MEDICAL SUPPLY FEE SCHEDULE Effective …

1 CodeModifier-StatusPADescriptionMin AgeMax AgeBegin DateEnd DateMax UnitsFeeA4206SC-Fee on FileNoSYRINGE WITH NEEDLE, STERILE, 1 CC OR LESS, EACH099910/01/200312/31 on FileNoSYRINGE WITH NEEDLE STERILE 3 CC EACH099910/01/200312/31 on FileNoSYRINGE WITH NEEDLE STERILE 5 CC OR GREATER EACH099910/01/200312/31 PricingNoNON-CORING NEEDLE OR STYLET WITH OR WTIHOUT CATHETER099901/01/200912/31 PricingNoSYRINGE STERILE 20 CC OR GREATER EACH099901/01/200912/31 PricingNoNEEDLE, STERILE, ANY SIZE, EACH099901/01/200912/31 on FileNoSTERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML099907/01/201512/31 on FileNoSTERILE WATER/SALINE, 500 ML099907/01/201712/31 on FileNoSUPPLIES FOR MAINTENANCE OF NON-INSULIN DRUG INFUSION CATHETER, PER WEEK (LIST DRUGS SEPARATELY)099907/01/201712/31 on FileNoINFUSION SUPPLIES FOR EXTERNAL DRUG INFUSION PUMP, PER CASSETTE OR BAG (LIST DRUGS SEPARATELY)

2 099907/01/201712/31 on FileNoSUPPLIES FOR MAINTENANCE OF INSULIN INFUSION CATHETER, PER 099901/01/201712/31 on FileNoSUPPLIES FOR EXTERNAL INSULIN INFUSION PUMP, SYRINGE TYPE CARTRIDGE, STERILE, EACH099901/01/201712/31 PricingNoINFUSION SET FOR EXTERNAL INSULIN PUMP, NON NEEDLE CANNULA TYPE099901/01/200912/31 PricingNoINFUSION SET FOR EXTERNAL INSULIN PUMP, NEEDLE TYPE099901/01/200912/31 on FileNoSYRINGE WITH NEEDLE FOR EXTERNAL INSULIN PUMP, STERILE, 3CC099910/01/200312/31 on FileNoREPLACEMENT BATTERY, ALKALINE (OTHER THAN J CELL)

3 , FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH099907/01/201712/31 on FileNoREPLACEMENT BATTERY, ALKALINE, J CELL, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH099907/01/201712/31 on FileNoREPLACEMENT BATTERY, LITHIUM, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH099907/01/201712/31 on FileNoREPLACEMENT BATTERY, SILVER OXIDE, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH099907/01/201712/31 on FileNoALCOHOL OR PEROXIDE, PER PINT099910/01/200312/31 on FileNoALCOHOL WIPES, PER BOX099910/01/200312/31 PricingNoBETADINE OR PHISOHEX SOLUTION, PER PINT099901/01/200912/31 PricingNoBETADINE OR IODINE SWABS/WIPES, PER BOX099901/01/200912/31 on FileNoURINE TEST OR REAGENT STRIPS OR TABLETS (100 TABLETS OR STRIPS)

4 099910/01/200312/31 PricingNoBLOOD KETONE TEST OR REAGENT STRIP, EACH099901/01/200912/31 on FileNoBLOOD GLUCOSE TEST OR REAGENT STRIPS FOR HOME BLOOD GLUCOSE MONITOR, PER 50 STRIPS099907/01/201712/31 on FileNoNORMAL, LOW, AND HIGH CALIBRATOR SOLUTIONS/CHIPS099907/01/201712/31 SUPPLY FEE SCHEDULE Effective 07/01/2017 Print date : 3/6/18 CodeModifier-StatusPADescriptionMin AgeMax AgeBegin DateEnd DateMax UnitsFeeA4258SC-Fee on FileNoSPRING-POWERED DEVICE FOR LANCET, EACH099907/01/201712/31 on FileNoLANCETS, PER BOX OF 100099907/01/201712/31 on FileNoPARAFFIN, PER POUND099907/01/201712/31 on FileNoADHESIVE SKIN SUPPORT ATTACHMENT FOR USE WITH EXTERNAL BREAST PROSTHESIS EACH02007/01/201712/31 PricingNoTUBING FOR BREAST PUMP, REPLACEMENT099901/01/200912/31 PricingNoADAPTER FOR BREAST PUMP.

