Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 43410 SUTURE OF ESOPHAGEAL WOUND OR INJURY $610.85 20060701 99999999 43415 SUTURE OF ESOPHAGEAL WOUND OR INJURY $931.76 20060701 99999999 43420 CLOSURE OF ESOPHAGOSTOMY OR FISTULA $544.08 20060701 99999999 43425 CLOSURE OF ESOPHAGOSTOMY OR FISTULA $853.32 20060701 99999999 43450 DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, $57.59 20060701 99999999 43453 DILATION OF ESOPHAGUS, OVER GUIDE WIRE OR STRING $75.92 20060701 99999999 43456 DILATION OF ESOPHAGUS, BY BALLOON OR STARCK DILATOR $127.46 20060701 99999999 43458 DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) FOR ACHALASIA $128.26 20060701 99999999 43460 ESOPHAGOGASTRIC TAMPONADE, WITH BALLOON (SENGSTAAKEN TYPE) $157.85 20060701 99999999 43499 UNLISTED PROCEDURE, ESOPHAGUS $400.67 19990701 99999999 43500 GASTROTOMY $413.88 20060701 99999999 43501 GASTROTOMY $715.48 20060701 99999999 43502 GASTROTOMY; WITH SUTURE REPAIR OF PRE-EXISTING ESOPHAGOGASTRIC LACERATION (EG, M $823.58 20060701 99999999 43510 GASTROTOMY $519.21 20060701 99999999 43520 PYLOROMYOTOMY, CUTTING OF PYLORIC MUSCLE (FREDET- RAMSTEDT TYPE $385.94 20060701 99999999 43600 BIOPSY OF STOMACH $71.98 20060701 99999999 43605 BIOPSY OF STOMACH $436.13 20060701 99999999 43610 EXCISION, LOCAL, OF ULCER OR TUMOR OF STOMACH $548.92 20060701 99999999 43611 EXCISION, LOCAL; MALIGNANT TUMOR OF STOMACH $641.24 20060701 99999999 43620 GASTRECTOMY, TOTAL $1,074.97 20060701 99999999 43621 GASTRECTOMY, TOTAL; WITH ROUX-EN-Y RECONSTRUCTION $1,091.22 20060701 99999999 43622 GASTRECTOMY, TOTAL; WITH FORMATION OF INTESTINAL POUCH, ANY TYPE $1,140.80 20060701 99999999 43631 GASTRECTOMY, PARTIAL, DISTAL; WITH GASTRODUODENOSTOMY $916.13 20060701 99999999 43632 GASTRECTOMY, PARTIAL, DISTAL; WITH GASTROJEJUNOSTOMY $914.94 20060701 99999999 43633 GASTRECTOMY, PARTIAL, DISTAL; WITH ROUX-EN-Y RECONSTRUCTION $929.96 20060701 99999999 43634 GASTRECTOMY, PARTIAL, DISTAL; WITH FORMATION OF INTESTINAL POUCH $1,145.89 20060701 99999999 43635 HEMIGASTRECTOMY OR DISTAL SUBTOTAL GASTRECTOMY INCLUDING PYLOROPLASTY, $89.79 20060701 99999999 43638 HEMIGASTRECTOMY OR PROXIMAL SUBTOTAL GASTRECTOMY, THORACIC OR $996.80 19990701 99999999 43639 GASTRECTOMY, PARTIAL, PROXIMAL, THORACIC OR ABDOMINAL APPROACH INCLUDING ESOPHAG $1,015.57 19990701 99999999 43640 VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR WITHOUT GASTROSTOMY $711.96 20060701 99999999 43641 VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR WITHOUT GASTROSTOMY $724.43 20060701 99999999 43644 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND RO $1,170.43 20060701 99999999 43645 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND $1,261.31 20060701 99999999 43651 LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL $451.80 20060701 99999999 43652 LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, SELECTIVE OR HIGHLY SELECTIV $541.09 20060701 99999999 43653 LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, ST $395.37 20060701 99999999 43750 PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE $238.95 19990701 99999999 43752 NASO- OR ORO-GASTRIC TUBE PLACEMENT, NECESSITATING PHYSICIAN¦S SKILL $36.91 20060701 99999999 43760 CHANGE OF GASTROSTOMY TUBE $48.41 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 170
