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 87472 B 04 N N 27.95 27.95 55.91 87475 B 04 N N 13.10 13.10 26.20 87476 B 04 N N 22.90 22.90 45.80 87477 B 04 N N 27.95 27.95 55.91 87480 B 04 N N 13.10 13.10 26.20 87481 B 04 N N 22.90 22.90 45.80 87482 B 04 N N 27.25 27.25 54.50 87485 B 04 N N 13.10 13.10 26.20 87486 B 04 N N 22.90 22.90 45.80 87487 B 04 N N 27.95 27.95 55.91 87490 B 04 N N 13.10 13.10 26.20 87491 B 04 N N 22.90 22.90 45.80 87492 B 04 N N 22.81 22.81 45.63 87495 B 04 N N 13.10 13.10 26.20 87496 B 04 N N 22.90 22.90 45.80 87497 B 04 N N 22.81 22.81 45.63 87498 B 04 N N 22.91 22.91 45.83 87500 04 1/1/2008 N N 29.42 87510 B 04 N N 13.10 13.10 26.20 87511 B 04 N N 22.90 22.90 45.80 87512 B 04 Y N Wednesday, April 01, 2009 Page 354 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 87515 B 04 N N 13.10 13.10 26.20 87516 B 04 N N 22.90 22.90 45.80 87517 B 04 N N 27.95 27.95 55.90 87520 B 04 N N 13.10 13.10 26.20 87521 B 04 N N 22.90 22.90 45.80 87522 B 04 N N 27.95 27.95 55.90 87525 B 04 N N 13.10 13.10 26.20 87526 B 04 N N 22.90 22.90 45.80 87527 B 04 Y N 87528 B 04 N N 13.10 13.10 26.20 87529 B 04 N N 22.90 22.90 45.80 87530 B 04 Y N 87531 B 04 N N 13.10 13.10 26.20 87532 B 04 N N 22.90 22.90 45.80 87533 B 04 Y N 87534 B 04 N N 13.10 13.10 26.20 87535 B 04 N N 22.90 22.90 45.80 87536 B 04 N N 43.45 43.45 86.90 87537 B 04 N N 13.10 13.10 26.20 87538 B 04 N N 22.90 22.90 45.80 87539 B 04 Y N Wednesday, April 01, 2009 Page 355 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 />
87472 B <strong>04</strong> N N 27.95 27.95 55.91<br />
87475 B <strong>04</strong> N N 13.10 13.10 26.20<br />
87476 B <strong>04</strong> N N 22.90 22.90 45.80<br />
87477 B <strong>04</strong> N N 27.95 27.95 55.91<br />
87480 B <strong>04</strong> N N 13.10 13.10 26.20<br />
87481 B <strong>04</strong> N N 22.90 22.90 45.80<br />
87482 B <strong>04</strong> N N 27.25 27.25 54.50<br />
87485 B <strong>04</strong> N N 13.10 13.10 26.20<br />
87486 B <strong>04</strong> N N 22.90 22.90 45.80<br />
87487 B <strong>04</strong> N N 27.95 27.95 55.91<br />
87490 B <strong>04</strong> N N 13.10 13.10 26.20<br />
87491 B <strong>04</strong> N N 22.90 22.90 45.80<br />
87492 B <strong>04</strong> N N 22.81 22.81 45.63<br />
87495 B <strong>04</strong> N N 13.10 13.10 26.20<br />
87496 B <strong>04</strong> N N 22.90 22.90 45.80<br />
87497 B <strong>04</strong> N N 22.81 22.81 45.63<br />
87498 B <strong>04</strong> N N 22.91 22.91 45.83<br />
87500 <strong>04</strong> 1/1/2008 N N 29.42<br />
87510 B <strong>04</strong> N N 13.10 13.10 26.20<br />
87511 B <strong>04</strong> N N 22.90 22.90 45.80<br />
87512 B <strong>04</strong> Y N<br />
Wednesday, April <strong>01</strong>, 20<strong>09</strong> Page 354 <strong>of</strong> 458
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