Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END K0858 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK $703.76 20071101 99999999 K0859 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIE $671.17 20071101 99999999 K0860 POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT $1,005.41 20071101 99999999 K0861 POWER WHEELCHAIR, GROUP 3 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK $568.14 20071101 99999999 K0862 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BA $703.76 20071101 99999999 K0863 POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SE $973.41 20161115 99999999 K0863 POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SE $1,005.41 20071101 99999999 K0864 POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID S $1,196.45 20071101 99999999 K0899 POWER MOBILITY DEVICE, NOT CODED BY SADMERC OR DOES NOT MEET CRITERIA $50.00 20071101 99999999 L0100 CERVICAL,CRANIOSTENOSIS,HELMET MOLDED TO PATIENT MODEL $53.45 20030401 99999999 L0110 CERVICAL,CRANIOSTENOSIS,HELMET,NON-MOLDED $96.70 20030401 99999999 L0112 CRANIAL CERVICAL ORTHOSIS, CONGENITAL TORTICOLLIS TYPE, WITH OR WITHOUT SOFT INT $659.86 20060701 99999999 L0120 CERVICAL,FLEXIBLE,NON-ADJUSTABLE (FOAM COLLAR) $23.71 20060701 99999999 L0130 CERVICAL,FLEXIBLE,THERMOPLASTIC COLLAR,MOLDED TO PATIENT $123.49 20060701 99999999 L0140 CERVICAL,SEMI-RIGID,ADJUSTABLE (PLASTIC COLLAR) $26.99 20060701 99999999 L0150 CERVICAL,SEMI-RIGID,ADJUSTABLE MOLDED CHIN CUP,(PLASTIC COL) $67.92 20060701 99999999 L0160 CERVICAL,SEMI-RIGID,WIRE FRAME OCCIPITAL/MANDIBULAR SUPPORT $85.95 20060701 99999999 L0170 CERVICAL,COLLAR,MOLDED TO PATIENT MODEL $412.90 20060701 99999999 L0172 CERVICAL,COLLAR,SEMI-RIGID THERMOPLASTIC FOAM,TWO PIECE $78.38 20060701 99999999 L0174 CERVICAL,COLLAR,SEMI-RIGID,THERMOPLASTIC FOAM,TWO PIECE WITH $211.18 20060701 99999999 L0180 CERVICAL,MULTIPLE POST COLLAR,OCCIPITAL/MANDIBULAR SUPPORT $230.90 20060701 99999999 L0190 CERVICAL,MULTIPLE POST COLLAR,OCCIPITAL/MANDIBULAR SUPPORT $346.13 20060701 99999999 L0200 CERVICAL,MULTIPLE POST COLLAR,OCCIPITAL/MANDIBULAR SUPPORTS $403.40 20060701 99999999 L0210 THORACIC,RIB BELT,CUSTOM FITTED $24.10 20060701 99999999 L0220 THORACIC,RIB BELT,CUSTOM FABRICATED $39.80 20060701 99999999 L0300 THORACIC-LUMBAR-SACRAL-ORTHOSIS(TLSO),FLEXIBLE,CUSTOM FITTED $147.23 20030401 99999999 L0310 TLSO,FLEXIBLE,(DORSO-LUMBAR SURGICAL SUPPORT)CUSTOM FABRICAT $123.91 20030401 99999999 L0315 TLSO,FLEXIBLE DORSO-LUMBAR SURGICAL SUPPORT,ELASTIC TYPE $180.00 20030401 99999999 L0317 TLSO,FLEXIBLE DORSO-LUMBAR SURGICAL SUPPORT,HYPEREXTENSION $223.70 20030401 99999999 L0320 TLSO,ANTERIOR-POSTERIOR CONTROL(TAYLOR TYPE)WITH APRON FRONT $267.17 20030401 99999999 L0321 TLSO, ANTERIOR-POSTERIOR CONTROL, WITH RIGID OR SEMI-RIGID POSTERIOR PANEL, PREF $330.52 20030401 99999999 L0330 TLSO,ANTERIOR-POSTERIOR-LATER CONTROL,WITH APRON FRONT $326.53 20030401 99999999 L0331 TLSO, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH RIGID OR SEMI-RIGID POSTERIOR PAN $385.34 20030401 99999999 L0340 TLSO,ANTERIOR-POSTERIOR-LATERAL-ROTARY CONTROL,WITH APRON FR $489.20 20030401 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 48
