La. Admin. Code tit. 40 § I-4339

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-4339 - Schedule of Maximum Allowances and Procedural Codes

A. This maximum allowable reimbursement schedule provides the basis for identification of prosthetic and orthopedic equipment reimbursable to providers. the coding system used is the health care financing administration common procedure coding system (HCPCS). No other coding methodology will be accepted for this program. Invoices submitted to the carrier/self-insured employer should be billed at the providers usual and customary rate, not the maximum allowable charge designated in this fee schedule. Reimbursement is limited to the least of:

1. the provider's usual and customary charge; or

2. a previously negotiated amount by the provider and carrier/self-insured employer; or

3. the allowable reimbursement schedule.

B. Prosthetic and Orthopedic Equipment

Office of Workers' Compensation Schedule of Maximum Allowances for Prosthetic and Orthopedic Equipment
HCPCS	Description	Purchase New
L0112	Cranial cervical orthosis	$2,007
L0113	Cranial cervical torticollis	$410
L0120	Cerv, flex, non-adj (foam collar)	$24
L0130	Cerv, flex, thermoplastic collar	$149
L0140	Cerv, semi-rigid, adj	$60
L0150	Cerv, semi-rigid, adj chin cup	$99
L0160	Cerv, semi-rigid, occ/mand supp	$191
L0170	Cerv, collar, molded to pat model	$626
L0172	Cerv, collar, semi-rigid thermopl	$129
L0174	Cerv, collar, semi-rigid, thermop	$251
L0180	Cerv, mult post collar, occ/mandi	$377
L0190	Cerv, mult post collar, occ/mandi	$488
L0200	Cerv, mult post collar, occ/mandi	$545
L0220	Thoracic, rib belt, custom made	$149
L0430	TLSO, a-p-l rotary control	$1,493.73
L0450	TLSO flex prefab thoracic	$261
L0452	TLSO flex custom fab thoraci	B.R.
L0456	TLSO flex prefab	$1,426
L0458	TLSO 2Mod symphis-xipho pre	$1,279
L0460	TLSO2Mod symphysis-stern pre	$1,440
L0462	TLSO 3Mod sacro-scap pre	$1,791
L0464	TLSO 4Mod sacro-scap pre	$2,132
L0466	TLSO rigid frame pre soft ap	$561
L0468	TLSO rigid frame prefab pelv	$688
L0470	TLSO rigid frame pre subclav	$957
L0472	TLSO rigid frame hyperex pre	$607
L0480	TLSO rigid plastic custom fa	$2,138
L0482	TLSO rigid lined custom fab	$2,328
L0484	TLSO rigid plastic cust fab	$2,668
L0486	TLSO rigidlined cust fab two	$2,830
L0488	TLSO rigid lined pre one pie	$1,440
L0490	TLSO rigid plastic pre one	$406
L0491	TLSO 2 piece rigid shell	$1,102
L0492	TLSO 3 piece rigid shell	$715
L0621	SIO flex pelvisacral prefab	$138
L0622	SIO flex pelvisacral custom	$388
L0623	SIO panel prefab	B.R.
L0624	SIO panel custom	B.R.
L0625	LO flexibl L1-below L5 pre	$79
L0626	LO sag stays/panels pre-fab	$112
L0627	LO sagitt rigid panel prefab	$590
L0628	LO flex w/o rigid stays pre	$120
L0629	LSO flex w/rigid stays cust	B.R.
L0630	LSO post rigid panel pre	$232
L0631	LSO sag-coro rigid frame pre	$1,473
L0632	LSO sag rigid frame cust	B.R.
L0633	LSO flexion control prefab	$411
L0634	LSO flexion control custom	B.R.
L0635	LSO sagit rigid panel prefab	$1,437
L0636	LSO sagittal rigid panel cus	$2,127
L0637	LSO sag-coronal panel prefab	$1,683
L0638	LSO sag-coronal panel custom	$1,892
L0639	LSO s/c shell/panel prefab	$1,683
L0640	LSO s/c shell/panel custom	$1,501
L0700	CTLSO	$1,878
L0710	CTLSO, a-p-l-control, molded	$2,023
L0810	Halo proc, cerv halo jacket	$2,506
L0820	Halo proc, cerv halo plaster body	$2,114
L0830	Halo proc, cerv halo Milwaukee type	$3,387
L0859	MRI compatible system	$1,829
L0861	Halo repl liner/interface	$309
L0970	TLSO, corset front	$133
L0972	LSO, corset front	$122
L0974	TLSO, full corset	$184
L0976	LSO, full corset	$172
L0978	Axillary crutch extension	$180
L0980	Peroneal straps, pair	$21
L0982	Stocking supp grips, set four	$20
L0984	Protective body sock, each	$56
L0999	Add to spinal orthosis NOS	B.R.
L1000	CTLSO (Milwaukee), inclusive	$2,020
L1001	CTLSO infant immobilizer	B.R.
L1005	Tension based scoliosis orth	$4,590.55
L1010	Add to CTLSO	$72
L1020	Add to CTLSO, kyphosis pad	$100
L1025	Add to CTLSO, kyphosis pad, floatin	$114
L1030	Add to CTLSO, lumbar	$78
L1040	Add to CTLSO, lumbar	$81
L1050	Add to CTLSO, sternal pad	$98
L1060	Add to CTLSO, thoracic pad	$95
L1070	Add to CTLSO, trapezius	$93
L1080	Add to CTLSO, outrigger	$52
L1085	Add to CTLSO, outrigger	$158
L1090	Add to CTLSO, lumbar sling	$94
L1100	Add to CTLSO, ring flange	$162
L1110	Add to CTLSO, ring flange	$236
L1120	Add to CTLSO, cover	$43
L1200	TLSO, inclusive furnishing	$1,649
L1210	Add to TLSO, lat thoracic ext	$239
L1220	Add to TLSO, ant thoracic ext	$232
L1230	Add to TLSO, milw type superstruc	$520
L1240	Add to TLSO, lumb derotation pad	$77
L1250	Add to TLSO, ant asis pad	$74
L1260	Add to TLSO, ant thor derot pad	$75
L1270	Add to TLSO, abdominal pad	$72
L1280	Add to TLSO, rib gusset	$79
L1290	Add to TLSO, lat troch pad	$72
L1300	Oth scolio proc, body jacket	$1,762
L1310	Oth scolio proc, postop body jack	$1,697
L1499	Unlisted proc spinal orthosis	B.R.
