dme fee schedule key updated november 13, 2019 · l2040 hkafo torsion bil rot straps $183.72...

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DME Fee Schedule Key Updated November 13, 2019

Complete List Sorted by HCPCS

All wheelchair codes and their fees are incorporated into the DME Fee Schedule. Distinct Electric,

Manual, and Replacement fees are listed in a separate row instead of in multiple columns.

Column Heading Description

HCPCS Procedure Code.

Note A - Covered for ages 2-20 years old

E – Electric Wheelchair

M – Manual Wheelchair

NR – The 2.7% rate reduction does not apply to this code.

Description Procedure Description.

COS Category of Service.

041 – Equipment and Prosthesis

048 – Supplies

Prior Approval

Required

Indicates whether Prior Approval is Required.

N – No PA required

Y – PA required

R – Continuous Rental - PA required

B – Rent to Purchase - PA required

E – Requires PA for Purchase or Modifications. Repairs require prior

approval when the sum of the repair is $400 or more.

H/P Indicates if the item is hand priced.

LTC Indicates whether the item is the responsibility of the Long Term Care Facility.

Y – LTC responsibility

N – Not LTC responsibility

Medicare Covered Indicates whether Medicare covers the items and if Medicare should be billed

prior to HFS.

Y – Bill Medicare prior to HFS

N – Not covered by Medicare, bill HFS directly within 180 days from the

date of service

If Medicare coverage policy is situational, bill Medicare.

2.7% Reduced

Purchase Price

2.7% Reduced

Rent Price

Maximum allowable price HFS will reimburse for the item. Public Act 097-0689

required the Department to reduce reimbursement rates by 2.7%. The posted

rates are reduced unless noted with “NR” in the Note column.

Any rate charged lower than the maximum.

Max Quantity Maximum quantity limit HFS will allow within the Max number of days.

Max Days Quantity limit time frame.

Note: For medical supplies, equipment, or appliances not on the fee schedule, providers should submit

a HFS1409, Prior Approval Request Form with medical documentation using a Not Elsewhere

Classified procedure code.

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DME Fee Schedule Key and Changes Effective 11/1/19

L3999 The Medicare indicator was changed from Y to N.



O & P codes The rates were changed to the Medicare rate in effect July 2019 – 6%

and -2.7% SMART Act Reduction.

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HCPCS Description 11/01/19 Rate w 2.7%

Smart Reduction Current Rate

A5500 Diabetic only cus prep of ots depth inlay $66.97 $42.29

A5501 Diabetic only cus prep shoe molded from cast $200.85 $147.81

A5503 Diabetic only mod ots mold shoe w/roll/rig $33.16 $24.14

A5504 Diabetic only mod ots mold shoe w/wedges $33.16 $24.14

A5505 Diabetic only mod ots mold shoe w/metata $33.16 $24.14

A5506 Diabetic only mod ots mold shoe w/off set he $33.16 $24.14

A5512 Diabetic only mul insert molded w/heat inc arch $27.32 $22.15

A5513 Diabetic only mul dent insert includ arch, cust $40.76 $33.05

A5514 Diabetic only cam tec 3/16 mat 35 durmtr>, cus fb $40.76 $40.76

L0112 Cranial cervical orthosis $1,271.02 $1,030.56

L0130 Flex thermoplastic collar mo $138.63 $106.14

L0140 Cervical semi-rigid adjustab $54.37 $41.62

L0150 Cerv semi-rig adj molded chn $97.22 $74.43

L0170 Cervical collar molded to pt $730.16 $559.09

L0174 Cerv sr 2pc thor ext pre ots $252.90 $193.64

L0180 Cer post col occ/man sup adj $409.72 $313.73

L0190 Cerv collar supp adj cerv ba $483.21 $369.98

L0200 Cerv col supp adj bar & thor $560.47 $429.15

L0220 Thor rib belt custom fabrica $117.33 $95.13

L0458 Tlso 2mod symphis-xipho pre $809.91 $656.69

L0462 Tlso 3mod sacro-scap pre $1,133.87 $540.08

L0464 Tlso 4mod sacro-scap pre $1,349.87 $1,094.50

L0470 Tlso rigid frame pre subclav $597.50 $484.45

L0472 Tlso rigid frame hyperex pre $367.67 $298.10

L0480 Tlso rigid plastic custom fa $1,371.66 $1,112.17

L0482 Tlso rigid lined custom fab $1,532.16 $1,242.30

L0484 Tlso rigid plastic cust fab $1,654.68 $879.27

L0486 Tlso rigidlined cust fab two $1,858.26 $1,378.89

L0488 Tlso rigid lined pre one pie $911.61 $739.15

L0490 Tlso rigid plastic pre one $256.89 $950.48

L0491 Tlso 2 piece rigid shell $697.43 $565.50

L0492 Tlso 3 piece rigid shell $454.15 $368.22

L0626 Lo sag rig pnl stays pre cst $70.79 $61.06

L0635 Lso sagit rigid panel prefab $907.42 $295.90

L0636 Lso sagittal rigid panel cus $1,231.22 $1,062.00

L0638 Lso sag-coronal panel custom $1,197.74 $1,033.14

L0640 Lso s/c shell/panel custom $950.25 $819.66

L0700 Ctlso a-p-l control molded $1,807.84 $1,384.30

L0710 Ctlso a-p-l control w/ inter $1,987.31 $1,521.72

L0810 Halo cervical into jckt vest $2,427.31 $1,858.63

L0820 Halo cervical into body jack $1,909.42 $1,462.07

L0830 Halo cerv into milwaukee typ $2,921.67 $2,237.20

L0859 Mri compatible system $1,034.44 $792.08

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L1000 Ctlso milwauke initial model $1,841.46 $1,410.05

