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 57020 04 N I 79.30 17.00 57022 04 N I 109.50 57023 04 N I 109.50 57061 04 N I 45.40 17.00 57065 04 N I 91.35 57100 04 N I 107.00 17.00 57105 04 N I 107.00 17.00 57106 04 N M Y 299.70 57107 04 N M Y 544.50 57109 04 N M Y 782.80 57110 04 N M Y 374.30 57111 04 N M Y 782.80 57112 04 N M Y 1022.80 57120 04 N M Y 299.70 57130 04 N M 180.30 57135 04 N I 121.55 17.00 57150 04 N I 18.25 57155 04 N I 257.40 57160 04 N I 27.65 57170 04 N I 28.60 57180 04 N I 48.75 17.00 Wednesday, April 01, 2009 Page 220 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 57200 04 N M 188.90 34.00 57210 04 N M 206.05 34.00 57220 04 N M 355.10 57230 04 N M 517.40 57240 04 N M Y 355.10 57250 04 N M Y 314.95 57260 04 N M Y 525.80 57265 04 N M Y 532.80 57267 04 N M 167.79 57268 04 N M Y 532.80 57270 04 N M Y 480.00 57280 04 N M 599.35 57282 04 N M Y 480.00 57283 04 N M Y 599.35 57284 04 N M 532.80 57285 04 1/1/2008 N M Y Y 352.36 57287 04 N M Y 467.50 57288 04 N M Y Y 631.25 57289 04 N M Y 674.20 57291 04 Y M Y Y 57292 04 Y M Y Y Wednesday, April 01, 2009 Page 221 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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