| Code | Description | States | Median rate |
|---|---|---|---|
| L3000 | Foot, insert, removable, molded to patient model, 'ucb' type, berkeley shell, each | 41 | $293.56 |
| L3001 | Foot, insert, removable, molded to patient model, spenco, each | 39 | $126.93 |
| L3002 | Foot, insert, removable, molded to patient model, plastazote or equal, each | 39 | $152.63 |
| L3003 | Foot, insert, removable, molded to patient model, silicone gel, each | 37 | $170.73 |
| L3010 | Foot, insert, removable, molded to patient model, longitudinal arch support, each | 40 | $167.23 |
| L3020 | Foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each | 40 | $190.38 |
| L3030 | Foot, insert, removable, formed to patient foot, each | 40 | $73.24 |
| L3031 | Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each | 31 | $122.70 |
| L3040 | Foot, arch support, removable, premolded, longitudinal, each | 36 | $44.84 |
| L3050 | Foot, arch support, removable, premolded, metatarsal, each | 36 | $45.16 |
| L3060 | Foot, arch support, removable, premolded, longitudinal/ metatarsal, each | 38 | $70.76 |
| L3070 | Foot, arch support, non-removable attached to shoe, longitudinal, each | 36 | $29.68 |
| L3080 | Foot, arch support, non-removable attached to shoe, metatarsal, each | 35 | $29.78 |
| L3090 | Foot, arch support, non-removable attached to shoe, longitudinal/metatarsal, each | 35 | $39.06 |
| L3100 | Hallus-valgus night dynamic splint, prefabricated, off-the-shelf | 40 | $38.55 |
| L3140 | Foot, abduction rotation bar, including shoes | 43 | $81.73 |
| L3150 | Foot, abduction rotation bar, without shoes | 43 | $74.71 |
| L3160 | Foot, adjustable shoe-styled positioning device | 15 | $55.42 |
| L3170 | Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each | 43 | $47.36 |
| L3201 | Orthopedic shoe, oxford with supinator or pronator, infant | 34 | $47.39 |
| L3202 | Orthopedic shoe, oxford with supinator or pronator, child | 34 | $48.62 |
| L3203 | Orthopedic shoe, oxford with supinator or pronator, junior | 32 | $44.14 |
| L3204 | Orthopedic shoe, hightop with supinator or pronator, infant | 30 | $43.17 |
| L3206 | Orthopedic shoe, hightop with supinator or pronator, child | 33 | $44.14 |
| L3207 | Orthopedic shoe, hightop with supinator or pronator, junior | 31 | $47.39 |
| L3208 | Surgical boot, each, infant | 30 | $26.96 |
| L3209 | Surgical boot, each, child | 31 | $30.95 |
| L3211 | Surgical boot, each, junior | 31 | $33.77 |
| L3212 | Benesch boot, pair, infant | 27 | $55.36 |
| L3213 | Benesch boot, pair, child | 24 | $60.06 |
| L3214 | Benesch boot, pair, junior | 24 | $63.98 |
| L3215 | Orthopedic footwear, ladies shoe, oxford, each | 34 | $77.69 |
| L3216 | Orthopedic footwear, ladies shoe, depth inlay, each | 31 | $84.83 |
| L3217 | Orthopedic footwear, ladies shoe, hightop, depth inlay, each | 31 | $86.63 |
| L3219 | Orthopedic footwear, mens shoe, oxford, each | 36 | $85.35 |
| L3221 | Orthopedic footwear, mens shoe, depth inlay, each | 32 | $86.65 |
| L3222 | Orthopedic footwear, mens shoe, hightop, depth inlay, each | 32 | $97.90 |
| L3224 | Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis) | 40 | $64.02 |
| L3225 | Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis) | 40 | $68.01 |
| L3230 | Orthopedic footwear, custom shoe, depth inlay, each | 33 | $218.84 |
| L3250 | Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each | 30 | $250.00 |
| L3251 | Foot, shoe molded to patient model, silicone shoe, each | 24 | $229.02 |
| L3252 | Foot, shoe molded to patient model, plastazote (or similar), custom fabricated, each | 29 | $185.10 |
| L3253 | Foot, molded shoe plastazote (or similar) custom fitted, each | 29 | $74.56 |
| L3254 | Non-standard size or width | 16 | $22.90 |
| L3255 | Non-standard size or length | 16 | $21.43 |
| L3257 | Orthopedic footwear, additional charge for split size | 25 | $44.75 |
| L3260 | Surgical boot/shoe, each | 36 | $25.00 |
| L3265 | Plastazote sandal, each | 24 | $40.50 |
| L3300 | Lift, elevation, heel, tapered to metatarsals, per inch | 41 | $48.51 |
