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

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Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult 28124 04 N M Y 259.40 28126 04 N M Y 209.40 28130 04 N M Y 412.00 28140 04 N M Y 394.00 28150 04 N M Y 209.40 28153 04 N M Y 144.70 28160 04 N M Y 224.70 28171 04 Y M Y Y 28173 04 Y M Y Y 28175 04 Y M Y Y 28190 04 N I 107.00 17.00 28192 04 N M Y 159.80 17.00 28193 04 N M Y 180.30 28200 04 N M Y 353.75 28202 04 N M Y 480.00 28208 04 N M 299.70 28210 04 N M Y 378.05 28220 04 N M Y 212.30 28222 04 Y M Y 28225 04 N M Y 212.30 28226 04 Y M Y Wednesday, April 01, 2009 Page 98 of 458
Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult 28230 04 N M Y 173.40 28232 04 N I Y 121.10 28234 04 N I Y 121.05 28238 04 N M Y 299.70 28240 04 N M Y 140.75 28250 04 N M Y 359.30 28260 04 N M Y 299.70 28261 04 N M Y 363.45 28262 04 N M Y 524.40 28264 04 N M Y 449.50 28270 04 N M Y 299.70 28272 04 N M Y 224.70 28280 04 N M Y 162.35 28285 04 N M Y 270.50 28286 04 N M Y 337.10 28288 04 N M Y 299.70 28289 04 N M Y 359.30 28290 04 N M Y 424.45 28292 04 N M Y 359.30 28293 04 N M Y 359.30 28294 04 N M Y 359.30 Wednesday, April 01, 2009 Page 99 of 458
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Healthcare and Family Services Prac
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Q State maximum amount now includes
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MODIFIERS RECOGNIZED IN PROCESSING
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HO Masters degree level; added 0601
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Health Care and Family Services Rev
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Hcpcs Note ProgCov Eff Date HP NDC
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Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois

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