L1600	HO, abd cont hip jnts, flex	$157
L1610	HO, abd cont hip jnts, flex, frej	$42
L1620	HO, abd cont hip jnts, flex, pavl	$123
L1630	HO, abd cont hip jnts, semi-flex	$155
L1640	HO, abd cont hip jnts, stat, pelv	$486
L1650	HO, abd cont hip jnts, stat, adj	$223
L1652	HO bi thighcuffs w sprdr bar	$511
L1660	HO, abd cont hip jnts, static	$209
L1680	HO, abd cont hip jnts, dyn, pel	$1,318
L1685	HO, abd cont hip jnt, postop	$1,088
L1686	HO, abd cont hip jnt, postop	$835
L1690	Combination bilateral HO	$511
L1700	Legg perthes ortho, Toronto	$1,570
L1710	Legg perthes ortho, Newington	$2,018
L1720	Legg perthes ortho, trilateral	$1,497
L1730	Legg perthes ortho, Scottish rite	$1,185
L1755	Legg perthes ortho, patten bottom	$1,448.82
L1810	KO, elastic w/joints	$98
L1820	KO, elastic w/condylar pads and joint	$132
L1830	KO, immobilizer, canvas longitud	$80
L1831	Knee orth pos locking joint	$422
L1832	KO, adj knee joints, pos orthosis	$556
L1834	KO, w/o knee joint, rigid, molded	$710
L1836	Rigid KO wo joints	$191
L1840	KO, derotation, m-l ant cruc lig	$1,034
L1843	KO single upright custom fit	$1,287
L1844	KO, sngl upright, thigh and calf	$795
L1845	KO, dbl upright, thigh and calf	$857
L1846	KO, dbl upright, thigh and calf	$1,059
L1847	KO adjustable w air chambers	$825
L1850	KO, Swedish type	$305
L1860	KO, mod supracond prosth socket	$1,000.78
L1900	AFO, spring wire, dorsiflex asst	$317
L1902	AFO, ankle gauntlet, custom fit	$97
L1904	AFO, molded ankle gauntlet, mold	$430
L1906	AFO, multilig ankle support	$110
L1907	AFO supramalleolar custom	$807
L1910	AFO, post, single bar, clasp atta	$276
L1920	AFO, sngl upright w/stat/adj stop	$331
L1930	AFO, custom fitted, plastic	$289
L1932	Afo rig ant tib prefab TCF/=	$1,280
L1940	AFO, molded to patient, plastic	$463
L1945	AFO, molded to patient, plastic	$847
L1950	AFO, spiral, molded to patient	$684
L1951	AFO spiral prefabricated	$1,205
L1960	AFO, post solid ankle, molded	$507
L1970	AFO, plastic molded to patient	$651
L1971	AFO w/ankle joint, prefab	$672
L1980	AFO, single upright free plantar	$351
L1990	AFO, double upright free plantar	$408
L2000	KAFO, single upright, free	$928
L2005	KAFO sng/dbl mechanical act	$5,879
L2010	KAFO, single upright, free ankle	$906
L2020	KAFO, double upright, free knee	$1,069
L2030	KAFO, double upright, free ankle	$937
L2034	KAFO pla sin up w/wo k/a cus	$2,939
L2035	KAFO plastic pediatric size	$250
L2036	KAFO, full plastic, double upright	$1,784
L2037	KAFO, full plastic, single upright	$1,524
L2038	KAFO, full plastic, w/o knee joint	$1,308
L2040	HKAFO, torsion control, bilateral	$162
L2050	HKAFO, torsion control, bilateral	$517
L2060	HKAFO, torsion control, bilateral	$598
L2070	HKAFO, torsion control, unilat	$124
L2080	HKAFO, torsion control, unilat	$352
L2090	HKAFO, torsion control, unilat	$426
L2106	AFO, fx ortho, tib fx cast	$766
L2108	AFO, fx ortho, tib fx cast	$1,064
L2112	AFO, fx ortho, tib fx orthosis	$518
L2114	AFO, fx ortho, tib fx orthosis	$600
L2116	AFO, fx ortho, tib fx orthosis	$719
L2126	KAFO, fx ortho, fem fx cast	$1,096
L2128	KAFO, fx ortho, fem fx cast	$1,569
L2132	KAFO, fx ortho, fem fx cast	$833
L2134	KAFO, fx ortho, fem fx cast	$1,042
L2136	KAFO, fx ortho, fem fx cast	$1,179
L2180	Add to lwr extrm fx ortho	$143
L2182	Add to lwr extrm fx ortho	$105
L2184	Add to lwr extrm fx ortho	$136
L2186	Add to lwr extrm fx ortho	$138
L2188	Add to lwr extrm fx ortho	$321
L2190	Add to lwr extrm fx ortho	$92
L2192	Add to lwr extrm fx ortho	$361
L2200	Add to lwr extrm, limited ankle	$58
L2210	Add to lwr extrm, dorsiflexion	$62
L2220	Add to lwr extrm, dorsiflexion	$80
L2230	Add to lwr extrm, split flat	$74
L2232	Rocker bottom, contact AFO	$140
L2240	Add to lwr extrm, round caliper	$77
L2250	Add to lwr extrm, foot plate	$325
L2260	Add to lwr extrm, stirrup	$189
L2265	Add to lwr extrm, stirrup	$144
L2270	Add to lwr extrm, varus/valgus	$49
L2275	Varus/vulgus correction, plastic	$120
L2280	Add to lwr extrm, inner boot	$414
L2300	Add to lwr extrm, abduction bar	$329
L2310	Add to lwr extrm, abduction bar	$150
L2320	Add to lwr extrm, non-mold lacer	$205
L2330	Add to lwr extrm, lacer molded	$381
L2335	Add to lwr extrm, ant swing band	$208
L2340	Add to lwr extrm, pre-tib shell	$507
L2350	Add to lwr extrm, socket, molded	$869
L2360	Add to lwr extrm, steel shank	$63
L2370	Add to lwr extrm, patten bottom	$269
L2375	Add to lwr extrm, torsion control	$138
L2380	Add to lwr extrm, torsion control	$150
L2385	Add to lwr extrm, knee joint	$158
L2390	Add to lwr extrm, knee joint	$100
L2395	Add to lwr extrm, knee joint	$191
L2397	Orthosis, suspension sleeve	$107
