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Medi-Cal Rates Information

Medi-Cal Rates as of 02/15/2020 (Codes L3254 thru L6900)

Medi-Cal Rates are updated and effective as of the 15th of the month and published to the Medi-Cal website on the 16th of the month


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Proc Type Proc Code Procedure Description Unit Value Basic Rate Child Rate ER Rate Conv Ind ER Ind Cut-back Ind Prof % Rental Rate Non-Physn. Med.Prac. Ind
P L3254 NONSTANDARD SIZE OR WIDTH 21.28 $21.28 --- -- 009 0 0 0.00 $0.00 Y
1 L3254 NONSTANDARD SIZE OR WIDTH 21.28 $21.28 --- -- 009 0 0 0.00 $0.00 Y
1 L3255 NONSTANDARD SIZE OR LENGTH 21.28 $21.28 --- -- 009 0 0 0.00 $0.00 Y
P L3255 NONSTANDARD SIZE OR LENGTH 21.28 $21.28 --- -- 009 0 0 0.00 $0.00 Y
P L3257 ORTHOPEDIC FOOTWEAR, ADDITIONAL CH 39.20 $39.20 --- -- 009 0 0 0.00 $0.00 Y
1 L3257 ORTHOPEDIC FOOTWEAR, ADDITIONAL CH 39.20 $39.20 --- -- 009 0 0 0.00 $0.00 Y
1 L3260 AMBULATORY SURGICAL BOOT EAC 76.53 $76.53 --- -- 009 0 0 0.00 $0.00 Y
P L3260 AMBULATORY SURGICAL BOOT EAC 76.53 $76.53 --- -- 009 0 0 0.00 $0.00 Y
P L3265 PLASTAZOTE SANDAL, EACH 50.40 $50.40 --- -- 009 0 0 0.00 $0.00 Y
1 L3265 PLASTAZOTE SANDAL, EACH 50.40 $50.40 --- -- 009 0 0 0.00 $0.00 Y
1 L3300 LIFT, ELEVATION, HEEL, TAPERED TO 32.78 $32.78 --- -- 009 0 0 0.00 $0.00 Y
P L3300 LIFT, ELEVATION, HEEL, TAPERED TO 32.78 $32.78 --- -- 009 0 0 0.00 $0.00 Y
P L3310 LIFT, ELEVATION, HEEL AND SOLE, NE 41.17 $41.17 --- -- 009 0 0 0.00 $0.00 Y
1 L3310 LIFT, ELEVATION, HEEL AND SOLE, NE 41.17 $41.17 --- -- 009 0 0 0.00 $0.00 Y
1 L3320 LIFT, ELEVATION, HEEL AND SOLE, CO 100.78 $100.78 --- -- 009 0 0 0.00 $0.00 Y
P L3320 LIFT, ELEVATION, HEEL AND SOLE, CO 100.78 $100.78 --- -- 009 0 0 0.00 $0.00 Y
P L3330 LIFT, ELEVATION, METAL EXTENTION ( 224.25 $224.25 --- -- 009 0 0 0.00 $0.00 Y
1 L3330 LIFT, ELEVATION, METAL EXTENSION ( 224.25 $224.25 --- -- 009 0 0 0.00 $0.00 Y
1 L3332 LIFT, ELEVATION, INSIDE SHOE, TAPE 39.16 $39.16 --- -- 009 0 0 0.00 $0.00 Y
P L3332 LIFT, ELEVATION, INSIDE SHOE, TAPE 39.16 $39.16 --- -- 009 0 0 0.00 $0.00 Y
P L3334 ORTHO SHOE MODIFY BLD UP 1/2 HEEL 4.93 $4.93 --- -- 009 0 0 0.00 $0.00 Y
1 L3334 ORTHOSES SHOE MOD BLDUP HALF IN. HEEL 4.93 $4.93 --- -- 009 0 0 0.00 $0.00 Y
1 L3340 HEEL WEDGE, SACH 21.36 $21.36 --- -- 009 0 0 0.00 $0.00 Y
P L3340 HEEL WEDGE, SACH 21.36 $21.36 --- -- 009 0 0 0.00 $0.00 Y
P L3350 ORTHOSES SHOE MODIFICATION HEEL WEDGE 6.57 $6.57 --- -- 009 0 0 0.00 $0.00 Y
1 L3350 ORTHOSES SHOE MODIFICATION HEEL WEDGE 6.57 $6.57 --- -- 009 0 0 0.00 $0.00 Y
1 L3360 ORTHOSES SHOE MODIFICATION SOLE WEDGE 7.96 $7.96 --- -- 009 0 0 0.00 $0.00 Y
P L3360 ORTHO SHOE MODIFY SOLE WEDGE 7.96 $7.96 --- -- 009 0 0 0.00 $0.00 Y
P L3370 SOLE WEDGE, BETWEEN SOLE 12.53 $12.53 --- -- 009 0 0 0.00 $0.00 Y
1 L3370 SOLE WEDGE, BETWEEN SOLE 12.53 $12.53 --- -- 009 0 0 0.00 $0.00 Y
1 L3380 CLUBFOOT WEDGE 10.33 $10.33 --- -- 009 0 0 0.00 $0.00 Y
P L3380 CLUBFOOT WEDGE 10.33 $10.33 --- -- 009 0 0 0.00 $0.00 Y
P L3390 OUTFLARE WEDGE 19.04 $19.04 --- -- 009 0 0 0.00 $0.00 Y
1 L3390 OUTFLARE WEDGE 19.04 $19.04 --- -- 009 0 0 0.00 $0.00 Y
1 L3400 ORTHOSES SHOE MODIFICATION MET BAR LOW 6.17 $6.17 --- -- 009 0 0 0.00 $0.00 Y
P L3400 ORTHO SHOE MODIFY METATARSAL BAR H 6.17 $6.17 --- -- 009 0 0 0.00 $0.00 Y
P L3410 METATARSAL BAR WEDGE, BETWEEN SOLE 22.79 $22.79 --- -- 009 0 0 0.00 $0.00 Y
1 L3410 METATARSAL BAR WEDGE, BETWEEN SOLE 22.79 $22.79 --- -- 009 0 0 0.00 $0.00 Y
1 L3420 FULL SOLE AND HEEL WEDGE, BETWEEN 17.36 $17.36 --- -- 009 0 0 0.00 $0.00 Y
P L3420 FULL SOLE AND HEEL WEDGE, BETWEEN 17.36 $17.36 --- -- 009 0 0 0.00 $0.00 Y
P L3430 HEEL, COUNTER, PLASTIC REINFORCED 20.64 $20.64 --- -- 009 0 0 0.00 $0.00 Y
1 L3430 HEEL, COUNTER, PLASTIC REINFORCED 20.64 $20.64 --- -- 009 0 0 0.00 $0.00 Y
1 L3440 HEEL, COUNTER, LEATHER REINFORCED 22.78 $22.78 --- -- 009 0 0 0.00 $0.00 Y
P L3440 HEEL, COUNTER, LEATHER REINFORCED 22.78 $22.78 --- -- 009 0 0 0.00 $0.00 Y
P L3450 ORTHO SHOE MODIFY CUSHION HEEL 62.81 $62.81 --- -- 009 0 0 0.00 $0.00 Y
1 L3450 ORTHOSES SHOE MODIFICATION CUSHION HEEL 62.81 $62.81 --- -- 009 0 0 0.00 $0.00 Y
1 L3455 HEEL, NEW LEATHER, STANDARD 9.25 $9.25 --- -- 009 0 0 0.00 $0.00 Y
P L3455 HEEL, NEW LEATHER, STANDARD 9.25 $9.25 --- -- 009 0 0 0.00 $0.00 Y
P L3460 HEEL, NEW RUBBER, STANDARD 4.10 $4.10 --- -- 009 0 0 0.00 $0.00 Y
1 L3460 ORTHOSES SHOE MODIFICATION NEW HEEL 4.10 $4.10 --- -- 009 0 0 0.00 $0.00 Y
1 L3465 HEEL, THOMAS WITH WEDGE 15.27 $15.27 --- -- 009 0 0 0.00 $0.00 Y
P L3465 HEEL, THOMAS WITH WEDGE 15.27 $15.27 --- -- 009 0 0 0.00 $0.00 Y
P L3470 HEEL, THOMAS EXTENDED TO BALL 17.80 $17.80 --- -- 009 0 0 0.00 $0.00 Y
1 L3470 HEEL, THOMAS EXTENDED TO BALL 17.80 $17.80 --- -- 009 0 0 0.00 $0.00 Y
1 L3480 HEEL, PAD AND DEPRESSION FOR SPUR 15.66 $15.66 --- -- 009 0 0 0.00 $0.00 Y
P L3480 HEEL, PAD AND DEPRESSION FOR SPUR 15.66 $15.66 --- -- 009 0 0 0.00 $0.00 Y
P L3485 HEEL, PAD, REMOVABLE FOR SPUR 30.24 $30.24 --- -- 009 0 0 0.00 $0.00 Y
1 L3485 HEEL, PAD, REMOVABLE FOR SPUR 30.24 $30.24 --- -- 009 0 0 0.00 $0.00 Y
1 L3500 ORTHO SHOE ADD LEATHER INSOL 6.16 $6.16 --- -- 009 0 0 0.00 $0.00 Y
P L3500 ORTHO SHOE ADD LEATHER INSOL 6.16 $6.16 --- -- 009 0 0 0.00 $0.00 Y
P L3510 ORTHOPEDIC SHOE ADD RUB INSL 6.16 $6.16 --- -- 009 0 0 0.00 $0.00 Y
1 L3510 ORTHOPEDIC SHOE ADD RUB INSL 6.16 $6.16 --- -- 009 0 0 0.00 $0.00 Y
1 L3520 O SHOE ADD FELT W LEATH INSL 8.40 $8.40 --- -- 009 0 0 0.00 $0.00 Y
P L3520 O SHOE ADD FELT W LEATH INSL 8.40 $8.40 --- -- 009 0 0 0.00 $0.00 Y
