Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois

Healthcare and Family Services 

Practitioner Fee Schedule Key 

For charges submitted by Physicians, Advanced Practice Nurses, Imaging 

Centers, Portable X-ray Companies, School-Based/Linked Health Centers, Local 

Health Departments, Encounter Rate Clinics, Independent Laboratories, 

Fee-For-Service Hospitals, and Optometrists and Dentists Providing Medical 

Services 

Revised 04-01-09 

*95951 appears on the fee schedule twice; © indicates child professional and technical 

components, (A) indicates adult professional and technical components 

HCPCS 

Note 

COLUMN 

HEADING 

A 

B 

C 

COLUMN DESCRIPTION 

CPT-4 or HCPCS Procedure Code 

Special billing information applies to the code. 

Professional and Technical components are each reimbursed at 

50% of the state maximum. 

To bill quantities: Number of tests performed on a single date 

of service should be billed using the days/units field. When the 

quantity exceeds 5, the claim must be submitted on paper and 

must be accompanied by supporting documentation. 

Professional and technical components are each reimbursed at 

50% of the state maximum, rounded to the nearest cent. 

To bill quantities: 

For bilateral, submit the procedure code, use modifier 50, and 

show quantity “1” in days/units field. 

For multiples that are not bilateral, claims must be submitted on 

paper. Submit the procedure code on one service section, and 

in the next service section submit the unlisted procedure code for 

any quantity beyond the first, listing total number and name of 

additional tests in the description field, and attach documentation 

of all tests performed. 

Reimbursement for professional and technical components split 

at a rate other than 50%. 

To bill quantities: Claims for multiple quantities must be 

submitted on paper. Submit the procedure code on one service 

section, and in the next service section submit the unlisted 

procedure code for any quantity beyond the first, listing total 

number and name of additional tests in the description field, and 

attach documentation of all tests performed. 

1

D 

E 

F 

G 

H 

I 

J 

K 

L 

M 

N 

Code is billable by encounter rate clinic only. 

Vaccine is supplied through the Vaccines For Children (VFC) 

program. The department reimburses for the administrative cost 

(practice expense) of the vaccine only, for ages 0-18 years, as 

shown in the Unit Price column. 

Vaccine is not available through the VFC. The department 

reimburses for the vaccine when it is medically necessary. 

Vaccine is supplied for children, but not adults, through the VFC. 

The department reimburses for the administrative cost (practice 

expense) of the vaccine only, for ages 0-18 years, as shown in 

the Unit Price column, and for the vaccine for adults, ages 19 

years and older, as shown in the State Max column when 

medically necessary. 

CLIA “A” rate for the full test. 

CLIA “W” rate for the waived test. 

Covered only for blood lead draws as a Healthy Kids service for 

ages 0-20 years, and must be billed with the U1 modifier as 

documentation that the service meets this description. 

Prior approval required for surgeon and assistant surgeon. 

Anesthesia services for these codes must be billed using the 

anesthesia five-digit procedure code. 

Number of eyes tested should be billed using the days/units field; 

quantity is either 1 or 2. 

Age restricted to 9-26 years. Vaccine is supplied through the 

VFC Program for ages 9-18 years. The department reimburses 

VFC-enrolled providers for administrative cost (practice expense) 

as shown in the unit price column. The department reimburses 

for the vaccine for ages 19-26 years, and ages 9-26 years for 

non-VFC providers as shown in the State Max column. 

Additional information is provided at 

. 

Prior approval required for physician-purchased and 

administered drug. Prior approval guidelines are provided at 

. 

P 

Add-on applies only when the Primary Care Physician provides 

services. 

2

Q 

State maximum amount now includes the Maternal Child Health 

Add-on amount for all providers. 

Prog Cov 

Eff Date 

HP 

APL 

NDC Ind 

Surg Ind 

Program 

Coverage 

Effective 

Date 

Hand Price 

Indicator 

Ambulatory 

Procedure 

Listing 

NDC 

indicator 

Surgery 

Indicator 

M1 (26) Modifier 1 

(26) 

M2 (TC) Modifier 2 

(TC) 

02-Title XIX coverage only (limited Transitional Assistance 

coverage) 

04-Medicaid covered services 

09-Qualified Medicare Beneficiary (QMB) coverage only 

(See Chap 100 Section 120.12, posted on our website at 

. 

Effective date of codes added on or after 01/01/07 or date 

of change in payment policy. 

If “Y”, special pricing methodology is applied. 

Anesthesia: Claims may be submitted electronically or on 

paper following the billing guidelines posted on our 

website at 

. 

Medical/surgical procedure: Claims must be submitted on 

paper. The name of the procedure and total number of 

times performed must be submitted in the description field 

and the procedure note must be attached. 

To bill quantities: The number listed in the days/units 

field must be “1” and the actual quantity must be included 

in the description/note field. 

Drugs: May be submitted electronically or on paper. The 

claim must contain the name of the drug, strength of the 

drug, and the amount given in the description/note field 

and must be billed according to NDC billing guidelines 

available on our website at 

. 

To bill quantities: The number listed in the days/units 

field must be “1” and the actual quantity must be included 

in the description/note field. 

Column has been removed to allow addition of more 

pertinent information. APL information may be viewed on 

our website at 

. 

