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 53270 04 N I 113.60 34.00 53275 04 N I 122.20 34.00 53400 04 N M Y 599.35 53405 04 N M Y 599.35 53410 04 N M Y 599.35 53415 04 N M Y 745.30 53420 04 N M Y 599.35 53425 04 N M Y 449.50 53430 04 N M 517.40 53431 04 N M 709.95 53440 04 N M 599.35 53442 04 N M Y 449.50 53444 04 N M 540.40 53445 04 Y M 53446 04 N M 494.90 53447 04 N M 449.50 53448 04 N M 842.25 53449 04 Y M 53450 04 N M 164.30 53460 04 N M 224.70 53500 04 N M Y Y 386.25 Wednesday, April 01, 2009 Page 210 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 53502 04 Y M 53505 04 Y M 53510 04 Y M 53515 04 Y M 53520 04 N M 314.95 53600 04 N I 52.80 53601 04 N I 47.80 53605 04 N I 47.80 53620 04 N I 75.10 53621 04 N I 69.55 53660 04 N I 41.80 53661 04 N I 42.10 53665 04 N I 36.00 53850 04 N M 576.80 53852 04 N M 576.80 53899 04 Y M Y 54000 04 N I 74.90 17.00 54001 04 N I 87.85 17.00 54015 04 N I 156.75 17.00 54050 04 N I 52.70 17.00 54055 04 N I 72.10 17.00 Wednesday, April 01, 2009 Page 211 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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