Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END E0164 COMMODE CHAIR,MOBILE,WITH FIXED ARMS $93.60 20030401 99999999 E0165 COMMODE CHAIR,STATIONARY,W DETACHABLE ARMS $9.36 20071101 99999999 E0167 PAIL OR PAN FOR USE W/COMMODE CHAIRS $13.01 20030401 99999999 E0168 COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH OR WITHO $15.09 20071101 99999999 E0170 COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE $188.04 20071101 99999999 E0171 COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, NON- ELECTRIC, ANY TYPE $34.70 20071101 99999999 E0175 FOOT REST FOR USE WITH COMMODE CHAIR, EACH $5.81 20071101 99999999 E0176 AIR PRESSURE PAD OR CUSHION, NONPOSITIONING $155.19 20030401 99999999 E0177 WATER PRESSURE PAD OR CUSHION,NONPOSITIONING $155.19 20030401 99999999 E0178 FOOT REST FOR USE W/COMMODE CHAIR EACH $155.19 20030401 99999999 E0179 DRY PRESSURE PAD OR CUSHION, NONPOSITIONING (EGGCRATE) $52.95 20030401 99999999 E0180 PRESSURE PAD, ALTERNATING WITH PUMP $312.00 20030401 99999999 E0181 PRESSURE PAD,ALTERNATING W/PUMP,HEAVY DUTY $33.28 20071101 99999999 E0182 PUMP FOR ALTERNATION PRESSURE PAD $30.12 20071101 99999999 E0184 FLOTATION MATTRESS,DRY $10.87 20071101 99999999 E0185 DECUBITUS CARE PAD,FLOATATION OR GEL PAD,W/FORAM LEVEL PAD $36.18 20071101 99999999 E0186 AIR $41.43 20071101 99999999 E0187 WATER $41.43 20071101 99999999 E0188 SYNTHETIC SHEEPSKIN PAD $3.10 20071101 99999999 E0189 LAMBSWOOL SHEEPSKIN PAD, ANY SIZE $10.81 20071101 99999999 E0191 HEEL OR ELBOW PROTECTOR EACH $0.93 20071101 99999999 E0192 LOW PRESSURE AND POSITIONING EQUALIZATION PAD FOR WHEELCHAIR $421.03 20030401 99999999 E0194 AIR FLUIDIZED BED $3,410.32 19910101 99999999 E0196 GEL $41.43 20071101 99999999 E0197 AIR PRESSURE PAD FOR MATTRESS $36.18 20071101 99999999 E0198 WATER PRESSURE PAD FOR MATTRESS $36.18 20071101 99999999 E0199 DRY PRESSURE PAD FOR MATTRESS $8.09 20071101 99999999 E0200 HEAT LAMP,W/O STAND INCL BULB,OR INFRARED ELEMENT $10.70 20071101 99999999 E0202 PHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOTOMETER $56.14 20071101 99999999 E0205 HEAT LAMP,W/STAND,INCL BULB,OR INFRARED ELEMENT $125.06 20071101 99999999 E0210 ELECTRIC HEAT PAD, STANDARD $89.64 20071101 99999999 E0215 ELECTRIC HEAT PAD, MOIST $86.80 20071101 99999999 E0217 WATER CIRCULATING HEAT PAD WITH PUMP $647.82 20030401 99999999 E0218 WATER CIRCULATING COLD PAD WITH PUMP $50.00 20071101 99999999 E0220 HOT WATER BOTTLE $9.13 20071101 99999999 E0221 INFRARED HEATING PAD SYSTEM $2,113.46 20030401 99999999 E0225 HYDROCOLLATOR UNIT, INCLUDES PADS $39.66 20071101 99999999 E0230 ICE CAP OR COLLAR $8.26 20071101 99999999 E0235 PARAFFIN BATH UNIT,PORTABLE(SEE MED SUPPLY CODE A4265 FOR PA $52.75 20071101 99999999 E0236 PUMP FOR WATER CIRCULATING PAD $92.62 20071101 99999999 E0238 NON ELECTRIC HEAT PAD MOIST $7.85 20071101 99999999 E0239 HYDROCOLLATOR UNIT/PORTABLE $1,692.56 20030401 99999999 E0240 BATH/SHOWER CHAIR, WITH OR WITHOUT WHEELS, ANY SIZE $10.40 20071101 99999999 E0241 BATH TUB WALL RAIL, EACH $2.60 20071101 99999999 E0242 BATH TUB RAIL,FLOOR BASE $4.16 20071101 99999999 E0243 TOILET RAIL,EACH $5.41 20071101 99999999 E0244 RAISED TOILET SEAT $5.20 20071101 99999999 E0245 TUB STOOL OR BENCH $10.40 20071101 99999999 E0246 TRANSFER TUB RAIL ATTACHMENT $9.36 20071101 99999999 E0247 TRANSFER BENCH FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING $11.00 20071101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 20
