INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) INJECTION, FILGRASTIM (G-CSF), 300 MCG INJECTION, FILGRASTIM (G-CSF), 4 80 MCG INJECTION FLUCONAZ OLE, 200 MG INJECTION, FOMEPIZ OLE, 15 MG INJECTION, FOMIVIRSEN SODIUM, INTRAOCULAR, 1.6 5 MG INJECTION, FOSCARNET SODIUM, PER 1000 MG INJECTION, GALLIUM NITRATE, 1 MG INJECTION, GALSULFASE, 1 MG INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC INJECTION, IMMUNE GLOBULIN, SUBCUTANEOUS, 100 MG INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, 1G INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, 10 MG INJECTION, RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN, INTRAVENOUS, 50 MG INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZ ED (E.G. POWDER), 500 MG INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZ ED (E.G. LIQUID), 500 MG INJECTION, GANCICLOVIR SODIUM, 500 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GATIFLOXACIN, 10MG INJECTION, GLATIRAMER ACETATE, 20 MG INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG INJECTION, GONADORELIN HYDROCHLORIDE, PER 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HEMIN, 1 MG INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 Page 3 Onc dx colon meta s noevid dx 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx colon extent unknown 00 9 C P7B 1 0 2006 0101 20070101 C Onc dx recta l T1-2 no progr 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx recta l T3 N0 no prog 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx recta l T1-3,N1-2noprg 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx recta l T4 ,N,M0 no prg 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx recta l M1 w/mets prog 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx recta l extent unknwn 00 9 C P7B 1 0 2006 0101 20070101 C Onc dx esopha g T1-T3 noprog 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx esopha gea l T4 no prog 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx esopha gea l mets recur 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx esopha gea l unknown 00 9 C P7B 1 0 2006 0101 20070101 C Onc dx ga stric no recurrence 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx ga stric p R1-R2noprog 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx ga stric unresecta ble 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx ga stric recurrent 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx ga stric unknown NOS 00 9 C P7B 1 0 2006 0101 20070101 C Onc dx pa ncrea tc p R0 res no 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx pa ncrea tc p R1/R2 no 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx pa ncrea tic unresecta b 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx pa ncrea tic unknwn NOS 00 9 C P7B 1 0 2006 0101 20070101 C Onc dx hea d/neck T1-T2no prg 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx hea d/neck T3-4 noprog 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx hea d/neck M1 mets rec 00 9 C P7B 1 0 2006 0101 20070101 P Onc dx hea d/neck ext unknown 00 9 C P7B 1 0 2006 0101 20070101 Onc dx ova ria n stg1A-B no pr 00 9 C P7B 1 0 2006 0101 20070101 Onc dx ova ria n stg1A-B or 2 00 9 C P7B 1 0 2006 0101 20070101 Onc dx ova ria n stg3/4 noprog 00 9 C P7B 1 0 2006 0101 00 9 C P7B 1 0 2006 0101 C P P 20070101 Onc dx ova ria n recurrence 20070101 P P Onc dx ova ria n unknown NOS 00 9 C P7B 1 0 2006 0101 20070101 Onc NHLstg 1-2 no rela p no 13 A C P7B 1 0 2006 0101 20070101 2006 1231 D Onc dx NHL stg 3-4 not rela p 13 A C P7B 1 0 2006 0101 20070101 2006 1231 C D Onc dx NHL tra ns to lg Bcell 13 A C P7B 1 0 2006 0101 20070101 2006 1231 D Onc dx NHL rela pse/refra ctor 13 A C P7B 1 0 2006 0101 20070101 2006 1231 D Onc dx NHL stg unknown 13 A C P7B 1 0 2006 0101 20070101 2006 1231 D Onc dx CML chronic pha se 00 9 C P7B 1 0 2006 0101 20070101 Onc dx CML a cceler pha se 00 9 C P7B 1 0 2006 0101 00 9 C P7B 1 0 2006 0101 20070101 Onc dx CML remission 00 9 C P7B 1 0 2006 0101 P 20070101 Onc dx CML bla st pha se 20070101 Onc dx CML dx sta tus unknown 13 A C P7B 1 0 2006 0101 20070101 Onc dx multi myeloma sta ge I 00 9 C P7B 1 0 2006 0101 P P P 20070101 Onc dx mult myeloma stg2 hig 00 9 C P7B 1 0 2006 0101 2006 1231 D P 20070101 P Onc dx multi myeloma unknown 00 9 C P7B 1 0 2006 0101 20070101 C Onc dx brst unknown NOS 00 9 C P7B 1 0 20070101 20070101 A Onc dx prosta te mets no ca st 00 9 C P7B 1 0 20070101 20070101 A Onc dx prosta te clinica l met 00 9 C P7B 1 0 20070101 20070101 A Onc NHLstg 1-2 no rela p no 00 9 C P7B 1 0 20070101 20070101 A Onc dx NHL stg 3-4 not rela p 00 9 C P7B 1 0 20070101 20070101 A Onc dx NHL tra ns to lg Bcell 00 9 C P7B 1 0 20070101 20070101 A Onc dx NHL rela pse/refra ctor 00 9 C P7B 1 0 20070101 20070101 A Onc dx NHL stg unknown 00 9 C P7B 1 0 20070101 20070101 A Onc dx CML dx sta tus unknown 00 9 C P7B 1 0 20070101 20070101 A Alcohol a nd/or drug a ssess Alcohol a nd/or drug screenin 00 00 9 9 I I Z2 Z2 9 9 0 0 20010101 20010101 20010101 20030101 N N Alcohol a nd/or drug screenin 00 9 I Z2 9 0 20010101 20010101 N Alcohol a nd/or drug services Alcohol a nd/or drug services Alcohol a nd/or drug services Alcohol a nd/or drug services Alcohol a nd/or drug services Alcohol a nd/or drug services Alcohol a nd/or drug services 00 00 00 00 00 00 00 9 9 9 9 9 9 9 I I I I I I I Z2 Z2 Z2 Z2 Z2 Z2 Z2 9 9 9 9 9 9 9 0 0 0 0 0 0 0 20010101 20010101 20010101 20010101 20010101 20010101 20010101 20030101 20010101 20010101 20010101 20010101 20010101 20010101 N N N N N N N Alcohol a nd/or drug services 00 9 I Z2 9 0 20010101 20010101 N Alcohol a nd/or drug services 00 9 I Z2 9 0 20010101 20010101 N Alcohol a nd/or drug services 00 9 I Z2 9 0 20010101 20010101 N Alcohol a nd/or drug services Alcohol a nd/or drug services 00 00 9 9 I I Z2 Z2 9 9 0 0 20010101 20010101 20010101 20010101 N N Alcohol a nd/or drug services 00 9 I Z2 9 0 20010101 20010101 N Alcohol a nd/or drug services 00 9 I Z2 9 0 20010101 20030101 N Alcohol a nd/or drug services 00 9 I Z2 9 0 20010101 20030101 N Alcohol a nd/or drug services 00 9 I Z2 9 0 20010101 20030101 N Alcohol a nd/or drug services 00 9 I Z2 9 0 20010101 20010101 N Alcohol a nd/or drug tra ining 00 9 I Z2 9 0 20010101 20010101 N Alcohol a nd/or drug interven Alcohol a nd/or drug outrea ch 00 00 9 9 I I Z2 Z2 9 9 0 0 20010101 20010101 20010101 20030101 N N Alcohol a nd/or drug preventi 00 9 I Z2 9 0 20010101 20030101 N Alcohol a nd/or drug preventi 00 9 I Z2 9 0 20010101 20030101 N Alcohol a nd/or drug preventi 00 9 I Z2 9 0 20010101 20010101 N Alcohol a nd/or drug preventi 00 9 I Z2 9 0 20010101 20010101 N Alcohol a nd/or drug preventi 00 9 I Z2 9 0 20010101 20010101 N Alcohol a nd/or drug preventi 00 9 I Z2 9 0 20010101 20010101 N Alcohol a nd/or drug hotline MH hea lth a ssess by non-md MH svc pla n dev by non-md Ora l med a dm direct observe Med trng & support per 15min MH pa rtia l hosp tx under 24 h Comm psy fa ce-fa ce per 15min Comm psy sup tx pgm per diem Self-help/peer svc per 15min Asser com tx fa ce-fa ce/15min Assert comm tx pgm per diem Fos c chld non-ther per diem Fos c chld non-ther per mon Supported housing, per diem Supported housing, per month Respite not-in-home per diem Menta l hea lth service, nos Alcohol/drug a buse svc nos Spec coll non-blood:a /d test 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 I I I I I I I I I I I I I I I I I I I Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20010101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 20030101 N N N N N N N N N N N N N N N N N N N Alcohol/drug screening Alcohol/drug service 15 min Prena ta l ca re a trisk a ssessm Antepa rtum ma na gement Ca recoordina tion prena ta l Prena ta l a t risk educa tion Follow up home visit/prenta l Prena ta lca re enha nced srv pk Nonmed fa mily pla nning ed Fa mily a ssessment 00 00 00 00 00 00 00 00 00 00 9 9 9 9 9 9 9 9 9 9 I I I I I I I I I I Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 20070101 20070101 20020101 20020101 20020101 20020101 20020101 20020101 20030101 20030101 20070101 20070101 20020101 20020101 20020101 20020101 20020101 20020101 20030101 20030101 A A N N N N N N N N Comp multidisipln eva lua tion Reha bilita tion progra m 1/2 d Comprehensive med svc 15 min Crisis interven svc, 15 min Beha v hlth da y trea t, per hr Psych hlth fa c svc, per diem Skills tra in a nd dev, 15 min Comp comm supp svc, 15 min Comp comm supp svc, per diem Psysoc reha b svc, per 15 min Psysoc reha b svc, per diem Ther beha v svc, per 15 min Ther beha v svc, per diem Com wra p-a round sv, 15 min Com wra p-a round sv, per diem Supported employ, per 15 min Supported employ, per diem Supp ma int employ, 15 min Supp ma int employ, per diem Psychoed svc, per 15 min Sex offend tx svc, 15 min Sex offend tx svc, per diem MH clubhouse svc, per 15 min MH clubhouse svc, per diem Activity thera py, per 15 min Multisys ther/juvenile 15min A/D ha lfwa y house, per diem A/D tx progra m, per hour A/D tx progra m, per diem Dev dela y prev dp ch, 15 min 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20030101 20030101 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 20030101 20030101 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 200304 01 N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N Tetra cyclin injection Aba relix injection Aba ta cept injection Abcixima b injection Acetylcysteine injection Acyclovir injection Ada limuma b injection Injection a denosine 6 MG 51 51 51 51 51 51 51 51 A A A A A A A A D C C D C C C D O1E O1E O1E O1E O1E O1E O1E O1E 1 1 1 1 1 1 1 1 P P P P P P P P 0 0 0 0 0 0 0 0 19 86 0101 20050101 20070101 19 9 9 0101 2006 0101 2006 0101 20050101 19 9 4 0101 19 9 70101 20050101 20070101 19 9 9 0101 2006 0101 2006 0101 20050101 20050101 Adenosine injection 51 A D O1E 1 P 0 19 9 9 0101 2004 0101 204 9 204 9 204 9 204 9 J0152 N N A N N N N N 20031231 N Adenosine injection 51 A C O1E 1 P 0 2004 0101 20050101 N Adrena lin epinephrin inject Aga lsida se beta injection Inj biperiden la cta te/5 mg Ala trofloxa cin mesyla te Alglucera se injection Amifostine Methyldopa te hcl injection Alefa cept Alpha 1 proteina se inhibitor Alprosta dil for injection 51 51 51 51 51 51 51 51 51 51 A A A A A A A A A A 204 9 204 9 .5 204 9 204 9 204 9 204 9 204 9 D C D D D D D C D D O1E O1E O1E O1E O1E O1D O1E O1E O1E O1E 1 1 1 1 1 1 1 1 1 1 P P P P P P P G P 0 0 0 0 0 0 0 0 0 0 19 86 0101 20050101 19 820101 20000101 19 9 30101 19 9 80101 19 84 0101 2004 0101 19 89 0101 19 9 70101 19 9 70101 20050101 19 9 70101 20000101 19 9 70101 19 9 80101 19 9 70101 2004 0101 19 9 9 0101 20000101 N N N N N N N N N N Alprosta dil urethra l suppos 51 A 204 9 D O1E 1 0 19 9 9 0101 20000101 N Amika cin sulfa te injection Aminophyllin 250 MG inj Amioda rone HCl Amphotericin B Amphotericin b lipid complex Ampho b cholesteryl sulfa te Amphotericin b liposome inj Ampicillin 500 MG inj Ampicillin sodium per 1.5 gm Amoba rbita l 125 MG inj Succinycholine chloride inj Ana dula fungin injection Injection a nistrepla se 30 u Hydra la z ine hcl injection Apomorphine hydrochloride Aprotonin, 10,000 kiu Inj meta ra minol bita rtra te Chloroquine injection Arbuta mine HCl injection Az ithromycin Atropine sulfa te injection Dimeca prol injection Ba clofen 10 MG injection Ba clofen intra theca l tria l Ba silixima b Dicyclomine injection Inj benz tropine mesyla te Betha nechol chloride inject Penicillin g benz a thine inj 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 A A A A A A A A A A A A A A A A A A A A A A A A A A A A A 204 9 204 9 204 9 204 9 204 9 .5 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 C D D D D D D D D D D C D D C D D D D D D D D D D D D D D O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 P P P P P P P P P P P P P P P P P P P P P P P P G P P P P 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2006 0101 19 84 0101 20010101 19 9 9 0101 20030101 20030101 20030101 19 84 0101 19 9 50101 19 820101 19 86 0101 20070101 19 86 0101 19 86 0101 20070101 2006 0101 19 820101 19 86 0101 19 9 9 0101 20000101 19 820101 19 820101 19 9 4 0101 19 9 9 0101 2006 0101 19 86 0101 19 820101 19 84 0101 19 820101 2006 0101 19 9 70101 20010101 19 9 9 0101 20030101 20030101 20030101 20000101 19 9 70101 19 9 70101 19 9 70101 20070101 19 9 70101 19 9 70101 20070101 2006 0101 19 9 70101 19 9 70101 19 9 9 0101 20000101 19 9 70101 19 9 70101 19 9 70101 19 9 9 0101 2006 0101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 N N N N N N N N N N N A N N A N N N N N N N N N N N N N N Penicillin g benz a thine inj 51 A 204 9 D O1E 1 P 0 19 820101 19 9 70101 N 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 009 5 009 5 Penicillin g benz a thine inj 51 A 204 9 D O1E 1 P 0 19 820101 19 9 70101 N Penicillin g benz a thine inj Penicillin g benz a thine inj Penicillin g benz a thine inj Biva lirudin Botulinum toxin a per unit Botulinum toxin type B Buprenorphine hydrochloride Busulfa n injection Butorpha nol ta rtra te 1 mg Edeta te ca lcium disodium inj Ca lcium glucona te injection Ca lcium glycer & la ct/10 ML Ca lcitonin sa lmon injection Inj ca lcitriol per 0.1 mcg Ca spofungin a ceta te Leucovorin ca lcium injection Inj mepiva ca ine HCL/10 ml Cefa z olin sodium injection Cefepime HCl for injection Cefoxitin sodium injection Ceftria xone sodium injection Sterile cefuroxime injection Cefota xime sodium injection Beta metha sone a cet&sod phosp Beta metha sone sod phosp/4 MG Ca ffeine citra te injection Cepha pirin sodium injection Inj cefta z idime per 