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 69020 04 N I 44.60 17.00 69100 04 N I 31.15 17.00 69105 04 N I 50.20 17.00 69110 04 N M 209.40 69120 04 N M 240.00 69140 04 N M 480.00 69145 04 N I 90.10 69150 04 N M Y 718.70 69155 04 N M Y 1198.70 69200 04 N I 26.60 69205 04 N I 74.90 69210 04 N I 21.40 69220 04 N I Y Y 28.50 69222 04 N I Y Y 57.30 69300 09 Y M 69310 04 N M 694.40 69320 04 N M 958.60 69399 04 Y M Y 69400 04 N I 28.15 69401 04 N I 22.15 69405 04 N I Y Y 115.10 Wednesday, April 01, 2009 Page 270 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 69420 04 N I 43.80 17.00 69421 04 N I 56.60 69424 04 N I 30.35 69433 04 N I 76.60 34.00 69436 04 N I 80.50 69440 04 N M 599.35 69450 04 N I 191.10 69501 04 N M Y Y 692.20 69502 04 N M Y Y 692.20 69505 04 N M Y Y 749.20 69511 04 N M Y Y 839.35 69530 04 N M Y Y 1198.70 69535 04 N M Y Y 1198.70 69540 04 N I Y 50.20 17.00 69550 04 N I Y 363.60 17.00 69552 04 N M Y 674.20 69554 04 N M Y Y 954.95 69601 04 N M Y Y 695.05 69602 04 N M Y 695.05 69603 04 N M Y Y 695.05 69604 04 N M Y Y 695.05 Wednesday, April 01, 2009 Page 271 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 />
69420 <strong>04</strong> N I 43.80 17.00<br />
69421 <strong>04</strong> N I 56.60<br />
69424 <strong>04</strong> N I 30.35<br />
69433 <strong>04</strong> N I 76.60 34.00<br />
69436 <strong>04</strong> N I 80.50<br />
69440 <strong>04</strong> N M 599.35<br />
69450 <strong>04</strong> N I 191.10<br />
695<strong>01</strong> <strong>04</strong> N M Y Y 692.20<br />
69502 <strong>04</strong> N M Y Y 692.20<br />
69505 <strong>04</strong> N M Y Y 749.20<br />
69511 <strong>04</strong> N M Y Y 839.35<br />
69530 <strong>04</strong> N M Y Y 1198.70<br />
69535 <strong>04</strong> N M Y Y 1198.70<br />
69540 <strong>04</strong> N I Y 50.20 17.00<br />
69550 <strong>04</strong> N I Y 363.60 17.00<br />
69552 <strong>04</strong> N M Y 674.20<br />
69554 <strong>04</strong> N M Y Y 954.95<br />
696<strong>01</strong> <strong>04</strong> N M Y Y 695.05<br />
69602 <strong>04</strong> N M Y 695.05<br />
69603 <strong>04</strong> N M Y Y 695.05<br />
696<strong>04</strong> <strong>04</strong> N M Y Y 695.05<br />
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