Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 57107 VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; WITH REMOVAL OF PARAVAGINAL TISSUE $916.70 20060701 99999999 57109 VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; WITH REMOVAL OF PARAVAGINAL TISSUE $1,123.86 20060701 99999999 57110 COLPECTOMY, OBLITERATION OF VAGINA $643.00 20060701 99999999 57111 VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; WITH REMOVAL OF PARAVAGINAL TISSU $1,126.59 20060701 99999999 57112 VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; WITH REMOVAL OF PARAVAGINAL TISSU $1,198.76 20060701 99999999 57120 COLPOCLEISIS (LE FORT TYPE) $394.59 20060701 99999999 57130 EXCISION OF VAGINAL SEPTUM $143.24 20060701 99999999 57135 EXCISION OF VAGINAL CYST OR TUMOR $140.46 20060701 99999999 57150 IRRIGATION OF VAGINA AND/OR APPLICATION OF MEDICAMENT $20.46 20060701 99999999 57155 INSERTION OF UTERINE TANDEMS AND/OR VAGINAL OVOIDS FOR CLINICAL BRACHYTHERAPY $284.13 20060701 99999999 57160 INSERTION OF PESSARY $32.66 20060701 99999999 57170 DIAPHRAGM FITTING WITH INSTRUCTIONS $33.81 20060701 99999999 57180 INTRODUCTION OF ANY HEMOSTATIC AGENT OR PACK FOR SPONTANEOUS $71.39 20060701 99999999 57200 COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL) $200.96 20060701 99999999 57210 COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR $252.42 20060701 99999999 57220 PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH $245.25 20060701 99999999 57230 PLASTIC REPAIR OF URETHROCELE (SEPARATE PROCEDURE) $283.50 20060701 99999999 57240 ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT $347.59 20060701 99999999 57250 POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE $314.47 20060701 99999999 57260 COMBINED ANTEROPOSTERIOR COLPORRHAPHY $452.04 20060701 99999999 57265 COMBINED ANTEROPOSTERIOR COLPORRHAPHY $578.51 20060701 99999999 57267 INSERTION OF MESH OR OTHER PROSTHESIS FOR REPAIR OF PELVIC FLOOR DEFECT, EACH $207.36 20060701 99999999 57268 REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE) $372.74 20060701 99999999 57270 REPAIR OF ENTEROCELE, ABDOMINAL APPROACH (SEPARATE $550.07 20060701 99999999 57280 COLPOPEXY, ABDOMINAL APPROACH $678.90 20060701 99999999 57282 SACROSPINOUS LIGAMENT FIXATION FOR PROLAPSE OF VAGINA $473.24 20060701 99999999 57283 COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY) $498.64 20060701 99999999 57284 PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, STRESS URINARY INCONTI $606.07 20060701 99999999 57285 PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF PERFORMED); VAGINAL $336.59 20080101 99999999 57287 REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC) $513.22 20060701 99999999 57288 SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR $647.08 20060701 99999999 57289 PEREYRA PROCEDURE, INCLUDING ANTERIOR COLPORRHAPHY $561.60 20060701 99999999 57291 CONSTRUCTION OF ARTIFICIAL VAGINA $398.46 20060701 99999999 57292 CONSTRUCTION OF ARTIFICIAL VAGINA $585.17 20060701 99999999 57295 REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT, VAGINAL APPROACH $332.96 20060701 99999999 57296 REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; OPEN ABDOMINAL APPROAC $628.96 20070101 99999999 57300 CLOSURE OF RECTOVAGINAL FISTULA $421.21 20060701 99999999 57305 CLOSURE OF RECTOVAGINAL FISTULA $629.87 20060701 99999999 57307 CLOSURE OF RECTOVAGINAL FISTULA $680.95 20060701 99999999 57308 CLOSURE OF RECTOVAGINAL FISTULA; TRANSPERINEAL APPROACH, WITH PERINEAL BODY RECO $491.46 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 198
