Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 21435 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) $751.37 20060701 99999999 21436 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED, MULTIP $1,157.62 20060701 99999999 21440 MANIPULATIVE TREATMENT OF ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) $224.74 20060701 99999999 21445 OPEN TREATMENT OF ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) $348.86 20060701 99999999 21450 TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE $247.93 20060701 99999999 21451 TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE $335.23 20060701 99999999 21452 TREATMENT OF OPEN MANDIBULAR FRACTURE $166.87 20060701 99999999 21453 TREATMENT OF OPEN MANDIBULAR FRACTURE $411.66 20060701 99999999 21454 OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE WITH $347.39 20060701 99999999 21461 OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE $523.31 20060701 99999999 21462 OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE $717.68 20060701 99999999 21465 OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE $547.58 20060701 99999999 21470 OPEN TREATMENT OF COMPLICATED CLOSED OR OPEN MANDIBULAR $1,014.18 20060701 99999999 UNCOMPLICATED TREATMENT OF TEMPOROMANDIBULAR 21480 DISLOCATION, $54.73 20060701 99999999 21485 COMPLICATED MANIPULATIVE TREATMENT OF TEMPOROMANDIBULAR $294.25 20060701 99999999 21490 OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION $551.78 20060701 99999999 21494 TREATMENT OF CLOSED OR OPEN HYOID FRACTURE $296.09 19990701 99999999 21495 OPEN TREATMENT OF CLOSED OR OPEN HYOID FRACTURE $351.38 20060701 99999999 21497 INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACTURE $290.59 20060701 99999999 21501 INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES $202.17 20060701 99999999 21502 INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES $322.86 20060701 99999999 21510 INCISION, DEEP, WITH OPENING OF BONE CORTEX (EG, FOR $288.98 20060701 99999999 21550 BIOPSY, SOFT TISSUE OF NECK OR THORAX $106.18 20060701 99999999 21555 EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX $190.68 20060701 99999999 21556 EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX $275.32 20060701 99999999 21557 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), $358.00 20060701 99999999 21600 EXCISION OF RIB, PARTIAL $320.49 20060701 99999999 21610 COSTOTRANSVERSECTOMY (SEPARATE PROCEDURE) $613.84 20060701 99999999 21615 EXCISION FIRST AND/OR CERVICAL RIB FOR OUTLET $513.99 20060701 99999999 21616 EXCISION FIRST AND/OR CERVICAL RIB FOR OUTLET $511.63 20060701 99999999 21620 OSTECTOMY OF STERNUM, PARTIAL $324.09 20060701 99999999 21627 STERNAL DEBRIDEMENT $523.07 20060701 99999999 21630 RADICAL RESECTION OF STERNUM $743.29 20060701 99999999 21632 RADICAL RESECTION OF STERNUM $743.48 20060701 99999999 21685 HYOID MYOTOMY AND SUSPENSION $658.65 20060701 99999999 21700 DIVISION OF SCALENUS ANTICUS $367.96 20060701 99999999 21705 DIVISION OF SCALENUS ANTICUS $474.43 20060701 99999999 21720 DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, $208.52 20060701 99999999 21725 DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, $319.45 20060701 99999999 21740 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM $635.27 20060701 99999999 21750 CLOSURE OF STERNOTOMY SEPARATION WITH OR WITHOUT DEBRIDEMENT (SEPARATE PROCEDURE $654.42 20060701 99999999 21800 TREATMENT OF RIB FRACTURE $57.43 20060701 99999999 21805 TREATMENT OF RIB FRACTURE $150.85 20060701 99999999 21810 TREATMENT OF RIB FRACTURE $299.44 20060701 99999999 21820 TREATMENT OF STERNUM FRACTURE $76.88 20060701 99999999 21825 TREATMENT OF STERNUM FRACTURE $351.23 20060701 99999999 21899 UNLISTED PROCEDURE, NECK OR THORAX $307.00 19990701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 110
