Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 40700 PLASTIC REPAIR OF CLEFT LIP $647.11 20060701 99999999 40701 PLASTIC REPAIR OF CLEFT LIP $943.20 20060701 99999999 40702 PLASTIC REPAIR OF CLEFT LIP $661.05 20060701 99999999 40720 PLASTIC REPAIR OF CLEFT LIP $710.65 20060701 99999999 40761 PLASTIC REPAIR OF CLEFT LIP $772.00 20060701 99999999 40800 DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH $74.07 20060701 99999999 40801 DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH $132.92 20060701 99999999 40804 REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH $77.33 20060701 99999999 40805 REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH $154.14 20060701 99999999 40806 INCISION OF LABIAL FRENUM (FRENOTOMY) $22.01 20060701 99999999 40808 BIOPSY, VESTIBULE OF MOUTH $61.15 20060701 99999999 40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH $76.90 20060701 99999999 40812 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH $118.76 20060701 99999999 40814 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH $183.91 20060701 99999999 40816 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH $192.22 20060701 99999999 40818 EXCISION OF MUCOSA OF VESTIBULE OF MOUTH AS DONOR GRAFT $163.92 20060701 99999999 40819 EXCISION OF FRENUM, LABIAL OR BUCCAL (FRENUMECTOMY, $138.66 20060701 99999999 40820 DESTRUCTION OF LESION OR SCAR OF VESTIBULE OF MOUTH BY $93.14 20060701 99999999 40830 CLOSURE OF LACERATION, VESTIBULE OF MOUTH $96.73 20060701 99999999 40831 CLOSURE OF LACERATION, VESTIBULE OF MOUTH $138.98 20060701 99999999 40840 VESTIBULOPLASTY $440.25 20060701 99999999 40842 VESTIBULOPLASTY $437.77 20060701 99999999 40843 VESTIBULOPLASTY $608.62 20060701 99999999 40844 VESTIBULOPLASTY $786.43 20060701 99999999 40845 VESTIBULOPLASTY $1,029.22 20060701 99999999 41000 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA $67.51 20060701 99999999 41005 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA $74.43 20060701 99999999 41006 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA $160.74 20060701 99999999 41007 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA $178.83 20060701 99999999 41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA $165.52 20060701 99999999 41009 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA $200.41 20060701 99999999 41010 INCISION OF LINGUAL FRENUM (FRENOTOMY) $77.74 20060701 99999999 41015 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA $203.47 20060701 99999999 41016 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA $224.28 20060701 99999999 41017 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA $211.30 20060701 99999999 41018 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA $263.10 20060701 99999999 41019 PLACEMENT OF NEEDLES, CATHETERS, OR OTHER DEVICE(S) INTO THE HEAD AND/OR NECK RE $244.06 20080101 99999999 41100 BIOPSY OF TONGUE $85.88 20060701 99999999 41105 BIOPSY OF TONGUE $80.04 20060701 99999999 41108 BIOPSY OF FLOOR OF MOUTH $65.19 20060701 99999999 41110 EXCISION OF LESION OF TONGUE WITHOUT CLOSURE $86.77 20060701 99999999 41112 EXCISION OF LESION OF TONGUE WITH CLOSURE $149.08 20060701 99999999 41113 EXCISION OF LESION OF TONGUE WITH CLOSURE $167.36 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 164
PROC-CODE DESC MAC BEG END 41114 EXCISION OF LESION OF TONGUE WITH CLOSURE $438.02 20060701 99999999 41115 EXCISION OF LINGUAL FRENUM (FRENECTOMY) $112.10 20060701 99999999 41116 EXCISION, LESION OF FLOOR OF MOUTH $158.23 20060701 99999999 41120 GLOSSECTOMY $625.19 20060701 99999999 41130 GLOSSECTOMY $681.52 20060701 99999999 41135 GLOSSECTOMY $1,201.85 20060701 99999999 41140 GLOSSECTOMY $1,298.70 20060701 99999999 41145 GLOSSECTOMY $1,545.37 20060701 99999999 41150 GLOSSECTOMY $1,222.11 20060701 99999999 41153 GLOSSECTOMY $1,355.23 20060701 99999999 41155 GLOSSECTOMY $1,587.75 20060701 99999999 41250 REPAIR OF LACERATION 2.5 CM OR LESS $96.06 20060701 99999999 41251 REPAIR OF LACERATION 2.5 CM OR LESS $126.68 20060701 99999999 41252 REPAIR OF LACERATION OF TONGUE, FLOOR OF MOUTH, OVER 2.6 CM $157.46 20060701 99999999 41500 FIXATION OF TONGUE, MECHANICAL, OTHER THAN SUTURE (EG, K- WIRE) $278.72 20060701 99999999 41510 SUTURE OF TONGUE TO LIP FOR MICROGNATHIA (DOUGLAS TYPE $282.40 20060701 99999999 41520 FRENOPLASTY (SURGICAL REVISION OF FRENUM, EG, WITH Z- PLASTY) $166.05 20060701 99999999 41800 DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES $61.25 20060701 99999999 41805 REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR STRUCTURES $86.78 20060701 99999999 41806 REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR STRUCTURES $145.00 20060701 99999999 41822 EXCISION OF FIBROUS TUBEROSITIES, DENTOALVEOLAR STRUCTURES $130.49 20060701 99999999 41823 EXCISION OF OSSEOUS TUBEROSITIES, DENTOALVEOLAR STRUCTURES $195.52 20060701 99999999 41825 EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), $89.51 20060701 99999999 41826 EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), $137.40 20060701 99999999 41827 EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), $210.10 20060701 99999999 41828 EXCISION OF HYPERPLASTIC ALVEOLAR MUCOSA, EACH SEXTANT OR $188.87 20060701 99999999 41830 ALVEOLECTOMY, INCLUDING CURETTAGE OF OSTEITIS OR SEQUESTRECTOMY $196.46 20060701 99999999 41872 GINGIVOPLASTY $163.04 20060701 99999999 41874 ALVEOPLASTY $178.39 20060701 99999999 41899 UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES $35.12 19990701 99999999 42000 DRAINAGE OF ABSCESS OF PALATE, UVULA $61.87 20060701 99999999 42100 BIOPSY OF PALATE, UVULA $74.71 20060701 99999999 42104 EXCISION, LESION OF PALATE, UVULA $105.79 20060701 99999999 42106 EXCISION, LESION OF PALATE, UVULA $133.55 20060701 99999999 42107 EXCISION, LESION OF PALATE, UVULA $266.13 20060701 99999999 42120 RESECTION OF PALATE OR EXTENSIVE RESECTION OF LESION $448.33 20060701 99999999 42140 UVULECTOMY, EXCISION OF UVULA $109.32 20060701 99999999 42145 PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, $482.16 20060701 99999999 42160 DESTRUCTION OF LESION, PALATE OR UVULA (THERMAL, CRYO OR CHEMICAL) $102.33 20060701 99999999 42180 REPAIR, LACERATION OF PALATE $137.66 20060701 99999999 42182 REPAIR, LACERATION OF PALATE $209.41 20060701 99999999 42200 PALATOPLASTY FOR CLEFT PALATE, SOFT AND/OR HARD PALATE ONLY $605.76 20060701 99999999 42205 PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF $587.14 20060701 99999999 42210 PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF $754.39 20060701 99999999 42215 PALATOPLASTY FOR CLEFT PALATE $495.66 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 165
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Medicaid Fee Schedule without Mods 200801

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