Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END CORRUGATED TUBING, NON-DISPOSABLE, USED WITH LARGE A7011 VOLUME NEBULIZER, 10 FEET $2.08 20030401 99999999 A7012 WATER COLLECTION DEVICE, USED WITH LARGE VOLUME NEBULIZER $2.81 20030401 99999999 A7013 FILTER, DISPOSABLE, USED WITH AEROSOL COMPRESSOR $0.76 20030401 99999999 A7014 FILTER, NONDISPOSABLE, USED WITH AEROSOL COMPRESSOR OR ULTRASONIC GENERATOR $4.36 20010101 99999999 A7015 AEROSOL MASK, USED WITH DME NEBULIZER $1.44 20030401 99999999 A7016 DOME AND MOUTHPIECE, USED WITH SMALL VOLUME ULTRASONIC NEBULIZER $11.88 20030401 99999999 A7017 NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, NOT USED WITH OX $12.78 20010101 99999999 A7018 WATER, DISTILLED, USED WITH LARGE VOLUME NEBULIZER, 1000 ML $0.51 20060701 99999999 A7019 SALINE SOLUTION, PER 10 ML, METERED DOSE DISPENSER, FOR USE WITH INHALATION DRUG $0.26 20030401 99999999 A7020 STERILE WATER OR STERILE SALINE, 1000 ML, USED WITH LARGE VOLUME NEBULIZER $2.10 20030401 99999999 A7025 HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM VEST, REPLACEMENT FOR USE WITH PATI $397.50 20071101 99999999 A7026 HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM HOSE, REPLACEMENT FOR USE WITH PATI $28.75 20030401 99999999 A7027 COMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVIC $186.52 20080101 99999999 A7028 ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, EACH $49.54 20080101 99999999 A7029 NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, PAIR $20.24 20080101 99999999 A7030 FULL FACE MASK USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH $188.64 20030401 99999999 A7031 FACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACH $69.77 20030401 99999999 A7032 REPLACEMENT CUSHION FOR NASAL APPLICATION DEVICE, EACH $40.53 20030401 99999999 A7033 REPLACEMENT PILLOWS FOR NASAL APPLICATION DEVICE, PAIR $28.41 20030401 99999999 A7034 NASAL INTERFACE (MASK OR CANNULA TYPE) USED WITH POSITIVE AIRWAY PRESSURE DEVICE $117.64 20030401 99999999 A7035 HEADGEAR USED WITH POSITIVE AIRWAY PRESSURE DEVICE $41.46 20030401 99999999 A7036 CHINSTRAP USED WITH POSITIVE AIRWAY PRESSURE DEVICE $13.94 20030401 99999999 A7037 TUBING USED WITH POSITIVE AIRWAY PRESSURE DEVICE $38.64 20030401 99999999 A7038 FILTER, DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE $3.23 20030401 99999999 A7039 FILTER, NON DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE $13.26 20030401 99999999 A7040 ONE WAY CHEST DRAIN VALVE $35.20 20071101 99999999 A7041 WATER SEAL DRAINAGE CONTAINER AND TUBING FOR USE WITH IMPLANTED CHEST TUBE $66.14 20071101 99999999 A7042 IMPLANTED PLEURAL CATHETER, EACH $159.65 20071101 99999999 A7043 VACUUM DRAINAGE BOTTLE AND TUBING FOR USE WITH IMPLANTED CATHETER $27.36 20071101 99999999 A7044 ORAL INTERFACE USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH $120.91 20030401 99999999 A7046 WATER CHAMBER FOR HUMIDIFIER, USED WITH POSITIVE AIRWAY PRESSURE DEVICE, REPLACE $19.51 20040101 99999999 A7501 TRACHEOSTOMA VALVE, INCLUDING DIAPHRAGM, EACH $100.18 20060701 99999999 A7502 REPLACEMENT DIAPHRAGM/FACEPLATE FOR TRACHEOSTOMA VALVE, EACH $47.61 20060701 99999999 A7503 FILTER HOLDER OR FILTER CAP, REUSABLE, FOR USE IN A TRACHEOSTOMA HEAT AND MOISTU $10.81 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 12
