Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 43 - Prosthetic and Orthopedic Equipment
Section I-4339 - Schedule of Maximum Allowances and Procedural Codes
Current through Register Vol. 50, No. 9, September 20, 2024
A. This maximum allowable reimbursement schedule provides the basis for identification of prosthetic and orthopedic equipment reimbursable to providers. the coding system used is the health care financing administration common procedure coding system (HCPCS). No other coding methodology will be accepted for this program. Invoices submitted to the carrier/self-insured employer should be billed at the providers usual and customary rate, not the maximum allowable charge designated in this fee schedule. Reimbursement is limited to the least of:
B. Prosthetic and Orthopedic Equipment
|
Office of Workers' Compensation Schedule of Maximum Allowances for Prosthetic and Orthopedic Equipment |
|||
|
HCPCS |
Description |
Purchase New |
|
|
L0112 |
Cranial cervical orthosis |
$2,007 |
|
|
L0113 |
Cranial cervical torticollis |
$410 |
|
|
L0120 |
Cerv, flex, non-adj (foam collar) |
$24 |
|
|
L0130 |
Cerv, flex, thermoplastic collar |
$149 |
|
|
L0140 |
Cerv, semi-rigid, adj |
$60 |
|
|
L0150 |
Cerv, semi-rigid, adj chin cup |
$99 |
|
|
L0160 |
Cerv, semi-rigid, occ/mand supp |
$191 |
|
|
L0170 |
Cerv, collar, molded to pat model |
$626 |
|
|
L0172 |
Cerv, collar, semi-rigid thermopl |
$129 |
|
|
L0174 |
Cerv, collar, semi-rigid, thermop |
$251 |
|
|
L0180 |
Cerv, mult post collar, occ/mandi |
$377 |
|
|
L0190 |
Cerv, mult post collar, occ/mandi |
$488 |
|
|
L0200 |
Cerv, mult post collar, occ/mandi |
$545 |
|
|
L0220 |
Thoracic, rib belt, custom made |
$149 |
|
|
L0430 |
TLSO, a-p-l rotary control |
$1,493.73 |
|
|
L0450 |
TLSO flex prefab thoracic |
$261 |
|
|
L0452 |
TLSO flex custom fab thoraci |
B.R. |
|
|
L0456 |
TLSO flex prefab |
$1,426 |
|
|
L0458 |
TLSO 2Mod symphis-xipho pre |
$1,279 |
|
|
L0460 |
TLSO2Mod symphysis-stern pre |
$1,440 |
|
|
L0462 |
TLSO 3Mod sacro-scap pre |
$1,791 |
|
|
L0464 |
TLSO 4Mod sacro-scap pre |
$2,132 |
|
|
L0466 |
TLSO rigid frame pre soft ap |
$561 |
|
|
L0468 |
TLSO rigid frame prefab pelv |
$688 |
|
|
L0470 |
TLSO rigid frame pre subclav |
$957 |
|
|
L0472 |
TLSO rigid frame hyperex pre |
$607 |
|
|
L0480 |
TLSO rigid plastic custom fa |
$2,138 |
|
|
L0482 |
TLSO rigid lined custom fab |
$2,328 |
|
|
L0484 |
TLSO rigid plastic cust fab |
$2,668 |
|
|
L0486 |
TLSO rigidlined cust fab two |
$2,830 |
|
|
L0488 |
TLSO rigid lined pre one pie |
$1,440 |
|
|
L0490 |
TLSO rigid plastic pre one |
$406 |
|
|
L0491 |
TLSO 2 piece rigid shell |
$1,102 |
|
|
L0492 |
TLSO 3 piece rigid shell |
$715 |
|
|
L0621 |
SIO flex pelvisacral prefab |
$138 |
|
|
L0622 |
SIO flex pelvisacral custom |
$388 |
|
|
L0623 |
SIO panel prefab |
B.R. |
|
|
L0624 |
SIO panel custom |
B.R. |
|
|
L0625 |
LO flexibl L1-below L5 pre |
$79 |
|
|
L0626 |
LO sag stays/panels pre-fab |
$112 |
|
|
L0627 |
LO sagitt rigid panel prefab |
$590 |
|
|
L0628 |
LO flex w/o rigid stays pre |
$120 |
|
|
L0629 |
LSO flex w/rigid stays cust |
B.R. |
|
|
L0630 |
LSO post rigid panel pre |
$232 |
|
|
L0631 |
LSO sag-coro rigid frame pre |
$1,473 |
|
|
L0632 |
LSO sag rigid frame cust |
B.R. |
|
|
L0633 |
LSO flexion control prefab |
$411 |
|
|
L0634 |
LSO flexion control custom |
B.R. |
|
|
L0635 |
LSO sagit rigid panel prefab |
$1,437 |
|
|
L0636 |
LSO sagittal rigid panel cus |
$2,127 |
|
|
L0637 |
LSO sag-coronal panel prefab |
$1,683 |
|
|
L0638 |
LSO sag-coronal panel custom |
$1,892 |
|
|
L0639 |
LSO s/c shell/panel prefab |
$1,683 |
|
|
L0640 |
LSO s/c shell/panel custom |
$1,501 |
|
|
L0700 |
CTLSO |
$1,878 |
|
|
L0710 |
CTLSO, a-p-l-control, molded |
$2,023 |
|
|
L0810 |
Halo proc, cerv halo jacket |
$2,506 |
|
|
L0820 |
Halo proc, cerv halo plaster body |
$2,114 |
|
|
L0830 |
Halo proc, cerv halo Milwaukee type |
$3,387 |
|
|
L0859 |
MRI compatible system |
$1,829 |
|
|
L0861 |
Halo repl liner/interface |
$309 |
|
|
L0970 |
TLSO, corset front |
$133 |
|
|
L0972 |
LSO, corset front |
$122 |
|
|
L0974 |
TLSO, full corset |
$184 |
|
|
L0976 |
LSO, full corset |
$172 |
|
|
L0978 |
Axillary crutch extension |
$180 |
|
|
L0980 |
Peroneal straps, pair |
$21 |
|
|
L0982 |
Stocking supp grips, set four |
$20 |
|
|
L0984 |
Protective body sock, each |
$56 |
|
|
L0999 |
Add to spinal orthosis NOS |
B.R. |
|
|
L1000 |
CTLSO (Milwaukee), inclusive |
$2,020 |
|
|
L1001 |
CTLSO infant immobilizer |
B.R. |
|
|
L1005 |
Tension based scoliosis orth |
$4,590.55 |
|
|
L1010 |
Add to CTLSO |
$72 |
|
|
L1020 |
Add to CTLSO, kyphosis pad |
$100 |
|
|
L1025 |
Add to CTLSO, kyphosis pad, floatin |
$114 |
|
|
L1030 |
Add to CTLSO, lumbar |
$78 |
|
|
L1040 |
Add to CTLSO, lumbar |
$81 |
|
|
L1050 |
Add to CTLSO, sternal pad |
$98 |
|
|
L1060 |
Add to CTLSO, thoracic pad |
$95 |
|
|
L1070 |
Add to CTLSO, trapezius |
$93 |
|
|
L1080 |
Add to CTLSO, outrigger |
$52 |
|
|
L1085 |
Add to CTLSO, outrigger |
$158 |
|
|
L1090 |
Add to CTLSO, lumbar sling |
$94 |
|
|
L1100 |
Add to CTLSO, ring flange |
$162 |
|
|
L1110 |
Add to CTLSO, ring flange |
$236 |
|
|
L1120 |
Add to CTLSO, cover |
$43 |
|
|
L1200 |
TLSO, inclusive furnishing |
$1,649 |
|
|
L1210 |
Add to TLSO, lat thoracic ext |
$239 |
|
|
L1220 |
Add to TLSO, ant thoracic ext |
$232 |
|
|
L1230 |
Add to TLSO, milw type superstruc |
$520 |
|
|
L1240 |
Add to TLSO, lumb derotation pad |
$77 |
|
|
L1250 |
Add to TLSO, ant asis pad |
$74 |
|
|
L1260 |
Add to TLSO, ant thor derot pad |
$75 |
|
|
L1270 |
Add to TLSO, abdominal pad |
$72 |
|
|
L1280 |
Add to TLSO, rib gusset |
$79 |
|
|
L1290 |
Add to TLSO, lat troch pad |
$72 |
|
|
L1300 |