500 mg Ceftiz oxime sodium / 500 MG Chlora mphenicol sodium injec Chorionic gona dotropin/1000u Clonidine hydrochloride Cidofovir injection Cila sta tin sodium injection Ciprofloxa cin iv Inj codeine phospha te /30 MG Colchicine injection Colistimetha te sodium inj Prochlorpera z ine injection Corticorelin ovine trifluta l Corticotropin injection Inj cosyntropin per 0.25 MG Cytomega lovirus imm IV /via l Da ptomycin injection Da rbepoetin a lfa injection Da rbepoetin a lfa , non-esrd Da rbepoetin a lfa , esrd use Epoetin a lfa , non-esrd Epoetin a lfa 1000 units ESRD Decita bine injection Deferoxa mine mesyla te inj Testosterone ena ntha te inj Bromphenira mine ma lea te inj Estra diol va lera te injection Depo-estra diol cypiona te inj Methylprednisolone 20 MG inj Methylprednisolone 4 0 MG inj Methylprednisolone 80 MG inj Medroxyprogesterone inj Medrxyprogester a ceta te inj MA/EC contra ceptiveinjection Testosterone cypiona te 1 ML Testosterone cypiona t 100 MG Testosterone cypiona t 200 MG Inj dexa metha sone a ceta te Dexa metha sone sodium phos Inj dihydroergota mine mesylt Aceta z ola mid sodium injectio Digoxin injection Digoxin immune fa b (ovine) Phenytoin sodium injection Hydromorphone injection Dyphylline injection Dexra z oxa ne HCl injection Diphenhydra mine hcl injectio Chlorothia z ide sodium inj Dimethyl sulfoxide 50% 50 ML Metha done injection Dimenhydrina te injection Dipyrida mole injection Inj dobuta mine HCL/250 mg Dola setron mesyla te Dopa mine injection Injection, doxerca lciferol Amitriptyline injection Enfuvirtide injection Epoprostenol injection Eptifiba tide injection Ergonovine ma lea te injection Erta penem injection Erythro la ctobiona te /500 MG Estra diol va lera te 10 MG inj Estra diol va lera te 20 MG inj Inj estrogen conjuga te 25 MG Etha nola mine olea te 100 mg Injection estrone per 1 MG Etidrona te disodium inj Eta nercept injection 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 57 51 57 51 51 51 51 51 51 51 51 51 51 00 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A 9 A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A 204 9 204 9 204 9 D D D C D D D C C D D D D D C D D D C D D D D D D C D D D D D D D D C D D D D D D D D C C D D D D C D D D D D D D D D S C D D D D D D D D D D D D D D D D D D D D D C C D C D D D C D D D D D D D D O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1D O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 P P P P P P P P L P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 820101 19 820101 19 820101 2004 0101 19 9 10101 20020101 20030101 20070101 2004 0101 19 820101 19 820101 19 820101 19 820101 20030101 20030101 19 820101 19 86 0101 19 820101 20020101 19 9 20101 19 9 00101 19 9 00101 19 9 10101 19 9 50101 19 9 50101 20020101 19 820101 19 9 6 0101 19 9 50101 19 820101 19 86 0101 19 9 80101 19 9 80101 19 9 30101 20020101 19 86 0101 19 820101 19 820101 19 84 0101 2006 0101 19 820101 19 9 50101 19 820101 20050101 20030101 2006 0101 2006 0101 2006 0101 2006 0101 20070101 19 9 20101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 20030101 19 9 4 0101 20020101 19 820101 19 820101 19 820101 20030101 19 820101 19 820101 19 820101 19 820101 2006 0101 19 820101 19 820101 19 820101 19 9 70101 19 820101 19 820101 19 86 0101 19 820101 19 84 0101 19 9 30101 19 9 6 0101 19 9 9 0101 2006 0101 20020101 19 820101 20070101 19 9 80101 20000101 19 86 0101 2004 0101 19 9 50101 19 820101 19 820101 19 820101 2006 0101 19 820101 19 9 00101 20000101 19 9 70101 19 9 70101 19 9 70101 2004 0101 19 9 70101 20020101 20030101 20070101 2004 0101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 20030101 20030101 19 9 70101 19 9 70101 20000101 20020101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 20020101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 80101 19 9 80101 19 9 70101 20020101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 2006 0101 19 9 70101 19 9 70101 19 9 70101 20050101 2006 0101 2006 0101 2006 0101 2006 0101 20070101 20070101 20010101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 20030101 19 9 70101 20030101 19 9 70101 19 9 70101 19 9 70101 20030101 20010101 19 9 70101 19 9 70101 19 9 70101 2006 0101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 80101 19 9 70101 20000101 2006 0101 20020101 19 9 70101 20070101 19 9 80101 20000101 19 9 70101 2004 0101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 2006 0101 19 9 70101 19 9 70101 20000101 N N N N N N N A N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N S A N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N A N N N N N N N N N N N N Filgra stim 300 mcg injection Filgra stim 4 80 mcg injection Flucona z ole Fomepiz ole, 15 mg Intra ocula r Fomivirsen na Fosca rnet sodium injection Ga llium nitra te injection Ga lsulfa se injection Ga mma globulin 1 CC inj Ga mma globulin 2 CC inj Ga mma globulin 3 CC inj Ga mma globulin 4 CC inj Ga mma globulin 5 CC inj Ga mma globulin 6 CC inj Ga mma globulin 7 CC inj Ga mma globulin 8 CC inj Ga mma globulin 9 CC inj Ga mma globulin 10 CC inj Ga mma globulin > 10 CC inj Immune globulin subcuta neous IV immune globulin Immune globulin 10 mg RSV-ivig Immune globulin, powder Immune globulin, liquid Ga nciclovir sodium injection Ga ra mycin genta micin inj Ga tifloxa cin injection Injection gla tira mer a ceta te Gold sodium thioma lea te inj Gluca gon hydrochloride/1 MG Gona dorelin hydroch/ 100 mcg Gra nisetron HCl injection Ha loperidol injection Ha loperidol deca noa te inj Hemin, 1 mg 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 51 00 00 51 51 51 51 51 51 51 51 51 51 51 51 51 51 A A A A A A A A A A A A A A A A A A A A 9 9 A A A A A A A A A A A A A A O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E O1E 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 9 4 0101 19 9 4 0101 20000101 2006 0101 20010101 19 9 30101 20050101 20070101 19 84 0101 19 84 0101 19 850101 19 84 0101 19 84 0101 19 84 0101 19 84 0101 19 84 0101 19 84 0101 19 84 0101 19 84 0101 20070101 20010101 20030101 19 9 80101 2006 0101 2006 0101 19 9 4 0101 19 84 0101 20020101 2004 0101 19 820101 19 86 0101 19 820101 19 9 80101 19 86 0101 19 89 0101 2006 0101 19 9 70101 19 9 70101 20000101 2006 0101 20010101 19 9 70101 20050101 20070101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 19 9 70101 20070101 2006 0101 2006 0101 19 9 80101 2006 0101 2006 0101 19 9 70101 19 9 70101 20020101 2004 0101 19 9 70101 19 9 70101 19 9 70101 19 9 80101 19 9 70101 19 9 70101 2006 0101 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 Q009 0 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 4 273.1 204 9 4 273.1 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 Q0087 186 2A1 4 5-23 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 15030 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 .5 204 9 204 9 .3 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 204 9 D D D D D D C C D D D D D D D D D D D C I I D D D D D C D D D D D D D D 009 5 0132 009 5 009 5 009 5 009 5 P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P L L 20051231 20051231 20051231 N N N N N N N A N N N N N N N N N N N A N N N N N N N N N N N N N N N N PUF___2007_Web_File L36 50 L36 51 L36 51 L36 52 L36 52 L36 6 0 L36 6 0 L36 70 L36 70 L36 71 L36 71 L36 72 L36 72 L36 72 L36 73 L36 73 L36 73 L36 75 L36 75 L36 77 L36 77 L3700 L3700 L3701 L3701 L3702 L3702 L3710 L3710 L3720 L3720 L3730 L3730 L374 0 L374 0 L376 0 L376 0 L376 2 L376 2 L376 3 L376 3 L376 4 L376 4 L376 4 L376 5 L376 5 L376 6 L376 6 L376 6 L3800 L3805 L3806 L3806 L3806 L3807 L3807 L3808 L3808 L3810 L3815 L3820 L3820 L3825 L3830 L3835 L384 0 L384 5 L384 5 L3850 L3855 L386 0 L386 0 L389 0 L389 0 L39 00 L39 00 L39 01 L39 01 L39 02 L39 04 L39 05 L39 05 L39 05 L39 06 L39 06 L39 07 L39 08 L39 08 L39 09 L39 09 L39 10 L39 10 L39 11 L39 11 L39 12 L39 12 L39 13 L39 13 L39 14 L39 14 L39 15 L39 15 L39 15 L39 16 L39 16 L39 17 L39 17 L39 18 L39 18 L39 19 L39 19 L39 20 L39 20 L39 21 L39 21 L39 21 L39 22 L39 22 L39 23 L39 23 L39 24 L39 24 L39 26 L39 26 L39 28 L39 28 L39 30 L39 30 L39 32 L39 32 L39 33 L39 33 L39 34 L39 34 L39 35 L39 35 L39 36 L39 36 L39 38 L39 38 L39 4 0 L39 4 0 L39 4 2 L39 4 2 L39 4 4 L39 4 4 L39 4 6 L39 4 6 L39 4 8 L39 4 8 L39 50 L39 50 L39 52 L39 52 L39 54 L39 54 L39 56 L39 6 0 L39 6 0 L39 6 1 L39 6 1 L39 6 1 L39 6 2 L39 6 2 L39 6 3 L39 6 3 L39 6 4 L39 6 4 L39 6 5 L39 6 5 L39 6 6 L39 6 6 L39 6 7 L39 6 7 L39 6 7 L39 6 8 L39 6 8 L39 6 8 L39 6 9 L39 6 9 L39 6 9 L39 70 L39 71 L39 71 L39 71 L39 72 L39 72 L39 73 L39 73 L39 73 L39 73 L39 74 L39 75 L39 75 L39 75 L39 76 L39 76 L39 76 L39 77 L39 77 L39 77 L39 78 L39 78 L39 78 L39 78 L39 80 L39 80 L39 82 L39 82 L39 84 L39 84 L39 85 L39 85 L39 86 L39 86 L39 9 5 L39 9 9 L4 000 L4 002 L4 010 L4 020 L4 030 L4 04 0 L4 04 5 L4 050 L4 055 L4 06 0 L4 070 L4 080 L4 09 0 L4 100 L4 110 L4 130 L4 205 L4 210 L4 350 L4 350 L4 36 0 L4 36 0 L4 370 L4 380 L4 386 L4 386 L4 39 2 L4 39 4 L4 39 6 L4 39 6 L4 39 6 L4 39 8 L4 39 8 L5000 L5010 L5020 L5050 L506 0 L5100 L5105 L5150 L5150 L516 0 L516 0 L5200 L5210 L5210 L5220 L5220 L5230 L5230 L5250 L5250 L5270 L5270 L5280 L5280 L5301 L5311 L5311 L5321 L5321 L5331 L5331 L534 1 L534 1 L54 00 L54 00 L54 00 L54 10 L54 10 L54 10 L54 20 L54 20 L54 20 L54 30 L54 30 L54 30 L54 50 L54 50 L54 6 0 L54 6 0 L5500 L5500 L5505 L5505 L5510 L5510 L5520 L5520 L5530 L5530 L5535 L5535 L554 0 L554 0 L556 0 L556 0 L556 0 L5570 L5570 L5570 L5580 L5580 L5580 L5585 L5585 L5585 L559 0 L559 0 L559 0 L559 5 L559 5 L56 00 L56 00 L56 10 L56 10 L56 11 L56 11 L56 13 L56 13 L56 14 L56 14 L56 16 L56 16 L56 17 L56 17 L56 18 L56 20 L56 22 L56 24 L56 26 L56 28 L56 29 L56 30 L56 31 L56 32 L56 34 L56 36 L56 37 L56 38 L56 39 L56 4 0 L56 4 2 L56 4 3 L56 4 3 L56 4 4 L56 4 5 L56 4 6 L56 4 6 L56 4 7 L56 4 8 L56 4 8 L56 4 9 L56 50 L56 50 L56 51 L56 52 L56 52 L56 53 L56 54 L56 54 L56 55 L56 55 L56 56 L56 56 L56 58 L56 58 L56 6 1 L56 6 5 L56 6 6 L56 6 8 L56 70 L56 70 L56 71 L56 71 L56 72 L56 73 L56 73 L56 73 L56 74 L56 75 L56 75 L56 76 L56 77 L56 78 L56 79 L56 79 L56 79 L56 80 L56 81 L56 81 L56 81 L56 81 L56 82 L56 83 L56 83 L56 83 L56 83 L56 84 L56 85 L56 85 L56 86 L56 88 L56 9 0 L56 9 2 L56 9 4 L56 9 5 L56 9 5 L56 9 6 L56 9 7 L56 9 8 L56 9 8 L56 9 9 L5700 L5701 L5701 L5702 L5702 L5703 L5703 L5704 L5705 L5706 L5707 L5710 L5711 L5711 L5712 L5712 L5714 L5714 L5716 L5716 L5718 L5718 L5722 L5722 L5724 L5726 L5726 L5728 L5728 L5780 L5780 L5781 L5781 L5782 L5782 L5785 L5785 L579 0 L579 0 L579 5 L579 5 L5810 L5811 L5811 L5812 L5812 L5814 L5814 L5816 L5816 L5818 L5818 L5822 L5822 L5824 L5826 L5826 L5828 L5828 L5830 L5830 L584 0 L584 0 L584 5 L584 6 L584 6 L584 7 L584 7 L584 8 L584 8 L5850 L5850 L5855 L5855 L5856 L5856 L5856 L5857 L5857 L5857 L5858 L5858 L5858 L59 10 L59 20 L59 20 L59 25 L59 25 L59 30 L59 4 0 L59 4 0 L59 50 200 100 200 100 200 100 200 100 200 100 200 100 200 300 100 200 300 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 300 100 200 100 200 300 100 100 100 200 300 100 200 100 200 100 100 100 200 100 100 100 100 100 200 100 100 100 200 100 200 100 200 100 200 100 100 100 200 300 100 200 100 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 300 100 200 100 200 100 200 100 200 100 200 100 200 300 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 100 200 100 200 300 100 200 100 200 100 200 100 200 100 200 100 200 300 100 200 300 100 200 300 100 100 200 300 100 200 100 200 300 4 00 100 100 200 300 100 200 300 100 200 300 100 200 300 4 00 100 200 100 200 100 200 100 200 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 200 100 100 100 200 100 100 100 200 300 100 200 100 100 100 100 100 100 100 100 200 100 200 100 100 200 100 200 100 200 100 200 100 200 100 200 100 100 200 100 200 100 200 100 200 100 200 300 100 200 300 100 200 300 100 200 300 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 300 100 200 300 100 200 300 100 200 300 100 200 300 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 200 100 100 100 200 100 100 200 100 100 200 100 100 200 100 100 200 100 200 100 200 100 200 100 100 100 100 100 200 100 200 100 100 200 300 100 100 200 100 100 100 100 200 300 100 100 200 300 4 00 100 100 200 300 4 00 100 100 200 100 100 100 100 100 100 200 100 100 100 200 100 100 100 200 100 200 100 200 100 100 100 100 100 100 200 100 200 100 200 100 200 100 200 100 200 100 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 200 100 100 200 100 200 100 200 100 200 100 200 100 200 100 100 200 100 200 100 200 100 200 100 100 200 100 200 100 200 100 200 100 200 100 200 300 100 200 300 100 200 300 100 100 200 100 200 100 100 200 100 4 3 4 3 4 3 4 3 4 3 4 3 4 4 3 4 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 4 3 4 3 4 4 3 3 3 4 4 3 4 3 4 3 3 3 4 3 3 3 3 3 4 3 3 3 4 3 4 3 4 3 4 3 3 3 4 4 3 4 3 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 4 3 4 3 4 3 4 3 4 3 4 3 4 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 3 4 3 4 4 3 4 3 4 3 4 3 4 3 4 3 4 4 3 4 4 3 4 4 3 3 4 4 3 4 3 4 4 4 3 3 4 4 3 4 4 3 4 4 3 4 4 4 3 4 3 4 3 4 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 3 3 4 3 3 3 4 4 3 4 3 3 3 3 3 3 3 3 4 3 4 3 3 4 3 4 3 4 3 4 3 4 3 4 3 3 4 3 4 3 4 3 4 3 4 4 3 4 4 3 4 4 3 4 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 4 3 4 4 3 4 4 3 4 4 3 4 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 4 3 3 4 3 3 4 3 3 4 3 3 4 3 4 3 4 3 4 3 3 3 3 3 4 3 4 3 3 4 4 3 3 4 3 3 3 3 4 4 3 3 4 4 4 3 3 4 4 4 3 3 4 3 3 3 3 3 3 4 3 3 3 4 3 3 3 4 3 4 3 4 3 3 3 3 3 3 4 3 4 3 4 3 4 3 4 3 4 3 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 