L1005 Tension based scoliosis orth $2,906.55 $2,356.70

L1010 Ctlso axilla sling $76.00 $58.18

L1020 Kyphosis pad $97.87 $74.93

L1025 Ctlso scoliosis orthosis kyphosis pad floating $141.19 $108.09

L1030 Lumbar bolster pad $71.11 $54.43

L1040 Lumbar or lumbar rib pad $80.52 $61.65

L1050 Sternal pad $91.13 $69.76

L1060 Thoracic pad $98.36 $75.30

L1070 Trapezius sling $101.89 $78.01

L1080 Outrigger $47.53 $36.37

L1085 Outrigger bil w/ vert extens $159.07 $121.79

L1090 Lumbar sling $91.39 $69.98

L1100 Ring flange plastic/leather $172.47 $132.05

L1110 Ring flange plas/leather mol $289.17 $221.41

L1120 Covers for upright each $34.55 $26.44

L1200 Furnsh initial orthosis only $1,625.10 $1,244.37

L1210 Lateral thoracic extension $222.19 $170.12

L1220 Anterior thoracic extension $216.26 $165.59

L1230 Milwaukee type superstructur $605.82 $163.90

L1240 Lumbar derotation pad $82.60 $63.24

L1250 Anterior asis pad $71.82 $54.97

L1260 Anterior thoracic derotation $85.66 $65.58

L1270 Abdominal pad $75.28 $57.68

L1280 Rib gusset (elastic) each $79.35 $60.73

L1290 Lateral trochanteric pad $70.58 $54.02

L1300 Body jacket mold to patient $1,565.11 $1,198.45

L1310 Post-operative body jacket $1,630.19 $1,248.29

L1600 Ho flex frejka w/cov pre cst $117.03 $89.60

L1610 Ho frejka cov only pre cst $49.71 $38.05

L1620 Ho flex pavlik harns pre cst $142.71 $109.26

L1630 Abduct control hip semi-flex $191.85 $146.90

L1640 Pelv band/spread bar thigh c $429.90 $329.16

L1650 Ho abduction hip adjustable $223.96 $171.48

L1652 Ho bi thighcuffs w sprdr bar $323.72 $262.47

L1660 Ho abduction static plastic $164.12 $125.65

L1680 Pelvic & hip control thigh c $1,034.60 $792.21

L1685 Post-op hip abduct custom fa $1,010.03 $773.39

L1686 Ho post-op hip abduction $850.92 $651.58

L1690 Combination bilateral ho $1,756.08 $1,344.66

L1700 Leg perthes orth toronto typ $1,412.88 $1,081.86

L1710 Legg perthes orth newington $1,799.14 $1,377.65

L1720 Legg perthes orth trilateral Tachdijan type $1,339.63 $1,025.79

L1730 Legg perthes orth scottish r $1,130.94 $865.99

L1755 Legg perthes patten bottom t $1,625.99 $1,245.05

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L1820 Ko elas w/ condyle pads & jo $129.07 $47.24

