Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END E1235 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM $167.16 20071101 99999999 E1236 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM $147.48 20071101 99999999 E1237 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM $148.77 20071101 99999999 E1238 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM $163.87 20071101 99999999 E1240 LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, (DESK OR FULL LENGTH) $105.04 20071101 99999999 E1250 LTWGT W/C FIXED FULL ARMS,SWING DETACH FOOTREST $63.11 20071101 99999999 E1260 LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL $63.11 20071101 99999999 E1270 LTWGT W/C,FIXED FULL ARMS,SWING DETACH ELEVATING LEGRESTS $63.11 20071101 99999999 E1280 HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL $148.09 20071101 99999999 E1285 HEAVY DUTY W/C,FIXED FULL ARMS,SWING AWAY DET FOOTREST $109.92 20071101 99999999 E1290 HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHAB $109.92 20071101 99999999 E1295 HEAVY DUTY W/C,FIXED FULL ARMS,ELEVATING LEGREST $131.19 20071101 99999999 E1296 SPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOOR $49.94 20071101 99999999 E1297 SPECIAL WHEELCHAIR SEAT DEPTH BY UPHOLSTERY $8.92 20071101 99999999 E1298 SPECIAL W/C SEAT DEPTH AND/OR WIDTH,BY CONSTRUCTION $43.35 20071101 99999999 E1310 WHIRLPOOL,NON-PORTABLE (BUILT IN TYPE) $231.93 20071101 99999999 E1340 REPAIR OR NONROUTINE SERVICE FOR DURABLE MEDICAL EQUIPMENT REQUIRING THE SKILL O $14.00 19990701 99999999 E1350 REPAIR OR NON-ROUTINE SERVICE (E.G., BREAKING DOWN SEALED $54.08 20030401 99999999 E1353 REGULATOR $54.08 20030401 99999999 E1355 STAND/RACK $34.32 20030401 99999999 E1372 IMMERSION EXTERNAL HEATER FOR NEBULIZER $139.15 20030401 99999999 E1390 OX $251.18 20060401 99999999 E1391 OXYGEN CONCENTRATOR, EQUIV TO 976 CU FT $200.39 20050101 99999999 E1392 OXYGEN CONCENTRATOR EQUIV TO 1220 CUBIC FEET $32.08 20060101 99999999 E1405 OXYGEN & WATER VAPOR ENRICHING SYST W/HEATED DELIVERY $258.35 20071101 99999999 E1406 OXYGEN & WATER VAPOR ENRICHING SYST W/O HEATED DELIVERY $216.50 20071101 99999999 E1500 CENTRIFUGE, FOR DIALYSIS $5.00 20071101 99999999 E1510 KIDNEY DIALYSATE DELIVERY SYST,KIDNEY MACHINE,PUMP RECIRCULA $5.00 20071101 99999999 E1520 HEPARIN INFUSION PUMP FOR DIALYSIS $5.00 20071101 99999999 E1530 AIR BUBBLE DETECTOR FOR DIALYSIS $5.00 20071101 99999999 E1540 PRESSURE ALARM FOR DIALYSIS $5.00 20071101 99999999 E1550 BATH CONDUCTIVITY METER FOR DIALYSIS $5.00 20071101 99999999 E1560 BLOOD LEAK DETECTOR FOR DIALYSIS $5.00 20071101 99999999 E1570 ADJUSTABLE CHAIR, FOR ESRD PATIENTS $5.00 20071101 99999999 E1575 TRANSDUCER PROTECTORS/FLUID BARRIERS,ANY SIZE EACH $5.00 20071101 99999999 E1580 UNIPUNCTURE CONTROL SYSTEM FOR DIALYSIS $5.00 20071101 99999999 E1590 HEMODIALYSIS MACHINE $5.00 20071101 99999999 E1592 AUTOMATIC INTERMITTENT PERITIONEAL DIALYSIS SYSTEM $5.00 20071101 99999999 E1594 CYCLER DIALYSIS MACHINE FOR PERITONEAL DIALYSIS $5.00 20071101 99999999 E1600 DELIVERY AND/OR INSTALLATION CHRGS FOR RENAL DIALYSIS EQUIP $5.00 20071101 99999999 E1610 REVERSE OSMOSIS WATER PURIFICATION SYSTEM $5.00 20071101 99999999 E1615 DEIONIZER WATER PURIFICATION SYSTEM $5.00 20071101 99999999 E1620 BLOOD PUMP FOR DIALYSIS $5.00 20071101 99999999 E1625 WATER SOFTENING SYSTEM $5.00 20071101 99999999 E1630 RECIPROCATING PERITONEAL DIALYSIS SYSTEM $5.00 20071101 99999999 E1632 WEARABLE ARTIFICIAL KIDNEY $5.00 20071101 99999999 E1634 PERITONEAL DIALYSIS CLAMPS, EACH $5.00 20071101 99999999 E1635 COMPACT PORTABLE TRAVEL HEMODIALYZER SYSTEM $5.00 20071101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 28
