| Code | Description | States | Median rate |
|---|---|---|---|
| L5000 | Partial foot, shoe insert with longitudinal arch, toe filler | 45 | $522.23 |
| L5010 | Partial foot, molded socket, ankle height, with toe filler | 45 | $1,256.78 |
| L5020 | Partial foot, molded socket, tibial tubercle height, with toe filler | 45 | $2,041.02 |
| L5050 | Ankle, symes, molded socket, sach foot | 44 | $2,374.90 |
| L5060 | Ankle, symes, metal frame, molded leather socket, articulated ankle/foot | 42 | $2,874.17 |
| L5100 | Below knee, molded socket, shin, sach foot | 44 | $2,436.06 |
| L5105 | Below knee, plastic socket, joints and thigh lacer, sach foot | 44 | $3,628.22 |
| L5150 | Knee disarticulation (or through knee), molded socket, external knee joints, shin, sach foot | 44 | $3,473.33 |
| L5160 | Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, sach foot | 44 | $3,777.87 |
| L5200 | Above knee, molded socket, single axis constant friction knee, shin, sach foot | 44 | $3,258.65 |
| L5210 | Above knee, short prosthesis, no knee joint ('stubbies'), with foot blocks, no ankle joints, each | 44 | $2,525.12 |
| L5220 | Above knee, short prosthesis, no knee joint ('stubbies'), with articulated ankle/foot, dynamically aligned, each | 42 | $2,870.26 |
| L5230 | Above knee, for proximal femoral focal deficiency, constant friction knee, shin, sach foot | 43 | $3,962.37 |
| L5250 | Hip disarticulation, canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot | 44 | $5,096.06 |
| L5270 | Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, sach foot | 41 | $5,514.26 |
| L5280 | Hemipelvectomy, canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot | 43 | $5,289.41 |
| L5301 | Below knee, molded socket, shin, sach foot, endoskeletal system | 43 | $2,376.36 |
| L5312 | Knee disarticulation (or through knee), molded socket, single axis knee, pylon, sach foot, endoskeletal system | 38 | $3,694.43 |
| L5321 | Above knee, molded socket, open end, sach foot, endoskeletal system, single axis knee | 43 | $3,237.17 |
| L5331 | Hip disarticulation, canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot | 43 | $4,803.79 |
| L5341 | Hemipelvectomy, canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot | 42 | $5,186.41 |
| L5400 | Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee | 40 | $1,226.32 |
| L5410 | Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment | 39 | $471.63 |
| L5420 | Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change 'ak' or knee disarticulation | 39 | $1,510.24 |
| L5430 | Immediate post surgical or early fitting, application of initial rigid dressing, incl. fitting, alignment and supension, 'ak' or knee disarticulation, each additional cast change and realignment | 37 | $536.43 |
| L5450 | Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, below knee | 40 | $419.23 |
| L5460 | Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, above knee | 39 | $551.14 |
| L5500 | Initial, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, direct formed | 42 | $1,322.92 |
| L5505 | Initial, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, plaster socket, direct formed | 44 | $1,756.87 |
| L5510 | Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model | 43 | $1,456.79 |
| L5520 | Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed | 44 | $1,438.35 |
| L5530 | Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model | 45 | $1,793.19 |
| L5535 | Preparatory, below knee 'ptb' type socket, non-alignable system, no cover, sach foot, prefabricated, adjustable open end socket | 44 | $1,756.91 |
| L5540 | Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, laminated socket, molded to model | 45 | $1,855.22 |
| L5560 | Preparatory, above knee- knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model | 45 | $1,984.44 |
| L5570 | Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed | 42 | $2,166.19 |
| L5580 | Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model | 44 | $2,418.70 |
| L5585 | Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, prefabricated adjustable open end socket | 43 | $2,541.23 |
| L5590 | Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon no cover, sach foot, laminated socket, molded to model | 43 | $2,451.08 |
| L5595 | Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, thermoplastic or equal, molded to patient model | 44 | $4,153.59 |
| L5600 | Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, laminated socket, molded to patient model | 44 | $4,513.86 |
| L5610 | Addition to lower extremity, endoskeletal system, above knee, hydracadence system | 42 | $2,096.47 |
| L5611 | Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4 bar linkage, with friction swing phase control | 44 | $1,577.98 |
