La. Admin. Code tit. 40 § I-4119
State of Louisiana Office of Workers' Compensation Schedule of Maximum Allowances for Durable Medical Equipment | ||||
HCPCS | Description | Purchase New | Purchase Used | Rental |
E0100 | Cane, adj/fixed, w/tip | $26 | $21 | $7 |
E0105 | Cane, quad/three prong | $61 | $47 | $9 |
E0110 | Crutches, forearm | $96 | $72 | $17 |
E0111 | Crutch forearm | $56 | $43 | $11 |
E0112 | Crutches underarm, wood, pair | $46 | $35 | $10 |
E0113 | Crutch underarm, wood, each | $29 | $22 | $7 |
E0114 | Crutches underarm, aluminum, pair | $64 | $48 | $11 |
E0116 | Crutch underarm, aluminum, each | $38 | $29 | $8 |
E0117 | Underarm springassist crutch | $269 | $202 | $27 |
E0118 | Crutch substitute | B.R. | B.R. | B.R. |
E0130 | Walker, rigid, adj/fixed hgt | $87 | $68 | $18 |
E0135 | Walker, folding, adj/fixed hgt | $102 | $79 | $18 |
E0140 | Walker w trunk support | $434 | $326 | $43 |
E0141 | Walker, wheeled, w/out seat | $142 | $107 | $24 |
E0143 | Folding walker, wheeled, w/out seat | $148 | $111 | $23 |
E0144 | Enclosed walker w rear seat | $383 | $287 | $38 |
E0147 | Walker, heavy duty, break sys | $501 | $381 | $51 |
E0148 | Heavyduty walker no wheels | $153 | $115 | $15 |
E0149 | Heavy duty wheeled walker | $269 | $201 | $27 |
E0153 | Platform attac, forearm crutch, ea | $86 | $64 | $9 |
E0154 | Platform attachment, walker, ea | $87 | $66 | $1 |
E0155 | Wheel attach, rigid pick-up walker | $33 | $25 | $4 |
E0156 | Seat attach, walker | $46 | $35 | $5 |
E0157 | Crutch attach, walker, ea | $101 | $76 | $11 |
E0158 | Leg extensions a walker | $36 | $27 | $4 |
E0159 | Brake for wheeled walker | $22 | $16 | $2 |
E0160 | Sitz bath, port, fits over seat | $44 | $33 | $5 |
E0161 | Sitz bath, port, fits over seat | $48 | $36 | $5 |
E0162 | Sitz bath chair | $180 | $139 | $18 |
E0163 | Commode chair, stat, w/fixed arms | $125 | $98 | $26 |
E0165 | Commode chair, stat, w/detach arms | $195 | $146 | $19 |
E0166 | Commode chair, mob, w/detach arms | $327 | $245 | $33 |
E0167 | Pail/pan use w/commode chair | $13 | $9 | $2 |
E0168 | Heavyduty/wide commode chair | $211 | $158 | $21 |
E0170 | Commode chair electric | $224 | ||
E0171 | Commode chair non-electric | $40 | ||
E0172 | Seat lift mechanism toilet | B.R. | B.R. | B.R. |
E0175 | Foot rest, use w/commode chair | $69 | $51 | $7 |
E0181 | Pres pad, alt w/pump, heavy duty | $382 | $287 | $38 |
E0182 | Pump alternating pressure pad | $275 | $206 | $27 |
E0184 | Dry pressure mattress | $344 | $258 | $38 |
E0185 | Gel pressure pad mattress | $336 | $258 | $47 |
E0188 | Synthetic sheepskin pad | $37 | $28 | $4 |
E0189 | Lambswool sheepskin, pad any size | $73 | $54 | $8 |
E0190 | Positioning cushion | B.R. | B.R. | B.R. |
E0191 | Heel/elbow protector, ea | $12 | $9 | $2 |
E0193 | Powered air flot bed | B.R. | $1,371 | |
E0194 | Air fluidized bed | B.R. | $4,016 | |
E0196 | Gel pressure mattress | $341 | $256 | $34 |
E0197 | Air pressure pad mattress | $232 | $204 | $32 |
E0198 | Water pressure pad mattress | $232 | $176 | $24 |