PROC-CODE DESC MAC BEG END L0350 TLSO,ANTERIOR-POSTERIOR-LATERAL-ROTARY CONTROL,FLEXION $534.33 20030401 99999999 L0360 TLSO,ANTERIOR-POSTERIOR-LATERAL-ROTARY CONTROL,FLEXION COMPR $534.33 20030401 99999999 L0370 TLSO,ANTERIOR-POSTERIOR-LATERAL-ROTARY CONTROL,HYPEREXTEN $278.62 20030401 99999999 L0380 TLSO,ANTERIOR-POSTERIOR-LATERALL-ROTARY CONTROL,WITH EXTEN $578.16 20030401 99999999 L0390 TLSO, ANTERIOR-POSTERIOR-LATERAL CONTROL (BODY JACKET) $843.03 20030401 99999999 L0391 TLSO, ANTERIOR-POSTERIOR-LATERAL-ROTARY CONTROL, WITH RIGID OR SEMI-RIGID POSTER $502.28 20030401 99999999 L0400 TLSO,ANTERIOR-POSTERIOR-LATERAL CONTROL MOLDED TO PATIENT $843.03 20030401 99999999 L0410 TLSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,TWO-PIECE CONSTRUCT $1,369.62 20030401 99999999 L0420 TLSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,WITH INTERFACE MATER $1,538.01 20030401 99999999 L0430 SPINAL ORTHOSIS, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH INTERFACE MATERIAL, $795.99 20060701 99999999 L0440 TLSO,ANTERIOR-POSTERIOR-LATERAL CONTROL (BODY JACKET) $1,028.61 20030401 99999999 L0450 TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES INTRACAV $118.75 20060701 99999999 L0452 TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES INTRACAV $39.00 20071101 99999999 L0454 TLSO FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM SACROCOCCYGEAL JUNCTION TO A $163.51 20060701 99999999 L0456 TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC REGION, RIGID POSTERIOR PANEL A $468.91 20060701 99999999 L0458 TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC SHEL $420.46 20060701 99999999 L0460 TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC SHEL $473.25 20060701 99999999 L0462 TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PLASTIC SH $588.65 20060701 99999999 L0464 TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, FOUR RIGID PLASTIC SHE $700.78 20060701 99999999 L0466 TLSO, SAGITTAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON W $245.42 20060701 99999999 L0468 TLSO, SAGITTAL-CORONAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR $280.16 20060701 99999999 L0470 TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON $528.08 20060701 99999999 L0472 TLSO, TRIPLANAR CONTROL, HYPEREXTENSION, RIGID ANTERIOR AND LATERAL FRAME EXTEND $280.28 20060701 99999999 L0474 TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR FRAME WITH FLEXIBLE SOFT APRON ANTERIOR $682.30 20030401 99999999 L0476 TLSO, SAGITTAL-CORONAL CONTROL, FLEXION COMPRESSION JACKET, TWO RIGID PLASTIC SH $1,406.97 20030401 99999999 L0478 TLSO, SAGITTAL-CORONAL CONTROL, FLEXION COMPRESSION JACKET, TWO RIGID PLASTIC SH $1,783.45 20030401 99999999 L0480 TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE LINER, $792.06 20060701 99999999 L0482 TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER, MUL $145.78 20071101 99999999 L0482 TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER, MUL $874.73 20060701 99999999 L0484 TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE LINER, $1,002.92 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 49
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