If “Y”, the 11-digit NDC must be billed according to NDC 

billing guidelines available on our website at 

. 

B = Obstetrical service 

N = Not considered surgical 

I = Incidental. Procedure may not pay separately when 

billed with other surgical codes. 

M = Major. Reimbursement for procedure includes 30- 

day postoperative care. 

Rate paid for the professional component of the 

procedure. 

Rate paid for the technical component of the procedure. 

3

Assist 

Surg 

Assistant 

Surgeon 

“Y” indicates services of an assistant at surgery may be 

paid. 

CoSurg Co-Surgeon “Y” indicates services of a co-surgeon may be paid. 

Unit Price 

Price for each unit when multiple quantities are billable or 

base amount payable for ages 0-20 years when followed 

by “©”. 

Max Qty Maximum 

Quantity 

The maximum quantity payable for the code. 

To bill quantities when the maximum quantity is 

greater than 1: 

Submit number of units performed or dispensed on a 

single date of service in the days/units field 

To bill quantities when the maximum quantity is 1, 

note field is blank, and HP is “N”: 

For bilateral procedures, submit the procedure code, use 

modifier “RT” and show quantity “1” in days/units field and 

in the subsequent service section submit the procedure 

code, use modifier “LT”, and show quantity “1” in 

days/units field. 

For multiples that are not bilateral, claims must be 

submitted on paper. Submit the procedure code on one 

service section, and in the next service section submit the 

unlisted procedure code for any quantity beyond the first, 

listing total # and name of additional procedures in the 

description field, and attach documentation of all 

State Max 

Add-ons 

State 

Maximum 

Surgical addon 

Child add-on 

Adult add-on 

procedures performed. 

The maximum allowable reimbursement (reflects 

combined professional and technical components where 

applicable). 

or base amount payable for ages 21 years and older 

when followed by “(A)”. 

Surg: The amount added to the state maximum when the 

procedure is performed in the practitioner’s office. This 

amount covers such items as casting and surgical 

supplies. 

Child: The amount added to the state maximum for 

services rendered to ages 0-20 years. Preventive 

medicine and Evaluation and Management code add-ons 

are payable only to Primary Care Providers. 

Adult: The amount added to the state maximum for 

services rendered to ages 21 years and older. Preventive 

medicine and Evaluation and Management code add-ons 

are payable only to Primary Care Providers. 

4

MODIFIERS RECOGNIZED IN PROCESSING ILLINOIS 

HEALTHCARE AND FAMILY SERVICE CLAIMS 

MODIFIER DESCRIPTION 

Updated 04/01/09 

HOW PAYMENT IS AFFECTED 

25 Significant, separately identifiable E&M service same physician same day May allow E&M payment separate from another service 

26 Professional component 

Pays professional component only (*see practitioner fee schedule, 

Notes A, B, C) 

50 Bilateral procedure 

Bill procedure code one time with modifier and quantity "1" to 

indicate bilaterals performed (*see practitioner fee schedule, Note 

B) 

51 Multiple procedures 

Applies only to billing multiple NDCs (**see Informational Notice to 

Physicians dated 12-21-07) 

52 Reduced services 

Goes to hand pricing, requires attachment of additional 

information 

53 Discontinued procedure Not payable; bill only for services completed 

59 Distinct procedural service Applies to Medicare crossovers only 

62 Two surgeons Each surgeon is paid at 50% state maximum 

73 Discontinued outpatient procedure prior to anesthesia administration Not payable; bill only for services completed 

74 Discontinued outpatient procedure after anesthesia administration Not payable; bill only for services completed 

76 Repeat procedure by same physician 

Applies only to billing multiple NDCs (**see Informational Notice to 

Physicians dated 12-21-07) 

80 Assistant surgeon Payment is based on minutes billed 

81 Minimum assistant surgeon Payment is based on minutes billed 

82 Assistant surgeon when qualified resident surgeon not available Payment is based on minutes billed 

90 Reference (outside) laboratory Not payable for APL or inpatient procedures 

91 Repeat clinical diagnostic laboratory test Applies to Medicare crossovers only 

AH Clinical psychologist Billable only by FQHC and RHC 

AJ Clinical social worker Billable only by FQHC and RHC 

AS 

Physician assistant, nurse practitioner, or clinical nurse specialist services for 

assistant at surgery 

Payment is based on minutes billed 

AT Acute Treatment 

Sterilization permit not required when procedure performed for 

acute reason and not for sterilization purposes 

Processes separately from same CPT with different eyelid 

E1 Upper left eyelid 

modifier

E2 

E3 

E4 

EP 

Lower left eyelid 

Upper right eyelid 

Lower right eyelid 

Service provided as part of medicaid early periodic screening diagnosis and 

treatment (EPSDT) program 


modifier 


modifier 


modifier 

Service is processed as a Healthy Kids service 

F1 Left hand, second digit Processes separately from same CPT with different digit modifier 

F2 Left hand, third digit Processes separately from same CPT with different digit modifier 

F3 Left hand, fourth digit Processes separately from same CPT with different digit modifier 

F4 Left hand, fifth digit Processes separately from same CPT with different digit modifier 

F5 Right hand, thumb Processes separately from same CPT with different digit modifier 