E0199 | Dry pressure pad mattress | $34 | $25 | $3 |
E0200 | Heat lamp, w/o stand | $98 | $73 | $13 |
E0202 | Phototherapy light w/photometer | $1,043 | $782 | $105 |
E0203 | Therapeutic lightbox tabletp | B.R. | B.R. | B.R. |
E0205 | Heat lamp, w/stand | $240 | $180 | $26 |
E0210 | Electric heat pad, std | $39 | $29 | $4 |
E0215 | Electric heat pad, moist | $95 | $71 | $10 |
E0217 | Water circ heat pad w pump | $693 | $520 | $77 |
E0218 | Water ciculating cold pad with pump | B.R. | B.R. | B.R. |
E0221 | Infared heating pad system | B.R. | B.R. | B.R. |
E0225 | Hydrocollator unit, includes pads | $473 | $355 | $47 |
E0231 | Non-contact wound warming device | B.R. | B.R. | B.R. |
E0232 | Warming cord for use with any wound warming device | B.R. | B.R. | B.R. |
E0235 | Paraffin bath unit, portable | $213 | $160 | $21 |
E0236 | Pump water circulating pad | $546 | $410 | $55 |
E0239 | Hydrocollator unit, portable | $472 | $354 | $47 |
E0240 | Bath/shower chair | B.R. | ||
E0241 | Bath tub wall rail, ea | B.R. | ||
E0242 | Bath tub rail, floor base | B.R. | ||
E0243 | Toilet rail, ea | B.R. | ||
E0244 | Raised toilet seat | B.R. | ||
E0245 | Tub stool/bench | B.R. | ||
E0246 | Transfer tub rail attachment | B.R. | ||
E0247 | Trans bench w/wo comm open | B.R. | ||
E0248 | HDtrans bench w/wo comm open | B.R. | ||
E0249 | Pad water circulating heat unit | $112 | $84 | $11 |
E0250 | Hosp bed, fix hgt, rail/mattress | $1,036 | $777 | $104 |
E0251 | Hosp bed, fix hgt, rail/no mattress | $853 | $640 | $85 |
E0255 | Hosp bed, hi-lo, rail/mattress | $1,356 | $1,017 | $136 |
E0256 | Hosp bed, hi-lo, rail/no mattress | $1,029 | $771 | $103 |
E0260 | Hosp bed, semi-elect, rail/mattress | $1,985 | $1,489 | $198 |
E0261 | Hosp bed, semi-elect, rail/no mattress | $1,690 | $1,268 | $169 |
E0265 | Hosp bed, tot elect, rail/mattress | $2,467 | $1,850 | $247 |
E0266 | Hosp bed, tot elect, rail/no mattress | $1,985 | $1,489 | $198 |
E0270 | Hosp bed, inst type | B.R. | ||
E0271 | Mattress, innerspring | $237 | $182 | $24 |
E0272 | Mattress, foam rubber | $250 | $186 | $26 |
E0273 | Bed board | B.R. | ||
E0274 | Over-bed table | B.R. | ||
E0275 | Bed pan, std, metal/plastic | $16 | $12 | $2 |
E0276 | Bed pan, fx, metal/plastic | $19 | $14 | $2 |
E0277 | Alternating pressure mattress | $9,594 | $7,195 | $959 |
E0280 | Bed cradle, any type | $47 | $35 | $7 |
E0290 | Hosp bed, fix hgt, w/o rails | $922 | $692 | $92 |
E0291 | Hosp bed, fix hgt, w/o rails | $670 | $502 | $67 |
E0292 | Hosp bed, hi-lo, w/o rails, w/mat | $1,037 | $778 | $104 |
E0293 | Hosp bed, hi-lo, w/o rails, w/o m | $883 | $662 | $88 |
E0294 | Hosp bed, semi-elect w/o rails | $1,613 | $1,210 | $161 |
E0295 | Hosp bed, semi-elect, w/o rails | $1,572 | $1,179 | $157 |
E0296 | Hosp bed, tot elect, w/out | $2,026 | $1,520 | $203 |
E0297 | Hosp bed, tot elect, w/out | $1,736 | $1,302 | $174 |
E0300 | Enclosed ped crib hosp grade | $3,416 | $2,562 | $342 |
E0301 | HD hosp bed, 350-600 lbs | $326 | ||
E0302 | Ex hd hosp bed 600 lbs | $861 | ||
E0303 | Hosp bed hvy dty xtra wide | $366 | ||
