LAC 40:I.4339. Schedule of Maximum Allowances and Procedural Codes

A. This maximum allowable reimbursement schedule provides the basis for identification of prosthetic and orthopedic equipment reimbursable to providers. the coding system used is the health care financing administration common procedure coding system (HCPCS). No other coding methodology will be accepted for this program. Invoices submitted to the carrier/self-insured employer should be billed at the providers usual and customary rate, not the maximum allowable charge designated in this fee schedule. Reimbursement is limited to the least of: 1. the provider's usual and customary charge; or 2. a previously negotiated amount by the provider and carrier/self-insured employer; or 3. the allowable reimbursement schedule. B. Prosthetic and Orthopedic Equipment Office of Workers' Compensation Schedule of Maximum Allowances for Prosthetic and Orthopedic Equipment HCPCS | Description | Purchase New L0112 | Cranial cervical orthosis | $2,007 L0113 | Cranial cervical torticollis | $410 L0120 | Cerv, flex, non-adj (foam collar) | $24 L0130 | Cerv, flex, thermoplastic collar | $149 L0140 | Cerv, semi-rigid, adj | $60 L0150 | Cerv, semi-rigid, adj chin cup | $99 L0160 | Cerv, semi-rigid, occ/mand supp | $191 L0170 | Cerv, collar, molded to pat model | $626 L0172 | Cerv, collar, semi-rigid thermopl | $129 L0174 | Cerv, collar, semi-rigid, thermop | $251 L0180 | Cerv, mult post collar, occ/mandi | $377 L0190 | Cerv, mult post collar, occ/mandi | $488 L0200 | Cerv, mult post collar, occ/mandi | $545 L0220 | Thoracic, rib belt, custom made | $149 L0430 | TLSO, a-p-l rotary control | $1,493.73 L0450 | TLSO flex prefab thoracic | $261 L0452 | TLSO flex custom fab thoraci | B.R. L0456 | TLSO flex prefab | $1,426 L0458 | TLSO 2Mod symphis-xipho pre | $1,279 L0460 | TLSO2Mod symphysis-stern pre | $1,440 L0462 | TLSO 3Mod sacro-scap pre | $1,791 L0464 | TLSO 4Mod sacro-scap pre | $2,132 L0466 | TLSO rigid frame pre soft ap | $561 L0468 | TLSO rigid frame prefab pelv | $688 L0470 | TLSO rigid frame pre subclav | $957 L0472 | TLSO rigid frame hyperex pre | $607 L0480 | TLSO rigid plastic custom fa | $2,138 L0482 | TLSO rigid lined custom fab | $2,328 L0484 | TLSO rigid plastic cust fab | $2,668 L0486 | TLSO rigidlined cust fab two | $2,830 L0488 | TLSO rigid lined pre one pie | $1,440 L0490 | TLSO rigid plastic pre one | $406 L0491 | TLSO 2 piece rigid shell | $1,102 L0492 | TLSO 3 piece rigid shell | $715 L0621 | SIO flex pelvisacral prefab | $138 L0622 | SIO flex pelvisacral custom | $388 L0623 | SIO panel prefab | B.R. L0624 | SIO panel custom | B.R. L0625 | LO flexibl L1-below L5 pre | $79 L0626 | LO sag stays/panels pre-fab | $112 L0627 | LO sagitt rigid panel prefab | $590 L0628 | LO flex w/o rigid stays pre | $120 L0629 | LSO flex w/rigid stays cust | B.R. L0630 | LSO post rigid panel pre | $232 L0631 | LSO sag-coro rigid frame pre | $1,473 L0632 | LSO sag rigid frame cust | B.R. L0633 | LSO flexion control prefab | $411 L0634 | LSO flexion control custom | B.R. L0635 | LSO sagit rigid panel prefab | $1,437 L0636 | LSO sagittal rigid panel cus | $2,127 L0637 | LSO sag-coronal panel prefab | $1,683 L0638 | LSO sag-coronal panel custom | $1,892 L0639 | LSO s/c shell/panel prefab | $1,683 L0640 | LSO s/c shell/panel custom | $1,501 L0700 | CTLSO | $1,878 L0710 | CTLSO, a-p-l-control, molded | $2,023 L0810 | Halo proc, cerv halo jacket | $2,506 L0820 | Halo proc, cerv halo plaster body | $2,114 L0830 | Halo proc, cerv halo Milwaukee type | $3,387 L0859 | MRI compatible system | $1,829 L0861 | Halo repl liner/interface | $309 L0970 | TLSO, corset front | $133 L0972 | LSO, corset front | $122 L0974 | TLSO, full corset | $184 L0976 | LSO, full corset | $172 L0978 | Axillary crutch extension | $180 L0980 | Peroneal straps, pair | $21 L0982 | Stocking supp grips, set four | $20 L0984 | Protective body sock, each | $56 L0999 | Add to spinal orthosis NOS | B.R. L1000 | CTLSO (Milwaukee), inclusive | $2,020 L1001 | CTLSO infant immobilizer | B.R. L1005 | Tension based scoliosis orth | $4,590.55 L1010 | Add to CTLSO | $72 L1020 | Add to CTLSO, kyphosis pad | $100 L1025 | Add to CTLSO, kyphosis pad, floatin | $114 L1030 | Add to CTLSO, lumbar | $78 L1040 | Add to CTLSO, lumbar | $81 L1050 | Add to CTLSO, sternal pad | $98 L1060 | Add to CTLSO, thoracic pad | $95 L1070 | Add to CTLSO, trapezius | $93 L1080 | Add to CTLSO, outrigger | $52 L1085 | Add to CTLSO, outrigger | $158 L1090 | Add to CTLSO, lumbar sling | $94 L1100 | Add to CTLSO, ring flange | $162 L1110 | Add to CTLSO, ring flange | $236 L1120 | Add to CTLSO, cover | $43 L1200 | TLSO, inclusive furnishing | $1,649 L1210 | Add to TLSO, lat thoracic ext | $239 L1220 | Add to TLSO, ant thoracic ext | $232 L1230 | Add to TLSO, milw type superstruc | $520 L1240 | Add to TLSO, lumb derotation pad | $77 L1250 | Add to TLSO, ant asis pad | $74 L1260 | Add to TLSO, ant thor derot pad | $75 L1270 | Add to TLSO, abdominal pad | $72 L1280 | Add to TLSO, rib gusset | $79 L1290 | Add to TLSO, lat troch pad | $72 L1300 | Oth scolio proc, body jacket | $1,762 L1310 | Oth scolio proc, postop body jack | $1,697 L1499 | Unlisted proc spinal orthosis | B.R. L1600 | HO, abd cont hip jnts, flex | $157 L1610 | HO, abd cont hip jnts, flex, frej | $42 L1620 | HO, abd cont hip jnts, flex, pavl | $123 L1630 | HO, abd cont hip jnts, semi-flex | $155 L1640 | HO, abd cont hip jnts, stat, pelv | $486 L1650 | HO, abd cont hip jnts, stat, adj | $223 L1652 | HO bi thighcuffs w sprdr bar | $511 L1660 | HO, abd cont hip jnts, static | $209 L1680 | HO, abd cont hip jnts, dyn, pel | $1,318 L1685 | HO, abd cont hip jnt, postop | $1,088 L1686 | HO, abd cont hip jnt, postop | $835 L1690 | Combination bilateral HO | $511 L1700 | Legg perthes ortho, Toronto | $1,570 L1710 | Legg perthes ortho, Newington | $2,018 L1720 | Legg perthes ortho, trilateral | $1,497 L1730 | Legg perthes ortho, Scottish rite | $1,185 L1755 | Legg perthes ortho, patten bottom | $1,448.82 L1810 | KO, elastic w/joints | $98 L1820 | KO, elastic w/condylar pads and joint | $132 L1830 | KO, immobilizer, canvas longitud | $80 L1831 | Knee orth pos locking joint | $422 L1832 | KO, adj knee joints, pos orthosis | $556 L1834 | KO, w/o knee joint, rigid, molded | $710 L1836 | Rigid KO wo joints | $191 L1840 | KO, derotation, m-l ant cruc lig | $1,034 L1843 | KO single upright custom fit | $1,287 L1844 | KO, sngl upright, thigh and calf | $795 L1845 | KO, dbl upright, thigh and calf | $857 L1846 | KO, dbl upright, thigh and calf | $1,059 L1847 | KO adjustable w air chambers | $825 L1850 | KO, Swedish type | $305 L1860 | KO, mod supracond prosth socket | $1,000.78 L1900 | AFO, spring wire, dorsiflex asst | $317 L1902 | AFO, ankle gauntlet, custom fit | $97 L1904 | AFO, molded ankle gauntlet, mold | $430 L1906 | AFO, multilig ankle support | $110 L1907 | AFO supramalleolar custom | $807 L1910 | AFO, post, single bar, clasp atta | $276 L1920 | AFO, sngl upright w/stat/adj stop | $331 L1930 | AFO, custom fitted, plastic | $289 L1932 | Afo rig ant tib prefab TCF/= | $1,280 L1940 | AFO, molded to patient, plastic | $463 L1945 | AFO, molded to patient, plastic | $847 L1950 | AFO, spiral, molded to patient | $684 L1951 | AFO spiral prefabricated | $1,205 L1960 | AFO, post solid ankle, molded | $507 L1970 | AFO, plastic molded to patient | $651 L1971 | AFO w/ankle joint, prefab | $672 L1980 | AFO, single upright free plantar | $351 L1990 | AFO, double upright free plantar | $408 L2000 | KAFO, single upright, free | $928 L2005 | KAFO sng/dbl mechanical act | $5,879 L2010 | KAFO, single upright, free ankle | $906 L2020 | KAFO, double upright, free knee | $1,069 L2030 | KAFO, double upright, free ankle | $937 L2034 | KAFO pla sin up w/wo k/a cus | $2,939 L2035 | KAFO plastic pediatric size | $250 L2036 | KAFO, full plastic, double upright | $1,784 L2037 | KAFO, full plastic, single upright | $1,524 L2038 | KAFO, full plastic, w/o knee joint | $1,308 L2040 | HKAFO, torsion control, bilateral | $162 L2050 | HKAFO, torsion control, bilateral | $517 L2060 | HKAFO, torsion control, bilateral | $598 L2070 | HKAFO, torsion control, unilat | $124 L2080 | HKAFO, torsion control, unilat | $352 L2090 | HKAFO, torsion control, unilat | $426 L2106 | AFO, fx ortho, tib fx cast | $766 L2108 | AFO, fx ortho, tib fx cast | $1,064 L2112 | AFO, fx ortho, tib fx orthosis | $518 L2114 | AFO, fx ortho, tib fx orthosis | $600 L2116 | AFO, fx ortho, tib fx orthosis | $719 L2126 | KAFO, fx ortho, fem fx cast | $1,096 L2128 | KAFO, fx ortho, fem fx cast | $1,569 L2132 | KAFO, fx ortho, fem fx cast | $833 L2134 | KAFO, fx ortho, fem fx cast | $1,042 L2136 | KAFO, fx ortho, fem fx cast | $1,179 L2180 | Add to lwr extrm fx ortho | $143 L2182 | Add to lwr extrm fx ortho | $105 L2184 | Add to lwr extrm fx ortho | $136 L2186 | Add to lwr extrm fx ortho | $138 L2188 | Add to lwr extrm fx ortho | $321 L2190 | Add to lwr extrm fx ortho | $92 L2192 | Add to lwr extrm fx ortho | $361 L2200 | Add to lwr extrm, limited ankle | $58 L2210 | Add to lwr extrm, dorsiflexion | $62 L2220 | Add to lwr extrm, dorsiflexion | $80 L2230 | Add to lwr extrm, split flat | $74 L2232 | Rocker bottom, contact AFO | $140 L2240 | Add to lwr extrm, round caliper | $77 L2250 | Add to lwr extrm, foot plate | $325 L2260 | Add to lwr extrm, stirrup | $189 L2265 | Add to lwr extrm, stirrup | $144 L2270 | Add to lwr extrm, varus/valgus | $49 L2275 | Varus/vulgus correction, plastic | $120 L2280 | Add to lwr extrm, inner boot | $414 L2300 | Add to lwr extrm, abduction bar | $329 L2310 | Add to lwr extrm, abduction bar | $150 L2320 | Add to lwr extrm, non-mold lacer | $205 L2330 | Add to lwr extrm, lacer molded | $381 L2335 | Add to lwr extrm, ant swing band | $208 L2340 | Add to lwr extrm, pre-tib shell | $507 L2350 | Add to lwr extrm, socket, molded | $869 L2360 | Add to lwr extrm, steel shank | $63 L2370 | Add to lwr extrm, patten bottom | $269 L2375 | Add to lwr extrm, torsion control | $138 