Contents
- Index
Order/Invoice Input Summary
Order/Invoice Input Summary For 12/03/1996 - 12/03/1996 PG:1
Type Total Initial
Invoice# Inv.Date Patient Amount Non-Allow
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17408 12/03/96 I 2322 COY, DALE A 814.00
Procedure Code: L3250 ORTHOPEDIC FOOTWEAR, CUSTO 556.00
Procedure Code: L3420 FULL SOLE AND HEEL WEDGE, 84.00
Procedure Code: L3440 HEEL, COUNTER, LEATHER REI 94.00
Procedure Code: L3030 FOOT, INSERT, REMOVABLE, F 80.00
17508 12/03/96 I 1297 PETERSON, NANCY 3048.61
Procedure Code: L5652 SUCTION SUSPENSION, ABOVE 311.76
Procedure Code: L5701 REPLACEMENT SOCKET AK/KD, 2736.85
17509 12/03/96 I 1297 PETERSON, NANCY 9119.60
Procedure Code: L5310 KNEE DISARTICULATION (OR T 3840.36
Procedure Code: L5613 ADDITION TO LOWER EXTREMIT 1752.43
Procedure Code: L5622 TEST SOCKET, KNEE DISARTIC 287.23
Procedure Code: L5631 ABOVE KNEE OR KNEE DISARTI 314.18
Procedure Code: L5650 TOTAL CONTACT, ABOVE KNEE 349.08
Procedure Code: L5652 SUCTION SUSPENSION, ABOVE 311.76
Procedure Code: L5694 ABOVE KNEE, PELVIC CONTROL 129.73
Procedure Code: L5696 ABOVE KNEE OR KNEE DISARTI 140.88
Procedure Code: L5697 ABOVE KNEE OR KNEE DISARTI 66.92
Procedure Code: L5705 REPLACEMENT CUSTOM SHAPE, 824.66
Procedure Code: L5920 ABOVE KNEE OR HIP DISARTIC 379.40
Procedure Code: L5950 ABOVE KNEE, ULTRA-LIGHT MA 556.33
Procedure Code: L5974 FOOT, SINGLE AXIS ANKLE/FO 166.64
17731 12/03/96 I 6041 KOPISH, JOE E 187.00
Procedure Code: A5500 DIABETICS ONLY, FIT/FOLLOW 155.00
Procedure Code: A5505 DIABETICS ONLY, MODIF (INC 32.00
17740 12/03/96 I 1543 LEE, ROBERT J 1868.00
Procedure Code: L2036 KAFO, FULL PLASTIC, DOUBLE 1338.00
Procedure Code: L1960 AFO, POSTERIOR, SOLID ANKL 530.00
17745 12/03/96 I 3554 TREDER, TRICIA ANN 3723.80
Procedure Code: L5700 REPLACEMENT SOCKET BK, MOL 2200.00
Procedure Code: L5629 BELOW KNEE, ACRYLIC SOCKET 241.00
Procedure Code: L5637 BELOW KNEE, TOTAL CONTACT 289.00
Procedure Code: L5655 SOCKET INSERT, BELOW KNEE 259.00
Procedure Code: L5668 BELOW KNEE, MOLDED DISTAL 94.00
Procedure Code: L5785 EXOSKELETAL SYSTEM, BELOW 489.00
Procedure Code: L8420 PROSTHETIC SOCK, WOOL, BEL 120.00
Procedure Code: L8470 PROSTHETIC SOCK, SINGLE PL 31.80
17783 12/03/96 I 533 KNAPP, LAURA W 100.00
Procedure Code: L4210 REPAIR OF ORTHOTIC DEVICE, 100.00
17794 12/03/96 I 6436 BELL, RICHARD 625.00
Procedure Code: L1960 AFO, POSTERIOR, SOLID ANKL 530.00
Procedure Code: L2830 ADDITION TO LOWER EXTREMIT 95.00
Order/Invoice Input Summary For 12/03/1996 - 12/03/1996 PG:2
Type Total Initial
Invoice# Inv.Date Patient Amount Non-Allow
------- -------- - --------------------------------------- ----------
17795 12/03/96 I 6415 WHITISH, JUSTIN 95.18
Procedure Code: L0500 LUMBAR-SACRAL-ORTHOSIS,(LS 95.18
17796 12/03/96 I 6453 HEISER, NICOLE 530.00
Procedure Code: L1960 AFO, POSTERIOR, SOLID ANKL 530.00
17798 12/03/96 I 370 MARQUARDT, STEVEN 1168.00
Procedure Code: L1685 HO, ABDUCTION CONTROL OF H 1168.00
17805 12/03/96 I 2424 DENNER, CONRAD D 755.00
Procedure Code: L1970 AFO, PLASTIC, MOLDED TO PA 647.00
Procedure Code: L2200 ADDITION TO LOWER EXTREMIT 108.00
17830 12/03/96 I 6392 WILLIAMS, JAMES J. 74.00
Procedure Code: L4210 REPAIR OF ORTHOTIC DEVICE, 74.00
17834 12/03/96 I 5361 SCHROUD, BURNELL D 530.00
Procedure Code: L7500 REPAIR OF PROSTHETIC DEVIC 450.00
Procedure Code: L7510 REPAIR OF PROSTHETIC DEVIC 80.00
17840 12/03/96 I 4463 VARELA JR., OSCAR J 49.00
Procedure Code: L3999 UNLISTED PROCEDURES FOR UP 46.45
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TOTAL: 22687.19