Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 90804 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $46.62 20060701 99999999 90805 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $52.02 20060701 99999999 90806 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $75.00 20060701 99999999 90807 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $78.00 20060701 99999999 90808 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $110.09 20060701 99999999 90809 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $114.24 20060701 99999999 90810 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $54.19 20060701 99999999 90811 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $59.28 20060701 99999999 90812 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $76.16 20060701 99999999 90813 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $80.06 20060701 99999999 90814 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $106.44 20030401 99999999 90815 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $110.89 20030401 99999999 90816 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $48.61 20060701 99999999 90817 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $53.38 20060701 99999999 90818 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $90.00 20060701 99999999 90819 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $78.00 20060701 99999999 90821 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $112.08 20060701 99999999 90822 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $115.60 20060701 99999999 90823 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $57.12 20060701 99999999 90824 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $61.26 20060701 99999999 90826 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $78.47 20060701 99999999 90827 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $82.04 20060701 99999999 90828 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $109.30 19990701 99999999 90829 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, L $111.95 19990701 99999999 90841 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY A PHYSICIAN, WITH CONTINUING $25.36 19990701 99999999 90843 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY A PHYSICIAN, WITH CONTINUING $42.00 19990701 99999999 90844 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY A PHYSICIAN, WITH CONTINUING $78.00 19990701 99999999 90845 MEDICAL PSYCHOANALYSIS $65.82 20060701 99999999 90846 FAMILY MEDICAL PSYCHOTHERAPY(WITHOUT_THE PATIENT PRESENT) $71.55 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 272
PROC-CODE DESC MAC BEG END 90847 FAMILY MEDICAL PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) BY $82.73 20060701 99999999 90849 MULTIPLE-FAMILY GROUP MEDICAL PSYCHOTHERAPY BY A PHYSICIAN, $25.38 20060701 99999999 90853 GROUP MEDICAL PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE- FAMILY $27.20 20060701 99999999 90857 INTERACTIVE GROUP MEDICAL PSYCHOTHERAPY $24.88 20060701 99999999 90862 CHEMOTHERAPY MANAGEMENT, INCLUDING PRESCRIPTION, USE, AND REVIEW $38.28 20060701 99999999 90870 ELECTROCONVULSIVE THERAPY $70.99 20060701 99999999 90871 ELECTROCONVULSIVE THERAPY $122.66 19990701 99999999 90880 MEDICAL HYPNOTHERAPY $83.76 20060701 99999999 90918 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES PER FULL MONTH; FOR PATIENTS UND $424.09 19990701 99999999 90919 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES PER FULL MONTH; BETWEEN THE SECO $338.03 19990701 99999999 90920 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES PER FULL MONTH; THROUGH AGE NINE $294.07 19990701 99999999 90921 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES PER FULL MONTH; FOR PATIENTS TWE $200.55 19990701 99999999 90922 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN FULL MONTH), PER DAY $13.98 19990701 99999999 90923 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS TH $11.05 19990701 99999999 90924 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN FULL MONTH), PER DAY; $9.68 19990701 99999999 90925 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN FULL MONTH), PER DAY; $6.70 19990701 99999999 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN EVALUATION $62.86 20060701 99999999 90937 HEMODIALYSIS PROCEDURE REQUIRING REPEATED EVALUATION(S) WITH OR $108.49 20060701 99999999 90945 DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, PERITONEAL, $63.76 20060701 99999999 90947 DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, PERITONEAL, $106.32 20060701 99999999 90997 HEMOPERFUSION (EG, WITH ACTIVATED CHARCOAL OR RESIN) $94.90 20060701 99999999 91000 ESOPHAGEAL INTUBATION AND COLLECTION OF WASHINGS FOR $36.49 20060701 99999999 91010 ESOPHAGEAL MOTILITY STUDY $142.41 20060701 99999999 91011 ESOPHAGEAL MOTILITY STUDY $169.02 20060701 99999999 91012 ESOPHAGEAL MOTILITY STUDY $181.49 20060701 99999999 91020 ESOPHAGOGASTRIC MANOMETRIC STUDIES $149.71 20060701 99999999 91022 DUODENAL MOTILITY (MANOMETRIC) STUDY $163.36 20060701 99999999 91030 ESOPHAGUS, ACID PERFUSION (BERNSTEIN) TEST FOR ESOPHAGITIS $83.53 20060701 99999999 91032 ESOPHAGUS, ACID REFLUX TEST, WITH INTRALUMINAL PH ELECTRODE $85.56 19990701 99999999 91033 ESOPHAGUS, ACID REFLUX TEST, WITH INTRALUMINAL PH ELECTRODE $111.63 19990701 99999999 91034 ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH NASAL CATHETER PH ELECTRODE(S) $188.96 20060701 99999999 91035 ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH MUCOSAL ATTACHED TELEMETRY PH $375.51 20060701 99999999 91037 ESOPHAGEAL FUNCTION TEST, GASTROESOPHAGEAL REFLUX TEST WITH NASAL CATHETER $118.50 20060701 99999999 91038 ESOPHAGEAL FUNCTION TEST, GASTROESOPHAGEAL REFLUX TEST WITH NASAL CATHETER $100.39 20060701 99999999 91040 ESOPHAGEAL BALLOON DISTENSION PROVOCATION STUDY $368.65 20060701 99999999 91052 GASTRIC ANALYSIS TEST WITH INJECTION OF STIMULANT OF $81.11 20060701 99999999 91055 GASTRIC INTUBATION, WASHINGS, AND PREPARING SLIDES $97.28 20060701 99999999 91060 GASTRIC SALINE LOAD TEST $28.84 19990701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 273
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Medicaid Fee Schedule without Mods 200801

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