Oth scolio proc, body jacket |
$1,762 |
|
|
L1310 |
Oth scolio proc, postop body jack |
$1,697 |
|
|
L1499 |
Unlisted proc spinal orthosis |
B.R. |
|
|
L1600 |
HO, abd cont hip jnts, flex |
$157 |
|
|
L1610 |
HO, abd cont hip jnts, flex, frej |
$42 |
|
|
L1620 |
HO, abd cont hip jnts, flex, pavl |
$123 |
|
|
L1630 |
HO, abd cont hip jnts, semi-flex |
$155 |
|
|
L1640 |
HO, abd cont hip jnts, stat, pelv |
$486 |
|
|
L1650 |
HO, abd cont hip jnts, stat, adj |
$223 |
|
|
L1652 |
HO bi thighcuffs w sprdr bar |
$511 |
|
|
L1660 |
HO, abd cont hip jnts, static |
$209 |
|
|
L1680 |
HO, abd cont hip jnts, dyn, pel |
$1,318 |
|
|
L1685 |
HO, abd cont hip jnt, postop |
$1,088 |
|
|
L1686 |
HO, abd cont hip jnt, postop |
$835 |
|
|
L1690 |
Combination bilateral HO |
$511 |
|
|
L1700 |
Legg perthes ortho, Toronto |
$1,570 |
|
|
L1710 |
Legg perthes ortho, Newington |
$2,018 |
|
|
L1720 |
Legg perthes ortho, trilateral |
$1,497 |
|
|
L1730 |
Legg perthes ortho, Scottish rite |
$1,185 |
|
|
L1755 |
Legg perthes ortho, patten bottom |
$1,448.82 |
|
|
L1810 |
KO, elastic w/joints |
$98 |
|
|
L1820 |
KO, elastic w/condylar pads and joint |
$132 |
|
|
L1830 |
KO, immobilizer, canvas longitud |
$80 |
|
|
L1831 |
Knee orth pos locking joint |
$422 |
|
|
L1832 |
KO, adj knee joints, pos orthosis |
$556 |
|
|
L1834 |
KO, w/o knee joint, rigid, molded |
$710 |
|
|
L1836 |
Rigid KO wo joints |
$191 |
|
|
L1840 |
KO, derotation, m-l ant cruc lig |
$1,034 |
|
|
L1843 |
KO single upright custom fit |
$1,287 |
|
|
L1844 |
KO, sngl upright, thigh and calf |
$795 |
|
|
L1845 |
KO, dbl upright, thigh and calf |
$857 |
|
|
L1846 |
KO, dbl upright, thigh and calf |
$1,059 |
|
|
L1847 |
KO adjustable w air chambers |
$825 |
|
|
L1850 |
KO, Swedish type |
$305 |
|
|
L1860 |
KO, mod supracond prosth socket |
$1,000.78 |
|
|
L1900 |
AFO, spring wire, dorsiflex asst |
$317 |
|
|
L1902 |
AFO, ankle gauntlet, custom fit |
$97 |
|
|
L1904 |
AFO, molded ankle gauntlet, mold |
$430 |
|
|
L1906 |
AFO, multilig ankle support |
$110 |
|
|
L1907 |
AFO supramalleolar custom |
$807 |
|
|
L1910 |
AFO, post, single bar, clasp atta |
$276 |
|
|
L1920 |
AFO, sngl upright w/stat/adj stop |
$331 |
|
|
L1930 |
AFO, custom fitted, plastic |
$289 |
|
|
L1932 |
Afo rig ant tib prefab TCF/= |
$1,280 |
|
|
L1940 |
AFO, molded to patient, plastic |
$463 |
|
|
L1945 |
AFO, molded to patient, plastic |
$847 |
|
|
L1950 |
AFO, spiral, molded to patient |
$684 |
|
|
L1951 |
AFO spiral prefabricated |
$1,205 |
|
|
L1960 |
AFO, post solid ankle, molded |
$507 |
|
|
L1970 |
AFO, plastic molded to patient |
$651 |
|
|
L1971 |
AFO w/ankle joint, prefab |
$672 |
|
|
L1980 |
AFO, single upright free plantar |
$351 |
|
|
L1990 |
AFO, double upright free plantar |
$408 |
|
|
L2000 |
KAFO, single upright, free |
$928 |
|
|
L2005 |
KAFO sng/dbl mechanical act |
$5,879 |
|
|
L2010 |
KAFO, single upright, free ankle |
$906 |
|
|
L2020 |
KAFO, double upright, free knee |
$1,069 |
|
|
L2030 |
KAFO, double upright, free ankle |
$937 |
|
|
L2034 |
KAFO pla sin up w/wo k/a cus |
$2,939 |
|
|
L2035 |
KAFO plastic pediatric size |
$250 |
|
|
L2036 |
KAFO, full plastic, double upright |
$1,784 |
|
|
L2037 |
KAFO, full plastic, single upright |
$1,524 |
|
|
L2038 |
KAFO, full plastic, w/o knee joint |
$1,308 |
|
|
L2040 |
HKAFO, torsion control, bilateral |
$162 |
|
|
L2050 |
HKAFO, torsion control, bilateral |
$517 |
|
|
L2060 |
HKAFO, torsion control, bilateral |
$598 |
|
|
L2070 |
HKAFO, torsion control, unilat |
$124 |
|
|
L2080 |
HKAFO, torsion control, unilat |
$352 |
|
|
L2090 |
HKAFO, torsion control, unilat |
$426 |
|
|
L2106 |
AFO, fx ortho, tib fx cast |
$766 |
|
|
L2108 |
AFO, fx ortho, tib fx cast |
$1,064 |
|
|
L2112 |
AFO, fx ortho, tib fx orthosis |
$518 |
|
|
L2114 |
AFO, fx ortho, tib fx orthosis |
$600 |
|
|
L2116 |
AFO, fx ortho, tib fx orthosis |
$719 |
|
|
L2126 |
KAFO, fx ortho, fem fx cast |
$1,096 |
|
|
L2128 |
KAFO, fx ortho, fem fx cast |
$1,569 |
|
|
L2132 |
KAFO, fx ortho, fem fx cast |
$833 |
|
|
L2134 |
KAFO, fx ortho, fem fx cast |
$1,042 |
|
|
L2136 |
KAFO, fx ortho, fem fx cast |
$1,179 |
|
|
L2180 |
Add to lwr extrm fx ortho |
$143 |
|
|
L2182 |
Add to lwr extrm fx ortho |
$105 |
|
|
L2184 |
Add to lwr extrm fx ortho |
$136 |
|
|
L2186 |
Add to lwr extrm fx ortho |
$138 |
|
|
L2188 |
Add to lwr extrm fx ortho |
$321 |
|
|
L2190 |
Add to lwr extrm fx ortho |
$92 |
|
|
L2192 |
Add to lwr extrm fx ortho |
$361 |
|
|
L2200 |
Add to lwr extrm, limited ankle |
$58 |
|
|
L2210 |
Add to lwr extrm, dorsiflexion |
$62 |
|
|
L2220 |
Add to lwr extrm, dorsiflexion |
$80 |
|
|
L2230 |
Add to lwr extrm, split flat |
$74 |
|
|
L2232 |
Rocker bottom, contact AFO |
$140 |
|
|
L2240 |
Add to lwr extrm, round caliper |
$77 |
|
|
L2250 |
Add to lwr extrm, foot plate |
$325 |
|
|
L2260 |
Add to lwr extrm, stirrup |
$189 |
|
|
L2265 |
Add to lwr extrm, stirrup |
$144 |
|
|
L2270 |
Add to lwr extrm, varus/valgus |
$49 |
|
|
L2275 |
Varus/vulgus correction, plastic |
$120 |
|
|
L2280 |
Add to lwr extrm, inner boot |
$414 |
|
|
L2300 |
Add to lwr extrm, abduction bar |
$329 |
|
|
L2310 |
Add to lwr extrm, abduction bar |
$150 |
|
|
L2320 |
Add to lwr extrm, non-mold lacer |
$205 |
|
|
L2330 |
Add to lwr extrm, lacer molded |
$381 |
|
|
L2335 |
Add to lwr extrm, ant swing band |
$208 |
|
|
L2340 |
Add to lwr extrm, pre-tib shell |
$507 |
|
|
L2350 |
Add to lwr extrm, socket, molded |
$869 |
|
|
L2360 |
Add to lwr extrm, steel shank |
$63 |
|
|
L2370 |
Add to lwr extrm, patten bottom |
$269 |
|
|
L2375 |
Add to lwr extrm, torsion control |
$138 |
|
|
L2380 |
Add to lwr extrm, torsion control |
$150 |
|
|
L2385 |
Add to lwr extrm, knee joint |
