-
Rule 1504. The orthotic and prosthetic codes, the L-code procedures that have set fees are listed in this rule. All other L-code procedures shall be listed in Medicare’s National Level II, HCPCS as adopted by reference in R 418.10107 and shall be reimbursed as a by report procedure. The maximum allowable fees for the L-code procedures are listed in the table in this rule:
as adopted by reference in R 418.10107
L0120 cervical, flexible, nonadjustable (foam collar)..........................................................................$17.29
L0130 cervical, flexible, thermoplastic collar, molded to patient.......................................................$117.02
L0140 cervical, semi-rigid, adjustable (plastic collar)..........................................................................$42.00
L0150 cervical, semi-rigid, adjustable molded chin cup ......................................................................$74.60
L0160 cervical, semi-rigid, wire frame occipital/mandibular support................................................$119.82 L0170 cervical collar, molded to patient model .................................................................................$796.31
L0172 cervical collar, semi-rigid, thermoplastic foam, two-piece .....................................................$110.00
L0174 cervical collar, semi-rigid, thermoplastic foam, two-piece with ............................................$194.07 L0180 cervical, multiple post collar, occipital/mandibular supports, ……………………… ............$314.44 L0190 cervical, multiple post collar, occipital/mandibular supports, ................................................$407.89
L0200 cervical, multiple post collar, occipital/mandibular supports, ................................................$430.12 L0210 thoracic rib belt, custom fitted...................................................................................................$28.85
L0220 thoracic rib belt, custom fabricated ...........................................................................................$90.00
L0300 tlso, flexible (dorso-lumbar surgical support), custom fitted ..................................................$124.59
L0310 tlso, flexible (dorso-lumbar surgical support), custom fabrica................................................$242.46
L0315 tlso, flexible (dorso-lumbar surgical support), elastic type, ....................................................$213.27
L0317 tlso, flexible (dorso-lumbar surgical support), hyperextension, .............................................$255.89
L0320 tlso, anterior-posterior control (taylor type), with apron ........................................................$336.00
L0330 tlso, anterior-posterior-lateral control (knight-taylor type) ....................................................$476.12
L0340 tlso, anterior-posterior-lateral-rotary control (arnold, ............................................................$567.22
L0350 tlso, ant.-posterior-lateral-rotary control, flexion c ................................................................$696.40
L0360 tlso, anterior-posterior-lateral-rotary control, flexion ..........................................................$1,551.72
L0370 tlso, ant.-posterior-lateral-rotary control, hyperextension ......................................................$349.60
L0380 tlso, anterior-posterior-lateral-rotary control, with .................................................................$614.95
L0390 tlso, anterior-posterior-lateral control molded to patient .....................................................$1,400.30
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L0400 tlso, ant.-posterior-lateral control molded to patient model, ...............................................$1,498.32
L0410 tlso, ant.-posterior-lateral control, two-piece construction, .................................................$1,626.40
L0420 tlso, anterior-posterior-lateral control, two-piece ................................................................$1,886.09
L0430 tlso, anterior-posterior-lateral control, with interface ..........................................................$1,062.50
L0440 tlso, ant.-posterior-lateral control, with overlapping front .....................................................$899.60
L0500 lso, flexible (lumbo-sacral surgical support), custom fitted ......................................................$99.00
L0510 lso, flexible (lumbo-sacral surgical support), custom .............................................................$214.00
L0515 lso, flexible (lumbo-sacral surgical support), elastic type, w/ ................................................$176.00
L0520 lso, anterior-posterior-lateral control (knight, wilcox types), .................................................$358.03
L0530 lso, anterior-posterior control (macausland type), with apron ................................................$359.95 L0540 lso, lumbar flexion (williams flexion type) .............................................................................$387.68
L0550 lso, anterior-posterior-lateral control, molded to patient .....................................................$1,273.00
L0560 lso, ant.-posterior-lateral control, molded to patient model, ................................................$1,590.56
L0565 lso, anterior-posterior-lateral control, custom fitted ................................................................$902.84
L0600 sacroiliac, flexible (sacroiliac surgical support), custom ..........................................................$60.09
L0610 sacroiliac, flexible (sacroiliac surgical support), custom ........................................................$224.46
L0620 sacroiliac, semi-rigid, (goldthwaite, osgood types), with apron .............................................$367.86
L0700 ctlso, ant.-posterior-lateral control, molded to patient model, .............................................$1,779.93
L0710 ctlso, anterior-posterior-lateral-control, molded to patient ..................................................$1,882.90
L0810 halo procedure, cervical halo incorporated into jacket vest .................................................$2,371.87
L0820 halo procedure, cervical halo incorporated into plaster body ..............................................$1,876.79
L0830 halo procedure, cervical halo incorporated into milwaukee type ........................................$2,829.65
L0860 addition to halo procedure, magnetic resonance image compatible .......................................$960.00 L0900 torso support, ptosis support, custom fitted.............................................................................$104.34
L0910 torso support, ptosis support, custom fabricated .....................................................................$302.09
L0920 torso support, pendulous abdomen support, custom fitted ......................................................$110.60
L0930 torso support, pendulous abdomen support, custom fabricated...............................................$328.72
L0940 torso support, postsurgical support, custom fitted...................................................................$103.04
L0950 torso support, postsurgical support, custom fabricated ...........................................................$299.10
L0960 torso support, postsurgical support, pads for postsurgical .......................................................$60.01 L0970 tlso, corset front.........................................................................................................................$99.30
L0972 lso, corset front ..........................................................................................................................$89.42
L0974 tlso, full corset .........................................................................................................................$155.56
L0976 lso, full corset ..........................................................................................................................$138.95
L0978 axillary crutch extension .........................................................................................................$167.24
L0980 peroneal straps, pair...................................................................................................................$15.17
L0982 stocking supporter grips, set of four (4) ....................................................................................$14.15
L0984 protective body sock, each ........................................................................................................$47.18
L1000 ctlso, inclusive of furnishing initial orthosis, including ......................................................$1,763.98
L1010 addition to ctlso or scoliosis orthosis, axilla sling .....................................................................$58.31
L1020 addition to ctlso or scoliosis orthosis, kyphosis pad..................................................................$75.11
L1025 addition to ctlso or scoliosis orthosis, kyphosis pad, floating .................................................$108.35
L1030 addition to ctlso or scoliosis orthosis, lumbar bolster pad.........................................................$55.27
L1040 addition to ctlso or scoliosis orthosis, lumbar or lumbar rib ....................................................$67.79
L1050 addition to ctlso or scoliosis orthosis, sternal pad .....................................................................$72.34
L1060 addition to ctlso or scoliosis orthosis, thoracic pad ...................................................................$83.09
L1070 addition to ctlso or scoliosis orthosis, trapezius sling ...............................................................$78.18
L1080 addition to ctlso or scoliosis orthosis, outrigger ........................................................................$48.08
L1085 addition to ctlso or scoliosis orthosis, outrigger, bilateral ......................................................$133.74
L1090 addition to ctlso or scoliosis orthosis, lumbar sling...................................................................$79.64
L1100 addition to ctlso or scoliosis orthosis, ring flange, plastic ......................................................$138.17
L1110 addition to ctlso or scoliosis orthosis, ring flange, plastic ......................................................$221.90
L1120 addition to ctlso, scoliosis orthosis, cover for upright, each .....................................................$34.51
L1200 tlso, inclusive of furnishing initial orthosis only ..................................................................$1,424.25
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L1210 addition to tlso (low profile), lateral thoracic extension..........................................................$227.34
L1220 addition to tlso (low profile), anterior thoracic extension .......................................................$192.48
L1230 addition to tlso (low profile), milwaukee type superstructure.................................................$493.91
L1240 addition to tlso (low profile), lumbar derotation pad.................................................................$67.46
L1250 addition to tlso (low profile), anterior asis pad..........................................................................$62.77
L1260 addition to tlso (low profile), anterior thoracic derotation .......................................................$65.74