3 4 3 4 3 4 3 4 3 4 3 4 3 3 4 3 4 3 4 3 4 3 3 4 3 4 3 4 3 4 3 4 3 4 4 3 4 4 3 4 4 3 3 4 3 4 3 3 4 3 INCLUDES FITTING AND ADJUSTMENT SHOULDER ORTHOSIS, SINGLE SHOULDER, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) SHOULDER ORTHOSIS, DOUBLE SHOULDER, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, CANVAS AND WEBBING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ORTHOSIS, ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INLCUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, INCLUDES NONTORSION JOINT/TURNBUCKLE, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ORTHOSIS, VEST TYPE ABDUCTION RESTRAINER, CANVAS WEBBING TYPE OR EQUAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ORTHOSIS, HARD PLASTIC, SHOULDER STABILIZ ER, PRE-FABRICATED, INCLUDES FITTING AND ADJUSTMENT ELBOW ORTHOSIS, ELASTIC WITH STAYS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ELBOW ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) ELBOW ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT ELBOW ORTHOSIS, ELASTIC WITH METAL JOINTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, FREE MOTION, CUSTOM-FABRICATED ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, EXTENSION/ FLEXION ASSIST, CUSTOM-FABRICATED ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, ADJUSTABLE POSITION LOCK WITH ACTIVE CONTROL, CUSTOM-FABRICATED ELBOW ORTHOSIS, WITH ADJUSTABLE POSITION LOCKING JOINT(S), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTS, ANY TYPE ELBOW ORTHOSIS, RIGID, WITHOUT JOINTS, INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ELBOW WRIST HAND ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT ELBOW WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT ELBOW WRIST HAND FINGER ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT ELBOW WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, SHORT OPPONENS, NO ATTACHMENTS, CUSTOM-FABRICATED WRIST HAND FINGER ORTHOSIS, LONG OPPONENS, NO ATTACHMENT, CUSTOM-FABRICATED WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE MATERIAL, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTS, ANY TYPE WRIST HAND FINGER ORTHOSIS, RIGID WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE MATERIAL; STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT WHFO, ADDITION TO SHORT AND LONG OPPONENS, THUMB ABDUCTION ('C') BAR WHFO, ADDITION TO SHORT AND LONG OPPONENS, SECOND M.P. ABDUCTION ASSIST WHFO, ADDITION TO SHORT AND LONG OPPONENS, I.P. EXTENSION ASSIST, WITH M.P. EXTENSION STOP WHFO, ADDITION TO SHORT AND LONG OPPONENS, M.P. EXTENSION STOP WHFO, ADDITION TO SHORT AND LONG OPPONENS, M.P. EXTENSION ASSIST WHFO, ADDITION TO SHORT AND LONG OPPONENS, M.P. SPRING EXTENSION ASSIST WHFO, ADDITION TO SHORT AND LONG OPPONENS, SPRING SWIVEL THUMB WHFO, ADDITION TO SHORT AND LONG OPPONENS, THUMB I.P. EXTENSION ASSIST, WITH M.P. STOP WHO, ADDITION TO SHORT AND LONG OPPONENS, ACTION WRIST, WITH DORSIFLEXION ASSIST WHFO, ADDITION TO SHORT AND LONG OPPONENS, ADJUSTABLE M.P. FLEXION CONTROL WHFO, ADDITION TO SHORT AND LONG OPPONENS, ADJUSTABLE M.P. FLEXION CONTROL AND I.P. ADDITION TO UPPER EXTREMITY JOINT, WRIST OR ELBOW, CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISM, EACH WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/ FLEXION, FINGER FLEXION/EXTENSION, WRIST OR FINGER DRIVEN, CUSTOM-FABRICATED WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/ FLEXION, FINGER FLEXION/EXTENSION, CABLE DRIVEN, CUSTOM-FABRICATED WRIST HAND FINGER ORTHOSIS, EXTERNAL POWERED, COMPRESSED GAS, CUSTOM-FABRICATED WRIST HAND FINGER ORTHOSIS, EXTERNAL POWERED, ELECTRIC, CUSTOM-FABRICATED WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, WRIST GAUNTLET WITH THUMB SPICA, CUSTOM-FABRICATED WRIST HAND ORTHOSIS, WRIST EXTENSION CONTROL COCK-UP, NON MOLDED, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) WRIST HAND FINGER ORTHOSIS, SWANSON DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) HAND FINGER ORTHOSIS, FLEXION GLOVE WITH ELASTIC FINGER CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND ORTHOSIS, WRIST EXTENSION COCK-UP, PREFABRICATED, INCLUDES FITTING/ADJUSTMENT WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, WRIST EXTENSION COCK-UP WITH OUTRIGGER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND ORTHOSIS, METACARPAL FRACTURE ORTHOSIS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND FINGER ORTHOSIS, KNUCKLE BENDER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND FINGER ORTHOSIS, KNUCKLE BENDER WITH OUTRIGGER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND FINGER ORTHOSIS, KNUCKLE BENDER, TWO SEGMENT TO FLEX JOINTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, OPPENHEIMER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, THOMAS SUSPENSION, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND FINGER ORTHOSIS, FINGER EXTENSION, WITH CLOCK SPRING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, FINGER EXTENSION, WITH WRIST SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT FINGER ORTHOSIS, SAFETY PIN, SPRING WIRE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT FINGER ORTHOSIS, SAFETY PIN, MODIFIED, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT FINGER ORTHOSIS, NONTORSION JOINT, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, PALMER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, DORSAL WRIST, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, DORSAL WRIST, WITH OUTRIGGER ATTACHMENT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND FINGER ORTHOSIS, REVERSE KNUCKLE BENDER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND FINGER ORTHOSIS, REVERSE KNUCKLE BENDER, WITH OUTRIGGER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND FINGER ORTHOSIS, COMPOSITE ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT FINGER ORTHOSIS, FINGER KNUCKLE BENDER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, COMBINATION OPPENHEIMER, WITH KNUCKLE BENDER AND TWO ATTACHMENTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WRIST HAND FINGER ORTHOSIS, COMBINATION OPPENHEIMER, WITH REVERSE KNUCKLE AND TWO ATTACHMENTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT HAND FINGER ORTHOSIS, SPREADING HAND, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ADDITION OF JOINT TO UPPER EXTREMITY ORTHOSIS, ANY MATERIAL; PER JOINT SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, AIRPLANE DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, ERBS PALSEY DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW WRIST HAND ORTHOSIS, MOLDED SHOULDER, ARM, FOREARM AND WRIST, WITH ARTICULATING ELBOW JOINT, CUSTOM-FABRICATED SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE RANCHO TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, RECLINING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, FRICTION ARM SUPPORT (FRICTION DAMPENING TO PROXIMAL AND DISTAL JOINTS), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT, MONOSUSPENSION ARM AND HAND SUPPORT, OVERHEAD ELBOW FOREARM HAND SLING SUPPORT, YOKE TYPE SUSPENSION SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SEO, ADDITION TO MOBILE ARM SUPPORT, ELEVATING PROXIMAL ARM SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT SEO, ADDITION TO MOBILE ARM SUPPORT, OFFSET OR LATERAL ROCKER ARM WITH ELASTIC BALANCE CONTROL SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT SEO, ADDITION TO MOBILE ARM SUPPORT, SUPINATOR SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT UPPER EXTREMITY FRACTURE ORTHOSIS, HUMERAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT UPPER EXTREMITY FRACTURE ORTHOSIS, RADIUS/ULNAR, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT UPPER EXTREMITY FRACTURE ORTHOSIS, FOREARM, HAND WITH WRIST HINGE, CUSTOM-FABRICATED UPPER EXTREMITY FRACTURE ORTHOSIS, COMBINATION OF HUMERAL, RADIUS/ULNAR, WRIST, (EXAMPLE--COLLES' FRACTURE), CUSTOM FABRICATED ADDITION TO UPPER EXTREMITY ORTHOSIS, SOCK, FRACTURE OR EQUAL, EACH UPPER LIMB ORTHOSIS, NOT OTHERWISE SPECIFIED REPLACE GIRDLE FOR SPINAL ORTHOSIS (CTLSO OR SO) REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE REPLACE TRILATERAL SOCKET BRIM REPLACE QUADRILATERAL SOCKET BRIM, MOLDED TO PATIENT MODEL REPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTED REPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY REPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY REPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY REPLACE HIGH ROLL CUFF REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFO REPLACE METAL BANDS KAFO, PROXIMAL THIGH REPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGH REPLACE LEATHER CUFF KAFO, PROXIMAL THIGH REPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGH REPLACE PRETIBIAL SHELL REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTS ANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE (E.G., PNEUMATIC, GEL), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WALKING BOOT, PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT PNEUMATIC FULL LEG SPLINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT PNEUMATIC KNEE SPLINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT REPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO REPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT STATIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, PRESSURE REDUCTION, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLER PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGHT, WITH TOE FILLER PARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBERCLE HEIGHT, WITH TOE FILLER ANKLE, SYMES, MOLDED SOCKET, SACH FOOT ANKLE, SYMES, METAL FRAME, MOLDED LEATHER SOCKET, ARTICULATED ANKLE/FOOT BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT BELOW KNEE, PLASTIC SOCKET, JOINTS AND THIGH LACER, SACH FOOT KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, BENT KNEE CONFIGURATION, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ('STUBBIES'), WITH FOOT BLOCKS, NO ANKLE JOINTS, EACH ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ('STUBBIES'), WITH ARTICULATED ANKLE/FOOT, DYNAMICALLY ALIGNED, EACH ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL DEFICIENCY, CONSTANT FRICTION KNEE, SHIN, SACH FOOT HIP DISARTICULATION, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT HIP DISARTICULATION, TILT TABLE TYPE; MOLDED SOCKET, LOCKING HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT HEMIPELVECTOMY, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE AXIS KNEE HIP DISARTICULATION, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT, SINGLE AXIS KNEE, SACH FOOT HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT, SINGLE AXIS KNEE, SACH FOOT IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT, SUSPENSION, AND ONE CAST CHANGE, BELOW KNEE IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION, BELOW KNEE, EACH ADDITIONAL CAST CHANGE AND REALIGNMENT IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION AND ONE CAST CHANGE 'AK' OR KNEE DISARTICULATION IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCL. FITTING, ALIGNMENT AND SUPENSION, 'AK' OR KNEE DISARTICULATION, EACH ADDITIONAL CAST CHANGE AND REALIGNMENT IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON-WEIGHT BEARING RIGID DRESSING, BELOW KNEE IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON-WEIGHT BEARING RIGID DRESSING, ABOVE KNEE INITIAL, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMED INITIAL, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMED PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO MODEL PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMED PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, NO COVER, SACH FOOT, PREFABRICATED, ADJUSTABLE OPEN END SOCKET PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL PREPARATORY, ABOVE KNEE- KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO MODEL PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMED PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PREFABRICATED ADJUSTABLE OPEN END SOCKET PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO PATIENT MODEL PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO PATIENT MODEL ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, HYDRACADENCE SYSTEM ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE - KNEE DISARTICULATION, 4 BAR LINKAGE, WITH FRICTION SWING PHASE CONTROL ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE-KNEE DISARTICULATION, 4 BAR LINKAGE, WITH HYDRAULIC SWING PHASE CONTROL ADDITION TO LOWER EXTREMITY, EXOSKELETAL SYSTEM, ABOVE KNEE-KNEE DISARTICULATION, 4 BAR LINKAGE, WITH PNEUMATIC SWING PHASE CONTROL ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, UNIVERSAL MULTIPLEX SYSTEM, FRICTION SWING PHASE CONTROL ADDITION TO LOWER EXTREMITY, QUICK CHANGE SELF-ALIGNING UNIT, ABOVE KNEE OR BELOW KNEE, EACH ADDITION TO LOWER EXTREMITY, TEST SOCKET, SYMES ADDITION TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEE ADDITION TO LOWER EXTREMITY, TEST SOCKET, KNEE DISARTICULATION ADDITION TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEE ADDITION TO LOWER EXTREMITY, TEST SOCKET, HIP DISARTICULATION ADDITION TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVECTOMY ADDITION TO LOWER EXTREMITY, BELOW KNEE, ACRYLIC SOCKET ADDITION TO LOWER EXTREMITY, SYMES TYPE, EXPANDABLE WALL SOCKET ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, ACRYLIC SOCKET ADDITION TO LOWER EXTREMITY, SYMES TYPE, 'PTB' BRIM DESIGN SOCKET ADDITION TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPENING (CANADIAN) SOCKET ADDITION TO LOWER EXTREMITY, SYMES TYPE, MEDIAL OPENING SOCKET ADDITION TO LOWER EXTREMITY, BELOW KNEE, TOTAL CONTACT ADDITION TO LOWER EXTREMITY, BELOW KNEE, LEATHER SOCKET ADDITION TO LOWER EXTREMITY, BELOW KNEE, WOOD SOCKET ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, LEATHER SOCKET ADDITION TO LOWER EXTREMITY, ABOVE KNEE, LEATHER SOCKET ADDITION TO LOWER EXTREMITY, HIP DISARTICULATION, FLEXIBLE INNER SOCKET, EXTERNAL FRAME ADDITION TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKET ADDITION TO LOWER EXTREMITY, BELOW KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME ADDITION TO LOWER EXTREMITY, BELOW KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET ADDITION TO LOWER EXTREMITY, BELOW KNEE SUCTION SOCKET ADDITION TO LOWER EXTREMITY, ABOVE KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M-L SOCKET ADDITIONS TO LOWER EXTREMITY, TOTAL CONTACT, ABOVE KNEE OR KNEE DISARTICULATION SOCKET ADDITION TO LOWER EXTREMITY, ABOVE KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME ADDITION TO LOWER EXTREMITY, SUCTION SUSPENSION, ABOVE KNEE OR KNEE DISARTICULATION SOCKET ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, EXPANDABLE WALL SOCKET ADDITION TO LOWER EXTREMITY, SOCKET INSERT, SYMES, (KEMBLO, PELITE, ALIPLAST, PLASTAZ OTE OR EQUAL) ADDITION TO LOWER EXTREMITY, SOCKET INSERT, BELOW KNEE (KEMBLO, PELITE, ALIPLAST, PLASTAZ OTE OR EQUAL) ADDITION TO LOWER EXTREMITY, SOCKET INSERT, KNEE DISARTICULATION (KEMBLO, PELITE, ALIPLAST, PLASTAZ OTE OR EQUAL) ADDITION TO LOWER EXTREMITY, SOCKET INSERT, ABOVE KNEE (KEMBLO, PELITE, ALIPLAST, PLASTAZ OTE OR EQUAL) ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER SYMES ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE, CUFF SUSPENSION ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED DISTAL CUSHION ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED SUPRACONDYLAR SUSPENSION ('PTS' OR SIMILAR) ADDITION TO LOWER EXTREMITY, BELOW KNEE / ABOVE KNEE SUSPENSION LOCKING MECHANISM (SHUTTLE, LANYARD OR EQUAL), EXCLUDES SOCKET INSERT ADDITION TO LOWER EXTREMITY, BELOW KNEE, REMOVABLE MEDIAL BRIM SUSPENSION ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISM ADDITION TO LOWER EXTREMITY, BELOW KNEE, SUSPENSION SLEEVE, ANY MATERIAL, EACH ADDITION TO LOWER EXTREMITY, BELOW KNEE, SUSPENSION SLEEVE, HEAVY DUTY, ANY MATERIAL, EACH ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, SINGLE AXIS, PAIR ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, POLYCENTRIC, PAIR ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, JOINT COVERS, PAIR ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, NOT FOR USE WITH LOCKING MECHANISM ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, NONMOLDED ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE L56 73 OR L56 79 ) ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, GLUTEAL/ISCHIAL, MOLDED ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE L56 73 OR L56 79 ) ADDITION TO LOWER EXTREMITY, BELOW KNEE, FORK STRAP ADDITION TO LOWER EXTREMITY PROSTHESIS, BELOW KNEE, SUSPENSION/SEALING SLEEVE, WITH OR WITHOUT VALVE, ANY MATERIAL, EACH ADDITION TO LOWER EXTREMITY, BELOW KNEE, BACK CHECK (EXTENSION CONTROL) ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, WEBBING ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, PADDED AND LINED ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, LIGHT ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, PADDED AND LINED ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL, SLEEVE SUSPENSION, NEOPRENE OR EQUAL, EACH ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC JOINT ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC BAND ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, SILESIAN BANDAGE ALL LOWER EXTREMITY PROSTHESES, SHOULDER HARNESS REPLACEMENT, SOCKET, BELOW KNEE, MOLDED TO PATIENT MODEL REPLACEMENT, SOCKET, ABOVE KNEE/KNEE DISARTICULATION, INCLUDING ATTACHMENT PLATE, MOLDED TO PATIENT MODEL REPLACEMENT, SOCKET, HIP DISARTICULATION, INCLUDING HIP JOINT, MOLDED TO PATIENT MODEL ANKLE, SYMES, MOLDED TO PATIENT MODEL, SOCKET WITHOUT SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY CUSTOM SHAPED PROTECTIVE COVER, BELOW KNEE CUSTOM SHAPED PROTECTIVE COVER, ABOVE KNEE CUSTOM SHAPED PROTECTIVE COVER, KNEE DISARTICULATION CUSTOM SHAPED PROTECTIVE COVER, HIP DISARTICULATION ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT MATERIAL ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE PHASE CONTROL (SAFETY KNEE) ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, VARIABLE FRICTION SWING PHASE CONTROL ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE LOCK ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING AND STANCE PHASE CONTROL ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION STANCE PHASE CONTROL ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, EXTERNAL JOINTS FLUID SWING PHASE CONTROL ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/HYDRA PNEUMATIC SWING PHASE CONTROL ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT AND MOISTURE EVACUATION SYSTEM ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT AND MOISTURE EVACUATION SYSTEM, HEAVY DUTY ADDITION, EXOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) ADDITION, EXOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) ADDITION, EXOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT MATERIAL ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE PHASE CONTROL (SAFETY KNEE) ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, HYDRAULIC SWING PHASE CONTROL, MECHANICAL STANCE PHASE LOCK ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE LOCK ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING, AND STANCE PHASE CONTROL ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION STANCE PHASE CONTROL ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, HYDRAULIC SWING PHASE CONTROL, WITH MINIATURE HIGH ACTIVITY FRAME ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/ SWING PHASE CONTROL ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, 4 -BAR LINKAGE OR MULTIAXIAL, PNEUMATIC SWING PHASE CONTROL ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION FEATURE, ADJUSTABLE ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ADDITION TO ENDOSKELETAL KNEE-SHIN SYSTEM, FLUID STANCE EXTENSION, DAMPENING FEATURE, WITH OR WITHOUT ADJUSTABILITY ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, KNEE EXTENSION ASSIST ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, MECHANICAL HIP EXTENSION ASSIST ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ALIGNABLE SYSTEM ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, ALIGNABLE SYSTEM ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE DISARTICULATION OR HIP DISARTICULATION, MANUAL LOCK ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAME ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, Page 4 Prefa b shoulder orthosis Prefa b dbl shoulder orthosis 38 38 A C A C D1F D1F P 0 P 0 20030101 20030101 20030101 N 20030101 N Abduct restra iner ca nva s&web 38 A C D1F P 0 19 820101 20010101 N Acromio/cla vicula r ca nva s&we 38 A C D1F P 0 19 820101 20010101 N SO ca p design w/o jnts CF 38 A C D1F P 0 2006 0101 2006 0101 N SO a irpla ne w/o jnts CF 38 A C D1F P 0 2006 0101 2006 0101 N SO a irpla ne w/joint CF 38 A C D1F P 0 2006 0101 2006 0101 N Ca nva s vest SO 38 A C D1F P 0 19 9 9 0101 20010101 N SO ha rd pla stic sta biliz er 00 9 2130 D Z2 P 0 20020101 20020101 N Elbow orthoses ela s w sta ys 38 A C D1F P 0 19 820101 20010101 N Prefa b elbow orthosis 38 A C D1F P 0 20030101 20030101 N EO w/o joints CF 38 A C D1F P 0 2006 0101 2006 0101 N Elbow ela stic with meta l joi 38 A C D1F P 0 19 86 0101 20010101 N Forea rm/a rm cuffs free motio 38 A C D1F P 0 19 84 0101 20010101 N Forea rm/a rm cuffs ext/flex a 38 A C D1F P 0 19 820101 20010101 N Cuffs a dj lock w/ a ctive con 38 A C D1F P 0 19 820101 20010101 N EO withjoint, Prefa brica ted 38 A C D1F P 0 20010101 20010101 N Rigid EO wo joints 38 A C D1F P 0 20030101 20030101 N EWHO rigid w/o jnts CF 38 A C D1F P 0 2006 0101 2006 0101 N EWHO w/joint(s) CF 38 A C D1F P 0 2006 0101 2006 0101 N EWHFO rigid w/o jnts CF 38 A C D1F P 0 2006 0101 2006 0101 N EWHFO w/joint(s) CF 38 A C D1F P 0 2006 0101 2006 0101 N Whfo short opponen no a tta ch Whfo long opponens no a tta ch WHFO w/joint(s) custom fa b 38 38 38 A A A C C C D1F D1F D1F P P P 0 0 0 19 820101 19 820101 20070101 20010101 20010101 20070101 N N A WHFO,no joint, prefa brica ted 38 A C D1F P 0 20000101 20010101 N WHFO, rigid w/o joints 38 A C D1F P 0 20070101 20070101 A Whfo thumb a bduction ba r Whfo second m.p. a bduction a Whfo ip ext a sst w/ mp ext s 38 38 38 A A A C C C D1F D1F D1F P P P 0 0 0 19 86 0101 19 86 0101 19 86 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 Whfo m.p. extension stop Whfo m.p. extension a ssist Whfo m.p. spring extension a Whfo spring swivel thumb Whfo thumb ip ext a ss w/ mp 38 38 38 38 38 A A A A A C C C C C D1F D1F D1F D1F D1F P P P P P 0 0 0 0 0 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 Action wrist w/ dorsiflex a s Whfo a dj m.p. flexion contro Whfo a dj m.p. flex ctrl & i. 38 38 38 A A A C C C D1F D1F D1F P P P 0 0 0 19 86 0101 19 86 0101 19 86 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 Torsion mecha nism wrist/elbo 00 9 C D1F P 0 19 9 50101 19 9 80312 Hinge extension/flex wrist/f 38 A C D1F P 0 19 86 0101 N N N N N N N N N N N N 20010101 Hinge ext/flex wrist finger 38 A C D1F P 0 19 84 0101 00 38 38 9 A A I C C D1F D1F D1F P P P 0 0 0 19 850101 19 820101 2006 0101 20070101 20010101 2006 0101 WHO w/o joints CF 38 A C D1F P 0 19 86 0101 N 20010101 Whfo ext power compress ga s Whfo electric custom fitted WHO w/nontorsion jnt(s) CF 2006 0101 Whfo wrst ga untlt thmb spica Wrist cock-up non-molded 38 38 A A C C D1F D1F P P 0 0 19 880101 19 86 0101 N 2006 1231 38 A C D1F P 0 20030101 A C D1F P 0 19 820101 N N 20030101 38 20010101 Prefa b ha nd finger orthosis 38 A C D1F P 0 20030101 38 A C D1F P 0 19 820101 N N 20030101 Flex glove w/ela stic finger 20010101 HFO w/o joints CF 38 A WHO wrist extension cock-up 38 38 C A WHO w nontor jnt(s) prefa b A L39 08 D1F P 0 2006 0101 N N 2006 0101 C D1F P 0 19 86 0101 20070101 C D1F P 0 20070101 D N N N 20010101 20010101 Prefa b wrist orthosis Whfo swa nson design N 20070101 2006 1231 D A Whfo wrist extens w/ outrigg 38 A C D1F P 0 19 86 0101 20010101 N Prefa b meta ca rpl fx orthosis 38 A C D1F P 0 2004 0101 2004 0101 N HFO knuckle bender 38 A C D1F P 0 19 820101 20010101 N HO w/o joints CF 38 A C D1F P 0 2006 0101 2006 0101 N Knuckle bender with outrigge 38 A C D1F P 0 19 820101 20010101 N HFO w/joint(s) CF 38 A C D1F P 0 2006 0101 2006 0101 N Knuckle bend 2 seg to flex j 38 A C D1F P 0 19 820101 20010101 N HFO w/o joints PF 38 A C D1F P 0 20010101 2006 0101 N Oppenheimer 38 A C D1F P 0 19 820101 20010101 N Thoma s suspension 38 A C D1F P 0 19 820101 20010101 N Finger extension w/ clock sp 38 A C D1F P 0 19 820101 20010101 N Finger extension with wrist 38 A C D1F P 0 19 820101 20010101 N Sa fety pin spring wire 38 A C D1F P 0 19 820101 20010101 N FO w/o joints CF 38 A C D1F P 0 2006 0101 2006 0101 N Sa fety pin modified 38 A C D1F P 0 19 820101 20010101 N FO nontorsion joint CF 38 A C D1F P 0 2006 0101 2006 0101 N Pa lmer 38 A C D1F P 0 19 820101 20010101 N Dorsa l wrist 38 A C D1F P 0 19 820101 20010101 N Dorsa l wrist w/ outrigger a t 38 A C D1F P 0 19 820101 20010101 N Reverse knuckle bender 38 A C D1F P 0 19 820101 20010101 N Reverse knuckle bend w/ outr 38 A C D1F P 0 19 820101 20010101 N HFO composite ela stic 38 A C D1F P 0 19 820101 20010101 Finger knuckle bender 38 A C D1F P 0 19 820101 38 A C D1F P 0 19 820101 N 20010101 Oppenheimer w/ knuckle bend 20010101 Oppenheimer w/ rev knuckle 2 38 A C D1F P 0 19 820101 N N 20010101 Sprea ding ha nd 38 A C D1F P 0 19 820101 38 38 A A C C D1F D1F P P 0 0 19 9 70101 19 86 0101 N 20010101 Add joint upper ext orthosis Sewho a irpla n desig a bdu pos 19 9 70101 20010101 SEWHO ca p design w/o jnts CF 38 A C D1F P 0 2006 0101 38 A C D1F P 0 19 820101 N N N 2006 0101 Sewho erbs pa lsey design a bd 20010101 Molded w/ a rticula ting elbow 38 A C D1F P Seo mobile a rm sup a tt to wc 32 A C D1D A Arm supp a tt to wc ra ncho ty 32 A C D1D 0 P R A P R Mobile a rm supports reclinin 32 A C D1D A P R SEWHO a irpla ne w/o jnts CF 38 A C D1F P 19 880101 2006 0101 0 19 86 0101 N N 20010101 0 19 84 0101 20051231 N N 20010101 N 0 19 86 0101 20010101 N 0 2006 0101 2006 0101 N Friction da mpening a rm supp 32 A C D1D A P R 0 19 86 0101 20010101 N Monosuspension a rm/ha nd supp 32 A C D1D A P R 0 19 880101 20010101 N Eleva t proxima l a rm support SEWHO ca p design w/jnt(s) CF 32 38 A A C C D1D D1F A P P R 0 0 19 86 0101 2006 0101 19 9 80101 2006 0101 N N P R Offset/la t rocker a rm w/ ela 32 A C D1D A SEWHO a irpla ne w/jnt(s) CF 38 A C D1F P P R 0 19 86 0101 19 9 80101 N 0 2006 0101 2006 0101 N Mobile a rm support supina tor SEWHFO ca p design w/o jnt CF 32 38 A A C C D1D D1F A P 0 0 19 86 0101 2006 0101 19 9 80101 2006 0101 N N SEWHFO a irpla ne w/o jnts CF 38 A C D1F P 0 2006 0101 2006 0101 N SEWHFO ca p desgn w/jnt(s) CF 38 A C D1F P 0 2006 0101 2006 0101 N SEWHFO a irpla ne w/jnt(s) CF 38 A C D1F P 0 2006 0101 2006 0101 N Upp ext fx orthosis humera l 38 A C D1F P 0 19 820101 20010101 N Upper ext fx orthosis ra d/ul 38 A