$158 |
|
|
L2390 |
Add to lwr extrm, knee joint |
$100 |
|
|
L2395 |
Add to lwr extrm, knee joint |
$191 |
|
|
L2397 |
Orthosis, suspension sleeve |
$107 |
|
|
L2405 |
Add to knee joint, drop lock |
$54 |
|
|
L2415 |
Add to knee joint, cam lock |
$172 |
|
|
L2425 |
Add to knee joint, disc/dial loc |
$168 |
|
|
L2492 |
Add to knee joint, drop lock ring |
$104 |
|
|
L2500 |
Add to lwr extrm, thigh/weight |
$337 |
|
|
L2510 |
Add to lwr extrm, thigh/weight |
$764 |
|
|
L2520 |
Add to lwr extrm, thigh/weight |
$482 |
|
|
L2525 |
Add to lwr extrm, thigh/weight |
$1,116 |
|
|
L2526 |
Add to lwr extrm, thigh/weight |
$627 |
|
|
L2530 |
Add to lwr extrm, thigh/weight |
$217 |
|
|
L2540 |
Add to lwr extrm, thigh/weight |
$412 |
|
|
L2550 |
Add to lwr extrm, thigh/weight |
$263 |
|
|
L2570 |
Add to lwr extrm, hip joint |
$581 |
|
|
L2580 |
Add to lwr extrm, pelvic sling |
$425 |
|
|
L2600 |
Add to lwr extrm, hip joint |
$251 |
|
|
L2610 |
Add to lwr extrm, hip joint |
$296 |
|
|
L2620 |
Add to lwr extrm, hip joint |
$286 |
|
|
L2622 |
Add to lwr extrm, hip joint |
$374 |
|
|
L2624 |
Add to lwr extrm, hip joint |
$325 |
|
|
L2627 |
Add to lwr extrm, plastic, mold |
$1,569 |
|
|
L2628 |
Add to lwr extrm, metal frame |
$1,533 |
|
|
L2630 |
Add to lwr extrm, band and belt |
$268 |
|
|
L2640 |
Add to lwr extrm, band and belt |
$352 |
|
|
L2650 |
Add to lwr extrm, pel/thor contr |
$132 |
|
|
L2660 |
Add to lwr extrm, thoracic contr |
$206 |
|
|
L2670 |
Add to lwr extrm, thoracic contr |
$208 |
|
|
L2680 |
Add to lwr extrm, thoracic contr |
$191 |
|
|
L2750 |
Add to lwr extrm ortho, plating |
$101 |
|
|
L2755 |
Carbon graphite lamination |
$187 |
|
|
L2760 |
Add to lwr extrm ortho, extens |
$74 |
|
|
L2768 |
Ortho sidebar disconnect |
$187 |
|
|
L2780 |
Add to lwr extrm ortho, non-corr |
$62 |
|
|
L2785 |
Add to lwr extrm ortho, retainer |
$29 |
|
|
L2795 |
Add to lwr extrm ortho, knee con |
$90 |
|
|
L2800 |
Add to lwr extrm ortho, knee con |
$98 |
|
|
L2810 |
Add to lwr extrm ortho, knee con |
$80 |
|
|
L2820 |
Add to lwr extrm ortho, soft int |
$79 |
|
|
L2830 |
Add to lwr extrm ortho, soft int |
$86 |
|
|
L2840 |
Add to lwr extrm ortho, tib sock |
$53 |
|
|
L2850 |
Add to lwr extrm ortho, fem sock |
$61 |
|
|
L2861 |
Torsion mechanism knee/ankle |
B.R. |
|
|
L2999 |
Unlisted proc lwr extrm orthoses |
B.R. |
|
|
L3000 |
Foot, insert, "UCB" type |
$162 |
|
|
L3001 |
Foot, insert, spenco |
$38 |
|
|
L3002 |
Foot, insert, plastazote |
$81 |
|
|
L3003 |
Foot, insert, silicone |
$162 |
|
|
L3010 |
Foot, insert, longitudinal |
$128 |
|
|
L3020 |
Foot, insert, longitudinal |
$136 |
|
|
L3030 |
Foot, insert, removable, formed |
$41 |
|
|
L3031 |
Foot lamin/prepreg composite |
B.R. |
|
|
L3040 |
Foot, arch support, longitudinal |
$41 |
|
|
L3050 |
Foot, arch support, metatarsal |
$41 |
|
|
L3060 |
Foot, arch support, longitudinal |
$54 |
|
|
L3070 |
Foot, arch support, nonremovable |
$34 |
|
|
L3080 |
Foot, arch support, nonremovable |
$34 |
|
|
L3090 |
Foot, arch support, nonremovable |
$47 |
|
|
L3100 |
Hallus-valgus night dyn splint |
$41 |
|
|
L3140 |
Foot, abduction rotation bars |
$61 |
|
|
L3150 |
Foot, abduction rotation bars |
$61 |
|
|
L3160 |
Shoe styled positioning dev |
B.R. |
|
|
L3170 |
Foot, plastic heel stabilzer |
$20 |
|
|
L3201 |
Ortho shoe, oxford, infant |
$50 |
|
|
L3202 |
Ortho shoe, oxford, child |
$55 |
|
|
L3203 |
Ortho shoe, oxford, junior |
$70 |
|
|
L3204 |
Ortho shoe, hightop, infant |
$63 |
|
|
L3206 |
Ortho shoe, hightop, child |
$53 |
|
|
L3207 |
Ortho shoe, hightop junior |
$55 |
|
|
L3208 |
Surgical boot, ea, infant |
$25 |
|
|
L3209 |
Surgical boot, ea, child |
$30 |
|
|
L3211 |
Surgical boot, ea, junior |
$58 |
|
|
L3212 |
Benesch boot, pair, infant |
$66 |
|
|
L3213 |
Benesch boot, pair, child |
B.R. |
|
|
L3214 |
Benesch boot, pair, junior |
B.R. |
|
|
L3215 |
Ortho shoes, ladies, oxford |
$108 |
|
|
L3216 |
Ortho shoes, ladies, depth inlay |
$150 |
|
|
L3217 |
Ortho shoes, ladies, hightop |
$163 |
|
|
L3218 |
Ortho shoes, ladies, surg boot |
$145 |
|
|
L3219 |
Ortho shoes, mens, oxford |
$126 |
|
|
L3221 |
Ortho shoes, mens, depth inlay |
$150 |
|
|
L3222 |
Ortho shoes, mens, hightop |
$163 |
|
|
L3224 |
Woman's shoe oxford brace |
$88 |
|
|
L3225 |
Man's shoe oxford brace |
$102 |
|
|
L3230 |
Ortho shoes, custom, depth inlay |
$482 |
|
|
L3250 |
Ortho shoes, custom molded |
$270 |
|
|
L3251 |
Foot, shoe molded to patient |
B.R. |
|
|
L3252 |
Foot, shoe molded to patient |
$121 |
|
|
L3253 |
Foot, molded shoe plastazote |
$114 |
|
|
L3254 |
Non-std size/width |
$193 |
|
|
L3255 |
Non-std size/length |
$193 |
|
|
L3257 |
Ortho shoes, add chrg split size |
B.R. |
|
|
L3260 |
Ambulatory surgical boot, ea |
$114 |
|
|
L3265 |
Plastazote sandal, ea |
$54 |
|
|
L3300 |
Lift, elevation, heel |
$54 |
|
|
L3310 |
Lift, elevation, heel and sole |
$47 |
|
|
L3320 |
Lift, elevation, heel and sole |
$114 |
|
|
L3330 |
Lift, elevation, metal extension |
$471 |
|
|
L3332 |
Lift, elevation, inside shoe |
$27 |
|
|
L3334 |
Lift, elevation, heel, per inch |
$54 |
|
|
L3340 |
Heel wedge, sach |
$27 |
|
|
L3350 |
Heel wedge |
$13 |
|
|
L3360 |
Sole wedge, outside sole |
$13 |
|
|
L3370 |
Sole wedge, between sole |
$34 |
|
|
L3380 |
Clubfoot wedge |
$34 |
|
|
L3390 |
Outflare wedge |
$34 |
|
|
L3400 |
Metatarsal bar wedge, rocker |
$30 |
|
|
L3410 |
Metatarsal bar wedge, betw sole |
$47 |
|
|
L3420 |
Full sole and heel wedge, betw sole |
$54 |
|
|
L3430 |
Heel, counter, plastic reinforced |
$67 |
|
|
L3440 |
Heel, counter, leather reinforced |
$47 |
|
|
L3450 |
Heel, sach cushion type |
$27 |
|
|
L3455 |
Heel, new leather, std |
$16 |
|
|
L3460 |
