Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 78585 PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION $228.33 20060701 99999999 78586 PULMONARY VENTILATION IMAGING, AEROSOL $101.37 20060701 99999999 78587 PULMONARY VENTILATION IMAGING, AEROSOL $111.53 20060701 99999999 78588 PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION IMAGING, AEROSOL, ONE $184.94 20060701 99999999 78591 PULMONARY VENTILATION IMAGING, GASEOUS, $109.70 20060701 99999999 78593 PULMONARY VENTILATION IMAGING, GASEOUS, WITH $132.87 20060701 99999999 78594 PULMONARY VENTILATION IMAGING, GASEOUS, WITH $184.95 20060701 99999999 78596 PULMONARY QUANTITATIVE DIFFERENTIAL FUNCTION (VENTILATION/PERFUSION) STUDY $282.85 20060701 99999999 78600 BRAIN IMAGING, LIMITED PROCEDURE $112.40 20060701 99999999 78601 BRAIN IMAGING, LIMITED PROCEDURE $132.15 20060701 99999999 78605 BRAIN IMAGING, COMPLETE STUDY $133.29 20060701 99999999 78606 BRAIN IMAGING, COMPLETE STUDY $152.60 20060701 99999999 78607 BRAIN IMAGING,COMPLETE STUDY TOMOGRAPHIC(ECT) $264.77 20060701 99999999 78608 BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); METABOLIC EVALUATION $1,495.20 19940101 99999999 78610 BRAIN IMAGING, VASCULAR FLOW ONLY $64.11 20060701 99999999 78615 CEREBRAL BLOOD FLOW $144.00 19990701 99999999 78630 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION $193.15 20060701 99999999 78635 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION $109.38 20060701 99999999 78645 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION $135.28 20060701 99999999 78647 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); TOMO $230.19 20060701 99999999 78650 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION $176.82 20060701 99999999 78660 DACRYOCYSTOGRAPHY (LACRIMAL FLOW STUDY) $90.87 20060701 99999999 78700 KIDNEY IMAGING $117.90 20060701 99999999 78701 KIDNEY IMAGING $136.30 20060701 99999999 78704 KIDNEY IMAGING $159.47 19990701 99999999 78707 KIDNEY IMAGING $185.04 20060701 99999999 78708 KIDNEY IMAGING WITH VASCULAR FLOW AND FUNCTION; SINGLE STUDY, WITH PHARMACOLOGIC $192.80 20060701 99999999 78709 KIDNEY IMAGING WITH VASCULAR FLOW AND FUNCTION; MULTIPLE STUDIES, WITH AND WITHO $199.00 20060701 99999999 78710 KIDNEY IMAGING(SPECT) $221.07 20060701 99999999 78715 KIDNEY VASCULAR FLOW ONLY $64.42 19990701 99999999 78725 KIDNEY FUNCTION STUDY ONLY $73.95 20060701 99999999 78730 URINARY BLADDER RESIDUAL STUDY $62.88 20060701 99999999 78740 URETERAL REFLUX STUDY (RADIONUCLIDE VOIDING CYSTOGRAM) $92.24 20060701 99999999 78760 TESTICULAR IMAGING $114.39 19990701 99999999 78761 TESTICULAR IMAGING $133.67 20060701 99999999 78800 RADIONUCLIDE LOCALIZATION OF TUMOR $152.44 20060701 99999999 78801 RADIONUCLIDE LOCALIZATION OF TUMOR $170.40 20060701 99999999 78802 RADIONUCLIDE LOCALIZATION OF TUMOR $216.41 20060701 99999999 78803 TUMOR LOCALIZATION (SPECT) $259.27 20060701 99999999 78804 RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL $320.14 20060701 99999999 78805 RADIONUCLIDE LOCALIZATION OF ABSCESS $140.99 20060701 99999999 78806 RADIONUCLIDE LOCALIZATION OF ABSCESS $252.31 20060701 99999999 78807 RADIONUCLIDE LOCALIZATION OF ABSCESS, SPECT $258.96 20060701 99999999 78810 TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION $1,495.20 19960101 99999999 78990 PROVISION OF DIAGNOSTIC RADIONUCLIDE(S) $10.92 19990701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 242
