CodeShort DescriptionEffectiveEndFeeEOBPAA421320+ CC SYRINGE ONLY 1/1/198799/99/99COST / NO MARKUP YYA4250URINE REAGENT STRIPS/TABLETS 1/1/198799/99/99COST / NO MARKUP NANAA4253BLOOD GLUCOSE/REAGENT STRIPS 1/1/198799/99/99COST / NO MARKUP NAYA4263PERMANENT TEAR DUCT PLUG 1/1/198799/99/99COST / NO MARKUP YNAA4300CATH IMPL VASC ACCESS PORTAL 1/1/198799/99/99COST / NO MARKUP YYA4310INSERT TRAY W/O BAG/CATH 1/1/198799/99/99COST / NO MARKUP YNAA4311CATHETER W/O BAG 2-WAY LATEX 1/1/198799/99/99COST / NO MARKUP YNAA4312CATH W/O BAG 2-WAY SILICONE 1/1/198799/99/99COST / NO MARKUP YNAA4313CATHETER W/BAG 3-WAY 1/1/198799/99/99COST / NO MARKUP YNAA4314CATH W/DRAINAGE 2-WAY LATEX 1/1/198799/99/99COST / NO MARKUP YNAA4315CATH W/DRAINAGE 2-WAY SILCNE 1/1/198799/99/99COST / NO MARKUP YNAA4316CATH W/DRAINAGE 3-WAY 1/1/198799/99/99COST / NO MARKUP YNAA4320IRRIGATION TRAY 1/1/198799/99/99COST / NO MARKUP NANAA4324MALE EXT CATH W/ADH COATING 1/1/198799/99/99COST / NO MARKUP YNAA4325MALE EXT CATH W/ADH STRIP 1/1/198799/99/99COST / NO MARKUP YNAA4326MALE EXTERNAL CATHETER 1/1/198799/99/99COST / NO MARKUP YNAA4335INCONTINENCE SUPPLY 1/1/198799/99/99COST / NO MARKUP YNAA4338INDWELLING CATHETER LATEX 1/1/198799/99/99COST / NO MARKUP YNAA4344CATH INDW FOLEY 2 WAY SILICN 1/1/198799/99/99COST / NO MARKUP YYA4346CATH INDW FOLEY 3 WAY 1/1/198799/99/99COST / NO MARKUP YYA4347MALE EXTERNAL CATHETER 1/1/198799/99/99COST / NO MARKUP NAYA4348MALE EXT CATH EXTENDED WEAR 1/1/198799/99/99COST / NO MARKUP NAYA4351STRAIGHT TIP URINE CATHETER 1/1/198799/99/99COST / NO MARKUP NAYA4352COUDE TIP URINARY CATHETER1/1/198799/99/99COST / NO MARKUP NAYA4353INTERMITTENT URINARY CATH 1/1/198799/99/99COST / NO MARKUP NANAA4354CATH INSERTION TRAY W/BAG 1/1/198799/99/99COST / NO MARKUP NAYA4355BLADDER IRRIGATION TUBING 1/1/198799/99/99COST / NO MARKUP YYA4356EXT URETH CLMP OR COMPR DVC 1/1/198799/99/99COST / NO MARKUP NANAA4357BEDSIDE DRAINAGE BAG 1/1/198799/99/99COST / NO MARKUP NAYA4358URINARY LEG OR ABDOMEN BAG 1/1/198799/99/99COST / NO MARKUP NAYA4359URINARY SUSPENSORY W/O LEG B 1/1/198799/99/99COST / NO MARKUP YNAA4361OSTOMY FACE PLATE 1/1/198799/99/99COST / NO MARKUP YNAA4362SOLID SKIN BARRIER 1/1/198799/99/99COST / NO MARKUP YNAA4364ADHESIVE LIQUID OR EQUAL 1/1/198799/99/99COST / NO MARKUP YNAA4365ADHESIVE REMOVER WIPES 1/1/198799/99/99COST / NO MARKUP YNAA4367OSTOMY BELT 1/1/198799/99/99COST / NO MARKUP YNAA4368OSTOMY FILTER 1/1/198799/99/99COST / NO MARKUP YNAA4369SKIN