L2405	Add to knee joint, drop lock	$54
L2415	Add to knee joint, cam lock	$172
L2425	Add to knee joint, disc/dial loc	$168
L2492	Add to knee joint, drop lock ring	$104
L2500	Add to lwr extrm, thigh/weight	$337
L2510	Add to lwr extrm, thigh/weight	$764
L2520	Add to lwr extrm, thigh/weight	$482
L2525	Add to lwr extrm, thigh/weight	$1,116
L2526	Add to lwr extrm, thigh/weight	$627
L2530	Add to lwr extrm, thigh/weight	$217
L2540	Add to lwr extrm, thigh/weight	$412
L2550	Add to lwr extrm, thigh/weight	$263
L2570	Add to lwr extrm, hip joint	$581
L2580	Add to lwr extrm, pelvic sling	$425
L2600	Add to lwr extrm, hip joint	$251
L2610	Add to lwr extrm, hip joint	$296
L2620	Add to lwr extrm, hip joint	$286
L2622	Add to lwr extrm, hip joint	$374
L2624	Add to lwr extrm, hip joint	$325
L2627	Add to lwr extrm, plastic, mold	$1,569
L2628	Add to lwr extrm, metal frame	$1,533
L2630	Add to lwr extrm, band and belt	$268
L2640	Add to lwr extrm, band and belt	$352
L2650	Add to lwr extrm, pel/thor contr	$132
L2660	Add to lwr extrm, thoracic contr	$206
L2670	Add to lwr extrm, thoracic contr	$208
L2680	Add to lwr extrm, thoracic contr	$191
L2750	Add to lwr extrm ortho, plating	$101
L2755	Carbon graphite lamination	$187
L2760	Add to lwr extrm ortho, extens	$74
L2768	Ortho sidebar disconnect	$187
L2780	Add to lwr extrm ortho, non-corr	$62
L2785	Add to lwr extrm ortho, retainer	$29
L2795	Add to lwr extrm ortho, knee con	$90
L2800	Add to lwr extrm ortho, knee con	$98
L2810	Add to lwr extrm ortho, knee con	$80
L2820	Add to lwr extrm ortho, soft int	$79
L2830	Add to lwr extrm ortho, soft int	$86
L2840	Add to lwr extrm ortho, tib sock	$53
L2850	Add to lwr extrm ortho, fem sock	$61
L2861	Torsion mechanism knee/ankle	B.R.
L2999	Unlisted proc lwr extrm orthoses	B.R.
L3000	Foot, insert, "UCB" type	$162
L3001	Foot, insert, spenco	$38
L3002	Foot, insert, plastazote	$81
L3003	Foot, insert, silicone	$162
L3010	Foot, insert, longitudinal	$128
L3020	Foot, insert, longitudinal	$136
L3030	Foot, insert, removable, formed	$41
L3031	Foot lamin/prepreg composite	B.R.
L3040	Foot, arch support, longitudinal	$41
L3050	Foot, arch support, metatarsal	$41
L3060	Foot, arch support, longitudinal	$54
L3070	Foot, arch support, nonremovable	$34
L3080	Foot, arch support, nonremovable	$34
L3090	Foot, arch support, nonremovable	$47
L3100	Hallus-valgus night dyn splint	$41
L3140	Foot, abduction rotation bars	$61
L3150	Foot, abduction rotation bars	$61
L3160	Shoe styled positioning dev	B.R.
L3170	Foot, plastic heel stabilzer	$20
L3201	Ortho shoe, oxford, infant	$50
L3202	Ortho shoe, oxford, child	$55
L3203	Ortho shoe, oxford, junior	$70
L3204	Ortho shoe, hightop, infant	$63
L3206	Ortho shoe, hightop, child	$53
L3207	Ortho shoe, hightop junior	$55
L3208	Surgical boot, ea, infant	$25
L3209	Surgical boot, ea, child	$30
L3211	Surgical boot, ea, junior	$58
L3212	Benesch boot, pair, infant	$66
L3213	Benesch boot, pair, child	B.R.
L3214	Benesch boot, pair, junior	B.R.
L3215	Ortho shoes, ladies, oxford	$108
L3216	Ortho shoes, ladies, depth inlay	$150
L3217	Ortho shoes, ladies, hightop	$163
L3218	Ortho shoes, ladies, surg boot	$145
L3219	Ortho shoes, mens, oxford	$126
L3221	Ortho shoes, mens, depth inlay	$150
L3222	Ortho shoes, mens, hightop	$163
L3224	Woman's shoe oxford brace	$88
L3225	Man's shoe oxford brace	$102
L3230	Ortho shoes, custom, depth inlay	$482
L3250	Ortho shoes, custom molded	$270
L3251	Foot, shoe molded to patient	B.R.
L3252	Foot, shoe molded to patient	$121
L3253	Foot, molded shoe plastazote	$114
L3254	Non-std size/width	$193
L3255	Non-std size/length	$193
L3257	Ortho shoes, add chrg split size	B.R.
L3260	Ambulatory surgical boot, ea	$114
L3265	Plastazote sandal, ea	$54
L3300	Lift, elevation, heel	$54
L3310	Lift, elevation, heel and sole	$47
L3320	Lift, elevation, heel and sole	$114
L3330	Lift, elevation, metal extension	$471
L3332	Lift, elevation, inside shoe	$27
L3334	Lift, elevation, heel, per inch	$54
L3340	Heel wedge, sach	$27
L3350	Heel wedge	$13
L3360	Sole wedge, outside sole	$13
L3370	Sole wedge, between sole	$34
L3380	Clubfoot wedge	$34
L3390	Outflare wedge	$34
L3400	Metatarsal bar wedge, rocker	$30
L3410	Metatarsal bar wedge, betw sole	$47
L3420	Full sole and heel wedge, betw sole	$54
L3430	Heel, counter, plastic reinforced	$67
L3440	Heel, counter, leather reinforced	$47
L3450	Heel, sach cushion type	$27
L3455	Heel, new leather, std	$16
L3460	Heel, new rubber, std	$13
L3465	Heel, Thomas w/wedge	$16
L3470	Heel, Thomas extended to ball	$54
L3480	Heel, pad and depression spur	$41
L3485	Heel, pad, removable spur	B.R.
