Attachment A - RFI Total Wholesale Unit Prices For Covered Products~1.xlsx
XLSX spreadsheet 47 KB Posted
- Attached to
- 25EHSPMDMEO2SUPP: Supplier Durable Medical Equip. & Oxygen-Resp. Equip. Wholesale Suppliers RFI
- Solicitation number
- BD-25-1039-EHS01-ASHWA-116943
- Issued by
- Massachusetts
About this file
This document is an Excel-based Request for Information (RFI) for Wholesale Unit Prices for Covered Products, likely issued by a state or local government healthcare procurement agency. The RFI covers ten distinct product categories including Continuous Glucose Monitors, CPAP/BiPAP Equipment, Enteral/Parenteral Products, External Infusion Equipment, Miscellaneous Products, Nebulizer Products, Oxygen Supplies, Surgical Dressings, Tracheostomy Products, and Urological Equipment and Supplies. Bidders are required to provide comprehensive pricing information, including current wholesale unit prices and proposed wholesale unit prices for both preferred and exclusive supplier scenarios across multiple HCPCS (Healthcare Common Procedure Coding System) codes.
The pricing document requires detailed manufacturer/brand name listings, specific product descriptions, and precise unit pricing for each healthcare supply category. Bidders must complete pricing information for every HCPCS code within the product categories they choose to bid on, with the option to submit proposals for preferred or exclusive supplier status. The RFI appears designed to establish a comprehensive pricing framework for medical supplies, allowing potential suppliers to provide granular pricing details across a wide range of medical equipment and consumable products. The document's structure suggests a competitive bidding process aimed at establishing favorable wholesale pricing for various medical supply categories.
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Other files
| File | Type | Posted |
|---|---|---|
| DME OXY Supplier RFI.docx | DOCX document | |
| Amendment 1 to the DME OXY Supplier RFI.docx | DOCX document | |
| DME OXY Supplier RFI - Q and A.2.docx | DOCX document |
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Instructions
| Preferred Supplier Cost Proposal Instructions | |
| Exclusive Supplier Cost Proposal Instructions | |
| Cost Proposal Requirements- Preferred Supplier | Cost Proposal Requirements- Exclusive Supplier |
| 1. Bidders must provide the requested information for every HCPCS code within the product categories they choose to bid on. | 1. Bidders must provide the requested information for every HCPCS code within the product categories they choose to bid on. |
| 2. Bidders need only fill out the categories they wish to bid on. All other category tabs should be left blank. | 2. Bidders need only fill out the categories they wish to bid on. All other category tabs should be left blank. |
| Tab 1. Continuous Glucose Monitors and Supplies- | Tab 1. Continuous Glucose Monitors and Supplies |
| For HCPCS Codes A9276, A9277 and A9278 the Bidder shall provide | For HCPCS Codes A9276, A9277 and A9278 the Bidder shall provide |
| The Current Wholesale Unit Price for the specified product/brands | The Current Wholesale Unit Price for the specified product/brands |
| Proposed Preferred Supplier Wholesale Unit Prices for the specified product/brands | Proposed Wholesale Unit Prices for the specified product/brands if chosen as the Exclusive Preferred Supplier |
| For the remainder of the HCPCS Codes, the supplier shall provide | For the remainder of the HCPCS Codes, the Bidder shall provide |
| List of each Product (Manufacturer/Brand Name) that will be provided under the Preferred Supplier Agreement for each HCPCS Code | List of each Product (Manufacturer/Brand Name) that will be provided under the Exclusive Supplier Agreement for each HCPCS Code |
| The Current Wholesale Unit Price for the identified Products | The Current Wholesale Unit Price for the identified Products |
| Proposed Preferred Supplier Wholesale Unit Prices for the identified product/brands | Proposed Wholesale Unit Prices for the identified product/brands if chosen as the Exclusive Preferred Supplier |
| Tab 2. CPAP and BiPAP Equipment and Supplies | Tab 2. CPAP and BiPAP Equipment and Supplies |
| For HCPCS Codes E0470, E0471, E0472 and E0601 the Bidder shall provide | For HCPCS Codes E0470, E0471, E0472 and E0601 the Bidder shall provide |
| The Current Wholesale Unit Price for the specified product/brands | The Current Wholesale Unit Price for the specified product/brands |
