dme fee schedule for items supplied to rural and … · e0161 sitz bath/equipment w/faucet u1 $...
TRANSCRIPT
HCPCS Description Modifier 1 Modifier 2 Modifier 3 NM Rural
Rate A4221 Supp non-insulin inf cath/wk U1 23.17$
A4222 Infusion supplies with pump U1 46.13$
A4224 Supply insulin inf cath/wk U1 23.17$
A4225 Sup/ext insulin inf pump syr U1 2.88$
A4557 Lead wires, pair U1 17.57$
A4595 Tens suppl 2 lead per month U1 22.07$
A4604 Tubing with heating element U1 54.80$
A4619 Face tent U1 2.07$
A4636 Handgrip for cane etc U1 KE 3.59$
A4636 Handgrip for cane etc U1 3.33$
A4637 Repl tip cane/crutch/walker U1 KE 1.89$
A4637 Repl tip cane/crutch/walker U1 1.76$
A4640 Alternating pressure pad U1 64.75$
A6550 Neg pres wound ther drsg set U1 27.16$
A7000 Disposable canister for pump U1 KE 9.89$
A7000 Disposable canister for pump U1 9.20$
A7003 Nebulizer administration set U1 2.38$
A7004 Disposable nebulizer sml vol U1 1.56$
A7005 Nondisposable nebulizer set U1 21.46$
DME FEE SCHEDULE FOR ITEMS SUPPLIED TO RURAL AND NON CONTIGUOUS AREAS NEW MEXICO FEE FOR
SERVICE PROGRAM - EFFECTIVE JANUARY 1, 2019
FOLLOWING MEDICARE DEFINITIONS, THE FOLLOWING LOCATIONS ARE CONSIDERED RURAL OR NON-
CONTIGUOUS BY MEDICARE. MEDICAID FOLLOWS THE MEDICARE DETERMINATION.
ALAMOGORDO, ARTESIA, CARLSBAD, CLAYTON, CLOVIS, DEMING , ESPANOLA, GALLUP, GRANTS, HOBBS, LAS
VEGAS, LOVINGTON, PORTALES, RATON, ROSWELL, RUIDOSO, SILVER CITY, SOCORRO, T OR C, TAOS, ZUNI
For a complete list of zip codes that are considered rural or non-contiguous, see the bottom of the fee schedule
chart
IN ORDER TO RECEIVE THE RURAL RATE, THE RURAL PROVIDER MUST USE THE U1 MODIFIER ON THE CLAIM
LINE IN ADDITION TO ANY OTHER RELEVANT MODIFIERS SUCH AS THE RR FOR RENTAL AND THE NU FOR
NEW EQUIPMENT.
WHEN TO BILL A RURAL RATE: The modifier U1, rural, may be used when the item is furnished in a rural area.
For example, if a resident of Artesia receives an item from a provider in Artesia, since Artesia is a rural area, the
provider could bill the U1 modifier for increased payment.
Note that the fee schedule for non rural DME rates are found on this same web page, under HCPCS Codes.USE OF THE KE MODIFIER:
The KE modifier can be used under the same circumstances that you would use the KE modifier on a Medicare
claim. Medicaid follows Medicare rules. Note that the KE modifier can only be used if the item was furnish in a
rural or non-contiguous area.
Under Medicare, in cases where accessories included in the 2008 Competitive Bidding Programs (CBPs) are
furnished for use with base equipment that was not included in the 2008 CBP, the KE modifier can be used. For
further information on the precise application of the KE modifier, please follow the instructions of your Durable
Medical Equipment Administrative Contractor (DME MAC).
A7006 Filtered nebulizer admin set U1 9.37$
A7007 Lg vol nebulizer disposable U1 4.22$
A7010 Disposable corrugated tubing U1 19.80$
A7012 Nebulizer water collec devic U1 3.69$
A7013 Disposable compressor filter U1 0.70$
A7014 Compressor nondispos filter U1 4.33$
A7015 Aerosol mask used w nebulize U1 1.76$
A7017 Nebulizer not used w oxygen U1 139.61$
A7018 Water distilled w/nebulizer U1 0.36$
A7027 Combination oral/nasal mask U1 172.34$
A7028 Repl oral cushion combo mask U1 46.75$
A7029 Repl nasal pillow comb mask U1 20.00$
A7030 Cpap full face mask U1 142.03$
A7031 Replacement facemask interfa U1 53.03$
A7032 Replacement nasal cushion U1 30.40$
A7033 Replacement nasal pillows U1 22.53$
A7034 Nasal application device U1 88.66$
A7035 Pos airway press headgear U1 28.17$
A7036 Pos airway press chinstrap U1 13.51$
A7037 Pos airway pressure tubing U1 26.57$
A7038 Pos airway pressure filter U1 3.82$
A7039 Filter, non disposable w pap U1 9.76$
A7044 Pap oral interface U1 105.04$
A7045 Repl exhalation port for pap U1 16.21$
A7046 Repl water chamber, pap dev U1 16.91$
B4034 Enter feed supkit syr by day U1 4.92$
B4035 Enteral feed supp pump per d U1 9.09$
B4036 Enteral feed sup kit grav by U1 6.54$
B4081 Enteral ng tubing w/ stylet U1 19.90$
B4082 Enteral ng tubing w/o stylet U1 14.56$
B4083 Enteral stomach tube levine U1 2.21$
B4087 Gastro/jejuno tube, std U1 33.66$
B4088 Gastro/jejuno tube, low-pro U1 36.16$
B4149 Ef blenderized foods U1 1.39$
B4150 Ef complet w/intact nutrient U1 0.57$
B4152 Ef calorie dense>/=1.5kcal U1 0.47$
B4153 Ef hydrolyzed/amino acids U1 1.67$
B4154 Ef spec metabolic noninherit U1 1.01$
B4155 Ef incomplete/modular U1 0.90$
