Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END K0080 ANTI-ROLLBACK DEVICE, PAIR $82.91 20030401 99999999 K0081 WHEEL LOCK ASSEMBLY, COMPLETE, EACH $32.98 20030401 99999999 K0082 22 NF DEEP CYCLE LEAD ACID BATTERY, EACH $100.63 20030401 99999999 K0083 22 NF GEL CELL BATTERY, EACH $113.07 20030401 99999999 K0084 GROUP 24 DEEP CYCLE LEAD ACID BATTERY, EACH $74.56 20030401 99999999 K0085 GROUP 24 GEL CELL BATTERY, EACH $150.78 20030401 99999999 K0086 U-1 LEAD ACID BATTERY, EACH $100.63 20030401 99999999 K0087 U-1 GEL CELL BATTERY, EACH $90.95 20030401 99999999 K0088 BATTERY CHARGER, LEAD ACID OR GEL CELL $102.81 20030401 99999999 K0089 BATTERY CHARGER, DUAL MODE $415.72 20030401 99999999 K0090 REAR WHEEL TIRE FOR POWER WHEELCHAIR, ANY SIZE, EACH $61.76 20030401 99999999 K0091 REAR WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR POWER WHEELCHAIR, ANY SIZE, EA $16.84 20030401 99999999 K0092 REAR WHEEL ASSEMBLY FOR POWER WHEELCHAIR, COMPLETE EACH $197.08 20030401 99999999 K0093 REAR WHEEL, ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER WHEELCHAIR, ANY $123.13 20030401 99999999 K0094 WHEEL TIRE FOR POWER BASE, ANY SIZE, EACH $40.10 20030401 99999999 K0095 WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR EACH BASE, ANY SIZE, EACH $56.46 20030401 99999999 K0096 WHEEL ASSEMBLY FOR POWER BASE, COMPLETE, EACH $226.12 20030401 99999999 K0097 WHEEL ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER BASE, ANY SIZE, EACH $49.17 20030401 99999999 K0098 DRIVE BELT FOR POWER WHEELCHAIR $2.61 20071101 99999999 K0099 FRONT CASTER FOR POWER WHEELCHAIR $65.58 20030401 99999999 K0100 AMPUTEE ADAPTER, PARI $90.44 20030401 99999999 K0102 CRUTCH AND CANE HOLDER $35.14 20030401 99999999 K0103 TRANSFER BOARD,
PROC-CODE DESC MAC BEG END K0130 FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE $49.78 20030401 99999999 K0131 SPRING-POWERED DEVICE FOR LANCET $17.16 20030401 99999999 K0132 MALE EXTERNAL CATHETER WITH OR WITHOUT ADHESIVE, WITH OR WITHOUT ANTI-REFLUX DEV $1.14 20030401 99999999 K0133 INTERMITTENT URINARY CATHETER, DISPOSABLE; STRAIGHT TIP $1.45 20030401 99999999 K0134 INTERMITTENT URINARY CATHETER, DISPOSABLE; COUDE (CURVED) TIP $2.91 20030401 99999999 K0135 INTERMITTENT URINARY CATHETER, REUSABLE; STRAIGHT TIP $1.38 20030401 99999999 K0136 INTERMITTENT URINARY CATHETER, REUSABLE, COUDE (CURVED) TIP $8.16 20030401 99999999 K0137 SKIN BARRIER; LIQUID (SPRAY, BRUSH, ETC.), PER OZ. $1.47 20030401 99999999 K0138 SKIN BARRIER; PASTE, PER OZ. $2.78 20030401 99999999 K0139 SKIN BARRIER; POWDER, PER OZ. $2.96 20030401 99999999 K0148 HYDROGEL DRESSING, EACH $3.66 20030401 99999999 