Podiatry Fee Schedule Key - Illinois Department of Healthcare and ...
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<strong>Healthcare</strong> <strong>and</strong> Family Services<br />

<strong>Podiatry</strong> <strong>Fee</strong> <strong>Schedule</strong> <strong>Key</strong><br />

Revised 01/01/2011<br />

HCPCS<br />

Prior Approv<br />

(Prior Approval)<br />

Prog Cov<br />

(Program Coverage)<br />

Effective Dt<br />

(Effective Date)<br />

H<strong>and</strong> Price<br />

NDC Ind<br />

(NDC Indicator)<br />

Surg Ind<br />

(Surgery Indicator)<br />

Asst Surg<br />

(Assistant Surgeon)<br />

State Max<br />

(State Maximum)<br />

CPT-4 or HCPCS Procedure Code<br />

If “Y”, prior approval is required. Prior approval guidelines are<br />

provided in the Chapter 200F Podiatric Services, Section F211, <strong>and</strong><br />

posted at http://www.hfs.illinois.gov/h<strong>and</strong>books/chapter200.html.<br />

04 – Medicaid covered services<br />

09 – Qualified Medicare Beneficiary (QMB) coverage only (See Chap<br />

100 Provider H<strong>and</strong>book, Section 120.12, posted at<br />

http://www.hfs.illinois.gov/h<strong>and</strong>books/chapter100.html.<br />

Effective date <strong>of</strong> codes added on or after 01/01/06 or date <strong>of</strong> change<br />

in payment policy.<br />

If “Y”, special pricing methodology is applied. Show detailed<br />

procedure information in description field, show quantity “1”, <strong>and</strong><br />

attach documentation <strong>of</strong> procedure performed.<br />

If “Y”, the 11-digit NDC must be billed according to NDC billing<br />

guidelines available on our website at<br />

http://www.hfs.illinois.gov/assets/ncd_112107.pdf.<br />

If “M”, reimbursement for procedure includes 30-day post-operative<br />

care.<br />

“Y” indicates services <strong>of</strong> an assistant surgeon may be paid.<br />

The maximum allowable reimbursement.<br />

INSTRUCTIONS FOR BILLING MULTIPLES<br />

*The number listed in the days/units field must always be “1”.<br />

Bilateral<br />

Not bilateral<br />

Claims may be submitted electronically or on paper. Submit the<br />

procedure code with modifier RT <strong>and</strong> quantity “1” in units/qty field; in<br />

the subsequent service section, submit the same procedure code with<br />

modifier LT <strong>and</strong> quantity “1” in units/qty field.<br />

Claims must be submitted on paper. Submit the specific procedure<br />

code on one service section, submit the unlisted procedure code for<br />

any quantity beyond one in the next service section, <strong>and</strong> list total<br />

number <strong>and</strong> name <strong>of</strong> additional tests in description field. Attach<br />

documentation for all procedures.<br />

Administered drugs<br />

Claims may be submitted electronically or on paper. Submit the<br />

HCPCS code with the name <strong>of</strong> the drug, strength <strong>of</strong> the drug, <strong>and</strong> the<br />

amount given in the description/note field; days/units must be “1”.<br />

The NDC must be submitted according to NDC billing guidelines<br />

available on our website at<br />

http://www.hfs.illinois.gov/assets/ncd_112107.pdf.