P L3530 ORTHO SHOE ADD HALF SOLE 19.97 $19.97 --- -- 009 0 0 0.00 $0.00 Y
1 L3530 ORTHO SHOE ADD HALF SOLE 19.97 $19.97 --- -- 009 0 0 0.00 $0.00 Y
1 L3540 ORTHO SHOE ADD FULL SOLE 31.99 $31.99 --- -- 009 0 0 0.00 $0.00 Y
P L3540 ORTHO SHOE ADD FULL SOLE 31.99 $31.99 --- -- 009 0 0 0.00 $0.00 Y
P L3550 O SHOE ADD STANDARD TOE TAP 5.58 $5.58 --- -- 009 0 0 0.00 $0.00 Y
1 L3550 O SHOE ADD STANDARD TOE TAP 5.58 $5.58 --- -- 009 0 0 0.00 $0.00 Y
1 L3560 O SHOE ADD HORSESHOE TOE TAP 4.48 $4.48 --- -- 009 0 0 0.00 $0.00 Y
P L3560 O SHOE ADD HORSESHOE TOE TAP 4.48 $4.48 --- -- 009 0 0 0.00 $0.00 Y
P L3570 O SHOE ADD INSTEP EXTENSION 53.57 $53.57 --- -- 009 0 0 0.00 $0.00 Y
1 L3570 O SHOE ADD INSTEP EXTENSION 53.57 $53.57 --- -- 009 0 0 0.00 $0.00 Y
1 L3580 O SHOE ADD INSTEP VELCRO CLO 18.17 $18.17 --- -- 009 0 0 0.00 $0.00 Y
P L3580 O SHOE ADD INSTEP VELCRO CLO 18.17 $18.17 --- -- 009 0 0 0.00 $0.00 Y
P L3590 O SHOE CONVERT TO SOF COUNTE 20.64 $20.64 --- -- 009 0 0 0.00 $0.00 Y
1 L3590 O SHOE CONVERT TO SOF COUNTE 20.64 $20.64 --- -- 009 0 0 0.00 $0.00 Y
1 L3595 ORTHO SHOE ADD MARCH BAR 9.60 $9.60 --- -- 009 0 0 0.00 $0.00 Y
P L3595 ORTHO SHOE ADD MARCH BAR 9.60 $9.60 --- -- 009 0 0 0.00 $0.00 Y
P L3600 ORTHOSES REPAIR ATTACH FLAT FERRUL PLATE 34.09 $34.09 --- -- 009 0 0 0.00 $0.00 Y
1 L3600 ORTHOSES REPAIR ATTACH FLAT FERRUL PLATE 34.09 $34.09 --- -- 009 0 0 0.00 $0.00 Y
1 L3610 TRANSFER OF AN ORTHOSIS FROM ONE S 63.15 $63.15 --- -- 009 0 0 0.00 $0.00 Y
P L3610 TRANSFER OF AN ORTHOSIS FROM ONE S 63.15 $63.15 --- -- 009 0 0 0.00 $0.00 Y
P L3620 ORTHOSES REPAIR ATTACH 1 PIECE STI 27.30 $27.30 --- -- 009 0 0 0.00 $0.00 Y
1 L3620 ORTHOSES REPAIR ATTACH 1 PIECE STIRRUP 27.30 $27.30 --- -- 009 0 0 0.00 $0.00 Y
1 L3630 TRANSFER OF AN ORTHOSIS FROM ONE S 62.31 $62.31 --- -- 009 0 0 0.00 $0.00 Y
P L3630 TRANSFER OF AN ORTHOSIS FROM ONE S 62.31 $62.31 --- -- 009 0 0 0.00 $0.00 Y
P L3640 ORTHOSES REPAIR TRANSFER SHOES 13.82 $13.82 --- -- 009 0 0 0.00 $0.00 Y
1 L3640 ORTHOSES REPAIR TRANSFER SHOES 13.82 $13.82 --- -- 009 0 0 0.00 $0.00 Y
1 L3650 SO 8 ABD RESTRAINT PRE OTS 35.98 $35.98 --- -- 009 0 0 0.00 $0.00 Y
1 L3660 SO 8 AB RSTR CAN/WEB PRE OTS 66.05 $66.05 --- -- 009 0 0 0.00 $0.00 Y
1 L3670 SO ACRO/CLAV CAN WEB PRE OTS 88.85 $88.85 --- -- 009 0 0 0.00 $0.00 Y
1 L3671 SO CAP DESIGN W/O JNTS CF 515.50 $515.50 --- -- 009 0 0 0.00 $0.00 Y
1 L3674 SO AIRPLANE W/WO JOINT CF 759.82 $759.82 --- -- 009 0 0 0.00 $0.00 Y
1 L3675 SO VEST CANVAS/WEB PRE OTS 87.86 $87.86 --- -- 009 0 0 0.00 $0.00 Y
1 L3677 SO HARD PLAS STABILI PRE CST 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L3678 SO HARD PLAS STABILI PRE OTS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L3702 EO W/O JOINTS CF 165.19 $165.19 --- -- 009 0 0 0.00 $0.00 Y
1 L3710 EO ELAS W/METAL JNTS PRE OTS 58.14 $58.14 --- -- 009 0 0 0.00 $0.00 Y
1 L3720 DOUBLE UPRIGHT W/FOREARM/ARM CUFFS, FREE 513.92 $513.92 --- -- 009 0 0 0.00 $0.00 Y
1 L3730 FOREARM/ARM CUFFS EXT/FLEX A 560.26 $560.26 --- -- 009 0 0 0.00 $0.00 Y
1 L3740 CUFFS ADJ LOCK W/ ACTIVE CON 842.23 $842.23 --- -- 009 0 0 0.00 $0.00 Y
1 L3760 WITH ADJUSTABLE POSITION LOCKING JOINT(S 286.10 $286.10 --- -- 009 0 0 0.00 $0.00 Y
1 L3761 EO, ADJ LOCK JOINT PREFAB OT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L3762 EO RIGID W/O JOINTS PRE OTS 61.51 $61.51 --- -- 009 0 0 0.00 $0.00 Y
1 L3763 EWHO RIGID W/O JNTS CF 733.55 $733.55 --- -- 009 0 0 0.00 $0.00 Y
1 L3764 EWHO W/JOINT(S) CF 776.78 $776.78 --- -- 009 0 0 0.00 $0.00 Y
1 L3765 EWHFO RIGID W/O JNTS CF 733.55 $733.55 --- -- 009 0 0 0.00 $0.00 Y
1 L3766 EWHFO W/JOINT(S) CF 776.78 $776.78 --- -- 009 0 0 0.00 $0.00 Y
1 L3806 WHFO W/JOINT(S) CUSTOM FAB 292.28 $292.28 --- -- 009 0 0 0.00 $0.00 Y
1 L3807 WHFO W/O JOINTS PRE CST 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L3808 WHFO, RIGID W/O JOINTS 168.41 $168.41 --- -- 009 0 0 0.00 $0.00 Y
1 L3809 WHFO W/O JOINTS PRE OTS 167.56 $167.56 --- -- 009 0 0 0.00 $0.00 Y
1 L3891 TORSION MECHANISM WRIST/ELBO 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L3900 HINGE EXTENSION/FLEX WRIST/F 612.56 $612.56 --- -- 009 0 0 0.00 $0.00 Y
1 L3901 HINGE EXT/FLEX WRIST FINGER 815.48 $815.48 --- -- 009 0 0 0.00 $0.00 Y
1 L3904 WHFO ELECTRIC CUSTOM FITTED 2049.88 $2049.88 --- -- 009 0 0 0.00 $0.00 Y
1 L3905 WHO W/NONTORSION JNT(S) CF 567.35 $567.35 --- -- 009 0 0 0.00 $0.00 Y
1 L3906 WHO W/O JOINTS CF 310.46 $310.46 --- -- 009 0 0 0.00 $0.00 Y
1 L3908 WHO COCK-UP NONMOLDE PRE OTS 47.08 $47.08 --- -- 009 0 0 0.00 $0.00 Y
1 L3912 HFO FLEXION GLOVE PRE OTS 62.73 $62.73 --- -- 009 0 0 0.00 $0.00 Y
1 L3913 HFO W/O JOINTS CF 154.95 $154.95 --- -- 009 0 0 0.00 $0.00 Y
1 L3915 WHO NONTORSION JNTS PRE CST 317.18 $317.18 --- -- 009 0 0 0.00 $0.00 Y
1 L3916 WHO NONTORSION JNTS PRE OTS 356.20 $356.20 --- -- 009 0 0 0.00 $0.00 Y
1 L3917 METACARP FX ORTHOSIS PRE CST 60.43 $60.43 --- -- 009 0 0 0.00 $0.00 Y
1 L3918 METACARP FX ORTHOSIS PRE OTS 70.80 $70.80 --- -- 009 0 0 0.00 $0.00 Y
1 L3919 HO W/O JOINTS CF 154.95 $154.95 --- -- 009 0 0 0.00 $0.00 Y
1 L3921 HFO W/JOINT(S) CF 183.77 $183.77 --- -- 009 0 0 0.00 $0.00 Y
1 L3923 HFO WITHOUT JOINTS PRE CST 22.26 $22.26 --- -- 009 0 0 0.00 $0.00 Y
1 L3924 HFO WITHOUT JOINTS PRE OTS 60.04 $60.04 --- -- 009 0 0 0.00 $0.00 Y
1 L3925 FO PIP DIP JNT/SPRNG PRE OTS 40.25 $40.25 --- -- 009 0 0 0.00 $0.00 Y
1 L3927 FO PIP DIP NO JT SPR PRE OTS 21.42 $21.42 --- -- 009 0 0 0.00 $0.00 Y
1 L3929 HFO NONTORSION JNTS PRE CST 65.79 $65.79 --- -- 009 0 0 0.00 $0.00 Y
