Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 58673 LAPAROSCOPY, SURGICAL; WITH SALPINGOSTOMY (SALPINGONEOSTOMY) $583.63 20060701 99999999 58700 SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL $453.95 20060701 99999999 58720 SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR $537.32 20060701 99999999 58740 LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) $531.20 20060701 99999999 58750 TUBOTUBAL ANASTOMOSIS $636.11 20060701 99999999 58752 TUBOUTERINE IMPLANTATION $638.01 20060701 99999999 58760 FIMBRIOPLASTY $555.89 20060701 99999999 58770 SALPINGOSTOMY (SALPINGONEOSTOMY) $592.06 20060701 99999999 58800 DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL, (SEPARATE $221.06 20060701 99999999 58805 DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL, (SEPARATE $329.00 20060701 99999999 58820 DRAINAGE OF OVARIAN ABSCESS $209.31 20060701 99999999 58822 DRAINAGE OF OVARIAN ABSCESS $426.98 20060701 99999999 58823 DRAINAGE OF PELVIC ABSCESS, TRANSVAGINAL OR TRANSRECTAL APPROACH, PERCUTANEOUS ( $179.53 20060701 99999999 58825 TRANSPOSITION OVARY(S) $421.25 20060701 99999999 58900 BIOPSY OF OVARY, UNILATERAL OR $314.19 20060701 99999999 58920 WEDGE RESECTION OR BISECTION OF OVARY, UNILATERAL OR $426.37 20060701 99999999 58925 OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL $521.74 20060701 99999999 58940 OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL $379.92 20060701 99999999 58943 OOPHORECTOMY PARTIAL OR TOTAL UNILAT OR BILAT OVARIAN MALIGN $870.14 20060701 99999999 58950 RESECTION OF OVARIAN MALIGNANCY WITH BILATERAL $747.59 20060701 99999999 58951 RESECTION OF OVARIAN MALIGNANCY W/BILAT SALPINGO- OOPHORECTOM $1,090.58 20060701 99999999 58952 RESECTION OF OVARIAN MALIGNANCY WITH BILATERAL $1,196.09 20060701 99999999 58953 BILATERAL SALPINGO-OOPHORECTOMY WITH OMENTECTOMY, TOTAL ABDOMINAL HYSTERECTOMY A $1,357.80 20060701 99999999 58954 BILATERAL SALPINGO-OOPHORECTOMY WITH OMENTECTOMY, TOTAL ABDOMINAL HYSTERECTOMY A $1,475.09 20060701 99999999 58956 BILATERAL SALPINGO-OOPHORECTOMY WITH TOTAL OMENTECTOMY, TOTAL ABDOMINAL $968.79 20060701 99999999 58957 RESECTION (TUMOR DEBULKING) OF RECURRENT OVARIAN, TUBAL, PRIMARY PERITONEAL, UTE $970.86 20070101 99999999 58958 RESECTION (TUMOR DEBULKING) OF RECURRENT OVARIAN, TUBAL, PRIMARY PERITONEAL, UTE $1,073.86 20070101 99999999 58960 LAPAROTOMY, FOR STAGING OR RESTAGING OF OVARIAN MALIGNANCY $753.90 20060701 99999999 58970 FOLLICLE PUNCTURE FOR OOCYTE RETRIEVAL ANY METHOD $163.09 20060701 99999999 58976 GAMETE INTRAFALLOPIAN TRANSFER ANY METHOD $177.29 20060701 99999999 58982 LAPAROSCOPY FOR VISUALIZATION OF PELVIC VISCERA $600.00 19990701 99999999 58999 UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL) $375.03 19990701 99999999 59000 AMNIOCENTESIS FOR DIAGNOSIS, ABDOMINAL APPROACH $60.73 20060701 99999999 59001 AMNIOCENTESIS; THERAPEUTIC AMNIOTIC FLUID REDUCTION (INCLUDES ULTRASOUND GUIDANC $123.09 20060701 99999999 59012 CORDOCENTESIS INTRAUTERINE ANY METHOD $163.11 20060701 99999999 59015 CHORIONIC VILLUS SAMPLING $95.59 20060701 99999999 59020 FETAL OXYTOCIN STRESS TEST $53.69 20060701 99999999 59025 FETAL NON-STRESS TEST $32.85 20060701 99999999 59030 FETAL SCALP BLOOD SAMPLING $94.55 20060701 99999999 59050 INITIATION AND/OR SUPERVISION OF INTERNAL FETAL $44.20 20060701 99999999 59051 FETAL MONITORING DURING LABOR BY CONSULTING PHYSICIAN (IE, NON-ATTENDING PHYSICI $39.07 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 202
