Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END L3961 SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INC $720.88 20060701 99999999 L3962 SEHOW,ABDUCTION POSITIONING,ERBS PALSEY DESIGN $458.11 20060701 99999999 L3963 SEWHO,MOLDED SHOULDER,ARM,FOREARM,AND WRIST,WITH ARTICULATIO $913.38 20030401 99999999 L3964 SEWHO,MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR,BALANCED $74.21 20071101 99999999 L3965 SEWHO-RADIAL ARM SUPPORT.ATTACHED TO WHEELCHAIR,BALANCED $103.82 20071101 99999999 L3966 SEWHO,MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR,BALANCED $77.06 20071101 99999999 L3967 SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THO $851.12 20060701 99999999 L3968 SEWHO, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR $91.33 20071101 99999999 L3969 SEWHO,MOBILE ARM SUPPORT,MONOSUSPENSION ARM AND HAND SUPPORT $76.39 20071101 99999999 L3970 SEWHO,ADDITION TO MOBILE ARM AUPPORT,ELEVATIONG PROXIMAL ARM $29.11 20071101 99999999 L3971 SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NO $807.91 20060701 99999999 L3972 SEWHO,ADDITION TO MOBILE ARM SUPPORT,OFFSET OR LATERAL $14.27 20071101 99999999 L3973 SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THO $851.12 20060701 99999999 L3974 SEWHO,ADDITION TO MOBILE ARM SUPPORT,SUPINATOR $12.55 20071101 99999999 L3975 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, $720.88 20060701 99999999 L3976 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIG $720.88 20060701 99999999 L3977 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR $807.91 20060701 99999999 L3978 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIG $851.12 20060701 99999999 L3980 UPPER EXTREMITY FRACTURE ORTHOSIS,HUMERAL $232.34 20060701 99999999 L3982 UPPER EXTREMITY FRACTURE ORTHOSIS,RADIUS/ULNAR $358.76 20060701 99999999 L3984 UPPER EXTREMITY FRACTURE ORTHOSIS,WRIST $230.32 20060701 99999999 L3985 UPPER EXTREMITY FRACTURE ORTHOSIS,FOREARM,HAND WITH WRIST HI $55.37 20071101 99999999 L3986 UPPER EXTREMITY FRACTURE ORTHOSIS,COMBINATION OF HUMERAL,RAD $55.45 20071101 99999999 L3995 ADDITION TO UPPER EXTREMITY ORTHOSIS,SOCK,FRACTURE OR EQUAL $18.58 20060701 99999999 L3999 UNLISTED PROCEDURES FOR UPPER LIMB ORTHOSIS $73.84 20030401 99999999 L4000 REPLACE GIRDLE FOR MILWAUKEE ORTHOSIS $865.76 20060701 99999999 L4002 REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE $0.50 20071101 99999999 L4010 REPLACE TRILATERAL SOCKET BRIM $507.05 20060701 99999999 L4020 REPLACE QUADRILATERAL SOCKET BRIM,MOLDED TO PATIENT MODLE $563.36 20060701 99999999 L4030 REPLACE QUADRILATERAL SOCKET BRIM,CUSTOM FITTED $361.73 20060701 99999999 L4040 REPLACE MOLDED THIGH LACER $328.73 20060701 99999999 L4045 REPLACE NON-MOLDED THIGH LACER $290.08 20060701 99999999 L4050 REPLACE MOLDED CALF LACER $424.41 20060701 99999999 L4055 REPLACE NON-MOLDED CALF LACER $269.71 20060701 99999999 L4060 REPLACE HIGH ROLL CUFF $271.14 20060701 99999999 L4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFO $373.08 20060701 99999999 L4080 REPLACE METAL BANDS KAFO,PROXIMAL THIGH $54.16 20060701 99999999 L4090 REPLACE METAL BANDS KAFO-AFO,CALF OR DISTAL THIGH $51.49 20060701 99999999 L4100 REPLACE LEATHER CUFF KAFO,PROXIMAL THIGH $66.96 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 62