<strong>Healthcare</strong> <strong>and</strong> Family Services<br />

<strong>Podiatry</strong> <strong>Fee</strong> <strong>Schedule</strong><br />

Revised 01/01/11<br />

HCPCS<br />

Prior<br />

Approv<br />

Prog<br />

Cov<br />

EffectiveDt<br />

H<strong>and</strong><br />

Price<br />

NDC<br />

Ind Surg Ind AsstSurg State Max<br />

10060 04 I 36.00<br />

10061 04 I 66.50<br />

10120 04 I 39.05<br />

10121 04 I 77.60<br />

10140 04 I 41.50<br />

10160 04 I 35.95<br />

11042 04 I 70.55<br />

11043 04 M 170.55<br />

11044 04 01/01/2010 N Y 219.35<br />

11045 04 01/01/2011 Y I<br />

11046 04 01/01/2011 Y M<br />

11047 04 01/01/2011 Y M<br />

11055 04 01/01/2006 I 22.15<br />

11056 04 01/01/2006 Y I<br />

11057 04 01/01/2006 Y I<br />

11100 04 I 50.20<br />

11420 04 I 38.30<br />

11421 04 I 50.85<br />

11422 04 I 64.80<br />

11423 04 I 77.90<br />

11424 04 I 92.40<br />

11426 04 I 127.48<br />

11719 04 01/01/2009 N 15.90<br />

11720 04 I 15.90<br />

11721 04 I 18.10<br />

11730 04 I 34.30<br />

11732 04 I 14.45<br />

11740 04 I 36.00<br />

11750 04 I 61.85<br />

11752 04 M 167.40<br />

11755 04 I 38.80<br />

11760 04 I 60.80<br />

11762 04 I 87.75<br />

11765 04 I 38.40<br />

12001 04 I 53.10<br />

12041 04 I 72.10<br />

13131 04 I 127.85

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

15320 04 01/01/2009 M Y 165.11<br />

15321 04 01/01/2009 Y N<br />

15335 04 01/01/2009 M 158.29<br />

15336 04 01/01/2009 Y N<br />

15340 04 01/01/2009 I 143.60<br />

15341 04 01/01/2009 M Y 16.19<br />

15365 04 07/01/2008 M 162.56<br />

15366 04 01/01/2009 Y N<br />

15400 04 M 165.30<br />

15420 04 01/01/2009 M Y 183.07<br />

15421 04 01/01/2009 M Y 49.73<br />

15430 04 01/01/2006 M Y 267.39<br />

15431 04 01/01/2006 Y M Y<br />

16000 04 I 45.80<br />

17000 04 I 52.70<br />

17003 04 Y I<br />

17004 04 I Y 86.59<br />

17110 04 I 74.90<br />

17111 04 I 43.05<br />

17270 04 I 45.25<br />

17271 04 I 64.50<br />

17272 04 I 85.60<br />

17273 04 I 106.75<br />

17274 04 I 117.20<br />

17276 04 M 162.00<br />

20550 04 I 31.75<br />

20600 04 I 30.40<br />

20605 04 I 33.00<br />

20680 04 01/01/2006 M Y 233.00<br />

27605 04 02/01/2006 M Y 359.30<br />

27606 04 02/01/2006 M Y 359.30<br />

27607 04 02/01/2006 M Y 292.30<br />

27610 04 02/01/2006 M Y 480.00<br />

27612 04 02/01/2006 M Y 374.55<br />

27613 04 02/01/2006 I 113.60<br />

27614 04 02/01/2006 I 264.25<br />

27615 04 02/01/2006 M Y 521.56<br />

27616 04 01/01/2010 M Y 722.21<br />

27618 04 02/01/2006 M 186.90<br />

27619 04 02/01/2006 M 268.40<br />

27620 04 02/01/2006 M Y 480.00<br />

27625 04 02/01/2006 M Y 480.00<br />

27626 04 02/01/2006 M Y 480.00

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

27630 04 02/01/2006 M 188.65<br />

27632 04 01/01/2010 M Y 230.50<br />

27634 04 01/01/2010 M Y 376.84<br />

27635 04 02/01/2006 M Y 374.55<br />

27637 04 07/01/2008 M Y 599.35<br />

27638 04 02/01/2006 M Y 599.35<br />

27640 04 02/01/2006 M 407.80<br />