L3500	Misc shoe add, insole, leather	$47
L3510	Misc shoe add, insole, rubber	B.R.
L3520	Misc shoe add, insole, felt	B.R.
L3530	Misc shoe add, sole, half	B.R.
L3540	Misc shoe add, sole, full	B.R.
L3550	Misc shoe add, toe tap, std	B.R.
L3560	Misc shoe add, toe tap, horseshoe	B.R.
L3570	Misc shoe add, special extension	B.R.
L3580	Misc shoe add, convert instep	B.R.
L3590	Misc shoe add, convert firm shoe	B.R.
L3595	Misc shoe add, march bar	B.R.
L3600	Trans ortho one to anoth, caliper	$67
L3610	Trans ortho one to anoth, caliper	$54
L3620	Trans ortho one to anoth, solid	$67
L3630	Trans ortho one to anoth, solid	$67
L3640	Trans ortho one to anoth, dennis	$34
L3649	Unlisted proc foot ortho shoes	B.R.
L3650	SO, figure "8" design abduction	$58
L3660	SO, figure "8" design abduction	$92
L3670	SO, acromio/clavicular	$105
L3671	SO cap design w/o jnts CF	$1,176
L3674	SO airplane w/wo joint CF	$1,543
L3675	Canvas vest SO	$229
L3677	SO hard plastic stabilizer	B.R.
L3702	EO w/o joints CF	$377
L3710	EO, elastic w/metal joints	$133
L3720	EO, dbl upright w/forearm/arm cuffs	$679
L3730	EO, dbl upright w/forearm/arm cuffs	$994
L3740	EO, dbl upright w/forearm/arm cuffs	$1,276
L3760	EO withjoint, Prefabricated	$653
L3762	Rigid EO wo joints	$140
L3763	EWHO rigid w/o jnts CF	$961
L3764	EWHO w/joint(s) CF	$1,085
L3765	EWHFO rigid w/o jnts CF	$1,674
L3766	EWHFO w/joint(s) CF	$1,772
L3806	WHFO w/joint(s) custom fab	$593
L3807	WHFO,no joint, prefabricated	$326
L3808	WHFO, rigid w/o joints	$486
L3900	WHFO, dynamic flexor hinge	$1,170
L3901	WHFO, dynamic flexor hinge	$1,439
L3904	WHFO, ext powered, electric	$2,622.33
L3905	WHO w/nontorsion jnt(s) CF	$1,294
L3906	WHFO, wrist gauntlet, patient model	$354
L3908	WHFO, wrist extension cock-up	$54
L3912	WHFO, flex glove w/finger control	$111.63
L3913	HFO w/o joints CF	$354
L3915	WHO w nontor jnt(s) prefab	$694
L3916	WHFO, wrist extension cock-up	$152
L3917	Prefab metacarpl fx orthosis	$138
L3919	HO w/o joints CF	$354
L3921	HFO w/joint(s) CF	$419
L3923	HFO w/o joints PF	$128
L3925	FO pip/dip with joint/spring	$73
L3927	FO pip/dip w/o joint/spring	$46
L3929	HFO nontorsion joint, prefab	$115
L3931	WHFO nontorsion joint prefab	$268
L3933	FO w/o joints CF	$279
L3935	FO nontorsion joint CF	$288
L3956	Add joint upper ext orthosis	B.R.
L3960	SEWHO, abduction	$802.41
L3961	SEWHO cap design w/o jnts CF	$2,193
L3962	SEWHO, abduction positioning, erbs	$642
L3967	SEWHO airplane w/o jnts CF	$2,589
L3971	SEWHO cap design w/jnt(s) CF	$2,458
L3973	SEWHO airplane w/jnt(s) CF	$2,589
L3975	SEWHFO cap design w/o jnt CF	$2,193
L3976	SEWHFO airplane w/o jnts CF	$2,193
L3977	SEWHFO cap desgn w/jnt(s) CF	$2,458
L3978	SEWHFO airplane w/jnt(s) CF	$2,589
L3980	Upr extrm fx ortho, humeral	$330
L3982	Upr extrm fx ortho, radius/ulnar	$372
L3984	Upr extrm fx ortho, wrist	$324
L3985	Upr extrm fx ortho, forearm, hand	$523
L3999	Unlisted proc upr limb orthosis	B.R.
L4000	Repl girdle Milwaukee orthosis	$1,233
L4002	Replace strap, any orthosis	B.R.
L4010	Repl trilateral socket brim	$630
L4020	Repl quad socket brim, molded	$922
L4030	Repl quad socket brim, custom	$603
L4040	Repl molded thigh lacer	$393
L4045	Repl nonmolded thigh lacer	$300
L4050	Repl molded calf lacer	$378
L4055	Repl non-molded calf lacer	$249
L4060	Repl high roll cuff	$291
L4070	Repl prox and dist upright KAFO	$324
L4080	Repl met bands KAFO, prox thigh	$93
L4090	Repl met bands KAFO-AFO, calf/thigh	$105
L4100	Repl leath cuff KAFO, prox thigh	$107
L4110	Repl leath cuff KAFO-AFO, calf/thigh	$86
L4130	Repl pretibial shell	$529
L4205	Ortho dvc repair per 15 min	B.R.