PROC-CODE DESC MAC BEG END L4110 REPLACE LEATHER CUFF KAFO-AFO,CALF OR DISTAL THIGHT $66.12 20060701 99999999 L4130 REPLACE PRETIBIAL SHELL $551.14 20060701 99999999 L4205 REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES $14.00 20010101 99999999 L4210 REPAIR OF ORTHOTIC DEVICE,REPAIR OR REPLACE MINOR PARTS $21.02 20030401 99999999 L4310 MULTI-POUNDS OR EQUAL ORTHOTIC PREPARATORY MANAGEMENT SYSTEM $255.52 20030401 99999999 L4320 ADDITION TO AFO,MULTI-PODUS ORTHOTIC PREPARATORY MANAGEMENT $86.10 20030401 99999999 L4350 PNEUMATIC ANKLE CONTROL SPLING(AIRCAST OR EQUAL) $81.51 20060701 99999999 L4360 PNEUMATIC WALKING SPLING(AIRCAST OR EQUAL) $157.58 20060701 99999999 L4370 PNEUMATIC FULL LEG SPLINT(AIRCAST OR EQUAL) $85.65 20060701 99999999 L4380 PNEUMATIC KNEE SPLINT(AIRCAST OR EQUAL) $45.25 20060701 99999999 L4386 NON-PNEUMATIC WALKING SPLINT, WITH OR WITHOUT JOINTS, PREFABRICATED, INCLUDES FI $74.75 20060701 99999999 L4390 REPLACE SOFT INTERFACE MATERIAL, MULTI-PODUS TYPE SPLINT $118.27 20030401 99999999 L4392 REPLACE SOFT INTERFACE MATERIAL, ANKLE CONTRACTURE SPLINT $10.91 20060701 99999999 L4394 REPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT $7.95 20060701 99999999 L4396 ANKLE CONTRACTURE SPLINT $77.80 20060701 99999999 L4398 FOOT DROP SPINT, RECUMBENT POSITIONING DEVICE $35.81 20060701 99999999 L5000 PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH,TOE FILLER $302.50 20060701 99999999 L5010 PARTIAL FOOT,MOLDED SOCKET,ANKLE HEIGHT,WITH TOE FILLER $680.89 20060701 99999999 L5020 PARTIAL FOOT,MOLDED SOCKET,TIBIAL TUBERCLE,HEIGHT W/TOE FILL $1,427.30 20060701 99999999 L5050 ANKLE,SYMES,MOLDED SOCKET,SACH FOOT $1,363.65 20060701 99999999 L5060 ANKLE,SYMES,METAL FRAME,MOLDED LEATHER SOCKET,ARTICULATED $1,866.29 20060701 99999999 L5100 BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT $1,335.91 20060701 99999999 L5105 BELOW KNEE,PLASTIC SOCKET,JOINTS AND THIGH LACER,SACH FOOT $2,648.43 20060701 99999999 L5150 KNEE DISARTICULATION,MOLDED SOCKET,EXTERNAL KNEE JOINTS,SHIN $2,593.85 20060701 99999999 L5160 KNEE DISARTICULATION,MOLDED SOCKET,BENT KNEE CONFIGUARTION $2,938.52 20060701 99999999 L5200 ABOVE KNEE,MOLDED SOCKET,SINGLE AXIS CONSTANT FRICTION KNEE $2,021.27 20060701 99999999 L5210 ABOVE KNEE,SHORT PROSTHESIS,NO KNEE JOINT,WITH FOOT BLOCKS $1,602.44 20060701 99999999 L5220 ABOVE KNEE,SHORT PROSTHESIS,NO KNEE JOINT,WITH ARTICULATED $2,198.48 20060701 99999999 L5230 ABOVE KNEE,FOR PROXIMAL FOCAL DEFICIENCY,CONSTANT FRICTION $2,783.15 20060701 99999999 L5250 HIP DISARTICULATION,CANADIAN TYPE;MOLDED SOCKET,HIP JOINT $4,453.97 20060701 99999999 L5270 HIP DISARTICULATION,TILT TABLE TYPE;MOLDED SOCKET,LOCKING $4,551.59 20060701 99999999 L5280 HEMIPELVICTOMY,CANADIAN TYPE;MOLDED SOCKET,HIP JOINT,SINGLE $5,083.14 20060701 99999999 L5300 BELOW KNEE,MOLDED SOCKET,SACH FOOT,ENDOSKELETAL SYSTEM $2,208.53 20030401 99999999 L5301 BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM $1,695.83 20060701 99999999 L5310 KNEE DISARTICULATION,MOLDED SOCKET,SACH FOOT ENDOSKELETAL $3,419.69 20030401 99999999 L5311 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS, SHI $2,064.60 20060701 99999999 L5320 ABOVE KNEE,MOLDED SOCKET,OPEN END,SACH FOOT,ENDOSKELETAL SYS $3,823.39 20030401 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 63
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