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 67830 04 N I 112.60 67835 04 N M 187.30 67840 04 N I 93.30 17.00 67850 04 N I 90.20 67875 04 N M Y 187.30 67880 04 N M 187.30 67882 04 N M Y 231.50 67900 04 N M Y 216.00 67901 04 N M 685.40 67902 04 N M 685.40 67903 04 N M 685.40 67904 04 N M Y 685.40 67906 04 N M 749.20 67908 04 N M 749.20 67909 04 N M 749.20 67911 04 N M 749.20 67912 04 N M Y 221.64 67914 04 N M 359.30 67915 04 N I 133.90 67916 04 N M 299.70 67917 04 N M 359.30 Wednesday, April 01, 2009 Page 266 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 67921 04 N M 359.30 67922 04 N I 130.70 67923 04 N M 299.70 67924 04 N M 359.30 67930 04 N M 189.00 17.00 67935 04 N M 244.50 17.00 67938 04 N I 80.90 17.00 67950 04 N M 359.30 67961 04 N M 324.05 67966 04 N M 345.70 67971 04 N M 449.50 67973 04 N M 449.50 67974 04 N M 449.50 67975 04 N M 449.50 67999 04 Y M Y 68020 04 N I 72.55 17.00 68040 04 N I 71.40 17.00 68100 04 N I 77.60 17.00 68110 04 N M 180.30 68115 04 N M 180.30 68130 04 N M 224.70 Wednesday, April 01, 2009 Page 267 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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