Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END L6380 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INIT $699.76 20060701 99999999 L6382 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INIT $875.01 20060701 99999999 L6384 IMMEDIATE POST SURGICAL OR EARLY FITTING,SHOULDER DISARTICUL $1,143.18 20060701 99999999 L6386 IMMEDIATE POST SURGICAL OR EARLY FITTING,EACH ADDITIONAL CAS $277.55 20060701 99999999 L6388 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF RIGI $278.47 20060701 99999999 BELOW ELBOW,MOLDED SOCKET,ENDOSKELETAL L6400 SYSTEM,INCLUDING SOFT $1,665.84 20060701 99999999 L6450 ELBOW DISARTICULATION,MOLDED SOCKET,ENDOSKELETAL SYSTEM $1,955.43 20060701 99999999 L6500 ABOVE ELBOW,MOLDED SOCKET,ENDOSKELETAL SYSTEM,INCLUDING SOFT $1,777.67 20060701 99999999 L6550 SHOULDER DISARTICULATION,MOLDED SOCKET,ENDOSKELETAL SYSTEM $2,929.10 20060701 99999999 L6570 INTERSCAPULAR THORACIC,MOLDED SOCKET,ENDOSKELETAL SYSTEM $3,393.71 20060701 99999999 L6580 PREPARATORY,WRIST DISARTICULATION OR BELOW ELBOW,SINGLE WALL $950.62 20060701 99999999 L6582 PREPARATORY,WRIST DISARTICULATION OR BELOW ELBOW,DIRECT FORM $723.67 20060701 99999999 L6584 PREPARATORY,ELBOW DISARTICULATION OR ABOVE ELBOW,MOLD. TO PT $1,168.16 20060701 99999999 L6586 PREPARATORY,ELBOW DISARTICULATION OR ABOVE ELBOW,DIRECT FORM $984.65 20060701 99999999 L6588 PREPARATORY,SHOULDER DISARTICULATION OR INTERSCAPULAR THORAC $1,676.66 20060701 99999999 L6590 PREPARATORY,SHOULDER DISARTICULATION OR INTERSCAPULAR $1,476.86 20060701 99999999 L6600 UPPER EXTREMITY ADDITIONS,POLYCENTRIC HINGE, PAIR $160.89 20060701 99999999 L6605 UPPER EXTREMITY ADDITIONS,SINGLE PIVOT HINGE, PAIR $167.08 20060701 99999999 L6610 UPPER EXTREMITY ADDITIONS, FLEXIBLE METAL HINGE, PAIR $139.61 20060701 99999999 L6611 ADDITION TO UPPER EXTREMITY PROSTHESIS, EXTERNAL POWERED, ADDITIONAL SWITCH, ANY $30.42 20071101 99999999 L6615 UPPER EXTREMITY ADDITION, DISCONNECT LOCKING WRIST UNIT $92.45 20060701 99999999 L6616 UPPER EXTREMITY ADDITION,ADDITIONAL DISCONNECT INSERT $32.32 20060701 99999999 L6620 UPPER EXTREMITY ADDITION, FLEXION-FRICTION WRIST UNIT $201.97 20060701 99999999 L6621 UPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION WRIST WITH OR WITHOUT FRI $169.03 20071101 99999999 L6623 UPPER EXTREMITY ADDITION,SPRING ASSISTED ROTATIONAL WRIST $286.18 20060701 99999999 L6624 UPPER EXTREMITY ADDITION, FLEXION/EXTENSION AND ROTATION WRIST UNIT $278.32 20071101 99999999 L6625 UPPER EXTREMITY ADDITION,ROTATION WRIST UNIT WITH CABLE LOCK $466.88 20060701 99999999 L6628 UPPER EXTREMITY ADDITION, QUICK DISCONNECT HOOK ADAPTER $197.62 20060701 99999999 L6629 UPPER EXTREMITY ADDITION,QUICK DISCONNECT LAMINATION COLLAR $91.58 20060701 99999999 L6630 UPPER EXTREMITY ADDITION, STAINLESS STEEL, ANY WRIST $100.96 20060701 99999999 L6632 UPPER EXTREMITY ADDITION, LATEX SUSPENSION SLEEVE,EACH $28.52 20060701 99999999 L6635 UPPER EXTREMITY ADDITION, LIFT ASSIST FOR ELBOW $129.00 20060701 99999999 L6637 UPPER EXTEMITY ADDITION, NUDGE CONTROL ELBOW LOCK $223.18 20060701 99999999 L6638 UPPER EXTREMITY ADDITION TO PROSTHESIS, ELECTRIC LOCKING FEATURE, ONLY FOR USE W $1,181.29 20060701 99999999 L6639 UPPER EXTREMITY ADDITION, HEAVY DUTY FEATURE, ANY ELBOW $112.71 20071101 99999999 L6640 UPPER EXTREMITY ADDITIONS, SHOULDER ABDUCTION JOINT, PAIR $141.79 20060701 99999999 L6641 UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, PULLEY TYPE $104.81 20060701 99999999 L6642 UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER,LEVER TYPE $135.46 20060701 99999999 L6645 UPPER EXTREMITY ADDITION,SHOULDER FLEXION-ABDUCTION JOINT $234.20 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 70