27641 04 02/01/2006 M 335.00<br />

27645 04 02/01/2006 M Y 599.35<br />

27646 04 07/01/2008 M Y 599.35<br />

27647 04 02/01/2006 M Y 499.50<br />

27648 04 02/01/2006 I 82.75<br />

27650 04 02/01/2006 M Y 359.30<br />

27652 04 02/01/2006 M Y 480.00<br />

27654 04 02/01/2006 M Y 449.50<br />

27656 04 07/01/2008 M Y 299.70<br />

27658 04 02/01/2006 M Y 224.70<br />

27659 04 07/01/2008 M Y 416.20<br />

27664 04 07/01/2008 M Y 182.50<br />

27665 04 07/01/2008 M Y 302.40<br />

27675 04 02/01/2006 M Y 239.30<br />

27676 04 02/01/2006 M Y 313.20<br />

27680 04 06/01/2009 M Y 381.50<br />

27681 04 02/01/2006 M Y 231.00<br />

27685 04 02/01/2006 M Y 262.20<br />

27686 04 02/01/2006 M Y 257.00<br />

27687 04 02/01/2006 M Y 262.20<br />

27690 04 02/01/2006 M Y 299.70<br />

27691 04 02/01/2006 M Y 524.40<br />

27692 04 02/01/2006 M Y 149.80<br />

27695 04 02/01/2006 M Y 374.55<br />

27696 04 07/01/2008 M Y 561.85<br />

27698 04 02/01/2006 M Y 453.70<br />

27700 04 02/01/2006 M Y 718.70<br />

27702 04 02/01/2006 M Y 749.20<br />

27703 04 02/01/2006 Y M Y<br />

27704 04 02/01/2006 M Y 249.35<br />

27705 04 02/01/2006 M Y 412.00<br />

27707 04 02/01/2006 M Y 359.30<br />

27709 04 02/01/2006 M Y 524.40<br />

27712 04 02/01/2006 M Y 674.20<br />

27715 04 07/01/2008 M Y 749.20<br />

27720 04 02/01/2006 M Y 629.90

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

27722 04 02/01/2006 M Y 733.85<br />

27724 04 07/01/2008 M Y 840.75<br />

27725 04 07/01/2008 M Y 840.75<br />

27732 04 02/01/2006 M Y 314.95<br />

27734 04 02/01/2006 M Y 599.35<br />

27760 04 02/01/2006 M 166.40<br />

27762 04 02/01/2006 M 235.80<br />

27766 04 02/01/2006 M Y 535.45<br />

27780 04 02/01/2006 M 152.60<br />

27781 04 02/01/2006 M 217.80<br />

27786 04 02/01/2006 M 152.60<br />

27788 04 07/01/2008 M 222.00<br />

27792 04 07/01/2008 M Y 299.70<br />

27808 04 02/01/2006 M 208.05<br />

27810 04 02/01/2006 M 305.15<br />

27814 04 02/01/2006 M Y 610.45<br />

27816 04 02/01/2006 M 224.70<br />

27818 04 02/01/2006 M 369.05<br />

27822 04 02/01/2006 M Y 599.35<br />

27823 04 07/01/2008 M Y 599.35<br />

27824 04 02/01/2006 M Y 232.20<br />

27825 04 02/01/2006 M Y 286.20<br />

27826 04 02/01/2006 M Y 515.70<br />

27827 04 02/01/2006 M Y 638.00<br />

27828 04 02/01/2006 M Y 696.90<br />

27829 04 02/01/2006 M Y 412.00<br />

27840 04 02/01/2006 M 138.20<br />

27842 04 07/01/2008 M 208.05<br />

27846 04 02/01/2006 M Y 378.70<br />

27848 04 02/01/2006 M Y 481.90<br />

27860 04 02/01/2006 I 77.10<br />

27870 04 02/01/2006 M Y 659.00<br />

27888 04 02/01/2006 M Y 599.35<br />

28001 04 I 136.05<br />

28002 04 I 143.95<br />

28003 04 M 246.85<br />

28005 04 M 270.50<br />

28008 04 I 147.95<br />

28010 04 M 123.35<br />

28011 04 Y M Y<br />

28020 04 M Y 224.70<br />

28022 04 M Y 153.65<br />

28024 04 M 146.15

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

28035 04 07/01/2008 M Y 524.40<br />

28039 04 01/01/2010 M Y 189.10<br />

28041 04 01/01/2010 M Y 248.90<br />

28043 04 M 149.80<br />

