Order Adopting Rules Relating to


A. Additions to the Chiropractic Fee Schedule (effective March 1, 2001) E. Establishment of Hospital Fees for Workers' Compensation Cases (effective January 1, 2001)
B. Adoption of a Durable Medical Equipment/Supply Fee Schedule (effective March 1, 2001) F. Reimbursement for Multiple Arthroscopic Procedures (effective March 1, 2001)
C. Deletion of Obsolete CPT Codes (effective March 1, 2001) G. Amendment of Industrial Commission Rule 104 (effective March 1, 2001)
D. Adoption of Fees for Physicians' Assistants (effective March 1, 2001)

Durable Medical Equipment/Supply Fee Schedule

CODE

DESCRIPTION

FEE

A4214

Sterile saline or water, 30 cc vial

$1.67

A4221

Supplies for maintenance of drug infusion catheter, per week (list drug separately)

$21.59

A4222

Supplies for external drug infusion pump, per cassette or bag (list drug separately)

$44.16

A4253

Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

$31.69

A4254

Replacement battery, any type, for use with medically necessary home blood glucose monitor owned by patient, each

$6.28

A4255

Platforms for home blood glucose monitor, 50 per box

$3.82

A4256

Normal, low, and high calibrator solution/chips

$10.92

A4258

Spring-powered device for lancet, each

$17.21

A4259

Lancets, per box of 100

$12.15

A4310

Insertion tray without drainage bag and without catheter (accessories only)

$6.26

A4311

Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

$14.16

A4312

Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone

$17.20

A4313

Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

$17.67

A4314

Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

$24.12

A4315

Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone

$25.17

A4316

Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

$27.09

A4320

Irrigation tray with bulb or piston syringe, any purpose

$4.32

A4351

Intermittent urinary catheter; straight tip, each

$1.47

A4352

Intermittent urinary catheter; coude (curved) tip, each

$5.67

A4353

Intermittent urinary catheter, with insertion supplies

$6.67

A4354

Insertion tray with drainage bag but without catheter

$11.25

A4355

Irrigation tubing set for continuous bladder irrigation through a three-way indwelling Foley catheter, each

$8.50

A4356

External urethral clamp or compression device (not to be used for catheter clamp), each

$43.27

A4357

Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each

$9.25

A4358

Urinary leg bag; vinyl, with or without tube, each

$6.33

A4359

Urinary suspensory without leg bag, each

$26.69

A4361

Ostomy faceplate, each

$17.52

A4454

Tape, all types, all sizes

$2.12

A4460

Elastic bandage, per roll (e.g., compression bandage)

$0.97

A4550

Surgical trays

$19.04

A4556

Electrodes (e.g., Apnea monitor), per pair

$9.84

A4558

Conductive paste or gel

$5.20

A4613

Battery charger; replacement for patient-owned ventilator

$116.92

A4618

Breathing circuits

$7.21

A4619

Face tent

$1.21

A4621

Tracheostomy mask or collar

$1.39

A4622

Tracheostomy or laryngectomy tube

$48.70

A4623

Tracheostomy, inner cannula (replacement only)

$5.31

A4624

Tracheal suction catheter, any type, each

$2.13

A4625

Tracheostomy care kit for new tracheostomy

$5.62

A4626

Tracheostomy cleaning brush, each

$2.59

A4628

Oropharyngeal suction catheter, each

$3.57

A4629

Tracheostomy care kit for established tracheostomy

$4.42

A4630

Replacement batteries for medically necessary transcutaneous electrical nerve stimulator (TENS) owned by patient

$5.96

A4631

Replacement batteries for medically necessary electronic wheelchair owned by patient

$96.43

A4635

Underarm pad, crutch, replacement, each

$4.15

A4636

Replacement, handgrip, cane, crutch, or walker, each

$3.46

A4637

Replacement, tip, cane, crutch, walker, each

$2.03

A4640

Replacement pad for use with medically necessary alternating pressure pad owned by patient

$54.44

A5051

Pouch, closed; with barrier attached (one piece)

$2.14

A5052

Pouch, closed; without barrier attached (one piece)

$1.59

A5053

Pouch, closed; for use on faceplate

$1.41

A5054

Pouch, closed; for use on barrier with flange (two piece)

$1.61

A5055

Stoma cap

$1.21

A5061

Pouch, drainable; with barrier attached (one piece)

$2.58

A5062

Pouch, drainable; without barrier attached (one piece)

$2.12

A5063

Pouch, drainable; for use on barrier with flange (two piece system)

$2.13

A5071

Pouch, urinary; with barrier attached (one piece)

$4.15

A5072

Pouch, urinary; without barrier attached (one piece)

$3.24

A5073

Pouch, urinary; for use on barrier with flange (two piece)

$3.04

A5081

Continent device; plug for continent stoma

$2.77

A5082

Continent device; catheter for continent stoma

$10.71

A5093

Ostomy accessory; convex insert

$1.58

A5102

Bedside drainage bottle, with or without tubing, rigid or expandable, each

$21.53

A5105

Urinary suspensory; with leg bag, with or without tube

$38.88

A5112

Urinary leg bag; latex

$33.02

A5113

Leg strap; latex, replacement only, per set

$3.81

A5114

Leg strap; foam or fabric, replacement only, per set

$7.24

A5119

Skin barrier; wipes, box per 50

$9.67

A5121

Skin barrier; solid, 6 x 6 or equivalent, each

$7.12

A5122

Skin barrier; solid, 8 x 8 or equivalent, each

$11.96

A5123

Skin barrier; with flange (solid, flexible or accordion), any size, each

$4.60

A5126

Adhesive or non-adhesive; disk or foam pad

$1.07

A5131

Appliance cleaner, incontinence and ostomy appliances, per 16 oz.

$13.80

A6154

Wound pouch, each

$13.69

A6196

Alginate dressing, wound cover, pad size 16 sq. in. or less, each dressing

$7.01

A6197

Alginate dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

$15.68

A6199

Alginate dressing, wound filler, per 6 inches

$5.04

A6200

Composite dressing, pad size 16 sq. in. or less, without adhesive border, each dressing

$9.06

A6203

Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing

$3.19

A6204

Composite dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

$5.94

A6207

Contact layer, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

$7.00

A6209

Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

$7.14

A6210

Foam dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

$19.00

A6211

Foam dressing, wound cover, pad size more then 48 sq. in., without adhesive border, each dressing

$28.01

A6212

Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

$9.25

A6214

Foam dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing

$9.82

A6216

Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

$0.05

A6219

Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing

$0.91

A6220

Gauze, non-impregnated, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

$2.46

A6222

Gauze, impregnated, other than water or normal saline, pad size 16 sq. in. or less, without adhesive border, each dressing

$2.03

A6223

Gauze, impregnated, other than water or normal saline, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

$2.30

A6224

Gauze, impregnated, other than water or normal saline, pad size more than 48 sq. in., without adhesive border, each dressing

$3.44

A6234

Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

$6.24

A6235

Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

$16.05

A6236

Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

$25.99

A6237

Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

$7.54

A6238

Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

$21.74

A6240

Hydrocolloid dressing, wound filler, paste, per fluid ounce

$11.68

A6241

Hydrocolloid dressing, wound filler, dry form, per gram

$2.45

A6242

Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

$5.79

A6243

Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

$11.75

A6244

Hydrogel dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

$37.46

A6245

Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

$6.93

A6246

Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

$9.46

A6247

Hydrogel dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing

$22.68

A6248

Hydrogel dressing, wound filler, gel, per fluid ounce

$15.49

A6251

Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

$1.90

A6252

Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

$3.10

A6253

Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

$6.05

A6254

Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

$1.16

A6255

Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

$2.89

A6257

Transparent film, 16 sq. in. or less, each dressing

$1.46

A6258

Transparent film, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

$4.10

A6259

Transparent film, more than 48 sq. in., each dressing

$10.43

A6263

Gauze, elastic, non-sterile, all types, per linear yard

$0.28

A6264

Gauze, non-elastic, non-sterile, per linear yard

$0.46

A6265

Tape, all types, per 18 sq. in.

$0.12

A6266

Gauze, impregnated, other than water or normal saline, any width, per linear yard

$1.83

A6402

Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

$0.12

A6403

Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

$0.41

A6405

Gauze, elastic, sterile, all types, per linear yard

$0.32

A6406

Gauze, non-elastic, sterile, all types, per linear yard

$0.76

E0100

Cane, includes canes of all materials, adjustable or fixed, with tip

$17.09

E0105

Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips

$45.38

E0110

Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips

$71.38

E0111

Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip

$43.18

E0112

Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips

$32.06

E0113

Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip

$17.13

E0114

Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips

$38.26

E0116

Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip

$22.49

E0130

Walker, rigid (pickup), adjustable or fixed height

$63.04

E0135

Walker, folding (pickup), adjustable or fixed height

$79.97

E0141

Rigid walker, wheeled, without seat

$109.97

E0142

Rigid walker, wheeled, with seat

$160.57

E0143

Folding walker, wheeled, without seat

$101.20

E0147

Heavy duty, multiple breaking system, variable wheel resistance walker

$548.27

E0153

Platform attachment, forearm crutch, each

$66.18

E0154

Platform attachment, walker, each

$67.25

E0155

Wheel attachment, rigid pick-up walker, per pair seat attachment, walker

$25.59

E0156

Seat attachment, walker

$22.56

E0157

Crutch attachment, walker, each

$78.14

E0158

Leg extensions for walker, per set of four (4)

