hcpcs coding: e2622/e2623 adjustable skin...

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ADJUSTER ORDER FORM Patient Reference: PAGE 1 of 6*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

SIZE & STYLE1

ADJUSTER® LOW & ADJUSTER® ORDER FORMHCPCS CODING: E2622/E2623 - ADJUSTABLE SKIN PROTECTION

Adjuster®Adjuster® Low

ADJUSTER® LOWPlease select size in the appropriate fabric chart below. Standard Adjuster® found on page 2.

$455.00 $455.00

DEP

TH

DEP

TH

WIDTH WIDTH

16” 16”

18” 18”19” 19”20” 20”16” 16”17” 17”

20” 20”

19” 19”

18” 18”

17” 17”

COMFORT-TEK™ STRETCH-AIR™

AJ-FL-1620 AJ-FL-1720 AJ-FL-1820 AJ-FL-1920 AJ-FL-2020





AJ-SL-1620 AJ-SL-1720 AJ-SL-1820 AJ-SL-1920 AJ-SL-2020





OR

QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.736.0925

Company Name/ACCT #:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Patient Reference:

For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving to your local drive. Then email or print and fax to Customer Support at [email protected] or 1.406.522.8563.\*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

COMFORT-TEK™FOR FLUID PROTECTION &

AN EASILY CLEANED SURFACE.

STRETCH-AIR™FOR PATIENT COMFORT

& HEAT DISSIPATION.

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QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.736.0925

$455.00

$455.00

$503.00

$503.00

DEP

THD

EPTH

WIDTH

WIDTH

14”

14”

15”

15”

16”

16”

18”

18”

10”

10”

11”

11”

22”

22”

19”

19”

12”

12”

13”

13”

23”

23”

20”

20”

14”

14”

15”

15”

24”

24”

21”

21”

16”

16”

17”

17”

20”

20”

13”

13”

19”

19”

12”

12”

18”

18”

11”

11”

10”

10”

17”

17”

STRETCH-AIR™

COMFORT-TEK™

AJ-F-1520 AJ-F-1620 AJ-F-1720 AJ-F-1820 AJ-F-1920 AJ-F-2020 AJ-F-2120 AJ-F-2220 AJ-F-2320 AJ-F-2420

AJ-F-1519 AJ-F-1619 AJ-F-1719 AJ-F-1819 AJ-F-1919 AJ-F-2019 AJ-F-2119 AJ-F-2219 AJ-F-2319 AJ-F-2419

AJ-F-1418 AJ-F-1518 AJ-F-1618 AJ-F-1718 AJ-F-1818 AJ-F-1918 AJ-F-2018 AJ-F-2118 AJ-F-2218 AJ-F-2318 AJ-F-2418

AJ-F-1317 AJ-F-1417 AJ-F-1517 AJ-F-1617 AJ-F-1717 AJ-F-1817 AJ-F-1917 AJ-F-2017 AJ-F-2117 AJ-F-2217 AJ-F-2317 AJ-F-2417

AJ-F-1216 AJ-F-1316 AJ-F-1416 AJ-F-1516 AJ-F-1616 AJ-F-1716 AJ-F-1816 AJ-F-1916 AJ-F-2016 AJ-F-2116 AJ-F-2216 AJ-F-2316 AJ-F-2416