E0304 | Hosp bed xtra hvy dty x wide | $928 | ||
E0305 | Bed side rails, half length | $186 | $140 | $19 |
E0310 | Bed side rails, full length | $240 | $181 | $27 |
E0315 | Bed access: boards/tables, any | B.R. | ||
E0316 | Bed safety enclosure | $254 | ||
E0325 | Urinal; male, jug-type | $14 | $11 | $3 |
E0326 | Urinal; female, jug-type | $13 | $10 | $3 |
E0328 | Ped hospital bed, manual | B.R. | B.R. | B.R. |
E0329 | Ped hospital bed semi/elect | B.R. | B.R. | B.R. |
E0350 | Control unit bowel system | B.R. | B.R. | B.R. |
E0352 | Disposable pack w/bowel syst | B.R. | B.R. | B.R. |
E0370 | Air elevator for heel | B.R. | B.R. | B.R. |
E0371 | Nonpower mattress overlay | $535 | ||
E0372 | Powered air mattress overlay | $649 | ||
E0373 | Nonpowered pressure mattress | $740 | ||
E0424 | Stat comp gas O2 system, rental | $455 | ||
E0425 | Stat comp gas O2 system, purchase | $4,550 | $3,413 | |
E0430 | Port gas O2 system, purchase | $2,150 | $1,613 | |
E0431 | Port gas O2 system, rental | $215 | ||
E0433 | Portable liquid oxygen sys | $67 | ||
E0434 | Port liquid O2 system, rental | $223 | ||
E0435 | Port liquid O2 system, purchase | $2,230 | $1,673 | |
E0439 | Stat liquid O2 system, rental | $455 | ||
E0440 | Stat liquid O2 system, purchase | $4,550 | $3,413 | |
E0441 | O2 contents, gaseous, per unit | $20 | ||
E0442 | O2 contents, liquid, per unit | B.R. | ||
E0443 | Port O2 contents, gaseous, unit | $10 | ||
E0444 | Port O2 contents, liquid, unit | B.R. | ||
E0445 | Oximeter non-invasive | B.R. | ||
E0446 | Topical Ox Deliver sys, nos | B.R. | ||
E0450 | Volume ventilator; stat/portable | B.R. | B.R. | $1,750 |
E0455 | O2 tent, excl croup/ped tents | B.R. | ||
E0457 | Chest shell (cuirass) | $721 | $540 | $72 |
E0459 | Chest wrap | $534 | $400 | $53 |
E0460 | Neg pressure vent; port/statonary | $9,053 | $6,790 | $905 |
E0461 | Vol control vent noninv int | $1,333 | ||
E0462 | Rocking bed w//w/o side rails | |||
$3,057 | $2,293 | $306 | ||
E0463 | Press supp vent invasive int | $1,964 | ||
E0464 | Press supp vent noninv int | $2,132 | ||
E0470 | RAD w/o backup non-inv intfc | $309 | ||
E0471 | RAD w/backup non inv intrfc | $773 | ||
E0472 | RAD w backup invasive intrfc | $773 | ||
E0480 | Percussor, elect/pneum, home mod | $670 | $503 | $67 |
E0481 | Intrpulmnry percuss vent sys | B.R. | B.R. | B.R. |
E0482 | Cough stimulating device | $600 | ||
E0483 | Chest compression gen system | $1,486 | ||
E0484 | Non-elec oscillatory pep dvc | $52 | $39 | $5 |
E0485 | Oral device/appliance prefab | B.R. | B.R. | B.R. |
E0486 | Oral device/appliance cusfab | B.R. | B.R. | B.R. |
E0487 | Electronic spirometer | B.R. | B.R. | B.R. |
E0500 | IPPB machine, w/built-in nebuliz | $1,152 | $864 | $115 |
E0550 | Humidifier, extensive sup humid | $526 | $394 | $53 |
E0555 | Humidifier, glass/autoclav plast | B.R. | ||
E0560 | Humidifier, supplemental humidi | $212 | $159 | $22 |
E0561 | Humidifier nonheated w PAP | $129 | $97 | $13 |
E0562 | Humidifier heated used w PAP | $363 | $272 | $36 |
E0565 | Compressor, air power source | $640 | $480 | $64 |
