hcpcs mod mod2 catg description fee - new jerseya4411 os ost skn barr extnd =4sq $5.36 a4412 os ost...

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EXHIBIT 5 Durable Medical Equipment, Prosthetics, Orthotics Supplies HCPCS Mod Mod2 CATG Description Fee A4216 OS Sterile water/saline, 10 ml $0.47 A4217 SU Sterile water/saline, 500 ml $3.29 A4217 AU OS Sterile water/saline, 500 ml $3.29 A4221 SU Maint drug infus cath per wk $23.77 A4222 SU Infusion supplies with pump $49.07 A4233 NU IN Alkalin batt for glucose mon $0.84 A4233 NU KL IN Alkalin batt for glucose mon $0.72 A4234 NU IN J-cell batt for glucose mon $3.81 A4234 NU KL IN J-cell batt for glucose mon $3.29 A4235 NU IN Lithium batt for glucose mon $2.46 A4235 NU KL IN Lithium batt for glucose mon $2.12 A4236 NU IN Silvr oxide batt glucose mon $1.76 A4236 NU KL IN Silvr oxide batt glucose mon $1.52 A4253 NU IN Blood glucose/reagent strips $38.79 A4253 NU KL IN Blood glucose/reagent strips $33.43 A4255 SU Glucose monitor platforms $4.11 A4256 SU Calibrator solution/chips $10.21 A4256 KL SU Calibrator solution/chips $8.80 A4257 SU Replace Lensshield Cartridge $13.39 A4258 SU Lancet device each $18.95 A4258 KL SU Lancet device each $16.34 A4259 SU Lancets per box $12.66 A4259 KL SU Lancets per box $10.91 A4265 SU Paraffin $3.56 A4280 PO Brst prsths adhsv attchmnt $5.55 A4310 OS Insert tray w/o bag/cath $7.50 A4311 OS Catheter w/o bag 2-way latex $13.24 A4312 OS Cath w/o bag 2-way silicone $16.10 A4313 OS Catheter w/bag 3-way $19.06 A4314 OS Cath w/drainage 2-way latex $25.21 A4315 OS Cath w/drainage 2-way silcne $27.09 A4316 OS Cath w/drainage 3-way $28.30 A4320 OS Irrigation tray $5.29 A4321 OS Cath therapeutic irrig agent $0.00 A4322 OS Irrigation syringe $3.09 A4326 OS Male external catheter $11.33 A4327 OS Fem urinary collect dev cup $44.38 A4328 OS Fem urinary collect pouch $10.97 A4330 OS Stool collection pouch $7.51 A4331 OS Extension drainage tubing $3.34 A4332 OS Lube sterile packet $0.13 A4333 OS Urinary cath anchor device $2.31 A4334 OS Urinary cath leg strap $5.18 A4336 OS Urethral insert $1.51 A4338 OS Indwelling catheter latex $11.09 A4340 OS Indwelling catheter special $33.34 A4344 OS Cath indw foley 2 way silicn $14.30 A4346 OS Cath indw foley 3 way $17.90 A4349 OS Disposable male external cat $2.12 A4351 OS Straight tip urine catheter $1.83 A4352 OS Coude tip urinary catheter $6.74 A4353 OS Intermittent urinary cath $7.34 A4354 OS Cath insertion tray w/bag $12.29 A4355 OS Bladder irrigation tubing $9.36 A4356 OS Ext ureth clmp or compr dvc $47.91 A4357 OS Bedside drainage bag $9.65 A4358 OS Urinary leg or abdomen bag $6.96 A4360 OS Disposable ext urethral dev $0.51 A4361 OS Ostomy face plate $19.17

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Page 1: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

HCPCS Mod Mod2 CATG Description FeeA4216 OS Sterile water/saline, 10 ml $0.47A4217 SU Sterile water/saline, 500 ml $3.29A4217 AU OS Sterile water/saline, 500 ml $3.29A4221 SU Maint drug infus cath per wk $23.77A4222 SU Infusion supplies with pump $49.07A4233 NU IN Alkalin batt for glucose mon $0.84A4233 NU KL IN Alkalin batt for glucose mon $0.72A4234 NU IN J-cell batt for glucose mon $3.81A4234 NU KL IN J-cell batt for glucose mon $3.29A4235 NU IN Lithium batt for glucose mon $2.46A4235 NU KL IN Lithium batt for glucose mon $2.12A4236 NU IN Silvr oxide batt glucose mon $1.76A4236 NU KL IN Silvr oxide batt glucose mon $1.52A4253 NU IN Blood glucose/reagent strips $38.79A4253 NU KL IN Blood glucose/reagent strips $33.43A4255 SU Glucose monitor platforms $4.11A4256 SU Calibrator solution/chips $10.21A4256 KL SU Calibrator solution/chips $8.80A4257 SU Replace Lensshield Cartridge $13.39A4258 SU Lancet device each $18.95A4258 KL SU Lancet device each $16.34A4259 SU Lancets per box $12.66A4259 KL SU Lancets per box $10.91A4265 SU Paraffin $3.56A4280 PO Brst prsths adhsv attchmnt $5.55A4310 OS Insert tray w/o bag/cath $7.50A4311 OS Catheter w/o bag 2-way latex $13.24A4312 OS Cath w/o bag 2-way silicone $16.10A4313 OS Catheter w/bag 3-way $19.06A4314 OS Cath w/drainage 2-way latex $25.21A4315 OS Cath w/drainage 2-way silcne $27.09A4316 OS Cath w/drainage 3-way $28.30A4320 OS Irrigation tray $5.29A4321 OS Cath therapeutic irrig agent $0.00A4322 OS Irrigation syringe $3.09A4326 OS Male external catheter $11.33A4327 OS Fem urinary collect dev cup $44.38A4328 OS Fem urinary collect pouch $10.97A4330 OS Stool collection pouch $7.51A4331 OS Extension drainage tubing $3.34A4332 OS Lube sterile packet $0.13A4333 OS Urinary cath anchor device $2.31A4334 OS Urinary cath leg strap $5.18A4336 OS Urethral insert $1.51A4338 OS Indwelling catheter latex $11.09A4340 OS Indwelling catheter special $33.34A4344 OS Cath indw foley 2 way silicn $14.30A4346 OS Cath indw foley 3 way $17.90A4349 OS Disposable male external cat $2.12A4351 OS Straight tip urine catheter $1.83A4352 OS Coude tip urinary catheter $6.74A4353 OS Intermittent urinary cath $7.34A4354 OS Cath insertion tray w/bag $12.29A4355 OS Bladder irrigation tubing $9.36A4356 OS Ext ureth clmp or compr dvc $47.91A4357 OS Bedside drainage bag $9.65A4358 OS Urinary leg or abdomen bag $6.96A4360 OS Disposable ext urethral dev $0.51A4361 OS Ostomy face plate $19.17

Page 2: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

A4362 OS Solid skin barrier $3.63A4363 OS Ostomy clamp, replacement $2.48A4364 OS Adhesive, liquid or equal $3.08A4366 OS Ostomy vent $1.37A4367 OS Ostomy belt $7.72A4368 OS Ostomy filter $0.27A4369 OS Skin barrier liquid per oz $2.54A4371 OS Skin barrier powder per oz $3.83A4372 OS Skin barrier solid 4x4 equiv $4.39A4373 OS Skin barrier with flange $6.59A4375 OS Drainable plastic pch w fcpl $18.04A4376 OS Drainable rubber pch w fcplt $49.96A4377 OS Drainable plstic pch w/o fp $4.50A4378 OS Drainable rubber pch w/o fp $32.29A4379 OS Urinary plastic pouch w fcpl $15.77A4380 OS Urinary rubber pouch w fcplt $39.20A4381 OS Urinary plastic pouch w/o fp $4.84A4382 OS Urinary hvy plstc pch w/o fp $25.85A4383 OS Urinary rubber pouch w/o fp $29.60A4384 OS Ostomy faceplt/silicone ring $10.10A4385 OS Ost skn barrier sld ext wear $5.36A4387 OS Ost clsd pouch w att st barr $0.00A4388 OS Drainable pch w ex wear barr $4.58A4389 OS Drainable pch w st wear barr $6.53A4390 OS Drainable pch ex wear convex $10.09A4391 OS Urinary pouch w ex wear barr $7.42A4392 OS Urinary pouch w st wear barr $8.59A4393 OS Urine pch w ex wear bar conv $9.49A4394 OS Ostomy pouch liq deodorant $2.71A4395 OS Ostomy pouch solid deodorant $0.05A4396 OS Peristomal hernia supprt blt $42.50A4397 OS Irrigation supply sleeve $5.03A4398 OS Ostomy irrigation bag $14.50A4399 OS Ostomy irrig cone/cath w brs $12.87A4400 OS Ostomy irrigation set $51.31A4402 OS Lubricant per ounce $1.46A4404 OS Ostomy ring each $1.62A4405 OS Nonpectin based ostomy paste $3.57A4406 OS Pectin based ostomy paste $6.03A4407 OS Ext wear ost skn barr <=4sq" $9.20A4408 OS Ext wear ost skn barr >4sq" $10.36A4409 OS Ost skn barr convex <=4 sq i $6.53A4410 OS Ost skn barr extnd >4 sq $9.49A4411 OS Ost skn barr extnd =4sq $5.36A4412 OS Ost pouch drain high output $2.84A4413 OS 2 pc drainable ost pouch $5.78A4414 OS Ost sknbar w/o conv<=4 sq in $5.18A4415 OS Ost skn barr w/o conv >4 sqi $6.30A4416 OS Ost pch clsd w barrier/filtr $2.89A4417 OS Ost pch w bar/bltinconv/fltr $3.91A4418 OS Ost pch clsd w/o bar w filtr $1.90A4419 OS Ost pch for bar w flange/flt $1.83A4420 OS Ost pch clsd for bar w lk fl $0.00A4422 OS Ost pouch absorbent material $0.13A4423 OS Ost pch for bar w lk fl/fltr $1.95A4424 OS Ost pch drain w bar & filter $4.99A4425 OS Ost pch drain for barrier fl $3.76A4426 OS Ost pch drain 2 piece system $2.87A4427 OS Ost pch drain/barr lk flng/f $2.92A4428 OS Urine ost pouch w faucet/tap $6.84

Page 3: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

A4429 OS Urine ost pouch w bltinconv $8.66A4430 OS Ost urine pch w b/bltin conv $8.95A4431 OS Ost pch urine w barrier/tapv $6.53A4432 OS Os pch urine w bar/fange/tap $3.77A4433 OS Urine ost pch bar w lock fln $3.51A4434 OS Ost pch urine w lock flng/ft $3.95A4450 AU OS Non-waterproof tape $0.09A4450 AV OS Non-waterproof tape $0.09A4450 AW OS Non-waterproof tape $0.12A4452 AU OS Waterproof tape $0.38A4452 AV OS Waterproof tape $0.38A4452 AW OS Waterproof tape $0.42A4455 OS Adhesive remover per ounce $1.47A4456 OS Adhesive remover, wipes $0.26A4461 SD Surgicl dress hold non-reuse $3.45A4463 SD Surgical dress holder reuse $13.98A4481 OS Tracheostoma filter $0.39A4483 OS Moisture exchanger $0.00A4556 SU Electrodes, pair $12.75A4557 SU Lead wires, pair $18.84A4558 SU Conductive gel or paste $5.72A4559 SU Coupling gel or paste $0.11A4561 PO Pessary rubber, any type $20.95A4562 PO Pessary, non rubber,any type $52.16A4595 SU TENS suppl 2 lead per month $30.25A4604 NU IN Tubing with heating element $60.46A4605 NU IN Trach suction cath close sys $17.22A4608 OX Transtracheal oxygen cath $52.63A4611 NU IN Heavy duty battery $206.27A4611 RR IN Heavy duty battery $21.39A4611 UE IN Heavy duty battery $154.71A4612 NU IN Battery cables $71.34A4612 RR IN Battery cables $7.27A4612 UE IN Battery cables $54.40A4613 NU IN Battery charger $151.42A4613 RR IN Battery charger $15.15A4613 UE IN Battery charger $109.50A4614 IN Hand-held PEFR meter $24.97A4615 SU Cannula nasal $0.75A4616 SU Tubing (oxygen) per foot $0.07A4617 SU Mouth piece $3.25A4618 NU IN Breathing circuits $9.33A4618 RR IN Breathing circuits $1.07A4618 UE IN Breathing circuits $7.00A4619 OX Face tent $1.27A4620 SU Variable concentration mask $0.62A4623 OS Tracheostomy inner cannula $6.88A4624 NU IN Tracheal suction tube $2.47A4625 OS Trach care kit for new trach $7.28A4626 OS Tracheostomy cleaning brush $3.35A4628 NU IN Oropharyngeal suction cath $3.85A4629 OS Tracheostomy care kit $4.86A4630 NU IN Repl bat t.e.n.s. own by pt $5.97A4633 NU IN Uvl replacement bulb $43.09A4635 NU IN Underarm crutch pad $5.38A4635 RR IN Underarm crutch pad $0.72A4635 UE IN Underarm crutch pad $3.56A4636 NU IN Handgrip for cane etc $3.24A4636 NU KE IN Handgrip for cane etc $3.76A4636 RR IN Handgrip for cane etc $0.39

Page 4: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

A4636 RR KE IN Handgrip for cane etc $0.45A4636 UE IN Handgrip for cane etc $2.36A4636 UE KE IN Handgrip for cane etc $2.74A4637 NU IN Repl tip cane/crutch/walker $1.93A4637 NU KE IN Repl tip cane/crutch/walker $2.24A4637 RR IN Repl tip cane/crutch/walker $0.27A4637 RR KE IN Repl tip cane/crutch/walker $0.32A4637 UE IN Repl tip cane/crutch/walker $1.46A4637 UE KE IN Repl tip cane/crutch/walker $1.69A4638 NU IN Repl batt pulse gen sys $0.00A4638 RR IN Repl batt pulse gen sys $0.00A4638 UE IN Repl batt pulse gen sys $0.00A4639 NU IN Infrared ht sys replcmnt pad $301.57A4640 NU IN Alternating pressure pad $62.79A4640 RR IN Alternating pressure pad $6.28A4640 UE IN Alternating pressure pad $47.10A5051 OS Pouch clsd w barr attached $2.17A5052 OS Clsd ostomy pouch w/o barr $1.56A5053 OS Clsd ostomy pouch faceplate $1.83A5054 OS Clsd ostomy pouch w/flange $1.88A5055 OS Stoma cap $1.49A5061 OS Pouch drainable w barrier at $3.70A5062 OS Drnble ostomy pouch w/o barr $2.33A5063 OS Drain ostomy pouch w/flange $2.84A5071 OS Urinary pouch w/barrier $6.31A5072 OS Urinary pouch w/o barrier $3.70A5073 OS Urinary pouch on barr w/flng $3.34A5081 OS Continent stoma plug $3.47A5082 OS Continent stoma catheter $12.48A5083 OS Stoma absorptive cover $0.66A5093 OS Ostomy accessory convex inse $2.04A5102 OS Bedside drain btl w/wo tube $23.54A5105 OS Urinary suspensory $42.80A5112 OS Urinary leg bag $30.90A5113 OS Latex leg strap $4.94A5114 OS Foam/fabric leg strap $9.39A5120 AU OS Skin barrier, wipe or swab $0.26A5120 AV PO Skin barrier, wipe or swab $0.25A5121 OS Solid skin barrier 6x6 $6.87A5122 OS Solid skin barrier 8x8 $11.47A5126 OS Disk/foam pad +or- adhesive $1.39A5131 OS Appliance cleaner $16.65A5200 OS Percutaneous catheter anchor $11.87A5500 TS Diab shoe for density insert $66.76A5501 TS Diabetic custom molded shoe $200.25A5503 TS Diabetic shoe w/roller/rockr $29.69A5504 TS Diabetic shoe with wedge $29.69A5505 TS Diab shoe w/metatarsal bar $29.69A5506 TS Diabetic shoe w/off set heel $29.69A5507 TS Modification diabetic shoe $29.69A5512 TS Multi den insert direct form $27.24A5513 TS Multi den insert custom mold $40.65A6010 SD Collagen based wound filler $32.51A6011 SD Collagen gel/paste wound fil $2.39A6021 SD Collagen dressing <=16 sq in $22.07A6022 SD Collagen drsg>16<=48 sq in $22.07A6023 SD Collagen dressing >48 sq in $199.82A6024 SD Collagen dsg wound filler $6.50A6154 SD Wound pouch each $15.10A6196 SD Alginate dressing <=16 sq in $7.72

Page 5: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

A6197 SD Alginate drsg >16 <=48 sq in $17.26A6199 SD Alginate drsg wound filler $5.55A6203 SD Composite drsg <= 16 sq in $3.52A6204 SD Composite drsg >16<=48 sq in $6.54A6207 SD Contact layer >16<= 48 sq in $7.71A6209 SD Foam drsg <=16 sq in w/o bdr $7.85A6210 SD Foam drg >16<=48 sq in w/o b $20.92A6211 SD Foam drg > 48 sq in w/o brdr $30.84A6212 SD Foam drg <=16 sq in w/border $10.19A6214 SD Foam drg > 48 sq in w/border $10.80A6216 SD Non-sterile gauze<=16 sq in $0.05A6217 SD Non-sterile gauze>16<=48 sq $0.00A6219 SD Gauze <= 16 sq in w/border $1.00A6220 SD Gauze >16 <=48 sq in w/bordr $2.71A6222 SD Gauze <=16 in no w/sal w/o b $2.24A6223 SD Gauze >16<=48 no w/sal w/o b $2.54A6224 SD Gauze > 48 in no w/sal w/o b $3.79A6229 SD Gauze >16<=48 sq in watr/sal $3.79A6231 SD Hydrogel dsg<=16 sq in $4.89A6232 SD Hydrogel dsg>16<=48 sq in $7.22A6233 SD Hydrogel dressing >48 sq in $20.15A6234 SD Hydrocolld drg <=16 w/o bdr $6.87A6235 SD Hydrocolld drg >16<=48 w/o b $17.66A6236 SD Hydrocolld drg > 48 in w/o b $28.61A6237 SD Hydrocolld drg <=16 in w/bdr $8.31A6238 SD Hydrocolld drg >16<=48 w/bdr $23.93A6240 SD Hydrocolld drg filler paste $12.85A6241 SD Hydrocolloid drg filler dry $2.70A6242 SD Hydrogel drg <=16 in w/o bdr $6.37A6243 SD Hydrogel drg >16<=48 w/o bdr $12.93A6244 SD Hydrogel drg >48 in w/o bdr $41.24A6245 SD Hydrogel drg <= 16 in w/bdr $7.63A6246 SD Hydrogel drg >16<=48 in w/b $10.42A6247 SD Hydrogel drg > 48 sq in w/b $24.97A6248 SD Hydrogel drsg gel filler $17.05A6251 SD Absorpt drg <=16 sq in w/o b $2.09A6252 SD Absorpt drg >16 <=48 w/o bdr $3.41A6253 SD Absorpt drg > 48 sq in w/o b $6.66A6254 SD Absorpt drg <=16 sq in w/bdr $1.27A6255 SD Absorpt drg >16<=48 in w/bdr $3.18A6257 SD Transparent film <= 16 sq in $1.61A6258 SD Transparent film >16<=48 in $4.52A6259 SD Transparent film > 48 sq in $11.49A6266 SD Impreg gauze no h20/sal/yard $2.02A6402 SD Sterile gauze <= 16 sq in $0.13A6403 SD Sterile gauze>16 <= 48 sq in $0.45A6407 SD Packing strips, non-impreg $1.97A6410 SD Sterile eye pad $0.41A6411 SD Non-sterile eye pad $0.00A6441 SD Pad band w>=3" <5"/yd $0.70A6442 SD Conform band n/s w<3"/yd $0.18A6443 SD Conform band n/s w>=3"<5"/yd $0.30A6444 SD Conform band n/s w>=5"/yd $0.59A6445 SD Conform band s w <3"/yd $0.34A6446 SD Conform band s w>=3" <5"/yd $0.43A6447 SD Conform band s w >=5"/yd $0.70A6448 SD Lt compres band <3"/yd $1.22A6449 SD Lt compres band >=3" <5"/yd $1.84A6450 SD Lt compres band >=5"/yd $0.00A6451 SD Mod compres band w>=3"<5"/yd $0.00

Page 6: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

A6452 SD High compres band w>=3"<5"yd $6.21A6453 SD Self-adher band w <3"/yd $0.64A6454 SD Self-adher band w>=3" <5"/yd $0.81A6455 SD Self-adher band >=5"/yd $1.46A6456 SD Zinc paste band w >=3"<5"/yd $1.34A6457 SD Tubular dressing $1.20A6501 SD Compres burngarment bodysuit $0.00A6502 SD Compres burngarment chinstrp $0.00A6503 SD Compres burngarment facehood $0.00A6504 SD Cmprsburngarment glove-wrist $0.00A6505 SD Cmprsburngarment glove-elbow $0.00A6506 SD Cmprsburngrmnt glove-axilla $0.00A6507 SD Cmprs burngarment foot-knee $0.00A6508 SD Cmprs burngarment foot-thigh $0.00A6509 SD Compres burn garment jacket $0.00A6510 SD Compres burn garment leotard $0.00A6511 SD Compres burn garment panty $0.00A6513 SD Compress burn mask face/neck $0.00A6531 AW SD Compression stocking BK30-40 $45.43A6532 AW SD Compression stocking BK40-50 $64.01A6545 SD Grad comp non-elastic BK $0.00A6545 AW SD Grad comp non-elastic BK $89.45A6550 SU Neg pres wound ther drsg set $24.82A7000 NU IN Disposable canister for pump $7.54A7000 NU KE IN Disposable canister for pump $8.75A7001 NU IN Nondisposable pump canister $31.32A7002 NU IN Tubing used w suction pump $3.63A7003 NU IN Nebulizer administration set $2.87A7004 NU IN Disposable nebulizer sml vol $1.61A7005 NU IN Nondisposable nebulizer set $29.18A7006 NU IN Filtered nebulizer admin set $8.55A7007 NU IN Lg vol nebulizer disposable $4.17A7008 NU IN Disposable nebulizer prefill $11.55A7009 NU IN Nebulizer reservoir bottle $39.80A7010 NU IN Disposable corrugated tubing $24.48A7012 NU IN Nebulizer water collec devic $3.76A7013 NU IN Disposable compressor filter $0.79A7014 NU IN Compressor nondispos filter $4.24A7015 NU IN Aerosol mask used w nebulize $1.73A7016 NU IN Nebulizer dome & mouthpiece $6.85A7017 NU IN Nebulizer not used w oxygen $140.74A7017 RR IN Nebulizer not used w oxygen $14.07A7017 UE IN Nebulizer not used w oxygen $105.55A7018 SU Water distilled w/nebulizer $0.40A7025 NU IN Replace chest compress vest $456.69A7026 NU IN Replace chst cmprss sys hose $30.19A7027 NU IN Combination oral/nasal mask $188.32A7028 NU IN Repl oral cushion combo mask $52.02A7029 NU IN Repl nasal pillow comb mask $21.25A7030 NU IN CPAP full face mask $170.72A7031 NU IN Replacement facemask interfa $63.14A7032 NU IN Replacement nasal cushion $36.68A7033 NU IN Replacement nasal pillows $25.71A7034 NU IN Nasal application device $106.46A7035 NU IN Pos airway press headgear $32.06A7036 NU IN Pos airway press chinstrap $16.47A7037 NU IN Pos airway pressure tubing $35.49A7038 NU IN Pos airway pressure filter $4.15A7039 NU IN Filter, non disposable w pap $13.87A7040 PO One way chest drain valve $41.45