BARRIER LIQUID PER OZ 1/1/198799/99/99COST / NO MARKUP YYA4371SKIN BARRIER POWDER PER OZ 1/1/198799/99/99COST / NO MARKUP YNAA4372SKIN BARRIER SOLID 4X4 EQUIV 1/1/198799/99/99COST / NO MARKUP YNAA4373SKIN BARRIER WITH FLANGE 1/1/198799/99/99COST / NO MARKUP YNAA4375DRAINABLE PLASTIC PCH W FCPL 1/1/198799/99/99COST / NO MARKUP YNAA4376DRAINABLE RUBBER PCH W FCPLT 1/1/198799/99/99COST / NO MARKUP YNAA4377DRAINABLE PLSTIC PCH W/O FP 1/1/198799/99/99COST / NO MARKUP YNAA4378DRAINABLE RUBBER PCH W/O FP 1/1/198799/99/99COST / NO MARKUP YNAA4379URINARY PLASTIC POUCH W FCPL 1/1/198799/99/99COST / NO MARKUP YNA


CodeShort DescriptionEffectiveEndFeeEOBPAA4380URINARY RUBBER POUCH W FCPLT 1/1/198799/99/99COST / NO MARKUP YYA4381URINARY PLASTIC POUCH W/O FP 1/1/198799/99/99COST / NO MARKUP YNAA4383URINARY RUBBER POUCH W/O FP 1/1/198799/99/99COST / NO MARKUP YNAA4384OSTOMY FACEPLT/SILICONE RING 1/1/198799/99/99COST / NO MARKUP YNAA4385OST SKN BARRIER SLD EXT WEAR 1/1/198799/99/99COST / NO MARKUP YNAA4387OST CLSD POUCH W ATT ST BARR 1/1/198799/99/99COST / NO MARKUP YNAA4388DRAINABLE PCH W EX WEAR BARR 1/1/198799/99/99COST / NO MARKUP YNAA4389DRAINABLE PCH W ST WEAR BARR 1/1/198799/99/99COST / NO MARKUP YNAA4390DRAINABLE PCH EX WEAR CONVEX 1/1/198799/99/99COST / NO MARKUP YYA4391URINARY POUCH W EX WEAR BARR 1/1/198799/99/99COST / NO MARKUP YNAA4392URINARY POUCH W ST WEAR BARR 1/1/198799/99/99COST / NO MARKUP YNAA4393URINE PCH W EX WEAR BAR CONV 1/1/198799/99/99COST / NO MARKUP YNAA4397IRRIGATION SUPPLY SLEEVE 1/1/198799/99/99COST / NO MARKUP YNAA4398OSTOMY IRRIGATION BAG 1/1/198799/99/99COST / NO MARKUP YNAA4399OSTOMY IRRIG CONE/CATH W BRS 1/1/198799/99/99COST / NO MARKUP YNAA4400OSTOMY IRRIGATION SET 1/1/198799/99/99COST / NO MARKUP YNAA4402LUBRICANT PER OUNCE 1/1/198799/99/99COST / NO MARKUP YNAA4404OSTOMY RINGS, EACH 1/1/198699/99/99COST / NO MARKUP YNAA4405NONPECTIN BASED OSTOMY PASTE 1/1/198799/99/99COST / NO MARKUP YYA4406PECTIN BASED OSTOMY PASTE 1/1/198799/99/99COST / NO MARKUP YYA4407EXT WEAR OST SKN BARR <=4SQö 1/1/198799/99/99COST / NO MARKUP YYA4408EXT WEAR OST SKN BARR >4SQö 1/1/198799/99/99COST / NO MARKUP YYA44091ST SKN BARR W FLNG <=4 SQö 1/1/198799/99/99COST / NO MARKUP YYA4410OST SKN BARR W FLNG >4SQ¾ 1/1/198799/99/99COST / NO MARKUP YYA4421OSTOMY SUPPLY MISC 1/1/198799/99/99COST / NO MARKUP YNAA4455ADHESIVE REMOVER PER OUNCE 1/1/198799/99/99COST / NO MARKUP YNAA4550SURGICAL TRAYS 1/1/198799/99/99COST / NO MARKUP YYA4615CANNULA