L1270 addition to tlso (low profile), abdominal pad ............................................................................$67.32
L1280 addition to tlso (low profile), rib gusset (elastic), each .............................................................$74.95
L1290 addition to tlso (low profile), lateral trochanteric pad ...............................................................$68.29 L1300 other scoliosis procedure, body jacket molded to patient model..........................................$1,451.36
L1310 other scoliosis procedure, postoperative body jacket ...........................................................$1,493.46
L1499 spinal orthosis, not otherwise classisfied....................................................................................BR
L1500 thkao, mobility frame (newington, parapodium types) ........................................................$1,650.36 L1510 thkao, standing frame ..............................................................................................................$828.93
L1520 thkao, swivel walker.............................................................................................................$1,486.64
L1685 ho, abduction control of hip joint, postop. Hip abduction ..................................................$1,033.49
L1686 ho, abduction control of hip joint, postop. Hip abduction type, .............................................$653.04
L1800 ko, elastic with stays, prefabricated, includes fitting and .........................................................$43.34
L1810 ko, elastic with joints, prefabricated, includes fitting and ........................................................$81.00
L1815 ko, elastic or other elastic type material with condylar pad(s) ..................................................$63.13
L1820 ko, elastic or other elastic type material with condylar pads ..................................................$103.00 L1825 ko, elastic knee cap, prefabricated.............................................................................................$35.83
L1830 ko, immobilizer, canvas longitudinal, prefabricated .................................................................$57.01
L1832 ko, adjustable knee joints, positional orthosis, rigid support, ................................................$480.05
L1834 ko, without knee joint, rigid, custom fabricated ......................................................................$674.46
L1840 ko, derotation, medial-lateral, anterior cruciate ligament, ......................................................$798.89
L1844 ko, single upright, thigh and calf, with adjustable flexion and ...............................................$734.88
L1845 ko, double upright, thigh and calf, with adjustable flexion and .............................................$583.78
L1846 ko, double upright, thigh and calf, with adjustable flexion and ..............................................$985.10 L1850 ko, swedish type, prefabricated ...............................................................................................$187.57
L1855 ko, molded plastic, thigh and calf sections, with double ........................................................$954.77
L1858 ko, molded plastic, polycentric knee joints, pneumatic knee ..............................................$1,221.93
L1860 ko, modification of supracondylar prosthetic socket, custom ..............................................$1,383.48
L1870 ko, double upright, thigh and calf lacers, with knee joints, ....................................................$909.28
L1880 ko, double upright, nonmolded thigh and calf cuffs/lacers with ............................................$550.82
L1900 afo, spring wire, dorsiflexion assist calf band, custom ...........................................................$234.40
L1902 afo, ankle gauntlet, prefabricated, includes fitting and .............................................................$52.02
L1904 afo, molded ankle guantlet, custom fabricated ........................................................................$333.00
L1906 afo, multi-ligamentus ankle support, prefabricated ...................................................................$86.17
L1910 afo, posterior, single bar, clasp attachment to shoe counter, ..................................................$174.27
L1920 afo, single upright with static or adjustable stop (phelps or ...................................................$286.29 L1930 afo, plastic, prefabricated ........................................................................................................$175.57
L1940 afo, plastic, custom fabricated .................................................................................................$429.68
L1945 afo, molded to patient model, plastic, rigid anterior tibial ...................................................$1,145.70
L1950 afo, spiral, (irm type), plastic, custom fabricated ....................................................................$647.18
L1960 afo, posterior solid ankle, plastic, custom fabricated ..............................................................$530.36
L1970 afo, plastic, with ankle joint, custom fabricated ......................................................................$618.24
L1980 afo, single upright free plantar dorsiflexion, solid stirrup, .....................................................$318.88
L1990 afo, double upright free plantar dorsiflexion, solid stirrup, ....................................................$459.09
L2000 kafo, single upright, free knee, free ankle, solid stirrup, ........................................................$881.27
L2010 kafo, single upright, free ankle, solid stirrup, thigh and calf ..................................................$803.35
L2020 kafo, double upright, free knee, free ankle, solid stirrup, ....................................................$1,132.33
L2030 kafo, double upright, free ankle, solid stirrup, thigh and calf ................................................$880.19
L2036 kafo, full plastic, double upright, free knee, custom ...........................................................$2,022.35
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L2037 kafo, full plastic, single upright, free knee, custom .............................................................$1,447.16
L2038 kafo, full plastic, without knee joint, multiaxis ankle, custom ............................................$1,024.83
L2040 hkafo, torsion control, bilateral rotation straps, pelvic ...........................................................$154.26
L2050 hkafo, torsion control, bilateral torsion cables, hip joint, .......................................................$413.88
L2060 hkafo, torsion control, bilateral torsion cables, ball bearing ..................................................$504.44
L2070 hkafo, torsion control, unilateral rotation straps, pelvic .........................................................$116.84
L2080 hkafo, torsion control, unilateral torsion cable, hip joint, ......................................................$312.50
L2090 hkafo, torsion control, unilateral torsion cable, ball bearing ..................................................$380.99
L2102 afo, fracture orthosis, tibial fracture cast orthosis, plaster ......................................................$521.09
L2104 afo, fracture orthosis, tibial fracture cast orthosis, .................................................................$619.81
L2106 afo, fracture orthosis, tibial fracture cast orthosis, .................................................................$747.33
L2108 afo, fracture orthosis, tibial fracture cast orthosis, custom ..................................................$1,170.03
L2112 afo, fracture orthosis, tibial fracture orthosis, soft, .................................................................$304.03
L2114 afo, fracture orthosis, tibial fracture orthosis, semi-rigid, ......................................................$440.38
L2116 afo, fracture orthosis, tibial fracture orthosis, rigid, ...............................................................$537.16
L2122 kafo, fracture orthosis, femoral fracture cast orthosis, ...........................................................$891.10
L2124 kafo, fracture orthosis, femoral fracture cast orthosis, ...........................................................$992.94
L2126 kafo, fracture orthosis, femoral fracture cast orthosis, ........................................................$1,356.79
L2128 kafo, fracture orthosis, femoral fracture cast orthosis, custom ............................................$1,498.50
L2132 kafo, fracture orthosis, femoral fracture cast orthosis, soft, ...................................................$525.66
L2134 kafo, fracture orthosis, femoral fracture cast orthosis, semi- ..................................................$803.12
L2136 kafo, fracture orthosis, femoral fracture cast orthosis, rigid ...................................................$878.87
L2180 addition to lower extremity fracture orthosis, plastic shoe .....................................................$101.75
L2182 addition to lower extremity fracture orthosis, drop lock knee ..................................................$79.63
L2184 addition to lower extremity fracture orthosis, limited motion ................................................$107.63
L2186 add. To lower extremity fracture orthosis, adjustable motion ................................................$130.80
L2188 addition to lower extremity fracture orthosis, quadrilateral ...................................................$260.22
L2190 addition to lower extremity fracture orthosis, waist belt ...........................................................$59.45
L2192 addition to lower extremity fracture orthosis, hip joint, .........................................................$309.80
L2200 addition to lower extremity, limited ankle motion, each joint...................................................$41.30
L2210 addition to lower extremity, dorsiflexion assist (plantar ..........................................................$58.40
L2220 add. To lower extremity, dorsiflexion and plantar flexion .......................................................$71.16
L2230 addition to lower extremity, split flat caliper stirrups and ........................................................$66.67
L2240 addition to lower extremity, round caliper and plate attachment ..............................................$72.66
L2250 add. To lower extremity, foot plate, molded to patient model, ...............................................$308.74
L2260 addition to lower extremity, reinforced solid stirrup (scott-....................................................$174.17
L2265 addition to lower extremity, long tongue stirrup .....................................................................$102.31
L2270 addition to lower extremity, varus/valgus correction ("t") ........................................................$46.67
L2275 add. To lower extremity, varus/valgus correction, plastic ......................................................$103.91
L2280 addition to lower extremity, molded inner boot ......................................................................$393.43
L2300 addition to lower extremity, abduction bar (bilateral hip .......................................................$233.93
L2310 addition to lower extremity, abduction bar, straight................................................................$106.88
