Regence BlueCross BlueShield of Oregon

CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
This communication is not intended to state or imply that certain codes are always paid in conjunction with
other codes. Payment is subject to standard claims adjudication, the member's benefits and eligibility at the
time of service, and Regence BCBSO payment policy and will be the lesser of billed charges or the plan allowable
amount.
Confidentiality Notice: This information is proprietary and confidential information of Regence BCBSO. It is for
the full use of the intended recipient(s) in assessing the Regence BCBSO fee schedule as it relates to the
recipient's practice. Any other use or disclosure to a third party is strictly prohibited, except as required by law
or otherwise allowed by the recipient's provider agreement.
Code
A4206
A4208
A4209
A4210
A4211
A4212
A4213
A4215
A4216
A4217
A4217AU
A4221
A4222
A4230
A4231
A4232
A4233
A4233NU
A4234
A4234NU
A4235
A4235NU
A4236
A4236NU
A4244
A4245
A4246
A4247
A4248
A4250
A4252
Modifier
AU
NU
NU
NU
NU
Description
1 CC sterile syringe&needle
3 CC sterile syringe&needle
5+ CC sterile syringe&needle
Nonneedle injection device
Supp for self-adm injections
Non coring needle or stylet
20+ CC syringe only
Sterile needle
Sterile water/saline, 10 ml
Sterile water/saline, 500 ml
Sterile water/saline, 500 ml
Maint drug infus cath per wk
Infusion supplies with pump
Infus insulin pump non needl
Infusion insulin pump needle
Syringe w/needle insulin 3cc
Alkalin batt for glucose mon
Alkalin batt for glucose mon
J-cell batt for glucose mon
J-cell batt for glucose mon
Lithium batt for glucose mon
Lithium batt for glucose mon
Silvr oxide batt glucose mon
Silvr oxide batt glucose mon
Alcohol or peroxide per pint
Alcohol wipes per box
Betadine/phisohex solution
Betadine/iodine swabs/wipes
Chlorhexidine antisept
Urine reagent strips/tablets
Blood ketone test or strip
Page 1 of 79
Maximum
Allowable
$0.32
$0.47
$0.64
$1.49
$14.00
$10.50
$0.43
$0.13
$0.24
$1.95
$1.95
$21.02
$41.70
$9.00
$3.75
$2.55
$0.76
$0.76
$3.43
$3.43
$2.21
$2.21
$1.58
$1.58
$2.48
$27.00
$7.67
$4.21
$1.60
$17.95
$3.67
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
A4253
A4253NU
A4255
A4256
A4256KL
A4257
A4258
A4258KL
A4259
A4259KL
A4265
A4267
A4280
A4281
A4282
A4283
A4284
A4285
A4286
A4290
A4310
A4311
A4312
A4313
A4314
A4315
A4316
A4320
A4321
A4322
A4326
A4327
A4328
A4330
A4331
A4332
A4333
A4334
A4335
A4336
A4338
A4340
A4344
A4346
NU
KL
KL
KL
Blood glucose/reagent strips
Blood glucose/reagent strips
Glucose monitor platforms
Calibrator solution/chips
Calibrator solution/chips
Replace Lensshield Cartridge
Lancet device each
Lancet device each
Lancets per box
Lancets per box
Paraffin
Male condom
Brst prsths adhsv attchmnt
Replacement breastpump tube
Replacement breastpump adpt
Replacement breastpump cap
Replcmnt breast pump shield
Replcmnt breast pump bottle
Replcmnt breastpump lok ring
Sacral nerve stim test lead
Insert tray w/o bag/cath
Catheter w/o bag 2-way latex
Cath w/o bag 2-way silicone
Catheter w/bag 3-way
Cath w/drainage 2-way latex
Cath w/drainage 2-way silcne
Cath w/drainage 3-way
Irrigation tray
Cath therapeutic irrig agent
Irrigation syringe
Male external catheter
Fem urinary collect dev cup
Fem urinary collect pouch
Stool collection pouch
Extension drainage tubing
Lube sterile packet
Urinary cath anchor device
Urinary cath leg strap
Incontinence supply
Urethral insert
Indwelling catheter latex
Indwelling catheter special
Cath indw foley 2 way silicn
Cath indw foley 3 way
Page 2 of 79
$8.25
$8.25
$3.89
$8.75
$8.75
$12.04
$8.75
$8.75
$0.25
$0.25
$3.33
$0.35
$3.41
$6.75
$10.89
$2.40
$6.11
$4.45
$3.71
$62.92
$4.98
$9.26
$10.70
$12.94
$15.77
$17.00
$18.30
$3.30
$8.02
$1.97
$6.73
$36.32
$10.36
$9.95
$2.11
$0.08
$1.43
$3.18
$0.31
$1.95
$7.64
$20.47
$10.32
$11.63
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
A4349
A4351
A4352
A4353
A4354
A4355
A4356
A4357
A4358
A4360
A4361
A4362
A4363
A4364
A4366
A4367
A4368
A4369
A4371
A4372
A4373
A4375
A4376
A4377
A4378
A4379
A4380
A4381
A4382
A4383
A4384
A4385
A4387
A4388
A4389
A4390
A4391
A4392
A4393
A4394
A4395
A4396
A4397
A4398
Disposable male external cat
Straight tip urine catheter
Coude tip urinary catheter
Intermittent urinary cath
Cath insertion tray w/bag
Bladder irrigation tubing
Ext ureth clmp or compr dvc
Bedside drainage bag
Urinary leg or abdomen bag
Disposable ext urethral dev
Ostomy face plate
Solid skin barrier
Ostomy clamp, replacement
Adhesive, liquid or equal
Ostomy vent
Ostomy belt
Ostomy filter
Skin barrier liquid per oz
Skin barrier powder per oz
Skin barrier solid 4x4 equiv
Skin barrier with flange
Drainable plastic pch w fcpl
Drainable rubber pch w fcplt
Drainable plstic pch w/o fp
Drainable rubber pch w/o fp
Urinary plastic pouch w fcpl
Urinary rubber pouch w fcplt
Urinary plastic pouch w/o fp
Urinary hvy plstc pch w/o fp
Urinary rubber pouch w/o fp
Ostomy faceplt/silicone ring
Ost skn barrier sld ext wear
Ost clsd pouch w att st barr
Drainable pch w ex wear barr
Drainable pch w st wear barr
Drainable pch ex wear convex
Urinary pouch w ex wear barr
Urinary pouch w st wear barr
Urine pch w ex wear bar conv
Ostomy pouch liq deodorant
Ostomy pouch solid deodorant
Peristomal hernia supprt blt
Irrigation supply sleeve
Ostomy irrigation bag
Page 3 of 79
$1.11
$1.00
$3.34
$4.00
$9.60
$6.70
$35.41
$6.45
$4.05
$0.49
$11.74
$2.61
$1.60
$3.70
$1.33
$6.27
$0.45
$4.69
$5.98
$4.05
$5.87
$12.92
$51.11
$4.61
$48.65
$22.00
$75.00
$4.96
$18.51
$59.59
$7.23
$3.84
$4.16
$4.58
$6.58
$8.85
$5.89
$9.15
$7.07
$2.58
$0.15
$30.44
$4.38
$17.67
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
A4399
A4400
A4402
A4404
A4405
A4406
A4407
A4408
A4409
A4410
A4411
A4412
A4413
A4414
A4415
A4416
A4417
A4418
A4419
A4420
A4421
A4422
A4423
A4424
A4425
A4426
A4427
A4428
A4429
A4430
A4431
A4432
A4433
A4434
A4435
A4450
A4450AU
A4450AV
A4450AW
A4452
A4452AU
A4452AV
A4452AW
A4455
AU
AV
AW
AU
AV
AW
Ostomy irrig cone/cath w brs
Ostomy irrigation set
Lubricant per ounce
Ostomy ring each
Nonpectin based ostomy paste
Pectin based ostomy paste
Ext wear ost skn barr <=4sq"
Ext wear ost skn barr >4sq"
Ost skn barr convex <=4 sq i
Ost skn barr extnd >4 sq
Ost skn barr extnd =4sq
Ost pouch drain high output
2 pc drainable ost pouch
Ost sknbar w/o conv<=4 sq in
Ost skn barr w/o conv >4 sqi
Ost pch clsd w barrier/filtr
Ost pch w bar/bltinconv/fltr
Ost pch clsd w/o bar w filtr
Ost pch for bar w flange/flt
Ost pch clsd for bar w lk fl
Ostomy supply misc
Ost pouch absorbent material
Ost pch for bar w lk fl/fltr
Ost pch drain w bar & filter
Ost pch drain for barrier fl
Ost pch drain 2 piece system
Ost pch drain/barr lk flng/f
Urine ost pouch w faucet/tap
Urine ost pouch w bltinconv
Ost urine pch w b/bltin conv
Ost pch urine w barrier/tapv
Os pch urine w bar/fange/tap
Urine ost pch bar w lock fln
Ost pch urine w lock flng/ft
1pc ost pch drain hgh output
Non-waterproof tape
Non-waterproof tape
Non-waterproof tape
Non-waterproof tape
Waterproof tape
Waterproof tape
Waterproof tape
Waterproof tape
Adhesive remover per ounce
Page 4 of 79
$9.22
$44.62
$1.21
$1.77
$4.89
$7.42
$6.50
$7.42
$5.25
$6.80
$4.60
$4.60
$4.60
$3.62
$4.51
$2.40
$3.84
$2.14
$1.28
$1.30
$9.61
$0.13
$1.50
$3.58
$2.51
$2.06
$2.25
$5.89
$6.21
$7.32
$4.72
$2.90
$2.75
$2.90
$6.26
$0.06
$0.06
$0.06
$0.06
$0.17
$0.17
$0.17
$0.17
$13.41
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
A4456
A4458
A4461
A4463
A4465
A4466
A4481
A4483
A4490
A4495
A4500
A4510
A4520
A4554
A4556
A4557
A4558
A4559
A4561
A4562
A4565
A4570
A4595
A4601
A4604
A4604NU
A4605
A4605NU
A4606
A4608
A4611
A4611NU
A4611RR
A4611UE
A4612
A4612NU
A4612RR
A4612UE
A4613
A4613NU
A4613RR
A4613UE
A4614
A4615
NU
NU
NU
RR
UE
NU
RR
UE
NU
RR
UE
Adhesive remover, wipes
Reusable enema bag
Surgicl dress hold non-reuse
Surgical dress holder reuse
Non-elastic extremity binder
Elastic garment/covering
Tracheostoma filter
Moisture exchanger
Above knee surgical stocking
Thigh length surg stocking
Below knee surgical stocking
Full length surg stocking
Incontinence garment anytype
Disposable underpads
Electrodes, pair
Lead wires, pair
Conductive gel or paste
Coupling gel or paste
Pessary rubber, any type
Pessary, non rubber,any type
Slings
Splint
TENS suppl 2 lead per month
Lith ion batt, non-pros use
Tubing with heating element
Tubing with heating element
Trach suction cath close sys
Trach suction cath close sys
Oxygen probe used w oximeter
Transtracheal oxygen cath
Heavy duty battery
Heavy duty battery
Heavy duty battery
Heavy duty battery
Battery cables
Battery cables
Battery cables
Battery cables
Battery charger
Battery charger
Battery charger
Battery charger
Hand-held PEFR meter
Cannula nasal
Page 5 of 79
$1.77
$2.80
$2.11
$8.59
$34.45
$32.25
$0.95
$5.22
$21.88
$18.69
$16.83
$25.95
$0.66
$0.75
$7.83
$14.00
$5.99
$0.10
$18.84
$32.02
$4.95
$16.04
$15.57
$106.08
$49.87
$49.87
$14.20
$14.20
$39.95
$43.42
$16.34
$157.64
$16.34
$118.24
$7.69
$75.47
$7.69
$57.55
$13.62
$136.14
$13.62
$98.45
$16.25
$0.51
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
A4616
A4617
A4618
A4618NU
A4618RR
A4618UE
A4619
A4619NU
A4620
A4623
A4624
A4624NU
A4625
A4626
A4627
A4628
A4628NU
A4629
A4630
A4630NU
A4633
A4633NU
A4635
A4635NU
A4635RR
A4635UE
A4636
A4636NU
A4636RR
A4636UE
A4637
A4637NU
A4637RR
A4637UE
A4639
A4639NU
A4640
A4640NU
A4640RR
A4640UE
A4927
A4930
A4931
A5051
NU
RR
UE
NU
NU
NU
NU
NU
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
NU
RR
UE
Tubing (oxygen) per foot
Mouth piece
Breathing circuits
Breathing circuits
Breathing circuits
Breathing circuits
Face tent
Face tent
Variable concentration mask
Tracheostomy inner cannula
Tracheal suction tube
Tracheal suction tube
Trach care kit for new trach
Tracheostomy cleaning brush
Spacer bag/reservoir
Oropharyngeal suction cath
Oropharyngeal suction cath
Tracheostomy care kit
Repl bat t.e.n.s. own by pt
Repl bat t.e.n.s. own by pt
Uvl replacement bulb
Uvl replacement bulb
Underarm crutch pad
Underarm crutch pad
Underarm crutch pad
Underarm crutch pad
Handgrip for cane etc
Handgrip for cane etc
Handgrip for cane etc
Handgrip for cane etc
Repl tip cane/crutch/walker
Repl tip cane/crutch/walker
Repl tip cane/crutch/walker
Repl tip cane/crutch/walker
Infrared ht sys replcmnt pad
Infrared ht sys replcmnt pad
Alternating pressure pad
Alternating pressure pad
Alternating pressure pad
Alternating pressure pad
Non-sterile gloves
Sterile, gloves per pair
Reusable oral thermometer
Pouch clsd w barr attached
Page 6 of 79
$0.75
$2.05
$0.82
$7.23
$0.82
$5.42
$1.20
$1.20
$0.51
$4.22
$1.40
$1.40
$4.47
$2.06
$10.00
$2.00
$2.00
$2.99
$3.42
$3.42
$38.75
$38.75
$0.50
$4.95
$0.50
$3.47
$0.35
$3.51
$0.35
$2.46
$1.00
$10.03
$1.00
$7.02
$271.14
$271.14
$5.18
$50.81
$5.18
$35.99
$4.58
$0.40
$3.39
$2.14
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
A5052
A5053
A5054
A5055
A5056
A5057
A5061
A5062
A5063
A5071
A5072
A5073
A5081
A5082
A5083
A5093
A5102
A5105
A5112
A5113
A5114
A5120
A5120AU
A5120AV
A5121
A5122
A5126
A5131
A5200
A5500
A5501
A5503
A5504
A5505
A5506
A5507
A5510
A5512
A5513
A6010
A6011
A6021
A6022
A6023
AU
AV
Clsd ostomy pouch w/o barr
Clsd ostomy pouch faceplate
Clsd ostomy pouch w/flange
Stoma cap
1 pc ost pouch w filter
1 pc ost pou w built-in conv
Pouch drainable w barrier at
Drnble ostomy pouch w/o barr
Drain ostomy pouch w/flange
Urinary pouch w/barrier
Urinary pouch w/o barrier
Urinary pouch on barr w/flng
Continent stoma plug
Continent stoma catheter
Stoma absorptive cover
Ostomy accessory convex inse
Bedside drain btl w/wo tube
Urinary suspensory
Urinary leg bag
Latex leg strap
Foam/fabric leg strap
Skin barrier, wipe or swab
Skin barrier, wipe or swab
Skin barrier, wipe or swab
Solid skin barrier 6x6
Solid skin barrier 8x8
Disk/foam pad +or- adhesive
Appliance cleaner
Percutaneous catheter anchor
Diab shoe for density insert
Diabetic custom molded shoe
Diabetic shoe w/roller/rockr
Diabetic shoe with wedge
Diab shoe w/metatarsal bar
Diabetic shoe w/off set heel
Modification diabetic shoe
Compression form shoe insert
Multi den insert direct form
Multi den insert custom mold
Collagen based wound filler
Collagen gel/paste wound fil
Collagen dressing <=16 sq in
Collagen drsg>16<=48 sq in
Collagen dressing >48 sq in
Page 7 of 79
$1.12
$1.24
$1.46
$1.68
$5.01
$10.32
$2.60
$1.68
$1.98
$6.72
$3.79
$2.90
$2.95
$7.60
$0.37
$2.54
$20.77
$43.79
$30.00
$3.04
$6.20
$0.30
$0.30
$0.30
$13.07
$19.34
$0.85
$11.92
$8.50
$39.95
$180.05
$29.34
$29.34
$29.34
$29.34
$29.34
$20.10
$24.49
$36.55
$19.96
$1.47
$13.55
$18.92
$202.30
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
A6024
A6025
A6154
A6196
A6197
A6198
A6199
A6203
A6204
A6205
A6206
A6207
A6208
A6209
A6210
A6211
A6212
A6213
A6214
A6215
A6216
A6217
A6218
A6219
A6220
A6221
A6222
A6223
A6224
A6229
A6230
A6231
A6232
A6233
A6234
A6235
A6236
A6237
A6238
A6239
A6240
A6241
A6242
A6243
Collagen dsg wound filler
Silicone gel sheet, each
Wound pouch each
Alginate dressing <=16 sq in
Alginate drsg >16 <=48 sq in
alginate dressing > 48 sq in
Alginate drsg wound filler
Composite drsg <= 16 sq in
Composite drsg >16<=48 sq in
Composite drsg > 48 sq in
Contact layer <= 16 sq in
Contact layer >16<= 48 sq in
Contact layer > 48 sq in
Foam drsg <=16 sq in w/o bdr
Foam drg >16<=48 sq in w/o b
Foam drg > 48 sq in w/o brdr
Foam drg <=16 sq in w/border
Foam drg >16<=48 sq in w/bdr
Foam drg > 48 sq in w/border
Foam dressing wound filler
Non-sterile gauze<=16 sq in
Non-sterile gauze>16<=48 sq
Non-sterile gauze > 48 sq in
Gauze <= 16 sq in w/border
Gauze >16 <=48 sq in w/bordr
Gauze > 48 sq in w/border
Gauze <=16 in no w/sal w/o b
Gauze >16<=48 no w/sal w/o b
Gauze > 48 in no w/sal w/o b
Gauze >16<=48 sq in watr/sal
Gauze > 48 sq in water/salne
Hydrogel dsg<=16 sq in
Hydrogel dsg>16<=48 sq in
Hydrogel dressing >48 sq in
Hydrocolld drg <=16 w/o bdr
Hydrocolld drg >16<=48 w/o b
Hydrocolld drg > 48 in w/o b
Hydrocolld drg <=16 in w/bdr
Hydrocolld drg >16<=48 w/bdr
Hydrocolld drg > 48 in w/bdr
Hydrocolld drg filler paste
Hydrocolloid drg filler dry
Hydrogel drg <=16 in w/o bdr
Hydrogel drg >16<=48 w/o bdr
Page 8 of 79
$4.66
$64.48
$19.36
$4.74
$10.59
$29.92
$3.84
$2.16
$4.02
$4.52
$5.75
$5.04
$11.34
$4.82
$12.84
$18.93
$6.26
$8.65
$9.95
$11.74
$0.03
$0.39
$0.39
$1.20
$2.04
$3.42
$1.38
$1.56
$2.33
$2.33
$2.22
$3.01
$6.87
$12.37
$4.22
$11.84
$17.57
$7.21
$14.80
$16.73
$38.71
$1.66
$4.42
$8.04
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
A6244
A6245
A6246
A6247
A6248
A6250
A6251
A6252
A6253
A6254
A6255
A6256
A6257
A6258
A6259
A6260
A6261
A6262
A6266
A6402
A6403
A6404
A6407
A6410
A6411
A6412
A6413
A6441
A6442
A6443
A6444
A6445
A6446
A6447
A6448
A6449
A6450
A6451
A6452
A6453
A6454
A6455
A6456
A6457
Hydrogel drg >48 in w/o bdr
Hydrogel drg <= 16 in w/bdr
Hydrogel drg >16<=48 in w/b
Hydrogel drg > 48 sq in w/b
Hydrogel drsg gel filler
Skin seal protect moisturizr
Absorpt drg <=16 sq in w/o b
Absorpt drg >16 <=48 w/o bdr
Absorpt drg > 48 sq in w/o b
Absorpt drg <=16 sq in w/bdr
Absorpt drg >16<=48 in w/bdr
Absorpt drg > 48 sq in w/bdr
Transparent film <= 16 sq in
Transparent film >16<=48 in
Transparent film > 48 sq in
Wound cleanser any type/size
Wound filler gel/paste /oz
Wound filler dry form / gram
Impreg gauze no h20/sal/yard
Sterile gauze <= 16 sq in
Sterile gauze>16 <= 48 sq in
Sterile gauze > 48 sq in
Packing strips, non-impreg
Sterile eye pad
Non-sterile eye pad
Occlusive eye patch
Adhesive bandage, first-aid
Pad band w>=3" <5"/yd
Conform band n/s w<3"/yd
Conform band n/s w>=3"<5"/yd
Conform band n/s w>=5"/yd
Conform band s w <3"/yd
Conform band s w>=3" <5"/yd
Conform band s w >=5"/yd
Lt compres band <3"/yd
Lt compres band >=3" <5"/yd
Lt compres band >=5"/yd
Mod compres band w>=3"<5"/yd
High compres band w>=3"<5"yd
Self-adher band w <3"/yd
Self-adher band w>=3" <5"/yd
Self-adher band >=5"/yd
Zinc paste band w >=3"<5"/yd
Tubular dressing
Page 9 of 79
$25.79
$7.55
$23.33
$22.46
$10.86
$6.48
$1.94
$2.16
$4.42
$0.78
$1.96
$2.67
$1.00
$2.78
$7.06
$8.72
$87.02
$3.59
$3.71
$0.07
$0.54
$7.43
$1.20
$0.38
$0.31
$0.31
$0.07
$0.43
$0.83
$0.18
$0.58
$2.12
$0.34
$1.79
$0.72
$1.08
$1.78
$2.67
$3.65
$0.39
$0.52
$0.89
$0.83
$0.74
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
A6504
A6530
A6531
A6531AW
A6532
A6532AW
A6533
A6534
A6535
A6536
A6537
A6538
A6539
A6540
A6541
A6544
A6545
A6545AW
A6549
A6550
A7000
A7000NU
A7001
A7001NU
A7002
A7002NU
A7003
A7003NU
A7004
A7004NU
A7005
A7005NU
A7006
A7006NU
A7007
A7007NU
A7008
A7008NU
A7009
A7009NU
A7010
A7010NU
A7011
A7012
AW
AW
AW
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
Cmprsburngarment glove-wrist
Compression stocking BK18-30
Compression stocking BK30-40
Compression stocking BK30-40
Compression stocking BK40-50
Compression stocking BK40-50
Gc stocking thighlngth 18-30
Gc stocking thighlngth 30-40
Gc stocking thighlngth 40-50
Gc stocking full lngth 18-30
Gc stocking full lngth 30-40
Gc stocking full lngth 40-50
Gc stocking waistlngth 18-30
Gc stocking waistlngth 30-40
Gc stocking waistlngth 40-50
Gc stocking garter belt
Grad comp non-elastic BK
Grad comp non-elastic BK
G compression stocking
Neg pres wound ther drsg set
Disposable canister for pump
Disposable canister for pump
Nondisposable pump canister
Nondisposable pump canister
Tubing used w suction pump
Tubing used w suction pump
Nebulizer administration set
Nebulizer administration set
Disposable nebulizer sml vol
Disposable nebulizer sml vol
Nondisposable nebulizer set
Nondisposable nebulizer set
Filtered nebulizer admin set
Filtered nebulizer admin set
Lg vol nebulizer disposable
Lg vol nebulizer disposable
Disposable nebulizer prefill
Disposable nebulizer prefill
Nebulizer reservoir bottle
Nebulizer reservoir bottle
Disposable corrugated tubing
Disposable corrugated tubing
Nondispos corrugated tubing
Nebulizer water collec devic
Page 10 of 79
$148.50
$35.02
$43.78
$43.78
$51.48
$51.48
$62.37
$71.28
$84.15
$84.15
$84.15
$84.15
$89.95
$89.95
$128.70
$29.95
$148.50
$148.50
$75.00
$35.00
$4.63
$4.63
$19.23
$19.23
$2.24
$2.24
$1.77
$1.77
$1.24
$1.24
$17.91
$17.91
$9.01
$9.01
$2.99
$2.99
$7.10
$7.10
$24.43
$24.43
$15.03
$15.03
$1.00
$2.31
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
A7012NU
A7013
A7013NU
A7014
A7014NU
A7015
A7015NU
A7016
A7016NU
A7017
A7017NU
A7017RR
A7017UE
A7018
A7020
A7020NU
A7025
A7025NU
A7026
A7026NU
A7027
A7027NU
A7028
A7028NU
A7029
A7029NU
A7030
A7030NU
A7031
A7031NU
A7032
A7032NU
A7033
A7033NU
A7034
A7034NU
A7035
A7035NU
A7036
A7036NU
A7037
A7037NU
A7038
A7038NU
NU
NU
NU
NU
NU
NU
RR
UE
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
Nebulizer water collec devic
Disposable compressor filter
Disposable compressor filter
Compressor nondispos filter
Compressor nondispos filter
Aerosol mask used w nebulize
Aerosol mask used w nebulize
Nebulizer dome & mouthpiece
Nebulizer dome & mouthpiece
Nebulizer not used w oxygen
Nebulizer not used w oxygen
Nebulizer not used w oxygen
Nebulizer not used w oxygen
Water distilled w/nebulizer
Interface, cough stim device
Interface, cough stim device
Replace chest compress vest
Replace chest compress vest
Replace chst cmprss sys hose
Replace chst cmprss sys hose
Combination oral/nasal mask
Combination oral/nasal mask
Repl oral cushion combo mask
Repl oral cushion combo mask
Repl nasal pillow comb mask
Repl nasal pillow comb mask
CPAP full face mask
CPAP full face mask
Replacement facemask interfa
Replacement facemask interfa
Replacement nasal cushion
Replacement nasal cushion
Replacement nasal pillows
Replacement nasal pillows
Nasal application device
Nasal application device
Pos airway press headgear
Pos airway press headgear
Pos airway press chinstrap
Pos airway press chinstrap
Pos airway pressure tubing
Pos airway pressure tubing
Pos airway pressure filter
Pos airway pressure filter
Page 11 of 79
$2.31
$0.53
$0.53
$2.61
$2.61
$1.60
$1.60
$4.20
$4.20
$8.64
$86.39
$8.64
$60.47
$0.25
$45.95
$45.95
$410.61
$410.61
$27.14
$27.14
$169.32
$169.32
$46.77
$46.77
$19.11
$19.11
$140.83
$140.83
$52.09
$52.09
$30.26
$30.26
$21.21
$21.21
$87.82
$87.82
$29.66
$29.66
$13.58
$13.58
$30.62
$30.62
$4.03
$4.03
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
A7039
A7039NU
A7040
A7041
A7042
A7043
A7044
A7044NU
A7045
A7045NU
A7045RR
A7045UE
A7046
A7046NU
A7501
A7502
A7503
A7504
A7505
A7506
A7507
A7508
A7509
A7520
A7521
A7522
A7523
A7524
A7525
A7526
A7527
A8000
A8000NU
A8000RR
A8000UE
A8001
A8001NU
A8001RR
A8001UE
A9270
A9274
A9276
A9277
A9278
NU
NU
NU
RR
UE
NU
NU
RR
UE
NU
RR
UE
Filter, non disposable w pap
Filter, non disposable w pap
One way chest drain valve
Water seal drain container
Implanted pleural catheter
Vacuum drainagebottle/tubing
PAP oral interface
PAP oral interface
Repl exhalation port for PAP
Repl exhalation port for PAP
Repl exhalation port for PAP
Repl exhalation port for PAP
Repl water chamber, PAP dev
Repl water chamber, PAP dev
Tracheostoma valve w diaphra
Replacement diaphragm/fplate
HMES filter holder or cap
Tracheostoma HMES filter
HMES or trach valve housing
HMES/trachvalve adhesivedisk
Integrated filter & holder
Housing & Integrated Adhesiv
Heat & moisture exchange sys
Trach/laryn tube non-cuffed
Trach/laryn tube cuffed
Trach/laryn tube stainless
Tracheostomy shower protect
Tracheostoma stent/stud/bttn
Tracheostomy mask
Tracheostomy tube collar
Trach/laryn tube plug/stop
Soft protect helmet prefab
Soft protect helmet prefab
Soft protect helmet prefab
Soft protect helmet prefab
Hard protect helmet prefab
Hard protect helmet prefab
Hard protect helmet prefab
Hard protect helmet prefab
Non-covered item or service
Ext amb insulin delivery sys
Disposable sensor, CGM sys
External transmitter, CGM
External receiver, CGM sys
Page 12 of 79
$11.44
$11.44
$34.19
$64.26
$155.27
$24.35
$90.26
$90.26
$1.45
$14.53
$1.45
$10.90
$14.56
$14.56
$90.25
$79.95
$58.00
$4.95
$13.00
$2.50
$4.75
$6.55
$1.37
$69.95
$89.95
$99.95
$26.95
$89.95
$1.89
$2.90
$7.95
$14.47
$144.77
$14.47
$108.59
$14.47
$144.77
$14.47
$108.59
$0.97
$27.50
$11.00
$575.00
$500.00
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
B4034
B4035
B4036
B4081
B4082
B4083
B4087
B4088
B4100
B4102
B4103
B4104
B4149
B4150
B4152
B4153
B4154
B4155
B4157
B4158
B4159
B4160
B4161
B4162
B4164
B4168
B4176
B4178
B4180
B4185
B4189
B4193
B4197
B4199
B4216
B4220
B4222
B4224
B5000
B5100
B9000
B9000NU
B9000RR
B9000UE
NU
RR
UE
Enter feed supkit syr by day
Enteral feed supp pump per d
Enteral feed sup kit grav by
Enteral ng tubing w/ stylet
Enteral ng tubing w/o stylet
Enteral stomach tube levine
Gastro/jejuno tube, std
Gastro/jejuno tube, low-pro
Food thickener oral
EF adult fluids and electro
EF ped fluid and electrolyte
Additive for enteral formula
EF blenderized foods
EF complet w/intact nutrient
EF calorie dense>/=1.5Kcal
EF hydrolyzed/amino acids
EF spec metabolic noninherit
EF incomplete/modular
EF special metabolic inherit
EF ped complete intact nut
EF ped complete soy based
EF ped caloric dense>/=0.7kc
EF ped hydrolyzed/amino acid
EF ped specmetabolic inherit
Parenteral 50% dextrose solu
Parenteral sol amino acid 3.