| L3310 | Lift, elevation, heel and sole, neoprene, per inch | 41 | $75.87 |
| L3320 | Lift, elevation, heel and sole, cork, per inch | 33 | $69.10 |
| L3330 | Lift, elevation, metal extension (skate) | 40 | $530.32 |
| L3332 | Lift, elevation, inside shoe, tapered, up to one-half inch | 42 | $68.73 |
| L3334 | Lift, elevation, heel, per inch | 42 | $36.11 |
| L3340 | Heel wedge, sach | 42 | $79.44 |
| L3350 | Heel wedge | 42 | $21.43 |
| L3360 | Sole wedge, outside sole | 41 | $33.13 |
| L3370 | Sole wedge, between sole | 42 | $46.21 |
| L3380 | Clubfoot wedge | 40 | $45.76 |
| L3390 | Outflare wedge | 41 | $46.30 |
| L3400 | Metatarsal bar wedge, rocker | 42 | $37.44 |
| L3410 | Metatarsal bar wedge, between sole | 43 | $86.64 |
| L3420 | Full sole and heel wedge, between sole | 43 | $52.50 |
| L3430 | Heel, counter, plastic reinforced | 42 | $151.68 |
| L3440 | Heel, counter, leather reinforced | 40 | $71.12 |
| L3450 | Heel, sach cushion type | 40 | $98.37 |
| L3455 | Heel, new leather, standard | 40 | $39.06 |
| L3460 | Heel, new rubber, standard | 40 | $32.00 |
| L3465 | Heel, thomas with wedge | 39 | $54.44 |
| L3470 | Heel, thomas extended to ball | 39 | $57.98 |
| L3480 | Heel, pad and depression for spur | 40 | $60.37 |
| L3485 | Heel, pad, removable for spur | 29 | $18.90 |
| L3500 | Orthopedic shoe addition, insole, leather | 38 | $28.07 |
| L3510 | Orthopedic shoe addition, insole, rubber | 38 | $28.34 |
| L3520 | Orthopedic shoe addition, insole, felt covered with leather | 37 | $29.68 |
| L3530 | Orthopedic shoe addition, sole, half | 38 | $30.80 |
| L3540 | Orthopedic shoe addition, sole, full | 39 | $48.60 |
| L3550 | Orthopedic shoe addition, toe tap standard | 38 | $8.43 |
| L3560 | Orthopedic shoe addition, toe tap, horseshoe | 37 | $21.35 |
| L3570 | Orthopedic shoe addition, special extension to instep (leather with eyelets) | 38 | $79.31 |
| L3580 | Orthopedic shoe addition, convert instep to velcro closure | 41 | $62.25 |
| L3590 | Orthopedic shoe addition, convert firm shoe counter to soft counter | 38 | $50.24 |
| L3595 | Orthopedic shoe addition, march bar | 39 | $39.71 |
| L3600 | Transfer of an orthosis from one shoe to another, caliper plate, existing | 42 | $71.22 |
| L3610 | Transfer of an orthosis from one shoe to another, caliper plate, new | 42 | $96.41 |
| L3620 | Transfer of an orthosis from one shoe to another, solid stirrup, existing | 42 | $72.13 |
| L3630 | Transfer of an orthosis from one shoe to another, solid stirrup, new | 41 | $96.41 |
| L3640 | Transfer of an orthosis from one shoe to another, dennis browne splint (riveton), both shoes | 40 | $40.45 |
| L3650 | Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf | 43 | $60.39 |
| L3660 | Shoulder orthosis, figure of eight design abduction restrainer, canvas and webbing, prefabricated, off-the-shelf | 38 | $96.22 |
| L3670 | Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf | 42 | $106.58 |
| L3671 | Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 37 | $794.60 |
| L3674 | Shoulder orthosis, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 32 | $1,032.30 |
| L3675 | Shoulder orthosis, vest type abduction restrainer, canvas webbing type or equal, prefabricated, off-the-shelf | 37 | $156.25 |
| L3677 | Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 10 | $155.05 |
| L3702 | Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 39 | $257.50 |
| L3710 | Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf | 42 | $118.18 |
| L3720 | Elbow orthosis, double upright with forearm/arm cuffs, free motion, custom fabricated | 44 | $627.25 |
| L3730 | Elbow orthosis, double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated | 42 | $888.30 |
| L3740 | Elbow orthosis, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated | 43 | $1,029.66 |
| L3760 | Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 41 | $427.22 |
| L3761 | Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf | 40 | $454.32 |
| L3762 | Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf | 42 | $93.90 |
| L3763 | Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 42 | $651.34 |
| 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 | 39 | $779.87 |
| L3765 | Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 38 | $1,160.16 |
| 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 | 39 | $1,210.73 |
| 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 | 38 | $404.18 |
| L3807 | Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 43 | $222.93 |
| L3808 | Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment | 42 | $323.75 |
| L3809 | Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type | 41 | $209.17 |
| L3900 | Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist or finger driven, custom fabricated | 42 | $1,273.40 |
| L3901 | Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, cable driven, custom fabricated | 40 | $1,521.61 |
| L3904 | Wrist hand finger orthosis, external powered, electric, custom fabricated | 37 | $2,793.67 |
| L3905 | Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 37 | $874.54 |
| L3906 | Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 45 | $384.53 |
| L3908 | Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf | 45 | $60.51 |
| L3912 | Hand finger orthosis (hfo), flexion glove with elastic finger control, prefabricated, off-the-shelf | 43 | $89.31 |
| L3913 | Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 39 | $240.99 |
| L3915 | Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 38 | $452.63 |
| L3916 | Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf | 37 | $447.70 |
| L3917 | Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 40 | $93.99 |
| L3918 | Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf | 39 | $89.00 |
| L3919 | Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 37 | $238.84 |
| L3921 | Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 36 | $286.79 |
| L3923 | Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 42 | $80.80 |
| L3924 | Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-the-shelf | 41 | $77.45 |
| L3925 | Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf | 42 | $48.46 |
| L3927 | Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, off-the-shelf | 35 | $31.11 |
| L3929 | Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 42 | $80.00 |
| L3930 | Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, off-the-shelf | 38 | $73.68 |
| L3931 | Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment | 42 | $177.10 |
| L3933 | Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment | 39 | $190.27 |
| L3935 | Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment | 34 | $196.71 |
| L3960 | Shoulder elbow wrist hand orthosis, abduction positioning, airplane design, prefabricated, includes fitting and adjustment | 43 | $687.93 |
| L3961 | Shoulder elbow wrist hand orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 36 | $1,467.27 |
| L3962 | Shoulder elbow wrist hand orthosis, abduction positioning, erb's palsey design, prefabricated, includes fitting and adjustment | 42 | $705.95 |
| L3967 | Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 35 | $1,768.79 |
| 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 | 37 | $1,660.47 |
| L3973 | Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 35 | $1,749.28 |
| L3975 | Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 36 | $1,495.95 |
| L3976 | Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 36 | $1,495.95 |
| 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 | 36 | $1,676.52 |
| L3978 | Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 36 | $1,766.19 |
| L3980 | Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment | 44 | $290.68 |
| L3981 | Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments | 32 | $879.06 |
| L3982 | Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment | 44 | $346.98 |
| L3984 | Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment | 43 | $309.62 |
| L3995 | Addition to upper extremity orthosis, sock, fracture or equal, each | 42 | $31.83 |
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.