Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END L3100 HALLUS-VALGUS NIGHT DYNAMIC SPLINT $20.38 20060701 99999999 L3140 FOOT,ABDUCTION ROTATION BARS,ATTACHED TO SHOE $41.98 20060701 99999999 L3150 FOOT,ABDUCTION ROTATION BARS,CLAMPED TO SHOE $38.38 20060701 99999999 L3160 FOOT,TORQUE HEELS $3.01 20071101 99999999 L3170 FOOT,PLASTIC HEEL STABILZER $23.99 20060701 99999999 L3201 ORTHOPEDIC SHOE,OXFORD WITH SUPINATOR OR PRONATOR,INFANT $2.00 20071101 99999999 L3202 ORTHOPEDIC SHOE,OXFORD WITH SUPINATOR OR PRONATOR,CHILD $2.00 20071101 99999999 L3203 ORTHOPEDIC SHOE,OXFORD WITH SUPINATOR OR PRONATOR,JUNIOR $2.00 20071101 99999999 L3204 ORTHOPEDIC SHOE,HIGHTOP WITH SUPINATOR OR PRONATOR,INFANT $2.00 20071101 99999999 L3206 ORTHOPEDIC SHOE,HIGHTOP WITH SUPINATOR OR PRONATOR,CHILD $3.00 20071101 99999999 L3207 ORTHOPEDIC SHOE,HIGHTOP WITH SUPINATOR OR PRONATOR,JUNIOR $3.00 20071101 99999999 L3208 SURGICAL BOOT,EACH,INFANT $3.00 20071101 99999999 L3209 SUURGICAL BOOT,EACH CHILD $3.00 20071101 99999999 L3211 SURGICAL BOOT,EACH,JUNIOR $3.00 20071101 99999999 L3212 BENESCH BOOT,PAIR,INFANT $6.13 20071101 99999999 L3213 BENESCH BOOT,PAIR,CHILD $6.13 20071101 99999999 L3214 BENESCH BOOT,PAIR,JUNIOR $6.13 20071101 99999999 L3215 ORTHOPEDIC FOOTWEAR, LADIES SHOES, OXFORD $5.37 20071101 99999999 L3216 ORTHOPEDIC FOOTWEAR, LADIES SHOES, DEPTH INLAY $5.37 20071101 99999999 L3217 ORTHOPEDIC FOOTWEAR,LADIES SHOES,HIGHTOP,DEPTH INLAY $6.84 20071101 99999999 L3218 ORTHOPEDIC FOOTWEAR,LADIES SURGICAL BOOT,EACH $35.17 20030401 99999999 L3219 ORTHOPEDIC FOOTWEAR, MENS SHOES, OXFORD $5.37 20071101 99999999 L3221 ORTHOPEDIC FOOTWEAR,MENS SHOES,DEPTH INLAY $6.84 20071101 99999999 L3222 ORTHOPEDIC FOOTWEAR,MENS SHOES,HIGHTOP,DEPTH INLAY $6.84 20071101 99999999 L3223 ORTHOPEDIC FOOTWEAR,MENS SURGICAL BOOT,EACH $26.00 20030401 99999999 L3224 ORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE ( $74.31 20060701 99999999 L3225 ORTHOPEDIC FOOTWEAR, MAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (OR $55.34 20060701 99999999 L3230 ORTHOPEDIC FOOTWEAR,CUSTOM SHOES,DEPTH INLAY $8.55 20071101 99999999 L3250 ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, $8.55 20071101 99999999 L3251 FOOT,SHOE MOLDED TO PATIENT MODEL,SILICONE SHOE,EACH $8.55 20071101 99999999 L3252 FOOT,SHOE MOLDED TO PATIENT MODEL,PLASTAZOTE,CUSTOM FABRICAT $8.55 20071101 99999999 L3253 FOOT,MOLDED SHOE PLASTAZOTE CUSTOM FITTED,EACH $8.55 20071101 99999999 L3254 NON-STANDARD SIZE OR WIDTH $8.55 20071101 99999999 L3255 NON-STANDARD SIZE OR LENGTH $8.55 20071101 99999999 L3257 ORTHOPEDIC FOOTWEAR,ADDITIONAL CHARGE FOR SPLIT SIZE $8.55 20071101 99999999 L3260 AMBULATORY SURGICAL BOOT,EACH $2.28 20071101 99999999 L3265 PLASTAZOTE SANDAL,EACH $2.28 20071101 99999999 L3300 LIFT,ELEVATION,HEEL,TAPERED TO METATARSALS,PER INCH $24.58 20060701 99999999 L3310 LIFT ELEVATION,HEEL AND SOLE,NEOPRENE,PER INCH $52.00 20060701 99999999 L3320 LIFT,ELEVATION,HEEL AND SOLE,CORK,PER INCH $0.23 20071101 99999999 L3330 LIFT,ELEVATION,METAL EXTENSION(SKATE) $266.82 20060701 99999999 L3332 LIFT,ELEVATION,INSIDE SHOE,TAPERED,UP TO ONE-HALF INCH $34.78 20060701 99999999 L3334 LIFT,ELEVATION,HEEL,PER INCH $17.99 20060701 99999999 L3340 HEEL WEDGE,SACH $40.18 20060701 99999999 L3350 HEEL WEDGE $10.80 20060701 99999999 L3360 SOLE WEDGE,OUTSIDE SOLE $16.79 20060701 99999999 L3370 SOLE WEDGE, BETWEEN SOLE $23.37 20060701 99999999 L3380 CLUBFOOT WEDGE $23.37 20060701 99999999 L3390 OUTFLARE WEDGE $23.37 20060701 99999999 L3400 METATARSAL BAR WEDGE,ROCKER $19.19 20060701 99999999 L3410 METATARSAL BAR WEDGE,BETWEEN SOLE $43.76 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 58