28045 04 M Y 224.70<br />

28046 04 07/01/2008 M 408.09<br />

28047 04 01/01/2010 M Y 527.94<br />

28050 04 07/01/2008 M Y 299.70<br />

28052 04 07/01/2008 M 299.70<br />

28054 04 07/01/2008 M Y 224.70<br />

28055 04 07/01/2008 M Y 302.40<br />

28060 04 02/01/2006 M Y 224.70<br />

28062 04 07/01/2008 Y M Y<br />

28070 04 07/01/2008 M Y 224.70<br />

28072 04 07/01/2008 M Y 161.90<br />

28080 04 M Y 180.30<br />

28086 04 07/01/2008 M Y 184.50<br />

28088 04 07/01/2008 M Y 184.50<br />

28090 04 M Y 175.75<br />

28092 04 07/01/2008 M Y 211.35<br />

28100 04 07/01/2008 M Y 224.70<br />

28102 04 07/01/2008 M Y 718.70<br />

28103 04 07/01/2008 M Y 718.70<br />

28104 04 07/01/2008 M Y 259.40<br />

28106 04 07/01/2008 M Y 449.50<br />

28107 04 07/01/2008 M Y 449.50<br />

28108 04 07/01/2008 M Y 259.40<br />

28110 04 M Y 359.30<br />

28111 04 07/01/2008 M Y 359.30<br />

28112 04 M Y 314.95<br />

28113 04 M Y 314.95<br />

28114 04 M Y 943.40<br />

28116 04 M Y 346.75<br />

28118 04 M Y 346.75<br />

28119 04 M Y 264.90<br />

28120 04 07/01/2008 M Y 259.40<br />

28122 04 M Y 253.90<br />

28124 04 M Y 259.40<br />

28126 04 M Y 209.40<br />

28130 04 07/01/2008 M Y 412.00<br />

28140 04 M Y 394.00<br />

28150 04 M Y 209.40<br />

28153 04 M Y 144.70

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

28160 04 M Y 224.70<br />

28171 04 07/01/2008 M Y 467.16<br />

28173 04 07/01/2008 M 418.51<br />

28175 04 M 262.17<br />

28190 04 I 107.00<br />

28192 04 M Y 159.80<br />

28193 04 M Y 180.30<br />

28200 04 M Y 353.75<br />

28202 04 07/01/2008 M Y 480.00<br />

28208 04 M 299.70<br />

28210 04 07/01/2008 M Y 378.05<br />

28220 04 02/01/2010 Y M Y<br />

28222 04 07/01/2008 Y M Y<br />

28225 04 02/01/2010 Y M Y<br />

28226 04 07/01/2008 Y M Y<br />

28230 04 M Y 173.40<br />

28232 04 I Y 121.10<br />

28234 04 I Y 121.05<br />

28238 04 M Y 299.70<br />

28240 04 M Y 140.75<br />

28250 04 M Y 359.30<br />

28260 04 M Y 299.70<br />

28261 04 M Y 363.45<br />

28262 04 07/01/2008 M Y 524.40<br />

28264 04 07/01/2008 M Y 449.50<br />

28270 04 M Y 299.70<br />

28272 04 07/01/2008 M Y 224.70<br />

28280 04 M Y 162.35<br />

28285 04 M Y 270.50<br />

28286 04 M Y 337.10<br />

28288 04 M Y 299.70<br />

28289 04 M Y 359.30<br />

28290 04 M Y 424.45<br />

28292 04 M Y 359.30<br />

28293 04 M Y 359.30<br />

28294 04 07/01/2008 M Y 359.30<br />

28296 04 M Y 419.00<br />

28297 04 M Y 419.00<br />

28298 04 M Y 359.30<br />

28299 04 M Y 430.51<br />

28300 04 M Y 374.55<br />

28302 04 07/01/2008 M Y 337.90<br />

28304 04 M Y 283.60

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

28305 04 07/01/2008 M Y 373.70<br />

28306 04 M Y 262.20<br />

28307 04 07/01/2008 M Y 299.70<br />

28308 04 M Y 202.50<br />

28309 04 07/01/2008 M Y 358.05<br />

28310 04 M Y 262.20<br />

28312 04 M Y 169.85<br />

28313 04 M Y 167.10<br />

28315 04 M Y 224.70<br />

28320 04 07/01/2008 M Y 378.05<br />

28322 04 M Y 244.90<br />

28340 04 M Y 270.00<br />

28341 04 07/01/2008 M Y 307.90<br />