Page 7: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

A7041 PO Water seal drain container $77.90A7042 PO Implanted pleural catheter $173.36A7043 PO Vacuum drainagebottle/tubing $29.52A7044 NU IN PAP oral interface $109.42A7045 NU IN Repl exhalation port for PAP $17.62A7045 RR IN Repl exhalation port for PAP $1.76A7045 UE IN Repl exhalation port for PAP $13.21A7046 NU IN Repl water chamber, PAP dev $17.66A7501 OS Tracheostoma valve w diaphra $110.28A7502 OS Replacement diaphragm/fplate $52.41A7503 OS HMES filter holder or cap $11.90A7504 OS Tracheostoma HMES filter $0.70A7505 OS HMES or trach valve housing $4.91A7506 OS HMES/trachvalve adhesivedisk $0.35A7507 OS Integrated filter & holder $2.61A7508 OS Housing & Integrated Adhesiv $3.01A7509 OS Heat & moisture exchange sys $1.48A7520 OS Trach/laryn tube non-cuffed $49.85A7521 OS Trach/laryn tube cuffed $49.40A7522 OS Trach/laryn tube stainless $47.42A7524 OS Tracheostoma stent/stud/bttn $81.27A7525 OS Tracheostomy mask $2.17A7526 OS Tracheostomy tube collar $3.54A7527 OS Trach/laryn tube plug/stop $3.76A8000 NU IN Soft protect helmet prefab $161.02A8000 RR IN Soft protect helmet prefab $16.10A8000 UE IN Soft protect helmet prefab $120.78A8001 NU IN Hard protect helmet prefab $161.02A8001 RR IN Hard protect helmet prefab $16.10A8001 UE IN Hard protect helmet prefab $120.78A8002 NU IN Soft protect helmet custom $0.00A8002 RR IN Soft protect helmet custom $0.00A8002 UE IN Soft protect helmet custom $0.00A8003 NU IN Hard protect helmet custom $0.00A8003 RR IN Hard protect helmet custom $0.00A8003 UE IN Hard protect helmet custom $0.00A8004 NU IN Repl soft interface, helmet $0.00A8004 RR IN Repl soft interface, helmet $0.00A8004 UE IN Repl soft interface, helmet $0.00E0100 NU IN Cane adjust/fixed with tip $19.69E0100 RR IN Cane adjust/fixed with tip $5.30E0100 UE IN Cane adjust/fixed with tip $15.25E0105 NU IN Cane adjust/fixed quad/3 pro $51.57E0105 RR IN Cane adjust/fixed quad/3 pro $7.91E0105 UE IN Cane adjust/fixed quad/3 pro $38.05E0110 NU IN Crutch forearm pair $76.20E0110 RR IN Crutch forearm pair $14.27E0110 UE IN Crutch forearm pair $57.14E0111 NU IN Crutch forearm each $55.92E0111 RR IN Crutch forearm each $8.75E0111 UE IN Crutch forearm each $43.16E0112 NU IN Crutch underarm pair wood $38.85E0112 RR IN Crutch underarm pair wood $8.87E0112 UE IN Crutch underarm pair wood $29.64E0113 NU IN Crutch underarm each wood $22.19E0113 RR IN Crutch underarm each wood $5.41E0113 UE IN Crutch underarm each wood $16.65E0114 NU IN Crutch underarm pair no wood $49.55E0114 RR IN Crutch underarm pair no wood $9.00E0114 UE IN Crutch underarm pair no wood $37.45

Page 8: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E0116 NU IN Crutch underarm each no wood $24.98E0116 RR IN Crutch underarm each no wood $5.67E0116 UE IN Crutch underarm each no wood $18.73E0117 NU IN Underarm springassist crutch $202.35E0117 RR IN Underarm springassist crutch $20.22E0117 UE IN Underarm springassist crutch $151.78E0130 NU IN Walker rigid adjust/fixed ht $63.42E0130 RR IN Walker rigid adjust/fixed ht $15.22E0130 UE IN Walker rigid adjust/fixed ht $47.52E0135 NU IN Walker folding adjust/fixed $67.40E0135 RR IN Walker folding adjust/fixed $15.62E0135 UE IN Walker folding adjust/fixed $49.48E0140 NU IN Walker w trunk support $326.44E0140 RR IN Walker w trunk support $32.65E0140 UE IN Walker w trunk support $244.84E0141 NU IN Rigid wheeled walker adj/fix $104.34E0141 RR IN Rigid wheeled walker adj/fix $20.24E0141 UE IN Rigid wheeled walker adj/fix $78.26E0143 NU IN Walker folding wheeled w/o s $108.81E0143 RR IN Walker folding wheeled w/o s $19.54E0143 UE IN Walker folding wheeled w/o s $81.43E0144 NU IN Enclosed walker w rear seat $288.20E0144 RR IN Enclosed walker w rear seat $24.51E0144 UE IN Enclosed walker w rear seat $183.72E0147 NU IN Walker variable wheel resist $520.20E0147 RR IN Walker variable wheel resist $52.02E0147 UE IN Walker variable wheel resist $390.17E0148 NU IN Heavyduty walker no wheels $114.98E0148 RR IN Heavyduty walker no wheels $11.51E0148 UE IN Heavyduty walker no wheels $86.23E0149 NU IN Heavy duty wheeled walker $202.00E0149 RR IN Heavy duty wheeled walker $20.20E0149 UE IN Heavy duty wheeled walker $151.49E0153 NU IN Forearm crutch platform atta $72.85E0153 RR IN Forearm crutch platform atta $8.23E0153 UE IN Forearm crutch platform atta $54.63E0154 NU IN Walker platform attachment $63.81E0154 RR IN Walker platform attachment $7.75E0154 UE IN Walker platform attachment $48.48E0155 NU IN Walker wheel attachment,pair $28.56E0155 RR IN Walker wheel attachment,pair $3.48E0155 UE IN Walker wheel attachment,pair $21.77E0156 NU IN Walker seat attachment $23.92E0156 RR IN Walker seat attachment $3.06E0156 UE IN Walker seat attachment $17.96E0157 NU IN Walker crutch attachment $63.02E0157 RR IN Walker crutch attachment $8.14E0157 UE IN Walker crutch attachment $47.27E0158 NU IN Walker leg extenders set of4 $29.12E0158 RR IN Walker leg extenders set of4 $3.21E0158 UE IN Walker leg extenders set of4 $21.98E0159 NU IN Brake for wheeled walker $16.12E0159 RR IN Brake for wheeled walker $1.63E0159 UE IN Brake for wheeled walker $12.11E0160 NU IN Sitz type bath or equipment $29.50E0160 RR IN Sitz type bath or equipment $4.55E0160 UE IN Sitz type bath or equipment $22.11E0161 NU IN Sitz bath/equipment w/faucet $27.54E0161 RR IN Sitz bath/equipment w/faucet $3.75E0161 UE IN Sitz bath/equipment w/faucet $20.62

Page 9: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E0162 NU IN Sitz bath chair $152.99E0162 RR IN Sitz bath chair $16.05E0162 UE IN Sitz bath chair $118.65E0163 NU IN Commode chair with fixed arm $115.80E0163 RR IN Commode chair with fixed arm $25.65E0163 UE IN Commode chair with fixed arm $80.80E0165 RR CR Commode chair with detacharm $19.13E0167 NU IN Commode chair pail or pan $12.60E0167 RR IN Commode chair pail or pan $1.32E0167 UE IN Commode chair pail or pan $9.49E0168 NU IN Heavyduty/wide commode chair $158.47E0168 RR IN Heavyduty/wide commode chair $15.93E0168 UE IN Heavyduty/wide commode chair $118.84E0170 RR CR Commode chair electric $168.76E0171 RR CR Commode chair non-electric $30.37E0175 NU IN Commode chair foot rest $69.54E0175 RR IN Commode chair foot rest $5.91E0175 UE IN Commode chair foot rest $43.50E0181 RR CR Press pad alternating w/ pum $27.36E0182 RR CR Replace pump, alt press pad $27.49E0184 NU IN Dry pressure mattress $173.77E0184 RR IN Dry pressure mattress $25.80E0184 UE IN Dry pressure mattress $133.27E0185 NU IN Gel pressure mattress pad $285.47E0185 RR IN Gel pressure mattress pad $47.19E0185 UE IN Gel pressure mattress pad $219.09E0186 RR CR Air pressure mattress $21.32E0187 RR CR Water pressure mattress $23.70E0188 NU IN Synthetic sheepskin pad $27.75E0188 RR IN Synthetic sheepskin pad $3.26E0188 UE IN Synthetic sheepskin pad $20.84E0189 NU IN Lambswool sheepskin pad $46.38E0189 RR IN Lambswool sheepskin pad $5.91E0189 UE IN Lambswool sheepskin pad $34.79E0191 NU IN Protector heel or elbow $10.49E0191 RR IN Protector heel or elbow $1.07E0191 UE IN Protector heel or elbow $7.83E0193 RR CR Powered air flotation bed $786.82E0194 RR CR Air fluidized bed $3,307.35E0196 RR CR Gel pressure mattress $28.99E0197 NU IN Air pressure pad for mattres $197.76E0197 RR IN Air pressure pad for mattres $32.10E0197 UE IN Air pressure pad for mattres $173.71E0198 NU IN Water pressure pad for mattr $197.76E0198 RR IN Water pressure pad for mattr $24.10E0198 UE IN Water pressure pad for mattr $150.07E0199 NU IN Dry pressure pad for mattres $33.65E0199 RR IN Dry pressure pad for mattres $3.35E0199 UE IN Dry pressure pad for mattres $25.24E0200 NU IN Heat lamp without stand $70.75E0200 RR IN Heat lamp without stand $11.30E0200 UE IN Heat lamp without stand $53.09E0202 RR CR Phototherapy light w/ photom $65.74E0205 NU IN Heat lamp with stand $173.20E0205 RR IN Heat lamp with stand $20.84E0205 UE IN Heat lamp with stand $129.90E0210 NU IN Electric heat pad standard $34.27E0210 RR IN Electric heat pad standard $3.22E0210 UE IN Electric heat pad standard $25.70E0215 NU IN Electric heat pad moist $63.22

Page 10: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E0215 RR IN Electric heat pad moist $6.95E0215 UE IN Electric heat pad moist $47.43E0217 NU IN Water circ heat pad w pump $443.10E0217 RR IN Water circ heat pad w pump $49.33E0217 UE IN Water circ heat pad w pump $332.30E0220 NU IN Hot water bottle $7.56E0220 RR IN Hot water bottle $0.79E0220 UE IN Hot water bottle $5.65E0225 NU IN Hydrocollator unit $346.87E0225 RR IN Hydrocollator unit $34.20E0225 UE IN Hydrocollator unit $260.14E0230 NU IN Ice cap or collar $7.57E0230 RR IN Ice cap or collar $0.85E0230 UE IN Ice cap or collar $5.66E0235 RR CR Paraffin bath unit portable $18.12E0236 RR CR Pump for water circulating p $40.19E0238 NU IN Heat pad non-electric moist $28.38E0238 RR IN Heat pad non-electric moist $2.86E0238 UE IN Heat pad non-electric moist $20.87E0239 NU IN Hydrocollator unit portable $472.32E0239 RR IN Hydrocollator unit portable $47.24E0239 UE IN Hydrocollator unit portable $354.26E0249 NU IN Pad water circulating heat u $104.58E0249 RR IN Pad water circulating heat u $11.50E0249 UE IN Pad water circulating heat u $78.44E0250 RR CR Hosp bed fixed ht w/ mattres $84.09E0251 RR CR Hosp bed fixd ht w/o mattres $61.24E0255 RR CR Hospital bed var ht w/ mattr $91.93E0256 RR CR Hospital bed var ht w/o matt $64.12E0260 RR CR Hosp bed semi-electr w/ matt $127.12E0261 RR CR Hosp bed semi-electr w/o mat $105.34E0265 RR CR Hosp bed total electr w/ mat $173.87E0266 RR CR Hosp bed total elec w/o matt $160.72E0271 NU IN Mattress innerspring $191.13E0271 RR IN Mattress innerspring $20.87E0271 UE IN Mattress innerspring $143.32E0272 NU IN Mattress foam rubber $176.39E0272 RR IN Mattress foam rubber $19.12E0272 UE IN Mattress foam rubber $132.29E0275 NU IN Bed pan standard $16.08E0275 RR IN Bed pan standard $1.68E0275 UE IN Bed pan standard $12.05E0276 NU IN Bed pan fracture $13.97E0276 RR IN Bed pan fracture $1.65E0276 UE IN Bed pan fracture $11.05E0277 RR CR Powered pres-redu air mattrs $584.14E0280 NU IN Bed cradle $33.49E0280 RR IN Bed cradle $3.72E0280 UE IN Bed cradle $25.11E0290 RR CR Hosp bed fx ht w/o rails w/m $57.49E0291 RR CR Hosp bed fx ht w/o rail w/o $41.77E0292 RR CR Hosp bed var ht w/o rail w/o $64.65E0293 RR CR Hosp bed var ht w/o rail w/ $62.16E0294 RR CR Hosp bed semi-elect w/ mattr $100.88E0295 RR CR Hosp bed semi-elect w/o matt $100.88E0296 RR CR Hosp bed total elect w/ matt $127.56E0297 RR CR Hosp bed total elect w/o mat $127.31E0300 NU IN Enclosed ped crib hosp grade $2,568.95E0300 RR IN Enclosed ped crib hosp grade $256.89E0300 UE IN Enclosed ped crib hosp grade $1,926.71

Page 11: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E0301 RR CR HD hosp bed, 350-600 lbs $228.58E0302 RR CR Ex hd hosp bed > 600 lbs $647.47E0303 RR CR Hosp bed hvy dty xtra wide $258.68E0304 RR CR Hosp bed xtra hvy dty x wide $697.46E0305 RR CR Rails bed side half length $13.69E0310 NU IN Rails bed side full length $175.70E0310 RR IN Rails bed side full length $20.60E0310 UE IN Rails bed side full length $132.95E0316 RR CR Bed safety enclosure $191.21E0325 NU IN Urinal male jug-type $9.03E0325 RR IN Urinal male jug-type $1.59E0325 UE IN Urinal male jug-type $6.48E0326 NU IN Urinal female jug-type $11.03E0326 RR IN Urinal female jug-type $1.25E0326 UE IN Urinal female jug-type $8.26E0371 RR CR Nonpower mattress overlay $377.47E0372 RR CR Powered air mattress overlay $458.01E0373 RR CR Nonpowered pressure mattress $524.67E0424 RR OX Stationary compressed gas 02 $173.17E0431 RR OX Portable gaseous 02 $28.77E0433 RR OX Portable liquid oxygen sys $51.63E0434 RR OX Portable liquid 02 $28.77E0439 RR OX Stationary liquid 02 $173.17E0441 OX Stationary O2 contents, gas $77.45E0442 OX Stationary O2 contents, liq $77.45E0443 OX Portable 02 contents, gas $77.45E0444 OX Portable 02 contents, liquid $77.45E0450 RR FS Vol control vent invasiv int $1,002.25E0457 NU IN Chest shell $645.24E0457 RR IN Chest shell $64.52E0457 UE IN Chest shell $483.89E0459 RR CR Chest wrap $53.43E0460 RR FS Neg press vent portabl/statn $654.71E0461 RR FS Vol control vent noninv int $1,002.25E0462 RR CR Rocking bed w/ or w/o side r $305.97E0463 RR FS Press supp vent invasive int $1,476.70E0464 RR FS Press supp vent noninv int $1,476.70E0470 RR CR RAD w/o backup non-inv intfc $197.39E0471 RR CR RAD w/backup non inv intrfc $493.99E0472 RR CR RAD w backup invasive intrfc $493.99E0480 RR CR Percussor elect/pneum home m $46.14E0482 RR CR Cough stimulating device $423.71E0483 RR CR Chest compression gen system $1,116.29E0484 NU IN Non-elec oscillatory pep dvc $38.77E0484 RR IN Non-elec oscillatory pep dvc $3.87E0484 UE IN Non-elec oscillatory pep dvc $29.09E0485 NU IN Oral device/appliance prefab $0.00E0485 RR IN Oral device/appliance prefab $0.00E0485 UE IN Oral device/appliance prefab $0.00E0486 NU IN Oral device/appliance cusfab $0.00E0486 RR IN Oral device/appliance cusfab $0.00E0486 UE IN Oral device/appliance cusfab $0.00E0500 RR FS Ippb all types $115.26E0550 RR CR Humidif extens supple w ippb $52.64E0560 NU IN Humidifier supplemental w/ i $131.95E0560 RR IN Humidifier supplemental w/ i $15.46E0560 UE IN Humidifier supplemental w/ i $98.96E0561 NU IN Humidifier nonheated w PAP $96.84E0561 RR IN Humidifier nonheated w PAP $9.67E0561 UE IN Humidifier nonheated w PAP $72.62

Page 12: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E0562 NU IN Humidifier heated used w PAP $272.60E0562 RR IN Humidifier heated used w PAP $27.25E0562 UE IN Humidifier heated used w PAP $204.45E0565 RR CR Compressor air power source $54.45E0570 RR CR Nebulizer with compression $16.91E0571 RR CR Aerosol compressor for svneb $29.69E0572 RR CR Aerosol compressor adjust pr $37.73E0574 RR CR Ultrasonic generator w svneb $39.87E0575 RR FS Nebulizer ultrasonic $107.92E0580 NU IN Nebulizer for use w/ regulat $121.31E0580 RR IN Nebulizer for use w/ regulat $12.13E0580 UE IN Nebulizer for use w/ regulat $90.97E0585 RR CR Nebulizer w/ compressor & he $36.82E0600 RR CR Suction pump portab hom modl $46.23E0601 RR CR Cont airway pressure device $90.59E0602 NU IN Manual breast pump $31.00E0602 RR IN Manual breast pump $3.11E0602 UE IN Manual breast pump $23.25E0605 NU IN Vaporizer room type $27.75E0605 RR IN Vaporizer room type $3.22E0605 UE IN Vaporizer room type $22.86E0606 RR CR Drainage board postural $20.48E0607 NU IN Blood glucose monitor home $70.16E0607 RR IN Blood glucose monitor home $7.01E0607 UE IN Blood glucose monitor home $52.61E0610 NU IN Pacemaker monitr audible/vis $249.75E0610 RR IN Pacemaker monitr audible/vis $26.34E0610 UE IN Pacemaker monitr audible/vis $187.34E0615 NU IN Pacemaker monitr digital/vis $442.62E0615 RR IN Pacemaker monitr digital/vis $61.43E0615 UE IN Pacemaker monitr digital/vis $331.97E0617 RR CR Automatic ext defibrillator $319.25E0617 RR KF CR Automatic ext defibrillator $354.45E0618 RR CR Apnea monitor $257.49E0619 RR CR Apnea monitor w recorder $0.00E0620 NU IN Cap bld skin piercing laser $918.11E0620 RR IN Cap bld skin piercing laser $91.80E0620 UE IN Cap bld skin piercing laser $688.58E0621 NU IN Patient lift sling or seat $85.67E0621 RR IN Patient lift sling or seat $9.71E0621 UE IN Patient lift sling or seat $64.58E0627 NU IN Seat lift incorp lift-chair $347.25E0627 RR IN Seat lift incorp lift-chair $34.73E0627 UE IN Seat lift incorp lift-chair $260.41E0628 NU IN Seat lift for pt furn-electr $347.25E0628 RR IN Seat lift for pt furn-electr $34.73E0628 UE IN Seat lift for pt furn-electr $260.41E0629 NU IN Seat lift for pt furn-non-el $347.25E0629 RR IN Seat lift for pt furn-non-el $34.73E0629 UE IN Seat lift for pt furn-non-el $260.41E0630 RR CR Patient lift hydraulic $101.67E0635 RR CR Patient lift electric $109.21E0636 RR CR PT support & positioning sys $1,107.29E0650 NU IN Pneuma compresor non-segment $686.85E0650 RR IN Pneuma compresor non-segment $93.31E0650 UE IN Pneuma compresor non-segment $515.15E0651 NU IN Pneum compressor segmental $964.34E0651 RR IN Pneum compressor segmental $96.44E0651 UE IN Pneum compressor segmental $723.26E0652 NU IN Pneum compres w/cal pressure $4,731.54

