Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END L1907 AFO, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM FABRICAT $265.28 20060701 99999999 L1910 AFO.POSTERIOR,SINGLE BAR,CLASP ATTACHMENT TO SHOE COUNTER $206.26 20060701 99999999 L1920 AFO,SINGLE UPRIGHT W/STATIC OR ADJ STOP(PHELPS OR PERLSTEIN) $157.25 20060701 99999999 L1930 AFO/CUSTOM FITTED,PLASTIC $180.74 20060701 99999999 L1932 AFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, $420.71 20060701 99999999 L1940 AFO, MOLDED TO PATIENT MODEL, PLASTIC $334.24 20060701 99999999 L1945 AFO,MOLDED TO PATIENT MODEL,PLASTIC,RIGID ANTERIOR TIBIAL $624.75 20060701 99999999 L1950 AFO/SPIRAL/MOLDED TO PATIENT MODEL(IRM TYPE) PLASTIC $522.07 20060701 99999999 L1951 ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTI $395.95 20060701 99999999 L1960 AFO, POSTERIOR SOLID ANKLE, MOLDED TO PATIENT MODEL, PLASTIC $383.21 20060701 99999999 L1970 AFO/PLASTIC MOLDED TO PATIENT MODEL,W/ANKLE JOINT $361.72 20060701 99999999 L1971 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, $220.98 20060701 99999999 L1980 AFO,SGL UPRIGHT FREE PLANTAR DORSIFLEXION,SOLID STIRRUP,CALF $312.57 20060701 99999999 L1990 AFO/DBL UPRIGHT FREE PLANTAR DORSIFLEXION,SOLID STIRRUP,CALF $367.42 20060701 99999999 L2000 KNEE-ANKLE-FOOT-ORTHOSES,SGL UPRIGHT,FREE KNEE,FREE ANKLE, $1,011.11 20060701 99999999 L2005 KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT, STANCE $1,931.89 20060701 99999999 L2010 KAFO,SGL UPRIGHT,FREE ANKLE,SOLID STIRRUP,THIGH&CALF BANDS, $883.52 20060701 99999999 L2020 KAFO,DBL UPRIGHT,FREE KNEE,FREE ANKLE,SOLID STIRRUP,THIGH $1,262.37 20060701 99999999 L2030 KAFO/DBL UPRIGHT,FREE ANKLE,SOLID STIRRUP,THIGH&CALF BANDS/ $764.12 20060701 99999999 L2034 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOT $1,016.93 20060701 99999999 L2035 KAFO, FULL PLASTIC, STATIC, PREFABRICATED (PEDIATRIC SIZE) $88.21 20060701 99999999 L2036 KAFO,FULL PLASTIC,DOUBLE UPRIGHT,FREE KNEE,MOLDED TO PATIENT $1,088.63 20060701 99999999 L2037 KAFO,FULL PLASTIC,SGL UPRIGHT,FREE KNEE,MOLDED TO PATIENT $1,106.81 20060701 99999999 L2038 KAFO,FULL PLASTIC,W/O KNEE JNT,MULTI-AXIS ANKLE,MOLDED TO $761.44 20060701 99999999 L2039 KAFO, FULL PLASTIC, SINGLE UPRIGHT, POLY-AXIAL HINGE, MEDIAL LATERAL ROTATION CO $1,815.80 20030401 99999999 L2040 HIP-KNEE-ANKLE-FOOT ORTHOSIS TORSION CONTROL,BILAT ROTATION{ $79.09 20060701 99999999 L2050 HKAFO,TORSION CONTROL,BIL TORSION CABLES,HIP JNT,PELVIC BAND $402.91 20060701 99999999 L2060 HKAFO,TORSION CONTROL.BIL TORSION CABLES,BALL BEARING HIP JN $493.79 20060701 99999999 L2070 HKAFO,TORSION CONTROL,UNIL ROTATION STRAPS,PELVIC BAND/BELT $73.64 20060701 99999999 L2080 HKAFO,TORSION CONTROL,UNIL TORSION CABLE,HIP JNT,PELVIC BAND $260.29 20060701 99999999 L2090 HKAFO,TORSION CONTROL,UNIL TORSION CABLE,BALL BEARING HIP JN $349.73 20060701 99999999 L2102 AFO,FRACTURE ORTHOSIS,TIBIAL FX CAST ORTHESIS,PLASTER TYPE $296.85 20030401 99999999 L2104 AFO,FX ORTHOSIS,TIBIAL FX CAST ORTHESIS,SYNTHETIC TYPE CASTI $285.43 20030401 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 54
