Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 84143 17-HYDROXYPREGNENOLONE $19.13 20060701 99999999 84144 PROGESTERONE, ANY METHOD $28.83 20060701 99999999 84146 PROLACTIN (MAMMOTROPIN), RIA $26.78 20060701 99999999 84150 PROSTAGLANDIN, ANY ONE, RIA $34.50 20060701 99999999 84152 PROSTATE SPECIFIC ANTIGEN (PSA); COMPLEXED (DIRECT MEASUREMENT) $25.42 20060701 99999999 84153 PROSTATE SPECIFIC ANTIGEN (PSA) $25.42 20060701 99999999 84154 PROSTATE SPECIFIC ANTIGEN (PSA); FREE $25.42 20060701 99999999 84155 PROTEIN, TOTAL, SERUM $5.06 20060701 99999999 84156 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE $3.69 20060701 99999999 84157 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREB $3.69 20060701 99999999 84160 PROTEIN, TOTAL, SERUM $2.80 20060701 99999999 84163 PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A) $20.80 20060701 99999999 84165 PROTEIN, TOTAL, SERUM $14.84 20060701 99999999 84166 PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH $24.92 20060701 99999999 84181 PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD OR OTHER BODY FLUID $14.28 20060701 99999999 84182 PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD OR OTHER BODY FLUID $15.09 20060701 99999999 84202 PROTOPORPHYRIN, RBC $19.83 20060701 99999999 84203 PROTOPORPHYRIN, RBC $7.22 20060701 99999999 84206 PROINSULIN, RIA $23.03 20060701 99999999 84207 PYRIDOXINE (VITAMIN B-6) $26.36 20060701 99999999 84210 PYRUVATE, BLOOD $15.01 20060701 99999999 84220 PYRUVIC KINASE, RBC $7.91 20060701 99999999 84228 QUININE $9.76 20060701 99999999 84233 RECEPTOR ASSAY $53.99 20060701 99999999 84234 RECEPTOR ASSAY $54.38 20060701 99999999 84235 RECEPTOR ASSAY $73.12 20060701 99999999 84238 RECEPTOR ASSAY $50.53 20060701 99999999 84244 RENIN (ANGIOTENSIN I) $30.40 20060701 99999999 84252 RIBOFLAVIN (VITAMIN B-2) $15.99 20060701 99999999 84255 SELENIUM, BLOOD, URINE OR TISSUE $35.28 20060701 99999999 84260 SEROTONIN, BLOOD $42.81 20060701 99999999 84270 SEX HORMONE BINDING GLOBULIN (SHBG) $13.11 20060701 99999999 84275 SIALIC ACID, BLOOD $11.26 20060701 99999999 84285 SILICA, BLOOD, URINE OR TISSUE $19.74 20060701 99999999 84295 SODIUM $6.65 20060701 99999999 84300 SODIUM $6.72 20060701 99999999 84302 SODIUM; OTHER SOURCE $6.79 20060701 99999999 84305 SOMATOMEDIN $29.38 20060701 99999999 84307 SOMATOSTATIN $15.32 20060701 99999999 84311 SPECTROPHOTOMETRY, ANALYTE NOT ELSEWHERE SPECIFIED $9.66 20060701 99999999 84315 SPECIFIC GRAVITY (EXCEPT URINE) $2.10 20060701 99999999 84375 SUGARS, CHROMATOGRAPHIC, TLC OR PAPER CHROMATOGRAPHY $16.43 20060701 99999999 84376 SUGARS (MON-, DI, AND OLIGOSACCHARIDES); SINGLE QUALITATIVE, EACH SPECIMEN $7.61 20060701 99999999 84377 SUGARS (MON-, DI, AND OLIGOSACCHARIDES); MULTIPLE QUALITATIVE, EACH SPECIMEN $4.61 20060701 99999999 84378 SUGARS (MON-, DI, AND OLIGOSACCHARIDES); SINGLE QUANTITATIVE, EACH SPECIMEN $9.66 20060701 99999999 84379 SUGARS (MON-, DI, AND OLIGOSACCHARIDES); MULTIPLE QUANTITATIVE, EACH SPECIMEN $9.66 20060701 99999999 84392 SULFATE, URINE $3.98 20060701 99999999 84402 TESTOSTERONE; FREE $35.19 20060701 99999999 84403 TESTOSTERONE, BLOOD, RIA $35.68 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 252
