Sorted By Description (pdf) - HFS

Durable Medical Equipment
Equipment and Prostheses ONLY - Listed Alphabetically
HCPCS Description COS
E0627
E2292 w
E2294 w
E0657
E0656
Prior
Purch.
Appr. LTC PartB Price
Updated as of: 8/21/2012
Rent MaxQty/Days
SEAT LIFT MECHANISM INCORPORATED INTO LIFT-CHAIR 41 Y N Y 308.52 0.00 N / A
SEAT,PLANAR,FOR PEDS SIZE W/C INCLUDES FIXED ATTACH HARDWARE 41 Y N N 0.00 0.00 N / A
SEAT.CONTOURED,FOR PEDS W/C INCLUDES FIXED ATTACH HARDWARE 41 Y N N 0.00 0.00 N / A
SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMP CH 41 Y N Y 520.70 0.00 N / A
SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRES 41 B N Y 554.80 55.48 N / A
V5095 nr SEMI-IMPLANTABLE MIDDLE EAR HEARING PROSTHESIS 41 Y Y N 0.00 0.00 N / A
L3960
L3962
L6384
L6550
L6300
L6320
L6310
L3677
Q0501
E0160
E0161
E2624 w
E2625 w
E2603 w
E2604 w
E2608 w
E2607 w
E2622 w
E2623 w
L3670
L3650
L3675
E1227 w
E2512
E2599
SEWHO;ABDUCTION POSITIONING, AIRPLANE DESIGN 41 Y N Y 504.72 0.00 N / A
SEWHO;ABDUCTION POSITIONING, ERBS PALSEY DESIGN 41 N N Y 456.50 0.00 1. / 365.
SHOULDER DISART OR INTERSCAPULAR THOACIC;IMMEDIATE POST-SURG 41 Y Y Y 1,486.00 0.00 N / A
SHOULDER DISART; MOLDED SOCKET, ENDOSKELETAL SYSTEM 41 Y Y Y 3,151.44 0.00 N / A
SHOULDER DISART; MOLDED SOCKET, SHOULDER BULKHEAD, FOREARM 41 Y Y Y 3,092.60 0.00 N / A
SHOULDER DISART; PASSIVE RESTORATION(SHOULDER CAP ONLY) 41 Y Y Y 1,460.73 0.00 N / A
SHOULDER DISART;PASSIVE RESTORATION (COMPLETE PROSTHESIS) 41 Y Y Y 2,802.76 0.00 N / A
SHOULDER ORTHOSIS,SHOUL JT DESIGN W/O JT,INC SOFT INF PREFAB 41 Y N N 0.00 0.00 N / A
SHOWER COVER FOR USE WITH ELEC OR ELEC/PNEU VAD REPLAC ONLY 41 N N Y 423.74 0.00 1. / 365.
SITZ BATH, PORTABLE, USED W/OR W/O COMMODE 41 N N Y 30.24 0.00 1. / 365.
SITZ BATH, PORTABLE, USED W/OR W/O COMMODE W/FAUCET ATTACH. 41 N N Y 22.87 0.00 1. / 365.
SKIN PROTEC AND POST W/C SEAT CUSH,ADJ WT ANY DEPT 41 Y N Y 0.00 0.00 N / A
SKIN PROTEC W/C SEAT CUSHION WIDTH < THAN 22 INS,ANY DEPTH 41 Y N N 0.00 0.00 N / A
SKIN PROTEC W/C SEAT CUSHION WIDTH 22 INS OR >,ANY DEPTH 41 Y N N 0.00 0.00 N / A
SKIN PROTEC/POSITI W/C SEAT CUSHION,WIDTH 22 INS OR>,ANY DEP 41 Y N N 0.00 0.00 N / A
SKIN PROTEC/POSITIO W/C SEAT CUSHION,WIDTH 22 INS ORLES A/DP 41 Y N N 0.00 0.00 N / A
SKIN PROTECTION W/C CUSHION ADJUST WIDTH ANY DEP 41 Y N Y 0.00 0.00 N / A
SO; ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE) 41 N N Y 26.37 0.00 1. / 365.
SO; FIGURE "8" ABDUCTION RESTRAINER 41 N N Y 36.64 0.00 1. / 365.
SO;VEST TYPE ABDUCTION RESTRAINER,CANVAS WEBBING OR EQUAL 41 N N Y 117.61 0.00 1. / 365.
SPECIAL HGT ARMS FOR WHEELCHR 41 Y Y Y 0.00 0.00 N / A
SPEECH GENERATING DEVICE ACCESSORY MOUNTING SYSTEM 41 Y Y Y 0.00 0.00 N / A
SPEECH GENERATING DEVICE, ACCESSORY NOT OTHERWISE CLASSIFIED 41 Y Y N 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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