Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 77072 BONE AGE STUDIES $15.86 20070101 99999999 77073 BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, SCANOGRAM) $30.04 20070101 99999999 77074 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; LIMITED (EG, FOR METASTASES) $43.20 20070101 99999999 77075 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETO $63.62 20070101 99999999 77076 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY, INFANT $51.17 20070101 99999999 77077 JOINT SURVEY, SINGLE VIEW, 2 OR MORE JOINTS (SPECIFY) $38.64 20070101 99999999 77078 COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON $104.66 20070101 99999999 77079 COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR S $74.89 20070101 99999999 77080 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXI $80.74 20070101 99999999 77081 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; APP $28.63 20070101 99999999 77082 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; VER $24.96 20070101 99999999 77083 RADIOGRAPHIC ABSORPTIOMETRY (EG, PHOTODENSITOMETRY, RADIOGRAMMETRY), 1 OR MORE S $25.65 20070101 99999999 77084 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BONE MARROW BLOOD SUPPLY $392.67 20070101 99999999 77261 THERAPEUTIC RADIOLOGY TREATMENT PLANNING $69.73 20060701 99999999 77262 THERAPEUTIC RADIOLOGY TREATMENT PLANNING $108.60 20060701 99999999 77263 THERAPEUTIC RADIOLOGY TREATMENT PLANNING $161.40 20060701 99999999 77280 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING $142.39 20060701 99999999 77285 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING $225.40 20060701 99999999 77290 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING $308.18 20060701 99999999 77295 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; BY THREE-DIMENSIONAL RECON $1,163.72 20060701 99999999 77300 BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL AXIS DEPTH DOSE, $68.85 20060701 99999999 77301 INTENSITY MODULATED RADIOTHERAPY PLAN, INCLUDING DOSE- VOLUME HISTOGRAMS FOR TARG $1,078.48 20060701 99999999 77305 TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED) $89.73 20060701 99999999 77310 TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED) $118.72 20060701 99999999 77315 TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED) $150.04 20060701 99999999 77321 SPECIAL TELETHERAPY PORT PLAN, PARTICLES, HEMI-BODY, TOTAL $171.17 20060701 99999999 77326 BRACHYTHERAPY ISODOSE CALCULATION $115.25 20060701 99999999 77327 BRACHYTHERAPY ISODOSE CALCULATION $169.71 20060701 99999999 77328 BRACHYTHERAPY ISODOSE CALCULATION $246.53 20060701 99999999 77331 SPECIAL DOSIMETRY (EG, TLD, MICRODOSIMETRY) (SPECIFY) $51.68 20060701 99999999 77332 TREATMENT DEVICES, DESIGN AND CONSTRUCTION $65.81 20060701 99999999 77333 TREATMENT DEVICES, DESIGN AND CONSTRUCTION $95.91 20060701 99999999 77334 TREATMENT DEVICES, DESIGN AND CONSTRUCTION $156.22 20060701 99999999 77336 CONTINUING MEDICAL RADIATION PHYSICS CONSULTATION IN SUPPORT $105.25 20060701 99999999 77370 SPECIAL MEDICAL RADIATION PHYSICS CONSULTATION $123.30 20060701 99999999 77371 RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE O $850.66 20070101 99999999 77372 RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE O $645.44 20070101 99999999 77373 STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MO $1,204.26 20070101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 238
PROC-CODE DESC MAC BEG END 77401 RADIATION TREATMENT DELIVERY, SUPERFICIAL AND/OR ORTHO VOLTAGE $58.71 20060701 99999999 77402 RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPP $58.71 20060701 99999999 77403 RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPP $66.33 20060701 99999999 77404 RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPP $71.07 20060701 99999999 77406 A $58.71 20060701 99999999 77407 RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS $68.94 20060701 99999999 77408 RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS $68.94 20060701 99999999 77409 RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS $83.58 20060701 99999999 77411 RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS $68.94 20060701 99999999 77412 RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLO $76.99 20060701 99999999 77413 RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLO $82.81 20060701 99999999 77414 RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLO $82.41 20060701 99999999 77416 RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLO $82.41 20060701 99999999 77417 THERAPEUTIC RADIOLOGY PORT FILM(S) $21.11 20060701 99999999 77418 INTENSITY MODULATED TREATMENT DELIVERY, SINGLE OR MULTIPLE FIELDS/ARCS, VIA NARR $460.46 20060701 99999999 77419 WEEKLY RADIOLOGY THERAPY MANAGEMENT; CONFORMAL $146.94 19990701 99999999 77420 WEEKLY MEGAVOLTAGE TREATMENT MANAGEMENT $65.70 19990701 99999999 77421 STEREOSCOPIC X-RAY GUIDANCE FOR LOCALIZATION OF TARGET VOLUME FOR THE DELIVERY O $110.54 20060701 99999999 77422 HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA USING A $50.74 20060701 99999999 77423 HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; 1 OR MORE ISOCENTER(S) WITH CO $66.22 20060701 99999999 77425 WEEKLY MEGAVOLTAGE TREATMENT MANAGEMENT $100.80 19990701 99999999 77427 RADIATION TREATMENT MANAGEMENT, FIVE TREATMENTS $164.97 20060701 99999999 77431 RADIATION THERAPY MANAGEMENT WITH COMPLETE COURSE OF THERAPY CONSISTING OF ONE O $97.14 20060701 99999999 77432 STEREOTACTIC RADIATION TREATMENT MANAGEMENT OF CEREBRAL LESION(S) (COMPLETE COUR $391.40 20060701 99999999 77435 STEREOTACTIC BODY RADIATION THERAPY, TREATMENT MANAGEMENT, PER TREATMENT COURSE, $439.08 20070101 99999999 77470 SPECIAL TREATMENT PROCEDURE (EG, TOTAL BODY IRRADIATION, $493.81 20060701 99999999 77600 HYPERTHERMIA, EXTERNALLY GENERATED $162.14 20060701 99999999 77605 HYPERTHERMIA, EXTERNALLY GENERATED $218.27 20060701 99999999 77610 HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S) $162.14 20060701 99999999 77615 HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S) $217.08 20060701 99999999 77620 HYPERTHERMIA GENERATED BY INTRACAVITARY PROBE(S) $164.02 20060701 99999999 77750 INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION $236.88 20060701 99999999 77761 INTRACAVITARY RADIOELEMENT APPLICATION $231.09 20060701 99999999 77762 INTRACAVITARY RADIOELEMENT APPLICATION $345.48 20060701 99999999 77763 INTRACAVITARY RADIOELEMENT APPLICATION $486.60 20060701 99999999 77776 INTERSTITIAL RADIOELEMENT APPLICATION $252.65 20060701 99999999 77777 INTERSTITIAL RADIOELEMENT APPLICATION $349.04 20060701 99999999 77778 INTERSTITIAL RADIOELEMENT APPLICATION $786.81 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 239
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