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 71040 04 N I 32.70 71060 04 N I 52.30 71090 04 N I 103.30 71100 A 04 N N 10.75 10.75 21.50 71101 A 04 N N 12.40 12.40 24.80 71110 A 04 N N 13.07 13.08 26.15 71111 A 04 N N 14.35 14.35 28.70 71120 A 04 N N 10.75 10.75 21.50 71130 A 04 N N 14.35 14.35 28.70 71250 B 04 N N 31.35 31.35 62.70 71260 B 04 N N 37.95 37.95 75.90 71270 B 04 N N 54.93 54.92 109.85 71275 B 04 N N 132.50 132.50 265.00 71550 B 04 N N 148.30 148.30 296.60 71551 B 04 N N 148.30 148.30 296.60 71552 B 04 N N 224.03 224.02 448.05 71555 B 04 N N 148.30 148.30 296.60 72010 A 04 N N 35.95 35.95 71.90 72020 A 04 N N 12.07 12.08 24.15 72040 A 04 N N 12.07 12.08 24.15 72050 A 04 N N 17.63 17.62 35.25 Wednesday, April 01, 2009 Page 278 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 72052 A 04 N N 18.25 18.25 36.50 72069 A 04 N N 11.40 11.40 22.80 72070 A 04 N N 11.40 11.40 22.80 72072 A 04 N N 10.47 10.48 20.95 72074 A 04 N N 10.75 10.75 21.50 72080 A 04 N N 12.70 12.70 25.40 72090 A 04 N N 29.45 29.45 58.90 72100 A 04 N N 14.35 14.35 28.70 72110 A 04 N N 18.95 18.95 37.90 72114 A 04 N N 18.95 18.95 37.90 72120 A 04 N N 18.95 18.95 37.90 72125 B 04 N N 31.35 31.35 62.70 72126 B 04 N N 37.95 37.95 75.90 72127 B 04 N N 54.93 54.92 109.85 72128 B 04 N N 31.35 31.35 62.70 72129 B 04 N N 37.95 37.95 75.90 72130 B 04 N N 54.93 54.92 109.85 72131 B 04 N N 31.35 31.35 62.70 72132 B 04 N N 37.95 37.95 75.90 72133 B 04 N N 54.93 54.92 109.85 72141 B 04 N N 148.30 148.30 296.60 Wednesday, April 01, 2009 Page 279 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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