Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois

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Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult 95851 04 N I 30.50 95852 04 N I 30.50 95857 04 N I 25.60 95860 04 N I 37.40 95861 04 N I 56.80 95863 04 N I 65.70 95864 04 N I 85.30 95865 C 04 N I 50.72 13.65 64.37 95866 C 04 N I 39.54 4.56 44.10 95867 04 N I 30.70 95868 04 N I 46.30 95869 04 N I 52.70 95870 04 N I 52.70 95872 04 N I 56.80 95873 C 04 N I 11.58 4.30 15.88 95874 C 04 N N 11.76 4.30 16.06 95875 04 N I 36.60 95900 04 Y I 95903 04 Y I 95904 04 Y I 95920 04 Y M Wednesday, April 01, 2009 Page 394 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 95921 04 N I 44.50 95922 04 N I 44.50 95923 04 N I 44.80 95925 04 N I 74.90 95926 04 N I 74.90 95927 04 N I 74.90 95928 04 N I 97.05 95929 04 N I 100.85 95930 04 N I 52.70 95933 04 N I 30.50 95934 04 N I 37.40 95936 04 N I 37.40 95937 04 N I 37.40 95950 C 04 N I 61.31 118.99 180.30 95951 C 04 2/1/2009 N I 81.51 *© 326.05 *© 407.56 51.66 95951 C 04 N I 71.18 *(A) 284.72 *(A) 355.90 95953 C 04 N I 77.53 102.77 180.30 95954 C 04 N I 119.09 106.61 1 224.70 95955 04 N I 62.05 95956 C 04 N I 100.41 294.32 394.73 95957 C 04 N I 65.03 37.30 102.33 Wednesday, April 01, 2009 Page 395 of 458
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Healthcare and Family Services Prac
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Q State maximum amount now includes
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MODIFIERS RECOGNIZED IN PROCESSING
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HO Masters degree level; added 0601
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Health Care and Family Services Rev
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Hcpcs Note ProgCov Eff Date HP NDC
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Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois

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