Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 23195 RESECTION HUMERAL HEAD $585.00 20060701 99999999 23200 RADICAL RESECTION FOR TUMOR $709.94 20060701 99999999 23210 RADICAL RESECTION FOR TUMOR $707.76 20060701 99999999 23220 RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS $846.35 20060701 99999999 23221 RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS $1,011.11 20060701 99999999 23222 RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS $1,230.57 20060701 99999999 23330 REMOVAL OF FOREIGN BODY, SHOULDER $107.78 20060701 99999999 23331 REMOVAL OF FOREIGN BODY, SHOULDER $381.05 20060701 99999999 23332 REMOVAL OF FOREIGN BODY, SHOULDER $665.59 20060701 99999999 23350 INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY $40.41 20060701 99999999 23395 MUSCLE TRANSFER, ANY TYPE FOR PARALYSIS OF $875.65 20060701 99999999 23397 MUSCLE TRANSFER, ANY TYPE FOR PARALYSIS OF $905.41 20060701 99999999 23400 SCAPULOPEXY (EG, SPRENGEL'S DEFORMITY OR FOR PARALYSIS) $773.34 20060701 99999999 23405 TENOMYOTOMY, SHOULDER AREA $520.33 20060701 99999999 23406 TENOMYOTOMY, SHOULDER AREA $632.89 20060701 99999999 23410 REPAIR OF RUPTURED SUPRASPINATUS TENDON (ROTATOR CUFF) OR $724.68 20060701 99999999 23412 REPAIR OF RUPTURED SUPRASPINATUS TENDON (ROTATOR CUFF) OR $798.21 20060701 99999999 23415 CORACOACROMIAL LIGAMENT RELEASE, WITH OR WITHOUT ACROMIOPLASTY, $516.86 20060701 99999999 23420 REPAIR OF COMPLETE SHOULDER (ROTATOR) CUFF AVULSION, $831.01 20060701 99999999 23430 TENODESIS FOR RUPTURE OF LONG TENDON OF BICEPS $572.01 20060701 99999999 23440 RESECTION OR TRANSPLANTATION OF LONG TENDON OF $584.81 20060701 99999999 23450 CAPSULORRHAPHY FOR RECURRENT DISLOCATION, $784.31 20060701 99999999 23455 CAPSULORRHAPHY FOR RECURRENT DISLOCATION, $870.97 20060701 99999999 23460 CAPSULORRHAPHY FOR RECURRENT DISLOCATION, $882.71 20060701 99999999 23462 CAPSULORRHAPHY FOR RECURRENT DISLOCATION, $896.51 20060701 99999999 23465 CAPSULORRHAPHY FOR RECURRENT DISLOCATION, $903.64 20060701 99999999 23466 CAPSULORRHAPHY FOR RECURRENT DISLOCATION WITH ANY TYPE $866.09 20060701 99999999 23470 ARTHROPLASTY WITH PROXIMAL HUMERAL IMPLANT (EG, NEER TYPE OPERATION) $997.25 20060701 99999999 23472 ARTHROPLASTY WITH GLENOID AND PROXIMAL HUMERAL $1,020.01 20060701 99999999 23480 OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXATION $594.94 20060701 99999999 23485 OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXATION $763.58 20060701 99999999 23490 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) $670.04 20060701 99999999 23491 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) $808.70 20060701 99999999 23500 TREATMENT OF CLOSED CLAVICULAR FRACTURE $121.75 20060701 99999999 23505 TREATMENT OF CLOSED CLAVICULAR FRACTURE $203.37 20060701 99999999 23515 OPEN TREATMENT OF CLOSED OR OPEN CLAVICULAR $446.71 20060701 99999999 23520 TREATMENT OF CLOSED STERNOCLAVICULAR DISLOCATION $125.02 20060701 99999999 23525 TREATMENT OF CLOSED STERNOCLAVICULAR DISLOCATION $190.19 20060701 99999999 23530 OPEN TREATMENT OF CLOSED OR OPEN STERNOCLAVICULAR $426.74 20060701 99999999 23532 OPEN TREATMENT OF CLOSED OR OPEN STERNOCLAVICULAR $461.39 20060701 99999999 23540 TREATMENT OF CLOSED ACROMIOCLAVICULAR DISLOCATION $124.45 20060701 99999999 23545 TREATMENT OF CLOSED ACROMIOCLAVICULAR DISLOCATION $175.57 20060701 99999999 23550 OPEN TREATMENT OF CLOSED OR OPEN ACROMIOCLAVICULAR $457.08 20060701 99999999 23552 OPEN TREATMENT OF CLOSED OR OPEN ACROMIOCLAVICULAR $487.63 20060701 99999999 23570 TREATMENT OF CLOSED SCAPULAR FRACTURE $130.77 20060701 99999999 23575 TREATMENT OF CLOSED SCAPULAR FRACTURE $223.47 20060701 99999999 23585 OPEN TREATMENT OF CLOSED OR OPEN SCAPULAR FRACTURE $524.26 20060701 99999999 23600 TREATMENT OF CLOSED HUMERAL (SURGICAL OR ANATOMICAL $183.80 20060701 99999999 23605 TREATMENT OF CLOSED HUMERAL (SURGICAL OR ANATOMICAL $312.16 20060701 99999999 23615 OPEN TREATMENT OF CLOSED OR OPEN HUMERAL (SURGICAL $586.36 20060701 99999999 23616 OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, WITH $1,225.92 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 114
