Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 25065 BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST $105.70 20060701 99999999 25066 BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST $284.65 20060701 99999999 25075 EXCISION, TUMOR, FOREARM AND/OR WRIST AREA $244.54 20060701 99999999 25076 EXCISION, TUMOR, FOREARM AND/OR WRIST AREA $367.43 20060701 99999999 25077 RAD RESECT TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST AREA $625.15 20060701 99999999 25085 CAPSULOTOMY, WRIST (EG, FOR CONTRACTURE) $368.29 20060701 99999999 25100 ARTHROTOMY, WRIST JOINT $276.33 20060701 99999999 25101 ARTHROTOMY, WRIST JOINT $322.83 20060701 99999999 25105 ARTHROTOMY, WRIST JOINT $417.87 20060701 99999999 25107 ARTHROTOMY, DISTAL RADIOULNAR JOINT FOR REPAIR $416.79 20060701 99999999 25110 EXCISION, LESION OF TENDON SHEATH, FOREARM AND/OR WRIST $279.23 20060701 99999999 25111 EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR) $233.71 20060701 99999999 25112 EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR) $287.86 20060701 99999999 25115 RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR $586.69 20060701 99999999 25116 RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR $532.50 20060701 99999999 25118 SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, $306.17 20060701 99999999 25119 SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, $429.29 20060701 99999999 25120 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $470.98 20060701 99999999 25125 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $528.33 20060701 99999999 25126 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $525.08 20060701 99999999 25130 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $326.61 20060701 99999999 25135 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $408.89 20060701 99999999 25136 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $353.85 20060701 99999999 25145 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), $470.17 20060701 99999999 25150 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION OR $471.28 20060701 99999999 25151 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION OR $512.47 20060701 99999999 25170 RADICAL RESECTION FOR TUMOR, RADIUS OR ULNA $708.27 20060701 99999999 25210 CARPECTOMY $364.86 20060701 99999999 25215 CARPECTOMY $535.76 20060701 99999999 25230 RADIAL STYLOIDECTOMY (SEPARATE PROCEDURE) $347.40 20060701 99999999 25240 EXCISION DISTAL ULNA (DARRACH TYPE PROCEDURE) $373.26 20060701 99999999 25246 INJECTION PROCEDURE FOR WRIST ARTHROGRAPHY $54.32 20060701 99999999 25248 EXPLORATION FOR REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST $346.07 20060701 99999999 25250 REMOVAL OF WRIST PROSTHESIS $400.62 20060701 99999999 25251 REMOVAL OF WRIST PROSTHESIS $608.87 20060701 99999999 25259 MANIPULATION, WRIST, UNDER ANESTHESIA $265.48 20060701 99999999 25260 REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST $536.92 20060701 99999999 25263 REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST $548.58 20060701 99999999 25265 REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST $653.27 20060701 99999999 25270 REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST $458.83 20060701 99999999 25272 REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST $504.96 20060701 99999999 25274 REPAIR, TENDON OR MUSCLE, EXTENSOR, SECONDARY, $580.23 20060701 99999999 25275 REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES $465.60 20060701 99999999 25280 LENGTHENING OR SHORTENING OF FLEXOR OR EXTENSOR $504.49 20060701 99999999 25290 TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR $515.27 20060701 99999999 25295 TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, $475.60 20060701 99999999 25300 TENODESIS AT WRIST $524.10 20060701 99999999 25301 TENODESIS AT WRIST $490.42 20060701 99999999 25310 TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR $568.66 20060701 99999999 25312 TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR $633.82 20060701 99999999 25315 FLEXOR ORIGIN SLIDE FOR CEREBRAL PALSY, FOREARM AND/OR WRIST $655.28 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 118