L4210	Repair orthotic device, minor parts	$57
L4350	Pneumatic ankle control splint	$84
L4370	Pneumatic full leg splint	$173
L4386	Non-pneum walk boot prefab	$227
L4392	Replace AFO soft interface	$34
L4394	Replace foot drop spint	$25
L4396	Static AFO	$240
L4631	Afo, walk boot type, cus fab	$2,212
L5000	Part foot, shoe insrt w/arch, toe	$657
L5010	Part foot, mold sockt, w/toe filler	$1,491
L5020	Part foot, mold sockt, tib hght	$2,240
L5050	Ankle, Symes, mold socket, sach	$2,820
L5060	Ankle, Symes, metal frame, molded l	$3,187
L5100	Below knee, molded socket, shin	$2,771
L5105	Below knee, plastic socket	$3,387
L5150	Knee disartic, molded socket, ext	$4,037
L5160	Knee disartic, molded socket, bent	$4,247
L5200	Above knee, mold socket, sngl axis	$3,691
L5210	Above knee, shrt prosth, no knee	$2,728
L5220	Above knee, shrt prosth, no knee	$3,428
L5230	Above knee, prox fem focal defic	$4,063
L5250	Hip disartic, Canadian type; molded	$5,500
L5270	Hip disartic, tilt table type; mold	$5,227
L5280	Hemipelvectomy, Canadian type; molded	$5,689
L5300	Below knee, molded socket, sach ft	$3,211
L5301	BK mold socket SACH ft endo	$3,672
L5312	Knee disart, SACH ft, endo	$5,276
L5321	AK open end SACH	$5,257
L5331	Hip disart canadian SACH ft	$7,438
L5341	Hemipelvectomy canadian SACH	$8,083
L5400	Immed postop/early fitting	$1,390
L5410	Immed postop/early fitting	$543
L5420	Immed postop/early fitting	$1,781
L5430	Immed postop/early fitting	$654
L5450	Immed postop/early fitting	$530
L5460	Immed postop/early fitting	$709
L5500	Init, below knee "PTB" type socket	$1,399
L5505	Init, above knee, ischial level soc	$2,261
L5510	Prep, below knee "PTB" type socket	$1,663
L5520	Prep, below knee "PTB" type socket	$1,869
L5530	Prep, below knee "PTB" type socket	$1,932
L5535	Prep, below knee "PTB" type	$1,936
L5540	Prep, below knee "PTB" type	$2,075
L5560	Prep, above knee-knee disarticulat	$2,496
L5570	Prep, above knee-knee disarticulat	$2,464
L5580	Prep, above knee-knee disarticulat	$2,752
L5585	Prep, above knee-knee disarticulat	$2,761
L5590	Prep, above knee-knee disarticulat	$2,701
L5595	Prep, hip disartic-hemipelvectomy	$3,926
L5600	Prep, hip disartic-hemipelvectomy	$4,335
L5610	Add to lwr extrm, above knee, hydra	$2,339
L5611	Add to lwr extrm, above knee-knee	$1,571
L5613	Add to lwr extrm, above knee-knee	$2,419
L5614	Abv knee-knee disartic	$3,877
L5616	Add to lwr extrm, above knee, univ	$1,765
L5617	AK/BK self-aligning unit ea	$809
L5618	Add to lwr extrm, test sockt, Symes	$295
L5620	Add to lwr extrm, test sockt	$361
L5622	Add to lwr extrm, test sockt, knee	$471
L5624	Add to lwr extrm, test sockt	$473
L5626	Add to lwr extrm, test sockt, hip	$519
L5628	Add to lwr extrm, test sockt, hemi	$560
L5629	Add to lwr extrm, below knee, acry	$413
L5630	Add to lwr extrm, Symes type, expa	$504
L5631	Add to lwr extrm, above knee/knee	$571
L5632	Add to lwr extrm, Symes type	$216
L5634	Add to lwr extrm, Symes type, post	$297
L5636	Add to lwr extrm, Symes type, med	$248
L5637	Add to lwr extrm, below knee, tot	$376
L5638	Add to lwr extrm, below knee, leat	$492
L5639	Add to lwr extrm, below knee, wood	$1,093
L5640	Add to lwr extrm, knee, leather	$623
L5642	Add to lwr extrm, above knee, leat	$623
L5643	Add to lwr extrm, hip disartic	$1,632
L5644	Add to lwr extrm, above knee, wood	$687
L5645	Add to lwr extrm, below knee, flex	$779
L5646	Add to lwr extrm, below knee, air	$693
L5647	Add to lwr extrm, below knee suct	$776
L5648	Add to lwr extrm, above knee, air	$756
L5649	Add to lwr extrm, Ischial contain	$2,369
L5650	Adds to lwr extrm, total contact	$558
L5651	Add to lwr extrm, above knee, flex	$1,561
L5652	Add to lwr extrm, suction suspens	$496
L5653	Add to lwr extrm, knee disartic	$581
L5654	Add to lwr extrm, sockt insrt, sym	$384
L5655	Add to lwr extrm, sockt insrt, bel	$299
L5656	Add to lwr extrm, sockt insrt	$371
L5658	Add to lwr extrm, sockt insrt, abv	$354
L5661	Add to lwr extrm, sockt insrt, mul	$593
L5665	Add to lwr extrm, sockt insrt, mul	$534
L5666	Add to lwr extrm, below knee, cuff	$91
L5668	Add to lwr extrm, below knee, mold	$131
L5670	Add to lwr extrm, below knee, mold	$353
L5671	BK/AK locking mechanism	$796
L5672	Add to lwr extrm, below knee, remv	$291
L5673	Socket insert w lock mech	$1,069
L5676	Adds to lwr extrm, below knee	$460
L5677	Adds to lwr extrm, below knee	$641
L5678	Adds to lwr extrm, below knee	$52
L5679	Socket insert w/o lock mech	$891
L5680	Add to lwr extrm, below knee, lacer	$318
L5681	Intl custm cong/latyp insert	$1,891
L5682	Add to lwr extrm, below knee, lacer	$622
L5683	Initial custom socket insert	$1,891
L5684	Add to lwr extrm, below knee, strap	$52
L5685	Bk back check	$184
L5686	Add to lwr extrm, below knee, check	$53
L5688	Add to lwr extrm, below knee, belt	$75
L5690	Add to lwr extrm, below knee, belt	$105
L5692	Add to lwr extrm, above knee, belt	$173
L5694	Add to lwr extrm, above knee, belt	$236
L5695	Add to lwr extrm, above knee, belt	$212
L5696	Add to lwr extrm, above knee/disar	$216