B9002 Enter nutr inf pump any type U1 RR 96.99$
B9002 Enter nutr inf pump any type U1 990.46$
E0130 Walker rigid adjust/fixed ht U1 RR 9.51$
E0130 Walker rigid adjust/fixed ht U1 59.09$
E0135 Walker folding adjust/fixed U1 RR 9.71$
E0135 Walker folding adjust/fixed U1 65.89$
E0140 Walker w trunk support U1 RR 32.85$
E0141 Rigid wheeled walker adj/fix U1 RR 11.97$
E0141 Rigid wheeled walker adj/fix U1 81.11$
E0143 Walker folding wheeled w/o s U1 RR 11.64$
E0143 Walker folding wheeled w/o s U1 84.95$
E0144 Enclosed walker w rear seat U1 RR 29.22$
E0147 Walker variable wheel resist U1 RR 50.28$
E0147 Walker variable wheel resist U1 502.73$
E0148 Heavyduty walker no wheels U1 RR 10.72$
E0148 Heavyduty walker no wheels U1 107.14$
E0149 Heavy duty wheeled walker U1 RR 17.33$
E0154 Walker platform attachment U1 RR 6.86$
E0154 Walker platform attachment U1 61.10$
E0155 Walker wheel attachment,pair U1 RR 2.81$
E0155 Walker wheel attachment,pair U1 26.79$
E0156 Walker seat attachment U1 RR 2.32$
E0156 Walker seat attachment U1 21.50$
E0157 Walker crutch attachment U1 RR 7.46$
E0157 Walker crutch attachment U1 70.55$
E0158 Walker leg extenders set of4 U1 RR 2.90$
E0158 Walker leg extenders set of4 U1 27.49$
E0159 Brake for wheeled walker U1 RR 1.70$
E0159 Brake for wheeled walker U1 16.69$
E0160 Sitz type bath or equipment U1 RR 3.67$
E0160 Sitz type bath or equipment U1 31.57$
E0161 Sitz bath/equipment w/faucet U1 RR 3.07$
E0161 Sitz bath/equipment w/faucet U1 25.66$
E0163 Commode chair with fixed arm U1 RR 14.77$
E0163 Commode chair with fixed arm U1 91.64$
E0167 Commode chair pail or pan U1 12.69$
E0168 Heavyduty/wide commode chair U1 RR 14.97$
E0168 Heavyduty/wide commode chair U1 149.31$
E0170 Commode chair electric U1 RR 179.60$
E0171 Commode chair non-electric U1 RR 32.99$
E0181 Press pad alternating w/ pum U1 RR 23.29$
E0182 Replace pump, alt press pad U1 RR 25.56$
E0184 Dry pressure mattress U1 RR 20.60$
E0184 Dry pressure mattress U1 181.09$
E0185 Gel pressure mattress pad U1 RR 33.78$
E0185 Gel pressure mattress pad U1 274.53$
E0186 Air pressure mattress U1 RR 19.86$
E0187 Water pressure mattress U1 RR 22.71$
E0188 Synthetic sheepskin pad U1 25.87$
E0189 Lambswool sheepskin pad U1 56.45$
E0193 Powered air flotation bed U1 RR 766.80$
E0199 Dry pressure pad for mattres U1 33.58$
E0250 Hosp bed fixed ht w/ mattres U1 RR 75.05$
E0251 Hosp bed fixd ht w/o mattres U1 RR 61.73$
E0255 Hospital bed var ht w/ mattr U1 RR 85.70$
E0256 Hospital bed var ht w/o matt U1 RR 73.08$
E0260 Hosp bed semi-electr w/ matt U1 RR 102.40$
E0261 Hosp bed semi-electr w/o mat U1 RR 94.73$
E0265 Hosp bed total electr w/ mat U1 RR 163.98$
E0266 Hosp bed total elec w/o matt U1 RR 150.64$
E0271 Mattress innerspring U1 RR 18.04$
E0271 Mattress innerspring U1 176.13$
E0272 Mattress foam rubber U1 RR 17.97$
E0272 Mattress foam rubber U1 175.24$
E0275 Bed pan standard U1 16.26$
E0276 Bed pan fracture U1 14.06$
E0277 Powered pres-redu air mattrs U1 RR 435.77$
E0280 Bed cradle U1 RR 3.41$
E0280 Bed cradle U1 32.23$
E0290 Hosp bed fx ht w/o rails w/m U1 RR 61.94$
E0291 Hosp bed fx ht w/o rail w/o U1 RR 45.81$
E0292 Hosp bed var ht no sr w/matt U1 RR 73.80$
E0293 Hosp bed var ht no sr no mat U1 RR 65.29$
E0294 Hosp bed semi-elect w/ mattr U1 RR 96.15$
E0295 Hosp bed semi-elect w/o matt U1 RR 86.59$
E0296 Hosp bed total elect w/ matt U1 RR 137.48$
E0297 Hosp bed total elect w/o mat U1 RR 119.26$
E0300 Enclosed ped crib hosp grade U1 RR 265.75$
E0301 Hd hosp bed, 350-600 lbs U1 RR 202.30$
E0302 Ex hd hosp bed > 600 lbs U1 RR 605.98$
E0303 Hosp bed hvy dty xtra wide U1 RR 219.99$
E0304 Hosp bed xtra hvy dty x wide U1 RR 640.29$
E0305 Rails bed side half length U1 RR 14.57$
E0310 Rails bed side full length U1 RR 15.61$
E0310 Rails bed side full length U1 155.99$
E0325 Urinal male jug-type U1 10.69$
E0326 Urinal female jug-type U1 10.27$
E0371 Nonpower mattress overlay U1 RR 297.54$
E0372 Powered air mattress overlay U1 RR 339.26$
E0373 Nonpowered pressure mattress U1 RR 373.69$
E0424 Stationary compressed gas 02 U1 RR 134.71$
E0431 Portable gaseous 02 U1 RR 24.00$
E0433 Portable liquid oxygen sys U1 RR 44.32$
E0434 Portable liquid 02 U1 RR 44.32$
E0439 Stationary liquid 02 U1 RR 134.71$
E0441 Stationary o2 contents, gas U1 64.20$
E0442 Stationary o2 contents, liq U1 64.20$
E0443 Portable 02 contents, gas U1 61.69$
E0444 Portable 02 contents, liquid U1 61.69$
E0447 Port o2 cont, liq over 4 lpm U1 92.54$
E0467 Home vent multi-function U1 RR 1,247.73$