PROC-CODE DESC MAC BEG END 43761 REPOSITIONING OF THE GASTRIC FEEDING TUBE THROUGH THE DUODENUM FOR ENTERIC NUTRI $82.53 20060701 99999999 43770 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GA $686.92 20060701 99999999 43771 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REVISION OF ADJUSTABLE GAS $789.99 20060701 99999999 43772 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GAST $601.85 20060701 99999999 43773 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL AND REPLACEMENT OF $790.19 20060701 99999999 43774 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GAST $604.16 20060701 99999999 43800 PYLOROPLASTY $504.68 20060701 99999999 43810 GASTRODUODENOSTOMY $538.68 20060701 99999999 43820 GASTROJEJUNOSTOMY $570.69 20060701 99999999 43825 GASTROJEJUNOSTOMY $718.95 20060701 99999999 43830 GASTROSTOMY, TEMPORARY (TUBE, RUBBER OR PLASTIC) (SEPARATE PROCEDURE) $380.04 20060701 99999999 43831 GASTROSTOMY, TEMPORARY (TUBE, RUBBER OR PLASTIC) (SEPARATE PROCEDURE) $364.27 20060701 99999999 43832 GASTROSTOMY, PERMANENT, WITH CONSTRUCTION OF GASTRIC TUBE $575.55 20060701 99999999 43840 GASTRORRHAPHY, SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCER, $567.96 20060701 99999999 43842 GASTROPLASTY, VERTICAL-BANDED, FOR MORBID OBESITY $812.12 20060701 99999999 43843 GASTROPLASTY, OTHER THAN VERTICAL-BANDED, FOR MORBID OBESITY $803.76 20060701 99999999 43845 GASTRIC STAPLING FOR MORBID OBESITY $1,054.93 20060701 99999999 43846 GASTRIC BYPASS WITH ROUX-EN-Y GASTROENTEROSTOMY $977.92 20060701 99999999 43847 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SMAL $1,072.44 20060701 99999999 43848 REVISION OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID OBESITY (SEPARATE PROCEDURE $1,143.78 20060701 99999999 43850 REVISION OF GASTRODUODENAL ANASTOMOSIS (GASTRODUODENOSTOMY) WITH $902.25 20060701 99999999 43855 REVISION OF GASTRODUODENAL ANASTOMOSIS (GASTRODUODENOSTOMY) WITH $921.31 20060701 99999999 43860 REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) WITH $908.24 20060701 99999999 43865 REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) WITH $982.26 20060701 99999999 43870 CLOSURE OF GASTROSTOMY, SURGICAL $377.77 20060701 99999999 43880 CLOSURE OF GASTROCOLIC FISTULA $872.30 20060701 99999999 43886 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONL $195.21 20060701 99999999 43887 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL OF SUBCUTANEOUS PORT COMPONENT ONLY $189.08 20060701 99999999 43888 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL AND REPLACEMENT OF SUBCUTANEOUS POR $267.86 20060701 99999999 44005 ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) FOR ACUTE BOWEL $642.14 20060701 99999999 44010 DUODENOTOMY, FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL $515.03 20060701 99999999 44015 NEEDLE CATHETER JEJUNOSTOMY FOR ENTERAL HYPERALIMENTATION $139.15 20060701 99999999 44020 ENTEROTOMY, SMALL BOWEL, OTHER THAN DUODENUM $566.70 20060701 99999999 44021 ENTEROTOMY, SMALL BOWEL, OTHER THAN DUODENUM $563.70 20060701 99999999 44025 COLOTOMY, FOR EXPLORATION, BIOPSY(S), OR $574.86 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 171
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Medicaid Fee Schedule without Mods 200801

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