| Proposed Preferred Supplier Wholesale Unit Prices for the specified product/brands | Proposed Wholesale Unit Prices for the specified product/brands if chosen as the Exclusive Preferred Supplier |
| For the remainder of the HCPCS Codes, the Bidder shall provide | For the remainder of the HCPCS Codes, the Bidder shall provide |
| List of each Product (Manufacturer/Brand Name) that will be provided under the Preferred Supplier Agreement for each HCPCS Code | List of each Product (Manufacturer/Brand Name) that will be provided under the Exclusive Supplier Agreement for each HCPCS Code |
| The Current Wholesale Unit Price for the identified Products | The Current Wholesale Unit Price for the identified Products |
| Proposed Preferred Supplier Wholesale Unit Prices for the identified product/brands | Proposed Wholesale Unit Prices for the identified product/brands if chosen as the Exclusive Preferred Supplier |
| Tab 3. Enteral Parenteral Products and Supplies | |
| For HCPCS Codes B4154 BO and BA, B4160 BO and BA, B4150 BO and BA, B4152 BO and BA, B4153 BO and BA the Bidder shall provide | Tab 3. Enteral Parenteral Products and Supplies |
| The Current Wholesale Unit Price for the specified product/brands | For HCPCS Codes B4154 BO and BA, B4160 BO and BA, B4150 BO and BA, B4152 BO and BA, B4153 BO and BA the Bidder shall provide |
| Proposed Preferred Supplier Wholesale Unit Prices for the specified product/brands if chosen as a Non-Exclusive Preferred Supplier | The Current Wholesale Unit Price for the specified product/brands |
| For the remainder of the HCPCS Codes, the Bidder shall provide | Proposed Wholesale Unit Prices for the specified product/brands if chosen as the Exclusive Preferred Supplier |
| List of each Product (Manufacturer/Brand Name) that will be provided under the Preferred Supplier Agreement for each HCPCS Code | For the remainder of the HCPCS Codes, the Bidder shall provide |
| The Current Wholesale Unit Price for the identified Products | List of each Product (Manufacturer/Brand Name) that will be provided under the Exclusive Supplier Agreement for each HCPCS Code |
| Proposed Preferred Supplier Wholesale Unit Prices for the identified product/brands | The Current Wholesale Unit Price for the identified Products |
| Proposed Wholesale Unit Prices for the identified product/brands if chosen as the Exclusive Preferred Supplier | |
| Tab 4. External Infusion Equipment and Supplies | |
| For HCPCS Codes A9274 and E0784 the Bidder shall provide | Tab 4. External Infusion Equipment and Supplies |
| The Current Wholesale Unit Price for the specified product/brands | For HCPCS Codes A9274 and E0784 the Bidder shall provide |
| Proposed Preferred Supplier Wholesale Unit Prices for the specified product/brands | The Current Wholesale Unit Price for the specified product/brands |
| For the remainder of the HCPCS Codes, the Bidder shall provide | Proposed Wholesale Unit Prices for the specified product/brands if chosen as the Exclusive Preferred Supplier |
| List of each Product (Manufacturer/Brand Name) that will be provided under the Preferred Supplier Agreement for each HCPCS Code | For the remainder of the HCPCS Codes, the Bidder shall provide |
| The Current Wholesale Unit Price for the identified Products | List of each Product (Manufacturer/Brand Name) that will be provided under the Exclusive Supplier Agreement for each HCPCS Code |
| Proposed Preferred Supplier Wholesale Unit Prices for the identified product/brands | The Current Wholesale Unit Price for the identified Products |
| Proposed Wholesale Unit Prices for the identified product/brands if chosen as the Exclusive Preferred Supplier | |
| Tabs 5 - 10: Miscellaneous Products, Nebulizer Products and Supplies, Oxygen Supplies, Surgical Dressings and Supplies Tracheostomy Products and Supplies, and Urology Products and SuppliesTab | |
| The Bidder shall provide | |
| List of each Product (Manufacturer/Brand Name) that will be provided under the Preferred Supplier Agreement for each HCPCS Code | |
| The Current Wholesale Unit Price for the identified Products | |
| Proposed Preferred Supplier Wholesale Unit Prices for the identified product/brands |
1. CGM Wholesale Price
| 1. Continuous Glucose Monitors and Supplies | ||||
| HCPCS Code | Modifier | Description | Product Manufacture/Brand Name(s) | Current Wholesale Unit Price(s) |
| A9276 | Sensor, invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system. | Dexcom G6 | ||
| Dexcom G7 | ||||
| Medtronic Enlite System | ||||
| Medtronic Guardian | ||||
| FreeStyle Libre 2 | ||||
| FreeStyle Libre 3 | ||||
| MiniMed | ||||
| A9277 | Transmitter, external for use with interstitial continuous glucose monitoring system. | Dexcom G6 | ||
