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 />
L7266 SERVO CONTROL,STEEPER OR EQUAL $513.76 20060701 99999999<br />
L7272 ANALOGUE CONTROL,UNB OR EQUAL $1,098.94 20060701 99999999<br />
L7274 PROPORTIONAL CONTROL,12 VOLT,UTAH OR EQUAL $3,437.72 20060701 99999999<br />
L7360 SIX VOLT BATTERY,OTTO BOCK OR EQUAL,EACH $128.38 20060701 99999999<br />
L7362 BATTERY CHARGER,SIX VOLT,OTTO BOCK OR EQUAL $134.84 20060701 99999999<br />
L7364 TWELVE VOLT BATTERY,UTAH OR EQUAL,EACH $247.06 20060701 99999999<br />
L7366 BATTERY CHARGER,TWELVE VOLT,UTAH OR EQUAL $323.22 20060701 99999999<br />
L7367 LITHIUM ION BATTERY, REPLACEMENT $183.91 20060701 99999999<br />
L7368 LITHIUM ION BATTERY CHARGER $238.40 20060701 99999999<br />
L7400<br />
ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST<br />
DISARTICULATION, ULTRA $144.77 20060701 99999999<br />
L7401<br />
ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW<br />
DISARTICULATION, ULTRALIGHT $162.07 20060701 99999999<br />
L7402<br />
ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER<br />
DISARTICULATION/INTERSCAPULAR T $175.03 20060701 99999999<br />
L7403<br />
ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST<br />
DISARTICULATION, ACRYL $173.96 20060701 99999999<br />
L7404<br />
ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW<br />
DISARTICULATION, ACRYLIC MAT $262.55 20060701 99999999<br />
L7405<br />
ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER<br />
DISARTICULATION/INTERSCAPULAR T $343.38 20060701 99999999<br />
L7500<br />
REPAIR OF PROSTHETIC DEVICE,HOURLY RATE(EXCLUDES V3014<br />
REP) $56.00 20071101 99999999<br />
L7510 REPAIR PROSTHETIC DEVICE,REPAIR OR REPLACE MINOR PARTS $7.80 20030401 99999999<br />
L7520 REPAIR PROSTHETIC DEVICE, LABOR COMPONENT, PER 15 MINUTES $14.00 20060101 99999999<br />
L7900 VACUUM ERECTION SYSTEM $410.44 20030401 99999999<br />
L8000 BREAST PROSTHESIS,MASTECTOMY BRA $34.21 20060701 99999999<br />
L8001<br />
BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED<br />
BREAST PROSTHESIS FORM, UNILA $98.74 20060701 99999999<br />
L8002<br />
BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED<br />
BREAST PROSTHESIS FORM, BILAT $129.88 20060701 99999999<br />
L8010 BREAST PROSTHESIS,MASTECTOMY SLEEVE $35.30 20071101 99999999<br />
L8015<br />
EXTERNAL BREAST PROSTHESIS GARMENT, WITH MASTECTOMY<br />
FORM, POST MASTECTOMY $46.35 20060701 99999999<br />
L8020 BREAST PROSTHESIS,MASTECTOMY FORM $175.95 20060701 99999999<br />
L8030 BREAST PROSTHESIS,SILICONE OR EQUAL $229.69 20060701 99999999<br />
L8035<br />
CUSTOM BREAST PROSTHESIS, POST MASTECTOMY, MOLDED TO<br />
PATIENT MODEL $1,730.61 20060701 99999999<br />
L8040 NASAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $1,269.52 20060701 99999999<br />
L8041 MIDFACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $1,530.25 20060701 99999999<br />
L8042 ORBITAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $2,865.62 20060701 99999999<br />
L8043 UPPER FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $3,209.50 20060701 99999999<br />
L8044 HEMI-FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $3,553.37 20060701 99999999<br />
L8045 AURICULAR PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $2,237.14 20060701 99999999<br />
L8046 PARTIAL FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $2,292.50 20060701 99999999<br />
L8047 NASAL SEPTAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $1,174.90 20060701 99999999<br />
L8049<br />
REPAIR OR MODIFICATION OF MAXILLOFACIAL PROSTHESIS, LABOR<br />
COMPONENT, 15 MINUTE I $18.82 20030401 99999999<br />
L8100 ELASTIC SUPPORT, ELASTIC STOCKING, BELOW KNEE, MEDIUM $28.08 20030401 99999999<br />
L8110<br />
ELASTIC SUPPORT,ELASTIC STOCKING,BELOW KNEE,HEAVY WEIGHT<br />
EAC $38.48 20030401 99999999<br />
L8130<br />
ELASTIC SUPPORT,ELASTIC STOCKING,ABOVE KNEE,MEDIUM WEIGHT<br />
EA $20.80 20030401 99999999<br />
L8140<br />
ELASTIC SUPPORT,ELASTIC STOCKING,ABOVE KNEE,HEAVY<br />
WEIGHT,EAC $26.00 20030401 99999999<br />
L8150<br />
ELASTIC SUPPORT,ELASTIC STOCKING,ABOVE KNEE,SURGICAL<br />
WEIGHT $33.28 20030401 99999999<br />
Hawaii <strong>Medicaid</strong> <strong>Fee</strong> <strong>Schedule</strong> <strong>without</strong> <strong>Mods</strong> 01/2008 74