L2320 addition to lower extremity, nonmolded lacer.........................................................................$178.76
L2330 addition to lower extremity, lacer molded to patient model ....................................................$341.16
L2335 addition to lower extremity, anterior swing band....................................................................$197.38
L2340 addition to lower extremity, pre-tibial shell, molded to .........................................................$388.32
L2350 add. To lower extremity, prosthetic type, (bk) socket, molded ..............................................$774.19
L2360 addition to lower extremity, extended steel shank ....................................................................$44.96
L2370 addition to lower extremity, patten bottom .............................................................................$223.04
L2375 addition to lower extremity, torsion control, ankle joint and ...................................................$99.17
L2380 addition to lower extremity, torsion control, straight knee .....................................................$106.97
L2385 addition to lower extremity, straight knee joint, heavy duty, .................................................$116.38
L2390 addition to lower extremity, offset knee joint, each joint ..........................................................$95.11
L2395 addition to lower extremity, offset knee joint, heavy duty, ....................................................$101.95
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L2397 addition to lower extremity orthosis, suspension sleeve ...........................................................$87.81
L2405 addition to knee joint, drop lock, each joint ..............................................................................$44.22
L2415 addition to knee joint, cam lock (swiss, french, bail types), ...................................................$159.56
L2425 addition to knee joint, disc or dial lock for adjustable knee ...................................................$158.17
L2435 addition to knee joint, polycentric joint, each joint .................................................................$143.80
L2492 addition to knee joint, lift loop for drop lock ring.....................................................................$88.60
L2500 add. To lower extremity, thigh/weight bearing, gluteal/ischial ..............................................$274.10
L2510 addition to lower extremity, thigh/weight bearing, quadri-.....................................................$631.12
L2520 add. To lower extremity, thigh/weight bearing, quadri-lateral ...............................................$374.57
L2525 addition to lower extremity, thigh/weight bearing, ischial .....................................................$873.78
L2526 addition to lower extremity, thigh/weight bearing, ischial .....................................................$595.12
L2530 addition to lower extremity, thigh/weight bearing, lacer, .......................................................$204.14
L2540 addition to lower extremity, thigh/weight bearing, lacer, .......................................................$367.33
L2550 addition to lower extremity, thigh/weight bearing, high roll ..................................................$249.53
L2570 addition to lower extremity, pelvic control, hip joint, clevis ..................................................$413.84
L2580 addition to lower extremity, pelvic control, pelvic sling .........................................................$403.24
L2600 addition to lower extremity, pelvic control, hip joint, clevis ..................................................$178.44
L2610 addition to lower extremity, pelvic control, hip joint, clevis, .................................................$211.00
L2620 addition to lower extremity, pelvic control, hip joint, heavy- .................................................$232.31
L2622 addition to lower extremity, pelvic control, hip joint, ............................................................$266.44
L2624 addition to lower extremity, pelvic control, hip joint, ............................................................$287.71
L2627 addition to lower extremity, pelvic control, plastic, molded to ...........................................$1,489.46
L2628 addition to lower extremity, pelvic control, metal frame, ...................................................$1,455.67
L2630 addition to lower extremity, pelvic control, band and belt, ....................................................$215.15
L2640 addition to lower extremity, pelvic control, band and belt, ....................................................$291.98
L2650 addition to lower extremity, pelvic and thoracic control, .......................................................$104.27
L2660 addition to lower extremity, thoracic control, thoracic band...................................................$161.94
L2670 addition to lower extremity, thoracic control, paraspinal .......................................................$148.21
L2680 addition to lower extremity, thoracic control, lateral support ................................................$135.96
L2750 addition to lower extremity orthosis, plating chrome or nickel, ...............................................$72.62
L2760 addition to lower extremity orthosis, extension, per extension, ...............................................$52.79
L2770 addition to lower extremity orthosis, any material, per bar or ..................................................$53.64
L2780 addition to lower extremity orthosis, non-corrosive finish, per ...............................................$58.80
L2785 addition to lower extremity orthosis, drop lock retainer, each ..................................................$27.54
L2795 addition to lower extremity orthosis, knee control, full ...........................................................$57.13
L2800 addition to lower extremity orthosis, knee control, kneecap, ....................................................$92.00
L2810 addition to lower extremity orthosis, knee control, condylar ...................................................$67.86
L2820 addition to lower extremity orthosis, soft interface for molded ...............................................$75.46
L2830 addition to lower extremity orthosis, soft interface for molded ...............................................$81.62
L2840 addition to lower extremity orthosis, tibial length sock, ..........................................................$30.06
L2850 addition to lower extremity orthosis, femoral length sock, ......................................................$42.15
L2999 unlisted procedures for lower extremity orthoses.......................................................................BR
L3000 foot insert, removable, molded to patient model, "ucb" type, ................................................$170.00
L3001 foot insert, removable, molded to patient model, spenco, each................................................... br
L3002 foot insert, removable, molded to patient model, plastazote or ................................................$99.00
L3003 foot insert, removable, molded to patient model, silicone gel, .................................................$99.00
L3010 foot insert, removable, molded to patient model, longitudinal ...............................................$135.00 L3020 foot insert, removable, molded to patient model, .....................................................................$99.00
L3030 foot insert, removable, formed to patient foot, each...................................................................BR
L3040 foot, arch support, removable, premolded, longitudinal, each ...................................................BR
L3050 foot, arch support, removable, premolded, metatarsal, each ......................................................BR
L3060 foot, arch support, removable, premolded, ................................................................................BR
L3070 foot, arch support, nonremovable, attached to shoe, .................................................................BR
L3080 foot, arch support, nonremovable, attached to shoe, metatarsal, ...............................................BR
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L3090 foot, arch support, nonremovable, attached to shoe, longitudin.................................................BR L3100 hallus-valgus night dynamic splint .............................................................................................BR
L3150 foot, abduction rotation bar, without shoes ................................................................................BR
L3215 orthopedic footwear, woman's shoes, oxford ............................................................................$94.18
L3216 orthopedic footwear, woman's shoes, depth inlay ...................................................................$108.00
L3217 orthopedic footwear, woman's shoes, hightop, depth inlay.....................................................$127.00
L3218 orthopedic footwear, woman's surgical boot, each....................................................................$87.00
L3219 orthopedic footwear, man's shoes, oxford ...............................................................................$102.87
L3221 orthopedic footwear, man's shoes, depth inlay ........................................................................$120.00
L3222 orthopedic footwear, man's shoes, hightop, depth inlay..........................................................$150.00
L3223 orthopedic footwear, man's surgical boot, each.........................................................................$91.00
L3230 orthopedic footwear, custom shoes, depth inlay .....................................................................$425.00 L3250 orthopedic footwear, custom molded shoe, removable inner mold, .......................................$381.00
L3251 foot, shoe molded to patient model, silicone shoe, each .........................................................$450.00
L3252 foot, shoe molded to patient model, plastazote (or similar), ..................................................$300.00
L3253 foot, molded shoe plastazote (or similar), custom fitted, each ..................................................$90.00 L3254 nonstandard size or width..........................................................................................................$38.00
L3257 orthopedic footwear, additional charge for split size ..............................................................$180.00 L3260 ambulatory surgical boot, each..................................................................................................$60.00
L3265 plastazote sandal, each ..............................................................................................................$35.00
L3300 lift, elevation, heel, tapered to metatarsals, per inch .................................................................$42.00
L3310 lift, elevation, heel and sole, neoprene, per inch .......................................................................$40.00
L3320 lift, elevation, heel and sole, cork, per inch................................................................................BR
L3330 lift, elevation, metal extension (skate).....................................................................................$275.00