| L5613 | Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4 bar linkage, with hydraulic swing phase control | 44 | $2,400.21 |
| L5614 | Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase control | 40 | $1,654.14 |
| L5615 | Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control | 22 | $6,662.95 |
| L5616 | Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control | 43 | $1,339.46 |
| L5617 | Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each | 41 | $529.78 |
| L5618 | Addition to lower extremity, test socket, symes | 45 | $289.37 |
| L5620 | Addition to lower extremity, test socket, below knee | 44 | $274.98 |
| L5622 | Addition to lower extremity, test socket, knee disarticulation | 45 | $384.15 |
| L5624 | Addition to lower extremity, test socket, above knee | 44 | $363.79 |
| L5626 | Addition to lower extremity, test socket, hip disarticulation | 44 | $503.15 |
| L5628 | Addition to lower extremity, test socket, hemipelvectomy | 44 | $497.64 |
| L5629 | Addition to lower extremity, below knee, acrylic socket | 44 | $316.89 |
| L5630 | Addition to lower extremity, symes type, expandable wall socket | 45 | $445.58 |
| L5631 | Addition to lower extremity, above knee or knee disarticulation, acrylic socket | 44 | $454.50 |
| L5632 | Addition to lower extremity, symes type, 'ptb' brim design socket | 45 | $227.74 |
| L5634 | Addition to lower extremity, symes type, posterior opening (canadian) socket | 44 | $316.54 |
| L5636 | Addition to lower extremity, symes type, medial opening socket | 45 | $252.32 |
| L5637 | Addition to lower extremity, below knee, total contact | 44 | $315.87 |
| L5638 | Addition to lower extremity, below knee, leather socket | 42 | $506.42 |
| L5639 | Addition to lower extremity, below knee, wood socket | 42 | $1,162.72 |
| L5640 | Addition to lower extremity, knee disarticulation, leather socket | 44 | $674.54 |
| L5642 | Addition to lower extremity, above knee, leather socket | 44 | $621.79 |
| L5643 | Addition to lower extremity, hip disarticulation, flexible inner socket, external frame | 44 | $1,527.98 |
| L5644 | Addition to lower extremity, above knee, wood socket | 42 | $584.19 |
| L5645 | Addition to lower extremity, below knee, flexible inner socket, external frame | 44 | $789.18 |
| L5646 | Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket | 44 | $539.67 |
| L5647 | Addition to lower extremity, below knee suction socket | 45 | $782.92 |
| L5648 | Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket | 44 | $651.18 |
| L5649 | Addition to lower extremity, ischial containment/narrow m-l socket | 43 | $1,955.70 |
| L5650 | Additions to lower extremity, total contact, above knee or knee disarticulation socket | 44 | $500.98 |
| L5651 | Addition to lower extremity, above knee, flexible inner socket, external frame | 43 | $1,192.65 |
| L5652 | Addition to lower extremity, suction suspension, above knee or knee disarticulation socket | 44 | $431.22 |
| L5653 | Addition to lower extremity, knee disarticulation, expandable wall socket | 44 | $606.76 |
| L5654 | Addition to lower extremity, socket insert, symes, (kemblo, pelite, aliplast, plastazote or equal) | 45 | $332.93 |
| L5655 | Addition to lower extremity, socket insert, below knee (kemblo, pelite, aliplast, plastazote or equal) | 44 | $275.01 |
| L5656 | Addition to lower extremity, socket insert, knee disarticulation (kemblo, pelite, aliplast, plastazote or equal) | 45 | $389.64 |
| L5658 | Addition to lower extremity, socket insert, above knee (kemblo, pelite, aliplast, plastazote or equal) | 44 | $377.28 |
| L5661 | Addition to lower extremity, socket insert, multi-durometer symes | 43 | $616.03 |
| L5665 | Addition to lower extremity, socket insert, multi-durometer, below knee | 44 | $501.47 |
| L5666 | Addition to lower extremity, below knee, cuff suspension | 45 | $71.48 |
| L5668 | Addition to lower extremity, below knee, molded distal cushion | 43 | $101.67 |
| L5670 | Addition to lower extremity, below knee, molded supracondylar suspension ('pts' or similar) | 43 | $284.07 |
| L5671 | Addition to lower extremity, below knee / above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert | 43 | $511.70 |
| L5672 | Addition to lower extremity, below knee, removable medial brim suspension | 43 | $306.41 |
| L5673 | Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric, or equal, with or without perforations, with or without breathable material, for use with locking mechanism | 43 | $709.74 |
| L5676 | Additions to lower extremity, below knee, knee joints, single axis, pair | 44 | $354.90 |
| L5677 | Additions to lower extremity, below knee, knee joints, polycentric, pair | 40 | $494.46 |
| L5678 | Additions to lower extremity, below knee, joint covers, pair | 43 | $40.58 |