F6 Right hand, second digit Processes separately from same CPT with different digit modifier 

F7 Right hand, third digit Processes separately from same CPT with different digit modifier 

F8 Right hand, fourth digit Processes separately from same CPT with different digit modifier 

F9 Right hand, fifth digit Processes separately from same CPT with different digit modifier 

FA Left hand, thumb Processes separately from same CPT with different digit modifier 

FP Service provided as part of family planning program Service is processed as a family planning service 

GN Outpatient speech therapy See Therapists Provider Notice dated 061605 

GO Outpatient occupational therapy See Therapists Provider Notice dated 061605 

GP Outpatient physical therapy See Therapists Provider Notice dated 061605 

GZ Item or service expected to be denied as not reasonable and necessary Not payable 

HD Pregnant/parenting women's program Service is processed as a postpartum depression screening 

Inpatient/outpatient psychiatric consultation or inpatient psychiatric 

subsequent care rate (**see Physician Provider Notice dated 

HE Mental health program 

102903)

HO Masters degree level; added 060108 effective 10/22/07 Billable only by FQHC and RHC 

LC Left circumflex coronary artery 

Processes separately from same CPT with different coronary 

artery modifier 

LD Left anterior descending coronary artery 



LT Left side Processes separately from same CPT with RT modifier 

NU New equipment Processes as Purchase 

P1 Normal, healthy patient Anesthesia converts to modifying units "0" 

P2 Patient with mild systemic disease Anesthesia converts to modifying units "1" 

P3 Patient with severe systemic disease Anesthesia converts to modifying units "2" 

P4 Patient with severe systemic disease that is a constant threat to life Anesthesia converts to modifying units "3" 

P5 Moribund patient not expected to survive without the operation Anesthesia converts to modifying units "4" 

P6 

Declared brain-dead patient whose organs are being removed for donor 

purposes Anesthesia converts to modifying units "0" 

QL Patient pronounced dead after ambulance called Not payable 

QM Ambulance service provided under arrangement by a provider of services Not payable 

QW CLIA waived test 

Processes at the waived CLIA rate (*see practitioner fee 

schedule, Note I) 

RC Right coronary artery 



RR Rental Processes as rental 

RT Right side Processes separately from same CPT with LT modifier 

SL State supplied vaccine 

Processes HPV vaccine to Obstetricians not enrolled with VFC 

(**see Physician Provider Notice dated 061507) 

T1 Left foot, second digit Processes separately from same CPT with different digit modifier 

T2 Left foot, third digit Processes separately from same CPT with different digit modifier 

T3 Left foot, fourth digit Processes separately from same CPT with different digit modifier 

T4 Left foot, fifth digit Processes separately from same CPT with different digit modifier 

T5 Right foot, great toe Processes separately from same CPT with different digit modifier 

T6 Right foot, second digit Processes separately from same CPT with different digit modifier

T7 Right foot, third digit Processes separately from same CPT with different digit modifier 

T8 Right foot, fourth digit Processes separately from same CPT with different digit modifier 

T9 Right foot, fifth digit Processes separately from same CPT with different digit modifier 

TA Left foot, great toe Processes separately from same CPT with different digit modifier 

TC Technical component 

Pays technical component only (*see practitioner fee schedule, 

Notes A, B, C) 

TT Individualized service provided to more than one patient in same setting 

Processes as coincident visit Long Term care(**see Physician 

Provider Notice dated 102903) 

U1 Local modifier-Blood lead draw 

Blood specimen drawn for lead analysis as part of Healthy Kids 

program (***see Chapter HK-200 Section 202.1) 

U2 Local modifier-Home Health nursing assessment visit 

Processes as assessment visit only (***see Home Health 

Handbook Section R-203.1) 

U4 Local modifier-Pregnancy resulting from rape Claim requires abortion payment application HFS form 2390 

U6 Local modifier-Service provided within 60 days of hospital discharge 

Processes as therapy visit within 60 days of hospital 

discharge(***see Therapy Providers Handbook Section J-211) 

U7 Local modifier-Pregnancy resulting from incest Claim requires abortion payment application HFS form 2390 

U8 Local modifier-Pregnancy threatening the mother's life Claim requires abortion payment application HFS form 2390 