L3332 lift, elevation, inside shoe, tapered, up to one-half inch............................................................$18.00 L3334 lift, elevation, heel, per inch ......................................................................................................$25.00
L3340 heel wedge, sach........................................................................................................................$70.00
L3350 heel wedge.................................................................................................................................$13.00
L3360 sole wedge, outside sole ............................................................................................................$15.00
L3370 sole wedge, between sole ..........................................................................................................$22.00
L3380 clubfoot wedge ..........................................................................................................................$32.00
L3390 outflare wedge ...........................................................................................................................$15.00
L3400 metatarsal bar wedge, rocker.....................................................................................................$56.00
L3410 metatarsal bar wedge, between sole ..........................................................................................$64.00
L3420 full sole and heel wedge, between sole .....................................................................................$32.00
L3430 heel, counter, plastic reinforced ................................................................................................$44.00
L3440 heel, counter, leather reinforced ................................................................................................$35.00
L3500 miscellaneous shoe addition, insole, leather...............................................................................BR
L3510 miscellaneous shoe addition, insole, rubber ...............................................................................BR
L3520 miscellaneous shoe addition, insole, felt covered with leather...................................................BR L3530 miscellaneous shoe addition, sole, half ......................................................................................BR
L3540 miscellaneous shoe addition, sole, full .......................................................................................BR
L3550 miscellaneous shoe addition, toe tap, standard...........................................................................BR
L3560 miscellaneous shoe addition, toe tap, horseshoe ........................................................................BR
L3570 miscellaneous shoe addition, special extension to instep ..........................................................BR
L3580 miscellaneous shoe addition, convert instep to velcro closure ...................................................BR
L3590 miscellaneous shoe addition, convert firm shoe counter to soft ................................................BR L3595 miscellaneous shoe addition, march bar .....................................................................................BR
L3650 so, figure of eight design abduction restrainer ..........................................................................$37.82
L3660 so, figure of eight design abduction restrainer, canvas and ......................................................$65.54
L3670 so, acromio/clavicular (canvas and webbing type)....................................................................$72.11 L3700 eo, elastic with stays ..................................................................................................................$44.51
L3710 eo, elastic with metal joints .......................................................................................................$78.83
L3720 eo, double upright with forearm/arm cuffs, free motion .........................................................$556.10
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L3730 eo, double upright with forearm/arm cuffs, extension/flexion ...............................................$766.44
L3740 eo, double upright with forearm/arm cuffs, adjustable position .............................................$908.66 L3800 whfo, short opponens, no attachments ....................................................................................$140.00
L3805 whfo, long opponens, no attachment.......................................................................................$256.00
L3810 whfo, addition to short and long opponens, thumb abduction .................................................$55.09
L3815 whfo, addition to short and long opponens, second m.p. .........................................................$51.16
L3820 whfo, addition to short and long opponens, i.p. extension .......................................................$87.86
L3825 whfo, addition to short and long opponens, m.p. extension stop ..............................................$55.14
L3830 whfo, addition to short and long opponens, m.p. extension .....................................................$71.98
L3835 whfo, addition to short and long opponens, m.p. spring ..........................................................$78.02
L3840 whfo, addition to short and long opponens, spring swivel thumb.............................................$53.45
L3845 whfo, addition to short and long opponens, thumb i.p. extension ............................................$69.02
L3850 whfo, addition to short and long opponens, action wrist, with .................................................$98.59
L3855 whfo, addition to short and long opponens, adjustable m.p. ....................................................$99.38
L3860 whfo, add. To short and long opponens, adjustable m.p. flexion ...........................................$136.03
L3900 whfo, dynamic flexor hinge, reciprocal wrist extension/flexion, ........................................$1,396.48
L3901 whfo, dynamic flexor hinge, reciprocal wrist extension/flexion, ........................................$1,481.20 L3902 whfo, external powered, compressed gas .............................................................................$2,137.19
L3904 whfo, external powered, electric ..........................................................................................$2,354.94
L3906 whfo, wrist gauntlet, custom fabricated ..................................................................................$384.00
L3907 whfo, wrist gauntlet with thumb spica, custom fabricated ......................................................$406.00
L3908 whfo, wrist extension control cock-up, prefabricated ...............................................................$38.21 L3910 whfo, swanson design .............................................................................................................$253.61
L3912 whfo, flexion glove with elastic finger control .........................................................................$69.00
L3914 whfo, wrist extension cock-up, prefabricated............................................................................$62.00
L3916 whfo, wrist extension cock-up, with outrigger, prefabricated.................................................$109.00 L3918 whfo, knuckle bender, prefabricated .........................................................................................$64.00
L3920 whfo, knuckle bender, with outrigger, prefabricated ................................................................$90.00
L3922 whfo, knuckle bender, two segment to flex joints, prefabricated..............................................$75.02 L3924 whfo, oppenheimer, prefabricated.............................................................................................$88.95
L3926 whfo, thomas suspension, prefabricated....................................................................................$71.96
L3928 whfo, finger extension, with clock spring, prefabricated ..........................................................$43.89
L3930 whfo, finger extension, with wrist support, prefabricated.........................................................$50.94
L3932 whfo, safety pin, spring wire, prefabricated ..............................................................................$38.12
L3934 whfo, safety pin, modified, prefabricated..................................................................................$40.91
L3936 whfo, palmer, prefabricated.......................................................................................................$75.73
L3938 whfo, dorsal wrist, prefabricated ...............................................................................................$74.25
L3940 whfo, dorsal wrist, with outrigger attachment, prefabricated....................................................$83.41 L3942 whfo, reverse knuckle bender, prefabricated.............................................................................$62.14
L3944 whfo, reverse knuckle bender, with outrigger, prefabricated ....................................................$78.52 L3946 whfo, composite elastic, prefabricated ......................................................................................$59.28
L3948 whfo, finger knuckle bender, prefabricated...............................................................................$46.85
L3950 whfo, combination oppenheimer, with knuckle bender and two ............................................$126.68
L3952 whfo, combination oppenheimer, with reverse knuckle and two ...........................................$141.50 L3954 whfo, spreading hand, prefabricated .........................................................................................$77.63
L3960 sewho, abduction positioning, airplane design, prefabricated.................................................$505.85
L3962 sewho, abduction positioning, erbs palsy design, prefabricated..............................................$457.52
L3963 sewho, molded shoulder, arm, forearm, and wrist with ......................................................$1,063.83
L3964 seo, mobile arm support attached to wheelchair, balanced, adj. .............................................$501.52
L3965 seo, mobile arm support attached to wheelchair, balanced, adj. .............................................$772.40
L3966 seo, mobile arm support attached to wheelchair, balanced, ...................................................$613.07
L3968 seo, mobile arm support attached to wheelchair, balanced and,..............................................$713.05
L3969 seo, mobile arm support, monosuspension arm and hand support, ........................................$563.81
L3970 seo, addition to mobile arm support, elevating proximal arm .................................................$193.93
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L3972 seo, addition to mobile arm support, offset or lateral rocker ..................................................$178.22
L3974 seo, addition to mobile arm support, supinator .......................................................................$109.98
L3980 upper extremity fracture orthosis, humeral, prefabricated.......................................................$197.13
L3982 upper extremity fracture orthosis, radius/ulnar, prefabricated.................................................$238.05
L3984 upper extremity fracture orthosis, wrist, prefabricated............................................................$219.47
