Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 19357 BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH TISSUE EXPANDER, INCLUDING SUB $926.80 20060701 99999999 19361 BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP, WITH OR WITHOUT PROSTHETIC IMP $1,075.08 20060701 99999999 19364 BREAST RECONSTRUCTION WITH FREE FLAP $1,838.78 20060701 99999999 19366 BREAST RECONSTRUCTION WITH OTHER TECHNIQUE $1,071.43 20060701 99999999 19367 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), $1,315.42 20060701 99999999 19368 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), $1,553.39 20060701 99999999 19369 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), $1,477.38 20060701 99999999 19370 OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST $424.59 20060701 99999999 19371 PERIPROSTHETIC CAPSULECTOMY, BREAST $506.66 20060701 99999999 19380 REVISION OF RECONSTRUCTED BREAST $502.19 20060701 99999999 19396 PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT $107.16 20060701 99999999 19499 UNLISTED PROCEDURE, BREAST $127.70 19990701 99999999 20000 INCISION OF SOFT TISSUE ABSCESS (EG, SECONDARY TO OSTEOMYELITIS) $96.95 20060701 99999999 20005 INCISION OF SOFT TISSUE ABSCESS (EG, SECONDARY TO OSTEOMYELITIS) $161.70 20060701 99999999 20100 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); NECK $448.20 20060701 99999999 20101 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); CHEST $167.73 20060701 99999999 20102 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK $175.84 20060701 99999999 20103 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY $258.18 20060701 99999999 20150 EXCISION OF EPIPHYSEAL BAR WITH/WITHOUT AUTOGENOUS SOFT TISSUE GRAFT OBTAINED TH $661.36 20060701 99999999 20200 BIOPSY, MUSCLE $83.98 20060701 99999999 20205 BIOPSY, MUSCLE $132.94 20060701 99999999 20206 BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE $52.62 20060701 99999999 20220 BIOPSY, BONE, TROCAR OR NEEDLE $84.38 20060701 99999999 20225 BIOPSY, BONE, TROCAR OR NEEDLE $102.23 20060701 99999999 20240 BIOPSY, EXCISIONAL $146.49 20060701 99999999 20245 BIOPSY, EXCISIONAL $367.87 20060701 99999999 20250 BIOPSY, VERTEBRAL BODY, OPEN $289.23 20060701 99999999 20251 BIOPSY, VERTEBRAL BODY, OPEN $253.09 20060701 99999999 20500 INJECTION OF SINUS TRACT $68.94 20060701 99999999 20501 INJECTION OF SINUS TRACT $39.54 20060701 99999999 20520 REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH $134.78 20060701 99999999 20525 REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH $155.47 20060701 99999999 20526 INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), CARPAL TUNNEL $46.50 20060701 99999999 20550 INJECTION, TENDON SHEATH, LIGAMENT, TRIGGER POINTS $39.27 20060701 99999999 20551 INJECTION; TENDON ORIGIN/INSERTION $43.41 20060701 99999999 20552 INJECTION; SINGLE OR MULTIPLE TRIGGER POINT(S), ONE OR TWO MUSCLE GROUP(S) $35.03 20060701 99999999 20553 INJECTION; SINGLE OR MULTIPLE TRIGGER POINT(S), THREE OR MORE MUSCLE GROUPS $39.29 20060701 99999999 20555 PLACEMENT OF NEEDLES OR CATHETERS INTO MUSCLE AND/OR SOFT TISSUE FOR SUBSEQUENT $165.01 20080101 99999999 20600 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION $40.93 20060701 99999999 20605 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION $42.08 20060701 99999999 20610 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION $48.79 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 104