* Practitioner Fee Schedule is posted on our website at 

http://www.hfs.illinois.gov/feeschedule/ 

**Provider Informational Notices are posted on our website at 

http://www.hfs.illinois.gov/releases/ 

***Provider Handbooks are posted on our website at 

http://www.hfs.illinois.gov/handbooks/

Health Care and Family Services Revised 4/1/09 

Practitioner Fee Schedule 

Add-On's 

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult 

00102 04 Y M 


00104 02 N N 44.40 


00124 04 Y I 











0016T 04 Y Y 



Wednesday, April 01, 2009 Page 1 of 458




0017T 04 Y M 



0019T 04 Y I 

00210 04 Y M 

00211 04 1/1/2009 Y M 









0030T 04 Y N 










00404 04 Y M 


00410 04 N I 112.40 

0042T B 04 N N 141.22 141.22 282.45 







0048T 04 Y M Y 


0051T 04 Y M Y Y 


00522 04 Y I 



00529 04 Y N 


























00604 04 Y M 



00625 04 1/1/2007 Y M 

00626 04 1/1/2007 Y N 

0062T 04 N M 509.95 





0063T 04 Y M 






0073T 04 N N 364.51 








0075T 04 N I 83.00 



0077T 04 N M Y Y 449.50 

0078T 04 N M Y Y 1,148.60 









0080T 04 Y N 


0081T 04 Y M 



























00904 04 Y M 





























0095T 04 Y M Y 

0101T 04 Y M 

0102T 04 Y M 

01112 04 Y I 

01120 04 Y M 







































01404 04 Y M 




0143T 04 Y N 









0147T C 04 N N 21.37 88.48 109.85 















































01829 04 N M 356.10 





















01935 04 1/1/2008 Y M 

01936 04 1/1/2008 Y M 

















01996 04 N I 14.25 


0500F 04 N B 44.10 



10021 04 N I 49.80 





10080 04 N I 70.65. 