PROC-CODE DESC MAC BEG END L2106 AFO,FX ORTHOSIS,TIBIAL FX CAST ORTHOSIS,THERMOPLASTIC TYPE $577.01 20060701 99999999 L2108 AFO,FX ORTHOSIS, TIBIAL FX CAST ORTHOSIS,MOLDED TO PATIENT $652.45 20060701 99999999 L2112 AFO,FX ORTHOSIS,TIBIAL FX ORTHOSIS,SOFT CUSTOM FITTED $278.42 20060701 99999999 L2114 AFO,FX ORTHOSIS,TIBIAL FX ORTHOSIS, SEMI-RIGID CUSTOM FITTED $442.48 20060701 99999999 L2116 AFO,FX ORTHOSIS,TIBIAL FX ORTHOSIS,RIGID CUSTOM FITTED $551.26 20060701 99999999 L2122 KAFO FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,PLASTER TYPE CASTI $570.86 20030401 99999999 L2124 KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,SYNTHETIC TYPE CAS $789.21 20030401 99999999 L2126 KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,THERMOPLASTIC TYPE $715.88 20060701 99999999 L2128 KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,MOLDED TO PATIENT{ $1,095.10 20060701 99999999 L2132 KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,SOFT CUSTOM FITTED $417.55 20060701 99999999 L2134 KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,SEMIRIGID CUSTOM $655.07 20060701 99999999 L2136 KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,RIGID CUSTOM FITTE $885.48 20060701 99999999 L2180 ADDITION TO LOWER EXTREMITY FX ORTHOSIS,PLASTIC SHOE INSERT $106.64 20060701 99999999 L2182 ADDITION TO LOWER EXTREMITY FX ORTHOSIS,DROP LOCK KNEE JOINT $51.50 20060701 99999999 L2184 ADDITION TO LOWER EXTREMITY FX ORTHOSIS,LTD MOTION KNEE JNT $46.27 20060701 99999999 L2186 ADDITION TO LOWER EXTREMITY FX ORTHOSIS,ADJ MOTION KNEE JNT $70.78 20060701 99999999 L2188 ADDITION TO LOWER EXTREMITY FX ORTHOSIS,QUADRILATERAL BRIM $45.01 20060701 99999999 L2190 ADDITION TO LOWER EXTREMITY FX ORTHOSIS,WAIST BELT $31.73 20060701 99999999 L2192 ADDITION TO LOWER EXTREMITY ORTHOSIS,HIP JNT,PELVIC BAND, $288.79 20060701 99999999 L2200 ADDITIONAL TO LOWER EXTREMITY LTD ANKLE MOTION EACH JOINT $52.18 20060701 99999999 L2210 ADDITION TO LOWER EXTREMITY,DORSIFLEXION ASSIST(PLANTAR $64.58 20060701 99999999 L2220 ADDITION TO LOWER EXTREMITY,DORSIFLEXION AND PLANTAR FLEXION $77.39 20060701 99999999 L2230 ADDITION TO LOWER EXTREMITY,SPLIT FLAT CALIPER STIRRUPS AND $86.84 20060701 99999999 L2232 ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE $7.34 20071101 99999999 L2240 ADDITION TO LOWER EXTREMITY,ROUND CALIPER AND PLATE ATTACH $86.26 20060701 99999999 L2250 ADDITION TO LOWER EXTREMITY,FOOT PLATE,MOLDED TO PATIENT MOD $382.09 20060701 99999999 L2260 ADDITION TO LOWER EXTREMITY,REINFORCED SOLID STIRRUPS $329.86 20060701 99999999 L2265 ADDITION TO LOWER EXTREMITY,LONG TONGUE STIRRUP $138.46 20060701 99999999 L2270 ADDITION TO LOWER EXTREMITY,VARUS/VALGUS CORRECTION(T) STRAP $51.47 20060701 99999999 L2275 ADDITION TO LOWER EXTREMITY, VARUS/VULGUS CORRECTION, PLASTIC MODIFICATION, PADD $83.43 20060701 99999999 L2280 ADDITION TO LOWER EXTREMITY,MOLDED INNER BOOT $340.37 20060701 99999999 L2300 ADDITION TO LOWER EXTREMITY,ABDUCTION BAR JOINTED ADJ $252.68 20060701 99999999 L2310 ADDITION TO LOWER EXTREMITY,ABDUCTION BAR-STRAIGHT $133.97 20060701 99999999 L2320 ADDITION TO LOWER EXTREMITY,NON-MOLDED LACER $128.11 20060701 99999999 L2330 ADDITION TO LOWER EXTREMITY,LACER MOLDED TO PATIENT MODEL $355.37 20060701 99999999 L2335 ADDITION TO LOWER EXTREMITY,ANTERIOR SWING BAND $182.14 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 55
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Medicaid Fee Schedule without Mods 200801

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