L2380 | Add to lwr extrm, torsion control | $150 L2385 | Add to lwr extrm, knee joint | $158 L2390 | Add to lwr extrm, knee joint | $100 L2395 | Add to lwr extrm, knee joint | $191 L2397 | Orthosis, suspension sleeve | $107 L2405 | Add to knee joint, drop lock | $54 L2415 | Add to knee joint, cam lock | $172 L2425 | Add to knee joint, disc/dial loc | $168 L2492 | Add to knee joint, drop lock ring | $104 L2500 | Add to lwr extrm, thigh/weight | $337 L2510 | Add to lwr extrm, thigh/weight | $764 L2520 | Add to lwr extrm, thigh/weight | $482 L2525 | Add to lwr extrm, thigh/weight | $1,116 L2526 | Add to lwr extrm, thigh/weight | $627 L2530 | Add to lwr extrm, thigh/weight | $217 L2540 | Add to lwr extrm, thigh/weight | $412 L2550 | Add to lwr extrm, thigh/weight | $263 L2570 | Add to lwr extrm, hip joint | $581 L2580 | Add to lwr extrm, pelvic sling | $425 L2600 | Add to lwr extrm, hip joint | $251 L2610 | Add to lwr extrm, hip joint | $296 L2620 | Add to lwr extrm, hip joint | $286 L2622 | Add to lwr extrm, hip joint | $374 L2624 | Add to lwr extrm, hip joint | $325 L2627 | Add to lwr extrm, plastic, mold | $1,569 L2628 | Add to lwr extrm, metal frame | $1,533 L2630 | Add to lwr extrm, band and belt | $268 L2640 | Add to lwr extrm, band and belt | $352 L2650 | Add to lwr extrm, pel/thor contr | $132 L2660 | Add to lwr extrm, thoracic contr | $206 L2670 | Add to lwr extrm, thoracic contr | $208 L2680 | Add to lwr extrm, thoracic contr | $191 L2750 | Add to lwr extrm ortho, plating | $101 L2755 | Carbon graphite lamination | $187 L2760 | Add to lwr extrm ortho, extens | $74 L2768 | Ortho sidebar disconnect | $187 L2780 | Add to lwr extrm ortho, non-corr | $62 L2785 | Add to lwr extrm ortho, retainer | $29 L2795 | Add to lwr extrm ortho, knee con | $90 L2800 | Add to lwr extrm ortho, knee con | $98 L2810 | Add to lwr extrm ortho, knee con | $80 L2820 | Add to lwr extrm ortho, soft int | $79 L2830 | Add to lwr extrm ortho, soft int | $86 L2840 | Add to lwr extrm ortho, tib sock | $53 L2850 | Add to lwr extrm ortho, fem sock | $61 L2861 | Torsion mechanism knee/ankle | B.R. L2999 | Unlisted proc lwr extrm orthoses | B.R. L3000 | Foot, insert, "UCB" type | $162 L3001 | Foot, insert, spenco | $38 L3002 | Foot, insert, plastazote | $81 L3003 | Foot, insert, silicone | $162 L3010 | Foot, insert, longitudinal | $128 L3020 | Foot, insert, longitudinal | $136 L3030 | Foot, insert, removable, formed | $41 L3031 | Foot lamin/prepreg composite | B.R. L3040 | Foot, arch support, longitudinal | $41 L3050 | Foot, arch support, metatarsal | $41 L3060 | Foot, arch support, longitudinal | $54 L3070 | Foot, arch support, nonremovable | $34 L3080 | Foot, arch support, nonremovable | $34 L3090 | Foot, arch support, nonremovable | $47 L3100 | Hallus-valgus night dyn splint | $41 L3140 | Foot, abduction rotation bars | $61 L3150 | Foot, abduction rotation bars | $61 L3160 | Shoe styled positioning dev | B.R. L3170 | Foot, plastic heel stabilzer | $20 L3201 | Ortho shoe, oxford, infant | $50 L3202 | Ortho shoe, oxford, child | $55 L3203 | Ortho shoe, oxford, junior | $70 L3204 | Ortho shoe, hightop, infant | $63 L3206 | Ortho shoe, hightop, child | $53 L3207 | Ortho shoe, hightop junior | $55 L3208 | Surgical boot, ea, infant | $25 L3209 | Surgical boot, ea, child | $30 L3211 | Surgical boot, ea, junior | $58 L3212 | Benesch boot, pair, infant | $66 L3213 | Benesch boot, pair, child | B.R. L3214 | Benesch boot, pair, junior | B.R. L3215 | Ortho shoes, ladies, oxford | $108 L3216 | Ortho shoes, ladies, depth inlay | $150 L3217 | Ortho shoes, ladies, hightop | $163 L3218 | Ortho shoes, ladies, surg boot | $145 L3219 | Ortho shoes, mens, oxford | $126 L3221 | Ortho shoes, mens, depth inlay | $150 L3222 | Ortho shoes, mens, hightop | $163 L3224 | Woman's shoe oxford brace | $88 L3225 | Man's shoe oxford brace | $102 L3230 | Ortho shoes, custom, depth inlay | $482 L3250 | Ortho shoes, custom molded | $270 L3251 | Foot, shoe molded to patient | B.R. L3252 | Foot, shoe molded to patient | $121 L3253 | Foot, molded shoe plastazote | $114 L3254 | Non-std size/width | $193 L3255 | Non-std size/length | $193 L3257 | Ortho shoes, add chrg split size | B.R. L3260 | Ambulatory surgical boot, ea | $114 L3265 | Plastazote sandal, ea | $54 L3300 | Lift, elevation, heel | $54 L3310 | Lift, elevation, heel and sole | $47 L3320 | Lift, elevation, heel and sole | $114 L3330 | Lift, elevation, metal extension | $471 L3332 | Lift, elevation, inside shoe | $27 L3334 | Lift, elevation, heel, per inch | $54 L3340 | Heel wedge, sach | $27 L3350 | Heel wedge | $13 L3360 | Sole wedge, outside sole | $13 L3370 | Sole wedge, between sole | $34 L3380 | Clubfoot wedge | $34 L3390 | Outflare wedge | $34 L3400 | Metatarsal bar wedge, rocker | $30 L3410 | Metatarsal bar wedge, betw sole | $47 L3420 | Full sole and heel wedge, betw sole | $54 L3430 | Heel, counter, plastic reinforced | $67 L3440 | Heel, counter, leather reinforced | $47 L3450 | Heel, sach cushion type | $27 L3455 | Heel, new leather, std | $16 L3460 | Heel, new rubber, std | $13 L3465 | Heel, Thomas w/wedge | $16 L3470 | Heel, Thomas extended to ball | $54 L3480 | Heel, pad and depression spur | $41 L3485 | Heel, pad, removable spur | B.R. L3500 | Misc shoe add, insole, leather | $47 L3510 | Misc shoe add, insole, rubber | B.R. L3520 | Misc shoe add, insole, felt | B.R. L3530 | Misc shoe add, sole, half | B.R. L3540 | Misc shoe add, sole, full | B.R. L3550 | Misc shoe add, toe tap, std | B.R. L3560 | Misc shoe add, toe tap, horseshoe | B.R. L3570 | Misc shoe add, special extension | B.R. L3580 | Misc shoe add, convert instep | B.R. L3590 | Misc shoe add, convert firm shoe | B.R. L3595 | Misc shoe add, march bar | B.R. L3600 | Trans ortho one to anoth, caliper | $67 L3610 | Trans ortho one to anoth, caliper | $54 L3620 | Trans ortho one to anoth, solid | $67 L3630 | Trans ortho one to anoth, solid | $67 L3640 | Trans ortho one to anoth, dennis | $34 L3649 | Unlisted proc foot ortho shoes | B.R. L3650 | SO, figure "8" design abduction | $58 L3660 | SO, figure "8" design abduction | $92 L3670 | SO, acromio/clavicular | $105 L3671 | SO cap design w/o jnts CF | $1,176 L3674 | SO airplane w/wo joint CF | $1,543 L3675 | Canvas vest SO | $229 L3677 | SO hard plastic stabilizer | B.R. L3702 | EO w/o joints CF | $377 L3710 | EO, elastic w/metal joints | $133 L3720 | EO, dbl upright w/forearm/arm cuffs | $679 L3730 | EO, dbl upright w/forearm/arm cuffs | $994 L3740 | EO, dbl upright w/forearm/arm cuffs | $1,276 L3760 | EO withjoint, Prefabricated | $653 L3762 | Rigid EO wo joints | $140 L3763 | EWHO rigid w/o jnts CF | $961 L3764 | EWHO w/joint(s) CF | $1,085 L3765 | EWHFO rigid w/o jnts CF | $1,674 L3766 | EWHFO w/joint(s) CF | $1,772 L3806 | WHFO w/joint(s) custom fab | $593 L3807 | WHFO,no joint, prefabricated | $326 L3808 | WHFO, rigid w/o joints | $486 L3900 | WHFO, dynamic flexor hinge | $1,170 L3901 | WHFO, dynamic flexor hinge | $1,439 L3904 | WHFO, ext powered, electric | $2,622.33 L3905 | WHO w/nontorsion jnt(s) CF | $1,294 L3906 | WHFO, wrist gauntlet, patient model | $354 L3908 | WHFO, wrist extension cock-up | $54 L3912 | WHFO, flex glove w/finger control | $111.63 L3913 | HFO w/o joints CF | $354 L3915 | WHO w nontor jnt(s) prefab | $694 L3916 | WHFO, wrist extension cock-up | $152 L3917 | Prefab metacarpl fx orthosis | $138 L3919 | HO w/o joints CF | $354 L3921 | HFO w/joint(s) CF | $419 L3923 | HFO w/o joints PF | $128 L3925 | FO pip/dip with joint/spring | $73 L3927 | FO pip/dip w/o joint/spring | $46 L3929 | HFO nontorsion joint, prefab | $115 L3931 | WHFO nontorsion joint prefab | $268 L3933 | FO w/o joints CF | $279 L3935 | FO nontorsion joint CF | $288 L3956 | Add joint upper ext orthosis | B.R. L3960 | SEWHO, abduction | $802.41 L3961 | SEWHO cap design w/o jnts CF | $2,193 L3962 | SEWHO, abduction positioning, erbs | $642 L3967 | SEWHO airplane w/o jnts CF | $2,589 L3971 | SEWHO cap design w/jnt(s) CF | $2,458 L3973 | SEWHO airplane w/jnt(s) CF | $2,589 L3975 | SEWHFO cap design w/o jnt CF | $2,193 L3976 | SEWHFO airplane w/o jnts CF | $2,193 L3977 | SEWHFO cap desgn w/jnt(s) CF | $2,458 L3978 | SEWHFO airplane w/jnt(s) CF | $2,589 L3980 | Upr extrm fx ortho, humeral | $330 L3982 | Upr extrm fx ortho, radius/ulnar | $372 L3984 | Upr extrm fx ortho, wrist | $324 L3985 | Upr extrm fx ortho, forearm, hand | $523 L3999 | Unlisted proc upr limb orthosis | B.R. L4000 | Repl girdle Milwaukee orthosis | $1,233 L4002 | Replace strap, any orthosis | B.R. L4010 | Repl trilateral socket brim | $630 L4020 | Repl quad socket brim, molded | $922 L4030 | Repl quad socket brim, custom | $603 L4040 | Repl molded thigh lacer | $393 L4045 | Repl nonmolded thigh lacer | $300 L4050 | Repl molded calf lacer | $378 L4055 | Repl non-molded calf lacer | $249 L4060 | Repl high roll cuff | $291 L4070 | Repl prox and dist upright KAFO | $324 L4080 | Repl met bands KAFO, prox thigh | $93 L4090 | Repl met bands KAFO-AFO, calf/thigh | $105 L4100 | Repl leath cuff KAFO, prox thigh | $107 L4110 | Repl leath cuff KAFO-AFO, calf/thigh | $86 L4130 | Repl pretibial shell | $529 L4205 | Ortho dvc repair per 15 min | B.R. L4210 | Repair orthotic device, minor parts | $57 L4350 | Pneumatic ankle control splint | $84 L4370 | Pneumatic full leg splint | $173 L4386 | Non-pneum walk boot prefab | $227 L4392 | Replace AFO soft interface | $34 L4394 | Replace foot drop spint | $25 L4396 | Static AFO | $240 L4631 | Afo, walk boot type, cus fab | $2,212 L5000 | Part foot, shoe insrt w/arch, toe | $657 L5010 | Part foot, mold sockt, w/toe filler | $1,491 L5020 | Part foot, mold sockt, tib hght | $2,240 L5050 | Ankle, Symes, mold socket, sach | $2,820 L5060 | Ankle, Symes, metal frame, molded l | $3,187 L5100 | Below knee, molded socket, shin | $2,771 L5105 | Below knee, plastic socket | $3,387 L5150 | Knee disartic, molded socket, ext | $4,037 L5160 | Knee disartic, molded socket, bent | $4,247 L5200 | Above knee, mold socket, sngl axis | $3,691 L5210 | Above knee, shrt