28344 04 M Y 172.80<br />

28345 04 M Y 216.00<br />

28360 04 07/01/2008 Y M Y<br />

28400 04 I 114.20<br />

28405 04 M Y 228.90<br />

28406 04 M Y 231.65<br />

28415 04 M Y 642.45<br />

28420 04 M Y 671.85<br />

28430 04 M 109.00<br />

28435 04 M Y 215.05<br />

28436 04 M Y 318.60<br />

28445 04 M Y 718.70<br />

28446 04 07/01/2008 M Y 626.74<br />

28450 04 M 98.00<br />

28455 04 M 277.50<br />

28456 04 07/01/2008 M Y 313.20<br />

28465 04 M Y 599.35<br />

28470 04 I 97.05<br />

28475 04 M 173.40<br />

28476 04 M Y 237.85<br />

28485 04 M Y 301.00<br />

28490 04 I 55.40<br />

28495 04 I 69.30<br />

28496 04 M Y 113.60<br />

28505 04 M Y 230.80<br />

28510 04 I 41.60<br />

28515 04 I 97.05<br />

28525 04 I Y 202.90<br />

28530 04 07/01/2008 I 57.30<br />

28531 04 07/01/2008 M Y 224.70

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

28540 04 I 138.75<br />

28545 04 I 152.60<br />

28546 04 07/01/2008 I Y 134.60<br />

28555 04 07/01/2008 M Y 480.00<br />

28570 04 07/01/2008 I 113.65<br />

28575 04 M 151.15<br />

28576 04 M Y 262.20<br />

28585 04 M Y 427.20<br />

28600 04 M 299.70<br />

28605 04 07/01/2008 M 299.70<br />

28606 04 M Y 299.70<br />

28615 04 M Y 368.45<br />

28630 04 I 112.40<br />

28635 04 07/01/2008 M Y 262.20<br />

28636 04 M Y 262.20<br />

28645 04 M Y 240.00<br />

28660 04 I 104.10<br />

28665 04 I 117.85<br />

28666 04 M Y 133.35<br />

28675 04 M Y 241.35<br />

28705 04 M Y 599.35<br />

28715 04 M Y 599.35<br />

28725 04 M Y 480.00<br />

28730 04 M Y 480.00<br />

28735 04 07/01/2008 M Y 599.35<br />

28737 04 07/01/2008 M Y 599.35<br />

28740 04 M Y 337.10<br />

28750 04 M Y 262.20<br />

28755 04 M Y 169.10<br />

28760 04 M Y 239.10<br />

28800 04 M Y 485.50<br />

28805 04 M 482.80<br />

28810 04 M Y 419.00<br />

28820 04 I Y 167.10<br />

28825 04 I Y 145.60<br />

28899 04 Y M Y<br />

29405 04 I 70.00<br />

29425 04 I 75.30<br />

29450 04 I 43.50<br />

29515 04 I 35.85<br />

29540 04 I 15.40<br />

29550 04 I 14.20<br />

29580 04 I 27.00

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

29700 04 I 24.15<br />

29730 04 I 36.00<br />

29740 04 I 46.55<br />

29750 04 I 44.30<br />

29799 04 Y I<br />

29891 04 07/01/2008 M Y 480.00<br />

29892 04 07/01/2008 M Y 480.00<br />

29893 04 07/01/2008 M 171.90<br />

29894 04 02/01/2006 M 480.00<br />

29895 04 07/01/2008 M Y 480.00<br />

29897 04 07/01/2008 M 480.00<br />

29898 04 02/01/2006 M Y 480.00<br />

29899 04 07/01/2008 M Y 659.00<br />

64455 04 01/01/2009 N 38.95<br />

64632 04 01/01/2009 N 90.50<br />

64704 04 01/01/2009 N 90.50<br />

73600 04 N 21.50<br />

73610 04 N 28.70<br />

73620 04 N 17.00<br />

73630 04 N 21.50<br />

73650 04 N 17.00<br />

73660 04 N 14.35<br />

76499 04 Y N<br />

81000 04 N 3.50<br />

82947 04 N 5.10<br />

84550 04 N 5.90<br />

85002 04 N 2.30<br />

85014 04 N 3.10<br />

85345 04 N 4.00<br />

85610 04 N 5.10<br />

85651 04 N 4.60<br />

85652 04 N 3.50<br />

87101 04 N 6.20<br />

