Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END E0673 SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALF LEG $289.61 20030401 99999999 E0690 ULTRAVIOLET CABINET,APPROPRIATE FOR HOME USE $2,021.35 20030401 99999999 E0691 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROT $898.59 20030401 99999999 E0692 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROT $1,128.37 20030401 99999999 E0693 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROT $1,390.98 20030401 99999999 E0694 ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BU $4,427.34 20030401 99999999 E0700 SAFETY EQUIPMENT(EG.BELT,HARNESS OR VEST) $48.10 20071101 99999999 E0701 HELMET WITH FACE GUARD AND SOFT INTERFACE MATERIAL, PREFABRICATED $153.35 20030401 99999999 E0705 TRANSFER BOARD OR DEVICE, ANY TYPE, EACH $55.64 20071101 99999999 E0710 RESTRAINTS, ANY TYPE (BODY, CHEST, WRIST OR ANKLE) $18.39 20071101 99999999 E0720 TENS,TWO LEAD,LOCALIZED STIMULATION $487.78 20030401 99999999 E0730 TENS, FOUR LEAD, LARGER AREA/MULTIPLE NERVE STIMULATION $532.82 20030401 99999999 E0731 FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS $594.69 19990701 99999999 E0740 REPLACEMENT BATTERY FOR TENS $522.87 20030401 99999999 E0747 OSTEOGENESIS STIMULATOR/_(NON-INVASIVE) $243.07 20071101 99999999 E0748 OSTEOGENIC STIMULATOR, NONINVASIVE, SPINAL APPLICATIONS $243.07 20071101 99999999 E0749 OSTEOGENESIS STIMULATOR (SURGICALLY IMPLANTED) $235.36 20071101 99999999 E0755 ELECTRONIC SALIVARY REFLEX STIMULATION (INTRA-ORAL/NON- INVAS $100.00 20071101 99999999 E0760 OSTOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON- INVASIVE $2,912.05 20030401 99999999 E0761 NON-THERMAL PULSED HIGH FREQUENCY RADIOWAVES, HIGH PEAK POWER ELECTROMAGNETIC EN $100.00 20071101 99999999 E0764 FUNCTIONAL NEUROMUSCULAR STIMULATOR, TRANSCUTANEOUS STIMULATION OF MUSCLES OF AM $1,077.58 20060101 99999999 E0765 FDA APPROVED NERVE STIMULATOR, WITH REPLACEABLE BATTERIES, FOR TREATMENT OF NAUS $84.13 20030401 99999999 E0769 ELECTRICAL STIMULATION OR ELECTROMAGNETIC WOUND TREATMENT DEVICE, NOT OTHERWISE $84.13 20071101 99999999 E0776 IV POLE $15.60 20071101 99999999 E0779 AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION 8 HOURS OR GREATER $18.42 20071101 99999999 E0780 AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION LESS THAN 8 HOURS $10.68 20071101 99999999 E0830 AMBULATORY TRACTION DEVICE, ALL TYPES, EACH $5.00 20071101 99999999 E0840 TRACTION FRAME,ATTACHED TO HEADBOARD,SIMPLE CERVICAL TRACTIO $6.44 20071101 99999999 E0849 TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING $51.53 20071101 99999999 E0850 TRACTION STAND,FREE STANDING,SIMPLE CERVICAL TRACTION $6.44 20071101 99999999 E0855 CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME $53.38 20071101 99999999 E0860 TRACTION EQUIPMENT, OVERDOOR, CERVICAL $4.69 20071101 99999999 E0870 TRACTION FRAME ATT TO FOOTBOARD,SIMPLE EXTREMITY TRACTION $8.92 20071101 99999999 E0880 TRACTION STAND;FREE STANDING,SIMPLE EXTREMITY TRACTION $9.57 20071101 99999999 E0890 TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE PELVIC TRAC- $9.60 20071101 99999999 E0900 TRACTION STAND, FREE STANDING, SIMPLE PELVIC TRACTION, (E.G., BUCK'S) $16.42 20071101 99999999 E0910 TRAPEZE BARS, A/K/A PATIENT HELPER, ATTACHED TO BED, WITH GRAB $19.04 20071101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 24