E0570 | Nebulizer, w/compressor | $207 | $155 | $21 |
E0572 | Aerosol compressor adjust pr | $53 | ||
E0574 | Ultrasonic generator w svneb | $56 | ||
E0575 | Nebulizer; ultrasonic | $1,078 | $809 | $108 |
E0580 | Nebulizer, glass/autoclav plast | $161 | $121 | $16 |
E0585 | Nebulizer, w/compressor and heater | $433 | $325 | $43 |
E0600 | Suction pump, home model, port | $491 | $368 | $50 |
E0601 | Cont airway pressure (cpap) dev | $1,172 | $879 | $117 |
E0602 | Manual breast pump | $41 | $31 | $4 |
E0603 | Electric breast pump | B.R. | B.R. | B.R. |
E0604 | Hosp grade elec breast pump | B.R. | B.R. | B.R. |
E0605 | Vaporizer, room type | $29 | $23 | $3 |
E0606 | Postural drainage board | $241 | $180 | $24 |
E0607 | Home blood glucose monitor | $261 | $205 | $30 |
E0610 | Pacemaker monitor, self-contained | $289 | $217 | $29 |
E0615 | Pacemaker monitor, self-contained | $502 | $377 | $61 |
E0616 | Cardiac event recorder | B.R. | ||
E0617 | Automatic ext defibrillator | $471 | ||
E0618 | Apnea monitor | $391 | ||
E0619 | Apnea monitor w recorder | B.R. | B.R. | B.R. |
E0620 | Cap bld skin piercing laser | $1,221 | $916 | $28 |
E0621 | Sling/seat, pat lift, canvas/nylon | $118 | $89 | $11 |
E0625 | Patient lift, kartop, bathroom | B.R. | B.R. | B.R. |
E0627 | Seat lift mech in comb lift-chair | $408 | $306 | $41 |
E0628 | Sep seat lift mech | $408 | $306 | $41 |
E0629 | Sep seat lift mech | $408 | $306 | $41 |
E0630 | Patient lift, hydraulic | $1,257 | $943 | $126 |
E0635 | Patient lift, electric | $1,608 | $1,206 | $161 |
E0636 | PT support and positioning sys | $1,473 | ||
E0637 | Combination sit to stand sys | B.R. | B.R. | B.R. |
E0638 | Standing frame sys | B.R. | B.R. | B.R. |
E0639 | Moveable patient lift system | B.R. | B.R. | B.R. |
E0640 | Fixed patient lift system | B.R. | B.R. | B.R. |
E0641 | Multi-position stnd fram sys | B.R. | B.R. | B.R. |
E0642 | Dynamic standing frame | B.R. | B.R. | B.R. |
E0650 | Pneumatic compress, non-seg home | $889 | $667 | $113 |
E0651 | Pneumatic compress, seg home mod | $1,133 | $850 | $116 |
E0652 | Pneumatic compress, seg home mod | $6,543 | $4,903 | $647 |
E0655 | Pneum appl use w/comp, half arm | $152 | $114 | $16 |
E0656 | Segmental pneumatic trunk | $807 | $605 | $81 |
E0657 | Segmental pneumatic chest | $758 | $568 | $76 |
E0660 | Pneum appl use w/comp, full leg | $199 | $149 | $28 |
E0665 | Pneum appl use w/comp, full arm | $172 | $129 | $17 |
E0666 | Pneum appl use w/comp, half leg | $176 | $132 | $25 |
E0667 | Pneum appl use w/seg comp, leg | $464 | $348 | $45 |
E0668 | Pneum appl use w/seg comp, arm | $545 | $409 | $54 |
E0669 | Segmental pneumatic appliance | $256 | $192 | $26 |
E0671 | Pressure pneum appl full leg | $580 | $435 | $58 |
E0672 | Pressure pneum appl full arm | $451 | $338 | $45 |
E0673 | Pressure pneum appl half leg | $374 | $281 | $37 |
E0675 | Pneumatic compression device | $537 | ||
E0676 | Inter limb compress dev NOS | B.R. | B.R. | B.R. |
E0691 | Uvl pnl 2 sq ft or less | $1,255 | $941 | $125 |