L5697	Add to lwr extrm, above knee/disar	$78
L5698	Add to lwr extrm, above knee/disar	$117
L5699	All lwr extrm prosth, shldr harnes	$182
L5700	Repl, socket, blw knee	$2,793
L5701	Repl, socket, abv knee/knee disarti	$3,354
L5702	Repl, socket, hip disarticulation,	$4,244
L5703	Symes ankle w/o (SACH) foot	$3,346
L5704	Repl, cust prot cover, blw knee	$523
L5705	Repl, cust prot cover, abv knee	$934
L5706	Repl, cust prot cover, knee disarti	$915
L5707	Repl, cust prot cover, hip disartic	$1,207
L5710	Add, exo knee-shin sys, manual lock	$417
L5711	Adds exo knee-shin sys, manual lock	$529
L5712	Add, exo knee-shin sys, friction sw	$554
L5714	Add, exo knee-shin sys, variable fr	$468
L5716	Add, exo knee-shin sys, mechanical	$827
L5718	Add, exo knee-shin sys, friction sw	$913
L5722	Add, exo knee-shin sys, pneum swing	$887
L5724	Add, exo knee-shin sys, fluid swing	$1,962
L5726	Add, exo knee-shin sys, ext joints	$2,261
L5728	Add, exo knee-shin sys, fluid swing	$2,416
L5780	Add, exo knee-shin sys, pneumatic	$1,286
L5781	Lower limb pros vacuum pump	$5,750
L5782	HD low limb pros vacuum pump	$6,062
L5785	Add, exo sys, blw knee, ult-lit mat	$565
L5790	Add, exo sys, abv knee, ult-lit mat	$935
L5795	Add, exo sys, hip dis, ult-lit mat	$1,396
L5810	Add, endo knee-shin sys, manual lck	$524
L5811	Add, endo knee-shin sys, manual lck	$776
L5812	Add, endo knee-shin sys, frict swng	$587
L5814	Endo knee-shin hydral swg ph	$5,337
L5816	Add, endo knee-shin sys, mech stanc	$945
L5818	Add, endo knee-shin sys, frict swng	$947
L5822	Add, endo knee-shin sys, pneum swng	$1,660
L5824	Add, endo knee-shin sys, fluid swng	$1,781
L5826	Miniature knee joint	$4,516
L5828	Add, endo knee-shin sys, fluid swng	$2,753
L5830	Add, endo knee-shin sys, pneum swng	$2,030
L5840	Add, endoskel knee/shin sys	$2,355
L5845	Knee-shin sys stance flexion	$2,576
L5848	Knee-shin sys hydraul stance	$1,545
L5850	Add, endo sys, abv knee/hip disart	$166
L5855	Add, hip disarticulation, mech	$335
L5856	Elec knee-shin swing/stance	$34,548
L5857	Elec knee-shin swing only	$12,291
L5858	Stance phase only	$26,708
L5910	Add, endo sys, blw knee, alignable	$471
L5920	Add, endo sys, abv knee/hip disart	$690
L5925	Add, abv knee, knee disarticulation	$437
L5930	High activity knee frame	$4,868
L5940	Add, endo sys, blw knee, ult-lit	$652
L5950	Add, endo sys, abv knee, ult-lit	$1,011
L5960	Add, endo sys, hip dis, ult-lit	$1,253
L5961	Endo poly hip, pneu/hyd/rot	$6,844
L5962	Add, blw knee, flex prot cover	$618
L5964	Add, abv knee, flex prot cover	$913
L5966	Add, hip disartic, flex prot cover	$1,163
L5968	Multiaxial ankle w dorsiflex	$5,222
L5970	All lwr extr pros, foot, ext keel	$222
L5971	SACH foot, replacement	$325
L5972	All lwr extr pros, flex keel foot	$418
L5973	Ank-foot sys dors-plant flex	$25,078
L5974	All lwr extr pros, foot, ankle/foot	$258
L5975	Combo ankle/foot prosthesis	$666
L5976	All lwr extr pros, energy storing	$592
L5978	All lwr extr pros, foot, ankle/foot	$332
L5979	Multiaxial ankle/foot, dynamic resp	$2,225
L5980	All lwr extr pros, flex foot system	$3,823
L5981	Flex-walk sys/equal	$2,920
L5982	All exo etal lwr extrm pros, axial	$610
L5984	All endo lwr extrm pros, axial rot	$655
L5985	Lwr ext dynamic prosth pylon	$408
L5986	All lwr extrm prosth, multi-axial	$652
L5987	Shank ft w vert load pylon	$10,338
L5988	Vertical shock reducing pylo	$2,871
L5990	User adjustable heel height	$2,607
L5999	Unlisted proc lwr extrm prosth	B.R.
L6000	Part hand, thumb remaining	$1,459
L6010	Part hand, little/ring finger rem	$1,468
L6020	Part hand, no finger remaining	$1,460
L6025	Part hand disart myoelectric	$11,500
L6050	Wrist disartic, mold sockt, flex	$2,243
L6055	Wrist disartic, mold sockt w/expan	$2,767
L6100	Blw elbow, molded socket, flex	$2,302
L6110	Blw elbow, molded socket	$2,443
L6120	Blw elbow, mold dbl wall split sock	$2,755
L6130	Blw elbow, mold dbl wall split sock	$2,553
L6200	Elbow disartic, mold socket	$3,106
L6205	Elbow disartic, mold socket	$3,550
L6250	Above elbow, mold dbl wall socket	$3,221
L6300	Shldr disart, mold socket, bulkhead	$3,878
L6310	Shldr disart, pass restor	$3,114
L6320	Shldr disart, pass restor	$1,873
L6350	Int-scap thor, mold sockt, bulkhead	$3,819
L6360	Int-scap thor, pass restor	$3,105
L6370	Int-scap thor, pass restor	$2,165
L6380	Immed postop/early fit, init rigid	$1,280
L6382	Immed postop/early fit, init rigid	$1,518
L6384	Immed postop/early fit, init rigid	$1,882
L6386	Immed postop/early fit, cast change	$436
L6388	Immed postop/early fit, rigid dress	$487
L6400	Blw elbow, mold sockt, endo sys	$2,445
L6450	Elbow disart, mold sockt, endo sys	$3,006
L6500	Above elbow, mold sockt, endo sys	$3,033
L6550	Shoulder disart, mold sockt, endo	$3,718
L6570	Interscap thor, mold sockt, endo	$4,267
L6580	Prep, wrist disart/blw elbow	$1,602
L6582	Prep, wrist disart/blw elbow	$1,486
L6584	Prep, elbow disart/above elbow	$2,170
L6586	Prep, elbow disart/above elbow	$2,135
L6588	Prep, shldr disart/int-scap thorac	$2,940
L6590	Prep, shldr disart/int-scap thorac	$2,883