$29.00

E0159

Brake attachment for wheeled walker, replacement, each

$17.05

E0160

Sitz type bath or equipment, portable, used with or without commode

$26.80

E0161

Sitz type bath or equipment, portable, used with or without commode, with faucet attachment/s

$25.01

E0162

Sitz bath chair

$118.12

E0163

Commode chair, stationary, with fixed arms

$89.82

E0164

Commode chair, mobile, with fixed arms

$173.03

E0167

Pail or pan for use with commode chair

$11.02

E0175

Foot rest, for use with commode chair, each

$63.17

E0176

Air pressure pad or cushion, nonpositioning

$86.84

E0177

Water pressure pad or cushion, nonpositioning

$90.97

E0178

Gel or gel-like pressure pad or cushion, nonpositioning

$98.38

E0179

Dry pressure pad or cushion, nonpositioning

$11.41

E0182

Pump for alternating pressure pad

$21.23

E0184

Dry pressure mattress

$185.71

E0185

Gel or gel-like pressure pad for mattress, standard mattress length and width

$305.09

E0191

Heel or elbow protector, each

$8.10

E0192

Low pressure and positioning equalization pad, for wheelchair

$369.14

E0197

Air pressure pad for mattress, standard mattress length and width

$179.65

E0198

Water pressure pad for mattress, standard mattress length and width

$208.45

E0199

Dry pressure pad for mattress, standard mattress length and width

$25.98

E0200

Heat lamp, without stand (table model), includes bulb, or infrared element

$75.62

E0202

Phototherapy (bilirubin) light with photometer

$59.72

E0205

Heat lamp, with stand, includes bulb, or infrared element

$185.10

E0210

Electric heat pad, standard

$26.46

E0217

Water circulating heat pad with pump

$473.55

E0225

Hydrocollator unit, includes pads

$370.70

E0230

Ice cap or collar

$7.55

E0238

Nonelectric heat pad, moist

$25.26

E0239

Hydrocollator unit, portable

$364.70

E0249

Pad for water circulating heat unit

$95.00

E0271

Mattress, inner spring

$211.78

E0272

Mattress, foam rubber

$193.03

E0275

Bed pan, standard, metal or plastic

$13.96

E0276

Bed pan, fracture, metal or plastic

$10.79

E0280

Bed cradle, any type

$30.97

E0310

Bedside rails, full-length

$169.55

E0325

Urinal; male, jug-type, any material

$8.19

E0326

Urinal; female, jug-type, any material

$8.52

E0441

Oxygen contents, gaseous, per unit (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned; 1 unit = 50 cubic ft)

$147.84

E0442

Oxygen contents, liquid, per unit (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned; 1 unit = 10 lbs)

$147.84

E0443

Portable oxygen contents, gaseous, per unit (for use only with portable gaseous systems when no stationary gas or liquid system is used; 1 unit = 5 cubic ft)

$18.20

E0444

Portable oxygen contents, liquid, per unit (for use only with portable liquid systems when no stationary gas or liquid system is used; 1 unit = 1 lb)

$18.20

E0560

Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery

$155.83

E0570

Nebulizer, with compressor

$18.34

E0575

Nebulizer, ultrasonic

$83.33

E0580

Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter

$127.85

E0607

Home blood glucose monitor

$63.73

E0609

Blood glucose monitor with special features (e.g., voice synthesizers, automatic timers, etc.)

$605.02

E0610

Pacemaker monitor, self-contained, checks battery depletion, includes audible and visible check systems

$200.68

E0615

Pacemaker monitor, self-contained, checks battery depletion and other pacemaker components, includes digital/visible check systems

$456.71

E0621

Sling or seat, patient lift, canvas or nylon

$80.25

E0627

Seat lift mechanism incorporated into a combination lift-chair mechanism

$321.75

E0628

Separate seat lift mechanism for use with patient owned furniture - electric

$321.75

E0629

Separate seat lift mechanism for use with patient owned furniture - nonelectric

$315.44

E0650

Pneumatic compressor, nonsegmental home model

$605.50

E0651

Pneumatic compressor, segmental home model without calibrated gradient pressure

$876.02

E0652

Pneumatic compressor, segmental home model with calibrated gradient pressure

$5,056.67

E0655

Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm

$92.14

E0660

Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg

$152.37

E0665

Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm

$125.42

E0666

Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg

$123.60

E0667

Segmental pneumatic appliance for use with pneumatic compressor, full leg

$308.82

E0668

Segmental pneumatic appliance for use with pneumatic compressor, full arm

$421.48

E0669

Segmental pneumatic appliance for use with pneumatic compressor, half leg

$171.02

E0671

Segmental gradient pressure pneumatic appliance, full leg

$396.17

E0672

Segmental gradient pressure pneumatic appliance, full arm

$307.83

E0673

Segmental gradient pressure pneumatic appliance, half leg

$255.79

E0690

Ultraviolet cabinet, appropriate for home use

$1,299.85

E0720

TENS, two lead, localized stimulation

$350.61

E0730

TENS, four lead, larger area/multiple nerve stimulation

$353.45

E0747

Osteogenesis stimulator, electrical, noninvasive, other than spinal applications

$3,364.35

E0748

Osteogenesis stimulator, electrical, noninvasive, spinal applications

$3,342.55

E0776

IV pole

$136.55

E0781

Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient

$252.64

E0791

Parenteral infusion pump, stationary, single or multichannel

$301.60

E0840

Traction frame, attached to headboard, cervical traction

$59.41

E0850

Traction stand, freestanding, cervical traction

$89.48

E0855

Cervical traction equipment not requiring additional stand or frame

$479.42

E0860

Traction equipment, overdoor, cervical

$32.40

E0870

Traction frame, attached to footboard, extremity traction (e.g., Buck's)

$94.30

E0880

Traction stand, freestanding, extremity traction (e.g., Buck's)

$101.78

E0890

Traction frame, attached to footboard, pelvic traction

$97.62

E0900

Traction stand, freestanding, pelvic traction (e.g., Buck's)

$103.88

E0942

Cervical head harness/halter

$16.09

E0943

Cervical pillow

$26.39

E0944

Pelvic belt/harness/boot

$39.73

E0945

Extremity belt/harness

$40.87

E0947

Fracture frame, attachments for complex pelvic traction

$503.87

E0948

Fracture frame, attachments for complex cervical traction

$503.87

E0950

Tray

$99.15

E0951

Loop heel, each

$16.81

E0952

Loop toe, each

$17.97

E0953

Pneumatic tire, each

$39.02

E0954

Semi-pneumatic caster, each

$39.91

E0959

Amputee adapter (device used to compensate for transfer of weight due to lost limbs to maintain proper balance)

$81.51

E0961

Brake extension, for wheelchair

$24.11

E0962

One-inch cushion, for wheelchair

$56.74

E0963

Two-inch cushion, for wheelchair

$67.78

E0964

Three-inch cushion, for wheelchair

$75.62

E0965

Four-inch cushion, for wheelchair

$80.84

E0966

Hook on headrest extension

$66.80

E0967

Wheelchair hand rims with eight vertical rubber-tipped projections, pair

$107.13

E0969

Narrowing device, wheelchair

$149.40

E0970

No. 2 footplates, except for elevating legrest

$39.05

E0971

Anti-tipping device, wheelchair

$53.30

E0972

Transfer board or device

$52.57

E0973

Adjustable height detachable arms, desk or full-length, wheelchair

$109.66

E0974

'Grade-aid' (device to prevent rolling back on an incline) for wheelchair

$64.06

E0975

Reinforced seat upholstery, wheelchair

$40.33

E0976

Reinforced back, wheelchair, upholstery or other material

$40.72

E0977

Wedge cushion, wheelchair

$55.47

E0978

Belt, safety with airplane buckle, wheelchair

$41.60

E0979

Belt, safety with Velcro closure, wheelchair

$31.93

E0980

Safety vest, wheelchair

$26.80

E0990

Elevating leg rest, each

$105.09

E0991

Upholstery seat

$43.76

E0992

Solid seat insert

$90.75

E0993

Back, upholstery

$44.35

E0994

Armrest, each

$15.98

E0995

Calf rest, each

$27.51

E0996

Tire, solid, each

$27.20

E0997

Caster with fork

$63.44

E0998

Caster without fork

$31.03

E0999

Pneumatic tire with wheel

$93.21

E1000

Tire, pneumatic caster

$29.20

E1001

Wheel, single

$91.15

E1065

Power attachment (to convert any wheelchair to motorized wheelchair, e.g., Solo)

$2,691.70

E1066

Battery charger

$213.73

E1069

Deep cycle battery

$107.16

E1226

Full reclining back for customized wheelchair

$442.38

E1227

Special height arms for wheelchair

$264.69

E1230

Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number

$1,833.76

E1296

Special wheelchair seat height from floor

$438.01

E1297

Special wheelchair seat depth, by upholstery

$89.53

E1298

Special wheelchair seat depth and/or width, by construction

$404.09

E1310

Whirlpool, nonportable (built-in type)

$2,048.25

E1372

Immersion external heater for nebulizer

$138.21

E1375

Nebulizer portable with small compressor, with limited flow

$216.56

E1700

Jaw motion rehabilitation system

$328.92

E1701

Replacement cushions for jaw motion rehabilitation system, package of six

$10.12

E1702

Replacement measuring scales for jaw motion rehabilitation system, package of 200