E0692 | Uvl sys panel 4 ft | $1,576 | $1,182 | $158 |
E0693 | Uvl sys panel 6 ft | $1,576 | $1,182 | $158 |
E0694 | Uvl md cabinet sys 6 ft | $6,182 | $4,637 | $618 |
E0700 | Safety equipment | B.R. | ||
E0705 | Transfer device | $77 | $56 | $8 |
E0710 | Restraints, any type | B.R. | ||
E0720 | Tens, two lead, loc stimulation | $593 | $445 | $59 |
E0730 | Tens, 4 lead, lrg area/mult nerve | $593 | $445 | $59 |
E0731 | Form fit garment del tens/nmes | $440 | ||
E0740 | Incontinence treatment systm | $730 | $548 | $73 |
E0744 | Neuromusc stimulator scoliosis | $1,052 | $789 | $105 |
E0745 | Neuromusc stimulator, elect shock | $939 | $704 | $94 |
E0746 | Electromyography, biofeedback dev | B.R. | ||
E0747 | Osteogenesis stimulator (non-inv) | $4,353 | $3,234 | $433 |
E0748 | Elec osteogen stim spinal | $5,433 | $4,072 | $543 |
E0749 | Osteogenesis stimulator (surg) | $3,161 | $2,371 | $316 |
E0755 | Elect salivary reflex stimulator | B.R. | B.R. | B.R. |
E0760 | Osteogen ultrasound stimltor | $4,515 | $3,386 | $451 |
E0761 | Nontherm electromgntc device | B.R. | B.R. | B.R. |
E0762 | Trans elec jt stim dev sys | $1,535 | $1,152 | $154 |
E0764 | Functional neuromuscularstim | $15,453 | $11,590 | $1,545 |
E0765 | Nerve stimulator for tx n and v | $117 | $88 | $12 |
E0769 | Electric wound treatment dev | B.R. | B.R. | B.R. |
E0770 | Functional electric stim NOS | B.R. | B.R. | B.R. |
E0776 | IV pole | $150 | $110 | $23 |
E0779 | Amb infusion pump mechanical | $23 | ||
E0780 | Mech amb infusion pump <8hrs | $14 | ||
E0781 | Ambulatory infusion pump, sgl/mul | $3,304 | $2,478 | $330 |
E0782 | Infusion pump, implantable | $4,258 | $3,193 | $426 |
E0783 | Programmable infusion pump | $11,432 | $8,574 | $1,143 |
E0784 | Ext amb infusn pump insulin | $583 | ||
E0785 | Replacement impl pump cathet | $660 | ||
E0786 | Implantable pump replacement | $11,151 | $8,363 | $1,115 |
E0791 | Parent infus pump, stationary | $3,317 | $2,488 | $332 |
E0830 | Ambulatory traction device | B.R. | B.R. | B.R. |
E0840 | Traction frame, att, simp cerv tr | $80 | $60 | $17 |
E0849 | Cervical pneum trac equip | $720 | $540 | $72 |
E0850 | Traction stand, free, simp cervic | $110 | $83 | $16 |
E0855 | Cervical traction equipment | $702 | $526 | $70 |
E0856 | Cervic collar w air bladder | $215 | $161 | $22 |
E0860 | Traction equip, ovrdoor, cervical | $58 | $44 | $12 |
E0870 | Traction frame, att, simple extrm | $122 | $92 | $16 |
E0880 | Traction stand, free, simple extr | $132 | $100 | $22 |
E0890 | Traction frame, footboard, pelvic | $149 | $120 | $41 |
E0900 | Traction stand, free, pelvic trac | $158 | $119 | $34 |
E0910 | Trapeze bars, att to bed, w/grab | $232 | $174 | $23 |
E0911 | HD trapeze bar attach to bed | $60 | ||
E0912 | HD trapeze bar free standing | $138 | ||
E0920 | Fx frame, att to bed, inc. weights | $487 | $365 | $49 |
E0930 | Fx frame, free, includes weights | $479 | $360 | $48 |
E0935 | Passive motion exercise device | $6,134 | $4,601 | $613 |
E0936 | CPM device, other than knee | B.R. | B.R. | B.R. |
E0940 | Trapeze bar, free, w/grab bar | $365 | $274 | $36 |
