| S1040 | Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) | 1 | 10 | 830 | $1,160 | $985.9K |
| A8003 | Helmet, protective, hard, custom fabricated, includes all components and accessories | 1 | 10 | 430 | $2,220 | $955.7K |
| L2280 | Addition to lower extremity, molded inner boot | 2 | 10 | 30 | $510 | $148.9K |
| L1960 | Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated | 1 | 10 | 170 | $480 | $84.3K |
| L2275 | Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined | 3 | 10 | 110 | $140 | $61.4K |
| L4360 | Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a… | 8 | 10 | 80 | $210 | $38.2K |
| L2820 | Addition to lower extremity orthosis, soft interface for molded plastic, below knee section | 4 | 10 | 100 | $90 | $28.6K |
| L1930 | Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment | 1 | 10 | 30 | $240 | $7.3K |
| L2270 | Addition to lower extremity, varus/valgus correction ('t') strap, padded/lined or malleolus pad | 2 | 10 | 40 | $50 | $3.3K |
| L4386 | Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific… | 1 | 10 | 30 | $110 | $3.3K |