L3985 upper extrem.fracture orthosis, forearm, hand with wrist hinge, ...........................................$496.93
L3986 upper extremity fracture orthosis, combination of humeral, ..................................................$476.56
L3995 addition to upper extremity orthosis, sock, fracture or equal, ..................................................$20.85 L3999 upper limb orthosis, not otherwise specified ..............................................................................BR
L4000 replace girdle for milwaukee orthosis ..................................................................................$1,107.83
L4010 replace trilateral socket brim ...................................................................................................$942.50
L4020 replace quadrilateral socket brim, molded to patient model ....................................................$748.37
L4030 replace quadrilateral socket brim, custom fitted......................................................................$438.67 L4040 replace molded thigh lacer.......................................................................................................$354.66
L4045 replace nonmolded thigh lacer.................................................................................................$285.01
L4050 replace molded calf lacer.........................................................................................................$358.70
L4055 replace nonmolded calf lacer...................................................................................................$232.27
L4060 replace high roll cuff ...............................................................................................................$276.12
L4070 replace proximal and distal upright for kafo ...........................................................................$244.52
L4080 replace metal bands kafo, proximal thigh..................................................................................$87.00
L4090 replace metal bands kafofo, calf or distal thigh.........................................................................$78.46
L4100 replace leather cuff kafo, proximal thigh ..................................................................................$90.62
L4110 replace leather cuff kafofo, calf or distal thigh..........................................................................$73.68 L4130 replace pretibial shell...............................................................................................................$431.00
L4210 repair of orthotic device, repair or replace minor parts ..............................................................BR
L4350 pneumatic ankle control splint (e.g., aircast), prefabricated......................................................$58.25
L4360 pneumatic walking splint (e.g., aircast), prefabricated............................................................$180.43
L4370 pneumatic full leg splint (e.g., aircast), prefabricated .............................................................$123.02
L4380 pneumatic knee splint (e.g., aircast), prefabricated ...................................................................$69.99
L5000 partial foot, shoe insert with longitudinal arch, toe filler ........................................................$400.00
L5010 partial foot, molded socket, ankle height, with toe filler ......................................................$1,217.00
L5020 partial foot, molded socket, tibial tubercle height, with toe ................................................$2,226.00 L5050 ankle, symes, molded socket, sach foot................................................................................$2,231.00
L5060 ankle, symes, metal frame, molded leather socket, articulated ............................................$2,691.00 L5100 below knee, molded socket, shin, sach foot .........................................................................$2,499.00
L5105 below knee, plastic socket, joints and thigh lacer, sach foot ................................................$3,215.69
L5150 knee disarticulation (or through knee), molded socket, external .........................................$3,599.00
L5160 knee disarticulation, (or through knee), molded socket, bent,..............................................$3,869.00
L5200 above knee, molded socket, single axis constant friction knee, ..........................................$3,081.00
L5210 above knee, short prosthesis, no knee joint ("stubbies"), with, ............................................$2,332.00
L5220 above knee, short prosthesis, no knee joint ("stubbies"), ....................................................$2,592.00
L5230 above knee, for proximal femoral focal deficiency, constant...............................................$4,198.00
L5250 hip dis-articulation, canadian type; molded socket, hip joint, .............................................$4,802.00
L5270 hip dis-articulation, tilt table type, molded socket, locking .................................................$4,760.75
L5280 hemipelvectomy, canadian type; molded socket, hip joint, single ......................................$4,713.13
L5301 below knee, molded socket, shin, sach foot, endoskeletal system .......................................$2,612.75
L5311 knee disarticulation, molded socket, enternal knee joints, shin............................................$3,859.00
L5321 above knee, molded socket, open end, sach foot, endoskeletal,...........................................$3,815.00
L5331 hip disarticlation, canadian type, molded socket, endoskeletal ............................................$5,450.14
L5341 hemipelvectomy, canadian type, molded socket, endoskeletal, hip .....................................$5,823.31
L5400 immediate post-surgical or early fitting, application of .......................................................$1,261.00
L5410 immediate post-surgical or early fitting, application of ..........................................................$333.00
L5420 immediate post-surgical or early fitting, application of .......................................................$1,547.71
L5430 immediate post-surgical or early fitting, application of ..........................................................$420.12
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L5450 immediate post-surgical or early fitting, application of non- ..................................................$363.27
L5460 immediate post-surgical or early fitting, application of non- ..................................................$476.46
L5500 initial below knee "ptb" type socket, "usmc" or equal pylon, no ........................................$1,262.00
L5505 initial, above knee-knee dis-articulation, ischial level .........................................................$1,685.00
L5510 preparatory, below knee "ptb" type socket, sach foot, plaster .............................................$1,535.00
L5520 preparatory, below knee "ptb" type socket, sach foot, ........................................................$1,347.00
L5530 preparatory, below knee "ptb" type socket, no cover, sach foot, ........................................$1,752.00
L5535 preparatory, below knee "ptb" type socket, no cover, sach foot, ........................................$1,569.73
L5540 preparatory, below knee "ptb" type socket, no cover, sach foot, ........................................$1,765.00
L5560 preparatory, above knee-knee disarticulation, ischial .........................................................$1,829.00
L5570 preparatory, above knee-knee disarticulation, ischial .........................................................$1,840.00
L5580 preparatory, above knee-knee disarticulation, ischial .........................................................$2,352.00
L5585 preparatory, above knee-knee disarticulation, ischial .........................................................$2,696.00
L5590 preparatory, above knee-knee disarticulation, ischial .........................................................$2,225.22
L5595 preparatory, hip disarticulation-hemipelvectomy, pylo........................................................$3,727.16
L5600 preparatory, hip disarticulation-hemipelvectomy, pylon, ....................................................$4,115.89
L5610 addition to lower extremity, endoskeletal above .................................................................$1,916.47
L5611 addition to lower extremity, endoskeletal system above ......................................................$1,491.40
L5613 addition to lower extremity, endoskeletal above, 4ar lin......................................................$2,268.50
L5614 addition to lower extremity, above knee--knee disarticula...................................................$3,508.49
L5616 addition to lower extremity, above knee, universal mult......................................................$1,257.18
L5618 addition to lower extremity, test socket, symes .......................................................................$654.32
L5620 addition to lower extremity, test socket, below knee ..............................................................$533.41
L5622 addition to lower extremity, test socket, knee disarticulation .................................................$729.81
L5624 addition to lower extremity, test socket, above knee...............................................................$635.07
L5626 addition to lower extremity, test socket, hip disarticulation ....................................................$777.71
L5628 addition to lower extremity, test socket, hemipelvectomy ......................................................$775.86
L5629 addition to lower extremity, below knee, acrylic socket .........................................................$220.64
L5630 addition to lower extremity, symes type, expandable wall socket...........................................$415.43 L5631 addition to lower extremity, above knee or .............................................................................$305.04
L5632 addition to lower extremity, symes type, "ptb" brim d ............................................................$205.52
L5634 addition to lower extremity, symes type, posterior opening ...................................................$281.57
L5636 addition to lower extremity, symes type, medial opening socket ............................................$235.86
L5637 addition to lower extremity, below knee, total contact............................................................$294.15
L5638 addition to lower extremity, below knee, leather socket .........................................................$450.48
L5639 addition to lower extremity, below knee, wood socket ........................................................$1,037.83
L5640 addition to lower extremity, knee disarticulation, leather ......................................................$591.89
L5642 addition to lower extremity, above knee, leather socket .........................................................$573.50
L5643 addition to lower extremity, hip disarticulation, flexible ....................................................$1,440.73
L5644 addition to lower extremity, above knee, wood socket ...........................................................$546.73
L5645 addition to lower extremity, below knee, flexible inner socket, .............................................$748.26
L5646 addition to lower extremity, below knee, air cushion socket ..................................................$507.18