K0149 HYDROCOLLOID DRESSING, EACH $5.99 20030401 99999999 K0151 FOAM DRESSING, EACH $65.37 20030401 99999999 K0154 WOUND POUCH, EACH $14.97 20030401 99999999 K0163 VACUUM ERECTION SYSTEM $355.53 20030401 99999999 K0164 OROPHARYNGEAL SUCTION CATHETER, EACH $3.53 20030401 99999999 K0165 TRACHEOSTOMY CARE KIT FOR ESTABLISHED TRACHEOSTOMY $3.81 20030401 99999999 K0166 METHYLPREDNISOLONE - ORAL, 4 MG $0.52 20030401 99999999 K0167 PREDNISOLONE - ORAL, 5 MG $0.03 19990701 99999999 K0168 ADMINISTRATION SET, SMALL VOL NON-FILTERED,PNEUMATIC NEBULIZER, DISPOSABLE $2.16 20030401 99999999 K0169 SMALL VOLUME NON-FILTERED PNEUMATIC NEBULIZER,DISPOSABLE $1.68 20030401 99999999 K0170 ADMINISTRATION SET, SMALL VOL, NON-FILTERED, PNEUMATIC NEBULIZER, NON-DISPOSABLE $29.31 20030401 99999999 K0171 ADMINISTRATION SET, SMALL VOL FILTERED PNEUMATIC NEBULIZER $9.07 20030401 99999999 K0172 LARGE VOLUME NEBULIZER, DISPOSABLE UNFILLED, USED WITH AEROSOL COMPRESSOR $4.39 20030401 99999999 K0173 LARGE VOL NEBULIZER, DISPOSABLE, PREFILLED, USED WITH AEROSOL COMPRESSOR $10.46 20030401 99999999 K0174 RESERVOIR, NON-DISPOSABLE, USED W LGE VOL ULTRASONIC NEBULIZER $39.99 20030401 99999999 K0175 CORRUGATED TUBING, DISPOSABLE, USED W LGE VOL NEBULIZER 100 FEET $22.13 20030401 99999999 K0176 CORRUGATED TUBING, NON-DISPOSABLE, USED W LGE VOL NEBULIZER,TEN FEET $2.11 20030401 99999999 K0177 WATER COLLECTION DEVICE, USED W LARGE VOLUME NEBULIZER $2.92 20030401 99999999 K0178 FILTER, NON-DISPOSABLE, USED W AEROSOL COMPRESSOR $0.79 20030401 99999999 K0179 FILTER, NON-DISPOSABLE,USED W AEROSOL COMPRESSOR OR ULTRASONIC GENERATOR $4.26 20030401 99999999 K0180 AEROSOL MASK, USED WITH DME NEBULIZER $1.50 20030401 99999999 K0181 DOME AND MOUTHPIECE, USED W SMALL VOL ULTRASONIC NEBULIZER $6.88 20030401 99999999 K0182 S $0.37 20030401 99999999 K0183 NASAL APPLICATION DEVICE, USED WITH CPAP $68.56 20030401 99999999 K0184 NASAL PILLOWS/SEALS, REPLACEMENT FOR NASAL APPLICATION DEVICE,PAIR $22.81 20030401 99999999 K0185 HEADGEAR, USED WITH CPAP DEVICE $37.82 20030401 99999999 K0186 CHIN STRAP, USED WITH CPAP DEVICE $13.83 20030401 99999999 K0187 TUBING, USED WITH CPAP $38.33 20030401 99999999 K0188 FILTER,DISPOSABLE,USED WITH CPAP DEVICE $3.20 20030401 99999999 K0189 FILTER, NON-DISPOSABLE, USED W CPAP DEVICE $13.16 20030401 99999999 K0190 CANISTER, DISPOSABLE, USED WITH SUCTION PUMP $8.01 20030401 99999999 K0191 CANISTER, NON-DISPOSABLE, USED WITH SUCTION PUMP $31.46 20030401 99999999 K0192 TUBING, USED WITH SUCTION PUMP $3.65 20030401 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 41
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