Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 51575 CYSTECTOMY, COMPLETE $1,459.21 20060701 99999999 51580 CYSTECTOMY, COMPLETE, WITH URETEROSIGMOIDOSTOMY OR $1,433.19 20060701 99999999 51585 CYSTECTOMY, COMPLETE, WITH URETEROSIGMOIDOSTOMY OR $1,658.56 20060701 99999999 51590 CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR SIGMOID $1,558.35 20060701 99999999 51595 CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR SIGMOID $1,861.32 20060701 99999999 51596 CYSTECTOMY COMPL W/CONTINENT DIVERSION INCL BOWEL ANASTOMOSI $1,963.82 20060701 99999999 51597 PELVIC EXENTERATION, COMPLETE, FOR VESICAL, PROSTATIC OR $1,863.15 20060701 99999999 51600 INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY $32.89 20060701 99999999 51605 INJECTION PROCEDURE AND PLACEMENT OF CHAIN FOR CONTRAST AND/OR $26.01 20060701 99999999 51610 INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY $40.43 20060701 99999999 51700 BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION $30.96 20060701 99999999 51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR R $19.82 20060701 99999999 51702 INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY) $21.90 20060701 99999999 51703 INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANA $58.37 20060701 99999999 51705 CHANGE OF CYSTOSTOMY TUBE $49.55 20060701 99999999 51710 CHANGE OF CYSTOSTOMY TUBE $66.41 20060701 99999999 51715 ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URET $168.80 20060701 99999999 51720 BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING $68.68 20060701 99999999 51725 SIMPLE CYSTOMETROGRAM (CMG) (EG, SPINAL MANOMETER) $178.89 20060701 99999999 51726 COMPLEX CYSTOMETROGRAM (EG, CALIBRATED ELECTRONIC EQUIPMENT) $232.33 20060701 99999999 51736 SIMPLE UROFLOWMETRY (UFR) (EG, STOP-WATCH FLOW RATE, MECHANICAL $30.09 20060701 99999999 51741 COMPLEX UROFLOWMETRY (EG, CALIBRATED ELECTRONIC EQUIPMENT) $51.59 20060701 99999999 51772 URETHRAL PRESSURE PROFILE STUDIES (UPP) (URETHRAL CLOSURE $181.65 20060701 99999999 51784 ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, OTHER THAN NEEDLE, $138.67 20060701 99999999 51785 ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL $150.11 20060701 99999999 51792 STIMULUS EVOKED RESPONSE (EG, MEASUREMENT OF BULBOCAVERNOSUS $180.61 20060701 99999999 51795 VOIDING PRESSURE STUDIES (VP) $223.63 20060701 99999999 51797 VOIDING PRESSURE STUDIES (VP) $186.18 20060701 99999999 51798 MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND $15.83 20060701 99999999 51800 CYSTOPLASTY OR CYSTOURETHROPLASTY, PLASTIC OPERATION ON $825.34 20060701 99999999 51820 CYSTOURETHROPLASTY WITH UNILATERAL OR BILATERAL $780.81 20060701 99999999 51840 ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY $551.43 20060701 99999999 51841 ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY $668.26 20060701 99999999 51845 ABDOMINO-VAGINAL VESICAL NECK SUSPENSION, WITH OR WITHOUT $546.20 20060701 99999999 51860 CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE $581.94 20060701 99999999 51865 CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE $735.21 20060701 99999999 51880 CLOSURE OF CYSTOSTOMY (SEPARATE PROCEDURE) $377.65 20060701 99999999 51900 CLOSURE OF VESICOVAGINAL FISTULA, ABDOMINAL APPROACH $675.48 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 188
PROC-CODE DESC MAC BEG END 51920 CLOSURE OF VESICOUTERINE FISTULA $561.93 20060701 99999999 51925 CLOSURE OF VESICOUTERINE FISTULA $744.32 20060701 99999999 51940 CLOSURE OF BLADDER EXSTROPHY $1,282.67 20060701 99999999 51960 ENTEROCYSTOPLASTY, INCLUDING BOWEL ANASTOMOSIS $1,188.89 20060701 99999999 51980 CUTANEOUS VESICOSTOMY $548.63 20060701 99999999 51990 LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE $535.99 20060701 99999999 51992 LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SY $582.01 20060701 99999999 52000 CYSTOURETHROSCOPY (SEPARATE PROCEDURE) $77.48 20060701 99999999 52001 CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF CLOTS $178.65 20060701 99999999 52005 CYSTOURETHROSCOPY, $115.52 20060701 99999999 52007 CYSTOURETHROSCOPY, $147.35 20060701 99999999 52010 CYSTOURETHROSCOPY, $115.85 20060701 99999999 52204 CYSTOURETHROSCOPY, WITH BIOPSY $118.32 20060701 99999999 52214 CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR $169.94 20060701 99999999 52224 CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR $152.94 20060701 99999999 52234 CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR $243.61 20060701 99999999 52235 CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR $286.51 20060701 99999999 52240 CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR $507.87 20060701 99999999 52250 CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, $196.97 20060701 99999999 52260 CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL $165.11 20060701 99999999 52265 CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL $108.76 20060701 99999999 52270 CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY $170.16 20060701 99999999 52275 CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY $213.08 20060701 99999999 52276 CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY $242.69 20060701 99999999 52277 CYSTOURETHROSCOPY, WITH RESECTION OF EXTERNAL SPHINCTER $285.52 20060701 99999999 52281 CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL $112.00 20060701 99999999 52282 CYSTOURETHROSCOPY, WITH INSERTION OF URETHRAL STENT $288.76 20060701 99999999 52283 CYSTOURETHROSCOPY, WITH STEROID INJECTION INTO STRICTURE $148.90 20060701 99999999 52285 CYSTOURETHROSCOPY FOR TREATMENT OF THE FEMALE URETHRAL $144.23 20060701 99999999 52290 CYSTOURETHROSCOPY $191.23 20060701 99999999 52300 CYSTOURETHROSCOPY $234.19 20060701 99999999 52301 CYSTOURETHROSCOPY; WITH URETERAL MEATOTOMY, UNILATERAL/BILATERAL WITH RESECTION $241.41 20060701 99999999 52305 CYSTOURETHROSCOPY $234.82 20060701 99999999 52310 CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, $143.45 20060701 99999999 52315 CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, $240.98 20060701 99999999 52317 LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY $326.69 20060701 99999999 52318 LITHOLAPAXY;CRUSHING OR FRAGMENTATION OF CALCULUS;OVER 2.5CM $436.67 20060701 99999999 52320 CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION) $237.10 20060701 99999999 52325 CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION) $318.07 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 189
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Medicaid Fee Schedule without Mods 200801

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