Medicaid Fee Schedule without Mods 200801
Medicaid Fee Schedule without Mods 200801
Medicaid Fee Schedule without Mods 200801
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PROC-CODE DESC MAC BEG END<br />
20970<br />
FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR<br />
ANASTOMOSIS $2,100.99 20060701 99999999<br />
20972<br />
FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR<br />
ANASTOMOSIS $1,783.10 20060701 99999999<br />
20973<br />
FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR<br />
ANASTOMOSIS $2,184.25 20060701 99999999<br />
20974 ELECTRICAL STIMULATION TO AID BONE HEALING $31.84 20060701 99999999<br />
20975 ELECTRICAL STIMULATION TO AID BONE HEALING $118.29 20060701 99999999<br />
20979<br />
LOW INTENSITY ULTRASOUND STIMULATION TO AID BONE HEALING,<br />
NONINVASIVE (NONOPERAT $24.40 20060701 99999999<br />
20982<br />
ABLATION, BONE TUMOR(S) (EG, OSTEOID OSTEOMA, METASTASIS)<br />
RADIOFREQUENCY, PERCUT $300.94 20060701 99999999<br />
20985<br />
COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR<br />
MUSCULOSKELETAL PROCEDURES $75.09 <strong>200801</strong>01 99999999<br />
21010 ARTHROTOMY, TEMPOROMANDIBULAR JOINT $487.32 20060701 99999999<br />
21015 DELETE $260.21 20060701 99999999<br />
21025 EXCISION OF BONE MANDIBLE $490.41 20060701 99999999<br />
21026 EXCISION OF BONE FACIAL BONE(S) $281.68 20060701 99999999<br />
21029 REMOVAL BY CONTOURING OF BENIGN TUMOR OF FACIAL BONE $426.77 20060701 99999999<br />
21030<br />
EXCISION OF BENIGN TUMOR OR CYST OF FACIAL BONE OTHER THAN<br />
MANDIBLE $239.75 20060701 99999999<br />
21031 EXCISION OF TORUS MANDIBULARIS $174.47 20060701 99999999<br />
21032 EXCISION OF MAXILLARY TORUS PALATINUS $189.08 20060701 99999999<br />
21034 EXCISION OF MALIGNANT TUMOR OF FACIAL BONE OTHER $721.00 20060701 99999999<br />
21040 EXCISION OF BENIGN CYST OR TUMOR OF MANDIBLE $231.92 20060701 99999999<br />
21044 EXCISION OF MALIGNANT TUMOR OF MANDIBLE $528.41 20060701 99999999<br />
21045 EXCISION OF MALIGNANT TUMOR OF MANDIBLE $709.72 20060701 99999999<br />
21046<br />
EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING<br />
INTRA-ORAL OSTEOTOMY (EG $675.79 20060701 99999999<br />
21047<br />
EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING<br />
EXTRA-ORAL OSTEOTOMY AND $822.74 20060701 99999999<br />
21048<br />
EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING<br />
INTRA-ORAL OSTEOTOMY (EG, $695.25 20060701 99999999<br />
21049<br />
EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING<br />
EXTRA-ORAL OSTEOTOMY AND $781.92 20060701 99999999<br />
21050<br />
CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE<br />
PROCEDURE) $511.64 20060701 99999999<br />
21060<br />
MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR<br />
JOINT $476.44 20060701 99999999<br />
21070 CORONOIDECTOMY (SEPARATE PROCEDURE) $390.13 20060701 99999999<br />
21073<br />
MANIPULATION OF TEMPOROMANDIBULAR JOINT(S) (TMJ),<br />
THERAPEUTIC, REQUIRING AN ANES $119.94 <strong>200801</strong>01 99999999<br />
21076<br />
IMPRESSION AND CUSTOM PREPARATION; SURGICAL OBTURATOR<br />
PROSTHESIS $667.43 20060701 99999999<br />
21077 IMPRESSION AND CUSTOM PREPARATION; ORBITAL PROSTHESIS $1,678.96 20060701 99999999<br />
21079<br />
IMPRESSION & CUSTOM PREPARATION:INTERIM OBTURATOR<br />
PROSTHESIS $1,129.20 20060701 99999999<br />
21080<br />
IMPRESSION & CUSTOM PREPARATION:DEFINITIVE OBTURATOR<br />
PROSTHE $1,285.36 20060701 99999999<br />
21081<br />
IMPRESSION & CUSTOM PREPARATION:MANDIBULAR RESECTION<br />
PROSTHE $1,161.63 20060701 99999999<br />
21082<br />
IMPRESSION & CUSTOM PREPARATION:PALATAL AUGMENTATION<br />
PROSTHE $1,023.73 20060701 99999999<br />
21083 IMPRESSION& CUSTOM PREPARATION:PALATAL LIFT PROSTHESIS $988.24 20060701 99999999<br />
21084 IMPRESSION & CUSTOM PREPARATION:SPEECH AID PROSTHESIS $1,137.00 20060701 99999999<br />
21085 IMPRESSION & CUSTOM PREPARATION:ORAL SURGICAL SPLINT $519.71 20060701 99999999<br />
21086 IMPRESSION & CUSTOM PREPARATION:AURICULAR PROSTHESIS $1,261.58 20060701 99999999<br />
21087 IMPRESSION & CUSTOM PREPARATION:NASAL PROSTHESIS $1,232.79 20060701 99999999<br />
Hawaii <strong>Medicaid</strong> <strong>Fee</strong> <strong>Schedule</strong> <strong>without</strong> <strong>Mods</strong> 01/2008 106