L6600	Upr extrm adds, polycent hinge, pr	$244
L6605	Upr extrm adds, sng pivot hinge, pr	$241
L6610	Upr extrm adds, flex metal hing, pr	$197
L6611	Additional switch, ext power	$592
L6615	Upr extrm add, disc locking wrist	$189
L6616	Upr extrm add, add disc locking wr	$80
L6620	Upr extrm add, flexion-friction wr	$327
L6621	Flex/ext wrist w/wo friction	$3,287
L6623	Upr extrm add, spring asst rotl wr	$657
L6624	Flex/ext/rotation wrist unit	$5,412
L6625	Upr extrm add, rot wrist unit	$691
L6628	Upr extrm add, quick disc hook adap	$503
L6629	Upr extrm add, quick disc lam coll	$173
L6630	Upr extrm add, stain steel, wrist	$280
L6632	Upr extrm add, latex susp sleeve	$63
L6635	Upr extrm add, lift assist elbow	$216
L6637	Upr extrm add, nudge cont elbw lck	$420
L6638	Elec lock on manual pw elbow	$3,594
L6640	Upr extrm adds, shldr abd joint, pr	$352
L6641	Upr extrm add, excurs amp, pulley	$190
L6642	Upr extrm add, excurs amp, lever	$226
L6645	Upr extrm add, shldr flex-abduction	$393
L6646	Multipo locking shoulder jnt	$4,532
L6647	Shoulder lock actuator	$746
L6648	Ext pwrd shlder lock/unlock	$4,675
L6650	Upr extrm add, shldr univ joint, ea	$412
L6655	Upr extrm add, std cont cable	$90
L6660	Upr extrm add, heavy duty cont cable	$101
L6665	Upr extrm add, teflon, cable lining	$60
L6670	Upr extrm add, hook-hand, cable	$62
L6672	Upr extrm add, harness, chest	$173
L6675	Upr extrm add, harness, figure "8"	$122
L6676	Upr extrm add, harness, figure "8"	$128
L6677	UE triple control harness	$426
L6680	Upr extrm add, test sockt, wrist	$302
L6682	Upr extrm add, test sockt, elbow	$295
L6684	Upr extrm add, test sockt, shldr	$340
L6686	Upr extrm add, suction socket	$632
L6687	Upr extrm add, frame type socket	$562
L6688	Upr extrm add, frame type socket	$665
L6689	Upr extrm add, frame type socket	$696
L6690	Upr extrm add, frame type socket	$755
L6691	Upr extrm add, removable insert, each	$337
L6692	Upr extrm add, silicone gel insert	$694
L6693	Lockingelbow forearm cntrbal	$4,080
L6694	Elbow socket ins use w/lock	$1,069
L6695	Elbow socket ins use w/o lck	$891
L6696	Cus elbo skt in for con/atyp	$1,891
L6697	Cus elbo skt in not con/atyp	$1,891
L6698	Below/above elbow lock mech	$796
L6704	Term dev, sport/rec/work att	$937
L6706	Term dev mech hook vol open	$558
L6707	Term dev mech hook vol close	$2,057
L6708	Term dev mech hand vol open	$1,338
L6709	Term dev mech hand vol close	$1,938
L6711	Ped term dev, hook, vol open	$966
L6712	Ped term dev, hook, vol clos	$1,779
L6713	Ped term dev, hand, vol open	$2,245
L6714	Ped term dev, hand, vol clos	$1,902
L6715	Term device, hook, dorr, mod #5xa	$391
L6721	Hook/hand, hvy dty, vol open	$3,380
L6722	Hook/hand, hvy dty, vol clos	$2,914
L6805	Term device, mod wrist flex unit	$414.87
L6810	Term dev, pinch tool, Otto Bock	$242.46
L6880	Term dev, hand, Bock, vo	$651
L6881	Term dev auto grasp feature	$5,875
L6882	Microprocessor control uplmb	$4,457
L6883	Replc sockt below e/w disa	$2,538
L6884	Replc sockt above elbow disa	$3,571
L6885	Replc sockt shldr dis/interc	$5,094
L6890	Term dev, glove abv hands, glove	$180
L6895	Term dev, glove abv hands, glove	$544
L6900	Hand restoration	$1,507
L6905	Hand restoration	$1,431
L6910	Hand restoration	$1,411
L6915	Hand restoration	$610
L6920	Wrist disart, ext pwr, inner socket	$7,144
L6925	Wrist disart, ext pwr, inner socket	$7,544
L6930	Blw elbow, ext pwr, inner socket	$7,670
L6935	Blw elbow, ext pwr, inner socket	$8,437
L6940	Elbow disart, ext pwr, inner socket	$9,586
L6945	Elbow disart, ext pwr, inner socket	$10,844
L6950	Above elbow, ext pwr, inner socket	$10,192
L6955	Above elbow, ext pwr, inner socket	$12,789
L6960	Shldr disart, ext pwr, inner socket	$12,611
L6965	Shldr disart, ext pwr, inner socket	$18,423
L6970	Int-scap-thor, ext pwr, inner socket	$18,726
L6975	Int-scap-thor, ext pwr, inner socket	$18,826
L7007	Adult electric hand	$5,504
L7008	Pediatric electric hand	$8,662
L7009	Adult electric hook	$5,616
L7040	Prehens act, Hosmer/equal, switch	$3,665
L7045	Elect hook, child, Michigan/equal	$2,101
L7170	Elect elbw, Hosmer/equal, switch	$7,622
L7180	Elect elbw, Utah/equal, myoelectr	$39,823
L7181	Electronic elbo simultaneous	$57,580
L7185	Elect elbw, adolescent, var village	$7,718
L7186	Elect elbw, child, var village	$11,139
L7190	Elect elbw, adolescent, var village	$9,820
L7191	Elect elbw, child, var village	$11,841
L7260	Elect wrist rotator, Otto Bock/equa	$2,558
L7261	Elect wrist rotator, Utah arm	$4,094
L7360	Six vlt bat, Otto Bock/equal, ea	$235
L7362	Bat charger, six volt, Otto Bock	$282
L7364	Twelve volt bat, Utah/equal, ea	$514
L7366	Batt charger, twelve volt, Utah/equ	$698
L7367	Replacemnt lithium ionbatter	$559
L7368	Lithium ion battery charger	$725
L7400	Add UE prost be/wd, ultlite	$440
L7401	Add UE prost a/e ultlite mat	$493
L7402	Add UE prost s/d ultlite mat	$532
L7403	Add UE prost b/e acrylic	$529
L7404	Add UE prost a/e acrylic	$799
L7405	Add UE prost s/d acrylic	$1,045
L7499	Unlisted procs upr extrm prosth	B.R.