| Dexcom G7 | ||||
| Medtronic Guardian | ||||
| FreeStyle Libre 2 | ||||
| FreeStyle Libre 3 | ||||
| A9278 | Receiver (monitor), external for use with interstitial continuous glucose monitoring system. | Dexcom G6 | ||
| Dexcom G7 | ||||
| Medtronic Guardian | ||||
| FreeStyle Libre 2 | ||||
| FreeStyle Libre 3 | ||||
| A4233 | NU | Replacement battery, alkaline (other than j cell), for use with medically necessary home blood glucose monitor owned by patient, each | ||
| A4234 | NU | Replacement battery, alkaline, j cell, for use with medically necessary home blood glucose monitor owned by patient, each. | ||
| A4235 | NU | Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each. | ||
| A4236 | NU | Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each. | ||
| A4239 | Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, | |||
| A4244 | Alcohol or peroxide, per pint. | |||
| A4245 | Alcohol wipes, per box | |||
| A4246 | Betadine or phisoHex solution, per pint. | |||
| A4247 | Betadine or iodine swabs/wipes, per box | |||
| A4250 | Urine test or reagent strips or tablets (100 tablets or strips). | |||
| A4253 | NU KS | Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips. | ||
| A4253 | NU KX | Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips. | ||
| A4256 | Normal, low and high calibrator solution / chips. | |||
| A4258 | Spring-powered device for lancet, each | |||
| E0607 | NU | Home blood glucose monitor. | ||
| E2100 | NU | Blood glucose monitor with integrated voice synthesizer. | ||
| E2101 | NU | Blood glucose monitor with integrated lancing/blood sample. | ||
| E2103 | NU | Non-adjunctive, non-implanted continuous glucose monitor or receiver |
2. PAP Wholesale Price
| 2. Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) Equipment and Supplies | ||||
| HCPCS Code | Modifier | Description | Product Manufacture/Brand Name(s) | Current Wholesale Unit Price(s) |
| E0470 | NU | Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask. (intermittent assist device with continuous positive airway pressure device) | ||
| E0471 | NU | Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask. (intermittent assist device with continuous positive airway pressure device) | ||
| E0472 | NU | Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with invasive interface, e.g., tracheostomy tube (humidifier not included) | ||
| E0601 | NU | Continuous positive airway pressure (CPAP) device. | ||
| A4604 | NU | Tubing with integrated heating element to used with positive pressure device. | ||
| A7027 | NU | Combination oral/nasal mask, used with continuous positive airway pressure device, each | ||
| A7028 | NU | Oral cushion for combination oral/nasal mask, replacement only, each | ||
| A7029 | NU | Nasal pillows for combination oral/nasal mask, replacement only, pair. | ||
| A7030 | NU | Full face mask used with positive airway pressure device, each. | ||
| A7031 | NU | Face mask interface, replacement for full face mask, each. | ||
| A7032 | NU | Replacement cushion for nasal application device, each. | ||
| A7033 | NU | Replacement pillows for nasal application device, pair. | ||
| A7034 | NU | Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap. | ||
| A7035 | NU | Headgear used with positive airway pressure device. | ||
| A7036 | NU | Chinstrap used with positive airway pressure device. | ||
| A7037 | NU | Tubing used with positive airway pressure device. | ||
| A7038 | NU | Filter, disposable, used with positive airway pressure device. | ||
| A7039 | NU | Filter, non disposable, used with positive airway pressure device. | ||
| A7044 | NU | Oral interface used with positive airway pressure device, each. | ||
| A7045 | NU | Exhalation port with or without swivel used with accessories for positive airway devices, replacement only. | ||
| A7046 | NU | Water chamber for humidifier, used with positive pressure device, replacement, each. | ||
| E0561 | NU | Humidifier, non-heated, used with positive airway pressure device. | ||
| E0562 | NU | Humidifier, heated, used with positive airway pressure device. |
3. Enteral Wholesale Price
| 3. Enteral and Parenteral Products and Supplies | ||||
| HCPCS Code | Modifier | Description | Product Manufacture/Brand Name(s) | Current Wholesale Unit Price(s) |
| B4154 | BO | Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (item furnished in conjunction with PEN services) | Glucerna | |
| B4154 | BA | Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (item furnished in conjunction with PEN services) | Glucerna | |
