Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 77781 REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 1-4 SOURCE POSITIONS OR CATHET $734.14 20060701 99999999 77782 REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 5-8 SOURCE POSITIONS OR CATHET $767.02 20060701 99999999 77783 REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 9-12 SOURCE POSITIONS OR CATHE $815.31 20060701 99999999 77784 REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; OVER 12 SOURCE POSITIONS OR CA $889.48 20060701 99999999 77789 SURFACE APPLICATION OF RADIOELEMENT $59.36 20060701 99999999 77790 SUPERVISION, HANDLING, LOADING OF RADIOELEMENT $58.45 20060701 99999999 78000 THYROID UPTAKE $39.87 20060701 99999999 78001 THYROID UPTAKE $53.19 20060701 99999999 78003 THYROID UPTAKE $45.12 20060701 99999999 78006 THYROID IMAGING, WITH UPTAKE $97.87 20060701 99999999 78007 THYROID IMAGING, WITH UPTAKE $104.62 20060701 99999999 78010 THYROID IMAGING $75.71 20060701 99999999 78011 THYROID IMAGING $97.44 20060701 99999999 78015 THYROID CARCINOMA METASTASES IMAGING $111.53 20060701 99999999 78016 THYROID CARCINOMA METASTASES IMAGING $147.10 20060701 99999999 78018 THYROID CARCINOMA METASTASES IMAGING $213.35 20060701 99999999 78020 THYROID CARCINOMA METASTASES UPTAKE (LIST SEPARATELY IN ADDITION TO CODE FOR PRI $55.02 20060701 99999999 78070 PARATHYROID IMAGING $136.66 20060701 99999999 78075 ADRENAL IMAGING, CORTICAL $193.92 20060701 99999999 78102 BONE MARROW IMAGING $89.22 20060701 99999999 78103 BONE MARROW IMAGING $149.08 20060701 99999999 78104 BONE MARROW IMAGING $165.98 20060701 99999999 78110 PLASMA VOLUME, RADIONUCLIDE VOLUME-DILUTION TECHNIQUE $39.25 20060701 99999999 78111 PLASMA VOLUME, RADIONUCLIDE VOLUME-DILUTION TECHNIQUE $93.57 20060701 99999999 78120 RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE) $66.88 20060701 99999999 78121 RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE) $108.37 20060701 99999999 78122 WHOLE BLOOD VOLUME DETERMINATION,INC. SEPARATE MEASUR PLASMA $169.50 20060701 99999999 78130 RED CELL SURVIVAL STUDY $117.81 20060701 99999999 78135 RED CELL SURVIVAL STUDY $185.67 20060701 99999999 78140 RED CELL SPLENIC AND/OR HEPATIC SEQUESTRATION $153.62 20060701 99999999 78160 PLASMA RADIOIRON DISAPPEARANCE (TURNOVER) RATE $133.65 19990701 99999999 78162 RADIOIRON ORAL ABSORPTION $123.83 19990701 99999999 78170 RADIOIRON RED CELL UTILIZATION $191.03 19990701 99999999 78172 CHELATABLE IRON FOR ESTIMATION OF TOTAL BODY IRON $21.30 19990701 99999999 78185 SPLEEN IMAGING ONLY $93.94 20060701 99999999 78190 KINETICS, STUDY OF PLATELET SURVIVAL, WITH OR WITHOUT DIFFERENTIAL ORGAN/TISSUE $232.38 20060701 99999999 78191 PLATELET SURVIVAL $265.36 20060701 99999999 78195 LYMPHATICS AND LYMPH GLANDS IMAGING $177.94 20060701 99999999 78201 LIVER IMAGING $95.31 20060701 99999999 78202 LIVER IMAGING $114.86 20060701 99999999 78205 LIVER IMAGING (SPECT) $223.01 20060701 99999999 78206 LIVER IMAGING (SPECT); WITH VASCULAR FLOW $222.19 20060701 99999999 78215 LIVER AND SPLEEN IMAGING $115.90 20060701 99999999 78216 LIVER AND SPLEEN IMAGING $135.84 20060701 99999999 78220 LIVER FUNCTION STUDY WITH HEPATOBILIARY AGENTS, $141.85 20060701 99999999 78223 HEPATOBILIARY DUCTAL SYSTEM IMAGING, INCLUDING GALLBLADDER $153.50 20060701 99999999 78230 SALIVARY GLAND IMAGING $90.27 20060701 99999999 78231 SALIVARY GLAND IMAGING $125.29 20060701 99999999 78232 SALIVARY GLAND FUNCTION STUDY $135.15 20060701 99999999 78258 ESOPHAGEAL MOTILITY $123.97 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 240