| L5679 | Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric, or equal, with or without perforations, with or without breathable material, not for use with locking mechanism | 44 | $596.80 |
| L5680 | Addition to lower extremity, below knee, thigh lacer, nonmolded | 43 | $296.71 |
| L5681 | Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code l5673 or l5679) | 43 | $1,245.53 |
| L5682 | Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded | 43 | $593.20 |
| L5683 | Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code l5673 or l5679) | 42 | $1,264.72 |
| L5684 | Addition to lower extremity, below knee, fork strap | 44 | $47.14 |
| L5685 | Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each | 45 | $119.41 |
| L5686 | Addition to lower extremity, below knee, back check (extension control) | 44 | $54.54 |
| L5688 | Addition to lower extremity, below knee, waist belt, webbing | 44 | $60.42 |
| L5690 | Addition to lower extremity, below knee, waist belt, padded and lined | 44 | $97.68 |
| L5692 | Addition to lower extremity, above knee, pelvic control belt, light | 44 | $131.43 |
| L5694 | Addition to lower extremity, above knee, pelvic control belt, padded and lined | 44 | $177.68 |
| L5695 | Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each | 43 | $164.10 |
| L5696 | Addition to lower extremity, above knee or knee disarticulation, pelvic joint | 44 | $183.16 |
| L5697 | Addition to lower extremity, above knee or knee disarticulation, pelvic band | 45 | $82.74 |
| L5698 | Addition to lower extremity, above knee or knee disarticulation, silesian bandage | 44 | $109.34 |
| L5699 | All lower extremity prostheses, shoulder harness | 43 | $186.87 |
| L5700 | Replacement, socket, below knee, molded to patient model | 44 | $2,821.57 |
| L5701 | Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model | 44 | $3,500.41 |
| L5702 | Replacement, socket, hip disarticulation, including hip joint, molded to patient model | 44 | $4,543.64 |
| L5703 | Ankle, symes, molded to patient model, socket without solid ankle cushion heel (sach) foot, replacement only | 37 | $2,216.41 |
| L5704 | Custom shaped protective cover, below knee | 44 | $569.88 |
| L5705 | Custom shaped protective cover, above knee | 44 | $950.73 |
| L5706 | Custom shaped protective cover, knee disarticulation | 43 | $981.32 |
| L5707 | Custom shaped protective cover, hip disarticulation | 43 | $1,355.02 |
| L5710 | Addition, exoskeletal knee-shin system, single axis, manual lock | 45 | $359.52 |
| L5711 | Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light material | 44 | $534.36 |
| L5712 | Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) | 45 | $422.03 |
| L5714 | Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control | 45 | $423.28 |
| L5716 | Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock | 45 | $742.78 |
| L5718 | Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control | 45 | $892.21 |
| L5722 | Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control | 45 | $963.93 |
| L5724 | Addition, exoskeletal knee-shin system, single axis, fluid swing phase control | 45 | $1,531.83 |
| L5726 | Addition, exoskeletal knee-shin system, single axis, external joints fluid swing phase control | 45 | $1,873.56 |
| L5728 | Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control | 44 | $2,418.46 |
| L5780 | Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control | 44 | $1,132.41 |
| L5781 | Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system | 36 | $3,922.14 |
| L5782 | Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty | 30 | $4,134.85 |
| L5783 | Addition to lower extremity, user adjustable, mechanical, residual limb volume management system (with or without lamination kit) | 27 | $2,695.95 |
| L5785 | Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) | 43 | $510.16 |
| L5790 | Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) | 43 | $704.29 |
| L5795 | Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) | 42 | $1,059.79 |
| L5810 | Addition, endoskeletal knee-shin system, single axis, manual lock | 44 | $481.54 |
| L5811 | Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material | 43 | $717.82 |
| L5812 | Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) | 45 | $556.39 |
| L5814 | Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock | 44 | $3,516.59 |
| L5816 | Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock | 45 | $832.93 |
| L5818 | Addition, endoskeletal knee-shin system, polycentric, friction swing, and stance phase control | 44 | $911.26 |
| L5822 | Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control | 44 | $1,731.37 |
| L5824 | Addition, endoskeletal knee-shin system, single axis, fluid swing phase control | 45 | $1,580.70 |
| L5826 | Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame | 41 | $3,032.61 |