L1831 Knee orth pos locking joint $267.28 $216.72

L1834 Ko w/0 joint rigid molded to $659.14 $504.71

L1840 Ko derot ant cruciate custom $854.01 $653.93

L1843 Ko single upright pre cst $814.82 handpriced

L1844 Ko w/adj jt rot cntrl molded $1,382.91 $1,121.30

L1845 Ko double upright pre cst $760.71 handpriced

L1846 Ko w adj flex/ext rotat mold $1,062.53 $779.78

L1847 Ko dbl upright w/air pre cst $522.33 handpriced

L1848 Ko dbl upright w/air pre ots $522.33 handpriced

L1860 Ko supracondylar socket mold $1,132.41 $867.10

L1900 Afo sprng wir drsflx calf bd $259.10 $198.38

L1904 Afo molded ankle gauntlet $409.91 $313.87

L1907 Afo supramalleolar custom $511.01 $414.32

L1910 Afo sing bar clasp attach sh $254.68 $194.98

L1920 Afo sing upright w/ adjust s $373.06 $285.65

L1930 Afo plastic $228.80 $60.06

L1932 Afo rig ant tib prefab tcf/= $810.36 handpriced

L1940 Afo molded to patient plasti $442.23 $338.60

L1945 Afo molded plas rig ant tib $1,019.35 $780.52

L1950 Afo spiral molded to pt plas $698.40 $534.77

L1951 Afo spiral prefabricated $762.65 handpriced

L1960 Afo pos solid ank plastic mo $562.93 $431.02

L1970 Afo plastic molded w/ankle j $628.54 $481.28

L1971 Afo w/ankle joint, prefab $425.69 $345.13

L1980 Afo sing solid stirrup calf $366.67 $280.78

L1990 Afo doub solid stirrup calf $424.38 $324.95

L2000 Kafo sing fre stirr thi/calf $1,015.89 $777.88

L2005 Kafo sng/dbl mechanical act $3,721.19 $2,650.50

L2010 Kafo sng solid stirrup w/o j $792.38 $606.73

L2020 Kafo dbl solid stirrup band/ $1,000.75 $766.30

L2030 Kafo dbl solid stirrup w/o j $983.67 $753.20

L2034 Kafo pla sin up w/wo k/a cus $1,844.81 $1,636.38

L2035 Kafo plastic pediatric size $157.33 $115.85

L2036 Kafo plas doub free knee mol $1,683.61 $1,289.17

L2037 Kafo plas sing free knee mol $1,505.96 $1,153.14

L2038 Kafo w/o joint multi-axis an $1,214.02 $929.59

L2040 Hkafo torsion bil rot straps $183.72 $140.67

L2050 Hkafo torsion cable hip pelv $442.54 $338.86

L2060 Hkafo torsion ball bearing j $553.53 $423.82

L2070 Hkafo torsion unilat rot str $140.95 $107.92

L2080 Hkafo unilat torsion cable $338.90 $259.50

L2090 Hkafo unilat torsion ball br $451.54 $345.75

L2106 Afo tib fx cast plaster mold $715.80 $548.10

L2108 Afo tib fx cast molded to pt $1,044.01 $799.43

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L2112 Afo tibial fracture soft $458.15 $350.81

L2114 Afo tib fx semi-rigid $573.85 $439.40

L2116 Afo tibial fracture rigid $699.93 $535.96

L2126 Kafo fem fx cast thermoplas $1,159.57 $887.92

L2128 Kafo fem fx cast molded to p $1,456.02 $1,126.05

L2132 Kafo femoral fx cast soft $883.78 $676.73

L2134 Kafo fem fx cast semi-rigid $1,046.51 $493.26

L2136 Kafo femoral fx cast rigid $1,145.26 $743.97

L2180 Plas shoe insert w ank joint $120.40 $92.17

L2182 Drop lock knee $103.79 $79.45

L2184 Limited motion knee joint $105.19 $80.54

L2186 Adj motion knee jnt lerman t $139.89 $107.12

L2188 Quadrilateral brim $254.31 $194.73

L2190 Waist belt $77.47 $59.31

L2192 Pelvic band & belt thigh fla $302.76 $231.82

L2200 Limited ankle motion ea jnt $45.64 $34.93

L2210 Dorsiflexion assist each joi $57.09 $43.70

L2220 Dorsi & plantar flex ass/res $73.49 $56.25

L2230 Split flat caliper stirr & p $86.88 $66.51

L2232 Rocker bottom, contact afo $88.23 handpriced

L2240 Round caliper and plate atta $86.48 $66.18

L2250 Foot plate molded stirrup at $303.35 $232.26

L2260 Reinforced solid stirrup $170.22 $130.33

L2265 Long tongue stirrup $122.09 $93.45

L2270 Varus/valgus strap padded/li $55.98 $42.85

L2275 Plastic mod low ext pad/line $118.39 $64.16

L2280 Molded inner boot $512.66 $392.55

L2300 Abduction bar jointed adjust $228.63 $175.05

L2310 Abduction bar-straight $104.47 $79.99

L2320 Non-molded lacer $175.18 $134.12

L2330 Lacer molded to patient mode $333.42 $255.31

L2335 Anterior swing band $255.29 $195.47

L2340 Pre-tibial shell molded to p $379.51 $290.59

L2350 Prosthetic type socket molde $756.62 $579.35

L2360 Extended steel shank $46.84 $35.86

L2370 Patten bottom $290.64 $222.54

L2375 Torsion ank & half solid sti $111.74 $85.55

L2380 Torsion straight knee joint $117.20 $89.73

L2385 Straight knee joint heavy du $133.45 $102.17

L2387 Add le poly knee custom kafo $173.36 $158.10

L2390 Offset knee joint each $92.97 $71.17

L2395 Offset knee joint heavy duty $132.87 $101.72

L2397 Suspension sleeve lower ext $110.85 $85.73

L2405 Knee joint drop lock ea jnt $79.19 $44.12

L2415 Knee joint cam lock each joi $110.33 $84.48

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L2425 Knee disc/dial lock/adj flex $130.19 $99.68

