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 54056 04 N I 71.40 17.00 54057 04 N I 71.40 17.00 54060 04 N I 88.50 17.00 54065 04 N I 107.00 34.00 54100 04 N I 88.50 17.00 54105 04 N I 114.25 17.00 54110 04 N M 321.45 54111 04 N M 585.75 54112 04 N M 717.90 54115 04 Y M 54120 04 N M Y 285.10 54125 04 N M Y 449.50 54130 04 N M Y Y 749.20 54135 04 N M Y Y 749.20 54150 04 N I 77.50 54160 04 N I 99.80 54161 04 N I 146.70 34.00 54162 04 N I 97.25 54163 04 N I 137.40 54164 04 N I 120.30 54200 04 N I 38.60 Wednesday, April 01, 2009 Page 212 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 54205 04 Y I 54220 04 N M 299.70 54230 04 N I 38.20 54231 04 N I 118.80 54235 04 N I Y 37.40 54240 09 Y I 54250 04 N I 54.55 54300 04 N M Y Y 425.80 54304 04 N M Y 670.10 54308 04 N M Y 599.35 54312 04 N M Y 670.10 54316 04 N M Y 670.10 54318 04 N M Y 670.10 54322 04 N M Y 480.00 54324 04 N M Y 538.00 54326 04 N M Y 670.10 54328 04 N M Y 958.60 54332 04 N M Y Y 670.10 54336 04 N M Y Y 958.60 54340 04 N M Y 538.00 54344 04 N M Y 670.10 Wednesday, April 01, 2009 Page 213 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 />
54056 <strong>04</strong> N I 71.40 17.00<br />
54057 <strong>04</strong> N I 71.40 17.00<br />
54060 <strong>04</strong> N I 88.50 17.00<br />
54065 <strong>04</strong> N I 107.00 34.00<br />
54100 <strong>04</strong> N I 88.50 17.00<br />
54105 <strong>04</strong> N I 114.25 17.00<br />
54110 <strong>04</strong> N M 321.45<br />
54111 <strong>04</strong> N M 585.75<br />
54112 <strong>04</strong> N M 717.90<br />
54115 <strong>04</strong> Y M<br />
54120 <strong>04</strong> N M Y 285.10<br />
54125 <strong>04</strong> N M Y 449.50<br />
54130 <strong>04</strong> N M Y Y 749.20<br />
54135 <strong>04</strong> N M Y Y 749.20<br />
54150 <strong>04</strong> N I 77.50<br />
54160 <strong>04</strong> N I 99.80<br />
54161 <strong>04</strong> N I 146.70 34.00<br />
54162 <strong>04</strong> N I 97.25<br />
54163 <strong>04</strong> N I 137.40<br />
54164 <strong>04</strong> N I 120.30<br />
54200 <strong>04</strong> N I 38.60<br />
Wednesday, April <strong>01</strong>, 20<strong>09</strong> Page 212 <strong>of</strong> 458
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