C D1F P 0 19 84 0101 20010101 N Upper ext fx orthosis wrist 38 A C D1F P 0 19 820101 20010101 N Forea rm ha nd fx orth w/ wr h 38 A C D1F P 0 19 880101 20010101 N Humera l ra d/ulna wrist fx or 38 A C D1F P 0 19 84 0101 20010101 N Sock fra cture or equa l ea ch Upper limb orthosis NOS Repl girdle milwa ukee orth Repla ce stra p, a ny orthosis Repla ce trila tera l socket br Repla ce qua dla t socket brim Repla ce socket brim cust fit Repla ce molded thigh la cer Repla ce non-molded thigh la c Repla ce molded ca lf la cer Repla ce non-molded ca lf la ce Repla ce high roll cuff Repla ce prox & dist upright Repl met ba nd ka fo-a fo prox Repl met ba nd ka fo-a fo ca lf/ Repl lea th cuff ka fo prox th Repl lea th cuff ka fo-a fo ca l Repla ce pretibia l shell Ortho dvc repa ir per 15 min Orth dev repa ir/repl minor p Ankle control orthosi prefa b 38 46 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 46 46 38 A A A A A A A A A A A A A A A A A A A A A C C C C C C C C C C C C C C C C C C D D C D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F P P P P P P P P P P P P P P P P P P P P P 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 89 0101 19 820101 19 850101 20050101 19 850101 19 850101 19 850101 19 850101 19 880101 19 850101 19 880101 19 850101 19 86 0101 19 86 0101 19 850101 19 86 0101 19 850101 19 84 0101 19 9 70101 19 850101 19 89 0101 19 9 6 0101 19 9 80101 20020101 20050101 19 9 6 0101 19 9 6 0101 19 9 6 0101 20050101 20050101 20050101 20050101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 70101 19 9 6 0101 2004 0101 N N N N N N N N N N N N N N N N N N N N N Pneuma ti wa lking boot prefa b 38 38 38 38 38 38 38 2130D A A A Repla ce AFO soft interfa ce Repla ce foot drop spint Sta tic AFO 2100.4 A Pneuma tic full leg splint Pneuma tic knee splint Non-pneum wa lk boot prefa b 2100.4 2133 A A A Foot drop splint recumbent 38 38 38 38 38 38 38 38 38 A A A A A A A A C D1F P 0 19 89 0101 2004 0101 N C C C D1F D1F D1F P P P 0 0 0 19 89 0101 19 89 0101 20030101 20030101 20030101 2004 0101 N N N C C C A Sho insert w a rch toe filler Mold socket a nk hgt w/ toe f Tibia l tubercle hgt w/ toe f Ank symes mold sckt sa ch ft Symes met fr lea th socket a r Molded socket shin sa ch foot Pla st socket jts/thgh la cer Mold sckt ext knee shin sa ch D1F D1F D1F P P P 0 0 0 19 9 70101 19 9 70101 19 9 70101 20010101 19 9 70101 20020101 N N N C D1F P 0 19 9 70101 20010101 N D D D C C C C C 2323 2323 2323 D1F D1F D1F D1F D1F D1F D1F D1F P P P P P P P P 0 0 0 0 0 0 0 0 19 820101 19 820101 19 820101 19 850101 19 850101 19 820101 19 89 0101 19 820101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 N N N N N N N N Mold socket bent knee shin s 38 A C D1F P 0 19 820101 19 9 6 0101 N Kne sing a xis fric shin sa ch No knee/a nkle joints w/ ft b 38 38 A A C C D1F D1F P P 0 0 19 820101 19 820101 19 9 6 0101 19 9 6 0101 N N No knee joint with a rtic a li 38 A C D1F P 0 19 820101 19 9 6 0101 N Fem foca l defic consta nt fri 38 A C D1F P 0 19 820101 19 9 6 0101 N Hip ca na d sing a xi cons fric 38 A C D1F P 0 19 820101 19 9 6 0101 N Tilt ta ble locking hip sing 38 A C D1F P 0 19 820101 19 9 6 0101 N Hemipelvect ca na d sing a xis 38 A C D1F P 0 19 820101 19 9 6 0101 N BK mold socket SACH ft endo Knee disa rt, SACH ft, endo 38 38 A A C C D1F D1F P P 0 0 20020101 20020101 20020101 20020101 N N AK open end SACH 38 A C D1F P 0 20020101 20020101 N Hip disa rt ca na dia n SACH ft 38 A C D1F P 0 20020101 20020101 N Hemipelvectomy ca na dia n SACH 38 A C D1F P 0 20020101 20020101 N Postop dress & 1 ca st chg bk 38 A C D1F P 0 19 820101 19 9 6 0101 N Postop dsg bk ea a dd ca st ch 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Postop dsg & 1 ca st chg a k/d 38 A C D1F P 0 19 820101 19 9 6 0101 N Postop dsg a k ea a dd ca st ch 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Postop a pp non-wgt bea r dsg 38 A C D1F P 0 19 820101 19 9 6 0101 N Postop a pp non-wgt bea r dsg 38 A C D1F P 0 19 820101 19 9 6 0101 N Init bk ptb pla ster direct 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Init a k ischa l plstr direct 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Prep BK ptb pla ster molded 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Perp BK ptb thermopls direct 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Prep BK ptb thermopls molded 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Prep BK ptb open end socket 38 A C D1F P 0 19 89 0101 19 9 6 0101 N Prep BK ptb la mina ted socket 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Prep AK ischia l pla st molded 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Prep AK ischia l direct form 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Prep AK ischia l thermo mold 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Prep AK ischia l open end 38 A C D1F P 0 19 880101 19 9 6 0101 N Prep AK ischia l la mina ted 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Hip disa rtic sa ch thermopls 38 A C D1F P 0 19 89 0101 19 9 6 0101 N Hip disa rt sa ch la mina t mold 38 A C D1F P 0 19 89 0101 19 9 6 0101 N Above knee hydra ca dence 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Ak 4 ba r link w/fric swing 38 A C D1F P 0 19 89 0101 19 9 6 0101 N Ak 4 ba r ling w/hydra ul swig 38 A C D1F P 0 19 89 0101 19 9 6 0101 N 4 -ba r link a bove knee w/swng 38 A C D1F P 0 19 9 4 0101 19 9 6 0101 N Ak univ multiplex sys frict 38 A C D1F P 0 19 86 0101 19 9 6 0101 N AK/BK self-a ligning unit ea 38 A C D1F P 0 19 9 6 0101 19 9 6 0101 N Test socket symes Test socket below knee Test socket knee disa rticula Test socket a bove knee Test socket hip disa rticula t Test socket hemipelvectomy Below knee a crylic socket Syme typ expa nda bl wa ll sckt Ak/knee disa rtic a crylic soc Symes type ptb brim design s Symes type poster opening so Symes type media l opening so Below knee tota l conta ct Below knee lea ther socket Below knee wood socket Knee disa rticula t lea ther so Above knee lea ther socket Hip flex inner socket ext fr 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 A A A A A A A A A A A A A A A A A A C C C C C C C C C C C C C C C C C C D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F P P P P P P P P P P P P P P P P P P 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 89 0101 19 86 0101 19 89 0101 19 86 0101 19 86 0101 19 86 0101 19 89 0101 19 86 0101 19 89 0101 19 86 0101 19 86 0101 19 880101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 N N N N N N N N N N N N N N N N N N Above knee wood socket Bk flex inner socket ext fra Below knee cushion socket 38 38 38 A A A C C C D1F D1F D1F P P P 0 0 0 19 86 0101 19 880101 19 86 0101 19 9 6 0101 20001213 2004 0101 N N N Below knee suction socket Above knee cushion socket 38 38 A A C C D1F D1F P P 0 0 19 880101 19 86 0101 19 9 6 0101 2004 0101 N N Isch conta inmt/na rrow m-l so Tot conta ct a k/knee disa rt s 38 38 A A C C D1F D1F P P 0 0 19 880101 19 86 0101 19 9 6 0101 19 9 6 0101 N N Ak flex inner socket ext fra Suction susp a k/knee disa rt 38 38 A A C C D1F D1F P P 0 0 19 880101 19 86 0101 19 9 6 0101 19 9 6 0101 N N Knee disa rt expa nd wa ll sock Socket insert symes 38 38 A A C C D1F D1F P P 0 0 19 86 0101 19 86 0101 19 9 6 0101 19 9 6 0101 N N Socket insert below knee 38 A C D1F P 0 19 86 0101 19 9 6 0101 Socket insert knee a rticula t 38 A C D1F P 0 19 86 0101 38 A C D1F P 0 19 86 0101 19 9 6 0101 Multi-durometer symes Multi-durometer below knee Below knee cuff suspension Socket insert w/o lock lower Bk molded supra condyla r susp 38 38 38 38 38 A A A A A C C C C C D1F D1F D1F D1F D1F P P P P P 0 0 0 0 0 19 880101 19 880101 19 86 0101 19 86 0101 19 86 0101 N 19 9 6 0101 Socket insert a bove knee 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 BK/AK locking mecha nism 38 A C D1F P 0 20020101 38 38 A A C C D1F D1F P P 0 0 19 86 0101 2004 0101 N N N N N N N 20020101 Bk remova ble media l brim sus Socket insert w lock mech 19 9 6 0101 2004 0101 Bk suspension sleeve Bk hea vy duty susp sleeve 38 38 A A Bk knee joints single a xis p Bk knee joints polycentric p Bk joint covers pa ir Socket insert w/o lock mech 38 38 38 38 A A A A L56 85 L56 85 C C D1F D1F P P 0 0 19 86 0101 19 880101 20050101 20050101 C C C C D1F D1F D1F D1F P P P P 0 0 0 0 19 86 0101 19 880101 19 84 0101 2004 0101 N N N 19 9 6 0101 19 9 6 0101 19 9 6 0101 2004 0101 2004 1231 2004 1231 N N N N N N Bk thigh la cer non-molded Intl custm cong/la typ insert 38 38 A A C C D1F D1F P P 0 0 19 86 0101 2004 0101 19 9 6 0101 2004 0101 N N Bk thigh la cer glut/ischia m Initia l custom socket insert 38 38 A A C C D1F D1F P P 0 0 19 86 0101 2004 0101 19 9 6 0101 2004 0101 N N Bk fork stra p Below knee sus/sea l sleeve 38 38 A A C C D1F D1F P P 0 0 19 86 0101 20050101 19 9 6 0101 20050101 N N Bk ba ck check Bk wa ist belt webbing Bk wa ist belt pa dded a nd lin Ak pelvic control belt light Ak pelvic control belt pa d/l Ak sleeve susp neoprene/equa 38 38 38 38 38 38 A A A A A A C C C C C C D1F D1F D1F D1F D1F D1F P P P P P P 0 0 0 0 0 0 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 86 0101 19 89 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 N N N N N N Ak/knee disa rtic pelvic join Ak/knee disa rtic pelvic ba nd Ak/knee disa rtic silesia n ba 38 38 38 A A A C C C D1F D1F D1F P P P 0 0 0 19 86 0101 19 86 0101 19 86 0101 19 9 6 0101 19 9 6 0101 19 9 6 0101 N N N Shoulder ha rness Repla ce socket below knee Repla ce socket a bove knee 38 38 38 A A A C C C D1F D1F D1F P P P 0 0 0 19 86 0101 19 9 4 0101 19 9 4 0101 19 9 6 0101 19 9 4 0101 19 9 4 0101 N N N Repla ce socket hip 38 A C D1F P 0 19 9 4 0101 19 9 4 0101 N Symes a nkle w/o (SACH) foot 38 A C D1F P 0 2006 0101 2006 0101 N Custom sha pe cover BK Custom sha pe cover AK Custom sha pe cvr knee disa rt Custom sha pe cvr hip disa rt Kne-shin exo sng a xi mnl loc Knee-shin exo mnl lock ultra 38 38 38 38 38 38 A A A A A A C C C C C C D1F D1F D1F D1F D1F D1F P P P P P P 0 0 0 0 0 0 19 9 4 0101 19 9 4 0101 19 9 4 0101 19 9 4 0101 19 86 0101 19 880101 20020101 20020101 20020101 20020101 19 9 6 0101 19 9 6 0101 N N N N N N Knee-shin exo frict swg & st 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Knee-shin exo va ria ble frict 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Knee-shin exo mech sta nce ph 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Knee-shin exo frct swg & sta 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Knee-shin pneum swg frct exo 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Knee-shin exo fluid swing ph Knee-shin ext jnts fld swg e 38 38 A A C C D1F D1F P P 0 0 19 86 0101 19 86 0101 19 9 6 0101 19 9 6 0101 N N Knee-shin fluid swg & sta nce 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Knee-shin pneum/hydra pneum 38 A C D1F P 0 19 86 0101 19 9 6 0101 N Lower limb pros va cuum pump 38 A C D1F P 0 20030101 20030101 N HD low limb pros va cuum pump 38 A C D1F P 0 20030101 20030101 N Exoskeleta l bk ultra lt ma ter 38 A C D1F P 0 19 880101 19 9 6 0101 N Exoskeleta l a k ultra -light m 38 A C D1F P 0 19 880101 19 9 6 0101 N Exoskel hip ultra -light ma te 38 A C D1F P 0 19 880101 19 9 6 0101 N Endoskel knee-shin mnl lock Endo knee-shin mnl lck ultra 38 38 A A C C D1F D1F P P 0 0 19 880101 19 880101 19 9 6 0101 19 9 6 0101 N N Endo knee-shin frct swg & st 38 A C D1F P 0 19 880101 19 9 6 0101 N Endo knee-shin hydra l swg ph 38 A C D1F P 0 19 9 70101 19 9 70101 N Endo knee-shin polyc mch sta 38 A C D1F P 0 19 880101 19 9 6 0101 Endo knee-shin frct swg & st 38 A C D1F P 0 19 880101 38 A C D1F P 0 19 880101 N 19 9 6 0101 Endo knee-shin pneum swg frc 19 9 6 0101 Endo knee-shin fluid swing p Minia ture knee joint 38 38 A A C C D1F D1F P P 0 0 19 880101 19 9 80101 38 A C D1F P 0 19 880101 N N 19 9 6 0101 19 9 9 0101 Endo knee-shin fluid swg/sta 19 9 6 0101 Endo knee-shin pneum/swg pha 38 A C D1F P 0 19 880101 N N N 19 9 6 0101 N Multi-a xia l knee/shin system 38 A C D1F P 0 19 9 4 0101 19 9 9 0101 Knee-shin sys sta nce flexion Knee-shin sys microprocessor 38 38 A A C C D1F D1F P P 0 0 19 9 6 0101 19 9 6 0101 19 9 6 0101 20050101 2004 1231 2004 1231 Microprocessor cntrl fea ture 38 A C D1F P 0 20020101 20050101 Knee-shin sys hydra ul sta nce 38 A C D1F P 0 20030101 20070101 Endo a k/hip knee extens a ssi 38 A C D1F P 0 19 880101 19 9 6 0101 N N N N C N Mech hip extension a ssist 38 A C D1F P 0 19 9 4 0101 19 9 50101 N Elec knee-shin swing/sta nce 38 A C D1F P 0 20050101 20050101 N Elec knee-shin swing only 38 A C D1F P 0 20050101 20050101 N Sta nce pha se only 38 A C D1F P 0 2006 0101 2006 0101 N Endo below knee a ligna ble sy Endo a k/hip a ligna ble system 38 38 A A C C D1F D1F P P 0 0 19 880101 19 880101 19 9 6 0101 19 9 6 0101 N N Above knee ma nua l lock 38 A C D1F P 0 19 9 4 0101 20000101 N High a ctivity knee fra me Endo bk ultra -light ma teria l 38 38 A A C C D1F D1F P P 0 0 19 9 6 0101 19 880101 19 9 6 0101 19 9 6 0101 N N Endo a k ultra -light ma teria l 38 A C D1 PUF___2007_Web_File S9 54 2 S9 54 2 S9 54 6 S9 558 S9 558 S9 558 S9 559 S9 559 S9 559 S9 56 0 S9 56 0 S9 56 0 S9 56 0 S9 56 2 S9 56 2 S9 56 2 S9 59 0 S9 59 0 S9 59 0 S9 59 0 S9 802 S9 802 S9 803 S9 803 S9 806 S9 810 S9 810 S9 810 S9 9 00 S9 9 00 S9 9 00 S9 9 70 S9 9 75 S9 9 76 S9 9 77 S9 9 81 S9 9 82 S9 9 86 S9 9 86 S9 9 88 S9 9 89 S9 9 89 S9 9 9 0 S9 9 9 1 S9 9 9 2 S9 9 9 2 S9 9 9 2 S9 9 9 4 S9 9 9 4 S9 9 9 6 S9 9 9 9 T1000 T1001 T1002 T1003 T1004 T1005 T1006 T1007 T1007 T1008 T1009 T1009 T1010 T1010 T1011 T1012 T1013 T1014 