MEDI-CAL BILLING INFORMATION
CASE W/O UNIT W/O UNIT+ TAX  OLD MEDI-CAL 
ITEM # DESCRIPTION TAX TAX AT 9.25% UPN QUALIFIER/UPN  HCPCS BILLING CODES cost 
BRIEFS
72096 AT EASE SPECIAL BRIEF, MEDIUM 8/12 96 47.69 0.4968 0.5427 UP075289728129 T4522 9997W YV 25
73072 AT EASE SPECIAL BRIEF, LARGE 6/12 72 47.69 0.6624 0.7236 UP075289736124 T4523 9997Y YV
74060 AT EASE SPECIAL BRIEF, X-LARGE 60/CS 60 39.74 0.6624 0.7237 UP075289740602 T4524 9907M YV
80096 AT EASE BRIEF, YOUTH 96/CS 96 40.59 0.4228 0.4619 UP075289800962 T4533 9997Q YV
91096 AT EASE PREMIUM BRIEF, SMALL 8/12 96 41.73 0.4347 0.4749 UP075289918124 T4521 9997T YV
92096 AT EASE PREMIUM BRIEF, MEDIUM 8/12 96 47.69 0.4968 0.5427 UP075289928123 T4522 9997W YV
93072 AT EASE PREMIUM BRIEF, LARGE 6/12 72 47.69 0.6624 0.7236 UP075289936128 T4523 9997Y YV
94064 AT EASE PREMIUM, X-LARGE 8/8 64 42.39 0.6624 0.7237 UP075289940644 T4524 9907M YV
66100 TENA BRIEF, SMALL 8/12 96 41.73 0.4347 0.4749 UK10768702661000 T4521 9997T 2H
67713 TENA CLASSIC PLUS BRIEF, MEDIUM 8/12 96 47.69 0.4968 0.5427 UK10768702677131 T4522 9997W 2H
67813 TENA CLASSIC PLUS BRIEF, LARGE 6/12 72 47.69 0.6624 0.7236 UK10768702678138 T4523 9997Y 2H
67914 TENA CLASSIC PLUS BRIEF, X-LARGE 5/12 60 39.74 0.6624 0.7237 UK10768702679142 T4524 9907M 2H
NU-012 NU-FIT ADULT BRIEF, MEDIUM 6/16 96 47.69 0.4968 0.5427 ON90891246144 T4522 9997W YU
NU-013 NU-FIT ADULT BRIEF, LARGE 4/18 72 47.69 0.6624 0.7236 ON90891246151 T4523 9997Y YU
NU-014 NU-FIT ADULT BRIEF, X- LARGE 4/15 60 39.74 0.6624 0.7237 ON90891248087 T4524 9907M YU
PF-012 FQP PER-FIT BRIEF, MEDIUM 6/16 96 47.69 0.4968 0.5428 ON90891246182 T4522 9997WYU
PF-013 FQP PER-FIT BRIEF, LARGE 4/18 72 47.69 0.6624 0.7237 ON90891246199 T4523 9997YYU
PF-014 FQP PER-FIT BRIEF, X-LARGE 4/15 60 39.74 0.6624 0.7237 ON90891258086 T4524 9907MYU
PV-015 PREVAIL BRIEF, YOUTH 6/16 96 40.59 0.4228 0.4619 ON90891500277 T4533 9997QYU
PV-011 PREVAIL BRIEF, SMALL 6/16 96 41.73 0.4347 0.4749 ON90891500260 T4521 9997TYU
IB-012 FIRST QUALITY BRIEF, MEDIUM 6/16 96 47.69 0.4968 0.5427 ON90891246205 T4522 9997W YU
IB-013 FIRST QUALITY BRIEF, LARGE 4/18 72 47.69 0.6624 0.7236 ON90891246212 T4523 9997Y YU
IB-014 FIRST QUALITY BRIEF, X- LARGE 4/16 64 42.39 0.6624 0.7237 ON90891100644 T4524 9907M YU
60032MMS ADULT BRIEF SUPER, SMALL 96/CS 96 41.73 0.4347 0.4749 ON23734220063 T4521 9997T2K
60033MMS ADULT BRIEF SUPER, MED 96/CS 96 47.69 0.4968 0.5428 ON23734220070 T4522 9997W2K
