Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END V2199 NOT OTHERWISE CLASSIFIED SINGLE VISION LENS $52.00 20030401 99999999 V2200 SPHERE BIFOCAL PLANO TO + OR - 4.00D PER LENS $41.45 20060701 99999999 V2201 SPHERE BIFOCAL + OR - 4.12 TO + OR - 7.00D PER LENS $44.26 20060701 99999999 V2202 SPHERE BIFOCAL + OR - 7.12 TO + OR - 20.00D PER LENS $39.81 20060701 99999999 V2203 SPHEROCYL BIFOCAL PLANO TO + OR - 4.00D,.12 TO 2.00D PER LEN $38.50 20060701 99999999 V2204 SPHEROCYL BIFOCAL PLANO TO + OR - 4.00D, 2.12 TO 4.00D PER L $40.16 20060701 99999999 V2205 SPHEROCYL BIFOCAL + OR - 4.00D, 4.25 TO 6.00D CYL PER LENS $39.67 20060701 99999999 V2206 SPHEROCYL BIFOCAL + OR - 4.00D, OVER 6.00D CYL PER LENS $42.13 20060701 99999999 V2207 SPHEROCYL BIFOCAL + OR - 4.25 TO + OR - 7.00D,.12 TO 2.00D $40.04 20060701 99999999 V2208 SPHEROCYL BIFOCAL + OR - 4.25 TO +OR- 7.00D,2.12 TO 4.00D $41.12 20060701 99999999 V2209 SPHEROCYL BIF + OR - 4.25 TO +OR-7.00D,4.25 TO 6.00D PER LEN $41.62 20060701 99999999 V2210 SPHEROCYL BIF +OR- 4.25 TO +OR- 7.00D,OVER 6.00D PER LENS $40.92 20060701 99999999 V2211 SPHEROCYL BIF +OR-7.25 TO +OR- 12.00D,25 TO 2.25D PER LENS $51.73 20060701 99999999 V2212 SPHEROCYL BIF +OR- 7.25 TO +OR- 12.00D,2.25 TO 4.00D PER LEN $48.08 20060701 99999999 V2213 SPHEROCYL BIF +OR- 7.25 TO +OR- 12.00D,4.15 TO 6.00D PER LEN $46.31 20060701 99999999 V2214 SPHEROCYL BIF SPHERE OVER +OR- 12.00D PER LENS $51.22 20060701 99999999 V2215 LENTICULAR (MYODISC) PER LENS BIFOCAL $129.14 20060701 99999999 V2216 LENTICULAR NONASPHERIC PER LENS BIFOCAL $51.07 20030401 99999999 V2217 LENTICULAR ASPHERIC LENS BIFOCAL $66.85 20030401 99999999 V2218 ANISEIKONIC PER LENS BIFOCAL $102.85 20060701 99999999 V2219 BIFOCAL SEG WIDTH OVER 28MM $17.78 20060701 99999999 V2220 BIFOCAL ADD OVER 3.25D $21.58 20060701 99999999 V2221 LENTICULAR LENS, PER LENS, BIFOCAL $88.64 20060701 99999999 V2300 SPHERE TRIF PLANO TO +OR- 4.00D PER LENS $50.16 20060701 99999999 V2301 SPHERE TRIF +OR- 4.12 TO +OR- 7.00D PER LENS $50.16 20060701 99999999 V2302 SPHERE TRIF +OR- 7.12 TO +OR- 20.00,PER LENS $50.16 20060701 99999999 V2303 SPHEROCYL TRI PLANO TO+OR-4.00D, .12-2.00D CYL PER LENS $54.15 20060701 99999999 V2304 SPHEROCYL TRIF PLANO TO +OR- 4.00D, 2.25-4.00D CYL PER LENS $58.46 20060701 99999999 V2305 SPHEROCYL TRI PLANO TO +OR- 4.00D, 4.25 TO 6.00 CYL PER LENS $58.46 20060701 99999999 V2306 SPHEROCYL TRIF PLANO TO+OR- 4.00D, OVER 6.00D CYL PER LENS $58.46 20060701 99999999 V2307 SPHEROCYL TRIF +OR- 4.25 TO +OR- 7.00D, .12 TO 2.00D PER LEN $58.46 20060701 99999999 V2308 SPHEROCYL TRIF +OR- 4.25 TO +OR-7.00D, 2.12 TO 4.00D PER LEN $58.46 20060701 99999999 V2309 SPHEROCYL TRIF +OR- 4.25 RO +OR- 7.00D, 4.25 TO 6.00 PER LEN $58.46 20060701 99999999 V2310 SPHEROCYL TRIF +OR- 4.25 TO +OR- 7.00D, OVER 6.00D PER LENS $58.46 20060701 