Parenteral sol amino acid 7Parenteral sol amino acid >
Parenteral sol carb > 50%
Parenteral sol 10 gm lipids
Parenteral sol amino acid &
Parenteral sol 52-73 gm prot
Parenteral sol 74-100 gm pro
Parenteral sol > 100gm prote
Parenteral nutrition additiv
Parenteral supply kit premix
Parenteral supply kit homemi
Parenteral administration ki
Parenteral sol renal-amirosy
Parenteral sol hepatic-fream
Enter infusion pump w/o alrm
Enter infusion pump w/o alrm
Enter infusion pump w/o alrm
Enter infusion pump w/o alrm
Page 13 of 79
$4.68
$6.94
$6.14
$20.73
$15.41
$2.37
$34.21
$34.21
$0.57
$5.31
$5.31
$1.49
$1.50
$0.69
$0.53
$1.62
$1.09
$1.62
$4.15
$1.24
$1.24
$1.29
$2.19
$2.87
$18.95
$27.63
$53.46
$64.18
$27.20
$12.53
$198.26
$256.19
$311.90
$356.40
$8.61
$8.93
$11.01
$27.89
$13.26
$5.18
$98.21
$1,068.80
$98.21
$801.59
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
B9002
B9002NU
B9002RR
B9002UE
B9004
B9004NU
B9004RR
B9004UE
B9006
B9006NU
B9006RR
B9006UE
E0100
E0100NU
E0100RR
E0100UE
E0105
E0105NU
E0105RR
E0105UE
E0110
E0110NU
E0110RR
E0110UE
E0111
E0111NU
E0111RR
E0111UE
E0112
E0112NU
E0112RR
E0112UE
E0113
E0113NU
E0113RR
E0113UE
E0114
E0114NU
E0114RR
E0114UE
E0116
E0116NU
E0116RR
E0116UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
Enteral infusion pump w/ ala
Enteral infusion pump w/ ala
Enteral infusion pump w/ ala
Enteral infusion pump w/ ala
Parenteral infus pump portab
Parenteral infus pump portab
Parenteral infus pump portab
Parenteral infus pump portab
Parenteral infus pump statio
Parenteral infus pump statio
Parenteral infus pump statio
Parenteral infus pump statio
Cane adjust/fixed with tip
Cane adjust/fixed with tip
Cane adjust/fixed with tip
Cane adjust/fixed with tip
Cane adjust/fixed quad/3 pro
Cane adjust/fixed quad/3 pro
Cane adjust/fixed quad/3 pro
Cane adjust/fixed quad/3 pro
Crutch forearm pair
Crutch forearm pair
Crutch forearm pair
Crutch forearm pair
Crutch forearm each
Crutch forearm each
Crutch forearm each
Crutch forearm each
Crutch underarm pair wood
Crutch underarm pair wood
Crutch underarm pair wood
Crutch underarm pair wood
Crutch underarm each wood
Crutch underarm each wood
Crutch underarm each wood
Crutch underarm each wood
Crutch underarm pair no wood
Crutch underarm pair no wood
Crutch underarm pair no wood
Crutch underarm pair no wood
Crutch underarm each no wood
Crutch underarm each no wood
Crutch underarm each no wood
Crutch underarm each no wood
Page 14 of 79
$94.05
$940.54
$94.05
$658.38
$391.57
$2,473.52
$391.57
$1,855.13
$391.57
$2,473.52
$391.57
$1,855.13
$1.36
$13.58
$1.36
$9.51
$3.17
$31.66
$3.17
$22.16
$4.70
$46.95
$4.70
$32.87
$3.27
$32.66
$3.27
$22.86
$2.39
$23.85
$2.39
$16.70
$4.13
$19.95
$4.13
$14.97
$2.48
$24.75
$2.48
$17.33
$5.09
$26.19
$5.09
$19.71
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0117
E0117NU
E0117RR
E0117UE
E0118
E0130
E0130NU
E0130RR
E0130UE
E0135
E0135NU
E0135RR
E0135UE
E0140
E0140NU
E0140RR
E0140UE
E0141
E0141NU
E0141RR
E0141UE
E0143
E0143NU
E0143RR
E0143UE
E0144
E0144NU
E0144RR
E0144UE
E0147
E0147NU
E0147RR
E0147UE
E0148
E0148NU
E0148RR
E0148UE
E0149
E0149NU
E0149RR
E0149UE
E0153
E0153NU
E0153RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Underarm springassist crutch
Underarm springassist crutch
Underarm springassist crutch
Underarm springassist crutch
Crutch substitute
Walker rigid adjust/fixed ht
Walker rigid adjust/fixed ht
Walker rigid adjust/fixed ht
Walker rigid adjust/fixed ht
Walker folding adjust/fixed
Walker folding adjust/fixed
Walker folding adjust/fixed
Walker folding adjust/fixed
Walker w trunk support
Walker w trunk support
Walker w trunk support
Walker w trunk support
Rigid wheeled walker adj/fix
Rigid wheeled walker adj/fix
Rigid wheeled walker adj/fix
Rigid wheeled walker adj/fix
Walker folding wheeled w/o s
Walker folding wheeled w/o s
Walker folding wheeled w/o s
Walker folding wheeled w/o s
Enclosed walker w rear seat
Enclosed walker w rear seat
Enclosed walker w rear seat
Enclosed walker w rear seat
Walker variable wheel resist
Walker variable wheel resist
Walker variable wheel resist
Walker variable wheel resist
Heavyduty walker no wheels
Heavyduty walker no wheels
Heavyduty walker no wheels
Heavyduty walker no wheels
Heavy duty wheeled walker
Heavy duty wheeled walker
Heavy duty wheeled walker
Heavy duty wheeled walker
Forearm crutch platform atta
Forearm crutch platform atta
Forearm crutch platform atta
Page 15 of 79
$18.18
$181.94
$18.18
$136.47
$350.00
$4.82
$48.24
$4.82
$33.77
$4.66
$46.58
$4.66
$32.61
$29.36
$293.50
$29.36
$220.14
$18.20
$93.82
$18.20
$70.36
$6.65
$66.50
$6.65
$46.55
$25.92
$259.12
$25.92
$194.33
$31.93
$319.29
$31.93
$223.50
$18.83
$188.27
$18.83
$131.79
$12.40
$123.99
$12.40
$86.79
$4.47
$44.72
$4.47
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0153UE
E0154
E0154NU
E0154RR
E0154UE
E0155
E0155NU
E0155RR
E0155UE
E0156
E0156NU
E0156RR
E0156UE
E0157
E0157NU
E0157RR
E0157UE
E0158
E0158NU
E0158RR
E0158UE
E0159
E0159NU
E0159RR
E0159UE
E0160
E0160NU
E0160RR
E0160UE
E0161
E0161NU
E0161RR
E0161UE
E0162
E0162NU
E0162RR
E0162UE
E0163
E0163NU
E0163RR
E0163UE
E0165
E0165NU
E0165RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Forearm crutch platform atta
Walker platform attachment
Walker platform attachment
Walker platform attachment
Walker platform attachment
Walker wheel attachment,pair
Walker wheel attachment,pair
Walker wheel attachment,pair
Walker wheel attachment,pair
Walker seat attachment
Walker seat attachment
Walker seat attachment
Walker seat attachment
Walker crutch attachment
Walker crutch attachment
Walker crutch attachment
Walker crutch attachment
Walker leg extenders set of4
Walker leg extenders set of4
Walker leg extenders set of4
Walker leg extenders set of4
Brake for wheeled walker
Brake for wheeled walker
Brake for wheeled walker
Brake for wheeled walker
Sitz type bath or equipment
Sitz type bath or equipment
Sitz type bath or equipment
Sitz type bath or equipment
Sitz bath/equipment w/faucet
Sitz bath/equipment w/faucet
Sitz bath/equipment w/faucet
Sitz bath/equipment w/faucet
Sitz bath chair
Sitz bath chair
Sitz bath chair
Sitz bath chair
Commode chair with fixed arm
Commode chair with fixed arm
Commode chair with fixed arm
Commode chair with fixed arm
Commode chair with detacharm
Commode chair with detacharm
Commode chair with detacharm
Page 16 of 79
$31.30
$4.68
$46.82
$4.68
$32.77
$1.49
$14.90
$1.49
$10.43
$1.96
$19.58
$1.96
$13.71
$7.32
$66.66
$7.32
$50.00
$1.98
$19.82
$1.98
$13.87
$1.48
$14.84
$1.48
$10.39
$2.13
$21.31
$2.13
$14.92
$1.69
$16.90
$1.69
$11.83
$14.43
$137.56
$14.43
$106.68
$6.00
$59.95
$6.00
$41.97
$4.20
$41.97
$4.20
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0167
E0167NU
E0167RR
E0167UE
E0168
E0168NU
E0168RR
E0168UE
E0170
E0170NU
E0170RR
E0171
E0171NU
E0171RR
E0175
E0175NU
E0175RR
E0175UE
E0181
E0181NU
E0181RR
E0182
E0182NU
E0182RR
E0184
E0184NU
E0184RR
E0184UE
E0185
E0185NU
E0185RR
E0185UE
E0186
E0186NU
E0186RR
E0187
E0187NU
E0187RR
E0188
E0188NU
E0188RR
E0188UE
E0189
E0189NU
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
NU
RR
UE
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
NU
RR
UE
NU
Commode chair pail or pan
Commode chair pail or pan
Commode chair pail or pan
Commode chair pail or pan
Heavyduty/wide commode chair
Heavyduty/wide commode chair
Heavyduty/wide commode chair
Heavyduty/wide commode chair
Commode chair electric
Commode chair electric
Commode chair electric
Commode chair non-electric
Commode chair non-electric
Commode chair non-electric
Commode chair foot rest
Commode chair foot rest
Commode chair foot rest
Commode chair foot rest
Press pad alternating w/ pum
Press pad alternating w/ pum
Press pad alternating w/ pum
Replace pump, alt press pad
Replace pump, alt press pad
Replace pump, alt press pad
Dry pressure mattress
Dry pressure mattress
Dry pressure mattress
Dry pressure mattress
Gel pressure mattress pad
Gel pressure mattress pad
Gel pressure mattress pad
Gel pressure mattress pad
Air pressure mattress
Air pressure mattress
Air pressure mattress
Water pressure mattress
Water pressure mattress
Water pressure mattress
Synthetic sheepskin pad
Synthetic sheepskin pad
Synthetic sheepskin pad
Synthetic sheepskin pad
Lambswool sheepskin pad
Lambswool sheepskin pad
Page 17 of 79
$0.77
$7.74
$0.77
$5.42
$9.73
$97.27
$9.73
$68.09
$151.73
$1,517.31
$151.73
$27.31
$273.06
$27.31
$5.61
$56.16
$5.61
$42.11
$24.60
$245.97
$24.60
$24.71
$247.14
$24.71
$19.71
$168.44
$19.71
$126.33
$42.43
$301.96
$42.43
$231.74
$19.17
$191.70
$19.17
$21.92
$219.15
$21.92
$2.90
$24.95
$2.90
$18.74
$4.52
$41.70
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0189RR
E0189UE
E0191
E0191NU
E0191RR
E0191UE
E0193
E0193RR
E0194
E0194RR
E0196
E0196NU
E0196RR
E0197
E0197NU
E0197RR
E0197UE
E0198
E0198NU
E0198RR
E0198UE
E0199
E0199NU
E0199RR
E0199UE
E0200
E0200NU
E0200RR
E0200UE
E0202
E0202RR
E0203
E0205
E0205NU
E0205RR
E0205UE
E0210
E0210NU
E0210RR
E0210UE
E0215
E0215NU
E0215RR
E0215UE
RR
UE
NU
RR
UE
RR
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
Lambswool sheepskin pad
Lambswool sheepskin pad
Protector heel or elbow
Protector heel or elbow
Protector heel or elbow
Protector heel or elbow
Powered air flotation bed
Powered air flotation bed
Air fluidized bed
Air fluidized bed
Gel pressure mattress
Gel pressure mattress
Gel pressure mattress
Air pressure pad for mattres
Air pressure pad for mattres
Air pressure pad for mattres
Air pressure pad for mattres
Water pressure pad for mattr
Water pressure pad for mattr
Water pressure pad for mattr
Water pressure pad for mattr
Dry pressure pad for mattres
Dry pressure pad for mattres
Dry pressure pad for mattres
Dry pressure pad for mattres
Heat lamp without stand
Heat lamp without stand
Heat lamp without stand
Heat lamp without stand
Phototherapy light w/ photom
Phototherapy light w/ photom
Therapeutic lightbox tabletp
Heat lamp with stand
Heat lamp with stand
Heat lamp with stand
Heat lamp with stand
Electric heat pad standard
Electric heat pad standard
Electric heat pad standard
Electric heat pad standard
Electric heat pad moist
Electric heat pad moist
Electric heat pad moist
Electric heat pad moist
Page 18 of 79
$4.52
$31.28
$0.82
$8.02
$0.82
$5.99
$24.25
$24.25
$90.00
$90.00
$30.67
$306.72
$30.67
$28.86
$209.19
$28.86
$183.75
$21.67
$209.19
$21.67
$158.73
$2.57
$25.72
$2.57
$19.29
$10.16
$74.84
$10.16
$56.16
$41.00
$41.00
$179.95
$17.13
$155.73
$17.13
$116.79
$2.53
$25.33
$2.53
$17.73
$3.88
$38.81
$3.88
$27.17
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0217
E0217NU
E0217RR
E0217UE
E0225
E0225NU
E0225RR
E0225UE
E0235
E0235NU
E0235RR
E0236
E0236NU
E0236RR
E0239
E0239NU
E0239RR
E0239UE
E0240
E0241
E0242
E0243
E0244
E0245
E0246
E0247
E0248
E0249
E0249NU
E0249RR
E0249UE
E0250
E0250NU
E0250RR
E0251
E0251NU
E0251RR
E0255
E0255NU
E0255RR
E0256
E0256NU
E0256RR
E0260
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
NU
RR
NU
RR
Water circ heat pad w pump
Water circ heat pad w pump
Water circ heat pad w pump
Water circ heat pad w pump
Hydrocollator unit
Hydrocollator unit
Hydrocollator unit
Hydrocollator unit
Paraffin bath unit portable
Paraffin bath unit portable
Paraffin bath unit portable
Pump for water circulating p
Pump for water circulating p
Pump for water circulating p
Hydrocollator unit portable
Hydrocollator unit portable
Hydrocollator unit portable
Hydrocollator unit portable
Bath/shower chair
Bath tub wall rail
Bath tub rail floor
Toilet rail
Toilet seat raised
Tub stool or bench
Transfer tub rail attachment
Trans bench w/wo comm open
HDtrans bench w/wo comm open
Pad water circulating heat u
Pad water circulating heat u
Pad water circulating heat u
Pad water circulating heat u
Hosp bed fixed ht w/ mattres
Hosp bed fixed ht w/ mattres
Hosp bed fixed ht w/ mattres
Hosp bed fixd ht w/o mattres
Hosp bed fixd ht w/o mattres
Hosp bed fixd ht w/o mattres
Hospital bed var ht w/ mattr
Hospital bed var ht w/ mattr
Hospital bed var ht w/ mattr
Hospital bed var ht w/o matt
Hospital bed var ht w/o matt
Hospital bed var ht w/o matt
Hosp bed semi-electr w/ matt
Page 19 of 79
$52.18
$468.69
$52.18
$351.50
$36.17
$366.90
$36.17
$275.17
$155.00
$155.00
$15.50
$35.51
$355.05
$35.51
$42.47
$424.67
$42.47
$318.52
$182.07
$39.95
$39.95
$35.85
$34.35
$39.95
$39.95
$78.95
$140.00
$8.79
$79.93
$8.79
$59.95
$73.04
$730.35
$73.04
$51.23
$512.28
$51.23
$95.59
$955.89
$95.59
$67.82
$678.15
$67.82
$114.29
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0260NU
E0260RR
E0261
E0261NU
E0261RR
E0265
E0265NU
E0265RR
E0266
E0266NU
E0266RR
E0271
E0271NU
E0271RR
E0271UE
E0272
E0272NU
E0272RR
E0272UE
E0275
E0275NU
E0275RR
E0275UE
E0276
E0276NU
E0276RR
E0276UE
E0277
E0277RR
E0280
E0280NU
E0280RR
E0280UE
E0290
E0290NU
E0290RR
E0291
E0291NU
E0291RR
E0292
E0292NU
E0292RR
E0293
E0293NU
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
NU
RR
NU
RR
NU
RR
NU
Hosp bed semi-electr w/ matt
Hosp bed semi-electr w/ matt
Hosp bed semi-electr w/o mat
Hosp bed semi-electr w/o mat
Hosp bed semi-electr w/o mat
Hosp bed total electr w/ mat
Hosp bed total electr w/ mat
Hosp bed total electr w/ mat
Hosp bed total elec w/o matt
Hosp bed total elec w/o matt
Hosp bed total elec w/o matt
Mattress innerspring
Mattress innerspring
Mattress innerspring
Mattress innerspring
Mattress foam rubber
Mattress foam rubber
Mattress foam rubber
Mattress foam rubber
Bed pan standard
Bed pan standard
Bed pan standard
Bed pan standard
Bed pan fracture
Bed pan fracture
Bed pan fracture
Bed pan fracture
Powered pres-redu air mattrs
Powered pres-redu air mattrs
Bed cradle
Bed cradle
Bed cradle
Bed cradle
Hosp bed fx ht w/o rails w/m
Hosp bed fx ht w/o rails w/m
Hosp bed fx ht w/o rails w/m
Hosp bed fx ht w/o rail w/o
Hosp bed fx ht w/o rail w/o
Hosp bed fx ht w/o rail w/o
Hosp bed var ht w/o rail w/o
Hosp bed var ht w/o rail w/o
Hosp bed var ht w/o rail w/o
Hosp bed var ht w/o rail w/
Hosp bed var ht w/o rail w/
Page 20 of 79
$1,142.91
$114.29
$111.43
$1,114.29
$111.43
$162.64
$1,626.39
$162.64
$138.41
$1,384.11
$138.41
$18.07
$180.67
$18.07
$135.50
$14.62
$139.97
$14.62
$104.47
$1.51
$14.45
$1.51
$10.84
$1.26
$12.48
$1.26
$9.36
$26.00
$26.00
$3.35
$31.09
$3.35
$23.31
$51.69
$516.87
$51.69
$44.18
$441.81
$44.18
$68.38
$683.82
$68.38
$58.19
$581.94
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0293RR
E0294
E0294NU
E0294RR
E0295
E0295NU
E0295RR
E0296
E0296NU
E0296RR
E0297
E0297NU
E0297RR
E0300
E0300NU
E0300RR
E0300UE
E0301
E0301NU
E0301RR
E0302
E0302NU
E0302RR
E0303
E0303NU
E0303RR
E0304
E0304NU
E0304RR
E0305
E0305NU
E0305RR
E0310
E0310NU
E0310RR
E0310UE
E0316
E0316NU
E0316RR
E0325
E0325NU
E0325RR
E0325UE
E0326
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
NU
RR
UE
Hosp bed var ht w/o rail w/
Hosp bed semi-elect w/ mattr
Hosp bed semi-elect w/ mattr
Hosp bed semi-elect w/ mattr
Hosp bed semi-elect w/o matt
Hosp bed semi-elect w/o matt
Hosp bed semi-elect w/o matt
Hosp bed total elect w/ matt
Hosp bed total elect w/ matt
Hosp bed total elect w/ matt
Hosp bed total elect w/o mat
Hosp bed total elect w/o mat
Hosp bed total elect w/o mat
Enclosed ped crib hosp grade
Enclosed ped crib hosp grade
Enclosed ped crib hosp grade
Enclosed ped crib hosp grade
HD hosp bed, 350-600 lbs
HD hosp bed, 350-600 lbs
HD hosp bed, 350-600 lbs
Ex hd hosp bed > 600 lbs
Ex hd hosp bed > 600 lbs
Ex hd hosp bed > 600 lbs
Hosp bed hvy dty xtra wide
Hosp bed hvy dty xtra wide
Hosp bed hvy dty xtra wide
Hosp bed xtra hvy dty x wide
Hosp bed xtra hvy dty x wide
Hosp bed xtra hvy dty x wide
Rails bed side half length
Rails bed side half length
Rails bed side half length
Rails bed side full length
Rails bed side full length
Rails bed side full length
Rails bed side full length
Bed safety enclosure
Bed safety enclosure
Bed safety enclosure
Urinal male jug-type
Urinal male jug-type
Urinal male jug-type
Urinal male jug-type
Urinal female jug-type
Page 21 of 79
$58.19
$106.31
$1,063.08
$106.31
$103.62
$1,036.17
$103.62
$133.61
$1,336.05
$133.61
$114.46
$1,144.62
$114.46
$230.97
$2,309.74
$230.97
$1,732.30
$220.28
$2,202.84
$220.28
$582.14
$5,821.38
$582.14
$247.34
$2,473.38
$247.34
$627.08
$6,270.84
$627.08
$12.30
$123.03
$12.30
$18.47
$157.97
$18.47
$119.54
$164.14
$1,641.42
$164.14
$1.43
$9.55
$1.43
$6.31
$0.95
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0326NU
E0326RR
E0326UE
E0371
E0371NU
E0371RR
E0372
E0372NU
E0372RR
E0373
E0373NU
E0373RR
E0424
E0424RR
E0431
E0431RR
E0433
E0433RR
E0434
E0434RR
E0439
E0439RR
E0441
E0442
E0443
E0444
E0445
E0450
E0450RR
E0457
E0457NU
E0457RR
E0457UE
E0459
E0459NU
E0459RR
E0460
E0460RR
E0461
E0461RR
E0462
E0462NU
E0462RR
E0463
NU
RR
UE
NU
RR
NU
RR
NU
RR
RR
RR
RR
RR
RR
RR
NU
RR
UE
NU
RR
RR
RR
NU
RR
Urinal female jug-type
Urinal female jug-type
Urinal female jug-type
Nonpower mattress overlay
Nonpower mattress overlay
Nonpower mattress overlay
Powered air mattress overlay
Powered air mattress overlay
Powered air mattress overlay
Nonpowered pressure mattress
Nonpowered pressure mattress
Nonpowered pressure mattress
Stationary compressed gas 02
Stationary compressed gas 02
Portable gaseous 02
Portable gaseous 02
Portable liquid oxygen sys
Portable liquid oxygen sys
Portable liquid 02
Portable liquid 02
Stationary liquid 02
Stationary liquid 02
Stationary O2 contents, gas
Stationary O2 contents, liq
Portable 02 contents, gas
Portable 02 contents, liquid
Oximeter non-invasive
Vol control vent invasiv int
Vol control vent invasiv int
Chest shell
Chest shell
Chest shell
Chest shell
Chest wrap
Chest wrap
Chest wrap
Neg press vent portabl/statn
Neg press vent portabl/statn
Vol control vent noninv int
Vol control vent noninv int
Rocking bed w/ or w/o side r
Rocking bed w/ or w/o side r
Rocking bed w/ or w/o side r
Press supp vent invasive int
Page 22 of 79
$8.43
$0.95
$6.31
$361.67
$3,616.65
$361.67
$438.85
$4,388.49
$438.85
$499.99
$4,999.86
$499.99
$141.89
$141.89
$23.74
$23.74
$41.30
$41.30
$23.74
$23.74
$141.89
$141.89
$61.96
$61.96
$61.96
$61.96
$98.95
$883.12
$883.12
$58.01
$580.13
$58.01
$435.07
$48.04
$480.42
$48.04
$692.53
$692.53
$883.12
$883.12
$275.09
$2,750.94
$275.09
$1,327.70