60034MMS ADULT BRIEF SUPER, LARGE 72/CS 72 47.69 0.6624 0.7237 ON23734220087 T4523 9997Y2K
60035MMS ADULT BRIEF SUPER, XL 60/CS 60 39.74 0.6624 0.7237 UP023734220094 T4524 9907M2K
UNDERGARMENTS
95430 AT EASE BELTED UNDERGARMENT 4/30 120 57.96 0.4830 0.5277 ON75289954306 T4535 9945DYV
PV-324 PREVAIL BELTED UNDERGARMENT 4/30 120 57.96 0.4830 0.5277 ON90891300303 T4535 9945DYU
SOLO MEDICAL SUPPLY 　 　 　 　 　
　 　 　 　 　 　 　 　 　
                                   5464 Research Drive · Huntington Beach, CA 92649 · (800) 429-0064 Fax (714) 893-8873
CASE W/O UNIT W/O UNIT+ TAX  OLD MEDI-CAL 
ITEM # DESCRIPTION TAX TAX AT 9.25% UPN QUALIFIER/UPN  HCPCS BILLING CODES
UNDERPADS
UFP-360 DRI-SORB PLUS FLUFF 30 X 36 10/10 100 52.44 0.5244 0.5729 ON8667923694 T4541 9900PPQ
HX3036 ADHERES LAYERED 30 X 36 10/10 100 52.44 0.5244 0.5729 ON8667923941 T4541 9900PPQ
HX3036+++ ADHERES LAYERED 30 X 36 75/CS 75 39.33 0.5244 0.5729 ON8667923945 T4541 9900PPQ
2175/85 ADHERES FLUFF 30 X 36  W/ADH STRIP 85/CS 85 41.06 0.4830 0.5277 ON8667923942 T4541 9900NPQ
2175/75 ADHERES FLUFF 30 X 36  W/ADH STRIP 5/15 75 36.23 0.4830 0.5277 ON8667923947 T4541 9900NPQ
3805 TUCKABLE 28 X 70 UNDERPAD 75/CS 75 36.23 0.4830 0.5277 ON8667923955 T4541 9900NPQ
3805X TUCKABLE 27 X 70 UNDERPAD 100/CS 100 48.30 0.4830 0.5277 ON8667923958 T4541 9900NPQ
1909 TUCKABLE 27 X 70 UNDERPAD 5/15 75 39.33 0.5244 0.5729 UP186679239528 T4541 9900PPQ
959B96MMS STA-PUT W/POLYMER 30 X 36  8/12 96 50.34 0.5244 0.5729 UK10694393103409 T4541 9900P2K
958B10MMS MAXICARE W/POLY UNDERPAD 30X36 5/10 50 26.22 0.5244 0.5729 UK10694393103300 T4541 9900P2K
13650 ULTRASHIELD PEACH 30 X 36 75/CS 75 39.33 0.5244 0.5729 UP078459136502 T4541 9900PWH
UP-100 FQP UNDERPAD 30 X 30 10/10 100 48.30 0.4830 0.5277 ON90891131006 T4541 9900NYU
SHIELDS - LINERS - PADS
90030-24 AT EASE COMPACT SHIELD 6/30 180 44.71 0.2484 0.2714 UP075289900303 T4535 9900RYV
94320 SAFE & SOFT BLADDER CONTROL PAD 9/20 180 44.71 0.2484 0.2714 UP075289943201 T4535 9900RYV
90200SAP AT EASE CONTOURED PEACH PAD 9/20 180 64.58 0.3588 0.3920 UP075289002069 T4535 9900SYV
60074 DIGNITY BRIEFMATES GUARD 4/30 120 43.06 0.3588 0.3920 UP044156600745 T4535 9900SVS
26955-175 DIGNITY NATURALS 7/25 175 62.79 0.3588 0.3920 UP044156269553 T4535 9900SVS
29654-180 DIGNITY REGULAR DUTY 4/45 180 44.71 0.2484 0.2714 UP044156269546 T4535 9900RVS
26950-180 DIGNITY EXTRA DUTY DOUBLE PAD 6/30 180 77.00 0.4278 0.4674 UP044156269508 T4535 9900TVS