PROC-CODE DESC MAC BEG END 25316 FLEXOR ORIGIN SLIDE FOR CEREBRAL PALSY, FOREARM AND/OR WRIST $785.38 20060701 99999999 25320 CAPSULORRHAPHY OR RECONSTRUCTION, CAPSULECTOMY, $616.58 20060701 99999999 25332 ARTHROPLASTY, WRIST $661.80 20060701 99999999 25335 CENTRALIZATION OF WRIST ON ULNA (EG, RADIAL CLUB HAND) $755.72 20060701 99999999 25337 RECONSTRUCTION FOR STABILIZATION OF UNSTABLE DISTAL ULNA OR DISTAL RADIOULNAR JO $614.19 20060701 99999999 25350 OSTEOTOMY, RADIUS $598.80 20060701 99999999 25355 OSTEOTOMY, RADIUS $662.90 20060701 99999999 25360 OSTEOTOMY $570.63 20060701 99999999 25365 OSTEOTOMY $793.95 20060701 99999999 25370 MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMEDULLARY $787.42 20060701 99999999 25375 MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMEDULLARY $836.25 20060701 99999999 25390 OSTEOPLASTY, RADIUS OR ULNA $681.93 20060701 99999999 25391 OSTEOPLASTY, RADIUS OR ULNA $881.02 20060701 99999999 25392 OSTEOPLASTY, RADIUS AND ULNA $840.02 20060701 99999999 25393 OSTEOPLASTY, RADIUS AND ULNA $956.62 20060701 99999999 25394 OSTEOPLASTY, CARPAL BONE, SHORTENING $542.20 20060701 99999999 25400 REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA $727.99 20060701 99999999 25405 REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA $904.54 20060701 99999999 25415 REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA $878.30 20060701 99999999 25420 REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA $1,011.65 20060701 99999999 25425 REPAIR OF DEFECT WITH AUTOGENOUS BONE GRAFT $921.76 20060701 99999999 25426 REPAIR OF DEFECT WITH AUTOGENOUS BONE GRAFT $907.78 20060701 99999999 25430 INSERTION OF VASCULAR PEDICLE INTO CARPAL BONE (EG, HARII PROCEDURE) $481.62 20060701 99999999 25431 REPAIR OF NONUNION OF CARPAL BONE (EXCLUDING CARPAL SCAPHOID (NAVICULAR)) (INCLU $485.39 20060701 99999999 25440 REPAIR OF NONUNION, SCAPHOID (NAVICULAR) BONE, $602.71 20060701 99999999 25441 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT $741.65 20060701 99999999 25442 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT $603.59 20060701 99999999 25443 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT $630.09 20060701 99999999 25444 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT $669.31 20060701 99999999 25445 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT $626.25 20060701 99999999 25446 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT $1,001.79 20060701 99999999 25447 INTERPOSITION ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS $617.52 20060701 99999999 25449 REVISION OF ARTHROPLASTY, INCLUDING REMOVAL OF IMPLANT, WRIST JOINT $761.68 20060701 99999999 25450 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING $528.40 20060701 99999999 25455 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING $586.50 20060701 99999999 25490 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) $624.23 20060701 99999999 25491 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) $658.38 20060701 99999999 25492 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) $761.00 20060701 99999999 25500 TREATMENT OF CLOSED RADIAL SHAFT FRACTURE $131.07 20060701 99999999 25505 TREATMENT OF CLOSED RADIAL SHAFT FRACTURE $289.18 20060701 99999999 25515 OPEN TREATMENT OF CLOSED OR OPEN RADIAL SHAFT $531.35 20060701 99999999 25520 CLOSED TREATMENT OF RADIAL SHAFT FRACTURE, WITH DISLOCATION OF DISTAL RADIOULNAR $366.03 20060701 99999999 25525 OPEN TREATMENT OF RADIAL SHAFT FRACTURE, WITH INTERNAL AND/ OR EXTERNAL FIXATION $710.36 20060701 99999999 25526 OPEN TREATMENT OF RADIAL SHAFT FRACTURE, WITH INTERNAL AND/ OR EXTERNAL FIXATION $844.86 20060701 99999999 25530 TREATMENT OF CLOSED ULNAR SHAFT FRACTURE $126.45 20060701 99999999 25535 TREATMENT OF CLOSED ULNAR SHAFT FRACTURE $288.08 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 119
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Medicaid Fee Schedule without Mods 200801

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