Medicaid Fee Schedule without Mods 200801
Medicaid Fee Schedule without Mods 200801
Medicaid Fee Schedule without Mods 200801
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PROC-CODE DESC MAC BEG END<br />
L0486<br />
TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITH<br />
INTERFACE LINER, MUL $1,129.24 20060701 99999999<br />
L0488<br />
TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH<br />
INTERFACE LINER, MUL $473.25 20060701 99999999<br />
L0490<br />
TLSO, SAGITTAL-CORONAL CONTROL, ONE PIECE RIGID PLASTIC<br />
SHELL, WITH OVERLAPPING $133.37 20060701 99999999<br />
L0491<br />
TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL<br />
SYSTEM, TWO RIGID PLAST $362.08 20060701 99999999<br />
L0492<br />
TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL<br />
SYSTEM, THREE RIGID PLA $4.12 20071101 99999999<br />
L0492<br />
TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL<br />
SYSTEM, THREE RIGID PLA $246.75 20060701 99999999<br />
L0500<br />
LUMBAR-SACRAL-ORTHOSIS (LSO), FLEXIBLE, (LUMBO-SACRAL<br />
SURGICAL SUPPORT), $60.41 20030401 99999999<br />
L0510<br />
LSO,FLEXIBLE(LUMBO-SACRAL SURGICAL SUPPORT)CUSTOM<br />
FABRICATED $123.69 20030401 99999999<br />
L0515 LSO,FLEXIBLE,LUMBO-SACRAL SURGICAL SUPPORT ELASTIC TYPE $81.72 20030401 99999999<br />
L0520 LSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,WITH APRON FRONT $255.29 20030401 99999999<br />
L0530 LSO,ANTERIOR-POSTERIOR CONTROL,WITH APRON FRONT $187.60 20030401 99999999<br />
L0540 LSO,LUMBAR FLEXION(WILLIAMS FLEXION TYPE) $267.76 20030401 99999999<br />
L0550<br />
LSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,MOLDED TO PATIENT<br />
MOD $843.03 20030401 99999999<br />
L0560<br />
LSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,MOLDED TO PATIENT<br />
MOD $1,440.34 20030401 99999999<br />
L0561<br />
LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH RIGID OR SEMI-<br />
RIGID POSTERIOR PANE $271.24 20030401 99999999<br />
L0565 LSO,ANTERIOR-POSTERIO-LATERAL CONTROL,CUSTOM FITTED $793.50 20030401 99999999<br />
L0600<br />
SACROILIAC, FLEXIBLE(SACROILIAC SURGICAL SUPPORT),CUSTOM<br />
FIT $77.18 20030401 99999999<br />
L0610<br />
SACROILIAC,FLEXIBLE(SACROILIAC SURGICAL SUPPORT)CUSTOM<br />
FABRI $77.18 20030401 99999999<br />
L0620<br />
SACROILIAC,SEMI-RIGID(GOLDTHWAITE,OSGOOD TYPES)WITH APRON<br />
FR $77.18 20030401 99999999<br />
L0621<br />
SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL<br />
SUPPORT, REDUCES MOTION AB $58.10 20060701 99999999<br />
L0622<br />
SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL<br />
SUPPORT, REDUCES MOTION AB $193.11 20060701 99999999<br />
L0623<br />
SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH<br />
RIGID OR SEMI-RIGID PA $9.68 20071101 99999999<br />
L0624<br />
SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH<br />
RIGID OR SEMI-RIGID PA $32.18 20071101 99999999<br />
L0625<br />
LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMBAR SUPPORT,<br />
POSTERIOR EXTENDS FROM L-1 T $43.27 20060701 99999999<br />
L0626<br />
LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR<br />
PANEL(S), POSTERIOR EXTE $36.75 20060701 99999999<br />
L0627<br />
LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND<br />
POSTERIOR PANELS, POS $193.79 20060701 99999999<br />
L0628<br />
LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL<br />
SUPPORT, POSTERIOR EXTEN $39.55 20060701 99999999<br />
L0629<br />
LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL<br />
SUPPORT, POSTERIOR EXTEN $32.29 20071101 99999999<br />
L0630<br />
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID<br />
POSTERIOR PANEL(S), POSTERI $76.36 20060701 99999999<br />
L0631<br />
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID<br />
ANTERIOR AND POSTERIOR PANE $483.98 20060701 99999999<br />
L0632<br />
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID<br />
ANTERIOR AND POSTERIOR PANE $84.13 20071101 99999999<br />
Hawaii <strong>Medicaid</strong> <strong>Fee</strong> <strong>Schedule</strong> <strong>without</strong> <strong>Mods</strong> 01/2008 50