40068 SPARTAN LINERS  7/25  175 43.47 0.2484 0.2714 UP044156400680 T4535 9900RVS
40052 DIGNITY X-LONG PADS  4/40  160 39.74 0.2484 0.2714 UP044156400529 T4535 9900RVS
30071 DIGNITY PLUS LINERS  7/25  175 43.47 0.2484 0.2714 UP044156300713 T4535 9900RVS
5007218O MAXISHIELD PADS 6/30 180 64.58 0.3588 0.3920 UP078459500730 T4535 9900SWH
BC-012 PREVAIL BLADDER CONTROL PAD 180 44.71 0.2484 0.2714 ON90891600205 T4535 9900RYU
PL-113 PANT LINER HEAVY W/ ELASTIC 4/24 96 41.07 0.4278 0.4674 ON90891161133 T4535 9900TYU
61214 DRY COMFORT DAY HEAVY 80/CS 80 34.22 0.4278 0.4674 UP768702612142 T4535 9900T2H
1530MMS MMS GARMENT LINER 4.5 X 14 5/25 125 31.05 0.2484 0.2714 UK10694393112050 T4535 9900R2K
635MMS MMS GARMENT LINER 7 X 17 8/25 200 71.76 0.3588 0.3920 UK10694393112029 T4535 9900S2K
WATERPROOF SHEETING
39075 QUILTED MATTRESS PAD 39 X 75 TWIN 1/EA 1 27.06 27.0600 29.5631 UK00044156390752 T4537 9947AVS
36080 QUILTED MATTRESS PAD 36 X 80 HOSP 1/EA 1 27.06 27.0600 29.5631 UK00044156360809 T4537 9947AVS
WASH  & CREAM
10308 CA REZZ ORIGINAL WASH 237 ml SPRAY 36/CS 36 114.21 3.1725 3.4659 UP757484303089 A4335 9980WJ8
10408 CA REZZ GENTLE WASH 237 ml SPRAY 36/CS 36 114.21 3.1725 3.4659 UP757484304086 A4335 9980WJ8
10208 CA REZZ CREAM 275 gm JAR 36/CS 36 268.27 7.4520 8.1413 UP757484202085 A6250 9980UJ8
10209 CA REZZ CREAM 275 gm TUBE 36/CS 36 268.27 7.4520 8.1413 UP757484102092 A6250 9980UJ8
SOLO MEDICAL SUPPLY 　 　 　 　 　
　 　 　 　 　 　 　 　 　
                                   5464 Research Drive · Huntington Beach, CA 92649 · (800) 429-0064 Fax (714) 893-8873
CASE W/O UNIT W/O UNIT+ TAX  OLD MEDI-CAL 
ITEM # DESCRIPTION TAX TAX AT 9.25% UPN QUALIFIER/UPN  HCPCS BILLING CODES
REUSABLE PANTS
16902 DIGNITY UNISEX PANT SMALL 1/EA 1 5.80 5.7960 6.3321 UP044156169020 T4536 9996JVS
16903 DIGNITY UNISEX PANT MEDIUM 1/EA 1 5.80 5.7960 6.3321 UP044156169037 T4536 9996QVS
16904 DIGNITY UNISEX PANT LARGE 1/EA 1 5.80 5.7960 6.3321 UP044156169044 T4536 9996YVS
16905 DIGNITY UNISEX PANT EXTRA LARGE 1/EA 1 5.80 5.7960 6.3321 UP044156169051 T4536 9997HVS
40201 LADY DIGNITY PANT SMALL 1/EA 1 5.80 5.7960 6.3321 UP044156402011 T4536 9996JVS
40202 LADY DIGNITY PANT MEDIUM 1/EA 1 5.80 5.7960 6.3321 UP044156402028 T4536 9996QVS
40203 LADY DIGNITY PANT LARGE 1/EA 1 5.80 5.7960 6.3321 UP044156402035 T4536 9996YVS
40204 LADY DIGNITY PANT EXTRA LARGE 1/EA 1 5.80 5.7960 6.3321 UP044156402042 T4536 9997HVS
