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 11750 04 N I 61.85 34.00 11752 04 N M Y 167.40 34.00 11755 04 N I 38.80 11760 04 N I 60.80 17.00 11762 04 N I 87.75 17.00 11765 04 N I 38.40 11770 04 N M 215.40 34.00 11771 04 N M Y 291.30 11772 04 N M Y 341.25 11900 04 N I 21.10 17.00 11901 04 Y I 11920 09 Y M Y Y 11921 04 N I 63.57 11922 04 N I 16.13 11950 09 Y M 11951 09 Y M 11952 09 Y M 11954 09 Y M 11960 04 N M Y 350.05 11970 04 N M 475.70 11971 04 N I Y Y 135.00 Wednesday, April 01, 2009 Page 20 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 11975 04 N I 108.00 11976 04 N I 108.00 11977 04 N I 108.00 11980 04 N M 108.00 11981 04 N I 72.30 11982 04 N I 87.00 11983 04 N I 108.00 12001 04 N I Y 53.10 17.00 12002 04 N I 58.40 17.00 12004 04 N I 69.70 17.00 12005 04 N I 100.40 17.00 12006 04 N I 145.80 17.00 12007 04 Y M 12011 04 N I 56.40 17.00 12013 04 N I 64.00 17.00 12014 04 N I 112.90 17.00 12015 04 N I 125.50 17.00 12016 04 N I 200.75 17.00 12017 04 N M 259.20 17.00 12018 04 N M 272.63 12020 04 N I 139.30 17.00 Wednesday, April 01, 2009 Page 21 of 458
Page 1 and 2: Healthcare and Family Services Prac
Page 3 and 4: Q State maximum amount now includes
Page 5 and 6: MODIFIERS RECOGNIZED IN PROCESSING
Page 7 and 8: HO Masters degree level; added 0601
Page 9 and 10: Health Care and Family Services Rev
Page 11 and 12: Hcpcs Note ProgCov Eff Date HP NDC
Page 27: 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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