PROC-CODE DESC MAC BEG END 21920 BIOPSY, SOFT TISSUE OF BACK OR FLANK $86.76 20060701 99999999 21925 BIOPSY, SOFT TISSUE OF BACK OR FLANK $195.40 20060701 99999999 21930 EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK $231.00 20060701 99999999 21935 RADICAL RESECTION OF TUMOR SOFT TISSUE BACK OR FLANK $808.50 20060701 99999999 22010 INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; CERV $566.96 20060701 99999999 22015 INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; LUMB $562.07 20060701 99999999 22100 PARTIAL RESECTION OF VERTEBRAL COMPONENT, SPINOUS $451.60 20060701 99999999 22101 PARTIAL RESECTION OF VERTEBRAL COMPONENT, SPINOUS $454.81 20060701 99999999 22102 PARTIAL RESECTION OF VERTEBRAL COMPONENT, SPINOUS $463.35 20060701 99999999 22103 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA O $106.06 20060701 99999999 22110 PARTIAL EXCISION OF VERTEBRAE (EG, FOR OSTEOMYELITIS) $573.05 20060701 99999999 22112 PARTIAL EXCISION OF VERTEBRAE (EG, FOR OSTEOMYELITIS) $573.06 20060701 99999999 22114 PARTIAL EXCISION OF VERTEBRAE (EG, FOR OSTEOMYELITIS) $574.56 20060701 99999999 22116 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRES $105.89 20060701 99999999 22206 OSTEOTOMY OF SPINE FOR CORRECTION FIXED DEFORMITY, $1,170.28 20080101 99999999 22207 OSTEOTOMY OF SPINE FOR CORRECTION FIXED DEFORMITY, $1,156.13 20080101 99999999 22208 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, THREE COLUMNS, ONE VER $291.29 20080101 99999999 22210 OSTEOTOMY SPINE POSTERIOR APPRCH CORRECTION OF DEFORMITY SGL $1,032.69 20060701 99999999 22212 OSTEOTOMY SPINE POSTERIOR APPRCH CORRECTION OF DEFORMITY SGL $850.29 20060701 99999999 22214 OSTEOTOMY SPINE POST APPRCH CORRECTION OF DEFORMITY SINGLE $864.80 20060701 99999999 22216 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE VERTEBRAL SEGMENT; $275.22 20060701 99999999 22220 OSTEOTOMY SPINE ANTERIOR APPRCH CORRECTION OF DEFORMITY SNGL $924.80 20060701 99999999 22222 OSTEOTOMY SPINE ANTERIOR FOR CORRECTION OF DEFORM SINGLE SEG $847.97 20060701 99999999 22224 OSTEOTOMY SPINE ANTERIOR CORRECTION OF DEFORMITY SINGLE_SEGM $927.37 20060701 99999999 22226 OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SE $273.23 20060701 99999999 22305 CLOSED TREATMENT OF VERTEBRAL PROCESS FRACTURE(S) $102.70 20060701 99999999 22310 CLOSED TREATMENT OF VERTEBRAL BODY FRACTURE(S), $128.36 20060701 99999999 22315 CLOSED TREATMENT OF VERTEBRAL FRACTURE AND/OR DISLOCATION, $483.91 20060701 99999999 22318 OPEN TREATMENT AND/OR REDUCTION OF ODONTOID FRACTURE(S) AND OR DISLOCATION(S) (I $1,091.30 20060701 99999999 22319 OPEN TREATMENT AND/OR REDUCTION OF ODONTOID FRACTURE(S) AND OR DISLOCATION(S) (I $1,237.44 20060701 99999999 22325 OPEN TREATMENT OF VERTEBRAL FRACTURE AND/OR $893.94 20060701 99999999 22326 OPEN TREATMENT OF VERTEBRAL FRACTURE AND/OR $1,097.16 20060701 99999999 22327 OPEN TREATMENT OF VERTEBRAL FRACTURE AND/OR $1,067.08 20060701 99999999 22328 OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) AND/OR DISLOCATION(S), $205.32 20060701 99999999 22505 MANIPULATION OF SPINE REQUIRING ANESTHESIA, ANY REGION $73.03 20060701 99999999 22520 PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTI $511.92 20060701 99999999 22521 PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTI $474.00 20060701 99999999 22522 PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTI $170.64 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 111
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Medicaid Fee Schedule without Mods 200801

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