| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| L1971 |
Ankle foot orthosis, plastic or other material with ankle joint, with or without dorsiflexion assist, prefabricated, includes fitting and adjustment |
350 |
199 |
$71K |
| L0650 |
Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf |
132 |
132 |
$63K |
| A4554 |
Disposable underpads, all sizes |
383 |
381 |
$13K |
| L3010 |
Foot, insert, removable, molded to patient model, longitudinal arch support, each |
109 |
69 |
$11K |
| T4523 |
Adult sized disposable incontinence product, brief/diaper, large, each |
123 |
121 |
$10K |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
307 |
307 |
$8K |
| L2820 |
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section |
119 |
79 |
$8K |
| L3030 |
Foot, insert, removable, formed to patient foot, each |
59 |
31 |
$4K |
| L2275 |
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined |
16 |
15 |
$2K |
| A5500 |
For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe |
61 |
32 |
$2K |
| T4537 |
Incontinence product, protective underpad, reusable, bed size, each |
42 |
40 |
$2K |
| A5513 |
For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each |
36 |
18 |
$2K |
| L3221 |
Orthopedic footwear, mens shoe, depth inlay, each |
27 |
17 |
$1K |
| L3410 |
Metatarsal bar wedge, between sole |
21 |
17 |
$1K |
| T4539 |
Incontinence product, diaper/brief, reusable, any size, each |
41 |
40 |
$1K |
| L3216 |
Orthopedic footwear, ladies shoe, depth inlay, each |
32 |
16 |
$1K |
| L2210 |
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint |
16 |
12 |
$399.14 |
| A4927 |
Gloves, non-sterile, per 100 |
72 |
71 |
$316.00 |
| A4239 |
Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service |
19 |
19 |
$0.00 |
| E2103 |
Non-adjunctive, non-implanted continuous glucose monitor or receiver |
18 |
18 |
$0.00 |