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 />
95251 <strong>04</strong> N N 15.40<br />
95803 <strong>04</strong> 1/1/20<strong>09</strong> Y N<br />
95805 A <strong>04</strong> N I 76.05 76.05 152.10<br />
95806 A <strong>04</strong> N I 55.27 55.28 110.55<br />
95807 A <strong>04</strong> N I 77.35 77.35 154.70<br />
95808 A <strong>04</strong> N I 96.65 96.65 193.30<br />
95810 A <strong>04</strong> N I 130.80 130.80 261.60<br />
95811 A <strong>04</strong> N I 136.15 136.15 272.30<br />
95812 A <strong>04</strong> N I 29.40 29.40 58.80<br />
95813 A <strong>04</strong> N I 40.90 40.90 81.80<br />
95816 A <strong>04</strong> N I 28.55 28.55 57.10<br />
95819 A <strong>04</strong> N I 26.35 26.35 52.70<br />
95822 A <strong>04</strong> N I 27.65 27.65 55.30<br />
95824 A <strong>04</strong> N I 26.35 26.35 52.70<br />
95827 A <strong>04</strong> N I 33.40 33.40 66.80<br />
95829 <strong>04</strong> N I 163.50<br />
95830 <strong>04</strong> N I 79.10<br />
95831 <strong>04</strong> N I 25.60<br />
95832 <strong>04</strong> N I 22.15<br />
95833 <strong>04</strong> N I 52.70<br />
95834 <strong>04</strong> N I 52.70<br />
Wednesday, April <strong>01</strong>, 20<strong>09</strong> Page 393 <strong>of</strong> 458
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