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200 100 100 100 4 4 3 3 4 4 3 4 4 3 4 4 4 3 4 4 3 4 4 4 3 4 3 4 3 3 4 4 3 4 4 3 3 3 3 3 3 3 4 3 3 4 3 3 3 4 4 3 4 3 3 3 3 3 3 3 3 3 3 4 3 3 4 3 4 3 3 3 3 3 3 3 3 3 4 4 4 3 4 4 4 3 3 4 3 4 4 3 4 3 4 4 3 4 4 3 3 4 3 4 3 3 3 3 4 3 4 3 3 3 3 3 3 3 4 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 4 4 3 3 3 3 3 3 3 4 3 4 3 4 3 4 3 4 3 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 4 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 4 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM HOME INFUSION OF BLOOD PRODUCTS, NURSING SERVICES, PER VISIT HOME INJECTABLE THERAPY; GROWTH HORMONE, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM HOME INJECTABLE THERAPY, INTERFERON, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM HOME INJECTABLE THERAPY; HORMONAL THERAPY (E.G.; LEUPROLIDE, GOSERELIN), INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM HOME INJECTABLE THERAPY, PALIVIZ UMAB, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM HOME THERAPY, IRRIGATION THERAPY (E.G. STERILE IRRIGATION OF AN ORGAN OR ANATOMICAL CAVITY); INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM HOME INFUSION/SPECIALTY DRUG ADMINISTRATION, NURSING SERVICES; PER VISIT (UP TO 2 HOURS) HOME INFUSION/SPECIALTY DRUG ADMINISTRATION, NURSING SERVICES; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE S9 802) RN SERVICES IN THE INFUSION SUITE OF THE IV THERAPY PROVIDER, PER VISIT HOME THERAPY; PROFESSIONAL PHARMACY SERVICES FOR PROVISION OF INFUSION, SPECIALTY DRUG ADMINISTRATION, AND/OR DISEASE STATE MANAGEMENT, NOT OTHERWISE CLASSIFIED, PER HOUR (DO NOT USE THIS CODE WITH ANY PER DIEM CODE) SERVICES BY AUTHORIZ ED CHRISTIAN SCIENCE PRACTITIONER FOR THE PROCESS OF HEALING, PER DIEM; NOT TO BE USED FOR REST OR STUDY; EXCLUDES IN-PATIENT SERVICES HEALTH CLUB MEMBERSHIP, ANNUAL TRANSPLANT RELATED LODGING, MEALS AND TRANSPORTATION, PER DIEM LODGING, PER DIEM, NOT OTHERWISE CLASSIFIED MEALS, PER DIEM, NOT OTHERWISE SPECIFIED MEDICAL RECORDS COPYING FEE, ADMINISTRATIVE MEDICAL RECORDS COPYING FEE, PER PAGE NOT MEDICALLY NECESSARY SERVICE (PATIENT IS AWARE THAT SERVICE NOT MEDICALLY NECESSARY) SERVICES PROVIDED AS PART OF A PHASE I CLINICAL TRIAL SERVICES PROVIDED OUTSIDE OF THE UNITED STATES OF AMERICA (LIST IN ADDITION TO CODE(S) FOR SERVICES(S)) SERVICES PROVIDED AS PART OF A PHASE II CLINICAL TRIAL SERVICES PROVIDED AS PART OF A PHASE III CLINICAL TRIAL TRANSPORTATION COSTS TO AND FROM TRIAL LOCATION AND LOCAL TRANSPORTATION COSTS (E.G., FARES FOR TAXICAB OR BUS) FOR CLINICAL TRIAL PARTICIPANT AND ONE CAREGIVER/COMPANION LODGING COSTS (E.G., HOTEL CHARGES) FOR CLINICAL TRIAL PARTICIPANT AND ONE CAREGIVER/COMPANION MEALS FOR CLINICAL TRIAL PARTICIPANT AND ONE CAREGIVER/COMPANION SALES TAX PRIVATE DUTY / INDEPENDENT NURSING SERVICE(S) - LICENSED, UP TO 15 MINUTES NURSING ASSESSMENT / EVALUATION RN SERVICES, UP TO 15 MINUTES LPN/LVN SERVICES, UP TO 15 MINUTES SERVICES OF A QUALIFIED NURSING AIDE, UP TO 15 MINUTES RESPITE CARE SERVICES, UP TO 15 MINUTES ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, FAMILY/COUPLE COUNSELING ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, TREATMENT PLAN DEVELOPMENT AND/OR MODIFICATION DAY TREATMENT FOR INDIVIDUAL ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES CHILD SITTING SERVICES FOR CHILDREN OF THE INDIVIDUAL RECEIVING ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES MEALS FOR INDIVIDUALS RECEIVING ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES (WHEN MEALS NOT INCLUDED IN THE PROGRAM) ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, NOT OTHERWISE CLASSIFIED ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, SKILLS DEVELOPMENT SIGN LANGUAGE OR ORAL INTERPRETIVE SERVICES, PER 15 MINUTES TELEHEALTH TRANSMISSION, PER MINUTE, PROFESSIONAL SERVICES BILL SEPARATELY CLINIC VISIT/ENCOUNTER, ALL-INCLUSIVE CASE MANAGEMENT, EACH 15 MINUTES TARGETED CASE MANAGEMENT, EACH 15 MINUTES SCHOOL-BASED INDIVIDUALIZ ED EDUCATION PROGRAM (IEP) SERVICES, BUNDLED PERSONAL CARE SERVICES, PER 15 MINUTES, NOT FOR AN INPATIENT OR RESIDENT OF A HOSPITAL, NURSING FACILITY, ICF/MR OR IMD, PART OF THE INDIVIDUALIZ ED PLAN OF TREATMENT (CODE MAY NOT BE USED TO IDENTIFY SERVICES PROVIDED BY HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT) PERSONAL CARE SERVICES, PER DIEM, NOT FOR AN INPATIENT OR RESIDENT OF A HOSPITAL, NURSING FACILITY, ICF/MR OR IMD, PART OF THE INDIVIDUALIZ ED PLAN OF TREATMENT (CODE MAY NOT BE USED TO IDENTIFY SERVICES PROVIDED BY HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT) HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT, PER VISIT CONTRACTED HOME HEALTH AGENCY SERVICES, ALL SERVICES PROVIDED UNDER CONTRACT, PER DAY SCREENING TO DETERMINE THE APPROPRIATENESS OF CONSIDERATION OF AN INDIVIDUAL FOR PARTICIPATION IN A SPECIFIED PROGRAM, PROJECT OR TREATMENT PROTOCOL, PER ENCOUNTER EVALUATION AND TREATMENT BY AN INTEGRATED, SPECIALTY TEAM CONTRACTED TO PROVIDE COORDINATED CARE TO MULTIPLE OR SEVERELY HANDICAPPED CHILDREN, PER ENCOUNTER INTENSIVE, EXTENDED MULTIDISCIPLINARY SERVICES PROVIDED IN A CLINIC SETTING TO CHILDREN WITH COMPLEX MEDICAL, PHYSICAL, MENTAL AND PSYCHOSOCIAL IMPAIRMENTS, PER DIEM INTENSIVE, EXTENDED MULTIDISCIPLINARY SERVICES PROVIDED IN A CLINIC SETTING TO CHILDREN WITH COMPLEX MEDICAL, PHYSICAL, MEDICAL AND PSYCHOSOCIAL IMPAIRMENTS, PER HOUR FAMILY TRAINING AND COUNSELING FOR CHILD DEVELOPMENT, PER 15 MINUTES ASSESSMENT OF HOME, PHYSICAL AND FAMILY ENVIRONMENT, TO DETERMINE SUITABILITY TO MEET PATIENT'S MEDICAL NEEDS COMPREHENSIVE ENVIRONMENTAL LEAD INVESTIGATION, NOT INCLUDING LABORATORY ANALYSIS, PER DWELLING NURSING CARE, IN THE HOME, BY REGISTERED NURSE, PER DIEM NURSING CARE, IN THE HOME, BY LICENSED PRACTICAL NURSE, PER DIEM DIAPER/INCONTINENT PANT, REUSABLE/WASHABLE, ANY SIZ E, EACH ADMINISTRATION OF ORAL, INTRAMUSCULAR AND/OR SUBCUTANEOUS MEDICATION BY HEALTH CARE AGENCY/PROFESSIONAL, PER VISIT MISCELLANEOUS THERAPEUTIC ITEMS AND SUPPLIES, RETAIL PURCHASES, NOT OTHERWISE CLASSIFIED; IDENTIFY PRODUCT IN "REMARKS" NON-EMERGENCY TRANSPORTATION; PATIENT ATTENDANT/ESCORT NON-EMERGENCY TRANSPORTATION; PER DIEM NON-EMERGENCY TRANSPORTATION; ENCOUNTER/TRIP NON-EMERGENCY TRANSPORT; COMMERCIAL CARRIER, MULTI-PASS NON-EMERGENCY TRANSPORTATION; STRETCHER VAN AMBULANCE RESPONSE AND TREATMENT, NO TRANSPORT TRANSPORTATION WAITING TIME, AIR AMBULANCE AND NON-EMERGENCY VEHICLE, ONE-HALF (1/2) HOUR INCREMENTS PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL I IDENTIFICATION SCREENING, PER SCREEN PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL II EVALUATION, PER EVALUATION HABILITATION, EDUCATIONAL; WAIVER, PER DIEM HABILITATION, EDUCATIONAL, WAIVER; PER HOUR HABILITATION, PREVOCATIONAL, WAIVER; PER DIEM HABILITATION, PREVOCATIONAL, WAIVER; PER HOUR HABILITATION, RESIDENTIAL, WAIVER; PER DIEM HABILITATION, RESIDENTIAL, WAIVER; 15 MINUTES HABILITATION, SUPPORTED EMPLOYMENT, WAIVER; PER DIEM HABILITATION, SUPPORTED EMPLOYMENT, WAIVER; PER 15 MINUTES DAY HABILITATION, WAIVER; PER DIEM DAY HABILITATION, WAIVER; PER 15 MINUTES CASE MANAGEMENT, PER MONTH TARGETED CASE MANAGEMENT; PER MONTH SERVICE ASSESSMENT/PLAN OF CARE DEVELOPMENT, WAIVER WAIVER SERVICES; NOT OTHERWISE SPECIFIED (NOS) SPECIALIZ ED CHILDCARE, WAIVER; PER DIEM SPECIALIZ ED CHILDCARE, WAIVER; PER 15 MINUTES SPECIALIZ ED SUPPLY, NOT OTHERWISE SPECIFIED, WAIVER SPECIALIZ ED MEDICAL EQUIPMENT, NOT OTHERWISE SPECIFIED, WAIVER ASSISTED LIVING, WAIVER; PER MONTH ASSISTED LIVING; WAIVER, PER DIEM RESIDENTIAL CARE, NOT OTHERWISE SPECIFIED (NOS), WAIVER; PER MONTH RESIDENTIAL CARE, NOT OTHERWISE SPECIFIED (NOS), WAIVER; PER DIEM CRISIS INTERVENTION, WAIVER; PER DIEM UTILITY SERVICES TO SUPPORT MEDICAL EQUIPMENT AND ASSISTIVE TECHNOLOGY/DEVICES, WAIVER THERAPEUTIC CAMPING, OVERNIGHT, WAIVER; EACH SESSION THERAPEUTIC CAMPING, DAY, WAIVER; EACH SESSION COMMUNITY TRANSITION, WAIVER; PER SERVICE VEHICLE MODIFICATIONS, WAIVER; PER SERVICE FINANCIAL MANAGEMENT, SELF-DIRECTED, WAIVER; PER 15 MINUTES SUPPORTS BROKERAGE, SELF-DIRECTED, WAIVER; PER 15 MINUTES HOSPICE ROUTINE HOME CARE; PER DIEM HOSPICE CONTINUOUS HOME CARE; PER HOUR HOSPICE INPATIENT RESPITE CARE; PER DIEM HOSPICE GENERAL INPATIENT CARE; PER DIEM HOSPICE LONG TERM CARE, ROOM AND BOARD ONLY; PER DIEM BEHAVIORAL HEALTH; LONG-TERM CARE RESIDENTIAL (NON-ACUTE CARE IN A RESIDENTIAL TREATMENT PROGRAM WHERE STAY IS TYPICALLY LONGER THAN 30 DAYS), WITH ROOM AND BOARD, PER DIEM NON-EMERGENCY TRANSPORTATION; STRETCHER VAN, MILEAGE; PER MILE HUMAN BREAST MILK PROCESSING, STORAGE AND DISTRIBUTION ONLY ADULT SIZ ED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, SMALL, EACH ADULT SIZ ED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, MEDIUM, EACH ADULT SIZ ED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, LARGE, EACH ADULT SIZ ED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, EXTRA LARGE, EACH ADULT SIZ ED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, SMALL SIZ E, EACH ADULT SIZ ED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, MEDIUM SIZ E, EACH ADULT SIZ ED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, LARGE SIZ E, EACH ADULT SIZ ED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, EXTRA LARGE SIZ E, EACH PEDIATRIC SIZ ED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, SMALL/MEDIUM SIZ E, EACH PEDIATRIC SIZ ED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, LARGE SIZ E, EACH PEDIATRIC SIZ ED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, SMALL/MEDIUM SIZ E, EACH PEDIATRIC SIZ ED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, LARGE SIZ E, EACH YOUTH SIZ ED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, EACH YOUTH SIZ ED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, EACH DISPOSABLE LINER/SHIELD/GUARD/PAD/UNDERGARMENT, FOR INCONTINENCE, EACH INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, REUSABLE, ANY SIZ E, EACH INCONTINENCE PRODUCT, PROTECTIVE UNDERPAD, REUSABLE, BED SIZ E, EACH DIAPER SERVICE, REUSABLE DIAPER, EACH DIAPER INCONTINENCE PRODUCT, DIAPER/BRIEF, REUSABLE, ANY SIZ E, EACH INCONTINENCE PRODUCT, PROTECTIVE UNDERPAD, REUSABLE, CHAIR SIZ E, EACH INCONTINENCE PRODUCT, DISPOSABLE UNDERPAD, LARGE, EACH INCONTINENCE PRODUCT, DISPOSABLE UNDERPAD, SMALL SIZ E, EACH DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, BARIATRIC, EACH POSITIONING SEAT FOR PERSONS WITH SPECIAL ORTHOPEDIC NEEDS SUPPLY, NOT OTHERWISE SPECIFIED FRAMES, PURCHASES DELUXE FRAME SPHERE, SINGLE VISION, PLANO TO PLUS OR MINUS 4 .00, PER LENS SPHERE, SINGLE VISION, PLUS OR MINUS 4 .12 TO PLUS OR MINUS 7.00D, PER LENS SPHERE, SINGLE VISION, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00D, PER LENS SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4 .00D SPHERE, .12 TO 2.00D CYLINDER, PER LENS SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4 .00D SPHERE, 2.12 TO 4 .00D CYLINDER, PER LENS SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4 .00D SPHERE, 4 .25 TO 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4 .00D SPHERE, OVER 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4 .25 TO PLUS OR MINUS 7.00 SPHERE, .12 TO 2.00D CYLINDER, PER LENS SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4 .25D TO PLUS OR MINUS 7.00D SPHERE, 2.12 TO 4 .00D CYLINDER, PER LENS SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4 .25 TO PLUS OR MINUS 7.00D SPHERE, 4 .25 TO 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4 .25 TO 7.00D SPHERE, OVER 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, .25 TO 2.25D CYLINDER, PER LENS SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 2.25D TO 4 .00D CYLINDER, PER LENS SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 4 .25 TO 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, SINGLE VISION, SPHERE OVER PLUS OR MINUS 12.00D, PER LENS LENTICULAR, (MYODISC), PER LENS, SINGLE VISION LENTICULAR LENS, NONASPHERIC, PER LENS, SINGLE VISION LENTICULAR, ASPHERIC, PER LENS, SINGLE VISION ANISEIKONIC LENS, SINGLE VISION LENTICULAR LENS, PER LENS, SINGLE NOT OTHERWISE CLASSIFIED, SINGLE VISION LENS SPHERE, BIFOCAL, PLANO TO PLUS OR MINUS 4 .00D, PER LENS SPHERE, BIFOCAL, PLUS OR MINUS 4 .12 TO PLUS OR MINUS 7.00D, PER LENS SPHERE, BIFOCAL, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00D, PER LENS SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4 .00D SPHERE, .12 TO 2.00D CYLINDER, PER LENS SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4 .00D SPHERE, 2.12 TO 4 .00D CYLINDER, PER LENS SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4 .00D SPHERE, 4 .25 TO 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4 .00D SPHERE, OVER 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4 .25 TO PLUS OR MINUS 7.00D SPHERE,.12 TO 2.00D CYLINDER, PER LENS SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4 .25 TO PLUS OR MINUS 7.00D SPHERE, 2.12 TO 4 .00D CYLINDER, PER LENS SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4 .25 TO PLUS OR MINUS 7.00D SPHERE, 4 .25 TO 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4 .25 TO PLUS OR MINUS 7.00D SPHERE, OVER 6 .00D CYLINDER,PER LENS SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, .25 TO 2.25D CYLINDER, PER LENS SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 2.25 TO 4 .00D CYLINDER, PER LENS SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 4 .25 TO 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, BIFOCAL, SPHERE