| L5827 | Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping | 18 | $6,869.77 |
| L5828 | Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control | 45 | $2,863.06 |
| L5830 | Addition, endoskeletal knee-shin system, single axis, pneumatic/ swing phase control | 44 | $1,916.59 |
| L5840 | Addition, endoskeletal knee/shin system, 4-bar linkage or multiaxial, pneumatic swing phase control | 42 | $3,587.30 |
| L5841 | Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control | 23 | $2,846.70 |
| L5845 | Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable | 44 | $1,723.32 |
| L5848 | Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability | 40 | $1,013.63 |
| L5850 | Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist | 44 | $127.56 |
| L5855 | Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist | 43 | $314.65 |
| L5856 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type | 30 | $23,555.13 |
| L5857 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type | 30 | $8,267.28 |
| L5858 | Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type | 27 | $18,271.46 |
| L5859 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s) | 21 | $14,555.24 |
| L5910 | Addition, endoskeletal system, below knee, alignable system | 44 | $357.23 |
| L5920 | Addition, endoskeletal system, above knee or hip disarticulation, alignable system | 44 | $519.66 |
| L5925 | Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock | 42 | $354.46 |
| L5926 | Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type | 25 | $731.46 |
| L5930 | Addition, endoskeletal system, high activity knee control frame | 42 | $3,236.25 |
| L5940 | Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) | 44 | $514.75 |
| L5950 | Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) | 44 | $775.80 |
| L5960 | Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) | 44 | $1,046.95 |
| L5961 | Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control | 24 | $4,814.67 |
| L5962 | Addition, endoskeletal system, below knee, flexible protective outer surface covering system | 43 | $594.36 |
| L5964 | Addition, endoskeletal system, above knee, flexible protective outer surface covering system | 43 | $1,026.31 |
| L5966 | Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system | 41 | $1,323.28 |
| L5968 | Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature | 40 | $3,387.88 |
| L5969 | Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s) | 17 | $12,690.06 |
| L5970 | All lower extremity prostheses, foot, external keel, sach foot | 45 | $203.12 |
| L5971 | All lower extremity prosthesis, solid ankle cushion heel (sach) foot, replacement only | 39 | $217.27 |
| L5972 | All lower extremity prostheses, foot, flexible keel | 44 | $367.20 |
| L5973 | Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source | 22 | $17,779.91 |
| L5974 | All lower extremity prostheses, foot, single axis ankle/foot | 44 | $231.84 |
| L5975 | All lower extremity prosthesis, combination single axis ankle and flexible keel foot | 44 | $432.19 |
| L5976 | All lower extremity prostheses, energy storing foot (seattle carbon copy ii or equal) | 44 | $553.91 |
| L5978 | All lower extremity prostheses, foot, multiaxial ankle/foot | 42 | $291.66 |
| L5979 | All lower extremity prosthesis, multi-axial ankle, dynamic response foot, one piece system | 44 | $2,395.63 |
| L5980 | All lower extremity prostheses, flex foot system | 44 | $3,858.28 |
| L5981 | All lower extremity prostheses, flex-walk system or equal | 44 | $3,109.18 |
| L5982 | All exoskeletal lower extremity prostheses, axial rotation unit | 44 | $601.59 |
| L5984 | All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability | 44 | $585.89 |
| L5985 | All endoskeletal lower extremity prostheses, dynamic prosthetic pylon | 45 | $267.40 |
| L5986 | All lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) | 44 | $662.92 |
| L5987 | All lower extremity prosthesis, shank foot system with vertical loading pylon | 39 | $6,706.67 |
| L5988 | Addition to lower limb prosthesis, vertical shock reducing pylon feature | 43 | $1,814.94 |
| L5990 | Addition to lower extremity prosthesis, user adjustable heel height | 38 | $1,735.16 |
| L5991 | Addition to lower extremity prostheses, osseointegrated external prosthetic connector | 18 | $10,129.00 |
| L5992 | All lower extremity prosthesis, foot shell for modular foot/non-solid ankle cushion heel (sach) replacement only | 15 | $114.72 |
Published Medicaid fee-for-service schedule amounts, not a coverage or eligibility guarantee. Managed-care plan rates can differ. Where no prior-authorization flag is shown, the state does not publish one. Descriptions are ProviderSignal's own plain-language labels or public-domain CMS text.