PROC-CODE DESC MAC BEG END 57310 CLOSURE OF URETHROVAGINAL FISTULA $331.08 20060701 99999999 57311 CLOSURE OF URETHROVAGINAL FISTULA $392.72 20060701 99999999 57320 CLOSURE OF VESICOVAGINAL FISTULA $449.04 20060701 99999999 57330 CLOSURE OF VESICOVAGINAL FISTULA $584.35 20060701 99999999 57335 VAGINOPLASTY FOR ADRENOGENITAL SYNDROME $780.14 20060701 99999999 57400 DILATION OF VAGINA UNDER ANESTHESIA $88.07 20060701 99999999 57410 PELVIC EXAMINATION UNDER ANESTHESIA $70.32 20060701 99999999 57415 REMOVAL OF IMPACTED VAGINAL FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA $97.29 20060701 99999999 57420 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; $65.00 20060701 99999999 57421 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) $90.14 20060701 99999999 57423 PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF PERFORMED), LAPAROS $464.05 20080101 99999999 57425 LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX) $663.24 20060701 99999999 57452 COLPOSCOPY (VAGINOSCOPY) $56.75 20060701 99999999 57454 COLPOSCOPY (VAGINOSCOPY) $87.39 20060701 99999999 57455 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE $81.91 20060701 99999999 57456 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH ENDOCERVICAL CURE $76.73 20060701 99999999 57460 COLPOSCOPY (VAGINOSCOPY); WITH LOOP ELECTROSURGICAL EXCISION(S) OF THE CERVIX (L $114.04 20060701 99999999 57461 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CO $141.67 20060701 99999999 57500 BIOPSY, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, $40.27 20060701 99999999 57505 ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION $56.39 20060701 99999999 57510 CAUTERIZATION OF CERVIX $80.95 20060701 99999999 57511 CAUTERIZATION OF CERVIX $82.21 20060701 99999999 57513 CAUTERIZATION OF CERVIX $111.82 20060701 99999999 57520 BIOPSY OF CERVIX, CIRCUMFERENTIAL (CONE), WITH OR WITHOUT $213.26 20060701 99999999 57522 CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND $190.06 20060701 99999999 57530 TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX $248.22 20060701 99999999 57531 RADICAL TRACHELECTOMY, WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORT $1,293.39 20060701 99999999 57540 EXCISION OF CERVICAL STUMP, ABDOMINAL APPROACH $554.03 20060701 99999999 57545 EXCISION OF CERVICAL STUMP, ABDOMINAL APPROACH $543.41 20060701 99999999 57550 EXCISION OF CERVICAL STUMP, VAGINAL APPROACH $314.73 20060701 99999999 57555 EXCISION OF CERVICAL STUMP, VAGINAL APPROACH $500.69 20060701 99999999 57556 EXCISION OF CERVICAL STUMP, VAGINAL APPROACH $464.27 20060701 99999999 57558 DILATION AND CURETTAGE OF CERVICAL STUMP $77.77 20070101 99999999 57700 CERCLAGE OF UTERINE CERVIX (TRACHELOPLASTY) $178.52 20060701 99999999 57720 TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL $210.64 20060701 99999999 57800 DILATION OF CERVICAL CANAL, INSTRUMENTAL (SEPARATE $31.10 20060701 99999999 57820 DILATION AND CURETTAGE OF CERVICAL STUMP $112.36 20030401 99999999 58100 ENDOMETRIAL BIOPSY, SUCTION TYPE (SEPARATE PROCEDURE) $56.43 20060701 99999999 58110 ENDOMETRIAL SAMPLING (BIOPSY) PERFORMED IN CONJUNCTION WITH COLPOSCOPY (LIST SEP $30.14 20060701 99999999 58120 DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC $173.40 20060701 99999999 58140 MYOMECTOMY, EXCISION OF FIBROID TUMOR OF UTERUS, $663.23 20060701 99999999 58145 MYOMECTOMY, EXCISION OF FIBROID TUMOR OF UTERUS, $436.81 20060701 99999999 58146 MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR MORE INTRAMURAL MYOMAS $806.36 20060701 99999999 58150 TOTAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL $837.47 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 199
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