L2492 Knee lift loop drop lock rin $106.52 $81.95

L2500 Thi/glut/ischia wgt bearing $284.18 $217.60

L2510 Th/wght bear quad-lat brim m $732.41 $560.82

L2520 Th/wght bear quad-lat brim c $488.12 $373.75

L2525 Th/wght bear nar m-l brim mo $1,035.07 $792.58

L2526 Th/wght bear nar m-l brim cu $581.61 $445.34

L2530 Thigh/wght bear lacer non-mo $217.80 $166.76

L2540 Thigh/wght bear lacer molded $412.11 $315.54

L2550 Thigh/wght bear high roll cu $309.00 $236.59

L2570 Hip clevis type 2 posit jnt $404.45 $309.69

L2580 Pelvic control pelvic sling $394.09 $301.76

L2600 Hip clevis/thrust bearing fr $193.69 $148.30

L2610 Hip clevis/thrust bearing lo $214.03 $163.87

L2620 Pelvic control hip heavy dut $227.04 $173.85

L2622 Hip joint adjustable flexion $288.98 $221.27

L2624 Hip adj flex ext abduct cont $354.34 $281.31

L2627 Plastic mold recipro hip & c $1,940.86 $1,486.16

L2628 Metal frame recipro hip & ca $1,422.61 $1,089.32

L2630 Pelvic control band & belt u $210.27 $160.99

L2640 Pelvic control band & belt b $285.37 $218.50

L2650 Pelv & thor control gluteal $125.67 $96.22

L2660 Thoracic control thoracic ba $162.72 $124.59

L2670 Thorac cont paraspinal uprig $144.85 $110.90

L2680 Thorac cont lat support upri $132.89 $101.75

L2750 Plating chrome/nickel pr bar $70.99 $54.34

L2760 Extension per extension per $51.60 $39.49

L2785 Drop lock retainer each $26.92 $20.60

L2795 Knee control full kneecap $74.49 $57.00

L2800 Knee cap medial or lateral p $91.47 $70.04

L2810 Knee control condylar pad $74.18 $56.77

L2820 Soft interface below knee se $73.75 $56.45

L2830 Soft interface above knee se $79.78 $61.08

L2840 Tibial length sock fx or equ $39.18 $29.99

L2850 Femoral lgth sock fx or equa $54.94 $42.06

L3000 Ft insert ucb berkeley shell $285.28 $110.32

L3001 Foot insert remov molded spe $120.13 $58.08

L3002 Foot insert plastazote or eq $146.68 $107.24

L3003 Foot insert silicone gel eac $158.22 $43.85

L3010 Foot longitudinal arch suppo $158.22 $107.24

L3030 Foot arch support remov prem $69.30 $22.09

L3031 Foot lamin/prepreg composite $111.23 handpriced

L3040 Ft arch suprt premold longit $42.76 $30.48

L3050 Foot arch supp premold metat $42.76 $16.89

L3060 Foot arch supp longitud/meta $66.99 $50.57

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L3070 Arch suprt att to sho longit $28.88 $21.80

L3080 Arch supp att to shoe metata $28.88 $21.80

L3090 Arch supp att to shoe long/m $36.98 $27.90

L3140 Abduction rotation bar shoe $80.85 $61.03

L3150 Abduct rotation bar w/o shoe $73.94 $55.79

L3224 Woman's shoe oxford brace $61.37 $44.81

L3225 Man's shoe oxford brace $67.03 $48.93

L3300 Sho lift taper to metatarsal $47.37 $35.75

L3310 Shoe lift elev heel/sole neo $73.94 $45.55

L3330 Lifts elevation metal extens $513.94 $327.89

L3332 Shoe lifts tapered to one-ha $66.99 $24.69

L3334 Shoe lifts elevation heel /i $34.63 $26.14

L3340 Shoe wedge sach $77.42 $43.44

L3350 Shoe heel wedge $20.78 $15.69

L3360 Shoe sole wedge outside sole $32.34 $24.40

L3370 Shoe sole wedge between sole $45.05 $34.00

L3380 Shoe clubfoot wedge $45.05 $34.00

L3390 Shoe outflare wedge $45.05 $29.73

L3400 Shoe metatarsal bar wedge ro $36.98 $27.90

L3410 Shoe metatarsal bar between $84.31 $50.30

L3420 Full sole/heel wedge btween $49.68 $37.50

L3430 Wedge heel sach $145.54 $73.17

L3440 Heel leather reinforced $69.30 $52.31

L3450 Shoe heel sach cushion type $95.85 $43.44

L3455 Shoe heel new leather standa $36.98 $23.36

L3460 Shoe heel new rubber standar $31.21 $18.75

L3465 Shoe heel thomas with wedge $53.17 $25.15

L3470 Shoe heel thomas extend to b $56.58 $42.07

L3520 O shoe add felt w leath insl $28.88 $21.80

L3530 Ortho shoe add half sole $28.88 $21.80

L3540 Ortho shoe add full sole $46.20 $34.88

L3550 O shoe add standard toe tap $8.12 $6.10

L3560 O shoe add horseshoe toe tap $20.78 $10.98

L3570 O shoe add instep extension $77.42 $58.41

L3580 O shoe add instep velcro clo $58.91 $35.81

L3590 O shoe convert to sof counte $48.52 $36.61

L3595 Ortho shoe add march bar $38.11 $28.77

L3600 Trans shoe calip plate exist $69.30 $52.31

L3710 Eo elas w/metal jnts pre ots $118.02 $82.69

L3720 Forearm/arm cuffs free motio $564.71 $432.38

L3730 Forearm/arm cuffs ext/flex a $749.03 $573.54

L3740 Cuffs adj lock w/ active con $888.03 $679.98

L3760 Eo adj jt prefab custom fit $413.34 handpriced

L3761 Eo, adj lock joint prefab ot $413.34 $76.19

L3762 Eo rigid w/o joints pre ots $88.87 $72.05

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L3763 Ewho rigid w/o jnts cf $618.48 handpriced

