| Code | Description | States | Median rate |
|---|---|---|---|
| L6000 | Partial hand, thumb remaining | 17 | $1,282.68 |
| L6010 | Partial hand, little and/or ring finger remaining | 17 | $1,308.42 |
| L6020 | Partial hand, no finger remaining | 18 | $1,316.93 |
| L6026 | Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s) | 28 | $4,480.51 |
| L6028 | Partial hand, finger, and thumb prosthesis without prosthetic digit(s) /thumb, amputation at metacarpal level, including flexible or non-flexible interface, molded to patient model, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by l6692 | 11 | $1,693.00 |
| L6050 | Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad | 43 | $1,974.39 |
| L6055 | Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad | 43 | $2,809.50 |
| L6100 | Below elbow, molded socket, flexible elbow hinge, triceps pad | 44 | $2,023.24 |
| L6110 | Below elbow, molded socket, (muenster or northwestern suspension types) | 45 | $2,158.60 |
| L6120 | Below elbow, molded double wall split socket, step-up hinges, half cuff | 45 | $2,504.75 |
| L6130 | Below elbow, molded double wall split socket, stump activated locking hinge, half cuff | 45 | $2,718.09 |
| L6200 | Elbow disarticulation, molded socket, outside locking hinge, forearm | 44 | $2,730.06 |
| L6205 | Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm | 43 | $4,007.84 |
| L6250 | Above elbow, molded double wall socket, internal locking elbow, forearm | 44 | $2,794.39 |
| L6300 | Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm | 45 | $3,780.08 |
| L6310 | Shoulder disarticulation, passive restoration (complete prosthesis) | 44 | $3,114.13 |
| L6320 | Shoulder disarticulation, passive restoration (shoulder cap only) | 42 | $1,673.72 |
| L6350 | Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm | 44 | $4,065.25 |
| L6360 | Interscapular thoracic, passive restoration (complete prosthesis) | 44 | $3,149.34 |
| L6370 | Interscapular thoracic, passive restoration (shoulder cap only) | 43 | $2,149.21 |
| L6380 | Immediate post surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow | 40 | $1,222.88 |
| L6382 | Immediate post surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow | 40 | $1,539.03 |
| L6384 | Immediate post surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic | 40 | $1,956.75 |
| L6386 | Immediate post surgical or early fitting, each additional cast change and realignment | 39 | $443.24 |
| L6388 | Immediate post surgical or early fitting, application of rigid dressing only | 40 | $456.56 |
| L6400 | Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping | 43 | $2,381.68 |
| L6450 | Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping | 44 | $3,208.29 |
| L6500 | Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping | 43 | $3,171.54 |
| L6550 | Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping | 44 | $3,953.64 |
| L6570 | Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping | 44 | $4,373.01 |
| L6580 | Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, usmc or equal pylon, no cover, molded to patient model | 42 | $1,647.38 |
| L6582 | Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, usmc or equal pylon, no cover, direct formed | 43 | $1,391.04 |
| L6584 | Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, usmc or equal pylon, no cover, molded to patient model | 42 | $2,121.97 |
| L6586 | Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, usmc or equal pylon, no cover, direct formed | 42 | $1,910.06 |
| L6588 | Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, usmc or equal pylon, no cover, molded to patient model | 42 | $2,979.66 |
| L6590 | Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, usmc or equal pylon, no cover, direct formed | 43 | $2,729.61 |
| L6600 | Upper extremity additions, polycentric hinge, pair | 44 | $194.61 |
| L6605 | Upper extremity additions, single pivot hinge, pair | 44 | $183.19 |
| L6610 | Upper extremity additions, flexible metal hinge, pair | 45 | $166.96 |
| L6611 | Addition to upper extremity prosthesis, external powered, additional switch, any type | 37 | $392.00 |
| L6615 | Upper extremity addition, disconnect locking wrist unit | 45 | $180.77 |
| L6616 | Upper extremity addition, additional disconnect insert for locking wrist unit, each | 43 | $66.04 |
| L6620 | Upper extremity addition, flexion/extension wrist unit, with or without friction | 45 | $311.78 |
| L6621 | Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device | 34 | $2,236.32 |
| L6623 | Upper extremity addition, spring assisted rotational wrist unit with latch release | 43 | $673.46 |
| L6624 | Upper extremity addition, flexion/extension and rotation wrist unit | 38 | $3,511.12 |
| L6625 | Upper extremity addition, rotation wrist unit with cable lock | 45 | $523.25 |
| L6628 | Upper extremity addition, quick disconnect hook adapter, otto bock or equal | 43 | $519.09 |
| L6629 | Upper extremity addition, quick disconnect lamination collar with coupling piece, otto bock or equal | 44 | $150.17 |
| L6630 | Upper extremity addition, stainless steel, any wrist | 45 | $211.08 |
| L6632 | Upper extremity addition, latex suspension sleeve, each | 43 | $65.33 |
| L6635 | Upper extremity addition, lift assist for elbow | 43 | $188.88 |
| L6637 | Upper extremity addition, nudge control elbow lock | 43 | $379.69 |
| L6638 | Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow | 35 | $2,344.34 |
| L6640 | Upper extremity additions, shoulder abduction joint, pair | 44 | $294.26 |
| L6641 | Upper extremity addition, excursion amplifier, pulley type | 44 | $181.65 |
| L6642 | Upper extremity addition, excursion amplifier, lever type | 43 | $247.16 |
| L6645 | Upper extremity addition, shoulder flexion-abduction joint, each | 44 | $331.37 |
| L6646 | Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system | 34 | $2,973.02 |
| L6647 | Upper extremity addition, shoulder lock mechanism, body powered actuator | 36 | $489.44 |
| L6648 | Upper extremity addition, shoulder lock mechanism, external powered actuator | 32 | $3,127.57 |
| L6650 | Upper extremity addition, shoulder universal joint, each | 44 | $332.22 |