E0470 Rad w/o backup non-inv intfc U1 RR 180.58$
E0471 Rad w/backup non inv intrfc U1 RR 415.41$
E0472 Rad w backup invasive intrfc U1 RR 487.22$
E0561 Humidifier nonheated w pap U1 RR 9.20$
E0561 Humidifier nonheated w pap U1 92.05$
E0562 Humidifier heated used w pap U1 RR 22.38$
E0562 Humidifier heated used w pap U1 223.90$
E0565 Compressor air power source U1 RR 57.67$
E0570 Nebulizer with compression U1 RR 12.36$
E0572 Aerosol compressor adjust pr U1 RR 34.88$
E0580 Nebulizer for use w/ regulat U1 RR 13.18$
E0580 Nebulizer for use w/ regulat U1 131.71$
E0585 Nebulizer w/ compressor & he U1 RR 32.66$
E0601 Cont airway pressure device U1 RR 77.63$
E0621 Patient lift sling or seat U1 RR 9.78$
E0621 Patient lift sling or seat U1 99.89$
E0627 Seat lift mech, electric any U1 RR 33.05$
E0627 Seat lift mech, electric any U1 330.47$
E0629 Seat lift mech, non-electric U1 RR 32.89$
E0629 Seat lift mech, non-electric U1 328.89$
E0630 Patient lift hydraulic U1 RR 84.91$
E0635 Patient lift electric U1 RR 133.05$
E0636 Pt support & positioning sys U1 RR 1,134.10$
E0705 Transfer device U1 RR 5.69$
E0705 Transfer device U1 56.40$
E0720 Tens two lead U1 247.29$
E0730 Tens four lead U1 249.38$
E0731 Conductive garment for tens/ U1 250.04$
E0776 Iv pole U1 KE 89.75$
E0776 Iv pole U1 RR KE 18.47$
E0776 Iv pole U1 RR 16.33$
E0776 Iv pole U1 152.70$
E0779 Amb infusion pump mechanical U1 RR 17.10$
E0780 Mech amb infusion pump <8hrs U1 11.91$
E0781 External ambulatory infus pu U1 RR 255.98$
E0784 Ext amb infusn pump insulin U1 RR 458.92$
E0791 Parenteral infusion pump sta U1 RR 326.01$
E0910 Trapeze bar attached to bed U1 RR 14.35$
E0911 Hd trapeze bar attach to bed U1 RR 47.18$
E0912 Hd trapeze bar free standing U1 RR 100.37$
E0940 Trapeze bar free standing U1 RR 25.92$
E0950 Tray U1 KE 99.06$
E0950 Tray U1 RR KE 9.92$
E0950 Tray U1 RR 9.17$
E0950 Tray U1 91.58$
E0951 Loop heel U1 KE 17.68$
E0951 Loop heel U1 RR KE 1.80$
E0951 Loop heel U1 RR 1.66$
E0951 Loop heel U1 16.31$
E0952 Toe loop/holder, each U1 KE 18.80$
E0952 Toe loop/holder, each U1 17.44$
E0953 W/c lateral thigh/knee sup U1 RR 8.91$
E0953 W/c lateral thigh/knee sup U1 89.07$
E0955 Cushioned headrest U1 RR KE 19.11$
E0955 Cushioned headrest U1 RR 17.66$
E0956 W/c lateral trunk/hip suppor U1 KE 96.16$
E0956 W/c lateral trunk/hip suppor U1 RR KE 9.62$
E0956 W/c lateral trunk/hip suppor U1 RR 8.91$
E0956 W/c lateral trunk/hip suppor U1 89.07$
E0957 W/c medial thigh support U1 KE 141.54$
E0957 W/c medial thigh support U1 RR KE 14.16$
E0957 W/c medial thigh support U1 RR 13.16$
E0957 W/c medial thigh support U1 131.62$
E0958 Whlchr att- conv 1 arm drive U1 RR 44.59$
E0959 Amputee adapter U1 RR 4.89$
E0959 Amputee adapter U1 48.71$
E0960 W/c shoulder harness/straps U1 KE 89.77$
E0960 W/c shoulder harness/straps U1 RR KE 8.99$
E0960 W/c shoulder harness/straps U1 RR 8.33$
E0960 W/c shoulder harness/straps U1 83.22$
E0961 Wheelchair brake extension U1 25.31$
E0966 Wheelchair head rest extensi U1 78.34$
E0967 Man wc rim/projection rep ea U1 RR 7.57$
E0967 Man wc rim/projection rep ea U1 75.62$
E0971 Wheelchair anti-tipping devi U1 RR 4.09$
E0971 Wheelchair anti-tipping devi U1 40.85$
E0973 W/ch access det adj armrest U1 KE 83.58$
E0973 W/ch access det adj armrest U1 RR KE 8.09$
E0973 W/ch access det adj armrest U1 RR 7.42$
E0973 W/ch access det adj armrest U1 76.54$
E0974 W/ch access anti-rollback U1 RR 8.64$
E0974 W/ch access anti-rollback U1 83.70$
E0978 W/c acc,saf belt pelv strap U1 KE 33.47$
E0978 W/c acc,saf belt pelv strap U1 RR KE 3.35$
E0978 W/c acc,saf belt pelv strap U1 RR 3.09$
E0978 W/c acc,saf belt pelv strap U1 30.86$
E0981 Seat upholstery, replacement U1 KE 42.65$
E0981 Seat upholstery, replacement U1 RR KE 4.34$
E0981 Seat upholstery, replacement U1 RR 4.05$
E0981 Seat upholstery, replacement U1 39.77$
E0982 Back upholstery, replacement U1 KE 46.62$
E0982 Back upholstery, replacement U1 RR KE 4.66$
E0982 Back upholstery, replacement U1 RR 4.35$
E0982 Back upholstery, replacement U1 43.46$
E0985 W/c seat lift mechanism U1 RR 23.00$
E0990 Wheelchair elevating leg res U1 KE 103.04$
E0990 Wheelchair elevating leg res U1 RR KE 10.30$
E0990 Wheelchair elevating leg res U1 RR 9.46$
E0990 Wheelchair elevating leg res U1 94.66$
E0992 Wheelchair solid seat insert U1 RR 9.45$
E0992 Wheelchair solid seat insert U1 94.45$
E0995 Wc calf rest, pad replacemnt U1 KE 30.31$
E0995 Wc calf rest, pad replacemnt U1 RR KE 3.04$
E0995 Wheelchair calf rest U1 RR 2.82$