$21.52

E1820

Soft interface material, dynamic adjustable extension/flexion device

$77.97

K0005

Ultralightweight wheelchair

$1,763.39

K0015

Detachable, nonadjustable height armrest, each

$173.31

K0016

Detachable, adjustable height armrest, complete assembly, each

$109.66

K0017

Detachable, adjustable height armrest, base, each

$48.75

K0018

Detachable, adjustable height armrest, upper portion, each

$27.23

K0019

Arm pad, each

$16.07

K0020

Fixed, adjustable height armrest, pair

$44.31

K0021

Antitipping device, each

$53.30

K0022

Reinforced back upholstery

$40.72

K0023

Solid back insert, planar back, single density foam, attached with straps

$88.05

K0024

Solid back insert, planar back, single density foam, with adjustable hook-on hardware

$104.22

K0025

Hook-on headrest extension

$66.80

K0026

Back upholstery for ultralightweight or high-strength lightweight wheelchair

$44.35

K0027

Back upholstery for wheelchair type other than ultralightweight or high-strength lightweight wheelchair

$44.35

K0028

Fully reclining back

$442.38

K0029

Reinforced seat upholstery

$40.33

K0030

Solid seat insert, planar seat, single density foam

$90.75

K0031

Safety belt/pelvic strap, each

$39.55

K0032

Seat upholstery for ultralightweight or high-strength lightweight wheelchair

$43.76

K0033

Seat upholstery for wheelchair type other than ultralightweight or high-strength lightweight wheelchair

$43.76

K0034

Heel loop, each

$16.81

K0035

Heel loop with ankle strap, each

$24.49

K0036

Toe loop, each

$17.97

K0037

High mount flip-up footrest, each

$39.05

K0038

Leg strap, each

$23.14

K0039

Leg strap, H style, each

$51.39

K0040

Adjustable angle footplate, each

$71.22

K0041

Large size footplate, each

$50.47

K0042

Standard size footplate, each

$29.53

K0043

Footrest, lower extension tube, each

$18.63

K0044

Footrest, upper hanger bracket, each

$15.87

K0045

Footrest, complete assembly

$54.00

K0046

Elevating legrest, lower extension tube, each

$18.63

K0047

Elevating legrest, upper hanger bracket, each

$72.95

K0048

Elevating legrest, complete assembly

$105.09

K0049

Calf pad, each

$27.51

K0050

Ratchet assembly

$31.00

K0051

Cam release assembly, footrest or legrest, each

$50.18

K0052

Swingaway, detachable footrests, each

$88.17

K0053

Elevating footrests, articulating (telescoping), each

$97.30

K0054

Seat width of 10, 11, 12, 15, 17, or 20 inches for a high-strength, lightweight or ultralightweight wheelchair

$99.81

K0055

Seat depth of 15, 17, or 18 inches for a high strength, lightweight or ultralightweight wheelchair

$90.71

K0056

Seat height less than 17 inches or equal to or greater than 21 inches for a high strength, lightweight, or ultralightweight wheelchair

$90.71

K0057

Seat width 19 or 20 inches for heavy duty or extra heavy-duty chair

$118.47

K0058

Seat depth 17 or 18 inches for a motorized/power wheelchair

$57.58

K0059

Plastic coated handrim, each

$30.25

K0060

Steel handrim, each

$26.47

K0061

Aluminum handrim, each

$37.55

K0062

Handrim with 8 to 10 vertical or oblique projections, each

$58.20

K0063

Handrim with 12 to 16 vertical or oblique projections, each

$77.70

K0064

Zero pressure tube (flat free insert), any size, each

$29.01

K0065

Spoke protectors, each

$42.41

K0066

Solid tire, any size, each

$27.20

K0067

Pneumatic tire, any size, each

$39.02

K0068

Pneumatic tire tube, each

$5.61

K0069

Rear wheel assembly, complete, with solid tire, spokes or molded, each

$95.30

K0070

Rear wheel assembly, complete with pneumatic tire, spokes or molded, each

$174.71

K0071

Front caster assembly, complete, with pneumatic tire, each

$104.20

K0072

Front caster assembly, complete, with semipneumatic tire, each

$62.72

K0073

Caster pin lock, each

$32.88

K0074

Pneumatic caster tire, any size, each

$29.20

K0075

Semipneumatic caster tire, any size, each

$39.91

K0076

Solid caster tire, any size, each

$24.37

K0077

Front caster assembly, complete, with solid tire, each

$56.13

K0078

Pneumatic caster tire tube, each

$9.16

K0079

Wheel lock extension, pair

$48.25

K0080

Antirollback device, pair

$127.13

K0081

Wheel lock assembly, complete, each

$38.80

K0082

22 NF deep cycle lead acid battery, each

$107.16

K0083

22 NF gel cell battery, each

$133.03

K0084

Group 24 deep cycle lead acid battery, each

$87.73

K0085

Group 24 gel cell battery, each

$177.42

K0086

U-1 lead acid battery, each

$107.16

K0087

U-1 gel cell battery, each

$106.99

K0088

Battery charger, lead acid or gel cell

$213.73

K0089

Battery charger, dual mode

$399.73

K0090

Rear wheel tire for power wheelchair, any size, each

$72.66

K0091

Rear wheel tire tube other than zero pressure for power wheelchair, any size, each

$19.81

K0092

Rear wheel assembly for power wheelchair, complete, each

$231.90

K0093

Rear wheel zero pressure tire tube (flat free insert) for power wheelchair, any size, each

$144.87

K0094

Wheel tire for power base, any size, each

$47.21

K0095

Wheel tire tube other than zero pressure for each base, any size, each

$47.21

K0096

Wheel assembly for power base, complete, each

$261.63

K0097

Wheel zero-pressure tire tube (flat free insert) for power base, any size, each

$59.58

K0098

Drive belt for power wheelchair

$25.95

K0099

Front caster for power wheelchair

$77.17

K0100

Wheelchair adapter for amputee, pair

$81.51

K0102

Crutch and cane holder, each

$41.35

K0103

Transfer board, less than 25 inches

$52.57

K0104

Cylinder tank carrier, each

$113.30

K0105

IV hanger, each

$94.84

K0106

Arm trough, each

$102.21

K0107

Wheelchair tray

$99.15

K0112

Trunk support device, vest type, with inner frame, prefabricated

$227.46

K0113

Trunk support device, vest type, without inner frame, prefabricated

$138.74

K0114

Back support system for use with a wheelchair, with inner frame, prefabricated

$723.19

K0115

Seating system, back module, posterior-lateral control, with or without lateral supports, custom fabricated for attachment to wheelchair base

$829.24

K0116

Seating system, combined back and seat module, custom fabricated for attachment to wheelchair base

$1,730.82

K0182

Water, distilled, used with large volume nebulizer, 1000 ml

$0.31

K0183

Nasal application device used with positive airway pressure device

$75.21

K0184

Nasal pillows/seals, replacement for nasal application device, pair

$22.82

K0185

Headgear used with positive airway pressure device

$34.11

K0186

Chin strap used with positive airway pressure device

$14.76

K0187

Tubing used with positive airway pressure device

$37.66

K0188

Filter, disposable, used with positive airway pressure device

$5.05

K0189

Filter, nondisposable, used with positive airway pressure device

$12.43

K0268

Humidifier, nonheated, used with positive airway pressure device

$102.26

K0270

Ultrasonic generator with small volume ultrasonic nebulizer

$38.40

K0280

Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each

$3.04

K0281

Lubricant, individual sterile packet, for insertion of urinary catheter, each

$0.12

K0283

Saline solution, per 10 ml, metered dose dispenser, for use with inhalation drugs

$0.33

K0407

Urinary catheter anchoring device, adhesive skin attachment

$2.10

K0408

Urinary catheter anchoring device, leg strap

$4.71

K0409

Sterile water irrigation solution, 1000 ml

$6.04

K0410

Male external catheter, with adhesive coating, each

$2.07

K0411

Male external catheter, with adhesive strip, each

$1.72

K0452

Wheelchair bearings, any type

$6.25

K0529

Sterile water or sterile saline, 1,000 ml, used with large volume nebulizer

$2.62

L0100

Cervical, craniostenosis, helmet molded to patient model

$432.50

L0110

Cervical, craniostenosis, helmet, nonmolded

$127.60

L0120

Cervical, flexible, nonadjustable (foam collar)

$21.39

L0130

Cervical, flexible, thermoplastic collar, molded to patient

$154.64

L0140

Cervical, semi-rigid, adjustable (plastic collar)

$53.37

L0150

Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)

$88.99

L0160

Cervical, semi-rigid, wire frame occipital/mandibular support

$126.69

L0170

Cervical, collar, molded to patient model

$536.13

L0172

Cervical, collar, semi-rigid thermoplastic foam, two piece

$108.71

L0174

Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension

$195.29

L0180

Cervical, multiple post collar, occipital/mandibular supports, adjustable

$265.60

L0190

Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types)

$399.80

L0200

Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension

$367.11

L0210

Thoracic, rib belt

$38.10

L0220

Thoracic, rib belt, custom fabricated

$87.07

L0300

TLSO, flexible (dorso-lumbar surgical support)

$143.73

L0310

TLSO, flexible (dorso-lumbar surgical support), custom fabricated

$268.59

L0315

TLSO, flexible (dorso-lumbar surgical support), elastic type, with rigid posterior panel

$186.94

L0317

TLSO, flexible (dorso-lumbar surgical support), hyperextension, elastic type, with rigid posterior panel