L3806 Whfo w/joint(s) custom fab $375.42 handpriced

L3807 Whfo w/o joints pre cst $206.66 $110.05

L3808 Whfo, rigid w/o joints $294.41 handpriced

L3900 Hinge extension/flex wrist/f $1,338.84 $1,025.17

L3901 Hinge ext/flex wrist finger $1,754.61 $1,343.56

L3906 Who w/o joints cf $418.84 $320.70

L3915 Who nontorsion jnts pre cst $439.33 handpriced

L3917 Metacarp fx orthosis pre cst $87.28 $70.76

L3918 Metacarp fx orthosis pre ots $87.28 $70.76

L3923 Hfo without joints pre cst $79.84 $26.08

L3929 Hfo nontorsion jnts pre cst $75.49 $65.56

L3931 Whfo nontorsion joint prefab $172.32 $149.66

L3933 Fo w/o joints cf $176.35 $107.03

L3960 Sewho airplan desig abdu pos $659.17 $504.72

L3962 Sewho erbs palsey design abd $596.18 $456.50

L3980 Up ext fx orthos humeral nos $319.73 $244.82

L3981 Ue fx orth shoul cap forearm $831.89 handpriced

L3982 Upper ext fx orthosis rad/ul $324.67 $104.01

L3984 Upper ext fx orthosis wrist $286.00 $218.98

L4000 Repl girdle milwaukee orth $1,200.00 $918.87

L4010 Replace trilateral socket br $729.39 $558.51

L4030 Replace socket brim cust fit $556.79 $426.36

L4040 Replace molded thigh lacer $377.07 $288.74

L4045 Replace non-molded thigh lac $278.55 $213.27

L4050 Replace molded calf lacer $373.46 $285.95

L4055 Replace non-molded calf lace $227.01 $173.81

L4060 Replace high roll cuff $295.09 $225.93

L4070 Replace prox & dist upright $238.97 $182.97

L4080 Repl met band kafo-afo prox $90.22 $69.06

L4090 Repl met band kafo-afo calf/ $76.76 $59.12

L4110 Repl leath cuff kafo-afo cal $72.02 $55.14

L4130 Replace pretibial shell $435.28 $333.28

L4360 Pneumat walking boot pre cst $235.12 $111.80

L4386 Non-pneum walk boot pre cst $143.99 $116.75

L4396 Static or dynami afo pre cst $152.41 $123.56

L4631 Afo, walk boot type, cus fab $1,338.71 $816.30

L5000 Sho insert w arch toe filler $521.47 $224.17

L5010 Mold socket ank hgt w/ toe f $1,457.04 $960.35

L5020 Tibial tubercle hgt w/ toe f $2,282.71 $1,747.93

L5050 Ank symes mold sckt sach ft $2,493.15 $1,909.07

L5060 Symes met fr leath socket ar $3,073.33 $2,353.33

L5100 Molded socket shin sach foot $2,482.48 $1,900.90

L5105 Plast socket jts/thgh lacer $3,503.32 $2,682.58

L5150 Mold sckt ext knee shin sach $3,894.86 $2,982.40

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L5160 Mold socket bent knee shin s $4,276.36 $3,274.51

