Wheelchair Cushions | |||||
HCPCS Codes | Wheelchair Product Description | Product Link | New Purchase Allowable w/ KE Modifier (Manual Chair) | New Purchase Allowable w/o KE Modifier (Power Chair) | Retail |
---|---|---|---|---|---|
E2601 | General Use Wheelchair Seat Cushion, width less than 22 inches, any depth | Curve | $67.89 | $58.51 | $88.00 |
Elements with Gel | $109.00 | ||||
E2602 | General Use Wheelchair Seat Cushion, width 22 inches or greater, any depth | Curve | $132.53 | $114.23 | $185.00 |
Elements with Gel | $195.00 | ||||
E2603 | Skin Protection Wheelchair Seat Cushion, width less than 22 inches, any depth | Ascent | $168.26 | $145.02 | $245.00 |
Hyalite | $237.00 | ||||
E2604 | Skin Protection Wheelchair Seat Cushion, width 22 inches or greater, any depth | Ascent | $209.12 | $180.25 | $306.00 |
Hyalite | $309.00 | ||||
E2605 | Positioning Wheelchair Seat Cushion, width less than 22 inches, any depth | Ridge | $294.36 | $253.71 | $394.00 |
E2606 | Positioning Wheelchair Seat Cushion, width 22 inches or greater, any depth | Ridge | $459.22 | $395.80 | $498.00 |
E2607 | Skin Protection and Positioning Wheelchair Seat Cushion, width less than 22 inches, any depth | M2 | $321.72 | $277.29 | $390.00 |
Maxx | $372.00 | ||||
Acta-Embrace | $352.00 | ||||
E2608 | Skin Protection and Positioning Wheelchair Seat Cushion, width 22 inches or greater, any depth | M2 | $386.35 | $333.00 | $418.00 |
Maxx | $448.00 | ||||
Acta-Embrace | $428.00 | ||||
Saddle 7 Series | $473.00 | ||||
E2609 | Custom fabricated wheelchair seat cushion, any size | Inception | Varies | Varies | Varies |
E2622 | Adjustable Skin Protection Wheelchair Seat Cushion, width less than 22 inches, any depth | Adjuster | $367.90 | $317.10 | $441.00 |
Adjuster X | $441.00 | ||||
Liberty X | $462.19 | ||||
E2623 | Adjustable Skin Protection Wheelchair Seat Cushion, width 22 inches or greater, any depth | Adjuster | $468.16 | $403.50 | $488.00 |
Adjuster X | $488.00 | ||||
Liberty X | $462.19 | ||||
E2624 | Adjustable Skin Protection and Positioning Wheelchair Seat Cushion, width less than 22 inches, any depth | Vector | $370.93 | $319.71 | $462.00 |
Vector X | $462.00 | ||||
Versa X | $462.00 | ||||
M2 ATI | $524.00 | ||||
Acta-Embrace ATI | $352.00 | ||||
E2625 | Adjustable Skin Protection and Positioning Wheelchair Seat Cushion, width 22 inches or greater, any depth | Vector | $469.58 | $404.73 | $509.00 |
Vector X | $509.00 | ||||
Versa X | $509.00 | ||||
M2 ATI | $552.00 | ||||
Acta-Embrace ATI | $428.00 |
Back Supports | |||||
HCPCS Codes | Wheelchair Product Description | Product Link | New Purchase Allowable w/ KE Modifier (Manual Chair) | New Purchase Allowable w/o KE Modifier (Power Chair) | Retail |
---|---|---|---|---|---|
E2611 | General Use Wheelchair Back Support, width less than 22 inches, any height, including any type mounting hardware | Elements Back | $346.69 | $298.82 | $354.00 |
Radius Back | $481.00 | ||||
Visco Back | $439.00 | ||||
E2612 | General Use Wheelchair Back Support, width 22 inches or greater, any height, including any type mounting hardware | Elements Back | $469.01 | $404.24 | $482.00 |
Radius Back | $534.00 | ||||