1 L3930 HFO NONTORSION JNTS PRE OTS 71.94 $71.94 --- -- 009 0 0 0.00 $0.00 Y
1 L3931 WHFO NONTORSION JOINT PREFAB 146.94 $146.94 --- -- 009 0 0 0.00 $0.00 Y
1 L3933 FO W/O JOINTS CF 122.06 $122.06 --- -- 009 0 0 0.00 $0.00 Y
1 L3935 FO NONTORSION JOINT CF 126.38 $126.38 --- -- 009 0 0 0.00 $0.00 Y
1 L3956 ADD JOINT UPPER EXT ORTHOSIS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L3960 SEWHO AIRPLAN DESIG ABDU POS 392.52 $392.52 --- -- 009 0 0 0.00 $0.00 Y
1 L3961 SEWHO CAP DESIGN W/O JNTS CF 961.18 $961.18 --- -- 009 0 0 0.00 $0.00 Y
1 L3962 SEWHO ERBS PALSEY DESIGN ABD 396.89 $396.89 --- -- 009 0 0 0.00 $0.00 Y
1 L3967 SEWHO AIRPLANE W/O JNTS CF 1134.82 $1134.82 --- -- 009 0 0 0.00 $0.00 Y
1 L3971 SEWHO CAP DESIGN W/JNT(S) CF 1077.21 $1077.21 --- -- 009 0 0 0.00 $0.00 Y
1 L3973 SEWHO AIRPLANE W/JNT(S) CF 1134.82 $1134.82 --- -- 009 0 0 0.00 $0.00 Y
1 L3975 SEWHFO CAP DESIGN W/O JNT CF 961.18 $961.18 --- -- 009 0 0 0.00 $0.00 Y
1 L3976 SEWHFO AIRPLANE W/O JNTS CF 961.18 $961.18 --- -- 009 0 0 0.00 $0.00 Y
1 L3977 SEWHFO CAP DESGN W/JNT(S) CF 1077.21 $1077.21 --- -- 009 0 0 0.00 $0.00 Y
1 L3978 SEWHFO AIRPLANE W/JNT(S) CF 1134.82 $1134.82 --- -- 009 0 0 0.00 $0.00 Y
1 L3980 HUMERAL, PREFABRICATED, INCLUDES FITTING 242.90 $242.90 --- -- 009 0 0 0.00 $0.00 Y
1 L3981 UE FX ORTH SHOUL CAP FOREARM 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L3982 RADIUS/ULNAR, PREFABRICATED, INCLUDES FI 293.32 $293.32 --- -- 009 0 0 0.00 $0.00 Y
1 L3984 UPPER EXT FX ORTHOSIS WRIST 168.89 $168.89 --- -- 009 0 0 0.00 $0.00 Y
1 L3995 ADDITION TO UPPER EXTREMITY ORTHOS 18.48 $18.48 --- -- 009 0 0 0.00 $0.00 Y
1 L4000 REPL GIRDLE MILWAUKEE ORTH 394.20 $394.20 --- -- 009 0 0 0.00 $0.00 Y
1 L4002 REPLACE STRAP, ANY ORTHOSIS 7.50 $7.50 --- -- 009 0 0 0.00 $0.00 Y
P L4002 REPLACE STRAP, ANY ORTHOSIS 7.50 $7.50 --- -- 009 0 0 0.00 $0.00 Y
1 L4010 REPLACE TRILATERAL SOCKET BRIM 439.24 $439.24 --- -- 009 0 0 0.00 $0.00 Y
1 L4020 REPLACE QUADRILATERAL SOCKET BRIM, 488.05 $488.05 --- -- 009 0 0 0.00 $0.00 Y
1 L4030 REPLACE QUADRILATERAL SOCKET BRIM, 313.41 $313.41 --- -- 009 0 0 0.00 $0.00 Y
1 L4040 REPLACE MOLDED THIGH LACER 327.76 $327.76 --- -- 009 0 0 0.00 $0.00 Y
1 L4045 REPLACE NON-MOLDED THIGH LAC 251.30 $251.30 --- -- 009 0 0 0.00 $0.00 Y
1 L4050 REPLACE MOLDED CALF LACER 331.49 $331.49 --- -- 009 0 0 0.00 $0.00 Y
P L4050 REPLACE MOLDED CALF LACER 331.49 $331.49 --- -- 009 0 0 0.00 $0.00 Y
P L4055 REPLACE NON-MOLDED CALF LACE 214.65 $214.65 --- -- 009 0 0 0.00 $0.00 Y
1 L4055 REPLACE NON-MOLDED CALF LACE 214.65 $214.65 --- -- 009 0 0 0.00 $0.00 Y
1 L4060 REPLACE HIGH ROLL CUFF 234.96 $234.96 --- -- 009 0 0 0.00 $0.00 Y
1 L4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR 225.97 $225.97 --- -- 009 0 0 0.00 $0.00 Y
P L4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR 225.97 $225.97 --- -- 009 0 0 0.00 $0.00 Y
P L4080 REPLACE METAL BANDS KAFO, PROXIMAL 46.92 $46.92 --- -- 009 0 0 0.00 $0.00 Y
1 L4080 REPLACE METAL BANDS KAFO, PROXIMAL 46.92 $46.92 --- -- 009 0 0 0.00 $0.00 Y
1 L4090 REPLACE METAL BANDS KAFO-AFO, CALF 44.60 $44.60 --- -- 009 0 0 0.00 $0.00 Y
P L4090 REPLACE METAL BANDS KAFO-AFO, CALF 44.60 $44.60 --- -- 009 0 0 0.00 $0.00 Y
P L4100 REPLACE LEATHER CUFF KAFO, PROXIMA 58.02 $58.02 --- -- 009 0 0 0.00 $0.00 Y
1 L4100 REPLACE LEATHER CUFF KAFO, PROXIMA 58.02 $58.02 --- -- 009 0 0 0.00 $0.00 Y
1 L4110 REPLACE LEATHER CUFF KAFO-AFO, CAL 57.29 $57.29 --- -- 009 0 0 0.00 $0.00 Y
P L4110 REPLACE LEATHER CUFF KAFO-AFO, CAL 57.29 $57.29 --- -- 009 0 0 0.00 $0.00 Y
P L4130 REPLACE PRETIBIAL SHELL 325.36 $325.36 --- -- 009 0 0 0.00 $0.00 Y
1 L4130 REPLACE PRETIBIAL SHELL 325.36 $325.36 --- -- 009 0 0 0.00 $0.00 Y
1 L4205 ORTHO DVC REPAIR PER 15 MIN 16.47 $16.47 --- -- 009 0 0 0.00 $0.00 Y
P L4205 ORTHO DVC REPAIR PER 15 MIN 16.47 $16.47 --- -- 009 0 0 0.00 $0.00 Y
P L4210 ORTHOSES UNLISTED REPAIRS 0.00 $0.00 --- -- 008 0 0 0.00 $0.00 Y
1 L4210 ORTHOSES UNLISTED REPAIRS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L4350 ANKLE CONTROL ORTHO PRE OTS 71.78 $71.78 --- -- 009 0 0 0.00 $0.00 Y
P L4350 ANKLE CONTROL ORTHO PRE OTS 71.78 $71.78 --- -- 009 0 0 0.00 $0.00 Y
P L4360 PNEUMAT WALKING BOOT PRE CST 168.00 $168.00 --- -- 009 0 0 0.00 $0.00 Y
1 L4360 PNEUMAT WALKING BOOT PRE CST 168.00 $168.00 --- -- 009 0 0 0.00 $0.00 Y
1 L4361 PNEUMA/VAC WALK BOOT PRE OTS 227.88 $227.88 --- -- 009 0 0 0.00 $0.00 Y
P L4361 PNEUMA/VAC WALK BOOT PRE OTS 227.88 $227.88 --- -- 009 0 0 0.00 $0.00 Y
P L4370 PNEUM FULL LEG SPLNT PRE OTS 106.40 $106.40 --- -- 009 0 0 0.00 $0.00 Y
1 L4370 PNEUM FULL LEG SPLNT PRE OTS 106.40 $106.40 --- -- 009 0 0 0.00 $0.00 Y
1 L4386 NON-PNEUM WALK BOOT PRE CST 99.66 $99.66 --- -- 009 0 0 0.00 $0.00 Y
P L4386 NON-PNEUM WALK BOOT PRE CST 99.66 $99.66 --- -- 009 0 0 0.00 $0.00 Y
P L4387 NON-PNEUM WALK BOOT PRE OTS 116.74 $116.74 --- -- 009 0 0 0.00 $0.00 Y
1 L4387 NON-PNEUM WALK BOOT PRE OTS 116.74 $116.74 --- -- 009 0 0 0.00 $0.00 Y
1 L4396 STATIC OR DYNAMI AFO PRE CST 99.32 $99.32 --- -- 009 0 0 0.00 $0.00 Y
P L4396 STATIC OR DYNAMI AFO PRE CST 99.32 $99.32 --- -- 009 0 0 0.00 $0.00 Y
P L4397 STATIC OR DYNAMI AFO PRE OTS 121.49 $121.49 --- -- 009 0 0 0.00 $0.00 Y
1 L4397 STATIC OR DYNAMI AFO PRE OTS 121.49 $121.49 --- -- 009 0 0 0.00 $0.00 Y
1 L4398 FOOT DROP SPLINT PRE OTS 45.72 $45.72 --- -- 009 0 0 0.00 $0.00 Y
P L4398 FOOT DROP SPLINT PRE OTS 45.72 $45.72 --- -- 009 0 0 0.00 $0.00 Y
P L4631 AFO, WALK BOOT TYPE, CUS FAB 1329.32 $1329.32 --- -- 009 0 0 0.00 $0.00 Y