PROC-CODE DESC MAC BEG END 84425 THIAMINE (VITAMIN B-1) $26.36 20060701 99999999 84430 THIOCYANATE, BLOOD $9.76 20060701 99999999 84432 THYROGLOBULIN $22.20 20060701 99999999 84436 THYROXINE, TRUE (TT-4), RIA $9.50 20060701 99999999 84437 THYROXINE (T-4) NEONATAL $8.95 20060701 99999999 84439 THYROXINE, FREE (FT-4), RIA (UNBOUND T-4 ONLY) $12.46 20060701 99999999 84442 THYROXINE BINDING GLOBULIN (TBG) $20.44 20060701 99999999 84443 THYROID STIMULATING HORMONE (TSH), RIA OR EIA $23.21 20060701 99999999 84445 THYROTROPIN RELEASING FACTOR (TRF), RIA $32.92 20060701 99999999 84446 TOCOPHEROL ALPHA (VITAMIN E) $19.60 20060701 99999999 84449 TRANSCORTIN (CORTISOL BINDING GLOBULIN) $24.87 20060701 99999999 84450 TRANSAMINASE, GLUTAMIC OXALOACETIC (SGOT), BLOOD $7.14 20060701 99999999 84460 TRANSAMINASE, GLUTAMIC PYRUVIC (SGPT), BLOOD $7.32 20060701 99999999 84466 TRANSFERRIN $17.65 20060701 99999999 84478 TRIGLYCERIDES, BLOOD $7.95 20060701 99999999 84479 TRIIODOTHYRONINE (T-3), RESIN UPTAKE $8.95 20060701 99999999 84480 TRIIODOTHYRONINE TRUE (TT-3), RIA $19.60 20060701 99999999 84481 TRIIODOTHYRONINE, FREE (FT-3), RIA (UNBOUND T-3 ONLY) $23.41 20060701 99999999 84482 TRIDOTHYRONINE (T-3); REVERSE $21.78 20060701 99999999 84484 TROPONIN $13.60 20060701 99999999 84485 TRYPSIN, DUODENAL FLUID $6.29 20060701 99999999 84488 TRYPSIN, FECES $6.12 20060701 99999999 84490 TRYPSIN, FECES $6.38 20060701 99999999 84510 TYROSINE, BLOOD $8.72 20060701 99999999 84512 TROPONIN, QUALITATIVE $10.64 20060701 99999999 84520 UREA NITROGEN, BLOOD (BUN) $5.45 20060701 99999999 84525 UREA NITROGEN, BLOOD (BUN) $4.02 20060701 99999999 84540 UREA NITROGEN, URINE $6.56 20060701 99999999 84545 UREA NITROGEN, CLEARANCE $9.12 20060701 99999999 84550 URIC ACID $6.25 20060701 99999999 84560 URIC ACID, URINE $6.56 20060701 99999999 84565 UROBILIN, URINE $7.73 20010101 99999999 84577 UROBILINOGEN, FECES, QUANTITATIVE $10.46 20060701 99999999 84578 UROBILINOGEN, URINE $2.72 20060701 99999999 84580 UROBILINOGEN, URINE $5.95 20060701 99999999 84583 UROBILINOGEN, URINE $4.21 20060701 99999999 84585 VANILLYMANDELIC ACID (VMA), URINE $21.42 20060701 99999999 84586 VASOACTIVE INTESTINAL PEPTIDE (VIP) $46.25 20060701 99999999 84588 VASOPRESSIN (ANTIDIURETIC HORMONE), RIA $46.91 20060701 99999999 84590 VITAMIN A, BLOOD $16.02 20060701 99999999 84591 VITAMIN, NOT OTHERWISE SPECIFIED $9.72 20060701 99999999 84597 VITAMIN K $18.94 20060701 99999999 84600 VOLATILES (ACETIC ANHYDRIDE, CARBON TETRACHLORIDE, $13.47 20060701 99999999 84620 XYLOSE ABSORPTION TEST, BLOOD AND/OR URINE $9.93 20060701 99999999 84630 ZINC, QUANTITATIVE $15.74 20060701 99999999 84681 C-PEPTIDE, ANY METHOD $28.75 20060701 99999999 84702 GONADOTROPIN, CHORIONIC $20.80 20060701 99999999 84703 GONADOTROPIN, CHORIONIC $10.38 20060701 99999999 84704 GONADOTROPIN, CHORIONIC (HCG); FREE BETA CHAIN $21.03 20080101 99999999 84830 OVULATION TESTS, BY VISUAL COLOR COMPARISON METHODS FOR HUMAN LUTEINIZING HORMON $8.41 20060701 99999999 85002 BLEEDING TIME $6.22 20060701 99999999 85004 BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT $9.04 20060701 99999999 85007 BLOOD COUNT $4.76 20060701 99999999 85008 BLOOD COUNT; MANUAL BLOOD SMEAR EXAMINATION WITHOUT DIFFERENTIAL PARAMETERS $4.76 20060701 99999999 85009 BLOOD COUNT $5.14 20060701 99999999 85013 BLOOD COUNT; SPUN MICROHEMATOCRIT $3.27 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 253
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