OVER PLUS OR MINUS 12.00D, PER LENS LENTICULAR (MYODISC), PER LENS, BIFOCAL LENTICULAR, NONASPHERIC, PER LENS, BIFOCAL LENTICULAR, ASPHERIC LENS, BIFOCAL ANISEIKONIC, PER LENS, BIFOCAL BIFOCAL SEG WIDTH OVER 28MM BIFOCAL ADD OVER 3.25D LENTICULAR LENS, PER LENS, BIFOCAL SPECIALTY BIFOCAL (BY REPORT) SPHERE, TRIFOCAL, PLANO TO PLUS OR MINUS 4 .00D, PER LENS SPHERE, TRIFOCAL, PLUS OR MINUS 4 .12 TO PLUS OR MINUS 7.00D, PER LENS SPHERE, TRIFOCAL, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00, PER LENS SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4 .00D SPHERE, .12-2.00D CYLINDER, PER LENS SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4 .00D SPHERE, 2.25-4 .00D CYLINDER, PER LENS SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4 .00D SPHERE, 4 .25 TO 6 .00 CYLINDER, PER LENS SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4 .00D SPHERE, OVER 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4 .25 TO PLUS OR MINUS 7.00D SPHERE, .12 TO 2.00D CYLINDER, PER LENS SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4 .25 TO PLUS OR MINUS 7.00D SPHERE, 2.12 TO 4 .00D CYLINDER, PER LENS SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4 .25 TO PLUS OR MINUS 7.00D SPHERE, 4 .25 TO 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4 .25 TO PLUS OR MINUS 7.00D SPHERE, OVER 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, .25 TO 2.25D CYLINDER, PER LENS SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 2.25 TO 4 .00D CYLINDER, PER LENS SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 4 .25 TO 6 .00D CYLINDER, PER LENS SPHEROCYLINDER, TRIFOCAL, SPHERE OVER PLUS OR MINUS 12 .00D, PER LENS LENTICULAR, (MYODISC), PER LENS, TRIFOCAL LENTICULAR NONASPHERIC, PER LENS, TRIFOCAL LENTICULAR, ASPHERIC LENS, TRIFOCAL ANISEIKONIC LENS, TRIFOCAL TRIFOCAL SEG WIDTH OVER 28 MM TRIFOCAL ADD OVER 3.25D LENTICULAR LENS, PER LENS, TRIFOCAL SPECIALTY TRIFOCAL (BY REPORT) VARIABLE ASPHERICITY LENS, SINGLE VISION, FULL FIELD, GLASS OR PLASTIC, PER LENS VARIABLE ASPHERICITY LENS, BIFOCAL, FULL FIELD, GLASS OR PLASTIC, PER LENS VARIABLE SPHERICITY LENS, OTHER TYPE CONTACT LENS, PMMA, SPHERICAL, PER LENS CONTACT LENS, PMMA, TORIC OR PRISM BALLAST, PER LENS CONTACT LENS PMMA, BIFOCAL, PER LENS CONTACT LENS, PMMA, COLOR VISION DEFICIENCY, PER LENS CONTACT LENS, GAS PERMEABLE, SPHERICAL, PER LENS CONTACT LENS, GAS PERMEABLE, TORIC, PRISM BALLAST, PER LENS CONTACT LENS, GAS PERMEABLE, BIFOCAL, PER LENS CONTACT LENS, GAS PERMEABLE, EXTENDED WEAR, PER LENS CONTACT LENS, HYDROPHILIC, SPHERICAL, PER LENS CONTACT LENS, HYDROPHILIC, TORIC, OR PRISM BALLAST, PER LENS CONTACT LENS, HYDROPHILLIC, BIFOCAL, PER LENS CONTACT LENS, HYDROPHILIC, EXTENDED WEAR, PER LENS CONTACT LENS, SCLERAL, GAS IMPERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, SEE 9 2325) CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, SEE 9 2325) CONTACT LENS, OTHER TYPE HAND HELD LOW VISION AIDS AND OTHER NONSPECTACLE MOUNTED AIDS SINGLE LENS SPECTACLE MOUNTED LOW VISION AIDS TELESCOPIC AND OTHER COMPOUND LENS SYSTEM, INCLUDING DISTANCE VISION TELESCOPIC, NEAR VISION TELESCOPES AND COMPOUND MICROSCOPIC LENS SYSTEM PROSTHETIC EYE, PLASTIC, CUSTOM POLISHING/RESURFACING OF OCULAR PROSTHESIS ENLARGEMENT OF OCULAR PROSTHESIS REDUCTION OF OCULAR PROSTHESIS SCLERAL COVER SHELL FABRICATION AND FITTING OF OCULAR CONFORMER PROSTHETIC EYE, OTHER TYPE ANTERIOR CHAMBER INTRAOCULAR LENS IRIS SUPPORTED INTRAOCULAR LENS POSTERIOR CHAMBER INTRAOCULAR LENS BALANCE LENS, PER LENS DELUXE LENS FEATURE SLAB OFF PRISM, GLASS OR PLASTIC, PER LENS PRISM, PER LENS PRESS-ON LENS, FRESNELL PRISM, PER LENS SPECIAL BASE CURVE, GLASS OR PLASTIC, PER LENS TINT, PLASTIC, ROSE 1 OR 2 PER LENS TINT, PLASTIC, OTHER THAN ROSE 1-2, PER LENS TINT, GLASS ROSE 1 OR 2, PER LENS TINT, GLASS OTHER THAN ROSE 1 OR 2, PER LENS TINT, PHOTOCHROMATIC, PER LENS ADDITION TO LENS; TINT, ANY COLOR, SOLID, GRADIENT OR EQUAL, EXCLUDES PHOTOCHROMATIC, ANY LENS MATERIAL, PER LENS ANTI-REFLECTIVE COATING, PER LENS U-V LENS, PER LENS EYE GLASS CASE SCRATCH RESISTANT COATING, PER LENS MIRROR COATING, ANY TYPE, SOLID, GRADIENT OR EQUAL, ANY LENS MATERIAL, PER LENS POLARIZ ATION, ANY LENS MATERIAL, PER LENS OCCLUDER LENS, PER LENS OVERSIZ E LENS, PER LENS PROGRESSIVE LENS, PER LENS LENS, INDEX 1.54 TO 1.6 5 PLASTIC OR 1.6 0 TO 1.79 GLASS, EXCLUDES POLYCARBONATE, PER LENS LENS, INDEX GREATER THAN OR EQUAL TO 1.6 6 PLASTIC OR GREATER THAN OR EQUAL TO 1.80 GLASS, EXCLUDES POLYCARBONATE, PER LENS LENS, POLYCARBONATE OR EQUAL, ANY INDEX, PER LENS PROCESSING, PRESERVING AND TRANSPORTING CORNEAL TISSUE SPECIALTY OCCUPATIONAL MULTIFOCAL LENS, PER LENS PRESBYOPIA CORRECTING FUNCTION OF INTRAOCULAR LENS AMNIOTIC MEMBRANE FOR SURGICAL RECONSTRUCTION, PER PROCEDURE VISION SUPPLY, ACCESSORY AND/OR SERVICE COMPONENT OF ANOTHER HCPCS VISION CODE VISION SERVICE, MISCELLANEOUS HEARING SCREENING ASSESSMENT FOR HEARING AID FITTING/ORIENTATION/CHECKING OF HEARING AID REPAIR/MODIFICATION OF A HEARING AID CONFORMITY EVALUATION HEARING AID, MONAURAL, BODY WORN, AIR CONDUCTION HEARING AID, MONAURAL, BODY WORN, BONE CONDUCTION HEARING AID, MONAURAL, IN THE EAR HEARING AID, MONAURAL, BEHIND THE EAR GLASSES, AIR CONDUCTION GLASSES, BONE CONDUCTION DISPENSING FEE, UNSPECIFIED HEARING AID SEMI-IMPLANTABLE MIDDLE EAR HEARING PROSTHESIS HEARING AID, BILATERAL, BODY WORN DISPENSING FEE, BILATERAL BINAURAL, BODY BINAURAL, IN THE EAR BINAURAL, BEHIND THE EAR BINAURAL, GLASSES DISPENSING FEE, BINAURAL HEARING AID, CROS, IN THE EAR HEARING AID, CROS, BEHIND THE EAR HEARING AID, CROS, GLASSES DISPENSING FEE, CROS HEARING AID, BICROS, IN THE EAR HEARING AID, BICROS, BEHIND THE EAR HEARING AID, BICROS, GLASSES DISPENSING FEE, BICROS DISPENSING FEE, MONAURAL HEARING AID, ANY TYPE HEARING AID, ANALOG, MONAURAL, CIC (COMPLETELY IN THE EAR CANAL) HEARING AID, ANALOG, MONAURAL, ITC (IN THE CANAL) HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, CIC HEARING AID, DIGITALLY PROGRAMMABLE, ANALOG, MONAURAL, ITC HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, ITE (IN THE EAR) HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, BTE (BEHIND THE EAR) HEARING AID, ANALOG, BINAURAL, CIC HEARING AID, ANALOG, BINAURAL, ITC HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, BINAURAL, CIC HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, BINAURAL, ITC HEARING AID, DIGITALLY PROGRAMMABLE, BINAURAL, ITE HEARING AID, DIGITALLY PROGRAMMABLE, BINAURAL, BTE HEARING AID, DIGITAL, MONAURAL, CIC HEARING AID, DIGITAL, MONAURAL, ITC HEARING AID, DIGITAL, MONAURAL, ITE HEARING AID, DIGITAL, MONAURAL, BTE HEARING AID, DIGITAL, BINAURAL, CIC HEARING AID, DIGITAL, BINAURAL, ITC HEARING AID, DIGITAL, BINAURAL, ITE HEARING AID, DIGITAL, BINAURAL, BTE HEARING AID, DISPOSABLE, ANY TYPE, MONAURAL HEARING AID, DISPOSABLE, ANY TYPE, BINAURAL EAR MOLD/INSERT, NOT DISPOSABLE, ANY TYPE EAR MOLD/INSERT, DISPOSABLE, ANY TYPE BATTERY FOR USE IN HEARING DEVICE HEARING AID SUPPLIES / ACCESSORIES ASSISTIVE LISTENING DEVICE, TELEPHONE AMPLIFIER, ANY TYPE ASSISTIVE LISTENING DEVICE, ALERTING, ANY TYPE ASSISTIVE LISTENING DEVICE, TELEVISION AMPLIFIER, ANY TYPE ASSISTIVE LISTENING DEVICE, TELEVISION CAPTION DECODER ASSISTIVE LISTENING DEVICE, TDD ASSISTIVE LISTENING DEVICE, FOR USE WITH COCHLEAR IMPLANT ASSISTIVE LISTENING DEVICE, NOT OTHERWISE SPECIFIED EAR IMPRESSION, EACH HEARING AID, NOT OTHERWISE CLASSIFIED HEARING SERVICE, MISCELLANEOUS REPAIR/MODIFICATION OF AUGMENTATIVE COMMUNICATIVE SYSTEM OR DEVICE (EXCLUDES ADAPTIVE HEARING AID) SPEECH SCREENING LANGUAGE SCREENING DYSPHAGIA SCREENING Page 5 Home inf blood prod nurs ser HT inj growth horm diem 00 00 9 9 I I 0088 Z2 Z2 9 9 0 0 200204 01 20020101 20031001 20020101 HIT inj interferon diem 00 9 I 0088 Z2 9 0 20020101 20020101 HT inj hormone diem 00 9 I 0088 Z2 9 0 20020101 20020101 HT inj pa liviz uma b diem 00 9 I Z2 9 0 20030101 00 9 I Z2 9 0 20030101 200309 30 N N N N 20030101 HT irriga tion diem 20030101 N N HT nursing visit 00 9 I Z2 9 0 20030101 20030701 200306 30 N HT nursing a ddl hr 00 9 I Z2 9 0 20030101 20030701 200306 30 N 20031231 RN infusion suite visit HT pha rm per hour 00 00 9 9 I I Z2 Z2 9 9 0 0 20020701 20020101 2004 0101 20020101 Christia n Sci Pra ct visit 00 9 I Z2 9 0 20020701 20020701 N Hea lth club membership yr Tra nspla nt rela ted per diem Lodging per diem Mea ls per diem Med record copy a dmin Med record copy per pa ge Not medica lly necessa ry svc 00 00 00 00 00 00 00 9 9 9 9 9 9 9 I I I I I I I 0088 0088 0088 Z2 Z2 Z2 Z2 Z2 Z2 Z2 9 9 9 9 9 9 9 0 0 0 0 0 0 0 200204 01 200204 01 2004 04 01 2004 04 01 20020101 20020101 20020101 200204 01 200204 01 2004 04 01 2004 04 01 20020101 20020101 20020101 N N N N N N N Serv pa rt of pha se I tria l Services outside US 00 00 9 9 I I 0088 Z2 Z2 9 9 0 0 2004 04 01 20020101 2004 04 01 20020101 N N Services provided a s pa rt of Services provided a s pa rt of Tra nsporta tion costs to a nd 00 00 00 9 9 9 I I I 0088 0088 0088 Z2 Z2 Z2 9 9 9 0 0 0 20000101 20000101 20000101 20000101 20000101 20000101 0088 Lodging costs (e.g. hotel ch 00 9 I 0088 Z2 9 0 20000101 00 00 00 00 00 00 00 00 00 00 9 9 9 9 9 9 9 9 9 9 I I I I I I I I I I 0088 0088 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 20000101 20000101 20010701 20010701 20010701 20010701 20010701 20010701 20010701 20010701 20000101 20000101 20010701 20010701 20010701 20010701 20010701 20010701 20010701 20010701 Da y Trea tment for Individua l Child Sitting Services 00 00 9 9 I I Z2 Z2 9 9 0 0 20010701 20010701 200304 01 20010701 N N N 20000101 Mea ls for clinica l tria l pa r Sa les ta x Priva te duty/independent nsg Nursing a ssessment/eva lua tn RN services up to 15 minutes LPN/LVN services up to 15min Nsg a ide service up to 15min Respite ca re service 15 min Fa mily/Couple Counseling Trea tment Pla n Development Mea ls when Receive Services 00 9 I Z2 9 0 20010701 00 00 00 00 00 00 00 00 00 9 9 9 9 9 9 9 9 9 I I I I I I I I I Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 9 9 9 9 1 9 9 9 9 0 0 0 0 0 0 0 0 0 20010701 20010701 20010701 20010701 20020101 20020701 20020701 20020701 20020701 200304 01 20010701 20030101 20010701 20020101 20020701 20020701 20020701 20020701 Persona l ca re ser per diem 00 9 I Z2 9 0 20020701 N N N N N N N N N N N 20030331 N N 20030331 N N N N N N N N N 20010701 Alcohol/Substa nce Abuse NOC Alcohol/Substa nce Abuse Skil Sign La ng/Ora l Interpreter Telehea lth tra nsmit, per min Clinic service Ca se ma na gement Ta rgeted ca se ma na gement School-ba sed IEP ser bundled Persona l ca re ser per 15 min N N 20020701 N N HH Aide or cn a ide per visit Contra cted services per da y 00 00 9 9 I I Z2 Z2 9 9 0 0 20020701 20030101 20020701 20030101 N N Progra m inta ke a ssessment 00 9 I Z2 9 0 20030101 20030101 N Tea m eva lua tion & ma na gement 00 9 I Z2 9 0 20030101 20030101 Ped compr ca re pkg, per diem 00 9 I Z2 9 0 20030101 20030101 Ped compr ca re pkg, per hour 00 9 I Z2 9 0 20030101 00 00 9 9 I I Z2 Z2 9 9 0 0 20030101 20030101 N N 20030101 Fa mily tra ining & counseling Home environment a ssessment 20030101 20030101 Dwelling lea d investiga tion 00 9 I Z2 9 0 20030101 00 00 00 00 9 9 9 9 I I I I Z2 Z2 Z2 Z2 9 9 9 9 0 0 0 0 20030101 20030101 20030101 20030101 20030101 20030101 20050101 20030101 NOC reta il items a ndsupplies 00 9 I Z2 9 0 20030101 00 00 00 00 00 00 00 9 9 9 9 9 9 9 I I I I I I I Z2 Z2 Z2 Z2 Z2 Z2 Z2 9 9 9 9 9 9 9 0 0 0 0 0 0 0 200204 01 200204 01 200204 01 200204 01 200204 01 200204 01 20030101 200204 01 200204 01 200204 01 200204 01 2004 0701 2006 0101 20030101 N 20030101 N-et; pa tient a ttend/escort N-et; per diem N-et; encounter/trip N-et; commerc ca rrier pa ss N-et; stretcher va n Amb response & trt, no tra ns Non-emer tra nsport wa it time N N 20030101 RN home ca re per diem LPN home ca re per diem Reusa ble dia per/pa nt Medica tion a dmin visit A09 9 8 N 2004 1231 N N N N N 20051231 N N N N N N N PASRR Level I 00 9 I 0112 Z2 9 0 200304 01 200304 01 N PASRR Level II 00 9 I 0113 Z2 9 0 200304 01 200304 01 N Ha bil ed wa iver, per diem Ha bil ed wa iver per hour Ha bil prevoc wa iver, per d Ha bil prevoc wa iver per hr Ha bil res wa iver per diem Ha bil res wa iver 15 min Ha bil sup empl wa iver/diem Ha bil sup empl wa iver 15min Da y ha bil wa iver per diem Da y ha bil wa iver per 15 min Ca se ma na gement, per month Ta rgeted ca se mgmt per month Serv a smnt/ca re pla n wa iver Wa iver service, nos Specia l childca re wa iver/d Spec childca re wa iver 15 min Specia l supply, nos wa iver Specia l med equip, noswa iver Assist living wa iver/month Assist living wa iver/diem Res ca re, nos wa iver/month Res, nos wa iver per diem Crisis interven wa iver/diem Utility services wa iver 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 I I I I I I I I I I I I I I I I I I I I I I I I Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 N N N N N N N N N N N N N N N N N N N N N N N N Ca mp overnite wa iver/session Ca mp da y wa iver/session Comm tra ns wa iver/service Vehicle mod wa iver/service Fina ncia l mgt wa iver/15min Support broker wa iver/15 min Hospice routine home ca re Hospice continuous home ca re Hospice respite ca re Hospice genera l ca re Hospice long term ca re, r&b Bh ltc res r&b, per diem 00 00 00 00 00 00 00 00 00 00 00 00 9 9 9 9 9 9 9 9 9 9 9 9 I I I I I I I I I I I I Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 Z2 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 