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0463RR
E0464
E0464RR
E0470
E0470NU
E0470RR
E0471
E0471NU
E0471RR
E0472
E0472NU
E0472RR
E0480
E0480NU
E0480RR
E0482
E0482NU
E0482RR
E0483
E0483NU
E0483RR
E0484
E0484NU
E0484RR
E0484UE
E0500
E0500RR
E0550
E0550NU
E0550RR
E0560
E0560NU
E0560RR
E0560UE
E0561
E0561NU
E0561RR
E0561UE
E0562
E0562NU
E0562RR
E0562UE
E0565
E0565NU
RR
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
Press supp vent invasive int
Press supp vent noninv int
Press supp vent noninv int
RAD w/o backup non-inv intfc
RAD w/o backup non-inv intfc
RAD w/o backup non-inv intfc
RAD w/backup non inv intrfc
RAD w/backup non inv intrfc
RAD w/backup non inv intrfc
RAD w backup invasive intrfc
RAD w backup invasive intrfc
RAD w backup invasive intrfc
Percussor elect/pneum home m
Percussor elect/pneum home m
Percussor elect/pneum home m
Cough stimulating device
Cough stimulating device
Cough stimulating device
Chest compression gen system
Chest compression gen system
Chest compression gen system
Non-elec oscillatory pep dvc
Non-elec oscillatory pep dvc
Non-elec oscillatory pep dvc
Non-elec oscillatory pep dvc
Ippb all types
Ippb all types
Humidif extens supple w ippb
Humidif extens supple w ippb
Humidif extens supple w ippb
Humidifier supplemental w/ i
Humidifier supplemental w/ i
Humidifier supplemental w/ i
Humidifier supplemental w/ i
Humidifier nonheated w PAP
Humidifier nonheated w PAP
Humidifier nonheated w PAP
Humidifier nonheated w PAP
Humidifier heated used w PAP
Humidifier heated used w PAP
Humidifier heated used w PAP
Humidifier heated used w PAP
Compressor air power source
Compressor air power source
Page 23 of 79
$1,327.70
$1,327.70
$1,327.70
$204.49
$2,044.89
$204.49
$522.52
$5,225.22
$522.52
$522.52
$5,225.22
$522.52
$39.58
$395.82
$39.58
$405.96
$4,059.63
$405.96
$1,003.65
$10,036.53
$1,003.65
$3.48
$34.86
$3.48
$26.15
$96.44
$96.44
$40.23
$402.30
$40.23
$13.90
$118.63
$13.90
$88.97
$8.69
$87.07
$8.69
$65.30
$22.47
$224.88
$22.47
$168.66
$57.60
$576.00
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0565RR
E0570
E0570NU
E0570RR
E0572
E0572NU
E0572RR
E0574
E0574NU
E0574RR
E0575
E0575NU
E0575RR
E0580
E0580NU
E0580RR
E0580UE
E0585
E0585NU
E0585RR
E0600
E0600NU
E0600RR
E0601
E0601NU
E0601RR
E0602
E0602NU
E0602RR
E0602UE
E0603
E0603NU
E0603RR
E0604
E0604RR
E0605
E0605NU
E0605RR
E0605UE
E0606
E0606NU
E0606RR
E0607
E0607NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
RR
NU
RR
UE
NU
RR
NU
Compressor air power source
Nebulizer with compression
Nebulizer with compression
Nebulizer with compression
Aerosol compressor adjust pr
Aerosol compressor adjust pr
Aerosol compressor adjust pr
Ultrasonic generator w svneb
Ultrasonic generator w svneb
Ultrasonic generator w svneb
Nebulizer ultrasonic
Nebulizer ultrasonic
Nebulizer ultrasonic
Nebulizer for use w/ regulat
Nebulizer for use w/ regulat
Nebulizer for use w/ regulat
Nebulizer for use w/ regulat
Nebulizer w/ compressor & he
Nebulizer w/ compressor & he
Nebulizer w/ compressor & he
Suction pump portab hom modl
Suction pump portab hom modl
Suction pump portab hom modl
Cont airway pressure device
Cont airway pressure device
Cont airway pressure device
Manual breast pump
Manual breast pump
Manual breast pump
Manual breast pump
Electric breast pump
Electric breast pump
Electric breast pump
Hosp grade elec breast pump
Hosp grade elec breast pump
Vaporizer room type
Vaporizer room type
Vaporizer room type
Vaporizer room type
Drainage board postural
Drainage board postural
Drainage board postural
Blood glucose monitor home
Blood glucose monitor home
Page 24 of 79
$57.60
$7.30
$72.95
$7.30
$35.96
$359.55
$35.96
$24.90
$249.00
$24.90
$94.39
$943.92
$94.39
$10.01
$100.07
$10.01
$75.04
$33.10
$331.02
$33.10
$37.69
$376.92
$37.69
$90.90
$909.00
$90.90
$4.99
$49.94
$4.99
$34.96
$28.99
$289.93
$28.99
$143.00
$143.00
$2.66
$22.90
$2.66
$18.86
$20.97
$209.70
$20.97
$6.30
$63.08
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0607RR
E0607UE
E0610
E0610NU
E0610RR
E0610UE
E0615
E0615NU
E0615RR
E0615UE
E0617
E0617NU
E0617RR
E0618
E0618NU
E0618RR
E0620
E0620NU
E0620RR
E0620UE
E0621
E0621NU
E0621RR
E0621UE
E0627
E0627NU
E0627RR
E0627UE
E0628
E0628NU
E0628RR
E0628UE
E0629
E0629NU
E0629RR
E0629UE
E0630
E0630NU
E0630RR
E0635
E0635NU
E0635RR
E0636
E0636NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
NU
Blood glucose monitor home
Blood glucose monitor home
Pacemaker monitr audible/vis
Pacemaker monitr audible/vis
Pacemaker monitr audible/vis
Pacemaker monitr audible/vis
Pacemaker monitr digital/vis
Pacemaker monitr digital/vis
Pacemaker monitr digital/vis
Pacemaker monitr digital/vis
Automatic ext defibrillator
Automatic ext defibrillator
Automatic ext defibrillator
Apnea monitor
Apnea monitor
Apnea monitor
Cap bld skin piercing laser
Cap bld skin piercing laser
Cap bld skin piercing laser
Cap bld skin piercing laser
Patient lift sling or seat
Patient lift sling or seat
Patient lift sling or seat
Patient lift sling or seat
Seat lift incorp lift-chair
Seat lift incorp lift-chair
Seat lift incorp lift-chair
Seat lift incorp lift-chair
Seat lift for pt furn-electr
Seat lift for pt furn-electr
Seat lift for pt furn-electr
Seat lift for pt furn-electr
Seat lift for pt furn-non-el
Seat lift for pt furn-non-el
Seat lift for pt furn-non-el
Seat lift for pt furn-non-el
Patient lift hydraulic
Patient lift hydraulic
Patient lift hydraulic
Patient lift electric
Patient lift electric
Patient lift electric
PT support & positioning sys
PT support & positioning sys
Page 25 of 79
$6.30
$47.30
$20.12
$190.87
$20.12
$143.17
$46.94
$384.23
$46.94
$288.18
$287.04
$2,870.37
$287.04
$264.67
$2,646.72
$264.67
$82.54
$825.47
$82.54
$619.10
$8.73
$90.62
$8.73
$68.31
$31.85
$318.46
$31.85
$238.84
$31.85
$318.46
$31.85
$238.84
$31.23
$312.21
$31.23
$234.14
$96.18
$961.83
$96.18
$104.58
$1,045.80
$104.58
$995.56
$9,955.62
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0636RR
E0650
E0650NU
E0650RR
E0650UE
E0651
E0651NU
E0651RR
E0651UE
E0652
E0652NU
E0652RR
E0652UE
E0655
E0655NU
E0655RR
E0655UE
E0656
E0656NU
E0656RR
E0656UE
E0657
E0657NU
E0657RR
E0657UE
E0660
E0660NU
E0660RR
E0660UE
E0665
E0665NU
E0665RR
E0665UE
E0666
E0666NU
E0666RR
E0666UE
E0667
E0667NU
E0667RR
E0667UE
E0668
E0668NU
E0668RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
PT support & positioning sys
Pneuma compresor non-segment
Pneuma compresor non-segment
Pneuma compresor non-segment
Pneuma compresor non-segment
Pneum compressor segmental
Pneum compressor segmental
Pneum compressor segmental
Pneum compressor segmental
Pneum compres w/cal pressure
Pneum compres w/cal pressure
Pneum compres w/cal pressure
Pneum compres w/cal pressure
Pneumatic appliance half arm
Pneumatic appliance half arm
Pneumatic appliance half arm
Pneumatic appliance half arm
Segmental pneumatic trunk
Segmental pneumatic trunk
Segmental pneumatic trunk
Segmental pneumatic trunk
Segmental pneumatic chest
Segmental pneumatic chest
Segmental pneumatic chest
Segmental pneumatic chest
Pneumatic appliance full leg
Pneumatic appliance full leg
Pneumatic appliance full leg
Pneumatic appliance full leg
Pneumatic appliance full arm
Pneumatic appliance full arm
Pneumatic appliance full arm
Pneumatic appliance full arm
Pneumatic appliance half leg
Pneumatic appliance half leg
Pneumatic appliance half leg
Pneumatic appliance half leg
Seg pneumatic appl full leg
Seg pneumatic appl full leg
Seg pneumatic appl full leg
Seg pneumatic appl full leg
Seg pneumatic appl full arm
Seg pneumatic appl full arm
Seg pneumatic appl full arm
Page 26 of 79
$995.56
$83.90
$679.92
$83.90
$509.94
$86.71
$867.04
$86.71
$650.29
$494.64
$5,004.86
$494.64
$3,750.29
$11.97
$101.89
$11.97
$76.51
$54.48
$545.39
$54.48
$409.10
$51.15
$512.38
$51.15
$384.31
$15.70
$150.81
$15.70
$113.09
$13.28
$129.33
$13.28
$97.12
$13.44
$130.36
$13.44
$97.79
$34.52
$305.66
$34.52
$229.25
$41.17
$417.16
$41.17
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0668UE
E0669
E0669NU
E0669RR
E0669UE
E0670
E0670NU
E0670RR
E0670UE
E0671
E0671NU
E0671RR
E0671UE
E0672
E0672NU
E0672RR
E0672UE
E0673
E0673NU
E0673RR
E0673UE
E0675
E0675NU
E0675RR
E0691
E0691NU
E0691RR
E0691UE
E0692
E0692NU
E0692RR
E0692UE
E0693
E0693NU
E0693RR
E0693UE
E0694
E0694NU
E0694RR
E0694UE
E0700
E0705
E0705NU
E0705RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Seg pneumatic appl full arm
Seg pneumatic appli half leg
Seg pneumatic appli half leg
Seg pneumatic appli half leg
Seg pneumatic appli half leg
Seg pneum int legs/trunk
Seg pneum int legs/trunk
Seg pneum int legs/trunk
Seg pneum int legs/trunk
Pressure pneum appl full leg
Pressure pneum appl full leg
Pressure pneum appl full leg
Pressure pneum appl full leg
Pressure pneum appl full arm
Pressure pneum appl full arm
Pressure pneum appl full arm
Pressure pneum appl full arm
Pressure pneum appl half leg
Pressure pneum appl half leg
Pressure pneum appl half leg
Pressure pneum appl half leg
Pneumatic compression device
Pneumatic compression device
Pneumatic compression device
Uvl pnl 2 sq ft or less
Uvl pnl 2 sq ft or less
Uvl pnl 2 sq ft or less
Uvl pnl 2 sq ft or less
Uvl sys panel 4 ft
Uvl sys panel 4 ft
Uvl sys panel 4 ft
Uvl sys panel 4 ft
Uvl sys panel 6 ft
Uvl sys panel 6 ft
Uvl sys panel 6 ft
Uvl sys panel 6 ft
Uvl md cabinet sys 6 ft
Uvl md cabinet sys 6 ft
Uvl md cabinet sys 6 ft
Uvl md cabinet sys 6 ft
Safety equipment
Transfer device
Transfer device
Transfer device
Page 27 of 79
$312.88
$17.32
$173.06
$17.32
$129.83
$131.13
$1,224.93
$131.13
$918.66
$39.22
$392.11
$39.22
$294.08
$30.47
$304.68
$30.47
$228.52
$25.32
$253.17
$25.32
$189.90
$363.04
$3,630.42
$363.04
$84.83
$848.32
$84.83
$636.24
$106.52
$1,065.25
$106.52
$798.94
$131.32
$1,313.16
$131.32
$984.87
$417.97
$4,179.65
$417.97
$3,134.76
$46.44
$3.67
$36.74
$3.67
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0705UE
E0710
E0720
E0720NU
E0720RR
E0730
E0730NU
E0730RR
E0731
E0731NU
E0740
E0740NU
E0740RR
E0740UE
E0744
E0744NU
E0744RR
E0745
E0745NU
E0745RR
E0747
E0747NU
E0747RR
E0747UE
E0748
E0748NU
E0748RR
E0748UE
E0749
E0749NU
E0749RR
E0760
E0760NU
E0760RR
E0760UE
E0762
E0762NU
E0762RR
E0762UE
E0764
E0764NU
E0764RR
E0764UE
E0765
UE
NU
RR
NU
RR
NU
NU
RR
UE
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
Transfer device
Restraints any type
Tens two lead
Tens two lead
Tens two lead
Tens four lead
Tens four lead
Tens four lead
Conductive garment for tens/
Conductive garment for tens/
Incontinence treatment systm
Incontinence treatment systm
Incontinence treatment systm
Incontinence treatment systm
Neuromuscular stim for scoli
Neuromuscular stim for scoli
Neuromuscular stim for scoli
Neuromuscular stim for shock
Neuromuscular stim for shock
Neuromuscular stim for shock
Elec osteogen stim not spine
Elec osteogen stim not spine
Elec osteogen stim not spine
Elec osteogen stim not spine
Elec osteogen stim spinal
Elec osteogen stim spinal
Elec osteogen stim spinal
Elec osteogen stim spinal
Elec osteogen stim implanted
Elec osteogen stim implanted
Elec osteogen stim implanted
Osteogen ultrasound stimltor
Osteogen ultrasound stimltor
Osteogen ultrasound stimltor
Osteogen ultrasound stimltor
Trans elec jt stim dev sys
Trans elec jt stim dev sys
Trans elec jt stim dev sys
Trans elec jt stim dev sys
Functional neuromuscularstim
Functional neuromuscularstim
Functional neuromuscularstim
Functional neuromuscularstim
Nerve stimulator for tx n&v
Page 28 of 79
$25.72
$15.92
$29.49
$294.96
$29.49
$12.00
$120.00
$12.00
$190.00
$190.00
$33.70
$336.98
$33.70
$235.89
$86.45
$864.45
$86.45
$40.00
$400.00
$40.00
$367.38
$3,696.98
$367.38
$2,746.79
$367.30
$3,673.04
$367.30
$2,754.79
$268.46
$2,684.61
$268.46
$305.24
$3,052.23
$305.24
$2,289.17
$68.50
$685.00
$68.50
$479.50
$1,044.76
$10,447.69
$1,044.76
$7,835.77
$7.96
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0765NU
E0765RR
E0765UE
E0776
E0776NU
E0776RR
E0776UE
E0779
E0779NU
E0779RR
E0780
E0780NU
E0781
E0781NU
E0781RR
E0782
E0782NU
E0782RR
E0782UE
E0783
E0783NU
E0783RR
E0783UE
E0784
E0784NU
E0784RR
E0785
E0785KF
E0786
E0786NU
E0786RR
E0786UE
E0791
E0791NU
E0791RR
E0840
E0840NU
E0840RR
E0840UE
E0849
E0849NU
E0849RR
E0849UE
E0850
NU
RR
UE
NU
RR
UE
NU
RR
NU
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
KF
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
Nerve stimulator for tx n&v
Nerve stimulator for tx n&v
Nerve stimulator for tx n&v
Iv pole
Iv pole
Iv pole
Iv pole
Amb infusion pump mechanical
Amb infusion pump mechanical
Amb infusion pump mechanical
Mech amb infusion pump <8hrs
Mech amb infusion pump <8hrs
External ambulatory infus pu
External ambulatory infus pu
External ambulatory infus pu
Non-programble infusion pump
Non-programble infusion pump
Non-programble infusion pump
Non-programble infusion pump
Programmable infusion pump
Programmable infusion pump
Programmable infusion pump
Programmable infusion pump
Ext amb infusn pump insulin
Ext amb infusn pump insulin
Ext amb infusn pump insulin
Replacement impl pump cathet
Replacement impl pump cathet
Implantable pump replacement
Implantable pump replacement
Implantable pump replacement
Implantable pump replacement
Parenteral infusion pump sta
Parenteral infusion pump sta
Parenteral infusion pump sta
Tract frame attach headboard
Tract frame attach headboard
Tract frame attach headboard
Tract frame attach headboard
Cervical pneum trac equip
Cervical pneum trac equip
Cervical pneum trac equip
Cervical pneum trac equip
Traction stand free standing
Page 29 of 79
$79.43
$7.96
$59.59
$7.84
$78.42
$7.84
$54.89
$15.80
$157.95
$15.80
$9.79
$9.79
$250.05
$2,500.47
$250.05
$405.34
$4,053.21
$405.34
$3,039.92
$772.90
$7,728.89
$772.90
$5,796.68
$3,900.00
$3,900.00
$3,900.00
$446.52
$446.07
$726.70
$7,266.96
$726.70
$5,450.24
$298.51
$2,985.12
$298.51
$15.41
$69.17
$15.41
$51.86
$38.90
$389.00
$38.90
$272.30
$13.62
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0850NU
E0850RR
E0850UE
E0855
E0855NU
E0855RR
E0855UE
E0856
E0856NU
E0856RR
E0856UE
E0860
E0860NU
E0860RR
E0860UE
E0870
E0870NU
E0870RR
E0870UE
E0880
E0880NU
E0880RR
E0880UE
E0890
E0890NU
E0890RR
E0890UE
E0900
E0900NU
E0900RR
E0900UE
E0910
E0910NU
E0910RR
E0911
E0911NU
E0911RR
E0912
E0912NU
E0912RR
E0920
E0920NU
E0920RR
E0930
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
NU
RR
NU
RR
Traction stand free standing
Traction stand free standing
Traction stand free standing
Cervical traction equipment
Cervical traction equipment
Cervical traction equipment
Cervical traction equipment
Cervic collar w air bladder
Cervic collar w air bladder
Cervic collar w air bladder
Cervic collar w air bladder
Tract equip cervical tract
Tract equip cervical tract
Tract equip cervical tract
Tract equip cervical tract
Tract frame attach footboard
Tract frame attach footboard
Tract frame attach footboard
Tract frame attach footboard
Trac stand free stand extrem
Trac stand free stand extrem
Trac stand free stand extrem
Trac stand free stand extrem
Traction frame attach pelvic
Traction frame attach pelvic
Traction frame attach pelvic
Traction frame attach pelvic
Trac stand free stand pelvic
Trac stand free stand pelvic
Trac stand free stand pelvic
Trac stand free stand pelvic
Trapeze bar attached to bed
Trapeze bar attached to bed
Trapeze bar attached to bed
HD trapeze bar attach to bed
HD trapeze bar attach to bed
HD trapeze bar attach to bed
HD trapeze bar free standing
HD trapeze bar free standing
HD trapeze bar free standing
Fracture frame attached to b
Fracture frame attached to b
Fracture frame attached to b
Fracture frame free standing
Page 30 of 79
$99.18
$13.62
$74.39
$46.67
$466.57
$46.67
$349.91
$14.53
$145.41
$14.53
$109.07
$5.23
$30.92
$5.23
$23.69
$12.65
$109.81
$12.65
$82.72
$18.61
$118.52
$18.61
$89.70
$31.00
$112.20
$31.00
$84.18
$26.07
$120.96
$26.07
$90.75
$16.27
$162.72
$16.27
$40.55
$405.54
$40.55
$93.15
$931.50
$93.15
$41.08
$410.76
$41.08
$36.66
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0930NU
E0930RR
E0935
E0935RR
E0940
E0940NU
E0940RR
E0941
E0941NU
E0941RR
E0942
E0942NU
E0942RR
E0942UE
E0944
E0944NU
E0944RR
E0944UE
E0945
E0945NU
E0945RR
E0945UE
E0946
E0946NU
E0946RR
E0947
E0947NU
E0947RR
E0947UE
E0948
E0948NU
E0948RR
E0948UE
E0950
E0950NU
E0950RR
E0950UE
E0951
E0951NU
E0951RR
E0951UE
E0952
E0952NU
E0952RR
NU
RR
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Fracture frame free standing
Fracture frame free standing
Cont pas motion exercise dev
Cont pas motion exercise dev
Trapeze bar free standing
Trapeze bar free standing
Trapeze bar free standing
Gravity assisted traction de
Gravity assisted traction de
Gravity assisted traction de
Cervical head harness/halter
Cervical head harness/halter
Cervical head harness/halter
Cervical head harness/halter
Pelvic belt/harness/boot
Pelvic belt/harness/boot
Pelvic belt/harness/boot
Pelvic belt/harness/boot
Belt/harness extremity
Belt/harness extremity
Belt/harness extremity
Belt/harness extremity
Fracture frame dual w cross
Fracture frame dual w cross
Fracture frame dual w cross
Fracture frame attachmnts pe
Fracture frame attachmnts pe
Fracture frame attachmnts pe
Fracture frame attachmnts pe
Fracture frame attachmnts ce
Fracture frame attachmnts ce
Fracture frame attachmnts ce
Fracture frame attachmnts ce
Tray
Tray
Tray
Tray
Loop heel
Loop heel
Loop heel
Loop heel
Toe loop/holder, each
Toe loop/holder, each
Toe loop/holder, each
Page 31 of 79
$366.57
$36.66
$27.00
$27.00
$28.30
$282.96
$28.30
$40.98
$409.77
$40.98
$2.21
$18.74
$2.21
$14.04
$4.35
$43.31
$4.35
$32.47
$4.19
$41.84
$4.19
$32.39
$55.85
$558.54
$55.85
$57.26
$572.53
$57.26
$429.39
$53.75
$537.43
$53.75
$390.56
$9.41
$93.98
$9.41
$70.49
$1.77
$17.16
$1.77
$12.86
$1.77
$17.02
$1.77
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0952UE
E0955
E0955NU
E0955RR
E0955UE
E0956
E0956NU
E0956RR
E0956UE
E0957
E0957NU
E0957RR
E0957UE
E0958
E0958NU
E0958RR
E0959
E0959NU
E0959RR
E0959UE
E0960
E0960NU
E0960RR
E0960UE
E0961
E0961NU
E0961RR
E0961UE
E0966
E0966NU
E0966RR
E0966UE
E0967
E0967NU
E0967RR
E0967UE
E0968
E0968NU
E0968RR
E0969
E0969NU
E0969RR
E0969UE
E0971
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
