Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END A6403 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 16 SQ. IN. LESS THAN OR EQUA $0.45 20060701 99999999 A6404 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE $0.46 20030401 99999999 A6405 GAUZE, ELASTIC, STERILE, ALL TYPES, PER LINEAR YARD $0.34 20030401 99999999 A6406 GAUZE, NON-ELASTIC, STERILE, ALL TYPES, PER LINEAR YARD $0.82 20030401 99999999 A6407 PACKING STRIPS, NON-IMPREGNATED, UP TO 2 INCHES IN WIDTH, PER LINEAR YARD $1.13 20060701 99999999 A6410 EYE PAD, STERILE, EACH $0.39 20060701 99999999 A6411 EYE PAD, NON-STERILE, EACH $0.25 20071101 99999999 A6412 EYE PATCH, OCCLUSIVE, EACH $0.17 20040101 99999999 A6422 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON- STERILE, WIDTH GREATER THAN $1.17 20030101 99999999 A6426 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE WIDTH GREATER THAN OR EQ $0.41 20040101 99999999 A6440 ZINC PASTE IMPREGNATED BANDAGE, NON-ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN O $11.38 20030401 99999999 A6441 PADDING BANDAGE, NON-ELASTIC, NON-WOVEN/NON-KNITTED, WIDTH GREATER THAN OR EQUAL $0.67 20061101 99999999 A6441 PADDING BANDAGE, NON-ELASTIC, NON-WOVEN/NON-KNITTED, WIDTH GREATER THAN OR EQUAL $0.67 20060701 99999999 A6442 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON- STERILE, WIDTH LESS THAN THR $0.17 20061101 99999999 A6442 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON- STERILE, WIDTH LESS THAN THR $0.17 20060701 99999999 A6443 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON- STERILE, WIDTH GREATER THAN $0.29 20061101 99999999 A6443 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON- STERILE, WIDTH GREATER THAN $0.29 20060701 99999999 A6444 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON- STERILE, WIDTH GREATER THAN $0.49 20061101 99999999 A6444 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON- STERILE, WIDTH GREATER THAN $0.49 20060701 99999999 A6445 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH LESS THAN THREE I $0.32 20061101 99999999 A6445 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH LESS THAN THREE I $0.32 20060701 99999999 A6446 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH GREATER THAN OR E $0.41 20061101 99999999 A6446 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH GREATER THAN OR E $0.41 20060701 99999999 A6447 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH GREATER THAN OR E $0.67 20061101 99999999 A6447 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH GREATER THAN OR E $0.67 20060701 99999999 A6448 LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH LESS THAN THREE INCHES, $1.16 20061101 99999999 A6448 LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH LESS THAN THREE INCHES, $1.16 20060701 99999999 A6449 LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL T $1.75 20061101 99999999 A6449 LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL T $1.75 20060701 99999999 A6450 LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL T $2.00 20061101 99999999 A6451 MODERATE COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD RESISTANCE OF 1.25 TO $4.00 20040101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 10
PROC-CODE DESC MAC BEG END A6452 HIGH COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD RESISTANCE GREATER THAN O $5.91 20060701 99999999 A6453 SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH LESS THAN THREE INC $0.61 20060701 99999999 A6454 SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH GREATER THAN OR EQU $0.77 20060701 99999999 A6455 SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH GREATER THAN OR EQU $1.39 20060701 99999999 A6456 ZINC PASTE IMPREGNATED BANDAGE, NON-ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN O $1.28 20060701 99999999 A6457 TUBULAR DRESSING WITH OR WITHOUT ELASTIC, ANY WIDTH, PER LINEAR YARD $1.14 20060701 99999999 A6530 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACH $28.08 20060121 99999999 A6531 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH $38.48 20060121 99999999 A6532 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40-50 MMHG, EACH $40.00 20060121 99999999 A6533 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACH $20.80 20060121 99999999 A6534 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACH $26.00 20060121 99999999 A6535 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40-50 MMHG, EACH $33.28 20060121 99999999 A6536 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18- 30 MMHG, EACH $95.00 20060121 99999999 A6537 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30- 40 MMHG, EACH $104.00 20060121 99999999 A6538 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40- 50 MMHG, EACH $104.00 20060121 99999999 A6539 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, EACH $28.08 20060121 99999999 A6540 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, EACH $28.08 20060121 99999999 A6541 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40-50 MMHG, EACH $28.08 20060121 99999999 A6542 GRADIENT COMPRESSION STOCKING, CUSTOM MADE $28.08 20060121 99999999 A6543 GRADIENT COMPRESSION STOCKING, LYMPHEDEMA $28.08 20060121 99999999 A6544 GRADIENT COMPRESSION STOCKING, GARTER BELT $1.00 20060121 99999999 A6549 GRADIENT COMPRESSION STOCKING, NOT OTHERWISE SPECIFIED $28.08 20060121 99999999 A6550 DRESSING SET FOR NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR $27.28 20060701 99999999 A6551 CANISTER SET FOR NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR $24.40 20040101 99999999 A7000 CANISTER, DISPOSABLE, USED WITH SUCTION PUMP, EACH $7.70 20030401 99999999 A7001 CANISTER, NON-DISPOSABLE, USED WITH SUCTION PUMP, EACH $30.90 20030401 99999999 A7002 TUBING, USED WITH SUCTION PUMP, EACH $3.58 20030401 99999999 A7003 ADMINISTRATION SET, WITH SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, DISPOSABL $2.08 20030401 99999999 A7004 SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, DISPOSABLE $1.64 20030401 99999999 A7005 ADMINISTRATION SET, WITH SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, NON-DISPO $28.18 20030401 99999999 A7006 ADMINISTRATION SET, WITH SMALL VOLUME FILTERED PNEUMATIC NEBULIZER $13.36 20030401 99999999 A7007 LARGE VOLUME NEBULIZER, DISPOSABLE, UNFILLED, USED WITH AEROSOL COMPRESSOR $4.93 20030401 99999999 A7010 CORRUGATED TUBING, DISPOSABLE, USED WITH LARGE VOLUME NEBULIZER, 100 FEET $21.28 20030401 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 11
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