1 L4631 AFO, WALK BOOT TYPE, CUS FAB 1329.32 $1329.32 --- -- 009 0 0 0.00 $0.00 Y
1 L5000 PROSTHETICS PARTIAL FOOT ARCH INSOLE 195.45 $195.45 --- -- 009 0 0 0.00 $0.00 Y
P L5000 PROSTHETICS PARTIAL FOOT ARCH INSOLE 195.45 $195.45 --- -- 009 0 0 0.00 $0.00 Y
P L5010 PROSTHETICS PARTIAL FOOT MOLDED ANKLE 558.45 $558.45 --- -- 009 0 0 0.00 $0.00 Y
1 L5010 PROSTHETICS PARTIAL FOOT MOLDED ANKLE 558.45 $558.45 --- -- 009 0 0 0.00 $0.00 Y
1 L5020 PARTIAL FOOT, MOLDED SOCKET, TIBIA 1236.57 $1236.57 --- -- 009 0 0 0.00 $0.00 Y
P L5020 PARTIAL FOOT, MOLDED SOCKET, TIBIA 1236.57 $1236.57 --- -- 009 0 0 0.00 $0.00 Y
P L5050 PROSTHETICS PLAST SOCKET SACH FOOT 955.80 $955.80 --- -- 009 0 0 0.00 $0.00 Y
1 L5050 PROSTHETICS PLAST SOCKET SACH FOOT 955.80 $955.80 --- -- 009 0 0 0.00 $0.00 Y
1 L5060 ANKLE, SYMES, METAL FRAME, MOLDED 1616.81 $1616.81 --- -- 009 0 0 0.00 $0.00 Y
P L5060 ANKLE, SYMES, METAL FRAME, MOLDED 1616.81 $1616.81 --- -- 009 0 0 0.00 $0.00 Y
P L5100 PROSTHETICS BELOW KNEE P.T.B. PLAST SOCK 1022.37 $1022.37 --- -- 009 0 0 0.00 $0.00 Y
1 L5100 PROSTHETICS BELOW KNEE P.T.B. PLAST SOCK 1022.37 $1022.37 --- -- 009 0 0 0.00 $0.00 Y
1 L5105 BELOW KNEE, PLASTIC SOCKET, JOINTS 1664.94 $1664.94 --- -- 009 0 0 0.00 $0.00 Y
1 L5150 PROSTHETICS KNEE BEARING PLAST SOCKET 1428.59 $1428.59 --- -- 009 0 0 0.00 $0.00 Y
P L5150 PROSTHETICS KNEE BEARING PLAST SOCKET 1428.59 $1428.59 --- -- 009 0 0 0.00 $0.00 Y
P L5160 PROSTHETICS KNEE BEARING BENT END 1368.19 $1368.19 --- -- 009 0 0 0.00 $0.00 Y
1 L5160 PROSTHETICS KNEE BEARING BENT END 1368.19 $1368.19 --- -- 009 0 0 0.00 $0.00 Y
1 L5200 PROSTHETICS ABOVE KNEE PLAST SOCKET 1405.01 $1405.01 --- -- 009 0 0 0.00 $0.00 Y
P L5200 PROSTHETICS ABOVE KNEE PLAST SOCKET 1405.01 $1405.01 --- -- 009 0 0 0.00 $0.00 Y
1 L5210 ABOVE KNEE, SHORT PROSTHESIS, NO K 1587.11 $1587.11 --- -- 009 0 0 0.00 $0.00 Y
1 L5220 ABOVE KNEE, SHORT PROSTHESIS, NO K 1904.69 $1904.69 --- -- 009 0 0 0.00 $0.00 Y
1 L5230 ABOVE KNEE, FOR PROXIMAL FEMORAL F 2411.38 $2411.38 --- -- 009 0 0 0.00 $0.00 Y
1 L5250 PROSTHETICS HIP DISARTICULATION CANADIAN 2083.60 $2083.60 --- -- 009 0 0 0.00 $0.00 Y
1 L5270 HIP DISARTICULATION, TILT TABLE TY 3943.93 $3943.93 --- -- 009 0 0 0.00 $0.00 Y
1 L5280 PROSTHETICS HEMIPELVECTOMY MOLD SOCKET 2293.96 $2293.96 --- -- 009 0 0 0.00 $0.00 Y
1 L5301 BELOW KNEE MOLDED SOCKET 1955.71 $1955.71 --- -- 009 0 0 0.00 $0.00 Y
1 L5312 KNEE DISART, SACH FT, ENDO 2908.66 $2908.66 --- -- 009 0 0 0.00 $0.00 Y
1 L5321 ABOVE KNEE MOLDED SOCKET OPEN 2811.55 $2811.55 --- -- 009 0 0 0.00 $0.00 Y
1 L5331 HIP DISARTICULATION CANADIAN TYPE 3736.33 $3736.33 --- -- 009 0 0 0.00 $0.00 Y
1 L5341 HEMIPELVECTOMY CANADIAN TYPE 4323.32 $4323.32 --- -- 009 0 0 0.00 $0.00 Y
1 L5400 PROSTHETICS BELOW KNEE IMMED POST SURG 668.05 $668.05 --- -- 009 0 0 0.00 $0.00 Y
1 L5410 ADDITIONAL CAST CHANGE,BELOW KNEE 202.18 $202.18 --- -- 009 0 0 0.00 $0.00 Y
1 L5420 PROSTHETICS ABOVE KNEE IMMED POST SURG 753.10 $753.10 --- -- 009 0 0 0.00 $0.00 Y
1 L5430 ADDITIONAL CAST CHANGE,ABOVE KNEE 208.92 $208.92 --- -- 009 0 0 0.00 $0.00 Y
1 L5450 IMMEDIATE POST SURGICAL OR EARLY F 132.66 $132.66 --- -- 009 0 0 0.00 $0.00 Y
1 L5460 IMMEDIATE POST SURGICAL OR EARLY F 164.63 $164.63 --- -- 009 0 0 0.00 $0.00 Y
1 L5500 PROSTHETICS BELOW KNEE EARLY POST SURG 580.66 $580.66 --- -- 009 0 0 0.00 $0.00 Y
1 L5505 PROSTHETICS ABOVE KNEE EARLY POST SURG 701.90 $701.90 --- -- 009 0 0 0.00 $0.00 Y
1 L5510 PREPARATORY, BELOW KNEE "PTB" TYPE 785.76 $785.76 --- -- 009 0 0 0.00 $0.00 Y
1 L5520 PREPARATORY, BELOW KNEE "PTB" TYPE 829.01 $829.01 --- -- 009 0 0 0.00 $0.00 Y
1 L5530 PREPARATORY, BELOW KNEE "PTB" TYPE 1105.22 $1105.22 --- -- 009 0 0 0.00 $0.00 Y
1 L5535 PREPARATORY, BELOW KNEE "PTB" TYPE 1210.22 $1210.22 --- -- 009 0 0 0.00 $0.00 Y
1 L5540 PREPARATORY, BELOW KNEE "PTB" TYPE 1065.00 $1065.00 --- -- 009 0 0 0.00 $0.00 Y
1 L5560 PREPARATORY, ABOVE KNEE- KNEE DISA 1050.23 $1050.23 --- -- 009 0 0 0.00 $0.00 Y
1 L5570 PREPARATORY, ABOVE KNEE-KNEE DISAR 1167.52 $1167.52 --- -- 009 0 0 0.00 $0.00 Y
1 L5580 PREPARATORY, ABOVE KNEE-KNEE DISAR 1254.54 $1254.54 --- -- 009 0 0 0.00 $0.00 Y
1 L5585 PREPARATORY, ABOVE KNEE-KNEE DISAR 1255.80 $1255.80 --- -- 009 0 0 0.00 $0.00 Y
1 L5590 PREPARATORY, ABOVE KNEE-KNEE DISAR 1492.80 $1492.80 --- -- 009 0 0 0.00 $0.00 Y
1 L5595 PREPARATORY, HIP DISARTICULATION-H 3219.48 $3219.48 --- -- 009 0 0 0.00 $0.00 Y
1 L5600 PREPARATORY, HIP DISARTICULATIONH 3430.00 $3430.00 --- -- 009 0 0 0.00 $0.00 Y
1 L5610 HYDRACADENCE SYSTEM 1572.18 $1572.18 --- -- 009 0 0 0.00 $0.00 Y
1 L5611 ADDITION TO LOWER EXTREMITY, ABOVE 1271.46 $1271.46 --- -- 009 0 0 0.00 $0.00 Y
1 L5613 ADDITION TO LOWER EXTREMITY, ABOVE 862.40 $862.40 --- -- 009 0 0 0.00 $0.00 Y
1 L5614 KNEE DISARTICULATION 4BAR LINKAGE 1062.81 $1062.81 --- -- 009 0 0 0.00 $0.00 Y
1 L5616 ADDITION TO LOWER EXTREMITY, ABOVE 631.81 $631.81 --- -- 009 0 0 0.00 $0.00 Y
1 L5617 ADDITION TO LOWER EXTREMITY, QUICK CHANG 244.46 $244.46 --- -- 009 0 0 0.00 $0.00 Y
1 L5618 PROSTHETIC TEST SOCKET PROCEDURE 108.27 $108.27 --- -- 009 0 0 0.00 $0.00 Y
1 L5620 PROSTHETIC TEST SOCKET PROCEDURE 108.27 $108.27 --- -- 009 0 0 0.00 $0.00 Y
1 L5622 PROSTHETIC TEST SOCKET, A.K. O K.B. 149.81 $149.81 --- -- 009 0 0 0.00 $0.00 Y
1 L5624 PROSTHETIC TEST SOCKET, A.K. O K.B. 149.81 $149.81 --- -- 009 0 0 0.00 $0.00 Y
1 L5626 PROSTHETIC TEST SOCKET, HIP DISAR/HEMIPE 174.10 $174.10 --- -- 009 0 0 0.00 $0.00 Y
1 L5628 PROSTHETIC TEST SOCKET, HIP DISAR/HEMIPE 174.10 $174.10 --- -- 009 0 0 0.00 $0.00 Y