PROC-CODE DESC MAC BEG END E1638 HEATING PAD, FOR PERITONEAL DIALYSIS, ANY SIZE, EACH $5.00 20071101 99999999 E1639 SCALE, FOR DIALYSIS, EACH $5.00 20071101 99999999 E1700 JAW MOTION REHABILITATION SYSTEM $41.49 20071101 99999999 E1701 REPLACEMENT CUSHIONS FOR JAW MOTION REHABILITATION SYSTEM, PKG. OF 6 $11.45 20060701 99999999 E1702 REPLACEMENT MEASURING SCALES FOR JAW MOTION REHABILITATION SYSTEM, PKG. OF 200 $23.05 20060701 99999999 E1800 DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 E1801 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH ELBOW DEVICE WITH RANGE OF MOTION ADJU $121.43 20071101 99999999 E1802 DYNAMIC ADJUSTABLE FOREARM PRONATION/SUPINATION DEVICE, INCLUDES SOFT INTERFACE $326.80 20071101 99999999 E1805 DYNAMIC ADJUSTABLE WRIST EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 E1806 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH WRIST DEVICE WITH RANGE OF MOTION ADJU $99.66 20071101 99999999 E1810 DYNAMIC ADJUSTABLE KNEE EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 E1811 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH KNEE DEVICE WITH RANGE OF MOTION ADJUS $126.22 20071101 99999999 E1812 DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROL $85.99 20071101 99999999 E1815 DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 E1816 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH ANKLE DEVICE WITH RANGE OF MOTION ADJU $128.23 20071101 99999999 E1818 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH FOREARM PRONATION / SUPINATION DEVICE $130.90 20071101 99999999 E1820 SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE $8.33 20071101 99999999 E1821 REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI- DIRECTIONAL STATIC PROGRESSIVE $10.51 20071101 99999999 E1825 DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 E1830 DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 E1840 DYNAMIC ADJUSTABLE SHOULDER FLEXION / ABDUCTION / ROTATION DEVICE, INCLUDES SOFT $371.93 20071101 99999999 E1841 MULTI-DIRECTIONAL STATIC PROGRESSIVE STRETCH SHOULDER DEVICE, WITH RANGE OF $453.00 20071101 99999999 E1902 COMMUNICATION BOARD, NON-ELECTRONIC AUGMENTATIVE OR ALTERNATIVE COMMUNICATION DE $50.00 20071101 99999999 E2000 GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC $48.77 20071101 99999999 E2100 BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER $48.80 20071101 99999999 E2101 BLOOD GLUCOSE MONITOR WITH INTEGRATED LANCING/BLOOD SAMPLE $18.86 20071101 99999999 E2120 PULSE GENERATOR SYSTEM FOR TYMPANIC TREATMENT OF INNER EAR ENDOLYMPHATIC FLUID $283.52 20071101 99999999 E2201 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR EQUAL $37.31 20071101 99999999 E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES $40.29 20071101 99999999 E2203 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN 22 IN $40.71 20071101 99999999 E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES $69.15 20071101 99999999 E2205 MANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUT PROJECTIONS, ANY TYPE, REPLACEMENT $3.19 20071101 99999999 E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH $4.00 20071101 99999999 E2207 WHEELCHAIR ACCESSORY, CRUTCH AND CANE HOLDER, EACH $4.27 20071101 99999999 E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH $11.68 20071101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 29
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