Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END L2340 ADDITION TO LOWER EXTREMITY,PER-TIBIAL SHELL,MOLDED TO PATIE $301.55 20060701 99999999 L2350 ADDITION TO LOWER EXTREMITY,PROSTHETIC TYPE,(BK) SOCKET $995.04 20060701 99999999 L2360 ADDITION TO LOWER EXTREMITY,EXTENDED STEEL SHANK $32.72 20060701 99999999 L2370 ADDITION TO LOWER EXTREMITY,PATTEN BOTTOM $282.82 20060701 99999999 L2375 ADDITION TO LOWER EXTREMITY,TORSION CONTROL,ANKLE JOINT $81.01 20060701 99999999 L2380 ADDITION TO LOWER EXTREMITY,TORSION CONTROL,STRAIGHT KNEE $95.66 20060701 99999999 L2385 ADDITION TO LOWER EXTREMITY,STRAIGHT KNEE JOINT,HEAVY DUTY $88.81 20060701 99999999 L2387 ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FABRICATED KNEE $114.64 20060701 99999999 L2390 ADDITION TO LOWER EXTREMITY,OFFSET KNEE JOINT,EACH JOINT $89.59 20060701 99999999 L2395 ADDITION TO LOWER EXTREMITY,OFFSET KNEE JOINT,HEAVY DUTY $98.74 20060701 99999999 L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE $56.84 20060701 99999999 L2405 ADDITION TO KNEE JOINT,DROP LOCK,EACH JOINT $41.10 20060701 99999999 L2415 ADDITION TO KNEE JOINT,CAM LOCK(SWISS,FRENCH,BAIL TYPES) $57.26 20060701 99999999 L2425 ADDITION TO KNEE JOINT,DISC OR DIAL LOCK FOR ADJUSTABLE KNEE $67.58 20060701 99999999 L2430 ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE EXTENSION, $67.58 20060701 99999999 L2435 ADDITION TO KNEE JOINT,POLYCENTRIC JOINT,EACH JOINT $112.21 20030401 99999999 L2492 ADDITION TO KNEE JOINT,LIFT LOOP FOR DROP LOCK RING $58.97 20060701 99999999 L2500 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,GLUTEAL $221.54 20060701 99999999 L2510 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,QUADRILATER $475.07 20060701 99999999 L2520 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,QUADRILATER $299.85 20060701 99999999 L2525 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,ISCHIAL CON $742.64 20060701 99999999 L2526 ADDITION TO LOWER EXTREM,THIGH/WEIGHT BEARING,ISCHIAL CONTAI $406.87 20060701 99999999 L2530 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,LACER,NONMO $216.31 20060701 99999999 L2540 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,LACER,MOLDE $354.49 20060701 99999999 L2550 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING,HIGH ROLL $239.17 20060701 99999999 L2570 ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,HIP JOINT,CLEVIS $474.60 20060701 99999999 L2580 ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,PELVIC SLING $356.24 20060701 99999999 L2600 ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,HIP JOINT,CLEVIS $207.90 20060701 99999999 L2610 ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,HIP JNT,CLEVIS $230.82 20060701 99999999 L2620 ADDITION TO LOWER EXTREMITY,PELVIC CNTRL,HIP JNT,HEAVY DUTY $219.42 20060701 99999999 L2622 ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,HIP JOINT,ADJ FLE $275.04 20060701 99999999 L2624 ADDITION TO LOWER EXTREMITY,PELVIC CONT,HIP JOINT,ADJ FLEX $344.43 20060701 99999999 L2627 ADDITION TO LOWER EXTREMITY,PELVIC CNTRL,PLASTIC,MOLDED TO $627.76 20060701 99999999 L2628 ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,METAL FRAME,RECIP $837.46 20060701 99999999 L2630 ADDITION TO LOWER EXTREMITY,PELVIC CNTRL,BAND & BELT,UNIL $180.77 20060701 99999999 L2640 ADDITION TO LOWER EXTREMITY,PELVIC CNTRL,BAND&BELT,BILATERAL $376.91 20060701 99999999 L2650 ADDITION TO LOWER EXTREMITY,PELVIC & THORACIC CNTRL,GLUTEAL $68.40 20060701 99999999 L2660 ADDITION TO LOWER EXTREMITY,THORACIC CNTRL,THORACIC BAND $120.75 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 56
