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 78140 B 04 N N 21.57 21.57 43.15 78185 B 04 N N 49.05 49.05 98.10 78190 04 Y N 78191 04 N N 18.65 78195 B 04 N N 49.05 49.05 98.10 78199 04 Y N 78201 B 04 N N 65.40 65.40 130.80 78202 B 04 N N 65.40 65.40 130.80 78205 B 04 N N 65.40 65.40 130.80 78206 B 04 N N 65.40 65.40 130.80 78215 B 04 N N 65.40 65.40 130.80 78216 B 04 N N 65.40 65.40 130.80 78220 B 04 N N 32.67 32.67 65.35 78223 B 04 N N 35.30 35.30 70.60 78230 B 04 N N 16.35 16.35 32.70 78231 04 N N 28.70 78232 04 N N 14.25 78258 B 04 N N 35.30 35.30 70.60 78261 04 N N 28.70 78262 04 N N 28.70 78264 04 N N 41.90 Wednesday, April 01, 2009 Page 302 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 78267 04 Y N 78268 B 04 N N 30.58 30.58 61.17 78270 B 04 N N 16.35 16.35 32.70 78271 B 04 N N 16.35 16.35 32.70 78272 B 04 N N 16.35 16.35 32.70 78278 C 04 N N 9.64 32.26 41.90 78282 B 04 N N 22.90 22.90 45.80 78290 B 04 N N 49.05 49.05 98.10 78291 B 04 N N 12.45 12.45 24.90 78299 04 Y N 78300 B 04 N N 39.22 39.22 78.45 78305 B 04 N N 58.80 58.80 117.60 78306 B 04 N N 58.80 58.80 117.60 78315 B 04 N N 17.62 17.62 35.25 78320 B 04 N N 33.67 33.67 67.35 78350 B 04 N N 62.25 62.25 124.50 78351 B 04 N N 74.75 74.75 149.50 78399 04 Y N 78414 04 N N 49.70 78428 04 N N 49.70 78445 B 04 N N 24.85 24.85 49.70 Wednesday, April 01, 2009 Page 303 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 />
78267 <strong>04</strong> Y N<br />
78268 B <strong>04</strong> N N 30.58 30.58 61.17<br />
78270 B <strong>04</strong> N N 16.35 16.35 32.70<br />
78271 B <strong>04</strong> N N 16.35 16.35 32.70<br />
78272 B <strong>04</strong> N N 16.35 16.35 32.70<br />
78278 C <strong>04</strong> N N 9.64 32.26 41.90<br />
78282 B <strong>04</strong> N N 22.90 22.90 45.80<br />
78290 B <strong>04</strong> N N 49.05 49.05 98.10<br />
78291 B <strong>04</strong> N N 12.45 12.45 24.90<br />
78299 <strong>04</strong> Y N<br />
78300 B <strong>04</strong> N N 39.22 39.22 78.45<br />
78305 B <strong>04</strong> N N 58.80 58.80 117.60<br />
78306 B <strong>04</strong> N N 58.80 58.80 117.60<br />
78315 B <strong>04</strong> N N 17.62 17.62 35.25<br />
78320 B <strong>04</strong> N N 33.67 33.67 67.35<br />
78350 B <strong>04</strong> N N 62.25 62.25 124.50<br />
78351 B <strong>04</strong> N N 74.75 74.75 149.50<br />
78399 <strong>04</strong> Y N<br />
78414 <strong>04</strong> N N 49.70<br />
78428 <strong>04</strong> N N 49.70<br />
78445 B <strong>04</strong> N N 24.85 24.85 49.70<br />
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