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 30801 04 N I 50.05 30802 04 N I 71.15 30901 04 N I Y Y 74.90 30903 04 N I Y Y 71.40 17.00 30905 04 N I 80.75 17.00 30906 04 N I 85.70 17.00 30915 04 N M 359.30 30920 04 N M 359.30 30930 04 N I Y Y 90.10 30999 04 Y M Y 31000 04 N I 39.35 31002 04 N I 51.50 31020 04 N M 180.30 31030 04 N M 480.00 31032 04 N M Y Y 718.70 31040 04 N M Y 359.30 31050 04 N M Y 412.00 31051 04 N M Y 412.00 31070 04 N M 180.30 31075 04 N M Y 599.35 31080 04 N M Y 898.95 Wednesday, April 01, 2009 Page 112 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 31081 04 N M Y 898.95 31084 04 N M Y 898.95 31085 04 N M Y 898.95 31086 04 N M Y 898.95 31087 04 N M Y 898.95 31090 04 N M Y 718.70 31200 04 N M Y 262.20 31201 04 N M 449.50 31205 04 N M Y 449.50 31225 04 N M Y 898.95 31230 04 N M Y 1,198.70 31231 04 N I 107.00 31233 04 N I 112.40 31235 04 N I 107.00 31237 04 N I 102.55 31238 04 N I 113.10 31239 04 Y M 31240 04 N M 221.90 31254 04 N M Y 262.20 31255 04 N M Y 449.50 31256 04 N M Y 180.30 Wednesday, April 01, 2009 Page 113 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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