Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 90655 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, FOR CHILDREN 6-35 MONTH $4.00 20040101 99999999 90656 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, FOR USE IN INDIVIDUALS $4.00 20050101 99999999 90657 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, 6-35 MONTHS DOSAGE, FOR INTRAMUSCULAR OR J $4.00 19990701 99999999 90658 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, 3 YEARS AND ABOVE DOSAGE, FOR INTRAMUSCULA $4.00 19990701 99999999 90659 INFLUENZA VIRUS VACCINE, WHOLE VIRUS, FOR INTRAMUSCULAR OR JET INJECTION USE $4.00 19990701 99999999 90660 INFLUENZA VIRUS VACCINE, LIVE, FOR INTRANASAL USE $4.00 20010101 99999999 90665 LYME DISEASE VACCINE, ADULT DOSAGE, FOR INTRAMUSCULAR USE $4.00 20010101 99999999 90669 PNEUMOCOCCAL CONJUGATE VACCINE, POLYVALENT, FOR INTRAMUSCULAR USE $4.00 19990701 99999999 90675 RABIES VACCINE, FOR INTRAMUSCULAR USE $4.00 20010101 99999999 90676 RABIES VACCINE, FOR INTRADERMAL USE $4.00 20010101 99999999 90680 ROTAVIRUS VACCINE, TETRAVALENT, LIVE, FOR ORAL USE $4.00 20010101 99999999 90690 TYPHOID VACCINE, LIVE, ORAL $4.00 20010101 99999999 90691 TYPHOID VACCINE, VI CAPSULAR POLYSACCHARIDE (VICPS), FOR INTRAMUSCULAR USE $4.00 19990701 99999999 90692 TYPHOID VACCINE, HEAT- AND PHENOL-INACTIVATED (H-P), FOR SUBCUTANEOUS OR INTRADE $4.00 20010101 99999999 90693 TYPHOID VACCINE, ACETONE-KILLED, DRIED (AKD), FOR SUBCUTANEOUS OR JET INJECTION $4.00 19990701 99999999 90698 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZA $4.00 20040101 99999999 90700 IMMUNIZATION, ACTIVE; DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCI $4.00 19990701 99999999 90701 IMMUNIZATION, ACTIVE $4.00 20010101 99999999 90702 IMMUNIZATION, ACTIVE $4.00 20010101 99999999 90703 IMMUNIZATION, ACTIVE $4.00 20010101 99999999 90704 IMMUNIZATION, ACTIVE $4.00 20010101 99999999 90705 IMMUNIZATION, ACTIVE $4.00 19990701 99999999 90706 IMMUNIZATION, ACTIVE $4.00 20000601 99999999 90707 IMMUNIZATION, ACTIVE $4.00 19990701 99999999 90708 IMMUNIZATION, ACTIVE $4.00 20010101 99999999 90710 IMMUNIZATION, ACTIVE; MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE $4.00 20010101 99999999 90712 IMMUNIZATION, ACTIVE $4.00 19990701 99999999 90713 IMMUNIZATION, ACTIVE $4.00 19990701 99999999 90714 IMMUNIZATION, ACTIVE $4.00 20060101 99999999 90715 TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), FOR USE IN I $4.00 20040101 99999999 90716 IMMUNIZATION, ACTIVE; VARICELLA (CHICKEN POX) VACCINE $4.00 19990701 99999999 90717 IMMUNIZATION, ACTIVE $4.00 19990701 99999999 90718 IMMUNIZATION, ACTIVE $4.00 20010101 99999999 90719 IMMUNIZATION, ACTIVE $4.00 19990701 99999999 90720 IMMUNIZATION, ACTIVE; DIPHTHERIA, TETANUS, AND PERTUSSIS (DTP) AND HEMOPHILUS IN $4.00 20010101 99999999 90721 IMMUNIZATION, ACTIVE; DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCI $4.00 19990701 99999999 90723 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND POLIO $4.00 20010101 99999999 90725 IMMUNIZATION, ACTIVE $4.00 20010101 99999999 90727 IMMUNIZATION, ACTIVE $4.00 20010101 99999999 90732 IMMUNIZATION, ACTIVE $4.00 19990701 99999999 90733 IMMUNIZATION, ACTIVE $4.00 19990701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 270