AJ-F-1015 AJ-F-1115 AJ-F-1215 AJ-F-1315 AJ-F-1415 AJ-F-1515 AJ-F-1615 AJ-F-1715 AJ-F-1815

AJ-F-1014 AJ-F-1114 AJ-F-1214 AJ-F-1314 AJ-F-1414 AJ-F-1514 AJ-F-1614

AJ-F-1013 AJ-F-1113 AJ-F-1213 AJ-F-1313 AJ-F-1413




AJ-S-1520 AJ-S-1620 AJ-S-1720 AJ-S-1820 AJ-S-1920 AJ-S-2020 AJ-S-2120 AJ-S-2220 AJ-S-2320 AJ-S-2420

AJ-S-1519 AJ-S-1619 AJ-S-1719 AJ-S-1819 AJ-S-1919 AJ-S-2019 AJ-S-2119 AJ-S-2219 AJ-S-2319 AJ-S-2419

AJ-S-1418 AJ-S-1518 AJ-S-1618 AJ-S-1718 AJ-S-1818 AJ-S-1918 AJ-S-2018 AJ-S-2118 AJ-S-2218 AJ-S-2318 AJ-S-2418

AJ-S-1317 AJ-S-1417 AJ-S-1517 AJ-S-1617 AJ-S-1717 AJ-S-1817 AJ-S-1917 AJ-S-2017 AJ-S-2117 AJ-S-2217 AJ-S-2317 AJ-S-2417

AJ-S-1216 AJ-S-1316 AJ-S-1416 AJ-S-1516 AJ-S-1616 AJ-S-1716 AJ-S-1816 AJ-S-1916 AJ-S-2016 AJ-S-2116 AJ-S-2216 AJ-S-2316 AJ-S-2416

AJ-S-1015 AJ-S-1115 AJ-S-1215 AJ-S-1315 AJ-S-1415 AJ-S-1515 AJ-S-1615 AJ-S-1715 AJ-S-1815

AJ-S-1014 AJ-S-1114 AJ-S-1214 AJ-S-1314 AJ-S-1414 AJ-S-1514 AJ-S-1614

AJ-S-1013 AJ-S-1113 AJ-S-1213 AJ-S-1313 AJ-S-1413




ADJUSTER®Please select size in the appropriate fabric chart below.

ORCOMFORT-TEK™

FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE.

STRETCH-AIR™FOR PATIENT COMFORT

& HEAT DISSIPATION.

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2 *All accessories are cosmetic changes to the cushion except for options in gray, which are add on items.ADJUSTER® ACCESSORIES

Solid Seat Pan & Hardware Kit(RSSP-N-HARD)

2.5REMOVABLE SOLID SEAT PAN & HARDWARE KITHCPCS Code: E2231 MSRP $387.00

Rigid Insert Not Glued(RGD-INSERT-UNGLUED)

2.6RIGID INSERTHCPCS Code: E0992 MSRP $65.00

The solid seat pan kit includes a slotted aluminum pan and attaching hardware to accommodate 7/8” or 1” tubing. The kit also comes with two different cross bars to accommodate various wheelchair frame types. This will fit both folding and non-folding seat rails. Lateral thigh support hardware can be easily attached.

3/16” Plastic rigidizing board.

2.3

Liner provides extra incontinence protection for the cushion.

One Incontinence Liner (INCON-LINER)

Two Incontinence Liners (INCON-LINER)

2.4

One Extra Stretch Air Outer Cover (X-STRETCH-AIR-CV)

Two Extra Stretch Air Outer Cover (2X-STRETCH-AIR-CV)

One Extra Comfort Tek Outer Cover (X-COMFORT-TEK-CV)

Two Extra Comfort Tek Outer Cover (2X-COMFORT-TEK-CV)

Kwik Strap® (KWIK-STRAP)

2.2KWIK STRAP®MSRP $16.00

Kwik Strap® provides extra security. Kwik Strap® is connected to the bottom of the cushion via hook & loop attachment and wraps around vertical canes to secure the cushion to wheelchair during transfers.

Rear View

2.7

EXTRA VICAIR® AIR CELLSMSRP $43.00 / 50 air cell pack

Pack of 50 Vicair® Air Cells (AIRCELL50)

VICAIR® PELVIC STABILIZER MSRP $118.00

(fits) 16W x 16D -OR- 16W x 18D (PS-1618)

(fits) 18W x 16D -OR- 18W x 18D (PS-1818)

2.1 INCONTINENCE LINERMSRP One = $60.00 - Two = $120.00

EXTRA COVERMSRP One = $62.00 - Two = $124.00

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BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE & PADS3 Please select sizes in the appropriate fabric & style charts below. Contact Customer Support for custom sizes that are not listed below 800.736.0925.