PROC-CODE DESC MAC BEG END L6646 UPPER EXTREMITY ADDITION, SHOULDER JOINT, MULTIPOSITIONAL LOCKING, FLEXION, ADJU $1,489.87 20060701 99999999 L6647 UPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, BODY POWERED ACTUATOR $245.27 20060701 99999999 L6648 UPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, EXTERNAL POWERED ACTUATOR $1,536.59 20060701 99999999 L6650 UPPER EXTREMITY ADDITION,SHOULDER UNIVERSAL JOINT, EACH $244.49 20060701 99999999 L6655 UPPER EXTREMITY ADDITION, STANDARD CONTROL CABLE, EXTRA $61.39 20060701 99999999 L6660 UPPER EXTREMITY ADDITION,HEAVY DUTY CONTROL CABLE $82.19 20060701 99999999 L6665 UPPER EXTREMITY ADDITION,TEFLON, OR EQUAL, CABLE LINING $25.27 20060701 99999999 L6670 UPPER EXTREMITY ADDITION, HOOK TO HAND, CABLE ADAPTER $46.87 20060701 99999999 L6672 UPPER EXTREMITY ADDITION,HARNESS,CHEST OR SHOULDER,SADDLE TY $129.51 20060701 99999999 L6675 UPPER EXTREMITY ADDITION,HARNESS,FIGURE OF "8" EIGHT TYPE $79.86 20060701 99999999 L6676 UPPER EXTREMITY ADDITION,HARNESS,FIGURE OF "8",FOR DUAL CONT $97.18 20060701 99999999 L6677 UPPER EXTREMITY ADDITION, HARNESS, TRIPLE CONTROL, SIMULTANEOUS OPERATION OF TER $21.92 20071101 99999999 L6680 UPPER EXTREMIITY ADDITION,TEST SOCKET,WRIST DISARTICULATION $177.50 20060701 99999999 L6682 UPPER EXTREMITY ADDITION,TEST SOCKET ELBOW DISARTICULATION $160.85 20060701 99999999 L6684 UPPER EXTREMITY ADDITION,TEST SOCKET,ELBOW DISARTICULATION $301.55 20060701 99999999 L6686 UPPER EXTREMITY ADDITION, SUCTION SOCKET $43.32 20071101 99999999 L6687 UPPER EXTREMITY ADDITION,FRAME TYPE SOCKET,BELOW ELBOW OR WR $306.29 20060701 99999999 L6688 UPPER EXTREMITY ADDITION,FRAME TYPE SOCKET,ABOVE ELBOW $336.58 20060701 99999999 L6689 UPPER EXTREMITY ADDITION,FRAME TYPE SOCKET,SHOULDER DISARTIC $375.71 20060701 99999999 L6690 UPPER EXTREMITY ADDITION,FRAME TYPE SOCKET,INTERSCAPULAR $438.70 20060701 99999999 L6691 UPPER EXTREMITY ADDITION, REMOVABLE INSERT, EACH $241.43 20060701 99999999 L6692 UPPER EXTREMITY ADDITION,SILICONE GEL INSERT OR EQUAL, EACH $419.09 20060701 99999999 L6693 UPPER EXTREMITY ADDITION, EXTERNAL LOCKING ELBOW, FOREARM COUNTERBALANCE $1,341.08 20060701 99999999 L6694 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM $470.33 20060701 99999999 L6695 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM $391.94 20060701 99999999 L6696 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM $621.35 20060701 99999999 L6697 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM $621.35 20060701 99999999 L6698 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, LOCK $382.21 20060701 99999999 L6700 TERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #3 $494.36 20030401 99999999 L6703 TERMINAL DEVICE, PASSIVE HAND/MITT, ANY MATERIAL, ANY SIZE $29.81 20071101 99999999 L6704 TERMINAL DEVICE, SPORT/RECREATIONAL/WORK ATTACHMENT, ANY MATERIAL, ANY SIZE $653.14 20070101 99999999 L6705 TERMINAL DEVICE,HOOK,DORRANCE,OR EQUAL,MODEL #5 $279.72 20030401 99999999 L6706 TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LI $38.91 20071101 99999999 L6707 TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LI $143.43 20071101 99999999 L6708 TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE $93.28 20071101 99999999 L6709 TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE $135.11 20071101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 71
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Medicaid Fee Schedule without Mods 200801

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