Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END L1010 ADDITION TO CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS(CTLSO) $35.43 20060701 99999999 L1020 ADDDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,KYPHOSIS PAD $72.56 20060701 99999999 L1025 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,KYPHOSIS PAD,FLOATIN $73.64 20060701 99999999 L1030 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,LUMBAR BOLSTER PAD $32.44 20060701 99999999 L1040 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,LUMBAR OR LUMBAR RIB $65.25 20060701 99999999 L1050 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,STERNAL PAD $55.76 20060701 99999999 L1060 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,THORACIC PAD $67.19 20060701 99999999 L1070 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,TRAPEZIUS SLING $56.99 20060701 99999999 L1080 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,OUTRIGGER $32.44 20060701 99999999 L1085 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,OUTRIGGER,BILATERAL $118.79 20060701 99999999 L1090 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,LUMBAR SLING $65.95 20060701 99999999 L1100 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,RING FLANGE,PLASTIC $105.14 20060701 99999999 L1110 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,RING FLANGE,PLASTIC $205.91 20060701 99999999 L1120 ADDITION TO CTLSO,SCOLIOSIS ORTHOSIS,COVER FOR UPRIGHT,EACH $45.01 20060701 99999999 L1200 THORACIC-LUMBAR-SACRAL ORTHOSIS(TLSO),INCLUSIVE OR FURNISHIN $1,347.53 20060701 99999999 L1210 ADDITION TO TLSO,(LOW PROFILE),LATERAL THORACIC EXTENSION $187.31 20060701 99999999 L1220 ADDITION TO TLSO,(LOW PROFILE),ANTERIOR THORACIC EXTENSION $163.24 20060701 99999999 L1230 ADDITION TO TLSO,(LOW PROFILE)MILWAUKEE TYPE SUPERSTRUCTURE $276.65 20060701 99999999 L1240 ADDITION TO TLSO,,(LOW PROFILE),LUMBAR DEROTATION PAD $58.18 20060701 99999999 L1250 ADDITION TO TLSO,(LOW PROFILE),ANTERIOR ASIS PAD $43.94 20060701 99999999 L1260 ADDITION TO TLSO,(LOW PROFILE),ANTERIOR THORACIC DEROTATION $48.45 20060701 99999999 L1270 ADDITION TO TLSO,(LOW PROFILE),ABDOMINAL PAD $65.37 20060701 99999999 L1280 ADDITION TO TLSO,(LOW PROFILE),RIB GUSSET(ELASTIC)EACH $65.66 20060701 99999999 L1290 ADDITION TO TLSO,(LOW PROFILE),LATERAL TROCHANTERIC PAD $91.99 20060701 99999999 L1300 OTHER SCOLIOSIS PROCEDURE,BODY JACKET MOLDED TO PATIENT MODE $1,184.61 20060701 99999999 L1310 OTHER SCOLIOSIS PROCEDURE, POST-OPERATIVE BODY JACKET $1,034.44 20060701 99999999 L1499 UNLISTED PROCEDURE FOR SPINAL ORTHOSIS $39.00 20030401 99999999 L1500 THORACIC-HIP-KNEE-ANKLE ORTHOSIS(THKAO),MOBILITY FRAME $1,416.27 20060701 99999999 L1510 THKAO,STANDING FRAME $888.72 20060701 99999999 L1520 THKAO,SWIVEL WALKER $1,900.93 20060701 99999999 L1600 HIP ORTHOSIS (HO),ABDUCTION CONTROL OF HIP JOINTS,FLEXIBLE $79.47 20060701 99999999 L1610 HO,ABDUCTION CONTROL OF HIP JOINTS,FLEXIBLE,FREJKA COVER ONL $29.65 20060701 99999999 L1620 HO,ABDUCTION CONTROL OF HIP JOINTS,FLEXIBLE,PAVLIK HARNESS $80.81 20060701 99999999 L1630 HO,ABDUCTION CONTROL OF HIP JOINTS,SEMI-FLEXIBLE(VON ROSEN) $89.57 20060701 99999999 L1640 HO,ABDUCTION CONTROL OF HIP JOINTS,STATIC,PELVIC BAND $192.89 20060701 99999999 L1650 HO,ABDUCTION CONTROL OF HIP JOINTS,STATIC,ADJUSTABLE,CUSTOM $126.12 20060701 99999999 L1652 HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH ADJUSTABLE ABDUCTOR SPREADER BAR, ADULT $168.06 20060701 99999999 L1660 HO,ABDUCTION CONTROL OF HIP JOINTS,STATIC,PLASTIC,CUSTOM FIT $76.55 20060701 99999999 L1680 HO,ABDUCTION CONTROL OF HIP JOINTS,DYNAMIC,PELVIC CONTROL $1,263.81 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 52