PROC-CODE DESC MAC BEG END L3420 FULL SOLE AND HEEL WEDGE,BETWEEN SOLE $25.78 20060701 99999999 L3430 HEEL,COUNTER,PLASTIC REINFORCED $75.55 20060701 99999999 L3440 HEEL,COUNTER,LEATHER REINFORCE $35.98 20060701 99999999 L3450 HEEL,SACH CUSHION TYPE $49.76 20060701 99999999 L3455 HEEL,NEW LEATHER,STANDARD $19.19 20060701 99999999 L3460 HEEL,NEW RUBBER,STANDARD $16.18 20060701 99999999 L3465 HEEL,THOMAS WITH WEDGE $27.59 20060701 99999999 L3470 HEEL,THOMAS EXTENDED TO BALL $29.38 20060701 99999999 L3480 HEEL,PAD AND DEPRESSION FOR SPUR $29.38 20060701 99999999 L3485 HEEL,PAD,REMOVABLE FOR SPUR $1.95 20071101 99999999 L3500 MISCELLANEOUS SHOE ADDITION,INSOLE,LEATHER $13.79 20060701 99999999 L3510 MISCELLANEOUS SHOE ADDITION,INSOLE,RUBBER $13.79 20060701 99999999 L3520 MISCELLANEOUS SHOE ADDITION,INSOLE,FELT COVERED WITH LEATHER $14.98 20060701 99999999 L3530 MISCELLANEOUS SHOE ADDITION,SOLE,HALF $14.98 20060701 99999999 L3540 MISCELLANEOUS SHOE ADDITION,SOLE,FULL $23.99 20060701 99999999 L3550 MISCELLANEOUS SHOE ADDITION,TOE TAP,STANDARD $4.19 20060701 99999999 L3560 MISCELLANEOUS SHOE ADDITION,TOE TAP,HORSESHOE $10.80 20060701 99999999 L3570 MISCELLANEOUS SHOE ADDITION,SPECIAL EXTENSION TO INSTEP $40.18 20060701 99999999 L3580 MISCELLANEOUS SHOE ADDITION,CONVERT INSTEP TO VELCRO CLOSURE $30.58 20060701 99999999 L3590 MISCELLANEOUS SHOE ADDITION,CONVERT FIRM SHOE COUNTER TO SOF $25.18 20060701 99999999 L3595 MISCELLANEOUS SHOE ADDITION,MARCH BAR $19.78 20060701 99999999 L3600 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER,CALIPER $35.98 20060701 99999999 L3610 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER,CALIPER PLA $47.36 20060701 99999999 L3620 TRANSFER OF AN ORTHOSIS FROME ONE SHOE TO ANOTHER,SOLID STIR $35.98 20060701 99999999 L3630 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER,SOLID STIRR $47.36 20060701 99999999 L3640 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER,DENNIS BROW $20.38 20060701 99999999 L3649 UNLISTED PROCEDURES FOR FOOT ORTHOPEDIC SHOES,SHOE MODIFICAT $36.40 20030401 99999999 L3650 SHOULDER ORTHOSIS,FIGURE OF "8" DESIGN ABDUCTION RESTRAINER $41.53 20060701 99999999 L3651 SHOULDER ORTHOSIS, SINGLE SHOULDER, ELASTIC, PREFABRICATED, INCLUDES FITTING AND $28.25 20060701 99999999 L3652 SHOULDER ORTHOSIS, DOUBLE SHOULDER, ELASTIC, PREFABRICATED, INCLUDES FITTING AND $85.14 20060701 99999999 L3660 SO,FIGURE OF "8" DESIGN ABDUCTION RESTRAINER,CANVAS & WEBBIN $57.20 20060701 99999999 L3670 SO,ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE) $84.70 20060701 99999999 L3671 SHOULDER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFA $386.62 20060701 99999999 L3672 SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT A $480.79 20060701 99999999 L3673 SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT A $524.01 20060701 99999999 L3675 SO, VEST TYPE ABDUCTION RESTRAINER, CANVAS WEBBING TYPE, OR EQUAL $75.29 20060701 99999999 L3677 SHOULDER ORTHOSIS, HARD PLASTIC, SHOULDER STABILIZER, PRE- FABRICATED, INCLUDES F $13.08 20071101 99999999 L3700 ELBOW ORTHOSES (EO),ELASTIC WITH STAYS $45.77 20060701 99999999 L3701 ELBOW ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G. NE $8.74 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 59
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