Sorted By Description (pdf) - HFS

Durable Medical Equipment
Equipment and Prostheses ONLY - Listed Alphabetically
HCPCS Description COS
L5668
L5670
L5665
L5672
L5682
L5680
L5637
L5690
L5688
L5639
L5686
L2360
L2250
L5649
L5653
L5640
L2330
L2200
L2280
L2320
L2390
L2395
L2397
L2370
L2630
L2622
L2570
L2600
L2610
L2620
L2580
Prior
Purch.
Appr. LTC PartB Price
Updated as of: 8/21/2012
Rent MaxQty/Days
LE; ADDITION, BK, MOLDED DISTAL CUSHION 41 N Y Y 79.57 0.00 1. / 365.
LE; ADDITION, BK, MOLDED SUPRACONDYLAR SUSPENSION 41 N Y Y 187.95 0.00 1. / 365.
LE; ADDITION, BK, MULTI-DUROMETER 41 N Y Y 403.43 0.00 1. / 365.
LE; ADDITION, BK, REMOVABLE MEDIAL BRIM SUSPENSION 41 N Y Y 248.73 0.00 1. / 365.
LE; ADDITION, BK, THIGH LACER, GLUTEAL/ISCHIAL, MOLDED 41 Y Y Y 433.21 0.00 N / A
LE; ADDITION, BK, THIGH LACER, NON-MOLDED 41 N Y Y 210.83 0.00 1. / 365.
LE; ADDITION, BK, TOTAL CONTACT 41 N Y Y 266.82 0.00 1. / 365.
LE; ADDITION, BK, WAIST BELT, PADDED AND LINED 41 N Y Y 86.92 0.00 1. / 365.
LE; ADDITION, BK, WAIST BELT, WEBBING 41 N Y Y 42.58 0.00 1. / 365.
LE; ADDITION, BK, WOOD SOCKET 41 Y Y Y 776.64 0.00 N / A
LE; ADDITION, BK,BACK CHECK (EXTENSION CONTROL) 41 N Y Y 40.09 0.00 1. / 365.
LE; ADDITION, EXTENDED STEEL SHANK 41 N N Y 35.86 0.00 1. / 365.
LE; ADDITION, FOOT PLATE, MOLDED TO PT, STIRRUP ATTACHMENT 41 N Y Y 232.26 0.00 2. / 365.
LE; ADDITION, ISCHIAL CONTAINMENT/NARROW M-L SOCKET 41 Y Y N 1,808.28 0.00 1. / 365.
LE; ADDITION, KNEE DISARTICULATION, EXPANDABLE WALL SOCKET 41 N Y Y 471.18 0.00 1. / 365.
LE; ADDITION, KNEE DISARTICULATION, LEATHER SOCKET 41 Y Y Y 510.50 0.00 N / A
LE; ADDITION, LACER, MOLDED TO PATIENT, CUST-FAB ONLY 41 Y Y Y 255.31 0.00 N / A
LE; ADDITION, LIMITED ANKLE MOTION, EACH JOINT 41 N Y Y 34.93 0.00 2. / 365.
LE; ADDITION, MOLDED INNER BOOT 41 Y N Y 392.55 0.00 N / A
LE; ADDITION, NON-MOLDED LACER, CUST-FAB ONLY 41 Y N Y 134.12 0.00 N / A
LE; ADDITION, OFFSET KNEE JOINT, EACH JOINT 41 N N Y 71.17 0.00 2. / 365.
LE; ADDITION, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT 41 N N Y 101.72 0.00 2. / 365.
LE; ADDITION, ORTHOSIS, SUSPENSION SLEEVE 41 N N Y 85.73 0.00 1. / 180.
LE; ADDITION, PATTEN BOTTOM 41 N N Y 222.54 0.00 1. / 365.
LE; ADDITION, PELVIC CONTROL, BAND/BELT, UNILATERAL 41 N N Y 160.99 0.00 1. / 365.
LE; ADDITION, PELVIC CONTROL, HIP JOINT, ADJUSTABLE FLEXION, 41 N N Y 221.27 0.00 2. / 365.
LE; ADDITION, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE JOINT E 41 N N Y 309.69 0.00 1. / 365.
LE; ADDITION, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE, FREE 41 N N Y 148.30 0.00 2. / 365.
LE; ADDITION, PELVIC CONTROL, HIP JOINT, CLEVIS/THRUST, LOCK 41 N N Y 163.87 0.00 2. / 365.
LE; ADDITION, PELVIC CONTROL, HIP JOINT, HEAVY DUTY, EACH 41 N N Y 173.85 0.00 2. / 365.
LE; ADDITION, PELVIC CONTROL, PELVIC SLING 41 N N Y 301.76 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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