L5647 addition to lower extremity, below knee, suction socket ........................................................$736.32
L5648 addition to lower extremity, above knee, air cushion socket...................................................$609.43
L5649 addition to lower extremity, ischial containment/narrow m-l ..............................................$1,882.67
L5650 addition to lower extremity, total contact, above knee or knee ..............................................$451.88
L5651 addition to lower extremity, above knee, flexible inner socket, ..........................................$1,111.63
L5652 addition to lower extremity, suction suspension, above knee or ............................................$606.28
L5653 addition to lower extremity, knee disarticulation, expandable ...............................................$661.74
L5654 addition to lower extremity, socket insert, symes (kemblo, ...................................................$426.49
L5655 addition to lower extremity, socket insert, below knee (kemblo, ...........................................$348.15 L5656 addition to lower extremity, socket insert, knee .....................................................................$343.38 L5658 addition to lower extremity, socket insert, above knee (kemblo, ...........................................$336.56
L5660 addition to lower extremity, socket inset, symes, silicone gel ................................................$533.65
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L5661 addition to lower extremity, socket insert, multidurometer, ...................................................$563.29
L5662 addition to lower extremity, socket insert, below knee, .........................................................$489.35
L5663 addition to lower extremity, socket insert, knee .....................................................................$637.86
L5664 addition to lower extremity, socket insert, above knee, .........................................................$614.54
L5665 addition to lower extremity, socket insert, multidurometer, ...................................................$473.96
L5666 addition to lower extremity, below knee, cuff suspension ........................................................$64.80
L5668 addition to lower extremity, below knee, molded distal cushion ..............................................$93.48
L5670 addition to lower extremity, below knee, molded supracondylar ...........................................$300.76
L5672 addition to lower extremity, below knee, removable medial brim .........................................$276.02 L5674 addition to lower extremity, below knee, latex sleeve ..............................................................$48.81
L5675 addition to lower extremity, below knee, latex sleeve ..............................................................$66.16
L5676 addition to lower extremity, below knee, knee joints, single .................................................$335.44
L5677 addition to lower extremity, below knee, knee joints, ............................................................$456.40
L5678 addition to lower extremity, below knee, joint covers, pair ......................................................$30.33
L5680 addition to lower extremity, below knee, thigh lacer, nonmolded ..........................................$281.74
L5682 addition to lower extremity, below knee, thigh lacer, ............................................................$578.90
L5684 addition to lower extremity, below knee, fork strap..................................................................$44.54
L5686 addition to lower extremity, below knee, back check (extension .............................................$47.29
L5688 addition to lower extremity, below knee, waist belt, webbing ..................................................$56.53
L5690 addition to lower extremity, below knee, waist belt, padded and .............................................$90.58
L5692 addition to lower extremity, above knee, pelvic control belt, ................................................$123.00
L5694 addition to lower extremity, above knee, pelvic control belt, ................................................$167.93
L5695 addition to lower extremity, above knee, pelvic control, sleeve ............................................$150.96 L5696 addition to lower extremity, above knee or knee ....................................................................$171.28
L5697 addition to lower extremity, above knee or knee ......................................................................$74.32
L5698 addition to lower extremity, above knee or knee ......................................................................$96.56
L5699 all lower extremity prostheses, shoulder harness ....................................................................$142.40
L5700 replacement, socket, below knee, molded to patient model .................................................$2,534.95
L5701 replacement, socket, above knee/knee disarticulation including .........................................$3,147.36
L5702 replacement, socket, hip disarticulation, including hip joint, ..............................................$4,021.66
L5704 replacement, custom shaped protective cover, below knee .....................................................$436.72
L5705 replacement, custom shaped protective cover, above knee .....................................................$800.64
L5706 replacement, custom shaped protective cover, knee ...............................................................$780.94
L5707 replacement, custom shaped protective cover, hip ..............................................................$1,049.19
L5710 addition, exoskeletal knee-shin system, single axis, manual ..................................................$332.93
L5711 addition, exoskeletal knee-shin system, single axis, manual lo...............................................$483.34
L5712 addition, exoskeletal knee-shin system, single axis, friction ..................................................$398.87
L5714 addition, exoskeletal knee-shin system, single axis, variable .................................................$387.18
L5716 addition, exoskeletal knee-shin system, polycentric mechanical ...........................................$674.65
L5718 addition, exoskeletal knee-shin system, polycentric, friction c ...............................................$843.24
L5722 addition, exoskeletal knee-shin system, single axis, pneumatic .............................................$835.75
L5724 addition, exoskeletal knee-shin system, single axis, fluid ...................................................$1,397.20
L5726 addition, exoskeletal knee-shin system, single axis, external ..............................................$1,610.24
L5728 addition, exoskeletal knee-shin system, single axis, fluid ...................................................$1,851.35
L5780 addition, exoskeletal knee-shin system, single axis, ...........................................................$1,059.79
L5785 addition, exoskeletal system, below knee, ultra-light material ...............................................$480.92
L5790 addition, exoskeletal system, above knee, ultra-light material ................................................$665.57
L5795 addition, exoskeletal system, hip disarticulation, ultra-light ...................................................$993.86
L5810 addition, endoskeletal knee-shin system, single axis, manual.................................................$450.67
L5811 addition, endoskeletal knee-shin system, single axis, manual.................................................$675.10
L5812 addition, endoskeletal knee-shin system, single axis friction..................................................$495.00
L5816 addition, endoskeletal knee-shin system, polycentric mechanical ..........................................$710.00
L5818 addition, endoskeletal knee-shin system, polycentric, friction................................................$888.94
L5822 addition, endoskeletal knee-shin system, single axis, pneumatic .........................................$1,576.30
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L5824 addition, endoskeletal knee-shin system, single axis, fluid ..................................................$1,400.00
L5828 addition, endoskeletal knee-shin system, single axis, fluid ..................................................$2,263.39
L5830 addition, endoskeletal knee-shin system, single axis, ..........................................................$1,756.46
L5840 addition, endoskeletal knee-shin system, single axis, ..........................................................$1,980.00
L5850 addition, endoskeletal system, above knee or hip ...................................................................$118.42
L5855 addition, endoskeletal system, hip disarticulation, mechanical ...............................................$285.88
L5910 addition, endoskeletal system, below knee, alignable system .................................................$335.26
L5920 addition, endoskeletal system, above knee or hip ...................................................................$491.14 L5925 addition, endoskeletal system, above knee, knee disarticulation.............................................$280.00
L5940 addition, endoskeletal system, below knee, ultra-light material..............................................$464.30
L5950 addition, endoskeletal system, above knee, ultra-light material ..............................................$720.17
L5960 addition, endoskeletal system, hip disarticulation, ultra-light .................................................$892.37
L5962 addition, endoskeletal system, below knee, flexible protective...............................................$490.00
L5964 addition, endoskeletal system, above knee, flexible protective...............................................$798.56
L5966 addition endoskeletal system, hip disarticulation, flexible ...................................................$1,035.31
L5970 all lower extremity prostheses, foot, external keel, sach foot..................................................$187.99
L5972 all lower extremity prostheses, flexible keel foot (safe, sten, .................................................$326.23
L5974 all lower extremity prostheses, foot, single axis ankle/foot.....................................................$215.70
L5976 all lower extremity prostheses, energy storing foot (seattl ......................................................$451.39
L5978 all lower extremity prostheses, foot, multixial ankle/foot .......................................................$270.13
L5979 all lower extremity prostheses, multixial ankle/foot, dynami...............................................$2,090.00
L5980 all lower extremity prostheses, flex-foot system ..................................................................$2,917.79
L5981 all lower extremity prostheses, flex-walk system or equal...................................................$2,382.65
L5982 all exoskeletal lower extremity prostheses, axial rotation unit................................................$535.13
L5984 all endoskeletal lower extremity prostheses, axial rotatio .......................................................$527.33
L5986 all lower extremity prostheses, multixial rotation unit ("mcp .................................................$586.57