40205 LADY DIGNITY PANT EXTRA EXTRA LARGE 1/EA 1 5.80 5.7960 6.3321 UP044156402059 T4536 9997PVS
40211 SIR DIGNITY PANT SMALL 1/EA 1 5.80 5.7960 6.3321 UP044156402110 T4536 9996JVS
40212 SIR DIGNITY PANT MEDIUM 1/EA 1 5.80 5.7960 6.3321 UP044156402127 T4536 9996QVS
40213 SIR DIGNITY PANT LARGE 1/EA 1 5.80 5.7960 6.3321 UP044156402134 T4536 9996YVS
40214 SIR DIGNITY PANT EXTRA LARGE 1/EA 1 5.80 5.7960 6.3321 UP044156402141 T4536 9997HVS
PROTECTIVE UNDERWEAR
AP0720 ATTENDS PROTECTIVE UNDERWEAR MED 4/20 80 39.74 0.4968 0.5428 UP186679281480 T4526 9932NPQ
AP0730 ATTENDS PROTECTIVE UNDERWEAR, LARGE 4/18 72 47.69 0.6624 0.7236 UP186679281497 T4527 9933NPQ
AP0740 ATTENDS PROTECTIVE UNDERWEAR, X-LARGE 4/14 56 37.09 0.6623 0.7236 UP186679281503 T4528 9934NPQ
PV-511 FQP PROTECTIVE UNDERWEAR, SM 4/22 88 42.50 0.4830 0.5276 ON90891500000 T4525 9917ZYU
PV-512 FQP PROTECTIVE UNDERWEAR, MED 4/20 80 39.74 0.4968 0.5427 ON90891500017 T4526 9932NYU
PV-513 FQP PROTECTIVE UNDERWEAR, LG 4/18 72 47.69 0.6624 0.7236 ON90891500024 T4527 9933NYU
PV-514 FQP PROTECTIVE UNDERWEAR, XL 4/14 56 37.09 0.6624 0.7237 ON90891500031 T4528 9934NYU
PV-517 FQP PROTECTIVE UNDERWEAR, XXL 4/12 48 31.80 0.6624 0.7237 ON90891501168 T4528 9934NYU
GLOVES
21211 VINYL EXAM POWDERED GLOVES, SM 10/CS 10 55.35 5.5350 6.0470 UP641932212118 A4927 9911B1S
21212 VINYL EXAM POWDERED GLOVES, MED 10/CS 10 55.35 5.5350 6.0470 UP641932212125 A4927 9911B1S
21213 VINYL EXAM POWDERED GLOVES, LG 10/CS 10 55.35 5.5350 6.0470 UP641932212132 A4927 9911B1S
20211 VINYL EXAM PWDRFREE GLOVES, SM 10/CS 10 55.35 5.5350 6.0470 UP641932202119 A4927 9911B1S
20212 VINYL EXAM PWDRFREE GLOVES, MED 10/CS 10 55.35 5.5350 6.0470 UP641932202126 A4927 9911B1S
20213 VINYL EXAM PWDRFREE GLOVES, LG 10/CS 10 55.35 5.5350 6.0470 UP641932202133 A4927 9911B1S
11111 LATEX EXAM POWDERED GLOVES, SM 10/CS 10 55.35 5.5350 6.0470 UP641932111114 A4927 9911B1S
11112 LATEX EXAM POWDERED GLOVES, MED 10/CS 10 55.35 5.5350 6.0470 UP641932111121 A4927 9911B1S
11113 LATEX EXAM POWDERED GLOVES, LG 10/CS 10 55.35 5.5350 6.0470 UP641932111138 A4927 9911B1S
10111 LATEX EXAM PWDRFREE GLOVES, SM 10/CS 10 55.35 5.5350 6.0470 UP641932101115 A4927 9911B1S
10112 LATEX EXAM PWDRFREE GLOVES, MED 10/CS 10 55.35 5.5350 6.0470 UP641932101122 A4927 9911B1S
10113 LATEX EXAM PWDRFREE GLOVES, LG 10/CS 10 55.35 5.5350 6.0470 UP641932101139 A4927 9911B1S
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