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 91011 04 N I 60.60 91012 04 N I 74.90 91020 04 N I 74.90 91022 C 04 N N 42.72 75.37 1 118.09 91030 04 N I 74.90 91034 C 04 N I 31.17 99.11 1 130.28 91035 04 N I 255.62 91037 04 N I 84.00 91038 C 04 N I 32.73 40.00 72.73 91040 04 N I 248.27 91052 04 N I 25.65 91055 04 N I 27.85 91065 04 N I 29.65 91105 04 N I 40.85 91110 C 04 N I 140.95 563.92 704.90 91111 C 04 N N 28.37 343.76 372.13 91120 04 N I 245.00 91122 04 N I 57.20 91123 04 N I 194.20 91132 04 Y I 91133 04 Y I Wednesday, April 01, 2009 Page 372 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 91299 04 Y I 92002 04 N N 27.55 92004 04 N N 46.45 92012 04 N N 23.30 92014 04 N N 44.45 92015 04 N I 18.45 92018 04 N I 152.60 92019 04 N I 152.60 92020 04 N I 19.50 92025 C 04 N I 9.04 6.29 15.33 92060 04 N I 24.90 92065 04 N I 22.15 92070 09 Y N 92081 04 N I 20.45 92082 04 N I 30.50 92083 04 N I 37.40 92100 04 N I 23.80 92120 04 N I 22.30 92130 04 N I 24.55 92135 L 04 N I 26.35 26.35 52.70 92136 04 N I 50.05 Wednesday, April 01, 2009 Page 373 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 />
91<strong>01</strong>1 <strong>04</strong> N I 60.60<br />
91<strong>01</strong>2 <strong>04</strong> N I 74.90<br />
91020 <strong>04</strong> N I 74.90<br />
91022 C <strong>04</strong> N N 42.72 75.37 1 118.<strong>09</strong><br />
91030 <strong>04</strong> N I 74.90<br />
91034 C <strong>04</strong> N I 31.17 99.11 1 130.28<br />
91035 <strong>04</strong> N I 255.62<br />
91037 <strong>04</strong> N I 84.00<br />
91038 C <strong>04</strong> N I 32.73 40.00 72.73<br />
91<strong>04</strong>0 <strong>04</strong> N I 248.27<br />
91052 <strong>04</strong> N I 25.65<br />
91055 <strong>04</strong> N I 27.85<br />
91065 <strong>04</strong> N I 29.65<br />
91105 <strong>04</strong> N I 40.85<br />
91110 C <strong>04</strong> N I 140.95 563.92 7<strong>04</strong>.90<br />
91111 C <strong>04</strong> N N 28.37 343.76 372.13<br />
91120 <strong>04</strong> N I 245.00<br />
91122 <strong>04</strong> N I 57.20<br />
91123 <strong>04</strong> N I 194.20<br />
91132 <strong>04</strong> Y I<br />
91133 <strong>04</strong> Y I<br />
Wednesday, April <strong>01</strong>, 20<strong>09</strong> Page 372 <strong>of</strong> 458
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