PROC-CODE DESC MAC BEG END 59070 TRANSABDOMINAL AMNIOINFUSION, INCLUDING ULTRASOUND GUIDANCE $301.72 20060701 99999999 59072 FETAL UMBILICAL CORD OCCLUSION, INCLUDING ULTRASOUND GUIDANCE $351.19 20060701 99999999 59074 FETAL FLUID DRAINAGE (EG, VESICOCENTESIS, THORACOCENTESIS, PARACENTESIS), INCLUD $286.32 20060701 99999999 59076 FETAL SHUNT PLACEMENT, INCLUDING ULTRASOUND GUIDANCE $287.42 20060701 99999999 59100 HYSTEROTOMY, ABDOMINAL, FOR REMOVAL OF HYDATIDIFORM MOLE $511.91 20060701 99999999 59120 SURGICAL TREATMENT OF ECTOPIC PREGNANCY $546.28 20060701 99999999 59121 SURGICAL TREATMENT OF ECTOPIC PREGNANCY $511.29 20060701 99999999 59130 SURGICAL TREATMENT OF ECTOPIC PREGNANCY $619.91 20060701 99999999 59135 SURGICAL TREATMENT OF ECTOPIC PREGNANCY $673.89 20060701 99999999 59136 SURG TX ECTPC PREG INTERSTITIAL IUP PARTIAL RESECT $587.66 20060701 99999999 59140 SURGICAL TREATMENT OF ECTOPIC PREGNANCY $289.90 20060701 99999999 59150 LAPAROSCOP TRMT ECTP PREG W/O SALPINGEST OOPHOREC $468.62 20060701 99999999 59151 LAPAROSCOP TRMT ECTP PREG W SALPINGEST OOPHORECT $465.12 20060701 99999999 59160 DILATION AND CURETTAGE FOR POSTPARTUM HEMORRHAGE (SEPARATE $158.35 20060701 99999999 59200 INSERTION OF HYGROSCOPIC CERVICAL DILATOR (EG, LAMINARIA) $29.09 20060701 99999999 59300 EPISIOTOMY OR VAGINAL REPAIR ONLY, BY OTHER THAN ATTENDING $90.70 20060701 99999999 59320 CERCLAGE OF CERVIX DURING PREGNANCY VAGINAL $120.55 20060701 99999999 59325 CERCLAGE OF CERVIX DURING PREGNANCY ABDOMINAL $193.77 20060701 99999999 59350 HYSTERORRHAPHY OF RUPTURED UTERUS $228.36 20060701 99999999 59400 TOTAL OBSTETRIC CARE (ALL-INCLUSIVE, ''GLOBAL'' CARE) $1,113.88 20060701 99999999 59409 VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS); $620.40 20060701 99999999 59410 VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY, FORCEPS OR BREECH $684.96 20060701 99999999 59412 EXT CEPHALIC VERSION W OR W/O TOCOLYSIS IN ADD TO DELIVERY $86.93 20060701 99999999 59414 DELIVERY OF PLACENTA FOLLOWING DELIVERY OUTSIDE HOSP $82.49 20060701 99999999 59425 ANTEPARTUM CARE ONLY; 4-6 VISITS $256.60 20060701 99999999 59426 ANTEPARTUM CARE ONLY; 7 OR MORE VISITS $397.16 20060701 99999999 59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE) $84.38 20060701 99999999 59510 C.SECTION;ALL CARE & DELIVERY $1,500.00 20060701 99999999 59514 CAESAREAN DELIVERY ONLY; $930.03 20060701 99999999 59515 CESAREAN DELIVERY ONLY INCL POSTPARTUM CARE $1,000.00 20060701 99999999 59525 SUBTOTAL OR TOTAL HYSTERECTOMY POST CESAREAN DEL $355.67 20060701 99999999 59610 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL DELIVERY (WITH OR WITH $1,093.81 20060701 99999999 59612 VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH OR WITHOUT EPISIOT $673.80 20060701 99999999 59614 VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH OR WITHOUT EPISIOT $732.38 20060701 99999999 59618 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, CESAREAN DELIVERY, AND POSTPAR $1,233.70 20060701 99999999 59620 CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESA $784.68 20060701 99999999 59622 CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESA $847.42 20060701 99999999 59812 SPONTANEOUS ABORTION ANY TRI COMPLETED SURGICALLY $187.22 20060701 99999999 59820 TREATMENT OF MISSED ABORTION, ANY TRIMESTER, COMPLETED MEDICALLY $216.21 20060701 99999999 59821 MISSED ABORTION SECOND TRIMESTER COMP SURG $214.16 20060701 99999999 59830 TREATMENT OF SEPTIC ABORTION $305.79 20060701 99999999 59840 LEGAL (THERAPEUTIC) ABORTION, BY DILATION $172.92 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 203
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Medicaid Fee Schedule without Mods 200801

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