Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END G0143 SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED I $28.00 20060701 99999999 G0144 SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED I $28.00 20060701 99999999 G0145 SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED I $28.00 20060701 99999999 G0147 SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, PERFORMED BY AUTOMATED SYS $15.73 20060701 99999999 G0148 SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, PERFORMED BY AUTOMATED SYST $21.00 20060701 99999999 G0159 PERCUTANEOUS THROMBECTOMY AND/OR REVISION, ARTERIOVENOUS FISTULA, AUTOGENOUS OR $689.17 20000101 99999999 G0160 CRYOSURGICAL ABLATION OF LOCALIZED PROSTATE CANCER, PRIMARY TREATMENT ONLY $895.53 19990701 99999999 G0163 POSTERIOR EMISSION TOMOGRAPHY (PET), WHOLE BODY, FOR RECURRENCE OF COLORECTAL $2,400.36 19990701 99999999 G0164 POSITRON EMISSION TOMOGRAPHY (PET), WHOLE BODY FOR RECURRENCOF MELANOMA CANCER $2,420.12 19990701 99999999 G0165 POSITRON EMISSION TOMOGRAPHY (PET) WHOLE BODY FOR RECURRENCEOF MELANOMA/MET CANC $2,400.36 19990701 99999999 G0166 EXTERNAL COUNTERPULSATION, PER TREATMENT SESSION $4.05 20060701 99999999 G0167 HYPERBARIC OXYGEN TREATMENT NOT REQUIRING PHYSICIAN ATTENDANCE, PER TREATMENT SE $32.32 20000101 99999999 G0168 WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY $23.82 20060701 99999999 G0169 REMOVAL OF DEVITALIZED TISSUE, WITHOUT USE OF ANESTHESIA (CONSCIOUS SEDATION, LO $35.26 20000101 99999999 G0170 APPLICATION OF TISSUE CULTURED SKIN GRAFTS, INCLUDING BILAMINATE SKIN SUBSTITUTE $128.70 20000101 99999999 G0171 APPLICATION OF TISSUE CULTURED SKIN GRAFTS, INCLUDING BILAMINATE SKIN SUBSTITUTE $109.31 20000101 99999999 G0179 INTENSITY MODULATED RADIATION THERAPY (IMRT) PLANNING, INCLUDES DOSE VOLUME NIST $47.36 20010101 99999999 G0180 PHYSICIAN CERTIFICATION SERVICES FOR MEDICARE-COVERED SERVICES PROVIDED BY A PAR $55.63 20010101 99999999 G0181 PHYSICIAN SUPERVISION OF A PATIENT RECEIVING MEDICARE- COVERED SERVICES PROVIDED $92.25 20060701 99999999 G0182 PHYSICIAN SUPERVISION OF A PATIENT UNDER A MEDICARE- APPROVED HOSPICE (PATIENT NO $103.97 20060701 99999999 G0184 DESTRUCTION OF LOCALIZED LESION OF CHOROID (FOR EXAMPLE, CHOROIDAL NEOVASCULARIZ $29.06 20010101 99999999 G0195 CLINICAL EVALUATION OF SWALLOWING FUNCTION (NOT INVOLVING INTERPRETATION OF DYNA $88.58 20030401 99999999 G0196 EVALUATION OF SWALLOWING INVOLVING SWALLOWING OF RADIO- OPAQUE MATERIALS $88.58 20030401 99999999 G0197 EVALUATION OF PATIENT FOR PRESCRIPTION OF SPEECH GENERATING DEVICES $81.75 20030401 99999999 G0198 PATIENT ADAPTATION AND TRAINING FOR USE OF SPEECH GENERATING DEVICES $59.77 20010101 99999999 G0199 RE-EVALUATION OF PATIENT USING SPEECH GENERATING DEVICES $61.12 20030401 99999999 G0200 EVALUATION OF PATIENT FOR PRESCRIPTION OF VOICE PROSTHETIC $81.75 20030401 99999999 G0201 MODIFICATION OR TRAINING IN USE OF VOICE PROSTHETIC $59.77 20010101 99999999 G0202 SCREENING MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, BILATERAL, ALL VIEWS $137.84 20060701 99999999 G0204 DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, BILATERAL, ALL VIEWS $145.19 20060701 99999999 G0205 DIAGNOSTIC MAMMOGRAPHY, FILM PROCESSED TO PRODUCE DIGITAL IMAGE ANALYZED FOR POT $91.91 20030101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 36