Page 13: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E0652 RR IN Pneum compres w/cal pressure $467.63E0652 UE IN Pneum compres w/cal pressure $4,126.23E0655 NU IN Pneumatic appliance half arm $109.78E0655 RR IN Pneumatic appliance half arm $13.31E0655 UE IN Pneumatic appliance half arm $82.31E0656 NU IN Segmental pneumatic trunk $606.60E0656 RR IN Segmental pneumatic trunk $60.59E0656 UE IN Segmental pneumatic trunk $455.01E0657 NU IN Segmental pneumatic chest $569.88E0657 RR IN Segmental pneumatic chest $56.89E0657 UE IN Segmental pneumatic chest $427.44E0660 NU IN Pneumatic appliance full leg $167.74E0660 RR IN Pneumatic appliance full leg $17.46E0660 UE IN Pneumatic appliance full leg $115.91E0665 NU IN Pneumatic appliance full arm $122.26E0665 RR IN Pneumatic appliance full arm $14.77E0665 UE IN Pneumatic appliance full arm $91.82E0666 NU IN Pneumatic appliance half leg $144.98E0666 RR IN Pneumatic appliance half leg $14.94E0666 UE IN Pneumatic appliance half leg $108.77E0667 NU IN Seg pneumatic appl full leg $339.96E0667 RR IN Seg pneumatic appl full leg $34.00E0667 UE IN Seg pneumatic appl full leg $254.96E0668 NU IN Seg pneumatic appl full arm $394.37E0668 RR IN Seg pneumatic appl full arm $38.92E0668 UE IN Seg pneumatic appl full arm $295.79E0669 NU IN Seg pneumatic appli half leg $182.76E0669 RR IN Seg pneumatic appli half leg $18.28E0669 UE IN Seg pneumatic appli half leg $137.09E0671 NU IN Pressure pneum appl full leg $436.12E0671 RR IN Pressure pneum appl full leg $43.62E0671 UE IN Pressure pneum appl full leg $327.08E0672 NU IN Pressure pneum appl full arm $338.87E0672 RR IN Pressure pneum appl full arm $33.89E0672 UE IN Pressure pneum appl full arm $254.16E0673 NU IN Pressure pneum appl half leg $281.58E0673 RR IN Pressure pneum appl half leg $28.16E0673 UE IN Pressure pneum appl half leg $211.21E0675 RR CR Pneumatic compression device $403.78E0691 NU IN Uvl pnl 2 sq ft or less $943.52E0691 RR IN Uvl pnl 2 sq ft or less $94.35E0691 UE IN Uvl pnl 2 sq ft or less $707.64E0692 NU IN Uvl sys panel 4 ft $1,184.79E0692 RR IN Uvl sys panel 4 ft $118.47E0692 UE IN Uvl sys panel 4 ft $888.60E0693 NU IN Uvl sys panel 6 ft $1,460.53E0693 RR IN Uvl sys panel 6 ft $146.06E0693 UE IN Uvl sys panel 6 ft $1,095.40E0694 NU IN Uvl md cabinet sys 6 ft $4,648.71E0694 RR IN Uvl md cabinet sys 6 ft $464.87E0694 UE IN Uvl md cabinet sys 6 ft $3,486.56E0705 NU IN Transfer device $49.59E0705 RR IN Transfer device $5.01E0705 UE IN Transfer device $37.21E0720 NU TE Tens two lead $95.00E0730 NU TE Tens four lead $100.00E0731 NU IN Conductive garment for tens/ $374.52E0740 NU IN Incontinence treatment systm $549.01E0740 RR IN Incontinence treatment systm $54.90E0740 UE IN Incontinence treatment systm $411.79

Page 14: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E0744 RR CR Neuromuscular stim for scoli $96.15EO745 NU IN Neuromuscular stim for shock $200.00E0745 RR CR Neuromuscular stim for shock $20.00E0747 NU KF IN Elec osteogen stim not spine $3,963.48E0747 RR KF IN Elec osteogen stim not spine $396.32E0747 UE KF IN Elec osteogen stim not spine $2,972.60E0748 NU KF IN Elec osteogen stim spinal $4,085.24E0748 RR KF IN Elec osteogen stim spinal $408.52E0748 UE KF IN Elec osteogen stim spinal $3,063.94E0749 RR KF CR Elec osteogen stim implanted $298.59E0760 NU KF IN Osteogen ultrasound stimltor $3,394.76E0760 RR KF IN Osteogen ultrasound stimltor $339.49E0760 UE KF IN Osteogen ultrasound stimltor $2,546.07E0762 NU IN Trans elec jt stim dev sys $1,154.54E0762 RR IN Trans elec jt stim dev sys $115.46E0762 UE IN Trans elec jt stim dev sys $865.88E0764 NU KF IN Functional neuromuscularstim $11,620.16E0764 RR KF IN Functional neuromuscularstim $1,162.00E0764 UE KF IN Functional neuromuscularstim $8,715.13E0765 NU IN Nerve stimulator for tx n&v $88.34E0765 RR IN Nerve stimulator for tx n&v $8.85E0765 UE IN Nerve stimulator for tx n&v $66.28E0776 NU IN Iv pole $127.77E0776 RR IN Iv pole $19.58E0776 UE IN Iv pole $94.01E0779 RR CR Amb infusion pump mechanical $17.57E0780 NU IN Mech amb infusion pump <8hrs $10.89E0781 RR CR External ambulatory infus pu $236.39E0782 NU KF IN Non-programble infusion pump $4,508.08E0782 RR KF IN Non-programble infusion pump $450.83E0782 UE KF IN Non-programble infusion pump $3,381.07E0783 NU KF IN Programmable infusion pump $8,202.34E0783 RR KF IN Programmable infusion pump $820.25E0783 UE KF IN Programmable infusion pump $6,151.77E0784 RR CR Ext amb infusn pump insulin $438.45E0785 KF IN Replacement impl pump cathet $421.71E0786 NU KF IN Implantable pump replacement $8,082.48E0786 RR KF IN Implantable pump replacement $808.25E0786 UE KF IN Implantable pump replacement $6,061.88E0791 RR CR Parenteral infusion pump sta $282.21E0840 NU IN Tract frame attach headboard $65.40E0840 RR IN Tract frame attach headboard $14.57E0840 UE IN Tract frame attach headboard $49.03E0849 NU IN Cervical pneum trac equip $541.08E0849 RR IN Cervical pneum trac equip $54.11E0849 UE IN Cervical pneum trac equip $405.78E0850 NU IN Traction stand free standing $93.76E0850 RR IN Traction stand free standing $12.88E0850 UE IN Traction stand free standing $70.33E0855 NU IN Cervical traction equipment $527.76E0855 RR IN Cervical traction equipment $52.77E0855 UE IN Cervical traction equipment $395.81E0856 NU IN Cervic collar w air bladder $161.73E0856 RR IN Cervic collar w air bladder $16.19E0856 UE IN Cervic collar w air bladder $121.31E0860 NU IN Tract equip cervical tract $35.74E0860 RR IN Tract equip cervical tract $6.84E0860 UE IN Tract equip cervical tract $26.81E0870 NU IN Tract frame attach footboard $110.31E0870 RR IN Tract frame attach footboard $13.88

Page 15: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E0870 UE IN Tract frame attach footboard $82.74E0880 NU IN Trac stand free stand extrem $112.05E0880 RR IN Trac stand free stand extrem $20.70E0880 UE IN Trac stand free stand extrem $84.80E0890 NU IN Traction frame attach pelvic $107.47E0890 RR IN Traction frame attach pelvic $34.47E0890 UE IN Traction frame attach pelvic $86.56E0900 NU IN Trac stand free stand pelvic $114.35E0900 RR IN Trac stand free stand pelvic $29.00E0900 UE IN Trac stand free stand pelvic $85.79E0910 RR CR Trapeze bar attached to bed $17.70E0911 RR CR HD trapeze bar attach to bed $45.11E0912 RR CR HD trapeze bar free standing $103.60E0920 RR CR Fracture frame attached to b $41.67E0930 RR CR Fracture frame free standing $41.67E0935 RR FS Cont pas motion exercise dev $23.87E0940 RR CR Trapeze bar free standing $28.67E0941 RR CR Gravity assisted traction de $40.67E0942 NU IN Cervical head harness/halter $20.84E0942 RR IN Cervical head harness/halter $2.46E0942 UE IN Cervical head harness/halter $15.62E0944 NU IN Pelvic belt/harness/boot $43.08E0944 RR IN Pelvic belt/harness/boot $4.83E0944 UE IN Pelvic belt/harness/boot $32.32E0945 NU IN Belt/harness extremity $46.54E0945 RR IN Belt/harness extremity $4.66E0945 UE IN Belt/harness extremity $36.03E0946 RR CR Fracture frame dual w cross $62.12E0947 NU IN Fracture frame attachmnts pe $636.78E0947 RR IN Fracture frame attachmnts pe $66.03E0947 UE IN Fracture frame attachmnts pe $477.58E0948 NU IN Fracture frame attachmnts ce $615.92E0948 RR IN Fracture frame attachmnts ce $61.57E0948 UE IN Fracture frame attachmnts ce $434.39E0950 NU IN Tray $94.07E0950 NU KE IN Tray $109.15E0950 RR IN Tray $9.42E0950 RR KE IN Tray $10.93E0950 UE IN Tray $70.56E0950 UE KE IN Tray $81.87E0951 NU IN Loop heel $17.18E0951 NU KE IN Loop heel $19.93E0951 RR IN Loop heel $1.72E0951 RR KE IN Loop heel $2.00E0951 UE IN Loop heel $12.87E0951 UE KE IN Loop heel $14.93E0952 NU IN Toe loop/holder, each $17.04E0952 NU KE IN Toe loop/holder, each $19.77E0952 RR IN Toe loop/holder, each $1.71E0952 RR KE IN Toe loop/holder, each $1.98E0952 UE IN Toe loop/holder, each $12.79E0952 UE KE IN Toe loop/holder, each $14.84E0955 NU IN Cushioned headrest $182.97E0955 NU KE IN Cushioned headrest $212.29E0955 RR IN Cushioned headrest $18.31E0955 RR KE IN Cushioned headrest $21.24E0955 UE IN Cushioned headrest $137.23E0955 UE KE IN Cushioned headrest $159.21E0956 NU IN W/c lateral trunk/hip suppor $89.21E0956 NU KE IN W/c lateral trunk/hip suppor $103.51

Page 16: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E0956 RR IN W/c lateral trunk/hip suppor $8.93E0956 RR KE IN W/c lateral trunk/hip suppor $10.36E0956 UE IN W/c lateral trunk/hip suppor $66.91E0956 UE KE IN W/c lateral trunk/hip suppor $77.63E0957 NU IN W/c medial thigh support $124.83E0957 NU KE IN W/c medial thigh support $144.83E0957 RR IN W/c medial thigh support $12.48E0957 RR KE IN W/c medial thigh support $14.48E0957 UE IN W/c medial thigh support $93.62E0957 UE KE IN W/c medial thigh support $108.62E0958 RR CR Whlchr att- conv 1 arm drive $44.53E0959 NU IN Amputee adapter $46.42E0959 RR IN Amputee adapter $4.67E0959 UE IN Amputee adapter $35.13E0960 NU IN W/c shoulder harness/straps $82.34E0960 NU KE IN W/c shoulder harness/straps $95.53E0960 RR IN W/c shoulder harness/straps $8.24E0960 RR KE IN W/c shoulder harness/straps $9.56E0960 UE IN W/c shoulder harness/straps $61.76E0960 UE KE IN W/c shoulder harness/straps $71.65E0961 NU IN Wheelchair brake extension $26.55E0961 RR IN Wheelchair brake extension $2.77E0961 UE IN Wheelchair brake extension $13.26E0966 NU IN Wheelchair head rest extensi $67.97E0966 RR IN Wheelchair head rest extensi $6.79E0966 UE IN Wheelchair head rest extensi $50.98E0967 NU IN Manual wc hand rim w project $68.94E0967 RR IN Manual wc hand rim w project $6.89E0967 UE IN Manual wc hand rim w project $51.71E0968 RR CR Wheelchair commode seat $18.83E0969 NU IN Wheelchair narrowing device $153.50E0969 RR IN Wheelchair narrowing device $15.36E0969 UE IN Wheelchair narrowing device $115.12E0971 NU IN Wheelchair anti-tipping devi $45.56E0971 RR IN Wheelchair anti-tipping devi $4.56E0971 UE IN Wheelchair anti-tipping devi $34.19E0973 NU IN W/Ch access det adj armrest $104.05E0973 NU KE IN W/Ch access det adj armrest $120.72E0973 RR IN W/Ch access det adj armrest $9.91E0973 RR KE IN W/Ch access det adj armrest $11.50E0973 UE IN W/Ch access det adj armrest $78.04E0973 UE KE IN W/Ch access det adj armrest $90.54E0974 NU IN W/Ch access anti-rollback $82.33E0974 RR IN W/Ch access anti-rollback $8.73E0974 UE IN W/Ch access anti-rollback $62.21E0978 NU IN W/C acc,saf belt pelv strap $38.64E0978 NU KE IN W/C acc,saf belt pelv strap $44.84E0978 RR IN W/C acc,saf belt pelv strap $3.87E0978 RR KE IN W/C acc,saf belt pelv strap $4.49E0978 UE IN W/C acc,saf belt pelv strap $28.65E0978 UE KE IN W/C acc,saf belt pelv strap $33.24E0980 NU IN Wheelchair safety vest $34.71E0980 RR IN Wheelchair safety vest $3.47E0980 UE IN Wheelchair safety vest $25.89E0981 NU IN Seat upholstery, replacement $42.67E0981 NU KE IN Seat upholstery, replacement $49.51E0981 RR IN Seat upholstery, replacement $4.34E0981 RR KE IN Seat upholstery, replacement $5.04E0981 UE IN Seat upholstery, replacement $32.31E0981 UE KE IN Seat upholstery, replacement $37.49

Page 17: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E0982 NU IN Back upholstery, replacement $46.63E0982 NU KE IN Back upholstery, replacement $54.11E0982 RR IN Back upholstery, replacement $4.66E0982 RR KE IN Back upholstery, replacement $5.41E0982 UE IN Back upholstery, replacement $34.97E0982 UE KE IN Back upholstery, replacement $40.57E0983 RR CR Add pwr joystick $246.77E0984 NU IN Add pwr tiller $1,705.19E0984 RR IN Add pwr tiller $158.56E0984 UE IN Add pwr tiller $1,315.78E0985 NU IN W/c seat lift mechanism $212.99E0985 RR IN W/c seat lift mechanism $21.32E0985 UE IN W/c seat lift mechanism $159.73E0986 NU IN Man w/c push-rim pow assist $5,107.45E0986 RR IN Man w/c push-rim pow assist $510.75E0986 UE IN Man w/c push-rim pow assist $3,830.61E0990 NU IN Wheelchair elevating leg res $90.33E0990 NU KE IN Wheelchair elevating leg res $104.81E0990 RR IN Wheelchair elevating leg res $11.96E0990 RR KE IN Wheelchair elevating leg res $13.88E0990 UE IN Wheelchair elevating leg res $70.58E0990 UE KE IN Wheelchair elevating leg res $81.89E0992 NU IN Wheelchair solid seat insert $84.92E0992 RR IN Wheelchair solid seat insert $8.25E0992 UE IN Wheelchair solid seat insert $63.70E0994 NU IN Wheelchair arm rest $17.65E0994 RR IN Wheelchair arm rest $1.76E0994 UE IN Wheelchair arm rest $13.25E0995 NU IN Wheelchair calf rest $23.92E0995 NU KE IN Wheelchair calf rest $27.75E0995 RR IN Wheelchair calf rest $2.40E0995 RR KE IN Wheelchair calf rest $2.78E0995 UE IN Wheelchair calf rest $17.96E0995 UE KE IN Wheelchair calf rest $20.84E1002 NU IN Pwr seat tilt $3,668.16E1002 NU KE IN Pwr seat tilt $4,255.87E1002 RR IN Pwr seat tilt $366.81E1002 RR KE IN Pwr seat tilt $425.59E1002 UE IN Pwr seat tilt $2,751.11E1002 UE KE IN Pwr seat tilt $3,191.90E1003 NU IN Pwr seat recline $3,974.13E1003 NU KE IN Pwr seat recline $4,610.87E1003 RR IN Pwr seat recline $397.42E1003 RR KE IN Pwr seat recline $461.10E1003 UE IN Pwr seat recline $2,980.60E1003 UE KE IN Pwr seat recline $3,458.15E1004 NU IN Pwr seat recline mech $4,406.49E1004 NU KE IN Pwr seat recline mech $5,112.50E1004 RR IN Pwr seat recline mech $440.64E1004 RR KE IN Pwr seat recline mech $511.25E1004 UE IN Pwr seat recline mech $3,304.85E1004 UE KE IN Pwr seat recline mech $3,834.36E1005 NU IN Pwr seat recline pwr $4,769.68E1005 NU KE IN Pwr seat recline pwr $5,533.88E1005 RR IN Pwr seat recline pwr $476.96E1005 RR KE IN Pwr seat recline pwr $553.38E1005 UE IN Pwr seat recline pwr $3,577.27E1005 UE KE IN Pwr seat recline pwr $4,150.42E1006 NU IN Pwr seat combo w/o shear $5,842.41E1006 NU KE IN Pwr seat combo w/o shear $6,778.49

Page 18: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E1006 RR IN Pwr seat combo w/o shear $584.22E1006 RR KE IN Pwr seat combo w/o shear $677.83E1006 UE IN Pwr seat combo w/o shear $4,381.81E1006 UE KE IN Pwr seat combo w/o shear $5,083.87E1007 NU IN Pwr seat combo w/shear $7,910.85E1007 NU KE IN Pwr seat combo w/shear $9,178.33E1007 RR IN Pwr seat combo w/shear $791.09E1007 RR KE IN Pwr seat combo w/shear $917.84E1007 UE IN Pwr seat combo w/shear $5,933.13E1007 UE KE IN Pwr seat combo w/shear $6,883.74E1008 NU IN Pwr seat combo pwr shear $7,911.56E1008 NU KE IN Pwr seat combo pwr shear $9,179.15E1008 RR IN Pwr seat combo pwr shear $791.15E1008 RR KE IN Pwr seat combo pwr shear $917.91E1008 UE IN Pwr seat combo pwr shear $5,933.68E1008 UE KE IN Pwr seat combo pwr shear $6,884.38E1009 NU IN Add mech leg elevation $0.00E1009 RR IN Add mech leg elevation $0.00E1009 UE IN Add mech leg elevation $0.00E1010 NU IN Add pwr leg elevation $1,035.13E1010 NU KE IN Add pwr leg elevation $1,200.98E1010 RR IN Add pwr leg elevation $103.51E1010 RR KE IN Add pwr leg elevation $120.10E1010 UE IN Add pwr leg elevation $776.36E1010 UE KE IN Add pwr leg elevation $900.75E1011 NU IN Ped wc modify width adjustm $0.00E1011 RR IN Ped wc modify width adjustm $0.00E1011 UE IN Ped wc modify width adjustm $0.00E1014 NU IN Reclining back add ped w/c $383.40E1014 RR IN Reclining back add ped w/c $38.35E1014 UE IN Reclining back add ped w/c $287.54E1015 NU IN Shock absorber for man w/c $120.44E1015 RR IN Shock absorber for man w/c $12.03E1015 UE IN Shock absorber for man w/c $90.32E1016 NU IN Shock absorber for power w/c $118.84E1016 NU KE IN Shock absorber for power w/c $137.88E1016 RR IN Shock absorber for power w/c $11.89E1016 RR KE IN Shock absorber for power w/c $13.80E1016 UE IN Shock absorber for power w/c $89.12E1016 UE KE IN Shock absorber for power w/c $103.40E1017 NU IN HD shck absrbr for hd man wc $0.00E1017 RR IN HD shck absrbr for hd man wc $0.00E1017 UE IN HD shck absrbr for hd man wc $0.00E1018 NU IN HD shck absrber for hd powwc $0.00E1018 RR IN HD shck absrber for hd powwc $0.00E1018 UE IN HD shck absrber for hd powwc $0.00E1020 NU IN Residual limb support system $220.29E1020 NU KE IN Residual limb support system $255.58E1020 RR IN Residual limb support system $22.01E1020 RR KE IN Residual limb support system $25.54E1020 UE IN Residual limb support system $165.21E1020 UE KE IN Residual limb support system $191.68E1028 NU IN W/c manual swingaway $186.92E1028 NU KE IN W/c manual swingaway $216.87E1028 RR IN W/c manual swingaway $18.69E1028 RR KE IN W/c manual swingaway $21.68E1028 UE IN W/c manual swingaway $140.18E1028 UE KE IN W/c manual swingaway $162.63E1029 NU IN W/c vent tray fixed $334.43E1029 NU KE IN W/c vent tray fixed $388.02