PROC-CODE DESC MAC BEG END E0911 TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, AT $49.85 20071101 99999999 E0912 TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FR $114.47 20071101 99999999 E0920 FRACTURE FRAME,ATTACHED TO BED,INCL WEIGHTS $6.44 20071101 99999999 E0930 FRACTURE FRAME,FREE STANDING,INCLUDES WEIGHTS $13.52 20071101 99999999 E0935 PASSIVE MOTION EXERCISE DEVICE $2.15 20071101 99999999 E0940 TRAPEZE BAR,FREE STANDING, COMPLETE W/GRAB BAR $36.59 20071101 99999999 E0941 GRAVITY ASSISTED TRACTION DEVICE ANY TYPE $66.29 20071101 99999999 E0942 CERVICAL HEAD HARNESS/HALTER $2.75 20071101 99999999 E0943 CERVICAL PILLOW $14.19 20030401 99999999 E0944 PELVIC BELT/HARNESS/BOOT $3.57 20071101 99999999 E0945 EXTREMITY BELT/HARNESS $4.79 20071101 99999999 E0946 FRACTURE FRAME DUAL W/CROSS BARS,ATTACHED TO BED $497.12 20030401 99999999 E0947 FRACTURE FRAME,ATTACHEMENTS FOR COMPLEX PELVIC TRACTION $479.17 20030401 99999999 E0948 FRACTURE FRAME,ATTACHMENTS FOR COMPLEX CERVICAL TRACTION $469.39 20030401 99999999 E0950 TRAY $89.58 20040101 99999999 E0951 LOOP HEEL EACH $22.34 19990701 99999999 E0952 LOOP TOE EACH $4.11 20071101 99999999 E0955 WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, PREFABRICATED, INCLUDING FIXED MOUNTI $20.22 20071101 99999999 E0956 WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, PREFABRICATED, INCLUDING FIX $9.85 20071101 99999999 E0957 WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, PREFABRICATED, INCLUDING FIXED MOUNT $13.79 20071101 99999999 E0958 WHEELCHAIR ATTACHMENT TO CONVERT ANY WHEELCHAIR TO 1 ARM DR $43.54 20071101 99999999 E0959 AMPUTEE ADAPTER(DEVICE USED TO COMPENSATE FOR TRANSFER OF $5.48 20071101 99999999 E0960 WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY TYPE $9.10 20071101 99999999 E0961 BRAKE EXTENSION FOR WHEELCHAIR $2.14 20071101 99999999 E0962 1" CUSHION ,FOR WHEELCHAIR $52.05 20030401 99999999 E0963 2" CUSHION,FOR WHEELCHAIR $78.35 20030401 99999999 E0964 3" CUSHION , FOR WHEELCHAIR $86.18 20030401 99999999 E0965 4" CUSHION FOR WHEELCHAIR $97.96 20030401 99999999 E0966 HOOK ON HEAD REST EXTENSION $8.84 20071101 99999999 E0967 WHEELCHAIR HAND RIMS W/8 VERTICAL RUBBER TIPPED PROJECTIONS $6.46 20071101 99999999 E0968 COMMODE SEAT,WHEELCHAIR $17.49 20071101 99999999 E0969 NARROWING DEVICE,WHEELCHAIR $16.93 20071101 99999999 E0971 ANTI=TIPPING DEVICE WHEELCHAIRS $4.34 20071101 99999999 E0973 ADJ HEIGHT DETACHABLE ARMS,DESK OR FULL LENGTH,WHEELCHAIR $10.95 20071101 99999999 E0974 GRADE-AID(DEVICE TO PREVENT ROLLING BACK ON AN INCLINE) W/C $5.03 20071101 99999999 E0977 WEDGE CUSHION,WHEELCHAIR $22.63 20030401 99999999 E0978 BELT SAFETY W/AIRPLANE BUCKLE WHEELCHAIR $4.33 20071101 99999999 E0980 SAFETY VEST,WHEELCHAIR $2.99 20071101 99999999 E0981 WHEELCHAIR ACCESSORY, SEAT UPHOLSTERY, REPLACEMENT ONLY, EACH $3.76 20071101 99999999 E0982 WHEELCHAIR ACCESSORY, BACK UPHOLSTERY, REPLACEMENT ONLY, EACH $4.39 20071101 99999999 E0983 MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TO MOTORI $235.68 20071101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 25
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Medicaid Fee Schedule without Mods 200801

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