UE
Toe loop/holder, each
Cushioned headrest
Cushioned headrest
Cushioned headrest
Cushioned headrest
W/c lateral trunk/hip suppor
W/c lateral trunk/hip suppor
W/c lateral trunk/hip suppor
W/c lateral trunk/hip suppor
W/c medial thigh support
W/c medial thigh support
W/c medial thigh support
W/c medial thigh support
Whlchr att- conv 1 arm drive
Whlchr att- conv 1 arm drive
Whlchr att- conv 1 arm drive
Amputee adapter
Amputee adapter
Amputee adapter
Amputee adapter
W/c shoulder harness/straps
W/c shoulder harness/straps
W/c shoulder harness/straps
W/c shoulder harness/straps
Wheelchair brake extension
Wheelchair brake extension
Wheelchair brake extension
Wheelchair brake extension
Wheelchair head rest extensi
Wheelchair head rest extensi
Wheelchair head rest extensi
Wheelchair head rest extensi
Manual wc hand rim w project
Manual wc hand rim w project
Manual wc hand rim w project
Manual wc hand rim w project
Wheelchair commode seat
Wheelchair commode seat
Wheelchair commode seat
Wheelchair narrowing device
Wheelchair narrowing device
Wheelchair narrowing device
Wheelchair narrowing device
Wheelchair anti-tipping devi
Page 32 of 79
$12.78
$18.29
$182.79
$18.29
$137.09
$8.92
$89.12
$8.92
$66.84
$12.47
$124.71
$12.47
$93.53
$41.18
$411.84
$41.18
$4.20
$41.73
$4.20
$31.58
$8.23
$82.26
$8.23
$61.70
$2.49
$24.57
$2.49
$14.02
$6.64
$67.38
$6.64
$50.53
$6.09
$60.98
$6.09
$45.72
$14.39
$143.91
$14.39
$14.64
$147.87
$14.64
$110.91
$3.90
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0971NU
E0971RR
E0971UE
E0973
E0973NU
E0973RR
E0973UE
E0974
E0974NU
E0974RR
E0974UE
E0978
E0978NU
E0978RR
E0978UE
E0980
E0980NU
E0980RR
E0980UE
E0981
E0981NU
E0981RR
E0981UE
E0982
E0982NU
E0982RR
E0982UE
E0983
E0983NU
E0983RR
E0984
E0984NU
E0984RR
E0984UE
E0985
E0985NU
E0985RR
E0985UE
E0986
E0986NU
E0986RR
E0986UE
E0988
E0988NU
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
Wheelchair anti-tipping devi
Wheelchair anti-tipping devi
Wheelchair anti-tipping devi
W/Ch access det adj armrest
W/Ch access det adj armrest
W/Ch access det adj armrest
W/Ch access det adj armrest
W/Ch access anti-rollback
W/Ch access anti-rollback
W/Ch access anti-rollback
W/Ch access anti-rollback
W/C acc,saf belt pelv strap
W/C acc,saf belt pelv strap
W/C acc,saf belt pelv strap
W/C acc,saf belt pelv strap
Wheelchair safety vest
Wheelchair safety vest
Wheelchair safety vest
Wheelchair safety vest
Seat upholstery, replacement
Seat upholstery, replacement
Seat upholstery, replacement
Seat upholstery, replacement
Back upholstery, replacement
Back upholstery, replacement
Back upholstery, replacement
Back upholstery, replacement
Add pwr joystick
Add pwr joystick
Add pwr joystick
Add pwr tiller
Add pwr tiller
Add pwr tiller
Add pwr tiller
W/c seat lift mechanism
W/c seat lift mechanism
W/c seat lift mechanism
W/c seat lift mechanism
Man w/c push-rim pow assist
Man w/c push-rim pow assist
Man w/c push-rim pow assist
Man w/c push-rim pow assist
Lever-activated wheel drive
Lever-activated wheel drive
Page 33 of 79
$39.00
$3.90
$27.30
$9.90
$103.95
$9.90
$77.96
$7.85
$74.03
$7.85
$55.94
$3.29
$32.81
$3.29
$24.33
$2.91
$29.11
$2.91
$21.83
$4.34
$42.63
$4.34
$32.28
$4.66
$46.58
$4.66
$34.94
$235.95
$2,359.53
$235.95
$167.65
$1,578.34
$167.65
$1,183.77
$19.17
$191.50
$19.17
$143.61
$459.22
$4,592.11
$459.22
$3,444.10
$278.25
$2,782.53
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E0988RR
E0990
E0990NU
E0990RR
E0990UE
E0992
E0992NU
E0992RR
E0992UE
E0994
E0994NU
E0994RR
E0994UE
E0995
E0995NU
E0995RR
E0995UE
E1002
E1002NU
E1002RR
E1002UE
E1003
E1003NU
E1003RR
E1003UE
E1004
E1004NU
E1004RR
E1004UE
E1005
E1005NU
E1005RR
E1005UE
E1006
E1006NU
E1006RR
E1006UE
E1007
E1007NU
E1007RR
E1007UE
E1008
E1008NU
E1008RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Lever-activated wheel drive
Wheelchair elevating leg res
Wheelchair elevating leg res
Wheelchair elevating leg res
Wheelchair elevating leg res
Wheelchair solid seat insert
Wheelchair solid seat insert
Wheelchair solid seat insert
Wheelchair solid seat insert
Wheelchair arm rest
Wheelchair arm rest
Wheelchair arm rest
Wheelchair arm rest
Wheelchair calf rest
Wheelchair calf rest
Wheelchair calf rest
Wheelchair calf rest
Pwr seat tilt
Pwr seat tilt
Pwr seat tilt
Pwr seat tilt
Pwr seat recline
Pwr seat recline
Pwr seat recline
Pwr seat recline
Pwr seat recline mech
Pwr seat recline mech
Pwr seat recline mech
Pwr seat recline mech
Pwr seat recline pwr
Pwr seat recline pwr
Pwr seat recline pwr
Pwr seat recline pwr
Pwr seat combo w/o shear
Pwr seat combo w/o shear
Pwr seat combo w/o shear
Pwr seat combo w/o shear
Pwr seat combo w/shear
Pwr seat combo w/shear
Pwr seat combo w/shear
Pwr seat combo w/shear
Pwr seat combo pwr shear
Pwr seat combo pwr shear
Pwr seat combo pwr shear
Page 34 of 79
$278.25
$10.16
$90.69
$10.16
$70.51
$8.73
$89.83
$8.73
$67.38
$1.54
$15.34
$1.54
$11.51
$2.76
$27.48
$2.76
$20.60
$366.44
$3,664.49
$366.44
$2,748.36
$397.02
$3,970.16
$397.02
$2,977.62
$440.20
$4,402.08
$440.20
$3,301.55
$476.48
$4,764.91
$476.48
$3,573.69
$583.64
$5,836.57
$583.64
$4,377.43
$790.30
$7,902.94
$790.30
$5,927.20
$790.36
$7,903.65
$790.36
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E1008UE
E1010
E1010NU
E1010RR
E1010UE
E1014
E1014NU
E1014RR
E1014UE
E1015
E1015NU
E1015RR
E1015UE
E1016
E1016NU
E1016RR
E1016UE
E1020
E1020NU
E1020RR
E1020UE
E1028
E1028NU
E1028RR
E1028UE
E1029
E1029NU
E1029RR
E1029UE
E1030
E1030NU
E1030RR
E1030UE
E1031
E1031NU
E1031RR
E1035
E1035NU
E1035RR
E1036
E1036NU
E1036RR
E1037
E1037NU
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
NU
RR
NU
Pwr seat combo pwr shear
Add pwr leg elevation
Add pwr leg elevation
Add pwr leg elevation
Add pwr leg elevation
Reclining back add ped w/c
Reclining back add ped w/c
Reclining back add ped w/c
Reclining back add ped w/c
Shock absorber for man w/c
Shock absorber for man w/c
Shock absorber for man w/c
Shock absorber for man w/c
Shock absorber for power w/c
Shock absorber for power w/c
Shock absorber for power w/c
Shock absorber for power w/c
Residual limb support system
Residual limb support system
Residual limb support system
Residual limb support system
W/c manual swingaway
W/c manual swingaway
W/c manual swingaway
W/c manual swingaway
W/c vent tray fixed
W/c vent tray fixed
W/c vent tray fixed
W/c vent tray fixed
W/c vent tray gimbaled
W/c vent tray gimbaled
W/c vent tray gimbaled
W/c vent tray gimbaled
Rollabout chair with casters
Rollabout chair with casters
Rollabout chair with casters
Patient transfer system <300
Patient transfer system <300
Patient transfer system <300
Patient transfer system >300
Patient transfer system >300
Patient transfer system >300
Transport chair, ped size
Transport chair, ped size
Page 35 of 79
$5,927.75
$103.41
$1,034.09
$103.41
$775.58
$34.48
$344.72
$34.48
$258.53
$10.82
$108.29
$10.82
$81.21
$11.88
$118.72
$11.88
$89.03
$21.99
$220.07
$21.99
$165.04
$18.67
$186.73
$18.67
$140.04
$33.41
$334.10
$33.41
$250.57
$105.35
$1,053.52
$105.35
$790.14
$47.69
$476.91
$47.69
$578.90
$5,788.98
$578.90
$811.56
$8,115.57
$811.56
$102.42
$1,024.20
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E1037RR
E1038
E1038NU
E1038RR
E1039
E1039NU
E1039RR
E1050
E1050NU
E1050RR
E1060
E1060NU
E1060RR
E1070
E1070NU
E1070RR
E1083
E1083NU
E1083RR
E1084
E1084NU
E1084RR
E1087
E1087NU
E1087RR
E1088
E1088NU
E1088RR
E1092
E1092NU
E1092RR
E1093
E1093NU
E1093RR
E1100
E1100NU
E1100RR
E1110
E1110NU
E1110RR
E1150
E1150NU
E1150RR
E1160
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
Transport chair, ped size
Transport chair pt wt<=300lb
Transport chair pt wt<=300lb
Transport chair pt wt<=300lb
Transport chair pt wt >300lb
Transport chair pt wt >300lb
Transport chair pt wt >300lb
Whelchr fxd full length arms
Whelchr fxd full length arms
Whelchr fxd full length arms
Wheelchair detachable arms
Wheelchair detachable arms
Wheelchair detachable arms
Wheelchair detachable foot r
Wheelchair detachable foot r
Wheelchair detachable foot r
Hemi-wheelchair fixed arms
Hemi-wheelchair fixed arms
Hemi-wheelchair fixed arms
Hemi-wheelchair detachable a
Hemi-wheelchair detachable a
Hemi-wheelchair detachable a
Wheelchair lightwt fixed arm
Wheelchair lightwt fixed arm
Wheelchair lightwt fixed arm
Wheelchair lightweight det a
Wheelchair lightweight det a
Wheelchair lightweight det a
Wheelchair wide w/ leg rests
Wheelchair wide w/ leg rests
Wheelchair wide w/ leg rests
Wheelchair wide w/ foot rest
Wheelchair wide w/ foot rest
Wheelchair wide w/ foot rest
Whchr s-recl fxd arm leg res
Whchr s-recl fxd arm leg res
Whchr s-recl fxd arm leg res
Wheelchair semi-recl detach
Wheelchair semi-recl detach
Wheelchair semi-recl detach
Wheelchair standard w/ leg r
Wheelchair standard w/ leg r
Wheelchair standard w/ leg r
Wheelchair fixed arms
Page 36 of 79
$102.42
$17.02
$170.19
$17.02
$32.28
$322.83
$32.28
$96.14
$961.38
$96.14
$119.02
$1,190.16
$119.02
$87.89
$878.94
$87.89
$63.19
$631.89
$63.19
$90.86
$908.55
$90.86
$119.44
$1,194.39
$119.44
$120.99
$1,209.87
$120.99
$121.33
$1,213.29
$121.33
$100.25
$1,002.51
$100.25
$98.00
$980.01
$98.00
$95.97
$959.67
$95.97
$77.01
$770.13
$77.01
$59.00
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E1160NU
E1160RR
E1161
E1161NU
E1161RR
E1161UE
E1170
E1170NU
E1170RR
E1171
E1171NU
E1171RR
E1172
E1172NU
E1172RR
E1180
E1180NU
E1180RR
E1190
E1190NU
E1190RR
E1195
E1195NU
E1195RR
E1200
E1200NU
E1200RR
E1221
E1221NU
E1221RR
E1222
E1222NU
E1222RR
E1223
E1223NU
E1223RR
E1224
E1224NU
E1224RR
E1225
E1225NU
E1225RR
E1226
E1226NU
NU
RR
NU
RR
UE
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
Wheelchair fixed arms
Wheelchair fixed arms
Manual adult wc w tiltinspac
Manual adult wc w tiltinspac
Manual adult wc w tiltinspac
Manual adult wc w tiltinspac
Whlchr ampu fxd arm leg rest
Whlchr ampu fxd arm leg rest
Whlchr ampu fxd arm leg rest
Wheelchair amputee w/o leg r
Wheelchair amputee w/o leg r
Wheelchair amputee w/o leg r
Wheelchair amputee detach ar
Wheelchair amputee detach ar
Wheelchair amputee detach ar
Wheelchair amputee w/ foot r
Wheelchair amputee w/ foot r
Wheelchair amputee w/ foot r
Wheelchair amputee w/ leg re
Wheelchair amputee w/ leg re
Wheelchair amputee w/ leg re
Wheelchair amputee heavy dut
Wheelchair amputee heavy dut
Wheelchair amputee heavy dut
Wheelchair amputee fixed arm
Wheelchair amputee fixed arm
Wheelchair amputee fixed arm
Wheelchair spec size w foot
Wheelchair spec size w foot
Wheelchair spec size w foot
Wheelchair spec size w/ leg
Wheelchair spec size w/ leg
Wheelchair spec size w/ leg
Wheelchair spec size w foot
Wheelchair spec size w foot
Wheelchair spec size w foot
Wheelchair spec size w/ leg
Wheelchair spec size w/ leg
Wheelchair spec size w/ leg
Manual semi-reclining back
Manual semi-reclining back
Manual semi-reclining back
Manual fully reclining back
Manual fully reclining back
Page 37 of 79
$590.04
$59.00
$223.37
$2,233.72
$223.37
$1,675.31
$84.32
$843.21
$84.32
$75.67
$756.72
$75.67
$92.48
$924.75
$92.48
$81.32
$813.24
$81.32
$93.94
$939.42
$93.94
$101.82
$1,018.17
$101.82
$82.14
$821.43
$82.14
$44.86
$448.56
$44.86
$64.00
$639.99
$64.00
$65.18
$651.78
$65.18
$65.12
$651.15
$65.12
$42.67
$426.69
$42.67
$53.02
$515.12
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E1226RR
E1226UE
E1227
E1227NU
E1227RR
E1227UE
E1228
E1228NU
E1228RR
E1230
E1230NU
E1230RR
E1230UE
E1232
E1232NU
E1232RR
E1232UE
E1233
E1233NU
E1233RR
E1233UE
E1234
E1234NU
E1234RR
E1234UE
E1235
E1235NU
E1235RR
E1235UE
E1236
E1236NU
E1236RR
E1236UE
E1237
E1237NU
E1237RR
E1237UE
E1238
E1238NU
E1238RR
E1238UE
E1240
E1240NU
E1240RR
RR
UE
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Manual fully reclining back
Manual fully reclining back
Wheelchair spec sz spec ht a
Wheelchair spec sz spec ht a
Wheelchair spec sz spec ht a
Wheelchair spec sz spec ht a
Wheelchair spec sz spec ht b
Wheelchair spec sz spec ht b
Wheelchair spec sz spec ht b
Power operated vehicle
Power operated vehicle
Power operated vehicle
Power operated vehicle
Folding ped wc tilt-in-space
Folding ped wc tilt-in-space
Folding ped wc tilt-in-space
Folding ped wc tilt-in-space
Rig ped wc tltnspc w/o seat
Rig ped wc tltnspc w/o seat
Rig ped wc tltnspc w/o seat
Rig ped wc tltnspc w/o seat
Fld ped wc tltnspc w/o seat
Fld ped wc tltnspc w/o seat
Fld ped wc tltnspc w/o seat
Fld ped wc tltnspc w/o seat
Rigid ped wc adjustable
Rigid ped wc adjustable
Rigid ped wc adjustable
Rigid ped wc adjustable
Folding ped wc adjustable
Folding ped wc adjustable
Folding ped wc adjustable
Folding ped wc adjustable
Rgd ped wc adjstabl w/o seat
Rgd ped wc adjstabl w/o seat
Rgd ped wc adjstabl w/o seat
Rgd ped wc adjstabl w/o seat
Fld ped wc adjstabl w/o seat
Fld ped wc adjstabl w/o seat
Fld ped wc adjstabl w/o seat
Fld ped wc adjstabl w/o seat
Whchr litwt det arm leg rest
Whchr litwt det arm leg rest
Whchr litwt det arm leg rest
Page 38 of 79
$53.02
$386.31
$26.20
$261.98
$26.20
$196.51
$26.45
$264.51
$26.45
$210.01
$2,135.26
$210.01
$1,601.44
$201.89
$2,018.77
$201.89
$1,514.10
$209.18
$2,091.77
$209.18
$1,568.83
$182.12
$1,821.03
$182.12
$1,365.77
$175.36
$1,753.52
$175.36
$1,315.13
$154.70
$1,547.06
$154.70
$1,160.29
$156.06
$1,560.56
$156.06
$1,170.44
$154.70
$1,547.06
$154.70
$1,160.29
$94.28
$942.84
$94.28
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E1270
E1270NU
E1270RR
E1280
E1280NU
E1280RR
E1295
E1295NU
E1295RR
E1296
E1296NU
E1296RR
E1296UE
E1297
E1297NU
E1297RR
E1297UE
E1298
E1298NU
E1298RR
E1298UE
E1310
E1310NU
E1310RR
E1310UE
E1353
E1355
E1372
E1372NU
E1372RR
E1372UE
E1390
E1390RR
E1391
E1391RR
E1392
E1392RR
E1405
E1405RR
E1406
E1406RR
E1700
E1700NU
E1700RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
RR
RR
RR
RR
NU
RR
Wheelchair lightweight leg r
Wheelchair lightweight leg r
Wheelchair lightweight leg r
Whchr h-duty det arm leg res
Whchr h-duty det arm leg res
Whchr h-duty det arm leg res
Wheelchair heavy duty fixed
Wheelchair heavy duty fixed
Wheelchair heavy duty fixed
Wheelchair special seat heig
Wheelchair special seat heig
Wheelchair special seat heig
Wheelchair special seat heig
Wheelchair special seat dept
Wheelchair special seat dept
Wheelchair special seat dept
Wheelchair special seat dept
Wheelchair spec seat depth/w
Wheelchair spec seat depth/w
Wheelchair spec seat depth/w
Wheelchair spec seat depth/w
Whirlpool non-portable
Whirlpool non-portable
Whirlpool non-portable
Whirlpool non-portable
Oxygen supplies regulator
Oxygen supplies stand/rack
Oxy suppl heater for nebuliz
Oxy suppl heater for nebuliz
Oxy suppl heater for nebuliz
Oxy suppl heater for nebuliz
Oxygen concentrator
Oxygen concentrator
Oxygen concentrator, dual
Oxygen concentrator, dual
Portable oxygen concentrator
Portable oxygen concentrator
O2/water vapor enrich w/heat
O2/water vapor enrich w/heat
O2/water vapor enrich w/o he
O2/water vapor enrich w/o he
Jaw motion rehab system
Jaw motion rehab system
Jaw motion rehab system
Page 39 of 79
$71.39
$713.88
$71.39
$105.33
$1,053.27
$105.33
$100.01
$1,000.08
$100.01
$47.15
$464.16
$47.15
$348.12
$10.97
$98.76
$10.97
$74.06
$38.79
$387.99
$38.79
$291.00
$172.31
$1,723.18
$172.31
$1,292.38
$24.54
$18.48
$19.01
$153.91
$19.01
$113.92
$141.89
$141.89
$141.89
$141.89
$41.30
$41.30
$172.26
$172.26
$155.85
$155.85
$31.92
$325.55
$31.92
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E1700UE
E1701
E1702
E1800
E1800NU
E1800RR
E1801
E1801NU
E1801RR
E1802
E1802NU
E1802RR
E1805
E1805NU
E1805RR
E1806
E1806NU
E1806RR
E1810
E1810NU
E1810RR
E1811
E1811NU
E1811RR
E1812
E1812NU
E1812RR
E1815
E1815NU
E1815RR
E1816
E1816NU
E1816RR
E1818
E1818NU
E1818RR
E1820
E1820NU
E1820RR
E1820UE
E1821
E1821NU
E1821RR
E1821UE
UE
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
Jaw motion rehab system
Repl cushions for jaw motion
Repl measr scales jaw motion
Adjust elbow ext/flex device
Adjust elbow ext/flex device
Adjust elbow ext/flex device
SPS elbow device
SPS elbow device
SPS elbow device
Adjst forearm pro/sup device
Adjst forearm pro/sup device
Adjst forearm pro/sup device
Adjust wrist ext/flex device
Adjust wrist ext/flex device
Adjust wrist ext/flex device
SPS wrist device
SPS wrist device
SPS wrist device
Adjust knee ext/flex device
Adjust knee ext/flex device
Adjust knee ext/flex device
SPS knee device
SPS knee device
SPS knee device
Knee ext/flex w act res ctrl
Knee ext/flex w act res ctrl
Knee ext/flex w act res ctrl
Adjust ankle ext/flex device
Adjust ankle ext/flex device
Adjust ankle ext/flex device
SPS ankle device
SPS ankle device
SPS ankle device
SPS forearm device
SPS forearm device
SPS forearm device
Soft interface material
Soft interface material
Soft interface material
Soft interface material
Replacement interface SPSD
Replacement interface SPSD
Replacement interface SPSD
Replacement interface SPSD
Page 40 of 79
$244.16
$10.02
$21.31
$115.65
$1,156.50
$115.65
$121.78
$1,217.79
$121.78
$308.52
$3,085.20
$308.52
$119.28
$1,192.77
$119.28
$99.99
$999.90
$99.99
$24.52
$245.15
$24.52
$126.62
$1,266.21
$126.62
$81.18
$811.80
$81.18
$18.92
$189.21
$18.92
$128.62
$1,286.19
$128.62
$131.30
$1,313.01
$131.30
$7.29
$72.80
$7.29
$54.59
$9.93
$99.36
$9.93
$74.54
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E1825
E1825NU
E1825RR
E1830
E1830NU
E1830RR
E1831
E1831NU
E1831RR
E1840
E1840NU
E1840RR
E1841
E1841NU
E1841RR
E2000
E2000NU
E2000RR
E2100
E2100NU
E2100RR
E2100UE
E2101
E2101NU
E2101RR
E2101UE
E2120
E2120NU
E2120RR
E2201
E2201NU
E2201RR
E2201UE
E2202
E2202NU
E2202RR
E2202UE
E2203
E2203NU
E2203RR
E2203UE
E2204
E2204NU
E2204RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Adjust finger ext/flex devc
Adjust finger ext/flex devc
Adjust finger ext/flex devc
Adjust toe ext/flex device
Adjust toe ext/flex device
Adjust toe ext/flex device
Static str toe dev ext/flex
Static str toe dev ext/flex
Static str toe dev ext/flex
Adj shoulder ext/flex device
Adj shoulder ext/flex device
Adj shoulder ext/flex device
Static str shldr dev rom adj
Static str shldr dev rom adj
Static str shldr dev rom adj
Gastric suction pump hme mdl
Gastric suction pump hme mdl
Gastric suction pump hme mdl
Bld glucose monitor w voice
Bld glucose monitor w voice
