Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois
Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois
Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult 38770 04 N M Y 918.40 38780 04 N M Y 998.80 38790 04 N I 220.85 38792 04 N I 105.40 38794 04 Y M 38999 04 Y M Y 39000 04 N M Y Y 718.70 39010 04 N M Y Y 718.70 39200 04 N M Y 749.20 39220 04 N M Y 749.20 39400 04 N I 314.95 39499 04 Y M Y 39501 04 N M Y Y 648.60 39502 04 N M Y Y 826.50 39503 04 N M Y Y 960.55 39520 04 N M Y Y 682.60 39530 04 N M Y Y 682.60 39531 04 N M Y Y 735.45 39540 04 N M Y Y 682.60 39541 04 N M Y Y 682.60 39545 04 N M Y Y 682.60 Wednesday, April 01, 2009 Page 156 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 39560 04 N M Y Y 708.60 39561 04 N M Y 803.05 39599 04 Y M Y 40490 04 N I 46.25 17.00 40500 04 N M 165.10 40510 04 N I 170.45 40520 04 N M Y Y 524.40 40525 04 N M Y Y 629.90 40527 04 N M Y Y 718.70 40530 04 N M Y Y 524.35 40650 04 N M Y Y 629.90 40652 04 N M Y Y 629.90 40654 04 N M Y Y 629.90 40700 04 N M Y Y 718.70 40701 04 N M Y Y 958.60 40702 04 N M Y 958.60 40720 04 N M Y Y 718.70 40761 04 N M Y Y 802.00 40799 04 Y M Y 40800 04 N I 39.90 17.00 40801 04 N I 76.15 Wednesday, April 01, 2009 Page 157 of 458
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Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty <strong>State</strong>Max Surg Child Adult<br />
39560 <strong>04</strong> N M Y Y 708.60<br />
39561 <strong>04</strong> N M Y 803.05<br />
39599 <strong>04</strong> Y M Y<br />
4<strong>04</strong>90 <strong>04</strong> N I 46.25 17.00<br />
40500 <strong>04</strong> N M 165.10<br />
40510 <strong>04</strong> N I 170.45<br />
40520 <strong>04</strong> N M Y Y 524.40<br />
40525 <strong>04</strong> N M Y Y 629.90<br />
40527 <strong>04</strong> N M Y Y 718.70<br />
40530 <strong>04</strong> N M Y Y 524.35<br />
40650 <strong>04</strong> N M Y Y 629.90<br />
40652 <strong>04</strong> N M Y Y 629.90<br />
40654 <strong>04</strong> N M Y Y 629.90<br />
40700 <strong>04</strong> N M Y Y 718.70<br />
407<strong>01</strong> <strong>04</strong> N M Y Y 958.60<br />
40702 <strong>04</strong> N M Y 958.60<br />
40720 <strong>04</strong> N M Y Y 718.70<br />
40761 <strong>04</strong> N M Y Y 802.00<br />
40799 <strong>04</strong> Y M Y<br />
40800 <strong>04</strong> N I 39.90 17.00<br />
408<strong>01</strong> <strong>04</strong> N I 76.15<br />
Wednesday, April <strong>01</strong>, 20<strong>09</strong> Page 157 <strong>of</strong> 458
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