| B4160 | BO | Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (Item furnished in conjunction with PEN services.). | Pediasure | |
| B4160 | BA | Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (Item furnished in conjunction with PEN services.). | Pediasure | |
| B4150 | BA | Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.(item furnished in conjunction with PEN services). | ||
| B4150 | BO | Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube,100 calories = 1 unit (orally administered, 1 can = 1 unit) | ||
| B4152 | BA | Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit. (item furnished in conjunction with PEN services). | ||
| B4152 | BO | Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube.100 calories = 1 unit (orally administered, 1 can = 1 unit) | ||
| B4153 | BA | Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (item furnished in conjunction with PEN services). | ||
| B4153 | BO | Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube.100 calories = 1 unit (orally administered, 1 can = 1 unit) | ||
| B4034 | Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressing, tape. | |||
| B4035 | Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressing, tape. | |||
| B4036 | Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressing, tape. | |||
| B4081 | Nasogastric tubing with stylet. | |||
| B4082 | Nasogastric tubing without stylet. | |||
| B4087 | NU | Gastrostomy/jejunostomy tube, standard, any material, any type, each. | ||
| B4088 | NU | Gastrostomy/jejunostomy tube, low-profile, any material, any type, each. | ||
| B4100 | BO | Food thickener, administered orally, per ounce. | ||
| B4185 | BA | Parenteral nutrition solution, per 10 grams lipids. | ||
| B4189 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix. | |||
| B4193 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix. | |||
| B4197 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix. | |||
| B4199 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix. | |||
| B4220 | Parenteral nutrition supply kit; premix, per day. | |||
| B4224 | Parenteral nutrition administration kit, per day. | |||
| B9002 | NU | Enteral nutrition infusion pump, any type. | ||
| B9004 | NU | Parenteral nutrition infusion pump, portable |
4. External Infus Wholesale Pri
| 4. External Infusion Equipment and Supplies | ||||
| HCPCS Code | Modifier | Description | Product Manufacture/Brand Name(s) | Current Wholesale Unit Price(s) |
| A9274 | External ambulatory insulin delivery system, disposable, each includes all supplies and accessories. | OmniPod | ||
| E0784 | NU | External ambulatory infusion pump, insulin. | Medtronic MiniMed 770G | |
| Medtronic MiniMed 780 | ||||
| OmniPod | ||||
| Beta Bionics iLet Insulin | ||||
| Pump | ||||
| Tandem T-Slim X2 | ||||
| A4220 | Refill kit for implantable infusion pump. | |||
| A4221 | Supplies for maintenance of non-insulin drug infusion catheter, per week (list drug separately). | |||
| A4222 | Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately). | |||
| A4223 | Infusion supplies not used with external infusion pump, Per cassette or bag (LIST DRUGS SEPARATELY) | |||
| A4224 | Supplies for maintenance of insulin infusion catheter, per week | |||
| A4225 | Supplies for external insulin infusion pump, syringe type cartridge, sterile, each | |||
| A4602 | Replacement battery for external infusion pump owned by patient, lithium. 1.5 volt, each. | |||
| E0776 | NU | IV pole. | ||
| E0776 | NU BA | IV pole. | ||
| E0779 | NU | Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater. | ||
| E0780 | NU | Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours. | ||
| E0781 | NU | Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient. | ||
| E0791 | NU | Parenteral infusion pump, stationary, single or multi-channel. | ||
| E1399 | U3 | Supplies for maintenance of insulin infusion pump, catheter each, (can be used for MassHealth members instead of A4224) | ||
| E1399 | U4 | Supplies for external insulin infusion pump, syringe type cartridge, sterile each (can be used for MassHeath members instead of A4225) | ||
| K0552 | Supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each. | |||
| K0601 | NU | Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each. | ||
| K0602 | NU | Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each. | ||
| K0603 | NU | Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each. | ||
| K0604 | NU | Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each. | ||
| K0605 | NU | Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each. |
5. MISC Wholesale Price
| 5. Miscellaneous Products | ||||