PROC-CODE DESC MAC BEG END 78261 GASTRIC MUCOSA IMAGING $162.78 20060701 99999999 78262 GASTROESOPHAGEAL REFLUX STUDY $166.94 20060701 99999999 78264 GASTRIC EMPTYING STUDY $167.02 20060701 99999999 78267 UREA BREATH TEST, C-14; ACQUISITION FOR ANALYSIS $10.86 20060701 99999999 78268 UREA BREATH TEST, C-14; ANALYSIS $93.09 20060701 99999999 78270 VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST) $59.61 20060701 99999999 78271 VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST) $62.73 20060701 99999999 78272 VITAMIN B-12 ABSORPTION STUDIES COMBINED, WITH $87.47 20060701 99999999 78278 ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING $199.74 20060701 99999999 78282 GASTROINTESTINAL PROTEIN LOSS $14.93 19990701 99999999 78290 BOWEL IMAGING (EG, ECTOPIC GASTRIC MUCOSA, MECKEL'S $127.32 20060701 99999999 78291 PERITONEAL-VENOUS SHUNT PATENCY TEST $135.39 20060701 99999999 78300 BONE IMAGING $106.53 20060701 99999999 78305 BONE IMAGING $153.23 20060701 99999999 78306 BONE IMAGING $188.43 20060701 99999999 78315 BONE IMAGING BY THREE PHASE TECHNIQUE $197.41 20060701 99999999 78320 BONE IMAGING TOMOGRAPHIC (SPECT) $235.68 20060701 99999999 78350 BONE DENSITY (BONE MINERAL CONTENT) STUDY $39.00 20060701 99999999 78414 DETERMINATION OF VENTRICULAR EJECTION FRACTION WITH PROBE $18.27 19990701 99999999 78428 CARDIAC SHUNT DETECTION $106.68 20060701 99999999 78445 VASCULAR FLOW IMAGING (IE, ANGIOGRAPHY, VENOGRAPHY) $81.15 20060701 99999999 78455 VENOUS THROMBOSIS STUDY (EG, RADIOACTIVE FIBRINOGEN) $160.15 19990701 99999999 78456 ACUTE VENOUS THROMBOSIS IMAGING, PEPTIDE $153.65 20060701 99999999 78457 VENOUS THROMBOSIS IMAGING (EG, VENOGRAM) $132.32 20060701 99999999 78458 VENOUS THROMBOSIS IMAGING (EG, VENOGRAM) $167.74 20060701 99999999 78459 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION $1,495.20 19960101 99999999 78460 MYOCARDIAL IMAGING,RESTING ONLY,QUANTITATIVE OR QUALITATIVE $111.91 20060701 99999999 78461 MYOCARDIAL IMAGING $204.49 20060701 99999999 78464 MYOCARDIAL IMAGING,TOMOGRAPHIC(SPECT)AT REST ONLY QUALITATIV $275.99 20060701 99999999 78465 MYOCARDIAL IMAGING TOMOGRAPHIC W/EXERCISE & REDISTRIBUTION $489.67 20060701 99999999 78466 MYOCARDIAL IMAGING, INFARCT AVID, AT REST QUALITATIVE $113.93 20060701 99999999 78468 MYOCARDIAL IMAGING, INFARCT AVID, AT REST WITH FIRST PASS_TE $152.13 20060701 99999999 78469 MYOCARDIAL IMAGING,INFARCT AVID, AT REST W/EMISSION COM. TOM $208.76 20060701 99999999 78472 CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, AT REST $221.07 20060701 99999999 78473 CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; MULTIPLE STUDIES, WALL MOTION STU $329.97 20060701 99999999 78478 MYOCARDIAL PERFUSION STUDY WITH WALL MOTION, QUALITATIVE OR QUANTITATIVE STUDY ( $77.27 20060701 99999999 78480 MYOCARDIAL PERFUSION STUDY WITH EJECTION FRACTION (LIST SEPARATELY IN ADDITION T $76.52 20060701 99999999 78481 CARDIAC BLOOD POOL IMAGING,FIRST PASS TECHNIQUE $211.58 20060701 99999999 78483 CARDIAC BLOOD POOL IMAGING, FIRST PASS TECHNIQUE; MULTIPLE STUDIES, RESTING AND $318.81 20060701 99999999 78494 CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SPECT, AT REST, WALL MOTION STUDY $271.81 20060701 99999999 78496 CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SINGLE STUDY, AT REST, WITH RIGHT $200.90 20060701 99999999 78499 UNLISTED CARDIOVASCULAR PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE $63.79 19990701 99999999 78580 PULMONARY PERFUSION IMAGING $142.19 20060701 99999999 78584 PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION $115.87 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 241
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