Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 20970 FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS $2,100.99 20060701 99999999 20972 FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS $1,783.10 20060701 99999999 20973 FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS $2,184.25 20060701 99999999 20974 ELECTRICAL STIMULATION TO AID BONE HEALING $31.84 20060701 99999999 20975 ELECTRICAL STIMULATION TO AID BONE HEALING $118.29 20060701 99999999 20979 LOW INTENSITY ULTRASOUND STIMULATION TO AID BONE HEALING, NONINVASIVE (NONOPERAT $24.40 20060701 99999999 20982 ABLATION, BONE TUMOR(S) (EG, OSTEOID OSTEOMA, METASTASIS) RADIOFREQUENCY, PERCUT $300.94 20060701 99999999 20985 COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES $75.09 20080101 99999999 21010 ARTHROTOMY, TEMPOROMANDIBULAR JOINT $487.32 20060701 99999999 21015 DELETE $260.21 20060701 99999999 21025 EXCISION OF BONE MANDIBLE $490.41 20060701 99999999 21026 EXCISION OF BONE FACIAL BONE(S) $281.68 20060701 99999999 21029 REMOVAL BY CONTOURING OF BENIGN TUMOR OF FACIAL BONE $426.77 20060701 99999999 21030 EXCISION OF BENIGN TUMOR OR CYST OF FACIAL BONE OTHER THAN MANDIBLE $239.75 20060701 99999999 21031 EXCISION OF TORUS MANDIBULARIS $174.47 20060701 99999999 21032 EXCISION OF MAXILLARY TORUS PALATINUS $189.08 20060701 99999999 21034 EXCISION OF MALIGNANT TUMOR OF FACIAL BONE OTHER $721.00 20060701 99999999 21040 EXCISION OF BENIGN CYST OR TUMOR OF MANDIBLE $231.92 20060701 99999999 21044 EXCISION OF MALIGNANT TUMOR OF MANDIBLE $528.41 20060701 99999999 21045 EXCISION OF MALIGNANT TUMOR OF MANDIBLE $709.72 20060701 99999999 21046 EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING INTRA-ORAL OSTEOTOMY (EG $675.79 20060701 99999999 21047 EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING EXTRA-ORAL OSTEOTOMY AND $822.74 20060701 99999999 21048 EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, $695.25 20060701 99999999 21049 EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING EXTRA-ORAL OSTEOTOMY AND $781.92 20060701 99999999 21050 CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) $511.64 20060701 99999999 21060 MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT $476.44 20060701 99999999 21070 CORONOIDECTOMY (SEPARATE PROCEDURE) $390.13 20060701 99999999 21073 MANIPULATION OF TEMPOROMANDIBULAR JOINT(S) (TMJ), THERAPEUTIC, REQUIRING AN ANES $119.94 20080101 99999999 21076 IMPRESSION AND CUSTOM PREPARATION; SURGICAL OBTURATOR PROSTHESIS $667.43 20060701 99999999 21077 IMPRESSION AND CUSTOM PREPARATION; ORBITAL PROSTHESIS $1,678.96 20060701 99999999 21079 IMPRESSION & CUSTOM PREPARATION:INTERIM OBTURATOR PROSTHESIS $1,129.20 20060701 99999999 21080 IMPRESSION & CUSTOM PREPARATION:DEFINITIVE OBTURATOR PROSTHE $1,285.36 20060701 99999999 21081 IMPRESSION & CUSTOM PREPARATION:MANDIBULAR RESECTION PROSTHE $1,161.63 20060701 99999999 21082 IMPRESSION & CUSTOM PREPARATION:PALATAL AUGMENTATION PROSTHE $1,023.73 20060701 99999999 21083 IMPRESSION& CUSTOM PREPARATION:PALATAL LIFT PROSTHESIS $988.24 20060701 99999999 21084 IMPRESSION & CUSTOM PREPARATION:SPEECH AID PROSTHESIS $1,137.00 20060701 99999999 21085 IMPRESSION & CUSTOM PREPARATION:ORAL SURGICAL SPLINT $519.71 20060701 99999999 21086 IMPRESSION & CUSTOM PREPARATION:AURICULAR PROSTHESIS $1,261.58 20060701 99999999 21087 IMPRESSION & CUSTOM PREPARATION:NASAL PROSTHESIS $1,232.79 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 106
PROC-CODE DESC MAC BEG END 21100 APPLICATION OF HALO TYPE APPLIANCE FOR MAXILLOFACIAL $222.39 20060701 99999999 21110 APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS $343.63 20060701 99999999 21116 INJECTION PROCEDURE FOR TEMPOROMANDIBULAR JOINT ARTHROGRAPHY $27.94 20060701 99999999 21120 GENIOPLASTY:AUGMENTATION(AUTOGRAFT,ALLOGRAFT,PROSTHETI C MAT) $313.07 20060701 99999999 21121 GENIOPLASTY:SLIDING OSTEOTOMY,SINGLE PIECE $388.79 20060701 99999999 21122 GENIOPLASTY:SLIDING OSTEOTOMIES,2 OR MORE OSTEOTOMIES $432.20 20060701 99999999 21123 GENIOPLASTY:SLIDING,AUGMENTATION W/INTERPOSITIONAL BONE GRFT $553.63 20060701 99999999 21125 AUGMENTATION,MANDIBULAR BODY OR ANGLE:PROSTHETIC MATERIAL $467.29 20060701 99999999 21127 AUGMENTATION,MANDIBULAR BODY OR ANGLE:W/BONE GRAFT ONLAY $520.80 20060701 99999999 21137 REDUCTION FOREHEAD:CONTOURING ONLY $443.98 20060701 99999999 21138 REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR BONE GR $551.27 20060701 99999999 21139 REDUCTION FOREHEAD; CONTOURING AND SETBACK OF ANTERIOR FRONTAL SINUS WALL $642.92 20060701 99999999 21141 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTIO $818.93 20060701 99999999 21142 RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, $918.27 20060701 99999999 21143 RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY $856.76 20060701 99999999 21145 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, ANY DIRECTION, REQUIRING BONE GR $858.81 20060701 99999999 21146 RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, ANY DIRECTION, REQUIRING BONE GRAF $917.08 20060701 99999999 21147 RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, ANY DIRECTION, REQUIRING $1,046.58 20060701 99999999 21150 RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (EG, TREACHER-COLLINS SYND $1,183.44 20060701 99999999 21151 RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDE $1,269.19 20060701 99999999 21154 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAF $1,327.25 20060701 99999999 21155 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAF $1,512.19 20060701 99999999 21159 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANC $2,110.76 20060701 99999999 21160 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANC $2,192.46 20060701 99999999 21172 RECONSTRUCTION SUPERIOR-LATERAL ORBITAL RIM AND LOWER FOREHEAD, ADVANCEMENT OR A $1,244.06 20060701 99999999 21175 RECONSTRUCTION, BIFRONTAL, SUPERIOR-LATERAL ORBITAL RIMS AND LOWER FOREHEAD, ADV $1,553.85 20060701 99999999 21179 RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; WITH GR $916.68 20060701 99999999 21180 RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; WITH AU $1,238.28 20060701 99999999 21181 REMOVAL BY CONTOURING OF BENIGN TUMOR OF CRANIAL BONES (EG, FIBROUS DYSPLASIA), $438.98 20060701 99999999 21182 RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING I $1,535.08 20060701 99999999 21183 RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING I $1,649.06 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 107
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