Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 15740 GRAFT $566.13 20060701 99999999 15750 GRAFT $656.13 20060701 99999999 15756 FREE MUSCLE FLAP WITH/WITHOUT SKIN GRAFT WITH MICROVASCULAR ANASTOMOSIS $2,178.00 20060701 99999999 15757 FREE SKIN FLAP WITH MICROVASCULAR ANASTOMOSIS $1,857.70 20060701 99999999 15758 FREE FASCIAL FLAP WITH MICROVASCULAR ANASTOMOSIS $1,852.23 20060701 99999999 15760 GRAFT $464.80 20060701 99999999 15770 GRAFT $435.90 20060701 99999999 15775 PUNCH GRAFT FOR HAIR TRANSPLANT $187.41 20030401 99999999 15776 PUNCH GRAFT FOR HAIR TRANSPLANT $262.26 20030401 99999999 15780 DERMABRASION $387.47 20060701 99999999 15781 DERMABRASION $252.70 20060701 99999999 15782 DERMABRASION $270.65 20060701 99999999 15783 DERMABRASION SUPERFICIAL ANY SITE(EG TATTOO REMOVAL) $208.75 20060701 99999999 15786 ABRASION $81.74 20060701 99999999 15787 ABRASION $14.18 20060701 99999999 15788 CHEMICAL PEEL, FACIAL; EPIDERMAL $127.82 20060701 99999999 15789 CHEMICAL PEEL, FACIAL; DERMAL $237.35 20060701 99999999 15792 CHEMICAL PEEL, NONFACIAL; EPIDERMAL $157.54 20060701 99999999 15793 CHEMICAL PEEL, NONFACIAL; DERMAL $199.60 20060701 99999999 15810 SALABRASION $259.01 19990701 99999999 15811 SALABRASION $281.82 19990701 99999999 15819 CERVICOPLASTY $502.17 20060701 99999999 15820 BLEPHAROPLASTY, LOWER EYELID $330.78 20060701 99999999 15821 BLEPHAROPLASTY, LOWER EYELID $362.61 20060701 99999999 15822 BLEPHAROPLASTY, UPPER EYELID $292.82 20060701 99999999 15823 BLEPHAROPLASTY, UPPER EYELID $432.04 20060701 99999999 15830 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, $766.11 20070101 99999999 15831 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING $633.41 19990701 99999999 15832 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING $592.70 20060701 99999999 15833 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING $530.86 20060701 99999999 15834 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING $533.13 20060701 99999999 15835 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING $547.68 20060701 99999999 15836 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING $459.86 20060701 99999999 15837 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING $441.37 20060701 99999999 15838 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING $387.09 20060701 99999999 15839 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING $398.25 20060701 99999999 15840 GRAFT FOR FACIAL NERVE PARALYSIS $770.34 20060701 99999999 15841 GRAFT FOR FACIAL NERVE PARALYSIS $1,189.02 20060701 99999999 15842 GRAFT FOR FACIAL NERVE PARALYSIS $1,977.93 20060701 99999999 15845 GRAFT FOR FACIAL NERVE PARALYSIS $724.64 20060701 99999999 15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL), $31.93 20060701 99999999 15852 DRESSING CHANGE (FOR OTHER THAN BURNS) UNDER ANESTHESIA $33.43 20060701 99999999 15860 INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST $92.57 20060701 99999999 15920 EXCISION, COCCYGEAL PRESSURE ULCER, WITH COCCYGECTOMY $361.18 20060701 99999999 15922 EXCISION, COCCYGEAL PRESSURE ULCER, WITH COCCYGECTOMY $492.19 20060701 99999999 15931 EXCISION, SACRAL PRESSURE ULCER, WITH PRIMARY SUTURE $401.71 20060701 99999999 15933 EXCISION, SACRAL PRESSURE ULCER, WITH PRIMARY SUTURE $549.95 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 100
PROC-CODE DESC MAC BEG END 15934 EXCISION, SACRAL PRESSURE ULCER, WITH LOCAL OR REGIONAL SKIN $617.36 20060701 99999999 15935 EXCISION, SACRAL PRESSURE ULCER, WITH LOCAL OR REGIONAL SKIN $759.23 20060701 99999999 15936 EXCISION, SACRAL PRESSURE ULCER, WITH OTHER FLAP CLOSURE $663.09 20060701 99999999 15937 EXCISION, SACRAL PRESSURE ULCER, WITH OTHER FLAP CLOSURE $788.36 20060701 99999999 15940 EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE $418.63 20060701 99999999 15941 EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE $588.18 20060701 99999999 15944 EXCISION, ISCHIAL PRESSURE ULCER, WITH LOCAL OR REGIONAL $613.04 20060701 99999999 15945 EXCISION, ISCHIAL PRESSURE ULCER, WITH LOCAL OR REGIONAL $694.45 20060701 99999999 15946 EXCISION, ISCHIAL PRESSURE ULCER, WITH OSTECTOMY, WITH $1,113.06 20060701 99999999 15950 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMARY SUTURE $347.78 20060701 99999999 15951 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMARY SUTURE $558.81 20060701 99999999 15952 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH LOCAL ROTATION $558.50 20060701 99999999 15953 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH LOCAL ROTATION $648.71 20060701 99999999 15956 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH MUSCLE OR $894.46 20060701 99999999 15958 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH MUSCLE OR $892.28 20060701 99999999 16000 INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL $32.04 20060701 99999999 16010 DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUENT $32.76 20030401 99999999 16015 DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUENT $117.01 20030401 99999999 16020 DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUENT $34.39 20060701 99999999 16025 DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUENT $69.98 20060701 99999999 16030 DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUENT $81.33 20060701 99999999 16035 ESCHAROTOMY $209.68 20060701 99999999 16036 ESCHAROTOMY; EACH ADDITIONAL INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR P $59.53 20060701 99999999 17000 DESTRUCTION BY ANY METHOD, INCLUDING LASER, WITH OR WITHOUT SURGICAL CURETTEMENT $27.90 20060701 99999999 17003 DESTRUCTION BY ANY METHOD, INCLUDING LASER, WITH OR WITHOUT SURGICAL CURETTEMENT $6.38 20060701 99999999 17004 DESTRUCTION BY ANY METHOD, INCLUDING LASER, WITH OR WITHOUT SURGICAL CURETTEMENT $115.15 20060701 99999999 17106 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); L $195.41 20060701 99999999 17107 DESTRUCT. OF CUTANEOUS VASC. PROLIFERATIVE LESIONS 10.0-50.0 $361.72 20060701 99999999 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS 17108 (EG, LASER TECHNIQUE); O $635.22 20060701 99999999 17110 DESTRUCTION BY ANY METHOD OF FLAT (PLANE, JUVENILE) WARTS $33.45 20060701 99999999 17111 DESTRUCTION BY ANY METHOD OF FLAT WARTS, MOLLUSCUM CONTAGIOSUM, OR MILIA; 15 OR $42.40 20060701 99999999 17250 CHEMICAL CAUTERIZATION OF A WOUND $21.11 20060701 99999999 17260 DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER $41.16 20060701 99999999 17261 DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER $52.31 20060701 99999999 17262 DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER $70.21 20060701 99999999 17263 DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER $80.98 20060701 99999999 17264 DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER $88.91 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 101
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