Sorted By Description (pdf) - HFS

Durable Medical Equipment
Equipment and Prostheses ONLY - Listed Alphabetically
HCPCS Description COS
L2136
L2126
L2038
L5312
L5160
L5150
L2415
L2405
L2492
L2425
L1836
L1832
L1840
L1846
L1845
L1820
L1810
L1830
L1831
L1860
L1844
L1850
L1834
L1843
L5666
L2628
L2627
L2510
L5984
L5976
L5970
Prior
Purch.
Appr. LTC PartB Price
Updated as of: 8/21/2012
Rent MaxQty/Days
KAFO;FRACTURE ORTH,FEMERAL FRAC, RIGID 41 Y N Y 743.97 0.00 N / A
KAFO;FRACTURE ORTH,FEMERAL FRACTURE,THERMOPLA TYPE CUST FAB 41 Y Y Y 887.92 0.00 N / A
KAFO;FULL PLASTIC, W/WO KNEE JOINT,MULTI-AXIS,ANKLE CF 41 Y Y Y 929.59 0.00 N / A
KNEE DISARTICULATION MLD SOCKTSGLAXIS PYLON SACH FT ENDOSKEL 41 Y N Y 3,583.11 0.00 N / A
KNEE DISARTICULATION; MOLDED SOCKET, BENT KNEE CONFIG, SACH 41 Y Y Y 3,274.51 0.00 N / A
KNEE DISARTICULATION;MOLDED SOCKET,EXTERNAL KNEE JOINTS SACH 41 Y Y Y 2,982.40 0.00 N / A
KNEE JOINT; ADDITION, CAM LOCK, EACH JOINT 41 N Y Y 84.48 0.00 2. / 365.
KNEE JOINT; ADDITION, DROP LOCK, EACH 41 N N Y 44.12 0.00 2. / 365.
KNEE JOINT; ADDITION, LIFT LOOP FOR DROP LOCK RING 41 N N Y 81.95 0.00 2. / 365.
KNEE JOINT;ADDITION,DISC/DIAL LOCK FOR ADJ KNEE,EACH JOINT 41 N N Y 99.68 0.00 2. / 365.
KNEE ORTHOSIS RIGID WITHOUT JOINT, INC. SOFT INTERFACE, PREF 41 N N Y 98.22 0.00 1. / 365.
KO; ADJUST KNEE JOINTS,UNIC/POLY POSTIONAL ORTH,RIG SUPP,PF 41 Y N Y 0.00 0.00 N / A
KO; DEROTATION, MED-LAT, ANTERIOR LIGAMENT, CUSTOM FAB TO PT 41 Y Y Y 653.93 0.00 N / A
KO; DOUBLE UPRIGHT, MED/LAT/ROT CONTROL, CUSTOM FAB 41 Y Y Y 779.78 0.00 N / A
KO; DOUBLE UPRIGHT, MED/LAT/ROT CONTROL, PRE-FAB 41 Y Y Y 0.00 0.00 N / A
KO; ELAS W/CONDYLAR PADS AND JO, W/OUT PAT CONT. PRE. FAB 41 N N Y 47.24 0.00 1. / 365.
KO; ELASTIC WITH JOINTS 41 N N Y 34.42 0.00 1. / 365.
KO; IMMOBILIZER, CANVAS LONGITUDINAL 41 N N Y 29.70 0.00 1. / 365.
KO; LOCKING KNEE JOINT, POSITION ORTHOSIS, PRE-FAB INCL F/A 41 N N Y 216.72 0.00 1. / 365.
KO; MOD OF SUPRACONDYLAR PROSTHETIC SOCKET, MOLDED TO PT 41 Y Y Y 867.10 0.00 N / A
KO; SINGLE UPRIGHT THIGH/CALF ADJ FLEX/EXT ST. UNIC/POLY, CF 41 Y Y Y 1,121.30 0.00 N / A
KO; SWEDISH TYPE 41 N Y Y 198.10 0.00 1. / 365.
KO; W/O KNEE JOINT, RIGID, MOLDED TO PATIENT 41 Y Y Y 504.71 0.00 N / A
KO;SINGLE UPRIGHT W/ADJ JOINT,MED-LAT CONTROL, UNIC/POLY, PF 41 Y N Y 0.00 0.00 N / A
LE ADDITION,BK,CUFF SUSPENSION 41 N Y Y 53.41 0.00 1. / 365.
LE ADDITION,PELVIC CONTROL,METAL FRAME,RECIP HIP JOINT/CABLE 41 Y N Y 1,089.32 0.00 N / A
LE ADDITION,PELVIC CONTROL,PLASTIC RECIP HIP JOINT/CABLE/MIL 41 Y Y Y 1,486.16 0.00 N / A
LE ADDITION,THIGH/WEIGHT BEARING QUADRILATERAL BRIM,MOLDED 41 Y Y Y 560.82 0.00 N / A
LE PROSETHESIS;ENDOSKELETAL, AXIAL ROTATION UNIT 41 N Y Y 447.99 0.00 1. / 365.
LE PROSTHESIS; ENERGY STORING FOOT 41 N Y Y 409.44 0.00 1. / 365.
LE PROSTHESIS; FOOT, EXTERNAL KEEL, SACH FOOT 41 N Y Y 151.35 0.00 1. / 365.
NOTE: For "w" definition, refer to Wheelchair Pricing Schedule. For
"nr", the 2.7% reduction doesn't apply to this code.
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