STYLE SIZE LEFT EXTRA LEFT RIGHT EXTRA RIGHT

3.5”L x 4”D BL-LPTSP2Z-3L4D-LH BL-LPTSP2Z-3L4D-LH BL-LPTSP2Z-3L4D-RH BL-LPTSP2Z-3L4D-RH




3.1 PREMIUM PAD SIZE & SHAPEHCPCS Code: E0953 MSRP $62.00

*Length (L) refers to the actual size dimension of the support from top to bottom edge. Depth (D) refers to the actual size dimension from anterior to posterior edge.

• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.1.• Make a fabric selection in 3.2.

COVER OPTIONS MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT

COMFORT-TEK™ $0.00/ea. LPTS-P2-COMFORT-FM LPTS-P2-COMFORT-FM LPTS-P2-COMFORT-FM LPTS-P2-COMFORT-FM

STRETCH-AIR™ $0.00/ea. LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM

GLIDEWEAR® $13.00/ea. LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM

FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.

STRETCH-AIR™FOR PATIENT COMFORT &

HEAT DISSIPATION.

COMFORT-TEK™FOR FLUID PROTECTION & AN

EASILY CLEANED SURFACE.

3.2 PREMIUM PAD COVER WITH FOAM INSERT

L

D

3.3

TT HARDWARE, SLOT MOUNT

A.

BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE

• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.3 from group A, B, -OR- C.

• TT long extention arms (section 3.4) will only work with TT style hardware.

SIZE MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT

FIXE

D

SMALL $141.00 BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-RH BL-LPTS-TT1FXSL1-RH

MEDIUM $141.00 BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-RH BL-LPTS-TT1FXSL2-RH

LARGE $141.00 BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-RH BL-LPTS-TT1FXSL3-RH

REM

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SMALL $248.00 BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-RH BL-LPTS-TT1RMSL1-RH

MEDIUM $248.00 BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-RH BL-LPTS-TT1RMSL2-RH

LARGE $248.00 BL-LPTS-TT1RMSL3-LH BL-LPTS-TT1RMSL3-LH BL-LPTS-TT1RMSL3-RH BL-LPTS-TT1RMSL3-RH

HARDWARE SIZEMAX CUSHION

THICKNESS CLEARANCE

RECOMMENDED CUSHION

THICKNESS

SMALL 3.0” 2.0”- 3.0”

MEDIUM 4.5” 3.0”- 4.5”

LARGE 6.5” 4.0”- 6.5”

TT H

ARD

WAR

E SL

OT

MO

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T- F

IXED

TT H

ARD

WAR

E SL

OT

MO

UN

T-

REM

OVA

BLE

SMALL MEDIUM LARGE

HARDWARE SIZE VS. CUSHION THICKNESS

2.0”- 3.0”

3.0”- 4.5”

4.0”- 6.5”

OR

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TT H

ARD

WAR

E PO

WER

MO

UN

T- F

IXED

TT H

ARD

WAR

E PO

WER

MO

UN

T-

REM

OVA

BLE

SMALL MEDIUM LARGE

HARDWARE SIZE VS. CUSHION THICKNESS

2.0”- 3.5”

3.0”- 5.5”

4.0”- 7.5”

TT HARDWARE, POWER MOUNT B.HARDWARE SIZE

MAX CUSHION THICKNESS CLEARANCE

RECOMMENDED CUSHION

THICKNESS

SMALL 3.5” 2.0”- 3.5”

MEDIUM 5.5” 3.0”- 5.5”

LARGE 7.5” 4.0”- 7.5”

SIZE MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT

FIXE

D

SMALL $185.00 BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-RH BL-LPTS-TT1FXPWL1-RH

MEDIUM $185.00 BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-RH BL-LPTS-TT1FXPWL2-RH

LARGE $185.00 BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-RH BL-LPTS-TT1FXPWL3-RH

REM

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8

SMALL $285.00 BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-RH BL-LPTS-TT1RMPWL1-RH

MEDIUM $285.00 BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-RH BL-LPTS-TT1RMPWL2-RH

LARGE $285.00 BL-LPTS-TT1RMPWL3-LH BL-LPTS-TT1RMPWL3-LH BL-LPTS-TT1RMPWL3-RH BL-LPTS-TT1RMPWL3-RH

NOTE: If choosing the Power Mount Hardware, choose the appropriate power mount type below.