PROC-CODE DESC MAC BEG END L2670 ADDITION TO LOWER EXTREMITY,THORACIC CNTRL,PARASPINAL UPRGTS $102.91 20060701 99999999 L2680 ADDITION TO LOWER EXTREMITY,THORACIC CONTROL,LATERAL SUPPORT $90.39 20060701 99999999 L2750 ADDITION TO LOWER EXTREMITY ORTHOSIS,PLATING CHROME OR NICKE $36.56 20060701 99999999 L2755 ADDITION TO LOWER EXTREMITY ORTHOSIS, CARBON GRAPHITE LAMINATION $106.78 20060701 99999999 L2760 ADDITION TO LOWER EXTREMITY ORTHOSIS,EXTENSION,PER EXTENSION $62.29 20060701 99999999 L2768 ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BAR $61.43 20060701 99999999 L2770 ADDITION TO LOWER EXTREMITY ORTHOSIS,STAINLESS STEE-PER BAR $46.96 20060701 99999999 L2780 ADDITION TO LOWER EXTREMITY ORTHOSIS,NON-CORROSIVE FINISH $48.74 20060701 99999999 L2785 ADDITION TO LOWER EXTREMITY ORTHOSIS,DROP LOCK RETAINER,EACH $28.68 20060701 99999999 L2795 ADDITION TO LOWER EXTREMITY ORTHOSIS,KNEE CONTROL,FULL KNEE $68.92 20060701 99999999 L2800 ADDITION TO LOWER EXTREMITY ORTHOSIS,KNEE CONTROL,KNEE CAP $84.76 20060701 99999999 L2810 ADDITION TO LOWER EXTREMITY ORTHOSIS,KNEE CONTROL,CONDYLAR $68.28 20060701 99999999 L2820 ADDITION TO LOWER EXTREMITY ORTHOSIS,SOFT INTERFACE FOR MOLD $102.02 20060701 99999999 L2830 ADDITION TO LOWER EXTREMITY ORTHOSIS,SOFT INTERFACE FOR MOLD $85.90 20060701 99999999 L2840 ADDDITION TO LOWER EXTREMITY ORTHOSIS,TIBIAL LENGTH SOCK $21.25 20060701 99999999 L2850 ADDITION TO LOWER EXTREMITY ORTHOSIS,FEMORAL LENGTH SOCK,FX $35.74 20060701 99999999 L2860 ADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, CONCENTRIC ADJUSTABLE TORSION $267.64 20030401 99999999 L2999 UNLISTED PROCEDURES FOR LOWER EXTREMITY ORTHOSES $29.12 20030401 99999999 L3000 FOOT,INSERT,REMOVABLE,MOLDED TO PATIENT MODEL,"UCB" TYPE $148.10 20060701 99999999 L3001 FOOT,INSERT,REMOVABLE,MOLDED TO PATIENT MODEL SPENCO,EACH $62.35 20060701 99999999 L3002 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, PLASTAZOTE $76.14 20060701 99999999 L3003 FOOT,INSERT,REMOVABLE,MOLDED TO PATIENT MODEL,SILICONE GEL,E $82.15 20060701 99999999 L3010 FOOT,INSSER,REMOVABLE,MOLDED TO PATIENT MODEL,LONGITUDINAL $82.15 20060701 99999999 L3020 FOOT,INSERT,REMOVABLE,MOLDED TO PATIENT MODEL LONGITUDINAL $93.55 20060701 99999999 L3030 FOOT,INSERT,REMOVABLE,FORMED TO PATIENT FOOT,EACH $35.98 20060701 99999999 L3031 FOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENG $5.99 20071101 99999999 L3040 FOOT,ARCH SUPPORT,REMOVABLE,PREMOLDED,LONGITUDINAL,EACH $22.18 20060701 99999999 L3050 FOOT,ARCH SUPPORT,REMOVABLE,PREMOLDED,METATARSAL,EACH $22.18 20060701 99999999 L3060 FOOT,ARCH SUPPORT,REMOVABLE,PREMOLDED,LONGITUDINAL/METATARSA $34.78 20060701 99999999 L3070 FOOT,ARCH SUPPORT,NON-REMOVABLE ATTACHED TO SHOE,LONGITUDINA $14.98 20060701 99999999 L3080 FOOT,ARCH SUPPORT,NON-REMOVABLE ATTACHED TO SHOE,METATARSAL $14.98 20060701 99999999 L3090 FOOT,ARCH SUPPORT,NON-REMOVABLE ATTACHED TO SHOE,LONGITUDINA $19.19 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 57
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