Bld glucose monitor w voice
Bld glucose monitor w voice
Bld glucose monitor w lance
Bld glucose monitor w lance
Bld glucose monitor w lance
Bld glucose monitor w lance
Pulse gen sys tx endolymp fl
Pulse gen sys tx endolymp fl
Pulse gen sys tx endolymp fl
Man w/ch acc seat w>=20"<24"
Man w/ch acc seat w>=20"<24"
Man w/ch acc seat w>=20"<24"
Man w/ch acc seat w>=20"<24"
Seat width 24-27 in
Seat width 24-27 in
Seat width 24-27 in
Seat width 24-27 in
Frame depth less than 22 in
Frame depth less than 22 in
Frame depth less than 22 in
Frame depth less than 22 in
Frame depth 22 to 25 in
Frame depth 22 to 25 in
Frame depth 22 to 25 in
Page 41 of 79
$119.28
$1,192.77
$119.28
$119.28
$1,192.77
$119.28
$59.99
$599.85
$59.99
$361.31
$3,613.05
$361.31
$427.65
$4,276.53
$427.65
$48.93
$489.33
$48.93
$51.62
$516.12
$51.62
$387.10
$17.80
$178.01
$17.80
$133.51
$267.66
$2,676.60
$267.66
$35.23
$352.23
$35.23
$264.18
$44.75
$447.46
$44.75
$335.62
$45.21
$452.25
$45.21
$339.17
$76.80
$767.90
$76.80
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E2204UE
E2205
E2205NU
E2205RR
E2205UE
E2206
E2206NU
E2206RR
E2206UE
E2207
E2207NU
E2207RR
E2207UE
E2208
E2208NU
E2208RR
E2208UE
E2209
E2209NU
E2209RR
E2209UE
E2210
E2210NU
E2210RR
E2210UE
E2211
E2211NU
E2211RR
E2211UE
E2212
E2212NU
E2212RR
E2212UE
E2213
E2213NU
E2213RR
E2213UE
E2214
E2214NU
E2214RR
E2214UE
E2215
E2215NU
E2215RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Frame depth 22 to 25 in
Manual wc accessory, handrim
Manual wc accessory, handrim
Manual wc accessory, handrim
Manual wc accessory, handrim
Complete wheel lock assembly
Complete wheel lock assembly
Complete wheel lock assembly
Complete wheel lock assembly
Crutch and cane holder
Crutch and cane holder
Crutch and cane holder
Crutch and cane holder
Cylinder tank carrier
Cylinder tank carrier
Cylinder tank carrier
Cylinder tank carrier
Arm trough each
Arm trough each
Arm trough each
Arm trough each
Wheelchair bearings
Wheelchair bearings
Wheelchair bearings
Wheelchair bearings
Pneumatic propulsion tire
Pneumatic propulsion tire
Pneumatic propulsion tire
Pneumatic propulsion tire
Pneumatic prop tire tube
Pneumatic prop tire tube
Pneumatic prop tire tube
Pneumatic prop tire tube
Pneumatic prop tire insert
Pneumatic prop tire insert
Pneumatic prop tire insert
Pneumatic prop tire insert
Pneumatic caster tire each
Pneumatic caster tire each
Pneumatic caster tire each
Pneumatic caster tire each
Pneumatic caster tire tube
Pneumatic caster tire tube
Pneumatic caster tire tube
Page 42 of 79
$575.92
$3.02
$30.31
$3.02
$22.75
$3.77
$37.77
$3.77
$28.33
$4.03
$40.24
$4.03
$30.19
$10.56
$105.59
$10.56
$79.19
$9.51
$95.28
$9.51
$71.46
$0.60
$5.92
$0.60
$4.45
$3.71
$36.90
$3.71
$27.67
$0.58
$5.45
$0.58
$4.10
$2.84
$28.24
$2.84
$21.16
$3.19
$28.89
$3.19
$21.65
$0.89
$8.92
$0.89
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E2215UE
E2219
E2219NU
E2219RR
E2219UE
E2220
E2220NU
E2220RR
E2220UE
E2221
E2221NU
E2221RR
E2221UE
E2222
E2222NU
E2222RR
E2222UE
E2224
E2224NU
E2224RR
E2224UE
E2225
E2225NU
E2225RR
E2225UE
E2226
E2226NU
E2226RR
E2226UE
E2227
E2227NU
E2227RR
E2227UE
E2228
E2228NU
E2228RR
E2228UE
E2231
E2231NU
E2231RR
E2231UE
E2310
E2310NU
E2310RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Pneumatic caster tire tube
Foam caster tire any size ea
Foam caster tire any size ea
Foam caster tire any size ea
Foam caster tire any size ea
Solid propulsion tire each
Solid propulsion tire each
Solid propulsion tire each
Solid propulsion tire each
Solid caster tire each
Solid caster tire each
Solid caster tire each
Solid caster tire each
Solid caster integrated whl
Solid caster integrated whl
Solid caster integrated whl
Solid caster integrated whl
Propulsion whl excludes tire
Propulsion whl excludes tire
Propulsion whl excludes tire
Propulsion whl excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster fork replacement only
Caster fork replacement only
Caster fork replacement only
Caster fork replacement only
Gear reduction drive wheel
Gear reduction drive wheel
Gear reduction drive wheel
Gear reduction drive wheel
Mwc acc, wheelchair brake
Mwc acc, wheelchair brake
Mwc acc, wheelchair brake
Mwc acc, wheelchair brake
Solid seat support base
Solid seat support base
Solid seat support base
Solid seat support base
Electro connect btw control
Electro connect btw control
Electro connect btw control
Page 43 of 79
$6.68
$4.46
$39.51
$4.46
$29.64
$2.21
$22.89
$2.21
$17.51
$2.35
$23.72
$2.35
$17.80
$1.97
$19.88
$1.97
$14.92
$9.71
$92.57
$9.71
$69.44
$1.65
$16.43
$1.65
$12.31
$3.58
$35.82
$3.58
$26.87
$169.79
$1,698.08
$169.79
$1,273.55
$88.38
$883.88
$88.38
$662.93
$14.51
$145.08
$14.51
$108.80
$105.79
$1,058.01
$105.79
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E2310UE
E2311
E2311NU
E2311RR
E2311UE
E2312
E2312NU
E2312RR
E2312UE
E2313
E2313NU
E2313RR
E2313UE
E2321
E2321NU
E2321RR
E2321UE
E2322
E2322NU
E2322RR
E2322UE
E2323
E2323NU
E2323RR
E2323UE
E2324
E2324NU
E2324RR
E2324UE
E2325
E2325NU
E2325RR
E2325UE
E2326
E2326NU
E2326RR
E2326UE
E2327
E2327NU
E2327RR
E2327UE
E2328
E2328NU
E2328RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Electro connect btw control
Electro connect btw 2 sys
Electro connect btw 2 sys
Electro connect btw 2 sys
Electro connect btw 2 sys
Mini-prop remote joystick
Mini-prop remote joystick
Mini-prop remote joystick
Mini-prop remote joystick
PWC harness, expand control
PWC harness, expand control
PWC harness, expand control
PWC harness, expand control
Hand interface joystick
Hand interface joystick
Hand interface joystick
Hand interface joystick
Mult mech switches
Mult mech switches
Mult mech switches
Mult mech switches
Special joystick handle
Special joystick handle
Special joystick handle
Special joystick handle
Chin cup interface
Chin cup interface
Chin cup interface
Chin cup interface
Sip and puff interface
Sip and puff interface
Sip and puff interface
Sip and puff interface
Breath tube kit
Breath tube kit
Breath tube kit
Breath tube kit
Head control interface mech
Head control interface mech
Head control interface mech
Head control interface mech
Head/extremity control inter
Head/extremity control inter
Head/extremity control inter
Page 44 of 79
$793.51
$214.21
$2,141.99
$214.21
$1,606.48
$183.08
$1,830.69
$183.08
$1,373.00
$29.09
$290.71
$29.09
$218.03
$143.68
$1,436.70
$143.68
$1,077.54
$127.50
$1,275.10
$127.50
$956.33
$6.25
$62.53
$6.25
$46.89
$3.95
$39.62
$3.95
$29.72
$121.78
$1,217.66
$121.78
$913.26
$31.40
$313.85
$31.40
$235.37
$236.18
$2,361.84
$236.18
$1,771.38
$448.00
$4,480.08
$448.00
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E2328UE
E2329
E2329NU
E2329RR
E2329UE
E2330
E2330NU
E2330RR
E2330UE
E2340
E2340NU
E2340RR
E2340UE
E2341
E2341NU
E2341RR
E2341UE
E2342
E2342NU
E2342RR
E2342UE
E2343
E2343NU
E2343RR
E2343UE
E2351
E2351NU
E2351RR
E2351UE
E2359
E2359NU
E2359RR
E2359UE
E2360
E2360NU
E2360RR
E2360UE
E2361
E2361NU
E2361RR
E2361UE
E2362
E2362NU
E2362RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Head/extremity control inter
Head control nonproportional
Head control nonproportional
Head control nonproportional
Head control nonproportional
Head control proximity switc
Head control proximity switc
Head control proximity switc
Head control proximity switc
W/c wdth 20-23 in seat frame
W/c wdth 20-23 in seat frame
W/c wdth 20-23 in seat frame
W/c wdth 20-23 in seat frame
W/c wdth 24-27 in seat frame
W/c wdth 24-27 in seat frame
W/c wdth 24-27 in seat frame
W/c wdth 24-27 in seat frame
W/c dpth 20-21 in seat frame
W/c dpth 20-21 in seat frame
W/c dpth 20-21 in seat frame
W/c dpth 20-21 in seat frame
W/c dpth 22-25 in seat frame
W/c dpth 22-25 in seat frame
W/c dpth 22-25 in seat frame
W/c dpth 22-25 in seat frame
Electronic SGD interface
Electronic SGD interface
Electronic SGD interface
Electronic SGD interface
Gr34 sealed leadacid battery
Gr34 sealed leadacid battery
Gr34 sealed leadacid battery
Gr34 sealed leadacid battery
22nf nonsealed leadacid
22nf nonsealed leadacid
22nf nonsealed leadacid
22nf nonsealed leadacid
22nf sealed leadacid battery
22nf sealed leadacid battery
22nf sealed leadacid battery
22nf sealed leadacid battery
Gr24 nonsealed leadacid
Gr24 nonsealed leadacid
Gr24 nonsealed leadacid
Page 45 of 79
$3,360.07
$159.67
$1,596.75
$159.67
$1,197.56
$309.38
$3,093.89
$309.38
$2,320.43
$33.84
$338.31
$33.84
$253.76
$50.75
$507.51
$50.75
$380.64
$42.29
$422.92
$42.29
$317.20
$67.65
$676.68
$67.65
$507.51
$63.18
$631.63
$63.18
$473.71
$16.19
$161.85
$16.19
$121.39
$9.05
$90.14
$9.05
$67.61
$12.41
$124.00
$12.41
$93.00
$8.53
$85.38
$8.53
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E2362UE
E2363
E2363NU
E2363RR
E2363UE
E2364
E2364NU
E2364RR
E2364UE
E2365
E2365NU
E2365RR
E2365UE
E2366
E2366NU
E2366RR
E2366UE
E2367
E2367NU
E2367RR
E2367UE
E2368
E2368NU
E2368RR
E2368UE
E2369
E2369NU
E2369RR
E2369UE
E2370
E2370NU
E2370RR
E2370UE
E2371
E2371NU
E2371RR
E2371UE
E2373
E2373NU
E2373RR
E2373UE
E2374
E2374NU
E2374RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Gr24 nonsealed leadacid
Gr24 sealed leadacid battery
Gr24 sealed leadacid battery
Gr24 sealed leadacid battery
Gr24 sealed leadacid battery
U1nonsealed leadacid battery
U1nonsealed leadacid battery
U1nonsealed leadacid battery
U1nonsealed leadacid battery
U1 sealed leadacid battery
U1 sealed leadacid battery
U1 sealed leadacid battery
U1 sealed leadacid battery
Battery charger, single mode
Battery charger, single mode
Battery charger, single mode
Battery charger, single mode
Battery charger, dual mode
Battery charger, dual mode
Battery charger, dual mode
Battery charger, dual mode
Power wc motor replacement
Power wc motor replacement
Power wc motor replacement
Power wc motor replacement
Pwr wc gear box replacement
Pwr wc gear box replacement
Pwr wc gear box replacement
Pwr wc gear box replacement
Pwr wc motor/gear box combo
Pwr wc motor/gear box combo
Pwr wc motor/gear box combo
Pwr wc motor/gear box combo
Gr27 sealed leadacid battery
Gr27 sealed leadacid battery
Gr27 sealed leadacid battery
Gr27 sealed leadacid battery
Hand/chin ctrl spec joystick
Hand/chin ctrl spec joystick
Hand/chin ctrl spec joystick
Hand/chin ctrl spec joystick
Hand/chin ctrl std joystick
Hand/chin ctrl std joystick
Hand/chin ctrl std joystick
Page 46 of 79
$64.03
$16.54
$165.35
$16.54
$124.02
$9.05
$90.14
$9.05
$67.61
$9.97
$99.73
$9.97
$74.82
$23.90
$238.34
$23.90
$178.76
$37.89
$378.89
$37.89
$284.17
$46.71
$467.03
$46.71
$350.28
$40.69
$406.79
$40.69
$305.08
$72.59
$725.84
$72.59
$544.38
$13.64
$136.28
$13.64
$102.22
$70.92
$709.01
$70.92
$531.78
$48.28
$482.81
$48.28
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E2374UE
E2375
E2375NU
E2375RR
E2375UE
E2376
E2376NU
E2376RR
E2376UE
E2377
E2377NU
E2377RR
E2377UE
E2378
E2378NU
E2378RR
E2378UE
E2381
E2381NU
E2381RR
E2381UE
E2382
E2382NU
E2382RR
E2382UE
E2383
E2383NU
E2383RR
E2383UE
E2384
E2384NU
E2384RR
E2384UE
E2385
E2385NU
E2385RR
E2385UE
E2386
E2386NU
E2386RR
E2386UE
E2387
E2387NU
E2387RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Hand/chin ctrl std joystick
Non-expandable controller
Non-expandable controller
Non-expandable controller
Non-expandable controller
Expandable controller, repl
Expandable controller, repl
Expandable controller, repl
Expandable controller, repl
Expandable controller, initl
Expandable controller, initl
Expandable controller, initl
Expandable controller, initl
Pw actuator replacement
Pw actuator replacement
Pw actuator replacement
Pw actuator replacement
Pneum drive wheel tire
Pneum drive wheel tire
Pneum drive wheel tire
Pneum drive wheel tire
Tube, pneum wheel drive tire
Tube, pneum wheel drive tire
Tube, pneum wheel drive tire
Tube, pneum wheel drive tire
Insert, pneum wheel drive
Insert, pneum wheel drive
Insert, pneum wheel drive
Insert, pneum wheel drive
Pneumatic caster tire
Pneumatic caster tire
Pneumatic caster tire
Pneumatic caster tire
Tube, pneumatic caster tire
Tube, pneumatic caster tire
Tube, pneumatic caster tire
Tube, pneumatic caster tire
Foam filled drive wheel tire
Foam filled drive wheel tire
Foam filled drive wheel tire
Foam filled drive wheel tire
Foam filled caster tire
Foam filled caster tire
Foam filled caster tire
Page 47 of 79
$362.12
$77.43
$774.41
$77.43
$580.79
$121.36
$1,213.54
$121.36
$910.17
$43.91
$439.13
$43.91
$329.36
$49.87
$498.59
$49.87
$373.95
$6.75
$67.71
$6.75
$50.79
$1.83
$18.45
$1.83
$13.85
$13.50
$135.01
$13.50
$101.28
$7.18
$71.94
$7.18
$53.95
$4.39
$44.01
$4.39
$33.00
$13.38
$133.79
$13.38
$100.36
$5.75
$57.72
$5.75
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E2387UE
E2388
E2388NU
E2388RR
E2388UE
E2389
E2389NU
E2389RR
E2389UE
E2390
E2390NU
E2390RR
E2390UE
E2391
E2391NU
E2391RR
E2391UE
E2392
E2392NU
E2392RR
E2392UE
E2394
E2394NU
E2394RR
E2394UE
E2395
E2395NU
E2395RR
E2395UE
E2396
E2396NU
E2396RR
E2396UE
E2397
E2397NU
E2397RR
E2397UE
E2402
E2402RR
E2500
E2500NU
E2500RR
E2500UE
E2502
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
Foam filled caster tire
Foam drive wheel tire
Foam drive wheel tire
Foam drive wheel tire
Foam drive wheel tire
Foam caster tire
Foam caster tire
Foam caster tire
Foam caster tire
Solid drive wheel tire
Solid drive wheel tire
Solid drive wheel tire
Solid drive wheel tire
Solid caster tire
Solid caster tire
Solid caster tire
Solid caster tire
Solid caster tire, integrate
Solid caster tire, integrate
Solid caster tire, integrate
Solid caster tire, integrate
Drive wheel excludes tire
Drive wheel excludes tire
Drive wheel excludes tire
Drive wheel excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster fork
Caster fork
Caster fork
Caster fork
Pwc acc, lith-based battery
Pwc acc, lith-based battery
Pwc acc, lith-based battery
Pwc acc, lith-based battery
Neg press wound therapy pump
Neg press wound therapy pump
SGD digitized pre-rec <=8min
SGD digitized pre-rec <=8min
SGD digitized pre-rec <=8min
SGD digitized pre-rec <=8min
SGD prerec msg >8min <=20min
Page 48 of 79
$43.28
$4.56
$45.55
$4.56
$34.18
$2.48
$24.74
$2.48
$18.54
$3.87
$38.68
$3.87
$28.99
$1.86
$18.53
$1.86
$13.91
$4.89
$48.71
$4.89
$36.53
$6.95
$69.39
$6.95
$52.05
$4.94
$49.32
$4.94
$37.00
$6.44
$60.13
$6.44
$45.10
$39.10
$390.97
$39.10
$293.20
$97.00
$97.00
$36.93
$369.18
$36.93
$276.88
$112.90
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E2502NU
E2502RR
E2502UE
E2504
E2504NU
E2504RR
E2504UE
E2506
E2506NU
E2506RR
E2506UE
E2508
E2508NU
E2508RR
E2508UE
E2510
E2510NU
E2510RR
E2510UE
E2601
E2601NU
E2601RR
E2601UE
E2602
E2602NU
E2602RR
E2602UE
E2603
E2603NU
E2603RR
E2603UE
E2604
E2604NU
E2604RR
E2604UE
E2605
E2605NU
E2605RR
E2605UE
E2606
E2606NU
E2606RR
E2606UE
E2607
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
SGD prerec msg >8min <=20min
SGD prerec msg >8min <=20min
SGD prerec msg >8min <=20min
SGD prerec msg>20min <=40min
SGD prerec msg>20min <=40min
SGD prerec msg>20min <=40min
SGD prerec msg>20min <=40min
SGD prerec msg > 40 min
SGD prerec msg > 40 min
SGD prerec msg > 40 min
SGD prerec msg > 40 min
SGD spelling phys contact
SGD spelling phys contact
SGD spelling phys contact
SGD spelling phys contact
SGD w multi methods msg/accs
SGD w multi methods msg/accs
SGD w multi methods msg/accs
SGD w multi methods msg/accs
Gen w/c cushion wdth < 22 in
Gen w/c cushion wdth < 22 in
Gen w/c cushion wdth < 22 in
Gen w/c cushion wdth < 22 in
Gen w/c cushion wdth >=22 in
Gen w/c cushion wdth >=22 in
Gen w/c cushion wdth >=22 in
Gen w/c cushion wdth >=22 in
Skin protect wc cus wd <22in
Skin protect wc cus wd <22in
Skin protect wc cus wd <22in
Skin protect wc cus wd <22in
Skin protect wc cus wd>=22in
Skin protect wc cus wd>=22in
Skin protect wc cus wd>=22in
Skin protect wc cus wd>=22in
Position wc cush wdth <22 in
Position wc cush wdth <22 in
Position wc cush wdth <22 in
Position wc cush wdth <22 in
Position wc cush wdth>=22 in
Position wc cush wdth>=22 in
Position wc cush wdth>=22 in
Position wc cush wdth>=22 in
Skin pro/pos wc cus wd <22in
Page 49 of 79
$1,128.90
$112.90
$846.68
$148.93
$1,489.17
$148.93
$1,116.86
$218.35
$2,183.56
$218.35
$1,637.64
$337.65
$3,376.51
$337.65
$2,532.39
$638.96
$6,389.60
$638.96
$4,792.19
$5.54
$55.29
$5.54
$41.47
$10.80
$107.95
$10.80
$80.96
$13.72
$137.05
$13.72
$102.79
$17.02
$170.34
$17.02
$127.77
$24.35
$243.36
$24.35
$182.55
$37.98
$379.66
$37.98
$284.73
$26.21
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E2607NU
E2607RR
E2607UE
E2608
E2608NU
E2608RR
E2608UE
E2611
E2611NU
E2611RR
E2611UE
E2612
E2612NU
E2612RR
E2612UE
E2613
E2613NU
E2613RR
E2613UE
E2614
E2614NU
E2614RR
E2614UE
E2615
E2615NU
E2615RR
E2615UE
E2616
E2616NU
E2616RR
E2616UE
E2619
E2619NU
E2619RR
E2619UE
E2620
E2620NU
E2620RR
E2620UE
E2621
E2621NU
E2621RR
E2621UE
E2622
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd>=22in
Skin pro/pos wc cus wd>=22in
Skin pro/pos wc cus wd>=22in
Skin pro/pos wc cus wd>=22in
Gen use back cush wdth <22in
Gen use back cush wdth <22in
Gen use back cush wdth <22in
Gen use back cush wdth <22in
Gen use back cush wdth>=22in
Gen use back cush wdth>=22in
Gen use back cush wdth>=22in
Gen use back cush wdth>=22in
Position back cush wd <22in
Position back cush wd <22in
Position back cush wd <22in
Position back cush wd <22in
Position back cush wd>=22in
Position back cush wd>=22in
Position back cush wd>=22in
Position back cush wd>=22in
Pos back post/lat wdth <22in
Pos back post/lat wdth <22in
Pos back post/lat wdth <22in
Pos back post/lat wdth <22in
Pos back post/lat wdth>=22in
Pos back post/lat wdth>=22in
Pos back post/lat wdth>=22in
Pos back post/lat wdth>=22in
Replace cover w/c seat cush
Replace cover w/c seat cush
Replace cover w/c seat cush
Replace cover w/c seat cush
WC planar back cush wd <22in
WC planar back cush wd <22in
WC planar back cush wd <22in
WC planar back cush wd <22in
WC planar back cush wd>=22in
WC planar back cush wd>=22in
WC planar back cush wd>=22in
WC planar back cush wd>=22in
Adj skin pro w/c cus wd<22in
Page 50 of 79
$262.05
$26.21
$196.54
$31.46
$314.70
$31.46
$236.03
$28.23
$282.40
$28.23
$211.82
$38.20
$382.02
$38.20
$286.50
$35.54
$355.34
$35.54
$266.51
$49.18
$491.77
$49.18
$368.84
$40.90