| L6655 | Upper extremity addition, standard control cable, extra | 45 | $73.58 |
| L6660 | Upper extremity addition, heavy duty control cable | 45 | $90.35 |
| L6665 | Upper extremity addition, teflon, or equal, cable lining | 45 | $45.63 |
| L6670 | Upper extremity addition, hook to hand, cable adapter | 44 | $48.73 |
| L6672 | Upper extremity addition, harness, chest or shoulder, saddle type | 45 | $174.25 |
| L6675 | Upper extremity addition, harness, (e.g., figure of eight type), single cable design | 45 | $114.07 |
| L6676 | Upper extremity addition, harness, (e.g., figure of eight type), dual cable design | 44 | $123.32 |
| L6677 | Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow | 35 | $287.98 |
| L6680 | Upper extremity addition, test socket, wrist disarticulation or below elbow | 45 | $232.73 |
| L6682 | Upper extremity addition, test socket, elbow disarticulation or above elbow | 44 | $259.59 |
| L6684 | Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic | 44 | $341.39 |
| L6686 | Upper extremity addition, suction socket | 45 | $622.68 |
| L6687 | Upper extremity addition, frame type socket, below elbow or wrist disarticulation | 45 | $559.49 |
| L6688 | Upper extremity addition, frame type socket, above elbow or elbow disarticulation | 44 | $567.07 |
| L6689 | Upper extremity addition, frame type socket, shoulder disarticulation | 44 | $689.27 |
| L6690 | Upper extremity addition, frame type socket, interscapular-thoracic | 44 | $732.25 |
| L6691 | Upper extremity addition, removable insert, each | 45 | $353.81 |
| L6692 | Upper extremity addition, silicone gel insert or equal, with or without locking mechanism, each | 44 | $553.12 |
| L6693 | Upper extremity addition, locking elbow, forearm counterbalance | 42 | $2,586.93 |
| L6694 | Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism | 43 | $709.74 |
| L6695 | Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism | 38 | $586.05 |
| L6696 | Addition to upper extremity prosthesis, below elbow/above elbow, 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 l6694 or l6695) | 38 | $1,264.72 |
| L6697 | Addition to upper extremity prosthesis, below elbow/above elbow, 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 l6694 or l6695) | 35 | $1,277.06 |
| L6698 | Addition to upper extremity prosthesis, lock mechanism, excludes socket insert | 43 | $514.04 |
| L6700 | Upper extremity addition, external powered feature, myoelectronic control module, additional emg inputs, pattern-recognition decoding intent movement | 14 | $27,340.33 |
| L6703 | Terminal device, passive hand/mitt, any material, any size | 41 | $346.38 |
| L6704 | Terminal device, sport/recreational/work attachment, any material, any size | 33 | $609.42 |
| L6706 | Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined | 42 | $363.09 |
| L6707 | Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined | 40 | $1,293.97 |
| L6708 | Terminal device, hand, mechanical, voluntary opening, any material, any size | 40 | $850.73 |
| L6709 | Terminal device, hand, mechanical, voluntary closing, any material, any size | 40 | $1,254.31 |
| L6711 | Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric | 40 | $626.79 |
| L6712 | Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric | 38 | $1,162.21 |
| L6713 | Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric | 38 | $1,472.69 |
| L6714 | Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric | 38 | $1,247.35 |
| L6715 | Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement | 15 | $3,298.89 |
| L6721 | Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined | 39 | $2,199.43 |
| L6722 | Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined | 39 | $1,903.63 |
| L6805 | Addition to terminal device, modifier wrist unit | 42 | $352.54 |
| L6810 | Addition to terminal device, precision pinch device | 44 | $191.61 |
| L6880 | Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) | 14 | $25,290.44 |
| L6881 | Automatic grasp feature, addition to upper limb electric prosthetic terminal device | 34 | $3,930.74 |
| L6882 | Microprocessor control feature, addition to upper limb prosthetic terminal device | 33 | $2,952.43 |
| L6883 | Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power | 38 | $1,671.40 |
| L6884 | Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power | 35 | $2,352.48 |
| L6885 | Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power | 35 | $3,307.41 |
| L6890 | Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment | 44 | $173.53 |
| L6895 | Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated | 41 | $606.30 |
| L6900 | Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining | 43 | $1,573.54 |
| L6905 | Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining | 43 | $1,536.55 |
| L6910 | Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining | 43 | $1,501.61 |
| L6915 | Hand restoration (shading, and measurements included), replacement glove for above | 43 | $613.13 |
| L6920 | Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal, switch, cables, two batteries and one charger, switch control of terminal device | 34 | $7,412.64 |
| L6925 | Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device | 34 | $8,122.42 |
| L6930 | Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device | 34 | $7,323.50 |
| L6935 | Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device | 36 | $8,350.17 |
| L6940 | Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device | 34 | $9,305.80 |
| L6945 | Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device | 34 | $10,502.61 |
| L6950 | Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device | 34 | $9,817.30 |
| L6955 | Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device | 34 | $11,582.78 |
| L6960 | Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device | 34 | $12,316.91 |
| L6965 | Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device | 34 | $14,086.35 |
| L6970 | Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device | 34 | $14,718.42 |
| L6975 | Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device | 33 | $16,157.32 |
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.