prosth, no knee | $2,728 L5220 | Above knee, shrt prosth, no knee | $3,428 L5230 | Above knee, prox fem focal defic | $4,063 L5250 | Hip disartic, Canadian type; molded | $5,500 L5270 | Hip disartic, tilt table type; mold | $5,227 L5280 | Hemipelvectomy, Canadian type; molded | $5,689 L5300 | Below knee, molded socket, sach ft | $3,211 L5301 | BK mold socket SACH ft endo | $3,672 L5312 | Knee disart, SACH ft, endo | $5,276 L5321 | AK open end SACH | $5,257 L5331 | Hip disart canadian SACH ft | $7,438 L5341 | Hemipelvectomy canadian SACH | $8,083 L5400 | Immed postop/early fitting | $1,390 L5410 | Immed postop/early fitting | $543 L5420 | Immed postop/early fitting | $1,781 L5430 | Immed postop/early fitting | $654 L5450 | Immed postop/early fitting | $530 L5460 | Immed postop/early fitting | $709 L5500 | Init, below knee "PTB" type socket | $1,399 L5505 | Init, above knee, ischial level soc | $2,261 L5510 | Prep, below knee "PTB" type socket | $1,663 L5520 | Prep, below knee "PTB" type socket | $1,869 L5530 | Prep, below knee "PTB" type socket | $1,932 L5535 | Prep, below knee "PTB" type | $1,936 L5540 | Prep, below knee "PTB" type | $2,075 L5560 | Prep, above knee-knee disarticulat | $2,496 L5570 | Prep, above knee-knee disarticulat | $2,464 L5580 | Prep, above knee-knee disarticulat | $2,752 L5585 | Prep, above knee-knee disarticulat | $2,761 L5590 | Prep, above knee-knee disarticulat | $2,701 L5595 | Prep, hip disartic-hemipelvectomy | $3,926 L5600 | Prep, hip disartic-hemipelvectomy | $4,335 L5610 | Add to lwr extrm, above knee, hydra | $2,339 L5611 | Add to lwr extrm, above knee-knee | $1,571 L5613 | Add to lwr extrm, above knee-knee | $2,419 L5614 | Abv knee-knee disartic | $3,877 L5616 | Add to lwr extrm, above knee, univ | $1,765 L5617 | AK/BK self-aligning unit ea | $809 L5618 | Add to lwr extrm, test sockt, Symes | $295 L5620 | Add to lwr extrm, test sockt | $361 L5622 | Add to lwr extrm, test sockt, knee | $471 L5624 | Add to lwr extrm, test sockt | $473 L5626 | Add to lwr extrm, test sockt, hip | $519 L5628 | Add to lwr extrm, test sockt, hemi | $560 L5629 | Add to lwr extrm, below knee, acry | $413 L5630 | Add to lwr extrm, Symes type, expa | $504 L5631 | Add to lwr extrm, above knee/knee | $571 L5632 | Add to lwr extrm, Symes type | $216 L5634 | Add to lwr extrm, Symes type, post | $297 L5636 | Add to lwr extrm, Symes type, med | $248 L5637 | Add to lwr extrm, below knee, tot | $376 L5638 | Add to lwr extrm, below knee, leat | $492 L5639 | Add to lwr extrm, below knee, wood | $1,093 L5640 | Add to lwr extrm, knee, leather | $623 L5642 | Add to lwr extrm, above knee, leat | $623 L5643 | Add to lwr extrm, hip disartic | $1,632 L5644 | Add to lwr extrm, above knee, wood | $687 L5645 | Add to lwr extrm, below knee, flex | $779 L5646 | Add to lwr extrm, below knee, air | $693 L5647 | Add to lwr extrm, below knee suct | $776 L5648 | Add to lwr extrm, above knee, air | $756 L5649 | Add to lwr extrm, Ischial contain | $2,369 L5650 | Adds to lwr extrm, total contact | $558 L5651 | Add to lwr extrm, above knee, flex | $1,561 L5652 | Add to lwr extrm, suction suspens | $496 L5653 | Add to lwr extrm, knee disartic | $581 L5654 | Add to lwr extrm, sockt insrt, sym | $384 L5655 | Add to lwr extrm, sockt insrt, bel | $299 L5656 | Add to lwr extrm, sockt insrt | $371 L5658 | Add to lwr extrm, sockt insrt, abv | $354 L5661 | Add to lwr extrm, sockt insrt, mul | $593 L5665 | Add to lwr extrm, sockt insrt, mul | $534 L5666 | Add to lwr extrm, below knee, cuff | $91 L5668 | Add to lwr extrm, below knee, mold | $131 L5670 | Add to lwr extrm, below knee, mold | $353 L5671 | BK/AK locking mechanism | $796 L5672 | Add to lwr extrm, below knee, remv | $291 L5673 | Socket insert w lock mech | $1,069 L5676 | Adds to lwr extrm, below knee | $460 L5677 | Adds to lwr extrm, below knee | $641 L5678 | Adds to lwr extrm, below knee | $52 L5679 | Socket insert w/o lock mech | $891 L5680 | Add to lwr extrm, below knee, lacer | $318 L5681 | Intl custm cong/latyp insert | $1,891 L5682 | Add to lwr extrm, below knee, lacer | $622 L5683 | Initial custom socket insert | $1,891 L5684 | Add to lwr extrm, below knee, strap | $52 L5685 | Bk back check | $184 L5686 | Add to lwr extrm, below knee, check | $53 L5688 | Add to lwr extrm, below knee, belt | $75 L5690 | Add to lwr extrm, below knee, belt | $105 L5692 | Add to lwr extrm, above knee, belt | $173 L5694 | Add to lwr extrm, above knee, belt | $236 L5695 | Add to lwr extrm, above knee, belt | $212 L5696 | Add to lwr extrm, above knee/disar | $216 L5697 | Add to lwr extrm, above knee/disar | $78 L5698 | Add to lwr extrm, above knee/disar | $117 L5699 | All lwr extrm prosth, shldr harnes | $182 L5700 | Repl, socket, blw knee | $2,793 L5701 | Repl, socket, abv knee/knee disarti | $3,354 L5702 | Repl, socket, hip disarticulation, | $4,244 L5703 | Symes ankle w/o (SACH) foot | $3,346 L5704 | Repl, cust prot cover, blw knee | $523 L5705 | Repl, cust prot cover, abv knee | $934 L5706 | Repl, cust prot