PROC-CODE DESC MAC BEG END 79000 RADIONUCLIDE THERAPY, HYPERTHYROIDISM $191.83 19990701 99999999 79001 RADIONUCLIDE THERAPY, HYPERTHYROIDISM $84.41 19990701 99999999 79005 RADIOPHARMACEUTICAL THERAPY, BY ORAL ADMINISTRATION $152.19 20060701 99999999 79020 RADIONUCLIDE THERAPY, THYROID SUPPRESSION $157.49 19990701 99999999 79030 RADIONUCLIDE ABLATION OF GLAND FOR THYROID $169.12 19990701 99999999 79035 RADIONUCLIDE THERAPY FOR METASTASES OF THYROID $186.03 19990701 99999999 79100 RADIONUCLIDE THERAPY, POLYCYTHEMIA VERA, CHRONIC $138.48 19990701 99999999 79101 RADIOPHARMACEUTICAL THERAPY, BY INTRAVENOUS ADMINISTRATION $158.70 20060701 99999999 79200 INTRACAVITARY RADIOACTIVE COLLOID THERAPY $165.04 20060701 99999999 79400 RADIONUCLIDE THERAPY, NONTHYROID, NONHEMATOLOGIC $163.31 19990701 99999999 79403 RADIOPHARMACEUTICAL THERAPY, RADIOLABELED MONOCLONAL ANTIBODY BY INTRAVENOUS INF $222.58 20060701 99999999 79440 INTRA-ARTICULAR RADIONUCLIDE THERAPY $165.29 20060701 99999999 79445 RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTERIAL PARTICULATE ADMINISTRATION $176.60 20050101 99999999 79900 PROVISION OF THERAPEUTIC RADIONUCLIDE(S) $12.00 19990701 99999999 79999 UNLISTED RADIONUCLIDE THERAPEUTIC PROCEDURE $32.54 19990701 99999999 80047 BASIC METABOLIC PANEL (CALCIUM, IONIZED) $30.51 20080101 99999999 80048 BASIC METABOLIC PANEL $11.70 20060701 99999999 80050 GENERAL HEALTH SCREEN PANEL $41.19 19940101 99999999 80051 ELECTROLYTE PANEL $9.69 20060701 99999999 80053 EXECUTIVE PROFILE $14.61 20060701 99999999 80055 OBSTETRIC PROFILE $21.14 20000601 99999999 80061 LIPID PROFILE $18.51 20060701 99999999 80069 RENAL FUNCTION PANEL $12.00 20060701 99999999 80072 ARTHRITIS PANEL $35.67 19990701 99999999 80074 ACUTE HEPATITIS PANEL $65.82 20060701 99999999 80076 HEPATIC FUNCTION PANEL $11.29 20060701 99999999 80090 ANTIBODY PANEL (EG, TORCH: TOXOPLASMA IFA, RUBELLA HI, $79.56 19990701 99999999 80100 DRUG, SCREEN; MULTIPLE DRUG CLASSES, EACH PROCEDURE $20.10 20060701 99999999 80101 DRUG, SCREEN; SINGLE DRUG CLASS, EACH DRUG CLASS $19.03 20060701 99999999 80102 DRUG, CONFIRMATION, EACH PROCEDURE $18.31 20060701 99999999 80150 AMIKACIN $20.83 20060701 99999999 80152 AMITRIPTYLINE $24.74 20060701 99999999 80154 BENZODIAZEPINES $25.56 20060701 99999999 80156 CARBAMAZEPINE $20.12 20060701 99999999 80157 CARBAMAZEPINE; FREE $11.11 20060701 99999999 80158 CYCLOSPORINE $24.95 20060701 99999999 80160 DESIPRAMINE $23.79 20060701 99999999 80162 DIGOXIN $18.35 20060701 99999999 80164 DIPROPYLACETIC ACID (VALPROIC ACID) $18.72 20060701 99999999 80166 DOXEPIN $13.00 20060701 99999999 80168 ETHOSUXIMIDE $22.58 20060701 99999999 80170 GENTAMICIN $22.65 20060701 99999999 80172 GOLD $13.66 20060701 99999999 80173 HALOPERIDOL $20.34 20060701 99999999 80174 IMIPRAMINE $14.43 20060701 99999999 80176 LIDOCAINE $20.30 20060701 99999999 80178 LITHIUM $9.13 20060701 99999999 80182 NORTRIPTYLINE $18.72 20060701 99999999 80184 PHENOBARBITAL $15.83 20060701 99999999 80185 PHENYTOIN; TOTAL $18.32 20060701 99999999 80186 PHENYTOIN; FREE $19.03 20060701 99999999 80188 PRIMIDONE $22.93 20060701 99999999 80190 PROCAINAMIDE; $14.05 20060701 99999999 80192 PROCAINAMIDE; WITH METABOLITES (EG, N-ACETYL PROCAINAMIDE) $23.15 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 243
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