Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END D0274 BITEWINGS FOUR FILMS $25.48 19990701 99999999 D0277 VERTICAL BITEWINGS - 7 TO 8 FILMS $46.80 20000101 99999999 D0290 POSTEROANTERIOR & LATERAL SKULL & FACIAL BONE, SURVEY FILM $67.60 19990701 99999999 D0310 SALIOGRAPHY $67.60 19990701 99999999 D0330 PANORAMIC FILM $47.32 19990701 99999999 D0340 CEPHALOMETRIC FILM $62.40 19990701 99999999 D0350 ORAL/FACIAL IMAGES (INCLUDES INTRA AND EXTRAORAL IMAGES) $26.00 20000101 99999999 D0415 BACTERIOLOGIC STUDIES FOR DETERMINATION OF PATHOLOGIC AGENTS $36.40 19990701 99999999 D1110 PROPHYLAXIS ADULT $36.40 19990701 99999999 D1120 PROPHYLAXIS CHILD $26.00 19990701 99999999 D1201 TOPICAL APPLICATION OF FLUORIDE(INCL PROPHYLAXIS) CHILD $30.16 19990701 99999999 D1203 TOPICAL APPLICATION OF FLUORIDE(EXCL PROPHYLAXIS) CHILD $4.16 19990701 99999999 D1204 TOPICAL APPLICATION OF FLUORIDE(EXCL PROPHYLAXIS) ADULT $4.16 19990701 99999999 D1205 TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHYLAXIS)- ADULT $40.56 19990701 99999999 D1206 TOPICAL FLUORIDE VARNISH; THERAPEUTIC APPLICATION FOR MODERATE TO HIGH CARIES RI $4.16 20070101 99999999 D1351 SEALANT PER TOOTH $24.32 19990701 99999999 D1510 SPACE MAINTAINER FIXED UNILATERAL $115.44 19990701 99999999 D1515 SPACE MAINTAINER FIXED BILATERAL $149.76 19990701 99999999 D1520 SPACE MAINTAINER REMOVABLE UNILATERAL $85.61 19990701 99999999 D1525 SPACE MAINTAINER REMOVABLE BILATERAL $158.08 19990701 99999999 D1550 RECEMENTATION OF SPACE MAINTAINER $31.20 19990701 99999999 D2140 AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT $30.94 20030808 99999999 D2140 AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT $38.53 20030808 99999999 D2150 AMALGAM TWO SURFACES PERMANENT $40.40 20030808 99999999 D2150 AMALGAM TWO SURFACES PERMANENT $50.02 20030808 99999999 D2160 AMALGAM THREE SURFACES PERMANENT $48.46 20030808 99999999 D2160 AMALGAM THREE SURFACES PERMANENT $60.63 20030808 99999999 D2161 AMALGAM FOUR OR MORE SURFACES PERMANENT $53.56 20030808 99999999 D2161 AMALGAM FOUR OR MORE SURFACES PERMANENT $66.90 20030808 99999999 D2752 CROWN PORCELAIN FUSED TO NOBLE METAL $234.00 19990701 99999999 D2792 CROWN FULL CAST NOBLE METAL $234.00 19990701 99999999 D2910 RECEMENT INLAY $28.08 19990701 99999999 D2920 RECEMENT CROWN $28.08 19990701 99999999 D2930 PREFABRICATED STAINLESS STEEL CROWN PRIMARY TOOTH $74.36 19990701 99999999 D2931 PREFABRICATED STAINLESS STEEL CROWN-PERMANENT TOOTH $80.60 19990701 99999999 D2932 PREFABRICATED RESIN CROWN $46.80 19990701 99999999 D2950 CROWN BUILD UP,INCLUDING ANY PINS $62.40 19990701 99999999 D2951 PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION $15.60 19990701 99999999 D2952 CAST POST AND CORE IN ADDITION TO CROWN $74.88 20070101 99999999 D2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN $74.88 19990701 99999999 D2970 TEMPORARY (FRACTURED TOOTH) $46.80 19990701 99999999 D3220 THERAPEUTIC PULPOTOMY (EXCL FINAL RESTORATION) $67.60 19990701 99999999 D3310 ONE CANAL (EXCLUDING FINAL RESTORATION) $260.00 19990701 99999999 D3320 TWO CANALS (EXCLUDING FINAL RESTORATION) $338.00 19990701 99999999 D3330 THREE CANALS (EXCLUDING FINAL RESTORATION) $416.00 19990701 99999999 D3351 APEXIFICATION/RECALCIFICATION-INITIAL VISIT (APICAL CLOSURE/CALCIFIC REPAIR OF P $80.29 19990701 99999999 D3352 APEXIFICATION/RECALCIFICATION-INTERIM MEDICATION REPLACEM ENT (APICAL CLOSURE/C $36.40 19990701 99999999 D3353 APEXIFICATION/RECALCIFICATION-FINAL VISIT (INCLUDES COMPLETED ROOT CANAL THERAPY $36.40 19990701 99999999 D3410 APICOECTOMY (PER TOOTH) FIRST ROOT $260.00 19990701 99999999 D3421 APICOECTOMY/PERIRADICULAR SURGERY-BICUSPID (FIRST ROOT) $338.00 19990701 99999999 D3425 APICOECTOMY/PERIRADICULAR SURGERY-MOLAR (FIRST ROOT). $416.00 19990701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 16