E0941 | Gravity asst traction device, any | $487 | $365 | $49 |
E0942 | Cervical head harness/halter | $21 | $16 | $2 |
E0944 | Pelvic belt/harness/boot | $48 | $36 | $5 |
E0945 | Extrm belt/harness | $47 | $36 | $5 |
E0946 | Fx frame, dual w/cross bars, att | $621 | $465 | $62 |
E0947 | Fx frame, attachments pelv tract | $636 | $477 | $66 |
E0948 | Fx frame, attachments cerv tract | $615 | $434 | $62 |
E0950 | Tray | $109 | $82 | $12 |
E0951 | Loop heel, ea | $20 | $15 | $2 |
E0952 | Loop toe, ea | $23 | $17 | $2 |
E0955 | Cushioned headrest | $282 | $212 | $28 |
E0956 | W/c lateral trunk/hip suppor | $138 | $103 | $14 |
E0957 | W/c medial thigh support | $193 | $144 | $19 |
E0958 | Wheelchair attachment | $539 | $404 | $54 |
E0959 | Amputee adapter | $109 | $83 | $11 |
E0960 | W/c shoulder harness/straps | $127 | $95 | $13 |
E0961 | Brake extension, wheelchair | $37 | $28 | $4 |
E0966 | Hook on head rest extension | $86 | $64 | $9 |
E0967 | Wheelchair hand rims | $163 | $122 | $17 |
E0968 | Commode seat, wheelchair | $188 | $141 | $19 |
E0969 | Narrowing device, wheelchair | $164 | $123 | $16 |
E0970 | No.2 footplates, exc elev leg rst | $51 | $38 | $5 |
E0971 | Anti-tipping device wheelchairs | $81 | $61 | $9 |
E0973 | Adj hgt detach arms, full length | $121 | $90 | $11 |
E0974 | "Grade-aid" | $83 | $62 | $9 |
E0978 | Belt, safety w/airplane buckle | $49 | $37 | $5 |
E0980 | Safety vest, wheelchair | $34.67 | $25.87 | $3.45 |
E0981 | Seat upholstery, replacement | $66 | $50 | $7 |
E0982 | Back upholstery, replacement | $72 | $54 | $7 |
E0983 | Add pwr joystick | $349 | ||
E0984 | Add pwr tiller | $2,668 | $2,059 | $248 |
E0985 | W/c seat lift mechanism | $283 | $212 | $28 |
E0986 | Man w/c push-rim pow assist | $6,792 | $5,094 | $679 |
E0988 | Lever-activated wheel drive | $418 | ||
E0990 | Elevating leg rest, ea | $145 | $113 | $16 |
E0992 | Solid seat insert | 121 | 88.08 | 11.42 |
E0994 | Arm rest, ea | $20 | $15 | $2 |
E0995 | Calf rest, ea | $39 | $28 | $4 |
E1002 | Pwr seat tilt | $5,660 | $4,245 | $566 |
E1003 | Pwr seat recline | $6,132 | $4,599 | $613 |
E1004 | Pwr seat recline mech | $5,799 | $5,099 | $680 |
E1005 | Pwr seat recline pwr | $7,359 | $5,520 | $736 |
E1006 | Pwr seat combo w/o shear | $9,015 | $6,761 | $901 |
E1007 | Pwr seat combo w/shear | $12,206 | $9,154 | $1,221 |
E1008 | Pwr seat combo pwr shear | $12,207 | $9,155 | $1,221 |
E1009 | Add mech leg elevation | B.R. | B.R. | B.R. |
E1010 | Add pwr leg elevation | $1,597 | $1,198 | $160 |
E1011 | Ped wc modify width adjustm | B.R. | B.R. | B.R. |
E1014 | Reclining back add ped w/c | $510 | $382 | $51 |
E1015 | Shock absorber for man w/c | $160 | $120 | $16 |
E1016 | Shock absorber for power w/c | $183 | $138 | $18 |
E1017 | HD shck absrbr for hd man wc | B.R. | B.R. | B.R. |
E1018 | HD shck absrber for hd powwc | B.R. | B.R. | B.R. |
E1020 | Residual limb support system | $340 | $255 | $34 |
E1028 | W/c manual swingaway | $288 | $216 | $7 |
E1029 | W/c vent tray fixed | $516 | $387 | $52 |
