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 86294 A 04 Y N 86300 B 04 N N 10.85 10.85 21.70 86301 B 04 N N 10.85 10.85 21.70 86304 B 04 N N 10.85 10.85 21.70 86308 B 04 N N 2.40 2.40 4.80 86309 B 04 N N 4.25 4.25 8.50 86310 B 04 N N 4.82 4.82 9.65 86316 A 04 N N 5.05 5.05 10.10 86317 09 Y 86318 A 04 N N 8.45 8.45 16.90 86320 B 04 N N 10.65 10.65 21.30 86325 B 04 N N 5.90 5.90 11.80 86327 B 04 N N 7.00 7.00 14.00 86329 A 04 N N 9.15 9.15 18.30 86331 A 04 N N 5.90 5.90 11.80 86332 B 04 N N 9.40 9.40 18.80 86334 B 04 N N 13.95 13.95 27.90 86335 A 04 N N 12.30 12.30 24.60 86336 B 04 N N 10.87 10.87 21.75 86337 B 04 N N 5.90 5.90 11.80 86340 A 04 N N 5.90 5.90 11.80 Wednesday, April 01, 2009 Page 340 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 86341 04 N N 11.80 86343 B 04 N N 8.07 8.07 16.15 86344 A 04 N N 1.15 1.15 2.30 86353 B 04 N N 5.90 5.90 11.80 86355 04 N N 15.81 15.81 31.62 86356 04 1/1/2008 N N 11.33 86357 04 N N 15.81 15.81 31.62 86359 B 04 N N 3.82 3.82 7.65 86360 B 04 N N 4.85 4.85 9.70 86361 B 04 N N 4.85 4.85 9.70 86367 04 N N 15.81 15.81 31.62 86376 A 04 N N 4.20 4.20 8.40 86378 B 04 N N 6.95 6.95 13.90 86382 A 04 N N 3.60 3.60 7.20 86384 A 04 N N 2.35 2.35 4.70 86403 A 04 N N 3.00 3.00 6.00 86406 A 04 N N 5.90 5.90 11.80 86430 B 04 N N 3.10 3.10 6.20 86431 B 04 N N 3.62 3.62 7.25 86480 04 N N 25.97 25.97 51.95 86485 B 04 N N 2.00 2.00 4.00 Wednesday, April 01, 2009 Page 341 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 />
86294 A <strong>04</strong> Y N<br />
86300 B <strong>04</strong> N N 10.85 10.85 21.70<br />
863<strong>01</strong> B <strong>04</strong> N N 10.85 10.85 21.70<br />
863<strong>04</strong> B <strong>04</strong> N N 10.85 10.85 21.70<br />
86308 B <strong>04</strong> N N 2.40 2.40 4.80<br />
863<strong>09</strong> B <strong>04</strong> N N 4.25 4.25 8.50<br />
86310 B <strong>04</strong> N N 4.82 4.82 9.65<br />
86316 A <strong>04</strong> N N 5.05 5.05 10.10<br />
86317 <strong>09</strong> Y<br />
86318 A <strong>04</strong> N N 8.45 8.45 16.90<br />
86320 B <strong>04</strong> N N 10.65 10.65 21.30<br />
86325 B <strong>04</strong> N N 5.90 5.90 11.80<br />
86327 B <strong>04</strong> N N 7.00 7.00 14.00<br />
86329 A <strong>04</strong> N N 9.15 9.15 18.30<br />
86331 A <strong>04</strong> N N 5.90 5.90 11.80<br />
86332 B <strong>04</strong> N N 9.40 9.40 18.80<br />
86334 B <strong>04</strong> N N 13.95 13.95 27.90<br />
86335 A <strong>04</strong> N N 12.30 12.30 24.60<br />
86336 B <strong>04</strong> N N 10.87 10.87 21.75<br />
86337 B <strong>04</strong> N N 5.90 5.90 11.80<br />
86340 A <strong>04</strong> N N 5.90 5.90 11.80<br />
Wednesday, April <strong>01</strong>, 20<strong>09</strong> Page 340 <strong>of</strong> 458
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