NASAL 1/1/198799/99/99COST / NO MARKUP NANAA4616TUBING (OXYGEN) PER FOOT 1/1/198799/99/99COST / NO MARKUP NANAA4617MOUTH PIECE 1/1/198799/99/99COST / NO MARKUP NANAA4618BREATHING CIRCUITS 1/1/198799/99/99COST / NO MARKUP NANAA4619FACE TENT 1/1/198799/99/99COST / NO MARKUP NANAA4620VARIABLE CONCENTRATION MASK 1/1/198799/99/99COST / NO MARKUP NANAA4623TRACHEOSTOMY INNER CANNULA1/1/198799/99/99COST / NO MARKUP NANAA4628OROPHARYNGEAL SUCTION CATH 1/1/198799/99/99COST / NO MARKUP NANAA4629TRACHEOSTOMY CARE KIT 1/1/198799/99/99COST / NO MARKUP NANAA4750ART OR VENOUS BLOOD TUBING 1/1/198799/99/99COST / NO MARKUP YNAA4772BLOOD GLUCOSE TEST STRIPS 1/1/198799/99/99COST / NO MARKUP NANAA5051POUCH CLSD W BARR ATTACHED 1/1/198799/99/99COST / NO MARKUP YNAA5052CLSD OSTOMY POUCH W/O BARR 1/1/198799/99/99COST / NO MARKUP YNAA5053CLSD OSTOMY POUCH FACEPLATE 1/1/198799/99/99COST / NO MARKUP YNAA5054CLSD OSTOMY POUCH W/FLANGE 1/1/198799/99/99COST / NO MARKUP YNAA7010DISPOSABLE CORRUGATED TUBING 1/1/198799/99/99COST / NO MARKUP NANAA7011NONDISPOS CORRUGATED TUBING 1/1/198799/99/99COST / NO MARKUP NANAA7030CPAP FULL FACE MASK 1/1/198799/99/99COST / NO MARKUP NAYA7031REPLACEMENT FACEMASK INTERFA 1/1/198799/99/99COST / NO MARKUP YY


CodeShort DescriptionEffectiveEndFeeEOBPAA7034NASAL APPLICATION DEVICE 1/1/198799/99/99COST / NO MARKUP NAYA7037POS AIRWAY PRESSURE TUBING 1/1/198799/99/99COST / NO MARKUP NAYA7042IMPLANTED PLEURAL CATHETER 1/1/198799/99/99COST / NO MARKUP NAYB4034ENTERAL FEEDING SUPPLY KIT; SYRINGE PER 1/1/198799/99/99COST / NO MARKUP YNAB4035ENTERAL FEEDING SUPPLY KIT; PUMP FED PER 1/1/198799/99/99COST / NO MARKUP YNAB4036ENTERAL FEEDING SUPPLY KIT; GRAVITY FED 1/1/198799/99/99COST / NO MARKUP YNAB4081NASOGASTRIC TUBING WITH STYLET 1/1/198799/99/99COST / NO MARKUP YNAB4082NASOGASTRIC TUBING WITHOUT STYLET 1/1/198799/99/99COST / NO MARKUP YNAB4083STOMACH TUBE - LEVINE TYPE 1/1/198799/99/99COST / NO MARKUP YNAB4086GASTROSTOMY/JEJUNOSTOMY TUBE 1/1/198799/99/99COST / NO MARKUP YYB4150ENTERAL FORMULAE CATEGORY I; SEMI-1/1/198799/99/99COST / NO MARKUP YNAB4151ENTERAL FORMULAE; CATEGORY I: NATURAL 1/1/198799/99/99COST / NO MARKUP YNAB4152ENTERAL FORMULAE; CATEGORY II: INTACT 1/1/198799/99/99COST / NO MARKUP YNAB4153ENTERAL FORMULAE; CATEGORY III: HYDROLIZED 1/1/198799/99/99COST / NO MARKUP YNAB4154ENTERAL FORMULAE; CATEGORY IV: DEFINED 1/1/198799/99/99COST / NO MARKUP YNAB4155ENTERAL FORMULAE;CATEGORY V:MODULAR 1/1/198799/99/99COST / NO MARKUP