| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 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 |
230 |
118 |
$2K |
| L0642 |
Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf |
15 |
15 |
$2K |
| L4002 |
Replacement strap, any orthosis, includes all components, any length, any type |
12 |
12 |
$862.28 |
| 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 |
228 |
117 |
$613.52 |
| K0003 |
Lightweight wheelchair |
54 |
52 |
$530.50 |
| A4253 |
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
26 |
24 |
$286.05 |
| A4259 |
Lancets, per box of 100 |
26 |
24 |
$6.16 |
| L4205 |
Repair of orthotic device, labor component, per 15 minutes |
12 |
12 |
$0.00 |