Visco Back | $514.00 | ||||
E2613 | Positioning Wheelchair Back Support, Posterior, width less than 22 inches, any height, including any type mounting hardware | Acta-Back | $436.25 | $376.01 | $507.00 |
IncrediBack | $435.00 | ||||
Acta-Embrace Back | $530.00 | ||||
Acta-Embrace LTS | $696.52 | ||||
E2614 | Positioning Wheelchair Back Support, Posterior, width 22 inches or greater, any height, including any type mounting hardware | Acta-Back | $603.74 | $520.37 | $596.00 |
IncrediBack | $536.00 | ||||
Acta-Embrace Back | $678.00 | ||||
Acta-Embrace LTS | $786.07 | ||||
E2615 | Positioning Wheelchair Back Support, Posterior Lateral, width less than 22 inches, any height, including any type mounting hardware | Acta-Back Deep | $502.06 | $432.72 | $601.00 |
IncrediBack | $493.00 | ||||
Acta-Relief | $684.08 | ||||
E2616 | Positioning Wheelchair Back Support, Posterior Lateral, width 22 inches or greater, any height, including any type mounting hardware | Acta-Back Deep | $675.49 | $582.21 | $677.00 |
IncrediBack | $621.00 | ||||
E2617 | Custom Fabricated Wheelchair Back Support | Custom Acta-Back | Varies | Varies | Varies |
Custom Acta-Back Deep | Varies | ||||
Custom Acta-Embrace | Varies | ||||
E2620 | Positioning Wheelchair Back Support, Planar with Lateral Supports, width less than 22 inches, any height, including any type mounting hardware | Acta-Back Contour | $607.92 | $637.96 | $605.00 |
Acta-Back LTS | $671.00 | ||||
Acta-Relief LTS | $870.65 | ||||
E2621 | Positioning Wheelchair Back Support, Planar with Lateral Supports, width 22 inches or greater, any height, including any type mounting hardware | Acta-Back Contour | $637.96 | $549.86 | $679.00 |
Acta-Back LTS | $744.00 | ||||
Acta-Relief LTS | $870.65 |
Accessories | |||||
HCPCS Codes | Wheelchair Product Description | Product Link | New Purchase Allowable w/ KE Modifier (Manual Chair) | New Purchase Allowable w/o KE Modifier (Power Chair) | Retail |
---|---|---|---|---|---|
E1020 | Residual Limb Support for a wheelchair | Quick-Release Amp | $266.18 | $229.42 | $338.00 |
Swing-Away Amp | $348.00 | ||||
E1028 | Manual swing-away, retractable or removable mounting hardware | Swing Away Arm Hardware | $229.25 | $197.59 | $263.00 |
EAD Arm Hardware | $322.00 | ||||
Durasoft Half Lap Tray Hardware | $243.00 | ||||
Swing Away Lateral Hardware | $263.00 | ||||
Head Support Hardware | $211.00 | ||||
E2209 | Arm trough with or without hand support | Comfort Arm | $118.95 | $102.52 | $138.00 |
Molded Arm | $73.00 | ||||
E0956 | Lateral trunk or hip support, any type including fixed mounting hardware | Flat Top Lateral Roll | $109.42 | $94.30 | $72.00 |
Lateral Pads | $79.00 | ||||
E0955 | Cushioned head support, any type including fixed mounting hardware | BodiLink Head Support | $224.42 | $196.93 | $230.00 |
E0995 | Calf rest/pad | Calf Protector | $33.75 | $29.08 | $55.00 |
E2619 | Replacement cushion cover | Cushion Cover | $55.57 | $47.88 | $60.00 |
E0992 | Solid seat insert | Rigid Insert | N/A | $105.62 | $63.00 |
K0108 | Wheelchair accessory, not otherwise specified | Comfort Foot Single | Varies | Varies | -------- |
Comfort Foot Double | -------- |