$253.61

L0320

TLSO, anterior-posterior control (Taylor type), with apron front

$292.17

L0330

TLSO, anterior-posterior-lateral control (Knight-Taylor type), with apron front

$366.31

L0340

TLSO, anterior-posterior-lateral-rotary control (Arnold, Magnuson, Steindler types), with apron front

$583.64

L0350

TLSO, anterior-posterior-lateral-rotary control, flexion compression jacket, custom fitted

$812.84

L0360

TLSO, anterior-posterior-lateral-rotary control, flexion compression jacket molded to patient model

$1,199.38

L0370

TLSO, anterior-posterior-lateral-rotary control, hyperextension (Jewett, Lennox, Baker, Cash types)

$327.36

L0380

TLSO, anterior-posterior-lateral-rotary control, with extensions

$459.42

L0390

TLSO, anterior-posterior-lateral control molded to patient model

$1,012.27

L0400

TLSO, anterior-posterior-lateral control molded to patient model, with interface material

$1,160.42

L0410

TLSO, anterior-posterior-lateral control, two-piece construction, molded to patient model

$1,353.03

L0420

TLSO, anterior-posterior-lateral control, two-piece construction, molded to patient model, with interface material

$1,340.34

L0430

TLSO, anterior-posterior-lateral control, with interface material, custom fitted

$1,063.26

L0440

TLSO, anterior-posterior-lateral control, with overlapping front section, spring steel front, custom fitted

$867.14

L0500

LSO, flexible (lumbo-sacral surgical support)

$107.14

L0510

LSO, flexible (lumbo-sacral surgical support), custom fabricated

$218.10

L0515

LSO, flexible (lumbo-sacral surgical support) elastic type, with rigid posterior panel

$130.10

L0520

LSO, anterior-posterior-lateral control (Knight, Wilcox types), with apron front

$319.98

L0530

LSO, anterior-posterior control (Macausland type), with apron front

$294.51

L0540

LSO, lumbar flexion (Williams flexion type)

$317.83

L0550

LSO, anterior-posterior-lateral control, molded to patient model

$953.75

L0560

LSO, anterior-posterior-lateral control, molded to patient model, with interface material

$1,043.57

L0565

LSO, anterior-posterior-lateral control, custom fitted

$1,040.64

L0600

Sacroiliac, flexible (sacroiliac surgical support)

$68.15

L0610

Sacroiliac, flexible (sacroiliac surgical support), custom fabricated

$184.81

L0620

Sacroiliac, semi-rigid (Goldthwaite, Osgood types), with apron front

$308.16

L0700

CTLSO, anterior-posterior-lateral control, molded to patient model (Minerva type)

$1,645.77

L0710

CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type)

$1,796.47

L0810

Halo procedure, cervical halo incorporated into jacket vest

$1,908.48

L0820

Halo procedure, cervical halo incorporated into plaster body jacket

$1,543.00

L0830

Halo procedure, cervical halo incorporated into Milwaukee type orthosis

$2,229.20

L0860

Addition to halo procedure, magnetic resonance image compatible system

$866.03

L0900

Torso support, ptosis support

$141.86

L0910

Torso support, ptosis support, custom fabricated

$283.37

L0920

Torso support, pendulous abdomen support

$160.87

L0930

Torso support, pendulous abdomen support, custom fabricated

$329.41

L0940

Torso support, postsurgical support

$113.65

L0950

Torso support, postsurgical support, custom fabricated

$291.65

L0960

Torso support, postsurgical support, pads for postsurgical support

$65.48

L0970

TLSO, corset front

$81.25

L0972

LSO, corset front

$83.05

L0974

TLSO, full corset

$169.70

L0976

LSO, full corset

$151.56

L0978

Axillary crutch extension

$136.84

L0980

Peroneal straps, pair

$12.41

L0982

Stocking supporter grips, set of four (4)

$13.52

L0984

Protective body sock, each

$43.15

L1000

CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model

$1,443.28

L1010

Addition to CTLSO or scoliosis orthosis, axilla sling

$58.12

L1020

Addition to CTLSO or scoliosis orthosis, kyphosis pad

$79.41

L1025

Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating

$90.25

L1030

Addition to CTLSO or scoliosis orthosis, lumbar bolster pad

$60.30

L1040

Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad

$72.58

L1050

Addition to CTLSO or scoliosis orthosis, sternal pad

$62.85

L1060

Addition to CTLSO or scoliosis orthosis, thoracic pad

$70.88

L1070

Addition to CTLSO or scoliosis orthosis, trapezius sling

$72.47

L1080

Addition to CTLSO or scoliosis orthosis, outrigger

$50.21

L1085

Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions

$139.50

L1090

Addition to CTLSO or scoliosis orthosis, lumbar sling

$65.17

L1100

Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather

$115.03

L1110

Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model

$194.84

L1120

Addition to CTLSO, scoliosis orthosis, cover for upright, each

$31.04

L1200

TLSO, inclusive of furnishing initial orthosis only

$1,235.45

L1210

Addition to TLSO, (low profile), lateral thoracic extension

$186.01

L1220

Addition to TLSO, (low profile), anterior thoracic extension

$157.49

L1230

Addition to TLSO, (low profile), Milwaukee type superstructure

$404.11

L1240

Addition to TLSO, (low profile), lumbar derotation pad

$69.55

L1250

Addition to TLSO, (low profile), anterior ASIS pad

$68.48

L1260

Addition to TLSO, (low profile), anterior thoracic derotation pad

$70.37

L1270

Addition to TLSO, (low profile), abdominal pad

$70.27

L1280

Addition to TLSO, (low profile), rib gusset (elastic), each

$62.65

L1290

Addition to TLSO, (low profile), lateral trochanteric pad

$71.03

L1300

Other scoliosis procedure, body jacket molded to patient model

$1,187.49

L1310

Other scoliosis procedure, postoperative body jacket

$1,221.94

L1500

THKAO, mobility frame (Newington, Parapodium types)

$1,350.32

L1510

THKAO, standing frame

$854.27

L1520

THKAO, swivel walker

$2,029.03

L1600

HO, abduction control of hip joints, flexible, Frejka type with cover

$91.61

L1610

HO, abduction control of hip joints, flexible, (Frejka cover only)

$31.21

L1620

HO, abduction control of hip joints, flexible, (Pavlik harness)

$102.78

L1630

HO, abduction control of hip joints, semi-flexible (Von Rosen type)

$122.64

L1640

HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs

$328.03

L1650

HO, abduction control of hip joints, static, adjustable (Ilfled type)

$173.95

L1660

HO, abduction control of hip joints, static, plastic

$121.66

L1680

HO, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type)

$1,000.22

L1685

HO, abduction control of hip joint, postoperative hip abduction type, custom fabricated

$1,055.40

L1686

HO, abduction control of hip joint, postoperative hip abduction type

$708.03

L1700

Legg Perthes orthosis, (Toronto type)

$1,229.74

L1710

Legg Perthes orthosis, (Newington type)

$1,445.49

L1720

Legg Perthes orthosis, trilateral, (Tachdijan type)

$1,067.78

L1730

Legg Perthes orthosis, (Scottish Rite type)

$805.63

L1750

Legg Perthes orthosis, Legg Perthes sling (Sam Brown type)

$139.86

L1755

Legg Perthes orthosis, (Patten bottom type)

$1,172.58

L1800

KO, elastic with stays

$63.05

L1810

KO, elastic with joints

$92.55

L1815

KO, elastic or other elastic type material with condylar pad(s)

$84.81

L1820

KO, elastic with condylar pads and joints

$92.17

L1825

KO, elastic knee cap

$41.09

L1830

KO, immobilizer, canvas longitudinal

$77.11

L1832

KO, adjustable knee joints, positional orthosis, rigid support

$576.27

L1834

KO, without knee joint, rigid, molded to patient model

$677.96

L1840

KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated to patient model

$712.65

L1843

KO, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, custom fitted

$685.87

L1844

KO, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, molded to patient model

$1,188.46

L1845

KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, custom fitted

$715.99

L1846

KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, molded to patient model

$897.37

L1850

KO, Swedish type

$204.62

L1855

KO, molded plastic, thigh and calf sections, with double upright knee joints, molded to patient model

$875.60

L1858

KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI)

$962.30

L1860

KO, modification of supracondylar prosthetic socket, molded to patient model (SK)

$793.65

L1870

KO, double upright, thigh and calf lacers, molded to patient model with knee joints

$815.64

L1880

KO, double upright, nonmolded thigh and calf cuffs/lacers with knee joints

$503.17

L1885

KO, single or double upright, thigh and calf, with funtional active resistance control

$790.99

L1900

AFO, spring wire, dorsiflexion assist calf band

$215.00

L1902

AFO, ankle gauntlet

$58.39

L1904

AFO, molded ankle gauntlet, molded to patient model

$334.30

L1906

AFO, multiligamentus ankle support

$97.69

L1910

AFO, posterior, single bar, clasp attachment to shoe counter

$190.11

L1920

AFO, single upright with static or adjustable stop (Phelps or Perlstein type)

$248.52

L1930

AFO, plastic

$168.17

L1940

AFO, molded to patient model, plastic

$380.05

L1945

AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction)

$697.92

L1950

AFO, spiral, molded to patient model (IRM type), plastic

$529.50

L1960

AFO, posterior solid ankle, molded to patient model, plastic

$394.04

L1970

AFO, plastic molded to patient model, with ankle joint

$582.81

L1980

AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'BK' orthosis)

$260.90

L1990

AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'BK' orthosis)