| HCPCS Code | Modifier | Description | Product Manufacture/Brand Name(s) | Current Wholesale Unit Price (s) |
| A4660 | Sphygmomanometer/blood pressure apparatus with cuff and stethoscope. | |||
| A4663 | Blood pressure cuff only. | |||
| A4670 | Automatic blood pressure monitor. | |||
| A4927 | Gloves, non-sterile, per 100. | |||
| A4930 | Gloves, sterile, per pair. | |||
| E0602 | NU | Breast pump, manual, any type. | ||
| E0605 | NU | Vaporizer, room type. | ||
| E0610 | NU | Pacemaker monitor, self-contained., (checks battery depletion, includes audible and visible check systems) |
6. Nebulizers Wholesale Price
| 6. Nebulizer Products and Supplies | ||||
| HCPCS Code | Modifier | Description | Product Manufacture/Brand Name(s) | Current Wholesale Unit Price(s) |
| A4216 | Sterile water, saline and/or dextrose, diluent/flush, 10 ml. | |||
| A4217 | NU | Sterile water/saline 500 ml. | ||
| E0565 | NU | Compressor, air power source for equipment which is not self- contained or cylinder driven. | ||
| E0570 | NU | Nebulizer, with compressor. | ||
| E0572 | NU | Aerosol compressor, adjustable pressure, light duty for intermittent use. | ||
| E0585 | NU | Nebulizer, with compressor and heater. | ||
| E1372 | NU | Immersion external heater for nebulizer. | ||
| K0730 | NU | Controlled dose inhalation drug delivery system | ||
| A4619 | NU | Face Tent | ||
| A7003 | NU | Administration set, with small volume nonfiltered pneumatic nebulizer, disposable. | ||
| A7004 | NU | Small volume nonfiltered pneumatic nebulizer, disposable. | ||
| A7005 | NU | Administration set, with small volume nonfiltered pneumatic nebulizer, non-disposable. | ||
| A7006 | NU | Administration set, with small volume filtered pneumatic nebulizer. | ||
| A7010 | NU | Corrugated tubing, disposable, used with large volume nebulizer, 100 feet. | ||
| A7012 | NU | Water collection device, used with large volume nebulizer. | ||
| A7013 | NU | Filter, disposable, used with aerosol compressor or ultrasonic generator. | ||
| A7014 | NU | Filter, nondisposable, used with aerosol compressor or ultrasonic generator. | ||
| A7015 | NU | Aerosol mask, used with DME nebulizer. | ||
| A7017 | NU | Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen. | ||
| A7018 | Water, distilled, used with large volume nebulizer, 1000 ml. | |||
| A7525 | Tracheostomy mask, each. |
7. Oxygen Wholesale Price
| 7. Oxygen and Respiratory Therapy Supplies | ||||
| HCPCS Code | Modifier | Description | Product Manufacture/Brand Name(s) | Current Wholesale Unit Price(s) |
| A4606 | Oxygen probe for use with oximeter device, replacement. | |||
| A4608 | Transtracheal oxygen catheter, each | |||
| A4614 | Peak expiratory flow rate meter, hand held. | |||
| A4619 | NU | Face Tent | ||
| A7525 | Tracheostomy mask, each. | |||
| A9900 | Miscellaneous DME supply, accessory and/or service component of another HCPCS code (for MassHealth Members only. Can be used in conjunction with HCPCS A9280 CO2 Monitoring Device) | |||
| E0445 | NU | Oximeter device for measuring blood oxygen levels non-invasively. |
8. Surg. Dressing Wholesale Pri
| 8. Surgical Dressings and Supplies | ||||
| HCPCS Code | Modifier | Description | Product Manufacture/Brand Name(s) | Current Wholesale Unit Price(s) |
| A4450 | AU | Tape, non-waterproof, per 18 square inches. | ||
| A4452 | AU | Tape, waterproof, per 18 square inches. | ||
| A4456 | Adhesive remover, wipes, any type, each. | |||
| A4461 | Surgical dressing holder, nonreusable, each. | |||
| A4463 | Surgical dressing holder, reusable, each. | |||
| A4490 | Surgical stockings above knee length, each. | |||
| A4495 | Surgical stockings thigh length, each. | |||
| A4500 | Surgical stockings below knee length, each. | |||
| A4510 | Surgical stockings full length, each. | |||
| A6010 | A1 | Collagen based wound filler, dry form, sterile, per gram of collagen. | ||
| A6011 | A1 | Collagen based wound filler, gel/paste, sterile, per gram of collagen. | ||
| A6021 | A1 | Collagen dressing, sterile, size 16 sq. in. or less, each | ||
| A6022 | A1 | Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each | ||
| A6023 | A1 | Collagen dressing, sterile, size more than 48 sq. in., each | ||
| A6024 | A1 | Collagen dressing wound filler, sterile, per 6 inches. | ||
| A6154 | A1 | Wound pouch, each. | ||
| A6196 | A1 | Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing. | ||
| A6197 | A1 | Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing. | ||
| A6198 | A1 | Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. in., each dressing. | ||
| A6199 | A1 | Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches. | ||
