Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END D7241 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY,W/UNUSUAL SURG $302.64 19990701 99999999 D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS(CUTTING PROC) $99.84 19990701 99999999 D7260 OROANTRAL FISTULA CLOSURE $99.84 19990701 99999999 D7270 TOOTH RE-IMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY $98.80 19990701 99999999 D7272 TOOTH TRANSPLANTATION $98.80 19990701 99999999 D7280 SURG EXPOSURE IMPACTED OR UNERUPTED TOOTH FOR ORTHODONTIC $78.00 20050102 99999999 D7281 SURGICAL EXPOSURE OF IMPACTED OR UNERUPTED TOOTH TO AID ERUP $78.00 19990701 99999999 D7283 PLACEMENT OF DEVICE TO FACILITATE ERUPTION OF IMPACTED TOOTH $78.00 20050102 99999999 D7285 BIOPSY OF ORAL TISSUE-HARD $78.00 19990701 99999999 D7286 BIOPSY OF ORAL TISSUE -SOFT $78.00 19990701 99999999 D7310 ALVEOLOPLASTY IN CONJUNCTION W/EXTRACTIONS-PER QUADRANT $93.60 19990701 99999999 D7311 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH $36.40 20050101 99999999 D7320 ALVEOLOPLASTY NOT IN CONJUNCTION W/EXTRACTIONS -PER QUADRANT $78.00 19990701 99999999 D7321 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH $31.20 20050101 99999999 D7410 RADICAL EXCISION LESION DIAMETER UP TO 1.25 CM $104.00 19990701 99999999 D7411 EXCISION OF BENIGN LESION GREATER THAN 1.25 CM $104.00 20030401 99999999 D7413 EXCISION OF MALIGNANT LESION UP TO 1.25 CM $208.00 20030401 99999999 D7414 EXCISION OF MALIGNANT LESION GREATER THAN 1.25 CM $260.00 20030401 99999999 D7420 RADICAL EXCISION LESION DIAMETER OVER 1.25 CM $104.00 19990701 99999999 D7430 EXCISION OF BENIGN TUMOR-LESION DIAMETER UP TO 1.25CM $130.00 19990701 99999999 D7431 EXCISION OF BENIGN TUMOR-LESION DIAMETER OVER 1.25 CM $104.00 19990701 99999999 D7440 EXCISION OF MALIGNANT TUMOR-LESION DIAMETER UP TO 1.25 CM $208.00 19990701 99999999 D7441 EXCISION OF MALIGNANT TUMOR-LESION DIAMETER OVER 1.25 CM $260.00 19990701 99999999 D7450 REMOVAL OF ODONTOGENIC CYST OR TUMOR-LESION DIAMETER UP TO $104.00 19990701 99999999 D7451 REMOVAL OF ODONTOGENIC CYST OR TUMOR-LESION DIAMETER 1.25CM $104.00 19990701 99999999 D7460 REMOVAL OF NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER $104.00 19990701 99999999 D7461 REMOVAL NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER OVER1.2 $130.00 19990701 99999999 D7465 DESTRUCTION OF LESION(S) BY PHYSICAL METHODS,ELECTROSURGERY $78.00 19990701 99999999 D7471 REMOVAL OF EXOSTOSIS - PER SITE $78.00 20000101 99999999 D7480 PARTIAL OSTECTOMY (GUTTERING OR SAUCERIZATION) $78.00 19990701 99999999 D7510 INCISION & DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE $62.40 19990701 99999999 D7511 INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE - COMPLICATED $62.40 20050101 99999999 D7520 INCISION & DRAINAGE OF ABCESS-EXTRAORAL SOFT TISSUE $55.33 19990701 99999999 D7521 INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE - COMPLICATED $525.90 20050101 99999999 D7530 REMOVAL OF FOREIGN BODY,SKIN,OR SUBCUTANEOUS AREOLAR TISSUE $31.20 19990701 99999999 D7540 REMOVAL OF REACTION PRODUCING FOREIGN BODIES,MUSCULOSKELETAL $208.00 19990701 99999999 D7550 SEQUESTRECTOMY FOR OSTEOMYELITIS $182.00 19990701 99999999 D7560 MAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR FOREIG $260.00 19990701 99999999 D7910 SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM $119.60 19990701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 18