$408.94
$40.90
$306.69
$55.02
$550.21
$55.02
$412.68
$4.64
$46.39
$4.64
$34.82
$49.52
$495.17
$49.52
$371.39
$51.96
$519.64
$51.96
$389.74
$26.97
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E2622NU
E2622RR
E2622UE
E2623
E2623NU
E2623RR
E2623UE
E2624
E2624NU
E2624RR
E2624UE
E2625
E2625NU
E2625RR
E2625UE
E2626
E2626NU
E2626RR
E2626UE
E2627
E2627NU
E2627RR
E2627UE
E2628
E2628NU
E2628RR
E2628UE
E2629
E2629NU
E2629RR
E2629UE
E2630
E2630NU
E2630RR
E2630UE
E2631
E2631NU
E2631RR
E2631UE
E2632
E2632NU
E2632RR
E2632UE
E2633
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
Adj skin pro w/c cus wd<22in
Adj skin pro w/c cus wd<22in
Adj skin pro w/c cus wd<22in
Adj skin pro wc cus wd>=22in
Adj skin pro wc cus wd>=22in
Adj skin pro wc cus wd>=22in
Adj skin pro wc cus wd>=22in
Adj skin pro/pos cus<22in
Adj skin pro/pos cus<22in
Adj skin pro/pos cus<22in
Adj skin pro/pos cus<22in
Adj skin pro/pos wc cus>=22
Adj skin pro/pos wc cus>=22
Adj skin pro/pos wc cus>=22
Adj skin pro/pos wc cus>=22
Seo mobile arm sup att to wc
Seo mobile arm sup att to wc
Seo mobile arm sup att to wc
Seo mobile arm sup att to wc
Arm supp att to wc rancho ty
Arm supp att to wc rancho ty
Arm supp att to wc rancho ty
Arm supp att to wc rancho ty
Mobile arm supports reclinin
Mobile arm supports reclinin
Mobile arm supports reclinin
Mobile arm supports reclinin
Friction dampening arm supp
Friction dampening arm supp
Friction dampening arm supp
Friction dampening arm supp
Monosuspension arm/hand supp
Monosuspension arm/hand supp
Monosuspension arm/hand supp
Monosuspension arm/hand supp
Elevat proximal arm support
Elevat proximal arm support
Elevat proximal arm support
Elevat proximal arm support
Offset/lat rocker arm w/ela
Offset/lat rocker arm w/ela
Offset/lat rocker arm w/ela
Offset/lat rocker arm w/ela
Mobile arm support supinator
Page 51 of 79
$269.71
$26.97
$202.28
$34.33
$343.20
$34.33
$257.39
$27.20
$271.93
$27.20
$203.96
$34.42
$344.24
$34.42
$258.17
$60.03
$600.44
$60.03
$450.30
$95.84
$958.12
$95.84
$718.59
$72.18
$721.79
$72.18
$541.34
$91.33
$913.41
$91.33
$685.06
$63.87
$638.75
$63.87
$479.05
$21.72
$217.19
$21.72
$162.88
$13.81
$138.10
$13.81
$103.57
$13.80
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
E2633NU
E2633RR
E2633UE
G0333
K0001
K0001NU
K0001RR
K0002
K0002NU
K0002RR
K0003
K0003NU
K0003RR
K0004
K0004NU
K0004RR
K0005
K0005NU
K0005RR
K0005UE
K0006
K0006NU
K0006RR
K0007
K0007NU
K0007RR
K0009
K0009NU
K0009RR
K0010
K0010NU
K0010RR
K0011
K0011NU
K0011RR
K0012
K0012NU
K0012RR
K0015
K0015NU
K0015RR
K0015UE
K0017
K0017NU
NU
RR
UE
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
Mobile arm support supinator
Mobile arm support supinator
Mobile arm support supinator
Dispense fee initial 30 day
Standard wheelchair
Standard wheelchair
Standard wheelchair
Stnd hemi (low seat) whlchr
Stnd hemi (low seat) whlchr
Stnd hemi (low seat) whlchr
Lightweight wheelchair
Lightweight wheelchair
Lightweight wheelchair
High strength ltwt whlchr
High strength ltwt whlchr
High strength ltwt whlchr
Ultralightweight wheelchair
Ultralightweight wheelchair
Ultralightweight wheelchair
Ultralightweight wheelchair
Heavy duty wheelchair
Heavy duty wheelchair
Heavy duty wheelchair
Extra heavy duty wheelchair
Extra heavy duty wheelchair
Extra heavy duty wheelchair
Other manual wheelchair/base
Other manual wheelchair/base
Other manual wheelchair/base
Stnd wt frame power whlchr
Stnd wt frame power whlchr
Stnd wt frame power whlchr
Stnd wt pwr whlchr w control
Stnd wt pwr whlchr w control
Stnd wt pwr whlchr w control
Ltwt portbl power whlchr
Ltwt portbl power whlchr
Ltwt portbl power whlchr
Detach non-adjus hght armrst
Detach non-adjus hght armrst
Detach non-adjus hght armrst
Detach non-adjus hght armrst
Detach adjust armrest base
Detach adjust armrest base
Page 52 of 79
$137.81
$13.80
$103.36
$57.00
$14.91
$149.14
$14.91
$76.42
$764.19
$76.42
$81.71
$817.11
$81.71
$26.96
$269.60
$26.96
$171.61
$1,716.14
$171.61
$1,287.12
$15.53
$155.30
$15.53
$168.52
$1,685.16
$168.52
$69.65
$696.51
$69.65
$402.16
$4,021.56
$402.16
$483.62
$4,836.15
$483.62
$306.75
$3,067.47
$306.75
$16.14
$161.54
$16.14
$121.16
$4.55
$45.43
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
K0017RR
K0017UE
K0018
K0018NU
K0018RR
K0018UE
K0019
K0019NU
K0019RR
K0019UE
K0020
K0020NU
K0020RR
K0020UE
K0037
K0037NU
K0037RR
K0037UE
K0038
K0038NU
K0038RR
K0038UE
K0039
K0039NU
K0039RR
K0039UE
K0040
K0040NU
K0040RR
K0040UE
K0041
K0041NU
K0041RR
K0041UE
K0042
K0042NU
K0042RR
K0042UE
K0043
K0043NU
K0043RR
K0043UE
K0044
K0044NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
Detach adjust armrest base
Detach adjust armrest base
Detach adjust armrst upper
Detach adjust armrst upper
Detach adjust armrst upper
Detach adjust armrst upper
Arm pad each
Arm pad each
Arm pad each
Arm pad each
Fixed adjust armrest pair
Fixed adjust armrest pair
Fixed adjust armrest pair
Fixed adjust armrest pair
High mount flip-up footrest
High mount flip-up footrest
High mount flip-up footrest
High mount flip-up footrest
Leg strap each
Leg strap each
Leg strap each
Leg strap each
Leg strap h style each
Leg strap h style each
Leg strap h style each
Leg strap h style each
Adjustable angle footplate
Adjustable angle footplate
Adjustable angle footplate
Adjustable angle footplate
Large size footplate each
Large size footplate each
Large size footplate each
Large size footplate each
Standard size footplate each
Standard size footplate each
Standard size footplate each
Standard size footplate each
Ftrst lower extension tube
Ftrst lower extension tube
Ftrst lower extension tube
Ftrst lower extension tube
Ftrst upper hanger bracket
Ftrst upper hanger bracket
Page 53 of 79
$4.55
$34.07
$2.53
$25.39
$2.53
$19.04
$1.56
$15.58
$1.56
$11.69
$4.14
$41.29
$4.14
$30.98
$3.89
$43.54
$3.89
$32.67
$2.15
$21.56
$2.15
$16.16
$4.81
$47.91
$4.81
$35.92
$6.64
$66.37
$6.64
$49.79
$4.70
$47.06
$4.70
$35.27
$2.80
$28.00
$2.80
$21.00
$1.74
$17.36
$1.74
$13.03
$1.48
$14.80
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
K0044RR
K0044UE
K0045
K0045NU
K0045RR
K0045UE
K0046
K0046NU
K0046RR
K0046UE
K0047
K0047NU
K0047RR
K0047UE
K0050
K0050NU
K0050RR
K0050UE
K0051
K0051NU
K0051RR
K0051UE
K0052
K0052NU
K0052RR
K0052UE
K0053
K0053NU
K0053RR
K0053UE
K0056
K0056NU
K0056RR
K0056UE
K0065
K0065NU
K0065RR
K0065UE
K0069
K0069NU
K0069RR
K0069UE
K0070
K0070NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
Ftrst upper hanger bracket
Ftrst upper hanger bracket
Footrest complete assembly
Footrest complete assembly
Footrest complete assembly
Footrest complete assembly
Elevat legrst low extension
Elevat legrst low extension
Elevat legrst low extension
Elevat legrst low extension
Elevat legrst up hangr brack
Elevat legrst up hangr brack
Elevat legrst up hangr brack
Elevat legrst up hangr brack
Ratchet assembly
Ratchet assembly
Ratchet assembly
Ratchet assembly
Cam relese assem ftrst/lgrst
Cam relese assem ftrst/lgrst
Cam relese assem ftrst/lgrst
Cam relese assem ftrst/lgrst
Swingaway detach footrest
Swingaway detach footrest
Swingaway detach footrest
Swingaway detach footrest
Elevate footrest articulate
Elevate footrest articulate
Elevate footrest articulate
Elevate footrest articulate
Seat ht <17 or >=21 ltwt wc
Seat ht <17 or >=21 ltwt wc
Seat ht <17 or >=21 ltwt wc
Seat ht <17 or >=21 ltwt wc
Spoke protectors
Spoke protectors
Spoke protectors
Spoke protectors
Rear whl complete solid tire
Rear whl complete solid tire
Rear whl complete solid tire
Rear whl complete solid tire
Rear whl compl pneum tire
Rear whl compl pneum tire
Page 54 of 79
$1.48
$11.08
$8.54
$85.37
$8.54
$59.76
$1.74
$17.36
$1.74
$13.03
$6.80
$67.97
$6.80
$50.99
$2.88
$28.89
$2.88
$21.68
$4.67
$46.76
$4.67
$35.06
$8.23
$82.18
$8.23
$61.62
$9.08
$90.69
$9.08
$68.00
$8.84
$88.28
$8.84
$66.23
$4.12
$41.27
$4.12
$30.96
$9.29
$92.74
$9.29
$69.55
$17.01
$170.04
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
K0070RR
K0070UE
K0071
K0071NU
K0071RR
K0071UE
K0072
K0072NU
K0072RR
K0072UE
K0073
K0073NU
K0073RR
K0073UE
K0077
K0077NU
K0077RR
K0077UE
K0098
K0098NU
K0098RR
K0098UE
K0105
K0105NU
K0105RR
K0105UE
K0108
K0195
K0195NU
K0195RR
K0455
K0455RR
K0552
K0601
K0601NU
K0602
K0602NU
K0603
K0603NU
K0604
K0604NU
K0605
K0605NU
K0606
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
RR
NU
NU
NU
NU
NU
Rear whl compl pneum tire
Rear whl compl pneum tire
Front castr compl pneum tire
Front castr compl pneum tire
Front castr compl pneum tire
Front castr compl pneum tire
Frnt cstr cmpl sem-pneum tir
Frnt cstr cmpl sem-pneum tir
Frnt cstr cmpl sem-pneum tir
Frnt cstr cmpl sem-pneum tir
Caster pin lock each
Caster pin lock each
Caster pin lock each
Caster pin lock each
Front caster assem complete
Front caster assem complete
Front caster assem complete
Front caster assem complete
Drive belt power wheelchair
Drive belt power wheelchair
Drive belt power wheelchair
Drive belt power wheelchair
Iv hanger
Iv hanger
Iv hanger
Iv hanger
W/c component-accessory NOS
Elevating whlchair leg rests
Elevating whlchair leg rests
Elevating whlchair leg rests
Pump uninterrupted infusion
Pump uninterrupted infusion
Supply/ext inf pump syr type
Repl batt silver oxide 1.5 v
Repl batt silver oxide 1.5 v
Repl batt silver oxide 3 v
Repl batt silver oxide 3 v
Repl batt alkaline 1.5 v
Repl batt alkaline 1.5 v
Repl batt lithium 3.6 v
Repl batt lithium 3.6 v
Repl batt lithium 4.5 v
Repl batt lithium 4.5 v
AED garment w elec analysis
Page 55 of 79
$17.01
$127.53
$10.17
$101.40
$10.17
$76.06
$5.73
$57.37
$5.73
$43.03
$3.11
$31.07
$3.11
$23.29
$5.45
$54.60
$5.45
$40.95
$2.36
$23.47
$2.36
$17.61
$9.22
$92.30
$9.22
$69.24
$75.49
$19.05
$190.50
$19.05
$250.05
$250.05
$10.00
$1.77
$1.77
$1.77
$1.77
$1.77
$1.77
$1.77
$1.77
$1.77
$1.77
$2,377.23
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
K0606NU
NU
K0606RR
RR
K0607
K0607NU
NU
K0607RR
RR
K0607UE
UE
K0608
K0608NU
NU
K0608RR
RR
K0608UE
UE
K0609
K0609KF
KF
K0672
K0730
K0730NU
NU
K0730RR
RR
K0730UE
UE
K0733
K0733NU
NU
K0733RR
RR
K0733UE
UE
K0738
K0738RR RR
K0739
K0800
K0800NU
NU
K0800RR
RR
K0800UE
UE
K0801
K0801NU
NU
K0801RR
RR
K0801UE
UE
K0802
K0802NU
NU
K0802RR
RR
K0802UE
UE
K0806
K0806NU
NU
K0806RR
RR
K0806UE
UE
K0807
K0807NU
NU
K0807RR
RR
K0807UE
UE
AED garment w elec analysis
AED garment w elec analysis
Repl batt for AED
Repl batt for AED
Repl batt for AED
Repl batt for AED
Repl garment for AED
Repl garment for AED
Repl garment for AED
Repl garment for AED
Repl electrode for AED
Repl electrode for AED
Removable soft interface LE
Ctrl dose inh drug deliv sys
Ctrl dose inh drug deliv sys
Ctrl dose inh drug deliv sys
Ctrl dose inh drug deliv sys
12-24hr sealed lead acid
12-24hr sealed lead acid
12-24hr sealed lead acid
12-24hr sealed lead acid
Portable gas oxygen system
Portable gas oxygen system
Repair/svc DME non-oxygen eq
POV group 1 std up to 300lbs
POV group 1 std up to 300lbs
POV group 1 std up to 300lbs
POV group 1 std up to 300lbs
POV group 1 hd 301-450 lbs
POV group 1 hd 301-450 lbs
POV group 1 hd 301-450 lbs
POV group 1 hd 301-450 lbs
POV group 1 vhd 451-600 lbs
POV group 1 vhd 451-600 lbs
POV group 1 vhd 451-600 lbs
POV group 1 vhd 451-600 lbs
POV group 2 std up to 300lbs
POV group 2 std up to 300lbs
POV group 2 std up to 300lbs
POV group 2 std up to 300lbs
POV group 2 hd 301-450 lbs
POV group 2 hd 301-450 lbs
POV group 2 hd 301-450 lbs
POV group 2 hd 301-450 lbs
Page 56 of 79
$23,773.86
$2,377.39
$18.34
$183.37
$18.34
$137.52
$11.47
$114.43
$11.47
$85.82
$760.99
$844.89
$69.99
$162.76
$1,627.57
$162.76
$1,220.67
$2.75
$27.31
$2.75
$20.50
$41.30
$41.30
$14.75
$116.88
$1,168.79
$116.88
$876.59
$188.41
$1,884.33
$188.41
$1,413.24
$213.24
$2,132.46
$213.24
$1,599.35
$141.39
$1,413.92
$141.39
$1,060.44
$214.55
$2,145.46
$214.55
$1,609.11
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
K0808
K0808NU
K0808RR
K0808UE
K0813
K0813NU
K0813RR
K0814
K0814NU
K0814RR
K0815
K0815NU
K0815RR
K0816
K0816NU
K0816RR
K0820
K0820NU
K0820RR
K0821
K0821NU
K0821RR
K0822
K0822NU
K0822RR
K0823
K0823NU
K0823RR
K0824
K0824NU
K0824RR
K0825
K0825NU
K0825RR
K0826
K0826NU
K0826RR
K0827
K0827NU
K0827RR
K0828
K0828NU
K0828RR
K0829
NU
RR
UE
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
POV group 2 vhd 451-600 lbs
POV group 2 vhd 451-600 lbs
POV group 2 vhd 451-600 lbs
POV group 2 vhd 451-600 lbs
PWC gp 1 std port seat/back
PWC gp 1 std port seat/back
PWC gp 1 std port seat/back
PWC gp 1 std port cap chair
PWC gp 1 std port cap chair
PWC gp 1 std port cap chair
PWC gp 1 std seat/back
PWC gp 1 std seat/back
PWC gp 1 std seat/back
PWC gp 1 std cap chair
PWC gp 1 std cap chair
PWC gp 1 std cap chair
PWC gp 2 std port seat/back
PWC gp 2 std port seat/back
PWC gp 2 std port seat/back
PWC gp 2 std port cap chair
PWC gp 2 std port cap chair
PWC gp 2 std port cap chair
PWC gp 2 std seat/back
PWC gp 2 std seat/back
PWC gp 2 std seat/back
PWC gp 2 std cap chair
PWC gp 2 std cap chair
PWC gp 2 std cap chair
PWC gp 2 hd seat/back
PWC gp 2 hd seat/back
PWC gp 2 hd seat/back
PWC gp 2 hd cap chair
PWC gp 2 hd cap chair
PWC gp 2 hd cap chair
PWC gp 2 vhd seat/back
PWC gp 2 vhd seat/back
PWC gp 2 vhd seat/back
PWC gp vhd cap chair
PWC gp vhd cap chair
PWC gp vhd cap chair
PWC gp 2 xtra hd seat/back
PWC gp 2 xtra hd seat/back
PWC gp 2 xtra hd seat/back
PWC gp 2 xtra hd cap chair
Page 57 of 79
$331.94
$3,319.48
$331.94
$2,489.60
$327.15
$3,271.50
$327.15
$418.79
$4,187.90
$418.79
$476.84
$4,768.40
$476.84
$456.68
$4,566.80
$456.68
$314.50
$3,144.96
$314.50
$403.71
$4,037.13
$403.71
$487.91
$4,879.08
$487.91
$491.12
$4,911.21
$491.12
$591.06
$5,910.57
$591.06
$541.11
$5,411.07
$541.11
$765.20
$7,651.98
$765.20
$650.65
$6,506.46
$650.65
$843.17
$8,431.74
$843.17
$774.28
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
K0829NU
K0829RR
K0835
K0835NU
K0835RR
K0836
K0836NU
K0836RR
K0837
K0837NU
K0837RR
K0838
K0838NU
K0838RR
K0839
K0839NU
K0839RR
K0840
K0840NU
K0840RR
K0841
K0841NU
K0841RR
K0842
K0842NU
K0842RR
K0843
K0843NU
K0843RR
K0848
K0848NU
K0848RR
K0849
K0849NU
K0849RR
K0850
K0850NU
K0850RR
K0851
K0851NU
K0851RR
K0852
K0852NU
K0852RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
PWC gp 2 xtra hd cap chair
PWC gp 2 xtra hd cap chair
PWC gp2 std sing pow opt s/b
PWC gp2 std sing pow opt s/b
PWC gp2 std sing pow opt s/b
PWC gp2 std sing pow opt cap
PWC gp2 std sing pow opt cap
PWC gp2 std sing pow opt cap
PWC gp 2 hd sing pow opt s/b
PWC gp 2 hd sing pow opt s/b
PWC gp 2 hd sing pow opt s/b
PWC gp 2 hd sing pow opt cap
PWC gp 2 hd sing pow opt cap
PWC gp 2 hd sing pow opt cap
PWC gp2 vhd sing pow opt s/b
PWC gp2 vhd sing pow opt s/b
PWC gp2 vhd sing pow opt s/b
PWC gp2 xhd sing pow opt s/b
PWC gp2 xhd sing pow opt s/b
PWC gp2 xhd sing pow opt s/b
PWC gp2 std mult pow opt s/b
PWC gp2 std mult pow opt s/b
PWC gp2 std mult pow opt s/b
PWC gp2 std mult pow opt cap
PWC gp2 std mult pow opt cap
PWC gp2 std mult pow opt cap
PWC gp2 hd mult pow opt s/b
PWC gp2 hd mult pow opt s/b
PWC gp2 hd mult pow opt s/b
PWC gp 3 std seat/back
PWC gp 3 std seat/back
PWC gp 3 std seat/back
PWC gp 3 std cap chair
PWC gp 3 std cap chair
PWC gp 3 std cap chair
PWC gp 3 hd seat/back
PWC gp 3 hd seat/back
PWC gp 3 hd seat/back
PWC gp 3 hd cap chair
PWC gp 3 hd cap chair
PWC gp 3 hd cap chair
PWC gp 3 vhd seat/back
PWC gp 3 vhd seat/back
PWC gp 3 vhd seat/back
Page 58 of 79
$7,742.79
$774.28
$495.22
$4,952.16
$495.22
$513.57
$5,135.67
$513.57
$591.06
$5,910.57
$591.06
$528.76
$5,287.59
$528.76
$765.20
$7,651.98
$765.20
$1,159.27
$11,592.72
$1,159.27
$527.10
$5,271.03
$527.10
$527.10
$5,271.03
$527.10
$634.63
$6,346.26
$634.63
$644.97
$6,449.67
$644.97
$620.12
$6,201.18
$620.12
$748.15
$7,481.52
$748.15
$719.34
$7,193.43
$719.34
$864.44
$8,644.41
$864.44
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
K0853
K0853NU
K0853RR
K0854
K0854NU
K0854RR
K0855
K0855NU
K0855RR
K0856
K0856NU
K0856RR
K0857
K0857NU
K0857RR
K0858
K0858NU
K0858RR
K0859
K0859NU
K0859RR
K0860
K0860NU
K0860RR
K0861
K0861NU
K0861RR
K0862
K0862NU
K0862RR
K0863
K0863NU
K0863RR
K0864
K0864NU
K0864RR
L0112
L0113
L0120
L0130
L0140
L0150
L0160
L0170
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
PWC gp 3 vhd cap chair
PWC gp 3 vhd cap chair
PWC gp 3 vhd cap chair
PWC gp 3 xhd seat/back
PWC gp 3 xhd seat/back
PWC gp 3 xhd seat/back
PWC gp 3 xhd cap chair
PWC gp 3 xhd cap chair
PWC gp 3 xhd cap chair
PWC gp3 std sing pow opt s/b
PWC gp3 std sing pow opt s/b
PWC gp3 std sing pow opt s/b
PWC gp3 std sing pow opt cap
PWC gp3 std sing pow opt cap
PWC gp3 std sing pow opt cap
PWC gp3 hd sing pow opt s/b
PWC gp3 hd sing pow opt s/b
PWC gp3 hd sing pow opt s/b
PWC gp3 hd sing pow opt cap
PWC gp3 hd sing pow opt cap
PWC gp3 hd sing pow opt cap
PWC gp3 vhd sing pow opt s/b
PWC gp3 vhd sing pow opt s/b
PWC gp3 vhd sing pow opt s/b
PWC gp3 std mult pow opt s/b
PWC gp3 std mult pow opt s/b
PWC gp3 std mult pow opt s/b
PWC gp3 hd mult pow opt s/b
PWC gp3 hd mult pow opt s/b
PWC gp3 hd mult pow opt s/b
PWC gp3 vhd mult pow opt s/b
PWC gp3 vhd mult pow opt s/b
PWC gp3 vhd mult pow opt s/b
PWC gp3 xhd mult pow opt s/b
PWC gp3 xhd mult pow opt s/b
PWC gp3 xhd mult pow opt s/b
Cranial cervical orthosis
Cranial cervical torticollis
Cerv flexible non-adjustable
Flex thermoplastic collar mo
Cervical semi-rigid adjustab
Cerv semi-rig adj molded chn
Cerv semi-rig wire occ/mand
Cervical collar molded to pt
Page 59 of 79
$888.00
$8,880.03
$888.00
$1,176.40
$11,763.99
$1,176.40
$1,111.28
$11,112.84
$1,111.28
$692.32
$6,923.16
$692.32
$706.19
$7,061.85
$706.19
$858.96
$8,589.60
$858.96
$819.18
$8,191.80
$819.18
$1,227.13
$12,271.32
$1,227.13
$693.42
$6,934.23
$693.42
$858.96
$8,589.60
$858.96
$1,227.13
$12,271.32
$1,227.13
$1,460.30
$14,602.95
$1,460.30
$1,112.12
$235.41
$26.93
$149.84
$64.97
$86.53
$119.22
$578.30
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L0172
L0174
L0180
L0190
L0200
L0220
L0430
L0450
L0454
L0456
L0458
L0460
L0462
L0464
L0466
L0468
L0470
L0472
L0480
L0482
L0484
L0486
L0488
L0490
L0491
L0492
L0621
L0622
L0625
L0626
L0627
L0628
L0630
L0631
L0633
L0635
L0636
L0637
L0638
L0639
L0640
L0700
L0710
L0810
Cerv col thermplas foam 2 pi