E1030 | W/c vent tray gimbaled | $1,627 | $1,220 | $163 |
E1031 | Rollabout chair, w/castors 5" > | $530 | $397 | $53 |
E1035 | Patient transfer system <301 | $856 | ||
E1036 | Patient transfer system 300 | $1,200 | ||
E1037 | Transport chair, ped size | $151 | ||
E1038 | Transport chair pt wt <=300lb | $25 | ||
E1039 | Transport chair pt wt 300lb | $48 | ||
E1050 | Fully-recl wheelchair, fixed arms | $1,257 | $943 | $126 |
E1060 | Fully-recl wheelchair, detac arms | $1,352 | $1,014 | $135 |
E1070 | Fully-recl wheelchair, detach arm | $1,352 | $1,014 | $135 |
E1083 | Hemi-wheelchair, fixed arms | $972 | $729 | $97 |
E1084 | Hemi-wheelchair, detach arms | $1,132 | $849 | $113 |
E1085 | Hemi-wheelchair, fixed arms | $854 | $641 | $85 |
E1086 | Hemi-wheelchair detach arms | $1,037 | $778 | $104 |
E1087 | Hi strength lightwgt wheelchair | $1,344 | $1,008 | $134 |
E1088 | Hi strength lightwgt wheelchair | $1,582 | $1,186 | $158 |
E1089 | Hi strength lightwgt wheelchair | $1,261 | $946 | $126 |
E1090 | Hi strength lightwgt wheelchair | $1,428 | $1,071 | $143 |
E1092 | Wide heavy duty wheel chair | $1,428 | $1,071 | $143 |
E1093 | Wide heavy duty wheelchair | $1,159 | $870 | $116 |
E1100 | Semi-reclining wheelchair | $1,157 | $867 | $116 |
E1110 | Semi-reclining wheelchair | $1,066 | $800 | $107 |
E1130 | Standard wheelchair, fixed arms | $576 | $432 | $58 |
E1140 | Wheelchair, detachable arms | $834 | $626 | $83 |
E1150 | Wheelchair, detachable arms | $914 | $686 | $91 |
E1160 | Wheelchair, fix full length arms | $763 | $572 | $76 |
E1161 | Manual adult wc w tiltinspac | $3,304 | $2,478 | $330 |
E1170 | Amputee wheelchair, fix arms | $937 | $703 | $94 |
E1171 | Amputee wheelchair, fix arms | $989 | $742 | $99 |
E1172 | Amputee wheelchair, detach arms | $1,209 | $907 | $121 |
E1180 | Amputee wheelchair, detach arms | $1,063 | $797 | $106 |
E1190 | Amputee wheelchair, detach arms | $1,254 | $940 | $125 |
E1195 | Heavy duty wheelchair | $1,428 | $1,071 | $143 |
E1200 | Amputee wheelchair | $1,031 | $774 | $103 |
E1220 | Wheelchair; specially sized | B.R. | ||
E1221 | Wheelchair w/fixed arm, footrests | $499 | $374 | $50 |
E1222 | Wheelchair w/fixed arm, legrests | $763 | $572 | $76 |
E1223 | Wheelchair w/det arms, footrests | $834 | $626 | $83 |
E1224 | Wheelchair w/det arms, legrests | $1,002 | $751 | $100 |
E1225 | Wheelchair; semi-rec back custom | $502 | $377 | $50 |
E1226 | Wheelchair; full rec back custom | $693 | $520 | $69 |
E1227 | Special height arms wheelchair | $291 | $218 | $29 |
E1228 | Special back height wheelchair | $318 | $239 | $32 |
E1229 | Pediatric wheelchair NOS | B.R. | B.R. | B.R. |
E1230 | Power operated vehicle | $2,479 | $2,208 | $248 |
E1231 | Rigid ped w/c tilt-in-space | B.R. | ||
E1232 | Folding ped wc tilt-in-space | $2,986 | $2,240 | $299 |
E1233 | Rig ped wc tltnspc w/o seat | $3,094 | $2,320 | $309 |
E1234 | Fld ped wc tltnspc w/o seat | $2,694 | $2,020 | $269 |
E1235 | Rigid ped wc adjustable | $2,594 | $1,945 | $259 |
E1236 | Folding ped wc adjustable | $2,288 | $1,716 | $229 |