E0995 Wheelchair calf rest U1 28.12$
E1002 Pwr seat tilt U1 RR KE 411.22$
E1002 Pwr seat tilt U1 RR 382.06$
E1003 Pwr seat recline U1 RR KE 461.29$
E1003 Pwr seat recline U1 RR 429.69$
E1004 Pwr seat recline mech U1 RR KE 509.41$
E1004 Pwr seat recline mech U1 RR 474.38$
E1005 Pwr seat recline pwr U1 RR KE 554.08$
E1005 Pwr seat recline pwr U1 RR 516.17$
E1006 Pwr seat combo w/o shear U1 RR KE 680.75$
E1006 Pwr seat combo w/o shear U1 RR 634.30$
E1007 Pwr seat combo w/shear U1 RR KE 886.38$
E1007 Pwr seat combo w/shear U1 RR 823.49$
E1008 Pwr seat combo pwr shear U1 RR KE 896.44$
E1008 Pwr seat combo pwr shear U1 RR 833.55$
E1010 Add pwr leg elevation U1 RR KE 119.32$
E1010 Add pwr leg elevation U1 RR 111.09$
E1012 Ctr mount pwr elev leg rest U1 RR 111.09$
E1015 Shock absorber for man w/c U1 128.58$
E1016 Shock absorber for power w/c U1 KE 133.32$
E1016 Shock absorber for power w/c U1 RR KE 13.34$
E1016 Shock absorber for power w/c U1 RR 12.40$
E1016 Shock absorber for power w/c U1 123.87$
E1020 Residual limb support system U1 RR KE 23.25$
E1020 Residual limb support system U1 RR 21.50$
E1028 W/c manual swingaway U1 RR KE 18.80$
E1028 W/c manual swingaway U1 RR 17.31$
E1029 W/c vent tray fixed U1 RR KE 39.29$
E1029 W/c vent tray fixed U1 RR 36.63$
E1030 W/c vent tray gimbaled U1 RR KE 123.38$
E1030 W/c vent tray gimbaled U1 RR 114.99$
E1031 Rollabout chair with casters U1 RR 47.20$
E1036 Patient transfer system >300 U1 RR 945.89$
E1037 Transport chair, ped size U1 RR 118.80$
E1038 Transport chair pt wt<=300lb U1 RR 18.09$
E1039 Transport chair pt wt >300lb U1 RR 37.01$
E1225 Manual semi-reclining back U1 RR 44.46$
E1226 Manual fully reclining back U1 RR 52.22$
E1226 Manual fully reclining back U1 513.08$
E1372 Oxy suppl heater for nebuliz U1 RR 18.20$
E1372 Oxy suppl heater for nebuliz U1 151.30$
E1390 Oxygen concentrator U1 RR 134.71$
E1391 Oxygen concentrator, dual U1 RR 134.71$
E1392 Portable oxygen concentrator U1 RR 44.32$
E1405 O2/water vapor enrich w/heat U1 RR 205.55$
E1406 O2/water vapor enrich w/o he U1 RR 157.28$
E2201 Man w/ch acc seat w>=20"<24" U1 RR 37.57$
E2201 Man w/ch acc seat w>=20"<24" U1 375.68$
E2202 Seat width 24-27 in U1 RR 50.73$
E2202 Seat width 24-27 in U1 507.25$
E2203 Frame depth less than 22 in U1 RR 49.50$
E2203 Frame depth less than 22 in U1 495.04$
E2204 Frame depth 22 to 25 in U1 RR 85.20$
E2204 Frame depth 22 to 25 in U1 851.97$
E2205 Manual wc accessory, handrim U1 RR 3.69$
E2205 Manual wc accessory, handrim U1 36.95$
E2206 Man wc whl lock comp repl ea U1 RR 4.32$
E2206 Man wc whl lock comp repl ea U1 43.31$
E2207 Crutch and cane holder U1 RR 4.89$
E2207 Crutch and cane holder U1 48.75$
E2208 Cylinder tank carrier U1 KE 107.44$
E2208 Cylinder tank carrier U1 RR KE 10.74$
E2208 Cylinder tank carrier U1 RR 9.89$
E2208 Cylinder tank carrier U1 98.90$
E2209 Arm trough each U1 KE 104.48$
E2209 Arm trough each U1 RR KE 10.46$
E2209 Arm trough each U1 RR 9.69$
E2209 Arm trough each U1 96.77$
E2210 Wheelchair bearings U1 KE 6.51$
E2210 Wheelchair bearings U1 RR KE 0.65$
E2210 Wheelchair bearings U1 RR 0.61$
E2210 Wheelchair bearings U1 6.03$
E2211 Pneumatic propulsion tire U1 RR 4.08$
E2211 Pneumatic propulsion tire U1 41.29$
E2212 Pneumatic prop tire tube U1 RR 0.68$
E2212 Pneumatic prop tire tube U1 6.63$
E2213 Pneumatic prop tire insert U1 RR 3.31$
E2213 Pneumatic prop tire insert U1 33.01$
E2214 Pneumatic caster tire each U1 RR 3.98$
E2214 Pneumatic caster tire each U1 37.78$
E2215 Pneumatic caster tire tube U1 RR 1.09$
E2215 Pneumatic caster tire tube U1 10.88$
E2219 Foam caster tire any size ea U1 RR 4.43$
E2219 Foam caster tire any size ea U1 40.95$
E2220 Solid propuls tire, repl, ea U1 RR 3.11$
E2220 Solid propuls tire, repl, ea U1 31.63$
E2221 Solid caster tire repl, each U1 RR 2.88$
E2221 Solid caster tire repl, each U1 28.57$
E2222 Solid caster integ whl, repl U1 RR 2.36$
E2222 Solid caster integ whl, repl U1 23.71$
E2224 Propulsion whl excl tire rep U1 RR 10.58$
E2224 Propulsion whl excl tire rep U1 105.67$
E2225 Caster wheel excludes tire U1 RR 1.98$
E2225 Caster wheel excludes tire U1 19.79$
E2226 Caster fork replacement only U1 RR 4.23$
E2226 Caster fork replacement only U1 42.32$
E2228 Mwc acc, wheelchair brake U1 RR 103.48$
E2231 Solid seat support base U1 RR 16.09$
E2231 Solid seat support base U1 160.91$
E2310 Electro connect btw control U1 RR KE 119.46$
E2310 Electro connect btw control U1 RR 111.04$
E2311 Electro connect btw 2 sys U1 RR KE 241.53$