1 L5629 ADDITION TO LOWER EXTREMITY, BELOW 98.56 $98.56 --- -- 009 0 0 0.00 $0.00 Y
1 L5630 PROSTHETIC EXPANDABLE WALL SOCKET 170.79 $170.79 --- -- 009 0 0 0.00 $0.00 Y
1 L5631 ADDITION TO LOWER EXTREMITY, ABOVE 192.50 $192.50 --- -- 009 0 0 0.00 $0.00 Y
1 L5632 PROSTHETIC P.T.B. BRIM DESIGN 80.69 $80.69 --- -- 009 0 0 0.00 $0.00 Y
1 L5634 ADDITION TO LOWER EXTREMITY, SYMES 227.81 $227.81 --- -- 009 0 0 0.00 $0.00 Y
P L5634 ADDITION TO LOWER EXTREMITY, SYMES 227.81 $227.81 --- -- 009 0 0 0.00 $0.00 Y
P L5636 ADDITION TO LOWER EXTREMITY, SYMES 113.17 $113.17 --- -- 009 0 0 0.00 $0.00 Y
1 L5636 ADDITION TO LOWER EXTREMITY, SYMES 113.17 $113.17 --- -- 009 0 0 0.00 $0.00 Y
1 L5637 ADDITION TO LOWER EXTREMITY 246.15 $246.15 --- -- 009 0 0 0.00 $0.00 Y
1 L5638 PROSTHETIC SLIP SOCKET 327.50 $327.50 --- -- 009 0 0 0.00 $0.00 Y
1 L5639 BELOW KNEE 959.10 $959.10 --- -- 009 0 0 0.00 $0.00 Y
1 L5640 PROSTHETIC WOOD O MOLD LEATHER SOCKET 134.48 $134.48 --- -- 009 0 0 0.00 $0.00 Y
1 L5642 PROSTHETIC WOOD O MOLD LEATHER SOCKET 134.48 $134.48 --- -- 009 0 0 0.00 $0.00 Y
1 L5643 ADDITION TO LOWER EXTREMITY, HIP D 690.03 $690.03 --- -- 009 0 0 0.00 $0.00 Y
1 L5644 PROSTHETIC WOOD O MOLD LEATHER SOCKET 134.48 $134.48 --- -- 009 0 0 0.00 $0.00 Y
1 L5645 ADDITION TO LOWER EXTREMITY, BELOW 427.29 $427.29 --- -- 009 0 0 0.00 $0.00 Y
1 L5646 BELOW KNEE CUSHION SOCKET 207.11 $207.11 --- -- 009 0 0 0.00 $0.00 Y
1 L5647 ADDITION TO LOWER EXTREMITY, BELOW 539.64 $539.64 --- -- 009 0 0 0.00 $0.00 Y
1 L5648 ABOVE KNEE CUSHION SOCKET 220.79 $220.79 --- -- 009 0 0 0.00 $0.00 Y
1 L5649 ADDITION TO LOWER EXTREMITY, ISCHI 829.38 $829.38 --- -- 009 0 0 0.00 $0.00 Y
1 L5650 PROSTHETIC TOTAL CONTACT SOCKET 203.88 $203.88 --- -- 009 0 0 0.00 $0.00 Y
1 L5651 ADDITION TO LOWER EXTREMITY, ABOVE 470.98 $470.98 --- -- 009 0 0 0.00 $0.00 Y
1 L5652 ADDITION TO LOWER EXTREMITY, SUCTI 81.20 $81.20 --- -- 009 0 0 0.00 $0.00 Y
1 L5653 ADDITION TO LOWER EXTREMITY, KNEE 402.64 $402.64 --- -- 009 0 0 0.00 $0.00 Y
1 L5654 PROSTHETIC LINER FOR SOCKET SUP CONDULAR 159.58 $159.58 --- -- 009 0 0 0.00 $0.00 Y
1 L5655 PROSTHETIC LINER FOR SOCKET 129.77 $129.77 --- -- 009 0 0 0.00 $0.00 Y
1 L5656 PROSTHETIC LINER FOR SOCKET 137.12 $137.12 --- -- 009 0 0 0.00 $0.00 Y
1 L5658 PROSTHETIC LINER FOR SOCKET 137.12 $137.12 --- -- 009 0 0 0.00 $0.00 Y
1 L5661 ADDITION TO LOWER EXTREMITY, SOCKE 344.89 $344.89 --- -- 009 0 0 0.00 $0.00 Y
P L5661 ADDITION TO LOWER EXTREMITY, SOCKE 344.89 $344.89 --- -- 009 0 0 0.00 $0.00 Y
P L5665 ADDITION TO LOWER EXTREMITY, SOCKE 392.19 $392.19 --- -- 009 0 0 0.00 $0.00 Y
1 L5665 ADDITION TO LOWER EXTREMITY, SOCKE 392.19 $392.19 --- -- 009 0 0 0.00 $0.00 Y
1 L5666 ADDITION TO LOWER EXTREMITY, BELOW 45.14 $45.14 --- -- 009 0 0 0.00 $0.00 Y
P L5666 ADDITION TO LOWER EXTREMITY, BELOW 45.14 $45.14 --- -- 009 0 0 0.00 $0.00 Y
1 L5668 BK MOLDED DISTAL CUSHION 58.80 $58.80 --- -- 009 0 0 0.00 $0.00 Y
1 L5670 PROSTHETIC SUPRA CONDULAR SUSPENSION 117.05 $117.05 --- -- 009 0 0 0.00 $0.00 Y
1 L5671 BK/AK LOCKING MECHANISM 425.50 $425.50 --- -- 009 0 0 0.00 $0.00 Y
1 L5672 ADDITION TO LOWER EXTREMITY, BELOW 135.28 $135.28 --- -- 009 0 0 0.00 $0.00 Y
1 L5673 SOCKET INSERT W LOCK MECH 502.73 $502.73 --- -- 009 0 0 0.00 $0.00 Y
1 L5676 PROSTHETIC KNEE JOINTS PAIR 203.01 $203.01 --- -- 009 0 0 0.00 $0.00 Y
1 L5677 ADDITIONS TO LOWER EXTREMITY, BELO 369.53 $369.53 --- -- 009 0 0 0.00 $0.00 Y
1 L5678 PROSTHETIC JOINT COVERS 23.76 $23.76 --- -- 009 0 0 0.00 $0.00 Y
1 L5679 SOCKET INSERT W/O LOCK MECH 418.94 $418.94 --- -- 009 0 0 0.00 $0.00 Y
1 L5680 PROSTHETIC THIGH LACER 134.76 $134.76 --- -- 009 0 0 0.00 $0.00 Y
1 L5681 INTL CUSTM CONG/LATYP INSERT 828.47 $828.47 --- -- 009 0 0 0.00 $0.00 Y
1 L5682 PROSTHETIC GLUTISCHIAL BEAR THIGH LACE 248.88 $248.88 --- -- 009 0 0 0.00 $0.00 Y
1 L5683 INITIAL CUSTOM SOCKET INSERT 828.47 $828.47 --- -- 009 0 0 0.00 $0.00 Y
1 L5684 PROSTHETIC FORK STRAP 32.98 $32.98 --- -- 009 0 0 0.00 $0.00 Y
1 L5685 BELOW KNEE SUS/SEAL SLEEVE 80.66 $80.66 --- -- 009 0 0 0.00 $0.00 Y
P L5685 BELOW KNEE SUS/SEAL SLEEVE 48.96 $48.96 --- -- 009 0 0 0.00 $0.00 N
1 L5686 PROSTHETIC BACK CHECK 19.85 $19.85 --- -- 009 0 0 0.00 $0.00 Y
1 L5688 PROSTHETIC WAIST BELT 43.44 $43.44 --- -- 009 0 0 0.00 $0.00 Y
1 L5690 ADDITION TO LOWER EXTREMITY, BELOW 75.60 $75.60 --- -- 009 0 0 0.00 $0.00 Y
1 L5692 PROSTHETIC PELVIC BELT FELT LINED 88.65 $88.65 --- -- 009 0 0 0.00 $0.00 Y
1 L5694 PROSTHETIC PELVIC BELT PADDED AND LINED 105.52 $105.52 --- -- 009 0 0 0.00 $0.00 Y
1 L5695 ADDITION TO LOWER EXTREMITY, ABOVE 94.50 $94.50 --- -- 009 0 0 0.00 $0.00 Y
1 L5696 PROSTHETIC HIP JOINT 105.52 $105.52 --- -- 009 0 0 0.00 $0.00 Y
1 L5697 PROSTHETIC PELVIC BAND 46.45 $46.45 --- -- 009 0 0 0.00 $0.00 Y
1 L5698 PROSTHETIC SILESIAN BANDAGE BELT 49.14 $49.14 --- -- 009 0 0 0.00 $0.00 Y
P L5698 PROSTHETIC SILESIAN BANDAGE BELT 49.14 $49.14 --- -- 009 0 0 0.00 $0.00 Y
1 L5699 ALL LOWER EXTREMITY PROSTHESES, SH 144.67 $144.67 --- -- 009 0 0 0.00 $0.00 Y
1 L5700 REPLACMT,SOCKET,BELOW KNEE, MOLD TO PATI 1625.05 $1625.05 --- -- 009 0 0 0.00 $0.00 Y
1 L5701 REPLACMT,SOCKET,ABV KNEE,KNEE DISARTICUL 2017.64 $2017.64 --- -- 009 0 0 0.00 $0.00 Y
1 L5702 REPLACMT,SOCKET,HIP DISARTIC INCL HIP JT 2578.12 $2578.12 --- -- 009 0 0 0.00 $0.00 Y
1 L5703 SYMES ANKLE W/O (SACH) FOOT 1544.40 $1544.40 --- -- 009 0 0 0.00 $0.00 Y
P L5703 SYMES ANKLE W/O (SACH) FOOT 1544.40 $1544.40 --- -- 009 0 0 0.00 $0.00 Y
1 L5704 CUSTOM SHAPE COVER BK 271.40 $271.40 --- -- 009 0 0 0.00 $0.00 Y