Page 19: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E1029 RR IN W/c vent tray fixed $33.44E1029 RR KE IN W/c vent tray fixed $38.80E1029 UE IN W/c vent tray fixed $250.82E1029 UE KE IN W/c vent tray fixed $291.01E1030 NU IN W/c vent tray gimbaled $1,054.57E1030 NU KE IN W/c vent tray gimbaled $1,223.53E1030 RR IN W/c vent tray gimbaled $105.46E1030 RR KE IN W/c vent tray gimbaled $122.36E1030 UE IN W/c vent tray gimbaled $790.93E1030 UE KE IN W/c vent tray gimbaled $917.66E1031 RR CR Rollabout chair with casters $53.04E1035 RR CR Patient transfer system <300 $643.86E1036 RR CR Patient transfer system >300 $902.63E1037 RR CR Transport chair, ped size $113.91E1038 RR CR Transport chair pt wt<=300lb $18.93E1039 RR CR Transport chair pt wt >300lb $35.91E1050 RR CR Whelchr fxd full length arms $106.93E1060 RR CR Wheelchair detachable arms $118.97E1070 RR CR Wheelchair detachable foot r $115.01E1083 RR CR Hemi-wheelchair fixed arms $75.78E1084 RR CR Hemi-wheelchair detachable a $103.01E1087 RR CR Wheelchair lightwt fixed arm $121.80E1088 RR CR Wheelchair lightweight det a $158.31E1092 RR CR Wheelchair wide w/ leg rests $134.94E1093 RR CR Wheelchair wide w/ foot rest $116.05E1100 RR CR Whchr s-recl fxd arm leg res $109.00E1110 RR CR Wheelchair semi-recl detach $106.74E1150 RR CR Wheelchair standard w/ leg r $82.07E1160 RR CR Wheelchair fixed arms $64.53E1161 NU IN Manual adult wc w tiltinspac $2,484.39E1161 RR IN Manual adult wc w tiltinspac $248.44E1161 UE IN Manual adult wc w tiltinspac $1,863.30E1170 RR CR Whlchr ampu fxd arm leg rest $90.63E1171 RR CR Wheelchair amputee w/o leg r $72.10E1172 RR CR Wheelchair amputee detach ar $92.72E1180 RR CR Wheelchair amputee w/ foot r $99.11E1190 RR CR Wheelchair amputee w/ leg re $114.51E1195 RR CR Wheelchair amputee heavy dut $112.12E1200 RR CR Wheelchair amputee fixed arm $85.27E1221 RR CR Wheelchair spec size w foot $44.02E1222 RR CR Wheelchair spec size w/ leg $71.18E1223 RR CR Wheelchair spec size w foot $77.72E1224 RR CR Wheelchair spec size w/ leg $85.21E1225 RR CR Manual semi-reclining back $47.46E1226 NU IN Manual fully reclining back $572.93E1226 RR IN Manual fully reclining back $58.97E1226 UE IN Manual fully reclining back $429.66E1227 NU IN Wheelchair spec sz spec ht a $291.38E1227 RR IN Wheelchair spec sz spec ht a $28.67E1227 UE IN Wheelchair spec sz spec ht a $218.56E1228 RR CR Wheelchair spec sz spec ht b $25.01E1230 NU IN Power operated vehicle $2,136.81E1230 RR IN Power operated vehicle $233.57E1230 UE IN Power operated vehicle $1,596.51E1231 NU IN Rigid ped w/c tilt-in-space $0.00E1231 RR IN Rigid ped w/c tilt-in-space $0.00E1231 UE IN Rigid ped w/c tilt-in-space $0.00E1232 NU IN Folding ped wc tilt-in-space $2,245.33E1232 RR IN Folding ped wc tilt-in-space $224.54E1232 UE IN Folding ped wc tilt-in-space $1,684.01

Page 20: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E1233 NU IN Rig ped wc tltnspc w/o seat $2,326.52E1233 RR IN Rig ped wc tltnspc w/o seat $232.65E1233 UE IN Rig ped wc tltnspc w/o seat $1,744.88E1234 NU IN Fld ped wc tltnspc w/o seat $2,025.40E1234 RR IN Fld ped wc tltnspc w/o seat $202.56E1234 UE IN Fld ped wc tltnspc w/o seat $1,519.04E1235 NU IN Rigid ped wc adjustable $1,950.30E1235 RR IN Rigid ped wc adjustable $195.04E1235 UE IN Rigid ped wc adjustable $1,462.72E1236 NU IN Folding ped wc adjustable $1,720.67E1236 RR IN Folding ped wc adjustable $172.06E1236 UE IN Folding ped wc adjustable $1,290.50E1237 NU IN Rgd ped wc adjstabl w/o seat $1,735.70E1237 RR IN Rgd ped wc adjstabl w/o seat $173.57E1237 UE IN Rgd ped wc adjstabl w/o seat $1,301.79E1238 NU IN Fld ped wc adjstabl w/o seat $1,720.67E1238 RR IN Fld ped wc adjstabl w/o seat $172.06E1238 UE IN Fld ped wc adjstabl w/o seat $1,290.50E1240 RR CR Whchr litwt det arm leg rest $108.17E1270 RR CR Wheelchair lightweight leg r $80.68E1280 RR CR Whchr h-duty det arm leg res $128.96E1295 RR CR Wheelchair heavy duty fixed $124.10E1296 NU IN Wheelchair special seat heig $438.81E1296 RR IN Wheelchair special seat heig $44.57E1296 UE IN Wheelchair special seat heig $329.11E1297 NU IN Wheelchair special seat dept $93.36E1297 RR IN Wheelchair special seat dept $10.37E1297 UE IN Wheelchair special seat dept $70.01E1298 NU IN Wheelchair spec seat depth/w $401.01E1298 RR IN Wheelchair spec seat depth/w $40.11E1298 UE IN Wheelchair spec seat depth/w $300.75E1310 NU IN Whirlpool non-portable $2,254.77E1310 RR IN Whirlpool non-portable $192.85E1310 UE IN Whirlpool non-portable $1,691.08E1353 OX Oxygen supplies regulator $29.75E1355 OX Oxygen supplies stand/rack $22.40E1372 NU IN Oxy suppl heater for nebuliz $171.18E1372 RR IN Oxy suppl heater for nebuliz $24.87E1372 UE IN Oxy suppl heater for nebuliz $107.70E1390 RR OX Oxygen concentrator $173.17E1391 RR OX Oxygen concentrator, dual $173.17E1392 RR OX Portable oxygen concentrator $51.63E1405 RR OX O2/water vapor enrich w/heat $209.99E1406 RR OX O2/water vapor enrich w/o he $190.08E1700 NU IN Jaw motion rehab system $307.77E1700 RR IN Jaw motion rehab system $30.18E1700 UE IN Jaw motion rehab system $230.83E1701 SU Repl cushions for jaw motion $10.89E1702 SU Repl measr scales jaw motion $21.85E1800 RR CR Adjust elbow ext/flex device $109.34E1801 RR CR SPS elbow device $127.14E1802 RR CR Adjst forearm pro/sup device $343.14E1805 RR CR Adjust wrist ext/flex device $118.01E1806 RR CR SPS wrist device $104.34E1810 RR CR Adjust knee ext/flex device $118.01E1811 RR CR SPS knee device $132.16E1812 RR CR Knee ext/flex w act res ctrl $90.29E1815 RR CR Adjust ankle ext/flex device $118.01E1816 RR CR SPS ankle device $134.24E1818 RR CR SPS forearm device $137.05

Page 21: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E1820 NU IN Soft interface material $85.83E1820 RR IN Soft interface material $8.58E1820 UE IN Soft interface material $64.38E1821 NU IN Replacement interface SPSD $110.51E1821 RR IN Replacement interface SPSD $11.04E1821 UE IN Replacement interface SPSD $82.90E1825 RR CR Adjust finger ext/flex devc $118.01E1830 RR CR Adjust toe ext/flex device $118.01E1840 RR CR Adj shoulder ext/flex device $390.41E1841 RR CR Static str shldr dev rom adj $475.65E2000 RR CR Gastric suction pump hme mdl $51.05E2100 NU IN Bld glucose monitor w voice $666.03E2100 RR IN Bld glucose monitor w voice $66.60E2100 UE IN Bld glucose monitor w voice $499.54E2101 NU IN Bld glucose monitor w lance $197.99E2101 RR IN Bld glucose monitor w lance $19.80E2101 UE IN Bld glucose monitor w lance $148.49E2120 RR CR Pulse gen sys tx endolymp fl $297.70E2201 NU IN Man w/ch acc seat w>=20"<24" $391.76E2201 RR IN Man w/ch acc seat w>=20"<24" $39.18E2201 UE IN Man w/ch acc seat w>=20"<24" $293.82E2202 NU IN Seat width 24-27 in $497.68E2202 RR IN Seat width 24-27 in $49.77E2202 UE IN Seat width 24-27 in $373.28E2203 NU IN Frame depth less than 22 in $503.00E2203 RR IN Frame depth less than 22 in $50.28E2203 UE IN Frame depth less than 22 in $377.24E2204 NU IN Frame depth 22 to 25 in $854.07E2204 RR IN Frame depth 22 to 25 in $85.42E2204 UE IN Frame depth 22 to 25 in $640.55E2205 NU IN Manual wc accessory, handrim $34.30E2205 RR IN Manual wc accessory, handrim $3.41E2205 UE IN Manual wc accessory, handrim $25.73E2206 NU IN Complete wheel lock assembly $42.71E2206 RR IN Complete wheel lock assembly $4.26E2206 UE IN Complete wheel lock assembly $32.03E2207 NU IN Crutch and cane holder $45.52E2207 RR IN Crutch and cane holder $4.56E2207 UE IN Crutch and cane holder $34.14E2208 NU IN Cylinder tank carrier $107.50E2208 NU KE IN Cylinder tank carrier $124.72E2208 RR IN Cylinder tank carrier $10.74E2208 RR KE IN Cylinder tank carrier $12.46E2208 UE IN Cylinder tank carrier $80.63E2208 UE KE IN Cylinder tank carrier $93.54E2209 NU IN Arm trough each $96.98E2209 NU KE IN Arm trough each $112.52E2209 RR IN Arm trough each $9.72E2209 RR KE IN Arm trough each $11.28E2209 UE IN Arm trough each $72.74E2209 UE KE IN Arm trough each $84.40E2210 NU IN Wheelchair bearings $5.93E2210 NU KE IN Wheelchair bearings $6.88E2210 RR IN Wheelchair bearings $0.51E2210 RR KE IN Wheelchair bearings $0.59E2210 UE IN Wheelchair bearings $4.45E2210 UE KE IN Wheelchair bearings $5.17E2211 NU IN Pneumatic propulsion tire $42.96E2211 RR IN Pneumatic propulsion tire $4.21E2211 UE IN Pneumatic propulsion tire $30.77

Page 22: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E2212 NU IN Pneumatic prop tire tube $6.17E2212 RR IN Pneumatic prop tire tube $0.64E2212 UE IN Pneumatic prop tire tube $4.64E2213 NU IN Pneumatic prop tire insert $31.92E2213 RR IN Pneumatic prop tire insert $3.20E2213 UE IN Pneumatic prop tire insert $23.92E2214 NU IN Pneumatic caster tire each $37.80E2214 RR IN Pneumatic caster tire each $4.16E2214 UE IN Pneumatic caster tire each $28.34E2215 NU IN Pneumatic caster tire tube $10.08E2215 RR IN Pneumatic caster tire tube $1.00E2215 UE IN Pneumatic caster tire tube $7.54E2216 NU IN Foam filled propulsion tire $0.00E2216 RR IN Foam filled propulsion tire $0.00E2216 UE IN Foam filled propulsion tire $0.00E2217 NU IN Foam filled caster tire each $0.00E2217 RR IN Foam filled caster tire each $0.00E2217 UE IN Foam filled caster tire each $0.00E2218 NU IN Foam propulsion tire each $0.00E2218 RR IN Foam propulsion tire each $0.00E2218 UE IN Foam propulsion tire each $0.00E2219 NU IN Foam caster tire any size ea $43.94E2219 RR IN Foam caster tire any size ea $4.96E2219 UE IN Foam caster tire any size ea $32.96E2220 NU IN Solid propulsion tire each $29.95E2220 RR IN Solid propulsion tire each $2.89E2220 UE IN Solid propulsion tire each $22.80E2221 NU IN Solid caster tire each $26.83E2221 RR IN Solid caster tire each $2.71E2221 UE IN Solid caster tire each $20.14E2222 NU IN Solid caster integrated whl $22.11E2222 RR IN Solid caster integrated whl $2.19E2222 UE IN Solid caster integrated whl $16.60E2224 NU IN Propulsion whl excludes tire $102.96E2224 RR IN Propulsion whl excludes tire $10.80E2224 UE IN Propulsion whl excludes tire $77.23E2225 NU IN Caster wheel excludes tire $18.27E2225 RR IN Caster wheel excludes tire $1.83E2225 UE IN Caster wheel excludes tire $13.69E2226 NU IN Caster fork replacement only $39.84E2226 RR IN Caster fork replacement only $3.98E2226 UE IN Caster fork replacement only $29.88E2227 NU IN Gear reduction drive wheel $1,888.65E2227 RR IN Gear reduction drive wheel $188.85E2227 UE IN Gear reduction drive wheel $1,416.48E2228 NU IN Mwc acc, wheelchair brake $983.07E2228 RR IN Mwc acc, wheelchair brake $98.30E2228 UE IN Mwc acc, wheelchair brake $737.33E2231 NU IN Solid seat support base $161.36E2231 RR IN Solid seat support base $16.14E2231 UE IN Solid seat support base $121.01E2310 NU IN Electro connect btw control $1,059.07E2310 NU KE IN Electro connect btw control $1,228.75E2310 RR IN Electro connect btw control $105.90E2310 RR KE IN Electro connect btw control $122.87E2310 UE IN Electro connect btw control $794.30E2310 UE KE IN Electro connect btw control $921.56E2311 NU IN Electro connect btw 2 sys $2,144.13E2311 NU KE IN Electro connect btw 2 sys $2,487.66E2311 RR IN Electro connect btw 2 sys $214.42

Page 23: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E2311 RR KE IN Electro connect btw 2 sys $248.78E2311 UE IN Electro connect btw 2 sys $1,608.09E2311 UE KE IN Electro connect btw 2 sys $1,865.75E2312 NU IN Mini-prop remote joystick $2,036.14E2312 NU KC IN Mini-prop remote joystick $2,596.84E2312 RR IN Mini-prop remote joystick $203.62E2312 RR KC IN Mini-prop remote joystick $259.69E2312 UE IN Mini-prop remote joystick $1,527.08E2312 UE KC IN Mini-prop remote joystick $1,947.62E2313 NU IN PWC harness, expand control $323.33E2313 RR IN PWC harness, expand control $32.35E2313 UE IN PWC harness, expand control $242.50E2321 NU IN Hand interface joystick $1,438.14E2321 NU KC IN Hand interface joystick $2,342.55E2321 NU KE IN Hand interface joystick $1,668.56E2321 RR IN Hand interface joystick $143.82E2321 RR KC IN Hand interface joystick $234.26E2321 RR KE IN Hand interface joystick $166.87E2321 UE IN Hand interface joystick $1,078.62E2321 UE KC IN Hand interface joystick $1,756.91E2321 UE KE IN Hand interface joystick $1,251.43E2322 NU IN Mult mech switches $1,276.38E2322 NU KC IN Mult mech switches $2,480.72E2322 NU KE IN Mult mech switches $1,480.88E2322 RR IN Mult mech switches $127.63E2322 RR KC IN Mult mech switches $248.07E2322 RR KE IN Mult mech switches $148.08E2322 UE IN Mult mech switches $957.29E2322 UE KC IN Mult mech switches $1,860.54E2322 UE KE IN Mult mech switches $1,110.67E2323 NU IN Special joystick handle $62.59E2323 NU KE IN Special joystick handle $72.62E2323 RR IN Special joystick handle $6.26E2323 RR KE IN Special joystick handle $7.27E2323 UE IN Special joystick handle $46.94E2323 UE KE IN Special joystick handle $54.46E2324 NU IN Chin cup interface $39.66E2324 NU KE IN Chin cup interface $46.01E2324 RR IN Chin cup interface $3.95E2324 RR KE IN Chin cup interface $4.59E2324 UE IN Chin cup interface $29.75E2324 UE KE IN Chin cup interface $34.51E2325 NU IN Sip and puff interface $1,218.88E2325 NU KE IN Sip and puff interface $1,414.17E2325 RR IN Sip and puff interface $121.90E2325 RR KE IN Sip and puff interface $141.44E2325 UE IN Sip and puff interface $914.17E2325 UE KE IN Sip and puff interface $1,060.64E2326 NU IN Breath tube kit $314.16E2326 NU KE IN Breath tube kit $364.50E2326 RR IN Breath tube kit $31.43E2326 RR KE IN Breath tube kit $36.47E2326 UE IN Breath tube kit $235.61E2326 UE KE IN Breath tube kit $273.36E2327 NU IN Head control interface mech $2,364.20E2327 NU KC IN Head control interface mech $3,591.81E2327 NU KE IN Head control interface mech $2,743.00E2327 RR IN Head control interface mech $236.42E2327 RR KC IN Head control interface mech $359.18E2327 RR KE IN Head control interface mech $274.30

Page 24: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E2327 UE IN Head control interface mech $1,773.15E2327 UE KC IN Head control interface mech $2,693.85E2327 UE KE IN Head control interface mech $2,057.24E2328 NU IN Head/extremity control inter $4,484.56E2328 NU KE IN Head/extremity control inter $5,203.09E2328 RR IN Head/extremity control inter $448.45E2328 RR KE IN Head/extremity control inter $520.30E2328 UE IN Head/extremity control inter $3,363.43E2328 UE KE IN Head/extremity control inter $3,902.33E2329 NU IN Head control nonproportional $1,598.35E2329 NU KE IN Head control nonproportional $1,854.44E2329 RR IN Head control nonproportional $159.83E2329 RR KE IN Head control nonproportional $185.44E2329 UE IN Head control nonproportional $1,198.76E2329 UE KE IN Head control nonproportional $1,390.83E2330 NU IN Head control proximity switc $3,096.99E2330 NU KE IN Head control proximity switc $3,593.19E2330 RR IN Head control proximity switc $309.69E2330 RR KE IN Head control proximity switc $359.31E2330 UE IN Head control proximity switc $2,322.75E2330 UE KE IN Head control proximity switc $2,694.91E2340 NU IN W/c wdth 20-23 in seat frame $376.28E2340 RR IN W/c wdth 20-23 in seat frame $37.64E2340 UE IN W/c wdth 20-23 in seat frame $282.23E2341 NU IN W/c wdth 24-27 in seat frame $564.46E2341 RR IN W/c wdth 24-27 in seat frame $56.45E2341 UE IN W/c wdth 24-27 in seat frame $423.35E2342 NU IN W/c dpth 20-21 in seat frame $470.38E2342 RR IN W/c dpth 20-21 in seat frame $47.04E2342 UE IN W/c dpth 20-21 in seat frame $352.79E2343 NU IN W/c dpth 22-25 in seat frame $752.62E2343 RR IN W/c dpth 22-25 in seat frame $75.25E2343 UE IN W/c dpth 22-25 in seat frame $564.46E2351 NU IN Electronic SGD interface $632.26E2351 NU KE IN Electronic SGD interface $733.56E2351 RR IN Electronic SGD interface $63.24E2351 RR KE IN Electronic SGD interface $73.37E2351 UE IN Electronic SGD interface $474.18E2351 UE KE IN Electronic SGD interface $550.16E2360 NU IN 22nf nonsealed leadacid $117.96E2360 RR IN 22nf nonsealed leadacid $11.85E2360 UE IN 22nf nonsealed leadacid $88.47E2361 NU IN 22nf sealed leadacid battery $126.22E2361 NU KE IN 22nf sealed leadacid battery $146.44E2361 RR IN 22nf sealed leadacid battery $12.62E2361 RR KE IN 22nf sealed leadacid battery $14.65E2361 UE IN 22nf sealed leadacid battery $94.68E2361 UE KE IN 22nf sealed leadacid battery $109.85E2362 NU IN Gr24 nonsealed leadacid $96.58E2362 RR IN Gr24 nonsealed leadacid $9.66E2362 UE IN Gr24 nonsealed leadacid $72.43E2363 NU IN Gr24 sealed leadacid battery $168.33E2363 NU KE IN Gr24 sealed leadacid battery $195.30E2363 RR IN Gr24 sealed leadacid battery $16.84E2363 RR KE IN Gr24 sealed leadacid battery $19.54E2363 UE IN Gr24 sealed leadacid battery $126.25E2363 UE KE IN Gr24 sealed leadacid battery $146.48E2364 NU IN U1nonsealed leadacid battery $117.96E2364 RR IN U1nonsealed leadacid battery $11.85E2364 UE IN U1nonsealed leadacid battery $88.47

Page 25: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E2365 NU IN U1 sealed leadacid battery $101.51E2365 NU KE IN U1 sealed leadacid battery $117.78E2365 RR IN U1 sealed leadacid battery $10.15E2365 RR KE IN U1 sealed leadacid battery $11.78E2365 UE IN U1 sealed leadacid battery $76.16E2365 UE KE IN U1 sealed leadacid battery $88.36E2366 NU IN Battery charger, single mode $238.58E2366 NU KE IN Battery charger, single mode $276.80E2366 RR IN Battery charger, single mode $23.92E2366 RR KE IN Battery charger, single mode $27.75E2366 UE IN Battery charger, single mode $178.94E2366 UE KE IN Battery charger, single mode $207.61E2367 NU IN Battery charger, dual mode $379.27E2367 NU KE IN Battery charger, dual mode $440.03E2367 RR IN Battery charger, dual mode $37.93E2367 RR KE IN Battery charger, dual mode $44.01E2367 UE IN Battery charger, dual mode $284.45E2367 UE KE IN Battery charger, dual mode $330.03E2368 NU IN Power wc motor replacement $467.50E2368 NU KE IN Power wc motor replacement $542.40E2368 RR IN Power wc motor replacement $46.76E2368 RR KE IN Power wc motor replacement $54.25E2368 UE IN Power wc motor replacement $350.63E2368 UE KE IN Power wc motor replacement $406.81E2369 NU IN Pwr wc gear box replacement $407.20E2369 NU KE IN Pwr wc gear box replacement $472.44E2369 RR IN Pwr wc gear box replacement $40.73E2369 RR KE IN Pwr wc gear box replacement $47.25E2369 UE IN Pwr wc gear box replacement $305.39E2369 UE KE IN Pwr wc gear box replacement $354.32E2370 NU IN Pwr wc motor/gear box combo $726.57E2370 NU KE IN Pwr wc motor/gear box combo $842.98E2370 RR IN Pwr wc motor/gear box combo $72.66E2370 RR KE IN Pwr wc motor/gear box combo $84.30E2370 UE IN Pwr wc motor/gear box combo $544.92E2370 UE KE IN Pwr wc motor/gear box combo $632.23E2371 NU IN Gr27 sealed leadacid battery $136.42E2371 NU KE IN Gr27 sealed leadacid battery $158.28E2371 RR IN Gr27 sealed leadacid battery $13.65E2371 RR KE IN Gr27 sealed leadacid battery $15.83E2371 UE IN Gr27 sealed leadacid battery $102.32E2371 UE KE IN Gr27 sealed leadacid battery $118.71E2372 NU IN Gr27 non-sealed leadacid $0.00E2372 RR IN Gr27 non-sealed leadacid $0.00E2372 UE IN Gr27 non-sealed leadacid $0.00E2373 NU IN Hand/chin ctrl spec joystick $709.72E2373 NU KC IN Hand/chin ctrl spec joystick $1,094.99E2373 NU KE IN Hand/chin ctrl spec joystick $709.72E2373 RR IN Hand/chin ctrl spec joystick $70.99E2373 RR KC IN Hand/chin ctrl spec joystick $109.51E2373 RR KE IN Hand/chin ctrl spec joystick $70.99E2373 UE IN Hand/chin ctrl spec joystick $532.31E2373 UE KC IN Hand/chin ctrl spec joystick $821.26E2373 UE KE IN Hand/chin ctrl spec joystick $532.31E2374 NU IN Hand/chin ctrl std joystick $483.29E2374 NU KE IN Hand/chin ctrl std joystick $560.72E2374 RR IN Hand/chin ctrl std joystick $48.33E2374 RR KE IN Hand/chin ctrl std joystick $56.07E2374 UE IN Hand/chin ctrl std joystick $362.48E2374 UE KE IN Hand/chin ctrl std joystick $420.56