10180 04 N I Y 130.55 


11001 04 N I 20.85 

11004 04 N M Y Y 154.43 

11005 04 N M Y Y 154.43 








11042 04 N I Y Y 70.55 

11043 04 N M Y 170.55 





11100 04 N I 50.20 17.00 



















11401 04 N I 50.20 17.00 



















11450 04 N M Y 215.40 34.00 



11463 04 N M Y 232.20 










11606 04 N M 185.52 17.00 































11901 04 Y I 

11920 09 Y M Y Y 








11970 04 N M 475.70 

11971 04 N I Y Y 135.00 










12001 04 N I Y 53.10 17.00 






12011 04 N I 56.40 17.00 





12017 04 N M 259.20 17.00 

12018 04 N M 272.63 
























13100 04 N I 110.04 

















14001 04 N M 291.69 











15002 04 1/1/2007 Y M Y 


15004 04 1/1/2007 Y M Y 


15040 04 N M 71.01 



15101 04 Y M Y Y 

15110 04 N M 71.01 



15116 04 N M Y 84.01 


15121 04 Y M Y 


















15201 04 Y M Y 








15301 04 N M Y 32.90 








15336 04 N M Y 47.01 
























15731 04 1/1/2007 N M Y 168.27 







15756 04 N M Y Y 1,306.65 































15842 04 N M Y 1,063.03 







15852 04 N I Y 31.95 





































17003 04 N I 8.85 13 115.05 

17004 04 N I Y 86.59 





























17311 04 1/1/2007 N M 216.00 














19101 04 N M 192.85 34.00 

















19296 04 N I 109.01 




19301 04 1/1/2007 N M Y 310.80 

19302 04 1/1/2007 N M Y 601.45 



















19361 04 N M Y 609.80 
















20101 04 N M Y 599.35 


20103 04 N M Y 189.37 34.00 

20150 04 Y M Y 





















20555 04 1/1/2008 N I 176.10 





















20696 04 1/1/2009 N M Y 332.64 

20697 04 1/1/2009 N I 349.27 









20900 04 N M Y Y 224.70 


20910 04 Y M Y Y 


























20985 04 1/1/2008 N M Y 83.23 















21045 04 N M Y Y 1,678.65 



































Wednesday, April 01, 2009 

Page 40 of 458


































21209 04 N M Y Y 1,198.70 


21215 04 N M Y Y 1,048.85 










































21344 04 N M Y 1,048.85 

































































































22206 04 1/1/2008 N M Y Y 1270.13 





























22526 04 1/1/2007 N M 509.95 













































22856 04 1/1/2009 N M Y Y 925.00 



22862 04 1/1/2007 N M Y 1104.45 


















































































































23920 04 N M Y 1048.85 
































































24359 04 1/1/2008 N M Y 341.04 















































































































































25391 40 N M Y 898.95 













































25606 04 1/1/2007 N M 301.00 





25609 04 1/1/2007 N M 443.95 




25630 04 N M 201.10 















































































































































































































26755 04 N I 104.10 







































27041 04 N I Y 258.20 17.00 









27057 04 1/1/2009 N Y 374.55 









































































































































































































































































































































































































































































































































Wednesday, April 01, 2009 Page 101 of 458




































































































































































































30117 04 N I 109.30 






































30901 04 N I Y Y 74.90 

30903 04 N I Y Y 71.40 17.00 





30930 04 N I Y Y 90.10 











































































31527 04 N M Y Y 192.95 17.00 

31528 04 N I Y Y 192.95 17.00 









































31620 04 Y I 56.70 























































































32504 04 N M Y 1,203.13 


32550 04 1/1/2008 N M 127.01 318.46 
















































33015 04 N I 204.05 








































33240 04 Y I Y 







33254 04 1/1/2007 N M Y 2,397.40 




































































33508 04 N M Y Y 17.04 

























































33726 04 1/1/2007 N M 2,721.45 































33803 04 N M Y Y 1,501.75 























33884 04 N M Y Y 249.09 
























































34804 04 N M Y 904.75 





















35013 04 N M Y 1,198.70 

















































35301 04 N M Y 1101.60 




































































35535 04 1/1/2009 N M Y 1109.75 



















35572 04 N M Y Y 209.75 





































































































36415 J 04 N I 4.10 



36416 J 04 5/1/2007 N I 4.10 





























































































































































































































































































41019 04 1/1/2008 N I Y 259.65 
















41145 04 N M Y Y 1048.85 

























































































































42900 04 Y M Y Y 34.00 






















































43240 04 N I Y 201.55 


43242 04 N I Y 201.55 