99999999 V2311 SPHEROCYL TRIF +OR- 7.25 TO +OR- 12.00D, .25 TO 2.25D PER LE $60.03 20060701 99999999 V2312 SPHEROCYL TRIF +OR- 7.25 TO +OR- 12.00D, 2.25 TO 4.00D PER L $76.48 20060701 99999999 V2313 SPHEROCYL TRIF +OR- 7.25 TO +OR- 12.00D, 4.25 TO 6.00D PER L $83.87 20060701 99999999 V2314 SPHEROCYL TRIF SPHERE OVER +OR- 12.00D, PER LENS $69.16 20060701 99999999 V2315 LENTICULAR (MYODISC) PER LENS TRIFOCAL $87.56 20060701 99999999 V2316 LENTICULAR NONASPHERIC PER LENS TRIFOCAL $72.88 20030401 99999999 V2317 LENTICULAR ASPHERIC LENS TRIFOCAL $75.78 20030401 99999999 V2318 ANISEIKONIC LENS TRIFOCAL $174.82 20060701 99999999 V2319 TRIFOCAL SEG WIDTH OVER 28MM $20.10 20060701 99999999 V2320 TRIFOCAL ADD OVER 3.25D $9.11 20060701 99999999 V2321 LENTICULAR LENS, PER LENS, TRIFOCAL $138.47 20060701 99999999 V2410 VARIABLE ASPHERICITY LENS SGL VISION FULL FIELD GLASS OR PLA $74.27 20060701 99999999 V2430 VARIABLE ASPHERICITY LENS BIF FULL FIELD GLASS OR PLASTIC $99.02 20060701 99999999 V2500 CONTACT LENS PMMA SPHERICAL PER LENS $76.22 20060701 99999999 V2501 CONTACT LENS PMMA TORIC OR PRISM BALLAST PER LENS $110.05 20060701 99999999 V2502 CONTACT LENS PMMA BIFOCAL PER LENS $110.05 20030401 99999999 V2503 CONTACT LENS PMMA COLOR VISION DEFICIENCY PER LENS $116.75 20060701 99999999 V2510 CONTACT LENS GAS PERMEABLE SPHERICAL PER LENS $97.91 20060701 99999999 V2511 CONTACT LENS GAS PERMEABLE TORIC PRISM BALLAST PER LENS $123.49 20060701 99999999 V2512 CONTACT LENS GAS PERMEABLE BIFOCAL PER LENS $129.99 20030401 99999999 V2513 CONTACT LENS GAS PERMEABLE EXTENDED WEAR PER LENS $129.99 20060701 99999999 V2520 CONTACT LENS HYDROPHILIC SPHERICAL PER LENS $83.88 20060701 99999999 V2521 CONTACT LENS HYDROPHILIC TORIC OR PRISM BALLAST PER LENS $118.74 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 80
PROC-CODE DESC MAC BEG END V2522 CONTACT LENS HYDROPHILLIC BIFOCAL PER LENS $118.74 20030401 99999999 V2523 CONTACT LENS HYDROPHILIC EXTENDED WEAR PER LENS $121.60 20060701 99999999 V2530 CONTACT LENS SCLERAL PER LENS (FOR MODIFICATION SEE 92325) $104.88 20060701 99999999 V2531 CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, S $426.92 20060701 99999999 V2599 NOT OTHERWISE CLASSIFIED CONTACT LENS $59.80 20030401 99999999 V2615 TELESCOPIC & OTHER COMPOUND LENS SYSTEM INC DISTANCE VISION $542.88 20030401 99999999 V2623 PROSTHETIC EYE PLASTIC CUSTOM $1,216.99 20060701 99999999 V2624 POLISHING/RESURFACING OF OCULAR PROSTHESIS $28.01 20060701 99999999 V2625 ENLARGEMENT OF OCULAR PROSTHESIS $331.46 20060701 99999999 V2626 REDUCTION OF OCULAR PROSTHESIS $210.88 20060701 99999999 V2627 SCLERAL COVER SHELL $999.32 20060701 99999999 V2628 FABRICATION AND FITTING OF OCULAR CONFORMER $221.68 20060701 99999999 V2629 NOT OTHERWISE CLASSIFIED PROSTHETIC EYE $364.00 20030401 99999999 V2630 ANTERIOR CHAMBER