POWER MOUNT MSRP PART NUMBER

QUANTUM add $0.00 LPTS-TT1-PW1

PERMOBIL add $0.00 LPTS-TT1-PW2

QUICKIE add $0.00 LPTS-TT1-PW3

ROVI add $0.00 LPTS-TT1-PW4

AVID REHAB add $0.00 LPTS-TT1-PW5

TT HARDWARE, POWER MOUNT OPTION

OR

BODILINK® MEDIAL KNEE/THIGH SUPPORT HARDWARE & PADS4

STYLE SIZE PART NUMBER

2.5”W x 3.5”D BL-MKTSP1-3W4D

3.5”W x 5”D BL-MKTSP1-4W5D

4”W x 6”D BL-MKTSP1-4W6D

2.5”W x 3.5”D BL-MKTSP2-3W4D

3.5”W x 5”D BL-MKTSP2-4W5D

5”W x 6”D BL-MKTSP2-5W6D

COMFORT-TEK FOR FLUID PROTECTION & AN EASILY CLEANED

SURFACE.

FOR PATIENT COMFORT& HEAT DISSIPATION.

STRETCH-AIR

FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.

4.2 PAD COVER MATERIAL

GlideWear® (MKTSP-GLIDE) (add $15.00)

Comfort-Tek (MKTSP-COMFORT)

Stretch-Air (MKTSP-STRETCH)

PAD SIZE & SHAPE HCPCS CODING: E0957 MSRP $130.00

4.1

• You may make one selection per column.• Choose between wedge or oval in 4.1.• Choose a cover material in 4.2. • Choose hardware size in 4.3.

D

W

WEDGE

OVAL

W

LEFT EXTRA LEFT RIGHT EXTRA RIGHT

BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4

3.4 TT LONG EXTENSION ARM 4” MSRP $37.00/arm

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4.3MEDIAL KNEE/THIGH SUPPORT SWING AWAY HARDWAREHCPCS CODING: E1028 MSRP $180.00

SIZE RECOMMENDED INFERIOR THIGH THICKNESSSmall 1.00”- 3.00”

Medium 2.00”- 5.00”

Large 3.00”- 7.00”

SIZE PART NUMBER

SMALL BL-MKTS-ST1SASL1

MEDIUM BL-MKTS-ST1SASL2

LARGE BL-MKTS-ST1SASL3SMALL MEDIUM LARGE

*Swing Away Hardware only, not available in Fixed Hardware**MKTS Hardware must be mounted to Removable Solid Seat

Pan in section 2.4***If Leg Length Discrepancy is needed on Removable Solid

Seat Pan, Offset Orientation must be selected

Inferior Thigh Thickness

SUBMIT BY EMAIL

Patient Reference 4: Page 1: Page 3: Page 5: Page 6:

Company Name/ACCT # 2: P: O: Number 2:

Requested By 2: Phone 2: Fax 2: Email 2: Ship To 2: Patient Reference 2: Check Box 1822: OffCheck Box 1823: OffCheck Box 1824: OffCheck Box 1825: OffCheck Box 1826: OffCheck Box 1827: OffCheck Box 1828: OffCheck Box 1829: OffCheck Box 1830: OffCheck Box 1831: OffCheck Box 1832: OffCheck Box 1833: OffCheck Box 1834: OffCheck Box 1835: OffCheck Box 1836: OffCheck Box 1837: OffCheck Box 1838: OffCheck Box 1839: OffCheck Box 1840: OffCheck Box 1841: OffCheck Box 1842: OffCheck Box 1843: OffCheck Box 1844: OffCheck Box 1845: OffCheck Box 1846: OffCheck Box 1847: OffCheck Box 1848: OffCheck Box 1849: OffCheck Box 1850: OffCheck Box 1851: OffCheck Box 1852: OffCheck Box 1853: OffCheck Box 1854: OffCheck Box 1855: OffCheck Box 1856: OffCheck Box 1857: OffCheck Box 1858: OffCheck Box 1859: OffCheck Box 1860: OffCheck Box 1861: OffCheck Box 1862: OffCheck Box 1863: OffCheck Box 1864: OffCheck Box 1865: OffCheck Box 1866: OffCheck Box 1867: OffCheck Box 1868: OffCheck Box 1869: OffCheck Box 1870: OffCheck Box 1871: OffPatient Reference 6: Check Box 1872: OffCheck Box 1873: OffCheck Box 1874: OffCheck Box 1875: OffCheck Box 1876: OffCheck Box 1877: OffCheck Box 1878: OffCheck Box 1879: OffCheck Box 1880: OffCheck Box 1881: OffCheck Box 1882: OffCheck Box 1883: OffCheck Box 1884: OffCheck Box 1885: OffCheck Box 1886: OffCheck Box 1887: OffCheck Box 1888: OffCheck Box 1889: OffCheck Box 1890: OffCheck Box 1891: OffCheck Box 1892: OffCheck Box 1893: OffCheck Box 1894: OffCheck Box 1895: OffCheck Box 1896: OffCheck Box 1897: OffCheck Box 1898: OffCheck Box 1899: OffCheck Box 1900: OffCheck Box 1901: OffCheck Box 1902: OffCheck Box 1903: OffCheck Box 1904: OffCheck Box 1905: OffCheck Box 1906: OffCheck Box 1907: OffCheck Box 1908: OffCheck Box 1909: OffCheck Box 19010: OffCheck Box 19011: OffCheck Box 19012: OffCheck Box 19013: OffCheck Box 19014: OffCheck Box 19015: OffCheck Box 19016: OffCheck Box 19017: OffCheck Box 19018: OffCheck Box 19019: OffCheck Box 19020: OffCheck Box 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(EXTRA LEFT) 3: OffBL-LPTSP1Z-3L4D-RH 3: OffBL-LPTSP1Z-3L4D-RH (EXTRA RIGHT) 3: OffBL-LPTSP1Z-3L5D-LH 3: OffBL-LPTSP1Z-3L5D-LH (EXTRA LEFT) 3: OffBL-LPTSP1Z-3L5D-RH 3: OffBL-LPTSP1Z-3L5D-RH (EXTRA RIGHT) 3: OffBL-LPTSP1Z-4L4D-LH 3: OffBL-LPTSP1Z-4L4D-LH (EXTRA LEFT) 3: OffBL-LPTSP1Z-4L4D-RH 3: OffBL-LPTSP1Z-4L4D-RH (EXTRA RIGHT) 3: OffBL-LPTSP1Z-4L6D-LH 3: OffBL-LPTSP1Z-4L6D-LH (EXTRA LEFT) 3: OffBL-LPTSP1Z-4L6D-RH 3: OffBL-LPTSP1Z-4L6D-RH (EXTRA RIGHT) 3: OffLPTS-P1-COMFORT (LEFT) 4: OffLPTS-P1-COMFORT (EXTRA LEFT) 4: OffLPTS-P1-COMFORT (RIGHT) 4: OffLPTS-P1-COMFORT (EXTRA RIGHT) 