Cerv col foam 2 piece w thor
Cer post col occ/man sup adj
Cerv collar supp adj cerv ba
Cerv col supp adj bar & thor
Thor rib belt custom fabrica
Dewall posture protector
TLSO flex prefab thoracic
TLSO flex prefab sacrococ-T9
TLSO flex prefab
TLSO 2Mod symphis-xipho pre
TLSO2Mod symphysis-stern pre
TLSO 3Mod sacro-scap pre
TLSO 4Mod sacro-scap pre
TLSO rigid frame pre soft ap
TLSO rigid frame prefab pelv
TLSO rigid frame pre subclav
TLSO rigid frame hyperex pre
TLSO rigid plastic custom fa
TLSO rigid lined custom fab
TLSO rigid plastic cust fab
TLSO rigidlined cust fab two
TLSO rigid lined pre one pie
TLSO rigid plastic pre one
TLSO 2 piece rigid shell
TLSO 3 piece rigid shell
SIO flex pelvisacral prefab
SIO flex pelvisacral custom
LO flexibl L1-below L5 pre
LO sag stays/panels pre-fab
LO sagitt rigid panel prefab
LO flex w/o rigid stays pre
LSO post rigid panel pre
LSO sag-coro rigid frame pre
LSO flexion control prefab
LSO sagit rigid panel prefab
LSO sagittal rigid panel cus
LSO sag-coronal panel prefab
LSO sag-coronal panel custom
LSO s/c shell/panel prefab
LSO s/c shell/panel custom
Ctlso a-p-l control molded
Ctlso a-p-l control w/ inter
Halo cervical into jckt vest
Page 60 of 79
$104.37
$219.74
$320.39
$450.77
$503.33
$100.29
$1,019.98
$174.72
$275.58
$790.29
$708.63
$797.61
$992.12
$1,181.09
$359.14
$431.07
$517.40
$367.43
$1,266.93
$1,291.20
$1,352.77
$1,435.22
$797.61
$224.78
$610.25
$401.39
$91.99
$244.14
$43.76
$61.93
$326.62
$66.66
$128.69
$650.00
$227.85
$839.64
$1,094.76
$750.00
$1,047.98
$893.09
$831.46
$1,538.95
$1,738.22
$2,092.94
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L0820
L0830
L0859
L0861
L0970
L0972
L0974
L0976
L0978
L0980
L0982
L0984
L1000
L1005
L1010
L1020
L1025
L1030
L1040
L1050
L1060
L1070
L1080
L1085
L1090
L1100
L1110
L1120
L1200
L1210
L1220
L1230
L1240
L1250
L1260
L1270
L1280
L1290
L1300
L1310
L1600
L1610
L1620
L1630
Halo cervical into body jack
Halo cerv into milwaukee typ
MRI compatible system
Halo repl liner/interface
Tlso corset front
Lso corset front
Tlso full corset
Lso full corset
Axillary crutch extension
Peroneal straps pair
Stocking supp grips set of f
Protective body sock each
Ctlso milwauke initial model
Tension based scoliosis orth
Ctlso axilla sling
Kyphosis pad
Kyphosis pad floating
Lumbar bolster pad
Lumbar or lumbar rib pad
Sternal pad
Thoracic pad
Trapezius sling
Outrigger
Outrigger bil w/ vert extens
Lumbar sling
Ring flange plastic/leather
Ring flange plas/leather mol
Covers for upright each
Furnsh initial orthosis only
Lateral thoracic extension
Anterior thoracic extension
Milwaukee type superstructur
Lumbar derotation pad
Anterior asis pad
Anterior thoracic derotation
Abdominal pad
Rib gusset (elastic) each
Lateral trochanteric pad
Body jacket mold to patient
Post-operative body jacket
Abduct hip flex frejka w cvr
Abduct hip flex frejka covr
Abduct hip flex pavlik harne
Abduct control hip semi-flex
Page 61 of 79
$2,055.43
$2,883.02
$927.33
$171.26
$87.00
$78.34
$141.01
$149.01
$156.20
$14.13
$13.19
$52.04
$1,850.97
$2,543.18
$52.99
$77.68
$94.92
$49.75
$73.46
$78.01
$85.78
$77.53
$47.93
$125.10
$75.66
$137.49
$227.52
$37.41
$1,590.26
$199.18
$206.31
$432.71
$63.18
$57.79
$60.99
$58.98
$68.32
$61.12
$1,285.91
$1,440.32
$98.09
$33.42
$107.45
$139.32
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L1640
L1650
L1652
L1660
L1680
L1685
L1686
L1690
L1700
L1710
L1720
L1730
L1755
L1810
L1820
L1830
L1831
L1832
L1834
L1836
L1840
L1843
L1844
L1845
L1846
L1847
L1850
L1860
L1900
L1902
L1904
L1906
L1907
L1910
L1920
L1930
L1932
L1940
L1945
L1950
L1951
L1960
L1970
L1971
Pelv band/spread bar thigh c
HO abduction hip adjustable
HO bi thighcuffs w sprdr bar
HO abduction static plastic
Pelvic & hip control thigh c
Post-op hip abduct custom fa
HO post-op hip abduction
Combination bilateral HO
Leg perthes orth toronto typ
Legg perthes orth newington
Legg perthes orthosis trilat
Legg perthes orth scottish r
Legg perthes patten bottom t
Ko elastic with joints
Ko elas w/ condyle pads & jo
Ko immobilizer canvas longit
Knee orth pos locking joint
KO adj jnt pos rigid support
Ko w/0 joint rigid molded to
Rigid KO wo joints
Ko derot ant cruciate custom
KO single upright custom fit
Ko w/adj jt rot cntrl molded
Ko w/ adj flex/ext rotat cus
Ko w adj flex/ext rotat mold
KO adjustable w air chambers
Ko swedish type
Ko supracondylar socket mold
Afo sprng wir drsflx calf bd
Afo ankle gauntlet
Afo molded ankle gauntlet
Afo multiligamentus ankle su
AFO supramalleolar custom
Afo sing bar clasp attach sh
Afo sing upright w/ adjust s
Afo plastic
Afo rig ant tib prefab TCF/=
Afo molded to patient plasti
Afo molded plas rig ant tib
Afo spiral molded to pt plas
AFO spiral prefabricated
Afo pos solid ank plastic mo
Afo plastic molded w/ankle j
AFO w/ankle joint, prefab
Page 62 of 79
$367.44
$176.24
$283.24
$141.17
$1,236.64
$905.45
$704.12
$1,536.53
$1,250.22
$1,512.63
$1,055.21
$900.31
$1,205.18
$86.79
$109.81
$85.11
$233.86
$462.80
$590.90
$106.02
$809.64
$600.00
$1,601.53
$646.16
$973.23
$457.02
$244.67
$998.69
$226.40
$74.51
$357.96
$91.54
$447.10
$257.49
$341.09
$210.31
$709.06
$404.41
$795.14
$755.98
$667.32
$421.93
$563.07
$372.45
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L1980
L1990
L2000
L2005
L2010
L2020
L2030
L2034
L2035
L2036
L2037
L2038
L2040
L2050
L2060
L2070
L2080
L2090
L2106
L2108
L2112
L2114
L2116
L2126
L2128
L2132
L2134
L2136
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2200
L2210
L2220
L2230
L2232
L2240
L2250
L2260
L2265
Afo sing solid stirrup calf
Afo doub solid stirrup calf
Kafo sing fre stirr thi/calf
KAFO sng/dbl mechanical act
Kafo sng solid stirrup w/o j
Kafo dbl solid stirrup band/
Kafo dbl solid stirrup w/o j
KAFO pla sin up w/wo k/a cus
KAFO plastic pediatric size
Kafo plas doub free knee mol
Kafo plas sing free knee mol
Kafo w/o joint multi-axis an
Hkafo torsion bil rot straps
Hkafo torsion cable hip pelv
Hkafo torsion ball bearing j
Hkafo torsion unilat rot str
Hkafo unilat torsion cable
Hkafo unilat torsion ball br
Afo tib fx cast plaster mold
Afo tib fx cast molded to pt
Afo tibial fracture soft
Afo tib fx semi-rigid
Afo tibial fracture rigid
Kafo fem fx cast thermoplas
Kafo fem fx cast molded to p
Kafo femoral fx cast soft
Kafo fem fx cast semi-rigid
Kafo femoral fx cast rigid
Plas shoe insert w ank joint
Drop lock knee
Limited motion knee joint
Adj motion knee jnt lerman t
Quadrilateral brim
Waist belt
Pelvic band & belt thigh fla
Limited ankle motion ea jnt
Dorsiflexion assist each joi
Dorsi & plantar flex ass/res
Split flat caliper stirr & p
Rocker bottom, contact AFO
Round caliper and plate atta
Foot plate molded stirrup at
Reinforced solid stirrup
Long tongue stirrup
Page 63 of 79
$357.29
$431.74
$1,029.46
$3,255.99
$929.30
$1,185.11
$1,020.63
$1,611.30
$142.98
$1,821.94
$1,503.08
$1,266.19
$173.93
$367.76
$520.69
$102.37
$315.63
$445.05
$533.48
$912.20
$368.22
$451.85
$541.91
$911.52
$1,740.37
$614.05
$769.91
$900.22
$89.15
$82.03
$94.29
$131.94
$247.02
$66.47
$271.41
$48.26
$53.63
$73.67
$71.71
$79.07
$64.26
$360.65
$152.60
$89.65
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L2270
L2275
L2280
L2300
L2310
L2320
L2330
L2335
L2340
L2350
L2360
L2370
L2375
L2380
L2385
L2387
L2390
L2395
L2397
L2405
L2415
L2425
L2430
L2492
L2500
L2510
L2520
L2525
L2526
L2530
L2540
L2550
L2570
L2580
L2600
L2610
L2620
L2622
L2624
L2627
L2628
L2630
L2640
L2650
Varus/valgus strap padded/li
Plastic mod low ext pad/line
Molded inner boot
Abduction bar jointed adjust
Abduction bar-straight
Non-molded lacer
Lacer molded to patient mode
Anterior swing band
Pre-tibial shell molded to p
Prosthetic type socket molde
Extended steel shank
Patten bottom
Torsion ank & half solid sti
Torsion straight knee joint
Straight knee joint heavy du
Add LE poly knee custom KAFO
Offset knee joint each
Offset knee joint heavy duty
Suspension sleeve lower ext
Knee joint drop lock ea jnt
Knee joint cam lock each joi
Knee disc/dial lock/adj flex
Knee jnt ratchet lock ea jnt
Knee lift loop drop lock rin
Thi/glut/ischia wgt bearing
Th/wght bear quad-lat brim m
Th/wght bear quad-lat brim c
Th/wght bear nar m-l brim mo
Th/wght bear nar m-l brim cu
Thigh/wght bear lacer non-mo
Thigh/wght bear lacer molded
Thigh/wght bear high roll cu
Hip clevis type 2 posit jnt
Pelvic control pelvic sling
Hip clevis/thrust bearing fr
Hip clevis/thrust bearing lo
Pelvic control hip heavy dut
Hip joint adjustable flexion
Hip adj flex ext abduct cont
Plastic mold recipro hip & c
Metal frame recipro hip & ca
Pelvic control band & belt u
Pelvic control band & belt b
Pelv & thor control gluteal
Page 64 of 79
$54.50
$119.06
$345.20
$255.54
$124.86
$200.08
$353.62
$189.32
$420.11
$765.22
$52.52
$208.81
$86.01
$95.41
$101.96
$154.58
$83.33
$119.10
$100.60
$69.27
$96.50
$113.90
$113.90
$80.49
$257.83
$628.97
$370.56
$987.77
$695.19
$186.75
$405.94
$238.54
$373.51
$417.53
$181.08
$218.24
$239.41
$233.43
$252.07
$1,304.95
$1,700.44
$199.12
$310.32
$121.80
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L2660
L2670
L2680
L2750
L2755
L2760
L2768
L2780
L2785
L2795
L2800
L2810
L2820
L2830
L2840
L2850
L3000
L3001
L3002
L3003
L3010
L3020
L3030
L3040
L3050
L3060
L3070
L3080
L3090
L3100
L3140
L3150
L3170
L3224
L3225
L3300
L3310
L3330
L3332
L3334
L3340
L3350
L3360
L3370
Thoracic control thoracic ba
Thorac cont paraspinal uprig
Thorac cont lat support upri
Plating chrome/nickel pr bar
Carbon graphite lamination
Extension per extension per
Ortho sidebar disconnect
Non-corrosive finish
Drop lock retainer each
Knee control full kneecap
Knee cap medial or lateral p
Knee control condylar pad
Soft interface below knee se
Soft interface above knee se
Tibial length sock fx or equ
Femoral lgth sock fx or equa
Ft insert ucb berkeley shell
Foot insert remov molded spe
Foot insert plastazote or eq
Foot insert silicone gel eac
Foot longitudinal arch suppo
Foot longitud/metatarsal sup
Foot arch support remov prem
Ft arch suprt premold longit
Foot arch supp premold metat
Foot arch supp longitud/meta
Arch suprt att to sho longit
Arch supp att to shoe metata
Arch supp att to shoe long/m
Hallus-valgus nght dynamic s
Abduction rotation bar shoe
Abduct rotation bar w/o shoe
Foot plastic heel stabilizer
Woman's shoe oxford brace
Man's shoe oxford brace
Sho lift taper to metatarsal
Shoe lift elev heel/sole neo
Lifts elevation metal extens
Shoe lifts tapered to one-ha
Shoe lifts elevation heel /i
Shoe wedge sach
Shoe heel wedge
Shoe sole wedge outside sole
Shoe sole wedge between sole
Page 65 of 79
$141.88
$134.24
$119.12
$74.75
$103.83
$47.23
$103.52
$68.69
$26.63
$80.18
$93.08
$59.45
$66.11
$71.51
$33.26
$47.13
$249.60
$105.09
$128.33
$138.47
$138.47
$157.65
$60.64
$37.39
$37.39
$58.61
$25.24
$25.24
$32.35
$34.35
$70.75
$64.68
$40.45
$44.77
$51.49
$41.42
$64.68
$449.69
$58.61
$30.32
$67.72
$18.20
$28.30
$39.39
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L3380
L3390
L3400
L3410
L3420
L3430
L3440
L3450
L3455
L3460
L3465
L3470
L3480
L3500
L3510
L3520
L3530
L3540
L3550
L3560
L3570
L3580
L3590
L3595
L3600
L3610
L3620
L3630
L3640
L3650
L3660
L3670
L3671
L3674
L3675
L3702
L3710
L3720
L3730
L3740
L3760
L3762
L3763
L3764
Shoe clubfoot wedge
Shoe outflare wedge
Shoe metatarsal bar wedge ro
Shoe metatarsal bar between
Full sole/heel wedge btween
Sho heel count plast reinfor
Heel leather reinforced
Shoe heel sach cushion type
Shoe heel new leather standa
Shoe heel new rubber standar
Shoe heel thomas with wedge
Shoe heel thomas extend to b
Shoe heel pad & depress for
Ortho shoe add leather insol
Orthopedic shoe add rub insl
O shoe add felt w leath insl
Ortho shoe add half sole
Ortho shoe add full sole
O shoe add standard toe tap
O shoe add horseshoe toe tap
O shoe add instep extension
O shoe add instep velcro clo
O shoe convert to sof counte
Ortho shoe add march bar
Trans shoe calip plate exist
Trans shoe caliper plate new
Trans shoe solid stirrup exi
Trans shoe solid stirrup new
Shoe dennis browne splint bo
Shlder fig 8 abduct restrain
Abduct restrainer canvas&web
Acromio/clavicular canvas&we
SO cap design w/o jnts CF
SO airplane w/wo joint CF
Canvas vest SO
EO w/o joints CF
Elbow elastic with metal joi
Forearm/arm cuffs free motio
Forearm/arm cuffs ext/flex a
Cuffs adj lock w/ active con
EO withjoint, Prefabricated
Rigid EO wo joints
EWHO rigid w/o jnts CF
EWHO w/joint(s) CF
Page 66 of 79
$39.39
$39.39
$32.35
$73.76
$43.45
$127.33
$60.64
$83.88
$32.35
$27.27
$46.49
$49.51
$49.51
$23.24
$23.24
$25.24
$25.24
$40.45
$7.06
$18.20
$67.72
$51.53
$42.44
$33.35
$60.64
$79.82
$60.64
$79.82
$34.35
$47.08
$76.55
$87.55
$651.62
$854.79
$126.90
$208.81
$92.08
$581.95
$782.94
$799.25
$361.64
$77.76
$534.63
$600.29
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L3765
L3766
L3806
L3807
L3808
L3900
L3901
L3904
L3905
L3906
L3908
L3912
L3913
L3915
L3917
L3919
L3921
L3923
L3925
L3927
L3929
L3931
L3933
L3935
L3960
L3961
L3962
L3967
L3971
L3973
L3975
L3976
L3977
L3978
L3980
L3982
L3984
L3995
L4000
L4010
L4020
L4030
L4040
L4045
EWHFO rigid w/o jnts CF
EWHFO w/joint(s) CF
WHFO w/joint(s) custom fab
WHFO,no joint, prefabricated
WHFO, rigid w/o joints
Hinge extension/flex wrist/f
Hinge ext/flex wrist finger
Whfo electric custom fitted
WHO w/nontorsion jnt(s) CF
WHO w/o joints CF
Wrist cock-up non-molded
Flex glove w/elastic finger
HFO w/o joints CF
WHO w nontor jnt(s) prefab
Prefab metacarpl fx orthosis
HO w/o joints CF
HFO w/joint(s) CF
HFO w/o joints PF
FO pip/dip with joint/spring
FO pip/dip w/o joint/spring
HFO nontorsion joint, prefab
WHFO nontorsion joint prefab
FO w/o joints CF
FO nontorsion joint CF
Sewho airplan desig abdu pos
SEWHO cap design w/o jnts CF
Sewho erbs palsey design abd
SEWHO airplane w/o jnts CF
SEWHO cap design w/jnt(s) CF
SEWHO airplane w/jnt(s) CF
SEWHFO cap design w/o jnt CF
SEWHFO airplane w/o jnts CF
SEWHFO cap desgn w/jnt(s) CF
SEWHFO airplane w/jnt(s) CF
Upp ext fx orthosis humeral
Upper ext fx orthosis rad/ul
Upper ext fx orthosis wrist
Sock fracture or equal each
Repl girdle milwaukee orth
Replace trilateral socket br
Replace quadlat socket brim
Replace socket brim cust fit
Replace molded thigh lacer
Replace non-molded thigh lac
Page 67 of 79
$927.24
$981.88
$328.48
$180.83
$260.58
$1,084.79
$1,341.14
$2,181.36
$717.16
$308.70
$59.51
$94.19
$195.86
$384.39
$76.40
$195.86
$232.29
$71.21
$46.23
$25.28
$70.55
$139.32
$154.30
$159.75
$615.56
$1,214.96
$665.20
$1,434.47
$1,361.65
$1,434.47
$1,214.96
$1,214.96
$1,361.65
$1,434.47
$230.28
$278.07
$267.59
$27.04
$1,102.64
$609.25
$729.42
$502.97
$414.30
$251.88
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L4050
L4055
L4060
L4070
L4080
L4090
L4100
L4110
L4130
L4205
L4350
L4360
L4370
L4386
L4392
L4394
L4396
L4398
L4631
L5000
L5010
L5020
L5050
L5060
L5100
L5105
L5150
L5160
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5301
L5312
L5321
L5331
L5341
L5400
L5410
L5420
L5430
Replace molded calf lacer
Replace non-molded calf lace
Replace high roll cuff
Replace prox & dist upright
Repl met band kafo-afo prox
Repl met band kafo-afo calf/
Repl leath cuff kafo prox th
Repl leath cuff kafo-afo cal
Replace pretibial shell
Ortho dvc repair per 15 min
Ankle control orthosi prefab
Pneumati walking boot prefab
Pneumatic full leg splint
Non-pneum walk boot prefab
Replace AFO soft interface
Replace foot drop spint
Static AFO
Foot drop splint recumbent
Afo, walk boot type, cus fab
Sho insert w arch toe filler
Mold socket ank hgt w/ toe f
Tibial tubercle hgt w/ toe f
Ank symes mold sckt sach ft
Symes met fr leath socket ar
Molded socket shin sach foot
Plast socket jts/thgh lacer
Mold sckt ext knee shin sach
Mold socket bent knee shin s
Kne sing axis fric shin sach
No knee/ankle joints w/ ft b
No knee joint with artic ali
Fem focal defic constant fri
Hip canad sing axi cons fric
Tilt table locking hip sing
Hemipelvect canad sing axis
BK mold socket SACH ft endo
Knee disart, SACH ft, endo
AK open end SACH
Hip disart canadian SACH ft
Hemipelvectomy canadian SACH
Postop dress & 1 cast chg bk
Postop dsg bk ea add cast ch
Postop dsg & 1 cast chg ak/d
Postop dsg ak ea add cast ch
Page 68 of 79
$378.63
$206.43
$307.58
$253.57
$91.19
$91.58
$105.86
$86.07
$503.55
$18.17
$74.94
$281.03
$191.61
$125.98
$18.39
$13.40
$131.11
$60.36
$1,215.54
$409.75
$987.32
$1,831.00
$2,186.09
$2,900.88
$2,265.90
$3,197.94
$3,306.65
$4,034.21
$3,303.49
$2,623.87
$2,982.51
$3,988.92
$5,190.78
$5,561.25
$5,505.64
$2,272.01
$3,652.28
$3,509.88
$4,980.11
$5,197.89
$1,084.52
$416.89
$1,309.94
$408.89
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L5450
L5460
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5560
L5570
L5580
L5585
L5590
L5595
L5600
L5610
L5611
L5613
L5614
L5616
L5617
L5618
L5620
L5622
L5624
L5626
L5628
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5639
L5640
L5642
L5643
L5644
L5645
L5646
L5647
Postop app non-wgt bear dsg
Postop app non-wgt bear dsg
Init bk ptb plaster direct
Init ak ischal plstr direct
Prep BK ptb plaster molded
Perp BK ptb thermopls direct
Prep BK ptb thermopls molded
Prep BK ptb open end socket
Prep BK ptb laminated socket
Prep AK ischial plast molded
Prep AK ischial direct form
Prep AK ischial thermo mold
Prep AK ischial open end
Prep AK ischial laminated
Hip disartic sach thermopls
Hip disart sach laminat mold
Above knee hydracadence
Ak 4 bar link w/fric swing
Ak 4 bar ling w/hydraul swig
4-bar link above knee w/swng
Ak univ multiplex sys frict
AK/BK self-aligning unit ea
Test socket symes
Test socket below knee
Test socket knee disarticula
Test socket above knee
Test socket hip disarticulat
Test socket hemipelvectomy
Below knee acrylic socket
Syme typ expandabl wall sckt
Ak/knee disartic acrylic soc
Symes type ptb brim design s
Symes type poster opening so
Symes type medial opening so
Below knee total contact
Below knee leather socket
Below knee wood socket
Knee disarticulat leather so
Above knee leather socket
Hip flex inner socket ext fr
Above knee wood socket
Bk flex inner socket ext fra
Below knee cushion socket
Below knee suction socket
Page 69 of 79
$357.81
$473.77
$1,041.56
$1,410.55
$1,279.36
$1,166.23
$1,627.49
$1,681.07
$1,794.32
$1,752.97
