Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END L5321 ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE AXIS $2,637.25 20060701 99999999 L5330 HIP DISARTICULATION,CANADIAN TYPE;MOLDED SOCKET,ENDOSKELETAL $4,512.07 20030401 99999999 L5331 HIP DISARTICULATION, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOIN $2,886.55 20060701 99999999 L5340 HEMIPELVECTOMY,CANADIAN TYPE;MOLDED SOCKET ENDOSKELETAL SYS $4,512.07 20030401 99999999 L5341 HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT, SI $5,082.35 20060701 99999999 L5400 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION $844.32 20060701 99999999 L5410 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION $168.16 20060701 99999999 L5420 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INIT $1,056.97 20060701 99999999 L5430 IMMEDIATE POST SURG. OR EARLY FITTING,APPLICAT. OF INIT. RIG $299.51 20060701 99999999 L5450 IMMEDIATE POST SURG. OR EARLY FIT.,APPLIC. OF NON-WT BEARING $166.00 20060701 99999999 L5460 IMMEDIATE POST SURG. OR EARLY FITTING,APPLIC. NON-WT BEARING $190.06 20060701 99999999 L5500 INITIAL,BELOW KNEE "PTB" TYPE SOCKET,"USMC"OR EQUAL PYLON $882.99 20060701 99999999 L5505 INITIAL,ABOVE KNEE-KNEE DISARTICULATION,ISCHIAL LEVEL SOCKET $1,182.52 20060701 99999999 L5510 PREPARATORY,BELOW KNEE "PTB" TYPE SOCKET, "USMC" OR EQUAL $906.99 20060701 99999999 L5520 PREPARATORY,BELOW KNEE "PTB" TYPE SOCKET, "USMC" OR EQUAL $956.90 20060701 99999999 L5530 PREPARATORY,BELOW KNEE "PTB" TYPE SOCKET, "USMC" OR EQUAL $1,275.68 20060701 99999999 L5535 PREPARATORY,BELOW KNEE PTB TYPE SOCKET, USMC OR EQUAL PYLON $1,396.75 20060701 99999999 L5540 PREPARATORY,BELOW KNEE PTB,TYPE SOCKET USMC OR EQUAL PYLON $1,229.29 20060701 99999999 L5560 PREPARATORY,ABOVE KNEE-KNEE DISARTICULATION,ISCHIAL LEVEL $1,212.13 20060701 99999999 L5570 PREPARATORY,ABOVE KNEE-KNEE DISARTICULATION,ISCHIAL LEVEL $1,347.61 20060701 99999999 L5580 PREPARATORY,ABOVE KNEE-KNEE DISARTICULATION ISCHIAL LEVEL $1,628.20 20060701 99999999 L5585 PREPARATORY,ABOVE KNEE DISARTICULATION,ISCHIAL LEVEL SOCKET $1,449.79 20060701 99999999 L5590 PREPARATORY,ABOVE KNEE-KNEE DISARTICULATION,LAMINATED SOCKET $1,723.08 20060701 99999999 L5595 PREPARATORY,HIP DISARTICULATION-HEMIPELVECTOMY,PYLON $4,400.50 20060701 99999999 L5600 PREPARATORY,HIP DISARTICULATION-HEMIPELVECTOMY,LAMINATED $3,959.33 20060701 99999999 L5610 ADDITION TO LOWER EXTREMITY,ABOVE KNEE,HYDRACADENCE SYSTEM $1,282.07 20060701 99999999 L5611 ADDITION TO LOWER EXTREMITY,ABOVE KNEE-KNEE DISARTICULATION $1,079.75 20060701 99999999 L5613 ADDITION TO LOWER EXTREMITY,ABOVE KNEE-KNEE DISARTICULATION $1,792.79 20060701 99999999 L5614 ADDITION TO LOWER EXTREMITY, ABOVE KNEE-KNEE DISARTICULATION, 4-BAR LINKAGE, WIT $860.88 20060701 99999999 L5616 ADDITION TO LOWER EXTREM.,ABOVE KNEE,UNIVERAL MULTIPLEX SYST $729.20 20060701 99999999 L5617 ADDITION TO LOWER EXTREMITY, QUICK CHANGE SELF-ALIGNING UNIT, ABOVE KNEE OR BELO $285.44 20060701 99999999 L5618 ADDITION TO LOWER EXTREMITY, TEST SOCKET, SYMES $146.17 20060701 99999999 L5620 ADDITION TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEE $150.76 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 64
