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custom-fabricated prosthetics, orthotics, and related items and services manufactured under the oversight of and signed off by a certified professional described in 7 AAC 120.300(a)(2)(C) will be based on the most applicable HCPCS code at the lesser of
(1) billed charges; or
(2) a price ceiling based on the following calculation:
(A) for items with more than 10 parts, an itemized list of the cost, with no provider mark-up, of up to 10 parts, with the total cost multiplied by 180 percent; or
(B) an itemized list of the cost, with no provider mark-up, of all parts used to manufacture the custom prosthetic or orthotic, with the total cost multiplied by 160 percent; additionally, charges and costs under this subparagraph include the following:
(i) a labor charge priced at the L7520 payment rate of the HCPCS per 15 minutes; and
(ii) additional bundled costs paid up to $1,064.10; the bundled cost items include the initial evaluation, diagnostic checks, and follow-up. (h) A provider enrolled under 7 AAC 120.300 as a prosthetics and orthotics provider may request reimbursement for labor and parts costs associated with adjustments to a prosthetic medically necessary to prevent injury to the residual limb due to residual limb measurement changes that do not require a full new customized prosthetic.
(i) Subject to the applicable provisions of 7 AAC 120.300 — 7 AAC 120.399, a provider enrolled under 7 AAC 120.300 as a prosthetics and orthotics provider may request payment for the reasonable direct costs of delivery or shipping as follows:
(1) from the manufacturer to the provider for customized or optimally configured durable medical equipment repair and replacement parts that are specialized or unique to a recipient’s equipment and for which the final unaltered purchase invoice price exceeds $250; the shipping method used must be the most cost-effective method available; the unaltered final purchase invoice, free of alterations described in (k) of this section, must include the purchase invoice for the replacement items or repair and must include shipping costs; if the unaltered final purchase invoice is free of alterations described in (k) of this section but contains one or more item in addition to the repair or replacement part, the department will pay for the shipping cost attributed to the repair or replacement part, as calculated by dividing the shipping cost on the unaltered final purchase invoice by the number of items purchased and multiplying by the number of repair or replacement parts specific to the recipient’s need; expedited, next day, rush, or delivery charges resulting from the use of a shipping method other than the most cost-effective method available will not be covered;
(2) from the dispensing provider to the recipient when the following conditions apply:
(A) the recipient resides outside the municipality where the business of the