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 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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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 />
72052 A <strong>04</strong> N N 18.25 18.25 36.50<br />
72069 A <strong>04</strong> N N 11.40 11.40 22.80<br />
72070 A <strong>04</strong> N N 11.40 11.40 22.80<br />
72072 A <strong>04</strong> N N 10.47 10.48 20.95<br />
72074 A <strong>04</strong> N N 10.75 10.75 21.50<br />
72080 A <strong>04</strong> N N 12.70 12.70 25.40<br />
72<strong>09</strong>0 A <strong>04</strong> N N 29.45 29.45 58.90<br />
72100 A <strong>04</strong> N N 14.35 14.35 28.70<br />
72110 A <strong>04</strong> N N 18.95 18.95 37.90<br />
72114 A <strong>04</strong> N N 18.95 18.95 37.90<br />
72120 A <strong>04</strong> N N 18.95 18.95 37.90<br />
72125 B <strong>04</strong> N N 31.35 31.35 62.70<br />
72126 B <strong>04</strong> N N 37.95 37.95 75.90<br />
72127 B <strong>04</strong> N N 54.93 54.92 1<strong>09</strong>.85<br />
72128 B <strong>04</strong> N N 31.35 31.35 62.70<br />
72129 B <strong>04</strong> N N 37.95 37.95 75.90<br />
72130 B <strong>04</strong> N N 54.93 54.92 1<strong>09</strong>.85<br />
72131 B <strong>04</strong> N N 31.35 31.35 62.70<br />
72132 B <strong>04</strong> N N 37.95 37.95 75.90<br />
72133 B <strong>04</strong> N N 54.93 54.92 1<strong>09</strong>.85<br />
72141 B <strong>04</strong> N N 148.30 148.30 296.60<br />
Wednesday, April <strong>01</strong>, 20<strong>09</strong> Page 279 <strong>of</strong> 458
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