4: OffLPTS-P1-STRETCH (LEFT) 4: OffLPTS-P1-STRETCH (EXTRA LEFT) 4: OffLPTS-P1-STRETCH (RIGHT) 4: OffLPTS-P1-STRETCH (EXTRA RIGHT) 4: OffLPTS-P1-GLIDE (LEFT) 4: OffLPTS-P1-GLIDE (EXTRA LEFT) 4: OffLPTS-P1-GLIDE (RIGHT) 4: OffLPTS-P1-GLIDE (EXTRA RIGHT) 4: OffBL-LPTS-TT1FXSL1-LH 2: OffBL-LPTS-TT1FXSL1-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1FXSL1-RH 2: OffBL-LPTS-TT1FXSL1-RH (EXTRA RIGHT) 2: OffBL-LPTS-TT1FXSL2-LH 2: OffBL-LPTS-TT1FXSL2-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1FXSL2-RH 2: OffBL-LPTS-TT1FXSL2-RH (EXTRA RIGHT) 2: OffBL-LPTS-TT1FXSL3-LH 2: OffBL-LPTS-TT1FXSL3-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1FXSL3-RH 2: OffBL-LPTS-TT1FXSL3-RH (EXTRA RIGHT) 2: OffBL-LPTS-TT1RMSL1-LH 2: OffBL-LPTS-TT1RMSL1-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1RMSL1-RH 2: OffBL-LPTS-TT1RMSL1-RH (EXTRA RIGHT) 2: OffBL-LPTS-TT1RMSL2-LH 2: OffBL-LPTS-TT1RMSL2-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1RMSL2-RH 2: OffBL-LPTS-TT1RMSL2-RH (EXTRA RIGHT) 2: OffBL-LPTS-TT1RMSL3-LH 2: OffBL-LPTS-TT1RMSL3-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1RMSL3-RH 2: OffBL-LPTS-TT1RMSL3-RH (EXTRA RIGHT) 2: OffBL-LPTS-TT1FXPWL1-LH 2: OffBL-LPTS-TT1FXPWL1-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1FXPWL1-RH 2: OffBL-LPTS-TT1FXPWL1-RH (EXTRA RIGHT) 2: OffBL-LPTS-TT1FXPWL2-LH 2: OffBL-LPTS-TT1FXPWL2-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1FXPWL2-RH 2: OffBL-LPTS-TT1FXPWL2-RH (EXTRA RIGHT) 2: OffBL-LPTS-TT1FXPWL3-LH 2: OffBL-LPTS-TT1FXPWL3-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1FXPWL3-RH 2: OffBL-LPTS-TT1FXPWL3-RH (EXTRA RIGHT) 2: OffBL-LPTS-TT1RMPWL1-LH 2: OffBL-LPTS-TT1RMPWL1-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1RMPWL1-RH 2: OffBL-LPTS-TT1RMPWL1-RH (EXTRA RIGHT) 2: OffBL-LPTS-TT1RMPWL2-LH 2: OffBL-LPTS-TT1RMPWL2-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1RMPWL2-RH 2: OffBL-LPTS-TT1RMPWL2-RH (EXTRA RIGHT) 2: OffBL-LPTS-TT1RMPWL3-LH 2: OffBL-LPTS-TT1RMPWL3-LH (EXTRA LEFT) 2: OffBL-LPTS-TT1RMPWL3-RH 2: OffBL-LPTS-TT1RMPWL3-RH (EXTRA RIGHT) 2: OffLPTS-TT1-PW2: OffLPTS-TT1-PW3: OffLPTS-TT1-PW4: OffLPTS-TT1-PW5: OffLPTS-TT1-PW6: OffGLIDEWEAR 2: OffCOMFORT-TEK 2: OffSTRETCH-AIR 2: OffBL-HSP2-6W3L 2: OffBL-HSP1-8W4L 2: OffBL-HSP2-6W3L 3: OffBL-HSP2-6W3L 4: OffBL-HSP1-8W4L 3: OffBL-HSP2-6W3L 5: OffBL-LPTS-TT1LARM4 (LEFT) 2: OffBL-LPTS-TT1LARM4 (EXTRA LEFT) 2: OffBL-LPTS-TT1LARM4 (RIGHT) 2: OffBL-LPTS-TT1LARM4 (EXTRA RIGHT) 2: OffBL-HSP2-6W3L 6: OffBL-HSP1-8W4L 4: OffBL-HSP2-6W3L 7: OffSubmit 11:

hcpcs coding: e2622/e2623 adjustable skin...

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