87220 04 N 4.70<br />

90703 04 N N 1.85<br />

97597 04 01/01/2011 Y N<br />

97598 04 01/01/2011 Y N<br />

99070 04 Y<br />

99199 Y 04 Y M<br />

99201 04 10/01/2009 N 27.95<br />

99202 04 10/01/2009 N 32.00<br />

99203 04 10/01/2009 N 41.60<br />

99204 04 10/01/2009 N 66.40

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

99205 04 10/01/2009 N 70.85<br />

99211 04 10/01/2009 N 12.30<br />

99212 04 10/01/2009 N 24.25<br />

99213 04 10/01/2009 N 28.35<br />

99214 04 10/01/2009 N 42.50<br />

99215 04 10/01/2009 N 48.00<br />

99231 04 10/01/2009 N 16.40<br />

99232 04 10/01/2009 N 24.90<br />

99233 04 10/01/2009 N 35.05<br />

99241 04 10/01/2009 N 32.15<br />

99242 04 10/01/2009 N 40.20<br />

99243 04 10/01/2009 N 51.30<br />

99244 04 10/01/2009 N 71.40<br />

99245 04 10/01/2009 N 92.80<br />

99251 04 10/01/2009 N 32.15<br />

99252 04 10/01/2009 N 33.95<br />

99253 04 10/01/2009 N 46.45<br />

99254 04 10/01/2009 N 66.40<br />

99255 04 10/01/2009 N 87.10<br />

99281 04 10/01/2009 N 14.35<br />

99282 04 10/01/2009 N 24.20<br />

99283 04 10/01/2009 N 32.20<br />

99284 04 10/01/2009 N 44.00<br />

99285 04 07/01/2008 N 69.25<br />

99307 04 01/01/2006 N 14.80<br />

99308 04 07/01/2008 N 18.91<br />

99309 04 07/01/2008 N 23.40<br />

99310 04 07/01/2008 N 32.05<br />

99324 04 02/01/2010 N 18.60<br />

99325 04 02/01/2010 N 26.70<br />

99326 04 02/01/2010 N 34.85<br />

99327 04 02/01/2010 N 42.95<br />

99328 04 02/01/2010 N 51.05<br />

99334 04 02/01/2010 N 16.00<br />

99335 04 02/01/2010 N 21.00<br />

99336 04 02/01/2010 N 26.05<br />

99337 04 02/01/2010 N 31.05<br />

99341 04 N 27.95<br />

99342 04 04/01/2010 N 37.40<br />

99343 04 04/01/2010 N 54.90<br />

99344 04 04/01/2010 N 70.55<br />

99345 04 04/01/2010 N 85.55<br />

99347 04 N 24.25

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

99348 04 04/01/2010 N 31.30<br />

99349 04 04/01/2010 N 47.50<br />

99350 04 04/01/2010 N 68.85<br />

G0127 04 02/01/2006 N 14.35<br />

G0245 09 Y N<br />

G0246 09 Y N<br />

G0247 09 Y N<br />

G0380 04 01/01/2007 N 14.35<br />

J0120 04 01/01/2006 Y Y N<br />

J0200 04 01/01/2006 Y Y N<br />

J0278 04 01/01/2006 Y Y N<br />

J0290 04 01/01/2006 Y Y N<br />

J0295 04 01/01/2006 Y Y N<br />

J0300 04 01/01/2006 Y Y N<br />

J0380 04 01/01/2006 Y Y N<br />

J0456 04 01/01/2006 Y Y N<br />

J0592 04 01/01/2006 Y Y N<br />

J0595 04 01/01/2006 Y Y N<br />

J0637 04 01/01/2006 Y Y N<br />

J0690 04 01/01/2006 Y Y N<br />

J0694 04 01/01/2006 Y Y N<br />

J0696 04 01/01/2006 Y Y N<br />

J0697 04 01/01/2006 Y Y N<br />

J0698 04 01/01/2006 Y Y N<br />

J0702 04 01/01/2006 Y Y N<br />

J0710 04 01/01/2006 Y Y N<br />

J0713 04 01/01/2006 Y Y N<br />

J0715 04 01/01/2006 Y Y N<br />

J0720 04 01/01/2006 Y Y N<br />

J0743 04 01/01/2006 Y Y N<br />

J0744 04 01/01/2006 Y Y N<br />

J0745 04 01/01/2006 Y Y N<br />

J0760 04 01/01/2006 Y Y N<br />

J0770 04 01/01/2006 Y Y N<br />

J0780 04 01/01/2006 Y Y N<br />

J0878 04 01/01/2006 Y Y N<br />

J1020 04 01/01/2006 Y Y N<br />

