Sorted By Description (pdf) - HFS

Durable Medical Equipment
Equipment and Prostheses ONLY - Listed Alphabetically
HCPCS Description COS
E0199
E0198
E0463
L5981
L8499
L8410
L8400
L8415
L8460
L8440
L8465
L8430
L8420
L8435
L8480
L8470
L8485
L0984
L5705
L5704
L5706
L5707
E0191
B9002
B9000
K0839 w
K0840 w
K0813 w
K0851 w
K0862 w
K0850 w
Prior
Purch.
Appr. LTC PartB Price
Updated as of: 8/21/2012
Rent MaxQty/Days
PRESSURE PAD;DRY, FOR MATTRESS, STANDARD 41 N N Y 16.46 0.00 2. / 365.
PRESSURE PAD;WATER, FOR MATTRESS, STANDARD 41 Y N Y 47.20 0.00 N / A
PRESSURE SUPPORT VENT W/VOLUM CONTROL,W/INVASIV INTERFACE 41 R N Y 0.00 832.70 N / A
PROSTHESIS; FLEX WALK SYSTEM OR EQUAL 41 Y Y Y 2,377.37 0.00 N / A
PROSTHETIC SERVICES; UNLISTED PROCEDURE FOR MISC. SERVICES 41 B Y N 0.00 0.00 N / A
PROSTHETIC SHEATH; AK, EACH 41 N Y Y 14.34 0.00 6. / 180.
PROSTHETIC SHEATH; BK, EACH 41 N Y Y 10.90 0.00 6. / 180.
PROSTHETIC SHEATH; UPPER LIMB, EACH 41 N Y Y 14.85 0.00 6. / 180.
PROSTHETIC SHRINKER; AK, EACH 41 N Y Y 46.17 0.00 2. / 180.
PROSTHETIC SHRINKER; BK, EACH 41 N Y Y 32.47 0.00 2. / 180.
PROSTHETIC SHRINKER; UPPER LIMB 41 N Y Y 42.68 0.00 2. / 180.
PROSTHETIC SOCK; MULTIPLE PLY, AK, EACH 41 N Y Y 16.44 0.00 6. / 180.
PROSTHETIC SOCK; MULTIPLE PLY, BK, EACH 41 N Y Y 14.54 0.00 6. / 180.
PROSTHETIC SOCK; MULTIPLE PLY, UPPER LIMB, EACH 41 N Y Y 15.63 0.00 6. / 180.
PROSTHETIC SOCK; SINGLE PLY, FITTING, AK, EACH 41 N Y Y 6.37 0.00 6. / 180.
PROSTHETIC SOCK; SINGLE PLY, FITTING, BK, EACH 41 N Y Y 4.62 0.00 6. / 180.
PROSTHETIC SOCK; SINGLE PLY, FITTING, UPPER LIMB, EACH 41 N Y Y 8.57 0.00 6. / 180.
PROTECTIVE BODY SOCK, EACH 41 N N Y 47.07 0.00 2. / 365.
PROTECTIVE COVER, CUSTOM SHAPED, ABOVE KNEE 41 Y Y Y 836.71 0.00 1. / 365.
PROTECTIVE COVER, CUSTOM SHAPED, BELOW KNEE 41 Y Y Y 456.39 0.00 1. / 365.
PROTECTIVE COVER, CUSTOM SHAPED, KNEE DISARTICULATION 41 Y Y Y 816.11 0.00 1. / 365.
PROTECTIVE COVER, CUSTOM SHAPED,HIP DISARTICULATION 41 Y Y Y 1,096.45 0.00 1. / 365.
PROTECTOR-HEEL OR ELBOW; EACH 41 N N Y 9.13 0.00 4. / 60.
PUMP; ENTERAL INFUSION, WITH ALARM 41 B N Y 0.00 0.00 N / A
PUMP; ENTERAL INFUSION, WITHOUT ALARM 41 B N Y 0.00 0.00 N / A
PWC GR TWO VERY HEAVY DUTY SINGLE POW OPT ST/BK 451-600 LB 41 Y N Y 0.00 0.00 N / A
PWC GR TWO X-HEAVY DUTY SINGLE POWE OPT ST/BK WT 601 OR > 41 Y N Y 0.00 0.00 N / A
PWC GROUP 1 STANDARD PORTABL SEAT/BACK UP TO AND INC 300 LBS 41 Y N Y 0.00 0.00 N / A
PWC GROUP 3 HEAVY DUTY CAPTANS CHAIR WT CAPACITY 301-450 LBS 41 Y N Y 0.00 0.00 N / A
PWC GROUP 3 HEAVY DUTY MLT OPT SEAT/BACK WT CAPACITY 301-450 41 Y N Y 0.00 0.00 N / A
PWC GROUP 3 HEAVY DUTY SEAT/BACK WEIGHT 301-450 LBS 41 Y N Y 0.00 0.00 N / A
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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