INTRAOCULAR LENS $197.46 20030401 99999999 V2632 POSTERIOR CHAMBER INTRAOCULAR LENS $311.40 20030401 99999999 V2700 BALANCE LENS PER LENS $39.13 20060701 99999999 V2710 SLAB OFF PRISM, GLASS OR PLASTIC. PER LENS $69.85 20030401 99999999 V2715 PRISM PER LENS $15.66 20060701 99999999 V2718 PRESSON LENS FRESNELL PRISM PER LENS $58.77 20030401 99999999 V2730 SPECIAL BASE CURVE GLASS OR PLASTIC PER LENS $22.69 20060701 99999999 V2740 TINT,PLASTIC,ROSE 1 OR 2 PER LENS $9.36 20030401 99999999 V2741 TINT,PLASTIC,OTHER THAN ROSE 1-2 PER LENS $8.11 20030401 99999999 V2742 TINT,GLASS ROSE 1 OR 2,PER LENS $5.74 20030401 99999999 V2743 TINT,GLASS OTHER THAN ROSE 1 OR 2 PER LENS $6.91 20030401 99999999 V2744 TINT,PHOTOCHROMATIC,PER LENS $8.54 20060701 99999999 V2745 ADDITION TO LENS, TINT, ANY COLOR, SOLID, GRADIENT OR EQUAL, EXCLUDES PHOTOCHROA $5.38 20060701 99999999 V2750 ANTI REFLECTIVE COATING, PER LENS $20.63 20060701 99999999 V2755 U-V LENS, PER LENS $9.15 20060701 99999999 V2756 EYE GLASS CASE $1.56 20040101 99999999 V2760 SCRATCH RESISTANT COATING, PER LENS $14.38 20060701 99999999 V2762 POLARIZATION, ANY LENS MATERIAL, PER LENS $28.15 20060701 99999999 V2770 OCCLUDER LENS, PER LENS $20.54 20060701 99999999 V2780 OVERSIZE LENS, PER LENS $10.98 20060701 99999999 V2782 LENS, INDEX 1.54 TO 1.65 PLASTIC OR 1.60 TO 1.79 GLASS, EXCLUDES POLYCARBONATE, $30.41 20060701 99999999 V2783 LENS, INDEX GREATER THAN OR EQUAL TO 1.66 PLASTIC OR GREATER THAN OR EQUAL TO 1. $34.28 20060701 99999999 V2784 LENS, POLYCARBONATE OR EQUAL, ANY INDEX, PER LENS $30.00 20060701 99999999 V2799 NOT OTHERWISE CLASSIFIED $1.56 20050101 99999999 V5010 ASSESSMENT FOR HEARING AID $52.00 20030401 99999999 V5011 FITTING/ORIENTATION/CHECKING OF HEARING AID $24.30 20030401 99999999 V5014 REPAIR/MODIFICATION OF A HEARING AID $142.05 20030401 99999999 V5030 HEARING AID MONAURAL BODY WORN AIR CONDUCTION $442.00 20030401 99999999 V5060 HEARING AID,MONAURAL,BEHIND THE EAR $312.00 20030401 99999999 V5247 HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, BTE (BEHIND THE EAR) $312.00 20030401 99999999 V5260 HEARING AID, DIGITAL, BINAURAL, ITE $338.80 20050103 99999999 V5264 EAR MOLD/INSERT, NOT DISPOSABLE, ANY TYPE $30.00 20020101 99999999 V5266 BATTERY FOR USE IN HEARING DEVICE $1.25 19950701 99999999 V5267 HEARING AID SUPPLIES / ACCESSORIES $4.48 20050103 99999999 V5275 EAR IMPRESSION, EACH $20.00 20021101 99999999 W0110 ADMINISTRATION OF INJECTION, INCLUDING COST OF THE DRUG $4.00 19990701 99999999 W0371 ALL INCLUSIVE DAILY VAC THERAPY $104.00 20030401 99999999 W0372 ALL INCLUSIVE VAC THERAPY AND SUPPORT, SURFACE $121.68 20030401 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 81
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Medicaid Fee Schedule without Mods 200801

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