1 L5705 CUSTOM SHAPE COVER AK 445.55 $445.55 --- -- 009 0 0 0.00 $0.00 Y
1 L5706 CUSTOM SHAPE CVR KNEE DISART 441.59 $441.59 --- -- 009 0 0 0.00 $0.00 Y
1 L5707 CUSTOM SHAPE CVR HIP DISART 627.74 $627.74 --- -- 009 0 0 0.00 $0.00 Y
1 L5710 PROSTHETIC MANUAL KNEE LOCK 221.64 $221.64 --- -- 009 0 0 0.00 $0.00 Y
1 L5711 ADDITIONS EXOSKELETAL KNEESHIN SY 359.38 $359.38 --- -- 009 0 0 0.00 $0.00 Y
1 L5712 PROSTHETIC SAFETY KNEE 289.00 $289.00 --- -- 009 0 0 0.00 $0.00 Y
1 L5714 PROSTHETIC VARIABLE FRICTION KNEE 170.66 $170.66 --- -- 009 0 0 0.00 $0.00 Y
1 L5716 ADDITION, EXOSKELETAL KNEESHIN SY 520.11 $520.11 --- -- 009 0 0 0.00 $0.00 Y
1 L5718 ADDITION, EXOSKELETAL KNEESHIN SY 560.56 $560.56 --- -- 009 0 0 0.00 $0.00 Y
1 L5722 EXOSKELETAL KNEESHIN SY 696.14 $696.14 --- -- 009 0 0 0.00 $0.00 Y
1 L5724 PROSTHETIC DUPACO KNEE UNIT 726.20 $726.20 --- -- 009 0 0 0.00 $0.00 Y
1 L5726 SINGLE AXIS 1265.35 $1265.35 --- -- 009 0 0 0.00 $0.00 Y
1 L5728 PROSTHETIC MAUCH SNS KNEE 1125.26 $1125.26 --- -- 009 0 0 0.00 $0.00 Y
1 L5780 PROSTHETIC HYDRAPNEUMATIC WITHOUT LOCK 345.48 $345.48 --- -- 009 0 0 0.00 $0.00 Y
1 L5781 LOWER LIMB PROS VACUUM PUMP 2520.06 $2520.06 --- -- 009 0 0 0.00 $0.00 Y
1 L5782 HD LOW LIMB PROS VACUUM PUMP 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L5785 ADDITION, EXOSKELETAL SYSTEM, BELO 317.63 $317.63 --- -- 009 0 0 0.00 $0.00 Y
P L5785 ADDITION, EXOSKELETAL SYSTEM, BELO 317.63 $317.63 --- -- 009 0 0 0.00 $0.00 Y
1 L5790 ADDITION, EXOSKELETAL SYSTEM, ABOV 417.97 $417.97 --- -- 009 0 0 0.00 $0.00 Y
1 L5795 ADDITION, EXOSKELETAL SYSTEM, HIP 534.19 $534.19 --- -- 009 0 0 0.00 $0.00 Y
1 L5810 ADDITION, ENDOSKELETAL KNEESHIN S 384.51 $384.51 --- -- 009 0 0 0.00 $0.00 Y
1 L5811 ADDITION, ENDOSKELETAL KNEESHIN 623.88 $623.88 --- -- 009 0 0 0.00 $0.00 Y
1 L5812 ADDITION, ENDOSKELETAL KNEESHIN S 393.19 $393.19 --- -- 009 0 0 0.00 $0.00 Y
1 L5814 ENDO KNEESHIN HYDRAL SWG PH 1622.66 $1622.66 --- -- 009 0 0 0.00 $0.00 Y
1 L5816 ADDITION, ENDOSKELETAL KNEESHIN S 689.08 $689.08 --- -- 009 0 0 0.00 $0.00 Y
1 L5818 ADDITION, ENDOSKELETAL KNEESHIN S 728.70 $728.70 --- -- 009 0 0 0.00 $0.00 Y
1 L5822 ADDITION, ENDOSKELETAL KNEESHIN S 683.69 $683.69 --- -- 009 0 0 0.00 $0.00 Y
1 L5824 ADDITION, ENDOSKELETAL KNEESHIN S 1243.27 $1243.27 --- -- 009 0 0 0.00 $0.00 Y
1 L5826 MINIATURE KNEE JOINT 1398.96 $1398.96 --- -- 009 0 0 0.00 $0.00 Y
1 L5828 ADDITION, ENDOSKELETAL KNEESHIN S 1687.63 $1687.63 --- -- 009 0 0 0.00 $0.00 Y
1 L5830 ADDITION, ENDOSKELETAL KNEESHIN 1623.21 $1623.21 --- -- 009 0 0 0.00 $0.00 Y
1 L5840 MULTIAXIAL KNEE/SHIN SYSTEM 1343.30 $1343.30 --- -- 009 0 0 0.00 $0.00 Y
1 L5845 KNEESHIN SYS STANCE FLEXION 1128.89 $1128.89 --- -- 009 0 0 0.00 $0.00 Y
1 L5848 KNEESHIN SYS HYDRAUL STANCE 677.28 $677.28 --- -- 009 0 0 0.00 $0.00 Y
1 L5850 ADDITION, ENDOSKELETAL SYSTEM, ABO 73.68 $73.68 --- -- 009 0 0 0.00 $0.00 Y
1 L5855 ADDIT,ENDOSKELETAL SYS,HIP DISARTIC MECH 183.27 $183.27 --- -- 009 0 0 0.00 $0.00 Y
1 L5856 ELEC KNEESHIN SWING/STANCE 15119.69 $15119.69 --- -- 009 0 0 0.00 $0.00 Y
1 L5857 ELEC KNEESHIN SWING ONLY 5365.04 $5365.04 --- -- 009 0 0 0.00 $0.00 Y
1 L5858 STANCE PHASE ONLY 11705.58 $11705.58 --- -- 009 0 0 0.00 $0.00 Y
1 L5859 KNEE-SHIN PRO FLEX/EXT CONT 0.00 $0.00 --- -- 007 0 0 0.00 $0.00 Y
1 L5910 ADDITION, ENDOSKELETAL SYSTEM, BEL 161.19 $161.19 --- -- 009 0 0 0.00 $0.00 Y
P L5910 ADDITION, ENDOSKELETAL SYSTEM, BEL 161.19 $161.19 --- -- 009 0 0 0.00 $0.00 Y
1 L5920 ADDITION, ENDOSKELETAL SYSTEM, ABO 236.13 $236.13 --- -- 009 0 0 0.00 $0.00 Y
1 L5925 ABOVE KNEE MANUAL LOCK 194.09 $194.09 --- -- 009 0 0 0.00 $0.00 Y
1 L5930 ENDOSKELETAL SYSTEM,KNEE CONTROL FRAME 1470.62 $1470.62 --- -- 009 0 0 0.00 $0.00 Y
1 L5940 ENDO SYSTEM, BK ULTRALIGHT MATL 310.89 $310.89 --- -- 009 0 0 0.00 $0.00 Y
1 L5950 ENDO SYSTEM,AK ULTRALIGHT MATL 453.71 $453.71 --- -- 009 0 0 0.00 $0.00 Y
1 L5960 ENDO SYSTEM, HIP DISART ULTRALIGHT MATL 562.20 $562.20 --- -- 009 0 0 0.00 $0.00 Y
1 L5961 ENDO POLY HIP, PNEU/HYD/ROT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L5962 ADDIT,ENDOSKELETAL SYS,BELOW KNEE,FLEXIB 348.79 $348.79 --- -- 009 0 0 0.00 $0.00 Y
1 L5964 ADDIT,ENDOSKELETAL SYS,ABOVE KNEE, FLEX 502.11 $502.11 --- -- 009 0 0 0.00 $0.00 Y
1 L5966 ADDIT,ENDOSKELETAL SYS,HIP DISARTIC,FLEX 650.97 $650.97 --- -- 009 0 0 0.00 $0.00 Y
1 L5968 MULTIAXIAL ANKLE W DORSIFLEX 1623.84 $1623.84 --- -- 009 0 0 0.00 $0.00 Y
1 L5970 ALL LOWER EXTREM PROS;FOOT EXT KEEL EACH 76.53 $76.53 --- -- 009 0 0 0.00 $0.00 Y
P L5970 ALL LOWER EXTREM PROS;FOOT EXT KEEL EACH 76.53 $76.53 --- -- 009 0 0 0.00 $0.00 Y
P L5971 SACH FOOT, REPLACEMENT 163.92 $163.92 --- -- 009 0 0 0.00 $0.00 Y
1 L5971 SACH FOOT, REPLACEMENT 163.92 $163.92 --- -- 009 0 0 0.00 $0.00 Y
1 L5972 ALL LOWER EXTREMITY PROSTHESES, FL 209.13 $209.13 --- -- 009 0 0 0.00 $0.00 Y
P L5972 ALL LOWER EXTREMITY PROSTHESES, FL 209.13 $209.13 --- -- 009 0 0 0.00 $0.00 Y
P L5973 ANK-FOOT SYS DORS-PLANT FLEX 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 N
1 L5973 ANK-FOOT SYS DORS-PLANT FLEX 12453.00 $12453.00 --- -- 009 0 0 0.00 $0.00 Y
1 L5974 ALL LOWER EXTREMITY PROSTHESES, FO 143.80 $143.80 --- -- 009 0 0 0.00 $0.00 Y
P L5974 ALL LOWER EXTREMITY PROSTHESES, FO 143.80 $143.80 --- -- 009 0 0 0.00 $0.00 Y
P L5975 COMBO ANKLE/FOOT PROSTHESIS 207.16 $207.16 --- -- 009 0 0 0.00 $0.00 Y
1 L5975 COMBO ANKLE/FOOT PROSTHESIS 207.16 $207.16 --- -- 009 0 0 0.00 $0.00 Y
1 L5976 ALL LOWER EXTREMITY PROSTHESES, EN 332.32 $332.32 --- -- 009 0 0 0.00 $0.00 Y