PROC-CODE DESC MAC BEG END E0248 TRANSFER BENCH, HEAVY DUTY, FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING $15.00 20071101 99999999 E0249 PAD FOR WATER CIRCULATING HEAT UNIT $15.37 20071101 99999999 E0250 HOSPITAL BED, WITH SIDE RAILS, FIXED HEIGHT, WITH MATTRESS $94.30 20071101 99999999 E0251 HOSP BED,W/SIDE RAILS,FIXED HGT,W/O MATTRESS $84.70 20071101 99999999 E0255 HOSPITAL BED, WITH SIDE RAILS VARIABLE HEIGHT, HI-LO, WITH $111.42 20071101 99999999 E0256 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS $73.62 20071101 99999999 E0260 HOSP BED W/SIDE RAILS,SEMI ELECT, HEAD & FOOT ADJ,W/MATTRESS $213.72 20071101 99999999 E0261 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS $187.72 20071101 99999999 E0265 HOSPITAL BED, TOTAL ELECTRIC WITH SIDERAILS (HEAD, FOOT AND $2,365.00 20030401 99999999 E0271 MATTRESS, INNERSPRING $20.62 20071101 99999999 E0272 MATTRESS,FOAM RUBBER $22.69 20071101 99999999 E0274 OVER-BED TABLE $194.48 20030401 99999999 E0275 BED PAN, STANDARD, METAL OR PLASTIC $18.61 20030401 99999999 E0276 BED PAN, FRACTURE, METAL OR PLASTIC $17.02 20030401 99999999 E0277 ALTERNATING PRESSURE MATTRESS $703.50 20071101 99999999 E0280 BED CRADLE,ANY TYPE $4.42 20071101 99999999 E0290 HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS $94.30 20071101 99999999 E0291 HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS $84.70 20071101 99999999 E0292 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESS $111.42 20071101 99999999 E0293 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITHOUT MATTRESS $73.26 20071101 99999999 E0294 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITH $210.69 20071101 99999999 E0295 HOSPITAL BED,SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITHO $187.72 20071101 99999999 E0300 PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED $283.86 20071101 99999999 E0301 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUN $380.10 20071101 99999999 E0302 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 60 $1,000.00 20071101 99999999 E0303 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUN $286.65 20071101 99999999 E0304 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 60 $1,155.00 20071101 99999999 E0305 BED SIDE RAILS, HALF LENGTH $22.67 20071101 99999999 E0310 BED SIDE RAILS,FULL LENGTH $20.57 20071101 99999999 E0315 BED ACCESSORIES;BOARDS OR TABLES,ANY TYPE $76.00 20040501 99999999 E0316 SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE $190.46 20071101 99999999 E0325 URINAL, MALE, ANY MATERIAL $9.06 20030401 99999999 E0326 URINAL, FEMALE, ANY MATERIAL $17.40 20030401 99999999 E0371 NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LE $451.75 20071101 99999999 E0372 POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH $548.13 20071101 99999999 E0373 NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS $581.41 20071101 99999999 E0424 STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTENTS (PER UNIT $200.39 20050101 99999999 E0431 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIE $34.34 20060401 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 21
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