Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 76801 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATER $87.43 20060701 99999999 76802 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATER $55.73 20060701 99999999 76805 ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE $108.78 20060701 99999999 76810 ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; C $101.50 20060701 99999999 76811 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATER $186.17 20060701 99999999 76812 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATER $107.47 20060701 99999999 76813 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER $88.39 20070101 99999999 76814 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER $57.43 20070101 99999999 76815 ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE $84.72 20060701 99999999 76816 ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE $70.34 20060701 99999999 76817 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL $74.64 20060701 99999999 76818 FETAL BIOPHYSICAL PROFILE $84.46 20060701 99999999 76819 FETAL BIOPHYSICAL PROFILE; WITHOUT STRESS OR NON-STRESS TESTING $75.79 20060701 99999999 76820 DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY $71.84 20060701 99999999 76821 DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY $79.75 20060701 99999999 76825 ECHOCARDIOGRAPHY, FETAL HEART IN UTERO $125.99 20060701 99999999 76826 ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATI $62.27 20060701 99999999 76827 DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE AND/OR CONTI $87.20 20060701 99999999 76828 DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE AND/OR CONTI $60.66 20060701 99999999 76830 ECHOGRAPHY, TRANSVAGINAL $77.68 20060701 99999999 76831 HYSTEROSONOGRAPHY, WITH OR WITHOUT COLOR FLOW DOPPLER $98.58 20060701 99999999 76856 ECHOGRAPHY, PELVIC (NON-OBSTETRIC), B-SCAN AND/OR REAL TIME $90.72 20060701 99999999 76857 ECHOGRAPHY, PELVIC (NON-OBSTETRIC), B-SCAN AND/OR REAL TIME $56.37 20060701 99999999 76870 ECHOGRAPHY, SCROTUM AND CONTENTS $86.02 20060701 99999999 76872 ECHOGRAPHY, PROSTATE, TRANSRECTAL $90.72 20060701 99999999 76873 ECHOGRAPHY, TRANSRECTAL; PROSTATE VOLUME STUDY FOR BRACHYTHERAPY TREATMENT PLANN $164.68 20060701 99999999 76880 ECHOGRAPHY, EXTREMITY, B-SCAN AND/OR REAL TIME WITH IMAGE $81.43 20060701 99999999 76885 ECHOGRAPHY OF INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; DYNAMIC (EG, RE $85.79 20060701 99999999 76886 ECHOGRAPHY OF INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; LIMITED, STATIC $70.97 20060701 99999999 76930 ULTRASONIC GUIDANCE FOR PERICARDIOCENTESIS $77.84 20060701 99999999 76932 ULTRASOUND GUIDANCE FOR ENDOMYOCARDIAL BIOPSY SUPERVISION $78.15 20060701 99999999 76934 ULTRASONIC GUIDANCE FOR THORACENTESIS $76.84 19990701 99999999 76936 ULTRASOUND GUIDED COMPRESSION REPAIR OF ARTERIAL PSEUDO- ANEURYSM OR ARTERIOVENOU $293.19 20060701 99999999 76937 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND EVALUATION OF POTEN $25.56 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 236
PROC-CODE DESC MAC BEG END 76938 ULTRASONIC GUIDANCE FOR CYST (ANY LOCATION), OR RENAL $87.97 19990701 99999999 76940 ULTRASOUND GUIDANCE FOR, AND MONITORING OF, VISCERAL TISSUE ABLATION $128.56 20060701 99999999 76941 ULTRASONIC GUIDANCE FOR INTRAUTERINE FETAL TRANSFUSION OR CORDOCENTESIS, RADIOLO $105.32 20060701 99999999 76942 ULTRASONIC GUIDANCE FOR NEEDLE BIOPSY $94.48 20060701 99999999 76945 ULTRASONIC GUIDANCE FOR ABSCESS OR COLLECTION DRAINAGE,CMPLT $82.20 20060701 99999999 76946 ULTRASONIC GUIDANCE FOR AMNIOCENTESIS $65.59 20060701 99999999 76948 ULTRASONIC GUIDANCE FOR ASPIRATION OF OVASUPERVIS. & INTERP $65.53 20060701 99999999 76950 ECHOGRAPHY FOR PLACEMENT OF RADIATION THERAPY FIELDS, B- SCAN $75.30 20060701 99999999 76960 ULTRASONIC GUIDANCE FOR PLACEMENT OF RADIATION THERAPY $75.30 19990701 99999999 76965 ULTRASONIC GUIDANCE FOR INTERSTITIAL RADIOELEMENT APPLICATION $291.68 20060701 99999999 76970 ULTRASOUND STUDY FOLLOW-UP (SPECIFY) $50.95 20060701 99999999 76975 GASTROINTESTINAL ENDOSCOPIC ULTRASOUND, RADIOLOGICAL SUPERVISION AND INTERPRETAT $82.40 20060701 99999999 76977 ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, PERIPHERAL SITE(S), ANY $35.86 20060701 99999999 76986 ECHOGRAPHY, INTRAOPERATIVE $134.33 19990701 99999999 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT (C $59.33 20070101 99999999 77002 FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, L $53.33 20070101 99999999 77003 FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PA $51.53 20070101 99999999 77011 COMPUTED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION $355.92 20070101 99999999 77012 COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJEC $232.54 20070101 99999999 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS $122.28 20070101 99999999 77021 MAGNETIC RESONANCE GUIDANCE FOR NEEDLE PLACEMENT (EG, FOR BIOPSY, NEEDLE ASPIRAT $357.48 20070101 99999999 77031 STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR NEEDLE PLACEMENT (EG, FO $218.86 20070101 99999999 77032 MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST (EG, FOR WIRE LOCALIZATION OR $49.86 20070101 99999999 77051 COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR $12.42 20070101 99999999 77052 COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR $12.42 20070101 99999999 77053 MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, RADIOLOGICAL SUPERVISION AND INTE $73.33 20070101 99999999 77054 MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, RADIOLOGICAL SUPERVISION AND I $105.53 20070101 99999999 77055 MAMMOGRAPHY; UNILATERAL $55.29 20070101 99999999 77056 MAMMOGRAPHY; BILATERAL $69.09 20070101 99999999 77057 SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF EACH BREAST) $58.01 20070101 99999999 77058 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH CONTRAST MATERIAL(S); UN $582.69 20070101 99999999 77059 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH CONTRAST MATERIAL(S); BI $720.80 20070101 99999999 77071 MANUAL APPLICATION OF STRESS PERFORMED BY PHYSICIAN FOR JOINT RADIOGRAPHY, INCLU $19.76 20070101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 237
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