XO Formulary Part #
Description
HCPCS Code
XO-BSS-A XO-ASL-1 XO-ASL-2 XO-ASL-3 XO-ASL-4 XO-ASL-5 XO-ASL-6 XO-ASL-7 XO-B42-A XO-BSPO-2 XO-BSPO-3 XO-BSPO-4 XO-BTPO-2 XO-BTPO-3 XO-BTPO-4 XO-BPPO-2 XO-BPPO-3 XO-BPPO-4 XO-BPPO-5 XO-FNO-A2 XO-FNO-A3 XO-FNO-A4 XO-FNO-A5 XO-FXO-B1 XO-FXO-B3 XO-FXO-B5 XO-FXO-C1 XO-FXO-C3 XO-FXO-C5 XO-KNI-A XO-KSO-A2 XO-KSO-A6 XO-ASE-6 XO-SAS-1 XO-SAS-2 XO-SAS-3 XO-SAS-4 XO-SAS-5 XO-SAH-1 XO-WSH-AC XO-TSE-AB XO-TSE-AC XO-TSH-AB XO-WSE-AC XO-WSE-AB XO-WSE-AC XO-WSH-AB
XO Ankle Support XS XO Ankle Support SM XO Ankle Support MD XO Ankle Support LG XO Ankle Support XL XO Ankle Support 2X XO Ankle Support 3X XO Ankle Support 4X XO Back LSO w/Cryotherapy SM-4X XO Boot Short SM & XO AFO Undersleeves (x2) XO Boot Short MD & XO AFO Undersleeves (x2) XO Boot Short LG & XO AFO Undersleeves (x2) XO Boot Tall SM & XO AFO Undersleeves (x2) XO Boot Tall MD & XO AFO Undersleeves (x2) XO Boot Tall LG & XO AFO Undersleeves (x2) XO Boot PEDI SM & XO AFO Undersleeves (x2) XO Boot PEDI MD & XO AFO Undersleeves (x2) XO Boot PEDI LG & XO AFO Undersleeves (x2) XO Boot PEDI XL & XO AFO Undersleeves (x2) XO Finger Orthosis SM XO Finger Orthosis MD XO Finger Orthosis LG XO Finger Orthosis XL XO FX Orthosis LT XS & XO WHO Undersleeeves (x2) XO FX Orthosis LT REG & XO WHO Undersleeeves (x2) XO FX Orthosis LT XL & XO WHO Undersleeeves (x2) XO FX Orthosis RT XS & XO WHO Undersleeeves (x2) XO FX Orthosis RT REG & XO WHO Undersleeeves (x2) XO FX Orthosis RT XL & XO WHO Undersleeeves (x2) XO Knee Immobilizer & XO KO Undersleeves (x2) XO Knee Support ROM w/Cryotherapy SM-2X & XO KO Undersleeves (x2) XO Knee Support ROM w/Cryotherapy 3X-7X & XO KO Undersleeves (x2) XO Sling Arm Shoulder XS XO Sling Arm Shoulder SM XO Sling Arm Shoulder MD XO Sling Arm Shoulder LG XO Sling Arm Shoulder XL XO Sling Arm Shoulder PEDI XS XO Sling Arm Shoulder PEDI SM XO Thumb Orthosis RT & XO WHTO Undersleeeves (x2) XO Thumb Orthosis LT & XO WHTO Undersleeeves (x2) XO Thumb Orthosis PEDI RT & XO WHTO Undersleeeves (x2) XO Thumb Orthosis PEDI LT & XO WHTO Undersleeeves (x2) XO Wrist Orthosis RT & XO WHO Undersleeeves (x2) XO Wrist Orthosis LT & XO WHO Undersleeeves (x2) XO Wrist Orthosis PEDI RT & XO WHO Undersleeeves (x2) XO Wrist Orthosis PEDI LT & XO WHO Undersleeeves (x2)
L1902 L1902 L1902 L1902 L1902 L1902 L1902 L1902 L0642 L4361 & L2840 (x2) L4361 & L2840 (x2) L4361 & L2840 (x2) L4361 & L2840 (x2) L4361 & L2840 (x2) L4361 & L2840 (x2) L4361 & L2840 (x2) L4361 & L2840 (x2) L4361 & L2840 (x2) L4361 & L2840 (x2) L3927 L3927 L3927 L3927 L3807 & L3995 (x2) L3807 & L3995 (x2) L3807 & L3995 (x2) L3807 & L3995 (x2) L3807 & L3995 (x2) L3807 & L3995 (x2) L1830 & L2397 (x2) L1833 & L2397 (x2) L1833 & L2397 (x2) L3670 L3670 L3670 L3670 L3670 L3670 L3670 L3809 & L3995 (x2) L3809 & L3995 (x2) L3809 & L3995 (x2) L3809 & L3995 (x2) L3908 & L3995 (x2) L3908 & L3995 (x2) L3908 & L3995 (x2) L3908 & L3995 (x2)
Charge Value Cost
$120.04 $120.04 $120.04 $120.04 $120.04 $120.04 $120.04 $120.04 $319.33 $483.59 $483.59 $483.59 $483.59 $483.59 $483.59 $483.59 $483.59 $483.59 $483.59 $38.15 $38.15 $38.15 $38.15 $362.97 $362.97 $362.97 $362.97 $362.97 $362.97 $359.94 $793.87 $793.87 $150.78 $150.78 $150.78 $150.78 $150.78 $150.78 $150.78 $362.97 $362.97 $362.97 $362.97 $165.64 $165.64 $165.64 $165.64
$14.74 $14.74 $14.74 $14.74 $14.74 $14.74 $14.74 $14.74 $69.78 $59.55 $59.55 $59.55 $59.55 $59.55 $59.55 $59.55 $59.55 $59.55 $59.55 $8.88 $8.88 $8.88 $8.88 $31.87 $31.87 $31.87 $31.87 $31.87 $31.87 $37.92 $54.77 $54.77 $13.93 $13.93 $13.93 $13.93 $13.93 $13.93 $13.93 $19.84 $19.84 $19.84 $19.84 $15.98 $15.98 $15.98 $15.98