Page 26: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E2375 NU IN Non-expandable controller $775.19E2375 NU KE IN Non-expandable controller $899.39E2375 RR IN Non-expandable controller $77.51E2375 RR KE IN Non-expandable controller $89.93E2375 UE IN Non-expandable controller $581.37E2375 UE KE IN Non-expandable controller $674.52E2376 NU IN Expandable controller, repl $1,214.75E2376 NU KE IN Expandable controller, repl $1,409.38E2376 RR IN Expandable controller, repl $121.48E2376 RR KE IN Expandable controller, repl $140.94E2376 UE IN Expandable controller, repl $911.08E2376 UE KE IN Expandable controller, repl $1,057.06E2377 NU IN Expandable controller, initl $439.57E2377 NU KE IN Expandable controller, initl $510.00E2377 RR IN Expandable controller, initl $43.95E2377 RR KE IN Expandable controller, initl $50.99E2377 UE IN Expandable controller, initl $329.69E2377 UE KE IN Expandable controller, initl $382.52E2381 NU IN Pneum drive wheel tire $68.94E2381 NU KE IN Pneum drive wheel tire $79.99E2381 RR IN Pneum drive wheel tire $6.91E2381 RR KE IN Pneum drive wheel tire $8.01E2381 UE IN Pneum drive wheel tire $51.71E2381 UE KE IN Pneum drive wheel tire $60.00E2382 NU IN Tube, pneum wheel drive tire $18.80E2382 NU KE IN Tube, pneum wheel drive tire $21.81E2382 RR IN Tube, pneum wheel drive tire $1.87E2382 RR KE IN Tube, pneum wheel drive tire $2.17E2382 UE IN Tube, pneum wheel drive tire $14.09E2382 UE KE IN Tube, pneum wheel drive tire $16.35E2383 NU IN Insert, pneum wheel drive $137.45E2383 NU KE IN Insert, pneum wheel drive $159.47E2383 RR IN Insert, pneum wheel drive $13.75E2383 RR KE IN Insert, pneum wheel drive $15.95E2383 UE IN Insert, pneum wheel drive $103.09E2383 UE KE IN Insert, pneum wheel drive $119.61E2384 NU IN Pneumatic caster tire $73.22E2384 NU KE IN Pneumatic caster tire $84.96E2384 RR IN Pneumatic caster tire $7.34E2384 RR KE IN Pneumatic caster tire $8.52E2384 UE IN Pneumatic caster tire $54.92E2384 UE KE IN Pneumatic caster tire $63.71E2385 NU IN Tube, pneumatic caster tire $44.80E2385 NU KE IN Tube, pneumatic caster tire $51.98E2385 RR IN Tube, pneumatic caster tire $4.49E2385 RR KE IN Tube, pneumatic caster tire $5.21E2385 UE IN Tube, pneumatic caster tire $33.58E2385 UE KE IN Tube, pneumatic caster tire $38.97E2386 NU IN Foam filled drive wheel tire $136.21E2386 NU KE IN Foam filled drive wheel tire $158.04E2386 RR IN Foam filled drive wheel tire $13.62E2386 RR KE IN Foam filled drive wheel tire $15.80E2386 UE IN Foam filled drive wheel tire $102.15E2386 UE KE IN Foam filled drive wheel tire $118.51E2387 NU IN Foam filled caster tire $61.08E2387 NU KE IN Foam filled caster tire $70.86E2387 RR IN Foam filled caster tire $6.11E2387 RR KE IN Foam filled caster tire $7.09E2387 UE IN Foam filled caster tire $45.84E2387 UE KE IN Foam filled caster tire $53.18

Page 27: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E2388 NU IN Foam drive wheel tire $45.60E2388 NU KE IN Foam drive wheel tire $52.91E2388 RR IN Foam drive wheel tire $4.56E2388 RR KE IN Foam drive wheel tire $5.29E2388 UE IN Foam drive wheel tire $34.21E2388 UE KE IN Foam drive wheel tire $39.69E2389 NU IN Foam caster tire $24.76E2389 NU KE IN Foam caster tire $28.73E2389 RR IN Foam caster tire $2.48E2389 RR KE IN Foam caster tire $2.88E2389 UE IN Foam caster tire $18.56E2389 UE KE IN Foam caster tire $21.54E2390 NU IN Solid drive wheel tire $38.72E2390 NU KE IN Solid drive wheel tire $44.93E2390 RR IN Solid drive wheel tire $3.87E2390 RR KE IN Solid drive wheel tire $4.49E2390 UE IN Solid drive wheel tire $29.02E2390 UE KE IN Solid drive wheel tire $33.67E2391 NU IN Solid caster tire $18.55E2391 NU KE IN Solid caster tire $21.53E2391 RR IN Solid caster tire $1.86E2391 RR KE IN Solid caster tire $2.15E2391 UE IN Solid caster tire $13.92E2391 UE KE IN Solid caster tire $16.15E2392 NU IN Solid caster tire, integrate $48.76E2392 NU KE IN Solid caster tire, integrate $56.57E2392 RR IN Solid caster tire, integrate $4.89E2392 RR KE IN Solid caster tire, integrate $5.67E2392 UE IN Solid caster tire, integrate $36.57E2392 UE KE IN Solid caster tire, integrate $42.43E2394 NU IN Drive wheel excludes tire $69.46E2394 NU KE IN Drive wheel excludes tire $80.59E2394 RR IN Drive wheel excludes tire $6.96E2394 RR KE IN Drive wheel excludes tire $8.07E2394 UE IN Drive wheel excludes tire $52.10E2394 UE KE IN Drive wheel excludes tire $60.45E2395 NU IN Caster wheel excludes tire $49.37E2395 NU KE IN Caster wheel excludes tire $57.28E2395 RR IN Caster wheel excludes tire $4.94E2395 RR KE IN Caster wheel excludes tire $5.73E2395 UE IN Caster wheel excludes tire $37.04E2395 UE KE IN Caster wheel excludes tire $42.98E2396 NU IN Caster fork $60.19E2396 NU KE IN Caster fork $69.84E2396 RR IN Caster fork $6.45E2396 RR KE IN Caster fork $7.49E2396 UE IN Caster fork $45.15E2396 UE KE IN Caster fork $52.38E2397 NU IN Pwc acc, lith-based battery $434.84E2397 RR IN Pwc acc, lith-based battery $43.48E2397 UE IN Pwc acc, lith-based battery $326.12E2402 RR CR Neg press wound therapy pump $1,553.40E2500 NU IN SGD digitized pre-rec <=8min $410.61E2500 RR IN SGD digitized pre-rec <=8min $41.07E2500 UE IN SGD digitized pre-rec <=8min $307.95E2502 NU IN SGD prerec msg >8min <=20min $1,255.59E2502 RR IN SGD prerec msg >8min <=20min $125.57E2502 UE IN SGD prerec msg >8min <=20min $941.70E2504 NU IN SGD prerec msg>20min <=40min $1,656.29E2504 RR IN SGD prerec msg>20min <=40min $165.65

Page 28: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E2504 UE IN SGD prerec msg>20min <=40min $1,242.20E2506 NU IN SGD prerec msg > 40 min $2,428.61E2506 RR IN SGD prerec msg > 40 min $242.85E2506 UE IN SGD prerec msg > 40 min $1,821.42E2508 NU IN SGD spelling phys contact $3,755.44E2508 RR IN SGD spelling phys contact $375.55E2508 UE IN SGD spelling phys contact $2,816.59E2510 NU IN SGD w multi methods msg/accs $7,106.66E2510 RR IN SGD w multi methods msg/accs $710.66E2510 UE IN SGD w multi methods msg/accs $5,329.99E2511 NU IN SGD sftwre prgrm for PC/PDA $0.00E2511 RR IN SGD sftwre prgrm for PC/PDA $0.00E2511 UE IN SGD sftwre prgrm for PC/PDA $0.00E2512 NU IN SGD accessory, mounting sys $0.00E2512 RR IN SGD accessory, mounting sys $0.00E2512 UE IN SGD accessory, mounting sys $0.00E2601 NU IN Gen w/c cushion wdth < 22 in $55.35E2601 NU KE IN Gen w/c cushion wdth < 22 in $64.22E2601 RR IN Gen w/c cushion wdth < 22 in $5.55E2601 RR KE IN Gen w/c cushion wdth < 22 in $6.44E2601 UE IN Gen w/c cushion wdth < 22 in $41.51E2601 UE KE IN Gen w/c cushion wdth < 22 in $48.16E2602 NU IN Gen w/c cushion wdth >=22 in $108.06E2602 NU KE IN Gen w/c cushion wdth >=22 in $125.37E2602 RR IN Gen w/c cushion wdth >=22 in $10.81E2602 RR KE IN Gen w/c cushion wdth >=22 in $12.54E2602 UE IN Gen w/c cushion wdth >=22 in $81.04E2602 UE KE IN Gen w/c cushion wdth >=22 in $94.03E2603 NU IN Skin protect wc cus wd <22in $137.19E2603 NU KE IN Skin protect wc cus wd <22in $159.17E2603 RR IN Skin protect wc cus wd <22in $13.73E2603 RR KE IN Skin protect wc cus wd <22in $15.93E2603 UE IN Skin protect wc cus wd <22in $102.89E2603 UE KE IN Skin protect wc cus wd <22in $119.37E2604 NU IN Skin protect wc cus wd>=22in $170.51E2604 NU KE IN Skin protect wc cus wd>=22in $197.83E2604 RR IN Skin protect wc cus wd>=22in $17.04E2604 RR KE IN Skin protect wc cus wd>=22in $19.77E2604 UE IN Skin protect wc cus wd>=22in $127.90E2604 UE KE IN Skin protect wc cus wd>=22in $148.40E2605 NU IN Position wc cush wdth <22 in $243.60E2605 NU KE IN Position wc cush wdth <22 in $282.63E2605 RR IN Position wc cush wdth <22 in $24.37E2605 RR KE IN Position wc cush wdth <22 in $28.28E2605 UE IN Position wc cush wdth <22 in $182.73E2605 UE KE IN Position wc cush wdth <22 in $212.01E2606 NU IN Position wc cush wdth>=22 in $380.04E2606 NU KE IN Position wc cush wdth>=22 in $440.93E2606 RR IN Position wc cush wdth>=22 in $38.02E2606 RR KE IN Position wc cush wdth>=22 in $44.11E2606 UE IN Position wc cush wdth>=22 in $285.02E2606 UE KE IN Position wc cush wdth>=22 in $330.69E2607 NU IN Skin pro/pos wc cus wd <22in $262.31E2607 NU KE IN Skin pro/pos wc cus wd <22in $304.34E2607 RR IN Skin pro/pos wc cus wd <22in $26.24E2607 RR KE IN Skin pro/pos wc cus wd <22in $30.44E2607 UE IN Skin pro/pos wc cus wd <22in $196.74E2607 UE KE IN Skin pro/pos wc cus wd <22in $228.26E2608 NU IN Skin pro/pos wc cus wd>=22in $315.02E2608 NU KE IN Skin pro/pos wc cus wd>=22in $365.49

Page 29: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

E2608 RR IN Skin pro/pos wc cus wd>=22in $31.49E2608 RR KE IN Skin pro/pos wc cus wd>=22in $36.54E2608 UE IN Skin pro/pos wc cus wd>=22in $236.27E2608 UE KE IN Skin pro/pos wc cus wd>=22in $274.12E2611 NU IN Gen use back cush wdth <22in $282.68E2611 NU KE IN Gen use back cush wdth <22in $327.97E2611 RR IN Gen use back cush wdth <22in $28.26E2611 RR KE IN Gen use back cush wdth <22in $32.79E2611 UE IN Gen use back cush wdth <22in $212.03E2611 UE KE IN Gen use back cush wdth <22in $246.00E2612 NU IN Gen use back cush wdth>=22in $382.40E2612 NU KE IN Gen use back cush wdth>=22in $443.67E2612 RR IN Gen use back cush wdth>=22in $38.24E2612 RR KE IN Gen use back cush wdth>=22in $44.36E2612 UE IN Gen use back cush wdth>=22in $286.79E2612 UE KE IN Gen use back cush wdth>=22in $332.73E2613 NU IN Position back cush wd <22in $355.70E2613 NU KE IN Position back cush wd <22in $412.69E2613 RR IN Position back cush wd <22in $35.58E2613 RR KE IN Position back cush wd <22in $41.28E2613 UE IN Position back cush wd <22in $266.78E2613 UE KE IN Position back cush wd <22in $309.52E2614 NU IN Position back cush wd>=22in $492.26E2614 NU KE IN Position back cush wd>=22in $571.13E2614 RR IN Position back cush wd>=22in $49.23E2614 RR KE IN Position back cush wd>=22in $57.12E2614 UE IN Position back cush wd>=22in $369.21E2614 UE KE IN Position back cush wd>=22in $428.37E2615 NU IN Pos back post/lat wdth <22in $409.35E2615 NU KE IN Pos back post/lat wdth <22in $474.94E2615 RR IN Pos back post/lat wdth <22in $40.94E2615 RR KE IN Pos back post/lat wdth <22in $47.50E2615 UE IN Pos back post/lat wdth <22in $307.00E2615 UE KE IN Pos back post/lat wdth <22in $356.19E2616 NU IN Pos back post/lat wdth>=22in $550.76E2616 NU KE IN Pos back post/lat wdth>=22in $639.01E2616 RR IN Pos back post/lat wdth>=22in $55.08E2616 RR KE IN Pos back post/lat wdth>=22in $63.90E2616 UE IN Pos back post/lat wdth>=22in $413.09E2616 UE KE IN Pos back post/lat wdth>=22in $479.27E2619 NU IN Replace cover w/c seat cush $46.44E2619 NU KE IN Replace cover w/c seat cush $53.89E2619 RR IN Replace cover w/c seat cush $4.64E2619 RR KE IN Replace cover w/c seat cush $5.39E2619 UE IN Replace cover w/c seat cush $34.85E2619 UE KE IN Replace cover w/c seat cush $40.44E2620 NU IN WC planar back cush wd <22in $495.67E2620 NU KE IN WC planar back cush wd <22in $575.09E2620 RR IN WC planar back cush wd <22in $49.57E2620 RR KE IN WC planar back cush wd <22in $57.51E2620 UE IN WC planar back cush wd <22in $371.76E2620 UE KE IN WC planar back cush wd <22in $431.33E2621 NU IN WC planar back cush wd>=22in $520.16E2621 NU KE IN WC planar back cush wd>=22in $603.50E2621 RR IN WC planar back cush wd>=22in $52.01E2621 RR KE IN WC planar back cush wd>=22in $60.34E2621 UE IN WC planar back cush wd>=22in $390.13E2621 UE KE IN WC planar back cush wd>=22in $452.63K0001 RR CR Standard wheelchair $55.10K0002 RR CR Stnd hemi (low seat) whlchr $85.92

Page 30: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

K0003 RR CR Lightweight wheelchair $94.07K0004 RR CR High strength ltwt whlchr $119.83K0005 NU IN Ultralightweight wheelchair $1,941.20K0005 RR IN Ultralightweight wheelchair $194.10K0005 UE IN Ultralightweight wheelchair $1,455.88K0006 RR CR Heavy duty wheelchair $128.51K0007 RR CR Extra heavy duty wheelchair $178.30K0010 RR CR Stnd wt frame power whlchr $380.20K0011 RR CR Stnd wt pwr whlchr w control $521.87K0011 RR KF CR Stnd wt pwr whlchr w control $579.42K0012 RR CR Ltwt portbl power whlchr $320.12K0015 NU IN Detach non-adjus hght armrst $164.44K0015 NU KE IN Detach non-adjus hght armrst $190.79K0015 RR IN Detach non-adjus hght armrst $16.45K0015 RR KE IN Detach non-adjus hght armrst $19.09K0015 UE IN Detach non-adjus hght armrst $123.32K0015 UE KE IN Detach non-adjus hght armrst $143.08K0017 NU IN Detach adjust armrest base $46.25K0017 NU KE IN Detach adjust armrest base $53.67K0017 RR IN Detach adjust armrest base $4.62K0017 RR KE IN Detach adjust armrest base $5.37K0017 UE IN Detach adjust armrest base $34.69K0017 UE KE IN Detach adjust armrest base $40.25K0018 NU IN Detach adjust armrst upper $25.84K0018 NU KE IN Detach adjust armrst upper $29.98K0018 RR IN Detach adjust armrst upper $2.57K0018 RR KE IN Detach adjust armrst upper $2.98K0018 UE IN Detach adjust armrst upper $19.39K0018 UE KE IN Detach adjust armrst upper $22.50K0019 NU IN Arm pad each $14.80K0019 NU KE IN Arm pad each $17.17K0019 RR IN Arm pad each $1.48K0019 RR KE IN Arm pad each $1.72K0019 UE IN Arm pad each $11.09K0019 UE KE IN Arm pad each $12.86K0020 NU IN Fixed adjust armrest pair $42.05K0020 NU KE IN Fixed adjust armrest pair $48.78K0020 RR IN Fixed adjust armrest pair $4.21K0020 RR KE IN Fixed adjust armrest pair $4.88K0020 UE IN Fixed adjust armrest pair $31.52K0020 UE KE IN Fixed adjust armrest pair $36.57K0037 NU IN High mount flip-up footrest $43.58K0037 NU KE IN High mount flip-up footrest $50.57K0037 RR IN High mount flip-up footrest $3.89K0037 RR KE IN High mount flip-up footrest $4.52K0037 UE IN High mount flip-up footrest $32.70K0037 UE KE IN High mount flip-up footrest $37.94K0038 NU IN Leg strap each $21.96K0038 NU KE IN Leg strap each $25.47K0038 RR IN Leg strap each $2.20K0038 RR KE IN Leg strap each $2.55K0038 UE IN Leg strap each $16.47K0038 UE KE IN Leg strap each $19.11K0039 NU IN Leg strap h style each $48.76K0039 NU KE IN Leg strap h style each $56.57K0039 RR IN Leg strap h style each $4.89K0039 RR KE IN Leg strap h style each $5.67K0039 UE IN Leg strap h style each $36.57K0039 UE KE IN Leg strap h style each $42.43K0040 NU IN Adjustable angle footplate $67.58

Page 31: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

K0040 NU KE IN Adjustable angle footplate $78.40K0040 RR IN Adjustable angle footplate $6.74K0040 RR KE IN Adjustable angle footplate $7.82K0040 UE IN Adjustable angle footplate $50.67K0040 UE KE IN Adjustable angle footplate $58.79K0041 NU IN Large size footplate each $47.89K0041 NU KE IN Large size footplate each $55.57K0041 RR IN Large size footplate each $4.81K0041 RR KE IN Large size footplate each $5.58K0041 UE IN Large size footplate each $35.92K0041 UE KE IN Large size footplate each $41.67K0042 NU IN Standard size footplate each $32.97K0042 NU KE IN Standard size footplate each $38.25K0042 RR IN Standard size footplate each $3.29K0042 RR KE IN Standard size footplate each $3.81K0042 UE IN Standard size footplate each $24.72K0042 UE KE IN Standard size footplate each $28.69K0043 NU IN Ftrst lower extension tube $17.67K0043 NU KE IN Ftrst lower extension tube $20.51K0043 RR IN Ftrst lower extension tube $1.76K0043 RR KE IN Ftrst lower extension tube $2.05K0043 UE IN Ftrst lower extension tube $13.27K0043 UE KE IN Ftrst lower extension tube $15.39K0044 NU IN Ftrst upper hanger bracket $15.06K0044 NU KE IN Ftrst upper hanger bracket $17.47K0044 RR IN Ftrst upper hanger bracket $1.51K0044 RR KE IN Ftrst upper hanger bracket $1.75K0044 UE IN Ftrst upper hanger bracket $11.29K0044 UE KE IN Ftrst upper hanger bracket $13.10K0045 NU IN Footrest complete assembly $51.24K0045 NU KE IN Footrest complete assembly $59.45K0045 RR IN Footrest complete assembly $5.13K0045 RR KE IN Footrest complete assembly $5.95K0045 UE IN Footrest complete assembly $38.44K0045 UE KE IN Footrest complete assembly $44.59K0046 NU IN Elevat legrst low extension $17.67K0046 NU KE IN Elevat legrst low extension $20.51K0046 RR IN Elevat legrst low extension $1.76K0046 RR KE IN Elevat legrst low extension $2.05K0046 UE IN Elevat legrst low extension $13.27K0046 UE KE IN Elevat legrst low extension $15.39K0047 NU IN Elevat legrst up hangr brack $69.21K0047 NU KE IN Elevat legrst up hangr brack $80.30K0047 RR IN Elevat legrst up hangr brack $6.94K0047 RR KE IN Elevat legrst up hangr brack $8.05K0047 UE IN Elevat legrst up hangr brack $51.89K0047 UE KE IN Elevat legrst up hangr brack $60.21K0050 NU IN Ratchet assembly $29.41K0050 NU KE IN Ratchet assembly $34.13K0050 RR IN Ratchet assembly $2.93K0050 RR KE IN Ratchet assembly $3.40K0050 UE IN Ratchet assembly $22.07K0050 UE KE IN Ratchet assembly $25.61K0051 NU IN Cam relese assem ftrst/lgrst $47.61K0051 NU KE IN Cam relese assem ftrst/lgrst $55.24K0051 RR IN Cam relese assem ftrst/lgrst $4.79K0051 RR KE IN Cam relese assem ftrst/lgrst $5.55K0051 UE IN Cam relese assem ftrst/lgrst $35.69K0051 UE KE IN Cam relese assem ftrst/lgrst $41.41K0052 NU IN Swingaway detach footrest $83.66