$1,843.78
$2,112.17
$2,341.00
$2,049.45
$3,660.93
$4,614.35
$2,154.09
$1,430.79
$1,987.46
$1,343.44
$1,101.44
$445.44
$253.33
$240.56
$339.27
$305.45
$443.46
$490.32
$257.72
$410.72
$356.33
$240.09
$286.03
$254.93
$241.44
$447.40
$1,024.80
$678.73
$669.94
$1,449.02
$534.82
$647.07
$475.66
$645.10
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L5648
L5649
L5650
L5651
L5652
L5653
L5654
L5655
L5656
L5658
L5661
L5665
L5666
L5668
L5670
L5671
L5672
L5673
L5676
L5677
L5678
L5679
L5680
L5681
L5682
L5683
L5684
L5685
L5686
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
L5700
L5701
L5702
L5703
L5704
L5705
Above knee cushion socket
Isch containmt/narrow m-l so
Tot contact ak/knee disart s
Ak flex inner socket ext fra
Suction susp ak/knee disart
Knee disart expand wall sock
Socket insert symes
Socket insert below knee
Socket insert knee articulat
Socket insert above knee
Multi-durometer symes
Multi-durometer below knee
Below knee cuff suspension
Socket insert w/o lock lower
Bk molded supracondylar susp
BK/AK locking mechanism
Bk removable medial brim sus
Socket insert w lock mech
Bk knee joints single axis p
Bk knee joints polycentric p
Bk joint covers pair
Socket insert w/o lock mech
Bk thigh lacer non-molded
Intl custm cong/latyp insert
Bk thigh lacer glut/ischia m
Initial custom socket insert
Bk fork strap
Below knee sus/seal sleeve
Bk back check
Bk waist belt webbing
Bk waist belt padded and lin
Ak pelvic control belt light
Ak pelvic control belt pad/l
Ak sleeve susp neoprene/equa
Ak/knee disartic pelvic join
Ak/knee disartic pelvic band
Ak/knee disartic silesian ba
Shoulder harness
Replace socket below knee
Replace socket above knee
Replace socket hip
Symes ankle w/o (SACH) foot
Custom shape cover BK
Custom shape cover AK
Page 70 of 79
$533.93
$1,632.13
$465.41
$973.92
$353.57
$580.09
$314.19
$281.53
$401.11
$393.16
$493.52
$415.24
$57.61
$90.99
$240.19
$537.85
$261.69
$580.91
$342.34
$435.81
$38.38
$484.09
$287.53
$1,047.22
$512.76
$1,047.22
$52.05
$101.97
$51.70
$56.60
$86.07
$126.47
$195.40
$132.26
$200.06
$86.81
$101.41
$199.35
$2,961.21
$3,598.49
$4,308.87
$1,987.15
$494.54
$811.88
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L5706
L5707
L5710
L5711
L5712
L5714
L5716
L5718
L5722
L5724
L5726
L5728
L5780
L5781
L5782
L5785
L5790
L5795
L5810
L5811
L5812
L5814
L5816
L5818
L5822
L5824
L5826
L5828
L5830
L5840
L5845
L5848
L5850
L5855
L5856
L5857
L5858
L5859
L5910
L5920
L5925
L5930
L5940
L5950
Custom shape cvr knee disart
Custom shape cvr hip disart
Kne-shin exo sng axi mnl loc
Knee-shin exo mnl lock ultra
Knee-shin exo frict swg & st
Knee-shin exo variable frict
Knee-shin exo mech stance ph
Knee-shin exo frct swg & sta
Knee-shin pneum swg frct exo
Knee-shin exo fluid swing ph
Knee-shin ext jnts fld swg e
Knee-shin fluid swg & stance
Knee-shin pneum/hydra pneum
Lower limb pros vacuum pump
HD low limb pros vacuum pump
Exoskeletal bk ultralt mater
Exoskeletal ak ultra-light m
Exoskel hip ultra-light mate
Endoskel knee-shin mnl lock
Endo knee-shin mnl lck ultra
Endo knee-shin frct swg & st
Endo knee-shin hydral swg ph
Endo knee-shin polyc mch sta
Endo knee-shin frct swg & st
Endo knee-shin pneum swg frc
Endo knee-shin fluid swing p
Miniature knee joint
Endo knee-shin fluid swg/sta
Endo knee-shin pneum/swg pha
Multi-axial knee/shin system
Knee-shin sys stance flexion
Knee-shin sys hydraul stance
Endo ak/hip knee extens assi
Mech hip extension assist
Elec knee-shin swing/stance
Elec knee-shin swing only
Stance phase only
Knee-shin pro flex/ext cont
Endo below knee alignable sy
Endo ak/hip alignable system
Above knee manual lock
High activity knee frame
Endo bk ultra-light material
Endo ak ultra-light material
Page 71 of 79
$804.68
$1,143.89
$369.00
$499.54
$448.45
$339.21
$591.08
$738.78
$860.19
$1,302.53
$1,576.35
$2,097.91
$928.49
$3,185.47
$3,358.21
$503.34
$606.05
$870.74
$450.89
$591.46
$511.88
$2,956.76
$689.69
$778.80
$1,381.01
$1,243.69
$2,582.73
$2,290.15
$1,996.83
$3,273.26
$1,426.97
$856.11
$103.74
$333.94
$19,111.94
$6,781.65
$14,796.35
$12,635.20
$293.72
$430.30
$353.69
$2,679.73
$505.77
$726.98
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L5960
L5961
L5962
L5964
L5966
L5968
L5970
L5971
L5972
L5973
L5974
L5975
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5985
L5986
L5987
L5988
L5990
L6000
L6010
L6020
L6025
L6050
L6055
L6100
L6110
L6120
L6130
L6200
L6205
L6250
L6300
L6310
L6320
L6350
L6360
L6370
L6380
Endo hip ultra-light materia
Endo poly hip, pneu/hyd/rot
Below knee flex cover system
Above knee flex cover system
Hip flexible cover system
Multiaxial ankle w dorsiflex
Foot external keel sach foot
SACH foot, replacement
Flexible keel foot
Ank-foot sys dors-plant flex
Foot single axis ankle/foot
Combo ankle/foot prosthesis
Energy storing foot
Ft prosth multiaxial ankl/ft
Multi-axial ankle/ft prosth
Flex foot system
Flex-walk sys low ext prosth
Exoskeletal axial rotation u
Endoskeletal axial rotation
Lwr ext dynamic prosth pylon
Multi-axial rotation unit
Shank ft w vert load pylon
Vertical shock reducing pylo
User adjustable heel height
Part hand thumb rem
Part hand little/ring
Part hand no fingers
Part hand disart myoelectric
Wrst MLd sck flx hng tri pad
Wrst mold sock w/exp interfa
Elb mold sock flex hinge pad
Elbow mold sock suspension t
Elbow mold doub splt soc ste
Elbow stump activated lock h
Elbow mold outsid lock hinge
Elbow molded w/ expand inter
Elbow inter loc elbow forarm
Shlder disart int lock elbow
Shoulder passive restor comp
Shoulder passive restor cap
Thoracic intern lock elbow
Thoracic passive restor comp
Thoracic passive restor cap
Postop dsg cast chg wrst/elb
Page 72 of 79
$830.92
$3,934.43
$635.58
$914.97
$1,186.22
$2,893.10
$198.94
$198.94
$317.93
$13,995.61
$251.97
$369.08
$507.71
$286.94
$2,444.49
$3,287.71
$2,656.46
$619.71
$585.87
$224.82
$620.09
$5,727.20
$1,590.45
$1,444.36
$1,436.72
$1,598.83
$1,490.66
$6,370.99
$1,760.71
$2,629.01
$1,896.52
$1,934.32
$2,432.34
$2,799.19
$2,872.72
$3,599.10
$2,679.01
$3,768.37
$3,128.06
$1,385.91
$4,235.39
$3,444.15
$1,647.16
$1,108.99
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L6382
L6384
L6386
L6388
L6400
L6450
L6500
L6550
L6570
L6580
L6582
L6584
L6586
L6588
L6590
L6600
L6605
L6610
L6611
L6615
L6616
L6620
L6621
L6623
L6624
L6625
L6628
L6629
L6630
L6632
L6635
L6637
L6638
L6640
L6641
L6642
L6645
L6646
L6647
L6648
L6650
L6655
L6660
L6665
Postop dsg cast chg elb dis/
Postop dsg cast chg shlder/t
Postop ea cast chg & realign
Postop applicat rigid dsg on
Below elbow prosth tiss shap
Elb disart prosth tiss shap
Above elbow prosth tiss shap
Shldr disar prosth tiss shap
Scap thorac prosth tiss shap
Wrist/elbow bowden cable mol
Wrist/elbow bowden cbl dir f
Elbow fair lead cable molded
Elbow fair lead cable dir fo
Shdr fair lead cable molded
Shdr fair lead cable direct
Polycentric hinge pair
Single pivot hinge pair
Flexible metal hinge pair
Additional switch, ext power
Disconnect locking wrist uni
Disconnect insert locking wr
Flexion/extension wrist unit
Flex/ext wrist w/wo friction
Spring-ass rot wrst w/ latch
Flex/ext/rotation wrist unit
Rotation wrst w/ cable lock
Quick disconn hook adapter o
Lamination collar w/ couplin
Stainless steel any wrist
Latex suspension sleeve each
Lift assist for elbow
Nudge control elbow lock
Elec lock on manual pw elbow
Shoulder abduction joint pai
Excursion amplifier pulley t
Excursion amplifier lever ty
Shoulder flexion-abduction j
Multipo locking shoulder jnt
Shoulder lock actuator
Ext pwrd shlder lock/unlock
Shoulder universal joint
Standard control cable extra
Heavy duty control cable
Teflon or equal cable lining
Page 73 of 79
$1,305.54
$1,652.81
$374.36
$411.46
$2,099.60
$2,850.18
$2,882.75
$3,856.31
$4,298.67
$1,460.85
$1,160.89
$1,972.44
$1,685.75
$2,854.31
$2,630.01
$164.83
$155.50
$141.82
$327.80
$173.32
$63.17
$271.47
$1,821.01
$583.98
$2,998.33
$499.44
$469.03
$118.87
$174.78
$52.70
$153.23
$352.37
$1,990.94
$279.40
$139.27
$188.36
$321.50
$2,511.01
$413.38
$2,589.75
$277.28
$81.23
$85.99
$39.99
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L6670
L6672
L6675
L6676
L6677
L6680
L6682
L6684
L6686
L6687
L6688
L6689
L6690
L6691
L6692
L6693
L6694
L6695
L6696
L6697
L6698
L6703
L6704
L6706
L6707
L6708
L6709
L6711
L6712
L6713
L6714
L6715
L6721
L6722
L6805
L6810
L6880
L6881
L6882
L6883
L6884
L6885
L6890
L6895
Hook to hand cable adapter
Harness chest/shlder saddle
Harness figure of 8 sing con
Harness figure of 8 dual con
UE triple control harness
Test sock wrist disart/bel e
Test sock elbw disart/above
Test socket shldr disart/tho
Suction socket
Frame typ socket bel elbow/w
Frame typ sock above elb/dis
Frame typ socket shoulder di
Frame typ sock interscap-tho
Removable insert each
Silicone gel insert or equal
Lockingelbow forearm cntrbal
Elbow socket ins use w/lock
Elbow socket ins use w/o lck
Cus elbo skt in for con/atyp
Cus elbo skt in not con/atyp
Below/above elbow lock mech
Term dev, passive hand mitt
Term dev, sport/rec/work att
Term dev mech hook vol open
Term dev mech hook vol close
Term dev mech hand vol open
Term dev mech hand vol close
Ped term dev, hook, vol open
Ped term dev, hook, vol clos
Ped term dev, hand, vol open
Ped term dev, hand, vol clos
Term device, multi art digit
Hook/hand, hvy dty, vol open
Hook/hand, hvy dty, vol clos
Term dev modifier wrist unit
Term dev precision pinch dev
Elec hand ind art digits
Term dev auto grasp feature
Microprocessor control uplmb
Replc sockt below e/w disa
Replc sockt above elbow disa
Replc sockt shldr dis/interc
Prefab glove for term device
Custom glove for term device
Page 74 of 79
$41.35
$156.99
$97.39
$119.74
$236.17
$192.93
$245.46
$376.10
$539.19
$467.78
$572.81
$701.08
$743.52
$321.66
$453.53
$2,260.24
$580.91
$484.09
$1,047.22
$1,047.22
$537.85
$267.75
$508.21
$323.27
$1,140.49
$795.83
$1,141.22
$535.26
$985.50
$1,243.82
$1,053.51
$2,573.83
$1,872.49
$1,614.22
$343.01
$162.31
$19,478.21
$3,254.81
$2,468.91
$1,661.88
$2,270.95
$3,444.15
$150.59
$502.77
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L6900
L6905
L6910
L6915
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7007
L7008
L7009
L7040
L7045
L7170
L7180
L7181
L7185
L7186
L7190
L7191
L7260
L7261
L7360
L7362
L7364
L7366
L7367
L7368
L7400
L7401
L7402
L7403
L7404
L7405
L7520
L7900
Hand restorat thumb/1 finger
Hand restoration multiple fi
Hand restoration no fingers
Hand restoration replacmnt g
Wrist disarticul switch ctrl
Wrist disart myoelectronic c
Below elbow switch control
Below elbow myoelectronic ct
Elbow disarticulation switch
Elbow disart myoelectronic c
Above elbow switch control
Above elbow myoelectronic ct
Shldr disartic switch contro
Shldr disartic myoelectronic
Interscapular-thor switch ct
Interscap-thor myoelectronic
Adult electric hand
Pediatric electric hand
Adult electric hook
Prehensile actuator
Pediatric electric hook
Electronic elbow hosmer swit
Electronic elbow sequential
Electronic elbo simultaneous
Electron elbow adolescent sw
Electron elbow child switch
Elbow adolescent myoelectron
Elbow child myoelectronic ct
Electron wrist rotator otto
Electron wrist rotator utah
Six volt bat otto bock/eq ea
Battery chrgr six volt otto
Twelve volt battery utah/equ
Battery chrgr 12 volt utah/e
Replacemnt lithium ionbatter
Lithium ion battery charger
Add UE prost be/wd, ultlite
Add UE prost a/e ultlite mat
Add UE prost s/d ultlite mat
Add UE prost b/e acrylic
Add UE prost a/e acrylic
Add UE prost s/d acrylic
Repair prosthesis per 15 min
Male vacuum erection system
Page 75 of 79
$1,574.70
$1,587.58
$1,302.99
$588.87
$6,310.50
$6,901.44
$6,846.82
$7,236.13
$8,197.59
$9,082.88
$8,562.13
$9,685.94
$10,549.09
$11,912.90
$11,828.06
$12,959.81
$2,829.38
$4,900.39
$3,059.97
$2,442.70
$1,310.81
$4,951.92
$29,712.36
$31,899.67
$5,201.37
$7,173.55
$6,461.69
$7,495.94
$1,840.73
$3,857.92
$215.24
$223.10
$422.60
$546.23
$309.96
$401.81
$244.01
$273.17
$294.99
$293.18
$442.50
$578.74
$35.51
$431.09
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L7902
L8000
L8001
L8002
L8015
L8020
L8030
L8031
L8032
L8035
L8040
L8040KM
L8040KN
L8041
L8041KM
L8041KN
L8042
L8042KM
L8042KN
L8043
L8043KM
L8043KN
L8044
L8044KM
L8044KN
L8045
L8045KM
L8045KN
L8046
L8046KM
L8046KN
L8047
L8047KM
L8047KN
L8300
L8310
L8320
L8330
L8400
L8410
L8415
L8417
L8420
L8430
KM
KN
KM
KN
KM
KN
KM
KN
KM
KN
KM
KN
KM
KN
KM
KN
Tension ring, vac erect dev
Mastectomy bra
Breast prosthesis bra & form
Brst prsth bra & bilat form
Ext breastprosthesis garment
Mastectomy form
Breast prosthes w/o adhesive
Breast prosthesis w adhesive
Reusable nipple prosthesis
Custom breast prosthesis
Nasal prosthesis
Nasal prosthesis
Nasal prosthesis
Midfacial prosthesis
Midfacial prosthesis
Midfacial prosthesis
Orbital prosthesis
Orbital prosthesis
Orbital prosthesis
Upper facial prosthesis
Upper facial prosthesis
Upper facial prosthesis
Hemi-facial prosthesis
Hemi-facial prosthesis
Hemi-facial prosthesis
Auricular prosthesis
Auricular prosthesis
Auricular prosthesis
Partial facial prosthesis
Partial facial prosthesis
Partial facial prosthesis
Nasal septal prosthesis
Nasal septal prosthesis
Nasal septal prosthesis
Truss single w/ standard pad
Truss double w/ standard pad
Truss addition to std pad wa
Truss add to std pad scrotal
Sheath below knee
Sheath above knee
Sheath upper limb
Pros sheath/sock w gel cushn
Prosthetic sock multi ply BK
Prosthetic sock multi ply AK
Page 76 of 79
$16.36
$33.49
$99.86
$131.34
$49.56
$195.39
$255.85
$255.85
$32.39
$2,916.77
$1,990.47
$1,890.94
$796.19
$2,399.32
$2,279.33
$959.72
$2,695.84
$2,561.05
$1,078.33
$3,019.35
$2,868.38
$1,207.75
$3,342.85
$3,175.72
$1,337.14
$2,098.44
$1,993.51
$839.37
$2,156.67
$2,048.84
$862.66
$1,105.29
$1,050.03
$442.13
$85.00
$119.05
$45.32
$40.04
$15.05
$21.45
$22.02
$59.87
$16.27
$18.59
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L8435
L8440
L8460
L8465
L8470
L8480
L8485
L8500
L8501
L8507
L8509
L8510
L8511
L8512
L8513
L8514
L8515
L8600
L8603
L8605
L8606
L8609
L8610
L8612
L8613
L8614
L8615
L8616
L8617
L8618
L8619
L8621
L8622
L8623
L8624
L8627
L8628
L8629
L8630
L8631
L8641
L8642
L8658
L8659
Pros sock multi ply upper lm
Shrinker below knee
Shrinker above knee
Shrinker upper limb
Pros sock single ply BK
Pros sock single ply AK
Pros sock single ply upper l
Artificial larynx
Tracheostomy speaking valve
Trach-esoph voice pros pt in
Trach-esoph voice pros md in
Voice amplifier
Indwelling trach insert
Gel cap for trach voice pros
Trach pros cleaning device
Repl trach puncture dilator
Gel cap app device for trach
Implant breast silicone/eq
Collagen imp urinary 2.5 ml
Inj bulking agent anal canal
Synthetic implnt urinary 1ml
Artificial cornea
Ocular implant
Aqueous shunt prosthesis
Ossicular implant
Cochlear device
Coch implant headset replace
Coch implant microphone repl
Coch implant trans coil repl
Coch implant tran cable repl
Coch imp ext proc/contr rplc
Repl zinc air battery
Repl alkaline battery
Lith ion batt CID,non-earlvl
Lith ion batt CID, ear level
CID ext speech process repl
CID ext controller repl
CID transmit coil and cable
Metacarpophalangeal implant
MCP joint repl 2 pc or more
Metatarsal joint implant
Hallux implant
Interphalangeal joint spacer
Interphalangeal joint repl
Page 77 of 79
$22.73
$33.91
$70.78
$39.56
$5.41
$9.95
$11.66
$633.14
$97.97
$33.35
$86.95
$201.17
$57.91
$1.72
$4.14
$75.08
$50.25
$591.44
$357.23
$588.57
$181.14
$5,187.19
$537.98
$587.33
$244.11
$15,234.92
$359.06
$83.64
$73.04
$20.88
$6,540.24
$0.50
$0.26
$51.50
$128.39
$5,517.13
$1,023.12
$142.55
$273.22
$1,728.34
$378.50
$249.08
$330.02
$1,536.30
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
L8670
L8680
L8681
L8682
L8683
L8684
L8685
L8686
L8687
L8688
L8689
L8690
L8691
L8693
L8695
Q0478
Q0479
Q0480
Q0481
Q0482
Q0483
Q0484
Q0485
Q0486
Q0487
Q0489
Q0490
Q0491
Q0492
Q0493
Q0494
Q0495
Q0496
Q0497
Q0498
Q0499
Q0500
Q0501
Q0502
Q0503
Q0504
Q0506
Q0510
Q0511
Vascular graft, synthetic
Implt neurostim elctr each
Pt prgrm for implt neurostim
Implt neurostim radiofq rec
Radiofq trsmtr for implt neu
Radiof trsmtr implt scrl neu
Implt nrostm pls gen sng rec
Implt nrostm pls gen sng non
Implt nrostm pls gen dua rec
Implt nrostm pls gen dua non
External recharg sys intern
Aud osseo dev, int/ext comp
Osseointegrated snd proc rpl
Aud osseo dev, abutment
External recharg sys extern
Power adapter, combo vad
Power module combo vad, rep
Driver pneumatic vad, rep
Microprcsr cu elec vad, rep
Microprcsr cu combo vad, rep
Monitor elec vad, rep
Monitor elec or comb vad rep
Monitor cable elec vad, rep
Mon cable elec/pneum vad rep
Leads any type vad, rep only
Pwr pck base combo vad, rep
Emr pwr source elec vad, rep
Emr pwr source combo vad rep
Emr pwr cbl elec vad, rep
Emr pwr cbl combo vad, rep
Emr hd pmp elec/combo, rep
Charger elec/combo vad, rep
Battery elec/combo vad, rep
Bat clps elec/comb vad, rep
Holster elec/combo vad, rep
Belt/vest elec/combo vad rep
Filters elec/combo vad, rep
Shwr cov elec/combo vad, rep
Mobility cart pneum vad, rep
Battery pneum vad replacemnt
Pwr adpt pneum vad, rep veh
Lith-ion batt elec/pneum VAD
Dispens fee immunosupressive
Sup fee antiem,antica,immuno
Page 78 of 79
$451.43
$379.91
$874.88
$4,930.52
$4,339.99
$642.34
$10,814.99
$6,900.84
$14,074.61
$8,980.73
$1,373.29
$3,787.36
$2,122.94
$1,207.20
$13.26
$146.30
$9,615.51
$71,703.68
$11,568.55
$3,623.49
$14,927.15
$2,898.81
$279.87
$232.95
$271.76
$12,941.04
$559.76
$880.02
$70.88
$201.88
$170.83
$3,325.51
$1,193.58
$372.71
$408.94
$132.87
$24.31
$406.58
$517.64
$1,035.28
$546.29
$680.01
$50.00
$24.00
CONFIDENTIAL AND PROPRIETARY
Regence BlueCross BlueShield of Oregon (Regence BCBSO)
DME Fee Schedule
For covered services provided on or after December 1, 2013
Q0512
Q0513
Q0514
Q4115
Q4121
Q4123
V2623
V2624
V2625
V2626
V2627
V2628
Px sup fee anti-can sub pres
Disp fee inhal drugs/30 days
Disp fee inhal drugs/90 days
Alloskin
Theraskin
Alloskin
Plastic eye prosth custom
Polishing artifical eye
Enlargemnt of eye prosthesis
Reduction of eye prosthesis
Scleral cover shell
Fabrication & fitting
Page 79 of 79
$16.00
$33.00
$66.00
$8.52
$22.73
$13.58
$2,500.00
$79.00
$600.00
$245.80
$2,656.00
$375.00