PROC-CODE DESC MAC BEG END 90734 MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, Y AND W-135 (TETRAVALENT), FOR $4.00 20040101 99999999 90735 IMMUNIZATION, ACTIVE; ENCEPHALITIS VIRUS VACCINE $4.00 20010101 99999999 90736 ZOSTER (SHINGLES) VACCINE, LIVE, FOR SUBCUTANEOUS INJECTION $4.00 20060101 99999999 90740 HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED PATIENT DOSAGE (3 DOSE SCHEDUL $4.00 20010101 99999999 90743 HEPATITIS B VACCINE, ADOLESCENT (2 DOSE SCHEDULE), FOR INTRAMUSCULAR USE $4.00 20010101 99999999 90744 IMMUNIZATION, ACTIVE, HEPATITIS B VACCINE; NEWBORN TO 11 YEARS $4.00 19990701 99999999 90746 IMMUNIZATION, ACTIVE, HEPATITIS B VACCINE; 20 YEARS AND ABOVE $4.00 19990701 99999999 90747 IMMUNIZATION, ACTIVE, HEPATITIS B VACCINE; DIALYSIS OR IMMUNOSUPPRESSED PATIENT, $4.00 19990701 99999999 90748 IMMUNIZATION, ACTIVE, HEPATITIS B AND HEMOPHILUS INFLUENZA B (HIB) VACCINE $4.00 20010101 99999999 90749 UNLISTED IMMUNIZATION PROCEDURE $4.00 19990701 99999999 90760 INTERVAL HISTORY AND EXAMINATION RELATED TO THE HEALTHY $41.29 20060701 99999999 90761 INTERVAL HISTORY AND EXAMINATION RELATED TO THE HEALTHY $18.53 20060701 99999999 90765 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE $50.53 20060701 99999999 90766 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE $18.53 20060701 99999999 90767 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE $30.69 20060701 99999999 90768 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE $17.51 20060701 99999999 90769 SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); IN $95.83 20080101 99999999 90770 SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); EA $8.97 20080101 99999999 90771 SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); AD $43.34 20080101 99999999 90772 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); S $11.90 20060701 99999999 90773 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); I $13.60 20060701 99999999 90774 ADMINISTRATION AND MEDICAL INTERPRETATION OF DEVELOPMENTAL $37.68 20060701 99999999 90775 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); E $17.41 20060701 99999999 90779 UNLISTED THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INTRAVENOUS OR INTRA-ARTERIAL I $4.00 20060101 99999999 90780 IV INFUSION THERAPY, ADMINISTERED BY PHYSICIAN OR UNDER DIRECT $37.06 19990701 99999999 90781 IV INFUSION THERAPY, ADMINISTERED BY PHYSICIAN OR UNDER DIRECT $18.53 19990701 99999999 90782 THERAPEUTIC INJECTION OF MEDICATION (SPECIFY) $3.68 19990701 99999999 90783 THERAPEUTIC OR DIAGNOSTIC INJECTION,INTRA-ARTERIAL $13.60 19990701 99999999 90784 THERAPEUTIC INJECTION OF MEDICATION (SPECIFY) $5.00 19990701 99999999 90788 INTRAMUSCULAR INJECTION OF ANTIBIOTIC (SPECIFY) $4.00 19990701 99999999 90799 UNLISTED THERAPEUTIC INJECTION $4.00 19990701 99999999 90801 PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION INCLUDING HISTORY, $104.43 20060701 99999999 90802 INTERACTIVE PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION USING PLAY EQUIPMENT, P $105.53 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 271
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