Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 21184 RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING I $1,655.66 20060701 99999999 21188 RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LEFORT TYPE) AND BONE GRAFTS (IN $1,088.47 20060701 99999999 21193 RECONSTRUCTION OF MANDIBULAR RAMUS, HORIZONTAL, VERTICAL, ''C'', OR ''L'' OSTEOT $752.38 20060701 99999999 21194 RECONSTRUCTION OF MANDIBULAR RAMUS, HORIZONTAL, VERTICAL, ''C'', OR ''L'' OSTEOT $837.82 20060701 99999999 21195 RECONSTRUCTION OF MANDIBULAR RAMUS, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXAT $798.52 20060701 99999999 21196 RECONSTRUCTION OF MANDIBULAR RAMUS, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION $957.49 20060701 99999999 21198 OSTEOTOMY, MANDIBLE, SEGMENTAL $671.17 20060701 99999999 21199 OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT $761.00 20060701 99999999 21206 OSTEOTOMY (EG, FOR PROGNATHISM, MICROGNATHISM, APERTOGNATHISM OR $713.15 20060701 99999999 21208 OSTEOPLASTY, FACIAL BONES $495.92 20060701 99999999 21209 OSTEOPLASTY, FACIAL BONES $374.08 20060701 99999999 21210 GRAFT, BONE $543.34 20060701 99999999 21215 GRAFT, BONE $564.66 20060701 99999999 21230 GRAFT $472.74 20060701 99999999 21235 GRAFT $326.87 20060701 99999999 21240 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT $735.48 20060701 99999999 21242 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT $684.79 20060701 99999999 21243 ARTHROPLASTY TEMPOROMANDIBULAR JNT W/PROSTHETIC JNT REPLACEM $975.12 20060701 99999999 21244 RECONSTRUCT OF MANDIBLE EXTRAORAL W/TRANSOSTEAL BONE PLATE $608.90 20060701 99999999 21245 RECONSTRUCT OF MANDIBLE OR MAXILLA SUBPERIOSTEAL IMPLANT PAR $541.81 20060701 99999999 21246 RECONSTRUCT MANDIBLE OR MAXILLA SUBPERIOSTEAL IMPLNT CMPLT $538.20 20060701 99999999 21247 RECONSTRUCTION OF MANDIBULAR CONDYLE WITH BONE AND CARTILAGE AUTOGRAFTS (INCLUDE $1,226.97 20060701 99999999 21248 RECONST MANDIBLE OR MAXILLA ENDOSTEAL IMPLANT PARTIAL $581.28 20060701 99999999 21249 RECONSTRUCT MANDIBLE/MAXILLA ENDOSTEAL IMPLANT COMPLETE $820.61 20060701 99999999 21255 RECONSTRUCTION OF ZYGOMATIC ARCH AND GLENOID FOSSA WITH BONE AND CARTILAGE (INCL $844.56 20060701 99999999 21256 RECONSTRUCTION OF ORBIT WITH OSTEOTOMIES (EXTRACRANIAL) AND WITH BONE GRAFTS (IN $849.64 20060701 99999999 21260 PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE GRAFTS $853.11 20060701 99999999 21261 PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE GRAFTS $1,394.56 20060701 99999999 21263 PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE GRAFTS $1,227.52 20060701 99999999 21267 ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, $963.10 20060701 99999999 21268 ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, $1,136.98 20060701 99999999 21270 MALAR AUGMENTATION, BONE OR ALLOPLASTIC MATERIAL $430.07 20060701 99999999 21275 SECONDARY REVISION OF ORBITOCRANIOFACIAL RECONSTRUCTION $486.52 20060701 99999999 21280 MEDIAL CANTHOPLASTY $295.27 20060701 99999999 21282 LATERAL CANTHOPEXY $237.19 20060701 99999999 21295 REDUCTION OF MASSETER MUSCLE (EG, TREATMENT OF BENIGN $102.04 20060701 99999999 21296 REDUCTION OF MASSETER MUSCLE (EG, TREATMENT OF BENIGN $227.37 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 108
PROC-CODE DESC MAC BEG END 21310 TREATMENT OF CLOSED OR OPEN NASAL FRACTURE WITHOUT $29.01 20060701 99999999 21315 MANIPULATIVE TREATMENT, NASAL BONE FRACTURE $84.80 20060701 99999999 21320 MANIPULATIVE TREATMENT, NASAL BONE FRACTURE $144.28 20060701 99999999 21325 OPEN TREATMENT OF NASAL FRACTURE $309.83 20060701 99999999 21330 OPEN TREATMENT OF NASAL FRACTURE $378.71 20060701 99999999 21335 OPEN TREATMENT OF NASAL FRACTURE $453.77 20060701 99999999 21336 OPEN TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR WITHOUT STABILIZATION $384.02 20060701 99999999 21337 TREATMENT OF CLOSED NASAL SEPTAL FRACTURE $197.82 20060701 99999999 21338 OPEN TREATMENT OF NASOETHMOID FRACTURE $517.51 20060701 99999999 21339 OPEN TREATMENT OF NASOETHMOID FRACTURE $554.27 20060701 99999999 21340 TREATMENT OF CLOSED OR OPEN NASOETHMOID COMPLEX FRACTURE, $479.29 20060701 99999999 21343 OPEN TX OF CLOSED OR OPEN DEPRESSED FRONTAL SINUS FRACTURE $911.42 20060701 99999999 21344 OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING POSTERIOR WALL) FRONT $920.66 20060701 99999999 21345 TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II $384.62 20060701 99999999 21346 OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT $592.85 20060701 99999999 21347 OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT $726.54 20060701 99999999 21348 OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); WITH BONE GRA $707.26 20060701 99999999 21355 MANIPULATIVE TREATMENT OF CLOSED OR OPEN FRACTURE OF MALAR AREA, $180.28 20060701 99999999 21356 OPEN TREATMENT OF DEPRESSED ZYGOMATIC ARCH FRACTURE (EG, GILLES APPROACH) $218.17 20060701 99999999 21360 OPEN TREATMENT OF CLOSED OR OPEN DEPRESSED MALAR FRACTURE, $347.32 20060701 99999999 21365 OPEN TREATMENT OF CLOSED OR OPEN COMPLICATED, (EG, MULTIPLE $797.25 20060701 99999999 21366 OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMIN $737.68 20060701 99999999 21385 OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTURE $525.73 20060701 99999999 21386 OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTURE $501.50 20060701 99999999 21387 OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTURE $467.94 20060701 99999999 21390 OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTURE $598.54 20060701 99999999 21395 OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTURE $544.13 20060701 99999999 21400 TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT'' $82.22 20060701 99999999 21401 TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT'' $169.83 20060701 99999999 21406 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT'' $377.59 20060701 99999999 21407 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT'' $645.46 20060701 99999999 21408 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT''; WITH BONE GRAFTING (INC $533.74 20060701 99999999 21421 TREATMENT OF PALATAL OR ALVEOLAR RIDGE FRACTURES (LEFORT I TYPE) $340.95 20060701 99999999 21422 TREATMENT OF PALATAL OR ALVEOLAR RIDGE FRACTURES (LEFORT I TYPE) $463.51 20060701 99999999 21423 OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); COMPLICATED (CO $574.91 20060701 99999999 21431 TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) USING $414.87 20060701 99999999 21432 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) $479.69 20060701 99999999 21433 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) $1,267.63 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 109
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