Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 73564 RADIOLOGIC EXAMINATION, KNEE $33.09 20060701 99999999 73565 RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR $25.75 20060701 99999999 73580 RADIOLOGIC EXAMINATION, KNEE, ARTHROGRAPHY $107.55 20060701 99999999 73590 RADIOLOGIC EXAMINATION $26.78 20060701 99999999 73592 RADIOLOGIC EXAMINATION $23.05 20060701 99999999 73600 RADIOLOGIC EXAMINATION, ANKLE $25.44 20060701 99999999 73610 RADIOLOGIC EXAMINATION, ANKLE $24.25 20060701 99999999 73615 RADIOLOGIC EXAMINATION, ANKLE, ARTHROGRAPHY $90.82 20060701 99999999 73620 RADIOLOGIC EXAMINATION, FOOT $23.05 20060701 99999999 73630 RADIOLOGIC EXAMINATION, FOOT $27.46 20060701 99999999 73650 RADIOLOGIC EXAMINATION $24.76 20060701 99999999 73660 RADIOLOGIC EXAMINATION $19.45 20060701 99999999 73700 COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY $229.20 20060701 99999999 73701 COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY $240.34 20060701 99999999 73702 COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY $292.08 20060701 99999999 73706 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, LOWER EXTREMITY, WITHOUT CONTRAST MATERIAL(S), $345.26 20060701 99999999 73718 MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHO $368.37 20060701 99999999 73719 MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITH $441.87 20060701 99999999 73720 MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY, $714.22 20060701 99999999 73721 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY $423.20 20060701 99999999 73722 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITH CONT $442.38 20060701 99999999 73723 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT C $787.12 20060701 99999999 73725 MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR WITHOUT CONTRAST MATERI $437.70 20060701 99999999 74000 RADIOLOGIC EXAMINATION, ABDOMEN $27.43 20060701 99999999 74010 RADIOLOGIC EXAMINATION, ABDOMEN $31.13 20060701 99999999 74020 RADIOLOGIC EXAMINATION, ABDOMEN $35.17 20060701 99999999 74022 RADIOLOGIC EXAMINATION, ABDOMEN $35.27 20060701 99999999 74150 COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN $259.18 20060701 99999999 74160 COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN $276.22 20060701 99999999 74170 COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN $362.28 20060701 99999999 74175 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN, WITHOUT CONTRAST MATERIAL(S), FOLLOWE $372.30 20060701 99999999 74181 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN $431.45 20060701 99999999 74182 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S) $446.99 20060701 99999999 74183 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), $792.67 20060701 99999999 74185 MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT CONTRAST MATERIAL(S) $438.11 20060701 99999999 74190 PERITONEOGRAM (EG, AFTER INJECTION OF AIR OR CONTRAST), RADIOLOGICAL SUPERVISION $49.74 20060701 99999999 74210 RADIOLOGIC EXAMINATION $53.40 20060701 99999999 74220 RADIOLOGIC EXAMINATION $57.52 20060701 99999999 74230 SWALLOWING FUNCTION, PHARYNX AND/OR ESOPHAGUS, WITH $73.05 20060701 99999999 74235 REMOVAL OF FOREIGN BODY(S), ESOPHAGEAL, WITH USE OF $132.88 19990701 99999999 74240 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER $88.76 20060701 99999999 74241 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER $89.65 20060701 99999999 74245 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER $114.41 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 230