E2311 Electro connect btw 2 sys U1 RR 224.48$
E2321 Hand interface joystick U1 RR KE 162.28$
E2321 Hand interface joystick U1 RR 150.85$
E2322 Mult mech switches U1 RR KE 148.13$
E2322 Mult mech switches U1 RR 137.99$
E2323 Special joystick handle U1 KE 72.45$
E2323 Special joystick handle U1 RR KE 7.24$
E2323 Special joystick handle U1 RR 6.74$
E2323 Special joystick handle U1 67.47$
E2324 Chin cup interface U1 KE 46.64$
E2324 Chin cup interface U1 RR KE 4.64$
E2324 Chin cup interface U1 RR 4.33$
E2324 Chin cup interface U1 43.48$
E2325 Sip and puff interface U1 RR KE 141.53$
E2325 Sip and puff interface U1 RR 131.84$
E2326 Breath tube kit U1 RR KE 36.78$
E2326 Breath tube kit U1 RR 34.28$
E2327 Head control interface mech U1 RR KE 275.58$
E2327 Head control interface mech U1 RR 256.78$
E2328 Head/extremity control inter U1 RR KE 521.54$
E2328 Head/extremity control inter U1 RR 485.88$
E2329 Head control nonproportional U1 RR KE 187.01$
E2329 Head control nonproportional U1 RR 174.31$
E2330 Head control proximity switc U1 RR KE 360.82$
E2330 Head control proximity switc U1 RR 336.20$
E2351 Electronic sgd interface U1 KE 741.79$
E2351 Electronic sgd interface U1 RR KE 74.18$
E2351 Electronic sgd interface U1 RR 69.15$
E2351 Electronic sgd interface U1 691.51$
E2359 Gr34 sealed leadacid battery U1 RR 18.76$
E2359 Gr34 sealed leadacid battery U1 187.52$
E2360 22nf nonsealed leadacid U1 RR 12.08$
E2360 22nf nonsealed leadacid U1 120.84$
E2361 22nf sealed leadacid battery U1 KE 139.42$
E2361 22nf sealed leadacid battery U1 RR KE 13.94$
E2361 22nf sealed leadacid battery U1 RR 12.94$
E2361 22nf sealed leadacid battery U1 129.39$
E2362 Gr24 nonsealed leadacid U1 RR 10.59$
E2362 Gr24 nonsealed leadacid U1 105.91$
E2363 Gr24 sealed leadacid battery U1 KE 181.76$
E2363 Gr24 sealed leadacid battery U1 RR KE 18.17$
E2363 Gr24 sealed leadacid battery U1 RR 16.84$
E2363 Gr24 sealed leadacid battery U1 168.38$
E2364 U1nonsealed leadacid battery U1 RR 11.65$
E2364 U1nonsealed leadacid battery U1 116.52$
E2365 U1 sealed leadacid battery U1 KE 103.85$
E2365 U1 sealed leadacid battery U1 RR KE 10.38$
E2365 U1 sealed leadacid battery U1 RR 9.57$
E2365 U1 sealed leadacid battery U1 95.77$
E2366 Battery charger, single mode U1 KE 209.14$
E2366 Battery charger, single mode U1 RR KE 20.95$
E2366 Battery charger, single mode U1 RR 19.33$
E2366 Battery charger, single mode U1 193.02$
E2367 Battery charger, dual mode U1 KE 421.36$
E2367 Battery charger, dual mode U1 RR KE 42.14$
E2367 Battery charger, dual mode U1 RR 37.91$
E2367 Battery charger, dual mode U1 379.06$
E2368 Pwr wc drivewheel motor repl U1 RR KE 50.72$
E2368 Pwr wc drivewheel motor repl U1 RR 47.00$
E2369 Pwr wc drivewheel gear repl U1 RR KE 45.81$
E2369 Pwr wc drivewheel gear repl U1 RR 42.57$
E2370 Pwr wc dr wh motor/gear comb U1 RR KE 73.33$
E2370 Pwr wc dr wh motor/gear comb U1 RR 67.55$
E2371 Gr27 sealed leadacid battery U1 KE 158.67$
E2371 Gr27 sealed leadacid battery U1 RR KE 15.87$
E2371 Gr27 sealed leadacid battery U1 RR 14.79$
E2371 Gr27 sealed leadacid battery U1 147.83$
E2373 Hand/chin ctrl spec joystick U1 RR KE 84.93$
E2373 Hand/chin ctrl spec joystick U1 RR 79.06$
E2374 Hand/chin ctrl std joystick U1 RR KE 54.76$
E2374 Hand/chin ctrl std joystick U1 RR 50.92$
E2375 Non-expandable controller U1 RR KE 83.96$
E2375 Non-expandable controller U1 RR 77.80$
E2376 Expandable controller, repl U1 RR KE 136.92$
E2376 Expandable controller, repl U1 RR 127.26$
E2377 Expandable controller, initl U1 RR KE 50.06$
E2377 Expandable controller, initl U1 RR 46.57$
E2378 Pw actuator replacement U1 RR 58.68$
E2381 Pneum drive wheel tire U1 KE 75.10$
E2381 Pneum drive wheel tire U1 RR KE 7.52$
E2381 Pneum drive wheel tire U1 RR 6.97$
E2381 Pneum drive wheel tire U1 69.62$
E2382 Tube, pneum wheel drive tire U1 KE 20.69$
E2382 Tube, pneum wheel drive tire U1 RR KE 2.07$
E2382 Tube, pneum wheel drive tire U1 RR 1.92$
E2382 Tube, pneum wheel drive tire U1 19.20$
E2383 Insert, pneum wheel drive U1 KE 153.06$
E2383 Insert, pneum wheel drive U1 RR KE 15.31$
E2383 Insert, pneum wheel drive U1 RR 14.21$
E2383 Insert, pneum wheel drive U1 142.13$
E2384 Pneumatic caster tire U1 KE 78.06$
E2384 Pneumatic caster tire U1 RR KE 7.82$
E2384 Pneumatic caster tire U1 RR 7.23$
E2384 Pneumatic caster tire U1 72.24$
E2385 Tube, pneumatic caster tire U1 KE 49.48$
E2385 Tube, pneumatic caster tire U1 RR KE 4.96$
E2385 Tube, pneumatic caster tire U1 RR 4.61$
E2385 Tube, pneumatic caster tire U1 45.92$
