Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END L5826 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, HYDRAULIC SWING PHASE CONT $1,593.19 20060701 99999999 L5828 ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID SWI $1,948.24 20060701 99999999 L5830 ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,PNEUMATIC $1,652.94 20060701 99999999 L5840 ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, MULTIAXIAL, PNEUMATIC SWING PHASE CONTR $1,891.71 20060701 99999999 L5845 ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION FEATURE, ADJUSTABLE $846.67 20060701 99999999 L5846 ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING $4,274.02 20030401 99999999 L5847 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE $12,193.31 20030401 99999999 L5848 ADDITION TO ENDOSKELETAL, KNEE-SHIN SYSTEM, HYDRAULIC STANCE EXTENSION, DAMPENIN $507.96 20060701 99999999 L5850 ADDITION,ENDOSKELETAL SYSTEM,ABOVE KNEE OR HIP DISARTICULAT $61.12 20060701 99999999 L5855 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, MECHANICAL HIP EXTENSION ASS $182.36 20060701 99999999 L5910 ADDITION,ENDOSKELETAL SYSTEM,BELOW KNEE,ALIGNABLE SYSTEM $159.58 20060701 99999999 L5920 ADDITION,ENDOSKELETAL SYSTEM,ABOVE KNEE OR HIP DISARTICULAT $257.22 20060701 99999999 L5925 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE DISARTICULATION OR HIP DISARTICU $221.45 20060701 99999999 L5930 ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAME $1,717.16 20060701 99999999 L5940 ADDITION,ENDOSKELETAL SYSTEM,BELOW KNEE,ULTRA-LIGHT MATERIAL $275.36 20060701 99999999 L5950 ADDITION,ENDOSKELETA SYSTEM,ABOVE KNEE,ULTRA-LIGHT MATERIAL $394.82 20060701 99999999 L5960 ADDITION,ENDOSKELETAL SYSTEM,HIP DISARTICULATION,ULTRA- LIGHT $477.00 20060701 99999999 L5962 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, FLEXIBLE PROCTECTIVE OUTER SURFACE CO $350.06 20060701 99999999 L5964 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, FLEXIBLE PROTECTIVE OUTER SURFACE COV $550.92 20060701 99999999 L5966 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, FLEXIBLE PROTECTIVE OUTER SU $708.19 20060701 99999999 L5968 ALL LOWER EXTREMITY PROSTHESIS, ANKLE, MULTIAXIAL SHOCK ABSORBING SYSTEM $1,716.58 20060701 99999999 L5970 ALL LOWER EXTREMITY PROSTHESES,FOOT,EXTERNAL KEEL,SACH FOOT $137.00 20060701 99999999 L5971 ALL LOWER EXTREMITY PROSTHESIS, SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMEN $137.00 20060701 99999999 L5972 ALL LOWER EXTREMITY PROSTHESES,FLEXIBLE KEEL FOOT(SAFE,STEN) $288.47 20060701 99999999 L5974 ALL LOWER EXTREMITY PROTHESES,FOOT,SINGLE AXIS ANKLE/FOOT $208.31 20060701 99999999 L5975 ALL LOWER EXTREMITY PROSTHESIS, COMBINATION SINGLE AXIS ANKLE AND FLEXIBLE KEEL $218.99 20060701 99999999 L5976 ALL LOWER EXTREMITY PROSTHESES,ENERGY STORING FOOT $472.48 20060701 99999999 L5978 ALL LOWER EXTREMITY PROSTHESES, FOOT, MULTIAXIAL ANKLE/FOOT (GREISSINGER $256.36 20060701 99999999 L5979 ALL LOWER EXTREMITY PROSTHESES, MULTIAXIAL ANKLE/FOOT, DYNAMIC RESPONSE $1,325.96 20060701 99999999 L5980 ALL LOWER EXTREMITY PROSTHESES,FLEX FOOT SYSTEM $2,281.74 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 68