Heel, new rubber, std |
$13 |
|
|
L3465 |
Heel, Thomas w/wedge |
$16 |
|
|
L3470 |
Heel, Thomas extended to ball |
$54 |
|
|
L3480 |
Heel, pad and depression spur |
$41 |
|
|
L3485 |
Heel, pad, removable spur |
B.R. |
|
|
L3500 |
Misc shoe add, insole, leather |
$47 |
|
|
L3510 |
Misc shoe add, insole, rubber |
B.R. |
|
|
L3520 |
Misc shoe add, insole, felt |
B.R. |
|
|
L3530 |
Misc shoe add, sole, half |
B.R. |
|
|
L3540 |
Misc shoe add, sole, full |
B.R. |
|
|
L3550 |
Misc shoe add, toe tap, std |
B.R. |
|
|
L3560 |
Misc shoe add, toe tap, horseshoe |
B.R. |
|
|
L3570 |
Misc shoe add, special extension |
B.R. |
|
|
L3580 |
Misc shoe add, convert instep |
B.R. |
|
|
L3590 |
Misc shoe add, convert firm shoe |
B.R. |
|
|
L3595 |
Misc shoe add, march bar |
B.R. |
|
|
L3600 |
Trans ortho one to anoth, caliper |
$67 |
|
|
L3610 |
Trans ortho one to anoth, caliper |
$54 |
|
|
L3620 |
Trans ortho one to anoth, solid |
$67 |
|
|
L3630 |
Trans ortho one to anoth, solid |
$67 |
|
|
L3640 |
Trans ortho one to anoth, dennis |
$34 |
|
|
L3649 |
Unlisted proc foot ortho shoes |
B.R. |
|
|
L3650 |
SO, figure "8" design abduction |
$58 |
|
|
L3660 |
SO, figure "8" design abduction |
$92 |
|
|
L3670 |
SO, acromio/clavicular |
$105 |
|
|
L3671 |
SO cap design w/o jnts CF |
$1,176 |
|
|
L3674 |
SO airplane w/wo joint CF |
$1,543 |
|
|
L3675 |
Canvas vest SO |
$229 |
|
|
L3677 |
SO hard plastic stabilizer |
B.R. |
|
|
L3702 |
EO w/o joints CF |
$377 |
|
|
L3710 |
EO, elastic w/metal joints |
$133 |
|
|
L3720 |
EO, dbl upright w/forearm/arm cuffs |
$679 |
|
|
L3730 |
EO, dbl upright w/forearm/arm cuffs |
$994 |
|
|
L3740 |
EO, dbl upright w/forearm/arm cuffs |
$1,276 |
|
|
L3760 |
EO withjoint, Prefabricated |
$653 |
|
|
L3762 |
Rigid EO wo joints |
$140 |
|
|
L3763 |
EWHO rigid w/o jnts CF |
$961 |
|
|
L3764 |
EWHO w/joint(s) CF |
$1,085 |
|
|
L3765 |
EWHFO rigid w/o jnts CF |
$1,674 |
|
|
L3766 |
EWHFO w/joint(s) CF |
$1,772 |
|
|
L3806 |
WHFO w/joint(s) custom fab |
$593 |
|
|
L3807 |
WHFO,no joint, prefabricated |
$326 |
|
|
L3808 |
WHFO, rigid w/o joints |
$486 |
|
|
L3900 |
WHFO, dynamic flexor hinge |
$1,170 |
|
|
L3901 |
WHFO, dynamic flexor hinge |
$1,439 |
|
|
L3904 |
WHFO, ext powered, electric |
$2,622.33 |
|
|
L3905 |
WHO w/nontorsion jnt(s) CF |
$1,294 |
|
|
L3906 |
WHFO, wrist gauntlet, patient model |
$354 |
|
|
L3908 |
WHFO, wrist extension cock-up |
$54 |
|
|
L3912 |
WHFO, flex glove w/finger control |
$111.63 |
|
|
L3913 |
HFO w/o joints CF |
$354 |
|
|
L3915 |
WHO w nontor jnt(s) prefab |
$694 |
|
|
L3916 |
WHFO, wrist extension cock-up |
$152 |
|
|
L3917 |
Prefab metacarpl fx orthosis |
$138 |
|
|
L3919 |
HO w/o joints CF |
$354 |
|
|
L3921 |
HFO w/joint(s) CF |
$419 |
|
|
L3923 |
HFO w/o joints PF |
$128 |
|
|
L3925 |
FO pip/dip with joint/spring |
$73 |
|
|
L3927 |
FO pip/dip w/o joint/spring |
$46 |
|
|
L3929 |
HFO nontorsion joint, prefab |
$115 |
|
|
L3931 |
WHFO nontorsion joint prefab |
$268 |
|
|
L3933 |
FO w/o joints CF |
$279 |
|
|
L3935 |
FO nontorsion joint CF |
$288 |
|
|
L3956 |
Add joint upper ext orthosis |
B.R. |
|
|
L3960 |
SEWHO, abduction |
$802.41 |
|
|
L3961 |
SEWHO cap design w/o jnts CF |
$2,193 |
|
|
L3962 |
SEWHO, abduction positioning, erbs |
$642 |
|
|
L3967 |
SEWHO airplane w/o jnts CF |
$2,589 |
|
|
L3971 |
SEWHO cap design w/jnt(s) CF |
$2,458 |
|
|
L3973 |
SEWHO airplane w/jnt(s) CF |
$2,589 |
|
|
L3975 |
SEWHFO cap design w/o jnt CF |
$2,193 |
|
|
L3976 |
SEWHFO airplane w/o jnts CF |
$2,193 |
|
|
L3977 |
SEWHFO cap desgn w/jnt(s) CF |
$2,458 |
|
|
L3978 |
SEWHFO airplane w/jnt(s) CF |
$2,589 |
|
|
L3980 |
Upr extrm fx ortho, humeral |
$330 |
|
|
L3982 |
Upr extrm fx ortho, radius/ulnar |
$372 |
|
|
L3984 |
Upr extrm fx ortho, wrist |
$324 |
|
|
L3985 |
Upr extrm fx ortho, forearm, hand |
$523 |
|
|
L3999 |
Unlisted proc upr limb orthosis |
B.R. |
|
|
L4000 |
Repl girdle Milwaukee orthosis |
$1,233 |
|
|
L4002 |
Replace strap, any orthosis |
B.R. |
|
|
L4010 |
Repl trilateral socket brim |
$630 |
|
|
L4020 |
Repl quad socket brim, molded |
$922 |
|
|
L4030 |
Repl quad socket brim, custom |
$603 |
|
|
L4040 |
Repl molded thigh lacer |
$393 |
|
|
L4045 |
Repl nonmolded thigh lacer |
$300 |
|
|
L4050 |
Repl molded calf lacer |
$378 |
|
|
L4055 |
Repl non-molded calf lacer |
$249 |
|
|
L4060 |
Repl high roll cuff |
$291 |
|
|
L4070 |
Repl prox and dist upright KAFO |
$324 |
|
|
L4080 |
Repl met bands KAFO, prox thigh |
$93 |
|
|
L4090 |
Repl met bands KAFO-AFO, calf/thigh |
$105 |
|
|
L4100 |
Repl leath cuff KAFO, prox thigh |
$107 |
|
|
L4110 |
Repl leath cuff KAFO-AFO, calf/thigh |
$86 |
|
|
L4130 |
Repl pretibial shell |
$529 |
|
|
L4205 |
Ortho dvc repair per 15 min |
B.R. |
|
|
L4210 |
Repair orthotic device, minor parts |
$57 |
|
|
L4350 |
Pneumatic ankle control splint |
$84 |
|
|
L4370 |
Pneumatic full leg splint |
$173 |
|
|
L4386 |
Non-pneum walk boot prefab |
$227 |
|
|
L4392 |
Replace AFO soft interface |
$34 |
|
|
L4394 |
Replace foot drop spint |
$25 |
|
|
L4396 |
Static AFO |
$240 |
|
|
L4631 |
Afo, walk boot type, cus fab |
$2,212 |
|
|
L5000 |
Part foot, shoe insrt w/arch, toe |
$657 |
|
|
L5010 |
Part foot, mold sockt, w/toe filler |
$1,491 |
|
|
L5020 |
Part foot, mold sockt, tib hght |
$2,240 |
|
|
L5050 |
Ankle, Symes, mold socket, sach |
$2,820 |
|
|
L5060 |
Ankle, Symes, metal frame, molded l |
$3,187 |
|
|
L5100 |
Below knee, molded socket, shin |
$2,771 |
|
|
L5105 |
Below knee, plastic socket |
$3,387 |
|
|
L5150 |
Knee disartic, molded socket, ext |
$4,037 |
|
|
L5160 |
Knee disartic, molded socket, bent |
$4,247 |
|
|
L5200 |
Above knee, mold socket, sngl axis |
$3,691 |
|
|
L5210 |
Above knee, shrt prosth, no knee |