Page 32: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

K0052 NU KE IN Swingaway detach footrest $97.06K0052 RR IN Swingaway detach footrest $8.36K0052 RR KE IN Swingaway detach footrest $9.70K0052 UE IN Swingaway detach footrest $62.73K0052 UE KE IN Swingaway detach footrest $72.79K0053 NU IN Elevate footrest articulate $92.32K0053 NU KE IN Elevate footrest articulate $107.11K0053 RR IN Elevate footrest articulate $9.22K0053 RR KE IN Elevate footrest articulate $10.70K0053 UE IN Elevate footrest articulate $69.24K0053 UE KE IN Elevate footrest articulate $80.34K0056 NU IN Seat ht <17 or >=21 ltwt wc $99.86K0056 RR IN Seat ht <17 or >=21 ltwt wc $9.99K0056 UE IN Seat ht <17 or >=21 ltwt wc $74.91K0065 NU IN Spoke protectors $46.68K0065 RR IN Spoke protectors $4.67K0065 UE IN Spoke protectors $35.01K0069 NU IN Rear whl complete solid tire $104.92K0069 RR IN Rear whl complete solid tire $10.49K0069 UE IN Rear whl complete solid tire $78.69K0070 NU IN Rear whl compl pneum tire $192.32K0070 RR IN Rear whl compl pneum tire $19.25K0070 UE IN Rear whl compl pneum tire $144.24K0071 NU IN Front castr compl pneum tire $114.71K0071 RR IN Front castr compl pneum tire $11.48K0071 UE IN Front castr compl pneum tire $86.02K0072 NU IN Frnt cstr cmpl sem-pneum tir $69.05K0072 RR IN Frnt cstr cmpl sem-pneum tir $6.90K0072 UE IN Frnt cstr cmpl sem-pneum tir $51.79K0073 NU IN Caster pin lock each $36.54K0073 RR IN Caster pin lock each $3.65K0073 UE IN Caster pin lock each $27.41K0077 NU IN Front caster assem complete $61.79K0077 RR IN Front caster assem complete $6.17K0077 UE IN Front caster assem complete $46.34K0098 NU IN Drive belt power wheelchair $24.63K0098 NU KE IN Drive belt power wheelchair $28.57K0098 RR IN Drive belt power wheelchair $2.46K0098 RR KE IN Drive belt power wheelchair $2.86K0098 UE IN Drive belt power wheelchair $18.45K0098 UE KE IN Drive belt power wheelchair $21.41K0105 NU IN Iv hanger $104.40K0105 RR IN Iv hanger $10.43K0105 UE IN Iv hanger $78.30K0195 RR CR Elevating whlchair leg rests $16.21K0195 RR KE CR Elevating whlchair leg rests $18.80K0455 RR FS Pump uninterrupted infusion $236.39K0552 SU Supply/ext inf pump syr type $2.78K0601 NU IN Repl batt silver oxide 1.5 v $1.16K0602 NU IN Repl batt silver oxide 3 v $6.68K0603 NU IN Repl batt alkaline 1.5 v $0.60K0604 NU IN Repl batt lithium 3.6 v $6.39K0605 NU IN Repl batt lithium 4.5 v $15.33K0606 RR KF CR AED garment w elec analysis $2,644.18K0607 NU IN Repl batt for AED $203.94K0607 NU KF IN Repl batt for AED $226.42K0607 RR IN Repl batt for AED $20.40K0607 RR KF IN Repl batt for AED $22.65K0607 UE IN Repl batt for AED $152.95K0607 UE KF IN Repl batt for AED $169.82

Page 33: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

K0608 NU IN Repl garment for AED $127.27K0608 NU KF IN Repl garment for AED $141.31K0608 RR IN Repl garment for AED $12.75K0608 RR KF IN Repl garment for AED $14.14K0608 UE IN Repl garment for AED $95.46K0608 UE KF IN Repl garment for AED $105.98K0609 SU Repl electrode for AED $846.39K0609 KF SU Repl electrode for AED $939.71K0672 PO Removable soft interface LE $74.92K0730 NU IN Ctrl dose inh drug deliv sys $1,810.22K0730 RR IN Ctrl dose inh drug deliv sys $181.02K0730 UE IN Ctrl dose inh drug deliv sys $1,357.66K0733 NU IN 12-24hr sealed lead acid $27.34K0733 NU KE IN 12-24hr sealed lead acid $31.72K0733 RR IN 12-24hr sealed lead acid $2.75K0733 RR KE IN 12-24hr sealed lead acid $3.19K0733 UE IN 12-24hr sealed lead acid $20.52K0733 UE KE IN 12-24hr sealed lead acid $23.80K0734 NU IN Adj skin pro w/c cus wd<22in $299.98K0734 NU KE IN Adj skin pro w/c cus wd<22in $348.04K0734 RR IN Adj skin pro w/c cus wd<22in $30.00K0734 RR KE IN Adj skin pro w/c cus wd<22in $34.81K0734 UE IN Adj skin pro w/c cus wd<22in $224.98K0734 UE KE IN Adj skin pro w/c cus wd<22in $261.03K0735 NU IN Adj skin pro wc cus wd>=22in $381.71K0735 NU KE IN Adj skin pro wc cus wd>=22in $442.87K0735 RR IN Adj skin pro wc cus wd>=22in $38.18K0735 RR KE IN Adj skin pro wc cus wd>=22in $44.30K0735 UE IN Adj skin pro wc cus wd>=22in $286.28K0735 UE KE IN Adj skin pro wc cus wd>=22in $332.15K0736 NU IN Adj skin pro/pos wc cus<22in $302.44K0736 NU KE IN Adj skin pro/pos wc cus<22in $350.90K0736 RR IN Adj skin pro/pos wc cus<22in $30.25K0736 RR KE IN Adj skin pro/pos wc cus<22in $35.09K0736 UE IN Adj skin pro/pos wc cus<22in $226.85K0736 UE KE IN Adj skin pro/pos wc cus<22in $263.19K0737 NU IN Adj skin pro/pos wc cus>=22" $382.87K0737 NU KE IN Adj skin pro/pos wc cus>=22" $444.21K0737 RR IN Adj skin pro/pos wc cus>=22" $38.28K0737 RR KE IN Adj skin pro/pos wc cus>=22" $44.42K0737 UE IN Adj skin pro/pos wc cus>=22" $287.15K0737 UE KE IN Adj skin pro/pos wc cus>=22" $333.15K0738 RR OX Portable gas oxygen system $51.63K0800 NU IN POV group 1 std up to 300lbs $1,169.96K0800 RR IN POV group 1 std up to 300lbs $117.00K0800 UE IN POV group 1 std up to 300lbs $877.47K0801 NU IN POV group 1 hd 301-450 lbs $1,886.22K0801 RR IN POV group 1 hd 301-450 lbs $188.60K0801 UE IN POV group 1 hd 301-450 lbs $1,414.65K0802 NU IN POV group 1 vhd 451-600 lbs $2,134.59K0802 RR IN POV group 1 vhd 451-600 lbs $213.45K0802 UE IN POV group 1 vhd 451-600 lbs $1,600.95K0806 NU IN POV group 2 std up to 300lbs $1,415.34K0806 RR IN POV group 2 std up to 300lbs $141.53K0806 UE IN POV group 2 std up to 300lbs $1,061.50K0807 NU IN POV group 2 hd 301-450 lbs $2,147.61K0807 RR IN POV group 2 hd 301-450 lbs $214.76K0807 UE IN POV group 2 hd 301-450 lbs $1,610.72K0808 NU IN POV group 2 vhd 451-600 lbs $3,322.80K0808 RR IN POV group 2 vhd 451-600 lbs $332.27

Page 34: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

K0808 UE IN POV group 2 vhd 451-600 lbs $2,492.09K0813 RR CR PWC gp 1 std port seat/back $218.32K0814 RR CR PWC gp 1 std port cap chair $279.45K0815 RR CR PWC gp 1 std seat/back $318.23K0816 RR CR PWC gp 1 std cap chair $304.75K0820 RR CR PWC gp 2 std port seat/back $233.18K0821 RR CR PWC gp 2 std port cap chair $299.35K0822 RR CR PWC gp 2 std seat/back $361.77K0823 RR CR PWC gp 2 std cap chair $364.14K0824 RR CR PWC gp 2 hd seat/back $438.26K0825 RR CR PWC gp 2 hd cap chair $401.20K0826 RR CR PWC gp 2 vhd seat/back $567.37K0827 RR CR PWC gp vhd cap chair $482.45K0828 RR CR PWC gp 2 xtra hd seat/back $625.19K0829 RR CR PWC gp 2 xtra hd cap chair $574.10K0835 RR CR PWC gp2 std sing pow opt s/b $367.19K0836 RR CR PWC gp2 std sing pow opt cap $380.78K0837 RR CR PWC gp 2 hd sing pow opt s/b $438.26K0838 RR CR PWC gp 2 hd sing pow opt cap $392.07K0839 RR CR PWC gp2 vhd sing pow opt s/b $567.37K0840 RR CR PWC gp2 xhd sing pow opt s/b $859.60K0841 RR CR PWC gp2 std mult pow opt s/b $390.83K0842 RR CR PWC gp2 std mult pow opt cap $390.83K0843 RR CR PWC gp2 hd mult pow opt s/b $470.56K0848 RR CR PWC gp 3 std seat/back $478.24K0849 RR CR PWC gp 3 std cap chair $459.80K0850 RR CR PWC gp 3 hd seat/back $554.75K0851 RR CR PWC gp 3 hd cap chair $533.38K0852 RR CR PWC gp 3 vhd seat/back $640.98K0853 RR CR PWC gp 3 vhd cap chair $658.44K0854 RR CR PWC gp 3 xhd seat/back $872.29K0855 RR CR PWC gp 3 xhd cap chair $824.01K0856 RR CR PWC gp3 std sing pow opt s/b $513.34K0857 RR CR PWC gp3 std sing pow opt cap $523.63K0858 RR CR PWC gp3 hd sing pow opt s/b $636.90K0859 RR CR PWC gp3 hd sing pow opt cap $607.41K0860 RR CR PWC gp3 vhd sing pow opt s/b $909.90K0861 RR CR PWC gp3 std mult pow opt s/b $514.17K0861 RR KF CR PWC gp3 std mult pow opt s/b $662.31K0862 RR CR PWC gp3 hd mult pow opt s/b $636.90K0863 RR CR PWC gp3 vhd mult pow opt s/b $909.90K0864 RR CR PWC gp3 xhd mult pow opt s/b $1,082.79L0112 PO Cranial cervical orthosis $1,236.93L0113 PO Cranial cervical torticollis $252.02L0120 PO Cerv flexible non-adjustable $22.46L0130 PO Flex thermoplastic collar mo $184.17L0140 PO Cervical semi-rigid adjustab $54.20L0150 PO Cerv semi-rig adj molded chn $104.69L0160 PO Cerv semi-rig wire occ/mand $141.88L0170 PO Cervical collar molded to pt $546.01L0172 PO Cerv col thermplas foam 2 pi $123.90L0174 PO Cerv col foam 2 piece w thor $232.58L0180 PO Cer post col occ/man sup adj $343.37L0190 PO Cerv collar supp adj cerv ba $459.91L0200 PO Cerv col supp adj bar & thor $442.87L0220 PO Thor rib belt custom fabrica $130.69L0430 PO Dewall posture protector $1,258.46L0450 PO TLSO flex prefab thoracic $172.35L0452 PO tlso flex custom fab thoraci $0.00L0454 PO TLSO flex prefab sacrococ-T9 $306.51

Page 35: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L0456 PO TLSO flex prefab $878.98L0458 PO TLSO 2Mod symphis-xipho pre $788.16L0460 PO TLSO2Mod symphysis-stern pre $887.12L0462 PO TLSO 3Mod sacro-scap pre $1,103.45L0464 PO TLSO 4Mod sacro-scap pre $1,313.63L0466 PO TLSO rigid frame pre soft ap $316.31L0468 PO TLSO rigid frame prefab pelv $388.08L0470 PO TLSO rigid frame pre subclav $629.34L0472 PO TLSO rigid frame hyperex pre $409.96L0480 PO TLSO rigid plastic custom fa $1,455.56L0482 PO TLSO rigid lined custom fab $1,622.12L0484 PO TLSO rigid plastic cust fab $1,611.53L0486 PO TLSO rigidlined cust fab two $1,713.40L0488 PO TLSO rigid lined pre one pie $887.12L0490 PO TLSO rigid plastic pre one $250.01L0491 PO TLSO 2 piece rigid shell $678.74L0492 PO TLSO 3 piece rigid shell $445.87L0621 PO SIO flex pelvisacral prefab $81.90L0622 PO SIO flex pelvisacral custom $218.72L0623 PO SIO panel prefab $0.00L0624 PO SIO panel custom $0.00L0625 PO LO flexibl L1-below L5 pre $48.67L0626 PO LO sag stays/panels pre-fab $68.88L0627 PO LO sagitt rigid panel prefab $363.27L0628 PO LO flex w/o rigid stays pre $74.14L0629 PO LSO flex w/rigid stays cust $0.00L0630 PO LSO post rigid panel pre $143.13L0631 PO LSO sag-coro rigid frame pre $907.25L0632 PO LSO sag rigid frame cust $0.00L0633 PO LSO flexion control prefab $253.42L0634 PO LSO flexion control custom $0.00L0635 PO LSO sagit rigid panel prefab $861.51L0636 PO LSO sagittal rigid panel cus $1,277.69L0637 PO LSO sag-coronal panel prefab $949.40L0638 PO LSO sag-coronal panel custom $1,165.59L0639 PO LSO s/c shell/panel prefab $949.40L0640 PO LSO s/c shell/panel custom $924.76L0700 PO Ctlso a-p-l control molded $1,711.65L0710 PO Ctlso a-p-l control w/ inter $1,776.81L0810 PO Halo cervical into jckt vest $2,217.73L0820 PO Halo cervical into body jack $1,828.81L0830 PO Halo cerv into milwaukee typ $2,654.88L0859 PO MRI compatible system $1,031.40L0861 PO Halo repl liner/interface $190.48L0970 PO Tlso corset front $100.15L0972 PO Lso corset front $96.54L0974 PO Tlso full corset $151.58L0976 PO Lso full corset $135.38L0978 PO Axillary crutch extension $162.97L0980 PO Peroneal straps pair $14.78L0982 PO Stocking supp grips set of f $13.78L0984 PO Protective body sock each $55.43L1000 PO Ctlso milwauke initial model $1,718.88L1001 PO CTLSO infant immobilizer $0.00L1005 PO Tension based scoliosis orth $2,828.58L1010 PO Ctlso axilla sling $56.82L1020 PO Kyphosis pad $73.18L1025 PO Kyphosis pad floating $140.77L1030 PO Lumbar bolster pad $53.86L1040 PO Lumbar or lumbar rib pad $66.05

Page 36: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L1050 PO Sternal pad $70.49L1060 PO Thoracic pad $80.97L1070 PO Trapezius sling $76.18L1080 PO Outrigger $46.86L1085 PO Outrigger bil w/ vert extens $130.32L1090 PO Lumbar sling $85.17L1100 PO Ring flange plastic/leather $138.22L1110 PO Ring flange plas/leather mol $216.23L1120 PO Covers for upright each $33.62L1200 PO Furnsh initial orthosis only $1,326.54L1210 PO Lateral thoracic extension $295.37L1220 PO Anterior thoracic extension $250.09L1230 PO Milwaukee type superstructur $641.70L1240 PO Lumbar derotation pad $66.35L1250 PO Anterior asis pad $61.17L1260 PO Anterior thoracic derotation $64.05L1270 PO Abdominal pad $65.60L1280 PO Rib gusset (elastic) each $78.46L1290 PO Lateral trochanteric pad $66.54L1300 PO Body jacket mold to patient $1,885.67L1310 PO Post-operative body jacket $1,878.10L1500 PO Thkao mobility frame $1,608.16L1510 PO Thkao standing frame $1,356.53L1520 PO Thkao swivel walker $2,516.64L1600 PO Abduct hip flex frejka w cvr $109.10L1610 PO Abduct hip flex frejka covr $40.61L1620 PO Abduct hip flex pavlik harne $125.53L1630 PO Abduct control hip semi-flex $143.46L1640 PO Pelv band/spread bar thigh c $456.47L1650 PO HO abduction hip adjustable $196.02L1652 PO HO bi thighcuffs w sprdr bar $315.03L1660 PO HO abduction static plastic $144.89L1680 PO Pelvic & hip control thigh c $1,031.57L1685 PO Post-op hip abduct custom fa $1,007.06L1686 PO HO post-op hip abduction $1,029.73L1690 PO Combination bilateral HO $1,708.96L1700 PO Leg perthes orth toronto typ $1,292.91L1710 PO Legg perthes orth newington $1,513.50L1720 PO Legg perthes orthosis trilat $1,115.63L1730 PO Legg perthes orth scottish r $983.88L1755 PO Legg perthes patten bottom t $1,379.70L1810 PO Ko elastic with joints $90.95L1820 PO Ko elas w/ condyle pads & jo $124.61L1830 PO Ko immobilizer canvas longit $87.80L1831 PO Knee orth pos locking joint $260.10L1832 PO KO adj jnt pos rigid support $686.31L1834 PO Ko w/0 joint rigid molded to $744.08L1836 PO Rigid KO wo joints $117.92L1840 PO Ko derot ant cruciate custom $876.12L1843 PO KO single upright custom fit $792.96L1844 PO Ko w/adj jt rot cntrl molded $1,384.28L1845 PO Ko w/ adj flex/ext rotat cus $869.76L1846 PO Ko w adj flex/ext rotat mold $1,141.23L1847 PO KO adjustable w air chambers $508.31L1850 PO Ko swedish type $267.60L1860 PO Ko supracondylar socket mold $1,106.55L1900 PO Afo sprng wir drsflx calf bd $228.40L1902 PO Afo ankle gauntlet $88.45L1904 PO Afo molded ankle gauntlet $411.73L1906 PO Afo multiligamentus ankle su $102.82

Page 37: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L1907 PO AFO supramalleolar custom $497.28L1910 PO Afo sing bar clasp attach sh $281.66L1920 PO Afo sing upright w/ adjust s $316.64L1930 PO Afo plastic $200.28L1932 PO Afo rig ant tib prefab TCF/= $788.63L1940 PO Afo molded to patient plasti $531.48L1945 PO Afo molded plas rig ant tib $783.73L1950 PO Afo spiral molded to pt plas $840.82L1951 PO AFO spiral prefabricated $742.21L1960 PO Afo pos solid ank plastic mo $625.71L1970 PO Afo plastic molded w/ankle j $799.03L1971 PO AFO w/ankle joint, prefab $414.24L1980 PO Afo sing solid stirrup calf $348.77L1990 PO Afo doub solid stirrup calf $450.06L2000 PO Kafo sing fre stirr thi/calf $968.33L2005 PO KAFO sng/dbl mechanical act $3,621.39L2010 PO Kafo sng solid stirrup w/o j $1,043.76L2020 PO Kafo dbl solid stirrup band/ $1,074.01L2030 PO Kafo dbl solid stirrup w/o j $1,101.22L2034 PO KAFO pla sin up w/wo k/a cus $1,842.24L2035 PO KAFO plastic pediatric size $155.72L2036 PO Kafo plas doub free knee mol $2,094.38L2037 PO Kafo plas sing free knee mol $1,853.19L2038 PO Kafo w/o joint multi-axis an $1,590.19L2040 PO Hkafo torsion bil rot straps $150.31L2050 PO Hkafo torsion cable hip pelv $413.47L2060 PO Hkafo torsion ball bearing j $520.42L2070 PO Hkafo torsion unilat rot str $114.59L2080 PO Hkafo unilat torsion cable $323.11L2090 PO Hkafo unilat torsion ball br $371.24L2106 PO Afo tib fx cast plaster mold $738.57L2108 PO Afo tib fx cast molded to pt $1,097.86L2112 PO Afo tibial fracture soft $501.71L2114 PO Afo tib fx semi-rigid $654.70L2116 PO Afo tibial fracture rigid $720.29L2126 PO Kafo fem fx cast thermoplas $1,351.75L2128 PO Kafo fem fx cast molded to p $1,749.02L2132 PO Kafo femoral fx cast soft $910.62L2134 PO Kafo fem fx cast semi-rigid $1,091.80L2136 PO Kafo femoral fx cast rigid $1,334.99L2180 PO Plas shoe insert w ank joint $99.15L2182 PO Drop lock knee $77.60L2184 PO Limited motion knee joint $104.88L2186 PO Adj motion knee jnt lerman t $140.15L2188 PO Quadrilateral brim $338.08L2190 PO Waist belt $79.61L2192 PO Pelvic band & belt thigh fla $385.26L2200 PO Limited ankle motion ea jnt $41.70L2210 PO Dorsiflexion assist each joi $62.19L2220 PO Dorsi & plantar flex ass/res $78.65L2230 PO Split flat caliper stirr & p $64.96L2232 PO Rocker bottom, contact AFO $87.95L2240 PO Round caliper and plate atta $70.80L2250 PO Foot plate molded stirrup at $300.84L2260 PO Reinforced solid stirrup $226.29L2265 PO Long tongue stirrup $99.70L2270 PO Varus/valgus strap padded/li $46.48L2275 PO Plastic mod low ext pad/line $106.72L2280 PO Molded inner boot $442.02L2300 PO Abduction bar jointed adjust $303.93