PROC-CODE DESC MAC BEG END 74246 RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, $93.04 20060701 99999999 74247 RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, $94.38 20060701 99999999 74249 RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, $120.59 20060701 99999999 74250 RADIOLOGIC EXAMINATION, SMALL BOWEL, INCLUDES MULTIPLE SERIAL $69.48 20060701 99999999 74251 RADIOLOGIC EXAMINATION, SMALL BOWEL, INCLUDES MULTIPLE SERIAL FILMS; VIA ENTEROC $68.44 20060701 99999999 74260 DUODENOGRAPHY, HYPOTONIC $69.06 20060701 99999999 74270 RADIOLOGIC EXAMINATION, COLON $90.00 20060701 99999999 74280 RADIOLOGIC EXAMINATION, COLON $124.50 20060701 99999999 74283 BARIUM ENEMA,THREAPEUTIC,FOR REDUCTION OF INTUSSUSCEPTION $163.58 20060701 99999999 74290 CHOLECYSTOGRAPHY, ORAL CONTRAST $42.01 20060701 99999999 74291 CHOLECYSTOGRAPHY, ORAL CONTRAST $17.50 20060701 99999999 74300 CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY $18.78 20030401 99999999 74305 CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY $42.49 20060701 99999999 74320 CHOLANGIOGRAPHY, PERCUTANEOUS, TRANSHEPATIC $125.20 20060701 99999999 74327 POSTOPERATIVE BILIARY DUCT STONE REMOVAL, PERCUTANEOUS VIA $85.99 20060701 99999999 74328 ENDOSCOPIC CATHETERIZATION OF THE BILIARY DUCTAL SYSTEM, $131.53 20060701 99999999 74329 ENDOSCOPIC CATHETERIZATION OF THE PANCREATIC DUCTAL SYSTEM, $131.53 19990701 99999999 74330 COMBINED ENDOSCOPIC CATHETERIZATION OF THE BILIARY AND $137.98 20060701 99999999 74340 INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER- ABBOTT), $107.55 20060701 99999999 74350 PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE $134.04 19990701 99999999 74355 PERCUTANEOUS PLACEMENT OF ENTEROCLYSIS TUBE $116.39 20060701 99999999 74360 INTRALUMINAL DILATION OF STRICTURES AND/OR OBSTRUCTIONS $125.82 20060701 99999999 74363 PERCUTANEOUS TRANSHEPATIC DILATATION OF BILIARY DUCT STRICTURE WITH OR WITHOUT P $235.78 19990701 99999999 74400 UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT KUB $84.06 20060701 99999999 74410 UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE $93.26 20060701 99999999 74415 UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE $98.06 20060701 99999999 74420 UROGRAPHY, RETROGRADE, WITH OR WITHOUT KUB $100.63 20060701 99999999 74425 UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM, NEPHROSTOGRAM, LOOPOGRAM) $57.07 20060701 99999999 74430 CYSTOGRAPHY, MINIMUM OF THREE VIEWS $47.66 20060701 99999999 74440 VASOGRAPHY, VESICULOGRAPHY, OR EPIDIDYMOGRAPHY $52.61 20060701 99999999 74445 CORPORA CAVERNOSOGRAPHY $66.31 20060701 99999999 74450 URETHROCYSTOGRAPHY, RETROGRADE $61.21 20060701 99999999 74455 URETHROCYSTOGRAPHY, VOIDING $65.21 20060701 99999999 74470 RADIOLOGIC EXAMINATION, RENAL CYST STUDY, TRANSLUMBAR, $62.37 20060701 99999999 74475 INTRODUCTION OF INTRACATHETER OR CATHETER INTO $155.46 20060701 99999999 74480 INTRODUCTION OF URETERAL CATHETER OR STENT INTO URETER $155.46 20060701 99999999 74485 DILATION OF NEPHROSTOMY OR URETERS WITH FLUOROSCOPIC $125.20 20060701 99999999 74710 PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION $48.19 20060701 99999999 74740 HYSTEROSALPINGOGRAPHY $58.16 20060701 99999999 74742 TRANSCERVICAL CATHETERIZATION OF FALLOPIAN TUBE, RADIOLOGICAL SUPERVISION AND IN $127.35 19990701 99999999 74775 PERINEOGRAM (EG, VAGINOGRAM, FOR SEX DETERMINATION OR EXTENT $73.09 20060701 99999999 75552 MAGNETIC RESONANCE (EG, PROTON) IMAGING, MYOCARDIUM $431.97 19990701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 231
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