$335.22

L2000

KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'AK' orthosis)

$721.05

L2010

KAFO, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'AK' orthosis), without knee joint

$657.30

L2020

KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'AK' orthosis)

$830.07

L2030

KAFO, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'AK' orthosis), without knee joint

$720.16

L2035

KAFO, full plastic, static, prefabricated (pediatric size)

$132.42

L2036

KAFO, full plastic, double upright, free knee, molded to patient model

$1,318.93

L2037

KAFO, full plastic, single upright, free knee, molded to patient model

$1,215.49

L2038

KAFO, full plastic, without knee joint, multiaxis ankle, molded to patient model (Lively orthosis or equal)

$1,016.00

L2039

KAFO, full plastic, single upright, poly-axial hinge, medial lateral rotation control, molded to patient model

$1,698.79

L2040

HKAFO, torsion control, bilateral rotation straps, pelvic band/belt

$129.82

L2050

HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt

$345.75

L2060

HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt

$443.75

L2070

HKAFO, torsion control, unilateral rotation straps, pelvic band/belt

$127.47

L2080

HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt

$271.83

L2090

HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt

$335.08

L2102

AFO, fracture orthosis, tibial fracture cast orthosis, plaster type casting material, molded to patient

$330.71

L2104

AFO, fracture orthosis, tibial fracture cast orthosis, synthetic type casting material, molded to patient

$350.88

L2106

AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, molded to patient

$483.35

L2108

AFO, fracture orthosis, tibial fracture cast orthosis, molded to patient model

$759.56

L2112

AFO, fracture orthosis, tibial fracture orthosis, soft

$360.65

L2114

AFO, fracture orthosis, tibial fracture orthosis, semi-rigid

$412.63

L2116

AFO, fracture orthosis, tibial fracture orthosis, rigid

$543.65

L2122

KAFO, fracture orthosis, femoral fracture cast orthosis, plaster type casting material, molded to patient

$583.04

L2124

KAFO, fracture orthosis, femoral fracture cast orthosis, synthetic type casting material, molded to patient

$723.81

L2126

KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, molded to patient

$967.28

L2128

KAFO, fracture orthosis, femoral fracture cast orthosis, molded to patient model

$1,218.99

L2132

KAFO, fracture orthosis, femoral fracture cast orthosis, soft

$573.46

L2134

KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid

$687.56

L2136

KAFO, fracture orthosis, femoral fracture cast orthosis, rigid

$840.70

L2180

Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints

$83.25

L2182

Addition to lower extremity fracture orthosis, drop lock knee joint

$65.16

L2184

Addition to lower extremity fracture orthosis, limited motion knee joint

$117.42

L2186

Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type

$130.11

L2188

Addition to lower extremity fracture orthosis, quadrilateral brim

$283.88

L2190

Addition to lower extremity fracture orthosis, waist belt

$73.73

L2192

Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt

$253.48

L2200

Addition to lower extremity, limited ankle motion, each joint

$33.80

L2210

Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

$54.85

L2220

Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint

$62.97

L2230

Addition to lower extremity, split flat caliper stirrups and plate attachment

$54.55

L2240

Addition to lower extremity, round caliper and plate attachment

$59.45

L2250

Addition to lower extremity, foot plate, molded to patient model, stirrup attachment

$252.60

L2260

Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)

$142.51

L2265

Addition to lower extremity, long tongue stirrup

$83.72

L2270

Addition to lower extremity, varus/valgus correction ('T') strap, padded/lined or malleolus pad

$38.18

L2275

Addition to lower extremity, varus/vulgus correction, plastic modification, padded/lined

$92.89

L2280

Addition to lower extremity, molded inner boot

$345.10

L2300

Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable

$194.80

L2310

Addition to lower extremity, abduction bar, straight

$87.46

L2320

Addition to lower extremity, nonmolded lacer

$146.26

L2330

Addition to lower extremity, lacer molded to patient model

$279.14

L2335

Addition to lower extremity, anterior swing band

$164.21

L2340

Addition to lower extremity, pretibial shell, molded to patient model

$387.50

L2350

Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for 'PTB,' 'AFO' orthoses)

$633.44

L2360

Addition to lower extremity, extended steel shank

$36.78

L2370

Addition to lower extremity, Patten bottom

$182.49

L2375

Addition to lower extremity, torsion control, ankle joint and half solid stirrup

$80.32

L2380

Addition to lower extremity, torsion control, straight knee joint, each joint

$87.52

L2385

Addition to lower extremity, straight knee joint, heavy duty, each joint

$95.22

L2390

Addition to lower extremity, offset knee joint, each joint

$77.82

L2395

Addition to lower extremity, offset knee joint, heavy duty, each joint

$118.81

L2397

Addition to lower extremity orthosis, suspension sleeve

$83.33

L2405

Addition to knee joint, drop lock, each joint

$37.94

L2415

Addition to knee joint, cam lock (Swiss, French, bail types) each joint

$174.07

L2425

Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint

$129.44

L2430

Addition to knee joint, ratchet lock for active and progressive knee extension, each joint

$75.15

L2435

Addition to knee joint, polycentric joint, each joint

$129.23

L2492

Addition to knee joint, lift loop for drop lock ring

$72.49

L2500

Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring

$224.27

L2510

Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model

$600.45

L2520

Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted

$327.49

L2525

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model

$1,123.75

L2526

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted

$605.60

L2530

Addition to lower extremity, thigh/weight bearing, lacer, nonmolded

$167.03

L2540

Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model

$300.55

L2550

Addition to lower extremity, thigh/weight bearing, high roll cuff

$204.17

L2570

Addition to lower extremity, pelvic control, hip joint, Clevis type, two position joint, each

$451.47

L2580

Addition to lower extremity, pelvic control, pelvic sling

$427.97

L2600

Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free, each

$146.00

L2610

Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each

$172.64

L2620

Addition to lower extremity, pelvic control, hip joint, heavy-duty, each

$190.08

L2622

Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each

$218.00

L2624

Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each

$296.37

L2627

Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables

$1,221.00

L2628

Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables

$1,434.31

L2630

Addition to lower extremity, pelvic control, band and belt, unilateral

$176.03

L2640

Addition to lower extremity, pelvic control, band and belt, bilateral

$238.90

L2650

Addition to lower extremity, pelvic and thoracic control, gluteal pad, each

$85.31

L2660

Addition to lower extremity, thoracic control, thoracic band

$132.49

L2670

Addition to lower extremity, thoracic control, paraspinal uprights

$121.26

L2680

Addition to lower extremity, thoracic control, lateral support uprights

$111.25

L2750

Addition to lower extremity orthosis, plating chrome or nickel, per bar

$59.42

L2755

Addition to lower extremity orthosis, carbon graphite lamination

$99.89

L2760

Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth)

$43.19

L2770

Addition to lower extremity orthosis, any material, per bar or joint

$43.89

L2780

Addition to lower extremity orthosis, noncorrosive finish, per bar

$51.09

L2785

Addition to lower extremity orthosis, drop lock retainer, each

$30.04

L2795

Addition to lower extremity orthosis, knee control, full kneecap

$60.40

L2800

Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull

$75.83

L2810

Addition to lower extremity orthosis, knee control, condylar pad

$55.52

L2820

Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

$61.73

L2830

Addition to lower extremity orthosis, soft interface for molded plastic, above knee section

$69.42

L2840

Addition to lower extremity orthosis, tibial length sock, fracture or equal, each

$38.74

L2850

Addition to lower extremity orthosis, femoral length sock, fracture or equal, each

$44.02

L3224

Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis)

$41.80

L3225

Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis)

$48.09

L3650

SO, figure of eight design abduction restrainer

$41.64

L3660

SO, figure of eight design abduction restrainer, canvas and webbing

$71.50

L3670

SO, acromio/clavicular (canvas and webbing type)

$99.66

L3700

EO, elastic with stays

$48.56

L3710

EO, elastic with metal joints

$100.86

L3720

EO, double upright with forearm/arm cuffs, free motion

$503.20

L3730

EO, double upright with forearm/arm cuffs, extension/flexion assist

$662.42

L3740

EO, double upright with forearm/arm cuffs, adjustable position lock with active control

$744.44

L3800

WHFO, short opponens, no attachment

$139.10

L3805

WHFO, long opponens, no attachment

$222.56

L3810

WHFO, addition to short and long opponens, thumb abduction ('C') bar

$45.08

L3815

WHFO, addition to short and long opponens, second M.P. abduction assist

$41.85

L3820

WHFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop

$71.89

L3825

WHFO, addition to short and long opponens, M.P. extension stop

$51.04

L3830

WHFO, addition to short and long opponens, M.P. extension assist

$58.89

L3835

WHFO, addition to short and long opponens, M.P. spring extension assist

$63.85

L3840

WHFO, addition to short and long opponens, spring swivel thumb

$43.73

L3845

WHFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop

$56.47

L3850

WHO, addition to short and long opponens, action wrist, with dorsiflexion assist

$80.67

L3855

WHFO, addition to short and long opponens, adjustable M.P. flexion control

$87.18

L3860

WHFO, addition to short and long opponens, adjustable M.P. flexion control and I.P.

