| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| L3000 |
Foot, insert, removable, molded to patient model, 'ucb' type, berkeley shell, each |
404 |
216 |
$113K |
| 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 |
2,239 |
1,413 |
$99K |
| L3219 |
Orthopedic footwear, mens shoe, oxford, each |
930 |
478 |
$83K |
| L3030 |
Foot, insert, removable, formed to patient foot, each |
972 |
481 |
$64K |
| L3215 |
Orthopedic footwear, ladies shoe, oxford, each |
778 |
392 |
$58K |
| A5512 |
For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each |
570 |
440 |
$28K |
| L3002 |
Foot, insert, removable, molded to patient model, plastazote or equal, each |
142 |
71 |
$16K |
| L3001 |
Foot, insert, removable, molded to patient model, spenco, each |
77 |
39 |
$8K |
| L3216 |
Orthopedic footwear, ladies shoe, depth inlay, each |
136 |
69 |
$6K |
| A4554 |
Disposable underpads, all sizes |
75 |
75 |
$4K |
| 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 |
25 |
13 |
$2K |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
12 |
12 |
$607.60 |
| A4927 |
Gloves, non-sterile, per 100 |
25 |
25 |
$111.75 |