PROC-CODE DESC MAC BEG END L5981 ALL LOWER EXTREMITY PROSTHESES, FLEX-WALK SYSTEM OR EQUAL $1,567.68 20060701 99999999 L5982 ALL EXOSKELETAL LOWER EXTREMITY PROSTHESES,AXIAL ROTATION $422.15 20060701 99999999 L5984 ALL ENDOSKELETAL LOWER EXTREMITY,PROSTHESES,AXIAL ROTATION $461.35 20060701 99999999 L5985 ALL ENDOSKELETAL LOWER EXTREMITY PROTHESES, DYNAMIC PROSTHETIC PYLON $144.06 20060701 99999999 L5986 ALL LOWER EXTREMITY PROSTHESES,MULTI-AXIAL ROTATION UNIT $540.53 20060701 99999999 L5987 ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLON $540.65 20071101 99999999 L5988 ALL LOWER EXTREMITY PROSTHESIS, COMBINATION VERTICAL SHOCK AND MULTIAXIAL ROTATI $943.67 20060701 99999999 L5989 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL SYSTEM, PYLON WITH INTEGRAT $2,438.65 20030401 99999999 L5990 ADDITION TO LOWER EXTREMITY PROSTHESIS, USER ADJUSTABLE HEEL HEIGHT $148.97 20071101 99999999 L5993 ADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY FEATURE, FOOT ONLY, (FOR PATI $50.00 20071101 99999999 L5994 ADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY FEATURE, KNEE ONLY, (FOR PATI $50.00 20071101 99999999 L5995 ADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY FEATURE (FOR PATIENT WEIGHT > $50.00 20071101 99999999 L6000 PARTIAL HAND,ROBIN-AIDS,THUMB REMAINING (OR EQUAL) $1,156.04 20060701 99999999 L6010 PARTIAL HAND,ROBIN-AIDS,LITTLE AND/OR RING FINGER REMAINING $1,308.42 20060701 99999999 L6020 PARTIAL HAND,ROBIN-AIDS,NO FINGER REMAINING (OR EQUAL) $1,198.14 20060701 99999999 L6025 TRANSCARPAL/METACARPAL OR PARTIAL HAND DISARTICULATION PROSTHESIS, EXTERNAL POWE $3,780.13 20060701 99999999 L6050 WRIST DISARTICULATION,MOLDED SOCKET,FLEXIBLE ELBOW HINGES $1,545.88 20030401 99999999 L6055 WRIST DISARTICULATION,MOLDED SOCKET WITH EXPANDABLE INTERFAC $2,357.53 20030401 99999999 L6100 BELOW ELBOW,MOLDED SOCKET,FLEXIBLE ELBOW HINGE,TRICEPS PAD $1,087.80 20060701 99999999 L6110 BELOW ELBOW,MOLDED SOCKET,(MUENSTER OR NORTHWESTERN SUSPEN.) $1,462.83 20060701 99999999 L6120 BELOW ELBOW,MOLDED DOUBLE WALL SPLIT SOCKET,STEP-UP HINGES $1,643.53 20060701 99999999 L6130 BELOW ELBOW,MOLDED DOUBLE WALL SPLIT SOCKET,STUMP ACTIVATED $2,193.93 20060701 99999999 L6200 ELBOW DISARTICULATION,MOLDED SOCKET,OUTSIDE LOCKING HINGE $2,157.85 20030401 99999999 L6205 ELBOW DISARTICULATION,MOLDED SOCKET,OUTSIDE LOCKING HINGE $3,255.65 20030401 99999999 L6250 ABOVE ELBOW,MOLDED DOUBLE WALL SOCKET,INTERNAL LOCKING ELBOW $2,077.22 20060701 99999999 L6300 SHOULDER DISARTICULATION,MOLDED SOCKET,SHOULDER BULKHEAD $2,711.83 20060701 99999999 L6310 SHOULDER DISARTICULATION,PASSIVE RESTORATION(COMPLETE PROST) $2,186.69 20060701 99999999 L6320 SHOULDER DISARTICULATION,PASSIVE RESTORATION(SHOULDER CAP) $1,855.29 20030401 99999999 L6350 INTERSCAPULAR THORACIC,MOLDED SOCKET,SHOULDER BULKHEAD $3,425.17 20060701 99999999 L6360 INTERSCAPULAR THORACIC,PASSIVE RESTORATION(COMPLETE PROSTH) $2,933.03 20060701 99999999 L6370 INTERSCAPULAR THORACIC,PASSIVE RESTORATION(SHOULDER CAP ONL) $1,537.57 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 69
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Medicaid Fee Schedule without Mods 200801

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