PROC-CODE DESC MAC BEG END L5622 ADDITION TO LOWER EXTREMITY, TEST SOCKET,KNEE DISARTICULATIO $195.97 20060701 99999999 L5624 ADDITION TO LOWER EXTREMITY, TEST SOCKER, ABOVE KNEE $220.04 20060701 99999999 L5626 ADDITION TO LOWER EXTREMITY, TEST SOCKET,HIP DISARTICULATION $281.57 20060701 99999999 L5628 ADDITION TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVICTOMY $238.33 20060701 99999999 L5629 ADDITION TO LOWER EXTREMITY, BELOW KNEE, ACRYLIC SOCKET $124.96 20060701 99999999 L5630 ADDITION TO LOWER EXTREMITY,SYMES TYPE,EXPANDABLE WALL SOCKE $289.75 20060701 99999999 L5631 ADDITION TO LOWER EXTREMITY,ABOVE KNEE OR KNEE DISARTICULATI $224.09 20060701 99999999 L5632 ADDITION TO LOWER EXTREMITY,SYMES TYPE,"PTB" BRIM DESIGN SOC $126.15 20060701 99999999 L5634 ADDITION TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPENING $262.99 20060701 99999999 L5636 ADDITION TO LOWER EXTREMITY,SYMES TYPE,MEDIAL OPENING SOCKET $130.64 20060701 99999999 L5637 ADDITION TO LOWER EXTREMITY,BELOW KNEE, TOTAL CONTACT $192.43 20060701 99999999 L5638 ADDITION TO LOWER EXTREMITY, BELOW KNEE, LEATHER SOCKET $368.90 20060701 99999999 L5639 ADDITION TO LOWER EXTREMITY,BELOW KNEE,WOOD SOCKET $985.39 20060701 99999999 L5640 ADDITION TO LOWER EXTREMITY,KNEE DISARTICULATION,LEATH. SOCK $410.71 20060701 99999999 L5642 ADDITION TO LOWER EXTREMITY,ABOVE KNEE,LEATHER SOCKET $256.45 20060701 99999999 L5643 ADDITION TO LOWER EXTREMITY,HIP DISARTICULATION,FLEXIBLE $796.52 20060701 99999999 L5644 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKET $278.32 20060701 99999999 L5645 ADDITION TO LOWER EXTREMITY,BELOW KNEE,FLEXIBLE INNER SOCKET $493.31 20060701 99999999 L5646 ADDITION TO LOWER EXTREMITY, BELOW KNEE, AIR CUSHION SOCKET $227.42 20060701 99999999 L5647 ADDITION TO LOWER EXTREMITY, BELOW KNEE SUCTION SOCKET $624.62 20060701 99999999 L5648 ADDITION TO LOWER EXTREMITY,ABOVE KNEE,AIR CUSHION SOCKET $214.66 20060701 99999999 L5649 ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M- L $997.82 20060701 99999999 L5650 ADDITIIONS TO LOWER EXTREMITY,TOTAL CONTACT,ABOVE KNEE $345.92 20060701 99999999 L5651 ADDITION TO LOWER EXTREMITY, ABOVE KNEE,FLEXIBLE INNER SOCK $543.77 20060701 99999999 L5652 ADDITION TO LOWER EXTREMITY,SUCTION SUSPENSION,ABOVE KNEE $110.48 20060701 99999999 L5653 ADDITION TO LOWER EXTREMITY,KNEE DISARTICULATION,EXPANDABLE $330.47 20060701 99999999 L5654 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,SYMES $206.97 20060701 99999999 L5655 ADDITION TO LOWER EXTREMITY,SOCKET,INSERT,BELOW KNEE $181.15 20060701 99999999 L5656 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,KNEE DISARTICULATI $262.18 20060701 99999999 L5658 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,ABOVE KNEE $185.86 20060701 99999999 L5660 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,SYMES,SILICONE GEL $338.41 20030401 99999999 L5661 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,MULTI-DUROMETER SY $398.15 20060701 99999999 L5662 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,BELOW KNEE,SILICON $338.41 20030401 99999999 L5663 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,KNEE DISARTICULATI $409.65 20030401 99999999 L5664 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,ABOVE KNEE,SILICON $409.65 20030401 99999999 L5665 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,MULTI-DUROMETER $412.36 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 65
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