Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 11921 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE $94.79 20060701 99999999 11922 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE $24.44 20060701 99999999 11950 SUBCUTANEOUS INJECTION OF ''FILLING'' MATERIAL (EG, SILICONE) $49.49 20060701 99999999 11951 SUBCUTANEOUS INJECTION OF ''FILLING'' MATERIAL (EG, SILICONE) $61.95 20060701 99999999 11952 SUBCUTANEOUS INJECTION OF ''FILLING'' MATERIAL (EG, SILICONE) $79.66 20060701 99999999 11954 SUBCUTANEOUS INJECTION OF ''FILLING'' MATERIAL (EG, SILICONE) $84.89 20060701 99999999 11960 INSERTION OF TISSUE EXPANDER(S) $537.58 20060701 99999999 11970 REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT PROSTHESIS $408.87 20060701 99999999 11971 REMOVAL OF TISSUE EXPANDER W/O INSERTION OF PROSTHESIS $151.08 20060701 99999999 11975 INSERTION OR REINSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES $41.56 19990701 99999999 11976 REMOVAL WITHOUT REINSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES $81.91 20060701 99999999 11980 SUBCUTANEOUS HORMONE PELLET IMPLANTATION (IMPLANTATION OF ESTRADIOL AND/OR TESTO $59.48 20060701 99999999 11981 INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT $82.56 20060701 99999999 11982 REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT $99.44 20060701 99999999 11983 REMOVAL WITH REINSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT $160.16 20060701 99999999 12001 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, $70.95 20060701 99999999 12002 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, $79.78 20060701 99999999 12004 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, $98.58 20060701 99999999 12005 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, $125.76 20060701 99999999 12006 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, $164.67 20060701 99999999 12007 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, $181.57 20060701 99999999 12011 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, $75.59 20060701 99999999 12013 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, $88.07 20060701 99999999 12014 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, $106.74 20060701 99999999 12015 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, $138.00 20060701 99999999 12016 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, $175.13 20060701 99999999 12017 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, $260.29 20060701 99999999 12018 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, $302.17 20060701 99999999 12020 TREATMENT OF SUPERFICIAL WOUND DEHISCENCE $118.68 20060701 99999999 12021 TREATMENT OF SUPERFICIAL WOUND DEHISCENCE $82.03 20060701 99999999 12031 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR $84.41 20060701 99999999 12032 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR $104.83 20060701 99999999 12034 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR $129.95 20060701 99999999 12035 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR $155.98 20060701 99999999 12036 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR $192.39 20060701 99999999 12037 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR $229.67 20060701 99999999 12041 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR $92.51 20060701 99999999 12042 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR $107.80 20060701 99999999 12044 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR $140.61 20060701 99999999 12045 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR $168.06 20060701 99999999 12046 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR $206.57 20060701 99999999 12047 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR $245.67 20060701 99999999 12051 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, $98.88 20060701 99999999 12052 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, $110.21 20060701 99999999 12053 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, $140.57 20060701 99999999 12054 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, $166.93 20060701 99999999 12055 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, $214.30 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 96
PROC-CODE DESC MAC BEG END 12056 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, $274.67 20060701 99999999 12057 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, $318.20 20060701 99999999 13100 REPAIR, COMPLEX, TRUNK $134.38 20060701 99999999 13101 REPAIR, COMPLEX, TRUNK $162.04 20060701 99999999 13102 REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITIO $52.41 20060701 99999999 13120 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS $139.51 20060701 99999999 13121 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS $179.03 20060701 99999999 13122 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS (LIST SE $60.73 20060701 99999999 13131 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, $159.07 20060701 99999999 13132 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, $252.72 20060701 99999999 13133 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS $92.13 20060701 99999999 13150 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS $176.14 20060701 99999999 13151 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS $190.43 20060701 99999999 13152 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS $279.51 20060701 99999999 13153 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS ( $100.38 20060701 99999999 13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, $456.31 20060701 99999999 13300 REPAIR, UNUSUAL, COMPLICATED, OVER 7.5 CM, ANY AREA $278.20 19990701 99999999 14000 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK $283.54 20060701 99999999 14001 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK $407.78 20060701 99999999 14020 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, $345.56 20060701 99999999 14021 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, $491.98 20060701 99999999 14040 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, $373.29 20060701 99999999 14041 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, $503.33 20060701 99999999 14060 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, $469.81 20060701 99999999 14061 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, $562.06 20060701 99999999 14300 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, MORE THAN 30 SQ CM, $646.26 20060701 99999999 14350 FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION OF RECIPIENT SITE $468.19 20060701 99999999 15000 EXCISIONAL PREPARATION OR CREATION OF RECIPIENT SITE BY $187.57 19990701 99999999 15001 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, B $43.86 19990701 99999999 15002 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, B $146.40 20070101 99999999 15003 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, B $29.76 20070101 99999999 15004 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, B $180.95 20070101 99999999 15005 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, B $59.52 20070101 99999999 15040 HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS $87.56 20060701 99999999 15050 PINCH GRAFT, SINGLE OR MULTIPLE, TO COVER SMALL $237.75 20060701 99999999 15100 SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/OR FEET $429.21 20060701 99999999 15101 SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/OR FEET $88.76 20060701 99999999 15110 EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR ONE PERCENT $465.83 20060701 99999999 15111 EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDIT $74.58 20060701 99999999 15115 EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, $480.32 20060701 99999999 15116 EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, $101.82 20060701 99999999 15120 SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS, $483.63 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 97
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