Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 58152 TOTAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL $764.59 20060701 99999999 58180 SUPRACERVICAL HYSTERECTOMY (SUBTOTAL HYSTERECTOMY), WITH OR $710.45 20060701 99999999 58200 TOTAL HYSTERECTOMY, INCLUDING PARTIAL VAGINECTOMY, WITH LIMITED $991.85 20060701 99999999 58210 RADICAL HYSTERECTOMY, WITH BILATERAL TOTAL PELVIC AND LIMITED $1,320.62 20060701 99999999 58240 PELVIC EXENTERATION FOR GYNECOLOGIC MALIGNANCY, WITH $1,849.01 20060701 99999999 58260 VAGINAL HYSTERECTOMY $591.29 20060701 99999999 58262 VAGINAL HYSTERECTOMY; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S) $652.63 20060701 99999999 58263 VAGINAL HYSTERECTOMY; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF E $712.17 20060701 99999999 58267 VAGINAL HYSTERECTOMY $722.94 20060701 99999999 58270 VAGINAL HYSTERECTOMY $650.62 20060701 99999999 58275 VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL COLPECTOMY $714.50 20060701 99999999 58280 VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL COLPECTOMY $720.14 20060701 99999999 58285 VAGINAL HYSTERECTOMY, RADICAL (SCHAUTA TYPE OPERATION) $864.51 20060701 99999999 58290 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; $807.83 20060701 99999999 58291 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; WITH REMOVAL OF TUBE(S) $888.17 20060701 99999999 58292 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; WITH REMOVAL OF TUBE(S) $940.29 20060701 99999999 58293 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; WITH COLPO-URETHROCYSTO $977.19 20060701 99999999 58294 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; WITH REPAIR OF ENTEROCE $866.46 20060701 99999999 58300 INSERTION OF INTRAUTERINE DEVICE (IUD) $51.59 19990701 99999999 58301 REMOVAL OF INTRAUTERINE DEVICE (IUD) $47.15 20060701 99999999 58321 ARTIFICIAL INSEMINATION; INTRA-CERVICAL $43.74 20030401 99999999 58322 ARTIFICIAL INSEMINATION; INTRA-UTERINE $49.67 20030401 99999999 58323 SPERM WASHING FOR ARTIFICIAL INSEMINATION $10.61 20030401 99999999 58340 INJECTION PROCEDURE FOR HYSTEROSALPINGOGRAPHY $38.69 20060701 99999999 58345 TRANSCERVICAL INTRODUCTION OF FALLOPIAN TUBE CATHETER FOR DIAGNOSIS AND/OR RE-ES $213.03 20060701 99999999 58346 INSERTION OF HEYMAN CAPSULES FOR CLINICAL BRACHYTHERAPY $302.67 20060701 99999999 58350 HYDROTUBATION OF OVIDUCT, INCLUDING MATERIALS $56.65 20060701 99999999 58353 ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE $167.34 20060701 99999999 58356 ENDOMETRIAL CRYOABLATION WITH ULTRASONIC GUIDANCE, INCLUDING ENDOMETRIAL $272.46 20060701 99999999 58400 UTERINE SUSPENSION, WITH OR WITHOUT SHORTENING OF ROUND $334.02 20060701 99999999 58410 UTERINE SUSPENSION, WITH OR WITHOUT SHORTENING OF ROUND $551.60 20060701 99999999 58520 HYSTERORRHAPHY, REPAIR OF RUPTURED UTERUS (NONOBSTETRICAL) $503.86 20060701 99999999 58540 HYSTEROPLASTY, REPAIR OF UTERINE ANOMALY (STRASSMAN TYPE) $610.80 20060701 99999999 58541 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; $565.62 20070101 99999999 58542 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WIT $625.98 20070101 99999999 58543 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G $636.34 20070101 99999999 58544 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G $688.37 20070101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 200
PROC-CODE DESC MAC BEG END 58545 LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL $648.58 20060701 99999999 58546 LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR $818.05 20060701 99999999 58548 LAPAROSCOPY, SURGICAL, WITH RADICAL HYSTERECTOMY, WITH BILATERAL TOTAL PELVIC LY $1,203.89 20070101 99999999 58550 LAPAROSCOPY, SURGICAL; WITH VAGINAL HYSTERECTOMY WITH OR WITHOUT REMOVAL OF TUBE $659.77 20060701 99999999 58551 LAPAROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA (SINGLE OR MULTIPLE) $582.41 20000101 99999999 58552 LAPAROSCOPY SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRAMS OR LESS; W $631.57 20060701 99999999 58553 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GR $813.79 20060701 99999999 58554 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GR $806.59 20060701 99999999 58555 HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE) $147.79 20060701 99999999 58558 HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY $215.73 20060701 99999999 58559 HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD) $275.75 20060701 99999999 58560 HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY M $304.09 20060701 99999999 58561 HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA $426.54 20060701 99999999 58562 HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY $212.31 20060701 99999999 58563 HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (ANY METHOD) $285.73 20060701 99999999 58565 HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE $336.69 20060701 99999999 58570 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; $460.67 20080101 99999999 58571 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH R $504.43 20080101 99999999 58572 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; $570.28 20080101 99999999 58573 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; W $643.31 20080101 99999999 58600 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL $224.12 20060701 99999999 58605 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL $203.59 20060701 99999999 58611 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT THE TIME OF $29.69 19990701 99999999 58615 OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE (EG, BAND, CLIP, FALOPE RING) $205.58 20060701 99999999 58660 LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEP $500.64 20060701 99999999 58661 LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPH $510.94 20060701 99999999 58662 LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PEL $508.46 20060701 99999999 58670 LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION $288.81 20060701 99999999 58671 LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY DEVICE (EG, BAND, CLIP, OR $298.17 20060701 99999999 58672 LAPAROSCOPY, SURGICAL; WITH FIMBRIOPLASTY $548.34 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 201
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Medicaid Fee Schedule without Mods 200801

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