P L5976 ALL LOWER EXTREMITY PROSTHESES, EN 332.32 $332.32 --- -- 009 0 0 0.00 $0.00 Y
P L5978 ALL LOWER EXTREMITY PROSTHESES, FO 178.44 $178.44 --- -- 009 0 0 0.00 $0.00 Y
1 L5978 ALL LOWER EXTREMITY PROSTHESES, FO 178.44 $178.44 --- -- 009 0 0 0.00 $0.00 Y
1 L5979 MULTIAXIAL ANKLE/FT PROSTH 1341.49 $1341.49 --- -- 009 0 0 0.00 $0.00 Y
P L5979 MULTIAXIAL ANKLE/FT PROSTH 1341.49 $1341.49 --- -- 009 0 0 0.00 $0.00 Y
P L5980 ALL LOWER EXTREMITY PROSTHESES, FL 1878.25 $1878.25 --- -- 009 0 0 0.00 $0.00 Y
1 L5980 ALL LOWER EXTREMITY PROSTHESES, FL 1878.25 $1878.25 --- -- 009 0 0 0.00 $0.00 Y
1 L5981 ALL LOWER EXTREM PROSTH,FLEXWALK SYS OR 1457.82 $1457.82 --- -- 009 0 0 0.00 $0.00 Y
P L5981 ALL LOWER EXTREM PROSTH,FLEXWALK SYS OR 1457.82 $1457.82 --- -- 009 0 0 0.00 $0.00 Y
P L5982 ALL EXOSKELETAL LOWER EXTREMITY PR 384.33 $384.33 --- -- 009 0 0 0.00 $0.00 Y
1 L5982 ALL EXOSKELETAL LOWER EXTREMITY PR 384.33 $384.33 --- -- 009 0 0 0.00 $0.00 Y
1 L5984 ENDOSKELETAL AXIAL ROTATION 338.05 $338.05 --- -- 009 0 0 0.00 $0.00 Y
P L5984 ENDOSKELETAL AXIAL ROTATION 338.05 $338.05 --- -- 009 0 0 0.00 $0.00 Y
P L5985 ALL ENDOSKELETAL LOWER EXTREMITY PROTHES 123.37 $123.37 --- -- 009 0 0 0.00 $0.00 Y
1 L5985 ALL ENDOSKELETAL LOWER EXTREMITY PROTHES 123.37 $123.37 --- -- 009 0 0 0.00 $0.00 Y
1 L5986 ALL LOWER EXTREMITY PROSTHESES, MU 376.03 $376.03 --- -- 009 0 0 0.00 $0.00 Y
P L5986 ALL LOWER EXTREMITY PROSTHESES, MU 376.03 $376.03 --- -- 009 0 0 0.00 $0.00 Y
P L5987 SHANK FT W VERT LOAD PYLON 3143.06 $3143.06 --- -- 009 0 0 0.00 $0.00 Y
1 L5987 SHANK FT W VERT LOAD PYLON 3143.06 $3143.06 --- -- 009 0 0 0.00 $0.00 Y
1 L5988 VERTICAL SHOCK REDUCING PYLO 892.69 $892.69 --- -- 009 0 0 0.00 $0.00 Y
P L5988 VERTICAL SHOCK REDUCING PYLO 892.69 $892.69 --- -- 009 0 0 0.00 $0.00 Y
P L5990 USER ADJUSTABLE HEEL HEIGHT 1142.65 $1142.65 --- -- 009 0 0 0.00 $0.00 Y
1 L5990 USER ADJUSTABLE HEEL HEIGHT 1142.65 $1142.65 --- -- 009 0 0 0.00 $0.00 N
1 L6000 PART HAND THUMB REM 856.69 $856.69 --- -- 009 0 0 0.00 $0.00 Y
1 L6010 PART HAND LITTLE/RING 950.10 $950.10 --- -- 009 0 0 0.00 $0.00 Y
1 L6020 PART HAND NO FINGERS 920.07 $920.07 --- -- 009 0 0 0.00 $0.00 Y
1 L6026 PART HAND MYO EXCLU TERM DEV 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L6050 WRIST DISARTICULATION, MOLDED SOCK 805.99 $805.99 --- -- 009 0 0 0.00 $0.00 Y
1 L6055 WRIST DISARTICULATION, MOLDED SOCK 1488.03 $1488.03 --- -- 009 0 0 0.00 $0.00 Y
1 L6100 BELOW ELBOW, MOLDED SOCKET, FLEXIB 815.10 $815.10 --- -- 009 0 0 0.00 $0.00 Y
1 L6110 BELOW ELBOW, MOLDED SOCKET, (MUENS 853.14 $853.14 --- -- 009 0 0 0.00 $0.00 Y
1 L6120 BELOW ELBOW, MOLDED DOUBLE WALL SP 987.19 $987.19 --- -- 009 0 0 0.00 $0.00 Y
1 L6130 BELOW ELBOW, MOLDED DOUBLE WALL SP 1236.13 $1236.13 --- -- 009 0 0 0.00 $0.00 Y
1 L6200 ELBOW DISARTICULATION, MOLDED SOCK 1141.93 $1141.93 --- -- 009 0 0 0.00 $0.00 Y
1 L6205 ELBOW DISARTICULATION, MOLDED SOCK 2060.63 $2060.63 --- -- 009 0 0 0.00 $0.00 Y
1 L6250 ABOVE ELBOW, MOLDED DOUBLE WALL SO 1173.23 $1173.23 --- -- 009 0 0 0.00 $0.00 Y
1 L6300 SHOULDER DISARTICULATION, MOLDED S 1468.22 $1468.22 --- -- 009 0 0 0.00 $0.00 Y
1 L6310 SHOULDER DISARTICULATION, PASSIVE 1894.54 $1894.54 --- -- 009 0 0 0.00 $0.00 Y
1 L6320 SHOULDER DISARTICULATION, PASSIVE 1215.57 $1215.57 --- -- 009 0 0 0.00 $0.00 Y
1 L6350 INTERSCAPULAR THORACIC, MOLDED SOC 2362.08 $2362.08 --- -- 009 0 0 0.00 $0.00 Y
1 L6360 INTERSCAPULAR THORACIC, PASSIVE RE 2540.85 $2540.85 --- -- 009 0 0 0.00 $0.00 Y
1 L6370 INTERSCAPULAR THORACIC, PASSIVE RE 1332.14 $1332.14 --- -- 009 0 0 0.00 $0.00 Y
1 L6380 IMMEDIATE POST SURGICAL OR EARLY F 593.60 $593.60 --- -- 009 0 0 0.00 $0.00 Y
1 L6382 IMMEDIATE POST SURGICAL OR EARLY F 660.10 $660.10 --- -- 009 0 0 0.00 $0.00 Y
1 L6384 IMMEDIATE POST SURGICAL OR EARLY F 1101.63 $1101.63 --- -- 009 0 0 0.00 $0.00 Y
1 L6386 IMMEDIATE POST SURGICAL OR EARLY F 222.95 $222.95 --- -- 009 0 0 0.00 $0.00 Y
1 L6388 IMMEDIATE POST SURGICAL OR EARLY F 232.49 $232.49 --- -- 009 0 0 0.00 $0.00 Y
1 L6400 BELOW ELBOW, MOLDED SOCKET, ENDOSK 1442.96 $1442.96 --- -- 009 0 0 0.00 $0.00 Y
1 L6450 ELBOW DISARTICULATION, MOLDED SOCK 2209.58 $2209.58 --- -- 009 0 0 0.00 $0.00 Y
1 L6500 ABOVE ELBOW, MOLDED SOCKET, ENDOSK 2062.10 $2062.10 --- -- 009 0 0 0.00 $0.00 Y
1 L6550 SHOULDER DISARTICULATION, MOLDED S 2990.12 $2990.12 --- -- 009 0 0 0.00 $0.00 Y
1 L6570 INTERSCAPULAR THORACIC, MOLDED SOC 3336.60 $3336.60 --- -- 009 0 0 0.00 $0.00 Y
1 L6580 PREPARATORY, WRIST DISARTICULATION 823.38 $823.38 --- -- 009 0 0 0.00 $0.00 Y
1 L6582 PREPARATORY, WRIST DISARTICULATION 649.95 $649.95 --- -- 009 0 0 0.00 $0.00 Y
1 L6584 PREPARATORY, ELBOW DISARTICULATION 1163.31 $1163.31 --- -- 009 0 0 0.00 $0.00 Y
1 L6586 PREPARATORY, ELBOW DISARTICULATION 1016.14 $1016.14 --- -- 009 0 0 0.00 $0.00 Y
1 L6588 PREPARATORY, SHOULDER DISARTICULAT 1730.58 $1730.58 --- -- 009 0 0 0.00 $0.00 Y
1 L6590 PREPARATORY, SHOULDER DISARTICULAT 1514.98 $1514.98 --- -- 009 0 0 0.00 $0.00 Y
1 L6600 PROSTHETIC POLYCENTRIC HINGES 67.89 $67.89 --- -- 009 0 0 0.00 $0.00 Y
1 L6605 PROSTHETIC SINGLE PIVOT HINGES 75.29 $75.29 --- -- 009 0 0 0.00 $0.00 Y
1 L6610 PROSTHETIC METAL FLEXIBLE HINGES 64.44 $64.44 --- -- 009 0 0 0.00 $0.00 Y
1 L6611 ADDITIONAL SWITCH, EXT POWER 270.47 $270.47 --- -- 009 0 0 0.00 $0.00 Y
1 L6615 PROSTHETIC FM100 WRIST DISCONNECT 71.22 $71.22 --- -- 009 0 0 0.00 $0.00 Y
1 L6616 UPPER EXTREMITY ADDITION, ADDITION 28.00 $28.00 --- -- 009 0 0 0.00 $0.00 Y
1 L6620 FLEXION/EXTENSION WRIST UNIT 149.29 $149.29 --- -- 009 0 0 0.00 $0.00 Y