43246 04 N I Y 249.70 56.70 




















































































43644 K 04 N M Y 942.28 

43645 K 04 N M Y 1017.05 












43770 K 04 N I Y 565.47 

43771 K 04 N I Y 652.01 







43825 04 N M Y YY 898.95 










43846 K 04 N M Y Y 770.00 




















































































































































































45320 04 N M Y 201.30 56.70 

































45395 04 N I Y 1015.28 


































































































46930 04 1/1/2009 N M 127.20 































































































48001 04 N M Y Y 801.90 















































49204 04 1/1/2008 N M Y 704.75 

































49440 04 1/1/2008 N I Y 133.76 465.96 




49450 04 1/1/2008 Y I Y 


































































































50385 04 1/1/2008 N M Y 137.81 572.99 

50386 04 1/1/2008 N M Y 104.23 356.14 



































50561 04 N I 301.85 56.70 










50593 04 1/1/2008 N M Y 267.81 2228.0 



































































51100 04 1/1/2008 N I 22.55 13.02 

51101 04 1/1/2008 N I 30.11 41.49 











































51798 A 04 N I 8.78 8.78 17.56 









































52282 04 N I 204.10 56.70 











































52920 04 Y Y 







53080 04 Y M 17.00 









53250 04 Y M 34.00 








































































































54401 09 Y M 









































































































56501 04 N I Y 52.70 17.00 


































































































































































































































59001 04 N B Y 89.80 



59020 C 04 N I 7.90 25.80 33.70 




















59200 04 N B 27.80 







59409 Q 04 4/1/2009 N B 924.45 

59410 Q 04 4/1/2009 N B 924.45 





59514 Q 04 4/1/2009 N B Y 1070.45 






59618 09 Y B 




















59898 09 Y B 

59899 04 Y B Y 









































































































































































































61798 04 1/1/2009 N N 1198.70 













































62201 04 N M Y Y 1048.85 














































63012 04 N M Y 1404.20 

































































































63621 04 1/1/2009 N M Y 201.37 




































































































































































































65114 04 N M 1048.85 




































































































































67041 04 1/1/2008 N M Y Y 613.65 











67113 04 1/1/2008 N M Y Y 809.66 







































































































































































































































































70030 A 04 N N 10.75 10.75 21.50 

70100 A 04 N N 11.40 11.40 22.80 
























70336 B 04 N N 148.30 148.30 296.60 











70450 B 04 N N 123.58 123.58 247.15 





70482 B 04 N N 54.92 54.92 109.95 
















70546 B 04 N N 204.77 204.78 409.55 



70549 B 04 N N 204.77 204.78 409.55 




70554 C 04 1/1/2007 N N 50.42 246.18 1 296.60 

70555 04 1/1/2007 N N 64.32 



70559 04 N N 88.02 
















71101 A 04 N N 12.40 12.40 24.80 







71270 B 04 N N 54.93 54.92 109.85 








































































73040 C 04 N I 6.03 17.47 23.50 

















73201 B 04 N N 37.95 37.95 75.90 


















































































































75557 C 04 1/1/2008 Y N 68.87 230.81 Y 299.68 


75559 C 04 1/1/2008 Y N 87.60 344.24 Y 431.84 


75561 C 04 1/1/2008 N N 76.18 325.65 Y 401.83 


75563 C 04 1/1/2008 Y N 90.99 404.09 Y 495.08 












































































































76150 B 04 Y N 


76376 C 04 N I 6.18 66.99 1 73.17 



76390 B 04 N I 148.30 148.30 296.60 

76496 A 04 Y I 

76497 B 04 Y I 

76498 B 04 Y I 









76514 C 04 N N 5.20 1.37 1 6.57 

























































76970 A 04 Y N 





77001 C 04 1/1/2007 N N 8.75 29.29 1 38.04 



77011 C 04 1/1/2007 N N 7.31 48.89 1 56.20 




77013 04 N N 233.70 








































77301 09 Y N 



















77399 09 Y N 1 






































77750 04 N N 105.98 35.32 141.30 

77761 04 N I 143.53 112.77 256.30 





77778 04 N I 146.47 62.78 209.25 

77785 04 1/1/2009 N 29.96 44.93 74.89 





















78099 04 Y N 









































78278 C 04 N N 9.64 32.26 41.90 























































































78804 C 04 N N 29.65 86.89 116.54 




78808 09 1/1/2009 Y 









79101 04 N N 57.30 







80047 04 10/1/2008 Y N 



80048 B 04 10/1/2008 N N 4.14 4.14 8.28 

80051 A 04 10/1/2008 N N 3.43 3.43 6.86 

80053 B 04 10/1/2008 N N 5.18 5.18 10.36 







80101 B 04 10/1/2008 N N 6.71 6.71 13.42 


80103 A 09 Y N 

80150 A 04 10/1/2008 N N 2.70 2.70 5.40 

















80176 A 04 10/1/2008 N N .86 .86 1.72 










80195 04 10/1/2008 N N 4.31 4.31 8.62 