PROC-CODE DESC MAC BEG END D4210 GINGIVECTOMY OR GINGIVOPLASTY PER QUADRANT $187.20 19990701 99999999 D4211 GINGIVECTOMY OR GINGIVOPLASTY PER TOOTH $20.68 19990701 99999999 D4240 GINGIVAL FLAP PROC, INCL ROOT PLANING PER QUADRANT $49.92 19990701 99999999 D4260 OSSEOUS SURGERY (INCL FLAP ENTRY & CLOSURE) PER QUADRANT $450.00 19990701 99999999 D4261 OSSEOUS GRAFT/SINGLE SITE (INCL FLAP ENTRY,CLOSURE,AND DONOR $250.00 19990701 99999999 D4341 PERIODONTAL SCALING & ROOT PLANING-PER QUADRANT $90.00 19990701 99999999 D4342 PERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH, PER QUADRANT $48.00 20030101 99999999 D5110 COMPLETE UPPER $520.00 19990701 99999999 D5120 COMPLETE LOWER $520.00 19990701 99999999 D5130 IMMEDIATE UPPER $416.00 19990701 99999999 D5140 IMMEDIATE LOWER $416.00 19990701 99999999 D5211 UPPER PARTIAL-ACRYLIC BASE (INC ANY CONVENTIONAL CLASPS/REST $416.00 19990701 99999999 D5212 LOWER PARTIAL-ACRYLIC BASE (INC ANY CONVENTIONAL CLASPS/REST $416.00 19990701 99999999 D5213 UPPER PARTIAL-PREDOMINANTLY BASE CAST BASE W/ACRYLIC SADDLES $520.00 19990701 99999999 D5214 LOWER PARTIAL-PREDOMINANTLY BASE CAST BASE W/ACRYLIC SADDLES $520.00 19990701 99999999 D5410 ADJUST COMPLETE DENTURE UPPER $41.81 19990701 99999999 D5411 ADJUST COMPLETE DENTURE LOWER $37.44 19990701 99999999 D5421 ADJUST PARTIAL DENTURE-UPPER $28.08 19990701 99999999 D5422 ADJUST PARTIAL DENTURE-LOWER $26.21 19990701 99999999 D5510 REPAIR BROKEN COMPLETE DENTURE BASE $43.68 19990701 99999999 D5520 REPLACE MISSING OR BROKEN TEETH-CMPLT DENTURE(EACH TOOTH) $49.92 19990701 99999999 D5610 REPAIR ACRYLIC SADDLE OR BASE $45.43 19990701 99999999 D5620 REPAIR CAST FRAMEWORK $49.92 19990701 99999999 D5630 REPAIR OR REPLACE BROKEN CLASP $49.92 19990701 99999999 D5640 REPLACE BROKEN TEETH-PER TOOTH $43.68 19990701 99999999 D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $72.80 19990701 99999999 D5660 ADD CLASP TO EXISTING PARTIAL DENTURE TOOTH,INVOLVING CLASP $42.01 19990701 99999999 D5710 REBASE COMPLETE UPPER DENTURE $135.20 19990701 99999999 D5711 REBASE COMPLETE LOWER DENTURE $135.20 19990701 99999999 D5720 REBASE UPPER PARTIAL DENTURE $90.95 19990701 99999999 D5721 REBASE LOWER PARTIAL DENTURE $90.95 19990701 99999999 D5730 RELINE UPPER COMPLETE DENTURE (CHAIRSIDE) $78.00 19990701 99999999 D5731 RELINE LOWER COMPLETE DENTURE (CHAIRSIDE) $78.00 19990701 99999999 D5740 RELINE UPPER PARTIAL DENTURE (CHAIRSIDE) $78.00 19990701 99999999 D5741 RELINE LOWER PARTIAL DENTURE (CHAIRSIDE) $87.36 19990701 99999999 D5750 RELINE UPPER COMPLETE DENTURE (LAB) $140.40 19990701 99999999 D5751 RELINE LOWER COMPLETE DENTURE (LAB) $145.60 19990701 99999999 D5760 RELINE UPPER PARTIAL DENTURE (LAB) $116.48 19990701 99999999 D5761 RELINE LOWER PARTIAL DENTURE (LAB) $121.68 19990701 99999999 D5810 TEMPORARY COMPLETE DENTURE (UPPER) $104.00 19990701 99999999 D5811 TEMPORARY COMPLETE DENTURE (LOWER) $104.00 19990701 99999999 D5820 TEMPORARY PARTIAL-STAYPLATE DENTURE (UPPER) $160.16 19990701 99999999 D5821 TEMPORARY PARTIAL-STAYPLATE DENTURE (LOWER) $160.16 19990701 99999999 D5850 TISSUE CONDITIONING -PER DENTURE UNIT $40.77 19990701 99999999 D7210 SURG REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPER $145.60 19990701 99999999 D7220 REMOVAL OF IMPACTED TOOTH-SOFT TISSUE $167.44 19990701 99999999 D7230 REMOVAL OF IMPACTED TOOTH-PARTIALLY BODY $245.44 19990701 99999999 D7240 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY $302.64 19990701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 17
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