5 REPLACEMENT099901/01/200912/31 PricingNoCAP FOR BREAST PUMP BOTTLE, REPLACEMENT099901/01/200912/31 PricingNoBREAST SHIELD AND SPLASH PROTECTOR FOR USE WITH BREAST PUMP, REPLACEMENT099901/01/200912/31 PricingNoPOLYCARBONATE BOTTLE FOR USE WITH BREAST PUMP, REPLACEMENT099901/01/200912/31 PricingNoLOCKING RING FOR BREAST PUMP, REPLACEMENT099901/01/200912/31 PricingNoDISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF 50 ML OR GREATER PER HOUR099901/01/200912/31 PricingNoDISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OFLESS THAN 50 ML PER HOUR099901/01/200912/31 on FileNoINSERTION TRAY WITHOUT DRAINAGE BAG AND WITHOUT CATHETER (ACCESSORIES ONLY)

6 099907/01/201712/31 on FileNoINSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE TWO-WAY ALL SILICONE099907/01/201712/31 on FileNoINSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER FOLEY TYPE THREE-WAY FOR CONTINUOUS IRRIGATION099907/01/201712/31 on FileNoINSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER FOLEY TYPE TWO-WAY ALL SILICONE099907/01/201712/31 on FileNoINSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER FOLEY TYPE THREE-WAY FOR CONTINUOUS IRRIGATION099907/01/201712/31 on FileNoIRRIGATION TRAY WITH BULB OR PISTON SYRINGE.

7 ANY PURPOSE099907/01/201712/31 on FileNoIRRIGATION SYRINGE, BULB OR PISTON, EACH099907/01/201712/31 on FileNoMALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION CHAMBER, ANY TYPE, EACH099907/01/201712/31 on FileNoFEMALE EXTERNAL URINARY COLLECTION DEVICE; METAL CUP, EACH099907/01/201712/31 on FileNoFEMALE EXTERNAL URINARY COLLECTION DEVICE; POUCH, EACH099907/01/201712/31 on FileNoEXTENSION DRAINAGE TUBING ANY TYPE ANY LENGTH WITH CONNECTOR/ADAPTOR FOR USE WITH LEG BAG OR UROSTOMY POUCH EACH099907/01/201712/31 on FileNoLUBRICANT, INDIVIDUAL STERILE PACKET.

8 EACH099907/01/201512/31 on FileNoINSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER FOLEY TYPE TWO-WAY LATEX WITH COATING 0A4311SC-Fee on FileNoINSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER FOLEY TYPE TWO-WAY LATEX WITH 099907/01/201712/31 AgeMax AgeBegin DateEnd DateMax UnitsFeeA4333SC-Fee on FileNoURINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT, EACH099907/01/201712/31 on FileNoURINARY CATHETER ANCHORING DEVICE, LEG STRAP, EACH099907/01/201712/31 PricingNoINCONTINENCE SUPPLY ; MISCELLANEOUS099901/01/200912/31 on FileNoINCONTINENCE SUPPLY , URETHRAL INSERT, ANY TYPE, EACH099907/01/201712/31 on FileNoINDWELLING CATHETER,FOLEY TYPETWO WAY LATEX WITH COATING (TEFLON SILICONE SILICONE ELASTOMER OR HYDROPHILIC ETC) 099907/01/201712/31 on FileNoINDWELLING CATHETER; SPECIALTY TYPE, (EG; COUDE, MUSHROOM, WING, ETC.)

9 EACH099907/01/201712/31 on FileNoINDWELLING CATHETER FOLEY TYPE TWO-WAY ALL SILICONE EACH099907/01/201712/31 on FileNoINDWELLING CATHETER FOLEY TYPE THREE WAY FOR CONTINUOUS IRRIGATION EACH099907/01/201712/31 on FileNoMALE EXTERNAL CATHETER WITH OR WITHOUT ADHESIVE DISPOSABLE EACH099907/01/201712/31 on FileNoINTERMITTENT URINARY CATHETER; STRAIGHT TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC) EACH099907/01/201712/31 on FileNoINTERMITTENT URINARY CATHETER; COUDE (CURVED) TIP, WITH OR WITHOUT COATING (TEFLON SILICONE SILICONE ELASTOMERIC OR HYDROPHILIC ETC)

10 EACH099907/01/201712/31 on FileNoINTERMITTENT URINARY CATH, WITH INSERTION SUPPLIES099907/01/201712/31 on FileNoINSERTION TRAY WITH DRAINAGE BAG BUT WITHOUT CATHETER099907/01/201712/31 on FileNoIRRIGATION TUBING SET FOR CONTINUOUS BLADDER IRRIGATION THROUGH A THREE-WAY INDWELLING FOLEY CATHETER EACH099907/01/201712/31 on FileNoBEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI REFLUX DEVICE, WITH OR WITHOUT TUBE EACH099907/01/201712/31 on FileNoURINARY DRAINAGE BAG, LEG OR ABDOMEN, VINYL, WITH OR WITHOUT TUBE, WITH STRAPS, EACH099907/01/201712/31 on FileNoOSTOMY FACE PLATE, EACH099907/01/201712/31 on FileNoSKIN BARRIER, SOLID, 4 X 4 OR EQUIVALENT, EACH099907/01/201712/31 on FileNoOSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLY, EACH099907/01/201712/31 on FileNoADHESIVE, LIQUID OR EQUAL, ANY TYPE, PER OUNCE099907/01/201712/31 on FileNoOSTOMY VENT ANY TYPE EACH099907/01/201712/31 on FileNoOSTOMY BELT, EACH099907/01/201712/31 on FileNoOSTOMY FILTER, ANY TYPE, EACH099907/01/201512/31 on FileNoOSTOMY SKIN BARRIER, LIQUID (SPRAY.)