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 87140 B 04 N N 0.57 0.57 1.15 87143 B 04 N N 3.60 3.60 7.20 87147 B 04 N N 1.60 1.60 3.20 87149 09 Y N 87152 09 Y N 87158 B 04 N N 0.57 0.57 1.15 87164 04 N N 14.00 87166 04 N N 14.75 87168 B 04 N N 2.25 2.25 4.50 87169 B 04 N N 2.25 2.25 4.50 87172 A 04 N N 2.25 2.25 4.50 87176 A 04 N N 3.85 3.85 7.70 87177 A 04 N N 3.60 3.60 7.20 87181 B 04 N 6.20 87184 B 04 N N 4.50 4.50 9.00 87185 A 04 N N 2.47 2.47 4.95 87186 B 04 N N 5.65 5.65 11.30 87187 B 04 N N 4.30 4.30 8.60 87188 B 04 N N 4.32 4.32 8.65 87190 04 N N 7.40 87197 B 04 N N 6.40 6.40 12.80 Wednesday, April 01, 2009 Page 350 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 87205 B 04 N N 1.75 1.75 3.50 87206 B 04 N N 2.10 2.10 Y 4.20 87207 B 04 N N 1.75 1.75 3.50 87209 B 04 N N 7.53 7.53 15.06 87210 B 04 N N 2.35 2.35 4.70 87220 B 04 N N 2.35 2.35 4.70 87230 B 04 N N 7.50 7.50 15.00 87250 04 N N 12.80 87252 B 04 N N 6.40 6.40 12.80 87253 B 04 N N 7.50 7.50 15.00 87254 A 04 N N 3.20 3.20 6.40 87255 A 04 N N 11.83 11.83 23.66 87260 B 04 N N 7.85 7.85 15.70 87265 B 04 N N 7.85 7.85 15.70 87267 B 04 N N 4.19 4.19 8.38 87269 B 04 N N 5.02 5.02 10.05 87270 B 04 N N 7.85 7.85 15.70 87271 B 04 N N 4.19 4.19 8.38 87272 B 04 N N 7.85 7.85 15.70 87273 B 04 N N 6.25 6.25 12.50 87274 B 04 N N 7.85 7.85 15.70 Wednesday, April 01, 2009 Page 351 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 />
87140 B <strong>04</strong> N N 0.57 0.57 1.15<br />
87143 B <strong>04</strong> N N 3.60 3.60 7.20<br />
87147 B <strong>04</strong> N N 1.60 1.60 3.20<br />
87149 <strong>09</strong> Y N<br />
87152 <strong>09</strong> Y N<br />
87158 B <strong>04</strong> N N 0.57 0.57 1.15<br />
87164 <strong>04</strong> N N 14.00<br />
87166 <strong>04</strong> N N 14.75<br />
87168 B <strong>04</strong> N N 2.25 2.25 4.50<br />
87169 B <strong>04</strong> N N 2.25 2.25 4.50<br />
87172 A <strong>04</strong> N N 2.25 2.25 4.50<br />
87176 A <strong>04</strong> N N 3.85 3.85 7.70<br />
87177 A <strong>04</strong> N N 3.60 3.60 7.20<br />
87181 B <strong>04</strong> N 6.20<br />
87184 B <strong>04</strong> N N 4.50 4.50 9.00<br />
87185 A <strong>04</strong> N N 2.47 2.47 4.95<br />
87186 B <strong>04</strong> N N 5.65 5.65 11.30<br />
87187 B <strong>04</strong> N N 4.30 4.30 8.60<br />
87188 B <strong>04</strong> N N 4.32 4.32 8.65<br />
87190 <strong>04</strong> N N 7.40<br />
87197 B <strong>04</strong> N N 6.40 6.40 12.80<br />
Wednesday, April <strong>01</strong>, 20<strong>09</strong> Page 350 <strong>of</strong> 458
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