Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END L5666 ADDITION TO LOWER EXTREMITY,BELOW KNEE,CUFF SUSPENSION $52.10 20060701 99999999 L5667 ADDITION TO LOWER EXTREMITY, BELOW KNEE, SOCKET INSERT, SUCTION SUSPENSION, WITH $1,446.63 20030401 99999999 L5668 ADDITION TO LOWER EXTREMITY,BELOW KNEE,MOLDED DISTAL CUSHION $73.26 20060701 99999999 L5669 ADDITION TO LOWER EXTREMITY, BELOW KNEE, SOCKET INSERT, SUCTION SUSPENSION WITHO $927.20 20030401 99999999 L5670 ADDITION TO LOWER EXTREMITY,BELOW KNEE,MOLDED SUPRACONDYLAR $195.23 20060701 99999999 L5671 ADDITION TO LOWER EXTREMITY, BELOW KNEE / ABOVE KNEE SUSPENSION LOCKING MECHANIS $382.21 20060701 99999999 L5672 ADDITION TO LOWER EXTREMITY,BELOW KNEE,REMOVABLE MEDIAL BRIM $156.15 20060701 99999999 L5673 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXIST $470.33 20060701 99999999 L5674 ADDITION TO LOWER EXTREMITY,BELOW KNEE,LATEX SLEEVE $73.43 20030401 99999999 L5675 ADDITION TO LOWER EXTREMITY, BELOW KNEE, LATEX SLEEVE SUSPEN $106.64 20030401 99999999 L5676 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE,KNEE JOINTS,SINGLE $259.25 20060701 99999999 L5677 ADDITIONS TO LOWER EXTREMITY,BELOW KNEE JOINTS,POLYCENTRIC $426.59 20060701 99999999 L5678 ADDITIONS TO LOWER EXTREMITY,BELOW KNEE,JOINT COVERS,PAIR $42.22 20060701 99999999 L5679 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXIST $391.94 20060701 99999999 L5680 ADDITION TO LOWER EXTREMITY,BELOW KNEE,THIGH LACER,NONMOLDED $154.37 20060701 99999999 L5681 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INS $621.35 20060701 99999999 L5682 ADDITION TO LOWER EXTREMITY,BELOW KNEE,THIGH LACER,GLUTEAL $490.16 20060701 99999999 L5683 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INS $621.35 20060701 99999999 L5684 ADDITION TO LOWER EXTREMITY,BELOW KNEE,FORK STRAP $55.14 20060701 99999999 L5685 ADDITION TO LOWER EXTREMITY PROSTHESIS, BELOW KNEE, SUSPENSION/SEALING SLEEVE, $60.50 20060701 99999999 L5686 ADDITION TO LOWER EXTREMITY,BELOW KNEE,BACK CHECK(EXT. CONT) $32.13 20060701 99999999 L5688 ADDITION TO LOWER EXTREMITY,BELOW KNEE,WAIST BELT,WEBBING $56.23 20060701 99999999 L5690 ADDITION TO LOWER EXTREMITY,BELOW KNEE,WAIST BELT,PADDED & L $68.65 20060701 99999999 L5692 ADDITION TO LOWER EXTREMITY,ABOVE KNEE,PELVIC CONTROL BELT $115.36 20060701 99999999 L5694 ADDITION TO LOWER EXTREMITY,ABOVE KNEE,PELVIC CONTROL BELT $147.77 20060701 99999999 L5695 ADDITION TO LOWER EXTREMITY,ABOVE KNEE,PELVIC CONTROL,SLEEVE $109.08 20060701 99999999 L5696 ADDITION TO LOWER EXTREMITY,ABOVE KNEE OR KNEE DISARTICULAT $143.37 20060701 99999999 L5697 ADDITION TO LOWER EXTREMITY,ABOVE KNEE OR KNEE DISARTICULATI $62.29 20060701 99999999 L5698 ADDITION TO LOWER EXTREMITY,ABOVE KNEE DISARTICULATION,SILES $70.70 20060701 99999999 L5699 ALL LOWER EXTREMITY PROSTHESES,SHOULDER HARNESS $223.78 20060701 99999999 L5700 ALL LOWER EXTREMITY PROSTHESES,FOOT,EXTERNAL KEEL,SACH FOOT $1,514.74 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 66
PROC-CODE DESC MAC BEG END L5701 ALL LOWER EXTREMITY PROSTHESES,SAFE FOOT $2,050.79 20060701 99999999 L5702 ALL LOWER EXTREMITY PROSTHESES,FOOT,SINGLE AXIS ANKLE/FOOT $3,138.63 20060701 99999999 L5703 ALL LOWER EXTREMITY PROSTHESES,ENERGY STORING FOOT $1,226.65 20060701 99999999 L5704 ALL LOWER EXTREMITY PROSTHESES,FOOT,MULTIAXIAL ANKLE/FOOT $444.89 20060701 99999999 L5705 ALL LOWER EXTREMITY PROSTHESES,FLEX FOOT SYSTEM $497.59 20060701 99999999 L5706 ALL EXOSKELETAL LOVER EXTREMITY PROSTHESES,AXIAL ROTATION UN $491.78 20060701 99999999 L5707 ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESES,AXIAL ROTATION $656.73 20060701 99999999 L5710 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL LOC $329.38 20060701 99999999 L5711 ADDITION EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL LOC $387.04 20060701 99999999 L5712 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FRICTION $382.69 20060701 99999999 L5714 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,VARIABLE $246.06 20060701 99999999 ADDITION,EXOSKELETAL KNEE-SHIN L5716 SYSTEM,POLYCENTRIC,MECHANICAL $600.34 20060701 99999999 L5718 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC,FRICTION $647.06 20060701 99999999 L5722 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,PNEUMATIC $560.77 20060701 99999999 L5724 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID SWIN $994.34 20060701 99999999 L5726 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,EXTERNAL $1,014.29 20060701 99999999 L5728 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID SWIN $1,845.55 20060701 99999999 L5780 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,PNEUMATIC $920.90 20060701 99999999 L5781 ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT $1,890.05 20060701 99999999 L5782 ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT $1,992.54 20060701 99999999 L5785 ADDITION,EXOSKELETAL SYSTEM,BELOW KNEE,ULTRA-LIGHT MATERIAL $285.22 20060701 99999999 L5790 ADDITION,EXOSKELETAL SYSTEM,ABOVE KNEE,ULTRA-LIGHT MATERIAL $458.34 20060701 99999999 L5795 ADDITION,EXOSKELETAL SYSTEM,HIP DISARTICULATION,ULTRA-LIGHT $591.40 20060701 99999999 L5810 ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL LO $443.88 20060701 99999999 L5811 ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL LO $649.18 20060701 99999999 L5812 ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FRICTION $496.29 20060701 99999999 L5814 HAFHASOIF JO $1,894.69 20060701 99999999 L5816 ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC,MECHANICA $795.29 20060701 99999999 L5818 ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC,FRICTION $801.31 20060701 99999999 L5822 ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,PNEUMATIC $789.20 20060701 99999999 L5824 ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID SWI $1,385.18 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 67
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Medicaid Fee Schedule without Mods 200801

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