Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 53449 SURGICAL CORRECTION OF HYDRAULIC ABNORMALITY OF INFLATABLE $504.80 20060701 99999999 53450 URETHROMEATOPLASTY, WITH MUCOSAL ADVANCEMENT $284.54 20060701 99999999 53460 URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL $312.65 20060701 99999999 53500 URETHROLYSIS, TRANSVAGINAL, SECONDARY, OPEN, INCLUDING CYSTOURETHROSCOPY (EG, PO $534.29 20060701 99999999 53502 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY, FEMALE $377.78 20060701 99999999 53505 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY $375.47 20060701 99999999 53510 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY $497.65 20060701 99999999 53515 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY $630.19 20060701 99999999 53520 CLOSURE OF URETHROSTOMY OR URETHROCUTANEOUS FISTULA, MALE $423.26 20060701 99999999 53600 DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND $42.95 20060701 99999999 53601 DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND $35.09 20060701 99999999 53605 DILATION OF URETHRAL STRICTURE OR VESICAL NECK BY PASSAGE OF $50.34 20060701 99999999 53620 DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM AND $57.92 20060701 99999999 53621 DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM AND $48.13 20060701 99999999 53660 DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR $25.92 20060701 99999999 53661 DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR $25.88 20060701 99999999 53665 DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION $31.54 20060701 99999999 53670 CATHETERIZATION, URETHRA $18.27 20030401 99999999 53675 CATHETERIZATION, URETHRA $56.53 20030401 99999999 53850 TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY MICROWAVE THERMOTHERAPY $475.57 20060701 99999999 53852 TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY RADIOFREQUENCY THERMOTHERAPY $464.57 20060701 99999999 53853 TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY WATER- INDUCED THERMOTHERAPY $330.37 20060701 99999999 54000 SLITTING OF PREPUCE, DORSAL OR LATERAL, (SEPARATE PROCEDURE) $73.34 20060701 99999999 54001 SLITTING OF PREPUCE, DORSAL OR LATERAL, (SEPARATE PROCEDURE) $103.30 20060701 99999999 54015 INCISION AND DRAINAGE OF PENIS, DEEP $207.58 20060701 99999999 54050 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, $55.81 20060701 99999999 54055 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, $58.49 20060701 99999999 54056 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, $57.97 20060701 99999999 54057 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, $75.55 20060701 99999999 54060 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, $95.34 20060701 99999999 54065 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, $117.14 20060701 99999999 54100 BIOPSY OF PENIS $73.71 20060701 99999999 54105 BIOPSY OF PENIS $144.20 20060701 99999999 54110 EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE) $496.48 20060701 99999999 54111 EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE) $662.61 20060701 99999999 54112 EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE) $774.16 20060701 99999999 54115 REMOVAL FOREIGN BODY FROM DEEP PENILE TISSUE $333.96 20060701 99999999 54120 AMPUTATION OF PENIS $499.00 20060701 99999999 54125 AMPUTATION OF PENIS $702.97 20060701 99999999 54130 AMPUTATION OF PENIS, RADICAL $980.12 20060701 99999999 54135 AMPUTATION OF PENIS, RADICAL $1,240.88 20060701 99999999 54150 CIRCUMCISION, CLAMP PROCEDURE $84.95 20060701 99999999 54152 CIRCUMCISION, CLAMP PROCEDURE $119.74 19990701 99999999 54160 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP OR DORSAL $122.85 20060701 99999999 54161 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP OR DORSAL $156.61 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 192
PROC-CODE DESC MAC BEG END 54162 LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS $167.12 20060701 99999999 54163 REPAIR INCOMPLETE CIRCUMCISION $156.28 20060701 99999999 54164 FRENULOTOMY OF PENIS $137.66 20060701 99999999 54200 INJECTION PROCEDURE FOR PEYRONIE DISEASE $50.18 20060701 99999999 54205 INJECTION PROCEDURE FOR PEYRONIE DISEASE $407.32 20060701 99999999 54220 IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM $106.48 20060701 99999999 54230 INJECTION PROCEDURE FOR CORPORA CAVERNOSOGRAPHY $66.90 20060701 99999999 54231 DYNAMIC CAVERNOSOMETRY, INCLUDING INTRACAVERNOSAL INJECTION OF VASOCACTIVE DRUGS $92.12 20060701 99999999 54235 INJ OF CORPORA CAVERNOSA W/PHARMACOLOGIC AGENT $43.05 20030401 99999999 54240 PENILE PLETHYSMOGRAPHY $69.80 20060701 99999999 54250 NOCTURNAL PENILE TUMESCENCE AND/OR RIGIDITY TEST $92.74 20060701 99999999 54300 PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, $533.72 20060701 99999999 54304 PLASTIC OPERATION ON PENIS FOR CORRECTION OF CHORDEE OR FOR $634.82 20060701 99999999 54308 URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING $562.00 20060701 99999999 54312 URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING $685.61 20060701 99999999 54316 URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING $844.70 20060701 99999999 54318 URETHROPLASTY FOR THIRD STAGE HYPOSPADIAS REPAIR TO RELEASE $579.02 20060701 99999999 54322 ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT $622.54 20060701 99999999 54324 ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT $806.50 20060701 99999999 54326 ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT $775.50 20060701 99999999 54328 ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT $769.44 20060701 99999999 54332 ONE STAGE PROXIMAL PENILE OR PENOSCROTAL HYPOSPADIAS REPAIR $850.74 20060701 99999999 54336 ONE STAGE PERINEAL HYPOSPADIAS REPAIR REQUIRING EXTENSIVE $1,078.15 20060701 99999999 54340 REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, $468.25 20060701 99999999 54344 REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, $879.70 20060701 99999999 54348 REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, $843.44 20060701 99999999 54352 REPAIR OF HYPOSPADIAS CRIPPLE REQUIRING EXTENSIVE DISSECTION $1,162.81 20060701 99999999 54360 PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION $574.41 20060701 99999999 54380 PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL $677.75 20060701 99999999 54385 PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL $781.26 20060701 99999999 54390 PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL $1,045.09 20060701 99999999 54400 INSERTION OF PENILE PROSTHESIS $508.38 20060701 99999999 54401 INSERTION OF PENILE PROSTHESIS INFLATABLE SELF CONTAINED $578.64 20060701 99999999 54402 REMOVAL OR REPLACEMENT OF NON-INFLATABLE (SEMI-RIGID) $448.93 19990701 99999999 54405 INSERTION OF INFLATABLE (MULTI-COMPONENT) PENILE PROSTHESIS, $741.57 20060701 99999999 54406 REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WIT $510.22 20060701 99999999 54407 REMOVAL, REPAIR, OR REPLACEMENT OF INFLATABLE (MULTI- COMPONENT) $673.77 19990701 99999999 54408 REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS $537.95 20020101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 193
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Medicaid Fee Schedule without Mods 200801

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