cover, knee disarti | $915 L5707 | Repl, cust prot cover, hip disartic | $1,207 L5710 | Add, exo knee-shin sys, manual lock | $417 L5711 | Adds exo knee-shin sys, manual lock | $529 L5712 | Add, exo knee-shin sys, friction sw | $554 L5714 | Add, exo knee-shin sys, variable fr | $468 L5716 | Add, exo knee-shin sys, mechanical | $827 L5718 | Add, exo knee-shin sys, friction sw | $913 L5722 | Add, exo knee-shin sys, pneum swing | $887 L5724 | Add, exo knee-shin sys, fluid swing | $1,962 L5726 | Add, exo knee-shin sys, ext joints | $2,261 L5728 | Add, exo knee-shin sys, fluid swing | $2,416 L5780 | Add, exo knee-shin sys, pneumatic | $1,286 L5781 | Lower limb pros vacuum pump | $5,750 L5782 | HD low limb pros vacuum pump | $6,062 L5785 | Add, exo sys, blw knee, ult-lit mat | $565 L5790 | Add, exo sys, abv knee, ult-lit mat | $935 L5795 | Add, exo sys, hip dis, ult-lit mat | $1,396 L5810 | Add, endo knee-shin sys, manual lck | $524 L5811 | Add, endo knee-shin sys, manual lck | $776 L5812 | Add, endo knee-shin sys, frict swng | $587 L5814 | Endo knee-shin hydral swg ph | $5,337 L5816 | Add, endo knee-shin sys, mech stanc | $945 L5818 | Add, endo knee-shin sys, frict swng | $947 L5822 | Add, endo knee-shin sys, pneum swng | $1,660 L5824 | Add, endo knee-shin sys, fluid swng | $1,781 L5826 | Miniature knee joint | $4,516 L5828 | Add, endo knee-shin sys, fluid swng | $2,753 L5830 | Add, endo knee-shin sys, pneum swng | $2,030 L5840 | Add, endoskel knee/shin sys | $2,355 L5845 | Knee-shin sys stance flexion | $2,576 L5848 | Knee-shin sys hydraul stance | $1,545 L5850 | Add, endo sys, abv knee/hip disart | $166 L5855 | Add, hip disarticulation, mech | $335 L5856 | Elec knee-shin swing/stance | $34,548 L5857 | Elec knee-shin swing only | $12,291 L5858 | Stance phase only | $26,708 L5910 | Add, endo sys, blw knee, alignable | $471 L5920 | Add, endo sys, abv knee/hip disart | $690 L5925 | Add, abv knee, knee disarticulation | $437 L5930 | High activity knee frame | $4,868 L5940 | Add, endo sys, blw knee, ult-lit | $652 L5950 | Add, endo sys, abv knee, ult-lit | $1,011 L5960 | Add, endo sys, hip dis, ult-lit | $1,253 L5961 | Endo poly hip, pneu/hyd/rot | $6,844 L5962 | Add, blw knee, flex prot cover | $618 L5964 | Add, abv knee, flex prot cover | $913 L5966 | Add, hip disartic, flex prot cover | $1,163 L5968 | Multiaxial ankle w dorsiflex | $5,222 L5970 | All lwr extr pros, foot, ext keel | $222 L5971 | SACH foot, replacement | $325 L5972 | All lwr extr pros, flex keel foot | $418 L5973 | Ank-foot sys dors-plant flex | $25,078 L5974 | All lwr extr pros, foot, ankle/foot | $258 L5975 | Combo ankle/foot prosthesis | $666 L5976 | All lwr extr pros, energy storing | $592 L5978 | All lwr extr pros, foot, ankle/foot | $332 L5979 | Multiaxial ankle/foot, dynamic resp | $2,225 L5980 | All lwr extr pros, flex foot system | $3,823 L5981 | Flex-walk sys/equal | $2,920 L5982 | All exo etal lwr extrm pros, axial | $610 L5984 | All endo lwr extrm pros, axial rot | $655 L5985 | Lwr ext dynamic prosth pylon | $408 L5986 | All lwr extrm prosth, multi-axial | $652 L5987 | Shank ft w vert load pylon | $10,338 L5988 | Vertical shock reducing pylo | $2,871 L5990 | User adjustable heel height | $2,607 L5999 | Unlisted proc lwr extrm prosth | B.R. L6000 | Part hand, thumb remaining | $1,459 L6010 | Part hand, little/ring finger rem | $1,468 L6020 | Part hand, no finger remaining | $1,460 L6025 | Part hand disart myoelectric | $11,500 L6050 | Wrist disartic, mold sockt, flex | $2,243 L6055 | Wrist disartic, mold sockt w/expan | $2,767 L6100 | Blw elbow, molded socket, flex | $2,302 L6110 | Blw elbow, molded socket | $2,443 L6120 | Blw elbow, mold dbl wall split sock | $2,755 L6130 | Blw elbow, mold dbl wall split sock | $2,553 L6200 | Elbow disartic, mold socket | $3,106 L6205 | Elbow disartic, mold socket | $3,550 L6250 | Above elbow, mold dbl wall socket | $3,221 L6300 | Shldr disart, mold socket, bulkhead | $3,878 L6310 | Shldr disart, pass restor | $3,114 L6320 | Shldr disart, pass restor | $1,873 L6350 | Int-scap thor, mold sockt, bulkhead | $3,819 L6360 | Int-scap thor, pass restor | $3,105 L6370 | Int-scap thor, pass restor | $2,165 L6380 | Immed postop/early fit, init rigid | $1,280 L6382 | Immed postop/early fit, init rigid | $1,518 L6384 | Immed postop/early fit, init rigid | $1,882 L6386 | Immed postop/early fit, cast change | $436 L6388 | Immed postop/early fit, rigid dress | $487 L6400 | Blw elbow, mold sockt, endo sys | $2,445 L6450 | Elbow disart, mold sockt, endo sys | $3,006 L6500 | Above elbow, mold sockt, endo sys | $3,033 L6550 | Shoulder disart, mold sockt, endo | $3,718 L6570 | Interscap thor, mold sockt, endo | $4,267 L6580 | Prep, wrist disart/blw elbow | $1,602 L6582 | Prep, wrist disart/blw elbow | $1,486 L6584 | Prep, elbow disart/above elbow | $2,170 L6586 | Prep, elbow disart/above elbow | $2,135 L6588 | Prep, shldr disart/int-scap thorac | $2,940 L6590 | Prep, shldr disart/int-scap thorac | $2,883 L6600 | Upr extrm adds, polycent