Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END L0486 TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER, MUL $1,129.24 20060701 99999999 L0488 TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER, MUL $473.25 20060701 99999999 L0490 TLSO, SAGITTAL-CORONAL CONTROL, ONE PIECE RIGID PLASTIC SHELL, WITH OVERLAPPING $133.37 20060701 99999999 L0491 TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLAST $362.08 20060701 99999999 L0492 TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PLA $4.12 20071101 99999999 L0492 TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PLA $246.75 20060701 99999999 L0500 LUMBAR-SACRAL-ORTHOSIS (LSO), FLEXIBLE, (LUMBO-SACRAL SURGICAL SUPPORT), $60.41 20030401 99999999 L0510 LSO,FLEXIBLE(LUMBO-SACRAL SURGICAL SUPPORT)CUSTOM FABRICATED $123.69 20030401 99999999 L0515 LSO,FLEXIBLE,LUMBO-SACRAL SURGICAL SUPPORT ELASTIC TYPE $81.72 20030401 99999999 L0520 LSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,WITH APRON FRONT $255.29 20030401 99999999 L0530 LSO,ANTERIOR-POSTERIOR CONTROL,WITH APRON FRONT $187.60 20030401 99999999 L0540 LSO,LUMBAR FLEXION(WILLIAMS FLEXION TYPE) $267.76 20030401 99999999 L0550 LSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,MOLDED TO PATIENT MOD $843.03 20030401 99999999 L0560 LSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,MOLDED TO PATIENT MOD $1,440.34 20030401 99999999 L0561 LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH RIGID OR SEMI- RIGID POSTERIOR PANE $271.24 20030401 99999999 L0565 LSO,ANTERIOR-POSTERIO-LATERAL CONTROL,CUSTOM FITTED $793.50 20030401 99999999 L0600 SACROILIAC, FLEXIBLE(SACROILIAC SURGICAL SUPPORT),CUSTOM FIT $77.18 20030401 99999999 L0610 SACROILIAC,FLEXIBLE(SACROILIAC SURGICAL SUPPORT)CUSTOM FABRI $77.18 20030401 99999999 L0620 SACROILIAC,SEMI-RIGID(GOLDTHWAITE,OSGOOD TYPES)WITH APRON FR $77.18 20030401 99999999 L0621 SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION AB $58.10 20060701 99999999 L0622 SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION AB $193.11 20060701 99999999 L0623 SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID PA $9.68 20071101 99999999 L0624 SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID PA $32.18 20071101 99999999 L0625 LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMBAR SUPPORT, POSTERIOR EXTENDS FROM L-1 T $43.27 20060701 99999999 L0626 LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOR EXTE $36.75 20060701 99999999 L0627 LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POS $193.79 20060701 99999999 L0628 LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR EXTEN $39.55 20060701 99999999 L0629 LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR EXTEN $32.29 20071101 99999999 L0630 LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERI $76.36 20060701 99999999 L0631 LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANE $483.98 20060701 99999999 L0632 LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANE $84.13 20071101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 50
PROC-CODE DESC MAC BEG END L0633 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PAN $135.19 20060701 99999999 L0634 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PAN $21.15 20071101 99999999 L0635 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGID POSTERIO $844.18 20060701 99999999 L0636 LUMBAR SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGID POSTERIO $1,070.07 20060701 99999999 L0637 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTER $624.97 20060701 99999999 L0638 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTER $621.81 20060701 99999999 L0639 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S), POSTE $624.97 20060701 99999999 L0640 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S), POSTE $493.33 20060701 99999999 L0700 CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSES(CTLSO),MOLDED TO PT $1,343.75 20060701 99999999 L0710 CTLSO,ANTERIOR-POSTERIOR-LATERAL-CONTROL,MOLDED TO PATIENT $1,374.77 20060701 99999999 L0810 HALO PROCEDURE,CERVICAL HALO INCORPORATED INTO JACKET VEST $1,849.84 20060701 99999999 L0820 HALO PROCEDURE,CERVICAL HALO INCORPORATIED INTO PLASTER BODY $1,280.28 20060701 99999999 L0830 HALO PROCEDURE,CERVICAL HALO INCORPORATED INTO MILWAUKEE TYP $2,737.33 20060701 99999999 L0859 ADDITION TO HALO PROCEDURE, MAGNETIC RESONANCE IMAGE COMPATIBLE SYSTEMS, RINGS A $528.06 20060701 99999999 L0860 ADDITION TO HALO PROCEDURES,MAGNETIC REASONANCE IMAGE CAMPAT $805.04 20030401 99999999 L0861 ADDITION TO HALO PROCEDURE, REPLACEMENT LINER/INTERFACE MATERIAL $101.62 20060701 99999999 L0900 TORSO SUPPORT,PTOSIS SUPPORT,CUSTOM FITTED $148.53 20030401 99999999 L0910 TORSO SUPPORT,PTOSIS SUPPORT,CUSTOM FABRICATED $148.53 20030401 99999999 L0920 TORSO SUPPORT,PENDULOUS ABDOMEN SUPPORT,CUSTOM FITTED $137.69 19990701 99999999 L0930 TORSO SUPPORT,PENDULOUS ABDOMEN SUPPORT,CUSTOM FABRICATED $148.53 20030401 99999999 L0940 TORSO SUPPORT,POST SURGICAL SUPPORT,CUSTOM FITTED $100.93 20030401 99999999 L0950 TORSO SUPPORT,POST SURGICAL SUPPORT,CUSTOM FABRICATED $100.93 20030401 99999999 L0960 TORSO SUPPORT,POST SURGICAL SUPPORT,PADS FOR POST SURGICAL $5.01 20071101 99999999 L0970 TLSO,CORSET FRONT $87.05 20060701 99999999 L0972 LSO,CORSET FRONT $77.89 20060701 99999999 L0974 TLSO,FULL CORSET $112.25 20060701 99999999 L0976 LSO,FULL CORSET $76.73 20060701 99999999 L0978 AXILLARY CRUTCH EXTENSION $272.30 20060701 99999999 L0980 PERONEAL STRAPS,PAIR $6.74 20060701 99999999 L0982 STOCKING SUPPORTER GRIPS,SET OF FOUR (4) $8.15 20060701 99999999 L0984 PROTECTIVE BODY SOCK, EACH $35.49 20060701 99999999 L0986 ADDITION TO SPINAL ORTHOSIS, RIGID OR SEMI-RIGID ABDOMINAL PANEL, PREFABRICATED $109.12 20030401 99999999 L1000 CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS(CILSO)INCLUSIVE $1,596.75 20060701 99999999 L1001 CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS, IMMOBILIZER, INFANT SIZE, PREFABRICATE $60.00 20071101 99999999 L1005 TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS, INCLUDES FITTING AND ADJUST $1,508.96 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 51
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Medicaid Fee Schedule without Mods 200801

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