1/16/01 Order Adopting (B) 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

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/

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)

Order Adopting Rules Relating to

Durable Medical Equipment/Supply Fee Schedule