80201 A 04 10/1/2008 N N 5.66 5.66 11.32 


80299 A 04 10/1/2008 Y N 











80418 B 04 10/1/2008 Y N 





















81003 A 04 10/1/2008 N N 1.09 1.09 2.18 

81005 A 04 10/1/2008 N N .86 .86 1.72 






81099 A 04 10/1/2008 Y N 





82009 A 04 10/1/2008 N N .86 .86 1.72 











82045 A 04 10/1/2008 Y N 







82104 B 04 10/1/2008 N N 3.58 3.58 7.16 






































82271 A 04 10/1/2008 N N 1.02 1.02 2.04 

82272 A 04 10/1/2008 N N 1.02 1.02 2.04 





82307 04 10/1/2008 N N 8.85 8.85 17.70 








































82491 B 04 10/1/2008 N N 6.09 6.09 12.18 















































































































83001 A 04 10/1/2008 N N 9.09 9.09 18.18 



















83037 04 10/1/2008 N N .74 .74 1.48 
























































83701 04 10/1/2008 N N 7.80 7.80 15.60 
























83876 B 04 1/1/2009 N N 5.68 5.68 11.36 




































































































































































































85044 04 N N 1.75 1.75 3.50 






























85301 B 04 10/1/2008 N N 5.29 5.29 10.58 


















































































































86317 09 Y 














































































86671 B 04 N N 8.01 8.01 16.02 















86701 B 04 3/1/2009 N N 6.48 6.48 12.96 


86703 B 04 3/1/2009 N N 10.01 10.01 20.02 


































































86891 04 N N 101.80 

















































87088 09 N Y 6.20 

























87181 B 04 N 6.20 











87206 B 04 N N 2.10 2.10 Y 4.20 


























































































































































87809 04 1/1/2008 N N 10.06 



87880 I 04 N N 4.20 



87880 H 04 N N 7.85 7.85 15.70 






87904 04 N N 32.44 9 291.96 


















88150 04 N N 1 3.50 




88155 04 N N 1 4.10 














88185 04 N N 1.05 24 25.20 







88230 B 04 N N 45.40 45.40 90..80 



















































88342 A 04 N N 6.72 6.72 Y 13.45 



















88381 C 04 1/1/2008 N N 31.82 83.72 115.54 

































90375 04 Y Y N 




90384 04 N Y N 107.70 

90385 04 N Y N 37.70 










90476 F 04 Y N 

90477 F 04 Y N 

90581 F 04 Y N 



90632 G 04 N N 6.40 56.15 

90633 E 04 N N 6.40 







90649 M 04 Y N 6.40 149.33 













90681 E 04 8/1/2008 N N 6.40 








90701 E 04 N N 6.40 

90702 F 04 N N 2.70 

90703 F 04 N N 1.85 1.85 

90704 F 04 Y N 























90735 F 04 N N 243.80 243.80 




90738 F 04 7/1/2008 Y 








90801 02 2/1/2009 N N 67.50 52.11 

90802 02 2/1/2009 N N 27.55 92.06 

90804 02 N N 27.55 

90805 02 N N 30.90 

90806 02 N N 47.50 

90807 02 N N 47.50 

90808 02 N N 64.80 

90809 02 N N 67.50 

90810 02 N N 31.70 

90811 02 N N 34.85 

90812 02 N N 47.50 

90813 02 N N 47.50 



90814 02 N N 63.45 

90815 02 N N 66.30 

90816 02 N N 31.65 

90817 02 N N 31.65 

90818 02 N N 47.50 

90819 02 N N 47.50 

90821 02 N N 65.90 

90822 02 N N 68.30 

90823 02 N N 33.30 

90824 02 N N 35.95 

90826 02 N N 47.50 

90827 02 N N 48.65 

90828 02 N N 65.05 

90829 02 N N 66.90 

90845 D 04 N N 


90847 02 N N 61.20 

90849 02 N N 61.20 

90853 02 N N 33.70 





90865 02 N N 63.40 


90875 02 N N 28.70 

90876 02 N N 47.50 





90899 02 Y N 

90901 09 Y I 







90951 04 1/1/2009 N I 252.35 

































91022 C 04 N N 42.72 75.37 1 118.09 











91110 C 04 N I 140.95 563.92 704.90 


















92025 C 04 N I 9.04 6.29 15.33 










92135 L 04 N I 26.35 26.35 52.70 
































92340 04 N N 30.09 












































































92601 04 N I 55.01 





























92953 04 Y I Y Y 






























93010 04 N I 11.05 5 55.25 









93040 A 04 N I 3.80 3.80 7.60 























93279 C 04 1/1/2009 N N 20.88 10.77 31.65 






















93299 04 1/1/2009 Y N 


93304 B 04 N I 26.50 26.50 53.00 


















93352 04 
















































































































94010 C 04 N I 7.65 29.75 37.40 

















































95004 04 N N 1.70 65 110.50 

95010 04 N N 6.60 65 429.00 












95071 04 N N 59.04 



























95803 04 1/1/2009 Y N 



























































95951 C 04 2/1/2009 N I 81.51 *© 326.05 *© 407.56 51.66 

95951 C 04 N I 71.18 *(A) 284.72 *(A) 355.90 


95954 C 04 N I 119.09 106.61 1 224.70 




















95980 04 1/1/2008 N I Y 22.92 















96040 04 8/1/2008 N N 40.20 








96125 09 1/1/2008 N N 46.07 7.81 










96361 04 1/1/2009 N N 152.90 8 1223.20 


96366 04 1/1/2009 N I 152.90 8 1223.20 









96375 04 1/1/2009 N I 27.98 2 55.96 








































































































98941 02 Y N 






































99199 04 Y I Y Y 

99201 P 04 2/1/2009 N N 27.95 1 27.95 1.60 1.60 

99202 P 04 2/1/2009 N N 32.00 1 32.00 1.60 1.60 


99204 P 04 2/1/2009 N N 66.40 1 66.40 3.25 3.25 




99211 P 04 2/1/2009 N N 12.30 1 12.30 .58 .58 




















99241 04 2/1/2009 N N 32.15 7.04 



99242 04 2/1/2009 N N 40.20 32.71 




























































99381 P 04 N N 32.15 59.75 




99385 P 04 2/1/2009 N N 32.15 C 66.40 (A) 72.81 38.56 

99386 P 04 2/1/2009 N N 66.40 38.56 

99387 P 04 2/1/2009 N N 66.40 38.56 




99391 P 04 N N 32.15 C 32.15 37.37 




99395 P 04 N N 32.15 C 42.50 A 53.50 43.15 







99460 04 1/1/2009 N 38.75 