E1237 | Rgd ped wc adjstabl w/o seat | $2,308 | $1,731 | $231 |
E1238 | Fld ped wc adjstabl w/o seat | $2,288 | $1,716 | $229 |
E1239 | Ped power wheelchair NOS | B.R. | B.R. | B.R. |
E1240 | Lightweight wheelchair | $1,081 | $811 | $108 |
E1250 | Lightweight wheelchair | $938 | $704 | $94 |
E1260 | Lightweight wheelchair | $1,150 | $863 | $115 |
E1270 | Lightweight wheelchair | $953 | $715 | $95 |
E1280 | Heavy duty wheelchair | $1,377 | $1,033 | $138 |
E1285 | Heavy duty wheelchair | $1,265 | $949 | $127 |
E1290 | Heavy duty wheelchair | $1,313 | $985 | $131 |
E1295 | Heavy duty wheelchair | $1,274 | $956 | $127 |
E1296 | Special wheelchair seat | $607 | $455 | $62 |
E1297 | Special wheelchair seat | $129 | $97 | $14 |
E1298 | Special wheelchair seat | $523 | $392 | $54 |
E1300 | Whirlpool, portable (overtub) | B.R. | ||
E1310 | Whirlpool, non-port (built-in) | $2,650 | $1,988 | $227 |
E1353 | Regulator | B.R. | ||
E1354 | Wheeled cart, port cyl/conc | B.R. | B.R. | B.R. |
E1355 | Stand/rack | B.R. | B.R. | B.R. |
E1356 | Batt pack/cart, port conc | B.R. | B.R. | B.R. |
E1357 | Battery charger, port conc | B.R. | B.R. | B.R. |
E1358 | DC power adapter, port conc | B.R. | B.R. | B.R. |
E1372 | Immersion ext heater nebulizer | $201 | $149 | $29 |
E1390 | Oxygen concentrator | $229 | ||
E1391 | Oxygen concentrator, dual | $229 | ||
E1392 | Portable oxygen concentrator | $67 | ||
E1399 | Durable medical equipment, misc | B.R. | ||
E1405 | O2 and water vapor enriching system | B.R. | ||
E1406 | O2 and water vapor enriching system | B.R. | ||
E1500 | Centrifuge | B.R. | B.R. | B.R. |
E1510 | Kidney, dialysate delivery system | B.R. | ||
E1520 | Heparin infusion pump dialysis | B.R. | ||
E1530 | Air bubble detector dialysis | B.R. | ||
E1540 | Pressure alarm dialysis | B.R. | ||
E1550 | Bath conductivity meter dialysis | B.R. | ||
E1560 | Blood leak detector dialysis | B.R. | ||
E1570 | Adj chair, esrd patients | B.R. | ||
E1575 | Transduc protectrs/fluid barriers | B.R. | ||
E1580 | Unipunct control system dialysis | B.R. | ||
E1590 | Hemodialysis machine | B.R. | ||
E1592 | Auto interm perit dialysis system | B.R. | ||
E1594 | Cycler dialysis mach perit dial | B.R. | ||
E1600 | Delv/install charges dialysis equ | B.R. | ||
E1610 | Rev osmosis water purif system | B.R. | ||
E1615 | Deionizer water purif system | B.R. | ||
E1620 | Blood pump dialysis | B.R. | ||
E1625 | Water softening system | B.R. | ||
E1630 | Recipro peritoneal dialysis sys | B.R. | ||
E1632 | Wearable artificial kidney | B.R. | ||
E1634 | Peritoneal dialysis clamp | B.R. | B.R. | B.R. |
E1635 | Compact travel hemodialyzer sys | B.R. | ||
E1636 | Sorbent cartridges, per case | B.R. | ||
E1637 | Hemostats for dialysis, each | B.R. | B.R. | B.R. |
E1639 | Dialysis scale | B.R. | B.R. | B.R. |
E1699 | Dialysis equip, uns, by report | B.R. | ||
E1700 | Jaw motion rehabilitation system | $362 | $271 | $35 |
E1701 | Repl cushions jaw motion rehab | $13 | $10 | $1 |
E1702 | Repl Measuring Scales Jaw Motion | $24 | $18 | $2 |
La. Admin. Code tit. 40, § I-4119