E2386 Foam filled drive wheel tire U1 KE 139.04$
E2386 Foam filled drive wheel tire U1 RR KE 13.91$
E2386 Foam filled drive wheel tire U1 RR 12.82$
E2386 Foam filled drive wheel tire U1 128.22$
E2387 Foam filled caster tire U1 KE 64.03$
E2387 Foam filled caster tire U1 RR KE 6.41$
E2387 Foam filled caster tire U1 RR 5.92$
E2387 Foam filled caster tire U1 59.18$
E2388 Foam drive wheel tire U1 KE 51.86$
E2388 Foam drive wheel tire U1 RR KE 5.19$
E2388 Foam drive wheel tire U1 RR 4.83$
E2388 Foam drive wheel tire U1 48.23$
E2389 Foam caster tire U1 KE 28.54$
E2389 Foam caster tire U1 RR KE 2.86$
E2389 Foam caster tire U1 RR 2.66$
E2389 Foam caster tire U1 26.57$
E2390 Solid drive wheel tire U1 KE 44.42$
E2390 Solid drive wheel tire U1 RR KE 4.44$
E2390 Solid drive wheel tire U1 RR 4.13$
E2390 Solid drive wheel tire U1 41.34$
E2391 Solid caster tire U1 KE 20.86$
E2391 Solid caster tire U1 RR KE 2.09$
E2391 Solid caster tire U1 RR 1.94$
E2391 Solid caster tire U1 19.39$
E2392 Solid caster tire, integrate U1 KE 52.66$
E2392 Solid caster tire, integrate U1 RR KE 5.28$
E2392 Solid caster tire, integrate U1 RR 4.89$
E2392 Solid caster tire, integrate U1 48.78$
E2394 Drive wheel excludes tire U1 KE 74.02$
E2394 Drive wheel excludes tire U1 RR KE 7.41$
E2394 Drive wheel excludes tire U1 RR 6.86$
E2394 Drive wheel excludes tire U1 68.50$
E2395 Caster wheel excludes tire U1 KE 53.76$
E2395 Caster wheel excludes tire U1 RR KE 5.38$
E2395 Caster wheel excludes tire U1 RR 4.99$
E2395 Caster wheel excludes tire U1 49.83$
E2396 Caster fork U1 KE 59.50$
E2396 Caster fork U1 RR KE 6.18$
E2396 Caster fork U1 RR 5.74$
E2396 Caster fork U1 55.43$
E2397 Pwc acc, lith-based battery U1 RR 47.09$
E2397 Pwc acc, lith-based battery U1 470.91$
E2402 Neg press wound therapy pump U1 RR 1,203.27$
E2601 Gen w/c cushion wdth < 22 in U1 KE 55.10$
E2601 Gen w/c cushion wdth < 22 in U1 50.70$
E2602 Gen w/c cushion wdth >=22 in U1 KE 111.73$
E2602 Gen w/c cushion wdth >=22 in U1 RR KE 11.18$
E2602 Gen w/c cushion wdth >=22 in U1 RR 10.32$
E2602 Gen w/c cushion wdth >=22 in U1 103.14$
E2603 Skin protect wc cus wd <22in U1 KE 139.92$
E2603 Skin protect wc cus wd <22in U1 RR KE 14.00$
E2603 Skin protect wc cus wd <22in U1 RR 12.91$
E2603 Skin protect wc cus wd <22in U1 129.02$
E2604 Skin protect wc cus wd>=22in U1 KE 183.24$
E2604 Skin protect wc cus wd>=22in U1 RR KE 18.32$
E2604 Skin protect wc cus wd>=22in U1 RR 16.97$
E2604 Skin protect wc cus wd>=22in U1 169.68$
E2605 Position wc cush wdth <22 in U1 KE 262.72$
E2605 Position wc cush wdth <22 in U1 RR KE 26.28$
E2605 Position wc cush wdth <22 in U1 RR 24.34$
E2605 Position wc cush wdth <22 in U1 243.36$
E2606 Position wc cush wdth>=22 in U1 KE 414.63$
E2606 Position wc cush wdth>=22 in U1 RR KE 41.47$
E2606 Position wc cush wdth>=22 in U1 RR 38.45$
E2606 Position wc cush wdth>=22 in U1 384.42$
E2607 Skin pro/pos wc cus wd <22in U1 KE 270.98$
E2607 Skin pro/pos wc cus wd <22in U1 RR KE 27.10$
E2607 Skin pro/pos wc cus wd <22in U1 RR 25.01$
E2607 Skin pro/pos wc cus wd <22in U1 250.12$
E2608 Skin pro/pos wc cus wd>=22in U1 KE 331.68$
E2608 Skin pro/pos wc cus wd>=22in U1 RR KE 33.16$
E2608 Skin pro/pos wc cus wd>=22in U1 RR 30.66$
E2608 Skin pro/pos wc cus wd>=22in U1 306.64$
E2611 Gen use back cush wdth <22in U1 KE 259.28$
E2611 Gen use back cush wdth <22in U1 RR KE 25.92$
E2611 Gen use back cush wdth <22in U1 RR 23.67$
E2611 Gen use back cush wdth <22in U1 236.80$
E2612 Gen use back cush wdth>=22in U1 KE 399.74$
E2612 Gen use back cush wdth>=22in U1 RR KE 39.97$
E2612 Gen use back cush wdth>=22in U1 RR 36.93$
E2612 Gen use back cush wdth>=22in U1 369.34$
E2613 Position back cush wd <22in U1 KE 384.89$
E2613 Position back cush wd <22in U1 RR KE 38.50$
E2613 Position back cush wd <22in U1 RR 35.67$
E2613 Position back cush wd <22in U1 356.61$
E2614 Position back cush wd>=22in U1 KE 547.45$
E2614 Position back cush wd>=22in U1 RR KE 54.75$
E2614 Position back cush wd>=22in U1 RR 50.83$
E2614 Position back cush wd>=22in U1 508.32$
E2615 Pos back post/lat wdth <22in U1 KE 441.30$
E2615 Pos back post/lat wdth <22in U1 RR KE 44.14$
E2615 Pos back post/lat wdth <22in U1 RR 40.88$
E2615 Pos back post/lat wdth <22in U1 408.76$
E2616 Pos back post/lat wdth>=22in U1 KE 594.02$
E2616 Pos back post/lat wdth>=22in U1 RR KE 59.40$
E2616 Pos back post/lat wdth>=22in U1 RR 55.02$
E2616 Pos back post/lat wdth>=22in U1 550.23$
E2619 Replace cover w/c seat cush U1 KE 53.08$
E2619 Replace cover w/c seat cush U1 RR KE 5.31$