$2,728 |
|
|
L5220 |
Above knee, shrt prosth, no knee |
$3,428 |
|
|
L5230 |
Above knee, prox fem focal defic |
$4,063 |
|
|
L5250 |
Hip disartic, Canadian type; molded |
$5,500 |
|
|
L5270 |
Hip disartic, tilt table type; mold |
$5,227 |
|
|
L5280 |
Hemipelvectomy, Canadian type; molded |
$5,689 |
|
|
L5300 |
Below knee, molded socket, sach ft |
$3,211 |
|
|
L5301 |
BK mold socket SACH ft endo |
$3,672 |
|
|
L5312 |
Knee disart, SACH ft, endo |
$5,276 |
|
|
L5321 |
AK open end SACH |
$5,257 |
|
|
L5331 |
Hip disart canadian SACH ft |
$7,438 |
|
|
L5341 |
Hemipelvectomy canadian SACH |
$8,083 |
|
|
L5400 |
Immed postop/early fitting |
$1,390 |
|
|
L5410 |
Immed postop/early fitting |
$543 |
|
|
L5420 |
Immed postop/early fitting |
$1,781 |
|
|
L5430 |
Immed postop/early fitting |
$654 |
|
|
L5450 |
Immed postop/early fitting |
$530 |
|
|
L5460 |
Immed postop/early fitting |
$709 |
|
|
L5500 |
Init, below knee "PTB" type socket |
$1,399 |
|
|
L5505 |
Init, above knee, ischial level soc |
$2,261 |
|
|
L5510 |
Prep, below knee "PTB" type socket |
$1,663 |
|
|
L5520 |
Prep, below knee "PTB" type socket |
$1,869 |
|
|
L5530 |
Prep, below knee "PTB" type socket |
$1,932 |
|
|
L5535 |
Prep, below knee "PTB" type |
$1,936 |
|
|
L5540 |
Prep, below knee "PTB" type |
$2,075 |
|
|
L5560 |
Prep, above knee-knee disarticulat |
$2,496 |
|
|
L5570 |
Prep, above knee-knee disarticulat |
$2,464 |
|
|
L5580 |
Prep, above knee-knee disarticulat |
$2,752 |
|
|
L5585 |
Prep, above knee-knee disarticulat |
$2,761 |
|
|
L5590 |
Prep, above knee-knee disarticulat |
$2,701 |
|
|
L5595 |
Prep, hip disartic-hemipelvectomy |
$3,926 |
|
|
L5600 |
Prep, hip disartic-hemipelvectomy |
$4,335 |
|
|
L5610 |
Add to lwr extrm, above knee, hydra |
$2,339 |
|
|
L5611 |
Add to lwr extrm, above knee-knee |
$1,571 |
|
|
L5613 |
Add to lwr extrm, above knee-knee |
$2,419 |
|
|
L5614 |
Abv knee-knee disartic |
$3,877 |
|
|
L5616 |
Add to lwr extrm, above knee, univ |
$1,765 |
|
|
L5617 |
AK/BK self-aligning unit ea |
$809 |
|
|
L5618 |
Add to lwr extrm, test sockt, Symes |
$295 |
|
|
L5620 |
Add to lwr extrm, test sockt |
$361 |
|
|
L5622 |
Add to lwr extrm, test sockt, knee |
$471 |
|
|
L5624 |
Add to lwr extrm, test sockt |
$473 |
|
|
L5626 |
Add to lwr extrm, test sockt, hip |
$519 |
|
|
L5628 |
Add to lwr extrm, test sockt, hemi |
$560 |
|
|
L5629 |
Add to lwr extrm, below knee, acry |
$413 |
|
|
L5630 |
Add to lwr extrm, Symes type, expa |
$504 |
|
|
L5631 |
Add to lwr extrm, above knee/knee |
$571 |
|
|
L5632 |
Add to lwr extrm, Symes type |
$216 |
|
|
L5634 |
Add to lwr extrm, Symes type, post |
$297 |
|
|
L5636 |
Add to lwr extrm, Symes type, med |
$248 |
|
|
L5637 |
Add to lwr extrm, below knee, tot |
$376 |
|
|
L5638 |
Add to lwr extrm, below knee, leat |
$492 |
|
|
L5639 |
Add to lwr extrm, below knee, wood |
$1,093 |
|
|
L5640 |
Add to lwr extrm, knee, leather |
$623 |
|
|
L5642 |
Add to lwr extrm, above knee, leat |
$623 |
|
|
L5643 |
Add to lwr extrm, hip disartic |
$1,632 |
|
|
L5644 |
Add to lwr extrm, above knee, wood |
$687 |
|
|
L5645 |
Add to lwr extrm, below knee, flex |
$779 |
|
|
L5646 |
Add to lwr extrm, below knee, air |
$693 |
|
|
L5647 |
Add to lwr extrm, below knee suct |
$776 |
|
|
L5648 |
Add to lwr extrm, above knee, air |
$756 |
|
|
L5649 |
Add to lwr extrm, Ischial contain |
$2,369 |
|
|
L5650 |
Adds to lwr extrm, total contact |
$558 |
|
|
L5651 |
Add to lwr extrm, above knee, flex |
$1,561 |
|
|
L5652 |
Add to lwr extrm, suction suspens |
$496 |
|
|
L5653 |
Add to lwr extrm, knee disartic |
$581 |
|
|
L5654 |
Add to lwr extrm, sockt insrt, sym |
$384 |
|
|
L5655 |
Add to lwr extrm, sockt insrt, bel |
$299 |
|
|
L5656 |
Add to lwr extrm, sockt insrt |
$371 |
|
|
L5658 |
Add to lwr extrm, sockt insrt, abv |
$354 |
|
|
L5661 |
Add to lwr extrm, sockt insrt, mul |
$593 |
|
|
L5665 |
Add to lwr extrm, sockt insrt, mul |
$534 |
|
|
L5666 |
Add to lwr extrm, below knee, cuff |
$91 |
|
|
L5668 |
Add to lwr extrm, below knee, mold |
$131 |
|
|
L5670 |
Add to lwr extrm, below knee, mold |
$353 |
|
|
L5671 |
BK/AK locking mechanism |
$796 |
|
|
L5672 |
Add to lwr extrm, below knee, remv |
$291 |
|
|
L5673 |
Socket insert w lock mech |
$1,069 |
|
|
L5676 |
Adds to lwr extrm, below knee |
$460 |
|
|
L5677 |
Adds to lwr extrm, below knee |
$641 |
|
|
L5678 |
Adds to lwr extrm, below knee |
$52 |
|
|
L5679 |
Socket insert w/o lock mech |
$891 |
|
|
L5680 |
Add to lwr extrm, below knee, lacer |
$318 |
|
|
L5681 |
Intl custm cong/latyp insert |
$1,891 |
|
|
L5682 |
Add to lwr extrm, below knee, lacer |
$622 |
|
|
L5683 |
Initial custom socket insert |
$1,891 |
|
|
L5684 |
Add to lwr extrm, below knee, strap |
$52 |
|
|
L5685 |
Bk back check |
$184 |
|
|
L5686 |
Add to lwr extrm, below knee, check |
$53 |
|
|
L5688 |
Add to lwr extrm, below knee, belt |
$75 |
|
|
L5690 |
Add to lwr extrm, below knee, belt |
$105 |
|
|
L5692 |
Add to lwr extrm, above knee, belt |
$173 |
|
|
L5694 |
Add to lwr extrm, above knee, belt |
$236 |
|
|
L5695 |
Add to lwr extrm, above knee, belt |
$212 |
|
|
L5696 |
Add to lwr extrm, above knee/disar |
$216 |
|
|
L5697 |
Add to lwr extrm, above knee/disar |
$78 |
|
|
L5698 |
Add to lwr extrm, above knee/disar |
$117 |
|
|
L5699 |
All lwr extrm prosth, shldr harnes |
$182 |
|
|
L5700 |
Repl, socket, blw knee |
$2,793 |
|
|
L5701 |
Repl, socket, abv knee/knee disarti |
$3,354 |
|
|
L5702 |
Repl, socket, hip disarticulation, |
$4,244 |
|
|
L5703 |
Symes ankle w/o (SACH) foot |
$3,346 |
|
|
L5704 |
Repl, cust prot cover, blw knee |
$523 |
|
|
L5705 |
Repl, cust prot cover, abv knee |
$934 |
|
|
L5706 |
Repl, cust prot cover, knee disarti |
$915 |
|
|
L5707 |