| A6203 | A1 | Composite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing. | ||
| A6204 | A1 | Composite dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing. | ||
| A6205 | A1 | Composite dressing, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing. | ||
| A6206 | A1 | Contact layer, sterile, 16 sq. in. or less, each dressing. | ||
| A6207 | A1 | Contact layer, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing. | ||
| A6208 | A1 | Contact layer, sterile, more than 48 sq. in., each dressing. | ||
| A6209 | A1 | Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing. | ||
| A6210 | A1 | Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing. | ||
| A6211 | A1 | Foam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing. | ||
| A6212 | A1 | Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing. | ||
| A6213 | A1 | Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing. | ||
| A6214 | A1 | Foam dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing. | ||
| A6215 | A1 | Foam dressing, wound filler, sterile, per gram. | ||
| A6216 | A1 | Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing. | ||
| A6217 | A1 | Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing. | ||
| A6218 | A1 | Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border, each dressing. | ||
| A6219 | A1 | Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing. | ||
| A6220 | A1 | Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing. | ||
| A6221 | A1 | Gauze, non-impregnated, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing. | ||
| A6222 | A1 | Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing. | ||
| A6223 | A1 | Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 square inches, but less than or equal to 48 square inches, without adhesive border, each dressing. | ||
| A6224 | A1 | Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 48 square inches, without adhesive border, each dressing. | ||
| A6228 | A1 | Gauze, impregnated, water or normal saline, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing. | ||
| A6229 | A1 | Gauze, impregnated, water or normal saline, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing. | ||
| A6230 | A1 | Gauze, impregnated, water or normal saline, sterile, pad size more than 48 sq. in., without adhesive border, each dressing | ||
| A6231 | A1 | Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size 16 sq. in. or less, each dressing. | ||
| A6232 | A1 | Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size greater than 16 sq. in., but less than or equal to 48 sq. in., each dressing. | ||
| A6233 | A1 | Gauze, impregnated, hydrogel for direct wound contact, sterile, pad size more than 48 sq. in., each dressing. | ||
| A6234 | A1 | Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing. | ||
| A6235 | A1 | Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing. | ||
| A6236 | A1 | Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing. | ||
| A6237 | A1 | Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing. | ||
| A6238 | A1 | Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing. | ||
| A6239 | A1 | Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing. | ||
| A6240 | A1 | Hydrocolloid dressing, wound filler, paste, sterile, per fluid ounce. | ||
| A6241 | A1 | Hydrocolloid dressing, wound filler, dry form, sterile, per gram. | ||
| A6242 | A1 | Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing. | ||
| A6243 | A1 | Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing. | ||
| A6244 | A1 | Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing. | ||
| A6245 | A1 | Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing. | ||
| A6246 | A1 | Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing. | ||
| A6247 | A1 | Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing. | ||
| A6248 | A1 | Hydrogel dressing, wound filler, gel, per fluid ounce. | ||
| A6250 | Skin sealants, protectants, moisturizers, ointments, any type, any size. | |||
| A6251 | A1 | Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing. | ||
| A6252 | A1 | Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing. | ||
| A6253 | A1 | Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing. | ||
| A6254 | A1 | Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing. | ||
| A6255 | A1 | Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing. | ||
| A6256 | A1 | Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing. | ||
| A6257 | A1 | Transparent film, sterile, 16 sq. in. or less, each dressing. | ||
| A6258 | A1 | Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing. | ||