$118.53

L3900

WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven

$1,086.76

L3901

WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven

$1,218.54

L3902

WHFO, external powered, compressed gas

$1,875.21

L3904

WHFO, external powered, electric

$2,480.63

L3906

WHO, wrist gauntlet, molded to patient model

$293.48

L3907

WHFO, wrist gauntlet with thumb spica, molded to patient model

$394.95

L3908

WHO, wrist extension control cock-up, nonmolded

$41.68

L3910

WHFO, Swanson design

$307.92

L3912

HFO, flexion glove with elastic finger control

$66.88

L3914

WHO, wrist extension cock-up

$67.34

L3916

WHFO, wrist extension cock-up, with outrigger

$88.35

L3918

HFO, knuckle bender

$59.74

L3920

HFO, knuckle bender, with outrigger

$71.23

L3922

HFO, knuckle bender, two segment to flex joints

$81.71

L3924

WHFO, Oppenheimer

$87.33

L3926

WHFO, Thomas suspension

71.81

L3928

HFO, finger extension, with clock spring

$42.41

L3930

WHFO, finger extension, with wrist support

$43.80

L3932

FO, safety pin, spring wire

$37.98

L3934

FO, safety pin, modified

$33.52

L3936

WHFO, Palmer

$61.97

L3938

WHFO, dorsal wrist

$65.18

L3940

WHFO, dorsal wrist, with outrigger attachment

$74.78

L3942

HFO, reverse knuckle bender

$51.72

L3944

HFO, reverse knuckle bender, with outrigger

$85.18

L3946

HFO, composite elastic

$69.90

L3948

FO, finger knuckle bender

$46.80

L3950

WHFO, combination Oppenheimer, with knuckle bender and two attachments

$110.20

L3952

WHFO, combination Oppenheimer, with reverse knuckle and two attachments

$122.13

L3954

HFO, spreading hand

$76.82

L3960

SEWHO, abduction positioning, airplane design

$573.42

L3962

SEWHO, abduction positioning, Erbs palsey design

$597.07

L3963

SEWHO, molded shoulder, arm, forearm, and wrist, with articulating elbow joint

$1,510.43

L3964

SEO, mobile arm support attached to wheelchair, balanced, adjustable

$592.43

L3965

SEO, mobile arm support attached to wheelchair, balanced, adjustable Rancho type

$945.35

L3966

SEO, mobile arm support attached to wheelchair, balanced, reclining

$706.83

L3968

SEO, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)

$901.23

L3969

SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support

$535.70

L3970

SEO, addition to mobile arm support, elevating proximal arm

$252.10

L3972

SEO, addition to mobile arm support, offset or lateral rocker arm with elastic balance control

$152.48

L3974

SEO, addition to mobile arm support, supinator

$115.57

L3980

Upper extremity fracture orthosis, humeral

$215.06

L3982

Upper extremity fracture orthosis, radius/ulnar

$265.70

L3984

Upper extremity fracture orthosis, wrist

$283.62

L3985

Upper extremity fracture orthosis, forearm, hand with wrist hinge

$420.91

L3986

Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist (example: Colles' fracture)

$486.79

L3995

Addition to upper extremity orthosis, sock, fracture or equal, each

$23.81

L4000

Replace girdle for Milwaukee orthosis

$927.39

L4010

Replace trilateral socket brim

$521.88

L4020

Replace quadrilateral socket brim, molded to patient model

$651.87

L4030

Replace quadrilateral socket brim, custom fitted

$358.92

L4040

Replace molded thigh lacer

$290.18

L4045

Replace nonmolded thigh lacer

$233.19

L4050

Replace molded calf lacer

$293.49

L4055

Replace nonmolded calf lacer

$190.04

L4060

Replace high roll cuff

$225.92

L4070

Replace proximal and distal upright for KAFO

$215.55

L4080

Replace metal bands KAFO, proximal thigh

$75.98

L4090

Replace metal bands KAFO-AFO, calf or distal thigh

$67.26

L4100

Replace leather cuff KAFO, proximal thigh

$75.86

L4110

Replace leather cuff KAFO-AFO, calf or distal thigh

$60.29

L4130

Replace pretibial shell

$414.92

L4350

Pneumatic ankle control splint (e.g., aircast)

$74.75

L4360

Pneumatic walking splint (e.g., aircast)

$209.13

L4370

Pneumatic full leg splint (e.g., aircast)

$134.20

L4380

Pneumatic knee splint (e.g., aircast)

$82.29

L4392

Replace soft interface material, static AFO

$17.99

L4394

Replace soft interface material, foot drop splint

$13.13

L4396

Static AFO for positioning, pressure reduction, may be used for minimal ambulation

$128.29

L4398

Foot drop splint, recumbent positioning device

$59.04

L5000

Partial foot, shoe insert with longitudinal arch, toe filler

$400.81

L5010

Partial foot, molded socket, ankle height, with toe filler

$968.04

L5020

Partial foot, molded socket, tibial tubercle height, with toe filler

$1,643.99

L5050

Ankle, Symes, molded socket, SACH foot

$1,818.55

L5060

Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot

$2,091.85

L5100

Below knee, molded socket, shin, SACH foot

$1,822.56

L5150

Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot

$2,659.64

L5160

Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot

$2,892.83

L5200

Above knee, molded socket, single axis constant friction knee, shin, SACH foot

$2,770.29

L5210

Above knee, short prosthesis, no knee joint ('stubbies'), with foot blocks, no ankle joints, each

$1,837.81

L5220

Above knee, short prosthesis, no knee joint ('stubbies'), with articulated ankle/foot, dynamically aligned, each

$2,089.00

L5230

Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot

$2,881.15

L5250

Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot

$3,929.63

L5270

Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot

$3,912.20

L5280

Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot

$3,882.23

L5300

Below knee, molded socket, SACH foot, endoskeletal system, including soft cover and finishing

$2,489.26

L5310

Knee disarticulation (or through knee), molded socket, SACH foot endoskeletal system, including soft cover and finishing

$3,693.16

L5320

Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee, including soft cover and finishing

$3,745.15

L5330

Hip disarticulation, Canadian type; molded socket, endo-skeletal system, hip joint, single axis knee, SACH foot, including soft cover and finishing

$4,785.26

L5340

Hemipelvectomy, Canadian type; molded socket, endoskeletal system, hip joint, single axis knee, SACH foot, including soft cover and finishing

$4,943.05

L5400

Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee

$1,031.41

L5410

Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment

$316.44

L5420

Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change 'AK' or knee disarticulation

$1,263.96

L5430

Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, 'AK' or knee disarticulation, each additional cast change and realignment

$381.12

L5450

Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee

$310.05

L5460

Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, above knee

$413.08

L5500

Initial, below knee 'PTB' type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, direct formed

$972.71

L5505

Initial, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot plaster socket, direct formed

$1,345.28

L5510

Preparatory, below knee 'PTB' type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model

$1,102.63

L5520

Preparatory, below knee 'PTB' type socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed

$1,089.13

L5530

Preparatory, below knee 'PTB' type socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model

$1,308.51

L5535

Preparatory, below knee 'PTB' type socket, non-alignable system, pylon, no cover, SACH foot, prefabricated, adjustable open end socket

$1,284.35

L5540

Preparatory, below knee 'PTB' type socket, non-alignable system, pylon, no cover, SACH foot, laminated socket, molded to model

$1,370.81

L5560

Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model

$1,472.00

L5570

Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed

$1,530.37

L5580

Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model

$1,786.59

L5585

Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket

$2,198.70

L5590

Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, laminated socket, molded to model

$1,820.66

L5595

Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model

$3,216.45

L5600

Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model

$3,457.53

L5610

Addition to lower extremity, endoskeletal system, above knee, hydracadence system

$1,568.04

L5611

Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with friction swing phase control

$1,220.25

L5613

Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with hydraulic swing phase control

$1,907.81

L5614

Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with pneumatic swing phase control

$1,292.41

L5616

Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control

$1,030.97

L5617

Addition to lower extremity, quick change self-aligning unit, above or below knee, each

$428.52

L5618

Addition to lower extremity, test socket, Symes

$226.70

L5620

Addition to lower extremity, test socket, below knee

$210.56

L5622

Addition to lower extremity, test socket, knee disarticulation

$274.57

L5624

Addition to lower extremity, test socket, above knee

$275.35

L5626

Addition to lower extremity, test socket, hip disarticulation

$361.10

L5628

Addition to lower extremity, test socket, hemipelvectomy

$386.11

L5629

Addition to lower extremity, below knee, acrylic socket

$240.69

L5630

Addition to lower extremity, Symes type, expandable wall socket

$339.90

L5631

Addition to lower extremity, above knee or knee disarticulation, acrylic socket

$332.77

L5632

Addition to lower extremity, Symes type, 'PTB' brim design socket

$185.72

L5634

Addition to lower extremity, Symes type, posterior opening (Canadian) socket

$230.38

L5636

Addition to lower extremity, Symes type, medial opening socket

$192.98

L5637

Addition to lower extremity, below knee, total contact

$218.80

L5638

Addition to lower extremity, below knee, leather socket

$381.14

L5639

Addition to lower extremity, below knee, wood socket

$849.14

L5640

Addition to lower extremity, knee disarticulation, leather socket

$484.29

L5642

Addition to lower extremity, above knee, leather socket

$469.24

L5643

Addition to lower extremity, hip disarticulation, flexible inner socket, external frame

$1,178.80

L5644

Addition to lower extremity, above knee, wood socket

$447.33

L5645

Addition to lower extremity, below knee, flexible inner socket, external frame

$604.29

L5646

Addition to lower extremity, below knee, air cushion socket

$414.97

L5647

Addition to lower extremity, below knee, suction socket

$602.45

L5648

Addition to lower extremity, above knee, air cushion socket

$498.63

L5649

Addition to lower extremity, ischial containment/narrow M-L socket

$1,806.81

L5650

Addition to lower extremity, total contact, above knee or knee disarticulation socket