Repl, cust prot cover, hip disartic |
$1,207 |
|
|
L5710 |
Add, exo knee-shin sys, manual lock |
$417 |
|
|
L5711 |
Adds exo knee-shin sys, manual lock |
$529 |
|
|
L5712 |
Add, exo knee-shin sys, friction sw |
$554 |
|
|
L5714 |
Add, exo knee-shin sys, variable fr |
$468 |
|
|
L5716 |
Add, exo knee-shin sys, mechanical |
$827 |
|
|
L5718 |
Add, exo knee-shin sys, friction sw |
$913 |
|
|
L5722 |
Add, exo knee-shin sys, pneum swing |
$887 |
|
|
L5724 |
Add, exo knee-shin sys, fluid swing |
$1,962 |
|
|
L5726 |
Add, exo knee-shin sys, ext joints |
$2,261 |
|
|
L5728 |
Add, exo knee-shin sys, fluid swing |
$2,416 |
|
|
L5780 |
Add, exo knee-shin sys, pneumatic |
$1,286 |
|
|
L5781 |
Lower limb pros vacuum pump |
$5,750 |
|
|
L5782 |
HD low limb pros vacuum pump |
$6,062 |
|
|
L5785 |
Add, exo sys, blw knee, ult-lit mat |
$565 |
|
|
L5790 |
Add, exo sys, abv knee, ult-lit mat |
$935 |
|
|
L5795 |
Add, exo sys, hip dis, ult-lit mat |
$1,396 |
|
|
L5810 |
Add, endo knee-shin sys, manual lck |
$524 |
|
|
L5811 |
Add, endo knee-shin sys, manual lck |
$776 |
|
|
L5812 |
Add, endo knee-shin sys, frict swng |
$587 |
|
|
L5814 |
Endo knee-shin hydral swg ph |
$5,337 |
|
|
L5816 |
Add, endo knee-shin sys, mech stanc |
$945 |
|
|
L5818 |
Add, endo knee-shin sys, frict swng |
$947 |
|
|
L5822 |
Add, endo knee-shin sys, pneum swng |
$1,660 |
|
|
L5824 |
Add, endo knee-shin sys, fluid swng |
$1,781 |
|
|
L5826 |
Miniature knee joint |
$4,516 |
|
|
L5828 |
Add, endo knee-shin sys, fluid swng |
$2,753 |
|
|
L5830 |
Add, endo knee-shin sys, pneum swng |
$2,030 |
|
|
L5840 |
Add, endoskel knee/shin sys |
$2,355 |
|
|
L5845 |
Knee-shin sys stance flexion |
$2,576 |
|
|
L5848 |
Knee-shin sys hydraul stance |
$1,545 |
|
|
L5850 |
Add, endo sys, abv knee/hip disart |
$166 |
|
|
L5855 |
Add, hip disarticulation, mech |
$335 |
|
|
L5856 |
Elec knee-shin swing/stance |
$34,548 |
|
|
L5857 |
Elec knee-shin swing only |
$12,291 |
|
|
L5858 |
Stance phase only |
$26,708 |
|
|
L5910 |
Add, endo sys, blw knee, alignable |
$471 |
|
|
L5920 |
Add, endo sys, abv knee/hip disart |
$690 |
|
|
L5925 |
Add, abv knee, knee disarticulation |
$437 |
|
|
L5930 |
High activity knee frame |
$4,868 |
|
|
L5940 |
Add, endo sys, blw knee, ult-lit |
$652 |
|
|
L5950 |
Add, endo sys, abv knee, ult-lit |
$1,011 |
|
|
L5960 |
Add, endo sys, hip dis, ult-lit |
$1,253 |
|
|
L5961 |
Endo poly hip, pneu/hyd/rot |
$6,844 |
|
|
L5962 |
Add, blw knee, flex prot cover |
$618 |
|
|
L5964 |
Add, abv knee, flex prot cover |
$913 |
|
|
L5966 |
Add, hip disartic, flex prot cover |
$1,163 |
|
|
L5968 |
Multiaxial ankle w dorsiflex |
$5,222 |
|
|
L5970 |
All lwr extr pros, foot, ext keel |
$222 |
|
|
L5971 |
SACH foot, replacement |
$325 |
|
|
L5972 |
All lwr extr pros, flex keel foot |
$418 |
|
|
L5973 |
Ank-foot sys dors-plant flex |
$25,078 |
|
|
L5974 |
All lwr extr pros, foot, ankle/foot |
$258 |
|
|
L5975 |
Combo ankle/foot prosthesis |
$666 |
|
|
L5976 |
All lwr extr pros, energy storing |
$592 |
|
|
L5978 |
All lwr extr pros, foot, ankle/foot |
$332 |
|
|
L5979 |
Multiaxial ankle/foot, dynamic resp |
$2,225 |
|
|
L5980 |
All lwr extr pros, flex foot system |
$3,823 |
|
|
L5981 |
Flex-walk sys/equal |
$2,920 |
|
|
L5982 |
All exo etal lwr extrm pros, axial |
$610 |
|
|
L5984 |
All endo lwr extrm pros, axial rot |
$655 |
|
|
L5985 |
Lwr ext dynamic prosth pylon |
$408 |
|
|
L5986 |
All lwr extrm prosth, multi-axial |
$652 |
|
|
L5987 |
Shank ft w vert load pylon |
$10,338 |
|
|
L5988 |
Vertical shock reducing pylo |
$2,871 |
|
|
L5990 |
User adjustable heel height |
$2,607 |
|
|
L5999 |
Unlisted proc lwr extrm prosth |
B.R. |
|
|
L6000 |
Part hand, thumb remaining |
$1,459 |
|
|
L6010 |
Part hand, little/ring finger rem |
$1,468 |
|
|
L6020 |
Part hand, no finger remaining |
$1,460 |
|
|
L6025 |
Part hand disart myoelectric |
$11,500 |
|
|
L6050 |
Wrist disartic, mold sockt, flex |
$2,243 |
|
|
L6055 |
Wrist disartic, mold sockt w/expan |
$2,767 |
|
|
L6100 |
Blw elbow, molded socket, flex |
$2,302 |
|
|
L6110 |
Blw elbow, molded socket |
$2,443 |
|
|
L6120 |
Blw elbow, mold dbl wall split sock |
$2,755 |
|
|
L6130 |
Blw elbow, mold dbl wall split sock |
$2,553 |
|
|
L6200 |
Elbow disartic, mold socket |
$3,106 |
|
|
L6205 |
Elbow disartic, mold socket |
$3,550 |
|
|
L6250 |
Above elbow, mold dbl wall socket |
$3,221 |
|
|
L6300 |
Shldr disart, mold socket, bulkhead |
$3,878 |
|
|
L6310 |
Shldr disart, pass restor |
$3,114 |
|
|
L6320 |
Shldr disart, pass restor |
$1,873 |
|
|
L6350 |
Int-scap thor, mold sockt, bulkhead |
$3,819 |
|
|
L6360 |
Int-scap thor, pass restor |
$3,105 |
|
|
L6370 |
Int-scap thor, pass restor |
$2,165 |
|
|
L6380 |
Immed postop/early fit, init rigid |
$1,280 |
|
|
L6382 |
Immed postop/early fit, init rigid |
$1,518 |
|
|
L6384 |
Immed postop/early fit, init rigid |
$1,882 |
|
|
L6386 |
Immed postop/early fit, cast change |
$436 |
|
|
L6388 |
Immed postop/early fit, rigid dress |
$487 |
|
|
L6400 |
Blw elbow, mold sockt, endo sys |
$2,445 |
|
|
L6450 |
Elbow disart, mold sockt, endo sys |
$3,006 |
|
|
L6500 |
Above elbow, mold sockt, endo sys |
$3,033 |
|
|
L6550 |
Shoulder disart, mold sockt, endo |
$3,718 |
|
|
L6570 |
Interscap thor, mold sockt, endo |
$4,267 |
|
|
L6580 |
Prep, wrist disart/blw elbow |
$1,602 |
|
|
L6582 |
Prep, wrist disart/blw elbow |
$1,486 |
|
|
L6584 |
Prep, elbow disart/above elbow |
$2,170 |
|
|
L6586 |
Prep, elbow disart/above elbow |
$2,135 |
|
|
L6588 |
Prep, shldr disart/int-scap thorac |
$2,940 |
|
|
L6590 |
Prep, shldr disart/int-scap thorac |
$2,883 |
|
|
L6600 |
Upr extrm adds, polycent hinge, pr |
$244 |
|
|
L6605 |
Upr extrm adds, sng pivot hinge, pr |
$241 |