L5200 Kne sing axis fric shin sach $3,307.45 $2,532.60

L5210 No knee/ankle joints w/ ft b $2,626.12 $2,010.88

L5220 No knee joint with artic ali $2,892.85 $2,215.12

L5230 Fem focal defic constant fri $4,338.83 $3,322.37

L5250 Hip canad sing axi cons fric $5,087.39 $3,895.55

L5270 Tilt table locking hip sing $5,668.34 $4,340.42

L5280 Hemipelvect canad sing axis $5,509.83 $4,219.02

L5301 Bk mold socket sach ft endo $2,437.74 $1,955.07

L5312 Knee disart, sach ft, endo $3,840.83 $3,583.11

L5321 Ak open end sach $3,250.64 $2,607.55

L5331 Hip disart canadian sach ft $4,761.02 $3,818.35

L5341 Hemipelvectomy canadian sach $5,060.89 $4,103.49

L5400 Postop dress & 1 cast chg bk $1,451.68 $1,111.58

L5410 Postop dsg bk ea add cast ch $401.07 $121.64

L5420 Postop dsg & 1 cast chg ak/d $1,833.41 $1,403.89

L5450 Postop app non-wgt bear dsg $430.33 $329.52

L5460 Postop app non-wgt bear dsg $564.41 $432.18

L5500 Init bk ptb plaster direct $1,341.78 $1,027.43

L5505 Init ak ischal plstr direct $1,887.52 $1,445.31

L5510 Prep bk ptb plaster molded $1,602.30 $1,226.94

L5520 Perp bk ptb thermopls direct $1,436.28 $1,099.80

L5530 Prep bk ptb thermopls molded $1,888.08 $1,445.73

L5535 Prep bk ptb open end socket $1,760.09 $1,347.73

L5540 Prep bk ptb laminated socket $1,864.20 $1,427.46

L5560 Prep ak ischial plast molded $2,124.14 $1,626.52

L5570 Prep ak ischial direct form $2,061.56 $1,578.59

L5580 Prep ak ischial thermo mold $2,558.68 $1,959.24

L5585 Prep ak ischial open end $2,996.44 $2,294.46

L5590 Prep ak ischial laminated $2,667.69 $2,042.73

L5595 Hip disartic sach thermopls $4,168.91 $3,192.25

L5600 Hip disart sach laminat mold $4,744.83 $3,633.24

L5610 Above knee hydracadence $2,288.40 $1,752.29

L5611 Ak 4 bar link w/fric swing $1,457.52 $1,116.06

L5616 Ak univ multiplex sys frict $1,336.78 $1,026.61

L5618 Test socket symes $304.03 $232.78

L5620 Test socket below knee $269.74 $206.55

L5622 Test socket knee disarticula $363.41 $278.25

L5624 Test socket above knee $363.26 $278.17

L5626 Test socket hip disarticulat $575.10 $440.36

L5628 Test socket hemipelvectomy $582.36 $445.93

L5629 Below knee acrylic socket $287.51 $220.13

L5630 Syme typ expandabl wall sckt $499.53 $382.49

L5631 Ak/knee disartic acrylic soc $397.49 $304.35

L5632 Symes type ptb brim design s $245.00 $187.57

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L5634 Symes type poster opening so $306.38 $234.60

L5636 Symes type medial opening so $234.19 $179.30

L5637 Below knee total contact $348.47 $266.82

L5638 Below knee leather socket $587.02 $449.49

L5639 Below knee wood socket $1,014.26 $776.64

L5640 Knee disarticulat leather so $666.69 $510.50

L5642 Above knee leather socket $617.99 $473.21

L5643 Hip flex inner socket ext fr $1,822.74 $1,395.73

L5644 Above knee wood socket $534.32 $409.14

L5645 Bk flex inner socket ext fra $886.41 $678.73

L5647 Below knee suction socket $719.61 $551.01

L5648 Above knee cushion socket $663.74 $508.23

L5649 Isch containmt/narrow m-l so $2,230.19 $1,808.28

L5650 Tot contact ak/knee disart s $441.63 $338.16

L5651 Ak flex inner socket ext fra $1,293.93 $990.81

L5652 Suction susp ak/knee disart $394.41 $302.00

L5653 Knee disart expand wall sock $615.39 $471.18

L5654 Socket insert symes $356.74 $273.14

L5655 Socket insert below knee $257.58 $197.23

L5656 Socket insert knee articulat $391.31 $299.63

L5658 Socket insert above knee $413.03 $316.27

L5665 Multi-durometer below knee $526.85 $403.43

L5666 Below knee cuff suspension $69.77 $53.41

L5668 Bk molded distal cushion $103.92 $79.57

L5670 Bk molded supracondylar susp $245.47 $187.95

L5671 Bk/ak locking mechanism $449.99 $360.87

L5672 Bk removable medial brim sus $324.84 $248.73

L5673 Socket insert w lock mech $715.15 $484.06

L5676 Bk knee joints single axis p $327.82 $251.01

L5677 Bk knee joints polycentric p $502.06 $384.44

L5678 Bk joint covers pair $35.93 $27.50

L5679 Socket insert w/o lock mech $595.96 $421.46

L5680 Bk thigh lacer non-molded $275.35 $210.83

L5681 Intl custm cong/latyp insert $1,196.88 $603.50

L5682 Bk thigh lacer glut/ischia m $565.76 $433.21

L5683 Initial custom socket insert $1,196.88 $613.17

L5684 Bk fork strap $43.55 $33.33

L5685 Below knee sus/seal sleeve $116.57 $94.50

L5686 Bk back check $52.37 $40.09

L5688 Bk waist belt webbing $55.63 $42.58

L5690 Bk waist belt padded and lin $113.54 $86.92

L5692 Ak pelvic control belt light $120.22 $92.05

L5694 Ak pelvic control belt pad/l $164.12 $125.66

L5695 Ak sleeve susp neoprene/equa $147.54 $112.96

L5696 Ak/knee disartic pelvic join $178.22 $136.46

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L5697 Ak/knee disartic pelvic band $84.64 $64.80