L5999 lower extremity prosthesis, not otherwise classified ..................................................................BR
L6000 partial hand, robinids, thumb remaining (or equal) ..............................................................$1,229.90
L6010 partial hand, robinids, little and/or ring finger remaining ...................................................$1,368.70
L6020 partial hand, robon aids, no finger remaining (or equal) ......................................................$1,276.09
L6050 wrist disarticulation, molded socket, flexible elbow hinges.................................................$2,263.00
L6055 wrist disarticulation, molded socket with expandable interface, .........................................$2,450.75
L6100 below elbow, molded socket, flexible elbow hinge, triceps pad ..........................................$2,229.00
L6110 below elbow, molded socket (muenster or northwestern suspension ..................................$2,284.04
L6120 below elbow, molded double wall split socket, step-up hinges, ..........................................$2,202.07
L6130 below elbow, molded double wall split socket, stump activated .........................................$2,396.27
L6200 elbow disarticulation, molded socket, outside locking hinge, .............................................$2,982.00
L6205 elbow disarticulation, molded socket with expandable interface, .......................................$3,370.85
L6250 above elbow, molded double wall socket, internal locking elbow, .....................................$3,267.79
L6300 shoulder disarticulation, molded socket, shoulder bulkhead, ..............................................$3,448.64
L6310 shoulder disarticulation, passive restoration (complete .......................................................$2,809.00
L6320 shoulder disarticulation, passive restoration (shoulder cap .................................................$1,581.89
L6350 interscapular thoracic, molded socket, shoulder bulkhead, .................................................$3,625.73
L6360 interscapular thoracic, passive restoration (complete ..........................................................$2,948.39
L6370 interscapular thoracic, passive restoration (shoulder cap only)............................................$1,880.09
L6380 immediate post-surgical or early fitting, application of .......................................................$1,130.00
L6382 immediate post-surgical or early fitting, application of .......................................................$1,520.00
L6384 immediate post-surgical or early fitting, application of .......................................................$1,764.86
L6386 immediate post-surgical or early fitting, each additional cast ................................................$371.72
L6388 immediate post-surgical or early fitting, application of rigid .................................................$406.94
L6400 below elbow, molded socket, endoskeletal system, including soft .....................................$2,147.89
L6450 elbow disarticulation, molded socket, endoskeletal system, ...............................................$2,853.88
L6500 above elbow, molded socket, endoskeletal system, including soft ......................................$2,856.22
L6550 shoulder disarticulation, molded socket, endoskeletal system, ...........................................$3,529.76
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L6570 interscapular thoracic, molded socket, endoskeletal system, ...............................................$4,051.49
L6580 preparatory, wrist disarticulation or below elbow, single wall ............................................$1,446.95
L6582 preparatory, wrist disarticulation or below elbow, single wall ...........................................$1,273.99
L6584 preparatory, elbow disarticulation or above elbow, single wa .............................................$1,894.64
L6586 preparatory, elbow disarticulation or above elbow, single wa .............................................$1,734.41
L6588 preparatory, shoulder disarticulation or interscapul .............................................................$2,616.40
L6590 preparatory, shoulder disarticulation or interscapul .............................................................$2,435.32
L6600 upper extremity additions, polycentric hinge, pair ..................................................................$173.63
L6605 upper extremity additions, single pivot hinge, pair .................................................................$171.44
L6610 upper extremity additions, flexible metal hinge, pair ..............................................................$154.12
L6615 upper extremity addition, disconnect locking wrist unit .........................................................$160.80
L6616 upper extremity addition, additional disconnect insert f ...........................................................$60.04
L6620 upper extremity addition, flexion-friction wrist unit ...............................................................$280.66
L6623 upper extremity addition, spring assisted rotational wrist un ..................................................$593.77
L6625 upper extremity addition, rotation wrist unit with cable lock..................................................$492.31
L6628 upper extremity addition, quick disconnect hook adapter, or equal ........................................$443.44
L6629 upper extremity addition, quick disconnect lamination coll....................................................$135.43
L6630 upper extremity addition, stainless steel, any wrist .................................................................$529.70
L6632 upper extremity addition, latex suspension sleeve, each ...........................................................$60.14
L6635 upper extremity addition, lift assist for elbow .........................................................................$185.00
L6637 upper extremity addition, nudge control elbow lock...............................................................$339.89
L6640 upper extremity addition, shoulder abduction joint, pair.........................................................$259.30
L6641 upper extremity addition, excursion amplifier pulley type......................................................$148.50
L6642 upper extremity addition, excursion amplifier level type ........................................................$201.28
L6645 upper extremity addition, shoulder flexion abduction join......................................................$295.49
L6650 upper extremity addition, shoulder universal joint, each.........................................................$313.32
L6655 upper extremity addition, standard control cable, extra ............................................................$69.53
L6660 upper extremity addition, heavy duty control cable ..................................................................$84.96
L6665 upper extremity addition, teflon, or equal cable lining..............................................................$42.64
L6670 upper extremity addition, hook to hand, cable adapter..............................................................$44.39
L6672 upper extremity addition, harness, chest or shoulder, saddle .................................................$156.07
L6675 upper extremity addition, harness, figure of eight type, for ...................................................$111.16
L6676 upper extremity addition, harness, figure of ei........................................................................$112.26
L6680 upper extremity addition, test socket, wrist disar ....................................................................$396.63
L6682 upper extremity addition, test socket, elbow disar ..................................................................$492.52
L6684 upper extremity addition, test socket, shoulder di ...................................................................$575.62
L6686 upper extremity addition, suction socket.................................................................................$546.47
L6687 upper extremity addition, frame type socket, b .......................................................................$485.00
L6688 upper extremity addition, frame type socket, a .......................................................................$490.36
L6689 upper extremity addition, frame type soc ................................................................................$623.71
L6690 upper extremity addition, frame type socket, .........................................................................$636.49
L6691 upper extremity addition, removable insert, each....................................................................$375.00
L6692 upper extremity addition, silicone gel insert or equal, each ....................................................$517.66
L6700 terminal device, hook dorrance, or equal, model #3 ...............................................................$480.17
L6705 terminal device, hook dorrance, or equal, model #5 ...............................................................$281.90
L6710 terminal device, hook, dorrance, or equal, model #5x ............................................................$456.45
L6715 terminal device, hook, dorrance, or equal, model #5xa...........................................................$435.00
L6720 terminal device, hook, dorrance, or equal, model #6 ..............................................................$789.68
L6725 terminal device, hook, dorrance, or equal, model #7 ..............................................................$465.24
L6730 terminal device, hook, dorrance, or equal, model #7lo ...........................................................$591.50
L6735 terminal device, hook, dorrance, or equal, model #8 ..............................................................$275.82
L6740 terminal device, hook, dorrance, or equal, model #8x ............................................................$359.60
L6745 terminal device, hook, dorrance, or equal, model #88x ..........................................................$329.03
L6750 terminal device, hook, dorrance, or equal, model #10p ..........................................................$325.22
Code Abbreviated Orthotic and Prosthetic procedures (L-CODES) MAP A complete listing of procedures and codes is found in HCPCS
as adopted by reference in R 418.10107
L6755 terminal device, hook, dorrance, or equal, model #10x ..........................................................$324.30
L6765 terminal device, hook, dorrance, or equal, model #12p ..........................................................$338.82
L6770 terminal device, hook, dorrance, or equal, model #99x ..........................................................$326.63
L6775 terminal device, hook, dorrance, or equal, model #555 ..........................................................$387.01
L6780 terminal device, hook, dorrance, or equal, model #ss555 .......................................................$413.69
L6790 terminal device, hook, accu hook or equal ..............................................................................$418.27
L6795 terminal device, hook, 2 load or equal .................................................................................$1,145.60
L6800 terminal device, hook, aprl vc or equal ...................................................................................$937.88
L6805 terminal device, modifier wrist flexion unit ............................................................................$314.94