|
|
L6610 |
Upr extrm adds, flex metal hing, pr |
$197 |
|
|
L6611 |
Additional switch, ext power |
$592 |
|
|
L6615 |
Upr extrm add, disc locking wrist |
$189 |
|
|
L6616 |
Upr extrm add, add disc locking wr |
$80 |
|
|
L6620 |
Upr extrm add, flexion-friction wr |
$327 |
|
|
L6621 |
Flex/ext wrist w/wo friction |
$3,287 |
|
|
L6623 |
Upr extrm add, spring asst rotl wr |
$657 |
|
|
L6624 |
Flex/ext/rotation wrist unit |
$5,412 |
|
|
L6625 |
Upr extrm add, rot wrist unit |
$691 |
|
|
L6628 |
Upr extrm add, quick disc hook adap |
$503 |
|
|
L6629 |
Upr extrm add, quick disc lam coll |
$173 |
|
|
L6630 |
Upr extrm add, stain steel, wrist |
$280 |
|
|
L6632 |
Upr extrm add, latex susp sleeve |
$63 |
|
|
L6635 |
Upr extrm add, lift assist elbow |
$216 |
|
|
L6637 |
Upr extrm add, nudge cont elbw lck |
$420 |
|
|
L6638 |
Elec lock on manual pw elbow |
$3,594 |
|
|
L6640 |
Upr extrm adds, shldr abd joint, pr |
$352 |
|
|
L6641 |
Upr extrm add, excurs amp, pulley |
$190 |
|
|
L6642 |
Upr extrm add, excurs amp, lever |
$226 |
|
|
L6645 |
Upr extrm add, shldr flex-abduction |
$393 |
|
|
L6646 |
Multipo locking shoulder jnt |
$4,532 |
|
|
L6647 |
Shoulder lock actuator |
$746 |
|
|
L6648 |
Ext pwrd shlder lock/unlock |
$4,675 |
|
|
L6650 |
Upr extrm add, shldr univ joint, ea |
$412 |
|
|
L6655 |
Upr extrm add, std cont cable |
$90 |
|
|
L6660 |
Upr extrm add, heavy duty cont cable |
$101 |
|
|
L6665 |
Upr extrm add, teflon, cable lining |
$60 |
|
|
L6670 |
Upr extrm add, hook-hand, cable |
$62 |
|
|
L6672 |
Upr extrm add, harness, chest |
$173 |
|
|
L6675 |
Upr extrm add, harness, figure "8" |
$122 |
|
|
L6676 |
Upr extrm add, harness, figure "8" |
$128 |
|
|
L6677 |
UE triple control harness |
$426 |
|
|
L6680 |
Upr extrm add, test sockt, wrist |
$302 |
|
|
L6682 |
Upr extrm add, test sockt, elbow |
$295 |
|
|
L6684 |
Upr extrm add, test sockt, shldr |
$340 |
|
|
L6686 |
Upr extrm add, suction socket |
$632 |
|
|
L6687 |
Upr extrm add, frame type socket |
$562 |
|
|
L6688 |
Upr extrm add, frame type socket |
$665 |
|
|
L6689 |
Upr extrm add, frame type socket |
$696 |
|
|
L6690 |
Upr extrm add, frame type socket |
$755 |
|
|
L6691 |
Upr extrm add, removable insert, each |
$337 |
|
|
L6692 |
Upr extrm add, silicone gel insert |
$694 |
|
|
L6693 |
Lockingelbow forearm cntrbal |
$4,080 |
|
|
L6694 |
Elbow socket ins use w/lock |
$1,069 |
|
|
L6695 |
Elbow socket ins use w/o lck |
$891 |
|
|
L6696 |
Cus elbo skt in for con/atyp |
$1,891 |
|
|
L6697 |
Cus elbo skt in not con/atyp |
$1,891 |
|
|
L6698 |
Below/above elbow lock mech |
$796 |
|
|
L6704 |
Term dev, sport/rec/work att |
$937 |
|
|
L6706 |
Term dev mech hook vol open |
$558 |
|
|
L6707 |
Term dev mech hook vol close |
$2,057 |
|
|
L6708 |
Term dev mech hand vol open |
$1,338 |
|
|
L6709 |
Term dev mech hand vol close |
$1,938 |
|
|
L6711 |
Ped term dev, hook, vol open |
$966 |
|
|
L6712 |
Ped term dev, hook, vol clos |
$1,779 |
|
|
L6713 |
Ped term dev, hand, vol open |
$2,245 |
|
|
L6714 |
Ped term dev, hand, vol clos |
$1,902 |
|
|
L6715 |
Term device, hook, dorr, mod #5xa |
$391 |
|
|
L6721 |
Hook/hand, hvy dty, vol open |
$3,380 |
|
|
L6722 |
Hook/hand, hvy dty, vol clos |
$2,914 |
|
|
L6805 |
Term device, mod wrist flex unit |
$414.87 |
|
|
L6810 |
Term dev, pinch tool, Otto Bock |
$242.46 |
|
|
L6880 |
Term dev, hand, Bock, vo |
$651 |
|
|
L6881 |
Term dev auto grasp feature |
$5,875 |
|
|
L6882 |
Microprocessor control uplmb |
$4,457 |
|
|
L6883 |
Replc sockt below e/w disa |
$2,538 |
|
|
L6884 |
Replc sockt above elbow disa |
$3,571 |
|
|
L6885 |
Replc sockt shldr dis/interc |
$5,094 |
|
|
L6890 |
Term dev, glove abv hands, glove |
$180 |
|
|
L6895 |
Term dev, glove abv hands, glove |
$544 |
|
|
L6900 |
Hand restoration |
$1,507 |
|
|
L6905 |
Hand restoration |
$1,431 |
|
|
L6910 |
Hand restoration |
$1,411 |
|
|
L6915 |
Hand restoration |
$610 |
|
|
L6920 |
Wrist disart, ext pwr, inner socket |
$7,144 |
|
|
L6925 |
Wrist disart, ext pwr, inner socket |
$7,544 |
|
|
L6930 |
Blw elbow, ext pwr, inner socket |
$7,670 |
|
|
L6935 |
Blw elbow, ext pwr, inner socket |
$8,437 |
|
|
L6940 |
Elbow disart, ext pwr, inner socket |
$9,586 |
|
|
L6945 |
Elbow disart, ext pwr, inner socket |
$10,844 |
|
|
L6950 |
Above elbow, ext pwr, inner socket |
$10,192 |
|
|
L6955 |
Above elbow, ext pwr, inner socket |
$12,789 |
|
|
L6960 |
Shldr disart, ext pwr, inner socket |
$12,611 |
|
|
L6965 |
Shldr disart, ext pwr, inner socket |
$18,423 |
|
|
L6970 |
Int-scap-thor, ext pwr, inner socket |
$18,726 |
|
|
L6975 |
Int-scap-thor, ext pwr, inner socket |
$18,826 |
|
|
L7007 |
Adult electric hand |
$5,504 |
|
|
L7008 |
Pediatric electric hand |
$8,662 |
|
|
L7009 |
Adult electric hook |
$5,616 |
|
|
L7040 |
Prehens act, Hosmer/equal, switch |
$3,665 |
|
|
L7045 |
Elect hook, child, Michigan/equal |
$2,101 |
|
|
L7170 |
Elect elbw, Hosmer/equal, switch |
$7,622 |
|
|
L7180 |
Elect elbw, Utah/equal, myoelectr |
$39,823 |
|
|
L7181 |
Electronic elbo simultaneous |
$57,580 |
|
|
L7185 |
Elect elbw, adolescent, var village |
$7,718 |
|
|
L7186 |
Elect elbw, child, var village |
$11,139 |
|
|
L7190 |
Elect elbw, adolescent, var village |
$9,820 |
|
|
L7191 |
Elect elbw, child, var village |
$11,841 |
|
|
L7260 |
Elect wrist rotator, Otto Bock/equa |
$2,558 |
|
|
L7261 |
Elect wrist rotator, Utah arm |
$4,094 |
|
|
L7360 |
Six vlt bat, Otto Bock/equal, ea |
$235 |
|
|
L7362 |
Bat charger, six volt, Otto Bock |
$282 |
|
|
L7364 |
Twelve volt bat, Utah/equal, ea |
$514 |
|
|
L7366 |
Batt charger, twelve volt, Utah/equ |
$698 |
|
|
L7367 |
Replacemnt lithium ionbatter |
$559 |
|
|
L7368 |
Lithium ion battery charger |
$725 |
|
|
L7400 |