PROC-CODE DESC MAC BEG END L1685 HO,ABDUCTION CONTROL OF HIP JOINT,POST-OPERATIVE HIP ABDUCT $1,077.14 20060701 99999999 L1686 HO,ABDUCTION CONTROL OF HIP JOINT,POST OPERATIVE HIP,CUSTOM $680.29 20060701 99999999 L1690 COMBINATION, BILATERAL, LUMBO-SACRAL, HIP, FEMUR ORTHOSIS PROVIDING ADDUCTION AN $911.67 20060701 99999999 L1700 LEGG PERTHES ORTHOSIS,TORONTO TYPE $1,317.41 20060701 99999999 L1710 LEGG PERTHES ORTHOSIS,NEWINGTON TYPE $1,458.77 20060701 99999999 L1720 LEGG PERTHES ORTHOSIS,TRILATERAL,(TACHDIJAN TYPE) $1,284.26 20060701 99999999 L1730 LEGG PERTHES ORTHOSIS,SCOTTISH RITE TYPE $947.32 20060701 99999999 L1750 LEGG PERTHES ORTHOSIS,LEGG PERTHES SLING (SAM BROWN TYPE) $97.38 20030401 99999999 L1755 LEGG PERTHES ORTHOSIS,PATTEN BOTTOM TYPE $1,029.45 20060701 99999999 L1800 KNEE ORTHOSIS (KO), ELASTIC WITH STAYS $39.83 20060701 99999999 L1810 KO,ELASTIC WITH JOINTS $65.53 20060701 99999999 L1815 KO,ELASTIC WITH CONDYLAR PADS $56.37 20060701 99999999 L1820 KO,ELASTIC WITH CONDYLAR PADS AND JOINTS $76.34 20060701 99999999 L1825 KO,ELASTIC KNEE CAP $22.77 20060701 99999999 L1830 KO, IMMOBILIZER, CANVAS LONGITUDINAL $87.51 20060701 99999999 L1831 KNEE ORTHOSIS, LOCKING KNEE JOINT(S), POSITIONAL ORTHOSIS, PREFABRICATED, INCLUD $138.76 20060701 99999999 L1832 KO,ADJUSTABLE KNEE JOINTS,POSITIONAL ORTHOSIS,RIGID SUPPORT $342.56 20060701 99999999 L1834 KO,WITHOUT KNEE JOINT,RIGID,MOLDED TO PATIENT MODEL $483.72 20060701 99999999 L1836 KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), INCLUDES SOFT INTERFACE MATERIAL, PREFAB $62.90 20060701 99999999 L1840 KO, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, CUSTOM FABRICATED $631.28 20060701 99999999 L1843 KO, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT, $42.63 20071101 99999999 L1844 KO, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT, $849.37 20060701 99999999 L1845 KO/DBL UPRIGHT,THIGH & CALF,W/ADJ FLEX& EXT JNT,MEDIAL-LATER $403.56 20060701 99999999 L1846 KO,DBL UPRIGHT,THIGH&CALF,W/ADJ FLEXION&EXT JNT,MEDIAL- LATER $744.02 20060701 99999999 L1847 KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH INFLATABLE AIR SUPPORT $271.16 20060701 99999999 L1850 KO/SWEDISH TYPE $222.29 20060701 99999999 L1855 KO/MOLDED PLASTIC,THIGH & CALF SECT,W/DBL UPRIGHT KNEE JNT $98.47 20071101 99999999 L1858 KO,MOLDED PLASTIC,POLYCENTRIC KNEE JNT,PNEUMATIC KNEE PADS $8.98 20071101 99999999 L1860 KO,MODIFICATION OF SUPRACONDYLAR PROSTH SOCKET,MOLDED TO PAT $780.56 20060701 99999999 L1870 KO,DBL UPRIGHT,THIGH&CALF LACERS,MOLDED TO PATIENT MODEL W/ $68.51 20071101 99999999 L1880 KO,DBL UPRIGHT,NON MOLDED THIGH&CALF CUFFS/LACERS W/KNEE JNT $48.94 20071101 99999999 L1885 KO, SINGLE OR DOUBLE UPRIGHT, THIGH AND CALF, WITH FUNCTIONAL ACTIVE RESISTANCE $814.33 20030401 99999999 L1900 ANKLE-FT ORTHOSIS,SPRING WIRE,DORIFLEXION ASSIST CALF BAND $146.01 20060701 99999999 L1901 ANKLE ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G. NE $8.35 20060701 99999999 L1902 AFO,ANKLE GAUNTLET,CUSTOM FITTED $45.66 20060701 99999999 L1904 AFO,MOLDED ANKLE GAUNTLET,MOLDED TO PATIENT MODEL $389.39 20060701 99999999 L1906 AFO/MULTILIGAMENTUS ANKLE SUPPORT $125.17 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 53
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Medicaid Fee Schedule without Mods 200801

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