PROC-CODE DESC MAC BEG END 23620 TREATMENT OF CLOSED GREATER TUBEROSITY FRACTURE $138.66 20060701 99999999 23625 TREATMENT OF CLOSED GREATER TUBEROSITY FRACTURE $253.74 20060701 99999999 23630 OPEN TREATMENT OF CLOSED OR OPEN GREATER TUBEROSITY $464.22 20060701 99999999 23650 TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH $180.50 20060701 99999999 23655 TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH $239.70 20060701 99999999 23660 OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCATION $464.21 20060701 99999999 23665 TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH $265.46 20060701 99999999 23670 OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCATION, $494.23 20060701 99999999 23675 TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH SURGICAL $333.81 20060701 99999999 23680 OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCATION, $614.28 20060701 99999999 23700 MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING $153.92 20060701 99999999 23800 ARTHRODESIS, SHOULDER JOINT $876.10 20060701 99999999 23802 ARTHRODESIS, SHOULDER JOINT $878.67 20060701 99999999 23900 INTERTHORACOSCAPULAR AMPUTATION (FOREQUARTER) $998.77 20060701 99999999 23920 DISARTICULATION OF SHOULDER $841.12 20060701 99999999 23921 DISARTICULATION OF SHOULDER $322.61 20060701 99999999 23929 UNLISTED PROCEDURE, SHOULDER $313.82 19990701 99999999 23930 INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA $166.04 20060701 99999999 23931 INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA $104.39 20060701 99999999 23935 INCISION, DEEP, WITH OPENING OF BONE CORTEX (EG, FOR $416.26 20060701 99999999 24000 ARTHROTOMY, ELBOW, FOR INFECTION, WITH EXPLORATION, DRAINAGE OR $357.63 20060701 99999999 24006 ARTHROTOMY OF THE ELBOW, WITH CAPSULAR EXCISION FOR CAPSULAR RELEASE (SEPARATE P $511.08 20060701 99999999 24065 BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW AREA $107.39 20060701 99999999 24066 BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW AREA $286.56 20060701 99999999 24075 EXCISION, TUMOR, UPPER ARM OR ELBOW AREA $225.58 20060701 99999999 24076 EXCISION, TUMOR, UPPER ARM OR ELBOW AREA $340.26 20060701 99999999 24077 RAD RESECT OF TUMOR SOFT TISSUE OF UPPER ARM OR ELBOW AREA $685.30 20060701 99999999 24100 ARTHROTOMY, ELBOW $304.37 20060701 99999999 24101 ARTHROTOMY, ELBOW $385.44 20060701 99999999 24102 ARTHROTOMY, ELBOW $490.98 20060701 99999999 24105 EXCISION, OLECRANON BURSA $235.26 20060701 99999999 24110 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $472.26 20060701 99999999 24115 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $584.41 20060701 99999999 24116 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $670.21 20060701 99999999 24120 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $385.10 20060701 99999999 24125 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $426.91 20060701 99999999 24126 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $472.54 20060701 99999999 24130 EXCISION, RADIAL HEAD $387.54 20060701 99999999 24134 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), $631.40 20060701 99999999 24136 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), $466.41 20060701 99999999 24138 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), $449.34 20060701 99999999 24140 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION OR $631.84 20060701 99999999 24145 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION OR $476.07 20060701 99999999 24147 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION OR $474.53 20060701 99999999 24149 RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CON $789.53 20060701 99999999 24150 RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMERUS $823.48 20060701 99999999 24151 RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMERUS $895.14 20060701 99999999 24152 RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK $532.44 20060701 99999999 24153 RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK $603.00 20060701 99999999 24155 RESECTION OF ELBOW JOINT (ARTHRECTOMY) $657.94 20060701 99999999 24160 IMPLANT REMOVAL $413.36 20060701 99999999 24164 IMPLANT REMOVAL $365.18 20060701 99999999 24200 REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA $96.60 20060701 99999999 24201 REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA $273.94 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 115
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