Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 15121 SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS, $146.33 20060701 99999999 15130 DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR ONE PERCENT OF $376.74 20060701 99999999 15131 DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITION $60.44 20060701 99999999 15135 DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HA $521.45 20060701 99999999 15136 DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HA $61.08 20060701 99999999 15150 TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25 SQ CM OR LESS $414.81 20060701 99999999 15151 TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; ADDITIONAL 1 SQ CM TO 75 $80.49 20060701 99999999 15152 TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ C $100.51 20060701 99999999 15155 TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, OR $446.71 20060701 99999999 15156 TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, OR $112.17 20060701 99999999 15157 TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, OR $122.23 20060701 99999999 15170 ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR ONE $205.07 20060701 99999999 15171 ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR E $60.74 20060701 99999999 15175 ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, G $307.59 20060701 99999999 15176 ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, G $96.08 20060701 99999999 15200 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE $382.18 20060701 99999999 15201 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE $72.61 20060701 99999999 15220 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE $395.06 20060701 99999999 15221 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE $65.26 20060701 99999999 15240 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE $460.84 20060701 99999999 15241 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE $102.79 20060701 99999999 15260 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR $676.17 20060701 99999999 15261 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR $122.51 20060701 99999999 15300 ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM O $174.50 20060701 99999999 15301 ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS, LEGS; EACH ADDITIONAL 1 $39.54 20060701 99999999 15320 ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS, MOUTH, NECK, E $202.83 20060701 99999999 15321 ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS, MOUTH, NECK, E $59.03 20060701 99999999 15330 ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR ONE P $174.22 20060701 99999999 15331 ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EAC $39.54 20060701 99999999 15335 ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GEN $194.60 20060701 99999999 15336 ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GEN $56.48 20060701 99999999 15340 TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE; FIRST 25 SQ CM OR LESS $180.64 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 98
PROC-CODE DESC MAC BEG END 15341 TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE; EACH ADDITIONAL 25 SQ CM $19.57 20060701 99999999 15342 APPLICATION OF BILAMINATE SKIN SUBSTITUTE/NEODERMIS; 25 SQ CM $63.77 20041001 99999999 15343 APPLICATION OF BILAMINATE SKIN SUBSTITUTE/NEODERMIS; EACH ADDITIONAL 25 SQ CM (L $13.92 20030401 99999999 15350 APPLICATION OF ALLOGRAFT (HOMOGRAFT), SKIN $212.91 20030401 99999999 15351 APPLICATION OF ALLOGRAFT, SKIN; EACH ADDITIONAL 100 SQ CM (LIST SEPARATELY IN AD $41.67 19990701 99999999 15360 TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE; TRUNK, ARMS, LEGS; FIRST 100 SQ CM $194.15 20060701 99999999 15361 TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE; EACH ADDITIONAL 100 SQ CM, OR EACH $45.05 20060701 99999999 15365 TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, EYELIDS, MOUTH, NECK, $204.97 20060701 99999999 15366 TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, EYELIDS, MOUTH, NECK, $56.67 20060701 99999999 15400 APPLICATION OF XENOGRAFT (HETEROGRAFT), SKIN $201.29 20060701 99999999 15401 1 $41.67 20060701 99999999 15420 XENOGRAFT SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS, MOUT $231.97 20060701 99999999 15421 XENOGRAFT SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS, MOUT $59.87 20060701 99999999 15430 ACELLULAR XENOGRAFT IMPLANT; FIRST 100 SQ CM OR LESS, OR ONE PERCENT OF BODY ARE $346.25 20060701 99999999 15570 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; TRUNK $447.63 20060701 99999999 15572 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; SCALP, ARMS, OR $435.42 20060701 99999999 15574 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; FOREHEAD, CHEEKS $471.48 20060701 99999999 15576 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, E $393.68 20060701 99999999 15580 PRIMARY ATTACHMENT OF OPEN OR TUBED PEDICLE FLAP TO RECIPIENT $403.57 19990701 99999999 15600 INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELAY'' OF SMALL FLAP, $126.11 20060701 99999999 15610 INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELAY'' OF SMALL FLAP, $150.11 20060701 99999999 15620 INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELAY'' OF SMALL FLAP, $185.18 20060701 99999999 15625 INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELAY'' OF SMALL FLAP, $102.37 19990701 99999999 15630 INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELAY'' OF SMALL FLAP, $204.34 20060701 99999999 15650 TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (EG, ABDOMEN TO $239.36 20060701 99999999 15731 FOREHEAD FLAP WITH PRESERVATION OF VASCULAR PEDICLE (EG, AXIAL PATTERN FLAP, PAR $614.89 20070101 99999999 15732 MUSCLE MYOCUTANEOUS OR FASCIOCUTANEOUS FLAP HEAD OR NECK $723.46 20070101 99999999 15732 MUSCLE MYOCUTANEOUS OR FASCIOCUTANEOUS FLAP HEAD OR NECK $752.66 20060701 99999999 15734 MUSCLE MYOCUTANEOUS OR FASCIOCUTANEOUS FLAP TRUNK $1,167.22 20060701 99999999 15736 MUSCLE MYOCUTANEOUS OR FASCIOCUTANEOUS FLAP UPPER EXTREMITY $903.23 20060701 99999999 15738 MUSCLE MYOCUTANEOUS OR FASCIOCUTANEOUS FLAP LOWER EXTREMITY $904.33 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 99
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