$369.73

L5651

Addition to lower extremity, above knee, flexible inner socket, external frame

$909.53

L5652

Addition to lower extremity, suction suspension, above knee or knee disarticulation socket

$330.20

L5653

Addition to lower extremity, knee disarticulation, expandable wall socket

$440.78

L5654

Addition to lower extremity, socket insert, Symes (Kemblo, Pelite, Aliplast, Plastazote or equal)

$251.17

L5655

Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal)

$212.85

L5656

Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal)

$285.55

L5658

Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal)

$275.38

L5660

Addition to lower extremity, socket insert, Symes, silicone gel or equal

$460.92

L5661

Addition to lower extremity, socket insert, multidurometer, Symes

$460.89

L5662

Addition to lower extremity, socket insert, below knee, silicone gel or equal

$428.44

L5663

Addition to lower extremity, socket insert, knee disarticulation, silicone gel or equal

$521.89

L5664

Addition to lower extremity, socket insert, above knee, silicone gel or equal

$502.81

L5665

Addition to lower extremity, socket insert, multidurometer, below knee

$387.79

L5666

Addition to lower extremity, below knee, cuff suspension

$53.02

L5667

Addition to lower extremity, below knee/above knee, socket insert, suction suspension with locking mechanism

$1,268.02

L5668

Addition to lower extremity, below knee, molded distal cushion

$85.51

L5669

Addition to lower extremity, below knee/above knee, socket insert, suction suspension without locking mechanism

$845.55

L5670

Addition to lower extremity, below knee, molded supracondylar suspension ('PTS' or similar)

$205.51

L5672

Addition to lower extremity, below knee, removable medial brim suspension

$225.84

L5674

Addition to lower extremity, below knee, latex sleeve suspension or equal, each

$50.02

L5675

Addition to lower extremity, below knee, latex sleeve suspension or equal, heavy duty, each

$72.55

L5676

Addition to lower extremity, below knee, knee joints, single axis, pair

$274.45

L5677

Addition to lower extremity, below knee, knee joints, polycentric, pair

$373.42

L5678

Addition to lower extremity, below knee joint covers, pair

$30.07

L5680

Addition to lower extremity, below knee, thigh lacer, nonmolded

$251.02

L5682

Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded

$473.65

L5684

Addition to lower extremity, below knee, fork strap

$36.45

L5686

Addition to lower extremity, below knee, back check (extension control)

$38.69

L5688

Addition to lower extremity, below knee, waist belt, webbing

$46.26

L5690

Addition to lower extremity, below knee, waist belt, padded and lined

$74.11

L5692

Addition to lower extremity, above knee, pelvic control belt, light

$100.64

L5694

Addition to lower extremity, above knee, pelvic control belt, padded and lined

$137.40

L5695

Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each

$126.84

L5696

Addition to lower extremity, above knee or knee disarticulation, pelvic joint

$140.13

L5697

Addition to lower extremity, above knee or knee disarticulation, pelvic band

$60.80

L5698

Addition to lower extremity, above knee or knee disarticulation, Silesian bandage

$99.42

L5699

All lower extremity prostheses, shoulder harness

$179.10

L5700

Replacement, socket, below knee, molded to patient model

$2,170.00

L5701

Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model

$2,606.01

L5702

Replacement, socket, hip disarticulation, including hip joint, molded to patient model

$3,296.99

L5704

Replacement, custom shaped protective cover, below knee

$405.95

L5705

Replacement, custom shaped protective cover, above knee

$725.36

L5706

Replacement, custom shaped protective cover, knee disarticulation

$711.03

L5707

Replacement, custom shaped protective cover, hip disarticulation

$937.43

L5710

Addition, exoskeletal knee-shin system, single axis, manual lock

$283.24

L5711

Addition, exoskeletal knee-shin system, single axis, manual lock, ultra-light material

$395.86

L5712

Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)

$331.71

L5714

Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control

$340.71

L5716

Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock

$552.00

L5718

Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control

$689.94

L5722

Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control

$728.89

L5724

Addition, exoskeletal knee-shin system, single axis, fluid swing phase control

$1,143.18

L5726

Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control

$1,317.49

L5728

Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control

$1,802.15

L5780

Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control

$867.11

L5785

Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)

$487.43

L5790

Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)

$544.57

L5795

Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)

$1,084.24

L5810

Addition, endoskeletal knee-shin system, single axis, manual lock

$368.73

L5811

Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material

$552.36

L5812

Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)

$428.13

L5814

Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock

$2,844.44

L5816

Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock

$647.97

L5818

Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase control

$727.32

L5822

Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control

$1,289.72

L5824

Addition, endoskeletal knee-shin system, single axis, fluid swing phase control

$1,161.47

L5826

Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame

$2,391.80

L5828

Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control

$2,138.75

L5830

Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control

$1,437.13

L5840

Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control

$2,657.25

L5845

Addition, endoskeletal knee-shin system, stance flexion feature, adjustable

$1,372.76

L5846

Addition, endoskeletal knee-shin system, microprocessor control feature, swing phase only

$4,151.65

L5850

Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist

$96.89

L5855

Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist

$260.35

L5910

Addition, endoskeletal system, below knee, alignable system

$274.30

L5920

Addition, endoskeletal system, above knee or hip disarticulation, alignable system

$401.85

L5925

Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock

$339.31

L5930

Addition, endoskeletal system, high activity knee control frame

$2,577.91

L5940

Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)

$379.90

L5950

Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)

$594.01

L5960

Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)

$730.13

L5962

Addition, endoskeletal system, below knee, flexible protective outer surface covering system

$480.50

L5964

Addition, endoskeletal system, above knee, flexible protective outer surface covering system

$709.29

L5966

Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system

$903.81

L5970

All lower extremity prostheses, foot, external keel, SACH foot

$153.82

L5972

All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock Dynamic or equal)

$287.31

L5974

All lower extremity prostheses, foot, single axis ankle/foot

$176.49

L5975

All lower extremity prosthesis, combination single axis ankle and flexible keel foot

$355.07

L5976

All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)

$424.14

L5978

All lower extremity prostheses, foot, multi-axial ankle/foot

$221.02

L5979

All lower extremity prostheses, multi-axial ankle/foot, dynamic response

$1,728.13

L5980

All lower extremity prostheses, flex-foot system

$2,808.09

L5981

All lower extremity prostheses, flex-walk system or equal

$2,265.55

L5982

All exoskeletal lower extremity prostheses, axial rotation unit

$437.84

L5984

All endoskeletal lower extremity prostheses, axial rotation unit

$431.45

L5985

All endoskeletal lower extremity prostheses, dynamic prosthetic pylon

$216.27

L5986

All lower extremity prostheses, multi-axial rotation unit ('MCP' or equal)

$479.93

L5987

All lower extremity prosthesis, shank foot system with vertical loading pylon

$5,509.64

L6000

Partial hand, Robin-Aids, thumb remaining (or equal)

$1,006.30

L6010

Partial hand, Robin-Aids, little and/or ring finger remaining (or equal)

$1,119.85

L6020

Partial hand, Robin-Aids, no finger remaining (or equal)

$1,044.08

L6050

Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad

$1,438.71

L6055

Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad

$2,005.19

L6100

Below elbow, molded socket, flexible elbow hinge, triceps pad

$1,457.63

L6110

Below elbow, molded socket (Muenster or Northwestern suspension types)

$1,546.07

L6120

Below elbow, molded double wall split socket, step-up hinges, half cuff

$1,801.72

L6130

Below elbow, molded double wall split socket, stump activated locking hinge, half cuff

$1,960.61

L6200

Elbow disarticulation, molded socket, outside locking hinge, forearm

$2,066.16

L6205

Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm

$2,758.00

L6250

Above elbow, molded double wall socket, internal locking elbow, forearm

$2,164.86

L6300

Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm

$2,821.66

L6310

Shoulder disarticulation, passive restoration (complete prosthesis)

$2,436.37

L6320

Shoulder disarticulation, passive restoration (shoulder cap only)

$1,330.95

L6350

Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm

$2,966.55

L6360

Interscapular thoracic, passive restoration (complete prosthesis)

$2,667.94

L6370

Interscapular thoracic, passive restoration (shoulder cap only)

$1,596.42

L6380

Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow

$925.08

L6382

Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow

$1,391.76

L6384

Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic

$1,925.33

L6386

Immediate postsurgical or early fitting, each additional cast change and realignment

$304.15

L6388

Immediate postsurgical or early fitting, application of rigid dressing only

$332.95

L6400

Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping

$1,757.39

L6450

Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping

$2,347.83

L6500

Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping

$2,456.32

L6550

Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping

$2,952.53

L6570

Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping

$3,314.89

L6580

Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, 'USMC' or equal pylon, no cover, molded to patient model

$1,265.56

L6582

Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, 'USMC' or equal pylon, no cover, direct formed

$1,146.25

L6584

Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, 'USMC' or equal pylon, no cover, molded to patient model

$1,797.62

L6586

Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, 'USMC' or equal pylon, no cover, direct formed

$1,682.28

L6588

Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, 'USMC' or equal pylon, no cover, molded to patient model

$2,210.48

L6590

Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, 'USMC' or equal pylon, no cover, direct formed