E2619 Replace cover w/c seat cush U1 RR 4.94$
E2619 Replace cover w/c seat cush U1 49.39$
E2620 Wc planar back cush wd <22in U1 KE 508.73$
E2620 Wc planar back cush wd <22in U1 RR KE 50.88$
E2620 Wc planar back cush wd <22in U1 RR 46.94$
E2620 Wc planar back cush wd <22in U1 469.33$
E2621 Wc planar back cush wd>=22in U1 KE 560.56$
E2621 Wc planar back cush wd>=22in U1 RR KE 56.06$
E2621 Wc planar back cush wd>=22in U1 RR 51.92$
E2621 Wc planar back cush wd>=22in U1 519.21$
E2622 Adj skin pro w/c cus wd<22in U1 KE 340.10$
E2622 Adj skin pro w/c cus wd<22in U1 RR KE 34.02$
E2622 Adj skin pro w/c cus wd<22in U1 RR 31.63$
E2622 Adj skin pro w/c cus wd<22in U1 316.26$
E2623 Adj skin pro wc cus wd>=22in U1 KE 431.57$
E2623 Adj skin pro wc cus wd>=22in U1 RR KE 43.16$
E2623 Adj skin pro wc cus wd>=22in U1 RR 40.13$
E2623 Adj skin pro wc cus wd>=22in U1 401.23$
E2624 Adj skin pro/pos cus<22in U1 KE 344.11$
E2624 Adj skin pro/pos cus<22in U1 RR KE 34.42$
E2624 Adj skin pro/pos cus<22in U1 RR 32.01$
E2624 Adj skin pro/pos cus<22in U1 320.06$
E2625 Adj skin pro/pos wc cus>=22 U1 KE 431.25$
E2625 Adj skin pro/pos wc cus>=22 U1 RR KE 43.12$
E2625 Adj skin pro/pos wc cus>=22 U1 RR 40.08$
E2625 Adj skin pro/pos wc cus>=22 U1 400.81$
E2626 Seo mobile arm sup att to wc U1 RR 68.57$
E2626 Seo mobile arm sup att to wc U1 685.57$
E2627 Arm supp att to wc rancho ty U1 RR 109.09$
E2627 Arm supp att to wc rancho ty U1 1,090.74$
E2628 Mobile arm supports reclinin U1 RR 74.55$
E2628 Mobile arm supports reclinin U1 745.61$
E2629 Friction dampening arm supp U1 RR 100.81$
E2629 Friction dampening arm supp U1 1,008.08$
E2630 Monosuspension arm/hand supp U1 RR 72.53$
E2630 Monosuspension arm/hand supp U1 725.32$
E2631 Elevat proximal arm support U1 RR 26.10$
E2631 Elevat proximal arm support U1 260.87$
E2632 Offset/lat rocker arm w/ela U1 RR 16.44$
E2632 Offset/lat rocker arm w/ela U1 164.48$
E2633 Mobile arm support supinator U1 RR 15.44$
E2633 Mobile arm support supinator U1 154.37$
K0001 Standard wheelchair U1 RR 39.91$
K0002 Stnd hemi (low seat) whlchr U1 RR 68.24$
K0003 Lightweight wheelchair U1 RR 69.95$
K0004 High strength ltwt whlchr U1 RR 99.56$
K0006 Heavy duty wheelchair U1 RR 105.78$
K0007 Extra heavy duty wheelchair U1 RR 139.22$
K0017 Detach adjust armrest base U1 KE 52.07$
K0017 Detach adjust armrest base U1 48.39$
K0018 Detach adjust armrst upper U1 KE 29.24$
K0018 Detach adjust armrst upper U1 27.19$
K0019 Arm pad each U1 KE 16.75$
K0019 Arm pad repl, each U1 15.51$
K0020 Fixed adjust armrest pair U1 KE 48.97$
K0020 Fixed adjust armrest pair U1 45.62$
K0037 Hi mount flip-up footrest ea U1 KE 44.53$
K0037 Hi mount flip-up footrest ea U1 RR KE 4.46$
K0037 High mount flip-up footrest U1 RR 4.16$
K0037 High mount flip-up footrest U1 41.52$
K0038 Leg strap each U1 KE 25.30$
K0038 Leg strap each U1 RR KE 2.53$
K0038 Leg strap each U1 RR 2.36$
K0038 Leg strap each U1 23.56$
K0039 Leg strap h style each U1 KE 55.33$
K0039 Leg strap h style each U1 RR KE 5.55$
K0039 Leg strap h style each U1 RR 5.16$
K0039 Leg strap h style each U1 51.45$
K0040 Adjustable angle footplate U1 KE 69.88$
K0040 Adjustable angle footplate U1 RR KE 6.98$
K0040 Adjustable angle footplate U1 RR 6.44$
K0040 Adjustable angle footplate U1 64.51$
K0041 Large size footplate each U1 KE 53.69$
K0041 Large size footplate each U1 RR KE 5.39$
K0041 Large size footplate each U1 RR 5.01$
K0041 Large size footplate each U1 49.88$
K0042 Standard size footplate each U1 KE 35.87$
K0042 Standard size footplate each U1 RR KE 3.58$
K0042 Standard size ftplate rep ea U1 RR 3.32$
K0042 Standard size ftplate rep ea U1 33.25$
K0043 Ftrst lower extension tube U1 KE 20.45$
K0043 Ftrst lower extension tube U1 RR KE 2.04$
K0043 Ftrst lowr exten tube rep ea U1 RR 1.90$
K0043 Ftrst lowr exten tube rep ea U1 19.05$
K0044 Ftrst upper hanger bracket U1 KE 17.60$
K0044 Ftrst upper hanger bracket U1 RR KE 1.77$
K0044 Ftrst upr hanger brac rep ea U1 RR 1.65$
K0044 Ftrst upr hanger brac rep ea U1 16.41$
K0045 Footrest complete assembly U1 KE 58.98$
K0045 Ftrst compl assembly repl ea U1 54.90$
K0046 Elev lgrst lwr exten repl ea U1 KE 20.52$
K0046 Elevat legrst low extension U1 19.11$
K0047 Elev legrst upr hangr rep ea U1 KE 76.76$
K0047 Elevat legrst up hangr brack U1 71.26$
K0050 Ratchet assembly U1 KE 33.92$
K0050 Ratchet assembly replacement U1 31.58$
K0051 Cam rel asm ft/legrst rep ea U1 KE 54.34$
K0051 Cam relese assem ftrst/lgrst U1 50.55$
K0052 Swingaway detach footrest U1 KE 89.69$