hinge, pr | $244 L6605 | Upr extrm adds, sng pivot hinge, pr | $241 L6610 | Upr extrm adds, flex metal hing, pr | $197 L6611 | Additional switch, ext power | $592 L6615 | Upr extrm add, disc locking wrist | $189 L6616 | Upr extrm add, add disc locking wr | $80 L6620 | Upr extrm add, flexion-friction wr | $327 L6621 | Flex/ext wrist w/wo friction | $3,287 L6623 | Upr extrm add, spring asst rotl wr | $657 L6624 | Flex/ext/rotation wrist unit | $5,412 L6625 | Upr extrm add, rot wrist unit | $691 L6628 | Upr extrm add, quick disc hook adap | $503 L6629 | Upr extrm add, quick disc lam coll | $173 L6630 | Upr extrm add, stain steel, wrist | $280 L6632 | Upr extrm add, latex susp sleeve | $63 L6635 | Upr extrm add, lift assist elbow | $216 L6637 | Upr extrm add, nudge cont elbw lck | $420 L6638 | Elec lock on manual pw elbow | $3,594 L6640 | Upr extrm adds, shldr abd joint, pr | $352 L6641 | Upr extrm add, excurs amp, pulley | $190 L6642 | Upr extrm add, excurs amp, lever | $226 L6645 | Upr extrm add, shldr flex-abduction | $393 L6646 | Multipo locking shoulder jnt | $4,532 L6647 | Shoulder lock actuator | $746 L6648 | Ext pwrd shlder lock/unlock | $4,675 L6650 | Upr extrm add, shldr univ joint, ea | $412 L6655 | Upr extrm add, std cont cable | $90 L6660 | Upr extrm add, heavy duty cont cable | $101 L6665 | Upr extrm add, teflon, cable lining | $60 L6670 | Upr extrm add, hook-hand, cable | $62 L6672 | Upr extrm add, harness, chest | $173 L6675 | Upr extrm add, harness, figure "8" | $122 L6676 | Upr extrm add, harness, figure "8" | $128 L6677 | UE triple control harness | $426 L6680 | Upr extrm add, test sockt, wrist | $302 L6682 | Upr extrm add, test sockt, elbow | $295 L6684 | Upr extrm add, test sockt, shldr | $340 L6686 | Upr extrm add, suction socket | $632 L6687 | Upr extrm add, frame type socket | $562 L6688 | Upr extrm add, frame type socket | $665 L6689 | Upr extrm add, frame type socket | $696 L6690 | Upr extrm add, frame type socket | $755 L6691 | Upr extrm add, removable insert, each | $337 L6692 | Upr extrm add, silicone gel insert | $694 L6693 | Lockingelbow forearm cntrbal | $4,080 L6694 | Elbow socket ins use w/lock | $1,069 L6695 | Elbow socket ins use w/o lck | $891 L6696 | Cus elbo skt in for con/atyp | $1,891 L6697 | Cus elbo skt in not con/atyp | $1,891 L6698 | Below/above elbow lock mech | $796 L6704 | Term dev, sport/rec/work att | $937 L6706 | Term dev mech hook vol open | $558 L6707 | Term dev mech hook vol close | $2,057 L6708 | Term dev mech hand vol open | $1,338 L6709 | Term dev mech hand vol close | $1,938 L6711 | Ped term dev, hook, vol open | $966 L6712 | Ped term dev, hook, vol clos | $1,779 L6713 | Ped term dev, hand, vol open | $2,245 L6714 | Ped term dev, hand, vol clos | $1,902 L6715 | Term device, hook, dorr, mod #5xa | $391 L6721 | Hook/hand, hvy dty, vol open | $3,380 L6722 | Hook/hand, hvy dty, vol clos | $2,914 L6805 | Term device, mod wrist flex unit | $414.87 L6810 | Term dev, pinch tool, Otto Bock | $242.46 L6880 | Term dev, hand, Bock, vo | $651 L6881 | Term dev auto grasp feature | $5,875 L6882 | Microprocessor control uplmb | $4,457 L6883 | Replc sockt below e/w disa | $2,538 L6884 | Replc sockt above elbow disa | $3,571 L6885 | Replc sockt shldr dis/interc | $5,094 L6890 | Term dev, glove abv hands, glove | $180 L6895 | Term dev, glove abv hands, glove | $544 L6900 | Hand restoration | $1,507 L6905 | Hand restoration | $1,431 L6910 | Hand restoration | $1,411 L6915 | Hand restoration | $610 L6920 | Wrist disart, ext pwr, inner socket | $7,144 L6925 | Wrist disart, ext pwr, inner socket | $7,544 L6930 | Blw elbow, ext pwr, inner socket | $7,670 L6935 | Blw elbow, ext pwr, inner socket | $8,437 L6940 | Elbow disart, ext pwr, inner socket | $9,586 L6945 | Elbow disart, ext pwr, inner socket | $10,844 L6950 | Above elbow, ext pwr, inner socket | $10,192 L6955 | Above elbow, ext pwr, inner socket | $12,789 L6960 | Shldr disart, ext pwr, inner socket | $12,611 L6965 | Shldr disart, ext pwr, inner socket | $18,423 L6970 | Int-scap-thor, ext pwr, inner socket | $18,726 L6975 | Int-scap-thor, ext pwr, inner socket | $18,826 L7007 | Adult electric hand | $5,504 L7008 | Pediatric electric hand | $8,662 L7009 | Adult electric hook | $5,616 L7040 | Prehens act, Hosmer/equal, switch | $3,665 L7045 | Elect hook, child, Michigan/equal | $2,101 L7170 | Elect elbw, Hosmer/equal, switch | $7,622 L7180 | Elect elbw, Utah/equal, myoelectr | $39,823 L7181 | Electronic elbo simultaneous | $57,580 L7185 | Elect elbw, adolescent, var village | $7,718 L7186 | Elect elbw, child, var village | $11,139 L7190 | Elect elbw, adolescent, var village | $9,820 L7191 | Elect elbw, child, var village | $11,841 L7260 | Elect wrist rotator, Otto Bock/equa | $2,558 L7261 | Elect wrist rotator, Utah arm | $4,094 L7360 | Six vlt bat, Otto Bock/equal, ea | $235 L7362 | Bat charger, six volt, Otto Bock | $282 L7364 | Twelve volt bat, Utah/equal, ea | $514 L7366 | Batt charger, twelve volt, Utah/equ | $698 L7367 | Replacemnt lithium ionbatter | $559 L7368 | Lithium ion battery charger | $725 L7400 | Add UE prost be/wd, ultlite | $440 L7401 | Add UE prost a/e ultlite mat | $493 L7402 | Add UE prost s/d ultlite mat | $532 L7403 | Add UE prost b/e acrylic | $529 L7404 | Add UE prost a/e acrylic | $799 L7405 | Add UE prost s/d acrylic | $1,045 L7499 | Unlisted procs upr extrm prosth | B.R. L7510 | RPR prosth dev, rpr/rep minor parts | $57 L7520 | Repair prosthesis per 15 min | B.R. L7600 | Prosthetic donning sleeve | B.R. L7900 | Male vacuum erection system | $771 L8000 | Breast prosth, mastectomy bra | $37 L8001 | Breast prosthesis bra and form | $180 L8002 | Brst prsth bra and bilat form | $237 L8010 | Breast prosth, mastectomy sleeve | $59 L8015 | Ext breastprosthesis garment | $86 L8020 | Breast prosth, mastectomy form | $222 L8030 | Breast prosth, silicone/equal | $325 L8031 | Breast prosthesis w adhesive | $505 L8032 | Reusable nipple prosthesis | $56 L8035 | Custom breast prosthesis | $5,265 L8039 | Breast prosthesis NOS | B.R. L8040 | Nasal prosthesis | $3,559 L8040 | Nasal prosthesis | KM | $3,381 L8040 | Nasal prosthesis | KN | $1,424 L8041 | Midfacial prosthesis | $4,290 L8041 | Midfacial prosthesis | KM | $4,076 L8041 | Midfacial prosthesis | KN | $1,716 L8042 | Orbital prosthesis | $4,820 L8042 | Orbital prosthesis | KM | $4,579 L8042 | Orbital prosthesis | KN | $1,928 L8043 | Upper facial prosthesis | $5,399 L8043 | Upper facial prosthesis | KM | $5,129 L8043 | Upper facial prosthesis | KN | $2,160 L8044 | Hemi-facial prosthesis | $5,977 L8044 | Hemi-facial prosthesis | KM | $5,678 L8044 | Hemi-facial prosthesis | KN | $2,391 L8045 | Auricular prosthesis | $3,933 L8045 | Auricular prosthesis | KM | $3,736 L8045 | Auricular prosthesis | KN | $1,572 L8046 | Partial facial prosthesis | $3,856 L8046 | Partial facial prosthesis | KM | $3,663 L8046 | Partial facial prosthesis | KN | $1,543 L8047 | Nasal septal prosthesis | $1,976 L8047 | Nasal septal prosthesis | KM | $1,878 L8047 | Nasal septal prosthesis | KN | $791 L8048 | Unspec maxillofacial prosth | B.R. L8049 | Repair maxillofacial prosth | B.R. L8300 | Truss, single w/std pad | $82 L8310 | Truss, dbl w/std pads | $130 L8320 | Truss, add to std pad, water pad | $60 L8330 | Truss, add to std pad, scrotal pad | $64 L8400 | Prosth sheath, blw knee, ea | $15 L8410 | Prosth sheath, above knee, ea | $22 L8415 | Prosth sheath, upr limb, ea | $23 L8417 | Pros sheath/sock w gel cushn | $108 L8420 | Prosth sock, wool, blw knee, ea | $20 L8430 | Prosth sock, wool, above knee, ea | $22 L8435 | Prosth sock, wool, upr limb, ea | $24 L8440 | Prosth shrinker, blw knee, ea | $43 L8460 | Prosth shrinker, above knee, ea | $75 L8465 | Prosth shrinker, upr limb, ea | $53 L8470 | Stump sock, sngl ply, fit, blw knee | $8 L8480 | Stump sock, sngl ply, fit, abv knee | $10 L8485 | Stump sock, single ply, fitting | $11 L8499 | Unlisted procedure misc prosth | B.R. L8500 | Artificial larynx, any type | $758 L8501 | Tracheostomy speaking valve | $118 L8505 | Artificial larynx, accessory | B.R. L8507 | Trach-esoph voice pros pt in | $60 L8509 | Trach-esoph voice pros md in | $157 L8510 | Voice amplifier | $363 L8511 | Indwelling trach insert | $105 L8512 | Gel cap for trach voice pros | $3 L8513 | Trach pros cleaning device | $7 L8514 | Repl trach puncture dilator | $136 L8515 | Gel cap app device for trach | $91 L8600 | Implant breast prosth, silicone/equ | $999 L8609 | Artificial cornea | $9,365 L8610 | Ocular | $936 L8612 | Aqueous shunt | $972 L8613 | Ossicula | $411 L8614 | Cochlear dev/system | $27,796 L8615 | Temporomandibular joint | $648 L8616 | Maxilla | $151 L8617 | Mandible | $132 L8618 | Palate | $38 L8619 | Coch imp ext proc/contr rplc | $11,931 L8621 | Distal humerus | $1 L8622 | Proximal ulna/radius | $1 L8623 | Distal ulna | $93 L8624 | Distal radius | $232 L8627 | Lunate | $10,133 L8628 | Carpus | $1,798 L8629 | Scaphoid | $257 L8630 | Metacarpophalangeal joint | $539 L8631 | MCP joint repl 2 pc or more | $3,162 L8641 | Metatarsal joint | $560 L8642 | Hallux implant | $454 L8658 | Interphalangeal joint | $488 L8659 | Interphalangeal joint repl | $2,774 L8670 | Vascular graft material, synthetic | $801 L8680 | Biliary stent, endoprosth (perm) | $668 L8681 | Pt prgrm for implt neurostim | $1,725 L8682 | Implt neurostim radiofq rec | $8,666 L8683 | Radiofq trsmtr for implt neu | $7,628 L8684 | Radiof trsmtr implt scrl neu | $1,089 L8685 | Implt nrostm pls gen sng rec | $19,010 L8686 | Implt nrostm pls gen sng non | $12,121 L8687 | Implt nrostm pls gen dua rec | $24,739 L8688 | Implt nrostm pls gen dua non | $15,785 L8689 | External recharg sys intern | $2,479 L8690 | Testicle | $6,838 L8691 | Osseointegrated snd proc rpl | $3,833 L8692 | Non-osseointegrated snd proc | B.R. L8693 | Aud osseo dev, abutment | $2,180 L8695 | External recharg sys extern | $24 L8699 | Prosthetic implant NOS | B.R. L9900 | O and P supply/accessory/service | B.R. L9999 | Sales tax, orthotic/prosth/other | B.R.