Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 22523 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTI $423.06 20060701 99999999 22524 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTI $405.55 20060701 99999999 22525 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTI $192.50 20060701 99999999 22526 PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL IN $231.20 20070101 99999999 22527 PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL IN $105.56 20070101 99999999 22532 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PR $1,192.02 20060701 99999999 22533 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PR $1,112.39 20060701 99999999 22534 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PR $278.81 20060701 99999999 22548 ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, $1,091.23 20060701 99999999 22554 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE $1,114.60 20060701 99999999 22556 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE $1,322.34 20060701 99999999 22558 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE $1,226.82 20060701 99999999 22585 ARTHRODESIS, ANTERIOR OR ANTEROLATERAL, EACH ADDITIONAL $303.46 20060701 99999999 22590 ARTHODESIS POSTERIOR TECH CRANIOCERVICAL W/BONE GRFT INTFIX $1,071.61 20060701 99999999 22595 ARTHRODESIS POST TECH C1/C2 W/BONE GRFT AND/OR INT FIX $1,009.66 20060701 99999999 22600 ARTHRODESIS, POSTERIOR TECHNIQUE, CERVICAL BELOW C2 SEGMENT, $981.00 20060701 99999999 22610 ARTHRODESIS POSTERIOR/POSTEROLATERAL TECH W/LOCAL BONE OR $854.36 20060701 99999999 22612 ARTHRODESIS POSTERIOR/POSTEROLATERAL TECH W/LOCAL BONE $1,200.94 20060701 99999999 22614 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; EACH ADDITIONA $339.12 20060701 99999999 22630 ARTHODESIS POSTERIOR INTERBODY TECH W/LOCAL BONE OR ALLOGRAF $1,179.48 20060701 99999999 22632 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, SINGLE INTERSPACE; EACH ADDITIONAL I $283.26 20060701 99999999 22800 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT $952.06 20060701 99999999 22802 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT $1,694.86 20060701 99999999 22804 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 13 OR MORE V $1,891.39 20060701 99999999 22808 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 2 TO 3 VERTEB $1,101.95 20060701 99999999 22810 ARTHRODESIS ANTERIOR FOR SPINAL DEFORMITY W/WO CAST W/BONEGR $1,500.89 20060701 99999999 22812 ARTHRODESIS ANTERIOR FOR SPINAL DEFORMITY W/WO CAST W/BONEGR $1,350.45 20060701 99999999 22818 KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND RESECTION OF VERTEBRAL SEGMENT $1,571.43 20060701 99999999 22819 KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND RESECTION OF VERTEBRAL SEGMENT $1,709.99 20060701 99999999 22830 EXPLORATION OF SPINAL FUSION $795.01 20060701 99999999 22840 POSTERIOR INSTRUMENTATION $792.17 20060701 99999999 22841 INTERNAL SPINAL FIXATION BY WIRING OF SPINOUS PROCESSES $88.50 19990701 99999999 22842 POSTERIOR INSTRUMENTATION $592.14 20060701 99999999 22843 POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIP $652.96 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 112
PROC-CODE DESC MAC BEG END 22844 POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIP $814.53 20060701 99999999 22845 ANTERIOR INSTRUMENTATION $582.00 20060701 99999999 22846 ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS $789.08 20060701 99999999 22847 ANTERIOR INSTRUMENTATION; 8 OR MORE VERTEBRAL SEGMENTS $582.00 20060701 99999999 22848 PELVIC FIXATION (ATTACHMENT OF CAUDAL END OF INSTRUMENTATION TO PELVIC BONY STRU $341.73 20060701 99999999 22849 REINSERTION OF SPINAL FIXATION DEVICE $949.61 20060701 99999999 22850 REMOVAL OF POSTERIOR NONSEGMENTAL INSTRUMENTATION $564.49 20060701 99999999 22851 APPLICATION OF PROSTHETIC DEVICE (EG, METAL CAGES, METHYLMETHACRYLATE) TO VERTEB $386.73 20060701 99999999 22852 REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION $412.09 20060701 99999999 22855 REMOVAL OF ANTERIOR INSTRUMENTATION $653.94 20060701 99999999 22857 TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTO $979.88 20070101 99999999 22862 REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC) ANTE $1,186.93 20070101 99999999 22865 REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, LUMBAR, $1,156.20 20070101 99999999 22899 UNLISTED PROCEDURE, SPINE $555.11 19990701 99999999 22900 EXCISION, ABDOMINAL WALL TUMOR, SUBFASCIAL (EG, DESMOID) $284.50 20060701 99999999 22999 UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM $757.48 19990701 99999999 23000 REMOVAL OF SUBDELTOID (OR INTRATENDINOUS) $286.62 20060701 99999999 23020 CAPSULAR CONTRACTURE RELEASE (SEVER TYPE $522.78 20060701 99999999 23030 INCISION AND DRAINAGE, SHOULDER AREA $193.66 20060701 99999999 23031 INCISION AND DRAINAGE, SHOULDER AREA $139.95 20060701 99999999 23035 INCISION, DEEP, WITH OPENING OF CORTEX (EG, FOR $572.05 20060701 99999999 23040 ARTHROTOMY, GLENOHUMERAL JOINT, FOR INFECTION, WITH EXPLORATION, $586.22 20060701 99999999 23044 ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLAVICULAR JOINT, FOR $462.90 20060701 99999999 23065 BIOPSY, SOFT TISSUE OF SHOULDER AREA $96.44 20060701 99999999 23066 BIOPSY, SOFT TISSUE OF SHOULDER AREA $223.29 20060701 99999999 23075 EXCISION, TUMOR, SHOULDER AREA $140.08 20060701 99999999 23076 EXCISION, TUMOR, SHOULDER AREA $392.82 20060701 99999999 23077 RADICAL RESECTION OF TUMOR SOFT TISSUE OF SHOULDER AREA $782.09 20060701 99999999 23100 ARTHROTOMY FOR BIOPSY, GLENOHUMERAL JOINT $403.26 20060701 99999999 23101 ARTHROTOMY FOR BIOPSY OR FOR EXCISION OF TORN $382.25 20060701 99999999 23105 ARTHROTOMY FOR SYNOVECTOMY $531.68 20060701 99999999 23106 ARTHROTOMY FOR SYNOVECTOMY $378.73 20060701 99999999 23107 ARTHROTOMY GLENOHUMERAL JNT W/JNT EXPLORATION W/WO REMOVAL $556.10 20060701 99999999 23120 CLAVICULECTOMY $418.42 20060701 99999999 23125 CLAVICULECTOMY $561.47 20060701 99999999 23130 ACROMIONECTOMY, PARTIAL OR TOTAL $470.30 20060701 99999999 23140 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $385.18 20060701 99999999 23145 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $580.87 20060701 99999999 23146 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $455.84 20060701 99999999 23150 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $488.66 20060701 99999999 23155 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $612.88 20060701 99999999 23156 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $515.20 20060701 99999999 23170 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), $419.39 20060701 99999999 23172 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), $414.51 20060701 99999999 23174 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), $572.91 20060701 99999999 23180 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR $527.54 20060701 99999999 23182 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR $582.02 20060701 99999999 23184 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR $630.56 20060701 99999999 23190 OSTECTOMY OF SCAPULA, PARTIAL (EG, SUPERIOR MEDIAL ANGLE) $425.52 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 113
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