| A6259 | A1 | Transparent film, sterile, more than 48 sq. in., each dressing. | ||
| A6260 | A1 | Wound cleansers, any type, any size. | ||
| A6266 | A1 | Gauze, impregnated, other than water, normal saline, or zinc paste, any width, per linear yard. | ||
| A6402 | A1 | Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing. | ||
| A6403 | A1 | Gauze, non-impregnated, sterile, pad size more than 16 sq. in. less than or equal to 48 sq. in., without adhesive border, each dressing. | ||
| A6404 | A1 | Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing. | ||
| A6407 | A1 | Packing strips, non-impregnated, sterile, up to 2 inch in width, per linear yard. | ||
| A6410 | Eye pad, sterile, each. | |||
| A6411 | Eye pad, non-sterile, each. | |||
| A6442 | A1 | Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three inches, per yard. | ||
| A6443 | A1 | Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three inches and less than five inches, per yard. | ||
| A6444 | A1 | Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than five inches, per yard. | ||
| A6445 | A1 | Conforming bandage, non-elastic, knitted/woven, sterile, width less than three inches, per yard. | ||
| A6446 | A1 | Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard. | ||
| A6447 | A1 | Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to five inches, per yard. | ||
| A6448 | A1 | Light compression bandage, elastic, knitted/woven, width less than three inches, per yard. | ||
| A6449 | A1 | Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard. | ||
| A6450 | A1 | Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches, per yard. | ||
| A6451 | A1 | Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to three inches or less than five inches, per yard. | ||
| A6452 | A1 | High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three inches or less than five inches, per yard. | ||
| A6453 | A1 | Self-adherent bandage, elastic, non-knitted/non-woven, less than three inches, per yard. | ||
| A6454 | A1 | Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three inches and less than five inches, per yard. | ||
| A6455 | A1 | Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to five inches, per yard. | ||
| A6456 | A1 | Zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard. | ||
| A6501 | Compression burn garment, bodysuit (head to foot), custom fabricated. | |||
| A6502 | Compression burn garment, chin strap, custom fabricated. | |||
| A6503 | Compression burn garment, facial hood, custom fabricated. | |||
| A6504 | Compression burn garment, glove to wrist, custom fabricated. | |||
| A6505 | Compression burn garment, glove to elbow, custom fabricated. | |||
| A6506 | Compression burn garment, glove to axilla, custom fabricated. | |||
| A6507 | Compression burn garment, foot to knee length, custom fabricated. | |||
| A6508 | Compression burn garment, foot to thigh length, custom fabricated. | |||
| A6509 | Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated. | |||
| A6510 | Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated. | |||
| A6511 | Compression burn garment, lower trunk including leg openings (panty), custom fabricated. | |||
| A6512 | Compression burn garment, not otherwise classified. | |||
| A6513 | Compression burn mask, face and/or neck, plastic or equal, custom fabricated. |
9. Trach Wholesale Price
| 9. Tracheostomy Equipment and Supplies | ||||
| HCPCS Code | Modifier | Description | Product Manufacture/Brand Name(s) | Current Wholesale Unit Price(s) |
| A4364 | Adhesive, liquid or equal, any type, per oz. | |||
| A4402 | Lubricant, per ounce. | |||
| A4450 | AU | Tape, non-waterproof, per 18 square inches. | ||
| A4450 | AW | Tape, non-waterproof, per 18 square inches. | ||
| A4452 | AU | Tape, waterproof, per 18 square inches. | ||
| A4452 | AW | Tape, waterproof, per 18 square inches. | ||
| A4456 | Adhesive remover, wipes, any type, each. | |||
| A4481 | Tracheostoma filter, any type, any size, each. | |||
| A4623 | Tracheostomy, inner cannula. | |||
| A4625 | Tracheostomy care kit for new tracheostomy. | |||
| A4626 | Tracheostomy cleaning brush, each. | |||
| A4629 | Tracheostomy care kit for established tracheostomy. | |||
| A5120 | AU | Skin barrier, wipes or swabs, each. | ||
| A7501 | Tracheostoma valve, including diaphragm, each. | |||
| A7502 | Replacement diaphragm/faceplate for tracheostoma valve, each. | |||
| A7503 | Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each. | |||
| A7504 | Filter for use in a tracheostoma heat and moisture exchange system, each. | |||
| A7505 | Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each. | |||
