La. Admin. Code tit. 40, § I-4119 - Maximum Allowance Schedules

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

Notes

La. Admin. Code tit. 40, § I-4119

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 39:1841 (July 2013), LR 40:375 (February 2014).

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