L6806 terminal device, hook, trs grip, vc ........................................................................................$1,219.79
L6809 terminal device, hook, trs super sport, passive ........................................................................$343.46
L6810 terminal device, pincher tool, otto bock or equal ....................................................................$172.66
L6825 terminal device, hand, dorrance, vo.........................................................................................$955.02
L6830 terminal device, hand, aprl, vc..............................................................................................$1,253.51
L6835 terminal device, hand, sierra, vo...........................................................................................$1,091.93
L6840 terminal device, hand, becker imperial....................................................................................$758.59
L6845 terminal device, hand, becker lock grip...................................................................................$704.22
L6850 terminal device, hand, becker pylite........................................................................................$637.78
L6855 terminal device, hand, robinids, vo .........................................................................................$811.19
L6860 terminal device, hand, robinids, vo soft ..................................................................................$615.22
L6865 terminal device, hand, passive hand ........................................................................................$301.42
L6875 terminal device, hand, bock vc ................................................................................................$719.47
L6880 terminal device, hand, bock vo................................................................................................$466.76
L6890 terminal device, glove for above hands, production glove......................................................$190.00
L6895 terminal device, glove for above hands, custom glove............................................................$732.76
L6900 hand restoration (casts, shading and measuremen................................................................$1,989.50
L6905 hand restoration (casts, shading and measuremen................................................................$1,990.23
L6910 hand restoration (casts, shading and measuremen................................................................$2,001.88
L6915 hand restoration (shading and measuremen ............................................................................$774.57
L6920 wrist disarticulation, external power, self-su........................................................................$6,434.34
L6925 wrist disarticulation, external power, self-su........................................................................$6,874.02 L6930 below elbow, external power, self-suspended inner socket, ...............................................$6,197.18
L6935 below elbow, external power, self-suspended inner socket, ...............................................$6,841.72
L6940 elbow disarticulation, external power, molded inner socket, ..............................................$8,002.61
L6945 elbow disarticulation, external power, molded inner socket, ..............................................$8,927.91
L6950 above elbow, external power, molded inner socket, removable ..........................................$7,987.74
L6955 above elbow, external power, molded inner socket, removable ..........................................$9,263.27
L6960 shoulder disarticulation, external power, molded inner socket, ..........................................$9,744.62
L6965 shoulder disarticulation, external power, molded inner ...................................................$11,544.00
L6970 interscapular-thoracic, external power, molded inner .......................................................$12,356.57
L6975 interscapular-thoracic, external power, molded inner .......................................................$13,619.84
L7010 electronic hand, otto bock, steeper or equal, switch controlled............................................$3,174.94
L7015 electronic hand, system teknik, variety village or equal, switc ............................................$5,611.94
L7020 electronic greifer, otto bock or equal, switch controlled ......................................................$3,466.69
L7025 electronic hand, otto bock or equal, myoelectronically .......................................................$3,428.95
L7030 electronic hand, system teknik, variety village or equal, .....................................................$5,488.37
L7035 electronic greifer, otto bock or equal, myoelectronically ....................................................$3,648.62
L7040 prehensile actuator, hosmer or equal, switch controlled ......................................................$2,609.59
L7170 electronic elbow, boston or equal, switch controlled ...........................................................$5,427.59
L7180 electronic elbow, boston, utah or equal, myoelectro ......................................................... $29,891.81
L7260 electronic wrist rotator, otto bock or equal...........................................................................$1,821.71
L7261 electronic wrist rotator, for utah arm....................................................................................$3,610.95
L7266 servo control, steeper or equal.................................................................................................$916.48
L7272 analogue control, unb or equal .............................................................................................$1,812.94
as adopted by reference in R 418.10107
L7274 proportional control, 12 volt, utah or equal..........................................................................$5,621.72
L7360 six volt battery, otto bock or equal, each.................................................................................$240.00
L7362 battery charger, six volt, otto bock or equal ............................................................................$242.00
L7364 twelve volt battery, utah or equal, each ...................................................................................$392.77
L7366 battery charger, 12 volt, utah or equal.....................................................................................$540.20
L7499 unlisted procedures for upper extremity prosthesis....................................................................BR
L7500 repair of prosthetic device, hourly rate......................................................................................$80.00
L7510 repair prosthetic device, repair or replace minor parts ...............................................................BR
L8100 gradient compression stocking, below knee, medium weight, each...........................................BR
L8110 gradient compression stocking, below knee, heavy weight, each ..............................................BR
L8120 gradient compression stocking, (linton or equal), each thigh ....................................................BR
L8130 gradient compression stocking, thigh length ..............................................................................BR
L8140 gradient compression stocking, thigh length ..............................................................................BR
L8150 gradient compression stocking, thigh length ..............................................................................BR
L8160 gradient compression stocking, full-length, each .......................................................................BR
L8170 gradient compression stocking, full-length, chap style each ......................................................BR L8180 gradient compression stocking, ..................................................................................................BR
L8190 gradient compression stocking, waist length each......................................................................BR
L8200 gradient compression stocking, waist length, each.....................................................................BR
L8210 gradient compression stocking, custom-made............................................................................BR
L8220 gradient compression, elastic stocking, lymphedema.................................................................BR L8300 truss, single with standard pad ..................................................................................................$58.56
L8310 truss, double with standard pads................................................................................................$92.46
L8320 truss, addition to standard pad, water pad .................................................................................$37.11
L8330 truss, addition to standard pad, scrotal pad................................................................................$34.27
L8400 prosthetic sheath, below knee, each ..........................................................................................$23.02
L8410 prosthetic sheath, above knee, each...........................................................................................$19.18
L8415 prosthetic sheath, upper limb, each ...........................................................................................$19.84
L8420 prosthetic sock, multiple ply, below knee, each ........................................................................$18.01
L8430 prosthetic sock, multiple ply, above knee, each ........................................................................$20.50
L8435 prosthetic sock, multiple ply, upper limb, each .........................................................................$19.46
L8440 prosthetic shrinker, below knee, each .......................................................................................$38.71
L8460 prosthetic shrinker, above knee, each........................................................................................$61.69
L8465 prosthetic shrinker, upper limb, each ........................................................................................$45.16
L8470 stump sock, single ply, fitting, below knee, each ........................................................................$6.18
L8480 stump sock, single ply, fitting, above knee, each ........................................................................$8.52
L8485 stump sock, single ply, fitting, upper limb, each .......................................................................$10.17
L8490 addition to prosthetic sheath/sock, air seal suction retent. ......................................................$134.87
L8499 unlisted procedure for miscellaneous prosthetic services...........................................................BR L8500 artificial larynx, any type............................................................................................................BR
L8501 tracheostomy speaking valve......................................................................................................BR
L8610 ocular..........................................................................................................................................BR
L8699 prosthetic implant, not otherwise specified ................................................................................BR
