Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 42220 PALATOPLASTY FOR CLEFT PALATE $377.89 20060701 99999999 42225 PALATOPLASTY FOR CLEFT PALATE $665.66 20060701 99999999 42226 LENGTHENING OF PALATE, AND PHARYNGEAL FLAP $619.03 20060701 99999999 42227 LENGTHENING OF PALATE, WITH ISLAND FLAP $628.99 20060701 99999999 42235 REPAIR OF ANTERIOR PALATE, INCLUDING VOMER FLAP $493.09 20060701 99999999 42260 REPAIR OF NASOLABIAL FISTULA $446.59 20060701 99999999 42280 MAXILLARY IMPRESSION FOR PALATAL PROSTHESIS $83.62 20060701 99999999 42281 INSERTION OF PIN-RETAINED PALATAL PROSTHESIS $94.69 20060701 99999999 42300 DRAINAGE OF ABSCESS $92.99 20060701 99999999 42305 DRAINAGE OF ABSCESS $285.09 20060701 99999999 42310 DRAINAGE OF ABSCESS $76.92 20060701 99999999 42320 DRAINAGE OF ABSCESS $128.16 20060701 99999999 42325 FISTULIZATION OF SUBLINGUAL SALIVARY CYST (RANULA) $129.65 20030401 99999999 42326 FISTULIZATION OF SUBLINGUAL SALIVARY CYST (RANULA) $201.36 20030401 99999999 42330 SIALOLITHOTOMY $100.70 20060701 99999999 42335 SIALOLITHOTOMY $185.74 20060701 99999999 42340 SIALOLITHOTOMY $267.22 20060701 99999999 42400 BIOPSY OF SALIVARY GLAND $37.10 20060701 99999999 42405 BIOPSY OF SALIVARY GLAND $151.22 20060701 99999999 42408 EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA) $242.76 20060701 99999999 42409 MARSUPIALIZATION OF SUBLINGUAL SALIVARY CYST (RANULA) $173.76 20060701 99999999 42410 EXCISION OF PAROTID TUMOR OR PAROTID GLAND $478.66 20060701 99999999 42415 EXCISION OF PAROTID TUMOR OR PAROTID GLAND $876.55 20060701 99999999 42420 EXCISION OF PAROTID TUMOR OR PAROTID GLAND $1,013.54 20060701 99999999 42425 EXCISION OF PAROTID TUMOR OR PAROTID GLAND $708.31 20060701 99999999 42426 EXCISION OF PAROTID TUMOR OR PAROTID GLAND $1,220.80 20060701 99999999 42440 EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND $412.20 20060701 99999999 42450 EXCISION OF SUBLINGUAL GLAND $255.15 20060701 99999999 42500 PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY $265.88 20060701 99999999 42505 PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY $363.40 20060701 99999999 42507 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE) $337.60 20060701 99999999 42508 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE) $495.40 20060701 99999999 42509 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE) $587.44 20060701 99999999 42510 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE) $459.64 20060701 99999999 42550 INJECTION PROCEDURE FOR SIALOGRAPHY $46.93 20060701 99999999 42600 CLOSURE SALIVARY FISTULA $276.77 20060701 99999999 42650 DILATION SALIVARY DUCT $36.80 20060701 99999999 42660 DILATION AND CATHETERIZATION OF SALIVARY DUCT, WITH OR WITHOUT $57.06 20060701 99999999 42665 LIGATION SALIVARY DUCT, INTRAORAL $154.98 20060701 99999999 42700 INCISION AND DRAINAGE ABSCESS $82.33 20060701 99999999 42720 INCISION AND DRAINAGE ABSCESS $252.51 20060701 99999999 42725 INCISION AND DRAINAGE ABSCESS $504.62 20060701 99999999 42800 BIOPSY $77.75 20060701 99999999 42802 BIOPSY $94.12 20060701 99999999 42804 BIOPSY $84.47 20060701 99999999 42806 BIOPSY $102.65 20060701 99999999 42808 EXCISION OF LESION OF PHARYNX $148.11 20060701 99999999 42809 REMOVAL OF FOREIGN BODY FROM PHARYNX $89.50 20060701 99999999 42810 EXCISION BRANCHIAL CLEFT CYST OR VESTIGE, CONFINED TO SKIN $207.30 20060701 99999999 42815 EXCISION BRANCHIAL CLEFT CYST, VESTIGE, OR FISTULA, $433.27 20060701 99999999 42820 TONSILLECTOMY AND ADENOIDECTOMY $217.62 20060701 99999999 42821 TONSILLECTOMY AND ADENOIDECTOMY $245.40 20060701 99999999 42825 TONSILLECTOMY, PRIMARY OR SECONDARY $192.63 20060701 99999999 42826 TONSILLECTOMY, PRIMARY OR SECONDARY $208.79 20060701 99999999 42830 ADENOIDECTOMY, PRIMARY $138.25 20060701 99999999 42831 ADENOIDECTOMY, PRIMARY $152.17 20060701 99999999 42835 ADENOIDECTOMY, SECONDARY $135.32 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 166