YNAB4156ENTERAL FORMULAE; CATEGORY VI: 1/1/198799/99/99COST / NO MARKUP YNAB4164PARENTERAL NUTRITION SOLUTION: 1/1/198699/99/99COST / NO MARKUP YNAB4168PARENTERAL NUTRITION SOLUTION; AMINO ACID 1/1/198799/99/99COST / NO MARKUP YNAB4172PARENTERAL NUTRITION SOLUTION; AMINO ACID 1/1/198799/99/99COST / NO MARKUP YNAB4176PARENTERAL NUTRITION SOLUTION; AMINO ACID 1/1/198799/99/99COST / NO MARKUP YNAB4178PARENTERAL NUTRITION SOLUTION: AMINO ACID 4/1/198899/99/99COST / NO MARKUP YNAB4180PARENTERAL NUTRITION SOLUTION; 1/1/198799/99/99COST / NO MARKUP YNAB4184PARENTERAL NUTRITION SOLUTION; LIPIDS 10% 1/1/198799/99/99COST / NO MARKUP YNAB4186PARENTERAL NUTRITION SOLUTION LIPIDS 20% W 1/1/198799/99/99COST / NO MARKUP YNAB4189PARENTERAL NUTRITION; COMPOUNDED 10 TO 51 4/1/198899/99/99COST / NO MARKUP YNAB4193PARENTERAL NUTRITION; COMPOUNDED 52 TO 73 4/1/198899/99/99COST / NO MARKUP YNAB4197PARENTERAL NUTRITION; COMPOUNDED 74 TO 4/1/198899/99/99COST / NO MARKUP YNAB4199PARENTERAL NUTRITION; COMPOUNDED OVER 4/1/198899/99/99COST / NO MARKUP YNAB4216PARENTERAL NUTRITION; ADDITIVES - HOMEMIX 1/1/198799/99/99COST / NO MARKUP YNAB4220PARENTERAL NUTRITION SUPPLY KIT; PREMIX 1/1/198799/99/99COST / NO MARKUP YNAB4222PARENTERAL NUTRITION SUPPLY KIT; HOME MIX 1/1/198799/99/99COST / NO MARKUP YNAB4224PARENTERAL NUTRITION ADMINISTRATION KIT 1/1/198799/99/99COST / NO MARKUP YNAB5000PARENTERAL NUTRITION; COMPOUNDED RENAL - 4/1/198899/99/99COST / NO MARKUP YNAB5100PARENTERAL NUTRITION; COMPOUNDED 4/1/198899/99/99COST / NO MARKUP YNAB5200PARENTERAL NUTRITION; COMPOUNDED STRESS- 4/1/198899/99/99COST / NO MARKUP YNAB9998NOC FOR ENTERNAL SUPPLIES 1/1/198799/99/99COST / NO MARKUP YNAB9999NOC FOR PARENTERAL SUPPLIES 1/1/198799/99/99COST / NO MARKUP YNAE0431PORT GAS O2SYS RENTAL MC REG FLOW HUMID 1/1/198799/99/99COST / NO MARKUP YNAE0434PORT O2 LIQ SYS RENT INC PORT CONTAINER 1/1/198799/99/99COST / NO MARKUP YNAE0441OXYGEN CONTENTS GASEOUS 1/1/198799/99/99COST / NO MARKUP NANAE0442OXYGEN CONTENTS LIQUID 1/1/198799/99/99COST / NO MARKUP NANAE0443PORTABLE 02 CONTENTS GAS 1/1/198799/99/99COST / NO MARKUP NANAE0444PORTABLE 02 CONTENTS LIQUID 1/1/198799/99/99COST / NO MARKUP NANAE0570NEBULIZER WITH COMPRESSOR E.G. DEVILBISS 1/1/198799/99/99COST / NO MARKUP NANAE0600SUCTION PUMP PORTAB HOM MODL 1/1/198799/99/99COST / NO MARKUP NANA


CodeShort DescriptionEffectiveEndFeeEOBPAE1353REGULATOR 1/1/198799/99/99COST / NO MARKUPNANAE1355STAND/RACK1/1/198799/99/99COST / NO MARKUPNANA