K0052 Swingaway detach ftrest repl U1 83.04$
K0053 Elevate footrest articulate U1 KE 102.20$
K0053 Elevate footrest articulate U1 94.86$
K0056 Seat ht <17 or >=21 ltwt wc U1 104.07$
K0065 Spoke protectors U1 50.13$
K0069 Rr whl compl sol tire rep ea U1 107.10$
K0071 Fr cstr comp pne tire rep ea U1 120.06$
K0072 Fr cstr semi-pne tire rep ea U1 73.39$
K0073 Caster pin lock each U1 38.64$
K0077 Fr cstr asmb sol tire rep ea U1 61.99$
K0098 Drive belt for pwc, repl U1 KE 28.05$
K0098 Drive belt power wheelchair U1 26.09$
K0105 Iv hanger U1 RR 10.94$
K0105 Iv hanger U1 109.39$
K0552 Sup/ext non-ins inf pump syr U1 2.88$
K0601 Repl batt silver oxide 1.5 v U1 1.25$
K0602 Repl batt silver oxide 3 v U1 7.13$
K0603 Repl batt alkaline 1.5 v U1 0.64$
K0604 Repl batt lithium 3.6 v U1 6.85$
K0605 Repl batt lithium 4.5 v U1 16.42$
K0733 12-24hr sealed lead acid U1 KE 32.10$
K0733 12-24hr sealed lead acid U1 RR KE 3.22$
K0733 12-24hr sealed lead acid U1 RR 3.00$
K0733 12-24hr sealed lead acid U1 29.93$
K0738 Portable gas oxygen system U1 RR 44.32$
K0800 Pov group 1 std up to 300lbs U1 RR 108.30$
K0800 Pov group 1 std up to 300lbs U1 1,082.89$
K0801 Pov group 1 hd 301-450 lbs U1 RR 184.13$
K0801 Pov group 1 hd 301-450 lbs U1 1,841.43$
K0802 Pov group 1 vhd 451-600 lbs U1 RR 224.61$
K0802 Pov group 1 vhd 451-600 lbs U1 2,246.11$
K0806 Pov group 2 std up to 300lbs U1 RR 145.88$
K0806 Pov group 2 std up to 300lbs U1 1,458.83$
K0807 Pov group 2 hd 301-450 lbs U1 RR 223.57$
K0807 Pov group 2 hd 301-450 lbs U1 2,235.71$
K0808 Pov group 2 vhd 451-600 lbs U1 RR 345.77$
K0808 Pov group 2 vhd 451-600 lbs U1 3,457.65$
K0813 Pwc gp 1 std port seat/back U1 RR 318.44$
K0814 Pwc gp 1 std port cap chair U1 RR 373.50$
K0815 Pwc gp 1 std seat/back U1 RR 420.21$
K0816 Pwc gp 1 std cap chair U1 RR 397.62$
K0820 Pwc gp 2 std port seat/back U1 RR 334.47$
K0821 Pwc gp 2 std port cap chair U1 RR 393.43$
K0822 Pwc gp 2 std seat/back U1 RR 455.88$
K0823 Pwc gp 2 std cap chair U1 RR 446.84$
K0824 Pwc gp 2 hd seat/back U1 RR 587.54$
K0825 Pwc gp 2 hd cap chair U1 RR 540.40$
K0826 Pwc gp 2 vhd seat/back U1 RR 851.15$
K0827 Pwc gp vhd cap chair U1 RR 732.74$
K0828 Pwc gp 2 xtra hd seat/back U1 RR 990.72$
K0829 Pwc gp 2 xtra hd cap chair U1 RR 935.40$
K0835 Pwc gp2 std sing pow opt s/b U1 RR 477.44$
K0836 Pwc gp2 std sing pow opt cap U1 RR 495.15$
K0837 Pwc gp 2 hd sing pow opt s/b U1 RR 585.46$
K0838 Pwc gp 2 hd sing pow opt cap U1 RR 521.89$
K0839 Pwc gp2 vhd sing pow opt s/b U1 RR 765.55$
K0840 Pwc gp2 xhd sing pow opt s/b U1 RR 1,165.87$
K0841 Pwc gp2 std mult pow opt s/b U1 RR 519.15$
K0842 Pwc gp2 std mult pow opt cap U1 RR 518.87$
K0843 Pwc gp2 hd mult pow opt s/b U1 RR 621.37$
87005 87511 87577 87831 88121 88321
87006 87512 87578 87832 88122 88323
RURAL AND NON-CONTIGUOUS ZIP CODES FOR USE WITH THE DME FEE SCHEDULE
87007 87513 87579 87901 88123 88324
87009 87514 87580 87930 88124 88325
87011 87515 87581 87931 88125 88330
87012 87516 87582 87933 88126 88336
87013 87517 87583 87935 88130 88337
87014 87518 87654 87939 88132 88338
87017 87519 87701 87942 88133 88339
87018 87520 87710 87943 88134 88340
87020 87521 87711 88009 88135 88341
87021 87522 87712 88020 88136 88342
87026 87523 87713 88022 88201 88343
87027 87524 87714 88023 88202 88344
87028 87525 87715 88025 88203 88345
87029 87527 87718 88026 88210 88346
87038 87528 87722 88028 88211 88347
87040 87529 87723 88029 88213 88348
87045 87530 87724 88030 88220 88349
87046 87531 87728 88031 88221 88350
87049 87532 87729 88034 88230 88351
87051 87533 87730 88036 88231 88352
87062 87537 87731 88038 88232 88353
87064 87538 87732 88039 88240 88354
87301 87539 87733 88040 88241 88355
87302 87543 87734 88041 88242 88401
87305 87544 87735 88042 88244 88410
87310 87545 87736 88043 88250 88411
87311 87547 87740 88045 88252 88414
87312 87548 87742 88049 88253 88415
87313 87549 87743 88051 88254 88416
87315 87551 87745 88053 88255 88417
87316 87552 87746 88055 88256 88418
87317 87553 87747 88056 88260 88419
87319 87554 87749 88061 88262 88421
87320 87556 87750 88062 88263 88422
87321 87557 87752 88065 88264 88424
87322 87558 87753 88101 88265 88426
87323 87560 87801 88102 88267 88427
87325 87562 87820 88103 88268 88430
87326 87564 87821 88112 88301 88431
87327 87565 87823 88113 88310 88433
87328 87566 87824 88114 88311 88434
87347 87569 87825 88115 88312 88435
87357 87571 87827 88116 88314 88436
87365 87573 87828 88118 88316 88439
87375 87575 87829 88119 88317
87510 87576 87830 88120 88318