PROC-CODE DESC MAC BEG END 42836 ADENOIDECTOMY, SECONDARY $186.13 20060701 99999999 42842 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR $491.26 20060701 99999999 42844 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR $758.93 20060701 99999999 42845 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR $1,258.65 20060701 99999999 42860 EXCISION OF TONSIL TAGS $134.78 20060701 99999999 42870 EXCISION LINGUAL TONSIL (SEPARATE PROCEDURE) $348.18 20060701 99999999 42890 LIMITED PHARYNGECTOMY $673.14 20060701 99999999 42892 RESECTION OF LATERAL PHARYNGEAL WALL OR PYRIFORM SINUS, DIRECT $819.60 20060701 99999999 42894 RESECTION OF PHARYNGEAL WALL REQUIRING CLOSURE WITH MYOCUTANEOUS FLAP $1,171.50 20060701 99999999 42900 SUTURE PHARYNX FOR WOUND OR INJURY $276.11 20060701 99999999 42950 PHARYNGOPLASTY (PLASTIC OR RECONSTRUCTIVE OPERATION ON PHARYNX) $498.59 20060701 99999999 42953 PHARYNGOESOPHAGEAL REPAIR $659.60 20060701 99999999 42955 PHARYNGOSTOMY (FISTULIZATION OF PHARYNX, EXTERNAL FOR FEEDING) $453.51 20060701 99999999 42960 CONTROL OROPHARYNGEAL HEMORRHAGE (PRIMARY OR SECONDARY, EG, $113.60 20060701 99999999 42961 CONTROL OROPHARYNGEAL HEMORRHAGE (PRIMARY OR SECONDARY, EG, $261.26 20060701 99999999 42962 CONTROL OROPHARYNGEAL HEMORRHAGE (PRIMARY OR SECONDARY, EG, $388.66 20060701 99999999 42970 CONTROL OF NASOPHARYNGEAL HEMORRHAGE (PRIMARY OR SECONDARY, EG, $236.80 20060701 99999999 42971 CONTROL OF NASOPHARYNGEAL HEMORRHAGE (PRIMARY OR SECONDARY, EG, $301.31 20060701 99999999 42972 CONTROL OF NASOPHARYNGEAL HEMORRHAGE (PRIMARY OR SECONDARY, EG, $360.24 20060701 99999999 43020 ESOPHAGOTOMY, CERVICAL APPROACH $449.01 20060701 99999999 43030 CRICOPHARYNGEAL MYOTOMY $463.34 20060701 99999999 43045 ESOPHAGOTOMY, THORACIC APPROACH $1,003.59 20060701 99999999 43100 EXCISION OF LOCAL LESION, ESOPHAGUS, WITH PRIMARY REPAIR $476.97 20060701 99999999 43101 EXCISION OF LOCAL LESION, ESOPHAGUS, WITH PRIMARY REPAIR $794.20 20060701 99999999 43107 TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHOUT THORACOTOMY; WITH PHARYNGOGASTROSTOMY $1,487.29 20060701 99999999 43108 TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHOUT THORACOTOMY; WITH COLON INTERPOSITION $1,698.39 20060701 99999999 43112 TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH THORACOTOMY; WITH PHARYNGOGASTROSTOMY OR $1,588.39 20060701 99999999 43113 TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH THORACOTOMY; WITH COLON INTERPOSITION OR $1,755.32 20060701 99999999 43116 PARTIAL ESOPHAGECTOMY, CERVICAL, WITH FREE INTESTINAL GRAFT, INCLUDING MICROVASC $1,608.11 20060701 99999999 43117 PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS, WITH THORACOTOMY AND SEPARATE ABDOMINA $1,582.62 20060701 99999999 43118 PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS, WITH THORACOTOMY AND SEPARATE ABDOMINA $1,665.09 20060701 99999999 43121 PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS, WITH THORACOTOMY ONLY, WITH OR WITHOUT $1,502.45 20060701 99999999 43122 PARTIAL ESOPHAGECTOMY, THORACOABDOMINAL OR ABDOMINAL APPROACH, WITH OR WITHOUT P $1,459.71 20060701 99999999 43123 PARTIAL ESOPHAGECTOMY, THORACOABDOMINAL OR ABDOMINAL APPROACH, WITH OR WITHOUT P $1,702.61 20060701 99999999 43124 TOTAL OR PARTIAL ESOPHAGECTOMY, WITHOUT RECONSTRUCTION (ANY APPROACH), WITH CERV $1,438.26 20060701 99999999 43130 DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS, WITH OR $659.19 20060701 99999999 43135 DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS, WITH OR $854.32 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 167
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