L5698 Ak/knee disartic silesian ba $108.57 $83.12

L5700 Replace socket below knee $2,790.93 $2,137.10

L5701 Replace socket above knee $3,462.41 $2,651.26

L5702 Replace socket hip $4,363.82 $3,341.51

L5704 Custom shape cover bk $569.05 $456.39

L5705 Custom shape cover ak $1,043.29 $836.71

L5706 Custom shape cvr knee disart $1,017.61 $816.11

L5707 Custom shape cvr hip disart $1,367.19 $1,096.45

L5710 Kne-shin exo sng axi mnl loc $325.37 $249.10

L5711 Knee-shin exo mnl lock ultra $546.06 $418.13

L5712 Knee-shin exo frict swg & st $389.81 $298.48

L5714 Knee-shin exo variable frict $396.64 $303.70

L5716 Knee-shin exo mech stance ph $784.28 $600.54

L5718 Knee-shin exo frct swg & sta $838.63 $642.17

L5722 Knee-shin pneum swg frct exo $1,019.84 $780.91

L5724 Knee-shin exo fluid swing ph $1,571.91 $1,203.65

L5726 Knee-shin ext jnts fld swg e $1,871.42 $1,433.00

L5780 Knee-shin pneum/hydra pneum $1,207.47 $924.59

L5785 Exoskeletal bk ultralt mater $470.01 $359.89

L5790 Exoskeletal ak ultra-light m $678.35 $519.43

L5795 Exoskel hip ultra-light mate $971.30 $743.74

L5810 Endoskel knee-shin mnl lock $517.51 $396.27

L5811 Endo knee-shin mnl lck ultra $714.16 $546.85

L5812 Endo knee-shin frct swg & st $537.43 $411.50

L5816 Endo knee-shin polyc mch sta $769.36 $589.10

L5818 Endo knee-shin frct swg & st $868.75 $665.22

L5822 Endo knee-shin pneum swg frc $1,593.69 $1,220.32

L5824 Endo knee-shin fluid swing p $1,506.51 $1,153.56

L5828 Endo knee-shin fluid swg/sta $2,681.20 $2,053.05

L5830 Endo knee-shin pneum/swg pha $1,807.84 $1,384.30

L5840 Multi-axial knee/shin system $3,548.30 $2,717.03

L5850 Endo ak/hip knee extens assi $115.73 $88.61

L5855 Mech hip extension assist $279.39 $213.92

L5910 Endo below knee alignable sy $327.64 $250.88

L5920 Endo ak/hip alignable system $480.01 $367.53

L5925 Above knee manual lock $303.97 $232.75

L5940 Endo bk ultra-light material $453.78 $347.46

L5950 Endo ak ultra-light material $703.81 $538.93

L5960 Endo hip ultra-light materia $1,052.38 $805.82

L5961 Endo poly hip, pneu/hyd/rot $4,343.14 handpriced

L5962 Below knee flex cover system $531.74 $426.45

L5966 Hip flexible cover system $1,313.91 $1,053.74

L5970 Foot external keel sach foot $197.65 $151.35

L5972 Flexible keel foot $360.04 $275.68

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L5974 Foot single axis ankle/foot $210.82 $161.42

