Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 41 - Durable Medical Equipment and Supplies Reimbursement Schedule, Billing Instructions, and Maintenance Procedures › Section I-4119 - Maximum Allowance Schedules

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Durable Medical Equipment
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
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.