Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END L7266 SERVO CONTROL,STEEPER OR EQUAL $513.76 20060701 99999999 L7272 ANALOGUE CONTROL,UNB OR EQUAL $1,098.94 20060701 99999999 L7274 PROPORTIONAL CONTROL,12 VOLT,UTAH OR EQUAL $3,437.72 20060701 99999999 L7360 SIX VOLT BATTERY,OTTO BOCK OR EQUAL,EACH $128.38 20060701 99999999 L7362 BATTERY CHARGER,SIX VOLT,OTTO BOCK OR EQUAL $134.84 20060701 99999999 L7364 TWELVE VOLT BATTERY,UTAH OR EQUAL,EACH $247.06 20060701 99999999 L7366 BATTERY CHARGER,TWELVE VOLT,UTAH OR EQUAL $323.22 20060701 99999999 L7367 LITHIUM ION BATTERY, REPLACEMENT $183.91 20060701 99999999 L7368 LITHIUM ION BATTERY CHARGER $238.40 20060701 99999999 L7400 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ULTRA $144.77 20060701 99999999 L7401 ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ULTRALIGHT $162.07 20060701 99999999 L7402 ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR T $175.03 20060701 99999999 L7403 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ACRYL $173.96 20060701 99999999 L7404 ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ACRYLIC MAT $262.55 20060701 99999999 L7405 ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR T $343.38 20060701 99999999 L7500 REPAIR OF PROSTHETIC DEVICE,HOURLY RATE(EXCLUDES V3014 REP) $56.00 20071101 99999999 L7510 REPAIR PROSTHETIC DEVICE,REPAIR OR REPLACE MINOR PARTS $7.80 20030401 99999999 L7520 REPAIR PROSTHETIC DEVICE, LABOR COMPONENT, PER 15 MINUTES $14.00 20060101 99999999 L7900 VACUUM ERECTION SYSTEM $410.44 20030401 99999999 L8000 BREAST PROSTHESIS,MASTECTOMY BRA $34.21 20060701 99999999 L8001 BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, UNILA $98.74 20060701 99999999 L8002 BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, BILAT $129.88 20060701 99999999 L8010 BREAST PROSTHESIS,MASTECTOMY SLEEVE $35.30 20071101 99999999 L8015 EXTERNAL BREAST PROSTHESIS GARMENT, WITH MASTECTOMY FORM, POST MASTECTOMY $46.35 20060701 99999999 L8020 BREAST PROSTHESIS,MASTECTOMY FORM $175.95 20060701 99999999 L8030 BREAST PROSTHESIS,SILICONE OR EQUAL $229.69 20060701 99999999 L8035 CUSTOM BREAST PROSTHESIS, POST MASTECTOMY, MOLDED TO PATIENT MODEL $1,730.61 20060701 99999999 L8040 NASAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $1,269.52 20060701 99999999 L8041 MIDFACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $1,530.25 20060701 99999999 L8042 ORBITAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $2,865.62 20060701 99999999 L8043 UPPER FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $3,209.50 20060701 99999999 L8044 HEMI-FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $3,553.37 20060701 99999999 L8045 AURICULAR PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $2,237.14 20060701 99999999 L8046 PARTIAL FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $2,292.50 20060701 99999999 L8047 NASAL SEPTAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $1,174.90 20060701 99999999 L8049 REPAIR OR MODIFICATION OF MAXILLOFACIAL PROSTHESIS, LABOR COMPONENT, 15 MINUTE I $18.82 20030401 99999999 L8100 ELASTIC SUPPORT, ELASTIC STOCKING, BELOW KNEE, MEDIUM $28.08 20030401 99999999 L8110 ELASTIC SUPPORT,ELASTIC STOCKING,BELOW KNEE,HEAVY WEIGHT EAC $38.48 20030401 99999999 L8130 ELASTIC SUPPORT,ELASTIC STOCKING,ABOVE KNEE,MEDIUM WEIGHT EA $20.80 20030401 99999999 L8140 ELASTIC SUPPORT,ELASTIC STOCKING,ABOVE KNEE,HEAVY WEIGHT,EAC $26.00 20030401 99999999 L8150 ELASTIC SUPPORT,ELASTIC STOCKING,ABOVE KNEE,SURGICAL WEIGHT $33.28 20030401 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 74
