Medicaid Fee Schedule without Mods 200801
Medicaid Fee Schedule without Mods 200801
Medicaid Fee Schedule without Mods 200801
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PROC-CODE DESC MAC BEG END<br />
L5701 ALL LOWER EXTREMITY PROSTHESES,SAFE FOOT $2,050.79 20060701 99999999<br />
L5702<br />
ALL LOWER EXTREMITY PROSTHESES,FOOT,SINGLE AXIS<br />
ANKLE/FOOT $3,138.63 20060701 99999999<br />
L5703 ALL LOWER EXTREMITY PROSTHESES,ENERGY STORING FOOT $1,226.65 20060701 99999999<br />
L5704 ALL LOWER EXTREMITY PROSTHESES,FOOT,MULTIAXIAL ANKLE/FOOT $444.89 20060701 99999999<br />
L5705 ALL LOWER EXTREMITY PROSTHESES,FLEX FOOT SYSTEM $497.59 20060701 99999999<br />
L5706<br />
ALL EXOSKELETAL LOVER EXTREMITY PROSTHESES,AXIAL ROTATION<br />
UN $491.78 20060701 99999999<br />
L5707<br />
ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESES,AXIAL<br />
ROTATION $656.73 20060701 99999999<br />
L5710<br />
ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL<br />
LOC $329.38 20060701 99999999<br />
L5711<br />
ADDITION EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL<br />
LOC $387.04 20060701 99999999<br />
L5712 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FRICTION $382.69 20060701 99999999<br />
L5714 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,VARIABLE $246.06 20060701 99999999<br />
ADDITION,EXOSKELETAL KNEE-SHIN<br />
L5716 SYSTEM,POLYCENTRIC,MECHANICAL $600.34 20060701 99999999<br />
L5718 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC,FRICTION $647.06 20060701 99999999<br />
L5722<br />
ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE<br />
AXIS,PNEUMATIC $560.77 20060701 99999999<br />
L5724<br />
ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID<br />
SWIN $994.34 20060701 99999999<br />
L5726 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,EXTERNAL $1,014.29 20060701 99999999<br />
L5728<br />
ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID<br />
SWIN $1,845.55 20060701 99999999<br />
L5780<br />
ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE<br />
AXIS,PNEUMATIC $920.90 20060701 99999999<br />
L5781<br />
ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL<br />
LIMB VOLUME MANAGEMENT $1,890.05 20060701 99999999<br />
L5782<br />
ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL<br />
LIMB VOLUME MANAGEMENT $1,992.54 20060701 99999999<br />
L5785<br />
ADDITION,EXOSKELETAL SYSTEM,BELOW KNEE,ULTRA-LIGHT<br />
MATERIAL $285.22 20060701 99999999<br />
L5790<br />
ADDITION,EXOSKELETAL SYSTEM,ABOVE KNEE,ULTRA-LIGHT<br />
MATERIAL $458.34 20060701 99999999<br />
L5795 ADDITION,EXOSKELETAL SYSTEM,HIP DISARTICULATION,ULTRA-LIGHT $591.40 20060701 99999999<br />
L5810<br />
ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL<br />
LO $443.88 20060701 99999999<br />
L5811<br />
ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL<br />
LO $649.18 20060701 99999999<br />
L5812 ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FRICTION $496.29 20060701 99999999<br />
L5814 HAFHASOIF JO $1,894.69 20060701 99999999<br />
L5816<br />
ADDITION,ENDOSKELETAL KNEE-SHIN<br />
SYSTEM,POLYCENTRIC,MECHANICA $795.29 20060701 99999999<br />
L5818<br />
ADDITION,ENDOSKELETAL KNEE-SHIN<br />
SYSTEM,POLYCENTRIC,FRICTION $801.31 20060701 99999999<br />
L5822<br />
ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE<br />
AXIS,PNEUMATIC $789.20 20060701 99999999<br />
L5824<br />
ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID<br />
SWI $1,385.18 20060701 99999999<br />
Hawaii <strong>Medicaid</strong> <strong>Fee</strong> <strong>Schedule</strong> <strong>without</strong> <strong>Mods</strong> 01/2008 67