N N N N N N N N N N N N N-ET; stretcher va n, milea ge Brea st milk proc/store/dist Adult siz e brief/dia per sm Adult siz e brief/dia per med Adult siz e brief/dia per lg Adult siz e brief/dia per xl Adult siz e pull-on sm 00 00 00 00 00 00 00 9 9 9 9 9 9 9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 I I M M M M M Z2 Z2 D1A D1A D1A D1A D1A 9 9 9 9 9 9 9 0 0 0 0 0 0 0 2004 0701 2004 0101 20050101 20050101 20050101 20050101 20050101 2004 0701 2004 0101 20050101 20050101 20050101 20050101 20050101 N N N N N N N Adult siz e pull-on med 00 9 6 0-9 M D1A 9 0 20050101 20050101 N Adult siz e pull-on lg 00 9 6 0-9 M D1A 9 0 20050101 20050101 N Adult siz e pull-on xl 00 9 6 0-9 M D1A 9 0 20050101 20050101 N Ped siz e brief/dia per sm/med 00 9 6 0-9 M D1A 9 0 20050101 20050101 N Ped siz e brief/dia per lg Ped siz e pull-on sm/med 00 00 9 9 6 0-9 6 0-9 M M D1A D1A 9 9 0 0 20050101 20050101 20050101 20050101 N N Ped siz e pull-on lg 00 9 6 0-9 M D1A 9 0 20050101 20050101 N Youth siz e brief/dia per Youth siz e pull-on Disposa ble liner/shield/pa d Reusa ble pull-on a ny siz e Reusa ble underpa d bed siz e Dia per serv reusa ble dia per Reuse dia per/brief a ny siz e Reusa ble underpa d cha ir siz e La rge disposa ble underpa d Sma ll disposa ble underpa d Disp ba ria tric brief/dia per Position sea t spec orth need Supply, nos Vision svcs fra mes purcha ses Eyegla sses delux fra mes Lens spher single pla no 4 .00 Single visn sphere 4 .12-7.00 Singl visn sphere 7.12-20.00 Spherocylindr 4 .00d/12-2.00d 00 00 00 00 00 00 00 00 00 00 00 00 00 38 00 38 38 38 38 9 9 9 9 9 9 9 9 9 9 9 9 9 A 9 A A A A 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 6 0-9 M M M M M M M M I I M I I D M C C C C D1A D1A D1A D1A D1A D1A D1A D1A Z2 Z2 D1A Z2 Z2 D1F D1F D1F D1F D1F D1F 9 9 9 9 9 9 9 9 9 9 9 P 9 Q Q Q Q Q Q 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20050101 20050101 20050101 20050101 20050101 20050101 20050101 20050101 20050101 20050101 20070101 2004 0101 2004 0101 19 850101 19 9 20101 19 850101 19 850101 19 850101 19 850101 20050101 20050101 20050101 20050101 20050101 20050101 20050101 20050101 20050101 20050101 20070101 20070101 2004 0101 20031001 20031001 20031001 20031001 20031001 20031001 N N N N N N N N N N A B N N N N N N N Spherocylindr 4 .00d/2.12-4 d 38 A C D1F Q 0 19 850101 20031001 N Spherocylinder 4 .00d/4 .25-6 d 38 6 0-9 2130 304 5.4 A C D1F Q 0 19 850101 20031001 Spherocylinder 4 .00d/>6 .00d 38 A C D1F Q 0 19 850101 38 A C D1F Q 0 19 850101 N 20031001 Spherocylinder 4 .25d/12-2d 20031001 Spherocylinder 4 .25d/2.12-4 d 38 A C D1F Q 0 19 850101 N N 20031001 Spherocylinder 4 .25d/4 .25-6 d 38 A C D1F Q 0 19 850101 38 A C D1F Q 0 19 850101 N 20031001 Spherocylinder 4 .25d/over 6 d 20031001 Spherocylindr 7.25d/.25-2.25 38 A C D1F Q 0 19 850101 N N 20031001 Spherocylindr 7.25d/2.25-4 d 38 A C D1F Q 0 19 850101 38 A C D1F Q 0 19 850101 20031001 Spherocylinder over 12.00d Lens lenticula r bifoca l Nona spheric lens bifoca l Aspheric lens bifoca l Lens a niseikonic single Lenticula r lens, single Lens single vision not oth c Lens spher bifoc pla no 4 .00d Lens sphere bifoca l 4 .12-7.0 Lens sphere bifoca l 7.12-20. Lens sphcyl bifoca l 4 .00d/.1 38 38 38 38 38 38 46 38 38 38 38 A A A A A A A A A A A C C C C C D C C C C C D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F Q Q Q Q Q Q Q Q Q Q Q 0 0 0 0 0 0 0 0 0 0 0 19 850101 19 850101 19 850101 19 850101 19 850101 2004 0101 19 850101 19 850101 19 850101 19 850101 19 850101 20031001 20031001 2004 0101 2004 0101 20031001 2004 0101 20031001 20031001 20031001 20031001 20031001 N 20031001 Spherocylindr 7.25d/4 .25-6 d 2130.B N N 20031231 20031231 N N N N N N N N N N N Lens sphcy bifoca l 4 .00d/2.1 38 A C D1F Q 0 19 850101 20031001 N Lens sphcy bifoca l 4 .00d/4 .2 38 A C D1F Q 0 19 850101 20031001 N Lens sphcy bifoca l 4 .00d/ove 38 A C D1F Q 0 19 850101 20031001 Lens sphcy bifoca l 4 .25-7d/. 38 A C D1F Q 0 19 850101 38 A C D1F Q 0 19 850101 N 20031001 Lens sphcy bifoca l 4 .25-7/2. 20031001 Lens sphcy bifoca l 4 .25-7/4 . 38 A C D1F Q 0 19 850101 N N 20031001 Lens sphcy bifoca l 4 .25-7/ov 38 A C D1F Q 0 19 850101 38 A C D1F Q 0 19 850101 N 20031001 Lens sphcy bifo 7.25-12/.25- 20031001 Lens sphcyl bifo 7.25-12/2.2 38 A C D1F Q 0 19 850101 38 A C D1F Q 0 19 850101 38 38 38 38 38 38 38 38 46 38 38 38 38 A A A A A A A A A A A A A C C C C C C C D C C C C C D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F Q Q Q Q Q Q Q Q Q Q Q Q Q 0 0 0 0 0 0 0 0 0 0 0 0 0 19 850101 19 850101 19 850101 19 850101 19 850101 19 850101 19 850101 2004 0101 19 850101 19 850101 19 850101 19 850101 19 850101 20031001 20031001 2004 0101 2004 0101 20031001 20031001 20031001 2004 0101 20031001 20031001 20031001 20031001 20031001 N 20031001 Lens sphcyl bifoca l over 12. Lens lenticula r bifoca l Lens lenticula r nona spheric Lens lenticula r a spheric bif Lens a niseikonic bifoca l Lens bifoca l seg width over Lens bifoca l a dd over 3.25d Lenticula r lens, bifoca l Lens bifoca l specia lity Lens sphere trifoca l 4 .00d Lens sphere trifoca l 4 .12-7. Lens sphere trifoca l 7.12-20 Lens sphcy trifoca l 4 .0/.12- N 20031001 Lens sphcyl bifo 7.25-12/4 .2 2130.B N N 20031231 20031231 N N N N N N N N N N N N N Lens sphcy trifoca l 4 .0/2.25 38 A C D1F Q 0 19 850101 20031001 N Lens sphcy trifoca l 4 .0/4 .25 38 A C D1F Q 0 19 850101 20031001 N Lens sphcyl trifoca l 4 .00/>6 38 A C D1F Q 0 19 850101 20031001 Lens sphcy trifoca l 4 .25-7/. 38 A C D1F Q 0 19 850101 20031001 Lens sphc trifoca l 4 .25-7/2. 38 A C D1F Q 0 19 850101 N N 20031001 Lens sphc trifoca l 4 .25-7/4 . 38 A C D1F Q 0 19 850101 38 A C D1F Q 0 19 850101 N 20031001 Lens sphc trifoca l 4 .25-7/>6 20031001 Lens sphc trifo 7.25-12/.25- 38 A C D1F Q 0 19 850101 N N 20031001 N Lens sphc trifo 7.25-12/2.25 38 A C D1F Q 0 19 850101 20031001 Lens sphc trifo 7.25-12/4 .25 38 A C D1F Q 0 19 850101 20031001 Lens sphcyl trifoca l over 12 Lens lenticula r trifoca l Lens lenticula r nona spheric Lens lenticula r a spheric tri Lens a niseikonic trifoca l Lens trifoca l seg width > 28 Lens trifoca l a dd over 3.25d Lenticula r lens, trifoca l Lens trifoca l specia lity Lens va ria b a sphericity sing Lens va ria ble a sphericity bi Va ria ble a sphericity lens Conta ct lens pmma spherica l Cntct lens pmma -toric/prism Conta ct lens pmma bifoca l Cntct lens pmma color vision Cntct ga s permea ble sphericl Cntct toric prism ba lla st Cntct lens ga s permbl bifocl Conta ct lens extended wea r Conta ct lens hydrophilic Cntct lens hydrophilic toric Cntct lens hydrophil bifocl Cntct lens hydrophil extend Conta ct lens ga s impermea ble 38 38 38 38 38 38 38 38 46 38 38 46 38 38 38 38 38 38 38 38 38 38 38 38 38 A A A A A A A A A A A A A A A A A A A A A A A A A C C C C C C C D C C C C C C C C C C C C D D D D C D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 850101 19 850101 19 850101 19 850101 19 850101 19 850101 19 850101 2004 0101 19 850101 19 84 0101 19 84 0101 19 84 0101 19 850101 19 850101 19 850101 19 850101 19 850101 19 850101 19 850101 19 850101 19 84 0101 19 850101 19 850101 19 850101 19 850101 20031001 20031001 2004 0101 2004 0101 20031001 20031001 20031001 2004 0101 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 Conta ct lens ga s permea ble 38 A D D1F Q 0 19 9 6 0101 20031001 N Conta ct lens/es other type Ha nd held low vision a ids Single lens specta cle mount Telescop/othr compound lens 46 46 46 46 A A A A C C C C D1F D1F D1F D1F Q Q Q Q 0 0 0 0 19 850101 19 850101 19 850101 19 850101 20031001 20031001 20031001 20031001 N N N N Pla stic eye prosth custom Polishing a rtifica l eye Enla rgemnt of eye prosthesis Reduction of eye prosthesis Sclera l cover shell Fa brica tion & fitting Prosthetic eye other type Anter cha mber intra ocul lens Iris support intra oclr lens Post chmbr intra ocula r lens Ba la nce lens Deluxe lens fea ture Gla ss/pla stic sla b off prism Prism lens/es Fresnell prism press-on lens Specia l ba se curve Rose tint pla stic Non-rose tint pla stic Rose tint gla ss Non-rose tint gla ss Tint photochroma tic lens/es Tint, a ny color/solid/gra d 38 38 38 38 38 38 46 52 52 52 38 00 38 38 38 38 38 38 38 38 38 38 A A A A A A A A A A A 9 A A A A A A A A A A D C C C D C C D D D C M C C C C D D D D D D D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F D1F P P P P P P P Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 850101 19 9 30101 19 9 30101 19 9 30101 19 9 30101 19 9 30101 19 850101 19 850101 19 850101 19 850101 19 850101 20050101 19 850101 19 850101 19 850101 19 850101 19 850101 19 850101 19 850101 19 850101 19 850101 2004 0101 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20031001 20050101 20031001 20031001 20031001 20031001 2004 0101 2004 0101 2004 0101 2004 0101 20031001 20050101 Anti-reflective coa ting UV lens/es Eye gla ss ca se Scra tch resista nt coa ting Mirror coa ting Pola riz a tion, a ny lens Occluder lens/es Oversiz e lens/es Progressive lens per lens Lens, 1.54 -1.6 5 p/1.6 0-1.79 g 38 38 00 38 38 38 38 38 00 38 A A 9 A A A A A 9 A D D C C D D C C C D D1F D1F Z2 D1F D1F D1F D1F D1F D1F D1F Q Q Q Q Q Q Q Q Q Q 0 0 0 0 0 0 0 0 0 0 19 850101 19 850101 2004 0101 19 850101 2004 0101 2004 0101 19 850101 19 850101 19 9 6 0101 2004 0101 20031001 20031001 20070101 20031001 2004 0101 2004 0101 20031001 20031001 20031001 2004 0101 2130.B 4 5-7 4 5-7 4 5-7 4 5-7 6 5-1 6 5-1 6 5-1 6 5-1 6 5-3 2133 6 5-3 2130 2130 2130 2130B 2130B 2130B 2130B 2130B 2130B 2130.B 2130B 2130B 2130.B 2130.B 2130.B Lens, >= 1.6 6 p/>=1.80 g 38 A 2130.B Lens polyca rb or equa l Cornea l tissue processing Occupa tiona l multifoca l lens Presbyopia -correct function Amniotic membra ne Vis item/svc in other code Miscella neous vision service Hea ring screening Assessment for hea ring a id Hea ring a id fitting/checking Hea ring a id repa ir/modifying Conformity eva lua tion Body-worn hea ring a id a ir Body-worn hea ring a id bone Hea ring a id mona ura l in ea r Behind ea r hea ring a id Gla sses a ir conduction Gla sses bone conduction Hea ring a id dispensing fee Impla nt mid ea r hea ring pros Body-worn bila t hea ring a id Hea ring a id dispensing fee Body-worn bina ur hea ring a id In ea r bina ura l hea ring a id Behind ea r bina ur hea ring a i Gla sses bina ura l hea ring a id Dispensing fee bina ura l Within ea r cros hea ring a id Behind ea r cros hea ring a id Gla sses cros hea ring a id Cros hea ring a id dispens fee In ea r bicros hea ring a id Behind ea r bicros hea ring a i Gla sses bicros hea ring a id Dispensing fee bicros Dispensing fee, mona ura l Hea ring a id, mona ura l, cic Hea ring a id, mona ura l, itc Hea ring a id, prog, mon, cic Hea ring a id, prog, mon, itc Hea ring a id, prog, mon, ite Hea ring a id, prog, mon, bte Hea ring a id, bina ura l, cic Hea ring a id, bina ura l, itc Hea ring a id, prog, bin, cic Hea ring a id, prog, bin, itc Hea ring a id, prog, bin, ite Hea ring a id, prog, bin, bte Hea ring id, digit, mon, cic Hea ring a id, digit, mon, itc Hea ring a id, digit, mon, ite Hea ring a id, digit, mon, bte Hea ring a id, digit, bin, cic Hea ring a id, digit, bin, itc Hea ring a id, digit, bin, ite Hea ring a id, digit, bin, bte Hea ring a id, disp, mona ura l Hea ring a id, disp, bina ura l Ea r mold/insert Ea r mold/insert, disp Ba ttery for hea ring device Hea ring a id supply/a ccessory ALD Telephone Amplifier Alerting device, a ny type ALD, TV a mplifier, a ny type ALD, TV ca ption decoder Tdd ALD for cochlea r impla nt ALD unspecified Ea r impression Hea ring a id noc Hea ring service Repa ir communica tion device 38 46 38 00 57 00 46 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 13 00 A A A 9 A 9 A 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 A 9 2130.B Speech screening La ngua ge screening Dyspha gia screening 00 00 00 9 9 9 N N 20031231 20031231 20031231 20031231 20031231 20031231 N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N F N N N N N N N D D1F Q 0 2004 0101 2004 0101 N 186 2A7 D C D S C C C M S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S D S D1F D1F D1F Z2 Z2 D1F D1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F O1F Q Q Q Q Q Q Q K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2004 0101 19 9 00101 2004 0101 2006 0101 20010101 2004 0101 19 850101 19 9 00101 19 84 0101 19 9 00101 19 9 00101 19 84 0101 19 86 0101 19 86 0101 19 820101 19 820101 19 820101 19 820101 19 820101 20030101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 19 820101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20030101 19 820101 19 9 00101 2004 0101 20031001 2004 0101 2006 0101 20031001 2004 0101 20031001 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 20010101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 20030101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 19 9 50101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20020101 20030101 19 9 50101 19 9 10101 N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N 186 2(a )(7) 186 2(a )(7) 186 2(a )(7) S S S O1F O1F O1F 1 1 1 0 0 0 19 9 00101 19 9 00101 19 9 00101 2004 0101 2004 0101 2004 0101 N N N 2130.B 186 2(a )(7) 2320 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 186 2A7 2320 W W W ...
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This note was uploaded on 02/21/2012 for the course CODEING unknown taught by Professor Unknown during the Spring '12 term at Joliet Junior College.

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