| A7506 | Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each. | |||
| A7507 | Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each. | |||
| A7508 | Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each. | |||
| A7509 | Filter holder and integrated filter and adhesive, for use as a tracheostoma heat and moisture exchange system, each. | |||
| A7520 | NU | Tracheostomy/laryngectomy tube, non-cuffed, polyvinyalchloride (PVC), silicone or equal, each. | ||
| A7521 | NU | Tracheostomy/laryngectomy tube, cuffed, polyvinyalchloride (PVC), silicone or equal, each. | ||
| A7522 | NU | Tracheostomy/laryngectomy tube, stainless steel [sterilzable and reusable], each. | ||
| A7523 | Tracheostomy shower protector, each. | |||
| A7524 | Tracheostoma stent/stud/button, each. | |||
| A7526 | Tracheostomy tube collar/holder, each. | |||
| A7527 | Tracheostomy/laryngectomy tube plug, each. |
10. Urology Wholesale Price
| 10. Urological Equipment and Supplies | ||||
| HCPCS Code | Modifier | Description | Product Manufacture/Brand Name(s) | Current Wholesale Unit Price(s) |
| A4217 | NU | Sterile water/saline 500 ml. | ||
| A4217 | AU | Sterile water/saline 500 ml. | ||
| A4310 | Insertion tray without drainage bag and without catheter (accessories only). | |||
| A4311 | Insertion tray without drainage bag with indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.) | |||
| A4312 | Insertion tray without drainage bag with indwelling catheter, foley type, two-way, all silicone. | |||
| A4313 | Insertion tray without drainage bag with indwelling catheter, foley type, three-way, for continuous irrigation. | |||
| A4314 | Insertion tray with drainage bag with indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.). | |||
| A4315 | Insertion tray with drainage bag with indwelling catheter, foley type, two-way, all silicone. | |||
| A4316 | Insertion tray with drainage bag with indwelling catheter, foley type, three-way, for continuous irrigation. | |||
| A4320 | Irrigation tray with bulb or piston syringe, any purpose. | |||
| A4321 | Therapeutic agent for urinary catheter irrigation. | |||
| A4322 | Irrigation syringe, bulb or piston, each. | |||
| A4326 | Male external catheter specialty type with integral collection chamber, each. | |||
| A4327 | Female external urinary collection device; meatal cup, each. | |||
| A4328 | Female external urinary collection device; pouch, each. | |||
| A4331 | Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each. | |||
| A4332 | Lubricant, individual sterile packet, each. | |||
| A4333 | Urinary catheter anchoring device, adhesive skin attachment, each. | |||
| A4334 | Urinary catheter anchoring device, leg strap, each. | |||
| A4338 | Indwelling catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each | |||
| A4340 | Indwelling catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each | |||
| A4344 | Indwelling catheter, foley type, two-way, all silicone, each. | |||
| A4346 | Indwelling catheter; foley type, three way for continuous irrigation, each. | |||
| A4349 | Male external catheter, with or without adhesive, disposable, each. | |||
| A4351 | Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each. | |||
| A4352 | Intermittent urinary catheter; coude (curved) tip, with or without coating (teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each. | |||
| A4353 | Intermittent urinary catheter, with insertion supplies. | |||
| A4354 | Insertion tray with drainage bag but without catheter. | |||
| A4355 | Irrigation tubing set for continuous bladder irrigation through a three-way indwelling foley catheter, each. | |||
| A4356 | External urethral clamp or compression device (not to be used for catheter clamp), each. | |||
| A4357 | Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each. | |||
| A4358 | Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each. | |||
| A4450 | AU | Tape, non-waterproof, per 18 square inches. | ||
| A4450 | AW | Tape, non-waterproof, per 18 square inches. | ||
| A4452 | AU | Tape, waterproof, per 18 square inches. | ||
| A4452 | AW | Tape, waterproof, per 18 square inches. | ||
| A5102 | Bedside drainage bottle with or without tubing, rigid or expandable, each. | |||
| A5105 | Urinary suspensory with leg bag, with or without tube, each. | |||
| A5112 | Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each. | |||
| A5131 | Appliance cleaner, incontinence and ostomy appliances, per 16 oz. | |||
| A5200 | Percutaneous catheter/tube anchoring device, adhesive skin attachment. |
File details come from the government source that posted it. Updated .