| Code | Description | States | Median rate |
|---|---|---|---|
| L1000 | Cervical-thoracic-lumbar-sacral orthosis (ctlso) (milwaukee), inclusive of furnishing initial orthosis, including model | 45 | $1,885.51 |
| L1005 | Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment | 39 | $3,041.25 |
| L1006 | Scoliosis orthosis, sagittal-coronal control provided by a rigid lateral frame, extends from axilla to trochanter, includes all accessory pads, straps and interface, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 24 | $1,065.34 |
| L1010 | Addition to cervical-thoracic-lumbar-sacral orthosis (ctlso) or scoliosis orthosis, axilla sling | 44 | $65.55 |
| L1020 | Addition to ctlso or scoliosis orthosis, kyphosis pad | 44 | $84.43 |
| L1025 | Addition to ctlso or scoliosis orthosis, kyphosis pad, floating | 43 | $126.40 |
| L1030 | Addition to ctlso or scoliosis orthosis, lumbar bolster pad | 44 | $62.14 |
| L1040 | Addition to ctlso or scoliosis orthosis, lumbar or lumbar rib pad | 45 | $76.54 |
| L1050 | Addition to ctlso or scoliosis orthosis, sternal pad | 44 | $82.14 |
| L1060 | Addition to ctlso or scoliosis orthosis, thoracic pad | 45 | $97.20 |
| L1070 | Addition to ctlso or scoliosis orthosis, trapezius sling | 44 | $88.48 |
| L1080 | Addition to ctlso or scoliosis orthosis, outrigger | 43 | $54.49 |
| L1085 | Addition to ctlso or scoliosis orthosis, outrigger, bilateral with vertical extensions | 42 | $148.27 |
| L1090 | Addition to ctlso or scoliosis orthosis, lumbar sling | 45 | $87.07 |
| L1100 | Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather | 41 | $166.68 |
| L1110 | Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather, molded to patient model | 43 | $251.96 |
| L1120 | Addition to ctlso, scoliosis orthosis, cover for upright, each | 44 | $39.18 |
| L1200 | Thoracic-lumbar-sacral-orthosis (tlso), inclusive of furnishing initial orthosis only | 45 | $1,574.76 |
| L1210 | Addition to tlso, (low profile), lateral thoracic extension | 45 | $244.89 |
| L1220 | Addition to tlso, (low profile), anterior thoracic extension | 45 | $220.82 |
| L1230 | Addition to tlso, (low profile), milwaukee type superstructure | 45 | $562.62 |
| L1240 | Addition to tlso, (low profile), lumbar derotation pad | 45 | $78.89 |
| L1250 | Addition to tlso, (low profile), anterior asis pad | 44 | $71.86 |
| L1260 | Addition to tlso, (low profile), anterior thoracic derotation pad | 45 | $77.10 |
| L1270 | Addition to tlso, (low profile), abdominal pad | 44 | $75.38 |
| L1280 | Addition to tlso, (low profile), rib gusset (elastic), each | 45 | $80.51 |
| L1290 | Addition to tlso, (low profile), lateral trochanteric pad | 45 | $74.87 |
| L1300 | Other scoliosis procedure, body jacket molded to patient model | 45 | $1,685.23 |
| L1310 | Other scoliosis procedure, post-operative body jacket | 43 | $1,751.13 |
| L1600 | Hip orthosis, abduction control of hip joints, flexible, frejka type with cover, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an inidividual with expertise | 43 | $118.46 |
| L1610 | Hip orthosis, abduction control of hip joints, flexible, (frejka cover only), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 42 | $42.81 |
| L1620 | Hip orthosis, abduction control of hip joints, flexible, (pavlik harness), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 43 | $130.68 |
| L1630 | Hip orthosis, abduction control of hip joints, semi-flexible (von rosen type), custom fabricated | 44 | $160.16 |
| L1640 | Hip orthosis, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated | 44 | $433.68 |
| L1650 | Hip orthosis, abduction control of hip joints, static, adjustable, (ilfled type), prefabricated, includes fitting and adjustment | 42 | $224.18 |
| L1652 | Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 42 | $335.34 |
| L1653 | Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, off the shelf | 25 | $347.96 |
| L1660 | Hip orthosis, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment | 42 | $160.16 |
| L1680 | Hip orthosis, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (rancho hip action type), custom fabricated | 44 | $1,158.61 |
| L1681 | Hip orthosis, bilateral hip joints and thigh cuffs, adjustable flexion, extension, abduction control of hip joint, postoperative hip abduction type, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 22 | $1,991.61 |
| L1685 | Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated | 44 | $1,107.45 |
| L1686 | Hip orthosis, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment | 44 | $874.53 |