Page 38: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L2310 PO Abduction bar-straight $104.15L2320 PO Non-molded lacer $208.49L2330 PO Lacer molded to patient mode $443.25L2335 PO Anterior swing band $192.33L2340 PO Pre-tibial shell molded to p $411.27L2350 PO Prosthetic type socket molde $1,002.62L2360 PO Extended steel shank $58.41L2370 PO Patten bottom $289.79L2375 PO Torsion ank & half solid sti $95.66L2380 PO Torsion straight knee joint $104.23L2385 PO Straight knee joint heavy du $113.40L2387 PO Add LE poly knee custom KAFO $140.12L2390 PO Offset knee joint each $98.79L2395 PO Offset knee joint heavy duty $132.46L2397 PO Suspension sleeve lower ext $99.93L2405 PO Knee joint drop lock ea jnt $77.05L2415 PO Knee joint cam lock each joi $107.33L2425 PO Knee disc/dial lock/adj flex $126.68L2430 PO Knee jnt ratchet lock ea jnt $126.68L2492 PO Knee lift loop drop lock rin $98.36L2500 PO Thi/glut/ischia wgt bearing $267.09L2510 PO Th/wght bear quad-lat brim m $715.81L2520 PO Th/wght bear quad-lat brim c $480.56L2525 PO Th/wght bear nar m-l brim mo $1,187.84L2526 PO Th/wght bear nar m-l brim cu $579.90L2530 PO Thigh/wght bear lacer non-mo $259.22L2540 PO Thigh/wght bear lacer molded $365.67L2550 PO Thigh/wght bear high roll cu $295.50L2570 PO Hip clevis type 2 posit jnt $403.26L2580 PO Pelvic control pelvic sling $450.84L2600 PO Hip clevis/thrust bearing fr $173.88L2610 PO Hip clevis/thrust bearing lo $239.94L2620 PO Pelvic control hip heavy dut $301.83L2622 PO Hip joint adjustable flexion $259.63L2624 PO Hip adj flex ext abduct cont $300.21L2627 PO Plastic mold recipro hip & c $1,765.80L2628 PO Metal frame recipro hip & ca $1,823.23L2630 PO Pelvic control band & belt u $255.33L2640 PO Pelvic control band & belt b $379.36L2650 PO Pelv & thor control gluteal $104.32L2660 PO Thoracic control thoracic ba $157.80L2670 PO Thorac cont paraspinal uprig $178.37L2680 PO Thorac cont lat support upri $165.80L2750 PO Plating chrome/nickel pr bar $83.30L2755 PO Carbon graphite lamination $115.44L2760 PO Extension per extension per $63.27L2768 PO Ortho sidebar disconnect $115.14L2780 PO Non-corrosive finish $68.99L2785 PO Drop lock retainer each $31.59L2795 PO Knee control full kneecap $80.83L2800 PO Knee cap medial or lateral p $90.31L2810 PO Knee control condylar pad $66.13L2820 PO Soft interface below knee se $84.45L2830 PO Soft interface above knee se $97.94L2840 PO Tibial length sock fx or equ $43.76L2850 PO Femoral lgth sock fx or equa $56.28L3000 PO Ft insert ucb berkeley shell $277.61L3001 PO Foot insert remov molded spe $116.89L3002 PO Foot insert plastazote or eq $142.73L3003 PO Foot insert silicone gel eac $154.00

Page 39: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L3010 PO Foot longitudinal arch suppo $154.00L3020 PO Foot longitud/metatarsal sup $175.35L3030 PO Foot arch support remov prem $67.45L3031 PO Foot lamin/prepreg composite $0.00L3040 PO Ft arch suprt premold longit $41.58L3050 PO Foot arch supp premold metat $41.58L3060 PO Foot arch supp longitud/meta $65.19L3070 PO Arch suprt att to sho longit $28.07L3080 PO Arch supp att to shoe metata $28.07L3090 PO Arch supp att to shoe long/m $35.98L3100 PO Hallus-valgus nght dynamic s $38.21L3140 PO Abduction rotation bar shoe $78.69L3150 PO Abduct rotation bar w/o shoe $71.94L3170 PO Foot plastic heel stabilizer $44.98L3224 PO Woman's shoe oxford brace $54.83L3225 PO Man's shoe oxford brace $61.58L3300 PO Sho lift taper to metatarsal $46.07L3310 PO Shoe lift elev heel/sole neo $71.94L3330 PO Lifts elevation metal extens $500.16L3332 PO Shoe lifts tapered to one-ha $65.19L3334 PO Shoe lifts elevation heel /i $33.72L3340 PO Shoe wedge sach $75.32L3350 PO Shoe heel wedge $20.24L3360 PO Shoe sole wedge outside sole $31.47L3370 PO Shoe sole wedge between sole $43.81L3380 PO Shoe clubfoot wedge $43.81L3390 PO Shoe outflare wedge $43.81L3400 PO Shoe metatarsal bar wedge ro $35.98L3410 PO Shoe metatarsal bar between $82.04L3420 PO Full sole/heel wedge btween $48.33L3430 PO Sho heel count plast reinfor $141.62L3440 PO Heel leather reinforced $67.45L3450 PO Shoe heel sach cushion type $93.29L3455 PO Shoe heel new leather standa $35.98L3460 PO Shoe heel new rubber standar $30.33L3465 PO Shoe heel thomas with wedge $51.71L3470 PO Shoe heel thomas extend to b $55.07L3480 PO Shoe heel pad & depress for $55.07L3500 PO Ortho shoe add leather insol $25.85L3510 PO Orthopedic shoe add rub insl $25.85L3520 PO O shoe add felt w leath insl $28.07L3530 PO Ortho shoe add half sole $28.07L3540 PO Ortho shoe add full sole $44.98L3550 PO O shoe add standard toe tap $7.85L3560 PO O shoe add horseshoe toe tap $20.24L3570 PO O shoe add instep extension $75.32L3580 PO O shoe add instep velcro clo $57.32L3590 PO O shoe convert to sof counte $47.20L3595 PO Ortho shoe add march bar $37.09L3600 PO Trans shoe calip plate exist $67.45L3610 PO Trans shoe caliper plate new $88.78L3620 PO Trans shoe solid stirrup exi $67.45L3630 PO Trans shoe solid stirrup new $88.78L3640 PO Shoe dennis browne splint bo $38.21L3650 PO Shlder fig 8 abduct restrain $56.44L3660 PO Abduct restrainer canvas&web $87.15L3670 PO Acromio/clavicular canvas&we $111.07L3671 PO SO cap design w/o jnts CF $724.74L3672 PO SO airplane w/o jnts CF $901.26L3673 PO SO airplane w/joint CF $982.26

Page 40: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L3675 PO Canvas vest SO $141.14L3702 PO EO w/o joints CF $232.24L3710 PO Elbow elastic with metal joi $106.90L3720 PO Forearm/arm cuffs free motio $722.52L3730 PO Forearm/arm cuffs ext/flex a $974.00L3740 PO Cuffs adj lock w/ active con $1,092.33L3760 PO EO withjoint, Prefabricated $402.22L3762 PO Rigid EO wo joints $86.49L3763 PO EWHO rigid w/o jnts CF $619.76L3764 PO EWHO w/joint(s) CF $779.98L3765 PO EWHFO rigid w/o jnts CF $1,031.30L3766 PO EWHFO w/joint(s) CF $1,092.07L3806 PO WHFO w/joint(s) custom fab $365.35L3807 PO WHFO,no joint, prefabricated $201.12L3808 PO WHFO, rigid w/o joints $326.34L3900 PO Hinge extension/flex wrist/f $1,072.01L3901 PO Hinge ext/flex wrist finger $1,472.96L3904 PO Whfo electric custom fitted $2,426.16L3905 PO WHO w/nontorsion jnt(s) CF $797.64L3906 PO WHO w/o joints CF $338.28L3908 PO Wrist cock-up non-molded $66.19L3912 PO Flex glove w/elastic finger $78.57L3913 PO HFO w/o joints CF $217.84L3915 PO WHO w nontor jnt(s) prefab $427.53L3917 PO Prefab metacarpl fx orthosis $84.97L3919 PO HO w/o joints CF $217.84L3921 PO HFO w/joint(s) CF $258.36L3923 PO HFO w/o joints PF $72.07L3925 PO FO pip/dip with joint/spring $40.89L3927 PO FO pip/dip w/o joint/spring $28.10L3929 PO HFO nontorsion joint, prefab $64.76L3931 PO WHFO nontorsion joint prefab $158.21L3933 PO FO w/o joints CF $171.61L3935 PO FO nontorsion joint CF $177.68L3956 PO Add joint upper ext orthosis $0.00L3960 PO Sewho airplan desig abdu pos $624.54L3961 PO SEWHO cap design w/o jnts CF $1,351.31L3962 PO Sewho erbs palsey design abd $594.43L3964 NU IN Seo mobile arm sup att to wc $652.17L3964 RR IN Seo mobile arm sup att to wc $65.21L3964 UE IN Seo mobile arm sup att to wc $489.09L3965 NU IN Arm supp att to wc rancho ty $1,040.67L3965 RR IN Arm supp att to wc rancho ty $104.09L3965 UE IN Arm supp att to wc rancho ty $780.50L3966 NU IN Mobile arm supports reclinin $783.97L3966 RR IN Mobile arm supports reclinin $78.40L3966 UE IN Mobile arm supports reclinin $587.98L3967 PO SEWHO airplane w/o jnts CF $1,595.45L3968 NU IN Friction dampening arm supp $992.10L3968 RR IN Friction dampening arm supp $99.20L3968 UE IN Friction dampening arm supp $744.08L3969 NU IN Monosuspension arm/hand supp $675.03L3969 RR IN Monosuspension arm/hand supp $67.52L3969 UE IN Monosuspension arm/hand supp $506.29L3970 NU IN Elevat proximal arm support $277.53L3970 RR IN Elevat proximal arm support $27.75L3970 UE IN Elevat proximal arm support $208.14L3971 PO SEWHO cap design w/jnt(s) CF $1,514.45L3972 NU IN Offset/lat rocker arm w/ ela $176.47L3972 RR IN Offset/lat rocker arm w/ ela $17.65

Page 41: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L3972 UE IN Offset/lat rocker arm w/ ela $132.35L3973 PO SEWHO airplane w/jnt(s) CF $1,595.45L3974 NU IN Mobile arm support supinator $149.68L3974 RR IN Mobile arm support supinator $14.98L3974 UE IN Mobile arm support supinator $112.26L3975 PO SEWHFO cap design w/o jnt CF $1,351.31L3976 PO SEWHFO airplane w/o jnts CF $1,351.31L3977 PO SEWHFO cap desgn w/jnt(s) CF $1,514.45L3978 PO SEWHFO airplane w/jnt(s) CF $1,595.45L3980 PO Upp ext fx orthosis humeral $292.85L3982 PO Upper ext fx orthosis rad/ul $412.38L3984 PO Upper ext fx orthosis wrist $305.04L3995 PO Sock fracture or equal each $36.12L4000 PO Repl girdle milwaukee orth $1,079.50L4002 PO Replace strap, any orthosis $0.00L4010 PO Replace trilateral socket br $670.03L4020 PO Replace quadlat socket brim $930.03L4030 PO Replace socket brim cust fit $569.94L4040 PO Replace molded thigh lacer $408.64L4045 PO Replace non-molded thigh lac $277.72L4050 PO Replace molded calf lacer $466.04L4055 PO Replace non-molded calf lace $226.33L4060 PO Replace high roll cuff $269.06L4070 PO Replace prox & dist upright $238.27L4080 PO Repl met band kafo-afo prox $87.52L4090 PO Repl met band kafo-afo calf/ $91.00L4100 PO Repl leath cuff kafo prox th $109.71L4110 PO Repl leath cuff kafo-afo cal $94.65L4130 PO Replace pretibial shell $420.05L4350 PO Ankle control orthosi prefab $75.68L4360 PO Pneumati walking boot prefab $243.20L4370 PO Pneumatic full leg splint $159.83L4380 PO Pneumatic knee splint $112.46L4386 PO Non-pneum walk boot prefab $140.12L4392 PO Replace AFO soft interface $20.80L4394 PO Replace foot drop spint $15.17L4396 PO Static AFO $148.29L4398 PO Foot drop splint recumbent $68.28L5000 PO Sho insert w arch toe filler $455.74L5010 PO Mold socket ank hgt w/ toe f $1,393.98L5020 PO Tibial tubercle hgt w/ toe f $1,787.52L5050 PO Ank symes mold sckt sach ft $2,206.49L5060 PO Symes met fr leath socket ar $3,321.74L5100 PO Molded socket shin sach foot $2,286.02L5105 PO Plast socket jts/thgh lacer $3,818.81L5150 PO Mold sckt ext knee shin sach $3,518.16L5160 PO Mold socket bent knee shin s $3,445.23L5200 PO Kne sing axis fric shin sach $2,981.01L5210 PO No knee/ankle joints w/ ft b $2,918.33L5220 PO No knee joint with artic ali $2,663.70L5230 PO Fem focal defic constant fri $3,431.32L5250 PO Hip canad sing axi cons fric $4,998.89L5270 PO Tilt table locking hip sing $4,639.02L5280 PO Hemipelvect canad sing axis $4,592.63L5301 PO BK mold socket SACH ft endo $2,071.00L5311 PO Knee disart, SACH ft, endo $3,026.74L5321 PO AK open end SACH $2,964.57L5331 PO Hip disart canadian SACH ft $4,194.98L5341 PO Hemipelvectomy canadian SACH $4,592.78L5400 PO Postop dress & 1 cast chg bk $1,085.58

Page 42: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L5410 PO Postop dsg bk ea add cast ch $376.87L5420 PO Postop dsg & 1 cast chg ak/d $1,371.04L5430 PO Postop dsg ak ea add cast ch $605.19L5450 PO Postop app non-wgt bear dsg $408.79L5460 PO Postop app non-wgt bear dsg $491.84L5500 PO Init bk ptb plaster direct $1,158.45L5505 PO Init ak ischal plstr direct $1,568.85L5510 PO Prep BK ptb plaster molded $1,313.18L5520 PO Perp BK ptb thermopls direct $1,584.72L5530 PO Prep BK ptb thermopls molded $1,557.95L5535 PO Prep BK ptb open end socket $1,710.89L5540 PO Prep BK ptb laminated socket $1,632.56L5560 PO Prep AK ischial plast molded $2,048.48L5570 PO Prep AK ischial direct form $2,063.30L5580 PO Prep AK ischial thermo mold $2,338.67L5585 PO Prep AK ischial open end $2,307.80L5590 PO Prep AK ischial laminated $2,406.26L5595 PO Hip disartic sach thermopls $4,009.37L5600 PO Hip disart sach laminat mold $4,435.46L5610 PO Above knee hydracadence $1,867.47L5611 PO Ak 4 bar link w/fric swing $1,453.26L5613 PO Ak 4 bar ling w/hydraul swig $2,210.50L5614 PO 4-bar link above knee w/swng $1,494.20L5616 PO Ak univ multiplex sys frict $1,225.04L5617 PO AK/BK self-aligning unit ea $505.39L5618 PO Test socket symes $267.34L5620 PO Test socket below knee $296.69L5622 PO Test socket knee disarticula $435.99L5624 PO Test socket above knee $378.87L5626 PO Test socket hip disarticulat $430.06L5628 PO Test socket hemipelvectomy $449.66L5629 PO Below knee acrylic socket $382.20L5630 PO Syme typ expandabl wall sckt $408.92L5631 PO Ak/knee disartic acrylic soc $528.42L5632 PO Symes type ptb brim design s $218.16L5634 PO Symes type poster opening so $321.65L5636 PO Symes type medial opening so $306.44L5637 PO Below knee total contact $332.45L5638 PO Below knee leather socket $528.12L5639 PO Below knee wood socket $1,288.34L5640 PO Knee disarticulat leather so $769.02L5642 PO Above knee leather socket $666.91L5643 PO Hip flex inner socket ext fr $1,403.89L5644 PO Above knee wood socket $532.75L5645 PO Bk flex inner socket ext fra $719.69L5646 PO Below knee cushion socket $523.31L5647 PO Below knee suction socket $751.02L5648 PO Above knee cushion socket $659.98L5649 PO Isch containmt/narrow m-l so $1,717.33L5650 PO Tot contact ak/knee disart s $587.11L5651 PO Ak flex inner socket ext fra $1,083.21L5652 PO Suction susp ak/knee disart $393.25L5653 PO Knee disart expand wall sock $524.95L5654 PO Socket insert symes $316.80L5655 PO Socket insert below knee $307.80L5656 PO Socket insert knee articulat $437.29L5658 PO Socket insert above knee $353.07L5661 PO Multi-durometer symes $550.50L5665 PO Multi-durometer below knee $461.84L5666 PO Below knee cuff suspension $70.93

Page 43: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L5668 PO Socket insert w/o lock lower $94.93L5670 PO Bk molded supracondylar susp $253.22L5671 PO BK/AK locking mechanism $448.66L5672 PO Bk removable medial brim sus $268.96L5673 PO Socket insert w lock mech $602.72L5676 PO Bk knee joints single axis p $326.85L5677 PO Bk knee joints polycentric p $444.73L5678 PO Bk joint covers pair $35.81L5679 PO Socket insert w/o lock mech $502.25L5680 PO Bk thigh lacer non-molded $351.57L5681 PO Intl custm cong/latyp insert $1,164.74L5682 PO Bk thigh lacer glut/ischia m $588.04L5683 PO Initial custom socket insert $1,164.74L5684 PO Bk fork strap $44.57L5685 PO Below knee sus/seal sleeve $113.41L5686 PO Bk back check $61.44L5688 PO Bk waist belt webbing $73.46L5690 PO Bk waist belt padded and lin $93.38L5692 PO Ak pelvic control belt light $119.86L5694 PO Ak pelvic control belt pad/l $163.63L5695 PO Ak sleeve susp neoprene/equa $171.09L5696 PO Ak/knee disartic pelvic join $181.28L5697 PO Ak/knee disartic pelvic band $72.41L5698 PO Ak/knee disartic silesian ba $118.13L5699 PO Shoulder harness $171.57L5700 PO Replace socket below knee $2,516.16L5701 PO Replace socket above knee $3,121.51L5702 PO Replace socket hip $3,934.19L5703 PO Symes ankle w/o (SACH) foot $2,098.10L5704 PO Custom shape cover BK $513.04L5705 PO Custom shape cover AK $940.57L5706 PO Custom shape cvr knee disart $917.40L5707 PO Custom shape cvr hip disart $1,232.53L5710 PO Kne-shin exo sng axi mnl loc $341.39L5711 PO Knee-shin exo mnl lock ultra $512.58L5712 PO Knee-shin exo frict swg & st $444.22L5714 PO Knee-shin exo variable frict $391.36L5716 PO Knee-shin exo mech stance ph $657.41L5718 PO Knee-shin exo frct swg & sta $821.69L5722 PO Knee-shin pneum swg frct exo $814.38L5724 PO Knee-shin exo fluid swing ph $1,695.67L5726 PO Knee-shin ext jnts fld swg e $1,569.07L5728 PO Knee-shin fluid swg & stance $2,388.06L5780 PO Knee-shin pneum/hydra pneum $1,032.69L5781 PO Lower limb pros vacuum pump $3,542.95L5782 PO HD low limb pros vacuum pump $3,735.08L5785 PO Exoskeletal bk ultralt mater $468.63L5790 PO Exoskeletal ak ultra-light m $648.55L5795 PO Exoskel hip ultra-light mate $968.46L5810 PO Endoskel knee-shin mnl lock $453.75L5811 PO Endo knee-shin mnl lck ultra $657.83L5812 PO Endo knee-shin frct swg & st $509.89L5814 PO Endo knee-shin hydral swg ph $3,288.54L5816 PO Endo knee-shin polyc mch sta $767.09L5818 PO Endo knee-shin frct swg & st $928.33L5822 PO Endo knee-shin pneum swg frc $1,904.52L5824 PO Endo knee-shin fluid swing p $1,712.64L5826 PO Miniature knee joint $2,812.31L5828 PO Endo knee-shin fluid swg/sta $3,112.56L5830 PO Endo knee-shin pneum/swg pha $1,836.77

Page 44: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L5840 PO Multi-axial knee/shin system $3,198.98L5845 PO Knee-shin sys stance flexion $1,587.11L5848 PO Knee-shin sys hydraul stance $952.18L5850 PO Endo ak/hip knee extens assi $120.91L5855 PO Mech hip extension assist $278.56L5856 PO Elec knee-shin swing/stance $21,353.09L5857 PO Elec knee-shin swing only $7,639.05L5858 PO Stance phase only $16,456.85L5910 PO Endo below knee alignable sy $357.37L5920 PO Endo ak/hip alignable system $478.58L5925 PO Above knee manual lock $303.07L5930 PO High activity knee frame $3,040.28L5940 PO Endo bk ultra-light material $491.52L5950 PO Endo ak ultra-light material $796.83L5960 PO Endo hip ultra-light materia $1,154.32L5962 PO Below knee flex cover system $530.18L5964 PO Above knee flex cover system $919.55L5966 PO Hip flexible cover system $1,184.53L5968 PO Multiaxial ankle w dorsiflex $3,217.78L5970 PO Foot external keel sach foot $183.19L5971 PO SACH foot, replacement $183.19L5972 PO Flexible keel foot $317.89L5973 PO Ank-foot sys dors-plant flex $15,410.73L5974 PO Foot single axis ankle/foot $210.19L5975 PO Combo ankle/foot prosthesis $410.50L5976 PO Energy storing foot $637.40L5978 PO Ft prosth multiaxial ankl/ft $263.23L5979 PO Multi-axial ankle/ft prosth $2,058.12L5980 PO Flex foot system $4,391.63L5981 PO Flex-walk sys low ext prosth $2,799.03L5982 PO Exoskeletal axial rotation u $521.45L5984 PO Endoskeletal axial rotation $513.84L5985 PO Lwr ext dynamic prosth pylon $255.06L5986 PO Multi-axial rotation unit $571.58L5987 PO Shank ft w vert load pylon $6,369.90L5988 PO Vertical shock reducing pylo $1,768.94L5990 PO User adjustable heel height $1,606.45L6000 PO Par hand robin-aids thum rem $1,225.74L6010 PO Hand robin-aids little/ring $1,400.35L6020 PO Part hand robin-aids no fing $1,243.46L6025 PO Part hand disart myoelectric $7,085.97L6050 PO Wrst MLd sck flx hng tri pad $1,998.97L6055 PO Wrst mold sock w/exp interfa $2,604.97L6100 PO Elb mold sock flex hinge pad $2,314.64L6110 PO Elbow mold sock suspension t $2,455.06L6120 PO Elbow mold doub splt soc ste $2,667.06L6130 PO Elbow stump activated lock h $2,886.40L6200 PO Elbow mold outsid lock hinge $2,460.70L6205 PO Elbow molded w/ expand inter $3,692.89L6250 PO Elbow inter loc elbow forarm $2,552.59L6300 PO Shlder disart int lock elbow $4,078.78L6310 PO Shoulder passive restor comp $2,912.39L6320 PO Shoulder passive restor cap $1,541.44L6350 PO Thoracic intern lock elbow $4,710.70L6360 PO Thoracic passive restor comp $2,873.00L6370 PO Thoracic passive restor cap $2,442.68L6380 PO Postop dsg cast chg wrst/elb $1,248.88L6382 PO Postop dsg cast chg elb dis/ $1,780.73L6384 PO Postop dsg cast chg shlder/t $2,292.98L6386 PO Postop ea cast chg & realign $482.97