PROC-CODE DESC MAC BEG END D7911 SUTURE - UP TO 5 CM $182.00 19990701 99999999 D7912 SUTURE - OVER 5 CM $208.00 19990701 99999999 D7960 FRENULECTOMY (FRENECTOMY OR FRENOTOMY) - SEPARATE PROCEDURE $75.00 19990701 99999999 D7970 EXCISION OF HYPERPLASTIC TISSUE - PER ARCH $208.00 19990701 99999999 D7971 EXCISION OF PERICORONAL GINGIVA $32.03 19990701 99999999 D9110 PALLIATIVE (ER) TREATMENT OD DENTAL PAIN-MINOR PROCEDURES $59.28 19990701 99999999 D9230 ANALGESIA $55.99 19990701 99999999 D9241 INTRAVENOUS SEDATION/ANALGESIA - FIRST 30 MINUTES $208.00 20000101 99999999 D9242 INTRAVENOUS SEDATION/ANALGESIA - EACH ADDITIONAL 15 MINUTES $52.00 20000101 99999999 D9310 CONSULTATION PER SESSION $66.56 20011001 99999999 D9440 OFFICE VISIT-AFTER REGULARLY SCHEDULED HOURS $60.00 19990701 99999999 E0100 CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, $13.52 20030401 99999999 E0105 CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERIALS, $50.04 20030401 99999999 E0110 CRUTCHES,FOREARM INC VARIOUS MATERIALS,ADJ OR FIXED PAIR CMP $84.01 20030401 99999999 E0111 CRUTCH FOREARM;INC VARIOUS MATERIALS,ADJ OR FIXED, TIP&HANDG $54.51 20030401 99999999 E0112 CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, $38.04 20030401 99999999 E0113 CRUTCH UNDERARM,WOOD,ADJ/FIXED, EACH, W/PAD, TIP OR HANDGRIP $39.13 20030401 99999999 E0114 CRUTCHES UNDERARM,ALUMINUM,ADJ OR FIXED,PAIR,W/PADS,TIPS,HAN $48.52 20030401 99999999 E0116 CRUTCH UNDERARM,ALUMINUM,ADJ OR FIXED,W/PAD,TIP,HANDGRIP $24.25 20030401 99999999 E0117 CRUTCH, UNDERARM, ARTICULATING, SPRING ASSISTED, EACH $19.27 20071101 99999999 E0130 WALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHT $82.90 20030401 99999999 E0135 WALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIGHT $101.63 20030401 99999999 E0140 WALKER, WITH TRUNK SUPPORT, ADJUSTABLE OR FIXED HEIGHT, ANY TYPE $36.08 20071101 99999999 E0141 WALKER WHEELED, WITHOUT SEAT $127.71 20030401 99999999 E0142 RIGID WALKER,WHEELED,/SEAT $128.54 20030401 99999999 E0143 FOLDING WALKER,WHEELED,W/O SEAT $120.91 20030401 99999999 E0144 ENCLOSED, FRAMED FOLDING WALKER, WHEELED, WITH POSTERIOR SEAT $11.99 20071101 99999999 E0145 WALKER,WHEELED,W/SEAT AND CRUTCH ATTACHMENTS $395.20 20030401 99999999 E0146 WALKER/WHEELED/WITH SEAT $329.68 20030401 99999999 E0147 HEAVY DUTY/MULT BREAKING SYST/VARIABLE WHEEL RESIST WALKER $57.48 20071101 99999999 E0148 WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH $127.05 20030401 99999999 E0149 WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE, EACH $223.20 20030401 99999999 E0153 PLATFORM ATTACHMENT, FOREARM CRUTCH, EACH $8.87 20071101 99999999 E0154 PLATFORM ATTACHMENT/WALKER/EACH $10.39 20071101 99999999 E0155 WHEEL ATTACHMENT,RIGID PICK-UP WALKER $3.11 20071101 99999999 E0156 SEAT ATTACHMENT/WALKER $3.12 20071101 99999999 E0157 CRUTCH ATTACHMENT/WALKER/EACH $6.78 20071101 99999999 E0158 LEG EXTENSIONS FOR A WALKER $3.83 20071101 99999999 E0159 BRAKE ATTACHMENT FOR WHEELED WALKER $1.93 20071101 99999999 E0160 SITZ TYPE BATH, PORTABLE, FITS OVER COMMODE SEAT $7.39 20071101 99999999 E0161 SITZ TYPE BATH/PORT/FITS OVER COMMODE SEAT/W FAUCET ATTACHME $1.89 20071101 99999999 E0162 SITZ BATH CHAIR $9.95 20071101 99999999 E0163 COMMODE CHAIR,STATIONARY,WITH FIXED ARMS $9.36 20071101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 19
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