Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END A4394 OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, LIQUID, PER FLUID OUNCE $2.76 20060701 99999999 A4395 OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, SOLID, PER TABLET $0.05 20060701 99999999 A4396 OSTOMY BELT WITH PERISTOMAL HERNIA SUPPORT $40.48 20060701 99999999 A4397 IRRIGATION SUPPLY SLEEVE $1.83 20060701 99999999 A4398 IRRIGATION SUPPLY;BAGS $14.93 20060701 99999999 A4399 IRRIGATION SUPPLY; CONE/CATHETER $10.31 20060701 99999999 A4400 OSTOMY ITTIGATION SET $63.84 20060701 99999999 A4402 OSTOMY LUBRICANT $4.00 20060701 99999999 A4404 OSTOMY RINGS $1.83 20060701 99999999 A4405 OSTOMY SKIN BARRIER, NON-PECTIN BASED, PASTE, PER OUNCE $3.40 20060701 99999999 A4406 OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE, PER OUNCE $5.74 20060701 99999999 A4407 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE, OR ACCORDION), EXTENDED WEAR, $8.76 20060701 99999999 A4408 OSTOMY SKIN BARRIER, WTIH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, $9.87 20060701 99999999 A4409 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, $6.22 20060701 99999999 A4410 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, $9.04 20060701 99999999 A4411 OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED WEAR, WITH BUILT-IN CONVE $3.06 20060701 99999999 A4412 OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE $1.62 20060701 99999999 A4413 OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE $5.50 20060701 99999999 A4414 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-I $4.93 20060701 99999999 A4415 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-I $6.00 20060701 99999999 A4416 OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH $2.75 20060701 99999999 A4417 OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FILTE $3.72 20060701 99999999 A4418 OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH $1.81 20060701 99999999 A4419 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FILTER (2 $1.74 20060701 99999999 A4421 OSTOMY SUPPLY MISC $4.68 20030401 99999999 A4422 OSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYSTAL PACKET) FOR USE IN OSTOMY POUCH TO $0.12 20060701 99999999 A4423 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIE $1.86 20060701 99999999 A4424 OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH $4.75 20060701 99999999 A4425 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH NON- LOCKING FLANGE, WITH FILTER $3.58 20060701 99999999 A4426 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE SYSTEM) $2.73 20060701 99999999 A4427 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 $2.78 20060701 99999999 A4428 OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH FAUCET-TYPE TAP $6.51 20060701 99999999 A4429 OSTOMY POUCH, URINARY, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUC $8.25 20060701 99999999 A4430 URETEROSTOMY SET $8.52 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 4
PROC-CODE DESC MAC BEG END A4431 OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET- TYPE TAP WITH VALVE (1 $6.22 20060701 99999999 A4432 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH NON- LOCKING FLANGE, WITH FAUCET-T $3.59 20060701 99999999 A4433 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH $3.34 20060701 99999999 A4434 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FAUCET-TYPE $3.76 20060701 99999999 A4450 AHDESIVE TAPE ALL SIZES $0.09 20021101 99999999 A4452 TAPE, WATERPROOF, PER 18 SQUARE INCHES $0.36 20030401 99999999 A4454 TAPE, ALL TYPES, ALL SIZES $0.86 19990701 99999999 A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE) $1.70 20060701 99999999 A4458 ENEMA BAG WITH TUBING, REUSABLE $1.86 20071101 99999999 A4460 ELASTIC BANDAGE, ACE $5.41 20030401 99999999 A4461 SURGICAL DRESSING HOLDER, NON-REUSABLE, EACH $3.29 20070101 99999999 A4462 ABDOMINAL DRESSING HOLDER/BINDER, EACH $3.53 20030401 99999999 A4465 NON-ELASTIC BINDER FOR EXTREMITY $8.10 20010101 99999999 A4481 THRACHEOSTOMA FILTER, ANY TYPE, ANY SIZE, EACH $0.53 20060701 99999999 A4483 MOISTURE EXCHANGER, DISPOSABLE, FOR USE WITH INVASIVE MECHANICAL VENTILATION $5.20 20030401 99999999 A4490 SURGICAL STOCKINGS ABOVE KNEE LENGTH, EACH $11.44 20030401 99999999 A4495 SURGICAL STOCKINGS THIGH LENGTH, EACH $11.44 20030401 99999999 A4500 SURGICAL STOCKINGS BELOW KNEE LENGTH EACH $7.28 20030401 99999999 A4510 SURGICAL STOCKINGS FULL LENGTH, EACH $11.44 20030401 99999999 A4521 ADULT-SIZED INCONTINENCE PRODUCT, DIAPER, SMALL SIZE, EACH $0.62 20030812 99999999 A4522 ADULT-SIZED INCONTINENCE PRODUCT, DIAPER, MEDIUM SIZE, EACH $0.66 20030812 99999999 A4524 ADULT-SIZED INCONTINENCE PRODUCT, DIAPER, EXTRA LARGE SIZE, EACH $0.69 20030812 99999999 A4550 SURGICAL TRAYS $5.20 20030401 99999999 A4554 DISPOSABLE UNDERPADS, ALL SIZES, (E.G., CHUX'S) $0.30 20030401 99999999 A4556 ELECTRODES (EG.APNEA MONITOR) $10.41 20060701 99999999 A4557 LEAD WIRES (EG.APNEA MONITOR) $15.74 20060701 99999999 A4558 CONDUCTIVE PASTE OR GEL $6.84 20060701 99999999 A4565 SLINGS $10.40 20030401 99999999 A4570 SPLINT $10.40 20030401 99999999 A4572 RIB BELT $10.40 20030401 99999999 A4580 CAST SUPPLIES $14.56 20030401 99999999 A4590 SPECIAL CASTING MATERIALS,HEXCELITE AND LIGHT CAST $20.80 20030401 99999999 A4595 TENS SUPPLIES, 2 LEAD, PER MONTH $26.00 20060701 99999999 A4604 TUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH POSITIVE AIRWAY PRESSURE DEV $6.68 20071101 99999999 A4605 TRACHEAL SUCTION CATHETER, CLOSED SYSTEM, EACH $16.00 20060101 99999999 A4606 OXYGEN PROBE FOR USE WITH OXIMETER DEVICE, REPLACEMENT $40.43 19990701 99999999 A4608 TRANSTRACHEAL OXYGEN CATHETER, EACH $58.15 20060701 99999999 A4609 TRACHEAL SUCTION CATHETER, CLOSED SYSTEM, FOR LESS THAN 72 HOURS OF USE, EACH $14.30 20030401 99999999 A4611 BATTERY HEAVY DUTY REPLACEMENT FOR PATIENT OWNED VENTILATOR $7.25 20071101 99999999 A4612 BATTERY CABLES;REPLACEMENT FOR PATIENT OWNED VENTILATOR $8.46 20071101 99999999 A4613 BATTERY CHARGER;REPLACEMENT FOR PATIENT OWNED VENTILATOR $9.21 20071101 99999999 A4614 PEAK EXPIRATORY FLOW RATE METER, HAND HELD $23.59 20060701 99999999 A4615 CANULA, NASAL $2.16 20030401 99999999 A4616 AEROSOL TUBING %PER FOOT< $9.36 20030401 99999999 A4617 MOUTH PIECE $5.20 20030401 99999999 A4618 IPPB SUPPLIES $7.31 20030401 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 5
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