PROC-CODE DESC MAC BEG END A7504 FILTER FOR USE IN A TRACHEOSTOMA HEAT AND MOISTURE EXCHANGE SYSTEM, EACH $0.64 20060701 99999999 A7505 HOUSING, REUSABLE WITHOUT ADHESIVE, FOR USE IN A HEAT AND MOISTURE EXCHANGE SYST $4.46 20060701 99999999 A7506 ADHESIVE DISC FOR USE IN A HEAT AND MOISTURE EXCHANGE SYSTEM AND/OR WITH TRACHEO $0.32 20060701 99999999 A7507 FILTER HOLDER AND INTEGRATED FILTER WITHOUT ADHESIVE, FOR USE IN A TRACHEOSTOMA $2.37 20060701 99999999 A7508 HOUSING AND INTEGRATED ADHESIVE, FOR USE IN A TRACHEOSTOMA HEAT AND MOISTURE EXC $2.74 20060701 99999999 A7509 FILTER HOLDER AND INTEGRATED FILTER HOUSING, AND ADHESIVE, FOR USE AS A TRACHEOS $1.41 20060701 99999999 A7520 TRACHEOSTOMY/LARYNGECTOMY TUBE, NON-CUFFED, POLYVINYLCHLORIDE (PVC), SILICONE OR $47.48 20060701 99999999 A7521 TRACHEOSTOMY/LARYNGECTOMY TUBE, CUFFED, POLYVINYLCHLORIDE (PVC), SILICONE OR EQU $47.05 20060701 99999999 A7522 TRACHEOSTOMY/LARYNGECTOMY TUBE, STAINLESS STEEL OR EQUAL (STERILIZABLE AND REUSA $45.16 20061101 99999999 A7522 TRACHEOSTOMY/LARYNGECTOMY TUBE, STAINLESS STEEL OR EQUAL (STERILIZABLE AND REUSA $45.16 20060701 99999999 A7523 TRACHEOSTOMY SHOWER PROTECTOR, EACH $25.23 20071101 99999999 A7524 TRACHEOSTOMA STENT/STUD/BUTTON, EACH $77.40 20060701 99999999 A7525 TRACHEOSTOMY MASK, EACH $2.07 20061101 99999999 A7525 TRACHEOSTOMY MASK, EACH $2.07 20060701 99999999 A7526 TRACHEOSTOMY TUBE COLLAR/HOLDER, EACH $3.37 20060701 99999999 A7527 TRACHEOSTOMY/LARYNGECTOMY TUBE PLUG/STOP, EACH $3.37 20060701 99999999 A8000 HELMET, PROTECTIVE, SOFT, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES $15.33 20070101 99999999 A8001 HELMET, PROTECTIVE, HARD, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES $15.33 20070101 99999999 A8002 HELMET, PROTECTIVE, SOFT, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND ACCESSO $15.33 20071101 99999999 A8003 HELMET, PROTECTIVE, HARD, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND ACCESSO $15.33 20071101 99999999 A9500 A $83.20 20030401 99999999 A9502 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC 99M TETROF $83.20 20030401 99999999 A9503 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC 99M, MEDRO $31.20 20030401 99999999 A9505 A $59.80 20030401 99999999 A9507 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, INDIUM IN 111 CAPROMAB P $1,855.00 20040101 99999999 A9510 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC99M DISOFEN $79.17 20010101 99999999 A9515 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99M PENTET $38.00 20030101 99999999 A9516 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, I- 123 SODIUM IODIDE CAPS $36.40 20030101 99999999 A9517 SUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC IMAGING AGENT, I-131 SODIUM IODIDE CAP $117.25 20030101 99999999 A9518 SUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC IMAGING AGENT, I-131 SODIUM IODIDE SOL $146.57 20030101 99999999 A9519 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99M MACROA $85.00 20030101 99999999 A9521 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99M EXAMET $231.44 20030101 99999999 A9524 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, IODINATED I-131 SERUM AL $17.68 20030101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 13
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