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 76100 A 04 N N 24.85 24.85 49.70 76101 A 04 N N 17.62 17.62 35.25 76102 A 04 N N 24.85 24.85 49.70 76120 A 04 N N 10.47 10.47 20.95 76125 A 04 N N 24.85 24.85 49.70 76140 04 N N 19.60 76150 B 04 Y N 76350 B 04 Y N 76376 C 04 N I 6.18 66.99 1 73.17 76377 C 04 N I 24.33 72.94 1 97.27 76380 04 N N 59.55 76390 B 04 N I 148.30 148.30 296.60 76496 A 04 Y I 76497 B 04 Y I 76498 B 04 Y I 76499 04 Y N 76506 B 04 N N 32.02 32.02 64.05 76510 A 04 N N 32.67 32.67 65.35 76511 A 04 N N 24.85 24.85 49.70 76512 A 04 N N 32.67 32.67 65.35 76513 A 04 N N 32.67 32.67 65.35 Wednesday, April 01, 2009 Page 292 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 76514 C 04 N N 5.20 1.37 1 6.57 76516 A 04 N N 24.85 24.85 49.70 76519 A 04 N N 24.90 24.90 49.80 76529 A 04 N N 32.67 32.67 65.35 76536 B 04 N N 34.00 34.00 68.00 76604 B 04 N N 31.35 31.35 62.70 76645 B 04 N N 31.35 31.35 62.70 76700 B 04 N N 37.95 37.95 75.90 76705 B 04 N N 31.35 31.35 62.70 76770 B 04 N N 37.95 37.95 75.90 76775 B 04 N N 31.35 31.35 62.70 76776 C 04 1/1/2007 N N 53.13 22.77 1 75.90 76800 B 04 N N 37.95 37.95 75.90 76801 B 04 N N 35.95 35.95 71.90 76802 B 04 N N 22.52 22.52 45.05 76805 B 04 N N 35.95 35.95 71.90 76810 B 04 N N 22.52 22.52 45.05 76811 B 04 N N 35.95 35.95 71.90 76812 B 04 N N 22.52 22.52 45.05 76813 C 04 1/1/2007 N N 32.36 39.54 1 71.90 76814 C 04 1/1/2007 N N 25.23 19.82 1 45.05 Wednesday, April 01, 2009 Page 293 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 />
76100 A <strong>04</strong> N N 24.85 24.85 49.70<br />
761<strong>01</strong> A <strong>04</strong> N N 17.62 17.62 35.25<br />
76102 A <strong>04</strong> N N 24.85 24.85 49.70<br />
76120 A <strong>04</strong> N N 10.47 10.47 20.95<br />
76125 A <strong>04</strong> N N 24.85 24.85 49.70<br />
76140 <strong>04</strong> N N 19.60<br />
76150 B <strong>04</strong> Y N<br />
76350 B <strong>04</strong> Y N<br />
76376 C <strong>04</strong> N I 6.18 66.99 1 73.17<br />
76377 C <strong>04</strong> N I 24.33 72.94 1 97.27<br />
76380 <strong>04</strong> N N 59.55<br />
76390 B <strong>04</strong> N I 148.30 148.30 296.60<br />
76496 A <strong>04</strong> Y I<br />
76497 B <strong>04</strong> Y I<br />
76498 B <strong>04</strong> Y I<br />
76499 <strong>04</strong> Y N<br />
76506 B <strong>04</strong> N N 32.02 32.02 64.05<br />
76510 A <strong>04</strong> N N 32.67 32.67 65.35<br />
76511 A <strong>04</strong> N N 24.85 24.85 49.70<br />
76512 A <strong>04</strong> N N 32.67 32.67 65.35<br />
76513 A <strong>04</strong> N N 32.67 32.67 65.35<br />
Wednesday, April <strong>01</strong>, 20<strong>09</strong> Page 292 <strong>of</strong> 458
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