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 95075 04 N N 38.84 95115 04 N I 6.50 95117 04 N I 8.30 95120 04 N I 6.50 95125 04 N I 8.30 95130 04 N I 4.20 95131 04 N I 8.60 95132 04 N I 12.75 95133 04 N I 17.00 95134 04 N I 21.30 95144 04 N I 14.30 95145 04 N I 21.60 95146 04 N I 32.40 95147 04 N I 37.80 95148 04 N I 43.25 95149 04 N I 48.60 95165 04 N I 36.00 95170 04 N I 12.30 95180 04 N N 47.50 95199 04 Y I 95250 04 Y N Wednesday, April 01, 2009 Page 392 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 95251 04 N N 15.40 95803 04 1/1/2009 Y N 95805 A 04 N I 76.05 76.05 152.10 95806 A 04 N I 55.27 55.28 110.55 95807 A 04 N I 77.35 77.35 154.70 95808 A 04 N I 96.65 96.65 193.30 95810 A 04 N I 130.80 130.80 261.60 95811 A 04 N I 136.15 136.15 272.30 95812 A 04 N I 29.40 29.40 58.80 95813 A 04 N I 40.90 40.90 81.80 95816 A 04 N I 28.55 28.55 57.10 95819 A 04 N I 26.35 26.35 52.70 95822 A 04 N I 27.65 27.65 55.30 95824 A 04 N I 26.35 26.35 52.70 95827 A 04 N I 33.40 33.40 66.80 95829 04 N I 163.50 95830 04 N I 79.10 95831 04 N I 25.60 95832 04 N I 22.15 95833 04 N I 52.70 95834 04 N I 52.70 Wednesday, April 01, 2009 Page 393 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 />
95075 <strong>04</strong> N N 38.84<br />
95115 <strong>04</strong> N I 6.50<br />
95117 <strong>04</strong> N I 8.30<br />
95120 <strong>04</strong> N I 6.50<br />
95125 <strong>04</strong> N I 8.30<br />
95130 <strong>04</strong> N I 4.20<br />
95131 <strong>04</strong> N I 8.60<br />
95132 <strong>04</strong> N I 12.75<br />
95133 <strong>04</strong> N I 17.00<br />
95134 <strong>04</strong> N I 21.30<br />
95144 <strong>04</strong> N I 14.30<br />
95145 <strong>04</strong> N I 21.60<br />
95146 <strong>04</strong> N I 32.40<br />
95147 <strong>04</strong> N I 37.80<br />
95148 <strong>04</strong> N I 43.25<br />
95149 <strong>04</strong> N I 48.60<br />
95165 <strong>04</strong> N I 36.00<br />
95170 <strong>04</strong> N I 12.30<br />
95180 <strong>04</strong> N N 47.50<br />
95199 <strong>04</strong> Y I<br />
95250 <strong>04</strong> Y N<br />
Wednesday, April <strong>01</strong>, 20<strong>09</strong> Page 392 <strong>of</strong> 458
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