J1030 04 01/01/2006 Y Y N<br />

J1040 04 01/01/2006 Y Y N<br />

J1094 04 01/01/2006 Y Y N<br />

J1100 04 01/01/2006 Y Y N<br />

J1170 04 01/01/2006 Y Y N<br />

J1200 04 01/01/2006 Y Y N

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

J1260 04 01/01/2006 Y Y N<br />

J1335 04 01/01/2006 Y Y N<br />

J1364 04 01/01/2006 Y Y N<br />

J1450 04 01/01/2006 Y Y N<br />

J1580 04 01/01/2006 Y Y N<br />

J1626 04 01/01/2006 Y Y N<br />

J1642 04 01/01/2006 Y Y N<br />

J1700 04 01/01/2006 Y Y N<br />

J1710 04 01/01/2006 Y Y N<br />

J1720 04 01/01/2006 Y Y N<br />

J1790 04 01/01/2006 Y Y N<br />

J1810 04 01/01/2006 Y Y N<br />

J1840 04 01/01/2006 Y Y N<br />

J1850 04 01/01/2006 Y Y N<br />

J1885 04 01/01/2006 Y Y N<br />

J1890 04 01/01/2006 Y Y N<br />

J1956 04 01/01/2006 Y Y N<br />

J1960 04 01/01/2006 Y Y N<br />

J2010 04 01/01/2006 Y Y N<br />

J2020 04 01/01/2006 Y Y N<br />

J2060 04 01/01/2006 Y Y N<br />

J2175 04 01/01/2006 Y Y N<br />

J2180 04 01/01/2006 Y Y N<br />

J2185 04 01/01/2006 Y Y N<br />

J2250 04 01/01/2006 Y Y N<br />

J2270 04 01/01/2006 Y Y N<br />

J2275 04 01/01/2006 Y Y N<br />

J2300 04 01/01/2006 Y Y N<br />

J2310 04 01/01/2006 Y Y N<br />

J2370 04 01/01/2006 Y Y N<br />

J2410 04 01/01/2006 Y Y N<br />

J2430 04 01/01/2006 Y Y N<br />

J2469 04 01/01/2006 Y Y N<br />

J2510 04 01/01/2006 Y Y N<br />

J2515 04 01/01/2006 Y Y N<br />

J2540 04 01/01/2006 Y Y N<br />

J2543 04 01/01/2006 Y Y N<br />

J2550 04 01/01/2006 Y Y N<br />

J2560 04 01/01/2006 Y Y N<br />

J2650 04 01/01/2006 Y Y N<br />

J2700 04 01/01/2006 Y Y N<br />

J2800 04 01/01/2006 Y Y N<br />

J2920 04 01/01/2006 Y Y N

Prior Prog<br />

H<strong>and</strong> NDC<br />

HCPCS Approv Cov EffectiveDt Price Ind Surg Ind AsstSurg State Max<br />

J2930 04 01/01/2006 Y Y N<br />

J3010 04 01/01/2006 Y Y N<br />

J3070 04 01/01/2006 Y Y N<br />

J3250 04 01/01/2006 Y Y N<br />

J3260 04 01/01/2006 Y Y N<br />

J3280 04 01/01/2006 Y Y N<br />

J3301 04 01/01/2006 Y Y N<br />

J3302 04 01/01/2006 Y Y N<br />

J3360 04 01/01/2006 Y Y N<br />

J3370 04 01/01/2006 Y Y N<br />

J3410 04 01/01/2006 Y Y N<br />

J3430 04 01/01/2006 Y Y N<br />

J3465 04 01/01/2006 Y Y N<br />

L3000 Y 04 N 113.38<br />

L3001 Y 04 N 59.69<br />

L3002 Y 04 N 110.22<br />

L3003 Y 04 N 45.07<br />

L3010 Y 04 N 110.22<br />

L3030 Y 04 N 22.70<br />

L3217 Y 04 N 82.25<br />

L3260 Y 04 01/01/2009 N 64.39<br />

L3649 Y 04 Y N<br />

Q3014 09 01/29/2010 N 25.00<br />

Q4100 04 01/01/2009 Y N N<br />

Q4101 04 01/01/2009 Y N N<br />

Q4102 04 01/01/2009 Y N N<br />

Q4103 04 01/01/2009 Y N N<br />

Q4104 04 01/01/2009 Y N N<br />

Q4105 04 01/01/2009 Y N N<br />

Q4106 04 01/01/2009 Y N N<br />

Q4107 04 01/01/2009 Y N N<br />

Q4108 04 01/01/2009 Y N N<br />

Q4110 04 01/01/2009 Y N N<br />

Q4111 04 01/01/2009 Y N N<br />

Q4112 04 01/01/2009 Y N N<br />

Q4113 04 01/01/2009 Y N N<br />

Q4114 04 01/01/2009 Y N N<br />

Q4115 04 01/01/2010 Y N<br />

Q4116 04 01/01/2010 Y N

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