PROC-CODE DESC MAC BEG END 20612 ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION $28.14 20060701 99999999 20615 ASPIRATION AND INJECTION FOR TREATMENT OF BONE CYST $130.44 20060701 99999999 20650 INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, $138.73 20060701 99999999 20660 APPLICATION OF CRANIAL TONGS, CALIPER, OR STEREOTACTIC FRAME, $158.66 20060701 99999999 20661 APPLICATION OF HALO, INCLUDING REMOVAL $308.58 20060701 99999999 20662 APPLICATION OF HALO, INCLUDING REMOVAL $288.62 20060701 99999999 20663 APPLICATION OF HALO, INCLUDING REMOVAL $263.23 20060701 99999999 20664 APPLICATION OF HALO, INCLUDING REMOVAL, CRANIAL, 6 OR MORE PINS PLACED, FOR THIN $432.00 20060701 99999999 20665 REMOVAL OF TONGS OR HALO APPLIED BY ANOTHER PHYSICIAN $79.91 20060701 99999999 20670 REMOVAL OF IMPLANT $137.06 20060701 99999999 20680 REMOVAL OF IMPLANT $217.12 20060701 99999999 20690 APPLICATION OF EXTERNAL FIXATION SYSTEM (EG, $192.28 20060701 99999999 20692 APPLICATION OF A MULTIPLANE(PINS OR WIRES IN MORE THAN 1 PLA $330.69 20060701 99999999 20693 ADJUSTMENT OR REVISION OF EXTERNAL FIXATION SYS. REQ. ANESTH $368.18 20060701 99999999 20694 DELETE $275.57 20060701 99999999 20802 REPLANTATION, ARM (INCLUDES SURGICAL NECK OF HUMERUS THROUGH $2,043.68 20060701 99999999 20805 REPLANTATION, FOREARM (INCLUDES RADIUS AND ULNA TO RADIAL $2,519.44 20060701 99999999 20808 REPLANTATION, HAND (INCLUDES HAND THROUGH METACARPOPHALANGEAL JOINTS) $2,601.18 20060701 99999999 20816 REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES $1,745.57 20060701 99999999 20822 REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES DISTAL TIP TO $1,638.74 20060701 99999999 20824 REPLANTATION, THUMB (INCLUDES CARPOMETACARPAL JOINT TO $1,715.63 20060701 99999999 20827 REPLANTATION, THUMB (INCLUDES DISTAL TIP TO MP JOINT) $1,593.29 20060701 99999999 20838 REPLANTATION, FOOT $1,959.62 20060701 99999999 20900 BONE GRAFT, ANY DONOR AREA $288.13 20060701 99999999 20902 BONE GRAFT, ANY DONOR AREA $424.70 20060701 99999999 20910 CARTILAGE GRAFT $424.70 20060701 99999999 20912 CARTILAGE GRAFT $304.21 20060701 99999999 20920 FASCIA LATA GRAFT $239.98 20060701 99999999 20922 FASCIA LATA GRAFT $286.84 20060701 99999999 20924 TENDON GRAFT, FROM A DISTANCE (EG, PALMARIS, TOE EXTENSOR, $315.82 20060701 99999999 20926 TISSUE GRAFTS, OTHER (EG, PARATENON, FAT, DERMIS, ETC) $293.90 20060701 99999999 20930 ALLOGRAFT FOR SPINE SURGERY ONLY; MORSELIZED $138.47 19990701 99999999 20931 ALLOGRAFT FOR SPINE SURGERY ONLY; STRUCTURAL $99.70 20060701 99999999 20936 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIB $138.47 19990701 99999999 20937 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); MORSELIZED (TH $150.25 20060701 99999999 20938 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); STRUCTURAL, BI $164.43 20060701 99999999 20950 MONITORING OF INTERSTITIAL FLUID PRESSURE (EG, WICK $80.39 20060701 99999999 20955 BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS $2,007.53 20060701 99999999 20956 BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS FIBULA ILIAC CREST $1,650.31 20060701 99999999 20957 BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS FIBULA METATARSAL $1,817.07 20060701 99999999 20962 BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS $1,687.16 20060701 99999999 20969 FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS $2,211.44 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 105
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