99466 04 1/1/2009 Y I 













99480 04 2/1/2009 N 79.04 

















99999 04 Y N Y Y 

A4206 04 N N 0.13 5 0.65 



A4209 04 N N 0.26 5 1.30 




A4261 04 N N 61.17 



A4269 04 Y Y N 

A9502 09 Y N 




A9527 04 1/1/2007 Y N 













D1203 04 N N 26.00 

E0720 09 Y 

G0008 04 N N 3.70 

G0009 04 N N 3.70 

G0010 04 N N 3.70 

G0101 04 N I 32.86 

G0102 04 N I 28.35 

G0103 B 04 N N 8.80 8.80 17.60 

G0104 04 Y I 


G0108 09 Y N 

G0109 09 Y N 


G0117 04 Y I 





G0123 04 N N 3.50 





G0130 B 04 N N 48.52 48.52 97.05 







G0159 04 N M Y 449.50 




G0170 04 Y M Y Y 

G0173 04 Y M Y 









G0202 B 04 N N 35.95 35.95 71.90 

G0204 B 04 N N 35.95 35.95 71.90 



G0237 04 Y I 



G0245 09 Y N 






G0251 04 Y N Y Y 

G0252 04 N N 35.25 35.25 70.50 




G0256 04 N I 256.30 
















G0288 B 04 Y I 

G0289 04 Y M Y 

G0290 04 Y M Y 

G0291 04 Y N M Y 

G0293 09 Y M 





G0297 04 N M Y 256.00 

G0300 04 N M Y 470.00 

G0306 A 04 N N 2.69 2.69 5.39 




G0339 B 04 Y N Y 

G0340 B 04 Y N Y 

G0365 A 04 N I 25.03 25.02 50.05 

G0377 04 1/1/2007 N N 9.81 






G0392 04 1/1/2007 N M 479.00 

G0393 04 1/1/2007 N M 479.00 


G0402 09 1/1/2009 Y N 



G0412 04 1/1/2009 N Y 674.20 




G3001 04 Y Y N 

G9001 09 Y N 









G9010 09 Y N 


















G9033 09 Y Y N 
















































































H0033 04 N N 118.10 1 118.10 



H1000 04 N N 14.60 

J0120 04 N Y N 5.49 1 5.49 


J0129 04 1/1/2007 N Y N 22.98 75 1723.50 




J0150 04 N Y 39.55 5 197.75 




J0190 04 Y Y N 

J0200 04 Y Y N 

J0205 04 N Y N 44.74 8 357.92 


J0210 04 N N 0.83 16 13.28 

J0215 N 04 Y Y N 

J0220 04 1/1/2008 Y Y 







J0285 04 N Y N 17.36 6 104.16 






J0300 04 Y N 

J0348 04 1/1/2007 Y Y N 


J0360 04 N Y N 15.92 12 191.04 

J0364 04 1/1/2007 N Y N 4.95 6 29.70 


J0370 04 N Y N 1.85 




J0400 04 1/1/2008 N Y 2.61 120 313.20 


J0460 04 N N 0.61 10 6.10 

J0470 04 N N 28.55 5 142.75 





J0480 04 N Y N 1,765.65 1 1765.65 











J0585 N 04 Y Y N 

J0587 09 Y N N 


J0594 04 1/1/2007 N Y N 15.07 60 904.20 











J0641 04 1/1/2009 N Y N 1.23 150 184.50 




J0695 04 Y Y 


J0697 04 N Y N Y Y 5.43 4 21.72 



J0704 04 N Y N 4.03 3 12.09 



























J0900 04 Y N 


J0950 04 N Y N 8.10 





J1015 04 N Y N 18.63 



J1040 04 N Y N 9.87 4 39.48 











J1162 04 N Y N 755.86 80 60468.80 












J1245 04 N Y N 5.09 6 30.54 






J1300 04 1/1/2008 N Y 207.34 90 18660.60 










































J1562 04 1/1/2007 N Y N 14.95 140 2093.00 











































J1825 04 N Y N 601.23 1 601.23 
















J2001 04 N Y N 0.06 20 1.20 




















J2310 04 N N N 5.57 2 11.14 



J2321 04 N N 8.04 2 16.08 




J2323 04 1/1/2008 N Y N 8.01 300 2403.08 




J2355 04 N Y N 305.04 1 305.04 



















J2513 04 N N 76.09 1 76.09 


























J2783 04 N Y N 133.87 3 401.61 

















J2993 04 N N N 1,503.32 2 3006.64 











J3101 04 1/1/2009 N Y N 59.91 50 2995.57 









J3243 04 1/1/2007 N N 1.33 100 133.00 










J3301 04 N N N 1.78 8 14.24 


J3303 04 N Y 1.76 4 7.04 



J3315 04 N Y N 604.34 3 1813.02 



















J3472 04 N Y N 0.13 1,000 130.00 














J7042 04 N Y N 1.52 2 3.04 










J7186 04 1/1/2009 N Y N 1.04 


J7189 04 N Y N 1.15 1,000 1150.00 


















J7310 04 N Y N 4,984.32 1 4984.32 









J7500 09 Y N N 




















J7604 04 1/1/2008 N Y N 5.53 1 5.53 





J7609 04 1/1/2007 Y Y N 

























































J8501 04 Y Y N 














J9010 04 N N N 637.29 3 1911.87 

































J9110 04 N Y N 9.01 4 36.04 






J9160 04 N Y N 1,694.66 6 10167.96 


























J9225 04 N Y N 5,500.00 1 5,500.00 

J9226 04 1/1/2008 N Y N 15,400.00 1 15,400.00 





J9261 04 1/1/2007 N Y N 117.01 30 3510.30 






J9266 04 N Y N 1,894.04 5 9470.20 













J9340 04 N Y N 104.60 3 313.80 

J9350 04 N Y N Y 972.24 3 2916.72 











J9600 04 N Y N 3,005.31 2 6010.62 


M0064 02 N N 10.00 

M0075 04 Y N 

M0076 04 Y N 

P3000 04 N N 3.55 

P3001 04 N N 11.45 

P7001 A 04 N N 6.40 6.40 12.80 

P9041 09 Y N 






P9050 04 Y N 

P9604 04 N N 2.90 





Q0044 02 N N 7.60 

Q0081 04 Y I 

Q0083 04 N I 19.00 



Q0111 B 04 N N 2.40 2.40 4.80 




Q0163 04 N Y N 0.09 2 0.18 

Q0164 04 N Y N 0.44 10 4.40 














Q0177 04 N Y N 0.09 16 1.44 




Q0181 04 Y Y N 

Q0515 04 Y Y N 

Q2004 04 Y Y N 

Q2009 04 N Y N 7.30 40 292.00 

Q2017 04 N Y N 320.97 6 1925.82 

Q3014 09 Y N 


Q3026 04 N Y N 55.40 

Q3031 04 Y N 

Q4001 09 Y N 



Q4004 09 Y N 



































Q4081 04 1/1/2007 N Y N 1.56 800 1248.00 




Q4086 04 1/1/2007 N N 260.53 2 521.06 

Q4087 04 7/1/2007 Y 



Q4090 04 7/1/2007 Y 

Q4091 04 Y 

Q4092 04 Y 

Q4100 04 1/1/2009 Y 

Q4101 04 1/1/2009 Y 
















R0070 04 N N 4.10 

R0075 04 N N 4.10 

R0076 09 Y N 

R454Z 04 1/1/2009 N 19.11 

S0017 04 N Y N 1.01 6 6.06 

S0021 04 Y Y N 

S0023 04 N Y N 1.04 4 4.16 

S0028 04 N Y N 1.24 2 2.48 







S0040 04 N Y N 15.64 10 156.40 




S0078 04 N Y N 109.50 2 219.00 






S0142 04 Y Y N 




S0162 04 N N 341.92 

S0166 04 N Y N 6.07 4 24.28 

S0190 04 N Y N 306.10 

S0191 04 N Y N 2.40 

S0195 04 N N 72.27 



S0630 04 N I 24.35 

S1015 04 Y N 

S1016 04 Y N 

S2066 04 1/1/2008 Y M 

S2067 04 1/1/2008 Y M 

S2068 04 Y M Y 

S2070 04 N I 198.98 


S2079 04 Y M Y Y 

S2080 04 N M Y 388.70 

S2083 04 N N 10.00 

S2118 04 1/1/2009 Y N 

S2225 04 N I 43.80 17.00 



S3626 04 Y N 

S3628 04 4/1/2008 


S4981 04 Y I 




Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax 

Surg Child Adult 

S4993 

04 

N 

Y 

N 

1.35 

91 

122.85 

S9123 


Y 

N 

S9124 


Y 

N 

S9125 


Y 

N 

S9127 


Y 

N 

S9460 


Y 

N 

S9474 


Y 

N 

S9480 


N 

N 

T1015 

D 


Y 

N 

0.0000 

1 

T1029 


N 

N 

Y 

41.30

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