L5976 Energy storing foot $534.73 $409.44

L5978 Ft prosth multiaxial ankl/ft $283.34 $216.97

L5981 Flex-walk sys low ext prosth $3,104.69 $2,377.37

L5982 Exoskeletal axial rotation u $583.24 $446.60

L5984 Endoskeletal axial rotation $585.06 $447.99

L5986 Multi-axial rotation unit $705.74 $540.38

L6000 Part hand thumb rem $1,602.64 $1,227.18

L6010 Part hand little/ring $1,783.48 $1,365.65

L6020 Part hand no fingers $1,662.80 $1,273.25

L6050 Wrst mld sck flx hng tri pad $2,261.74 $1,731.87

L6055 Wrst mold sock w/exp interfa $2,884.98 $2,209.09

L6100 Elb mold sock flex hinge pad $2,288.82 $1,752.60

L6110 Elbow mold sock suspension t $2,421.41 $1,854.12

L6120 Elbow mold doub splt soc ste $2,738.63 $2,097.03

L6130 Elbow stump activated lock h $2,889.31 $2,212.43

L6200 Elbow mold outsid lock hinge $2,976.32 $2,279.05

L6205 Elbow molded w/ expand inter $4,105.77 $3,143.92

L6250 Elbow inter loc elbow forarm $2,928.18 $2,242.19

L6300 Shlder disart int lock elbow $4,038.77 $3,092.60

L6310 Shoulder passive restor comp $3,660.27 $2,802.76

L6320 Shoulder passive restor cap $1,907.62 $1,460.73

L6350 Thoracic intern lock elbow $4,425.25 $3,388.52

L6360 Thoracic passive restor comp $3,841.89 $2,941.84

L6370 Thoracic passive restor cap $2,228.03 $1,706.07

L6380 Postop dsg cast chg wrst/elb $1,288.64 $986.72

L6382 Postop dsg cast chg elb dis/ $1,534.07 $1,174.66

L6384 Postop dsg cast chg shlder/t $1,940.67 $1,486.00

L6388 Postop applicat rigid dsg on $468.49 $358.72

L6400 Below elbow prosth tiss shap $2,475.92 $1,895.87

L6450 Elb disart prosth tiss shap $3,235.90 $2,477.83

L6500 Above elbow prosth tiss shap $3,177.58 $2,433.16

L6550 Shldr disar prosth tiss shap $4,115.63 $3,151.44

L6570 Scap thorac prosth tiss shap $4,594.55 $3,518.17

L6582 Wrist/elbow bowden cbl dir f $1,542.84 $1,181.40

L6586 Elbow fair lead cable dir fo $2,035.66 $1,558.76

L6590 Shdr fair lead cable direct $2,825.58 $2,163.61

L6600 Polycentric hinge pair $206.39 $158.04

L6605 Single pivot hinge pair $212.43 $162.66

L6610 Flexible metal hinge pair $200.82 $153.76

L6615 Disconnect locking wrist uni $194.95 $149.25

L6616 Disconnect insert locking wr $58.70 $44.92

L6620 Flexion/extension wrist unit $340.79 $260.94

L6623 Spring-ass rot wrst w/ latch $649.18 $497.09

L6625 Rotation wrst w/ cable lock $481.13 $368.42

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L6628 Quick disconn hook adapter o $517.89 $396.55

L6629 Lamination collar w/ couplin $176.48 $135.12

L6630 Stainless steel any wrist $259.96 $199.06

L6632 Latex suspension sleeve each $58.78 $45.08

L6635 Lift assist for elbow $187.89 $143.88

L6637 Nudge control elbow lock $367.84 $281.67

L6640 Shoulder abduction joint pai $306.35 $234.58

L6641 Excursion amplifier pulley t $178.39 $136.59

L6642 Excursion amplifier lever ty $262.29 $200.83

L6645 Shoulder flexion-abduction j $331.30 $253.68

L6650 Shoulder universal joint $359.33 $275.14

L6655 Standard control cable extra $69.71 $53.35

L6665 Teflon or equal cable lining $41.67 $31.89

L6670 Hook to hand cable adapter $43.39 $33.22

L6672 Harness chest/shlder saddle $199.10 $152.45

L6675 Harness figure of 8 sing con $108.65 $83.18

L6676 Harness figure of 8 dual con $113.67 $87.02

L6680 Test sock wrist disart/bel e $279.85 $214.28

L6682 Test sock elbw disart/above $309.42 $236.91

L6684 Test socket shldr disart/tho $420.44 $321.94

L6686 Suction socket $623.88 $477.71

L6687 Frame typ socket bel elbow/w $521.81 $399.55

L6688 Frame typ sock above elb/dis $577.51 $442.20

L6690 Frame typ sock interscap-tho $810.35 $620.50

L6691 Removable insert each $319.87 $244.91

L6692 Silicone gel insert or equal $581.93 $455.59

L6694 Elbow socket ins use w/lock $715.15 $652.15

L6695 Elbow socket ins use w/o lck $595.96 $543.47

L6696 Cus elbo skt in for con/atyp $1,196.88 handpriced

L6697 Add to UE Other than cong oratyp cust int $1,196.88 handpriced

L6698 Below/above elbow lock mech $449.99 $410.35

L6706 Term dev mech hook vol open $381.24 $347.66

L6707 Term dev mech hook vol close $1,348.57 handpriced

L6708 Term dev mech hand vol open $891.46 $812.96

L6709 Term dev mech hand vol close $1,265.22 handpriced

L6711 Ped term dev, hook, vol open $611.73 $557.85

L6712 Ped term dev, hook, vol clos $1,126.35 handpriced

L6713 Ped term dev, hand, vol open $1,421.51 handpriced

L6714 Ped term dev, hand, vol clos $1,204.01 handpriced

L6721 Hook/hand, hvy dty, vol open $2,140.05 handpriced

L6722 Hook/hand, hvy dty, vol clos $1,844.85 handpriced

L6805 Term dev modifier wrist unit $348.98 $267.21

L6810 Term dev precision pinch dev $185.53 $142.05

L6890 Prefab glove for term device $181.73 $139.15

L6895 Custom glove for term device $607.64 $465.27

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L6900 Hand restorat thumb/1 finger $1,764.56 $1,351.17

L6905 Hand restoration multiple fi $1,746.42 $1,337.27

L6910 Hand restoration no fingers $1,716.84 $1,314.62

L7700 Pros soc insert gasket/seal $136.14 $133.08

L8042 Orbital prosthesis $3,054.68 $2,785.70

L8042 Orbital prosthesis - modifier KM $2,901.96 $2,785.70

L8042 Orbital prosthesis - modifier KN $1,221.90 $2,785.70

L8300 Truss single w/ standard pad $76.32 $58.42

L8310 Truss double w/ standard pad $135.20 $103.52

L8330 Truss add to std pad scrotal $44.68 $34.19

dme fee schedule key updated november 13, 2019 · l2040 hkafo torsion bil rot straps $183.72...

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