$2,099.63

L6600

Upper extremity additions, polycentric hinge, pair

$142.06

L6605

Upper extremity additions, single pivot hinge, pair

$140.27

L6610

Upper extremity additions, flexible metal hinge, pair

$134.71

L6615

Upper extremity addition, disconnect locking wrist unit

$145.15

L6616

Upper extremity addition, additional disconnect insert for locking wrist unit, each

$53.78

L6620

Upper extremity addition, flexion-friction wrist unit

$232.23

L6623

Upper extremity addition, spring assisted rotational wrist unit with latch release

$647.76

L6625

Upper extremity addition, rotation wrist unit with cable lock

$460.26

L6628

Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal

$362.81

L6629

Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal

$110.81

L6630

Upper extremity addition, stainless steel, any wrist

$163.23

L6632

Upper extremity addition, latex suspension sleeve, each

$56.69

L6635

Upper extremity addition, lift assist for elbow

$133.40

L6637

Upper extremity addition, nudge control elbow lock

$284.53

L6640

Upper extremity additions, shoulder abduction joint, pair

$252.77

L6641

Upper extremity addition, excursion amplifier, pulley type

$121.50

L6642

Upper extremity addition, excursion amplifier, lever type

$164.69

L6645

Upper extremity addition, shoulder flexion-abduction joint, each

$303.99

L6650

Upper extremity addition, shoulder universal joint, each

$315.61

L6655

Upper extremity addition, standard control cable, extra

$62.04

L6660

Upper extremity addition, heavy duty control cable

$69.52

L6665

Upper extremity addition, Teflon, or equal, cable lining

$34.88

L6670

Upper extremity addition, hook to hand, cable adapter

$38.56

L6672

Upper extremity addition, harness, chest or shoulder, saddle type

$153.05

L6675

Upper extremity addition, harness, figure of eight type, for single control

$90.95

L6676

Upper extremity addition, harness, figure of eight type, for dual control

$105.14

L6680

Upper extremity addition, test socket, wrist disarticulation or below elbow

$175.72

L6682

Upper extremity addition, test socket, elbow disarticulation or above elbow

$194.27

L6684

Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic

$264.00

L6686

Upper extremity addition, suction socket

$596.16

L6687

Upper extremity addition, frame type socket, below elbow or wrist disarticulation

$436.86

L6688

Upper extremity addition, frame type socket, above elbow or elbow disarticulation

$434.23

L6689

Upper extremity addition, frame type socket, shoulder disarticulation

$520.25

L6690

Upper extremity addition, frame type socket, interscapular-thoracic

$566.92

L6691

Upper extremity addition, removable insert, each

$262.41

L6692

Upper extremity addition, silicone gel insert or equal, each

$423.54

L6700

Terminal device, hook, Dorrance or equal, model #3

$392.87

L6705

Terminal device, hook, Dorrance or equal, model #5

$230.65

L6710

Terminal device, hook, Dorrance or equal, model #5X

$261.39

L6715

Terminal device, hook, Dorrance or equal, model #5XA

$259.64

L6720

Terminal device, hook, Dorrance or equal, model #6

$646.12

L6725

Terminal device, hook, Dorrance or equal, model #7

$312.81

L6730

Terminal device, hook, Dorrance or equal, model #7LO

$515.32

L6735

Terminal device, hook, Dorrance or equal, model #8

$225.67

L6740

Terminal device, hook, Dorrance or equal, model #8X

$320.68

L6745

Terminal device, hook, Dorrance or equal, model #88X

$281.52

L6750

Terminal device, hook, Dorrance or equal, model #10P

$282.36

L6755

Terminal device, hook, Dorrance or equal, model #10X

$283.08

L6765

Terminal device, hook, Dorrance or equal, model #12P

$299.10

L6770

Terminal device, hook, Dorrance or equal, model #99X

$283.75

L6775

Terminal device, hook, Dorrance or equal, model #555

$317.14

L6780

Terminal device, hook, Dorrance or equal, model #SS555

$354.84

L6790

Terminal device, hook, Accu hook or equal

$342.23

L6795

Terminal device, hook, 2 load or equal

$955.34

L6800

Terminal device, hook, APRL VC or equal

$767.37

L6805

Terminal device, modifier wrist flexion unit

$257.68

L6806

Terminal device, hook, TRS Grip, Grip III, VC, or equal

$1,238.69

L6807

Terminal device, hook, Grip I, Grip II, VC, or equal

$998.02

L6808

Terminal device, hook, TRS Adept, infant or child, VC, or equal

$852.20

L6809

Terminal device, hook, TRS Super Sport, passive

$299.11

L6810

Terminal device, pincher tool, Otto Bock or equal

$146.07

L6825

Terminal device, hand, Dorrance, VO

$860.44

L6830

Terminal device, hand, APRL, VC

$1,025.61

L6835

Terminal device, hand, Sierra, VO

$893.41

L6840

Terminal device, hand, Becker Imperial

$651.84

L6845

Terminal device, hand, Becker Lock Grip

$619.54

L6880

Terminal device, hand, Bock, VO

$381.90

L6890

Terminal device, glove for above hands, production glove

$128.82

L6895

Terminal device, glove for above hands, custom glove

$473.89

L6900

Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining

$1,352.35

L6905

Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining

$1,344.67

L6910

Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining

$1,149.84

L6915

Hand restoration (shading and measurements included), replacement glove for above

$579.72

L6920

Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

$5,054.46

L6925

Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

$6,804.17

L6930

Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

$5,085.80

L6935

Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

$6,909.76

L6940

Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

$6,644.93

L6945

Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

$8,119.32

L6950

Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

$7,552.89

L6955

Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

$9,045.62

L6960

Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

$10,246.43

L6965

Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

$10,928.19

L6970

Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

$11,387.37

L6975

Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

$12,454.12

L7010

Electronic hand, Otto Bock, Steeper or equal, switch controlled

$2,766.17

L7015

Electronic hand, System Teknik, Variety Village or equal, switch controlled

$4,395.65

L7020

Electronic greifer, Otto Bock or equal, switch controlled

$2,577.25

L7025

Electronic hand, Otto Bock or equal, myoelectronically controlled

$2,600.83

L7030

Electronic hand, System Teknik, Variety Village or equal, myoelectronically controlled

$3,977.07

L7035

Electronic greifer, Otto Bock or equal, myoelectronically controlled

$2,663.55

L7040

Prehensile actuator, Hosmer or equal, switch controlled

$2,135.15

L7045

Electronic hook, child, Michigan or equal, switch controlled

$1,224.16

L7170

Electronic elbow, Hosmer or equal, switch controlled

$5,636.45

L7180

Electronic elbow, Boston, Utah or equal, myoelectronically controlled

$24,740.96

L7185

Electronic elbow, adolescent, Variety Village or equal, switch controlled

$5,566.08

L7186

Electronic elbow, child, Variety Village or equal, switch controlled

$6,699.32

L7190

Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled

$5,846.28

L7191

Electronic elbow, child, Variety Village or equal, myoelectronically controlled

$7,000.39

L7260

Electronic wrist rotator, Otto Bock or equal

$1,490.51

L7261

Electronic wrist rotator, for Utah arm

$2,713.31

L7266

Servo control, Steeper or equal

$999.80

L7272

Analogue control, UNB or equal

$1,731.37

L7274

Proportional control, 6-12 volt, Liberty, Utah or equal

$4,350.00

L7360

Six volt battery, Otto Bock or equal, each

$180.72

L7362

Battery charger, six volt, Otto Bock or equal

$189.75

L7364

Twelve volt battery, Utah or equal, each

$301.80

L7366

Battery charger, twelve volt, Utah or equal

$406.53

L7900

Vacuum erection system

$414.50

L8000

Breast prosthesis, mastectomy bra

$33.32

L8010

Breast prosthesis, mastectomy sleeve

$47.37

L8020

Breast prosthesis, mastectomy form

$172.67

L8030

Breast prosthesis, silicone or equal

$249.76

L8300

Truss, single with standard pad

$73.76

L8310

Truss, double with standard pads

$113.41

L8320

Truss, addition to standard pad, water pad

$49.55

L8330

Truss, addition to standard pad, scrotal pad

$49.10

L8400

Prosthetic sheath, below knee, each

$14.35

L8410

Prosthetic sheath, above knee, each

$16.33

L8415

Prosthetic sheath, upper limb, each

$16.24

L8417

Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each

$57.59

L8420

Prosthetic sock, multiple ply, below knee, each

$18.98

L8430

Prosthetic sock, multiple ply, above knee, each

$20.87

L8435

Prosthetic sock, multiple ply, upper limb, each

$18.74

L8440

Prosthetic shrinker, below knee, each

$39.71

L8460

Prosthetic shrinker, above knee, each

$55.26

L8465

Prosthetic shrinker, upper limb, each

$49.26

L8470

Prosthetic sock, single ply, fitting, below knee, each

$5.06

L8480

Prosthetic sock, single ply, fitting, above knee, each

$6.97

L8485

Prosthetic sock, single ply, fitting, upper limb, each

$8.42

L8490

Addition to prosthetic sheath/sock, air seal suction retention system

$100.63

L8500

Artificial larynx, any type

$499.83

L8501

Tracheostomy speaking valve

$111.01

 


Go Back to January 16, 2001 Order Adopting These Rules

Return to N.C. Industrial Commission Home Page

Return to NCIC Alternate Home Page


N.C. Industrial Commission 4319 Mail Service Center Raleigh, NC 27699-4319
Webmaster:  (919) 807-2500 Fax:  (919) 715-0282
Internet Address:  http://www.comp.state.nc.us/