PROC-CODE DESC MAC BEG END L8170 ELASTIC SUPPORT,ELASTIC STOCKING,FULL LENGTH,HEAVY WEIGHT $104.00 20030401 99999999 L8210 ELASTIC SUPPORT,ELASTIC STOCKING,CUSTOM MADE $131.36 20030401 99999999 L8239 ELASTIC SUPPORT, NOT OTHERWISE SPECIFIED $17.77 20030401 99999999 L8300 TRUSS,SINGLE WITH STANDARD PAD $102.55 20060701 99999999 L8310 TRUSS,DOUBLE WITH STANDARD PADS $110.27 20060701 99999999 L8320 TRUSS,ADDITION TO STANDARD PAD,WATER PAD $41.59 20060701 99999999 L8330 TRUSS,ADDITION TO STANDARD PAD,SCROTAL PAD $38.87 20060701 99999999 L8400 PROSTHETIC SHEATH,BELOW KNEE,EACH $12.32 20060701 99999999 L8410 PROSTHETIC SHEATH,ABOVE KNEE,EACH $14.19 20060701 99999999 L8415 PROSTHETIC SHEATH,UPPER LIMB,EACH $12.64 20060701 99999999 L8417 PROSTHETIC SHEATH/SOCK, INCLUDING A GEL CUSHION LAYER, BELOW KNEE OR ABOVE KNEE, $38.37 20060701 99999999 L8420 PROSTHETIC SOCK, WOOL, BELOW KNEE, EACH $13.85 20060701 99999999 L8430 PROSTHETIC SOCK,WOOL,ABOVE KNEE,EACH $14.65 20060701 99999999 L8435 PROSTHETIC SOCK,WOOL,UPPER LIMB, EACH $13.85 20060701 99999999 L8440 PROSTHETIC SHRINKER,BELOW KNEE,EACH $38.87 20060701 99999999 L8460 PROSTHETIC SHRINKER,ABOVE KNEE,EACH $72.55 20060701 99999999 L8465 PROSTHETIC SHRINKER,UPPER LIMB, EACH $22.03 20060701 99999999 L8470 STUMP SOCK,SINGLE PLU,FITTING,BELOW KNEE,EACH $4.73 20060701 99999999 L8480 STUMP SOCK,SINGLE PLY,FITTING,ABOVE KNEE,EACH $5.54 20060701 99999999 L8485 STUMP SOCK, SINGLE PLY, FITTING, UPPER LIMB, EACH $6.88 20060701 99999999 L8490 ADDITION TO PROSTHETIC SHEATH/SOCK, AIR SEAL SUCTION RETENTION SYSTEM $99.66 19990701 99999999 L8499 UNLISTED PROCEDURE FOR MISCELLANEOUS PROSTHETIC SERVICES $38.93 20030401 99999999 L8500 ARTIFICIAL LARYNX,ANY TYPE $442.19 20060701 99999999 L8501 TRACHEOSTOMY SPEAKING VALVE $69.71 20060701 99999999 L8505 ARTIFICIAL LARYNX REPLACEMENT BATTERY / ACCESSORY, ANY TYPE $2.00 20071101 99999999 L8507 TRACHEO-ESOPHAGEAL VOICE PROSTHESIS, PATIENT INSERTED, ANY TYPE, EACH $19.79 20060701 99999999 L8509 TRACHEO-ESOPHAGEAL VOICE PROSTHESIS, INSERTED BY A LICENSED HEALTH CARE PROVIDER $51.59 20060701 99999999 L8510 VOICE AMPLIFIER $119.36 20060701 99999999 L8511 INSERT FOR INDWELLING TRACHEOESOPHAGEAL PROSTHESIS, WITH OR WITHOUT VALVE, REPLA $34.36 20060701 99999999 L8512 GELATIN CAPSULES OR EQUIVALENT, FOR USE WITH TRACHEOESOPHAGEAL VOICE PROSTHESIS, $1.59 20060701 99999999 L8513 CLEANING DEVICE USED WITH TRACHEOESOPHAGEAL VOICE PROSTHESIS, PIPET, BRUSH, OR E $2.45 20060701 99999999 L8514 TRACHEOESOPHAGEAL PUNCTURE DILATOR, REPLACEMENT ONLY, EACH $44.54 20060701 99999999 L8515 GELATIN CAPSULE, APPLICATION DEVICE FOR USE WITH TRACHEOESOPHAGEAL VOICE $51.83 20060701 99999999 L8600 IMPLANTABLE BREAST PROSTHESIS, SILICONE OR EQUAL $47.00 20071101 99999999 L8603 COLLAGEN IMPLANT, URINARY TRACT, PER 2.5 CC SYRINGE, INCLUDES SHIPPING AND NECES $322.40 20030401 99999999 L8609 ARTIFICIAL CORNEA $440.82 20071101 99999999 L8610 OCULAR $44.09 20071101 99999999 L8612 AQUEOUS SHUNT $45.77 20071101 99999999 L8613 OSSICULA $19.35 20071101 99999999 L8614 COCHLEAR DEVICE/SYSTEM $1,308.33 20071101 99999999 L8615 TEMPOROMANDIBULAR JOINT $30.51 20071101 99999999 L8616 MAXILLA $71.07 20071101 99999999 L8617 MANDIBLE $62.07 20071101 99999999 L8618 PALATE $17.74 20071101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 75
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Medicaid Fee Schedule without Mods 200801

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