Add UE prost be/wd, ultlite |
$440 |
|
|
L7401 |
Add UE prost a/e ultlite mat |
$493 |
|
|
L7402 |
Add UE prost s/d ultlite mat |
$532 |
|
|
L7403 |
Add UE prost b/e acrylic |
$529 |
|
|
L7404 |
Add UE prost a/e acrylic |
$799 |
|
|
L7405 |
Add UE prost s/d acrylic |
$1,045 |
|
|
L7499 |
Unlisted procs upr extrm prosth |
B.R. |
|
|
L7510 |
RPR prosth dev, rpr/rep minor parts |
$57 |
|
|
L7520 |
Repair prosthesis per 15 min |
B.R. |
|
|
L7600 |
Prosthetic donning sleeve |
B.R. |
|
|
L7900 |
Male vacuum erection system |
$771 |
|
|
L8000 |
Breast prosth, mastectomy bra |
$37 |
|
|
L8001 |
Breast prosthesis bra and form |
$180 |
|
|
L8002 |
Brst prsth bra and bilat form |
$237 |
|
|
L8010 |
Breast prosth, mastectomy sleeve |
$59 |
|
|
L8015 |
Ext breastprosthesis garment |
$86 |
|
|
L8020 |
Breast prosth, mastectomy form |
$222 |
|
|
L8030 |
Breast prosth, silicone/equal |
$325 |
|
|
L8031 |
Breast prosthesis w adhesive |
$505 |
|
|
L8032 |
Reusable nipple prosthesis |
$56 |
|
|
L8035 |
Custom breast prosthesis |
$5,265 |
|
|
L8039 |
Breast prosthesis NOS |
B.R. |
|
|
L8040 |
Nasal prosthesis |
$3,559 |
|
|
L8040 |
Nasal prosthesis |
KM |
$3,381 |
|
L8040 |
Nasal prosthesis |
KN |
$1,424 |
|
L8041 |
Midfacial prosthesis |
$4,290 |
|
|
L8041 |
Midfacial prosthesis |
KM |
$4,076 |
|
L8041 |
Midfacial prosthesis |
KN |
$1,716 |
|
L8042 |
Orbital prosthesis |
$4,820 |
|
|
L8042 |
Orbital prosthesis |
KM |
$4,579 |
|
L8042 |
Orbital prosthesis |
KN |
$1,928 |
|
L8043 |
Upper facial prosthesis |
$5,399 |
|
|
L8043 |
Upper facial prosthesis |
KM |
$5,129 |
|
L8043 |
Upper facial prosthesis |
KN |
$2,160 |
|
L8044 |
Hemi-facial prosthesis |
$5,977 |
|
|
L8044 |
Hemi-facial prosthesis |
KM |
$5,678 |
|
L8044 |
Hemi-facial prosthesis |
KN |
$2,391 |
|
L8045 |
Auricular prosthesis |
$3,933 |
|
|
L8045 |
Auricular prosthesis |
KM |
$3,736 |
|
L8045 |
Auricular prosthesis |
KN |
$1,572 |
|
L8046 |
Partial facial prosthesis |
$3,856 |
|
|
L8046 |
Partial facial prosthesis |
KM |
$3,663 |
|
L8046 |
Partial facial prosthesis |
KN |
$1,543 |
|
L8047 |
Nasal septal prosthesis |
$1,976 |
|
|
L8047 |
Nasal septal prosthesis |
KM |
$1,878 |
|
L8047 |
Nasal septal prosthesis |
KN |
$791 |
|
L8048 |
Unspec maxillofacial prosth |
B.R. |
|
|
L8049 |
Repair maxillofacial prosth |
B.R. |
|
|
L8300 |
Truss, single w/std pad |
$82 |
|
|
L8310 |
Truss, dbl w/std pads |
$130 |
|
|
L8320 |
Truss, add to std pad, water pad |
$60 |
|
|
L8330 |
Truss, add to std pad, scrotal pad |
$64 |
|
|
L8400 |
Prosth sheath, blw knee, ea |
$15 |
|
|
L8410 |
Prosth sheath, above knee, ea |
$22 |
|
|
L8415 |
Prosth sheath, upr limb, ea |
$23 |
|
|
L8417 |
Pros sheath/sock w gel cushn |
$108 |
|
|
L8420 |
Prosth sock, wool, blw knee, ea |
$20 |
|
|
L8430 |
Prosth sock, wool, above knee, ea |
$22 |
|
|
L8435 |
Prosth sock, wool, upr limb, ea |
$24 |
|
|
L8440 |
Prosth shrinker, blw knee, ea |
$43 |
|
|
L8460 |
Prosth shrinker, above knee, ea |
$75 |
|
|
L8465 |
Prosth shrinker, upr limb, ea |
$53 |
|
|
L8470 |
Stump sock, sngl ply, fit, blw knee |
$8 |
|
|
L8480 |
Stump sock, sngl ply, fit, abv knee |
$10 |
|
|
L8485 |
Stump sock, single ply, fitting |
$11 |
|
|
L8499 |
Unlisted procedure misc prosth |
B.R. |
|
|
L8500 |
Artificial larynx, any type |
$758 |
|
|
L8501 |
Tracheostomy speaking valve |
$118 |
|
|
L8505 |
Artificial larynx, accessory |
B.R. |
|
|
L8507 |
Trach-esoph voice pros pt in |
$60 |
|
|
L8509 |
Trach-esoph voice pros md in |
$157 |
|
|
L8510 |
Voice amplifier |
$363 |
|
|
L8511 |
Indwelling trach insert |
$105 |
|
|
L8512 |
Gel cap for trach voice pros |
$3 |
|
|
L8513 |
Trach pros cleaning device |
$7 |
|
|
L8514 |
Repl trach puncture dilator |
$136 |
|
|
L8515 |
Gel cap app device for trach |
$91 |
|
|
L8600 |
Implant breast prosth, silicone/equ |
$999 |
|
|
L8609 |
Artificial cornea |
$9,365 |
|
|
L8610 |
Ocular |
$936 |
|
|
L8612 |
Aqueous shunt |
$972 |
|
|
L8613 |
Ossicula |
$411 |
|
|
L8614 |
Cochlear dev/system |
$27,796 |
|
|
L8615 |
Temporomandibular joint |
$648 |
|
|
L8616 |
Maxilla |
$151 |
|
|
L8617 |
Mandible |
$132 |
|
|
L8618 |
Palate |
$38 |
|
|
L8619 |
Coch imp ext proc/contr rplc |
$11,931 |
|
|
L8621 |
Distal humerus |
$1 |
|
|
L8622 |
Proximal ulna/radius |
$1 |
|
|
L8623 |
Distal ulna |
$93 |
|
|
L8624 |
Distal radius |
$232 |
|
|
L8627 |
Lunate |
$10,133 |
|
|
L8628 |
Carpus |
$1,798 |
|
|
L8629 |
Scaphoid |
$257 |
|
|
L8630 |
Metacarpophalangeal joint |
$539 |
|
|
L8631 |
MCP joint repl 2 pc or more |
$3,162 |
|
|
L8641 |
Metatarsal joint |
$560 |
|
|
L8642 |
Hallux implant |
$454 |
|
|
L8658 |
Interphalangeal joint |
$488 |
|
|
L8659 |
Interphalangeal joint repl |
$2,774 |
|
|
L8670 |
Vascular graft material, synthetic |
$801 |
|
|
L8680 |
Biliary stent, endoprosth (perm) |
$668 |
|
|
L8681 |
Pt prgrm for implt neurostim |
$1,725 |
|
|
L8682 |
Implt neurostim radiofq rec |
$8,666 |
|
|
L8683 |
Radiofq trsmtr for implt neu |
$7,628 |
|
|
L8684 |
Radiof trsmtr implt scrl neu |
$1,089 |
|
|
L8685 |
Implt nrostm pls gen sng rec |
$19,010 |
|
|
L8686 |
Implt nrostm pls gen sng non |
$12,121 |
|
|
L8687 |
Implt nrostm pls gen dua rec |
$24,739 |
|
|
L8688 |
Implt nrostm pls gen dua non |
$15,785 |
|
|
L8689 |
External recharg sys intern |
$2,479 |
|
|
L8690 |
Testicle |
$6,838 |
|
|
L8691 |
Osseointegrated snd proc rpl |
$3,833 |
|
|
L8692 |
Non-osseointegrated snd proc |
B.R. |
|
|
L8693 |
Aud osseo dev, abutment |
$2,180 |
|
|
L8695 |
External recharg sys extern |
$24 |
|
|
L8699 |
Prosthetic implant NOS |
B.R. |
|
|
L9900 |
O and P supply/accessory/service |
B.R. |
|
|
L9999 |
Sales tax, orthotic/prosth/other |
B.R. |
|
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.
