| L2128 | Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, custom fabricated |
| L1950 | Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, custom fabricated |
| L2036 | Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
| L2037 | Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
| L2108 | Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom fabricated |
| L0638 | Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated |
| S1040 | Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) |
| L3904 | Wrist hand finger orthosis, external powered, electric, custom fabricated |
| L4030 | Replace quadrilateral socket brim, custom fitted |
| G6014 | Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 mev or greater |
| L3913 | Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3933 | Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment |
| L3765 | Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3702 | Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3906 | Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3763 | Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3671 | Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L2520 | Addition to lower extremity, thigh/weight bearing, quadri- lateral brim, custom fitted |
| L2526 | Addition to lower extremity, thigh/weight bearing, ischial containment/narrow m-l brim, custom fitted |
| L2320 | Addition to lower extremity, non-molded lacer, for custom fabricated orthosis only |
| L3253 | Foot, molded shoe plastazote (or similar) custom fitted, each |
| L0484 | Tlso, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated |
| L0486 | Tlso, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated |
| L0480 | Tlso, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated |
| L0482 | Tlso, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated |
| L8701 | Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated |
| L8702 | Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated |
| L3921 | Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3806 | Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment |
| L3766 | Elbow wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3905 | Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3764 | Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3935 | Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment |
| L3971 | Shoulder elbow wrist hand orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3977 | Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L4050 | Replace molded calf lacer, for custom fabricated orthosis only |
| L4040 | Replace molded thigh lacer, for custom fabricated orthosis only |
| L4045 | Replace non-molded thigh lacer, for custom fabricated orthosis only |
| L8035 | Custom breast prosthesis, post mastectomy, molded to patient model |
| A5501 | For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe |
