Djo HCPCS Codes

ESTIMATED PATIENT FINANCIAL RESPONSIBILITY
ATTENTION – The amounts included in the following table are based on current Enovis charge amounts for various orthotic products provided by Enovis. These
amounts are provided to you to assist you with better understanding your potential out-of-pocket costs/financial responsibility for the product(s) you are receiving.
Generally, insurers like Medicare will pay 80% of the amount your insurer determines is allowable/payable for the covered product (after you have met any annual
deductible amounts). You generally are then responsible for payment of the remaining 20% coinsurance amount. If you have a secondary insurer, Enovis or the Contract
Supplier (for Medicare beneficiaries only) will submit a claim to that insurer for your 20% coinsurance amount. You will be responsible for any unpaid balance due after
your primary and/or secondary insurer have processed the claim. We recommend that you check your individual plan coverage limits with your insurer’s Member
Benefits department.
Enovis makes a reasonable effort to comply with the No Surprises Act disclosure and notice requirements specified at 45 CFR § 149.430. For more information about the
No Surprises Act and your rights and responsibilities under the Act, please visit our website found at https://www.djoglobal.com/no-surprises-act.
HCPCS Product Description Retail Price HCPCS Product Description Retail Price
L4350 Ankle Brace, Stirrup Style $110.00 L1830 Knee Immobilizer $105.00
L1902 Ankle Foot Orthosis, Lace-Up or Gauntlet Style $100.00 L1833 Knee Orthosis w/ Adjustable ROM Hinge $600.00 - $850.00
L1906 Ankle Foot Orthosis, Multi Ligament Style $150.00 L1851 Knee Othosis - Single Upright $600.00 - $1,000.00
L4397 Ankle Foot Orthosis, Night Splint, Dynamic $195.00 L1844 Knee Orthosis - Single Upright Custom Fabricated $1,850.00
L1930 Ankle Foot Orthosis, Rigid Plastic Style $290.00 L1852 Knee Orthosis - Double Upright $1,000.00
E0100-5 Cane - Standard & Quad Type $23.00 - $60.00 L1846 Knee Orthosis - Double Upright Custom Fabricated $1,870.00 - $2,120.00
LO120 Cervical Collar - Foam Style $35.00 L4370 Leg Splint, Pneumatic $230.00
L0150 Cervical Collar - Semi Rigid $130.00 LO641 Lumbar Orthosis w/ Stays/Panels $90.00
LO174 Cervical Collar - Semi Rigid w/ Thoracic Extension $335.00 L0642 Lumbar Orthosis, Saggital Control $475.00
LO172 Cervical Collar - Philadelphia Type $155.00 L0648 Lumbar-Sacral Orthosis w/ Ant. & Post. Panels $1,190.00
E0110-4 Crutches Standard & Forearm Style $53.00 - $90.00 L0650 Lumbar-Sacral Orthosis w/ Ant., Post. & Lateral Panels $1,360.00
L3761 Elbow Orthosis - Range of Motion $490.00 L0464 Thoracic-Lumbar-Sacral Orthosis $1,720.00
L3762 Elbow Orthosis - Wrap Style $115.00 LO621 Sacroiliac (SI) Belt $95.00 - $115.00
L3730 Elbow Orthosis - Custom Fabricated $1,020.00 L3650 Shoulder Immobilizer/Clavical Support $70.00
L3924 Finger/Thumb Orthosis $105.00 L3660 Shoulder Immobilizer Orthosis $125.00
L3040 Foot-Arch Support - Longitudinal $50.00 L3675 Shoulder Orthosis/Abduction Restrainer $185.00
L3050 Foot-Arch Support w/ Metatarsal Support $30.00 L3670 Shoulder Orthosis - UltraSling $135.00
L3060 Foot-Arch Support w/ Metatarsal & Longit. Support $85.00 L3960 Shoulder-Elbow-Wrist-Hand-Orthosis-UltraSling Quadrant $600.00
L3510 Foot-Arch Support w/ Rigid Insole $95.00 L3980 Upper Extremity Fracture Orthosis, Humeral $370.00
L3100 Hallus-Valgus Night Splint $50.00 L3984 Upper Extremity Fracture Orthosis, Wrist $410.00
E0191 Heel/Elbow Protector $50.00 E0135 Walker - Adjustable Folding w/o Wheels $90.00
L3332 Heel Lifts - Plastic or Leather $30.00 - $50.00 E0143 Walker - Adjustable Folding w/ Wheels $125.00
L3170 Heel Stabilizer - Plastic or Silicone $30.00 - $50.00 L4361 Walking Boot, Pneumatic $335.00
L1686 Hip Orthosis $1,100.00 L4387 Walking Boot, Non-Pneumatic $185.00
L1812 Knee Orthosis w/ Joints $220.00 L3809 Wrist-Hand-Finger Orthosis, No Joints $200.00
L1820 Knee Orthosis w/ Condylar Pads $160.00 L3908 Wrist Orthosis, Cock-Up Style $70.00
MKT00-13343 Rev A (12/23)

Djo HCPCS Codes

Uploaded by

Copyright:

Available Formats

Djo HCPCS Codes

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Djo HCPCS Codes

Uploaded by

Copyright:

Available Formats

ESTIMATED PATIENT FINANCIAL RESPONSIBILITY

L3924 Finger/Thumb Orthosis $105.00 L3660 Shoulder Immobilizer Orthosis $125.00

L1686 Hip Orthosis $1,100.00 L4387 Walking Boot, Non-Pneumatic $185.00

MKT00-13343 Rev A (12/23)

You might also like