Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END E0984 MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TO MOTORI $116.69 20071101 99999999 E0985 WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM $18.25 20071101 99999999 E0986 MANUAL WHEELCHAIR ACCESSORY, PUSH-RIM ACTIVATED POWER ASSIST, EACH $413.47 20071101 99999999 E0990 ELEVATING LEG REST EACH $16.71 20071101 99999999 E0992 SOLID SEAT INSERT $6.50 20071101 99999999 E0994 ARM REST,EACH $3.30 20071101 99999999 E0995 CALF REST,EACH $3.15 20071101 99999999 E0997 CASTER WITH A FORK $169.31 20030401 99999999 E0998 CASTER WITHOUT FORK $135.78 20030401 99999999 E0999 PNEUMATIC TIRE W WHEEL $72.50 20030401 99999999 E1001 WHEEL SINGLE $73.28 20030401 99999999 E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY $4,364.78 20071101 99999999 E1003 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTIO $395.21 20071101 99999999 E1004 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR $4,438.21 20071101 99999999 E1005 REPLACEMENT, BATTERIES FOR MEDICALLY NECESSARY ELECTRIC $4,474.33 20071101 99999999 E1006 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOU $581.01 20071101 99999999 E1007 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH M $786.71 20071101 99999999 E1008 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH P $786.78 20071101 99999999 E1009 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG $97.22 20071101 99999999 E1010 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYST $102.94 20071101 99999999 E1011 MODIFICATION TO PEDIATRIC WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPEN $50.00 20071101 99999999 E1014 RECLINING BACK, ADDITION TO PEDIATRIC WHEELCHAIR $32.86 20071101 99999999 E1015 SHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACH $11.46 20071101 99999999 E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH $13.14 20071101 99999999 E1017 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MANUAL WHEELCHAIR, $13.14 20071101 99999999 E1018 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, E $13.14 20071101 99999999 E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR $24.32 20071101 99999999 E1028 WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWA $206.54 20071101 99999999 E1029 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED $36.95 20071101 99999999 E1030 ROLLABOUT CHAIR, WITHOUT ARMS $116.53 20071101 99999999 E1031 WHLCHR,STNDRD,DETACH DESK $54.41 20071101 99999999 E1035 GERIATRIC CHAIR $613.20 20071101 99999999 E1037 TRANSPORT CHAIR, PEDIATRIC SIZE $97.64 20071101 99999999 E1038 TRANSPORT CHAIR, ADULT SIZE $40.01 20071101 99999999 E1039 TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY 250 POUNDS OR $40.01 20071101 99999999 E1050 FULLY-RECLIN W/C,FIXED FULL LENGTH ARMS,SWING AWAY DET ELEV $182.95 20071101 99999999 E1060 FULLY RECLIN W/C DETACH ARMS,DESK,OR FULL LENGTH ,DET LEG $119.14 20071101 99999999 E1065 POWER ATT(TO CONVERT W/C TO MOTORIZED WHEELCHAIR) $2,922.58 20030401 99999999 E1070 FULLY-RECLIN W/C,DET ARMS , SWING AWAY DET FOOTREST $117.06 20071101 99999999 E1083 HEMI/ W/C FIXED FULL LENGTH ARMS,SWING AWAY DET ELEVAT LEG $96.20 20071101 99999999 E1084 HEMI-W/C, DET ARMS DESK OR FULL LNGTH ARMS,SWING AWAY LEG $112.84 20071101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 26
PROC-CODE DESC MAC BEG END E1085 HEMI-W/C FIXED FULL LGNTH ARMS,SWING AWAY DET FOOT RESTS $76.96 20071101 99999999 E1086 HEMI-W/C DET ATMS DESK OR FULL,SWING AWAY DET FOOTRESTS $96.20 20071101 99999999 E1087 HIGH STRENGTH LTWGT W/C,FIXED FULL ARMS,SWING AWAY DET ELEVA $165.56 20071101 99999999 E1088 HIGH STRENGTH LTWGT W/C,DET ARMS DESK OR FULL,DET ELEV LEG $126.88 20071101 99999999 E1089 HIGH STRGTH LTWGT W/C,FIXED ARMS,SWING AWAY DET FOOTRESTS $139.41 20071101 99999999 E1090 HIGH STRENGTH LTWGT W/C,DET ARMS DESK OR FULL,DRT FOOT RESTS $119.08 20071101 99999999 E1092 WIDE HEAVY DUTY W/C,DET ARMS DESK OR FULL,SWING DET ELEV LEG $109.95 20071101 99999999 E1093 WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL $177.97 20071101 99999999 E1100 SEMI-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING $135.20 20071101 99999999 E1110 SEMI-RECLIN W/C DET ARMS,ELEVATING LEG REST $135.20 20071101 99999999 E1130 STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING $57.72 20071101 99999999 E1140 WHEELCHAIR,DETACH ARMS,DESK/FULL LENGTH,SWING DETACH FOOTRES $57.72 20071101 99999999 E1150 W/C,DET ARMS,_DESK OR FULL SWING AWAY DET ELEVATING LEGRESTS $83.20 20071101 99999999 E1160 WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE $74.36 20071101 99999999 E1161 MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE $235.92 20071101 99999999 E1170 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY $86.55 20071101 99999999 E1171 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, $83.08 20071101 99999999 E1172 AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) $126.78 20071101 99999999 E1180 AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) $116.54 20071101 99999999 E1190 AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) $111.51 20071101 99999999 E1195 HEAVY DUTY W/C,FIXED OR FULL ARMS,SWING DET ELEVAT LEGRESTS $147.78 20071101 99999999 E1200 AMPUTEE W/C,FIXED FULL ARMS,SWING DETACH FOOTREST $101.83 20071101 99999999 E1211 MOTORIZED W/C,DET ARMS DESK OR FULL SWING,DET ELEV LEG REST $3,844.44 20030401 99999999 E1220 W/C;SPECIALLY SIZED OR CONSTRUCTED,AND JUSTIFICATION $268.01 20071101 99999999 E1221 WHEELCHAIR WITH FIXED ARM, FOOTRESTS $43.16 20071101 99999999 E1222 WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS $74.36 20071101 99999999 E1223 WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS $70.69 20071101 99999999 E1224 WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS $79.82 20071101 99999999 E1225 SEMI-RECLINING BACK FOR CUSTOMIZED WHEEL CHAIR $37.36 20071101 99999999 E1226 FULL RECLINING BACK FOR CUSTOMIZED WHEELCHAIR $73.89 20071101 99999999 E1227 SPECIAL HEIGHT ARMS FOR WHEELCHAIR $13.34 20071101 99999999 E1228 SPECIAL BACK HEIGHT FOR WHEELCHAIR $36.40 20071101 99999999 E1230 POWER OPER VEHICLE(3 WHEEL NON-HIGHWAY) INDICATE BRAND NAME $196.46 20071101 99999999 E1231 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITH SEATING SYSTE $189.20 20071101 99999999 E1232 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEATING SYS $192.45 20071101 99999999 E1233 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SEATING SY $199.41 20071101 99999999 E1234 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT SEATING $192.89 20071101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 27
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