L7510	RPR prosth dev, rpr/rep minor parts	$57
L7520	Repair prosthesis per 15 min	B.R.
L7600	Prosthetic donning sleeve	B.R.
L7900	Male vacuum erection system	$771
L8000	Breast prosth, mastectomy bra	$37
L8001	Breast prosthesis bra and form	$180
L8002	Brst prsth bra and bilat form	$237
L8010	Breast prosth, mastectomy sleeve	$59
L8015	Ext breastprosthesis garment	$86
L8020	Breast prosth, mastectomy form	$222
L8030	Breast prosth, silicone/equal	$325
L8031	Breast prosthesis w adhesive	$505
L8032	Reusable nipple prosthesis	$56
L8035	Custom breast prosthesis	$5,265
L8039	Breast prosthesis NOS	B.R.
L8040	Nasal prosthesis	$3,559
L8040	Nasal prosthesis	KM	$3,381
L8040	Nasal prosthesis	KN	$1,424
L8041	Midfacial prosthesis	$4,290
L8041	Midfacial prosthesis	KM	$4,076
L8041	Midfacial prosthesis	KN	$1,716
L8042	Orbital prosthesis	$4,820
L8042	Orbital prosthesis	KM	$4,579
L8042	Orbital prosthesis	KN	$1,928
L8043	Upper facial prosthesis	$5,399
L8043	Upper facial prosthesis	KM	$5,129
L8043	Upper facial prosthesis	KN	$2,160
L8044	Hemi-facial prosthesis	$5,977
L8044	Hemi-facial prosthesis	KM	$5,678
L8044	Hemi-facial prosthesis	KN	$2,391
L8045	Auricular prosthesis	$3,933
L8045	Auricular prosthesis	KM	$3,736
L8045	Auricular prosthesis	KN	$1,572
L8046	Partial facial prosthesis	$3,856
L8046	Partial facial prosthesis	KM	$3,663
L8046	Partial facial prosthesis	KN	$1,543
L8047	Nasal septal prosthesis	$1,976
L8047	Nasal septal prosthesis	KM	$1,878
L8047	Nasal septal prosthesis	KN	$791
L8048	Unspec maxillofacial prosth	B.R.
L8049	Repair maxillofacial prosth	B.R.
L8300	Truss, single w/std pad	$82
L8310	Truss, dbl w/std pads	$130
L8320	Truss, add to std pad, water pad	$60
L8330	Truss, add to std pad, scrotal pad	$64
L8400	Prosth sheath, blw knee, ea	$15
L8410	Prosth sheath, above knee, ea	$22
L8415	Prosth sheath, upr limb, ea	$23
L8417	Pros sheath/sock w gel cushn	$108
L8420	Prosth sock, wool, blw knee, ea	$20
L8430	Prosth sock, wool, above knee, ea	$22
L8435	Prosth sock, wool, upr limb, ea	$24
L8440	Prosth shrinker, blw knee, ea	$43
L8460	Prosth shrinker, above knee, ea	$75
L8465	Prosth shrinker, upr limb, ea	$53
L8470	Stump sock, sngl ply, fit, blw knee	$8
L8480	Stump sock, sngl ply, fit, abv knee	$10
L8485	Stump sock, single ply, fitting	$11
L8499	Unlisted procedure misc prosth	B.R.
L8500	Artificial larynx, any type	$758
L8501	Tracheostomy speaking valve	$118
L8505	Artificial larynx, accessory	B.R.
L8507	Trach-esoph voice pros pt in	$60
L8509	Trach-esoph voice pros md in	$157
L8510	Voice amplifier	$363
L8511	Indwelling trach insert	$105
L8512	Gel cap for trach voice pros	$3
L8513	Trach pros cleaning device	$7
L8514	Repl trach puncture dilator	$136
L8515	Gel cap app device for trach	$91
L8600	Implant breast prosth, silicone/equ	$999
L8609	Artificial cornea	$9,365
L8610	Ocular	$936
L8612	Aqueous shunt	$972
L8613	Ossicula	$411
L8614	Cochlear dev/system	$27,796
L8615	Temporomandibular joint	$648
L8616	Maxilla	$151
L8617	Mandible	$132
L8618	Palate	$38
L8619	Coch imp ext proc/contr rplc	$11,931
L8621	Distal humerus	$1
L8622	Proximal ulna/radius	$1
L8623	Distal ulna	$93
L8624	Distal radius	$232
L8627	Lunate	$10,133
L8628	Carpus	$1,798
L8629	Scaphoid	$257
L8630	Metacarpophalangeal joint	$539
L8631	MCP joint repl 2 pc or more	$3,162
L8641	Metatarsal joint	$560
L8642	Hallux implant	$454
L8658	Interphalangeal joint	$488
L8659	Interphalangeal joint repl	$2,774
L8670	Vascular graft material, synthetic	$801
L8680	Biliary stent, endoprosth (perm)	$668
L8681	Pt prgrm for implt neurostim	$1,725
L8682	Implt neurostim radiofq rec	$8,666
L8683	Radiofq trsmtr for implt neu	$7,628
L8684	Radiof trsmtr implt scrl neu	$1,089
L8685	Implt nrostm pls gen sng rec	$19,010
L8686	Implt nrostm pls gen sng non	$12,121
L8687	Implt nrostm pls gen dua rec	$24,739
L8688	Implt nrostm pls gen dua non	$15,785
L8689	External recharg sys intern	$2,479
L8690	Testicle	$6,838
L8691	Osseointegrated snd proc rpl	$3,833
L8692	Non-osseointegrated snd proc	B.R.
L8693	Aud osseo dev, abutment	$2,180
L8695	External recharg sys extern	$24
L8699	Prosthetic implant NOS	B.R.
L9900	O and P supply/accessory/service	B.R.
L9999	Sales tax, orthotic/prosth/other	B.R.

La. Admin. Code tit. 40, § I-4339

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994), amended by the Workforce Commission, Office of Workers' Compensation, LR 39:1847 (July 2013), LR 40:375 (February 2014).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.