1 L6621 FLEX/EXT WRIST W/WO FRICTION 1440.62 $1440.62 --- -- 009 0 0 0.00 $0.00 Y
1 L6623 UPPER EXTREMITY ADDITION, SPRING A 247.89 $247.89 --- -- 009 0 0 0.00 $0.00 Y
1 L6624 FLEX/EXT/ROTATION WRIST UNIT 2474.01 $2474.01 --- -- 009 0 0 0.00 $0.00 Y
1 L6625 PROSTHETIC ROTATION WRIST W CABLE LOCK 272.66 $272.66 --- -- 009 0 0 0.00 $0.00 Y
1 L6628 UPPER EXTREMITY ADDITION, QUICK DI 280.56 $280.56 --- -- 009 0 0 0.00 $0.00 Y
1 L6629 UPPER EXTREMITY ADDITION, QUICK DI 79.33 $79.33 --- -- 009 0 0 0.00 $0.00 Y
1 L6630 PROSTHETIC WD400S HEAVY DUTY WRIST 76.95 $76.95 --- -- 009 0 0 0.00 $0.00 Y
1 L6632 UPPER EXTREMITY ADDITION, LATEX SU 36.96 $36.96 --- -- 009 0 0 0.00 $0.00 Y
1 L6635 PROSTHETIC HOSMER POSITIVE LOCK ELBOW 115.08 $115.08 --- -- 009 0 0 0.00 $0.00 Y
1 L6637 UPPER EXTREMITY ADDITION, NUDGE CO 203.70 $203.70 --- -- 009 0 0 0.00 $0.00 Y
1 L6638 ELEC LOCK ON MANUAL PW ELBOW 1575.05 $1575.05 --- -- 009 0 0 0.00 $0.00 Y
1 L6640 PROSTHETIC ABDUCTION JOINT 109.69 $109.69 --- -- 009 0 0 0.00 $0.00 Y
1 L6641 UPPER EXTREMITY ADDITION, EXCURSIO 103.34 $103.34 --- -- 009 0 0 0.00 $0.00 Y
1 L6642 UPPER EXTREMITY ADDITION, EXCURSIO 129.68 $129.68 --- -- 009 0 0 0.00 $0.00 Y
1 L6645 PROSTHETIC FLEXION/ABDUCT JOINT 149.05 $149.05 --- -- 009 0 0 0.00 $0.00 Y
1 L6646 MULTIPO LOCKING SHOULDER JNT 1986.49 $1986.49 --- -- 009 0 0 0.00 $0.00 Y
1 L6647 SHOULDER LOCK ACTUATOR 327.03 $327.03 --- -- 009 0 0 0.00 $0.00 Y
1 L6648 EXT PWRD SHLDER LOCK/UNLOCK 2048.78 $2048.78 --- -- 009 0 0 0.00 $0.00 Y
1 L6650 PROSTHETIC UNIVERSAL SHOULDER JOINT 145.71 $145.71 --- -- 009 0 0 0.00 $0.00 Y
1 L6655 PROSTHETIC CONTROL CABLE AND HOUSING 32.03 $32.03 --- -- 009 0 0 0.00 $0.00 Y
1 L6660 HEAVY DUTY CONTROL CABLE 78.52 $78.52 --- -- 009 0 0 0.00 $0.00 Y
1 L6665 UPPER EXTREMITY ADDITION, TEFLON, 21.89 $21.89 --- -- 009 0 0 0.00 $0.00 Y
1 L6670 PROSTHETIC HOOK AND HAND CABLE ADAPTOR 26.84 $26.84 --- -- 009 0 0 0.00 $0.00 Y
1 L6672 PROSTHETIC BILATER FIG 8 NW RING SINGLE 104.77 $104.77 --- -- 009 0 0 0.00 $0.00 Y
1 L6675 HARNESS FIGURE OF 8 SING CON 62.51 $62.51 --- -- 009 0 0 0.00 $0.00 Y
1 L6676 HARNESS FIGURE OF 8 DUAL CON 77.72 $77.72 --- -- 009 0 0 0.00 $0.00 Y
1 L6677 UE TRIPLE CONTROL HARNESS 186.83 $186.83 --- -- 009 0 0 0.00 $0.00 Y
1 L6680 TEST SOCKET PROCEDURE 179.71 $179.71 --- -- 009 0 0 0.00 $0.00 Y
1 L6682 TEST SOCKET PROCEDURE 179.71 $179.71 --- -- 009 0 0 0.00 $0.00 Y
1 L6684 TEST SOCKET PROCEDURE 179.71 $179.71 --- -- 009 0 0 0.00 $0.00 Y
1 L6686 UPPER EXTREMITY ADDITION, SUCTION 364.79 $364.79 --- -- 009 0 0 0.00 $0.00 Y
1 L6687 UPPER EXTREMITY ADDITION, FRAME TY 265.30 $265.30 --- -- 009 0 0 0.00 $0.00 Y
1 L6688 UPPER EXTREMITY ADDITION, FRAME TY 291.55 $291.55 --- -- 009 0 0 0.00 $0.00 Y
1 L6689 UPPER EXTREMITY ADDITION, FRAME TY 350.18 $350.18 --- -- 009 0 0 0.00 $0.00 Y
1 L6690 UPPER EXTREMITY ADDITION, FRAME TY 380.01 $380.01 --- -- 009 0 0 0.00 $0.00 Y
1 L6691 UPPER EXTREMITY ADDITION, REMOVABL 209.13 $209.13 --- -- 009 0 0 0.00 $0.00 Y
1 L6692 UPPER EXTREMITY ADDITION, SILICONE 413.00 $413.00 --- -- 009 0 0 0.00 $0.00 Y
1 L6693 LOCKINGELBOW FOREARM CNTRBAL 1297.85 $1297.85 --- -- 009 0 0 0.00 $0.00 Y
1 L6694 ELBOW SOCKET INS USE W/LOCK 502.73 $502.73 --- -- 009 0 0 0.00 $0.00 Y
1 L6695 ELBOW SOCKET INS USE W/O LCK 418.94 $418.94 --- -- 009 0 0 0.00 $0.00 Y
1 L6696 CUS ELBO SKT IN FOR CON/ATYP 828.47 $828.47 --- -- 009 0 0 0.00 $0.00 Y
1 L6697 CUS ELBO SKT IN NOT CON/ATYP 828.47 $828.47 --- -- 009 0 0 0.00 $0.00 Y
1 L6698 BELOW/ABOVE ELBOW LOCK MECH 425.50 $425.50 --- -- 009 0 0 0.00 $0.00 Y
1 L6703 TERM DEV, PASSIVE HAND MITT 240.50 $240.50 --- -- 009 0 0 0.00 $0.00 Y
1 L6704 TERM DEV, SPORT/REC/WORK ATT 522.51 $522.51 --- -- 009 0 0 0.00 $0.00 Y
1 L6706 TERM DEV MECH HOOK VOL OPEN 288.79 $288.79 --- -- 009 0 0 0.00 $0.00 Y
1 L6707 TERM DEV MECH HOOK VOL CLOSE 1102.72 $1102.72 --- -- 009 0 0 0.00 $0.00 Y
1 L6708 TERM DEV MECH HAND VOL OPEN 746.30 $746.30 --- -- 009 0 0 0.00 $0.00 Y
1 L6709 TERM DEV MECH HAND VOL CLOSE 1080.94 $1080.94 --- -- 009 0 0 0.00 $0.00 Y
1 L6711 PED TERM DEV, HOOK, VOL OPEN 476.26 $476.26 --- -- 009 0 0 0.00 $0.00 Y
1 L6712 PED TERM DEV, HOOK, VOL CLOS 876.88 $876.88 --- -- 009 0 0 0.00 $0.00 Y
1 L6713 PED TERM DEV, HAND, VOL OPEN 1106.72 $1106.72 --- -- 009 0 0 0.00 $0.00 Y
1 L6714 PED TERM DEV, HAND, VOL CLOS 937.39 $937.39 --- -- 009 0 0 0.00 $0.00 Y
1 L6715 *12TERM DEVICE, MULTI ART DIGIT 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L6721 HOOK/HAND, HVY DTY, VOL OPEN 1666.10 $1666.10 --- -- 009 0 0 0.00 $0.00 Y
1 L6722 HOOK/HAND, HVY DTY, VOL CLOS 1436.30 $1436.30 --- -- 009 0 0 0.00 $0.00 Y
1 L6805 TERM DEV MODIFIER WRIST UNIT 157.33 $157.33 --- -- 009 0 0 0.00 $0.00 Y
1 L6810 TERM DEV PRECISION PINCH DEV 96.51 $96.51 --- -- 009 0 0 0.00 $0.00 Y
1 L6880 *12ELEC HAND IND ART DIGITS 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L6881 TERM DEV AUTO GRASP FEATURE 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L6882 MICROPROCESSOR CONTROL UPLMB 0.00 $0.00 --- -- 009 0 0 0.00 $0.00 Y
1 L6883 REPLC SOCKT BELOW E/W DISA 1102.87 $1102.87 --- -- 009 0 0 0.00 $0.00 Y
1 L6884 REPLC SOCKT ABOVE ELBOW DISA 1909.77 $1909.77 --- -- 009 0 0 0.00 $0.00 Y
1 L6885 REPLC SOCKT SHLDR DIS/INTERC 2724.70 $2724.70 --- -- 009 0 0 0.00 $0.00 Y
1 L6890 PREFAB GLOVE FOR TERM DEVICE 92.39 $92.39 --- -- 009 0 0 0.00 $0.00 Y
1 L6895 CUSTOM GLOVE FOR TERM DEVICE 215.08 $215.08 --- -- 009 0 0 0.00 $0.00 Y
1 L6900 PROSTHETIC HAND PARTIAL HAND THUMB O FIN 654.89 $654.89 --- -- 009 0 0 0.00 $0.00 Y