| L1690 | Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment | 44 | $1,774.87 |
| L1700 | Legg perthes orthosis, (toronto type), custom fabricated | 43 | $1,449.36 |
| L1710 | Legg perthes orthosis, (newington type), custom fabricated | 43 | $1,754.96 |
| L1720 | Legg perthes orthosis, trilateral, (tachdijan type), custom fabricated | 44 | $1,298.35 |
| L1730 | Legg perthes orthosis, (scottish rite type), custom fabricated | 44 | $1,052.08 |
| L1755 | Legg perthes orthosis, (patten bottom type), custom fabricated | 44 | $1,531.34 |
| L1810 | Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 44 | $96.19 |
| L1812 | Knee orthosis, elastic with joints, prefabricated, off-the-shelf | 41 | $77.24 |
| L1820 | Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 43 | $130.11 |
| L1821 | Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, off the shelf | 26 | $142.79 |
| L1830 | Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf | 44 | $68.78 |
| L1831 | Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment | 41 | $279.66 |
| L1832 | Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 42 | $613.63 |
| L1833 | Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf | 41 | $506.15 |
| L1834 | Knee orthosis, without knee joint, rigid, custom fabricated | 42 | $744.13 |
| L1836 | Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf | 42 | $100.95 |
| L1840 | Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated | 42 | $918.60 |
| L1843 | Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 41 | $842.28 |
| L1844 | Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated | 41 | $1,520.77 |
| L1845 | Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 42 | $765.02 |
| L1846 | Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated | 43 | $1,098.87 |
| L1847 | Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 41 | $538.54 |
| L1848 | Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf | 37 | $536.00 |
| L1850 | Knee orthosis, swedish type, prefabricated, off-the-shelf | 43 | $218.82 |
| L1851 | Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf | 40 | $679.68 |
| L1852 | Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf | 40 | $634.46 |
| L1860 | Knee orthosis, modification of supracondylar prosthetic socket, custom fabricated (sk) | 43 | $1,072.08 |
| L1900 | Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom fabricated | 44 | $261.49 |
| L1902 | Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf | 43 | $83.12 |
| L1904 | Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated | 42 | $443.67 |
| L1906 | Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf | 45 | $117.47 |
| L1907 | Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated | 44 | $544.86 |
| L1910 | Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment | 42 | $262.80 |
| L1920 | Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom fabricated | 42 | $323.18 |
| L1930 | Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment | 44 | $230.08 |
| L1932 | Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 43 | $832.61 |
| L1933 | Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, off-the-shelf | 25 | $897.24 |
| L1940 | Ankle foot orthosis, plastic or other material, custom fabricated | 44 | $484.69 |
| L1945 | Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom fabricated | 44 | $913.66 |
| L1950 | Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, custom fabricated | 44 | $743.22 |
| L1951 | Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 41 | $806.00 |
| L1952 | Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, off-the-shelf | 25 | $856.26 |
| L1960 | Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated | 44 | $545.24 |
| L1970 | Ankle foot orthosis, plastic with ankle joint, custom fabricated | 44 | $693.12 |
| L1971 | Ankle foot orthosis, plastic or other material with ankle joint, with or without dorsiflexion assist, prefabricated, includes fitting and adjustment | 41 | $437.50 |
| L1980 | Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'bk' orthosis), custom fabricated | 44 | $349.60 |
| L1990 | Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'bk' orthosis), custom fabricated | 44 | $431.50 |
Published Medicaid fee-for-service schedule amounts, not a coverage or eligibility guarantee. Managed-care plan rates can differ. Where no prior-authorization flag is shown, the state does not publish one. Descriptions are ProviderSignal's own plain-language labels or public-domain CMS text.