Page 45: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L6388 PO Postop applicat rigid dsg on $396.54L6400 PO Below elbow prosth tiss shap $2,436.00L6450 PO Elb disart prosth tiss shap $2,798.60L6500 PO Above elbow prosth tiss shap $2,883.85L6550 PO Shldr disar prosth tiss shap $3,439.51L6570 PO Scap thorac prosth tiss shap $4,204.05L6580 PO Wrist/elbow bowden cable mol $1,413.43L6582 PO Wrist/elbow bowden cbl dir f $1,248.88L6584 PO Elbow fair lead cable molded $1,895.51L6586 PO Elbow fair lead cable dir fo $1,698.83L6588 PO Shdr fair lead cable molded $2,602.47L6590 PO Shdr fair lead cable direct $2,423.98L6600 PO Polycentric hinge pair $225.59L6605 PO Single pivot hinge pair $222.75L6610 PO Flexible metal hinge pair $150.17L6611 PO Additional switch, ext power $364.58L6615 PO Disconnect locking wrist uni $165.77L6616 PO Disconnect insert locking wr $68.22L6620 PO Flexion/extension wrist unit $273.49L6621 PO Flex/ext wrist w/wo friction $2,025.37L6623 PO Spring-ass rot wrst w/ latch $578.59L6624 PO Flex/ext/rotation wrist unit $3,334.81L6625 PO Rotation wrst w/ cable lock $479.73L6628 PO Quick disconn hook adapter o $432.10L6629 PO Lamination collar w/ couplin $158.07L6630 PO Stainless steel any wrist $194.40L6632 PO Latex suspension sleeve each $58.60L6635 PO Lift assist for elbow $182.27L6637 PO Nudge control elbow lock $331.20L6638 PO Elec lock on manual pw elbow $2,214.36L6640 PO Shoulder abduction joint pai $336.88L6641 PO Excursion amplifier pulley t $192.94L6642 PO Excursion amplifier lever ty $261.51L6645 PO Shoulder flexion-abduction j $291.09L6646 PO Multipo locking shoulder jnt $2,792.80L6647 PO Shoulder lock actuator $459.77L6648 PO Ext pwrd shlder lock/unlock $2,880.38L6650 PO Shoulder universal joint $349.67L6655 PO Standard control cable extra $72.10L6660 PO Heavy duty control cable $82.79L6665 PO Teflon or equal cable lining $48.11L6670 PO Hook to hand cable adapter $53.31L6672 PO Harness chest/shlder saddle $184.88L6675 PO Harness figure of 8 sing con $122.61L6676 PO Harness figure of 8 dual con $131.59L6677 PO UE triple control harness $262.67L6680 PO Test sock wrist disart/bel e $263.73L6682 PO Test sock elbw disart/above $282.84L6684 PO Test socket shldr disart/tho $401.49L6686 PO Suction socket $540.30L6687 PO Frame typ socket bel elbow/w $529.49L6688 PO Frame typ sock above elb/dis $491.68L6689 PO Frame typ socket shoulder di $810.35L6690 PO Frame typ sock interscap-tho $697.00L6691 PO Removable insert each $332.43L6692 PO Silicone gel insert or equal $511.61L6693 PO Lockingelbow forearm cntrbal $2,513.89L6694 PO Elbow socket ins use w/lock $602.72L6695 PO Elbow socket ins use w/o lck $502.25L6696 PO Cus elbo skt in for con/atyp $1,164.74

Page 46: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L6697 PO Cus elbo skt in not con/atyp $1,164.74L6698 PO Below/above elbow lock mech $448.66L6703 PO Term dev, passive hand mitt $390.97L6704 PO Term dev, sport/rec/work att $529.24L6706 PO Term dev mech hook vol open $314.73L6707 PO Term dev mech hook vol close $1,236.49L6708 PO Term dev mech hand vol open $828.61L6709 PO Term dev mech hand vol close $1,109.29L6711 PO Ped term dev, hook, vol open $595.31L6712 PO Ped term dev, hook, vol clos $1,096.10L6713 PO Ped term dev, hand, vol open $1,383.40L6714 PO Ped term dev, hand, vol clos $1,171.72L6721 PO Hook/hand, hvy dty, vol open $2,082.62L6722 PO Hook/hand, hvy dty, vol clos $1,795.38L6805 PO Term dev modifier wrist unit $360.23L6810 PO Term dev precision pinch dev $168.25L6881 PO Term dev auto grasp feature $3,620.07L6882 PO Microprocessor control uplmb $2,745.98L6883 PO Replc sockt below e/w disa $1,908.47L6884 PO Replc sockt above elbow disa $2,098.76L6885 PO Replc sockt shldr dis/interc $2,873.00L6890 PO Prefab glove for term device $204.56L6895 PO Custom glove for term device $503.66L6900 PO Hand restorat thumb/1 finger $1,601.01L6905 PO Hand restoration multiple fi $1,581.91L6910 PO Hand restoration no fingers $1,644.79L6915 PO Hand restoration replacmnt g $564.67L6920 PO Wrist disarticul switch ctrl $6,019.63L6925 PO Wrist disart myoelectronic c $6,949.58L6930 PO Below elbow switch control $6,056.96L6935 PO Below elbow myoelectronic ct $7,079.68L6940 PO Elbow disarticulation switch $8,389.82L6945 PO Elbow disart myoelectronic c $9,406.38L6950 PO Above elbow switch control $8,995.16L6955 PO Above elbow myoelectronic ct $10,772.93L6960 PO Shldr disartic switch contro $10,865.31L6965 PO Shldr disartic myoelectronic $12,783.55L6970 PO Interscapular-thor switch ct $13,155.45L6975 PO Interscap-thor myoelectronic $14,414.20L7007 PO Adult electric hand $3,535.52L7008 PO Pediatric electric hand $5,543.02L7009 PO Adult electric hook $3,354.86L7040 PO Prehensile actuator $2,752.06L7045 PO Pediatric electric hook $1,457.92L7170 PO Electronic elbow hosmer swit $5,288.82L7180 PO Electronic elbow sequential $32,424.45L7181 PO Electronic elbo simultaneous $35,479.56L7185 PO Electron elbow adolescent sw $6,467.88L7186 PO Electron elbow child switch $9,853.56L7190 PO Elbow adolescent myoelectron $9,085.38L7191 PO Elbow child myoelectronic ct $10,187.64L7260 PO Electron wrist rotator otto $1,775.14L7261 PO Electron wrist rotator utah $3,231.43L7266 PO Servo control steeper or equ $893.04L7272 PO Analogue control unb or equa $2,007.51L7274 PO Proportional ctl 12 volt uta $5,662.80L7360 PO Six volt bat otto bock/eq ea $273.48L7362 PO Battery chrgr six volt otto $252.04L7364 PO Twelve volt battery utah/equ $479.23L7366 PO Battery chrgr 12 volt utah/e $645.54

Page 47: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L7367 PO Replacemnt lithium ionbatter $344.74L7368 PO Lithium ion battery charger $446.90L7400 PO Add UE prost be/wd, ultlite $271.39L7401 PO Add UE prost a/e ultlite mat $303.82L7402 PO Add UE prost s/d ultlite mat $328.10L7403 PO Add UE prost b/e acrylic $326.09L7404 PO Add UE prost a/e acrylic $492.16L7405 PO Add UE prost s/d acrylic $643.68L7900 PO Male vacuum erection system $465.26L8000 PO Mastectomy bra $33.23L8001 PO Breast prosthesis bra & form $111.06L8002 PO Brst prsth bra & bilat form $146.08L8015 PO Ext breastprosthesis garment $53.08L8020 PO Mastectomy form $216.32L8030 PO Breast prosthes w/o adhesive $291.72L8031 PO Breast prosthesis w adhesive $291.72L8032 PO Reusable nipple prosthesis $34.69L8035 PO Custom breast prosthesis $3,244.08L8040 PO Nasal prosthesis $2,461.37L8040 KM PO Nasal prosthesis $2,338.31L8040 KN PO Nasal prosthesis $984.54L8041 PO Midfacial prosthesis $2,966.74L8041 KM PO Midfacial prosthesis $2,818.41L8041 KN PO Midfacial prosthesis $1,186.69L8042 PO Orbital prosthesis $3,333.44L8042 KM PO Orbital prosthesis $3,166.75L8042 KN PO Orbital prosthesis $1,333.37L8043 PO Upper facial prosthesis $3,733.45L8043 KM PO Upper facial prosthesis $3,546.76L8043 KN PO Upper facial prosthesis $1,493.37L8044 PO Hemi-facial prosthesis $4,133.46L8044 KM PO Hemi-facial prosthesis $3,926.79L8044 KN PO Hemi-facial prosthesis $1,653.38L8045 PO Auricular prosthesis $2,598.34L8045 KM PO Auricular prosthesis $2,468.43L8045 KN PO Auricular prosthesis $1,039.33L8046 PO Partial facial prosthesis $2,666.74L8046 KM PO Partial facial prosthesis $2,533.42L8046 KN PO Partial facial prosthesis $1,066.70L8047 PO Nasal septal prosthesis $1,366.71L8047 KM PO Nasal septal prosthesis $1,298.39L8047 KN PO Nasal septal prosthesis $546.68L8300 PO Truss single w/ standard pad $76.08L8310 PO Truss double w/ standard pad $159.29L8320 PO Truss addition to std pad wa $48.22L8330 PO Truss add to std pad scrotal $44.53L8400 PO Sheath below knee $18.93L8410 PO Sheath above knee $22.92L8415 PO Sheath upper limb $21.68L8417 PO Pros sheath/sock w gel cushn $66.49L8420 PO Prosthetic sock multi ply BK $20.33L8430 PO Prosthetic sock multi ply AK $23.50L8435 PO Pros sock multi ply upper lm $19.82L8440 PO Shrinker below knee $48.81L8460 PO Shrinker above knee $60.12L8465 PO Shrinker upper limb $44.00L8470 PO Pros sock single ply BK $6.02L8480 PO Pros sock single ply AK $8.30L8485 PO Pros sock single ply upper l $10.08L8500 PO Artificial larynx $685.49

Page 48: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

L8501 PO Tracheostomy speaking valve $108.96L8507 PO Trach-esoph voice pros pt in $37.10L8509 PO Trach-esoph voice pros md in $96.71L8510 PO Voice amplifier $223.74L8511 PO Indwelling trach insert $64.40L8512 PO Gel cap for trach voice pros $1.91L8513 PO Trach pros cleaning device $4.60L8514 PO Repl trach puncture dilator $83.50L8515 PO Gel cap app device for trach $55.89L8600 PO Implant breast silicone/eq $563.24L8603 PO Collagen imp urinary 2.5 ml $393.90L8606 PO Synthetic implnt urinary 1ml $193.99L8609 PO Artificial cornea $5,769.31L8610 PO Ocular implant $625.30L8612 PO Aqueous shunt prosthesis $597.23L8613 PO Ossicular implant $302.32L8614 PO Cochlear device $17,284.73L8615 PO Coch implant headset replace $399.36L8616 PO Coch implant microphone repl $93.02L8617 PO Coch implant trans coil repl $81.24L8618 PO Coch implant tran cable repl $23.22L8619 PO Coch imp ext proc/contr rplc $7,420.22L8621 PO Repl zinc air battery $0.55L8622 PO Repl alkaline battery $0.29L8623 PO Lith ion batt CID,non-earlvl $57.28L8624 PO Lith ion batt CID, ear level $142.80L8627 PO CID ext speech process repl $6,324.80L8628 PO CID ext controller repl $1,095.43L8629 PO CID transmit coil and cable $158.55L8630 PO Metacarpophalangeal implant $303.88L8631 PO MCP joint repl 2 pc or more $1,957.77L8641 PO Metatarsal joint implant $315.74L8642 PO Hallux implant $276.79L8658 PO Interphalangeal joint spacer $275.29L8659 PO Interphalangeal joint repl $1,708.71L8670 PO Vascular graft, synthetic $502.09L8680 PO Implt neurostim elctr each $406.73L8681 PO Pt prgrm for implt neurostim $1,297.42L8682 PO Implt neurostim radiofq rec $5,278.95L8683 PO Radiofq trsmtr for implt neu $4,646.68L8684 PO Radiof trsmtr implt scrl neu $614.20L8685 PO Implt nrostm pls gen sng rec $11,579.27L8686 PO Implt nrostm pls gen sng non $7,388.47L8687 PO Implt nrostm pls gen dua rec $15,069.25L8688 PO Implt nrostm pls gen dua non $9,615.40L8689 PO External recharg sys intern $1,527.41L8690 PO Aud osseo dev, int/ext comp $4,212.39L8691 PO Osseointegrated snd proc rpl $2,361.18L8695 PO External recharg sys extern $14.74Q0480 PO Driver pneumatic vad, rep $79,750.51Q0481 PO Microprcsr cu elec vad, rep $12,866.81Q0482 PO Microprcsr cu combo vad, rep $4,030.13Q0483 PO Monitor elec vad, rep $16,602.32Q0484 PO Monitor elec or comb vad rep $3,224.12Q0485 PO Monitor cable elec vad, rep $311.28Q0486 PO Mon cable elec/pneum vad rep $259.09Q0487 PO Leads any type vad, rep only $302.26Q0489 PO Pwr pck base combo vad, rep $14,393.32Q0490 PO Emr pwr source elec vad, rep $622.58Q0491 PO Emr pwr source combo vad rep $978.78

Page 49: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

Q0492 PO Emr pwr cbl elec vad, rep $78.84Q0493 PO Emr pwr cbl combo vad, rep $224.53Q0494 PO Emr hd pmp elec/combo, rep $190.00Q0495 PO Charger elec/combo vad, rep $3,698.71Q0496 PO Battery elec/combo vad, rep $1,327.53Q0497 PO Bat clps elec/comb vad, rep $414.53Q0498 PO Holster elec/combo vad, rep $454.83Q0499 PO Belt/vest elec/combo vad rep $147.78Q0500 PO Filters elec/combo vad, rep $27.04Q0501 PO Shwr cov elec/combo vad, rep $452.21Q0502 PO Mobility cart pneum vad, rep $575.73Q0503 PO Battery pneum vad replacemnt $1,151.46Q0504 PO Pwr adpt pneum vad, rep veh $607.60Q0506 PO Lith-ion batt elec/pneum VAD $756.33V2020 PO Vision svcs frames purchases $56.55V2100 PO Lens spher single plano 4.00 $47.11V2101 PO Single visn sphere 4.12-7.00 $49.64V2102 PO Singl visn sphere 7.12-20.00 $57.49V2103 PO Spherocylindr 4.00d/12-2.00d $40.91V2104 PO Spherocylindr 4.00d/2.12-4d $45.30V2105 PO Spherocylinder 4.00d/4.25-6d $49.32V2106 PO Spherocylinder 4.00d/>6.00d $54.46V2107 PO Spherocylinder 4.25d/12-2d $52.05V2108 PO Spherocylinder 4.25d/2.12-4d $51.82V2109 PO Spherocylinder 4.25d/4.25-6d $57.62V2110 PO Spherocylinder 4.25d/over 6d $58.84V2111 PO Spherocylindr 7.25d/.25-2.25 $61.34V2112 PO Spherocylindr 7.25d/2.25-4d $66.96V2113 PO Spherocylindr 7.25d/4.25-6d $73.58V2114 PO Spherocylinder over 12.00d $81.74V2115 PO Lens lenticular bifocal $68.90V2118 PO Lens aniseikonic single $75.59V2121 PO Lenticular lens, single $76.05V2200 PO Lens spher bifoc plano 4.00d $61.66V2201 PO Lens sphere bifocal 4.12-7.0 $66.76V2202 PO Lens sphere bifocal 7.12-20. $75.75V2203 PO Lens sphcyl bifocal 4.00d/.1 $62.20V2204 PO Lens sphcy bifocal 4.00d/2.1 $63.86V2205 PO Lens sphcy bifocal 4.00d/4.2 $69.62V2206 PO Lens sphcy bifocal 4.00d/ove $70.32V2207 PO Lens sphcy bifocal 4.25-7d/. $64.74V2208 PO Lens sphcy bifocal 4.25-7/2. $66.85V2209 PO Lens sphcy bifocal 4.25-7/4. $67.97V2210 PO Lens sphcy bifocal 4.25-7/ov $72.61V2211 PO Lens sphcy bifo 7.25-12/.25- $75.41V2212 PO Lens sphcyl bifo 7.25-12/2.2 $76.61V2213 PO Lens sphcyl bifo 7.25-12/4.2 $79.47V2214 PO Lens sphcyl bifocal over 12. $96.83V2215 PO Lens lenticular bifocal $90.00V2218 PO Lens aniseikonic bifocal $117.06V2219 PO Lens bifocal seg width over $50.39V2220 PO Lens bifocal add over 3.25d $43.43V2221 PO Lenticular lens, bifocal $87.23V2300 PO Lens sphere trifocal 4.00d $76.06V2301 PO Lens sphere trifocal 4.12-7. $73.45V2302 PO Lens sphere trifocal 7.12-20 $74.50V2303 PO Lens sphcy trifocal 4.0/.12- $72.61V2304 PO Lens sphcy trifocal 4.0/2.25 $78.29V2305 PO Lens sphcy trifocal 4.0/4.25 $80.77V2306 PO Lens sphcyl trifocal 4.00/>6 $82.90

Page 50: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

V2307 PO Lens sphcy trifocal 4.25-7/. $79.89V2308 PO Lens sphc trifocal 4.25-7/2. $80.01V2309 PO Lens sphc trifocal 4.25-7/4. $82.31V2310 PO Lens sphc trifocal 4.25-7/>6 $83.69V2311 PO Lens sphc trifo 7.25-12/.25- $80.66V2312 PO Lens sphc trifo 7.25-12/2.25 $81.17V2313 PO Lens sphc trifo 7.25-12/4.25 $91.43V2314 PO Lens sphcyl trifocal over 12 $104.24V2315 PO Lens lenticular trifocal $129.87V2318 PO Lens aniseikonic trifocal $176.41V2319 PO Lens trifocal seg width > 28 $51.33V2320 PO Lens trifocal add over 3.25d $63.01V2321 PO Lenticular lens, trifocal $128.30V2410 PO Lens variab asphericity sing $99.73V2430 PO Lens variable asphericity bi $129.96V2500 PO Contact lens pmma spherical $97.75V2501 PO Cntct lens pmma-toric/prism $148.90V2502 PO Contact lens pmma bifocal $183.43V2503 PO Cntct lens pmma color vision $168.94V2510 PO Cntct gas permeable sphericl $113.95V2511 PO Cntct toric prism ballast $191.73V2512 PO Cntct lens gas permbl bifocl $226.56V2513 PO Contact lens extended wear $190.21V2520 PO Contact lens hydrophilic $125.43V2521 PO Cntct lens hydrophilic toric $218.37V2522 PO Cntct lens hydrophil bifocl $212.51V2523 PO Cntct lens hydrophil extend $169.30V2530 PO Contact lens gas impermeable $201.17V2531 PO Contact lens gas permeable $489.09V2623 PO Plastic eye prosth custom $1,045.38V2624 PO Polishing artifical eye $54.91V2625 PO Enlargemnt of eye prosthesis $333.85V2626 PO Reduction of eye prosthesis $179.96V2627 PO Scleral cover shell $1,426.01V2628 PO Fabrication & fitting $278.76V2700 PO Balance lens $45.54V2710 PO Glass/plastic slab off prism $77.11V2715 PO Prism lens/es $13.98V2718 PO Fresnell prism press-on lens $31.89V2730 PO Special base curve $19.02V2744 PO Tint photochromatic lens/es $14.98V2745 PO Tint, any color/solid/grad $12.02V2750 PO Anti-reflective coating $18.47V2755 PO UV lens/es $14.99V2760 PO Scratch resistant coating $15.31V2762 PO Polarization, any lens $52.77V2770 PO Occluder lens/es $22.59V2780 PO Oversize lens/es $11.30V2782 PO Lens, 1.54-1.65 p/1.60-1.79g $57.00V2783 PO Lens, >= 1.66 p/>=1.80 g $64.27V2784 PO Lens polycarb or equal $41.80V2786 PO Occupational multifocal lens $0.00

Page 51: HCPCS Mod Mod2 CATG Description Fee - New JerseyA4411 OS Ost skn barr extnd =4sq $5.36 A4412 OS Ost pouch drain high output $2.84 A4413 OS 2 pc drainable ost pouch $5.78 A4414 OS Ost

EXHIBIT 5Durable Medical Equipment, Prosthetics, Orthotics Supplies

Modifiers: NU Purchased, New(MOD) RR Rented

UE Purchased, UsedKM Replacement of Facial Prosthesis including new impression/mouKN Replacement of Facial Prosthesis using previous master moldAU Urological, ostomy or trach itemAV Item with prosthetic/orthotic deviceAW Item with a surgical dressingKE Bid Under Round I of the DMEPOS CompetitiveEquipment KF--C

Bid Program For Use With Non-Competitive Bid Base KL DMEPOS Item Delivered Via MailKC Replacement of Special Power Wheelchair Interface

Categories: IN Inexpensive and Other Routinely Purchased Items(CATG) FS Frequently Serviced Items

CR Capped Rental ItemsOX Oxygen and Oxygen EquipmentOS Ostomy, Tracheostomy & Urological ItemsSD Surgical DressingsPO Prosthetics & OrthoticsSU SuppliesTE Transcutaneous Electrical Nerve StimulatorsTS Therapeutic Shoes