PROC-CODE DESC MAC BEG END G0206 DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, UNILATERAL, ALL VIEWS $117.19 20060701 99999999 G0207 DIAGNOSTIC MAMMOGRAPHY, FILM PROCESSED TO PRODUCE DIGITAL IMAGE ANALYZED FOR POT $75.43 20030101 99999999 G0236 DIGITIZATION OF FILM RADIOGRAPHIC IMAGES WITH COMPUTER ANALYSIS FOR LESION DETEC $15.38 20020101 99999999 G0237 THERAPEUTIC PROCEDURES TO INCREASE STRENGTH OR ENDURANCE OF RESPIRATORY MUSCLES, $18.91 20060701 99999999 G0238 THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION, OTHER THAN DESCRIBED BY $12.74 20060701 99999999 G0239 THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION, OTHER THAN SERVICES DESC $8.70 20060701 99999999 G0240 CRITICAL CARE SERVICE DELIVERED BY A PHYSICIAN, FACE TO FACE; DURING INTERFACILI $153.86 20020101 99999999 G0241 EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO G0240) $76.92 20020101 99999999 G0245 INITIAL PHYSICIAN EVALUATION AND MANAGEMENT OF A DIABETIC PATIENT WITH DIABETIC $33.87 20060701 99999999 G0246 FOLLOW-UP PHYSICIAN EVALUATION AND MANAGEMENT OF A DIABETIC PATIENT WITH DIABETI $17.09 20060701 99999999 G0247 ROUTINE FOOT CARE BY A PHYSICIAN OF A DIABETIC PATIENT WITH DIABETIC SENSORY NEU $20.56 20060701 99999999 G0248 DEMONSTRATION, AT INITIAL USE, OF HOME INR MONITORING FOR PATIENT WITH MECHANICA $167.67 20060701 99999999 G0249 PROVISION OF TEST MATERIALS AND EQUIPMENT FOR HOME INR MONITORING TO PATIENT WIT $100.48 20060701 99999999 G0250 PHYSICIAN REVIEW, INTERPRETATION AND PATIENT MANAGEMENT OF HOME INR TESTING FOR $7.06 20060701 99999999 G0253 PET IMAGING FOR BREAST CANCER, FULL AND PARTIAL-RING PET SCANNERS ONLY, STAGING/ $1,788.18 20030401 99999999 G0254 PET IMAGING FOR BREAST CANCER, FULL AND PARTIAL- RING PET SCANNERS ONLY, EVALUAT $1,788.18 20030401 99999999 G0262 SMALL INTESTINAL IMAGING; INTRALUMINAL, FROM LIGAMENT OF TREITZ TO THE ILEO CECA $613.55 20030401 99999999 G0265 CRYOPRESERVATION, FREEZING AND STORAGE OF CELLS FOR THERAPEUTIC USE, EACH CELL L $6.27 20030401 99999999 G0266 THAWING AND EXPANSION OF FROZEN CELLS FOR THERAPEUTIC USE, EACH ALIQUOT $6.27 20030401 99999999 G0268 REMOVAL OF IMPACTED CERUMEN (ONE OR BOTH EARS) BY PHYSICIAN ON SAME DATE OF SERV $24.13 20060701 99999999 G0272 NASO/ORO GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GU $12.76 20030401 99999999 G0273 RADIOPHARMACEUTICAL BIODISTRIBUTION, SINGLE OR MULTIPLE SCANS ON ONE OR MORE DAY $367.08 20030401 99999999 G0274 RADIOPHARMACEUTICAL THERAPY, NON-HODGKIN'S LYMPHOMA, INCLUDES ADMINISTRATION OF $160.89 20030401 99999999 G0275 RENAL ARTERY ANGIOGRAPHY (UNILATERAL OR BILATERAL) PERFORMED AT THE TIME OF CARD $9.80 20060701 99999999 G0278 ILIAC ARTERY ANGIOGRAPHY PERFORMED AT THE SAME TIME OF CARDIAC CATHETERIZATION, $9.80 20060701 99999999 G0281 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR CHRONIC STAGE II $9.73 20060701 99999999 G0283 ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHE $9.73 20060701 99999999 G0288 RECONSTRUCTION, COMPUTED TOMOGRAPHIC ANGIOGRAPHY OF AORTA FOR SURGICAL PLANNING $317.98 20060701 99999999 G0289 ARTHROSCOPY, KNEE, SURGICAL, FOR REMOVAL OF LOOSE BODY, FOREIGN BODY, DEBRIDEMEN $62.31 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 37
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Medicaid Fee Schedule without Mods 200801

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